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Good evening, everybody. Hi, my name is Mac. Welcome to our fifth session. Uh We're going to have a session uh today that's going to be run by two doctors. We have Sanjana with us. She's an F two in Northern Ireland and we also have Hannah who is a, who's an F two in KSS. And um as always, we want to just remind you that this session was originally created and presented by Doctor S Patra. She's a qualified pharmacist and a doctor. And here's a QR code that you can use to access all the recordings from those sessions. Uh We highly recommend that you watch those videos, they cover all the same sections, but there will be, there's more practice questions that you can watch and uh before every session, you can send us any questions about those videos that you would like us to answer at the end. And um as you all know, we love the PSA blueprint, we highly recommend that you use it. There's another QR code for you. Please do have a look at it um to see what topics are commonly covered during the PSA and the next session. And then the next slide is just our usual disclaimer. We just want to make sure that, um, you know, we just want to tell you, uh, every time that this is something that we do, um, in our free time, we do it voluntarily and while we always make every effort to make sure that there's no mistakes in any of those sessions. If you do spot any mistakes, please do, let us know and, uh you can read more about about this um in the disclaimer session, uh section of mind the bleep and there's a privacy policy there as well. All of those sessions will be recorded and they will be available on mind the bleep afterwards. And I think without further ado, I'm going to now let Sandra nurse start her session and she's going to talk about um providing information and that's it. Thank you. Just to make sure everyone can hear me. All right, if you let me know if my speaker is working, ok, then everything's working fine. You're absolutely fine. So, hi everyone. My name is Sanjana. I'm F two. I'm working up in northern Ireland at the moment. I'm doing a rotation in ophthalmology. It's an academic rotation. If anyone is going to be working in Northern Ireland or is currently working in Northern Ireland, don't feel free to give me a shout. I might pop my um email into the chat later on. So without further ado, let's get started. Um So in this session, we're going to be covering the communicating information section of the PSA and then later on, um Hannah's gonna take, take over and she's going to cover the drug monitoring section. So um so this is the appendix, you might have seen this in previous there. So it's giving us examples of clinical cases and related item stars for each section of the um the PSA. So here we have under medicine, we have um oral hyperglycemic corticosteroids, nitrates, for example. So these are just examples of what you might expect to see in the PSA itself. And I've just used this as um a little bit of a curriculum to for my own questions for the rest of the session as well. These are my learning objectives. So just to understand the structure of what to expect in the providing information section and then just practicing some questions related to all those previous fields that you saw in the appendix. So here are my tips for approaching the section. So the providing information section is basically um seven questions that form um part of the part of the PSA um you have around. If you, if you cut down the the whole PSA, you'll probably get around seven minutes to do this section and you have six questions in total, that's approximately a minute per question. Um But in the grand scheme, it's not as important as the prescribing and prescription review questions. It doesn't give you the same number of marks. So, um if you're not able to find an answer, don't be afraid to move on. Um, for the sake of timing in this section, put in an answer anyway, because there's no negative marking and you might, because you might not always have time to go back and check. Um I, when I was doing the PSA used a combination of my own medical knowledge for the section, but also feeling quite comfortable with the BNF. So if you know which treatment summaries cover what section and um being able to find a drug quickly on the BNF using control f these all speed up how quickly you might be able to find answers. Um And also don't be afraid to just use the method of um, just cutting down any answers which don't make sense first and then just looking up the ones which do. So, um mind the bleep on the website, there is a passing the PSA um section which I believe is also in, inserted later on in the slides for recommended resources. And it's got a good flow chart of all the different treatment, summaries to keep in mind. So I would recommend going ahead and looking at that as well. So, uh without further ado, let's get started on our first practice question, um I'll read it out and then um Magda's going to put up a pause and we'll give you a minute to answer the question as well. So this is, um, a question. A case presentation is a 70 year old gentleman presents to his GP complaining of a one month history of pain in his hip and shoulder girdle. Um, the pain is worse in the morning and eases throughout the day. He's got past medical history of depression and, um, social history. He's retired and a nonsmoker, um, investigations show that the ESR is 50 is normal and his emg is normal. He is referred to rheumatology and is started on 15 mg of prednisoLONE daily. What piece of information is most important to give the patient considering he will be on steroids long term. And those are your options there if you'd like to have a read my day, if you let me know what the timing is looking like as well. Sure, of course. Uh So we'll give you about a minute to answer this question. I'm just going to turn off my camera. So you're not um distracted by my face. God. So, so another 10 seconds try to select an answer even if you're not entirely sure. All right. So we have a relatively even split between two answers. We have uh 42% of people who decide who selected double the dose of steroids during an illness with a fever. Ok. And 38% selected check blood sugars daily as steroids can cause um blood sugar levels to rise. And a few people who also went for B and C. OK. Brilliant. Thank you for that. So I'm seeing that there is a bit of a, a mix between A and D there. So the correct answer to this question is D double the dose of steroids. Um So the thing to keep in mind for this section of the PSA is every single question will be asking you what the most important piece of information will be. Um So when you are weighing up, uh which one is more important, I think it is more important to let the patient know that uh to let them know to