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Hi, everyone. Welcome to our first pass the PA session of 2025. Uh My name is Anna. I'm an fy two doctor at Manchester Infirmary. Um and I've got Sophia with me as well. Hi. Um yeah, I'm an E one in Northern Carolina at the top of Manchester. Um I apologize on my phone. My microphone is a little bit wobbly touch wood. Everything's gonna go swimmingly but um just let us know in the chart if there are any problems uh during the presentation. Ok. So let's get started. Um I've just got some learning objectives to go through. So here, here we are. This is what we're going to cover in the first session. So I'm going to teach you how to navigate medicines complete. Um I know most people are familiar with the BNF because from day one of med school, that's what we're used to using. There are some advantages of using medicines complete and sometimes med school just don't go over how to use it very efficiently. So hopefully they can direct you and give you some good tips. Um This session mostly focuses on prescribing, but we will go over some drug monitoring and we've got a calculation question as well. So if we just go to the next slide, this is sort of the structure of the PSA, there are eight sections, the majority of the mites which we'll go through are the prescribing section. And here we can see we've got the prescribing section there. Um Therapeutic drug monitoring section seven and calculation skills, which we'll go over today as well. There is another session isn't there, Sophia that goes more in depth on calculation skills. This is just addressing clinical factors. Um The PSA has a 200 mics and you've got 100 and 20 minutes to go through the exam. So it is very time pressured. You are going to feel rushed, but that's entirely normal. It is sort of reflective of real life situations when you get to working. Some of you might be foundation doctors and some of you may be fine all your medical students, but it is a time pressure environment um when you're on the wards. And so it annoyingly it's true to the NHS. There, there are a couple points here that I'd like to mention um because it's such a time pressured exam and you need really good time management and um efficient use of the BNF. So that includes if you don't know it to just flag it and move on, there's no negative marking. So at the end, if you come back to a question, you're still not sure you should just fill something in if you really don't know the answer to the question. Um I've got some resources at the end as well that will help practice for the PSA, so I know that PSA teaching isn't, we're best covered in medical school. Um, but the best thing you can do is really mock exam style questions. So I'll put you in the direction of some past papers and some question marks as well. Uh It's computer based exam. So make sure you activate all your accounts um, beforehand and have your password handy for the day. Uh And also make sure you go through the BNF and thats complete and know how to use them before you um attempt the exam. So next slide please. So this is our recommended sort of overall timing that you spend on each section based on uh the number of marks. So you can see that prescribing the whopping 80 MS out of 200. So that's why you should spend the most time on it. And the rest of the questions um are two mics each usually. So things like, um providing information that should, that they really shouldn't take long. It should be 30 seconds per question. Whereas calculation we've allowed a bit more time because it could be a bit tricky with two or three step questions that you need to, um, make sure that, you know, um, you're working out too before you answer them next slide please. Ah So yeah, this is the prescribing section. Um So this is from the PSA blueprint so published by the British Pharmacological Society. Got a link at the end as well. Of which are the common topics that come up for the prescribing section which is obviously very useful to know. So you know which topics to revise the sort of saying that the the blueprint it emphasizes sort of there is a base knowledge that a minimally competent foundation doctor should know. So yes, the BNF will help you, but there are some things that are not in the BNF that you will need to know. And that's why it's important to go through these topics as well beforehand. Um If we just go to the next slide, please, um Oh, just before I do, could you just go back? Um So the is style usually represents a clinical scenario and then it asks you to prescribe a single appropriate medicine or an IV fluid. Um And so it's usually 10 marks. So five for the correct drug and five for dose frequency. Um and for IV fluids, it's slightly different. I think it's um rate uh volume and something else that's not rate, volume and duration as well. Um So how it's marked, I'll just go on to that next, you get five for the medicine and the most optimal medication will score five points. And then the British Pharmacological Society, uh PSA organization will um preemptively come up with other uh drugs because inevitably there are, there is some variation of what you can prescribe and what's appropriate to prescribe and we'll rank them from sort of 4 to 0. Um And then you can also get marks for uh the dose route and frequency. I think one thing to know is if you prescribed an inappropriate drug um or a sub optimal drug, for example, that's worth two marks. You can only then score two marks in the dose route frequency section as well. Um So yeah, next slide please. Um then we've got the drug monitoring section. So that's eight questions, which is two marks, which