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Hello, everyone. Welcome to the third session of the PAS a series today. This course will be on adverse drug reactions by Dr Besancon, and he'll be covering the four types of adverse drug reactions that will come up in the PS PSA and the reaction that you should look out for one preparing for your exam. So, um, introduce, uh, Hassan now. Well, everyone let me just turn on my camera. I think you can all see the slides, but if not, just put me in a proper message on the chat. Uh, yes, I am. Uh, my name is Hassan. I am a academic F one, um, in the Thames Valley greenery. And today I'm going to be going over a little bit about, uh, the PS PSA in particular going over adverse drug reactions. So if you are able to on a separate tab, if you can get either medicines complete or the TNF ready just so you can practice the questions and you become more familiar with the approach, right? And if you can't see the change in my slide just proper message on the chest as well. But yes. Um, on the session format, I was hoping to go a little bit over the exam format. If this is the first time you've joined one of these sessions going over a little bit of the general tips for the PSSA, then we'll go on to the main focus, which is the four different items. Style questions are different types of questions you've been asked for adverse drug reactions. I'll briefly touch upon common drugs that come up in the PAS a every year and then at the end, um, I've got some post sorry, some mock exam questions that I'll be sending over my slides to the team. They'll be sharing with you, and you can use that as a revision tool, right? So let's first start off by talking about the exam format and general tips. So the PS A is a 200 mark exam that you have to sit in two hours. I believe now every medical school has to sit this exam, um, during the final year generally, and if you aren't successful the first time around, you can sit at some time in F Y one where it's a requirement. So with the bulk of the marks that comes ups A. It's generally from the first to so on prescribing and prescription review. So my advice to you is that when you're advising the PSSA really home in on getting the skills, their shortage, because that's where the bulk of the marks come from, and then everything afterwards minus maybe the calculation skills is should be quite rapid fire, and you should be able to get that through quite quickly because the PS A isn't necessarily exclude. The first two sections is not necessarily a exam that test your clinical skills, but it's an exam that sees how well you are at control F and finding the right search terms and being familiar with the TNF as a tool. So with the section I'm talking about today is adverse drug reactions. So if we say that there's eight items so eight questions each worth two marks, then that is 60 marks total. That's about 8% of the whole time you should allocate. It was 8% of the marks, and that means you should be spending maximum 10 minutes on this section. Um, so it is quite easy marks if you know how to go around using, be and therefore medicines complete to find the tools you're looking for to answer the questions. And this is a bit of guidance that people that right, the PS, the questions are given, and I think it's quite useful to touch upon when you're thinking about how to revise. So, uh, you're going to test in a range of clinical setting. So medicine surgery, elderly care attempts to pop up, particularly when it comes down to opioid conversions. Pediatrics can come up, psychiatry can. So a few questions on antipsychotics can very occasionally appear. And it does appear one of the pas amoxin their official website. And you can have some questions on O. N. G and general practice as well. Because of prescribing being a quite fiddly task, they naturally you will have drug errors that occur, And what the NHS have done is they've compiled a list of common drugs that are typically prescribed wrongly, or at least when they are prescribed wrongly. They have some quite serious consequences. So you will be tested on these in the PSSA, and the most common ones are opioids, anticoagulants, insulin. So being able to know how to convert someone's insulin, how to adjust the dose is based on someone's reports is quite important skill knowing what about antibiotics that's always prescribed and knowing how to prescribe fluids? There's three other categories there that don't really come up in the PS PSA anymore because if one aren't required, really too, um, usually be able to prescribe them. And those are chemotherapy agents, antipsychotics. And, um, let me see what the other agent chemotherapy and oh, anesthetic agents as well. But to be fair with you, um, the patient in on how things go with the exams, anything is really fair game because some of the nature of topics can be searched up on the, uh, the n F website, so anything can really happen. But these are the most common ones. I advise over want to at least get your head wrapped around and knowing how to find the information on the TNF. And in terms of revision tools, there's two that generally come up every year. There's the past, the PS, a book by William Brown Um, and there are the official question papers that students can do on the PS a website myself. Personally, I know that everyone used the past the PS a book. I personally resented it because I