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Bye. Yeah. Can anybody everybody hear me? Ok, sorry about this. Ok, so that's a bit better. Hi, sorry about that. Having some technical difficulties here. Um Sorry about that. Um So I was just saying my name is Tara. Um I'm currently working as a resident medical officer over in Perth, in Western Australia. And I'm here tonight um presenting our final part of the PSA series uh for the 6 p.m. series. Um So tonight, I'm just gonna be covering just the last three sections um of the PSA that we haven't talked about yet. So gonna do a bit on uh planning management, a bit on providing information to patients and then gonna do some calculations so I could sit here and talk for ages and ages and ages about all the different types of questions and everything that they could possibly throw at you, but we don't have time for all that. So what I'm going to do tonight is I've got, I've got some practice questions. I'm going to try and highlight what I think are some key concepts when it comes to doing the PSA and just to make sure that you're aware of certain parts of the B NF, um which I think are going to be really useful when you're doing the exam. So I'm sure at this point, um, you've realized that there's eight different sections to the P SA. So the ones we're gonna be doing looking at tonight are section three, section four, section five. And look, the most important thing about the P SA is, don't forget you have this great resource that you can use. You have the B NF. So it's, it's open book essentially. Now, I know that doesn't it, it's an exam. Look, exams are always going to be stressful. But remember you do, there is help there and the information is there, you just have to maybe know where to look for it. So hopefully that's gonna be something that I'm gonna be able to show you tonight. Um OK. So, uh without further ado uh we'll start, um we're gonna start with section free. So section free is all about planning and management. So essentially you're gonna get asked eight questions. Each one of the questions is gonna be worth about two marks and you're gonna be given a list of five different options. All they want to do is they just want to see that you are going to be safe, that you're going to choose. What's the most appropriate management for the given scenario. So what sort of scenarios can they brought you? It can be all sorts of things from managing pain. Can you follow sort of the wh o pain ladders as starting off basic like paracetamol, then moving up to your anti-inflammatories, then your weak opioids. Um Somebody who's maybe newly diagnosed with diabetes, anticoagulation, people are in hospital like DVT prophylaxis, people who are on warfarin, um antibiotics, things like that. Um So things that you need to have in the back of your head when you're thinking about planning management for somebody is, I suppose, what state of illness are they in? How bad is their illness? Like if they have, if they have hypertension, is it at the point that it's really bad? It's like 100 and 80 systolic, they're symptomatic, they need to go to the Ed or is it something that the GP can manage that they can just start them on some tablets? Other things to think about. Is there any contraindications? Is this, is this a pregnant lady and you don't want to give her anything that's going to be potentially teratogenic? These are all just things to think about in the back of your mind. Um Also just to be aware of, look, sometimes the answer is that we don't need to give them any medication, things could be managed through lifestyle changes. And there's also there's a whole ream of non pharmacological therapies that, that can also be used in different scenarios. So without further ado nothing me yapping, um we're going to go on and start off with our first question. So I have some polls, um, which are hopefully going to work. Um, so, look, um, we'll go for, we'll try these questions. I'm gonna, I'll give you about, about a minute or so. Um, to have a go, I actually, this first poll is not, I don't think it's going to work. I've tried fixing it and it's not, it's not working for me. But anyway, look, I'll let you have a read of the question and I'll give you the minute you can open up the B NF. You can go through, have a look, pretend this is a real exam and go and see if you can find the information that you're looking for. So this is a 72 year old lady. She's come to her GP, she's hypertensive. Um, she's got average daytime BP of about 100 and 58 systolic background of osteoarthritis. She just takes some Panadol doesn't really drink or smoke exam is otherwise unremarkable. So what is the most appropriate medication to start her on at this point? So, look, I'll give you some minute to have a little look and see what you come up with? OK. So I think that's been about a minute or so. So the right answer is option number one amLODIPine. So I'm just gonna explain where this answer comes from. So essentially what they're asking you in this question is. Do you know what this is? So, let me see if probably make this bigger might help. Um So this is the nice guidelines when it comes to managing uh to managing hypertension. So this lady, she's elderly, she's over the age of 65. So that's going to put her down here. I don't know if you can see my mouth or not, but this is gonna put her down in to, she needs to be started on a calcium channel blocker. There's nothing in the history that suggests that she has any sort of hypertensive urgency. She's no headache. There's no mention of any papilledema or anything she doesn't need to go to hospital. This is something the GP can manage. She's not on any antihypertensives at the moment. Um And she's had an ambulatory BP that's been done. We know her blood, she is hypertensive throughout the day. Um And because she's over 55 we can start him on a calcium channel blocker. So the only calcium channel blocker, sorry, the appropriate calcium channel blocker in that list there is amLODIPine. So what we can do is look if you can't remember what the, you know, what's the