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One that's doing that. Still doing ok. And are you able to let me see? Oh, I can. Oh, yeah, I can. If I click on it, that changes for you, doesn't it? Ok. Yeah. Yeah, it changes for me. Ok. Ok. I will keep an eye on, on the chat then and answer any questions that come up. Amazing. Thank you. Um, yeah, I think that sounds great. Let's just wait for people to join. Um, three months. Yeah, we've got some people already here. I can see. So we'll just give a few minutes and then hi, everyone who, who's already watching and we'll give you a few minutes to let people join and then we can start, um, if you could just let us know if you can hear us just so that we, you know, we're not doing, uh, we're not accidentally just talking to ourselves just like a, a yes or a thumbs up would be appreciated. Deathly silence. Ok. That is racially. Oh, wait on the chat. Yeah. Ok. Mhm. Oh, also those of you who, um, are here already if you feel like you have a spare minute, if you don't mind scanning the QR code, there's a little, um, survey that we're doing at the moment. Um If you could spare us a few minutes for that, that would be great while we wait for the rest of you guys to join and we're just gonna give one or two more minutes and then we can get started. Ok. All right. I think, let's get started here. And do you mind just waiting yourself for the moment because I think I can hear an echo mix. All right. So, hi, everyone. My name is Milly. I'm one of the F one doctors working in East London at the moment. And, um, yeah, I'm currently working in Psychiatry and I'll be doing your session today on A PSA and I've got Aeron with me, Aeron. You can say hello as well if you want to help yourself for that. Um, if you want to. Hi, good evening. All. My name is Erin. I'm one of the, uh, military F I ones currently working at, uh, in the northeast. I'm on vascular surgery. So, prescription review and Ad Rs. That's just something I do almost every day. I'll just be monitoring the chats and, uh, doing some polls and things for you guys to get some interaction. Thank you for joining. All right, let's get started. So, this is our third session of our PSA series that we're doing at the moment. So we're gonna be focusing on prescription review and adverse drug reactions two of the sections are covered in the PSA. Um, so with prescription review, we want to really ensure that you can systematically review them. As Aaron said, it's something that you'll do on a day to day basis as a doctor as well. Um, things to look out for would be things like dosing errors, contraindications, withholding medications, um, and nephrotoxic medications and adverse drug reactions. Again, being aware of some kind of drug reactions that are fairly common. Being aware of interactions with, with drugs itself, the side effects toxicities, um and how to treat adverse drug reactions as well. So we're gonna start by talking about prescription review. Prescription review is after prescription section, your second biggest review, you have usually eight items and it comprises 32 of a total of 200 marks. Um, in terms of how that would break down in terms of the time you should spend in a minute would be 2.5 minutes per question in the exam. You might find that you will need a little bit more time or less time depending on how fast you are. But suggested would be around spending around that much time per question. So, yeah, this is on the top, you can see a picture of what your prescription review would look like. So there you'll have a relatively brief case stem. Um, usually what medications they're on. Um, any examination findings, any negations, often it's compromised of two different parts. So you can see question A and question B. So for example, in question A, which drugs are most likely causing the hematosis? And in um question B, which drugs are most likely contributing to the impaired renal function? Um So you'll have to think about the same amount of drugs twice if that makes sense. Um And then you just click them, always make sure that you look at how many prescription they want you to review. So they could ask you to look at one or two or three different ones. So make sure you read that very carefully. Um And yeah, that's pretty much all on the format of prescription review. We're gonna do some questions now. So we're gonna spend time put um doing five questions on prescription review. So question one, I'm going to read it out. It's quite short. So it's a 3033 year old woman. Um She comes to the GP with palpitations. She as part of her workup for a palpitation. She ha she has an ECG um in terms of her past medical history, she's got recurrent thrush, she's got hyperthyroidism and she's got depression and anxiety. Her drugs are listed below. Um There's no known drug allergies and her EC G I've just summarized for you guys. So it is sinus rhythm and rate is 68 BPM. Pr interval was 0.12 seconds. The C is normal. So less than 120 the Q TC is 0.52. So my question for you guys now would be which drug is most likely responsible for these ECG findings. I'm going to give yourself around two minutes and let me, yeah, try and use the poll if you can. So you can click away on the pole and then click back to Advir Chat as well. OK. Keep answering. I can see six responses already. Sure. Don't. I think I saw that. I'll just keep it going for a second again. One thing I should have probably mentioned, feel free to use the BNF for this. You can use the BNF in the exam. Yeah, for, for these kind of questions. Um I was just saying to Millie at the start that uh my control F key just started to kind of light up. Um Yeah, but um if you're familiar with, with the kind of common side effects, then it'll just speed you up. But if in doubt, yeah, you, you should have the B NF up on one side and then the question on the other in the real exam. Um Yeah, we can talk a bit more about the practicality and how you would do that. There's