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GP gauntlet #3 (contraception, menstrual symptoms, analgesia, neuro)

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elliptic's version from 2018-05-20 03:52

Some contraception, etc

Question Answer
COCP contraindications x 8clotting x2 (current or past VTE, thrombophilia), vascular x4 (CAD, uncontrolled hypertension, cerebrovascular disease, migraine with aura), organs involved with oestrogen x2 (severely impaired liver function, breast or genital tract cancer)
Reasonable general first line COCP?Femme-Tab 20/100 (ethinyloestradiol 20mcg / levonorgestrel 100mcg). Can increase oestrogen to Femme-Tab 30/100.
COCP with antiandrogenic progestin (useful for acne, bloating, breakthrough bleeding, breast tenderness)ethinyloestradiol 20mcg / drospirenone 3000mcg.
POPlevonorgestrel 30 micrograms (Microlut)
Missed COCP advice?Take the pill most recently missed straight away. This may mean 2 pills in 1 day. If >24 hours overdue, take the following additional precautions: 1. use condoms for 7 days, 2. if less than 7 pills since last placebo break, consider emergency contraception if unprotected sex in past 5 days, 3. if less than 7 pills left before next placebo, skip the placebos and continue the active pills.
Emergency contraception?levonorgestrel 1.5mg PO stat, within 72 hours of unprotected sexual intercourse. OR ulipristal acetate 30mg within 120 hours (but then use barrier method until next period).
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Menorrhagia, etc

Question Answer
Definition of menorrhagia>80mL / cycle. or >7days. or unacceptable to the woman
Drug treatments for menorrhagiatranexamic acid, 1g qid or 1.5g tds for first 3-5days of menstruation. mirena. COCP. medroxyprogesterone 10mg, 1-3 times/day on days 1-21 of a 28 day cycle, for up to 6 months... or for anovulatory cycles, 10mg daily for the same 12 days of each calendar month.
Investigations for menorrhagiaFBE, pregnancy test. Pap if indicated. Also consider coags, ferritin, TSH. Consider uterine imaging (USS/saline-infused sonography, or hysteroscopy) if suspicious for uterine pathology (irregular bleeding; unresponsive to medical therapy, or anyone >40)
Treatment for primary dysmenorrhoeaCOCP containing 30mcg ethinyloestradiol. NSAID.
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Analgesia, etc

Question Answer
3 NSAIDs, including low GI risk and low CV riskUsual 1st choice: ibuprofen 200-400mg tds. Low GI risk, higer CV risk: diclofenac 25-50mg 2-3 times/day. Lower CV, higher GI risk: naproxen 250-500mg bd. onsider coadministering with PPI (eg. pantoprazole 40mg daily).
Tramadol dosage and precautionstramadol immediate-release 50 to 100 mg orally, up to QID prn. Consider coadministering with docusate + senna 50+8 mg, 1-2 tabs nocte. Avoid if risk of seizures or serotonin syndrome
Conversion factors to oral morphine equivalent daily dose: codeine, tramadol, tapentadolcodeine mg/d x 0.13, tramadol mg/d x 0.2, tapentadol mg/d x 0.4
Conversion factors to oral morphine equivalent daily dose: endone, norspan, fentanyl patchendone mg/d x 1.5, norspan mcg/h x 2, fentanyl patch mcg/h x 3
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Neuro drugs

Question Answer
Causes of papilloedema1. Malignant hypertension. 2. Raised intracranial pressures due to space occupying lesions or infection. 3. Renal failure. 4. Chronic carbon dioxide retention. 5. Idiopathic intracranial hypertension, and 6. Hypocalcaemia.
Partial seizures, rxCarbamazepine MR 100mg nocte. Titrate weekly by 100-200mg/d to initial target dose of 200mg bd. Max dose 600mg bd.
Tonic-clonic seizures, rxPotential for pregnancy: Levetiracetam 250mg bd 1 week, increase to initial target dose of 500mg bd. Max dose 1500mg bd. For everyone else: Sodium valproate 500mg, daily for 1 week, then increase to initial target dose of 500mg bd. Max dose 1500mg bd.
Acute seizureSupportive (prevent aspiration, trauma), Rule out secondary causes. If >5m, 10mg midazolam IV over 2+ minutes, or IM if IV access can't be obtained, then sodium valproate 40mg/kg up to 3000mg, IV over 3-5 min.
Acute migraine rxNSAID (eg ibuprofen 400-600mg; repeat in 4-6 hours if needed). If nausea, add metoclopramide. If not relieved, prescribe a triptan for next time, eg. sumatriptan 50-100 mg; wait at least 2 hours before repeating dose if needed (max 300mg/d).
Precautions around triptans 1. Contraindicated in known/suspected CAD. 2. Don't use within 24h of ergotamine or dihydroergotamine. 3. If the patient is taking an SSRI or SNRI, counsel about the symptoms of serotonin syndrome. Limit triptan use to less than 10 days per month.
Name 4 migraine prophylaxis optionsConsider if requiring acute treatment 2-4 times/month; continue for 8-12 weeks to assess efficacy. Titrate each at 1+ weekly intervals ot max tolerated dose. 1. Amitriptyline 10mg nocte (max 75mg/d). 2. Candesartan 4mg/d (max 32mg/d). 3. Propranolol 20mg nocte (max 160mg in 2-3 divided doses). 4. Pizotifen 0.5mg nocte (max 1.5-3mg).
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More neuro drugs

Question Answer
Cluster headache rx1. Sumatriptan 6mg sc / 20mg im stat. 2. ?High flow O2. 3. (Consider bridging with) Prednisone 50mg/d for 5 days, then taper. 4. (Preventative rx) Verapamil 80mg tds, tapering up to 120 then 160 at 2 weekly intervals.
Trigeminal neuralgia rxCarbamazepine MR 100mg bd, titrating at weekly intervals to 400mg bd as needed/tolerated.
Greater occipital neuralgia1. Greater occipital nerve block. 2.Pregabalin 75 mg nocte; can gradually increase dose q3-7d to max 150-300mg bd.
Overactive bladder rxoxybutynin 2.5-5mg bd-tds; or 3.9mg/d patch twice weekly. Anticholinergic so can get hot as hare, blind as a bat (mydriasis), dry as a bone, red as a beet, mad as a hatter.
Parkinson's rxLevodopa+carbidopa 50+12.5mg, tds, titrating to 100+25 tds. A less ideal option is pramipexole MR (0.375mg/d, slowly titrated to 4.5mg/d).
Rx for dementia (alzheimers, parkinsons)Donepezil PO 5mg nocte, or rivastigmine 4.6mg transdermally, once daily applied for 24 hours.
Restless legs syndrome, treatmentExclude iron deficiency, pregnancy, renal failure. Recommend exercise and sleep hygeine. Mild/infrequent symptoms: levodopa+carbidopa 100+25mg before bed prn. Mod/severe symptoms: pregabalin 75mg before bed, or pramipexole 0.125mg 2-3 hr before bed. (These are starting doses)
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