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And, uh, if you have any questions, please email it on skis yet outlook dot com and we're more than happy to assist you with it. Or you can just message off messenger page, um, quite responsive on there as well. And please, least since we're free platform, please share. It's in your social, and we will re treat re reports you on all our social. We rely on your support to carry on with that zoom subscription. And, yeah, all our facilities. So thank you so much. Today is present. Er is actually, uh, one off someone who's given a presentation with us infections disease resulting in with us before if you remember him from last year. Last economic here is Jack Wellington is a medical student, but however, he does have a MSE in infectious disease from London School of Tropical Medicine. Um, I'm sure you'd see it on the slides. Do, um so I'll just hand it over to him. We can start sharing, Jack. Okay. So let me just share my screen a minute. Um, Okay, fine. I can see that. Yep. Continued. Amazing. Amazing. Great. Okay, so thank you for the introduction. I'm Jack. I did do a master's at the London School of Financial Medicine. Thank you for mentioning on. I'm basically I in collaboration with Ask Easy. It starts this new cause called Farm Easy, which I'll get into in a bit. But basically, today is gonna be a complete pharmacology PT prep. So we're gonna have chosen sort of your high yields questions. You're high yield topics which, commonly company in the progress has, um, finals. So hopefully you'll enjoy and definitely engaged and asked loads of questions. Ah, okay. Okay. So just a brief overview of overview of what pharmacy is gonna be back. So it's going to split in two parts, and the first part is going to be discovering some of my favorite topics. So antimicrobial chemotherapy, everything to do with antibiotics and antimicrobials painkillers. Instead, it'd drugs in psychiatry, which is another common area which comes up a lot in finals a bit about anesthesia and surgery, because we don't really get toward that much chemotherapy and chemotherapy immune suppression. This is really important that you don't get out much at all on the the chemotherapeutic drugs, etcetera. But it comes up a lot with side effects in finals. So it's good to know and then for psychology, which I'll be coming again today. And this is just some of the things we're gonna be covering in the series, which will be coming soon. And again. Yes. So we disclaimer this crash balls will focus on the clinical aspects and practice pharmacology talk through simulated cases. But we're more clinical. So this is more focused towards your clinical med students and try and trying to get the best mark your training finals. Okay, so today, um, aims and textures of this session, we're gonna be covering some basic pharmacology of most commonly used medications and everyday chemical practice. Now, that's quite hard to shorten down into a session. But I've chosen some of the most important, and we're gonna detail the indications the Contra indications and 80 yards of said drugs commonly asked in clinical examinations, Special focus on 80 yards, which do come up a lot and then demonstrate potential STD questions which may come up in the progress test or finals. I need to some of the topics I'm I'm gonna be covering today. So important me. Antibiotics, infection. Caesar's covers most of medicine, so it's good to know your basic antibiotics and allergies, etcetera. You're see my peak 450 in Jesus' inhibitors. This is really common question on. It's good to know the list because it'll come up. Nice guidelines. 80. A sponsor indications. Toxicology on dosages. They do ask sometimes quite specific dosages of certain drugs, so I'll be covering the asthma. So let's get Royan stripper. It's a question one a 54 year old female presents to a local GP. Surgery Concerns, as she has been experienced, increased increasing dyspnea at rest and lethargy. She's a past medical history of a s while manage with warfarin for several years. Upon taking a thorough history, she also explains her most recent iron A is slightly high. You check a patient records and find out the most recent eye on a is 5.6. So which of the following concurrent medications is most likely to cause it's abnormal results? And if we could have to pull up your breath, amazing and forth is that is a pullup. Yes, it is. Yeah, it is. If you could just let me know the most popular and said when it's finished, I'll be great sure? Yeah. So the most popular on So we have a C. Okay, fine. Okay, so this question is quite tricky. But you consulted, try and work up from the history. So this person's in this business got asked which is being managed with war from for several years on. But there's more increasing dyspnea address and lethargy. So one of these, so even alone if you don't even talk about the eye eye on our one of these drugs, cause is which is indicated for A S causes this sort of picture long term on if I go through each one. So griseofulviin is a type of anti fungal, so wouldn't really make sense in this case, because operable it's it could be in a rash, but it doesn't really cause this increased in dyspnea arrest and lethargy. Carbamazepine is a anti epileptic s O. In this history. Well, on anti athletic wouldn't really be indicated from the question. And allopurinol is for gout. Prophylaxis is so the most likely answer is amiodarone on. Basically, if you see, ask an increased iron, are the treatments for a ask can include, um, your drill on this increasing dyspnea resting energy could be a sign of restaurant bold mint as a side effect of amiodarone. Same on something called pulmonary fibrosis. So and it's also an inhibitor. A see why people, if I see her and hence why the eye on our could go up. So the the answer is, if I can prevent the answer is I mean, I'm going to go inside it more now. So why is this system really important? So major enzymes responsible for certain drug metabolic process is approximately 75% are in this system on the system is related to the deactivation or facilitated excretion of metabolites and drug products, etcetera. So some drugs are actually bile activated by such and science classically clopidogrel, which is 90 platelets and coding, which is a okay so also important in cholesterol hormone investment. Decent assistant get tablets. So the reason why the system I brought it up is a lot of drugs pastor this system and get metabolized. Therefore, Susan medications actually can induce the system or inhibit system. There's a little note to the bottom, which is really important, but smoking is also can affect the C Y. P one a two system which is quite a similar cytochrome system, so this is what it looks like. And it is certain. Drugs which can induce which makes, which allows metabolism on these enzymes, react quicker on needs, the drugs and alcohol and the inhabitants. So most so when you talk about in juices. Most people remember we found this in carbamazepine, which is an anti player. Sorry, 90 epileptic, a sodium channel blocker. Alcohol. So the chronic alcohol abuse his acute is actually inhibitory and finish urine. So there's enough, which is another anti epileptic. As I said before, receive all Vin is a is an anti fungal which is used will, say, dramatic fighting laundromat. Suffice Infections Phenobarbital, which is a barbiturate, which is using anesthetics and bends. Rapid secrets induction on sulfonylurea. So, for example, Glipizide, which is an anti diabetic drug, think John's Warts, which is a cluster. This is a classic, um, scenario which, like Gallons later stage on sports, is a herbal remedy, which you can get from, say, hold the bars on. But it really does play. Have it on a