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Drug Prescribing

Topic Page no

General advice 2

1 HTN – Patient is present in the cubicle 3

2 Community Acquired Pneumonia ( CAP) 6

3 COPD – Doxycycline 9

4 Pulmonary Embolism - Apixaban 13

5 Hospital acquired Pneumonia (HAP) 15

( Non-valvular Atrial fibrillation)
6 Stroke prophylaxis : Non-valvular Atrial fibrillation 17

7 DVT Treatment – RIVAROXABAN 20

8 VTE Prophylaxis – Postpartum 23

9 MRSA – Vancomycin 29

10 Premature Rupture of Membrane ( PROM) 34

11 Lithium – NSAIDS 38

12 Palliative care 41
13 Palliative care – syringe driver 44

14 UTI - Out/In- prescription (Nitrofurantoin) 47

15 Acute Pyelonephritis 53
16 Cellulitis - Diabetic foot 56

17 Quinsy in child – Abx and IV fluids 62

18 Acute Pancreatitis IV fluid prescription to adult 70

19 VTE Risk assessment - Elderly Lady 78
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Prescription writing - General advice

1. Use only black pen, all capital letters on the FIRST SHEET OF PRESCRIPTION
2. WRITE name, age address, date of birth (dd-mm-yyyy), NHS number hospital
number
3. in allergy status- Write Allergy (if mentioned) and reaction. Please verify by
putting your name signature and date. If NO allergy is known for the patient write
‘NKDA’ ( No Known Drug Allergy) and sign.
4. Three sections to be filled in the prescription
1) ANTIBIOTICS
2) REGULAR medications
3) As required/ Prn medications
5. In Palliative care only as required medications prescribed, don’t prescribe Regular
Medications.
6. Biggest challenge in prescription writing is to write and complete prescription
with all prescribed medicines (Most doctors just right less than half medicines
because there is no time) [You only score to write medications in the Prescription
here with patient details ]
7. Date to be added just once on the top row, not to be written separately for each
medicine prescribed
8. while prescribing medicine write drug name, dose, route, start date, stop date
signature ( don’t scribble ,write first or last name in capital letters ) GMC number.
Indication and additional information not very important, do it only when you have
finished writing all medications if at all needed
9. While mentioning times to be prescribed just write what time and circle write in
24 hours format. For Ibuprofen BD, write 8 and 20 with circle.
10. Only acceptable short forms are g and mg. MICROGRAMS, UNITS and PUFFS
to be written in full and capital letters
11. only generic name of the medications to be written in prescription. when there is a
accepted combination (like SERETIDE ) mention generic name in additional
information
12. In filling as required medications date and time not required. Here frequency and
maximum dose should be mentioned .In the prn medication morphine 2.5 mg four
hourly, frequency is 4° (hourly) and maximum dose will be 15 mg
13. If you notice a medicine wrongly prescribed or wrong dose of medicine you can
always check BNF for what condition the medication is prescribed for and the
patients age (child, adult, elderly) suppose if you check Clarithromycin for chest
infection for elderly patient you will find Dosage as 500 milligram 7 days in the
BNF.
If there is patient present in cubicle - ask presenting complaint (don’t explore and
Objective here is to fill up prescription)
- What medical conditions they have.
- What medications they are taking
- If they are concerned about any side effects,
- Allergy.
When asked what medications he takes, the patient sometimes bring out a bag of
medication bottles. Here you have to copy the medications in the prescription these
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bottles will have all information required to fill up the prescription with drug name,
route, dose, for how many days. Sometimes stop date not given.

HTN – Patient is present in the cubicle

Where are you
You are the FY 2 doctor in the acute medical admission unit
Who is the patient
Mr Jack Connor aged 58 year admitted to the hospital AMU (Acute medical unit) ward
with some complaints.
Other information
No known allergies
Regular Medications
Aspirin 75mg PO 1 tab OD
Atorvastatin 20mg PO 1 Tab OD HS
Ramipril 2.5mg PO 1 tab OD
Levothyroxine 50 microgram 1 tab OD Mane
What you must do
Talk to the patient and write prescription for this patient.
Patient is present inside the cubicle.
If the regular medications are not given in the question ask the patient about his
regular medications
Hello I am doctor I am one of the junior doctors in the AMU Department
can I please confirm your name and Age?
How may I call you?
what brought you to the hospital today?
How are you doing now?
I am here to fill your prescription chart.
Do you have any medical conditions?
Do you take any medications?
Do you have any allergies?
Any serious side effects with your regular medications?
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Do you have any concerns ?

Thank you for the information I will now write the prescription for you.
How and when to take levothyroxine.

Take levothyroxine once a day in the morning, ideally at least 30 minutes before having
breakfast or a drink containing caffeine, like tea or coffee. Food and caffeinated drinks can
both stop your body taking in levothyroxine properly so it does not work as well.
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Community Acquired Pneumonia ( CAP)

Where are you

You are the FY2 doctor in the Acute medical admission ward (AMU)

Who is the patient

Mr George Reece aged 62years presented to the A&E department with productive cough and
shortness of breath. He has been shifted to the AMU.
He has been diagnosed with community acquired pneumonia.
Consultant has advised to start him on Clarithromycin tablets 500mg PO twice daily for 7 days

Other information
His regular medications are as follows

Salbutamol inhaler 100-200micrograms ( 1-2 puffs) per day prn up to 4 times per day.
Seretide ( Fluticasome and Salmeterol) inhalation OD aerosol 250microgram, 1 puff mane
Ipratropium inhalation OD aerosol 20-40 micrograms (1-2 puffs) 3 to 4 times day.
Prednisolone tablets 30mg PO OD daily for 7 days
Ramipril tables 2.5mg PO once daily
Aspirin tablets 75mg PO once daily
Atorvastatin 20 mg PO once daily before bed time.
Levothyroxine sodium tablets 50micrograms PO once daily

Further information
Comorbidities: COPD, Hypothyroidism, HTN, Hypercholesterolemia
Allergy – Penicillin Type of reaction – Rash

What you must do

Prescribe Clarythromycin and regular medications
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Information –

Patient is allergic to Penicillin. Clarythromycin can be given to patient allergic to Penicillin.

Clarithromycin and Atorvastatin - Combining these medications may significantly increase the
blood levels of Atorvastatin. This can increase the risk of side effects such as liver damage and a
rare but serious condition called rhabdomyolysis that involves the breakdown of skeletal muscle
tissue.

Withhold Atorvastatin until the end of Clarythromycin course.

