Norwich PSA Course

Course Guide 2023/24

Thank you for attending the Norwich PSA Course this year run by Dr Suprateeka Talukder and Dr Catherine Dominic.
In this document you can find a summary of the important learning points from our course slides, which we decided
to put together in this format instead of distributing the slides. We hope this will be more useful to you.

The mock examination will be sent out to you along with this guide. Please try to complete the mock without
referring to this as it will be more useful that way. The live session work-through of the mock will take place on the
17/01/23 at 19:00. Any questions you have please email us.

The Exam

• The PSA was introduced to ensure all junior doctors are safe prescribers
• It is a 2 hour online assessment with access to the BNF and MedicineComplete permitted from the exam
interface
• There is a PSA Blueprint which introduces each section and allocates marks – download and work through
this. https://prescribingsafetyassessment.ac.uk/resources/PSA-Blueprint-July-2023.pdf

There are 8 sections, split as per this diagram. The 7

clinical settings are divided as per the grey box.
These are broad categories that contain most
aspects of medical care – this is a general idea of the
structure.

• Therapeutic groups that are commonly examined (high risk) are:

o Insulin
o Anticoagulants
o Opioids
o IV fluids
o Antibiotics
• It is important to have a good understanding of these as there will be at least 2 items on each across the
sections of the exam
• During the exam we recommend that you open the following tabs alongside the exam: BNF, BNFc (child) and
MedicinesComplete
• Familiarise yourself with the BNF treatment summaries – these cover common conditions and how to treat
them. Knowing how these are phrased will be very helpful e.g. search Poisoning for overdose management
• Familiarise yourself also with the subsections of each drug monograph
 Indications and dose will allow you to search the dose
you need to prescribe based on indication.
Contra-indications will delineate under which conditions
you should not prescribe this medication.
The most useful sections are interactions, side-effects
and monitoring requirements as these are sections of
the PSA or common question types.
The pregnancy section will tell you if contra-indicated in
pregnancy and the hepatic and renal impairments
sections will tell you in the drug has any effect on these
organs, when to adjust the dose and any eGFR or other
cut-offs for prescribing.
Patient and carer advice can be useful for the
communicating information section of the PSA exam.

This is what the prescription forms will look like in the examination.
When you start typing in the box it will start to present you with
various options.

• We recommend doing the past papers on the official website up to 3 times each in the course of your
preparation.
• We also recommend the exercises in the PassThePSA book to build up your foundation.
• PassMed, GeekyMedics and other question banks also have questions you can use in addition.

If you follow this summary of how long to spend per

section you should finish the PSA exam with 20
minutes to spare, based on a total of 120 minutes.
Tips and Tricks

• Ctrl+F for interactions, side effects and other things found on a page
• AND/OR searches in the BNF
o For example if searching for a drug causing sleep disturbance
Sleep AND (drug1 OR drug2 OR drug3)
If any of these cause sleep issues it will be top of the search generally
• Revise for finals alongside PSA as most of what you need to learn will be from there – important to know
common management pathways e.g. acute asthma exacerbation
• Interactions in the BNF – need to practice typing these in quickly
• Generally, have the BNF open during practice and try to find the answers as quickly as possible.
• Remember things are often phrased differently so think about alternatives e.g. it may yellowing of vision in
the question but be phrased in the side-effects as visual disturbance
• Be wary of contraindications
• Be wary of subtleties in examination and investigations given to you
• Doses may vary depending on parameters like eGFR
• Be careful of different doses for different indications
• Think of best route of administration – e.g. in patients who are NBM,
unsafe swallow or vomiting

Learning Points from Example Questions

• As we are unable to directly share with you some of the example questions used, we have instead
summarised the learning points here.

