PSA Flashcards

Question

Paracetamol Overdose

Answer 1

antioxidant flutathione is quickly depleted toxic NAPQI builds up N-acetyl cysteine (NAC) Replenishes Glutathione Paracetamol Nomograms measure at least 4 hours after ingestion Need NAC if levels above the line staggered dose or unknown time of ingestion NAC tx is advised Start acetylcysteine before levels if \>150mg/kg paracetamol

Answer 2

IV aminoglcoside abx for severe ifxns **Once Daily regimen monitoring** normally high dose (5-7mg/kg) regimen with once daily regimen monitoring timnig of measurements depends on local guidelines use hartford 7mg/kg nomogram and increase interval if needed **Divided Daily dosing** Divided daily dosing for renal failure 1mg/kg (12hrly) and endocarditis 1mg/kg (8hrly) might need to adjust dose for this method

Answer 3

BNF recommendations

Answer 4

Sertraline 50mg OD Enoxaparin 20mg S/C OD for moderate risk ppx (40mg high risk) Levonorgestrel 1.5mg stat within 72hrs Ulipristal 20mg stat within 120 hrs APIXABAN PE/DVT 10mg OD for 7d then 5mg APIXABAN AF 5mg OD (reduce to 2.5mg if \>80 + other things) APIXABAN post surgery ppx = 2.5mg LACTULOSE 15ml BD

Answer 5

If they have Asthma too it should have already been diagnosed **Bronchitis** - low o2 leads to hypertension and RHF **Emphysema** - damaged aveoli and co2 retension - cachexic and prolonged forced expiration Diagnose - **Spirometry**. .. . . the other stuff is for acute **Asthma:** raised eosinophil count +/- diurnal variation +/- peak flow varition over time (at least 400ml) FEV1/FVC = \<0.7 FEV1 of predicted for severity -\>80% =mild stage 1 50-79 = moderate stage 2 30-49 = stage 3 severe \<30% = stage 4 very severe **Simplified drugs** Non asthmatic = SAMA + LABA + LAMA Asthmatic = LABA + ICS (can add in LAMA if refractory Mucolytics for productive cough SABA = Albuterol (can also use SAMA first line in uk but need to switch to SABA for second line) LAMA = ibatropium (2ND line ICS+LABA instead if asthmatic features) LABA- ending in -alol COPDER - long term management O2 and smoking cessation = only things that prelong life (and colume reduction surgery in some patients **O2 - 88-92%** * -long term - IX if FEV1 \<30%/cyanosis/raised JVP* * - 2 ABG 3w apart offer if \<7.3 kPa or 7.2-8 and peripheral/pulmonart oedema or polycythamia* **Exacerbation** ECG, ABC, CXR important to see if anything else causing Add ABX if sputum looks infected. Cycle between doxycycline (ruin teeth) and azithromycin (QT prolongation so check ECG first) - azithromycin used for prophylaxis in UK - amoxicillin, doxycycline or clarithromycin for acute in UK **Causative organisms** Haemophilus influenzae (most common cause) Streptococcus pneumoniae Moraxella catarrhalis **IX** The following investigations are recommended in patients with suspected COPD: post-bronchodilator spirometry to demonstrate airflow obstruction: FEV1/FVC ratio less than 70% chest x-ray: hyperinflation, bullae, flat hemidiaphragm. Also important to exclude lung cancer full blood count: exclude secondary polycythaemia body mass index (BMI) calculation **Ventilation** Non invasive ventilation benefits pts with pH 7.25-7.35 Invasive ventilation if pH \<7.25

