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Sorry about that. We're gonna on, you're supposed to get feedback. Yeah. No, we can just sign and that. Yeah. Uh Got him. OK. Yeah. OK. Apologies. Uh very dodgy into that today. Um So I was explaining the time you all um skip, didn't uh hear that and you have any questions specifically about how to use the f put them in the chat and we'll address them when we have uh time later. But for the purpose of getting to you today, um we will uh carry uh Yeah. All right. So what I will be doing is going through uh briefly the all the domains, a bit of background history on it and um then we will do some work examples, two work examples for each section. Um So I'll go through this pretty quickly because because everyone would have an idea about this, but it's just to say that the section one, our first domain eight questions, 80 marks six minutes per question. So, you know, it would 40% percent of the total mark. So as you can imagine this one is a, it is gonna take a lot of your time. So it's not an evenly spaced exam in terms of time, the sections that will take more time, more effort and we will have to um you know, when you're doing the exam, keep that in mind. Um So no, it's more than one correct answer. It's a clinical judgment. Uh uh comments on acute conditions like anapis such as asthma COPD, uh important terms, constipation, pain and what factors that this specific patient uh uh may have. So the components to this, there are two components that you will see, will go through through all the domains. Uh part is reasoning and, and, and the other part is a measurable action. So we need to decide on the most appropriate prescription to right, basic circumstances of this patient. So it may uh what may be good for one patient may not be for another one. And then the measurable action is we need to write this prescription uh uh safe, effective because we can give a drug an ineffective dose. That's not a proper question, but we may not sign it. That's not for legal prescription. So all these into consideration when writing a prescription, that's what you will see. Uh you'll be tested on the uh question is a clinical scenario followed to prescribe a single or intravenous fluid. Um just a requirement to write a prescription on a variety of prescription forms. So I'm gonna show you what that looks like. And again, as we said, acute condi conditions was unimportant symptoms. Yeah. And use a judgment to discern which one for each of them. So some prescribing check must be eligible. You know, it's, this is for when you actually uh writing prescriptions on s and all these things, this legible part is a particular area. I have problems. So legible, unambiguous, proved generic name. Yeah. So that's important. And we'll go through some examples in capital when you're writing it without abbreviations signed. Yeah. And you have to specify as to what uh P RN means P RN up towards the maximum QT Ds, whatever the case is and indication for review and start stop date. Yeah. So we must have a time period especially we see it all the time in the hospital with antibiotics include the duration, how long we want it for. Yeah. Yeah. So just some basics we will do this pretty quickly. Pharmacodynamics the effect of the drug on the body. This is what we, we will have to take into consideration. This is basic pharmacology, you know, involves uh receptor binding, post receptor effects chemicals, you know, and pharmacokinetics is another thing we have to take into consideration the effect of the body on a drug. Yeah, there's all these different uh factors that affect bioavailability, absorption, metabolism and elimination. Take these things into consideration, especially if a patient has something like renal failure and the drug is renally created, you know, accumulation because a lot of things, a lot of factors cytochrome P 450 important, we all know that that's one of the major enzymes. And there are many subtypes in the liver deals with me uh metabolizing drugs and some drugs may inhibit or induce this enzyme. So that may cause an interaction with other drugs. So we have to keep this in mind and we must know, know uh at least have a group of the major inhibitor and induces. So when we inhibitor, we have to think of it the way through which means if a drug in is ap 450 inhibitor, it's inhibiting the metabolism of the drug. So there will be increased levels of other very important, decreased enzyme activity means increased concentration because you are slowing metabolism. Yeah. So there's uh quite a lot of them. They always an exhaustive list. Uh This is just AAA little uh that you can remember a few of them and we, you know, a devices, whatever you want. There, there's a lot of different ways that you remember. But these are some of the most important ones that we think that you should remember. Yeah. The more questions you do as well. You'll realize that these ones come up over inducers again, will increase the enzyme activity. So it will, it is increasing metabolism of the drug and rendering it, you know, uh ineffective for some of this uh being bar all of these things, alcohol as well. But this is a we go through some of them and to some of the questions now. Mm OK. So uh question one Fre Miller presents the GP excessive thirst repeat episode. That's kind of infection. She has a false investigations including thyroid function HP A1C, hyperlipidemia, osteoarthritis tension. She takes atorvastatin, amLODIPine or Ibuprofen omeprazole. No known drug allergies. HBA1C is 72 other bloods are remarkable. She's given lifestyle advisor by her GP but prescribed one appropriate medication to help manage her diabetes at this stage. Oops, apologies for the slide here, but it's a straightforward question. It's a very, very common question to come up. They will get gradually more difficult throughout the day. By the end of the day, I would like everybody here to know um from heart the management for type two diabetes in adults. Um I think it's useful not just for this exam but for you alive for your SBA S. We have some nice summary slides later showing that um there'll be a few questions today related to this type of question. For those of you online. I think