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Hi, everyone. Um Thank you. Yes. Uh Thank you for those of you that replied on the chat. Welcome to our past the PSA series. I will brilliant. Can we have the slides shared James that? Oh, that a a ok, perfect. Um We'll make a start, other people can filter in. Um So hello and welcome to our P SA series. Um intro to the PSA is what we're gonna cover today. So we're gonna talk about the exam format tips that we have um and a little bit of different question types. Um My name is Tess. Um I'm a foundation doctor in Sussex and Julie um is working at Royal Berkshire Hospital. Um If we go to the next slide. Um So this will be a four part series um where we're gonna cover all the different sections of the PSA. It won't just be us, there's different um, f ones that will be doing some of the teaching too. Um And we are supported by health education England later on in sort of in, in the spring. We'll also be having the Thursday 15 sessions that we were on last year. These will be weekly sessions covering a variety of specialties um and topics to help you prepare for finals. If you have summer finals. Um If you follow all our of our, um if you follow all of our social media, you'll be kept up to date with that. Um But let's focus on the PSA today. So, next slide. So, um this is just a little overview of what the PSA includes. So it's a, a two hour exam with 60 questions that are broken up into different types of questions. I've stolen this graphic from the psa's website. Basically, you're gonna have some prescribed, some reviews of prescriptions, planning management information, giving um calculations, you can look at drug monitoring and adverse drug reactions and then some data interpretation at the end and it will cover a wide variety of specialties to prepare you for F one. It's quite a time pressured exam. Um So you have 100 and 20 minutes to do 60 questions. Um W and key to success is good time management and efficient use of the B NF which we're gonna go over today. Um There's no negative marking. So if you really don't know an answer or you're running out of time, you can just click some of those multiple choice questions at the end just so you have a chance of getting it right. Um Practice makes perfect as well. So there are past papers online, your university will probably provide you some practice papers and ques meed also um has really good resources. It's all computer based. Um So if we're thinking about sort of practical tips for the exam, make sure you've activated your account before you turn up and you know your password, you'll also need your ID um and a pen if you want to make any notes, especially for the calculation questions. Um If we go to the next slide, um so, although there are 60 questions and 100 and 20 minutes, it's not just sort of two minutes per question because some questions are worth a lot more than others. So if you just click next, it'll show you which each section is, we just click next. Perfect. So you can see here in yellow, the prescribing section, although it's only eight questions actually makes up 40% of the mark. So you need to spend a lot longer on those questions than say the data interpretation at the very end. Um If we go next, so this is our sort of suggestions for how you might break down the timings. Um You do what works for you, but this is our suggestion and basically you just move on in the exam and then if you've got any time at the end, you can come back and review any questions that you've flagged. Um You can screenshot this now while we've got it up, but you will get the, the sort of slides I think at the end. Um so just give everyone a second to screenshot it if that's ok. Perfect. Um So I usually, I usually use these timings in my practice um papers as well. Um because it is really more time pressure than you'd imagine it would be. Um I think we've got one slide ahead. There should be one that says prescribing. Yeah, perfect. Um So section one prescribing is the the highest sort of met section you'll be asked to prescribe for common acute and chronic conditions, um also pain management fluids. Um and as well as these high yield topics that I've put in those two bubbles, you'll need to do common things like antidepressants, antihypertensives, contraceptives, inhalers, um bisphosphonates, et cetera. So it's important to um do lots of practice papers to think about these questions and you get five points for the correct drug and five for like the correct way to prescribe it. So the dose, the route of frequency. So it's really important to use the VNF carefully. Ok? Um I've popped an go back one second. I've popped an example question on here. It's just from the PSA website where they show you the question format. This is the layout you will see on the um sort of computer based examination. Be really careful when you're prescribing. They might include in the stem any contraindications they might have a renal or liver impairment or it might be a woman of childbearing age and that the medication isn't suitable for them, check for allergy status and any drug interactions with their sort of current drugs. Ok. So if we move on prescription review, um so this is eight questions again. Um but they are sort of two parts A and B. Um And you just click the drugs that you think are the answer in each column for A and B. They will ask you either for one or two texts per column. So examples of sort of drug drug interactions that you might see are things like Warfarin and Clarithromycin and you can use the medicines, complete interaction checker for this because you won't have the the phone app BNF. Unfortunately, and it's important to learn common side effects of drugs so that you don't have to keep checking, for example, that ace inhibitors cause a dry cough. Um So it can really help if you have in your head, a list of common side effects and interactions if