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Hi, everyone. Thanks for joining us today for the third, um, the third presentation in our PSA series. Uh My name is Anna, I'm NF one working at Manchester Royal Infirmary. And yeah, just doing this with Med Tech. Um, be sure to follow us on our socials. Uh We'll be doing other series as well. Like we had a final series last year that was really popular. Um, but yeah, thanks everyone for joining us. Um, can I have the next slide, please? Yeah, that's just us. Um, we're a teaching group run by F ones. We're sort of all over the country. So I work at the Royal and Manchester. Um, and this is the third out of the fourth um, session that we're doing on the PSA. And, um, in this one, we'll cover the prescription review section of the PSA. So if you go to the next slide please, and that's it there. So it's usually the second section. Um, oh, second section of the uh exam. It's worth about 16% 32 marks of the total um, paper. And I always thought it's a reasonably, I wouldn't say easy because it's just like an annoying exam, but one of the easier ways to get um marks on the PSA, so I just want to go through it with you guys. I've got some practice questions um and give you some tips on how to get uh to search through the BNF probably for interactions and things. Um So it's, it's 32 marks. So that would leave you about 20 minutes for the whole section or 2.5 minutes per question. And I always thought that it's ridiculous of how time pressured the PSA is. I thought like there's actually no chance in real life that you would have to review a prescription chart in 2.5 minutes. But to be honest, working as a doctor, now, I realize things are actually quite that time pressured, not saying that you would have to do like 20 prescriptions all at once. But um it is, it is quite time pressured. So it is, it is kind of useful. I hate to admit it. But next slide please. Um Yeah, so what's the point of this section? Well, the first point is, yeah, people change. So especially when people are admitted to hospital, they're coming with a different clinical presentation and therefore you need to be reviewing the medication because it could always be contributing to whatever they've come in with. Um And therefore we just need to be doing constant medication review and you know, with our aging population, many people are on a lot of different kinds of medications which increases your risk for interactions and things like that. So that's really the point of it. Um, yeah, this is like a table from an equip study in 2009, which was the most frequent type of prescription errors. Um, and thank God for pharmacists in the hospital because they check everything that you do, which is really good. Um, because I can't imagine the state of the NHS without pharmacists. Um But yeah, you can see a mission on admission, underdosing and overdosing or things like that. Um Cool. The next slide, please. Great. And this is an example of what a prescription review uh question will look like. Um Can everyone read that? Ok, because a lot of the um upcoming questions will look like that. So if someone could just ping A yeah, in the chart, it's clear enough to read if anyone great, brilliant. So you'll see a few things you can see up there. It says it's worth four marks. That's usually two marks for question A and then two marks for question B. So I'll go through some things that you should really pay attention to. So the first thing is the case presentation which will usually have the age um the sex and the symptoms of the patient and they could all be clues as to what's happening. Oh, your answer, I mean, it wasn't a practice question. Uh We could we could see if that's right. Um, but I'll just go through, um, the different parts. So that's our case presentation. Past medical history is always a good shout because it gives you clues as to what medications could be potentially being prescribed, which I always find helpful because you'll inevitably recognize some prescriptions that are in the prescription review. But for example, if you're like, oh, I'm not really sure what d do is you can always look at the past medical history, which will give you a clue as to what kind of class of drugs it's going to be in. Um, other things on examination. So you should always be checking observations because, um, some drugs can cause things like hypertension, brady, bradycardia as well. Um, and that, that'll give you clues too and then investigations also really important electrolyte abnormalities bound to come up 100%. Um, things like cytopenias, hb dropping acute kidney injury, they could all come up and be under the investigations too. Um, and perfect. So the other thing is, and this is really silly, but I'm sure I probably lost a mark because I just didn't read it properly when it says like two prescriptions. So you just make sure you, you're taking the amount of things it's asking you to. So for a, you'll need to be doing, um, the prescriptions where I put my laptop in, um, and B2 as well. Great. Um, in terms of what could come up, it could be things like dosing errors. So another thing you should really be checking is not only the dose but the frequency because the dose might be right. But if you're taking it like amLODIPine and it's written twice daily though, that's not correct. Um So just pay particular attention to that as well, the route as well, but they're less likely to catch you up with a route. It's most likely gonna be a dose and a frequency thing. Cool. Next slide, please. Yeah, so I've just listed some things that are likely to come up in the prescription view section. So