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My name is, my name is uh Ahmed Hassan. Uh Azaria introduced me. I'm uh, I just finished my, um medical school at Cardiff University. I'm now working as af one doctor. Uh, so I just wanted to uh do this lecture basically to give you guys some tips and tricks from the PSA exam. I know it can be quite overwhelming because obviously there's a lot of medications in health care, there's thousands and thousands of medications, but I'll try and hopefully make it uh quite simple for you to give you some tips and tricks on how you can, um, pass the PSA. Uh So we're gonna start now I'll go, so the content of this lecture, we, we're gonna be going through the structure of the assessment quickly. Uh just to give you an overview and then we're gonna be going through each of the sections here. Um, as you know, there are eight sections in the PSA exam. So I'll just be giving you some tips and tricks in each section. So, uh just a brief overview of the structure of the uh PSA exam. It constitutes of eight sections as you can see here in this diagram and it mainly covers seven clinical settings in health care. So, including medicine, surgery and others as well. Just the typical things that you get assessed, you know, in your uh progress tests and um MC Qs. So nothing, nothing different. Uh So, and I've included it in the diagram. Er, you know, the amount of time you should be spending in each of the sections. Er, so from my experience and the experience of uh my colleagues that have done the PSA exam, it's quite uh it, it's a bit time pressure to be honest, but the good thing about it is that the answers are usually quite clear. It's not, you don't have, usually you have that dilemma um that you have in the MC QS where you're thinking between two options. Oh, is it A, is it B is it C so usually if you know how to use the B NF, you're confident with that, er, then it should be quite straightforward and most people pass er, first time as well. So, er, don't, yeah, don't overstress about it. So, the first section of the PSA exam is section one. it's the prescribing section and it's the biggest section of the exam. It constitutes about 40% of the ex er, it's 40% of the exam and uh it's made out of eight questions. So you should be spending about six minutes per question uh in this section. And uh usually you know if you're quite confident with the, with the uh with the question. Uh and uh uh and you know how to use the BNF. Uh six minutes is very doable. You don't need more than that. So in terms of uh the answer, you should be choosing the, you know, the correct drug dose route and frequency, uh using the drop down menu as I'm sure you've seen in your uh mock exams and the way it's marked basically, as you can see here in the right a diagram, the optimal. So you get five marks for the choice of the medicine and then the other five marks depend on your dose route and frequency. So if you get the right medicine straight away, you can, you're guaranteed five marks. Uh then the uh dose route and frequency depends on the optimal answers. Uh But usually if you use the BNF, you check the uh you know the renal function and everything else, you can make sure that the dose you, you're given the frequency and the route is correct. So moving on, uh so the way you, you should approach uh section one is that you should be looking, obviously read the question, the history examination and investigations and then the things that you should have in mind is the age sex disease and current drugs. And I, I'll explain why these are important uh to uh to read them quite carefully. So when you're going through these questions. The first thing you want to look at uh, as well as the history is the age. And the reason why that's important is that, for example, sometimes in the elderly, you want to avoid certain medications including, uh for example, anticholinergics. So for example, if you have a question, patient coming in, who are elderly with an overactive bladder, you should straight away rule out some medications that can cause trouble in the uh elderly uh population. Uh for example, oxybutynin. So, Mirabegron is a safer option here that you can use for um patients with overactive bladder. This is just an example with age why it can be important uh sex as well. Er, if you have a pa if you have a female patient er, in the pregnant years, then you want to try and avoid charter drugs. I've included uh some of them here which are quite common. Uh past medical history is important because uh if patients, for example, have peptic ulcer disease or other uh diseases, then you can also uh try and avoid certain medications. Um for example, yeah, nsaids, if a patient has a peptic ulcer disease and other examples are listed here. Uh So cu current drugs is uh is important as well to think about, uh we're gonna talk about uh interactions in more detail in the, in the further sections. Uh But one common example that comes uh sometimes in the PSA uh is uh a patient who's taking uh omeprazole and then we need to prescribe them um like an antiplatelet. Uh And in this example, you, you want to try and avoid uh omeprazole because clopidogrel is a pro drug that is uh activated by the CIP enzymes. Specifically cip two C 19 and omeprazole specifically inhibits this enzyme. So if you're asked to prescribe a uh uh an antiacid with a patient that is taking uh clopidogrel, then you, you want to, you, you can use other options such as lansoprazole or pantoprazole. So these are just examples why you should consider the age sex disease and medications in the prescribing section. So we're just gonna uh go through some questions. Now, I want to be uh I want you to be as interactive as, as as possible. So if you can, uh I'll give you uh one minute, uh actually I'll give you about two minutes to read this. So, um AFA 56 year old man presents to the ed with vomiting for three days past medical history of uh gastritis. Otherwise is well on examination, his apar heart rate is 100 and 15, rhythm is regular BP, is 100/50 GBP not raised. Uh He's a bit uh IC at 21 oxygen saturation is 97. Uh heart sounds are normal and these are the investigations. Um If you think about what fluid you would prescribe in this patient and if you can answer in the in the chat, please? OK. So OK. Any, any more? Uh So we, we have one answer here before I ve the answer any more. Any more answers? OK, great. So yeah, so we have two answers here. Sodium chloride, 0.9% IV uh 500/10 minutes, which is the correct answer. Uh So I'm, I'm just going to explain uh make try and make it simple for you. So sometimes uh like I at this stage, like last year, when I was at this stage, I was sometimes confused where when I should be giving like fluid resuscitation. But there are some criteria that according to NAS guidelines that you should look at er before you should consider uh fluid resuscitation. So that includes uh systolic BP of less than 100 heart rate, greater than 90 CRT greater than two. if a patient is tachy as well or use of five. So if a patient has any of these criteria, I should be considering fluid oration and nice guidelines. Also says that uh for fluid versus station, you should use a crystalloid uh containing sodium in the