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Dr. Aisha Musa, presents the final webinar of the 10-part National teaching series titled "Prescribing in Surgery." This final session allows medical professionals to revisit and consolidate all topics taught in this 10-part series. By the end of the session, attendees will have acquired valuable insights into prescribing VTE prophylaxis & analgesia, fluids & electrolytes, antibiotics & blood transfusion. Attendees will also learn prescribing in pre-op, surgical emergencies and the prescription of diabetes medication. Individuals will also learn prescribing in general surgery, colorectal, urology, T&O, ENT and Paediatrics using case-based scenarios informed by local and national guidelines. Don't miss this chance to edge your skills and knowledge in this crucial area.

Learning objectives

1. To understand and identify the fundamental principles of prescribing in the surgical environment. 2. To comprehend different case scenarios in which surgical prescriptions are necessary and viable. 3. To consolidate knowledge learned in our 10 part prescribing in surgery series 4. To acquire valuable insights into prescribing VTE prophylaxis & analgesia, fluids & electrolytes, antibiotics & blood transfusion using scenarios 5. To learn prescribing in pre-op, surgical emergencies and the prescription of diabetes medication using cases 6. To learn prescribing in general surgery, colorectal, urology, T&O, ENT and Paediatrics using case-based scenarios

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Computer generated transcript

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

Ok. Hello, my name is, um, and I'm one of the doctors. Um, that's part of the prescribing and surgery series. Today's session will be, uh, our Q and A session. So our final session, uh, but before we start the session, we've got a, a quick talk by Daniel who's from the BMA. Thanks like that. So, uh, yeah, just very quickly for me, it was just gonna be a bit of an update about what's going on. Um, but you've probably been getting emails anyway. Um, yeah, I'm sure everyone watching now and on repeat, um, is a member anyway. But, um, if you wanted to take advantage of a little exclusive, um, for mind the bleep, you can get a, a month free of reviews like QR code that's on the screen. Um, so, yeah, so I'm sure everyone knows what the BMA is, what it does. Um, the way I like to look at it is, is uh, free fold, um, individual, local and, and national, um, so on an individual, um, sense, it's, it's sort of like, um, things like the contract checker. So helping you, um, with any sort of personal problems that, that are unique, uh, just to you. Um, so, yeah, so all that sort of things, um, local is, is more sort of, you know, a group of, er, f two s for example, and you're having sort of a similar issue with your voters. Um, we have people that are on the ground every trust who can, who can sort of come in and, and sort that out and then obviously national what's going on, um, in terms of strikes and what not at the moment. Um, so, yeah, this was over a month ago now, but just a recap of, of the, of the, of the next mandate that we've got that runs until 19th of September. So the turnout was slightly less, um, 61% I think before it was about 71. Um, but yeah, they obviously strike guess the strike action was, was still massively high at 97.97. And obviously, er, Asos was just something that we introduced for, for this time round. Um, also got a big, big guess as well. So, actually sort of striking. Um, yeah, this is sort of where we are. Um, despite the government constantly telling us that that's it, that's the final offer. Um, so things are, things are working despite the feeling like they're, they're not. Um, so, yeah, so we just gotta keep going basically. Um, so, yeah, a little update. There's no, obviously no new dates, um, for junior strikes as as the talks continue. Um The consultants agreed their deal last month. Um So that's coming into effect now they'll get back paid to, to March. Um And then there was ao offer to the SAS doctors which was rejected and there's no plans for those guys to strike yet. They've obviously got their mandate and haven't actually striked yet. Um But, but they're also having talks continue. Um So, yeah, there's a bit of a length female that I've condensed from last week. Um, sadly I don't have any inside information. II sort of get told what everyone else gets told at the same time. Um, but essentially, it sounds like there's, there's good, um, progress, um, with, with the government. Um, and it sounds, sounds quite positive. Um, so, yeah, so I'm waiting just