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Hi there, guys. Thanks very much for everyone who's joined on time. We'll give it a few more minutes for everyone else to join the session. And if someone doesn't mind dropping a message in the chat just to make sure that they can hear me In the meantime, for those of you here here, if you don't mind scanning the QR code or you can just click on this link in the chat, it'll take us over to slide, uh, where you guys will be able to answer the questions that will go through today. Okay, um, I guess we'll be in now, so thank you very much. Everybody has joined that for today's session. My name is Chang, uh, currently NFL doctor studying at Milton Teens Hospital. And we will be going through how to answer questions related to palliative care. Uh, during the TSA. Um, I'm feeling a bit groggy today, so I apologize in advance. I just had my vaccines yesterday. Quick reminder for everyone else is here. Make sure you get your coat and flu shots. So again, before we begin bunch of group effort on doctors who prepared this cause to help you as a supplement for UPS A. And if any of the patients are cases are, um, related to none of the patients are related to real life scenario, and any similarities are coincidental. And want to always consult your university for any exam related quiz and support. And always consult the TNF or medicines completely accurate up to date information with regards to drugs and prescriptions. And before we begin so quickly, shouted out a message from, uh, we're looking for another tutor to join our team on the 21st of November. There's going to be a session about psychiatric emergencies. We're going to introduce who is willing to give a talk, Uh, when I was online covering the mental state exam and some key emergency scenarios. Just new electrical movement syndrome, secretary syndrome, etcetera. So anybody who is here today is interested in giving this teaching session, and then we would like to get a bunch of feedback from the portfolio. Please do shoot an email to I. CSM dot dot academics at gmail dot com. So today is learning objectives. Based on the feedback that we've got on the previous sessions so far, it seems like a lot of you want to focus a bit more with regards to drug conversions, looking into opioid analgesia and, uh, on the, uh, pain bladder. So that's what we're going to be focusing on a bit more today, But we'll also be covering a bit of the non analgesic side of palliative medicine. Um, and somebody asked me during the third session what the past Marc was for when I did the TSA. So for the specific exam that I did on the date that it was held, the past Marc for us was 63.5%. So in my opinion, I think that's a fairly, um, decent Pathmark. And most of you know, all of you actually should definitely be able to pass. Uh, today's, uh, after attending with all costs. So let's just quickly talk about what the care medicine actually is, according to the definition, is, um, it's all about improving the quality of life of patients and also the families of the patients. Uh, for when they're facing challenging challenge is associated with life threatening illnesses. And it's not just the physical aspect, but also the psychological, social and spiritual aspects of medical caregiving. As well, the way that I like to think about it in a in a real life practical day today scenario is, um, for me, when I'm practicing palliative medicine, it's all about providing adequate medical care, and I will leave pain. Any symptoms always stress caused by a serious illnesses. So it's not always just about end of life patients who are dying. It's about anyone really who is suffering from various symptoms that they may have from the medical comorbidities. Uh, about that. But it's actually back on with some actual questions. So let's start off with this case here. We've got an 85 year old man who's been on the water the past three weeks. He was initially admitted following a community acquired pneumonia, and he's currently waiting for his care package to be increased before discharge. He got a D in a fall in place. So during the morning walk around, he starts complaining that he got some back pain and the consultant asks you to modify his allergies here in terms of your past medical history. He's got hypertension, benign prostatic uh, and he's had an MRI in 2004, so this is a list of his medications. He's on aspirin, ramipril, simvastatin, finasteride, paracetamol and he's also got a g t n spray. So which of the following options do you guys think is the most suitable next line option? Would it be a codeine phosphate, 60 mg orally four times a day? Is it be or more? 2.5 mg, uh, orally every four hours. Is it paracetamol? 1 g oral EKGs. Is it ibuprofen? 400 mg P. O. Q. D. S Or is it pretty? Small? 