OSCE

Question 1

History Taking

Answer 1

1. Current Medications
   - What to Gather: Name, dose, indication, duration, efficacy, formulation, frequency.
   - How to Ask: “What medications are you taking? Are they working for you?”
2. Non-Prescribed Drugs
   - What to Gather: OTC, herbal, recreational, borrowed meds.
   - How to Ask: “Do you take any supplements, OTC meds, or recreational drugs?”
3. Adherence
   - What to Gather: Missed doses, challenges.
   - How to Ask: “Do you ever miss doses? What makes it hard to stick to them?”
4. Medical History
   - What to Gather: Conditions, surgeries, allergies.
   - How to Ask: “Any health issues, past surgeries, or allergies?”
5. Social History
   - What to Gather: Smoking, alcohol, living, family history.
   - How to Ask:
   - Smoking/Alcohol: “Do you smoke or drink? How much?”
   - Living: “Who do you live with?”
   - Family: “Any family health issues like diabetes or heart problems?”
6. Closing the Encounter
   - What to Do: Summarize, check for concerns, thank, explain next steps.
   - How to Do It:
   - Summarize: “So, you’re taking X for Y, with Z concerns.”
   - Ask: “Is there anything else to add?”
   - End: “Thanks for sharing. We’ll review your care plan.”

Question 2

History Taking plus extra info for chatgpt

Answer 2

1. Current Medications
   - What to Gather: Name, dose, indication, duration, efficacy, formulation, frequency.
   - How to Ask: “What medications are you taking? Are they working for you?”
2. Non-Prescribed Drugs
   - What to Gather: OTC, herbal, recreational, borrowed meds.
   - How to Ask: “Do you take any supplements, OTC meds, or recreational drugs?”
3. Adherence
   - What to Gather: Missed doses, challenges.
   - How to Ask: “Do you ever miss doses? What makes it hard to stick to them?”
4. Medical History
   - What to Gather: Conditions, surgeries, allergies.
   - How to Ask: “Any health issues, past surgeries, or allergies?”
5. Social History
   - What to Gather: Smoking, alcohol, living, family history.
   - How to Ask:
   - Smoking/Alcohol: “Do you smoke or drink? How much?”
   - Living: “Who do you live with?”
   - Family: “Any family health issues like diabetes or heart problems?”
6. Closing the Encounter
   - What to Do: Summarize, check for concerns, thank, explain next steps.
   - How to Do It:
   - Summarize: “So, you’re taking X for Y, with Z concerns.”
   - Ask: “Is there anything else to add?”
   - End: “Thanks for sharing. We’ll review your care plan.”

(- patient details
- name
- age
- gender
- weight
- height
- presenting complaint and hx of complaint
- PMH
- Feh
- Sxh
- Dxh (inc allergies)
- any other relevant info
- tests and investigations
- Assessment of symptoms

Question 3

Responding to patient queries, signs and symptoms (A patient asking for advice about common ailments, new or recurring symptoms,
or about medications.)

Answer 3

1. Medication History
   - What to Gather: Medications taken or missed.
   - How to Ask: “Have you taken any medications for this? Have you missed any doses?”
2. Symptom Details
   - What to Gather: Duration, triggers, relief factors.
   - How to Ask:
   - “How long have you had these symptoms?”
   - “Does anything make them better or worse?”
3. Medical History
   - What to Gather: Other conditions or health issues.
   - How to Ask: “Do you have any other health conditions, like diabetes or asthma?”
4. Social History
   - What to Gather: Smoking, alcohol, living conditions.
   - How to Ask:
   - “Do you smoke or drink? How much?”
   - “Do you have any challenges at home or work that might affect your health?”
5. Counsel on Recommendations
   - What to Do: Explain treatment, dose, side effects, and lifestyle advice.
   - How to Do It:
   - “I recommend taking [product]. Use it [how to take]. Possible side effects include [list].”
   - “Also, try [non-pharmacological advice, e.g., rest, hydration].”
6. Safety Netting
   - What to Do: Advise on red flags and follow-up.
   - How to Do It:
   - “If your symptoms get worse, like [specific red flags], seek medical help immediately.”
   - “Come back if this doesn’t improve within [timeframe].”