drug interactions. So we'll go through how we're going to check for interactions during prescription review. And my friend Vicky is going to go through that as well um on how to check it on medicines complete because she's more familiar with that. Um Obviously serious dosing errors, suboptimal prescription. So things like prescribing senna in the morning of the night, obviously not great for an obvious reason. Um and drug contraindications and common drugs which cause causes side effects too great. Next slide, please. So I want everyone if you can to just take a minute, find this page on the BNF. So if you just type in BN F um and appendix one, it used to be in the paper B NF. Now, I don't know, someone said last week that you're not allowed to use the paper B NF in the pa and I've honestly not got an answer for that or if anyone else knows if you are allowed to use a paper BNF because this is a page that wasn't on the electronic B NF last year, but it is now. Um So if everyone could please like bring up this page, um it gives you a really good a review of like which common drugs cause hypernatremia, which common drugs cause hepatotoxicity, nephrotoxicity. Um Which drugs have an anticoagulant effect? Um And which drugs cause hypertension. Um Has anyone heard of this sort of page? Oh Brilliant. Someone's posted it in the chat. Great. Yeah, just have a little click come back. II really want people to stick it in and it's really great. And then once you, once you get onto interactions, you just control f for example, if the questions is asking you which two prescriptions cause hypernatremia control f type in hypernatremia and then a whole list of drugs that cause hypernatremia will come up. Um which is one way to do it. And obviously it's not an exhaustive list. It's the most common drugs that will cause hypernatremia, but they should only really be testing you on um the most common drugs that would cause hypernatremia, not like random ones that like rare, like one in a million chance. Um So that being said I have read through the BPS and they're learning objectives for the PSA they do say like a basic prescribing knowledge and awareness is expected. That wouldn't necessarily mean that all the information is in the BNF that you would need to know for the PSA. But that being said, I think like 95% of the information that you need for the PSA is on the BNF, there's just going to be one or two questions. So if you just press the control and the F button now, I mean, I don't know if you're on a laptop, it should come up with a little search bar in the corner and then if you're on an apple, there would be command F um But I assume everyone's going to be taking this um test like at Uni with Windows computers. So once you've pressed the control button and the F button on your keyboard, it will just come up with a little search bar and you can type whatever and it will highlight all the words on that page that contain the word hyponatremia for example. And you'll be able to like um s go for. Does that make sense? Um We can go through the next slide though? I hope everyone's found that. Ok. Um And then, yeah, Vicky, you'll just talk us through. Hi. Yeah, my name is Vicky, not, not William. Um I'm part of the um med committee as well. I'm just coming on literally just briefly for this slide as I found this. So, so helpful um for this section just because I think the thing with this section is, it's not actually, you know, I don't think it's like the trickiest section but I think what is tricky is that there's so many drugs to, like, um, check and to see if they're interacting that it's quite hard to do under, um, the time pressure. So I think what's really useful about medicines complete is that, um, you can type in all the drugs in the list. And so I don't have access to medicines complete anymore. I used to have it when I was pra practicing for the PSA but your uni should give you, um, oh, apparently you can't use. Ok. Well, ok, if you are then it was honestly so helpful and I did use it. Um, but really sorry if you can't use it if that's the case. Um, yeah, so use it if you can use it because you can just type in all the drugs there and it gives you like all the interactions between the drugs and it's very, very handy all in all in one go. Otherwise, um, you can, you should be able to have access to medicines completely for, for the PSA exam. Um, it's a bit strange that your uni didn't give you access to it cos it's, it's an option to use in the, um, the PSA exam. Um, but yeah, so basically use it if you can, um, if not, the BNF does have an interactions checker, it's just a lot slower. So you have to, you have to um click on the like one drug that you want, go on to the interaction page and you have to probably control f to find the other drugs that interact with it. So you can't put it all into the same search bar if that makes sense, which is, is obviously a lot quicker if you can do that on medicines complete in real life. When you have the B NF, the app is great. You can actually do this exact same thing on the app. It's just not on the computer version for some reason, I've not found a way to do it on the computer with the B NF so far as like it is and medicines complete. Um, ok, I've got a question here once you type in all the drug names, which you, you just literally just click search like I think, sorry, the in the screenshot there. Um, ok. I'm really sorry if you're not able to use it. But anyway, if, if you are, I found it quite helpful, but I'll, I'll stop confusing everyone, ma'am. I don't know if you, because you're sharing right now, would you be able to share a