Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Good afternoon, everyone. Thanks very much for joining today's session. We'll give it a few more minutes. We'll play. Start around three or four past one. If you guys want to join on the sly, no dot com you can scan this QR code or typing this number just to answer some of the questions that we've got for today's session and we'll begin shortly. Thanks very much. Okay. Good afternoon, everybody. Thanks very much. Once again for joining. Uh, my name is Doctor Cheng, and we'll be covering, uh, towards, um the sorry, we're reaching towards the end of our P s. A prep course. Now, today we'll be covering various different abbreviations, including I n ours and UTIs and all of the other smaller topics, which we weren't really able to dedicate an entire session, too. I just want to, first of all, apologize for last week's session. Sorry. Um, there was some last minute changes with the timings, and things got a bit muddled up, but we're going to be rescheduling last session, last week's session onto next week. So next week we'll be having two sessions instead of one, so it should be a two hour session, and the time has also been changed for nine AM So if your able to join next week just to let you know it's going to be a two hour session covering two different topics at 9 a.m. But we'll talk more about that later. Mhm. So here's the same disclaimer that we always show the beginning of my sessions. We're going to be providing this course to help as a supplement. And if you have any questions, make sure you always consult your university or check DNF and medicines complete for the most up to date information. So we're going to be covering a few of the smaller topics, which I particularly found quite hard to answer myself. I feel like, um, like I said, we're not going to be dedicating an entire session just on iron ore just on this, but we'll try and cover bits and bobs. Um, these of topics that you guys have also suggested the feedback that you'd like to be covered, so hopefully this session will be of use to. So the first one we're going to be talking about is what to do when a question asks, How would you respond to a certain eye on are, So we'll start off with the first question straight away. We've got a 68 year old gentleman who is presented to the emergency department with a new onset. Left sided weakness. He's got a bit of facial droop and a reduced G. C s of nine. A CT head has revealed an intracranial bleed, and his iron are currently is 6.66 point three. Sorry. His past medical history includes atrial fibrillation, and he's got a mechanical aortic valve. Drug history wise, he's on bisoprolol 5 mg once a day and he's also on warfarin. 5 mg once a day. So out of the following options which one is the most suitable for the management of this patient? Would you go with option one? Swap the patient on to a dose pack option to withhold the warfarin and give tranexamic acid. Option three. We'll hold warfarin. Give oral vitamin and I am option four. Reduce the warfarin dose by 2 mg and then review all the last option. Withhold warfarin and give one unit of fresh frozen plasma. So option 123 or five. If you guys want to jump on slide. Oh, and shoot your answers into the chat. I'll give you a few minutes to have a look at this question. Okay? We're still getting some answers. Okay, so let's have a look at the cloud. So it seems like the majority of you have indeed gone for option three, which was give vitamin it iron. Um, I can see that some of those put, uh, three and five. We got someone in the chat saying to, uh, so the correct answer for this question was indeed, option three. Uh, we have hold warfarin and to give oral vitamin D in it. So let's go through warfare management. And hopefully going through this explanation will help you answer a question such as this. What is warfarin? Let's begin with that. So it's a vitamin K antagonist, and it prevents the formation of the four essential clotting factors 279 and 10. And it's a tablet that usually takes about 48 to 72 hours to fully have an anti coagulant effect in the body. Now we measure the eye on our, which is the number that tells us how long it takes essentially for the blood to clot. And there are various different indications and these different indications about different target I in ours. This can all be found on the B N F, and we can go through this later. But if a patient has had a DVT or a P, or if they're on a F or if they have a bioprosthetic heart valve, typically their target I in our is 2.5, so we want the in our to be between 2 to 3. If it's high, then free, then it tells us that it takes longer for the blood to clot. So they're over warfarin nine ized, whereas if it's less than two, then it's telling us that they're actually at risk of clotting. So we need to make sure that we balance it between two and free for these conditions. The main condition that was mentioned on B N f for a target I know 3.5 is if the patient has had recurrent DVT s or recurrent PS and they're already on anti coagulation, and the i n are already above two. So if a patient was in this category, but they were still getting recurrent DVT s then you want to increase the n r 23.5. So that's all good and jolly. But most of the questions will actually give you an eye on our, which is above five or above eight. And you have to answer the question based on quite high I in our doses. So the most important thing is, if a patient has had a major bleed, then the first thing that you want to do is you want to stop warfarin. Of course, you want to give them Vitamin K, which on the B N f and when you prescribe is actually prescribed as vitamin it. I, um, and the recommendation for from the B N F. Is that you give it IV, and the next step would