Lara has made a poll. So you can. No, not for this one. The typing. So you that's fine. So if you type in your answer and then we'll review it in about 30 seconds. Dancing audio spectro. What is, what is going bad? Mm mm OK. So we'll go through um you here. So I'm sure all of you have said Metformin. Um Obviously there's a dose range for Metformin. Now, this question asks, prescribed on appropriate medication to help manage her diabetes. At this stage. Always read the question. There are a lot of questions in this exam um where the wording is quite specific and normally this would be related to the initiation of the medication. So I hope that everyone's got 500 mg here. Uh Metformin can be given in two forms been given as er, an instant release. It can be given as a sustained release. A modified release ordinarily you would use um, uh, an instant release form which is just written as Metformin. If the patient has a history of IBS or, or bowel issues, you can go straight from modified release or delayed release. Uh, and there's evidence to show that this reduces the number of gastrointestinal side effects. There's no information about this here. So I'd expect you to say just, uh Metformin 500 mg would be the most appropriate starting dose. Obviously, it would be all, it would be once a day. Um If there are any questions about that, I'll just put it in the chart. Any questions here? No good. OK. We'll move on questions here. All right. So question 23 month old male baby Mohammed is brought into the GP surgery with a fever of 39 1. He is irritable and he's crying. He is not feeling well and his mother reports a reduction in the number of wet nappies on examination there is a non blanching rash noted on the a he's lethargic irritable and looks flushed. His chest is clear and abdomen is soft and nontender observation are there temperature is 39 1 can get the BP 96 heart rate, 160 refill time. Four seconds. Uh Your mother had a normal pregnancy and vaginal delivery of two like meningitis. We want a prescription for one drug that is most appropriate. Remember, reasoning and judgment to help manage this patient initially. So have a think about it and you can put your answer in the chat as well online. If you feel here, you can shout out the answer. No is less than 300. I they constipation. Do you have anything going on a different question? How are people, you know it for you, you know? Ok. Yeah. How are you using it? The Yeah. Yeah. So a bit of the medical emergencies in the community, one of the important features of the B NF. So yeah, anyone knows the dosage 300 right? Ok. So going to Yeah, when suspecting meninges as we did, we went through the reduce we n not feeding well and with the rash the high patient now, very important the patient is setting good because if we suspect meningitis in hospital treatment will be different. So this is in GP, has access to certain medications and usually we'll give IV medication in hospital blood at the GP. We not give any medication we'll give an I 10 dose of Ben Pen, which is available at the practice one dosage only. And how do you know how much you give again? 1 to 11 month, 300 mg one dose. Now, of course, it patient will be transferred to hospital. Yeah. So do you think that this patient, if the GP is waiting on this Benzyl penicillin? Should we wait or call the ambulance until he gets that or send hospital? It's a more practical question. It shouldn't delay. No, technically, no. Yeah. If it's available, we give it, if not we go to the hospital. Yeah. So this was at the practice one of those of Ben, of course in the hospital give Ceftrixone and all these things, you know. All right. OK. Next, so that's a brief run through of that. So, online, I think we're OK there. Yeah, I think we, we're answering questions. We go on. I remember I am, I am all right. So second question, second uh domain, sorry. Prescription review, right? Eight questions, 32 marks. Um Each question has a part, a part bi need to choose uh 1 to 3 correct answers from a long list of medications. Good. So you were tested on one of the four areas, contraindications, adverse drug reaction interactions in those areas and why we put these all throughout. So you can see there's a lot of overlap but how you answer the questions change in di in different domains. But there's a lot of overlap throughout the domains, reason and judgment. We have to analyze the parts of the prescription including safety. Is it a safe prescription with the dosage with the route? Whatever we're talking about effectiveness and suitability for a patient based on the clinical criteria and the meas measurable action is determining if a prescription is safe, effective or suitable uh for a patient given the drug route of administration or dose. So you have to take all these factors into consideration. As you see a lot of overlap with the first part in prescribing. So the format uh prescription review of the patient's current medication followed by a list of them that may be causing an issue that will be identified. The the issue may be an adverse effect. It may be a contraindication, maybe a drug interaction or ineffectiveness or dosage or whatever the case is and you'll be required to interpret the medications in regards to this patient and identify these issues. Yeah, so you're recognizing the errors in dosing in effective prescriptions. That's what it, we're reviewing a prescription to look at safety effectiveness, dosing all these factors. So basic principles when addressing this just so we look at basic principle for prescription writing for review, this is a nice little uh you know mechanism to remember what the fact is looking at. So patient details reaction allergy is very, very important. We may want to give uh patient you know, like Ben Pen, for example. But if they are allergic to medicine, it's an important thing to take into consideration. Sign uh contraindications, the drug route of administration, uh intravenous fluids if needed, if it goes alongside the, the medication, blood clot prophylaxis, especially patients in hospital for a long time, uh antiemetic, especially when you're giving things like morphine, giving antiemetic alongside is al always very important. All right. So