it's an obvious answer. Great, click it and move on. If not, I used to start with checking for any interactions and then checking any medications. I wasn't sure about against the BNF to see if they've made any mistakes. Um It can take a long time. So if you're getting really stuck, I would flag it, maybe click some options just so you don't lose like zero marks and then just move on and come back at the end if you have time. OK? OK. So if we move on to. Yeah. So these sections are now much, um, sort of smaller points wise. Um These ones are worth only two marks each. So we suggest doing about a minute per, per question. Um In planning management, you'll be given a stem, um, a question and then five choices to choose from. I would recommend reading the question first. So you know what you're looking for when you read the stem. Um And then the options might include different prescription options, non-drug options and also not doing anything um which might be the valid option. So just read the options carefully. Don't click on the first one you see. OK, moving on. Um So providing information, this is all about what would you communicate to a patient. Um Sometimes there might be more than one correct answer, but it's about what's the most important for that patient. Um So you can look in the BNF in the patient carer advice and in the contraindications side effects sections. And if there's like a safety warning, that's usually something very important to mention to the patient. Um If we move on to calculation skills, um I personally like the calculation skills section, but it's kind of like a love hate thing. Um For most people, if you don't like it or even if, if you know you, you feel quite confident in the section, do practice it because it can be a good way to boost your marks. Later on in the exam. Um, but like the other sections don't agonize over it. There are other sections to come and move on if you're stuck. Um, I've just put the in green, I've put a little box about the sort of what 1% means and what one in 1000% means. It can be in the heat of the exam. Quite confusing, doing your unit conversions and your orders of magnitude. So be very careful with that. And I actually wrote down every single step on paper just to make sure I wasn't making a mistake. Um There is an onscreen calculator provided in the exam, but I would recommend bringing your own one. It's much quicker to use. Um but it can't be a scientific one. It needs to be the really like simple ones you get in primary school. OK? So if we go to the next slide, um adverse drug reactions, so I've just popped um the free example that's on the PSA website. Um Here it's again, multiple choice. Um just choose one option from the five and you get two marks for the right choice. So if you really don't know, just choose one, you might be asked to identify the reaction that's happening or the cause of the reaction, whether that's the specific medication or a drug, drug interaction or as you see in this example, you might be asked to manage a, a drug reaction. OK? Um If we move on nearly at the end of the different question types. Um So drug monitoring. Um again, this is just two marked questions. So we suggest a minute per question and you choose the right option from five. This is where it's useful to know common monitoring requirements for drugs that need monitoring. Um but it's not just about monitoring for harmful side effects. So for example, furosemide, you'd be checking the the kidney function to check for harmful side effects. You're also monitoring the benefit for some drugs. Furosemide. You might be asked to um you might be monitoring the daily weights to see if it's working. So be really careful with the question. Are they asking you about monitoring for the benefits or the harms? Ok. So they can try and catch you out there and then data interpretation is the last section. It's also my least favorite section if I wanna, I ran out of time anyway and just clicked some random questions in the real exam. Um And that will happen. Um time, time will fly by. Um And if there's a couple of tricky questions earlier on, um you may just run out of time. So prioritize the sections that you know, you're good at from practicing. Um and then then you can sort of get the marks in those sections you're good at. Um you'll be given a clinical scenario here and some sort of data to interpret whether that's a blood test or a graft like a paracetamol. Um uh um, and then you'll be asked to decide an action to take based on that. Um, that might be stopping or increasing the dose of something or um, what, what did I say, reducing or increasing the dose, stopping something completely changing to a different medication or you might be asked to just not do anything. Ok. Um So if you like this section maybe come to this first and then go back to a section that you don't like as much. Um Because there is a chance you may run out of time. I'm gonna hand over to Julie now, who's gonna give us amazing top tips using the B NF in the most efficient manner possible. Great. Um Hi, everyone. So I'm just going to run through top tips for using the B NF because essentially the P SA is just a big old exam on how to use the B NF. Um I would recommend in the lead up to the P SA really getting to know the B NF and all medicines complete, which is the other kind of prescription book that you can use if you want. I personally use the B NF and I think most of my other med school friends use the B NF as well. Um I would recommend that perhaps up to the exam kind of just using it every day during placement during exam revision, wherever you might be thinking of prescribing a drug or thinking about a drug when you're on placement just to get familiar with where things are, um, how it works and just get used to using the treatment, summaries and the interaction, check it. Um, and I'll run through some tips. So these are the drug