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Hi, everyone. Thanks for joining. We are just um gonna give it another minute just to allow people to log in and then we'll get started. Ok, in response to your question. Um Kia, sorry, I hope I've pronounced that right. Um Yes, I think we will be sharing um the content we're just working on how best to share it. I think we're working on a website at the moment. Um But we'll keep you posted. Ok. It's two minutes past. I'm sure people can just join in. We've just got a packed session. So I think it's good if we just get started um as soon as possible. So, welcome back to the PSA series from MedTech. This a session two and the focus could be more on the prescribing and there's also some leftover bits from the calculation skills. Um So we've got uh your two lovely tutors today, Julie and Tess. Um and they'll just go into a bit more about what they're gonna cover today. So I'll let you guys take it away. Hi, everyone. Um Welcome back. Um So for those of you, like, like um Vicky said, we'll spend this session going through prescribing and calculation. Um in the first half of the series, we'll run through some tips and advice about each session about each section of the PSA in particular. And then we have about 10 example questions and we'll run through all of the answers for those as well at the end. And if, as always, if you have any questions, put them on the chat, which you can access on the right hand side of your screen, I think, and we'll do our best to answer them as we go along. So if you could switch to the next slide, please, thank you. So, just a little bit about who we are, first of all. So, Metic is a teaching organization run by F ones. We're supported by health education in England. What we do is provide free accessible and teaching resources to med medical students. This is one of our seriess that we do. So we'll be doing a PSA series session um every Thursday for the next three weeks. Um And you can keep up with that on our social media. And then we also do Thursday 15 series, which is our finals teaching, which will also be every Thursday and it will start at around springtime and that will be for revision for your finals. Um So that's us and then we'll run through just really quickly the exam format as well. So as you probably already know, you have 100 and 20 minutes to complete the PSA and the PSA is made up of eight sections. We'll be covering section one predominantly and uh, a little bit of section five with some calculation skills. It's a mainly time pressured exam using the BNF or medicines, complete whatever you choose. And section one, which is the prescribing is probably the most, um, time intensive, uh, not time intensive, the most it will take you probably the most time and should take you the most time because it has the most marks out of the whole exam. I think it has about 40% of the marks of the entire exam are in section one. So we'll go through that in more detail as well. And then this is our suggested timing breakdown for the exam. So per section, as you can see, prescribing has the most marks per question. And so we've allocated that the most time and then we've just given a rough suggestion of minutes per question. Um It's, it would be a good idea to practice with these timings. Um when you're doing your mock papers and get, just get a feel of how quickly you can look through the B NF and answer all of the questions in time. We'll be practicing some of the timings later um with the prescribing questions as well and then moving on to prescribing. So this is just a bit of a repeat from our last session. But this is more for those of you that just need some reminding. So the prescribing section is made up of eight questions. It will include a brief vignette of the patient, their symptoms or their condition that they're diagnosed with any examination findings, um any investigations and or past medical history. And then the question will ask you to prescribe the most appropriate drug for that patient symptoms or that condition that they have. Each question is 10 marks and half of that marks will be for the correct drug. And the other half will be for the for how you prescribe it basically. So that will be the correct dose route or frequency. The questions are likely to include an acute scenario. So that might be like an M I or a stroke, some chronic disease and will include at least two fluid prescription questions which we will run through in more detail. The most important section of the BNF for this section is the treatment summaries. Um And some of the high yield topics that we think would be good to go through before your exam are insulin opiates, antibiotics, fluids, anticoagulation. Um And I think our questions probably include a little element of all of those today. So this is just a screenshot of the PSA um mock question uh that is just available for free on the website. Um So this is just what it will look like for those of you that maybe haven't had a chance to have a look at the PSA format. Um The question will ask you to give you the name of the medication, the dose, the route and the frequency. So I think from what I remember, it won't be free text. So as soon as you start typing in the medicine box, it will come up with suggestion of things that you can click. Um So there isn't really a chance of prescribing things with an incorrect spelling mistake and your prescription, you prescribe a signature and your date will already be input for you. So you don't have to worry about that during the exam and just some other kind of quick little tips for the prescribing section. Um I personally chose to double check everything with the BNF even if I thought I knew it. Um This was just because the prescribing section is so valuable for marks. I just didn't want to lose anything. And I think it would be a good idea if you have some time either during that section or some time at the end, just to double check things and to check the individual drug doses for each indication. So one drug can have multiple indications and therefore can have multiple doses. So just make sure that you don't just write down the the first dose that you see on a drug page, actually check it with the indication and if it's correct, and also if they give you a big old vignette of the patient in that question, just double check any cautions or contraindications for the drug that you're prescribing with the information that you're given, it might be that they're just giving you that information to kind of put you off. But sometimes it might actually just be quite useful and relevant to the relevant to what you're prescribing. And also I've put control F in a love heart at the top because it will be absolutely your best friend. Remember to control f everything. It will take you straight to the most relevant section of the B NF. And then this is the same size from last time. So this is just some high yield treatment, summaries that I would recommend getting familiar with. Um just to know what information is there and what information isn't there and what you might need to revise and memorize the BNF definitely has a lot more information than you think. And probably if you had unlimited time, um you could probably answer the majority of the whole PSA the PSA exam with just the BNF. So everything should be there for you if you can't remember it and then if we just quickly go to calculation scale. So this is section five of your exam. Um It includes eight questions which are about two marks. Each. Most questions will be 2 to 3 steps, but definitely prepare for three steps. So that will be a question that involves you maybe doing three small calculations to get to the final answer. I think more increasingly, the question is becoming a little bit more um more likely to be three steps. So definitely prepare for that. Um They're fairly easy marks to score. Um And you do get an onscreen calculator, but that can be a bit clunky and a bit time consuming to use. So I'd definitely suggest bringing your own calculator, but this has to be a basic one, not a, not a scientific one or anything that can store information. So before your psa just make sure you've got a physical basic calculator that you can use and bring it with you and bringing a pen or pencil with you so that you can write down your calculations on a piece of paper. This is just so that you can write down everything step by step. And just when you're double checking your answers at the end, it will be really useful for you to be able to see your own