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Hello everyone. Good evening. Welcome to our second course. Um I am Viv, I'm one of the minor bleep F one cos um I'm also an academic foundation year two doctor in Cornwall. Tonight, Magda is gonna be running us through medical emergency prescribing. Um So just a bit of um some housekeeping and a bit of information from me. Um We are a lovely big team at mind. The bleak. Um These are some of the people that might be important to be aware of. Um Our prescribing leads. Sona has been quite instrumental in designing this course. Um In 2022 she designed a course it's all available prerecorded. Um And I'll show you how to get onto that in a moment. Um But what we really strongly recommend is that you watch her videos first and then join these live sessions. The, the purpose of this course is to provide live opportunity to ask us questions, to go through questions, to get the most of it. We'd recommend looking through some of that and we try and cover the gaps that that course wasn't able to because of obvious time constraints. Um Today's session will be quite interactive. Magda's prepared um a few different clinical scenarios to go through. They're mostly based on the first section which is your prescribing section. And remember that was a section that's worth 40% of your exam. So if you get all the marks for that section, you're in really good stead to pass because remember the, the pass rate is about 6065. Um but it's good to try and aim for sort of 80% pass rate for your PSA and then you will so through with no problem. So that's the QR code for Sona course. Um Hello everyone. Thank you for me in the chat. It's good to have some engagement already. Um To find the course. If you go onto the mind, the Bleak website and you type in prescribing safety assessment course, um You should be able to enroll, it's free to make a mind the bleep account and then all of the videos will be laid out like this. So obviously today we're doing um, prescribing a medical emergencies. So you'd click on that recording and watch it. You have the option to watch it on a slower or faster speed. If that helps you, you can also just go on youtube and find all of her recordings. Um Mohamed has asked, is there repeats one? So we're not going to do a repeat session, but that was recorded. Um And if you just bear with me a few days, I will try and get that onto youtube and definitely on to me. Um we, this is a very active course, so we're very happy for you and we'd like you to email us in questions and let us know your comments and your thoughts so that we can make sure every session is tailored. There's a good number of you on the course, but we want to help as many of you as possible and make sure everything we do is is sort of accurate and helpful. So please, with us, let us know your thoughts, give us your questions. Um That's common questions we'll cover at the end. Just wanted to give a bit of a disclaimer. Um So this as opposed to sort of over reviewing the sessions at the end of the session, I'll go back through a few logistics of when the exams are. I'll go through what the rest of our sessions are going to cover. Um, and just some of the commonly asked questions throughout this session, send your questions in through the chat and I will at the end will go through them. All. All right. Um Just a disclaimer. Um That's really important for us to mention we're all fully full time doctors making these sessions voluntarily unpaid in our free time. We try our absolute best to make these sessions accurate at the point of release so that we've checked the guidelines recently. We've checked the B NF. There may be some errors. Um We apologize for that, but we're not saying that this is all perfect. So just be aware of that. Um We do our best but just wanna give that disclaimer. Um And there's sort of for mind the terms and conditions that you can refer to if you're interested in that. So Magda is on the call, she is gonna start us off. Um As I've mentioned, please just write your messages in the chat. Magda won't be looking at them through the session. I'll be looking through them and compiling them and we'll go through them at the end. If there's any super pertinent ones, I may interrupt Magda just to clarify something. Um But we hope you enjoy. The plan is for us to finish about 15 to 10 minutes before eight. So that we have a good amount of time to do the questions because that's the interactive bit. That's probably the most useful. Um So thank you all for joining. Um I will pass over to Magda and I will hide both my face and my voice for now and I will uns share my screen. Ok. Oh, Maggie, you're muted. 00, there you go. Um Right. So I hope you can see the slides now and thank you very much for this lovely introduction biv. So as was already mentioned, we're going to be talking about prescribing in emergencies today and a lot of the questions that we're going to cover today are going to be um you're going to encounter them in the first section of the PSA which is the prescribing section. The learning objectives for today are to help you recognize and prescribe the right medication in common medical emergencies that you're going to encounter both on the exam and your clinical practice. And we also want you to be familiar with some acute conditions like anaphylaxis, hypoglycemia, DKA, going to cover some other stuff as well today. So just to make sure that you have a good idea of what to prescribe in those situations and you can use that knowledge both on the exam and in your daily practice. No, this is a small introduction. So a lot of the things that we use in medicine now, a lot of things that a lot of um sorry, a lot of lessons uh in medicines were learned from aviation actually where investigations into near misses and um some um some accidents as well led to different practices. So in aviation, they have two types of um two types of ways of dealing with situations. They do have checklists, they read through their guidelines when they have time to do it, but they also have something called memory items because aviation recognizes that in emergency situations, it is very difficult to find time to read through the printed out guidelines. They want to make sure that the pilots know certain items and they can record them from memory and in fact, the medicine, it should be exactly the same. So there are studies that show that in stressful situations, um we can have some trouble recalling that information, which is why it's very difficult to practice regularly to help minimize this effect. So this is just um a small introduction and this is why um I wanted to cover um medical