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Perfect. Sorry about that. Sorry about that guys. Um So welcome to prepare for practice. Um My name is Katie. I'm an F one in Musgrove Park Hospital. Um I'm with, hi, I'm Karen. I'm one of the F ones in Musgrove as well in Taunton. Uh I'm Jake another F one at Musgrove. Perfect. So, um today we're going to be covering prescribing. Um just a bit about us, we all work kind of different jobs. I just started a geriatrics job. Um We work at quite a busy D GH um Yeah, if anyone's coming, it's a great hospital to work at. Um So we'll go over kind of some of the basics today. Oh, let me change slides. So we'll go over a few things. So firstly run through safe prescribing. Some of this might seem like things, you know, already, especially if you've done your psa um I think the point of the session for our point of view and I think what you guys would get the most out of is just imagine you the f one kind of prescribing from the perspective of the fifth year is quite different to when you get to the actual thing. A lot of the time, you know, f one you're the big prescribers. Um We'd say get a piece of paper, write down as you go along. Um So we're gonna cover a few things as I've popped up above. Um Yeah, a few scenarios. So principles. Um So we're going through a systematic approach to how you prescribe. So that would be firstly, um checking the patient's identity sounds really obvious, but you're prescribing a lot, you're prescribing quickly, it's easy to make mistakes. Um check the allergies, check for indications, contraindications, a lot of the time you'll be bleeped, you'll say, can you prescribe this for a patient? And you think, why am I actually doing that? Take a minute to kind of stop and reflect on that? Um And then for each prescription kind of cover the name of it, the dose of it, the route, um start dates, review dates that's particularly important for antibiotics. Um Think about again if it's a regular medication or APR N um and then kind of as below um trying to think of anything else. Our signature and bleep is really important so people can contact you. Perfect. So um just to go over a few more things, so make sure it's legible capitals, help with that, make sure it's um a generic name. So try not to use brand names. It can be tempting because they're quicker um and just try and make it as clear as possible. So make sure you're not using abbreviations. Um, and it's a bit kind of we say unambiguous. So try and if you know your handwriting's bad, make sure it doesn't like another drug name, an exception to the, um, brand name would be Insulin where they do want brand names. So just bear that in mind. All right. So, um, I'm gonna talk you through some common prescriptions that you'll most likely be having to do as an F one. And I think it's really good to know kind of the go to ones that you're gonna be using for almost any patient that will come into the hospital. Um, so we're just gonna go for a scenario to kind of imagine this more in a real life situation. So, um, this is a 57 year old lady, for example, who's come for abdo pain, very common, especially if you're doing a surgical job. Um, they come with one day history of Colicky left flank pain where their groin with also nausea and vomiting. Otherwise no other symptoms past medical history of hypertension type two diabetes. Um, on examination, her obs are most seem completely fine, slightly hypertensive heart rate, slightly, slightly tacky as well. Um, but I always fairly stable apart from the pain. Um, so she's still got that left leg tenderness as you do examine her. And then, um, on the investigations, you find that she's got a Ureteric stone as you probably expect from the presentation. Um, so just to think about this presentation, um, does anyone want to put in the chart? Some kind of simple prescriptions that you probably want to do to help this patient out or if you're admitting this patient, just some things you'd want to do for any admitting patient. Really, I'll just give you a few, a few moments for that. Uh, so this patient has so they're struggling with severe pain and they also have nausea and vomiting. So I guess to get on top of that for any patient presenting with that. Exactly, you'd want to get some analgesia and, um, some antiemetics probably as well. And then this patient might not need to be admitted. But if they were to be admitted, they, um, would need their regular medications as well. So you'd have to make sure those are all up to date. Cos you wouldn't want them to miss any doses. A lot of patients don't bring their regular medications in with them to hospital. So they probably need to be requested from pharmacy as well, all of which can take some time. And then if this is a potential surgical patient as well, it's always good to think about BT profile access. Um, or knowing what the kind of anti, um, coagulation is that they normally have anyway. Um, so just to go through the first one of these things. So, patient, regular