UMP

BRONCHOSCOPY EXPLANATION

Explain what the procedure is

Explain the reason for the procedure

Before

Oral intake

6 hours before – clear fluids (sips) only

2 hours before – NBM

Also if high-risk (e.g. transbronchial biopsy) depending on risk/benefit

- Stop clopidogrel 1 week before (unless high risk, e.g. drug-eluting stent)

- Stop warfarin 5 days before (± give LMWH)

- Stop DOAC 48 hours before

During

- Midazolam sedative (→amnesia)

- Lidocaine spray/gel to the nose, throat and windpipe

After

- No eating/drinking 2 hours after as throat still numb

- No driving, alcohol, operating machinery, or signing legal documents for 24 hours

- Keep someone with you for 24 hours

- Arrange follow-up

Risks

Lung damage/collapse

Infection

Bleeding (haemoptysis)

Sore nose/throat

Sedation side effects

Pneumothorax

OGD EXPLANATION

Explain what the procedure is

Explain the reason for the procedure

Before

Oral intake

6 hours before – sips of water only (sips)

2 hours before – completely NBM

Also

Stop acid suppressive medications 2 weeks before e.g PPI

During

Option of non-sedated or sedated

Lidocaine throat spray or midazolam sedative (→amnesia)

Continuous suction

Air passed through scope (→fullness, belching)

After

Arrange follow-up

If had throat spray: No eating/drinking 2 hours after as throat still numb

If had sedation: No driving, alcohol, operating machinery or signing legal documents for 24 hours

Keep someone with you for 24 hours

Risks

Perforation (<0.1%)

Bleeding

Infection (aspiration pneumonia)

Sore throat

Dental damage

Sedation side effects

COLONOSCOPY EXPLANATION

Explain what the procedure is

Explain the reason for the procedure

Before

Oral intake

2 days before – low fibre diet

1 day before – clear fluids only after light breakfast

2 hours before – NBM

Also

Sodium picosulfate sachet afternoon before and morning of the procedure (bowel prep_

Stop iron tablets 1 week before, and constipating agents 4 days before (e.g. codeine)

During

- Midazolam sedative (→amnesia)

- Digital rectal examination prior to scope insertion

- Air passed through scope (→bloating, you may feel like you need to go to the toilet)

After

No driving, alcohol, operating machinery, or signing legal documents for 24 hours

Keep someone with you for 24 hours

Arrange follow-up

Risks

Perforation (0.1%)

Bleeding

Infection

Abdominal discomfort

Sedation side effect

FLEXIBLE SIGMOIDOSCOPY explanation

Explain what the procedure is

Explain the reason for the procedure

Before

Oral intake

2 hours before – NBM

Also

Phosphate enema 2 hours before (can be self-administered at home)

During

Digital rectal examination prior to scope insertion

No sedation required

After

Arrange follow-up

Risks

Perforation

Bleeding

Infection

Abdominal discomfort

ERCP counselling

explain:

Camera test through mouth to check/treat bile & pancreas ducts (e.g. stones, blockages).

Before

* NBM 6 hrs.

* IV line for sedation ± antibiotics.

* Bloods, stop blood thinners if needed.

* Consent after risks/benefits explained.

During

* Sedation (relaxed but awake).

* Camera through mouth to small bowel.

* Dye + X-rays to see ducts.

* May remove stones, place stent, take sample.

* ~30–60 mins.

---

After

* Monitored in recovery.

* No food/drink until swallowing safe.

* Mild sore throat/bloating common.

* Report pain, fever, vomiting.

* Follow-up appointment

---

benefits

* Diagnose + treat in one test.

* Avoids surgery.

risks

* **Common**: infection, bleeding.

* **Rare**: Perforation, aspiration, death (<0.5%).

---

alternatives

* MRCP (scan only).

* Surgery** if ERCP not possible.

---

doing nothing

* Ongoing blockage → worsening of symptoms

RRT counselling

1. haemodialysis

- 4 hours 3 times a week come into hospital (significant impact on quality of life)

- fistula (unsightly)

side effects: itchy skin, fatigue, swelling

2. peritoneal dialysis

how it works: give fluid into tummy. There is a lining around your organs called the peritoneum. Blood gets filtered through the lining of the peritoneum and into the fluid. The waste fluid is then drained. The cycle is repeated.