emergencies first because this is um something where it is very important to just not just rely on B NF but be able to just recall certain information quickly. And especially in the first section of prescribing se section of the PSA, you will notice that most of the questions are actually open in the questions, they then give you options to choose from. And uh this is the section as mentioned on Tuesday. This is the section that carries the most points. So it is probably a good idea to spend most time preparing for this one. And he will usually be asked to prescribe one drug. He will be given a clinical scenario first. It may include some lab values, it may include some vital signs, for example. And then you will be asked to prescribe one medication based on that clinical scenario. And it is quite common to see emergency uh scenarios including emergency prescribing in that section. Right? Let's just go to the next slide. So what I prepared for today is five clinical scenarios and I'm just going to read the scenario for you. I'm going to ask you to tell me what you think the diagnosis might be. And then I'm going to ask what you think should be prescribed to help in this situation. And the first case is a 32 year old woman with a history of seasonal aller allergies coming to the emergency department. After experiencing sudden difficulty breathing, she has swelling of her lips and face and a widespread rash approximately uh that appeared approximately 10 minutes after eating a piece of cake at a birthday party. Her friends reported that the cake contained nuts, uh which she had avoided for years due to mild allergy in the past upon arrival. The patient is anxious with audible wheezing and struggles to speak in full sentences. Her BP is 85/50. Her heart rate is 1, 115 BPM and she has visible hives across the chest and arms. Her tongue appears swollen and she's beginning to have difficulty swallowing. So I noticed that somebody already posted some ideas in the chat. If you, if some other people want to also say, what do you think the diagnosis is? So, Magda, I'm just manning the chat. We've got one so far. Does anyone have any other thoughts about what this diagnosis would be? And then I'll read them back to Magda. Looks like we've only got one person contributing. So try your best guys just to be engaged with this OK, lovely. We've got lots coming through, everyone's very safely and clearly identified. This is anaphylaxis, which is really obviously important not to miss. Um anyone want to develop any further. What type subtype of anaphylaxis is this just having a look through her vitals? Great. Exactly, Han. So obviously she's hypotensive. So this is anaphylactic shock. So really important to recognize the BP as well. Brilliant guys. Um mag D you can continue. Yes, I II suspect that this is there's not going to be any disagreement on this one. So we know what it is. Now, the question is, what are we going to prescribe? And the question on the PSA would normally ask you to prescribe, prescribe one drug to help with the symptoms and you will be expected to give the name of the drug, the dose and the route of administration as well. So if you want to put some ideas in the comments as well, that would be great. Great. So it looks like we're getting lots of good answers through um pretty consistent. You, you, yeah, I'm actually looking at the answers right now as well and yeah, it's a lot of good answers. Indeed. Fantastic. I think um looking at the answers in, in the chat, I think we're all in agreement that it's going to be adrenaline that we're going to be prescribing. It's going to be not 0.5 mg and it's going to be given by intramuscular injection Now, it is important to mention when you're going to, when you're prescribing for anaphylaxis that it is one in 1000 concentration as opposed to one in 10,000 concentration, which is used um in different situations. So this is something that you need to remember as well. Obviously, in this scenario, you are asked to prescribe one specific drug. However, there are other things that you can cons in if you're following guidelines for managing anaphylaxis, you will often see. And in B NF as well, it is mentioned that you can also prescribe an antihistamines such as uh chlor chlorphenamine. I'm so sorry, which is 10 mgs IV or IM and corticosteroids. Um 200 mg IV. It is important to mention that both antihistamines and cortico corticosteroids can be given, but they're not actually part of the initial management. You would only be giving those uh to prevent late phase reactions and they, they will be given at a later time. So the first drug that is given and this is why this is the correct answer to this question is um adrenaline, you give that first and you can repeat every five minutes if there is no improvement. So that's basically how we would manage it. Um You may see similar questions also in the prescribing. Uh uh I think the section is called. Um I'm so sorry. Do you remember what the section is called where we can, where we look for errors in prescribing. I don't remember the prescription review section which is review. There you go. I'm so sorry. So in prescription review, you can also sometimes find similar questions because for example, exactly you, you, you may see errors of prescribing where people prescribe correctly adrenaline. But it is for example, prescribed at the wrong concentration, which would be one in 10,000. For example, it could be uh the wrong route of administration as well. It could be prescribed as IV rather than IM which is not the right route to use in emergency situation, especially in, in particular, in anaphylaxis. Um The follow up treatment will probably not come up on the exam, but it is like I said, it's very, very useful to also remember that steroids and antihistamines can be used after adrenaline. Now, all of this information can be found on B NF. We didn't actually include a screenshot for this one. We will have a screenshot for the, for the next case and um you will be able to find the treatment summary for anaphylaxis in the same section of, of the BNF. So we'll get to that in one second where you can actually find that information. However, I, like I said, this is what I mean by stressing the importance of memory items while it is possible to find all of that information on the B NF. It is also very likely that you will just not have the time during the exam to look up the answers for every question. This is why it's really important to at least for certain scenarios and in particular for emergencies to just remember certain treatments and certain which which you already do because you gave us a lot of great