OSCE Atlas · Oxford Y4

Oxford ICC · Year 4 · 2025–26

Signs bank

Sign → differential → investigations (bedside → bloods → imaging). Each examination has its own colour, used consistently across this site.

Investigations

Investigation map

Core tests at the top — shared across nearly every exam. Further down: exam-specific tests. Expand any test for deployment details and when to think of it.

Differentials

Differential atlas

All differentials grouped by examination. Expand any tile for the sign that points to it.

GMC Practical Skills · Year 4

Procedures

23 GMC practical skills (indication, steps, CI, complications) plus 15 special investigations (what a patient needs to know: prep, what it involves, common and serious rare complications).

GMC generic requirements — applies to every procedure

Introduce yourself, verify patient identity, confirm the procedure is indicated
Explain the procedure and gain informed consent including possible complications
Hand hygiene + appropriate PPE; universal precautions throughout
Safe sharps disposal; dispose of clinical waste in appropriate receptacles
Label samples at the bedside immediately; document procedure, findings, and aftercare plan
Ensure appropriate monitoring and follow-up; maintain confidentiality

Assessment & Monitoring

Baseline physiological observations

Indirect

Indication

Any patient assessment, admission clerking, early warning scoring (NEWS)

Steps

Temperature — tympanic or oral; normal 36.1–37.2°C
Respiratory rate — count over a full 60 seconds; normal 12–20/min
Pulse — rate, rhythm, character; normal 60–100/min
BP — correct cuff size, patient relaxed, arm at heart level
SpO₂ — pulse oximeter on finger; normal ≥95%
Urine output — from catheter bag or fluid chart; target ≥0.5 mL/kg/h
Record on NEWS chart; escalate per trust protocol

Key

RR is the most sensitive early warning parameter — don't rush it. NEWS ≥5 = urgent review; ≥7 = emergency response

Peak expiratory flow rate (PEFR)

Indirect

Indication

Asthma monitoring, exacerbation severity assessment, treatment response

Steps

Set pointer to zero; patient stands or sits upright; full breath in
Seal lips tightly around mouthpiece; blast air out as hard and fast as possible
Reset; repeat — take best of 3

Interpret

Compare to predicted (age/height/sex chart or patient's personal best)
<50% predicted = moderate attack; <33% predicted = severe / life-threatening

Ophthalmoscopy (fundoscopy)

Indirect

Indication

Headache/raised ICP, visual disturbance, DM/HTN retinopathy, optic disc assessment, papilloedema

Steps

Dim room; dilate pupils if available (tropicamide 1%)
Dioptre dial to 0; use right eye for patient's right eye; approach 15° lateral from arm's length
Look for red reflex (absent = cataract or vitreous haemorrhage)
Converge toward pupil; adjust dioptre wheel to focus on optic disc
Disc: margins, colour, cup:disc ratio (<0.5 normal)
Follow four vessel quadrants; assess AV ratio, nipping, silver/copper wiring
Ask patient to look at the light to expose macula

Key findings

Papilloedema: blurred disc margins, disc hyperaemia — raised ICP
Optic atrophy: pale disc — MS, ischaemia, previous optic neuritis
AV nipping / silver wiring: hypertensive retinopathy
Dot/blot haemorrhages, hard exudates, new vessels: diabetic retinopathy

Otoscopy

Indirect

Indication

Ear pain, discharge, hearing loss, vertigo, tinnitus

Steps

Select speculum (4 mm adult, 2.5 mm child)
Pull pinna up and back in adults to straighten canal
Insert gently; advance while looking through scope
Identify canal then tympanic membrane: normal = pearly grey, cone of light at 5 o'clock R / 7 o'clock L

Key findings

Red, bulging TM ± absent light reflex: acute otitis media
Amber/dull TM, fluid level: otitis media with effusion (glue ear)
Perforation: hole visible, may see middle ear
Pearly white mass: cholesteatoma — refer ENT urgently

Sampling & Diagnostic

Venepuncture

Indirect

Indication

Blood sampling for laboratory analysis

Steps

Tourniquet; palpate vein (antecubital fossa preferred)
Clean with 70% isopropyl alcohol; allow to dry 30 s before inserting needle
21–23G needle, bevel up, 15–30°; advance until blood enters barrel
Order of draw: blood culture → blue (citrate) → gold SST → green (heparin) → purple (EDTA) → grey (fluoride)
Release tourniquet before withdrawing; apply pressure; label immediately at bedside

Complications

Haematoma, haemolysis (do not shake tubes), vasovagal

Key

If using butterfly: prime the tubing with discard blue tube first, then start order of draw

Peripheral blood cultures

Direct

Indication

Suspected bacteraemia: pyrexia (>38°C or <36°C), rigors, clinical sepsis

Steps

Two sets from two separate sites (both peripheral venepuncture)
Clean skin with 2% chlorhexidine in alcohol; allow to dry 30 s — do not fan
Clean bottle tops with alcohol swab; inoculate aerobic bottle first then anaerobic; fill to line (8–10 mL each)
Label: name, DOB, hospital number, time, site; send to lab promptly; do not refrigerate

Avoid

Do not take from existing IV lines — high contamination risk; use dedicated peripheral venepuncture

Complications

Contamination (false positive — most common), haematoma, pain

Arterial blood gas (ABG)

Direct

Indication

Respiratory failure assessment, acid-base disturbance, lactate in sepsis, monitoring ventilation

Steps

Modified Allen's test: compress radial + ulnar arteries; patient clenches fist until blanched; release ulnar only — hand should flush pink within 5–7 s (confirms adequate collateral). Proceed only if positive
Wrist dorsiflexed 30–60°; palpate radial pulse; clean with chlorhexidine
Pre-heparinised syringe; insert at 45° bevel up; advance until pulsatile blood fills syringe
Remove needle; firm pressure 5 minutes (longer if anticoagulated)
Expel air bubbles; cap and label; send to analyser immediately

Contraindications

Failed Allen's test (inadequate collateral circulation)
AV fistula on that arm; local infection; coagulopathy (relative)

Complications

Haematoma (most common), arterial spasm, thrombosis (rare), nerve injury, infection

Capillary blood glucose

Indirect

Indication

Glucose monitoring in DM, suspected hypo/hyperglycaemia, DKA monitoring, peri-operative glucose management

Steps

Warm hands; clean lateral aspect of fingertip with alcohol wipe; allow to dry
Pierce with lancet; wipe away first drop; apply second drop to test strip; read result

Interpret

Normal fasting: 4–5.6 mmol/L
<4 mmol/L = hypoglycaemia: treat if symptomatic — 15–20 g fast-acting carbohydrate (Lucozade, dextrose gel) or IV 10% glucose if unable to eat

Urine multi-dipstick test

Indirect

Indication

Suspected UTI, renal disease, DM monitoring, haematuria, jaundice workup

Steps

Explain MSU technique: clean genitalia; start voiding; catch mid-portion in sterile pot
Dip strip for 1–2 s; lay flat; read at times specified on strip

Interpret

Nitrites + leucocytes: bacterial UTI
Blood: haematuria — UTI, stones, cancer; confirm with microscopy
Protein: nephrotic syndrome, UTI, pre-eclampsia
Glucose: DM (renal threshold ~10 mmol/L), renal glycosuria
Ketones: DKA, starvation, alcoholic ketoacidosis
Bilirubin / urobilinogen: liver disease patterns

Swab (throat / nose / wound)

Indirect

Indication

Suspected local infection: wound, throat (tonsillitis), nose (MRSA screen, respiratory pathogens), ear, genital

Steps by site

Throat: depress tongue; swab tonsils and posterior pharynx vigorously; avoid teeth, tongue, and uvula
Nose: insert swab 1–2 cm; rotate against mucosa; repeat other nostril
Wound: remove surface exudate with saline gauze first; swab the purulent area — not the wound edges
Correct transport medium (charcoal for most bacterial swabs); label fully; send within 4 h or refrigerate overnight

Key

Document recent antibiotics on request form — affects sensitivity

3- or 12-lead ECG

Indirect

Indication

Chest pain, palpitations, syncope, dyspnoea, pre-operative assessment, arrhythmia monitoring

Lead placement

Limb leads: RA red · LA yellow · LL green · RL black (ground). Mnemonic: Ride Your Green Bike
V1: 4th ICS, right sternal border; V2: 4th ICS, left sternal border
V3: between V2 and V4; V4: 5th ICS, mid-clavicular line
V5: anterior axillary line (same horizontal as V4); V6: mid-axillary line (same horizontal as V4)
Patient supine, limbs relaxed, no talking or movement

Check

Calibration: 25 mm/s speed, 10 mm/mV amplitude — confirm on printout
Poor electrode contact = wandering baseline; 3-lead = continuous monitoring (limb leads only)

IV Access & Infusions

Intravenous cannulation

Direct

Indication

IV drug or fluid administration, blood transfusion, contrast administration

Steps

Tourniquet proximal; choose vein (antecubital fossa, dorsum of hand, forearm)
Clean with chlorhexidine; allow to dry 30 s
Stretch skin; insert at 15–30° bevel up; look for flash of blood in chamber
Advance catheter only (not needle) into vein; release tourniquet; remove stylet
Connect Luer cap or giving set; flush with 10 mL saline to confirm patency (no swelling/resistance)
Secure with transparent dressing; date and time the cannula

