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Hello guys. So hello. So the exam should start. Now. If you have any issues, please write in the chart and we can help you with that. Hopefully there won't be any issue and you can access the exam easily. Good. Um We have two changes, two questions, uh 130. Um So what you need to do is just refresh uh where you are. Uh Don't worry. So uh make sure you wanna leave the page. Yes. Ok. Hi guys. I'm just gonna repeat that. Sorry to interrupt your exam. Uh We've made two changes. Question one and question 30. What we need you to do is refresh your exam. Uh And if you've answered one and 30 redo those questions, it will save the answers. Don't worry about that. Uh If it asks you to leave page, say yes. Um if there are any issues, just let us know in the chat and we'll help you out. Ok. Hi, everyone. We're gonna be starting in the next few minutes. So got. Yeah. Yeah. Ok. Ok. Um Right. Welcome back. Uh We've given as much time as possible for everyone to finish uh their practice paper. Well done there. Were some really good scores. I know there are a couple of issues, um, which we can go over, but hopefully not too many. Uh, we have the, we decided to, to do top five scores. Cos there are quite a few of you that sat it. We're gonna go over those at the end and then we'll send certificates, um, in the next few days. Uh, but let's go over the paper first and as part of this, we'll, we'll do some teaching. So it's not just a review of the paper, you get a bit more teaching about some of the, the core things that might come up in your exam. So to begin with, um obviously, this is representative at is 50% of the exam. The real thing will be exactly double if you haven't done a, a timed paper before. Hopefully, it's given you an idea of the, the kind of time you need to stick to for the exam. Um We're gonna utilize more of the clinical teaching fellows here at South End. Uh And we're gonna take a section each. Uh and this will take us over probably in the next two hours. You can carry on asking questions as you go along in the chat and we'll stop uh to answer them, we should have plenty of time. So section one prescribing you four questions here in the paper. Um When comes the GP to discuss contraception, it's cut out. Yeah. Yeah. I know. It's, it's all right. Sorry guys for me just close this I was fine. It's ok. Yeah, I think it should be ok. Right. Yeah, it's ok. Just uh ok. Four. Can everyone hear me? Not in the room? Yeah, thanks for the input uh online. Can somebody just comment? Yes. Good, good. Ok. If you miss that, I was basically just saying that we're gonna um we'll go over the scores at the very end of the day, we'll take uh a different, you're gonna have a different tutor for each section. We'll go over and do some teaching along with a review of the paper. So, uh question one, actually, I won't read it out. You've just done it. Um So the key thing here uh is the patient's request. Now, remember for anything in medicine, if the patient has a preference, you have to respect that. If it's in an exam, you don't question it in real life, you might. But if they've said the patient doesn't want something that means you're not gonna prescribe it. And it really is that black and white. So here, the patient said that they would prefer not to have an IUD or an implant. Um, as her friend had a bad experience. So it's really directing you at uh only one drug that you're going to prescribe. She doesn't have any allergies other than aspirin. Um And she's not taking any regular medications. BMI is normal and she's 26. So this, uh, is the correct answer. Um, we made a slight change to the wording, um, because it didn't say before, she'd prefer not to have an IUD. So hopefully you were all able to then rule that out. But even if that had been in there, IUD isn't a drug that you'd be expected to prescribe in the PSA, it's a very complicated one because it's a procedure as well. Um, So it involves more than just the prescription. So if you think there might be an option, you can rule that out. Um It wouldn't be expected at this level. So even if we'd left that in, hopefully you would have been more guided towards medroxy progesterone, which is uh the depo and there are two ways of prescribing it. So you can do it intramuscular, which is 100 and 50 mg every 12 weeks or you can do uh the 100 high, it's 100 and 4 mg subcutaneously every 13 weeks. You can. Uh Yes, sure. Um You can. Uh No, they're the two options. Yeah, it's not moving. Is it lacking or? Sorry guys? Yeah. What's the question? Um You wouldn't describe every 12 weeks or you prescribe you anything that you would prescribe for a long time in? I think it's because it was just, I think that's probably fair enough. And actually, as I keep on going on about this exam, ask for an initial prescription. So you're probably right. It's actually better to you. Did you write that? Um, yeah. So, I think if you have to look, that's a tricky one. Yeah, if you've written stat, I think that's fine. I think staff for 12 weeks is appropriate. But, yeah, I agree. I think that's acceptable. So, sorry, if that, uh, is that some gps and some, you know, these have professional, they recheck them in six months. So the cancer will come three months, six months, whatever the case is and transdermal, transdermal. Yeah, it's less on the BNF. Yeah. Ok. Fine. This is not the best question. Um Yeah. Would that be um I would avoid writing brand names in the exam itself. I would write the drug but yes, I mean that's the, the same drug and it is known as the, the depo. So, OK, there are a few variations that would also be correct. We can't give you uh the marks back. But for learning purposes, transdermal patch would be acceptable and writing Depo Provera, I wouldn't say it's the best answer, but it is not incorrect. So yeah, you would get marks for that but in your exam try and write the drug if you can. Yeah. Yeah, that's true. And the drop down will be more obvious. Uh So yeah, apologies if that um affects your marks at all. But um hopefully at least you learned uh the principle of it. All right, we'll move on unless there are any more questions? No, no. Yeah. Yes, sir. Yeah, it's not moving. Ok. Yes. Yes, it is. Yeah, that's fine. Fine. So, question two, a 68 year old man admitted with decompensated cardiac failure is extremely short of breath. He has bilateral pitting edema to his mid thighs. He's unable to lie flat. These are his obs anything stand out. No, my restless. Yeah. Low sats on oxygen. Not a good sign. Uh, respirate up, not a good sign. Uh a bit tacky BP and temperature. Ok. So he has heart failure. He has ischemic heart disease. He has B ph uh he takes Pazol Ramipril clopidogrel. No allergies, write a prescription for one drug that's most appropriate to treat this edema initially. So uh the wording of the question is key here. So initially, um this is the correct answer. So you could have had flusemide 40 you could have had 20 you could have had 5050 is an unusual dose. You don't see it often in, in real life, but uh you can give it according to the B NF. Now, I know some people may have gone for a higher dose and you may have seen this in real life. Um It's not advisable, this is an initial management. So when you've got somebody uh who's acutely overloaded and you're trying to to offload them, you start with small doses and you repeat, you don't go straight in at a big dose. You may have seen this but it's not good practice. So uh yes, it's not uncommon to see 80 mg written, but this is not how it should be taught. It's not how it should be practiced. You should start with 20 or 40. Um ideally IV. And then you should reassess and if you think they need more, you give it and that's safer. So you get lesser complications, less electrolyte derangement. Uh If you do it gradually rather than giving one huge hit. Uh And as this is initial management, it's once only or stat. OK. Any questions on that, hopefully everyone got that one. Um Fine. How do you monitor somebody clinically? So you're giving them famide, they're overloaded. What are the things you're looking for to see if it's working? Yeah. So certainly in a 24 hour period you're doing daily weights that's crucial to see. And what are you aiming for? Do you know, target weight loss? It's even easier than that. It's a kilogram a day. So when you're offloading acute um acute edema, you normally try and lose a kilogram a day. So it's quite brutal. Uh How else could you monitor it? Urinary sodium to see if it's effective? Uh You could do, it's not, it's not commonly done. But yeah, you could do. Is there an easier way if they get better? And how would you monitor that respirate? And oxygen saturation is brilliant. The first change you're going to see if it's pulmonary edema is improvement in the SATS. So just um yeah, just remember that for your exams in real life as well. Uh When you're offloading, you're really looking for improvements, saturations, respiratory rate and that will happen before you notice big weight fluctuations. Ok. Question three. Uh quite wordy. You've done it already, so I won't read out everything. Um but you've got a 68 year old with a history of diabetes. Uh, it's about complications of diabetes. She's got a tingling sensation. Um H B1 C is 55. Fasting glucose is 8.1. Uh and it says in the question, the GP suspects diabetic neuropathy. So it's a question about how to manage symptomatic diabetic neuropathy. Um So there are two correct answers here according to the B NF, you can give amitriptyline and the dose of amitriptyline is written 10 2 25 in real life. Uh and in the B MF, if you actually go to the formulations, you only get 10 or 25. So if you said 15, it's not a dose that we actually give. So, although it says 10 to 25 it should be 10 or 25. Um it's better to start low and build up. So I think 10 would be preferable, but 25 would be acceptable. Uh and it's better to take it at night just because it can cause drowsiness. You could have had DULoxetine. Er, and that's also first line. Uh And that would be 60 mg, po once a day. And this is the source. Any questions on that? Nothing online. Nothing in the room. Everyone happy. I need to wait a bit because there's a bit of, yeah, I can wait a bit. That's fine. What about drug interactions of furosemide and other on