Examination Always have a chaperone who can also guard the door. Ask friends and family mem bers to leave, unless the patient wants them to stay (this also provides an opportunity to ask questions which the patient may not have answered fully with others present). As with a ny examination it is essential to keep the patient informed about what you are going to do. Start with the patient lying fl at on their back with arms by their sides. See Fig. 3.21. Abdominal Assess for scars, striae, hernias, body hair distribution, everted umbilicus, dis tension, tenderness including loins ( guarding, rebound), masses, organomegaly, percuss (m asses, shifting dullness). Ask the patient to move her feet apart, bend her knees and let her legs fl op outwards. Hav e a strong light source directed at the vulva and gloves on both hands. Vulval Look for rashes, ulcers, warts, lumps or other lesions; spread the labia majora usin g your non-dominant thumb and index fi nger and look for lesions, lumps, discharge (urethra l/vaginal), bleeding; ask the patient to push down (look for prolapse) and cough. OHFP.indb 156 OHFP.indb 156 30/05/2014 16:18 30/05/2014 16:18 157 FEMALE REPRODUCTIVE SYSTEM Vaginal Insert a well-lubricated index and middle fi nger (dominant hand) into the vagina a nd feel for the cervix, noting the size, shape, consistency and whether it is mobile or ten der. Feel above, below and to the sides (adnexae) for masses or tenderness. Finally palpate the uterus by placing your other hand above the pubic symphysis and press down with the fi ngers at the cervix; pressing up feel for uterine position (anteverted/ retroverted), size , shape, consistency, mobility and tenderness. Inspect the fi nger afterwards for blood or discharge. Cusco \200\231s speculum Whilst the patient is in the same position insert a wel l lubricated and warmed speculum into the vagina. Look at the cervix for ulceration, bleedi ng, cysts or other lesions and the cervical os. If required take swabs and/or a cervical sm ear. Consider Sims speculum (for examining prolapses), rectal examination. Pubic bone Clitoris Bladder Uterus Rectum Cervix Fig. 3.21 Examination of the female reproductive system. Table 3.19 Descriptive terms in gynecology Anatomy Introitus the entrance to the vagina Adn exae the areas lateral to the cervix where the ovaries are located Abnormal bleeding Climac teric phase of irregular periods and associated symptoms prior to menopause Intermenstrual bleeding between periods Oligomenorrhoea infrequent menstruation, >42d menstrual cycle Meno pause the end of menstruation Menorrhagia excessive blood loss during menstruation (>80ml/c ycle) Postcoital bleeding after sexual intercourse Postmenopausal bleeding >6mth after the menopause Primary amenorrhoea failure to start menstruating by 16yr Secondary amenorrhoea a bsence of menstruation for >6mth after menstruation has started and not due to pregnancy Pain Dysmenorrhoea pain associated with menstruation Dyspareunia pain associated with sexua l intercourse, can be superfi cial (eg vulval or entrance to vagina) or deep (only on deep penetration) _OHFP.indb 157 _OHFP.indb 157 30/05/2014 16:18 30/05/2014 16:18 158 CHAPTER 3 History and examination Obstetric History Current pregnancy estimated due date (EDD), gestation, last menstrual period (LMP), method of conception, scan results, site of placenta, rhesus status, concerns, attitude to pregnancy; current symptoms bleeding, other vaginal discharge, headache, visual disturbanc e, dysuria, urinary frequency or urgency, constipation, vomiting, GORD. Previous pregnancies number of pregnancies (gravidity), number of deliv- eries \211 24/40w ks (parity), miscarriages, terminations (reason, gestation, method), stillbirths, complicat ions: vomiting, anemia, bleeding, group B strep, BP, proteinuria, gestational DM, poor feta l growth, admission. Delivery history method of delivery and reason (vaginal, ventouse, forceps, elective/emerge ncy Cesarean), gestation, birthweight, sex, complications (fever, prolonged rupture of memb ranes, CTG trace), postnatal baby problems (feeding, infection, jaundice), admission to SCB U/NNU, outcome (how is the child now), postnatal maternal prob- lems (pain, fever, bleeding , depression). Past gynae history previous problems, operations, STIs. Past medical history DVT, PE, DM, a dmissions, psychiatric problems. Family history DM, iBP, pre-eclampsia, congenital abnormal ities, DVT, PE, multiple pregnancies. Social history support from family/partner, type of housing, employ- ment, fi nancial probl ems, smoking, alcohol, substance abuse. Table 3.20 Antenatal care Gestation (wk) Standard antenatal care: purpose of each visit Booking FBC, G+S, red cell antibodies, rubella, syphilis, hepatitis B, HIV serology, sickle-cell di sease, BMI, BP, urine dipstick and culture USS for gestational assessment and nuchal screen ing Urine, BP, serum screening (for Down \200\231s and neural tube defects) USS for fetal a nomalies and growth and placental position Fundal height, BP, urine, FBC, red cell antibodi es, anti-D if rhesus \200\223ve Fundal height, BP, urine Fundal height, BP, urine, anti-D if rhesus \200\223ve Fetal position, fundal height, BP, urine Discuss induction, fetal pos ition, fundal height, BP, urine 11 \200\22314 16 20 28 25*, 31* 34 36, 38, 40* 41 For the fi rst pregnancy only. OHFP.indb 158 OHFP.indb 158 30/05/2014 16:18 30/05/2014 16:18 159 OBSTETRIC Examination Fetal heart Audible from 12wk using a Doppler ultrasound and 24wk using a Pinar d stethoscope; it is faster than the mother \200\231s (110 \200\223160bpm). Weight Plot mot her \200\231s weight and BMI (b p604) at the booking visit. Inspection Striae, linea nigra (line of pigmentation from the pubic sym- physis to the navel that darkens during the 1st t rimester), venous disten- sion, scars, oedema. Fundal height The fundus (top of the uterus) is palpable from about 12wk gestation; it shou ld be measured from the top of the pubic symphysis to the top of the fundus with a tape mea sure. Between 16 and 36wk the fundal height in centimeters should be the same as the gestat ion 2cm, eg 23 \200\22327cm at 25wk. Fundal height is unreliable after 36wk. See Fig. 3.2 2. 36 weeks 40 weeks 22 weeks 16 weeks 12 weeks Fig. 3.22 Location of the fundus as pregnancy progresses. Fetal lie After 32wk it is possible to assess the position of the fetus by palpating across the abdomen for the fetal head: \200 Longitudinal head palpable in midline \200 Obliqu e head palpable in iliac fossa \200 Transverse head palpable in lateral abdomen. Presenta tion Palpation after 32wk can also assess the presentation though this is liable to change until about 36wk. By palpating both ends of the fetus the position of the head can be deter mined: \200 Cephalic head is at the bottom \200 Breech head is at the top. Engagement T his is assessed by palpating the base of the uterus above the pubic symphysis between two h ands to assess how much of the pre- senting part is palpable. If only the top 1/5th of the presenting part is palpable the fetus has \200\230engaged \200\231. Blood pressure must be monitored regularly to assess for pregnancy induced iBP; consider urine dipstick and fundo scopy too. Urine dipstick for protein (pre-eclampsia) and glucose (DM). USS Lie, presentati on and engagement can be confi rmed on USS. _OHFP.indb 159 _OHFP.indb 159 30/05/2014 16:18 30/05/2014 16:18 160 CHAPTER 3 History and examination Psychiatric History Are you safe? sit so the patient is not between you and the door, remove all potent ial weapons, be familiar with the panic alarm, check notes/ask staff about previous violenc e, low threshold for a chaperone. Set the scene make sure you are both comfortable, ensure privacy and that you will not be d isturbed, eg give the bleep to someone else, have tissues available, emphasize confi dentia lity. Basics full name, age, marital status, occupation, who were they referred by, current statu s under Mental Health Act. Past psychiatric history previous psychiatric diagnoses, in-patient/day patient/out-patient care, do they have a community psychiatric nurse (CPN), previous deliberate self-harm (DSH ), previous treatments and eff ects, ever been admitted under the Mental Health Act. Medica tion history current and previous medications, eff ects, did they/ do they take it, allergi es/reactions, alternative/herbal remedies. Personal history \200 Childhood pregnancy, birth, development (b p164), associated memories, names of schools attended, reason if changed schools, types of school (mainstream /specialist), age of leaving school, qualifi cations. Employment loss of jobs, which did they enjoy, why did they change, ask about unemployment and why. Relationships current relationship(s) and sexual orientation, list of major relationships and reasons for ending, any children and who they live with and relatio nship to patient. Forensic contact with police, convictions or charges, sentences, out- standing charges. Personality how would they describe their personality now and before the illness? How would others describe it? Social history occupation and duration of employment/unemploy- ment, where they live, conce rns over money, friends and relationships, hobbies. Drug and alcohol smoking, alcohol, illicit drugs. Family history family tree with parents a nd siblings, ages, occupations, relationships, illnesses. OHFP.indb 160 OHFP.indb 160 30/05/2014 16:18 30/05/2014 16:18 161 PSYCHIATRIC Examination Psychiatrists examine the mind through talking to the patient. Much of the info rmation is gleaned whilst taking the history and should be organ- ised under the following headings: Appearance racial origin, age, dress, make-up, hairstyle, jewelry, tattoos, cleanliness, ne glect, physical condition. Behavior appropriateness, posture, movement (excessive, slow, exag- gerated), gestures, tic s, facial expression, eye contact, anxiety, sus- piciousness, rapport, abnormal movements, aggression, distraction, concentration. Mood the patient \200\231s subjective assessment of their mood. Aff ect interviewer \200 \231s objective assessment of mood and appropriateness of patient \200\231s response, eg fl at, reactive, blunted. Speech form accent, volume, rate, tone, quantity, hesitations, stuttering; content associat ions (derailment, changing between subjects), puns. Thought form rate, fl ow (eg blocked), connection (eg fl ight of ideas, derail- ment); content beliefs about self, beliefs about o thers, thought insertion/ withdrawal/control/broadcast, beliefs about the world/future, del usions, overvalued ideas, obsessions, compulsions, ruminations, rituals, phobias. Perception illusions, hallucinations (visual, auditory, tactile, olfactory), unusual experi ences, depersonalisation, derealisation. Cognition this can be tested formally using the Mini-Mental State Examination (MMSE) on b p 343, often the Abbreviated Mental Test Score (AMTS) is used instead (b p341). Risk thoughts of deliberate self-harm, suicide, harming others, plans, acquiring equipment, writing note s, previous suicide attempts. Insight awareness of illness and need for treatment. De \201 ning \200\230mental illness \200\231 What constitutes abnormal behavior to the ex tent of constituting a mental illness can be a controversial and diffi cult area, subject t o allegations of cultural and political bias and even suggestions of undue infl uence from the pharmaceutical industry. Two main classifi cation systems are accepted: \200 The Diag nostic and Statistical Manual of Mental Disorders, produced by the American Psychiatric Ass ociation; the 5th edition (2013) is currently in use: DSM-5 The International Classifi cation of Diseases, published by the World Health Organization ( covers all of medicine); 10th edition (1992) is currently in use: ICD-10. Each classifi cation carries a slightly diff erent emphasis and diagnostic criteria; in rar e instances, this results in an abnormal condition recog- nised in one, but not the other. _OHFP.indb 161 _OHFP.indb 161 30/05/2014 16:18 30/05/2014 16:18 162 CHAPTER 3 History and examination Common terms in psychiatry Aff ect pattern of observable behaviors which refl ects emotions experienced Anxiety feeling of apprehension caused by anticipation of perceived danger App roved clinician a doctor entitled to recommend compulsory admis- sion for treatment under t he 2007 Mental Health Act Cognition the process of thinking, reasoning and remembering Comp ulsion repetitive behaviors in response to obsessions; often to relieve the distress caused by them, eg washing hands Delirium acute onset of disordered cognition with attentional de fi cits; typically involves changes in arousal and may be associated with hallucinations De lusion a fi xed, false belief that goes against available evidence and is not explained by the person \200\231s religious or cultural background Dementia global organic deterioration of cognition with preserved consciousness Depersonalisation altered sense of self as if de tached or outside the body Derealisation altered sense of reality as if detached from surro undings Emotion a complex state of feeling that results in physical and psycho- logical cha nges that infl uence thought and behavior Euphoria pathologically exaggerated feeling of we llbeing Flight of ideas rapid switching of topics where the thread of connection can be det ermined (eg sound, content) Formal admission admission under a section of the Mental Health Act Hallucination a false sensory perception in absence of a real stimulus, eg hearing voi ces; feature of psychosis if the subject lacks recognition of the false nature Illusion fal se interpretation of a real external stimulus, eg seeing a shadow and thinking it is a pers on Informal admission voluntary admission as a psychiatric in-patient Insight the ability o f a person to recognize their mental illness Mania abnormal elevation of mood with grandios e ideas, increased energy and agitation, pressure of speech, distractibility, and pleasure seeking Mood emotional state that colors the person \200\231s perception of the world Obses sion recurrent unwanted thoughts or images, eg my hands are dirty Passivity delusional beli ef in external control of a person \200\231s actions or thoughts Personality disorder endur ing and infl exible behavioral patterns that markedly diff er to societal norms Phobia pers istent, irrational fear of an activity, object or situation, leading to the desire to avoid the feared stimulus; beyond voluntary control Psychosis disordered thinking and perception without insight, often accompanied by delusions or hallucinations Ruminations a compulsion to consider an idea or phrase Stereotype repeated pattern of movement or speech