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Good afternoon, everyone thanks very much for joining on time and today is our final session, we'll be going through the post course mark. Uh We have a few of things that will be quickly going through as well. We'll wait for some more people to join and then we'll start the session soon thanks very much for the message melinda, Yes, we'll make sure that all of the sessions will be uploaded as catch up content. We're just reaching out to make sure that all that has been finalized and uploaded okay, so we've actually got quite a long session today. Uh It's scheduled to be two hours, but I do expect it will run over quite quite a bit so well let's get started uh with the introduction, so again the same disclaimer is always uh we've prepared this course to help you prepare for your ps psA exam. If you do have any exam related questions, or you need any support, make sure you always consult your university and always check the b. N. F. Or medicine complete to make sure you have the up to date information on uh relevant drugs and prescriptions, so today's topics will be going through a quick run from how to actually use the medicines, complete interaction checker because I've been getting a lot of messages from people saying that they're not too sure how to use it or where to find it, so I'll go through that step by step to start off with then. There will be a quick survey. This survey is going to be used by myself and the other people who have prepped. This course, you want to use it for research purposes to see what the demand is in terms of ps, a revision, how it differs between different universities, and what sort of resources we can offer to help improve uh preparing for the PSA and upcoming years, then we'll be going through the post course mock, and we'll also be going through the answers for each of the mock questions together, So that's why I expect today's session will be quite lengthy, but we will have a break in between, so whilst away if everyone else to join, we'll quickly go through medicines complete and how to actually find the interactions. Checker, so once you've locked in, when you when you sit your ps exam, you'll have time to set your station up to log in or to the relevant website and you'll have um this as the front page of medicines complete what I recommend you do is, whilst you're before the exam starts, you have time because you have time to set everything up, just type a list of random medication, so let's try uh lot of pain, ramipril, I'll see tamal, I prefer it in gardena, I don't know how many appetite, but I want to type this and I press, enter. You'll see that normally, I've instructed you guys to look for the interactions tab down here, but currently there's nothing here and we've also got nothing from the search results, so what you need to actually do is it actually mentioned that here, if you're searching for interactions, results will be more accurate with an interaction search. This can be accessed by referring to your chosen publication and selecting the interactions filter, So all that means, is you need to click the b n f or be nfc. I mean the interaction is going to be the same for the medications anyways, so you click b n f and now you can see under here. We have the interactions tab, and once you click that interactions tab you'll have this search bar open and obviously it's given us some of the interactions from the list of medications that we've typed, so what I recommend is you start off by loading this page up and then you can just cross all these out and then you'll have this interactions tab ready. You can also just have your your regular medicines, complete openness up of tab and obviously you'll have your b n f and your the ps a. Assessment website open on all all the different tabs, but that's essentially a step by step process on how you can access the interactions. Checker on medicines complete, just see if there are any questions mhm, uh The rest of the sessions will be uploaded and all the session slide slash recordings will be uploaded by the end of this week. Hopefully okay, so if you guys want to hop off onto this. Qr code, I've sent the link into the chat. This will take you to our post course survey. You'll need to access you'll need to fill in the survey in order to access the form for the mock exam as well. There is an option for you at the end to opt out of the research. So after you filled it all in, if you don't want your data to be used for research purposes, That's completely fine you have the option to state that you don't want your data used, but otherwise, if you guys want to head over to this site here and fill in the survey. Once you've done that on the second page, it will give you the the form for the mock exam that we're going to be doing today, so. Again, if you scan this qr code or click the link in the chat that will take you over to the survey. In the meantime, I'm just going to share a video that was given to us uh by the n. D. You, who have been sponsoring our series over the past few weeks, okay, okay, and I'll just get everything's set up on my end now, so hopefully that gives you guys enough time to fill in um a survey okay for those of you have just joined. If you want to fill in this survey here now, um the m. D. U. I mean not only do they provide medical indemnity, but they also have lots of great online resources. I think it's free as a medical student and it's really useful for you guys since you'll be on placements, they also provide elective cover as well, so that's a um I think the m. D. U. Is what I use during my electives as well, and as when, as and when you become a doctor, it's very strongly recommended that you have some sort of coverage anyway, so um why not sign up for the end do you now whilst you have the chance, the final thing that I have to say before we start the mock exam is that we've timed all of the slides, so you'll have a certain allocated time, No you'll have a certain allocation for each question. We did receive the feedback from the pre course survey, So thank you very much for that we're going to keep the timing is the same just because we want to make as consistent as possible uh between the pre course and the post course um mock exams, so I understand that some of the timing's might you might feel a bit pressured, but hopefully um through the past 10 sessions that we've had together, you'll feel a bit more confident in asking these questions again and the recordings are all uploaded on our official medal page. If you go to the AMSA England page, you should be able to access all the previous events with all the recordings attached, okay, so assuming that everyone has finished filling in the survey, now we'll start off with the mock exam afterwards, we'll have a break and then we'll go for the answers together. The mock exam should run for an hour, so let's get started since it's already 10 past one okay and the exam should the mock exam should start right now, okay guys a good job of making it through to the end of the mock exam, we'll have a