found it quite, um, written really weirdly. And it was hard to follow Additionally, because it's a book, it's not up to date. Things like hypoglycemia management, A C s management are quite outdated. And you wouldn't want to rely on that to know the theory, but maybe to have some question practice, I strongly encourage going over the question papers themselves. They're so much more of a useful skill. And, um, I feel like you can really develop yourself and see how you're improving by doing the question papers. And, yeah, just a quick summary of the N F or medicines complete. Um, universities can either. Uh, you can have some discrepancy on how the PS PSA is tested. Some people they have to do the exam on a tablet. Some people on a computer, depending on the university. Uh, some universities say you can only use the TNF. My university imperial were allowed to use either be an F or medicines. Complete medicines completed just this B n f, but presented a slightly nice and easy user friendly format. And if you have the option, I strongly recommend medicines completely, just so much easier to find out things like drug reactions and the like. And just the comment I wrote. The bottom is control, plus your friends, because that's really what this section is about. So once you log on and you're registered, then you write the name of the medication you're on. And, for instance, I wrote ibuprofen. You click on the drug, and then it's very easily set where it says you can click on the side effects. It tells you how common and uncommon they are. You can click on interactions, and it's just a game of control f and finding the other drugs that I mentioned the stem. And you know, if there's a reaction or not. Yeah, there's a few in here, and, uh, yeah, that's an example. So I looked at the boat settling down, and it goes straight to the point and tells me the severity of the interaction. And that's something quite useful when you really are quite clueless in the questions that can sometimes offer right moving on. We'll talk about that with the item styles of the different types of questions you can be asked. And there's four types of questions you can ask in this section, I've shortened adverse drug reactions down to a DRS. The first question they will be asking you is, um, identifying likely adverse reactions. So ask you a question where they've given you quite a long stem and they say, what is the most likely side effect of drug X? So it could be an antibiotic? It could be some something slightly less common, like methotrexate, tacrolimus or things like that. So there will be a better way. If you know about the drug class, then it's a bit easier for you, but it's always good to just double checking by searching it up on the TNF medicines complete the second type of question you can be asked is identifying drugs causing specific adverse reactions? So be a patient who, you'll find has a worsening electrolyte abnormality. So hyperkalemia is quite common. And then they say, Oh, these are the patients prescriptions. Which drug is most likely to be contributing to the hypokalemia or hip? A toxicity and generally, for these questions will give you some investigation finding. So LFTs glucose, um, use the knees and like third type of questions to be asked is identifying drug interactions. So now there was explicitly say which drug is interacting with the other drug in the stem to cause the presentation. And finally, I'll be asking you about how to manage the adverse effects of certain drugs. Whether that is hypoglycemia, which is quite a common thing, too, that would be asking you about in the PS PSA exams. I can also be something that is very bizarre interaction. But what they'll do most often is that they'll say what the adverse effect is. So it could be something like malignant hypothermia, which can happen when you're giving some anesthetic agents. So yes, like I mentioned, some of this will require a bit of background knowledge. But most questions. It's a game of reading the buzz words of the question control F and checking your answers. So I have made a list of questions for each of the topic. If I can ask everyone to get a copy of the TNF ready, please don't use the book. Go grab a link. Um, and try to have a go at answering this question, please. And I'll just give you guys about one or two minutes And if you can message on the chat, uh, what do you think the answer is, then? I think that'd be great, Right? So I think we've got some responses. So thank you to Alexandra and carrots for messaging. And, yes, if anyone's waiting, uh, still feel free to write it down on the chat below. Yes. Uh, the way I would approach these questions is that they'll give you so much information and, uh, like I mentioned earlier, if it's about 10 minutes you want to spend on this whole section and there's eight or so questions, then that's quite a bit of information that you're really trying to process your way around The quick way you can answer this question is you can narrow it down into what they actually asking you. So, firstly, what I want to do for this section, just read the question. Ignore the stem. So first question is item start A is select the adverse effects that is most likely to cause by this treatment. And then what I do is I scan this and it's generally towards the end, we will say, what is the treatment in this case is penicillin, which is a type of penicillin. So I have