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Yeah. Hello. Good evening, everyone. Can you hear me? Thanks. Okay, Brilliant. Thanks, Phil. So good evening. I'm Doctor Ross. I'm one of the F one doctors from Clinical Assess. I sat the clinical assessment exam last year, and it was successful, so we decided to start this course for international medical graduates so they could also start their career in the UK. So this lecture today is on prescribing, and it's probably one of the most daunting areas of the exam. But I'm hoping that we can help you with that today so that you can be more confident for your exam. Okay, so the names of today we're going to go through the medication history, some basics of prescribing, and then we're gonna look at some cases. Now, before we get stuck in, I'm just going to put a pole up. So if you could answer this question here, have you used the B n f before? Okay. Okay. So we've got about 64% say no and 35% say yes. Okay. Not to worry. So we're going to look at that in a little bit more detail, so let's continue So outline of the ski scenario. So this is the general format that you're, uh, expected to do to greet the patient. Take a medication history. Then you'd be expected to prescribe some medications and refer to the B N F and also trust guidelines. And then, importantly, you should then explain those changes to the patient. And that can include the indication of the treatment you started. So why have you given this medication? What's its purpose and safety netting? Are there any side effects or any red flags that the patient should be aware of? Should they develop some complications that they should immediately come back to the hospital? So I think the most difficult thing about this station is that you don't have a lot of time, and so even when you're doing a medication history, you need to be really aware of the time that you have. So it's really important, though, that you establish what regular medications the patient is currently taking. Things like the dose, the root and the frequency as well. It's also important to ask, Are they also taking some over the counter medications? Any remedies or supplements? Now this one is extremely important. Does the patient have any allergies. Furthermore, you'd have to go into the chronic medical conditions because sometimes that could also be a contrary indication. So you need to understand if there's some preexisting condition which will make them ineligible for starting the medication. Pregnancy is also really important. There are medications that are contraindicated in pregnancy and could be harmful to a developing fetus. So it's a very important question in a reproductive age female Now this is also really important and it's commonly missed. You need to understand if the patient has any condition which could possibly impair the liver or the kidneys, because this will affect many drugs, which are excreted through the urinary system or metabolized in the liver. So let's get into the basics of prescribing, so you will need to use a black pen. And it's important because on our drug charts you have a green pen is used by the pharmacist, so make sure you don't bring a green pen to the exam. But use a black pen at all times, and it mustn't be ambiguous, so you can't put a range of doses. You must be a specific dose, and also your handwriting must be legible, So writing in capitals is the best. Um, in real life, people don't always do that. But for the purpose of this exam, you want to make sure that the Examiner can read your writing. This point here is very crucial, really, because there have been a lot of errors that have been made in reality where doctors have used abbreviations and the nurses have misinterpreted those abbreviations and people have been given higher doses of drugs which has caused harm. So no abbreviations. We will spell out units and not use a you and also for micrograms. We would write that out in the forward rather than using any sort of abbreviations. Now, for the purpose of this exam, we're also going to use the approved generic name's not trade names. There are some exceptions to this, but for this exam, you do not need to know that at all. So I'm just going to avoid that topic all together. Now. It's really important that you put your signature as well on the prescription that you indicate the duration of the treatment. Um, that's really important as well. And also, when it comes to antibiotics, it's important that patients complete the full course of antibiotics and they don't stay on the antibiotic for too long because we know there are complications as well. Uh, one of those being Clostridium difficile. So we don't want to encourage her at all, and frequency is really important, so we'll go into that in a little bit more depth. Now, one thing that hasn't been mentioned here but is important as well is writing the indication for the medication. And in practice, people don't often do that. And it can be confusing when you're not sure why that particular medication was started or why it was stopped. So you do get into the habit of writing why you started that. What? The indication, what's the diagnosis So that whoever looked at that drug chart can understand why you'd done that. Okay, so there are some abbreviations that you can use when it comes to the roots. So P o is for Oral IV is intravenous s c is subcutaneous. Okay. We've also got topical where you can put t o p as well inhaled INH and nebulizer. So any b and then PR is perrectal. Does anyone have any questions? So far about what we've covered. I'll just look at the chart to see if there's any questions before we move on. Okay. Are you following me so far? Yes. So you will be provided with a pen, but we were told to also bring a pen to the exam. So I think just for your own safety, just bring bring a black pen if you can, Um and are you allowed to use the B N f? Absolutely, Yes. You're expected to use the B N F. Actually, So it's good practice. Um, now, in some cases, you might already know what the management is, and you think you know what you're going to prescribe, so you don't want to refer to the B N F? But actually, it's It's really good practice to refer to it. So you will. You won't be marked negatively for using the TNF. It's quite the opposite, especially if you if you verbalize that, you know I'm doing your prescription at the moment. But I will just have a check with my book just to be sure that I've done that correctly. So it's just that extra layer of safety. Okay, so I think we'll move on. Unless there are more questions. Doctor, the Army is here with us today, so feel free to chime in. Do you want to add anything to that as well? Yeah, To find the vein prominence. Okay, that was That's fine. Okay, so I mentioned frequency as well. So frequency is important. And so you need to be very clear about whether the patient is taking that medication once a day. Is it twice a day, which is B D. Three times a day, which is TDs. Um, Q d s is four times. So, um is once in the morning. So you can actually, um, you can actually just do once a day, and then that's also fine. As long as you indicate on the drug chart what time you're going to administer as well. Yes. You will get the slides from from today and yesterday as well. I'll send them out to your emails. Okay, so the B n f. So as we saw, only 37% of you have actually used the TNF before. So you're going to have to get familiar with the TNF because it's going to be in your exam. So you want to know the layout very well. You want to be able to look up different medications and their indications to be able to comfortably check the contraindications, the dose, the roots, side effects also interactions and other considerations like renal impairment, liver impairment like we mentioned before. And is it safe for pregnancy? So I'm going to show you a little bit if that so in the B N f, there is a section where you can actually look at side effects of different drugs, and it will give you a long list of all the drugs that can fit into that category. So as you can see drugs with anti platelet effects, you can actually see there's a vast range of drugs right here and below that table. 