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Hello, everyone. Good evening and welcome to our fourth session for the PSA for IM GS course that we're running. I'm Viv. I'll be Cohos tonight. We've actually got a lovely guest with us today, Leah, who's an F two doctor working in KSS. She's also one of the co leads at mind the bleep for the IM GS. Um And so she has lived experience of doing this as an I MG. Um And so we'll sort of be dotting in her tips throughout the session. So today, before we go to the next slide, we'll be covering specialty prescribing. It's quite a vast topic. Um We've got a few different question types and a few subsections for the various specialties we'll cover in a second. Um I will start off our talk as we always do just referencing Sonus course. So mind the bleep have a free PSA course that you can watch um on demand, so you can watch it through the website. Um If you scan that code, it's also all been uploaded onto youtube. Um And the way we structured this course is sort of building on things that son has already covered, ideally covering any medications or any topics that weren't covered in that. But the best thing for you to do would be to watch her videos. You could do it on your commute to work, for example, and then joining our sessions with any questions you've got, and we're happy to answer questions if you have any from the, from questions that were in that course. Um, next slide. So, um, as always, we love the PSA blueprint. Um A few of you have sent in feedback asking what are the commonly prescribed drugs. Um And throughout the session today, we've got screenshots where they actually do specify certain drugs or certain drug classes to be aware of. Um if you want to have it open for the session, you can scan that code just a very quick, quick disclaimer as always. Um Obviously, this is an entirely voluntary session. We've done our absolute best to make original questions that are interesting and hit different parts of the mark scheme, but we are all working full time. And although we want this to be that as we can, there may be some mistakes. So if in the live session, there's anything that's unclear, send a question. Um And if you're watching this on demand, you're watching it on youtube or Med or please do pop a comment if you think anything is inaccurate or incorrect or if you think anything is unclear. Um And our full disclaimer is available at those links there. Um So today's learning objectives are to cover some possible question topics from eldercare, psychiatry, og pediatrics and GP. I've actually not put that in the exact order they're coming up today, but we'll be covering a range of question types from them doing some practice questions. So we'll be using the polls today and we'll be using the BNF. Um, a lot of you feedback that you'd like to see us use the BNF live. So Leah will kindly use that for some of the questions. Um If at the end anything's unclear or you couldn't, you couldn't figure out where in the BNF to look, we can go over that as well. So this is the appendix that we'll keep referencing um throughout. Um, and obviously it's a good chunk of questions that come from the specialties. Um So in two weeks time, we'll be covering medicine and surgery. Um, but today we're covering quite a few different things. Um, so now has two lectures relating to these topics. So definitely worth checking out. Um, but this blueprint does give you a bit of an idea about what things could come up for each subsection. Um So, er, just a quick reminder, obviously there's eight sections. Your most highly rated section will be the first section. We've got quite a few prescription writing questions for that reason today. Um, our next session is on, I believe providing information and drug monitoring. So we have a few less questions on those topics just on the basis that next week we will be going over those specific sections. Um But yeah, I just wanted to remind everyone of the different sections and the mark allocation. Um The last thing to mention was again, a lot of people had been asking what drugs do I need to know? What's the highest yield content? Um This is appendix of the blueprint just to be aware that that yellow box that's circled. Those are topics where they have to be at least two questions. Um or two marks of the paper has to come from them. Obviously, the word antibiotics, for example, is quite broad, but for some of them like opiates, you could probably predict a little bit more what the kind of question types are. Um So just something to be worth being aware of I would say. Um So I'm gonna hand over to leah. Um as always it's an interactive session. So have your B NF ready or medicines complete ready by your side, be ready to answer the polls. Um Once again, we'll be making this quite strict timing. Um It won't be the exact timing for all of the questions as your PSA but we do want that time pressure element. So try your best if you're not sure, just throw a guess. Um Like you would in the real exam. Um Any questions with relating to things that we're covering, just send in the chat and any broader questions will answer sort of at the end. Um I will hide that I will be in the background. Um If anyone does have any questions and Sona and Magda are also on the call, so there's quite a few of us to help moderate the chat. Um So enjoy everyone. Thank you. Thanks, Viv. Um So nice to be here with you guys. I'm gonna do my best to have this um session be as useful as possible. Obviously, we're covering a lots of different topics and we can go over every single possible topic. Um But hopefully it gives you a good overview of the kind of questions that are gonna come and how to deal with it. Even if you don't necessarily know the question um by memory, you can always find it in the B NF just if you know how to use it and get more comfortable using it. Um So I did that exam a little less than a year ago when I was in I MG. So II hadn't even seen the B NF before. So it takes a bit of practice. But um hopefully it should, it should be ok for everyone. Um Yeah, so, um I'll just give some tips um as we go along, but we'll start with elderly care. And so, um based on that there's um a different range of topics that might come in. There is the IV Fluids, questions, laxatives and analgesia, which is very common for the elderly. Um, so