It 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.
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.
|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.