range of 100 and 30 to 154 maybe mils per liter with a bolus. Uh So a bots of 500 mils less than 15 minutes. So uh for the purpose of the PSA anything 15 minutes and less is fine. So if you start giving 20 minutes or 30 minutes then you will be losing box. So make sure in these kind of questions will improve your cation, you use 15 minutes or less. And the examples that you can use for fluid was cation. So any crystalloid sodium chloride plasma, light ringer solution hotman if you want to make it simple for yourself, just you can just go for the sodium chloride. You don't, you don't have to, you know, be uh you don't have to use anything fancy. Uh sodium chloride is fine. Uh So moving on to the next question actually, before I do that any any questions uh for the uh for the first question, sorry, I just can't see the chart. Uh OK. OK. I'll take that silence as a no. OK. So moving on to the next question now. Uh so this is a 72 year old female patient admitted to the ward following a uh radiographically inserted gastrostomy procedure. Her post operative recovery has been uncomplicated and she is quite stable on examinations. She's apyrexial uh heart rate of 82 rhythm is regular BP is normal 120/75 G VP, not raised respirator 18 and she's saturating 97%. She weighs 60 kg. These are the investigations here. I'll just give you two minutes to think about what you would put uh if you had this question. OK. So we have um we have an answer here. OK. Any, any more for I VE the answer. So we have someone saying sodium chloride um 0.9% plus K cl 40 millimoles 1 L over 12 hours. OK. We have another answer here as well. Um sodium chloride, glucose and potassium chloride. OK. Anything any any other answers? OK. So actually uh I'll just, so, so both answers that we uh I was given here is actually both of them are correct and will be awarded. Uh uh Fox. Uh So I'll just show you the the the answer. So I picked uh sodium chloride, glucose er and potassium chloride. Er This is this is uh quite a safe option to use. You know, if you, if you asked for uh fluid maintenance. And uh as as I will, as you guys will see in the next slide, you there are also other options that you can use that will also be fine and you will be awarded full marks. Uh So just going through the uh criteria for fluid maintenance. Uh So I would actually say uh really advise that you guys memorize uh this criteria uh because it will also help you as a doctor as well when you start. Uh foundation is so fluid maintenance wise, uh The criteria is that you should be giving patients fluids uh 25 to 30 mils per kilogram uh per day of water. And that should be that should include one millim m per kilogram per day of sodium potassium and chloride. And also you should be giving uh from about 50 to 100 g of glucose per day just to avoid uh starvation. Uh So for the hypothetical patient that we had on the last uh slide, uh this is a 60 kg patient. So for them, they will need the following uh one h 1800 mils of fluids per day, 60 million MS of sodium, potassium and chloride and 50 to 100 g of glucose. So for the PSA exam, if you had a patient like that, you can actually use three different fluids. You can use the sodium chloride uh 0.18 and glucose 4% potassium chloride, 0.15 that, that is fine or you can use glucose 5% with potassium chloride, either um 40 millimoles or 20 millimoles. So the the 0.3 potassium chloride solution has er 40 millimoles and the 0.15 potassium chloride solution has 20 millimoles and you can see this er in the table on the right hand side and this is also something else that I would suggest. I would advice that you guys also become familiar with before the PSA uh so that you know, you know how many millimoles you were giving when you uh prescribed the fluids to the patients. Uh So ss something to note here for this patient. If you have given er 11 L of sodium chloride, 0.9 you, you've actually exceeded the requirement because they only need 60 millimoles of sodium. So if you give 1 L of 0.9 sodium chloride, you've exceeded that already. You've given 135. So you don't need to give that. OK. I think I have some. OK. Yeah. Yeah. So we had a question here about why we used sodium 0.18 and not 0.9. I think I've explained that. Oh yeah, I've had two questions actually saying that uh and when you guys actually start work, you will see a lot of, do you see a lot of people giving um just maintenance fluids 0.9 sodium chloride. And that's actually a like if you are very strict with the nice guidelines that, that does not follow it because people will be giving, you know, 3 L sodium chloride 0.9%. And that's actually exceeding the requirement that they need per day. One pharmacist told me that one bag of sodium chloride, 0.9 is uh equals to 20 packets of crisps of las. So you can imagine if you, if you're giving them 23 L, they, they, they basically, you've given them 60 packets of crisps uh containing sodium. So you don't need a, you don't need that. Uh So yeah AAA safe option to use for the PSA are these that are included in this slide and you can give it over eight hours uh to 12 hours. But uh usually, you know, patients require 2 L. So I would say eight hours is actually better for your patients as well because that means you leave them with eight hours of uh no fluids, which is basically similar to uh when they're sleeping, uh they're not drink. So usually patients will not be drinking when they're sleeping. So eight hours is fine as well. Any questions? Ok. We have a question. How do we know how much potassium to give with gas? With gastric losis, for example? Ok. Ok. That, that, that's a good question. Um So, so that from my experience, I haven't actually had to do that for my PSA exam. Uh but in the um in the B NF, there is also a section on um replacement. So there is fluid maintenance, fluid ation and fluid replacement. It gets quite complicated uh with fluid replacement. From my experience, I haven't had any question with replacement in the, in the uh in the PSA. But if you want to work out, you know, gastric closes, et cetera, you can use the B NF uh to calculate how much they're losing. Uh based on for example, what procedure they're having or what symptoms they're having. You can use the B NF to do that. But as I said, from my experience, I haven't seen any question uh for a replacement in the PSA. Yeah. OK. Moving on. OK. Next question. So a 74 year old man is being treated on the medical ward for a achy eye on the ward round. He's found to be sweaty, confused and drowsy past medical history of type two diabetes, drug history of Metformin 1 g, twice daily with meals and gliclazide, 80 mg twice daily with meals. Examination the axial heart uh tachycardic at 100 and 10 BP 1 43/79 76 g VP not raised. Ok. I think we already have some answers here. Yeah. So we, we, we have some answers here. Um 10% glucose, 200 meals, over 15 minutes, 20% glucose, 100 meals over 10 minutes, 20% dextrose, 100 mils over 10 minutes. Yeah. Ok. That's fine. Yeah. So the, these are, these are all correct answers. Uh So in, in this, er, example, II used uh 10% solution uh to 200 mils over 15 minutes, but you can also use uh 20% solution as well as long as you're giving 15 to 20 g of glucose within 15 minutes. Er, then that, that, that