What vaccinations can/can’t pregnant women get?
SHOULD get flu vaccine
- whopping cough
- travel/tetanus if appropriate
Live vaccines NOT recommended: BCG (vaccination against tuberculosis) MMR (measles, mumps and rubella) oral polio (which forms part of the 5-in-1 vaccine given to infants) oral typhoid yellow fever
A 63-year-old man is 4 days post hemi-colectomy. He has reduced oral intake. He has been prescribed intravenous sodium chloride 0.9% 1L over 8 hours.
What is the most important option to monitor for dehydration.
A. Jugular venous pressure
B. Mucous membranes
C. Skin Turgor
E. Urine Output
Name a diabetic drug from each class
DPP4i - Alogliptin, Vidagliptin, Linagliptin
SGLT2i - Canagliflozin, Dapa-, Empa-
Thiazolidinediones - pioglitazone
Sulphonylurea - Glipzide, glibenclamide, tolbutamide, glicazide
Biguanides - Metformin, Phenmorphin
A 34-year-old woman is 38+2/40 weeks pregnant. She has two days of a stinging pain whilst passing urine and passing small amounts of urine more frequently. She denies blood in the urine. Fetal movements are normal. PMH. Gestational diabetes. Metformin 1g BDS.
37.3°C, HR 90/min and rhythm regular, BP 124/77 mmHg, RR 18/min, O2 sat 99% RA
Urine dip: Glucose -ve, ketones -ve, leukocytes 3+, blood -ve, nitrites +ve
Which abx can you and can’t you use?
Cefalexin is a widely used antibiotic which is generally regarded as safe in all stages of pregnancy.
- Gentamicin is used to treat severe and complicated upper UTI, or urosepsis. The patient’s observations are stable and do not suggest complicated infection. There is a risk of auditory or vestibular nerve damage in the
neonate when aminoglycosides are used in the second and third trimesters of pregnancy, therefore their use should be avoided unless absolutely essential.
- Metronidazole is used for PID. It is generally avoided in pregnancy due to limited information regarding safety.
- Nitrofurantoin should be avoided in late pregnancy/at
term, due to neonatal haemolysis.
- Trimethoprim is to be avoided in pregnancy, particularly
in the first trimester, due to its teratogenic effects.
A 46 year old woman attends Ambulatory Care with a swollen left leg and shortness of
breath on exertion. Two days previously she flew home from a business trip in Australia.
PMH. Hypertension. DH. Ramipril 1.25 mg PO daily. No known drug allergies.
O/E: 37.0°C, HR 120/min and rhythm regular, BP 136/85 mmHg, RR 20/min, O2 sat 95% RA.
A left leg deep vein thrombosis and pulmonary embolism are suspected
What do you prescribe?
APIXABAN OR RIVAROXABAN due to change in NICE guidelines... If suspected PE, start an anticoagulant that could be continued after PE confirmed: 1st line Apixaban or rivaroxiban 2nd line (1st line if Ca) LMWH for 5d then dabigatran OR LMWH + Warfarin for 5days
In UNSTABLE patients -> UFH and if no CI
A 56-year-old woman has hypothyroidism. She was last seen in clinic 6 months ago where
her dose Levothyroxine dose was increased as she reported tiredness, dry skin and feeling
more forgetful than usual. PMH. hypothyroidism and hypertension. DH. Levothyroxine sodium 75 micrograms, Amlodipine 5 mg.
Thyroid Stimulating Hormone (TSH) 0.2 mU/L (0.3–4.2)
Free T4 16.2 pmol/L (9–25)
Do you change her meds?
The blood tests show a low TSH indicating she is being over treated, so her dose must be reduced. This should be done in small increments (unless the
patient is overtly thyrotoxic), so reduction of her dose by 25micrograms is the most
appropriate answer. This should be followed by a repeat blood test in 6-8 weeks.
A 29-year-old man has recently undergone an open reduction and internal fixation (ORIF)
of his distal radius following a motorcycle accident. He complains of pain post-procedure.
DH. Paracetamol 1 g PO four times a day, ibuprofen 400 mg PO three times a day. No known
Write a prescription for ONE additional oral medication for analgesia.
Based on the WHO analgesic ladder, the next most appropriate analgesic option would be a
weak opioid, such as Codeine, Dihydrocodeine or Tramadol. Codeine tends to be the
preferred option due to less severe side effects (Tramadol can cause agitation and
hallucinations, particularly in elderly patients) although it is known to be constipating, so this should be considered when prescribing this medication.
Co-Codamol/Co-dydramol - contain paracetamol, hes on max
Naproxen/aspirin - no due to current NSAIDs
Stronger opioids such as Morphine could be suitable options later down this patient’s treatment
1st - Paracetamol (4g/d) and/or NSAIDs (if not CI) (ibuprofen or naproxen)
2nd - Add in codeine (weak opioid) 30 mg 4 times a day. Alternatives: Dihydrocodeine 30mg 4 times a day; Tramadol 100mg 4 times a day.
3rd - Stop codeine, replace with morphine sulfate
How do you take alendronate? and why
Alendronic acid tablets should be swallowed whole with plenty of water while sitting or standing.
This should usually be on an empty stomach at least 30 minutes before breakfast (or another
oral medicine) and patients should stand or sit upright for at least 30 minutes after taking the
tablet. The upright posture limits the risk of the tablet remaining in the oesophagus and
promoting oesophageal ulceration. The drugs must be given on an empty stomach because food
and beverages interfere with gastrointestinal absorption and delay gastric emptying. Delayed
gastric emptying would increase the amount of time the alendronic acid spends in the stomach,
which would increase the risk of gastric ulceration.