quick 23 minute break, just so you guys can have a bit of a rest and then we'll carry on with the rest of the session, going through the answers together okay, so the feedback link has been sent into the chat, just in case anyone does have to dip off early, but we'll be going through the all the questions together, we will start now okay, so this was the first question that you guys had we're looking at a 16 year old who presented the emergency department with shortness of breath and the question was to write a prescription for one drug that is the most appropriate to help treat a condition. So the most important things to take away from this question is that she's got a past medical is to have asthma. She's a 16 year old girl. She has been given to salbutamol nebulizers already and currently her respiratory rate is normal, so we've got someone who have known asthma They've coming with shortness of breath. They've had some salbutamol and now things look like they've stabilized, so what is the next uh step that you would take in this scenario, so we've got the answers from the primark uh, so, from the the pre course mock and this is what everyone said, so most of you had said prednisolone, which is in deep the correct answer. Some people have said i petroleum bromide Now this isn't wrong, but it wouldn't get you the full marks and we'll go through why that is together. So for the management in children age two years and over on the b. N. F. It says here that in all cases of acute asthma, children should prescribe an adequate dose of or prednisolone when we have a look at the b. N. F. Guidelines. Here, we can see if someone who's age 16, they recommend 40 to 50 mg daily for at least five days so that would have been the correct answer. Yes, you can give like a tropea um in patient's who have come in with an acute exacerbation of asthma, but at the moment that doesn't seem to be any clinical indication for it. She's um stable. Her respirator was fine, so we're not too worried about her breathing at the moment, you'll probably get maybe four marks or six marks for saying i potro p, um but you wouldn't get the full marks because it's not technically like a correct next line management. You would give you can write either 40 or 50 mg of prednisolone and you get full marks for that okay. So the second question we had someone who presented with a sore throat in the g. P. Practice and again this was a prescription question, So the key things that I would be looking for in this question will be that they have recently finished their fourth cycle of chemotherapy for lung cancer. They have a mechanic's oral allergy, they have a, and we can see in the picture here that they've got a bit of a white tongue, so these are the important things to look for in a question like this, you would be thinking oral candid ISIS, and so you want to be treating that. As such, again, in the precose mark, most of you did say in the statue, we had a few various senses, and we had a lot of people saying different things in terms of the route, so the correct answer for this would have been on a statin uh 100,000 units p. O. Q. D. S. For seven days, so to get full marks that would have been the full prescription that you have to right we can see underneath statin for oral candidiasis. It tells you everything here so the root is orally p. O. And it's that 100,000 units four times a day for seven days. You can click this link here in order to find the full treatment summaries, but essentially what they recommend here is either in the statin or miconazole, remember that she had a miconazole allergy, and so therefore we would not prescribe that so the statin would be the correct answer for this question. Okay Question of three we have a four year old boy who's presented to the g. P. With perianal itching um and again it's a prescription question so the thing that I would look for in this here is that they've got perianal itching. The father has also started to experience similar symptoms and I mean this kind of gives it away the fact that there are small white worms which are noted On examination of the perianal skin, so this patient has a threadworm infection and the correct prescription which pretty much everyone got right. Last time is indeed mebendazole, so you prescribed mebendazole 100 mg PO and for the duration will be once only so it's just one dose you can see here for fred worms, anyone between six months to 17 years and any adult. You just give them one stat dose and if they do have a re infection, they may need another dose after two weeks. There's more information under the helm, infants infection, part, but essentially under fred worms you can see here. Mebendazole is the drug of choice for treating a threadworm infection. The last prescribing question um was a 22 year old male who was in an altercation and he got bitten during a fight. The important things that I would look for in this question here is that what is the murder injury, so he was bitten and we're assuming that it was from another person. He has a penicillin allergy. Now this is very important and also it's important to read the question. The question says write a prescription for one drug that's most appropriate as prophylaxis, So when it comes to bites, you can treat them for prophylaxis or for active treatment. The question states here prophylaxis and sometimes this can make a bit of a difference to make sure you read the questions carefully. So most of you in the pre course mom got this correct and we said doxycycline, so the correct answer. Indeed for question for is either doxycycline or metronidazol now it's not um we'll we'll accept most answers for this. Obviously on the ps PSA exam, there will be a set way to write it down and what I mean by that is when we have a look at the prescription recommendation for doxycycline. It says here you give 200 mg daily on the first day and then for a maintenance dose, you can either give them 100 mg a day or you can give them 200 mg a day, so there's a few different ways of writing that initial prescription. If you go back to the question, um the question says write a prescription for one initial drug that's most appropriate, so we can see here for Doctor franklin. If you were going to give them 200 at the, on the first day, i mean, 200 daily for three days, then you can just write doxycycline 200 mg orally once a day for three days. If you're going to give them 200 on the first day and then 100 on day two and day three, then the technically the correct way to write it would be doctor cycling 200 mg orally once only, and then you give them another prescription of doctor cycling 100 mg once a day for two days, but because the question was stating what's the initial treatment, you give either one of these answers, would have been correct, we can see under the skin infection section that metronidazole is also the other medication that you would have to give so it's either Doctor cycling or metronidazole, and again for metronidazole, you just prescribed as 400 mg three times a day for three days, so in real practice, you would