should be fine in the past. They used to use er, 40% but er, that's quite that irritates the veins so they no longer use um this, so yeah, as long as you're using 10% or 20% you should be fine within 15 minutes as well. Yeah. Ok. Next question. Uh sorry, we have a, we have a question uh, oh, sorry. It's not a question. It's just I put up, um, just general maintenance fluid. There was a question on the potassium. Um, so this is about the losses, isn't it? They, uh, but I just put out the general, um, one about maintenance fluid because we get asked that a lot in our exams and you will be doing that a lot of as your f one as well. Is this is a question about how much potassium you usually add to your maintenance fluid. And usually it's one minimal per kg uh per day of potassium. That's on average. You add, um, it's just something to bear in mind for your, for your maintenance mai maintenance fluids. So this, this doesn't necessarily mean, uh it doesn't account for any gastrosis or any kind of in real life. You usually have like a pharma like a pharmacist designated to that specific ward that you're in and you'll be able, they will be able to um, they've got dieticians as well and they usually are really good at calculating all the extra losses. Um But for your exams and for also for real, um when you start working as F one F two, I think it's worth knowing how much potassium uh that you need to add to your normal fluid. Thank you. Thank you. So, so, so yeah. Uh with, yeah, exactly as said um, so as as long as you're giving the one per kilogram per day of sodium, potassium and chloride, then that should be fine. So in the, but in the psa uh you know, if you're giving 1 L for example of um of so sodium and uh ss of sodium and potassium, but you haven't given glucose, they're not gonna, they, they, they're not gonna give you less marks because obviously you've only given 1 L. So you can cover for the glucose in the next bag if that makes sense. So uh so, so either either or uh with pota like sodium, potassium and glucose or just sodium and potassium should be fine in your answers. Uh They're not, you, you're not gonna lose marks. Um Yeah, I hope that makes sense. OK. So moving on to the next question. Um Sorry, before we move on to the next question, did you want to? I mean, I've got this a few things here, points on U the use of BNF. Um It because um you know, you will be, you know, electronic if it's, you know, if it is still an electronic exam, there's, you've got access to G NF or the um you know, online B NF um which you can access, I think it's useful to know how to use that to navigate that. Um And we, and I don't know, I'm sure you all know about the control plus F function. So just, you know, get used to get comfortable with using and you can, you know, you can look up like um mock papers, get comfortable with using um control plus F and looking for things like um you know, you can access treatment, summaries that would actually give you your medical management for common conditions, ok? You can access um you, you know, get comfortable with using the BNF to access side effects and also drug monitoring because you can, there's quite a lot of information BNF that you can access in, in the exam, but you just have to know how to do that and you have to be able to be comfortable doing it. So just familiarize yourself with the, the BNF, the electronic version in the exam and get used to doing that. Ok, because there's a lot of information already on there. Um And that, that you can access. Yeah, thank, thank you. Uh I've actually got some screenshots of where to find everything as well uh on the, on the, on the next few slides. Ok. That's brilliant. Thank you. Hopefully, that should be clear as well. Yeah, thank you. Uh OK. Moving on to the, there's no questions we can move on to the next question now. Uh So this is a 55 year old woman on the gastro ward had an elective lap, uh laparoscopic cystectomy two hours ago. She feels nauseated and has vomited twice past medical history of obesity, er type two diabetes and bipolar disorder, uh, drug history of Ramipril glycoside, Metformin and QUEtiapine as well. Uh, she was given morphine and dexamethasone in the recovery room and postoperative IV fluid is in progress on examination, apyrexial heart rate. 98 rhythm, regular BP 112/90 respirate 20 saturating 97. And these are the investigations here pres er, write one prescription for one drug that is most appropriate to treat her nausea and vomiting. Uh fe feel free to use the B NF as well. Ok. I'll give you another 30 seconds. Ok. So we have uh answers here. Cyclizine, uh 50 mg, T DS or just 50 mg. We have also the roots IV and we also have Im. OK. That's good. Uh Yeah, so these are all co correct answers. Uh So here I've, I chose uh cyclizine 50 milli uh 50 mg uh IV. But IV and Im are both fine, be careful with uh po administration if a patient is v er is vomiting, er, because obviously they, they, they're unable to swallow. So if a patient is vomiting, et cetera, then you should always go for the IV or I or IM if possible. Yeah. And in, in, in, in that case as well, if you have chosen another dose or another route, unfortunately, you would, you'd have scored zero. because because because of the reason I've just mentioned, um and we have another answer here on, on, on. Ok, I am. Ok. So I believe, yeah, one second, I'm just uh Yeah, I think O oo on the third one should usually be fine. Uh But oh second we have another. Yeah, so, so I just, it's just something extra that I've kind of put there um about the BNF. Um I just can't remember because I did my BPA while ago. But um the, the B NF that they give you on the online version is that called the Medicine Complete. Cos you can access the B NF but there is another one version that you can access on the electronic version. Um I think it's called The Medicines Complete. Um Yeah, they, they, they can also choose to access the BNF through through. Nice as well. Oh yeah, you can have a look at the nice guidelines as well. Yeah, I've just put a few things here um in terms of prescribing specifically to just be aware in special population group about renal impairment and um elderly or patients with uh you know, young patients, especially as well just to, just to be aware of certain things when you're prescribing. Yeah. Thank you. Yeah. Yeah. Uh Odansetron should be fine as well. Yeah. Yeah. Yes. I don't know if you guys do what this is what I've hired. Um I don't know if you've got any questions on morphine or, or the use of um opioids for pain relief. I think that usually comes up in PSA or e even in progress test. Um It's, I think one of the, it's a very common kind of question that comes up in high yield is the patients with um renal impairment, we avoid giving them oral off. So we give oxyCODONE, we switch them to oxyCODONE. Um That's people with renal impairment uh for opioids. And it's worth knowing the conversion between you conversion, converting from one to the another. And I think that should all be on past med if you guys have access to pass med converting between different opioids, but this is like a high yield. Um Just thing that I just mentioned, um it's, it, it's quite a common question that comes up about in a patient with