1 g IV, Q. D s. And if you guys want to go on to the slide, though. Oh, sorry, I've heard that audio is cutting off a bit. Give me one second. How about now? Is it? Is the audio better? Oh, I'm sorry. Let me just jump up to meddle again. Is it much better now? Perfect. Sorry about that, guys. So I'll just quickly go over the question again. So it's an 85. Actually, I'm sure you'll be able to read it all, but it's an 85 year old guy. He's come in with a cap, and he's complaining of back pain. So your consultants asked you to change his pain Relief. Which of these five options would be the best stop next line, uh, to monitor is pain relief. And if you guys want to jump onto the slider to answer the question, just give it a few more seconds. Okay? So based on the word cloud we've got here, it seems like we've got a mixture of ibuprofen versus codeine phosphate. Um, let's just stop the session jump back. So this, I will admit, was actually a bit of a trick question. And the correct answer was actually paracetamol 1 g or Aleve, two MGs. Now, the reason why this is the correct answer is because if we have a closer to the drug chart, we can see that the paracetamol is described as 1 g Q d s, uh, just on prn side. So they should stay over there as well, but something on oral party tomorrow. But it's on the prn side, so we don't actually know if he's been taking it regularly or not. Of course, in real life clinical practice, you look at the drug chart and see how many times he's had it. But the next step, according to the wh a ladder would be to give him regular paracetamol, and then you would review him in 24 hours to see if this pain relief is well controlled until after then. You could consider about escalating into different medications, but the first line would be to actually change from PRN direct ability to mall. And just to reassure you guys, I've made the questions quite tricky. The PS PSA exam questions typically will be a bit easier. Um, I've made them harder for teaching purposes. And so if you guys and when you guys will be able to answer these questions, you should be pretty much fine for the actual PS PSA exam. So let's go through the W H o pain bladder. The first line for pain relief is obviously your typical non opioid medication, so your box standard paracetamol your ibuprofen and any other incidents Now on top of that, the W two also recommend giving an infusion therapies. And, uh, this can include medications such as antidepressants, and he had left. It's muscle relaxants, corticosteroids, your topical capsizing, that kind of stuff. And so those things that you can consider adding on top of your non opioid analgesia. Now, of course, if the patients on this and it still complaining of pain, we've got to think about escalating it. So the next step would be starting some week opioids and your typical week. Okay, DC, in clinical practice are codeine dihydrocodein, Uh, tramadol and Hydrocodone Mall. Just a quick note for those of you. If you want to wear a condom, all is a mixture of codeine and paracetamol, and often in the TSA, they will try and treat you out by prescribing cocoa, the mall and paracetamol. And then you can calculate the dose is actually be taking more than what is recommended for paracetamol. Um, sometimes it might also include codeine. Hydromorphone is essentially the same thing, but instead of having codeine, it's got hydrocodone in it. But again, it's the same concept. Now, the same week isn't adequately managed with this. Then we got to start thinking about adding stronger opioids. So this includes your morphine, oxycodone and the fentanyl, Um, and all that jazz. So let's move on to the next question. If you're like me, uh, 74 year old man now who presented to the emergency department is going to shorten and externally rotated. Left hip X ray reveals a left sided neck of the hip fracture. He's got a past medical history of hypertension. Osteoporosis? Uh, it's not getting allergies. He's on my ramipril for hypertension and not a member of the osteoporosis. And you can see this X ray. He's got a nice fracture there of his left ear. He's been prescribed born grandma party tomorrow or a week. You just buy the emergency department team, which has been taking regularly, Uh, but he's still complaining of some pain. And so my question to you guys is which of the following would be the most suitable Next line analgesia. I'll do the five options here. Uh huh. Let me just open the would cloud again. So if you guys want to drop your answer on the slide Oh, sorry. How's the audio issue now? By the way, I think it might be an Internet problem more than anything. Okay, so let's have a look at the word cloud. So it seems like the majority of you have gone for ibuprofen and a fair amount of you guys have gone for or more. So the correct answer was actually indeed, your mouth this again. It's frustrating, but it's a trick question, typically in terms of family, according to the wh a stepladder, most of you guys are right. The next time we would think about would be adequate for adding and 75 of the parents use more. However, the reason why I specifically added this question is because the PSSA will also assess a bit of your medical knowledge. And in terms of hip fracture management, the nice recommendations are currently actually state that and said they're not recommended for pain relief when it comes to fractures. So once you've given your paracetamol, if that's not controlling the pain, the next step actually is to increase it to opioid analgesia. After that, if it's not controlled, then you would consider femoral nerve block. So the correct answer in this case was indeed or more. I just want to reiterate that this is solely for the management of hip fractures, which it would be mean for them to add. But it's good for you guys to know. Now that and since we're not actually recommended, but in pretty much 99% of the other pain relief questions, the next line would indeed be either break them. So in terms of the W h O pain ladder, let's skip straight away and have a quick chat about strong opioids and morphine. Uh, specifically because this is where the majority of your calculation questions will be based on. So I'm thinking about Okay, what