Y3 - Safe prescribing

Question 1

What key investigation should be done in an child with unexplained fever over 38 degrees

Answer 1

URINE sample within 24 hours

Send for microscopy and culture

Question 2

When taking a paediatric medication history, what is it important to ask about?

Answer 2

• Birth weight
• drug allergies
• use of inhalers or creams
• any over the counter medication use
• patient tablet or liquid preference
• breast or bottle bed
• is mother on any medication if patient breast fed

Question 3

E.coli is a …

Answer 3

Gram negative rod shaped bacteria

Question 4

What routine advice should be give to parents of children who develop urinary tract infections to prevent reoccurence?

Answer 4

• Toilet hygiene: wipe front to back
• keep well hydrated
• do not delay toilet and hold urine in
• wear loose underwear

Question 5

Information from a paediatric history which may suggest constipation?

Answer 5

• decreased stool frequency
• pain on defaecation
• recent change in diet
• overflow soiling mistaken for diarrhoea

Question 6

Main difference between adult and paediatric management of constipation?

Answer 6

dietary interventions should not be used alone as 1st line tx, unlike in adults

Combination tx w/
–> laxatives
–> toilet schedules
–> dietary modification (fluid and adequate fibre)
–> encourage physical activity

Question 7

Recommended fibre intake for adults suffering with constipation

Answer 7

30g per day

Question 8

If a patient is taking liquid preparations in mls, what is important to consider when writing their prescription chart :

Answer 8

PRESCRIBE IN mg

Need to work out dose in Mg

Question 9

What important information should you give the parents of a patient who has just started a disimpaction and maintenance regime for constipation?

Answer 9

• open sachets and pour into water, stir until dissolves
• can add squash to make it taste nicer
• can be given at any time of the day: start in the morning so full dose can be given within 12 hours
• don’t have to drink it all in one go
• but must drink it all to have clinical development
• may not work immediately
• Diet and lifestyle: fluid intake, adequate fibre and exercise
• follow up with GP or outpatient services

Question 10

Side effects of constipation treatment in kids

Answer 10

• stomach pains
• dehydration
• nausea

Important to keep patient well hydrated

Question 11

Contraindications for the COCP

Answer 11

• history of breast cancer (can be used after 5 years if no evidence and non-hormonal methods unacceptable)
• migraine with aura
• personal PMHx venous or arterial thrombosis
• severe or multiple risk factors for arterial disease OR VTE
• transient cerebral ischaemic attacks without headaches

Question 12

Combined oral contraceptive pill’s should be avoided in patients who have two of the following critiera:

Answer 12

• obesity (BMI > 30)
• SMOKING
• Diabetes mellitus
• FHx of arterial disease in 1st degree relative aged under 45
• HTN –> blood pressure above 140 systolic or 90 diastolic
• migraine without aura

Question 13

Important questions to ask patient before starting contraceptoin?

Answer 13

Is she already using contraception?

Has she had emergency hormonal contraception?

Recently given birth?

Has she had a miscarriage or termination?

Does she normally have a regular cycle?

LMP?

Question 14

Why is it important to ask a patient when they had their last menstrual period when considering starting the progestogen only pill?

Answer 14

POP
1. Can be started day 1-5 of menstrual cycle without needing any additional protection

2. If at any point in the cycle
   –> pregnancy test first
   –> start POP BUT patient needs to use additional barrier methods for the next 48 hours

Starting POP on days 5-28 is OFF LABEL USE

Question 15

Progesterone only Pill COUNSELLING

MODE OF ACTION

Answer 15

MODE OF ACTION

• suppresses ovulation
• increases hostile cervical mucus
• reduction in activity of cilia in the fallopian tube

Question 16

Progesterone only Pill COUNSELLING

Advantages

Answer 16

• very effective when taken correctly
• sex doesn’t need to be interrupted
• can be used in women where COC not suitable
• may reduce risk of endometrial cancer
• Desogestrel may help manage dysmenorrhoea
• fertility returns to normal when POP stopped

Question 17

Progesterone only Pill COUNSELLING

Disadvantages

Answer 17

1. pills must be taken same time each day
   —–> 3 hour window
   —–> 12 hour window for desogestrel
2. Adverse effects
   - unscheduled bleeding
   - breast tenderness
3. Doesn’t protect against STI
4. Ovarian cyst
5. Headache
6. Libido changes
7. Cardiovascular disease –> MI, VTE, STROKE

Question 18

If a women vomits within how many hours of taking an oral contraceptive, should she take another on:

Answer 18

If vomits within 2 hrs of taking pill - another one should be taken

If D&V > 24hrs
- avoid sex or use barrier methods during illness and for 48hrs after

Question 19

Missed pill advice for POP

Answer 19

If missed POP
- take asap
- then next pill at normal time
- may mean taking 2 pills in 24 hrs

IF UPSI after missed pill and within 48hrs of restarting POP
–> consider emergency contraception

Question 20

Important additional supplement a women may take during pregnancy

Answer 20

FOLIC ACID 400 micrograms daily up until 12th week of pregnancy
—> reduce risk of neural tube defects

