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Hello and welcome everyone. Today we're going to be going through a few stations now about for Mycology s If you don't already know, this is part of Ah Siris off lectures. Uh, just that we're just going through different specialties and you're just on. All we do is just go through a few common stations on. We ask that few of you volunteer, so it's as interactive. It's possible. My name is Abdullah. I'm one of the final the medical students that card ish on. I'll be doing the first half of this lecture, and then my colleague Mohammed rolled to the second half. Okay, Uh, I'd also like to make sure that everyone if I don't any questions, make sure you use the coupon a function on avoid using the chart. We'll use the chart where the lots of interactions on the audience. So if I'm asking you questions, you can put the answers there. Okay, on defend. One wants to volunteer. Just message. And Mohammed privately on, he'll let me know. Okay, so let's get going. So I'm just going to go through kind of the main things to ask in a medication of pharmacology history. Obviously it starts the same as most history. So always explore for the presenting complaint, using whatever method you use such a Socrates. And then, once you get to the drug and history, that's when you'll need to go into a bit more detail. So the way I remember it is the three double using the for ages. That's kind of a focus history taking in terms of pharmacology. So before you do that, always ask open questions. So, uh, do you take your medication as prescribed? And then you can ask about what they actually take on. So they all kind of the names of the medications that they take, what they take it for. So sometimes drugs can be used for two different conditions, or they have. They have kind of versatility in the way they can be used for amitriptyline confusing depression. You can also be using your plastic pain so it's good to justify. It's good to kind of determine what it's used for on when do they take the medication So sometimes it matters when the medication is taken, so if it's a tienda of the day or in the morning, how they take it so I didn't take it with water to take it with food. Did he get standing up sitting down? So that's that could be important for some medications as well Explore later in this presentation. And how much did it takes? We're talking about the dosage. Yeah, so a lot of the time it's good to ask if they have a list with them and in the exam, they actually, Sometimes we'll have a list in front of them and they'll just give you the list on. It will answer some of your questions about the dosages on the medication. They don't assume they're taking everything on that cause. Most of the time, it's have described list. So you always still have to ask the question. Do you take these as prescribed and then how often you take them? So obviously the frequency matters on how long also, So if they've recently complained off kind of a symptom, it could be a side effect of the medication they've recently started. So it's important to ask how long they've been taking the medication for, and then always ask about over the counter medication such as I'm approaching perceptible on herbal remedies as well, allergies are very important, and some examiners will unfortunately, failure if you don't ask for this and always explore the social history focusing on smoking and alcohol. And sometimes even recreational drugs on diet can also and effects some drugs as well. So it's important to ask you about all right, in terms of investigations, it follows the same structures. Old station. So there's an opening. Um, I like to use it should be Boston's that she might have already hurdles, and it just splits the investigations to kind of a nice way to think about it. So it's kind of chronological order. So you approach the patient. What would you do it that that sites, observations, examinations, bloods, common ones being SBC's um, knees. Then do you think about the orifice? Is so these exams like PR exam also like sputum sample or urine dip or or a fecal sample as well, and then X rays. So this I use this to think about all imagings, not just X rays of CT's Emory bad scans. ECD can be important in ruling out kind of cardiovascular causes and also side effects of medications. That's important to mention Onda special tests such a lumbar puncture sometimes or antibody screens confused. But I'll see it's less likely to be using a pharmacologist a shin, but just in case. So that's the structure when you're having your mind still be boxes. Management, as always can be, can be splitting conservative medical surgical, the pharmacology history you can always say Check the be enough for interactions and side effects of the current medication they're taking. Patient education is always going to be key because a lot of the time they're taking a wrong dose or they're taking it the wrong way on also, medical. So a lot of the time in the management, you're gonna be either stopping the medication or consider stopping it, UH, offering alternatives as well. But always after that, after discussion with a senior, especially with a drug which is like to do outside with psychiatry because sometimes, and if you stop the drug too fast, then you can get withdrawal symptoms or problems as well. On surgical is just there for the structure, but again unlikely to come up in a likely to be using a pharmacology station. So keep concepts. So you probably heard of this ovarian times that you've heard of it so much because it's important. So cytochrome p 4 50 induces and inhibitors. So I have my own acronyms. I'm just going to go through this quickly and then we'll do our first station. So the way I remember is crops that induces cramps, not drugs. So chronic alcohol intake carbamazepine offer a fun person A for anti epileptics pee for phenobarbitone on DA uh, the other anti epileptics s for Saint John's wort and also for smoking, which also inhibits another enzyme. See, I p 1 80 years old. And the way I remember inhibitors is actually a zols. So antibiotics except for refund person because that's the are in crops. Yeah. Then I'm the old room. If you're in a lot acute alcohol intake, so realize here. See, here is for chronic alcohol intake. So let me get my legs the point. So your chronic alcohol intake for crops, it's acute inhibitors. SSRI for the two s is sergiev alkylate on zols for anti fungal such as ketoconazole on also on, um, Emeprazole as well. So it's never one has their own way, is kind of written remembering this, but kind of differentiate between the ages and essence here because there is a and essence in both of them. A good way to remember kind of the induces it is if you just picture a guy kind of. And if you close your eyes for me on uh, and his picture, a guy called John leaning on a wall. He has a cigarette in his left hand's maybe a bottle in his right on. He just falls own, has a seizure and is incontinent. So in that scenario, the guys called John is a chronic alcoholic because he has a beer bottle smoking and also he has a seizure. And then he's incontinent. So the crops up. So that's a way to remember kind of the induces I use. Well, see him just stick to the all right so substrates that surgery. It's subsidies are actually the medications that are affected by these induces and inhibitors We've talked about on the way to remember. This is counterparts. The warfarin can come up a lot because a lot of patients are more friends. C o C p. So they're called combined or contraceptive and also anti epileptics and statins as well is very common, uh, common interactions. So these are medications that can come up in histories of the patients taking two of these, or is an acute situation where they were already on one medication, like a base inhibitor, And then you suddenly give them another anything. Certainly give them another medication. So the cost when it started and macrolides on as we've explored. So macrolide is one of the antibiotics that inhibited so it will will prevent the started from being broken down on so it will stay in the body for longer. And so it's a risk of off rhabdomyolysis. And is this examples of these like me to turn on? All of these are found an osteopath dot com. So that's the kind of website I'd recommend to. You have a book which has goes into more detail. This is another step it from asking stop Well, has ALS the kind of electrolyte imbalances onda causes of them. So if you look at hyperkalemic is very common thing that the common exams, uh, a synonym bit is and a all these this was like the statin can increase in potassium as well and said's rarely, sometimes heparin, a swell that these are the common things that come up. So I have a look at this. We don't have time to go through everything, but it'll be in the presentation, okay? And