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Fortunately, the vast majority of calculations you will need to perform as a junior doctor are relatively straightforward. This chapter will use examples of calculations common to clinical practice and hence the PSA and offer simple strategies for completing them. While working through these examples, try to keep in mind the following questions: Which pieces of information are relevant?

How can I simplify the information? A handy tip is to pick out and write down the information you select to be relevant in a way that makes it easier for you to manipulate, i. Does my answer look reasonable? When you arrive at your answer, do not just write it down and move on. Compare it with what you already know about drugs and doses and decide if it looks reasonable. This seems an obvious step, but is often missed out. One of the most common calculations in clinical practice involves calculating the volume of a solution that will give the correct dose.

This is an intentionally simple example to illustrate a key equation. If you have not performed this kind of calculation before and want a quick way of calculating the answer see the following: Write out the information in this format making sure the units are the same for both numerators and both denominators: Rearrange the equation so that X is on its own: You should get 1 mL as your answer.

If you were asked to calculate the dose rather than the volume, use the same equation, but flip the numbers over on both sides so that X is still the numerator. This will make rearranging the equation to solve X much easier. Now have a go at the example Questions 6. Answer 83 SIX Question 6. If there is 1 g in mL, in 1 mL there is 0. Memorize this and apply it to similar questions later on. Express this as a percentage. Answer An alternative way of expressing concentration is demonstrated on adrenaline epinephrine preparations in the emergency box on resuscitation trolleys.

Different concentrations exist for different indications. You may use a calculator at any time Question 6. What volume of solution was he given? Answer 85 Calculation Skills Question 6. So now use it as a reference point: Do not be caught out. This is a 0. Explanation B the quick way: Errors like this can and do happen, particularly when doctors are tired on long night shifts.

Avoid this by always thinking about the units you are working with and convert all volumes or masses into the same unit. You should also know that micrograms are always written out in full in drug charts. This protects patients from drug errors.

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You should spot and underline micrograms in this question, and be drawn to thinking about the units and that they indicate a small expected size of a dose — this is consistent with 0.

Answer 0. A 1 in concentration allows a substantial dose 0. A 1 in 10 solution would require 3 mL to be administered intramuscularly: Answer 86 0. What dose in milligrams of furosemide was given? Answer You may use a calculator at any time Question 6.

The ampoule contains 80 mg in 2 mL. What volume of solution is required? Calculation Skills The next few sample questions move away from concentrations of solutions. For some, the calculations involved in these questions will seem more intuitive as the answers are proportions of vials or fixed volumes, which are easier to visualize. Using distracting information, like age and weight, is a useful tip when writing questions to test yourself. It reflects real-life clinical practice. Answer 40 mg Question 6.

Write the relevant bits down and discard the rest. If you have calculated a volume of 15 mL, this is highly unlikely to be appropriate for slow IV bolus administration in a paediatric patient. Answer 88 1. What volume do you need to give? Investigations reveal the following: You decide to initiate treatment dose enoxaparin LMW heparin at a dose of 1. What dose do you give? Which syringe size will you choose for Mrs Bett? Note that you can discard any excess. If you are extra keen, you can express as a volume how much you would need to discard.

It is a simple multiplication. All of the information is clinically relevant, but not for your calculation. This has occurred on several occasions with insulin, leading to catastrophic results. You might think your writing is easy to read, but others may not and it is, after all, only 3 or 4 more letters. Answer 75 mg or units Question 6. Then calculate how many millilitres contain units. Use the equation to calculate that if: Again, this question requires little explanation.

Choose the syringe size from which you can give the whole dose. Your patients will not thank you for giving them two injections when they could have one!

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Clinical point Most hospitals now use drug charts that make LMW heparin syringe size selection easier. If not, there is nothing to stop you from making it clear on the drug chart. The more information you can give to the nursing staff administering the drugs, the safer your prescription will be. Answer 90 80 mg units discard units, i.