that in my head, and I also have the adverse effect options. So what I want to do because I want to go into the the NFL, medicines complete, and I write penicillin down, I go into side effects, and I control F and I right. Whichever option comes up first, Um, in this case, uh, grandma s citosis or if it's quite short section it will generally only have one or two side effects, so it will be quite easier to pick out which one's correct or not. In this case, the answer is indeed from both sides opinion. So well done. Everyone who got that right. So, like I mentioned the questions asking which effect is most likely to occur, uh, certain drugs can have multiple side effects. Uh, and you don't have to worry about that. You want to worry about where it says most common or very common side effects, and you want to look at that section compared to all the others. If there's nothing there that's in the options. If you look at the next section, which is uncommon side effects and then rare and so on until you get one of the options that are. The question is asking of you. So in this case of penicillin blurred visions Option B and hyperhydrosis, which is just the fancy term for excessive sweating, they're not side effects. A great life cytosis and interstitial nephritis again, Incredibly rare, less likely to occur. So in this case, from the CYTOPENIA is a common or very common adverse effect of penicillin such as penicillin. Uh, and therefore, this is the most likely thing to occur, and it is the answer. So just to really show it how simple this section is I went on to the drug class, Um, and I just write control F and I went straight to from both cytopenia and it's that's how it's the answer. Great. I'll be I'm going to give another two minutes, and I want people to have a crack at this question, please. Right. Well, you all answered at the same time. Great. So, yes. Um, let's go over this question the same way as before. That is way too long to read, and I personally just get check out at that point it to there is a thing with the PS a exam where some students do not complete all the questions because they really are, uh, you know, combing through every single word which is not really want to you want to do for this section? So, yes, let's carry on same thing as before. What are the things I want to look at? In this case? It is select the prescription that's most likely to contribute to a postural hypertension. This question is quite nice because it's told me exactly what the thing I'm looking for is so in this case, postural hypertension. If the off chance it didn't, um, then I would quickly have a read of the case presentation briefly. I mainly would want to focus on the on examination findings and the investigations because that could say the question was something like, um what is the most likely contributes drug contributing to her hyperkalemia hyponatremia? Then I want to look at the investigations here if it says just a very generic electrolyte abnormalities and like, yes, so what I want to have in my head is postural hypertension. That's a buzz word. I'm going to control it with just a bit, and then I have the drugs and you can do it whatever way you want. If you have a rough idea, then go for that one first. If you're completely clueless, then top to bottom. Right, Levothyroxine first right, postural hypertension. Nothing comes up. Go to the next one and the next one and keep going until you get the answer. So, yes. In this case, you're all right. It is mirtazapine. Lightheadedness is the most common presenting symptom of postural hypertension and symptoms are generally quite worse when you're standing and resolve when you are resuming a superimposed posture. So be careful in these questions when sometimes you can be a bit distracted where you read the beginning part where it says that the patient was feeling a bit dizzy and you check for dizziness. But the question is actually asking you on postural hypertension to make sure that you are searching for the term they're asking you about. And in this case, if you are all right, it is mirtazapine. That is a common has a common side effect of the stroke hypertension in patients. And that's actually the reason why we prescribe it at night, because you probably are not going to wake up at night and suddenly have a bit of a fall. Much more great. Same thing as before. I went on the drug class. I worked with a spine down and then I just can't control their friends scrolled me all the way down to the side effects where you mentioned that it's postural. Hypertension is a very common side effect. Great. This is item style three. I want you to again have ago reading the stem, please, and then having a go answering the question. All right, so I'm happy to carry on. So with this question, you've got quite a bit of information yet again, which they add in. But the focus is you want to have a look at the key part. In this case, it is the prescription that is most likely to interact with digoxin to cause toxicity. So my trick here is that I would instead of going for each one of these drugs. So I'm writing alendronate down and then looking at the interactions for digoxin, and if that's not it, then go to the next one and the next one next one that will take too long. What you want to do if you want to write digoxin down because that's a common factor. Um, and then on Digoxin, you want to write the going to interactions