Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Prescribing Safety Assessment (PSA) Post Course Material Dr Sachin Khunti, Dr Nitisha Khunti and Nehal KhuntiPost Course Information • Please read the PSA blueprint for all information regarding mark schemes • https://prescribingsafetyassessment.ac.uk/resources/PSA-Blueprint.pdf • Please complete practice papers on the PSA website • Useful website links are at the end of this powerpoint • Please, please, please review us on Facebook and Trustpilot! J • https://www.facebook.com/medvance.uk • https://uk.trustpilot.com/review/medvance.uk 2 Prescribing Safety Assessment (PSA)Top Tips • Study the BNF in the next week – familiarise yourself with all the treatment summaries including analgesia conversion in Palliative Care • Learn the fluids table as mentioned earlier • Interactions - always use Medicines Complete • Simple calculator and Pen and Paper • Paper copy of the BNF for electrolyte deficiency questions • Practice the past papers with the tips and tricks learnt today! • Relax and don’t panic! 3 Prescribing Safety Assessment (PSA)Answers to Mock Exam Questions Prescribing = 10 Marks - 5 Marks for correct Drug - 5 Marks for correct dose, route, frequency, duration - Can be multiple 10 mark answers 1. Cholestyramine – 4g OR 8g – Oral – Once Daily 2. Buspirone Hydrochloride – 5mg – Twice Daily OR Three Times Daily 3. Methyldopa – 250mg – ORAL – Twice Daily or Three Times Daily 4. Sodium Chloride 0.9% – 1 L – Intravenous – Over 4 Hours 4 Prescribing Safety Assessment (PSA)Answers to Mock Exam Questions Prescribing Review = 4 Marks per question - 2 Marks for completely correct Question A – 0 marks if you get one error - 2 Marks for completely correct Question B – 0 marks if you get one error - May ask for multiple options and answer can be the same for both parts 5. A = Olanzapine + Indapamide / B = Amlodipine 6. A = Omeprazole + Escitalopram / B = Carbamazepine 7. A = Amisulpride / B = Metformin + Spironolactone 8. A = Citalopram / B = Citalopram 5 Prescribing Safety Assessment (PSA)Answers to Mock Exam Questions Planning Management = 2 Marks per question - Will always only ask for 1 option 9. Clarithromycin 10. Vancomycin 2000mg IV 11. Levetiracetam 12. Erythromycin 6 Prescribing Safety Assessment (PSA)Answers to Mock Exam Questions Planning Management = 2 Marks per question - Will always only ask for 1 option (in the mock we had more than 1 option to make the question harder and get you used to using the BNF 13. Sodium valproate - Seek medical advice if you develop abdominal pain 14. Amiodarone – 4 answers – Seek medical advice if you develop any visual disturbances, Seek medical advice if you develop new onset breathlessness, Get a chest x-ray prior to commencing oral therapy, Check TFTs prior to commencing oral therapy and then 6 monthly 15. Levonorgestrel - If you miss a pill by 3 hours, you may not be protected 7 Prescribing Safety Assessment (PSA)Answers to Mock Exam Questions Calculations = 2 Marks per question - Will always only be one correct answer and always answer to the correct decimal place and unit otherwise you will get 0 marks 16. 70 tablets 17. 80.6 mL/min 18. 3.3 L 19. 182 tablets 8 Prescribing Safety Assessment (PSA)Answers to Mock Exam Questions Adverse Drug Reactions = 2 Marks per question - Will always only ask for 1 option (in the mock we had more than 1 option to make the question harder and get you used to using the BNF 20. Ramipril 21. Ramipril + Tiotropium + Oxybutynin 22. Salbutamol + Sertraline 23. Metronidazole + Lithium 9 Prescribing Safety Assessment (PSA)Answers to Mock Exam Questions Drug Monitoring = 2 Marks per question - Will always only ask for 1 option (in the mock we had more than 1 option to make the question harder and get you used to using the BNF 24. Ketoconazole – 4 appropriate – Obtain an ECG + Monitor adrenal function + Monitor liver function + Monitor for signs of nausea, vomiting or jaundice 25. Leflunomide – 1 least appropriate – obtain an ECG 26. Lithium – 4 appropriate – FBC + U+Es + TFTs + Cardiac function 27. Phenytoin tablets – 1 