Miscellaneous For Finals

Hannah Cooke, 2016/17
Miscellaneous for Finals

Microbiology and Antibiotics
Basic Microbiology
Gram positive bacteria stain purple/ blue due to the presence of peptidoglycan in the cell wall.
These typically lead to chest and skin infections
- Gram positive cocci include staphylococcus and streptococcus

o Staphylococci are bunched and include S.aureus (coagulase positive) and other
forms that are coagulase negative
o Streptococci form chains and include -haemolytic (pneumonia) -haemolytic
(pyogenes) and -haemolytic forms (enterococci)
- Gram positive rods include listeria and clostridium
Gram negative bacteria stain red/ pink. These typically lead to GI infections and UTI
- Gram negative cocci are Neisseria strains

- Gram negative rods are mainly found as gut flora or lead to bowel infections
o Enterobacteria include E.coli, proteus, and klebsiella
Beta-Lactam Antibiotics
Penicillins, cephalosporins and carbopenems are all Beta-lactam antibiotics
- These are a common cause of drug allergy, and can lead to anaphylactic shock
- Cephalosporins and carbopenems may not necessarily lead to a reaction in someone
penicillin allergic, but there is a ~10% chance
Many of the Beta-lactam antibiotics be considered “broad-spectrum” due to their activity against
both gram positive and gram negative bacteria
Penicillins
In order of increasing spectrum, penicillins include
- Penicillin V
- Benzylpenicillin
- Amoxicillin
- Flucloxacillin
- Co-amoxiclav (augmentin – amoxicillin and clavulanic acid)
- Tazocin (pipperacillin/tazobactem)
Penicillin can be used in conjunction with a β-lactamase inhibitor, to overcome bacterial resistance
through β-lactamase release
Cephalosporins
In order of increasing spectrum, cephalosporins include
- Cefuroxime
- Ceftriaxone
- Cefalexin
There are four generations of cephalosporins that have been developed, earlier classes are generally
better for gram positive and later generations gram negative
Carbapenems
In order of increasing spectrum, carbapenems
- Meropenem (NB: C.diff risk)

- Etrapenem
Macrolides
Macrolides are used where there is penicillin hypersensitivity. They are broad spectrum antibiotics,
however they are generally less effective than penicillins and therefore second-line
- Erythromycin
- Clarithromycin
- Clindamycin (NB: C.diff risk)
Quinolones
The commonest quinolones are ciprofloxacin and levofloxacin
- Ciprofloxacin is effective against Gram –ve organisms and is therefore used in gastroenteritis
and pyelonephritis
- Levofloxacin is effective in Gram +ve chest infections
Tetracyclines
Tetracyclines include
- Doxycycline, this is most commonly used in atypical chest infections e.g. COPD exacerbation
- Tetracycline, this is used for oral infections
These cannot be given to children, as they can penetrate into bone and teeth, blackening them
Aminoglycosides
Aminoglycosides are used in Gram –ve infections, they are IV preparations due to their narrow
therapeutic window (nephrotoxic and ototoxic)
- Gentamycin
Glycopeptides
Glycopeptides, like aminoglycosides, are nephrotoxic and therefore the two should not be used
together
- Vancomycin is a glycopeptide, and is used to treat C.diff and MRSA
Metronidazole
Metronidazole is used in anaerobic infections
- Alcohol cannot be ingested alongside metronidazole
Specific Guidelines
Infection Antibiotic(s) Dose

C.difficile Metronidazole AND 400mg TDS 14/7
Vancomycin 500mg QDS 14/7
MRSA Vancomycin 1g BD (IV)
(Nasal mupirocin and chlorhexidine
wash)
S.aureus Flucloxacillin 500mg QDS 5/7
Streptococci Penicillins
Bacteroides Metronidazole
(anaerobes)
Gut Coliforms Ciprofloxacin
Gentamycin
Cephalosporins
UTI Nitrofurantoin 1st 50mg TDS 3/7
Trimethoprim 2nd 200mg BD 3/7
Ciprofloxacin if ascending 500mg BD 1/52
LRTI Co-amoxiclav AND 625mg TDS 5/7
Clarithromycin 500mg BD 5/7
Sepsis Tazocin 4.5g TDS (IV)
Anti-Coagulants
There are several blood tests used to assess the efficacy of clotting, this is known as the clotting
screen
- FBC, specifically looking at platelet count

- Prothrombin Time (PT), expressed as INR
o This assesses the extrinsic clotting pathway (factors I, II, V, VII, X)
o It can be prolonged in liver failure, vitamin K deficiency, DIC, and warfarin treatment
o Normal INR: 0.8 – 1.2
- Activated Partial Thromboplastin Time (APTT)
o This assesses the intrinsic clotting pathway (factors I, II, V, VIII, IX, X, XI, XII)
o It can be prolonged in liver failure, DIC, haemophilia, and heparin treatment
o Normal APTT: 29 – 42 seconds

- Thrombin Time
o This can be prolonged in DIC, disorders of fibrin/fibrinogen, and heparin treatment
o Normal TT: 14.5 – 18.5 seconds
Additional tests where indicated can include
- D-dimers
o D-dimers are a fibrin degradation product
o It can be raised in PE, DVT and DIC
- Bleeding time
o This assesses platelet function, but is rarely performed
- Factor VIII assay
Anti-Platelets
Antiplatelet drugs should be stopped 7 days prior to elective surgery to reduce the risk of bleeding
Aspirin
Aspirin is a COX inhibitor. Its use as an anti-platelet is generally in primary and secondary prevention
of cardiovascular disease
- 75mg OD is a typical dose for angina, previous MI, previous TIA or stroke, peripheral arterial
disease
- 75mg OD in primary prevention may be recommended for patients with diabetes >50, or
CVD disease risk >20%
300mg aspirin is used acutely in ACS and ischaemic CVA
Cautions and contraindications include
- Children <16, due to the risk of Reye’s syndrome

- Peptic ulceration
- Haemophilia and other bleeding disorders
- NSAID sensitive asthma
- Severe renal failure
It is important to warn patients taking aspirin of the symptoms of GI bleeding, advise them to take
the medication with food, and co-prescribe a PPI
ADP Receptor Antagonists
Clopidogrel and prasugrel are ADP receptor antagonists
- Their use is primarily during PCI and post-ACS for 12 months