give them Doctor cycling and metronidazole because they have this penicillin allergy, but because the question stated just write the prescription for one initial drug either, all would have been acceptable for this question. Um This this type of question you probably wouldn't get in the real exam. I guess thinking back because it's a bit wishy washy, but just in case um either or of these answers would have been suitable for this. What was the answer to question one and two question mom was prednisolone uh 40 mg and question too was uh a statin okay, so let's carry on. Next, we have the prescription review question so we had someone who has been admitted following a collapse and the question was which two prescriptions are the most likely to have interacted now. There are three main culprits here which most of you guys had identified. During the pre course mark, we had most people say isosorbide, amlodipine and sildenafil, so as you said there's three potential options, but the question says which two are the most likely to have interacted now. If you had searched this on medicines complete. If you have the entire list up here, we can see that they found free main results now. All of these technically have a risk of hypertension, but from the free, of these, the most severe one which the manufacturer specifically advises to avoid with study based evidence is the isosorbide mononitrate and sildenafil, So the correct answer for this would have been those two options for the second prescription review question we had someone who has come in with a. K. I, and the question was to identify which free prescriptions will have most likely contributed to the development of the AKI and again we've got an assortment of different medications here. In the Precose smoke, most people said frusemide, ibuprofen, and gentamicin, and some people have also said ramipril, so let's go through this together. Again, If you go into the medicines, complete interactions, checker, and you type all those medications, then this is the list of options that we get here from the medicines complete recommendations. The three main ones that they say to look out for is this one here, so frusemide increases the risk of nephrotoxicity with gentamicin, and this one here, gentamicin and ibuprofen can increase the risk of nephro toxicity, so the correct answer here would have been frusemide, gentamicin him and ibuprofen now. Ramipril is acknowledged, but it doesn't specifically state here that there is a risk of nephro toxicity, um so it's not as evidence based as these three options. When given together, the third question, we had someone who's come in with an exacerbation of their parkinson symptoms and they are on an assortment of medications here. This one most of you got right last time and hopefully this time around as well, we've got most people saying metoclopramide, we've got some people saying entacapone and I can understand why so let's just quickly go through why metoclopramide is the correct answer, so metoclopramide mode of action is that it's an anti doping dopaminergic medication and obviously in parkinson's disease, you have a degeneration of the substantial I bread to really water it down and that causes a dopamine deficit, so if you've got dopamine deficit and then you give them another anti dopamine medication, then things aren't going to go well for the parkinson's patient. When we search the medications interactions, we can see here that you got to read it very carefully, so entacapone increases the exposure to levodopa, so it does have an interaction, but actually increases the efficacy of levo dopa, whereas levodopa and metoclopramide, okecie here, metoclopramide decreases the effects of levodopa and so the correct answer for this question was metoclopramide the fourth and final prescription review question um we've got someone who's um been admitted with a new bradycardia, heart rate is 36. What two medications are most likely to be the cause of this new bradycardia, so again we've got a list of various medications and it seems like most of you at right around, last time, we said verapamil and propanolol. So the key thing to take away from this Question is that beta blockers should not be prescribed uh for someone who has a nondihydropyridine calcium channel blocker. Again, if you type all those medications here, uh we can see that in this box down here, it states that panel and verapamil can increase the risk of bradycardia and can increase the risk of hypertension and so it's contra, indicated the key non dye hydro, period in calcium channel blockers that you should be aware of. In particular are your verapamil and your diltiazem, and again as you said the potential effects of having a beta blocker with these medications is that they can become bradycardic, hypertensive, or they can have some various areas for me as an conduction deficits okay, so we have one other thing to sedate with these Questions here is that in the real exam you actually have more questions for each prescription review, essentially there's four marks in total per prescription review, which will mean that you've got four medications to identify, so for a question like this, we've got to identify two medications here. There's also be a part b which would say which two medications blah, blah, blah, blah, blah, um same. For questions like this, If it says select one prescription, then there'll be a section be saying state free medications which have no uh incorrectly prescribed or the doses are wrong, so just to keep aware of that. In terms of planning management, so we've got a 52 year old woman who has come in with five episodes of diarrhea and they've got a stool sample, which is c diff toxin positive as well as c diff antigen positive. Um They've recently been discharged following a course of catholics um So out of these options, which is the most appropriate management for this patient. Last time, most of you got it correct. He said oral vancomycin and indeed for the first line management in someone who's had no previous treatment for c difficile. We give them vancomycin and if you go to gastrointestinal system infections and bacterial therapy, you can see that the entire guidelines are recommended as stated here, so for a first episode of mild moderate severe c diff, you give them oral vancomycin. Second line, you can give them oral uh maximize in and then if they have another episode of c diff infection, then you go down this route here, but the correct answer for this indeed was oral vancomycin 100 and 25 mg q. D. S. Okay, so question to we've got a 56 year old man who's come in with a painful rash um nothing really that significant in the history here. On examination, he's got a particular maculopapular rash on the anterolateral aspect and it's um there's a dermatomal distribution looking at this photo is pretty much all you need to do in order to make a diagnosis. This is likely a gentleman who's got shingles and what's the most appropriate management option. Out of the following, so most of you have some acyclovir, which is correct, so someone