we'll touch a bit upon that. So, um, I think my tip would be because it seems like there's a lot of different topics to just remember that this is re, this isn't really testing your medical knowledge per se. It's just how you, you're gonna prescribe some medications and how you can find them on the B NF. So don't worry too much. But if you feel really uncomfortable with one specific topic or you feel like that's something you really don't know a lot about, then just read a bit on the B NF about it, um, before the, the PSA, so, um, I would say laxatives and analgesia are something common for the elderly. Um, and then you have some of the, uh, common, um, medications. So with the elderly patients, they're gonna be on multiple medications at once. That's a lot about the interactions and the side effects of these medications, how to control pain, how to control, uh, chronic disease symptoms. Um, and then just some information on the common medications like anticoagulants, antiepileptics and so on. Um, so yes, I think we'll just start with our first question, uh, which is a prescription review. Um, and we'll let you know when the time is up so we can start reading that one. We'll give you another 20 seconds. I think unfortunately the pole options are only giving you an option to pick one per, um, question So if you're just able to type for this one just because you'll obviously need to select three, that would be great. OK. So it looks like although we had some pole issues, people have generally all picked very similar. So I can see codeine Mirtazapine and prednisoLONE. Um somebody's put codeine Mirtazapine and Ramipril and it doesn't seem that seems to be the predominant answers. Yeah. OK. So yeah, well done. So this is the answer. So I'm just gonna go through the question uh out loud. So an 80 year old woman is brought to A&E by her daughter who noticed her mom becoming confused. Her past medical history is an M I hypertension and depression and her current regular medicines are listed. So she's on aspirin, atorvastatin, prednisoLONE, codeine clopidogrel, Mirtazepine and Ramipril on examination. There's just a bunch of her observations that show that everything is normal. And so like the three prescriptions most likely contributing to her confusion. So I think sometimes we feel maybe the need to double check everything but in those types of questions, you won't have time to go through every single medication on the B NF. Some you might know by memory, some might be really obvious for you and that's great and others you might be a bit hesitant about and that's the only ones I would actually check. So steroids would lead to confusion. Usually any analgesics such as codeine morphine, all the okay would lead to confusion so you could type these out. Um let's say, for example, you were confused whether Mirtazapine um caused confusion or not, I'll just show the B NF. What I would do is just type it really quickly. Um So select Mirtazapine and then control F can be your best friend and just checking whether confusion is a side effect and it's a common side effect. So, in that way, I would be able to just double check one, I'm not really sure about and it wouldn't take that long. Um So that's how I would approach this question. Um There's there. Yeah, and under the care, they're mostly on a lot of medications and most of them can cause confusion. So as I mentioned, there's the, OK, the steroids, the benzodiazepines, the anticholinergic antidepressants, anticonvulsants, some antiemetics like metoclopramide antipsychotics. Um these can all lead to confusion and even some medications that can cause um electrolyte abnormalities like diuretics that can lead to hyponatremia uh might be a cause of um confusion. So hopefully that was simple and clear. Um So here I was just writing some more tips. So it's difficult to go through each option. As I mentioned, sometimes interaction Checker uh on medicine complete or it can be helpful. Um If you're using the book, the DNF book, there's the appendix one that has like a list of, let's say, um nephrotoxic medications or uh medications that lead to high potassium level and they just list them if not, you could just search them on the DNF when there is some you're hesitant about. Um, and so these types of questions could ask you about, um, like confusion or electrolyte abnormalities or any other side effects. So it's just a good practice on how to find this quickly. Um Another thing that they, that they might ask is, um, what's, for example, which medications were ordered in a dose that might be dangerous? Um So just familiarize yourself with some dose ranges, you don't really have to know an exact dose. But for example, if I told you that we were prescribing Met Metformin 5 mg, you would know that that wouldn't really make a lot of sense because maybe you're used to seeing 500 mg or five or 1 g and things like that, something that can also pop up are the units you need to be careful with. So, um, sometimes it might be, um, difficult to notice when you're under the stress of time, but be careful with the microgram versus mm milligram doses. Uh, for thyroid medications like levothyroxine or for digoxin, um, just make sure it's M CG and things like that, uh, are worth noting. So that's for the types of prescription reviewed questions that come up. OK. Question number two. Uh, we'll give you one minute for this one, everyone and you should be able to use the poll for this question since it's just a single. All right. We'll give you five seconds. So if anyone else has an idea, OK. So it looks like we're split actually between option B and option D we split down. OK. So I'll just first start by reading the question. So it says a 75 year old man with metastatic prostate cancer is receiving palliative care at the hospice. He's currently on morphine uh modified release 20 mg BD for pain control. He has started becoming more confused in the past two days. His blood today show an egfr of 20 millimeter per minute. Select the most appropriate management option at this stage. So you could either stop morphine and give regular Cocodamol stop morphine and start uh oxyCODONE 10 mg or oxyCODONE 20 mg or you could just continue morphine and check for causes of his confusion. So for this question, the answer would actually be um option B um and I'll just go through it. So