double the dose of steroids during an illness with a fever comparatively over causing the blood sugars to rise, which is also true. Um But in uh in a more comparative set um scenario, we want to avoid an adrenal crisis more than we want to um avoid a hyperglycemia as II suppose. But I know that in a normal case scenario, we would be informing a patient of both of these things. So in terms of a, I'm just gonna go back to the um the questions I'm just going through why um each scenario, why each option might not have been correct. So a it is important to check the blood sugars um daily, but um it might not be, it might not be as important um to do it actually every day. So it is important to check blood sugars. But not every day. Um It's also in terms of b uh it's correct to that is correct. It is important to continue um exercising regularly. Um But it's not as important as what we want to um avoid in terms of an adrenal crisis. Then common side effect of the of prednisoLONE is, is mood alteration and ability, but it does not require an emergency phone call to the GP. When this happens, it can be discussed in a normal appointment as well. And then in terms of e um there is a link between corticosteroids and peptic ulceration and perforation. But and patients are usually covered co prescribed with PPI S to um prevent this. Um but there's no hard and fast rule to say that they must absolutely avoid um spicy foods though. So this is um a just showing um sept adrenal crisis. So, in patients who are taking long term steroids, there can be suppression of the um hypopituitary adrenal axis. So, if glucocorticoids are stopped too quickly, um the endogenous production of steroids may not be sufficient enough to meet the body's needs. So, during any um times of stress, sick day rules apply. So we want to maintain levels of cortisol as close to the physiological level as possible. Um And that's something that patients should be absolutely educated on when they're starting long time, long term steroids. And um they're usually given leaflets to explain these rules and generally also given um a steroid emergency card, which will they all carry um at all times. Um and something. So an adrenal crisis just to explain what symptoms are like, are usually quite nonspecific. Um, fatigue, gastrointestinal upset muscle pain, dizziness. So it's very important to educate um patients on this while they're starting on a long term steroids. Um Just to give a little bit more information about the previous question, even though the diagnosis was included in the question, the reason why they were started on long term steroids was because they had a diagnosis of polymyalgia, rheumatica. Ok. Um I know you might have questions so we can probably leave it until the end there. Um And so I'll move on to the next practice question here. So this is a 65 year old lady who presents to the GP um to ask about her medication. She had an episode of a brief visual um disturbance which was diagnosed as a tia a on MRI brain findings. The tia A clinic has started her on 75 mgs of clopidogrel. Once daily as secondary prevention, she has a past medical history of migraine and type two diabetes. Um She takes Metformin and ZOLMitriptan. Um she's experiencing side effects with the clopidogrel. So what information is most important to convey to the patient? A the dose will be gradually tapered to stop completely. Constipation is a very common side effects side effect. Um So take agre alongside it if um clopidogrel is not tolerated. Aspirin will be trialed and e um she shouldn't take omeprazole alongside it to prevent side effects. So, if we start another poll for this amazing, and we're going to give you a minute again to answer this question. Just to let everyone, uh know, please do use the BNF during, uh answering these questions as well. It will help you practice for the actual exam. Give you another 20 seconds if you want to have a look in the B NF as well. All right. So it looks like most people went for answer D. If clopidogrel is not tolerated, aspirin will be trialed. Um 23% of people selected answer E and a couple of people went for A B and C as well. The D and E were D specifically brilliant. That's good because well done to everyone who chose D. That is the correct answer. Um So in this scenario, we're looking at the 65 year old, she's just come in with a tia A, she's been started on clopidogrel once daily um as secondary prevention. Um So the two main uh pieces, two main sections of the BNF that I you might want to use to answer the question would be the clopidogrel drug summary and the um BNF treatment summary for um stroke. Um But it might just be, you might be able to answer using your own general medical knowledge as well. So just going through each um each response. So a is not correct because clopidogrel does not need uh tapering. Um Generally speaking, um, if there is a medication that does need to be tapered, it would usually be under the um treatment cessation section of the drug summary. And um clopidogrel doesn't have anything like that under it. Um Then in terms of b constipation is a side effect, but it's listed as uncommon under the side effects section of the clopidogrel drug summary. Um diarrhea is uh actually a more common gastrointestinal um side effect and then tag if anyone knows um what tag is, it is another antiplatelet. Um So it will increase the bleeding risk if it's taken alongside clopidogrel. Uh But you can double check this by using the interaction section. So if you put tag and clopidogrel both together under um the interaction section and BNF, it will show that it increases bleeding risk um than for D clopidogrel is um is if it's not tolerated, aspirin will be trialed. This is the correct answer and the BNF treatment summary for stroke explains this. Um So yeah, if we see I've just put in screenshots of it. So it says that if um clopidogrel is contraindicated or not tolerated aspirin um will be used. And then the last response that was is you should take omeprazole alongside it to prevent side effects. Um Another thing is um if you again look up omeprazole together under interactions, um it is usually indicated not to CP, prescribe both of these together because omeprazole decreases the efficacy of clopidogrel. Um And also um good or reflux symptoms are not a common side effect of clopidogrel if you generally know about it. So it's not usually indicated to prescribe these two medications together. Um Yeah. So again, I'll take questions for any of these questions at the end. So we'll move on to the, the next question, practice. Question three here. So, um in this, uh we've got a 58 year old gentleman who injures his left achilles tendon and undergoes an achilles tendon repair. He's got past medical history of type two diabetes and hypertension on examination. His weight is 