PSA - general

• Generic questions of particular types•  8 different question types• 7 different domains of clinical activity:

– Medicine– Surgery– Elderly care– Paediatrics– Psychiatry– O&G– GP

PSA – general 2

• The questions will try to illustrate important prescribing points

• Tests skills from “Tomorrow’s Doctors”

• Realistic clinical cases

• Not Zebras

• No sudden death questions

• Following questions are very similar to real PSA but no formatted

Q1 Prescribing item

• 75 yo female• Gradual onset increasing breathlessness• H/o ischaemic heart disease• Afebrile• Normotensive• Peripheral oedema• Normal bloods• Write a prescription for one drug that will provide

rapid relief of her symptoms

Marks

• 2 Marks for drug

• 2 Marks for route

• 1 Mark for indicating date and time

• 1 Mark for signing

Q2 prescribing item

• 65 yo male• Recent long haul flight• Sudden onset breathlessness• Pleuritic chest pain• Tachycardic• D-dimers elevated• Normal CXR; CT-PA indicates PE• A drug that is indicated immediately for

treatment of PE

Drug choices

• Drop down menu

• 4 points for correct choice

• 1 point for date/time

• 1 point for signing

• Warfarin would score 0 points

Q3 Prescription review

• 70 year old man

• Admitted with back pain

• Develops melaena

• Liver function tests deranged; ALT 259

• Which drugs are likely to be responsible?

• 1 mark per correct tick

Drugs list

• Co-amilofruse

• Metformin

• Valsartan

• Rifampicin

• Flucloxacillin

• Voltarol

• Aspirin

Q 4 Prescription review

• 83 year old woman

• Admitted from nursing home

• Confused and aggressive, particularly in evenings

• Identify one drug that may be causing confusion (1 mark)

• One that may cause a serious prescribing error (1 mark)

Current prescription

• Metformin 500mg 12 hourly po

• Aspirin 75 mg once daily po

• Ibuprofen 400mg 8 hourly po

• Ramipril 10mg po daily

• Temazepam 10mg po nocte

• Phenytoin 1500mg bd po

Q 5 planning management

• 18 year old girl brought admits to deliberate overdose

• History of anorexia nervosa• Weighs 50kg• Took alcohol and paracetamol 40 tabs 8 hours

ago• Smells of alcohol, slurred speech but

normotensive and normal kidney/liver function• Paracetamol level 110 mg/l• Select most appropriate management options

(max 4 marks)

Management options

• Activated charcoal

• Methionine

• N-acetylcysteine

• Naloxone

• Desferrioxamine

• Diazepam

Q 6 planning management

• 72 year old man

• Known myeloma

• Abdominal pain

• Bone pain

• Generally unwell

• Investigations – bloods normal but serum Calcium 3.22 mmol/l with normal albumen

Options

• Corticosteroids

• Calcichew

• Calcitonin

• Pamidronate

• Cinacalcet

• Frusemide

Q 7 communicating information

• 45 year old man with recently diagnosed HIV

• On HAART for 3 months but stopped 2 months ago due to side effects

• CD4 count falls from 280 to 180 cells/mm3

• Started on septrin 960mg once daily

• What information should he be told about his new drug?

Select One

• Septrin should not be taken if trying to conceive

• Septrin may stain teeth• The drug should be discontinued if rash

develops and medical help sought• Blood tests will need to be performed

during treatment• Breathlessness is normal while taking

septrin

Q 8 communicating information

• 45 year old HIV-ve Somali female

• Chronic cough, weight loss, fevers

• CXR apical consolidation/ cavities

• Sputum AFB+ve

• Commences Rifater 4 tabs od, ethambutol 1200mg od, pyridoxine

• What information should you tell her about her drugs?

Select One

• She is not entitled to free treatment under UK law

• She may be detained under the public health act if she fails to take her treatment

• Her urine, tears and saliva may change colour and that is normal

• She should have an eye test at the beginning of treatment

• She must take her tablets every day

Q 9 Communicating information

• 20 year old student

• Unprotected vaginal sex with regular boyfriend

• Misses pill on day 8

• On COCP “Logynon”

• What would you advise?

Communicating information

• She should take another pill immediately and resume normal pill-taking with no extra precaution

• She should take emergency contraception

• She should take an extra pill but abstain from sex or use a condom for seven days

• She should discard her current pill packet and start a new one from scratch

Q 10 Dose calculation

• A 22 year old, 70kg man with severe asthma to be treated with iv aminophylline

• Given 350mg as slow iv infusion

• Comes in 10ml vials 25mg/ml

• Write up a maintenance infusion for 500mcg/kg/ hour in ml/minute

Calculation skills

• A diabetic patient with peripheral vascular disease, a history of AF, DVT and recent severe PE is admitted after falling and fracturing his hip

• He is on warfarin, but this is stopped for the operation

• He is to be given iv heparin instead• Calculate a dose and an infusion rate for

him in ml/hr. He weighs 83kg.

Percentage doses

• 1% solution = 1g per 100ml = 1000mg per 100ml = 10mg/ml

• 0.1% solution = 0.1g per 100ml = 100mg per 100ml = 1mg/ml

• If a 5mg / hour dose is required of a 0.1% solution = 5ml/hr

Calculation skills

• A 12 month old child is admitted with meningitis

• The causative organism is found to be Neisseria meningitidis

• It is decided to treat with iv benzylpenicillin

• Calculate a suitable dose

Answer

• What is the likely weight of a 12 month old child?

• What does the BNF say about doses?

• Is this a severe infection?