be to give dry prothrombin complex concentrate. And that's essentially a factors 279 and 10. The B N F also states that if no PCC is available, then you can give fresh frozen plasma. But it's not quite as effective as the prothrombin complex. If the patient has an iron, are which is greater than eight. Um, and they have signs of a minor bleed. For example, let's say a nose bleed, then you want to stop the warfarin, and you still want to give them the vitamin A. Die an IV because they've got quite a high iron are. And then you can consider restarting the warfarin when the iron ore has come back down to less than five. If they have a really high iron, are above eight, but there's no signs of a bleed. Then first scenarios like this. There's no actual indication for the to giving them IV medication. So you stop the warfarin. You'd give Vitamin A dye on orally, and then again, you'd restart warfarin. When the iron is less than five, the next range to remember is if it's between five and eight. So if it's between five and eight and they have a minor bleed, you essentially stop the warfarin. You give them IV vitamin K, and again you restart it when it's less than five. The last option is if it's between five and eight. But if they have no bleeds, then you would withhold 1 to 2 doses and you would reduce the maintenance dose. So I guess the main takeaway from this is if they've got a major bleed. Stop everything. Give them I the vitamin and I own if they have a minor bleed, Uh, irregardless of what they're i n r is, you give them IV vitamin K. I mean, if there's no bleed, if it's super high, you want to give them some extra vitamin K to make sure that they don't. They're not at risk of further bleeding, whereas if it's between 5 to 8, then you just want to monitor and maintain, uh, them at a lower dose. And this is the screenshot that was taken straight from the B N F, and we can find links to this later. But this summarizes everything nicely. Um, if you get stuck, you can always look this up in the middle of your exams, and this tells you step by step, what you should be doing, depending on what the I N. R. Is, and depending on whether they have no bleed, a minor bleed or if they have a major bleed. Now, if they have a major bleed, then of course, it doesn't really matter what the I N R. Is. It's the bleeding that you want to control because it's quite a significant bleed. So let's jump. Oops, Sorry. Let's jump over to the next question. So we have this time you've been bleeped by a nurse to review a patient's warfarin dose. His most recent i n I 7.6. He's currently on warfarin for prophylaxis of recurrent DVT s and his target I N R is 3.5 on examination. His heart rate is 78. His BP is 1 50/80 for his respirations 19, his SATs 95% on room air and his temperature is 37.1. So given the topic that we've just gone through just now, which of these following options would you guys say is the most suitable management again? If you guys want to type on the slide Oh, or if you want to type in the chat, just give a few minutes for some of us to type in their answers. Okay, let's see what everyone's answers are. So we've got quite a big mix of answers, actually got five people saying three, we've got four people saying 44 people saying five. So maybe it was my explanation, which wasn't the greatest, So let's go through this case together. So we're bleed by nurse to review someone's warfarin dose. His most recent iron are is 7.6. So already we're thinking, What range does this fit in? Does this fit in the greater than eight range, or does it fit in within the five great range? So because it's 7.6, we're going to be a bit less worried. We can see his indication for the warfarin is not really that important or that significant at this point in time, The most important thing that you want to establish from this question is, what's his iron are currently? Is he actively bleeding or not? Now we can see, based on the limited information we've got here, there is no report of him having an active bleed. So in a situation like this, if we go back to this side here, his iron are was 7.6, which is between 5 to 8, and he's not having a bleed. So the correct answer actually was, I think it was Option five, which is withhold wants two doses and you would reduce the maintenance dose. So that was the last option here. Um, there's a few tricks or trick answers in this option. Free an option for both are on because we consider restarting the warfarin when the iron is less than five. That's the cut off for when you want to restart warfarin. So both of these answers you can already rule out straight away. So you'd be choosing between 12 and five. He's not got any major. Any signs of any minor or major bleeds, So you would withhold it for a few days and then you'd reduce the dose. Okay. And we have one more question here. So I'm sorry this time you're in the clinic and one of your patient's has been, uh, newly started on warfarin. Which of the following options would you say is the most important information that should be provided for this patient? Should it be that a warfarin tablets are brown, be warfarin. Tablets should be stopped before dental procedure. See, binge drinking should be avoided. Uh, d warfarin is not affected by the dietary intake, or E. If the dose is missed, then they should take two tablets the next day. Okay, let's have a look at what everyone is um, saying very good. So the majority of you are saying Option three, which was that they shouldn't be drinking alcohol. Let's have a look at the options again and let's go through them one by one. So option one warfarin Tablets of Brown. I mean, you know it's true, but it's not really an important, important fact. That should be status Elevation. Option two Warfarin should be stopped