Hussein Elghazaly He315@ic.ac.uk Prescribing Tutorial Hussein Elghazaly He315@ic.ac.uk

Outline Prescribing in the OSCEs Anatomy of the Drug Chart Using the BNF Prescribing Medications Prescribing IV Fluids

Outline Prescribing in the OSCEs Anatomy of the Drug Chart Using the BNF Prescribing Medications Prescribing IV Fluids

Prescribing in the OSCEs Unlikely to be a station on its own. Most likely scenario: after history/ examination. May be part of a clinical skills station e.g. IV fluids.

Prescribing in the OSCEs Unlikely to be a station on its own. Most likely scenario: after history/ examination. May be part of a Clinical Skills station e.g. IV fluids. Example: History This patient presented with SoB. Take a history and prescribe an appropriate medication.

Prescribing in the OSCEs Unlikely to be a station on its own. Most likely scenario: after history/ examination. May be part of a Clinical Skills station e.g. IV fluids. Example: Examination This patient presented with SoB. Perform a respiratory examination and prescribe an appropriate medication.

Prescribing in the OSCEs Unlikely to be a station on its own. Most likely scenario: after history/ examination. May be part of a Clinical Skills station e.g. IV fluids. Example: Clinical Skills This patients needs IV fluids. Prescribe fluids in their drug chart and set-up an IV infusion.

Prescribing in the OSCEs They could ask you to prescribe it on an iPad/ write it down on a piece of paper. Furosemide, 40 mg, oral, once a day OR They can ask you to fill in a drug chart:

Prescribing in the OSCEs You do not need to remember the doses * You may need to work out the medication by yourself, or the examiner will tell you which medication to prescribe. If you need to work it out yourself: It will be something really easy Use the BNF to find the appropriate medication * Some drugs are worth remembering for the OSCE and written. The main one to remember is Adrenaline.

Outline Prescribing in the OSCEs Anatomy of the Drug Chart Using the BNF Prescribing Medications Prescribing IV Fluids

Anatomy of the Drug Chart Patient Details Regular Prescriptions Once Only Prescriptions Fluid Prescriptions Oxygen Prescription

Patient Details * * Tip: If you’re given a drug chart in the OSCE, check the ‘Previous Adverse Reactions’ part of the patient’s drug chart before you prescribe any medication.

Regular Prescriptions Patient Details Date and Time Name Dose Medication Route Frequency Your Name + Signature

Regular Prescriptions Different drug charts have different structures. But they all have the same main components.

Regular Prescriptions Different drug charts have different structures. But they all have the same main components. Frequency Abbreviation stat  once only  once a day O.D. twice a day B.D.S. three times a day T.D.S. four times a day Q.D.S. five times a day every X hour(s)/minute(s)/day(s)/month(s) over X hour(s)/minute(s)  As required, maximum FREQUENCY PRN, max X g/24h

Once Only Prescriptions

Fluid Prescriptions

Oxygen Prescriptions

Outline Prescribing in the OSCEs Anatomy of the Drug Chart Using the BNF Prescribing Medications Prescribing IV Fluids

Using the BNF You’re not expected to know the doses for OSCEs. You will have access to the BNF (most likely electronic) in your stations, if required. Two Approaches: Search the condition (if you know the diagnosis) Search the drug itself (if you know it, or if told by the examiner)

Using the BNF Mrs. Margaret Jenkins (DOB: 20/08/1930) is an 88 year-old lady who became acutely breathless and is coughing up pink frothy sputum. She has a past medical history of hypertension, diabetes and acute coronary syndrome and was diagnosed with left ventricular systolic dysfunction 2 weeks ago. On examination, she has bilateral basal crackles as well as sacral and peripheral oedema. Diagnosis?

Using the BNF Mrs. Margaret Jenkins (DOB: 20/08/1930) is an 88 year-old lady who became acutely breathless and is coughing up pink frothy sputum. She has a past medical history of hypertension, diabetes and acute coronary syndrome and was diagnosed with left ventricular systolic dysfunction 2 weeks ago. On examination, she has bilateral basal crackles as well as sacral and peripheral oedema. Diagnosis? Acute Heart Failure/ Acute Pulmonary Oedema

Using the BNF Searching the condition

Using the BNF Searching the condition

Using the BNF Searching the condition

Using the BNF Searching the drug

Using the BNF Searching the drug

Using the BNF Searching the drug

Using the BNF Searching the drug Drug: Furosemide Dose: 40 mg (20-50mg accepted) Frequency: Once Daily Route: IV

Using the BNF Searching the drug Drug: Furosemide Dose: 40 mg (20-50mg accepted) Frequency: Once Daily Route: IV

Using the BNF Physical Copy If you are given a physical copy of the BNF, the process is identical. The only difference is that, instead of searching the condition/ drug, you will need to check them in the index.

Outline Prescribing in the OSCEs Anatomy of the Drug Chart Using the BNF Prescribing Medications Prescribing IV Fluids

Essentials of Every Prescription - Checklist The Date Patient ID (Name and Hospital No.) The Drug Name and Formulation (if applicable) Dose Frequency Route Prescriber’s Name and Signature * If you’re given a drug chart in the OSCE, check the ‘Previous Adverse Reactions’ part of the patient’s drug chart before you prescribe any medication.