Morphine side effects
Morphine acts on opioid receptors in the brain to depress neurotransmission which can potentially cause drowsiness and confusion.
Morphine acts on opioid receptors in the bowel to inhibit peristalsis which leads to constipation many palliative patients require a laxative as prophylaxis against
Opioids cause miosis (pinpoint pupils)
WITHDRAWAL - Sweating and agitation are phenomena associated with withdrawal of opioid dependence
How to evaluate response to steroids in PMR?
ESR / CRP should respond within a week or two if the diagnosis is correct, but are unlikely to do so as rapidly as the clinical symptoms. NB ESR may be normal or only minimally elevated in a quarter of PMR pts emphasising that it is symptomatic response to corticosteroids that is usually the best guide to successful treatment.
What should you do before you give adenosine?
Warn the patient!
Before administering adenosine, all patients must be warned that they will experience chest
discomfort and a sensation that people describe as ‘feeling like they are about to die’. The effects
of adenosine are unlikely to last more than 1–2 minutes as it has a very short half-life of less than
10 seconds. Rapid onset of action is required, so it is administered intravenously for immediate
effect. Other side effects of adenosine include hypotension
Sx of lithium toxicity and how to monitor lithium
diarrhoea, vomiting, drowsiness, tremor, thirst, increased urination, muscle weakness confusion and ataxia
Drugs that reduce eGFR e.g. furosemide can precipitate this
Take a sample 12 hours after last dose, FBC not needed regularly, serum lithium level needed weekly and after each dose change until stable -> then 3 monthly
What to check before vancomycin administration?
Serum Creatinine - clearance of vanc is reduced with reduced renal function
Uncommonly causes neutropenia and thombocytopenis
What to check before statin administration?
NICE requires ALT or AST to be checked before administering statins as statins are metabolised by the liver
According to BNF CXR baseline isn’t required (British Society of Rheum recommend it)
Don’t start if LFTs abnormal as risk of liver cirrhosis
If you become neutropenic -> stop methotrexate not reduction
drugs that cause hyperkalaemia
Potassium sparing diuretic e.g. amiloride, spiro
Azole, Penicillins, trimethoprim
Causes of hyperkalaemia ar DREAD; drugs renal failure endocrine (addisons) artefact and DKA
Dont forget to repeat the blood sample esp if ECG normal
Which drugs do we stop before surgery?
Antiplatelets e.g. aspirin
Anticoagulants e.g. heparin
Metformin and insulin should be stopped and replaced with sliding scale
Patients on long term steroids, these need to be stopped and a supplementary IV steroids need to be given as the long term steroid use can cause adrenal atrophy
Drug errors on prescription chart
LOOK AT G VS MG!!
Drugs that are not indicated i.e. don’t line up to their PMHx and could belong to another patient
Look at whether the indication lines up to the dose
if paracetamol and cocodamol and over the 4g per day. Stop paracetamol if pt in pain.
Drugs that affect lithium excretion
- enzyme inhibitors
- reduced excretion e.g. ACEi, diuretics and NSAIDs (if diuretics have to be given give a loop diuretic not a thiazide)
Some patients whilst they are recovering from AKI enter a polyuric phase where their urine output increases and fluid input may not keep pace resulting in dehydration and electrolyte abnormalities. UO exceeding 200ml/h should raise suspicion.
3L IV fluids per day (8hoursly bags) (two salt one sweet)
When isn’t metformin first line?
don’t start if patient has egfr <45
Drugs that cause confusion
Glucocoritcoids e.g. prednisolone in elderly
What range should blood glucose be for patients taking insulin therapy
best to recommend that patients should maintain a blood-glucose concentration of between 4 and 9 mmol/litre for most of the time (4–7 mmol/litre before meals and less than 9 mmol/litre after meals).
Phenoxymethylpenicllin for 10 DAYS
mechanical herat valve - 3-4
venous thromboembolism: target INR = 2.5, if recurrent 3.5
atrial fibrillation, target INR = 2.5
Pt wants to go from tablet (Eplim) anticonvulstant to oral solution (eplim). They are both the same strength.
She takes NaValp 200mg/5ml Eplim 7.5ml 12 hourly.
How many tablets should she take each day if they come in 100mg strength
NaValp 200mg/5ml Epi
She takes 7.5ml -> 300mg
She takes 2 a day -> 600mg
therefore 6 tablets
Hypoglycaemia IV dose
15g IV using 20% glucose
If thats unsuitable/unavailable -> 10%
VTE prophylaxis pre surgery
1st line LMWH or rivaroxaban
If those are unsuitable -> apixaban or dabigatran
Drugs to stop if they’re having AKI/renal dysfunction
ACE and ARBs
Allopurinol is renally excreted
Warfarin patient + surgery
Stop taking ~5 days before surgery
If day before/day of surgery the INR is >1.5 give vitamin K
If they’re bleeding you could consider PCC
Mild or moderate -> Amox (allergy -> clary/doxy)
Severe -> Co-Amox with clari/ery (allergy -> levofloxacin)
IDA first line
Microgynon with HTN on f/u
Switch to cerazette
ambulatory BP not required
Which one of these shouldn't be co prescribed Bisoprolol 5mg od Aspirin 75mg od Ramipril 10mg od Indapamide 2.5mg od Verapamil 80mg tds
Bisoprolol and verapamil - can cause life threatning bradycardia