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: Angiotensin II Receptor Blockers
Function? Reduces BP by inhibiting effects of AT II
Example? Losartan
SE? 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 mannitol -> osmotic diuresis -> v ICP
Loop NKCC2 furosemide, bumetanide
DCT NCC bendroflumethiazide
C.duct ENaC amiloride/spironolactone -> K+ sparing
Pharmacology - Angina
Nitrates
What? Generates NO
Function? Cause Vasodilatation = v PVR -> vBP
Example? Glyceryl Trinitrate (GTN) spray
SE? Postural Hypotension, Headaches

Myocardial Infarction
MORPHINE Pain relief, some vasodilatation
OXYGEN ^O2 to ischaemic tissues
NITRATES Vasodilatation
ASPIRIN 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 No treatment

1 = Moderate risk Oral anticoagulants e.g. Aspirin
2+ = High risk 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

Parkinson’s Disease

Huntington’s Disease

Alzheimer’s 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
1. Simple Partial -> no LOC, Jacksonian march
2. Complex Partial -> usually temporal, smell/taste, visual
hallucinations
3. 2o generalised -> whole brain affected w/LOC
Tx: Carbamazepine

IDIOPATHIC 1o GENERALISED
1. Childhood absence -> petit mal
2. 1o generalised tonic-clonic -> grand mal on waking
3. Juvenile myclonic epilepsy -> morning clumsiness
Tx: Sodium Valproate
Pharmacology - Epilepsy
Carbamazepine
Function: Inhibits sodium channels
SE: Drowsiness, ataxia, dizzy, vNa, Neutropenia

Sodium Valproate
Function: Inhibits Na/Ca channels, ^GABA -> inhibitory
SE: Teratogenic, hepatotoxic

Lamotrigine
Function: Inhibits Na/Ca channels
SE: Steven-Johnson Syndrome
Pharmacology - MG
What: Autoimmune disease with AChR antibodies,
inhibit action of Ach on postsynaptic membrane
PC: Fatiguable muscle weakness, N reflexes
Ix: Tensilon Test (edrophonium), Antibody screen
Tx: Acetylcholinesterase Inhibitor – Pyridostigmine
Stops breakdown of ACh so around longer to
stimulate receptor

Remember LEMS in SCLC

->VGCC -> v Reflexes
Pharmacology - PD
What: Degeneration of dopaminergic neurons in the SNpc
PC: Tremor, Rigidity, Bradykinesia
Ix: Clinical diagnosis
Tx: 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: v GABA synthesis in basal ganglia
PC: Chorea, Psychosis, Dementia
Tx: GABA agonist e.g. Baclofen
DA antagonist e.g. Chlorpromazine

Pharmacology – Alzheimer’s
What: Loss of cholinergic neurons in nuclei
Neurofibrillary tangles with tau protein
Tx: 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 e.g. Ondansetron

(vagus nerve and CTZ)
Pharmacology - Constipation
LAXATIVES
Bulking agents e.g. Methylcellulose, Fybogel
(^ faecal mass = ^ peristalsis)

Stimulants e.g. Docusate, Glycerol suppository

(^motility)

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
Tx: NSAIDs
Steroids for acute flare
DMARDs
e.g. Methotrexate – folic acid antagonist
pancytopenia, teratogenic, pneumonitis, ulcers
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

Conn’s 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 – Conn’s
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 K + sparing

Metabolic acidosis (DKA) Addison’s
Crush # Haemolysis of sample

PC: Asymptomatic, Fast irregular pulse, Chest pain,

Palpitations, Weakness, Lightheadedness
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 Staph, Strep
E.coli, Salmonella, Neisseria
Shigella, Pseudomonas
Helicobacter
Microbiology
GRAM + COCCI
Chains? Clusters?
Streptococcus Staphylococcus
Blood agar? Coagulase/DNAse?

Alpha haemolysis Beta haemolysis Positive Negative

Optochin? 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 No
Escherichia Coli 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
Bacilli settle seal in and contain and kill
in lung Apex Infecting bacilli

The Lungs
Pulmonary TB

In apex of lung there

Is more air and less
Bacilli settle blood supply
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
Bone and Joint TB

Genito urinary TB
TB
PC: General MSK Tb
Weight loss Pott’s Disease
Night sweats Septic Arthritis
Lethargy
Abdominal TB
Pulmonary TB Peritonitis
Haemoptysis Ascites
Chest pain
Chronic dry cough Genitourinary TB
Dysuria
TB Meningitis Sterile Pyuria
TB
Ix: Sputum culture x 3 Ziehl Neelson/
Lowenstein-Jenson stain
CXR
Mantoux test Latent/vaccination
Quantiferon
 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/ IVDU’s)
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
Kaposi’s 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 Hypoglycaemia

Jaundice Tachycardia
Anaemia 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: Cellulitis
Bug: Staphylococcus Aureus/Epidermidis
Ix: Blood cultures, wound swab
Tx: 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
H. Influenzae
Strep.Pneumoniae
Ix: LP, Bloods, blood cultures, ABG, ECG
Tx: 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: Community acquired pneumonia

Bug: Strep.Pneumoniae
Ix: CXR, Sputum culture, NPA, FBC
Tx: Amoxicillin, ?O2
Issues: 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: Malaria until proven otherwise!

Bug: Plasmodium
Ix: Serial thick and thin blood films, Bloods
Tx: Antimalarials, Tx Hypoglycaemia, Fluids
Quiz
Andy’s 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
Andy’s 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: An atypical pneumonia

Ix: CXR (Right apex), Bloods (vNa), Cultures (Gram -)
Bug: Legionella Pneumophila
Tx: IV Erythromycin
Thank you – questions?