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Hi, everyone. There's still a few people coming in, so we'll probably start around five past. Hi, everyone. Welcome to our PSA session four with me and you. Um We're today gonna be covering the calculations and data interpretation sections. Um It might just be useful to grab a calculator if you haven't got one already. Um because we'll go through the calculation section first and then the data interpretation section a little bit later. Um We'll try and keep an eye on the chat as we go along. Um But if not, we'll answer all of your questions at the end and for those of us who couldn't make it today and enjoying virtually, we welcome you to today's lecture as well. Um Wait, great. So just to start off with this is the exam structure of the PSA if you've been to any of our other sessions, you probably will have seen this before. Um It's a time pressured exam. Um and good time management and efficient use of the BNF are kind of the key to success. Um If you don't know the question, it's better off just to flag it and just move on. Um there's no negative marking. So it's multiple choice. So if you don't know something, it's better just to fill it in if you really don't know. And just guess you've got a 20% chance of getting it. Right. Um, the good resources, um, for the PSA are kind of past papers on their website, which are probably the closest kind of thing that I used anyway to what the real life exam was like. Um, but I know a few people on myself that use the ResMed ones before as well and they were really good. Um And obviously come to our sessions as well. Um So it's a computer based exam. Um So make sure you activate your account beforehand. Your med school should kind of make you aware of all the stuff you need to do beforehand anyway and make sure you have your password handy for the day. Um, try and arrive early so you can make sure that you log in, obviously computer problems stress on the day. Um, not ideal. So try and arrive kind of 5, 10 minutes early just to make sure that you've got logged in and set up. Um, and remember you'll need your ID and a pen for making the notes, um especially in calculation section. Um, there's no pass mark, um, every papers reviewed afterwards, but it's usually kind of in the region of about 65%. Um So this is just a run through of all of the different sections of the PSA. So I think we've covered all of the other ones um in our last few sessions, which will be on our website. Um And the last two that we're covering are calculations and data interpretation today. So a few learning objectives um so we'll go through them now and then we'll circle back to them at the end as well to kind of recap what we should have learned. So with the calculation section, we're gonna go through the basic drug dosage, calculations, fluids, and kind of peds, fluid calculations, infusion rates and then opiate prescribing as well, which are the kind of big hallmarks of what you'll need to know. Um And then for data interpretation, he's gonna go through um some stuff on insulin, um some blood work bits and Bobs, um gentamicin and how to dose it and uh understanding all of that. Um I nr with Warfarin and Bits and Bobs and how to use medicines complete to guide the medication adjustment. So let's start off with some calculations. If you haven't already got um a pen, I'd suggest that you get a pen and just a piece of paper. Um and um a calculator as well before we start. So the calculation section of the PSA is eight questions. So it's two marks per question. Um So it's one of the shorter sections. Um But anywhere that you can pick, you can pick up marks is for the best. Um It's probably one of the more straightforward sections as well. So kind of making sure that you've got that under your wing would be a good thing. Um It's usually any questions on fluids and drug calculations. Um, but commonly tested things that you kind of need to know are pediatric fluids, um, infusion rates and particularly they really like testing opiate breakthrough dosages. Um So just making sure that you kind of know um bits and bobs around that nice. So we'll get straight into it. We'll do some questions. Um And then we'll go straight to the answer and then we'll explain them. Obviously, we've only got a certain amount of time this morning. Um and we don't want to take too much out of your time on a Saturday morning. So we'll give you about half a minute a minute depending on how hard the question is and then we'll go through it. So don't worry if you don't get it in time, we're gonna go through the explanation anyway. Nice. So our first question is a 70 kg patient is being prescribed amLODIPine, which is a CCB for hypertension. The prescribing instructions state to administer amLODIPine at naught 0.5 mg per kilogram once daily. What is the correct dose of amLODIPine to be administered to the patient? So we'll give you about half a minute to work this one out and for anyone else that wants to interact, I'll be also doing a short pole as well, which I'm just trying to get ready. Yeah, nice. So shall we go to the answer? Great. So the answer is 35 mg. Um So we'll go through the explanation. So um the dose of amLODIPine is prescribed based on the person's weight. So in this case, it's naught 0.5 mgs per kilogram. So all you need to do, oh, I don't know why that's duplicated, but um all you need to do is times their weight by um kind of what the prescription needs per kilogram. So in this case, naught 0.5 times 70 is 35. So that was a nice straightforward one to start off with. So this one is the next one. It's about pediatric fluid calculation. So we'll give you a little bit longer to work this one out. So a 10 year old child weighing 30 kg is admitted to the hospital, you assess their fluid status and you find them to be euvolemic. So using the 421 rule, which is just below the question, please calculate the total daily fluid requirement. So how much is needed in the 1st 24 hours of their admission? We'll give you about a minute to sort this one out and I'll try and sort out a pole as well. Mhm Nice. So shall we go over to the answer? So the answer was c um if you had enough time to work it out, congrats if you got the right answer. Um And we'll go through the explanation now. So the 421 rule is a formula for calculating IV fluid requirements for Children based on their weight. It's quite commonly tested in PSA questions. Um So it's, it's a nice thing to be able to remember. It's fairly easy to remember. So it's, so the calculation is for the 1st 10 kg of a, a child's body weight, um It's four mils per per hour. Um for the next 10 kg, it's two meals and then for the remaining, it's one per per kilogram afterwards. So you can see here that we've used the 421 rule. Um So we've got a total of 70 mils per hour that the child needs and then you times that by 24 hours for the hours in the day and then you get a total of um 1680 mils as their daily requirement. I guess I, we just got a question from the chat and just seeing who it's from. Oh Megan. So