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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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

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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.