Answer 6

Palpitations? - exclude arrhythmias with Holter Monitering (24hr potable 3 lead ecg) fast = tachycadia? Narrow = \<3 boxes (0.12s) - wide is \> Adenosine = 6mg then 12 then 12 (IV adenosine needs to be infused via a large-calibre vein or central route) **Ventricular Fibrillation** MC cause of death following an MI **SVT** no p waves, HR\>150, regular if haemodynamically stable do vagal manouvres if this fails give IV adenosine 6mg\>12mg\>12mg (veramapril if asthmatic) **AF** no p, irregularly irregular, \<150 - chaotic background and flutter sawtooth Torsades de points = turning of points around heart therefore changing amplitude V-tach - monomorphic, wide complex, fast rhythm Diltiazem (CCB) can be used instead of beta blocker in asthmatics **AF MX** stable or unstable (haemodynamically) (DC cardioversion if unstable) rate control off if 48h and give if \>48hr (sotalol, amiodarone, flecainide) - if CHF then use digoxin in acute setting if already on beta blocker . . rate limiting CCB contraindicated in excerbation HF stable and decide to cardiovert? (beneficial in young, non CAD, low risk) \<48hr - heparinise and give DC cardioversion (anticoag not needed after unless CHADVAS score) or amiodarone \>48hrs either anticoag 3 weeks before and 4 weeks after DC conversion or TOE to exclude left atrial appendage (LAA) thrombus then can heparanise and DC cardiovert immediatelly if previous cadioversion failure should have 4w amiodarone before DC cardioversion **CHA2DV2ASC** - determine anticoag strategy: 0- non aspirin no longer recommended 1- consider for males 2 - offer anticoag (NOAC or Warfarin) **HASBLED** score if starting warfarin - high risk =\>3 Slow Narrow and wide not as important here PACE if too slow or unstable Atropine helps for the first two - maybe 3rd Idioventricular rhythm has no p waves as only ventricles contracting **stability -** American Heart Association, includes systolic blood pressure \< 90 mm Hg, altered mental status, cardiac ischemia, or severely decompensated heart failure due to the underlying rhythm.

Answer 7

**ACEi** - *enalapril, lisinopril, perindopril and ramipril.* **ARBs** - *candesartan, irbesartan, losartan, valsatan* **CCBs** - *amlodipine, felodipine and nifedipine.* **Diuretics** - *indapamide and bendroflumethiazide.* Bendroflumethiazide **first, check for:** * confirm elevated clinic BP with ABPM or HBPM* * assess for postural hypotension.* * discuss adherence* **Step 1 treatment** patients \< 55-years-old or a background of type 2 diabetes mellitus: ACE inhibitor or a Angiotension receptor blocker (ACE-i or ARB): (A) angiotensin receptor blockers should be used where ACE inhibitors are not tolerated (e.g. due to a cough) patients \>= 55-years-old or of Afro-Caribbean origin: Calcium channel blocker (C) ACE inhibitors have reduced efficacy in patients of Afro-Caribbean origin are therefore not used first-line If CCB give peripheral oedema it can be switched for 2nd line indapamide to relieve symptoms **Step 2 treatment** if already taking an ACE-i or ARB add a Calcium channel blocker or a thiazide-like Diuretic if already taking a Calcium channel blocker add an ACE-i or ARB for patients of Afro-Caribbean origin taking a *calcium channel blocker for hypertension, if they require a second agent consider an ARB in preference to an ACE inhibitor* (A + C) or (A + D) **Step 3 treatment** add a third drug to make, i.e.: if already taking an (A + C) then add a D if already (A + D) then add a C (A + C + D) **Step 4 treatment** NICE define step 4 as resistant hypertension and suggest either adding a 4th drug (as below) or seeking specialist advice if potassium \< 4.5 mmol/l add low-dose spironolactone if potassium \> 4.5 mmol/l add an alpha- or beta-blocker