like you the, for, for an announcement that should be this week, the email went out last week saying next week we'll, we'll have some, er, news on an agreement. So I'm waiting to hear that with you guys as well. Um, but yeah, but it, it does feel like a different, different phase, like they said. Um, I can't remember time since 2022 since this began that such a period has gone, um, without any strikes. Um, so, yeah, so it must, must be good. Um, what's, what's happening? I would hope so. But obviously if, if that, if that changes, um, if the government is sort of stalling as, as they did before. Let's, let's be honest and then, then we will call for industrial action again. So, yeah, so sort of touching back on the individual support side of things. Um These are sort of some of the questions that we, that we get. Um So yeah, so just think of BMA as your first port of call, not just for obviously things of the strikes, but also just your day to day um things around leave. Um Anything nonclinical really. Um Sometimes we get confused with MDU but MDU and mps, the indemnity, they deal with sort of the more clinical side of things whereas we are fully um nonclinical. Um So yeah, contract checker, biggest, biggest thing that we'll start um reminding everybody about soon with, with the upcoming inductions in July and August, 25% of the contracts we checked last year that was mainly around July, August inductions um were wrong. So, yeah, so just get into the mode if you're not already of just sending it in to us and we'll check it before, before you sign it if you sign it and we check it, it's fine. You shouldn't have signed something that was wrong. So it's not the end of the world, but hopefully, um you remember to send it to us first. Um You've got obviously full access to lots of other tools um as part of a BMA member. Um So BMA library, full access to that um clinical key as well, which is a point of care tool. Um We run a series of webinars as well that are available um you to watch live and obviously er on, on, on demand as well. And you've got full access to B MJ learning and you'll be getting a copy of the B MJ through the post, but you can also um turn, turn that off. I get those through the post and, and they can be a lot and we just know that you, you can turn, turn those off if you would like to. Um, that's it for me. I'll hand you back to Aisha and, and let you go on the session. Thank you. Thank you, Daniel. So I'm just gonna present the side now. Ok. Um So this is our final session in our prescribing surgery series. Uh So it's our Q and A session and just to introduce myself, I'm, I uh I shoulda um and I'm one of prescribing surgery codes. So just a disclaimer. Um, you know, prescri prescribing surgery series has been created by Gene Doctors entirely on a basis. Um And um kind of everything we discussed is accurate to the best of our knowledge. And neither of these, the teachers nor mindedly take responsibility for any unintentional inaccuracies. And this, this is just to show you that is our final session in our prescribing and surgery series. So, thank you all for joining. Um So last week, I um I sent out a survey asking uh what topics you'd like to be covered. And as you can see, there's a variety of topics and quite a lot of people wanted a recap session. Um There was one person that asked us to cover medical emergencies. And as mentioned last week, our colleagues in mind that people are hopefully in the next few months going to deliver um a minor be session on prescribing in medicine. So our 10 part series is solely uh covering prescribing in surgery. So let's start with our first case. So our first case will be covering GT prophylaxis and analgesia, which was our first session of the series. So 64 year old female presents with inability to weight, bear and with a shortened and externally rotated uh right leg. Um She is um admitted to trauma and orthopedics and undergoes uh surgery for her neck of femur fracture. In terms of her past medical histories, she's got osteoporosis. Um She's got no known drug allergies. She weighs 98 kg and her co clearance is 40 mL per minute. Uh She'll stay in hospital for a few days postoperatively. So the question is what vte prophylaxis should she be prescribed on a 24 hour regime whilst in hospital? Um So I'm just gonna start the whole. Ok. So the most popular option so far is a enoxaparin, 40 mg once daily. Any I lances give it a few more seconds. Ok. So it's still the most popular option. Um And yes, the correct answer is and it's requiring 40 mg once daily. So I'll just go to the next slide to explain it. Um So this is just showing that uh for prophylaxis of DVT