thinking and see maybe if you've gone somewhere, if you've done something wrong, like put a decimal point somewhere where you shouldn't have. Um So those are my little tips for calculation skills. And then, so this is something that someone told me with my calculation skills and that was to do a logic check. So when you get an answer, um just think to yourself, does that, does that actually logically make sense? Have, you know, would it, does it logically sound, does it sound logical to prescribe 101 tablets for a patient. Um for example. So just doing a quick logic check when you get your answer, um It's a good idea. And if you get an answer with a decimal point, it doesn't necessarily mean that you've done it wrong. You might need to round the answer if you get a decimal point and the num and the, the question is asking about a number of packs, for example. Um but you may not need to do that if it's for an infusion or an injection. So just make sure just double read the the question, just check if it asks you to round or not or if it's appropriate. And the other thing, oh, sorry Vicky, if you just go back a little bit. Um The other thing is to just get familiar with converting between different units. So I've put a little bit um on the right hand side about going between Millie Macro and Nano. Um It's probably the, the, the only trickiest part about calculations is just getting that right. Um So it might be useful to memorize that practice, just prescribing between different units, especially if you see it on the ward on placement. Just think about OK. If that was in grams, what would it be milligrams or mammograms or something like that? Um Some other basic calculation things that come up is percentage volumes at the top in the green box. So it's important to remember that 1% comes in, it means 1 g in 100 mil. Um And so for example, at, at something of an infusion that was 20% would mean 20 g in 100 mil. Similarly, things like adrenaline um come in descriptions like one in 1000 1 in 10,000. So one in 1000 means 1 g in 1 mL and one in 10,000 would mean 1 mg in 10 mils. And that's especially important because you might get, I know that it's different. The dose doses of adrenaline are different for different indications. So it would be good to get that right. Um Yes and the so we're just gonna move on to questions. I think I maybe ran through that really quickly but it was only because to get through, get through to the question. Was that an OK pace for everyone? Thank you, Anna for putting that in the comments. Is that ok? Are we happy to move on to the questions? If there's any questions, please say now or if you want to go back to any of the slides and screenshot, then we can go and do that now as well. I'll just double check the chat. Cool. Um Thank you Lizzie. So I think the timings for these questions, we'll try to do three. I think realistically we would have, we would suggest maybe 5 to 6 minutes for the actual prescribing questions in about a minute and a half for the calculation questions. So we can do that for some of the calculation questions. But I think for the prescribing in order to get through everything that we want to get through, we might just do a little bit quicker um and do three minutes for each prescribing question. Obviously, if you don't have enough time or you run out of time, don't worry, this is just to run through everything and we can talk, we'll talk, we'll talk through the answers in more detail. Um So if everyone's happy, we can proceed. So this is the first calculation question. Um I'll start the timer if everyone wants to get their pen and paper and calculation um and calculator ready and then we can stop. So I'll start the timer now. OK. So we'll move on to question two and time for question three. OK. So the next few questions will be prescribing questions which will allocate you all three minutes for. So I'll start the timer now and get your B NF up if you haven't already or medicines complete whatever you want to choose and you can use that. So I'll start the timer for three minutes from now. Everyone is ready on to the next question. Now, on to the next question. On to the next question to question eight. Can we move? Yeah, on to the next question please. And on to the last question. Oh, technical error. OK. OK. Great questions. All done. OK. Brilliant. So you're on some thicker breather. Um If you've got something written down, great. Don't worry though. We're gonna go through them now. Um So what we'll do is we'll do it like last week. So before we click on the slide, um, Vicky, I'm gonna get people to put their answers in the chat and then we'll go and see what, what answers I've put. So for question one, which was a calculation question um about a patient with pyelonephritis getting gentamicin. Um What volume in milliliters did people get if they can put that in the chart? So what volume for the, the f the one the first dose did people get? OK. If, if anyone got an answer, someone suggested 59.5 mil, I've got two people saying that any other suggestions or is everyone happy with 59.5? Someone said 60. OK. Probably thinking about like the practicalities of giving it 59.5. Yeah. OK. So if we go to the next slide, Vicky. So yeah, I got 59.5 mil here. And to be honest, I don't know what the nurses would actually give. I know obviously a syringe, you know, you can, you can give half a mil. Um So I think that would be very possible um here and I would probably write in in the PSA I would probably write point point five mil here rather than rounding um just in terms of my workings, I've put them there for everyone in case anyone got different answers. So you take the dose, you want you times it by the weight that gives you the overall dose you want. So 7 mg times the 85 kg the patient weighs, then you've got your strength and basically the way I convert is I say, what have I got and what do I want And how am I gonna get there? So I know that 20 mg is two mils. Um So then you take the two mil, I basically, I divide that by 20 to get what, what, how many mils gives me 1 mg and then I times by the milligrams I want so 595 and that gives me the meals I want. So that's how I do them. And I always write those steps out on a bit of paper just to make sure I'm following the logic. OK. Has anyone got any questions about that before we move on? Um OK. Someone said, oh, let me share the feedback link. Thank you for asking for that. OK. So I'm sending the feedback form for anyone that needs to leave it early. Um Anyone got any questions about the question one? I don't think so. OK. So before we go to the next slide, um has anyone got any suggested answers for question two? So this was the question um about a patient being discharged home with P RN or a Morph. And about how many bottles we would send them home with. I was once doing a, a prescription on the computer and it came up with 100 bottles. So definitely wrong. Gonna put that out there. Um, I did notice. Don't worry, but it happens when you're on the computer and things are automatically clicked. Ok. So we've got people suggesting three bottles, three bottles, three bottles. It's making me question my math. But if we go to the next slide, I got two bottles. Um So I've worked out how many milligrams maximum they could have. So I took if they take the 10 mg every time rather than the five and they're taking it literally every six hours and then every single day, hopefully the pain's getting better. But if they took the absolute maximum we've prescribed um I calculated that as 280 mg that they could maximally take. Um And then if you look at the strength in the bottle, um it's 10 mg per five mil. So you can either do it the sort of again how I did it before. So divide by 10 and then times by 280 or you can just look at it and say, OK, 10 mg five mil I'm just gonna divide by two. So I got 100 and 40 mils is the volume we need and if they are 100 mil bottles. I calculated that I needed two bottles there. Um The people saying three. Do, do you now agree with my two bottles? Oh, the questions say every four hours? Ok. I changed it but I obviously didn't change both slides. So I apologize and absolutely, it would have been three bottles and I sincerely apologize. I thought I changed it. Ok. As long as we're all on the same board, like how we're working it out, I apologize. Um Perfect. Ok. Um And then the last calculation question um was asking how long an infusion would take, given the sort of volume and rate that I'd given you. Um And that was for IV, Ciprofloxacin. Um What, what