with a dermatomal uh dermatome aly, distributed rash. You're thinking shingles obviously caused by varicella zoster virus. If you look at the herpes virus infection section, there's a recommendation for the use of acyclovir for treatment for question. Three, we've got a 28 year old who's come in with irregular periods. They've got a bit of hirsutism on the face and ovarian cysts are found on a scam, leading to a diagnosis of pecos, so what's the most appropriate first line management option we've got metformin. We've got a weight loss and exercise we got, I us we've got the c. O. C. P. And we've got uh medroxy progesterone as state and in the pre course mark most of you said weight loss. Some of you said the c. O. C. P. So for the first line management for pecos. It is actually indeed lifestyle modifications and the ones that they recommend healthy eating, regular, physical, exercise, and maintaining a healthy weight or if someone is obese that to encourage weight loss and then if that isn't successful, then typically the first line management would indeed be the c. O. C. P. Unless contra indicated. Question four we've got an 84 year old woman who has been brought in by ambulance following an episode of shortness of breath. They've got um extensive past medical history. On examination, the most significant things that we can see here is that their respirators a bit high, the oxygen is a bit low on two liters and course crackers ahead at the lung bases, and then the x ray pretty much gives it away. We've got cardiomegaly, we've got pulmonary edema and we've got a bit of a pleural effusion, so what's the most appropriate management option so we can produce from this question stem that this patient has likely come in with an acute exacerbation of heart failure and the patient is actively breathless that's the most important thing to take away from this, so which of these five medications would be the most suitable most of you got it correct. Last time, we've got frusemide uh 44 you said that and that is the correct answer. So the symptoms are descriptive of an acute exacerbation of heart failure. The first line management for anyone who's coming in with shortness of breath or a dema, secondary to fluid retention will be loop diuretics, so classically you've got your frusemide, but I think bumetanide is also used. Um Yep stated here, so you can give them bumetanide or you can give them torsemide um as the diuretic of choice to relieve breathlessness and edema and again this is under the chronic heart failure section for the interest of time. I'll answer most of the questions in the chat. Um once we've finished just for the sake of the recording and so people can head off at the end, but I will come back and answer the questions okay. So in terms of providing information, we've got a 22 year old man who's essentially been diagnosed with depression and he's been started on certainly 50 mg orally once a day, which of the following is the most important information that should be prescribed to should be provided to the patient, so we got a list of five different options here, most of you last time set be, so let's go through the answers together so be is indeed correct, so option one you may experience sexual dysfunction as a side effect. It's true, but it's not the most important information that should be provided, remember the question is out of the following, which is the most important that we should let them know. The second one obviously is the most important now, the five options because you know if his suicidal force uh may worsen that he's not already aware of this, then things could go worse and deteriorate for the patient. Option three is also very true. Um If you don't taper the weaning dose over a course of a few weeks, then they can experience withdrawal side effects such as gastrointestinal disturbance, headaches, dizziness, etcetera, etcetera, but again it's not the most important thing that should be uh told option four. If this move does not improve over the next few weeks, another antidepressant can travel. Again, this is true, but it's not important and the dose can increase be increased up to a maximum of 200 mg, but again it's not the most important thing that we want to be telling the patient for this case. Question to we've got 15 year old, who's got extensive scarring due to sick via acne and the dermatologist has agreed to try a course of oral ice to try to know him which of the following is the most important that should be provided. She's an increased risk of headaches. She may experience unintentional weight loss. She'll need a pregnancy test before and for the first three months of treatment. Her fbc needs to be monitored regularly, or she may experience changes in her mood, so most of you last time went along with pregnancy test. Some of them said she may experience changes in her mood. The pregnancy test option is the correct answer for this question here, so let's go through them, one by one, so she's at an increased risk of headaches. It's true, but again it's not the most important thing when we look at the other options, she may experience unintentional weight loss. Yeah it's not unknown side effect that's documented on the b. N. F, and it's not an fda approved side effects, so that one is false, option three is true, so ice tretinoin has a serious risk of teratogenicity, and if you look under the sorry, if you look under the pregnancy prevention section under ice tretinoin, then you'll find more information specifically on b. N. F. With regards to that and they recommend that oh sorry that that is incorrect. I'll change that for when the handouts are sent out, essentially, she'll need pregnancy test before starting and during the first three months because of the risk of teratogenicity. Her fbc needs to be monitored. There's nothing that goes along that line on the b. N. F. And she may experience changes in her mood. This is true and there is a possible risk of neuropsychiatric reactions in some patient's, but again it's not the most important, I would say it's more important to make sure that you rule out any potential um trata genic babies and under the contraception and conception section of Isotretinoin own, we can see here that they need regular follow up in pregnancy testing and again if you look under the prescribing for females of childbearing potential under isotretinoin. Um They against a TIA that pregnancy testing should be carried out on the same day as prescribing and dispensing, so sometimes the exact answer may not be specifically stated as a control F. Function on the b. N. F. And you may need to use a bit of your common sense or your clinical judgment skills. It doesn't specifically stay state here that it should be done before starting and for the first three months, but you can kind of tell based on reading this information and having a look through the eye structure to know in page that there is a serious risk of teratogenicity, So for question three we've got somebody who has urinary retention symptoms. An 81 year old male to do he's been started on finasteride