a certain drug and if they have a renal impairment, can you switch it to a different drug? Um So yeah, so it's important to notice these things when you're prescribing. Yeah. Thank you. Yeah. Yeah. So uh sorry, actually, uh thanks for the correction guys. I've, I've just had a few messages about um Ondansetron. Uh Yeah, as, as you correctly pointed out Onda Ondansetron can cause a QT prolongation. And in that case here, it's actually um contraindicated uh because of the prolonged QT interval. Uh So, yeah, that, that, that's the reason I actually haven't included it in the, in the correct answers. Yeah, I apologize. Uh Thanks for correcting uh pointing that out guys. Yeah. Any, any other questions? Yeah. So I think, you know, at least um you know, again, b NF will have all the contraindications side effects um and everything going there so special. So yeah, it's but yeah, very good cool. She'll move on to the next. Yeah. OK. This uh this is the last question guys. Uh so just give it a go. Yes. OK. Mhm. Just give another 30 seconds. OK. So we have a few answers here that I've come through. Uh some people have mentioned um Enoxaparin, Rivaroxaban. Uh So Rivaroxaban 10 mg once daily for five weeks orally. Uh we have enoxaparin 40 mgs of OK. Uh So I II went for enoxaparin er 40 mg subcu er so as as with these questions, each, each hospital in practice has a different er guideline. So in my hospital, we use amoxapine and other hospitals, they use other things as well. Er So uh so, so, so the options here that would include O vs Ox Soarin 40 mg, sco uh tinzaparin uh 4500 units, Sco Darin and Varox Ofan. I think we had a question about loading dose as well. Uh Just have a look at it. OK? I mean, I think I in practice usually they, they don't try and give, they don't try, you know, to, to give you guys questions that could cause confusion. So if there is uh a question about, you know uh about a potential drug that should be g er given as a loading dose. First, I think if you, if you put either or usually after these exams they, er, see all the answers and see, you know, what people have put and, er, if there are some, if they think there, there was some confusion, people giving different answers, they would usually, like, adjust the marks. So I wouldn't worry too much about that. They, yeah, they usually the questions that they, they wouldn't want to confuse you or anything like that. Um, so, yeah, these are the options here, uh, as we discussed and again, you can use the B NF as well to, to find, you know, the, the dose and everything like that. Uh, so, II just a quick point regarding, uh, prophy, uh, VTA prophylaxis, any patient that is having an orthopedic surgery, uh, and, uh, you asked to give them, uh, prophylactic dose. It should be 40 MGS. Uh, I'm talking about orthopedic surgery in particular because the BNF, uh, sees that as a high risk. Uh, so things like elective, total hip, uh, replacement, other surgeries that are classed as moderate risk. It should be 20 MGS sub and, uh, all other medical patients, uh, for prophylaxis is usually 40 mg of enoxaparin. Uh, I'm just talking about oxapyrine here guys. Uh, just not, not to confuse her with other, uh, medications because that's the one I'm, I'm most familiar with, uh, with my hospital. Moving on to the next question. Uh, oh, actually, I think this is the last one here. Ok. Ok. I'll give you guys another 30 seconds. Feel free to use the BNF as well. OK. That's fine. So we have a few answers here. We have uh Mirabegron and DULoxetine uh 50 mg OD OK. That's fine. So the, the answer I got here was Myrin 50 mgs po once daily. And the reason I went for that is uh as we mentioned earlier in the uh in the presentation today that anticholinergics caution, anticholinergics with the elderly. So you should be using other options such as Mirabegron. In this case, it's urge urinary incontinence. So that's, it's either oxybutynin or Mirabegron, uh someone I think put DULoxetine and that's usually used in stress incontinence. So it wouldn't be the case here. Yeah, and this is just a, a more detailed explanation why we've used. Mirr, I will send you the uh the slides will be shared afterwards so you can look at it again. Uh just moving on to the next section. Now, I'll try and be a bit quicker. I think we spent a lot of time in the first one. I just want to, to spend a lot of time because it's the biggest section. So section two is prescription reviewer. So this one is uh eight marks counts for about 16 per er 16% of the exam. So it's the, it's the uh second biggest part of the exam. You should be spending about 2.5 minutes per question. Uh And uh and Yeah, it's 32 marks. So, in terms of the themes that you would come across in this section, uh you would have questions on contraindications, adverse drug reactions, interactions and those errors and the common scenarios that you will see are those drugs listed here. Some of the tips and tricks that I uh found very useful when I did my psa er, was that to learn common side effects and contraindications? Because you wouldn't really have a lot of time to look up everything. And something that I also, uh, someone told me about last year is if you actually search appendix one on the BNF, search, uh, it's gonna give you all the common, uh, side effects, uh, that you would ex that you would ex, you know, you would see a lot on the psa exam like hyponatremia, uh, diarrhea constipation if you guys can try it now and tell me if it works, it, it worked for me when I tried it. So, uh, hopefully it should, it should work for you guys. Ok. And then, uh, we'll just move you on now to a question here. A 65 year old man on the surgical ward is being treated for an infected distal fails following surgery. Two weeks ago, he is nauseated and has not eaten or drunk much for the last tw er, 48 hours past medical history, renal transplant. Uh IGA nephropathy, drug history. Just his normal, uh, meds on the right here, one presc uh I select one prescription, er, that needs to be withheld and two prescriptions that are most likely contributing to his hyperkalemia. So I, II think I'll try and keep it shorter for each question. Uh I think I'll give it 30 seconds just so that we don't over overrun with the time. Ok. So we have one, we have, uh, so I'm on now, um, Ramipril and tacrolimus for hyperkalemia and paracetamol for uh that should be temporarily withheld. Ok. So uh so yeah, so the, the one drug that should be temporarily withheld is actually Ramipril uh because the patient is nauseated and he is at risk of dehydration. Uh and there is something called sick day rules for uh ace inhibitors. So if a patient is at risk of dehydration, they should uh stop taking ace inhibitors due to the risk of AKI eye. So, yeah, so the first one is Ramipril and then hyperkalemia is, yeah. Ra Andro now I've, I've just given you guys a list of common uh medications that cause you know, side effects that you will see in the er in this section in, in the psa exam, hyperkalaemia and hypo and hyperkalemia. I'm not gonna go through each uh one by one, but you will have the slides afterwards. So you can look at it uh when you do your, your revision. Ok. Next question, 81 year old woman presents to her GP with fatigue and headache, past medical