would we be given this formula in the exam for this type of question or do we need to memorize it? Is it another B NF or medicines complete? I would, yeah, I would say that um generally sometimes they do give you the formula but there are also questions that sometimes they do not give it. So it's a hit or miss and sort of this thing. However, I think fluid uh pediatric fluid requirements are something worth to learn and keep in your mind because as you get closer to finals, it's one of those things that you're expected to know of by heart, unless it's a neonatal fluid, which is entirely different. Yeah. So um it's also worth mentioning that if a child is dehydrated. So in this case, they were euvolemic um generally, unless the question tells you otherwise, um you'd assume that they're kind of got a 10% deficit. Um So that means that you calculate the total 24 hour fluid requirements, you can use um a different formula. So to calculate the fluid deficit uh in a dehydrated patient, um you'd calculate the percentage that they're dehydrated. So in this case, 10% so 10 times their weight and then times that 10, so that gives you the number of milliliters that they need to have added on for the 24 hour period. So that means that their total fluid requirement is the maintenance fluids plus their fluid deficit that you've worked out. Um So if the child was dehydrated, in this case, it would be 4680 mils that they'd need during the day. Um Generally, the PSA usually just assumes that they're UIC um and it would be maintenance fluids. But um occasionally there are a few practice questions that I did that kind of assumed that they were 10% dehydrated So it's just something to mention. Um, Catherine. I think we just got another question for your, um, to see. Uh n has said that isn't there the 150 20 mil rule as well for pediatric fluids? Oh, I haven't heard of that one. Have you heard of that one yet? Yes. So 115 and 20 is usually the calculation that you need to take into account when prescribing maintenance fluids as well. Those ratios may change depending on the age of the child as well. So if you're dealing with a neonate, which is any infant up to the age of 28 days, they will give you the values because there's some ultra specialist stuff that you wouldn't expect to know if it's a resuscitation fluid as well. Like we've mentioned here, we also have to take that into account and that's a different sort of thing. So the 150 20 mill rule, it's some sort of general maintenance fluid on a 24 hour daily basis for anyone that's not a neonate and above. Nice. I that answers your question. So we'll move on to the next question if that's all of the questions today. Um So the next question is a 70 kg patient is prescribed Vancomycin for a severe infection. The dosing guideline for Vancomycin recommends an initial loading dose of 25 mg per kilogram followed by 15 mg per kilogram every 12 hours and that is maintenance dose. It's just worth mentioning that the patient has normal renal function. What is the total amount of vancomycin the patient will receive in the 1st 24 hours. So that includes the loading and the maintenance doses. Give you about a minute to sort this one out. Nice. So that's about a minute. Now. Um shall we reveal the answer? Hi. So the right answer was D um and then we'll pop through the explanation now. So in this case, uh the loading dose, um you need to work out and then you need to work out two of the maintenance doses cos they're given 12 hours um apart. So assuming that the loading dose is given and then the maintenance dose is immediately given after that. Um Then there's another maintenance dose within that 24 hour period. So first of all, we'll work out the loading dose which is 25 times 70. So that's a total of 1750. So that's your loading dose. Move that aside for the moment. Um And then you've got main two maintenance doses to, to kind of work out. So the maintenance dose was 15 mg per kilogram. So 15 times 70 which is 1050. Um And then you times that by two to get 2000, 100. So that's the total maintenance dose that they'll get in 24 hours. Um And then you add on that loading dose to get 3850. Any questions about that one at all? Sounds like everyone chose D so not that much, but yeah, let's go. Great. Excellent. So we'll move on. Um So a patient is receiving furosemide IV for acute pulmonary edema. The IV dose is 40 mgs. The doctor prescribes to decides to switch the patient to oral furosemide. The recommended conversion is that oral fursemide is absorbed at 50% by availability compared to the IV dose. What is the equivalent oral dose of furamide for this patient? Can I give you about half a minute for this one? Nice. So if we go through the answers now, so the correct do uh dose was C 80 mgs and then we'll go through the explanation. So the patient's currently receiving 40 mgs IV. Um So if we're switching it to oral, um it has 50% of the effect of an IV dose, which is what's meant by the 50% bioavailability. So, for it to have the same effect, it means that we have to times the or the IV dose by two to get the same effect orally. Um So in this case, it'd be 40 times two, which is 80. Um Any questions about that one at all, b bioavailability is um something that PSA does quite like to test. Um And once you get your head around it, it's one of the easier questions. Great. So if there's no questions about that one, we can move on to our fifth and final question of the calculation section. So a 70 year old patient with advanced cancer is prescribed a continuous morphine sulfate infusion at a rate of 30 mgs per hour. For pain management. The patient reports experiencing breakthrough pain and the guidelines recommend that breakthrough doses should be 1/6 at the total daily dose of the regular opioid regimen, which dose of morphine sulfate should be prescribed for each breakthrough pain episode. So I'll give you about uh 45 seconds to let this one out. Nice. So if we go through the answer for real, the answer. So the uh correct answer was da 120 mg. So if we go to the explanation slide, um opioid prescribing is really commonly tested in the PSA but also in your finals as well. Um So I think it's an important thing to try and remember that usually the breakthrough doses would be about 1/6 of kind of the person's whole day dose. Um So we'll go through this one first and then we'll have a bit of a chat about that afterwards. Um So in this question, um the first thing that you need to do is calculate the person's total daily dose of morphine that they're getting. So they're getting a continuous infusion of 30 mg each hour. So first of all, if you calculate the whole daily dose, which is 30 times 24 you get a total daily dose of 720 mgs. And then afterwards, we need to calculate the breakthrough dose from that. So um the question has been quite nice to you and said that uh the breakthrough dose is 1/6 of the total daily dose. So if you take your 720 that you've got divide it by six and then you get 100 and 20 mg as that person's um breakthrough pain dose. It's worth mentioning