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Um, and let's see how many people will come. I'm not sure how I actually see how many people here. Oh, ok. Yeah, Vicky. Do you know how I actually see if people have actually joined? Is it people? So you go on the little, um, circle thing with the like two people underneath the chat? Yeah, there's currently we've got 27 people in. Oh, right. Ok. Very good. If you have 27 I think we could probably just make a start. Ok. Cool. Lovely. Um, just to confirm for those who are here today, could you possibly message in the chat just saying that our volume is working and the slides are working or to say hi. That would be great as a start. There you go. Ok. Lovely. That's all fine. Ok, then, so, hello, my name is, has I'm on the Thursday to 15 committee, er, or med teaching committee. Thank you all for coming today. Um, this is our PSA series, um, for your exams. I know some of you have it, have it tomorrow, some of you got it in the coming few weeks. Um, so we've done a series of four lectures. And I think this is our final one today. Uh, today we've got Emily who is an F one in Manchester, but I can let her introduce herself. Um, just to let you know Emily can't actually see the group chat. So I'll be looking at the group chat. Um, and we'll just see if we do answer questions during or we'll actually do it at the end, of course. Um, this is an hour session, but we'll see how it goes. So I'll hand it over to Emily. Thank you. Amazing. Um Like I said, like I was just introduced, my name's Emily. I'm here to lead the fourth installment of the series on the PSA, I'm an fy one doctor at the Manchester Royal Infirmary, um recently graduated from Saint Andrews and Manchester Medical Schools. Um So I sat the P sa very recently this time last year, actually. Um Hopefully I've got some good and useful tips for you this evening. So just to begin with a quick disclaimer whilst I start the PSA only last year. It is possible that there have been some changes whilst I have tried to fact check as far as feasibly possible. It probably would be recommended just across reference, any official resources before your examination date to properly update yourselves. I honestly as well just found this useful to familiarize myself with the exact method of examination. Exactly how many questions exactly what the rules were. It just took a lot of the stress out of the situation as well. So, information discussed tonight has primarily been taken from the official PSA blueprint. Again, I've got a link to it later on in the presentation. Something that you could maybe just have a glance over tonight, especially if your exam is tomorrow. Um It's published in July 2023. So it's very up to date and accurate as well. Um Furthermore, with an approaching exam date, also, I just wanna emphasize what works for one person might not work for the rest. So whilst I'm about to discuss some tips and pointers that I personally found useful, I'd recommend with sort of night before syndrome, just stick to any examination practices and resources that you're probably already familiar with. So let's just take a brief moment and outline what we're gonna talk through this evening. So I've been asked just to run through five sections of the exam. So we will go through what the different question styles are for each of these exams, have a quick introduction about discussing the weighting of each section just in terms of the number of marks available. And then I've got a suggested time distribution that I use and I found really useful. It incorporates some spare time as well, er in case you get stuck. And then the main part of this session is just gonna be signposting you mainly to common themes that arise in each of the five sections. That I'm going through tonight. So as we're quite limited for time and I appreciate that some of you might have your PSA tomorrow, I thought because it's not possible to go into incredible depth in all of the areas we could use this as kind of like a crash course evening for some points that it might be worth just refreshing your memory about before tomorrow. Um I'm gonna try as far as I can to chat over some key topics and then answer any questions at the end. So the focus of this session is on these sections here. Let's just go through them in a little bit of depth. So planning management, this section, you're gonna have to select the most important treatment option from a five possible options that are presented to you. Um We'll discuss this in general in a few slides on, but it's worth just noting as well that it doesn't always have to be pharmacological. You can have some options in there. For example, like physiotherapy to consider as well providing information. So this is an important section that I found quite time consuming. If I'm honest with you, it's gonna ask the candidate to identify the most important counseling point when starting a new treatment again, I'll discuss it a bit more thoroughly in a few slides of time, but it's probably worth just noting that within the five options presented to you, you might find some options that are factually correct. But just ask yourself, are they the most important piece of information out of these five that I need to tell the patient a really common example for this would be anticoagulants. So whilst three of the pointers might be factually correct and you know, you do have to do all this monitoring. What might be the most critical piece of information to tell a patient is signs and symptoms of serious bleeds. Then we move on to adverse drug reactions. This section actually comprises of four possible question types. So like I mentioned, we'll expand on this in a bit more depth later on, I'll talk through them all and give you some pointers as to most commonly qu like tested areas for this drug monitoring. So this is about um best monitoring options, typically things like blood tests, planning blood tests. Um but there are some unique exam points as well and then finally, data interpretation. So you're gonna be presented with a piece of data, asked to interpret it and then make a decision or an outcome based on what you've interpreted from that data. This could be withdrawing a medicine, changing a medicine, changing the dose of a medicine or honestly as well, even making no change. So don't forget that option too, moving on to exam waiting. So if we just chat through some of the points, so you might see in resources that questions are referred to in the P SA by items So here's just a quick distribution on the waiting of questions uh for the sections that we're gonna go through tonight. And if you like me and you personally prefer to view things visually. This is just sorry. I including some of the sections that I've been discussed in previous sections. You can see the prescribing section obviously in the PSA is gonna be very heavily weighted. But you know, these sections are also worth really putting some effort into because you can mop up some quick and easy marks, especially if you struggle with the actual prescribing section. But visually, this is sort of the distribution that we're looking at. So you can see tonight we're gonna discuss approximately a third of the exam. This is a potential timing recommendation. Now, this is one that I followed and I found worked really well for me, it might be worth, you know, having a look at seeing if you think it would work for you. The way that I calculated with this was based on the waiting of each section. So obviously, some sections are worth considerably more than others. So I allocated the time according to the waiting. If you total all of these up, it will take you to 100 and 17 minutes. So in 100 20 minute paper, this is gonna give you three minutes of wiggle room, some sections, you will naturally be a bit faster at than others. So you can buy yourself time. So I actually found that I was fairly quick with the prescribing section, especially on the P SA platform where you type in a few letters at the start and then it gives you all the options. I found it majorly sped up the process. Whereas for example, things like adverse drug reactions, I personally found a bit more tricky just because I struggle to remember a lot of the side effects and you can get quite bogged down with the B NF and medicines, complete sections. So I'd recommend if that's the case, use the flag function. So if you're finding that you're spending a really long time on one question, flag it, come back to it. Move on and try and buy yourself some time back. That's probably the biggest tip I'd recommend actually in the P SA. It's a test of prescribing, but also a test of time management. Now, moving on to the majority of this talk, we're just gonna go through each of those five individual sections that I'm covering tonight and I'm just gonna try and give you some study tips and some last minute advice, some last minute facts that you can broach each question style with, er, and then signage you to, to some common topics again, if it's the night before your exam prioritize getting an early night going