are two marks. Each. Um Common topics include, you know, digoxin, insulin, methotrexate, amiodarone, um carbimazole and levothyroxine statins, things like that got a handy list there. So again, these, this is typically not on there. There are some medications that have monitoring on the drug monograph page, but some of these don't have it on the drug monograph page. So it's useful to go over these topics and find out the monitoring requirements for each drug. We we obviously can't do that for every drug that could be included in the PSA going until like 10 p.m. So um there will be, this is just to guide you in the right direction. Next slide, please. Um And then calculation scales like I said, we've only got one this, so it's spend too much time on it. But, um, sort of again, an overview of what could be included in, in that section too. Uh, so you do have access to the BNF during the exam. So, like I mentioned before, you've got access to either the BNF and the BN FC or you've got access to the BNF through medicines complete as well. Um, and because the medicines com, uh, everyone's sort of familiar with the BNF. Um, so I'll just go through medicines complete for snacks. Um This is sort of an example of why I think it's useful to be familiar with medicines complete as well as the BNF. For example, I don't know if you've ever been in a and you've got to prescribe for a community required pneumonia and you're sat there with the ipad and you're panicking typing in pneumonia, nothing's coming up on the BNF. Whereas if you go on to, yeah, medicines complete. If you type in pneumonia, the search function is just miles better, more advanced. So it will come up with the right treatment center which is a respiratory system infections, antibacterial therapy. Whereas on the BNF, that's just something you need to know. That's where pneumonia is. Um It's just such a, it's just more comprehensive search engine than the BNF. So next slide, please. Yeah. So this is the home page. Your medicine is complete. You would then scroll down this little arrow at the bottom. Um And that would bring you to the next page which would show you um the B NF and the B NFC, which you will have access to during the exam. And then if you click the BNF, for example, it would bring you to this. Uh There are some real key areas here um to look out for. So you've got drugs which will obviously have all your drug monographs on there, the treatment summaries, um such as respiratory system infections and guidance. And we'll just go through what each of these pages include. So the first one we've got is treatment summaries. And you can organize that by either condition or by body system and it's um arranged alphabetically and then you've got your drug monographs as well, which is also arranged um uh alphabetically, although most of the time it's just quicker to search the drug instead of going through the drug monograph page. Um And then also guidance. So this is where all of our lovely, you know, prescribing palliative care pages lies prescribing a hepatic immuno impairment. Um So these are also really important. Um And it's just nice that's all grouped together on meds complete, right? So I think that we should attempt the questions now. Um Let me just check, check to see if there's any questions. No. OK. Shall we start, get started on the questions then? So I'm gonna give roughly a attempting to promote, but we'll read out the question to you. So we might just spend a little less time, um, for the prescribing questions. So you have enough time to look through the BNF and actually come up with a prescription. So let me just get a timer. Um, um, we're gonna go through all of the questions, 10 questions, one after another. Um, and then after we've done the questions, we're gonna go through the answers altogether. So if you haven't already just have BNF open, um, if you're familiar with medicines complete, you can have that open as well and have a piece of your piece of paper and a pen ready. If you need to jot anything down, you'll get a piece of paper and a pen during the PSA as well. So give 10 more seconds for everyone to get the F in and then we'll make a stop. So the first question, um, so this is a 42 year old woman who has severe upper quadrant pain and vomiting for the past two days with a history of gallstones. And you can see that they've got asthma and eczema. Um, on examination, drowsy, pale, high heart rate and a low BP that she does have one peripheries and normal heart sounds. You can see the bloods ecg shows sinus tachycardia, chest X ray is normal. So your task is to write a prescription for one IV fluid that is most appropriate and you'll have approximately 2.5 minutes. Let's go. This one should be relatively easy. So we'll move to the second question. So this is a 69 year old man on the stroke ward, having experienced right hand dysphasia starting around 24 hours ago. He's currently n by mouth and he on examination, um normal temperature, heart rate is fine. BP is slightly on the high side in keeping with his hypertension. J BP is not visible. Heart sounds are normal, no peripheral edema. He's catheterized and he's got a urine output of 80 MS per hour. His estimated weight is 80 kg. You can see his blood results that are largely within range and his CT shows are in keeping with his stroke. So far, he's received two bags of sodium chloride with potassium, both 1 L, both over 12 hours. So your task is to write a prescription for one IV fluid that is most appropriate. That's one minute four, that's two minutes and that's two minutes Thursday. Thank you. So, don't worry if you struggled on that question, IV fluid prescribing is always a tricky one third question. A third year old woman is in the emergency department with irritability and drowsiness. She's dropped her G CS from 15 to 9. She's got a past medical history of type one diabetes and normally takes novorapid and Lantus on examination. She is unresponsive and clammy temperature is fine. Heart rate is on the high side, but it's regular BP is ok. Um And saturating fine as well. The BG is done, make note of those results and the prescribing request is write a prescription for one IV fluid that is most appropriate to treat her symptoms. So, to answer this question, um, this requires a certain level of background knowledge that Anna was talking about before. That's two minutes and that's two minutes. 