Answer 8

Not all wheezing asthma but should always consider Ominous = lots of air trapping and not much room for air movement PFTS = spirometry ach agonist = Methacholine Negavite Spirometry does not exclude asthma: ix further with fractional exhaled nitric oxide (FeNO) testing **Tx** Bronchoconstricion with bronchodilators Inflammation with anti-inflammatories Stabalisers can be used for athletic asthma as you can take pre-emptivly (cromolyn/ nedocromil) short course of prednisolone for acute episodes (eg 5day hx of wheeze and cough and already on medicaiton) **Adult Tx** 2- jump in here if Newly-diagnosed asthma with symptoms \>= 3 / week or night-time waking Salmeterol = LABA aka a 'controller' **Child 5-16 tx** The same as adult but stop LRTA at 4 Jump to 2 if Newly-diagnosed asthma with symptoms \>= 3 / week or night-time waking 8 week trial: After 8-weeks stop the ICS and monitor the child's symptoms: if symptoms did not resolve during the trial period, review whether an alternative diagnosis is likely if symptoms resolved then reoccurred within 4 weeks of stopping ICS treatment, restart the ICS at a paediatric low dose as first-line maintenance therapy if symptoms resolved but reoccurred beyond 4 weeks after stopping ICS treatment, repeat the 8‑week trial of a paediatric moderate dose of ICS **Exacerbation** Life threatening: *SpO2 \<92% PEF \<33% best or predicted Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis* Nebs = Ipratropium (muscarinic antagonist)/ salbutamol PEFR = peak espiratory flow rate ( they should know their best) All patients to receive PO prednisolone Oxygen through non rebreath MDI = metered dose inhalors Rescue medication : Racemic adrenaline neb, subq adrenaline, IV magnesium all used to try and prevent intubation **Grades** 1 - intermitent 2/3/4 = intermittent 2. mild 3. moderate 4. severe Refractory = tx not working **Adult Corticosteroid Doses** \<= 400 micrograms budesonide or equivalent = low dose 400 micrograms - 800 micrograms budesonide or equivalent = moderate dose \> 800 micrograms budesonide or equivalent= high dose. **Paeds Corticosteroid Doses** \<= 200 micrograms budesonide or equivalent = paediatric low dose 200 micrograms - 400 micrograms budesonide or equivalent = paediatric moderate dose \> 400 micrograms budesonide or equivalent= paediatric high dose. **Maintenance and reliever therapy (MART)** a form of combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required MART is only available for ICS and LABA combinations in which the LABA has a fast-acting component (for example, formoterol) **Criteria for discharge** been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours inhaler technique checked and recorded PEF \>75% of best or predicted

Answer 9

**Who** CVD RFs : old fat and hypertensive Thrush: sore itchy foreskin in men polyuria, polydipsia, blurred vision **How** The randam blood glucose is useful for the T1DM who comes in with all the sx The tests are better as they go down. HbA1C measures glycosylated end products so is therefore an average over 90 days But cannot r/o diabetes as haemaglobinopathies affect levels **IFG/IGT** Impaired fasting glucose = FPG \>6.1 but \<7.0 mmol/L and should be offered OGTT to r/o DM Impaired glucose tolerace = Pre-diabetes **T1 DM** AI desruction of pancrease old person with normal BMs last year presenting with polydisia, polyuria and very high BMs is same as young GAD and IA-2 are antibodies **Tx** with insulin Monitor at least 4 times a day, including before each meal and before bed **Pre-Diabetes** **Mx** lifestyle modification = weight loss, increase exercise, change diet At least yearly F/U blood tests Metformin for their FPG or HbA1c is progressing towards T2DM **T2DM** **Mx** Check HbA1c q3-6 months then every 6 months when stable 1. Lifestyle: target = 48 mmol/mol 2. Add metformin: target = 48mmol/mol 3. If \>58 add another drug: target = 53 mmol/mol 4. If still \>58 add another or consider Insulin Keep metformin when starting insulin and consider the others **If metformin not initially tolerated then:** First try modified release meformin 1. Lifestyle: target = 48 mmol/mol 2. Add another drug: target = 48mmol/mol 3. If \>58 add another drug: target = 53 mmol/mol 4. If still \>58 consider Insulin Drugs **Metformin**: the diarhoea will go away **Sulfonylureas** (pick as cheap and been around ages): watch out for the hypoglycaemia esp in CKD pts- increases insulin expression **TZD** = thiazolidinedione = pioglitazone : can cause CHF **GLP1 mimetic** (exenatide) criteria = BMI\>35 and unable to lose weight or \<35 but insulin would have significant occupational implicatons . . . only continue if a 1% HbA1c reduction or weight loss of 3% in 6 months SGLT-2i can cause DKA so avoid **Alpha Glucosidase** inhibitors mean that glucose not absorbed so dirahoea and smeel flatulance **RF modification** **Htn:** 1st line ACEi \<80 target 140/90 clinic (135/85) \>80 target 150/90 (145/85) **Antiolatelets** offered **Lipids** = QRISK2 score = atorvastatin 20mg ON **Retinopathy -** sudden vision loss = vitrious haemorhage **Nephropathy** All diabetic patients require annual screening for albumin:creatinine ratio (ACR) in early morning specimens ACR \> 2.5 = microalbuminuria Mx: Start ACEi diet restrict protein gd control of BP, BM, Lipids **Neuropathy** 1st line: amitriptyline, duloxetine, gabapentin or pregabalin 2nd- try another one of the drugs 3. tramadol can be used as rescue therapy 4 - refer to pain mx clinic] **Charcot Foot** Mild pain considering of joint dysruption swollen, red and warm **Sick Diabetic** cont normal insulin regime and check BMs regularly **MODY** maturity onset diabetes of the young (MODY) - type Hepatic Nuclear Factor 1 Alpha (HNF1A). HNF1A accounts for 70% of MODY cases. Sulfonylureas (e.g. gliclazide) are the optimal treatment in HNF1A-MODY. **Small bowel bacterial overgrowth syndrome (SBBOS)** DM at ro this excessive gut bateria sx: chronic diarhoea, bloating, flatulance, abdo pain dx: hyrodogen breath test tx: rifaximin and DM control **Dietary advice** encourage high fibre, low glycaemic index sources of carbohydrates include low-fat dairy products and oily fish control the intake of foods containing saturated fats and trans fatty acids limited substitution of sucrose-containing foods for other carbohydrates is allowable, but care should be taken to avoid excess energy intake discourage use of foods marketed specifically at people with diabetes initial target weight loss in an overweight person is 5-10%