without an y goal Thought insertion delusional belief by a person that an external agency is putting t houghts into his/her mind (a passivity phenomenon) OHFP.indb 162 OHFP.indb 162 30/05/2014 16:18 30/05/2014 16:18 163 NEONATAL EXAMINATION Neonatal examination The baby check is a key component of life in pediatrics. All neonates should be examined within 72h of birth with the aim of: \200 Identifying unwell babies (t one and respiratory rate are very important) Identifying abnormalities (especially reversible ones). Preparation prior to the examinatio n you should check the maternal notes for: signifi cant maternal illness, gestation at birt h, birthweight, type of delivery, problems at delivery (meconium, premature rupture of memb ranes (PROM), group B strep, low Apgar scores). Introduction introduce yourself to the mother/parents, off er congratulations and explain t hat you \200\231ve come to examine their baby. Ask if the baby has passed feces and urine, is feeding well and if there are any concerns; ask them to undress the baby to the nappy wh ile you wash your hands. Settled baby consider doing the following fi rst as they are diffi cult if the baby is cryi ng: listening to the heart and feeling the apex beat, counting the respiratory rate, feelin g the femoral pulse and looking in the eyes. Crying baby try getting the baby to suck (pacifi er, breast, bottle, par- ent \200\231s lit tle fi nger, your little fi nger), if this fails swaddle the baby and ask the parents to gi ve the baby a feed then return in 30min. Overall take a few moments just to look, ask yourself is the baby: jaun- diced, blue, dysmo rphic, moving normally, breathing normally? Neuro tone (degree of head support, spontaneous symmetrical limb movements), Moro refl ex is not routinely performed. Head anterior and po sterior fontanelle (bulging, sunken), head circum- ference, eyes red re \202 ex (paler in pigmented babies), face (dysmorphic?), ear shape and position (tags, pits, top of insertion of pinna should be at the level of the eyes), palate (with your little fi nger), suck re \202 ex. Hands/arms \201 ngers (number, shape, color), palms (single crease in 60% of Dow n \200\231s and 1% of non-Down \200\231s), symmetrical arm movement. Chest respiratory rate (RR >60 is abnormal), listen to the heart, apex beat, gently feel the clavicles for fractu res. Abdo palpate (to exclude hepatomegaly, splenomegaly, masses), descended testes, patent anus, enlarged clitoris, femoral pulses. Hips/feet anterior hip creases (symmetrical?), Ba rlow test (fl ex hip to 90 , press posteriorly, feel for a click/clunk if the hip dislocat es), Ortolani test (after Barlow \200\231s abduct the hips one at a time whilst pressing on the greater trochanter with your middle fi nger, feel for a click/clunk as the hip relocat es), note repetition of these tests can cause hip instability, ankles (talipes, correctable or not), toes (number, shape, color). Turn baby over spine (straight), sacrum (lumps, dimp les, hair tufts, skin defects), buttocks (blue spots \200\223 make a note), posterior hip creases. Plot in the red book: weight, head circumference, examination. _OHFP.indb 163 _OHFP.indb 163 30/05/2014 16:18 30/05/2014 16:18 164 CHAPTER 3 History and examination Pediatric History Basics age in days (until 1mth), weeks (until 2mth), months (until 2yr) or years, g ender, who gave the history, who was present. Current state feeding and drinking, weight gain, wetting nappies/passing urine, fever, bowe ls, crying, runny nose (coryza), cough, breathing prob- lems, pulling ears, drawing up legs , rash. Birth pregnancy problems and medications, gestation at birth (37 \200\22342/40 is normal), type of delivery (NVD, induced, ventouse, forceps, if LSCS ask why), resuscitation, special care, birthweight, premature rupture of mem- branes (PROM), group B strep (GBS), meconium, maternal pyrexia during labor, vitamin K (IM or oral), feeding (breast, bottle, type of mi lk). Immunisations check the child is up to date with vaccinations (Table 3.21); jabs will be po stponed if the child is unwell or febrile beforehand and children often get a slight fever for <24h afterwards. Table 3.21 UK vaccination schedule May get tuberculosis (BCG) and/or hepatitis B if at risk Birth 2mth Diphtheria, tetanus, pertussis, polio and Haemophilus infl uenzae type b (DTaP/IPV/Hib), pn eumococcal disease (PCV) and rotavirus Diphtheria, tetanus, pertussis, polio and Haemophilu s infl uenzae type b (DTaP/IPV/Hib), meningococcal group C disease (MenC) and rotavirus Dip htheria, tetanus, pertussis, polio and Haemophilus infl uenzae type b (DTaP/IPV/Hib) and pn eumococcal disease (PCV) Measles, mumps, rubella (MMR), Haemophilus infl uenzae type B (Hib ), pneumococcal (PCV), meningococcal group C disease (MenC) Infl uenza 3mth 4mth 12 \200\22313mth 2yr and 3yr 3yr4mth \200\2235yr Diphtheria, tetanus, pertussis and polio (DTaP/IPV), MMR 12 \200\22313yr 14yr Human papilloma virus (girls only) Tetanus, diphtheria and polio (Td/IPV) and meningococcal group C disease (MenC) Development see Table 3.22 and ask about school performance. Social history who the child l ives with, who has parental responsibility, parental jobs, smoking, nursery/school attendan ce, type of school (mainstream, special needs), academic ability, sporting ability, friends at school, enjoyment of school, foreign travel. Family history family tree with parents and siblings, ask diplomatically about consanguinit y if relevant, any illnesses in the family, how are their parents and siblings at the momen t, asthma, eczema, hayfever, DM, epi- lepsy, other diseases specifi c to presenting complai nt. OHFP.indb 164 OHFP.indb 164 30/05/2014 16:18 30/05/2014 16:18 165 pediatric Examination Much of the examination can be performed by simply observing the child; this us ually has the advantage of limiting tears. Approach younger chil- dren gently whilst they a re sitting on a parent \200\231s knee and feeling secure. Examination is much the same as f or adult patients, but include the following: If unwell ABC and resuscitate, see b p234. Ch aperone ask a nurse to accompany you if a child of either sex is over 10yr, there is a chil d protection issue or whenever you feel it is necessary. Hydration fontanelle, capillary-re fi ll ( \211 2s), warm peripheries, mucous membranes, tears if crying, skin turgor, sunken eyes, tachycardia, lethargy. Respiratory grunting, head bobbing, nasal fl aring, tracheal t ug, cervical lymphadenopathy, recession (sternal, subcostal, intercostal). Cardiovascular c yanosis (check mouth), clubbing, mottled skin, murmurs may radiate to the back, femoral pul ses (coarctation), radiofemoral delay, dextrocardia, hepatomegaly (heart failure). Abdomina l check the external genitalia if young, relevant or boys with abdominal pain (torsion), ne ver do a PR (though seniors might). Neurological AVPU (Alert, responds to Voice, responds t o Pain, Unresponsive), fontanelles, tone, refl exes (including Moro and grasp refl ex if yo ung), head circumference (growth chart), development (Table 3.22). Table 3.22 Key stages in childhood development Age 6wk Gross motor Fine motor Holds head in line Lifts head up Speech Startles to sound Eyes follow 180 \232 Coos Social Smiles Eyes follow 90 \232 Laughs 3mth 6mth Sits unsupported Pulls to stand Transfers objects Babbles Objects to mouth Finger \200\223thumb grip Points \200\230Mama, dada \200\231 Waves goodbye 9mth 12mth Walks First words Finger foods unsupported 18mth Running 2yr Scribbles Asks for \200\230wants \200\231 Feeds alone Jumps Copies line 2 \200\2233-word sentences Name and age Dry by day Uses fork Uses tricycle Copies circle 3yr 4yr Hops Copies cross Counts to 10 Dry by night ENT always check the ears and throat if there is a suspicion of infection; describe the col or, appearance and if an eff usion or pus is present. Weight, height should be plotted on a sex-specifi c growth chart. Head circumference this i s especially important in infants and those with neurological disease; the measurement shou ld be plotted on a sex-specifi c chart. _OHFP.indb 165 _OHFP.indb 165 30/05/2014 16:18 30/05/2014 16:18 This page intentionally left blank Chapter 4 Prescribing 167 Prescribing \200\223 general considerations 168 How to prescribe \200\223 best practice 1 69 Drug interactions 171 Reporting adverse drug reactions 171 Special considerations 172 Co ntrolled drugs 173 Enzyme inducers and inhibitors 174 Endocarditis prophylaxis 175 Night se dation 176 Steroid therapy 177 Topical corticosteroids 178 Empirical antibiotic treatment 1 79 Clostridium diffi cile (C. diff ) 180 _OHFP.indb 167 _OHFP.indb 167 30/05/2014 16:18 30/05/2014 16:18 168 CHAPTER 4 Prescribing Prescribing \200\223 general considerations Prescribing medicines is rarely taught well in medical school, yet it is one of the fi rst tasks you \200\231ll be asked to do on day one . Even the most experienced of doctors will only know by heart the dose and frequency of a maximum of 30 \200\22340 drugs, so do not worry if you cannot even remember the dose of par acetamol; for adults it \200\231s 1g/4 \200\2236h PO max 4g/24h in divided doses (b p211). Many medical errors in hospital involve drugs so it is important to consider a few things e very time you want to prescribe a drug, rather than just writing a prescription as a knee-j erk reaction. Indication Is there a valid indication for the drug? Is there an alterna- tive method to so lve the problem in question (such as move to a quiet area of the ward rather than prescribe night-time sedation)? Contraindications Are there contraindications to the drug you are about to prescribe? Does the patient have asthma or suff er with Raynaud \200\231s syndrome, in which case B-blocker s may create more prob- lems than they solve. Route of administration If a patient is