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COPD – Doxycycline

Where you are

You are FY2 in medicine department
Who is the patient
Mr Michael Richard aged 52, admitted for acute exacerbation of COPD
Other information
Allergic to Penicillin, Azithromycin, Clarithromycin. Reaction - Rash.
What you must do
Prescribe :
Clarythromycin
Seretide 250 EVO haler one puff BD
Salbutamol 100micrograms 1-2 puffs PRN
Terbutaline one to two puff as required
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Information –

Since the patient is allergic to Azithromycin - cannot prescribe Clarythromycin because they
are same class ( Macrolides) of drugs. There is cross reactivity.

Instead prescribe Doxycycline.

Doxycycline:
Dose for adult :- Initially 200 mg daily for 1 dose, then maintenance 100 mg once daily for 5
days in total,
Prescribe first dose 200mg in once only medication area for the first day.
Then 100mg maintenance in the regular medication area for the next 4 days.
Seretide
SERETIDE contains two medicines, Fluticasone propionate and Salmeterol
Xinafoate. Fluticasone propionate belongs to a group of medicines known as corticosteroids.

Seretide (50 micrograms Salmeterol and 500 micrograms fluticasone propionate) is indicated
for the symptomatic treatment of patients with COPD, with a FEV1 <60% predicted normal
(pre-bronchodilator) and a history of repeated exacerbations, who have significant symptoms
despite regular bronchodilator therapy.

Terbutaline - Terbutaline Sulfate 500 microgram per 1 dose

Dose:- By inhalation of powder For Adult
500 micrograms up to 4 times a day, for persistent symptoms.
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Pulmonary Embolism - Apixaban

Who are you
You are the FY 2 doctor in the medical department
Who is the patient
Mrs Barbara Davies aged 65 years admitted for Pulmonary embolism and was treated.
eGFR 86, D Dimer 4000, CTPA : Hypoperfusion
Other information
Regular medications :-
Atorvastatin 20mg OD
Aspirin 75 mg OD

Allergy - codeine - Reaction – Itching

What you must do

Prescribe Apixaban for 6 months.
Treatment of deep-vein thrombosis, Treatment of pulmonary embolism for Apixaban

By mouth - Adult - Initially

10 mg twice daily for 7 days, then maintenance 5 mg twice
daily.
Don’t prescribe Aspirin as it can increase the risk of bleeding if given with Apixaban
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Hospital acquired Pneumonia (HAP)

( non-valvular atrial fibrillation)
Where are you
You are the FY 2doctor in the medical department
Mrs Olivia Murphy aged 83 years admitted for non-valvular atrial fibrillation developed
hospital acquired pneumonia.

Other information
Her weight = 62 kg
Her recent eGFR= 32

Regular medications
Atenelol 25 mg OD
Apixaban 5mg BD

What you must do

Prescribe Doxycycline and her regular medications in the drug chart.

Doxycycline:
Dose for adult :- Initially 200 mg daily for 1 dose, then maintenance 100 mg once daily for5
days in total.

[If the question tells you to prescribe only the maintenance dose then prescribe only
the maintenance dose of 100mg OD for 4 days]

Dose adjustments for atenolol in Renal impairment (BNF)

With oral use: Max. 50 mg daily if eGFR 15–35 mL/minute/1.73 m2; max. 25 mg daily or
50 mg on alternate days if eGFR less than 15 mL/minute/1.73 m2.

[ No need to change the dose of Atenelol here because the eGFR is 32 - can give 25mg
OD]

ARBs and ACE inhibitors nephrotoxic – so do not give if the eGFR is very low.

Dose adjustments for Apixaban in Renal impairment (BNF)

When used for prophylaxis of stroke and systemic embolism in non-valvular atrial
fibrillation, manufacturer advises reduce dose to 2.5 mg twice daily if serum-creatinine
133 micromol/litre and over is associated with age 80 years and over or body-weight 60 kg
or less; reduce dose to 2.5 mg twice daily if creatinine clearance 15–29 mL/minute.

For this patient reduce the dose of Apixaban to 2.5mg BD because there is renal
impairment ( eGFR is 32 and he is more than 80 years old)
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Stroke prophylaxis : Non-valvular Atrial fibrillation

Where you are
Yo are FY2 in Medicine
Who is the patient
Mr Jonathan David, age 85years, was diagnosed with non-valvular atrial fibrillation.
Other information
Patient has CABG 10 years ago.
Serum creatinine – 148 micromol/litre [ Reference range: Male Adult: 59 - 104 μmol/L,
Female Adult: 45 - 84 µmol/L]
Regular medicine
Atenelol 25mg PO OD

No known allergies

What you must do

Prescribe apixaban for stroke prophylaxis
Information Apixaban : Prophylaxis of stroke and systemic embolism in non-
valvular atrial fibrillation and at least one risk factor (such as previous stroke or transient
ischaemic attack, symptomatic heart failure, diabetes mellitus, hypertension, or age 75
years and over)for apixaban

By mouth - Adult -5 mg twice daily, alternatively 2.5 mg twice daily, reduced dose used
in patients with at least two of the following characteristics: age 80 years and over, body-
weight 60 kg or less, or serum creatinine 133 micromol/litre and over.

This patient is over 80 years and serum creatinine is 148 which is more than 133 – so
prescribe low dose Apixaban = 2.5mg twice daily.

Atenelol
AF alone – 50 to 100mg /day
Max 50mg /day if eGFR 15-35ml, 25mg /day or 50mg on alternate days if eGFR is less
than 15ml
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DVT Treatment - RIVAROXABAN

Who are you
You are the FY 2 doctor in the medical Department
Who is the patient
Mr James Hobart 57 years presented with calf pain and diagnosed with DVT.
Other information.
Regular medications
Amlodipine 5mg OD
Aspirin 75mg OD
Paracetamol PRN
What you must do
Prescribe Rivaroxaban for 6 months

Treatment of deep-vein thrombosis, Treatment of pulmonary embolism for

Rivaroxaban
By mouth Adult
Initially 15 mg twice daily for 21 days, then maintenance 20 mg once daily, to be taken
with food, for duration of treatment, consult product literature.

It is better to avoid taking Aspirin with Rivaroxaban ( to reduce the risk of bleeding)
though it is not contra-indicated to take them together. Do not prescribe Aspirin.
No interactions were found between Amlodipine and Rivaroxaban.

No interactions were found between Paracetamol and Rivaroxaban.

What drugs should not be taken with Rivaroxaban?