on the diagnosis of BPH, and a bit of important information in the social history is that he lives at home with his wife and he has carers who visit twice a day, so we can assume that the carers will be assisting him uh for his daily activity, activities of daily living, and also possibly for his medication prescription, so which of the following is the most important finasteride should be crushed before consumption. It shouldn't be handled by anyone of child bearing age. His metformin will need to be changed due to interactions. He may experience testicular pain as a side effect, or his ps a reference ranges need adjustment, so we had a bit of a broader um selection on this question, last time, but most of you all right finasteride's should not be handled by anyone of a child bearing age, so finasteride can be crushed before administration, but it's not it's not a recommendation. I mean you can take it whole. You can have it crushed depending on how the oral intake for the patient is preferred. Finasteride should not be handled by anyone of child bearing age because it states that women of childbearing potential um should avoid handling crushed or broken tablets and essentially it's because finasteride can be absorbed through the skin and that can cause birth defects in male babies, and that's why it should be avoided in anyone of childbearing potential, his metformin doesn't need to be changed. There's no um interaction that can be found between metformin and finasteride on b. N. F. Um Testicular pain is documented as a potential side effect, but it's under frequency not known, so and again it's not as important as um this risk of tomato jenness, it, Ian, male babies, and again there's no adjustment that's required in terms of the PSA reference ranges, so the answer it was two for this question here okay, So now we're going to go along onto the calculation questions, we've got someone who's come in with a swollen left leg and raise d dimer. All shout has shown that he's got a DVT and you've been asked to start him on a box of par in 750 micrograms per kilo every 2012 hours and the patient weighs 72 at kilograms. So the most important things here is to read the question carefully. It says what's the total dose in milligrams of the enoxaparin that the patient needs again in the 1st 24 hours. So last time we got quite a big difference in terms of the range of answers, we got some people saying that they should give 100 and 8 g, so make sure you always have a look at your units carefully when you're prescribing the way to calculate, this is so the dose was 750 micrograms per kilo, and the patient weighs 72 kg uh so that would tell us that they need 54,000 unit micrograms and that will be over 12 hours. Let's just have a look here again, so it's 750 every 12 hours, so the 12 hour dose for his weight would be 54 k. Now. Obviously, the question has asked us to calculate over 24 hours, so we need to double this number, which gives us 108888 as at 108000, and the question also asked for the dose in milligrams, so we need to convert from micrograms 2 mg, which is divided by 1000 and your answer would be 108 mg over a 24 hour period. Okay question to uh we have a 52 year old woman with type two diabetes. She's about to be started on exenatide for glycemia control for the first month. She needs to take five microgram story of the exenatide twice a day and the exenatide is prepared as a five microgram per 1.2 mL solution after three weeks. She stops all the medications and so what's the total volume of exenatide that the patient has had over this period. So the important things to take away is that they take five micrograms, but that's twice a day, each microgram is 1.2 mL, and she's had it for three weeks in total, so we got a big range of um answers here. Most of you opted with 504 millimeters um which I believe actually is incorrect. I think the correct answer was 50.4 millimeters, so let's go through this together, so we're told that five micrograms is the same as 1.2 mL and they're having it twice a day, which means they're having 2.4 millimeters in a day. They've had it for 21 days, which is three weeks, so 2.4 times 21 gives you 50.4, so the answer for this is 50.4 millimeters um Sometimes in the pizza, you may get a similar question style like this where it's about calculating the number of milliliters or the number of pills, for example that the patient takes so there's another example on the notes for this slide, which you can have a look through uh if a patient on a weaning dose, for example, so if they're starting on 40 mg of penicillin, but they cut down every week by 5 mg, so there's more stuff in the notes for you guys to read through for the calculation section okay. This next question here, this is probably one of the most difficult calculation questions that you'll get in the p. S. A. We've got 55 year old man who's recovering in the post operative ward following a cabbage. He's been prescribed dopamine 0.3% via an iv infusion at a rate of three micrograms per kilo per minute and he weighs 84 kg, so what's the delivery rate in milliliters per hour that the infusion pump should be set to. We can see here from the pre course answers that we've got a range of everything um. I'm not too sure if anyone actually I think there was one person who got the correct dose um in the pre course mark, so let's go through this question together, so we know that the rate in terms of dose per kilo per minute is three and the patient weighs 84 kg, so you're times those do together. We find out that the patient needs 252 micrograms per minute. Now, the question stated what's the dose per hour, so, uh if your time's up by 60 that gives us the answer of 15,120 micrograms per hour. Now the question also specifically asked for the um answer in milliliters, so what do we need to do, we need to convert this dose into milliliters based on the fact that it's a 0.3% concentration strength, so what does that all mean well, let's go through it step by step if you have a 1% solution that means you've got 1 g of a medication uh diluted in 100 mL, so therefore, if you have something that's 0.3% that means that you would have no 0.3 g of a medication diluted in every 100 mils. If we convert that into milligrams and then into micrograms. That tells us that in 1000 mL of a solution, we've got 300,000 micrograms that's been diluted in that, let's simplify it by dividing both sides by 100 and that tells us that in every milliliter, we've got 3000 micrograms now, we need 15,000 micrograms um to be given over an hour, so what do we need to do all we have to do is divide 15,000, 120 by 3000, and that gives us the total number of units, which is um 5.4 millimeters and you can kind of make that rough estimate already because we know that in one mil, there's 3000 but we need 15,000, so that's five times as much they will need about five mil more now, this can get a bit confusion um confusing. I would still recommend going through this way step by step, but if you really find it difficult, then we've added a quick, little cheat sheet, so if you