Sizes

14G (orange): major haemorrhage · 16G (grey): blood transfusion / theatre · 18G (green): routine adult · 20–22G (pink/blue): small veins / children

Don't

Avoid arm with AV fistula, lymphoedema, or ipsilateral to mastectomy

Complications

Haematoma, tissuing (extravasation), phlebitis, infection, arterial puncture

Set up an IV infusion

Direct

Indication

IV fluid or drug administration

Steps

Check prescription — 5 rights: right patient, drug, dose, route, time; check allergies and expiry
Spike bag with giving set (aseptic); close roller clamp; squeeze drip chamber until half full
Open clamp to prime giving set (expel all air bubbles)
Connect to cannula; set rate via infusion pump or manual drip count
Manual drip rate: (volume mL × drop factor) ÷ time in minutes; standard giving set = 20 drops/mL
Monitor site for tissuing; check flow rate hourly if manual

Key

Two-person check for high-risk drugs (KCl, insulin infusions). Never add KCl to a hanging bag

Prepare & administer injectable drugs (IM / SC / IV)

Direct

IM injection

Sites: deltoid (outer upper arm, 2–3 finger-breadths below acromion) or vastus lateralis (outer thigh)
21–23G needle; stretch skin (or Z-track for irritant drugs); insert at 90°; aspirate; inject slowly; apply pressure; max 5 mL

SC injection

Sites: lateral abdomen, outer thigh, outer upper arm
25–27G short needle; pinch skin; insert at 45° (or 90° with short needle); no aspiration needed; inject slowly

IV bolus

Flush cannula with saline; administer drug at prescribed rate; flush after
Two-person check for high-risk drugs

Complications

Accidental IV injection (if IM/SC intended), haematoma, nerve injury, infection, lipodystrophy (repeated SC)

Administration

Prescribe & administer oxygen

Indirect

Indication

SpO₂ <94% (or <88% in hypercapnic RF risk), acute respiratory distress, CO poisoning, cardiac arrest, post-anaesthesia

Delivery devices

Nasal cannulae (1–4 L/min → ~24–36% FiO₂): comfortable; allows eating and talking
Simple face mask (5–10 L/min → ~35–55%): minimum 5 L to flush CO₂ from mask
Venturi mask (24%, 28%, 35%, 40%, 60%): fixed FiO₂ — preferred in COPD / Type II RF
Non-rebreather mask (15 L/min → >90%): severe hypoxia, CO poisoning, anaphylaxis

Targets

Most patients: SpO₂ 94–98%
Type II RF risk (COPD, obesity hypoventilation, NMD): SpO₂ 88–92%

Caution

Uncontrolled high-flow O₂ in Type II RF may worsen hypercapnia — always prescribe with target SpO₂ range on drug chart

Instruct patients in inhaler use

Indirect

pMDI technique

Remove cap; shake well; exhale fully away from device
Seal lips; begin slow inhalation; press canister once at the start of the breath
Continue slow deep breath over 5 s; hold breath 10 s; exhale slowly; wait 30–60 s before second puff

Spacer (use with pMDI)

Actuate once into spacer; breathe in and out through mouthpiece 5 tidal breaths
Recommended for all children and adults with poor coordination

DPI (Turbohaler / Accuhaler)

Load dose per device; exhale away from device; seal lips; breathe in fast and hard; hold 5–10 s
Do NOT shake DPIs — inspiratory flow drives drug delivery (opposite of pMDI)

Review

Ask patient to demonstrate at every asthma/COPD review — poor technique is a leading cause of treatment failure

Safe blood transfusion

Simulation

Indication

Hb <7 g/dL (symptomatic or perioperative); <8 g/dL in cardiac disease
Active haemorrhage with haemodynamic compromise

Steps

Send group & screen or crossmatch (correctly labelled tube + signed form)
Collect blood from blood bank; carry immediately to ward
Bedside check (two qualified staff): patient wristband vs unit label — verify full name, DOB, hospital number, blood group, unit number, expiry
Obtain consent; ensure ≥16G IV access; start infusion slowly for first 15 minutes — observe for reactions
One unit maximum over 4 hours; record observations pre-transfusion, at 15 min, and post-unit

Transfusion reactions

Febrile non-haemolytic (most common): fever, chills — slow transfusion, paracetamol; usually continue
Acute haemolytic (ABO incompatibility — most dangerous): fever, rigors, back/loin pain, haemoglobinuria — STOP immediately, IV fluids, urgent haematology
Anaphylaxis: urticaria, bronchospasm, hypotension — STOP, IM adrenaline
TACO (fluid overload): acute pulmonary oedema — slow/stop, IV furosemide, sit upright
TRALI: acute lung injury within 6 h of transfusion — stop; supportive O₂; ICU if severe

Catheters & Tubes

Male & female urinary catheterisation

Direct

Indication

Acute urinary retention, accurate fluid balance (critical illness, post-op), neurogenic bladder, pre/intra-operative

Steps

Strict sterile technique throughout; chaperone for intimate procedure; catheter size 12–16 Fr
Male: retract foreskin; clean glans; instil lidocaine 2% gel into urethra; wait 5 min; insert catheter to full length (bifurcation) before inflating balloon — never inflate until fully in bladder
Female: separate labia; clean; lubricate catheter tip; insert ~4 cm; urine drains before inflating balloon
Inflate balloon with 10 mL sterile water; withdraw until resistance; connect drainage bag; replace foreskin
Document: date, time, catheter size, balloon volume, indication

Contraindications

Suspected urethral trauma (pelvic fracture, blood at meatus) — do NOT attempt; alert urology for suprapubic catheter

Complications

CAUTI (most common long-term), urethral trauma/false passage, haematuria, balloon inflation in urethra

Nasogastric tube placement

Simulation

Indication

Enteral feeding, drug administration, gastric decompression (post-op ileus, obstruction), gastric lavage

Steps

NEX measurement: Nose → Ear → Xiphisternum; note this length
Lubricate tube; patient sitting, head slightly flexed forward
Advance through nose; at posterior pharynx ask patient to sip water and swallow — advance during each swallow
Continue to NEX length; secure temporarily
Confirm placement before ANY use: aspirate gastric fluid; test pH with CE-marked indicator paper
Safe if pH ≤5.5; if pH 5–6 or unable to aspirate → arrange CXR for radiological confirmation
Do NOT use until confirmed; document confirmation method and time

Contraindications

Base of skull fracture: use oral route (risk of intracranial placement)

Complications

Pulmonary placement (SERIOUS — hence mandatory confirmation), epistaxis, oesophageal trauma, vomiting

Local anaesthetics

Direct

Key agents & doses

Lidocaine: max 3 mg/kg plain; 7 mg/kg with adrenaline. 1% solution = 10 mg/mL → 21 mL max for 70 kg (plain)
Bupivacaine: max 2 mg/kg (plain); 3 mg/kg with adrenaline; longer acting (2–8 h)
Aspirate before injecting; inject subcutaneously or into tissue plane; wait 2–3 min before starting procedure

Avoid adrenaline in end-arteries

Digits (fingers, toes), penis, nose tip, ear pinna — risk of ischaemic necrosis

LA systemic toxicity

Progression: perioral tingling → metallic taste → tinnitus → dizziness → confusion → seizures → cardiac arrest (VF)
Treatment: stop injection; ABC; 20% Intralipid IV (lipid emulsion rescue); call for help

Surgical Skills

Surgical scrubbing, gowning & gloving

Direct

Steps

Remove jewellery and watches; check nails are short, clean, and unvarnished
Traditional scrub (3–5 min): nail brush for subungual debris; antiseptic soap (chlorhexidine or povidone-iodine); systematic: fingertips → interdigital spaces → hands → wrists → forearms to 2 cm above elbow
Alternatively: alcohol surgical hand rub per manufacturer protocol
Hands above elbows throughout; dry with sterile towel (blotting, fingertips to elbow); don sterile gown (circulating nurse assists); closed-technique gloves

Key

Once scrubbed: hands remain in sterile field (above waist). If contaminated, re-scrub. Consider double-gloving — glove puncture is common

Wound care & basic wound closure

Direct

Wound assessment

Colour: red = granulating / inflamed; yellow = sloughy; black = necrotic; pink = epithelialising
Size, depth, exudate amount and type, surrounding skin (erythema, maceration), odour
Irrigate with normal saline (high-pressure syringe for traumatic wounds)

Dressing choice

Non-adherent (Mepitel): clean/healing wound, low exudate
Alginate (Sorbsan): sloughy/infected, high exudate
Foam (Allevyn): cavity wounds, moderate/high exudate
Hydrocolloid: low-moderate exudate; promotes autolytic debridement

Sutures

Interrupted sutures: needle at 90° to skin; equal bites each side; evert wound edges; knot away from wound line
Removal timings: face 5–7 days · scalp 7–10 · trunk 7–10 · lower limb 10–14

Complications

Wound infection, dehiscence, haematoma, seroma, keloid scar

Moving & handling (including frail patients)

Indirect

Principles

TILE assessment: Task · Individual capacity · Load (weight, attachments, compliance) · Environment (space, floor)
Use equipment: hoist (full lifts), slide sheets (bed repositioning), transfer board/belt
Minimum 2 people for dependent patients; handler: back straight, knees bent, load close, avoid twisting
Frail patients: assess falls risk; ensure call bell in reach; communicate clearly throughout; check for dislodged IV/catheter/drain after repositioning

Risks

Back injury (staff), falls (patient), pressure injury during repositioning, dislodged lines/catheters/drains

Special Investigations

Not expected to perform or interpret these — know: indication, preparation, what it involves for the patient, common complications, and serious/rare complications.