Some products that may interact with this drug include: mifepristone, other drugs that can
cause bleeding/bruising (including antiplatelet drugs such as clopidogrel, "blood thinners"
such as warfarin, enoxaparin), certain antidepressants (including SSRIs such as fluoxetine,
SNRIs such as desvenlafaxine/venlafaxine)

To reduce your risk of an AFib-related stroke, you should take rivaroxaban (XARELTO® ) once a
day with your evening meal. If you miss a dose of XARELTO®, take it as soon as you remember
on the same day. Take your next dose at your regularly scheduled time.

Why do you have to take XARELTO in the evening?

XARELTO® 15 mg and 20 mg tablets should be taken orally once daily with the evening
meal to reduce the potential risk of decreased efficacy of therapy

Can I take Xarelto on empty stomach?

Rivaroxaban 2.5 mg and 10 mg tablets can be taken with or without food.
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VTE Prophylaxis - Postpartum

Question
Where you are
You are in the OBG department

Who the is the patient

Mrs. Katherine Jones, 42 years old lady

She gave birth to her 4th baby yesterday by vaginal delivery which was
prolonged and had to use forceps, and later she had PPH of about 1.2
litres of blood.

Other information

Her height was 165 cm, weight 65kg.

Patient’s regular medications:

Levothyroxine
Bisphophonates [Every Sunday]
Atorvastatin
Calci-D3
Co-codamol [PRN]

What you should do

Write a prescription for her VTE prophylaxis after doing her VTE risk
assessment.

Information:-

Risk assessment chart kept inside the cubicle.

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According to her condition she falls under moderate risk for VTE
Age more than 35 years -1
Parity more than 3 - 2
PPH more than 1 litre – 3

If 2 or more risk factors – Intermediate risk [ Give at least 10 days of prophylactic

LMWH]

You can give Delteparin 5000 units OD for 10 days.

If Dalteparin already printed on the chart fill up that box.

Do not forget to write height and weight also in the chart along
with the patient details.
Alondronate :- Treatment of postmenopausal osteoporosis
By mouth - For Adult (female) - 10 mg daily, alternatively 70 mg once weekly.

(Patient takes it every Sunday) 1st and 8th May is Sunday. To be given only on Sundays.

Calcium is an essential nutrient needed by all living creatures, including

humans. Vitamin D is a prohormone that helps the body absorb calcium, which is
essential for bone health.
The best time to take calcium tablets is with a meal, and roughly two hours before
and four to six hours after taking any other medications that might interact with the
calcium pills.

Do not prescribe Co-codamol as codeine is contra indicated in breast feeding ladies

because codeine can go through the breast milk to the babies and can cause drowsiness
and respiratory depression in babies. Instead prescribe Paracetamol.
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Guideline on Dalteparin Dosing for VTE Prophylaxis & Treatment

Based on Body Weight and Renal Function
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PREVENTION OF VTE

Creatinin Body Weight (kg)

e
Clearance < 50kg 50 - 99kg 100 – 150 kg > 150 kg
(CrCl)
(ml/min)
> 30 2500 units S/C 5000 units S/C 7500 units S/C 5000 units
once daily once daily once daily twice daily
15 – 30 2500 units S/C 2500 units S/C 5000 units S/C 5000 units
once daily once daily once daily once daily
< 15 Unfractionate Unfractiona Unfractiona Unfractionat
d heparin ted heparin ted heparin ed heparin
(UFH) 5000 (UFH) 5000 (UFH) 5000 (UFH) 5000
units S/C units S/C units S/C units S/C
twice daily twice daily three times three times a
a day day

Treatment of VTE 200 units per kg daily

Creatinine Clearance (CrCl) Dose Weight (kg) Dose

(ml/min)

Body Weight (kg)

>30 7,500 units S/C 69 - 82 15,000 units S/C
once daily once daily
< 46
>30 10,000 units 83 - 120 18,000 units S/C
S/C once daily once daily
46 - 56
100 units/kg S/C
>30 12,500 units > 120 TWICE daily
S/C once daily
57 - 68 If >150kg, discuss
with Haematology
15-30ml/min Reduce dose of LMWH with anti Xa monitoring in any patient if
concerned about bruising/bleeding or after the patient has received 7 days of
Dalteparin
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MRSA - Vancomycin

Question
Where you are
You are in the medical ward

Who the is the patient

Mr Oliver Smith 75 years old admitted for MRSA.

Other information

New medications to be prescribed

Mupirocin Ointment BD 5 days.
Vancomycin

Patient’s regular medications:

Amlodipine 10mg OD PO
PCM PO/IV 1gm PRN 6 hourly

Further information
Patient is allergic to Penicillin

Weight of the patient 85 Kg

eGFR 53

What you should do

Write the prescription in the prescription chart

Information:

Which medications can be given to patients who

are allergic to Penicillin
Tetracyclines (e.g. doxycycline),
Quinolones (e.g. ciprofloxacin),
Macrolides (e.g. clarithromycin),
Aminoglycosides (e.g. gentamicin) and
Glycopeptides (e.g. vancomycin)

How long should vancomycin be given?

The usual dose is 40 milligrams per kilogram (mg/kg) of body weight, divided into 3 or 4 doses,
and taken for 7 to 10 days. However, dose is usually not more than 2000 mg per day.

How fast can you infuse vancomycin?

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Vancomycin should be infused slowly in a dilute solution (2.5 to 5.0 mg/ml) at a rate no greater
than 10 mg/min and over a period not less than 60 minutes to avoid rapid infusion-related
allergic reaction known as Red man syndrome. This is the most common allergic reaction in
younger patients (under age 40) who received intravenous vancomycin.
Oral Vancomycin
Please note oral vancomycin should not be used to treat systemic infections as it is not
significantly absorbed from the GI tract and hence therapeutic drug monitoring is not necessary.
What is a normal eGFR number?In adults, the normal eGFR number is more than 90. eGFR
declines with age, even in people without kidney disease. See chart below for average estimated
eGFR based on age.
Mupirocin is an ointment to be applied to nostrils for 5 days.

VANCOMYCIN (FOR IV USE IN ADULTS) RESTRICTED USE

ANTIBIOTIC

Presentation: Vials contain 500mg or 1g dry powder

Indication: RESTRICTED USE This is a restricted antibiotic and should be prescribed

in accordance with the Antimicrobial Prescribing Guidelines or on a
Consultant Microbiologists recommendation.

Loading dose: Based on ACTUAL body weight.