on with a nice clear head. But if you think, you know, you don't know something as well as you might like to that, I've brought up tonight, have a quick flick through it before you go into your exam tomorrow. So let's start out with planning management again just in the top corner. I'm gonna summarize of. So you can keep an eye on how much each section's weighted in terms of marks planning management. OK. So in this section, questions are gonna present you with a clinical scenario and you're gonna have to try and select the most important treatment or intervention. Typically it's gonna be as part of initial management. But this section, I'd really recommend just taking a moment and carefully reading the question. What type of management is the question actually asking you to identify? So, is it a preventative management? So something like statins are a really common example for this. So statins prevent cardiovascular disease and with so make sure you're reading the question is asking you about primary prevention. So in which case, it's gonna be a different dose to secondary prevention. So the primary prevention is a 20 mg once daily dose where secondary prevention aka is in the question stem, it mentions known ischemic heart disease, cerebrovascular disease, peripheral arterial disease, then you're gonna prescribe a different dose. It's going to be the 80 mg dose. So make sure you're really reading the question stem. Is it asking to provide uh prescribe a curative therapy? For example, antimicrobial or symptomatic? So this could be in a question about infection, for example, if you've got a patient with a rip roaring infection, are you trying to cure the infection? Prescribing an appropriate antimicrobial or if they're really struggling with temperatures, something like paracetamol IV or oral to help, try and bring down those temperatures. Another example of symptomatic might be things like GTN sprays and then finally, palliative, this is a huge section and you could have again, lectures completely dedicated to palliative therapies, but you might see it maybe written as anticipatory medicines. This could be considering things like breathlessness, agitation, any type of um excess saliva management. So your medications like your glycopyrronium bromide, your hyoscine hydrobromide. These are all things that you can and try and rely on as well, like I mentioned before, remembering your non-drug therapy. So these are things that you would also consider in man planning management. So pt physiotherapy things like you ted. So in my trust, definitely you have to actually prescribe these as well. So these are your VT E prevention stockings and then something like Tens machines. I remember I attended a webinar before my PSA and someone mentioned tens machines. I've never actually heard of them before. This is a um transcutaneous electrical nerve stimulation machine. These are really common actually in pain management and things like muscle spasms. Typically, you see these used in questions about um like sports injury management or endometriosis. So these are all things that you can consider in addition to Pharma pharmaceutical management and then finally, the planning management section, it's really worth considering when you're reading the question, if there are any special scenarios that you need to account for or any contraindications for certain medications. So I had to go through a lot of the past papers and then I had to think about what sort of came up in my P SA. I must admit I could only remember certain things that I found difficult during my PSA couldn't remember a lot of it off, off the top of my head. But these are some things that I would recommend just familiarizing yourself with before you go into the exam. So here are some key points. So UTI S I've got a slide on in a moment just because a lot of people just remember trimethoprim nitrofurantoin. But um there are different indications and durations of therapies depending on who the patient is that you're prescribing for anticoagulants again in this day and age, you might automatically jump to something like a doac. But remembering if you read in the question stem, if the patient's on a mechanical heart valve, then you need to be prescribing Warfarin instead of a doac things like allergies, this is really important to consider. So, whilst clinically and in clinical practice, you might be really emphasizing trying to work out. Is it a true allergy? Is it a documented more of an intolerance in an exam like the PSA? It's not supposed to be subjective it's an ob object, an objective assessment of your prescription skills, they're not gonna have any gray areas. II was recommended and a piece of advice I just followed was if the question mentions an intolerance, a previous drug reaction, a known or documented allergy, irrespective of the severity, then have a look through the other options before you jump to providing that option, it might not be the single best answer. Things like drug history are really important to consider. So, is the patient already on any therapies? That might mean one of the five listed options wouldn't probably be the best choice. Typically, I'd consider this if in the drug history section, it says the patient's on a statin, this commonly comes up if you're looking to prescribe antimicrobials. Um The most common interaction being between statins and Clarithromycin. So it can exacerbate myopathies. Um It's a big no, no one co prescribing. So typically you'd hold the statin if the patient really requires Clarithromycin or try to find uh an alternative. Another common indication where sort of drug history is important to consider is if the patients on any enzyme inducing or inhibiting medications, and typically these questions come up with things like contraception options. So another one to read over if you feeling a bit unsteady with those in the past medical history section, things like renal function in the B NF, you're probably used to practicing with it by now, but you have um reduced doses for certain medications depending on renal function and reduced doses that you can follow. Um, has the patient been on any recent antibiotics? It says in the stem that they've been on broad spectrum antibiotics a couple of weeks ago, they're now coming in with diarrhea, then you might be considering, um, c diff as opposed to just a simple infective gastroenteritis. In which case, you know, you're thinking vancomycin therapy, um, if the patients had an episode of C diff, you know, within 12 weeks, then it's a different therapy altogether. It's something like for Doxycin. Again, these aren't to, I'm not trying to scare you by suggesting that you remember all these specifics, these are the things that you pick up along the way. But what I am suggesting is that if you read a question and there is a slight twist within the question stem like, oh, they've had ac diff infection 12 weeks ago, then it might just be worth, you know, flagging that up in your heart in your mind. And then when you're going through the indications in the doses section, using that control f search function, just so you can see if you're missing anything. Some other things to consider are caps versus HA S. So I'm sure you're all aware, community acquired pneumonia versus hospital acquired pneumonias have different antimicrobial requirements. Just have a vague understanding of things like the cut off points. So cap is technically anything acquired in the community up to. So within the 1st 48 hours of admission to hospital, whereas hap is anything after 48 hours. So if it says the patient's been in hospital for three days, then, you know, you know which route to go down and again control f and you can use hospital and it will automatically jump down to the hap section symptom duration as well is another one to consider. So a common pitfall here that I found a couple of times and I've even seen myself in practice as an F one doctor is something like gout. So an acute gout flare whilst allopurinol would be the actual urate lowering therapy. Remember that typically this isn't started unless the patient's already established on it within an acute flare. So if the question's asking you sort of indicating signs and symptoms of gout, for example, red hot big toe, then you might consider nsaids or colchicine as the option before you would consider allopurinol. So just really taking a moment to read the question. Contraception in hit is a huge topic. So I've got some slides on that coming up. Analgesia. Again, a huge topic, got some slides on that. And then finally, perioperative management, typically, this is about diabetes and management of diabetes around the operative period. I've got some sides on that too, but I do just have a couple of medications with just some specifics that you can either look up or try and remember just to save you a bit of time. So moving on to some of these specifics, the lower UTI S. So like I mentioned before, trimethoprim and nitrofurantoin, lots of people remember them three day course. Quite simple to remember. Lots of us have had first