if you're on the wards, um a normal ward and you work out that somebody's breakthrough dose would be 100 and 20 mg. It would definitely definitely be worth double triple checking that because this is a palliative care question. Um So that would be a really, really high dose of morphine to give you regular average Joe. Um So in palliative care questions, if you get a, if you kind of get an answer like that, that would probably be reasonable. But if it's just kind of saying, oh, this person's on a ward, you might just wanna recheck your answer. So yeah, any questions about that one at all. Um And if not, we'll go on to data interpretation with you. Right. Right. So I think uh if you have any questions, just do take your time to answer it in the chat and uh we'll just give you a bit of a break and while doing this break, it would be really great if you, if And if you guys are able to open the B NF or medicines complete, whichever you guys are more comfortable in using to help answer these questions for data interpretation. So in data interpretation, it's six questions in total for the exam. Each question worth tw two marks which will give a grand total of 12 marks in these questions. You'll be given a set of data in aspects of a clinical scenario that you yourself will have to take the lead and make the decision based on the clinical situation that you're given and the investigation results that they choose to provide to you. Now, in these scenarios, you as the doctor will have to do any of the following decisions. You can choose to stop a drug that they are currently on. You can increase a dose of a drug, you can decrease a dose of a drug. You can even start a new drug if you wanted to prescribe another drug together with the existing ones to improve treatment or efficacy or in some instances, you absolutely don't have to do nothing at all. This just basically tests your judgment and your clinical knowledge to see what's the most appropriate management step next. And the order of these questions uh do not go from easy to hard, they're all scattered all over the place. So you can get an easy one and start and a hard one over the neck. So the difficulty varies with this. So uh once everyone is all right, with their B NF and uh medicines complete, then we can get started with looking at the questions and answers of the explanation and these questions, I think I will introduce the stem and everyone will just have a chance to read through it on their own pace and try to answer the question. And this will really test what information you want to dissect as the most important to help you find the correct parts of the B NF. All medicines complete to try to find the correct information to solve the question. So we will start with the very first question at this moment and you'll have three minutes to complete it. The think we just about reached the mark to review the answers once everyone has a chance to have a look. So the answer for this question is uh answer B add atorvastatin 20 mg once a day. Now let's dissect this question a little bit. You want to see the most important points on what could determine treatment. So we have a 68 year old year old woman. She coming to a GP for a follow up for some blood results. The most important thing to know is why she came in. She has no symptoms since her last appointment. So there was nothing acutely unwell going on, which is good. One thing to note is sometimes you have to look at the past medical history and the social history. So she's quite sedentary active smoking history, quite a significant family history for Angina as well. So has a lot of risk factors in her lifestyle would say. And when you go to investigations, the GP has currently done the following things just to explore around that. Most notably, out of all of this is her c risk score. And with the cur risk score, the cur risk is basically a scoring system that we use to assess the likelihood of someone um going to suffer a cardiovascular disease or uh incident within the next five yeah, 5 to 10 years. And usually we want to start medication if that score is above 10%. So if you're not so sure what to do with that, you can always go to your treatment, summaries. And in this particular section, you want to find a cardiovascular disease risk assessment. And since she's not having symptoms at all, we can say that she has the potential to have uh angina, but she's not having it yet. So we need to focus on primary prevention to prevent all of this from happening in the first place as much as possible. Since her bloods are also showing that she's abnormal for lipids overall. If you will go to lipid lowering therapy in the primary prevention part of it, you would see that that will recommend lipid lowering therapy. And with that, you will go down to find atorvastatin, which is what they usually recommend over there to prevent her CVD due to a high Q risk two score. And since this is the first time we're gonna give her this medication, since she's not having it before, we are just going to start with the lowest dose of 20 mg once a day. Yep. So that is quite a lot to dissect for one of the very first questions. But that's a more effort you can get for some of those straightforward questions in a section like this. So if everyone's happier with that, we can move on to the next question and have a look at it. And again, I'm gonna give you guys about 2 to 3 minutes to have a little read about this question and see what you guys think. So, for what Emily Emily, I think um I'm just seeing a question right now does not have hypercholesterolemia. So 10 mg once a day that 10 mg once a day is usually quite a small dose. First of all, we usually wanna start 20 based on your Q risk assessment as well. So that's also essential finals knowledge. You wanna start. Secondly, 10 mg. It's usually sometimes linked with a early familial hypercholesterolemia as well. So yeah, there's a combination of factors where we don't really usually start with 10 mg. It's m mostly due to the fact that that's too small of a dose. We usually like to start 20 at bare minimum unless there's contra integration status you are getting. All right. So that is time for everyone. Let's go through the answers. And uh there was an error in the text on the previous one that C was meant to say 100 mcg. So I do apologize for that, but uh everyone's still got most of the correct answer here. And that sc level for 100 mcg once a day. So to dissect this question, we have a 26 year older man who has come to his GP again, he complains of lack of energy and intolerance to cold and he is known to have hypothyroidism. So that will get you thinking. Hm. These symptoms do sound like his hypothyroidism is acting up again and he's already having a liver thyroxine therapy to try to solve that in the past. So, what the GP has done is he has done some fiber function tests kindly to see if the fi liver fibroin therapy is indeed working at the moment. And it turns out it shows a pattern that he is deficient in his thyro hormone as well. So we would need to actually