this patient is already on morphine twice a day. So option A wouldn't really make a lot of sense because you would be, if you switched him to Cocodamol, you would be giving him uh weaker. OK? So it wouldn't really control his pain. Um You don't really wanna go down on the o on the pain ladder um And you wanna give him something equivalent to the current dose of morphine he's on. Um Why do we wanna stop the morphine? So usually when the eeg fr becomes less than 30 the kidneys are affected, we avoid morphine because the kidneys can treat uh excrete it and it's just gonna accumulate in the and the patient's blood and that might be the cause of his confusion. So, in this case, stopping morphine would be the next best thing and um you could switch him to another opiate that's just as strong. And in this case, it would be oxyCODONE, but you would wanna come converted to the appropriate dose. So what you could do if you're not sure about the appropriate um oxyCODONE dose, you could come here and just write OK. Conversion. Let's say you weren't sure how to find it. So ate conversion is the first thing that oops sorry. Mhm. Um I'm not sure why not. One second one. Let's try something else. Actually, I OK. So sometimes when I write opiate conversion it shows up sometimes it doesn't. So if you go to palliative care treatment summary and again, just use um control F it's your best friend and go to oxyCODONE, you would find a table that would give you the equivalent doses of opioid analgesics. Um So in this case, um the equivalent dose to 10 mg of oral morphine, it says oxyCODONE would be 6.6 mg. So it's a 1.5 to 1 ratio. Um Sometimes it's just a 1 to 2 ratio. So it would be half the dose. Um So oxyCODONE is twice as strong as morphine and sometimes it's um 1.5 to 1. So in this scenario, even if you do consider uh 1.5 to 1, it would be um approximately 13 mg. So if you round down it's 10 mg BD, that's the closest uh appropriate dose. When you wanna convert those to um S um uh option Z would I mean checking for the causes of his confusion is uh obviously an important part of the management. But the first thing you wanna do in this case is to stop the morphine and make sure that that's not the cause of his um confusion due to the low G fr. So hopefully that was clear. I don't know if there's more questions about this one before we move on. So I'm just gonna talk a bit about the analgesia. So it might be worth reviewing the pain ladder and the common side effect of OK, because it's possible to have one of these questions. So I actually got this slide from um pla I don't know if any other angies here studied from that. So it might look familiar might be easy to study from. So if you remember the pain ladder, you start with simple analgesia like paracetamol or nsaids and then you go up to weak opiates like codeine, dihydrocodeine traMADol and then the strong opiates morphine, fentaNYL and then oxyCODONE diamorphine. Um When someone is at a specific step, you wanna first increase the dose before you jump to the next step. Um, and you wanna avoid going down, which is why, um, in our question, we didn't wanna switch him to Cocodamol. Um, you could add medications from the lower steps, but you don't wanna lower it. Um, if a higher status, what's controlling the patient's pain. Um, so the opioid dose conversion tables are all present in the DNF, like I just showed, um, it's also worth noting that all patients who start strong ate will need laxatives. Um And there are different types of laxatives to know about. So it might also be worth uh going through. We have the stimulant laxatives like senna, we have the stool softeners like docusate. Um So just reviewing that a bit might be useful and opiates can also cause uh nausea and vomiting with some patients. So they might require some antiemetics. And it's worth noting the most common ones. Um just to know that metoclopramide has some significant side effects and it's contraindicated in bowel obstruction. So it's just worth um remembering sometimes um they might show you options of patches and OK patches. And this can be useful if someone has a controlled pain. Uh Yeah, the pain is under control at a specific dose, but it's not really good for a breakthrough pain. So just keep in mind that the patch can have a slow onset. Um So you don't really wanna give that if someone is acutely in pain and needs some pain relief. Um And if a patient develops side effects to a certain opiate, just switching them to something equivalent, um might also be uh the next best step in management, it might to resolve their symptoms. Um So hopefully that was le we just had a quick question about the people that you showed earlier and how you converted from morphine to Multicodon. Yes. So if you come on this one, it's, there's a few tables so um that you can read through. So this one is the one that says the equivalent dose to 10 mg of oral morphine. So if we go to the, for example, morphine IV or S CT, you would just half the dose. So 10 mg of oral morphine would be equivalent to 5 mg of IV more morphine for oxyCODONE. It's 6.6 mg. But usually with uh when switching from morphine to oxyCODONE, it's just easier to remember that oxyCODONE is twice as strong as morphine. So you can just half the dose. And that logic also works because when we convert to OK, it's us uh convert one opioid from to the other. It's usually sensible to have a bit of a lower um dose. So you could just use this table to know um the appropriate conversion dose. And also um it might be worth opening the mind the bleep uh article because there's also like um a good summary on how to prescribe analgesia and how to switch from one to the other. So I don't know if that's answered the question. Think that was perfect. Yeah. Yes. So just that's just the QR code. Ok. Next question. All right. We'll give you another 10 seconds and then we'll go through the answer. Ok. So it looks like the majority of people went for a and the second most picked answer was b ok, nicely done. So I'll just treat it um quickly. So a 77 year old woman is noted to have a raised I nr of 6.1. She's well with no signs of bleeding and she's currently being treated for gout. She has a medical history of AFIB and osteoporosis. Um and she's on Warfarin and there's just a series of doses she's on and paracetamol. So there were multiple um