this is actually a floater from the asking stop, but which goes through of the drugs that you should avoid or reduce the difference in renal failure on again. This could come up in acute stations. And even if it's not pharmacology station, we can come up in acute history on you. Have to stop this medication because they created it is too high, for example, on advise you and idolize you to kind of memorize and pages three oh, 2 to 3 or seven and Austin stop if you have the book because it has almost everything you need to know for kind of pharmacology station. So moving to the first case. So do we have any volunteers? It was never wanting. That's fine. We'll just run through the station. But it'll just be a bit more interactive if we have someone to do the history of least anyone. Okay, that's fine. So we'll just go through the history on um, I'll try and make it is a tractor responsible, so I'll just ask questions. And if you can just say what you thinking in the chart, Okay. I think someone might, uh, so as a nose do the history. Okay. Or do you wanna put your my konzi? Yeah. You? Yeah. You can hear me. Well, look so nice to hear from you. Okay? So you have a read of that. Tell me when you're ready and we'll start. Okay. Get this one already. Okay. Uh, so let's try me 31 time. You just you just go ahead and have my name is a NASA 1. 14 students here with GP practice. I'm going to take your name and your date of birth, please. Uh, my name's in on on. I'm just 63 years old. Is okay. Pacoima. Yep. This one. Okay. Could you tell me why you come in today? Yeah. So I've just had a bit of trouble sleeping. Really? When I kind of go to lie down, I got this pain in my chest and, uh, yeah, obviously. Okay. Uh, could you tell me a bit more about that? Yeah. So it's, um, really is being going on for past few weeks, and I don't know what's happening. Really? Um, I don't have ever had anything like it. Okay. Where exactly is the pain? The pain is kind of like in the middle of my chest in the middle of the chest. Okay. How would you describe the pain? Yeah, I see. It's kind of a burning, actually. Yeah, a bidding pain. Okay, on Is the pain spread anywhere else? Um, no, no. Just, you know, if the pain makes it, you know, if anything makes the pain better or worse. So, yeah, When I lie down, it's the worst. Sometimes at night, I have to sit up and try to try to fall asleep. That way to kind of get rid of the pain. Okay. Okay. So long dot makes the West. Sure. On. How would you rate the pain out of 10 times of severity? 10 being the worst. I'd say this is kind of a five, but it's enough to keep me awake like I can't sleep with it. Okay. Sure. Sure on. Did you have any other symptoms at all? Uh, no, no. Just that. Okay. Gonna ask you just some other general questions about your health um Do you have any medical conditions? Yeah. So am I Have osteoporosis, I think. Has diabetes on, uh, have back pain as well? Kind of chronic back pain. Okay. Did you take any medications for those things? Yes. So I take, um, alendronic acid. Is it for osteoporosis? Um, and I also did they proportion for my back pain on for the diabetes? I take metformin. The glipizide, I think. Okay. Sure on. Do you have any allergies? Yeah. My letter to penicillin, I think. And what happens when you take penicillin? Uh, I get rough rush of it. Sure. Um, do you take anything over the counter? Yes. The ibuprofen I'm taking is over the counter. Okay. Sure on. Do you share medications with anyone else? No. No. Okay. On with these medications. See, it seems like you know what you're taking them for. Uh, what do you When do you take these medications? Um, so I just take the turns. I'm not too good at kind of keeping track. I just take them when I remember them. The day really on. You know the strength of the medications that you take. I'm not too sure. The bike and do your list afterwards. Sure. Uh, how long have you been taking these medications? Um, the diabetes medication and the island, Or it I said I've been taking for at least for years. Really? But the ibuprofen I started about a month ago because the battery is not a bit worse. Okay, I see. That's fine on. But what do you do if you miss a dose of the medication? Um, I just take it when I remember. I don't think I've ever missed it, To be honest, if anything, I'll take it like before I sleep. If I have mister during the day or something. Sure. Okay. With the stuff they take, Especially with the back pain and ibuprofen. Do you feel like it's helping or do you still have problems with your back pain or anything else? It does help a bit. Double brushing. Yeah. So you know. So if you experience any side effects from any of these medications, uh, I don't think so. Okay. Sure. On these these questions, we ask everyone but you smoked for Yeah. How much do you smoke? 20 a day. 20 day. And how long has that been? Both. Oh, for, like 30 years. Okay on. Do you drink? It'll no, no, no. Okay. And this is just a question. We ask everyone, but you take any recreational drugs on. Know When I went out to the teenage, I used to take kind of cocaine, but that was only a few times. Okay? Sure. Okay. And then I stopped. Now, that's fine. Um, do you have any ideas In terms of what could be causing your pain? No. No, I have no idea. No gym. Any expectations from ourselves in terms of what you want to get out of this, just get rid of the pain reading. Just pain. Okay, short. That's fine on just some general off questions about you. Systemically. Do you have any nausea or vomiting? Ah, no, no. Any diarrhea? Constipation. You know, No. Any joint aches or muscle aches? You know, headaches? No. Open your balls. Okay. Yes, sir. Yeah, Coughing, you know, traveled anywhere recently? No. Any dodgy restaurants, you know, called Case hasn't get a note for depression, so that's fine on me. And that includes the consultation. Thank you very much for your time. All right. Thank you. So do you want to summarize that and getting rid of your differentials. Okay, so today I'm taking history from Fisher. Hold him on. Who is 63 years old? They come in today with a 34 week history or retrosternal. Chest pain was described has been burning on with my mind down on. They also have a history or osteo approach something. It was diabetes, and back page was tripped on a lot of acid. I'm on metformin on day was one of the diabetic drug was Well, she's allergic to penicillin. And you get the rash. There's, um I was also a smoker. Has spoken about your day for 20 years on so much doctor French. For this would be that the patient is suffering with reflex because of the bed in pain, on the nature of where it is a swell. Okay, so what do you think's causing this or your differential s? I think it could be so since this is the medication, eustation could be the alanon of acid because, uh, Montel, that they basically they don't have to be very consistent with what he's taking it. Eso I think that could cause the reflux also the appropriate it was. Well, that could also cause a problem, because it will irritate the joint because of those two drugs could causing the reflux. Okay, So how do you go about investigating the patient? Eso to escape the patient for reflux? I don't think there's many routine investigations that are done or reflux. We do an examination, uh, do some been side test. So, uh, do any CG? Um, there's a lot you do do tee be for reflux, I think is largely just a couple minutes. So they would They would do anything routine for reflux. I think the main way they would diagnose that is likely just stopped, like, for instance, there to stop the ibuprofen and then start a PPI on. Then if the symptoms get better from that, essentially, diagnosis is the reflex. My other things that we could we might do is like, man does could be or like, a ph study. But I don't think those things I don't routine. Okay, so you do a few blood and they all come back negative. Um, what would be kind of your management with it, But anything else you'd like to see? What is that? Did a bit of management there. So for my husband, then So I start off with patient advice. Advise them that the condition they have the Symbicort reflux, but it's basically the ass, and rest of it's coming up and irritating their esophagus. I would advise them that they can, for instance, not too close to when they go to bed because they know when they like out, it gets worse. Having smaller meals at that time would be better. Is any foods that you notice that trigger it on to avoid those foods. Also, like losing weight would help us well, the patient a smoker. So if they were to quit smoking like prefer them to smoking cessation services, then it is the medication of you. We would look to stop that appropriately, uh, helps try something else. Give advice on how they should be taking the other one of acid. It's so sitting upright, Um, and then