SESSION 1:

• Trimethoprim shouldn’t be given in pregnancy (especially the

first trimester) as it is a folate antagonist.
Urinary tract infection treatment can be found under the
treatment summary urinary-tract infections which summarises
by renal function and pregnancy as well. You would then go to
the page for nitrofurantoin which is helpfully hyperlinked and
select the correct dose.
• In scenarios with a bleed, don’t forget to stop all anticoagulants and antiplatelets, particularly DOACs.
• In the context of hypotension, suspend antihypertensives as they will be contributing to the presentation if it
is a collapse.
• Principles of treating hypoglycaemia:
If patient has reduced conscious levels it is inappropriate to give oral glucose. You cannot give glucose IM so
if this is an option. Also check the dose of IM glucagon to ensure it is correct before you select this – the dose
should be 1mg.
100mL of 20% or 200mL of 10% glucose IV is generally the correct option in an unconscious patient.
• Isotretinoin is highly teratogenic, and female patients should ensure not to become pregnant whilst on this.
Under the monitoring requirements section of the BNF you can find which tests should be done – FBC, U&E
and LFTs should be checked before starting treatment with repeat tests to regularly monitor abnormalities in
FBC and LFTs.
• There is a section on conception and contraception under the pregnancy section of the isotretinoin BNF page
• Target dose of gentamicin is 1.5mg/kg and need to calculate how many grams to prescribe. Always note the
change in units as this is a common trick. 1.5mg*patient’s weight / 1000 to give answer in grams instead of
milligrams.
• Oxybutynin can cause acute urinary retention as it is an antimuscarinic drug. Voiding the bladder is under
parasympathetic control. Ach binds to muscarinic receptors on bladder to induce bladder contraction and
micturition. Parasympathetic inhibition (with anticholinergics) thus carries a risk of tipping this patient with
BPH into urinary retention
• To find out Does Drug X have a risk of urinary retention? -> Search drug -> Ctrl+F [retention] or (retention
AND (drug))

SESSION 2 and 3:

