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Hi, everyone just checking. Can you all hear me? Ok. Yeah, I can hear you. Ok, super. So everyone thanks for joining in tonight. Um Hope everyone has managed to get through every today with the bad weather and everything. All right, but this is being recorded. So anyone that if you know of anyone that wasn't able to connect or whatever, we'll be able to get them the like later on. So my name's Owen. I'm one of the um if one's helping with foundation to finals this year and myself and alongside Kra who have just put this talk together for you all tonight with regards to the prescribing safety exam, which is coming up, I believe next week. Um Kra put most of the work into these slides, a lot of work into these slides and unfortunately, can't make it tonight. So you have all drawn, the shorts drawn are stuck with me, unfortunately. So um we will make a start then. So if somebody is just able to say the slides moving. Alright there. Yep. Ok, great. So we'll start off having a wee look at the, the structure of the PSA exam. I'm sure you are all familiar with this, but on the day of the exam itself, it's a slightly larger exam than most of the mocks. Um, it's made up of the eight sections totaling 200 marks. You're then given, uh, much like most of the other exams, you said you're given a mark out of 200 then that mark is judged off, uh, uh, a pass mark that is set based on the standard of the paper overall. So I believe I was looking back at ours there, I believe the pass mark was 59%. But that would obviously change on a year to year basis based on the performance of different papers. And as well, I believe the paper that Queens will set will, the queen's choosing will set won't necessarily be the same that all universities will set will set. It'll depend on the time of the exam in each individual university. However, regardless, I suppose it's just about trying to get as good a broad knowledge of all these different sections and score as high a mark as possible. So as you're well above whatever that pass mark is gonna ultimately end up being. So what we, what we're gonna do tonight is we'll run through each of these, we'll look at prescribing some talk around with these sort of more general planning calculations sections and then move on towards um looking at drug monitoring and some data interpretation as well in general. So the paper itself as it says, it's a two hour paper. Um One of my biggest bits of advice would be is do all the practice papers on the PSA website and also on the British Pharmaceutical Society, I believe, have the, the link to some mock, you have to pay for them. Unfortunately, but they are very um from memory, very accurate and very reflective. Even like the user interface on the computer is very reflective of the PSA exam itself. Um I'm sure you are all well aware, but now to use a control E function and really that is a lifesaver because this two hours it is quite a tight for time paper, I thought certainly in mocks and also on the, on the day as well, unfortunately. So getting used to this control E function is, is really key to speeding it up. And um, I feel as though, yeah, it's almost essential I would say to be able to, you won't be able to, unfortunately get through it just by scrolling and trying to read things. You do need to, to practice, learn to pick out keywords and things that you'll need to then um, complete some of the questions, apologies, some of these um, tables I haven't copied over very well. There's just some of these ones and things I'm not sure what that's about. But, um, and this is a general break down of the questions with regard to prescribing and things. Um, obviously some of the bigger topics that you could imagine with regards to prescribing this medicine in general practice feature very highly and then other topics that would have been very prominent, possible for written finals as well. You know, things like P psychos and G. And as you could imagine, especially with medicine and GP elderly care as well. The sort of the nature of what you could be asked is very broad. So I suppose it just is reflective. Unfortunately, there is quite a broad range of, of, of knowledge needed for the PSA some of the advice that I would give would be to be familiar with the treatment summary section on the B NF. And this is quite a useful table here. So if you don't know what the treatment is, you then look for the B NF. And thankfully, a lot of these are very um well laid out and very self-explanatory that they will give you 1st, 2nd, 3rd line management of conditions and also directly link in them the specific page for whatever medication you need. So say, for example, there's a, there's a case as I've shown later on here on Acne and you're looking to prescribe some Erythromycin. For example, there will be a link there to take you directly to the Erythromycin page where you get your doses routes of administration and things like that. Um obviously, there there is a potential, the PSA certainly have some more less common shall we say prescribing scenario? So it is good to know. Certainly this is, this was taken off. I believe it was past the bleep, this, this table, but I had this sitting beside me for my PSA revision and it just, it just goes to show what some of these, well, she might look about something for anxiety at night. There isn't a treatment summary not called anxiety. So it's just knowing and sort of trying to have a very broad understanding of what is in each of these treatment, summaries and what they, what they relate to looking at the prescribing section initially, then. So this will consistently, they have 8 to 10 mark questions. You get five marks for the drug choice and then you get five marks combined for um dose route and frequency. It is worth saying, you know, before I want to alarm anybody, there is frankly quite a wide range. Well, for a lot of questions, there is quite a wide range of answers and certainly there wouldn't be anything where, unless it's very obvious that you have to be specifically have one answer to this question. There are a range of answers and as I mentioned later on, especially in relation to things like fluids. There certainly is more than one way to get 10 out of 10 on these questions. So don't worry about being too prescriptive that way. As long as it, I suppose it's a, it's a logical evidence based drug choice and the subsequent dose and RR and frequency that you choose is correct relative to that. Then you should be on to getting a high mark. It will always be one drug per question. You'll not be asked to prescribe, say two drugs for any particular scenario. As is, I suppose the same in real life prescribing. It's always really important to check allergy status and a lot of the times certainly from doing this, they will try and catch out. Unfortunately, with some, maybe even on the prescription review section, somebody will be given something they're allergic to or for the first line drug may be contraindicated on account of that. Likewise, it's also really important in these questions that they will have, you know, for example, things like trimethoprim, they will have somebody with a low eg fr nitrofurantoin, they will have somebody with a low eg fr and you'll have to then adjust and adjust your treatment or adjust your prescription on account of that and can be very wide ranging, as we've said. So things like acute conditions, acute things like infections, um, asthma exacerbations, these more chronic conditions here, as we've talked