ACTUAL BODY DOSE DILUTION VOLUME DURATION OF
WEIGHT 0.9% Sodium chloride INFUSION
<40 Kg 750mg 250mL 90 minutes
40-59 Kg 1g 250mL 120 minutes
60-90 Kg 1.5g 500mL 180 minutes
>90 Kg 2g 500mL 240 minutes

Maintenan Give the first maintenance infusion 12 or 24 hours after the loading infusion
ce dose : according to dose interval below.

eGFR DOSE OF Dose interval Volume of 0.9%

(mL/min) VANCOMYCIN Sodium chloride
<20 PLEASE DISCUSS WITH CLINICAL MICROBIOLGIST
20-29 500mg 24 hours 250mL
30-39 750mg 24 hours 250mL
40-54 500mg 12 hours 250mL
55-74 750mg 12 hours 250mL
75-90 1g 12 hours 250mL
>90 1.25g 12 hours 250mL
The maintenance dose must be REVIEWED in light of the first trough level
taken and adjusted appropriately to achieve the desired target range.

Target Range: The standard range is 10-20mg/L

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DOCUMENT in EXCEPTIONS:
- Staphylococcus aureus infections
the notes &
drug chart. - Deep-seated infections (i.e. infective endocarditis, osteomyelitis) In
these instances the target range is 15-20mg/L
DISCUSS with a Microbiologist if you are unsure what target range to use.
Monitoring All patients require plasma vancomycin measurements – this is done by
taking a trough sample (pre-dose)

Dosing Interval Time of 1st trough Further Monitoring

level
Twice daily dosing Before 3rd or 4th dose every 2 - 3 days, or
Once daily dosing Before 2nd or 3rd dose daily if the patient has
unstable
renal function
GIVE the prescribed dose immediately after the TROUGH level, DO NOT wait for
results. MONITOR RENAL FUNCTION throughout treatment with
Vancomycin.

Above drug calculation chart is given in the exam.

Loading dose depends on the body weight

Maintenance dose depends on the eGFR
As per the chart since the patient is 85 kg Loading dose will be 1.5gm in 500ml NS over
180 min.
Since the eGFR is 53 - maintenance dose will be 500mg with 12 hourly interval in 250ml
NS
Write the loading dose in the once only medication area and the maintenance dose in the
antibiotic section.
Since you have to monitor the drug level after 3rd or 4th dose – leave the box empty from
3rd dose
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Premature Rupture of Membrane ( PROM)

Question
Where you are
You are FY2 in Gynecology
Who is the patient
Mrs Sophie Williams, age 38.
She is 34 weeks pregnant and now presented with premature rupture of membrane

Other information
Regular medications–
Calcichew
Metformin 500mg BD

Allergic to penicillin. Reaction : rash

What you must do

Prescribe :
Dexamethasone 10mg 12hourly IM
Erythromycin 250mg QDS PO for 10 days

Premature rupture of membranes (PROM) is a rupture (breaking open) of the

membranes (amniotic sac) before labour begins < 37 weeks.
If PROM occurs before 37 weeks of pregnancy, it is called preterm premature rupture of
membranes (PPROM).

How long can you stay pregnant with ruptured membranes?

Fetal membrane rupture has traditionally been regarded as an irreversible process: the
mean latency period from membrane rupture to delivery is 12 days at 20–26 weeks of
gestation and 4 days at 32–34 weeks of gestation

Premature rupture of membranes treatment and management

• Antibiotic administration:

Prophylactic antibiotics for P-PROM appear to reduce complications due to preterm

delivery and postnatal infection.
Antibiotics should be administered to patients with preterm PROM because they prolong
the latent period and improve outcomes.
o Erythromycin 250 mg qds for 10 days (or until labour is established if this is
sooner) following the diagnosis of P-PROM

o If Group B streptococcus is isolated from a swab or if erythromycin is contra-

indicated then penicillin or clindamycin is usually recommended.
o
• Tocolytics - eg, atosiban, nifedipine or ritodrine - are no longer recommended, as they
do not significantly improve perinatal outcome.

• Corticosteroid prophylaxis
Between 24+0 and 33+6 weeks of gestation women should be offered a single course
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of antenatal corticosteroids i.e. Dexamethasone 12mg intramuscular. Two

bolus doses either 12 hours or 24 hours apart.
Steroids can be considered up to 35+6 weeks gestation on an individual
basis by a Consultant Obstetrician.
If the woman is contracting the obstetrician should consider prescribing the steroids 12
hours apart. This is an unlicensed indication for this medication, but is commonly used
within practice.
•Antenatal corticosteroids can be considered for women between 23+0 and 23+6 weeks
of gestation who have pre-labour rupture of membranes. However, the decision to
administer corticosteroids at gestations less than 24+0 weeks should be made by a
senior obstetrician (ST5 and above) taking all clinical aspects into consideration
Dexamethason and Erythromycin interaction – BNF information
Dexamethasone is predicted to cause hypokalaemia (potentially increasing the risk of
torsade de pointes) when given with Erythromycin. Manufacturer makes no
recommendation.

- BNF information does not mention Erythromycin and Dexamethasone should not be given
together.

Dexamethasone and Metformin

Dexamethasone may interfere with blood glucose control and reduce the effectiveness of
Metformin and other diabetic medications. Monitor your blood sugar levels closely. You
may need a dose adjustment of your diabetic medications during and after treatment with
dexamethasone.
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LITHIUM - NSAIDS
Where you are
You are FY2 in Psychiatric ward

Who is the patient

Mr Harry Callum, age 55 years.
He has injured his leg and has pain.

Other information
He has been diagnosed with COPD

Regular medications :
Ipratropium Bromide 20 (1 puff BD)
Atorvastatin 20mg PO OD
Lithium 800mg PO OD
Tiotropium
Seretide

Allergic – Nil known

What you must do

Prescribe Ibuprofen

Information –

Do not prescribe NSAIDS when the patient is on Lithium.

When combined with lithium, NSAIDs can increase lithium levels in the blood resulting in
an increased risk for serious adverse effects like confusion, tremor, slurred speech, and
vomiting.
Examples of non-prescription NSAIDs include: Ibuprofen, Naproxen.

You can prescribe Paracetamol for pain.

Lithium dose

For Adult
Initially 1–1.5 g daily, dose adjusted according to serum-lithium concentration, doses are
initially divided throughout the day, but once daily administration is preferred when serum-
lithium concentration stabilised.

Lithium levels are normally measured one week after starting treatment, one week after
every dose change, and weekly until the levels are stable. Once levels are stable, levels are
usually measured every 3 months. Lithium levels should be measured 12 hours post-dose.