timings did everyone get for that one? Yes, we are. Absolutely. If it's four hourly, it comes to 2.1 bottles. So you'd probably have to give them three, which is why I changed it to a six hourly so that it wouldn't be potentially overdosing the patient by giving them loads. Um ok, so for question three, everyone's suggesting six minutes 60 minutes apologies. Um So if we go to the next slide, Vicky, that is absolutely what I got. Um So, um basically this is quite, quite a simple question. So you divide the, the meals by the meals per minute and get the 60. Um Right, if your questions asking you the opposite, so you've got the minutes and the volume and you need to find the rate. It will often come out with something with lots of decimals. And that doesn't mean you're wrong, like Julie said earlier, just read the question. Think, do they want you to give sort of full amounts? Do they want you to give something with decimals potentially? And sometimes they may state to two decimal places or to one decimal place. So be sure you give an answer with the right number of decimal places if they state it. OK? You don't always have to have a nice round number to be right. Um And just another thing on calculation questions, I would strongly recommend going on the medics website. They have a page on calculation questions, different examples, different types um with worked sort of explanations that I found really helpful um when I was revising. So we've only done a couple here. I would strongly recommend G medics page. Someone's put up a question. The progression. Does the infusion any include one days? Um Yeah. So um the we we're giving them 400 mg three times a day and, and the bottle has 400 mg. So you need an a separate bottle for each dose essentially. Um And the rate that is put up at is gonna be calculated individually each time you put it up because it's eight hours in between. OK. Does that make sense if it doesn't message? But for now we'll move on. Um So the next question was the one about, um, prescribing H RT. Um, now with prescribing, there's often, OK, we've shown you the answer that I've put, there's often more than one correct answer and they take this into account in the PSA. Ok. Um, I think we've shown the answer. But does anyone want to suggest what answers they popped up? What answers do people get? OK. We'll go on to the next slide cause we've shown it anyway. OK. So I went for a less duet which is um an oral combined um H RT thing. Um And you take a tablet every day and if you look on the B NF, it talks about like the different colors, the tablets come in the PSA doesn't really like allow for that. So I wrote it out how I imagine they often if it's like a brand dependent thing, like a, you know, inhalers often you need to write the brand or, or things like this, it will have the like the full name written out and the brand name um to choose from. So be very careful with your dropdown options. Um I've highlighted things in this question that are super important to your choice of HRT. So her last period was six months ago. We, we call that perimenopausal. So if you've had your a period, any time in the last 12 months, you're perimenopausal. If you've had no periods for 12 months, then you're post menopausal. Um If you're looking in her past medical history, there's no sort of talking about hysterectomy or any removal of the womb, um, which is really important. We'll, we'll mention that on the next slide where that's important. And in her current prescription, she's not on any other, um, sort of, um, sex hormones. Ok. Um, she's got no, I hope no contraindications or interactions. II, didn't write any intentionally. Um And in the question, it very specifically says she'd prefer something oral, that's really important. They'll often say, you know, the patient would prefer a patch or, or they're nil by mouth. So you need to prescribe something that the patient is gonna be happy with. OK. Um I'll talk a little bit in a second about why I chose this leste duet. Um but it basically contains estrogen and progesterone. Um And that comes in two different strengths of tablets, the two different colors to mimic the natural hormone cycle. OK? Um So if we go on to the next slide, I can see there's a couple of comments in the chat. Um oh, the question stated that she wanted a patch guys. I'm very sorry. Um So the person who put ever sequi um that is the patch equivalent. Absolutely. Um Because um it's sort of sequential. OK? And that's got both estrogen and progesterone. So that would be the equivalent to you at. I'm sorry, we um obviously, things did get changed in the slides and then didn't get changed back. Um in terms of wearing the BNF, you find the formulations. So this is an example of where you don't and you have to learn it. Um which is why I've done a slide on it. I couldn't find, um you can't, you can't find sort of what you give to whom. Um So it's important to learn some examples. Um an answer to your question, Christine. Um it's not that you shouldn't prescribe the brand name. It's that on the PSA um usually you have to type in the actual generic name and then it might come up with the generic name and different brands and then you need to be very careful about what you're choosing to make sure it's the one you want. OK. Um So in terms of how you choose what you want, you need to, to ask, do they have a room, do they not? And are they proge receiving progesterone from something like an in your own device? If they have had a hysterectomy or they have a Mirena coil, you can give them estrogen only otherwise everyone needs progesterone with it. OK. Um And then whether they're perimenopausal or postmenopausal, determines whether they can have the sequential like cyclical HRT that we've done in this case. So that would be a less duet or for the people that correctly did the patch. I apologize was ever sequi OK. But if they um are postmenopausal, you can do continuous HRT. That's the same dose throughout. Um And there are some examples um on the screen but there are, there are more. OK. OK. I apologize for the patch oral thing. OK. Has anyone got any other questions about this? So like I say, um a table like this II got this off sort of GP notebook. It's not um on the BNF, unfortunately, unlike some of the other really helpful treatment, summaries. So why can't you put El Conti? Um So that is because she has had a period about six months ago. Um So she's considered perimenopausal rather than post menopausal at this point. So we'd want to give something sequential, not, not continuous. OK. OK. Brilliant. So, um what did people put for the insulin question? How do you choose the strength? Um is that's for the H RT I'm assuming? Um So I believe um you would start with sort of the lowest strengths and, and move up depending on symptom control cause obviously, hormones, they do have considerable side effects. So you're gonna wanna sort of give the minimum that's controlling their symptoms. Um OK. No idea what dose to give for insulin couldn't find anywhere. Lizzie. You are describing how I felt in the actual psa exam when it asked me to do insulin, which is why we've done this question. I could not find the dose. Yes. So the BNF really helpfully says something like according to requirements. Yeah. So someone suggested insulin glargine one unit. Likely che someone said she they chose insulin Deamer. Yeah. So if in the PSA I mean, if it lets you do um according to requirements, that's great. But that's usually for your sort of meal doses, usually the long acting insulin is a, is a fixed dose. Um So if we go on to the next slide, we can start going through how I got to my answer. Um And like I say, there are lots of different answers and you might have different guidance at your hospitals. So very much in, in real life, you'll be guided by your local guidelines and your diabetic team. Um But this is a good sort of general principles to follow. So the BNF, all, all the information I could really find on there is that the first line long acting basal insulin is twice daily insulin detemir. OK. Um So that's why I chose that here. Um There is a, a type one diabetes summary which is where I found this um recommended insulin regimen, ok? Um And crucially, I chose the flexpen um prefilled pens. You don't want your patients at home drawing up their own sort of random amounts of insulin you wanted to have um the prefilled so that they can safely inject without making any mistakes. Ok. How did I get here? So I based it on the weight. So if everyone just remembers the