Answer 10

1% means: 1g in 100ml or 10mg in 1 ml for w/v calculations 1g in 100g for w/w calculations 40mg dose of 80mg/2ml solution 2ml x 80mg = xml \*40mg Adrenaline 1in1000 for anaphylaxis, 1 in 10,000 for CPR 1 in 1000 means mg = ml

Answer 11

**Rapid-acting insulin analogues** the rapid-acting human insulin analogues act faster and have a shorter duration of action than soluble insulin (see below) may be used as the bolus dose in 'basal-bolus' regimes (rapid/short-acting 'bolus' insulin before meals with intermediate/long-acting 'basal' insulin once or twice daily) insulin aspart: NovoRapid insulin lispro: Humalog **Short-acting insulins** soluble insulin examples: Actrapid (human, pyr), Humulin S (human, prb) may be used as the bolus dose in 'basal-bolus' regimes **Intermidate-acting insulins** isophane insulin many patients use isophane insulin in a premixed formulation with **Long-acting insulins** insulin determir (Levemir): given once or twice daily insulin glargine (Lantus): given once daily

Answer 12

In the 2013 guidelines NICE recommend the following requirements for maintenance fluids: ## Footnote 25-30 ml/kg/day of water and approximately 1 mmol/kg/day of potassium, sodium and chloride and approximately 50-100 g/day of glucose to limit starvation ketosis So, for a 80kg patient, for a 24 hour period, this would translate to: 2 litres of water 80mmol potassium

Answer 13

\*as FFP can take time to defrost prothrombin complex concentrate should be considered in cases of intracranial haemorrhage Major bleeding whatever the INR: - stop warfarin, give intravenous vitamin K 5mg, prothrombin complex concentrate Octilex = corrects factors 1972

Answer 14

antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides psychiatric drugs: lithium, benzodiazepines aspirin carbimazole methotrexate sulfonylureas cytotoxic drugs amiodarone

Answer 15

**Lithium** range = 0.4 - 1.0 mmol/l take 12 hrs post-dose **Ciclosporin** trough levels immediately before dose **Digoxin** at least 6 hrs post-dose **Phenytoin** levels do not need to be monitored routinely but trough levels, immediately before dose should be checked if: adjustment of phenytoin dose suspected toxicity detection of non-adherence to the prescribed medication

PSA Flashcards

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