Question 4

Medicine review

Answer 4

1. Non-Adherence
   - What to Gather: Issues with taking medications as prescribed.
   - How to Ask:
   - “Are you taking your medications as prescribed?”
   - “Have you had any difficulties, like side effects or forgetting doses?”
2. Optimising Medication Regimen
   - What to Gather: Patient-specific factors (indications, lab results, interactions).
   - How to Do It:
   - Review current medications for appropriateness: “Are all medications still needed?”
   - Check for interactions or adjustments needed:
   - “How well are these medications working for you?”
3. Monitoring Requirements
   - What to Gather: Ensure lab tests or other monitoring has been done.
   - How to Ask:
   - “Have you had any recent blood tests or health checks related to your medications?”
   - Arrange tests if required: “We may need to monitor [specific test] for safety.”
4. Recommendations or Adjustments
   - What to Do: Suggest changes based on findings.
   - How to Do It:
   - “I recommend adjusting [medication] to improve [issue].”
   - “We’ll also need to consider [alternative treatment] for better results.”
5. Signposting if Needed
   - What to Do: Refer to another professional if required.
   - How to Do It:
   - “I think it’s best to involve [specialist, GP, etc.] for further evaluation.”
6. Closing the Review
   - What to Do: Summarize findings and next steps.
   - How to Do It:
   - “To summarize, we’ll adjust X, monitor Y, and follow up in Z weeks.”
   - “If you have any concerns, contact [relevant professional or service].”

Question 5

Clinical check

Answer 5

1. Identify Clinical Issues
   - What to Gather:
   - Sub-optimal therapy (wrong drug, dose, duration).
   - Drug-drug interactions.
   - Wrong indication or contraindications.
   - Allergies or side effects.
   - How to Do It:
   - Check for medication appropriateness: “Is this the best drug for the condition?”
   - Look for interactions: “Any known interactions?”
   - Verify correct dose and duration: “Is the dose appropriate for this patient?”
2. Develop an Action Plan
   - What to Gather:
   - Patient’s understanding and adherence.
   - Alternative medications if needed.
   - Referral requirements (specialists).
   - How to Do It:
   - Counseling: “Let’s review how you’re taking your medications and their benefits.”
   - Referral: “You may benefit from seeing [specialist].”
   - Alternatives: “Consider switching to [medication] for better results.”
3. Ensure Monitoring Requirements
   - What to Gather:
   - Required lab tests, check-ups, and ongoing monitoring.
   - How to Do It:
   - Ask: “Have you had your [test] recently?”
   - Arrange tests: “We need to schedule a [test] to monitor progress.”
4. Close the Clinical Check
   - What to Do:
   - Summarize key points, actions, and next steps.
   - How to Do It:
   - “We’ve adjusted your treatment and will follow up in [timeframe].”
   - Confirm any questions or concerns: “Let me know if anything changes before then.”

Question 6

Patient Counselling

Answer 6

1. Indication
   - What to Gather: Explain why the medication is prescribed.
   - How to Do It: “This medication is for [condition], which will help with [specific benefit].”
2. Duration of Treatment
   - What to Gather: Clarify how long the treatment should be taken.
   - How to Do It: “You should take this for [time period]. It’s important not to stop early, even if you feel better.”
3. Administration Instructions
   - What to Gather: Provide specific instructions (e.g., inhaler technique).
   - How to Do It:
   - Inhaler: “Here’s how to use your inhaler. Breathe in deeply after pressing down on the canister.”
   - Pill: “Take [dose] with/without food at [time].”
4. Adverse Effects & Benefits
   - What to Gather: Explain possible side effects and the benefits of the medication.
   - How to Do It:
   - Benefits: “This should improve your [symptom/condition].”
   - Side effects: “You might experience [side effects]. If they continue or worsen, contact us.”
5. Compliance & Missed Dose Instructions
   - What to Gather: Address adherence and missed doses.
   - How to Do It:
   - Compliance: “Make sure to take it as prescribed every day.”
   - Missed Dose: “If you miss a dose, take it as soon as you remember, unless it’s nearly time for the next one.”
6. Ongoing Monitoring Requirements
   - What to Gather: Explain any follow-up tests or check-ups.
   - How to Do It: “You’ll need to have [test] after [time period] to ensure this medication is working.”
7. Storage & Safe Disposal
   - What to Gather: Explain how to store and dispose of the medication safely.
   - How to Do It: “Store it in a cool, dry place, and dispose of any unused medication safely at a pharmacy.”
8. Patient’s Understanding
   - What to Gather: Confirm the patient understands their treatment plan.
   - How to Do It: “Can you tell me how you’ll be taking this medication and why?”