least appropriate – Monitor blood pressure 10 Prescribing Safety Assessment (PSA)Answers to Mock Exam Questions Data Interpretation = 2 Marks per question - Will always only ask for 1 option 28. Morphine 10mg Oral solution for breakthrough pain 29. Full dose NAC for paracetamol staggered overdose over 2 hours 30. Keep the dose the same for gentamicin for endocarditis treatment 11 Prescribing Safety Assessment (PSA)Introduction to the Prescribing Safety Assessment • The Prescribing Safety Assessment (PSA) is a summative exam taken by all final year medical students • It is now an online exam • The exam needs to be passed to be able to prescribe as a foundation year doctor • 60 questions equaling 200 marks in 120 minutes (+/- extra time) • Core knowledge, problem solving skills and safety in prescribing • Online BNF is the KEY! 12 Prescribing Safety Assessment (PSA)13 Prescribing Safety Assessment (PSA) https://prescribingsafetyassessment.ac.uk/resources/PSA-Blueprint.pdfc Assessment Structure Section Marks Distribution of Marks Clinical Settings 1 – Prescribing 80 8 questions – 10 marks each - Medicine 2 – Prescription Review 32 8 questions – 4 marks each - Surgery 3 – Planning Management 16 8 items – 2 marks each - Elderly Care 4 – Communicating Information 12 6 questions – 2 marks each - Paediatrics 5 – Calculations 16 8 questions – 2 marks each - Psychiatry - Obstetrics and 6 – Adverse Drug Reactions 16 8 questions – 2 marks each Gynaecology 7 – Drug Monitoring 16 8 questions – 2 marks each - General Practice 8 – Data Interpretation 12 6 questions – 2 marks each TOTAL MARKS 200 14 Prescribing Safety Assessment (PSA)15 Prescribing Safety Assessment (PSA)16 Prescribing Safety Assessment (PSA)17 Prescribing Safety Assessment (PSA)18 Prescribing Safety Assessment (PSA)Medicines Complete Slide Instructions • Photo top left - This is the page you do not want – as you cannot see the correct interaction button – the button on the left that says interactions in this screenshot medicationske you to the correct interaction page where you can type in the • Photo top right - If you do come to this page – click the BNF link in the middle next to the search bar, if you click, a link will appear saying all publications – click on this • Photo bottom right- Then click on the BNF box in red where it says 60 results • Photo bottom left - his will bring you to the interaction checker – click this and you will come to the correct page 19 Prescribing Safety Assessment (PSA)20 Prescribing Safety Assessment (PSA)Section 1 - Prescribing • 8 questions – 10 marks each = 80 marks (40% of entire paper) • 5 marks for correct medication, 5 marks for correct dose, route and frequency • Get the medication wrong – 0 marks • Aim for 4 – 5 minutes per question (32 – 40 minutes overall for 8 questions) • Type in the medication, dose, route, frequency, duration – you will then get a drop down box and you must pick the answer you want • Common scenarios – acute or chronic conditions, prescribing fluids, pain management 21 Prescribing Safety Assessment (PSA)Enzyme Inhibitors vs Inducers • Enzyme Inhibitors: • Enzyme Inducers: • SICKFACES.COM G • SCRAP G • Sodium Valproate • Sulphonureas • Isoniazid • St Johns Wort • Cimetidine • Smoking • Ketoconazole • Carbemazepine • Fluconazole • Rifampicin • Alcohol (binge drinking) • Alcohol (chronic use) • Clarithromycin • Phenobarbitol • Erythromycin • Phenytoin • Sulphonamides • Griseofulvin • Ciprofloxacin • Omeprazole • Metronidazole • Grapefruit juice 22 Prescribing Safety Assessment (PSA)Fluids • Resuscitation • Maintenance • Electrolyte imbalances eg. Hypercalcaemia • Hypoglycaemia • Diabetic Ketoacidosis 23 Prescribing Safety Assessment (PSA) Fluids Prescribing Emergency No Emergency No Emergency No Only Maintenance alone needed No Is there a fluid Resuscitation? hypoglycaemia? hypercalcaemia? without any losses? deficit? Yes Yes Yes Yes Yes 0.9% Sodium 10% Glucose 0.9% Sodium For routine maintenance alone: It is likely there is Chloride Chloride • 25-30ml/kg/day of water going to be a need 150ml over <15 • 1mmol/kg/day of