before having dental procedures is incorrect. Warfarin can actually be continued for most outpatient dental procedures. So for the majority of procedures, they will be okay on warfarin. Option four is incorrect because it can be affected by some foods. I think cranberry juice can actually increase the iron, are levels and having a diet which is high in vitamin K. Having lots of green leafy green vegetables can also affect your eye on our option five is, uh, incorrect. You should never ask a patient to double dose there warfarin tablets if they've missed it, it's not like the c, o, C, P, um, and Option three. Having an acute high level of alcohol intake will affect the level of warfarin. Um, it will affect the way that the warfarin is metabolized in the body. So Option three is indeed the correct answer for this question. Okay, so next we'll have a quick run through for UTI s. And again we'll start off with a question. We've got a 24 year old female who attends her GP appointment with a two day history of dysuria and an offensive smelling urine. You do a urine dip, and it reveals a ph of six. She's two plus on Luke sites one plus on nitrites, and everything else is negative. So if you guys could write a prescription for one medication to alleviate her symptoms And for this question, if you could remember to write the medication, the dose, the route, the frequency and the duration so I'll give you guys a bit more time to answer this question. Okay? It's good to see that we're slowly getting some answers coming in. Okay, so we're getting a good range of answers now, uh, let the remaining people to type up their responses. Okay, so we've got a nice range of answers here. Uh, got Cipro. We've got trimethoprim. We've got nitro. Now, let's have a look here out of these options. Oh, Whoever is typed in nitrofurantoin 50 mg Q. D s or relief for three days. Well done. You get full marks for that. And there was some Oh, yeah, actually, this one here. Yeah. Trimethoprim 200 mg B d for three days. Almost would have got full marks for that. Make sure that you state that it's orally. I know it's obviously it's quite obvious when you're in the clinic, but for the prescription, you'll have to make sure that it's written as P O. So, in order to correct to get the full marks for this question, you would have had to specify that you It's to be for three days only because she's a young and fit female. Uh, she's not pregnant. We'll go through the indications for UTI management together now. Okay, so UTIs are quite a common PS a question. And when it comes to writing a prescription, there's only one thing that you'll really need to consider. And that is, are they pregnant, or are they a male patient? So let's go through the management real quick for each of these patient's. If you have a non pregnant female, then the first line is either nitrofurantoin or trimethoprim either. Always fine as long as you write down the correct dose, and it's for a three day course and again on B N F. There's a nice summary, which we can go through together later. It tells you that for non pregnant women, choice of antibiotic therapy for first line it states here is orally. You can give the nitrofurantoin or trimethoprim. Either one would give you the full marks. If you went for anything else, like fossil mice in pip messily numb or amoxicillin, then you wouldn't have got the full marks. Technically, you would get some marks but wouldn't get the full 10 because it's not the first line indication. So that's the options for non pregnant females. Now, if you have a pregnant female, then the options change slightly. The first line recommendation is nitrofuran tone, and the second line option is either amoxicillin or Keflex in and for pregnant females, you need to make sure that the prescription is for seven days. We can see here again on the B N f. It's stated quite nicely. First line is Nitro second line. You can either give amoxicillin or Keflex in. There are some alternative second lines. Um, in real clinical practice, you could consult your local microbiologist. You could check micro guide things like that, and they may offer some alternative solutions. But we're sticking to the B and F because that's all that we have for the PSA. And then the last question or the last type of, um, UTI patient you may get is in the mail Patient's. So the first line for them is again nitrofurantoin or trimethoprim. For this time, you need to make sure you prescribe it as a seven day course again, a nice, quick and easy summary first line nitrile trim F and for second line, uh, you can consider if they have a diagnosis of pilot nephritis or prostatitis. And again you have the guidelines summaries on the page. If you suspect that it may be either or so let's go over, let's go over to this next question here. So this time we have a 26 year old female who presents your G P. We have a four day history of a stinging sensation when passing urine. She's currently emptying your bladder 7 to 8 times a day, which she states is unusual for her. She's also currently 17 weeks pregnant. She has a past medical history of migrants board and endometriosis. She's on paracetamol and ibuprofen regularly. She's got nitro ology, and an MSU sample is collected and sent off to the labs for M C. N s. So you're in the clinic. You've seen this patient. Please, could you write a prescription for one medication to alleviate her symptoms And again, make sure that you write the medication, The dose, the root, uh, the frequency and also the duration to get the full marks. Okay, we're getting a good range of answers. I'll just let the rest of you finish typing up your answers, and then we'll go through this question together. Okay, Good. We're getting a big range of answers for this one. So let's have a look. So