70 kg. Um His lab investigations show an EGFR over 60 his plates that his platelets are 245. Um and due to his risk of reduced mobility, he is offered a 14 day supply of enoxaparin sodium injections for vte prophylaxis. Uh what information is most important for him to know about? So, a he will receive mechanical vte prophylaxis in the form of antiembolism. Stockings to both legs. B the injection will be given intramuscularly C and OXY can cause low potassium in the blood d. Um A common side effect is necrosis at the site of injection and e he should look out for any signs of bleeding. And if we start another port for that. So again, we're going to give you a minute and we ha we really encourage all of you to try to answer all the questions, makes the session more interactive and it also gives you a chance to test yourself. We'll give you maybe another 20 seconds. Mhm So it looks like for this question, uh 96% of people actually went for answer E that he should look for any signs of bleeding and uh 3% selected A as well. Ok. Brilliant. Thank you. So, um everyone who went for e you are correct, that is the right answer. Um I'll go through why am isn't um in most scenarios, mechanical VT prophylaxis would be indicated. Uh But if you read through the question, you can see it's a 58 year old gentleman. He had a left achilles tendon um repair. So, uh mechanical prophylaxis, uh when you undergo orthopedic surgery is only indicated in the foot or the leg, which has, uh which is, which hasn't had any um operations or surgeries done to it. So that's the reason why a wouldn't work because it's mentioned the answer option mentions both legs. Um There's a list of contraindications um for on the BNF um summary for VT E um about which um when we te is not uh indicated. So that would be things like any patients with a previous acute stroke, peripheral neuropathy, leg edema, et cetera. Um So the second option was intramuscular. So I think most of us know that um any low, low molecular weight. Heparins are given subcutaneously. Um C was it causes low potassium in the blood. So, um a side effect of enoxaparin is actually hyperkalemia um because it causes inhibition of aldosterone secretion. And that would be uh you can find out a little bit more about that under the enoxaparin sodium drug summary as well. Um The fourth option was injection site necrosis um which is a side effect, but it's not a common side effect. It's an uncommon side effect. So make sure to read each option properly before you choose it and he is the correct answer. Um So hemorrhage is a very common side effect of um any uh low molecular weight heparins. He should be counseled on all forms of bleeding, whether that's coughing, vomiting up blood, um blood through the back passage, um avoiding any situations which would cause trauma like heavy lifting. Um and coming also counseling to make sure that he comes back to hospital if he has any situations which involve head trauma. Um So well done everyone for that question, we'll move on to the next one here. So um practice question four. So this is an obs and gynae related one. We've got a mother who naturally gives birth to a healthy baby girl in the maternal unit of the hospital after a few hours. She has a few questions for you about childhood vaccinations. Um She had meningitis as a young adult and wants to know if her baby will receive a vaccine for this. What information is most important to give her um A, the vaccinations for her child will be recorded in the blue book given to her to collect her child's health data. B. Um The first set of vaccines will be given um to her child at four weeks of age, C at eight weeks. Her child will receive um vaccinations for a range of infections including meningococcus group B. Um D. Her child will receive a HPV vaccine at one year old and E the Mmr vaccine was removed from the UK vaccination schedule due to an increased risk of autism. So, yeah, I like it. If you don't mind starting on the pole for this, that would be great. And OK, and you should be able to see the pole now and we'll give you a minute to answer the question and um just to make sure everyone sh um there is an A B NFC. So the Children section of the BNF, um if you're struggling to find any information on the adult section, going to give you another maybe 30 seconds to try to answer the question. And um if you feel like this one is a little bit more difficult, I'm I just wanted to remind you that on the PSA there's no penalties for incorrect answer. So always try to answer the questions even if you're not entirely sure of the answer. Absolutely. Have a go. Mm. Ok. Ok. Maybe five more seconds. And then we'll tell you what the correct answer is. At the moment, it looks like 78% of people went for answer. C, um, 12th would be and a couple of people went for A and D as well. Ok. Ok. So majority of people have gone for C which is, uh, well done, the correct answer. Um, I'll go through why the other options aren't correct again. So, um in the scenario for, so in terms of a, um it's not a blue, but that's used for vaccinations to be recorded. So in um if you go, if you notice, um if you've been to any pediatric uh settings, they would have a, a red book. So um most Children are given a red book that records all their health and developmental reviews, including their vaccinations. Um It is, it is very, very easy to get, uh very, very easy to get it mixed up there, there is a blue book, but it's more for, um it's more for I think pharmaceutical industry. So uh it's more uh it, it's actually a red book than um b um is not correct because the first set of that is given to a child according to the UK schedule is at eight weeks. So, um the treatment summary um that I would recommend you look at when you're answering a question like this is um the immunization schedule treatment summary which is found on the BN FC. So you can see here that 88 weeks at eight weeks old, we get um the DPT vaccine, the Meningococcal B vaccine, the rotavirus vaccine. So that makes the third option correct. So at eight weeks, she is uh her child will receive vaccinations for a range of infections including meningococcus group B. Um The fourth option, which was her child will receive a HPV vaccine at one year old isn't correct HPV vaccine. According to the UK vaccine, vaccination schedule was given to um young adults at 11 to 14 years of age. So usually when they're in high school and the um option E was the Mmr vaccine and its link with autism. Um So that's just generally incorrect. Um There was research by I think a person called Andrew Wakefield who was subject to quite a lot of controversy because he published some fraudulent research which showed a link between the two, but it's been subsequently proven that there's no, there's no um link absolutely between the Mmr and the um link between