Question 7

Lifestyle optimisation including diagnostic skills

Answer 7

1. Smoking Status
   - What to Gather: Current smoking habits, willingness to quit.
   - How to Do It:
   - “Do you currently smoke? How many cigarettes a day?”
   - “Would you be open to discussing ways to quit?”
2. Alcohol Intake
   - What to Gather: Frequency, amount, and type of alcohol consumed.
   - How to Do It:
   - “How much alcohol do you drink in a week?”
   - “It’s best to stay within the recommended limit of [units]. Would you consider cutting back?”
3. Recreational Drug Use
   - What to Gather: Any recreational drug use or history.
   - How to Do It:
   - “Do you use any recreational drugs? How often?”
   - “Using drugs can impact your health, would you be open to exploring alternatives?”
4. Diet & Nutrition
   - What to Gather: Eating habits, portion sizes, food choices.
   - How to Do It:
   - “Can you describe your typical daily diet?”
   “A balanced diet with plenty of fruits and vegetables can improve your health.”
5. Physical Activity
   - What to Gather: Exercise frequency, type, and duration.
   - How to Do It:
   - “How often do you engage in physical activity?”
   - “Aim for 30 minutes of moderate activity most days to improve your health.”
6. Wellbeing
   - What to Gather: Mental health, stress levels, overall emotional state.
   - How to Do It:
   - “How are you feeling emotionally? Any stress or anxiety?”
   - “Taking time for yourself and managing stress can improve your overall wellbeing.”
7. Quality of Sleep
   - What to Gather: Sleep patterns, disturbances, or issues.
   - How to Do It:
   - “How many hours of sleep do you get on average?”
   - “Good sleep hygiene can help you feel better, let’s talk about improving your sleep.”
8. Diagnostic Skills
   - What to Do: Perform relevant tests.
   - How to Do It:
   - Blood Pressure: “Let’s check your blood pressure to assess your cardiovascular health.”
   - Peak Flow Meter: “Please blow into this peak flow meter to assess your lung function.”
   - Oxygen Saturation: “Let’s check your oxygen levels using this pulse oximeter.”

Question 8

Points to consider (Anil Sharma)

Answer 8

Patient background
o Patient demographics (ages, sex, height, weight etc)
o Presenting complaint and history of complaint
o Past medical history- any contraindications or cautions?
2. Prescribed medication and therapeutic goals
o What has been prescribed and why?
o Is the drug appropriate for the indication?
3. Actual and potential drug problems
o Are there actual issues with the drug chart, or do you
foresee issues arising?
o Drug-related problems:
i. Inappropriate / untreated indication
ii. Sub-therapeutic dose / overdose
iii. Adverse drug reaction
iv. Drug interaction or contraindications
v. Impact of renal / hepatic impairment
Points to Consider
4. Are there any issues related to antimicrobial
stewardship?
o Are antibiotics prescribed as per local
guidelines or test results?
o Have the antibiotics been reviewed at 72
hours?
o Has the duration of treatment been
specified?
5. Resolving issues
o Do nothing – is always an option, but is it
appropriate?
o Monitoring – symptoms, patient parameters,
blood results etc.
o Pharmacist to resolve – e.g. endorse
instructions on drug chart, counsel patient
etc.
o Discuss with nurse – e.g. advise on
administration etc.

Question 9

How to take a drug history?