16 drugs that increased serum potassium. They've got all these medications here, which increase potassium and obviously, um, at this level in this exam, it's not going to be too relevant. But once you get into the foundation program, there is another exam for prescribing called the prescribing Safety Assessment, and in that exam this will become more important because it's a little bit higher level, Um, but at this level, you won't even really have enough time to sort of look into this too much. So there are some drugs you're gonna have to sort of just learn that they can cause hypochelemia. Um, but I will go into the sort of scenario you'll see in the exam, and it's a little It's much simpler than than this. But I just want you to be aware that the B N F can give you a lot of information and you can find groups of drugs very quickly that cause a particular side effect. Okay, so here there is also a section in the TNF for interactions. So right here I've looked up aspirin. Okay, so if we look over here in the top, right, so it says aspirin. High dose is predicted to increase the risk of renal impairment when given with bisphosphonates and then in brackets, it says, clog clogged. Drain it. So before you prescribe a particular drug, you can actually look up and see if there's any interactions with some of the regular medications that the patient might already be on. So it's really good practice to use the B N F. Because you might pick up something there, so I'll give you another example right here. It says Aspirin in brackets high dose increases the risk of renal impairment when given with optimization. So at this level, I don't expect your scenario in the clinical assessment to be that tricky or that difficult because you don't have a lot of time to be looking at interactions. So it's typically going to be one of the interactions they expect you to know, and we're going to go into that in a little bit more detail. So this is a typical drug chart, and this is not one from the ward, so it's actually just for teaching purposes only. But it's great because you can actually use these to practice, so I'll be able to send you a PdF, and you guys can print it out if you want, and you can practice prescribing as well. But essentially here we've got the area where you can fill in the patient's information, and that's one of the most important areas because you need to make sure that that's filled out on every single page. So if you're given multiple pages, you need to make sure you fill that out with the patient's information. So this is the area where you can see it's called regular prescriptions. So these are the regular medications. So as well as prescribing the right medication, you should prescribe it in the right area of the drug chart. So these are your regular prescriptions. So here we've got a space here for the year. We've got on the top right on the right day, slash month. Okay, so you should fill that out for the duration of treatment that you want to give for that medication. And then you've got different times going down in the green row right there. Sorry, the green column. And you can take next to the times, or you can actually write in a different time, so I'll show you how you can do that later. And here we've got space with the dose. A place where the route the start date your signature and you also have to print your name as well because they want to be able to identify who made the prescription and a review date right here. Now this section here where it says pharmacy, that's not for you. That's for the pharmacist. and then below. That is indication. So that's what I mentioned before. That is really good practice to write. What the indication is, why are you giving this medication? Is there a particular diagnosis? Um, and on what basis are you prescribing that? So that's really good. So, like I said in this area right here, you should fill this out first before you prescribe your medication. Because what could happen is you fill out a drug chart with all these medications, and then you write the wrong patient's information and they get that medication instead. So make sure you do that first. Okay, So we're going to start with the case, and I'm going to have a volunteer to come up as well and give it a go, and then we'll have a little discussion about it as well and take any questions. Okay, so this is a case right here. You are an F one doctor on the stroke ward. Mrs. Sandra Hammond presented to the hospital today with a dense left sided weakness and slurred speech. Her symptoms started eight hours ago. The MRI showed an acute ischemic stroke in the right middle cerebral artery territory, but she was not to be thrombolysis as instructed by a consultant. Dr West. Please follow the trust guidelines and prescribe her appropriate treatment along with her regular medications. And this is trust guidelines below. Patients with an acute ischemic stroke should be commended on high dose aspirin and PPI cover. In our trust, we commonly use a med result. Check B N f for further guidance. So let's give this a go now. What's important is you don't need to know a lot about the pathophysiology of stroke or anything like that to prescribe correctly in this scenario or any of those scenarios. However, knowing a little bit about the condition might make you a bit more relaxed and more comfortable with what you need to do. But just remember that as long as you're following the guidelines, you can actually prescribe correctly. And I think for me when I was in this exam, that was the most daunting thing is like prescribing for something that I've never prescribed for before. But actually, if you just read the instructions and you follow it logically, you can actually pass that station. So I would like someone to come up and take a medication history from me, and then we can move onto the next part of the case. So who would like to do that? Any volunteers? Just the medication history. You don't have to prescribe. But just ask me some questions that you think are important before you give someone medication. Okay. Um, hum, That's fine. Thank you. So I'm going to invite you to speak, so you should be able to turn your mic on shortly. Hello? Okay, awesome. Hello. Thank you for the chance. No worries, No worries. So, um, take your time and take the medication history from you. Remember, you don't have a lot of time in the station, so just get the most essential information that you need before so that you can safely prescribe some new medication to me. Okay. Hello. My name is Rohan, one of the junior doctors here today. Can I confirm your name and date of birth, please? Yes, you can. Hello. Nice to meet you. My name is Mrs Sandra Hammond. Hello, Miss Sandra. Miss Sandra, I'm going to ask you a few questions before I'm going to, uh, to continue prescribing your medications. Is that okay with you? Yes, that's fine. Okay, Sandra, uh, So do you take any medications for for chronic diseases at all? Um, yeah, I do. I take one medication. Actually, I can't remember the name of it. I think it's a tall atorvastatin. Atorvastatin. Right. That's the one. Yes. Yeah. And what are you taking it for? Um, well, I have high cholesterol, Actually. Most people in my family do Okay, Do you Do you have any other chronic diseases? No. No, that's it. Just the high cholesterol, right? Yes. Yes, Doctor. Okay, so