the list? So it started a drug interaction is famide. And the other thing is I think that question is, yeah, there's a question asking about uh essentially, would you give friz even though it can interact with some of the drugs they're on. The answer is yes, because um what's going to kill you quicker? The drug interaction or acute pulmonary edema, pulmonary edema will kill you quicker. Fluide is um always going to be the drug of choice. What it, the, the way that you, you go about it is you give the flusemide and you get them, you offload them as quickly as possible. And then you can think about drug interactions and other things, but you're still going to give the flusemide. Another one is um I think that was answered. Would amitriptyline hydrochloride be correct with amitriptyline and hydrochloride. Yes, because you're, you're giving the exact drug. That's fine. I mean, uh I don't think we included the hydrochloride. Um It, yeah, you can do, but it's, it's overkill. You don't need to say the formulation, you just need to put the drug. So I wouldn't try and put too much information, just put the drug name as enough. What about Venlafaxine? I think for Venlafaxine if I remember that came up after. So it wasn't first line, it was an alternative on the B NF after DULoxetine. So the order in which the drugs are listed in B NF is important. So, when you're looking at it, I don't know why you would choose one further down the list first. If you're reading an order and it comes up, then put that drug in first. So, Venlafaxine, er I think can be used, but it's not as high up the list as DULoxetine or amitriptyline. OK. We'll move on to question four. So this is about a patient with a macrocytic anemia. Um and they've got intrinsic factor antibodies that are positive. So, what's the diagnosis? Pernicious anemia? Very good. And why is that important? I'll be more specific. Why is pernicious anemia um rather than macrocytic anemia important. Yeah, the treatment pernicious anemia requires um a more aggressive treatment. So having that diagnosis is important and you get that from the clinical information here. Uh So no allergies uh on levothroxine. And the question's asking for an initial prescription in case it's the first drug you're given. So this is the correct answer. Hydroxycobalamin. And because they've got pernicious anemia when you go to the B NF, um you do need to look for pernicious anemia and not just macrocytic anemia. And when you do that it will say uh 1 mg er on alternative days until no further improvement and then 1 mg every three months and you don't need to worry about longevity here. It's the initial. So the correct answer is 1 mg uh once only or stat is fine, would you get the marks for once a day or alternative? Uh I mean, it depends on how the question's worded. If we look at the wording here, it's just asking for the initial prescription rather than what do we give uh generically. So if it's worded like that, I would just give that drug. But I think for the real exam, it will, it will be obvious dosages though. You wouldn't always just prescribe the first dose of everything. Uh No, you would uh prescribe more than that. But the, the, the way that we've written this is to try and prevent ambiguity um for your exam is it dropped down still for the drugs? Yeah. So I think my answer is gonna be see what comes up and choose the most appropriate, but I worded it in that specific way today because I just didn't want a, you know, massive variation of answers. Um And it's the principle again, I mean, you, you know, the principle of how to prescribe it. So that's the take home, it's not uh you know, the exact marks you got. What do I actually use to treat? There's another question saying, uh why is it not it, there's a warning for, maybe you can read it for, uh I would need to look that up. I think what I'll do, I think that's a reply from someone saying that's why it's not used. There's um why is it not used? So, there's a question saying why can't we give Cyanocobalamin instead uh off the top of my head. I can't remember what the BNF says about that. Um, but somebody's put, it has a warning for vegans. So what I'll do is I'll have a look when um I got it, I got it wrong. Yeah. Um Treatment in with iron injections. Oh, by ss or, or Yeah. Yeah. OK. Fine. Right. I'll, I'll summarize. So the question is why can you not give uh cyanocobalamin instead? Uh why does it have to be hydroxycobalamin? It's because Cyanocobalamin is an oral treatment. We're dealing with pernicious anemia here. Uh It requires im, so it has to be IM treatment. It can't be oral. Uh it's not strong enough. So if you've got, and that's the key thing about pernicious anemia. If it's not pernicious anemia, it's just um a mild max anemia. Maybe an um a good example of the chronic alcoholic. They have a macrocytic anemia and you can give uh cyanocobalamin orally, but this is a very specific management for a specific disease hydroxy. This is from the BNF hydroxycobalamin is retained in the body longer than cyanocobalamin and thus the maintenance therapy can be given at intervals of up to three months. Perfect. So that's your reasoning. So, thanks for that. Ok. Uh, we'll move on to section two prescription review. All right. So let's go through the questions and prescription review now. So I want to read all the questions. Um, we saw this man had a fall at home. Uh, we want to see the medications that have contributed to the fall. So again, we look at uh the usual culprits are or BP medications. Yeah, look at the question as well. BP, uh lying versus standing. We know he has an element of postural orthostatic hypotension, which has a definition of a drop in systolic BP by more than 20 or 20 or more or a drop in diazole by 10 or more. So, either or will constitute um postural orthostatic hypotension. So we know what we're looking at in terms of uh drugs. AmLODIPine, furosemide, tamsulosin and bisoprolol. Yeah. Am amLODIPine being or calcium channel blocker. Furosemide being or a loop diuretic tamsulosin or alpha one blocker, bisoprolol or beta blocker. Yeah, I think pretty straightforward when we have to pick those drugs out of here. Any questions on that? No. OK. Next one. they asked select the one medication is most likely associated with anticholinergic effect. You all know, I love my sympathetics, parasympathetics. Fun stuff. Oxybutynin. Yeah. Oxybutynin used in a bit of uh medical treatment for uh urge incontinence especially uh to treat an overactive bladder. How does it work again? Muscarinic being the parasympathetics is important for urination. So, the muscarinic squeeze the bladder, the detrusor muscle activate the detrusor muscle and it relaxes the internal urethral sphincter. Right. So, an antimuscarinic will allow the bladder to relax and counteract that opening of the internal urethral sphincter by and and thus treating the overactive bladder, it relaxes the detrusor, right. That's the main goal of it. Yeah. And of course, we have to be very careful, especially in treating elderly patients who will be the ones usually presenting with this urge incontinence. Um, because they can, uh, you know, suffer from this anticholinergic effect as well. Question. Yeah. Oxybutynin obviously is a false risk. Um, and there's five things up there with and oxybutynin that would potentially present with this presentation. Absolutely. Oxybutynin, not one. It's a very good question. You know, the question is, why is oxybutynin, uh, even though it can contribute to a false risk, why can't it, uh, be as one of the medications there? Because, uh, simply, but we have identified the cause of being postural orthostatic hypotension. So we know it's a drop in BP, the inability to get up that BP back up as quickly as possible. So, these would be the most likely culprit can contribute. Absolutely. But we're looking at BP medications first in postural orthostatic hypotension. Yeah. All right. Moving on some is a 70 year old who presents with a and shortness of breath, right? Um, so we're looking at this patient past medical history of asthma, gout hypertension anxiety, lots of drama. Um, two medications that have most likely contributed to shortness of breath. All right. And two medications that you would, that you should be cautious about co prescribing due to potential hypersensitivity and or hematological reactions. So, refers to propranolol and Ibuprofen. We should know this. Yeah, beta blockers and Ibuprofen uh usually can exacerbate asthma and should be avoided. I beta blockers can cause bronchoconstriction. And in in actuality, what it prevents is bronchodilation because of the beta two effect of bronchodilation. So it actually blocks that in an acute asthmatic attack. So you won't be having the response as uh easily. And of course, straight from the BNF Allopurinol and Enalapril, enalapril is predicted to increase the risk of hypersensitivity and hematological reactions. Yeah. One given with allopurinol. OK. Um Citalopram and Ibuprofen both can increase the risk of bleeding when mixed. Um And he's got a severe prosperity. So when cos that's I would argue that's hematological, which is it? Yeah. Yeah. But is it a potential for uh oh you mean in, in this regard hypersensitivity? Because I thought it was like something that, oh, that's how you read it instead of, I mean it is possible. Uh I mean the the, the hypersensitivity reaction. Well, that, yeah, you can explain, but I think it's, it's more the question is more about, yeah, that, that's what I would take away from it. II agree. Um You know, they're looking at this specific thing. If you look at what the BNF says, you can tell how we derive this question. Uh looking at the hypersensitivity and hematological reactions. I think the A may have thrown you off a little bit there and you're quite right about the, the citalopram and the uh uh Ibuprofen causing the increased risk of bleeding. But I don't think it was a focus of this question so much. So II, II would be more on the side of get testing the hypersensitivity side of things. Yeah, but I do get your point in that to be honest with you. Yeah. No. All right. 