it seems like the majority of you have gone for Catholics in for seven days. Um, which is very good. We've also got a mixture of some of our answers. We've got some people saying nitro, and we've got some people saying amoxicillin. So let's go through this question together. Let's pretend that I was in the exam and I got this question. How would I interpret this? So first thing to look at, we've got a prescription question. Okay, so what she come in for? She's got steam sensation when passing urine. Sounds like she's got a UTI with increased frequency. Okay. And she's currently pregnant, sir. What I would do next is I would hop over to either the b n f or medicines complete. If you got urinary tract infection, we get a nice treatment summary located here. So all this, um, interesting stuff to read, but we're not really focused on that for the PSA. We want to go straight to the drug treatment, So we've got a lower urinary tract infection in a pregnant woman. Okay, so one of the first line options. So the first line option it says here is nitrofurantoin, as we stated earlier in the session. However, we've got to remember to double check with the allergies. We can see here that this lady is actually allergic to nitrofuran tone. So if you did prescribe Nitro, you would have got zero marks for this question, I'm afraid. Okay, so she's not suitable for nitro. So what are the next recommendations or or second line, or we would give it as a first line because Nitro is not suitable. We can either give amoxicillin or we can give Catholics in now. Note in brackets, it says. For the amoxicillin, they only recommend giving it if you know that the culture is susceptible to amoxicillin treatment. So to get the full marks you would have had to go to Catholics in You can quickly do a control F and search for urinary tract infection. And here we go lower urinary tract infection in pregnancy. In adults, we can give it 500 mg twice daily and this duration for seven days. Let's go back to the question. We can see that an MSU has been sent off to the labs. However, we don't know whether or not it's going to respond to amoxicillin. So, technically, I want to say, if you did prescribe amoxicillin, you would get some marks, but you wouldn't get full marks because it's not the recommended first medication you would give for this scenario. The recommended medication would indeed the cephalexin 500 mg, or the twice a day for seven days, so those are some of the niche key points which they might try and throw in there to trick you, uh, for these questions. Okay. Next, we're going to be talking about neural tube defects. Let me just clear up the word cloud again. Okay, so here we are again. We'll start off with a question. We've got another 26 year old female who attends your GP appointment, and she's asking for pregnancy advice. She wants you to start to try for a baby and says that one of her friends has had to take tablets to prevent the baby from being born without a hole in it. Spine. She got past medical history of hemorrhoids and alopecia are IATA, and her drug history is not really that significant. So which of the following is the most suitable prescription? Would you prescribe folic acid 400 micrograms orally once a day until week 12, would you prescribe the same thing, but until birth, would you prescribe it at 500? Sorry. 5 mg orally until week 12. Throw the cast of 5 mg until birth. Or would you reassure the patient that she's not at risk of having a baby with spina bifida? Nope. Okay. So it seems like the majority of you have said one, which was to give the folic acid at 400 micrograms until week 12. So let's go through the management of preventing neural tube defects together. So, first of all, quick summary as to um, what a neural tube defect is is essentially, um, defect that occurs when the neural tube doesn't close properly during the embryonic development, and you can get conditions like spine a bit, spina bifida or an N carefully. The important thing to take away from this slide is the patient's, which are at risk. So if your patient has had a previous child with a neural tube defect, if they are on any anti epileptic medication, if they are diabetic, or I guess the most important thing is if they have sickle cell disease. If your patient is any of these, then you need to be thinking about um so you should be getting red flags waving around in your head because they will need a slightly different prescription. So what do we typically prescribe? So for all pregnant patient's who don't have any of those aforementioned conditions, there are a pretty low risk of developing a neural tube defect, so we would give them folic acid at 400 micrograms until week 12. For the majority of the high risk patients', we would give them a stronger dose at 5 mg, and again, we would stop that at Week 12. The most important thing is if a patient has sickle cell disease, then that's the only condition where we would increase the Foley cancer prescription, and we would carry it on until birth. So the main takeaway is if there are normal, healthy pregnant lady, give them a small dose of folic acid until week 12. If they're at a higher risk, give it until, um, so give out 5 mg, and if they have sickle cell disease, then you want to carry it on all the way until the birth or the delivery of the baby. So just to check that you are all paying attention, I've got another question here. This time we have a 29 year old female who's asking again fifth pregnancy advice. She is currently six weeks pregnant and states that her mother told her to come to the G P for advice about taking some extra nutritional supplements to support the baby's development Past medical issue I she's got off orthostatic hypertension, sickle cell disease and a factor five laid