increase his levothyroxine dose. No, this will involve you looking into the B NF and levothyroxine just to see what the drug is and he is having uh primary hypothyroidism. Now, it's worth to note that he is a young man as well, not elderly, which has a different entire rule to it. So it's important to look at age. But just looking into adults, we can see that um they usually recommend an increase of 25 to 50 mcg uh when you wanna start the dose and that is the recommended safe level for it. So in the P SA, you want to play it safe when you want to increase the dose. So even though you can increase it to 100 and 25 which was my mistake. And the other one, I do apologize, it is generally safer to start increasing it slower. So increasing it by 25 mcg is the more correct answer, which is why 100 mcg once a day is the correct answer for this. Um And just for your information in case you do ask us for finals as well. When you do wanna change your levo fibroin dose, you will want to repeat fiber function test in 4 to 6 weeks to make sure that the fiber control has been successful. So we do have a really long dot questions. I think we will give you an extra minute. So about 3 to 4 minutes this time to try to dissect all of this information. OK. All right. And that is the time to spend for this questions. Do not worry if you don't manage to complete it, we'll go through the answers anyway. So from what you should get from this, you should have get choice number D excuse me, which is to start 30 mill millimeters of calcium gluconate, 10% over five minutes. Now, there are a few things to dissect and to point out from this question. So we have a 50 year old gentleman being admitted to gastroenterology due to um progressive ascites that was noted on a CTA P and his symptoms as well. He has also been found to have palpitation on his chest since his admission to the gastroenterology ward, which is quite concerning as well. And uh we can confirm the important history is that he has liver cirrhosis secondary to alcohol. And he also has uh essential tremors, which is another thing to not to cover as to why. Um other things to know is that we started him on SPIR no lock to an award and again for the essential tremors, he has propranolol as well. Now, we have a lot of these investigative findings, but the things to note are the E CG findings where that says that there are no narrow T waves um at wave amplitude that is greater than five millimeters, which means it's tall, which can kind of give you a hint as tall and tendon. Um The QR S complex is also quite prolonged as well. And so is the uh pr interval. Then we look at the VBG and we've shown that the abnormal result is that potassium is quite raised and not only is raised, it significantly raised as well and just thinking all over sting, he has ascites secondary to liver cirrhosis, which the best um the best diuretic to treat this would be spironolactone in this case. But as you know, spironolactone can cause hyperkalemia. And this is the situation that we're dealing with. And this is why he's having the new onset heart palpitations. So, from remembering your value of 6.6 this is classified as a severe hyperkalaemia, which is noted down in your treatment summary. Uh When you search up hyperkalaemia, uh hyperkalaemia treatment summary has actually listed down albeit and a giant wall attacks the hierarchy of treatment that you want to use you. And we will go back to the answers over here. Calcium gluconate is the best first line and we will go through the all the other medications that we can do next. After that, the second part uh adding another diuretic like furosemide wouldn't solve this issue as actually, he's already been given the diuretic. We're just gonna give him way more diuretic and he's gonna, we out more, he's gonna get even more dehydrated which which add another problem to the issue. Adding salbutamol is not a good idea and that is why I've highlighted propranolol as essential tremors because salbutamol is a beta antagonist as well. Uh agonist and uh propranolol is a beta blocker as well. So they just kind of come out with each other and it would just do nothing to the treatment at all. Act rapid and 10% dextrose is appropriate to treat for hyperkalaemia. But it's not very first thing we do. The, the reason why calcium gluconate is the very first thing is the priority is to stabilize the myocardium ak A stop the heart from going into an arrhythmia. Which is why calcium gluconate is used for then lastly sodium zirconium or, or maybe you were launching a textbook as calcium resonium. Those either those two can be used to treat hyperkalemia, but they have a very slow onset in acting to reduce it, they remove potassium through the few feces. So this would take quite a few hours to do so. It's not the best thing to give if we have a very acute severe hyperkalaemia, like in this case. And for all of you folks for reference to prepare for finals, I've prepared a lot of screenshots of what to do and when to panic and not to panic when you see a hyperkalaemia as long as a treatment hierarchy, just to in summary, as a quick reminder and refresher for finals in the future as well. F there's any questions we can go through the chart, but I'm just gonna be moving to the very next question that we have over here. And uh again, you will have around two or three minutes for this one and uh we'll see what everyone gets. All right. That is your time to answer this question. And the answer for this would be uh D Gentamicin 420 mg IV over a 36 hour period. Now, Gentamicin dosing is one of those very tricky things that you have to learn for the P SA. But it's something that is going to be kept to, it's going to be something that is going to keep appearing in your practice papers. And it is very clearly pointed out in your syllabus as a core thing to need to know for the PSA. So you need to get as very comfortable with it as much as possible with it. Sadly, and as well as when you guys become future f ones, when you join us in the wards, this is something you have to do on a daily basis as well as it is quite a common strong antibiotic that we usually give. We need to first start as to some information here, we are treating a urosepsis. So secondary to a uti um she weighs 60 kg as gentamicin dosing requires your weight. So that is something important to highlight. Another thing we need to make sure is that we need to see what sort of dose have we started her on the gentamicin? She's having 420 mg at the moment. And that is a good thing to point out because if we do need to increase the dose, we want to make sure we're increasing it as a safe limit. As one important thing to note is that gentamicin, the max dose you want to give is 560 mg per er once a day. No matter what, that's your maximum dose. If you calculate a number higher than 560 you still have to give 560 max, then we need to check her renal function, um particularly her urine urea creatinine and her EGFR and her urinary function is fine in this case. But if it's not fine, then we need to think