history of hypothyroidism. Uh, ti a hypertension, depression and constipation. Her regular medications are, is on the right hand side. Uh, examination BP 11, 5/58 investigations showing hypernatremia creatinine is 100 and 20 g fr is 41. Ok. So we'll go through the answers now. So, yeah, um, typical medications that cause hypernatremia include SSRI s, uh, such as citalopram and also, uh, di diuretics as well can cause hypernatremia. Uh So these are two medications that uh cause hypernatremia. In this case, serious dosing error is uh levothyroxine because it should be given daily. Again. I've included common drugs that cause hypernatremia that you might see in the PSA and also common contraindication questions as well. Just to be aware of then you can look at it uh, when you do your revision after the, after the lecture. Ok. Next question, 76 year old man on the medical ward, uh, he's on treatment for shortness of breath has become, uh, he's become confused past medical history, co PDM I anxiety and rhinitis, regular medications on the right smokes 20 cigarettes per day. He's a bit parial BP 16, 5/87 respiratory 19 investigations. As you can see here, three medications that are causing, uh, contributing to his confusion and one medication that is most likely contributing to his hyperkalemia, uh hyperglycemia. Ok. Yeah. So on, uh, Cocodamol, diazePAM and prednisoLONE, uh causing confusion and uh, prednisoLONE causing also, uh, hypoglycemia. Uh, one last, one last question. Ok. Uh, so in this case, the medications that are causing, uh, dys dyspepsia is an acid and prednisoLONE and medications causing loose stools. Er, genic acid and lansoprazole. So, loose stools and constipation is quite a common side effect and is bound to come in the exam. Er, you know, but there's also loads of medication that can cause, you know, constipation and diarrhea. But the common ones I've listed here, um, just to make you guys aware, uh, just to save you time basically. Um, but you can always also use the appendix one that I've mentioned earlier or search through it individually. Um, but yeah, it will save you time if you know, if you have an idea of, of these medications beforehand. Ok. And, uh, these are just some slides on drugs causing dy causing dyspepsia and autotoxicity as well. Uh, the big one, is alagic acid, it is quite common, um, as well, autotoxicity loop diuretics, uh, quite common and also, uh, glycosides such as gentamicin. And I've also included the medications that cause QT common ones that cause QT prolongation and also uh peripheral neuropathy as well. Again with hepatotoxicity and nephrotoxicity. Sorry, I know this is, is quite a lot of medications. But, uh, just for something to note here, co Amoxiclav and flucloxacillin are associated with cholestatic jaundice. Uh, this is a question that also comes up in PSA So, if you have a patient with uh abnormal LFT S and uh, you know, you've given a list of medications called amox and flucloxacillin are quite common to cause that. So, moving on to uh section three, this is eight questions, makes 8% of the exam and it's a single best answer out of five answers. Common themes that come up in this section include uh questions about symptom control acute conditions and chronic conditions. And these are some common scenarios that can come up anaphylaxis, asthma, hypertension, diabetes infections. Uh And as we said earlier, if you get stuck, the BNF has a really good section on treatment, summaries uh that you can use. This is where you can find it. I am sure you guys have seen it already. And also another thing uh to know as well is uh sometimes you asked to convert opioids in palliative care and you can find that by just by scrolling down through medicines, er guidance and you can go through uh prescribing in palliative care. OK. First question, feel free to use the B NF as well. Yeah, I'll give it another 10 seconds. OK. So we have an answer here. Trimethoprim. OK. So yeah, the correct answer, the answer is actually um trimethoprim. Uh And the reason for that. So uh you know, the common antibiotics they use for UTI is trimethoprim and nitrofurantoin. But if you actually look at the renal impairment section in the BN F and for Nitrofuran two and it says avoid if the EGFR is less than 45. Uh So if you have a patient with an EGFR of less than 45 you should be going for the um trimethoprim. But also another uh another sometimes they also uh in the question they have that the patient is on like sensitive to called Trimex zole, for example, and called Trimex azole contains trimethoprim. And if they're sensitive to that medication that they, they also cannot have trimethoprim. So if that's the case, you can use uh Cefalexin er instead. But in this question here, the correct answer is trimethoprim er because uh yeah, the EGFR is less than 45. So you can't be using tri er NATO in here. OK. Next 1, 52 year old woman presents to the GP with ongoing constipation. Past medical history of go chronic back pain, drug history of Co uh Lantz and SENNA select the most appropriate management option at this stage. OK. So I'm just gonna review the answer. Um So the the answer here is docusate sodium. Er So this question is actually related to er opioid related constipation. And this is you, you will find that in the treatment summary of constipation. So for uh opioid induced constipation, the BNF states that you should uh use an osmotic laxative or a sodium dos and also a stimulant laxative. Uh So, in this case, uh in this case, the patient is taking Coco which is, you know, which is causing the constipation, they're taking Asena, which is a stimulant laxative. So, in, in that case, you should be adding uh sodium Doyce to loosen the stools. So when I was a medical student, I always get you, you know, used to get confused with what is, what, what other drug, er, what other classes of uh you know, laxative. So I've just given you guys a quick diagram here that er shows the different classes of laxatives and some examples as well. OK. Moving on to section four. So this is when it starts, you know, to become a little bit shorter now. So this is six, is 6% of the exam. Er, so just six questions and you should be spending about one a quarter of a minute per question here. So the er this question, this section is actually quite straightforward because uh most of the information you will find in the patient and carer advice or directions for administration or dispensing information sections of the BNF. Uh So it shouldn't, it shouldn't require a lot of like cognitive thought as long as you uh you know, quite happy with where to find the information control f er and just going down to search for these sections, you should be fine. The common scenario is that come up in this uh section is breastfeeding, contraception, antibiotics, pregnancy and side effects. And in this section as well, multiple answers could be correct. So, always think about the, the patient in question and what matters to them as well. Uh, uh, as we will see in the, in the questions to come now there will be a lot of, er, right answers. But you just have to think about what is the most relevant to the patient in question. And, er, for the, for the missed doses of contraceptive pills, you can actually