autism. So, Mmr is still very much a part of the UK vaccination schedule. Um And again, we'll take for questions about each related question at the end and we'll move on uh for sake of time. So this is practice question five. We've got a 33 year old man who was diagnosed with PTSD after a horrible accident at work eight months ago. He's been um engaging well with trauma focused CBT and EMDR therapy. However, he is still experiencing significant symptoms. He has started on sertraline um as first line pharmacological management and has been taking this for a month now. He doesn't have a past medical history. Um What information is most important for him to know about serine? Um A SSRI S like s actually not better tolerated and safer in overdose compared to other classes of antidepressants. B. Um He should not stop the medication abruptly. C SSRI s can have some dangerous interactions with some foods. D one of the main side effects is galactorrhea. E he will be reviewed in three months time to check how well the medication is working. So if we start another poll for that, thank you getting all the credit for starting the polls. But I think it's actually, well, I know it's actually doing it with us as well. Ok. Absolutely. Thanks. And we, we magda who've done the thing to organize the sessions, right? Uh Let's say let's give you guys another 40 seconds maybe for this question. Sweet. OK. So we have 86% of people went for answer B 4% for A and 8% for E nobody selected C or D. OK. Brilliant. So B is the correct answer. So I down to the 86% there. So um the reason why it's the correct answer is because we want to avoid um SSRI discontinuation syndrome in any patient. Um, when we're stopping SSRI s, the dose should be gradually reduced over four weeks. Um, and you might have noticed in the question that he has been taking it for a month. So if he was to, um, abruptly stop the medication, it's more likely to put him risk of withdrawal symptoms. So, um, and some of these withdrawal symptoms can be quite severe. So it's very, very important that we um gradually reduce the dose over a four week period. Um For anyone who chose a um the the main, uh the main two parts of the BNF that I used most. Um that would be relevant to this question would be the sertraline drug summary and the antidepressant drugs treatment summary. So, um if you look up um in the antidepressant treatment summary, it tells us that SSRI S are battery tolerated but um but better tolerated for overdoses. But if you think about how the question is worded again, it's very important to let the patient know what the most important piece of information is. Um It's very unlikely that most patients will be thinking about overdose scenarios. So it's not really that relevant to let them know what it's what we call like if it is better tolerated or not. Um Of course, if they ask you a question related to it, it is worth telling them. Um And in terms of uh comparatively the se second option is more in the grand scheme of things. Um, for anyone for de um Gala is a side effect but it's not a, it's not one of the main or common side effects. It's a very rare side effect. Um, and that will be found under, under the surgery and drug summary. And for e um, it is important to review, um, any patients who are started on antidepressant medication three months, however, is quite a long time. Um In the antidepressant medication treatment summary, it says that uh patients should be reviewed every 1 to 2 weeks at the start of the antidepressant treatment. So three months would be too long for that. Um Yeah, so we'll move on to the next question. This is the last one for my section. Um So perhaps question six, we've got a 22 year old woman who presents to GP uh requesting emergency contraception. She's had a single episode of unprotected sex four days ago and she would prefer oral methods of contraception. She is prescribed a single dose of 30 mg prist acetate as emergency contraception. Um select the single most information, single most important information option that should be provided to the patient. Um A her next period is likely to be later than expected following this medication. Um B this treatment will provide adequate contraception for the next five days of treatment. Um C if she vomits within three hours of taking the tablet, a second dose will be required da common side effect is tremor and e she will need her ears and es to be checked after treatment. So, if we start another poll for that, thank you. So again, we'll give you a minute for this one. And um, I was also going to say if you have any questions about this, um, this case or the previous ones, please feel free to post them in a chat section and we'll try to answer all of those either as we go in the chat or at the end of this session as well. Yeah, I'll, um, during, um, a section, I'll go through the chat and I'll add in any answers and if they're not, uh, um, we can discuss them at the end as well if they, we need more discussion and let's give it another 10 seconds maybe, right? So, for this question, almost everybody selected answer d 96% and 3% went for a, ok. Ok. Um All right. So the correct answer is c um, so the reason why, um, ok, I can see why a lot of people went for D and A. So let me talk to her. So for a, um, her next period is likely to be later than expected following this medication. Um, that is true. So under the, um, ili Prestol acetate drug summary, you'll, you'll find that it says period may be early or late. Um, so I think I was just being very pedantic with the way that I had, um way that I had said about how this, how this answer has been put across. So it says likely to be later. So, um that does not include the fact that it could also be early. Um So that's the reason why it doesn't, it isn't the right answer. However, if none of the other options made sense and a made the most sense, maybe that would be the right in, in the grand scheme it would work out. But some of the other options are better in terms of comparison, work better for which ones are more important. So um for b um the treatment will provide adequate contraception, that's just wrong. There's nothing that mentions that under the um rystal acetate drug summary, C is the correct answer because if you look under the IRS acetate summary and you look under the patient and carer advice section. Um The first thing that says is if vomiting occurs within three hours of taking a dose, a replacement dose should be taken. Um Now, I can also see why people went for D tremor is a side effect of ili prostal acetate. But again, I've been pedantic with the style of on. So I've said it's a common side effect and again, tremor is a very rare side effect of flis acetate and it's also underneath the side effects section of the IRS acetate drug summary. Then some people also went for