Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

PRESCRIBING Part A AND JAKE GODDING KATIE NELObjectives ◦ To revise the basic principles of safe prescribing. ◦ To learn to safely and appropriately prescribe common medications, including analgesia, anti- emetics, laxatives, VTE prophylaxis, anti-coagulation, antibiotics, IV fluids, and electrolyte replacement. ◦ To practise applying this learning to tackling common clinical scenarios.PRINCIPLESOF SAFE PRESCRIBING Systematic APPROACH 1. Confirm patient identity 2. Check allergy status 3. Consider indications and contraindications 4. Write prescription, including: ◦ Name ◦ Dose ◦ Route ◦ Start date / Stop or review date / Duration ◦ Regular / PRN / STAT ◦ Frequency / Maximum frequency or dose ◦ Indication ◦ Continued / Changed / New ◦ Signature and contact details 5. Check prescriptionBASIC PRINCIPLES All drug prescriptions must be: ◦ Legible ◦ IN CAPITALS ◦ An approved (generic) name eg. salbutamol not Ventolin® ◦ Without abbreviations ◦ UnambiguousCOMMON PRESCRIPTIONSSCENARIO 1 Mrs Adams is a 57 year old woman who was admitted to ED with abdominal pain. History: ◦ HPC - 1 day history of colicky left flank pain radiating to groin with associated N+V. No fever/cough/SOB/chest pain/bowel changes. ◦ PMH – HTN, T2DM. ◦ SHx – Lives with husband. Non-smoker. Minimal alcohol. Examination: ◦ NEWS 1: RR 20, SpO2 98% on air, BP 158/87, HR 111, Alert, Temp 36.7 ◦ Appears clinically stable but visibly in a lot of pain. ◦ WWP. Pulse reg, good volume. HR >100. HS normal. ◦ Chest clear. Good AE throughout. ◦ Abdo soft, non-distended. Left flank tenderness. No guarding/peritonitis. BS present. ◦ Calves SNT. No oedema/erythema. Investigations: ◦ Bloods – eGFR >90, CRP 12, Na 136, K 4.2, LFTs NAD, INR 1.0, WCC 9.2, Hb 125. ◦ CT KUB – Left distal ureteric stone.REGULAR MEDICA TIONS ◦ Make sure you have an accurate and up-to-date list of regular medications from either the: ◦ Patient ◦ Patient’s relatives ◦ GP records ◦ Previous drug chart or medical records ◦ Clearly record on the drug chart that these are the regular or admission medications ◦ Always prescribe essential regular medications carefully and promptly, including: ◦ Diabetes medications ◦ Parkinson’s medications ◦ Anti-epileptics ◦ Anti-psychotics and other psychiatric medications ◦ Immunosuppressants ◦ Anti-coagulationANALGESIAANTI-EMETICS Anti-emetic Dose Route Frequency Indication Cautions Side-effects Ondansetron 4-8mg PO/IM/IV TDS Chemo- or Congenital long QT Constipation radiotherapy; syndrome; Post-operative Pregnancy Cyclizine 50mg PO/IM/IV TDS Vertigo; Severe heart failure Euphoria Motion N+V Metoclopramide 10mg PO/IM/IV TDS Chemo- or Bowel obstruction; radiotherapy; Parkinsonism; Young Post-operative women Prochlorperazine 5-10mg PO TDS Migraine Hypothyroidism; 12.5mg IM TDS Parkinsonism 3-6mg BUC BDLAXA TIVES Laxative Dose Route Frequency Indication Cautions Side-effects Macrogol (eg. T-TT PO TDS Osmotic Bowel obstruction; Electrolyte Laxido, Movicol) IBD imbalances Senna 7.5- PO ON Stimulant Bowel obstruction Electrolyte 15mg imbalances Docusate 100- PO OD-BD Stool softner Bowel obstruction Electrolyte 200mg imbalances Ispaghula husk T PO BD Bulk-forming Bowel obstruction Glycerol 4g PR STAT Faecal suppositories impaction Phosphate T PR STAT Faecal enemas impactionVTE RISK ASSESSMENTVTE ProphylaxisSCENARIO 2 Mrs Davis is a 79 year old woman who was admitted to ED with fever and SOB. History: ◦ HPC - 5 day history of fever, cough with green sputum, and worsening SOB. Recently started on erythromycin by GP. No chest pain/abdominal pain/urinary symptoms/bowel changes. ◦ PMH – HTN, Osteoarthritis, AF, Aortic stenosis, Mechanical heart valve. ◦ SHx – Lives alone. Ex-smoker. No alcohol. Examination: ◦ NEWS 4: RR 22, SpO2 98% on 1L, BP 124/77, HR 108, Alert, Temp 38.2 ◦ Appears clinically stable. ◦ WWP. Pulse irreg, good volume. HR >100. Audible mechanical valve but HS otherwise normal. ◦ Right basal crepitations. Good AE throughout. ◦ Abdo soft, non-tender. BS present. ◦ Calves SNT. No oedema/erythema. Investigations: ◦ Bloods – eGFR 86, CRP 133, Na 138, K 3.5, LFTs NAD, INR >10, WCC 14.6, Hb 112. ◦ CXR – Right lower lobe consolidation.ANTI-COAGULA TION ◦ Always prescribe anticoagulation carefully and promptly, BUT FIRST, consider if there are any contraindications, such as: ◦ Bleeding – Trauma/Fall, UGIB, Haematuria etc ◦ Risk of bleeding – Trauma/Fall, Invasive procedures, Thrombolysis ◦ If there are contraindications, remember to hold anticoagulants (but still prescribe them!) ◦ Carefully monitor the clotting profile to ensure anticoagulants are within therapeutic range ◦ Be slightly cautious of using concurrent anticoagulant therapies ◦ Review whether anticoagulant therapy is in each patients’ best interestsWarfarin DosingWarfarin DosingWarfarin REVERSALSCENARIO 3 Mr Matthews is a 67 year old man who was admitted to ED with fever and lower abdominal pain. History: ◦ HPC – 2 day history of fever and feeling generally unwell. No cough/SOB/chest pain/bowel changes. ◦ PMH – HTN, BPH, LTC in situ while awaiting TURP. ◦ SHx – Lives with wife. Non-smoker. Minimal alcohol. Examination: ◦ NEWS 6: RR 22, SpO2 98% on air, BP 98/62, HR 126, Confused, Temp 38.3. ◦ Appears clinically unwell. ◦ Hot and clammy. Pulse reg, thready. HR >100. HS normal. ◦ Chest clear. Good AE throughout. ◦ Abdo soft, non-distended. Suprapubic tenderness with guarding. No peritonitis. BS present. LTC in situ but draining pus and debris with minimal urine output. ◦ Calves SNT. No oedema/erythema. Investigations: ◦ Bloods – eGFR 77, CRP 186, Na 137, K 3.2, LFTs NAD, INR 0.9, WCC 17.4, Hb 132.ANTIBIOTICS ◦ Make sure there is evidence of infection ◦ Try to obtain samples for MC+S before starting antibiotics ◦ Use the MicroGuide app (or equivalent local antibiotic prescribing app) ◦ Always prescribe antibiotics promptly, BUT FIRST CHECK FOR ALLERGIES!! ◦ Make sure to specify a duration or stop/review date ◦ Carefully monitor the inflammatory markers ◦ Take advice from Microbiology if needed.Fluids OSCE Stop Fluids - https://oscestop.education/prescribing/adult-intravenous- fluids/#Contents_of_intravenous_fluids_mmolL Resuscitation Fluids ◦ Normal saline 500ml IV STAT (over 15-30 mins) ◦ Consider giving 250ml boluses in elderly patients Maintenance Fluids ◦ Normal saline or Hartmann’s 1L IV over 8-10 hours Replacement Fluids ◦ Calculate fluid balance and then prescribe in similar way to maintenance fluidsELECTROLYTE REPLACEMENTSummaryKey Learning Points ◦ ALWAYS stick to your system! ◦ For the PSA: ◦ Read the Pass the PSA textbook - First edition - https://kupdf.net/download/pass-the-psa-pdfpdf_5a573ddae2b6f5163ff97476_pdf; Second edition - https://dokumen.pub/pass-the-psa-2nd-edition-0702077690-9780702077692.html ◦ Get yourself a non-scientific calculator ◦ Practise using the online BNF (MedicinesComplete > NICE) ◦ Download the BNF and MicroGuide (or equivalent) apps and bookmark the Renal Drug Handbook ◦ Use your final year to practise prescribing common medications as much as possible ◦ Make sure you familiarise yourself with your local drug charts/EPMA (and get access ASAP) ◦ Make friends with your ward pharmacists ◦ If in doubt, just ask for help!Questionshttps:/forms.gle/Cr5xtaWKrmVX7FrT8