30. Thank you. Next question. So, 23 year old woman presents to the ed with one day history of ABDO pain, nausea and vomiting doesn't have any past medical history. And on an examination, she's drowsy and she has a normal temperature. Heart rate is elevated. BP is low. Her respiratory rate and oxygen saturations. Um her respiratory rate is a bit high but her oxygen saturations are doing ok. She's 60 kg and make note of the cap, the cap glucose results and she's had an ABG as well. So the prescribing request is to write a prescription for the initial insulin therapy required to treat her DK A. So this one is pushing the limits of what you would be asked in the actual PSA but still something that you could be asked. That's two minutes. That's two minutes. 30. Thank you. So that's, yeah. So we've got a 34 year old man presented to the emergency department with two day history of worsening shortness of breath and chest tightness and wheezing. He's been using his reliever inhaler more frequently, but it's not working, feeling increasingly fatigued and his symptoms are worse at night. He's got a history of asthma and hay fever. He's on a inhaler, two puffs daily inhaler is required. Um, the social history is listed there. Uh, on examination, his obs are listed. You can note he's tachycardic and his respirate is elevated and his doctor down. Um, despite being on 15 L of oxygen via non breathe mask, he's not able to complete centers on examination and he's got a bilateral diffuse expiratory. Wheeze. The question is asking you to write a prescription for one medication that's most appropriate to treat his symptoms. And I'll just give you a minute to answer this. Not a minute. Sorry, two minutes and 30 seconds. One minute so far, two minutes so far, 2.5. Great. I moving on to the next question, we have a 65 year old woman presenting to A&E with a two day history of worsening shortness of breath and a cough which is productive past medical history of COPD, uh type two diabetes and osteoarthritis on Metformin 500 mgs twice daily. Salbutamol inhaler is required on a psa inhaler twice daily. Um, temperature is borderline, heart rate is 92 minutes a bit raised BP. 100 and 40/85 respirate is raised. Oxygen saps are 88% on air. You can notice she's using accessory muscles, um, breathing and can hear bilateral wheezing surgical crackles on auscultation. She's commenced on oxygen salbutamol and I nebs write a prescription of one additional drug that is most appropriate. I'll give you another 2.5 minutes for this one. After this. We'll be moving on to the short of questions. Two minutes so far. That's 2.5 minutes. Thank you. Moving on to therapeutic drug monitoring. You have a, um, a minute per question. 50 year old, 58 year old woman is commenced on atorvastatin for the secondary prevention of cardiovascular disease following a recent MRI uh PMH of hypertension and ischemic heart disease. On bisoprolol 5 mg once daily. Aspirin, 75 mg once daily and 10 mg once daily. Which of the following is the most appropriate investigation to monitor for adverse effects atorvastatin after three months of treatment. And that's one minute. Thank you. Next question. 50 year old woman is commenced on levothyroxine for primary hyperthyroidism. At what time intervals should thyroid stimulating hormone be checked during the first year of levothyroxine therapy? That's one minute. Thank you. 29 year old woman is being reviewed in the outpatient psych clinic following a recent discharge a week ago from the ward due to schizoaffective disorder with depression. The clinic is to review her cloZAPine medication due to previous treatment resistance, OLANZapine under so that the most appropriate parameter to monitor at this point in time, the patient undergoes this new treatment. That's one minute last question. Well, than everyone getting their eight year old child with a history of epilepsy presents to the emergency department and status epilepticus. A loading dose of phenytoin is administered. You are asked to prescribe a maintenance dose of phenytoin sodium. The child weighs 24 kg. It's available as a 250 mg per five mil ul which volume of phenytoin should be administered per dose to two decimal places and that's time out. So uh very well done everyone for getting through those 10 questions. I hope you didn't find it too stressful, but also a little bit stressful that so that we know you're learning something. Um So we'll go through the answers. Um So starting with the fluids questions. So, prescribing in general is the most intimidating part of the PSA and fluids in particular, always make everyone very confused. So the easiest way to think about it is four different categories, recess maintenance, um whether you're placing anything um and any additional fluids that you might need to give. So well. So for this first question, she's hemodynamically unstable. You can tell from the high heart rate