E um so and is not um a type of blood test that needs to be checked with the patient because there's no evidence even within the acetate drug summary which mentions this, it would usually be on safety information. Um There have been some rare cases of liver injury, so they do sometimes require LFT S to be checked and monitored, but there's no mention of using East there. So that's again the wrong answer. Um I can understand that this is probably something that people have questions about. So please put it into the chat and I will try my best to answer it and we can discuss it at the end, but I will stop sharing my screen now. So Hina can start. Thank you so much Sanja. Now, so we're going to have another presenter. Now, I mentioned her before. It's who's going to talk to talk about uh therapeutic drug monitoring, which is very, very useful for both the PSA and for your clinical practice as well. I think there's a chance we're going to go a little bit over just to let you know. I think we're going to finish closer to quarter past eight. And yes, and we're going to try to answer all of your questions from the past as well. Uh So please do post the chats as, as they come up. Thank you. Thank you for everyone for contributing. Thank you. I can't actually see the slides just yet. Oh, there you go. And, and yeah, and I think you need to just uh show us the full screen. There you go. Amazing. Yes. Hello everyone. My name is RNA and I'm gonna be presenting uh in this session about therapeutic drug monitoring. So I'm just gonna turn off the camera so you get distracted. Um So let's start with the learning objectives uh for this section of the PSA uh mainly it's about reasoning and judgment. So it's uh it's mainly about deciding on how to monitor the beneficial as well as the harmful effects of medicines. And uh in terms of uh and that this is mainly to for your ability to increase safety and efficiency. Uh It's another objective is for measurable action, which means identifying the appropriate methods uh to sorry uh appropriate methods to assess the success or failure of a therapeutic uh intervention and choosing the right time to assess an intervention. So in, in this uh section of the PSA, we have eight cases, uh typical scenarios with a presentation and history. Uh It's uh it, it involves making a judgment on how best to assess the impact of these treatments that are either ongoing or being planned. So you guys are expected to demonstrate that you understand how to plan appropriate monitoring for the beneficial and harmful effect uh based on clinical history, examination and investigation. Uh So you have eight cases. Uh Of course multiple choice questions with two marks each. So by the time you get to this section, which is the seventh section, uh you will gauge how much time to, to give for each question and keep in mind that some of the questions can actually uh be uh answered from, from your medical information. So, um you've already seen the slight drug monitoring uh is worth 16 marks in total. So we're gonna start with the cases, feel free to pop in any questions you have in the chat as we go. Um I'm gonna read out the the the cases. Um, and here we go. Ok. Case number one is a 52 year old male. Uh, he has a history of type two diabetes, hypertension and hyperlipidemia. Um, he is taking insulin glargine which is long acting 40 units, insulin, insulin, lispro rapid acting, 10 units, Metformin 1 g twice daily and Lisinopril 20 mg daily. Uh So his chief complaint is he presents to the clinic with a frequent hypoglycemic episodes, uh, with dizziness, sweating and confusion and these episodes have been occurring several times a week, uh particularly in the early morning. His BP is 1 30/85. Uh heart rate, 76 regular, no acute distress and mild tremors are noted. The following are his blood results. So the patient's symptoms of hypoglycemia and low fasting blood glucose suggests possible over insulin maybe and inadequate dosing adjustments. Uh So let's go to the first for the first question. So what factors could contribute to the patient's frequent hypoglycemic episodes despite his insulin reg regimen. Is it the use of Metformin? Which does not typically cause hypergly hyperglycemia overdose of insulin, glycin or lispro potentially due to incorrect dosing or timing, increased physical activity, which could decrease the effectiveness of insulin or the presence of hyperlipidemia which affects blood glucose metabolism. Ok. So let's give you a minute for that and maybe another 10 seconds. All right. So 91% of people went for answer B and 8% went for a yes. OK. So the majority went with the correct answer. And we're gonna go through the BNF website um to see if we can eliminate some of the answers here. Uh And also as I said, you can use your medical knowledge to answer some of the questions in this section. Um It doesn't always have to go through BNF. Although if you are not sure, then you can always go for the BNF. So, question number two, we were you still on the same case? How should the patient's in insulin therapy be adjusted to prevent further hypoglycemic episodes? Is it increasing the dose of the insulin gra glargine to improve control, discontinue all insulin and rely on the oral medications, adjust doses, potentially reducing glargine or lispro and monitor blood glucose levels more frequently or maintain the regimen the current regimen and provide education on recognizing and managing hypoglycemic symptoms. I can see that someone said, is it possible to get rid of the tiny window at the bottom of my screen? And I II thought I hid it. Do you still see it? I think it's gone now. I think it's ok now. Thank you. Ok. So I see that 100% of the answers. RC. Yeah. Uh I think you are correct. Let's give it another five seconds maybe. So. Yeah, we got 92% of, ok. So the correct answer is C actually, and uh this is something because I II saw that someone asked that question. This is something from, it's just from your prior knowledge. And let's go actually to the PNF. OK. So in the treatment, summaries, I just looked up the hypoglycemia. And so this doesn't answer the second question. The second question is from medical knowledge, but for the first question, one of the answers was, uh regarding Metformin, which is one of the patient's medications. So here we can see that it mentions the medications that are unlikely to result in hypoglycemia, which leaves you with the, with the option that it is, in fact, insulin which is responsible for the hypoglycemia. Uh So if we go back to the slide show, uh we moved to the second case. Uh So here we have a 55 year old male with a history of hypertension type two diabetes and uh CKD stage three, he is on Lisinopril, Metformin one, sorry, 20 mg daily. Metformin 1 g twice daily, and digoxin 0.125 mg daily. And he is coming complaining