options to decide on. And actually the answer was a to hold one or two doses of Warfarin and reduce the next dose. And again, what's really nice is we don't really need to have anything ingrained in our memory. It's just going through the B NF. Um So for this one, you would have, you would wanna go to the treatment summary of oral anticoagulants and literally just typing that will lead you to this page. So if we go back to the question that says she has an I NR of 6.1 and there's no bleeding. So that leads us to this point. So it just says, I nr 5 to 8, no bleeding, we withhold one or two doses of warfarin and reduce subsequent maintenance dose. So that's how you'd find the answer. Um So hopefully that's, that's clear on how to find it. And that's our questions for elderly care. So we're gonna move on to pediatrics. Um Again, there's a range of topics uh that could be asked in pediatrics. Um It could be allergies, common infections in Children. Um there won't really be much polypharmacy, but there'll be asthma and anaphylaxis TK A vaccinations, cystic fibrosis, again, fluid replacement. Um And it's a really broad range of topics and I don't know if anyone else worries like me, but when, maybe when you see all of that, it feels a bit overwhelming. Um, but again, um, I mean, it's not really testing your medical knowledge. It's just about knowing how to find the answers on the PNF mostly. Um, so I'm sure you know a lot about these topics and there might be some things that you don't really know how to quickly find on the B NF. So that's just a good summary for you to just review the topics you're not really sure of and just play a bit with the Pian F and, and, and see what's on there. So our first practice question is on planning management. I'll just read it now. So a five year old girl is brought to A&E due to increasing shortness of breath stridor and a rash over her body. The girl was at her friend's birthday party and symptoms started after she had a slice of cake, select the most appropriate management option at this stage. So a 1 mg Chlorphen mean po 2 b2 0.5 mg Chlorphen, I mean IMC 0.15 mL, Adreno im and D 500 mcg, Adreno iron. We'll give you a minute for this one. All right, everyone 10 seconds we have covered this topic before. So hoping to see a few more answers. OK. So the predominant answer was to see 0.15 millimeters of iron adrenaline. OK. Yup. Amazing. So that's the correct answer. So yes, I know you guys um have practiced anaphylaxis before, but that's just to remember that doses are very different for Children. So I'll just show you how I would have quickly found it. So I know it's anaphylaxis adrenaline and if I just come here, um I'm just searching for the age. So with ped pediatrics, it's either gonna be age or weight um dependent tho those. So she's five years old. So she requires 100 and 50 mcg using ain one in 1000. So 1 mg per milliliter injection. And so sometimes you just have to uh switch the, the unit. So if it's 100 and 50 mcg, that's 0.15 mg, that's also 0.15 millimeter of adrenate. And in so yeah, next question. So a six month old boy is diagnosed with a uti and prescribed trimethoprim. His weight is 7 kg. The preparation of trimethoprim is 50 mg per five millimeter. What dose will you prescribe him? We'll give you one minute of this. 30 seconds left everyone. OK. We haven't had as many answers for this one. So I think people, ah we've just had quite a few come through. Um Obviously, the calculation questions are pretty time, pressure. They're about a minute, a minute, 15. Um The majority of people have gone for B which was 2.8 mL, BD. Um and 30% have gone for er D which is 28 mL. OK. Nice. So yeah, I think time is the biggest factor in these ones. Um They're all going to be um simple calculations and you have the calculators. So don't worry too much about it and it's mostly gonna be the same style of calculations. So once you get used to it. So and in this case, it would be B so um the first thing I would do in this case is open again. Um The PNF just type quickly trimethoprim indication and dose. So it would be 4 mg per kilogram. BDI would just wanna note as well to just be careful with the indications. So in this case, it was a lower uti so it's still 4 mg per kilogram twice a day. So if we come back, um that boy is 7 kg, you just multiply by four that's 28 mg. They state that the suspension is 50 mg per five mil. So it's just 10 mg per mil. So you're just dividing by 10 and that's how you get, you would get 2.8 mL. And then again, just don't forget that it's BD. Not once a day based on the pian F. So yeah, well done. Next question. So a seven year old boy is reviewed onward, drown following an emergency repair of testicular torsion. He has been suffering with significant postoperative nausea and vomiting on examination. He is maintaining his own airway saturating 99% on room air respiratory rate. 16 bilateral air entry, BP is 100 and 1/68 heart rate. 81 heart sounds normal capillary refill too. Um Temperature is normal abdomen, soft nontender and he has dry mucous membranes and he weighs 18 kg. So write the prescription for the IV fluid that is most appropriate and please include the infusion rate in millimeters per hour. We will give you three minutes for this. Um You probably would have closer to six in the real thing and just put your answers in the chat when you're ready, right? You've got another minute to go. Please put your answers in the chat. All right. Could be another 15 seconds. If anyone else has an answer, please do put it in the chat. Ok. Yup. So sorry that did you say the time was up? Uh Yes, let's go for it. Yeah. So in this case, um we, we wanna just prescribe some fluid maintenance. So the option would be sodium chloride, 00.9% and glucose 5%. Um And it's 1400 mL over 24 hours and you would just divide that by 24 to get meals per hour and that would be 58. Um So how to, to get to that number? Basically. Um something to remember, I think it's just the easiest way is that the 1st 10 kg, you would prescribe 100 mL per kilogram per 24 hours. For the next 10 to 20 kg is 50 then anything over 20 kg is 20 mils. So in this case, for the 1st 10 kg, you're multiplying by 100 mils and then for the next 8 kg, you're multiplying by 50 1400 MS is the total he would get over the day. So if it was um a bolus, it would be different. If it was