medications, um, there's a few places you can find these, um, patients quite often you'll find, will have a long list of medications and they will not know a single one of their names. Um, so a good way to find those out is, um, always ask a patient if they have their prescription with them. A lot of patients. When they know they're coming into the hospital, they will bring their most recent GP prescription. That's really good. So, uh, source to use, um, a lot of trusts will provide you access with um, the GP records as well for patients. So you can often find a list of them on there with their NHS number and then a really good place to look as well. Um, they're not always up to date as previous TT OS, um, will, will have all of their drugs that they got discharged with most recently. So especially if someone's been in the hospital recently, that would be really useful. Um So some drugs that are probably more, um important to prescribe would be, well, all of them are important, but more you won't be more prompt with them would be things like, um, diabetes medications, especially for patients on insulin. You wouldn't really want them to miss any insulin doses that they'd have with their meals, any Parkinson's medications, any anti epileptics, any antipsychotics, immunosuppressants, not so much as an fy, you don't often prescribe those. But um, and then anticoagulation as well. It's very important. We don't want them to miss that dose. And then, so moving on in this scenario, this patient's got the flank pain. So, um for that analgesia, you'd want to as I'm sure you guys would know if you've probably already done the PSA the who pain ladder. So, starting off with paracetamol, adding in nsaids such as Ibuprofen and then going on to potentially codeine or traMADol and then potentially thinking about stronger opiates such as Oramorph oxyCODONE. Um So I actually find this slide really, really helpful during my F one, I use it almost every day. Um It can depend on the trust, the exact doses. But II don't think you'd go too wrong if you use these um especially for surgical patients, you almost always will prescribe them some form of either orum or for oxyCODONE and knowing kind of which G FR is for which one is really helpful. And also it's so age dependent for the dose, it's actually gonna be helpful for them. So knowing that as well is really, is really good. So I just really recommend using these um or some form of this child or especially in your first shadowing week as an F one, just finding out from the F one, what kind of other charts to use for pain relief for these patients. Um So then moving on to the next one. So again, with this patient, they were having they suffering with nausea, they were vomiting, you wanna try and get on top of that, of an antiemetic. So, um, there's, I think it's really important, er, and it's something I wish I knew a bit more going into F one was knowing a bit more about antiemetics, especially kind of the go to that you're gonna be using almost every day. So, Ondansetron is a really, really common one that I think is probably the one I go to the most and, um, it's a really helpful one, you can give it three times a day using most different routes. And um it's really important especially for POSTOP patients. So again, if you have a surgery job, you'll be using a lot of, you're prescribing a lot of Ondansetron and the dose for that is 4 to 8 mg. You can put the range there as well in the form, which is useful to know. So they, the nurse can always space it off of how nauseous or what the patient would prefer. Um And then another one that you might use or is important to know about cyclizine. I think that's also another one that's very common. Um, something to be aware of about with cyclizine though is that it is, it can cause a euphoric side effects. So it can be quite addictive for patients. So often it's not the first go to unless it does have those specific indications of being vertigo associated or associated with motion nausea and vomiting. And then you've got some like um metoclopramide, another really um useful one to know about. And then also there's a few others on here that you might use in palliative care. Um such as Haloperidol in small doses can be used in palliative and then also leave a prema predniSONE le aromasine, leave him a premazine. That's the one, sorry, it's not on the chart. That one's um I think almost the first one you go to in palliative care as well, which is I wanted to know about. And then obviously, we're giving all these patients a lot of opiates. We're giving these patients Ondansetron, both of which are very constipating. It's important to prescribe laxatives when you're prescribing these for patients. So the most commentary that I find myself prescribing almost every, for every patient with opiates, um uh Laxido and Senna. So Laxido and Macrogol Movicol is also fine. Um And those doses are really useful to know that a lot of um trusts actually have when they're prescribing. If it's electronic prescribing, they'll