lot of medication interactions, which are cancer later and then smoking, smoking it can induce this system as well. And there's a little new monitor you can use. It's called Craps out Drugs on day. To be honest, I I just learned it. But if you want to remember the most important carbamazepine refined to say, alcohol products planetary in in Saint John's warts, then you could use this drug. And so this demonic. And then there's the opposite. So you have your inhibitors. There's a lot more inhibited structural in. So the classic ones, which come up a lot in PT and Finals, is sodium Outbreak, which is another anti epileptic ciprofloxacin, which is a antibiotic, is a fluoroquinolone sulfonamide, which is another antibiotic cemented in, which is a hitch to our main better on like sorry stomach acid on the mattress. All is well, which is the PPI alcohol but the acute alcohol intake rather than chronic eyes. And I sit, which is an anti TB drugs, Um, your macrolide such a risk from icing clarithromycin on and interestingly, grapefruit is so This is why, when a patient, the patient information say, on a certain so psychiatric drugs such as SSRI is, it will say you cannot consume grapefruit juice on this drug because it inhibits and inhibits those SSRI zing. There's antipsychotic drugs, which therefore can turn into toxicity. And so be really careful. If says, great future. Is there any sort of any sort of fruit juice? Then think. Okay, maybe this is in fact, in the system. Ketoconazole for consul business anti fungal again al appear. And also gout's amiodarone, which is, if you have a question on this is rule of thumb. If you have a question on one of the options, is amiodarone one of the, um, of the choices it's most like You could have got your amiodarone, so have that in the back. You mind, UM, you'll join affects a lot of things. It can cause Palmer fibrosis because heightened, uh, hyperthyroidism it's It affects your potassium. It's it's horrendous. It's not a very nice drug, but it is useful for asthma and anti arrhythmic. So keep in mind, um, you know, drink retina via which is an antiviral SSRI XYZ. Just searching curiosity. Cuna Kristen, which is an antibiotic. It's hardly used, but it's on the list on QuitNet E, which is indicated in malaria. So these initiate you can learn, inspire and Monica, it's called some certain silly compounds annoyingly inhibits enzymes were. I haven't really learned that I've just learned the most important ones so that I what I would take from this is your anti epileptics low which ones are induces, know which ones which are inhibitors. Um, and also alcohol is a really important one to learn the difference between coric and Cutes on also your TB drugs to re family since the in juicer eyes and I said, is the inhibitor. If you can remember that as well, because it it's usually going to come up in exam questions and then always remember seeing John Sports and great fridges. So example. Drug interaction. Why, there's a listen So warfarin Warfarin is a blood thinner on do It works by a visiting K metabolism, etcetera. Now the problem with I thought I was going to a friend that the pill, the combined or contraceptive pill onfi awful in which is which is used in asthma management and on balsa so can be used in COPD, that lung disease. So, Wiesel, this importance, the warfrin you Condoleeza on it depends on whether the drug is being in just or inhibited, so rule of thumb is if the iron our has increased, then it's on C Y. P 450 inhibitor. So, for example, in this case, your amiodarone it could be cemented in. It could be so involved, right? It could be any of those eyes in eyes. It it could be any of those drugs. So what happens if your iron are goes up so you can believe and cause these bruises etcetera? Now, if you decrease the eye on our, that means the war friend gets metabolized quicker and induce, so therefore, it's gonna be excreted partner, and it's not gonna have the full of fact. So in juices such as we found this in fan Italian carbamazepine, those drugs will actually decrease Sienna. So in the exam, remember, increased Diana inhibitor decrease Diana inducer the pill. So again, most important is to see why people 50 in juices because this will decrease the efficacy off the pill so classically the question would be like on someone come in. And they now the now pregnant on day of being on the pill, and they're wondering why they got pregnant and then they realize on the drug list they've been taken syndrome sports over the counter. Therefore, they've gone pregnant. And this this is sort of classical scenarios, which makes theophylline. So the offline Zahr can be quite a nasty drug and it can make people quite nauseous on a drip, cetera, But it's really important because of toxicity. So if you increase the serum level, say, an inhibitor, that's why people 50 on him so it may cause toxicity and theophylline toxicity is quite nasty on to need to be corrected on the one the way the correct it is actually buy a human dialysis. So you don't want someone to become theophylline toxic or aminophylline, which is another. Another related drug toxicity is really important. If you think of the office on, then obviously decrease efficacy and inducer. So these are just some of the example drug interactions which are quite important to pick up on. But the most important I'd lose this walk this warfrin that comes up a lot on the pill. So, talking about interactions, I'm gonna do some spot interactions, so I'm gonna give you a scenario, and then it would be great if in the chat you could tell me sort of some of the drugs which may be reacting here. Yeah, eso a 45 year old male with uncontrolled stage two hypertension has just been commenced on amiloride. His current regime consists of ramipril um amlodipine. So what do you think is the drug in traction? And then just let me know in the chart what people say. So we've got kind of split with a meal or in and ramipril Well, and I'm not a Penis. Well, okay, So amiloride I was being quite nasty because the famous potassium sparing diuretic is it's been around a lactone. So that's why I want to change that a bit. But, um, in the right, is it potassium sparing diuretic. Now, if you combine if there's on ram a girl on amiloride the same time, this can interact, and this can pools hyperkal Um, yeah. So you want to be careful when prescribing this? Even though the guidelines say, for example, BP guidelines, they'll be add spironolactone, they will say, but your potassium has to be below 4.5 to actually prescribe potassium sparing diuretic as a zoo. Birds. I think the bid stage of hypertension guidelines. So if you're going to add. So it's, for example, if someone has a BP on there on ramipril there on, um, a lot of pain and you want it, you want to commence another agents. Then you look at the potassium to see whether it's below above 4.5, and depending on what that is, then you prescribed to say below 4.5. You can give a militarized spironolactone if it's above. Then you go down the more beetle blocker alpha blocker, which there's a really important, quite common in traction. That's one a 65 year old female with a history of cardiovascular disease. Prevent presents with increased in my algia after starting an antibiotic for cellulitis. And this is a really important interaction that commonly comes up to think about the drug, which would be used for cardiovascular disease on also for cellulitis. So you got some people saying, Stacked in and clarithromycin. Some people are saying two o'clock stolen was also good seller like this. Good. Okay, so this is your statins and macrolides so a really important interaction between needs. It can cause rhabdomyolysis. So if you're on concurrent statins, um, acolytes, then it