CT / MRI of the Head

Indication

CT: acute stroke (exclude haemorrhage before thrombolysis), head injury (NICE criteria), SAH (LP if CT −ve), SOL, hydrocephalus — urgent first-line
MRI: posterior fossa lesions, MS plaques, dementia, encephalitis; not for acute/unstable patients

Preparation

CT plain: remove metal from head/neck; no other prep
CT with contrast: eGFR check (nephropathy risk if <60); allergy screen; hold metformin 48 h after if eGFR <60
MRI: full metal/implant screen — pacemaker, cochlear implant, ferromagnetic clips = absolute CI; claustrophobia screen (pre-medicate with midazolam if needed)

What it involves

CT: lie still, 5–10 min, loud but not confined; contrast = warm/metallic flush on injection
MRI: 30–60 min; very loud banging (ear protection provided); confined bore; no movement; breath-hold instructions for some sequences

Common complications

Contrast: nausea, flushing, transient metallic taste, extravasation at cannula site. MRI: claustrophobia anxiety

Serious / rare

CT contrast: anaphylaxis (<0.1%), contrast-induced nephropathy — pre-hydrate if high risk
MRI: implant displacement or heating; gadolinium — nephrogenic systemic fibrosis (NSF) if eGFR <30

CT Chest / Abdomen / Pelvis (incl. CTPA, CTKUB)

Indication

CTPA: suspected PE (Wells intermediate/high or PERC positive)
CT CAP: cancer staging, source of sepsis, acute abdominal pain
CTKUB: renal/ureteric calculi (no contrast needed)

Preparation

IV contrast (CTPA/CAP): eGFR check, allergy screen, IV cannula; hold metformin 48 h if eGFR <60
Oral contrast (bowel opacification): clear liquid + contrast agent 1–2 h before
CTKUB: no contrast, no prep required

What it involves

Lie in scanner; 10–20 min; breath-hold instructions for chest; IV contrast = warm flush + metallic taste; no movement

Common complications

Nausea, flushing, warmth, extravasation at IV site

Serious / rare

Anaphylaxis (<0.1%); contrast-induced nephropathy — pre-hydrate if high risk
Ionising radiation — discuss benefit/risk; avoid in pregnancy unless essential

MRI Abdomen & Pelvis (incl. MRCP)

Indication

MRCP: biliary/pancreatic pathology — choledocholithiasis, biliary stricture, PSC, pancreatic mass
Liver lesion characterisation, renal/adrenal/pelvic masses

Preparation

Full metal/implant screen (pacemaker = absolute CI)
MRCP: NBM 4–6 h (empty gallbladder improves imaging)
Gadolinium contrast: check eGFR — CI if <30 (NSF risk); claustrophobia screen

What it involves

45–60 min in bore; very loud (ear protection); breath-hold instructions; possibly IV gadolinium (warm flush); no movement

Common complications

Claustrophobia; gadolinium: nausea, transient warmth/headache

Serious / rare

Implant displacement/heating; gadolinium NSF if eGFR <30

Bronchoscopy (incl. BAL)

Indication

Haemoptysis, abnormal CXR/CT (endobronchial lesion), suspected lung cancer (biopsy), foreign body, BAL for infection (PCP, fungal, TB), sarcoidosis

Preparation

NBM 4–6 h; IV access; supplemental O₂; throat/nasal LA spray ± IV sedation (midazolam); coagulation screen if biopsy planned (INR <1.5, platelets >50)

What it involves

Awake with sedation; flexible scope via nose or mouth into bronchi; will cough; biopsies/BAL performed (not felt); 20–30 min; recovery 1–2 h
Throat/nasal spray numbs the airway — nothing to eat or drink until gag reflex fully returns (usually 1–2 h)
Bring someone to drive you home; no driving for 24 h after sedation
Blood-streaked sputum for 24 h after biopsy is normal; post-BAL fever is common

Common complications

Cough, transient hypoxia, sore throat, post-procedure fever (BAL), minor haemoptysis (after biopsy)

Serious / rare

Significant haemorrhage (post-biopsy in vascular tumours), pneumothorax (~1–5% with transbronchial biopsy), respiratory failure, laryngospasm

Pleural tap (thoracocentesis)

Indication

Diagnostic: exudate vs transudate (Light's criteria), cytology, microbiology
Therapeutic: large symptomatic effusion (max 1.5 L per sitting)

Preparation

Confirm effusion on USS first (mandatory; reduces pneumothorax risk); mark site
Coag screen: platelets >50, INR <1.5; LA at insertion site; needle goes above the rib (neurovascular bundle runs below)

What it involves

Seated leaning forward; LA injected (stinging); needle/drain inserted; pressure sensation during fluid drainage; 15–30 min; drain stitched/dressed afterwards

Common complications

Pain at site, vasovagal episode (most common), minor bleeding

Serious / rare

Pneumothorax (~5% with USS guidance)
Haemorrhage; empyema if technique breaks asepsis
Re-expansion pulmonary oedema: draining >1.5 L at once — presents as cough, dyspnoea, hypoxia

Chest drain

Indication

Large/tension pneumothorax, haemothorax, empyema, chylothorax, large or recurrent pleural effusion

Key points

USS guidance for fluid collections; strict sterile technique; LA at insertion site
Seldinger small-bore (12–14 Fr) = effusions; surgical large-bore = haemothorax/trauma
Triangle of safety: lateral thorax between anterior/posterior axillary lines, above 5th ICS

What it involves

LA injected; Seldinger technique (needle → guidewire → dilators → drain); drain stitched in; connected to underwater seal (bubbling = air leak); 2–7 days typically; patient will feel drain movement on breathing

Common complications

Pain (significant), drain blockage, displacement, site infection, subcutaneous emphysema

Serious / rare

Haemothorax (vessel injury), visceral perforation (lung, liver, spleen, heart), neurovascular bundle injury

Coronary angiography (± PCI)

Indication

Angina evaluation, pre-CABG assessment, post-ACS (NSTEMI/STEMI for primary or elective PCI)

Preparation

NBM 4–6 h; IV access; eGFR check; hold metformin 48 h; review anticoagulants; consent including PCI possibility

What it involves

Awake with light sedation; LA at radial (preferred) or femoral artery; catheter advanced to aortic root; contrast injected into coronary arteries under fluoroscopy; 30–60 min; PCI (stent/balloon) may be performed same sitting
Post-procedure: access site compression band (radial) or manual pressure/sandbag (femoral); bed rest; wrist band worn for 2–4 h (radial); avoid heavy lifting for 1 week; keep access site clean and dry
Bring someone to drive you home; no driving on the day; watch for: increasing swelling or bleeding at access site, sudden chest pain, arm or leg colour/temperature change → go to A&E

Common complications

Haematoma at access site (more common with femoral), contrast reaction, transient arrhythmia, angina during contrast injection

Serious / rare

Stroke, MI (coronary artery dissection), arterial perforation, death (~0.1%), contrast nephropathy

Echocardiogram — TTE & TOE

TTE indication

Cardiac function/structure, valve disease, pericardial effusion, LV wall motion (post-MI), HF assessment — first-line non-invasive echo

TOE indication

Endocarditis (valve vegetations — superior views), LAA thrombus before cardioversion, prosthetic valve assessment, aortic dissection, intraoperative monitoring

TTE preparation

No prep required; gel applied to chest; painless; ~30 min; no complications

TOE preparation

Fast (NBM) for 4–6 h before the procedure — stomach must be empty due to sedation and aspiration risk
IV sedation (midazolam) + throat LA spray
Bring someone to drive you home — no driving or operating machinery for 24 h after sedation
CI: oesophageal varices, recent oesophageal surgery, stricture, active oesophageal bleeding

What TOE involves

Sedated; probe swallowed into oesophagus; patient will gag initially; excellent posterior cardiac views; 20–30 min; recovery 1–2 h
Throat spray numbs throat for 1–2 h — nothing to eat or drink until swallowing/gag reflex fully returns

Common (TOE)

Sore throat (may last 24 h), pharyngeal discomfort, nausea/gagging during procedure

Serious / rare (TOE)

Oesophageal perforation (<0.01%), aspiration, respiratory/cardiovascular depression from sedation

Duplex scanning (vascular USS)

