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PSASession 2: Planning Management andCommunicating information Thursday 16 January, Dr Ololade Tijani & Dr Alexander WallaceResearchLearningOutcomes • Build on medicines complete knowledge • Identify how to adapt medications depending on clinical scenarios • Learn how to find medication information to communicate with patients • Medicines Complete top tips (interactions tool, appendix 1, ‘AND’ search, etc) • Planning management • pre/post-theatre • infections: antibiotics/(antifungals, antivirals), penicillin cross sensitivity • DKA • opioids • diabetes • Communicating information • contraception and HRT • follow-up monitoring • side effects • administration informationPlanning ManagementPlanning Management ● 8 items, 16/200 marks ● Suggested is 1 minute/question ● SBA style questions ● Will generally not include a diagnosis in the stem ● Questions can be based around: ○ Differential diagnoses ○ Investigations ○ Treatment and management ○ Risk management and safety ○ Palliative carePlanning ManagementQuestion 1 Case Presentation Answers: A 47 year old woman has been listed for an OGD in 4 weeks timA Increase to Omeprazole 40mg OD Her PMH includes: GORD, Asthma, T2DM. DH: Omeprazole 20mg PO OD, Metformin 500mg PO BD. B Stop her metformin 24 hours before OGD On examination: All of her vital signs are within normal range. She has a persistent cough that she reports gets worse when C No change in management required lying down or eating. D Switch Omeprazole 20mg to Famotidine 20mg OD What is the most appropriate option for the management of E Add Ranitidine 150mg BD this patient?Answer 1 Case Presentation Answers: A 47 year old woman has been listed for an OGD in 4 weeks A Increase to Omeprazole 40mg OD time. Her PMH includes: GORD, Asthma, T2DM. DH: Omeprazole 20mg PO OD, Metformin 500mg PO BD. B Stop her metformin 24 hours before OGD On examination: All of her vital signs are within normal C No change in management required range. She has a persistent cough that she reports gets D Switch Omeprazole 20mg to Famotidine 20mg OD worse when lying down or eating. E Add Ranitidine 150mg BD What is the most appropriate option for the management of this patient? Tips Contraindications Cautions Monitoring requirementsQuestion 2 Case Presentation Answers: A 65 year old man is a surgical inpatient recovering from an electivA Administer insulin lispro with next meal and continue VRII total hip replacement. PMH T1DM. DH Insulin lispro (Humalog) 10 units SC TDS with meals, Insulin glargine (Lantus) 22 units SC ON. for 1 hour afterwards. On examination: Alert oriented to time and place. Vital signs are B Continue VRII for another 6 hours and discontinue once within normal range. He is currently on a VRII since yesterday evening, are stable. and Lantus 17 units SC ON. C Stop VRII immediately, and start normal insulin regime the following day. What is the most appropriate option for the management of this D Increase insulin glargine to 22 units and administer insulin patient? lispro with next meal. E Continue VRII until at least 48 hours post operative.Answer 2 Case Presentation Answers: A 65 year old man is a surgical inpatient recovering from an electivA Administer insulin lispro with next meal and continue VRII total hip replacement. PMH T1DM. DH Insulin lispro (Humalog) 10 units SC TDS with meals, Insulin glargine (Lantus) 22 units SC ON. for 1 hour afterwards. On examination: Alert oriented to time and place. Vital signs are B Continue VRII for another 6 hours and discontinue once within normal range. He is currently on a VRII since yesterday evening, are stable. and Lantus 17 units SC ON. C Stop VRII immediately, and start normal insulin regime the following day. What is the most appropriate option for the management of this D Increase insulin glargine to 22 units and administer insulin patient? lispro with next meal. E Continue VRII until at least 48 hours post operative. Tips Control “F” will help navigating guidelinesQuestion 3 Case Presentation Answers: A 32 year old woman admitted to the maternity A IV Amoxicillin 500mg following induction of labour. On admission it was found she was Group B Streptococcus positive. B IM Benzathine benzylpenicillin 2.4 units On examination: HR 90. RR 18, BP 