control f, and then you can write the drug classes down, Uh, the drug name. Sorry. And then I will tell you if there's an interaction or not. If no search results come up, then you know it's probably not on that list of interactions. If it does, then you could, um, that probably will be the answer. If you do find that there's multiple drugs coming up. And, um, there is, uh, only one answer that would be correct. Then you want to read the stamp question again to see what specifically is asking for is asking for a specific things like Toxicity is asking for a particular side effect because not all drugs, when they interact with digoxin or any other drug, will have the same effect. So in this case, you are all right. Some people have commented it is cholecalciferol. High doses is the most likely to interact with causing digoxin toxicity, and it is down to the hyper calcemia that can be induced by high doses. That you take, um, the other drugs when you were to search for them. If you were to, um, then they won't come up with any options. You know, it's incorrect. And yes, So what I've done is I went on to writing the Suboxone, um, and then I clicked on the interactions and it says called Calciferal. So explains it. And it says here, which is what? One of the reasons I really like about this computer will be an F. It's quite clear saying it's a quite a severe reaction to occur, right? And finally, the last type of question. I want you all to have a crack at the same as before. Please read the stem and, uh, and let me know what you think in one or two minutes, right? I think quite a few of you have responded by now. You're getting much faster at this. I realized that's brilliant. Yes, same thing as before. I would look at that question, and I would look at the key details most appropriate and management. So then I will look at the stamp saying Okay, managing what? And over here it says a little bit of what's happened So this question is quite nice. It tells me exactly what the patients develop. Malignancy. Hypothermia of chance. It would be very rare where it wouldn't tell you. But then you kind of want to work out based on the case presentation. So this is a bit of a harsh one, because, like I mentioned, you're not really expected to know much about anesthetic drugs, But you may be asked about in the finals. So in this case, it's, uh, Lorraine and socks meconium that are doing something clearly wrong with the patient's temperature being incredibly high. Malignant hypothermia. Hence the name, um, but yes. So what you want to do is I would search for that term in the first instance to see if I get any options. So I just quickly show you if I write malignant hypothermia down. What I notice is that you have some treatment summaries. This is on the TNF as well. That medicine is complete. Makes it quite easier to pick up on. Um, I strongly encourage before the PSSA. You spend 1 to 2 hours, uh, going through the TNF to find out certain treatment summary, at least be familiar with where everything is because on the day when you realize you're searching up for a new term or a new treatment summary and there's so much that's written, you may panic and miss some of the key important information. Um, so the most in this case, it is on anesthesia in general, and we're just going to talk about this a minute. Other things you want to talk that treatment summary are things like opioid conversions, steroid conversions, Um, a little bit on anxiolytics. I believe there's a section on antibiotic use, Um, which is very useful. A section on overdose is, um, there's a section called Believe Medical Emergencies in the Community, which has arguably the best, uh, explanation on how to manage hypoglycemia, which is again, It's a common thing that pops up in the PSSA and just be familiar with those things, so that on the day we have to quickly search a little bit on the theory. Then you have those options available to you. Yes, going back, I noticed for this question is that it has a section called Anesthesia in general, and we'll go on that just a minute. Um and then it has some questions from my question stem step and, uh, the ones that we mentioned. And then it says one of the options here Dantrolene as well, So that can give me a rough idea if I really press the time. What the options, what the answer is. So if I click on the treatment summary, you find out that actually quite long and don't read that again. Just do the control f so right, malignant and it pops up. So explains a little bit of what it is if you haven't come across the condition before, so it's potentially lethal. Complication anesthesia. What causes So in the case, a rapid rise in temperature, increased muscle rigidity, and at the bottom it will tell you the drug that is used for treatment. Usually, if you want to click on that, then it tells me what it's useful. So it's used for treatment of millions hypothermia, and that's you know that's the answer. Just going back. Yes, everyone that wrote down cutting down You are correct, Um, and the way you want to do is is you want to search the term if not to the drug, and it should give you the answer because on each drug on the TNF, it should say what is used to treat so therefore, would be a searchable term, something you can find when you write the drug down. And, yes, malignant hypothermia. It's quite rare to occur now, but it's very important for, uh, anaesthetist to