monograph. So I've just put up an example of Ramipril there and I've highlighted the ones that I think are the sections of each drug monograph that you'll probably use the most. Um You'll be using the indications and dose contraindications, all of that and more of those sections you'll use, they'll be more relevant to the certain types of questions that we'll have. Um I would recommend that I think as soon as you open up the P SA, get the B NF up and all medicines complete and start to split screen. So that way when you need to use it, you can just immediately scroll over to the B NF um and click exactly what you need and use control F as well cause that will be your best friend um when it comes to the P SA as well. So if you go to the next slide, I'll just quickly talk about the interactions checker. So like I said before, medicines complete is also available for you to use. Unfortunately, I can't access the medicines complete anymore because I'm not a uni so I wasn't able to screenshot what the interactions check or medicines complete looks like. Exactly. But it is for you to use. I've heard from other people that some people prefer medicines complete. It has a bit of a cleaner interface, but obviously it's not as familiar as the BNF, especially if you're used to using the BNF. Um, most of the time. So when it comes to this, it's really your personal preference. Just try both of them out when you're revising for the PSA or doing exam papers, try using both of them, see which one feels the most natural and the most comfortable for you and then stick with that. Um I know some people use both used both during the exam. So they use the BNF for all of the drug indications and all of the information. But then also had medicines complete open just for the interactions, checker because some people prefer the interactions checker. So whatever you do, just go with what you feel is the most natural and make sure that when you open up your exam to have all of everything open and split screen so that you can click and find things as easily and as quickly as possible. So if you move on to the next slide, um as most of you know, the treatment summaries are are available for you to use through the B NF. So these will have various kind of information and guidance based on different indications, different diseases. Um If we go on to the next slide you'll see these ones that I think are perhaps the most relevant for the PSA you can screenshot these if you like. Um, these are the treatment summaries that I would suggest you get really familiar with. Um, in the lead up to the exam, have a look through, read through, see what information is there in those treatment. Summaries and what information isn't there, there is a lot of things on the, in the B NF that you might not know is actually there for you um that you can use during the PSA for example, um the oral anticoagulation treatment summary is where you'll find all of the things about Warfarin and Inr and what to do if your inr is too high or low and similarly in poisoning and emergency treatment summary, you'll find things about um what to give if someone has a paracetamol overdose and also if someone is having maybe a reaction to their psychiatric drug. Um So I'd really recommend just taking a run look through all of these treatment summaries and seeing what's there as it will definitely help when it comes to the PSA if you move on to the next slide. So this is just more specifically about um the prescribing in palliative care treatment summary. And I've just put this up for you here cause I think it's probably the one of the most useful things that you can have during your exam. Um So I've just screenshot of two of the tables that are on there and that's just the opioid um conversion tables that are there for you to use. Um It, there is also information there on how to switch between oral morphine to patches, um which is a very classic psa question. Um It might be worth remembering the basic kind of conversion so kind of or, or a morph to morphine, that sort of thing just so that you can do it quickly without having to look at this table um during the exam. But if you get stuck or your mind blanks and you know that these are there for you and importantly, you won't find it. If you just type in morphine on BNF, it will be under the prescribing and palliative care treatment summary. So if you move on as well, if you don't mind. Um So I just wanted to show you this quick little tip that someone showed me whilst I was revising for the PSA I don't know if you're able to kind of, I don't know how well the screen is there for you to see. But if you look at the search bar on top of the screenshot, you can see that um there's a little and or bracket thing that you can do. So this is a tip for your prescription review slash adverse drug reaction questions. So if a question is asking you to compare information between multiple drugs, where you, for example, if the question is what drug would cause drugs out of these, out of this patient's list would cause them muscle cramps. You could type in muscle cramps and then in capital letters and, and then open bracket and then type in each drug and then in between each drug if you put or the BNF will automatically kind of filter the word muscle cramp against all of those drug monographs and then whatever comes up will be the drug that contains that word muscle cramps. Um I would say, for example, you can see when I've typed in muscle cramps and all of those drugs there, the results come up as amLODIPine, which is the correct answer. Um And if you open up amLODIPine, you will see the muscle cramps and the side effects and that isn't there for any of those other drugs. Um I would also just a extra double check. You don't wanna lose points just also just click on the drug when you, when that comes up and just make sure that it is under the correct section um that you're looking for so