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Okay. Just going to start off with our first question. That's just go straight into it. Mr. Pee, is this 7 57 year old man who's a builder Admit it was lower back pain after lifting on, he describes it as a shooting pain down the back of his legs. But the MRI spine shows nothing. Currently, he's taping taking paracetamol with some or a morphine. So which analgesia would be the most appropriate? Um, to start him on just okay, it's most of you. Yesterday in the feedback form. Ah, said that you like the fact that we've kept it to a minute and a half, so I do the same for today. Just a recent relates, really? Example. Conditions. Okay, another 12th for those with you haven't submitted. Answer. All right. And tighness up. Just gonna shadow results. Um, so as you can see over half of you who have voted, uh, truezyme a triptolin, which is the correct choice. So I I think the key thing to realize in this case is the pain he's describing is neuropathic pain. Because Lassic Lee starts in the back. And then Brady eights down the back of the legs on because he's already taking the maximum dose off paracetamol that you can take in the day on. Also because his neuropathic in nature up titrating the or morphine, it's unlikely to get the pain under control. So the most sensible thing is to start him on the low dose amitriptyline to take at night on. Do usually would tell the patient with any other neuropathic agent that it takes a couple of weeks for it to take its full effect. So yet patient should be expecting the pain to go down straight away when he starts the amitriptyline. So that's first case done. So we're moving on to taste to Mr Ali, a 44 year old man presents to his GP with right sided ankle pain after an injury whilst playing sports on DA. The option listed are all of the medications that he's taking right now on the on review off this medication list. Which one off them would you like to stop? Okay, so that's times up, given your bit more time just because it's a tricky one. So Ah, I love you have gone for B and there are some A's and C's so let me just go through the right answer now. So So the correct answer is actually a so I know I think a lot of you have chosen be because obviously you're going up the, um uh wh tro pain ladder and in which paracetamol would be the first line. But the only thing in this case is that if you look at the list so he is on a regular cocoa tamal, but Paris eat more as required on also because he's been taking this list of medication for the past two weeks after obtaining the injury. But he's still presenting with the ankle pain, which means with this is not fully the pain is not fully under control on D. I think a lot of you have gone for either a or B. It's because you know that paracetamol the maximum dose is 4 g in a day. And obviously, if he has already taken 4 g of cocoa tomorrow or that's essentially use up all of the Paris eat more those allowances and any as required paracetamol would go over the limit on brisk him having acute liver failure. So I think in this case you would want to keep him on the regular Coke Odom. Or just so he would have a regular pain relief and you would stop the paracetamol on. Do you would think about another pain relief agent to make sure the pain relief is controlled on Do you would probably want to keep the voter off just because that's a topical ibuprofen gel on. But it is actually fine to keep in this case if he if that helps him so yet the correct answer would be a paracetamol onda. Um, just a screening. Sure. If you've gone, Teo Paris eat more on Be enough. It does tell you the maximum dose per day. Um, so next case Mr. T is a 73 old man who weighs 75 killer kilos in hospital for an elective surgery. So he's currently knew my mouth on done. He has not drunk all day, and it's currently eight in the morning. So you do some blood for him, and it shows that is blood results. Um, normal. But what would you like to prescribe for the next 24 hour period to make sure that he has his maintenance fluid? Okay, So, times up I'm gonna end the pole here. So only just over half a few voted. But the majority who voted are correct is one liters apartment followed by two bags off 5% dexterous with some additional kcl s. I think fluid is quite a big topic, and a lot of people might not feel confident on this topic. So we're just gonna go into ah, little bit more depth in a bit, but essentially a table. Just shows are each kind of fluid there components on as well as their the concentration off each electrolyte compared with the plasma on because you can see with normal saline, because the sodium chloride is just consist off sodium and chloride. Irons was a bit of calcium on do. Usually, people will say Hartmann's is preferred as a maintenance fluid just because the component is quite close. Teo, the physiological component off serum on day five tens dextrose just mainly consist off blew coast Ondimba, 5% is usually 50 g in 1 m, and in terms of how to work out in this case, eso just need to have some basic knowledge off the fluid as well as electrolyte requirement in adult so usually in terms of fluid requirement, you need 30 mils per kilogram in a day on because we've got a 75 kg man we times sent. If I'd buy 30 that gives us 2250 mils on in terms off the rest of the electrolyte requirements, so you would normally need one minimal pap kilogram for, um, sodium, potassium and chloride. So in this case, that would be 75 minimally off sodium