- Clopidogrel is more commonly used
Clopidogrel is given at 300mg initially prior to PCI, and at 75mg OD for secondary prevention
Prasugrel is given at 60mg initially prior to PCI, and at 10mg OD for secondary prevention
Ticagrelor
Ticagrelor is an antiplatelet with the same indications as ADP receptor antagonists
- 180mg initially, then 90mg BD
GP IIb/IIIa Antagonists
Abciximab is rarely used, requiring IV admission under specialist supervision (usually in a CCU
setting)
Heparin
LMWH is given as a subcutaneous injection
- Enoxaparin (clexane) and dalteparin are examples

- 20 – 40mg OD
UFH can be given as a subcutaneous or intravenous injection
- When giving patients IV heparin infusion, measure APTT every 4 – 6 hours

Warfarin
Warfarin is a vitamin K antagonist, and takes 2 – 3 days to exert its full effects
Monitoring of INR in patients on warfarin must occur regularly. This can be undertaken by the
patient themselves using a finger-prick blood test where the patient does not have time to attend
anti-coagulant clinics
- Twice a week for 1 – 2 weeks

- Weekly until stable
- Every 6 – 12 weeks when stable
When a patient is initially prescribed warfarin, they should be given the following advice
- Take the prescribed dose at the same time every day

- Report any bruising or bleeding immediately
- Avoid pregnancy as warfarin is teratogenic
- Avoid NSAIDs and aspirin, use paracetamol as an analgesic
- Avoid activities with a high risk of injury. Do not prescribe warfarin to patients with a high
falls risk
- Remind all medical and dental carers of warfarin use
- Avoid heavy alcohol use and cranberry juice
Where a patient on warfarin has life-threatening bleeding, the anticoagulant effect of warfarin can
be reversed using IV infusions of the following
- Vitamin K 10mg slowly

- Beriplex (Prothrombin complex) 50 units/kg (or FFP 15mg/kg)
Where bleeding is minor, give 2mg vitamin K IV
If the patient has INR >8 without bleeding, stop warfarin and give oral vitamin K 2.5mg. Check INR
after 24 hours, and re-start warfarin at a lower dose when INR <5.0
- If INR is 6 – 8 stop warfarin and re-start when INR <5

- If INR is 4.5 – 6 give a lower dose of warfarin
Warfarin should be stopped 5 days prior to elective surgery where it is determined that the risk of
bleeding is greater than the risk of thrombosis
- Dalteparin bridging can be used to anticoagulate in the interim period before surgery
- In emergency surgery give beriplex, or if surgery can be delayed >6 hours, IV vitamin K
Doses
Indication Target INR

PE, DVT 2–3
Recurrence of DVT whilst on warfarin 3–4
AF 2–3
Artificial aortic valve 2.5 – 3.5
Artificial mitral valve 3–4
Where a patient requires rapid anticoagulation, a loading dose of 5 – 10mg is recommended,

titrating to achieve target INR. Where there is no need to anticoagulate rapidly e.g. AF, an initial
dose of 2 – 3mg is recommended, this will take several weeks to achieve target INR
- When giving patients a loading dose of warfarin it is important to cover with LMWH/heparin
infusion for the following reasons
o Warfarin takes a while to begin working
o Initial doses of warfarin transiently make the patient more hypercoagulable
The colour of the warfarin tablet indicates the dose
Novel Oral Anticoagulants
NOACs include rivaroxaban, apixaban, and dabigatran
- These do not require regular monitoring of INR, but do not have any reversible agents to use
in bleeding
- All but dabigatran work as factor X inhibitors (ban Xa)
NOACs are not licensed for all of the indications of warfarin, but can be used in the following
conditions
- AF
- VTE prevention post-operatively

- VTE treatment (rivaroxaban only)
Pain Management
There are two main types of pain fibres in the nervous system, both synapse with second order
neurones in the dorsal horn with considerable plasticity – this is described as the ‘gate control’
theory of pain
- C fibres are unmyelinated and transmit dull, poorly localised and ill-defined sensation
- A-delta fibres are myelinated and transmit sharp, well localised sensation
As pain is transmitted by many different pathways and neurotransmitters, there are many targets
for analgesia
Chronic pain can be defined as pain that has persisted for >3 months. Total pain is a concept that has
physical, spiritual, psychological, and social aspects
- Cancer pain is often a combination of multiple different forms of pain, and interferes greatly
with QOL
Assessment of Pain
In adults, assessment of pain severity is generally through history and examination, with patients
rating their pain severity out of 10
- Using the visual analogue scale (VAS) is a more sensitive way of assessing pain, with the
patient marking their pain on a scale from “no pain” to “pain as severe as it could possibly
be”
More detailed, multi-dimensional scales exist to assess pain
- The McGill pain questionnaire assesses the sensory, affective, and evaluative aspects of pain
In children >3, or adults with learning disabilities, there can be assessment of pain using the Wong-
Baker faces pain rating scale
- This shows 6 – 8 facial expressions showing a range of emotions

In children <3, assessment of pain is usually with examination of facial activity, crying and body
movements
- The modified behavioural pain scale or CRIES scale can be used to assess this objectively
Non-Pharmacological Analgesia
In infants <12 months of age, sweet solutions can be used to reduce pain responses during painful
procedures
- Breast milk is also effective for the same purpose

In adults, TENS machines can be used in chronic pain
In the trauma setting, reassurance of patients can help to reduce pain by reducing anxiety
Pain Relief in Adults
Prescribing analgesics often follows the WHO pain ladder
1. Paracetamol or NSAID
2. Weak opioid (codeine, dihydrocodeine, tramadol, buprenorphine)
3. Strong opioid (morphine, diamorphine, oxycodone, hydromorphone, fentanyl)
Titrating Analgesics
Paracetamol PO is a good first line analgesic for mild pain; IV paracetamol can also be used and has a
higher analgesic effect
- Dose in adults is 1g QDS (max 4g/24hr)

- In adults <50kg it is best to use a 500mg dose
Where paracetamol alone is ineffective, codeine PO (usually given as co-codamol 30/500mg PO) is
usually the next step
- Dose in adults is 30 – 60mg QDS (max 240mg/24hr)

- Tramadol is an alternative to codeine
o Dose in adults is 50 – 100mg QDS (max 400mg/24hr)
When escalating a patient up the analgesic ladder from a weak opioid to a strong opioid, it is
important to prescribe a sufficient dose to increase the analgesic effect
- 10mg of oral morphine is equivalent to 100mg of codeine/dihydrocodeine/tramadol

- There is no ceiling dose for strong opioids, only side effects will prevent escalation in dose
NSAIDs can be titrated in a similar way to paracetamol and opioids
- Ibuprofen is weakest, dose in adults in 400mg QDS (max 2.4g/24hr)

