Y3 - Safe prescribing Flashcards
What key investigation should be done in an child with unexplained fever over 38 degrees
URINE sample within 24 hours
Send for microscopy and culture
When taking a paediatric medication history, what is it important to ask about?
- Birth weight
- drug allergies
- use of inhalers or creams
- any over the counter medication use
- patient tablet or liquid preference
- breast or bottle bed
- is mother on any medication if patient breast fed
E.coli is a …
Gram negative rod shaped bacteria
What routine advice should be give to parents of children who develop urinary tract infections to prevent reoccurence?
- Toilet hygiene: wipe front to back
- keep well hydrated
- do not delay toilet and hold urine in
- wear loose underwear
Information from a paediatric history which may suggest constipation?
- decreased stool frequency
- pain on defaecation
- recent change in diet
- overflow soiling mistaken for diarrhoea
Main difference between adult and paediatric management of constipation?
dietary interventions should not be used alone as 1st line tx, unlike in adults
Combination tx w/
–> laxatives
–> toilet schedules
–> dietary modification (fluid and adequate fibre)
–> encourage physical activity
Recommended fibre intake for adults suffering with constipation
30g per day
If a patient is taking liquid preparations in mls, what is important to consider when writing their prescription chart :
PRESCRIBE IN mg
Need to work out dose in Mg
What important information should you give the parents of a patient who has just started a disimpaction and maintenance regime for constipation?
- open sachets and pour into water, stir until dissolves
- can add squash to make it taste nicer
- can be given at any time of the day: start in the morning so full dose can be given within 12 hours
- don’t have to drink it all in one go
- but must drink it all to have clinical development
- may not work immediately
- Diet and lifestyle: fluid intake, adequate fibre and exercise
- follow up with GP or outpatient services
Side effects of constipation treatment in kids
- stomach pains
- dehydration
- nausea
Important to keep patient well hydrated
Contraindications for the COCP
- history of breast cancer (can be used after 5 years if no evidence and non-hormonal methods unacceptable)
- migraine with aura
- personal PMHx venous or arterial thrombosis
- severe or multiple risk factors for arterial disease OR VTE
- transient cerebral ischaemic attacks without headaches
Combined oral contraceptive pill’s should be avoided in patients who have two of the following critiera:
- obesity (BMI > 30)
- SMOKING
- Diabetes mellitus
- FHx of arterial disease in 1st degree relative aged under 45
- HTN –> blood pressure above 140 systolic or 90 diastolic
- migraine without aura
Important questions to ask patient before starting contraceptoin?
Is she already using contraception?
Has she had emergency hormonal contraception?
Recently given birth?
Has she had a miscarriage or termination?
Does she normally have a regular cycle?
LMP?
Why is it important to ask a patient when they had their last menstrual period when considering starting the progestogen only pill?
POP
1. Can be started day 1-5 of menstrual cycle without needing any additional protection
- If at any point in the cycle
–> pregnancy test first
–> start POP BUT patient needs to use additional barrier methods for the next 48 hours
Starting POP on days 5-28 is OFF LABEL USE
Progesterone only Pill COUNSELLING
MODE OF ACTION
MODE OF ACTION
- suppresses ovulation
- increases hostile cervical mucus
- reduction in activity of cilia in the fallopian tube
Progesterone only Pill COUNSELLING
Advantages
- very effective when taken correctly
- sex doesn’t need to be interrupted
- can be used in women where COC not suitable
- may reduce risk of endometrial cancer
- Desogestrel may help manage dysmenorrhoea
- fertility returns to normal when POP stopped
Progesterone only Pill COUNSELLING
Disadvantages
- pills must be taken same time each day
—–> 3 hour window
—–> 12 hour window for desogestrel - Adverse effects
- unscheduled bleeding
- breast tenderness - Doesn’t protect against STI
- Ovarian cyst
- Headache
- Libido changes
- Cardiovascular disease –> MI, VTE, STROKE
If a women vomits within how many hours of taking an oral contraceptive, should she take another on:
If vomits within 2 hrs of taking pill - another one should be taken
If D&V > 24hrs
- avoid sex or use barrier methods during illness and for 48hrs after
Missed pill advice for POP
If missed POP
- take asap
- then next pill at normal time
- may mean taking 2 pills in 24 hrs
IF UPSI after missed pill and within 48hrs of restarting POP
–> consider emergency contraception
Important additional supplement a women may take during pregnancy
FOLIC ACID 400 micrograms daily up until 12th week of pregnancy
—> reduce risk of neural tube defects
Women who are at higher risk : take 5mg daily until week 12
—> previous spina bifida in pregnancy
—> epilepsy medication?