78 year old gentleman presented with a fall. There's just one question about like or you can tell them about the control level. Oh In BN. Oh OK. So there's a question you don't need to show them. Oh, like someone is asking how to answer part B quickly. Oh Yes. So if you want to answer part, we find things within the BNF quickly again, you know what you're looking at or use control F, you can fill in the, the, you look in the specific categories, interactions or whatever you want to look into. But control F is a good feature that we can use to find things quickly. All right, so Damien presented with a fall um past medical history, hypertension type two diabetes, af all this fun stuff. Um, his gcs was 12. It's found to have weakness in the right, upper and lower limbs. Power of two found to have slurred speech. Uh, you know, we, we did these observations are there. Uh, CT head is pending. Blood test shows nothing too much out of the way. Um, any drug history is there. So the clicking doctor notices an abnormality on the ECG. So we get this ECG select one prescription that is most important to suspend until initial investigations have been completed. Yeah. So the first one we're looking at is I pick some up. Yeah. And why you think about Apixaban is because the patient having this uh, bleed. Yeah, you could have a, it could, the patient fell right clinically did the patient fall because of a stroke. The patient have a bleed because of the fall. We don't know, but it's a high risk for bleeding, especially, uh you know, uh hemorrhage. So we'd want to suspend Apixaban clinically as you go forward. Remember, patients take these Apixaban sometimes in the morning. If you took it after II, if the fall happened after you took the Apixaban, then we'll hold it. That's still what we will do. But clinically, we'll have to look at if it has bleed after the CT head reversal agents and so on. But that's way after select two prescriptions that are most likely responsible for the E CG findings. So what do you think about the ECG finding D D? Yeah. Did we all see that? Reverse T Yeah, Nike, whatever it is, the uh reverse T seen in digoxin toxicity, right? PSA beams and Fetter used in asthma and COPD and both of them together can increase the risk. There's a lot of things that can increase the risk of digoxin toxicity and it's also important to be aware. So you would, you would have had one answer there from the get go. You see an ECG you think most likely? Yeah. So that one should have come up to your mind right away. Of course, we have hypokalemia, all these other things that can lead to ditch toxicity. But now you're searching with ditch and from the list there. So it's very strategic how you have to approach this. You can't have no information. You can't be searching amLODIPine versus Metformin causing this thing. So your, your initial idea takes you half the way and then you can check after that. Yeah. So it's a bit of strategic uh answering. Yeah. Yeah. Um, medicines complete. Yeah. Oh, with medicines complete. That's fine. Ok. All right. So this 176 year old gentleman, Mister Perkins with the orthopedic department sustained intracapsular neck or femur fracture. Yeah. Tripping over the uneven pavement. Um past medical history of asthma diabetes, BPH and idiopathic Parkinson's disease. Um, blood test, respiratory and all those things. Are there select one prescription that is most appropriate, appropriate to be converted to an equivalent transdermal preparation while the patient is nil by mouth. And I'll tell you as a foundation doctoring doctor, whatever you're doing, this is very, very important from the get go and you'll see it all the time and it's very, very important. So the first uh question what we want to convert is the, yeah, the called dopa. Again, this is the Parkinson's medication and you, when you learn more about Parkinson's medication, which you already know is given at a specific time. And it's very important that patients do not miss their doses. Yeah. So that's the one that we would have to uh be very quick about changing to transdermal preparation. And even for your own practice, if you see the patient on Parkinson's, that should be on your mind right away. You need to get that information from clicking in the patient and prescribe that medication at the time that they take. Yeah. And the next thing is select one prescription that is most appropriate to be converted to a continuous infusion for the duration of the operation. Again, diabetes, uh colitis. Um One of the thing is the novomix. Yeah, it's containing both short and long acting insulin. So you can have a dip and uh uh rise which may not be uh conducive in the operation. Patient going to hypo and so on. So we convert it to rate infusion good at one point to always remember any time you put the patient on variable rate infusion, the long acting insulin is always continued. Yeah, we do not want to have rebound hyperglycemia. So in the background of a variable rate infusion, yeah, we always continue long acting insulin. Good Lantus is your back of the No and continue. Yes. So why isn't it? L No, no, no. We the question asking which one we continue, we converting, which must be converted to a continuous infusion? Yeah. So you wouldn't you? So you continue to be in that situation like you. Yeah, but not as a continuous infusion. OK. So the, the the question here is the continuous infusion part of it, the Lantus is given as, as normally given. But the continuous infusion means that that short acting insulin, we give it over with fluids depending on the patient's blood glucose, on what we call a variable rate infusion. So that's infusion. Yeah. The Lantus is still given how it's normally given. Yeah, by the injection they're not eating. So we don't have it. Yeah. You what? I think the question that I think someone else is also don't feel no, no, no, that's fine. I think II agree that the wording could be slightly clearer but the point is any insulin should be converted to the infusion. But you are right. You should continue the long acting in addition. No, but no but no, because I'm confused. We talk about it Yeah. So the, the that was, yeah, that, yeah, so I have a question about, uh and so I was looking at the form and I was there and they have a patch, isn't it? It's, that's not matter of bias, but it's co do, it's a co do patch. No. But if the question asking you essentially, uh you, you need to how to convert uh dopamine questions are asking, what do you need to do with that? Do you need to do patch? The brand name isn't important. The point is that's the drug that they need as a patch. So the patch would be a patch. But remember the question, I'm not asking you what we're converting it to. It's just asking you which one we need to convert. If that makes sense, you're thinking they're thinking higher. The question is asking because the question is asking, which is the most appropriate to be converted to the equivalent transdermal patch? We don't care what the patch is. Yeah, we don't care what the patches we just converted some. Mhm Yeah. So it's not asking uh which, which drug, but which one of their current drugs would we need to have a patch version of? You? See what I mean? It's not asking for a direct patch. It's that the fact that they're on a drug which they can't have that's vital. So you'd need to give them a transdermal version of something that would have the same effect. And currently we do give them your tine patch because that's what's available, to be honest with you. Yeah. And what? Yeah. Yeah. OK. So section three is planning management and basically this is testing your clinical judgment about the questions and what will you do to manage the cases? So question number one mark is a 5058 year old man who came to his GP for diabetes. He's well, generally follows all lifestyle modification. He had some gi symptoms while he was on Metformin. But this was solved and now he's on modified release. He is confident with his treatment. Observations are fine. BMI is 28 past medically. He is hypertensive. He's having chronic heart failure, ejection fraction of 45% and his ECG is normal blood are fine apart from Phosphon blood glucose, which is high and HBA1C is obviously high drug history. Metformin twice daily, modified release, once daily, Bisoprolol, once daily. What is the most appropriate management for his diabetes at this stage? What do you think the answer would be why I put increased Metformin? And I know it's Flosin. But wouldn't you increase the Metformin to the higher dose? Ok. We'll come to that. That's a very nice point. Any other suggestion? Yes, we add a drug. Actually, the A1C is about 48. That's not uh not correct, but I will, we'll talk about it. Yes, that's correct. So basically here we are not managing his diabetes because the target for diabetes control is 48. That's correct. But we add a second drug when it's 58 millimoles. The answer here you imagine is heart failure and adding the GLU is not for the diabetes. It's for the heart failure risk because SGL twos are part of the four treatments of heart failure, which are basically the ace inhibitor beta blocker SGL twos and the spiral lactone. So this question is mainly asking you about treating his heart rather than treating his uh diabetes. So if his S one C not to the target level, which is above 48 less than 48 if it's 450 or something, I would say add the SGL to check how was it? You can also increase the Metformin if needed. But here, our main concern is treating the heart failure, not the diabetes, even other questions. Yeah, but still, I mean, the patient is having diabetes but the management option from the next medication is treat the heart failure. And for also if you it Yeah, it says once Metformin is um tolerated, which is so other scenario, the same question came and the patient is not diabetic. What would you pick still frozen? So it's not for diabetes, it's for heart failure. It was a measure of heart fail, especially with 45% which is moderate, reduced erection fraction. Would it say appropriate management for his diabetes disease even matter? I don't think it will be phrased like this, right? The minute, the minute you see heart failure, always remember, this is an essential drug in heart happy. Yes. Spironolactone. That's usually second line. It's SGL T two, second line. So new guideline, they're all first line. So you have to start all for management of heart failure, which is spinal lactone entresto, the, the SNRI beta blockers and angio that was previously, you, you