answers in the in the chat. So this is this is what I was trying to stress by mentioning, memorizing certain things, right? So we have case number two and uh in this case, we have a 64 year old man with a history of type two diabetes who is brought to the emergency department by his wife. She reports that he became suddenly confused and irritable while watching TV. At home, over the past hour, he began, he, he began sweating, profusely, developed tremors and complained of feeling extremely weak. So on arrival to the ed, the patient was drowsy and disoriented and unable to answer simple questions. His skin was clammy and he appeared pale. His wife mentioned that he took his regular dose of insulin that morning but skipped lunch due to nausea. She wasn't sure if he had anything to eat since then. His heart rate was 100 and five BPM. BP was 100 and 35/85 and blood glucose was 2.5 millimoles per liter. What do you think is the diagnosis here? No, looks like there's some really great answers coming through. Um This is your presc prescription writing section So if everyone could try and do the specific dose, drug and route of administration, remember, you'd get five points for the drug choice and then five points for the route and dose. So the most useful for you all would be to practice doing it fully. And obviously, throughout the session, you can have the BNF with you and practice using the B NF in real time. Great. So mare it looks like we've got some suggestions of um 1 mg, intramuscular glucagon, 15 to 20 g of glucose, 10% IV, over 15 minutes, 10 mg of 20% dextrose IV. Uh Over 15 minutes. There we go. It was 5% glucose, 1 L over eight hours and recheck and someone suggested that if his airway is protected and his following commands, we could give him po glucose tablets again. Just to remind you guys try and write it out as you would need to in the, the PSA which would be the dose, the route of administration and the time frame you would be giving it. Ok. So great ideas. And in this scenario, and you correctly, by the way, did we talk about uh the diagnosis? I think we did already, we already agreed that this is hypoglycemia, right? Uh So in terms of treatment, it will depend on whether the patient is conscious or not like some people mentioned as well. So we can choose different routes of administration. And the BNF actually suggests that the first thing that we should be giving is uh the, the, the first treatment of choice would be glucose that's given IV. And we want to give between 15 and 20 g of glucose. So that works out to 100 and 5200 mL bolus. And um that is given SAT and Glucagon is also an option, but that would normally be used only in patients where we don't have IV access and we don't have any way to establish that access quickly in patients who are, who are, who are conscious and alert. It is also possible to sometimes go in with glucose tablets. I don't actually um remember at the moment if B NF recommends that um it doesn't, no, I do rec I do under I do remember that it doesn't recommend it as the first treatment option. Um And there are also certain preparations that can be absorbed via gums, which can be used in patients that are unconscious. But again, this is not what the BNF suggests as the first treatment option. So, um for the exam, um you should actually it's probably the safest to go with what the treatment summaries on the BNF suggest. And in this case, like you said, it's going to be glucose, there's also a possibility to give 20% glucose. But again, it's not really done routinely. And if I recall correctly, it is not suggested as a first line treatment, 10% is suggested as the first line treatment on the BNF. So when do we actually correct um hypoglycemia again, as the B NF, we should correct hypoglycemia in any patient with blood glucose concentration, less than four millimoles per liter. And that's whether they do or don't have symptoms of hypoglycemia. So, in this particular case, we had a patient who was symptomatic and the blood glucose was 2.5. So it's absolutely correct to um to manage that with IV glucose. So this is the section on the B NF where you can find uh treatment, summaries and uh in treatment summaries, they're actually organized alphabetically, you can uh look up hypoglycemia. So you can actually look up first medical emergencies in community and then under that heading, you will find hypoglycemia and this is what you will find. You will see the guidelines for correcting hypoglycemia. And uh it will tell you to use glucose 10% intravenous infusion. And uh it will also give you guidelines both for Children and for adults, you can see that glucose 20% is also listed here. So that's also a possibility. And if you chose that answer on the PSA, it would probably be marked as correct as well. Um There are is in, especially in the prescribing section of the BNF, there isn't just one correct answer. There's usually a few different options and uh like I mentioned earlier as well, it's not just uh either 10 points or zero points. It will be marked based on the correct choice of drug, the correct dosage, the correct route of administration. So there's a possibility of getting points for different parts of your answer. And I think, right, just going to go to the next slide in that case. And in terms of prescribing error in this scenario, it is not something that you would be. Um I don't think this is something where you would lose points uh on the PSA. Um I think Soar pointed out that you are more likely to lose points for underdosing glucose in this scenario rather than prescribing too much. However, in clinical practice, of course, it is possible to administer too much glucose which could lead to rebound hyperglycemia treatment delay is another possible prescribing error, wasting time trying to attempt IV access. It is something that in your clinical practice will be more important than on the PSA because the PSA will probably ask rather straightforward questions and you will don't have to take IV access into consideration or if it, if you do it will tell you straight away that you need to prescribe in a scenario where you don't have IV access. In which case, prescribing Glucagon would be um would be the correct treatment of choice. So this is how the treat the section and treatment of, of hypoglycemia looks like on the B NF. It summarizes everything really well, it tells you when you need to correct it, it tells you what the recommendations are for treatment, it gives you first line treatment. It usually specifies other options as well and for the purpose of, of the PSA it is probably go best to go with the treatment summaries. Um on the B NF. Right. So here's the next case. We have a 24 year old woman with type one diabetes. This time who was brought into the emergency department by her roommate, the patient has been feeling unwell for the past two days with nausea, vomiting and abdominal pain. She also reports excessive thirst and frequent urination on examination. She's drowsy and mildly confused with deep rapid breathing and fruity odor on her breath. Heart rate is 100 and 10 BP is 95/60 respiratory rate is 28 and SP O2 is 98% on room air blood glucose. 