Answer 9

• No right or wrong way to confirm a drug history - develop your own logical approach & checklist
• What needs to be confirmed:
  1. Name and dose of all medications
  the patient is currently taking AND
  how does the patient take it
  2. Patient compliance * Is the patient compliant with their medication  if not .. why?
• Prescribed
• Over the counter
• Herbal / vitamins
• Recreational
• Recently stopped
• Recently changed
• Borrowed
• Recent vaccinations
  3. Is the patient having any problems
  with their medication?
• Is the patient having any side effects?
• Difficulties using the medication?
  4. Does the patient have support
  with any of their medication
• Do they do their medication themselves (independent) or have help from family members?
• Do they have a NOMAD box or original packs?
• Do they have carers who administer the medication at home?
• Are they in a care home where medication maybe administered by nursing staff?
  5. Allergies * Does the patient have any allergies?
• If so, what is the nature of the reaction?

Question 10

Question 1: What would you record as this patient’s current in-clinic blood pressure?

Answer 10

If in-clinic BP > 140/90 mmHg, take another reading. If substantially
different, take a third reading. Record lower of 2nd or 3rd reading as clinic BP.
* 165/98 mmHg, 150/92 mmHg, 152/93 mmHg

Question 11

Question 2: What should be done next in order to establish a diagnosis of hypertension?

Answer 11

If 140/90 mmHg to 180/120 mmHg offer ABPM (or HBPM if ABPM
unavailable).

Question 12

Question 3: What other tests or investigations would you like to carry out at this
stage? Explain why these investigations are useful.

Answer 12

• offer a bpm or hbpm if declined
• investigate for target organ damage
• assess CV risk
• testing for target organ damage
• haematuria
• arrange measurement of:
  1. urine albumin:creatinine ratio (test for presence of protein)
  2. HbA1C ( diabetes)
  3. Electrolytes, creatinine, and estimated glom filtration rate (test for chronic kidney disease)
• examine the fundi
• arrange for 12-lead ecg to be performed (assess cardiac function and detect left ventricular hypertrophy)
• assess CV risk using QRISK3 - 2018

Question 13

does patient have hypertension

Answer 13

1. stage 1 - clinic 140/90 - 159/99 and home 135/85 - 149/94
2. stage 2 - 160/100 - 180/120
3. stage 3 - severe - 180+ / 120+

Question 14

Risk Factors for CV

Answer 14

Modifiable
* smoking
* cholesterol
* blood pressure
* BMI

• Non-modifiable
• age
• ethnicity
• sex
• FHx

Question 15

Address life-style/modifiable factors for CV?

Answer 15

healthy diet
* total fat intake <30%, saturated fat <7%
* reduce sugar intake, particularly refined sugars
* 5 portions fruit and veg daily
* 2 portions fish (inc. one oily) weekly
* low salt
* maximum alcohol intake 14 units/wk with alcohol free days
* weight loss
* BMI 18.5-25
* exercise
* at least 150 minutes/wk of moderate intensity activity

Question 16

Question 7: What are the pharmacological targets used to treat/manage
hypertension, i.e. where and how do the medicines recommended by NICE for
hypertension work?

Answer 16

ACEi (end in “pril”) – inhibit angiotensin converting enzyme
* ARB (end in “sartan”) – block angiotensin receptors
* CCB (usually end in “pine”) – block calcium channels
* Thiazide-like diuretic (indapamide) – inhibits Na/Cl co-transporter causing diuresis and
Na off-load
* Beta-blockers (usually end in “olol”) – block beta-2-receptors
* Alpha-blockers (usually end in “osin”) – inhibit alpha-1-receptors
* MRA (spironolactone) – inhibit mineralocorticoid receptor

Question 17

Angiotensin Converting Enzyme (ACE) Inhibitors

Answer 17

DOSE:
* Initially ramipril 1.25-2.5mg OD, max. 10mg OD
* Others: perindopril, lisinopril, enalapril
* Titrate up to control BP to target
* DURATION: usually lifelong
* Rationale: blocks production of angiotensin II to
prevent vasoconstriction
* Side effects:
* Cough
* Angioedema
* Alopecia
* Electrolyte imbalance
* Hypotension
* Dry mouth
* Altered taste
* C/I: Hx of angioedema with ACEI
* Cautions: African-Carribbean patients may not respond
as well, 1st dose hypotension
* Monitoring:
* Renal function
* Electrolytes (potassium)
* Blood pressure
When?
* Before starting
* After initiation
* After dose increase
* Periodically thereafter
* Counselling:
* Take first dose sitting down or before bed
* Notes
* ACE inhibitor should be titrated up to control BP to
target