weight was 40 kg, OK. We'll go to the next slide and I will which will hopefully show how I work it out if we go to an Xi Vicky. Amazing. OK. So when you start insulin um for the first time, um mo more, more so in type one diabetics, you work out their total daily dose that they are going to need by dividing their kilogram weight by two. OK. So for a really nice simple example, someone that weighs 60 kg needs 30 units in totals a day, total a day. And for a type one diabetic, 50% of that is gonna be long acting and 50% is going to be rapid acting. OK? So the maths worked out well here for me in my trust, we, we do Lantus rather than um Levemir. So we did and that's once a day. So 15 units because it's half of the total daily dose, which we said was 30. So they get their 15 units at night and then they get rapid acting. The other 15 divided by three because you have three meals a day. OK? And you normally go for no rapid um to have with your meals. Now, obviously, um the B NF has said Levemir is, is first line. Um So our trust is obviously doing what at once. Um So for our patient, I then divided the I think I got was it 10 for our patient? And I divided that by two. So five units BD because this was a child. Um That was just weighing 40 kg. Ok. Um What other questions before I carry on? Is this the same for Children and adults? Um and is Levemir the same as Detemir? So Levemir I'm pretty sure is the brand name I apologize. So insulin detemir is, is, is Levemir. Ok. Um in the question, no, it didn't say it was a type one diabetic but it was a 13 year old. Um and she only weighed 40 40 kg. Um So, and, and there was also a history of, of um autoimmune sort of hyperthyroidism in the family. So that's what I was trying to get at. It wasn't a sort of older, more overweight lifestyle kind of thing. And there was no family history of diabetes, which is more common with type two diabetes. Um Is it the same for Children and adults? I'm going to be honest, I don't know if you want to message our Instagram page. We can or maybe we can put an update in our email. Um But I would, I would assume sort of, yeah, Children are more likely to be type one diabetics. Um for the sake of this, these questions. Um equally, I think it's more likely that you'll get um sort of diabetic emergencies. So be confident about your prescribing for DK A or um like hypoglycemia, which we will go through a bit later. Um But if you asked to start the dose, um think about like this and then um your rapid acting is basically a third times three. Ok. Um, for type two diabetes, your longacting is only 20% of your total daily dose. Um, and I, they might not then have anything with meals. Ok. And not for prescribing, but for prescribing management questions, um, you would often be asked, do you need to change the dose if they're having high or low blood sugars? Ok. And it's really important for these planning management questions. Um whether um they have low or high glucose prob problematic glucose in the morning or the evening, you change the dose, that's the other time of the day. So for example, if they're having really low or high b high BMS in the morning, you would change the evening dose cos that's what's going to have the effect on the next morning. You don't sort of reactively change the morning dose cos that's when the problems happening. You change the long acting dose in the evening and, and vice versa. Ok? And when you are changing doses, don't just suddenly, you know, halve it or double it make changes 20% at a time. So if they're taking 15 units a day, you could increase or decrease by three units. Ok? Um and you, you would never just stop long acting insulin. Um um it even if they're not eating and drinking, but you can stop a short acting if they've missed a meal. Ok? Um Equally if they're having surgery the day before and the day of surgery, you've reduce any long acting incident by 20% just that day. Ok. Um, so someone said, how did I choose which Levemir pen? There's a few different ones all with the same strength. Yes, absolutely. So, here is where, um, it's really important to see what the difference is. Um, I chose the prefilled pen. That was the difference. The other ones you had to, they were like cartridges or something for drawing it up yourself. You want the prefilled pens is the safest device. Ok? Um This is why we give like novorapid usually as our sort of shorter acting one rather than things like a act rapid because that one requires drawing up into a syringe. Ok. Um Yes, the session is being recorded. Um Someone's asked, can you not give 10 units once a day? So yes. So if you were giving something like Lantus, you would give 10 units a day. But because I was going off what the BNF says and it says first line is BD. Um Deamer. Um That's why I gave five units twice a day instead. Ok. Um Perfect. Any other questions on the incident? Ok. Um, before we go on to opioids, I had a patient today, tell me they'd had a lot of cocodamol and then just like giggle about it. I still don't know how much they've taken, but I'll never know. Um, Okie doke. I don't see any more questions about insulin unless I've missed any. So what did people put for the opioid question? Question six, I was asking for breakthrough pain relief for someone that was on a buprenorphine patch. Where did I find the information originally? Is this about insulin? OK. And so in answer to Lizzie's question about the insulin. So again, w the topics we've chosen today are, are things that aren't, um, sort of on the VNF Unfortunately. So there are things that we thought it's important for us to sort of go through and explain and for you guys to learn. Um because the questions that are just sort of like, what would you give? How much Aspirin would you give for acs Management? That kind of stuff is, is very clear and easy to find. So you just need to practice finding those things. Whereas for these ones, we thought we'd go into the slightly more complicated ones um to help you guys. OK. Um So, so if you said she couldn't figure out the strength of the patch. Absolutely. That's something we can go through. Anyone have any suggestions for the breakthrough, pain relief for question six, I made this question like specifically mean. So don't worry if you weren't sure someone suggested um 20 mg, morphine, almost stressed. 2121. OK, perfect. Let's go to the next slide. I've got quite AAA couple of slides now on, on opio. Just not. So we'll go through them in turn. So this is just a reminder of the question. Um So it's the 52.5 patch. Ok. Um We'll come back to that what that means in a moment. Um In fact, no, we won't. We'll do that at the bottom of the slide. So the patches. No, sorry, go back on the for me patches for these numbers that come with them. Can we, can we go back home, please? Sorry. It's just taking a while to load. Oh no, that's fine. That's fine. II wasn't sure if, if it had crashed or not. Ok. So with fentaNYL and buprenorphine patches, they're written with like a number in, in, in little commas. OK? That means micrograms per hour. OK. So these patches you slap them on takes a a few hours for the levels to build up in the blood and, and take effect, but they are releasing that many micrograms per hour. OK? And they come in uh you know, patches that last for three days, seven days. Um not sure if there are other sort of lengths of days, but the number tells you what they're releasing in micrograms an hour. Ok. Um And we'll look at the BNF in a second but um basically the B NF tells you what that is equivalent to in morphine if taken orally. OK. So if we go to the next slide, um so at the very top in the right hand side, I've just um taken a little screenshot of the, there's a big table for b there's a buprenorphine table and a fentaNYL table. And this basically says um the weight of, in fact, oh, it's covered it up. Uh Have we not got my animations? OK. No worries guys. So underneath this, if you look on the B NF under pain relief, there should be a table for buprenorphine and a table for fentaNYL. And it says, well, each patch is equivalent to an oral morphine. I'm afraid we can't see it because it's not, not animated itself. OK? Um And it will tell you when you look at it, the 52.5 mcg an hour is equivalent to having 100 and 26 mg of oral morphine a day. OK? So now we have a total dose of equivalent morphine that we're having in the day. We can work out our breakthrough doses that we want to give. So we want to give a te between 1/10 to 1/6 of the overall 24 hour dose, which is any modified release and