different options on how to do that, but we can talk about that afterwards as well. I'm just gonna give you guys 20 more seconds. All right. I think in this period of time we're gonna keep it at that. So as I unfortunately already revealed the answer earlier. So if we look at the question, we need to identify what um is actually the abnormality in this ECG finding. So the QTC in this case is um elevated. So QTC roughly should be around 450 milli uh 450 milliseconds. Um In this case, it's elevated quite grossly. Um And the drug that's responsible for that is most likely fluconazole. So well on to the 29% of you that got. All right, well done. Um I'm gonna tell, you know how you would easily find that because most likely you're not going to know that fluconazole causes QT elevation. So there is a really useful table called appendix one which you guys might have been familiar with appendix. One has all the interactions um that uh but it has a really good list of interactions such as things causing hyperkalemia, hyperkalemia. Um It also has a section on drugs that prolong the QT interval. So if you've already identified that decreased QT interval as lung, you can look at all of these drugs as Aaron was saying earlier, um control F is a really good thing as well. So you can skip to QT um very easily if you click on that and then equally in QT, you could look for the drugs individually so that you don't have to read for the entire list of this. Um And yeah, fluconazole is a drug that causes QT elongation. So fluconazole is the right answer. The best one, you can also find it. So sometimes it's not listed in this. So you could also look up the individual drugs and then look at the cautions, for example. So you can see on the bottom, this is what um the screenshot from fluconazole. Um And it says that there's a and it, it can cause QT prolongation, QT interval, prolongation. Um So that's another way how you could have gotten there anyway. So two different ways. Basically, um someone saying list that as a common side effect under sertraline SSRI uh Let me have a look at that as well if that's the case. And I do apologize. I try to uh uh for this question to myself. So if that's the case, then yeah, well done for finding out. Um I will have a look at that or maybe Aaron, if you could have a look at that and we'll pop the answer to the shot. If that's the case, maybe both of these answers would have been flexible. Um So yeah, any other questions or we move on from now, we'll come back to us with the sertraline afterwards. Um And question number two. So we have a 70 year old gentleman. Um He's just been caught by the on call doctor and your goal is to renew his structure. He had ami two years ago. He's got now his kidney heart disease and he's got hyperthyroidism. He is taking all the medications at the bottom. He has a penicillin allergy where he gets a rash. Um, and your job is to select the two drugs that most likely contain a serious dosing error. And I'm gonna give you two minutes again for that. And some of you are very quick at this. Yes. Yeah. Mhm. Ok. If you could only select one drug that's fine, just select one drug and, and think of the other one for yourself. Um I don't think there's an option to do that on metal. Unfortunately, for two girls. Um that sounds fine. All right, I'm gonna leave it at there and last answer, answer now. So majority of you are, I'm all right. So, um the important information, I guess in the stem in this one would be that he had an MRI two years ago. Um and that would indicate that his atorvastatin should be on 80 mg. Um, primary versus secondary prevention. Um And then the other very commonly drug that's involved in the PSA is levothyroxine. Um levothyroxine is prescribed in micrograms and not in milligrams. Um And this is a common mistake that you might find in the PSA essentially. So A and D well done to answering, that would be your correct answers. Now, if you don't notice this by heart, which a lot of you want, um This is how you would go there. So there's a lot of, so things like levothroxine. I would advise just know there's a few drugs that are prescribed in my, in my hands. However, you can also just look up the drugs themselves, there's only five drugs and this available. So you could look them up and then look at the dose. So I think um uh the yes, so the left you can see the leo in cyst, but it's prescribed in micrograms. So that's how you would get there in terms of the atorvastatin again. Um knowing primary risk, secondary prevention doses um is quite key in this case. Um And then if you go on indication and dose, you can see that they should be on 80 mg once daily, I suppose to 20 mg that this gentleman was on. So yeah, always check for units definitely. Um and know some of the common drugs and doses. Um So things like you want to know your beta blockers, you want to know your anti hypertensive medication roughly in a range. Um It will just help to save you time. All the information is there on the BNF. Um but it will help you to save time. No. Um right question number three. So we have a 40 year old um gentleman. He, a few days ago, he went to A&E um he was to blood. Um he's now in hospital, he's um got pneumonia. Um in terms of past medical history, he's got a gastric ulcer, he's got high BP and he's got diabetes as well. Um, he got his drugs are below and he's got a penicillin allergy as a lot of patients do. Um, he's anaphylactic against it. You've got his opss below. So in this case, which drugs are most important to stop in this patient in this situation at the moment. So again. Oh, thanks for putting 22 pulse in your iron. That is two pulse for you John. So you can go one on each. Um Yeah, I'll give you a minute and a half again. Ok? You can see some great answers. Keep answering. So, all right, I'm gonna leave it at that. Um So two important things in this case, II noticed that when I was reading it earlier, it's maybe not quite clear, but this patient is