have almost P RN packs or order sets. So they'll have laxatives already prescribed in groups with the doses that's very helpful to go to. And again, in your first week of shadowing, it's really important to just check. Do you have this in your system? Cos it will save you a lot of time. Um But yeah, those are the two I most commonly use. And then obviously you've got things like Glycerol suppositories and phosphate enemas um for patients that they have more of a lower fecal impaction. So then um the last thing I'm gonna cover for this scenario. So again, we're thinking about admitting a patient, every single trust will have a different VT e performer that you're gonna want to fill out that every patient will need it done if they're being admitted. And um you just have to go through to assess their risk really for whether they would need something like an oxy. And um some of the things you'd want to consider were, is this patient gonna be having a reduced mobility whilst they're in hospital? Is this patient gonna be staying for quite a long time in hospital? So I think in a lot of performance, it's over three days. And is this patient gonna be likely to have surgery or is already a POSTOP patient? All of which can increase their risk um for, for needing VT prophylaxis and then on these forms, they'll also have a bleeding resection as well. Um which you can see on the chart, it's also really important to be aware of which anti of checking if patients are already on anticoagulation. So, um if they're already taking Apixaban BD and you don't need to stop that for any reason, you don't need to then give them an oxy and prophylactically on top of that. And there's often a part on the performer to note that down and just to go over a bit about um, dosing specifically OXY cos that's what we use in our trust. And I think a lot of other trusts is um, the most common one you're gonna be prescribing is 40 mg once every evening for almost every patient unless they do have um quite poor kidney function or have a very low weight. Um, so again, this trust guideline will be different depending on where you're working. And, um, but I would say that's the most important one to know the prophylactic dose. And then for actually treating something like a pe, for example, it'll differ again, but it can be between 1.5 mg per kilogram that you might be prescribing, that'll be a once daily dose or you could do a one, a one meg per kilogram dose, which would be BD and it depends on where you're working. Cool. So, um moving on to another scenario guys. Um So Missus Davis, so she's a 79 year old woman that's come in to Ed with a fever and shortness of breath. Um So a bit of a history, she's got a five day history of the above um cough with green sputum. Uh She's recently started on some Erythromycin by her GP. Um and she's got no other gi symptoms or urinary symptoms. Um This is a bit about her past medical history. So she's got hypertension, osteoarthritis, af aortic stenosis and of no a mechanical heart valve. Um social history she lives alone and she is a nonsmoker and she doesn't drink alcohol. Um So you examine her, she's using a four, so she's a bit tachypneic, needing a bit of oxygen. Um, and she's a bit tachycardic and febrile. Uh other than that, she appears clinically stable. Um, you examine her and she's got an irregular pulse. So we know she's got af good volume, heart rate, audible mechanical valve. Um but otherwise her heart sounds are normal. She's got right basal PPIs, but good air entry. Her abdomen is fine and her calves are soft, non tender. Um you do some bloods for her. So she's got raised inflammatory markers, but her renal function looks all right. And then you check her clotting um because I'm thinking about the mechanical heart valve and that shows that her inr is greater than 10. Um and her chest X ray shows right lower lobe consolidation. So can anyone put in the chart just thinking about her inr kind of why that might be, I'll give you a few moments. Ok. Or any reason why her inr would be high? Anyone have any ideas? Don't worry. If not, that's fine. Yeah, someone said antibiotics. So we noticed from the history that she's on Erythromycin prescribed by her GP. Um And Erythromycin is one of the number of medications that interact with Warfarin. Um And does anyone know kind of from the scenario? Why have I presumed that she's on Warfarin? She's got quite a clear indication why she'd need to be on that. Yeah, exactly. So she's on a mechanical heart valve on a me has a mechanical heart valve. Um af, yeah. So obviously if you're thinking about af thinking about anticoagulation, often we found find now that a lot of our patients are on Dox. Um and we're just gonna go on to speak a bit more about warfarin and anticoagulation as a whole. Um So make sure you're really careful about prescribing anticorrelation and you clarify what dose they're on. Um It's one of those things that if they are on it for things like af mechanical heart valve, if they, you know, are not