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
Obstetrics &
Medicine Surgery Elderly Care Paediatrics Psychiatry General Practice
Gynaecology
Allergies Infection (e.g. Hypercholesterolaemia
Unstable angina Acute Thromboprophylaxis Intravenous fluids Depression Anxiety Acute Oral contraception HRT
Prescribing otitis media, epiglottitis, Hypertension Urinary tract
asthma Dyspepsia Antibiotics Analgesia Laxatives Analgesia behavioural disturbance Bladder instability
croup), Reflux infection

Interactions Medication Diuretics Reviewing prescribing in

Prescription errors Causes of symptoms Pre-operative assessments Antihypertensives
Cases will be more
pregnancy Interactions
Patients presenting with
review difficult to find common symptoms
and signs Benzodiazepines Opioids with OCP

Acute (e.g. asthma,

Acute (e.g. bleeding, low Acute (e.g. back pain) Asthma
Planning pulmonary oedema, MI),
BP, acute abdo) Chronic Chronic (e.g. Parkinson’s Acute anaphylaxis Diabetic
Cases will be more Cases will be more Cases will be more
management Chronic (e.g. COPD, difficult to find difficult to find difficult to find
(e.g. IBD, oncology) disease, dementia) ketoacidosis Dehydration
diabetes, angina)

Advising about drugs in Antihypertensives Nicotine

Anticoagulants Antidepressants
Communicating Oral hypoglycaemics Tamoxifen Antibiotics
Bisphosphonates Diuretics
Vaccinations Insulin Cystic
Benzodiazepines
breast feeding Advising replacement NSAIDs,
information Corticosteroids Nitrates Heparin Finasteride fibrosis Acne about drugs preconception latanoprost Sildenafil
Anti-epileptics Hypnotics Antipsychotics
OCP, HRT Vaccinations

Infusion rates (e.g. Fluid replacement Dosing

Intravenous lorazepam
Calculation Skills Aminophylline infusion dopamine), intravenous Digoxin elixir by weight Buccal Lidocaine injections
Haloperidol injection
fluid volumes midazolam

Benzodiazepines
Adverse drug Renal impairment Liver Bleeding Opioid toxicity Dehydration Collapse Hypoglycaemia Vomiting
Antimuscarinic effects
Oestrogenic effects Headache Ankle swelling
reactions function Hyponatraemia Vomiting Constipation Substance abuse Interactions with the OCP Dizziness Lethargy
Antipsychotics

Digoxin, insulin, Fluid replacement Blood Carbimazole

Lithium Antipsychotic Statins ACE inhibitors
Drug monitoring methotrexate, transfusion Antibiotics Theophylline Anti- Asthma therapy Diabetes Monitoring safety of OCP
drugs Antibiotics
amiodarone, oxygen Anticoagulants epileptics

Data TFTs, glucose, INR, renal Antibiotic concentrations Hb, U&Es, CXR, anti- PEFR, paracetamol
Lithium concentration BP and OCP HRT and LFTs
Cholesterol, BP, diuretics
interpretation function Fluid replacement epileptic concentrations poisoning 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 • Investigations
• An 80 year old man is admitted with • ECG Confirms Atrial Flutter
two weeks of mild breathlessness.
• PMHx- Asthma
• Prescribing Request:
• DHx- Symbicort Inhaler twice a day
• Write a prescription for one drug
• On Examination
to treat the underlying cause of
• HR 150 BPM, BP 125/90, RR 16/min,
SpO2 96% (Air) T37.4
his breathlessness
• Chest Clear
• Pulse Irregularly iregegular
• No murmurs
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 • Investigations
• 24 year old woman • MRI Brain- small meningioma not
• New diagnosis of epilepsy with requiring surgery
complex partial seizures • Na 130,
• On Examination • Prescribing Request:
• Nil to find • 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

✔️
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
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.