24 ph is seven point point 18 and serum ketones 3.2 millimoles per liter. So what is the diagnosis? So, Magda, we're getting a lot of DK A S coming through. Amazing, lovely. I think we're all happy with DKA as the main diagnosis. So my question here is um, what drug would you prescribe to help correct the patient's blood glucose and alleviate her symptoms. Prescribe one drug for now and remember to give the name of the drug dosage, the route of administration and the rate if, if appropriate. So Magda, so far we've got four answers. Uh Two are suggesting giving 500 mils of 0.9% sodium chloride over 15 minutes. So stat uh one suggesting 500 mils of Hartman's. Um there's been a few suggestions of giving insulin or actrapid. So I wonder if you should talk us through that a little bit. I think this question is a little bit or the way I phrase the question is probably a little bit. Um It's not entirely clear because obviously managing DKA is not just prescribing one treatment. It involves giving IV fluids and there are different fluids. And we're worried about quite a few things, few things. At the same time, we're worried about electrolytes. We're worried about blood glucose. Uh We're worried about low BP here as well. So I tried to phrase it in a way to, to suggest that we want to correct the patient's blood glucose because um in particular, um insulin needs to be prescribed uh weight here. So I was trying to point you to that answer, but whoever said that we need to prescribe IV fluids, uh that is obviously correct. It's just um I was trying to point you in a slightly different direction with this question. So I would say, OK, so um before I tell you exactly how I thought uh this question should be answered, I just put some um criteria for diagnosing DKA, which I'm sure is just a review for all of you guys. Um So we're looking at blood glucose which is um more, which is higher than 11 millimoles per liter, um or known diabetes because um in certain situations these days, uh with patients who are on SGLT two inhibitors, you don't necessarily see elevated blood glucose levels. Um We should, uh we're looking for ketonemia, blood ketones of more than three millimoles per liter or there's ketonuria two plus or more on standard urine dip. Um And we're looking for acidosis. Um and we're looking for bicarb of less than 15 and uh ph less than 7.3. Um mm mm. Mm. Mm. Oh Yeah, this is, I mentioned this here. I will mention uh something about um normal glycemic DKA in a second on a different slide as well. Um So this is what the BNF tells us about diabe diabetic ketoacidosis. Um They should be diagnosed promptly and managed intensively. Uh The initial drug management for DKA involves intravenous fluid replacement. Like very like many of you suggested followed by intravenous insulin and patient who nor patients who normally take long acting insulin, they should continue their usual dose. So we don't change that at all. And I think I saw some answers in the uh in the chat as well about monitoring potassium levels because when we give patients insulin, the potassium is going to drop. So we're aiming to um maintain that at a level that uh we may, we're aiming to replace that if necessary as well to make sure that it doesn't drop below an acceptable level. So my uh answer to this question was uh to give um insulin first. And like I said, this is something that we need to prescribe by weight. If you had a question like that, uh that weight would be given in the question, which I didn't include in my scenario. But um if you check on the BNF, um it actually doesn't specify the dose and it tells you to check local guidelines. The local guidelines in my hospital are nt 0.11 units per kilogram per hour. I am pretty sure that this is um true for most places, but the BNF tells you to check the local guidelines. So this is again, something that is good to just have memorized because um during the exam, you might find suggestions like that on the BNF. And uh it doesn't actually, I don't think it gives you the actual dosing of insulin. So in terms of fluid management errors, um it is possible to not in this particular scenario, not in this question, but if the question was raised differently, you may want to check if somebody is also looking at checking the potassium levels, that might be a question possibly in the monitoring section. I wonder if that might might appear in that section. Um So I think I saw an answer, somebody gave an answer that we're going to slide uh start sliding scale, which is basically where we prescribe both insulin and dextrose because it is possible to overcorrect and this is actually how it is managed in clinical practice. You wouldn't just prescribe actrapid. We would prescribe both and based on the measurements, the blood uh blood um glucose measurements, we would, we would adjust those rates um in terms of monitoring, uh BM and ketones would be measured hourly uh during the infusion. And we would adjust a, adjust the dosing and rates based on, on those measurements. This is something that was very rare before. But now because patients are being prescribed SGLT two inhibitors such as ALOIN, for example, you may see symptomatic patients with um high ketones and um with acidosis, but the blood glucose will be normal because this is actually caused by um by the drug, its itself rather than um well not drug itself. But um it is a side effect of using that particular treatment in a diabetic patient. So this is something that is quite useful. You have certain risk factors um for, for normal glycemic DKA and which includes alcohol use, for example, cirrhosis infection, ketogenic diet, major illness. There's a lot of, of things that uh that could happen. But SGLT two inhibitors are also on that list and diagnostic criteria are slightly different. So blood glucose would be less than 13.9. Uh but the patients would still be acidotic, they would still have positive serum ketones in terms of management, there's very little difference. We would still use fluid resuscitation. Uh We would still give continuous insulin infusion and uh it would still be prescribed together with Dextro. So we're still using sliding scale for management of normal glycemic DKA. But it's just something to that you should be aware of that. It's not always necessary to have high, high blood glucose these days because patients who are on SGLT two inhibitors can also present uh with symptoms of DKA with normal BM. Right. Case number four is a 45 year old woman undergoing chemotherapy for breast cancer who presents to the emergency department with two day. Hi with a two day. His sorry history of fever chills and fatigue. She has also noticed a mild cough and some shortness of breath and on examination, she appears unwell and is febrile with a temperature of 38.5. Heart rate is 100 and 20 BP is 90/50 respiratory rate is 22 and her oxygen saturation is 95 on room air. Her white cell count is not 0.3 neutrophils are naught. 