and potassium for this man on do usually, regardless off your weight. You usually need 50 to 100 g off her day off glucose just to avoid ketosis or glycolysis from happening on. So normally, 50 as a zombie to give them a little bit off blew coz minimum 50 g. That's enough in an adult to stop that from happening on if we just go back to our answers, Um, so one leader apartment already consists off more than enough sodium, so Teo satisfy this man sodium requirement on gum in terms off the rest. In terms of potassium, so one liter has about five millimeters of potassium on do you would need to add some more potassium into the dextrose back to make up for rough requirement on your see, because the option gives us 45 millimeters for potassium. Just to be aware that in real life you can never really make up the exact amount of electrolytes someone needs in the day on day, usually you would, ah, standard practice is that in someone who is no by mouth and who's, uh, potassium on? Uh, you re electrolyes is not raised. You would just get 40 millimoles off Casey, our added, either in a normal saline bag or a five cent dextrose bag to stop to make sure that they have some potassium that day and to make sure they're taxing. Don't doesn't dip too low on normally. You can give either one or two bags off textures, um on. And also another thing, people often say is in a normal average weight. Adults are about 70 to 75 kg, you conducive to sweets and one salty, so that just means two bags off one liter glucose with one bag of normal saline. So that's the general rule, but obviously depends on the weight. You would titrate it up or down, so just going to talk on in terms off the VNF if you are. If you need some guidance, you can always search on the search for fluids and electrolyte and does. It does give you a page off a rough summary off electrolyte replacement therapy, but it is quite long winded and quite convoluted. But there are some useful tips like it tells you the treatment or management plan for ah hypokalemia if you forget that in the exam. So just make sure before your exam have a read of this page on. Just make sure you remember if you need some guidance, remember Teo search fluid and electrolytes s so that you can have some Uh, yeah, rough top up during the exam. So just gonna go a little bit more in depth in terms of fluid management. So usually there's two reasons why you want to give fluid through through intravenously, so it's either resuscitation purposes. We'll maintenance purposes on decisive patient, and it's usually someone who is very fluid to play depleted or in us or who are susceptible in septic shock. So in healthy adults control your know you can give a fluid challenge off 500 mils of normal state line over 10 to 15 minutes and monitor their BP to see if that picks up on If, Ah, patient has quite a lot of comorbidities quite frail Owsley, especially with heart disease or heart failure, you would want to cut that down to 250 normal state line on down. And if they're extremely frail, you might want to extend the time period to about half a now as well to make sure that their heart conclude. Put with the amount of fluid going in on in Children is normally 20 mils per kilogram over 10 to 15 minutes. So in Children's always very weight dependent, so make sure you know you haven't up to date wait for the child that you're trying to resuscitate Onda again. ALOF This fluid in resuscitation section is normal saline that you would give on. You could move on to the maintenance section, so this is where it kind of difference between adults and Children in times off the type of fluid you give so in adults is always normal. Saline On Daz, we're talking. If the patient is fine with no core morbidities or infection or dehydration, you would stick to 30 million per kilogram if they're near by mouth. Obviously, if they are not know my mouth, they're drinking other fluid. You want to take that into account on replace as necessary Onda how to work how the fluid deficit is usually by asking the nurse and stuff to keep a input and output chart to see once the net loss or getting at the end of the day on if there is any extra fluid loss is, for example, if someone is having diarrhea, vomiting, or if someone is a febrile or septated, they would have more insensible loss is through their breathing as well as sometimes through their stool. You would then, uh, estimate the rough fluid deficit and replace us appropriate. So because it's not an exact signs. And sometimes it's very hard to estimate the exact insensible loss. There's general rule that people roughly in an adult with without any kind morbidity is depending on the weight. You can lose up to 100 to 800 mils, um, off water. If basically they just completely fine on. Or if you are septic or February, you can double the amount of your usual insensible loss is. So just make sure that you take that into account and he's usually if they are febrile, you probably need one extra liter off normal saline on top of what they have to make up for the deficit on in Children and infant on DA What? Messing infant. I mean, uh, any, uh, intern over 28 days, because neonate under 28 days have their spread a specific fluid replacement rules that we're not going to go into because it's quite complicated. Eso In Children and infants, you normally give normal saline with five cent dextrose, so usually this is a solution that's already available in a bag so you don't need to hook on them on 22 separate bags is already