Phase 2

Sarah Foster

Aims
Core pharmacology
Antibiotics

HIV
TB
Hepatitis
Malaria
Quiz

Pharmacology - Cardiac

BP = CO X PVR
CO = HR X SV

Pharmacology - Cardiac
Hypertension

Angina
MI
Clotting

Hypercholesterolaemia
AF

Pharmacology - HTN
ACEi

ARB

Diuretics

Pharmacology - HTN
ACE inhibitors
What?
Inhibit ACE in the lungs
Function? Reduces BP, vNa/H2O retention
Example? Ramipril
SE?
Cough due to bradykinin -> switch to ARB
ARBs
What:
Function?
Example?
SE?

Angiotensin II Receptor Blockers

Reduces BP by inhibiting effects of AT II
Losartan
Dizziness, Headache, Hyperkalaemia

Pharmacology - HTN
Calcium channel blockers
What?
Block influx of Ca into cells
Function? Reduces BP, Vasodilatation,
- Ionotrope (v contractn) - Dromotrope (v HR)
Example? Verapamil/diltiazem/amlodipine
SE?
Ankle swelling
Diuretics
PCT
CA
Loop
NKCC2
DCT
NCC
C.duct ENaC

mannitol -> osmotic diuresis -> v ICP

furosemide, bumetanide
bendroflumethiazide
amiloride/spironolactone -> K+ sparing

Pharmacology - Angina
Nitrates
What?
Function?
Example?
SE?

Generates NO
Cause Vasodilatation = v PVR -> vBP
Glyceryl Trinitrate (GTN) spray
Postural Hypotension, Headaches

Myocardial Infarction
MORPHINE Pain relief, some vasodilatation

OXYGEN

^O2 to ischaemic tissues

NITRATES
ASPIRIN

Vasodilatation

COX1 inhibitor, x platelet aggregation

Pharmacology - MI

Pharmacology - Clotting
ANTIPLATELETS
Clopidogrel Platelet aggregation inhibitor (ADP cant bind)
Ticagrelor Platelet aggregation inhibitor (binds P2Y12
receptor -> ADP cant bind)
Aspirin
Inhibits thromboxane production, lasts 7 days
ANTICOAGULANTS
Dalteparin Direct thrombin inhibitor, LMWH
Warfarin
Vitamin K inhibitor (Clotting factors II, VI, XI,X)
-> monitor INR, interactions
Dabigatran Direct thrombin inhibitor
Rivaroxaban Factor Xa Inhibitor

Pharmacology - ^Cholesterol
STATINS
What?

HMG CoA Reductase Inhibitor

Function?

Reduce cholesterol
Stabilise plaque
Anti-inflammatory properties

Example?

Simvastatin

SE?

Rhabdomyolysis
->Muscles break down
->Haematuria

Pharmacology - AF
What:

Atrial Tachyarrythmia, common

Rapid irregularly irregular pulse

Why:

^ATRIAL PRESSURE e.g. HTN, Hyperthyroid

^ATRIAL MUSCLE MASS e.g CM, HF
ATRIAL INFLAMMATION e.g. Surgery, MI

PC:

Asymptomatic, heart palpitations,

chest pain, stroke/TIA, dyspnoea,
fatigue, syncope, lightheadedness

Pharmacology - AF
Types:

PAROXYSMAL
PERSISTENT
PERMANENT

Ix:

ECG

Underlying cause e.g. TFTs

Pharmacology - AF
Tx:

Underlying cause e.g. Alcohol, thyroid

Rate control
e.g. beta blockers
Rhythm control i.e. Cardioversion
Anticoagulants based on CHA2DS2-VASc score
e.g. Aspirin, Warfarin

Pharmacology - AF
CHA2DS2-VASc
SCORE

O = Low risk
1 = Moderate risk
2+ = High risk

No treatment
Oral anticoagulants e.g. Aspirin
Oral anticoagulants e.g. Dabigatran