Do not be intimidated by this kind of question. They are often no more difficult to answer. This may involve interpreting information in the form of charts or Calculation Skills You may use a calculator at any time Question 6.

Blood results are as follows: Experience with a once-daily aminoglycoside program administered to 2, adult patients. Antimicrobial Agents and Chemotherapy ; Use the nomogram above to select a suitable dose and dosing interval. She has proteinuria and brisk reflexes. You treat her as an emergency for pre-eclampsia. The nurse puts equipment on the bedside as shown in the Figure.

How much sodium chloride NaCl 0. Abnormal monitoring results stimulate changes in the dosing interval frequency rather than the dose. For this question: Already on anticoagulant e. If prescribing enoxaparin reduce standard dose of 40 mg to 20 mg od if eGFR 2.

Use the BNF to calculate the dose according to weight. Thrombolysis in PE is definitely not warranted here: Its anticoagulant effects occur after 48—72 h, so concomitant heparin must be given. This question specifically asked for a drug that is indicated immediately in the treatment of this PE, i. LMW heparin, although warfarin will probably be started concomitantly.

Most patients will require 2—3 days of 10 mg before the INR increases from 1. A and B. Marking Guide for Questions 7. For example, the prescription should appear as: He has also noticed that he has to sleep with three pillows as he is breathless when he lies flat. He has a history of asthma for which he occasionally needs a salbutamol inhaler; the inhaler has not helped his recent breathlessness.

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He is currently taking furosemide 20 mg once daily. His chest examination is unremarkable and his JVP is not elevated. Mild pitting oedema is present. An echocardiogram has also been requested. Prescribing request: Write a prescription for ONE drug for long-term treatment of his condition. Selection of an ACE-inhibitor over a betablocker in this scenario reflects the presence of asthma which contraindicates a beta-blocker.

Dose, route, frequency 2. Be wary of the question asking for one prescription for a condition usually requiring two drugs — there will be a catch! ACEinhibitors can cause postural hypotension so they are best given in the evening. There are marks for giving the correct timing of the drug: Perindopril is also an ACEinhibitor.

The BNF recommends giving perindopril in the morning: Ramipril is also an ACE-inhibitor. It has no effect on mortality while ACEinhibitors and beta-blockers do. Spironolactone is used as an adjunct in moderate-to-severe heart failure when ACE-inhibitors and beta-blockers are inadequate i.

Score 9. Further, the peak flow a measure of severity of bronchoconstriction and hence asthma is at his baseline. Doing It Yourself A. Drug choice For example, the prescription should appear as: He denies any medical history. Chest clear, JVP not raised, no peripheral oedema. WCC Neut. Hb MCV Value 7. ACEinhibitors are first-line therapy for hypertension in those under 55 years.

His mild hypokalaemia may actually be helped by an ACEinhibitor which can cause hyperkalaemia ; it should obviously be investigated and monitored but that is not the focus of this question. ACE-inhibitors can cause postural hypotension so generally they are best given in the evening.

Note there are two forms of perindopril with different doses perindopril erbumine and perindopril arginine ; both are licensed in hypertension but the differing doses stress the need to write full names. ACE-inhibitors can cause postural hypotension so they are best given in the evening. She has a background of asthma and has just started smoking.

She is getting little benefit from her salbutamol inhaler her only medication. You are the first doctor to see the patient. Dose, route, frequency A. After oxygen which you are told is being arranged , the treatment includes salbutamol and ipratropium nebulizers, oral or intravenous steroids and potentially theophylline; much later magnesium may be considered.

As the question asked for the first drug for relief of breathlessness, salbutamol should be first. Further, she is not benefitting from inhaled salbutamol.

While a core part of managing an exacerbation of asthma, its onset of action is slower than salbutamol, hence salbutamol is a more appropriate answer. It therefore has no effect on acute breathlessness. She also had a transient ischaemic attack last year and has controlled hypertension. You are asked to see her because of central crushing chest pain which came on when she walked to the toilet two minutes ago.