conversion and oral morphine management. The first thing you've got to understand is that there are two different preparations of morphine. You can have your immediate release, and you can have your modified release tablets or capsules and essentially immediate release. Uh, basically means when they take the medication, it will release quickly into the system, and the pain relief will be faster. The benefits are that you can provide quick and easy pain relief, but the negative aspects are that they wear off quicker and so you can see here for this patient who's pain level is the salary, but this is the pain level you can give them regular immediate release. Morphine. Soft paper. They're going to ask for it quite often, and so this patient has had 60 mg of morphine in total, but six times a day. Whereas if we look at modified release formulations. These will release the morphine over a longer, slower period of time, and not only that more convenient for the nurses, because they only have to administer it twice a day rather than six times a day. We also have the additional benefit. Of course, the patient is going to hopefully be in pain, Um, less times a day now. Of course, if the patient's pain level does increase and they have these long periods where the patient will be in pain, we've got to think about adding rescue doses. And typically in clinical medicine, you will see this prescribed as or more. And this is when they have breakthrough pain. So breakthrough pain. All that means essentially, is when the analogy that they're on isn't enough to control the level of pain that they're in. So during these periods, we've got to think about adding some extra, um, extra rescue notices. Okay, So when it comes to calculating questions like this, the first thing you need to do is to establish the total amount of morphine that they have had over the 24 hour period. So this will include your morphine modified release tablets. This will include having more, more. This will include having codeine, tramadol and various other opioid derivatives. Once you calculate the total amount of morphine that they had in 24 hours, the next step is quite simple. All you need to do is convert that into a regular medication dose. So what does this all actually mean? Well, let's go through step by step. Let's see, we've had a patient who's been on morphine 20 mg twice a day, and they also had four doses of all the more 5 mg in the last 24 hours. The first step is to convert this over and find out how much more thing they had in total. So in the last 24 hours they had to 20 mg tablets, and they had 45 mg of civil and more so 20 times 2345 times four. That means about 60 million lbs in total. Now I want you to do next is essentially the majority of the questions, and in clinical practice you'll describe this as a by a B C D formulation, so they had 60 mg in total, so we're going to give them 30 mg twice a day. The official guidelines on the TNF do state that modified release preparations can be given IV is the 24 hour preparation or 12 hour preparations. But the most of the questions that the essay and in real life clinical practice, we tend to go for a 12 hour prescriptions. So the next common question that you'll get when it comes to opioid conversion is to calculate the breakthrough dose. Um, and the concept is very straightforward. It's pretty much the same as before. The first step is to establish the total amount of morphine and a cat in the 24 hour period. And then the next step is you either divide that total amount by six, or or some clinicians will divide it by 10. But generally the box channels number is six. So you can. What do you mean by that? Well, if we take the case that we just talked about just now, if the patient was on modified at least 30 mg twice a day. But that means that in a 24 hour period you have 60 mg in total, so if you divide that by six, that will give us 10 mg, and that will be our breakthrough dosage. So what we'll do is on the prescription chart. We would write up or more 10 mg on the PRN side offer any additional breakthrough pain relief. I'm just going to check to see if there are any questions on metal so far. Uh, okay, Uh, that's a good question. Um, typically, it does depend case by case, for example, for some patients, they might, um, have an allergy or contraindications to answer is in which case you wouldn't think about giving them ibuprofen. And you might think about giving a different, um, non opioid analgesics. Or you could just go up to the next step on the labor. You've also sometimes got to think about the actual clinical context just by looking at the patient. Does it look like they're in a lot of pain? And do you think that giving them ibuprofen isn't actually going to do anything? In that case, you might also think about skipping up to the next step on the ladder. But that's all. When we're talking about real life clinical practice in terms of the pas a, uh, the general advice would be to try. You want to, um, different options from that step? If it says it says in the question of the patient is still in a lot of pain, or if it says that they've already tried. A few different formulations are a few different medications. That's usually when you think about escalating to the next step. Okay, so let's talk about the in between, which is the weak opioid. And this is all about, uh, we're going to be focusing essentially on codeine, your dihydrocodein your tramadol. So the opioids, which aren't mixed with anything else. So this is