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and so welcome everyone to par three of our prescribing Siris. Hopefully, some of you joined us before. One part, too on. So once again it's Give me and I today, um, we'll be going through some MCQ questions for the PS PSA. As though the previous Westchester a previous days serious, we'd recommend that you get up to the N F on your computer and your calculator on your computer as well, so that we consume you ate the exam is best become, um, and yesterday we got some feedback that people wanted to kind of short on the time period. We were answering the questions, And so we'll give you a minute and a half today to give you an insecure It's It's just to try and stimulated stimulated exam a bit more, I think roughly you have a minute for the shorter questions. So if you want, if you want to try and put more pressure on yourself and maybe trying answer it in that short a time period, um and so just introduce myself. Um, I am current I, um, an F two doctor currently working oncology in London on Dull 100 TV to introduce herself I everyone? My name's EBI Mean F one doctor down in London, currently on geriatrics. Are you happy to start even? Let's go ahead. So again, just last night, we're just going to go through a series of questions. So starting with question one, we have Mrs Collins, who is a 73 year old lady who was admitted for the fall. She's a little bit confused in any shape. His dehydrated doesn't have a temperature spiked. 38.5. Unfortunately, she doesn't have a list of all her regular medications with her, and she can't recall the most over had. Her daughter thinks that she takes these medications below. So levothyroxine ramipril feroze a mind by supple oh, aspirin, Dictaphone back and center. And she was recently started on a course of antibiotics for a UTI. By her GP, her bloods are listed below um, so you could have a look at those on based on those blood results. Which of the following medications would you like to stop? So a liver thyroxin and Senna at center and diclofenac the ramipril phrase and I didn't finish See aspirin on diclofenac or d all of the above. So we'll start the poll on Do give you a minute and a half. Okay. Okay, guys. 10 seconds left. So if you're not quite answer and just try and have a guess and we'll end it. Uh, okay, on, um well done. So Theanti is be so we'd want to stop her ramipril her for a smile on her Dictaphone IQ on. But this is, um this is because when she, as we can see, hear from her crackin, I'm raising 330. She's actually in a stage three a k i. They're normal baselines under 90 on. In that instance, we'd want to stop a number of nephrotoxic medications and avoid a few that might precipitate her worsening of renal function. So in this instance, we'd want to stop 18 hip It is. So that's why I would be stopping the ramipril, which is an ace inhibitor. Um, on this is because, uh, a snap it is work by reducing the levels of angiotensin two, so they prevent the constriction of the effort arterial on. So for this reason, they decrease the hydrostatic pressure in the kidneys. That we want to stop that and then said is Well, we won't stop on this because they block the prostaglandin so which usually don't like the Afrin arterial. So they grew that reduces the blood flow to the glomerulus. Would want to stop that as well on again. She's on furosemide, a diuretic as well on a number of other medications listed here. So just take note of what you'd want to stop on. But you want to avoid in a k, I might worsen the renal function on a number of rain leaks excreted drugs that you'd want to consider possibly reducing the dose or changing the dose off. And so that's not table there. Okay, so we'll do just a school. That right? Andare passive. Karen for question number two. Okay, great. So Ms Edmunds is a lovely 66 year old lady who's comfort seeing you in a GP practice for a routine checkup. She's hypertensive with the BP 148 88 on her blood showed that she got high cholesterol with a prediabetic HBA one c um, her possible her family history is that her father died of a heart attack aged 75 and her mother had a straight cut 80 so you can't let her Q risk and you find that she's got 12% risk of cardiovascular event in the next 10 years. So you discussed starting a statin on which blood test is most important That you check in three months time and after starting at all the statin say we will launch for now. Yeah, And you have one minute, 30 seconds. That's half the time up, guys. 45 seconds left. Okay, 10 seconds. If you don't answer, just have a random guess to. This was a little bit a trick question, guys. And it's good that you will notice. LFT is a really important one starting a statin. And if they have a transaminitis of greater than three times, their baseline lft is you would stop you statin. But they specifically asked what blood tests you want to check in three months time on? If we if you go to the next slide 80. If we look at the drug monitoring off, um, patients on statins, the liver function guidance, they gave it actually slightly on the liver function. Test guidance to get a slightly unclear on it. Says repeat within three months and at 12 months, whereas the diabetic, this patient you that high risk of diabetes should have the test repeated HBA one c repeated after