he came to ae with um vomiting blood. He's not currently vomiting blood. I apologize if that was unclear. Um However, his BP is very low or sort of coming into a shock, BP, not quite by definition but definitely low. Um Also he's allergic to penicillin yet. He has been prescribed a um antibiotic that has a potential reaction of cross reaction closin. So we need to stop the cephalosporin due to a cross reaction, an allergy reaction with penicillin. Um and we also need to stop his BP medication because his BP, his BP is low. So there's no need. Um arguably the BP stopping medication, arguably he might have had it today already, but definitely it should be temporary withheld given the clinical situations, um, because he's unwell. So that's why you would stop that. There's not really any indication to stop any of the other drugs I was aware. Um, the Tranexamic gasses. Um, there's no indication to stop this Metformin. There's no information from what we have to stop. The cyber and Iva is for the atorvastatin. Yes, they're not as crucial in this moment, but we should definitely keep them all going. So the most important ones to stop would be those two. Um Now again, how would you, if you don't notice just by looking at question, how would you solve this? So, always check allergies and yeah, always just look up the medications as well. Um It is actually if you go on allergies and cephalosporins and that it will actually be there that there is a on the BNF that there is a hypersensitivity reaction in a fair amount, a very few number of patients, but it is there. So you should not forget that. Um And then again, observations are very crucial when you review a prescription. That's the one thing that I think it was highlighting earlier that that's something that as a doctor, you will do this um day in day out reviewing how their vitals are and you should be able to recognize that if they have a BP drop, you should at least withhold or medication that could potentially make your BP worse. So, things like nitrates are quite commonly um contraindicated if someone has low BP, any BP medications, um if they're bleeding, any medications that could encourage that bleeding, things like warfarin, any blood thinners, you need to stop as well, things like that. Um So that's how you would answer that question again in appendix one. There is a table that starts that cause hypertension. Um, and you can look at that as well. So if you are unsure if a drug can cause hypertension, this is what you would go for. Um, but most of these are anti hypertensive medications in all. Fine. So, yeah, that's how you would answer that. Ham. So question number four. So we have a 28 year old woman. She comes to A&E and she has a sudden onset of right heel pain or, uh, uh, left, let's say left ear based on the picture of left ear pain. Um, in terms of her past medical history, she's got P ID Pelvic inflammatory disease very recently. Um, she's also got hay fever and she's got fibromyalgia. Her medications are listed below. She's got no allergies. Um, and when you examine her, she is limping, um, from her left foot and she is visibly in pain and then her left heel looks like dust. So it's bruised and it's swollen and it's, it's quite poorly defined. So, my question would be which single drug has most likely caused her symptoms. So I'm gonna give you two minutes again or 1.5, see how far you get. So without, without giving away the answer. Um I've actually seen that there has been a growing movement on social media about this specific side effect. I saw that as well actually. Yeah, I saw that and um, I'm not sure if it, if it's Instagram calling me out as a massive nerd, but I just thought to point that out. Um And there's also been just campaigns on the wards that I've seen for the whole award, just ask us to review if we're going to prescribe this drug. Essentially, it is definitely an adverse adverse reaction to be aware of. Um Yeah, um like when I made this question, it was before I saw all of those videos on social media. Actually, it was not prompted by this. Um But it is definitely good to be aware. Um because as doctors, we should always aim to do no harm. Um Unfortunately, all of the medications will have side effects. Um But we should definitely be aware of that. All right, I've got loads of responses so well done. You guys are very fast. Um And very good apparently. Um So yes, so, um as seen by the picture, you've got sort of that poorly defined heel which and the pain quite sudden onset, which would indicate a achilous tendon rupture. Um, again, you could talk about, you know, all the tests like simmons tests and things like that when you can test the tendon itself. Um, and then the drug that's most likely associated with that is moxifloxacin, which is a type of antibiotic. Um, so again, this is sort of a very odd one to know. Um, but I think it's a very important one to know and again, the same principle apply that if you don't know, um you could look up drugs individually and look at what could be causing that. So if you've already kind of just from the statin, this is an achilles tendon rupture, but you're not quite sure which medication could be causing that you could look at. So you can either actually look at if you see in BMF, I put in tendon rupture on the top, right? Um And then it comes up with um Moxifloxacin almost on the second answer. Um as it comes up as a side effect there. So that's one thing to look out for. But if you can't do that or if you can't figure anything, you can go in and drug yourself. And then you can look at the important safety indicate safety information or the side effects. You can also use control F and you can search for key phrases like tendon rupture or M SK or um just yeah, any of or pain, anything that you could think that it would most likely come under. Um, you can look for that and then yeah, if you, so if you don't know that quinolones cause that, that's how you would find that. Um Yeah, that's