in deficiency. Drug history is nil. And, uh, in terms of allergy, she's got an aspirin allergy. So please write a prescription for one medication to prevent the formation of a neural tube defect. So remember, we want the medication. We want the dose. We want the route. We want the frequency and we want the duration. So it seems like I was managed able to get the message across to you guys. We have further cast if I'm in the rooms or leep once a day until delivery until birth until birth. There we go. We've got the main words and I was looking for very good. Is folate the same as further kassid for PS A? It's a good question. Um, I would have thought so. But let me get back to that. At the end of the session, we can jump onto the PS a website and see if they accept Foley and folic acid. A separate answer or not, and that will give us the definitive answer. So remind me to come back to this question at the end of today's session. Just to show you guys a summary. If you type neural tube defect, there's a nice prevention, um, page here and you can see here that those want to become pregnant or advice to have folic acid supplementation before conception. And until week 12, higher dose is recommended for those who are at risk of concede being a child with a neural tube defect. And this includes having a previous child with an N T. D being on anti epileptics, having diabetes or having sickle cell disease. If you go over to folic acid, you can see here prevention, uh, in those were low risk. We give them this dose here, prevention to those who are high risk. We give them this dose here, and we'll make sure you don't miss this one out. Specifically, it states for those with sickle cell disease, you want to carry out carry it out throughout the pregnancy. Okay, so I think we're actually almost approaching the end of our session. There wasn't too many, um, important acronyms or abbreviations that I could think of, which would be relevant for today's session. So if there are any questions. After this, we can go through them together. But this last one is something that really threw me off, and it took me a while to get my head around until I finally understood what they were actually asking for. So this one is covering a synod. Bitters. We have an 85 year old gentleman who again has come to your GP clinic for a routine review one week after increasing his ramipril dose from 5 mg to 10 mg orally once a day and below are his most recent blood test results that were done so his blood test results from today show that his sodium is 137, his potassium is 419, he's urea is 6.8 and his creatinine is 117 with an e g. R of 86. You compare this to his blood tests. Um, what's that about two months ago? And his sodium's 135. His potassium is 4.2. His your ear is 4.9, creatinine is 86 his egfr is 93. So which of the following is the most? Pardon me. Sorry. Which of the following is the most suitable management option. Would you? A carry on the round pill at 10 mg be. Would you stop the ramipril completely? See, Would you switch back to the 5 mg or only once a day? Uh, D Would you recheck his BP while she's in the clinic? Or E. Would you recheck his bloods again in two weeks? So the options are just carry on the ramipril stop it completely. Go back to his original dose, recheck what his BP is like in the clinic, or recheck his Bloods in two weeks time. So you guys to have a bit of a think before answering this question because it's trickier than what it might seem like. Okay, so it seems like we're getting quite a fast split in terms of the answers. It seems like the majority of you are split between options one and 31 was carrying on the dose at 10 mg, and three was reducing back to 5 mg. We've got some people who also actually saying to recheck the birds in two weeks. So the correct answer for this question was indeed actually Option three, which was to switch back to 5 mg. So let's go through this together and and I'll try and explain why that is with a C inhibitor management for hypertension. There's one important bit of knowledge that you just need to know. As frustrating as it is, this information isn't available on B N f. It is available on CKs, but I'm 99% certain that you don't have access to CKs. It'll be classed as cheating if you do go onto it, unless your university specifically says you can. So this is a bit of knowledge that you need to take away from this session, and I'm afraid you'll just need to learn this. You wouldn't be able to find it anywhere on B N F. To the best of my knowledge, or at least I haven't been able to find it. So when you start a patient on an ace inhibitor, or when you increase the dose is you need to be keeping an eye on either their e g f R. All that created him if the egfr drops, but it drops by less than 25% or again if the creatinine increases. But if it increases by less than 30% the recommendation is that you don't modify the ACE inhibitor dose and you would recheck the levels in two weeks time Now. Conversely, if the egfr drops by a greater than 25% or if the creatinine increases by greater than 30% in a real practice, you would investigate whether there any other causes, like if the patient was volume depleted and they were going into a pre renal AKI. Or you would consider if there are any other drugs which may be contributing to the renal function dropping. For example, if the patient's on any NSAID, Xeni vasodilators any diuretics but for the purpose of the P S. A. In terms of managing this patient in the acute setting, you've got to stop the ACE inhibitor dose. Or you would reduce the dose to a previously tolerable dose and then recheck were in 5 to 7 days, so to summarize, if they have a bit of a drop in the renal function with those specific numbers. But it's not greater than 25 or not