find that in the missed doses section, er, in the contraceptive er, medications on the BNF as well. But I've, I've given you guys also a summary er, of contraceptive pills. And what happens if you miss the doses? Uh, we'll talk about that later on later slides. So, first question, 77 year old female is seen in the ophthalmology clinic with glaucoma. She is started on Latanoprost eye drops. She is advised to apply one drop to the affected eye each evening. Select the most important information option that should be provided for the, for the patient regarding eye drops. Ok. So the correct answer here is C be, uh, she should be warned that the to post may cause eye discoloration. Uh, the first one present in breast milk and should be avoided during breastfeeding is not very relevant to this patient here. 77 year old female. So, uh, that, that's coming back to the point that you should always think back to the patient. Er, in question OK. So this is just a quick diagram, a quick summary of what to do um with missed oral conceptive pills. Uh just in case it comes up, I've tried to make it as simple as possible. Uh But for the, just a brief overview, combined contraceptive pill. Yeah, it can be taken as a pill patch or ring, er, it's taken daily for three weeks and then there is one week of pill free period. Uh And so in terms of what happens if there's, if there is one tablet missed, if, if the missed, if the, if it's taken before the next one, then it's fine. If two tablets are missed, then you should, er, consider. Er, so, so you should, you should be using in condoms for seven days and further management depends on the following things here. If it's in the first week of the pack, then uh they will need an emergency contraception, contraception if they had intercourse in the pill free period or the first week of the pill, uh FF or the first week of the pill. Yep. Er, this, if, if the missed, if the, if the missed dose is in the second week of the packet, then there is no action to be taken. If it's in the third week, then, er, you should make the pill free week again. This is uh also similar, a brief summary but with the progesterone only pill, uh it should be taken on the day, day, one of the cycle and it should be taken at the same time every day. Uh So in this case, uh, and with this pill, if any tablet is missed, then, uh, then you should think about whether it's, uh, less than three hours late or greater than three hours late. If it's less than three hours late, then there was no action if it's more than three hours late. Uh, then you also have to think about whether they had intercourse, er, three days prior to the missed pill or uh or, and after the missed dose, if that's the case, then, er, they should use condoms for two days. If they had intercourse three days prior to the missed pill and, or after the missed pill, then they should consider emergency emergency contraception in addition to condoms for two days. So this is just a brief uh summary of what to do in missed pills. OK. Section five. This is also 8% of the exam. Uh So when I did the exam, I found, I found this section quite time consuming for me. Sometimes uh the questions are usually quite simple, just simple calculations. You know, if you've made it to med school, you're very, you're, you're more than, you know, capable of answering these questions. They're quite simple mathematical questions, but sometimes they just uh include a lot of unnecessary information. Uh So just practice and, you know, practice what informations are, are actually relevant to the question and what information is just uh acts as a, as a distraction. Um But it's quite simple mathematical questions based on four different things. Uh Usually the questions will ask you to calculate based on the weight uh or calculate dilutions or calculate frequencies or rates. And also one thing uh that I also uh it's important for you guys to get your head around is uh to understand the pre uh percentage in a solution. So 1% means 1 g and 100 mil uh which is basically the same as 10 mg in one meal. Uh But as long as you understand that you should be fine, er, we don't have time unfortunately to go through mathematical questions in this lecture. Cos er this was just like a, a quick er er lecture. Um but yeah, all the information that you need will be in the question. Uh although sometimes there, there is distracting information. So, so just think what is actually relevant to the question section? Six is also 88 questions counts for 8% of the exam and you should be spending uh one and quarter of a minute uh per question and it's a single best answer question. The common themes that er come up in this section is adverse reactions, er, identifying also a drug causing a specific drug reaction, er, also identifying drug interaction as well and managing adverse reactions. Th this is quite common er, and it's, you know, typical past meds questions like with overdose, er, so it shouldn't be anything different to that. Er, if you're unsure of an interaction, you can always use the interaction, er, section in the B NF and just control F to find out uh the medication, er, that you want to try, that. You want to try, try and find out basically. Er, so just a quick question here. A 67 year old woman presents to the GP because she's experiencing excessive tiredness and reports black uh loose stools past medical history of hypertension, af type two diabetes, depression, drug history. Just her regular medications on, on the right here. In addition to the, the be 100 and 50 mg BD investigations, hemoglobin is, is low. What is the prescription most likely to inter interact with the, uh, the gabbi to cause gi bleeding? Ok. So we have an answer here. So it's actually Citalopram. Uh So this is APD uh or pharmacodynamic interaction between the medications. So SSRI S increase the risk of bleeding, uh because they actually prevent the uptake of serotonin into platelets which impairs the platelet aggregation because serotonin is quite important for platelet aggregation. Uh So we should be wary of using accessories in things like wax aspirin and, or also even nsaids as well because it can increase the risk of bleeding. Next question. 