need to add one by one. But recently guideline says that you need to add all of them together. I don't have to worry about this because I highly doubt such questions will come. Uh but this is obviously a common question. So the patient comes with diabetes, even if they don't have heart failure, if they have a risk for heart failure like previous M I or any cardiovascular disease, you still give uh give those in not just heart failure as you to. Ok. So now it's updated in 2022 patients with type two diabetes or on Metformin. And as your inhibitor should be given in addition to Metformin, the following circumstances, cure is more than 10% established CVD, chronic heart failure, three conditions, you always add it. And if it's heart failure, you add it regardless of diabetes. Basically. Next. So let's look at this is a very important treatment as soon as we diagnose, right. There's no, yes, but we we this is not something to discuss because it has a lot of things Uh So basically this is a very important slide. You can take a picture for it. Actually A1C target is usually in and you motivate people to have uh regular checkups every 3 to 6 months, then six monthly. And this will be a consideration also for relaxed targets in order of child patients. So patient age needs to be taken into consideration a treatment dependent H A1C target. So when you, when you start the treatment like this patient, the target should be less than 48 right? And he was 47. So it was fine and this will be the target, whether it was lifestyle or a single medication. When will you add the second drug? When the target is 58 which will we come to now? So a patient came with diabetes. You started Metformin, which is a first line. Obviously, you need to aim until it's 48. If it exceeded 48 which means you need to more advise a patient with increasing the dose lifestyle modification. If it arrived to more than 58 then you consider adding different drugs. And this is the case if they don't have any cardiovascular risk, there's a cardiovascular risk, you would add a zero to anyways. Uh Of course, if it's a hypoglycemic agent like sulphonylurea, the target will be a bit higher. It is 53 not 58. So put this into consideration again, Metformin is the first line SGL to and for for heart conditions. If Metformin is contraindicated, then AGL SGL two monotherapy can be considered or other drugs can also be considered based on CV risk. Basically medication management. Again, we said second drug added after 58. And what will be the second options? You have usually DDB four inhibitors, 5 L sulfon or AGL two inhibitors. It depends, that's usually the second line. Uh They don't prefer using GLP once that's why it's in third line therapies where you combine three drugs or you start on insulin. And that will be basically the, the, the decision of the, I don't think even GP can decide on this. I probably it's the endocrinologist, right? If it's third three medications are not working GP specialist, probably specialist. But yeah, anyways uh con for review other therapies and start with insulin risk factor modification. Always remember when you manage person with diabetes, you need to modify the risk factors. So, hypertension always prescribe ace inhibitors or add ups depending on the uh if you have any contraindication for that BP targets is similar from diabetes. That's a miss people have misinformation that the target for non diabetes is lower than the people normal, not the same if the person's target is 135 or 80 the same for diabetic. No same target. Basically no difference. Antiplatelets always for people with cardiovascular diseases. M I whatever lipids and statins. 20 mg as first line, if there's more than one risk for primary prevention, secondary prevention. Always 80 mg as you remember from stroke. And am I any questions on diabetes? So in this, in this type of scenario, just generally even like, oh, you add the the but you say the HBA1C is not, not in the right level. Would you also titrate up the Metformin as well and add or would you just add the second drug and leave it where it is and not that good. I think it would be better clinical judgment if it's very high and you expect the dlo wouldn't help in lowering it. You need to increase the Metformin. Yes. Increase it. But if it's a bit high and you expect that because it will work and help you achieve the target, you can try with the gabapentin review later, then add the Metformin. That would be the best answer. Do you agree? So, ok. Any more questions? Thank you. Bye bye. Next question. 75 year old female, a retired teacher came to her GP because of worsening joint pain, which is in her hands and knees. She has a history of osteoarthritis. Five years ago, she had trietol got minimal relief but didn't try any other medication for arthritis. She's concerned about the impact of her daily activities as she enjoys gardening and playing the piano. Simple scenario oa five years ago, took paracetamol. Didn't take anything else past medically hypertensive hyperkalemia, drug history, amLODIPine, simvastatin, paracetamol, no allergies, nonsmoker drinks wine a bit, lives alone walks 30 minutes a day active. Uh, everything else looks fine apart from reduced range of motion in her hands, investigations, obviously, osteoarthritic changes, blood and test. Everything is fine. The GP considers to improve her pain management and quality of life. What would be the first line? Topical NSAID? Basically, it's, it's a very simple direct question. Paracetamol didn't work. She's doing paracetamol. First line you try is topical nsaids and the guideline on this is very clear. If we have a look at it here, it's topical nsaids like diclofenac gel. It's a first line treatment for localized osteoarthritic pain, particularly for oi affecting the knees and hands, which is the case in this patient. If it didn't work, then we can move on to oral. And basically we have out of options and oral nsaids. TraMADol intra injections everything else. Yes. Um, when you go on the, like Ibuprofen, there's two different options. There's the fended or IB gel and they both have different, um, IB gel. You can only give up to three times a day, whereas the offender you up to four times a day. Um, I went for that cos it made the most sense to my brain. But, um, I was thrown off by this, potentially only being able to apply three times a day versus four. It's the same drug. It's not, um, I'm not sure it's a different drug. I, I've never heard of this drug. The con is different. I think it's the concentration difference. If it's 3 to 4, could you just repeat the question again? Sorry. Just one or less of ibuprofen. Yeah. When you, when you search for ibuprofen and you go for the dosing, yeah, there's two different gels. There's the fended or there's the Idu gel and the I do gel specifically says apply up to three times a day. Whereas this question is, uh for four times a day, which is like the fended, but basically they're both different um, frequencies. The const may be different. I would guess. I don't know. Is there another answer you would change? No, no. The answers are clear. Depend on the preparation manufacturers. Can, I wouldn't worry too much about that. Just, just obviously for this, it's the most correct answer. And to be honest, they won't even try to trick you by giving one of the form between three and four. Yes, this is dumb. But it's no because, because I, when I was on GP, they brought up new guidelines for managing pain. And that actually physio and exercise was actually first line now and you only go to either topical or oral after, you know, try physio for X amount of time. But what no, what I'm saying is the, the question has got referred to a physiotherapist. I can do joint exercise and what are those guidelines? I'm just a, I'm just a, so for purposes of the exam, your guidelines are those on the B NF. So I'll just reverse whatever's on there. So, when it talks about, uh, treatment or osteoarthritis follow up. But even so what Kimber says, correct, because she's tried already oral therapy with paracetamol and that would come after the physio. So you would guess she tried physio didn't work, didn't work. Now we're moving to our topical then oral. So you wouldn't go back down, you wouldn't go back down the reach that stage, then you need to. But it, it's only because he didn't say that's why I was asking for that. And then you said you wouldn't skip to oral before doing the either. Would you say so? Like, that's a lot of inference. But would you get before the, she was diagnosed five years ago? Yeah. Like I'm not, I'm not, I'm not even like this isn't, this is not a question this is more about. So I go to the exam, that's what this is. Just follow whatever it says in the DNR. Um, because like, because that's a lot of before the top or before or after then that makes sense. Ok. So anyways, we will check, Sam will check this now and, uh, let us know any other question. No, anything like that? Ok. Oh, I think unless you're mean, are you mean, am I mean? No, no, no, not. Yeah. So, so me, me, so the same question you asked was asked here and we will check into it and let you know the same question. 