a really useful conversion chart, which I have taken straight from the B N F. And this will tell you the necessary conversions from any other medication into morphine. So the key conversions to be aware of is when you need to convert from codeine down to morphine or when you need to come back from morphine orally to morphine, South Carolina. I d. So essentially, what this means is, if the patient was on 300 mg of codeine, the level of energy so that's given to the patient is the same as 30 mg of morphine. There's nothing else that you take away from this all you need to remember at least two numbers here. When you're converting someone from codeine morphine, you divide it by 10. And when you're converting someone from all morphine to some idea what I am morphine divided by two and I'll show you guys where this is located on the TNF. Later on, let's run through, um, this example question. So I'd like you guys to re prescribe analgesia for a patient who is currently taking 60 mg of codeine four times a day, and they've also had three doses of or more 5 mg. So I like to convert this into morphine sulfate, modified release B D or 12 hour early. And I would also like to calculate the breakthrough dose. So I'll give you guys a feeling. It's just to do that. So just to reiterate, remember, when we're converting from codeine into morphine, we calculate the full codeine dose and divide by 10. And what you guys have your answers for the morphine sulfate and the arm, or if you want to put it on slider or in the chat, Okay, we'll give it a few more seconds, and then we'll go through it together. Yeah. Getting some answers through on Slider. Thank you very much to those of you who have answered. Okay, so this is good. We're getting a big mix of answers. Let me see if I can show you guys. So it seems like everyone has come up with different answers. Um, for both the regular medication as well as the PRN breakthrough doses. Okay, let me just stop the the voting and let's go through this together then. So first of all, we need to calculate the total amount of codeine in that they've been 90 60 mg tablets four times a day, so they had 240 mg of codeine. In general, this is equivalent to 24 mg of morphine. And here is the magic number. All we need to do is to protect those by 10. The thing that your next, um they have to do is to calculate how much or more than that because you've got to remember the three doses of breakthrough medication because they're paying isn't well controlled. So if they had three doses of the 5 mg of or more, that's 15 mg. So 15 plus 24 will give us 39 mg of morphine in the last 24 hours. Of course, you don't typically have 39 million tablets, so we'll round it up to 40 mg in total and as a 12 hour prescription that will come out to 20 mg of bleeding so you can get more things for a modified release. 23 22 tablets twice a day. So the next part of the question was to complete the or more prescription. So what do we do? We take the total dose. So that's 40 mg, and then we deployed by six. But it gives us a really awkward number. We got 6.666 regular, and in clinical practice, we wouldn't prescribe as that, so we wouldn't prescribe. It was 6.66. We wouldn't describe seven. We would prescribe six, because everything you need to think about is how we make a lot of nurses easier. And what we mean by that is drying up. Six and 2 30 mg of normal is going to be very difficult. For the nurses. There is the risk of errors. Um, so we've got to think, Do we prescribe the P R N? UH, 5 mg, or 7.5 mg. So when it comes to the more and more we typically prescribe, it always prepared as 2.5 mg Holocaust. And so it's a lot easier for the nurses to administer the affordable when we did it in doses of 2.5. So when you get like 6.666, we got the same or down or do you? Uh, And after the two options, 5 mg would, um, put the patient at risk of underdosing, and therefore it's going to be an effective, whereas 7.5 mg. Uh, we're more likely to get that pain under control, and therefore it would be more appropriate when it comes to higher doses. You got to take that with a pinch of salt and think okay to be on the safe side, and maybe you could prescribe it at a lower dose. But when it comes to questions like this, when we're talking about a relatively low dose of morphine, we tend to overdose them rather than under dose them. A quick note about using your morphine in clinical practice. Remember that actually, this is also rather than 50 s as well or more is the brand name of the drug is not the official name. And so when you're prescribing, you wouldn't be prescribing it as or more you would be prescribing it as morphine oral solution. The other thing to be aware of is to make sure I always describe as the dosage in milligrams and not the volume in millimeters. So this is the screen start taking from E. K, which the system, you know. But sometimes you can see when you take morphine. You have a ton of options here, and everything in this red box is your more type of morphine or a solution, and we can see that there's a lot of varying concentrations. We've got 10 mg per five mils, 10 mg a bill, and we also have 20 mg per meal. And so it's very important that you're sorry about the delay responding volume. Let's say you're instantly prescribed. It's five millimeters. If the nurse chose this one here and there will be administering 10 mg of morphine, whereas if you get five mills of this, preparation will be giving them 100 mg of morphine. A top of that. There's a lot