psa tutorial - university of aberdeen · psa tutorial dr jonny whitfield honorary clinical senior...
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PSA Tutorial Dr Jonny Whitfield
Honorary Clinical Senior Lecturer Aberdeen University Lead for PSA
PSA
• Basic facts about PSA and timings • Overview of each section from the “PSA Blueprint” with worked
examples • Prescribing • Prescription review • Planning Management • Communicating Information • Calculation Skills • Adverse Drug reactions • Drug Monitoring • Data Interpretation
Structure of PSA
• Prescribing- 8 items, 10 marks each • Prescription review- 8 items, 4 Marks each • Planning Management- 8 items, 2 marks each • Providing Information- 6 items, 2 marks each • Calculation Skills- 8 items, 2 marks each • Adverse Drug Reactions- 8 items, 2 marks each • Drug Monitoring- 8 items, 2 marks each • Data Interpretation- 6 items, 2 marks each
Structure PSA
• Total of 60 Items in 2 hours (120min) • Therefore 2 minutes per item!
• 200 marks in total • Pass mark on papers in February sitting
• Paper A- 62% • Paper B- 65%
Example topics
Medicine Surgery Elderly Care Paediatrics Psychiatry Obstetrics & Gynaecology General Practice
Prescribing Unstable angina Acute asthma Dyspepsia
Thromboprophylaxis Antibiotics Analgesia
Intravenous fluids Laxatives Analgesia
Allergies Infection (e.g. otitis media, epiglottitis, croup), Reflux
Depression Anxiety Acute behavioural disturbance
Oral contraception HRT Bladder instability
Hypercholesterolaemia Hypertension Urinary tract infection
Prescription review
Interactions Medication errors Causes of symptoms and signs
Pre-operative assessments Diuretics Antihypertensives Benzodiazepines Opioids
Cases will be more difficult to find
Reviewing prescribing in pregnancy Interactions with OCP
Patients presenting with common symptoms
Planning management
Acute (e.g. asthma, pulmonary oedema, MI), Chronic (e.g. COPD, diabetes, angina)
Acute (e.g. bleeding, low BP, acute abdo) Chronic (e.g. IBD, oncology)
Acute (e.g. back pain) Chronic (e.g. Parkinson’s disease, dementia)
Asthma Acute anaphylaxis Diabetic ketoacidosis Dehydration
Cases will be more difficult to find
Cases will be more difficult to find
Cases will be more difficult to find
Communicating information
Oral hypoglycaemics Corticosteroids Nitrates
Tamoxifen Antibiotics Heparin Finasteride
Anticoagulants Bisphosphonates Diuretics Anti-epileptics Hypnotics
Vaccinations Insulin Cystic fibrosis Acne
Antidepressants Benzodiazepines Antipsychotics
Advising about drugs in breast feeding Advising about drugs preconception OCP, HRT
Antihypertensives Nicotine replacement NSAIDs, latanoprost Sildenafil Vaccinations
Calculation Skills Aminophylline infusion Infusion rates (e.g. dopamine), intravenous fluid volumes
Digoxin elixir Fluid replacement Dosing by weight Buccal midazolam
Intravenous lorazepam Haloperidol injection Lidocaine injections
Adverse drug reactions
Renal impairment Liver function Hyponatraemia
Bleeding Opioid toxicity Vomiting
Dehydration Collapse Constipation
Hypoglycaemia Vomiting Substance abuse
Benzodiazepines Antimuscarinic effects Antipsychotics
Oestrogenic effects Interactions with the OCP
Headache Ankle swelling Dizziness Lethargy
Drug monitoring Digoxin, insulin, methotrexate, amiodarone, oxygen
Fluid replacement Blood transfusion Antibiotics Anticoagulants
Carbimazole Theophylline Anti-epileptics
Asthma therapy Diabetes Lithium Antipsychotic drugs Monitoring safety of OCP Statins ACE inhibitors
Antibiotics
Data interpretation
TFTs, glucose, INR, renal function
Antibiotic concentrations Fluid replacement
Hb, U&Es, CXR, anti- epileptic concentrations
PEFR, paracetamol poisoning Lithium concentration BP and OCP HRT and LFTs Cholesterol, BP, diuretics
and K+
Prescribing Skills- Knowledge and Skills
• Reasoning and Judgement: Deciding on the most appropriate prescription (drug, dose, route and frequency) to write based on the clinical circumstances and supplementary information