0.1 and C RP is 110. Do you wanna start with the diagnosis first? Mhm Yeah. Right. I'm looking at some of the answers on in the chat and it looks like most of the people agree that it's neutropenic sepsis. So we would say that the patient is neutropenic neutropenic if the neutrophils are usually less than one in particular, we're worried, we're really worried if the neutrophils are less than naught 0.5. And uh this patient has a heart rate of 100 and 20. The tachycardic, the tachypneic and the BP is quite low. So it is um it is OK to say that it, that is, this is less, this is likely to be sepsis in terms of, oh, have I already asked? Right. So, in this question again, we would, we would probably see a question uh that asks you to prescribe one drug that is the most appropriate choice in this situation. So, in particular, in this scenario, think about what is the most important drug that you want to prescribe here, what would, what would be your first choice and the one that you need to administer first and put your answers in the chats and again, name those and, and frequency. All right. So. Mhm Amazing. So we have a few, there's a little bit more disagreement on this on this question. And um as far as I can tell, most most answers are correct, they're not necessarily correct as the first line of treatment though. So given that we diagnose neutropenic sepsis, um we have to start the patient on broad spectrum antibiotics first. This is something that you need to do within the first hour of suspected suspected sepsis. Everything else will come after that. Um In terms of specific antibiotics that you're going to use. Um In your clinical practice, you will notice that uh trusts have their own guidelines and they will vary. However, you're prescribing one broad spectrum antibiotic here. And um I specifically want you to remember that if you're, if you want to prescribe tazocin, most people call it tazocin, please don't write tazocin on the exam. It is formerly called piperacillin and tazobactam and it is very important to write the full name instead of what it may be known as by most clinicians. So, um the neutropenic sepsis that, that piperacillin and tazobactam is going to be the correct answer. It's a broad, broad spectrum antibiotic. You should always be given uh giving IV antibiotics in case of neutr neutropenic sepsis. Um the most commonly used dose uh for neutropenic sepsis will be 4.5 g IV four times a day. So T DS, you are absolutely right that you also want to give a bolus of fluids. Um If you're not too worried about overload you, it's absolutely fine to give 500 mL of Saline, for example, stat and reassess after each bolus. However, again, I just want to stress that for this particular question. If you're asked to prescribe, only always think about that, that question which specifies that you're supposed to prescribe one drug that is most appropriate there, there will often, you will often see questions where a few different treatment options exist or the whole management of the condition involves a few different drugs. So you will have to decide which one is the most important. And in this case, it is going to be broad spectrum antibiotics. I saw some answers about Phil Grasim. II can answer this question. I can say something about that at the end of this session. But until then, so prescribing errors is not uh recognizing neutropenic sepsis and not prescribing the antibiotics quickly enough. And I can't stress enough that you don't wait for blood results. You don't wait for any cultures or anything like that. If you suspect neutropenic sepsis, you just start antibiotics within one hour of um making that uh differential diag of. Um when you say that you suspect neutropenic sepsis, um over resuscitation is possible if you give too much uh IV fluids. Um that is something that happens sometimes in certain patients. So think about it when you're giving the boluses of fluids, right? Let's start the last case. And then we will answer some of the questions at the end of this session as well. Uh So my last case is a 52 year old man with a known history of Addison's disease, presents to the emergency department, feeling un sorry, increasingly unwell over the past two days, he reports severe fatigue, nausea, vomiting and abdominal pain. He mentions having a recent flu like illness with a fever and cough despite taking his regular medication, his symptoms have worsened and he is now feeling dizzy and weak on examination. The patient appears pale and lethargic. His skin shows uh increased pigmentation particularly in the creases of his hands and around his scars. Heart rate is 100 and five. BP is 85/50 respiratory rate is 20. Oxygen saturation is 97 on air sodium is 100 and 30 potassium 5.8 and blood glucose is 3.4. So first of all, let's just very quickly uh figure out the diagnosis and then we'll do treatment, OK? Just because we're getting close to 8 p.m. now. And I already saw, saw some correct answer in the chat. I think I'm going to um to say that uh I'm happy that most people, well, most people, a few people said that this is Addisonian crisis, which it is. And what would you do in this situation? What one drug would you prescribe to, to treat this patient's current symptoms? Amazing. I think uh some of you and also looked um on the BNF and it specifies uh with Addisonian crisis. The treatment varies depending on, on the cause and uh when it results from septic shock, this is the dose that the BNF recommends. It's 50 M GS every six hours to be given in combination with. Oh sorry. Oh I hope I and I inserted the right screenshot. It is oh yeah, it is intravenous infusion. So you normally give a staff dose and then obviously you reassess after that and you give further doses if necessary. And I think this is what most people said. Yes. Exactly. Yes. Yes. Yes. Yes. Yes. The only difference I think is some