- Naproxen dose in adults in 250mg TDS (max 1.5g/24hr)
- Diclofenac dose in adults is 25 – 50mg TDS (max 150mg/24hr)
Adjuvant analgesics can be used at any stage on the pain ladder, examples include
- NSAIDs (ibuprofen, naproxen, diclofenac), bisphosphonates and steroids for bone pain
- Anti-depressants (amitriptyline) and anti-convulsants (gabapentin, pregabalin, valproate,
carbemezapine) for neuropathic pain
- Steroids and NSAIDs for enlarging tumours (including raised ICP)
- Smooth muscle relaxants (hyoscine, glycopyrronium) for colic
Acute Pain
Pre-hospital analgesia can include inhalational anaesthetic agents, usually Entonox
- This is self-administered using a demand valve to prevent overdose

- It may take ~4 minutes to take effect
Where patients have acute, severe pain IV morphine is generally used. It is important to recognise
that opiate naive patients respond very differently to morphine, and therefore slow IV injection and
dose titration should be used
- For adults; prescribe 5mg IV every 4 hours, but give at a rate of 1 – 2mg/minute, stopping
when there is a response
- In elderly patients consider using lower doses
When titrating morphine to pain, the medication can be given more regularly than every 4 hours,
but be cautious of causing overdose
Chronic Pain
When assessing how to manage a patient’s chronic pain, it is essential to take a thorough drug
history to establish what medications and dosages have and haven’t worked in the past
- Advance pain medication in accordance with the analgesic ladder

Starting patients on morphine will usually involve 5 – 10mg of immediate release morphine 4 hourly
(6 times daily), this should be reviewed daily and increased 30 – 50% daily until pain is controlled
- Morphine sulphate preparations are immediate release e.g. oramorph liquid, sevredol
tablets
When pain is controlled switch the patient to 12 hourly modified release morphine. This should be
half the dose of the total dose of immediate release morphine used in 24 hours
- For breakthrough pain give 1/6th of total daily morphine as immediate release morphine
(either oral or transmucosal)
- Zomorph capsules and MST are modified release morphine preparations
Second line strong opioids can be considered where morphine is not tolerated
- Subcutaneous diamorphine (3mg oral morphine = 1mg sc diamorphine)

- Oxycodone (10mg oral morphine = 5mg oxycodone)
- Hydromorphine (10mg oral morphine = 1.3mg oral hydromorphine)
The oral route is preferred initially for analgesics
- Where the oral route is not appropriate there can be topical, transmucosal, subcutaneous or
intravenous delivery
- Topical delivery includes buprenorphine (butrans) and fentanyl patches
- 25µg fentanyl patch is equivalent to 60mg morphine over 24 hours
- 24mg butrans patch is equivalent to 240mg codeine over 24 hours
- In the terminal phase, syringe drives can be used. These are portable, enable delivery of
multiple medications, and are relatively non-invasive
Opioid Side Effects
Side effects are common to all opioid analgesics
- Constipation
- Nausea and vomiting
- Sedation and confusion
- Dry mouth
- Visual hallucinations, mood changes, euphoria, and dysphoria
- Itching
In opioid toxicity the patient may present with intractable nausea, hallucinations, drowsiness,
myoclonic jerks, pinpoint pupils, and respiratory depression
Opioids are contraindicated in patients with acute respiratory depression, comatose patients, and
those with raised ICP (as they prevent accurate assessment of pupils)
Patients may develop physical dependence to morphine, and suffer withdrawal symptoms
Prescribe an anti-emetic alongside morphine in opiate naïve patients. Patients will usually develop
tolerance to the emetogenic effects of morphine after a week
- Cyclizine 50mg TDS PRN is best

Always prescribe a laxative alongside opioid analgesics and continue it for the duration of treatment
Somatic Pain
Somatic pain is aching and often constant, and it may be dull or sharp. Often somatic pain is worse
with movement
- In cancer, somatic pain is often due to bone metastasis

Often it is treated with NSAIDs, but there is a degree of pain relief that can be achieved with opioids.
Visceral Pain
Visceral pain is either constant or cramping. It is poorly localised and can be referred to other areas
of the body
- In cancer this can be due to infiltration of abdominal organs causing liver stretch, bowel
obstruction etc.
Visceral pain often responds well to steroids, however colic will often need adjuvant smooth muscle
relaxants (e.g. hyoscine butyl bromide)
Steroids should also be considered to reduce tumour oedema e.g. dexamethasone 4 – 8mg
Neuropathic Pain
Neuropathic pain arises as a disturbance of function or a pathological change in a nerve or the

nervous system. The features of neuropathic pain are summarised below
Component Descriptors Examples

Steady, dysaesthetic Burning, tingling, constant, Diabetic neuropathy
aching, itching Post-herpetic neuropathy
Paroxysmal, neuralgic Stabbing, shock-like, electric, Trigeminal neuralgia
shooting Nerve root compression
Neuropathic pain is partially responsive to opioids and NSAIDs
- Adjuvants are important in neuropathic pain e.g. TCAs, gabapentin, steroids

Ketamine, methodone, and nerve blocks can be used in extreme cases
Pain Relief in Children
WHO guidance in children recommends a two-step approach to analgesia
1. Mild pain
- Children <3 months should be given paracetamol
- Children >3 months can be offered both paracetamol and ibuprofen
2. Moderate-to-severe pain should be treated with opioids
Paracetamol doses in children are summarised in the table below
Age Dose Max Dose (/24hr)

1 – 3 months 30 – 60mg TDS 60mg/kg
3 – 6 months 60mg QDS 240mg
6 – 24 months 120mg QDS 480mg

2 – 4 years 180mg QDS 720mg
4 – 8 years 240mg QDS 1g
8 – 10 years 360mg QDS 1.5g
10 – 12 years 500mg QDS 2g
Ibuprofen doses in children are summarised in the table below
Age Dose Max Dose (/24hr)

