pharmacology 2* 1
Which Gene Mutation causes Congenital Insensitivity to Pain
SCN9A
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What is the Treatment of Pain to reduce Tissue Damage (3)
1) NSAIDs
2) Steroids
3) Cooling
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What is the Treatment of Pain which acts at the Spinal Cord
1) Opioids
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What is the Mechanism of Action for Paracetamol
Inhibits the Synthesis of Prostaglandins
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What do Cyclo-Oxygenase do
COX is a group of enzymes that generate inflammatory mediators such as Prostaglandin and Thromboxane
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What are the Adverse Effects of NSAIDs on the Cardiovascular System
As a result of Altered Renal Function, Fluid Retention can precipitate heart failure
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Newer NSAIDs are COX2 Inhibitors only. Why is this more beneficial
COX2 Only Inhibitors can cause less bleeding as GI Tract and Platelets have mainly COX1
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List 5 NSAIDs which are more specific and selective for COX2
1) Ibuprofen
2) Naproxen
3) Diclofenac
4) Parecoxib (NEW)
5) Celecoxib (NEW)
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NSAIDs that are COX2 Inhibitors are not recommended to patients who are at risk of Cardiovascular Disease.
Explain Why (3)
1) Absence of Antiplatelet effects
2) Slightly pro-thrombotic
3) Increased Risk MI and Stroke
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How many days prior to Elective Surgery due NSAIDs need to be stopped
5 Days
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What are the effects of Weak Opioids on Cardiovascular Systems (5)
1) Reduced Sympahtetic Outflow
2) Increased Vagal Tone
3) Bradycardia
4) Hypotension
5) Excitation
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What are the effects of Weak Opioids on Respiratory System (2)
1) Inhibits Cough Reflex
2) Respiratory Depression
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Opioids create Analgesia at the Spinal Cord and Brainstem.
Explain how Analgesia is caused in these two areas
Analgesia at the Spinal Cord is caused by reduced pain fibre transmission to Kappa Opioid Receptors
Analgesia at the Brainstem is caused by reduced pain projection to higher centres by Mu Opioid Receptors
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How is the effect of Opioids reversed
Nalozone 400mcg I.V
Dramatic Reversal of MU Receptor Opioid Effects.
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Any Chronic Opioid Medication will precipitate some withdrawal reaction if suddenly stopped
What is the effect of Acute Withdrawal of Opioids after long term use (7)
1) Hypertension
2) Tachycardia
3) Tachypnoea
4) Diarrhoea
5) Sweating
6) Anxiety
7) Hallucinations
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What is Tramadol and Nefopam
Newer Oral Opioids
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For Post Operative Analgesia, Morphine Patient Controlled Analgesia can be used.
What is the Procedure
1) Syringe Driver Intermittent IV Bolus delivery initiated with by patient
1mg minimum frequency every 5 minutes.
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What is the treatment for Sever Chronic Pain
Oral Morphine Syrup or Tablets
Morphine S.C
Diamorphine S.C
Fentanyl Transdermal Patch that lasts 5 Days for constant and slow release
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Why are Co-Analgesics used alongside Analgesics
To increase the likelihood of pain relief
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List Two Medications effective for Chronic Neurogenic Pain
1) Gabapentin
2) Pregabalin
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List Antidepressant Drugs (3)
1) Amitryptiline
2) Duloxetine
3) Citalopram
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What is the Peak Concentration
Maximum Serum Concentration that drugs achieve in an area of the body.
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What factors affect the Distribution of Drugs in Elderly.
(4)
Elderly Patients have reduced
1) Lean Body Mass
2) Body Water
3) Serum Albumin
4) Kidney Weight
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What are the effects of a Reduced Lean Body Mass on the Volume of Distribution of Drugs
Reduced Volume Distribution for Drugs that bind to Muscle (Digoxin)
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What does Albumin do?
Albumin helps keep fluid in your bloodstream so it doesn't leak into other tissues. It is also carries various substances throughout your body, including hormones, vitamins, and enzymes
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Capacity of the Liver to Metabolise Drugs does not appear to decline consistently for all drugs.