K+, Na+, Cl- for >3L of water per 500ml over <15 minutes 1000ml over 4 • 50-100g/day of glucose day, so it is likely you minutes hours will need 1000ml (No potassium) Example: over <6 hours, (No potassium) (No potassium) however care must 0.9% sodium chloride with 0.3% be taken in not giving OR (40mmol/L) Potassium Chloride the fluids too fast. 1000ml over 8-12 hours Example: 20% Glucose 0.9% Sodium 75ml over <15 OR Chloride with 0.3% minutes Potassium Chloride (40mmol/L) (No potassium) 5% glucose with 0.15% (20mmol/L) Potassium Chloride 1000ml over 4-6 hours 1000ml over 8-12 hours 24 Prescribing Safety Assessment (PSA)Fluids Please please please do not get too bogged down with fluids! Emergency Resus - This is the case if the patient is in shock, BP is low with systolic <90 or diastolic <60 and heart rate high Emergency hypoglycaemia - Guidelines in the BNF - https://bnf.nice.org.uk/treatment-summary/hypoglycaemia.html Emergency hypocalcaemia - Aggressive fluid management 25 Prescribing Safety Assessment (PSA)Fluids Continued Maintenance - For routine maintenance, you need 25-30ml/kg/day of water along with 1mmol/kg/day of K, Na, Cl, and 50-100g glucose per day - An example prescription over 24 hours for a 70kg adult would therefore need to be 25x70 up to 30x70 = 1750-2100 ml per day of water, along with approx. 70mmol of potassium, sodium and chloride. - In 1000ml sodium chloride there is already 154 mmol of Na and Cl, therefore more of this is not needed, however there is no K. therefore you need to add K to the bag. As this is maintenance at 1mmol/kg, we need approx. 70 mmol potassium per day. This can be done in 2 bags – 40mmol in the first (also known as 0.3%) and then 20mmol (0.15%) in second bag. The second bag could also contain 40mmol (0.3%), as it is still near to the 70mmol per day. Fluid deficit - It is likely there is going to be a need for >3L of water per day, so it is likely you will need 1000ml over <6 hours, however care must be taken in not giving the fluids too fast. - In fluid deficit, especially as in the question from our paper, we had a patient who was NBM, had just been resuscitated, also had no urine output for 10 hours – he was very dehydrated. This would mean 3-4L fluids would be needed in 24 hours – I would recommend 1 litre over 6 hours would be ideal for this prescription. - Again in practice, it depends on the size of the patient, co-morbidities eg heart failure, age (elderly) 26 Prescribing Safety Assessment (PSA)Example 80kg male NBM prior to surgery, no other losses • This patient requires Maintenance fluids. For routine maintenance alone: • 25-30ml/kg/day of water • 1mmol/kg/day of K+, Na+, Cl- • 50-100g/day of glucose • 80kg x 25 = 2000ml / 80kg x 30 = 2400ml. • Therefore between 2000-2400ml per day of water = 2000ml • 80kg x 1mmol/kg/day = 80mmol/day K+, Na+ and Cl- • 50-100g/day glucose • 1000ml 0.9% sodium chloride with 0.3% (40mmol/L) Potassium Chloride over 8 - 12 hours • 1000ml water, 150mmol Na+, 190mmol Cl-, 40mmol K+ • 1000ml 5% glucose with 0.3% (40mmol/L) Potassium Chloride over 8 - 12 hours • 1000ml water, 50g glucose, 40mmol K+, 40mmol Cl- • Total = 2000ml water, 150mmol Na+, 230mmol Cl-, 80mmol K+, 50g Glucose 27 Prescribing Safety Assessment (PSA)Section 2 - Prescription Review • 8 questions – 4 marks each = 32 marks (16% of entire paper) • Aim for 2 – 2.5 minutes per question (16 – 20 minutes overall for 8 questions) • Tick box exercise from the list provided. You can tick the same option for all questions if necessary and multiple tick options • Common scenarios - prescription errors, interactions 28 Prescribing Safety Assessment (PSA)Statin Therapy Guidelines Non-HDL cholesterol • Statins after 3 months should lead to >40% reduction in non-HDL cholesterol • >40% reduction à continue the current dose • =< 40% reduction à consider increasing the dose ALT • ALT and other LFTs are known to increase with the use of statins • ALT increase of >1 to <3x upper limit of normal à continue statin, recheck LFTs in 4-6 weeks • >= 3x upper limit of normal à stop statin Creatine Kinase • CK is known