Question 18

Angiotensin Receptor Blockers (ARB)

Answer 18

DOSE:
* Initially losartan 50mg OD, max. 100mg OD
* Others: candesartan, valsartan, irbesartan
* Titrate up to control BP to target
* DURATION: usually lifelong
* Rationale: blocks action of angiotensin II at AT1
receptors
* Side effects:
* GI disturbances
* Hypotension
* Anaemia
* Angioedema
* Hypoglycaemia
* Electrolyte imbalance
* C/I: none
* Cautions: heart valve stenosis, elderly, Hx of
angioedema
* Monitoring:
* Renal function
* Electrolytes (potassium)
* Blood pressure
When?
* Before starting
* After initiation
* After dose increase
* Periodically thereafter
* Counselling:
* Take first dose sitting down or before bed
* Notes
* ARB should be titrated up to control BP to target

Question 19

Question 9: Should this patient be offered medication to control his cholesterol ? If
yes, what would you offer and how would you follow-up?

Answer 19

The decision to start statin treatment should be made after an informed
discussion with the person about the risks and benefits of treatment, taking
into account factors such as co-morbidities, potential benefits from lifestyle
intervention, and the person’s preference.
* The aim of treatment is to achieve a greater than 40% reduction in non-
HDL-C levels.
* Patients should also adhere to non-pharmacological treatment

Question 20

For primary prevention of CVD?

Answer 20

high-intensity statin treatment (atorvastatin
20 mg daily) should be offered to people:
* Aged 84 years and younger if their estimated 10-year risk of developing CVD using
the QRISK3 assessment tool is 10% or more.
* With type 1 diabetes (without the need for a formal risk assessment) who are aged
more than 40 years, have had diabetes for more than 10 years or have established
nephropathy, or have other CVD risk factors.
* With chronic kidney disease, or familial hypercholesterolaemia (without the need for
a formal risk assessment).

Question 21

HMG-coA reductase inhibitors (statins)

Answer 21

OSE:
* Atorvastatin 20mg or 80mg
* Others: simvastatin, rosuvastatin, pravastatin,
fluvastatin
* Titrate up to reduce non-HDL-C by 40%
* DURATION: usually lifelong
* Rationale: blocks enzyme involved in cholesterol
synthesis
* Side effects:
* muscle effects, inc. toxicity
* GI disturbances
* sleep disorders
* nose bleeds
* skin reactions, inc. severe
* C/I: none
* Cautions: those at increased risk of muscle effects,
hypothyroidism, haemorrhagic stroke
* Monitoring:
* Liver function
* Lipids
When?
* three months after
initiation
* Counselling:
* Advise patients to report promptly unexplained
muscle pain, tenderness, or weakness.
* Notes
* Adequate contraception during treatment and a
month after stopping

Question 22

Follow up (for issues identified, monitoring etc)

Answer 22

• Follow-up
  (further appointments,
  next review, safety-
  netting, etc.)
  Diagnosis of Stage 1 hypertension confirmed
  U+E in 7-10 days after ACEi/ARB
  Repeat HBPM 4/52 after starting
• Further monitoring
  (tests, investigations,
  efficacy check, etc.)
  Blood results
  QRISK > 10%
  ECG
  ACR
• Referral to other HCP
  (GP, nurse, physio,
  secondary care, smoking
  cessation, MH team etc.)
  If required for ECG anomalies or other issues uncovered or
  outside scope of practice
• Prescribing and
  Clinical Check
  (medications
  started/stopped/changed,
  rationale, clinical check for
  appropriateness)
  Prescribe ACEi/ARB at appropriate dose
• Other relevant details
  (social, lifestyle, family,
  MAR pt, tray pt, carer /
  support with meds, vegan
  etc.)
  Counsel on primary prevention