come with normal saline with the fax sent glucose in one bag, so the rule is generally every day, depending on their weight, they need ah 100 mils per kilogram for the fast hang kilogram of the weight on. Then, for the next 10 to 20 kg, they need 50 miles per kilogram on anything that's in excess off 20 kg off their weight. They need 20 mils per kilogram per day to make that up. So yes. So, usually for Children, you would again. You would want a up to date weight on, but just need to do some calculations, work out the total, then divide by 24 to a work. How What's the rate of replacement that you going to give thumb? I'm just gonna have a look at that. Yes, If someone asked, someone asked me to repeat. The insensible loss is so yes. So insensible loss is depending on the way. If someone is, um, higher way they can lose up to 800 mils off fluid in the day s. Oh, yeah, just really, really great that so we could move on to case for. But if you've got any more questions, just put it in the chat. I'll try to get to it later on. 11 year old boys bought too early by ambulance with hives, Andrew edema and shortness of breath Symptoms started after eating peanuts at school. So you've given him 300 micrograms off adrenaline with the concentration one in 1000. Onda. The question would like you to work. How? How many meals off? Um, adrenaline. You have administers. So I'll give you 15 more seconds just because only half of you have ah, submitted and answer. Just tried. Teo sent me an Ansel Have an educated guess, and we'll go through it in a bit. Okay, I'm gonna end the cold. Uh, a share. The results. So majority voted have a beautiful B, which is the right answer. So I'm just gonna go through out. Why? So essentially Ah, you just need to know that one in 1000, because that's the concentration of adrenaline that were given. So that means is 1 g in 1000 mils on. But when it's obviously 1 g is equivalent to 1000 mg on de century, that is 1 mg in one mil and then 300 microgram. You just want to convert that into the same unit, so that's divided by 1000. So that's no 10000.3 mg on then. Obviously no points. If 11 mg is eyes in 11 mg is is in one mil than north 10.3 mg is equivalent Teo no 0.3 million because it's a 1 to 1 ratio. So that's how you work it out. So I think the most important thing to learn, especially with adrenaline. Is that a concentration off? One in 1000 Means 1 g in 1000 mills. Okay, so go down to x one. So this one should be relatively simple. So you're in any resource and you've got a septic patient who is 32 years old on gum. Stood observation are as below. Uh, patient is hypertensive tachycardia on febrile. Which fluid? Recent, uh, would you like to give for resuscitation? Look, I'm gonna end up a little bit early just because it's quite a simple question. Ondas. Most of you have correctly identified that be 500 mils off normal saline would be, ah, type of fluid you give because the patient is 32 on. We haven't mentioned that that there is any kind morbidities or heart failure. And, uh, yeah, your standard fluted fluid would be 500 mils of normal saline on sometimes if you see some improvement, or even if the BP doesn't improve after one fluid bolus, you can give another one after 10 to 15 minutes on deviously. If the BP doesn't respond after to bolus is, um, patient is intercepted shock that's unresponsive to fluid challenge on by that time, you probably want to you to get involved. Teo, get some, uh, minor trips to make sure the BP picks up. So going on to the next one, Mrs. Stevens, 81 year old lady, was admitted seven days ago with neutropenic sepsis on a background of breast cancer on going undergoing chemo, which was given 18 days ago on She's now being treated with 2 g off kept track. Soon on, she has had two days off multiple types. Seven stool after starting the cataracts own and c diff positive on stool culture. So you started vancomycin, and the question is asking which, uh monitoring requirement is needed. So in terms of monitoring requirement, I'm just asking if there is any monitoring requirement needed for vancomycin itself. Not, um, what the patient needs to be monitored. Tastes a minute and a half is up on the clothes up there. Okay, so most of you have comfort he on then significant proportion have gone for D. So again, it's been a tricky one, because the correct answers, actually, no monitoring needed. I'm just gonna go through. Why? So I think I love you. Have gone for D because obviously the patient's having diarrhea and you want to, ah, monitor the renal function to make sure that patients not developing a K I. That is absolutely correct in terms of managing the patient. But the question is asking if any monitoring is eat needed for vancomycin. So banked my son doesn't tend to affect the kidneys, so you wouldn't really want to the renal function to monitor the treatment effect on I know in bn f. It does say a consider peril. Periodic auditory testing by the condition is that if the patient is on any auto toxic drugs concurrently so because in the questions them, we have a mention, whether so, the patient is not on any auto toxic on 12 6 or medications as far as we know. So, um, in this case, actually, no monitoring is needed on the bar If we said the patient is on the things like gentamicin or amikacin, which are both Reno and Nephrotoxic on daughter toxic. In that case, we would need periodic auditory testing to make sure that patients not developed being any new onset deafness or hearing impairment. Onda. Just