and the low BP. So fluids to give is a rhesus fluid, a crystalloid fluid and that is typically 0.9% sodium chloride or plasma, light 500 mils given over 15 minutes or less. Um Sometimes you say stat, but um the b the PSA doesn't actually let you type stat into it. So it has to be 15 minutes or less. So if you got that correct correctly, then you can give yourself 10 marks. These are other acceptable answers. So this is what we were talking about before. So we have to get the drug itself correctly and here they only accept crystalloids or ringers or Hartmans will talk about those a bit later. Um And if you've got on that, then you can award yourself five if you got it correctly for the rest of the answer. But if you didn't get any of these fluids, then you get zero marks. So that's why it's really important to know um the drug that you want to prescribe. So as you know, we have to give resource fluids. This page isn't actually on the BNF. This is taken from the nice guidelines. It's some of that background knowledge that you just have to know. You give a bolus 500 mils over less than 15 minutes. Um Very unlikely. They will give you a sort of question whether the patient has heart failure and the answer is 250 mils, it's more likely going to be 500 mils. So just try to memorize that it'll be useful for a as well. Um This is what it would look like on the actual P SA um platform on the software recommend. If you don't already have an account, you should do an account on the PSA official website. And there are three practice papers on there that you can have a go at, they will get you into the rhythm of the format of questions, but we all found that the questions on the practice assessments are a lot easier than what actually shows up in the actual exam. Um Did you want me to go through the uh website, the prescribed safety assessment website quickly? Um We could do it at the end at the end. Yeah, no worries. Thanks, Anna. Um So this is a brief table of all the different types of fluids you can prescribe. It's taken off the nice website. It looks very intimidating. But the key things that you need to know here are the sodium chloride 0.9 uh the glucose 5% and the Hartman's and sometimes you'd also um give sodium chloride 0.18% with the 4% glucose as well as a maintenance fluid. Um But there are other types of fluids out there as you'll see on the PSA website. Um It'll come with a longer list of um different types of fluids, but those are the main ones you need to know about. I say that it's quite cheeky because the next question doesn't have any of the fluids mentioned in this table, but we'll get to that. Um So just try to remember the sodium of sodium content of of each of these fluids and the potassium. So for the second question, so he's he hemodynamically stable. So we know that he doesn't need recess fluids. He is nil by mouth. He's had a stroke. His urine output is ok. We know that um, anything over 0.5 mils per kg per hour is ok. So he's doing great. So he doesn't need any recent fluids. He needs maintenance fluids. So this is a bit of a tricky question. And if you got this right, then you're sorted. But this question is here to demonstrate how you would work through giving maintenance fluids. So the answer would be glucose, 5% potassium chloride, 0.3% solution 1 L over 12 hours. And these are the other acceptable answers. So we'll go through it step by step. So, maintenance fluids, we have a daily requirement of water, sodium, potassium and glucose. Those are, those are the four main components of maintenance fluids. And so we know this patient is 80 kg. So they would need approximately 2 L 2.5 L of water, 80 millimoles of sodium, 80 millimoles of potassium and everyone regardless of weight needs about 50 to 100 g of glucose. So what we can calculate so far is that they've had two bags of the 0.9% sodium with the 0.15% potassium chloride. You just kind of have to know that 0.1% 0.15% potassium chloride equates to 20 millimoles. Um And that's 1 L of that bag 1 L of potassium chloride, 0.3% equates to 40 millimoles. Um And we'll talk about how we can think about percentages and um conversions from um liquids in a second. Um But that's just something that you'll have to remember. Unfortunately, so we can calculate um that this patient has had 2 L of water. They've had 308 millimoles of 40 millimoles of potassium and no glucose. So this patient is very much at risk of sodium overload. Um and is in a potassium deficit and has received no glucose. So we need to top that up. Um So the best options here would be the glucose 5% and potassium chloride 0.3% over 12 hours, this might make it a little bit easier to show you. So when you write glucose in the psa, um it will give you a list of solutions and you can see the only two options here are glucose 5% um with the potassium chloride, 0.3% solution. That's the only one that matches exactly what we need. I appreciate that you might not have had access to this beforehand, but it's always useful to think about what is the patient in deficit of and what do they need. So, as a summary, this is on the left side, that's what the patient got um after their two bags of sodium chloride with the um potassium and then the middle one is what they'll get after their prescription. And the last one is what their ideal would be. So you can see you've gotten enough water, they still got too much sodium, but the potassium is getting there and the glucose is getting there and their next bag could always um compensate for that. So if you made a note that this patient needed glucose and this patient need so needed uh potassium and give yourself a pat on the back next