Sunderland HBP Medicine - Prescribing Blog

Case 5b

6/8/2016

Diagnosis: perforated viscus, the xray appearance and story would go with a likely diagnosis of perforated peptic ulcer, although any perforated hollow organ could cause this picture of free gas under the diaphragm (remember to differentiate it from gas in the hiatus of the stomach)

Priorities: physiological resuscitation/fluid therapy, pain relief, antibiotics. 2 further things to think about, DVT prophylaxis and the prescription of normal medication.

Now please prescribe these on a standard drug and fluid chart

John Smith dob 12.5.1970 X12345

Answers in a couple of days

Case 5 Emergency admission with Abdominal Pain

6/8/2016

A 45 yr-old man is admitted with severe abdominal pain. His Chest X-ray is displayed opposite.

First of all: What is the diagnosis?

Your registrar says that the patient is going to theatre in the next hour for an exploratory laparotomy. They have asked you to "sort that out"

You do an ABC assessment and the patient is alert but complaining of severe pain. They are tachycardic and have cold hands. Their blood pressure is maintained.

What 3 issues do you need to prescribe for before theatre, and what important but often overlooked 2 further issues should you bear in mind when clerking the patient?

Answers to the this question coming in a day or so then you will be asked to prescribe for them....why not give it a go already??

The x-ray for this case was taken from radiopaedia....don't click on the link just yet or you'll spoil the suspense!! But once you have had a stab at the diagnosis then have a look.

Case courtesy of Dr Frank Gaillard, <a href="http://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="http://radiopaedia.org/cases/18593">rID: 18593</a>

Case 4c

6/8/2016

Information before leaving the surgery

How to take the pill (every day, same time every day)
What to do if pill missed
What side effects to deal with
Potentially advice re STD avoidance

The FP10 prescription is below

Case 4b

6/8/2016

Q1.        What 4 questions would you like to ask Naomi?

1.       Smoking ? - She has smoked 10 cigarettes/day 15 years.

2.       Headaches/migraines? - She has never experienced migraines.

3.       Personal Hx or FHx of VTE, breast cancer, HTN or diabetes? - She has no personal or family history of VTE, breast cancer, high blood pressure or diabetes.

4.       Problems with gallstones or gallbladder? - She had her gallbladder removed in 1995.

Q2.      Which 2 investigations would you perform? (remember you are in GP)

You take her weight and check her blood pressure.

BP 110/85 mmHG
BMI 38 kg/m2

Q3. Please prescribe Naomi Banks an appropriate oral contraceptive.

Patient details;
Name: Naomi Banks
DOB: 12/5/1979
Address: 123 Rose View
Sunderland
SR47TP

Prescribing 4

6/8/2016

This week we are looking at a GP/Women's health question. This has been provided by Catherine Thatcher, TF at Sunderland:

You are a foundation doctor based in General Practice.

Naomi Banks has made an appointment to discuss her contraception.

She is 36 year old. She has three children; she gave birth to her last child 2 years ago. Since then she has been using condoms but would now like to switch to an oral contraceptive.

(Some of her close friends have had a bad experience with both the implant and the coil, and she has heard that the depo-provera injections can make you gain weight.)

Q1. What 4 questions would you like to ask Naomi?
Q2. What investigations/examinations would you like to do....remember you are in GP?

Case 3b the answers

6/8/2016

More Drug calculations....again I think you will all get more from this if you actually prescribe the the drugs/fluids/additives on a real drug chart
1. The fluid protocol in your hospital for children is as follows. Maintenance fluids: 4ml/kg/hr first 10 kilo, 2ml/kg/hr 2nd 10 kilos, 1ml/kg/hr subsequent weight. Prescribe maintenance fluids Maintenance for 5, 11, 18, 25 and 30 kg children on a drug chart

5kg 5x4=20 ml/hr
11kg 10x4 + 1x2 = 42ml/hr
18kg 10x4 + 8x2 = 56ml/hr
25kg 10x4 +10x2 + 5x1 = 65ml/hr
30 kg 10x4 +10x2 + 10x1 = 70ml/hr

2. A more difficult one. In the HDU adrenaline (epinephrine) is mixed as 4mg in 50 ml of saline and administered using a syringe driver. You are asked to prescribe 5 microgrammes per kilo per hour for an 80 kg man. What infusion rate (in ml/hr) is required?