about fluid prescriptions as well. I suppose there's scope then to look at other things, potentially, maybe not necessarily in prescribing things like diabetes and given lifestyle advice around that. I mean, I think for this section, it is really important to practice and familiarize using the treatment summaries that are on the B NF. I think a, a wise way to approach this would be to look at asking yourself the question, what drug you would prescribe. And then once you land on a sensible drug, you then um look and check the B NF and check for its route, its dose and its, its interval and its frequency. For example. Now it does become a lot more second nature to you. When you get to F one, believe me, you'll start to remember commonly used um drugs and commonly prescribed intervals and interactions and things like that. However, for the sake of the exam, obviously just be quick and be speedy, but it is definitely worthwhile checking all these answers on the, on the B NF. So I've attached a video here ii assu I assume these would all be fairly well practiced at this point or if you haven't worked through your mocks. I've tried to keep these all from one mock to try and not spoil and they try and not spoil the um spoil the surprise when you go to them for want of a better term, but just to give you a wee run through of the, of the, the interface and this is what the exact same one looks like. So you can see here all the different choices, spirolactone and furosemide, which we're going for. So it is just important, you know, to make sure that on this, when the dropdown comes up that you do click on the dropdown because if you take 40 mg, you need to then go down from where it dropped down and click on to that. And likewise the same for medicines, frequencies, routes of administration and things like that. Does that all make sense? So does that if anyone has any questions at any stage, just pop them into the chat, I can see them here and they'll, they'll pop up as I'm talking or likewise, just feel free to unmute and um feel free to unmute and just pass away, looking at, at uh at prescribing fluids. And I can actually, I can remember distinctly that's coming up as a, as a question of multiple questions. I actually on our exam, um obviously the same sort of the same sort of general rules for fluids that we would talk about for ay and for practical exa for um re exams, still apply things like 250 mills or 500 milli boluses given quickly um in the case of shock or hypovolemia, um it's probably worthwhile to remember this parking criteria. You know, we, if we weren't asked about it in PSA, we were, we were asked about it in our written finals. So just to be aware of it. Um and remember that for me and if, if you were asked to prescribe in a burns case, um it would be Hartman's then would be the ideal fluid, I suppose one that you would like to prescribe and then remembering your general rules around electrolyte replacement and sort of volume and quantity of water. That is worth saying when I go back to what I said originally, you would only be asked to say write up one bag of fluids, for example, for a scenario, um You wouldn't be asked to prescribe, say maintenance fluids for 24 hours comprising of Dextros and, and the Crestor, for example. Um however, we were like from memory, it was hypercalcemia or something. I think we were asked to prescribe around. So it, well, it was just to prescribe, say the first bag that you would use to to treat that, as I said on the previous point, um there's usually a spectrum of doses, volumes, flow rates and things for fluids. Um and they can be quite wide. So don't be getting too bogged down, you know, anything, say, for example, if you prescribe something over six hours for a lot of the time 4 to 8 or even 4 to 10 might be perfectly acceptable. So don't get too stressed about that. And as long as your answer is justifiable within what is I suppose normal clinical practice. So then you that you shouldn't have any answer for that and they shouldn't be marking that too harshly as long as everything else is I is correct. Um One of the biggest tips of advice I would give for these are as well especially for prescribing and also for the calculation section which we're going to come to um ask, just ask yourself, does it make sense? Like, for example, you know, we'll come to it later on if you're being asked around like the total volume of fluid that, that the antibiotic is made up. And whether if you're getting a, an answer that's coming out and say like the thousands of mils, for example, ask yourself, you know, have you ever seen it a liter and a half bag of fluid with for Gentamicin or for Vancomycin or something like that? And it, you get no like that, maybe just prompt yourself to come back and to come back and have a look at it. Likewise with even things like fluids. You know, if you find yourself and you've put in an answer and you're giving somebody, what would ultimately be said, 5678 L of fluid over a very short period of time, just think to yourself maybe. Is that necessarily the right, the the right, the right approach to this or is this the right train of thought for this frail elderly person that's got a bit of heart failure and renal failure as well. Looking then at Antiemetics and I suppose some of the main things just to try and keep this um as brief as possible. So this is a brilliant youtube video and II would encourage you all to have a look at it it's, if you, you probably have already seen it before, it's, the Armando has one, that goes sort of through the pharmacology of antiemetics, certainly in a lot better detail than I would ever be able to go through. So, but just to run through some of the main ones that you might be asked to prescribe would be things like metoclopramide, which is, uh, which is a dopamine agonist. It's obviously, it's really important to avoid that in Parkinson, Parkinsonism as it would obviously antagonize they've already deplete dopamine stores that they would have. Um It's also an important contraindication. I'm in a surgical job at the minute. I it would be contraindicated in things like acute bowel, acute abdomen, acute bowel obstructions and dialysis and things like that. I would just um encourage some caution if you were prescribing it in that scenario. Um Cyclizine is another one, probably the most common one and most common first line antiemetic. Certainly, by the time you are finished rotation, one next year, you know, cyclizine, 50 mg T DS will roll off the tongue and it don't roll off the pen at that stage. But whatever the equivalent and encompass will be, um it's usually a pretty good first line and the emetic. However, in cardiac patients or people with a really extensive cardiac history, it is advisable. Certainly with severe heart failure, I believe if you look at the B NF or if you look at some of the iodine injection fraction of less than 20%. But I think don't quote me on that uncertain if, if the question was hinting towards somebody with a history of heart failure or they were particularly edematous, maybe like to yourself, the cyclizine, the right option and have a look back at your treatment. Summaries to see if there's any other guidance on where to go from from that. Um Ondansetron is another common one. You know, typically typical dose would be 4 mg, eight hourly. Um up to a maximum of 12 mg a day. First line. Anyway, for, for vomiting, I wouldn't routinely go any higher than that. However, the big one with it, as I've said on the screen here would be pro on QT. So for