question. Um So this is a hypoglycemic glycemia question. So they've already got a background of type one diabetes. Um And their G CS is dropping, you can see that their um glucose is 2.2. So they're having a hypoglycemic episode. And the best thing for this patient would be to give them glucose, they're hemodynamically stable. So you don't need vus fluids. So you can appreciate that. Um It might be tricky to find the exact volumes on the B NF. We'll talk through that. So if you type in hypoglycemia on the BN F, it will give you um roughly what solutions you need to give. So it says glucose, 10% or glucose, 20%. Um If you wrote 50% then unfortunately, that would not score your mark because as it says, um it's not recommended as it's hypertonic. So this is another useful page that medical emergencies in the community page actually shows us the exact volumes of glucose that we need to give and you can see here if you gave 10% then you'd need to give this adult between 100 and 50 to 200 mils infused over um 15 minutes and 20%. And just to note that medical emergencies in the community page is also very good for peds prescribing. For example, in a, in a patient who you suspect has bacterial meningitis, um which dose of benzyl penicillin to give? Yeah, definitely. No, we'd highly recommend the medical emergencies and community page just have a look through those. Um And it's useful for acies as well because you could be asked um any of those scenarios in your Aussies. Um So this is another question on how to convert between percentages of um glucose and bringing that into grams. Um A lot of people do get confused about what does this percentage mean. So if you just think about if 10% refers to 10 g in 100 mils um and write that down on a piece of paper, even at the start of your psa exam, just write it at the top of your um uh B blank piece of paper. It will help with your conversions and dose calculations later on um fluid prescribing top tips. We did also have the answer in question. I think it's after this top tip section. Um But so the main top tips for fluid prescribing uh think about whether it's any of these four scenarios. So recess fluids um correcting the emergencies. So that's like your hyperkalaemia, hypercalcemias and your glucose, your hypoglycemias thinking about whether it's maintenance and then replacing any fluid losses. And we've made a little handy table here for you just to go over it. This is the easiest way to think about fluids in the PSA and in clinical practice, just take a screenshot, you'll have access to the slides later as well. Um And if you just try to memorize this little flow chart, then you'd be able to um just prescribe fluids in any scenario. There we go. Insulin question. So this question already told you that she's had a DK A and it requires you to have that clinical knowledge on how to treat AD DK A I think of it as VIP treatment for people in DK A. So you need to give them volume insulin um and potassium. So um assuming that you've already given the insulin, this question, the resource fluids. This question is asking about the insulin and the most appropriate answer here would be the soluble insulins such as actrapid, uh dose would be six units given intravenously. So we'll talk through this question. Insulin prescribing is quite a hard one other acceptable answers. Any of the soluble insulins got novorapid, Apidra HumuLIN or HumaLOG and give six units IV. So we know for DK A we need to give 0.1 units per kg. Yeah, it's a fixed rate um of insulin. The B NF doesn't exactly have any clear guidelines. It, the nice page does but it redirects you to the JB DS guidelines. And so we've highlighted it here. So if you've memorized this, then great, you know, you, you have to get a traffic or human s at 0.1 kg per hour. But the PSA um system does also help you a little bit. So if you know, you have to give insulin, it gives you these options on what you can prescribe. I think of um anything that has like rye in it, like novorapid or um act rapid, acts either rapidly or is a short acting insulin. And the ones that begin with l like Levemir and Lantus are the long acting ones, glargine as well, longacting and lodging. Um So if you search in the B NF, um just type in insulin, it will give you a summary page of all the different types of insulin. Um And if you already know you have to give some type of soluble insulin, then it would point you towards insulin aspart, which is just the generic name for novorapid. And so that's why these ones are all accepted insulin, Gluta as well as, and that's a Pedra and um Lispro as well. Alternatively. So if you're familiar with the monograph of the, of a drug on the BNF, if you scroll down, um it will have um medicinal forms and you can click on that and it will show you um how the drug is actually available to administer to the patient. So, um if you, if you click on that, it will show you this page on which ones are soluble to give to the patient. And again, it, it reiterates that you could give novorapid or s so it just shows that there are multiple ways to reach the right answer. Um But just knowing where to find it. So click around on the BNF. Um familiarize yourself, familiar, familiarize yourself with using control F as well to find specific things that you need and get used to using the search bar. Um which would be very helpful for adverse drug reactions. Things like typing the drug using and, and typing each reaction in turn to see which reaction matches with it, which drug and medicinal forms is really useful for fluids as well. For example, if you, if you've forgotten which fluids have potassium in them, you can look up