recognize because it has a mortality up to 80% which is really quite high. But when you administer Dantrolene and under safe medical management, this mortality drastically reduces. It's quite incredible, right? And that's it's really what comes into the questions. I feel like this would be a good way to at least engage yourself and knowing what are the methods of how I'm actually attempt each question. What the key part is I need to look out for? I think the common theme is I wouldn't waste your time reading the whole question unless you're absolutely stuff you don't know what what's going on. And then you can slowly go comb your way through it and then find out what the common terms are, right. Uh, yeah, this was a question. Where do you find the treatment Summary section on the TNF. So unfortunately, I don't have a common list. Um, is what I can say, which is a bit annoying, but at the same time, they'll be so much that is really unuseful. If I just I do have my old notes from the psh from last year. So if you just bear with you one quick second, I'm going to see where if I had anything written down, that might be common things that maybe you can search up for when I'm not here. And then you're doing your own revision. Uh, here we go. So if you can still hear me, um, the list of things to look at is warfarin drug adjustments, which is very important. So you have a question on if a patient has a intracranial bleed, how do you stop the warfarin? What? The specific things you should start and stop that is under oral anticoagulants. Anything on heparin is under parenteral anticoagulants. Opioid dose conversion is under prescribing and palliative care benzodiazepine dose conversion is under hypnotics, and anxiolytics steroid dose conversion is under glucocorticoid therapy. Acute asthma management is under asthma or dash acute. Anything on missed pills that I take of contraception can be found generally on the drug itself. So if you write the drugs, uh, for example, uh, there's a gastro, uh, then you do control F and you search for Ms Dose and tell you the answer for that how to treat hypochelemia is under fluid and electrolytes. Um, then if you want to ask about anything related, uh, you have a good chance by writing heavy menstrual bleeding. For some reason, the TNF doesn't right Under the medical term, anything for vaccine schedule is under immunization schedule. Uh, my management is under acute coronary syndromes. Uh, information on which drugs to stop before surgery is under surgery and long term medication. Anything on ACE inhibitors is under drugs affecting the vein. An angiotensin system overdoses. You want to write poisoning? Uh, comma emergency treatment. Uh, medical emergencies in the community is the second treatment summary for GP stuff and hypoglycemia. Um, anything on Addison's disease is under glucocorticoid replacement during stress. So it tells you how to how to change the doses or what to give When a patient's ill, um, things like if you write diabetes, commerce, surgery and medical illness that tells you how to manage diabetic patients who require surgery uh, pneumonia management is under respiratory system infections, comma, antibacterial therapy. And to be honest, you can just write pneumonia, or if it was something related, right, G I system infections come up under there. Another example is effective. Endocarditis will come up under cardiovascular system infections. Um, and then very rarely they will ask you maybe something on diabetes insipidus management, and that will be under posterior pituitary hormones and antagonists. So that's a long list, but hopefully that was useful. Um, I will make sure to write in the chat at the end as well, so you can copy and paste, but so don't worry if that was any other questions or concerns. Yes, Um, common drugs. Uh, this should be slightly quicker section because the TSA, they will ask you on some of the drugs you have never heard of before. And again, that just shows you that the this section, at least it's just a matter of control F. But there's common things that come up right. And like the saying goes, common things are common. The most important thing I want you to get out of today is try to remember these two abbreviations and this is on the enzyme in induces and enzyme inhibitors. There are more than these, but these are the ones that routinely kind of come up in clinical practice and then the exam. So enzyme induces. What will happen is that when you're prescribing this alongside another medication, what can happen is that by inducing the enzyme, the other drug will have a lower concentration, and you might have to adjust the dose by increasing it or changing the medication that's being the enzyme inducer. You remember that using the abbreviation PC breast, which is sent to Winn Carbamazepine Barbiturates campus in chronic alcohol use and soften Algeria's so gliclazide and enzyme inhibitors, it is the, uh, the abbreviation is a, uh, devices. And you have, uh, allopurinol omeprazole disulfiram valproate itemized super flux in acute intoxication of ethanol and sulfacetamides. Uh, what kind of kind of note from here, If you want to do a quick eyeball, you notice that quite a few of these are anti epileptic medications. Um, so, generally, if you have a question that as a patient who has epilepsy and prescribe something new, you're wondering what's causing interaction. Be a good thing to