we'll go to the first class. Ok. So quite a lengthy question here. Um uh take my time with it. So a 50 year old man presents the same day emergency care with a three week history of cough and productive green sputum fatigue and pruritic chest pain, worse on inspiration. So, already interestingly, a differential in your head based on that he reports acutely pain, left sided great toe, which he's been taking a rescue medication for one day previously prescribed to him for this issue. He cannot remember the name of it. He has a history of asthma, depression, impaired glucose tolerance, gout and acid reflux. I should say drug history is below. Um He is allergic to penicillin, has a severe rash to it and doxycycline. Uh anaphylaxis on his examination, bilateral basal and spirit because of scattered wheeze heart sounds are normal, abdomen, soft, non tendon, no peripheral edema, but an erythematous and tendon left sided grade to these are his observations and these are his bloods have a look at them. What stands out if anything or even up to the that. Yeah. Yeah. So co PS up and white cells are up. So we're thinking um probably infected. Ok. Uh D dime is uh 250 BM is 6.9. So that's consistent with impaired glucose tolerance. Chest X rays are right sided, lower zone, airspace shadow, consistent with consolidation. E CG just shows sinus rhythm. Uh peak flow is done a few a minute, slightly off his baseline. The clar doctor initially prescribed Amycin salbutamol and ipratropium. So two parts of this question, a one medication that's most important to stop while the patient patients and part B selection, the two medications would most likely contribute to the risk of a gas intestinal bleed in this patient. So give you a minute to answer that and then we'll go with you. Yes. Good point with the exam. A lot of the technique that you should not just with this exam. Your father of words, it's fair to say to trick you but you need. And this is a good example of it. A lot of information here about how much of it is relevant. So as you're going through, you should make mental highlights. I would I actually go through if I had a physical exam paper, I'd go to highlight just the bits that I think would be OK. And if you're very unlucky, they might ask you questions. Um Nothing to do with uh the information that's given before. All right. So give enough for 30 seconds. OK. Mhm. They still sang on each. Are we using the microphone? Because the audio, the laptop is actually not, we're not using it to the weakest connect. I thought you guys trying to put down because that is fine. OK. It's just the audio. So some of you are saying online that audio is great. It seems OK in the room. So uh just keep on giving us feedback how it is. I think it's temperamental, but first of the time will crack on. So we'll go with the answers. Well, them to those of you that um put these answers. So uh select the one medication that's most important to stop. Um While the patient's taking Clarithromycin, colchicine and the two that can cause a bleed for this question, you don't need to know any of the blurb actually. So it should be quite easy. You shouldn't need to look very much up SSI S and Ibuprofen classic examples. We'll go over the reasons why. So um part A is an example of testing of knowledge of the system. Um So here we've got an example of uh people with the enzyme inducers and inhibitors. So, Clarithromycin is a ma as you all know that uh is used to treat community pneumonia. It is used for apical, it could be used for uh citti there's a lot of use as brain drug, but it's a terrible drug interactions. Uh And this will be a problem when you're working in hospitals as well. 250 inhibitor. Um And in this case, uh with, even if you didn't know that you could look up the interaction using the B where it says to my pre to the in increased exposure to cultures. OK. OK. So this would be um the best. Now there is um an interaction with salbutamol and would you want to stop salbutol in this case over um is a more important drug. So, Clarithromycin, the colchicine would be the best answer. And then part b oral inflammatory drug increase the risk of gi bleed, particularly in steroids. Um And giving an SSRI alone can also do the same thing giving them together can theoretically cause uh a severe reaction. Um And would be the most appropriate answer. Are there any questions on this? So, oh, this was just a um highlight that you could have potentially said the patient was on it um because there's an interaction I wouldn't have accept that it would be a bit of a rogue answer, but it wouldn't be incorrect. Um The key thing with this exactly. You may have more than one correct answer is the better answer. It's a question saying should uh stop colchicine as there's an um yes in colchicine here and you look an alternative agent. What's the quickest way to check the interactions if you're not sure. Yeah. So the quickest way to check the interactions is, uh, I'm not going to do it just because I don't want to play up with. Got to search the drug. Then you go to the top right. And you click on interactions, drug in specifically that you want them with. There is an alphabet, scroll down and find the drug for you to put it in. Um, we had another question earlier about things complete. All I can see you've been told. So I've emailed um the PSA directly and, and what they respond to us with is we don't have a complete, you shouldn't have vaccine medicines. Some people have said on differently. This is what we've been told. So as far as we know, it's just uh the B NF. So I think so that we don't give you inaccurate, we will stick with that. Why aren't you stopping omeprazole saying that uh as it's an enzyme inhibitor, it's does omeprazole though, it's an inhibitor um isn't as severe a very good point. It's a very good point and people forget uh that uh omeprazole and lansoprazole uh have a similar interaction in real life really worked actually. Um But if you go on the BNF, the reaction isn't as severe as this, but it's worth remembering and, and it is a really good uh highlight that and actually something that I find really annoying because PPI S are never really, I identified as drug reactions in hospitals and they do all