Indication

DVT (first-line), carotid stenosis (TIA/stroke), peripheral arterial disease, renal artery stenosis, AAA surveillance, varicose vein mapping

What it involves

Non-invasive; B-mode USS + Doppler flow assessment; gel applied to skin; probe pressure to assess vein compressibility (DVT = non-compressible)
15–30 min; painless; no radiation; no prep; no contraindications

Complications

None

Endoscopy — OGD & colonoscopy

OGD (gastroscopy)

Haematemesis/melaena (urgent), dysphagia, dyspepsia not responding to PPI, Barrett's surveillance, H. pylori biopsy

Colonoscopy

PR bleeding, change in bowel habit, iron deficiency anaemia, colorectal cancer screening/surveillance, IBD assessment; sigmoidoscopy = left-sided/rectal pathology only

Preparation

OGD: NBM 6 h food / 2 h fluids; throat LA spray ± IV midazolam
Colonoscopy: full bowel preparation day before (PEG or sodium picosulfate — causes profuse diarrhoea); clear fluids only on prep day; IV midazolam + fentanyl

What it involves — OGD

Scope via mouth → oesophagus → stomach → duodenum; ~15 min; biopsies not felt; bloating/belching common after
Throat spray numbs throat — nothing to eat or drink until swallowing reflex fully returns (~1 h); bring escort; no driving for 24 h if sedated

What it involves — colonoscopy

Scope via rectum → entire colon; 30–60 min; cramping/bloating during; polypectomy performed if polyps found; recovery 1–2 h
Bring someone to drive you home; no driving for 24 h after sedation; drink plenty of fluids to rehydrate after bowel prep
If polyps removed: avoid NSAIDs for 1 week (↑bleeding risk); watch for: heavy PR bleeding, severe abdominal pain, fever → A&E urgently

Common complications

OGD: sore throat, bloating, transient dysphagia
Colonoscopy: bloating, cramping, incomplete procedure (5–10%), post-polypectomy syndrome (transient fever/pain)

Serious / rare

OGD: perforation (0.01%), haemorrhage post-biopsy, aspiration
Colonoscopy: perforation (0.1%, higher post-polypectomy), haemorrhage post-polypectomy (~1%)

Barium swallow

Indication

Dysphagia assessment — oesophageal stricture, pharyngeal pouch, achalasia; modified barium swallow (with speech therapy) for oropharyngeal dysphagia

Preparation & what it involves

NBM 4–6 h; drink chalky barium sulphate contrast (or water-soluble Gastrografin if perforation suspected — barium causes severe peritonitis if extravasates)
X-ray/fluoroscopy images taken during swallowing; different consistencies tested; quick, no sedation

Common complications

Constipation (barium absorbs water in colon), white stools for 1–2 days

Serious / rare

Aspiration of barium (aspiration pneumonitis — more serious than water-soluble contrast); barium impaction (very rare)

ERCP

Indication

Choledocholithiasis (CBD stones), biliary stricture (malignant or benign), PSC, post-surgical biliary leak, chronic pancreatitis with ductal stones/stricture

Preparation

NBM 6 h; IV access; sedation ± GA; coag screen (INR <1.5, platelets >50); prophylactic IV antibiotics; full consent

What it involves

Side-viewing duodenoscope → second part of duodenum; ampulla of Vater cannulated; contrast injected into biliary/pancreatic duct under fluoroscopy; sphincterotomy + stone removal or stent placement as needed; 30–60 min; recovery 2–4 h
Bring someone to drive you home; no driving for 24 h after sedation
After ERCP — seek urgent help if: worsening or severe abdominal pain (pancreatitis), fever/rigors (cholangitis), jaundice worsening, or vomiting blood

Common complications

Post-ERCP pancreatitis (3–5% — most common); cholangitis; abdominal pain and bloating

Serious / rare

Perforation (<0.5%), haemorrhage post-sphincterotomy, cholangitis if drainage fails, death (<0.1%)

Abdominal ultrasound

Indication

Gallstones/cholecystitis, liver disease, jaundice (biliary dilation vs hepatocellular), renal disease, abdominal mass, AAA, ascites (diagnosis and USS-guided tap), pelvic masses

Preparation & what it involves

Fasting 4–6 h for gallbladder (bile-distended gallbladder = better imaging); full bladder for pelvic/renal
Gel on skin; probe pressed over abdomen; 15–30 min; painless; no radiation; safe in pregnancy

Complications

None

Nuclear medicine scans (incl. thyroid scan)

Scans by type

Bone scan (Tc-99m MDP): skeletal metastases, osteomyelitis, Paget's
V/Q scan: PE (when CTPA contraindicated — allergy, renal failure, pregnancy)
PET-CT (FDG): cancer staging, restaging, response assessment
MIBG scan: phaeochromocytoma, neuroblastoma
Thyroid scan (Tc-99m or I-123): nodule characterisation — hot = autonomous adenoma/Graves'; cold = higher malignancy risk; ectopic thyroid tissue

Preparation

IV or oral radiotracer; waiting period (30 min to 24 h depending on tracer) before imaging
PET-CT: NBM 4–6 h; avoid strenuous exercise 24 h before; blood glucose <11 mmol/L
Thyroid scan: stop antithyroid drugs (carbimazole/PTU) 5–7 days before; avoid iodine-containing contrast or supplements for 4–8 weeks before
After scan: advise limiting close contact with pregnant women/infants for 24 h (small radiation dose)

What it involves

IV or oral tracer; rest period; lie in gamma camera or PET scanner (20–90 min); not confined like MRI; some scans require multiple visits (e.g. I-123 thyroid at 4 h and 24 h)

Common complications

Mild soreness at injection site; occasional nausea; mild claustrophobia (camera not confined)

Serious / rare

Very rare allergic reaction to tracer; ionising radiation (low dose, proportionate to benefit — discuss risk/benefit with patient); I-131 therapy (diagnostic dose only here) requires radiation isolation

Clinical Pharmacology · Y4 Syllabus

Drugs

For each drug: know its indication, mechanism of action, and common side-effects. Doses are not required in Year 4.

Emergency Drugs

For each: indication, mechanism, common side-effects, route. Doses not required in Year 4.

Cardiac arrest

Adrenaline (epinephrine)

Mech: α + β adrenoceptor agonist → ↑SVR (α), ↑HR/contractility (β1), ↑coronary perfusion pressure during CPR
Route: IV/IO
SE: tachyarrhythmias, HTN, ↑myocardial O₂ demand

Amiodarone

Mech: class III antidysrhythmic (K⁺ channel block + Na⁺/Ca²⁺ channel effects) → ↓defibrillation threshold
Route: IV/IO after 3rd shock in shockable arrest (VF/pVT)
SE: hypotension on infusion

Acute pulmonary oedema

Furosemide

Mech: inhibits Na⁺/K⁺/2Cl⁻ cotransporter in thick ascending limb of loop of Henle → ↓preload (early venodilation), then diuresis
Route: IV
SE: hypokalaemia, hyponatraemia, dehydration, ototoxicity (high dose)

Nitrates (GTN)

Mech: NO donor → venodilation → ↓preload; arterial dilation → ↓afterload at higher doses
Route: SL spray, IV infusion
SE: headache, flushing, hypotension; CI if SBP <90 mmHg or recent PDE5 inhibitor use

Oxygen

Mech: correct hypoxaemia; use non-rebreather mask to target SpO₂ 94–98%
SE: caution in Type II RF — titrate with Venturi mask if risk

Acute severe asthma

Salbutamol (SABA)

Mech: β2-adrenoceptor agonist → bronchial smooth muscle relaxation
Route: nebulised (back-to-back in severe); IV if life-threatening
SE: tremor, tachycardia, hypokalaemia (high dose)

Ipratropium (SAMA)

Mech: muscarinic (M3) antagonist → bronchodilation + ↓secretions
Route: nebulised (add to salbutamol in severe/life-threatening)
SE: dry mouth, urinary retention, acute angle-closure glaucoma if mist reaches eyes

Prednisolone / hydrocortisone

Mech: glucocorticoid → ↓airway inflammation; ↓mucus secretion; potentiate β2 agonists
Route: oral prednisolone (if able to swallow); IV hydrocortisone (if not)
SE: short course SE minimal; see continuing-care section for systemic SE

Magnesium sulfate

Mech: bronchial smooth muscle relaxation via Ca²⁺ channel blockade + NMDA antagonism
Route: IV infusion (if not responding to 1st-line treatment)
SE: flushing, hypotension, respiratory depression

Anaphylaxis

Adrenaline 1:1000 IM

Mech: α agonist → vasoconstriction, ↑BP; β1 → ↑HR; β2 → bronchodilation + ↓mast cell degranulation
Route: IM (anterolateral thigh) — first-line, do not delay
SE: palpitations, headache, anxiety; safe to give IM even in error

Chlorphenamine

Mech: H1 antihistamine → block histamine at H1 receptors (skin and mucosa)
Route: IV/IM (after adrenaline)
SE: sedation, dry mouth, urinary retention