review the these medications in particular, right? And then other things that are common are easier. So the paracetamol, it generally is very safe. Um, the side effect profile is incredibly rare, but you can on the off chance you could have from the cytopenia. Knows what the interactions is that again. It's very safe. The only reason why it gets a bad rap is because people overdose on it. Um, but if you really were to, um, look for interaction if a patient has a heavy drinker, um, naturally, the hepatic function will be deranged. So I'll be a bit careful of prescribing paracetamol, at least on the doses you would normally give. Um, So if I had a patient in acute liver failure Sorry, I probably would not want to give paracetamol and look for an alternative agent. Um then flew. Cloxacillin actually can cause metabolic acidosis when given processing more. But that's quite niche. And again, process more kind of interact with warfarin because warfare interact with everything so you could have an increased iron. Are I think someone has made a question down. Can we find anywhere Information. How much to increase? Decrease the medication? Unfortunately, no is the answer. There would be some sections Where if the drug is very common, where you have to adjust the dose then, uh, there should be something available under the TNF of the medicines complete, I think an example off the top of my head. And this did come up in the PS PSA for me last year is on patients starting levothyroxine. Um, whilst also be having a strong cardiac history because that is slightly different. So I think if you scroll down to the TNF medicines complete, there should be a section on initiating dose. Um and that might tell you how to increase medication and so on, because the reality is that if someone has a long term, quite severe cardiac history, you have to slowly try to titrate levothyroxine. I believe, compared to a regular patient does not have that history and other things like opioid medication that it should be under prescribing and palliative care how to increase or decrease. But I think a level of that would be knowledge that you should be familiar with so knowing how to make a when, you know, a patient is having a lot of using all the breakthrough medication for opioids and their palliative. How to make that into a regular medication and do the conversions that's generally is available under the prescribing palliative care section. Uh, apart from that has increased decreased medications. When it comes down to things like, um, uh, insulin, uh, is a bit fiddly, So if you have the chance, I probably speak to an F one or one of the endocrinologists. You can kind of go over it with you. However, if you can please remind me at the end of the session, once we finish, then I can brush up my notes to give you the exact information that would be useful to you because I think insulin is like the main one you probably would like to know about. But the chance you don't know after doing the questions and practicing, then maybe just doing a bit of reading around the topic. But please do remind me that question at the end. Yes, moving onto analgesia. NSAID common examples are ibuprofen, naproxen, um, and side effect profiles are dyspepsia, diarrhea, the very common gi I ulcerations. We will learn about also be aware that they can worsen asthma and contraindicated. Uh, AKI, Um And then when it comes down to know where the interactions it is quite a lot. So SSRI warfarin and do X Uh, they can all cause bleeding. But when you have an NSAID with a steroid, then that can generally cause a G. I bleed. Uh, it can interact with ACE inhibitors causing hyper cholemia when it comes to direct six. Then it can interact and cause an a k i terms of opioids. Um, some of the stronger medication you have tramadol, morphine, codeine and the like. The side effect profile constipation. Very common. Dry mouth is the same. Uh, you also have some confusion. So we're bit careful of giving it to elderly patients. Same reason, Uhm, is why dizziness? Something we have to factor in, uh over those symptoms which can sometimes come up, is just be aware. If a patient has a loss of consciousness or change in consciousness and there's difficulty breathing, that's probably an overdose. You want to get some of that looks. And for that notes were the interactions. So it is a CNS depressant. So with alcohol, it can worsen that SSRI uh, sumatriptan and saint John's wort can cause serotonin syndrome, which is a psychiatry emergency, technically because it's a psychiatric medication. But these patients have been managed in I t U I still, I still don't know why, as a side topic, why we still talk about sending chain John's wort. I don't know. Anyone in my life has ever taken that as a supplement, but I'm still waiting for the day, right? And then let's put on steroids. Um, common things are hydrocortisone dexamethasone. Side effect profile is Cushing's syndrome. So with that, you can have other things as well, so you can have fluid retention that can build up, particularly in the legs. You can have a proximal myopathy uh, G I alteration again with combined with the NSAIDs, and it can cause bleeding osteoporosis. You're slightly more prone to infections, and I wouldn't say that they cause diabetes, but they can at least impaired glucose control and cause the hypoglycemic state, uh, long term that can cause hypertension and ankylosis