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ISCE Crash Course Presents: CLINICAL PHARMACOLOGY, THERAPEUTICS AND COMMUNICA TION STA TION asmeen Al Sadek, Final Year medical student at Cardiff University JOIN OUR FACEBOOK PAGE FOR FUTURE EVENTSPlease check notes under these slides for extra info To get the slides and a certificate of attendance, please fill out the feedback formStation information ■What are you required to do? 7 minutes to talk to a patient or relative/carer regarding a specific task relating to therapeutics like undertaking a medication review, explaining and answering the patient’s questions regarding a new medication or taking a history about a possible adverse reaction.  Summarise the case Answer standardised questions relating to standardised clinical resources and clinical reasoning. At 11 minutes, answer questions relating to clinical care and patient management.Station 1 Vignette: ■65 year old female presents to GP and explains she is worried because she feels like something is not right after starting a new medication. ■ Please take a detailed history, making sure to conduct a medication review.1) Please summarise the case 2) Formulate a differential diagnosis 3) What investigations do you want to conduct?o Drug List: 1. Amlodipine 2. Bendraflumethiazide 3. Lithium 4. Vitamin D 5. Salbutamol INH 6. Formeterol INHInvestigations ■ Hb: 130 (115-165) ■ WCC: 5 (3.6-11) ■ MCV: 90 (80-100) ■ Na+: 140 (133-146) ■ Ca2+(adjusted): 6.1 (2.2-2.6) ■ Creatinine: 90 (45-84) ■ LFs normal ■ CRP: 1 (<5 mg/L) ■ PTH normalHow do you want to manage the patient?Hyponatremia Headaches, Diuretics (THIAZIDES), • Admit immediately if: acute onset, symptomatic, signs confusion, of hypovolemia irritability, ACE inhibitors, tricyclics • Stop provoking medications and recheck sodium conc (Na< 135 mol/L) muscle antidepressants, anti- in 2 weeks Mild – 130-135 weakness, • Treat underlying cause cramps psychotic drugs, anti- • Hypovolemia: 0.9% saline Moderate – 125-129 epileptic drugs, anti- • Hypervolemia: fluid restriction Severe - <125 • SIADH (in neurological causes): Fluid restriction and cancer agents, PPIs, Tolvaptan (vasopressin antagonist) ecstasy Hypercalcemia Bones, moans, Thiazide diuretics, • Immediate management: IV fluids and stones and bisphosphonates if necessary groans lithium, excessive vit D, • Stop or reduce dose of offending drugs and recheck Ca>5.5 vit A or calcium calcium levels in 3 weeks – if hypercalcemia persists, investigate for malignancy Hypokalemia Muscle twitches, Loop diuretics, thiazides - Stop medications and recheck potassium in 2 muscle cramps diuretics, insulin, weeks. or weakness, - >2.5 mmol/l: Sando-K 2 tablets TDS or add 20-40 K<2.7 mmol/L paralysis, salbutamol mmol/l KCl to IV fluids abnormal heart - <2.5 mmol/l: 40 mmol/L KCl in 1L 0.9% saline over rhythms 6 hours - NEVER GIVE >10 mmol/h K+ ECG: Prolonged PR interval, T wave flattening Hyperkalemia Lethargy, ACE inhibitors, ARBs, - Stop medication and repeat potassium levels in 2 nausea, muscle weeks. weakness, NSAIDs, Aspirin, - If ECG changes: calcium glauconite 10 ml 10% IV over (K>5.5 mom/L) paresthesia 15 mins Pottassium sparing - Actrapid insulin 10 units in 250 ml 10% dextrose IV Mild – 5.5-5.9 diuretics, beta blockers, over 30 mins Moderate – 6-6.4 ECG changes: - Neb salbutamol tall tented T K containing laxatives - If K+<5.9, calcium resonium + lactulose (to prevent Severe - >=6.5 or ECG waves, p wave (Movicol and Fibogel) constipation) changes flattening, bradyarrhythmia abnormality s sSummary ■ In any medication history: ■ Check for interactions!!! ■ Have an idea of the common causes and symptoms associated with common electrolyte disorders (e.g. hyponatremia, hypo/hyperkalemia): https://oscestop.com/U&Es_interpretation.pdf ■ Management: ABCDE, address cause, stop offending drug if present, treat as per the disorder present.Station 2 Vignette: 37-year-old female presents to the GP feeling unsettled with increased agitation and anxiet. She recently was started on a new medication and thinks it might be linked to her symptoms. Please take a full history, and conduct a thorough medication review.1) Please summarise the case 2) Formulate a differential diagnosis 3) What investigations