three months. So it was really a bit of ah nitpicky question on reading through the parameters on the be enough. But it's good that you'll know that I left and something you should check in, uh, patient starting on a statin. It's not there. Bit of a trick question there hope that makes sense. Then everyone can see why you would check at the different timeframes liver function test. You'd probably check if you're worried that they're gonna get transaminitis. You check. Wouldn't check them out. Three months. You're checking before and moving on to the next one. So question for you, we have Mrs Collins again. On this is the 73 year old lady who was admitted following a four on After bit of time. You've actually managed to get more of an accurate list of her medications from Head GP, so her list is listed below. She's on levothyroxine. Ramipril buys opera loan, aspirin, metformin, a map result. Dick prophetic Senna and Night Fear and turn to the antibiotic started for her UTI on here again of the blood that we did in an E. And so she's still a bit drowsy. So we decide to do an ABG on her just to give a bit more clarity of where possibly this drowsiness is coming from on. You have these, you know, just these results below. So have a little look at those on following those results that they just stopped there. Which medication above do we think is causing these ABG results that you can see with a halibut thyroxin be Haram approval. See her metformin d in meprazole or the the Depression? So when I'm not well, just under 1.5 minutes to answer that question can save. Hopefully you guys okay, 10 seconds left. If you're not sure, just getting an answer now can listen. So the correct answer was See, the majority got that corrected metformin on this. We conceived from her ABG as she is slightly acidotic as happy. 8 to 7.31. Have oxygen and carbon dioxide levels are within range. That doesn't seem to be causing her drowsiness on. We concede. Actually, her lactate is very raised that this is more relaxed. IQ acidosis on. But if you go onto the be enough on on metformin, one off the cautions is when it's used concomitantly with an ace inhibitor or diuretic. Um, it can cause lactic acidosis. So this is something that you really want to stop in anyone with an a k I on. I've again the table here so specifically, if they're easier, far is on the 30 but actually met for being after says to stop metformin. If if there is any instance, we're gonna keep kidney injury and as it can worsen the kidney function as well. So yeah, lax acidosis can coincide with metformin knees. Onda. I'll hand able to your question before great. So next we have. Mister Rooney was an 85 year old gentleman who's your treating for a lower, spiritually trucked infection. He's a background of atrial fibrilation, high BP and Type two diabetes. The medications usually takes a war friend 5 mg once a day, can decide in 16 mg once a day on metformin modified release. 500 mg. His eye on our target There was I not today it's 4.8 and his target range is 2 to 3 for his F Which one of the acute medications is responsible for his clotting abnormality. Is it a power settle? See, be coded C or a moth d ciprofloxacin or ondansetron. So give me a minute. And, uh okay, great, cause just 10 seconds left. If you don't, you'll just have a guest. Well, and, uh, and so lovely immaturity of you who answered that question. Correct. I think they're a few people that weren't quite sure what the answer is going to be. So we will go through that now. So the answer is D at ciprofloxacin on the question with kind of trying to get out here was your sick for 50 induces and inhibitors. If we go in the next side, we'll just discuss that. And so any drug which oxes uh huh. Sit for 50 enzyme inhibitor will cause accumulation off the third, the drug product in the blood. The only caveat to this is if the drug needs to be hypothetically metabolized before we're coming into its active fall, in which case it would be less effective. In the case of off warfarin, we know that it's metabolized by the liver. And so, by having a sip for 50 enzyme inhibitor, Immune said. More warfarin accumulating so the and I will increase. And so on a cream to remember These is a oh, devices. These are your inhibited. Remember, that's allopurinol on that result to sulfur and every three myson sodium valproate Eisen eyes it ciprofloxacin, an acute binge of alcohol on so funny mites. And so, if in doubt it some of the antibiotics to remember if yours to my son and your ciprofloxacin. And it seems like most people answer there on got the idea of the question, So that's good. Um, well, can you go on to the next room? Uh, question. Number five is missing. He was a 43 year old lady who has recently started taking Carbimazole for her fire talk sclerosis. She comes to see you a month later, complaining some hair lost soul and glands in the store throat on the context of starting carbimazole recently, what investigation should be done first, Fpc's LFTs a year in depth urine culture or tea FT's so we just want you to call. Okay, 32nd test of your own 10 seconds. If you're not sure, just have a guest now. So yeah, that was the majority that age 5% go that correct. So full blood count. It is really important in this instance on if you go into the be enough the safety important safety