for medical management, this would be to start up PPI on, see if they respond well to that, and then in terms of surgery, they wouldn't really be any sort of routine surgical management for this. Just be the lifestyle stuff and then you seem to be up. Okay. All right. And station, I'm gonna ask you a question. So how do you exactly take the alendronate? So I think this is the one where you tell him to miss me. Take it once a week. Take it when you wake up in the morning so they'll be on an empty stomach. Take it with a full glass of war on. Then they just have to stay upright for 30 minutes before they do it now. Yeah, the Yeah. So, you know, So say that maybe the Examiner, like, you know, the 30 minute gonna stay on the empty stomach because you have entered on that tiny points. See that from good. Good. So very good. Very good. So if you go into the history, So yeah. So it was simply breakfast. Little pain with lying down? No. No. Kind of red flags on he. Yeah. So I just added the allergy. So a lot of people fall into the trap when I say, Do you have any allergies? They They're like and the present says yes. It's like penicillin. Then it just move on is good that you asked. So what happens when you take that a lot. People don't ask that. But, yes, it was important to establish whether it's a rash or it's under floxin. So anything like that? Okay, family history isn't always important in drug history. And yes, and social history. I just kind of made up, but yeah, that was good. One thing I did it, so that was very good. You would have passed that easily. I'd say when you're asking questions like the red flags don't couple and symptoms together, Don't be like constipation or diarrhea or kind of muscle pain or joint pain, cause a patient will either get confused or they'll just answer one of the one of the things on examples. What kind of mark you down for doing that? Okay. Yeah. So you had us everything individually, so the patient isn't, uh, confused. All right, so differentials s, which is going to special. You want to relax, have angina because a lot of people get heartburn, but it's actually kind of sort of angina. Most of your pain is also another differentiation of peptic ulcer as well, since the ibuprofen is an NSAID that it's quite prone to doing that so investigations. Like you said, you want us to do a lot of messages with it, especially for you in a GP, but because they take another profin. And they could have kind of an ulcer since he is. It was kind of like the irritation that something you want to check their not bleeding. You want to check that? You know you want to check. Electrolytes is well and on because they're kind of taken alendronic acid and the taking it incorrectly as well. You wanna? You might consider doing a bone profile as well, but again, you're in a routine and do that offices. You could do your e a breath test because again they might have kind of reflex. What kind of like an ulcer? But it could be due to, um, something called a trip I roll, put pylori. That's how you test for endoscopy. Like he said, it's not routinely done, but it would be done if the other things, if the other kind of on and investigations were concerning on D. C's actually said it was good and there's no really special testing. So management. Yes, it's mainly patient education. It's about the alendronic acid. The ibuprofen is while taking it with food. Unless you said it's also did not show up with this. And so yeah, the smoking cessation so always mentioned everything to do with lifestyle. So smoking sensation she was really good with the drinking alcohol cut down on alcohol. Um, exercise diet. So, like you said, spicy foods, you say, like avoid triggers You could even say are providing that Provide a picture with the leaflet about kind of my things that cause heartburn and not avoid it. Um, on the AcipHex twice. And she's eating like me. A bad time is really good. So you mentioned all that, But I got I always say like, Oh, I double check with the TNF. I make sure to follow up with the GP, you know, medical. So again, assistant considering alternative. The ibuprofen, like you, said, you mentioned giving a PPI as well. And that's what you would give this part of a kind of like a triple therapy if they did have my Loria's well. But again, it's unlikely in this case on also, if they take it out and one of us that the reason you do calcium and vitamin D is to make sure that they actually kind of replete in that, uh, because you need to be repeated when you're taking the bisphosphonate. It's like alendronic acid case of viral than more than you would have passed that. All right, thank you very much. So we've actually go bit of time. We could only do the history here. Does anyone want to volunteer to do a history or so you just quickly real. You've got a volunteer bila. Don't. Yep. Do you want to put you Michael? What? Hello? Yeah, my name. DT Hi. Nice to meet you. So this is the briefing for the presentation. If you want to have a read, and when you're ready, we'll do the history. We won't have time to do the rest of the station, but we'll quickly do the history. Okay. Okay. Well, yeah, yeah. Um, just a little trick treating. Yeah, Go. So yeah. Well, no. Okay, So do you wanna go ahead? Uh, yeah. So hello. I'm like, No, I'm one of the fusion associate. Can I take your name and the tooth part, please? Higher. My name's Sylvia, and I'm 60 years old, so Hello, Cynthia. somewhat worked you in today here. And so I'm just I'm feeling quite well myself. Actually, I'm just worried that money that sugar levels are a bit high, right? So high How? How Ah, you got to know about this means that your blood sugar level is high. So I should have regularly check my blood glucose using one of those kind of machines you give me on. I've noticed that have been kind of, like, above 15 for the past few weeks, so that's quite high for me. So I don't know what's going on. Right. Okay, So you say you just mentioned that you are worried about your blood sugar levels on you regularly check your blood sugar, But that machine, which is, uh, yeah, and, uh, it is since three weeks. Uh, staying high. Um, have you noticed any kind of, uh, are you taking any kind of medications for that? Yes. Um, so I take insulin. I think I have type one diabetes, so it's a kind of two types of incident. Um, yeah. Yep. And are you regularly taking that very compliant, don't that? Yeah. Yeah. So usually it's very well controlled, and I think because it's prescribed and everything. I heavy notice any kind of far, like, Oh, have you experiencing any kind of symptoms with this? Ah, uh, blood sugar reading? Um, no, really. No, no, that's the thing. I feel quite well on myself. I'm just worried about the high blood sugar, him any kind off. Ah, like still, I'm just mentioning some things if you think that it is ah, present that we know. Like any kind off excess you tossed? No. Ah, frequent urination. Um, any victim nous numbness. Uh huh. Right. Um, heavy changed anything recently. Like any other medication or your diet? No, Actually, I haven't really changed anything. Hi. Right. Sorry. I would like to give up that station. Um, society. No, no, it's fine. So, you know, so I can just, like, ask our basic past medical history for family history and social history just to finish in. Yeah, for you. Okay. To tell me like, uh, do you have any other medical condition? Yes. So I have a policy mild to Romantica, and I take a prednisolone for that. Right. And how long you are taking that? Um, I've been put. I was put on that a few months ago. Ah, you months. It's like a new new medication for you. Uh, yeah, kind of. All right. Okay. And any other medications? Uh, yeah. I take a statin as well. Right? And how long you are taking that? I was taking that for about 10 years. Any acid, right? Ah, would you like to tell me any other medical condition, Which I don't know. No. No, that's right. Okay, on. I would like to know. Do you take any kind of over the counter medication? Horrible medication? No. And the allergies. Oh, any kind off surgeries in the past? No. Okay, Now, I would like to ask you some, like a family history, which is, like, any medical condition which runs in your family. Just just for the interest of time. I think. I think that's it. So you've done the pharmacology. Okay. That way. Thank you so much. Okay, so we'll just move on now on. We'll just direct the questions to the whole audience. So this is the history. Um all right. So yeah, this is the history. What do you think might be going on if you want to put in the trial. What do you think is, uh, going on? Why do you think that That sugar was high? That new medication badness alone. So you have permissible is definitely contributing to it. So if I No. Yeah, so and this And this is the key one here. But there was a bit of the the investigations, So these kind