another thing to mention because sometimes you can get asked in the P s a r treatment for a c diff infection on. Then it will give you, um, vancomycin IV or vancomycin or or just to make sure that you know, the treatment for C diff is always or a bank myson because obviously the infection is in the garden. And, um, if you give it IV, the distribution into the gut into intraluminally itself will be very limited, so it wouldn't treat the infection adequately. Therefore, you always need Teo give it orally to make sure that the C diff is adequately treated. Hey. Okay, so I think that's why I talk about ah before with you only want to monitor hearing if they are on conquer mittens therapy with other water, toxic drugs where it is. But in this case, she's not, so we don't need to monitor anything. Okay, So Okay, seven. Uh, Mr Wise, a 62 year old gentleman who you're seeing GP with a productive too productive cough and fever for a couple of days. Eso the obs are as follows and then you also got some blood results and the X ray. So given that what is the most appropriate course off action. Okay, so I think on this, like, the only thing that's missing is the X ray. So it actually just showed a, um, right to lower lobe, uh, consolidation, I think the rest of the obs and bloods of there on what you're doing that I'm just gonna copy and paste the feedback link for today. So just whenever you have some time spare two minutes for me to do that, I'm gonna wait a little bit longer for this one, just because only half of you have submitted something. Okay, so I'm gonna stop out there. So again, the majority of selected for C, which is the correct answer. So to be able to answer this question, you kind of need to know the treatment algorithm for a community acquired pneumonia on DC The most well known score for, um, categorizing cap is the Curb 65 score s. So if we just go back to a calculator, there's nothing in the question. Some suggest that the patient is confused on DA, uh, in terms off. Sorry. I just realized that you really is not present. Um, sorry about that. Um, on day. The patient's respiratory rate, it's no elevated. BP is find means he scheme of Dimetapp, medically stable on down. He's 62 years old, which means that it's under 65 so it doesn't score on the age. Um, So, um, all in all, the patient is, ah, human dynamically stable on well enough to have a cause off, um, or antibiotic at home. So normally, the treatment algorithm is if patients course of 01. So even if the urea slightly high in this case, you would still send home with, uh or or amoxicillin because the maximum score this patient can score is one. And if patients scores are two, you would then consider admit into hospital on you would start on comb Oxy class because obviously that's got a broader spectrum of actions on different scores. Uh, more than two. Then you would definitely admit patients into the hospital on D would start him on IV Comas club as well. Ast by the clarithromycin Just because you want to cover the atypicals with a career for my son and you would do some urinate antigen for legionella as well on, but usually when you go on the hospital system. You don't need to select each off the atypical organisms Teo investigate for there's usually a atypical pneumonia screen, which will give you all three. So that's Ah, chlamydia legionella on bike, a plasma so that should normally cover everything on done. You can always discontinued a career from mice, and when the screen comes back negative, so just gonna go to the next one. Ms. Lim, a 25 year old lady, is two day Postop shoe. Now struggling was nausea, vomiting, pain and constipation. And today she starts showing some involuntary contractions off her neck muscles. It was a witch off. The medication she's on is responsible for this complication pay. So I'm gonna ended that on d Majority have gone for D, which is correct. Most of your permanent wouldn't even need to set up for it because it's quite well known that my top, um, a taco Promide can cause muscle spasms. And it's known as to dystonic reactions. On another thing that they concern, um, test you on is if someone has had, ah, this medication they might have. Essentially, I oscillation upwards like her eye spasms. So that's called ocular gyrate crisis That's also quite classic in this case. But essentially just need to. So if you if you don't know that, you might just have to search each off the medication listed on go to side effects to see ah, which off the mentions Muscle spasm, um, to work out the right answer. So, uh, case nine. We've got 22 year old man presenting to the GP complaining off increasing shortness of breath and wheezing. He's got asthma on door me takes albuterol salmeterol and fluticasone GP prescribes a short cause off or prednisolone on amoxicillin for effective exacerbation. So which off? The listed option as the most likely adverse effect to happen? Uh, with pregnancy alone case, I'm gonna end the cold here. Uh, I've got quite varied responses for this one because obviously understand, it's quite hard to gauge because all of them actually quite common side effects of complications. But I think the thing to notice in this question is that the patient has been treated for exacerbation of asthma star. You're only gonna get a short course of Orapred in s low. And that's normally seven days. A moderate dose rather than high does so Normally you would give 30 mg off or pride for seven days of 5 to 7 days to treat an exacerbation. So the correct