Pharmacology - AF
BETA BLOCKERS
What?
Block beta adrenoreceptors
Function? v HR and force of contraction, v BP
Example? Bisoprolol
SE?
Bradycardia -> dizzy
CARDIOVERSION
What?
Drugs/Transthoracic electrical shock
Function? Restore sinus rhythm
Example? Pharmacological e.g. Amiodarone
Electrical
SE?
Failure, VF with ECV, emboli

Pharmacology - Respiratory
Asthma

COPD
Pneumonia
TB

Pharmacology Asthma
What:

Reversible bronchoconstriction due to

inflammation in hyperactive airways.
Type 1 HS

Tx:

SABA (Salbutamol = Ventolin) -> RELIEVE

Beta agonists are sympathomimetics
Cause bronchodilatation
Steroids (Beclemetasone) -> PREVENT
Inhibit Phospholipase A2, v inflammation

Pharmacology Asthma
Steroids (Beclemetasone, Budesonide) -> PREVENT
AIRWAY INFLAMMATION

INFLAMMATION

Pharmacology Asthma
Tx:

Poor control:
LABA (Salmetarol)
Leukotriene Receptor Antagonist (Montelukast)
Oral Steroids
LAMA (Ipratropium Bromide = Atrovent)

Life threatening Asthma attack:

O2
IV Salbutamol, Theophyllines (aminophylline),
MgS04, Hydrocortisone

Pharmacology COPD
What:

Progressive airflow limitation, not fully

reversible
Bronchitis/emphysema

Tx:

Stop smoking
Inhaled LABA, SABA and LAMA
Mucolytics (Carbocysteine)
O2
Vaccines

Pharmacology - Neuro
Epilepsy
Myasthenia Gravis

Parkinsons Disease
Huntingtons Disease
Alzheimers Disease
Headaches

Pharmacology - Epilepsy
What:

Spontaneously recurring seizures other

than febrile convulsions without metabolic
abnormality or acute cerebral insult.
A seizure is a clinical event due to abnormal XS
neuronal DC leading to a sudden disturbance of
neurological function

Types:

FOCAL any age, intracerebral defect

GENERALISED <30, no defect, 3Hz spike EEG

Pharmacology - Epilepsy
FOCAL

Tx:

1. Simple Partial -> no LOC, Jacksonian march

2. Complex Partial -> usually temporal, smell/taste, visual
hallucinations
3. 2o generalised -> whole brain affected w/LOC
Carbamazepine

IDIOPATHIC 1o GENERALISED

Tx:

1. Childhood absence -> petit mal

2. 1o generalised tonic-clonic -> grand mal on waking
3. Juvenile myclonic epilepsy -> morning clumsiness
Sodium Valproate

Pharmacology - Epilepsy
Carbamazepine
Function:
SE:

Inhibits sodium channels

Drowsiness, ataxia, dizzy, vNa, Neutropenia

Sodium Valproate
Function:
SE:

Inhibits Na/Ca channels, ^GABA -> inhibitory

Teratogenic, hepatotoxic

Lamotrigine
Function:
SE:

Inhibits Na/Ca channels

Steven-Johnson Syndrome

Pharmacology - MG
What:
PC:
Ix:
Tx:

Autoimmune disease with AChR antibodies,

inhibit action of Ach on postsynaptic membrane
Fatiguable muscle weakness, N reflexes
Tensilon Test (edrophonium), Antibody screen
Acetylcholinesterase Inhibitor Pyridostigmine
Stops breakdown of ACh so around longer to
stimulate receptor

Remember LEMS in SCLC

->VGCC -> v Reflexes

Pharmacology - PD
What:
PC:
Ix:
Tx:

Degeneration of dopaminergic neurons in the SNpc

Tremor, Rigidity, Bradykinesia
Clinical diagnosis
L-dopa (can cross BBB -> DDC -> Dopamine)
DA agonists e.g. Bromocriptine, Pramipexole
MAO-B Inhibitors e.g. Seligiline, ^ synaptic DA
COMT inhibitors e.g. Entacapone, v L-dopa metabolism
Cholinergic antagonists e.g. Orphenadrine, v SEs
Manage Depression
Respite care