• Prescribing section is probably the most relevant to FY1 life – there are 8 questions on 8 different clinical
scenarios. You will be asked to prescribe one drug/fluid.
• Each question is worth 10 marks so this is worth 80/200 ->40% of the exam
• Each question has 5 marks for drug choice and 5 marks for dose, route and frequency. There are often several
combinations that can receive full marks and several options which can obtain suboptimal (3/4/5) marks.
• There will be 2 fluid prescribing questions.
• You will be asked to prescribe drugs on various sections of a drug chart
o Once-only/STAT – here, the frequency will be pre-filled as once-only
o Regular
o Fluids/infusions – here, the route will be pre-filled as IV
o GP prescription form – duration will be pre-filled (7, 14 or 28 days etc)
• Write exactly what the BNF says even if different in clinical practice – this will be the correct answer
• If a drug is unlicensed in the BNF, it is not the correct answer for the PSA
• Question stems are organised into: case presentation, on examination and investigations (relevant blood and
other test results)
• Hormone replacement therapy for menopause can come up
o If the patient still has a uterus, give oestrogen + progesterone e.g. estradiol with norethisterone
(Kliovance)
o If the patient had has a hysterectomy, just give oestrogen as you no longer need the protective effect
of progesterone protecting the uterus lining to prevent hyperplasia and endometrial cancer
o Duration: Cyclic combined HRT if LMP < 1 year ago and Continuous combined HRT if >1 year ago
• Key principles in prescribing are important, but in the PSA your signature will be pre-filled.
• In giant cell or temporal arteritis know when to use IV vs oral steroids. Under the treatment summary
corticosteroids, inflammatory disorders or corticosteroids, general use you can find the correct information if
asked to prescribe in GCA/TA. Alternatively, you can search prednisolone in the BNF and then ctrl+F giant cell
arteritis.
• GCA is a medical emergency, adults need 40-60mg pred daily until remission, with the higher dose used if
visual symptoms occur.
• In a patient with gout not having an acute flare but with a history of flares and renal stones prescribe
allopurinol 100mg OD. This is the only licensed drug available for the treatment of patients with uric acid
renal stones. The BNF recommendation is to start with the 100mg dose and titrate upwards but cover with
naproxen as gout can flare up when allopurinol is initiated.
• Gout is caused by an accumulation of uric acid, which reaches levels that exceed its solubility in blood. As a
result, uric acid crystallizes around joints. White blood cells such as neutrophils are drawn to these sites,
which contributes to the inflammatory response – causing inflammation, redness, and pain. Colchicine works
to inhibit various inflammatory mechanisms and alleviate inflammation and pain at the site of gout attacks.
Useful for gouty arthritis.
• Allopurinol works by inhibiting xanthine oxidase, the enzyme responsible for converting hypoxanthine to uric
acid
• For cholesterol therapy with statins, atorvastatin is now the
recommended drug by NICE. Dose should be as per ->
• Treatment summary for cardiovascular disease risk assessment and
prevention can be used to determine which medication to use in the context.
• Acute opioid overdose – high-dose regimen is used when rapid titration with naloxone is necessary to
reverse potentially life-threatening effects. Initially 400 micrograms -> 800 for up to 2 doses at 1 minute
intervals -> if no response to preceding dose up to 2mg.
• The opioid toxidrome includes: decreased consciousness, decreased RR and tidal volume, miosis and possible
hypotension. A-E approach, and ensure safe airway and no other cause of reduced consciousness. Naloxone
IV ideally as antidote but can be IM if unable to establish vascular access.
• Management of T2DM:
o Standard-release metformin hydrochloride is recommended as the first choice for initial drug
treatment for all patients, due to its positive effect on weight loss, reduced risk of hypoglycaemic
events, and the additional long-term cardiovascular benefits associated with its use.
o Metformin hydrochloride has an anti-hyperglycaemic effect, lowering both basal and postprandial
blood-glucose concentrations. It is not associated with weight gain, and does not stimulate insulin
secretion and therefore, when given alone, does not cause
hypoglycaemia.
o Sulfonylureas, such as gliclazide, glimepiride, glipizide, and tolbutamide,
may cause hypoglycaemia
o Note: if the patient has cognitive impairment and is not able to test for
hypoglycaemia, hence it would be dangerous to prescribe a
sulfonylurea.
• Treatment for candidiasis: Clotrimazole pessary 200mg PV 3 days or
clotrimazole 10% cream 5g PV STAT. In pregnancy always give local treatment
not systemic.
• Learn the circumstances for emergency contraception and the missed pull rules. If asked to prescribe
emergency contraception consult the treatment summary with the same name.
• Uipristal - Within 5 days of Unprotected sex
• Levonorgesterol - within three days of unprotected sex. Be mindful it needs to be double dose if BMI is over
30 or over 70kg women
• In pregnancy if DOACs which were being used for the treatment of VTE are suspended, you need to prescribe
LMWH or UFH which do not cross the placenta and therefore do not cause fetal bleeding or teratogenicity
instead. ->
• Otitis media is a common paediatric presentation. The treatment for this can be found under the treatment
summary Ear infections, antibacterial therapy. Ensure to check whether the patient is penicillin allergic or not
as this will affect your choice of medication.