with uh uh of nausea, fatigue and episodes of palpitation. Over the past week, we measured his BP and it's 1 35/85 and the heart heart rate is 55 BPM. Uh The physical exam is normal except for mm mild pedal edema. His creatinine is mildly raised. His potassium is within range 4.8 and the digoxin level is 2.4 and the therapeutic range is 0.8 and two. So in this particular instance, giving the patient's symptoms and the elevated serum digoxin level, we suspect digoxin toxicity. Uh considering the patient's d we know that he has impaired renal clearance which could be contributing to his increased digoxin levels. And this obviously necessitates close monitoring and dose adjustments. I would like to note that this unit of creatinine is not very common in the US, but we have the baseline uh written in the uh in this unit and in the PSA they will give you all the units and all the ranges. So you don't have to worry about that. So, question number one for this case, how should the digoxin therapy be adjusted in this particular case? Is it a increase the dose, the dose to compensate for reduced renal function? B discontinue the medication and monitor the patient closely c reduce the dose and contact. Uh and conduct regular TDM to maintain levels within the therapeutic range and D switch from digoxin to a different cardiac medication without monitoring just double checking. Uh Because some people said in the chart that they can't actually see your screen, I can, they can't see the question. I can see it but I can see it on my other monitor as well. Should I maybe stop sharing and then share again. Can you, can I just ask everybody? Can you still, can you see question one? Uh It should be the question about uh Digoxin. OK. So for a lot of people, it's still showing B NF. Uh and it's still stuck on hypoglycemia apparently. OK. Let me see. I'm not entirely sure why I can see something different. Um Yes, II that's why I kept the other monitor to for the issue. Maybe I can stop sharing and then I'm gonna share again. OK? Give us, can everybody see the question now? I think it's fine now it's working now. OK. Amazing. So if you can put on the call for this question and a couple of people ask if you can show the question again, the case, the case. Absolutely. There you go. And let's release the pole. Let's give it a minute. No worries. We'll give you a little bit longer. I do apologize. Uh We tried to use the BNF like, like a lot of you suggested um in the previous feedback forms, but sometimes um sometimes computers just don't want to work with us. Yeah, they don't cooperate. Maybe if I use the B NF again, I'll just stop sharing and share again. If it's not a huge waste of time, I think. Um Let's maybe see if, if people, um let's go, let's get through this question and then maybe we ask if people would find it useful to actually see how to use the PNF. Maybe they're a little bit more confident using it now. So maybe let's give it another 20 seconds. Hopefully, that will be enough. OK. So you've got a relatively close to even split between B and C B and C. So the correct question actually is B we discontinue and we monitor because digoxin toxicity is a serious toxicity. And let's go through a question too before we go to BNF. So when should digoxin levels be monitored to avoid toxicity? Is it two hours before the next dose, one hour after a dose and at least six hours after a dose or at least six hours before a dose? Ok. Let's give it another 30 seconds. OK. So we have 80% of people selected answer C OK. And 12 selected A and eight selected D. All right then. So the right answer is C at least six hours after a dose. And shall we try to go to the B NF again? I think some people in the chat suggested that that would be useful. So let's give it a go. OK. So for the first question, we're talking about an overdose and this is something. If we look up digoxin and we go to the side effects, we're gonna find this overdose section which says if toxicity occurs, digoxin should be withdrawn, serious manifestations require urgent specialist management. So this is regarding the first question for the monitoring requirements. Same thing we if we navigate to the section and we go for monitoring requirements, we get here and we get this section which says that blood should be taken at least six hours after a dose. So to get here, we simply look up digoxin on BNF. And the first one is side effects. The second one is monitoring requirements. Usually these are the the the sections where we might find uh uh sections about overdose and monitoring requirements. So let's go back to the slides and I just wanna make sure that everybody can see. Case three. Now I can see it. But if people in the chat could also confirm that they can see it. That would be great. No, I think we're the same thing again. Yeah, I'll just stop sharing and it's not a problem. OK. Sorry, I'm trying to. Ok. So case three, I hope everybody can see now. Um a 42 year old female presenting with rheumatoid arthritis, mild hepatic steatosis depression uh is currently on methotrexate 20 mg weekly, uh folic acid 1 mg daily and sertraline 50 mg daily. So we should know that usually folic acid would not be given on the day, which methotrexate would usually be given. Uh She's coming presenting, complaining of increased uh fatigue, uh mouth ulcers and recent episode of shortness of breath over the past two weeks. Her BP is normal 1 20/75 heart rate is 80 on, on the physical exam. We see oral ulcers, mild pallor but no joint swelling. Her, for her lab results, her hemoglobin is reduced. Uh Her white blood cells platelets are and platelets are within range for her liver function test. Uh The ast and alt are both slightly elevated and her serum methotrexate level is elevated above the therapeutic range. So the clinical symptoms and the laboratory findings raise concern about methotrexate toxicity uh which is potentially exacerbated by her underlying liver condition given her high methotrexate levels. So let's move to the first question. How should the methotrexate be monitored in this patient to prevent toxicity? Is it a there is no need for monitoring b full blood count and renal and liver liver function tests repeated every 1 to 2 weeks until therapy is stabilized. C serum methotrexate levels three hours after a dose and D full blood count every month until therapy is stabilized. Ok. Let's give it another 10 seconds. Ok. So 96% of people went for answer B and 4% for D. Ok. B is the correct question and we will see the answer later on in BN F. Let's move to question two for the same case. How should the management of methotrexate be adjusted in this patient to prevent further toxicity? Is it increasing dose to overcome the hepatic metabolism discontinue immediately without any further treatment, reduce the dose, the dose and perform