hand interactions with this, do that in GP placements or even in the hospital. But remember for males, it's slightly different. It's a seven day course. And then for pregnant women, it's nitrofuran toin. So you don't prescribe trimethoprim to pregnant women. It's a folate antagonist. So it's teratogenic. Um That's just one to remember. I think, I don't know if anyone's heard the term cory, this is a catheter associated urinary tract infection. I think it would be a little bit harsh for this to come up in the PSA. But whilst we're talking about it, I just sort of briefly mention um for catheterized patients, we don't treat any asymptomatic bacteria in the urine. We only start to treat whenever it's symptomatic. And in practice, what you would do is consider removing the um catheter or changing it if it's been in for over seven days. Um Don't let this however delay any antibacterial treatment. So you'd remove it or change it and you'd send a sample for a culture and sensitivity and this would, this would guide what antimicrobial you would prescribe, moving on now to contraception. So I appreciate there is limited time this evening. So I tried to come up with a brainstorm of just some common themes associated with questions that they could ask around contraception. Again. Try not to worry, don't stress most of this information. If not all of it, you could find within the medicines complete or the B NF summary using control F or just knowing where to navigate within the different sections. But if you have some time or it's something that you have read over, learned before and just could familiarize yourself with, it might help speed up um your responses in some of the questions. So, contraception is really easy to test. It can come up in the planning management questions, it can come up in the giving information sections. So I just thought I would discuss through some of these things. So the combined versus the mini pill, I've got a slide on and the combined pill coming up next, there are some absolute contraindications in which case, you might prescribe the mini pill. Uh The missed pill rules, these are really easy to test as well. Now these are something that you can find within the medicines complete. And B NF So again, this was something I knew that I really struggled to remember. Keep in the forefront of my mind. So it, this was one of the things that I would be checking during my paper emergency contraception don't have that much time to discuss it tonight. But in summary, you've got the Prestol acetate. So this is the brand name LL one and just try to remember that you, you can take this up to five days post. You might see it written UPI u psi unprotected sexual intercourse. So five days or 100 and 20 hours for the L1, you've got the Lev Norel or the leel pill. This is for 72 hours or three days POSTOP. And then like I mentioned before, you've got these two pharmaceutical options, but don't forget the other types of therapies. So the copper IUD this is actually the most effective method of emergency contraception provided the patient meets the criteria for insertion, postpartum. And this section also, I'd recommend just includes breastfeeding. Again, there are lots of ins and outs, there are lots of specifics and options. But for me personally, I just found it really easy to remember that the pop was quite a good option. Postpartum. So the pop can be started anytime. Postpartum doesn't affect breastfeeding. So I found this was a really good and easy one to remember. Um in terms of some other and small points to learn about postpartum, um the combined pill. So it's absolutely contraindicated if you're breastfeeding, uh less than six weeks postpartum. And then also remember your side effect profile of the combined pill, it can increase your VT E risk. So it shouldn't, it absolutely shouldn't be used within the 1st 21 days postpartum. Anyway, um postpartum surgery or all sort of prothrombotic um states for the body. So if you're adding in the A pill that further increases your risk of VTA, it's just not recommended at all. And then things like the I US and IUD S um you've got two insertion windows. So either you get that inserted within the 1st 48 hours after childbirth or you wait and then it's after four weeks. So there's just some quick and easy points to remember. But again, last minute, emphasize postpartum. Remember your mini pill is a great option. Then any special considerations. So when it comes to contraception, things like special considerations, I'd remember are weight. So overweight patients um patients with I think it's ABM I over 26 or a body weight greater than 70 kg for emergency contraception. This affects your doses. So you tend to use the L1, the ala Prestol or if for whatever reason you have to use or the patient wishes for the levanil, then you double the dose depending on the weight and then finally interactions. So I guess the most important thing to remember here is epileptics. So things like carBAMazepine, a really common enzyme inducer um is gonna reduce the efficacy of some of those contraceptive pills and especially emergency contraception. So again, like I remember the pop the mini pill for postpartum, I found it really easy to just remember in epileptics, typically preferred answers, sort of like the IUD the I US. Um But you can also use the progesterone only injection. So just talking through some of these, now the combined oral contraceptive pill. So this is really great pill. It is used to make periods regular, lighter, less painful. Um but it does have side effect profiles and risks to be aware of. So, whilst it's great in that it reduces the risk of ovarian and endometrial. I group those together in my head. Those are sort of the parts of the female that are in the center. That's how I used to remember it. So the ovaries and endometrial are sort of together. Uh it reduces the risk of those cancers, but it can increase the risk of your breast and your cervical cancer. So sort of outer parts of the femur I, that's just how my brain used to remember it. Um It also increases the risk of VTA stroke and ischemic heart disease, especially in smokers. So you're gonna be really cautious of patients that smoke. Like I mentioned before, you have these contraindications to be aware of. In which case, you might consider different um options than the combined oral contraceptive pill in the UK. We have the UK M EC the medical eligibility criteria. This is something that's often commonly tested in um past paper questions even on past med, for example. So UK M EC four correlates to an unacceptable health risk. AK it's an absolute contraindication and the C ATP the combined pill has a couple of those just to be aware of. So, if the patient's 35 years old and smoking more than 15 cigarettes a day, that's the cut off. Like I said, if you're a smoker, um, you already have an increased risk of things like ischemic heart disease and stroke. So you're not gonna add in a pill that increases the risk any further. But remember, 15 mites a day migraine with aura. Uh, so also associated with the stroke risk, er breastfeeding less than six weeks postpartum. And then like I mentioned before, just any sort of past medical history um of VTA stroke, ischemic heart disease and then current breast cancer, you're not gonna add in a pill that would further increase your risk. Now, moving on to the missed pills, I don't wanna spend too much time on this because a lot of the information can be found in the exam um as well. So you can feel free to take a screenshot of this information. I've got one on the pop here as well. I guess the main things that emphasize on this section is for the C OCP the combined pill. It's important to remember these parts here. So when you need to refer the patient for emergency contraception, this is quite common in the planning management section. So the way I used to remember this is typically, I just remember a rule that you should seek emergency contraception or use barrier protection or abstain from sex until you've at least taken a pill for seven days in a row. That's what I was once told. If you'd prefer to just sort of learn these rules or look them up in the exam, then that also works whatever works for you. Um, whenever you take the combined oral contraceptive pill, conventionally, it is typically taken for a 21 day period and then stopped for seven days. It's to try and mimic a normal menstrual cycle similar to the uterine bleed. Um But it's worth just noting, actually noting in the question whether this is how the patient is taking it, trying to determine the pattern of how they're taking the combined pill because it's actually becoming quite unfashionable now to take it in this fashion, um guidance updated in 2019, which basically found that there was no medical benefit from having a withdrawal bleed. So you might see patients taking three months continuously and then having a pause or just not having a pause at all. So just clarify what plan the patient is taking that combined oral contraceptive pill on in terms of the mini pill, you have the different