greater than 30 you would keep an eye on them and you'd recheck the levels in two weeks time if the egfr does drop by greater than 25% or the creatinine does increase my greater than 30%. If you've newly started the myelination until you would stop it or if you have increased the dose, then you would cut back to the dose and you would recheck again in 5 to 7 days. So this type of question, what you actually need to do is you need to get your calculators out, and you need to calculate how much change there was. So, um, how do we do this? So today's creatinine was 217 and previously it was nice to be 86. So we can see here that the patient has had a 36% increase in their creatinine. So because it's greater than 30% you would have to cut the dose down. Um, and let's just double check with the U. G F R 86 divided by 93. What's that? Um, so that means that the EGFR has dropped by 8%. So the e g f l. We're not actually too worried about, but the quest, uh, being sorry. The C care specifically recommends either. Or so it's either the egfr dropping or the creatinine increasing. And because we've got one of those two, which is positive, that created an increasing by 35%. We need to switch the dose back to 5 mg or really once a day. And it sucks that this is a bit of knowledge that you just need to know. But at least we've covered it today. So you guys will be able to take this away from today's session and you'll be able to, um, hopefully if this does come up, you'll know the how to answer the question now. So just to summarize, we've got, uh, all the key treatment summaries. The links to the treatment summaries are on the slides here. And let's just quickly go over to the CK. So again, this you wouldn't have access to this, uh, in the actual exam. But we can see here what do the state? It's down here. So if the egfr decreased by less than 25% or the creatinine increased about less than 30% don't modify and recheck. If it does, then the recommendation is I have to stop it. Or to reduce the dose to a previously tolerated lower dose. So that is, those are the two options that you have when it comes to this sneaky ace inhibitor question. Okay, So just to remind you guys again next week, we'll be doing the schedule data interpretation session, and then last week's drug monitoring session will also be added on next week. Both of these will be covered by Doctor seven, and it will be from nine o'clock till 11. 15 with a short break in between. Um, but this is the last session from myself. We'll be doing the mock session, um, in two weeks time, so make sure you will tune in for that. I'd be really thankful if you could all provide some feedback for today's session. And if there are any questions, it doesn't have to be related today's session. It can be from any aspect of the P s. A. If you guys have any questions, then feel free to put them in the chat or to put them on slide. Oh, and I'll go through some of the questions now whilst we still have some time left. So that's sorry. So the next session will be on the 19th of November So it'll be next Saturday at 9 a.m. u k. Time, and the slides will be sent out with the recording. I'll try and upload them as soon as I can. Okay, so we've got a question saying, Are there any good resources to learn what we're what? Medications to stop before surgery? Uh, that's a good question. Um, in the past, the PS a book, there is an acronym that they use, which is quite good. Um, let me see if I can find what it was. So, uh, my main advice would be, um don't try not to stress too much with regards to what medications to be stopped. Or like specifically, what timings? They should be stopped before surgery. But the this was the acronym that is provided in the past. The PS a book. Let me just put in the chat. So it's I lack op stands for insulin, lithium anticoagulants, Uh, c o c p. Potassium. Sparing diuretics, oral hypoglycemics and pull in the pill slash of race inhibitors. So these are the medications that you should be stopping before surgery, and there are different indications as to when you would stop them. So the CS, C, P and the HRT. You would stop it four weeks before surgery. Medications like lithium, you would stop the day before potassium sparing diuretics on ACE inhibitors. You'll stop on the day of surgery anticoagulants and anti platelets. Well, it really depends on what they are on, so it's quite variable. Um, you wouldn't be expected to learn these times Girls for the PS PSA, and what you would normally do is you look at your local hospital policy to see when you actually stop it. And it's the same thing with oral hypoglycemic drugs or insulins again. It does depend on what type of surgery they're having. If it's major or minor, what medications they're already on all that kind of stuff. Um, the important ones are any hormonal therapy like the C, o, C, P or H R. T stopped four weeks before lithium you stopped the day before and any diuretics or a snippet as you stop on the day of surgery. But the acronym that they recommend from past the PSSA was a laptop, and I felt that was quite useful. There was a question when we were answering the previous Oh, it was the folate and folic acid. Let me just log onto the PS PSA exam website now and we can find out the answer for that. Yes. Okay, so you can see when your time folate. We don't get an option as folic acid is the only option there. So for specifically for writing your answers when it comes to neural tube defects, make sure that you prescribe it as folic acid. And you see you've got your 500 mg tablets or your 400 microgram tablets. I didn't know there was an oral solution, so that's pretty interesting to know. Yeah, you wouldn't prescribe as far that you prescribed as folic acid. OK, so just to run for some of the questions on slide