of investigations, you going to go into the differentials and good. But the key ones that you'd want to do here is just blood sugar. Obviously. I need you wanna check? Kind of, like, possibly a personal vascular exam. A few 100 examine you on. Defy. So this is kind of like the blood that I've come back. If you could put in the chart what you think might be going on. So I did one of the thing on examination that could be contributing to the presentation. What do you think? So what do you think the love under the injection site might be indicating anyone in Detrol? Yeah, like a life of district is I kind of gave her way of it because it was in the other side, like a dystrophy on. If you would have asked further So this is where it is, the hard one. But if you would have asked like Do you rotate sites when you inject? Then she would have said that. No, I should have keep it in one spot because the other ones are getting sore. So yeah, so if we have a look at the management, do you think you want to say is you want to rotate the site? So that's a big problem when people keep injecting in the same site. Because insulin is kind of like an anabolic medication, it stimulates kind of like accumulation of fact. You can impair the absorption off future insulin that goes into the same spot. So they advise you to kind of take a quadrant somewhere and then actually rotate within that country and sometimes rotate the whole. The whole injection site itself is well, and as with any pharmacology history, you want to check, be enough with all the medication and follow up with the GP and awful the lifestyle kind of things as well on D. If that doesn't work, then we know that it's a problem with the actual prednisone. Now it's needed for the PMR. Usually what they do is they tape. They taper it down to kind of kind of control the conditions. You don't actually need it long term, so they eventually taper down. But people will tell you when they're on diabetes went as soon as I take prednisolone that glucose control goes and goes goes out of the roof. So it's very important to kind of advise. Advise the patient about that. All right, so Okay, three. We don't have time to kind of go through this, so I'm just gonna go through this quickly. So this is a patient, a 65 year old patient who presents with the drowsiness on fatigue. So if you have a look at the history here and if you can form a differential so I'm just going to do also is this feeling tired? Onda bit drowsy. Uh, he's only really started a PPI. Otherwise, he's been taking his other medication kind of regularly. So what do you think might be going on in this situation? It's a bit of a hard one without investigations, but we'll get that in a bit. Speaking of terrorism, the initial initial thing, What do you think is going on Yeah, yeah. So I got someone she said Hyponatremia stray. Oh, it well done. Yeah. So that's a volunteer thing that could be happening. So if you move on so differential. So remember, if they're feeling kind of like drowsy or tired on the hyper tired, but then they're like a hypothyroid didn't always suspect hypothyroidism and the me. I could be one of the, well, electrolyte imbalance. Or someone said on malignancy, You want to realize, Well, it was quite sudden, insidious onset. There's a lot of blood that sometimes you have to do with people who were presenting with tiredness benefit in a pharmacology station. You'll know a lot of time, you know, like it's something to do with the medication. So blood you'd want to do is kind of fbc with the anemia. You in these for the electrolytes? Yes, else. Any inflammatory conditions this is indeed could actually make you quite tight if it's if you're deficient. Photon on T. I. D. C. Is just kind of to confirm that anemia or anything, and TFC it's for a virus on if on examination that has some focal neurology that it would be wise to get sort of brain imaging as well to kind of reload to space, occupying the gym and the CD as well. And again, I think, with the thyroid. And it can cause bradycardia. So these are a set of bloods. Have a look at this. I haven't kind of highlighted them in exams in the examine. Tell you the abnormal result that a star next to it, I made a bit harder here, so you have to look through this. Tell me, what do you think? It's abnormal. Part already said it. It's good to practice on anything. Yeah. Yep. So hyponatremia. So that's the only thing that's obvious here. So Okay, so that picture is not supposed to be that, but so there's a lot of things that actually can cause hyponatremia. But interestingly, PPI is one of the ones that and really cause it on has actually come up in exams in the past. So it's actually quite common cause SSRI is the more common cause actually on. That's why I really actually the person he had depression on the way that works through S I a teenage levothyroxine as well and needs to be taken on empty stomach. So If you ask me in the history, how do you take your levothyroxine? I would have probably said with food or something. So that's another thing you probably consult the patient on, which kind of emphasize the point off. Always ask how the patient is taking the medication because even if it's not related to the presentation is something to advise the patient and can cause a little like later problems as well. On it could be affecting his tiredness as well. So maybe he's not absorbing it properly because he's not taking on an empty stomach. So it's about like alendronate acid in that sense, but you don't have to kind of sit up right on it. And, as I said, always check the B N f for interactions and current drugs and follow up with your GP on medical. So hyponatremia kind of should be dangerous if it's quite severe. In this case, it's quite miles, so the range for a mile is like 100 3834. Um, usually the first thing you do is check medication on. We found some offending agent, so hopefully, once we've taken them off that medication or found them an appropriate replacement that will improve. If it doesn't, however, then you may have to take. You may have to do more investigations to kind of to kind of determine, of course, and the way you do this. A suit through several investigations, such was like You're in a research urinary sodium, and that's kind of establish that the patient's kind of usually make hyper over limit I purposely make. And then that rules out some conditions. Then you can kind of hone in. But basically, if someone hyper any treatment and they're not kind of improving, then you may have to in some cases, fluid. Restrict. Uh uh. If the valenica hypos limit on, sometimes you may have to administer drugs like told up tons and tons, but that's that's something. So even if that comes up in the escape station on the Oscars station, you know, it was just refer to a senior, and just to just a you just say I'll do the necessary investigations and a man is the hyponatremia in that sense. But in this case, in a pharmacologist a shin that changing the drug will change it. Just be aware of something called osmotic diet demyelination syndrome. And that happens when sodium is corrected too fast in the body on. So the Range Day and the two numbers to remember is 46. You can only raise the sodium from 46 a 24 hour period taking the medication off. We'll do that gradually anyway. This is just when you're treated actively treating them and fluid restricting them or giving them giving them saline or anything like that. Okay, that's the end of my presentation. Does anyone have any questions, actually, and just quickly go through. So there's some drugs that caused type of the treatment. So the most common ones, I kind of diuretics, Lupron, Dyazide s or eyes, especially citalopram some antipsychotic so well on carbamazepine. And there's also a huge lift it off like rare hundreds off drugs that really caused that, one of them being PPI. So I was a bit kind of harsh and saying this, But even if you didn't know this and he said I would have checked it at the end f for possible side effects, then the exam. We would have known that you're safely practicing, okay, and and that's it really so I'm going to go to That is quite about that. Yeah, that's it. So we'll move on to my colleague Bahama to use. Will do a couple more stations on. Um, hopefully have one more volunteer. It would be great if you just had one more. I got two more stations, But even if you just have one, that would be great. We just start to show my screen. Yeah. Okay, Sir, do we have any volunteers? I don't think so. Some people have raised their hands, so it so the liver is and so Yeah. So the NT you've already even so. Julia, do you wanna do you want to put you on my car? Yeah. Hi. Weather gradually. Um, So this is the briefing markets. A 63 year old mine who presents his GP restaurants of breath. So I'll give you a minute to breathe through it on