the time and PPI S some warfarin is another one I've personally seen patients who have been on water roof and it's actually really ok. Uh, is certainly be as hemorrhage is listed in the common side effects. Um Ibuprofen, acetylene. Yeah. Yeah, that correct. Right. Yeah, absolutely. So, SSRI s alone can cause gi hemorrhage. Um and together with Ibuprofen, that risk is, is um, ok, we'll move on for the time any more questions about that, put it in and out and we'll get back to you. Um But uh let's move on to question two, right? And you know, just remember, require some background knowledge. If you have to put all these medications into BNF all the time, you run short of time. So you'll be very strategic with your searches as well. So down to the acute medical unit with a uti uh he has given dose of gent and started on regular, is a past medical history of hypertension, a foid arthritis. Uh We look at your drug history next, we check, come out heart sounds irregular. Um supra tendon is on palpation, af chest feels art way his bloods. Are there anything interesting one? White cells quite high neutrophils? So we're thinking it's uh a bit high. Well, um and also bilateral uh abnormal renal bronch echogenicity, such a uh love this radiology thing uh with acute nephritis, um no evidence of hydronephrosis or infection. So we review these med medications and we know that the patient is, uh, regularly or it's usually given once we can ask you. So, what do we want from? What does the question want from us? Select the one medication that is most appropriate to start? Patient is taking methotrexate part B. Select the one medication that is most appropriate to hold is due while you guys aren't having a lot of um feedback on that. So the audio is not very good. So what we're gonna do after this question, we're gonna have a five minute break. We're gonna try and see if we can fix it and then we'll return. OK. All right. So what do you guys think for the one medication is most appropriate to stop and you'll get this the hard to ask the most appropriate. Yeah, to stop while the patient is taking methotrexate. Yeah, Ibuprofen. Anyone else? One folic acid? OK. And what about part B select one that is most appropriate to folic acid? Go to the answer. Now. It's, yeah. So we want explain why we think. So the first one Ibupro as well as using BNS. So meth methotrexate should not to be given with Ibuprofen. This a little bit here of the, the BNF uh is of toxicity and think about it. Logically, this patient is on Ibuprofen for pain relief, P RN. Yeah, it's not a critical patient for the patient. So most appropriate has an adverse effect that's severe evidenced by a study. So that's probably no evidence and not a critical medication. So it will be the most for the space. Now, methotrexate antagonist. Yeah. So it's a dihydrofolate reductase inhibitor. That's how it works. And this is important uh folic acid especially is important in nucleotide biosynthesis. So we do have to give folic acid. Uh it resupplementation when the patient is on methotrexate. However, methotrexate is usually given once weekly. So we give folic acid all throughout, but on the days we give methotrexate. Why? Because it will reduce the effectiveness. We're giving something and taking it away at the same time. So we it is going to reduce the effectiveness of the methotrexate. So before the acid supplements are given but avoid it on the day of the methotrexate and that's uh the basics of folic acid and methotrexate. Any questions pretty straightforward. That one. Yeah. Yeah. Ok. So we'll take a five minute break here just to sort out the audio for those online and we'll uh get back shortly. Yeah. Mhm. Let me know you anything before. Ok. Looks good. Ok. Yeah. No, sure, sure. So you, you guys have to order this here. Oh my. Uh we were section three prescription. Yeah. Yeah. Yeah. Ok. I think it's better to just respond. Yeah. Uh Right. All right. It's not change. All right. All right. Tell you. Ok. I Yeah, because, ok guys, we're gonna be starting in a minute, right? It sounds, is it taking? Yeah. All right. So sorry about that again. Um Hopefully the audience is a bit better. Um We're trying, trying our best with our NHS wifi here. Um What we'll do going on is that I'll spend a little bit less time on this uh initial part and we'll focus more on practice questions just for the sake of time and I'm sure everyone's well prepared already. So, just a brief overview. Again, this is eight questions, planning management section tested on three main areas of symptom control, acute conditions and chronic conditions and co the common scenario. If you can see the anaphylaxis asthma and those things. Yeah, reasoning and judgment. What treatment would be most appropriate and selective treatment based on that patients circumstances. Again, this is how we would look at it. I will want to focus on the common scenarios here because that's what you'll be most likely tested on to be safe. Anaphylaxis, asthma, hypertension, diabetes and, and infections. All right. So we'll go test in one. Ok. So I have a 48 year old female teacher visits. The GP complains of frequent migraines in the past six months. She describes headaches as unilateral throbbing and often accompanied by nausea, photophobia, episodes last for about 4 to 6 hours and occur twice a week. She's been using over the counter Ibuprofen with minimal relief. So we've got some drilling outside that's not helping. Um I'll let you read the rest of it. Just let me know if anything stands out from the information on the slide. OK. We're having feedback. The audio is better, so that's good. So just stick with us. OK? Anything stand out in the room, anything you're concerned about? Ok. So you are relevant for sure. Anything else? Ok. Looks uh fairly excellent. So we'll move on. So GP is considering prophylactic treatment. So read the question care from prophylactic treatment. All right, please select the most appropriate management option at this stage. Mark it with a tip. Well, I'll give you a couple of minutes and we'll go over the answer. That's good that you. Yeah. OK. Questions bye. See, I see. Oh OK. We can bring. Yes, II can tell that you. Yeah. Where? Yeah, this one. OK. Question