Most patients achieve steady-state serum lithium concentrations within 5 days. Depending
on the indication for lithium treatment, target serum concentrations vary. Patients with acute
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mania typically require a higher serum concentration than those taking lithium for
prophylaxis against relapse.

The efficacy of lithium in the treatment of acute manic episodes has been recognised for
several decades, primarily using concentrations in the range of 0.8 to 2 mmol/L

Lithium and Salbutamol interaction {BNF)

Salbutamol is predicted to cause hypokalaemia (potentially increasing the risk of
torsade de pointes) when given with Lithium. Manufacturer makes no
recommendation.
Do not prescribe Salbutamol
Tiotropium is a long-acting, anticholinergic bronchodilator for the long-term, once-daily,
maintenance treatment of bronchospasm and dyspnoea associated with chronic obstructive
pulmonary disease (COPD), including chronic bronchitis and emphysema.

Seretide contains Fluticasone with Salmeterol ( Sameterol is a long-acting bronchodilator)

Dose - Seretide inhaler regularly every day, usually twice a day but sometimes reducing to
once a day if the asthma is well controlled.
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Palliative care
Where are you
You are the FY 2 doctor in the Hospice

Who is the patient

Mrs Victoria Wilson aged 90 was admitted to the hospital with metastatic pancreatic
cancer.

Other information about the patient

She is terminally and Palliative care has been decided for the patient.
She is to be discharged to the hospice for the continuation of the care.

She cannot eat or drink well

Her list of medications are inside the cubicle.

What you must do

Please refer to the handover notes and write her medications in the drug chart.

Patient is not inside the cubicle.

Hand over note

Pt Name – Mrs Victoria Wilson
DOB
Hospital number NHS number
Address
Allergy – Penicillin
Reaction – Rashes

Dear Doctor,
Mrs admitted to the hospital with metastatic cancer.
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She is terminally ill. Palliative care has been decided for her.
Patient cannot eat or drink well.

Plan
To be discharged to the hospice and continue the care in the hospice.
She has been discharged with the following medications.

Cyclizine SC 50mg Every 8 Maximum Nausea prn

hrs 3 times per and
day vomiting
Morphine SC 2.5mg – 5mg Every Maximum Pain prn
2-4 hrs 20mg per
day
Hyoscine SC 400microgram Every Maximum To reduce prn
hydrobromide 2-4 hrss 2.4 mg per excessive
day respiratory
secretions
Midazolam SC 2.5mg – 5mg 2 hrly Maximum Agitation prn
20mg per
day
Atorvastatin PO 10mg Once at Daily
bedtime
Paracetamol PO 1gm Every Maximum Pain prn
4-6 4 grams per
hours day
Information:
In palliative care medications are given subcutaneously especially if they cannot eat and
drink.
Since this patient cannot eat and drink well, give the medications only subcutaneous route.
Do not give oral or IV route.
In this case don’t give Paracetamol and Atorvastatin as they are given orally.
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Palliative care – syringe driver

Where are you
You are the FY 2 doctor in the Hospice

Who is the patient

Mrs Joanne Taylor aged 90 was admitted to the hospital with metastatic pancreatic cancer.

Other information about the patient

She is terminally and Palliative care has been decided for the patient.
She is to be discharged to the hospice for the continuation of the care.

She cannot eat or drink well

Her list of medications are kept inside the cubicle.

What you must do

Please refer to the handover notes and write her medications in the drug chart.

Patient is not inside the cubicle.

Hand over note

Pt Name – Mrs Joanne Taylor
DOB
Hospital number / NHS number
Address
Allergy – Penicillin
Reaction – Rashes

Dear Doctor,
Mrs Joanne Taylor admitted to the hospital with metastatic pancreatic cancer.
She is terminally ill. Palliative care has been decided for her.
Patient cannot eat or drink well.

Plan
To be discharged to the hospice and continue the care in the hospice.
She has been discharged with the following medications.

Morphine via syringe driver 30mg per 24 hours

Morphine S/C for breakthrough pain

Cyclizine SC 50mg Every 8 Maximum Nausea prn
hrs 3 times per and
day vomiting
 45

Hyoscine SC 400microgram Every Maximum To reduce prn

hydrobromide 2-4 hrss 2.4 mg per excessive
day respiratory
secretions
Midazolam SC 2.5mg – 5mg 2 hrly Maximum Agitation prn
20mg per
day
Atorvastatin PO 10mg Once at daily
bedtime
Paracetamol PO 1gm Every Maximum Pain prn
4-6 4 grams per
hours day

Information:
In palliative care medications are given subcutaneously especially if they cannot eat and
drink.
Since this patient cannot eat and drink well, give the medications only subcutaneous route.
Do not give oral or IV route.
In this case don’t give Paracetamol and Atorvastatin as they are given orally.

How is breakthrough morphine calculated?

Breakthrough opioid doses are based on a calculation of 1/6th of the daily dose - these
doses may be adjusted up or down to avoid the use of decimal points and to allow a
practical dose to be administered.
Since this patient’s daily Morphine dose is 30mg/24 hour – morphine dose for
breakthrough pain will be 5mg PRN. [30/6=5]
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UTI - In/Out- patient prescription - Nitrofurantoin

Where you are
You are FY2 in Medicine

Who is the patient

Miss Amelia Miller, age 35, presented with fever and burning micturition

Other information
 48

She was prescribed Nitrofurantoin for UTI

Other Information
Regular medications :
Amlodipine
Atorvastatin
PCM PRN

eGFR - Low

Allery – Penicillin Reaction – Rash

What you must do

Prescribe Nitrofurantoin

Nitrofurantoin.
Renal impairment - For nitrofurantoin
Risk of peripheral neuropathy; antibacterial efficacy depends on renal secretion of the drug
into urinary tract.
In adults:
Avoid if eGFR less than 45 mL/ minute/1.73 m2; may be used with caution if eGFR 30–
44 mL/ minute/1.73 m2 as a short-course only (3 to 7 days), to treat uncomplicated lower
urinary-tract infection caused by suspected or proven multidrug resistant bacteria and only
if potential benefit outweighs risk.

Patient has low eGFR. So don’t prescribe Nitrofurantoin.

Instead prescribe Trimethoprim for 3 days.

Dose for adult ( Lower urinary-tract infection) - 200 mg twice daily for 3 days (7 days
in males).

[ If the eGFR is not below 45ml/min then prescribe – Nitrofurantoin].