During Which Phase of the Metabolism Reaction do most Metabolic Changes occur
Phase I Reaction (P450)
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What are the causes of Metabolic Changes in the Phase I Reaction (P450)
(5)
1) Decrease Blood Flow in the Liver
2) Decrease Liver Mass
3) Decline of Liver's Ability to Recover from Injury
4) Malnutrition
5) Diseases affecting Hepatic Functions i.e. Heart Failure
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What happens in Phase I Metabolism
Phase I: Modification
Oxidation, Reduction, Hydrolysis.
Converts Drugs into Metabolites to facilitate excretion.
Hepatic Clearance of Drugs Metabolised by Phase I Reactions is more likely to be prolonged in the elderly
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What happens in Phase II Metabolism
Phase II: Conjugation
Adds charged species (Glutathione, Sulfate, Glycine), making Drugs ready for Excretion
Medications undergoing Phase II Hepatic Metabolism are generally preferred in the elderly due to inactive metabolites.
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What is the difference between Phase I and Phase II Reactions
Phase I reactions convert Drugs to Active Metabolites.
Phase II Reactions Adds charged species to drugs so drugs become ready to be excreted and form inactive metabolites.
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Why is there an Age Related Decrease of Kidney Function?
Creatine Clearance decreases in 2/3 of population. However we also get an increase in Creatine as Muscle Mass Decreases in Elderly
this results in Prolongation of Drugs Half Life and Possible Accumulation to Toxic Level if Dose not modified.
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What are the effects of Analgesics on Ageing on Pharmacodynamics
Increased Level and Duration of Pain Relief
Drug taking longer to be expelled from the body
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What are the causes of Drug-Drug Interactions (5)
1) Increased or Decreased Drug's Absorption
2) Additive Effects due to Similar Effects of Drugs
3) Antagonizing Effects due to opposite effects of drugs
4) Changes in Drug Metabolism
5) Duplication of Drug Therapy
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What is the Risk of Taking ACE Inhibitor and Potassium
Hyperkalemia
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What is the effect of Dementia on Drugs
Dementia can increase sensitivity to drugs with CNS or Anticholinergic Activity (Paradoxical Reactions)
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What is the risk of Taking Alpha Blockers and Anticholinergics together
Urinary Retention
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What are the Principles of Prescribing in Elderly
Start with a Low Dose and Titrate Slowly
Avoid Starting 2 Agents at the Same Time
Reach Therapeutic Dose before Switching or Adding Agents
Determine Therapeutic Endpoints and Plan for Assessment
Avoid Prescribing to Treat Side Effect of Another Drug
Use 1 Medication to Treat 2 Conditions
Consider Drug-Drug and Drug-Disease interactions
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What is the Effective Time Limit of Sedatives
Less than 2 hours. If we need prolonged Sedation, we will need to add more Anaesthetics.
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What is Anxiolysis
A level of sedation in which a person is very relaxed and may be awake. The person is able to answer questions and follow instructions.
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What Drugs are Available for Sedation (5)
1) Alcohol
- Disinhibition, Nausea
- Slow Recovery
2) Tetrahydrocannabinol (THC)
- Nausea
- Illegal
3) Opiates
- Euphoria (state of intense happiness and self-confidence), Nausea, Respiratory Depression
4) Major Tranquilisers: Chlorpromazine, Haloperidol
- Profound Anxiety & Hypotension
5) Minor Tranquillisers: Benzodiazepines
- Drowsiness
- Prolonged Effect
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Give an Example of a Minor Tranquiliser
- Benzodiazepine
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What is Propofol
a short-acting medication that results in a decreased level of consciousness and a lack of memory for events.