1 – 3 months 5mg/kg TDS
3 – 6 months 50mg TDS 30mg/kg
6 – 12 months 50mg QDS 30mg/kg
1 – 4 years 100mg TDS 30mg/kg
4 – 7 years 150mg TDS 30mg/kg
7 – 10 years 200mg TDS 30mg/kg (max 2.4g)
10 – 12 years 300mg TDS 30mg/kg (max 2.4g)
Morphine is the first line opioid in children at a dose of 100 – 200mcg/kg, and can be given via
several routes
- Oral or intranasal are preferred

o Intranasal analgesia requires adequate dilutant to produce the correct dose in
0.2ml. This is administered all in one nostril
- Intravenous
Metoclopramide should not be given in children, therefore use ondansetron as an anti-emetic
alongside morphine
If the child’s weight is not known, the Luscombe formula is used for children aged 1 – 10: weight in
kg = (3x age in years) + 7
OSCE Scenarios
Inhaler, Spacer, and PEFR Technique
Peak Flow
The following method should be explained to patients
1. Stand or sit up straight

2. Zero the meter
3. Hold the device without fingers obstructing the meter in any way
4. Take a full deep breath in, and enclose lips around the mouthpiece
5. Exhale as hard and fast as possible, tell them to remember it is the speed of their exhalation
that is measured
6. Repeat to give three recordings and take the best result
Inhaler Technique
For an MDI
1. Remove cap and shake inhaler

2. Breathe out gently
3. Put mouthpiece between your lips, ensuring a tight seal so no medication can escape
4. As you begin to breathe in slowly and deeply, press the canister down to release one puff of
medication. Continue the deep, slow breath in
5. Remove inhaler from mouth and hold breath for 10 seconds
Wait for 30 seconds before taking another dose
For acuhaler (circular shaped inhaler)
1. Push thumb grip away until it clicks

2. Slide the lever away until it clicks, making the dose available for inhalation
4. Hold device horizontally, and put mouthpiece to lips
5. Suck in really quickly and deeply
6. Remove inhaler from mouth and hold breath for 10 seconds
Spacer Technique
1. Remove cap from the inhaler, and shake the inhaler

2. Put the inhaler into the end of the spacer
4. Put the mouthpiece between your lips, ensuring a tight seal so no medication can escape
5. Press the inhaler to put one puff of medication into the spacer
6. Breathe in slowly and steadily. If the spacer makes a whistling sound, you are breathing in
too fast
7. Remove the spacer from your mouth and hold your breath for 10 seconds
• For children, it is best to just advise keeping a tight seal with the spacer and
breathing in and out 5 times as above
If a second dose is needed, remove the inhaler and shake it again, repeating the above steps. Make
sure to wait for 30 seconds in between puffs
For babies make sure to cuddle them while using the spacer, smile and appear relaxed
- Place the mask over their mouth and nose to make a good seal
- Press the inhaler to put one puff of medication into the spacer
- Count to 10 slowly to ensure that the baby has taken several breaths of the medication with
the spacer
Clean the spacer with soap and water every month, leaving it to air dry
Use reward charts with children and spacers, make sure to give them lots of encouragement
Medication Counselling
General Approach
Wash hands and introduce yourself to the patient, check patient details
- Explain and gain consent for the consultation e.g. I was just hoping to talk to you today a bit
about the new medication that you’ve been started on, and answer any questions that you
might have about it
Establish the patient’s prior knowledge and understanding of their condition
- What have you been told about your condition up to this point
- What do you understand about the medication?
- Ideas, concerns and expectations
ATHLE(IT)CS format is useful from here, regularly checking understanding and giving opportunity for
questions
Action
- Explain what the treatment is and how it works

o Chunk information, and check their understanding regularly as you go
o Use diagrams where relevant
Timeline
- When to take the medication (e.g. morning, evening, with food, same time every day)
How to take
- PO, SC, topical

Length of treatment
Effects
- Usual time before effects will become apparent
Important side effects
- Differentiate between common, and important/serious
Tests
- Monitoring blood tests that will be required
Contraindications
Supplementary advice
- Always offer written literature
Ideas, concerns, and expectations – empathise
Double check for any outstanding questions or queries
ALWAYS SUMMARISE THE INFORMATION GIVEN
- You can check the patient’s understanding by asking them to relay some of the key
information back to you where relevant
Atypical/ Typical Antipsychotics
Schizophrenia is caused by an over-activity of chemicals that transmit messages in the brain.

Antipsychotics work by blocking the receptors in the brain that respond to the over-active chemicals,
and reduce the signals being sent
(Antipsychotic) is a tablet that is taken once a day, or can be given as injection every few weeks
- We’ll start at a low dose, and gradually build it up to see how you respond
- Usually people take these medications long term if they are working for them
- It tends to take a few weeks before you will start to see an effect
There are some important side effects to be aware of
- They can cause people to gain weight, and increase their blood sugar levels
o This can increase the risk of diabetes, strokes, and heart attacks. So it’s important to
try and keep a healthy diet while taking these medications
o We will be regularly monitoring your blood tests just to check that this isn’t
happening with you
- They can sometimes cause problems with movement
o Restless legs
o Muscle spasms and twitches, quite commonly can have trouble with the movement
of their eyes
o Tremor
o Stiffness
- They can sometimes cause constipation, dry eyes, dry mouth, and trouble passing water
- Some people can feel quite drowsy when taking these medications
- They can cause people to feel lightheaded
There are lots of things that we can do if any of these side effects happen, so it’s important to
mention if you’re experiencing any side effects
There are some important things to look out for, and make sure to contact a doctor quickly if you are
experiencing
- Feeling very hot, shaking, and having very stiff muscles

- (Clozapine only) sore throat and fever
We will check blood tests quite regularly to make sure that the medication isn’t causing any
problems
- Clozapine weekly FBC for 18/52, then fortnightly for the rest of the first year, then monthly
- All antipsychotics 3 monthly HbA1c, lipids, BMI, and blood pressure
Lithium
Mania is thought to be due to an imbalance of the chemicals that transmit messages in the brain.
The exact way in which lithium works is unknown, but it is thought that it helps to re-establish the
normal signals that the nerves in the brain produce
Lithium tablets are usually taken once a day, at the same time every day
- If you respond well to the medication, it might be the case that you carry on taking it for the
rest of your life
- It might be a few weeks before you start to notice an effect
- It can cause some damage to the kidneys, and to the thyroid gland in your neck which
produces hormones
o We will be regularly checking blood tests to make sure that if this starts to happen
that we can correct the changes early
- Common side effects of lithium include
o Tremor
o Feeling thirsty and going to the toilet more than often
o Weight gain
o Swelling
o Feeling a bit drowsy and not as sharp as normal
o Mention teratogenicity in women
- It is really important to note that lithium is dangerous if you take too much. It’s important to
keep hydrated, and always mention to doctors and dentists that you’re taking lithium as
sometimes it can interact with other medications. Things to look out for include
o Diarrhoea and vomiting

o Coarse tremor
o Being very thirsty and passing lots of urine
o Slurring your speech
o Feeling unsteady when walking
It’s important to carry out regular blood tests while you’re on lithium
- We will measure the lithium levels in your blood every week to start with, and when they’re
stable we will check them every 3 months
- Every 6 months we will also check your kidney function and look at your thyroid hormones
just to make sure that the drug isn’t causing any problems
Contraindications to lithium
- 1st trimester of pregnancy (in some cases this is unavoidable)