regular TDM along with more frequent liver function tests and maintain the current dose and monitor for additional side effects. Some people ask in the chat, what does T DM stand for? I think it's therapeutic drug monitoring, monitoring. Yes. Sorry about that. Uh We, we mentioned it in the beginning of the, of the session. Sorry about that guys. OK. So let's give it another 20 seconds. OK. So 88% of people selected answer C and 11 went for B OK. The correct question, the correct answer is actually C and if we can go to BNF again, OK. So this patient has impaired hepatic metabolism. So we should have a full blood count, renal and liver function tests repeated every 1 to 2 weeks until the therapy is stabilized. And afterwards, patients should be monitored every 2 to 3 months. I hope that clarified the first question. Now, for the second question, we cannot stop methotrexate because it, it is very dangerous to actually. And this comes from previous medical knowledge, we know that the importance of methotrexate and we know that it has a small therapeutic window. So we cannot discontinue it without any further treatment. That's why the correct answer is actually c I'm sorry, I can't see the, the, the other perce, the percentage of the answers. I'm assuming it was B and C, it was indeed 80 83% of people went for answer. C So that's the correct answer and 16% for B yes. So this is why B is, is not correct. We cannot discontinue it immediately without any further treatment. It is very dangerous to do so. So I hope that was clear. I'm gonna go back um to share again. Hopefully everybody now can see Case four. Not yet. OK. Three at the moment. Case three. OK. But you can see the slides. Yes, you can see the slides and now it's case four. So case four, we have a 30 year old male presenting with bipolar disorder, hypertension and CKD stage two. He is taking lithium 900 mg daily, hydrochlorothiazide 25 mg daily, Lisinopril 10 mg daily and he is presenting complaining of uh severe nausea, tremors and confusion over the past 24 hours. On examination. His BP was 1 40/90 heart rate was 95. Uh on physical exam, he had coarse hand tremors, disorientation and mild dehydration. His bloods showed that his serum lithium level is 2.2 where the therapeutic range is 0.6 to 1.2. His creatinine is slightly above baseline and his sodium is only mildly below baseline. So the clinical symptoms and elevated lithium level suggest lithium toxicity which is potentially exacerbated by his CKD along with the concurrent use of hydrochlorothiazide, which is a diuretic which can increase lithium levels. Now, I would like to know that here, I used lithium but on the PS in in the PSA, you will find uh the brand name, they will al always mention the brand name. So let's go for the first question. How should lithium therapy be adjusted in this patient to prevent future toxicity? Is it a increase the dose? The dose to counteract any future declines in kidney function b discontinue and replace it with another mood stabilizer without further monitoring. C reduce the dose while discontinue hydrochlorothiazide and conduct regular therapeutic drug monitoring along with kidney function monitoring or d discontinue the current lithium dose, but add a potassium supplement to balance electrolytes. So we'll give you another 40 seconds for this question. And I was going to suggest that maybe um maybe we could just leave the, the the part where we show you how to use the B NF for the last two questions till the end. So that maybe we get through the last two questions without doing it in the middle and then we just show how to find the answers at the end of the the end. Yes. Yes. We we just have one more case other than that. So yeah, we join them. Yeah. That's, that makes perfect sense. OK. So let's give you another 10 seconds. OK. So 92% of people went for answer C and 7% went for B. OK. So C is correct and we, I will show you then we'll just join them. We'll go for BNF and I will explain why it's C and not B but again, just from the, from the idea is we cannot discontinue lithium without further monitoring and just change it to another mood stabilizer. It is not safe practice. So we'll just go to the second question here. How Freq frequently should lithium therapy be monitored in this patient to prevent future toxicity? Is it a weekly until stable? Then biyearly B monthly for one year, then biyearly C no need for monitoring after the dose is stabilized or D every three months after the dose is stable. OK. We'll give you another 30 seconds. OK? Five more seconds. Right. So for this one, we have a much more even split. We have like 59% for D, 36% for A and 4% for B this is interesting. So the correct question is the correct answer is every three months after the dose is stable and we will see it at the end, we'll just keep the um anticipation high. So moving fast to case five. So we can go to BNF. Uh we have a 60 year old female uh with hyperlipidemia type two diabetes me mellitus hypertension. She's taking atorvastatin 40 mg daily. Metformin 1 g twice a day and amLODIPine 10 mg daily. Uh the she complained is uh the she presents the clinic with complaints of muscle pain and weakness, particularly in her thighs and shoulders, which started a few weeks ago and have progressively worsened. Her BP is 1 30/80 heart rate is 78. She has tenderness in her proximal muscles but no joint swelling. Her, her creatinine kinase is 800 which is way above the normal range. Uh Her LFT S her um she has mildly elevated ast and alt and serum creatinine is 1.1 which is within range. So, question one, what is the role of therapeutic drug monitoring in managing patients on atorvastatin therapy? Is it a, it is not, it's routinely used to adjust to adjust atorvastatin doses ba based on drug concentration levels in the blood. Is it generally not used instead monitoring for adverse effects like myopathy for liver enzyme elevations, crucial. And uh CT DM helps to predict the effectiveness of atorvastatin in lowering cholesterol levels. D TDM is essential for adjusting doses based on lipid panel results alone. OK. So let's give you a minute. OK, 10 more seconds. I and we have 95% of people who selected answer B and 4% went for C. OK. The correct answer is, in fact, b and this clearly is from previous medical knowledge and we'll actually see on BNF that they don't, that there aren't any monitoring requirements. So we'll check it again on BNF. So for question two, how should atorvastatin therapy be managed in this patient to address her symptoms and prevent further complications? Is it a increase the dose of atorvastatin to improve cholesterol control? Despite the muscle symptoms, b discontinue atorvastatin immediately and avoid all statins in the future. C reduce atorvastatin dose. Consider switching to a different statin and monitor CK levels