types. So the mini pill is a bit stricter in terms of when you have to take the tablet. So for the traditional PO PS, you technically would have a missed or delayed dose if you're taking the pop every day at 9 a.m. and you only remember at 2 p.m. the next day that you hadn't taken it, that's technically a missed or delayed dose for the cerazette. Uh It's becoming a lot more popular because it obviously has this longer window. So again, just learn those. If I can sign posting now to a resource, I'd really recommend the past med contraception section. I personally learned all of my contraception information resources, facts from this resource. I found it really succinct and clear explanations. Um I found it the best one but use whatever you guys find helpful. Um Emily, I just jump in two seconds. So we got two questions on the chat if that's the case. So this was an earlier question, which was uh which one would you go for first colchicine or setting gout? I think they're just asking, what do you go for first for treating gout? And the second question was, please, could you repeat how you remember that? The combined pill reducing ovarian and endometrial question mark? Yeah, of course. So um as for gout management again, just go off. What is in the BNF II? Think so first line from memory is either Nsaids or colchicine. So I think you'd definitely get marked for either of them. I don't think they'd have both of them as an option. The only thing I could think about maybe um where you'd be less inclined to prescribe an NSAID is if the patient has something like gastritis or is already on a A PPI or requires an additional PPI dose and that would be a consideration I'd focus on um otherwise just check the BNF. Um But I think the main emphasis, if there was a question on gout would be, it might have either an option of an NSAID or an option of colchicine with the option of allopurinol. Um My main point for bringing that up was I guess just to be aware of, is it an acute flare or is it asking you to sort of provide long term rate, lower lowering therapy? As for the second question, this is a bit of just a silly way that I used to remember. So I used to group them together. So in my head, sort of the endometrium and the ovaries were close together anatomically. So I used to remember that they were together and it reduced the risk of those as for breast and cervical, they're further away. They're not as close together. I don't know, it was just something that visually I used to find quite helpful to remember. I'm not sure if that's helpful for anyone else, but I'm quite a visual learner. So that's just how I remembered it. Hopefully, that's OK. Um Analgesia. So again, this is a huge section. This is something that you can have lecture after lecture after lecture on. Um But I'd recommend just whenever you're tackling an analgesia question, having this ladder sort of in the back of your mind, have a basic awareness of it generally start low. Remember any adjuvant therapies that you can add in. So as we discussed before, things like tens machines, if there are options, consider those espe especially in a patient that has loads of comorbidities, loads of medications, things like adjuvants are really helpful to rely on. Whenever you start to prescribe opioids. Be aware that these are high risk medicines. There are lots of facts that you can very easily become swamped with and pain relief is difficult to remember sometimes. So I've just tried to summarize some very quick facts for you that I just found useful to, to learn in renal patients, fentaNYL patches are really good. They're really useful in renal impairment. So consider that if it's an option, any opioid medications I used to struggle sometimes to remember where to find them. There's really good opiate guidance within the palliative care section, either in the B NF or in medicines complete. So all of these screenshots are actually from the palliative care section. Uh in terms of opioid overdose, whenever you're reading a question and the patient is on morphine or Oramorph or even codeine, but typically morphine or Oramorph have a look and see if the question that has any signs or stigmata of respiratory C NSD depression, pinpoint pupils. In which case, the question might be trying to signpost you to opioid overdose and prescribing things like naloxone to reverse opioid overdose things to remember about breakthrough pain So you've got your background analgesia. So this is your modified release. So if we're thinking about morphine, you might have the patient on modified release, morphine 12 hour release. So twice a day, if you total this up, the breakthrough prescription should be 1/6 to 1/10 of this dose. If the patient is using breakthrough two or more times typically greater than two times in 24 hours, you might consider that the pain is not adequately controlled. So you might consider reviewing and increasing the background that modified release analgesia. When you go to increasing background analgesia, typically, I'd recommend that you don't increase it in steps or increments larger than a third to a half the daily total dose. So you do it slowly again monitoring for any signs of opioid overdose. And then finally, opioid conversions found in the palliative care section, like I mentioned before, a big help for me during this section was control f if you were unsure about anything control F doses, control F equivalent control F conversions and it'll take you straight down to the section that you need to know. Also just some time saving specifics to remember, feel free to take a screenshot of this as well. These are pain types that I didn't necessarily think applies, you know, to the who analgesic ladder. These are ones that just I found helpful to remember. So if a question was talking about trigeminal neuralgia, I just knew straight away. CarBAMazepine is actually the first line things like renal colic uloma. And then, like we mentioned before, is the question asking you in similar to gout, is it asking you about symptom relief or is it asking you about sort of prevention? So, prevention is the propranolol, whereas if you have an acute attack, then you're gonna prescribe one of these things here. So feel free to take a screenshot of that. I'm sure the size will be distributed afterwards. Perioperative management. So finally, for this section, you might be asked on the appropriate management or control of some drugs in and around surgery. Most of the questions that I've ever come across have been regarding hyperglycemic agents. Um I have a table on the next slide that again, just feel free to screenshot. It's not very difficult to understand or interpret. So unfortunately, just one of those things you have to either learn or look up. Um for insulins, one thing I'd like to mention is to navigate to the section in the B NF or in medicines complete. If you type in diabetes surgery, it will take you to a subsection called management of diabetes during surgery. And this is where all the rules are insulins. I think you would be unlucky to get in the P SA COS most of the rules are as per local guidelines. So unlikely to come up in a national prescribing exam. But a good rule of thumb to just consider is if the patient has really poor control already of their BMS before surgery and you're about to put them through the physiological stress of surgery, which is gonna increase their BMS further. Or if you, um, are making a meal by mouth for a period where they're gonna miss greater than one meal. Then as a general rule of them, it might be safest to consider, uh, you might see it typed as VR II, a variable rate insulin infusion such as a point to um consider you typically continue them on this variable rate until they either are allowed to eat again or they're stable on previous glucose lowering therapy. And then finally, just quickly some little facts to remember. So ace inhibitors arbs typically stop 24 hours before diuretics. So your furosemide, your bumetanide, your spiro, you stop the morning of the C OCP and H RT like we discussed before. So for the combined pill, it really increases your risk of VTA and strokes, especially in smokers. So you actually stop it four weeks before surgery. This should allow enough time to return to normal levels of coagulation. In terms of restarting these medications, you typically wait about two weeks until after the surgery because surgery in itself has a procoagulant effect on the body. So again, if you're already increasing the likelihood of clots, then you're not gonna add in a pill which could increase the risk any further lithium, you stopped 24 hours before antibiotic, prophylaxis, I wrote this up tentatively. I wouldn't worry too much about this. Again. I think it'd be quite unlikely for this to come up. It's quite specialist. Typically it would be things, um, like Cesarean sections. But again, you can search surgical prophylaxis and there's a treatment summary there for you. And then the final thing that I could think of in terms of the perioperative management might be fluids. So when I had a look through the past