example, again, when we come to our um monitoring and se our sections later on, if you see a question around, say a patient has recently been started on Dansetron and what investigation might you like to monitor for side effects in this patient? There's a good chance it'll be QT prolongation, an important point on cyclizine as well. I would never prescribe an IV as it can actually give people a sort of a euphoric sensation or a bit of a high and it can be addictive. So if you're prescribing cyclizine, I would prescribe either po or I am if they're at the point where they're vomiting, obviously, and they can't maybe keep all medications down. Um However, I think for the purpose of the exam either would be fine but just for a tip for real life P ri M would be my would be my go to for cycling. Just um as I was just putting the last touches on, on this presentation, I feel as though this these guidelines are really useful. I haven't enclosed the whole document here, but it, it's a fantastic document that looks through some of the main symptoms and palliative cure. Things like, you know, this is we're talking about morphine obviously for peeing and then the antiemetics here. Um it goes through other things like sort of agitation bleary in, in the last days of life and things around pain as well, you know, more, more complex and more sort of more um in, in intricate than this. However, as I say, I would really encourage you all to have a look at it from a prescribing point of view and also from a thinking down the line to f one point of view. But some of the things that I think are most relevant for yourselves would be this table here. So I would be, I would be familiar with the sort of transition from certainly probably oral to subcu morphine and then the oxyCODONE as well. So basically, if it's an equivalent chem chem, an equivalent substance oral to subcut is tends to be divided by two um or they were morphine, oxyCODONE. So as you can see here, oxyCODONE is, which is the short tech and Long Tech. Um because I know the PSA I quite like to put in brand names to try and confuse you sometimes um is as you can see sort of almost twice as potent as oral morphine. So we just to bear that in mind. And as you can see here, just another nice summary for um for the antiemetics and I would probably pay a particular focus at least first to um these first two here. So their indications and their cautions, these doses become slightly less relevant as this is, this is all set in the context of the final days of life and things like strange drivers. However, if you were to look at the B NF for any of these medications, you would find whatever the indica whatever the dose is for the indication that you're after. This is another one to bear in mind. Probably more. So actually for the prescription review section that we're going to chat about in a minute, but these are the enzyme inducers and enzyme inhibitors. So basically, if you were to have any drugs, like for example, like warfarin and things and also co prescribed with any of these, it might be worth flagging those as an interaction or something that could in the case of an enzyme inhibitor or an enzyme inducer, either increase or decrease the potency of a particular drug depending on on its action. Um I've been asked to have a chat around laxatives as well and some of the different types of access. So, um, really they fall into a couple of main sections, um, sort of to start with the first type that we would sort of tend to move to first line in practice as well would be. And they are, they're a gentler active to start off with the osmotic ones and they work sort of, as they said, they tend drawing water from the bile luma into the stool via osmosis to help try to loosen it its passage through the through the gi tract. The typical example of that would be moca would be well mool but most commonly in the hospital would be used. Laxido, I ever go dose 1 to 2 sachets twice daily. Um Feeling that we would then move on to things like Sana and sodium picosulfate or bisacodyl probably more. So again in the hospital more commonly, these two, but I have seen bisco prescribed as well. So there are stimulants and I remember stimulant is S for stimulant, S for cena and sodium pus suf and they work by affecting basically the enteric nervous system and the nervous system innervating the gut to help increase peristalsis. Typical dose for seven would be 7.5 to 15 mg, typically starting at 7.5 mg at night. But as I say, medications can vary and II don't know of any reasons why you wouldn't be able to start it during the day if that, if it worked better for giving patients, um, stool softeners and the most similar to the osmotic diuretics would be things like sodium docusate. Typically 100 mg three times a day can go to 200 mg. I've seen quite often as well. Um I suppose the disadvantage of that is, and I've heard that from different talks. It's quite a high tablet burden. So you're giving people, I see six tablets a day and a lot of clinicians would seem to doubt the eff efficacy of it rather to some of these other other laxatives that have AAA better effect. Um Another option of things like enema, but I'm not really gonna go into that today. I don't think it would be particularly relevant for you, but I don't think you'd be asked to prescribe an enema and the P SA and, but just for real life, just bear in mind issues like obstruction and I would be contraindications of these or severe electrolyte derangement as well. This was uh uh just to help, try and suppose, help orientate people to this. This was some guidelines that are found from a Trust of England with regards to the different types of constipation. Um And what to go for, I would say in practice, just drawing your eye as opioid induced constipation, like in practice, whether it be it um correct or incorrect. A lot of the times first, these 1st and 2nd lines are reversed. But if something helps, if, if this helps, try to orientate yourselves or to help you. Remember, for, for, if a question like this comes up, then I think it's a pretty good resource otherwise. So that's prescribing sort of raffled through there. Is anyone have any questions or anything so far or are we happy enough to go on? Grand? So we will crack on here and have a look at prescription reviews then. So this is the second section. Um So if you have questions and you have medications to review or you have prescriptions to review is maybe a better way of phrasing that. Um, so if you break it down, you should allocate at least 20 minutes to it. However, from memory, this section is tricky. I find it probably the trickiest section and it, it can be quite tight for times. So it is good to have a good base knowledge of your common interactions, common risks and side effect profiles of the common drugs to try and help speed this section up. And really the interaction checker A control f are gonna be your friend in this section. Big time. Some of the main things to look out for in this top one again is, is the one that sort of sticks out in my head from the exam that we had would be things like, um, checking the units. So Digoxin and levothyroxine are typically the ones that you would see given in micrograms, methotrexate and bisphosphonates being given daily instead of weekly is quite a big one. And then just making sure that you're not giving somebody too much, for example. So paracetamol typically 4 g is the max dose. But for example, if you have a, have a 30 or 30 kg 35 40 kg patient or somebody with really severe liver disease, that