pretty much all there is to say for that. Uh OK, let's move on to question number five, which is our last question for this section. So we have a 55 year old patient. Um, they have routine bloods. Um, they've got gout rheumatoid arthritis, type two diabetes and ischemic heart failure. The drugs are listed below. Um, they have no known drug allergies. Now, in terms of our investigations, the investigations today, the G FR is 45 about two weeks ago, the G FR was 18. Um, so I'll just put those, that's an AK A stage two. So in light of tests, blood test, which drug would you most likely stop? I give you guys 1.5 or three minutes. See how far you get. Ok. No, you're just giving you guys a little bit more time. I know that's quite a lot of drugs to look up. All right, I've got a few responses. So I think I'm going to keep her at that. So, um, essentially what this question is asking you is we've got this patient with renal impairment, acute renal impairment. Um, GFR is 35 at the moment, um, which drugs do need to be stopped. So there's some, the moment on, I think there's something worth remembering which drugs should be stopped if, um, we've got renal impairment. Um, so the answer for this question today would be Ketoprofen, Methotrex, methotrexate and Spironolactone. All right. And we're gonna go over why these medications and why not the other ones should be stopped. All right. So, um, there's a few potentially nephrotoxic medications in the set. All right. Um, you, what you could do is you could go on appendix one, there is a lot of drugs on there that could cause nephrotoxic. So that can give you a little bit of a screening action. Um, there's some drugs that you might know by heart. So for example, Nsaids, um, I think a lot of people are aware that need to stop them. Um, um, and yeah, it might be worth looking up the individual drugs in this case. So for example, um, I lie this on the right side. It is for Metformin. So with Metformin, um, you should only avoid it if the EGFR is actually less than 30 according to the BNF. Um, I know not often it would still be stopped, but according to BNF, um, it's only indicated if your D fr is less than 30. So it's always worth looking at what is actually EDF R in this case. Um, there is something there's a normal called, I think it's called Dam. So it's diuretics, ace inhibitors, um A BS Metformin and NSAID that's in it. But then I think there's, there's sometimes different omics as well that to cover as many drugs for that as well as well uh available. But I would just point back to appendix one um with renal impairment as well. There is a lot of subsections on each individual drug that you can use. Um Again, if it says caution. So I'm aware that some of the drugs just say caution may adjust those. Um If there's no other drugs, you might want to caution that, but there are some drugs that specifically say stop do not use. So those will take priority over something. For example, I know that's something you said all allopurinol. Um with that one, we just need to be cautious, but it definitely, it's not the most important one to stop if that makes sense. Um So yeah, I hope that was clear, gonna move on to section the next section now, which is a rare drug reactions. Obviously, any questions feel free to put them in a chat and um we can answer them from there and we can also go back at the end of the section as well. So a rare stroke reactions. So, um we've covered them a little bit already actually with the quinolones. Um So it is eight items and less in the psa um each will be worth two marks. Um So 16 marks in total, which is not a lot. Um However, it's quite straightforward. Um It is suggested that you spend around the minute per question, which is not a very long time. So, it's very good to know if you have, um, a good base knowledge of adverse drug reactions, um, of common drugs and maybe interacts as well. Um, because you will be pressed for time if you have to look up every single drug for this one. Um, sim, similar principles. So you're gonna have a stem on the left side, you might have some investigation findings, you might have some observations. Um, it's going to be a question which usually says, oh, which drug causes this? Um, and then you're gonna have some options and select one. So just stuff. Let's do some questions. Um, so we have a 55 year old man. Um, he's been prepped for surgery. Um, he's got regular medications, um, er, during surgery, the an anesthetist is considering to use Propofol. Um, so which of his regular medications is most likely to interact with Propofol. I'm gonna give you guys a minute. I think on this. All right. I think I'm gonna keep that there trying to keep it nice and brief. So the majority of you are right. It is. Um, I'm just gonna go over why? That's right. And why the people who said d are potentially also. Right. Um, so if we think of the drug classes, Propofol is a beta blocker. VRL is a calcium channel blocker, um, they interact with each other, they can cause bradycardia and hypertension. Um in terms of why I think sodium mro is the less appropriate action. But not unless worth mentioning. Um If you go on the BNF and look at the interaction between sodium bro and um propofol, um it says that there is a severe reaction but it's theoretical. So if you have possible theoretical interactions that you see on the BNF, that should go lower than an actual interaction that's documented and that's well known. So I agree that um it's not the most straightforward but um theoretical will go rank less or lower than an actual interaction if that makes sense. Um In terms of how you could find this out if you're not aware of it, so you could click on the drug itself. So we know that it has to interact with propofol. So you can click on interactions of propofol. Um And then you could um control f and look for all the drugs if you wanted to, if you are using medicines complete, which hopefully a lot of you are aware and I would encourage to