- infection (peritonitis)

- need to do it your self

- weight gain

- blood sugar variation

3. renal replacement therapy

- risk of rejection

- need to find a donor, average wait is 3y

- average lifespan of a kidney is 10-15 years

general prescribing tips

- write mg out in full i.e micrograms

- with fluids - write out 0.9% sodium chloride instead of 0.9% NaCl or 0.9% saline

- if cancelling a medication, do a squiggly line and sign and date

Things to consider in prescribing patients with renal impairment

1. if there is reduced renal excretion, drugs stay in the body for longer -> need to decrease dose

2. whether the drugs cause further renal impairment

3. drugs which rely on the normal processes of the kidney to get them to their site of action become less effective

Things to consider in prescribing patients with hepatic impairment

1. whether the drugs cause further hepatic impairment

2. drugs which rely on being metabolised by the liver to active/inactive/toxic metabolites may not be metabolised as much with hepatic impairment

which drugs can common;y cause DIILD (drug induced interstitial lung disease?)

a lot but commonly:

1. nitrofurantoin

2. methotrexate

3. amiodarone

4. bleomycin

what happens if you take metronidazole and alcohol

also common side effect of metro

Metronidazole and alcohol can produce a disulfiram-like reaction

(cant drink alcohol on the metro

side effect: metallic taste in mouth

spironolactone side effect

gynaecomastia (bc it has anti-androgenic propreties)

importantly, NOT galactorrhea

metoclopramide and domperidone side effect

galactorrhea

(me=rhea)

what medications can cause sore gums

ciclosporin, amlodipine, phenytoin

phenytoin side effect

can cause acquired factor VIII deficiency as a side effect, leading to bleeding tendencies.

opioid overdose antidote

Naloxone

paracetamol overdose antidote

acute overdose (ingested in < 1 hour)

- if <1 hour since last ingestion

- consider activated charcoal if ingested >150 mg/kg

- 1-8 hours ingestion

- take bloods after 4 hours

- plot levels of paracetamol on nomogram

- if above line of concern: treat with NAC

- 8+ hours

- take bloods immediately

- if >150 mg/kg ingested or level of paracetamol is above nomogram,: start NAC

- 24 hours

- if presence of liver derangement (RUQ pain, deranged LFTs, jaundice, encephalopathy) - treat with NAC

staggered overdose (ingested in > 1 hour)

- start NAC immediately

- do bloods after 4 hours

- if results are unremarkable, NAC can be stopped. (senior review needed)

therapeutic excess - i.e an overdose without the intention of self harm

- start NAC if symptomatic

(NAC is not indicated if below nomogram UNLESS: uncertainty over timing of overdose, staggered overdose, unconscious patient)

how does NAC work

salicylate poisoning antidote

there is no antidote! so should be managed supportively

can consider:

1. IV fluids

2. activated charcoal

3. potassium replacement

4. sodium bicarb

what happens in an aspirin overdose

initially a respiratory alkalosis followed by a metabolic acidosis. Tinnitius can also be a feature

TCA overdose therapy

IV sodium bicarbonate

ethylene glycol toxicity management =

fomeprizole

DOAC reversal (e.g apixaban, rivaroxaban)

andexanet-alfa

dabigatran reversal

Idarucizumab

dapagliflozin - what is a side effect in diabetics

can cause euglycaemic hyperosmolar ketoacidosis

drugs that predispose to gout

gout vs pseudo gout

what fluids do you give to someone who is nil by mouth (NBM

THIAZIDE DIURETICS effects, also what can it worsen?

hyponatremia, hypokalaemia, hypercalcemia,

Thiazide Takes back calcium (into the blood)

Loop diuretic Loses calcium (into the urine)

TZDs can worsen glucose tolerance

CALCIUM CHANNEL BLOCKERS side effect

gingival hyperplasia

P450 INDUCERS

"CRAPGPS"

Carbamazepine

Rifampicin

Alcohol (chronic use)

Phenytoin

Griseofulvin

Phenobarbital

Sulfonylureas

INDUCE RAGE

P450 INHIBITORS

"SICKFACES.COM"

Sodium valproate

Isoniazid

Cimetidine

Ketoconazole

Fluconazole

Alcohol (acute use)

Chloramphenicol

Erythromycin (and macrolides)

Sulfonamides

Ciprofloxacin

Omeprazole

Metronidazole

ACE inhibitor side effect

angioedema! can present even after a year.

tetracyclines side effect

black hairy tongue

risk of taking DAPT and NSAIDs

peptic ulcers and then GI bleed

types of antiemetics

5-HT3 antagonists: ondansetron

D2 antagonists: metoclopramide, prochlorperazine

H1 antihistamines: promethazine, cyclizine

complication of taking antiemetic

with metoclopramide and prochlorazine

a complication can be an oculogyric crisis

- eyes roll upwards

- mouth opens

- tongue protrudes

treated with procyclidine

amiodarone complication

thyrotoxicosis

drug counselling tips

first ask about condition

lifestyle factors

STATINS side effect, when to take

- musculoskeletal: rhabdomyolysis, myalgia

- Gastrointestinal: nausea, vomiting, elevate liver enzymees

take at night to maximise effect!