of, uh, essentially a number and actually happens to make sure you explain things I always describe as a dose. Not, uh, I think our trust here is that you can see some option twice on the second one. It actually fills in most of the prescription form for you. So when you click this, this is what actually pops up. It gives you milligrams already. It tells you that it's going to be oral liquid every four hours on the prn side. So in the majority of trust, they should have safer ways of administering or prescribing medication. But you've got to always make sure that you're prescribing it correctly. So all we do is we will type either 5 mg or 10 mg or 7.5 mg. Um, as we discussed in that practice question. Okay, so here's the next question, and this is a question which when I first saw when I started realizing, yes, I felt very hard to answer. But actually, if we take the same principles that we've been doing so far, it's a rather to be easy question to answer. So during your walk around. You see a surgeon for probably. He was admitted following a community acquired pneumonia, and she's complaining. A bit of 30 chest pain. She's already on a lot of allergies here, and the consultants says, Okay, let's increase the analgesia to finish the patch. Um, just a tightness. When you get the truck chart, you notice that she's had four doses of her or more than the last 24 hours. So she's got metastatic breast cancer in there. She's on Copaxone Class I. The TVs for the community acquired pneumonia. She's already on morphine for paperwork release, 60 mg twice a day. She's taking the expand from a F, and she's also taking, um, or more 10 million grounds on the They are inside. And now she's already had four doses. So my question for you guys is, um, to please write a prescription for a fentanyl patch. I'll just reset the but cloud again. Okay. What? Okay, we've got some good answers coming in on the word cloud so far. Remember that we want the medication. We want the dose. We want the root, and we also want the frequency. And whilst everyone else is finishing off the prescription writing, Charis has asked a really good question. So they've asked, So I can break through. Morphine only been taken every four hours, So it's essentially the answer is both Yes and no. I think technically, there is no maximum upper limit as to how many times a patient can have the breakthrough or, um, or sometimes you'll see in questions. And maybe even in clinical practice, a patient might have had eight doses, Um, in the last 24 hours. But what we tend to do is we prescribe it as four hour early, and then we will monitor the patient over the next 24 hours. Now, if the patient is taking 5 mg of or more, um, every four hours over the last 24 hours, then that gives us a good indication that we're not adequately managing their pain control. And then so you typically prescribe it as that you would monitor them for 24 hours and see Oh, do we need to modify? Do we need to increase, or can we decrease the level of analgesia that they're having and essentially the reason why we put it every four hours so that we have that upper limit. So if they start reaching the upper limit, that's when we start thinking Okay, maybe we need to change the level of pain relief that we're offering the patient. So it's more as a safety issue. But it's also so we can monitor and titrate the level of analgesia that we offer the patients. Okay, so let's have a look at the word cloud. So the majority of you have come to the correct conclusion. The answer is a fentanyl 75 patch. However, if you prescribe it just as this, you wouldn't technically get the full marks. Um, so I will demonstrate what I mean. Okay, so here's the question again. So it seems like the most of you getting the hang of the the steps that you need to take in terms of converting, uh, easier first two weeks free. And it's kind of clear the total dose that they had so many things 60 mg twice a day. So that's 120. And they also had borders of 10 mg or more. That's over 40. So that brings us to a total of 160 mg of morphine, and now it seems like most of you, by now have understood where you can find all the charts. But if you don't know all these your head over to the TNF and search prescribing in palliative care or you just palliative care and that is the key that will be going through later, we pretty much have to answer any and all palliative questions. When you do go to prescribe the palliative care and you scroll down, you will have this nice charter here, and it tells you that this is a 72 hour fentanyl patch conversion chart, and it's approximately equivalent to the following 24 hours. That's a horrible. So if the patient was taking around 100 mg, then you'd consider giving events and 50 patch or if they were taking 180 mg. Then you consider the 75 patch. Now in our question here that I've been taking 160. So proxies me is close to the 180 dose, rather than 100 twenty's. And so therefore, we started with the fentanyl 75 patch and that you can give them that we would monitor to see if that was working well or not. And then you can obviously, um, consider any breakthrough medication changing the patch. But this is a patch that goes on every three days. So it's got four marks on this question. It is the official prescription that you have had to write them down because if we go back a bit, question was asking for medication, those roots and frequency. And so we've got medication. We've got the dose, which is one application. We've got the root, which is