appropriate management of hypertension. If you can't remember this nice little diagram, I just want to show you that there is so much information in the B NF. So now mine might look a little different because I'm accessing this from Australia. But essentially, if you go into the B NF, you can type in, you can just type in hypertension. It has all this information for loads and loads of different common conditions and presentations. So if you type hypertension into the BNF, you get a whole pile of information, had to assess them non pharma management, all the different treatment thresholds. At what point do we start treating BP? What targets are we aiming for? And then it goes on to drugs are available to treat um to treat hypertension. And if you scroll down through it, it comes up, it's all that same information that is just in that lovely diagram there, but it's all just in word form. And if we scroll down here, we can see that for patients over the age of 55 they should be started on a calcium channel blocker. If that doesn't work, then we can start them on an ace inhibitor and ARB and so on and so on. Um So that's all I wanted to show you essentially is that just look, even if you can't remember what a treatment algorithm is. That information is in the B NF if you just, if you just go looking for it. So um next question, I think there's a poll for this one if it'll work. But as you've seen my technology skills are somewhat limited. Um but we'll give this a go. Um So let's see. OK, there we go. So question two. So this is 22 year old lady. She's gone into her GP, she's been complaining of some dysuria. She's about six months pregnant. No, past medical history. Not on any regular meds, no allergies. She's just got a bit of suprapubic tenderness. She's a voice. Ok. Your analysis is positive though. So, what is the most appropriate antibiotic to start her on? So, I'll let you all go and you can go and have a little look at the BNF again and, uh, see what you think and if you want to um vote in the poll as well and then we can see, see what people are thinking. OK. So I think that's about enough time. OK. So let's have a look at the pole. All right. So most of you have gone for option number four nitro and to for seven days and let's have a little look and that is the correct answer. Um So well done for everybody who got that. So I'm just gonna go through for it just to explain it. So this lady's pregnant and she's come in with what sounds like a uti. So if we go to the B NF, we can just type in urinary tract infections, it comes up and it gives us what the most appropriate antibiotic is to give if it's a man, if it's a nonpregnant female, if it's a pregnant woman, if they have recurrent uti S, et cetera, et cetera. So if we scroll down, have a look at pregnant women, so the first line option is nitrofur and tone. So the next question then becomes, well, how long are we going to give it for? So if we go into the um summary for nitrofur and to, and we can scroll down, it has all the different indications and different doses. And if we scroll down here and we can see down at the bottom nitrofurantoin for an adult 50 mg four times a day for three days. Or this is the important med brackets seven days if it's a man or a pregnant woman. So that's why option number four is the correct option, the nitrofurantoin for a week. Um And just to go through. So if we go back to this, so, amoxicillin is a second line, um second line option if there's no improvement after 48 hours. Um and then if we go down the reason trimethoprim isn't. So trimeprimine, those doses were male and female. But the reason why we can't give trimera is because it is uh it is teratogenic and you're supposed to avoid it during pregnancy. So, OK, moving on, we have another question. So this is gentleman. He's come in for three day history, cough fever, known CO PD. He's low grade tachycardia. His BP is 89 systolic. He's a bit CPN based on room air and he's afebrile at the moment. So the next question is what is the best fluids to give him? So I think we have another poll here if I can set this up and, um, you can all go and have a look and see what you think. Yeah. No. No. Oh, sorry. Uh, that should be the powerpoint back up there. Ok. I'll give you another few seconds and then we'll see. And just for the person who was asking there about, uh, about nitrofurantoin. Um, so Nitrofurantoin is the first line for a UTI in pregnancy. Um, It's safe to give in pregnancy up until they, they just say in the BNF just to avoid it around term because there's potential of um hemolytic reaction. Um But it's, it, other than that, it's very safe in pregnancy. It's the first time option. We'd only give the amoxicillin if they weren't responding to the nitrofurantoin after 48 hours. Um So the answer is it's, it's still going to be nitrofur to for a week. Um ok. Um I'll come back to some of these other questions in a minute. Um And so I'm just gonna see what the pole has come up. OK. So most of you have gone for the first one. So we're gonna give him just um just to start bolus of normal saline over 15 minutes and that is the correct option. Um So just to go through this, this is nice to have this lovely um flow diagram as well when it comes to fluid management. So when we had a look at his abs, he's got low grade tachycardia. His BP is 89 systolic. Um So he's, he's probably a li a li a little bit septic. So what they, um what they advised doing in that point is just to give a fluid bouse initially. So he's kind of an algorithm too, but he needs, he needs to have a fluid bo he needs to be fluid resuscitated. Um Other questions that they can ask you about um in the PSA is more to do with maintenance fluids. And if we look down here at the bottom, I'm not really going to touch on this too much, but when you're charting somebody maintenance fluids, it's just important to think. Are they meeting all of these requirements? So for an adult, they should be getting like 25 to 30 mils per kilo of water a day. Um making sure that they're getting one minimal per kilo per day of potassium. And are they