increases the risk of a rhabdomyolysis picture on. This is what is happening in this case with the increased milder. So if you do have, if you do see a statin macrolide, then think maybe you should either, You know, change medication a lot. Adjust it so that the risk is reduced. So because insulin is a drug, use is antibiotic use for cellulitis, but it doesn't really have a interaction. Statins, the cloxacillin class I'll go on to that later can cause constipation in the long term. But last night, my classic scenario, which would be happening here the next one a 30 year old male with a history of type one bipolar disorder has presented prevent to any confusion and course tremor. After starting indapamide, what do you think is happening? You know well in traction. Think people are saying a lady, um, toxicity with tires. I'd good lithium and fire size of eyesight's could increase the chance. The risk off lifting process. It e on lithium toxicity presents with confusion. Course trainer. Heightened flaxseed very similar to a sort of, um, a serotonin syndrome, um, sensitivity with about without. Obviously that is different courses, but classically, it's confusion. Course tremor on sort of. Also reflex isn't all that change isn't but the course. Tremor is the important thing, and fireside can increase your chance of lithium toxicity. Now. Lithium toxicity and lithium is a narrow in a narrow therapeutic index drug, so you can become toxic even if you're in range. So always be careful with lithium side sides. Next, 1 40 year old and a 40 year olds known IV IV drug user presents the anti with hearing loss and deranged renal function. The patient is currently on treatment for effective endocarditis, and it's passed from the history. I got a house apartment, a history of coughing. Think about want me? Well, two drugs may be interacting again. Injury Generally, a few gentamicin and, um, diarrhetics are a senators thing. The contrary goes, yeah, very good. So gentamicin classically nephrotoxic ototoxic on. Do you have to measure levels of gentamicin when you when you're prescribing it Now gentamicin is a It's a great antibiotic for gram negative bacteria, but it quits the side effects and quite nasty on D. It is indicated in infected and leukocytosis a gram. Negative cover. I'm in treatment and obviously a loop diuretic such as Feruzzi mice it hand cause it can be ototoxic on can cause deranged renal function. So this interactions very important on do you should remember this because gentamicin comes up a lot as a side effect of an antibiotic and loop diuretic, of course. So excellent 56 year old gentleman presents the Amy with Braddock Foggia following a change. The medication complete heart walk is noted on the C G. And this is very important. Yep, beat a blocker and, uh, calcium channel block Father, Some pizza block is which can you know which we use for f is Nancy arrhythmic etcetera on also Iraq mil So verapamil is a constant child bottle, but it's a different kind of class in trouble for so it's not like your amlodipine is actually very similar to diltiazem. It's more centrally acting, then peripheral, such as, um, not to be nifedipine a possibility. So when you use a beauty blocker and essentially a central acting calcium channel blocker, it can cause this profound rather large here, quite refractory brother cardio because it can cause complete heart block. So always remember, if you see a bit of blocker on a central prostate channel blocker on a drug charge. Informed someone and change it good, So question ship bit different. 25 old male is found agitated, too confused outside a nightclub surrounded by his friends. You're working as an F one of the local emergency services. In a call to help his friends says, Sorry if you get a little, Um, his friend says that that that they have been party and whilst consuming large quantities of alcohol, they notice his friend she was now agitated, took something before entering the club. He said he took Ecstasy earlier while it's being transferred, the hospital she sees is which needs management by an invasive airway support. So which of the following medications may be used to help manage the situation? We have the most popular answer been 10. I can't eat it. Also, even after lunch, it has it been launched. I think it's B, which is a more popular answer. Okay, sweetie, 1%. Okay, fine. So this is quite a tricky question. So if I talk through these drugs first on what they're indicated for So, firstly, dancing, dancing lean is used in the treatment of malignant hypothermia on do it's it interacts with sarcoplasm it particular in and calcium release. So in this, in this scenario, malignant hypertension, uh, is not really indicated safe country. It's not really needed lorazepam. I'll come back onto back 11 is a It works through government a shin, and it's usually from muscle spasticity on. It's one of the first lines in alongside gabapentin for M s, but I messed spaciticity on. It's also used in cerebral palsy, but it doesn't really help it. It doesn't really help us a muscle relaxant in this case, so don't buy pens on is a barbiturate, and it's used in anesthesia induction. So this person's heart invasive a response. They probably be probably have bean insulated. So I didn't want to say integrated because I would've given away. But that's probably one has been happened, happened. So he's already had that. So so genotype pencils not really indicated and then separate happened in. So if you know what this scenario is, then you probably know the answers to the answer to sit, perhaps it in. Um, let me Yeah, so the answer is to perhaps I/O lorazepam. Lorazepam is obviously a benzo, but it would, it would be indicated in, say, status epilepticus. Now this person has taken ecstasy and consume a large quantities of alcohol, so there's probably being a overdose or exercising, so therefore, this would be a serotonin syndrome on. But if he's already being intubated with invasive airway sports, then the next thing is probably to start using Separate Happened in which is one of the treatments of serotonin syndrome. So etiology. This is really important because a lot of, um, elicit drug you drug use works through serotonin on Be joking me in order. And and so it's really important to know this interaction so accumulation of high serum serotonin levels and it's commonly caused by drug interactions and certain agents so classically antidepressants on mono, Amy and Ox days and have a cysts, Um, which of the old fashioned antidepressant elicit drugs so ecstasy and amphetamines are most commonly cause in serotonin syndrome. Tramadol, which is the synthetic opioid which helps is no palpable, also has SSRI activity. So classically finals questions will have Tramadol in the question on the next thing you know they're on and then on there on an SS are Iran SNRI, and they start becoming agitated, hyperreflexic and confused and diaphoretic cetera. So tramadol is a really good on one. To know is an interaction the serotonin syndrome and and obviously triptan strip dance. I used for migraines and on dead aches and cluster headaches, sometimes a while, so triptans work through serotonin. Argon is, um so, therefore would be another. It could cause serotonin syndrome now interactions. So Saint John's wort on jewel SSRI TCS may also cause serotonin syndrome, So be careful. Remember your herbal over the counter remedies when it comes pharmacologic, and this is what serotonin injury looks like. You have your diet for recess, your agitation, increased bile sounds. Diarrhea so classically SSRI schools. Diarrhea on serotonin in the gut, if you have more, therefore, can cause diarrhea. So another important thing to do with serotonin is if you have carcinoid, the carcinoid