Learn this! Both for finals and for PSA it is important

to know which antihypertensive to choose, why and
when to add further medications (diagrams from
BNF and Passmedicine)
• If asked about a patient with reflux you can go to the BNF treatment summary on dyspepsia. This
recommends trialling a PPI for 4 weeks e.g. lansoprazole 30mg OD for 4 weeks
• Patient with bowel obstruction and asked to prescribe an anti-emetic -> cyclizine 50mg IV/IM, ondansetron
4mg IM/IV. Metoclopramide is contraindicated in complete bowel obstruction (under the contraindications
section of the BNF).
• PR bleed + LIF pain -> diverticulitis. There is a treatment summary
on diverticular disease and diverticulitis which you can use to find
the correct antibiotic. Then click the hyperlink to the antibiotic to
find the correct dose for the indication.
• Folic acid doses in pregnancy – will need higher dose (5mg) if sickle
cell, diabetes, previous child with neural tube defects, or on
antiepileptic medications.
FLUIDS MADE EASY
• 3 main fluids you need to know:
o Sodium chloride 0.9%
o Sodium chloride 0.9% + Potassium
▪ Either 0.3% (40mmol)
▪ Or 0.15% (20mmol)
o Glucose
▪ Either 5% if all well
▪ 20% if not
• Daily requirements for a normal human are:
o Water 25-30ml/kg/24hr
o Glucose 50-100 g/24hr
o Sodium 1 mmol/kg/24hr
o Potassium 1 mmol/kg/24hr
o Replace these by 24 hours, no need to be extremely exact but roughly. Be careful with potassium as
maximum 10mmol/hr.
• Maintenance fluid -> in a 70yo weight 80kg typically:
o NaCl 0.9% + KCl 0.3% - 1000mL - over 12 hours
o Second bag – Glucose 5% + KCl 0.3% - 1000mL - over 12 hours
• Some losses (replacement) e.g. in diarrhoea and cannot keep water down:
o NaCl 0.9% + KCl 0.3% (40mmol) – 1000mL – over 4-6 hours
• Hypoglycaemia (emergency)
o Glucpse 20% 100mL over 15 mins
o See treatment summary on hypoglycaemia
• Resuscitation (emergency) – patient with low BP, tachycardia, clearly unwell, clammy and sweaty,
peripherally shutting down -> fluid bolus!
o NaCl 0.9% 500mL over 15 mins
• Hypokalaemia (emergency) – usually a history of D&V, generally give you a low potassium on the blood test
section
o NaCl 0.9% + KCl 0.3% - 1000mL – over 4 hours
o So at the max rate of 10mmol/hr
• Hypercalcaemia (emergency) – stones, bones, groans, moans, short QT
o NaCl 0.9% 1000mL over 4 hours
• Maintenance in children -> see diagram
• Back to other prescriptions…
• Pulmonary oedema will often present as a patient with sudden SOB on a background of heart disease and
HTN, with crackles in the examination section.
• Answer is generally furosemide with a dose in the
range of 20-50mg an acceptable answer. Must be IV.
• Causes of pulmonary oedema -> most commonly NSTEMI, aortic stenosis but can be separated into
cardiogenic and non-cardiogenic causes.
• Asthma initial treatment – important to know salbutamol dose.
Generally in the range of 2.5-5 and must be nebulised. ->
• Learn both acute and chronic management for asthma
• Chronic is:
o <5y - #1 SABA, #2 mod-dose ICS 8w trial, #3 LTRA, #4 specialist
o ≥5y - #1 SABA, #2 low-dose ICS, #3 LTRA, #4 LABA
• Acute is:
o Oxygen, Salbutamol 5mg, Ipratropium 500 mcg, Hydrocortisone 100mg, MgSO4 1.2-2mg,
aminophylline, prednisolone 40-50mg PO OD for 5d. Hydrocortisone over pred during acute
generally as difficult for SOB patients to swallow the pred whereas HC is IV.
• Learn also the severity classification e.g. 33-92 CHEST for life-threatening and this + a normal pCO2 is near-
fatal.
• Remember that the prednisolone dose in COPD is different – 30mg PO once daily instead of 40, and for 7-14
days instead of 5
• Acute treatment of COPD – Oxygen, salbutamol 5mg, iptratropium 500mcg, aminophylline, ventilation (so
different to asthma).
• If you get confused both conditions have treatment summaries you can consult.
• Treatment of DVT has now been changed from LMWH to DOACs! Remember this because some trusts still
use LMWH instead, but as always the BNF answer is the correct answer not standard clinical practice.
• General treatment dose anticoagulation is apixaban 10mg PO twice daily or rivaroxaban 15mg PO twice daily.
Both of these options would score full marks as per the BNF Venous Thromboembolism treatment summary.
• Prophylactic dose anticoagulation is generally heparin 5000 units SC – check for renal failure as you will need
to adjust the dose, and look for reasons not to give the standard treatment such as pregnancy, medical vs
surgical patients, type of surgery etc. The treatment
summaries and indications/dose separate patients into
medical and surgical and further stratify by type of
surgery and risk of VTE.
• There is also an ‘anticoagulation’ treatment summary.
• Generally will have at least one analgesia question. Look
at what the patient has already had and go up the pain
ladder from there ->
• Remember other types of pain have other treatments:
o E.g. amitriptyline, pregabalin and gabapentin for
neuropathic pain
o Carbamazepine for trigeminal neuralgia
o Specific treatments for migraines
o Lower back pain – first line NSAID or weak opioid if contraindicated.
• Calcium gluconate has different doses for hypocalcaemia vs use in hyperkalaemia:
o 10% 10mL slow IV for the former
o 10% 30mL slow IV in the latter (stabilises the cardiac membrane but has no effect on the level of
potassium in the blood)
• Remember the ECG features of hyperkalaemia as this will often also be presented to you in the investigations
section of the question.
• Addisonian crisis is a common scenario as it is an emergency
presentation. Treatment is hydrocortisone 100mg IM or IV. In all
conditions being treated with steroids, patients will need a double dose
during acute illness.
• Different causes of nausea have different preferred antiemetics:
o Post-op – ondansetron
o Palliative – cyclixine
 o Chemo – ondansetron, metoclopramide
o Parkinson’s – domperidone
o Hyperemesis gravidarum - promethazine
• Often will be asked what to do with a patient for whom
metformin is not working for diabetes – there are a few
different correct answers here but it depends on the patient
factors and any contraindications they have so check these
carefully. ->
• Remember the side effects of the diabetes medications such
as pancreatitis, contraindications in heart failure or bladder
cancer etc.
• If asked a question about meningitis, ensure to check the setting. There is a treatment summary called
medical emergencies in the community which you should use if it is a GP setting with meningitis. Also check
the penicillin allergy status as cefotaxime is given instead of benzylpenicillin if the patient is allergic.