also meeting their sugars? So there's not gonna be one fluid that's gonna be perfect. That's going to give somebody all of these, the potassium, the sugar everything. So they're gonna have to end up getting a little bit of this and a little bit of that. But the important thing to just think about is just make sure that are you meeting their electrolytes, are you meeting, meeting their fluid intake? But I'm not, I'm not going to dwell too much on that. Um Just in the B NF as well. They have, if you, if you go down, if you just type in fluids, they have a list of um what electrolytes and everything is in all the, all the different fluids from normal Saline Harmans, everything. Um So you can have a look at that when you're looking at prescribing fluids. Um ok, so next one, we're gonna move on to then is section four providing information. Um I'll come back to some of those other questions just at the end or when you guys are um looking up your answers for the next questions. Um So the section four it is the next one we're going to touch on briefly is all about providing information. So it's only six questions this time. Again, two marks each. So what they want to see here is that you're able to focus on what is the key piece of information to give to the patient here. What piece of information is going to allow the patient to make an informed decision and what i it's also very important. What bits of information are, are you going to give them that's going to ensure that the patient is going to be safe and that the medication you're giving them is going to be as effective as it can be. So, things that they tend to ask about in this tends to be things like or hypoglycemics, antipsychotics. Again, anticoagulations keeps coming up, things to think about in this story is, what is the patient's demographic? Is this um is this a female of childbearing age and you're going to start them on um on antiepileptics? Do they want to have a family? This is things to think about other things is, are they already on some preexisting medication that's going to potentially interact with whatever you want to prescribe them? Um So those are just things to think about. Um So we'll move on now, we have another question. Um So this is a young man. He's come in, he's going to be started on cloZAPine for schizophrenia. He's already been trialed on two different antipsychotics. Hasn't, hasn't had any great effect for him. So he's now been started on cloZAPine. So what's the most important information to give this young man who is starting on cloZAPine? So I'll see if I can get a poll up here. Mm Sorry. I'm just seeing that there. I'm not sure if you guys can see the powerpoint, I'll try and there that should be it back there. Now, I'm not sure why it disappeared. Sorry about that. OK. I'll give you a few more seconds. OK. So I think that's bad enough. OK. So most of you have gone for a that cause the pain can cause agranulocytosis and that's the correct answer. So, in this question, I suppose what we're thinking about is what from a safety point of view, what it is, something that's very important to tell the patient and that granulocytosis is something that can potentially be fatal. So that's something that's really important to highlight to the patient. It's similar to if um somebody has been started on the oral contraceptive pill, it's important to highlight the fact that, you know, if they have pain in their calves, that they should seek medical attention because the contraceptive pill um has this propensity to cause um to cause DVTs to cause PE es. But that's just something to make sure that the patient is aware of. So similarly enough with a cosine, cloZAPine can cause agranulocytosis. So that's obviously a big safety issue. So that's something that's very important to highlight with the patient if we also go through the other, the other options. So we search cspine on the B NF. So we can see here that from the start um in the BNF, they have like a nice little box and it says like important safety information. And so here this is about um blood monitoring for cloZAPine. And here um the first one is that um smoking does have an effect on cloZAPine levels. So if somebody stops smoking, we start taking Ecigarettes said that we need to check their levels again. Um Again, this is just a bit uh just to highlight to you that if you scroll down through the B NF, you'll find lots of this information. So monitoring requirements. So here we can see that needs to check the levels at the start, then at six months, then yearly. Um other things, then we can go down to side effects. So we can see it can cause um arrhythmias. All sorts of different things can cause agranulocytosis which is important um because that happens um it can, it, it, it ca it um can cause a lot of issues. Um ok, so next question we have um we have um this 84 year old lady, she has unfortunately been diagnosed with osteoporosis by her GP. She currently takes a bit of amLODIPine atorvastatin, some calcium supplements and her GP wants to start her on Alendronate. So what is the most important information to tell this lovely 84 year old lady who's going to be starting on Alendronate? No. Ok. Give you a few more seconds. Ok, so that'll do. Ok. So most of you have gone with the option that she should take her calcium supplement at 30 minutes before Alendronate. And that would be correct. Um So with this question because she's on calcium supplements, calcium supplements can affect the absorption of alendronate. So lots of different things can affect the absorption of bisphosphonate. That's why it's really important when patients take bisphosphate, they need to have it on an empty stomach. Um at least like half an hour before breakfast or any other oral medications they need to then make sure that they're sitting up afterwards that they're drinking plenty of water. Um, they even say sometimes for the calcium supplements to even wait nearly four hours. But at, at least as long as it's at least half an hour. So if we go and look at um alendronic acid on the BNF, we can have a look at the, they have a