people suggested f 50 some people suggested 100. So in septic shock, the gut, the what BNF suggests is 50 mg, right, in terms of prescribing errors on the dosing. So if you're um if you're reviewing, um if you have some questions would ask you to review prescriptions, always make sure that the dose is correct. Double check it with the B NF if you're not sure, um underdosing and overdosing in some cases as well is uh is something that you're looking for misdiagnosis is, is something that is also um possible prescribing error if you just read the sepsis here and you don't recognize that the patient requires um hyd uh needs hydrocortisone. That would of course mean that you would lose points for this question, right? I think I'm going to uh ask viv now to tell me if there are any questions or if there's anything that she would like to add because these are the five clinical scenarios that I've prepared for today. II know that these are just examples of possible questions and you know, there's, and there's other medical emergencies that you should know and know how to manage. It's good to look up the treatment summaries on the B NF and try to familiarize yourself with those. It's going to make it so much easier to answer the questions quickly because like I said, in theory, this is an open book exam and you could technically look up all the answers, but there's just not enough time and it's good to just know common treatment options as well, which is also going to be good for your clinical practice. Not just for the exam because um, common presentations, the common problems you should know the treatment of treatments of. Um So I've got um some slides ready just going through some questions that we had submitted in advance. I flagged a few questions, Magda, just that people were asking. I've just put my camera back on as well. Um So thank you for that magda. That was five really important scenarios. Um I think the question on neutropenic sepsis has created a bit of conversation. So I'll just get my side up that I've sort of prepped during that just to discuss through. I think it's a bit tricky with the PSA you don't want to stress yourself out and feel like there's lots of unknown conditions that you're gonna have to just, just know and that's gonna be the thing that loses marks. Um Most things that come up will be things that you're able to predict and prepare for. They might be a condition or two or a calculation or two. You're not sure about if you focus on getting the bulk of the marks and not stressing about one thing. That's the, probably the best thing you can do. Um I would say just you do need to just know that the, the first line treatment basically nationally for neutropenic sepsis is always picked as, um and there are a few examples of the PSA that you would need to know. I think meningitis is helpful to just know off by, off off the top of your head, bacterial versus viral. So knowing about your Cyclo Ketrax, um but your BNF does tell you that um for each pen sepsis that just doesn't come up as a treatment summary. Um What I'll do is I'll just upload my side to talk through. Um the PSA assessment, I will send that through in a second. Um I'm just seeing if there's any other questions, Magda, you won't have access to nice or nice treatment summaries. Um But they're really helpful to use to prepare for the exam. Um So go on and one comment, I think um I think for the PSA as long as you go with a broad spectrum IV antibiotic, you would still get marks because there is not one correct answer in this se in this uh section. And sometimes even if the answer is not 100 100% correct, you will probably get six points instead of eight, for example, because they have a whole panel of doctors that uh reviews those questions after the exam and they all discuss and they all make their suggestions as to what the best answer would be and then they mark based on that. So it isn't just one answer that you need to get. Right. So right fifth now you're abused, it's just loading. So I'll just let it load. Sorry, I was just gonna say, ah, we'll start going through some of the questions. If anyone has any other questions, put them through the chat, we'll look at them. Um, ma I'll let you man the chat whilst I'll just go through this. So just to say the blueprints really helpful, it's wordy, but I really recommend having that and seeing that there's also a freely available um psa guide for writing exam questions. So you can see the types of language they would use. Um I didn't find it the most helpful, but I just wanted to let you know that's a resource you can use. Um So we'll go back to that in a second. So I think just the neutropenic sepsis question, Magda did sort of highlight this. There are three things here. You could be treating, you could be treating sort of the overarching neutropenic sepsis, the hypotension, I think somebody suggested fluids or the neutropenia. Um And the PSA may give you a scenario where there are multiple things that you could treat. The point of the PSA is what's the most important thing to do. First. Obviously, this patient was hypotensive but not at a dangerous level. Getting the antibiotics in is gonna treat the source, which is the sepsis, which is the most important thing you need to do. Um You wouldn't, II don't think the PSA would even really ask about treatment for neutropenia. Um, never say never. Um, but yeah, that is the most important thing to prioritize. Um, I think I've linked another exa OK, that's sort of the other questions. Um We'll go into this in a second. Sometimes it will ask you um and the monitoring question, you know, what's the most important thing to monitor? And there will be two things and the answers that you could monitor and again, it's what's the most important thing to monitor. So, is it something that could be a life or death um thing? Um or it will be like, what do you need to let the patient know about? And it's the thing that's gonna be more common that's more likely as opposed to the extremely rare. So I'm gonna go through some questions sent before. Um How do you logged today's session on Hras I've screenshot it on Horis. You go to your main page, personal learning log and then start a new form on that, right? And then fill it out. Just be aware some of your trusts if you're an F one, they have a min maximum on how many online sessions that you can log. So just be aware that's a thing. Um, and this wouldn't be a core session. This would be an non call. The next pre question was, could you please go through once, only medications for emergency prescribing? I wasn't really sure what this question was asking at. Um, I think once only