136/89. Cervix C IV Ceftriaxone 2g dilated to 6cm. Foetal head is engaged. Contractions 1 every 30 minutes. CCG NAD. D IV Clindamycin 300mg NKDA E oral Erythromycin 250mg QDS What is the most appropriate option for the management of this patient?Answer 3 Case Presentation Answers: A 32 year old woman admitted Preterm prelabour A IV Amoxicillin 500mg rupture of membranes (P‑PROM). B IM Benzathine benzylpenicillin 2.4 units On examination: HR 90. RR 18, BP 136/89. Cervix dilated to 6cm. Foetal head is engaged. Contractions 1 C IV Ceftriaxone 2g every 30 minutes. CCG NAD. D IV Clindamycin 300mg NKDA E oral Erythromycin 250mg QDS What is the most appropriate infection prophylaxis management for this patient?Answer 4 Case Presentation Answers: A 62 year old man is on a HCOLL ward being treated for chronic venous ulcer disease. The nurses are concerned as he is becoming increasingly confused and and has an abnormal breathing pattern. PMH: HFpEF, T2DM, HTN, COPD, PVD. DH: Candesartan A Initiate broad spectrum antibiotics and start oxygen 12mg OD, Ramipril 10mg ON, Furosemide 40mg OD, Metformin 1.5g TDS, Dapagliflozin 10mg OD, Gliclazide 40mg OD. Trelegy 2 puffs BD, Salbutamol PRN. therapy B Start IV fluids and a fixed rate insulin infusion On examination: HR 87, BP 138/ 89, RR 25, O2 90% RA, T 37.2, BM 11.9 (6.0-10.0), ACVPU C Increase Metformin dose to 2mg TDS VBG (RA): pH 7.28 CO2: 7.31 D Administer nebulised bronchodilators and a STAT dose of O2: 6.32 furosemide HCO3: 14.4 Ketones: 4.5 Lactate: 1.45 E Start IV fluids and send off for urine and serum osmolality Na: 138 K: 3.7 What is the most appropriate option for the management of this patient?Answer 4 Case Presentation Answers: A 62 year old man is on a HCOLL ward being treated for chronic venous ulcer disease. The nurses are concerned as he is becoming increasingly confused and and has an abnormal breathing pattern. PMH: HFpEF, T2DM, HTN, COPD, PVD. DH: Candesartan A Initiate broad spectrum antibiotics and start oxygen 12mg OD, Ramipril 10mg ON, Furosemide 40mg OD, Metformin 1.5g TDS, Dapagliflozin 10mg OD, Gliclazide 40mg OD. Trelegy 2 puffs BD, Salbutamol PRN. therapy B Start IV fluids and a fixed rate insulin infusion On examination: HR 87, BP 138/ 89, RR 25, O2 90% RA, T 37.2, BM 11.9 (6.0-10.0), ACVPU C Increase Metformin dose to 2mg TDS VBG (RA): pH 7.28 CO2: 7.31 D Administer nebulised bronchodilators and a STAT dose of O2: 6.32 furosemide HCO3: 14.4 Ketones: 4.5 Lactate: 1.45 E Start IV fluids and send off for urine and serum osmolality Na: 138 K: 3.7 What is the most appropriate option for the management of this patient? Tips For common protocolised management familiarise yourself with guidelines. DKA HHS Hyperkalaemia Hyperglycaemia NB Do not learn guidelines off by heart as treatment will differ between trusts.Question 5 Case Presentation Answers: An 84 year old man is in hospice with a diagnosis of terminal prostate cancer. He is receiving PO modified-release A Switch to Fentanyl 50 microgram patch every 24 hours morphine 40mg BD, with a daily total of 40mg PO morphine and PO morphine 20mg PRN. PRN for pain management. He is still complaining of pain B Increase regular morphine to 60mg BD. with a pain score of 8/10. C Switch to Fentanyl 50 microgram patch every 72 hours On examination: Comfort observations. Oxygen 2L NC for and PO morphine 12mg PRN. comfort care. D Switch to Buprenorphine 20 microgram patch every 72 What is the most appropriate option for the management hours. of this patient? E Switch to Buprenorphine 35 microgram patch every 72 hours and PO morphine 12mg PRN.Answer 5 Case Presentation Answers: An 84 year old man is in hospice with a diagnosis of terminal prostate cancer. He is receiving PO modified-release A Switch to Fentanyl 50 microgram patch every 24 hours morphine 40mg BD, with a daily total of 40mg PO morphine and PO morphine 20mg PRN. PRN for pain management. He is still complaining of pain B Increase regular morphine to 60mg BD. with a pain score of 8/10. C Switch to Fentanyl 50 microgram patch every 72 hours On examination: Comfort observations. Oxygen 2L NC for and PO morphine 12mg PRN. comfort care. D Switch to Buprenorphine 20 microgram patch every 72 What is the most appropriate option for the management hours. of this patient? E Switch to