whole page and all different interactions and it goes down for there's loads and loads and loads of them. Um And we can see there's loads of different calcium supplements, but essentially all of them should be taken at least half an hour um after the, after the alendronate because they can interfere with their, with its absorption. Um So just to go back as well, I think somebody had asked about denosumab. So that's a look, that's a really good point. So denosumab is um is really useful because it can be used in renal impairment. So look in reality GP would definitely um check renal function. Um Make sure that her renal function is OK, that she's going to be able to tolerate the allen draw, not other things like you'd probably um need to talk about, tell her about, you know, the risk of um osteonecrosis of the jaw, the risk of um fragility fractures and all. Um again, this is all stuff you do in real life. This is just a very limited question. You just sort of have to go with what you're given in the brief and in this case, we're going to give her for whatever reason we're going to give her Alendronate instead of denosumab. Um So yeah, it's just gonna, it's just asking you about this phosphonates and just trying to see, do you know about this potential interaction? But yeah, look very fair point. In reality, we'll check your renal function and go from there. Um OK. So next question we have. So this 60 year old man, he's coming to his GP, he's complaining some thirst, some polyurea and he's had his HBA1C tested. And unfortunately for him, he is now been diagnosed with type two diabetes and we're going to start him on glipiZIDE. So what is the most important thing to tell this 60 year old gentleman? Ok, a few more seconds. Ok. So the answer for this one is that gliclazide can cause hypoglycemia. So that's really important to tell him, uh, to make sure that he knows what to do if he does potentially become hypoglycemic to make sure that he knows to, you know, take a sugary drink, take some fast acting carbs. Um, and to make sure as well he's aware, he's aware of the symptoms and that the, this is something that, um, the glycoside can potentially cause. So they do like asking about these oral hypoglycemic agents. Um They can ask you stuff about like which ones have the potential to cause hyperglycemia? That's something that's common. Um Another thing to know is which ones are weight neutral, which ones, um can potentially cause weight gain. So, Glipizides unfortunately can cause both hyperglycemia and weight gain. Um um sorry, I should have had a slide um in about all the or, or a hyperglycemic, but that's really something, something I would definitely advise just having, having a quick look and just having a rough idea which ones can cause hyperglycemia and whether or not they can cause weight gain, weight loss or if they're weight neutral. Um because those tend to be the types of questions we like to ask about. Um But anyway, we'll move on because this is one I think can cau a section that I think can cause quite a bit of stress to a lot of people calculations. So look, you're only given, you're given six questions again, like all these other questions that I've talked about, they're the, they're still just worth two marks. So look, I know that they can sometimes cause a lot of stress. But at the end of the day, there's only six questions, they're only worth two marks each. So if you're doing really well in all the other sections, it's OK that the calculations, you know, maybe don't go as well. But I'm gonna try, I've got quite a few examples in this and I'm gonna try and break them down so you can see sort of how we're getting the answers um and try and give you the skills that, you know, if you come across something similar, you know, how to approach it, how to go through it. So, the kinds of calculations that they get you to do are calculating a dose of medication. Often it's Children because a lot of medications for Children are often based on, based on weight. Other things that they like to get you to calculate is the rate of the medications, the rate of the infusion, um, or something like that. Um, so look, we'll, we'll go for it. I have a few examples. Um There's no poll for these. Um I like I'll give you a little bit of time. You can see what answers you come up with and then I'll go for it and I'll try and explain where we're getting the answers from. OK. So first question, we have the five year old girl, she's coming to Rheumatology Clinic. She has this stiff swollen knee, her elbows are sore, she's got pains everywhere. She's a bit of a fever, a bit of a rash, a bit of lymphadenopathy and she has now been diagnosed with systemic juvenile arthritis. So the plan from the rheumatologist is they want to start her on Ibuprofen, 60 mg per kilograms a day and that's going to be, so that's 60 mg per kilo per day and that's going to be divided up into four f four doses. Um And Ibuprofen is available as this oral solution which contains 100 mg per five mil. So how much of this liquid Ibuprofen solution does she need to take per dose? So I'll give you guys, I'll give you guys a minute or two and I'll go for the answer then. Ok? I'll give you a few more seconds. Ok? So look, let's go for the answer and see how you are getting on. OK? So there, there's a couple, there's a couple of important pieces of information in this question. So first of all, the rheumatologist wants to give her 60 mg per kilo a day of Ibuprofen. So she, we have her weight there. It's 18 kg and they want to give that whole dose of Ibuprofen. They want to divide that up into four smaller doses. So she gets it four times a day. So when we go through this, there's a couple of things that we need to calculate. First of all, we need to calculate what is the total amount of Ibuprofen that we need to give her per day. We then need to divide that by four because they want to give that whole big dose, split it up into four smaller doses. So we need to then once we have that calculated, we then need to calculate how many mils of this liquid Ibuprofen do we need to give