information under carbimazole it flags up that neutropenia in a granule. Oh, so cytosis are on complications off starting carbimazole. So it's really important. Ask the patient to report any symptoms of any sickness or feeling unwell specifically having a sore throat on if there are. And if there is any, uh, clinical evidence infection, you still white cell count. So full blood count as carbons. All can suppress the white cell count. So it's really important to do that on. If there's any indication of this, you'd want to stop that straight away. Thea other thea Other questions So lefties It is not necessarily indicated in this year and different culture. I'm gonna be very useful. In this instance, they might show signs of urine infection on fire. In fact, function tests is more actually in keeping with drug monitoring for lithium tends to be the medication that can affect the thyroid function. So that's something to bear in mind for left knee. And what drug monitoring say? Well, don't singer, she they got that right. Um okay. On your hand. Back up to parents case six. Great. So next we have Mrs Peter's. He was an 82 year old lady with metastatic breast cancer. She was started on the end of, like, pathway. So four days ago, and you record to see her to review her opiate analgesia. She's experiencing ongoing bony pain and has fine, um, in terms of her allergy to currently should take it 1 g Parsons small IV Q D s on. She's on 30 mg BD. And what if I release morphine? Um, she's not going anything prescribed p r n. So that's your job. You're gonna prescribe for something for breakthrough pain. And so what would you prescribe? Um, would you prescribe, um, the difference on morphine or more morphine or more on different doses? Same. We don't just a pole. Great. Cause 30 seconds. Nothing. And just give it a guess again. I'm sure 85 more seconds. Great. No wonder that okay, it looks like people find this question quite hard on. We'll go through the answer now. So the answer is or UM, or 10 mg to hourly. And if we go back to where we had all the options on the visa, that's all right. So if you look at options a N. C. Which is morphine and modified release, the reason we wouldn't prescribe this is breakthrough Pain. Relief is a modified release. Medication is set to work over 12 hours, which is why it's given twice a day so we can immediately discount a and see because if she's in pain in that movement, that's not going to fix the pain on answers. B, D and e alarm off. Which isn't it like an instant release medic medication. So it's onset of action will be within 20 minutes, and you expect it to peak about an hour. Um, and then if we go on to the, um, palliative slide, so on the be enough treatment summary is it kind of tells us which does sister look at. So the rule with palliative analgesia is that you add up the total amount of opiates in the day from their modified release on, but then divide it by six. So the breakthrough pain relief should be 1/10 216. But the kind of standard things that used is normally 16. If the pain relief say, this lady was on 30 mg modified release twice a day, so it will. She was taking 60 mg of morphine in the day in her regular mints, so her breakthrough dose was gonna be 10 mg of immediate release on. Do you normally prescribe it every 2 to 4 hours? Um, so it's normally prescribed two hours. I think when they give those Rangers and time range is, it can get a bit confusing. But if I'm honest, if you give a dose range to the nursing staff or a time reach, they'll go with the shortest time range of the highest dose range. Um, cause it's actually just a bit confusing to arrangement. So it's normally 16 regular dose. I've given every two allergy, and it was a bit of the trick question except combining the palette of an urge easier with, um, a bit of a drug calculation that Hey, buddy, that make sense. Everyone not having much action in the chapter of people are confused. Please do post cause I'm having a look at it. Great. Um you want to take about an expression so questions never We've got, Mister Doctor. Here is a 56 year old gentleman attending any with dark stools. And he described these particularly as dark tari stools that smell quite foul. He has recently started on a course of steroids for COPD. As he felt a bit tight chested. I had a background is listed below on his drug medications. His drug history includes lisinopril amlodipine by Sokolow Rivaroxaban prednisolone and I profin So given this any presentation that we've got him which medications might you consider stopping based on the history of us? Um, so have a little look. Is it lisinopril amlodipine rebroke stammered. Profin was up below prednisone, and I have proven rivaroxaban prednisone, rivaroxaban, prednisone. I've Britain. Well, wise up rivaroxaban on prednisone. So 30 seconds left, Everyone okay, 10 seconds. If you're not sure. Just have a guess. So, yes. Well, don't, uh, the sometimes interview that her answer D That is the correct answer. So it was a bit of a vague history, but the history does sound like he's telling us A history of Melena, which is this black tar restores. That's often and indication of an upper GI I bleed on. If we've reviewed his jock history. There are number of medications that could be precipitating this upper gi bleed. And so, uh, prednisolone and