bleeding or have any contraindications, you want to be prescribing it quite promptly. Um It's common particularly when your clar is NF one that you'll see people coming in with things like um falls or fails, possible head injury, um upper gi bleed hematuria and in general, I think is an F one would tend to be quite cautious about holding um their Apixaban or the Raban or whatever anticoagulant they might be on. Um You know, you can always review it with a senior, I would say, but if you are on clerking and you're worried about the possibility of bleeding, you know, it's always best to just hold it to begin with. Um And then kind of phrase it with your senior. Um Yeah, we talked about so sort of contraindications as I've said, um, make sure that you're monitoring that clotting and check what your hospital's local kind of guidelines are. So, in Musgrove where we work, it's quite irritating. We don't have finger prick inr. So every time you want to check someone's in r you need to send off a full clotting tube, um, which I think is done because it's more accurate, but it does mean, you know, it can be quite kind of difficult sometimes you have patients that are difficult to bleed and you end up just having to regular, regularly monitor their inr particularly if you're bridging them or restarting their warfarin and that kind of thing. Um And always review whether anticoagulation is in their best interest. So I just started a job, we have a lot of patients coming in with falls, they would have been started on um a DOAC kind of in, you know, a few years ago for af and it's, it's always best to kind of, you know, consider actually sort of is this, you know, it's a benefit risk situation, there's always that increase of bleeding that you need to be counseling patients on. Um And I think particularly, you know, with older frailer patients, it's a conversation that's kind of worth having. Um you know, you know, speak to your consultant, you read first, but kind of go from there. Um And just think, do they still have a clear indication for this? Obviously in this case with the lady's mechanical heart valve. She does. Um So a bit about Warfarin. So we don't see that many patients on Warfarin anymore as I'm sure you've noticed. Um that means when you do see them, it's often, you know, something that we're less familiar with. Um and it's worth kind of familiarizing yourself when you start f one particularly in your shadowing period. Um Just have a look. How does your trust prescribe? Warfarin? It's different, different places, do it a bit differently. So we have electronic prescribing, but some things like Warfarin insulin is still on paper charts. So when you do start try and find out where all of this stuff is because it comes up and, you know, it's always a a, I don't know, time overnight or some sometime when you don't know where it might be. So it's one of those things that's worth finding out about early on. Um Generally there's kind of different target inr s often you'll see people on the kind of 2 to 3. Um In this case, this lady um she has a mechanical heart valve. So we generally say, I think 3 to 4. So 3.5 would be her target Inr. Um And as we've kind of touched upon already, Warfarin is what we know, it's a bit of a dirty drug. So it interacts with a lot of different things, which is part of the reason why we don't like it. And we're switching patients over. Um So in this case, she's on Erythromycin. So that will be why her inr has probably so up to, to 10. Um So just be aware of that if you are prescribing new medications to a patient that's on Warfarin, um then think about, could they be impacting on the IR at all? Ok, so a bit about warfarin dosing as well. Um So in general, as an F one, you're kind of unlikely to be starting patients on warfarin, although it does occasionally happen um in, you know, what you're most likely to be doing is kind of um holding their warfarin and having to restart them on it. And that's often kind of perioperatively, you'll find that the warfarin dose, you know, they might need it held. Um There are kind of should be clear guidelines. So definitely familiarize yourself early on with your trust, local guidelines. Um The BNF also has some good guidelines about warfarin dosing and management of high inr that we'll touch upon in a minute. Um So you can see on this chart if we look at the kind of maintenance dose adjustments, um it shows you, you know, just kind of follow that really. And then when that in a gets over five, that's when you're thinking about, you know, further management um of the over anticoagulation. Um essentially, and as an F one, you know, you can follow this chart um if they're not kind of bleeding acutely and you just found that, that inr isn't in range by all means, you know, adjust it and just document it as you go. Um, it's often good to speak to patients when you're adjusting their warfarin. You know, it is good practice anyway to inform people when you're changing their medications, but particularly Warfarin, you'll