whenever you're ready. Just let me know when we consult the history. Um, okay, I can try. Great. Hi. My name is Julia. I'm one of the the doctors here. I confirm your name and date of birth, please. Yeah. It is marking on 63 years old Okay. Hi. Mark on. But, um, what's brought you into the doctors today? Yeah, Doctor. I mean, getting a little short short of breath for the past couple of weeks now, and it's really bothering me. So I thought I just come in and check on what's going on. Okay. Could you tell me about more about this shortness of breath? Yes, sir. It's been going on for the past three weeks. I'd stay on normally. I grew for midnight. Well, late night walks on. Normally, I'm able to walk about half an hour, 40 minutes. But for the past three weeks, I can only walk for about five minutes and then after head back, it's getting quit worrying, you know. Okay. I'm sorry to hear that. That must be about stressful for you. Is, um So do you get any other association symptoms with this shortness of breath such as chest pain? No, I haven't any chest pain. No. Okay, but we need to associate symptoms. I don't know if it's linked to tours, but I've had, like, a painful mouth when I'm swallowing water. Or when I'm swallowing food. I don't know if it's got anything to do with that, but I thought I'd mention it. Okay. Yeah, That's thank you for mentioning that. I think everything is important. Um, so do you have I'm just gonna ask a few short questions. Now. It's semester. No questions. Have you had any night sweats at all? And if, um, any bleeding from anywhere? No, any. Ah, weight loss. It'll a little bit lost? No. Okay. On. Do you mentioned this painful mouth? Do you have a sore throat? Um, no. I want to say it's a smoker. It's mostly my mouth. Really? When I'm swallowing water, it is. Could be painful sometimes. And that happened over the past few weeks is all okay. How about when you eat? Yeah, it's when I eat his. Oh, yeah. And have you had any changes to your voice? No. No changes to my voice. Okay. On D Ah, I'm just gonna ask you about your past medical history. Now, do you have any medical conditions? Yes. So I have asthma. I've had asthma for quite a long time now. I also suffer from depression, but I'm on medication for that. I also have hypertension, which I'm also medication for on. But I've got a bit of anxiety is Well, okay. Thank you for sharing that with me so that we brings us to the next, um, questions quite nicely. What medications that you take and what do you take the before? Yeah. I've actually got a list for you, Doctor, if you can. If yes, sir. There's a room. I prescribe medications. Right. So the salbutamol in back with his own. That's reask months. That right? Yeah. Actually, in for depression and then the amlodipine and ramipril for high BP. That's correct. You do You take all these, uh, spring tribe? Yeah. I take them all it's prescribed, but I have noticed that I've been using the albuterol inhaler a lot more for the past couple of weeks. A lot more frequently. Okay. And do you take any medication over the counter? Yeah. I've been taking, like, a perfect and I'm I've been having some knee pain for the past couple of weeks. They're being taken. I'm perfect for that on, but I wouldn't say it's over the counter, but my brother suffers from anxiety. Um, Andi, I haven't been able to get a appointment with the doctor yet, so I've just been taking his base operable Stop a law which is GP prescribed to him for his anxiety. So I've been taking that as well. Okay. And how often have you been taking the Vistaril is helpful for, um, hum be every day now. Yeah, I say every day since How long? Um, about a month. About a month. Okay. Um, so, yeah, ideally, you should try to get a doctor's appointment before taking any medication like that. Um, for the future. But thank you for telling me about that. And are you allergic to any medications? Do you have any family history of any medical conditions? Yeah. I think this asthma runs in the family a bit. On also anxiety. My brother has anxiety. And the mother also, it'll come anxiety. And, uh, do you work or are you retired? Um, no, I don't work. I just liver home alone. The amber tired. And do you get around the house? All right. Um, I do. Yeah, I do. Yeah, it's fine. It's just mostly a night. Um, I've been to struggle a bit more because my breathless my breath Let's get worse at night. I noticed. Yeah, I understand. Do you have stairs in your house? Come. Uh, yes, I do. And how are you finding getting up and down the stairs? I'm generally fine. Yeah, I'm getting up and down the bills. Good. And do you smoke at all? No, I've never smoked. Good. And do you drink alcohol? Uh, very rarely. Okay. And we asked this of everyone. But do you take any recreational drugs or No, don't. Okay. And do you have any main concerns? I'm just the shortness of breath. It's what we're being, Really? I'm hoping it doesn't get any worse, but yeah, it's just I don't know what's causing it. Really? Do you have any idea what this could be? You know, you just said you don't. You have no idea. That's okay. Yeah. Uh, and he presented anything you're expecting, in particular from today's visit. Um, maybe some tests to find out what's going on. Okay, I thank you for speaking with the work. No worries. So Julio's you honor and present back what you found from history. Um, so you want me to get, like, a short one, or Yeah, just a short one. Yeah, Just of the main points. I saw Mark today, a 63 year old male presenting with shortness of breath to the past three weeks on about kind of asthma, depression and hypertension. And I'm society okay on. What are your differentials at this point on my top one is Ah, adverse reaction. Um, from the bisoprolol, um, worsening his act. Asthma acutely. Um, possibly, um it could also be that his asthma needs hum a review on that. His cell, beautiful. Isn't giving him those cell be smelling beclomethasone. Isn't, um, giving him the relief he needs? But my top one is the bisoprolol affecting Oscillo. Um, how would you investigate this patient? Um, I would do bedside. I would to his, um oxygen saturations, heart rate, BP, and, um, peak flow meter on. Uh huh. Mm ah, maybe some pounds a cold bmp just just to make sure if my beef heart failure, but he doesn't have a history of also, um, and imaging. I'm not sure if you would need Teo anything and also check his asthma, check his inhaler technique to make sure he's they're not chronically hurt. So one of the investigations you do is a chest X ray. Would you be able to interpret this X ray for me? Um, okay, so the apices look clear, and so do you. Uh, okay, I forgot what it's called, but like the diet from Costco die on, but they're looks to be some, um, something on the patient's riot lung. I'm not sure if that's Perry from feel coughing. I'm not sure that's right. Um or if this is just a normal chest X ray at night. That's right. That's right. All right. You're done. World. And Julia, I think you did really blow, So we'll go through the history first on by Think you took a really good history First got the presenting a plane, you got the shortness of breath and the history of presenting complaint. You got information out to me. I think you started with the open ended questions, which was good on the one thing you did really well was rollout red flag symptoms. So you asked about weight loss. You asked about hemoptysis any blood at all? Because you're thinking we want to rule out like a blank malignancy. So I think you did a really good job of ruling out all the red flag symptoms as well. Um, on you asked about associated symptoms. So that's where you got the pain for mouth. Would you happen to know? Yes. It's okay if you don't, but do you know why he had the pain for mouth? A disappointed time? Um, could it because of Are the steroids inhaled? Yes, it is. Possibly because be because of the, uh Yeah, exactly. It is. It is. We're going to more detail, but you're correct. S o. And the painful mouth is a symptom off all brush, which is a side effect of one of his inhalers. They're beclomethasone inhaler. So that's why you had the pain from that off? Um, Andi, I mentioned that he was particularly breathless at night because that's what you typically see in asthma. The diurnal variation on you, so you would get the shortness of breath tends to be worse and evening or later in the afternoon, past medical history, you got the stuff from asthma, depression, anxiety, hypertension on the drug history. You made sure to go through all the medications, ask which medication I was using, And what for? On you did a good job of asking for any other over the counter medications because I made sure to say, this is my prescribe a list of medications So it could be easy for you to just take that as a given and know ask about any other medications. But you did go to ask if I