immediate release opioids they're taking. Um And we wanna give that every 2 to 4 hours. OK? Which you can see here in the bit that I've highlighted where I've screenshot it from the B NF. OK? Now, usually you would use a s an immediate release version of the same slow release background drug. So for example, immediate release morphine and um slow release morphine, slow release, oxyCODONE and, and immediate release oxyCODONE. However, fentaNYL, we don't give as an oral equivalent. Um So you have to use either morphine or if they're renally impaired use oxyCODONE. OK. That's how you sort of that. So that's the drug you use and that's how we're gonna figure it out. So if you go to the following slide, I've worked out the sort of the maths, the question answer, so to speak. Um And II also got um 21 as the sort of the highest dose we're giving them. Um in, in reality, um You'd, you'd write a range and I've suggested 10 to 20 is, is a sensible range. Um because you've got to think about what the tablet strengths are as well. Um I think if you put 12.6 to 21 a nurse would come and not be very impressed. Um But they will have a range of answers they allow as long as it's within a safe range. Ok. Um Let me just check in on the questions now. OK. So could you give sublingual buprenorphine for breakthrough pain? Um I believe that is not the sort of standard guidance. Um I'm not sure how fast that, so how long that would last in the body because it's quite a strong opioid. So I think that's why we, especially with like fentaNYL that would last a few seconds. Um And so it would be sort of pointless. Um So Maisie has asked a question that Lizzie has very helpfully answered. So it's prescribing inal care. Any question with opioids ple or like pain relief, please go to prescribing inal care and click on the management of pain. OK. It has all these beautiful tables in it and also little paragraphs explaining things like the calculation for breakthrough pain. OK. It is definitely my favorite one on, on the B NF. Um Would you prescribe as morphine or Oramorph? So you should prescribe uh as morphine sulfate. OK. Um And ideally you'd write like immediate release next to it, but I don't think the, the PSA exam lets you do that. Um Yeah, that, that's my answer to that. You then write that it's oral um et cetera. What do you mean by? Is there an option for P RN? So this, this is P RN. This is for breakthrough pain. Bye rather than saying 2 to 4 hourly. Oh, I see. Um So I can't you, you need to, you need to try out the, the PSA sort of um what am I trying to say? The PSA online version? Um It would usually be in a PRN drug chart. So that would be explained that it's PRN for pain or as required for pain. Um But it's really important when you're prescribing PRN drugs that you sort of say a frequency and a maximum, either number of doses or total dose so far for opioids. I tend to write six doses a day. Um, but for something like paracetamol, I'd write 4 g in 24 hours or if it's a, a little old lady that, um, that doesn't weigh much, I'd write 2 g in, in 24 hours. Um, so is your question in the PSA is there a drop down option for as required? Possibly? Um, um, so you'll have to, you'll have to try that out. Your uni will probably have passed papers um that you could sort of do to see how that works. Um OK. And then if we go to the next slide, which is a bit more opioids, um it's just some, some safety things always check um for renal impairment and if the EGFR is sort of trending down or it's, you know, below 30 or even below 45 you might want to consider oxyCODONE, um below sort of 10 is where you would consider a fentaNYL, but that would be a palliative sort of care team discussion. Um I wouldn't just do that on your own as an F one. Um The most common side effects are the sort of constipation and nausea. It's really important to prescribe a regular laxative and in any of your like prescription review questions, just remember constipation um is, is a big one um when you want to increase the dose um because they're having sort of several breakthrough pain doses a day. Um You need to not increase it by more than a third to a half of what they were having before in 24 hours. OK. And for all these calculations, the recommendation is that you convert them using the table that's in the prescribing palliative care summary and convert them all to their oral morphine equivalent. So if someone was taking um say 100 M GS of codeine, you would say right? So the equivalent is they are taking 10 mg of or a day, for example. So you'd add up any doses they're taking. Um and then dose increase by that by a third to a half. OK. But all the answers are in the BNF for the opioid questions, which is beautiful. Um Obviously it's the palliative palliative care section. So there is other things in palliative care other than pain management. If you keep scrolling down beyond pain, it tells you what to prescribe for many different other symptoms. Um things like nausea and cough, I think and et cetera. So it's worth familiarizing yourself with, with those things as well. Ok. Let me just see what questions people have got. Yeah. So use, use the practice papers on the official prescribing safety assessment to understand the format. Um It's very important. Um So how do we know the max dose ie six a day? Um So often if, if there is a maximum dose for uh for anything that the BNF suggests it. So cyclizine, you know, 100 and 50 mgs ideally max a day, paracetamol, 4 g a day. Um, generally for your, your opioids, your, your P RN opioids and your G medications. So you just in case medications when someone is dying, we, we say maximum six doses a day. Um, and in real life, that is also helpful cause it can help. It means the nurses flagged to us if the patients needing more so that we can go and reassess their symptoms. Ok. Someone's uh Evelyn lost connection. Um Yes, that would the, if you're increasing the dose, it, you would include um breakthrough pain if they are, if they are genuinely having it um and have been needing it regularly. Um Just be very sort of cautious not to overdose a patient. Ok? Um If we go on to the next slide, I promise we're nearly done with opioids. They're just a very important topic. Um and quite high yield for the PSA. Um So, um this is just another thing about sort of changing opioids, whether it's between different, different opioids or different routes. Um You always convert to oral morphine um in between to make sure that you don't make any mistakes. So you'd never be like, ah um I'm going to divide my codeine dose by 20 to get my oxyCODONE dose. Um We, we literally have charts in our hospital um that say, right? Convert to codeine to, to morphine, right? And then what do I want? How do I convert that to the oxyCODONE or the traMADol or whatever. OK. So write your, your sort of answers out in calculation questions and be very careful. Um If you are changing between routes that that's chill, if you're changing to a different opioid. Um for example, um oxyCODONE because they've got reduced renal function or because they are not really tolerating the morphine. Um You should consider reducing the dose you give by about 25 to 50% to avoid a sort of overdose during the switch period. This is because the different opioids, um especially when you think about the traMADol and stuff, they actually attach to different receptors and different people have different numbers of receptors in the body and you don't know how they're going to react. Um So if it's safe to do so and the patient isn't in sort of severe pain, reduce the dose as much as you can. If they're in lots of pain, you might only reduce it by like 15%. Um But it's, it's, it's very important that once you've done your calculations and you've worked out what you wanna give, just reduce it a little bit. OK? Um Yeah, I've put an example um in my, in my notes, but unless anyone wants me to go through that, I think it's, it's pretty, it's pretty clear from the, the BNF how you do all the conversions. Um If we go to the next slide, this is the last one on opioids. Oh I've put the example here. Perfect. OK. So say you've got a patient having oral codeine, they're taking 30 mg four times a day. So 100 and 20 total, I convert that to m oral morphine. So 12 mg reduce the dose. Um Here, I've gone for reducing it by a third. So because that made my maths easier. Um So I've gone to 8 mg, oral morphine equivalent per day. Um And then I've just converted that to Sub oxyCODONE. Um So overall, I know I want to give 4 mg. Um It's quite a low dose. Um