- contraindicated in pregnancy?

when should steroid be withdrawn gradually?

the BNF suggests gradual withdrawal (i.e over weeks) of systemic corticosteroids if patients have:

- received more than 40mg prednisolone daily for more than one week

- received more than 3 weeks of treatment

- recently received repeated courses

METHOTREXATE antidote to overdose

folinic acid

ACE INHIBITOR drug counselling

ACTION

works to relax and widen blood vessels

TIMING

taken once a day, usually in the morning

HOW TO TAKE IT

tablet taken with water

LENGTH OF TREATMENT

usually long-term

EFFECTS

preserves kidney function

reduces blood pressure

helps with management after a heart attack or stroke

TESTS

check kidney function

regular home BP monitoring

IMPORTANT SIDE EFFECTS

can initially cause some dizziness

nausea, vomiting

CONTRAINDICATIONS

history of angioedema

pregnancy

try to limit nsaid use

SUMMARISE, SAFETY NET AND LEAFLET

lifestyle factors cmon

BISPHOSPHONATE drug counselling

ACTION

prevents bone from breaking down, and also rebuilds new bone

TIMING and HOW TO TAKE IT

- take as a tablet with water weekly (for alendronate and risedronate). for zoledronate its an annual infusion

- 30 mins before eating

- sit up straight for the 30 minutes

LENGTH OF TREATMENT

long-term

can have drug holiday after 5 years after doing DEXA

EFFECTS

will help to reduce risk of osteoporotic fractures

TESTS

regular dental check ups required (for osteonecrosis of the jaw), renal function tests

IMPORTANT SIDE EFFECTS

- oesophagitis

- osteonecrosis of the jaw

- Gi (nausea, vomiting, constipation)

- atypical stress fractures

CONTRAINDICATIONS

- pregnancy

- unable to sit upright for 30 minutes

- renal impairment

SUPPLEMENTARY INFO

lifestyle factors also important!

DOAC drug counselling

A

works to thin blood

T

tablet taken once daily

H

- take with glass of water

- sit upright

L

for VTE - 3/6 months. For AF - lifeliong

E

prevents clot formation

T

before starting renal function tests. And then renal function tests annually

I

- GI disturbance

- bleeding (safety net: if severe bruising, head injury, prolonged epistaxis then seek medical advice)

C

- current bleeding

- risk of major bleeding

- renal impairment

- pregnancy?

S

none

INSULIN drug counselling

ACTION

works by replacing normal insulin which helps glucose be absorbed from the bloodstream into cells

TIMING

HOW TO TAKE IT

there are different insulin regimens e.g injection into thigh

LENGTH OF TREATMENT

long-term

EFFECTS

TESTS

CBG should be done before each meal

IMPORTANT SIDE EFFECTS

- weight gain

- sharps injuries

- hypoglycaemic / hyperglycaemic episode (safety net for symptoms such as confusion)

CONTRAINDICATIONS

none

SUPPLEMENTARY INFO

none

IRON TABLETS counselling

ACTION

works by replacing iron levels, helps body make RBC

TIMING

works best if taken before food, however most people take with food due to GI irritation

HOW TO TAKE IT

taken as a tablet or syrup- dose can vary from 1-3 times a day, or on alternate days