prescribing would be anything that's a stat or given there. And then, um, if you can't think of a diagnosis of medication, where can you look up the answer? So you can do, you can do obviously the treatment summaries. If there is one, if you're thinking, you, you think you vaguely know the antibiotic, then I would look up the antibiotic and I would go to indications and see is there indication for whatever it is that I want to treat? And if it's not there, you can try a second line for the questions that don't have treatment summaries that you can't use the open book to get the answer. It's probably, again, it's not worth spending a lot of your time on. It is a time pressured exam. The best thing you can do is you can flag the question and at the end, go back to it. If you can guess, then you can put something there. Um And obviously, if it's a multiple choice, there's options in front of you and you just go with the one that you think makes the most sense. Um But the prescribing section, yes, you, you do ideally want to know a rough drug cos that's gonna be a 10 month question for the other sections. If you don't know, I think flag and move on because you'll be able to reach the low hanging fruit and get the points there. Um, I hope that helps that question. Er, where can you get free PSA papers? So the top is the PSA website. Once you're registered to sit the exam through your Deanery, um, you should be able to sit one free paper. I believe. If not two underneath, I've just linked the British Pharmacological Society. Remember they are the ones that write the PSA, they're one of the, the groups that write it. They have a few free resources. I would do all of these if you can. Some people don't know they, they exist but I use them. I found them helpful. They also offer some paid papers. Um There are lots of question marks you can pay for made by other people and other companies. But this company, the BPS, the British Pharmacological Society, they write your PSA. So if I was to buy any papers, I would buy it from this company. I mentioned this in the last session papers. One and two are 15 lbs and paper. Three is 30 lbs. Um But they do have these free questions as well. Um When a and this was sort of what I was talking about earlier when a drug has a particular side effect, how do we navigate the B NF quickly. So I would search a drug and then go down to side effects and control or you can control effort. Um Should we consider that the drug as a particular side effect is rare according to the BNF? Um So usually it would be a common side effect that would come up. But I have in my exam, there was some, it was a rare effect that came up as an answer option. Um If you've got lots of options, you would pick the one that's common over the one that's uncommon. So if the question was about, you know, what's the side effect of amLODIPine? And the options gave you angioedema or erectile dysfunction and flushing, you would pick flushing because that's the more common one. Um I've just listed a few other questions. Do you need to write duration? So, for the prescribing bit and I think I've put an example here. You would need to put three characters or more and then select your drug, the dose, the route and the frequency usually you wouldn't feel duration. Um And you wouldn't need to do a, a signature. Although in real life you would and you wouldn't need to date it, it will automatically date it. So yes, those, all those white boxes you'd have to fill out. Um And if you can't find the option that you want to select, you may not have the right medication because it, it gives you all the options. Um, so if you can't find it at all, then you probably got the wrong one. Usually it does have lots and lots of options though. Um, I've just put in just so your record, I think the one that's got a fiddly layout is this prescription. And again, the BPS website has a free prescribing bundle. I think it's not many questions, but I would recommend using that because this layout is fiddly not really how you would do it in real life and it takes a bit of time. So that's probably you worth practicing. Um for the other sections like prescription review where you're checking for medical, um for medical prescribing errors. Um It's just tick boxes and that's generally simple. Obviously, if there's an A and A B, you just want to be careful that you select your A column correctly and your B column correctly. Um And again, planning management is quite an easy layout. You just click it. So that's quite self explanatory as is adverse drug reactions. So, the main one that's a um interesting interface and can be tricky would be the prescribing section. Um All right. Just a reminder of the sections and the rough timings. This is from the PSA from the mind, the bleep psa um article we've got. So it's a rough idea of timings. Um I started on the prescribing section. I spent most of my time on it. Um, reminder of the dates if you're sitting in the September 10th sitting, you should have been told by your foundation school and you should have access to the PSA website. Um If you haven't heard clarify with them, so that, you know, I know you, you, you know, when to prepare for, this is just an overview of, of our session. So our next week is gonna be on calculation skills and adverse drug reactions. Um And this is so course. So we would recommend that you watch that lecture first before coming to our session. It's just because obviously, we've, we've placed this course quite close to your actual exam because we, we didn't think you'd want to be doing this two months ago when you were not even starting F one. But to make this as useful as it can be, we love that you're sending in your questions in advance and that we can go through them. And so's course really goes through a lot of the basics. Um I think somebody had asked actually about how to navigate the B NF. So's first lecture to the one at the top outlining and crucial time saving tips. She goes through exactly how to do how to navigate the B NF and she shares her screen while she does it. So we're not gonna go through that. We would recommend that you watch that lecture. If there's still queries, obviously, we're happy to ask them. Um That's the video on youtube and that's what you'd search if you don't have me, if you don't have a, um, mind the bleep account that they are free to make, we would recommend. And that's just our next session. These are the resources I recommend in the last session. Um, I'm not affiliated with any of the groups other than obviously working for free for mind. The bleep. Um, have I got anything else? No. So, um, if anyone has any other questions, then we