I was just doing the example for the for the maths is that clear to anyone? Has anyone got any questions about opioids before we move on? So important one not to harm patients? OK. If everyone's happy, then I'm gonna hand over to Julie and she's going to do um her lovely fluid questions. Hello, everyone. Thanks for sticking with us. Um So we'll go on to question seven. So if everyone can just write down in the comments, what they, what fluid they prescribed for this patient who is nil by mouth following a stroke. A very real scenario during my weekend of uncles. Has anyone got any answers down to this question? Someone said 1 L saline plus 0.3% case potassium chloride 8 to 12 hourly. Anyone else think anything different pota sodium 1.5 L over 16 hours I've got to add potassium. That's OK. And yeah, everyone kind of saying the same thing. And if you go on to the next slide, we'll see the answer which most of you, most all of you are correct. So the answer would be pota um sodium chloride, 0.9% plus potassium. You'd want the 0.3% strength and you'd give about 100 mils IV infusion. And then the other thing that the question will ask you is about the frequency that you can give it over. So you can give that over 8 to 12 hours. And I just chose just 12 hours. But anything if you put anything between 8 to 12, that would also be completely correct. So if we move on to the next slide, I have a little slide on a maintenance fluid. So this is what the question was asking. This is a patient who's had a stroke and he's made nil by mouth. So he's not necessarily, these aren't resuscitation fluids. These aren't necessarily replacement fluids either. They are just maintenance to keep him nutritionally and electrolyte um replete whilst he's not by mouth until he has his N GT then. So the important thing with maintenance fluids and the, and the thing that you'll probably really need to revise um slash memorize when you're revising for the PSA is the table on the right hand side and that is your daily requirements. But I'll just quickly run through the kind of fluids that you need to know for your just for your fluids. Um So the first kind of type of fluid I'd remember is your sodium chloride, 0.9%. Um And this is um your most ge kind of just generic fluid. So in about 1000 mils of of sodium chloride, you'll get 100 and 50 millimoles of sodium and 100 and 50 millimoles of chloride. And then in your sodium chloride plus potassium and your potassium comes in two strengths. So you can get 0.3% or 15%. So that will contain the same amount of sodium chloride as I said above. But your 0.3% potassium will contain 40 millimoles of potassium and your 0.15 potassium will contain 20 mils of potassium. There is also a um what was I gonna say? I can't remember what I was going to say with that. But then the other, the other third type of fluid that you could give is glucose. So you'd give a 50.5% strength glucose for maintenance. And that in, in 1000 mils of that, you'll get about 50 g of glucose. And then you can give, there's also a 20% strength that comes in a smaller volume and that will give you 20 g. And that is for when you have um any hypoglycemic um situations that might occur. I can see there's a lot of comments, I'll just quickly on see if there's a, there is anything. Um So not sure if I had a said, I thought we were doing a whole day. So I did this. Not sure if I had the electrolytes correctly. 5% glucose with 0.3% K cl 1 L over two times two each eight hours and then 0.9% over. Ok. So you've done three bags over eight hours. Um I'll run through the kind of maintenance requirements. So the that I've put here on the side. So for some for so just so just for water, um each person needs roughly 25 to 30 mils per kilogram per 24 hours. Um sodium and potassium and also chloride, which I haven't put on the table, you need one millim per kilogram per 24 hours. And for glucose, you need roughly 50 to 100 g um every 24 hours. So that gives you the daily requirements in that last column. Uh And I think Hannah, I think that would also what you've put would also would also apply. So 5% glucose would give you about 50 g. Um Yeah, so I think so what you've prescribed there does meet the requirements, but realistically um for the nursing team as well, it would probably be easier to prescribe two bags over a longer period of time than it would be to prescribe three bags over eight hours each time. Um So as a general rule, um what you can give is one bag of salty, which is sodium chloride plus your 0.3% potassium over 8 to 12 hours. And then a second bag which is another liter um of sugary, which is your glucose plus potassium over the 8 to 12 hours. Uh Does anyone have any questions about that? Isn't giving? Oh no, someone's lead to that question. I thought elderly people should get less water though. Um So that is a very good point and that is when you're, that is more relevant when you're thinking about perhaps resuscitation fluids, when you're giving someone a lot of water, a lot of fluid very quickly. And we'll run through that in the next few slides. When I talk about resuscitation fluids. You're absolutely right. But when you're thinking about maintenance loads, you also want to, you definitely think about fluid overload and whether they have a history of heart failure. Um, but generally with maintenance fluids because you're giving it over such a long period of time, 8 to 12 hours, that risk of fluid overload is much less than with resuscitation fluids when you're giving it to them in like fif when you're giving them almost half a liter or a quarter of a liter in 15 to 30 minutes, I think actually ra daily requirement, there is a suggestion of 20 to 25 mils per kilogram per day. Um out of fluids. So, Hannah. Yeah, I think you, you might be right. Um, I'm not familiar with that guideline but um, in, in general, in practice, we don't necessarily prescribe different maintenance fluids for different ages. Or at least I don't, I don't know if Tesla, um, we usually prescribe the same level of fluids and then the most important thing that the PSA probably won't obviously ask you to do is the importance of carrying out fluid balance assessments before and after your bags of IV fluid. Um So you need to assess your patient after each bag of fluid and see if they're showing any signs of fluid overload or any signs of fluid depletion. So, some classic signs of fluid overload are um pitting edema crepitations. Um when you listen to their lungs and some signs of fluid depletion are reduced, skin, tiger dry mucous membranes. So, taking a look inside their mouth, um their legs and their tongue fine. OK. So I'll move on to the next question and this was a question about a crash called. So does anyone have any ideas what they were prescribed for this question? So, Divina, you put with 0.18 sodium chloride work as well. Um II don't see why it wouldn't if you gave it over the correct, if you gave the correct volume over the corre through the correct time, but it really is just uh I think if you prescribe 0.18 saline and the nurses would probably come back to you and say prescribe 0.9 because that is just the standard. Thanks. So would we use two of the 0.3% saline? Yeah, you would cause you want to give them 40 millimoles of potassium, not sorry, 4080. Does anyone have any answers for this question? So someone's put uh iron glu on 1 mg once daily, Lizzie's put Bucco 1.5 cheap glucose gel. Omar and Laura have put IV glucose and a range of answers there any more. Fine. So we'll move on to the next question. So I put glucose 20% 100 mils IV over 20 minutes. So in a hypoglycemic patient, you want each, they should be a patient should be receiving about 15 to 20 g of glucose. So if we go back to what we spoke about in the calculation section, 1% an an an infusion volume of 1% means 1 g in 100 mils. So a 20% bag of glucose gives you 20 g of glucose in 100 mils. So that bag, that infusion volume instantly has that target of 15 to 20 g of glucose in an episode of hypoglycemia. If you were to give a 10% bag of glucose, they'd get about, the patient would receive 10 g in 100 mils. So you'd need to give about 100 and 50 to 200 mils of 10% glucose to give the whole dose of, of glucose that you want to give. Either. Either answer is correct. Um, I just chose 20% because that is, I think what more people tend to give. But in the PSA either question would be correct. As long as you make sure you give them that full dose of fif it, give them at least 15 to 20 g of glucose in the, um, in that bag. And I chose um to