- Breast feeding
- Pre-existing untreated renal impairment or hypothyroidism
- Untreated hyponatraemia
SSRI/SNRI
Depression is thought to be due to an imbalance of chemicals that transmit messages in the brain.
Anti-depressant medications work by re-adjusting the balance of some of those chemicals
(particularly one called serotonin)
SSRIs are tablets that you take once per day, at the same time every day
- If you respond well to the medication, we would usually carry on with it until things have
been stable for about 6 – 9 months
- You might not notice any effect until about 4 – 6 weeks’ time, this is completely normal and
we would encourage you to keep going with the medication until that time when we will
make an appointment to check on how you’re doing
- Initially you might start to feel a bit more anxious and jittery, and some people do
experience some thoughts and feelings about ending their life
o It’s really important to talk to someone if you start to experience anything like this.
I’ll provide you with some telephone numbers and we are always here at the surgery
for you to come and talk to
- Insomnia
- Headaches
- Weight gain or weight loss
- GI upset
- Loss of libido, or sexual difficulties
- It’s important to make an appointment if you’re experiencing any of these things so we can
see how we can go about improving them
o Never suddenly stop taking the SSRI as they can have quite nasty withdrawal effects,
so it’s important to reduce the dose slowly
Bisphosphonates
Osteoporosis is a condition where the bones become brittle as the cells within the bone are causing
bone breakdown. Bisphosphonates work by slowing down the activity of those cells, and therefore
helping the bone to become denser
These are tablets that you take once per week
- It’s important to take them first thing in the morning, on the same day every week
- Make sure you’ve got an empty stomach, and take them with a full glass of water
- Keep upright (either standing or sitting up straight) and don’t eat anything for 30 minutes
after taking them
- Acid reflux is common

- Bloating and indigestion can occur
- Some people notice a change in their bowel movements
- Very rarely they can cause damage to the bone in your jaw, so it’s important to have regular
check-ups at the dentist
o Watch out for pain in the mouth, and loose teeth
Contraindicated in pregnancy and in people with stomach ulcers
Donepezil
Donepezil is a medication that we give to help with your memory, and slow the progression of
memory disorders like Alzheimer’s disease. It works by blocking the breakdown of a stimulant
chemical in your brain, increasing brain signal transmission
It is a tablet, that is taken in the evening
- If the medication is working for you, we will carry it on until it doesn’t seem to be having an
effect any more
- Tummy upset
- Insomnia
- Headaches
- Dizziness and feeling light headed
- Some people experience vivid or scary dreams, and some might experience strange
symptoms like hearing or seeing things that are not necessarily there
Monitoring is with a memory test at 6 weeks, and just to check how you are getting on with the
medication. We will then monitor you with memory tests every 6 – 12 months or so
Warfarin
Warfarin is a medication that thins the blood. It works by decreasing the levels of the factors in our
blood that trigger blood clots to form
Warfarin is a tablet, that is taken in the evening (so that if the INR is found to be high on that day the
dose can be lowered/omitted earlier)
- It is important to take warfarin at the same time every day

- We will start you at a low dose, and adjust the dose based upon your blood test results. It
may be the case that the amount of warfarin that you’re taking changes quite regularly to
begin with, this happens with many people and is just so that we can make sure that we are
using the right dose for you
- Duration of treatment differs dependent on indication
There are some important things to be aware of when you’re taking warfarin
- As warfarin thins your blood, it increases your risk of bleeding

o Try to avoid activities that risk injury and bruising
o If you notice that you develop a big bruise, are bleeding heavily, or that you are
passing black/tarry stools it is important to see a doctor
o It is best to avoid taking medications like ibuprofen and aspirin, as these can
increase the risk of bleeding from your stomach while you’re taking warfarin
- Try and avoid drinking lots of alcohol, as this can affect how the warfarin is broken down by
your body
- Always mention to doctors and dentists that you’re taking warfarin, as it can interact with
lots of different medications and it increases your risk of bleeding
- Warn of teratogenicity in women
- Avoid foods such as cranberry juice and spinach
We will measure your blood levels twice a week for the first two weeks, and then every week until
they are stable
- We will check them every 6 – 8 weeks from that point

- We might check your blood more regularly if the levels are out of range and we need to
adjust the dose
Statins
A statin is a medication that works to decrease the level of bad cholesterol in the blood stream. By
dropping down the bad cholesterol levels, the risks of conditions such as heart attacks and strokes
can be decreased
A statin is a tablet that is taken once a day, in the evening
- Usually we would recommend that you carry on taking a statin for a long time
- They work to decrease your disease risk over a long period of time
There are some common side effects that people can experience with statins
- Muscle aches and pains are quite common, and usually mild. These tend to fade with time
o If you experience severe muscle pains, or notice your urine go very dark it is very
important to see a doctor just so we can check that there isn’t any serious muscle
damage taking place. This is very rare.
- Headache
- Tummy upset
Very rarely they can cause some damage to the liver, so we will check your liver function when you
start taking the statin and again in 3 months, and double check after 1 year
- We will check your cholesterol levels every 6 months, just to make sure that the statin is
working well and that we are at the right dose for you
Contraindications
- Pregnancy
- Advise the patient to avoid grapefruit
Methotrexate
Methotrexate is a medication that works by dampening down the immune system, and by reducing
the activity of the immune system it helps to prevent our immune system from damaging and
attacking our own cells
Methotrexate is a tablet, and you take it once a week
- Take it on the same day every week, and we will give you a folic acid tablet to take on the
other days
- You should start to see an effect with methotrexate within 6 months if it is working
- If it works, we will continue it in the long term
There are some important side effects to be aware of with methotrexate
- Hair loss
- Headaches
- Stomach upset
There are some rare, but serious, things that can sometimes happen. So there are some important
things to look out for
- It can cause a suppression in the bone marrow, meaning that the number of blood cells we
make decreases
o If you notice any bruising or abnormal bleeding, make sure to see a doctor. It is best
to avoid medications like ibuprofen and aspirin for this reason, as they can make you
more likely to bleed
o You might notice that you’re feeling more tired or breathless than usual
o If you have a fever, it is important to see a doctor straight away just to make sure
that you haven’t developed an infection because your immune cell levels have fallen
too low
- It can cause liver damage, so try to avoid drinking excessive alcohol
- It can sometimes cause lung damage, so if you become breathless or develop a persistent
cough, make sure to come and see us
These complications are rare, but we will do regular blood tests just to make sure that they are not
developing in you
- FBC, U&Es, LFTs every 2 weeks until dose stabilised. Then every 3 months
If you are trying to get pregnant, make sure to come and tell us as this medication can be damaging
to the baby. So we would want to see about swapping it before you became pregnant.
Levodopa
So levodopa is a tablet that works by replacing a chemical called dopamine in the brain, it is this
chemical that is lacking in the brains of people with PD
It is tablet that you take three times per day, and it is best to take it with food
- You should start to see effects very quickly