—> coeliac or malabsorption issues, DM
—> BMI of 30 of more
—> sickle cell, thalassaemia or thalassaemia trait
1st line RCOG guidance for nausea and vomiting in pregnancy
1st line –> CYCLIZINE or PROCHLORPERAZINE
CAUTION
- prochlorperazine in young women due to risk of dystonia
2nd line –> domperidone , metoclopramide
Ondansetron
–> beware concern about cardiac and renal malformations
Treatment of DVT in pregnancy
LMWH –> like enoxaparin SC
–> continue for remainder of pregnancy
–> and at least 6 weeks post natal
What would be the drug of choice is a patient with gestational diabetes had high blood sugars despite treatment with metformin
INSULIN
NICE guidelines for gestational diabetes
Fasting plasma glucose below 7mmol/L
–> diet and exercise trial
If targets not met within 1-2 weeks
—> metformin
Only give insulin if:
—> metformin contraindicated or unacceptable to women
opioid example which is safe in breast feeding
dihydrocodeine
Symptoms of pre-eclampsia include
- Swelling of feet, ankles, face and hands caused by fluid retention
- severe headache
- vision problems
- pain just below ribs
What medication options are available to manage raised BP in pregnancy:
- Labetalol
- Or nifedipine
OR if neither labetalol or nifedipine
–> methyldopa
For women at high risk of pre-eclampsia - ensure what is prescribed:
75-150mg aspirin daily from 12 weeks gestation until birth
Patients undergoing elective knee replacement should be given thromboprophylaxis - options include:
- Aspirin 75mg or 150mg OD for 14 days
- LMWH for 14 days w/ anti-embolism stockings until discharge
- DOAC (e.g. apixaban, dabigatran or rivaroxaban)
What are some indications that a patient may require fluid resuscitation?
RR > 20 breaths / minute
HR > 90 beats / minute
Systolic BP < 100mmHg
Cool peripheries or CRT > 2 seconds
45 degree passive leg raise suggests fluid responsiveness
NICE guidelines for fluid resuscitation
Sodium chloride 0.9%
Hartmann’s
You want to use crystalloids which contain sodium in the range 130-154
Prescribe a bolus of 500mls over 15 minutes
Patients at risk of fluid overload should be given what bolus of sodium chloride 0.9%
Given 250ml IV fluid bolus of NaCl 0.9% over 10 minutes
NICE guidelines for routine maintenance fluids
25-30 mL/kg/day of water
1mmol/kg/day of potassium, sodium and chloride
Approximately
50-100g of glucose to limit starvation ketosis
Which antibiotic is known to increase the concentration of warfarin thus leading to increased INR and increased risk of bleeding?
CLARITHROMYCIN
a potent CYP3A4 inhibitor
Appropriate management for a patient with an increased INR? (INR = 8)
- Stop warfarin
- administer phytomenadione
- restart warfarin once INR < 5
Why is warfarin withheld before surgery:
- long half time
- need to allow time for INR to fall below at least 1.4 by day of operation
How can patients take medication if they are NBM?
can use 30mls of water to take regular medication that is being continued on the morning of the operation
When prescribing LMWH what is it important to check in a patient?
- renal function
- weight
- full blood count
Medication considerations in the post-operative period
- Pain –> may lead to ileus, nausea and vomiting and immune suppression
- Nausea and vomiting –> around 25% of patients experience one or both of nausea and vomiting in the post operative period
- NBM –> intravenous fluids?
Scoring system used to assess whether an anti-emetic needs to be considered in a patient in the post operative period?
APFEL SCORE
1 point for
- female
- smoker
- history of post operative nausea and vomiting
- motion sickness
Considerations for a patient at discharge after surgery?
- Pain relief
- Anti-emetics
- Laxatives
- VTE prophylaxis
- Regular medications
What potential issues are there with prescribing ciprofloxacin:
- prolong QTc
- can lower seizure threshold
- can cause photosensitivity
- can exacerbate myasthenia gravis
If metformin alone is not controlling this patients blood glucose level; what options are available for treatment?
Metformin should be combined with one of the following:
1. Sulphonylurea
–> can cause hypoglycaemia
–> moderate weight gain
2. Pioglitazone
–> increased risk of heart failure when combined with insulin
–> risk of bladder cancer
3. DPP-4 inhibitor
–> associated with weight gain
–> less incidence of hypoglycaemia
4. SGLT-2 inhibitor
–> when sulphonylureas are contraindicated
–> slight risk of DKA