give them IV glucose because in the vignettes, they have collapsed. So I'm assuming that they are not awake enough for to be able to give them a glass of orange juice or something like that or to give them um gluco gel, like some of you suggested. And if we go on to the next slide, Vicky, I'll just run through the hypoglycemia guidelines. So there is a treatment summary on the BNF very helpfully um for hypoglycemia. And unlike some of the things that we've spoken about previously in the presentation, this is actually quite here. Um So the guidance is if the patient is conscious and able to eat, give them uh a sugar rich snack. So that's something like orange juice biscuits some anything that will give them about 10 to 20 g of glucose or you can give them some Gluco gel with the same kind of volume um if they're not unconscious. So if they've collapsed or you feel like they're unable to eat. So that includes if they're drowsy or vomiting, um, you need to give them something that is not oral. So if they've not got IV access, you want to give them Im Glucagon. And in most hospital settings, it's very unlikely that they won't have IV access already or that it won't be easy to give to, uh, insert IV access. Um, the most ideal option if they're unconscious and hypoglycemic is IV because UN that's just straight in the vein, you know, you've given it to them. Um So if in the vignette, it says that they have IV access, I would always prescribe it as um the IV glucose rather than Glucagon first. Um So in this case, like I mentioned before, you can either give them 10% or 20% glucose with 20%. You can give them just 100 mils of it with a 10% glucose. You need to give about 100 and 50 to 200 mils for them to reach their full um that give them the full amount of glucose that they need to wake them back up. Uh Remember to not ever prescribe, well, at least not for the PSA at least 50% glucose. It's basically like in like injecting trecal into their veins and it is very high risk of extravasation. So definitely don't do that. And um helpful tip for real life rather than the PSA is that after you've given someone hyper hypoglycemic um treatment after an episode, there might be some rebound, um high high glucose readings, but you don't necessarily need to treat that as they'll probably naturally kind of their glucose. Their blood sugars will naturally start to settle. Obviously, unless that's a DK A, then you need to be managing that. But this is just for a normal hypo hypoglycemia. Um Here's some, see, some questions. So we said due to the decreased consciousness, I think it's so they respond to always sort of being alert. I chose the Iron Glucagon. Would this get less marks than the fluid option in this context? Um I completely understand your, your reasoning there. Definitely. So decrease consciousness, you didn't choose the or you went for the Im Glucagon. Um I think it would be more appropriate to give them the IV. Um Like I said IV access is the, is the most ideal. And I think Im Glucagon is more for in a com is more appropriate for a community setting or if there or if there really is no IV access or no possibility to get IV access. So I think in a first line, decrease consciousness, give them um IV glucose and any other questions? Oh, no worries. OK. Brilliant. Um So if we're all happy with the hypoglycemia question, we can move on to question nine. And this was about a lady that you were asked to see because she was responsive, but drowsy and felt lightheaded. Anyone put anything down. No, 250 Ml Saline, over 10 minutes. Lovely. Anyone got anything different? 250 someone said stop, someone said over 15 minutes would be nice range of answers. Um So we'll move on to the next slide if that's OK, Vicky. So here everyone got the, the type of fluid, right? Um And so it's Saline, 0.9% which is the classic, um the standard uh type of fluid you give for resuscitation. And I've chosen a volume of 250 mils. And that's because I have put that, this lady is 85 years old, which I haven't included a past medical history of, of heart failure or anything like that. That would be a contraindication, but just purely going off of her age. Um 250 MS would be more appropriate as she is vulnerable um of, of to be fluid overloaded if you give 500 mils and it can be given over a volume of stat to a range of 30 minutes. Um I've just chosen 30 minutes. Um I think in the vignette itself it doesn't sound so urgent as to need a stat, but that's just a kind of clinical reasoning. Um kind of kind of thing. I don't necessarily, I don't think you'd be marked down for giving stat, but anything between 10 to 30 minutes sounds sounds appropriate. Um It doesn't sound like an emergency crash situation where you'd need to be squeezing the bag into her. She's just a little old lady with, with an infection and her BP has just gone down a little bit. So, did that question make sense? Oh And Hanna, I don't think PSA accepts stat for fluid duration. Um So there you go. So maybe you can't give stat. Actually, II wasn't aware of that but anything between 10 to 30 minutes I would think is very, is, is absolutely fine uh to give. And if you move on to the next slide, I've just got a little slide of fluid resuscitation. So, fluid resuscitation, I'm sure as many of you know, is just all about reversing the signs of shock. So it would involve uh doing an urgent assessment, which I will assume that you have done for this question in terms of this one yet. So the signs of shock can be hypertension. So a systolic below 90 someone who's tachycardic uh tachypneic or a capillary refill time more than two seconds. So if you get any of those signs in your on examination um section in your, in your vignette, then you can assume that they're in some sort of hemodynamic instability alongside if they give you something um a piece of information like they're being treated for an infection. Um then that's also more likely that they're in some sort of um instability as well. And the type of fluids that we give again, have gone through, you can give 500 ml of Saline or Heart MS. But I think Saline is more standard over 15 to 30 minutes and you want to give a smaller volume of 250 mils in patients at risk of fluid overload. So that's if they've got a history of heart failure, um, or renal failure or um if they're particularly elder elderly, I put my mark of elderly at like 65 which is maybe a bit, you know, I think that's quite, it is quite dependent and I think frailty has an element to do with it as well. But if you, if you give someone young, younger than 65 500 mils, I think it would generally be ok if they don't have a past medical history that um would suggest otherwise. And the most important thing realistically, a real life situation about giving bonuses is that you want to reassess after each bolus. So you want to see if giving each bonus has affected their BP or that or any signs of shock that they were displaying beforehand, if you get to 2 L of boluses and they're still not responding. Um That's when you want to uh coil Mered or speak to someone more senior. Uh just have a quick look through the chart. See if there's any questions and Tessa said I always got 15 minutes. Um Something like less than 20. 0, whoops, sorry, apologies. If that is the guidelines, I've always done it over 3015 to 2030 minutes. But um I would double check that with your, with your guidelines with the B NF. Um and just see what, what, how long of resusci guidelines, um resuscitation fluids you need to give. Fine. Does anyone have any other questions? Apologies if there's any discrepancies between guidelines? No, let me move on to the next slide which is just a quick little. Um Can we move on to the next slide? Oh, it's just loading. No, that's OK. Thank you. Um So this is just a, an algorithm that nice has um very kindly given us this. I is not in the B NF. So do not think that this will be in the VNF. Um But this is just a, a kind of something for you to arise and look over um unless it is in the B NF. No, I don't think so. Um about, it's just about IV fluid therapy. So it goes through resuscitation and replacement and maintenance and it's a good little thing to revise and look over and kind of summarizes everything quite nicely. So we'll move on uh to more IV fluids cause he doesn't love them. Um I'm just gonna quickly go through pediatric IV fluids. So funnily enough, I didn't realize pediatric IV fluids were in the PSA. So when it was my turn to the PSA I never ever revised for it and then when the question actually came up in my PSA, I was