Question 23

Hospital Drug Chart Guide

Answer 23

One of the key responsibilities of a hospital pharmacist is to review the drug chart of each patient on their ward to ensure that:
* The patient’s regular medication has been prescribed, if appropriate to the patient’s current situation (e.g. based on renal function).
* Any regular medication not prescribed has been purposefully stopped or with-held, and not forgotten by the prescriber.
* Any new medication is prescribed appropriately based on indication, dose, route of administration, duration and patient factors (e.g. age, weight,
allergies, co-morbidities etc.)
1. Allergy Section
* Most important part of the chart;
no meds should be administered
without this being filled.
* If no allergy, document as ‘None
Known’ or NKDA.
* If allergy, must state name of drug
AND nature of reaction
2. Patient Details
* Name, address, date of
birth, gender.
* Check you’ve got the right
patient!
3. Patient Height, Weight &
Surface Area
* Will usually only need weight
to clinically check drug doses
4. Admin Info
* Admission date.
* Hospital name – have they been
transferred to you?
* Ward name – where to send the chart
back to if requested meds from
dispensary?
* Consultant name – which doctor team
should you divert your queries to?
* Chart number – are all meds
prescribed here or do you need to find
another chart?
5. Supplementary Charts
* Some meds need additional monitoring
and dose considerations, so they are
prescribed on separate special charts.
* These include insulin, warfarin and
syringe drivers – will cover later in
course.
6. Oxygen Prescription
* Oxygen should be prescribed like a
drug.
7. Once-only Medication
* Also called the STAT side of the chart.
* Prescriber should write the following:
o Date to administer.
o Name of drug.
o Dose of drug.
o Route of administration.
o Time to administer.
o Prescriber signature.
* Nursing staff use the column on the far
right to document drug administration.
8. Meds Management Section
* Section filled by pharmacy staff only.
* Med history: technician or pharmacist will
confirm the drug history using at least 2
sources – tick box to show the sources.
Compliance issues documented.
* Meds reconciled: pharmacist ensures that all
meds are accounted for -continued, stopped,
with-held. If issues to resolve, do not tick.
* Document blood results, GP and community
pharmacy details, and whether the discharge
script completed.
9. Acute Antimicrobial Prescription
* Short courses of antibiotics, antifungals and antivirals should be
prescribed here.
* Prescriber should document course start date, drug name, drug
dose and route of administration, and their signature.
* Prescriber or pharmacist may document indication, review
date/course length and if choice is compliant with guidelines /
based on microbiology advice / based on sample cultures and
sensitivities.
* Pharmacist will sign box to say they are happy that the choice is
clinically appropriate and correctly prescribed.
* Nursing staff will sign box with their initials to show they have
given a dose.
* NB: One day = one column.
* Review column should be completed by medics within 72h of
prescribing the drug. They should review the script to see if it’s
still needed, if the drug should be switched to an alternative
based on culture results, or if the route of administration can be
switched from IV route to PO - this encourages better
antimicrobial stewardship.
10. Prolonged Antimicrobial Section
* Longer courses (over 7 days) of antibiotics, antifungals
and antivirals should be prescribed here.
* Prescriber, pharmacist and nurse will still complete the
same sections as previously.
* Review date / course completion date should still be
documented and reviewed, as well as indication to
ensure prolonged antimicrobial course is suitable.
* Section is usually used for complex infections which need
long antibiotic courses (e.g. bone infections) or long-term
prophylaxis.
11. VTE Prophylaxis
* All patients should be assessed by the doctor to see if
they are at risk of developing blood clots whilst in
hospital.
* If deemed at risk, will need to prescribe VTE prophylaxis.
* Exact choice will vary between hospitals, but it usually a
once-daily subcutaneous injection.
12. New Medication
* Drug is newly prescribed during this admission – see that
‘started’ has been circled on drug chart.
* Prescriber fills in usual – date, route, drug name, dose,
and signature.
* Pharmacist signs to state its clinically appropriate.
* Nurse signs to show they’ve administered the dose.
13. Regular Medication
* Patient’s usual medication from home has been
prescribed – see that ‘continued’ has been circled on
drug chart.
* Prescriber, pharmacist and nurse fill in same sections as
previously discussed.
* Pharmacist or technician will fill in supply box – is the
drug kept as stock on the ward? Has the patient brought
in a supply from home? Has a box been ordered and
dispensed by the hospital dispensary?
Ideally, patient will take all of the medication as prescribed on the drug chart. In reality, this isn’t always the case. Codes are used in the nurse administration
box to document what actually happened:
* Nurse’s initials – medication has been administered as prescribed.
* Number 2 – Patient isn’t on the ward so cannot receive the dose. The patient may be in theatre, having a scan, having a coffee in the canteen etc.
* Number 3 – Patient cannot receive the dose. They may be unable to swallow the tablet, they may not have IV access, they may be receiving medicines
via alternative routes (e.g. via NG feeding tube). This is a prime opportunity for a pharmacist’s input – can we crush the tablets, are there alternative
formulations or do we need a completely different drug?
* Number 4 – Patient refused medicine. This often presents as another opportunity for pharmacist intervention – why are the refusing? Is it that they
do not understand the indication? Do they not like the flavour of the medicine? Are they having difficulty swallowing a tablet? Have the original
symptoms resolved – e.g. diarrhoea, constipation, pain?
* Number 5 – Medicine unavailable. This again is a signal for pharmacist/technician intervention. The drug isn’t available on the ward, so it needs to be
ordered.
* Number 6 – Other. The nurse should write the full reason on the allocated section on the back of the drug chart.
* X or line through the box – Do not administer as per prescriber request. May be used to with-hold a drug – e.g. while waiting for renal or hepatic
function to improve. May be used for doses such as once weekly – will cross out the boxes on the days where the drug is not needed.
14. When Required Medication
* Used for medicines that are not needed every day – e.g.
painkillers or anti-sickness medication.
* Prescriber should document indication so that nursing
staff know when to offer the patient the medication
5. Fluid Infusions
* Bags of fluid may be administered
to patients if dehydrated, e.g.
* The type of fluid, its strength, its
volume and route of
administration must be specified.
* Infusion rate may be specified
(mL/hour) or the time over which
to give the fluid (minutes or hours
16. Drug Infusions
* Medication that must be administered as an intravenous infusion must be prescribed on this side
of the drug chart.
* The drug name and dose must be specified. Usually, the drug will need to be further diluted
before administration – this fluid must be specified on the drug chart, as well as its volume.