that it is under side effects and not under indication or something. Um And then I've just kind of run through, I'm sorry if this is going too quickly, but um I've just kind of run through specific tips for each section of the B NF as well. So for the prescribing question, um double check because this is like Tess said the section that comes with the most points. And so you should probably allocate yourself the most time to do that as well. Um Just double check everything with the B NF. Um I think that, I think that there's enough time to do that, even if you're absolutely certain, you just don't want to have missed something really small or accidentally misread the question and get something wrong and miss out on potentially 10 marks. And then when you're prescribing specific doses, double check the indication. So for a certain drug, um there might, there might be several doses depending on the indication. So just make sure which dose that you're, you're prescribing. And if it's for the correct thing and also with the patient's um kind of details, check, check cautions and contraindications underneath that drug monograph, check it against that patient's past medical history or any abnormal investigation, test results that they give you a lot of the time the psa might try and confuse you and give you unnecessary information that you don't need, but sometimes it might actually be information that you need. So definitely it's worth reading the patient blurb completely and taking into taking into account all of the information that they give you. And then the prescription review like Tess said, you can, it's basically just to spot the error. So you, it means that maybe perhaps there's been an error in the timing of the, of the drug, the frequency, the the route, the dose or the units. And this is where it's really useful to use the B NF. You can use that and or tip that I mentioned earlier or just use the search bar for B NF like a search engine. I know I did and for planning management, um it's more about using the relevant treatment, summaries and finding the keywords as quickly as possible. And so this is where split screening and control thing. Um All of your keywords will be very useful. So we move on to the next slide. Oh There you go. So providing information. Um The most important subsections of the drug monograph will be the ones that I've put there. So the important safety information, patient information are carried by some directions for administration. So this section you will have to read the patient brief um clearly and then also use your clinical judgment as to what you think is perhaps the most important piece of information that will be that, that, that that particular patient will want. Um So it won't be that they'll want every single drug monitoring, it will point to something specific and that will be reflected in the answers that you have offered to you. And with the calculation skills like Tess said earlier as well, be very careful with your units. And I'd also, I also wrote down every single step of my calculations. Um I think this is useful in case you've gone wrong somewhere you can always see where exactly you've gone wrong and spend less time trying to correct that mistake. Um With drug monitoring kind of self explanatory, the most important section of the BNF will be the monitoring requirement. Subsection and with data interpretation, the treatment summaries might come in useful. Like I mentioned, the Warfarin um section is under oral anticoagulation. Um And again, just control f for any keywords, but it will mostly probably come from your own knowledge and to date interpretation. So that's just a very quick run through of B NF. Um The other kind of tip is to, I don't know how many of you have the paper B NF available to you. Um It might be that you bought it or have it or have it in your library. This can be useful for you to have during the exam. So I think there is, I personally didn't use it, but I know that tested. So I think there is a section at the very back of the B NF that has a big old list of all the common drugs and all of the common side effects that they cause. So you can, if you're able to bring it in with you, you might be able to just have that one page just open in front of you just for you to scroll through. Um If you're getting a bit um over overdone with the screens. Um And if that, if that would be useful for you. So again, it might be worth just you having a flick through the paper B NF seeing if there's any really useful pages for you and then bring it in with you if you want. Um I think there was also some mention of I back in the day slash last year. Um I think you're allowed to make minimal notes on the B NF. So that could be um anything that you're really struggling to remember, like the maintenance fluid requirements um for a person or anything to do with timing, whatever you think might be useful. I believe that you were allowed to do that last year. Um I would double check with your, with your med school um if that is allowed for you this year as well, but that might be particularly useful for you. Um And then if you move on to the next slide, I've just put in a couple of resources that I found useful whilst I was doing the PSA so the past PSA book is about 20 lbs on Amazon. Um I found it really, really helpful. I ran through the past papers in there about 2 to 3 times each. Um Also you have the actual prescribing safety assessment, um question banks themselves with lots of mock papers. Um I did those quite a lot as well and repeated them, repeated each exam paper about twice as well. And then the other thing that I use that I got from a friend was these at a glance books. So they, there's, there's a textbook and a workbook with loads of questions and answers um, that I did as well. The main kind of take home message of the PSA is just practice, makes perfect. So just practice with whatever