paper questions and any past paper questions that I tried when it came to fluids in the perioperative period, generally, most of the time it was in a fit. Well, chap, that's going for an elective procedure. That's about 80 kg. So it's basically asking you for maintenance fluids. So he's not eating and drinking. So therefore requires maintenance. But just because this is sort of what has been in the papers before, doesn't mean that it's gonna necessarily be in your paper. Make sure you read, ensure that he's not acutely unwell. He doesn't require any recess fluids, make sure that he's not got any already existing surgical drain or anything else. Um He's not vomiting, diarrhea that would require any replacement fluids. If it's purely maintenance fluids, then I was always taught to remember just really quickly. Uh One salty too sweet. So this is a regime that I still use now in my practice. So the adult requirements for you to remember if you'd like to work it out. This way is that an adult typically needs 20 to 30 mil mils per kilogram per day of water. They need one millim per kilogram per day of sodium or potassium and they need between 50 to 100 g of glucose. So I was taught a regime where you could prescribe a liter bag of normal saline with 0.3% potassium chloride added into it. Then, so that's your salty, your saline and then you two sweets. So you'd prescribe a liter bag of 5% dextrose with again, some potassium in it just to meet your potassium requirements, followed by just a liter bag of dextrose. But again, this is a regime that I found worked especially for, you know, stable patients, non-diabetic patients where the question was only asking me to maintain their requirements, make sure there isn't any other um information being given to you that you might be missing. And like I mentioned before, feel free to take a screenshot. I found this actually quite easy to remember because I've put in bold, the only bits that are really different. So Metformin is only actually different if you're on a three times a day regime, which you only see in sort of more severe diabetic cases in which case you only emit that middle like lunchtime dose you. So all you just er emit the morning dose, they can have it in the evening again and then your sgt SGL T two inhibitors, you admit full stop on the day of surgery. Otherwise the rest you continue as normal. But again, you can find this, this was something that even though it is fairly simple, I used to struggle to remember. So you can find this within the medicines complete and be enough. OK. Moving on to the next section. We're, we're getting there guys sorry about this. Um Providing information. This section is gonna ask you to select, like I mentioned before, the most critical, the most important piece of counseling information to tell a patient when they're starting a new treatment, typically from a list of five. So when I went through all of the past papers, these are some common themes that came up some common drugs. So we'll go through some of them. Now, inhalers reviewing inhaler technique, my favorite resource for this was on geek metics. If you navigate to the inhaler technique section, I used to love the PDF print out and it was just like a a tick box. It was really good for Aussies as well. Um But summarized a lot of the information in summary, if we just go through it very quickly. Now, remember you shake the inhaler, you breathe out gently form a tight seal once you've sort of emptied your lungs and then it's a slow and a steady inhalation whilst pressing the canister ideally, try and hold your breath for 10 seconds and then exhale away from the inhaler. Remembering to recap the inhaler. It's important to tell the patient to try and wait for 30 seconds to a minute between repeat puffs. And then I'm pretty sure this came up in my psa after a steroid inhaler. Remember to tell the patient to rinse the mouth to try and prevent um oral candidiasis, moving on to antidepressants and antipsychotics. So most common come up would be something like an SSRI So counseling a patient starting an SSRI um it's important to remind them that they should not stop the medication suddenly cos you will continue it even for a period when they feel it symptomatically, they are better um in under thirties or those deemed very high risk, you are following them up within the first week of initiation. And this is because, you know, SSRI S and starting SSRI S, it can take for even six weeks before they start to kick in before they start to take effect. So those feelings of hopelessness, the symptoms that the patients coming in with might actually get a bit worse before they get better. So it's really important to warn the patient of this. Um, a lot of patients really struggle if they're started on an SSRI, they're obviously, you know, not in the best place to begin with and then they're starting to take this medication, they're not noticing any therapeutic benefit and it can really, really increase their, their feelings of hopelessness for antipsychotics again, just a couple of things down there, photosensitivity with all antipsychotics im important to tell patients to wear SPF That was one of the questions that I've once come across. Things like drowsiness. This is really important. For example, if in the stem of the question, it says that the patient is a long distance driver or the patient operates heavy machinery. If you're increasing the risk of daytime somnolence, this is really dangerous and patients need to know about this. And then the alcohol is contraindicated with these because it can enhance the effects of alcohol. Lithium might be important to tell the patient about signs of lithium toxicity. So, tremors, hyperreflexia, polyuria, confusion, cloZAPine, agranulocytosis is the big one. Now, obviously, this is one of those scenarios where agranulocytosis might be an option. But if you're gonna tell a patient that you know, cloZAPine could cause agranulocytosis, I wish you the best of luck. I'm not sure that most of my patients would understand what that means. It might be better counseling them on things like infection risk. So they might notice that they get infections quicker, more, easily, more severely, looking out for frequent infections because of this reduction in your cell count. And then finally, sodium valproate. Whilst this is typically not used in women and girls, if it is, then they must be supported on a pregnancy prevention program. So a counseling point is to exclude pregnancy before starting and then that they must remain on highly effective contraception during the treatment, anticoagulants. Um Emily, we've got another question if that's OK. Uh which antipsychotic is associated with photosensitivity. So it's actually all antipsychotics. So if at all antipsychotics, you can tell the patient to avoid direct sunlight as far as I'm aware. Um, if with very high doses, that's typically when you start to see photosensitivity, but it's recommended if you're on antipsychotics, um to use SPF and avoid direct sunlight cool. And, uh, we got, I think you probably maybe, or you could touch on it later when you talk about, um, insulin advice is, er, could you explain the indication of variable versus fixed rate, insulin infusion? And then another one was, what's the fluid regime for dextrose? Um, ok. So fixed rate versus variable rate ID, just to reassure you, I don't think that would come up in P SA, I've hardly had to do that myself, but generally variable rate is what they would use postoperatively because you adjust the insulin dose depending on the need of the patient. And obviously in a perioperative period, um, a patient's going through a lot of physiological stress. They are having periods of nail by mouth, even after uh surgery, especially if it's something like abdominal surgery. When they are allowed to eat, they might be experiencing a lot of nausea, not want to eat. So generally I'd say stick with a variable rate. I find it a lot safer. Um, the second question about the Dextros. Um I'm not entirely sure w what the question, I'm sorry. I don't entirely understand the question, but in terms of maintenance fluids, I was always just taught, you know, that salty bag and then too sweets. So your dextrose is like your, your sweet bags you need between 50 to 100 g of glucose a day. So the dextrose is just ensuring that you're meeting those glucose requirements. Hopefully, that's all right. Yeah. Um or one more just add it is how do you approach resuscitation fluid versus replacement fluid questions? Ok. Um I'll come back to that at the end if that's all right. Um Just cause that's a whole different kettle of fish. And I actually haven't really written up any sizes on fluids, but we can go through that if you want generally when it comes to resuscitation, I would always remember, you know, I think actually I'll just mention it. Now, um resuscitation, this is the urgent fluid. So if you've got a very unstable patient, that's when you're gonna consider rhesus. So these are the hemodynamically unstable patients. These are the patients that you're really