11, Jack is a nine year old boy came to his GP with his two months has been struggling to keep up with his peers. During physical education class. His teacher spoke to the moms and explained that Jack basically struggling to breathe and that's always behind despite using his inhaler, which is altam. He has not been participating in activities because of the symptoms. All vaccines are fine. Inhaler technique is reviewed by the GP because that's the first thing you need to do and it was fine acceptable vitals looks fine on room air which means not an acute, it's rather a chronic problem that's happening but not at the moment. Medical examination are remarkable except that he's having eczema of lesions on the arms and legs possibly might eczema and asthma attends local school to moms works as a clairvoyant. I don't know why some you pick this clairvoyant as a work and other is I reversed. The A I had to go yesterday. No, I wanted them to be teachers and he changed. I It's a tell. Yeah. No, he said what would like an LGBT do I not? Ok. So drug history is 200 easy inhaler. Salbutamol P RN. No non drug allergies. The GP arranged for a blood test. What is the appropriate management option at this point? What do you guys think? So he's on all these salbutamol? So next. It's basically asthma management in 5 to 12 years. Basically. Yes, inhaled. Yes. Correct. And it is 102 100 betamethasone twice daily. That's the answer. It's a very easy stepwise approach for asthma. It's a whole guideline. What you need to start first? What's second, one's third, always start the low dose first. Which 102 100 basically depends also on the age. If you have a look here, chil Children 5 to 11, 102 112 to 17 is 200 to 400 adults is the same. It's a very straightforward question. I hope you all answered correctly. Any questions about this? No? Ok. Next 30 year old female, she's a graphic designer. Her name is Tony, visited to her GP with a three day history of a painful red left eye which was associated with blurred vision. She also reports gritty sensation in the eye and sensitivity to light. She wears contact lenses regularly. So sudden eye pain with blurring of vision, she's wearing uh lenses, no significant positive with the history, no medications, nonsmoker, occasional alcohol consumption on examination, visual x was reduced in the left eye and the left eye examination reveals a red inflamed conjunctiva. And the Coronal Thorin staining shows a small ulcer investigation. Basically is bacterial corneal ulcer possibly related to compact lens use. So this is a typical um diagnosis that you need to find the find the absolute correct option to pick for what do you think the answer is refer? Basically, it's as simple as that you need to refer immediate to ophthalmologist for assessment and treatment. Why is that these corneal ulcers are very serious conditions that are not something to be managed by the GP. Uh So this is I tried to summarize this a bit and basically corneal ulcers are more common in people who wear contact lenses and for such people, you need to refer direct to ophthalmologist. Yes, chicol can be used but it should be prescribed by Opher to GP. That's why that's not the correct answer. Uh And GP, the ophthalmologist might, might prescribe a different antibiotic doesn't have to do oral antibiotics can be used. Yes. Also, ophthalmologists will do that. Discontinue contact lenses use and maintaining eye hygiene is important. So as a GP, you'll just advise her to stop using the lenses, maintaining the hygiene. You are referring ophthalmologist. Uh these are these guidelines where urgent referral should be. I think this is something that you need to be aware of in case. Such question comes in the exam and our is basically the severe disease of corneal ulceration. Others are ma mainly infection uh mostly are infection Oto cellulitis, recent surgery and the others basically are, yeah, basically infection. Any question, can you if they had like a standard bacterial conjunctivitis and or a contact lens user that there was no ulceration, would you still have to refer them according to my information. I don't think so, but Sam may be a note, it's because of the ulceration that they need. The referral is because of the, because of the. Yes. Correct. Um Yes, but, but it's uh it's corneal involvement. So it's just a bacterial infection, conjunctivitis with, with a contact lens without corneal involvement. 24. The ulceration is the point. Yes. Other questions. Hang on online. No. Ok. Excellent. Oh, you, yes. Ok. I get. So I will move on to the uh session. Four, session four is providing information before talking about that. Uh Let me introduce myself again. This is hey uh teaching fellow from Southend. So, yeah, nice to meet you. So this uh this session would be quite chill because it is quite a strict for one because it is all about the navigation of the BNF rather than doing the clinical reasoning or knowing about the clinical knowledge. So I will quickly run through it about the questions. So uh question three. So Emma, she is middle age lady come with the rheumatoid arthritis and uh the rheumatologist uh decided to start the methotrexate. So you already know about the uh levels of side effect of methotrexate. And uh you might want to know about the past medical history uh because of the contraindication of the me methotrexate. So uh past medical history, apart from the rheumatoid arthritis, there is no other past medical history and uh the most important information of the methotrexate uh should be chosen in the given uh provider options. So, in the provider options, I would approach this question with the exclusion method. So first of all, you might already know that uh for the pregnancy, uh methotrexate should be stopped uh for the uh women or men uh who has a plan of doing a family. So we need to stop it six months in advance. That is why uh pregnancy one is not absolutely an option. So uh the other side of that like hair loss and also uh the uh uh the other one like uh type two diabe diabetes you might see in the side effect. But when you look at the frequency, it is under the session of uh and no one, right? That is why uh we will choose the uh liver toxicity. But because in the question, it mentioned, what is the most important piece of information one you look into the B NF it had mentioned twice under the session of caution and also the monitoring session. That is why I would choose this one. And if you want to know about how to take the uh methotrexate, it should be taken with loads of water and it doesn't matter without or with uh food. So I would choose option three. Yeah. Do you have any question? No, anything online? No good to go for question 14. Uh So in question 14, Lara, she is 65 year old with osteoporosis Lara is now on alendronic acid 17 mg power once weekly. So this is the question I II won't uh read through in details. This is a question that you would save time for the other difficult question in your psa because you all know uh how to take alendronic acid. And if you look at the uh B NF, it is under the discrete uh direction for the administration. So uh for uh uh for, for the medication that is quite tricky to uh how to take medication. So uh you can look at the direction for the administration it will be uh provided uh in details. So I won't uh discuss about this question uh in detail because you, you will uh get the answer straight away. Yeah. So uh the next question, question 15, she is Alice, she is 52 year old lady admitted with the uh history of CO PD and she is now on Tio Trion and she has been previously using the Celtol Spr N and regarding the past medical history, she is a COPD patient and Seol inhaler be her. So before starting the Tio Trion, she is a bit worried about the side effect. So uh what is the most important piece of information? So uh in this question, I would approach with the exclusion method as well. So in Tio Trp, uh you, when you look at to the option two, you all know that rescue inhaler is a seol, not tiotropium. And uh when you look at the side effect, there is no weight gain. If you're not quite sure, you can search with the control F and search for weight gain. It hasn't mentioned in the B NF. So you can exclude that. And the other one, when you look at to the indication and dose, it is mentioned as a once daily drug. So twice daily is not an option. And uh the tricky point is option A or E. So when you look at to the uh side effect, it cause arrhythmia and also it cause dry mouth and glaucoma. But when you look at into the caution potion, it is only for for the people with a past medical history of heart condition. So in this question, when you look at it, there is no other heart underly uh underlying heart condition. So I would choose option one, any questions so far? All good, then I will pass on to the next person or would you like to take a short break? Take a short break? Yeah. So this is a time and a 10 minute short break. Thank you. Thank. I'm just guys will take a short break for 10 minutes and we'll be back at 310. Hi, everyone. We're gonna be starting again. Yeah, nausea control. So we'll be continuing with calculation. That is section five, the easiest uh thing for us, maybe doctor's calculations. So we have a three year old child uh with asthma who requires a cymol nebulizer and the recommended dose is 0.15 mg per kg. The child's weight is 15 kg. So we already have an idea of how much dosage we need. It will be 0.15 multiplied by 15 is equal to 2.25 mg total dose. The nebulizer is available in uh five mg per ml. So if we have to calculate how much of uh milliliters, uh we should be giving, it will be 2.25 divided by five which comes down to 0.45 mL. S is uh that ok with everyone, everyone got that. Yeah. So this question is about a child uh who has bacterial infection to be treated with amoxicillin and the recommended dose uh is 50 mg per kg per day in 23 divided dose. The child's weight is 20 kg. Amoxicillin, oral suspension is available as 250 mg per 5 mL. So calculate the volume of amoxicillin suspension. Uh that is required to the nearest ML and here. So the dose uh that is required is uh 50 times 20 based on the weight of the child, 1000 mg per day based on the volume and that is available. So that would be 1000 divide by 250 multiplied by five. So that will be 20 mL. And we said in three divided doses, uh so divided by three that comes down to 6.66 nearest to 7 mL per dose. Next question. Sorry. So this one is uh simply about uh a 42 year old patient with type two diabetes. Uh who's been prescribed insulin glargine. The endocrinologist uh recommends a dose of 0.2 units per kg per day. The patient's weight is 90 90 kg and the concentration uh is of 100 units per ML. So what is the volume of insulin glargine? Uh The patient should inject once daily to the nearest 0.1 mL. So again, based on the weight, 0.2 multiplied by 90 that is uh 18 units uh per day. One unit has 0.01 mL because we had 100 units equal to 1 mL. So one unit is equal to 0.01 mL and that multiplied by 18 is 0.18 mL. Finally, the last question. Um So there's a question I think, but I'm not sure if this question spring round up or down, you would round up preferably because it's 6.66. So that was 7 mL. I think that's the question that you're asking. Yeah, you would round up finally. Uh So you have a 25 year old uh female with anemia who is prescribed uh oral iron supplements. The recommended dose uh for replacing iron deficiency is 