a tour of the starting, Uh, when did you start taking it? Oh, it's been about two years now. So how do you take it? Like, how many times a day I just take it at night. I just take one. Yeah, at night. And only one pill, right? Yes. So, um, you're not taking any other medications. Just that's what was happening, right? Yes, just just that one. Okay, so, um, we're going to to convince you on aspirin. Uh, it's, uh oh. Sorry. I forgot to ask How What's the dose of the pravastatin that you're taking? Yes. I take 40 mg. 40 mg. 40. Yeah, do you have? Do you have any allergies at all? No, I don't actually know. Know Allergies. Do you take any over the counter medications? No, not at all. Okay, that's great. And, uh, yeah, we're going to prescribe the aspirin. So our first check with, uh, with my book here before, uh, writing down the the details. Uh, is that okay? Yeah. Yeah, that's fine. That's brilliant. So before that, how can I do this, like, right now? Okay. No, that's fine. You know, that's that's great. So you've taken a medication history? That's all I need to do to do so. Well done. You You asked me about the allergies, which is great, and you try to establish if there's any medical conditions, anything like that. So that was good. And you also established the dose. And when I take the medication and what medication I'm actually taking, so that's great. So remember, you don't have a lot of time. So you want to get all of that information as quickly as possible. But thank you. That was really good. Have I missed anything? Um, no. I don't think you've missed anything. You've got enough for this station. so, I mean, in reality, you ask a lot more questions, but for the purpose of the exam, Did you do enough? Yes, you did enough to actually pass that station do pretty well. So of course you're not. You didn't ask a lot about I didn't ask about like, uh, liver impairment or renal impaired anything like that. But in this particular it's not, like, indicated so much, so that's completely fine. But obviously, you know that that's fine. That's right. The only thing is, is that sometimes so with insets, they can actually affect the kidneys and stuff. So at this level, though, I do think that you did enough, so it should be fine. Okay. It's a very like, simple case is very straightforward. They haven't put all these multiple layers in there to catch you out, so they're not actually trying to catch you up. So I think what you've done is absolutely fine. Um, okay. No worries. So let's move on. So if I asked you to meet your microphone? Brilliant. Thank you, Doctor. Um, do you have any points to add, or should I move on? Um, yeah, just, uh, a few words. So the station is like a combined station ish. You take a history and then you you do the prescribing, but you're still meant to ask the patient. The patient doesn't actually know that you're there to prescribe the medications. So a mistake that I made was when I walked into my prescribing station. I actually just said, um, yeah, I'm here to prescribe your medications and he said, Oh, okay. I didn't know I needed any medications. So then I had to, like, take a step back and say, Oh, high like you. You've come here for blah, blah, blah, blah, blah And yeah, I'm just here to prescribe some medications to help with what you're going through, like your disease and blah, blah, blah like take a short They do a short introduction because sometimes they don't Actually, no. Well, they know what they're just acting like. They don't know that you're there to prescribe. And, um, while you're prescribing, make sure you sign post before you start prescribing on the sheet. Um, because sometimes you forget that the patient is there and you're just writing or, um, you just focus on just getting all the stuff from the patient or like the information from the patient. But you actually mag like your eyes is marked on that station. So I don't know how you put in my eyes for that station. I've forgotten how maybe doctor tell you later, but yeah, I don't know if I made any sense. Yeah, that's all I had. But you did so well. I think you got everything you needed to Like, um, doctor said to pass the station. So that's excellent. Thank you so much. Um, yeah, in terms of, like, taking the history. So for me, Um, I think Doctor Naomi did like a much better job at it. But for me, I was, um, under a lot of pressure. So I wanted to sort of deal with the prescribing and then kind of talk to the patient, like after, when I just kind of wrap it all up and explain what I've been doing. So there was a point where, in my case, the patient was trying to interact with me, and I literally said to the patient, Oh, Mrs Hammond, I'm really sorry, but I'm actually trying to, you know, do your prescription. I'm going to be with you shortly. I just want to make a mistake on your prescription. And the Examiner, like, looked at me and she sort of smiled like it wasn't, you know, it wasn't really It's actually okay, because not everyone can do that or multitask. So if you find that it's distracting you, I would say, um I mean, don't be afraid to sort of let them know what you're doing and that you're gonna have a word with them afterwards, but it's really important and that you leave enough time to do that. So it's a bit risky, because if you don't, then obviously it looks a little bit bad. But remember, the primary goal of that station is to assess whether you can prescribe safely, so I wouldn't worry about it too much. But yeah, definitely the best case scenario. You come in and introduce yourself and let the patient know what's happening and why you're there. So, yeah, so let's, um let's move on. Okay. So can you just read that first though? So we can see this trust guidelines. Patient has an acute ischemic stroke and should be commenced on high dose aspirin, 300 mg and PPI cover. So, um, the PPI is just to come to protect the lining of the gut. And as it says in our trust, we commonly use omeprazole also check be and therefore further guidance. So that's been put there for a reason. So let's go to the next page. So we did the medication history and this is what we gathered. So it's over. Starting 40 mg medical history of hypercholesterolemia. No allergies, right? So that's what we need. So this is your task just back. So yeah, this is your task. You've got three things here. Your high dose aspirin, 300 mg proton pump inhibitor PPI, which was a meprazole in this case and regular medications right now. And what was the regular medication? Does anyone remember? You can type it in the chat atorvastatin. Anyone remember the dose? 40 mg Perfect. So that's the task. We've got three things we need to remember. So this is what do we go to the back of the TNF and you'll see the index and we can look up aspirin. So right there you can see aspirin. So that's on page 134. So aspirin, so as you can see there's, like a blue box on the right, which shows the different formulations of aspirin and their indications in bold. So if we look closely right there, we can see acute ischemic stroke. Right. So this is what we can see. Acute ischemic stroke by mouth, right. An adult? Yes. 300 mg, once daily for 14 days to be initiated 24 hours after from dialysis or as soon as possible, within 48 hours of symptom onset in patients not receiving from dialysis. Now, do you remember the details of the case? If not, we'll we'll go back. Was this patient thrombolysis were they to be through embolized? No, from dialysis. Okay, maybe I'll give a little bit more background, just in case. So from dialysis is when we use, um, alter plays. Okay to basically dissolve the clot. Okay. Some patients who have an ischemic stroke if they present the hospital within a certain period of time, usually less in 4.5 hours, they may be eligible for thrombolysis. It can be given much later as well, but it depends on whether the brain is still getting enough perfusion. Um, but in this case. The consultants said this patient will not be thrombolysis. Okay, so that means according to the TNF, right? As soon as possible, they should receive this aspirin, and preferably within 48 hours. Okay, so this is the information we extracted from here. We know that it's by mouth. So it's oral or PPO, right? The dose is 300 mg. The duration is 14 days, and we need to start as soon as possible within 48 hours of the symptom onset. So we fill out the patient's information. Okay, I'm going to write in the aspirin, so, as you can see, let's go through this. So we've got patient information filled out first the year 2022. We've got aspirin, Right? 