Lower urinary-tract infections for nitrofurantoin

By mouth using immediate-release medicines

Adult -50 mg 4 times a day for 3 days (7 days in males and pregnant women).

What antibiotics treat UTI in renal failure?

In summary, antimicrobials with anticipated effectiveness in patients with urethritis/cystitis
and chronic renal insufficiency are selected fluoroquinolones (ciprofloxacin,
levofloxacin) and trimethoprim alone. Nitrofurantoin should not be used because of low
urine drug concentrations.

Trimethoprim in Renal impairment

Manufacturer advises caution in impairment.
Dose adjustments
 49

In adults
Manufacturer advises dose reduction to half normal dose after 3 days if eGFR 15–
30 mL/minute/1.73 m2.
Manufacturer advises dose reduction to half normal dose if eGFR less than
15 mL/minute/1.73 m2.

Dosage and strength

Trimethoprim tablets contain 100mg or 200mg. The liquid contains 50mg in 5ml. The
usual dose of trimethoprim to: treat urinary tract infections (UTIs) is 200mg twice a day –
your doctor might recommend you double the first dose to 400mg.

Amlodipine is available in tablets and capsule form and in a range of strengths,

including 2.5 milligrams (mg), 5mg, and 10mg quantities.
For adults: starting with 5 mg once daily with a maximum dose of 10 mg daily.
No interactions were found between amlodipine and Trimethoprim.

No clinically significant interaction between amlodipine and atorvastatin has been

reported.
No interactions were found between Atorvastatin (Lipitor) and trimethoprim.
Lipitor is available in four strengths: 10 milligrams (mg), 20 mg, 40 mg, and 80 mg.
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Outpatient prescription – FP10 form

Pharmacy stamp Title, Forename, Surname and address

Age -
Mrs. Emma Jones
DOB – 30 Moseley Road
03/05/1990 Levenshulme
Please don’t stamp over age box Manchester
Number of days of treatment M15 4KM
N.B. Ensure dose is stated

NHS number - 123456789

Endorsements

TRIMETHOPRIM 200mg tablets

200mg twice a day for 3 days
Supply 6 tablets.

AMLODIPINE 10mg tablet

10mg once a day for 14 days
Supply 14 tablets

ATORVASTATIN 40mg
40mg once a day for 14 days
Supply – 14 tablets

Signature of prescriber Date

For dispenser
Number of prescription form

NHS FP10SS0406
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Acute Pyelonephritis
Where you are
You are FY2 in Medicine

Who is the patient

Mrs Emily Brown, aged 85 years.
She has been diagnosed with acute pyelonephritis

She has a history of Rheumatoid arthritis and HTN

Other information
Weight of the patient is 65kg
eGFR is 40

Allergy to Clarithromycin. Reaction - Rash.

Regular medications :
Methotrexate 7.5mg once weekly every Tuesday
Folic acid 1mg daily except Tuesday
Amlodipine 10mg OD

What you must do

Prescribe Cefalexin

Both Cefalexin and Methotrexate can increase the risk of nephrotoxicity.

Almost all the antibiotics increase the serum level of Methotrexate and increase the toxicity
of Methotrexate.
Withold Methotrexate when you are giving antibiotics. Methotrexate can be
safely be stopped for 2 weeks. If stopped for more than 4 weeks then there will be flare up
of Rheumatoidarthritis.
Taking folic acid
Folic acid helps protect the healthy cells in your body and reduces some of the side
effects of methotrexate. It can make you less likely to be sick (vomit) or get diarrhoea.
Your doctor will usually start you on one 5mg folic acid tablet, taken once a week. Take it
the day after your methotrexate.

Do not take folic acid on the same day as your methotrexate. It can stop your
medicine from working properly.

Why do you only take methotrexate once a week?

If methotrexate is taken too frequently – daily instead of weekly, for instance – it can
suppress bone marrow, reducing blood cell production and impairing the immune
system. This can make the body susceptible to infections and, in the worst-case scenario,
result in death

How and when to take methotrexate

 54

If you take methotrexate once a week, take it on the same day each week. There's usually a
reminder on your pill packet and patient card, telling you which day to take your medicine.
55
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Cellulitis - Diabetic foot

Where you are

You are FY2 in Medicine

Who is the patient

Mr Mason Robert, aged 55, has been admitted due to cellulitis on the leg ( diabetic foot)

Other information
Patient has been diagnosed with Diabetes.
He is on Metformin 500mg TDS PO

Body Wt = 65 kg.
eGFR = 93 (Normal)

Allergic - Penicillin. Reaction - rash.

What you must do

Prescribe Co-trimoxazole with Gentamycin or metronidazole

Moderate or severe Diabetic foot infection ( BNF)

Treatment duration is based on clinical assessment; minimum of 7 days and up to 6 weeks

for osteomyelitis (use oral antibacterials for prolonged treatment).
In severe infection, intravenous antibacterials should be given for at least 48 hours
(until stabilised).

• Oral or Intravenous first line:

o Flucloxacillinwith or without intravenous gentamicin and/or metronidazole, or co-
amoxiclav with or without intravenous gentamicin, or intravenous ceftriaxone wit
h metronidazole.
o Alternative in penicillin allergy:
o cotrimoxazole [unlicensed] with or without intravenous genta
micin and/or metronidazole.
Metronidazole
( BNF) Moderate to severe diabetic foot infection,

By intravenous infusion For Adult -500 mg every 8 hours.

 57

Oral dose For Adult - 400 mg 3 times a day for 5–7 days.

CO-TRIMOXAZOLE

Moderate to severe diabetic foot infection

By mouth for Adult

960 mg twice daily.

By intravenous infusion for Adult

960 mg every 12 hours, increased if necessary to 1.44 g every 12 hours.
GENTAMICIN

Moderate to severe diabetic foot infection,

By intravenous infusion for Adult

Initially 5–7 mg/kg once daily, subsequent doses adjusted according to serum-gentamicin
concentration. If the eGFR is very low then do not prescribe Gentamycin.