potassium chloride and go on to medicinal forms and solutions for uh infusion and it would come up with the um with the available fluids that you can prescribe, that have potassium in them. Um Just a quick summary on the difference between DK and HHS. Um The way we think about it is DKA is something that type one diabetics tend to get and it tends to be a very acute thing that happens. Um The reason being is because um it's acute because of that build up of ketones and so their blood sugar tends to go up a lot faster compared to patients in HHS. The patients with HHS tend to be type two diabetics who have had diabetes for a longer time and they slowly build up their blood glucose. So the body can kind of compensate for all these little changes over time. So they tend to present less acutely. Um but when they, when you do find they have a HS, they tend to be very, very dehydrated, they have a very, very high blood sugar. Um And that's one way you can differentiate between these two conditions. HHS is slower, older patients type two diabetes. DK A tends to have more acute, more pain, more vomiting tends to be in younger patients, type one diabetics. I'll pass on to Anna for the rest of the questions. Thank you. And this shouldn't take too long because uh they, they're short of questions and I'm not actually going to go through the, the actual treatment of asthma and COPD just to point you in the right direction on how to get to these answers. So if you go um back, actually back a slide and this is the answer that's um on the question, sorry, on the prescribing, I didn't go through it. Sorry. Yeah. So, um you have to be able to recognize that this man is having a severe asthma attack, um, that sort of evidence by the fact, his saturations are low. Despite uh oxygen maximal oxygen therapy, he's unable to complete sentences and has an expert wheeze despite already having his albut inhaler. So you have to figure out that um this patient will need nebulizers instead of an inhaler. And the right drug to give would be salbutamol in this instance. Um 5 mg, although you can't, I think um I think 2.5 mg is also an accepted answer and 50 minutes or 30 minutes would be acceptable as well. So you press next. Um Yeah, there we go. 2.5 to 5 mg repeated every 15 to 30 minutes or when required to P RN as well. So this is, I guess, I guess what I want to point out is by this question is if you know what to prescribe, search the drug first because you're skipping steps. So salbutamol should in theory come to mind if it doesn't. That's OK. We can go through how to get to the answer. If you just type into salbutamol, you'll be able to um get to the answer more quickly. Um But if you don't know what to prescribe, you can go on to the treatment summaries and look up asthma acute. There's also a separate treatment summary for asthma chronic. Um and then you can skip two management adults which is highlighted and purple there next slide. Um And then we were talking about using control F um So you could use control f then next slide to type in neb uh oh sorry. And it would um jump quickly to the, the relevant section and you can also type in Neb and it would jump to the nebulizer section as well just like that. And it's honestly, it's, it's annoying but these tips do actually really help with your time management and the PSA and it's what's going to make the difference. You, you need the time to think about the answer. You shouldn't use the time to route through the BNF, which is why it's so important to be familiar with meds complete and the BNF before the exam. Uh Next question, please. So we've got um a woman, 65 year old woman with an acute exacerbation of COPD. Uh the, the temp is borderline so it could be infective um or not. But in either case, you would be prescribing prednisoLONE. Um um And then that would be a 30 mg um dose for five days. Uh And it'll be once a day as well to be able to get to this. Um You would either realize, sorry if you could go back a slide, sorry. So she's already on it for an additional treatment. So she's already on oxygen, salbutamol, ipratropium nebs, there's not much else we can give her in the acute um acutely other than the prednisoLONE. And if sex slide, um either predniSONE will come to mind or you'll have to go to the treatment summary uh where there is a COPD page and then um on the left hand side and meds complete, it will come up with this um section where you'll be able to see management of exacerbations of COPD. So part of the question is being able to recognize as an exacerbation um of COPD and working from there to see what's most appropriate to prescribe next slide. Um So here we go. Short acting, inhaled bronchodilator. So I already prescribed the salbutamol nebs and can also um give Pitro Nebs alongside this um and in the absence of significant contraindications. So this example of contraindications would be like adrenal insufficiency. Um And you would click on then predniSONE, it will just take you to the drug monograph. Um Just hold on one second. Yeah, next slide please. And then once you click on prednisoLONE, uh the first indication that comes up on the BNF will be acute exacerbations of COPD. Um And it gives you the exact dose. Perfect. And then we've got um a 58 year old woman who's commenced rheumato a statin. So we're moving on to therapeutic drug monitoring. Now, this could catch some people out, I think um because some things obviously come to mind when we're thinking statin therapy, we're thinking we probably do need lipid profile and we need um a liver function test likely and creatine kinase. What that sounds kind of right? You can get myalgia when