this girl? So calculating the total dose of the Ibuprofen. So they want to give 60 mg per kilo per day. So she weighs 18 kg. So 60 by 80 is 0 1080 mg. So that's the whole dose of Ibuprofen for the full day. They then want to divide that into four smaller doses. So we divide that by four, we get 270 mils milligrams. So she's gonna get 270 mg of Ibuprofen four times a day. And that adds up to this 1080 mg total. The next thing we need to do is that's how many milligrams we want to give her. But we don't have tablets sitting here, we have this liquid liquid solution sitting there and the concentration of this solution is 100 mg per five mil. So the way that I think about it, this is just the way my brain works. I don't know if this has helpful or not, but when it comes to calculating these sort of things, II go for it in a stepwise approach. So I think, well, there's 100 mg in five mils. So I want to know how many milligrams is there in one single M. So if we divide that by five, we've divided five by five to get one. So if we divide 100 by five, we get 20. So there's 20 mg in one mil at this solution. So now we want to figure out, well, how many mils do we need to give her in order to give her 270 mg? So what do we do to 20 to get it to, to, to get 270 we multiply it by 13.5. So if we multiply one by 13.5 we get 13.5. So look, that's maybe a little bit confusing. I don't know if that's helpful or not. The other way of looking at it is just 270 mg. If we divide that by 100 and then multi five by five, we get the same answer. But whatever whatev whatever works for you. Um So hopefully that makes that makes some sense. So we're calculating the whole dose of the Ibuprofen, we're dividing it by four cos they want to give it in four small doses. And then we want to figure out how many mils of the solution that we need to give her in order to give her 270 mg and we've gone through that. So hopefully that makes good sense. So with all these questions, just try and break it down into smaller steps. What do I need to do first? And hopefully, then it won't be, it won't be as, as daunting. So the next question we have is we have this 10 year old boy on the children's board and we're gonna give him some maintenance food, gonna give him a bit of saline, bit of glucose, a bit of potassium and we have his weight there and they've calculated this maintenance fluid using this. Sorry. That's an awful spelling. But anyway, the holiday Segar formula. So 100 mils per kilo for the 1st 10 kg and then plus 50 mils per kilo for each, each kilogram, he weighs between 11 and 20 kg. And I, you can read that there anyway. Um, so I'm laboring the point but essentially what rate should we, um, set his pump out to give his fluids over 24 hours. So it's a bit complicated. But I'll let you have, I'll give you a bit of time and then we'll go for it. Ok? Give you a little bit longer. Ok. So look, we'll go for this. This is a bit complicated. So what are the key pieces of information we've been given? So we've been given a weight, he weighs 32 kg and we have this, it's a bit complicated formula that they want us to use. So look, we'll go, we'll go for it bit by bit. So first of all, we want to calculate what is the total volume of fluids that this boy needs to have? Then in order to calculate the rate or how fast we need to give it. We need to, we need to figure out how to give this volume over 24 hours. So if we start off by calculating what is the total amount of fluids we need to give him. So we know that this child weighs 32 kg. And according to that algorithm, we need to give him 100 mils per kilo for the 1st 10 kg that he weighs. So 100 by 10 gives us 1000 mL as per that formula. Then for every kilo, he weighs between 11 and 20 he needs to be given 50 mils per kilogram. So 50 mils per kilo for that extra 10 kg he has between 10 and 20. So that gives us 500 mils. Then for every kilo, he weighs over 20 kg, he needs to get another 20 mils per kilo. So 20 to 32 is 12 kg. He's 12 kg over 20. So 20 by 12 gives us 240. So if we add up all of those numbers, we can see that the total amount of fluids, maintenance fluids that this boy needs in a 24 hour period is 1740. So then they want us to calculate how fast do we need to give this? So he needs 1740 mils per 24 hour period. So if we divide 1740 by 24 he needs to be getting 72.5 mL every hour. So we've calculated the total volume of fluids he needs to get. So because he weighs 32 kg, that 1st 10 kg, he gets 100 mils per kilogram. For that 2nd 10 kg, he gets 50 mils per 1050 mils per kilogram. And for that remaining 12 kg, he gets 20 mils per kilogram and all that adds up to 1740. So that's the total amount of fluids he needs per day in a tw in a 24 hour period. So we want to figure out how many mils does he need to get every hour. So we're dividing that number by 24 and that's how we got the 72.5. So I'm just gonna go back for a second. Cos I think some people I'd like you to take that in. I'm gonna go back briefly. Cos I think some people were a little bit confused how we got to 13.5 for that last question. So that last question was to remind you the girl in the Rheumatology clinic who's gonna be started on Ibuprofen. So we want to calculate what is the total dose of ibuprofen she gets per day. They want to give her 60 mg per kilogram every day. So 60 by 18 is 1080 in the vinaigrette. They've said that they want to give that total dose of ibuprofen split into four daily divided doses. So that total big dose, they want to to be divided into four smaller doses. So we're gonna divide about 1080 by four and that gives us 270 mg. I think the bit that's maybe causing confusion is this whole liquid solution business. So we know that the concentration of the liquid Ibuprofen is that there is 100 mgs in every 5 mL. So we want to know how many MGS is there in just 1 mL. So if we divide 100 by five, we get 20 mgs. So for every one m of solution, there is 2020 little mgs of Ibuprofen sitting in there. So we want to know how many little mill little milliliters are there. Do we need to get 270 mg of Ibuprofen? So if we divide 270 by 