300 mg oral start date. The sixth signature. We've got a name printed. We've got a review data on the 19th, because obviously the duration of treatment was 14. 14 days, and the indication is acute ischemic stroke. So, as you can see, um, it's the sixth today, but we're starting here on the seventh, and that's because I've written this as a stat dose. So basically the first dose I'm going to give right now and that the other regular medications will start from the following day so you can do it that way, or you can decide to just write all of it in the regular medications. But of course, you would try to keep the same amount of time between the same amount of time between each dose, so I have the same sort of interval. So if you do this, um, in an exam is perfectly fine. So, as I said, you have to prescribe in the right area of the drug chart so you can see right here. It says once only medications. So these are medications that you give stat or immediately, but you only give them once you don't expect to repeat them again. So I gave one stat dose today, and then I wrote up the rest of the medication as a regular medication on the subsequent days because they needed a duration of 14 days of treatment with the high dose aspirin. Okay, now, one thing I should mention if we look at the top of the drug chart, so I filled in the information the hospital number of the patient, the surname therefore name, uh, the date of birth. Their weight. So if provided with all that information you to fill it in the consultant because you were given that information that was Dr West and the Ward Stroke Ward. The date the chart is written rewritten. So I wrote the date and NKDA stands for no known drug allergies. So you can also write that in to your drug chart. Can I go back to the previous like, Yes. Let's do that. Yeah. Moment. Let's see what's going on here. 25. Okay. Okay. Was there something about the aspirin that you wanted to ask Esther? Okay. We've got a few questions we can do with all of them, so let's go through. Um, let's see Esther first. Because you're on the aspirin page. Is that something you wanted to ask about? The aspirin? The remaining days. Okay. Yes. Good to get I'm glad you noticed that. So if we move forward, So these are the two days that are left, So I've prescribed that. So basically, yeah, you didn't have enough space, right? To write the full duration. Okay. So you can write in the rest to make sure there is actually two weeks. So let's go back. That's a great question. So let's see if we write the aspirin dose on the six as a stat dose on a separate page for the start date for the regular medications. Should we write six or seven? Great question. So, um yeah, I think it's more appropriate to probably write the seven because you're actually starting the regular, um, prescription on the seventh. So that's absolutely fine. Yeah, but that's not a big deal, because you haven't indicated that it should be given on on the six in the regular. But just for clarity. Yes, you should, actually. Right, um, on the seventh when you've actually started it. So that's great. Let's see what else we have. Can you Okay in the candidate information, they say we are allowed to use the iPad, TNF and also the book. Are there any differences on how to use either one? Yes. Huge difference is the The iPad is probably a lot easier, because you can just type it in and search unless you've got a B n f. And you've practiced with it and you know how to use it. So I mean, Doctor Naomi. I'd love to hear your input on that, but I find the AP version to be quite simple. Um, yeah, I agree. Um, the online be enough is much easier, but I don't know. It depends on which country you're in right now, because you might not have access to the online. Be enough. So, um um, I don't know, just explore both of them, and then just try to see which is which one you prefer. Because people have, like, preferences. Yeah, but I think the online line is easier for me. But some people find, like, the pdf, you know, the hard copy easier. I don't know. It depends on you. Yeah. Mhm. Yeah. No, that's true for me personally, because under exam pressure and I've got, like, a an actual book that I'm flicking through. I just find that a nightmare. Like, um, to be honest, because all the nerves and everything, but I think it really depends what you've been practicing with. If you've got one you can practice with or you've got, like, a pdf version of the physical book, then you can kind of sort of know where things are already. Um, so There's probably some key pages that you can just memorize as well, so you can just flip to it. You don't even have to look it up in the index. So that's also one advantage of that. So is this how a typical prescription station is presented? Are there any variations? Um, I think you'll find it would be a lot simpler than this, to be honest. But what I wanted to do was give you an example where even if the case is complex, if you just sort of take each step as it comes and and look at the instructions and the guidelines that you can actually still prescribe. So my intention is to show you something just a little bit tricky. Um, and see how you navigate it so that you won't be intimidated by whatever the case is that you'll just stick to. Okay, it is to be an f. This is what I need to do with the medication history. Let me look at this medication. What does it say? So the next case we're going to do is actually something that's a little bit more realistic to what you might see, Should I say the side effects or a safety net after I look it up in the TNF. Okay, that's a great question. So we're going to come to that. I'll answer your question in a moment. Okay? So, see, did you use an iPad? And can you show us or describe how to use it? Yeah, I can definitely show you. I haven't prepared anything with the iPad, so it's going to be a little bit different, but I might be able to do another session using the iPad, but I think it will be a little bit different because you have to search and just type it in the search books. But it's a lot simpler than this, to be honest, because you already know what you're looking for. Like, for instance, if you're just typing, aspirin can just come up with the same information with all the different indications. So it should be a lot simpler, but we can do that if we have time. So I just move to the next slide. Okay, so it's the aspirin. Okay, So the next task was to give a PPI to protect the lining of the gut, and it said that the trust guidelines they commonly use a mat result. So again, we've looked up omeprazole. We found it here. And as you can see in the blue box, you've got indications and dose. So we need to find the right indication, which would give us the right dose that we need. So it's not there. So if we scroll down, you will see this. Okay, so prophylaxis right for NSAID associated Also, this is why we're giving omeprazole right to prevent the