in surgical patients, you give uh 40 mg every 24 hours. Um and you can give a uh low mile. So you give low mile with heparin and enoxaparin is just an example. OK? And this slide is showing to you um that in clinical practice, you need to take into account the patient's weight and renal function. Um So in this case, his weight is 99 kg and his creatinine clearance is 14 mL per minute. Uh So in clinical practice, you would also prescribe 14 mg once daily. Um So make sure to when you, when you start prescribing um you, you use your local trust guidelines if that makes sense. OK? Any questions for this case, OK. We'll move on to our second case. Then uh before we move on to our second case, I just want to show you that in terms of the duration, nice test for fragility fractures need to offer VT E prophylaxis uh for a month. OK. So, so this is our second case um and this will be covering analgesia. So during her hospital stay, she's prescribed 15 mg of morphine sulfate, modified release BD and P RN morphine sulfate 5 mg for her perioperative pain she's also been prescribed P RN laxatives and anti sickness medication. You were asked to review after the morning ward round and she reports developing widespread and worsening pain, hyperalgesia and allodynia. Um So just to let you know, hyperalgesia is increased sensitivity to feeling pain, whereas allodynia is pain due to stimulus that doesn't usually cause pain. So for example, pain from light touch. So the question is, how will you manage her pa her pain? So I'll just start pulling. OK, just give me a few more seconds to respond. OK? Give me a few more seconds and the response is fine. OK. So the correct answer is e so e is to um seek specialist, a specialist advice and reduce the dose by 30 to 50%. So obviously, the options were quite similar to each other. So on the next slide, I would explain why, why this is the correct answer. Um So this is showing you. So the patient has opioid induced hyperalgesia. So that tends to present with widespread worsening pain, hyperalgesia, allodynia and myoclonus, which is su sudden involuntary muscle twitching. Um So the guidelines um are that you should seek special specialist advice and also consider reducing the dose by 30 to 50%. But you can also consider uh opioid switch uh using nsaids and or adjuvants. I hope that makes sense. Was there any questions for the previous scenario? OK. Then, so we're gonna move on to case two. So this is covering fluids and electrolyte imbalances, which was our um one of our sessions um as part of the series. So a 12 year old boy is admitted to the pediatrics ward and is being treated for acute exacerbation of asthma. So he has a past medical history. He's got asthma. Um he for which he takes his albuterol inhaler. He has no known drug allergies. Uh he weighs 40 kg. Um and on examination, his stress rate is 12. His stats are 99% on room air. His temperature is 36.5 and his BP is 100 and 30/80 heart rate. 80 heart has one or two present. Um, he's got a um, but it's improving as he's been treated for his asthma. So in terms of his investigations, um, they are all within normal range. Um, so the question is calculate the 24 hour maintenance, fluid volume requirements for this patient. And I'll release the question into the pool. So please do want to. Mhm. Give me a few more seconds to respond. Uh, if you don't need to support, you can just put that into the chat as well. Ok, so you've got one response for b 1800 any other responses? Ok, give me a few more seconds. Ok, so far 1800 to 1000 800 mL is the most popular one. so the a the answer is actually seen which is uh, so 1000 900 mL over 24 hours. Um but I'll explain it in the next slide. Um So when calculating fluid requirements for Children uh over the over one month, what we use is we'd use this holiday uh sugar formula. Um And so, um I'll just show you the work out in the next slide. So um essentially for the 1st 10 kg, you would uh do 10 kg times 100 mL, which is 1000 millimeters. Then the next 10 kg, you would do 10 kg times 50 mL, which is 500 M and for the remaining weight, which in this case is 20 kg, you do 20 kg times 20 mL which is 400 mL. So the total fluid maintenance requirement for this child is 1900 mL over a 24 hour period. Does that make sense? Is there any questions? Ok. So we can move on to the next case then. Um So this is also improves in electrolyte imbalances. Um So a 39 year old man is being treated in the trauma and orthopedics department for major trauma. He's otherwise fit and well, he, he has no known past medical conditions. He's not currently on any medications and he has no known drug allergies. During admission, he