any get you. OK. Hopefully everyone has got the correct answer is to pyramid. Why is it to pyramid? Well, let's go over the options. There's some key information for the blurb question that will help you get that. Um So let's start with propranolol. Propranolol is first line for migraine prophylaxis. Why wouldn't we give it here? Ask me very good. Uh It is a contraindication. It's not an absolute contraindication, but for a prophylactic long term daily drug, you don't want to be giving a nonselective beta blocker to an asthmatic you're asking for problems, occasional propranolol can be used. Um P RM for asthmatics. So, um for example, with anxiety um or you know, uh anything where they might need um the effects of it symptomatically, but this is normally done at a low dose of 10 mg rather than 40 every now and then rather than daily, the other options. So you've got topiramate amitriptyline, um are used for migraine prophylaxis, second line of therapies. Um Most people are probably gonna get here using the B NF. So, um if you do need that, did anyone in the room use the B NF to get this answer? Did you all do that? Yeah, you'll see the list though. The question. She's definitely gone through the menopause as the pyramid complication age or can assume it would be OK. Yeah. So, uh there's a question, uh we'll get onto a question about uh has the patient gone through the menopause um to answer that in a second, um acupuncture relaxation? Yes, there are actually in the B NF. But uh these are adjuncts. You wouldn't use these therapies as an isolated treatment. And sumatriptan er, is a very important drug in migraine, but in acute migraine, not prophylaxis. Um this is the table that I've made for your acute versus uh prophylactic migraine management. Uh feel free to take a picture screenshot. It should, uh in fact, it does contain everything you will need to know. Certainly for the exam. So we'll just go over the two. So if your acute migraine treatment, you're gonna start with a Triptan or an NSAID or paracetamol, you can use combinations as well, look out for the age of the patient. So if they're a child to 12 to 17 year old bracket, then Triptan would be nasal. They tolerate this much better. Second line treatment, uh metoclopramide or uh prochlorperazine, you're not gonna be asked about this as to specialist knowledge um for prophylaxis. However, you might be asked uh second or third lines and we'll go over those first lines, we said are propranolol, topiramate and amitriptyline. Now, topiramate is uh teratogenic. Um The question will say it will make it very clear whether the patient has gone through the menopause or not. I've left it deliberately ambiguous to get you thinking the yes and given. If A is unsuitable, have a few months, child care should be informed here. So, the key thing here is that it's not um that topiramate can't be given in childbearing age, but the patients should be informed. Um And they should be advised if they're uh family planning, then it it should be avoided. If they're not family planning, then using uh sensible measures and protection is perfectly adequate. But the key thing here is about um informing the patient, why not uh amitriptyline. So, amitriptyline comes up after topiramate uh in the B NF. Um could they both be correct? Yes. Uh for, for your actual exam, the two options together probably wouldn't be given. Um Yes, it's a matter of order. So if you, I haven't got the links to the page. But if you go on the B NF, the way it's written is that after the first line, you would start, well, as part of your first line, you would start to pyramid next in line and then Amitriptyline after this. Um I've designed a question to really make you think. So. So this is far more tricky than you'll get in the real exam. It's far more uh ambiguous. But I would say if I had the two options, I would choose the pyramid first. Um Because of the way it's written in the order of BF So after that acupuncture, 10 sessions over 5 to 8 weeks. Um Adjunct ri there is a very good evidence for this in, in migraine. It's a very high dose 400 mg and then your third line um drugs like frovatriptan or ZOLMitriptan. Uh And these, these are the type of mini prophylaxis fourth line uh Candesartan uh can also be used. OK. So um if I was in your position, I would try and uh memorize 1st and 2nd line for these drugs acute uh and prophylaxis, but it's unlikely you'll be asked about second line in exam. Oh yeah. OK. So to clarify first line for acute, uh it is an oral triptan and either an NSAID or paracetamol to begin with. However, you can give all three, but you would start normally with the Triptan and combine it with one of the two if that fails, you can combine three, but you kind of work up in that way. Yeah. Any more questions? Good, good, good. Um, if there are any more questions about that with them, uh, in the chat, but hopefully that will, uh, summarize it. So this is a question, uh, got you designed to, to think about the order of drugs, but it's far harder than you were getting the actual exam. Ok. Oh, yeah. Sorry. Um, the other thing to note, if you look in the um past medical history, the patient's had a hysterectomy. So uh sorry, I should have um mentioned that earlier. So here that makes the question very easy because actually they don't need to be uh consented for family planning. All right, there you go. Question two. All right. Question two. Ray sa 68 year old lady was admitted to the hospital with a cap. She also complained of having palpitations off and on for three weeks and she did not seek medical attention for this on admission. She was found to have new atrial fibrillation. She has a background of hypertension type two diabetes and she's currently taking Metformin and Ramipril her child. Last score is four. All right, you wanna wait last score. Yeah. So we'll go through that a little bit as well. So select the most appropriate management option to prevent uh CV stroke in this patient. So it's testing your knowledge a bit of guidelines. Um What is most appropriate for this patient. Um the clinical significance of child blast score. How do we get to fall? We gave you the child score but what are the criteria that got us to fall? Oh, online. You can