worried about replacement fluids are slightly different. So if you have a patient that's vomiting, but it's hemodynamically stable, then you might need to review their electrolytes and in a vomiting patient, they might have a really low potassium, they might other otherwise be quite well, but you'll need to prescribe them a specific type of fluid depend depending on, for example, their potassium level to bring it back up in into range. I don't think you'd get a question on that, but um that's just sort of an explanation on replacement fluids. It's specifically targeting what is deplete within that patient recess fluids are different in that. If you've got a patient that's hemodynamically unstable, you need to stabilize them and quickly. And it is actually quite important to mention. Um Sorry, I didn't mention this before on the PSA platform. It is quite possible to get um marked down even though you think you're putting in the correct answer. So for recess fluids, you're gonna give them a bolus or a fluid challenge. So in somebody like you or I a fairly young, well, no major cardiovascular history. I'm gonna try and get a bolus of five 100 mils and I'm gonna challenge them and put it in over less than 15 minutes. This is typically what we're taught in someone a bit more frail or known heart conditions or heart failure that would be susceptible to fluid overload. Then you know, the priority is to resus resuscitate them. They're quite unwell. So you're still gonna b with them, still gonna push it in, but you might consider a reduced dose of 250 mils. Now, on the prescribing safety assessment platform, whilst you're always taught like over a period of less than 15 minutes. If you actually put in 15 minutes into the platform. From my personal experience, I was always taught at Manchester, you would get it marked wrong because the key point is that it should be over less than 15 minutes. So I'd recommend if you do get a question on rus fluids put in the bolus, put in however much you want to give them. And then I was always entering 10 minutes because yes, it's slightly quick. And then maybe in reality, you might give, you might give it over sort of 1210 to 12 minutes in a patient that is prone to overload. You might need to slow it down a bit more. But um the point is to challenge them to give them that shot to bring them back up into a stable level. So just put over 10 minutes on the platform and then you won't get marked down for the less than 15 minutes if you put 15 minutes, hope that's ok. Um Am I good to continue? Yeah, you can carry on. Yeah, or anticoagulants. So this is one of those really important, um, ones with lots of the time, multiple correct answers are present, but it's important on prioritizing the importance of the correct answers. So, signs and symptoms of bleeding, especially like acute or severe bleeds. So, is there any hematuria blood in the urine? Are you having dark stools? Um Are you having unexplained, large bruises or nosebleeds lasting over the 10 minutes? That might require um m more medical assistance. These are things to tell the patients about Warfarin. There's a couple of counseling points. So it's best taken with food. You need to tell the patient that it requires regular monitoring. So they'll have to go for regular blood tests to monitor the I NR. So initially, when you start a patient on Warfarin until their I NR becomes stable, you're monitoring it frequently. So every 3 to 4 days, then as it starts to become more stable, you'll monitor it maybe twice a week and then when it becomes stable or you've been on it a long time and it's stable, it can go as far as even 12 weeks. Uh Another one to remember is just interactions with certain foods. A funny one that always sticks in my brain is cranberry juice. And then whenever you are on Warfarin, you should also carry with you an anticoagulant alert card. So if the patient's going to a dentist and has a oral procedure done, they should let whoever know that they're on Warfarin on a blood thinner. And then finally doac er an important counseling point for this is that you need to be strict with taking the doac. Um they have relatively short half lives so omitted or even delayed doses can really reduce the anticoagulant effect. Um It can diminish between 12 and 24 hours after the last dose was taken, bisphosphonates. Um in general, even for Aussies, um it's important to let the examiners know that with bisphosphonates, it's important that you're assessing the cognition of the patient, you're providing uh you're prescribing them for. So, if the patient has cognitive issues, they're probably not gonna be compliant with this because you have to tell them to take the bisphosphonate in a very specific way. Um Or else it cause huge gastric irritation. So, bisphosphonates to take with plenty of water on an empty stomach. So typically, first thing in the morning, um, get yourself up, take your bisphosphonate with a big glass of water, then go about, you know, clean the house, do all your chores in the morning, at least 30 minutes before having any food or critically. Any other oral medications has to be 30 minutes plus afterwards and then sort of stand or sit or move about upright for 30 minutes after taking some hypoglycemics to just be aware of. So, again, these are questions that I don't think I really realize until I start to do a lot of past papers. When you're providing information to patients, it's requiring you to understand potential side effects or risks with certain medications, process what they are and then jump to the answer. So there's like a middle step in between the question and the answer. So, Metformin, a common side effect of Metformin is lactic acidosis. You're not gonna be able to tell a patient to look out for lactic acidosis unless they're medically trained they might not know what the signs and symptoms are. So, it's not asking you directly to remember that Metformin causes lactic acidosis. It's you to identify that. If you're on Metformin, you should probably tell a patient to look out for things like dyspnea. So, breathing that fast breathing uh abdominal pain and then to monitor their blood glucose because they might be in DK A uh result in all urea, especially in elderly patients. It's important to monitor for signs and symptoms of hypo S SGL T two. drugs, weight loss is a big one, UTI S and then one that came up, I think for me was S GTL T two inhibitors are commonly caused um euglycemic ketoacidosis. So again, signs and symptoms of ketoacidosis, uh um dyspnea, the abdominal pain, even if your blood sugar is technically coming back as normal when you're monitoring it with finger prick. And then finally just be aware of some insulin sick day rules. Um I do have time to go into them all now. But as a general rule of them, if the patient's on insulin, you shouldn't stop it during sick days because of the risk of ketoacidosis. You need to check more frequently. Um Being sick. I is like a stress response to glucose in the blood is gonna go up. Um Pardon me? So you need to check it more frequently. Typically 1 to 2 hours, including during the night. Theoretically, um you can avoid lipodystrophy by injecting in different sites. So that's insulin methotrexate. Again, we're just gonna glaze over this one. I think the most important one to know is that it's taken weekly, not daily, weekly typically. But again, just check if the stem has any other con um information typically avoid giving with nsaids, trimethoprim and PPIs PPIs because it can actually increase the um amount of methotrexate in the body. And then it has some monitoring. Before again, you can find all this information in the drug profile. Um whenever you look it up and then the key for this one is pregnancy. So this doesn't just apply to females. Um You mustn't be pregnant for at least six months even after treatment cessation. But for males as well on methotrexate, the B NF advises that you use appropriate and effective contraception for at least six months after treatment. So that's something that a lot of people don't realize um methotrexate can cause mucositis. It can cause myelosuppression. So again, whenever you're counseling a patient, you might counsel them on symptoms and signs of anemia. So shortness of breath, thrombocytopenia, any bleeding or bruising, neutropenia, increased infection. And then the most common one lung manifestation is this pneumonitis. So, nonproductive cough, dyspnea, malaise fever, statins are taken nightly. Most common um side effects is myopathy and of the myopathies, myalgia. So, the muscle pains are most common, but you can even get things like rhabdomyolysis. You can't take it in pregnancy. And then like I mentioned before, a couple of um slides from the start, um you can't take it with macrolides. So Erythromycin, Clarithromycin, um statin should be stopped while you complete this course. And then ISOtretinoin a trade name Accutane. This came up in my PSA you need monthly pregnancy tests. Um You also need to be using effective contraception. So one user independent. So user independent method of contraception