use. There's also the interaction checker. Now, I know that it's not, some people are not quite sure if the interaction checker is working in the PSA the answer is I don't have the answer for that either. Um They change it all the time, but I would definitely recommend spending a little bit of time and getting to know the additional features on medicines complete in case they are available. Um The interaction checker on medicines complete is amazing. You can just pop in all your drugs so you could pop in all your six drugs all at the same time and it will come up with a list of the drugs. Um and it will rank them as well and then you can look at them and it, yeah, it will save you a lot of time, especially if there's a lot of drugs that you don't know. Um So yeah, that would be two different approaches on how you could potentially figure out this. Um So I hope that makes sense. Any questions as always in the chat help to answer and we'll go on to the next question. So we have a 40 year old woman, um, and she's come with a new onset for regular periods. Um, she's got her regular medications are below. So my question for you would be which drug is most likely to be responsible for her symptoms and you have one minute. All right. And that is one minute done. So, uh, well done to the majority of you, you've got it right. So we've got irregular periods. Um, most likely be caused by a progesterone only pill which is de Detrol. Um I can see that some of you also answered D and C and I'm gonna go over why that isn't the case. Um, because both I think from memory can potentially cause irregular periods as well. So, um again, how would you find out about this if you don't know? So, I think it's worth knowing that Detrol is a production on your pill and the common side effect of that one is a regular periods as opposed to the combined pill, which has um regulating effect on periods. Um If you go on Detrol and if you look up the drug itself under common or very common side effects, it does say menstrual cycle irregular i irregularities. Um Again, I would recommend using control f because side effects, there's a lot of them. And if you have to read for the entire section, um you might run out of time. So if you just control f and then go with menstrual or something like that, you will, it will highlight it like it did here in this case. Um I believe that the one on the bottom. Now, I not actually, I think that's the one for risperiDONE potentially that I copied. So you can see that for Detrol, it's a common or very common side effect. Whereas for this drug frequency not known, which usually means very low frequency for the drug, which means that if you want to determine which one is more likely it will have to be the one that has a higher frequency of the side effects, right? Um On medicines complete, again, there is something called the adverse drug reaction checker as well. Um Where you put in your drugs at the top and you can put in the reaction that you're looking for. Um, again, uh, this is something that's again, query. If this is available on the PSA, I would recommend them, checking it out if you haven't already, it can save you a lot of time if you know how to use it. Um, but I would not rely on it, um, in case it isn't available for the PSA. Um But it's definitely a very good tool to stop to play around with and have a look at it basically. Um So yeah, that's that question. Moving on to question number eight, we have a 55 year old woman. Um She's meant to be started on Warfarin. She has epilepsy and she's got tinea pedis. Um and she's a recent TB contact, which is why she's taking all of the below medications. She doesn't have any allergies. Now, which of the drugs is most likely to interact with Warfarin to cause an increased in R I'm gonna give you guys a minute on that. OK. Yeah. All right. And this is time. Well done if you managed to answer in time. So I think this is a bit of a, I probably made a bit of a mean question um because all of these drugs are going to interact with Warfarin. However, um the question was one how, which one can cause an increased I nr uh the answer of that is fluconazole, well done to the majority. You got that right. Um The thing with Warfarin is that um it's um a very common subtract of your um C YP 450 enzyme. Um All of those drugs that I've listed below are examples of um inducers slash inhibitors. Um So you first need to identify I'll be looking for an inducer, an inhibitor. Um And which one is it out of those? All right. So remember that your cy four P metabolizes the drug. Uh which means that if you um inhibit the um P 415, you get higher drug levels because you have less of the enzyme that gets rid of the drug, meaning more drug. Um If you have an inducer, you have more metabolism, meaning to decrease levels. So it sounds a bit contradictory actually at this to me. Um So wh while remembering that there is some minimal mix that, you know, um in terms of random of different ones. So I've, I think a common one and good ones for inducers would be crap GPS. Um So you've got your carBAMazepine er ramp and alcohol. So that's chronic alcohol use. Um uh Griseolum PHENobarbital sulfure and S John's wort um inhibitors is sick. Faces.com. So you've got sodium viroid um isozide, cimetidine, ketoconazole, flucazol, iodine, also acute alcohol, um Chlorophenol, EFC sulfonamide, ciprofloxacin, omeprazole, and metroNIDAZOLE and also grapefruit juice, which I couldn't fit into pneumonic anymore. Um So yeah, and then your substrates. Again, it's well worth knowing some substrates. Warfarin is a common one. Um satins potentially s as well, but I think usually it'll be one of those um or maybe Fin as well. Um Also I know that fin is mentioned twice in sta rates and inducers. I tried to look up the answer of that. Um And I'm still not sure why that is. Um I don't know if you had any suggestions on that. Um But if you look it up, it's just some of both. Um I do have not have the answer for