of another way to calculate the dose. Normally, assuming everything is fine. Like in this case, your dose will be calculated on the basis of 7 mg per kilogram. If her renal function was quite terrible, then we need to reduce it to 3 mg per kilogram. And that is because we need to be safe with this drug as gentamicin is primarily excreted through your kidneys. And if this is continues to accumulate a lot in the kidneys and through the bloodstream, it can increase the risk of nephrotoxicity and most more commonly o toxicity. So you will get uh hearing problems and tinnitus with it as well. So we've taken the gentamicin level like we did in the question over here and we've, so we've seen that it was 5.0 and it's good to notice the time that was taken because we usually wanna take it between a six and 12 hour period from when we first start the dose. So we consider in that range and as good as 5.0 then we need to look in the chart. OK. They have given 5.0. So we mark 5.0 on the uh y axis. Then we want to see the sampling time. So the time that that was taken from the dose given at 11, once dose points intersect to intersect within the 36 hour region of this no gram. So therefore, the best thing that we need to do is uh increase the interval of the dose to 36 hourly while not changing the dose. And to go into more detail about gentamicin in the exam, there are two ways that can be used to monitor gentamicin dosing that they could ask you, they could ask you to use the gentamycin nomogram or the graph that we've just used in this question, which is a more common example or they could be a bit mean and say that uh they could use peak and control values instead. Now though you can find these sorts of explanations within the gentamicin page um on the B NF when you such a drug under monitoring requirements. However, to really summarize into detail and this is what has helped me prepare for it as well. Peak value does peak value basically means does the dose need to change if it's too high? We need to reduce the dose if trough. Basically means that the time between each dose need to extend or stay the same. If the trough level is too high, you need to increase the interval. So that could increase it to 36 or even 48 hours depending on what it is. And one thing I've noted in the therapeutic drug monitoring page for your future reference because it did appear in a previous PSA setting was a gentamicin prescribing an endocarditis cos it has its own rules that are different to every other condition, which is why I piloted earlier on that. We need to know why we've given a gentamicin in the first place. Right? I'm just seeing this. Any questions. Wait jam. Ok. Where did you get your info on dosing and renal impairment being 3 mg per kilogram? Ah, so you can find that in the renal impairment part of your gentamicin page. However, this is also something that could be used in finals and if you have it in the back of your mind as well to prepare for finals, that could come in handy as well. But you can generally, in case you forget through due to the pressure of the exam, you can look into the renal impairment parts of the B NF under gentamicin to find that um, anything you want to add to that Catherine? No, I don't think so. I think, yeah, the BN F's your best friend is 100% the answer. Yeah. Awesome. Right. Very nice questions everyone. And, uh, before we move on to the next one, I think because Gentamycin is not the only body that you have to deal with to monitor your antibiotics. Unfortunately, um, something that you probably need to have a worth to read is Vancomycin and Tiopronin because those antibiotics are quite um commonly used um in the wards as well, albeit they are the stronger versions that we don't tend to use for most infections, but they also require monitoring. So it is a good shout to have a look in the monitoring requirements as well as the treatment summary pages. Just to get an idea of how they should be monitored just in case you need to uh look into it if a question asks for Tiopronin or Vancomycin. Now, we have a another very long question and this would take quite some time around uh three minutes and then uh we will take it from there. All right. That is time, everyone for this question is time flies really fast for it. Um And the answer that we would like to see is D uh I VN Acyl CS 9000 mg over one hour period in 200 mL of 0.9% sodium chloride. Now, this is uh quite an uh unfortunate thing that we tend to see in uh A&E from time to time. And I, for those of you who have uh yet to do your ed placements, um expect to see just at least once um of an example of an overdose of a particular medication. So, this 20 year old, uh, university student actually came in at 3 a.m. and they came in because their roommate found them feeling nauseous, drowsy and just feeling quite unwell, sort of being a good friend. He helped him to go into the hospital emergency department where he told us that he ingested about 3500 mg of paracetamol tablets in one single swallow. And that is very important to notice because you need to know the mechanism of the overdose and how much he has taken. Um, you also need to know when this has been taken. So this has been taken around eight pm the previous day before they found it on 3 a.m. this morning as well. Ideally, you want to get other information from a patient such as his weight and has he taken anything else on top of the paracetamol? Thankfully, this is a bit more straightforward. He's only taking the paracetamol. So, uh when we look at the investigations that they've given us, they've given us, uh quite a, a range of things. But the most important things that struck to us is the paracetamol concentration because we're dealing with a paracetamol overdose and an abnormal result of random glucose at 10, which is a bit high. So you would want to go into the poisoning section of the B NF or your medicines complete. Uh, this is, will contain all your emergency treatment. Needed for any overdose of any substance that's listed on there. Then you just need to go down the paracetamol uh poisoning section. So uh first we need to get some numbers down. We need to calculate how much paracetamol he has taken overall. So 30 tablets times 500 mg is 15,000 mg of paracetamol circulating in his body in total blimey. Then we need to calculate the time between the time of the overdose and the time that he got into the emergency department. And that is a seven hour period. So why do we need to bother with all of this? Because it does help us categorize what type of overdose he has taken? Um I'm just gonna explain it right now. But if you guys forget in the exam, the explanation is indeed in the treatment summary of that page and A B NF. But essentially an acute overdose is an ingestion of a potentially toxic dose of paracetamol in an hour or less. Basically, this definition means taking a dangerous amount in one or multiple goals within that same one hour period. This intention could be linked to self harm. A staggered overdose is an indigestion of a potentially toxic