gout lining from being eroded and to prevent peptic ulcers and so on. So as it says, look by mouth adult 20 mg once daily. Okay, so we have everything we need. So now we can prescribe. So, omeprazole, we're using a black pen in capitals. Okay, we've got the dose. 20 mg the root P o oral. We've got our start date here, signature printed name prophylaxis, and we've got the dates there, and I put a tick next to the time that I want it to be given. And we've also got the regular medication. So atorvastatin, 40 mg okay. And the indication is written there as well. So this treatment is ongoing. Um, so as long As you're giving the aspirin, you're going to need PPI cover so it will be you'll be giving that alongside the aspirin, and the patient's regular medication will be unchanged. The atorvastatin. Any questions about that? And again, just note that I've written that in the regular prescriptions. So it's important that you write it in the right area of the drug chart. Any questions at all? Can I move on? Okay, I'm assuming I can move on. So your question was, should I say the side effects or safety net after I look up in the TNF? Quick question. Okay. Yes. We're supposed to prescribe 14 days ago. It's still upset. 10 days. How do we go about it? Okay, you answered that. So the first question. So how many days will I write the statins for? So this is essentially as long as the patient is admitted, you're just going to prescribe, right? So it's not. You don't have to keep filling out the whole drug chart. I just wanted to show that you know, as long as the patient is admitted, you will prescribe them with their regular medications, which they will continue on discharge. So you don't need to actually write up the whole thing. The Examiner's will get that you understand what you're doing If you're, you know, stuff for time. Um, that's good. That's good. Next question we're supposed to prescribe for 14 days, but it starts at 10 days. How do you get so It's similar to what I showed before, how you just prescribed that to for the 14 day duration so you can just keep adding on so that you've got the full coverage for the whole period, Ideally, but I do think that if you were, um, prescribing and like, for instance, you know it has the indication if you wrote in there like a note, like a duration 14 days or something, even if you didn't prescribe up for the whole 14 days. The example has has obviously noted that you understand that this should be continued for 14 days, and as long as the practice, as long as the prescription has been signed, um, four. Even if you've only written the first two dates, someone else will actually right in the other dates because you've already authorized the prescription. So I think it's a good practice to write up the whole chart, Of course. But I'm just saying, if you are really pushed for time and the the station ends and you've only written the first week, for instance, But you've actually noted that should be continued for a duration of 14 days. Um, I'm pretty sure that it will be okay, but yeah, ideally, please write it all up. So let's see what else we've got here. How many days will I write the statins for? That's exactly how the drug chart looks. Is this exactly how the drug chart looks in the exam? Doctor in the army, this question is for you. Do you remember? Was it this this one? Because we were using this one to practice with. I'm just trying to recall if it was the exact same. I think it was the exact same. Yeah, it was the exact same. Um, it was black and white. It wasn't green and white, but it was It was the exact same prescription because I don't feel I was confused or had any difficulty. So it was Yeah, it was the exact same. I think the boxes were smaller and it was black and white, but everything else is like exactly the same. See? And that's the same, Like, prescribing prescription forms. We use it in the hospitals as well. I don't know if it's the same, isn't it? Is it the same? Is it the same in the hospital? What? This one? Yeah. No, no, no. It's completely different. Yeah, it's different. It's different because even this one, it doesn't actually have frequency. Right? So, um, you just indicate how often you're going to give it. But actually, it doesn't actually say like, frequency. So, um, I can show you guys what a real drug chart it looks like. But, for example, I think it's going to resemble this one. It was this one. Okay. Um okay. Thank you, Doctor. Young man. Like I said. So, uh, great question. Sorry. So yes. Um, omeprazole so, yeah. If you're giving high dose aspirin stack, then yes, you give PPI step, right? The thing is, for this, um, for this station, they're not trying to catch you out, right? They're not trying to catch you out. Also, this scenario is already a little bit more complicated than the normal one. I just wanted to demonstrate that you have to be aware of regular medications, and you can also, um, look up in the TNF to find what you're going to prescribe. But definitely it's a good practice to give you. We're going to give high dose aspirin, especially that you give a med result as a stat dose as well to protect the lining. Um, some doctors don't do that, but I would advise that. So, yes, that's a great question. What do you write? Um, what do you write in the place of review date? Okay, yes, that's a good question as well. So the review date is it's not mandatory. You don't have to write something in there all the time. It becomes important when it comes to like antibiotics and stuff. But in terms of other medications is not. It's not essential to have that in there, of course, unless you're aware of a specific duration that it needs to be given. But if it's ongoing and you don't see any indication why it would stop, then you don't have to fill that out on a slightly unrelated note. Is there going to be every 10 prescription in the exam or as junior doctor you're not allowed to fill out F P 10 prescriptions. So I highly doubt that although I know that it's it's been written on the syllabus, but it would be so strange to do that since you're not actually allowed to do that. So it wouldn't be, um wouldn't be safe, So I don't think they would do that. To be honest. No, I can't see any where I can indicate the drug is for 14 days without writing it out. Are you able to show, please? Yeah. So indication. So, like, let me go back. Uh, right. So you see what I've got, Indication, Um, you can write stuff here too. So as long as you indicate something about the duration, that's absolutely fine. But of course, the writing in all the dates that you would like it to be given is fine. There is another way where you can actually strike off. So after you've given the 14 days, you can actually strike off the rest so that people are aware that you don't want to give it beyond that date as well. So that's also good practice, but again at this level, and they're not expecting everything to be perfect, but I'm just trying to give you the basic tools that you need to pass the station. But definitely that is that is perfectly fine. And there's many things you can write in this box. I'm going to talk about that later as well. Like, there's something that I was confused about for the exam, and only to find out that you could just write it in the box. And the Examiner would then know that you're aware of it. So let's go back. Nope. Okay, so we said for prophylaxis. So we've got 20 mg once daily. Okay, so we did that. So would anyone like to explain this to the patient? So let's say you've done this. Now you've prescribed everything that you need. Who wants to try explaining this to the patient? And remember, when you're explaining stuff to the patient, you have to use a patient centered language so you can't use medical terms. Try not to over complicate things. So does anyone want to try that? Rehab is offering again. If there's anyone else want to try as well. Okay, well, let s to try this time, so I'm going to bring you up to the stage. Okay, Esther, you should be able to use your microphone now. Hi. Hi. Yes, we can hear you. Um, so you can have a go. You can try to explain what you've done to the patients to explain what you prescribed and why. Okay. Hello, Mrs um, Sandra Almond. All right, so I just prescribed, um, your medication for you giving that You just got a a stroke. Um, So we're going to give you the aspirin. 