suddenly develops chest pain and an ECG is conducted which shows tall tented T waves and widened P waves. Uh So on examination of his Respi rate is 12. He sat on 99% of room air. His temperature is 36.5 and his BP is 100 and 40/70 heart rate is 100 heart sounds 1 O2 present with no added heart sounds and his chest is clear. So in terms of his investigations, they're all normal except his potassium uh which is 6.6. So it's very raised. Uh So he has been given um calcium gluconate, 10% IV, 30 mL for hyperkalemia already. So the question is what IV infusion, should he be prescribed to shift potassium into the cells? So I'm just gonna start the before give you a few seconds to answer. OK. Any suggestions? OK. Right. In the chart as well. OK. So the answer is e so insulin glucose IV infusion. The reason why it's not a is because calcium chloride has the same uh role as calcium gluconate in that it protects the heart and has really been given calcium gluconate. Um It's not B or C because um glucose, 10% IV uh 100 and 50 to 200 mL and uh glucose, 20% IV, 75 to 100 mL. Um either all are used in hyperglycemia and it's not D because D is used in severe hypercalcemia. So the correct answer is D um So this is just showing you uh some guidelines which um I don't know if you can make it out but essentially it says you would give um insulin glucose IV infusion. Um So please use your local policy um in terms of how much of insulin and glucose to use. For example, in my local policy, it says to give 10 units soluble insulin in 50 mL, 50% glucose over 15 to 30 minutes. So it will differ depending on your local trust. So always make sure to use your local trust guidelines. OK. So any questions for the previous case? OK. So we're gonna move on to case four. and this will be covering antibiotics and blood transfusions. Um So a 30 year old female presents to ae with dysuria, painful periods and green vaginal discharge. Uh she's not pregnant. She's referred to the OBGYN team. They review her a note on uh vaginal examination. She's got inflamed cervix and green vaginal discharge. It's also noted they have taken uh vaginal swabs and uh her bloods which show that her inflammatory markers are raised. They ask you to start her on antibiotics for pelvic inflammatory disease. So which antibiotics would you prescribe for her pelvic inflammatory disease? Just gonna start the pull. I'll give you a few seconds to answer this question. OK. OK. So far the most popular option is C Doxycycline and metroNIDAZOLE. Any other suggestions? Ok. So, so far C is the most popular. So the answer is a, so A is uh Doxycycline 100 mg BD for 14 days. Me and me for 400 mg BD for 14 days and the one of dose of cefTRIAXone, 1 g im So, the key thing to know about this scenario is that she's not pregnant uh because doxycycline can't be given to pregnant women as per the BN. Um uh They mentioned that in the first trimester, annual studies, it affects uh scal development and the 2nd and 3rd trimester, it may cause discoloration of the child's teeth and in at large doses, it can also cause maternal uh hepatotoxicity. Um So B is not correct because B is used for hepatic encephalopathy and it's not C because Doxycycline and metroNIDAZOLE um are used in uh patients with ani animal bites when the patient is panallergic. And it's not d because uh amoxicillin, crocin and omeprazole is triple therapy for H pylori and it's not vancomycin uh because it's used for CDF cil infection. OK. So this is just showing you again uh the B NF guidelines showing it's Doxy Doxycycline, metroNIDAZOLE and CEF and one of CEF Trioxone or P ID. That's for 14 days. I hope that makes sense. Was there any question for the previous case before we move on to case five? OK. So case five, this uh is recovering antibiotics from blood transfusions. So, a 54 year old man presents to A&E with major gi bleeding. He's been transfused red cells and he has been investigated by the gastroenterology team for his gi bleeding and he tell his past medical history is called atrial fibrillation. Uh He's currently taking Warfarin and Bris. Um And he's got no known drug allergies. Uh In the meanwhile, you've been asked to manage his warfarin prescription, considering his major bleeding. Uh So the question is, how should he manage his warfarin prescription during his major bleeding? So just release the pull into the chest, give me a few seconds, any suggestions for this question, you can put it into the chat, you answer as well or you can use the call. OK? So we'll give it a few more seconds. Ok? So, so far the most popular option is uh a stop warfarin, give uh Vitamin K IV injection and then give tried uh prothrombin