and symptoms closely or D continue the current dose of atorvastatin and add a muscle relaxant to manage symptoms. Ok. One minute. Yeah. Could you tell us what the level was again? It is. Yes, sure. It is the creatine kinase. I think they meant what the value was. Oh, yes, let's go back. So the value was 800 the normal range is 22 to 198. OK. Let's give it 10 more seconds. Ok. So we have 66% of people who selected on to C 27% for B and 5% for D. OK. So the correct answer is in fact, C and we will go through BNF to explain why it is. Well, it's definitely not b because we cannot discontinue atorvastatin and just, just from a high. But uh because you can always try switching to a different statin, but we'll go to BNF and explain that further for now, let's go for the final question question three for this case. How should have this patient been monitored before initiating therapy? Is it a no need for prior monitoring? B lipid profile LFT S within three months and after one year and uh T FT ST FT S is so LFT S is liver, liver function test and T FT S is thyroid function tests. Is it c monitoring is required for statins other than atorvastatin or the lipid profile. LFT S to be repeated every three months and baseline K levels. OK. And let's give it a another 40 seconds to answer this question. And then we will go to the B NF and I will show you how to find the correct answers. I do apologize for the technical difficulties. OK. So we have a very even split 50% for, for B and 50% for D, right? So we have a very even split for this 1 50% for B and 50% for D. OK. So the correct an answer is actually B and now I think we can go to the BNF to discuss the last two cases. OK. So for case four, we were uh this patient just to, for a quick reminder, had an elevated the uh serum lithium level which suggested the serum toxicity. So the question was how should li lithium therapy be adjusted to prevent future toxicity? The correct answer was reduce the dose, discontinue hydrochlorothiazide and conduct regular therapeutic drug monitoring along with kidney function monitoring. So here, as we can see on B NFI, don't know if I hope everybody can see. Um we, I looked up lithium carbonate and I went to the monitoring requirements and here you can get all the information that you needed. First of all, lithium have had, they have a narrow therapeutic uh uh uh over toxic ratio and they should therefore not be prescribed unless we can monitor. That's one samples should be taken 12 hours after the dose to achieve uh the serum concentration of 0.4 to one millimoles per liter. Uh And let me just show you the hydrochlorothiazide part because this is actually the answer for the second question. OK. So in this case, we just go control f in the in the. Oh sorry, terribly sorry. I am using the wrong link. Oh It's not working. OK. So I'm gonna go to interactions if you can see right here and I'm gonna view interactions for lithium and I'm gonna type in hydrochlorothiazide and you can see here that hydrochlorothiazide increases the concentration of lithium and it has a severe interaction. And this is why the answer is c So I hope that that is clear. This is for question one as for question two, just to remind you, it was how frequently should lithium therapy be monitored in this patient to prevent uh future toxicity. And the answer is right here every three months after the dose is stable. So here it says routine serum lithium monitoring should be performed weekly after initiation and after each dose change until the concentrations are stable, then every three months. OK. So for this patient, she has uh CKD, she has a renal issue, renal clearance issue. So it should be monitored every three months after the dose is stable period. So I know this is, this may be a bit um complicated but it's just a matter of going back to the to the case to the to the history of the patient and reading this the whole paragraph, it's always worth it to look up renal clearance, for example, or kidney disease. And to mention if there uh to see if the monitoring requirement changes for this particular patient. Now not to take a lot of your time. Uh For the last case for the atorvastatin, obviously, we were worried about the atorvastatin levels. Ok. So first of all, for the first question, as a reminder, what is the role of the therapeutic drug monitoring in managing patients with atorvastatin therapy? As we all know, drug monitoring is generally not used for atorvastatin, we only monitor for adverse effects like myopathy and liver enzyme elevations. This is from our previous knowledge. Now, for the second question, how should atorvastatin therapy be managed in this patient to address her symptoms? Here, we have the monitoring. So we know that we cannot discontinue atorvastatin and avoid all statins because they are needed for this patient and we cannot continue the current dose of atorvastatin. Uh A muscle relaxant is not enough. We have to reduce the dose, consider a different statin because the patient is responding uh uh badly for with atorvastatin. And we need to monitor CK levels and her symptoms closely because she is having atorvastatin induced myopathy. As for the third question, which is how should this patient have been monitored before initiating therapy here, if we look up atorvastatin monitoring requirements again, we have here before starting this treat this the uh sorry, the treatment with statins, we have to have at least one full lipid profile including cholesterol, HDL, cholesterol and non HDL cholesterol, triglyceride concentrations, thyroid stimulating hormone and renal function should be assessed. I don't have the chat. So I don't know if people have other questions. But uh here before initiating a statin treatment, creatinine kinase concentration should be measured in patients who have had persistent generalized and unexplained muscle pain. So I hope this was clear. Right. Thank you so much. I was going to just switch to my slides for, well, my slides, ah slides for a second. First of all, I wanted to just apologize to everybody for running over so much. We had some technical difficulties. Um We tried to use the B NF live and that caused some problems and also we tried to do two sessions to cover two topics in one session, which was also quite difficult in terms of managing time. So I really, I'm really sorry for that. So, just very quickly to remind you, we're going to do one more session this Sunday on prescribing in medicine and surgery. And this is going to be our last session with practice questions before the PSA which is on the 10th. While on Monday, we're going to do AQ and a session. We're just, we're just going to cover some last minute tips and tricks and you can ask us any additional questions during that session as well. And that will be everything that we'll cover before Tuesday.