300. You're going to take one tablet, which is 300 mg, and we're going to give this to you for 14 days. We're also going to give you another medication called, um, I'm in Brazil, and that is to protect your stomach because of the aspirin. And for that, we're giving you also for 14 days. You're also going to take 20 mg. Um, once a day. Okay. And you would also continue your regular medication that you take your statins as you take it. Um, at night. Um, would you have any questions for me? Yes. You mentioned, um, aspirin. Why am I taking that doctor? Yes. So the aspirin? Yeah. Sorry about that. So the aspirin is for the stroke is to help to heal and prevent for the strokes. I see. Okay, so what happens if I don't take that? Oh, yeah. So it's important that you take this medication as we prescribe. If you do not take the aspirin, um, you could get you could get another stroke, which would be very bad for, you know, for you. Um, Okay, um and is there anything I need to be aware of? Um, any side effects or anything? I should be dangerous or Yes, absolutely. Every medication that every medication, a side effect for the aspirin there is There is risk of bleeding. So we want you to be aware if you go to the washroom and you see that you are there is blood in your stool or blood in your urine, or you're vomiting blood. Um, you need to, um you know, let us know that immediately. And if you also feel ringing in your ears or you feel yeah, yes. Please do let us know about that. Okay. And, um, while you're on the aspirin, we would also do some blood tests for you, um, to check your kidneys and make sure that everything is okay. Okay. Thank you, Doctor. Thank you. Okay. All right. Great. Great. That was really good, Doctor. And, um, can you come up as well? I'd like you to chime in on this. Uh, that was excellent. Talked. She did so well. Yeah. I mean, you have to keep prompting Have she did. So, uh, yeah, yeah, honestly, if you can, you can do that in the exam and just maintain your composure and explain to the patient in this way, it will be really, really good. Um, I think in terms of the the aspirin, like mentioning that you're not taking it could mean that she's at increased risk of having another stroke is great. Um, and so, yeah, it's worth also, like knowing a few side effects and things like that. So you you mentioned about the risk of bleeding and so on? Um and it's Yeah. It's also good to sometimes say that, you know, the risk is kind of outweighed by the benefit of taking this medication. So that's why we're starting this. But yeah, it was It was really, really good. Keep it up. Keep it up. All right. Thank you, Doctor. Thank you. That's the rest. And, Doctor, I appreciate that. Don't worry. We want the next case. So case, too. So we're going to need another volunteer as well. So Jane Humphries is a 52 year old female who has been admitted for a community acquired pneumonia. Please take a medication history from Ms Humphries and prescribe an appropriate antibiotic. As per trust guidelines, A copy of the hospitals Antibiotic policy is provided as well as a copy of the TNF. So this question is, um it's going to be more relevant to the exam, this kind of question. So who wants to take a brief medication history from Ms Humphries? Okay. Um well, let's invite you to the stage, so you should be able to use your microphone now. Okay. Can you hear me? Yes, I can hear you. Okay. Ready when you are. Hello. My name is Anwar. I'm one of the junior doctors on the word. Uh, can I just confirm your name and date of birth, please? Yes. I'm Jane Humphries. My date of birth birth is the first of February 1970. Okay. Thank you. Uh, so, uh, may I ask if you know why you are here? Um, no, I don't, actually. All right, Uh, so you've been admitted for pneumonia, and I just like to talk to you about your medication. Uh, is that okay? Yes. Pneumonia. I'm just so confused you. Well, I guess you explained it to me. That's fine. Yeah. Okay, so, pneumonia, it's a chest infection. Okay. Yeah. And would like to, uh, put you on some medication, But before we do that would, uh I'd like to take a short medication history. Would that be okay? Oh, yes. Thank you, Doctor. Thank you. Uh, sir, can you just tell me if you're currently on any medication for any other, uh, condition? Um, yeah. I take a statin for my high cholesterol. Okay, uh, and how what's the dose of this of the statin? Uh, I think it's 80 mg. Okay. And do you know the name? The exact name? Yes. Atorvastatin. All right. Thank you. Uh, and how often do you take this drug? I take it every day. Yeah, right in the morning or night, actually. Yeah. All right. Uh, do you take this by mouth or Okay. Thank you. Uh, do you take any other medication, like over the counter drugs or any supplements? Um, occasionally, I'll take paracetamol when I have pain, but that's about it. All right. Is this pain diagnosed? Like maybe, uh, for any condition, Like pain from any other diagnosed condition? No. No, it's just sometimes I just get really weird back pains and stuff, so I just take a bit paracetamol. All right. Thank you. Uh, do you have any allergies? No. Okay, that's good to know. Um, do you think or Okay, you said that you don't have any, uh, illness or anything? Uh, any condition apart from what you're taking statins for, Am I right? That's correct, Doctor. Yes. Okay, but do you have any symptoms and sorry. Any side effects from the statins that you're taking? No. No. Any muscle pain or change in your in color fatigue? Okay. Thank you. All right. So I'm just going to fill this in, and then, uh, come up with, uh, yeah. Trip and plan for you, if that's okay. Thank you for answering questions. Thank you very much dot Thank you. Okay. Awesome. Um, so, yeah, you've got all the information you needed. You did really well, and we know that it's atorvastatin. 80 mg. We know the past medical history. Very brief, but that's what we need for this station. So, as you can see, we've got a lot of information going on here. So, um, are you familiar with Curb 65? If you're not, that's okay. Okay. Okay. It's going to be quite important, so we'll go through it together. Just come in the next slide. Okay? Okay. So Curb 65. So we're using it to gauge the severity of the pneumonia, which will then guide our management. Okay. And we're going to refer to the trust guidelines that we saw on the previous slide. So the curve, 65 different components of confusion, okay. And that can be summarized by the abbreviated mental testicle. So if it's eight or below, then we could say that confusion at one point. Urea. If it's above seven. Minimal polluter, that would be another point. The respiratory rate is more or legal to 30. Then that will be another point. And also, BP is important. So systolic BP less than 19, or the diastolic BP is 60 or less than 16. And if the patient is over 65 or 65 So 65 or a club will be another point. So let's bring up the patient information. So, based on this information that we have in the top right corner, can someone tell me what the carbs is? The place? You can just type it in the trap ones. Please repeat. Okay. What would the Curb 65 score being to this patient countries