20 we find that there's 13.5. So if you do it the other way, this is confusing you. So there's 20 mg in one mil. If we multiply 20 by 13, we get a total of 270 mg. So hopefully, that makes a bit more sense. Hopefully. Um just before we move on, I'm just going to check and see if anyone's put anything in the chart just about that last fluid question. You don't have the slides anymore. OK. I'm very sorry. I don't know. I don't know why this keeps cutting out. Um I'll bring I'll put them up again. Sorry about this. OK? That should be the slides back. So look, I'll run through, I'll run through that fluid one again, very quickly. Very sorry. So just for that fluid one again, what we did was he weighs 32 kg. So we were giving him 100 mils per kilo for the 1st 10 kg because the 2nd 10 kg then he gets 50 mils per kilo. And for that 12 kg cos 2032 20 to 32 is 12. So 20 mils per kilo times 12 is 240. So that gives us a total that he needs about 1700 odd mils in 24 hours. So we want to find out how many mils do we give him in one hour? So we divide that number by 24 and that's where we got the 72.5. Ok. I'm gonna move on or not. My computer's frozen. There we go. Ok. So next question, we have a 45 year old gentleman. He's come into Ed with Wheeze and angioedema after accidentally he had some pesto which contained pine nuts. And unfortunately for him, he is allergic to pine nuts. He has anaphylactic reactions when he takes pine nuts. So they've go, they're going to give him naught 0.5. Sorry, that should be naught. 0.5 mL. Sorry, naught 0.5 mL of one in 1000 adrenaline. I am. So he gets naught 0.5. That should be milliliters of this one in 1000 adrenaline. So how many milligrams of adrenaline have we given him? Ok, give you a few more seconds. Ok. So to go through this one, so this gentleman is given naught 0.5 mL that should be of one in 1000 adrenaline. So we want to know how many milligrams of adrenaline is that? So, I it's, it is very stupid. This whole notion of one in 1000 adrenaline. It's very confusing but essentially, sorry, my computer is frozen. Um Essentially what one in 1000 adrenaline is. It means that there is 1 g of adrenaline for. Sorry, I'm gonna wait a minute and see if my computer decides to move. I'm very sorry about all these technical difficulties tonight. Um I'm gonna try to stop sharing for a second to see if this works. Ok. Ok. I'm gonna share my screen again. Very sorry about this. Uh OK, there we go. Sorry now. Ok. So he has naught 0.5 M uh naught 0.5 mL of one in 1000 adrenaline. So what one in 1000 adren one in 1000 adrenaline means that there's 1 g of adrenaline diluted in 1000 mL of solution. So another way of looking at that is that there's 1000 mg in 1000 mL of solution or to simplify that even further. There is 1 mg of adrenaline in every milliliter of solution. So this gentleman has been given half a milliliter of adrenaline. So if there's 1 mg in 1 mL of solution and he's been given half a milliliter of solution, there is going to be naught 0.5 mg. So the answer is naught 0.5 mg. So how we got there again? One in 1000 adrenaline means there's 1 g of adrenaline diluted in a liter of solution. Another way of looking at that is 1000 mg in 1000 mL of solution, which to simplify it even further 1 mg per milliliter. So if he's been given half a milliliter of solution, that's the equivalent of naught 0.5 mg. So the answer is naught 0.5 mg. So hopefully that makes sense. Yeah. So naught 0.5 mg is the same as 500 mcg. So yes, that's right. Um I'm gonna try, I'll try putting, sending that feedback. Oh, I'm sorry for the person who was looking for that. So hopefully that makes sense. So I think just I think we just have one more question after this. So just another thing that I just wanted just to highlight um is just when it comes to local anesthetic. So local anesthetic like lidocaine, you often you get 1% lidocaine, you can get 2% lidocaine. What that means is that there's 1 g of lidocaine in 100 mils of solution. So 1 1% lidocaine is the equivalent of 1 g lidocaine in 100 mils of solution. So this can all just get a bit complicated, but that's just something just to bear at the back of your mind. So I think this is the last question now. So this question is to do with opioid analgesia. Um So what you might often have to do is you might be asked um to um calculate somebody's break for analgesia um or to switch between different um different doses of different opioids. So this question, we have a 77 year old gentleman. He's got, unfortunately, got metastatic lung cancer and he needs some break for analgesia. So he's currently on paracetamol codeine, uh two tablets, four times a day as well as morphine sulfate tablets, 10 mg, three times a day. So how much breakthrough analgesia should we get? And we're gonna be using mor morphine sulfate tablets just for his breakthrough analgesia. So I'll give you a bit of time going to give you a few more seconds. Ok? So key things, this gentleman is on uh paracetamol codeine and he's also on morphine sulfate tablets. So in order to calculate his breakthrough analgesia, we need to calculate how, how much morphine is this gentleman getting in total every day. So we need to calculate his total amount of morphine that he's getting every day. And if we look, if you just type in palliative care or type in opioids into the DF, they have a whole big section on it. So here we can see the break for analgesia. If you're not sure what it is, it should be essentially about 1/6 of the total amount of morphine that they're getting per day. Um They also the B NFS. Great. It has this whole big table of all the different conversions between all of the different opioid analgesia. It also even has the different conversions if you're going to be starting them on a syringe driver as well. So if we go back to our question to this gentleman, um he's getting essentially eight tablets which each contain 30 mg of codeine. So codeine is metabolized into um into morphine. So we need to calculate how much morphine is he getting from that? Those code, those tablets that contain codeine. So from our table