topical. Um, but the frequency, which is every three days, you might think that this is the dosage here. But this is actually the name of the medication that we're giving. And just to back myself up, this is from the official TSA website. So when I said on the third session, when you have a difficult question like this when you're not too sure how to actually write the prescriptions, go onto the TSA, go on to one of the more exams, choose any question it doesn't matter and how to fiddle around to see how the prescription should actually be written. So you can see here when you go on to more question. You have an event now. It will give you the medicine as this and not 75 McG around for our patch. And that's through the drop down. This and the actual post would be one application. Uh, of course, it's going to stop the beginning as a patch and the frequency, because these are sent to our matches will be every three days. Let's have a good break here, and we will actually go through, um, how to use the TNF and medicines complete to get to the palliative care questions. So on be an effusion type palliative. It's going to give you this drop down here. Same wave medicines complete if you search palliative care and enter. We've got you to make sure you choose the TNF one rather than be an F two Children. Unless your questions specifically asking about pediatric palliative care. And here you've essentially got a list of everything that you need to know, um, for palliative medicine and you can see here we have the fentanyl patch conversions you see up here, we also have conversions for buprenorphine patches and this was the conversion chart that I showed you guys earlier. And there's some other stuff that we're going to be looking at later on. Essentially on medicines complete. It's the same thing. It's worth worth the same. Just different website. Here. We have the same grafts here. Let's just see if there are any questions. Okay? Okay. Right. So let's carry on this chart. I just added, just for you guys to use as a reference point, you obviously won't have this chart in the PSSA. But when you're doing these sort of conversions or patch questions, you can feel free to use this resource to see. Um, you can see that roughly 180 mg of or more morphine. Sorry is the same as a 75 mg patch. You've got some interesting conversions here. Of course. The take away points, like I said earlier, is when you're converting from codeine to morphine, remember that you divide by 10 when you're converting from oral morphine to sub uh, oral morphine to subject morphine, make sure you divide by to everything else you can have a read through. Remember, you're not expected to memorize all of these conversions, but there are some of the key ones that you need to know of, Uh, which has highlighted during the session today. Okay, so here is our next question. You're the on call F one has just been bleeding by a nurse to prescribe some medication. And this is a very, very, very typical scenario you get during your on call sessions. Um, got 74 year old lady who was admitted following a non infected exacerbation of COPD, and she was treated on her admission with the acute COPD management protocol. And despite some improvement in a clinical status, she's still quite breathless. And you notice that this is the fifth presentation for her in the last year. She was reviewed by the palliative team on admission, and they documented helpfully to prescribe an opioid, um, to help with the breathlessness. But they didn't specifically write down which opioid to prescribe. So after the following options, which medication do you guys think should be prescribed to assist with her breathlessness? You just want to answer a B, c d or e on the slider. Uh huh. Okay. So let's have Oh, let's have a look at the answers. Okay, So it's not showing up. The full answers. But most of you had said B and some of you had said See the questions on the side of you and I will come back at the end of the session. Thank you very much for letting me know, Uh, so we've got a mix mixture of C and B and the answer I would say between two here, I would not go with Option B rather than see, uh, two main reasons. Let's go through what? We're actually prescribing this, uh, beginning of so morphine obviously doesn't have the benefit of providing analgesia that, as a side effect of it also does induce some respiratory depression and the palliative Methodist. And when patients are quite breakfast and agitated because of this, we can offer them some small doses of the opioid. Uh, listen to that side effect of suppressing their breathlessness. Um, absolutely two options here. The reason why option B is better than Option C is because a starting at a lower dose and B is on the prn side. Um, option C will be on the radio side. And after the two options. I mean, you don't know if the patient is going to constantly be breakfast or not. And so if you got the prn side as to whether the patient gets agitated and becomes breakfast, that's when we can consider doing a bit of or more to help suppress the breathlessness. So this year becomes well controlled. Over the next few days, however, she does start to complain of some chest pain and you're outside consultants. Prescribe some regular morphine sulphate and change or more prescription, uh, if needed. And you know so for the past 24 hours, she has had eight doses of the or more family, so she's not on any regular medications. She's only on the doses of the or more. So, um, for the purpose of