find that these patients have often been on it for years and years and years and they've not been switched to a DOAC and they become quite familiar with it, you know, they know the doses they're on, they know what's going to impact their inr and that kind of thing. Um So just check with the patient, you know, if you're unsure of the dose that they were on before they came in, clarify it with them, find out why they were on it and that sort of thing. Um early on any questions, sorry, I should have said so far about Warfarin. Perfect. So Warfarin reversal, um there's pretty good guidelines on this, you know, this is one that I definitely make a note of it. It's pretty standard in terms of what you do, as I mentioned earlier. The BNF has a really good table that looks similar to this. Um So in our case, this lady's RNR was 10, but we weren't worried about her um acutely bleeding. So that's going to put her in kind of this middle box. Um So we want to obviously stop her warfarin give her some Vitamin K So in this case, it's orally um and recheck her Inr and then she might need further doses of Vitamin K And then when that Inr is back down in rate, you know, below five, getting close to range, that's when you're thinking about restarting it. So you'd want to go back to that table beforehand um for some patients and this is kind of why it's important to find out why they are on the Warfarin to begin with. You might need to think about things like bridging with Clexane, which I would say even as an F one now, I still feel a bit unsure of sometimes. Um but sometimes particularly in surgical patients, it becomes more relevant. Um So if you're worried about that by all means, you know, discuss it with seniors, I say if you're ever unsure it, it seems. And at first when someone told me to do this, it was a bit like, oh really? But just speak to hematology if you're not sure. And often, you know, we have bridging guidelines, but they're sort of very hard to find very deep than the internet. So if you're not sure to begin with, you can just give him a call. Um and they often don't mind answering a very quick question when you get kind of over um inrs of eight and you're worried about bleeding along the side. So particularly major bleeding, this is, you know, not something that you'd be managing on your own as an F one, but that's when you start thinking about, um, kind of further blood blood products. So, you know, um, prothrombin complex and that kind of thing and you'd obviously very much not be on your own as an one at this point and have escalated to your senior and ultimately hematology. Ok. Um, so I'm gonna talk about the final scenario this evening, which is, um, about a chap. He's 67 years old, admitted to ed with fevers and low abdominal pain, two day history of the symptoms, just feeling generally awful. Um, no chest or gi tract symptoms, background of hypertension. Um B ph with a long term catheter in situ while he's awaiting to procedure. Um, he lives with his wife, a nonsmoker, no alcohol. Um, on review, he's using a six, he's tachypneic, tachycardic hypotensive and confused and febrile. Um, and based on that, um, unsurprisingly appears clinically unwell, feels hot and clammy, regular pulse, but thready with a tachycardia, clear chest, soft abdomen, but suprapubicly tender with guarding not peritonitic has bowel sounds with the catheter in situ and you can see there's visible pus and debris, um, in the catheter tubing with low urine output. Um, the investigations for this chap are there. So we've just done a set of bloods. Um, it shows he's got high crp um, a high white cell count. Um, and some of his electrolytes. Um, based on that scenario. There's a few things that I would want to prescribe. Um, we've covered already the, the need when you're larking these patients in either on the medical or surgical take, um, that you would need to do the regular medication and think about VT prophylaxis and any analgesia. Um, there's probably three different types of drugs that I would want to prescribe in this case. Um, has anyone got any ideas about what I might be thinking based on that presentation alone? Just pop it in the chat fluids. Yeah. Good. This will be you in four months time on a surgical take. Um, so some ideas. Yeah. So IV fluids. Uh, there's one of my three that I would want to prescribe. Um IV paracetamol. That's another one. So, something for the fever. Um, and there's one more thing that I'm thinking of based on the, the obs and the presentation at the moment. Yeah. Probably uti antibiotics. Exactly. Um, so we've got all three there that I was thinking of. So, um, the first thing that I would be thinking about would be antibiotics for this chap. He has come in, he's febrile. He looks unwell. We've got a clear source of infection with pus and debris in the catheter. Um, and we've kind of ruled out initially other areas of infection such as a chest infection or things like cellulitis. So, it all points towards, um, a urine infection and given his obs, um, he's