to increase with the use of statins • CK increase of >1 to <5 x upper limit of normal à continue statin with regular CK monitoring • >=5x upper limit of normal à stop statin 29 Prescribing Safety Assessment (PSA)Drugs to Stop in Acute Kidney Injury • Diuretics • Specific Antifungals • E.g. Furosemide, • Amphotericin B Bendroflumethiazide, Indapamide, Spironolactone • Specific chemotherapy and immunosuppressants • ACE Inhibitors and ARBS • Cyclophosphamide • E.g. Ramipril, Candesartan • Contrast media • NSAIDs • E.g. Ibuprofen, Celecoxib • Specific Antibiotics • Aminoglycosides – e.g. Gentamicin • Vancomycin 30 Prescribing Safety Assessment (PSA)Section 3 – Planning Management • 8 questions – 2 marks each = 16 marks (8% of entire paper) • Aim for 1 – 1.5 minutes per question (8 – 12 minutes overall for 8 questions) • Tick box exercise – select one option from the list provided • The question usually asks for the most appropriate management option • Common scenarios - prescription errors, interactions, acute and chronic disease management 31 Prescribing Safety Assessment (PSA) Glucose Lowering Medications Biguanides Sulphonureas TZDs DPP-4 Inhibitors SGLT-2 Inhibitors Eg/ Metformin Eg/ Gliclazide Eg/ Pioglitazone Eg/ Sitagliptin Eg/ Dapagliflozin Side Effects o GI effects o Weight gain o GI effects o GI effects o UTIs / genital o Anorexia o Dark urine o Weight gain o Oedema infections o Taste disturbances o Hypo-glycaemia o Visual disturbances o Pain o Constipation o Lactic acidosis o Headaches o Pancreatitis o Dry mouth o Bone fracture o Reduced urination o Back pain o Lactic acidosis o Metabolic acidosis o Ketoacidosis o Heart failure o Ketoacidosis o Ketoacidosis Contra- indications o eGFR <30 o Bladder cancer o Haematuria Cautions o Risk factors for o Can encourage o Risk factors for o Complicated lactic acidosis weight gain bladder cancer, urinary tract o Elderly heart failure and infections o G6PD deficiency bone fractures Monitoring o Renal function o Liver function o Renal function 32 Prescribing Safety Assessment (PSA)Section 4 – Communicating Information • 6 questions – 2 marks each = 12 marks (6% of entire paper) • Aim for 1 – 1.5 minutes per question (6 – 9 minutes overall for 6 questions) • Tick box exercise – select one option from the list provided • The question usually asks for the most appropriate or most important piece of information. • Common scenarios - providing information on treatment monitoring and side effects and providing information on how to take medications and what important symptoms to look out for and when to seek medical advice. 33 Prescribing Safety Assessment (PSA)Section 5 – Calculations • 8 questions – 2 marks each = 16 marks (8% of entire paper) • Aim for 2 minutes per question (16 minutes overall for 8 questions) • Type in the answer into the space provided. The unit is given, so work out the answer in the unit provided • Calculator is available on the PSA site. You can also use a basic calculator, which I would recommend 34 Prescribing Safety Assessment (PSA)Calculations Weights • 1000 nanograms = 1 microgram • 1000 micrograms = 1 milligram • 1000 milligrams = 1 gram • 1000 grams = 1 kilogram • % w/v (weight/volume) = grams in 100 millilitres • e.g. 15% w/v = 15 grams in 100 millilitres Volumes • 1000 millilitres = 1 litre • % v/v (volume/volume) = millilitres in 100 millilitres • e.g. 15% v/v = 15 millilitres dissolved in 100 mililitres 35 Prescribing Safety Assessment (PSA)Section 6 – Adverse Drug Reactions • 8 questions – 2 marks each = 16 marks (8% of entire paper) • Aim for 1 – 1.5 minutes per question (8 – 12 minutes overall for 8 questions) • Tick box exercise – select one option from the list provided • Common scenarios - most likely drug reaction, the most likely drug interaction or the management of an adverse drug reaction • Question Types • Type A = Identify the most likely adverse effect of a specific drug. E.g. most common side effect • Type B = identify the most likely medication causing the ADR. E.g. Hypokalaemia • Type C = identify the most likely drug interaction causing the