would then become probably 2 mg. So if you started creeping up the doses, that could be something that would be quite a tricky one. But it's just something to bear in mind of that. You're not giving people loads of paracetamol or loads of paracetamol and cocodamol, for example, which would be again, one that I'd imagine could be quite easily assessed to trick people out like this whole section. To be honest is really who can spot the quite sneaky errors and in trying to in and them trying to catch people out um important drug interactions. So things like beta blockers and rate rate limit and calcium channel blockers. Warfarin and those drugs like SMC and some of the other enzymes inhibitors and inducers, lithium and a lot of drugs. Really, I didn't even put any in there because they, they would run off the page interactions with lithium um methotrexate and trimethoprim is another one that I've seen in the past. And in some of the, they both work on like B12 and DNA metabolism. So they're an interaction and then they say concomitant use of two anticoagulants, for example, an oxy and an OxyIR and being started or when somebody's already on treatment dose and ask for Apixaban, for example, or Rivaroxaban or anything like that looking as well at things like suboptimal prescriptions which you know, is quite a, a broad term. But things like in AK I for example, maybe just a a wee Metformin being continued or an NSAID or an ace inhibitor that has been missed off when you realize that this patient has come in and their EGFR has gone from greater than 60 to 45 or 50 their creatinine's up at well above 100 um things like pregnancy as well. So for example, pregnancy and methotrexate, it's being contraindicated, things like valproate rack in here, um just worth bearing in mind and then long term steroids as well. Just making sure that say for the patient may need, if they're in acutely unwell state, they may need their steroid dose uh doubled for the duration of that illness usually. And there is a good guide. There is a good treatment summary. If you look at the steroids, I find that one in the treatment in the treatment summaries, there is a good guideline on sort of the weaning process of steroids and also that process of doubling them up looking in at some of the some of the main side effects of these main types of medications. However, I am going to skip on here and I'm gonna come back to that in a wee second. Um, looking at insulin. Um, I suppose it certainly is. And there are questions on insulin can be asked. It's just to remember to, when you're talking about insulin, you want to crack using a short acting insulin. So for novorapid or more commonly in the sort of interest anyway, Pedra, um, obviously you want to take, adjust your insulin if they're increase it, if they're hyperglycemic, reduce it, if they're recurrently hypoglycemic, and this would be your sort of safe rule here by 10% of the time or two units, whichever is more and just making sure you're looking at the right dose. For example, if they're having a morning hypo, you would need to look at the dose of what they've been given, say from tea time previously and vice versa. If they're hypoing at night, it's probably the breakfast dose or the dose from the morning time causing the issues. Whereas I don't think that will come up on a prescription section. It, it certainly could be one that you could be given advice on counseling patients on looking then at pre-op medication reviews. So it's certainly worthwhile to bear in mind that things like the pill or different types of H RT obviously can greatly increase risk of thrombosis. So it's worthwhile remembering to stop those. Some, a lot more of these can be a bit more controversial with regards to whether they're held or not held in the peroperative period. However, it is good to, it would be good to have at least just a general knowledge of that. However, I'm not going to dwell on it on the basis of the fact that there are higher yield things to try and um get your head around for this exam. This is something that is examined, certainly is antipsychotic side effects. So these have sort of extra prominal side effects, sort of acute dystonia, akathisia, tardive, dyskinesia and things like oculogyric crises. Um Just to be aware of them again, I wouldn't be getting too bogged down in the specific management of these, but just be aware of them as a side effect profile in things like antipsychotics, metoclopramide, other drugs like that. Um Specifically a lot of things that I like to ask about that, you could be asked to pick out on a, on a medication chart in this section. So you could be given this patient's drug Cardex being told that they've presented with an exacerbation of their psoriasis. And then all of a sudden you could realize that there was one of these drugs lurking about there that is potentially they've recently even started on that's caused them an exacerbation. Typically, things like beta blockers and lithium would be the two classic ones. But other things like ace inhibitors and nsaids can also cause it um obviously things with epilepsy, things like ciprofloxacin is known for reducing seizure threshold. Um and also obviously any illicit substances like cocaine or amphetamines, but also alcohol then or whilst they're not maybe drugs in the traditional sense that we would think of in the prescri prescribing exam, this nonetheless certainly can interact with things that we prescribe and as such, we need to bear in mind um that they need considered when we're considering what has happened to these patients. And maybe if it is a result of a medication interaction, so the can cause c diff um things like oxic is a big, is, is a big one in, in the hospital setting to be aware of, for example. So somebody's presenting with, with a tape seven and in the exam, somebody's presenting with a tape seven stew um it comes back and see if positive what's causing it. Well, then there could well be one of those things like PPI S as well. And omeprazole would be the other one that I would jot down for that as a cause. If you see either of those, your sort of suspicion proceed. If you know, they will be the two that if anything comes up, they would, you're most likely to have the right answer for um peripheral neuropathy and then QT prolonging drugs. So we've already talked about one of them here on Dansetron and fluconazole actually is one that I came across, you know, that we had to start somebody on and I realize it was QT prolonged and you just have to work that up before and be safe and make sure that that's been either addressed or discussed, I suppose before you like about prescribing it. Um, other ones. So like some of the antipsychotics here are pepper citalopram. I suppose it down to, to check out other um antipsychotics like OLANZapine and other drugs like that and amiodarone as well as another one that can prolong qt all that aside. Um We just lucky man at the probably the biggest cheater hack that I could advise for the for the, the PSA. So if you go on to the home page of the PSA type in, in your search bar, appendix one and then, so it's this one here. If you haven't heard of it, it's appendix one interaction and II don't blame you for not listening to me too much. But if, if you take one thing from this lecture, it would be learn that be aware of this and know how to use it. So, appendix one basically runs through here. There's lots of the stuff at the start isn't particularly relevant about pharmacokinetics and all that. Whenever we get to the, the really