can go through them. I think, mind you, it looks like most, ah, I think someone's asking for the PSA assessment course. I will send that in the chat now for everyone. Uh, I haven't changed the slides. If anyone thinks they've frozen. I've, I'm still just on the Recommended Resources page. Um, if that's all right. Um, I'll just get the link up magnet. Was there anything you wanted to talk through in terms of preparation or how? Well you felt prepared for the PSA? Oh. Right. I think if you, you mentioned the last time that it, it, that you felt that your medical school didn't really prepare you very well for this type of exam. Um, so I just wanted to, um, tell you that you probably figured out by now that I'm an I MG myself. I studied in Italy in Milan. And, um, of course, the way we, we did pharmacology was very different while we covered a lot of biochemistry and a lot of pharmacology. Uh, none of, none of it was really practical prescribing, which is what the PSA is about, I think, um, well, other than, other than just practicing and, and really going through the mock exams that, that you can find, um, that you will, you will be provided with, uh, when you log into your PSA account. Other than I used the PSA uh past the pa uh past the PSA textbook, which I found quite helpful. Although um we wanted to, uh we did uh say earlier that this is probably not always the best source for the most up to date guidelines. However, just in terms of familiarizing with yourself with uh the format of questions, it's still very useful. Um and it provides good explanations for why certain answers are better than others, other than, you know, I think it's better to do a little bit uh but more regularly rather than try to cram before the exam just because this exam is, is more about gaining certain skills rather than just memorizing things. So try to try to do a little bit, a few questions every day, maybe spend an hour a day to, to try to practice and, and, and you know, and feel more comfortable um searching the B NF quickly and, and then also it will be easier to, to find the right answers. If you already know certain treatments um from memory for certain common conditions, you don't need to know all of them and you definitely don't need to remember all the dosages. But try to know that. For example, I think a lot of people asked um where we found the answer to the hydrocortisone question. I just because you know, if you remember that you need, you need to give hydrocortisone. It's actually easier to find a dose of the drug than go through all the treatment summaries during the exam. So if you know it's hydrocortisone, you can find a dosage in five seconds. Uh If you need to read through the treatment summary, it's going to take you much longer. I think that's, but in terms of giving you hope, uh I passed, uh I passed uh the PSA on my first try. It's definitely doable. Don't stress too much about it. And also if you don't pass on your first tray, that's not a problem at all. You will have. Um I think free tries in total. I think uh im GS are allowed free, uh free tries. So the first one is, it's not a big problem if you don't pass. However it is possible. So we, I've sent out the feedback form at the bottom. I've just added a bit about any questions, maybe that you've still got from today for whatever reason you don't want to put them on the chat. Um And yeah, I think hopefully most of you are on the I MG whatsapp group or you've signed up to our mailing list. If you haven't sent up to a mailing list, I'll just send a link of that. Now. Um, and I'll either send a form or suggest that you email, um, this email address with any questions. Um, cos again, it's quite nice for us to be able to prepare an answer and have it sort of well researched and well answered. This is the generic fy one mind the bleep by, um, email, if you have any generic questions, just email there, we check that quite regularly. Um, it says the feedback form has already been filled out. Hm, I'm not sure it's coming up for me. If anyone else is having the same problem, can you just thumbs up that comment? Can you come up with a list of the most common prescriptions to memorize? Um, I'll see we can have a look to see if there is any resource like that. Um, I would say all of the, um, emergency medicine prescribing treatment, summaries on B NF. Know all of those. That's definitely my strong recommendation. Did. Um, we've got a question about somebody who also studied in Milan. Did you face a lot of difficulties while prepping for the exam? Knowing how different pharmaco was? Well, I do think it was, it was specifically because, um, the way we did pharmacology in Milan, it still covered the same topics. I think the main difficulty was that we didn't really focus on practical prescribing So it's not going to be completely different. It's not that you, you've never heard about certain medications or certain treatment, it will be very similar. It's just getting used to actually doing it in practice, which as you, as, you know, in Italy, it's, it's not the main focus basically. So this is why I would suggest just, just going through the mock exams and, and just doing as many questions as possible. Um, I'm aware everyone that we have overran that everyone may have busy days at work and ed on the wards. So if you haven't finished, you have no more questions and obviously feel free to leave. Um Please do fill out the feedback. I've also put the original mailing list feedback form. Um Maybe for now, we'll just say submit questions through that form. Um If I can think of a slightly more efficient way of doing it, then we'll be in contact. But if we at least have your emails, then I can email round. Um Just be careful. A few people inputted an email that wasn't valid when I then went to email. Um So just to make sure that you've put it in correctly on the form, um Has um if anyone's still having issues opening that feedback form, can you just message in the chat and I can send a different link? Um Now, ideally, um for everyone else, have a lovely evening. Thank you for joining. Um Do watch um so's lecture before next week, if any of the things that she goes through in that lecture weren't clear, let us know in advance and then we can talk through it at the end. Sort of like how I've done today, um by bringing up your questions and trying to answer them visually to help with that. Um Me and Magda will just sort of sit here for a few minutes if there's any last minute things. Um, ok, I'll try and put a link in now. Um, yeah, so we'll, we'll just sit here and if there's nothing else and then we'll probably tune out in about two minutes if that's all right.