use the pool in the chart. There's a pool for you to select now for the. Yeah. From now on there will be a pool. The answers are those online. It will be easier to do on the pool. The initial sections have to be written out. Yeah. Sorry. Right. Ok. Oh no. All right. What do we, we have some answers online. What about in the room? I we have a pizza about anything else. Anything else? All right. So Apixaban, so according to our guidelines, all direct oral anticoagulants, although a should be initiated for severe prevention in patients with af and that's why we use charge vas score. We use a score to be able to tell us when do we start our treatment? Yeah, or what should we do? So va score, what do you think she was scoring for? Mhm. Hypertension one. Yeah. Female one. Yeah. Age 65 to 74. Yeah. And diabetes. So she was going for so according to the guidelines, if it's zero, no treatment, if it's one, we can consider treatment in males, no treatment for females and two or more, we need to offer anticoagulation and do a or or go to for that. Um, Apixaban, the big Edoxaban Rivaroxaban. All of the, the, the first line things that we would use. Some people may have chosen aspirin. Um No, at this dose, it's not a treatment dose. Uh and it will not prevent um it's probably good for the patient anyway, but it's not in any guidelines. Clopidogrel again is an antiplatelet like aspirin. Um But we need a doac in this case, um Our vitamin epoxide reductase inhibitors uh Warfarin uh I only contraindicated Warfarin is not a very, it requires a lot of monitoring, very sort of drug and we have better choices like Oxana. That's, that's, you know, better now. So guidelines have uh improved to that effect. So, remember your in prevention. How do we get there our child? Yeah. Why would we use Warfarin today in 2024? What conditions? Sorry. Metallic. So I, so I'll speak to my, I, what, what in what scenarios would you use? Warfarin in 2024? There are at least three. I want you to know we've had Metallic Car and Fossil Syndrome. There are conditions that, you know what the conditions are. Yes. You wouldn't just start warfarin in somebody with an antibodies. They have to have had at least two clots, at least two clots, more cardiovascular muscle even. Yeah. And uh another condition. Anything else? Uh Any other scenarios? Yes. Yeah. Uh So you've got a patient and uh they present to, you're working at the emergency care. They with a swollen left leg they've been on Aaban for a while. DVT shows uh no things like that treatment is perfect. So why would you use, use Warfarin but are ineffective? It's really, so if you have patients already on a and they have a clot, then uh there's not much more you can do. After that, you have to go to Warfarin. We don't have any other options. If you do, then the target ir slightly higher. It's normally um instead of 2.5 it's about 3.5. So 3 to 4, but it is patient specific. OK. But just yeah, good question. So some uh do license for reduced um uh G FR but below normal, below 30 it gets really tricky. Um So Warfarin can be better for those patients. Um And the in patients who are on dialysis, I've never seen anyone on a a treatment other than Warfarin at that point. Yeah. So, you know, as you know, with uh uh keeping with the PSA as well, the with renal uh derangements, you also have splitting of the dose and reduced dose in in reduced GFR for a lot of the do. But simple answer Warfarin for uh significantly reduced GFR. All right. So section four. Yeah. Uh it is a section, some of the common scenarios, contraception, breastfeeding antibiotics, so on. Yeah. So we, I uh have to identify the high yield information as you can see very short low question mark. So we have to be on this and require some background knowledge and selecting the most important information. So it's very uh important to keep the information. Uh single best answer again. No specific guidelines for the section. Question specific how we address it. Yeah, and knowing the common scenarios are important but having a good background knowledge is good. So see you a 26 year old. Oh, you can. That's fine. Um Yes, darling. This is a straightforward section expecting everybody to get a quick mark here. Uh So if a patient 26 year old female presents to GP uh to discuss medications she's taking, she wants to start family planning. Uh and she has a background of epilepsy. She takes sodium valproate 300 mg twice a day. She read on the internet that some antiepileptic medications can cause problems with pregnancy. So what's the most appropriate advice to give her regarding valproate? Do we continue it? Do we continue it to take folic acid with it until 12 weeks? Do we reduce the dose? Do we stop it completely and change to a different anti epileptic or do we continue it as folic acid to the 12th week uh of pregnancy? But at a higher dose, 5 mg rather than 400. Ok. We'll give you a minute to answer but you can use. Yeah. Ok. So we can move on to 97% have the correct answer. So, um valproate is the most genic drugs that we commonly prescribe if you ever see a question about it in pregnancy. Uh It's a very, very common question. The answer is gonna be to stop it. Always to stop it. You don't reduce the dose, you don't add other uh things to offset it. It's a very easy answer here. Um So in reality, you would change to uh another anti epileptic because here in the room online have some suggestions which anti epileptic drugs are less or not. Ok. So we've had let or kera any other suggestions. Sorry, Lamore Junior. Any others? Yeah. Very good for those online. LamoTRIgine is normally the preferred antiepileptic in women of childbearing age. Um I'd say in my experience, most women who have uh generalized seizures or partial seizures are started on it from the beginning. Um If they're not as normal because they failed it. Uh and then it becomes tricky and then it's uh you know, with family planning, it becomes quite a specialist area. But for your stage, your knowledge oxygen is, is preferred in childbearing age is a big, no, no. OK. So something nice. Black and white question. Not too complex. Any questions on that when we move on. Good. All right. All right. So Jack is an old boy who presents to the GP with his