Oh, will there be an AM's A. P s. A mock exam for us? Yes, there will be a mock exam, which will be happening in two weeks time at one o'clock. So that will be the 26th of November at one PM uh, will be is the current scheduled time for the AM's A P s a mark. We have the previous sessions all recorded on our medal page. Um, if you jump over to medal and go on our A counter and to England. You should be able to access all of the previous sessions. I think you might need to be a registered member or medal, but it's a free registration. So recommend that you do that and you'll have access to all of our recordings, as well as all of the other resources that are available from the different groups on metal. The monitoring requirements when starting a patient on ramipril is essentially what I was stated over here. You just want to keep an eye on the egfr 1 to 2 weeks after starting the treatment and again 1 to 2 weeks after each dose is increased. Um, things like BP measurements. I think that's less relevant for in terms of what raw knowledge you need to learn before the exam. Um, so whenever you start someone on an ace inhibitor or increase the dose, you checked the real function in a week's time, see if they have this drop or not. And then, um, that is when you would consider if you need to change The dose is how long does ramipril need to have an effect. That's a good question. I have no clue. Actually, um, it seems like they say, because they say to check the BP four weeks after each dose Titrations I would assume it takes, um less than four weeks. To my knowledge, I don't think it cooks in straight away. I think it does take some time for it to build up and have a proper effect. Will you repeat the last answer? Yes. So the last answer was indeed it was three, which was switched back to 5 mg or the once a day. Even though they're creating in, it's still, even though both creatinine measurements are within the normal range, What you have to do is you have to calculate the actual percentage increase. So let's just double check to make sure I got my math right. B 117 divided by 86 and then, if we time that by 100 and then minus 100. So they were initially at 86. That's their baseline measurement, and then they're creating an increase to 117. So they have had a 36% increase in their creatinine. And just to double check that. Let's just make sure 86 times one point what did you say? 36. And that gives us 117. So they've had a 36% increase in their creatinine dose. So even though it's in the normal range because of that increase, that sudden increase in the in the creatinine we need to cut it back to a previously tolerable dose, which was the 5 mg. So hopefully that explains the answer. What is the difference between fresh frozen plasma and Cryer precipitate? It's a good question. Um, let me just go back to the options. Where was it? So your prothrombin complex concentrate is essentially, uh, to the best of my knowledge is essentially a nice, concentrated package of your factors. 279, 10 fresh frozen plasma. You're really testing my knowledge. I'll be honest. I don't remember off the top of my head what it is. Um, what I can say is, if we go to the oral anticoagulant summary, it tells you you know that the target iron are And what? Um, which one's you? They recommend target. I n r 2.5 tells you what they would recommend. 3.5 duration blah, blah, blah again under the hemorrhage section. Here we go. So we can see that the recommendation for a major bleeders you would always give, um, dried PCC if if you have it available. Um, their recommendation is if you don't have any available, for example, you know, you just don't have any stop at the moment, but, um, on the wards, you do have some fresh frozen plasma, Then they recommend giving at least that, but it's not as effective as the PCC. Hopefully, that answered part of your question with checking side effects for a list of medications such as those in the PSL. What's the most efficient and fastest way to do it? Um, the most efficient and fastest way that I'm aware of is still quite a long winded way. The best way that I would recommend is to jump on two medicines complete and not the B n f. Um, how would I do it? So let's say I'll come with a list of random medications, a lot of pain. Ramen pro. Um, I don't know what what? We have morphine we could do, um, hyper fin. I'm struggling to think of medications now, Delta Kearin. Uh, let's take water in there as well. So just type out the entire list here. And then he'll say, Oh, there's no results for that. Obviously, you're not expecting there to be any results. But then, if you go to interactions here, it will automatically search, um, each of these interactions. And here we have a list of various things to be aware of so we can see Delta part and cause bleeding, as can ibuprofen. So there's a severe theoretical risk you can see orphan adults part would increase the risk of bleeding. I have proven more foreign, so this is the quickest way that I'm aware of. Um, it's the only way we're using. My state's long winded is because if you have a list of seven or eight medications, you're going to have to, um, type up each of these options. The reason why we don't recommend the B n f is what was the last one? When you do social list, they don't give you that kind of condensed summary. What they do give you is this interactions list. So then, if you want to, for example, morphine mm, it gives you a list of all the different types of interactions a little bit, but then you'd have to one by one. There's no way of combining it altogether. So then we would have to go. Control left is I'm not getting on a list. No, you have to do. Okay. Is ramipril on the list? Know, and you have to go for it one by one by one. I mean, it's it's not feasible. So