Chapter 2 - Prescription Review

Question 1

PReSCRIBER acronym for checking prescriptions?

Answer 1

Patient details
Reactions/allergies
Sign the chart
Contraindications
Route of admin
IV fluids/drugs
Blood clots (need for anticoag)
Emesis (antiemetics)
Relief (analgesia)

Question 2

Side effects (and thus the loose contraindications) of steroids? (is also worth referring to when thinking of prophylactic co-prescriptions with long-term steroids)

Answer 2

STEROIDS
- stomach ulcers
- thin skin
- oEdema
- Right + left heart failure
- osteoporosis
- infection (esp candida)
- diabetes
- cushing’S Syndrome

Question 3

Side effects (and thus the loose contraindications) of NSAIDs? (is also worth referring to when thinking of prophylactic co-prescriptions with long-term NSAIDs)

Answer 3

NSAID
- no urine (renal failure)
- systolic dysfunction (heart failure)
- asthma
- indigestion
- dyscrasia (clotting abnormality)

Question 4

3 categories of side effects of antihypertensives?

Answer 4

All = hypotension

Mechanistic = bradycardia for BB/CCB, electrolyte disturbance for ACEi’s/diuretics

Individual classes = individual side effects for specific drug classes

Question 5

Specific side effects to ACEi’s, BBs, CCBs, and Diuretics (thiazides + K-sparing)?

Answer 5

ACEi’s = cough
BBs = wheeze in asthma, worsen acute heart failure (but help chronic HF)
CCB = peripheral oedema + flushing
Diuretics = renal failure
- subclasses
thiazides = gout
K-sparing = gynaecomastia

Question 6

2 situations where IV fluids are prescribed?

Answer 6

Maintenance for pt NBM
Replacement for pt dehydrated/acutely unwell

Question 7

Replacement fluid type selection rules?

Answer 7

All patients 0.9% saline (crystalloid) unless:
- hypernatraemia/hypoglycaemic = 5% dextrose
- ascites = human-albumin solution
- shocked from bleeding = blood transfusion (or crystalloid if no blood available)

Question 8

Assessment method for replacement fluid - how much and how fast to give?

Answer 8

Assess TRIAD of HR, BP, urine output
- high HR/low BP = 500ml bolus STAT (<20 mins)
- low urine output only (no obstruction) = 1L over 2-4 hrs then reassess the triad

Question 9

General rule for prescribing IV fluid for a sick patient?

Answer 9

Never prescribe more than 2L at a time - effect on patient of IV fluid must be reviewed regularly to assess correct volume + rate

Question 10

Rough predictions of how fluid-depleted a patient is by their obs (TRIAD)?

Answer 10

Reduced urine output (oliguric = <30ml/hr, anuric = 0 ml/hr) alone = 500ml depleted
Reduced urine output + high HR = 1L depleted
Reduced urine output + high HR + low BP = >2L depleted

Question 11

Maintenance fluid rules for adults + elderly daily requirement?

Answer 11

3L IV per 24 hours = adults
2L IV per 24 hours = elderly

Electrolytes = 1L 0.9% saline, 2L 5% dextrose, put 20 mmol KCl in 2 of these bags to provide potassium (40 mmol per day apparently)

Question 12

2 main blood clot prophylaxis options?

Answer 12

LMW heparin (e.g. dalteparin 5000 units s/c)
Compression stockings

Question 13

Contraindications to LMWH + compression stockings for blood clot prophylaxis?

Answer 13

LMWH - recent stroke, current bleed/high risk of bleed
CSs - peripheral arterial disease (will cause acute limb ischaemia)

Question 14

Antiemetic choices (3) in currently nauseated patient?

Answer 14

Prescribe as REGULAR:
Cyclizine 50mg 8hrly IM/IV/oral - causes fluid retention so don’t use in heart failure
Metoclopramide 10mg 8hrly IM/IV if heart failure
Ondansetron 4mg/8mg 8hrly IV/oral if Parkinson’s/young woman (Metoclopramide risk of exacerbating sx or acute dystonia)

Question 15

Antiemetic choices (2) in currently not nauseated patient?

Answer 15

Prescribe AS REQUIRED:
Cyclizine 50mg up to 8hrly IM/IV/oral (unless HF)
Metoclopramide 10mg up to 8hrly IM/IV if heart failure

Question 16

Pain ladder - including regular and ‘as required’ pain relief

Answer 16

None - regular = nil, as required = paracetamol 1g up to 6hrly oral
Mild - regular = paracetamol 1g 6hrly oral, as required = codeine 30mg up to 6hrly oral (or tramadol)
Severe - regular = cocodamol 30/500 2 tablets 6hrly oral, as required = morphine sulphate (10mg/5ml) 10mg up to 6hrly oral (must write the strength i.e. 10mg/5ml before the dose)

Question 17

Difference between metoclopramide + domperidone with respect to worsening Parkinson’s symptoms?

Answer 17

Domperidone does NOT cross blood-brain barrier so is safe to continue in Parkinson’s, but metoclopramide does and so must be stopped

Question 18

4 key drug-related causes of confusion in the elderly?

Answer 18

Antimuscarinic drugs - oxybutynin
Opioids - tramadol
Antiemetics - cyclizine
Benzodiazepines - diazepam

Question 19

Issue with NSAIDs + methotrexate?

Answer 19

Increased nephrotoxicity risk

Question 20

Situation where methotrexate should be withheld?

Answer 20

Acute infection

Question 21

Route rule for insulin?

Answer 21

ALWAYS given subcut except for short-acting insulin which can be given as IV infusion