two months. He has a history of asthma and is on Salol. His symptoms have not been uh well controlled with salbutamol GP decides to start in or B as well. Uh The dosage, yeah. Uh The technique is assessed and is good important piece of information. Uh We, we assess this patient his uh heart rate, 70 BPA, 175 temperature, normal respiratory 20 a 99%. When we look at his ex, we examine him clinically. There is nothing much to find except for flexural eczema. He has a past history of and asthma attends a local school lives with his mom. Uh One works as a physiotherapist and the other is a university administrator. Two. Hi, his drug history is 200 P RN for the salbutamol and no known drug allergy. The GP arranges for routine bloods to be taken. So what do we want to know which of the following is the most important piece of information to provide uh to the patient? That's a good example to show you that the question can give you a lot of information as we start a lot. This section say you have to be able to discern what is vital to answer the question. Don't get bogged down in the integrity there. But what do we need to offer the patient? So, what do you think? 100 something. Ok. Ok. What do you guys think rinse? Ok. So online agrees, we agree again with the steroid usage. Um There's a risk of oral candidiasis. Now, of course, we can use drugs to treat it. Uh nystatin uh mouthwash is usually used, but you're not gotten to that point yet. So we can avoid, again rinsing them out after use of these steroids. Yeah. Typical basic information that we provide for this patient. Good. That's fine. All right. So the fun. Yeah, it's a good point. Yeah. I mean, that's what we would want them to rinse and spit it out. Yeah, because again, I, it, it's will, uh, that might not cause effect but if you're doing it all the time. So if you have the upper gi uh you know, maybe like esophageal candidiasis may be ending up with it anyway. So we get to the next part of calculation skills, everyone's favorite section, you know um is normally a yeah, there's no falls for this one. This one you put your hand with your calculation. So get all of your pen and paper and whatnot. Now important to note that these calculations based on weight based on dilations, uh dilution, sorry and uh calculate frequencies or rates, right? It's not going to be very difficult. The calculations are usually quite simple. So, but you have to keep in mind the drug, the dosage calculations and units, units, units, units, remember your units of measurement, basic arithmetic, nothing too bad. Um and adjustments based on weight, body surface area and unit conversions. Yeah. Again, this is an important slide that you must keep in your knowledge value. This is something that you need to know. And I advise that everyone. Uh remember this screenshot again, take a picture of whatever you want to do. Um But it's an important piece of information to know, especially for this section. Just wait a second. Sorry if you want a screenshot, just go back for 10 seconds. Oh, yeah. Yeah, if you want to slide, hold for a few seconds, so you can see. OK. All right. So question one. Yeah. A 68 year old man with severe uh hypertension is admitted to the hospital. The doctor decides to administer a continuous IUD infusion of GTN for BP control. GTN is available as a not 0.1% solution. Prescribed dose is five micro per kilogram per minute and the patient weighs 75 kg. Calculate the rate at which the IV pump should be set in mil per hour to deliver the prescribed dose of GT and IV. Yeah. Ok. So just get, yeah. Ok. And uh for those online just put your answers in the chart. I Yeah, its better now. I ok. Ok. That box it. Ok because yeah pretty soon I know right. Um ok. Oh let's let's what are you guys thinking in the room? 25225 22.5. So that's what I say. 25 5225 and 22.5. Any other 22.2 0.5. All right. So let's go through it quickly here. So again, not difficult arithmetic, but it's just to make sure you understand the conclusions. Very, very important. So 0.1% solution is 1 mg. That's the first thing we need to. That's probably why you might with the uh the percent to, to grams of milligrams, that's why you're out by factor uh 10 possibly. Uh anyway, yeah, so and again, multiply by five times the uh 75 mcg, that's where we get 3 75 mcg per minute. And our rate will be 0.375 mils per minute. Remember if we bring it back to milligrams of micrograms, mils and uh milliliters and milligrams are direct invasion. I could have put milligrams there per minute. Wouldn't be a difference. It's just a solution but we need to divide by 1000 to go from micrograms to milligrams or milliliters same difference. And then we multiply this again, very important if we stop there. Remember what the question asks for mi or what? So that's why we multiply by 60 minutes because we have meals per minute or 60 minutes. Uh We get 22.5 mils per all everyone. OK. With that. Are there any other percentage that the ones you need to know are 95% of the time you're gonna get a 1% solution? A naught 0.1% and a na na one. OK. I've never seen the question outside of these ranges. The easiest way to do is just remember that 1%. Solution is 10 mg. The M you can grade that your brain you with that. Yeah. Yep. I did like it after the Yeah. Thank you. What any questions just ask the way, but we'll move on for the sake of time. A much easier question, different type of question. Uh So patient requires IV hydration with normal saline. So prescriptions as follows. Uh and it wants you to calculate the average rate. Um Why do we do this in practice? Because average rates are useful to make sure we don't exceeded. Um especially if there's a drug given in uh in the fluid. We want to make sure we don't exceed guidelines for total amounts, total rates given over a period of time. Um These are very straightforward questions though. Uh If you're looking at an average, essentially, well, I won't give you the answer yet. Essentially, you just need to um look at your total volume and look at the time. So this should only take you a minute. I'll give you a minute and we go with the answer and again, read the question, look at the units that they want the answer in the most important thing about this