have a 1% concentration um medication, and you need to convert it from milligrams 2 mL, then all you need to do is divide the total number of milligrams by 10. If we have 1% 1% solution and you need to convert from micrograms 2 mL, then all you need to do is convert the total micrograms by 10,000. If we have anything that's less than 1% say no 10.5% then if you want to convert that then all you need to do is divide the total milligrams by five or a and if you want to convert it from micrograms 2 mL, then you definitely divided by 5000, so if we apply this box to this question here, the first thing that you should do is calculate the total dose in milligrams or micrograms, whatever the question states as we've done, so here, so we need 15,120 micrograms in an hour, we want to convert from micrograms 2 mL and we know that the concentration was 0.3%. So if we use this bottom formula here, we've got 0.3% from micrograms 2 mL, therefore it would be 15,100 and 20 micrograms divided by 3000, which is this equation that we've got at the end here to apply to some different questions. Let's see how to convert 520 mg of a drug, um which is prepared a 1% concentration into milliliters well. If you want to use this equation here, we can take this top line here all we have to do is take 520 mg and divided by 10, which gives us the answer and it's explained here step by step if we've got um if we need to convert this microgram dose into no 0.5% and that's used this bottom equation here. Again, so we want more 0.5% all you have to do is 3720 divided by 5000, which gives you this dose here, So again, I'd recommend working it out step by step, which has been all been explained for each of these different scenarios, but if you really struggle with it, then you can just learn these equations in this box here. Okay So the last calculation question we've got an eight year old girl who needs treatment for meningitis with k thyroxine at 15 mg per kilo with the max dose of 250 mg twice a day for 100 for 14 days. The tablets are given a dose of 100 and 25 mg per tablet and she currently weighs 25 kg how many tablets will she have to take to fully complete her course. As stated here, so most people uh said 84 last time and we've got a few rogue options as well, but the actual correct answer I believe is 56 so let's go through this together, so we're told that the medication dose um should be 15 mg per kilo and the patient weighs 25 kg, so that tells us that they need 375 mg. The important thing is we need to note the max dose here, the max, the max dose that they state is 250 so even if their weight goes above whatever that would be in terms of this calculation, so in this case, even though we're the calculation has said that we need to give 375. In actual fact, we've already crossed that maX dose threshold, so we should only be giving them 250 mg. We know that the tablets are prescribed as 100 and 25 mg tablets, so if we need to give them 250 mg, then that means you have to give them two tablets the prescription was 250 mg twice a day, so that means every day they're taking four tablets and they're taking it for two weeks, which means four times 14, gives us 56 so the answer for this is 56 tablets okay. Uh Next, we have some adverse drug reactions, We have one of each question type, So this first one here is that this patient has been started on amitriptyline and what's the most likely adverse effect that is to be caused by this treatment. We've got five different options. Lots of people said some varying options down here, but most of you said drowsiness. If we look at the amitriptyline side effects, we can see that drowsiness is under common or very common and then the other four options are under the frequency, not known. So after the five options. Drowsiness is indeed the most likely side effect. Question too, we have a 59 year old woman presented to the gp, we've increased shortness of breath which of the following medications is most likely to be contributing to her breathlessness. We've got six different options here hydroxychloroquine, bisoprolol, to cangrelor, aspirin, ramipril, and atorvastatin, so most people opted for bisoprolol, Takagi law, or ramipril. The correct answer for this one was actually two caldolor and why that is we'll go through together. Um step by step, so this is the side effect profile for to Kagle or one thing to be aware of is that in the question it goes on about shortness of breath, breathlessness, but b. N. F states it as dyspnea, so make sure that you're familiar with some of the other medical terminologies that the b. N. F might use. We can see that it's under common or very common for to Canberra law now. If you search for disney for bisoprolol or for ramipril, then it does show up, but the important thing to be aware of it is and in fact I'll demonstrate it by having a look here, you go to be softener, which is what murder people went for and we control that for dyspnea you can see here that the side effects for all beta blockers, dyspnea is common for all of them, but for bisoprolol fumarate. Specifically, it doesn't actually state dis, mere anywhere so for software. Specifically, it's not really a known super common side effect under all beta blockers. In general, it is quite common, but for soft floors. Specifically, we don't have any documentation and it's the same for ramipril. If we search this year, yes, it's known under all angiotensin converting enzyme inhibitors that it's a common or very common side effect, but again for ramipril. Specifically, there's nothing really stated here, whereas if we go for Takakura law, you can see that it doesn't say for all. I forget what drug class to calculate is off the top of my head, but it doesn't say for all of that medication, so this we can tell it's talking specifically about to calculus so after the free options actually to calculate would have been the the correct or the most suitable answer. Okay adverse drug reaction question types see um which of the following medications is most likely to be contributing to this patient who has a bit of renal impairment. We've got various different options. Ramipril and ibuprofen are the two most likely contributing factors. If we have a look at the side effect profiles, we can see that for ramipril, renal impairment is under common or very common, whereas for I profin, it's not really specifically stated as a common or very common side effect or if anything, it's under the frequency not known and it's more talking about patient's who have pre existing renal impairment and more likely to go into renal failure and again this is more with topical use. So out of these two options, ramipril is actually the better answer for this question. Specifically the last adverse drug reaction question we have someone who is on warfarin, their iron are, has been checked and it comes back as 9.4 and they have no clinical signs of active bleeding, so we've got five different management options and last time in the pre course mark we had a range of different options here so if you go to the oral anticoagulants. Treatment summary