• Measureable Action: Writing a safe, effective and legal prescription for medicines using the documentation provided to tackle specific indications highlighted by the question
Prescribing Skills Example Question 1
• Case Presentation • An 80 year old man is admitted with
two weeks of mild breathlessness. • PMHx- Asthma • DHx- Symbicort Inhaler twice a day
• On Examination • HR 150 BPM, BP 125/90, RR 16/min,
SpO2 96% (Air) T37.4 • Chest Clear • Pulse Irregularly iregegular • No murmurs
• Investigations • ECG Confirms Atrial Flutter
• Prescribing Request: • Write a prescription for one drug
to treat the underlying cause of his breathlessness
Prescribing Skills Example Question 1
Prescribing Skills Example Answer 1
VERAPAMIL
40mg ORAL
JONATHAN WHITFIELD
24/02/2016 8 HOURLY
Rationale For Marks
• Drug Choice • Rate limiting Calcium Channel
Blocker (Verapamil/ Diltiazem) 4 marks
• Digoxin 2 Marks • Beta Blocker 0 Marks (CI in
Asthmatic Patient)
• Dose, Route and Frequency • Diltiazem MR 120mg Once a day
4 Marks • Verapamil 40-120mg Three
times a day (8 Hourly) 4 Marks • Digoxin125-250 Micrograms
Once a day 4 marks • Signature 1 Mark • Todays Date 1 Mark
Prescribing Skills Example Question 2
• Case Presentation • 24 year old woman • New diagnosis of epilepsy with
complex partial seizures
• On Examination • Nil to find
• Investigations • MRI Brain- small meningioma not
requiring surgery • Na 130,
• Prescribing Request: • Write a prescription for a drug
to prevent seizures
Prescribing Skills Example Question 2
Prescribing Skills Example Answer 2
LAMOTRIGINE
25mg ORAL
JONATHAN WHITFIELD
24/02/2016 DAILY
Rationale For Marks
• Drug Choice • Lamotrigine 4 marks • Carbamezapine- could worsen
hyponatraemia as can cause an SIADH 1 Mark
• Sodium Valproate or Phenytoin- not first line for focal seizures and teratrogenic 1 Mark
• Dose, Route and Frequency • Lamotrigine 25mg Oral Once a day
4 Marks • Carbemazapine 100 -200mg Oral
once/twice a day (8 Hourly) 4 Marks
• Sodium Valproate 600mg Oral Once/divided dose 4 marks
• Phenytoin 150-300mg Oral Once Daily/ divided dose 4 marks
• Signature 1 Mark • Todays Date 1 Mark
Prescription Review
• Reasoning and Judgement: Deciding which components of the current prescription list are inappropriate, unsafe or ineffective for a patient based on their clinical circumstances
• Measureable Action: Identifying prescriptions (drugs, doses or routes) that are inappropriate, unsafe or ineffective from amongst the current list of prescribed medicines
Prescription Review Example Question 1
Prescription Review Example Question 1
Question A Question B
Prescription Review Example Answer 1
Question A Question B
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✔ ️ ✔ ️
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Rationale For Marks
Prescription Review Example Question 2
Prescription Review Example Question 2
Question A Question B
Prescription Review Example Answer 2
Question A Question B
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Rationale For Marks
Planning Management
• Reasoning and Judgement: Deciding which combination of therapies would be most appropriate to manage a particular clinical situation
• Measureable Action: Selecting the most appropriate combination of treatment strategies based on individual patient circumstances
Planning Management Question 1
Planning Management Question 1
A
Planning Management Answer 1
A
✔ ️
Rationale for Marks
Communicating Information
• Reasoning and Judgement: Deciding what are the important bits of information that should be provided to patients to allow them to choose whether to take the medicine and to enhance its safety and effectiveness
• Measureable Action: Selecting the information that is most appropriate
Communicating Information Question 1
Communicating Information Question 1
A
Communicating Information Answer 1
A
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Rationale for Marks
Calculation Skills
• Reasoning and Judgement: Making an accurate drug dosage calculation based on numerical information