using a six, he's actually triggering the kind of quite a few sepsis markers. So he's hypotensive tachycardic febrile. Um So this would be a urosepsis until proven otherwise. And given that he's got a long term catheter likely to be associated with a um his catheter. Um Every trust that you work in will have different microbiology guidance. Um And my top tip for your first couple of days, whatever job you start and whether that's a medical surgical, pediatric, whatever even a psych job is now where your um local antibiotic guidance is. So Musgrove uses micro guide. Um and if you've lots of trust use micro guide which comes as an app, you can get it on the computer as well. Some trusts have their own like internet based guidance, but that would be one of the first questions I'd be asking when you start your job. Um for our local guidance, we use some weird and wacky antibiotics for everything um with big lovers of Cotrimoxazole, which I'd never used or for or like seen you until I came here. Um But for eps specifically, our guidance is Cefuroxim and Gentamicin. So, Gentamicin is quite a common one for um urinary tract um kind of covering gram negative urinary tract infections. Um So you might find that quite commonly used. It comes with lots of um issues around monitoring and dosing and stuff. Um But I will let you figure that out often if you've got that as part of your trust formula. It will come as part of your micro guide app. Anyway, um, the key with antibiotics is if you're suspecting sepsis, you know, sepsis six, I'm not gonna teach you to suck eggs. But, um, what you need to do is make sure you've got the relevant samples before you start antibiotics. If you're suspecting a urosepsis, uti you need to get urine samples. If there's like kind of like visible pus, you need to try and get samples of that so they can try and culture it before you go in with the big stuff. Um Obviously, there's obvious evidence of infection here, antibiotic, stewardship and all of that. Um It's important that we're not just kind of treating blindly. We've got a, a working theory. Um But always don't, if you can't get these kind of cultures, if they can't pass urine, et cetera, don't let that delay, prescribing you antibiotics. Um And a really important reminder there in capitals is to check for allergies, um, and cross sensitivities as well, especially with penicillin allergies. Um There's a lot of work in our pharmacy at the moment to try and de label people with penicillin allergies because there are people with childhood rashes from 70 years ago, um, duration or stop date so often it's, if you're prescribing ivs, it's called the 70 72 hour mark is when you review whether ivs are still required. Um And if you're going for kind of a IV to all switch beyond that. It's normally five or seven day courses for most infections. Um And you can make decisions based on monitoring inflammatory markers and speak to micro. Always a lot of trust don't let F one speak to microbiology. So that may be a job for your sh os or regs. Um, but don't let that put you off if you're not sure if you need to escalate the antibiotics and it's always better to seek help. Um, someone in the chat mentioned IV fluids was really important. This chat. If I just go back to the original scenario, had a BP of, um, 98/62. So, can someone pop in the chat? Exactly the prescription? They would prescribe. So, type out as if you were writing on a drug chart or on the electronic system, um, the exact prescription that you would prescribe. So, what type of fluid, what route, um, over how long et cetera, et cetera for this gentleman. Don't worry if you're not sure. I feel like fluids is something you give it a go. Yeah. Give it a go. It's something that you're expected to do quite early on in F one. And if you, if you've done the PSA, you'll have a reasonable idea about what, what kind of thing you're giving. But then the PSA is one thing, but actually how you do it in real life is a lot different. We've got some very good answers coming in anyway. Um So people have gone for 500 meals of sodium chloride, saline IV. Um stat or over 15 minutes. Yeah, perfect. So your um fluids come, you need to prescribe, know how to prescribe fluids in kind of three different settings. Um Resuscitation fluids is the easiest um thing to remember. It's basically you give normal Saline or Hartmann's 500 mils IV and stat or over means the same thing over sort of 50 minutes. You're giving a bolus very quickly to try and uh, um, um, bump the BP back up. If they're elderly, they've got a history of heart failure or KD. You might be a bit more cautious and give 250 more boluses, which you can always give another 250 if they respond. Well, um, with fluid boluses, you can kind of keep giving 23 or four of them. But if they're not responding after that many, then you need to start thinking actually, maybe their BP is not fluid responsive. Um And if they are, have got an escalation plan, you might need to start thinking about things like itu for BP