on bnfl medicines complete you get this nice chart here, which basically gives you. All the answers you need is iron are was 9.6, but he's got no um signs of active bleeding, so all you need to do is you need to stop it. You need to give the vitamin k uh by mouth so orally and then you would repeat it if the iron are still high blah, blah, blah, but the most important thing is you would want to give oral vitamin k okay, so drug monitoring we've got someone who is diagnosed with Zollinger Ellison syndrome and that started on omeprazole which electrolytes should be monitored before and during treatment. This is a fairly box standard one and most of you on it right last time you said magnesium. When you search omeprazole on the b. N. F. And you look at the monitoring section. It states here that magnesium concentration should be considered before and during prolonged treatment. Um whilst omeprazole is known to have a side effect or a potential risk of hyponatremia. The actual b. N. F. Recommendations for monitoring is to look for their magnesium concentrations. Question to we have got someone who has been treated for atrial fibrillation and he is currently being rate controlled with digoxin. It's like the most appropriate option to monitor the effects of the digoxin after one day of treatment. Do we look at the BP, digoxin levels, potassium levels, heart rate, or renal function. Most of you last time went for digoxin levels, some people went for renal function, one person went the heart rate, which actually is the correct answer for this question, so we've got to remember the question states to monitor the aims of the treatment and what are we aiming to do with digoxin. We're trying to rate control the patient who's got a f, so. If we want to best assess the effects of the treatment, then you want to look at the heart rate. If the heart rate is coming down, then that means that they're being rate controlled, which tells you that the digoxin is working at its intended effect go through that. Again the question is the most appropriate option to monitor the effect, monitor the effects of the the digoxin. Yes, we can look at the serum digoxin levels, but that's not really going to be telling us about the effects of the the digoxin, that's more telling us whether the patient at risk of having um an overdose of digoxin or if they're not excreting it properly. In terms of the actual use, we're using it to control the heart rate, so looking at the heart rate would be the most suitable option to monitor the effects, options. Uh Question three we've got someone who's been diagnosed with type one diabetes and they started on a long acting and a short acting insulin regime, what's the target hBA once commencing treatment pretty much, all of you got it right last time, which is indeed less than 48 millimoles and again if you look at the type one diabetes section. Treatment summary um they stay here aimed for hba one c of 48 ball, lower drug monitoring question for we've got an 82 year old woman who has uh been admitted with an acute episode of delirium. She's bedbound, and she's prescribed dalteparin for the prophylaxis of forming a v. T. E. What is the most appropriate option to monitor for adverse effects of this prescription after 24 hours of treatment, would we look at the i. N. R. Would we look at the f. B. C. D. Dimer, the prothrombin time, or the APTt again, last time, we had quite a range of options, more people going for fbc than Aptt, but quite a fair split. If we look at dalteparin, then under the adverse effect, we can find that heparin induced from the cytopenia is the things to look out for and they stayed here that the platelet count should be measured before treatment and regular monitoring should be done if given longer than four days now. Obviously, there wasn't an option stating platelet count, but you all, I'm sure you all know by now that under the f. B. C. As well as looking at the hemoglobin and the white cell count. You'd also be looking at the platelet counts, so fbc is the correct option after the five here okay, So some data interpretation, we've got someone who's gone for a regular health check up in the clinic, they've got a bit of hypertension. What's the most appropriate management step for a BP out of these five options, most of you went for offering ambulatory BP monitoring and indeed if you look at the treatment summary for hypertension. Further diagnosis Stage two hypertension they need a clinical BP of 160 over 100 and an ambulatory daytime average of 100 and 50/95. So, without this because it's an end without this ambulatory management, we wouldn't really start treatment, so you need to make sure you have an ambulatory BP reading of over 100 and 50/95 before you start medical treatment. This time, we've got an eight year old boy who's admitted to the hospital treated for endocarditis. In terms of the drug history, he's currently on gentamicin 87.5 mg iv and his weight is 35 kg in the investigations. We can see that the peak dose which has taken one hour after giving the gentamicin, has gone up to seven mil, the grams per lita, and his pre dose, which is taken before giving his next dose is 1 mg. So based on these findings what's the most appropriate gentamicin prescription to be made. Based on the results, and we've got various um list of different options, different doses, we've got doses lower, we've got doses higher, We've got changes in terms of the frequency of how regularly we give the medication, and again we had quite a big range in terms of the options here, so we can see that the peak dose was seven and the reference range that the b n f gives us is 5 to 10, and we can see that the predose level is one and the reference range again at the givers is less than two. If you look at gentamicin under therapeutic drug monitoring, where's it gone, we have the options here, so the the peak dose or the one hour dose level should be between 5 to 10 and the predose concentration should be less than two, so because he fits within those ranges, we can carry on with the medication at the same dose which was 87.5 every eight hours okay. I think this might be our last question, I've got a data interpretation one here we have a 69 year old gentleman who's recovering after a Hartman surgery. Um He's had it two days ago for colorectal cancer. He is currently on morphine sulfate 40 mg orally twice a day as well as some procedural metformin and doxazosin. The patient of his drowsy and he has some pinpoint pupils. He's got a bit of a fever. His heart rate's a bit fast. His BP is stable. His breast rate is quite lower eight. His oxygen levels are nice. 2% on room air, spell sounds are present and fecal content is noted in his stoma bag. His creatinine level on investigations is also quite high at 244 so what's the most appropriate option regarding his pain relief, so the question specifically is asking about his pain relief. Do we switch to oxycodone 40 do we increase the morphine sulfate to 50. Do we switch to oxycodone 80. Do we switch to oxycodone 20 or do we stop all of his medication, so we had