tumor. It causes diarrhea swell because it's too much serotonin anastrozole, side effects, hyper reflexia, and it's great in your lower extremities and tremor, which is also great on the lower extremities. You can get a clonus and then autonomic instability, so they often really hypertensive in tachycardia on. But if you look at their pupils. They'll be my dry axis. Management supported him. Seizure control. So this is where your lorazepam and diazepam it's natural will come in handy. But if it's severe and they've already being intubated and nothing's you know it's not improving, then you can get used Cipro happened in which is an antihistamine, actually, and it works on. It works to reduce serotonin and mop little lap. Now club promazine. This is controversial because you're promising is actually an anti, um, is an antipsychotic. So if if you suspect neuro lactic malignant syndrome usually because of antipsychotic is, um Andi they look very similar. So serotonin syndrome and NMS look quite similar. There are certain things which is different. But be careful because if you chew, do go down the copay missing roots, then you don't want to miss neuroleptics. Malignant syndrome now wide, wide, small bowel. This in detail is because toxicities and you should know your anti dates. So I'm gonna do a couple on beginning. If you could put your answers in the chapel, be well so a 24 year old female presents a any having ingested 50 paracetamol tablets over one hour. This is all that one's not started. This is a classic, and you don't Not everyone should know. Yeah, neck. So I was just having a drink. Yeah, you got me. Process. Mall knock and let's just stop at letting us Utah Assisting. Now. One thing to note on exam since I have seen um on past cetera, is if you use Knack IV, it can cause a non an athletic reactions or a lawn i g anaphylactoid reaction. So just remember that you can get sort of allergic reaction, but it's not full blown anaphylaxis. So if that happens with match, then you can You can stop it and then stop the transfusion thing. Infusion and and then restart expectorant. Ill. The allergic reactions that happens into control. Yes. Next one. A 40 year old male has developed increased lethargy and respiratory depression following major abdominal surgery. He is on PCA and pinpoint pupils are elicited. Now another classic antidote. You should know. Yep, in the lock soon. It's a great yes, exactly. Okay. Oh, it's naloxone or now tracks them. So a lot of the Time IV drug users actually carry Narcan. Narcan is the is no locks or the naltrexone I can't remember which one it is, but it's one of the old opiate antagonist, so this could be used to reverse old joints now patient controlled analgesia. And he usually has a restriction on how much they are allowed to self administer, but that if the question say, in a major surgery, and then you go on a wall, trans and the patient is slumped with respiratory depression and you see pinpoint pupils think this is an opiate toxicity, because the PCA will probably be either through an app. Ajira Well, which will be another static or a look. I'm sorry, my acting I'm sitting like Activia cane or or an opioid. So always remember if you see PC and aggression or pinpoint pupils respiratory to trust depression. Think Opie, a little cysty good and 18 year old male is brought to Amy Post overdosed attempt. He's complaining of biologic tinnitus and ABG shows metabolic acidosis. What do you think it's happening? Your people are saying aspirin or does good says it's honestly, which is aspirin on buses, an overdose so classically bilateral stenosis Andre the ABG. We'll change your question. You may see to ABG. It's the first one will show a respiratory alkalosis and then the next. The next one will be a matter. Bolic acidosis. So that's the change. The fluctuation. So go from respiratory apple. It's it's a metabolic. Status is on the way you treat. This is IV by heart. On a low humans. Our list is dependent on the severity. So next 1 56 your females just received the cardinals be unnoticed that instead of 5 mg from does alarm, 50 mg is being given. So how would you treat this? Yeah, people saying for a minute. Good. This is a benzo. So there is a toxin street midazolam is a benzo, and it's short acting, and it's usually given for sedation. A twilight sedation in the colonoscopies and endoscopy. But obviously this is a no overdose of midazolam. So bends over those hands used flumazenil, which is a a gover on target list on. But it's actually it's not really used because from us know is quite it's not very nice trucks years, So it's in. I see you. I mean, I've been told that they don't really use, and it's just supportive treatment, but it is in the text books so just use it. 45 year old female has been drinking homemade spirits. She begins to feel palpitations and blood visions on when, when arriving in any and achy eyes diagnosed to remember is that she may have drunk on trees and stuff. Another classic and you don't question, well, chances with for me I got omeprazole and ethanol, right? So nowadays, for yourself. So ethylene glycol, which is an anti freeze. You can reverse that with the medicine which works fire alcohol. Dehydrogenase classically was afternoon, so the treatment for methanol poisoning was ethanol. But nowadays we use from Episode 78 year old male who is being under the specials cardiology unit presents with yellow green vision moments in confusion. What you think I've been Yeah, I think people got it. Digoxin toxicity. Did you kind great. So the drops in, which is used in a lot of heart failure, Aricept, cetera. And it can cause this box ISTEA, yellow, green vision, vomiting and confusion on you can use a specific antibody binds threat and it's called Did you mind? Is quite easy. Ones left. 12 year old male has just been taken off. Act so and his current A PTT is markedly prolonged, bit bit more trickier, this one get a protamine self. It, it's said, prolongs a p C. T. On these happening with Back Mount. So therefore, use person. It's often very good. Next question. 24 year old male receives from businesses family Connecticut USA. To discover a painful itchy rash on the lower portion was like his used, and it just means and percent cream and moisturized. Probably few centers, but this hasn't been effected. He visits the GP twice what this could possibly be and what is causing the rash you inspect is like to find a clear or it matters margin around what appears to be an insect bite on a Dema. He informed you that whilst residents family, they were doing many outdoor activities, including mounds and hiking. What do you give for this scenario? Any of the others have the poor result. I can't really see. See the holes? Yep. So this is the most from going on is the most popular answer. Okay, so yeah, today, you might know Is Lyme disease on Do, um, it's a tick born, um is a typical bacteria called really a big ferry on it. Causes like to see is classically, which this target rush so it reflects just margin around the insect bites. Now, classically Lyme disease is not really not communist country, but it's good to know because it comes up on exams on Do Think There's been some cases in Scotland's in the head produces etcetera, but classically the questions out outdoor mountain Haijun on. Then it got bitten. And then they've got this target rash. So but the rule of thumb for any tick born bacteria, bacterial infections or like Tiefest or anything like that doxycycline, tetracyclines they used. And that's just classic. Usually now with Lyme disease, if there is no symptoms and I've been bitten by tech and he knows he's been my sex, you don't have to treat so you don't always treated take by basically the doctor. Cycling would be