1.5 g of elemental iron per week. Ferulate uh 200 mg tablet contains 70 mg of elemental iron in each uh tablet. How many tablets uh should she be taking uh to receive uh the required uh replacement? So that would be 1500 divided by 70 mg of elemental ile. And that would be 21.4 tablets per week and that divided by seven would be three tablets per day. Yeah, sure. Just doing like three tablets just goes a bit under 1.5. So I think I was gonna say, but I put four. So it goes over 1.5 because that's just a requirement. But do you, would, you always like the deficiencies? Would you just, I think both the doses would be fine because um, um, for you to get uh like an iron toxicity, the dose should be really high. So I guess four would be also correct. Um, you, you're saying four, right? Can you repeat? That's what you're saying. II hate numbers. I said 3.2 or something like I got it wrong. But basically, I mean, um, you just, you know how you do it the other. So I tried it the other way. So time out from three point it was like 3.10 or something like that, which is really minus, you just put three, right? But then, um, I timed it out the other way and then it was hitting like 1.47 which seemed a lot lower than 1.5. And that was why I was like, oh, maybe you have to do four. And then that was a lot over. It was like 1.8 or 1.9. But then I was like, you can't really, that's not iron toxicity. Right. Right. But you'd want something to be above if you have anemia. Basically, your isn't reaching the 1.5 but four tablets is much over. So you do need to reach the 1.5. The target is approximately OK. That's what you're saying. I, no, no, I get it. I get what you mean. But it's iron, right? Yeah, like we're not talking about something that's like has a very narrow thing that if you're going too much under too much over, it's not gonna have that therapeutic effect on sense. Of course, taking four is not gonna like bother that patient maybe fuck it, sorry, maybe like just mess up their gi or something. But like, you know, like it's like I get what you're saying, but also normal, it's just the calculation. I think your teachers with me look like that. So that's about the calculation part. Uh Next part is if there's any questions. Sure. There's a few questions, please. Uh Can I see the working for question 18 again? Sure. That's the what about this one? I'm guessing? Question 18 is not as you round it up. Oh yeah, that's fine. It says to the 00.11. Yeah. Yeah. Yeah, it's 0.2. So on the actual thing, you'll put 0.2 right? Yeah, it's to the nearest 0.20 now. Yeah. Fine. Uh, can I see the working, um, ok. All right. Yeah, thank you. I think that's ok. So hello everyone. So I'll go over session six, which is like quite straightforward. So you can just type in the drug and see the side effects and you will see the reactions. So the first question is, question number 20 he's a 38 year old male depression, uh, management medications and CBD. So he's basically say, mm, showing symptoms of, um, what we say anticholinergic symptoms. So, and then we pick one of the drugs, uh, from the list. So, uh, that would be amitriptyline and because, uh, sertraline and the other medications, they can also have these anticholinergic side effects. But, uh, amitriptyline is the worst. So it can. So we pick the best answer from that is amitriptyline. A, uh, yeah, sertraline is the first line. But, uh, this is like, uh, certainly would be. Yes. Yes, I agree. But, uh, the question asking that, which is the medication that can give the, you know, worse symptoms. So that's why we're picking Amitriptyline TCA. Yeah. And so which is the most likely to have been prescribed despite the severe depression, amitriptyline is far, far more likely to, of course, those symptoms in such relief. There's a very small anticholinergic effect with SSRI s there is a huge antic effect with. So that's the key differentiator. OK. So that's over question 21. Uh So mm eight. this is a quite long question but IW wouldn't talk everything. So 80 year old woman uti and then um after giving the medication, she is given some symptoms of like uh pulmonary reactions. Um uh x-ray also shows some infiltrates. So um a consultant has given a medication and then he's thinking he might have a drug reaction. So which medication is likely responsible from the list? So that would be nitrofurantoin. So these are the most common uh medications to give in UTI S and then it is uh very common to get the acute pulmonary reactions. That's why we picked it. Uh So yeah, I wouldn't uh read through all the explanations. So it's uh al already already on PNF. So, so yeah, let's give it a go. So the next one, any questions? Ok. Question 22 is all, it's all on the already on it. So, a 68 year old female af uh managed on sotalol and then she also got diagnosed with RA and given some DA S and then she is uh presented to the, presented with symptoms of palpitation and light lightheadedness, ec D. So prolonged QT. So which medication can cause prolonged QT? Basically, we're asking uh So the from the list that will be hydroxychloroquine, uh which is given as A DDA T and RA. So it can cause QT prolongation and combine with sotalol. So it's given the symptoms. So we have a list of medications that cause like QT prolongation. So it's a quite good table. So anybody wants to take a picture. So I will pause it for a moment. Just a note on this. Um, there are a lot of drugs that can cause QT prolongation. I would try and learn as many of them as you can through your finals. But on the BNF, it doesn't have all of these drugs as significantly prolong QT, there are actually very few. So I differentiate with this exam for it to be mentioned, I would check in the interactions but in terms of theory, there's a much wider list and this will be everything you need for your exam. Yeah. Oh, when I ran into the BNF, I got the answer. Right. Because I just, yeah, but I couldn't find it on the B NF. Just a like sanity check. What was it like? Did you, you didn't have any frequency, unknown, frequency unknown? But if you do a control, that's it. Yeah. Right. Basically. Yeah. Yeah. Yeah. That's cool. So uh the last question for my session, 22 year old male acute psychotic episode, uh admitted to the psychiatric unit. And uh basically, I wouldn't read all. So he is diagnosed with symptoms and then diagnosed with a neuroleptic malignant syndrome. So given his drug um regimen, which is the most likely drug. So we already know haloperidol and it's a typical antipsychotics and it can cause uh these symptoms, you know, uh LeAlan syndrome. So, yeah. So the hypo, yes. OK. That explanation would be. So uh yeah, because of the rapid blockage of dopamine receptors and then these are responsible for regulating the muscle movement and thermal regulation. Uh So that's why uh we because of this drug, it is causing neuroleptic malignant syndrome. So any questions? So I think it's quite straightforward one. So everyone ready. So any questions as well. So it's quite straightforward. So, yeah, it's done. So section seven drug monitoring. Who is gonna be all right. Hey guys. So someone said if you type appendix one on Nice BNF, all the tables will come up including the drugs for QT prolongation. And I know that if you type appendix one on Nice BNF, it'll show tables with the drugs including QT prolongation, the type of men one not gonna walk through. Yeah. Make a note of that. Oh, that's, oh, that's who said that they deserve it. Yeah, that's really good. I just wasn't aware of that type. Just type um appendix one. This is so good. I thought it was just hyper wait for PSA people to know about this. Yeah. Yeah, we'll go back to medicines complete GMC referral because they just trying to make it so hard for no reason. Like what was the point? Of getting rid of the, um, yeah, they, they didn't want people to, they wanted people to think, uh, uh, their reason was to increase rationale rather than, um, like, yeah, to increase your rational and reduce the rational. Which, which one I do get. But, yeah, it's harsh. It's ok. So, monitoring, this should be quick and easy. Right. So, um, 70 year old female attends heart failure, whatever clinic, whatever. What do you need to monitor? Did they, did anyone have a problem with this? Sorry, I I'm not gonna read it. I did anyone have a problem with this? So if you go to BNF and you click monitoring, the answer is right there. Yeah, this should be the section that you really should just move quickly. Is that OK? So um you would need to monitor spironolactone. So one week after initiation and then monthly for three months. Yeah, and then it goes on I think like uh so monthly for the first three months, then every three months for a year, then every six months. That's actually how it is the whole thing. But from the list of options, it's one week after initiation and then monthly for three months. This is you should also know this for your spas. I think, I think spironolactone is one of these that comes up occasionally. Is that OK? Can we move on? OK. Another person with hypertension and prescribed Lisinopril. How often do you mo how would you monitor this basically. Again, if you go to BNF, click on monitoring, it will show that the renal function electrolytes checked before starting and increasing the dose and then during periodically, during treatment. Does that make sense? There's no specific cut for this. But you need to remember that people who are have hypertension are on Lisinopril. They will have occasional checkups. A lot of them are diabetic so they'll have occasional checkups. So this will be part of the checkup. There's no set guideline that says you need to do it every three months or every whatever months. Yeah. Is that OK? Any questions? Uh Sarah, does that answer your question? Renal function? Yeah. OK. Moving on 26. Um So some lady that was diagnosed with epilepsy with multiple clonic. So she was on some, a lot of treatments, nothing worked out. And now she's being prescribed sodium valproate. What do you do? This is a last resort as you can read from the question, obviously, you have to consent about like some pregnancy prevention program and it, it's a lot of things. So obviously this um like women of childbearing age ideally shouldn't be on this medication. But if it comes down to it, this is what they would