questions, fact that you have available to you, um and practice with friends and things like that. So we'll run through questions next. We've done one question for each section of the PSA just to give you an overall feel of what the exam is like. Um, I don't know whether you would like to go through the realistic timings for each question or we can just do a blanket, give you a few minutes for each section. Um, if you want to pop up on the chat and say whether you want realistic timings or just generic timings per each question, the questions are on the powerpoint and we have it back. Sorry. Sorry. That's huh. Oh, no one said anything. Um, well, we have half an hour so we could do like what's maths, er, that someone has said? Oh, realistic, please. Ok. So we go realistic. Um, so I think that means that we'll just get the timer up on our face. Yeah. So if you don't have it open already, get the B NF or medicines complete open in front of you. And if you have a calculator, whether it's on your phone. Um just some preparation for the calculation skills and some pen and paper. Um and don't worry too much. Um If you get slightly overwhelmed by the, by the questions, um the rest of our series will go through each section in more detail to help you. And this is just to give you an idea and a feel of what the PSA is like. Absolutely. I think we said in the advertising that this session would be a bit more like the calculation questions. But we'll, we, um we're gonna focus on that slightly more in session too along with prescribing because we thought it was important to give everyone a flavor of the types of questions that there are. Um So, so can I leave it? Can I leave it to you to do the time? Timing? Yeah. So the first question I prescribing one will give about 5.5 minutes too. Um And then the other ones are all a lot shorter. So we'll do um probably minute and a half, 22 minutes 15 for the prescription review and then about one minute per the other questions. Um But we will obviously go through the answers. So don't nobody panic if you haven't got that. Um So this sort of show you really how, how tight the timing is and the real thing? OK, cool. So, so we will time and we will um move on to the next question when the timing is done. Yeah, we'll just say move on, please. Yes, then should we start now? Yeah. So if you don't mind, thank you. Ok. So we've got less than a minute left on this first prescribing question and we'll move on to the next one very shortly. And if people just write down their answers for each question on paper, we, when we run through the answers, we will ask you to pop them in the chat. OK? So if we move on to the next one now, so we'll have, we'll give about 22 and a bit minutes for this question. OK. So we're going to give you just one minute for the next question. But don't worry cause we will go over ways to know the answers um in a bit. So if we perfect f see yes. OK. If we move on to the next question also one minute. OK. And then on to the next question, this is one minute 15. OK? And then on to the next question, one minute, on to the next question or a minute long and then on to the last question also a minute. OK. So your home. OK. So gonna take a, take a breather that's quite fast paced. Um especially towards the end. Um Well done. If you wrote anything down, um, we're gonna go through the answers one by one and it would really help us if people could throw ideas into the chat section. It's completely fine if it's wrong. Um, that's the whole point. If we thought you'd get every single question, why there would be no point in having this talk. Um, so go back, go back. Ok. Well, you've seen this now. Um, it's fine. Um, we can show the answer so we'll, we'll go through the first prescribing question. Um, does anyone want to put, since we've gone back a slide their ideas into the chat? What did people write? So, what drug did people go for? Um And what dosing and frequency did they go for? You can just put what you saw flash up on the screen. So, ok, someone suggested flucloxacillin. IV. One person said 1 g, the other person said it's 2 g Q Ds or every six hours, which is the same if I'm right. Yeah. Lots of flucloxacillin. Yeah, Q Ds. Yeah. Ok. Yeah. Lovely. Ok. Um So we won't put the, the question back back up because we'd have to go back. But basically it said write a prescription for one IV. So intravenous drug that is most appropriate to treat the cellulitis. Um So for those of you that put IV, already, we've got the, the root correct. Um But if you put fluoxac in and then you put oral, you'd still get the five points of having the right drug. Um So if we press next. Um Perfect. Um So basically I went into um the B NF treatment summary for I think skin infections or something like that and you go to the cellulitis section. Um and it shows you that the first choice for oral or IV is flucloxacillin. And if they're penicillin allergic, um you can go Clarithromycin or Erythromycin or Doxycycline. But in this um patient, I said um no known drug allergies. NK DA. Um So we could just go for the flu clock. Um Obviously, if in the description, it said the infection was near the eyes or nose, you'd need to go for Tam ICAB. Um and their creatinine clearance as well. And the question was um I think 45. So we didn't need to decrease it, but it's also always worth checking that there's no reason you need to adjust the dose, whether they're elderly or have renal impairment, et cetera. Um So once you click on flucloxacillin, you go to the indications and it tells you by slow intravenous injection, you can give 1 to 2 g every six hours. I think in the real thing, they give you a range of options. Um So you probably be marked correct if you put 1 g or 2 g, I went for 2 g because of the CRP and the white cell count being very high. I wanted to make sure I was treating the infection adequately. Um But his news was three. So 1 g would also