window with, with the appendix one from the BNF on it? Just so we can have a sc go through it as a group? Um, just to show how useful it is if you're able, I mean, if you're not just that's fine as well. I can try to do it at the end of the presentation. Um, with me. Yeah, that's fine. Um, obviously the other way to check for interactions is just typing and I'll give you, I'll give you clues throughout the presentation as to which drugs you should really be checking which drugs should give you. Alarm bells as well when you see them on the prescription chart because some drugs are what we call dirty drugs and have the highest risk of interacting with the drugs. And there's obviously like enzyme inducers and inhibitors, which I'll go over to um which might contribute to that. Um If you could just get the appendix one interactions page, the one that you just posted in the chat, so we can just give a scroll so that people can see how that works and that would be really useful. Perfect. Great. Yeah, so just scroll all the way down the first bit is really not that interesting. Um But then it gets into these drugs that can cause hepatotoxicity, it'll say keep scrolling. Um nephrotoxicity anticoagulant effects and honestly, it's good revision material as well. So if you want to get familiar with these tables, you can as well before you sit the PSA um and then I don't know if you're able to do the control f maybe so people can see what that looks like. Yeah, perfect. So I assume you're like MEMS just type clopidogrel. So every time clopidogrel is on the page he'll be able to scroll through each instance. So we can see it has an antiplatelet effect. Um, if he got to the next one maybe, or down, what else does it do? Oh, well, we know what all the clock drugs do. Oh, well, there we go. It only, it has an antiplatelet effect which maybe we all knew because it's an antiplatelet drug, but it's still really useful. How would you find that page on BNF? Literally just type in appendix one and it should be the first page that comes up. Is that ok? Cool. Shall we go back to the slide? So it's question time. So I'm going to give everyone 2.5 minutes per question like you would get in the exam, just make sure you write down your answers. We've not got a pile function, which is a bit annoying, but go grab some paper and a pen or you can just do it on your notes app on your phone, however you want to do it, I'll give everyone a minute and then we can just get into the questions if that sounds good. And what I'll do is, um can you just search into Google? No, the only thing you're allowed to um have access to during the PSA is the BNF or Meds complete. Um So that's why it's so useful to know how to use the BNF and be aware of these useful pages within the BNF. Um If you scroll up in the chat, we've listed a really good list of important pages in the BNF as well. Sorry. Whilst I'm giving this preamble, everyone, please continue to find a pen and paper. Um and we can grab that and share it. Um And I also will share all the resources at the end of the presentation. What I found useful to revise for this exam too. So, is everyone ready to go? Oh, how do you search for appendix one in the actual exam? So they'll let you open up the BNF during the exam and there'll be invigilators and you can just type in appendix one at the top of the BNF. Correct, right. Shall we get started? Then I'm going to put the timer on the clock and then ma'am, I'll just let you know when to move on to the next question. If that's OK. Yes, you can, you can check interactions on the BNF too that under each drug monograph, there will be a section for interactions. Cool. Let's, I mean, I'll explain it as well when we go through all these questions at the end. So shall we go onto the first question? Next question, please. Next question please. Next question, please. Question please. And our final question and that's our time. I'll give everyone a minute to recover from that, take a deep breath in. Um And then we'll just move on to the answers and I'll, I'll give everyone a minute. How did we find that? It's time pressure, isn't it? There's so many prescriptions, especially some of the questions. There's some, some more prescriptions and some have less, but it is really time pressured. So I'll go through some tips as well as to how I tackle the questions. Um, it is really an exam about exam technique more than anything. Um, obviously it's helpful to know um you know, the knowledge behind it just to be familiar. So you spend less time looking things up as well. And that's why when I explain the answer is I'll go through the pharmacology of it a little bit just so we are aware of why the interactions happen. And I always find that once you've explained it, it's easier to remember things like that as well. So let's move on. Let's let's go to the answers then next slide, please. Yeah, I want to start with number one. Ok. So let's read the questions together, shall we? So it says select the two prescriptions. I, this is what I do. I, the first thing I'll do is read what the questions are asking me. So select two prescriptions are most likely to be contributing to hematemesis. So we've got someone with hematemesis, we can see quickly, we can read off you 72. Um He's had two episodes in the last month. He's got a previous relevant medical history of peptic ulcer disease and af so that should already be alarm bells. He's probably going to be on an anticoagulant for af, so that's going to be your first alarm bowel. And what's the next one? So like the one prescription that contains a serious dosing error. So, you know, you'll have to be on the