Women who are at higher risk : take 5mg daily until week 12
—> previous spina bifida in pregnancy
—> epilepsy medication?
—> coeliac or malabsorption issues, DM
—> BMI of 30 of more
—> sickle cell, thalassaemia or thalassaemia trait

Question 21

1st line RCOG guidance for nausea and vomiting in pregnancy

Answer 21

1st line –> CYCLIZINE or PROCHLORPERAZINE

CAUTION
- prochlorperazine in young women due to risk of dystonia

2nd line –> domperidone , metoclopramide

Ondansetron
–> beware concern about cardiac and renal malformations

Question 22

Treatment of DVT in pregnancy

Answer 22

LMWH –> like enoxaparin SC
–> continue for remainder of pregnancy
–> and at least 6 weeks post natal

Question 23

What would be the drug of choice is a patient with gestational diabetes had high blood sugars despite treatment with metformin

Answer 23

INSULIN

Question 24

NICE guidelines for gestational diabetes

Answer 24

Fasting plasma glucose below 7mmol/L
–> diet and exercise trial

If targets not met within 1-2 weeks
—> metformin

Only give insulin if:
—> metformin contraindicated or unacceptable to women

Question 25

opioid example which is safe in breast feeding

Answer 25

dihydrocodeine

Question 26

Symptoms of pre-eclampsia include

Answer 26

- Swelling of feet, ankles, face and hands caused by fluid retention - severe headache - vision problems - pain just below ribs

Question 27

What medication options are available to manage raised BP in pregnancy:

Answer 27

1. Labetalol 2. Or nifedipine OR if neither labetalol or nifedipine --> methyldopa

Question 28

For women at high risk of pre-eclampsia - ensure what is prescribed:

Answer 28

75-150mg aspirin daily from 12 weeks gestation until birth

Question 29

Patients undergoing elective knee replacement should be given thromboprophylaxis - options include:

Answer 29

1. Aspirin 75mg or 150mg OD for 14 days 2. LMWH for 14 days w/ anti-embolism stockings until discharge 3. DOAC (e.g. apixaban, dabigatran or rivaroxaban)

Question 30

What are some indications that a patient may require fluid resuscitation?

Answer 30

RR > 20 breaths / minute HR > 90 beats / minute Systolic BP < 100mmHg Cool peripheries or CRT > 2 seconds 45 degree passive leg raise suggests fluid responsiveness

Question 31

NICE guidelines for fluid resuscitation

Answer 31

Sodium chloride 0.9% Hartmann's You want to use crystalloids which contain sodium in the range 130-154 Prescribe a bolus of 500mls over 15 minutes

Question 32

Patients at risk of fluid overload should be given what bolus of sodium chloride 0.9%

Answer 32

Given 250ml IV fluid bolus of NaCl 0.9% over 10 minutes

Question 33

NICE guidelines for routine maintenance fluids

Answer 33

25-30 mL/kg/day of water 1mmol/kg/day of potassium, sodium and chloride Approximately 50-100g of glucose to limit starvation ketosis

Question 34

Which antibiotic is known to increase the concentration of warfarin thus leading to increased INR and increased risk of bleeding?

Answer 34

CLARITHROMYCIN a potent CYP3A4 inhibitor

Question 35

Appropriate management for a patient with an increased INR? (INR = 8)

Answer 35

- Stop warfarin - administer phytomenadione - restart warfarin once INR < 5

Question 36

Why is warfarin withheld before surgery:

Answer 36

- long half time - need to allow time for INR to fall below **at least 1.4** by day of operation

Question 37

How can patients take medication if they are NBM?

Answer 37

can use 30mls of water to take regular medication that is being continued on the morning of the operation

Question 38

When prescribing LMWH what is it important to check in a patient?

Answer 38

- renal function - weight - full blood count

Question 39

Medication considerations in the post-operative period

Answer 39

1. Pain --> may lead to ileus, nausea and vomiting and immune suppression 2. Nausea and vomiting --> around 25% of patients experience one or both of nausea and vomiting in the post operative period 3. NBM --> intravenous fluids?

Question 40

Scoring system used to assess whether an anti-emetic needs to be considered in a patient in the post operative period?

Answer 40

APFEL SCORE 1 point for - female - smoker - history of post operative nausea and vomiting - motion sickness

Question 41

Considerations for a patient at discharge after surgery?

Answer 41

1. Pain relief 2. Anti-emetics 3. Laxatives 4. VTE prophylaxis 5. Regular medications

Question 42

What potential issues are there with prescribing ciprofloxacin:

Answer 42

- prolong QTc - can lower seizure threshold - can cause photosensitivity - can exacerbate myasthenia gravis

Question 43

If metformin alone is not controlling this patients blood glucose level; what options are available for treatment?

Answer 43

Metformin should be combined with one of the following: ***1. Sulphonylurea*** --> can cause hypoglycaemia --> moderate weight gain ***2. Pioglitazone*** --> increased risk of heart failure when combined with insulin --> risk of bladder cancer ***3. DPP-4 inhibitor*** --> associated with weight gain --> less incidence of hypoglycaemia ***4. SGLT-2 inhibitor*** --> when sulphonylureas are contraindicated --> slight risk of DKA