SESSION 4
• Prescription review section – 8 questions, 4 marks each, 32 marks total, 16% of the paper, 2 mins per Q
• Need to find the issue: prescribing errors, side effects, interactions, contraindications
• Common errors include:
o Timing
▪ Statins – given at night
▪ Steroids – given in morning
▪ Diuretics – given in morning
▪ Sleeping tablets – given at night
o Frequency
▪ Alendronic acid – generally once weekly
▪ Psych depot infections – generally every 1-2 weeks or every few months
o Route
▪ PO cannot if vomiting
▪ SC – insulin, LMWH etc
o Dose
▪ Check against the BNF
▪ Common trick is to change the units
▪ Common things prescribed in micrograms not mg:
• Levothyroxine
• Digoxin
• Tamsulosin
• Naloxone
• Salbutamol
• Check side effects and interactions using AND/OR, Ctrl+F and
the interactions section – even if you think you know, still check.
• Example is QT and citalopram ->
• Check the wording of the question. For example if asked about
an interaction and the question is specifically worded as
‘interact and should be monitored and doses adjusted’ look for
this same wording when doing your interactions search
(citalopram and omeprazole).
• Planning management section – easier version of prescribing, 8
questions, 2 marks each, 16 marks total, 8% of the paper, 1 min
per question.
• Again need to learn common presentations and their management.
• Overdoses frequently come up here -> Use poisoning, emergency treatment treatment summary for these
questions. Frequently need to know where to use a more extreme option such as haemodialysis so look at
the cut-offs for this.
• Common conditions e.g. psoriasis have treatment summaries but the sections are split on presentation e.g.
psoriasis of the trunk and limbs. So check the vignette to make sure you are looking for the right indication
and dose.
• Pabrinex is not prescribed as this, as are things with brand names. Always learn the generic name. For this it
is Vitamin B substances with ascorbic acid 2 pairs by IV infusion.
• Learn treatment of alcohol withdrawal as this is also a common scenario – when to give chlordiazepoxide,
pabrinex, thiamine etc.