Things to keep in mind Write in block capitals Use the generic name not brand name of the drug. The only exceptions: Insulin Anti-epileptic drugs (e.g. phenytoin) Anti-psychotics Inhalers For doses, accepted abbreviations are g (grams) and mg (milligrams). Micrograms must be written in full (Not µg or mcg) ‘Units’ must be written in full

Prescribing Medications: Example 1 You take a history from Mr Jason Anderson, a 29 year-old man who has come in with chest pain, preceded by fever, muscle ache and a sore throat. A diagnosis of acute pericarditis is made. Mr Anderson is admitted to the ward for observation and requires regular ibuprofen. Prescribe regular ibuprofen to the patient.

Prescribing Medications: Example 1 Ibuprofen, 400mg, oral, three times a day.

Prescribing Medications: Example 1 Ibuprofen, 400mg, oral, three times a day. Jason Anderson 1/1/1990 IBUPROFEN 400 mg P.O 31/3/19 Your name and signature

Prescribing Medications: Example 2 When you get to the ward that morning, Mr Anderson is in a lot of pain. You are decide to prescribe co-codamol (30/500) once only. He also says that he couldn’t sleep overnight due to the pain and so you decide to prescribe paracetamol as required. Prescribe both medications to Mr Anderson.

Prescribing Medications: Example 2 Co-codamol (30/500), 2 tablets, oral, once only. 31/3/19 11:30 Co-codamol (30/500) 2 tablets ORAL Name and Signature

Prescribing Medications: Example 2 2) Paracetamol, 1 g, as required, maximum 4 times per day. Jason Anderson 1/1/1990 Paracetamol MAKE SURE THIS GOES IN THE AS REQUIRED SECTION OF THE DRUG CHART! 1g P.O PRN for pain, max 4g/24 hr 31/3/19 Your name and signature

Outline Prescribing in the OSCEs Anatomy of the Drug Chart Using the BNF Prescribing Medications Prescribing IV Fluids

Prescribing IV Fluids One of the clinical skills stations can be setting-up an IV infusion. This may be accompanied by prescribing fluids. IV fluids have a specific section in the drug chart, so make sure you prescribe there. The prescription should include: Date of Administration Route of Administration Total volume to be administered Rate of infusion Approved generic name of the fluid Approved generic name of any drug added

Prescribing IV Fluids Normal Saline 20 mM KCl in Normal Saline

Prescribing IV Fluids: Examples Prescribe 300 mL of IV normal saline to Mr Anderson over 6 hours. A routine ECG revealed that Mr Anderson has broad QRS complexes and tented T-waves. U&Es indicate hyperkalaemia. Prescribe an infusion of 10 Units of Insulin (Actrapid) in 250 mL of 10% Glucose over 30 minutes.

Prescribing IV Fluids: Examples Prescribe 300 mL of IV normal saline to Mr Anderson over 6 hours. 0.9% Sodium Chloride 300 mL 31/3/19 11:00 50 mL/h Name and Signature

Prescribing IV Fluids: Examples 2) A routine ECG revealed that Mr Anderson has broad QRS complexes and tented T-waves. U&Es indicate hyperkalaemia. Prescribe an infusion of 10 Units of Insulin (Actrapid) in 250 mL of 10% Glucose over 30 minutes. 10% GLUCOSE 250 mL Over 30 minutes OR 500 mL/h 31/3/19 11:00 Name and Signature INSULIN (ACTRAPID) 10 units

Prescribing: Question 1 Prescribe gliclazide to a 45 year-old patient with uncontrolled T2DM on the ward.

Prescribing: Question 1 Prescribe gliclazide to a 45 year-old patient with uncontrolled T2DM on the ward.

Prescribing: Question 2 Prescribe an appropriate medication to a patient with Cushing’s syndrome.

Prescribing: Question 2 Prescribe an appropriate medication to a patient with Cushing’s syndrome.

Prescribing: Question 2 Prescribe an appropriate medication to a patient with Cushing’s syndrome. Jason Anderson 1/1/1990 METYRAPONE 250 mg P.O 31/3/19 Your name and signature

Prescribing: Question 3 Prescribe an appropriate medication to a 25 year-old patient with hypothyroidism.

Prescribing: Question 3 Prescribe an appropriate medication to a 25 year-old patient with hypothyroidism. Jason Anderson 1/1/1990 LEVOTHYROXINE SODIUM 100 micrograms P.O 30 mins before breakfast 31/3/19 Your name and signature

Prescribing: Question 4 Prescribe insulin to a patient with T1DM.

Prescribing Insulin Insulin Example Onset of Action Peak Effect Duration Short-Acting Aspart (NovoRapid) 10-20 mins 1-3 hrs 3-5 hrs Intermediate-Acting Isophane (Humulin) 1-2 hrs 4-12 hrs 14-24 hrs Long-Acting Glargine (Lantus) 3-4 hrs No clear peak 22-24 hrs

Prescribing Insulin There is no ne way of prescribing insulin. It needs to be prescribed in the Drugs that Require Monitoring section of the drug chart. Titrated according to the blood glucose levels. Knowing which insulin to give and what doses to administer is complex and is very unlikely to come up in the OSCE or written.

Extra Practice

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