hypokalemic states, uh, know where the interactions aspirin, which I mentioned, and well as NSAID, digoxin can cause toxicity and anything since I mentioned earlier that it can cause hypoglycemia, anything that can also cause hypoglycemia or interact with it. So, erythromycin, uh, that will have compounded effect. And, uh, antifungals like ketoconazole, particularly with all use compared to topical it increase the exposure of the steroids, make you more likely to have Cushing's. Then in terms of anti hypertensive agents, you have a PSA inhibitors. Um, like ramipril side effect profile is things like a dry cough. Um, a obvious side effects that people tend to forget is that it's a high BP medication so it can cause hypertension and postural hypertension. Other things that can cause as well because it interacts with Brennan. Um, endocrine system is that can cause renal impairment and hypochelemia as a result, so you can contribute to an A. K I, um spironolactone can also is astronomically can cause hypercalcemia on its own. But when you combine it with this inhibitors, it just really takes people over the edge. And you have to treat those patients with hypochelemia, usually terms of ARBs. Um then you have losartan again. Hypertension hyperlipidemia calcium channel blockers like amlodipine can cause peripheral edema and some flushing symptoms in the face. Um, interestingly, grapefruit juice can increase the concentration of calcium channel blockers, but it's incredibly mild. Um, that wouldn't really worry about it, but it's something that's commented on in the TNF uh, the main interaction, which I want you to be worried about in finals and the PSSA never give verapamil with the beta blocker ever, ever, ever. It will cause a patient to be a systolic, and it is an absolute nightmare to bring them back. For that, um, other hypertensive agents, these are in brackets because they really are slightly more extreme end. Um, but they are used and something problem in finals. And the PSSA is, uh, it's a receptor antagonist. So spironolactone these can cause hypercalcemia, as I mentioned earlier course, because gynecomastia as well and because it can cause hypochelemia anything else that can cause hypoglycemia as well. It will have an interaction with and really shoot those numbers up for potassium, so things like dalteparin based inhibitors tackle on cyclosporin heparin's and, um like And for beta blockers, you have metoprolol be aware that it can worsen the asthma and acute heart failure. They can also masks symptoms of hypoglycemia. So the patient is on insulin and also on a beta blocker. They may not realize that they're in a hypoglycemic state. They may become unconscious and more likely to, uh, yes. Know where the interactions beta blockers can worsen hypertension quite considerably. And as I mentioned earlier, the interaction with the verapamil it causes bradycardia and asystole. And yes, I feel like that's quite a lot of reactions, but I feel like I couldn't have ended this topic without talking about disorder and reaction. Uh, this is something that I didn't realize until after I sat my finals. To be fair, um, so the question I had and it was along the lines of there was a patient who had required some antibiotics and the answer. Everything was screaming. You have to give metronidazole. But for some reason, the stem kept on talking about the woman going on holiday with the husband to Italy, too. Do you think was wine testing or something like that? Um, and I was like, That's completely irrelevant. Just give metronidazole be done with it. And then afterwards, um, I was happy with what I have written. My friends were happy, and one of my friends said, Oh, no, no, I didn't. I wrote metronidazole as well. But I got told by someone else that that causes disulfiram reaction. Not six years of medical school. I was like, What's What's that? So that it turns out that's what the That's why I was mentioning so much about the alcohol and my question, and I actually got it wrong. But yes, the sovereign reaction is something that's kind of important, but I don't really think it's talked about at the university. But essentially, what I saw from reaction is any type of drug that interacts with alcohol and just makes you feel very unpleasant. You start vomiting, you feel flushed, you feel dizzy. Dizziness, abdominal discomfort and your general hangover like symptoms. And that's all from itself is a drug that we can give in psychiatry to patients who are who wish to try and reduce the alcohol intake because of the unpleasant side effects it causes. But there are some drugs that can cause, uh interact with alcohol and cause a similar effect, and those drugs are There's a list, but the most common wants to be aware of is Metronidazole Thank you to Conazole. Metronidazole is a big one that everyone talks about But in case the patient doesn't drink, then actually, this reaction can still occur according to be n f following small exposure to alcohol. So if someone spray alcohol based perfume or aerosol sprays that can actually cause symptoms as well. Right? And that is the end of my, uh, session. I have included my email below in case someone would like to ask any particular questions about the PS A teaching. Otherwise, if you're interested in the AFP because I'm currently doing that as an F one here, um, I'm more than happy to answer any questions. I do know that previously someone