SESSION 5:
• Providing information section – choosing the most important piece of information that a doctor needs to give
to a patient about a specific treatment. Each Q has a clinical scenario with 5 options. 6 questions in this
section, 2 marks each, 12/200 of total score.
• Main things covered: providing information about important adverse effects, providing directions on how to
take the medication, advice about contraception, drugs to avoid during conception
• Important adverse effects include:
o SSRI – suicidal ideations may worsen in the first 4 weeks, takes 6 weeks to work
o Carbimazole – report fever/sore throat ASAP due to agranulocytosis risk
o ACEI – measure U&Es in 2 weeks of starting, patient may have bilateral renal artery stenosis – ACEI
could trigger an AKI. Must stop if creatinine rises by 30% or eGFR reduces by 20%.
• Specific directions on how to take medications:
o ACEI – take at night due to postural hypotension risk
o Bisphosphonates – 30 mins before breakfast, whilst sitting/standing and remain so for 30 mins after
as can cause oesophagitis
• If carbimazole causes neutropenia it should be discontinued. It
should be followed by radio-iodine and then surgery. Patients should
be advised that radioiodine therapy is contraindicated in pregnancy
and breastfeeding, and that she should avoid pregnancy for at least
4 months after radioiodine therapy.
• When taking trimethoprim, patients should report sore throat to a
healthcare professional as this is the first adverse effect which
occurs in toxicity.
• Another common communication question asks about missed doses
of oral contraceptives. --→
• Check the section for levonorgestrel for a similar advice section for
progesterone-only contraception as the rules differ due to stricter
time-frames.
• If started on doxycycline you should separate the dose from ferrous
sulphate by at least 2 hours, as tetracyclines bind to divalent cations
and this reduces absorption leading to a subtherapeutic antibiotic
dose.
• Key themes include:
o NOACs/warfarin – bleeding risk
o Salbutamol – seek attention if usual dose isn’t relieving symptoms
o Steroid inhalers – technique, reducing the risk of oral thrush
o Methotrexate – drug interactions
o Oral hypoglycaemics – be aware of sx of hypoglycaemia
o Contraception – missed pills, emergency contraception etc
o Teratogenic drugs
• The calculation section involves calculating doses or rates of administrations of medicines. This is NOT
multiple choice. There are 8 questions each worth 2 marks – total 16 marks.
• If a question requires multiple steps of arithmetic, be systematic and carefully write down your working on
the paper that the test centre will provide
• Look at your answer and think: does this make sense?
• You are allowed a basic handheld calculator in the exam (NOT a scientific calculator). Familiarise yourself with
this. There's also a online scientific calculator.
• If you are really struggling with a particular question, just flag it and move on
• Examples include:
o Correct number of tablets to achieve required dose
o Dose adjustments based on weight or BSA
o Diluting a drug for administration in infusion pump
o Convert different expressions of drug doses and concentrations
• These are 1,2,3 or rarely 4 step calculations
• Need to understand rates, times, %, tablets, vials
• Know conversions and check which unit they expect the
answer in:
o 1000 nanograms (ng) = 1 microgram (mcg)
o 1000 micrograms (mcg) = 1 milligram (mg)
o 1000 milligrams (mg) = 1 gram (g)
• Know which information is useful to the question and which
is not/there to trick you
• If calculated dose is over maximum dose in question, just
give max dose
o Volume = dose/concentration
o Concentration = volume/dose
• Calculate amount of drug given from a % w/v formulation
• X % w/v – X g in 100ml
o Eg. 1% Clotrimazole cream – 1g in 100ml, so
1000mg in 100ml
• Others:
o - x % w/w – x g in 100 grams
o x % v/v - x ml in 100 milliliters
• Assume it is % w/v unless stated otherwise!
• Ratios are similar to the percentages
o Eg. Adrenaline
o 1 in 1000 – 1g in 1000ml
o 1 in 10,000 – 1g in 10,000 ml

• May also need to determine how much more can be

given – calculate an additional dose of a drug that
has been given before until it reaches its maximal
dose.
• If asked how many – may need to calculate number
of tablets, vials, ampoules etc to meet a set number
of doses over a period of time.
• Vials and ampoules cannot be reused so must be
rounded up to a whole number.