dose of paracetamol over more than one hour. So if it were the case in this example, because the patient had taken it all in one swallow, we can assume that it's an acute overdose because it's all within that same one hour period less than an hour. So it cats in that had there been a staggered overdose. If we use the same number of dirty tablets you take in total as an example, the patient may take four in the first hour and then 10 in the next hour and then eight within the next three hours and then maybe another eight in the last two hours before he's come into the emergency department. So knowing how much he's taken and over what time period is very important to categorize because that will affect the treatment and our treatment regime later on. So he let's look at the B NFS criteria for the acute overdose. Now that we've uh uh have uh established that it is an acute overdose. He is definitely not doing so good as he fits the criteria of ingesting more than the safe amount in one go, uh which is 4500 mg pretty much his, his body is toast at this point. So that leaves us a question of what we can do for him. We s based on the guidelines over here, we sadly cannot consider activated charcoal as he didn't present within a one hour period from his ingest ingestion of a large dose of paracetamol had he presented about 9 p.m. the previous day. This would be the best choice as it goes in and absorbs all of the medication while it has a complete digestion before it absorbs into the gi tracts, we will have to move on to an oxy cysteine. Therefore, and note that an ayte can be also considered in hepatotoxicity. And those who present with eight hours uh of ingest of ingestion of more than 100 and 50 mg per kilogram of paracetamol. If there is an ongoing delay of eight hours or more in obtaining the paracetamol concentration after the dose. So for the psa the exam, um they will probably give you a paracetamol graph like this or you probably need to see it in the B NF itself. Now, these graphs, whether they chose to give you or not or you have to find in the B NFO is complete. It's calibrated for the standard 21 hour regime only. So anything on the paracetamol page that says 12 hour regime or 14 hour regime do not use that at all. For the exam, we've taken his power acetol concentration is 95 and the time frame is seven hours. So as we were to graft that onto the graph does, does lie above the treatment line which means he does need an a cyst of cysteine. And from the clinical scenario, we can infer that we are giving the very first dose as nothing has been given since then or we weren't told. So note that his weight is 60 kg and 60 kg times 100 and 50 mg will equal 9000 mg over an hour period. Now, the reason why I've highlighted the glucose is because you have a choice of putting the N ayte in either dextrose or saline. And since for some reason, he's hyperglycemic, we don't really wanna give him any more glucose as that would drive it even more crazy. So your sodium chloride would be a better bet in this bit and do not. That it's important to know if we're given the first dose or the second dose as in another setting that I've been told that we're told to give the second um part of the treatment which is listed over there. So just be a bit careful for that bit. Yeah, this is one of your examples of very long questions. So yeah, I apologize for the very long winded explanations of it as well. We've gone to something a bit shorter right now. Two minutes uh time starting right now to answer this question over here. So while everyone is doing this question, I'll just set up a pole and for sure, in man, how do you choose between a 12 hour snap regimen and a 21 hour regimen? So your for this purpose of the exam and in standard practice, we usually go with the 21 hour regimen unless they specifically tell you to go for the 12 hour snap. A 12 hour snap regimen is usually a specialist sort of regimen. So that's not something we'd be tested at this stage. So always use a 21 hour regimen and your paracetamol nomogram is also 21 hours. So that's your big clue as well. All right. Um If everyone's happy with this one, we will review the answer as e for this case where we are looking at I nr So this question was inspired by something I actually had to see within like the first two months of my F one. But um this in this particular scenario, this lady has unfortunately had a, a usual picture of uh bleeding or hemorrhage. In this case, a hemothorax. Unfortunately, the woman was also on warfarin as this was and that this is the cause of the major bleed. And the warfarin already given has been stopped. We need to also try to see how we're gonna stop this further. So that's why we highlight to all this information over here. Vitamin K or sometimes I'd like to say fom meade has already been given. So um the next best step would be for protein, uh dry protein, uh dry prothrombin complex concentrate or P TCC T Xa can be given but doesn't really solve the underlying cause of hemorrhage. Um Either Roaz is a monoclonal antibody only given to reverse one type of DOAC only, which is DBI fresh rosen and precipitate can give intrinsic causing factors. But it is not really the best choice to solve and really stop this underlying hemorrhage. So when you go under your oral anticoagulant page, you would go under the hemorrhage page over here, er which would um highlight your warfarin treatment and how to stop warfarin from all the information we found with the I NR and everything uh I nr was quite high and this is a major bleed. So therefore you want to uh focus on the top part which says to give Vitamin K and uh P TCC as well. And this is something that you need to know for finals as well. But in the purpose of this exam, you just go to this page and it says everything just in case you forget. And uh that's just the example of the page to show you about what to prescribe if needed for another question for Drive Pro from being complex. And this page over here just basically highlights a summary of hierarchy from what we've seen from the B NF to see uh what sort of treatment we need to give as well as this theme does pop up in your finals as well. Now we move on to another question and we give about 1 to 2 minutes for this one. All right. And uh it's time for this question. Now let's have a look at the answer. The answer would be a increase the pre evening dose novorapid by two units. So just to quickly highlight the important bits. Um this th it's a 13 year old girl just trying to see how her glucose control is for her type one diabetes we n have to see what type of insulin she takes and the schedule of it, which is why I highlight her drug history and we want to see her glucose control, which is not doing too well but not horrible at this stage. And most importantly, you'll be given a table exactly like this in the exam itself to have you look at the tracking of her glucose, uh, whenever she has a meal before or before she goes to bed. No, just to summarize how we solve this, each uh capillary blood glucose level is taken