- If it works for you, we will carry it on in the long term. But it may be the case that we have to
add in other medication for it to carry on working
There are some important side effects to be aware of. If you do experience these it is important to
come back and tell us, as there are other medications that we can give you to reduce the side effects
- Tummy upset
- Light-headedness
- It can cause people to have vivid dreams or nightmares
- Some people may experience strange sensations, such as hearing or seeing things that are
not necessarily there
- Involuntary movements
Metformin
Metformin is a tablet that works to decrease your blood sugar by increasing the amount of sugars
taken up by and stored in the liver
It is a tablet, and usually we start you on one tablet per day, and gradually increase the dose as you
need
- It is best to take the tablet in the morning with food, try to take it at the same time each day
- If it is working it will be carried on in the long term
There are some important side effects with metformin. If these are troublesome for you, come back
and see us and we can consider changing the type of metformin we give you
- The commonest is diarrhoea

- Others include weight loss, tummy pain, and nausea
Very rarely it can increase the levels of acid in your blood. This is very uncommon, but if you start to
feel very unwell it is important to see a doctor urgently
We will measure your kidney function every year while you’re taking metformin, just to make sure
we’re able to continue giving it
Clinical Skills
General Rules
Wash hands and introduce yourself
Always establish patient identity prior to proceeding with anything else
- Name and DOB

- Check wristband
Explain the procedure and gain consent, always check allergies
Wash hands, and wear both gloves and an apron (± eye mask)
If drawing up a drug always use a blue 23G needle, detach and place in sharps bin. Then attach
needle for delivery (do not unsheathe) and prime syringe
- Clean tops of ampoules with a steret prior to mixing with dilutant

- Keep ampoules until completion of injection in case of anaphylaxis
Change gloves and apron between prepping drug and delivering drug
When cleaning skin use 30 seconds crosshatch technique and allow to air-dry for 30 seconds
Document procedure in notes
Drawing up Medications
Always check expiry dates and evidence of tampering, and with any drugs ensure a second checker
for dose/drug (including for dilutants e.g. 0.9% NaCl)
[that you want] x volume/ [that you have] = volume required
If drawing up a drug always use a blue 23G needle, detach and place in sharps bin. Then attach
needle for delivery (do not unsheathe) and prime syringe
- Clean tops of ampoules with a steret prior to mixing with dilutant

- Keep ampoules until completion of injection in case of anaphylaxis
When injecting an IV medication into an infusion bag inject using ANTT through the injection port
- Ensure to complete and stick a ‘drug additive’ label onto the fluid bag
Nasogastric Tube
Indications (lasts 6 – 8 weeks)
- Swallowing dysfunction
- Free drainage in bowel obstruction
- Nutrition in the unconscious patient
Contraindicated in nasal obstruction and ?basal skull fracture
“I need to insert a thin flexible tube into your nose and down into your stomach to enable us to feed
you directly into your stomach. It might be a little uncomfortable and cause you to retch, but the
procedure is quick and shouldn’t be painful. If at any point you want to stop, raise your hand”
Sit the patient upright and get them to blow their nose.
Collect NG tube, vomit bowel, water and straw, enteral syringe, and pH strips
- Measure NG tube length from xiphisternum to nostril to ear lobe

- Lubricate NG using water
- Insert through nostril while encouraging the patient to swallow sips of water
- Aspirate from tube (if cannot get any aspirate: inject air, advance tube, retract tube, or get
patient to lie on left side)
- Test pH of aspirate, if <5.5 confirmed position in stomach. Can remove guidewire now and
tape tube in place
- If position not confirmed leave guidewire in place try giving patient coloured fluid and
aspirating, or arrange urgent CXR
IM Injections
Locations
- Deltoid: 1 – 2 cm below acromion

- Vastus lateralis: hand breath below greater trochanter and above knee, use middle third
- Ventrogluteal: place palm on greater trochanter and extend index finger to reach ASIS,
extend middle finger out to iliac crest. Inject between middle and index
Use Z-track technique and a 90-degree angle, aspirate prior to injecting
SC Injections
Locations
- Lateral aspects of upper arms

- Umbilical region of abdomen or lower loins
- Lateral aspects of thighs
Pinch the skin and use a 45-degree angle, aspirate prior to injecting
Consent and Refusal of Consent
Wash hands and introduce yourself to the patient, check patient details
- Explain and gain consent for the consultation e.g. I was just hoping to talk to you today a bit
about xyz procedure
Establish the patient’s prior knowledge and understanding of their condition

- What have you been told about your condition up to this point
- What do you understand about the procedure?
- Ideas, concerns and expectations
o Is there any particular aspect of the procedure that is worrying you?
Explain what the procedure is and how it works
- Chunk information, and check their understanding regularly as you go

- Use diagrams where relevant
- Discuss potential complications
What the alternatives are, including what would happen without the procedure
- Contextualise the information with respect to risk, related back to the patient’s concerns
Supplementary advice
- Always offer written literature
Ideas, concerns, and expectations – empathise
Double check for any outstanding questions or queries
ALWAYS SUMMARISE THE INFORMATION GIVEN
- You can check the patient’s understanding by asking them to relay some of the key
information back to you where relevant
If the patient still is refusing to consent to a procedure, escalate to senior support
Self-Discharge Against Medical Advice
Assess the patient’s capacity to self-discharge
- Can they understand, retain, weigh-up information and communicate their decision
Explain what treatment is still required, and the consequences of refusing treatment
Explore other options which may be acceptable to both the patient and clinician
Ideally get the patient to fill in a self-discharge form
Discharge Planning
Discharge planning in the elderly is usually complex and co-ordinated by many different professional
groups. The emphasis is on achieving a timely but safe discharge with effective transfer of care and
rehabilitation
- Patients may require additional services that they did not access prior to admission
o Local authority (means tested) v health authority (universally available) services
Medical Factors
Full medical history with systems review, physical examination
- Ensure that patient is stable