was taking drink, taking anything else. That's where you got the bisoprolol from. So in this patient, he was taking his brother's Bastrop alone on this actually happened. I don't if I can't say it, but it has happened in kind of faucets before in the pharmacology station where the patient is taking medication. I prescribed for them, rather from one of their family members. So it's always worth asking. Are you taking any other medications? Um, on the picture was also taking ibuprofen for the knee pain on. I'll go into in a better. I'll explain why I've highlighted I've gryffindors. Well, um, so you got a family history of asthma. He eat enough. Excellent. So I don't worry about that, But he had Anxiety is raw on. Do you difficult of asthma or social history? So whether he smoked or not, because this is a risk factor for conditions to test COPD left lung militancy is wrong on you. Asked whether he works. So then you could be thinking about occupational risks, such as if it was a builder or other sorts of things which could lead to Risperdal conditions as well. Now, in terms of investigations, one thing I would say is, whenever you're doing a history or examination, the first thing you should do is the relevant history examinations. For example, if you're doing a respiratory history on, the first thing you say say is you do a full of this pretty examination, we'll say feeding. If your station is a respiratory examination, say the first investigation you do is a full respiratory history just to get an overall picture of the patient on. Did a good job off talking about the new scores? And you say you do respiratory rate or desaturations s. So you get all of that with in the new school on, you could consider doing a perk rules. So what part is you probably all heard about the bell score, so the bone score determines whether you have a P e or not. On what investigations to do to determine whether you have a B on the Percle is basically the opposite of a bell score on a particle is used to basically rule out to be so. In this patient's case, it's unlikely to be a P E because patients have shortness of breath for about three or four weeks. So you could just say you would use the purple to rule out to be. That's one thing I learned to drink my Oscar revision last year. It tells the Bloods there's not much blood you can really do. I guess you could do FBC just to do a general check up for the patient on Also check for anemia because in, um, it anemia can also present a strong dose of breath. If it's quite severe, you could also consider checking for flunking Marcus. Such a CRP Oh yes, are just in case the patient has some sort of effective reason for the shortness of breath. Just pneumonia. Um, in terms of imaging, I would just do a chest X ray at all, or if the patient's treatment of breath just always say you do a chest X ray. Just in case is something more going on and also also always do an EKG at the base. Last one was a breath just to rule out any cardiac causes. You did ask in the history about any chest pain at all, which is really important, which is another red flag. But I just do it easy, just in case. Do without any cardiac causes on. In terms of special tests, patient already had a diagnosis of asthma. So in reality, I don't know whether they do spirometry or exhale nitric oxide testing. Where does all that? I'm not diagnostic tests you do for asthma on. You could also consider Ask them to do a people diary just to see how the asthma control is going on. But once you put in some implementation in place, such as telling them, stop taking, taking them stop along. You can look at the peak for a diary and see if that's made a difference to the shortness of breath. The tour. So in terms of differentials, the top defense show or the diagnosis would have been asked for on uncontrolled asthma, and this would have been triggered by the bisoprolol. I'm perfect. So you you correctly identify that Bystolic along causes block a constriction which reduces, it basically makes it all summer. A lot worse on D bisoprolol is contraindicated in patients with asthma and sometimes COPD as well. The reason why I mentioned ibuprofen is perfect is an NSAID, and the patient was taking ibuprofen for the knee. Pain on I'm a Perfect can also cause blocker constriction. So for your fourth years, you haven't done your PSC next year. Um, one of things you learn is and said's as an analgesic method is contraindicated in patients with asthma or COPD, because insets can also cause bulk of constriction. In reality, lots of people with asthma take ibuprofen with no problems. It's just worth bearing that in mind. I perfect can also cause blocker constriction. Anxiety is another differential, the patient mentioned was anxious, and anxiety is also another good differential for shortness of breath. Lignin. See, you'd really did a good job of trying to rule that out on dust, another differential for shortness of breath and join again. You asked about chest pain, heart failure you mentioned at the blood test. You do pro BNP, which is the test for heart failure. So in terms of differentials, try and come up with a board range of differentials, not just stick with respiratory conditions. Think about cardiac conditions, that is angina. Heart failure. Also, anemia get also cause shortness of breath as well. It's anxiety, which is a psychiatrist, condition which can also cause shortness of breath. So in terms of the management, I spaced up into conservative on medical for this patient. Conservatively, you did a bit of management within the history, which is quite impressive. You mentioned not to really take this topical or prescribed medication without a doctor's appointment, So the first thing you do is explain to the patient why the asthma may be more uncontrolled than usual. So avoid taking and said's on the bicep alone on Explain the risks of taking prescription medications without it being properly prescribed. You also mentioned checking inhaler technique, which is really important you. And if the patient's has a diagnosis for 10, 20 years, it's always worth checking if they're union inhaler correctly on also follow up the GP. But always in all my Oscar stations, I always say, I'd like to make sure this patient follows up with the GP because a lot of the time you're examiners go BG peas s. So I think that will appreciate that you're taking a holistic approach. The patient on it shows that you have an appreciation appreciation for the GP is role in the long term management of the patient. So in every station, I'd always say Make sure this patient has a follow up of the GP even if the actual station takes place in the hospital. Environment on the patient also mentioned hey had anxiety so you would sign post them to self help books and and it just website regarding anxiety and you may consider starting him on some medication. Four things idea in terms off medical treatment as we mentioned and said's both insects and be two blockers can cause work for instructions which can worsen your asthma. Eso you'd consider alternative to that. So alternatives to ibuprofen. You use the who pain ladder. So you start over paracetamol on, then work your way up words. If that doesn't work also for the oil fresh, you'd consider starting them on an anti fungal medication such as Nice Saturn on then. Also, this patient was on search. Allene. It's antidepressant and also taking ibuprofen on. But if you check on the B N f. Taking unnecessary plus and said significantly increases the risk of upper gi bleed. So you're either give them some PPI is for protection, or you'd consider changing one of those on. In this patient's case, we change the NSAID, so hopefully that will help with reducing the risk. Often Upper GI bleed so bold. And Julia, I think you did really, really well there. You definitely would have passed out station, I think. Rays. So we put one more station. What time did What time is it? Seven or six. Okay, So if there is someone keen to volunteer on, you can take history. If not, we can just go through it. As we're of the larger. We have any volunteers or should just go through it quickly. So I think some people raise their hand. But tube it is Julia. And did you want to do it again? What do you think if we're if it's all the time, I can just go through this up to you. Sure. Yeah. We can just go through a seven or six. So you have We can just skirted as a group. Um so what? We can do is if you guys want to type in questions in the charts, and I can try and answer them just like an ulcer. Reformats. So what kind of questions did you ask a media? Yeah. Okay, so your heart sounds and Socrates Socrates is really important, because this this is a pain history. So, in any pain history, you go through soccer trees, site on said character radiation. So it's Yeah, we're on the head, so I'll just give some of the