before each event. So before her breakfast, before her lunch, before dinner and before she goes to sleep, insulin is pretty much only taken after eating and the basal dose before she goes to sleep. So the aim of this monitoring is to assess if the previous dose of insulin before she takes her blood glucose for the next event has done its job to keep the glucose in its range. So far, if at a particular time, like in this case, uh that uh it's out of range, that means the previous dose before that is not enough. Therefore, in this example, since the pre bedtime glucose is high, it means the insulin taken after dinner is not enough. Therefore, as a general rule, um which annoyingly is not really clear stated very clearly in your B NF or medicines complete. But through practicing a lot of questions, you'll find that they like to um advocate for a safe increase of insulin by two units. Hence why we the best answer would be a in this scenario, right? So the next question over here is about H RT and uh we gu guys uh give you a shot at this question and see how you guys feel about it. And that is time for this question. So hopefully you guys got the answer e to ignore all the remaining pills in her pack to start an entirely new pack immediately and abstain from um sexual intercourse and use B contraception for seven days. Now, highlighting and po information, she is a micro gun on dirty, which is a form of uh C OCP. She is just about to finish her third month, her third month pack and that's something we need to uh notice about how far she's going through her common contraception. The scenario that we face is is that she's forgotten to take her three pills with a third role of her medication. So, like we confirmed previously, she's about to finish this month's pack. Um She has had, she's been sexually active with multiple partners as well. So we need to assess the safety with her contraceptive use as well. Uh And we also need to know um how long she's uh had this uh unsafe colitis as well because she's flew about 24 hours ago. So that's important to know the best way to solve these questions because it's quite hard to see in the BN FMS is complete, is to actually study a table like this. This table is provided currently by the Faculty of Sexual Reproduction and Healthcare or the FS or H here in the UK. And it's probably one of the best tables I've ever seen that really summarizes all these points as well. So whenever you have anything like this from unsafe sex, you pregnancy test should be done within 21 days of unprotected sex as well. And if you had to read through this table, you can start to work out about and start to learn about when it's safe to start contraception. When do you need to start emergency contraception? When do you have to not do anything at all or when you could just ignore the rest of the pills, like in this case and just continue on earlier on with the next following packs. And that's something really important to notice as well. One important thing to note as well is to just have a read through on the treatment. Summaries for emergency contraception, hormonal contraceptives and non hormonal contraceptives as well as those films can unexpectantly sometimes turn up in the actual exam. So that is good to have a read around those topics as well as well as it does help to read around for your final exams as well. And good news, everyone that is the very last questions I have for my topic. It is quite a long time, but the data interpretation side is one of the longer sort of uh sets of questions that you have to deal with such a short amount of time in the exam. Nice. So, um if we just go over the learning objectives again, so we've covered all of that in the calculation section and a lot of all of that in the data interpretation section. Um I appreciate that it's a lot to take in. Um But hopefully it's been a good whistle whistle stop tour of um all of those things that we hope to cover at the start of the session. Um So this is just again, what we've covered. Um So calculation skills and data interpretation um and just to kind of remember that it does all link in with all of the stuff that you'd really be revising for finals anyway. Um So it, it kind of stretches across the whole of the curriculum. Um But most of the stuff that you will be um asked, especially in the calculation section, um You won't really need to have any knowledge of kind of final stuff necessarily. Um It should all be there either in the B NF or um on paper for you to be able to work out. So these are a few um of the resources that we all used in the committee um when we were kind of um working towards our PSA um so definitely the online resources for the PSA and they've made themselves 100% I think anyway, personally, um is the best, is the best thing to use in the run up to the P SA especially the mock papers. Um There's a few other things so B PSE learning, um they've got nine free modules for you to be able to do and then you can purchase some mock papers. Um The geeky medics uh PSA Question Bank is really worth investing in, in my opinion. Um It's got a wide variety of questions and it's not that expensive either. Same goes with past medicine um alongside your finals kind of questions. It, it is useful. Um And then the script modules as well that I think lots of universities are pushing now. Um They're quite useful as well just to kind of refresh your memory before you start f one especially um in prescribing. Um But they can be useful in the run up to the PSA as well. Um But yeah, the B NF and medicines complete are 100% your best friend in the PSA. So just get practice and practice and practice, get familiar with the um sections of the B NF that you're gonna need to know. So this is just our feedback form which we aim to appreciate your feedback and your appreciation, our appreciation for everyone to attend our sessions. Um I'm glad everyone's enjoyed the hard work. We've put in so far. But we would like to improve anything that we have presented just so that it's better presented for the next section or maybe even some better suggestions of how we could make this more interactive or perform better in the future. Everyone's feedback, no matter how big or small is greatly appreciated. And it will contribute greatly for our own research as well as we strive to improve uh a small part of medical education on our side as well. So that's it from us this morning. Um This is the end of our PSA series for the moment. Um Obviously they'll be available as recordings on our website. Um The next time that we'll be running, um, sessions will be for our final series. Um We're hoping to start them in March. Um But obviously keep an eye on our social media. Um And we'll be publishing the dates a bit sooner the time if anybody's got any questions, just pop them in the chat and we're happy to answer them. Yeah, I think um there were a couple Catherine. So let's just have a look. Let's see. Um So Eleanor Harry, uh good news. We've just finished as well. So that'll answer your question. Um Yeah, sorry. It took quite