if you jump on two medicines complete and if you just type more at once, then it will give you the entire list of potential indications. The other thing is, of course, if you have done enough practice and you've answered these types of questions before, you'll tend to know which ones you'd sort of be looking out for. So with this, you can already tell Okay, the patient's are more for him. Uh, which is a blood thinning medication. They're on dalteparin, which is a low molecular heparin. So already already, you'd be thinking, Okay, these two, they shouldn't really be on together, and then ibuprofen as well has a risk of GI bleeds. So these are the three medications. If you looked at this. Would you be thinking? Okay, Those are the ones that I should be looking for first, um, so it does come with practice and experience in terms of answering these types of questions again and again. Oh, I see. I meant in terms of side effects of each individual medications, not the interactions. Sorry. Uh, the side effects, the the best way would be to go on to the medication, clicking the side effects part here. And I was reading through, um, or doing and control F. And, for example, calcium channel blockers can cause peripheral edema. So if you just did peripheral, then we can see here. Okay. It's a common or very common side effect of peripheral edema. So again, using the control f and finding quickly searching for what side effects you're looking for is the best way. The only annoying thing is sometimes they will word it differently to how the question states it. So the question might say, Okay, the patient has come in with lower limb swelling. If you type in swelling, it's not going to come up. So you need to be able to recognize, um, that peripheral edema is the same thing as lower limb swelling. So sometimes it won't be as easy as doing a control left. In that case, you just need to quickly skim through and see what you can find. Uh, that's the only the way that I can think of. That's the way that I did it. Hopefully, if there is a more efficient way, then someone else will be able to, um, clarify in the chat. But that's how I did it. Okay, so it seems like a lot of people are asking about, uh, f f p p c c Cryer precipitate. Um, it's something that I'm not fully researched or I'm not confident to answer any of these questions on. So what I can do is, um, on the slides for today's session. I'll have a quick summary at the back as to what the different types are, what is actually contained in each different sample and what the indications are for that rather than me going through and Googling all the different answers. I'll do a little summary slide at the end of the session, uh, so that when these slides are out at the end, there'll be a slide on the different types of, um, the difference between FFB cry precipitate and PCC. So I'll have to slide at the end before that gets sent out To answer all your questions with regards to that, do we have access to both? Be an FM medicines complete in the PS exams. You should do again. This is something that you need to double check with your university. Imperial. Um, they strongly recommended to use medicines complete. Uh, I think it was more of a personal preference from our lead tutor, but he said that the med the interface for medicines complete is nice to you. And as I said, you have the benefit of the interactions checker. The only thing is, when you log in normally after logging via Shiva life and for us, uh, we had Imperial college, so make sure that you double check with your university. I'll try logging on to, um, medicines complete whilst you have the time. If not, you might need to set up an account to do so. Now, sometimes I know that you might. It's not easy to find the interactions option. For example, Right now it's not available. I can't type so when you type a lot of pain and sorrow Grill, for example. Right now, we don't have the interactions option here. The key thing to do is if you don't see it, you need to make sure you're clicking the B n f or the B N F C. So the moment you click B N f, you can see that you have the interactions option that pops down there. So hopefully Bushra, if you try that, that should take it. Uh, that should take you to the interactions checker. What I would recommend is you normally have, like, a good 10 minutes or so in front of your computer so that you can log in so that you can set up all the pages. So I would recommend the moment you get on your computer. At the moment you've got the exam loaded up and ready to go. Go on to your medicines complete because you can have as many tabs as you want. Open. Go on. Two medicines complete and then make sure you've got this interactions checker pre loaded up just because it stays that extra bit of time. So then when the question does come up you can just type in whatever you need, And then you can, uh, ask the questions. So my only other advice would be, uh, in terms of preparation for the P s. A. Make sure that you use this a lot because this interface can sometimes be a bit clunky to make sure you know how to use the interactions checker before the exam. Okay, so I think that's the majority of the question. Let me just want to make sure, um so that should be everything. Thank you very much, everybody for who's had hung out to the end of the session. Uh, as I said, next week's session will be at nine AM and we will be doing, uh, last week's and next week's session together so you'll have a two hour session on data interpretation and drug monitoring. So we look forward to seeing you next week and then in a fortnight's time, will be our last session when we'll have our final mock exam. Okay, there's no more questions. We will end the session there and thanks very much, everybody See you next week