ADR. E.g. Warfarin interactions and INR • Type D = identify the most likely management option for the ADR. E.g. Anaphylaxis 36 Prescribing Safety Assessment (PSA)Hyperkalemia vs Hypokalaemia • Drugs causing Hyperkalaemia • Drugs causing Hypokalaemia • ACE inhibitors • Aminophylline • Angiotensin Receptor Blockers • Theophylline • Aldosterone antagonists • B2Agonists • Spironolactone • Salbutamol/Salmeterol • Heparins • Corticosteroids • NSAIDs • Prednisolone • Tacrolimus • Diuretics • Trimethoprim • Furosemide, Indapamide, Bendroflumethiazide • Stimulant Laxatives (excessive use) • Senna 37 Prescribing Safety Assessment (PSA)Section 7 – Drug Monitoring • 8 questions – 2 marks each = 16 marks (8% of entire paper) • Aim for 1 – 1.5 minutes per question (8 – 12 minutes overall for 8 questions) • Tick box exercise – select one option from the list provided • Common scenarios - most appropriate monitoring option for the drug or condition mentioned 38 Prescribing Safety Assessment (PSA)Section 8 – Data Interpretation • 6 questions – 2 marks each = 12 marks (6% of entire paper) • Aim for 1 – 1.5 minutes per question (6 minutes overall for 6 questions) • Tick box exercise – select one option from the list provided • Common scenarios - most appropriate monitoring option for the drug or condition mentioned 39 Prescribing Safety Assessment (PSA)Useful BNF print screens • The next few slides have print screens of useful terms to use in the search bar of the BNF • Control F or Command F depending on Computer vs Mac = most useful to find information quickly in BNF • For side effects especially – use the search function as shown in some slides in this post course material - Remember to put • AND in between the side effect and the drug • OR in between the different drugs • Eg. Dry cough AND ramipril OR tiotropium OR x OR y OR z • Remember the drug most likely causing the effect is the one which has that side effect in the more common side effect list eg. UNCOMMON is still more common than FREQUENCY UNKNOWN 40 Prescribing Safety Assessment (PSA)41 Prescribing Safety Assessment (PSA)42 Prescribing Safety Assessment (PSA)43 Prescribing Safety Assessment (PSA)44 Prescribing Safety Assessment (PSA)45 Prescribing Safety Assessment (PSA)46 Prescribing Safety Assessment (PSA)47 Prescribing Safety Assessment (PSA)48 Prescribing Safety Assessment (PSA)49 Prescribing Safety Assessment (PSA)50 Prescribing Safety Assessment (PSA)51 Prescribing Safety Assessment (PSA)52 Prescribing Safety Assessment (PSA)53 Prescribing Safety Assessment (PSA)54 Prescribing Safety Assessment (PSA)55 Prescribing Safety Assessment (PSA)56 Prescribing Safety Assessment (PSA)57 Prescribing Safety Assessment (PSA)58 Prescribing Safety Assessment (PSA)59 Prescribing Safety Assessment (PSA)60 Prescribing Safety Assessment (PSA)61 Prescribing Safety Assessment (PSA)62 Prescribing Safety Assessment (PSA)Lithium Side Effects and Toxicity • Side Effects = LITHIUMS • Monitoring • Leukocytosis • Narrow therapeutic window • Insipidus —> polyuria = kidney problems • Monitor levels 12 hours after last dose • Tremor/teratogenic • Hypothyroidism • Toxicity = CATS • Interactions with ANT = ACE inhibitors, Antibiotics (Tetracycline, Metronidazole) • Cerebellar ataxia, choreiform, coma NSAIDs, Thiazides • Athetosis, ataxia, apathy • Upset stomach - NVD • Tremor (course) • Muscle weakness • Spasticity, seizures, slurred speech • Skin - Acne, Psoriasis 63 Prescribing Safety Assessment (PSA)64 Prescribing Safety Assessment (PSA)65 Prescribing Safety Assessment (PSA)66 Prescribing Safety Assessment (PSA)DKA Management Link • https://www.nnuh.nhs.uk/publication/flow-chart-for-diabetic-ketoacidosis-in- adults-management-of/ • Management below in notes 67 Prescribing Safety Assessment (PSA)68 Prescribing Safety Assessment (PSA)69 Prescribing Safety Assessment (PSA)Thank you Please leave us a Trustpilot and Facebook Review J Facebook review = https://www.facebook.com/medvance.uk Trust pilot review = https://uk.trustpilot.com/review/medvance.uk For any other questions or queries, please email us at: info@medvance.uk