Serum-gentamicin concentration should be measured after 3 or 4 doses, then at least every 3 days
and after a dose change (more frequently in renal impairment).
Do not give Gentamicin more than 3 days without discussing with Microbiology.
Metformin

Initially 500 mg once daily for at least 1 week, dose to be taken with breakfast, then
500 mg twice daily for at least 1 week, dose to be taken with breakfast and evening meal,
then 500 mg 3 times a day, dose to be taken with breakfast, lunch and evening meal;
maximum 2 g per day.
•
No interactions were found between metformin and metranidazole

No interactions were found between metformin and gentamycin

No interactions were found between metformin and Cotrimazole

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Guidance notes for the new gentamicin prescribing,

administration & monitoring chart
& online gentamicin calculator
 61

NURSING
STAFF

• Each dose and time for gentamicin to be given must be prescribed on the prescription
section of the gentamicin
chart:

• Date and time of administration must be completed in the administration section of the
chart by the staff member administering the dose of gentamicin. It is important to
document the time gentamicin is given in order to interpret the levels of gentamicin and
to calculate the time of the next dose.

• Gentamicin levels should be taken 6-14 hours after the start of the infusion. If you know
that a patient has not has a level taken then please contact a member of the medical
team.

• Gentamicin must also be prescribed on the TPAR. The time and dose of gentamicin will
not be documented. Instead, the doctor will prescribe the dose “as charted” and not
document a time for administration.

• The date and time of administration of gentamicin must be signed on the TPAR as
well as the gentamicin chart.
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If the patient reports any adverse effects which may be considered attributable
to gentamicin then please discuss with medical staff. These include:

o new tinnitus
o dizziness
o poor balance
o hearing loss
o oscillating vision
o decrease in urine output / oliguria

• To minimise the risk of toxicity, duration of treatment should be limited to 72 hours.

All gentamicin prescriptions that continue beyond this must be discussed and
agreed with microbiology or an infection specialist.

• If you think that a dose is due but it has not been prescribed, contact the prescriber.
Ideally this should be identified during normal working hours. Do NOT administer a
dose based on what is documented at the top of chart.

Quinsy in child – Abx and IV fluids

Where you are

You are FY2 in the emergency department

Who is the patient

Miss Sarah Davies, age 6 yrs, has been diagnosed with peritonsillar abscess quinsy
She was managed in the emergency department
There are no signs of dehydration

Weight of the child is 23kg

Other information
Consultant has advised the following meds :
Phenoxymethylpenicillin
Metronidazole

No known allergy

What you must do

Write down the prescription for the above medications and IV fluid for maintenance.

[Available fluid bag : 500ml]

Acute sore throat for Phenoxymethylpenicillin ( BNF)

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Child 6–11 years -250 mg PO 4 times a day, alternatively 500 mg twice daily for 5–10
days.
Metranidazole - Acute oral infections for metronidazole (BNF)
Child 3–6 years -100 mg PO every 12 hours for 3–7 days.

Paediatric - IV fluid prescription - Information

There are three indications for IV fluids in infants and children: routine
maintenance, replacement and resuscitation.

Routine maintenance
Routine maintenance fluid therapy is required if the current oral intake is not sufficient to remain
hydrated.
For example, if the patient is ‘nil by mouth’ for any significant period, full maintenance fluids will
be required.
Alternatively, if the patient can obtain some of their intake orally, but is not completely meeting
their fluid requirements, they may be given a percentage of full maintenance fluids based on their
intake.
Replacement
Replacement fluid therapy is required if there is an existing fluid deficit and the oral route is not
possible or impractical.
Examples of clinical situations where this may occur include:
• Prolonged poor oral intake
• Vomiting
• Diarrhoea
• Increased insensible losses (e.g. fever, excessive sweating)
• Diabetic ketoacidosis
• Burn injuries
Resuscitation
Resuscitation is required if the patient is shocked. Types of shock and their underlying causes
include:
• Hypovolaemic: gastroenteritis, burns, diabetic ketoacidosis, heatstroke, haemorrhage
• Distributive: sepsis, anaphylaxis, neurological injury (neurogenic)
• Cardiogenic: congenital heart disease, arrhythmia
• Obstructive: cardiac tamponade, tension pneumothorax, congenital heart disease
 64

Assessment of volume status

To determine the indication for IV fluids it is important to take a focussed history and examine
the child. The volume status of the child should be assessed looking for features of clinical
dehydration or shock.

Diagnosis of dehydration or shock based on the presence of the clinical features listed below.

Clinical dehydration
Clinical features suggesting dehydration include:

• Appears unwell/deteriorating*
• Altered responsiveness (irritable, lethargic)*
• Sunken eyes*
• Tachycardia*
• Tachypnoea*
• Reduced skin turgor*
• Dry mucous membranes (not reliable if the child is mouth breathing or just after a drink)
• Decreased urine output

*These clinical features are red flags, the presence of which may predict a higher risk of
progression to shock.

Clinical shock
Clinical shock is defined by the presence of one or more of:

• Decreased level of consciousness

• Pale or mottled skin
• Cold extremities
• Pronounced tachycardia
• Pronounced tachypnoea
• Weak peripheral pulses
• Prolonged capillary refill time
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• Hypotension

Children have a large physiological reserve. They will compensate until they become very
unwell and then deteriorate rapidly.

Hypotension is a sign of decompensated shock and indicates that the child is critically unwell.

Resuscitation fluids
Glucose-free balanced crystalloids (e.g. Hartmann’s solution) are recommended as initial
resuscitation fluids.
Boluses of fluid are required if the patient is shocked or haemodynamically compromised.
The standard fluid for resuscitation is 0.9% sodium chloride with no additives via intravenous
(IV) or intraosseous (IO) access (if IV access is not possible) in a standard bolus of 10 mL/kg over
<10 minutes.1
Exceptions to this rule in which smaller boluses may need to be used:
• Neonatal period (<28 days of age)
• Diabetic ketoacidosis
• Septic shock
• Trauma
• Cardiac pathology (e.g. heart failure)
After the bolus has been administered, the volume status should be re-assessed (e.g. heart rate,
respiratory rate, capillary refill time). If the patient is still shocked urgent senior advice should be
sought.
If further fluid is required, the paediatric intensive care team should be contacted with
consideration of other measures (e.g. inotropic support).
Maintenance fluids after resuscitation
If a resuscitation bolus adequately reverses shock, then the next stage of treatment would be to
assess the requirement for fluid replacement.
NICE guidelines advise that after shock has been treated, the fluid deficit and 24-hour replacement
fluids should be calculated in the same way as for any other child who was not shocked.

Worked example: resuscitation

A 6-year old boy who weighs 23kg is admitted with gastroenteritis. He is repeatedly vomiting
oral fluids. Clinically he displays signs of shock and is 8% dehydrated.
Resuscitation fluids
• Bolus = 23 kg x 20 mL/kg = 460 mL over <15 minutes

Replacement fluids (dehydration)

For patients with dehydration without clinical features of shock, rehydration via the oral or
nasogastric route is preferred.