be, would also be very valid. Um Perfect. Ok, so don't click next, please. Um can anybody put in the chart for the prescription review questions? Um Which two medications did they think were most likely to cause the hyperkalemia in the prescription review question? So that was question A was the two most likely to cause hyperkalemia and then question B within that it was also which two are most likely to interact and cause harm? Ok. So you haven't got any suggestions that they thought for the prescription question. The Yes. Yeah. So someone suggested Ramipril cyclo cycloSPORINE as causes of hyperkalemia or everyone's suggesting those two beautiful. OK. OK. Um And then what about ones that are most likely to interact and cause harm that? OK. So we've got two people suggesting the statin and the cycloSPORINE shouldn't be prescribed together. Um So if we press next, these are absolutely right. Um And we're gonna now go over why? Let me just find my slides here. Um So the approach um you can use for questionnaire um is you can firstly, you can just learn common causes of the different electrolyte imbalances. And I'm gonna go over a few acronyms on the next slide. Um I also use the BNF um paper version, but obviously someone has told me in the chat that you're not allowed that this year and then there's Julie's and or method um that you can use in the sort of online B NF search function. However, um often the side effects, it just says electrolyte imbalance and it doesn't say which electrolytes are most likely to be caused um problems by that drug. Um I also found though in the interactions checker that Ramipril it actually says underneath it, Ramipril and cycloSPORINE can increase the risk of hyperkalemia. So there might be some more information there if you're looking for it. Um For question B um I personally recommend the medicines complete interaction checker. Um You need an open Athens login from your university and then you just type all the medications that the patient is prescribed. Um And it will tell you if there's any interactions, whether they're severe or, or less severe, you can also manually check for each drug if there are interactions, but that takes a lot longer. Um And for common or severe interactions, it's helpful to learn them so that you're not wasting time looking for in the exam. Um So if we go to the next slide, um if we just pop the next slide on. Beautiful. Thank you. Um So I've just sort of summarized some causes of hyper and hypokalemia on this page, I found this really useful um for the PSA and also real life. Um So the two acronyms are dread. So you're on a, that's for hyperkalemia because you're on a heightened state. So higher hyper. Um And then there's dire a sort of depressed state for hypokalemia. Um And I've just put the sort of different reasons you can have these um imbalances and then for the hyperkalemia drug causes um it doesn't really roll off the tongue but I learnt the acronym hat C it doesn't really make any sense, but that's how I learned it and it's just Heparins, ace inhibitors, tacrolimus cyclosporin, which was in the question and aldosterone antagonists um especially if you have like ace inhibitors and like spironolactone or aplin together and that can be a real cause of hyperkalemia. Um So you would always before giving spironolactone or Aplin check the potassium before and then after starting treatment to see if it's had an effect. Um And if they do have a raised potassium, you need to hold it. Ok. Um If we go on to the next slide, um So these are just some medications that can cause hyponatremia. That's also quite a common question. Um in the exams, quite easy to remember that the SSRI si think and, and the be methide in particular. Um And then I've popped a few key interactions that I found in my notes here. So the macrolides, the statins and then, and azole antifungals basically interact with everything and as does Clarithromycin, to be honest. Um So if it's on, if it's on a prescription review question, Clarithromycin is probably um a culprit. Um perfect. Now, before we go to the next slide um for the planning management question, um has anyone got any suggestions what that they put for the most appropriate management option? So this was question three. The options were sort of hold all the medications until the A AK I had resolved or don't make any changes. Hold the Metformin, hold the Ramipril or switch the Metformin to insulin. What people put in the chart. Ok. Someone said they double check the PSA website and it says you can still use the paper version. It sounds like you need to check with your unis um, whether or not they're allowing it because it can be quite useful tool. Yes. So we can try and get access to the interactions checker for next week so that we can show you guys. Um but basically it's just you go on the medicines complete B NF and in the search bar, you just type in all the medications and then down the side, it offers that you can check the interactions. Um OK. Has anyone got any suggestions for the planning management question? What would they do for this patient? That has an AK I someone suggested holding the Ramipril. Does everyone agree with Sophie? Well, I agree with Sophie if we go to the next slide. Absolutely. Hold the amoil. Um So the acronym I learn for um AK I um sort of drugs is diamond. So stop all diuretics, be very careful with iodine, I um stop any ace inhibitors or um angiotensin receptor blockers. Um Those ones are all like sort of um nephrotoxic, then Metformin is less about them that, that causing damage to the kidneys, but more about the fact that it's not, um, it's going to cause a lactic acidosis. And the same with the opiates, the kidneys aren't getting rid of it. So it's going to build up and you can get an opioid toxicity. So you need to be very careful with opioids. Um You can sort of switch to something like oxyCODONE if someone's got a very