complex. OK? And this is the correct answer. Uh So this is just showing uh the nice guidelines. So you, when you go into the treatment summary and you go into the oral anticoagulants section, there's a sec uh section on hemorrhage. Um So it says in the case of major bleeding, you would stop Warfarin, you would give uh Vitamin K by slow IV injection. And you'd also give a dry prothrombin complex which contains factors 279 and 10. And it also gives you guidelines on what to do um I in minor bleeding, if there's no bleeding and depending on I nr levels as well, I hope that makes sense. So any questions on the previous case? OK. So case six will be covering prescribing and pre op. Um, so a 58 year old female is scheduled for a left knee replacement in six weeks. In terms of her past medical history, she's been diagnosed with osteoarthritis. Uh, and she, she takes, uh, the H RT, uh, she's got no known drug allergies. So the question is prior to her surgery, how would you manage her H RT prescription? So I'll release, uh, the pole into the top. Give me a few seconds to answer the call or you can put your answer in the chat, any suggestions? Ok. Give you a few more seconds. Ok. So the answer is b so you would stop H RT four weeks before surgery. So this is from um, the E NF from the treatment summary in the sex hormone section. Um So it says, uh for major surgery under general anesthesia including orthopedic surgery, um, because of the risk of VT E, uh you would need to stop H RT 4 to 6 weeks prior to surgery and you'd only restart it, uh, after full mobilization. Ok. So any questions for the previous case? Ok. So we're gonna move on to case seven and this will be covering uh diabetes medication. Um, so a 61 year old female is scheduled for an elective inguinal hernia repair tomorrow morning. So she's diagnosed with type two diabetes for which she takes aglypt 5 mg once daily and she's got no known drug allergies. Um, so the question is, how will you manage her linaGLIPtin prescription on the morning of her surgery? Um, will you admit it the day before surgery will reduce the dose by 20%? Will you emit it on the morning of the surgery? Will you continue as normal or will you em emit on the morning of the surgery and the following 24 hours? Um, after, uh, so I'm just gonna release this, the go into the shop. They so far have the option to continue as normal. Any other suggestions? Ok. So the most popular option is to continue as normal. And that is the correct option. So this is just uh guidelines from the Center for Perioperative Care. And it shows that in the case of Gliptin and other DPP four inhibitors, you would take it as normal. So you take it as normal um throughout the whole perioperative period, the day prior to admission. If the patient has an AM surgery, if the patient has APM surgery, it doesn't matter. You would take it as normal uh throughout the whole perioperative period. I hope that makes sense. Any questions for the previous case. Ok. So we'll move on to case eight, which will be covering surgical emergencies. Part one. So 50 year old male presents to A&E with inability to urinate for the past few hours and he's in a lot of pain. He also has urinary frequency um and urgency. Um So he he has very frequent urgency. Um In the past, uh he's been given painkillers in terms of his abdominal examination. He's got suprapubic pain and palpable distended bladder. Uh ad re examination has been done which shows enlarged prostate and the bladder scan shows that there's 800 mL of urine in his bladder. You suspect he has acute retention secondary to BPH, uh which is benign prostatic hyperplasia. So, the question is how you uh manage his acute retention secondary to benign prostatic hyperplasia. Uh So I'm just gonna release the call into the chart. I'll give you a few seconds to respond. So, so far, the most uh popular option is a catheterized and prescribed tamsulosin, 4400 mcg per hour once daily. Any other suggestions? Ok. So far, um the most uh probably option is option A which is the correct answer. Um So A is correct. B is, is it, it's not correct? So you can't wait, you need to treat his acute retention and it's not c because you wouldn't just catheterize, you'd also need to give the um tamsulosin because it's secondary to DVH. Um it's not d because uh phenoxymethylpenicillin is used for um acute sore throat and it's not fluoxil because it's used for soft tissue infections like cellulitis. Um You need to check your local uh trust guidelines uh as to catheterize patients. So it tends to be when the blood scan shows a volume of 300 to 400 mL plus. Uh but uh some consultants may consider catheterizing at a