Observations are normal. Doing It Yourself Question 7. Note you must actually pick a dose you should never prescribe a range for any drug as it is your responsibility, not the nurses, to ensure a specific, safe dose. There will be a local policy for the management of chest pain, which will give you some guidance.

Aspirin, while important in the treatment of ACS and sometimes given preemptively before the diagnosis is confirmed may improve outcomes, but would provide little symptomatic benefit beyond its unintentional in this case anti-inflammatory properties. Therefore, its side effect profile should prevent its use in stable angina.

Again note that a specific dose not a range must be specified. Beyond asthma for which he uses a beclomethasone inhaler, twice daily, he has no medical history of note.

His chest is clear and there are no murmurs on auscultation of the heart. Write a prescription for ONE drug to treat the underlying cause of his breathlessness. His age, lack of a precipitant or adverse features make rate control preferable to rhythm control he would also require formal anticoagulation if cardioversion were to be attempted as onset was over 48 hours ago.

First-line therapy for rate control is either a rate-limiting calcium-channel blocker e. Beta-blockers are contraindicated in asthma. DIGOXIN 2 Digoxin should be used in patients in whom beta or calcium-channel blockade is inadequate as poly-therapy or contraindicated as monotherapy.

He says he has not passed urine for five days and reports painful abdominal distension. Examination reveals a palpable bladder with over a litre of urine visible on bladder scan.

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Hb Value 8. The first potassiumlowering therapy is insulin and dextrose; insulin causes cellular uptake of potassium, and the dextrose is given to prevent subsequent hypoglycaemia. Write a prescription for a drug to prevent seizures. Carbamazepine, however, also causes SIADH and is therefore not appropriate here as the sodium would likely drop further which itself may provoke more seizures. Furthermore, lamotrigine has the best safety profile in pregnancy of all antiepileptic drugs.

She has a BMI of 18 and no other medical history.

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A fasting blood glucose was 8. Therefore it is inappropriate and unsafe here. You will be asked to identify the most appropriate option from a list of five for each scenario see Fig. Unlike previous sections, this section predominantly assesses your ability to plan 8 monitoring for particular drugs rather than respond to their results.

Effective drug monitoring utilizes history and clinical examination as well as investigations. You will be asked to plan an appropriate monitoring strategy by choosing the most suitable option from a list of five for a given scenario. The emphasis here is the most suitable option: For example, statins are associated with a risk of myopathy in those with risk factors for it, i.

When prescribing simvastatin, a creatine kinase level should be checked at baseline in these patients. However, if the clinical situation reveals no such risk factors then a baseline check of creatine kinase is not the most suitable option and alternatives, e.

Rather than presenting a dry list of parameters to check for each drug, this chapter uses clinical scenarios as in the exam to work through the drugs that commonly require monitoring. Much of this chapter is revision of previous ones.

The microbiologist contacts you to advise commencement of IV vancomycin of which the patient is likely to require a prolonged course. Before prescribing vancomycin, which one of the following parameters would be the most important for you to check? Renal function must be taken into account when choosing a dosing regimen for vancomycin. For your own learning, the two classic side effects of vancomycin are nephrotoxicity and ototoxicity.

Look out for these in similar questions about vancomycin. B Vancomycin is renally eliminated and is not known to be hepatotoxic. A measure of ALT would not be necessary at this stage. C CRP is an acute phase protein used to check for the presence of inflammation and thus infection ; while helpful in identifying infection and thus likely to already be available in this patient , it is not required at baseline for monitoring of therapy with vancomycin.

It would help in monitoring the inflammatory response and thus presence of infection , but clinical markers of response would be more helpful. D Vancomycin may uncommonly cause neutropenia, but this would normally occur after at least a week of therapy. Neutrophil count is not required for baseline monitoring. E Thrombocytopenia is a rare side effect of therapy with vancomycin.