be on. So again, you go to BNF and BNF would say well, yeah, so you need to m mea measure. Um you need to monitor FTS and FBC S. But at this point, it's just logic that you should do a pregnancy test. It's not there, but it's part of, do you guys agree? Did anyone get, I think this question, everyone got this correctly. So, yeah, um, again, I think it's just stating the same thing. Yeah, 27. So, um, some guy came back from a gap here in Africa, wherever that is and, uh, he has TB, so he got like the, the right medications and now you're being asked to monitor. So this is actually a bit quite like I would say complex but not really. So you need to go to each and every one of them and check what you need to monitor, right? And then combine all of them together. So that's four medications, you check each one of them and then you combine all of them. So it ends up being like FP CS LFT S visual test. That's for the I think and renal function uh Sam was nice enough to create the stable for you. So please know it because it helps. So for each one, this is what you need to monitor and combined monitoring is the LFTs full blood tests, renal function and visual activity. Yes. Yes. So uh this medication he's gonna be on prolonged convenient. He says the consultant thinks that he might need a prolonged course. I, no, I get it. I can't read, I don't read because he's always had his PC done to diagnose because the white cells and everything done guys. Let's think logically. You're gone to the GP, you're on all these medications. Are they gonna measure just your LFT and eyes and renal function? They're not gonna measure your f prior to therapy. He's just had it when he's about to start it. So that's why, how, yeah, II would say, OK, let's say you came back from Africa. You were diagnosed in A&E A&E, they messed up your blood results. Everything is chaotic. You go to your GP, your GP is like, oh my God, I never got these blood tests and everyone's screaming. So they're going to do it again. Just imagine everybody. Yeah. Any questions. Yeah, I think that's it from my side. So I'm gonna hand it to ahmed. This is the last thing and before we say uh oh my God, he's fine because the, the camera and the camera is here here. Hello. Hello, doctors. OK. 58 years old male patient with a history of primary hypertension has recently started treatment with Ramipril 2.5 mg once daily following ambulatory BP of 162. Over 97. He has no known drug allergies. He takes no other regular medications. He returns to the clinic for routine follow up for uh after two weeks of therapy. His BP today in the clinic 130/85 82. What is the problem with the labs that we are seeing right now? So, we have the basic renal functions uh one month ago and the renal functions were here today. So what are the problem? What is the problem? We have the glomer filtration rate? It's much lower, the creatinine is higher. OK. The question here. And please guys who are online, do, are we expecting a decrease in the, is it a decrease in the filtration rate? And why can anyone tell me why? Yes, you know why? What's how, what is the problem? Why do we expect the and how paradoxically we say the ace inhibitors uh protect the kidney in the same time, we are expecting a decrease in the gr this is a very interesting thing when I first knew about it. Yeah. How do they affect the kidneys? That's the first step. OK. Thank you. Thank you. So again, OK. Do you know why? What's the problem? What's the effect? It's a very interesting thing. OK. So ha so first the ace inhibitors their function, their function. OK. Then another answer more. Answer the main function. OK is to decrease the angiotensin uh two. OK. The angio tends to is uh how the body responds basically to increase uh low BP. It's a physiological mechanism to increase the BP to get higher BP. So it increases the BP, not only that it tries to protect the kidney, increase the pressure of the kidney. OK. So if you decrease it, you decrease, you want to give something that decreases the pressure of the kidney. Ace inhibitors, vasodilate cause vasodilation of the efferent of yours, the blood getting out from the kidney. Ok. So this leads to lower pressure inside the kidney. Ok. In the long term, this is uh in the long term, this is uh uh nephroprotective, this protects the kidney. However, if you have a um an endstage renal disease, for example, or a kidney that is not already functioning, the G FR is low. Ok. That's why in low, very low GFR, we don't give the ace inhibitor. So do we expect the question here? Do we expect the G fr to decrease the question is how much? And here's the answer. Oh sorry. OK. So in this case, OK, we'll continue with the Ramipril because we are expecting the G FR to decrease. Ok. It only here decreased less than 25%. Ok. It's OK. It's acceptable for the GFR to decrease up to 30%. Ok. So now we understand this important concept how the ace inhibitors are kidney protective. At the same time, they decrease the G FR and they are not allowed in patients with very low GFR. Ok. The other the other answers? Ok. Uh stop Ramipril immediately. Ok. No, cause still within the acceptable range. Ok. Uh reduce the dose again, still in the acceptable range. OK. Any question related to ace inhibitors or to this option, please. Yes, please. Um I opted to move into calcium channel blocker because they're 55. Um, also, I wasn't sure exactly how much it was in range, but because they're over 55 I just assumed that that was what the question was. Ok. So, um, if the, if the, so the main thing is we do, uh, a practical, uh, we do trials and, and the trial say that the empirical evidence says that it's ok there 30%. So just memorizing this point, but you are not right. If we increase more than 30% the CCB is a very good option at that point. OK. So if like uh uh if the increase in the, if the G fr, for example, what was the G fr if the G fr for example, uh became uh 5040 the CRE became 140 you answer would be right. The question more are why do we change the, the reason we don't change to another drug straight away is that practically when you prescribe, you don't want to switch uh drugs to uh to su the patients already on that drug. So they're already getting physiological changes that may still be beneficial and you're within the, the range um that you can continue. So yes, if they've been started on the calcium channel blocker, perfect, but they haven't been. So it's better to continue the drug they're already on than change prematurely. So that's the clinical judgment behind the question as well. Uh, and that's a general principle throughout, unless they're having an adverse effect, that's not within a tolerable range. Then, yes, you were to change it. You'll see a lot of patients and you'll think, like, why are they over 55? But not on this. But it's actually you see it a lot with, especially with antidiabetics and anti hypertensives. I know this is becoming a bit nuance but if you saw this in real life, yeah. Um and I might have done the maths wrong but the creatinine um there's only four more. It can only go up by four more. Um Yeah, sure. So it's right. It's right. It's like it's like close if you saw this in your life and they were over 55 8, the problem with that attitude is then half of this exam is going questions. You're not wrong in real life. Yes, you would absolutely consider switching agents. But for this exam, it's going to be designed to test you in a very specific way. And here it's about what is the upper limit of tolerability for an increase incorrectly? That's the question. That's the crux of it. You need to recognize that. But yeah, of course, in real life, you would consider doing them. They're just guidelines. And again, here in the answer, you are a very, you are still a safe doctor. You will recheck the uh the kidney functions after two weeks, do not leave the patient. So you, you are still a safe doctor. Ok. You expect that the GFR maybe it will not, maybe it will not incr increase more than that. Maybe it will get better. Ok. So you will still recheck the renal function after two weeks. Thank you. Ok. Next question, Sam, 35 years old male presented to his GB following uh, for follow up his diabetes. He has a type one diabetes and is compliant with a basal bullous regime. He reports exercising. Uh going to the gym maybe eats a balanced diet follows uh carb counting strictly which he has done for a lifelong. So what's the problem here in this patient? BP? Hm. Uh white blood uh oxygen, respiratory rate, uh pulse, no problem BMI a little bit on the higher side but um mm not a problem. Y BCS sodium potassium. The H B1 C. OK. Uh Do you remember? OK. Sorry. So the HB one C his, his, his diabetes is not con his diabetes is not controlled in this case. So what are the options that in that are in front of us? Ok. Should we change the insulin? Should we add another drug? What are the other possible antidiabetics that we can add? Why don't we add the, who chose the SITagliptin by the, the Gliptin by any chance anyone chose the Gliptin Exide exenatide? No one. The culture is the Metformin. Why can anyone and who and for the online guys choose excellent OK. OK. So for the online guys and for you guys here, uh can you tell me, can anyone tell, tell me why you chose the, the Metformin, which is the right answer on this? No, thank you. But uh uh understanding the basis, this is a very good answer, by the way, sorry, 11 of the, one of the answers. OK. So w more than um can I can anyone? OK. So uh reduces the insulin requirement to add it to the therapy. OK. So why, why not? So what WW what's what the difference between that and SITagliptin? What, why don't we give the SITagliptin or eggs and diet? I don't know what. Thank you so much. Can you, can you tell me more about this? Uh they, this is a type one diabetes patient. You're right. You're right. Thank you. You're right. Yeah, and the patient can produce insulin. You need to work with what you have. We are giving the patient extra insu insulin. OK. So the Metformin in this patient, the Metformin is what uh what she got it wrong but it, it knows the answer. She goes dance alone but she knows the answer. Don't worry about it. Just carry on around, please. So you, you, oh well, please consider adding Metformin. OK. So the patient, the blood, the BMI is 25. OK. Uh is uh