4mg in 50 ml: 4000micrograms in 50 ml: 80 micrograms/ml

80kg man 5 mcg/kg/hr 5x80 = 400mcg/hr

400mcg/hr= 400/80 ml/hr =5ml/hr

3. You are on the admisssions unit and a patient has been admitted with a significant overdose (you could think what I mean by that) but for the timebeing you are asked to prescrive the N-acetyl cysteine for the patient (65 kg). Prescribe this on a fluid chart.

First infusion (based on an acetylcysteine dose of approx. 150 mg/kg)—add requisite volume of Acetylcysteine Concentrate for Intravenous Infusion to 200 mL Glucose Intravenous Infusion 5%; infuse over 1 hour.

60–69 kg 49 mL

Second infusion (based on an acetylcysteine dose of approx. 50 mg/kg; start immediately after completion of first infusion)—add requisite volume of Acetylcysteine Concentrate for Intravenous Infusion to 500 mL Glucose Intravenous Infusion 5%; infuse over 4 hours.

60–69 kg 17 mL

Third infusion (based on an acetylcysteine dose of approx. 100 mg/kg; start immediately after completion of second infusion)—add requisite volume of Acetylcysteine Concentrate for Intravenous Infusion to 1 litre Glucose Intravenous Infusion 5%; infuse over 16 hours

60–69 kg 33 mL

Case 3 more drug calculations

6/8/2016

More Drug calculations....again I think you will all get more from this if you actually prescribe the the drugs/fluids/additives on a real drug chart

The fluid protocol in your hospital for children is as follows. Maintenance fluids: 4ml/kg/hr first 10 kilo, 2ml/kg/hr 2nd 10 kilos, 1ml/kg/hr subsequent weight. Prescribe maintenance fluids Maintenance for 5, 11, 18, 25 and 30 kg children on a drug chart
A more difficult one. In the HDU adrenaline (epinephrine) is mixed as 4mg in 50 ml of saline and administered using a syringe driver. You are asked to prescribe 5 microgrammes per kilo per hour for an 80 kg man. What infusion rate (in ml/hr) is required?
You are on the admisssions unit and a patient has been admitted with a significant overdose (you could think what I mean by that) but for the timebeing you are asked to prescrive the N-acetyl cysteine for the patient (65 kg). Prescribe this on a fluid chart.

Prescribing 2b the answers

6/8/2016

1. You are looking after an adult admitted with DKA. The protocol asks for an Insulin infusion at 0.05 units/kg/hour via 50 ml syringe driver. Describe HOW you would set up the infusion. 45kg adult. Prescribe this on an infusion/additive chart

Insulin syringe for insulin, 50 units added to 49.5ml normal saline: 1 unit per ml
45 kg/0.05 unit per/kg/hr 2.25 units per hour.
2.25 ml per hour via syringe driver

2. You need to administer an iv bolus of Morphine, which comes as 10mg of powder in a vial. How would you give a 3mg slow bolus?

10 ml of saline in 10 ml syringe
Dissolve morphine in 10 ml to make 1mg/ml solution
3ml bolus

3. You are asked to prescribe 15g/kg calpol (or paracetamol suspension I hear you cry) for a child (8Kg). What volume has to be delivered, and how would that be delivered practically. Prescribe it on a drug chart as a once only drug

15g x 8kg 120g
Paracetamol suspension (not calpol) 120mg/5ml (note 250/5ml is also available....a whole patient safety nightmare that we will not discuss here)
120g=5000ml of calpol…….1000 spoons so hopefully you will have thought that there is an issue with that....remember the pharmacy rule of threes

We can discuss this at the drop-in session. More calculations coming soon

Case 2...drug calculations

6/8/2016

Drug Calculations:

Drug calculations are part of the PSA.....and part of your work as an F1 next year. Increasingly electronic means are used to reduce human error with drug calcs, but for the time being you need to be able to do the calcs yourself. As with the previous problem I suggest that you do these calculations and prescribe them on the appropriate paperwork.....good luck, answers early next week
MC

You are looking after an adult admitted with DKA. The protocol asks for an Insulin infusion at 0.05 units/kg/hour via 50 ml syringe driver. Describe HOW you would set up the infusion. 45kg adult. Prescribe this on an infusion/additive chart
You need to administer an iv bolus of Morphine, which comes as 10mg of powder in a vial. How would you give a 3mg slow bolus?
You are asked to prescribe 15g/kg calpol (or paracetamol suspension I hear you cry) for a child (8Kg). What volume has to be delivered, and how would that be delivered practically. Prescribe it on a drug chart as a once only drug

More calcs next!!

Case 2 coming soon

5/8/2016

Case 1 is in the archive which can be found here