answers. Actually, Candida, uh, I'll just go through wide a rest of them. It's no quite correct. So, um is actually, um, osteoporosis. It will only be a problem if someone is on long term, uh, cortical steroid on deviously. This is only a short course that that doesn't apply here again. Similar reasoning for weight game on. But obviously hyperglycemia can be a concern but is usually only a concern in people with diabetes where you need to titrate that that anti diabetic medication or titrate their insulin to account for three extra steroid intake. But in ah, 22 year old man who's only past medical history is asthma. His pancreas functions would be intact. So um yes, there might be hypoglycemia, but his pancreas can respond to it and bring the blood from the back down to normal. So again, that wouldn't be really concerning. Wouldn't be a clickable in this case, Onda finally like hypokalemia. So again, that is only really associate it with the long term Uh ah, steroid intake and when you stop the steroid. Suddenly you go into an Addisonion crisis, which is not really applicable in this case because you would just normally stop the course off or a pred after seven days, because again, it's a moderate does. You don't really need to taper it as well. You can just stop it all together. So that only leaves us with planted er So obviously, um, that can ah puts you at high risk off or candidiasis is on. Also, if you remember, if you have low dose steroid inhalers you normally want to like rent your mouth's fully after using it just because again, that can put you at higher risk of or candidiasis is. So, uh, that's finished with moving onto up in ultimate case. Ah, 34 year old woman presenting to medical assessment unit with a painful swollen right leg. DVT is diagnosed and you commenced her on don't apart and 6000 unit twice a day. Eso which off? The following is correct. Hey, so the time is up. Um, just gonna share the results. Yes, sir. Again, majority are correct. I have gone for C, which is a low molecular weight heparin does not cross the placenta. Um, so yeah, normally, with any, uh, low molecular weight heparin or does axe, you don't really need to monitor any crossing or I'll ask the option B. It says a PTT racial must be monitored. So that's only with heparin, not low molecular weight heparin. Because with heparin you need to monitor the A PTT ratio and adjust infusion rate accordingly every six hours. So so. But it doesn't apply to Delta part because that's a low molecular weight. Heparin Onda. I think if you go to Delta, parents paid on, be in F on go down teo pregnancy. It does directly say that low molecular weight does Does not cross Presenter. Therefore see is the correct answer on DA. It doesn't mention anything about giving lower doses in pregnancy. So that's wrong on. Obviously, she shouldn't expect any vaginal bleeding well, so on the treatment, because that would be, ah, grave concern and she should be tracked out. If that happens well, on a low molecular weight heparin, okay, And then just don't go to the last case. Mr. Barroso, a 83 old man presenting hospital was a swollen, painful left calf ultrasound double confirms a lower limb, a DVT, and you commenced him on apixaban. Um, so how long will he need to be on apixaban four case? That's the last question done on D. Yet majority have opted for be with some saying lifelong. So majority of people are correct. So basically, if you pay attention to the past medical history that Patronus has got prostate cancer, obviously that puts you at higher inflammatory wrist. And also high risk off crossing on dot Yes. So if you go down, um, to anticoagulant treatment does say which this would be classified as a provoked a DVT because the risk factor of cancer is there s so you would normally keep them on for six months at least, if not more on after six months, patient can be reviewed in anti coagulation clinic to see if an extra period of treatment is needed. But if the patient has gotten, um, unprovoked pee. Sorry. So I just said patient has a provoked be there four ized 3 to 6 months, and after that they will be reviewed in Anticoagulations clinic to see if they've had adequate response is with X extra risk factors are present to prolong the treatment. But if the patient has no risk factors to begin with, that's an unprovoked pee on. We want Teo. Keep them on treatment for six months at least. So in this case, six months is the correct answer on. I think we've just done all of the questions. I hope that didn't take too long. If you can complete the feedback form, that would be great. Um, yes. Someone has kindly just, um, uh, send a link for, um, the from but end realism treatment. Thank you so much on D. I'm just gonna stay on here for a couple of more minutes. If you got any questions, I'm just gonna put the, um, linked to the feedback form again. Okay, so someone has asked for yesterday's link, so just give me a second. Let me just get yesterday's link. Okay? That's yesterday. Seeming Yeah. Thank you guys for attending this. I understand. It's quite a big ask on a Friday afternoon. I'm good luck to your psh exams. Um, so I really recommend I think this book would pass in the ps A. That one is quite good. And also, um, all off the so far, the four tutorials from this week has been uploaded. So once this's finishes, I will upload this one again. Um, so I'm just gonna send a link one last time. Okay, so the top one is today's link on The second one I'm about to send is yesterday is link.