ball with the dosing and the frequency. So, should we get some answers in the chat? What we think the answers are before we reveal someone? Be brave, put something in the chat, anything goes, I mean, the whole point we're all learning. So there's no judgment in the child at all. They've got interesting. So we are agreeing on the warfarin for sure. Um Shall we and B have we got anything for B as well? The one with the dosing error, I feel like I was a bit mean with this question, I'm not gonna lie but the thing out but OK, let's reveal the answer. So yes, it, it is salbutamol. I'll explain it in a bit. So the answer to your question A is sertraline and Warfarin. And the reason for that is they both can put you at risk for bleeding. So when combined together, you've got an even more increased risk of bleeding. So I've got some um some people have said omeprazole as well. Omeprazole generally is doing the thing that's preventing you from bleeding because it reduces the acid secretion from your stomach. So um that's for the peptic ulcer disease. I can see why it's like you've associated with the peptic ulcer disease and maybe that's why, um, we've put that, um, I will and the salbutamol is because it says Q Ds and not QD spr N isn't um, four times a day as needed because from this prescription, it looks like he should be taking the salbutamol inhaler regardless of his symptoms four times a day, which would precipitate you to probably hyperkalemia and probably would also cause you to be probably tachycardic as well throughout the day. So your blue inhaler, albuterol inhaler should only be used as a reliever inhaler. So when you've got symptoms, um so should we, should we just press next and then I can show you on the BNF. Um how I found this. So the first thing is if we actually would you mind just going back a slide, I just want to explain how I would comb through this prescription list about which drugs I want to check. So Cocodamol, is it a shout? Because we know opiates are kind of iffy drugs. So I'm sure if you type in Cocodamol, it probably shows it doesn't increase your bleeding risk. Um So that could be one you check in the back of your head. Um Warfarin just always check Warfarin. It's just a terrible drug it interacts with honestly. Absolutely everything. So I would always be checking Warfarin and generally check any CNS drug. So that includes sertraline, obviously. Um it's a drug that acts on your neuroreceptors and is likely to cause all sorts of things as well. So that's how we would wean that out from the question. So I've said, OK, I think probably Warfarin is probably going to be something that I need to check. So if we press next. Yeah, so we're on, we've typed in Warfarin on the drug monograph. Warfarin's come up on the BNF and then under Warfarin it'll have interactions. You can just click on interactions and then under interactions, it will be click here to see all the interactions that Warfarin has and then you'll get this little box and then you can just type in quickly as fast as you can really um which drug that you think is causing the problem. So you can see that both of these concurrent use may increase the risk of developing this effect of anticoagulation. I hope that makes sense. Um Yeah, great. That is question one done. So if we move on to question two and this one was about renal impairment and hyperglycemia, both questions have come up on all these practice. Questions that I was doing that are put out by the British Pharmacological Society. So these are symptoms that usually come up on the prescription review. So have we got answers for a, first of all in the trap? This one is a bit, a bit tricky. This one, I think, I think B is OK. A is a bit A is a bit tricky. So we've lost the slide. So you've got one taker for Metformin and colchicine. OK. OK. Were we less sure about this question? Maybe another Met Metformin and colchicine? I think we lost the slides again. OK. We one question to and do we know what colchicine is for? Does anyone know what we use that for? What? From his past medical? Oh, really? Me answers. OK. Yeah. Perfect. Stop. Great gout. Yeah. So acute flare of gout is what colchicine is used for. So this, that suggests this man is currently having an acute flare of his gout um fine. Um And then b any any anything for b lots of gout. I love it. Prescription contributing to hypoglycemia. Fabulous. You've got little endocrinologists in the chart. Love to see it. OK. Shall we review the answers? So I can completely see why you would put Metformin for this answer because it's always a drug that you hear about to stop in AK and it's one of the damn drugs, isn't it? So, but the reason we stop it in AK is not because it usually causes renal injury. It's because it contributes to lactic acidosis, which can worsen AKI, especially when someone's unwell. And that's the reason why we stop it. So the actual answer is Clarithromycin and colchicine. And um the reason is if we go to the next slide, next slide, please, Clarithromycin is what we call an enzyme inducer. So we've got the cyp three, a four enzyme in our body. And that is responsible that enzyme is responsible for the metabolites of 50% of all medications. So, it's a very important enzyme system and some drugs are either inducers or inhibitors of the drug. So that means they can, if the drug is metabolized by cyp three A four, as it's a substrate of that enzyme, um, it can either be rapidly broken down by an inducer or it could either stay in the body for way too long, which would be an inhibitor. And Macs as in Clarithromycin, very famously an enzyme inducer. And I will go through at the