ibuprofen can both if you look on the side effects of the VNF can both increase the risk of a peptic ulcer or bleeding from the lining of the stomach s o. They might both precipitate this upper gi I bead on. He's also on rivaroxaban, which is a dose pack which is going to obviously causing deplete more s. So we would want to stop all of these to Brent. Prevent any further blood loss on DTA. Make sure to keep them stable a swell. So if you see those and you hear history like this is definitely worth stopping those medications. All right, so well done. Today's eating, like you said with the prednisolone and the and said's normally of patients are on long term on both sides. Or if they are taking high dose steroids like prednisone, you would prescribe them a PPI to stop this situation happening. That's the first thing to treat them with the high dose of pantoprazole. So in the community anyone who's taking that kind of dose of medication should be on the PPI. Uh huh. Great. So Case eight. Ms Grey and 70 year old ladies brought to a any by her daughter who's concerned that she's confused. She was seen by her GP two days ago and started on antibiotics for UTI because she had some frequency, urgency and distribute. You find that she's a fibril as a no tachycardia normal respirator, normal BP roughly on down and rest of six out of 10. So she is confused show background of rheumatoid arthritis and high BP. You review her medications, which all of them are in her drug shop. Close. It was 80 of the medicines that she's on normally, which one would you stop? And then we just launched the pope, right. We're halfway through. I got people little bit longer to answer. This one seems to be taking a bit longer to get responses in, so give you another 20 seconds. Okay, Great. Well, and the pulling that. I've seen a few questions in the chart, so I always wanted a minutes. Well, um, so I think you will find this question little bit harder and we'll go through the answer and why This is the case. But yeah, he is the correct answer. Taking 46% of you got that right. And so if we just go back to the side But all the answers on I'll talk you through what is going on. And so at the next light shows methotrexate and trimethoprim. They work on the same access they're both antifolate medications on Do you wouldn't want to give them concurrently because that could be really detrimental. We've actually seen the patient was given both at the same time and ended up with a horrible pancytopenia. As a result, on it was Big date X in the hospital. That can be very dangerous to get the babies the same time because it works too aggressively on the same policy way. The reason that you had stopped trimethoprim and not the methotrexate is that she's been long term or methotrexate. I have rheumatoid arthritis on it. It seems a rheumatoid is currently stable. We wouldn't want to change, um, anything in terms of her rheumatoid long term management because we could then initiate a flare. And that's not the current problem. There's also a lot of other antibiotics which you can treat utilize with so much safer to try her on nitrofurantoin and in terms of the other medications for in Dipro and a lot of being, we wouldn't stop because there's no issues of pressure currently on in terms of the printer pro. There's no issue that she's bradycardic, which would be another reason to stop it on the atorvastatin. She's not complaining of any myalgia, and you haven't seen a transaminitis on her. I left. You see that wouldn't be indicated to stop by there, and and so if he just goes to slides forward, fat. And so there's an interaction section on the be enough where you can look up the medication. You type one in click interaction on top, the other one in, and it would flag these up as the risk of minor suppression. Like we said, um, which have any dangerous. It can also cause the nephrotoxic steeper. The mile is depression is really quite severe, and it could be quite a long time for the counts to improve. And then let me just have a little with questions in the chat. So in terms of access to recordings. I think they go on to meddle. Um, Andi, it's being recorded. So those things going to meddle, I'm not quite sure how it normally works. The guys, if you're given a log in or have to give feedback to get the link on. But that's, um, being sorted, and I will get some clarification from Italy from that it should be the same is normal on in terms of stopping the stories. Suddenly, yes, you would never stop a dose like 30 mix of pred without weaning down on different people. Do it differently the job and one At the moment. People are often on steroids for metastatic spinal cord compression, for which they go on to 8 mg twice a day, and we don't tend to wean by 2 mg every three days. And the other thing to note with steroids is that they keep people awake because they're really lively. So if you think of your normal quarters all access, it peaks in the morning and then trends down so you don't want to give someone a steroid just before they go to sleep. Unless that unless they're having a good life for any aspirin back or you're worried that there could expect spinal cord compression is right now. Otherwise, you'd give, um, although I should give the steroids in the morning and then at lunch time. And that's how you do your