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Okay, so let's just get straight into where we got our first case. Mrs. Be is a 52 year old Caucasian lady who you have asked to see after their ambulatory BP monitoring on. But it showed a BP off 1 64/85 on, uh, Nexium in a shin. There is ah, no clinical findings. So which medication would you start in this case? Um, one second. Yes. So I'll give you a minute and a half to vote on the answers, and then we'll go through it, Okay? Just a couple of more seconds. So far, 60% of you have voted. I just ah, couple of more, and then we'll go through. The answer is relatively easy. Question for the first one. Okay, I'm going to stop that there on, but you can see most of you have opted for the right answer, which is ramipril 2.5 mg once daily. And basically, um, because I don't think you can actually find the algorithm for treating hypertension in the beer. Never self. But this is something that's quite basic that you just need Teo. No. So, uh, essentially anyone under the age of 55 whose know Africa or being you normally start with an L East inhibitor or angiotensin receptor blocker on, then your next step, if hypertension is not controlled, would be adding a calcium channel blocker where somewhere over the age of 55 or higher is Africa. Robien. You would start with a calcium channel blocker as a first line on the caveat to that is usually if someone, regardless of age, has Type two diabetes. You would want to start first line with an ace inhibitor for kidney protective reasons. But just because they're hard at high risk of developing diabetic nephropathy on the ACE inhibitor have been found. Teo clinically better to prevent that complication from occurring. So that's the first taste done. It's a second case. Mr. Edwards is a 72 year old gentleman with metastatic prostate cancer. He has been in hospital being treated for a UTI, but his pain is no longer being adequately controlled, so the palliative care team has reviewed him and suggested combating him onto a syringe driver. So currently is taking IV paracetamol ah, four times daily as well as cold Jane, 30 mg, four times daily, some sub cotton morphine on some or, um, or for as required on. Um, so basically, the question is asking you how much is, um, morphine sub cart needed? Teo Adequately control. He's paying, given what he's already taken. So going to stop the pool again. So you've got a minute and a half on day try to work out in answer. So I think this question is a little bit tricky, so I'll give you up to two minutes to, uh, come up with something. Okay? Last 10 seconds and we'll go through the answer. Okay. Good. And that, uh so the majority of years kind of split between C on d e. I can understand why a lot of people have gone for see because, um, if you're having morphine sub cup 5 mg for our leader, I mean six doses in a day. That's 30 mg on plus three lots of 10. That's 60. But the correct answer is actually 51. I know this question's bit tricky, so we'll go through that properly. So in the B n f. If you type in prescribing Impala, it'd car on the top such bar on you Scroll down. You'll find this opiate conversion table. So because the bioavailability between different routes off administration would be different. Therefore, ah, orally. So 30 mg off or a morphine. It's different to 30 mg off sub cutting morphine. So on this table you can see all of the root and a different format off. The opiate is listed on the left hand side on what with their equivalent does on the right hand side. And I'm just going to show you how to work through this problem. So I think another thing some people have ignored is that codeine also is a week O p a. Therefore, when you're working out the total dose off opiate needed in a syringe driver, you need to include codeine as well as the sub cut on the or uM or S O back to the table where you can see a screenshot on top. So old 100 mg off codeine is equivalent to 10 mg off morphine, so that's 10 in one. So you work out the amount of codeine they have in a day, which is 120 mg because they have four lots off after 30 mg, and then you would divide that by 10 to give you the morphine equivalent. So that's 12 mg. And then in terms off, uh, or um or combating to sub cutting morphine. That's to toe one, because 10 mg is equivalent of five, so that's 2 to 1. So the sub cut morphine the patient has been receiving, um, is, um, 30 mg, because that's already sub car. You don't really need Teo convert that, whereas the or um or if it's 30 mg, so you would times up to that 60 on one. You add them all together. That's equivalent to 102 mg off or morphine on, because you want that as a syringe driver. Essentially, syringe driver is a syringe where you have a continuous of injection into subcutaneously, so you would then divide that by two to give you the overall does off sub cotton morphine over 24 hours. Eso I hope that makes sense. If there's any questions, we'll free to comin down below, and we can always come back to it. Eso we're gonna go on to our case. Three. Mrs Be is a 52 year old lady who you have asked to see after the ambulatory BP monitoring, which showed a, uh value off 164 over 85 on done examination. There is no clinical findings. So that's the same lady from the first question and majority of you already started her on ramipril. Um however, uh, this question is asking, What should you do prior to starting the medication? So I'm gonna launch the hall right now. On. You get about a minute and a half to do that. Hey, five more seconds. I'm going to close that now. Yeah, so again. Ah, the majority of you have voted are correct. Um, in saying that you need to check your e a an electrolyte prior to starting. And