Buprenorphine 35 microgram patch every 72 hours and PO morphine 12mg PRN.Communicating/Providing InformationProviding information 6 items, 12/200 marks Suggested is 1 minutes/ question6. A 60-year-old woman is discussing with her GP about medication options for her type 2 diabetes. The GP initiates discussion about pioglitazone and provides her with information on this medication. PMH - Breast cancer, HTN, Previous MI, T2DM. What is the most important information her GP needs to give her? A Increased risk of heart failure so will require monitoring for signs of HF B Contraindicated in patients with active/previous breast cancer C Increased risk of infection D This medication can cause weight gain E She needs to have LFTs prior to starting treatment6. A 60-year-old woman is discussing with her GP about medication options for her type 2 diabetes. The GP initiates discussion about pioglitazone and provides her with information on this medication. PMH - Breast cancer, HTN, Previous MI, T2DM. What is the most important information her GP needs to give her? A Increased risk of heart failure so will require monitoring for signs of HF B Contraindicated in patients with active/previous breast cancer C Increased risk of infection D This medication can cause weight gain E She needs to have LFTs prior to starting treatmentTips CTRL + F Important sections A 30-year-old male asks his dermatologist if he can be initiated on 7. methotrexate to help with his severe psoriasis which has not responded well to previous therapies. He has a friend who is on methotrexate whose psoriasis is much better since using methotrexate so he is keen to be started on it. The dermatologist gives him some information on methotrexate to help him make an informed decision. Which of these is the most important ? A He will need to take this medication daily for it to work effectively B He will need to take folic acid on the day he takes his methotrexate C He will need effective contraception during and for at least 6 months after treatment D He should drink lots of water to reduce risk of toxicity E There is a potential side effect of seizures A 30-year-old male asks his dermatologist if he can be initiated on 7. methotrexate to help with his severe psoriasis which has not responded well to previous therapies. He has a friend who is on methotrexate whose psoriasis is much better since using methotrexate so he is keen to be started on it. The dermatologist gives him some information on methotrexate to help him make an informed decision. Which of these is the most important ? A He will need to take this medication daily for it to work effectively B He will need to take folic acid on the day he takes his methotrexate C He will need effective contraception during and for at least 6 months after treatment D He should drink lots of water to reduce risk of toxicity E There is a potential side effect of seizures Tips Methotrexate: Weekly NOT daily Contraception for both male + female during treatment and for at least 6 months after Folic acid on days not on methotrexate (anti-folate) Avoid concurrent NSAID use – increased risk of renal toxicity Report immediately any feature of blood disorders (e.g. sore throat, bruising, and mouth ulcers), liver toxicity (e.g. nausea, vomiting, abdominal discomfort and dark urine), and respiratory effects (e.g. shortness of breath). Avoid exposure to UV light (including intense sunlight, sunlamps, and sunbeds) – risk of photosensitivity reactions Trimethoprim/Co-trimoxazole increases the risk of haematological side-effects when given with methotrexate8. A 10-year-old patient with asthma is experiencing shortness of breath and difficulty talking, with their parent noticing they sound wheezy. The parent calls 999 and an ambulance is being sent. What is the most important information the patient and their parent need before the ambulance arrive? A A maximum of 4 puffs of the inhaler can be used B The patient may develop some tremors C The patient should be reviewed by their GP within 2 working days. D Up to 10 puffs of the salbutamol inhaler can be used E The child will develop a high heart rate and the salbutamol must be stopped if this occurs8. A 10-year-old patient with asthma is experiencing shortness of breath and difficulty talking, with their