details, ask you how the headache is. So I would say the headache is at the front of my head on. It's mostly on one side. So it's a unilateral today in terms of the onset that's a comes on randomly on the counter is still being in nature turns his associates symptoms. I'd say I do get some nausea, vomiting, um, on diet. Also, notice and flashing lights is go. They last for about four hours on I'd say on the severity scale of 1 to 10 on states about eight or 10. Yep. So some really good questions here, sir? Yep. Those are vomiting. Is it? Well, yeah, Okay. That's a really good question. So I see, um, but there's nothing which makes it worse, but in terms of what makes it better, lying down in dark room helps. Also, I take paracetamol, which also used to help, but it's not helping anymore. I don't really get any visual changes, but I do get some flushing lights. I'm I have had a history of migraine in the past, but this is come on quite recently over the past, I'd say past month and see. That's good people asking about a focal urology trying to relate any red flags s o. There's no focal neurology. No, no. Past easier. Okay, in terms of past medical history, um, mentioned I've had migraines when younger and in terms of drug history, someone's asked about combined or contraceptive pill. Yes, I do. Take the combined or contraceptive pill on diet. Also, take policy tomorrow. Um, I used to take it once. I used to take two or three tablets every day. When I'm taking, um, 1 g every four hours. Yeah. There's no tenderness to my temporal region. Okay, No fevers. So I'm going to a social history, so I smoke about 10 a day. I know quite a stress to work. I'm a teacher. Um, and so I'm taking about smoking. I'm so probably smoking a lot more than I should nowadays as well. Okay, um, I don't take any alcohol. Um, I don't have any other medical conditions. Just migraines when I was younger. Um, And just to remind you the only medications I take is the combine. It'll contraceptive on paracetamol on. I'm taking a gram every four hours. Ah, generally allergies on I tend to keep myself well hydrated. The story of that was a bit messy. Was just trying to read the charts and try and answer all the questions that we'll move on to the history. Serve Honda Headache. About three weeks to four past three weeks to a month. Um, terms of soccer cheese on. This is what you would have got past medical history are just have migraines. When I was younger policy tomorrow, I'm taking about 6 g because I was taking about 1 g every four hours on and also taking the combine or contraceptive pill terms of family history. There was no significant family history on I smoke about 10 a day. So what differentials? Two people have in mind in terms of this history. So medication overuse had a migraine. All right, Good migraine migraine. Someone's mentioned about paracetamol. Faster headache is oh, idiopathic intracranial hypertension. These are all really good differentials for headaches a few times about closure. Glaucoma years. All right, we'll go through some differentials now. So migraine migraine would be the top defensive just because of the just because of how the patients presented with the union lateral headache with the sugar issue associated nausea and vomiting. Also, I mentioned the flashing lights, which would suggest migraine with aura. Um, Andi, typically lying down in a dark room. Tell pops with migraine headaches is, oh, medication overuse. Headache is another really good differential, which has come up in osteo before in the past are chronic university. So with medication overuse headaches, you tend to get that. When people are using a lot of medications on you get the headache for about at least 15 days. I think in a month on what tends to happen is you take the medication that initially helps with the headache, but then you get something called a rebound headache, so the headache gets a lot worse. Then after you've taken the medication. Space occupying lesion is another important differential on when you're asking questions. It's important to rule out red flag symptoms, which would suggest a space occupying lesion, for example. For, for example, with special diploma lesions. You'd have, um, personality changes, possibly depending on the region where the space occupying lesion is in the brain. Also, you could have a spacer kringle lesion. Other symptoms you could get is if the headache change of the posture, which would indicate increased intracranial pressure on also, if the headache is triggered by coughing or sneezing again, which indicates raising differential pressure. Does the meningitis people ask about fear? Oh, which is good on also next, if this is what you would get in meningitis. So when I asked about tenderness to the temporal regions, which is what you would get in temporal arteritis your school, so ask for your product, a shin and any visual changes at all. First of headaches as well, which tends to last about 15 minutes to two hours on. It's normally a stabbing pain around one eye, and it tends to be the same side every time on you get. Let's we'll let her lips swelling. Bread nous um, another differentials. Attention had a I mentioned The patient is quite stressed at work, so this can also trigger a tension headaches, which is normally described as a tight band around the head. But it's more me a low intensity to a migraine, so you don't really get nausea or vomiting with the attention headaches you want to get into your pathic integrating of hypertension, which tends to be more in obese, obese females. But I do. Perfect. Interpreting the hypertension is another really good differential on you to pick your blood vision. Um, and you can also get other neurology such as six Know Porc could be present as well. Um, yeah, so but these are the main differentials, I'd say, for this patient. In terms of investigations, we've taken like a headache in urological history, so I always do a full neurological examination, including for dust. Be checking for any couple of dumb era papilledema, which would indicate rays intracranial pressure. Also, do a new school terms of bloods. You can do in FBC check for raised white cells, which one AM which would indicate infection. Also, CRP, especially yes off for temporal arthritis imaging. You do a CT head for this patient on Do for Special Test is being considered love puncture for raising to print your pressure or it's diagnostic for idiopathic intracranial hypertension. So in terms of the monitoring of the patient, it's pretty difficult one. But, um, a couple of people did recognize I was taking a lot of paracetamol. I was taking 1 g every four hours, which would lead to about 6 g in a day. On this patient was actually based on a patient I saw during my GP practice, where a patient initially presented with a headache ended up taking a paracetamol overdose by accident on there, one to decide or anything. But they just didn't read the instructions on on the paracetamol box and ended up taking six around the policy to one every day for the past couple of weeks. So the initial thing you do is on, Did you spit up pretty conservative medical? Um, but initial thing you do for this patient is actually you would admit them to hospital quite quickly because the patient was taking 6 g of paracetamol every day for the past couple of weeks. um so when you do is you told the Examiner that you were checked talk space, and if you do check stock space, it would actually recommend you to admit this patient immediately. For NSAID are cystine infusion for this patient. So this is kind of a red herring. I was doing a headache. History on the patient's ended up with a party tomorrow. Voters. Well, this just highlights importance of making sure you know about the basic dosage is for these important medications, such as paracetamol. You can take over 4 g in a day. Make sure that the patient is aware of that patient was also on a combined all the contraceptive pill on the patient is suffering from migraine with aura. So combined court or contraceptive pills are contraindicated with patients with migraine A Dora as there's increased risk off stroke and of the cerebral vascular events. So you would look at alternative contraceptions such as condoms or are you D devices and you explain this for the patient Israel In terms of the medical management for migraines, you would use electric tons plus or plus and said's or paracetamol. You also use anti emetics as the patient was vomiting on in terms of perfect axis you could use for panel. Oh are to permit where one thing you have to keep in mind for to perforate is you tend not to use this with patients who are child bearing age as it's teratogenic on. But it's contraindicated pregnancy and can also reduce that effectiveness off model contraceptives so you would stick with Propenerol in terms of prophylaxis. You could also consider telling the patient to take vitamin D too, or fiber riboflavin 400 mg once daily. Um, I near. That's just the general manager for this patient again. Just spit split it up into conservative medical and surgical. And, yeah, think that's all. It's a quick thing. Make sure you know how to read a paracetamol normal grams. I only learned this a few weeks before my finals are finals All ski and they could give you a policy tomorrow. Normal gram breath, um, in paracetamol over this, I think last year there was quite a few. It was about 23 stations, which included a procedural over this. So it is a common topic which comes up in our skis. So does anyone have to interpret prostate among the ground graphs. You can mess it in the chart if anyone knows. Yeah, exactly. So what you do is you wait for about four hours on, then you plot the concentration, um, off the procedure on the graph. And if it's on the line or above the treatment line would start them on an infusion of NSAID are cystine okay, All times that it is 7. 