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*Medicine: Prescribing > Prescription Review > Flashcards

Prescription Review Flashcards

1
Q

Many prescriptions errors can be madee and this emphasises the need for a comprehensive prescribing routine that may be followed every time you prescribe. The following mneumonic (PReSCRIBER) covers all these pitfalls and related traps within the PSA.

What constitutes PReSCRIBER?

A
  • Patient details (always check the name!)
  • Reaction (ie. allergy plus the reaction)
  • Sign the front of the chart
  • check for Contraindications to each drug
  • check Route for each drug
  • prescribe Intravenous fluids if needed
  • prescribe Blood clot prophylaxis if needed
  • prescribe antiEmetic if needed
  • prescribe pain Relief if needed
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2
Q

How do you ensure the correct patient details?

A
  • New chart? → write name, DoB, hosp number
  • Current chart? → check the name + DoB
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3
Q

How do you notice and record reactions?

A
  • New chart? → complete allergy box incl any drug rxn mentioned by pt
  • Current chart? → check allergy box

Do not forget that co-amoxiclav and Tazocin both contain penicillin

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4
Q

What should you remember to do with each prescription chart and even each individual prescription?

A

Sign the front of the chart / sign the prescription

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5
Q

Which drugs increase bleeding?

A
  • Aspirin
  • Heparin
  • Warfarin
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6
Q

What are the contraindications to the drugs that increase bleeding?

A
  • Avoid in pts who are bleeding, suspected bleeding or at risk of bleeding
  • Prophylactic heparin is contraindicated in acute ischaemic stroke (risk of bleeding into the stroke)
  • Enzyme inhibitors can increase warfarin’s effect (and thus increase INR or PT)
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7
Q

STEROIDS

What are the side-effects (and thus loosely, the contraindications) of steroids?

A
  • Stomach ulcers
  • Thin skin
  • oEdema
  • R + L heart failure
  • Osteoporosis
  • Infection (incl candida)
  • Diabetes (commonly causes hyperglycaemia, uncommonly diabetes)
  • cushing’s Syndrome
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8
Q

NSAID

What are the cautions and contraindications for NSAIDs?

A
  • No urine (renal failure)
  • Systolic dysfunction (HF)
  • Asthma
  • Indigestion
  • Dyscrasia (clotting abnormality)

N.B. Aspirin is not CI in renal failure, heart failure or asthma

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9
Q

What 3 categories can we divide the side-effects of antihypertensives into?

A
  • Hypotension (all)
  • Mechanistic
    • bradycardia → beta-blockers, CCBs
    • electrolyte disturbance → ACEi, diuretics
  • Specific
    • ACEi → dry cough
    • Beta-blockers → wheeze (in asthma), worsening acute HF (but helps chronic HF)
    • CCB → peripheral oedema + flushing
    • Diuretics → renal failure, gout (loops), gynaecomastia (K-sparing)
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10
Q

What should be remembered when checking the route for each drug?

A
  • Vomiting → IM/IV/SC anti-emetics; also if short-term vomiting then not necessary to change route of other drugs too
  • NBM → should still receive oral meds, incl prior to surgery
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11
Q

There is no single ‘right’ answer for most fluid prescriptions, but there are always ‘wrong’ answers.

In which two situations are IV fluids prescribed?

A
  1. Replacement fluids for dehydrated/acutely unwell pt
  2. Maintenance in pt who is NBM

In both instances, one must consider which fluid, how much to give and how fast

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12
Q

For replacement, which fluid should be given to all patients (as a rule of thumb)?

A

0.9% NaCl (crystalloid)

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13
Q

What are the exceptions to giving NaCl 0.9% for fluid replacement?

A
  • Hypernatraemic or hypoglycaemic → 5% dextrose
  • Ascites → human-albumin solution (HAS)
  • Shocked from bleeding → blood transfusion
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14
Q

For replacement fluids, how much fluid should be given and how fast?

A
  • Start by assessing BP, HR and urine output
  • If tachycardic + hypotensive → 500mL bolus stat (or 250mL in HF)
  • Reassess patient (HR, BP, UO)

Can predict how fluid-depleted an adult is by looking at obs
* Reduced urine output → 500mL of fluid depletion
* Reduced UO + tachycardia → 1L of fluid depletion
Reduced UO + tachy + shock → >2L fluid depletion

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15
Q

How much fluid should be prescribed as the maximum for a sick patient (replacement fluids)?

A
  • Never more than 2L
  • Effect on pt and thus rate of subsequent fluids should be reviewed regularly
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16
Q

For maintenance fluids, which fluids should be given and how much?

A
  • Adults require 3L IV fluid / 24 hrs and elderly require 2L
  • Adequate electrolytes by 1 salty + 2 sweet → 1L 0.9% NaCl and 2L 5% dextrose
17
Q

For maintenance fluids, what is the potassium requirement?

A
  • Use 5% dextrose or 0.9% NaCl containing KCl
  • Guided by U+Es
  • W/ normal potassium level, pts require roughly 40 mmol KCl per day, so put 20 mmol KCl in two bags
  • IV potassium should not be given at more than 10 mmol/hour
18
Q

How fast do we give maintenance fluids?

