7 Tips for filling in a drug chart

Hello medics,

Here is a topic to get us all excited…filling in a drug chart. They love testing this in an OSCE and of course they should - you should be able to do this safely, as it will be asked of you the second you walk onto the ward.

Below are 7 tips to help you fill in the drug chart correctly and avoid common mistakes that are both dangerous and time consuming.

Lets gets started!

1) Do you have the right patient?

Before you even look at a drug chart, check that you have the right patient’s drug chart. A lot of drug charts are computer based, but that doesn’t mean it is impossible to make a mistake.

In the OSCE, ensure you compare the drug patient information to the patient in-front of you.. Although not seen yet during my days of taking exams or examining, one day they will test this by having a different patient.

2) Handwriting

You need to have legible handwriting anywhere in the patients notes for obvious reasons, but on a drug chart, the stakes just got a little higher. Have clear handwriting, use capitals, a good pen. Whatever helps, just make sure that you and someone else can read it. Drug errors occur so often due to problems with handwriting i.e. the wrong dose or even the wrong medications.

3) Check with BNF

If you are not sure about a medication dose, refrain from making it up. Double check in the BNF. In the OSCE you will be provided with a BNF, and so show you are safe and competent. When on the wards, again you have access to a BNF (book and app version), seniors and also an amazing pharmacist. Become familiar with using the BNF, from being familiar with the different chapters, to how to read the busy pages.

4) Write your name and bleep

When prescribing any medication, you need to leave your information in order for your colleagues to contact you in case of any issues, and also for auditing purposes. So write your name, position and bleep.

5) Check drug allergies

SO IMPORTANT. Please check drug allergies before even writing anything. The patient may have a red wristband, so please read this. Also ask the patient if they have any allergies. The drug allergy may even be already written on the prescription chart. Double check this before proceeding.

6) Check weight (especially paediatrics)

Again, drug charts may have already this information written on it. A few drugs are dependent on weight. Weight is vital for paediatrics, so do not forget this.

7) Other drug charts

There may be counterparts to the main drug chart, so be aware of this. Ie there may be an insulin sliding scale chart, a warfarin chart, fluid chart. Be familiar with all the drug charts available. Many hospitals have differing drug charts, and as stated above, some are also on computers. The point is that you recognise the different charts and the information that is required on them

Hoping this information has helped guide you to hopefully getting maximum marks on the OSCE/being a safer doctor.

For snippets of information please follow my social media, Lx

Psychiatry: Risk assessment

hello fellow medics,

I hope you are all well and working hard towards your exams.

In this blog I am going to talk about an area that causes students/doctors a tiny bit of anxiety: being faced with a suicidal patient.

Both in a clinical setting and in the OSCE, there are some important considerations to make a safe risk assessment of the situation, and hence manage your patient accordingly.

Lets get started…

A good history

When taking any history will allow you to naturally pick up on information that will help you to find out if this patient is at risk of causing harm to themselves. So practice those skills of: taking a thorough psychiatry history and communication skills.

Previous psychiatric history

A patient with a previous psychiatry history is more at risk, i.e. a long history of depression/anxiety, substance abuse, previous deliberate self harm or suicidal ideations. You want to also find out if they have been admitted into a mental health hospital (informally or formally). Finding out why they had the admission, the treatments and for how long, will give you an idea of how serious their mental health has been and can be- don’t underestimate the past.

Social situation

I have emphasised in previous blogs how important social history is for so many reasons. In this case, if you have a patient who has suicidal ideation, you want to ask about: who they live with (living alone being more worrying than living with friends and family), do they partake in illicit drugs/alcohol (with these two, the act of deliberate self harm is far more risky), do they have family (this will be protective, i.e. a husband or brothers or sisters. More on this below). Do they have a job? Do they have financial difficulties?

Previous DSH (deliberate self harm) /suicidal ideations

Ask if they have ever done any DSH, if so: what type of DSH and what were their intentions (ending life Vs Getting some release/feeling pain). If they have had any suicidal intent in the past, what did they do and what happened? Did someone find them? Did they tell someone/call 999.

Protective factors

These are factors that may protect someone from committing suicide that you want to find out about. You would like to know their family set up, do they have children, do they have a caring wife/husband. Are they religious? Some would say that if they have a faith, that this may be protective. Do they live with people who can keep them safe. There are many factors which will make you feel that the patient is safe, this may be a combination of many things you have picked up or just a gut feeling. This gut feeling has to be supported by a good consultation however.

Access to items

Patients who have suicidal intent with an overdose and also have access to medications (i.e. they take antidepressants and may be stock piling) Vs a patient who would think about shooting themselves, but have no access to a gun (although this is debatable as the act of ‘shooting’ is more violent and therefore more worrying). The point is: Do they have access to anything harmful? Again, it takes some digging and communication skills to 1) maintain trust with the patient 2) avoid alienating them 3) show compassion.

Intent

Asking a patient with suicidal thoughts the question “Are you planning on ending your life?” may sound ridiculous, but patients may wish they were not here, want to be dead BUT not actually have the intent. Both situations are worrying, but if they have NO intent to do it, it gives time to organise community mental health team rather than a ‘crisis’. This comes with practice and trust between you and your patient.

I hope you found the above useful and it has given you some notes to go by. It is an intense subject, but so common in real life and also tested in OSCEs. The key message: be kind, compassionate and have great communication skills. Listen to the patient and be a non judgemental empathetic doctor/medical student.