maintenance fluid, it would be different. And in this case because he's uh vomiting, um it would also be wise to give a fluid that has some dextrose in it. Um So fluid replacement is a big topic. I think the easiest way for you guys to just review it quickly is to check mind the bleep as well. They have a really good summary on pediatric IV fluid prescribing. Um And I think just summarizing it, finding a way for you to just finding what's the best way for you to prescribe it quickly. And once you can get that number, any type of questions that require fluids, it would be very straightforward. Hopefully. So, yeah, I think we can move on to the next question. So now we're in the psychiatry um topic. So with psychiatry, um obviously, there would be questions about antidepressants, antipsychotics and so on benzodiazepines. Um And they could ask about the side effects of these me medications. Um or sometimes there are questions about uh what you would communicate with the patient um regarding what to expect when starting certain medications or what to monitor. Um and so on. So again, I think the best step would be to just have a think about topics you're really unfamiliar with, maybe play a bit with the B NF. But other than that, most of the things can easily be found. Um So we'll just practice that. So for this question, I just um used one from the actual P SA mark that you find online and I'll just read it now. So a 25 year old man presents to the ez with painful eye and neck spasms that started abruptly today. His past medical history consists of paranoid psychosis of recent onset uh in terms of drugs. He is on risperiDONE 2 mg po 12 hourly. He smokes cannabis daily uses a nicotin vaporizer as required on examination, you find him agitated with extreme upward deviation of the eyes, painful extension and lateral flexion of the cervical spine. And the airway is safe, write a prescription for one drug that's most appropriate to treat his eye and neck spasms. And that's how it would show up on, on the exam. We will once again give you a couple of minutes and then when you're ready, put your answer in the chat, making sure you do the three boxes that are there. Yeah, we'll give you another 45 seconds. So don't get to the answer in the chat. OK. So we've got a few answers. Um Yeah, we've got Procyclidine 2.5 P OTD S, we've got Procyclidine 5 mg. IV. Uh We've also got diazePAM 5 mg daily that modify based on response. So a bit of a mixed. Um All right. So, um actually, I'll just show how I approached it. Um First, so my first step would be not to panic if you can't remember the name of an exact medication. And also always use B NS because I think when I first started prepping for the P SA I used to just worry um that I wouldn't remember the exact name of a certain medication. Um So how I would approach this is in this case, um I know that they're describing dystonia. So I would just type dystonia and the first thing that would pop up is procyclidine hydrochloride. So by clicking here and just scrolling, you can find that you could prescribe it for acute dystonia, either five or 10 mg. Um And I think also what, what I because II see the do the range of responses, I think in this case, um The confusion is that we just wanna prescribe something right now for the acute dystonia he's in rather than a prolonged course of medication. Um So we just wanna prescribe one dose of, of something that would treat the dystonia. Um So I would have given procyclidine 5 to 10 mg, either IM or IV because if we go back to the question, actually, they describe that he has painful extension and lateral flexion of the cervical spine. So, in this case, it might be a bit more difficult for him to swallow the medication appropriately, even though it says the airway is safe, you don't really wanna give him something orally because his neck is really flexed and it might just be easier to get something quick and, and easy like so Im or Ivy um and again, to go back to the B NF. Um So it says 5 to 10 mg. And I think it's just worth showing that if you go to medicinal forms, um solution for injection, you can see how the medication is sold. So, in this case, um the injection outputs of procyclidine are 10 mg per two MS. So if you had to prescribe something as Well, that's how you would just um find the appropriate dose or one or 2 mL. Um So yeah, that, that would be how I would have approached it. And I think looking back because it's from the P SA mo that's the options that the option they also um offered. So I don't know if that's clear, I think, yeah, I think typing the typing dystonia, for example, in DNF is like the surest way you can get an accurate option of medication that would be indicated in this case. And yeah, also just always be careful about the route you decide to choose for your patient. If they're nauseous or vomiting, you also wanna avoid oral medications and so on. Just imagine an actual patient in front of you and whether or not they could swallow what you prescribe. Um If there's nothing else, we can skip, we can go to the next question. So that's one other question. That's the communicating information type. So a 25 year old woman visits her GP surgery as she has been suffering from depression for the past year, her GP decides to start her on SSRI S, select the most important information option that should be provided for the patient. So, so a lifelong therapy with SSRI S would be required. B it may take 2 to 4 weeks before an effect can be seen. C SSRI S may lower her serum sodium D monitoring of her bloods will be required or e if there is no response in four weeks, a combination of antidepressants might be considered one minute for this question, everyone, 10 seconds left. So submit your answers if you haven't already. Ok. So 90% of people went for B and 9% went for E OK, great. So most of you guests drive um in this situation, the most important might just be to let your patient know that even though they don't see any benefit in the next few days, um it actually takes some times before SSRI s have any effect at all and for them to continue taking the medication until that time. Um For those who said, ei think the usually whether or not you're considering increasing the dose, if there's no effect or maybe even switching to another antidepressant, it wouldn't necessarily be the most important