Prescribing Practice Case study
Case Study 1
Mrs KL is 48 years of age and was brought to A/E at 4pm this afternoon after having a grand mal seizure. She had another in A/E; this resolved after two doses of 4 milligrams each of lorazepam iv. She has had epilepsy since her teens; she gets one seizure every 1-2 years. She is adherent to her usual treatment of 300mg phenytoin once daily (taken at 10pm) and phenobarbitone 60milligrams twice daily. She wears an alert bracelet. She has no known allergies.
She is generally very well but was diagnosed by her GP two days ago as having a urinary tract infection & was prescribed ciprofloxacin 250milligrams twice daily for five days. Her symptoms at the time included frequency & burning; her temp was noted as 38.3C; urinalysis tested positive for nitrites and protein.
Today, the admitting registrar has decided to admit Mrs KL for observation and she has been transferred from A/E to the medical admissions unit where you are the FY1 doctor. Her medicines have not been written up & the nurse looking after her has asked you to do so. Mrs KL is a bit drowsy but oriented to time, place, person; obs have been fine since admission; temp 37.1C since admission. Her notes from the registrar indicate that a phenytoin level has been sent from A/E and that the phenytoin dose should be increased to 350 milligrams daily, commencing tonight.
What you have to do now
- Please write up on a prescription chart all of the medicines you consider appropriate for Mrs KL. Use the prescription chart on BB – I have a copy attached here. Alternatively use your own hospital’s prescription chart.
- Write down the entry you would make in Mrs KL’s medical notes.
- List the information you would pass on verbally to the nurse looking after Mrs KL.
What will happen next?
At the end of next week, I will send you answer notes and a scanned prescription so that you can compare your management plans and your prescription with what would be considered reasonable and safe practice. There is no single correct way to do things but this will be a guide to reasonable and safe practice.
To obtain benefit from these cases, you must write down your own case note for the patient’s record and write your own prescription. In actually writing your own prescription and writing down what you would put in the medical notes, you have to think very seriously about the clinical aspects of this case and about the benefit to risk balance of all of your plans for Mrs KL. This problem is based on a real life scenario encountered by one of the FY1s with whom I worked in the past. You will notice that while the case requires you to write a prescription, it is your actual clinical knowledge that underpins your decisions about what you prescribe. Writing the prescription will hone your technical skills and get you practised in knowing what goes where on the form & doing it correctly so the patient can receive the drugs – clearly, an ambiguous or incorrect prescription here could cause considerable delay & even significant harm for Mrs KL.
- Dr Adam Feather’s Prescribing Skills Module 7 includes useful information on phenytoin – it’s towards the end of the pdf file