Its uses include the starting and maintenance of general anesthesia, sedation for mechanically ventilated adults, and procedural sedation
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What is the Process of General Anaesthesia (4)
1) Induction
- Rapid Pleasant Production of Unconsciousness
2) Secure Airway
- Optimum Head Position
- May need Laryngeal Mask Airway or Endotracheal Tube
3) Maintenance
- Gas or IV
- Analgesia
+/- Muscle Relaxant
4) Emergence
+/- reversal of muscle relaxation
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What are the 4 different types of IV General Anaesthetic
1) Propofol
2) Thiopentone
3) Ketamine
4) Etomidate
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List 5 Muscle Relaxants used to overcome Laryngeal Reflexes
1) Suxamethonium
2) Atracurium
3) Cisatracurium
4) Rocuronium
5) Pancuronium
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What are the Side effects of Muscle Relaxants
1) Depolarising
2) Muscle Pain
3) Occasional Prolonged Paralysis
4) Malignant Hyperthermia
5) Histamine Release
6) Hypotension
7) Slow Onset
8) Tachycardia
9) Renally Excreted Unchanged
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What Patient Factors can cause complication during an Operation
Pre Existing Disease
1) Cardiac
- Aortic Stenosis
- Coronary Artery Disease
2) Respiratory
- COPD
- Asthma
3) Diabetes
- Associated with Renal and Cardiovascular Pathology
Past Medical History
- Drugs, Allergies
- Previous GA, any problems>
- Respiratory Obstructive Diseases and Restrictive Disease
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What are the signs of Haemorrhage post surgery (4)
1) Falling Blood Pressure
2) Increased Heart Rate
3) Suction container full of blood
4) Loads of wet swabs being piled in a corner
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What are the NICE Guidelines for Medical Prescriptions for Dental Abscesses
If the Patient has a Dental Abscess:
- Amoxicllin 500mg tds for 5/7days
- Penicillin V 500mg qds for 5/7 days
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What considerations should be made before prescribing Antibiotics (5)
1) Are Antibiotics Necessary
2) What is the site of Infection
3) What is the Organisms Sensitivity
4) What is the appropriate or available route of administration
5) What Antibiotics are safe for the patient
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What are the general signs of Severe Infection
- Fever
- Lymphadenopathy
- Cellulitis
- Diffuse Swelling
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What are the signs of Systemic Infections
- Fever
- Malaise
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If you do not expect the pathogen to have entered the bloodstream, Describe Local Tests that could be done to isolate the pathogen
Local Tests via Needle Aspiration to collect Pus.
Pus is then sent off to the lab and then gram stained to identify the pathogen.
After 2/3 days you will know exactly what the pathogen is and what the antibiotic sensitivities are. This is useful as you can then amend your treatment plan.
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What is an Empiric Antibiotic
Prescription of an Antibiotic based on what usually causes these infections. It is a guess and the first choice of antibiotic.
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Before prescribing Antibiotics you also need to consider Differential Diagnoses.
Dental Abscesses may not always be caused by Infection. List other possible causes
- Localised Lymphadenopathy due to other inflammation or neoplasm
- Salivary Stone
- Parotitis
- Unerupted Tooth
- Mumps (Viral)
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What organism causes Pharyngitis
S.Pyogenes (Group A Streptococcus)
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What organism causes Dental Abscesses
Viridan Group Streptococci
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When we are trying to treat infection, the site of infection must be considered.
What considerations should be made about the site of infection
- What is the pH of the site
- Is the antibiotic lipid soluble
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What is Primary Resistance of Antibiotics
Some bacteria will be resistant to some antibiotics automatically.
For example:
Pseudomonas are automatically resistant to Peniciilin and Aerobic Bacteria are not susceptible to Metronidazole
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What is Acquired Resistance of Antibiotics
- Due to Mutation or Horizontal Gene Transfer.
- The bacteria started off sensitive to an antibiotic but a mutation caused the offspring to be resistant
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How do we test Antibiotic Sensitivity
- Dilutional Liquid Culture (MIC and MBC)
- Antibiotic Discs
- e-Tests
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How are Chromogenic Plates used to detect Antibiotic Resistance/Sensitivity
Chromogenic Plates has lots of enzyme in it. If a resistance bacteria is grown, the enzymes will cause a colour change indicating the bacteria is there. Either Blue or Pink
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Lowest MIC = Best Antibiotic
True or False
False
The MIC in the Lab is not a complete indicator of whether the antibiotic with the lowest MIC is the one to use.
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How much Antibiotic Do you need?
Drug must attach to the binding target but also occupy an adequate number of binding sites and for a long time.
These factors are related to the concentration of antibiotic needed
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What is Concentration Dependent Killing
How High the Concentration is above MIC
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What is Time Dependent Killing
The time that serum concentrations remain above the MIC during the Dosing Interval
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What is the Appropriate Treatment for Pharyngitis
- Penicillin V
- Oral
- Every 6 Hours
- 10 days
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Which Antibiotics may promote Clostridium Difficile Infections (5)
- Ciprofloxacin
- Clindamycin
- Cephalosporins
- Co-amoxiclav
- Carbapenems