good stuff down here, this goes through basically drugs that are hepatotoxic nephrotoxic and drugs that cause particular particular electrolyte derangement. So if you have, for example, the question is what, which of these drugs is contributing to hyperkalemia. If you have those lists of drugs, just go on to appendix. One control f and just type each of the drug names out really quickly. And one of them will inevitably come up in the table that says drugs that cause low potassium drugs are called high potassium and not is the best way of either checking your answer or getting the answer if you don't know it. Because if it's in this, they won't mark if it's MS and you selected it, it won't be marked wrong because this is where a lot of the answers are, are drive from. Does that make sense? And is everyone sort of familiar with how or happy enough with how to access appendix? One great. So planning management then, so I would say this one is probably the most like MC QE of your written finals at like of this exam. So you'll be provided with, you know, shock H five options and pick the most, picking the most appropriate treatment. For example, given the scenario that you're asked to face. Um I would really look back at this section. Remember we talked about the Acne, for example, earlier on you go in here to do your treatment summary for Acne, you will then have really it all it all laid out for you and you just use your knowledge and um use your knowledge and apply it to the scenario then to prescribe whatever is, is relevant. So say for example, the scenario is that you're asked to prescribe, say somebody that's failed these topical treatments and you're asked to prescribe some antibiotic for them. You could then just click on your Lamy here or Doxycycline, whichever, whichever one you think and you would then um that will give you a dose and you would just add it in there or click on it. It might give you the option in this section. It will give you the option, sorry of penicillin, amoxicillin, whatever, just get your dose and go from there, then this is what it'll look like. So what we're talking about here, so watery diarrhea, loose stools um and then C diff positive and then you, you get an option here much like your MC Qs to try and uh pick the, pick the correct one. So does anyone feel brave and want to shout out or type in a chat? Which one they think they go for? So if we say this is ABCD E from top to bottom, which one they go for in the trial? Yeah, very good. So C diff is sort of classic one where IV isn't, doesn't necessarily translate to stronger. Um And we're assuming here, I suppose assuming that this is the first episode of C Diff because if you get into recurrent episodes, then things like famcin do play into it. But you know, that will not complicate things too much. And Vancomycin uh Po six are they this is another one as well. I thought this was quite a good one because it's unfortunate goes to demonstrate that this probably isn't, this isn't one of that you would find a treatment summary for in the B NF particularly easily for. So it's the sort of thing that you, you know, it's good to have a good baseline knowledge of really. Um, so does anyone want to hazard a guess as to what look at what's going on with this patient? Um And select an appropriate option here. Again, we'll work from the top. This top one here is a right down to the bottom here. Yeah, so there's D and I agree. Yeah. So we all know this is obviously DKA. Um and in the case of A DK where it varies from a variable rate of insulin, for example, is that it's a fixed rate based on the patient's weight and obviously you would want to then contain insulin largely then. So knowing that that is a long acting insulin, Lantus says it would more commonly be known here and knowing that that always sort of continues and it's the same with a variable rate insulin as well. If you're ever, when you f one that will become your, one of your other bread and butters, it would be things like prescribing, starting variable rates or your fasting fluids or GK fluids or whatever, like sort of interchangeable names, keeping, making sure, making sure your Lantus or your to go or whatever your long acting insulin is prescribed is still going regardless of fasting status and things like that. But just to reiterate for DK A, it's a fixed rate insulin infusion in the acute treatment. Looking at then the next section for everyone happy enough. So far, any questions super. Um so looking at this next section on communicating information. So this is similar a wee bit M CQ like in that you're given these five sections, five pieces of information and you're asked to then select the most important option to basically counsel the patient on. Um Thankfully, a lot of these are sort of medications that you could almost probably write the question for, write the, the counseling point for yourself prior to seeing the question. However, the important thing for this would be to look at the sections relating to drugs around things like important safety information, patient and care or advice or monitoring requirements. So again, say, for example, you were counseling somebody on carbimazole and there were all the different options, you would say control F carbimazol find that bring it up. And instead of clicking individually on this, that when you're on the B NF section, if you use control F and say really, it's the questions asking around, you know, white cells or agranulocytosis. If you control F that, that'll then bring you down to that section um around particular advice or say, for example, one of the options is a drug cau causing, it causes diarrhea, for example. And you want to know. Well, I don't know if carbimazole causes that or not. If you control the effort and search, start typing it in, then that will bring it up in a light. There's no results shown when you can move on to the next one or if it then flags it will end. That could be your answer. That doesn't ii, I'm not sure if that is one for all loose stools, but certainly for the agranulocytosis on it, it, it, it's one to bear in mind. My advice for a lot of these ones would be, um, the tended, the answers to these tended to be the more sort of holistic ones. And what I mean by that is that they didn't, they weren't typically overtly medical investigations or side effects. A lot of them would relate to things like, you know, say, quality of life really indicators. So even in like the next section, we talk about how you assess the efficacy of a treatment. A lot of the times it will relate to things like, um, has it improved, like, say, for example, itch or has it improved the patient's symptoms more so than has it decrease their C RP or their white cells or something? For example, does everyone know what I mean by that? It's important, obviously, it's not a one to catch fits all, but certainly the perspective that we got in a lot of the people in my year would concur would be that it's a, a lot of it, it's quite patient focused as it should be. And a lot of the right answers in this section would be very, for a day to day advice that you might give patients. And also, as I said, the symptoms that are most important to the patient's presentation, um, a lot of these will have more than one right answer here. Um But it's unfortunately as in the case with like single best answers, um some may be more correct than others and it's about picking out the most relevant one and the most important one to tell your patients. These are some, um these are some of the ones that you