- Undertake basic investigations related to presenting complaint
Nutritional assessment by malnutrition universal assessment tool (MUST)
- Acute disease effect

- Anthropomorphic calculations
- Biochemical and haematological factors
- Ongoing nutritional difficulties e.g. swallow problems, pain
Function
ADLs and IADLs
- Cooking
- Shopping
- Washing
- Toileting
- Dressing
Mobility and balance
Social
As for normal social history
- Who lives at home with the patient

- What environment is the patient living in e.g. residential care, supported living, own home
(flat, stairs, bungalow)
- Social circle and frequent contacts
- Formal and informal care, what is specifically done for the patient
Environmental
Home comfort and safety
Transport to and from hospital
Discharge Summary
Demographics
- Patient
o Name
o Hospital number
o DOB
o Address
o GP details
- Hospital stay
o Consultant
o Ward & hospital
o Admission and discharge date
o Discharge destination
- Summary details
o Date written
o Your name, grade, and signature
Clinical details
- Presentation
o History
o Examination
- Investigations
o Important investigation results
o Any awaited results
- Diagnosis and co-morbidities
- Management
Future management
- Follow-up appointment
- Actions for GP
Medications
- Any changes to regular medications, and reasons why altered

- TTO
Errors and Angry Patients

Medical Errors and Incident Reporting
The most important thing to do is make sure the patient is safe by using an A to E assessment and
stabilisation, escalating care as required
When an incident occurs
- Inform the patient and their relatives

o Apologise
o Explain how the error occurred
- Document well in the notes
- Ensure your seniors are aware of what has happened
- Report the incident via a reporting system
o This is usually an incident report form on Datix
- Reflect and learn from the error
Incidents should be reported even where no harm has come to the patient
- A ‘near miss’ is an event that could potentially lead to harm if allowed to progress
Dealing with an Angry Patient
Introduce yourself, and keep a calm manner throughout
- Ensure that you are in a good setting, ideally a private location

- Always consider your safety, and give clear boundaries to the patient if they are being
aggressive or rude
Allow the patient to vent their anger without interruption
- Validate their feelings, but do not collude. Always apologise early

o “I am sorry to hear that you feel that way”
o “Given everything that you’ve told me, it’s understandable that you feel this way”
- Focus on the patient
o Explore their concerns
o Acknowledge their concerns and repeat them back
- Apologise, focussing on their specific anxiety
Avoid giving no information, even if you do not know how to proceed, reassure the patient that you
will look further into the matter and escalate to senior colleagues. Stress to the patient that you are
taking their complaint seriously.
Ensure that a clear, realistic plan is established
- Arrange follow-up to discuss further, and inform of progress
Inform the patient of their right to complain (practice manager at GP, PALS in hospital)
DNACPR
Approach with SPIKES format. Prior to discussing with the patient/family, discuss as a medical team
regarding CPR and ceilings of care
- Would the patient be for ITU (intubation, ventilation, hemofiltration, inotropes etc.)?
- Would the patient be for NIV?
Always involve the patient (where they have capacity) or their family in DNACPR discussions
Appropriate setting
- Quiet side room

- No interruptions
- Other staff with you as needed e.g. nurse familiar to the patient/ family
Perceptions
- Ask person/ family what they know so far about what’s going on with their illness so far
o Ask questions about progress
▪ “How have things changed for you/them over the past few months, relative
to how you/they was before how you/they are now”
o Correct misconceptions, chunk and check
o Highlight the deterioration in the patient’s condition
- Discuss regarding co-morbidities and clinical progress/ deterioration
- Address ICE
Invitation
- Given how things are going at the moment, I was wondering if it might be helpful for us to
have a discussion about what might happen if you were to become more unwell, and be
approaching the end of your life
o Ask if the patient would rather wait for relatives to be present etc.
- I want to talk about a very specific situation that we discuss with many people as they
approach the end of their life. I was hoping to talk to you about resuscitation (CPR), is this
anything you’ve discussed before?
Knowledge
- So this is talking about a very specific situation where your heart stops or your breathing
stops
- In this circumstance, in some patients, we would consider doing CPR to try and re-start their
heart
o In patients like you, who have lots of different illnesses, and are older and more frail.
Often CPR is not effective in re-starting the heart
▪ Chunk/ check
o If we do re-start the heart, often the patient does not return to their previous level
of health and may be left in a coma for example
▪ Chunk/ check
o The process of CPR is very distressing, and can cause a lot of damage for example
breaking bones, and in your case we think that it would be very unlikely to bring you
back
▪ Chunk/ check
- Because of this, there is a form that we would recommend filling in called a DNACPR form.
What this states, is that in the very specific situation that if your heart was to stop or you
were to stop breathing, we would not start doing CPR and allow you to die peacefully and
comfortably
o Chunk/check
Do you have any questions?
Clarify that you are going to continue with the best medical care possible to try and get you better,
and avoid the situation happening all together.
Paeds OSCE Histories
Abdominal Pain
SOCRATES
- Relationship of pain to eating and defaecation

- Vomiting
- Bowel habit
- GI bleeding
- Urinary symptoms
- Fever
- Weight loss (+ growth charts)
Effect of pain on daily living and schooling
NB: Abdominal migraine
- Paroxysmal episodes of intense, acute periumbilical pain lasting >1 hour with intervening
normal health
- Pain interferes with normal activity
- Associated with anorexia, nausea, vomiting, headache, photophobia, pallor
Management by discussing triggers, and in the acute phase simple analgesia ± pizotifen as
prophylaxis if >2 per month
Constipation
General history alongside
- Frequency of defaecation
- Consistency of stools
- Duration of constipation
- Associated pain, both on passing stool and in intervening periods
- PR bleeding
- Weight loss (+ growth)
- Episodes of faecal incontinence
- Abdominal distension and vomiting
Red flags would be features of Hirschprung’s disease and neurological symptoms
Management plan for functional constipation should include
- Disimpaction if there are palpable faeces

o Use an osmotic laxative (movicol) and electrolytes, if not tolerated or ineffective
after 2 weeks switch for a stimulant/osmotic/softener
o Try and avoid suppositories and enemas in children
- Maintenance therapy for all cases
o Dietary advice
o Regular movicol (but not stimulant laxatives)
o Behavioural advice
▪ Encourage regular post prandial trips to the toilet
▪ Reward charts
▪ Not punishing the child, especially for involuntary incontinence
Developmental Delay
History factors should include