above uh 25. Ok. Uh And another, another answer is uh the Metformin will increase the sensitivity, decrease the need. We don't need to switch to an insulin. This is the wrong answer. The ace take lit and will not have uh will not uh have the same uh effect in this uh type one diabetic patient. OK. Any question regarding about this antidiabetic? Uh I've got a question on the floor. When would you consider an HBA1C target of less than 48 in a type one diabetic? Oh, this is a, this is a niche question you want to get. This is also on steroids, right? These are weights that very, no, it's been mentioned earlier. No, if anything in pregnancy you probably tolerate slightly is you want to avoid hypos. So when would you, when would you consider as a physician allowing a lower target than 48 in a type one diabetic? It's quite a simple answer. Yeah, exactly. So it's a combination of patient preference and proven good control. Um So you can consider it people on insulin pumps or just very, very well. Um you know, years of tight monitoring and evidence that they don't go into high Os, then you can agree a bespoke plan with the patient. And this is a whole individualized patient planning because a lot of type one diabetics are very well educated, very on the ball and they are aware of the risks of high HBA1C over time. So they want to maybe to reduce the risk and aim for 43 rather than 48. So just be aware of that. But yeah, you won't need to know that. For example, description. Ok. Uh 30 years old lady with schizophrenia, migraine asthma uh attends her e for routine blood, she feels well herself. However she reports regular wheeze which is worse at night. She takes salbutamol, cloZAPine, citalopram, carp, paracetamol ibuprofen and even more. You don't know. OK. But uh those are the questions that we mentioned here for this patient. Her GP is concerned about the following blood tests. OK. What's the most uh problematic thing in this patient? What's the most worrisome, worrisome thing in this patient? Thank you for like, OK, so www why do we uh why, why do you say that now? Because she has low white blood cell? OK. So uh OK, that's a very uh that's one of the answers. So, one of the important things to take care when you prescribe uh cloZAPine. What are the other worrisome things? Doctors in this, in not in the labs but on uh uh the clinical picture of this patient? The regular be the clinical? OK. So neutrophils here are not less than uh OK. Neut neutrophils oo point specifically. 0.5. Thank you for, for, for this answer. Thank you so much. OK. Thank you so much. Um OK. So the neutrophils list uh list of 4.5 white blood cell less than 1.3 and the recurrent wheezes in this patient. This patient has many problems uh related to his medications. Ok. So in this case, in, in this, in this, in this patient, we will stop the cloZAPine, we'll stop the propranolol, we will stop the ibuprofen. Anyone got this wrong by any chance. So, what are the problems of ci got it wrong? I have a question. Yeah. Why would you not stop citalopram? Because citalopram is not indicated. Uh It can cause um manic symptoms and she's schizophrenic and she has no history of depression or anything. So I don't even know why she's on it. So I put that on because it makes no sense why she's on Cital. OK. So um this is a very important uh uh question. OK? You know what? Now we are changing the, you are removing the citalopram, cramp. OK? Because you think that there is no indication for it rather than because of its side effect. OK? Usually, usually as a GP or as an fy one, you can discontinue a medication after a asking your senior. OK? If there is a side effect, suppose that in in this case, this patient, maybe she had a depression, she has a history of other uh psychiatric disorder and she was put on Citalopram and sometimes the psychiatrists try different regimens. Sometimes they combine citalopram and uh cloZAPine. OK. So there is no reason to discontinue the citalopram. In this case, there is no side effect that you can see the citalopram is not the one that's causing the wheezes. It's not the one that's causing the agranulocytosis. So don't discontinue something without side effects, especially if a psychiatrist prescribed it or an oncologist. No, I know that. But sometimes some of these questions are like that's also not indicate so why they're even on it. So the psa questions with schizophrenia needs to think of it as more positive and negative symptoms and citalopram has shown better improvement in negative symptoms. So it can be started. I agree with you. It's not like a typical schizophrenia patient on Citalopram, but it could be more schizophrenia with more negative symptoms and Citalopram is working out for you. It's just some of the PSA questions. It's like you would also stop that because there's no indication. So they didn't want you to know if something is prescribed by mistake, you need to stop it. Yeah, that's tricky. Yeah. So what I say, I realize that there are some questions you've got to look at um what information you're given and connect the dots from the information you are given. Is there a specific reason why this drug needs to be stopped is and for something are more obvious, but when you're talking about psychiatric medications, you need to be really careful and they wouldn't design a question where they expect you to suddenly stop all psychiatric medications. That's just not being thank you realistic. So, um yeah, so I think in this case, the ones that are being stopped is very specifically that information can get from the blur, but there's no information directly linked. So the nsaids and the beta blockers, OK. It's uh final uh revision for this uh case, the nsaids and the beta blockers. Do we know why do we stopped it? Because the, if the patient has asthma, uh ideally, this patient should, should not be put on propranolol uh to start with. OK. And of course, we shouldn't give an N for this patient. Uh But the, the main problem here is the cloZAPine. CloZAPine is a very dangerous drug. Ok? Up to the extent that psychiatrists have uh something called cloZAPine clinics. They, they have cloZAPine clinics only to monitor cloZAPine. CloZAPine can, can kill a patient but it can save the patient. Ok? And when the drug has many side effects, it has many effects. Ok? Um So agranulocytosis of cloZAPine is extremely important and whenever you uh uh uh c the, the, the name cloZAPine uh take this in consideration and in exam, uh think of stopping cloZAPine a lot, you know, because they will, they will uh test you uh in, in, in your knowledge about cloZAPine. Any other question regarding this final case? OK. I think that's it. Thanks. OK, good. We're almost at the end of the day, we'll finish about an hour early. Um So a few things to mention. Uh so we'll keep the chat open a little bit longer. Any questions about any of this, you can put it in. Um, we need you to complete the feedback, but that will be available at the end. Uh, and when you do that, you'll get a certificate. Uh, the other thing is, uh, as I said earlier, we would go over the top scores. Um, so should we do that now? From, uh, yeah, from the practice paper? Yeah, I'll, I'll just read it out. So, um, for those that are, we're debating whether the top three or top five, but I think we should keep the top three as we said before. Uh, so, uh, in order, so in third place on to shio, they're very good. Uh, second place we have Asher Thompson who we know, but she's not here today. Um, from bars. Yeah. Yeah. Uh, we see, she may not want it, she may want it. Uh, and by, I won't say what the marks are but by half a marker, well done to Hiba Yusuf from Barts, er, who got the best score today. So, I don't know. Yeah, I'm not sure whether we know Hiba, that's, uh, she one of ours. Anyway, what we'll do, we'll put our email address in the chat if any of those top three would like a certificate. Um, then if you email us with your name, uh, the name you'd like to appear on the certificate. Uh, and the best email address you want us to send it to, we'll do that within the next week. They did pretty well. I won't, I won't say the scores. They did pretty well. Remember these, we stopped, uh, we stopped looking at the scores at about one minute to two. That was the cut off. That was as long as we could wait. So, if you uh submitted anything after that, uh, apologies. Yeah. Sorry. Two or the same. Two of the same, the same. Yeah. Yeah. Yeah, exactly. Yeah. So fine. Um Any questions uh before we leave, can you explain why the physiology causes the increase ahmed, you were able to come back. And the question is asking, could you go over your explanation for the physiology of why uh there's a transient increase in creatinine when you start uh an ace inhibitor? Ok. So OK, this is a very important question indeed. OK. So basically the ace inhibitors are expected to decrease the blood, the pressure, the kidney pressure, the perfusion pressure. OK. Because um they allow the blood to go through the efferent arterioles more easily. They vasodilate the efferent arterioles. Ok. So the blood gets outside of the kidney easily. The perfusion pressure decreases. OK. When you decrease the perfusion pressure, decrease the pressure on the kidney. This is uh uh ki kidney protective for the long term. However, this decreases uh the the filtration rate. When you do that, this decreases the filtration rate. OK. So again, they just wanna confirm that it dilates the night. Ye yes, yes. It dilates the efferent uh a artery. OK. Any other question among other, uh among other things that it does? But this is a very important for us? Thank you. Thank you guys. Will the link to the questions still be open if you've done it and you wanna try again? You can, you have till eight today. Um Any other questions? When do you read? How do I get the? So you're going to get the, I'll, I'll send the feedback form now. Oh, you can get it now. So guys, if you fill the feedback form, you can get a certificate and we would really appreciate it. Thank you very much, everyone. Um Yeah, I think, I think here when the urea is raised but not of creatinine, the patient is a drug but what does it mean when creatinine is high? It means it's not due to dehydration, it's due to uh an intrarenal injury. Two. Yeah, I know zero consent for I'm gonna kids.