based on the information that's provided in the right hand corner? Correct. So the answer is to Okay, so let us look at that. The A M. T is five. So we said if it's eight or below, that would be one point conclusion. Okay? And the urea is 9.8, so that's above seven. So that's two. So everything else, it's within the normal range. Okay, So 81 mg, we don't have enough time to go into that. That's going to be part of more like psychiatry. Lecture that we're going to do is, um we'll save that for another time. Yes, abbreviated mental test for So we'll go into that another time. They could prepare another time, So let's let's keep moving So these are the trust guidelines. Okay, So if the current 65 score is, what are we going to do to this patient? Based on the guidelines, just type in the chat hospital admission, Okay. In the form of, uh, medication. So if someone says amoxicillin and to recognizing brilliant. So that's where you can see so anticipations information right here. Okay, so we've got our detention community acquired pneumonia, and you're getting five days motorcycling and recognizing. Okay, so does anyone see an issue with us doing that? I don't mind the dates in here. All the dates wrong with this. It's not I'm not trying to catch her up. This is dates running between the one main. Uh, which one? Okay, that's a good point. Yet you could do that. You could do that to prevent someone from elongating the treatment. Right? Because if you haven't lost it after a month, you're actually right in the dating at first. So it's more than five days, right? Anything else? Okay. What do you do? Yeah, that's another one. Can't hear me. Well, can you hear me now? Uh huh. Yes. Okay. So importantly, let's just go to the basics. So we are in an antibiotic prescription. So that's why he prescribed this. Not in the regular area where there's a designated area for antibiotics. That's what we need to go. We need to have a duration we need to protect. Right? We need to make sure everything is correct. Date with New date. Make sure that we have an indication. Okay. Need to write in capitals and the black pen. We need to fill out the year. So we put you on this one Not only want to learn. Okay, So, atorvastatin, 80 mg, right? But we can't give talks that in, just giving through the medicine. Okay, This is something you're gonna have to memorize, because it's high. You like They like to use this example in the eighties. Does anyone know why? Connecting to hang on, to cancel that? Some of the complications. Okay, great. So let's go back to you as to why did I cancel kind of thing? Good question. So if we look at the initial trust migraines, right. Okay. So if you look at the curb 65 words to amoxicillin, um, you got one brand there, right? Uh, eight hours. So I think our early right There's something. It's a power. It's three times a day, right? No one will stand that every eight hours, right? So, essentially what you want to do is you want to ensure that the the medication you're giving is spaced out evenly, so you're not giving one after four hours and the other one much later. So you want to make sure that the peak concentration of the drug is more stable, that you're getting the right concentration throughout the day, so you want to spread that out accordingly. So it's every hour. You want to try and get as close as possible to do that. They say, If you look at the Clarithromycin, it's every 12 hours, right? So that's twice a day, two times 24. So that's twice a day. So let's go back to this weakening. So that would be eight in the morning and eight at nine. That makes sense. So essentially, um, this one didn't actually have the right. I'm in a tick, buy it and then write the other woman. So as it says on the thing you can take or insert times required. People think that the nurses will actually give that medication, Uh, specific time. But if you write any time, you know that. So to ensure that the drug is based now, evening with the same interval each those you want to make sure to get it out. Let's keep going. Any issues with this tendency in problems, Any issues? Okay, we've got something here. Right? So yes. Amoxicillin. If you look at the dose, what did the trust guidelines? That one brand, isn't it? So we have to be very aware the dose of what we're doing. Why don't we start not to sit in that six and carry it? Good question. So, ideally, you would start it at the same time. Okay, So what I want you to do is so when you get to the PS PSA, which is going to come much later, you're gonna have to do a prescription with you where you actually have to look at the prescription and notice what needs to be changed. Doing errors that so again you have to ensure that you have, um, these medications given up right interview, and we also want to start around the same time. So it's a similar to when you have the aspirin will be a method, or you don't want to stagger it. We want to make sure we do it at the same time. Great. Anything else, anyway? Okay, Okay, let's move on. Because I think I think I think you get the time to remove one. But someone had the right answer. So, um, in terms of the two recognizing, uh, we could also increase the risk of biography in the statin because we have an increase the concentration of the statin. Therefore, we're going to see the other side effects manifesting because the liver is not able to metabolize it appropriately. So you need to explain that to the patients. Right. So to wrap this up, need someone to now explain this to the patient without using medical technology too much and making it as clear as possible, and we would like to do that. Okay. What? You can do that. Okay. Thank you. Yeah. Uh, I'm just going to I can't remember, Jean, I think. Okay. Uh, all right, Jane. So, um, we're going to prescribe, uh, two medications for you for your infection. Uh, they're antibiotics. This will help to fight the infection. Uh, the names of the drugs are amoxicillin, which you which we're going to give you 500 mg twice a day. And the second is clarithromycin, which is also going to be twice a day and, uh, 500 mg. Uh, do you have any questions? Um, so the So let's just start the amoxicillin is 1 g. Okay, Okay. Three times, three times a day. Okay. And the CLARITHROMYCIN is 505 100 twice a day. All right? Yeah. All right. Okay. Uh, do you have any questions concerning the medications I just mentioned? Um, yes, I I don't know what their purposes. Why Why are you giving that to me? Okay, so the amoxicillin and clarithromycin are antibiotics that will help to fight the infections and that they've been prescribed at that Does, uh, because of different factors, like your age And, uh, your, uh uh What these things called again, Uh, BP and respiratory rate. I've forgotten what these things are. Yeah, uh, so that's why they have been prescribed to you. Uh, and I would also like to stop the, uh, statin that you're taking. Yeah. Uh, this is this is because of the clarithromycin that we're giving you. So, uh, I forgot to mention, but the clarithromycin and amoxicillin will be given for five days. Right. And you take it by mouth, or was it IV? Can't remember IV. Yeah. Okay, so we're going to stop your atorvastatin. And this is because the clarithromycin, uh, prevents the clarithromycin. Will affect how the atorvastatin is metabolized in your body. So how it's broken down, Right? Okay. Do you understand that yet? So if we give the clarithromycin and the atorvastatin at the same time, Uh, the atorvastatin wouldn't be broken down properly because of the CLARITHROMYCIN. And it will lead to some unwanted symptoms, like, uh, muscle weakness and, uh, fatigue. And we wouldn't want that. So we're going to stop the atorvastatin just for the period that the CLARITHROMYCIN will be