LENGTH OF TREATMENT

long-term

EFFECTS

will help with iron deficiency symptoms

TESTS

Hb 3-4 weeks after starting tablets to assess response

IMPORTANT SIDE EFFECTS

GI irritation

metallic taste

black/green stools

CONTRAINDICATIONS

none

SUPPLEMENTARY INFO

none

LEVODOPA drug counselling

ACTION

- increases dopamine

TIMING AND HOW TO TAKE IT

- take as a tablet 3-4 times daily with food

- given with carbidopa

LENGTH OF TREATMENT

- long term

EFFECTS

TESTS

IMPORTANT SIDE EFFECTS

- nausea

CONTRAINDICATIONS

SIDE EFFECTS

- nausea

- postural hypotension

LEVOTHYROXINE drug counselling

ACTION

works by replacing normal thyroid hormone

TIMING

every day before breakfast on an empty stomach

HOW TO TAKE IT

LENGTH OF TREATMENT

long-term

EFFECTS

will help with hypothyroid symptoms

TESTS

TSH testing every 2-3 months until stable. Once stable, TSH testing annually

IMPORTANT SIDE EFFECTS

if dose too high: hyperthyroid symptoms

if dose too low: hypothyroid symptoms

CONTRAINDICATIONS

none

SUPPLEMENTARY INFO

METHOTREXATE drug counselling

ACTION

disease modifying drug, helps to suppress immune system

TIMING

HOW TO TAKE IT

- once weekly tablet. Take folic acid on another day

- take on same day each week

LENGTH OF TREATMENT

long-term if effective

EFFECTS

TESTS

- Bloods before starting

- Bloods every 2 weeks until therapy stabilised

- Once stabilised, bloods every 2 months

IMPORTANT SIDE EFFECTS

- alopecia

- GI disturbance

- headaches

- liver and lung toxicity

CONTRAINDICATIONS

- pregnancy - should stop 6 months before conception (so should men)

- breast feeding

- liver impairment

SUPPLEMENTARY INFO

STATINS drug counselling

A – Action

Lowers cholesterol → reduces risk of heart attack/stroke.

T – Timing

Take once daily, usually at night. If miss a dose take straight away. Don't double

H – How to take it

Swallow with water, with or without food.

L – Length of treatment

Long-term (usually lifelong).

E – Effects

Lowers cholesterol, reduces cardiovascular risk.

T – Tests

Monitor liver function and cholesterol via blood tests.

I – Important side effects

Muscle pain, fatigue, GI disturbance, rhabdo, liver dysfunction (rare).

C – Contraindications/Complications

Avoid excess alcohol; beware of drug interactions.

S – Supplementary advice

Lifestyle changes (diet, exercise) enhance effect.

STEROIDS drug counselling

A – Action

Anti-inflammatory & immunosuppressive.

Replaces steroids called cortisol which we normally produce.

L – Timing

Take once in the morning. If missed, take ASAP. Don’t double.

T – How to take it

With/after food. Swallow with water.

H – Length of treatment

Short or long-term. Taper if long-term.

E – Effects

Reduces symptoms & flare-ups.

T – Tests

Monitor BP, glucose, weight, bone, adrenal function.

I – Important side effects

Short-term: insomnia, mood changes, increased appetite, indigestion.

Long-term: osteoporosis, diabetes, Cushingoid features, infection risk, adrenal suppression

C – Contraindications/Complications

Caution in DM, HTN, ulcers, infections. No live vaccines.

S – Supplementary advice

Carry steroid card. Don’t stop abruptly. Follow sick day rules. Bone protection if long-term.

SICK DAY RULES

- must increase steroid dose (to mirror normal physiological increase in steroids when ill)

WARFARIN drug counselling

A - Action

Vitamin K antagonist. Vitamin K part of clotting cascade. Prevents clotting

T - Timing

Oral tablet once daily

initially given with heparin for 3-5 days

H - How to take it

In evening

L - Length of treatment

Can be lifelong

E - Effects (benefits)

Prevention of clotting

T - Tests

INR -

once a day for a week,

then once a week

once stable - once every 3 months

I - Important side effects

- N/V

- bleeding, bruising, dark stools

C - Complications/Contraindications

- keep a warfarin yellow book

- avoid eating leafy greens, cranberry juice

- if miss a dose, take another within 24 hours. Dont double dose on a day

- If you miss for more than 2-3 doses, contact doctor

- tell doctor you are on warfarin before having a procedure

S - Summary

- summarise

- leaflet

- safety net.

ANAPHYLAXIS prescribing

0.5 mg OR 0.5 mL 1:1000 IM STAT

ANALGESIA prescribing

ASTHMA prescribing

STAT

- salbutamol 5mg NEB

- prednisolone 40mg PO (40 = asthma dose, 30 = COPD dose)

- ipratropium bromide (500 micrograms) NEB (if severe)

dont think you can give: (magnesium sulfate 2g IV (if severe))

PRN - always give indication here

- salbutamol 5mg NEB every 15-30 mins

- ipratropium bromide (500 micrograms) NEB (if severe)

QDS max frequency is 6 times daily

REGULAR

- Prednisolone 40mg PO for 5 days

if severe:

- oxygen

ASTHMA BURST therapy prescribing

COPD prescribing

STAT

- salbutamol 5mg NEB

- prednisolone 30mg PO (40 = asthma dose, 30 = COPD dose)

- Ipratropium 250micrograms or 500micrograms NEB

PRN - always give indication here

- salbutamol 5mg NEB

REGULAR

- Prednisolone 30mg PO

ANTI-INFECTIVES

500mg amoxillin TDS

if severe:

- oxygen via venturi mask. target range - 88-92 if co2 retainers

RENAL COLIC prescribing

1. diclofenac sodium - STAT, 75mg, IM

2. metoclopramide - PRN, 10mg, PO, TDS

NSTEMI prescribing

STAT

1. morphine 10mg PO or 5mg IV

2. metoclopramide (for morphine) - 10mg IV

2. oxygen if sats < or equal to 94%

3. Glyceryl trinitrate: 2 puffs, sublingual

4. aspirin 300mg PO

5.

- clopidogrel 300mg PO

- prasugrel 60mg PO

- ticagrelor 180mg PO

REGULAR

fondaparinux 2.5mg PO OD

HYPERKALAEMIA prescribing

STAT

Calcium Gluconate 10% 10 mL (stabilises cardiac membranes)

Salbutamol 10mg NEB (moves K+ into cells)

INFUSIONS

Dextrose 50% 50mL with inulin (actrapid) 10 units

PULMONARY OEDEMA prescribing

Furosemide 40mg PO OD

Morphine

N - GTN

O - oxygen

Position sit up straigh

DKA prescribing

the actrapid should be within 50mL sodium chloride

it should be given at 0.1 units/kg/hour and you alwasy give 50 units

HHS prescribing

IL 0.9% sodium chloride over 1 hour

also VTE prophylaxis due to hypervisvosity

STEMI prescribing

STAT

1. morphine 10mg PO or 5mg IV

2. metoclopramide (for morphine) - 10mg IV

2. oxygen if sats < or eual to 94%

3. Glyceryl trinitrate: 2 puffs, sublingual

4. aspirin 300mg PO

5.

- clopidogrel 300mg PO

- prasugrel 60mg PO

- ticagrelor 180mg PO

PNEUMONIA (community acquired) prescribing

depends on CURB 65 score

1. mild (0.1)

Amoxicillin 500mg, PO, TDS for 5 days

2. moderate (2)

Amoxicillin 500mg, PO TDS for 5 days

if pen allergic: Clarithromycin 500mg, PO BD for 5 days

if atypical suspected:

Amoxicillin 500mg, PO TDS for 5 days

+ Clarithromycin 500mg, PO BD for 5 days

3. severe (3 or more)

- Co-amoxiclav 1.2g IV TDS (every 8 hours) WITH clarithromycin 500mg PO BD

NEUTROPENIC SEPSIS prescribing

ANTI-INFECTIVE: piperacillin with tazobactam 4.5g IV every 6 hours for 48 hours

after that change to vancomycin or meropenem

VTE PROPHYLAXIS prescribing

enoxaparin SC 40mg OD

in thromboprophylaxis section!!

OR

in renal impairment

5000 units unfractionated heparin BD (every 8-12 hours)

PERI-OP prescribing

FLUIDS - maintenance]

2 sweet 1 salty

5% dextrose 500mL with 20mmol potassium chloride 8h

5% dextrose 1000mL with 40mmol potassium chloride 8h

0.9% sodium chloride 500mL with 20 mmol potassium chloride 8h

THROMBOPROPHYLAXIS

ENOXAPARIN 40MG SUBCUT OD

REGULAR

Senna

15mg, PO ON

Omeprazole

20mg, PO OD

Paracetamol

1 gram, PO, QDS, max 4g a day

Cyclizine

50mg, PO, max 3 times a day

PRN - always put reason why

Morphine

10mg, PO, max dose every 4 hours

FT SOP MC

FLUIDS prescribing

daily requirement

Na+/K+ = 1 mmol/kg/day

water = 25-30 mL/kg/day

Glucose = 50-100g/day

in 1L of 0.9% NaCl - 154 mmol of Na and Cl

In 1L of Dextrose 5% - 50g of glucose

dont give more than 10 mmol per hour for K+

POST STROKE

1. atorvastatin

2. ramipiril

3. bisoprolol

4. aspirin

5. clopidogrel

how to stop a medication

1. put a clear line

2. name

3. signature

4. reason for stopping