split dosings for storage. You don't give them one in the morning one in the evening because it's just there. Another sleep, um, interactions on the B n f soup. We've shown the VNF the previous couple of days the online version. So how it works, is it into three sections? You've got your drugs, you got treatment. Some reason there's an interaction section. So when you talk into the VNS online down the left hand side, you should have those three options. And if you click on the interaction section, you should be able to type in one drug and then type in another drug on it should give you this screen. The interface might look slightly different on different, but what browses? Um, basically, that's clear to you. And if if we get a bit more time, it, um, we can do what we didn't finish the slides and go into the DNF and have a little look to show you I can show you where they are. I'll be great. Thanks. See? So question nine and and your ass to see a 69 year old lady who has aged fibrillations and the skin it quantities. She's on more friend with an eye on our target of 2 to 3. He's been having episodes axis the two hours. Now she's otherwise she's human dynamically stable, So her warfarin regime is 2 mg once a day, and she's also on by supper low 1.25 mg. Her bloods, taken after the abstracts have started, are listed below. So she's got a him grab 121 white cell count, turn platelets 300 then iron off of 5.8, which you can see it's at slightly outside of her range. So which of the following is best? Is the best course of action after having passing these but results about right on with this one. I'm not expecting to you to know this off the top of your head because I forget every time. So I really would rely on the be enough for this one. Yeah. Okay, 30 seconds left. Everyone, give you a bit longer. If people seem to be needing a bit on, let's look up, That's one minute, 30 seconds. But it seems that it's a lot more response is coming, and so we'll just leave it for minutes. Cup second. Sorry, no minutes before I was okay. 10 more seconds, guys. Have the guess that you have a time so well done majority of you that got the correct answer, which is a to stop warfarin and to give either vitamin K 3 mg on just two point in the direction off. Where to go on the be enough for this on the treatment summary is there is an oral anticoagulants summary which comes up with warfarin. Is one of them on? It does have have summarized in this table here, but it's got all of these listed below. It's got a lot of information sift through. But if you know where it is and you know where to look, it will speed things up on in the exam. So, following her history, she's got this episode excess, which isn't causing her to be hemodynamically unstable and actually her HPV was in wizard but within range or not, worryingly low. So we're not thinking that this is a major bleed. So on we knew her eye and I was 5.8. So as it's not over eight, we're not gonna be doing any of these. So we'll be treating her by stopping the warfarin. Well, given IV vitamin K. So 123 mg on that. This is called phyto. Never pronounce that fighter. Send a Dione. A zit comes up. I think it'll be enough there for that on D? Yes, that we'd want to give IV. Given this minor beating on you might, you might consider restarting the warfarin once the eye on our comes back under under five for that. So just to go through it quickly. So major bleeding you'd stop the warfarin, you to give IV vitamin K 5 mg on did also give a prothrombin complex or fresh frozen plasma. I think they tend to give peach tea Concentrate on preference. Frustrating cosmic. That so that might be in a surgical emergency, for example, anything if they are hemodynamically unstable. If the I know is a eight, you would stop the warfarin. You'd give IV vitamin K on. You might repeat this if the iron or remains high over 24 hours again, he'd restarted well from when the iron I was under five in Einar eight. But there's no bleeding. You'd stop the warfarin. Need to get a little NK. I think when you prescribe it, it comes up as the intravenous solution taken orally. So I think it comes up in ampules ampoules. You usually as there's a bit of a bizarre one, that they end up taking the IV solution. But really, um, Andi, you repeat again. If the iron are still raised over 24 hours on and then the same restart the war from once the iron I was under five. Um, with 5 to 8 with minor bleeding, you'd stop the warfarin, you to give it in KIC and you restart one under five on if the'yre last between five and eight. But there's no bleeding. You'd withhold one or two doses and need reduce the subsequent maintenance dose says all very complex on. I was dread seeing patient more from when they come in to hospital that there's often yet there's this clear guidance on the be enough to say that I was to remember it that if they're bleeding, you tend to give it IV or if it's our in our if they're not bleeding and it's on our five, we need to give it for me. And, yeah, so that's that was the worth noting for this In practice, you'd also probably want to take a group and save of anyone that's showing obsessed of bleeding because they could certainly become him under it down a little bit unstable and in which case you would then want to possibly consider transfusion. So it's better to