given. But as soon as you're done with that dose, then we can continue with the atorvastatin. Does that sound okay to you? Um, it's quite I'm quite worried because the statin statin is for my, uh, cholesterol. They I mean, my GP told me that if I am, I'm taking the statin to prevent me from having like, a stroke or something, you know. So if you stop my statin, wouldn't I get a stroke or I understand your worries, but the period for which the statins will be stopped is just five days, and that's not enough time to reverse the full effect. So by the time we start the, um, by the time five days have elapsed, then we start the statins again, and it will be business as usual. Yeah, okay. Yes. Thank you for explaining it to me. Thank you. Okay. Awesome. Doctor weight. I hope I was correct with what I said about the statins. Like the effect of the statins. Not like being reversed immediately. Is that right? I wasn't sure. I said, like I told the patient that the effect of the statins wouldn't be reversed immediately, like within five days. But I'm not sure if that's correct. Oh, no, you're correct. You're correct. So you don't go into mechanism too much. But you do need to just reassure the patient that they treat their statin treatment. Being withdrawn will not significantly increase any risk or have a serious effect on them, which is true. So it five days of not taking a statin is not gonna have a profound effect. So you are right. But just you can reassure them. That's fine. Yeah. Okay. So, Doctor, um, are you still here? Can you give some feedback? Um, I think this is where she would get the most points because this is her eyes, and it was really great. Uh, just don't forget to do this. I don't, like, focus on prescribing and forget about icing the patient. So this is where you can get the ice. Yeah. I was wondering why you could get points for the eyes for the station, but I think this is it. Well, you, like, speak about, like, side effects, and you speak about all you're actually given to the patient and ask them if they have any questions or concerns. And then you get your four points there. But, yes, it was great. And the comments? No other comments, Doctor. Brilliant. Thank you. So yeah, we have one question. Can we start the statin on the Aleve instead of cancelling the chart? Exactly. You don't have to cancel off the whole chart. You can just withhold uh, statin. So you make that clear in the chart that you withholding so you would put an X in all those other boxes. So it's not given, and they can recommend treating once the Claritin has been stopped. So just wondering, how much time would you allocate to take a medication history? And how long would you allocate for actually writing out your prescription? Yeah, that depends on you and how you've practiced. And if you're really confident about prescribing, um, again, for me, I did it completely different. So, you know, I went in and I wanted to get down to the task and then deal with the patient later. It wasn't ideal because I could tell the Examiner was like, Okay, this is interesting. I didn't really say much to the patient. I just let them know that I've come to prescribe some medications. I took the medication history whilst I was writing it. I asked kindly to not be interrupted until I'm done, and then I spoke to the patient, but I think it's better to kind of speak first and then try to fit it in. So I don't think you should rush it, to be honest, like the prescription is really important But I don't think they penalizing you heavily unless you do something like which is really, really bad. So even if it's not perfect, even if there was a note like okay, you could have crossed off the rest of the chart so no one extends your prescription or something. I don't think that's enough for you to fail it or something. So you do your best to be accurate, but it's not going to be perfect. And I think they're aware of that. So, yeah, in terms of time management, that is the key to this station. I think I think it's all about how you manage that time. And if you know what you're like and you know that you're going to need a bit of extra time prescribing, then you need to find a way around that and make sure you've left enough time. So, guys, we've actually come to the end of this presentation, so if you could fill out the feedback form, that would help us a lot, and you can also claim a certificate as well. Once you do that, which will, um, you can use it on your portfolios as well for your Foundation program, so that would be really great. I want to thank everyone for attending. Now. There's a little bit more that I do. Yes, we will send the slides. Um, there's a little bit more that I wanted to go into is going to talk about fluid prescriptions, but we're gonna have to do that on another date because there's a little bit more stuff to go into. And I think it might get a little bit tricky if I try to do it all at once. So we'll go into fluids a little bit more, and I'll give you all the background of how to prescribe fluids. Um, so if you have any questions again, you can email us. But also, if you could feel like that feedback that helps us a lot and we can start looking in more sessions. Which place of the TNF would be recommended knowing for the exam? Um, I would say Just start looking at the index. Just looking at random medications, just getting used to actually like using it. Also interactions. That's a good good place in the TNF to know. Um, Doctor Naomi, do you have any suggestions? The appendix so check like the other back of the the end of, uh, there's like an appendix where you can find lots of my stuff. I don't use the paper be enough, but people who use the paper being a refugee to speak about the appendix. So if you get your hands on the paper, be enough. Just, um, check the appendix out and just practice honestly with the prescribing station. It's all about practicing and practicing and practicing. You have to find your own style because people have different advice, like speak to the patient while you're doing the prescription, or speak to patients after the prescription. It depends on you. So just practice and time yourself and see what it's comfortable for. You find people to practice with, um, just practice and yeah, because it's a really, um, difficult station. It's not difficult, but it's just really time constraint. And if you don't take care, you just leave the prescription prescribing station and then you'll be a bit down because you didn't finish. So practice. It's all I say. Yeah, yeah, yeah, that's what advice, I would say, because I practice. But then it didn't prepare for reality like situation when you're under pressure is different, so try to get this type of practice, but with less time that you used to that and don't do anything differently. So if you've been practicing with the paper version, like with that practicing with the version. So with that, don't change it up on the day. Just see what we used to. And it is different practice. I was looking at the end and medication from the other side. Yeah, you can do that. Um, looking at, uh, rite indication that so And yeah, the last second. Know yourself. Like, you know, you feel that kind of person that when you come in and like, multitasking have taken it, If you want to just experiment, I wouldn't like that. So I have to send it and, uh, you know, I don't want to make a mistake. I will get a prescription, and I'm going to discuss, But everyone is different. So yeah, that was right. Yeah. So you guys, thanks for attending. We really appreciate it. And then I'm going to fill out to help to improve. Thank you. You guys. So I will see you in another state. Uh huh. And any time studying? Um, motivated? Uh, yeah. You have to decide. Okay, guys. Okay,