Platelet count is not required for baseline monitoring. Following a discussion between the patient and the GP a decision is made to start her on the cholesterollowering agent simvastatin. Before prescribing simvastatin, which one of the following parameters would be the most important to check? If active liver disease or transaminases ALT or AST are raised more than three times the normal range then statins are contraindicated or if already being taken should be stopped.

Note that transaminases i. B A measurement of blood pressure might be useful in assessing cardiovascular risk in this patient, but is not specifically relevant to therapy with simvastatin. C Creatine kinase need only be checked at baseline in patients who are considered to be at increased risk of the rare side effect of myopathy.

There is no indication that this patient is at increased risk. D Serum albumin is a measure of the synthetic function of the liver see Chapter 3.

Statins should be used with caution in patients with a history of liver disease. However, NICE guidance only requires a measure of transaminases before commencing statins. Thus, this is not the most appropriate answer.

E The dose of simvastatin is not weight based. Be careful as there are two normal ranges presented with different units. Based on the information you have, it would be reasonable to assume that no dose change is required. B See justification for Option A. C See justification for Option A. D Post-dose phenytoin levels are not routinely required. The average half-life of phenytoin approximately 24 hours is such that after 14 days of therapy there is unlikely to be significant diurnal variation in the plasma level.

One should consider the level in the context of the patient: She is told that she will be required to attend her GP surgery for regular blood tests, which will be more frequent during the first few months of therapy. Which one of the following statements regarding monitoring therapy with lithium is true? She is prescribed a low dose initially of 7. Concerning the appropriate monitoring of methotrexate therapy, which one of the following statements is true? C Full blood counts are not routinely required in patients on lithium.

D Routine serum lithium monitoring should be performed weekly after initiation and after each dose change until concentrations are stable, and then every 3 months thereafter. E Sodium depletion is known to increase the risk of lithium toxicity and patients are advised to avoid making changes in their diet that would lead to increased or decreased sodium intake.

Monitoring of full blood count at regular intervals is imperative, but once therapy has been stabilized, full blood count can be monitored every 2—3 months. B According to the BNF, a CXR is not required at baseline although the British Society of Rheumatology recommend one ; however, it may be required later on if pulmonary toxicity is suspected.

Methotrexate must be stopped immediately under these circumstances. E Methotrexate is predominantly renally excreted and toxicity is more likely in the presence of renal dysfunction. He has no other significant past medical history. Which one of the following parameters is important to check and record before commencing treatment? She has no significant past medical history but has been taking a combined oral contraceptive pill containing ethinylestradiol and levonorgestrel for the last 2 years.

She requests a prescription for a further supply of her pill. Before responding to her request, which one of the following parameters would it be most important to check?

Fasting blood glucose must be tested at baseline and at regular intervals thereafter. C Not routinely required at baseline. D Not required at baseline. E Baseline ECG prior to commencing an antipsychotic drug is only usually indicated in patients with cardiovascular disease or associated risk factors.

We are told that this patient has no significant past medical history, so this is not the most appropriate choice in this case. B Not required. D Not required. E Not specifically required for patients on contraceptive medication unless anaemia is suspected. Which one of the following statements is true regarding appropriate monitoring of amiodarone? The GP advises her to report any sore throat immediately. Which one of the following should be checked first in a patient presenting with a sore throat who is prescribed carbimazole?

T4 may be raised in the absence of hyperthyroidism. C Raised serum transaminases and acute liver dysfunction are recognized side effects of amiodarone. It is important to monitor liver function at regular intervals throughout the duration of therapy, and not only in the case of suspected hepatotoxicity.

D The dose of amiodarone is chosen independently of renal function, and renal failure is not a recognised side effect. E Amiodarone should be commenced with caution in patients with hypokalaemia owing to an increased risk of arrhythmias. A full blood count, including neutrophil count, is imperative. B It is more important in the first instance to rule out bone marrow suppression. A throat swab will not reveal bonemarrow suppression and is not indicated at this point. C Blood cultures are not indicated at this point without other features of infection, and would like throat swabs take much longer to deliver a result e.