Question 24

clinical check example

Answer 24

clinical issues identified
patient characteristics
Patient “type” – young female of childbearing potential, needs to be
on PPP
Co-morbidities – epilepsy, nil else
Patient allergies, intolerances and preferences – none, ?prefer regular
brand
* Medication characteristics
Indication – epilepsy, contraception
Changes in regular treatment – none; however prescription does not
match record
Duration – regular monthly medication; appropriate
Dose, frequency, strength – dose transcription error, can’t check dose
unless know preparation
Formulation – category 2 AED; ?prescribe by brand
Compatibility – no interactions
Monitoring requirements – regular epilepsy rev, including PPP –
?annual risk acknowledgement
*Medication administration
Route – appropriate
Need for aids – no
Action needed
check DoB
Must been on PPP – no longer compliant with this.
Needs to be urgently addressed.
Dose difference between record and script. May
be a simple transcription error when script
produced, but dose may have changed.
Investigate and rectify if necessary.
May be better to prescribe by brand – does the
patient have a usual brand?
Ensure review process in place. Including for
Annual Risk Acknowledgement and PPP

Question 25

clinical check example

Answer 25

aissue idenitified
Ptient characteristics
Patient “type” – no issues
Co-morbidities – none
Patient allergies, intolerances and preferences – none
* Medication characteristics
Indication – anxiety-related insomnia and panic disorder
Changes in regular treatment – starting medication, on regular SJW
Duration – appropriate follow-up in place
Dose, frequency, strength – citalopram ok, diazepam likely underdose
Formulation – no issues
Compatibility – citalopram + SJW Ix
Monitoring requirements – GP f/u
*Medication administration
Route – appropriate
Need for aids – no
action needed
Stop SJW – advise pt on signs and symptoms of
the serotonin syndrome.
Ensure review in place for follow-up of effect and
dose escalation of citalopram if necessary.
Diazepam dose is low – was this meant to be
higher?