20. So I think well ended their um thank you much for listening to our presentation from college is quite difficult. One to teach because there's so many drugs and so many different side effects of these medications. So we try to go through the important medications, which can come up. One thing I'd suggest is knowing as a bill a suggested rich drugs was which electrolyte abnormalities, which medications are contraindicating pregnancy on, also know about common dosages. For example, paracetamol in and draw nick acid that you take, you know, once weekly and how you take on Johnny Kassid, Um, another medication I wasn't aware of was methotrexate before my finals. Osti, I don't know about the dosages off methotrexate. Um, and it's just important to know that me? The tracks. It is once a week drug. But once daily in my station, the patient in your list of the medications on it said they were taking methotrexate once daily, which was incorrect, and I didn't recognize that. So just keep in mind about these common important medications on Have a good idea of what basic is to expect in these patients. Yeah, so if you fill out the few black form, you should get the slides. And also the recording is currently being recorded, so hopefully you get access to that as soon as possible. But someone's ask. Can I explain the graph again? Yeah, I'll go back on. Explain the girls. Oh, one sec second. So So this is the treatment line on what you do is your rate for four hours, and then you'd plot the plasma concentration on this graph. So, for example, if you took after eight hours possible concentration off, that's 80 so you'd go read up eight hours and you go up to 80. So this is above the treatment line. So if the plotted data point is above the treatment line on the treatment, I would start them on if in a set on 16, if you block their concentration and it's below the treatment line, then they don't need an infusion of NSAID Sistine. Um, so hopefully that explains that. Yeah. For for the passage. Momma. Grandma, you tend to take it after four hours. Ingestion. No admission. I think it's after ingestion. Um, but remember, if it's a starter dose, you wouldn't do this. You just start them on in a sentence. Esteem. So, for example, in the patient I came up with the patient was taking 6 g every day for the past 23 weeks, so that would count is a starter dose. So you wouldn't really do a paracetamol mammogram investigation in that patient. You just start the patient on, um, on a sitar cysty. If it's not, if it's not struggling, then you do. If there is an alternative, Um, I don't think there's an alternative. If it's well, can I stop? I would just be going to the QR code. Someone's asking for that. Um, I don't think there's an alternative investigation for you in terms of management. Yes, with if you if have ingested house, eat more on within an hour on the come into admission you give them, um, activated charcoal, but that's what we're because I have to present within an hour off hospital ingestion. But it tends to be just. In essence, it's dementia tends to be the common medication to give on just from I Am Donald, coveted in his pre recession last week, but a common side effect off s attacks. 16 infusion is on AFLAC Toyed reactions don't get make that mixed up with on a full axis reactions. They're quite different. With anaphylactoid reactions, you can just reduce the rate off. The Anisette are cystine. I continue to continue giving it to them. And that's come up in Austin stations before where you've had a patient with the prostate, Um, over days, given them and that sort of 16 on day, come up with the anaphylactic reaction and ask you, How did you manage that patient? So just know the difference between an Aflac tried and anaphylaxis reactions trying to screw it up and see if there's any are the Russians. Why did we give beat blockers? I think so. I don't know what's up in reference to be two blockers such as propranolol can be used as a prophylaxis from migraines. Um, what migraines. Really get a CT in reality? Not really. I don't know for you to get a CT scan, but in a Noski station, you won't get marked down for coming up with some imaging for headache. You can always say you can't rule out any images of any other severe red flag causes, often headaches. So, in terms of managing an inflammatory reaction, little correct me if I'm wrong, but I think you just slow the rate off the NSAID are cystine on, you can consider giving them at the histamine. I think, Um, I think that's all Yeah, Yeah. Abdullah mention in the chart. You can be given a migraine history and they can give you a CT scan and it's normal on, say gently off. Don't let that threw you off. Actually reminds me when we did the chest X ray. Um, when I asked you to do the test X ray interrupt the test sexually, but that was actually a normal chest X ray. So in Oscar stations they can very easily just give you a normal investigation. So don't let that worry you off. If they give you a scan on everything seems to be normal. Uh huh. Yeah, Yeah. Or distract the name of the questions. Enough electrode reactions. How did they present? Um, I don't know how to They presented it. Do you get? Do you get a rush? Do you get a rash or shortness of breath with that? With anaphylactoid reactions? Yeah, you definitely get a rush. I don't know if she got the shortness of breath. Yeah, I'm looking up. I don't think you slow it down. You stop it. Then you give a slower rate is Well, you don't slow it down. You have to stop it. Let's look, you give it a survey. It? Yeah. Okay. Uh, if the feedback form isn't working, if you message our Facebook Facebook page, we can try and start something out, send you the slides directly to email. So, yeah, you can get you feel you feel that fade, you know, shortness of breath. Anxious. There is always a worry that it could be honest relaxants as well. So I think that's why they stop it. And then this year Yeah, Okay. Mohammed, would you? Some was asking. So if they took it within one hour. You would wait four hours, then do bloods for process. Well, they took it within one hour. I left presented. Then you could start with the activated charcoal. I think I think it's a because I explained what started. Those is He was like, take it within an hour. So then he was like, Would you rate Okay, so would you wait four hours to do bloods actually know that if ingested it, it won't go? Um, I think it also depends on how much they've taken it. So if they've taken, like, an obscene amount, then you wouldn't wait. You'd stop them. One and s are consistent. Straight every Yeah. Yeah. Um, So if someone asked about if you've missed any previous sessions, would it be possible to get a slide? Your a few message on Facebook group on. Message them with what? What session? You missed. We can send you the feedback form for that so you can fill it out retrospectively on. Then you ask, you get access to side of according afterwards, so, yeah, if you just message the Facebook page with what session you want to catch a form. All right, Well, just give it a few couple of minutes, and then we'll just end a presentation. Want to ask anything? Thank you. Nothing was coming here. Yeah, I think it is. And if you have any questions, just messages on Facebook and we'll request. Okay. All right. Yeah. Yeah. What do you want? Anything? No, nothing. I was just checking a job. Um uh huh. Oh, yes. Oh, someone's asking about time. So we know me. Start at, um, 66 PM um, learned a London time. That's G M T o B S t, um, were 6 p.m. We start British time and will only last for about what? Now what now and a half. And the next session is on the third, which would be obscene. Gynie hurts. I thank you very much for helping out Daniel and Hurriyah on thinking, um of the legs. Oh, for a great talk. Thank you, everyone.