nil by mouth, then it is pointless prescribing oral medications; use the BNF or ask the pharmacist to help you use alternative routes of admin istration. Remember IM and SC injections are painful, so avoid these if possible. Drug interactions Some drugs are incompatible when physically mixed together (eg IV furosem ide and IV metoclopramide), and other drug combinations should ring alarm bells (eg ACEi wi th K+-sparing diuretics). Look through the patient \200\231s drug chart to spot potential d rug interactions (b p171). Adverse eff ects All drugs have side eff ects. Ensure the benefi ts of treatment outweigh t he risk of side eff ects and remember some patients are more prone to some side eff ects th an others (eg Reye \200\231s syndrome in children with aspirin, or oculogyric crises in you ng females with metoclo- pramide). Some side eff ects should prompt urgent action (such as stopping statin drugs in patients who complain of muscle pains, or patients who get wheezy with B-blockers), but others can be advantageous if they are not exposing the patient to un necessary risks (such as slight sedation with some antihistamines). Administering drugs Sometimes it \200\231s necessary for doctors to pre- scribe and adminis ter a drug to the patient. Always double check the drug prescription and the drug with anot her member of staff (qualifi ed nurse or doctor). This is not a sign of uncertainty, this i s a sign that you are meticu- lous and will greatly limit the chance of a drug error occurr ing, which would make you look careless. If in doubt Never prescribe or administer a drug you are unsure about; even if it is a dire emergency seek senior help or consult the BNF or a pharmacist. OHFP.indb 168 OHFP.indb 168 30/05/2014 16:18 30/05/2014 16:18 169 HOW TO PRESCRIBE \200\223 BEST PRACTICE How to prescribe \200\223 best practice Knowing how drugs work and their common side eff e cts is very useful, but you must also be able to safely prescribe them. There are a few bas ic rules about prescribing, and even if you are slightly unsure ask the ward or hospital ph armacist or consult the BNF; it \200\231s not a sign of failure. The basics There are usual ly at least four drug sections on the drug card (Figs 4.1 \200\2234.3); once-only, regular medications, PRN ( as required ) medications, and infusions (fl uids) (b p380). Other secti ons might include O2, anticoagulants, insulin, medications prior to admission, and nurse pr escriptions. Labeling the drug card As with the patient \200\231s notes, the drug card shou ld have at least three identifying features: name, DoB, and NHS number (the NPSA advice is that the NHS number should be used whenever possible to help avoid errors). There are usual ly spaces to document the ward, consultant, date of admission and number of drug cards in u se (1 of 2, 2 of 2, etc). The allergy box Ask the patient about allergies; check old drug c ards if available. Document any allergies in this box and the reaction precipitated; eg pen icillin l rash. If there are no known drug allergies then record this too. Nurses are unabl e to give any drugs unless the allergy box is complete. Writing a prescription Use black pe n and write clearly, ideally in capitals. Use the generic drug name (eg diclofenac, not Vol tarol ) and clearly indicate the dose, route, frequency of administration, date started, a nd circle the times the drug should be given (Figs 4.2 and 4.3). Record any specifi c instr uctions (such as \200\230with food \200\231) and sign the entry, writing your name and ble ep number clearly on the fi rst prescription. Common abbreviations IV \200\223 intravenous PO \200\223 by mouth IM \200\223 intramuscular SC \200\223 subcutaneous PR \200\223 by rectum INH \200\223 inhaled NEB \200\223 nebulised STAT \200\223 immediately g \200 \223 gram microgram avoid mcg or g , one tablet, two tablets Controlled drugs S ee b p173. Changes to prescriptions If a prescription is to change do not amend the origina l; cross it out clearly and write a new prescription (Fig. 4.1) (see b p170). Initial and d ate any canceled prescriptions and record a reason if appropriate (eg B-blocker stopped in wheezy asth- matic patient). Rewriting drug cards When rewriting drug cards ensure the corr ect drugs, doses and original start dates are carried over and that the old drug card(s) ar e crossed through and fi led in the notes. od \200\223 once a day/24h om \200\223 every morning on \200\223 every night bd \200 \223 twice a day/12h tds \200\223 three times a day/8h qds \200\223 four times a day/6h u nits \200\223 avoid \200\230IU \200\231 or \200\230U \200\231 PRN \200\223 as required mg \200\223 milligram ml \200\223 milliliter _OHFP.indb 169 _OHFP.indb 169 30/05/2014 16:18 30/05/2014 16:18 170 CHAPTER 4 Prescribing Drug PARACETAMOL Date/Time / / / / 0600 Route PO Dose 1g Start 05.08.14 0800 1000 Additional instructions 1200 1400 Signature Drugstore 1800 2200 Dr C J Flint 0000 Fig. 4.1 Example of canceled drug prescription for a regular medication. 