end which ones are inducers and which ones are inhibitors. But I think the main thing is if you get familiar of the drugs that are either enzyme inducers or inhibitors, you know, they're the problem drugs and they're the ones you need to be looking up in the exam and that just cuts away all the nonsense. Like you don't have to be looking through every drug. Now, you know that, that, oh, I remember seeing that on some lists somewhere that's probably the drug that's causing the issue. So the reason it's Clarithromycin is because it's an inducer. Um, it rapidly accumulates the um metabolite products of colchicine and that's what contributes to the renal impairment if that makes sense. So we can see that this side effects is from the colchicine drug monograph on the BN F and you can see it can cause kidney injury and renal impairment and especially in people with already have renal impairment. And I'm sure that I put in the case that the guy had CKD stage two, so he'd be more prone to that side effect. I hope that makes sense. Um And then, yeah, you can just go on the interactions check and you can see that colchicine and Clarithromycin interact too great. If we can move on, please. Next slide. Yeah. And then this one. So I'm really glad to see no one put Metformin in. So we've got some antidiabetic drugs which do cause hyperglycemia and some of that don't. And famously Suen ias like Gliz, I do cause hyperglycemia. And that's because um they increase insulin secretion. So any antidiabetic drug that increases insulin secretion is going to cause hyperglycemia. So that's why glycoside is. And then obviously insulin, glargine is a long acting insulin, which can also cause hyperglycemia. Great, thanks. Can I get the next slide? So this would actually be a turmeric question. I just honestly couldn't really think of a second question that could go along with this. So that's why it's turmeric. So I thought, let's, let's give a little break in the middle of the question. So what do we think? What did we get for this? One, two prescriptions that have precipitated this for anything that we noticed on the um examination as well that stands out from the obs, lots of Atenolol. Atenolol and, um, Wrapper Mills. Yes. Yes. It's def she's definitely bad, isn't she? Is there anything else that you might expect from this patient? Fabulous monas on it. She's saying heart block and hypertension. Yeah. We, we would, we would probably expect hypertension. Shall we, should we press next? So, yeah. Great. It is a Tenolol verapamil. That's because when they're coadminister, they will be negatively inotropic Coron, it will just send your BP right down to your boots. It will slow your heart rate right the way down. It will have an effect on the AVN Ner as well. So will result in complete heart block. Usually I'm seeing Lysin, II mean, I don't think that there is an interaction between them but I will double check. Now. Um do we know why we're using Dapagliflozin in this lady? I mean, I haven't put that she's got diabetes. So Dapagliflozin has started to be used in congestive heart failure. That's because you can think that. So um Dapagliflozin is an SGLT two inhibitor. So what it does, it means that you just basically pee out all your glucose which results in a lower HBA1C and lower general low glucose. But because obviously glucose is leaving the blood into the collecting system, water will follow by osmosis. So that means you're offloading a lot of urine. It works as a diuretic basically. So it can be really helpful and usually they say diuretics aren't. Um Oh, what's the word? They don't improve mortality? But I think SG LTT S actually have been proven to contribute to lessening mortality in those with heart failure. Ok. Yeah, perfect. Thanks for looking at that. Hannah. Um Yeah, and the thing with these questions is always most likely, isn't it? So it could be a right answer, but it's always going to be the most likely. And beta blockers and calcium channel blockers is always probably something that's going to come up. Should we press next? Yeah. Thank you. Great. Yeah. And then we can see and the interactions but we can see increases the risk of cardiovascular adverse effects when giving with atenolol. And that's especially true for people with existing heart conditions like that lady with congestive heart failure. Great. Yeah, risk of bradycardia hypertension. Perfect. And if you go onto the appendix, one, there, there is a section for hypertension. It will have drugs that cause hypertension and those drugs will come up too. Perfect. So, um we've got a 25 year old woman seeking emergency contraception. She's got iron deficiency, anemia, epilepsy and uterine fibroids. So already, I hope people's tingly senses are going off because we hear epilepsy and we hear probably a CNS drug involved. So select one prescription that's likely to interact. Perfect. You guys are on it, sending you little answers in the chat and we just got a quick question how did the PSA website mo compared to the real thing, in terms of difficulty? I thought they were pretty on par. I mean, that, I think it was difficult but you have to remember the pathway is about 60%. So you don't have to get everything right. Like, even if you got what, what is it? It's eight questions. You got five of them, right? And you've got eight of them. The other three completely wrong, you'd still be ok if you know what I mean, you don't have to get every single thing, right? Um Which is I know quite difficult to hear as a me because you want to do as best as you can. But 60% I think is a reasonable pass mark. And I don't actually know anyone who failed