support, um, maintenance fluids is probably the second easiest type of fluids to prescribe. So that is generally you're prescribing bags of either normal Saline Hartman's or a 5% glucose IV over 8 to 10 hours. Um, some people will be near by mouth for operations. So you'll need to have a think about what the best maintenance fluids are. Um There's a lot of theory around fluids and calculating one mol of sodium potassium and chloride ions and 25 mils per kig um per day. And, but uh in real life, actually, a Hartmann bag over eight hours is often what people will do if someone is nil by mouth or a saline bag with added potassium um is the way it's done because they won't be requiring a full 24 hours maintenance fluids. They'll often only need it from midnight until the end of their operation, which might only be 12 hours. Um The hardest one unfortunately is replacement fluids. So for this, you need to rely on the nursing staff to complete fluid input, output charts accurately and kind of have a, a reasonable understanding of the patient's fluid status and what they're losing and what they're having in. And then you can work out what the deficit is um to replace what they've lost. If someone's having lots of vomiting, um if you can get a rough idea or if they've got an NG and they've got lots of output from their NG, you can get a rough idea of how much fluid they're losing and therefore how much you need to replace. Um So we said antibiotics, fluids and then someone mentioned paracetamol. So if someone's febrile, um most patients on their drug chart will have paracetamol written up anyway, but paracetamol is your antipyretic um of choice for most patients. And IV um if they've got no oral access or they're very unwell. Um The last thing for this case was to talk about electrolyte replacement. So the potassium in this chat was 3.2 on admission. Um So for someone that's got a potassium that's 2.5 to 3.5 generally you replace it orally with something like Sando K or K cli. Think this is guidance taken from it's not from our hospital but a different hospital in the region. Um It's very good. Um And every hospital will have guidance about refeeding bloods or electrolyte replacement. Um So for oral replacement of potassium, you use Sanaka, which is generally two sachets, no, sorry, two tablets. Um T es um they're not very nice. Um They're not as bad as the magnesium replacement tablets, which is like liquid chalk. Um potassium and magnesium are the two most important electrolytes to replace. So you replace those first and then you think about calcium, then phosphate. Um If your potassium level is below 2.5 you go for IV um thinking about your rules that you probably learned for the PSA where you can only give 10 millimoles of potassium um per hour. So if you're prescribing 0.3% potassium chloride, that's got to be over a minimum of four hours. Um Phosphate is largely replaced orally. Um and magnesium, if it's above naught 0.5. This is probably the easiest one to remember is oral magnesium aspartate, which is uh I think one sachet BD of aspartate and IV um is normally 20 millimoles over a few hours and you just have to be aware of cardiac arrhythmias. Some centers like you to have patients on cardiac monitoring um if that's available um that's the end of that case and um kind of at the end of the talk. So what, what are our takeaway messages that are key here? Um Is that prescribing? Is the bread and butter of your job? You will be the primary prescriber in whatever team you're working in, whether that's a medical job, a surgical job, a psych job, um pediatric job less. So, but you still need to be aware um and you need to make sure that you're a safe prescriber. You're checking who you're prescribing for paper charts, check everything, check the name, um check that it's the current chart that's being used, et cetera, electronic prescribing. You need to check that you're on the right patient every time you need to be checking allergies. Um You've all hopefully passed the PSA at this point as you um are heading towards F one. So being familiar with the common things that we talked about um fluids is really important anticoagulation. Um VT E, Donax, Warfarin Heparin and being familiar with your where to find information about prescribing locally for things like antibiotics, um for VT E and for um kind of electrolyte replacement as well. Is there anything you would add? From a summary point of view? Um We've not mentioned. So the other thing we've not mentioned is pharmacists. Um which you don't, I don't know, I just didn't really think about it much when I was a medical student. Um, but as soon as you're on the wards, you'll see pharmacists around. Um, and they're there to help you. It depends on how they like to operate. Sometimes they'll come and find you and, and give you a bit of a balling about your dodgy prescribing. Um Other times they'll just kind of scroll in the notes and slip away unnoticed. So if you do have questions about prescribing, particularly, you know, things