35 year old woman attends her GP for a medication review past medical history, type one, diabetes, lymph node, tuberculosis, hypothyroidism, bipolar affective disorder, drug history, just the regular medications on the right. In addition to a combined oral conceptive pill, select the prescription most likely to interact with contraceptive pill. Ok. This is a classic one. yeah. So the answer is er, rifampicin. So, Rifampicin is a sip er inducer and obviously cip metabolizes the contraceptive pill. So if the sip enzymes are overactive, then that means contraceptive pill is metabolized quickly and it is less effective in the body. Ok. So just a brief overview of uh we are actually just going to focus on the drug interactions here in my uh in the in the next few slides. So just quickly interactions can be categorized into pharmacodynamic and pharmacokinetic interactions. The pharmacokinetic interactions can be further displayed into uh ad me or absorption distribution, metabolism and excretion. So the next section here is just showing you guys the common pharmacodynamic interactions that could come up. Uh So dox aspirin increased the risk of gi bleeding, also nsaids and aspirin increased the risk of gi bleeding, ssris and dox slash nsaids increased the risk of gi bleeding as per the uh previous question that we did and also diuretic combinations and diuretics with uh ace inhibitors as well. These can cause uh renal failure. So, moving on to pharmacokinetic interactions, er as we said, uh it can be split into absorption distribution metabolism and excretion. So for absorption, uh just a few examples that could come up as well is uh taking medications that can interfere with the absorption of one another. For example, omeprazole and an antifungal uh such as uh itraconazole, uh itraconazole. So, omeprazole obviously reduces the stomach acid and uh itraconazole requires an acidic environment for absorption. So, if you give both of them together, you can reduce the risk of absorption of the antifungal and reduce its effectiveness. Also another common example as well is tetracyclines with iron or calcium salts. So, actually tetracycline, if you give it with iron or calcium salts, they can chelate together or bind together and that can reduce the absorption of the tetracycline and uh render it less effective basically. So the solution to this in practice is to ensure that there is a time period between both of these uh medications when they're administered at least uh 2 to 3 hours moving on to distribution. Uh This is like more complex and less likely to come in the psa exam. But just to make you guys aware um that is based on the plasma protein binding. Uh So some medications have higher affinity to the plasma proteins. Uh So if they buy with higher affinity, then the drugs that are bound to the plasma protein can become dissociated. And then when they become dissociated, they they are actually in their active form. So it can potentially cause toxicity. If uh if a drug is then is unbound from the plasma protein. So I think we have a question here. Will they expect us to know which type of reaction it is or just identify the drugs? Uh No, mainly j just identifying the, the drugs. No, they wouldn't ask you what kind of, what kind of interaction or what kind of reaction? Er it is if it's type A type B or type C, for example, no, they did not expect you to, to know that. So, for metabolism from eco kinetic interactions. So this is mainly based on the cip uh for 50 enzymes. So as you know, the drugs are mainly metabolized in the liver but also can be metabolized in different things uh for like the kid or even the skin sometimes. But uh that liver is the primary site of metabolism and the CIP enzymes are responsible for about 80% of metabolism that happens in the liver. So this interaction is more uh you know, is most important for the drugs with the narrow therapeutic index which I have listed here. So if you have a question with any of these medications, then you should think about whether you know, any drugs can interfere with their metabolism. Uh So just I've given you some pneumonics uh to help you remember, the cip induces and the sip inhibitors sip in induces uh you can use the pneumonic craps and that gives you the different medications or, and the cip inhibitors you can use this pneumonic here and that hopefully will make it easy for you guys to remember. Uh Also something to note is that smoking can also cause, uh can also induce t enzymes. And that is important for cloZAPine and OLANZapine. So if you have a, a patient who's a smoker and they're taking these medications, uh, then, yeah, you should, you should be aware, uh, you can, you can sometimes reduce the dose of these uh medications to counter for the smoking or actually change the medication completely. Give another medication. So, moving on to excretion. Now, uh this is important for the elderly patients who have a reduced EGFR. Uh So again, this is important for the drugs with another therapeutic index. If they, if, if they are being taken with a patient, uh with a reduced EGFR, you should be careful. Ok. Section seven. Now, nearly there. So this is also uh 8% of the exam. So, uh, as you guys can see like the, the, the, the first two sections are the biggest ones and then it, uh the, the further sections afterwards count for less. Uh, so this is also a single best answer. Best. Uh, out of five. The common scenario is that could come up include antibiotics, er, such as Gentamicin, Vancomycin, also infusions and also long term medications such as digoxin and lithium. Er, also, this section is quite straightforward. You can find all the information that you need in the drug monitoring section, uh, most questions that will come up in this section will be, you know, you will be able to find it easily in the B NF. Er, sometimes it's not in the B NF but in that case, you can just use common sense, you know, er, to try and to try and think or guess basically and it's only, it's, it's only a small section anyway. So if you're not sure of an answer, just, just put what you think is right and move on. Uh just a quick tip here. Uh Make sure you read the question carefully and think and know exactly you know what time point you're asking for monitoring? Is it a baseline? Three months or 12 months? Because the uh drug monitoring requirements differ between the different time points. So uh just make sure you read the question carefully. OK. The last section. Now uh section eight, the data interpretation, uh this one is only 6% of the exam. You should be spending about one quarter of a minute per question and it's o only six, yeah, only six questions. So it's a single best answer. Out of five common scenarios that are, can come up include plasma drug concentrations, uh thyroid function tests, chest X ray and ECG S just uh a tip here. Make sure you have a general idea how to adjust medication er, based on the er plasma drug levels. But you don't, you don't have to know anything crazy. They usually just give you the graph er itself for you to interpret. So, uh you shouldn't worry too much about that. So common uh plasma drug concentrations, concentrations that can come up include lithium gentamicin and Vancomycin. So, lithium, uh you know, samples should be taking six hours post dose. The target concentration should be between 0.4 to one gentamicin. Uh when they're given the medicated, when they're given the gentamicin infusion uh samples, the, the levels should be tested after six hours uh after they, they have the dose. And as you can see here in this uh graph on the, on the right hand side. Uh So here you can tell, you know what the concentration of the medication is. Six hours post it was administered. And then that gives you an idea when you have to do the dosing interval or when you basically have to give the next dose depending on the concentration in the plasma. So, as you can see, it's quite straightforward just by using the graph and trying to figure out er the dosing interval. Uh Vancomycin as well can some uh sometimes come up as well? Uh I'm sure you've seen it in your practice questions. Uh So this is just monitoring uh the trough concentration uh bef before you administer the next one and this er tough concentration should be calculated after 3 to 4 doses and you