lower volume if the patient is in a lot of pain, if this is bacterin retention. Um and it depends on like a case by case basis. What's the cause of past medical history, et cetera? So please do make sure to use your vocal class guidelines. Uh So this is just showing you um nice guidelines saying that acute urine is a medical emergency. Um And you would catheterize and also uh before the f is removed, you'd give an alpha adrenoreceptor blocker. An example of which is tamsulosin and the dose of tamsulosin would be 400 mcg once daily. So make sure to give micrograms, not milligrams. Um Yup, any questions for the previous case? Ok. So case nine is covering surgical emergencies. Part two. So a 52 year old man is admitted to A&E with severe bone pain in his fibula. He reports having a fever and recently having surgery for a fibular fracture. He has his past medical history. It's called type two diabetes for which he takes Metformin five 100 mg BD and he's got no known drug allergies. He's referred to orthopedics who have conducted an X ray taken tissue M CMS as in microscopy and uh culture and sensitivity and have started him on flucloxacillin 2 g psi V for Osteomyelitis. The nurse reports that he appears unwell and you are to see him. So his respirate is 16 which is high. Um He, he starts the 98% on room air. Uh His temperature is 38 for fever. His BP is 100/70. So he's hypertensive and his heart rate is 100 and 36. He's, he's tachycardic. His chest is clear. Um His urine dip is clear and his cap refill is three seconds. So the question is, how would you manage him? Currently, I just release the pole into the top. Give you a few seconds to answer the question. So, so far, the most popular option is C which is take buds, including blood cultures and lactate, catheterized and give IV pills and IV antibiotics. Any other suggestions. Does anyone have any other suggestions? You can put it into the T as well? OK. So far C is the most popular option, which is correct. Um So this patient has set the second dose of osteomyelitis. So it's not A or B because uh he doesn't require oxygen because he's maintaining his saturation on room air and it's not D or E because it's not uh D or E, they're not uh complete answers. Um It's C because it includes um everything. So he set for six except for oxygen, which he doesn't require. Um So this is just showing you um the sepsis action tool from the sepsis trust. Um So essentially shows you kind of number flag criteria, red flag criteria and it lets you know to start the sepsis six pathway. So in terms of sepsis six, it's give three, take 32, you would take uh lactate and, and give oxygen if required, you would take blood culture and give antibiotics. You take uh urine output or you'd catheterize by catheterizing them and you would give uh IV fluids. So I hope that makes sense any questions for the previous case? Ok. So we're gonna move on to case 10. And so this covers a general surgery, colorectal and neurology. Um So we had a session on this and this case will cover urology. So a 33 year old pregnant woman is admitted to hospital and managed for poorly controlled hypothyroidism. She has a inserted during her admission before urinary retention you off to see her and she reports having diphtheria and a foul urine. She's not so unwell and she's able to tolerate oral medication. So it does have past medical history. She's got hypothyroidism for which she takes hemo and she's got no known drug allergies. Her catheter has changed and the consultant wants you to prescribe her antibiotics. So the question is, which antibiotics would you prescribe for her catheter associated uti? So I just release the pole into the chest. I'll give you a few ques uh seconds to answer this question. OK. So far the most popular option is B which is Cephalexin, uh 500 mg 2 to 3 times a day for 7 to 10 day. Um Any other suggestions you can put your answer in the chat as well. OK. So, so far the it's the most uh popular answer, which is correct. So, Cephalexin 500 mg 2 to 3 times a day for 7 to 10 days. So the reason why it's not uh Pillin now, uh hydrochloride, 400 mg, um initial dose than 200 mg is because this is second line for uti in nonpregnant women. And you'd only use it if there's no improvement after at least 48 hours or if the first line option is not suitable. And the reason why it's not CNI to uh 15 mg. Uh Q DS is because um it's not used in catheter associated uti uh in pregnant women, but you can use it in ca catheter associated uti in nonpregnant women uh or men. Um And it's not d because Fosphomycin 3 g per or single dose is second line for uti in nonpregnant women. Uh Again, if there's no improvement