you, when you commence from statins, but it's about what is routinely monitored at three months of treatment. And that would be liver function tests. And you can actually get this on through the BNF. But there are some drugs where you won't find the monitoring requirements. So if we went to atorvastatin on the BNF, as the drug monograph, next slide, we can jump to monitoring monitoring requirements and it would show you that um before starting treatment with statins. So not at three months, but before we need baseline lipid profiles and triglycerides, um TSH and renal function, but at three months, it would, it's LGS that we need and we need to repeat that at 12 months. And then um in terms of when it should be continued and discontinued because that's another question that can be asked on the PSA if it's not more than three times the upper limit, then um it, it can still be continued. And then I wanted you to just talk about CK as well because it's a common thing that comes up um during, sorry, it's 8 p.m. So thank you for everyone who um joined us for the hour. We won't take much longer to finish the session, but there is a feedback link in the chat as well. Um So yes, Creatine kinase, this is only needed if the patient has unexplained muscle symptoms. And the only reason to discontinue it is if it's five times the upper limit of normal and if it's less than that, it's very unlikely that it's um, the cause of their muscle pain is due to statins and other things should be explored. Other diagnosis next time, please. Um You have question eight. So II was a bit annoyed actually because um I edited this answer slide. I didn't answer, um, edit the question slide and I wanted to keep it vague by putting thyroid hormone treatment for hyperthyroidism instead of a natural question. I put levothyroxine. So that was going to be another for you to figure out what exactly which drug, which drug is it. And then what do you do monitoring that drug? But we've given it away already with levothyroxine. Um And so how often should you be checking TSH during the first year of hormone therapy? Um This is every three months until stable again, you can find this in the B NF. So press next. Um If for example, you forgot because our minds are funny things. It's time pressured environment. You, you forget what, what, what drug it is that you use in thyroid hormone replacement, you could just type in thyroid. And this is what I like about meds complete is because this wouldn't ordinarily come up on the BNF um itself, but it will come up on um meds complete. If you type in thyroid, the treatments for me for hyperthyroidism will come up. Um And then press the next slide, please. Um Yeah, I was just showing you what will come up if you type in thyroid in the BNF, like this is just useless for when you're in an exam next slide. Um And then it will show you that it's levothyroxine that's used. Um And it says also to measure TSH levels every three months until stable levels have been achieved. And then yearly after question nine. So then we've got a 29 year old woman who started on cloZAPine. And um it's a bit of a tricky wording on this question, I think because they ask you the most appropriate parameter to monitor um at this time whilst they undergo this treatment. And I think the key um thing about this question is the most important parameter. Um and it's for blood count and that's because clarine most notably and also severely causes can cause agranulocytosis and is the most important side effects to be aware of. But there are, there are other things that you do need to do. For example, you need to do blood lipids and wait at baseline at three months and yearly. And that's because of the metabolic side effects of um all antipsychotic drugs, but um including cloZAPine, but the most important would be um the the full blood count to um monitor the risk of agranulocytosis. And this is just from the PSA blue print, which I will link at the end as well about therapeutic drug monitoring. Um And it just says at the bottom, there are examples of prescriptions that might require appropriate monitoring or digoxin for atrial fibrillation, inhaled corticosteroids, oral contraception, levothyroxine. And they're just mm um examples that can come up and likely are to come up in the PSA and uh worth revising um before you uh sit the exam. Um And then our final calculation question, we've got an eight year old child that's in status. Um They've clearly not responded to initial therapy. And so Phenytoin is administered um and a loading dose has already been given, so been given. So you need to figure out what um maintenance dose needs to be given per dose. So if we go to the BNF or meds complete, we can find stasis epilepticus. Um and you need to make sure you're on the BN FC and it will, and you need to identify the child is eight years old. So this is the correct um section one month to 11 years to be looking at the loading dose is stated and then you need uh 2.5 to 5 mgs per kilogram twice daily. So that's per dose. So five mgs times by 24 kg um which is stated in the question is 100 and 20 mgs. And so um we've got this sort of dose over volume times concentration triangle, which is another thing that you can jot down before the exam um starts just so it's there and you don't have to figure out what it is before you've been bombarded with like 100 and 50 questions. Um And so if you do 100 and 20 then the concentration needs to be in milligrams per meal. So 250 divided by five would give you 50 mg per meal and 100 and 20 divided by 50 will give you 2.4 meals. Um because it also ate 2.5 mg. You can also accept an answer 1.2 mils. Um We