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MEDICATION REVIEWS, MEDICATION HISTORIES AND PRESCRIBING Intercalating medical student, Lancaster Medical School Editorial Scholar, The BMJ TOPICS 1 The Medication History 2 Medication reviews 3 Intro to prescribing The meHistoryn THE MEDICATION HISTORY Can you tell me some things it is important to ask about in the medication history? https://www.menti.com/alasrp19z4pg Menti.com Code: 4586 9282 THE MEDICATION HISTORY FOR OSCES We will now talk through how to take a thorough medication history in an OSCE scenario. Liwashing your hands (COVID cohort here so I do it even in histories),f, checking ID, explaining the station and gaining consent. “from Lancaster University. Today I’ve been asked to have a chat with you about your medications, but before I do, can I please check your name and date of birth? Is it okay for me to proceed?” ICE *** REMEMBER TO ASK ICE *** I try to ask ICE around about the five minute mark. (Full disclaimer, it is a mystery to me where it fits into OSCE mark schemes, so that might lose marks for structure.) Just try to ask it at a time that feels right to you. 1. Have you any ideas about why we are talking about your medicines today? 2. Have you any concerns or worries about your medicines? 3. Is there anything in particular you would like us to do for you today? THE SUPER 6 CURRENT MEDICATION 1 What is the medicine? 2 What is the medicine for? 3 How many do you take? 4 you take it? 5 When did you start taking it? 6 it? do you take THE SUPER 6 CURRENT MEDICATION the medications you are currently taking.’ut Ask super six questions medicinesr each of their prescribed THE SUPER 6 NON-PRESCRIBED MEDICATION bought yourself, over the counter or online?’ If yes, ask super six questions about these too Does anyone know why this might be important to ask? OTHER MEDICINES SPECIFICALLY ASK 1 ABOUT... Inhalers 2 Sprays 3 Patches 4 Injections 5 Eye drops and ear drops 6 ointmentsams, PEOPLE MAY NOT THINK OF THESE AS MEDICINES SUPER 6 ANY OF THESE TOO ALLERGIES are you allergic to any medicines? What happened when you took that medicine? Document any allergies and adverse events clearly. Ask the patient if they experience any significant side effects from the medicines they’re taking. SOCIAL HISTORY support at home Do you get any help with your medicines at home? Friends/family/carers? alcohol Do you drink alcohol? How much? How often? occupation Do you work? What do you do for work? Shift work? smoking Do you smoke? How much? How often? recreational drugs Do you use recreational drugs? What drugs? How much/often? diet and exercise Do you exercise? How much/often? What is your diet like? INFORMATION GIVING Address any of the patient's concerns Address any of your own concerns Practical prescribing part of this book is your new best friendPLAN OF ACTION Relies heavily on ICE. Might be any of the following: No change Stopping medications Starting new medications Changing doses Referral to other healthcare professional PLAN OF ACTION L L O What is the goal? A What is the goal? G G Who will do what? M Who will do what? M E Over how long? R Over how long? T T Any monitoring R required?oring G required? O O S L COMMUNICATE THIS WITH THE PATIENT The medication re(station in an osce) THE STATION WILL GIVE YOU... Patient’s clinical context Some investigations to review List of medications You will have to make changes and explain these changes to the patient I thought the easiest way to goexample...his would be using a worked MEET THE PATIENT This is Jenny, a 72 year old lady. Jenny has been recently discharged from hospital following an exacerbation of HF She lives at home, is mobile and independent PMH. HTN, Stage 3 CKD, T2DM, TIA, osteoarthritis You see Jenny in the GP surgeryJENNY’S MEDICATIONS Clopidogrel 75 mg daily S Amlodipine 10 mg daily S (prescribed after TIA) N Metformin 1000 mg twice N Oxycodone 5 mg PRN (for I daily (for type 2 diabetesI Calcium carbonate 500 mg T Furosemide 40 mg daily T with vitamin D 200 IU daily (for A (for heart failure) A osteoporosis prevention) I Lisinopril 20 mg daily (foI Allopugout) 100 mg daily (for D Aspirin 81 mg daily (for D Pantoprazole 40 mg daily (for E cardiovascular protection)E gastroesophageal reflux M M disease) APPROPRIATE? NECESSARY? INTERACTIONS?JENNY’S MEDICATIONS Clopidogrel 75 mg daily S Amlodipine 10 mg daily (foS (prescribed after TIA) N Metformin 1000 mg twice N Oxycodone 5 mg PRN (for I daily (for type 2 diabetesI Calcium carbonate 500 mg T Furosemide 40 mg daily T with vitamin D 200 IU daily (for A (for heart failure) A osteoporosis prevention) I Lishypertension) daily (fIr Allopugout) 100 mg daily (for D Aspirin 81 mg daily (for D Pantoprazole 40 mg daily E cardiovascular E (for gastroesophageal reflux M protection) M disease) MENTI.COM CODE 4586 9282 JENNY’S MEDICATION REVIEW All of Jenny’s drugs are appropriate given her PMH and presentation. BUT gireview them, there are some things for us to think about.o Metformin - monitor renal function as Jenny has CKD and metformin is not suitable for patients with eGFR less than 30 Clopidogrel and still needed - could this be simplified?let therapy is Pantoprazole - is long term PPI still needed? Are the benefits outweighing the side effects/problems? TIPS FOR THE MED REVIEW OSCE Don’t deep it - Stations are short, they are probably not trying to trick you out Don’t lie - It is better to say ‘I’m not sure, I’ll check with my senior, than go ahead and make a clinically unsafe decision time answering their questions and concerns and be interested in what they have to tell you. Don’t impose changes/plans onto patients, propose them to them. INTRO TO PRESCRIBING SEVEN DEADLY SINS OF PRESCRIBING Not knowing abbreviations and your drug leading zeroes Not knowing Not calculating/ your patient checking doses Not taking an Not giving clear accurate history instructions Illegible handwriting LEGAL REQUIREMENTS OF A PRESCRIPTION 1. Patient’s name 2. Patient’s age (if under 12) 3. Patient address 4. Date 5. Prescriber name 6. Prescriber profession and registration number 7. Prescriber address LEGAL CLASSIFICATION OF MEDICATIONS General sales list (gsl) May be sold in shops in packs of 16 Pharmacy-only (P) ( Sold under the supervision of a pharmacist in a pharmacy Prescription only me(icine ,May only be supplied on a prescription Prescription only controlled drug ,May only be supplied on a prescription, harmful or prone to misuse TYPES OF HOSPITAL PRESCRIPTIONS REGULAR PRESCRIPTIONS ONCE Only (STAT) PRESCRIPTIONS AS REQUIRED (PRN) PRESCRIPTIONS ,Dose can be a range, this is usually not the case for regular Indication - importantficult to regulate Frequency in hours Max dose in 24 hoursPRESCRIBING PRINCIPLES Include ALL patient details Use BLOCK CAPITALS and black ink Use approved name for drug Ensure the dose is clear Only use approved abbreviations Include route, start dose and indication Use correct section of chart Never alter a prescription, cross out, date and sign Sign aFill in allergies sectionn FOLLOW TRUST POLICY Fill in patient name on all sides of the chart REFERENCES Lancaster Medical School Y3 Therapeutics My own notes NICE CKS Top 100 drugs book Geeky Medics OSCEstopTHANK YOU