Best of luck with all your revision, i know it has been tough on all students and doctors throughout the World, don’t lose hope and keeping working towards the end goal.

L x

5 Tips for new doctors

Hello fellow medics,

Starting as a new doctor can be tricky. Despite great advances in medical education with shadowing junior doctors in clinical years, nothing is quite the same as being on that ward as a FY1.

Below are five tips to give you a general overview of ways to help you enjoy (yes enjoy) being a newly qualified doctor. This is advice I give to my students and to family members.

Speak up

Junior doctors get so worried about speaking up if they don’t understand something or mishear a terminology used by the consultant on the dreaded ward round. You need to remember two things 1. You are new 2. Your seniors forget what it is like to be new. So rather than have a mini panic attack in the nurses room as you didn't understand why you are asking for the MRI chest/abdomen/pelvis, actually say to your seniors “Please can you clarify why Mr Jones needs a CT?”.

Trust me, it is better to be a safe doctor who asks questions than one that doesn’t and makes a mistake.

Be organised

It is like being back in school (I mean this is a non patronising way). Pack all your pens, paper and essentials (in this case not a dictionary or pencil case BUT a stethoscope and BNF). Be prepared and look the part. I tend to advocate a clip board box (check it out on amazon). You do not want to be fumbling in front of your consultant looking for a pen or stethoscope.

Get the apps

This is the first thing I told my brother when he first started work. It can help your day to day tasks run smoothly. We are lucky that we live in an era where we can look things up and why not help this by having the best apps downloaded on your phone. My list will be short, and there are probably 100’s of apps, but these are my go to:

  1. BNF

  2. MDcalc

  3. RxGuidelines/Microguide (microbiology guidelines for your trust)

  4. Buku Medicine

  5. NHS Palliative Care Guidelines (NHS Scotland)

Make friends

Make friends with everyone, from the nurses to the porters. Be nice and respectful to everyone. You cannot work in a hospital without a team ethos. On those lonely medical shifts in the middle of the night, you would rather you had a comforting chat with a nurse or Porter than be known as the obnoxious new FY1.

Try to enjoy it

Lastly, many of us had different experiences of our first few months as a foundation doctor- some loved it and some loathed it. I would say, whatever your experience try to enjoy it. It is tough and there are lots to learn on the job (the biggest jump you may have in your life is going from a medical student to a FY1) but its through those horrid night shifts, moody consultants or that damn bleep that you look back and smile as you build resilience and friendships.

This is just a taster of some tips, I hope that they gave you some direction for those who will be starting work in August. The NHS is a wonderful organisation to work for, so be excited for the next adventure of your life.

Look after yourselves x

RED FLAGS: Gastroenterology history taking skills

Morning fellow medics,

I hope that you are all well and safe in whichever part of the World you are in. I have followers and readers from different aspects of the globe which proves how universal medical education is. It is great to see you all checking out my social media and blog posts.

Moving onto the aim of the post - lets have a look at ‘red flags’ in gastroenterology. These are symptoms that the patient will present with (maybe a single symptom or multiple) which warrants further investigation or a two week wait referral (cancer referrals by which the patient has to be seen within 2 weeks).

As always stated: below is just a summary and the list is not exhaustive. The aim of this blog is not to teach you new material, but to remind you and a trigger to get you thinking.

Weight loss

Weight loss is a red flag in any system, with the all important question being whether it is intentional or unintentional. Weight loss may also be a manifestation of a lack of appetite (which is also a worrying feature). Find out how much weight loss has occurred and in what amount of time.

Dysphagia

Difficulty in swallowing can mean many things, so knuckle down what the patient means. Is it that the food is getting stuck? Is it indigestion? If food it getting stuck, get an idea of the course of symptoms, did it start as solids and now its fluid? (which would indicate progression of symptoms/occlusion). This is where your history taking skills come into action

Dyspepsia

Dyspepsia itself is not an issue, as we all have had dyspepsia time to time (indigestion). It becomes an issue when faced with age + worsening symptoms. If you have a 60 year old man come in with new onset of dyspepsia that is getting worse, this may be different to a 40 year female with a poor diet/lifestyle, who has a bit of heart burn in the evening.

Change in bowel habits

A change in bowel habit needs to explored in detail - is it looser? Is the patient opening their bowel more often or less often? How long have the symptoms been present? A short episode of loose bowels is not as worrying as a long history of diarrhoea plus waking up in the night to open bowels. Do not forget that constipation is also an alarming symptom.

Per rectal bleeding

Ask about the colour of the blood- bright red or dark red. Is the blood mixed in with the stools or on the surface of the stools (giving you an indication of the location of the bleed). Ask about pain on defecation, which may indicate a fissure. Per rectal bleeding is a concerning symptom for a patient, but can be embarrassing, so ask these questions sensitively.

Abnormal investigations: high platelets or new low haemoglobin

Both of these are a cause for concern. High platelets are indicative of inflammation which may be due to cancer and a low haemoglobin may indicate a bleed from the GI tract.

I hope that the list above gave you a reminder of some red flags in gastroenterology to get you thinking. An excellent resource to be familiar with is CKS NICE - it has a summary of the NICE guidelines and also has a section on red flags in gastroenterology. Click link to check it out.

If you are interested in having one to one revision (or even join forces with a friend) please check out the website for further information.

Best of luck in the upcoming SJT!

L x