5 th Year- Prescribing in the Community

1. 5th Year-Prescribing in the Community Ally Duncan Education Fellow and Anaesthetic Registrar

2. Aims and Objectives: • Learn how to manage common primary care clinical scenarios • Learn how to use prescribing resources • Be aware of the medico-legal and ethical issues of prescribing • Prescribing practice

3. Case 1 – in GP Surgery • Julie Jones 24 years old • Saw Practice Nurse today on her way to work • 4 day history of dysuria, frequency and low abdo pain • Urinalysis positives: • Protein • Blood • Nitrites • The nurse leaves you a note “Can youdo a prescription, she’s coming to collect it after work?” • The nurse is no longer available to speak to • What do you do?

4. Questions • What is the likely diagnosis? • What other possibilities should you consider? • Will you prescribe? If so, what? • If not why not? What would you do instead?

5. Learning point • The person who signs the script is always responsible (GMC / medico-legal) • Do you know all the information? • Whole history? • Past history? • Is the patient pregnant? • On other medications? • Allergic to any medication? • Is there a history of recurrent UTIs? • Is the patient systemically well?

6. Case 1 – part 2 • The patient comes in to see you on her way home from work. • You review her and diagnose a UTI. • She has no relevant PMH, she is not pregnant, she is not on any medication and has no allergies. • What are you going to prescribe? • What does she need to know?

7. What to prescribe? • Get information from local formularies and the BNF

9. What is the minimum the patient needs to know?

10. What the patient wants to know • What are you prescribing? (includes preparation, dose, frequency and length of course) • Any special instructions? E.g. food, sleep, driving • What would happen if they don’t take the medication? • Potential side-effects? • What to do if • The medication doesn’t work? • They suffer side-effects? • They miss a dose?

11. Sample Prescription 123456 PJR A1 JONES JULIE NKDA 06/09/11 01/01/1987 TRIMETHOPRIM  200mg po 06/09/11 A doctor 09/09/11  ADOCTOR 123 Urinary tract infection 3 days

12. Case 2 • Fred Holland • 40 years old. No significant PMH. Married with 3 children • Frequent attender to GP: • PC: Facial rash • Requesting flucloxacillin (again!) “It seems to clear it… but why does it keep on coming back?”

13. Learning point • Just because it gets better doesn’t mean it’s due to the medication!

14. Case 3 • Antonio Brunello • 22 years old. Just returned from his elective in India • Suffering with diarrhoea and abdominal cramps • Feels lethargic but otherwise well • Not on any regular medication “My friends all took an antibiotic which they bought in the local chemist and are now better… ”

15. Ethical principles • Autonomy: Give the patient what he wants / needs • Justice: Using resources / increasing resistance • Beneficence: May well improve patient • Maleficence: Side effect profile?

16. Case 4 • Suresh Singh • 14 years old • Came in 2 days ago with tonsillitis • GP registrar prescribed amoxicillin • Now has a widespread erythematous rash “Is this an allergy? Can he have an alternative antibiotic?”

17. Case 5 • Fred Holland • 40 years old. Married with 3 children • Frequent attender with facial rash “I forgot to mention last time - I’ve got a bit of irritation down below. The tip of my penis is red and I sometimes get a bit of a clear discharge… No other symptoms, nor does my wife. I just need something to clear it.” • What do you do?

18. Learning point • Just because it’s in the BNF, doesn’t make us experts! We’re not always the best to investigate / manage • Ethics of discussing with the wife?

19. Case 6 – GP surgery • Jimmy Addleston • 4 years old • Recently joined a nursery • His mother asks for some advice “He seems to be itchy down below. I noticed some white threads in his poo…” • What is the likely diagnosis? • Write a prescription on FP10

20. Learning points • Patients often don’t need investigating, the history tells all • Non-prescribing factors • Patient UK leaflets

21. Case 7 – home visit • James Cann, 70 years old • COPD • Takes inhalers • Lives alone, receives no community support • Unkempt appearance, filthy house • Increasing shortness of breath and cough for the past 3 days • Green sputum. No haemoptysis • No chest pain • NKDA

22. Case 7 • Examination findings • Pulse 70 bpm (sinus) • BP 140/90 • Respiratory rate 16 • Pulse oximetry 92% on air • Temperature 37.2° • Peak flow 125 L/s (Previously 170) • Bilateral wheeze on auscultation “Can you give me something to help?”

23. Learning points • Acute management of exacerbation of COPD • Consider a‘social prescription’ as well.

24. Case 8 – in GP surgery • Alex Hunter, 4 months old • Weight 7kg • Crying • Pyrexial (Tympanic temperature 38.2 celsius) • Pulse 120 bpm • Left tympanic membrane injected “Can you write a prescription for him?” “

25. Alex Hunter 30 Tree Lane, M42 5PH 4 months ago! Paracetamol sugar free suspension 120mg/5mL 5mls every 6 hours as required 200 mLs Your Name Today!

26. Case 8 “…Alex doesn‘t like the taste of paracetamol… Is there an alternative?” Medication? Dose?

27. Alex Hunter 30 Tree Lane, M42 5PH 4 months ago! Ibuprofen sugar free suspension 100mg/5mL 2.5mLs every 8 hours as required 200 mLs Your Name Today!

28. Case 9 • What’s the diagnosis? • What are the management options?

29. Summary • We’ve managed some common primary care clinical scenarios. • We’ve looked at the issues around when to prescribe and when not to. • We’ve explored some prescribing resources such as the BNF and local formularies. • We’ve practised writing prescriptions.

30. Next session: • After this session you may want to try the Practical Prescribing ivimeds package. • In the next session we will be looking at counselling patients, compliance / concordance and drug monitoring.