indicated here. Now I've given you a nice table of antibodies finals. I'm not going to go through all of them, but I'm gonna go through son so classically, um, you know, the most common questions pts would be finals would be plus tritium difficile, which is this resistant stomach but basically on do. It's quite nasty, and it's quite resistant. But importantly, the guidelines have changed. So previously it was metronidazole been bank mice and if that wasn't working, but now guidelines suggest if you have a first episode off CDF, vancomycin or Ultram 10 days. If that doesn't work, then you go to for Dax a mycin, which is a new antibiotic. Use. Precede it, and that's all on. If that does not work, then vancomycin orally and or metronidazole i v. So this has changed. Definitely learn this and guy with antibiotics that you can usually get away with saying I followed the local kind lines. But this the new guidelines national. And this is a very important to learn if you have a life threatening C diff infection, vancomycin, P O and Metronidazole IV, And the other important thing is, if there's recurrent C diff, give the doctor my son now other ones to learn which important of the STDs. So gonorrhea changes according to, because again it's resistant, according according to local guidelines. But at the moment, you can get away with giving half trucks, and I am, um, Andi with any STDs, which are cruises Oh, in such a strike. Nicest use metronidazole on the other, A tick bites tetracyclines and then also learn your rescue tract. So you're uncomplicated cap community acquired pneumonia. Atypical pneumonia such as Legionella. You give it to my son, Um, but if it's uncomplicated, you can get away with given amoxicillin or pretty myself. Now, really important with any antibiotics is your anaphylaxis, which I'll get on later. So just always make sure you will fail your ski. If you do not say, Um um, allergy to any of these, you know, antibiotics or any drug. So always check allergies, so another importance of antibiotics would come up classically questions. Is your anti TB drugs now? There is a way to learn this on, I'll tell you. But so remember is in families. In is again, let's see by people 50 in juicer and the effect you should know it causes red orange body secretions. Now this could be anything from tears, sweat spit. It will go red orange, and it's just classic the drug. It's also it's also excreted through the kidneys eyes, and I said so the ones Lynn peripheral neuropathy. And you can treat this with Pyridoxine it's a paradox. Is vitamin B six on isoniazid depletes vitamin B six. Therefore, you would give it here is in the minds. This is gonna It will cause a high Purisima and I got your largest beautiful. Now this one's important because it causes an optic neuritis picture more specifically retrobulbar neuritis. So if you're starting on TV drugs on Daniel, you would want to ask the visual acuity in this patient and instruct my said mass second line. You don't really have to learn it. It's got exactly the same. Side effects is gentamicin because they're in the same family is amenable exercise. So we're gonna go through some of the address drug reactions for antibiotics. A 65 year old female presents with increasing Where's jaundice after being treated for osteomyelitis four weeks ago. Now in that table, it would have said what you treat also myelitis talk with. So let's see what you think. No one said it would. Okay, Okay. It's fine. I can go through it. Um, so the answer is Picasso seven. So you treat you treat osteomyelitis for about six weeks with a beater. Lacked a means stable. Antibiotics. Such a screw boxes selling on flu constantly. Lincoln cause a prolonged cholestasis, so it's not quick, but the policies will occur later on next. 1 24 year old male presents with a new onset. Mark your plaque in a rush to be entreated for o. M. He has recently recovered from glandular fever, which is caused by E V E V V. Yeah, I've been saying Mark seven. Good. So amoxicillin you got a rash? May be be be, um I a I would be lying if I told you the actual reason I was I was taught in my masters, but I can't remember. So it causes a rash with the movie. An 18 year old female presents the any after experience in a generalized tonic clonic seizure. Obviously, uh, let's see. Sorry is usually well managed. What antibiotic do you think's happening? This business said clarithromycin. Okay. Okay, so this is Yeah, this is quite specific. So ciprofloxacin decreases the seizure threshold now. You couldn't stay clarithromycin remarkably because it does work through on. See why people 50 inhibition buts. Ciprofloxacin is the classic one which causes lower seat officials. It also can cause a Achilles tendon. Opathy or a tendonitis picture, so always be careful when amusing. Ciprofloxacin. It also causes profound diarrhea. So it's it's this quite nasty drug, But it's important Indication wise or meningococcal septicemia. Prophylaxis. They'll give ciprofloxacin a small. For that 26 year old male. Experience is an awful reactions with new medication to track of the nicest after, after drinking alcohol, you have people saying Metro good. So this is metronidazole is called the dye salt from effect. Now DISULFIRAM was used for, uh, um, alcohol withdrawal ear's to get people off of alcohol, and it causes this basically a hangover effect if you use if if use it. If you drink alcohol the same time, so match. Nice slow, cause this is classic by sulphur fact. This year old male female Sorry is being treated for acne and has developed increased in sensitivity to sunlight. So it makes 15 tetracycline and doxycycline. So yeah, just like so, doxycycline is a type of tetracycline, so any tetracyclines can cause a photosensitive reaction. It also caused something called it a black hairy tongue, which is it could be foul smelling etcetera, but it's distributable. But yes, so accurate mints. They usually give, like on Oxy Touch cycling or Lima Cyclen. So they're all in the same family, but it can cause quite profound churches. Sensitivity. Ah, 47 year old male is being treated for a luethi and has developed and itchy rash Governess pulls them positives. One mix, I think. Just people saying amoxicillin or trimethoprim. Yeah, this is trimethoprim to trimethoprim is used for lower UTI, so it can also be useful. Higher UTI star Such a spinal arthritis But trimethoprim works by anti folate metabolism, so therefore it can cause a rash and it can also cause per itis. But nothing it can cause is mild suppression. So really do be careful if if you're on trimethoprim and you need and your folate deficient, for example, a one month old male who is being prescribed nightspots it recently. But it's not just have drawn this hemolysis is expected. If you've done off of obstetrics and gynecology, this would be helpful. So when I answered boxes it in Okay, amoxicillin for everything. Yes can call Joneses. Yes, amoxicillin can control trend causes cholestasis. That would be, um that would be correct, in a sense, but it doesn't cause her mal assess. You know, someone said Nitrofurantoine. I think g six pd deficiency. Great. Yeah, exactly. Nail on the head. So ciprofloxacin nitrofuran tear in and sulfonamide they caused a g six PD deficiency sort of crisis. It will cause Humala cyst. So if your G six PD deficiency then on Hollis is can happen with these antibiotics. And classically, the homologous cysts causes bite cells and hines body and on blood film cetera. So, yes, and it usually is a very young newborn child who's just mean on, um, nitrofurantoin for an infection. But yeah, I always remembered she six pd. Good question for 26 year old female presents for local GP practice increasing insomnia and delusion. You suspect an acute manic episode and refer to the CM H t, which subsequently diagnosis type of bipolar haven't been described. Lithium is a mood stabilizer, but serum Libyan levels need to be checked. So when should you measure these? I think he is the most popular down so so called. Good on. That would be correct. So you measure lithium levels 12 hours post dosage now does. It could be a a bit of a nightmare to actually learn So this again is wrote memory. You learn it because it could be important. So lithium, 12 hours post dosage. So initiation. When you start with your you check weekly until stable. Then your mainstay measurements is every three months. If you change the regime, you take a sample one week. Post. Oh, should change men. Check weekly until stable. Thing to take from This is your check. Lithium levels. 