do you want to conduct?2 hours later, she develops a fever of 39 Degrees Celsius and complains that her muscles feel rigid What are you going to do? Management ■ Important to classify type of serotonin toxicity ■ Serotonin syndrome usually results from overdose or concurrent use of serotonergic drug with SSRI. ■ Features of serotonin syndrome include 1) neuromuscular excitation, 2) autonomic effects and 3) altered mental status ■ Mild: hyper-reflexia, autonomic symptoms like sweating ■ Moderate: Characterised by anxiety, agitation and tachycardia. ■ Severe: Medical emergency!!! Characterised by hyperthermia and hypertonia. ■ Admit to hospital! ■ This patient has severe serotonin syndrome so REQUEST SENIOR HELP IMMEDIATELY ■ ABCDE- IV fluids, ECG, cooling measures ■ Bedside observations- monitor vitals using NEWS chart, ensuring that temp, BP and HR are recorded. ■ Cessation of tramadol and citalopram – request psych input to decide how to go about this to avoid withdrawal effects ■ IV benzodiazepine and anti seratonergic drug like chlorpromazine or cyproheptadineStation 3 Vignette: 32-year-old female comes to see you to seek advice regarding starting contraception. She uses barrier methods but would like to start a pill that her friends are taking (the Combined Oral Contraceptive Pill). Please have a conversation with her and answer any questions she might have.She presents to A+E 2 months later with shortness of breath. What are you going to do?COCP discussion ■ Please read over this patient leaflet as it contains everything you need to know to answer any questions that patient might have: https://patient.info/sexual-health/hormone-pills-patches-and-rings/combined-oral- contraceptive-coc-pill Important thing to note: CONTRAINDICATIONS are important here: These include: ■ Being over 50 years old ■ Having migraine with aura ■ Smoker and over 30 years old ■ Having more than one risk factor for heart disease (smoking, diabetes, obesity, HTN) ■ History of venous thrombosis ■ If you had a baby up to 6 weeks ago and are breastfeedingManagement of DVT and PE ■ Investigation for DVT: If 2 level Well’s score >=2, DVT very likely, perform leg vein ultrasound within 4 hours. If scan positive, start treatment. If ultrasound not available, perform d dimer test, if positive, start interim therapeutic coagulation then perform ultrasound within 24 hours. If Well’s score <2, perform d dimer test, if positive, perform ultrasound, if negative, think about other diagnoses. ■ Investigation for PE: same as for DVT but imaging is CTPA. Treatment: ■ DVT: Anticoagulation with DOAC for 3 months  e.g. apixaban, rivaroxaban ■ PE: PROVOKED: 3 months of a DOAC  e.g. apixaban, rivaroxabanDVTPEStation 4 Vignette: 34-year-old patient with treatment resistant schizophrenia comes in to see you as he has been told he will be prescribed clozapine. She doesn’t know much about the drug, so please have a conversation with her about.1 month later she presents to A+E with a horrible cough and a fever . What investigations would you like to do?Blood results FBC • Haemoglobin: 135 (125-175 g/L) • Lymphocytes: 0.9 x 10 /L (1-4 x 10 /L) 9 • WCC: 1.3 x 10 /L (4-11 x 10 /L) 9 9 • Neutrophil: 0 (2-8 x 10 /L)How would you manage this patient?Agranulocytosis – symptoms and management ■ defined asanabsoluteneutrophil count(ANC) < 500/mm , bywhitebloodcell(WBC) count< 2000/mm  and relativelymphopenia. ■ Temp> 38 degrees– takebloods toexcludeinfection ■ Prevention:MONITORING ■ Mx:Stop Clozapine, Sepsis 6if necessary, treatinfection ifpresentwith Abx, granulocytecolonystimulating factor (G-CSF) e.g. filgrastim tohelp bodyproducemoreWBCs. Refertospecialisttodecideonwhetherto continue clozapine.Clozapine explanation ■Anti-psychotic medication used in schizophrenia when two other medications have failed to control symptoms of psychosis. ■Works by stabilising levels of certain chemicals in the brain. ■Available as tablets, oral liquid medicine and melt-in-the-mouth (orodispersible) tablets. ■Taken once a day at the same time. ■If you forget to take a dose, take it as soon as you remember. If close to next dose, take next dose and leave out forgotten dose. Never take 2 together. If missed doses for more than 2 days, speak with clinician