05.08.14 Drug IBUPROFEN Date Route PO Dose 400mg Start 05.08.14 Time 12:35 Max frequency 6 hourly Max dose/24h 1.2g 400mg Dose Indications for use Analgesia/fever Route PO Given by Signature Dr C J Flint Drugstore SN Jones Fig. 4.2 Example of drug prescription for a PRN medication. Date Drug Dose Route Time Prescribed Given by Time 03.08.14 ASPIRIN 300mg PO STAT C J Flint SN Jones 15:35 Fig. 4.3 Example of a once-only (STAT) medication. Verbal prescriptions Verbal prescriptions are only generally acceptable for emergency situ- ations, and the drug(s) should be written up at the fi rst opportunity. If a verbal prescr iption is to be used, say the prescription to two nurses to minimize the risk of the wrong drug or dose being given. Check your local prescribing policy fi rst. Self-prescribing F1s can only prescribe on in-patient drug cards and TTOs. The GMC s Good M edical Practice (2013) guidance states you should avoid pro- viding medical care to yourse lf or anyone with whom you have a close personal relationship . OHFP.indb 170 OHFP.indb 170 30/05/2014 16:18 30/05/2014 16:18 171 REPORTING ADVERSE DRUG REACTIONS Drug interactions A list of specifi c drug interactions are shown in Appendix 1 of the BNF. Pharmacokinetic interactions occur when one drugs alters the absorption, distribution, met abolism, or excretion of another drug which alters the fraction of active drug, causing an aberrant response to a standardized dose. See the following examples: \200 Absorption met al ions (Ca2+, Fe3+) form complexes with tetracyclines and decrease their absorption and therefore bioavailability Distribution warfarin is highly bound to albumin, so drugs such as the sulfonamides which c ompete for binding sites cause displacement of warfarin, increasing both its free fraction and anticoagulant eff ect \200 Metabolism rifampicin is a potent enzyme inducer (b p174) and increases metabolism of the OCP, reducing its clinical eff ectiveness; other forms of contr aception should be used in such circumstances \200 Excretion quinidine reduces the renal clearance of digoxin, resulting in higher than anticipated levels of serum digoxin and incr easing the risk of digoxin side eff ects and/or toxicity. Pharmacodynamic interactions occur when two or more agents have affi nity for the same site of drug action, such as: \200 Salbutamol and propranolol (a non-specifi c B-blocker) hav e opposing eff ects at the B-adrenergic receptor; clinical eff ect is determined by the rel ative concentrations of the two agents and their receptor affi nity. Drugs which commonly h ave interactions include digoxin, warfarin, antiepileptics, many antibiotics, antidepressan ts, antipsychotics, theophylline and amiodarone. If in doubt, look in the BNF. Reporting adverse drug reactions The Yellow Card Scheme has been running for over 40 years, and is coordinated by the Medicines and Healthcare products Regulatory Agency (MHRA). Duri ng drug development, side eff ects with a frequency of 1:1000 or greater (more common) are likely to be identifi ed, so the Yellow Card Scheme is important in detecting rarer side ef f ects once a drug is in general use and all doctors have a duty to contribute to this. Yel low tear-out slips in the back of the BNF are completed and sent off and used to monitor ad verse drug reactions. The forms can be completed by any healthcare worker and even by patie nts. Common drug reactions such as constipation from opioids, indi- gestion from NSAIDs, an d dry mouth with anticholinergics are well rec- ognised and considered minor eff ects and d o not need reporting. Sinister drug eff ects such as anaphylaxis, hemorrhage, severe skin reactions etc must be r eported via the Yellow Card Scheme, irrespective of how well documented they already are. A ny suspected reaction from a new drug (drugs marked with an inverted triangle ( ) in the BN F) must also be reported by this scheme. _OHFP.indb 171 _OHFP.indb 171 30/05/2014 16:18 30/05/2014 16:18 172 CHAPTER 4 Prescribing Special considerations Every prescription should be carefully considered with specifi c ref l ection of the patient in question. If in doubt, consult the BNF or speak to the pharmacis t or a senior. There are some groups of patients for whom prescriptions must be even more c arefully considered. Patients with liver disease The liver has tremendous capacity and rese rve so liver disease is often severe by the time the handling of most drugs is altered. The liver clears some drugs directly into bile (such as rifampicin) so these should be used ca utiously if at all. The liver also manufactures plasma proteins and hypoproteinaemia can re sult in increased free fractions of some agents (phenytoin, warfarin, prednisolone) and res ult in exaggerated pharmacodynamic responses. Hepatic encephalopathy can be made worse by