would be, for example, the I US, the IUD the intrauterine systems, it doesn't rely on the patient to do anything because implanted, user dependent would be barrier protection or things like remembering to take a pill, you can't breastfeed. And then this is the point that's really critical. It can affect mood anxiety and increase suicidal ideation. We've already discussed contraception previously, but this is another common one and then finally, oh yeah, there's, there are just some, some points to read over. Finally, some sections in the B NF that I would really find useful if you're stuck are these ones. So the important safety information, patient carer advice uh and then control f to find the information you're looking for adverse drug reactions. We're getting there guys. Um These are the different types of questions that you could be asked. So you could have an adverse, you could have a, a patient on a specific drug and be asked to identify the adverse effect. You could be presented with signs and symptoms of an adverse effect or presentation and have to identify the drug or you could have a patient coming in with signs and symptoms. You've got like the presenting complaint, history, presenting complaint, and then you've got your drug history and then you've got two interacting medications that could be causing this presentation and you'd have to identify that or, and I used to get thrown by this because I thought this would technically come under the planning management section. You could get a patient, for example, that is on a penicillin antibiotic and they're penicillin allergic and they are in the stem having an anaphylaxis type response. And it's asking you to initiate appropriate management or treatment in response to this adverse drug reaction. So it could be asking you about um adrenaline. Um, whilst this list is by no means exhaustive. This was a list from my own notes that I compiled when I was studying for it last year of just some common drugs that were coming up repeatedly in papers, er, and side effects. I just found quite useful to keep aware of. Again, you would be able to find this. Please don't stress, please don't worry. Er, you can control f these symptoms and signs, but again, if you can just remember a couple of them, it might save you time managing an AD R. So this is that last type of question. Um I'd recommend just having a vague awareness about anaphylaxis, common overdoses managing high. I NR S and hypos, what you might already know initial management. Just some very quick points to sort of implement your knowledge. Anaphylaxis. The adrenaline use is very potent. It's one in a 1000 ratio compared to in a S which is one in 10,000. And then in terms of the doses, the exact doses, the mils that you're prescribing, it varies on age. I'll sign, post you to a resource in a couple of slides. Um some good shortcuts to know all your common overdose management. If you type in poisoning into the search bar, you'll find them all. It will come up in the B NF and in medicines complete high I NR management is found in oral anticoagulants summary section. And then for hyperglycemia, I did it once in a past paper question which was asking me and in the question stem, it mentioned a very cacic low body weight patient. If you have a very thin patient, er really low BM I or the question simply mentions that they're cachectic. Something like Im Glucagon is not gonna be effective. You can't use iron Glucagon because this requires that you already have good glucose reserve and glucose in the form of fat in your body. So if you're cachectic, it's just not gonna work. If you're uh really poor conscious level, you've got a low or drop in G CS, something like oral might not work. So in those cases, if you combine those something like IV, glucose might be your best option. And then for DK A, most of the questions that I came across were mainly about flues. So like we mentioned earlier on um the bolus and then knowing to put in 10 minutes as opposed to 15, this is the resource I was mentioning again. When I came to rev revising, I found resources that I liked, tried to limit the number of resources I used. So I personally had a pass med subscription and just found the past med textbook, the best place in terms of being succinct and accurate and just it's presented nicely, you can check this on the day, but just for time purposes, be familiar with a few common themes. And finally, we're almost there guys, last couple of slides. Um The last two sections, I'm gonna group together as I find that they lead on from each other quite nicely. And when I was studying for one, I found that it flowed. So like drug monitoring, I found flowed quite nicely with data interpretation because often a lot of the monitoring requires you to interpret the data. So questions in this section can ask you to plan monitoring. So typically blood samples at appropriate times. Again, this is all found under the drug profile. If you can't remember in the B NF, the medicine is complete. Just really read. The question is asking you to monitor before they started or after they've commenced the medication And then another really important thing is if you consider, for example, diuretics. So, furosemide and fluid overload. Are you trying to monitor the therapeutic effect or are you trying to monitor for harmful effects? So, if you've got a fluid overloaded patient and you're pumping in loads and loads of IV furosemide, you might do daily weights to monitor. Are we managing to get the fluid off? Hence, are we managing to get that therapeutic effect? So daily weights could be your, your answer or are you trying to monitor for renal impairment? Cos if you're pumping those with this IV diuretic into a patient? It's one of those damn drugs that can cause it. An AK I so diuretics, your ace, your Metformins uh and your nsaids. Um So monitor for those harmful effects. The answer might be using these or daily renal function bloods, data interpretation. Er, again, presenting you with information, asking you to interpret the data that it presents. This could be drug concentrations, typically hemoglobin reviews or white cell counts if we've got those like agranulocytosis medications, er, and then drug grafts and nomograms, I will say, I don't remember, I don't recall having any drug graphs and I used to get myself really worried about them. So try not to worry about them. I've got a few that we can talk through. Now again, this is just uh another sort of chichi that I've combined. Um You can use this to guide any topics, er, or familiarize yourselves with, but please don't stress about covering it all. So, I've got slides on digoxin toxicity and gentamicin monitoring that I'll talk through. But just for the others, um, Carbimazol. When I was looking through my notes, I found a specific past paper question whereby a patient was coming in and they were complaining of symptoms and signs of nausea, vomiting a horrendous, um, irresponsive to analgesia, sort of epigastric, um middle gi abdominal pain and it actually required you to either know, remember or look up that carbimazol can cause acute pancreatitis. And then in terms of the drug monitoring answer, uh one of the, the appropriate answer was ultrasound abdomen. So just remember, it's not always gonna be a blood test. You might be looking at scans, you might be planning all sorts of management here. Agranulocytosis questions. You've got some big hitters here. Er, full blood count would probably be in one of the answers um that you'd be looking for statins. I always remembered liver, liver, liver, liver, you know, you're monitoring a lot of things for full lipid profile, for therapeutic effect, even things like thyroid function. But the liver is sly monitored. So it's monitored before three months and 12 months. So I just find it helpful to remember that oxygen therapy I'm on rest job at the moment. So this is at the forefront of my mind, but oxygen is a drug. It requires prescription. It's really poorly prescribed. And at my trust, whenever we prescribe oxygen, we have to prescribe also the target saturations. So you might get presented with an ABG or a CBG. If you see a CBG, don't be thrown. It's the exact same as an ABG. It's just taken from the air lobe as opposed to stabbing rest patients every single day in the wrist. So you might be looking at the ABG results and trying to work out if this is a chronic retainer. So, is it AC O PD patient that's got terrible lungs that's been really unwell for a long time. And the bicarb is really high indicating that they're potentially retaining. In which case, whenever you prescribe oxygen, you might do it to target ser 88 to 92 and you'd want to use a ventura mask. So you wouldn't necessarily use nasal cannula just because these are really inaccurate at delivering exact amounts of oxygen. Whereas ventura are the most accurate option at delivering oxygen and knowing exactly what the patient's receiving. Uh The other thing to mention with oxygen is just, you know, in if the question stem is acutely unwell patient, you whack a 15 L non rebreath