that. Um But yeah, anyway, so we're looking, in this case, we're looking for an increased in r which means we want more of the drug of Warfarin, which means we want an inhibitor, which um in this case was r fluconazole. So yeah, that's how you would get the answer. Again. You could also look at the, again, the interaction checker and put all the drugs in there. Um And then look what it will do to you. But I think in this, in this case, quite important to know your enzyme inducers and inhibitors. Um And well worth remembering them for at least the exam I would say. Um And yeah, that's that question. Um So we've got two more questions. We've got question nine, we've got a 29 year old male, he's an inpatient on a psych ward. Um He's now very drowsy. Um And this is quite untypical for him because, um, I saw him two hours ago and he was, um, incredibly aggressive and he was threatening to staff and he was, he was hitting chairs and he was just, he had to be restrained. Um, he's got a positive of his, um, schizophrenia. That's why he's here. Um, his regular medications. Um, so he's on Clozapin, um, once daily and he's on LORazepam P RN. Uh, he's also on paracetamol P RN. Um He doesn't have any allergies. So you examine him. Um So he's drowsy. Um He's seen Asmus when you look at his eyes and his respiratory rate is six. So my question for you would be, what drug should we give him? Now, let me give you one minute. Oh, flu is taking a Lido and naloxone now. Interesting. All right, last seconds and that's time so well done. So again, I think this is a bit of a mean question from my side. Um Definitely the two differentials that we're looking at would be an opiate overdose um or a benzo as an overdose. Um Both can result in a patient being quite drowsy and respiratory depression. Um There's two key factors that I think are differentiated to. So, nystagmus is more commonly seen in a a benzodiazepine overdose as opposed to an opiate overdose, which we have pinpoint pupils very textbook. Like also this patient is not on any opioids, he's only on paracetamol 1 g. Um And he had to be strained suggesting that his LORazepam was probably used recently. Um And you might have had a bit too much LORazepam or reacted back to it. Um So LORazepam, benzodiazepine overdose, um the antidote for that one would be for menocil 200 mcg. Um If now, if you don't know how, if you don't know the answer, which is fair, fair enough. Um There is a treatment summary called poisoning um which is actually a very good one. I would highly recommend um being aware of that one. There is all the drugs that you can see on the left side. Um All the different overdoses that you can think of things like lithium overdose. Um I think paracetamol overdose, snake bites, things like that. Um And you can just go to your, your sections. So if you go on your benzodiazepine sections, it will say that um charcoal can be given within one hour and it's not two hours so charcoal can be given. Um And it says that f fumazenil can be given as well. I know that it says that it's unlicensed indication. The reality is that it is given um other benzodiazepine overdose um in practice. Um and it's also the only correct option in this case. So don't be fooled by the unlicensed action in this case. Um It is the appropriate drug to give. Um Yeah, that's that question. And we've got a last question for today. Also a psychiatry question. You can tell that I'm working in psychiatry at the moment. Um, we've got a 3032 year old gentleman. Um, he's got schizophrenia, so he's been started on Clozapin. Unfortunately. Um, he doesn't have any allergies. Now, my question would be, what monitoring should this patient have at six months? I give you guys one minute. I'm sorry, there's a lot to read in the questions. Ok. 20 more seconds. I need to look in and answer. If you know, time, pressure have a bit of a split between D and E at the moment or the split becomes or more of a split now between ABC as well. All right. Keep it at that. So again, II know this is quite a confusing question because you have to read a lot of words in a very quick amount. Uh correct answer would be D um So how to so lipids and weight? I think lipids are in all of the answer. So just ignore liquid lipids anyway, that's the correct answer. Um So yeah, lipids and weight are commonly measured in most antipsychotics because the patients um will put on and will have abnormal metabolism of that. Uh fasting that glucose as well. Four black count and clozapin of course, is quite important. Um And prolactin is commonly measured in most antipsychotics as well. Um Now I know that if you click on the BNF and you click on the monitoring requirement of clozapin itself, it will come up with this big section. So unfortunately, you're just going to have to read through all of that. Um and try and process as much information as you can in a very short amount of time which the majority of you did actually get. Right. So well done for that. So it says here that for example, you should monitor prolactin concentration at six months and then yearly, um you should have um limb uh blood counts, things like that. Um I think I've copped it off unfortunately, in this case. Um But essentially it will say that um all of the ones previously should have been monitored at six months. Um And I think if I remember correctly are not routinely monitored, um making this correction incorrect, it says under HEPA to monitor liver function. Um I think if I remember correctly, it says to monitor liver function. If they have a hepatic impairment, um can double check that though. Definitely. Um But yeah, you're right. If that was the case, then you would be most correct. Definitely. Um um Yeah, and just, yeah, read it carefully. I think that's the most common um take away from this message. I hope for you guys say that this is not a question that comes up um from the format at least because it's a bit confusing. I think, well worth knowing that um antipsychotics