Question 26

clinical check example

Answer 26

issue identified
1.Sertraline dose
o Type of SSRI, so suitable first line choice
o Starting dose for depressive illness is usually 50mg
OD, not 25mg OD
* 2.Sertraline quantity
o NICE guidelines- ideally review patients within 2
weeks of starting medication
o 4-week supply on prescription
* 3. Sertraline and clopidogrel interaction
o Severe interaction, increased risk of bleeding
* 4. Omeprazole and clopidogrel interaction
o Omeprazole predicted to decrease antiplatelet effect
of clopidogrel
action needed
Issue 1 Resolution
o Discuss w GP
o Recommend dose changed and get
new script
* Issue 2 Resolution
o Speak with patient to confirm that they
are due to have a review with GP in
next 2-4 weeks
* Issue 3 Resolution
o Counsel patient on signs of bleeding
(e.g. blood in stool)
* Issue 4 Resolution
o Discuss w GP
o Swap omeprazole to a different PPI
that doesn’t interact, e.g. lansoprazole

Question 27

clinical check ex

Answer 27

issue idenitified
Meropenem 1g TDS
* 1st line based on guidelines for HAP with non-severe pen allergy
* Dose not appropriate based on CrCL; should be 1g BD
* Meropenem and sodium valproate interaction: C/I as reduces
sodium valproate levels – could lead to seizure
- Acute kidney injury (CrCL: 31 ml/min); need to review already
clinically checked medication:
* Tinzaparin 4500 units OD – clinically appropriate
* Epilim 500mg BD – clinically appropriate
* Alendronic acid 70mg SUN: C/I if CrCL < 35ml/min
* Adcal D2 caplets: 2 BD: clinically appropriate
* Mirtazapine 15mg ON: risk of accumulation
- Interaction with Alendronic acid and adcal D3
action needed
- Speak to the medical team and advise
meropenem to stop (note: important not to
stop anti-epileptic treatment in this case – may
loose seizure control)
- No IV second line in antimicrobial guidelines –
likely team would need to speak to
microbiology
- Monitor CrCL over the week – if still
<35ml/min by Sunday when Alendronic acid
due, hold the Alendronic acid
- Mirtazapine; monitor for s/e – on low dose
- Alendronic acid and adcal interaction – give
Alendronic acid 30 mins before adcal.

Question 28

clinical check ex

Answer 28

issue identified
1. Carbamazepine Prescription
o Carbamazepine is classed as a ‘Category 1’
antiepileptic by the MHRA/CHM, meaning patients
should be maintained on the same brand to ensure
seizure control is maintained. Brand not specified on
drug chart.
* 2. Flucloxacillin Prescription
o Choice of antibiotic is as per local guidelines for
cellulitis in a child.
o However, capsules prescribed. Based on age and
that liquid carbamazepine is prescribed, would be
more suitable for child to be prescribed liquid
flucloxacillin.
* 3.Ibuprofen Prescription
o Suitable for indication, but incorrect dose prescribed
* 4. Interactions
o Non-severe interaction between carbamazepine and
flucloxacillin – increased risk of hepatotoxicity
o Non-severe interaction between carbamazepine and
ibuprofen – increased risk of hyponatraemia
action needed
* Issue 1 resolution
o Endorse the chart with the brand that
the patient was taking prior to
admission: Tegretol
* Issue 2 resolution
o No dose change is needed when
switching patients
from flucloxacillin capsules
to suspension, so can just
endorse drug chart with the word ‘liquid’
and supply. It’s courteous to highlight
this to the doctor and the nurse caring
for the patient.
* Issue 3 resolution
o Discuss with doctor to increase dose to
150mg TDS based on age, to ensure
pain optimally managed
* Issue 4 resolution
o Monitor LFTs and Na levels

Question 29

clinical check ex

Answer 29

issue identified
pixaban dose incorrect: Should be 5mg BD
o Cr <133 (CrCL >90)
o Age < 80
o Wt >60kg
- Bisoprolol dose within license for AF
o Patient is already taking bisoprolol – is this instead of
current dose or on top of current dose
nteraction with apixaban and clopidogrel → increased
bleeding risk
action needed
Discuss with prescriber – explain dose incorrect and
advise dose increase
Discuss with prescriber – whether instead of or in
addition to current dose. Outcome will need to be
communicated to primary care colleagues;
endorsement made on Rx
Discuss with prescriber; will likely need to stop due to
bleeding risk and apixaban can also be used in stroke
prevention