on them until you have some more ABG information to guide your oxygen management. You can always down titrate um gentamicin. We'll discuss azaTHIOprine again. Just a quick fact to remember for any M SK or rheumatological questions. Uh TPMT at this late stage, you know, I think that's a fairly niche question, but it's just about sort of monitoring for toxicity, amiodarone. Remember your thyroid lithium, you're looking for signs of toxicity. So we discussed it before, like tremors, hyperreflexia, um polyuria. It's quite insulting to the kidneys and then finally, low sodium. This has also come up a couple of times. The thing to emphasize here is slow correction. So you can't correct sodium any faster than 10 millimoles per liter in 24 hours. Um If they've had a lot of Saline, if they've been to critical care and they've had some hypertonic saline, then the question might be asking, you need to make sure, you know, you haven't increased the sodium by any more than 10 millimoles in 24 hours. So you might consider holding medications like furosemide or um y sorry, omeprazole and switching it to something like famotidine, which doesn't affect sodium levels so much, but still provides gastric protection. OK. Last couple slides. So Digoxin, I'm not gonna stay for too long on this because I think it's very niche. But again, it's quite easy for them to test. And there is sort of data that you can interpret in the way of this. Reverse TI on ECG. So if you see this, it's a sign of digoxin toxicity, some of the points just while I'm here, potassium can actually really affect your digoxin. So if you've got low potassium, it can predispose you to toxicity. So one of the monitoring questions could be you use. These is the patient on any other medication that's gonna alter the potassium. Are they on a diuretic? And then one thing that I actually didn't appreciate as a medical student. So I really started working was the relationship between magnesium and potassium. They go really hand in hand. So if your magnesium is low, chances are your potassium is gonna be low. So you might need to correct the magnesium or monitor it as well as the potassium, which is then gonna have a downstream effect on your digoxin. And then converting all of this information you can find within the um indications and dose section, final section. Now. So peaks and troughs and graphs again, I'd say not to worry too much about them. They don't come up that often. But if they do, you know, flag the question if you're having any difficulty. So typically when it comes to peaks and troughs, it's gonna ask you about something like gentamicin. So gentamicin is an aminoglycoside. So it has a very narrow therapeutic index and it also can be quite toxic. So it's one of those that requires really serial monitoring. So the peak is up here. Uh I got this graph from osmosis, which I think is an American website, but I found it very useful to sort of help understand and explain. So the peak is the highest concentration of medication and the way that I remembered this is it's sort of, it really depends on how much that you give the patient. So it's gonna peak after you give them the dose. If you get a peak measurement come back and the peak is coming too high, it's because you've given too much of the medication. So if you're reviewing the information and the peak dose is too high, you need to, the peak measurement is too high, you need to reduce the dose. The principle of a trough is determined really by the time that you give the next dose. So you give the next dose before all of the drug is fully cleared from the body. And this means that you're constantly, while the patient is sick and requires the medication, you're constantly keeping them at a level. Even if it's towards the lower end, it's still within that therapeutic index. So that is a trough there. If the trough measurement comes back too high, you try and imagine this section shifted across. So if you were to follow that line down, you've basically given the drug too soon. So I'll try and repeat that again. Cos that was something I found a bit tricky. If the peak levels come back too high, you've given too much of the medication. If the trough levels come back too high, you've given the next dose too soon. If it comes back low, then you've given it too late and you can increase the frequency. So that's just something to learn and then finally, nomograms. So again, I'm loath to really discuss through this one because they're all gonna be slightly different. And it is gonna require you to just take a moment on the day to appreciate what the axis are asking of you. So we've got the concentration on this side and then we've got the time between the start of an infusion and the sample dr on this hour on this axis. So if in the question stem, it says that the patient had X medication at X time and then down later and the information it's asking you to interpret, it's got a little table with the blood at the time at which the bloods were taken. You can go here and identify, really use the normogram to determine whether you need to increase the time between doses. So something like gentamicin is typically given within 20 once in a 24 hour period, but it might be required to sort of extend that period depending on the levels of gentamicin. So it it should be fairly self explanatory. I find these ones a little bit easier to interpret than peaks and troughs generally. But because it's kind of here in front of you and tells you what to do. But the only point I'd like to mention and emphasize here is if you land on a line, you always go up, you always prescribe safe. So if you land exactly on this line here in between 24 hours and 36 hours. Rather than causing an injury to the kidneys, you'd be safe and you'd go for the 36 hour option. And finally, now this is where I've got most of the information from tonight. It's taken from the official PSA sort of blueprint from January, er, from July. And again, just really summarizes where the rise of the PSA get the ideas from most of the questions. So I've had a look through this and tried to sort of sign posts you to the most important points. But I'd recommend, you know, if your exam is tomorrow, make sure you get a good rest, but just have an idea of some of the things that could potentially come up. And then I guess all that that leaves me to say really is thank you for coming. Best of luck for tomorrow. If you're sitting your exam tomorrow, if you're sitting in a couple of weeks, best of luck with your studying, I really would recommend personally from my personal experience that the best possible stance at handling the PSA is good time management and feeling well rested and going in with a fresh mind. You can look anything up that you need to and you can use the flag function if you feel like you're taking too long on a question and come back to it later on. Um These are just my sources as well, so I will hang around for a few minutes if you have any specific questions that I can offer any help with otherwise thank you for attending. Mhm. Let's see. Good. II think it looks like there's not any other questions there. Um, so perfect here. A lot of thank you. Yeah, hopefully that was useful. I feel like that was very much a crash course, but that was great, I think. Yeah. Any more questions guys, if not actually, what did you answer any of the questions on? There's quite a few on from the fluids. I don't, I don't know if they were the ones that you answered before. Uh I think so. Yeah. Yeah, I go through then. Ok, perfect. Ok. Well, I think we'll end the session now. Oh, um I think she asked you if the trough level is higher though. Ok. So the, the trough level was the one that was determined by sliding the graph across. So if the trough level is high, you've basically given the next dose too soon. So you're going to increase the interval in between giving your drugs. If the trough level is low, you need to give the drug a bit more frequently to make sure that that even the trough is within that therapeutic index for the drug to work and then which vary mass should be given. Co PDI don't think you'd be asked that. Um, that's even now on my respiratory job that is typically, you know, uh based on sort of a couple of days worth of information. You, you track what the ABG S and CBG S have been doing. Um uh I think a common one to go with is the 24% venturia. Um But I think by principle, you know, if you all the questions I had come across would be writing up oxygen for like 88 to 92%. So that's um via VM, you might see venturia mask. Um They'd probably just ask you to identify the more accurate oxygen delivery method in which case it would be a venturia as opposed to nasal cannula. Um I think that's everything. Excellent. Well, thank you so much, Emily. It was all right. Thank you. And yeah, I think for anyone worried about the slides, um, this recording should be available after the sessions here, please just fill in the feedback form and yeah, you'll be able to see them afterwards. Um So I think we'll end it there then. Well, thank you so much. Thank you.