be prepared in this kind of situation. Okay, and I just want to clarify. I made an error in explaining to you about stockings started. You never should stop, so it's suddenly if it's a patient who is, you know, well and stable. But in the case of someone who's having an upper GI, I bleed. You would instantly stopped the steroids and get some hydros pantoprazole because an opportunity believe mean someone's really unstable. And if they've had a small bleed and present hospital of Melena, they're likely to help like they're really high risk of having another really big bleed on. But this is something that people die off quite easily. So we wouldn't consider weaning steroids in the situation of opportunity. But normally, in any other situation, yes, you would, um, and someone answer. Ask what? The question. What? The answer was for the question. What? Which? It was a B C D o e. That was the right ones, if you want. You know, it was a sort of warfarin and give IV vision. Okay, Great. And so, Mr Bowel for 79 your Jensen presented hospital with fever and confusion. He was being treated for your sepsis. Sadly, he had a perirectal on the ward because he spiked a temperature, becomes tachycardia and hypertensive and say seems acutely septic. Um, and as a result, was going to fast. Um and so it's given a loading dose of digoxin by the Medrol. No 0.75 mg. What time should you take bloods to get up last night? Digoxin level following have been given this medication. Say we were Don't suppose now like I self with you the time. Okay, 20 seconds left. Okay. I just have a guess everyone and we'll close the pole. Okay? And not today so exactly making you got this question right six hours after dose since is another case of something you probably wouldn't know. Stop your head so well, then, everyone that obviously getting the grips of using the VNS. I'm so forget the next page, I think just screen short where you find it. Yeah, so it just says should be taken six hours after dose. Say someone asking, Where is in the B N F? So if you go under drug sections and search to Jackson under the monitoring requirements of digoxin, it it will give you this screen. And so that should should be clear and actually is quite good thing to remember, because this drug, if it's in this situation, is given in an emergency. It's a great that we give things in emergency when someone's really on well, but we just remember to monitor them. So for patients spikes and you get some gentamicin well, vancomycin or digoxin. If they're going to last a half, then it's important that we do want it to the medications that we give them on, especially as an F one next year. That will be something that you guys do a lot off is I pick up the pieces after the metric has coming. Made like a great plan that saves some was life. But you got You have to chase the stuff that make sure it doesn't become dangerous later on. And great. So nearly that's the principle question. So we've got Mister Singh, who is a 65 year old gentleman with type two diabetes. His diabetes was initially managed with metformin alone. However, for in persistently high B m's, the GP is added in glipizide 40 mg once a day, too. With medications. What should be told the patient prior to starting glipizide. And that's good. Okay, sorry. Let me get a little thanks. Thank you. On 30 seconds after room. Okay. Five seconds. If you're not sure. Just have a guest. No, me and, uh Okay, Yeah, Well done. That is the craft Answer. Ready. So you need to count them. They might experience hypoglycemic episodes, and then you're eating regular meals, so you need to make them aware of hotter. Look out for those signs. Hyperglycemia. And how do you have long acting carbohydrates on, But then I'll just go through the rest of the answers, so B is incorrect. that doesn't apply to Glipizide. Actually, that's more in keeping with starting one high dose steroid, for example, as we talked about earlier, um, again, See is incorrect. That's referring to metformin. So yes, he is already on metformin, so that probably hopefully would've been counseled when he started that d. So it's not a contraindication to driving, however, drivers on it, because I need to be particularly aware of the fact they might be having this high. Please. These hypoglycemic episodes on if they are unable to control these are progressing or capsules. We might have to consider starting another undertow best medication and on day on day. So sorry I forgot to explain that Click Reside is a cellphone urea, which expert actually increasing in silence secretion, which is why you end up getting these hypos more often on Also, if that's for this reason, that is incorrect. You're actually more likely to gain weight while you're on them because it increases the insulin secretion so more likely to absorb glucose on their four put on weight. So you might not consider this the patients with high B M I who were trying to lose weight. Okay, great guys last question on We're just trying to find your feedback. Think so? Just that with us in terms of the feedback. I'm sorry on your one of you has to go, we can always send out. I don't know if they could send out. In retrospect, all poster on line if you need to really leave, um, case 12. Mrs Mafia is admitted time with preeclampsia. She started two weeks pregnant with her