41857258It is recognised that many of the sections in this resource pack will not be suitable for Sessional GPs, Practice Prescribing Report data is not available and, unless in a regular post, follow up of patients is difficult. Case reports will obviously be an appropriate method as would significant events. Suggested below is a review of prescribing that may be helpful.

Prescribing habits

Collect 20 consecutive consultation in which prescribing is an issue – this could be stopping or changing medication, a conscious decision not to prescribe or changing a dose or regimen. A template is available here

Example

Sex Age Diagnosis Prescribing choice Why did you choose this course of action
F 3 Sore throat Penicillin V 125mg qid Chid was unwell some pus on tonsils
M 37 Back pain Co-codamol 8-500 Acute back pain following lifting analgesia only
M 65 Diabetes Increase metformin from 500 bd to 1000mg bd Patient has HBa1c of 8.5 and is obese – increasing dose logical choice
F 44 Depression Cipralex 10 mg od New depression I know that Cipralex well tolerated
M 6 Sore throat Penicillin V 125mg qid Mum pressurised for antibiotics – child feverish
F 60 Hypertension Increase Ramipril to 10mg od Uncontrolled hypertension on 5mg Ramipril – I remembered to have U+E checked in a week
F 32 Cough Advice only Patient had 3 day history of non productive cough chest clear advice only
M 65 Chest pain GTN spray aspirin Anginal sounding pain infrequently given GTN as a therapeutic trial investigations instigated (ecg and bloods), aspirin given as a preventative until diagnosis established/refuted
F 4 Otitis media Amoxycillin 125mg tid Child in pain with fever mother wanted treatment
M 27 Dental abscess Metronidazole 400mg tid Unable to access dentist for 3 days had facial swelling and pain
F 19 Morning after pill request Levonelle 1 Appropriate prescription also told to take the two at once – I picked this up on my recent contraception course
F 17 Anxiety Propranolol SR 80 mg Exam nerves – did not want to prescribe sedative drug
M 12 Asthma Seretide 125mcg Patient on salbutamol and beclamethasone (200 mcg bd) still symptomatic next step is to add a long acting b 2 agonist
F 2 Runny nose and cough Amoxycillin 125mg tid Had symptoms for 3 days with purulent nasal discharge – chest clear
F 56 Anxiety and depression Diazepam 2mg (20 only given) cipralex 10mg This lady was very anxious I therefore prescribed short term diazepam in addition to an anti depressant which should help long term
M 52 Hypertension No prescription This patient had borderline hypertension, I discussed the options with him and he is going to try diet and exercise for 3 months – for follow up
M 63 Stable angina Increased dose of statin This patient has chronic stable angina and a cholesterol of 5.6. evidence suggests that this should be lower I therefore increased the dose of simvastatin from 20 to 40mg
F 4 Sore throat red eyes chloramphenicol eye drops, amoxicillin 125mg tid Sticky eye red and red throat
M 2 Sore throat Amoxicillin 125mg tid Red throat brother of the patient above
F 35 Postponement of menstruation Primolut N tds Going on holiday in 2 weeks time wished menstrual cycle postponed

Learning points identified from these cases

I was struck by the fact that I saw six children with infections in the twenty patients – probably a reflection of the time of year and the normal case mix I see as a locum. I prescribed antibiotics to all six and I am sure that is not the correct course of action. I also issued four prescriptions with proprietary names. I have used cipralex twice as my antidepressant of choice, I am aware that it is more expensive than other antidepressants. I have made some alterations to patients long term medications that I believe are appropriate and I have used the choice not to prescribe on two occasions.

Action to be taken/changes to be made

I think I need to look closely at my prescribing of antibiotics in children. I am aware that parental pressure can influence my choice to prescribe. I also need to prescribe generically where appropriate and think about my first choice antidepressant.