Pharmacology - HD
What:
PC:
Tx:

v GABA synthesis in basal ganglia

Chorea, Psychosis, Dementia
GABA agonist e.g. Baclofen
DA antagonist e.g. Chlorpromazine

Pharmacology Alzheimers
What:

Tx:

Loss of cholinergic neurons in nuclei

Neurofibrillary tangles with tau protein
Cholinesterase Inhibitors to ^ Ach
e.g. Donepezil, Rivastigmine

Pharmacology - Headache
Cluster
Triptans e.g. Sumatriptan (5HT agonists vasoconstrict -> v inflamm)
Ca Channel blockers e.g. Verapamil

Trigeminal Neuralgia
Antiepileptics e.g. Carbamazepine
Headache
COX1 Inhibitor e.g. Aspirin
Triptans
Ergotamine (vasoconstriction, inhibit trigeminal NT)

Pharmacology - Headache
Temporal Arteritis
Steroids e.g. Prednisolone ASAP before Bx
Bacterial Meningitis
3rd generation Cephalosporin e.g. Ceftriaxone ASAP

Pharmacology - GI
Vomiting
Constipation

Pharmacology - Vomiting
ANTI-EMETICS
H2 Receptor Antagonist e.g. Cyclizine
(v gastric acid)
D2 Receptor Antagonist e.g. Metoclopramide, Domperidone
(CTZ in CNS)
5HT antagonists
(vagus nerve and CTZ)

e.g. Ondansetron

Pharmacology - Constipation
LAXATIVES
Bulking agents
e.g. Methylcellulose, Fybogel
(^ faecal mass = ^ peristalsis)
Stimulants
(^motility)

e.g. Docusate, Glycerol suppository

Stool softeners

e.g.Arachis Oil enema

Osmotic
e.g. Lactulose, Phosphate enema
(retain fluid in bowel)

Pharmacology - MSK
RHEUMATOID ARTHRITIS
What:

Chronic systemic inflammatory disease

Symmetrical deforming peripheral polyarthritis
Does not affect DIP joints

Ix:

RhF 70%, Anti-CCP 98%

Anaemia of Chronic Disease, ^Platelets, ^ ESR/CRP
NSAIDs
Steroids for acute flare
DMARDs
e.g. Methotrexate folic acid antagonist
pancytopenia, teratogenic, pneumonitis, ulcers

Tx:

Pharmacology - MSK
TNF alpha INHIBITORS
Why?
NICE failed 2 DMARDs after adequate trial
Examples: Infliximab
anti-TNF antibody
Etanercept
TNF alpha receptor
Adalimumab Monoclonal TNF Ig
Issues:
Expensive, 35% no response
RITUXIMAB
What?
Anti-CD20 monoclonal antibody -> B cell cytopenia
+MTX in severe RA if no response MTX/anti-TNF

Pharmacology - Endocrine
Acromegaly
Thyroid
Conns Syndrome

Hypokalaemia
Hyperkalaemia

Pharmacology - Acromegaly
What: Excessive growth hormone after fusion of epiphyses
(growth plates)
Why: Pituitary adenoma (99%)
PC:

Due to XS hormones, local pressure and hypopituitarism,

sweating headache, increase size of hands feet jaw,
oligo/amenorrhoea, infertility

O/E:

Coarse facies (prominent supraorbital ridges, prognathism)

increased interdental spacing, macroglossia, doughy spade
like hands, CTS, bitemporal hemianopia

Pharmacology - Acromegaly
Ix:

OGTT and GH, normally ^ gluc would inhibit GH release

MRI pituitary fossa

Tx:

Transphenoidal removal of the tumour

Somatostatin analogues inhibit GH release from a.pituitary
e.g.Octreotide

Issues: DM
Vascular (HTN, Cardiomyopathy, HF)
OP
OSA

Pharmacology - Thyroid
HYPERTHYROID
Thyroidectomy
Radioactive Iodine
Carbimazole
->stops coupling and iodination of thyroglobulin by TPO
-> Reduce T3 and T4