may um like to talk about. Um So for example, here, so take this first one here, how I might approach this crisis. So you can see you've skimmed down here and even this patient has been started on a note. So if you brought a pl on up in the VNF, you would see obviously the section where it talks about monitoring requirements, things like that, you could either click down each of those and you would probably see something along the lines of potassium needing to be measured in a week. Um And that would be the best way to approach these questions as I say. Um And that they heard talks about and it says it explicitly the most important piece of informa of, of information. So it's about, it's about working through these, as you can see more, most of these are worse. Uh, most of these are relevant, but it's, it's, it's about working through each of these and trying to pick out the, pick out the correct one. And as you can see here, this is just one that, um, just to show you what the answers and what the feedback will look like. Um As you can see here, certainly male lower her serum sodium like that. That's true. However, and again, what I was talking about, sort of the more holistic side of this is that the right answer tends to be the one that the patient will actually fail or will actually see. So this, this will have a much, for example, sort of to contextualize and this will have a much greater effect on whether the patient is compliant with her treatment than, than if they have one in all likelihood, is likely to be a very small transient decrease in their sodium for which they will most likely be most likely and emphasize, most likely be asymptomatic of. However, if somebody all of a sudden thinks that they're getting worse or, or, or not any better, well, then the sertraline could go in the bed and the patient could be very non compliant with their medication. So it's, that's where I think the point that I'm trying to prove there is everyone happy with that so far again, folks, I can see the chat so just type away or just unmute me at any stage if you would like um looking at at calculations. So this unfortunately is probably just one that, you know, I for anyone that did a level maths or things like that, it is just practice is the best way of doing it. You can't really be particularly theoretical on this and you, I would find it very difficult to lecture anyone on this other than just getting used to the questions. Some tips that I have sort of given for this would be work through the calculations twice or even go backwards. So once you get your answer, try and reverse it, go backwards to try and make sure that all your units are correct. Um be I'm sorry, be familiar then with unit conversions, which we'll talk about in the next slide. But also then your preparations and what 1% means for example, which we will discuss now. So what I would say is learn this off here. So basically just go in steps of 1000. So there's just 1000 mcg in a milligram, there's 1000 nanograms in a microgram. And then obviously there's 1000 mg in a gram if you kept going this direction here, one of my um top tips for prescribing and just for basically life as well when you're working this out is, if you remember that 1% is 10 mg per mill, then you can effectively work out any like that whole percentage thing becomes very, very second nature because then you know, 10% will become 100 mg in a mill 0.1% will be 1 mg per mill. And you can just work it all out from there effectively and it saves you having to remember at all. So again, if I know I've already said this, but if you remember one thing from today, I would remember this because it makes it, it makes your calculations section potentially a lot easier to revise for. And it means you don't have to remember as much information looking then at this section. So sort of how I would approach some of these questions. So this is regards to the preparation of amphotericin infusion and this is all, you know, obviously a lot of these to be honest are quite, shall we say less common drugs? You're not, don't, don't be getting bogged down in that because the sort of numerical principles I suppose for these will all be the same and it will, you'll see this next question. There's a question about the eye drops and things that you know, you wouldn't come across very often, but that's just to help try and so you and make you focus on the mads. So another point on these questions as well, sort of that I would advise is more often than not, there would be a lot more numbers than you need. So don't be thinking as though you have to. Well, this is now talking about like 5% glucose and 1 mg per meal of this, this question box may be used for multiple stems of questions. So this case presentation might have a slightly different calculation to it depending on what exam you're setting, usually all set the same. But I mean, in like all future exams or mocks for example. So just bear that in mind that don't think you have to use all the information necessarily. So if you have read through that, I suppose my approach and thinking to this question would have been along the lines of so how much amphotericin do we actually need? First of all. So this is a 36 kg child and the dose is 5 mg per kilogram. So we need 100 and 80 mg of of um amphotericin. And then basically ho how many meals of this reconstituted solution? So this is what basically the the medication is, it's 4 mg per mill when it's all made up. How much of this do we need to get to this? 100 and 80 mg when you just divide in be your four and it's your 45 mills then which is then added into this. So you've soon realize that this whole basically last paragraph becomes slightly irrelevant because that's then to do with the volume of glucose that you would need to produce this. But in reality, it's asking us how much solution do we actually need? So don't feel as though don't be getting bogged down with needing necessarily to use every number. Some you will unfortunately have to. But as I say, don't be getting bogged down. This again is an example of one that some of these calculations can, don't be overthinking it too much. So this is a patient that needs Vanco and gram R for a prosthetic knee infection. And so then what is the minimum volume of Vancomycin which we need to delete this down to 5 mg per mill so nice and easily. So if you have 1000 mg, so just converting your units, 1 g is 1000 mg and you need to have it from five mils. So if you divide to get from sorry to get from 1000 mg to 5 mg and then you divide by 200 so then you need 200 mg of billion to make up your Vancomycin. So they they they can be fairly straightforward as well. In practice, this is actually slightly different in that it's just certain doses have a certain volume on a sheet that you prescribe off. Some of you may have seen the bank chart. Some of these in the in the night paper, this trust may not have but just to make you aware, obviously, if it comes out slightly different in the exam. Just work on what they're saying. Um again, and this one here is one that you could probably do without much actual medical knowledge. So just working out how much potassium somebody's been given. Just the trick with this one is just watch your units because or you will step up and say the like of this question is this is a 20 Miol per liter bag, but it's only 500 mils. So it's only gonna be 10 million, 10 million MS given in that bag, for example. So instead of 40 a lot of people would probably end up with 50 in this question would have just seen the 