if there's any history of asthma eso how you would work that our is you would typing on a search far in VNF ramipril on. Then you go down. So there's a ah tape, but there's different hyperlinks on just immediately. Once you open the ramipril page on, then you would go down to monitoring on. It should say that um, you need to start a check your urea and a lot of electrolyte prior to starting. And also, if obviously, um, in your clinical knowledge, you wouldn't know that a, uh yeah, 18 him to sometimes can be a contraindications toe asthma s. So that's always a good thing to check on. The reason you do check for you reelect relied is because, um the way around April works on the androgen synthesis and system that would lower your renal profusion on DA. It's quite normal to see urea and electrolyte worsen after initially starting the ramipril. But however, you would want to get a baseline off you on the east before starting, and also check it again in 2 to 4 weeks. Time to see if there has been a significant worsening after you re electrolyte. And usually if the rise in your e electrolyes less than 30% from the baseline, you couldn't confidently keep your patient on a sin Hip bitters. But if you find that after starting a sin hip bitters there you any is worsens to above 30% off the baseline, then that's an indication that there renal function is being adversely affected on to prevent them from developing further complications like CKD or a K I. You would consider stopping the ramipril and change them on to something else. So yeah. So, in terms off eight and hip, uh, checking your knees is very important. Before starting, we're gonna go on to the next question, Mister Singh, 50 year old man presenting the hospital with a neck episode of acute mania. There's a background bipolar disease, which requires three previous inpatient admission under the mental health at you're you're booking is outpatient appointment to check his serum. Listen, next level in six months on, what's the target level for Mister Singh? So, yeah, another 1.5 minute and we'll go through the answer. Okay. I'm gonna start the pole now on. Most of you have opted for D, which is the correct answer. Um, so, yes, was again to find out. The answer for this is you type in lithium carbonate old, just lithium on the B NH be in F search bar, and then that takes you to the main page for lithium. And you got to go down to monitoring requirement on Essentially, it tells you on the B n f that the target lithium concentrations, no 0.8 to 1. So lithium is one of those drugs with a very narrow therapeutic range. So you would once you start someone on lithium, you would want Teo check it quite frequently until their serum level stabilizes. And then you would check that every now and then to make sure they're still within range. So they're they're manic. Episode is being managed. And sometimes, if, ah, someone is overdosing on lithium or if their serum levels above one, they can get complications like black cows collapsed. Blurry vision on the most well known zob Vesely nephrogenic diabetes insipidus on that can lead to, um, excessive thirst. And also diary siz. Um Okay, so gonna move onto number five. Um, Mrs. Be is a 76 year old lady who is on warfarin for a mechanical heart valve on usually her target. I and R is 3 to 4 s. Oh, she's got a recent diagnosis of breast cancer. Onda, um, she's going to have left mastectomy on door wide local excision in a week's time on. She's attending her pre obsess mint now. And what would you like to do with her warfarin? Okay. Gonna stop that there. So most of you have opted for D onda? Yes. That is indeed the right answer. So how you find that out is by typing in or anti coagulant on the search run Be NF on that, give you a essentially a list a summary off all of the orienting regulant, including warfarin and some of the know acts on you go down to the warfarin part and it does tell you what happens to how to manage warfarin surgery and also house of manage. If the iron are is ah higher than the target level on. Also, it gives you different scenarios off different range of iron are on What if someone is bleeding and how to, uh, under treatment for those things? Um, yeah, So I just put up a screenshot and essentially on the top. You can see that warfarin should be stopped five minutes before Sorry, five days before elective surgery on. But usually you want to target our in our That is, um, if if the and I still over 1.5 before surgery, because that's hot, quite high risk of bleeding. You want to give a vitamin K you for 5 to 10 mg Teo lowered iron not down on because in this case, a mechanic. Heart valves are put you out Quite high. Risk off clots and thrombosis. You would, Bridget, with low molecular weight. Temporal in on gum. Yeah, and that should, um, make sure your patient have a relatively low risk off developing clots throughout the peri operative period on when the peri operative period is over. And they are hemodynamically stable, with no added risk of bleeding. You would then start to bridge the warfarin again after a couple of days off surgery on, then whenever to target I know is reached that then you would stop the low molecular weight and continue the patient on that warfarin. So next case, Mrs Grange, a 68 year old lady, presents the hospital three days history off, right upper quadrant, pain and fevers got past medical history off or stones and various other things on examination. She's feberal jaundiced. There is some local parroting is, um, over the right quadrant on do the blood shows. She's got high inflammatory markers and also a obstructive cholestasis picture. Um, so you're reviewing her drug chart on day? There's five different things that