Hydrocortisone

Mech: glucocorticoid → ↓inflammation; prevents biphasic reaction (onset 4–6 h — adjunct, not first-line)
Route: IV/IM
SE: minimal with single dose

Hypoglycaemia

Oral glucose / dextrose gel

Use: if conscious and able to swallow; 15–20 g fast-acting carbohydrate (Lucozade, dextrose tablets)

IV glucose (10% dextrose)

Mech: direct glucose provision; raises blood glucose rapidly
Route: IV; used if unable to take orally or unconscious
SE: extravasation (10% less irritant than 50%); hyperglycaemia if excessive

Glucagon

Mech: binds glucagon receptor → ↑hepatic glycogenolysis and gluconeogenesis → ↑blood glucose
Route: IM or SC; used when no IV access; ineffective in starvation or alcohol-related hypoglycaemia (depleted glycogen)
SE: nausea, vomiting

Seizures

Benzodiazepines

Mech: positive allosteric modulators of GABA-A receptor → ↑Cl⁻ conductance → ↓CNS excitability
Agents: lorazepam (IV/IM preferred in hospital), diazepam (IV or rectal), midazolam (buccal — out-of-hospital or paediatrics)
SE: respiratory depression (have flumazenil and resuscitation equipment available), sedation, hypotension

Levetiracetam / phenytoin (2nd-line)

Use: if seizure continues after benzodiazepines (status epilepticus); IV loading dose
SE: phenytoin — cardiac arrhythmias (must be given slowly under monitoring)

Opioid intoxication

Naloxone

Mech: competitive μ-opioid receptor antagonist → rapidly reverses respiratory depression, sedation, and miosis
Route: IV/IM/intranasal; onset seconds (IV) to minutes (IM); very short half-life (30–90 min) — may need repeat doses or continuous infusion if long-acting opioid involved
SE: precipitates acute withdrawal (pain, agitation, vomiting, tachycardia) in dependent patients; titrate carefully — aim for adequate ventilation, not full reversal

Continuing-Care Drugs

Know: mechanism of action, therapeutic indications, and common side-effects. One example drug per class is sufficient.

Cardiovascular

Beta-blockers
bisoprolol

Mech: β1-adrenoceptor blockade → ↓HR, ↓contractility, ↓BP; ↓renin release
Uses: HF (stable), angina, post-MI, AF rate control, HTN
SE: bradycardia, bronchospasm (CI in asthma), fatigue, cold peripheries, masks hypoglycaemia symptoms

CCB dihydropyridine
amlodipine

Mech: L-type Ca²⁺ channel block → peripheral arterial vasodilation
Uses: HTN, angina
SE: peripheral oedema, flushing, headache

CCB non-DHP
verapamil / diltiazem

Mech: ↓AV node conduction + negative inotropy (cardiac-selective)
Uses: AF rate control, angina, SVT
SE: bradycardia, constipation; CI with β-blockers (complete heart block risk)

ACE inhibitors
ramipril

Mech: block ACE → ↓angiotensin II + ↑bradykinin → vasodilation + ↓aldosterone
Uses: HF, HTN, post-MI, CKD with proteinuria (renoprotective)
SE: dry cough (bradykinin), ↑K⁺, AKI; angioedema (rare, serious); CI: pregnancy, bilateral renal artery stenosis

ARBs
losartan

Mech: block AT1 receptor → same end-effect as ACE-I but without bradykinin accumulation
Uses: as ACE-I but preferred when ACE-I causes intolerable cough; CI: pregnancy
SE: ↑K⁺, AKI (renovascular disease)

Loop diuretics
furosemide

Mech: inhibit NKCC2 cotransporter in thick ascending limb → ↓Na⁺/H₂O reabsorption
Uses: HF oedema, pulmonary oedema, cirrhotic ascites
SE: hypokalaemia, hyponatraemia, dehydration, ototoxicity (high IV dose)

Thiazide diuretics
bendroflumethiazide

Mech: inhibit Na⁺/Cl⁻ cotransporter in DCT
Uses: HTN (1st-line), mild oedema; note: ↑Ca²⁺ reabsorption (useful in hypercalciuria/stones)
SE: ↓K⁺, ↓Na⁺, ↑urate (gout), impaired glucose tolerance, ↑Ca²⁺

Aldosterone antagonist
spironolactone

Mech: competitive aldosterone receptor antagonist → K⁺-sparing diuresis
Uses: HF (↓mortality), cirrhotic ascites, Conn's syndrome, resistant HTN
SE: ↑K⁺ (CI with ACE-I/ARB caution), gynaecomastia, menstrual irregularity

Nitrates
GTN / ISMN

Mech: NO donor → venodilation → ↓preload; ↓afterload at higher doses; coronary vasodilation
Uses: acute angina (GTN SL spray), angina prophylaxis (ISMN)
SE: headache, flushing, postural hypotension; tolerance with long-acting forms (nitrate-free interval)

Statins
atorvastatin

Mech: inhibit HMG-CoA reductase → ↓hepatic cholesterol synthesis → ↑LDL receptors → ↓LDL
Uses: 1° and 2° CVD prevention; statin also has anti-inflammatory plaque-stabilising effects
SE: myopathy/rhabdomyolysis (check CK if muscle pain), ↑transaminases; CI: pregnancy, active liver disease

Antiplatelet agents
aspirin / clopidogrel

Aspirin: irreversibly inhibits COX-1/2 → ↓TXA₂ → ↓platelet aggregation
Clopidogrel: P2Y12 ADP receptor antagonist → ↓platelet aggregation
Uses: ACS (dual antiplatelet post-stent), TIA/ischaemic stroke prevention
SE: GI haemorrhage (aspirin), bruising; clopidogrel — TTP (rare)

Anticoagulants
LMWH / warfarin / DOACs

Heparin/LMWH: potentiates antithrombin III → inhibits IIa + Xa; SC; reversal = protamine
Warfarin: inhibits vitamin K-dependent factors (II, VII, IX, X); monitor INR; reversal = vitamin K / FFP / PCC
DOACs: rivaroxaban/apixaban (direct Xa inhibitors); dabigatran (direct IIa); no routine monitoring; reversal = idarucizumab (dabigatran), andexanet alfa (Xa inhibitors)
Uses: VTE treatment/prevention, AF stroke prevention, mechanical valves (warfarin)
SE: all — haemorrhage; warfarin — multiple drug/food interactions (CYP2C9, vitamin K foods)

Cardiac glycosides
digoxin

Mech: inhibits Na⁺/K⁺-ATPase → ↑intracellular Ca²⁺ → +ve inotropy; ↑vagal tone → ↓AV node conduction
Uses: AF rate control, HF with AF
SE: narrow therapeutic index — toxicity: N/V, yellow-green visual disturbance, arrhythmias (worsened by ↓K⁺)

Antidysrhythmics
amiodarone / adenosine / atropine

Amiodarone (class III + multi-channel): AF/VT/VF; SE: thyroid dysfunction, pulmonary fibrosis, photosensitivity, liver toxicity, corneal deposits
Adenosine: endogenous purine → profound AV block (seconds); terminates SVT; SE: chest tightness, flushing, transient asystole; half-life ~10 s
Atropine: muscarinic antagonist → ↑HR; use: symptomatic bradycardia; SE: dry mouth, urinary retention, confusion (elderly)

Respiratory

SABA
salbutamol

Mech: selective β2-adrenoceptor agonist → bronchial smooth muscle relaxation
Uses: acute asthma/COPD relief inhaler
SE: tremor, tachycardia, ↓K⁺ (high doses)

LABA
salmeterol / formoterol

Mech: long-acting β2 agonist (≥12 h); formoterol = fast onset → can be MART regimen reliever
Uses: asthma add-on (always with ICS), COPD maintenance
SE: as SABA; should not be used without ICS in asthma (↑mortality risk)

SAMA / LAMA
ipratropium / tiotropium

Mech: muscarinic (M3) antagonist → bronchodilation via ↓bronchoconstriction
Uses: COPD (tiotropium = maintenance); acute severe asthma (ipratropium added to nebulised salbutamol)
SE: dry mouth, urinary retention, constipation; acute angle-closure glaucoma if mist in eyes

Inhaled corticosteroids
beclomethasone / budesonide

Mech: local glucocorticoid → ↓airway inflammation, ↓eosinophil recruitment, ↓mucus secretion
Uses: asthma (step 2 onwards); COPD (frequent exacerbators)
SE: oral candidiasis (rinse mouth after), dysphonia; systemic SE at very high doses

Systemic corticosteroids
prednisolone / hydrocortisone

Mech: broad glucocorticoid and mineralocorticoid effects → ↓inflammation; immunosuppression
Uses: acute exacerbations of asthma/COPD, other inflammatory conditions
SE (long-term): ↑glucose, HTN, osteoporosis, immunosuppression, Cushing's syndrome, adrenal suppression, peptic ulcer, cataracts, avascular necrosis

Methylxanthines
theophylline / aminophylline

Mech: PDE inhibitor → ↑cAMP → bronchodilation + anti-inflammatory; also adenosine receptor antagonist
Uses: severe asthma/COPD (add-on); IV aminophylline in life-threatening asthma
SE: narrow therapeutic index — tachycardia, arrhythmias, seizures, N/V; multiple drug interactions