second child. She's convinced on the beautiful 20 mg an hour for the 1st 30 minutes to be till comes in 100 mg. Her 20 mil ampules, the albuterol need to be diluted toe 1 mg with 5% glucose. How many male of 5% glucose it should the labetalol be added to So another one of our lovely calculation questions. And get your pen and paper out on. We will redo the whole, give you guys a bit longer. This question because it is quite hard. But we don't worry. We'll get you the answer and you have is asking where the calculator is. You try using the one on your computer because the one in the PS PSA is quite punky calculator It's not like your phone one, and so just have a good deal. Computer. Yeah, they want their companies. It's most close to the one in the exam would be your computer calculator. It's That's two minutes. I'll give you guys in other minutes so that people can really give it a good stuff. Okay, guys, 15 seconds. If you're not sure how the guess we'll go through how to work yourself travel and the and great. So it was very mixed, uh, opinion there. So we'll go to the answer. Everything go to the next slide. And so we are given an ampule of 100 mg and 20 mils and were told that we have a target concentration of 1 mg in one milk. So to make the labetalol, which is a fixed dose of 100 mg into the concentration of 1 mg a mill, we need to make sure that the fluid it's diluted in is 100 mils. So we're not changing anything to do with the dose of the beetle. That's a fixed ampules. If you think of the, um, for your pickup and from the drugs covered, you're not gonna change the amount of insulin that all we're changing is what we're adding it to. So we need to make it so it's 100 mg in 100 mils. We know that there's already 20 mil in the ampule, so that volume is already gone. And so you take 20 mils. We're trying to make 100 miles to get it to 100 mils with 100 mics in. So we take off the 20 mils that we know is in the ampule. And that leaves us with age males to want to give, want to get the little on 80 mcg mills of five single you guys, that's he was in the checks. People get confused about these questions. Uh, some of that may be looking great. Does anyone will give you again? Does that make sense? So what fixed dose off the albuterol on. It's in a 20 mil ampule. We want to make the concentration toe one mega mill, and we know that the dose we have is 100 mics in 20 mils, so we need to make it up to a concentration. We usually go up to a volume of 100 mils and to do that we already have 20 mils, so they're remaining amount of fluid to get it. $200 is 80. Did I sensories coming out for me? Straight again? Yeah, it says that. That's exactly it. So we've got a target amount to make it The concentration we need, which is 100. We know it comes in 29 on pure. So you take that off on that equals 80. Cool. Okay, great guys. The Caucasian one's a bit weird, but I want to get your head around them. I think that you quite easy marks because it's maths. And you just, you know, if the answer there you go to, right? Pretty much, um, anyone get any questions from stuff here today or everyone's girlfriend? Have some dinner if you want. We can quickly. I'm happy to exit and just show you right from the interactions are great on. Be enough and, well, okay. So tomorrow, when the IV and I got because we're both on call, so and it will be really on be might be getting Someone has to step in because one of the doctors there is a doctor sign. Of course, isn't going to make it on, but we'll have another session tomorrow. I don't Friday and it will be exactly the same way that was this. Covering similar content and just giving you guys a chance to practice the exam again. As we've said, it does come understandably different format. When you're looking at it, that just a top here. Just like we found the treatment summaries yesterday. You could go onto interactions on. So, uh, I think it might be a little bit easier than using this one on your phone. You can type in two at once on, but you can click for example, back today, Onda unfortunately, probably have to scroll down through all of the different drugs here. But it will come up with these big red boxes of what you shouldn't prescribe it in and what it might be allowed in. But you must be aware of the risk of, for example, hypokalemia. So the red boxes don't describe them together, and the drug only flags up on the drop down down the side. If there is an interactions, if you pass a a the drug, you know it wasn't a on You can't see the drug. You're looking for, then you're fine. Yeah, Exactly. Yeah, great. Thanks, everyone. And it was placed in the link to the feedback, which is on the Facebook. Thinks don't have currently the other things. So if you just have a look on there and fill out, that would be great. I've been really nice teaching you guys would last three days. I hope it's been helpful. I'm really good luck with your exam. Okay? It will be great. Yeah. Yeah. Enjoy the rest of sessions in the next couple of nights. It's been really fun teaching you guys. So good luck with your vision goes off. Okay. All right. And even sense. But we'll help you. Uh, your uncle's cheap out a couple of days of sure it will be gone. I'm right. I'm gonna get something to go get something. Enjoy the ski trip. Yes. Enjoy. On a day to ride by, everyone