A
  • 3L → 8 hrly bags (24/3)
  • 2L → 12 hrly bags (24/2)
19
Q

What is the blood clot prophylaxis for patients in hospital?

A
  • Majority given prophylactic LMWH → dalteparin 5000 units daily SC + TEDS
    • avoid warfarin/heparin if bleeding
    • don’t give TEDS if peripheral arterial disease
20
Q

Which antiemetic is prescribed for a nauseated patient?

A
  • Regular antiemetic
  • Cyclizine 50mg 8-hrly IM/IV/oral for most cases (SE: fluid retention)
  • Metoclopramide 10mg 8-hrly IM/IV if heart failure

Cyclizine is a good first-line treatment for almost all cases except cardiac cases (as it can worsen fluid retention), whereas metoclopramide 10mg 8-hrly IM/IV is safer

21
Q

Which antiemetic is prescribed for non-nauseated patients?

A

Same as nauseated but ‘as-required’ rather than regular

22
Q

When should metoclopramide (dopamine antagonist) be avoided?

A
  • Parkinson’s patients due to risk of exacerbating symptoms
  • Young women due to risk of dyskinesia ie. unwanted movements especially acute dystonia → procyclidine will abort these dystonic attacks
23
Q

What pain relief should be prescribed for patients?

A
  • No more than 4g paracetamol per day
  • NSAIDs can be introduced at any stage (if no CI)
  • Morphine sulphate may be given orally → oramorph - the usual strength is 10mg/5mL
24
Q

What is the painkiller treatment for neuropathic pain?

A
  • Pain arising from nerve damage or disease → shooting / stabbing / burning
  • 1st-line → amitriptyline 10mg oral nightly OR
  • pregabalin 75mg oral 12-hrly
  • Painful diabetic neuropathy → duloxetine 60mg oral daily
25
Q

Which drugs are eliminated by the kidneys?

A
  • CVS → atenolol / digoxin
  • Neuro → opioids / gabapentin / lithium
  • Infection → penicillins / aminoglycosides
  • Other → LMWH / allopurinol / metformin
26
Q

What are the nephrotoxic drugs (4)?

A
  • NSAIDs
  • Aminoglycosides
  • Radiographic contrast material
  • Trimethoprim
27
Q

For sick-day rules, which drugs are to be withheld if there is a risk of volume depletion?

A
  • ACEi
  • ARBs
  • Diuretics
  • NSAIDs
  • Metformin
28
Q

Which drugs are hepatotoxic?

A
  • Dose-dependent → paracetamol / methotrexate
  • Idiosyncratic → phenytoin / co-amoxiclav
29
Q

Which drugs can precipitate encephalopathy?

A
  • Sedatives → opioiods / benzos / TCAs
  • Hypokalaemic effects → diuretics
  • Constipating effects → antimuscarinics
30
Q

Which drugs are prescribed in micrograms, but often mistakenly substituted for miligrams?

A
  • Digoxin
  • Levothyroxine
  • Tamsulosin
  • Inhaled bronchodilators
31
Q

Which drugs are prescribed in units?

A
  • Insulin
  • Heparins
32
Q

Which drugs are prescribed weekly?

A
  • Bisphosphonates
  • Methotrexate

Don’t mistake for daily

33
Q

Who are paracetamol dosing errors likely in?

A
  • Children
  • Adults receiving IV paracetamol who either have low body weight or existing liver disease
34
Q

What are common drug interaction scenarios?

A
  • Electrolyte abnormalities
  • Renal impairment
  • Postural hypotension/dizziness
  • Arrhtyhmias (particular heart block, increased QTc)
  • Over/under-anticoagulation
  • Theophylline interactions
  • Lithium interactions
35
Q

What is the interaction between methotrexate and trimethoprim?

A

Both folate antagonists

36
Q

What is the interaction between SSRIs and antiplatelets/NSAIDs?

A

Inhibit serotonin uptake in platelets (SSRIs) which creates theoretical risk of increasing bleeding especially with NSAIDs

37
Q

What are the signs of serotonin syndrome?

A
  • Confusion
  • Agitation
  • Hyperthermia
  • Hyperrefflexia
  • Clonus
  • Hypertonia
38
Q

What is the treatment for serotonin syndrome?

A
  • Withdraw serotonergic drugs
  • Cooling and supportive care
  • Benzos as required
39
Q

Which kinds of drugs precipitate hepatic encephalopathy?

A
  • Drugs with sedative effects: sedating anti-histamines (e.g. chlorphenamine), benzodiazepines
  • Drugs with potassium-lowering effects (because hypokalaemia increases renal ammonium production): thiazide diuretics, loop diuretics (e.g. furosemide)
  • Drugs with constipating effects: opioids, calcium-channel blockers, etc

Some examples work by more than one of these mechanisms (e.g. opioids).

*Medicine: Prescribing (13 decks)

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