HYPOTHYROID
Thyroxine
T4, metabolised slowly so OD
Replaces deficiency

Pharmacology Conns
What: Primary Hyperaldosteronism

Why: Adrenal adenoma 2/3, Adrenal hyperplasia 1/3

PC:

Hypertension, Polyuria, Polydipsia, weakness due to vK+,

headaches, lethargy

Ix:

Bloods - ^Na+, vK+, v Renin

ABG metabolic alkalosis
CT/MRI

Tx:

Surgical removal of adenoma

Spironolactone (aldosterone antagonist) ^ K+

Pharmacology - HypoK
What:

<3.5mmol/L. Most common electrolyte in hospitals

Why:

^ LOSS = Loop/Thiazides, Burns, D&V, Conns

TC shift Alkalosis, Insulin & Glucose, Glue sniffing

PC:

Asymptomatic
Generalised weakness, muscle pain, constipation
Muscle weakness/paralysis, resp failure, ileus

Pharmacology - HypoK
Ix:

Bloods -> U&Es vK+, vNa+ (diuretics), Mg2+, Glucose

ECG

Tx:

K+ replacement Sando K

Pharmacology - HyperK
What:

>5.5mmol/L
MEDICAL EMERGENCY
Myocardial excitability -> VF -> Arrest

Why:

Oliguric renal failure

Metabolic acidosis (DKA)
Crush #

PC:

Asymptomatic, Fast irregular pulse, Chest pain,

Palpitations, Weakness, Lightheadedness

K + sparing
Addisons
Haemolysis of sample

Pharmacology - HyperK
Ix:

Bloods - ^K+
ECG

Tx:

Stabilise heart, Shift K+ to IC , Promote renal excretion

IV access, Cardiac monitor
10mL Calcium Gluconate 10% IV -> ^ threshold potential
Insulin -> moves K+ into cells, Glucose
?Nebulised Salbutamol -> moves K+ IC
Polystyrene Sulfonate Resin
Dialysis

Microbiology
BACTERIA
Obligate IC ?

Gram Stain?

C.Trachomatis

Yes

No
M. Tuberculosis

Rods

Cocci

Clostridium, Listeria
E.coli, Salmonella,
Shigella, Pseudomonas
Helicobacter

Staph, Strep
Neisseria

Microbiology
GRAM + COCCI
Chains?

Clusters?

Streptococcus

Staphylococcus

Blood agar?

Coagulase/DNAse?

Alpha haemolysis
Optochin?

Beta haemolysis
Positive
Negative
Strep. Pyogenes (GBS) S.Aureus
S.epidermidis
Tx: Flucloxacillin/Vancomycin MRSA

+ Strep. Pneumoniae

- Strep. Viridans Tx: Amoxicillin

Microbiology
GRAM RODS
Ferment lactose on Maclonkey/CLED?

Yes
Escherichia Coli

No
Oxidase?

+
Pseudomonas

Proteus

Antibiotics
INHIBIT CELL WALL SYNTHESIS = Beta lactams
e.g. Penicillins, Cephalosporins, Carbapanems

Antibiotics
INJURE PLASMA MEMBRANE
e.g. Antifungals - Nystatin

Antibiotics
INHIBIT NUCLEIC ACID REPLICATION
e.g. DNA Gyrases Ciproflaxacin (C.diff) Rifampicin

Antibiotics
INHIBIT PROTEIN SYNTHESIS
e.g. Chloramphenicol, Erythromycin, Doxycycline (teeth)

Antibiotics
INHIBIT METABOLITE PRODUCTION
e.g. Trimethoprim for UTIs (creatinine)

TUBERCULOSIS (TB)
What:

Infection with Mycobacterium Tuberculosis/

Mycobacterium Bovis.

Who:

1/3 of the world population affected

How:

Airborne droplets.