20 to 20 then a quarter of this bag. So it really is just, you know, we you don't sometimes need a lot of medical knowledge for this, but it's just being systematic working through the right numbers and not being distracted by the extra numbers they put in there to throw you off. Does that make sense? Great. So, well, thankfully, you will be glad to hear her most, most of the way through this now. So we'll just run through some of these other ones, adverse drug reactions. So most of the AD R ss are, this can be found in like side effects interactions or cautions. Um And again, so if you're asked, you know, you're given a list of medications and ask which one of these causes w whatever side effect. For example, if you control f type that side effect in, if you go through each of them type in which side effect or else go with, it's like, say electrolytes, go back to your appendix one. But the way I would have done this in the exam was if I was given, say which of these drugs. And this is a bad example because most drugs would probably have headaches and the side effects somewhere for which drug causes headaches or which drug is most likely to cause headaches. I would then go through each of the five drugs I would go in, click on each of them, control a headache and whichever one there will be whatever the side effect is, invariably one drug, it will be more common than the others. Like for example, some of them might have two or three of them might have the side effect in very rare or frequency not known section, but there would probably, the way it will be written is there will be one will have it in like the common or very common section, for example, or else one will have the name side effect and the rest won't and it'll be more obvious to you. But that's how I quickly searched through to either check me answers. If I didn't, if I just thought I knew the question or if you didn't have a clue to work through, as I say, it comes back to this point to pick the one where it's most common and as you can see here. Um So basically, it was somebody presenting with jaundice, Billy Rubin. Um Does anyone know if anyone wants to shout out or type into the chat without searching it or if you want to, I'll go off and try and work out my, work out my logic there. But if anyone wants to tape into the chat or shout out which one of these you think it may be is contributing to their jaundice? Oh Yeah, well done. So let's see. Sorry. So I'll flick back there. So again, just another wee eight memoir. Maybe that probably more so typically co Amoxiclav, but a lot of the penicillins and a lot of the um penicil antibiotics in general are contributing to jaundice. And indeed, if you, as I say, we'll look at the wee video here. So this is me looking through. So say I thought, oh, is this Metformin? I my control f up here that jaundice isn't coming up. So I thought, well, hang on maybe. Is it? Well, I know it's not one of them, but hang on. It could be flucloxacillin here and there you go. So if I type in jaundice, then all of a sudden if this comes up, like if it comes up in a box like that, that's gonna be your answer. It won't be ambiguous like they won't write a question where it's ambiguous. That make it will have two of the drugs will have a big one and make it a big box like this. That's gonna be your answer. Basically as simplistic as that sounds thankfully. II, it's not all awkward. It can be straightforward at times as well and likewise as well. And Aspirin or if you had a control left that it would have likely come up as nothing and then you want to scratch that one and then move on to your next one. Obviously, you don't have to search up every drug. But if, if you know for a fact, one or two don't cause it, obviously, that's part of your exam technique, just scratch those and save time because as I said, it's a, it's a tight exam. You will need, you will need your time to go through it. Um looking then at drug monitoring. So this again comes back to this point here, but I remember what I was talking about like holistic holistic requirements. So, and an answer sort of what is the best test? A lot of the times it's not the really biochemical test. It's, it's um it's often the one that will provide relief to the patient or the one that is most sort of relevant to the patient's symptoms and their conditions. So if you use this example of sort of Theresa made in the context of fluid overload, in terms of monitoring for the beneficial of the therapeutic effect weight would be the, the most, the best, the best one there because that's effectively showing that, that the patient's effectively dire, it's noninvasive, it's cheap to do. And you know, does it really, uh for example, think of it, is there much use in measuring a patient's BNP? If the patient still feels rotten, they're not gonna be conferring any benefit from their fluate. For example. Likewise, things like bisoprolol in the context of a tachycardia. Well, something as simple as the patient's pulse may well be the most appropriate investigation, you know, do we need to start doing echoes and things like that? Not necessarily. And, and then the other ones say, for example, it could be things like exercise, tolerance for furosemide could equally be if, if there was a number of different options, given things like exercise tolerance for that or spironolactone or things like other medication. However, on the flip side of that, it's just important to ascertain the context of what the question is asking here. First, if you are being asked to monitor for the, the um the negative side effects of a drug, well, then, you know, certainly obviously with Theresa May, the big thing that everyone thinks about is it's nephrotoxic. So then you do need to check you and, and these patients to make sure that they're not, you're not throwing them into the AK I as well as you know, diaries sing them. Um the approach to this one certainly would be um, s the medication. It's, if you look in this monitoring are important safety information, probably these two main ones on the B NF, then that's gonna be where your answer is going to going today. Um So this is one that we talked about here. Um So this is the one we're talking about metoprolol um in the context of this A, so it's important to look at what we're, what we're aiming in this patient. So if we look at the stem of this question with BP, well, their BP is actually fine there. So that's not gonna really tell us much. You know, we could do an echocardiogram fair enough. But you know, it's, it's metoprolol. So like we're not actually treating valvular abnormality, for example. And you know, we, we can, there's other ways there's other more convenient ways of telling us that telling us that um the patients in af we don't need to put them through an echo to do that um peak flow. Well, you know, they're short of breath fair enough. But that's as I say, probably you can tell yourself that's probably not the most effective question here to ask plasma, metoprolol. Will, you know, what's that going to show us if they're that they're taking their medication when they're compliant potentially, but it's not actually going to do anything for the symptoms. So the problem with this patient is they're in F AF and the simplest and probably most effective way of improving and reflecting on whether the metoprolol is fixing this patient's symptoms of palpitations is to see if their heart rate has slowed. For example. So the heart rate in this case would be the most appropriate investigation. Does everyone sort of