didn't go over contraception um contraceptives in this, but we do have another session later on that will go over contraception. Um But this goes to show you how important meds complete is as well because if you type contraception meds complete, it will come up with um uh all the relevant treatment, summaries including the um IUD. And then if you press next, you can also just search missed pill, which is important in um I think it's is it communicate, communicating information um and it will come up with the relevant drugs as well. So um I just think, yeah, it's worth learning how meds complete works as well. Next slide. Um And then this is for upcoming um sessions. So you can look at this before we, you come to our next session on Thursday. Next Thursday is appendix one. And it's just common interaction and common side effects from certain drugs. Uh really worth looking at um and then I've just also included some useful resources too on the next page. So this is the psa blueprint. It's the curriculum set out by the British Pharmacological Society about how the exam is structured, what the aims are of each question. And I think that if you put yourself in the mindset of the person who wrote the exam, you will be able to understand the exam much better and understand what they're looking for as well. Uh The British Pharmacological Society themselves have got nine free e-learning modules that goes through how the exam is structured as well. I think it's really worth doing that again just to get the idea um of the structure of the exam. Um and it's also from the official people who've written the exam as well and there are mock papers available to purchase, but I would recommend that you go to the prescribing safety assessment website, which is where you'll be taking the exam because there are three free mock tests that you can do, which I can show you as well. Um In terms of question banks, I know Ki Medics has a question bank and so does, oh could you just go back? Sorry. And so does passed. Um And here's a little link to the appendix, one interactions and script modules as well. There are these are sort of um free modules available to any medical student and foundation doctors um as well. And there is just a few modules that you can do monitoring medicines would be useful for therapeutic drug monitoring and toxic tablets as well. So I think we did hit all of our learning objectives today. Just to remind me, remind you, we went through navigating meds complete. We did some prescribing, including some fluids. Um, insulin went through aspirin CVD and then went quickly through contraception and we managed to hit some drug monitoring questions as well. Um Let me just share my screen so I can show you the prescribing safety assessment website. I have got it up. I do bear with me. So here we are. And this is the website once you've logged on and then if you just scroll, you can get onto assessments and um, if you click on this little tab here, you can get to practice assessments and on here will be mock tests that you can do. Um, and you can attempt them as many times as you want and reset the results as well. And then I'll just show you the format of uh the exam as well. And it's just really useful because this is exactly how you will see it in the exam. So if you know what the interface is like, you won't be surprised by it when you get to the exam, that's the last thing you want to worry about. And this is how they're usually structured. You've got a case presentation, an examination and some investigations first um you can type in any medication, for example, probably you want furosemide. In this case, you can um type in which tablets you'd want and dose and um the route as well. And then you just press next, you can also flag this would be flagging the questions to make them for review at the end. Um And then you can just see which questions are flagged as well because they'll be, they'll have the little orange mark on them. Ok? I don't know if you wanted to go through the next upcoming session. Sophia. Yeah. And so if you haven't filled out the feedback form already, we'd really, really appreciate it. It can help us learn for the future sessions. Um I'll just go over the next few um sessions that we have coming up. So if you haven't already as well, we've got a link tree. Oops. Um and we've got all the things on there such as how to sign up to our next session, how to join our mailing list, um and all the future sessions coming up as well. So um our next session is next Thursday at 7 p.m. on the 16th of Jan and we'll go through some of the other sections of the PSA um and we'll be running through to the 25th. So the 25th is a Saturday. That's a bit of an odd one. And it's gonna be at 11 a.m. Um So we look forward to seeing you at all of these and just to make you aware as well, we have a word finals series coming up in March and we'll be going through each of the main categories of the MLA and going through 10 high yield questions in an M CQ format and similar to today. We'll give you the questions and we'll give you the explanations as well and any top tips to help you pass. Um Does anyone else have any other questions? Oops, I'll just put the link tree you back into the chat, but thank you very much for joining everyone. Um We know we went over time a little bit but uh your feedback really does matter to us and we do make changes if you take on board. Um So do let us know what you thought of it. We really hope it was useful and gave you a brief overview of how to um, do the P SA and tackle those questions. Um So all the best and hope to see you next week. Thanks so much, everyone. Thank you.