in the B NF, we can see that 100 mg of codeine is the equivalent of 10 mg of morphine. So he's getting 30 by eight is 240. So he's getting 240 mg of codeine every day. So what how much morphine is he getting? So if 100 mg of codeine is the same as 10 mg of morphine, 240 mg of codeine is gonna be the same as 24 mg of morphine. So we now need to Calcate what is his total morphine intake? How much morphine is he taking every day? So he's getting 24 mg of morphine from the codeine and he's also taking free 10 mg tablets of morphine sulfate. So that gives us a total amount of morphine that he is getting every day of 54 mg. And when we went to look at the B NF, we saw that your break for analgesia should be about 1/6 of the total amount of morphine you're getting every day. So if we divide 54 by six, we get 9 mg. So his breakthrough analgesia is going to be 9 mg of morphine of those morphine sulfate tablets. So to go over that again, we first of all, we need to calculate his the total amount of morphine that he's getting every day. So he's taking 3 10 mg tablets of morphine sulfate. So that's 30. But he's also taking codeine and codeine as we know is metabolized to morphine. So he's taking eight tablets each of which contain 30 mg of codeine. We know that 100 mg of codeine is the same of 10 mg of morphine. So 240 mgs is gonna be the same as 24 mgs of morphine. If we add the 24 and the 30 we get 54 and it's great for analgesia. It needs to be 1/6 of that total amount of morphine he's getting every day. So that gives us an answer of 9 mg. So hopefully that makes sense. Um The only other thing I just wanted to touch on briefly then is just another thing just to be aware of is when you're converting between different units, between kilograms grams, milligrams, micrograms, just be sure, just have a quick look before your exam and make sure you know how to convert between uh between the different units. Cause that's something else. Um That's really helpful in these exams. Um So look, I'm just gonna have a look and see if anyone's put anything else in. Um, just in the chat. Um I think just to go back earlier, I know some people had asked some questions. So with regards to that stat bolus of fluid for the man who had CO PD had fever, that was a bit hypertensive. Um So yeah, look, you're, you're right, you can 250 mils tends to be the dose that we would give for heart failure. Um 500 mils wasn't an option in that question. So 250 is, is the closest answer. The important thing there was that we were giving him a cry um a crystalloid. So the normal saline, the 250 mils, ideally it should be 500 but 250 mils was the closest answer in that question. Um Somebody else was then asking about Entresto. I think that was in relation to the question. Um Somebody who had hypertension and I think we're starting them on a calcium channel blocker. Um Now to my knowledge, um Entresto is not licensed for hyperten. Well, it's, it's certainly not first line anyway, for hypertension. Um It is predominantly used in heart failure. Um So no, we'd probably, we still would start her on a calcium channel blocker. Um I'm not 100% sure about the UK. I know certainly in Australia when it comes to heart failure. Um They've changed the guidelines anyway, since I was in medical school. So you can in Australia anyway. I'd have to, I'd double check with the UK. But you can now start Entresto de Novo for heart failure. So they don't have to be on, um They don't have to be on um an ace or an ARB for three months and the maximal tolerated dose or anything like that. You can now, certainly in Australia anyway, you can. And II think last time I looked, that was the guide, that was the guidelines from the European Society of Cardiology is that you can now start Entresto de Novo as per their latest guidelines. Um But yeah, look, if you have any other questions, please let me know. I want to apologize so much for the technical difficulties and I'm very sorry about that. Um um But look, I hope that that's given you just an idea just of, you know, some tips to try and help you get through things just that's made you aware of what is available in the BA NF, the B NF. Look, it's an open book exam you have, there's loads of resources in the B NF if you go looking for it and sometimes it can be a bit overwhelming just trying to know where to look. Um Look some, look, there's gonna be some questions that you're gonna go read and you're not gonna, you might have to look up, you might anything in the B NF, it may just be just to check just to reassure. Um, I know other things you are going to have to just go hunting for the answers. Um, but the answers are, there just don't panic, take things slowly. If the calculations are still really something you, what I would say is don't panic too much about them at the end of the day, they're not worth a whole pile more marks than any of these other questions. So if, if you can't figure it out, it's fine. Don't worry, just move on, go on, move on to next question. It's something that you do know the answer to. Uh I'm just reading the questions in the chat. Now look, if, if you just want to go on, that's no problem. If you could fill in that feedback form, that would be great. Again, very sorry about all the technical difficulties. Um I'll answer any other questions anyone has in the chat or if anybody wants to ask anything, go, go ahead. Um ok. Um I'm just gonna read this out. So some somebody's asked in the chart. Uh OK. Please edit the following question when solving questions where the questions are. So what is the benefit of medication that can be monitored? Um ok. Um I'm I'm sorry, I'm not 100% sure what the question asking, but I suppose what's the benefit of medication that can be monitored. So I suppose if they're on something, um, I don't know, say lithium, say digoxin, um, say digoxin that has an hour periodic index. Um, I suppose if you can monitor the level, you get a more accurate indication, maybe of if it is in that therapeutic window and if they are getting the right level in their bloodstream and if it, the drug is being absorbed properly