low renal function. Um, no nsaids, it's supposed to say continue the cardioprotective aspirin dose. I'm not sure why that's cut off there. So, if someone's on sort of 75 mgs of aspirin a day, you might consider sort of continuing that. But if they're on a 300 mg dose, you're probably gonna stop that. And any other nsaids for pain relief, you're gonna hold them while they've got the AK I. Um, and then the last D in Diamond is, um, disease modifying medications. They've usually got a very narrow therapeutic range. You're at risk of them not working or a toxic level, um developing. So if you want to keep giving them, you need to closely monitor them. Um, but it might be a case of stopping them. Um The reason we're not holding the Metformin in this case is because the EGFR is still over 30. Um So someone had a worse AKI you might hold the Metformin and that would be a valid option. But here we can continue it because the EGFR is above 30 OK. Um And then before we go on to the next slide, has anyone got any suggestions for the providing information questions? So this patient, this was a question about a patient starting carbimazole for the hyperthyroidism and what's the most important information this patient should be given? So, some OK, people saying, C so sort of tell your, tell your GP, if you get a sore throat warning or infective symptoms, anyone disagreeing with C? OK. So if we press next. Um So for carbimazole, when you click on the BNF, it has an important safety section. Um and it highlights three things that are very important and it also has the same information, patient carer advice. Um So the safety information relevant to carbimazole is the neutropenia agranulocytosis, which I've got here. Um There's also an increased risk of congenital malformations. However, this patient is already on effective contraception. Um So, although we would obviously tell the patient all of this, the most important thing here is the, the neutropenia and the risk um of sort of bone marrow suppression. OK. Um Option B take before breakfast is actually for levothyroxine. So for hyperthyroidism, um D is, is, is true, they will sort of measure to see if it's working, but it's not as important safety information as C and ei completely made up. Um The on the safety information, there's also something about acute pancreatitis. Um It would be worth mentioning in real life to a patient Um But the fact that in the patient carer advice, it only talks about the sore throat, um mouth ulcers, et cetera suggests that that's more important. Um And also this patient's never had acute pancreatitis. So that sort of last sentence about reexposure and life threatening acute pancreatitis is, is less likely. OK. Um So I'm gonna hand over to Julie for the next set of questions. Yeah. So again, um these are for the calculation questions. So this is about the amount the milligrams of sodium chloride that the patient would have received in 10 minutes. So if we can just pop into the chat, what you think your answer was again? No, no worries if it was incorrect or if you're worried about it being incorrect and we'll talk through the workings out and how I would have done it. Anyone? Oh, so aura said 1500 mg. Anyone else agree or disagree? So you've got 1200. I think that's enough variety to lead us to the answer. So if you, if you don't mind James putting it on to the next slide, can you have the next slide, please? Thank you. Um So the answer was 1500. Um So I've just put my workings out on there. So, so, so it says that a 0.9% bag of saline is given. So you know that 0.9% will mean that they've had 9 mg in a meal and they've and the bleb said that she will have received 500 mils. So what I've done is 9 mg times 500 which gives you the total amount of so um milligrams of sodium chloride in the entire bag. And you know that that was given in 30 minutes and 30 divided by three gives you 10 minutes. So I've just divided the amount of the total number of milligrams of sodium chloride in the entire bag divided that by three. And then that's given us 1500 mg of sodium chloride in 10 minutes. OK. If 1% is 1 g, I mean someone's got a question. If if 1% is 1 g in one in 100 mils then wouldn't 0.9% be 0.9 g. Yes, I'm now confused. Um Yeah, so that would be nine 900 mg. Yeah. There you go. Test has on the workings out for me. So that would be 900 mg in 100 mil. So it would be 1 mg and 100 MTI need your help. Just that one. Yeah, I think that works. But also the the the clue here is um in the medication forms on the sodium chloride. It says active ingredient, sodium chloride. Yeah. Yeah. So I think I think our mass that I put in the chat is correct. Um But equally um they've done the math for you on the BNF saying you don't need to do that. Exactly. So if you get stuck and if you get confused, if you literally just Google sodium chloride into BNF, it will tell you the amount of the active ingredients. And when you look under for medicinal forms, it tells you how much the active ingredient is. So it tells you the 0.9% infusion of saline would give you 9 mg per one mil. Um So you don't necessarily always have to remember what the percentage means in terms of concentration of fluids. I'm sorry, I got Confuzona section. Um But yeah, so that is the working out for that. And I hope everyone understood and that I didn't make it 10 times worse for you all. Um So if we move on, oh no, actually, before we move on, um if any people can pop into the chat, their answer for the adverse drug reaction question. So this was the question about what drug was most likely to interact with sim simvastatin to cause the the patient's symptoms. So the options were paracetamol, sodium valproate, colchicine or Carba, carBAMazepine or Ramipril. What does everyone think? Colchicine? Anyone agree, disagree. No. So we'll move on to the next slide and we'll show the answer and it was indeed colchicine. So the the tip for this question