it. So that's always good. So, yeah, we've got carBAMazepine and Paracetamol showed we press it. You're absolutely right. Absolutely. And you're already doing the MG, you're already doing the hard work by coming here and doing a revision session. So don't be too hard on yourself. Yeah. So carBAMazepine again is part of um the C YP three A four system. So it's an inducer of um drugs. So the sorry hormonal contraception, there are substrates of the CYP three A four system. So carBAMazepine actually reduces the efficacy of hormonal contraception and that's also something that comes up often. So I thought worth going through and then can we see why the paracetamol is the one with the dosing ever. This one was also a bit sneaky. I'm not going to lie. Yeah, exactly. Over 4 g in 24 hours. So it's not technically wellness that you can take paracetamol four hourly but nowhere in that prescription does it say a maximum of 4 g in 24 hours? And therefore it can lead to a dosing error. Um, so on this kind of, if you see four hourly, um make sure you just realize that that's more than 4 g in 24 hours, which is sort of dilemma and can lead to accumulation and uh potentially paracetamol toxicity. A lot of patients actually do come in because they just chronically take paracetamol and they end up with like paracetamol levels of like 50 just because they always take paracetamol, cool you to press next. So this one you might be like, well, how would I find that? So you'd have to go into the treatment summary for a contraceptive. So there's a nice little link path there at the top. There's nice BF treatment, summaries contraceptives. It's a lovely little page for your acies as well. There's prescribing stations and it just um it, it lets you know about the conception interactions um as well. So if we press next, yeah, perfect. So it applies to both. So I never know how to say that one. I think it's, let's say I just know it as L1 the lo one drug Ilir acetate and Leno gest. They both will interact with carBAMazepine. So they usually say to take um double the dose of the levonogestrel. Um but there's no studies to say that it will be effective. So it's I feel a bit bad for those girls. Yeah. Press next please. Yeah, perfect. And this is another way you could do it. So maybe you're like, oh, so that would be a good way if you were like emergency contraception. Like I don't know which drugs you use for emergency contraception. Well, you don't even need to know because there's a specific treatment summary for contraception. But if you're like, oh, I can remember one of the drugs that you use for emergency contraception. You will see that it interacts with both of them as well. Cool. So you press next. Perfect. And yeah, that's just the maximal programs on the day that I was talking about. Too great. Next, the feedback for might need to be released if that could be released by anyone who's cohosted with me. Um I don't think a lot of prescribing contraception comes up, but the hit certainly does come up in the other sections and that will be covered next week. I'm sure especially contraceptives and hit, but it's not really something we focus on on this section. So what do we think? And what do we think of this one? Ok, A and B. So this one says three medications and it can be up to three. It wouldn't really be anything past three because I just think it would be difficult to come up with four drugs that will do the same thing. Be a bit overkill. No. Oh, yeah. Running out, it's difficult, isn't it? Um, I'm sure that constipation is one of the sections on appendix one. So it might be worth next time to just get to the constipation section versus where we want to be, isn't it? The appendix one and see how many drugs come up on that list instead of like going through each separate drug if you know what I mean? And that's why I think definitely go have a look at appendix one after this and try and get familiar with all the different sections. Oh, bless you. OK. I'm sorry about that. I hope that me explaining which drugs cause constipation will just stick in your mind. That's the reason why we do this kind of thing and it will help you in the exam. Yeah, bless you. OK. Shall we reveal the answer? Yeah. Um So we've got cloZAPine. CloZAPine is like one of those random drugs that you will, you obviously like encounter things like Rapam, paracetamol, omeprazole like they're very common drugs. Um So my other thing would be if this is a drug you're not so familiar with. Just keep that one in mind as one of the ones to look up. Um because one of cloZAPine, s most common side effects is constipation. It can even result in acute bowel obstruction too. In some people we know opiates like codeine. So any opiate at all is going to cause you constipation. Um codeine, you know, C for constipation. Let's just remember it that way. Oh, well, we could do cloZAPine as well. C for constipation. There we go. And ferrium rate often results in small dark hard stores as well. Um And in terms of Ben has constipation listening to common side effects too. I don't know. Uh I did not know that. Um Let me just have a look at that. I do not know that if that's an oversight on my part. I'm sorry. Um I, is it under common or very common? Maybe that's sort of the difference. So if we press next. Oh, perfect. You've liked it. Thanks, Francesca. Very common. I sound corrected. Well done. Francesco. We, we could have gone up to four there, I guess. So I'll accept breo as a correct answer as well. So we've got constipation. This is for so all antipsychotic drugs. So there we go. We know that anything OLANZapine Cozine, all of these are going to