parent noticing they sound wheezy. The parent calls 999 and an ambulance is being sent. What is the most important information the patient and their parent need before the ambulance arrive? A A maximum of 4 puffs of the inhaler can be used B The patient may develop some tremors C The patient should be reviewed by their GP within 2 working days. D Up to 10 puffs of the salbutamol inhaler can be used E The child will develop a high heart rate and the salbutamol must be stopped if this occurs Tips Treatment summaries9. A 37-year-old primigravida presents in labour following a concealed pregnancy. She has consequently had no antenatal appointments and due to her PMH of recurrent VTEs due to antiphospholipid syndrome, she is on warfarin. What is the most important information to be aware of? A There is a possibility of the patient developing blue toe syndrome B The baby is at increased risk of having a foetal abnormality C The mother needs to be offered immediate prophylaxis with intramuscular vitamin K D The mother’s INR needs to be checked immediately after delivery E The safest analgesia for the mother would be tramadol for pain control while she is on warfarin9. A 37-year-old primigravida presents in labour following a concealed pregnancy. She has consequently had no antenatal appointments and due to her PMH of recurrent VTEs due to antiphospholipid syndrome, she is on warfarin. What is the most important information to be aware of? A There is a possibility of the patient developing blue toe syndrome B The baby is at increased risk of having a foetal abnormality C The mother needs to be offered immediate prophylaxis with intramuscular vitamin K D The mother’s INR needs to be checked immediately after delivery E The safest analgesia for the mother would be tramadol for pain control while she is on warfarin Tips Cautions & contraindications for DOACs/Warfarin Monitoring requirements10. A patient with Parkinson’s disease is about to be initiated on clozapine following episodes of psychosis which have not responded well to other agents. Which of the following information does his carer need to know? A This medication can cause anaemia B This medication is contraindicated in Parkinson’s disease C This medication can cause hypersalivation D The patient should have physical health monitoring at least once a year E Seek urgent medical attention if the patient develops signs and symptoms of infection10. A patient with Parkinson’s disease is about to be initiated on clozapine following episodes of psychosis which have not responded well to other agents. Which of the following information does his carer need to know? A This medication can cause anaemia B This medication is contraindicated in Parkinson’s disease C This medication can cause hypersalivation D The patient should have physical health monitoring at least once a year E Seek urgent medical attention if the patient develops signs and symptoms of infectionPSABlueprintPSABlueprintPSABlueprintPSABlueprintPSABlueprint •Get comfortable with using Medicines Complete •Use Ctrl + F •Split-screen •Interaction checker (MC): type drug name then‘enter’,and so on… •Search“**”AND“**”e.g.“heart failure”AND“worsens”: medications with both mentioned in the drug monograph e.g.dronedarone Appendix1 (find through search bar) 20 tables Drugs that cause hepatotoxicity •Drugs that cause sedation •Drugs that cause nephrotoxicity •Drugs that cause peripheral neuropathy •Drugs that cause bradycardia •Drugs that cause serotonin syndrome •Drugs that cause hypotension •Drugs that cause myelosuppression •Drugs that prolong the QT interval •Drugs that increase serum potassium •Drugs with antimuscarinic •Drugs that cause hyponatraemia effects •Drugs that cause ototoxicity •Drugs with CNS depressant effects •Drugs with neuromuscular blocking effectsTreatment summaries •Familiarise yourself with them •Medication classes •Specificconditions •Surgeryand long-term medications •Fluids and electrolytes,Poisoning •Medical emergencies in the community(hypoglycaemia,asthma,ACS,anaphylaxis,seizures, meningitis,meningococcal disease,croup) •Infections are broken down into bodysystems e.g.skin infections,central nervous system infectionsFluids •Search potassium chloride with glucose and sodium chloride •Viewmedicinal formsQuestions?