asked me to for the list of conditions. Uh, so I am quickly going to copy and paste it onto the chat for you all, so you don't have to write everything down. Uh, but in the meantime, if anyone has any other questions, please do you feel free to ask? It's almost done. All righty. Let's see if I can type here, right? So for some reason, I'm unable to add it into the chat. But what I will do is, um I will add it as an extra slide to my presentation. So you can use that as a resource just to quickly go over my presentation. Once again, I want to say that right at the end there is eight or so mark questions which are similar to the exam that I was give. And in the previous years, um, and I really feel like you can really push you to understand how to be familiar with using, um, the B NH four medicines, complete other things. Is that included a template so that if on the off chance you won't have a cracker making your own questions with friends, if that's a hobby you have, then I've got the information there as well. So you can make that quite simple. Uh, going back. Yes, I think other questions. I think someone asks me, uh, let's see here. So what, You find cancer that can find information. Oh, right. So I think someone asked me a question on How can we find how much to increase or decrease medications if a patient is on induced inhibitors? It really won't say unfortunately, but I don't expect them to ask you, because that would be something that registrar would know or a consultant, uh, of chance I would maybe Look at the patient is clearly in renal failure, hepatic failure or impairment. Sorry. You want to write? Sometimes it write that down, the medicines complete, and there's a section for it. If you click that, it would say something like, Oh, and if a patient has renal impairment as defined by this value, then half the dose. Um, and that could be something useful. But I think particularly for gentamicin, maybe, um, and that will tell you how to adjust the medication accordingly. Um, other questions is, Let's see. Yes, I've answered that. So I'm going to add it to the slides at the end. And, um, hopefully once that shared out, you'll have that as a resource. Where slash? When will the slides be uploaded? I'm not too sure about that question. Sorry, but I feel like one of the team members. And second answer that maybe on the chat. But I'll make sure to send over the slides them today, and it's just a matter of having that sent out to you whenever you're ready. But please feel free to answer the feedback forms. If you find this session useful and just give me a nod. You find things that particularly helpful or any improvement or any changes, or if you'd like me to do another session in the future or anything like that. But, yes, I believe the session is recorded, high is recorded, and I've sent out the feedback forms. So once enough, if you respond to that, we'll be releasing the slides and the recording. Um, yeah. So I guess in that case, if you really are keen to do those questions, then make sure the feedback form and I'll add in all the rest. Thanks so much. Uh, if there's no more questions, Thank you, Doctor can for this really informative talk. Like I said, the feedback for me is in the chat, and we're grateful if you could really feel that in, and we'll release the slides and recording shortly. Um, I'll just hang around for the next five or 10 minutes. If anyone has any last minute questions, I'm happy to answer them. Oh, great. I think there's some last questions. Uh, thank you. Uh, so, uh, it's gentamicin says to avoid excessive dosages of these patients. Use ideal weight for height to calculate parental dose and monitor serum. Gentamicin constructions closely. How do I calculate ideal weight? Right. There might be a calculation for it. Uh, if you were to Google that one, I don't have it at the top of my head. If I do believe there is something there, But why can't they? More often than not, they would tell you how to prescribe gentamicin and make it very clear cut in the questions from my experience. The reason why I say that is because gentamicin is one of those weird drugs for every trust prescribed it differently under different conditions. Um, some drug, some trust, like mine. It's, uh, Martin Keen's University Hospital. They do this thing where they prescribe it once a day by know other places to prescribe it twice a day at a lower dose and how they do it. It's all different. The, uh while to say to you is, don't worry about that on the question. It will tell you exactly the circumstances to prescribe the medication and how what the factor is to look for. And it's just a matter of using medicines complete or the TNF to find out what using the calculations that they recommend uh, next question. What was the answer in the end for the last metronidazole question, Uh, I'm not too sure off the top of my head, but I think the answer, uh, could be found if you were. If I was to write the condition down onto CKs Nice. And then it will say what? The first line agent is metronidazole and they'll give you an alternative. It would have been whatever that would have, uh, was, uh, thank you for the question. At the end of the day, I'm perfectly happy and passing the end. So if there's no more questions, we'll end the event here. Thank you, everyone for coming. And once again. Thank you, Doctor Has her on Khan. No worries. Best of luck to everyone. Mhm.