cause you constipation, honestly. All antipsychotic drugs cause you everything they're horrible drugs to be on. Um Next, that's why I say C NS drugs are generally the ones to be looking up. Um opioids. Yeah, we know that as well. Uh Next and yeah, iron, constipation and Francesca's also reminded us of Benja can cause that too. And then in terms of hypernatremia, I don't think I actually went through it. Um Could you just go back a few slides for question again? Thank you. Well, there's definitely an interact section for hypernatremia on the appendix one. So we've got benzoylmethide there and the next, oh, it's called a peanut. Am I Blind? CloZAPine? Is there? Omeprazole? Isn't. You're so right. OK. So this is the difficulty with it. Um I honestly do not know. CloZAPine caused hypernatremia, but it's literally right there. I can say that. So we could have gone four and three. Omeprazole is a difficult one. So they always say omeprazole is all the PPI S can drop your sodium. Um Benzoyl methy methide does that because it one second, I've got it written down here. Um It blocks the N ac Cotransporter in the distal convoluting tubule, which means that sodium's excreted out into the urine which causes a decrease in sodium in the blood, which makes sense because we use it as an anti diuretic. We use it as a hypertensive as well antihypertensive. So we want to get the water out to drop the BP. So that, that's quite straightforward. I assume cloZAPine does this by Si DH or something like that. And omeprazole, they always say causes hypernatremia to any PPI S but it's not listed. And the reason that this was put in was to say it's not always going to be in the BNF, which is quite annoying too, but most of the time it is going to be on the BNF. Um, and then we've got our last question. Sorry about that guys. Yep. So we've got someone with vomiting, confusion and agitation. They've got a history of M Parkinson's and hypertension. What are we not prescribing them? What should be taken off that chart? And what has the dosing error? Lovely. And if you know, if you've suspected a dosing arrow, what is, what is the error and what you, you guys are completely right? Is metoclopramide and haloperidol. What about um what about the history is telling you? Like they should not be prescribed? Yeah, someone asked is the only way to get the answer to search each drug individually. So try to give some tips throughout including giving some tips about drugs that are often like repeat offenders and ones that you should be searching as a priority. Um including the enzyme inducers and inhibitors, which I'll go through. And like I said, you don't need to remember if it's an inhibitor and whatever you just need to remember that it's on this list of drugs that are annoying, basically. Um I've said about CNS drugs and warfarin as well can be annoying drugs as well and to look up um and the interaction checker, you know, the one with the table, someone asked if that's available on the online BNF and it is and it will be there for your PSA as well. Um That gives you a quick way to search things as well. Um Yeah, Parkinson's perfect. So we just move on to the correct answers this next slide whenever you can. Yeah. No, I hope your internet not crash. Yeah, perfect. And then I'll just explain that. So it is methyamine Haid and that's because they both act on D2 receptors, dopamine two receptors in various parts of the body, especially Harrier, which acts on the corpus striata, which is part of the basal ganglia. And obviously Parkinson's is a loss of doer neurons in the basal ganglia. So definitely not haloperidol. Honestly, never haloperidol. It's also one of the dirty drugs that cause various different side effects. So both mesopram and hydol are dopamine antagonists. So we really want, we just don't want to be messing around with dopamine and Parkinson's. So if you press next, they'll, they both can cause drug induced parkinsonism and they can exacerbate existing Parkinson's as well. So we just move on to the next slide. Yeah, there's haloperidol and contraindication. So that's another important part. So this is what you see when you search out any drug, this is called the drug monograph. Your important sections in this prescription and V section will be your contraindications, cautions and interactions. Honestly, the renal impairment and hepatic impairment can be useful as well. You can quickly see if they're going to affect the kidneys or not. So, if you've got a kidney question, you can just be like, oh, I have no idea if Haloperidol has an effect on the kidneys, you can just quickly smash that renal impairment. But, and then be like, great, it doesn't move on. Probably does to be honest. But there we go. Um, it says contraindicated in Parkinson's disease next. And it's ACN S drug. So, like I said, they're always horrible metoclopramide. So yeah, indications contraindications. Oh, I don't guess I was interested if you can take in pregnancy, which I don't think you can, but yeah, can't have it in Parkinson's either. Um Next, someone said clopi girl should be given daily knowledge. Did I put, what can we just go back? Sorry. OK. I to have it out just, yeah, just back to the question. That is right as well. I didn't, I did not notice that that is also wrong. Should not just be given once um fine, but it's also it was also verapamil because that should be as Sophie said divided in 2 to 3 daily doses. Um having 480 mg, three times a day will certainly not be great for you. But thanks for pointing that out, Stuart. Um Yeah, just next. I think that's all of our questions and we've just hit about eight. We've just got