immediately. ■Contraindicated in pregnancy and breastfeeding, heart conditions or blood vessel diseases, liver, kidney or prostate problems, breathing problems, severe constipation, epilepsy, depression, glaucoma, myasthenia gravis, jaundice and pheochromocytoma. ■Make sure you establish if they take herbal or OVTC medications that might interact with clozapine. ■Important that we monitor you throughout treatment (regular blood tests, weight check, waist circumference, glucose levels) to check for side effects. ■Drinking alcohol should be avoided. ■ If having operation, tell doctor you are taking clozapine as it can interfere with anaesthetic. ■If you have diabetes, glucose levels need to be checked more often as linked with metabolic syndrome. ■Starting or stopping smoking can affect levels of clozapine in blood so seek advice. ■Treatment is long term so don’t change dose or stop treatment suddenly. Dose needs to be reduced gradually over a week or so with advice from clinician. Side effects of clozapine Rare but serious side effect: if you experience symptoms such as muscle stiffness, a very high temperature, feeling confused, a fast heartbeat and sweating, you should contact your doctor immediately. These can be signs of a rare but serious condition known as neuroleptic malignant syndrome. Common side effects Exercise + dietician advice.Important things to remember in explanation stations: ■ Spend 1-2 mins gathering a short history. Gather PC, HPC, DH, PMH and SH. ■ RISK ASSESS if psych condition!!!- Risk to self and risk to others. ■ Ask if they have any pressing concerns in the beginning so you know to address them ■ Elicit info - check understanding – elicit info – check understanding ■ For side effects mention mild SE and serious SE (like sertonin syndrome, neuroleptic malignant syndrome) ■ Always offer info pamphlet in the end, or websites or resources that they can read in their free timeDrug interactions Ciclosporin +hypercalcemia Drugs to avoid in renal insufficiency: • Metformin • NSAIDs • Diuretics • ACE inhibitors • Statins presentation • Always conduct a medication review – ask about all the drugs they take, how they take it, if there are any side effects, and check if there are any interactions. • Don’t forget to ask about the rest of the history: PMH, Allergies, FH and SH!!! There might be clues in there to help with diagnosis. • Make sure pre-existing conditions are not contra-indicated before starting meds. • Don’t forget to STOP the drug if it’s causing an adverse reaction e.g. serotonin syndrome • If you don’t know which antibiotic to prescribe, say that you would refer to the local microguide and the BNF and ask a senior. • Be aware of how to recognise and treat common electrolyte abnormalities. • Patient.co.uk to access pamphlets that explain conditions and drugs in layman terms for patients- they split it into questions • and answers just as it would be in a station.lish reason forLinks to OSCE stop pages that are useful for pharmacology stations : https://oscestop.com/Common_drugs_to_explain.pdf https://oscestop.com/Common_side_effects.pdfPotential stations: ■ Medication review: identifying meds that cause side effects ■ Recognizing drug interactions ■ Discussing use of contraceptive (COCP, Progesterone-only pill)- these pages contain everything you need to know for explanation. https://patient.info/sexual-health/hormone-pills-patches-and-rings/combin ed-oral-contraceptive-coc-pill  COCP explanation https://patient.info/sexual-health/hormone-pills-patches-and-rings/proges togen-only-contraceptive-pill-pop  POP explanation ■ Anti-psychotic explanation (Olanzapine, clozapine) ■ Anti-epileptic explanation ■ Anti-depressant explanation (SSRIs most likely) ■ Asthma and COPD review – be aware of asthma and COPD treatment guidelines Asthma guidelin Questions so check symptom control: In the past 4 weeks,  How often did your asthma prevent you from getting as much done at work, school or home?  Have you had SOB?  How often did asthma symptoms (wheezing, coughing, chest tightness, SOB) wake you up at night or earlier than usual in the morning?  How often have you used the reliever inhaler (usually blue)? COPD guideline sFurther questions? Email me at AlSadekY@cardiff.ac.uk