piece of information you would wanna tell your patient. Um So in this case, it would be more important maybe to just let her know that even though there's no effect to continue with taking the medication and medication compliance essentially. Um And I just wrote down um that in these types of questions, sometimes multiple choices can be correct, but it might not, it might not be the most important piece of information or the most relevant one for your patient at that time. So if you see an option, that makes sense, just necessarily and choose it, just make sure you read through all the options. So for example, SSRI s like serotonin may actually cause hyponatremia. So see would be correct, but it was not, it wouldn't really necessarily be relevant in this fit 25 year old woman. Um, it might be more relevant in elderly patients that are on multiple medications that are causing them to have low sodium, for example. So that's just something I wanted to point out. But yeah, moving on to obs and Gynae. So this is also a really big topic um with a range of of possible questions from contraception to hormone replacement therapy, um medications that are contraindicated perhaps in pregnancy, um and so on and so forth. So let's start with the first question. Um I'll just read it. A 31 year old woman asks her GP to start her on the combined oral contraceptive pill. She used it previously in her early twenties and tolerated it. Well, she delivered her first child nine months ago and is currently breastfeeding. She's a smoker smokes around 10 cigarettes a day. So past medical history includes migraine with aura and asthma. Her BMI is 32 kg. Select the most appropriate information option that should be provided to the patient. So a breastfeeding is an absolute contraindication to uh combined uh oral contraceptives. B migraines with aura is the absolute contraindication. C ABM I of 32 is the absolute contraindication or d being a smoker. Again, we'll give you one minute for this question. OK. 10 seconds left. OK. So we had 58% went for B and a bit of a split between A and B for the others. OK. Nice. So, yeah, in this case, um B would be the appropriate answer. So migraines with aura is an absolute contraindication. Um And I'll just show you again how I would have quickly checked it on the DNF. So they mentioned that she wants combined oral contraceptives. So I would just try to find some uh option of medication. And again, um just control f and I would drive, let's say migraine and see what it has to say. So it shows up as a contraindication for all combined hormone hormonal contraceptive. Um In this case, if we look at, for example, um breastfeed uh yeah, if we look at breastfeeding, there's a section here. Um It would just say that for all combined hormon hormonal contraceptives, it's safe to use uh six months or more postpartum. And in this case, our patient uh delivered her baby nine months ago, so it would be safe for her. Um Also, I just wanna show another thing about smoking. Um So in this case, smoking in patients aged 35 years and over would be the contraindication, but our patient is 31. So um there might be these little nuances. So if you feel like you have the time you could always check them out or if you, you're absolutely sure that, you know, migraines with aura is definitely an option. Contraindication. You could just click it. But yeah, it's, it's things like that, that you could search if you had any doubt. Um, just control f all the way and you'll find them pretty quickly. Ok. Our next question. Um, it a bit of a long one but I'll just read it. So, a 30 year old woman phoned her GP for advice. She's worried because she forgot to take her contraceptive pill yesterday. Her pill today is due in six hours. She has had unprotective sexual intercourse in the last two days. The contraceptive pill she takes is ethynyl estradiol, levonorgestrel for 21 days of each cycle. She wants to do what to know, she wants to know what to do regarding her missed pill and whether she needs emergency contraception. So select the most appropriate information option. A take the pill due today and resume with the rest of the pack. Normally she does not need additional contraception measures or B take the pill due today and resume with the rest of the pack. Normally she will require additional contraceptive measures for the next seven days. C. She will need emergency contraception before restarting her pills or D she should take two pills today and continue with the rest of the pack. Normally starting tomorrow, she does not need additional contraception measures. We'll give you about a minute, 10 seconds left everyone. Ok, Leah. Again, it looks a bit split for this one, but 63% have gone for D and a bit of a split between A and C. OK. Nice. Um So yeah, sometimes this can be a bit confusing which is why I decided to just do a small revision for both you and me. Um So I tried to summarize it but first, um the answer in this case would be d she should take two pills today and continue with the rest of the pack normally starting tomorrow and she doesn't need any additional measures. So just to go back to the stem of the question, I think in these cases, just make sure whether or not she's on a combined oral contraceptive or just on a progesterone only pill. Um and just check how many pills were missed. So she said she missed the pill yesterday and the next pill is due today in six hours. So essentially she just missed one pill. Um And that's, yeah, that's gonna be important here. So I just tried to summarize it in the easiest way possible. Um So for combined oral contraceptive, if the patient missed one pill, then that's easy. Just they just need to take the last pill as soon as possible. Even if that means taking two pills in one day, then that's fine. So taking the pill that she's supposed to take anyway that day and the one she missed and because it's just one missed pill she doesn't need any emergency contraception. If there's two or more missed pills when it's a combined OCP, then same as missing one pill. You wanna take the last pill as soon as possible. However, patients need to avoid unprotected sexual intercourse until they have taken seven pills in a row. So they would require a week of taking the pill regularly before they have food protection again. Um, and then there's just like some new