a couple more slides to go through. So if you want to take a picture of the slide, just some common drug to drug interactions. Um I just wish someone would come up with a proper exhaustive list and we could just all remember that, but this is as close as I could get to in the past week. Um And it's just like something you can use in your brain of Oh, yeah, I remember saying something about nsaids and something about SSRI S like, so you don't even need to know the exact interaction if you just know like, oh yeah, I don't think they don't sound right together. Then you can just prioritize them in the exam to be searching if that makes sense. As a room. Got a picture of that. I mean, the slides are will be uploaded, not slides, the recording will be uploaded. The previous two have already been uploaded to the med ball. So if you click on med tick at the top there, um I feel like a youtuber, a med at the top there, you'll be able to see the previous recordings as well. So you press next. Yeah. And this is a really good table that we could, you could probably take a picture of as well. Press next. 00 She just disappeared next again. Oh OK. Wait, that's so sad. So basically it was an animation before and then Metal didn't let her do as animation. Let me try and get it up myself. Um And, and then I can share it in the chat um because it's a really useful table. Do we get in there? Do you know what, I'll upload it to our Instagram story later on today and then everyone can just go on the page and, and I'll upload it there and people can just take a screenshot. It's just, I'll put the Instagram in the chart and it is a lovely, lovely table. Um If we press next, sorry about lack of animations. And next again, and then this was just the list I was talking about inducers and inhibitors and like you don't really need to understand the enzyme system. You can if you're interested in it. But if you just remember these drugs being problem drugs, you know, to search them up in the exam, you don't have insta OK? Trying to think what else we can Facebook have you on Facebook. I can upload it to the Facebook should not be a problem or I can share my screen at the end of this. It's obviously not that big of a deal. Um But I certainly put it on Instagram too and that is, I think that is everything on the slide. So was it, was that everything then you sort of cut out there? Yeah, I will try to actually get it up now if you just bear with me one minute. Oh Perfect Mas on the case. That's on the case. Um So guys that is the end of the session where you've just hit eight, so great timing from me. Um Just give myself a pat on the back for that, please, please, please. It would be so helpful if you could provide feedback. Oh, beautiful. We've got the table here. Love it, please. Would you mind just providing some feedback? I kind of want to be like, I kind of want to make more psa questions and get sort of a question bank going. Oh, I also have this actually really good slide about recommended resources that I want to share with everyone that I use to help me pass my PSA um if we can. Yeah, so that actually really good point. If you're not sure what the answer is, it's a time pressured exam. And if you're like, there is no way in 2.5 minutes, I'm going to figure this out. Put anything down, make sure if as for three, make sure you put down three drugs because that would be if you lost out on because of that flag it, flag it and move on. And then at the end of the exam, if you've got any time left, you can go back to those questions when the questions you flagged. But if you really are running out of time, don't just sit there and be like six pages deep and trying to figure out what the answer is if that makes sense. Um Can we just send the feedback thing again? If that's OK. So in terms of question banks, the GKI medics one is really good. There's loads and loads of questions, you can just spam them. And do you know what? Even if you don't do it in timed conditions, you're still refreshing which drugs cause which interactions. And I know people are always like, yeah, it's just exam technique but you do, the more you do try to memorize these interactions, the less time you're wasting the exam as well, especially on the prescription review section. Um I think it's just really useful. Yeah, past medicine psa question back is also good and also included in the finals. Um One, if you've already got the finals one and yeah, script modules. I know in Liverpool, I didn't know if you still need to do this in Liverpool, but they made us do the script modules and as annoying as e-learning is I think they were quite useful. Um And then this uh these are the um BNFL that we've currently listed there, the E learning BPS assessment. So they're earing modules that go through the structure of the exam. They're really brief but because it's written by the people who do the PSA you can get quite good insight of what the exam is going to be like. And they have three past papers that I've mentioned before in the past cost 40 lbs. So it's like it's a lot. The PSA question bank is good because it's 10 lbs and it's so many questions. Um, and you're not gonna, honestly, if you run out, I would be so impressed. Um, I'm sure I did like 10% of it. I'm not going to lie and then, yeah, official practice papers as well. I hope that was helpful, everyone and I hope to see you all next week. On Thursday. We'll go through everything else. So it might be a bit of a longer session, like hour and a half. Probably. I don't want to promised an hour, but it, it would be really great to see as many of you as possible next week. Thanks so much.