have a lot of monitoring requirements anyway. Um So it's worth knowing that they um often impact your um glucose um metabolism. So often people with schizophrenia will go on to have diabetes. Um They will also continue to put on weight and have hypercholesteremia. Full blood count is of course, very important in um cloZAPine specifically because of the risk of um atos. Um Yeah, and prolaxin again, very important in all in psychotics anyway. So, yeah, that was our last question. Uh Now if there's any questions I'm happy to answer and go back. We've got around five minutes or so. Um I've got a feedback form as well. I'm really grateful that you can either scan the QR code on the side um or click on the link as well. It will take you straight through, it will take less than a minute, I promise. Um And you guys can give us some valuable feedback on what you would like to be covered as well. Um And then if you have more time and more energy, you can fill out the survey link on the left side as well. Um Yeah, thank you for coming again. Any questions, please let us know. I'll just go through the chat and II think most of it hopefully should have been covered. Um Yeah, I can see your thumbs up from Aaron. Um Yeah, so we've covered up with SSRI I we've covered Yeah, perfect. Yeah. And yeah, with the SSRI, I do apologize um that it also causes QTC prolongation should have maybe made it a bit less confusing for her first question. Um, so for the drug compatibility checker, it will be um, location dependent. So some, some universities and trusts when you take the PSA will allow you to have the BNF and, and all medicines complete. So you can have two, both of them. Um, but some, some units or some test locations will just let you have the, just the BNF. Um, as, as of I believe this year. Um, it's, it's the online only BNF, at least it was in Liverpool last year as well. I know last year there were a couple of disappointed people who came in with paper B NFS ready to flick the appendix, the physical appendix one. But they were told, please leave your paper B NF outside and use the control f appendix one. Yeah. Um II would say just get, get familiar with one, get really familiar with either B NF essentially if you say the, the B NF is, is the one that you should get comfortable with. And that's the one that I chose. I know some people were really good at doing meds complete, but it, it'll just depend on when or where you're sitting the exam. Um Yeah, I think it's a safer bet to go with be BNF for that reason. Um Theoretically you should be allowed the medicines complete. So that's what they say when you prepare to do PSA but I'm aware of some people not having been able to access it. No, I as far as aware, all of the interaction, checker and drug compatibility checkers are not available on the BNF. Um The other benefit of the medicines complete that I found is a lot more structured. Um I find the layout a lot more accessible to me. Um But yes, um unfortunately, it's a little bit confusing in terms of what things I do. So my advice would be to if you want to use. If you're happy to use the BF, that's absolutely fine. Just go with that. Um You can also um practice if medicines complete uh how to react to medicine complete. Um So there is my university gave me an account via a or you should be or whatever I think you have and you can log in with that. Um You can also log in if you have an NHS account, you can also log in with your NHS email as well. If you write the BN uh when you write the PSA itself, there will be a top in the top um corner, there will be an uh a link to the BNF and the medicines complete as well and that will take you through there. So on the day, exam day itself, you're not going to need an account to open medicines complete, however you can do that as well. Yeah, thanks Erin soma sit around. Um If you do do the PSA So I know that the official PSA website has some practice papers. Um You can look at that and then access the B NF from that and see how that works. I think that's a quite a good way of um seeing how it will actually be in the exam. And I think the other thing that we talked about earlier was how to use the split screen as well. Um So some people prefer to use the split screen because you're gonna have to swap from the exam page which is a tab to the E NF slash medicine complete. So some people prefer to use a split screen. Um Some people prefer to switch tabs either way is absolutely fine. I just ended up using searching tabs. Um because I found that a lot easier and I found that having the information update was easier for me. Um But if you don't wanna search tabs, maybe split screens works fine. No way, I think, try and see which way is best for you and then just stick with that. And thank you, Rebecca for that. All right, thanks. I Aaron, do you wanna take that uh medicines complete? Answer that by that was posted just now cause I know that you, you're the one that sat down. Yeah. So um I think so at the University of Liverpool, we had access to both the B NF and Mets. However, during the exam briefings that we, we just, we just got um in the lead up to, we were strongly advised to practice with the B NF. Um because sometimes medicines complete whilst useful won't load or would crash. Um I know of some universities and some other universities, but obviously I didn't study that, that recommended just the B NF and they would just mandate 11 side psa one side B NF. Um Yeah, I mean, in my experience, II just got used to the BNF. So uh and in terms of how you access multiple tabs, um again, it's, that will be down to your exam location where we were allowed to have a split screen. So II personally have like a half, half of my screen psa then the other half has a Google Chrome with multiple tabs on the BNF with each one preloaded, I guess as long as you're not Googling things, I think theoretically we would have been able to Google things technically because I don't think as far as I'm aware, there