• Measureable Action: Recording the answer accurately with appropriate units of measurement
Calculation skills • Metric – Weights
• 1000 nanograms = 1 microgram • 1000 micrograms = 1 milligram • 1000 milligrams = 1 gram • 1000 grams = 1 kilogram
• Metric – Volumes • 1000 millilitres = 1 litre • 1g= 1ml of water/solution • % v/v (volume/volume) = ml in 100 ml e.g. 30% v/v = 30 millilitres in 100
mililitres • % w/v (weight/volume) = grams in 100 ml e.g. 5% w/v = 5 grams dissolved in
100 ml • 1 in 1000 = 1 gram in 1000 ml e.g. adrenaline 1:10,000 = 100 micrograms/ml
Calculation Skills Question 1
Calculation Skills Question 1
• Answer
Calculation Skills Question 1
• 40 * 5= 200 micrograms per minute • 200* 60= 12, 000 micrograms an hour • 12,000/5000= 2.4 mls
Rationale for Marks
Adverse Drug Reactions
• Reasoning and Judgement: Identifying likely adverse reactions of specific drugs, drugs that are likely to be causing specific adverse drug reactions, potentially dangerous drug interactions and deciding on the best approach to managing a clinical presentation that results from the adverse effects of a drug
• Measureable Action: Selecting likely adverse reactions of specific drugs, selecting drugs to discontinue as likely causes of specific reactions, avoiding potential drug-interactions and providing appropriate treatment for patients suffering an adverse event
Adverse Drug reaction Question 1
• Case Presentation: 45 year old female attending blood pressure follow up with you, her GP. She started Ramipril 3 months ago. Despite good compliance she her BP is 150/92. You decide to titrate up her Ramipril. You check her FBC and UEs before doing this.
• Question: Based on the known adverse effects of Ramipril, select the one parameter you are more interested in checking when you carry out the blood tests.
Adverse Drug Reactions Question 1
A White Cell Count
B Neutrophil Count
C Serum Sodium
D Serum Albumin
E Serum Potassium
Adverse Drug Reactions Question 1
A White Cell Count
B Neutrophil Count
C Serum Sodium
D Serum Albumin
E Serum Potassium ✔ ️
Rationale for Marks
• ACE-I can cause Hyperkalaemia directly due to RAS inhibition and indirectly due to impact on renal function.
• Also need to monitor renal function • ACE-I can cause mild hyponatraemia but pottasium is more important
here
Drug Monitoring
• Reasoning and Judgement: Deciding on how to monitor the beneficial and harmful effects of medicines.
• Measureable action: Identifying the appropriate methods of assessing the success or failure of a therapeutic intervention.
Drug monitoring Question 1
Drug monitoring Question 1
CD4 cell count CD8 cell count patient reported symptoms plasma HIV RNA total lymphocyte count
Drug monitoring Question 1
CD4 cell count CD8 cell count patient reported symptoms plasma HIV RNA total lymphocyte count
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Rationale for Marks
Plasma HIV RNA should be measured in all patients at baseline and regularly during therapy since it is the most reliable indicator of response to antiretroviral therapy (ART) and is useful in predicting clinical progression. The goal of therapy is viral load suppression below the limits of assay detection (<20 to 75 copies/mL depending upon the assay used). Patients who have a suboptimal early decrease in viral load could be confused about how to take their regimen or be non-adherent.
Data Interpretation
• Reasoning and Judgement: Deciding on the meaning of the results of investigations as they relate to decisions about on-going drug therapy
• • Measureable Action: Making an appropriate change to a prescription
based on those data
Data Interpretation Question 1
Data Interpretation Question 1
Data Interpretation Question 1
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Data Interpretation Question 1
What to do next
• Do lots of questions • 4 papers on the PSA website (Paper C seems a bit tricky)
• Make sure that you use the feedback function once you have done the questions
• Books also available (eg. Pass the PSA), questions of varying standards.