section is reading the question. Um So many times you get an answer and then you just have missed that last step where they ask for it in a slightly different way and they will do that because otherwise the questions can be too easy. It pops up more. Ok. Um I think we're getting all ready in the room 404 100. It's not a great question. Absolute banger. So two ways of doing it, the complicated way is to calculate the rates of individual bags. Uh I wouldn't do this. I would just look at total volume total time, look at the units that they want 400 miles an hour. And often the reason we do that is we'd be on a guideline. For example, let's take DK A and you're looking at a, a maximum amount of uh fluid that you want to prescribe in the 1st 24 hours or a paracetamol overdose and you want to make sure that you're not exceeding uh the average and it may stay uh ensure that uh uh an infusion rate of uh uh 400 mils per hour is not exceeded. All right. So there is some practicality behind this uh that you may need to do in real life, not just for the exam. OK. Section six. Yeah. All right. So in this section, uh or adverse drug reactions, a question, 16 marks. And these are the common scenarios, we, we will ask a different uh you know, different components of this really, which is identifying the adverse reaction, what's causing it, um an interaction and how do we manage it. Yeah. So those are the likely things that we will be asked the different types of questions as we say we must identify it, uh presentation. What is the adverse reaction that we may expect? Um considered presentation with uh interactions and um how do we manage these patients uh interaction. So the 1st 1, 45 year old male patient with a history of hypertension type two diabetes, hypercholesterolemia presents for a routine health checkup. He's currently on multiple medications for his medical issues. Blood tests are below anything stands out to you at AST Yeah. It's important to know those and their relationship with one another as well. Uh, is normal but on a higher range of normal, uh, AP is. Ok. Yeah. And, um, which of the following is most likely cause of his elevated liver enzymes and online you used to pull. Yeah. How we are not. Yeah. Mostly stuff in. All right. Ok. Right. Yes, that's what. Yeah. Yeah. All right. So what do you think that statin induced if I was online as well? Getting with that, we know that statins can cause that statin and five therapies can potentially cause elevated liver enzymes. Uh, statins are more common and, and you know, it, it's something that we look at when we start patients on statins and we check their liver enzymes and a lot of people may get frightened and you know, what do we do? Sorry with it. Now, some people chose, uh, Metformin induced hepatotoxicity online. Yeah. So that 10% shows Metformin induced heart toxicity. That is something that some has made up. It's not a real thing. Um Maybe that, you know, some people talk in different ways, but it's not a thing. The most important thing that we want to get from this point is that statins uh can present with elevated liver enzymes. OK. On starting them. OK, good. Any questions on that? OK. We'll move on. Question. 2, 50 year old male with a stable history of plaque, psoriasis has experienced a noticeable worsening of his condition over the past few months with developing new plaques and increasing itching. He's recently started on a new medication. Select the one medication is most likely responsible for his psoriasis exacerbations. Ok. And while you're answering that he was in the grand round the other day, what interleukins drive psoriasis. There are quite a few to be fair. You give me a couple of answers. I'll give you two and six. Yeah, there's some bigger ones. 1722 23. Uh the newer therapies for psoriasis that are essentially a cure tend to uh target 17 and 23. No, not at all. Just uh yeah. So there's quite a few. The big ones in 2024 are 1723. Um, therapies used to target uh 6, 1112, uh a few others. No, this is the immunological, um, the immunological uh dry arthritis. Yeah. And we prefer, um, treatments for IL 23. They provide more pizza, which is important. Ok. So it should be relatively straightforward. Um Some of you might not know what sr is. If you look this up in the V Ns, does it come up? Good? You should do. Is anyone saying no? And what does it come up as? Yeah, good. So, um for those you don't know is one of the mainstay treatments for chronic plaque psoriasis. So your initial treatments for psoriasis are gonna be a combination of what, two things? Very good. So uh in the room you had uh a steroid and a Vitamin D analogs. Your Vitamin D analogs are calci for trial and your main steroids are gonna be betamethasone. The combination of these come in two forms. Uh So Dovonex and insular, they're exactly the same thing. Um But insular is a foam. There's an example of a brand name that might come up that will be in the B NF where you may have to search this. Um So it can take a little longer a two step question. But when you do that, very important, you find that the treatment with psoriasis is not an exacerbation which brings us on to this propranolol. Did everyone say that the propranolol? Um So uh one of the more common questions in the exam, so, triggers for chronic conditions, um things that can make chronic conditions worse. Uh for psoriasis, you're looking at beta blockers, nonsteroidal antiinflammatories and ace inhibitors as your big three. And then other things like lithium hydroxychloroquine as well. Ok. Any questions on that? No, s some people have methotrexate. They know methotrexate is used as a treatment for psoriasis. Be the most effective, um, disease modifying antat drug in chronic uh, psoriasis. Ok. So we're actually doing quite well for time. Um, so I think we'll have a five minute coffee break and toilet break. Um, we'll keep it running online, uh, to stay with us and then we'll come back for the final two sessions. Ok. Yes. Uh, ok. Um, so I just have, um, guys, you're still online. Uh, we just to be specific, obviously because of the feedback issue, we'll give you until 1050 so eight minutes. So if you could come back in line for 1050 I'll just write that in the chart as well.