after at least 48 hours or the first line is not suitable. Um And the reason why it's not e uh reflexin 200 mg BD is because this is used in epididymo oitis. Uh And this is just showing you again in cat associated uti you'd use cephalexin and the dose for adults would be 500 mg 2 to 3 times a day for 7 to 10 days. It can be increased if necessary to 1 to 1.5 g, 3 to 4 times a day. Uh increased doses are used in severe infections if that makes sense. So any questions for the previous case? Two. Ok. So this is our last case for today. Um and this is covering uh the content for last week's session. So last week's session was on TN ENT and pediatrics. So this will be covering ent and pediatrics. And so the case is, um, a, a three year old boy presents to A&E with right ear pain and a fever. His mom reports that he's been feeling uh generally unwell. He's got, uh he's not been diagnosed with any medical condition. He's not currently taking any medications and he's got no known drug allergies. He weighs and he weighs 12 g kg. So in terms of the otoscopy findings, he's got a bulging red inflamed tympanic membrane and he's got no perforation. He's diagnosed with otitis media and you're asked to start him on antibiotics. Uh So the question is, uh which antibiotics were you prescribe for his Otitis media? And I released the last pole of the day into the chat and I'll give you a few seconds to it. So, ok, so far our most popular option is um bean which is co amox 250 slash 100 and 25 mg per all T DS for 5 to 7 days. Uh Any other options, any other suggestions for this question? It can also be answered in the chat as well. OK. So, so uh so the most popular answer is B uh 250 slash 100 and 25 mg per oral T DS for 5 to 7 days. Um The correct answer is A which is amoxicillin, 2 50 mg T DS for 5 to 7 days. So the reason why it's uh A is because A is the first sign in otitis media. If the patient's not penitent allergic, the reason why it's not B is because um tamoxifen is used as second line for Otitis media in Children who are not penicil allergic. So you would only use this if they have worsening symptoms despite being on 2 to 3 days of antibacterial treatment. Whereas in his case, we are, we're just start you on the treatment. Now. Um It's not c because uh Clathromycin is used as first life for, for Otitis Media in Children who are penicillin allergic. Um And you need to dose it according to the age and weight. So because he's three years old and he weighs 12 kg, you would give him a dose of 100 and 25 mg BD for 5 to 7 days. Um And it's not D because flucloxacillin 100 and 25 to 250 mg Q DS is used for Otitis external if there is no penicin an allergy. Um and it's not to eat because cefTRIAXone, 1.2 g per or once daily is used for meningitis. And this is the dose you would give um to him because he weighs up to 50 kg and he's one month to 11 years old. I hope that makes sense. Um So this is just showing you that in the case of otitis media, first line in a patient in a child that's not penicin aller allergic is amoxicillin. And because he's uh three years old, he used to give a dose of 250 mg three times a day for 5 to 7 days. And this would be uh by mouth. OK. I hope that makes sense. Is there any uh questions for this case? Ok. Um So these are my references uh and this is just a feedback form that I'll be releasing into the chart. Um And this will just uh help us know uh what we've done well, how we can improve um how beneficial you found this talk. And it will also allow you to have a certificate for your attendance. Um So as I mentioned, this is our final um our final lecture in our temp parts, uh prescribing a surgery series as part of the mind, the police organization. Um So thank you very much for attending um our sessions. I hope you found them useful. Um If you didn't manage to attend any of our sessions or if you'd like to perhaps go through the lectures again, go through the slides, we will, we would have um already uploaded um the powerpoint slides and the uh recordings on the metal platform. I also be um uploaded these uh slides um and the recording of today's session as well. So hopefully, you can go through it at your own pace and you can revisit it as many times as you want. Um As I mentioned earlier, um hopefully, our colleagues as part of the mind the bleep organization over the next couple months, we will also be creating a similar series where we'll go through prescribing in medicine. So thank you very much for attending today's session. II, hope you found it uh useful. Um And, and thank you again for me uh from doctor her Gemma and Doctor Sonia Trosia uh as part of the prescribing uh team. Thank you.