- Ask about key features of all 4 areas

o Key milestones and when achieved, start 1 below and work up/down as necessary. If
a delay identified question further
▪ Motor: hand dominance, balance
▪ Fine motor: vision, hand dominance
▪ HSL: startles, responds, turns to sounds out of sight, verbal/non-verbal
communication
▪ SEB: smiling, interaction with other children
- Any evidence of regression
- Is the child given the opportunity to try and develop e.g. encouraged to move, spoken to
regularly?
Faltering Growth
History factors should include
- Nutrition
o Quantify intake
o Hungry?
o Timing of weening
o Regurgitation or posseting (forceful, bile stained, effortless)
o Stool output
- Family history, of parents and siblings
- Developmental milestones
- Systems review
o Breathlessness, cyanosis, recurrent chest infection
o Bowel habit, tummy pain
o Urinary symptoms
o Neurological symptoms
o Dermatological symptoms
Seizure/Funny Turn
Differentials and history as in adults
Reflex anoxic seizures are common in children (part of cardiac reflex syncope differentials), these
occur when the child has a sudden unexpected fright or pain
- They go pale grey and lose consciousness

- Often they are stiff and have convulsions, lasting <1 minute
- This is self-limiting and often recurrent, usually stopping at school age
Blue breath-holding attacks are slightly different, occurring during vigorous crying
- The child cries vigorously, becomes silent, goes blue around the lips and loses consciousness
- They may be floppy or stiff, but come round in <1 minute
- This is self-limiting
Advise in both cases to put the child on their side and keep an eye on them until it ends. Ensure they
get plenty of rest after it finishes, and try to act as if nothing has happened (don’t punish or reward
them, don’t fuss them)
Can do EEG after second episode to double check. ECG is recommended
Bruising
Factors to cover
- Preceding illness
- Trauma (did you see it happen)
- Lethargy, decreased exercise tolerance, recurrent infections
- Any bruises appear suddenly without explanation
- Mobility of the child
- Bruising/ bleeding/ swelling after vaccinations or at birth
- Nutrition
Enuresis
Primary
- Nocturnal/ diurnal
- Do they indicate that they want to go to the toilet?
- Is it every day/ every night?
- How many times per night?
- Do they pass small volumes or large volumes?
- Do they wake up after an episode?
- In the day any urinary symptoms
o Dysuria etc.
o Frequency e.g. do they do to the toilet more than their peers in the day
- Any swelling, bruising, vomiting
- Constipation
Secondary (clarify how long they have been dry for, >6 months is secondary)
- Nocturnal/ diurnal
- Diabetes
- UTI
- Emotional triggers
Large volumes of urine in the first few hours of the night is typical for bedwetting, variable volumes
at multiple times indicates overactive bladder

Miscellaneous For Finals

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Miscellaneous For Finals

Uploaded by

Copyright:

Available Formats

Hannah Cooke, 2016/17

Miscellaneous for Finals

- Gram positive cocci include staphylococcus and streptococcus

- Gram negative cocci are Neisseria strains

Penicillins, cephalosporins and carbopenems are all Beta-lactam antibiotics

In order of increasing spectrum, penicillins include

In order of increasing spectrum, cephalosporins include

In order of increasing spectrum, carbapenems

- Meropenem (NB: C.diff risk)

The commonest quinolones are ciprofloxacin and levofloxacin

- Vancomycin is a glycopeptide, and is used to treat C.diff and MRSA

Metronidazole is used in anaerobic infections

- Alcohol cannot be ingested alongside metronidazole

Infection Antibiotic(s) Dose

- FBC, specifically looking at platelet count

o Normal APTT: 29 – 42 seconds

Cautions and contraindications include

- Children <16, due to the risk of Reye’s syndrome

ADP Receptor Antagonists

Clopidogrel and prasugrel are ADP receptor antagonists

- Their use is primarily during PCI and post-ACS for 12 months

Ticagrelor is an antiplatelet with the same indications as ADP receptor antagonists

- 180mg initially, then 90mg BD

LMWH is given as a subcutaneous injection

- Enoxaparin (clexane) and dalteparin are examples

UFH can be given as a subcutaneous or intravenous injection

- When giving patients IV heparin infusion, measure APTT every 4 – 6 hours

- Twice a week for 1 – 2 weeks

- Take the prescribed dose at the same time every day

- Vitamin K 10mg slowly

- Beriplex (Prothrombin complex) 50 units/kg (or FFP 15mg/kg)

Where bleeding is minor, give 2mg vitamin K IV

- If INR is 6 – 8 stop warfarin and re-start when INR <5

Indication Target INR

Where a patient requires rapid anticoagulation, a loading dose of 5 – 10mg is recommended,

Novel Oral Anticoagulants

NOACs include rivaroxaban, apixaban, and dabigatran

- VTE prevention post-operatively

- This shows 6 – 8 facial expressions showing a range of emotions

- Breast milk is also effective for the same purpose

Pain Relief in Adults

Prescribing analgesics often follows the WHO pain ladder

- Dose in adults is 1g QDS (max 4g/24hr)

- Dose in adults is 30 – 60mg QDS (max 240mg/24hr)

- 10mg of oral morphine is equivalent to 100mg of codeine/dihydrocodeine/tramadol

- Ibuprofen is weakest, dose in adults in 400mg QDS (max 2.4g/24hr)

Pre-hospital analgesia can include inhalational anaesthetic agents, usually Entonox

- This is self-administered using a demand valve to prevent overdose

- Advance pain medication in accordance with the analgesic ladder

- Subcutaneous diamorphine (3mg oral morphine = 1mg sc diamorphine)

Opioid Side Effects

Side effects are common to all opioid analgesics

- Cyclizine 50mg TDS PRN is best

- In cancer, somatic pain is often due to bone metastasis

Neuropathic pain arises as a disturbance of function or a pathological change in a nerve or the

Component Descriptors Examples

Neuropathic pain is partially responsive to opioids and NSAIDs

- Adjuvants are important in neuropathic pain e.g. TCAs, gabapentin, steroids

Pain Relief in Children

WHO guidance in children recommends a two-step approach to analgesia

Age Dose Max Dose (/24hr)

6 – 24 months 120mg QDS 480mg

Ibuprofen doses in children are summarised in the table below