If this is impractical or contraindicated, IV fluid therapy may be considered with volumes

based on the percentage-dehydration.

Choice of fluid
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Replacement fluids should be adjusted according to existing electrolyte excess or deficit and
any anticipated ongoing losses (e.g. diarrhoea).

Use isotonic crystalloid that contains sodium with added glucose (e.g. 0.9% sodium chloride +
5% glucose).

If there are ongoing losses (e.g. diarrhoea, vomiting) supplement with potassium (e.g. 10
mmol/L).

The U&Es and plasma glucose should be monitored at least every 24 hours, or more
frequently if there are electrolyte abnormalities.

Calculating percentage dehydration by clinical assessment

Clinical signs of dehydration are only detectable when the patient is 2.5 – 5% dehydrated.
Therefore, a child that has symptoms/signs of dehydration, but no red flag features will be
approximately 5% dehydrated.

If any red flag features of dehydration are present, or the child is clinically shocked, then it is
common practice to assume 10% dehydration.

It is important to treat shock rapidly with an initial fluid bolus before replacement fluids are
administered.

Calculating a fluid deficit

Once percentage dehydration is known, a fluid deficit is calculated using the following
formula:

Maximum 8% dehydration

• Fluid deficit (mL) = % dehydration x weight (kg) x 10

Worked example: Replacement fluid

A child who weighs 23kg is 8% dehydrated. Calculate their total fluid requirement over 24
hours:

• Fluid deficit = 8% dehydration x 23 x 10 = 1840 mL

• residual deficit (1840ml) minus Amount given as bolus ( Resuscitation) ( 23X 20 =
460ml)

Replacement fluid = 1840 minus 460 = 1380/48 hrs = 1380 divide by 48 = 28.7ml/hr

Routine maintenance fluid

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Choice of fluid
For a child (>28 days of age), first line maintenance fluid is usually isotonic crystalloids + 5%
glucose (e.g. 0.9% sodium chloride + 5% glucose).

Calculation of fluid requirements

There are specific formulae for calculating the volumes of maintenance fluids in paediatrics.

There are different formulae for patients in the neonatal period, which is up to 28 days of age,
and for those who are older.

Children (>28 days of age)

Routine maintenance fluids for children are calculated by weight

First 10 kg - 4ml/kg/hr

Second 10kg - 2ml/kg/hr

For each kg over 20kg - 1ml/kg/hr

Worked example: maintenance fluid

Calculate the per hour maintenance fluids and hourly infusion rate for a 23kg child:
10 X 4 = 40 mL/hr for the first 10kg
10 X 2 = 20 mL/hr for the next 10kg
3 X 1 = 3 mL/hr for the final 3kg
Total = 63 mL/hr For 24 hrs = 63 X 24 = 1512ml/24hrs [ Round it off to 1500ml/24 hrs]
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Acute Pancreatitis IV fluid prescription to adult

Where are you
You are the FY 2 doctor in the medicine department

Who is the patient

Mr Jonathan David 62 years, diagnosed with acute pancreatitis, now posted for
cholecystectomy.

Other information
He also has Asthma and DVT

Weight of the patient is 67kg

Regular medications
Amlodipine 10mg OD
Seretide 250 EVO inhaler 1puff BD
Salbutamol 100 microgram PRN

Allergy – Pencillin Reaction - Rash

Further information
Patient is allergic to Penicillin Reaction – Rash

What you must do

Prescribe
Meropenem 500mg IV TDS
IV Fluids for maintenance

HCO3 GLUC
+ K+ Cl – –
FLUID Na (mm OSE
TONICITY (mmo (mmo
TYPE ol/L) (mmo (mmol/
l/L) l/L)
l/L) L)

Human 3.5- 100-

N/A 135-145 22-26 3.5-7.8
plasma 5.0 110
(for
 71

compari
son)

Sodium Isotonic
chloride
0.9% Used for 154 154
(Normal resuscitation/main
saline) tenance

Isotonic
Hartman
n’s Used for 131 5 111 29
solution resuscitation/main
tenance

Sodium
Hypotonic
chloride
0.18% / 30 30 40g/L
Used for
Glucose
maintenance
4%

Hypotonic
5% Dext
50g/L
rose Used for
maintenance

When prescribing IV fluids, remember the 5 Rs:

• Resuscitation
• Routine maintenance
• Replacement
• Redistribution
• Reassessment

Normal values
 72

• Na: 135-145 mmol/L • Creatinine: 68-110µmol/L

• K: 3.5-5.0 mmol/L • Urea: 2.5-6.7 mmol/L
• Hb: 130-180 g/L

Resuscitation fluids
Initial fluid bolus -Administer an initial 500 ml bolus of a crystalloid solution (e.g NaCl
0.9%/Hartmann’s solution) over less than 15 minutes.

Calculating maintenance fluids

Daily maintenance fluid requirements (as per NICE guidelines):

• 25-30 ml/kg/day of water and
• approximately 1 mmol/kg/day of potassium, sodium and chloride and
• approximately 50-100 g/day of glucose to limit starvation ketosis (however note
this will not address the patient’s nutritional needs)
Weight-based potassium prescriptions should be rounded to the nearest common fluids
available. Potassium should NOT be manually added to fluids as this is dangerous.

Weight-based potassium prescriptions should be rounded to the nearest common fluids

available (for example, a 67 kg person should have fluids containing 20 mmol and 40
mmol of potassium in a 24-hour period

This patient - Weight is 67 kg,

Fluid requirement is 30ml/kg/24hours:- 30 X 67 = 2010ml ( round of to
2000ml/24 hours = given as500ml / 6 hrs = 83ml /hr (round of to
85ml/hour).
No information is given in the question about whether he has already lost any fluids and
also no information on ongoing fluid loss. We can just give a normal maintenance fluid.

Better to Give NS with Potassium and 5% dextrose

You can write 500ml bag ( 4 bags alternative bags of NS and Dextrose)
with 20mmol KCL in each bag.

If the question specifically states to write Hartman’s solution then you

can prescribe 2 bags of 1 litre of Hartman’s solution every 12 hrs.
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VTE Risk assessment - Elderly Lady

62 year old lady admitted after fall.
Her eGFR is 72

Task:
Do VTE risk assessment and prescribe VTE prophylaxis.

Her regular medications are as follows:

Amlodipine 10mg OD
Levothyroxine 50 microgram OD
Atorvastatin 20mg OD
Alondronate 70mg every Sunday
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