They may be indicated later. D Carbimazole is known to be associated with hepatic disorders, but this is not the priority in the first instance.

The priority at this stage is to assess for bone marrow suppression. The dose of gentamicin is 60 mg, by IV infusion, 3 times daily. Concerning the monitoring of gentamicin therapy in infective endocarditis, which one of the following statements is true? Which one of the following parameters would be the most important for you to monitor at regular intervals in the primary care setting?

D For a multiple daily dose regimen, both pre- and post-dose levels must be checked at regular intervals. E Gentamicin is principally renally excreted from the body. Patients with renal dysfunction are at increased risk of toxicity, thus monitoring of renal function is required at regular intervals in patients on gentamicin.

It is possible that the patient may have been concomitantly started on a beta blocker but this is not mentioned. B While ramipril may cause hyponatraemia, urinary sodium would not be a suitable method for detecting this. C Serum creatinine is a sufficient measure of renal function.

Measuring urine output would not be practical in a primary care setting. ACE-inhibitors are known to cause hyperkalaemia, hyponatraemia and, in some cases, acute kidney injury.

E It is possible to measure serum levels of ACE, but it is not a relevant measurement in the monitoring of either ACE-inhibitor therapy or of heart failure. Serum ACE is characteristically raised in active sarcoidosis. Which one of the following parameters would be the most important to monitor during treatment with digoxin?

Before starting treatment, which one of the following parameters would be the most important for you to check? C Not required for patients on digoxin. It does not cause hypotension unlike calcium-channel blockers and betablockers which makes it a good choice for patients with arrhythmias and hypotension needing treatment. D Not required for patients on digoxin. Serum potassium is a more relevant parameter as hypokalaemia increases the risk of digoxin toxicity.

B Vitamin D supplementation should be considered for patients on sodium valproate at risk of osteoporosis; however, a vitamin D level would not be routinely checked at baseline. C Not required. E A measure of renal function is not routinely required prior to commencing treatment with sodium valproate. It is neither significantly renally cleared nor nephrotoxic.

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In patients with severe renal impairment, it might be necessary to adjust the dose based on careful monitoring, but we are not given any indication that this patient has severe renal impairment. The psychiatrist asks you to ensure that appropriate monitoring is carried out so that therapy can continue. Regarding the appropriate monitoring of therapy with clozapine, which one of the following statements is correct?

B Registration with a clozapine monitoring service is required for all patients. C Not routinely required in patients on clozapine. Clozapine must be immediately stopped under these circumstances. You will be asked to identify the most appropriate option from a list of five for each scenario. This places a considerable burden on the NHS in terms of morbidity, mortality and cost.

Adverse drug reactions as a cause of admission to hospital: Prospective analysis of patients. BMJ There are four different types of question you might be asked in this section and it is likely you will be asked one of each type.

Much of this chapter will be revision of earlier concepts. TYPE 1: TYPE 2: Handy tip It is advisable to know the difference between a common reaction and a dangerous one. For example, a common reaction to statins is myalgia and a dangerous one is rhabdomyolysis. Common reactions covered might include new renal impairment, hypokalaemia, hepatic dysfunction and urinary retention.

This type of reaction is sometimes referred to as a Type A reaction — common, predictable and dose related. Type A and B reactions are comprehensively discussed in pharmacology texts, but this summary should suffice for the PSA. Please fill this form, we will try to respond as soon as possible.

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Prostate Cancer Diagnosis: Office based transrectal saturation biopsy is covered in detail. Other topics explored include template guided biopsy and image-guided biopsy as well as a completely new paradigm for prevention of complications. PSA, Biopsy, and Beyond will be of great value and utility to all practicing urologists. Prostate Cancer Detection: JavaScript is currently disabled, this site works much better if you enable JavaScript in your browser. Current Clinical Urology Free Preview.

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About this book Based on the highly successful first edition of Prostate Biopsy: Show all. Pages Prostate Cancer Screening: Navigating the Controversy Hilton, William M.

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