Additional resources for Sessional GPs
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.
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.
| Sex | Age | Diagnosis | Prescribing choice | Why did you choose this course of action |
|---|---|---|---|---|
| F | 3 | Sore throat | Penicillin V 125mg qid | Child 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.