understand my thinking and treatment and thinking and rationale behind that? Um Again, another one is here is the number of loose stools. So say if you're talking about, you know, assessing the efficacy of the pyramid, well, it's not the biggest impact on my patient's quality of life is probably the fact that they're going to the toilet all day. So if you can judge whether you've stopped that, that's probably the most effective way of testing if your treatments work. As I said, I've picked one here because I think we all know this is a fairly the big hitter in terms of monitoring requirements that, that everyone loves to be asked about in their exams. This is the section here and obviously you could get advice on things like patient and carer advice. For example, that the information will be in there some uh just very general um and drug monitoring requirements here. Obviously, that's this far from exhaustive and then data interpretation here to be data interpretation. Unfortunately, it is a it's a challenging one to trend teacher gave you information on because the it is so such a such a broad church in terms of the types of questions that it can be asked. Um you know, you could be asked to interpret blood tests, for example, in the context of statins, for example, and realizing that you have a big massive transaminitis. Well, then we need to stop that drug. You could be asked to see this sort of isolated leukocytosis and realize, oh hang on this patient's on steroids. Um and other things that it talks about are things like being able to interpret blood tests as we've seen levels. So, for example, if a gent comes back it 1.1 well, do we hold that or do we give today's dose as prescribed? Does anyone feel brave at telling me, what do we do with that? So if we have a 10 to just a ag of 1.1 because again, extremely common scenario, a gentle level of 1.1. Do we give today's dose or do we hold it? And the patient doesn't have endocarditis, by the way, if anyone's wondering grand. So with gentamicin, so we're supposed to preempt one of our future slides. So your gentamicin trough level has to be less than, than one before you would prescribe the next dose unless it's, it's, it's a severe infection like endocarditis or you're invited otherwise. But that will fair to say that will about two days into F one, you'll, that'll be, you'll be rolling that off your tongues. But for example, you know, that's, that's one of the things just to be aware of and other things like bank levels or um I and I for example, could be other things that you could be asked to interpret or hold or augment in the context of the gat interpretation. A lot of the stuff that this talks about as well is like paracetamol over dose. I think that would be a very challenging one to be honest, but you may be asked to read off that. Now, the the um paracetamol overdose graph, for example, but I think that would be quite unfair. Um As you can see, we've talked about our gent here. Um even interpret and say you need to realize that the patient on morphine should be switched to one of these. Um and then optimizing insulins, then as we talked about earlier on. So if somebody, if you see, so if you're giving the trends of somebody's diabetic control and you realize that they're recurrently having morning hype, morning hypos knowing that it's in the evening dose that you probably need to go back and uh uh and change. These are some of the drugs that if you, if you see any of these in your exam, you should start to be thinking, oh, hang on, I need to therapeutically monitor these perhaps or actually take a drug, take a level to, to see how we're going with those. Um So things like obviously, the main ones would be gent um lithium would probably the main three that I would pick from that. And these are other ones here again, Gent and bank and lithium is the big one here, obviously. Um knowing and also knowing the symptoms of lithium toxicity to look at um as you can see listed here and unable to, you know, that could be. Well, as a question that could come up in that communicating information section as to what the most important advice that you have to give this patient is. And certainly in those cases, things like lithium cloZAPine Carbimazole with those big sort of alarm bell side effects and alarm bell, um adverse reactions that you need to counsel the patient on like that could, that's a very fair game to be assessed. So that's I've kept you there for over an hour now. So apologies for that. Um That's a very quick run through the P SA and II appreciate it. It's, it's a fairly big exam. It's a wee bit different to the one you have done. But when you have the B NF and you have the knowledge that you have all built up, you all done your finals, you have all, you know, you have had the benefit of having things like purple pen and stuff throughout the year. Um I would have just would all manage it fairly well. My advice would be from this stage on obviously, you know, take what you want from your learning, but just questions, questions, questions get used to the type of exams that the types of answers that come up get used to the type of side effects they like to ask about the type of monitoring they like to ask about because as I've said, it does seem to be and I had a look back through some papers there when I was preparing this, it does seem to be the same type of things come up on the same style of questions I like to ask. So if you get a good grasp of all that, um I feel as though you're well, you're well fit, you use all the well fit to answer most of what it throws up at you. Um So that's my email there, folks. I'm happy to answer any questions, you know about this or about anything relating to the finals. Um You, your oy coming up obviously down the tracks fairly quickly as well. You should have said at the start M and F one in Craig at the minute. So if anyone's there, feel free to just come and see, come and find me next week, I'd be happy to help work through anything in relation to this or any of your exams, as I say, skis and stuff after that and K in the Belfast trust as well. So either the two of us would be more than happy to, to seek some advice. Um The one thing I don't have is a feedback. II think at the minute, I might ask if that's posted in to say it might try and get that posted into your, like your group chat or something just to see if you could give us some feedback and we are trying to run. We are trying to, um, just look at this sort of peer directed teaching and look at um, foundation def finals as a concept moving forward and things like peer share. So any feedback would be greatly appreciated. Um Could we potentially of these slides for vision? Yeah. No, I don't see any reason if you want them and you want to drop me an email. I can, I can send you some. That's probably the best way of doing it. Um, my emails there or like otherwise I can speak to Kiara, I'm sure we can get a link posted to them anyway. I have no issue. It's just trying to figure out the best way to do it. I might have to take some of those videos out, but no, absolutely. I'm happy for you is to either email me directly and get to them quicker or I will figure out how we get them out to you over the weekend. Does anyone have any questions from it? No, that's great. Um Thanks for listening to everyone. I know Friday nights. Can that the last thing you want to be doing is thinking of PSA not at least to me talking about it. So um no bother. I'm glad you all got some use out of it and best of luck with the exams everyone. Alright.