she's taking. Which one off them would you want to stop in this case. Okay, I'm going to stop that there. So most of you have opted for a again. This is bit of a tricky one, cause the correct answer is B. I understand why a lot of you have opted for a and so basically, I think because a lot of you are thinking about her LFTs are increasing. There's some transaminitis. Therefore, atorvastatin would be the most reasonable thing to stop on. The thing is, I do think that is correct, but usually that's not clinically done. And also, when you look at the BNSF when you put in atorvastatin and then go down to, um, hepatic impairment, it does say that usually only prolonged transaminitis warrants stopping the atorvastatin on down. So this one, uh, the correct answers, actually, metformin because, um so yes. So there we go. So when you are typing that for me and then go down to a quarter runs on or further information so because this patient has high white cells, it's septic on also dehydrated. There's a risk off lactic acidosis happening on also because, um, there is a sort of baseline. If I go back, it tells you the patient's baseline EKG fr is over 90 but now it has decreased to 50. So although it's know even though under be in FSS, you would stop it when the E G F is less than 30. But the combination off AKI as well as patient being very ill February having a lot of insensible loss of fluid on behind risk or further dehydration means you don't want Teo. Keep giving the metformin because any kind of acid acidosis can put patient at extremely high risk off developing septic shock. So that's why, in this case, metformin is the most. Um, uh, it's the first drug that you would want to stop, although I do understand why most people have gone for atorvastatin, so we're going to go on tour. Next case, Mister eight is a 90 year old gender to 92 year old gentlemen. He was admitted with low consciousness after being found by his care of eso. You do a set of blood and noticed that he's got a massive increase off his creatinine from his baseline on The carriers has also bought a list of his regular medications andan listed for you that, uh, which medication would you want to suspend? Ah, In other words, which medication do you think has caused the creatinine rise soon? Okay, since most of you have go to him going to end the poor here, Onda. So you're almost all of you have opted for be which is absolutely correct. And, um, your one off the Yeah, because thing that we probably will notice because n says contract is a natural toxic on gum. Contribute Teo Massive AKI Zo. Yes, I'm not gonna explain that further, but we'll let's go onto case eight. Ms Eddie. So she's a six year old girl who needs IV catheter accin because she's developed acute appendicitis on do normally, the dose off for tax, um, is 50 mg per kilogram three times daily. And her weight is 24 kg on usually the antibiotics, it's delivered over 20 minutes in 100 mils off normal saline. So, given that information, I'd like you to work how the rate at which the calf attack seems should be delivered. So again, this might be a little bit tricky, so I'll give up to two minutes for you to work that out. Sorry, guys, because the, um, whole only comes up on the separate screen, so sometimes I might have to Ah, yes. Which my screen? Just to run the pole. Sorry about that. Okay. I'm going to stop the pole. Now on. Most of you have opted for B, which is the correct answer. So just going to go through how to, ah, work out the answer. So because it's 50 mg per kilogram and the patient waits 24 so hard does the total um, those would be 1200 mg. That works out to be 1.2 a gram on because you want to deliver all off the medication in 20 minutes on. Obviously, the deliverer rate is in, um, milligram gram per hour. So there's three lots of 20 minutes and an hour. So you just simply times that by three on, then you get your 3.6 per hour. So that's how to work it out on Case nine Urine GP as an f two. You asked to see a patient by the warfarin clinic nurse. A 76 year old man has an eye enough sampling. Nine, but it's not. He's not got any signs of bleeding. Some warfarin for proxy. It's more a f. And he's recently prescribed an antibiotic for a cap by one of the GPS on, uh, which off the antibiotic exist most likely to be prescribed in his case. Okay, okay, I'm going to stop the question there. So most of you have opted for he was a referral myson again. That is correct. So the way to find that out can be a little bit time consuming. So again, you go onto warfarin page and then, ah, there's a tab which you need to click into court interactions on dumb because most I think that the exam is still mostly done on a computer. Once you get onto the interaction patient would be our list off all the medications that have potential interactions with the drug that you're interested in. So essentially, what you may have to do ISAT you don't know is to just command or control f on Diapin each off the options on, see what it says next to theophylline on in this taste. So if I go back, um, options A B and D uppers, Um, uh, a lot of penicillin on DA when you find penicillin or amoxicillin in that one. It doesn't specifically say it would increase the and I just say, say, alters it on in rough ampicillin in, actually, um uh, decreases the iron are so the only the only correct answer here would be a referral mycin on just a bear in mind that all macrolide do interact with iron are and make you more prone to bleeding on. But, um, yes. So obviously this testing on your knowledge on enzyme inhibitors and enzyme inducers on does both acronyms for you to help remembering that. So I think unfortunately for this, you just have to, um, either remember it or go using the time consuming way off trying to search up each off the options to see ah, whether they dio they interact with warfarin on gum. Yes. So there we go. Uh, next question, Mr. Bedford. 