12 hours dosage Now Other medications which comedy come up for Just tree is penicillin. Penicillin is again an anti epileptic, but it's it's again. It causes a lot of side effects, a lot of problems, so it's not measured routine but trough levels immediately before next. Dosage, if toxic, on adjustment to current machine and or compliance. So, basically trough levels. If you suspect boxes City Jackson, it's not. It's measured routinely, but the things to take from digoxin is six hours post dosage check and then you measure 8 to 12 hours. Post last dosage. If toxicity you suspected you usually check would just be six hours post dosage. But if there's success itchy that age 12 hours post last time and the other one's lead cyclosporin, it's like this morning again is one of those drugs which causes the hair a lot of side effects and just learn it Trough levels immediately before X. Good question. Five 30 year old male presents a knee was diffused after on pain, increasing the worsening diarrhea which he empties his bowel 10 to 15 times daily. There's a lot He has refused a gastro who conduct an MRI enterography which demonstrates Rose Thorn also has been counseled. String sign They started on Metho. What should you monitor in this patient? On what condition is this? Does anyone launched a pool? Yeah, for lunch exceeds you were really common answer. Great. So and that would be correct. So this person has probably cruise disease because again, the increasing with diarrhea, abdominal pain, bowels, bowel open in 10 to 15 times they last all watch. And then the MRI. Interbrand confirms the diagnosis. So Rose on also and cancel string sign a pretty much pathognomic the crowns and then the methotrexate is a main stay treatment or remission. So the things from that to learn about methotrexate is you have to measure the full blood count because it can. It can cause my discretion because it works by a folate folic distance. This basically you knees and LFTs. Now the reason why you'd measure LFTs is because methotrexate can cause blood dyscrasia on liver services. There's being recorded on it. So that's why now my skylines adopt the LFTs is a routine, measured now drug monitoring. So this again comes up a lot on. We're going to go through some, see if you could put in the tractor. Be great. 45 year old male presents headaches on Measuring his BP Manually, A region of 100 50/95 is notice you start a medication. Well, what would the drug B and then how would you want a trip? There's several same check renal function before sanitation. If it is, do you need a great eight centimeters you needs? This person would probably be given in a stent. Hepatitis into the the hypertension guidelines on Yes, you treats so you monitor renal functions to use. And he's really importantly. That's when 23 year old female with a past medical history of Crone's has been started on a medication for remission, and this is not methotrexate. Think of another drug you think people are saying as if they're open your hand? Yeah, we got a deep EMT. Good. So yeah, I'll come on TPMT. So a third type in ons You checked, but lefties and full bloods. So for any of these immunomodulator drugs, always check. FEC is entire drinking, cause a, uh I got two later, but you should always monitor allergies. TPMT This is an enzyme which is a therapy in is the top Bystrom people are deficient in it. So if you do know, um if you do know measure TPMT activity before is a live being induction, then they could go into a complete a granulocytosis neutropenia everything. A bone marrow suppression. So you need to definitely ultra and actors come up in example to definitely mantra yes. 30 year old male who suffers from generalized seizures, predominant epilepsy. It started on a medication. It's a bit more hard. Think of your anti epileptics main thing Warts. Which one of those would be usually drug motors? You know, people got it started about 48 juice and do the LFTs. Great. Yeah, exactly. Good about grey LFTs. And I'll get on some. Why? That is later 65 year old female. It it started on medication for a F There's a form of rhythm control she's developed a pft is a consequence of before to cover this. So what would you Morning. Okay, so it's It's an every day amiodarone. Someone said, do everything as monitoring. Yeah, Okay. Yeah. Yeah. So you know, it would make sense. Yeah, but so the nice guideline suggest amiodarone You check TFT is because of that viral dysfunction LFTs because it can cause liver dysfunction. Um, on Did you do this every six months. But when you start amiodarone, you should get a chest. Actually, Sinus well, but for every six months to empty is Matty's main importance visual mail where the curious to score about over 10%. So therefore it started on the medications help lower cholesterol. So what? What you news what you use on also, wash monitor. So people saying statins and do a liver function tests very good. So if you are really struggling and you want to know, you know which tests to do LFTs always pretty much comes up. So allergies FBC your knees. They're pretty much sure want to go for but for statins, you would measure LFTs now curious to score above 10%. So this person will probably be given a high intensity start in situ support. Statin so statin she would measure a lefty's. So a 24 year old female has longstanding Type one bipolar disorder control by lithium, the blood taken for monitoring purposes. So apart from be, you know, the dosage is what would you monitor? Yeah, there's a There's a mixture of onset I ride LFT using knees. FBC renal function Everything. I'd like to add a born profile that so Okay, okay, so the ones to measure the level. So obviously lithium level pft on you, and he's so those the only ones which nice guideline suggest you could probably do all of them. To be honest with you, it's one of those drugs which you should do all of them. But there is the ones that you should monitor off the often than not. Good question 6 57 year old female presents to any with wisdom, excisional chest pain and dyspnea. Past medical history of stable angina is noted and controlled with these opera lot simvastatin and sibling, your G t m p r N amlodipine was commenced a second line medical management. But the patient experience significant ankle edema there by gym and I terminating a multiple, which may be added to his current regime. Because how whole lot be real? I think the most common answer is see? Okay, so this question is not very nice. Actually, it's all about your guidelines. Now I find it ridiculous that we're supposed to learn the guidelines when if you go to a knee, they're all plastered everywhere. But, for example, of assist, you should know the guidelines, so the correct answer would be Knick around. Now I can understand why people would say nifedipine, but I felt being a mom being there in the same family discount insurance block is. So if someone has significant ankle edema and they had 22 minute