was no firewall restriction on ours. So you could just open up tabs. You, it was, it was quite literally like using your computer like you are now, you could use enough tabs, but I suspect that certain locations might have restrictions on that. Um But it is essentially you can imagine it just using like your computer now and opening a tap. Um And then there was a question of how long did you study for it? Um I think again, this is very different from person to person and how much time you want to spend on it. Um, I would recommend, I think I did around two of two weeks of fairly relaxed, um, relaxed. Um, studying for it. I would say, um I do, I'm not the kind of person who likes sleep things at the last minute, but I did find that I was running out of questions to do. Um So I think you can do it in shorter times as well. Um But I would definitely recommend loads of practice questions as many as you can do um And doing it under time pressure as well. Um You don't have to do the entire exam every time, but practicing maybe each section under time pressure, I think is very important so that, you know, where your strengths are as well and how you can split it. I don't know a what would you recommend anything in terms of how long to study for it? Um So like yourself, I only spent a couple of weeks. All right. Um And the majority, I would, I would just essentially I II went into it just knowing that I've done enough placement and because I was studying for the M and the PSA at the same time, they crossover. Um So one of the things that will stand you in good stead with the PSA that I found was just having clinical experience because a lot of the questions like the SSRI I question that was at the start. Need a bit of clinical judgment. So it, and I think that's one of the things that the PSA is trying to get at, which is why they've got like examination findings and they won't tell you the, the, the diagnosis, they'll just, I, or they'll give you lab results, but they won't take the next step because that's for you to, um, interpret that. They've got a new AK I and they should stop these medications which is really similar to, it was an fy one. Yeah. So like, like yourself, I've only spent a couple of weeks and in terms of the resources, I just did a load load of questions. I did my, um, I think not, not to promote, but in my past experience, II was subscribed to ques meed again. I'm not sponsored like I got II did all of the PSA questions. We also did the, the mock, um, psa questions as well and I attended a couple of these sessions as well just to really get my. So when I attended the session, I kind of just used the, the discussion but, um, trying to get in the head of one of the other, one of the presenting doctors to see how they would think about the question. Um Another thing that I think was asked previously further up on the chat was, will they give you essentially when a question asks for you to pick two drugs or three mistakes. There will be, there will be three mistakes and there will only be three mistakes. There won't be five mistakes and then you'll have to pick the worst three. That would be really hard. So they should make it fairly obvious. You know, in this claim, I wrote these questions myself, they are not up to psa standard. They're meant to give you an idea of what the questions are. I've tried to match them as close as I can. But if there's an error, for example, like it was with the sub in question, it should be, it will be obvious to you. Um And it will be very clear um in terms of the resources I use. So I would start by using the mock papers on the PSA page. Um There was also a book called Past the PSA. I had access to a free PDF version that was given to me by my medical school um which I found quite informative. I was using the past med questions. I think they're OK for the PA PSA just to if you have time and if you have pass med anyway, you might as well do those questions. They give you a little bit of an overview and a bit of a practice. Um And then the one that I would recommend you can also ask other doctors to see if they've got any questions or any resources like these have um the one resource that I would recommend if you can afford it is the um British Pharmacology um Association. They have some mock papers. I believe you get two half papers and one full paper or something around that for 40 quid. So it is spendy. But we shared, we ended up sharing that resource with you think eight people at least. So if you find a lot of people to share it with, um it becomes very affordable and those papers, I found that they match the level of um difficulty. That wasn't a PSA the best. Um because the mock PSA that's on the PSA website is, is quite easy. Um It doesn't really compare to the difficulty. So dose would, that would be my recommendation? Awesome. I don't think there's any more questions. Um Yes, yes, yes. Uh So the next sess, well, I think it was on Saturday, isn't it Saturday before? It was Saturday 25th? Yeah. Uh it is on Saturday because um we are well aware that we want to get four sessions in before um before the PSA basically. Um So we didn't want to do it this first day because you have, you told you will have the PSA on Thursday. So as a um kind of bit of a exception to the rule, we're gonna have the session this Saturday at 11 a.m. It's our last session for the PSA if you can join, please do. Um But it will be recorded as well. So if you have plans for a Saturday, um enjoy them and just watching on the recording. Um And then in terms of after that, we'll take a quick break and then we'll start our ro to final series as well. Um So if you follow us on Instagram or anything, um we'll keep you guys updated there in terms of how many sessions we're gonna do. So, yeah. Um gonna give one more minute to see you have any questions but feel free to leave. Enjoy the rest of your evening. Um Yeah, no worries. It was my pleasure. All right, and I'm gonna stop Brilinta now. Um.