like warfarin or any complicated things where you're a bit stuck on who to ask, you know. Yeah. You don't always feel like you can escalate it to an hr red or they might not know they are a fountain of knowledge. So don't be afraid to ask them and often they love talking to you about it and we'll talk your ear off about it a bit. So they're already useful and just if you prescribed something, make sure you let the nurses know, particularly if it's time sensitive. It happens so much. We prescribe antibiotics for a septic patient and you know, the nurses are busy. They're not just looking after that patient, you know, and they try their best but it, you know, our electronic system relies on them refreshing it and being at their computer all the time, you know, it's no one's fault that things do get delayed. So, just make sure they're aware, things like hyperkalemia management or if you're in VR S or DKA, that's the time critical stuff as well on top. Yeah. So, I think maybe when you're making your jobs list for the day, um, I know it's very easy to be like, oh, maybe prescribing could be left later. Cos it's quite a quick thing to do. But I think a lot of hospitals bear in mind. The pharmacy isn't open 24 hours and, um, if you want someone to have medication that day, if you don't prescribe it kind of early on, they have to be ordered and dispensed and that can take 4 to 5 hours. Um, so if you order something in prescribe something in the evening, it's very likely that patient's not gonna get it till the next day if the ward doesn't have it. So, just being aware of things like that and I think guidelines most important really find out where they are on like day one and just, um, something that's come to my head as well is about controlled drugs. So when we're discharging patients from hospital, um, some centers f ones can prescribe controlled drugs to go on att ot ta. Some centers can't, um, but just being aware that if you need to order things like morphine or oxyCODONE or gabapentin et cetera for patients to go home and do that early because it's a long process to get that dispensed from pharmacy. Yeah. Even if it's a regular medication. Yeah, if they've come in on it and they're staying on it, you'll probably still need to, you know, prescribe it and sign for it as you would a normal control drug. Um So that's the end of our session for this week. We'll pop the, uh, oh, we've got some more key learning points here. Whoops. Um We've kind of talked through these already, but the PSA hopefully you've all passed and you've got resources for if you haven't and you want more help. Um You let us know in the chat if there's any specific questions you've got. Now, um, the B NF and Micro guide will be your best friends for prescribing and in your last few weeks of placement, just try and get familiar with prescribing R CF one that you're shadowing if you can, you know, come up with a prescription and practice it because you will be doing that. And it's, although it's supported, you will be expected to be able to do it fairly confidently. Um So use your shadowing time as well as an F one, whatever you have to make sure that you understand the systems. Um This was prescribing part A. Um and there'll be a part B session in a week's time, um, which will cover things about end of life medication, renal prescribing. Um, I think there will be some bits on incident, potentially as well. Um, and be another group of doctors doing that for you. Um, we pop the feedback link in the chat if you wouldn't mind just taking a couple of minutes to fill that in. And if anyone's got any questions in the meantime, more than happy to um, answer them to the best of our ability. Even if it's not about prescribing, if there's anything else about the job that you want some advice on, um, quite happy to give you some honest advice. Thank you for listening. If not, you guys don't rush it once. So thanks Megan. And if anyone wants um, any of the like screenshots from the slides, if you want us to go back to any, you're happy to do that too. If you need to take pictures of them for reference, I know that quite a few of us have got like a fold in our phones of just useful, useful screenshots and prescribing bits. It is useful. If you find guidelines you like, even if they're not your own trust ones, then keep them on your phone because sometimes trust, you know, they have different guidelines or better guidelines than others. Thanks for coming. Mhm. No problem. Um And if any of you are part of any like medical school societies that would be happy to kind of share the info about this teaching series. Um There's various um teaching sessions over the next kind of couple of months. Um It's all available on the Facebook page. Uh I think it's on Instagram as well. Now please go and follow it and if you've got any med socks or big societies that could share the information, that would be good just to try and get word out and about a bit again. If there's no more questions, we will end it there. Thanks everyone.