a bit. The data interpretation was quite a lengthy part. Um I'm not Tanvir, sorry. Could you just go back to the flow chart if that's OK. Of course, I think he is referring to he or she is referring to the uh contraception chart. So this is the chart that you can use to help learn. As I said, it is one of the best summarized uh charts. I've actually seen out there on the online world as well. But if you want to read a, in a bit more detail, you can always go on to the SR HS website where you can find not only the chart but some more detailed explanations and guidelines that are up to date in the UK as well. Yeah, they're really us user friendly as well on the website. Um You can kind of open up leaflets and things like that of the guidelines. Um And I found them really user friendly before. Let's go through Sophie Cruz. Um How long do we get for each question again? So you want to start with your section, Catherine? Let's have a look. Um So for the calculation section, it's so you get an unlimited amount of time really for each section, but you should be aiming for um a certain number of minutes. So I'll just grab up the first bit. Uh I'm not lying to you. Um So for the calculation section, you've got eight questions and you've got two marks um per question. So you should aim for roughly about 10 minutes. Um And then for the data interpretation section, um there are six questions with two marks each. So you should roughly be aiming for about six minutes. But when you've got a harder question in there, they can take a little bit longer. So a little bit of leeway. Yeah. Right. Um, ok. Yeah. Answered Megan Hodgson feedback form for Thursday. I think if you scan the QR code but, uh, fill in the form for the previous section, but fill in another form for our section. I think that shouldn't be a problem as well. But, uh, we do appreciate your feedback and thank you for letting us know we'll pass on your good thoughts and say and uh sayings to the previous people who've done this teaching, shall we bump up the QR code again? Just so that people can tell us, I think I would maybe have to flip that too fast. There we go. Um Khan has come back to say that just sorry just on the gentamicin question real quick. The renal per doesn't mention reducing the dose from 7 mg to 3 kg. Oh Let's just have a look and I'll have a look on my B NF. All right. Sure. Was it in the, was it in a separate section section? You it could it could be actually because it does mention a BNF. Maybe not a gentle my question. Um Right. Red, I'm just having a quick look on my side as well just in case consumed product literature. OK. So right. They probably changed it because it used to say but it doesn't say anymore now. OK. That's fine. So if they want you to use the 3 mg, they probably would have given it to you to be fair because it's not on the B NF anymore from last time. So they'll probably give you the renal dose from that. But uh so the 3 mg is something that we actually seen in the wards as well. Um Not so sure it's the same in your trust. Caffine. Yeah, it is. But I think in the PSA, if it's not on the B NF anymore, they, they'd give you that information. You wouldn't be expected to memorize it. Exactly. Yeah. Um, let's keep going down James Abston. Can you explain what is meant by the f, by forgotten to take three pills from the third row in the last question? Ok. Yeah, I think I've made that question a little bit hard just to try to test if people who is actually seen it. Um, a pack of contraception pills. Um, I appreciate it. If you haven't used it. You've probably never seen one before, but essentially a pack of, uh, C OCP is laid out on four rows, uh, four rows of each of those rows containing seven pills. So you have three, the top three rows are your active pills. I'd like to call it. So you take that seven days, seven days, seven days and then your last pill is your, um, I will call it, do your dut pills, which is like your uh I don't have the word in my mind. Maybe caffeine can help out. But that's a sensitive pills. Inactive. Yeah. So that question aims to say that she's completed her first row of active contraception, her second row of active contraception pills and she's just on her third row of contraception pills. So she hasn't quite touched that part of a cycle where she needs to take the inactive pills from that bit. So if you look on the internet actually to, to see a picture of a pack of contraceptive pills for one month, then you probably see what I mean from that bit. Um Anything else? I see. Oh yeah, I've got lots of people enjoying the session. I like to see that what they will be recording. Yep. So the QR code is just a feedback form for the questionnaire as well and the recordings and the results will be uploaded very shortly, hopefully within the next week or two at most. It's about teaching. Ok. Do you have the correct link? Um, just wondering, that's all. Let me look. Right. Um Maybe this is the correct link. I'll have a look. Yep, that's the correct now. So, apologies everyone for that. Yeah. And um we'll just hang around for another uh, 5 to 10 minutes just to, in case there's any auto questions anyone would like to ask. Um Right, Catherine maybe, uh maybe you can help with this one. I'm not appearing to upload the correct link for this one. What was this? Sorry for the, I can't see the questions. Unfortunately. Were you able to see the chart or I can't see the, I can't see the chat annoyingly, right? Ok. Um, for the feedback form it says it's still a teaching evaluation link. Oh, ok. Fine. Just give me one second then. Hm. The QR codes working on my phone for the feedback form. Let me, yeah, I tried to put in the link like the the direct URL onto the chart. But the thing is it's still the teaching evaluation link, not the link relevant to QR code. Let's have a look. OK. I'll try and put something on the chat but it might not come through. Oh, won't come through. You won't let me post anything in the chat. Um Yeah, I've sent it to you. You Yeah, I'm just having a look. So it's the, it's the exact same thing that I put in the chart over here. So just a bit confused here. Mhm Question about the session today. I'm just having a look and see. I right J and then we have the correct the correct length of the QR code over here. Let's see. Hmm Are we able to, are we able to distribute it to everyone afterwards from the session? Cos I don't think, I think all of our story. Yeah, let's just put it on a Insta story for everyone to have a look. Um Yeah, cause I think all of the, all the things we are having are linking to that other feedback form. So mhm The middle feeback link works. OK. So if you're able to access that link, um then go ahead. But uh otherwise we'll put you on our Instagram page as well for that, right? Great. So um I hope you all enjoyed our session. Um Me and you probably sign off now, but obviously if you have any other questions, feel free to message us on social media um and one of us will get back to you. Um But yeah, I hope you have a good rest of your Saturday guys. Bye.