I'm not being then nifedipine probably gonna do exactly say so. You would then choose a different agents, and Nick around would be the one indicated now angina pectoris management. And as I said before, we covered be two blocks of wrap it'll never used. So first line is an aspirin and the statin and then stumbling, Golgi tiene the nitrates to, you know, relieve symptoms when untaxed will happen. Important things notes about short acting Nitrates is because you become tolerant. So therefore you could switch onto a longer acting nitrates that such as isil I So that's always an option. So second line, you then combined beater blocker. Um um or accounting tunnel blocker, which is not verapamil is. It has, um, so which are causing trouble? Blockage, strictures. Amlodipine, nifedipine cetera. Yes. You don't want to combine a beats, a blocker and a calcium channel blocker, and you just want to use the constant help. Okay, Then you could use for rock mill. Older tells them If you do combine, then use the dihydrofolate in vision, which is a multiple, etcetera. Now this is but it supports the third line. There's a couple of different options you could choose So you would go for beat a blocker on D c c b a dihydrate pyridine custom trouble. Guess it's just my father be. But then you may add a third agent. So there's a couple you can choose either Breaking Rinaldi seen Nick around so on a long acting Nitrates. So, um so obviously in this case. It's just neck a Randall. They all have to from mechanisms on. They all have different side effects, or so so is with no chain. It's all always with, you know, brushing up on those side effects. But that's always that's always related. Question seven. 75 year old Caucasian male presents a any with exertion or just being disappear and syncope. A past medical history of systolic heart failure is noted, and control will be operable enalaprilat in a minute. A chest X ray shows acute pulmonary edema and you suspect an acute decompensation of heart failure started frusemide importantly, that was already sent and sorry. Following this, you conduct the CT and see co existence s what would be added fact, the whole please. Thank you. So the most common answer is See the Jackson? Yes. So this is you give digoxin. Now the digoxin is using a half a cup. It's also used. If there is co existent f, you would give a strong person, um, and also about the others. Now again, it's your protest. Your guidelines. So the heart failure management first line is a beater blocker and a niece inhibitor combined. Then if second line, and they don't have a really high potassium. Then you would give mild, austere own and tackiness, so classically experience Lecter. But it is also with noting is also with learning the different other drugs in that happen in our family, because it may throw you if you don't know it. So a parent, home and middle, right there at the drugs, which I'll just even a tightness. Now the third line is this is where you have to choose. According to the indication. So I've been breathing is when your solid rate is above 75 BPM and a left ventricular function is lasting 35. So then you give out braiding to Cuba, trilled. That certain is when your left on ventricular function is less than 35%. And if you're symptomatic, digoxin, coexist, hydralazine and nitrates. So this is particularly indicated in patients off African Caribbean sun on. Um, the thing to notice hydralazine is it is one of the known causes off drug induced Lupus. Um, on it's really important to them, so usually hydralazine and broke. And, um, I other two, which commonly cause drug induced Lupus. Um, and in a question. If they want the antibody, it's anti histamine for drug induced list. Lupus to just barely. I might. And then, if there's curious abnormality, cardiac resynchronization pressure, a 12 year old female presents that aiming was increasing wisdom and discipline. Weeks past. Medical history of acid is notice and controlled with the salbutamol inhaler inhaler prn ICS lotus. She cannot complete the senses has a heart rate of 130. Her roads you sat below 92% and respiratory. It's both searching. She started on 15 liters of oxygen via non rebreathe mask. Nebulized Sabir, an aural project in five days. So following admission, you want to restart her on maintenance therapy. So what could be added to the previous regime? Thank you. Okay, so I think most people are going for a and that's which be like right, That's it. Good. Now ask him a management's. This is something you should learn for finals and for the SVR ski so written on practical exams because it is really important. So the initial diagnosis is faster. You would give a suburb so so beautiful. So this is your Ventolin, your blue inhaler. Then, if it's not controlled or the initial diagnosis of aspirin has persistent symptoms. Then you could add on a low dose inhaled cortical steroid so classically salbutamol back low Mattis own. You can also use fluticasone those sort of, you know, combined the regimes. Then, if that's not working, so in this case, then you would add on an ultra so montelukast, which works as a leukotriene receptor antagonist on, but that will be added on as a sort of trial basis. It might not work, but it could improve. So it's again it depends. If that's not working, then you do a Sabir Lotus eyes. Yes, on my knees are the little lab a such a salmeterol. You can continue the ultra if it's responsive. If North today is is redundant next, if that's not working, then there's a couple options. So a Sabbath plus or minus an ultra, and then you switch a lab ICS to a low Joe's marks. So and then, if that doesn't work, then a stab plus or minus an ultra and a medium dose march on a low, you switch to fix those medium dose. Sorry, they're fixtures medium dose. I see it on a separate lab If all else fails, then you can basically, you're gonna ask late. You're going to seek special advice by this time because you don't want to be playing around with these medications and a kid who is quite fully or business quite poorly. So you could, you know, increase the dose. The ice. Yes, you could try a llama on theophylline. So remember the offline there's the toxicity and because with it but most of time, you just gonna referred to a respiratory now asthma attack classifications. So this is quite useful for practical exams, but also for written papers because they will give you the You know, this the stats, basically the patient, the obs. An annual to determine what's give you a mild, moderate asthma. There, the pier PFR is about 50 to 75%. Best of predicted respiratory is less than 35. Heart rate's under 100 10 on his normal speech severe. So between 13 3 to 50% respiratory rate is above 25. Heart rate's about 110 on. It's in complete sentences. To be a bit, that would be quite preference, life threatening. So if any of these, then you're gonna escalate and it's gonna be, you know, you have to treat really quickly so below 33% below 92% on saturations. So that warrants an ABG to see if there's any acidosis. Recurrent features of exhaustion, confusion or coma. Heart rate less so if their brother Karthik, if their height no hypertensive arrhythmia developments. And if there's any signs of respect to test the stress, such a Sinuses into a recession, etcetera, and then the big ones to know silent chest or normal. Captain. Yes, if if you just do that ABG and there's a normal Kappa happening, then this is near fatal. So, um so basically, um So I do apologize. Any one of these features is life threatening, and then that goes on to go in into near fatal. So this is like a riot. The ends and they're usually hypercapnia, and they require a mechanical ventilation. So if you do see a normal kappa on, um, on an ABG, for example, then