Risks:

Immunodeficiency, overcrowding, poor

ventilation, household contact, extremes age

Pulmonary TB
Macrophages + lymphocytes
seal in and contain and kill
Infecting bacilli

Bacilli settle
in lung Apex

The Lungs

Pulmonary TB
In apex of lung there
Is more air and less
blood supply

Bacilli settle
in apex and
granuloma
forms

Bacilli taken in
lymphatics
to hilar lymph
nodes
The Lungs
Granuloma + Lymphatics + Lymph nodes = Primary Complex

TB spreads beyond the lungs

TB Meningitis

Miliary TB
Bacilli settle
in lung Apex
Bacilli taken
to hilar lymph
nodes

Pleural TB

The Lungs
Genito urinary TB

Bone and Joint TB

TB
PC:

General
Weight loss
Night sweats
Lethargy
Pulmonary TB
Haemoptysis
Chest pain
Chronic dry cough
TB Meningitis

MSK Tb
Potts Disease
Septic Arthritis
Abdominal TB
Peritonitis
Ascites

Genitourinary TB
Dysuria
Sterile Pyuria

TB
Ix:

Sputum culture x 3

CXR
Mantoux test
Quantiferon

Ziehl Neelson/
Lowenstein-Jenson stain
Latent/vaccination

TB
Tx:

Rifampicin (6/12) red/orange urine

Isoniazide (6/12) Hepatitis (severe)
Pyrazinimide (2/12) Hepatitis (common)
Ethambutol (2/12) Ocular toxicity
12/12 for TB Meningitis
Up to 2 years for MDR-TB

HIV
What: Retrovirus (RNA) affecting CD4 cells (Th)
Who:

33 million people affected worldwide

UK 77,400 (>80% heterosexual sex)
Sheffield 700 patients

How:

Mother to child
Risky sexual behaviour
Blood-blood (transfusions/ IVDUs)

HIV
PC:

Acute sero-conversion illness

2-6 weeks after exposure
Non-specific illness. Fever, myalgia, lethargy.
Late presentation of HIV
Chronic diarrhoea (>3months)
Persistent generalised lymphadenopathy (PGL)
Weight loss, infections, night sweats,fever.
Opportunistic infections.

HIV

HIV - AIDS
What:

Acquired Immunodeficiency Syndrome

PC:

Usually CD4 <350

Oesophageal Candidiasis - Nystatin
Pulmonary or extrapulmonary TB - RIPE
PCP - Cotrimoxazole
Kaposis sarcoma HAART, chemo
Shingles - Aciclovir

HIV
Ix:

HIV ELISA test (> 3 months after exposure)

RDT

Tx:

HAART usually combination

Contact tracing
Prophylaxis - co-trimoxazole (septrin)
Prevention!
Pregnancy Csection, Bottle feed, Tx baby

Malaria
What: Blood borne parasitic infection
Vector: Female anopheles mosquito saliva
Types: Plasmodium falciparum
Plasmodium Malariae
Plasmodium Vivax
Plasmodium Ovale

Malaria
Lifecycle:

Hypnozoites

RELAPSE

Malaria
Who: Pregnancy, kids, foreign travelers, HIV
PC: Fever in a returning traveller
Myalgia, Malaise, D&V, Headache

OE: Splenomegaly
Jaundice
Anaemia

Hypoglycaemia
Tachycardia
Tachypnoea

Malaria
Ix:

Serial thick and thin blood films

Tx:

ABCDE Supportive
Antimalarials e.g. Quinine, Artesenate

Issues: Cerebral Malaria, Resp. Acidosis, Anaemia

Hypoglycaemia, Co-infection

Malaria
Prevention:
1. Vector Control
e.g. mosquito nets, residual spraying
2. Appropriate anti-malarial prophylaxis
e.g. Malarone, Doxycycline, Chloroquine

Hepatitis
What: Inflammation of the liver
Why:

Infection (Hepatitis, Herpes), Malignancy,

Inflammation (cholecystitis/pancreatitis)
Drugs (paracetamol, alcohol)

PC:

Jaundice, Fever, Abdo Pain, Malaise, N&V

OE:

Jaundice, ^Temp, Tender RUQ

Hepatitis
Types:

A/E Faecal Oral Route

B/C Blood products
D
IVDU users, need Hep B

Who:

90% babies chronic Hep B

90% adults clear Hep B

Tx:

Supportive
Prevent hepatic failure

Hepatitis Serology
Core Antigen cAg = ACUTE ^^^ Virus replication
Envelope Antigen eAg = Over time
Surface Antigen sAg =
Protection, clearance, vaccination

Hepatitis Serology
^^^LFTs, AntiHBc IgM = ACUTE
^LFTs, AntiHBc IgG = CARRIER
N LFTs, AntiHBs = VACCINATION
N LFTs, AntiHBs, Anti HBc IgG = RECOVERY

Quiz
Arthur, 60 year old male diabetic has sore, hot red leg
after tripping over 3 days ago. No calf tenderness, leg
swelling or chest pain.
What:
Bug:
Ix:
Tx:

?
?
?
?

Quiz
Arthur, 60 year old male diabetic has sore, hot red leg
after tripping over 3 days ago. No calf tenderness, leg
swelling or chest pain.
What:
Bug:
Ix:
Tx:

Cellulitis
Staphylococcus Aureus/Epidermidis
Blood cultures, wound swab
Flucloxacillin/Vancomycin

Quiz
Scarlett, 18 year old female student, 2 day history of fever,
vomiting and headache.
What:

Bug:
Ix:
Tx:

?
?
?

Quiz
Scarlett, 18 year old female student, 2 day history of fever,
vomiting and headache.
What:

Meningitis

Bug:

NHS N.Meningitides

Ix:
Tx:

H. Influenzae
Strep.Pneumoniae
LP, Bloods, blood cultures, ABG, ECG
Benzylpenicillin, CEFTRIAXONE STAT

Quiz
Betty, an adorable 87 year old lady has had a cough for
3/7. She becomes very short of breath, pyrexic and is
coughing up green sputum.
What:
Bug:
Ix:
Tx:
Issues:

?
?
?
?
?

Quiz
Betty, an adorable 87 year old lady has had a cough for
3/7. She becomes very short of breath, pyrexic and is
coughing up green sputum.
What:
Bug:
Ix:
Tx:
Issues:

Community acquired pneumonia

Strep.Pneumoniae
CXR, Sputum culture, NPA, FBC
Amoxicillin, ?O2
CURB65 score (score 5 = ^^^mortality)

Quiz
Andy, a 22 year old med student has just got back from his
elective in Namibia. He is feeling very tired and has a
fever.
What:
Bug:
Ix:
Tx:

?
?
?
?

Quiz
Andy, a 22 year old med student has just got back from his
elective in Namibia. He is feeling very tired and has a
fever.
What:
Bug:
Ix:
Tx:

Malaria until proven otherwise!

Plasmodium
Serial thick and thin blood films, Bloods
Antimalarials, Tx Hypoglycaemia, Fluids

Quiz
Andys friend Lee, went to Ibiza for a lads holiday. He has
had R-sided chest pain, SOB and a dry cough for 8/7. He
now has a headache, chills and myalgia.
HR 125, BP 75/50, RR 40, Temp 38.5oC, O2 89%

What:
Ix:
Bug:
Tx:

?
?
?
?

Quiz
Andys friend Lee, went to Ibiza for a lads holiday. He has
had R-sided chest pain, SOB and a dry cough for 8/7. He
now has a headache, chills and myalgia.
HR 125, BP 75/50, RR 40, Temp 38.5oC, O2 89%

What:
Ix:
Bug:
Tx:

An atypical pneumonia
CXR (Right apex), Bloods (vNa), Cultures (Gram -)
Legionella Pneumophila
IV Erythromycin

Thank you questions?