63 old gentleman presents to you who's his GP with a two day history off painful big toe on Be got past medical history of hypertension stemi and heart failure with Aygestin fraction off fifth deep sent you take some floods on D to check his uric acid and CRP level suspecting this is gout. on gum. He takes some medication listed below us. Please select the one that you think that has contributed to this's presentation. Uh huh. Can going to stop the pole here. Now. Ondas, most of you have correctly identified again. The answer is he on reason for that is usually there's ah, so uric acid is really likely to crystallize once it gets above a certain concentration in the serum on do with frozen wide. You more likely to, um, get dehydrated because of diuresis is therefore increasing the level of uric acid in the blood on datscan. Why, you likely to, uh, get crystallization when you're ah, have gout as well as on diuretics. So I think we've got two more questions on Yeah, And if you, uh, such a frozen might and go down to cautions does tell you on the first line that it can exacerbate gout. So, uh, you know, ultimate question, Mr See 83 old was in Mississippi is GCS eight after graduate decline over the last few months. Um, so his carousel he's not been himself on also brought you a list of his medications on down on fluid status examination. You find that he's clinically you believe it on on his blood test that you find that he's got a massively ah, a low sodium on D. Yes, sir. Please consider ah, what might be going on on which of these medications could stop. Hey, so most of you have opted for a which is again correct. So, um, again, for this one, I think because some off the yes A questions you might not be able to find everything on the B n F because he does rely on some general medical knowledge on, But I think in this case it might be worse just to go over SIADH a little bit on. Also, try to remember some off the drug roots that lower the serum sodium on, but might be helpful when it comes to a question like this. But essentially what in terms of hyponatremia cysts on? But first thing you want to do, too. In terms of assessing the patient is Teo try to assess their fluid status on deviously. It can be divided into hypo of anemia euvolemia as well. Hyperbole mia on because in this hip patient, the you've determined that he's you believe make on this a couple of things that can cause you believe it. Hyponatremia on. Do usually you want to do a, uh, thyroid function test? Because hypothyroidism can contribute to that on also Addisonion crisis. So sometimes you want to do a nine. AM Cortisol is well, but in this case is trying. Tomo. Basically, the cause is at I saw a SIADH via too much ADH production. Onda. Um, so some of the common on drug roots that can lower your sodium includes SSR eyes. You're on long term SSRI. Your sodium level can be low and also carbamazepine. That's quite a classic cause up SIADH on doll. So a PPI stand also do it or lansoprazole one or Metrazol on if someone really need a PPI cover. In the case of SIADH, sometimes you can, um so if if it's a cute say you moan pneumonia or ah, men and dry it is, you can stop it for a small amount of time. But if they really need the cover, you can switch them to something called famotidine to cover that period because that was the offer's gastric lining protection as well. But in this case, you, um uh sertraline, carbamazepine and lansoprazole or can contribute to hyponatremia. So I think we're onto. So yes, just a little pen Later, Um, remind you. Ah, the pacifier be ology off that. So I think we're on to our last case. Mrs. Avery. 58 year old lady with rheumatoid arthritis presents to you for a checkup. Eso she is on me for tracks A us off eight months ago and her symptoms have been stable on Do. Um, yes, sir. It below. So her drug history and some of her blood test. So when does misses a very needs her next blood taken. Okay, okay. I think I'm going to stop the pole down. Yes. Ah, again, Most of your correct said answers three months. So again, if you go to the page on methotrexate and go down to monitoring yet requirement says, usually when you start the patient off, you need to monitor that quite regularly. About 1 to 2 weeks on dwa. It's they've you stabilize the bone, you need to monitor that every 2 to 3 weeks. Just because mental track state is toxic to the bone marrow and you need to monitor especially for blood count to make sure they're not being two immuno suppressed because sometimes they can have very low white cells and you put them at risk off having neutropenic sepsis is so. I think that is everything. Um, today we got one last session tomorrow. I'm happy to stay on for a couple of more minutes on. Please, Can you just do the QR code to give me some feedback? Just also pace the link off for the feedback form on here. A swell, uh, if you prefer using link. Yes. So someone asked in terms of that antibiotic that I in our question that really threw my son is an indicated for cap. So sometimes you can give macrolide if you find a typical pneumonia because sometimes you would want to test legionella antigen in their urine. Um, okay, so I'm gonna ask me to go through a question too. I'll go back in a bit. Yes. Oh, one second. Let me just stop sharing so I can go on to another page to stop to share the link for the feedback for yesterday and today as well. Okay, so this link is four yesterday, and I just find you two days link on this link is four day. Okay, I would just go back