s edative drugs (night sedation, opioids etc), and fl uid overload by NSAIDs and corticostero ids is well documented in liver failure. Hepatotoxic drugs (such as methotrexate and isotre tinoin) should only be used by experts as they may precipitate fulminant hepatic failure an d death. Patients with estab- lished liver failure have an increased bleeding tendency so a void IM injections and employ caution if using any anticoagulant drugs. Paracetamol can be used in liver disease, but consider a reduced dose; consult BNF/pharmacist. Special conside rations for patients with liver disease are listed under each drug monograph in the BNF. Patients with renal disease Patients with impaired renal function should only be given neph rotoxic drugs with extreme caution as these may precipitate fulminant renal failure; these include NSAIDs, gentamicin, lithium, ACEi, and IV contrast. Any patient with renal disease (impairment or end-stage renal failure) will have altered drug handling (metabolism, cleara nce, volume of distribution etc) and more careful thought must be given when prescribing fo r the patients with GFR <60ml/min, and senior input sought when GFR <30ml/min (BNF, pharmac ist or senior); the amount, dosing frequency, and choice of drug needs careful thought. Rem ember that a creatinine in the \200\230normal \200\231 range does not mean normal renal fu nction, see b p373. Special considerations for patients with renal disease are listed under each drug monograph in the BNF. Pregnant patients Many drugs can cross the placenta and have eff ects upon the fetus. In th e fi rst trimester (weeks 1 \200\22312) this usually results in con- genital malformations, and in the second (weeks 13 \200\22326) and third trimesters (weeks 27 \200\22342) usually results in growth retardation or has direct toxic eff ects upon fetal tissues. There are n o totally \200\230safe \200\231 drugs to use in pregnancy, but there are drugs known to be particularly troublesome. The minimum dose and the shortest duration possible should be us ed when prescribing in pregnancy and all drugs avoided if possible in the fi rst trimester. \200 Drugs considered acceptable penicillins, cephalosporins, heparin, ranitidine, paracetamol, codeine Drugs to avoid tetracyclines, streptomycin, quinolones, warfarin, thiazides, ACEi, lithium, NSAIDs, alcohol, retinoids, barbiturates, opioids, cytotoxic drugs and phenytoin. Special considerations for pregnant patients are listed under each drug mono- graph in the BNF. OHFP.indb 172 OHFP.indb 172 30/05/2014 16:18 30/05/2014 16:18 173 CONTROLLED DRUGS Breastfeeding patient As with pregnant patients, drugs given to the mother can get into bre ast milk and passed on to the feeding baby. Some drugs become more concentrated in breast m ilk than maternal plasma (such as iodides) and can be toxic to the child. Other drugs can s tunt the child \200\231s suckling refl ex (eg barbiturates), or act to stop breast milk pro duction altogether (eg bromocriptine). Speak to a pharmacist before prescribing any drug to a mother who is feeding a child breast milk. Special considerations for patients who are b reastfeeding are listed under each drug monograph in the BNF. Children see the British National Formulary for Children. Neonates are more unpredictable i n terms of pharmacokinetics and pharmacodynamics than older children; prescriptions for thi s age group should be undertaken by experienced neonatal staff and drugs double- checked pr ior to administration. After the fi rst month or two the gut, renal system and metabolic pa thways become more predictable. Almost all drug doses still need to be calculated by weight (eg mg/kg) or by body-surface area (BSA). There are a few drugs which should never be pres cribed in children by a non-specialist, including tetracycline (causes irreversible stainin g of bones and teeth), aspirin (predisposes to Reye \200\231s syndrome); others should be u sed with caution such as prochlorperazine and isotretinoin. Always consult the BNF for chil dren when prescribing for pediatric patients. Controlled drugs Controlled drugs (CDs) are those drugs which are addictive and most often abused or stolen, and are subject to the prescription and storage requirements of the Misus e of Drugs Regulations 2001; they include the strong opioids (morphine, diamorphine, pethid ine, fentanyl, alfentanil, remifentanil, methadone), amphetamine-like agents (methyl- pheni date (Ritalin ), and cocaine (a local anesthetic). These agents are stored in a locked cab inet and a record of their use on a named patient basis is required to be kept by law. Some other drugs may be kept in the CD cupboard such as concentrated KCl, ketamine, benzodiazep ines and anabolic steroids, but this is not a legal requirement and will depend upon local policy. The weaker opioids (codeine, tramadol) are not treated as controlled drugs though t hey are still often misused.