and has been effective, I guess. Um Yeah, sorry. Um I know that's probably not what you're looking for. Uh some problems with the communication section of the PSA any tip. Yeah, look, OK, look, the communication section is hard because it is, it is a bit of a judgment call with some of these questions. Um What I'd say is have a read through often there'll be one maybe two that you're like, oh, it could be this, it could be that things that I think that they like to emphasize are is patient safety. So like I said with um cloZAPine and the agranulocytosis, that's a safety concern with somebody who's on the contraceptive pill. The risk of getting DVTs P ES is a safety concern. So I'd say try and think about trying part of things that would be related to patient safety. Um That I think that's the main thing that they tend to prioritizing these questions. Yeah, patient safety and other than that, I guess just things that would lessen the effect of the drug. So like if they're on calcium supplements that they need and they're on bisphosphonates that they need to take them at different times or if they're on some medication that's going to interact with Warfarin um or something like that. Um ok. Yeah, I'll go back to the codeine conversion question. That is not a problem. I'll go back to that now. Uh Sorry, I'm just double checking. I haven't missed any other questions. Ok. Um So look, I'll go back to that coding question now. Um Just make sure I'm OK. That should be, I don't know why it keeps uh stop sharing my screen. I think it's, it should be still sharing them. So to go back to the codeine conversion. OK. So this gentleman is on paracetamol and codeine. He's on um oh geez co Cocodamol. Is that what they call in the UK? I've been away too long. I can't remember. Um But anyway, but he's, he's on a tablet that has each tablet has 30 mg of codeine in it and he takes two tablets four times a day. So two by four is eight. He's taking eight tablets, each of which contains 30 mg of codeine. He's also taking morphine, sulfate tablets. In other words, morphine, he is taking free free 10 mg tablets of morphine every day. So the question is this isn't meeting his pain requirements. We're gonna give him some breakthrough analgesia. So the first thing that we need to think about when we're calculating breakthrough analgesia is we need to calculate what is the total amount of morphine that he is taking every single day. So, and it tells us this in the BNF, if you can't remember, it tells us here standard rescue dose of morphine for break for analgesia is normally 10 to. So normally we say a sip of whatever his total dose of morphine he is taking in 24 hours. And this is they have the conversion tables for between all of the different opioids. So if we go back to this, so we know that codeine is metabolized in the body to morphine. So codeine think of it in your head. Codeine equals morphine. But we want to figure out how much morphine is there in all this codeine he's getting. So each tablet that he's taking that paracetamol, codeine mix the cocodamol or Panine Fort or whatever they're calling it. Each one of those tablets has 30 mg of codeine and he's taking eight tablets every single day. So that means he's taking a total of 240 mg of codeine or in other words, he's taking some amount of morphine and we want to figure out how much morphine is there. Is he getting from all of this coding? So from our table in the B NF which I'm gonna go back to. It's here. Oral coating is 100 mg of oral codeine is the equivalent of 10 mg of morphine of oral morphine. So if we go back to this 100 mg of codeine is the same as 10 mg of morphine. This guy though he's not taking 100 mg, he's taking 240 mg of codeine every single day. So 240 mg of codeine is the same as 24 mg of morphine. So codeine is metabolized in the body down to morphine. He takes 240 mg of codeine every single day. And that from our calculation is the same, it breaks the body metabolizes that down to 24 mg of morphine. So we want to know what is the total amount of morphine that he's taking? Cause he's not only taking codeine, he's also taking some morphine, just oral morphine and he's taking, he is taking 10 mg tablets of morphine and he's taking that three times a day. So three by 10 is 30. So he's taking 30 mg of oral morphine and the equivalent of 24 mgs of morphine that 24 comes from the body breaking down that codeine. So 24 mgs of morphine from the codeine and 30 mgs of just oral morphine. So that gives us the total amount of morphine he's taking every day is 54 mg. Now, the question's asking is, what is his breakthrough analgesic. So what are we going to give him when the morphine tablets and the codeine aren't the they're not cutting his pain, he's still in pain and he needs a bit extra on top. So, breakthrough analgesia is gonna be 1/6 of the total amount of morphine he's taking. So if he's taking 54 mg of morphine in a 24 hour period, what is 54 divided by six? And that gives us 9 mg. So 9 mg of morphine is going to be his break for analgesia. So he can take his paracetamol codeine four times a day, his oral morphine three times a day. And if he still gets a l the pains just he's just getting too bad, he can take an extra 9 mg of morphine. So hopefully that makes sense maybe. Um OK, I'll leave it, I'll leave it. I'll leave it for a minute and look if anyone else has any other questions, look, please feel free to ask. Absolutely. No bother. Sorry again about all the technical problems. Um Look, if anyone has any questions, any feedback, please let us know. Thank you all so much for coming. Like I said, I'll hang around here for another minute or two. Any questions? Look, I'm more than happy to help. OK? And the best of luck with everything everybody. Um but you are, you all do great. Just take your time and look, try not to panic too much about the calculations. So honestly, they're not, they're not worth that many points. It's not worth it. Focus on what, what you're good at. Ok, so look um I'm just gonna uh look I'm turn off my mic and look if anyone's any questions, let me know.