Student Success in the Prescribing Safety Assessment (PSA)

Vilius Savickas, Reem Kayyali

• Publisher: CRC Press
• Year: 2020
• Print ISBN:
  9781138447011
• eBook ISBN:
  9781909368316
• Edition: 1
• Topic: Medicine
• Subtopic: Internal Medicine & Diagnosis

Student Success in the Prescribing Safety Assessment (PSA) The Prescribing Safety Assessment (PSA) is a two-hour open-book online examination which comprises eight sections incorporating eight main types of questions. The questions are structured around clinical case-based scenarios, requiring a holistic approach to analysing information and identi

Chapter 1

Prescribing

READ BEFORE YOU START

• There are eight ‘Prescribing’ question items in the PSA worth 10 marks each (80 marks in total).

• You will be marked in two main areas of ‘Drug Choice’ and ‘Dose and Route’ (each worth 4 marks). You will be eligible for all 4 marks if you provide an optimal answer that cannot be improved and 3 marks if you provide an answer that is good but is suboptimal on some grounds (e.g. cost-effectiveness, likely adherence). You shall be eligible for 2 marks if you provide an answer that is likely to provide benefit but which is clearly suboptimal for more than one reason, and 1 mark for an answer that has some justification and deserves some credit. The correct date (timing) on the prescription and prescriber’s signature are worth 1 mark each.

NB the authors of this publication appreciate the fact that a variety of answers (in a decreasing order of appropriateness for the patient) may be accepted for the purpose of the examination. However, the inclusion of clinically inappropriate or less-appropriate options or any option that may be unethical or which may breach any legislation has been avoided whenever possible. Therefore, while in some cases as many as four or more answer options may be acceptable, the majority of questions include one or a maximum of two correct answers.

• There are four types of prescribing questions in the PSA assessment and in this chapter (hospital once-only medicines, hospital regular medicines, hospital fluid prescription charts and FP10 prescriptions). See the templates for each prescription type presented in Appendix 1 together with the examples of correctly written prescriptions – use these templates when answering the questions. The templates may be photocopied if necessary.

• Each question will ask you to prescribe one medicine that is most appropriate for the management of an acute condition, a chronic condition or the patient’s symptoms (e.g. pain).

• The questions may include high-risk medicines (e.g. anticoagulants, opioids, insulin), medicines that are in common use (e.g. antibiotics) and intravenous (IV) fluids.

• Note that to answer some of the questions, which involve IV infusions (particularly IV fluids), you may need to refer to additional reference sources, such as Medusa Injectable Medicines Guide¹ or the Handbook on Injectable Drugs by LA Trissel.²

QUESTION 1

A 66-year-old Caucasian gentleman attends your primary care diabetes clinic for a routine check-up.

PMH: T2DM, hypertension, angina, atrial fibrillation

DH: metformin 1 g OM, 500 mg at noon and 500 mg in the evening, ramipril 5 mg OM, atenolol 50 mg OD, glyceryl trinitrate sublingual spray 400 micrograms PRN, simvastatin 40 mg ON and aspirin 75 mg OM

SH: smokes 21 cigarettes a day

On Examination

Temperature 36.7°C, HR 87/min and irregular, BP 132/80 mmHg, RR 15/min, O₂ sat 98% on air

Investigations

Na⁺ 136 mmol/L (135–146), K⁺ 4.7 mmol/L (3.5–5.0), Cr 95 µmol/L (79–118), eGFR 73 mL/min/1.73 m², glucose 13.2 mmol/L (4–9), HbA_1c 62 mmol/mol (48–59); weight: 110 kg; height: 1.82 m

On questioning, the gentleman admits that he is very reluctant to take more tablets but would rather take another oral medication than use an injectable one, as he has a terrible fear of needles.

Write a prescription for ONE drug that will help to improve the long-term control of this patient’s T2DM.

(Use the general practice prescription form provided in Appendix 1)³

QUESTION 2

A 67-year-old woman presents to the A&E department with a 7-day history of shortness of breath, chest tightness, productive cough and fever.

PMH: iron deficiency anaemia

DH: ferrous sulphate 200 mg BD

SH: glass of wine every other day, non-smoker

On Examination

Temperature 39.2°C, HR 120/min and regular, BP 89/55 mmHg, RR 25/min, O₂ sat 95% on air

Patient appears to be confused (GCS 9/15)

Weight: 62 kg

Investigations

WBC 17.4 × 10⁹/L (4–11), Neut 12.5 × 10⁹/L (2.0–7.5), Plt 378 × 10⁹/L (150–400), Hb 9.2 g/dL (11.5–16.5), D-dimer 140 nanograms/mL (<500 nanograms/mL), PT 13 seconds (12–16)

Na⁺ 153 mmol/L (135–146), K⁺ 4.8 mmol/L (3.5–5.0), Cr 98 µmol/L (79–118), U 14.3 mmol/L (2.5–6.7), CRP 219 mg/L (<10)

CXR: right basal consolidation

Following an initial assessment your colleague writes a prescription for benzylpenicillin IV 1.2 g QDS. However, after checking your local antibiotic guidelines and the BNF, you realise that benzylpenicillin monotherapy may be inadequate for the severity of this patient’s condition.

Write a prescription for ONE medicine that would be appropriate to add to the current treatment regimen for this patient.

(Use the hospital ‘regular medicines’ prescription chart provided in Appendix 1)

QUESTION 3

You are a house officer on the Acute Stroke Unit. A 45-year-old man has suffered an ischaemic stroke and has been nil by mouth for about a week. He was recommenced on ora...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• About the Authors
• Dedication
• Introduction
• Chapter 1 Prescribing
• Chapter 2 Prescription Review
• Chapter 3 Planning Management
• Chapter 4 Communicating Information
• Chapter 5 Calculation Skills
• Chapter 6 Adverse Drug Reactions
• Chapter 7 Drug Monitoring
• Chapter 8 Data Interpretation
• Answers
• Appendix 1: Templates of the Prescriptions to be used for Questions in Chapter 1
• Appendix 2: List of Common Abbreviations
• Appendix 3: Introduction to Prescribing and Pharmaceutical Care
• Appendix 4: The Guide to Using and Revising the British National Formulary