Gastrointestinal

PPIs
omeprazole / lansoprazole

Mech: irreversibly inhibit H⁺/K⁺-ATPase (proton pump) on parietal cells → ↓gastric acid
Uses: GORD, peptic ulcer, H. pylori eradication (triple therapy), NSAID gastroprotection
SE: ↓Mg²⁺ (long-term), ↑C. diff risk, ↓B12 absorption, ↑fracture risk

H2 receptor antagonists
famotidine

Mech: block H2 receptors on parietal cells → ↓acid secretion (less effective than PPIs)
Uses: mild peptic ulcer, GORD, NSAID gastroprotection
SE: headache; rarely hepatotoxicity

Anti-emetics
ondansetron / metoclopramide / cyclizine

Ondansetron: 5-HT3 antagonist → blocks chemoreceptor trigger zone; use: chemo/post-op N/V; SE: constipation, ↑QT
Metoclopramide: D2 antagonist + 5-HT4 agonist → prokinetic + anti-emetic; use: N/V, gastroparesis; SE: extrapyramidal reactions (dystonia, tardive dyskinesia — avoid >5 days)
Cyclizine: H1 antihistamine + antimuscarinic; use: motion sickness, opioid-induced N/V; SE: sedation, dry mouth

Laxatives
senna / macrogol / lactulose

Senna: stimulant laxative → ↑peristalsis; use: constipation, bowel prep; SE: colic
Macrogols (e.g. Movicol): osmotic → retain water in stool; soften and bulk; use: constipation, bowel prep
Lactulose: osmotic + ↓colonic pH → ↓NH3 absorption; use: constipation, hepatic encephalopathy

Diabetes mellitus

Metformin (biguanide)

Mech: activates AMPK → ↓hepatic gluconeogenesis; ↑peripheral insulin sensitivity
Uses: T2DM first-line (weight-neutral/↓weight); also cardiovascular benefit
SE: GI (N/V/D — take with food), lactic acidosis (rare); CI: eGFR <30, AKI, contrast/surgery — hold 48 h

Sulfonylureas
gliclazide

Mech: close KATP channels on β-cells → depolarisation → ↑insulin secretion (glucose-independent)
Uses: T2DM add-on (if metformin insufficient or CI)
SE: hypoglycaemia (main risk), weight gain

Insulins

Mech: bind insulin receptor → ↑glucose uptake (GLUT4), ↑glycogen synthesis, ↓gluconeogenesis, ↑protein/fat synthesis
Types: rapid-acting (aspart/lispro — onset <15 min); short-acting (Actrapid — onset 30 min); intermediate (NPH); long-acting/basal (glargine/detemir — once daily flat profile)
SE: hypoglycaemia (main risk), weight gain, lipodystrophy at injection sites

SGLT-2 inhibitors
dapagliflozin / empagliflozin

Mech: block renal SGLT-2 → ↑urinary glucose excretion → ↓blood glucose; also ↓weight, ↓BP
Uses: T2DM add-on (also HF and CKD benefit irrespective of DM)
SE: UTI, genital thrush (glucosuria), euglycaemic DKA; hold before surgery/prolonged fasting; CI: eGFR <30

Analgesics (WHO ladder)

Paracetamol (step 1)

Mech: central COX inhibition + endocannabinoid system modulation (mechanism not fully elucidated)
Uses: mild-moderate pain, fever; first-line for most pain
SE: safe at therapeutic doses; hepatotoxicity in overdose — antidote: N-acetylcysteine (NAC)

NSAIDs (step 1–2)
ibuprofen / naproxen / diclofenac

Mech: inhibit COX-1/2 → ↓prostaglandin synthesis → analgesia, antipyrexia, anti-inflammation
Uses: musculoskeletal pain, renal colic, dysmenorrhoea, inflammatory arthritis
SE: GI ulceration/haemorrhage (prescribe with PPI), AKI (↓prostaglandin-mediated renal perfusion), fluid retention, ↑BP, bronchospasm (aspirin-sensitive asthma), ↑CV risk
CI: peptic ulcer, CKD (eGFR <30), HF, anticoagulated patients

Weak opioids (step 2)
codeine / tramadol

Codeine: weak μ-opioid agonist; prodrug → morphine via CYP2D6 (ultra-rapid metabolisers at risk of toxicity); SE: constipation, nausea, sedation
Tramadol: weak μ-opioid + SNRI (serotonin/noradrenaline reuptake inhibitor); SE: lowers seizure threshold, serotonin syndrome risk (with SSRIs/MAOIs), constipation, dizziness

Strong opioids (step 3)
morphine / oxycodone / fentanyl

Mech: μ-opioid receptor agonists → ↓pain transmission at spinal cord and supraspinal level
Uses: severe pain, dyspnoea in palliative care, acute MI (morphine)
SE: constipation (always co-prescribe laxative), N/V, respiratory depression, sedation, dependence; tolerance develops
Reversal: naloxone (competitive opioid antagonist — see emergency section)

Antibiotics

Beta-lactams
penicillins / cephalosporins / carbapenems

Mech: inhibit PBP (penicillin-binding proteins) → ↓cell wall synthesis → bactericidal
Amoxicillin: broad gram +ve/−ve · Co-amoxiclav: + β-lactamase inhibitor · Flucloxacillin: anti-staphylococcal (MSSA) · Ceftriaxone (3rd gen): broad spectrum · Meropenem: widest spectrum (reserve for MDR/ESBL)
SE: allergy (true IgE anaphylaxis <1% of reported reactions; ~2% cross-reactivity with cephalosporins), rash, C. diff (broad-spectrum)

Aminoglycosides
gentamicin

Mech: bind 30S ribosomal subunit → misreading of mRNA → bactericidal vs gram-negative organisms
Uses: gram-negative sepsis (often combined with beta-lactam)
SE: nephrotoxicity + ototoxicity (both concentration-dependent) — monitor levels

Quinolones
ciprofloxacin

Mech: inhibit DNA gyrase (topoisomerase II) + topoisomerase IV → ↓DNA replication → bactericidal
Uses: UTI, GI infections, atypical pneumonia, bone infections
SE: QT prolongation, tendinopathy/Achilles tendon rupture (↑risk with corticosteroids — warn patients), ↑C. diff risk, photosensitivity; CI: pregnancy, children (developing cartilage)

Nitroimidazoles
metronidazole

Mech: reduced in anaerobic conditions → forms toxic radical → DNA strand breakage → bactericidal
Uses: anaerobic infections, C. diff (oral), H. pylori (triple therapy), BV, Trichomonas, amoebiasis, Giardia
SE: metallic taste, N/V, peripheral neuropathy (prolonged use), disulfiram-like reaction with alcohol (warn patients)

Glycopeptides
vancomycin

Mech: bind D-Ala-D-Ala terminus of peptidoglycan → ↓cell wall synthesis (different target from β-lactams — active against MRSA)
Uses: MRSA (IV), severe C. diff (oral — not absorbed, acts in gut)
SE: nephrotoxicity, ototoxicity; red man syndrome (flushing/rash/hypotension — infuse over ≥60 min, not anaphylaxis); monitor trough levels

Macrolides
clarithromycin / azithromycin

Mech: bind 50S ribosomal subunit → inhibit translocation → bacteriostatic
Uses: atypical pneumonia (Mycoplasma, Legionella, Chlamydia), H. pylori (triple therapy), penicillin allergy for chest infections
SE: GI (N/D), QT prolongation, hepatotoxicity; multiple drug interactions (CYP3A4 inhibitor)

Tetracyclines
doxycycline

Mech: bind 30S subunit → ↓aminoacyl-tRNA binding → bacteriostatic (broad spectrum incl. atypicals)
Uses: atypical pneumonia, Chlamydia, Lyme disease, malaria prophylaxis, acne
SE: GI, photosensitivity (warn: sunscreen), dental staining/enamel hypoplasia; CI: children <8 years, pregnancy

Nitrofurantoin

Mech: reduced by bacterial nitroreductases → toxic intermediates → multiple intracellular targets
Uses: uncomplicated lower UTI only (concentrates in urine; inadequate tissue levels for pyelonephritis)
SE: GI, pulmonary toxicity (long-term), peripheral neuropathy; CI: eGFR <30 (poor urinary concentration), G6PD deficiency

Drug Counselling Station

OSCE Counselling Framework — use every time

Short history: Allergies · current Meds · PMHx · ICE · what they already know
Benefits: why this drug, what it does — in plain language
Practical info: how & when to take · missed dose · sick day rules · interactions
Monitoring: blood tests and follow-up reviews needed
Side effects: common + serious
Alternatives: other medications · lifestyle changes
Safety net: when to seek urgent help
Chunk and check: pause and verify understanding throughout

BNF may be provided in the station — know where to find: indications, interactions, monitoring, and counselling notes sections.