ones. So if the pills were missed in week one of the cycle, you might need to consider emergency contraception for a week two. That's easy. You can just forget about it for a week three. Emergency contraception is also not needed, but the patient would have to omit the pill free interval. So just continue with a whole pack um for the progesterone only pill. So it's a bit different. Um You wanna make, you wanna see how many hours it's been. So if it's more than three hours late on a traditional pill or more than 72 hours late on the mini pill, you take the missed pill as soon as possible and you continue with the pack at the usual time, you abstain, you abstain from unprotected sexual intercourse for the next two days. Um An emergency contra contraception is required if unprotected sexual intercourse occurred after the missed pill and within 48 hours of restarting the pill. So I don't know if after an hour of a session with my voice. This got a bit confusing but maybe if you just reread it later, it's, um, pretty straightforward. So I think just having them in blocks and clear blocks in your minds could allow you to answer those questions easily. Hopefully. So, I don't know if there's any questions or we can just a question about how you would find information for missed pills. So, would it be in your B NF or is this something you'd need to? Yeah. So I think you could, um that's actually something I haven't personally checked. So treatment summaries are always something you could go to if it's not a specific dose you're looking for and if it's more about um things like that so we can discover together a bit. So hormonal contraceptives. Um And yeah, let's just check. Um So and I think treatment summaries are your best bet at finding something. But for that question specifically, um I'm not too sure if anything has been said. Ok, so you could, yeah, so there are actually you a link that would get you to that. So again, you can just see my method of literally just typing the thing you need and then control F and you'll find someplace on the B NF that can help you. Um Even if you don't usually know how to find it. So it's pretty straightforward, hopefully. Yeah. But yeah, I think my advice would be for some topics that are um that might take you a long time to read in the PNF. It might be worth just reviewing before the exam, not everything, but again, just topics you really feel unfamiliar with or you completely forgot about. So in my case, contraceptives are something I tend to forget quickly. So I feel like it would really take a lot of time and the exam to read through a treatment summary in the BNF. So I would suggest mainly reviewing it beforehand. Instead, I think we've also had some suggestions from people watching that you can search any combined pill and there is information about missed pills. Um, you wouldn't be able to open that pop up in the exact. Um, but I do, I think knowing, knowing it does help because it is quite a high yield topic. Um All right. So next question, that would be our last question for up and Gyne. So a 32 year old woman presents to her GP with thirst and increased urinary frequency and she's 19 weeks pregnant weighs 79 kg. She has hypertension, rheumatoid arthritis and recurrent dvts. And her current regular medications are listed here. It's like the first question we did. Um, on investigations, you find that the capillary glucose is 15.8 sole, select two medications that should not presc be prescribed during pregnancy and should be stopped immediately and question B select two medications which might contribute to her deranged glucose level. We'll give you a minute 30 for this one. Everyone and again, sorry. Um put your answer in the chat for this one. We'll give you another 30 seconds. Ok? We haven't had anyone put any questions in the chart yet. Um So do put your answers in the chat, everyone for a and then for b apologies, pa is paracetamol. I think that's a typo from my end. Ok. So for a le looks like we've got a bit of a combination. We've I'm seeing Pix Thean Clopidogrel. I'm seeing clo clotrimazole. Um And then for me, I'm seeing prednisoLONE um bendroflumethiazide. Yeah. Ok. Um So for this one, the answers would be for pregnancy, apixaban bendroflumethiazide and sorry, that's also a mistake. A typo but clopidogrel would also not be indicated in pregnancy. So it's fine if you chose whichever of these. And then for the ones that contribute to the range glucose, it's the thiazide and the prednisoLONE, they could increase hyperglycemia. So I think from the answers, it looks like you're managing to find um the answer is on the B NF quickly. So again, this is not the type of questions where you could um search each one individually. But if you feel like there are some that are very obvious and that, you know, that's great and others that you're a bit on the fence about, you could search um maybe in this case, the drugs that cause hyperglycemia were a bit more obvious for you than pregnancy and that's what you would be searching for. So, yeah, um uh I could go over to the BNF again and show it, but I think um I think poss probably um you guys kind of saw how we can find those kind of things. Um So I could just show one example. So just like Apixaban, there's a side effects and a pregnancy section and that's where you would just jump and see manufacturer advises to avoid. And sometimes with pregnancy, some drugs are um advised to be avoided in the first trimester. Some in the last trimester is also just worth double checking. Um Where in the pregnancy the patient is. Um So yeah, those are some, just some screenshots of how it would show up. So those are the side effects of thiazide. You would find hyperglycemia, Apixaban to tell you to avoid in pregnancy and so on. Um I'm just aware of time. So I'm just gonna jump to our last topic which is GP and that's the basically the range uh of topics that you could have. So it could really be anything um from headaches to um hypercholesterolemia to um pneumonia to multiple medication questions. Um So those would be the most common ones. So we can just quickly jump to the question. So a 45 year old man presents to the clinic with a two day history of a painful vesicular rash over the left, left side of his trunk, write a prescription for one drug that is most appropriate to treat his rash. We'll give you two