saving time. I will just go to this question here real quickly. So any time the 24 hour dose, which is 82.5 mg, more, more she has had 20 mg of morphine in total. So if you want to prescribe that B e d preparation the diet too, so he prescribed as morphine sulfate want to release 10 mg twice a day and what should be prescribed well if we get the total amount 15 20 divided by six That will give us to, UH, 3.333 recurring. And as we discussed earlier, between 2.5 and 5 mg. It's typically better, especially lower doses over prescribed rather than under prescribed, and make sure that the pain is adequately controlled. Okay, so now we're going to go into some more palliative, non pain relief questions. So we have a 16 year old man who presented to the emergency department with a chronic headache, and they had a sudden onset of new seizures. He's got the past, which was small cell lung cancer, not cardiology. He's not any medications, uh, which showed more full well, the market lesions with expensive surrounding edema. He's asking about carbamazepine 100 mg b d for seizure prophylaxis. And the question is, please write a prescription for one drug that is most appropriate to manage the edema. Oh, so if you guys want to write down a prescription for wonder if that would be appropriate to help the edema for this case and just drop it on to slide. Oh, okay. It looks like most of you are getting the answers right? So let's do this one together. So When you go into the b n f you've got, you're prescribing in palliative care. And if we scroll down a bit a bit, a bit a bit, in fact, you can think on symptom control here, this gives all the other palliative answers that we need. So let's have a look at what we're going to be answering We are looking for Oh, where's it gone? Well, I got past it. Sorry, actually, the alcohol because the convulsions time I just knew. Yeah. Ah, here we go. Yeah, so it's to have raised intracranial pressure. And so if we click on dexamethasone here, scroll down, scroll down. And here we go. So we have cerebral edema associated with brain tumors, and the dosage here is by mouth 0.5 to 10 mg daily. Technically, you would be right by prescribing anything from this part here. However, um, I always start with the low dose first when you're not sure, and then we can increase it. Um, as we see as necessary. Some of you have said IV dexamethasone. You would get some artery, but you wouldn't get full marks again because there's no key indication at the moment. for IV over oral medication. The question doesn't specifically say that he cannot tolerate all the medication. And so that's why we would give it as oral over IV. Um, okay, let's quickly wish through some more questions. It's okay during your on call shift. You actually ask you this question because again, it's just another opioid conversion question, which you guys can answer in your own time. You send out the slides, so just a little more beans off your question. Okay, so this time you have a good attitude to review. Reality of Award. She's 90 year old female is receiving end of life treating for metastatic breast cancer. She has the details of nine and no visible signs of distress. But the family, the website, have said that she's starting to have a rate of breathing, and they're finding the rattling breath sounds quite a it's nothing. She's had a history of breast cancer and heart failure, and she's currently on morphine, so cut the Paxil answered, cut and how the parallel so cut. The question is, please prescribe one medication to manage this patient's condition, and what we mean by this is essentially really the breathing and the wrestling breath sounds. We're almost at the end of the session that I belong to. Your question is left. You just give it a few more seconds. Okay, so it seems like the majority of you have said hi seen hydrobromide and someone has a full march of this person who's also typed in the the dose in the room and the frequency. So let's go through this question real quick together if you go back to the palliative part of the TNF. So when you get a question that says I have excessive respiratory secretions or they have a house it worded in the question when they have wrestling breath sounds, this is a buzz word saying that they've got some excessive respiratory secretions. All these secretions are clogging up the airways, and therefore they're having this difficulty breathing because of all the plugging and you can see here, you actually have three different options. You've got high seen hydrobromide highest in beautiful bromide and glycoprotein bromide. All three of these options are equally valid responses. You would get full marks for choosing any of these three, uh, trust. For some reason, we prefer to use glycoprotein bromide, but the other two are equally viable options. Now the question is, which one do you prescribe it as if you look here? We've got excessive respiratory secretions, either as a sub Q injection or a subject infusion. So between the two, of course, the first line you would typically go for sub Q injections because it's not going to be a continuous infusion that you give them. If, despite the subcutaneous injections, the patient was still having lots of excess of secretions, that's when you would consider escalating to an infusion. So if you did prescribe it as this one, you wouldn't you would be correct. But you wouldn't get full mark because it's not the best first line option. You would get four marks if you prescribed it as this option here.