Antihypertensives

Benefits

High BP is usually symptomless but silently damages vessels → ↑risk of stroke, MI, HF, CKD, and retinopathy
Antihypertensives lower BP to safe targets, preventing these long-term complications

NICE HTN pathway

Practical

ACE-I/ARB: once or twice daily; rise slowly from bed/chair in first weeks (postural hypotension)
Thiazide diuretics: take in the morning (diuretic effect — avoid at night)
Missed dose: take same day if remembered; never double up
Sick day rules (SADMAN): if vomiting, diarrhoea, or unable to eat/drink — stop ACE-I/ARB/diuretic; restart when well; contact GP if illness lasts >2 days (AKI risk)

Monitoring

U&Es + eGFR: 1–2 weeks after starting ACE-I/ARB (check for AKI and ↑K⁺); annually thereafter
BP: review at 4 weeks; then 6–12 monthly once stable
BP targets: <80 yrs → clinic <140/90 (ABPM <135/85) · ≥80 yrs → clinic <150/90 (ABPM <145/85)

Side effects

ACE-I: dry persistent cough (10% — switch to ARB if troublesome); ↑K⁺; postural hypotension
CCB: ankle swelling, flushing, headache (usually settles in 2–4 weeks)
Thiazides: ↓K⁺, ↑urate/gout, impaired glucose tolerance

Safety net

Facial/lip/tongue swelling → stop ACE-I and call 999 (angioedema)
Significant dizziness/falls when standing, muscle weakness, markedly reduced urine → contact GP same day

Alternatives

Lifestyle: low-salt diet (<6 g/day), regular exercise, weight loss, limit alcohol, stop smoking
Other drug classes per NICE pathway depending on comorbidities and tolerability

Statins

Benefits

Lower LDL cholesterol → ↓risk of heart attack, stroke, and cardiovascular events
Used for primary prevention (high CVD risk) and secondary prevention (established CVD/diabetes)

Practical

Atorvastatin: any time of day; simvastatin: at night (peak hepatic cholesterol synthesis overnight)
Missed dose: skip; take next dose at usual time; do not double up
Grapefruit juice: avoid large amounts with simvastatin/atorvastatin (inhibits CYP3A4 → ↑statin levels → ↑myopathy risk)

Monitoring

Fasting lipid profile at 3 months (aim >40% ↓LDL from baseline, or LDL <1.8 mmol/L in very high risk)
LFTs: before starting and at 3 months; recheck if symptomatic
CK: only if muscle symptoms — not routinely

Side effects

Muscle aches (myalgia): common, usually mild; report if severe or limiting
Rhabdomyolysis (rare, serious): severe muscle pain + dark/tea-coloured urine → stop immediately and go to A&E
Transient ↑LFTs; GI upset (nausea, constipation)

Key interactions

Grapefruit juice (large amounts): ↑statin levels → ↑myopathy risk
Fibrates (gemfibrozil): ↑myopathy risk — combination usually avoided
Warfarin: statins can ↑INR — closer monitoring needed when starting
Clarithromycin/erythromycin: ↑statin levels — temporary dose review may be needed

Safety net

Dark/tea-coloured urine + muscle pain → stop immediately and go to A&E (rhabdomyolysis)
Jaundice or persistent abdominal pain → stop and contact GP (hepatotoxicity)
Pregnancy: stop statin immediately — teratogenic; effective contraception essential

Steroids (prednisolone / corticosteroids)

Benefits

Powerful anti-inflammatory/immunosuppressant — suppresses the immune system in conditions such as RA, IBD, asthma, vasculitis, transplant rejection
Short courses rapidly settle inflammation; long-term courses control ongoing disease activity

Practical

Take in the morning with food or milk — mimics the body's natural cortisol peak (reduces insomnia); food reduces GI irritation
Never stop suddenly if taken for >3 weeks — the adrenal glands suppress over time and cannot respond to stress; dose must be tapered gradually under medical guidance
Steroid emergency card: must be carried at all times; show to all healthcare providers including paramedics, dentists, and anaesthetists — essential in any emergency or surgery

Sick day rules + Addisonian crisis

During fever or significant illness: double the usual steroid dose — the body needs more cortisol when stressed; continue until recovered
Never miss a dose during acute illness — the body cannot make its own stress response if adrenally suppressed
Addisonian crisis: vomiting and unable to keep tablets down → IM/IV hydrocortisone 100 mg + call 999 urgently; do not wait; carry an IM kit if prescribed

Monitoring

BP and blood glucose (steroids → hyperglycaemia); U&Es; weight
Bone protection: co-prescribe calcium + vitamin D from the outset; DEXA scan if long-term (>3 months); bisphosphonate if high fracture risk
Eye review (cataracts); consider gastroprotection with PPI if also on NSAIDs

Side effects

Short-term: mood changes/euphoria, insomnia, ↑appetite, ↑blood glucose, fluid retention
Long-term: weight gain, Cushingoid features (moon face, buffalo hump), osteoporosis, ↑infection risk, skin thinning/easy bruising, cataracts, HTN, peptic ulcer, adrenal suppression, avascular necrosis (femoral head)
Signs of infection may be masked — seek help for any fever or unusual symptoms

Safety net

Vomiting + cannot take tablets → IM hydrocortisone and 999 (Addisonian crisis)
Any fever or infection signs → seek urgent review (immunosuppressed; reduced inflammatory response)
Any surgical or dental procedure → always inform the team you are on steroids (stress dose protocol)

SSRIs (antidepressants)

Benefits

Treat depression and anxiety disorders by increasing serotonin availability in the brain
Effective for: depression, GAD, panic disorder, OCD, PTSD, social anxiety

Practical

Take at same time daily; can be taken with or without food
Full antidepressant effect takes 4–8 weeks — initial SE settle in first 2 weeks but mood improvement takes longer; do not stop because it does not seem to be working in the first few weeks
Do not stop suddenly — taper gradually over weeks to months to avoid discontinuation syndrome (electric shock/"brain zap" sensations, dizziness, flu-like symptoms, irritability)
Continue for at least 6 months after remission (2+ years if recurrent depression)

Suicidality warning

In the first 1–2 weeks of starting, some patients notice increased anxiety or agitation before mood lifts — very rarely thoughts of self-harm may transiently worsen before improving
Contact GP or crisis team urgently if new or worsening thoughts of suicide or self-harm — do not wait for next appointment
Especially important in patients under 25: increased monitoring in the first weeks is recommended

Monitoring

Review at 2 weeks (risk assessment), 4–6 weeks (efficacy), then monthly for first 3 months
U&Es if elderly (↑risk of hyponatraemia/SIADH — can present as confusion or falls)

Side effects

Common (usually settle in 2 weeks): nausea, diarrhoea, headache, insomnia, dry mouth, ↑sweating
Ongoing: reduced libido, delayed orgasm/ejaculation — discuss openly; these are common
Serious: hyponatraemia (especially elderly); ↑GI bleeding risk (especially with NSAIDs)

Key interactions

NSAIDs + SSRIs: significantly ↑GI bleed risk — add PPI if both needed
Tramadol / triptans: serotonin syndrome risk — usually avoid combination
MAOIs: absolutely contraindicated (serotonin syndrome — potentially fatal); 2-week washout between agents
Warfarin: ↑bleeding risk; closer INR monitoring

Alternatives

Psychological: CBT (first-line mild-moderate depression/anxiety); mindfulness-based therapy
Other antidepressants: SNRIs (duloxetine/venlafaxine), mirtazapine, TCAs
Lifestyle: regular exercise, structured routine, social support, alcohol reduction

Metformin

Benefits

Lowers blood glucose in T2DM by reducing liver glucose production and improving insulin sensitivity
Weight-neutral or mild weight loss; cardiovascular protective benefits; does not cause hypoglycaemia when used alone

Practical

Take with or immediately after meals — significantly reduces GI side effects
Start low, increase slowly over weeks (↓GI SE); modified-release (MR) formulation if standard causes persistent GI intolerance
Missed dose: take with next meal; do not double up

Sick day rules

STOP metformin if: vomiting/diarrhoea causing dehydration, serious acute illness, or unable to eat — lactic acidosis risk when dehydrated (rare but serious)
Before IV contrast dye or surgery: withhold for 48 h before and restart only once kidney function confirmed normal post-procedure (contrast → AKI → lactic acidosis risk)
Also stop if eGFR drops to <30 at any monitoring check

Monitoring

HbA1c every 3–6 months until target stable, then 6-monthly
eGFR and U&Es annually; B12 levels every 1–2 years on long-term treatment (impairs B12 absorption)

Side effects

GI: nausea, diarrhoea, abdominal discomfort — common at start, usually improves over weeks
Metallic taste; ↓B12 absorption (long-term)
Lactic acidosis (very rare — mainly in renal impairment): nausea, abdominal pain, weakness, rapid breathing

Safety net

Hypoglycaemia is uncommon with metformin alone — but if also on sulfonylurea or insulin, know symptoms: shakiness, sweating, confusion, palpitations → eat fast-acting sugar
Severe nausea, breathlessness, muscle pain when unwell on metformin → seek urgent help (lactic acidosis)