SESSION 6:
• Adverse Drug Reactions – 8 questions, 2 marks each,
16 marks total, 8% of paper, 1 min per Q
• Adverse effect most likely (Ctrl+F), Adverse effect
caused by which medication (AND/OR), interactions, treatment of adverse effects (similar to MAN)
• Look at which side effects are common or very common – the answer will generally be one of these and not
one of the rarer side effects.
• Again remember things are phrased differently – for digoxin and
yellowing of the vision, the side-effect is vision disorders not explicitly
yellowing
• If asked for an ototoxic medication from a list – AND/OR search. Use
hearing or a synonym instead of ototoxicity as this is more likely to
highlight the answer.
• This section is just a case of practicing Ctrl+F and looking at the side
effects sections for medications generally e.g. to find leucopenia
under methotrexate.
• Interactions with statins – search BNF interactions checker. If pain and
aching arms and legs probably something like clarithromycin.
• Monitoring drug therapy section – 8 questions, 2 marks each, 16 marks total, 8% of paper, 1 min per Q
• Common things which need monitoring – antipsychotics, COCP, anticoagulants
• Digoxin – requires serum electrolytes monitoring. Will need to know this for medication counselling OSCEs
generally, so learn this from the table In the OSCEStop book or website of common drug counselling stations.
• The monitoring section of the BNF is generally all you need for this section.
• DOACs – patients should be monitored for signs of bleeding or anaemia with treatment stopped if severe
bleeding occurs. No routine anticoagulant monitoring is required as INR tests are unreliable.
• Gout treatment monitoring for the beneficial effects of treatment – urate is generally measured.
• Beneficial effects of treatment during first 6 hours after rehydration following a collapse – blood pressure.

SESSION 7:
• Data interpretation – 6 questions, 2 marks each, total of 12 marks.
• May be asked to review CXR, ECGs etc but the abnormality will be obvious because this is a pharmacology
exam, they’re interested in what you do, and not the diagnosis per se.
• Common questions:

• Paracetamol nomogram:
o If plasma conc is above the line at 4h post ingestion ->
NAC
o Evidence of toxicity:
o 1 stop drug
o 2 supportive
o 3 antidote
• Warfarin:
o Over anticoagulation INR:
▪ <6 (reduce dose), 6-8 (omit for 2d then reduce), >8 (omit and give 1-5mg PO Vit K)
▪ If minor bleeding with INR >5 give IV vit K instead 1-3mg.
▪ If major bleed stop drug, 5-10mg IV Vit K, PCC
o Most target INRs are around 2.5, unless recent VTE, or metallic heart valves (A 3.0, M 3.5)
• Levothyroxine dose adjustment - Increase the dose of levothyroxine. The smallest increase. OR Assuming
there is poor adherence to medication, keep the same dose and check the TSH level later
• Statins:
o A patient has raised ALT/AST, should you stop their statin therapy?
▪ Only discontinue statin therapy if AST/ALT is more than three times the upper limit of
normal
o A patient suffers persistent, generalised, unexplained muscle pains, can you start him on a statin?
▪ Firstly check his creatinine kinase (CK) level (otherwise not routinely checked)
▪ If CK level > 5x upper limit of normal, repeat measurement after 7 days
▪ If CK level is still greater than 5x upper limit of normal, do not start statin therapy.
▪ If CK level is raised but less than 5x upper limit of normal, the statin should be started at a
lower dose
o If a statin is suspected to cause myopathy and the CK level is markedly raised (>5x upper limit) or if
the muscular symptoms are severe, treatment should be discontinued. If symptoms resolve, and CK
levels return to normal, the statin should be reintroduced at a lower dose.
o Is the current dose effective?
▪ At three months, target is: greater than 40% reduction in non-HDL-cholesterol concentration
• Q&A with Dr Loke and Dr Mir – no slides for this