that would be indicative of life threatening aspirin. Silent chest is there just exhausted? Absolutely exhausted. So this will then progress to a near fatal um, aspirin. Now, how do you manage all this and is an acronym. Um, and it's cool. Oh, Oh, s P h I t. I'm going. I'm not going to swear. So the way to learn this oxygen Oh, 202 driven nebulizers Saba nebulizers Back to back the glucocorticoids. It's just hydrocortisone or practice Osama, such as a prescription be offering. So if none of that works, then you go into you know, your seek specialist vice of the Tear Me is, you know, specialist area and you to go. Phew! Offline Magnesium on. I'll ask why magnesium Does anybody know why you would give my easier and what it does people are saying bronchodilation Yeah, it's a potent. Yeah, exactly is a broke It is a potent bronchodilator. That's why you give it. But at this stage, you all know as an F one, you know, we're gonna be doing all this TMB you're gonna be You know, you're gonna be shipped off to the side of that because this this is a consultant area and reg an anti escalate. Exactly. The question knowing 56 year old male presents a any with severe potassium pain, which was exacerbated urine postprandial period. The pain is 10 hour 10 required IV opioids, analgesia to achieve relief. That should give you a clue on examination. He has visible scleral icterus on a distended abdomen on inspecting Yasmin, you know, just peri umbilical. Bruise and request. I do feel resuscitation juice. Ongoing hypertension. He has a past history of crowns and has been in remission for many years. What do you think? What drug is causing this? Oh, his. Thank you. Think majority of put See. Okay. And that would be the correct answer. So this is pancreatitis on back. It is is comes up a lot in exams, and I'll go on to the different causes. But this is packet itis on d on this person's got, you know, drawn this understanded abdomen on D and also this peri umbilical bruising, which is indicative off a hammer. Odjick, pancreatitis and such as? You can get great in a sign on Also, Colin sign. It's business hypertensive. He has crowns, so he's on a drug. Which is we being given remission now? These drugs are used. Um, so for remission, the two drugs did you usually use our is a typing and my cap, you're in crowds and steroids, even though it is a known cause of packets of production of prostatitis risk and it's not really used for permission is used for induction. So it's usual. Flare ups, etcetera. Mesalamine is usually is all ST quietest. Andre Infliximab is your you know, your monitor around body 30. So why is it all important? This is where the eye gets smashed. Acronym comes into play, so etiology, pancreatitis. It could be that you're perfect at mostly median Perfect. Goldstone's Actonel trauma Steroids just prize mumps and antrum virus is unknown. Causes of pancreatitis. Enter virus is a quite a big family. Suspicion ones can cause. I'm packet. I just auto immune system polyarteritis know dosa and and something which you probably won't see in this country. But it's really interesting. His truck a marriage is ask arises, which is a which is a womb basically on what it does you can Google on YouTube extraction of US crisis. It will literally clog up your intestines. Your bile duct stricture was, This is pancreatitis and yeah, it's it's quite fascinating, the way school being bad. Um, it's just it's just on the acronym and the things this is real important that height, Big calcium, you know, Hypocalcemia high pitched right triglyceride split, Serena. So high triglyceride and all kind of my bronze on Hypo Femia can cause pancreatitis. He also pee and then drugs, which we're going to go on. So the drugs causing pancreatitis, you don't have to learn all of them. But you should know the medicine for so steroids. Number one prides back lettuce own fluticasone. All of those can cause pancreatitis that pentamidine which is used for parasitic infections and prednisone infections. He's a diabetic. Dana's mean, which is heart therapeutic Age is one of the HIV drugs valve rates A surgeon about rate. This is why you check out of cheese, so develop breaking cause pancreatitis called Stasis Mazal a scene and sulfasalazine it thins So your your allow antique lysine. It drugs such as sitagliptin on these can also cause pancreatitis, blasted ray dye a size control pancreatitis. The realism eyes tetracyclines, sulfonamide. It's the ones the lead steroids A. The typing operate, um, is on a Z. That's what I would let the next question. And it's the last. I do promise. A 65 year old male presents with local GP surgery, complaining of progressively Western rash located in his perineum. Let me put. He has had to take those more 35 mg twice every eight hours for the pain. That's basically the full dose, every the full dose being dosed, and it's feeling a sciatic and feverish. His past history consists of Type two diabetes mellitus, but she has taken medication for on examination. He looks unwell, tacky and hypotensive. You inspect the rash to find demarcated arithmetic bowl I also aeration of foul smelling odor. What is the drug cause of this? So what's the Ms Wilson is going the most common. Is he good? And that would be the correct answer. So, doctor, so this person is already septic on Do. This person has quite a mask infection. Perineum. Now this is called form years, gangling on only SGLT two inhibitors. Our associate it with this, this town green on do It's, um, it's a common, but it's one of those things you should learn. So I think, like indications like when I so metformin. Basically 80 ostomy is common. A Z are off. Metformin is gosh gosh, intestinal tract. So it's diarrhea dyspepsia, and it could be quite refused area. And then the classic one to learn is lactic acidosis. It's rare, but it's always important to remember this impressions revolving around the thumb. Seven areas. This is a blank temizkanoglu presides. Any of those drugs this can cause hypocalcemia Sorry, hypoglycemia. I do apologize. College Stasis syndrome of inappropriate ADH on increase weights and appetizing. So the ones I'd learned is hypoglycemia. SIADH and increased weight get thins. So pine tree types of spread. Um, but it is a known ADR and Moshe, you can get I'm not going to try and dance up basically your glitazones. So it I would lean each one of these it increased fracture risk, but it causes fluid retention. So if you have a coat existent heart billing, you wouldn't want to get it increases your chance of bladder cancer. So, for example, say someone is you got a past history of bladder cancer or it's hard shifts. Does, um, I A. Says you would not want to give a little, um in cause liver dysfunction and increased my Now this is a bows. So your alpha blockers, like hostages inhibitors such as activists, and this is predominantly diarrhea picture. It can cause the hepatitis A bread help you one more Matics. So examine ties. Most common is envy. It is also a known pancreatitis, but this is rare and it's not. I wouldn't learn that, but it can, and it's no injuries on less than you and an SGLT two inhibitors season. You, uh, buts. The one sellin it causes glyco Syria, too. This results an increased UTI and genital infection frequency hands the predominance before meals gangrene, but it's rare. It also increases the lower limb at the risk of low will announce station. So you have to check feet regularly if you'll prescribe to write this drug, and it can also cause a normal glycine it ketoacidosis so even know it's really good for losing weight and getting the sugars sugars down. It does cause a lot of these that quite severe 80 oz on that is everything. I I do apologize for running over, but I hope it was very useful. And if you