Bisphosphonates

Benefits

Inhibit osteoclast-mediated bone resorption → ↑bone mineral density → ↓fracture risk in osteoporosis
Also used in Paget's disease, bone metastases, and hypercalcaemia of malignancy

Critical administration

Take on an empty stomach, first thing in the morning, with a full glass of plain water (200 mL) — no other liquid
Remain strictly upright (sitting or standing) for at least 30 minutes after taking — do not lie down; prevents oesophageal damage
No food, other drinks, or other tablets for 30–60 minutes after taking
Alendronate: usually taken once weekly (70 mg) — choose the same day each week; mark on a calendar
Missed weekly dose: skip if past mid-week; take next dose as usual the following week
Calcium + vitamin D supplement usually co-prescribed — take at a different time of day from bisphosphonate (reduces absorption of both)

Monitoring

eGFR + calcium before starting (CI if eGFR <35); annually during treatment
DEXA scan at 3–5 years to assess response
Dental review before starting — inform dentist you are on bisphosphonates; maintain excellent dental hygiene throughout

Side effects

GI: dyspepsia, oesophageal irritation or ulceration (mitigated by correct upright posture and hydration); musculoskeletal aches
Osteonecrosis of jaw (ONJ): rare but serious — risk ↑with IV bisphosphonates or dental extractions; avoid invasive dental procedures if possible; report jaw pain or exposed bone urgently
Atypical femoral fracture: very rare with long-term use (>5 years); present as thigh or groin pain — report promptly

Safety net

New thigh or groin pain → stop and seek urgent review (atypical femoral fracture)
Jaw pain, swelling, or exposed bone → urgent dental or specialist review (ONJ)
Heartburn not settling or dysphagia → stop and contact GP; severe oesophageal pain → A&E

Warfarin

Benefits

Anticoagulant — prevents dangerous blood clots; used in AF (↓stroke risk), DVT/PE treatment/prevention, and prosthetic heart valves

Practical

Take at same time daily — usually 5–6 pm (allows dose adjustment based on morning INR result)
Missed dose: take same day if remembered; if next day, skip — never double up; note in yellow anticoagulant book
Carry the yellow anticoagulant alert card at all times; show at every healthcare contact
Inform all healthcare providers (GP, dentist, pharmacist, any surgeon) you are on warfarin

Monitoring

INR: frequent at start (every 2–3 days until stable); then every 1–3 months when stable; recorded in yellow anticoagulant book
Target INR: 2–3 (AF, DVT/PE); 2.5–3.5 (mechanical heart valve)

Key interactions

Vitamin K foods (spinach, kale, broccoli, green tea): maintain a consistent intake — do not suddenly increase or decrease; no need to avoid completely
Alcohol: limit to ≤14 units/week; binge drinking especially dangerous (unpredictable INR fluctuations)
Many medications interact — antibiotics, antifungals, NSAIDs, amiodarone, statins all affect INR; always check with pharmacist before starting any new medicine (including OTC)
St John's Wort (herbal): significantly ↓warfarin effect — avoid completely

Side effects

Bleeding: bruising, prolonged bleeding from cuts, nosebleeds, heavy periods, blood in urine or dark/tarry stools
Warfarin-induced skin necrosis (rare — first week of treatment)

Safety net

Major bleeding or head injury → 999 / A&E urgently; take anticoagulant card
Coughing/vomiting blood, blood in urine, black tarry stools → same-day urgent care
Any new medication started → check for INR interaction with pharmacist first
Before elective surgery or dental extraction: inform team well in advance — may need to stop 5 days before; bridging LMWH may be required

Alternatives

DOACs (rivaroxaban, apixaban, dabigatran): no routine INR monitoring; preferred for AF and VTE in most patients now
Warfarin still preferred: mechanical heart valves, antiphospholipid syndrome

Methotrexate

Benefits

Disease-modifying drug (DMARD) for RA, psoriasis, and inflammatory conditions — reduces inflammation and prevents joint damage
Takes 6–12 weeks for full effect; not a painkiller; works by inhibiting folate metabolism in rapidly dividing immune cells

Critical practical points

ONCE WEEKLY ONLY — never daily; check the day of the week on every prescription; daily dosing can be fatal
Also prescribed folic acid 5 mg once weekly on a DIFFERENT day from methotrexate — reduces mouth ulcers, nausea, and other folate-depletion side effects; do not take on the same day
Take with food to reduce nausea; some patients split into two doses 12 hours apart
Carry the methotrexate information card at all times; show at all healthcare contacts

Monitoring (mandatory)

FBC + LFTs + U&Es: every 2 weeks until dose stable for 6 weeks; then monthly for 3 months; then 3-monthly thereafter
Watch for: ↓WBC (↑infection risk), ↑LFTs (hepatotoxicity), ↑creatinine
Chest X-ray before starting (baseline for pneumonitis monitoring)

Side effects

Common: nausea, mouth ulcers (both reduced by folic acid), fatigue, mild alopecia
Serious: bone marrow suppression (↑infection risk), hepatotoxicity (↑with alcohol — absolutely avoid), pneumonitis (new dry cough/breathlessness → stop immediately and seek urgent review), teratogenicity

Key interactions

NSAIDs: ↑methotrexate toxicity — avoid or use only under close specialist guidance
Trimethoprim / co-trimoxazole: folate antagonist → ↑toxicity — avoid; use alternative antibiotics
Alcohol: hepatotoxic — do not drink alcohol while on methotrexate
Live vaccines: contraindicated (immunosuppressed)

Safety net + contraception

STOP and seek urgent help if: unexpected bruising/bleeding, persistent mouth ulcers, fever, new dry cough, or breathlessness — take methotrexate card to A&E
Teratogenic: effective contraception mandatory for both partners; stop 3 months before planned conception; if pregnancy suspected → stop immediately and seek urgent advice

Antibiotics (general counselling)

Benefits

Kill or inhibit bacterial growth to treat or prevent bacterial infection
Different classes for different organisms — choice based on likely pathogen and local resistance patterns

Practical

Complete the full course even if feeling better — stopping early risks relapse and promotes antibiotic resistance
Take at evenly spaced intervals (e.g., three times daily = every 8 hours)
Co-amoxiclav and metronidazole: with food (↓GI SE); amoxicillin/flucloxacillin: ideally on empty stomach; doxycycline: with food

Drug-specific warnings

Metronidazole: avoid all alcohol during treatment and for 48 hours after — disulfiram-like reaction (severe flushing, nausea, vomiting, palpitations)
Doxycycline: avoid prolonged direct sunlight or use high-SPF sunscreen (photosensitivity); do not take with dairy, antacids, or iron (↓absorption)
Ciprofloxacin / fluoroquinolones: report any tendon pain, especially Achilles → stop if tendinopathy develops; avoid in pregnancy and children

Monitoring

Usually none for standard short courses
Prolonged or IV courses: LFTs, FBC, U&Es; gentamicin → drug levels required

Safety net

Rash, facial swelling, or breathing difficulty → stop and call 999 (anaphylaxis)
Watery or bloody diarrhoea during or after antibiotics → seek medical advice (C. difficile)
Symptoms not improving after 48–72 hours → contact GP for review

Levothyroxine

Benefits

Replaces thyroxine that the thyroid is not producing enough of (hypothyroidism)
Restores normal metabolism, energy levels, and other thyroid-regulated functions; usually lifelong treatment

Practical

Take on an empty stomach, 30–60 minutes before food — or consistently at bedtime (≥2–4 hours after eating); same time every day
Do not switch brands without medical advice (bioavailability differences between formulations may affect TSH)
Missed dose: take as soon as remembered (even the next day); do not double up
Lifelong in most causes of hypothyroidism (autoimmune, post-thyroidectomy, post-radioiodine)

Absorption interactions

Take levothyroxine at least 4 hours apart from: calcium tablets, iron supplements, antacids (aluminium/magnesium), proton pump inhibitors, cholestyramine — all significantly reduce absorption
Coffee within 30 minutes also reduces absorption — strictly observe the fasting window

Monitoring

TSH (+ free T4): at 8 weeks after starting or any dose change; annually once stable
Target TSH: 0.4–4.0 mU/L in most patients (lower targets in some contexts, e.g. thyroid cancer)
If pregnant or planning pregnancy: check TFTs urgently — requirements often increase in pregnancy and under-replacement risks fetal neurodevelopmental damage

Side effects

At correct dose: none expected
If over-replaced (TSH too low): palpitations, AF, anxiety, tremor, ↑sweating, weight loss, heat intolerance, diarrhoea, insomnia, ↑fracture risk — report promptly
If under-replaced (TSH too high): fatigue, weight gain, cold intolerance, constipation, dry skin/hair, depression, bradycardia — report at next review

Safety net

Palpitations or rapid/irregular heartbeat → contact GP promptly (over-replacement; ↑AF risk)
Pregnancy: urgent TFT check — dose increase usually needed immediately
Chest pain or severe palpitations → A&E

Other interactions

Warfarin: levothyroxine ↑INR — monitor closely after any dose change
Amiodarone: blocks T4→T3 conversion; close TFT monitoring required