minutes for this one. Everyone. Ok. So it looks like we're getting a few coming through for Acyclovir 800 mg five times a day for seven days. Yeah, great. So, yeah, I think it's a pretty, pretty obvious from this question that, um, the patient has shingles. So, two ways again to check, um, the prescription if you really don't know what to prescribe, maybe in shingles, it's obvious that you could just write that or if there's a certain um antiviral you're familiar with. So, Acyclovir, you would just open it up and check, just make sure the indication is correct. So in this case, you would wanna go um to the shingles treatment and exactly it's 800 mg five times a day for seven days. But obviously there's um different options that are all equally valid. So it would all be correct. Um OK. Next question, I'm just gonna read it out loud and I think that's our last question of the day. So again, I'm ending it with one of the official P SA questions. A 65 year old woman presents to her GP with bilateral leg muscle aches. She has hypertension and hyperlipidemia. Her current regular medicines. In addition to simvastatin, 20 mg po daily are listed and on investigation, the creatine kinase is 5500 select the prescription that is most likely to interact with simvastatin to cause her myopathy. So it's either amLODIPine, aspirin, ezetimibe, gemfibrozil or Ramipril. We'll give you another 40 seconds everyone. OK? For the sake of time, I will wrap up that one. So it looks like 81% have gone for option D OK. Nice. Um Sorry, I can't scroll. Yeah. So it's Gemfi Brazil. So I'm assuming everyone that's answered correctly managed to find it on either the BBN F or medicine compete. I think in this case, interaction, checker and medicine compete is the most straightforward one, but I don't have access to it right now to be able to show you, but you can also do it um on the B NF um I think just by opening interaction. So in this case, um the interactions with simvastatin and you can just check here. So it on fibroid increases the exposure to simvastatin severity is high. So you know that these drugs would be interacting. So yeah, just familiarize yourself with how to check for interactions and that's an easy point to score. Um So yeah, thank you for um answering all these questions. I think just as a summary of what to keep in mind when you're trying to answer questions. Um is do I know what is the treatment for this condition? Which is a bit of the mix that we saw today? So if you're sure about the treatment of the condition, you know the name of the medication, then you can search directly under the medication on the DNF. So just type the name of that drug. So like Acyclovir, look at the indication and then select the appropriate dose you want. If you really don't know what the medication would be, then just check the treatment summaries on the B NF. Um, that can be really helpful. Um And I think the mind the bleep website also has a very useful table. So as you saw me struggle a bit, at first, I couldn't really find an opiate conversion when I just typed that. Um and instead I had to type palliative care. So things like that are worth just double checking. Um So you can find this stable mind, the bleep and it would give you like keys of how to find the appropriate treatment, summary titles on the B NF. Um So then you can really just find anything you need on that website. Um And yeah, hopefully, hopefully it was a good session and it was clear and um I just wanted to say before I hand over back to viv that um If you wanted to reach out to me at any point during the year, obviously, I'm just acting as a co uh I MG leads uh this cos for I MG, sorry, my brain just stopped working. But yeah, if you have any ideas of things that you would want to see from mind the bleep with regards to IM GS or if you had any questions or needed advice on anything, just feel free to reach out and I'll be happy. Um, have a chat. So, yeah, I don't know if this, if you wanna go over the last few slides. Um If not, I can just say, yeah, that we have me and hello. Hello, everyone. Um Leah, thank you so much for that session. It's a mammoth, mammoth topic. Um And so we were able to show quite a variety of question types which was really good. Um And go through some of the key things. The blueprint that was referenced throughout the session is really important. Um Leah, if you wouldn't mind getting the Google slides up, um We have run five minutes over. So if anyone needs to leave, then please do. I've just released the feedback form. Now, um I will say there was a few comments around whether some of the questions were using or not clear and I will say the PSA marks are good to use. I personally found them a lot easier than the real thing. Um I'm not saying that to scare you, but I'm just saying, as I've said in previous sessions, you don't want to be too reliant on any one resource. Um And sometimes the questions can be confusing and there are what feels like multiple correct options. Um So with the, I think it was the question around pregnancy and amLODIPine, it is a difficult question, but there is room for them to ask that sort of thing in the exam. And the reason why amLODIPine wasn't, the, the answer is because the B Ns specifies that if they've got uncontrolled maternal hypertension, you wouldn't, that you would override that risk and you would prescribe it. Um So some questions and psa it will be very simple. You might have an anaphylaxis question which we've already practiced a few times, but others will be a bit more nuance, a bit more confusing and you don't want to be shocked by that. They won't all be necessarily straightforward and quick ones. I'm not saying that to scare you. It's just to be well aware that that they can be questions of feel misleading. And I know on my, on my exam, I had a few questions that were very confusing. You know, it's not worth spending all your time on, but it just, you don't want to be shocked and find that that then throws you for the rest of the session. Um We've just got up the link. I think this link is not correct. Oh Is this on the um Yeah, just on the, if you go on to the slide here, then that will be there should be updated link, sorry. Just at the very end, I added it on um I sent the feedback form um for everyone watching the recording. We'll end it here. Thank you for joining