should have a target concentration of uh, 10 to 15, if it's, um, you know, if it's less than that, then you can consider increasing the, er, the dose of the Vancomycin. If it's more than that, then you can decrease the dose of the Vancomycin. So it's, it's quite, it's common sense really just be aware that the target concentration changes for severe infections and it's 15 to 20 mg per liter. Uh, so just lastly now, just a quick before we uh finish the lecture, I just wanted to give you some tips on the uh uh how to adjust insulin because it, I think it's also quite a quite a common question that can come up. So adjusting insulin, uh usually a question will be given to you and then they will give you a graph. For example, a patient has uh a higher plasma glucose concentration at a certain time of the day. And then they will tell you what you should do with the uh insulin. So just to make it simple. Uh so insulin regimens can be a basal bolus or a twice daily uh regimen. So a basal bolus regimen is usually for type one diabetes and uh where you give a long acting uh insulin with uh short or rapid boluses with each meal. So just uh some rules that you should consider when a if a question is asking you to uh you know, adjust the insulin. Er so for short acting insulin, you shouldn't adjust more than two units daily. So you can't adjust, for example, four units at, at one time. No, II it should, no, it should be no more than two units and also adjust one insulin at a time. So, uh however, if actually, if the question uh shows you that all the plasma glucose concentrations, they are all raised. Obviously, you wanna, you, you might be thinking I need, I need to change more than one insulin. But in this case, you, you you can actually just uh change the long acting insulin because it affects uh all the all the afterwards. So as you can see here on this diagram on the left, it's just showing you the impact of each dose and how it impacts the next dose. So for example, the breakfast dose is affecting the lunch uh plasma concentration of glucose and the lunch dose is affecting the plasma glucose concentration of the evening dose and et cetera, et cetera. Uh and the basal dose is actually having an impact on all of them. Uh But if so, if you have the basal dose in the morning in this, in this figure here, it's, it's showing that it's giving it at bedtime, but if you have it in the morning, then it's actually impacting all of them. So if all of them are raised, then that's a clue that you should be changing the basal er dose and with the basal dose, yeah, you shouldn't adjust more than two units every 3 to 4 days. I hope. II think we might have a question here. OK. No. OK. Right. And then uh just to quickly uh through the other regimen uh the twice daily regimen, this is usually for type two diabetes. Uh And again, this is showing you uh how each uh intermediate dose is affecting the other dose. Um So for example, here, the breakfast short acting dose uh is affecting the lunch time, plasma, concentration of glucose, et cetera. And uh just a quick rule here as well. You shouldn't be adjusting more than two units every 3 to 4 days. Yeah. OK. Uh Any questions for insulin adjusting or uh section eight or section seven of the exam? OK. So I think the uh we'll actually come to the end of the uh of the PSA lecture. Sorry II think it was er we ran over time but I wanted just to cover everything and try and give you tips on each section. I know that we haven't covered for example calculations but I think they, they, they're, they're quite straightforward. Um So if you guys have any any questions, please let me know now or if you, you can feel free to email me as well if you have any questions. OK. OK. We have a question here. Will, will we be expected to prescribe fingertip units? OK. Sorry. I'm actually not sure what you mean by that. Uh Can you Claro can you cla OK. With steroids? Ok. I see. Oh, ok. Ok. Uh so the question is, um, will, will, you know, medical students be expected to prescribe, uh for example, steroids ac according to uh body surface area? Ok. I personally, I personally haven't seen it in my uh psa exam. Er, so I think it would be very unlucky if you actually, if you guys had to do that. Uh, as far as I know you shouldn't have any, some, something like that. No. Ok. We have another question here. What if multiple drugs cause hyperkalaemia or another electrolyte abnormality? But the question only wants one or two answers. Ok, I see. I see. Um, again, II, don't think the, the PSA II don't think they're trying to trick you guys. So usually even, even if you had a question and they, uh, they found out after the exam that multiple drugs can potentially cause hyperkalemia, they will adjust the marks. So you, you should, you shouldn't be, you shouldn't be treated unfairly in this, uh, in, in, in this aspect. So, yeah, I wouldn't worry too much about that and you can always use the appendix one that I've mentioned earlier. Uh, just to quickly check, you know, what, what medications are causing hyperkalaemia, et cetera. So, yeah. Ok. For the, I think we have another question here. Thank you so much. That was really good. Ahmed. Um, yes, I mean, just echoing what Ahmed already said in terms of, I think it's all about practice and just practicing, especially, you know, you know, you have very limited time and you have quite a lot of questions there. So I think practicing mock papers is essential. I would recommend either Quest Meed or Pulse Notes. Um They have pulse notes actually have quite a few papers. Um uh some of them are free whereas for, for others you have to pay. Um And I think anybody has got some papers as well. So the ones that I use myself were quite, was quite mad and positive. But I know other people who used other resources and that's fine as well. But I think the key here is to practice and to get a hang of the whole format and to do it under time conditions whilst using the BNF in, in an exam format because that's how you will um be able to do well. Um because I know one thing I found the hardest was in my uh exam was that I was really running out of time and I was spending quite a lot of time on the calculation questions. Um The calculation questions are not difficult but they, they did take a bit of time there because you, you, you do have to think quite a few things. Um So practice the calculation questions, time yourself. And I think, yeah, they, they kind of key things. Uh any other thing you want to say about practicing any past papers. They're the ones that I use myself. Um, yeah, I mainly, you know, I, II mainly like the, er, post post Meed has a very quick section on the P SA. Er, I've, I've done, I've made sure that I finished them. Er, but I think mainly the, the ones that helped me most was the mock exams, er, by the PS, by the official P SA website. Er, that, that was quite informative. Um, and yeah, pulse Notes is also, it is quite good as well. Yeah, that's it. II would agree. Um, so, yeah, if you don't mind just doing the, um, the feedback for us guys. Thank you so much for coming. I know this was your Sunday evening. Um, but the slides will be uploaded, hopefully, uh, and we'll put everything up for you. So, yeah, good luck with your exam. And thank you.