quite a split um list of answers here with most people saying stop all the medication, but a fair amount say switching to oxycodone 20 and then we have some people saying all the other options, so the correct answer is switching to oxycodone 20 so why is stopping all the medications incorrect well. First of all you know the other medications are important for his disease control. He's on the metformin uh for his diabetes and he was also on a medication for his BPH, so they should be carried on unless they're know to be interacting and affecting his uh renal function, for example, and the patient still needs postop analgesia. I mean he's just at a surgery um Two days ago, he's going to be in a lot of pain, so we want to make sure that we get on top of his pain control so that he can recover quicker. Yes The patient does have signs of opioid toxicity as noted by his pinpoint pupils, you know his really low respirator eight breaths a minute, now, we can tell from his raise, creating in the likely secondary to an a. K. I. So why is the oxycodone option better than the meth uh then the what was he on and the morphine sulfate so oxycodone is hepatically metabolized, whereas morphine is renally excreted, so therefore, if he's got renal impairment, yes, we shouldn't carry on the morphine, Oxycodone would be a better alternative substitution, so what you need to then do is calculate the total dose of morphine that he's on he's on 40 mg twice a day so that means he's having 80 mg in 24 hours, we need to convert the morphine dose into oxycodone and if you look at the b. N. F. Section under palliative care, there is a nice conversion chart, which I can show you guys at the end. If you need, but basically for every 10 mg of morphine, it's equivalent to 6.6 mg of oxycodone, so what you need to do is you need to find out what two thirds of 80 mg is, which is 53 mg of oxycodone, which is roughly the same as 25 mg of oxycodone twice a day. Out of the following options from the answers, 20 mg twice a day was the closest option that we had we could either have gone for 20 mg twice a day or 40 mg twice a day, I mean we know that he's already got opioid toxicity, so it's probably better for us to under dose rather than overdose and worse in his um toxicity symptoms, so therefore out of the following options out of those five giving oxycodone 20 mg twice a day would be the most suitable answer for this question and that brings us to the end of the session uh with only a few minutes past five free, rather so that's quite good, thank you very much to everyone who's stopped by till the end. If the rest of you guys who haven't left yet, can please provide some feedback for today's session, but again for all 12 sessions that we've had in the past that would be really appreciated. If anyone has any questions stick them into the chat now and we'll go through them together okay, so uh someone has asked, I can't access the interactions. Checker, will it be available in the exam. Um It's a good question so the way to the way that I access medicines complete was through Imperial, so Imperial told us that you had we had access our students, two medicines complete, and therefore we had access from the very beginning. It might depend on whether or not your university gives you access to medicines complete or not. I think you should still be able to create your own account um and if so then you should be able to access the interactions. Checker that we went through how to access the interactions. Checker at the very start of the session, so if you didn't see that, then I would recommend okay, were you here at the start, ellie, when I went through how to find the interactions, check a step by step mhm, okay, so when you type a list of medications, try this again 222 so if you want to type in these this following list and then make sure that you're selecting b. N. F, not all publications under b and f you should have this interactions. Tab can you just check to see if you still have that or not, whilst you do that, I'll answer some of the other questions. If they're Cdiff antigen positive, doesn't that mean they've had a previous infection um No, I don't think so I think it's if it's if they're Cdiff antibody positive then it might mean it means that they've had a previous infection. If they're anti, june positive well, actually, I'm not too sure off the top of my head, um I don't think so I think for for the seed of question, it was the fact that they antigen positive and they're also toxin positive, the fact that the toxin positive essentially confirms that they've got an active infection. We're not told in the questions them that they've had a previous c diff infection in the past. So, based on the fact that they've got this first time presentation of severe diarrhea and the fact that they're antigen, but also more importantly, antibody positive and toxin positive. Rather that tells us that it's more likely going to be a first infection. Obviously, if in the stem it said that they had a previous bout of diarrhea and the tree to proceed. If like eight weeks in the past, then you would assume that they've had a previous infection. If that makes sense where do we check the opioid conversion charts, So if you type palliative then you get this treatment summary here, treat prescribing in palliative care. If we scroll down. Um If you go through the palliative care session that we had there'll be a lot more detail on that, but essentially this is the chart that you should be referring to, so we can see here, we've got morphine oral, which is your base point that you should be looking at, so for every 10 mg of oral morphine, it's the same as 100 mg of codeine, so for example, if you're converting from a codeine codeine to a morphine dose, you need to figure out how much codeine they're in there, taking a total, you divide by 10 and then that will tell you how much morphine you should be prescribing. If you're going from morphine orally to morphine sub cut, then you divide it by two. If you're going from morphine orally to oxycodone orally, you can see that we have to find out two thirds of the dose. Those are probably the most important conversions that you need to be aware of so, from codeine to morphine, morphine to oxycodone and then morphine orally to morphine sub cut, but essentially this is all the equivalent dose is that they recommend in terms of um converting between opioids okay. If there are any other questions feel free to stick them in the chat, Otherwise that will bring us to um the end of the ps, a preparation course. So thank you very much to everyone who's stuck by to the end and hopefully those of you who are watching this on the recording uh Thank you very much for watching to the end. Again, if you have any other questions feel free to reach out to the Anza England pages, we have on facebook and instagram, and we also have an email as well, so reach out to those accounts. If you need any uh help or advice with your p. S. A. Other than that, thank you very much and good luck with your p. S. A. Exams and I wish you all the very best.