Prescription review

Question 1

What to look at reviewing prescriptions

Answer 1

1. allergies
2. any drugs contributing to their current state e.g. renal toxicity
3. electrolytes abnormalities
4. dosage and frequency of drugs
5. any blood thinners risks>benefits

Question 2

PReSCRIBER mnemonic

Answer 2

Patient details
Reaction (allergy)
Sign front of chart
Contraindications
Route of drug
Intravenous fluids?
Blood clot prophylaxis? 
antiEmetic?
pain Relief?

Question 3

Side effects (contraindications) of STEROIDS mnemonic

Answer 3

Stomach ulcers
Thin skin
oEdema
Right and left heart failure
Osteoporosis 
Infection (candida)
Diabetes (hyperglycaemia)
cushing's Syndrome

Question 4

Considerations for NSAID mnemonic

Answer 4

No urine (intra-renal cause of AKI)
Systolic dysfunction
Asthma
Indigestion 
Dyscrasia (clotting abnormality)

Question 5

Antihypertensives side effects

Answer 5

hypotension
bradycardia (beta blockers and CCBs)
electrolyte disturbances (ACEi and diuretics)
ACEi - dry cough
Beta blockers - wheeze, worsen acute heart failure
CCBs - peripheral oedema
Diuretics - renal failure
- thiazide - gout
- K-sparing (spironoLACtone) - gynaecomastia

Question 6

Fluid prescribing - which?

Answer 6

all patients give 0.9% saline unless

• hypernatraemic/hypoglycaemic: give 5% dextrose
• ascites: give human albumin solution (maintains oncotic pressure and 0.9% saline worsens ascites)
• shocked due to blood loss: replace with blood

Question 7

Fluid replacement - How much?

Answer 7

1. assess HR, BP and urine
2. bolus 500ml in <15mins then reassess
   - if oliguric - 1L over 2-4hrs
3. never prescribe more than 2L

Question 8

IV potassium

Answer 8

do not give more than 10mmol/hour

Question 9

Fluid maintenance

Answer 9

• approx. 2-3L over 24hrs
• 1 salty and 2 sweet - 1L 0.9% saline and 2L 5% dextrose
• KCl can be added to dextrose or saline - approx. 40mmol per day
• give 1 bag over 8-12hours

Question 10

Antiemetic common traps

Answer 10

metoclopramide - avoid in patients with Parkinsons and young women
- dopamine agonist - exacerbates symptoms and causes dyskinesia

Question 11

Choosing antiemetics - nauseated

Answer 11

Cyclizine 50mg 8hourly IM/IV/oral but can cause fluid retention
metoclopramide 10mg 8hourly IM/IV if heart failure
ondansetron 4mg or 8mg 8hourly IV/oral

Question 12

Choosing antiemetics - not nauseated

Answer 12

as required
cyclizine 50mg up to 8hourly IM/IV/oral
metoclopramide 10mg up to 8hourly IM/IV if heart failure

Question 13

Choosing pain relief - no pain

Answer 13

nil regular

PRN - paracetamol 1g up to 6hourly oral

Question 14

Choosing pain relief - mild

Answer 14

paracetamol 1g 6hourly oral

PRN - codeine 30mg up to 6hourly oral

Question 15

Choosing pain relief - severe

Answer 15

co-codamol 30/500, 2 tablets 6hourly oral

PRN - morphine sulphate (10mg/5ml) 10mg up to 6 hourly oral

Question 16

Neuropathic pain relief

Answer 16

NSAID 400mg 8 hourly if not contraindicated
1st line - amitriptyline 10mg oral at night
2nd line - pregabalin 75mg oral 12hourly
diabetic neuropathy - duloxetine 60mg oral daily