• Marks for correct dose, frequency, signing

Q11 Prescribing item

• A 25 year old 32/40 pregnant woman comes to your surgery in primary care

• She has been in contact with a child with chicken pox

• She doesn’t think she had chicken pox as a child• The laboratory say she has a booking blood but

have not yet tested for chicken pox immunity• What will you prescribe?

Options

• Pooled human immunoglobulin

• Varicella zoster immune globulin

• Acyclovir 800mg five times daily

• Valacyclovir 1g tds

• Nothing, wait for the result of the blood test

Q12 Prescribing options

• A 73 year old woman is recovering after major bowel surgery for cancer of the colon

• She is nil by mouth

• Write a prescription for intravenous fluids for the first 24 hours

Q13 ADRs

• A 42 year old man with psoriasis is admitted with weight loss, fatigue, anorexia and diarrhoea

• His ALT is 223, alk phos 384

• His FBC shows Hb 7.5 g/l, WBC 1.2 cells/mm3, platelets 44

• Which of the following drugs is likely to be responsible and why?

Drug list

• Acitretin 25mg od po

• Methotrexate 7.5mg od po

• Peppermint water 10ml prn

• Gaviscon 10ml prn po

• Atenolol 50mg od po

Q14 Prescription review

• An 88 year old man is admitted following a fall; he has fractured his hip

• He will be having surgery in the next few days

• Which medications should be reviewed/ discontinued for his operation?

Current prescriptions

• Amlodipine 10mg po od

• Warfarin 7.5mg od po

• Ramipril 10mg od po

• Simvastatin 20mg po od

• Metformin 500mg od tds

• Meloxicam 7.5 mg od

Post op

• He develops renal impairment. Which of the drugs is likely to be responsible?

Q15 Adverse Drug Reactions

• A 71 year old man with alcoholic liver disease, angina, heart failure, hypertension, ascites and recurrent bacterial peritonitis comes to your surgery complaining of bilateral superficial pain and swelling in his chest

• Which of these drugs is likely to be responsible?

Drug list

• Doxasocin 8mg orally od

• Amitriptyline 75mg po od

• Ciprofloxacin 500mg bd po

• Spironolactone 100mg od

• Isosorbide mononitrate 40mg bd

Q16 ADR

• You are called to the doors of the GU clinic where a patient has just collapsed after treatment

• The patient was given im antibiotics but the clinic has closed and the staff have all left

• The patient is wheezy and has a BP of 90/60 and a pulse of 150/min

• Which of the following will you administer?

Choices

• Penicillin-specific antibodies (Penibind) 1 vial iv stat

• Dobutamine 2.5mcg/kg/min iv infusion

• Morphine sulphate 10mg iv

• Adrenaline 500mcg im

• Normal saline (0.9%) iv over 10minutes

• Ceftriaxone 2G im stat

Q17 ADR

• A 68 year old man with hypertension, CCF and diabetes has been admitted with palpitations and breathlessness

• His heart rate is 220 bpm• ECG reveals supraventricular tachycardia• He is given treatment in the A&E

department• He immediately drops his blood pressure

and then goes into asystole

Which drugs are likely to have caused this?

• Metformin 500mg po 12 hourly

• Lisinopril 5mg po daily

• Aspirin 75mg po daily

• Propanolol 80mg bd po

• Verapamil 10mg iv by slow infusion over 3 minutes

Q 18 Drug monitoring• A 72 year old woman presents with back pain• She is found to have discitis of the vertebral

bodies with an associated psoas abscess• She is commenced on antibiotics in the form

of ciprofloxacin 750mg bd po and rifampicin 600mg od po

• Which of the following should be used to monitor her response to treatment and likely complications?

Drug monitoring

• Serum creatinine

• Serum C-Reactive Protein

• X rays of spine

• Symptoms of pain at the site

• Liver function tests

• Bowel habit

• White cell count

Q 19 Drug monitoring

• A 20 year old woman with polycystic kidneys is being treated for a urinary infection and systemic sepsis

• She is to be treated with iv gentamicin• She weighs 82 kg• Her creatinine is 82 umol/l• Calculate a suitable dose• How would you monitor her subsequent

doses?

Gentamicin moitoring

• By clinical response• By measuring creatinine • By pure tone audiogram• By measuring pre and post dose gentamicin

levels• By measuring gentamicin levels against a

nomogram• By measuring trough levels at 18-24 hours

and re-dosing only when levels <1.0mg/l

Q 20 Drug monitoring

• A 58 year old woman is being treated for hyperthyroidism

• She has been started on

• carbimazole 20mg od ten days ago

• Propanolol 50mg bd po ten days ago

• She complains of a sore throat and tiredness

• What should you do?

Drug monitoring

• Reassure her

• Swab her throat for bacterial infection and prescribe amoxicillin 500mg tds po

• Give aspirin mouthwashes

• Check thyroid function urgently and discontinue propanolol

• Urgently check the full blood count and discontinue carbamazepine

Q21 Drug monitoring• A 62 year old man is being treated for a DVT;

he has been on treatment for six weeks

• He takes 4mg warfarin a day and has been stable with INR 2.3-2.8 for four weeks

• He attends for checking of his blood tests

• His INR is 5.1

• He has not bled from anywhere

• What should you do?

Drug monitoring

• Stop warfarin and give vitamin K 3mg iv

• Add dabigatrin

• Check whether he has started any new medications lately

• Adjust the warfarin dose according to his treatment booklet

• Withold 1 or 2 doses of warfarin and reduce subsequent maintenance dose