is to just use the, use the interaction, check, interactions, checker. So if you click on simvastatin and run through each of the drugs that is on, that is offered to you. Um You're looking for the drug that is either most likely to increase the exposure of simvastatin or cause a risk of rhabdomyolysis, which is the symptom that the patient is experiencing with muscle aches. So, when you typed in paracetamol, you would have seen that there is an increased risk of, of hepatotoxicity. So you could maybe at that point in your um answering the question, think that the answer potentially might be paracetamol. If nothing else gives you a correct answer. Um With sodium valproate, there was no interaction. When you're touching colchicine, it would have shown a severe interaction that causes rhabdomyolysis. CarBAMazepine does the opposite of what you want. So it would have reduced the exposure of simvastatin and Ramipril wouldn't have been an interaction at all. So this is just one of those questions where using the interactions check uh interactions checker, whichever one you, you prefer either the B NF or the medicines complete will give you the answer. And you don't necessarily need to remember all of the side effects or interactions of, of simvastatin by heart. Um And then moving on to a drug monitoring question, this was the question that asked, what, what side effects would you ask the patient to watch out for? Um If people can pop on, pop it into the chat, what they thought was the most likely answer? Oh, and it's there. Now, hopefully none of you saw that remove it from your mind and put it into the chat or even if you did see the answer, then you can put it into the chat. Well, we'll just show you what the slide said. So the answer was persistent cough. Um So when you type in, um, a Aliab into the BNF, um, and you go straight to the drug monitoring um, section, which is what I did. And then in that section, there wasn't anything that was relevant to the answers that were offered. I believe it tells you something about monitoring for infection, but nothing quite so specific and it definitely doesn't mention E sr um And then if you scroll down to the patient and carer advice, the first subsection there is TB and it, and it advises that we suggest our patients watch out for symptoms of TB um that include persistent cough, weight loss and fever. Um and persistent cough is one of the options that were offered on, on that in that answer. So, you know that the answer is persistent cough, there is nothing about weight loss or nausea or vomiting mentioned there in TBS. And and the persistent golf answer is the most single best answer there. Um What were the other options? Again, someone has asked, I'll get that for you. So the other options were e sr nausea and vomiting. Number of flares of uh severe psoriasis, a arthritis, presence of a persistent cough or altered mood and presence of a persistent cough was the single best answer for that question. Uh And OK, great. And then moving on to the penultimate. Oh, no, the last question which is data, data interpretation. Um This was the warfarin and high I nr questions. So, does anyone have any suggestions for the answer to that question might be and pop it into your chest panic and off hematology? That is what we do in reality. Huh? So II alluded to where the answer might be to this question a few times during the presentation. Um What treatment summary you might find it in? Someone's got a which is stop Warfarin, get IV the K and someone suggested stop Warfarin and give AK and if you move on to the next question, um next slide, sorry, we'll see what the answer is. Um And yes, the answer is stop Warfarin and give IV bit K. Um And so that's because there is so the IR so I've screenshot of what it says on the um treatment summary and this IR guidance is under the treatment summary for all anticoagulation. So the inr is raised, it's above eight, it's 8.3 and there's some minor bleeding. And so what it says in the BNF is that in this scenario, you would stop Warfarin and give Vitamin K by slow IV injection. And it says if the, if the inr is still too high after 24 hours to restart the warfarin when the inr is below five. So there is your answer. Um And someone said, where do you find this treatment summary? It's under all anticoagulation. So again, this is where it's really important to run through the treatment summaries. Um I don't know if many of these screenshot is where I had put what I what I had put as the, as the useful treatment, summaries and this would be under one of those. Um So that is all of our questions done. I hope everyone found that somewhat useful and thank you very much for listening. Oh, sorry. Were you saying something? Test you just waving, get replied, don't no one use this QR code. Oh again, do not QR code. Um Ignore it. Um So you just want to say thank you much. Thank you very much for listening. We'll send out some feedback forms. I think they come automatically through medal. Um Tell us what you liked, didn't like if there's anything that we can improve for the next few um sessions from our series. And we hope it was useful in terms of the next few sessions. We'll be running through more specific um sections of the P SA. So we'll talk a bit more in detail about prescribing and prescription review and we'll go in more into more detail about calculation skills and give you some more example, questions to run through and practice on. Thank you everyone. Um And then if you scroll a couple of slides down and then this is, yeah, these are our next few sessions. So we just want Thursday for the next three weeks at the same time, same place and our social media. If you wanted to keep following us and seeing what events we have coming up. Thanks everyone and yes, please do fill out our feedback form. We really need them for our portfolio. Thank you everyone and good luck. Thanks everyone.