really, really confused. Um and quite shocked. So don't be me and you're not going to me because you're gonna know that this is in the, this might come up in the PSA. So pediatric fluids, the PSA will, if it decides to test you on, it will most likely go through a maintenance fluid question or a resuscitation, fluid question. Um, replacement of pediatric fluids is a little bit um more complicated. Um But II cover that in the slides as well. So this slide here, I've gone through fluids for a child that is older than 28 days. This is just for the sake of time. Um But it's important to know that maintenance requirements for Children younger than this would be different. So the normal fluid that you would give uh for maintenance is sodium for 0.9% and glucose 5% for a child and that is over 8 to 12 hours. And the volume that you give depends on depends on their weight. So for the 1st 10 s of a child's weight, you calculate the fluid that they need at 100 mga 100 mils per kilogram per day. For, for anything between 10 to 20 you give them 50 mg, 50 mL of, of per kilogram per day. And if it's over 20 you give them 20 mils per kilogram per day. So by that, if that wasn't explanatory what that means is for. So for a 15 kg child, you calculate their 1st 10 kg at 100 mL per kilogram. So that would be 1000 mL and then for their next 5 kg because they're 15 kg, you calculate that as 50 mils times five per day. So that would give you 250 mils and then you give the and then you add those two together. So you add 1000 mils and 250 mils together. And that gives you a total maintenance fluid for over the whole 24 hours of 1250 mils. Over 24 hours. You don't want it depending on their weight. Um You don't want to give um a male child more than 2.5 L or a female child, anything more than 2 L. And I've just put on the right a um the guidelines from the Whittington Hospital, which isn't even where I work, but it just had really nice guidelines that I found that I thought were quite clear. Uh Does anyone have any questions about that? Uh OK. And then if you go on to the next slide, I'll quickly go on to resuscitation or replacement. So, resuscitation, same as adults you want to give them. So sodium chloride, 0.9% for ap for a pediatric patient. Um the volume that they, that you give depends on their weight. Once again, So with Children, basically everything depends on their weight. Um And so if you get any kind of question with a pediatric patient, just always, you know, make a note of um make a note of that weight cause it will probably be relevant to the question. Um So you'd calculate the volume that you give by calculating 10 milli 10 mL per kilogram and you give that over 10 minutes um replacement I won't go through in too much detail, but it is on the slide and I don't really think the psa will go through it, but replacement is a bit trickier. It does involve a little bit of calculation. The type of fluid that you would give is sodium chloride and glucose 5%. But for replacement, you need to calculate a child's percentage dehydration. And for that, you need to know how their weight when they were well and their current weight. Um and then you calculate the percentage of that and then using that and you calculate their fluid deficit and which is all on the screen for you. And then you then calculate their total fluid replacement by um removing that fluid def no, by adding their fluid deficit and their maintenance fluid volume. I've put a worked example on the right hand side for you to look at in your own time when you get the slides. Um I appreciate that we're 45 minutes over the over the time. So I won't go through at this moment and we'll go on to the next question, which is the last question. So this was a question about asthma. If anyone has any questions about fluids, please feel free to put them on the chart. Um Apologies if it feels like I'm rushing through this. So any questions for the 25 year old university student complaining of shortness of breath? So A R per petone 400 mcg twice a day. Anyone else think anything different or agree? No. OK. We'll move on to the onto the on slide in that case. So, yeah, absolutely. Right. Uh Blome FS BD. And so this is very easily found in the asthma chronic treatment summary. If you find that treatment summary and then control FF because remember control F is your best friend and quickly type in adult if you really can't be able to just scroll down, um you'll be able to see the um BNF summary, that kind of explains that very succinctly and I've just put on the right hand side, the um what the beclomethasone monograph looks like on the BNF and it um suggest prophylaxis prophylaxis of asthma 400 mcg twice daily. I just went for the upper the upper range. But you if you prescribed anything between 200 to 400 it would also still be um still be correct. So if you move on to the next slide, I've got a little summary of adult chronic asthma. Um So the BNF treatment summary for Asthma offers both nice and BT S guidelines uh which can be a bit confusing, I personally think and I it, it's true that the PPS A will won't penalize you if you choose to follow either, either guidelines. So if you choose to follow the nice guidelines or the BT S guidelines, both are on the BNF for you to use and to follow whatever you choose. Just make sure that for each step you're following the same guidelines. So don't follow nice step one and then BT S step two, stick to the same guidelines and practice and revise using one or the other. Don't on the day of the PSA start using um start for some reason, reading the BT S guidelines when you were doing revision, using the nice guidelines just for consistency and just to kind of avoid any um any easy mistakes. And I've just put down so on this ladder, I've used nice guidelines just because that's what's most familiar to me and like, um so I've just put down a step, step wise ladder of, of chronic asthma. So with this patient in the vignette, he was on Salam, which is salbutamol A Saba and he was showing signs of um nighttime kind of uh breathlessness and more regular use of his Thalamo inhaler. And those would be both indications to start a low dose, inhaled corticosteroid in BT S guidelines also suggest that if a patient's had an asthma attack in the last two years, that would also be an indication to start uh a steroid if they don't have one already. And on the left hand side, I've put just some, um, kind of generic and trade names for common asthma drugs. So I've put, I put in the vignette Salol as in his kind of medication history and not salbutamol. And that's because I think sometimes they like to kind of keep you, keep you on your toes and give you the, give you the trade names. So Salbutamol um can come in Salol easy inhaler or Ventolin, that clomesone can be called Kny or Soro. Um And that clot with four for me le back. Um So you, if you, if you type in, if you don't know what they mean, um just type it into BNF almost always, they will say they will have their trade um the trade names associated with the generic names. So you can always type it in. Um Yes and just double check. I think this is one of those questions where I personally get a bit confused because I do think that the asthma, the asthma guidelines are a little bit confusing with what to add when. So definitely get up the treatment summary as soon as you see an asthma question and then you can just follow the guide um follow the steps as you go. Does anyone have any questions about that. No, lovely. Um So that is all of the questions and all of the answers done. Uh Thank you everyone for coming. I think we've resent the feedback form for you guys to fill out. Um And that will mean that you can get slides available to you as well. And remember that this is the second of our four part PSA series. So we will be doing another session next Thursday and that will be on prescription review and then we'll be doing another session the week after that and that will be on everything else in the PSA and we'll be at the same time, same link and if you move on to our next skip a few slides, Vicky. Yeah. And then one after, yeah. Um and if you follow us on our social media, you can see all of our events and um keep up to date if there's any kind of event changes or anything like that. If you have any questions, please ask us on the chat now or email us on the email address on the screen or Facebook us, Instagram us, you know, anything, any form of contact tiktok Us if you want, I don't know how you would do that. But um thank you everyone for coming.