The New Prescriber E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 883

Veröffentlichungsjahr: 2024

Beschreibung

Take an evidence-based approach to prescribing decisions with this comprehensive guide

Prescribing decisions are among the most important parts of clinical practice. Balancing patient needs, possible drug interactions, the probability of adverse drug reactions, and more requires an evidence-based approach rooted in pharmacological principles. The New Prescriber: An Integrated Approach to Medical and Non-medical Prescribing offers a thorough, accessible introduction to the core components of prescribing, essential for any student preparing for clinical practice. Now fully updated to reflect the latest best practices and to address questions raised by different prescribing settings, it promises to continue as the key introduction to this vital subject.

Readers of the second edition of The New Prescriber will also find:

• An introduction to the principles of pharmacodynamics and pharmacokinetics
• New sections covering topics including illegal and illicit drugs, overdose and deprescribing, and more
• A thorough glossary with key terms

The New Prescriber is ideal for all non-medical prescribing students, nursing, allied health professionals, and medical students.

Leseprobe

Table of Contents

Cover

Table of Contents

Title Page

Copyright Page

List of Contributors

Foreword

Preface

Acknowledgements

SECTION 1: The Patient

CHAPTER 1: The Consultation

THE CONSULTATION

ELEMENTS OF A CONSULTATION

(A) PREPARING FOR THE CONSULTATION AND SETTING GOALS

(B) ESTABLISHING THE INITIAL RAPPORT

(C) TO (G) HISTORY TAKING/DIAGNOSIS HYPOTHESIS

THE TRADITIONAL MEDICAL HISTORY

(H) PHYSICAL EXAMINATION/NEAR‐PATIENT TESTS

(I) TO (K) DIAGNOSIS

(L) TREATMENT

(M) TO (P) SUMMARISING AND CLOSING THE CONSULTATION

(Q) AND (R) RECORDING AND PRESENTATION OF CONSULTATION FINDINGS

FUTURE ADVANCES IN CONSULTATION

SUMMARY

ACTIVITY

REFERENCES

FURTHER READING

WEBSITES

CHAPTER 2: Accountability and Prescribing

DEFINING ACCOUNTABILITY

ASSURING QUALITY

CLINICAL GOVERNANCE

THE FIVE SPHERES OF ACCOUNTABILITY

PROFESSIONAL ACCOUNTABILITY

ACCOUNTABILITY TO YOUR PATIENT

ACCOUNTABILITY TO THE PUBLIC/SOCIETY

ACCOUNTABILITY TO THE EMPLOYER

ACCOUNTABILITY TO SELF

USING THE FIVE SPHERES OF ACCOUNTABILITY

THE PROCESS OF ACCOUNTABLE PRACTICE

ACCOUNTABLE PRESCRIBING

CONCLUSION

SUMMARY

ACTIVITY

REFERENCES

FURTHER READING

USEFUL WEBSITES

CHAPTER 3: Prescribing and the Law

INTRODUCTION

PROFESSIONALISM

AUTHORITY TO PRESCRIBE

REQUIREMENTS FOR A LAWFUL PRESCRIPTION

SUPPLYING A PRESCRIPTION‐ONLY MEDICINE WITHOUT A PRESCRIPTION

PATIENT SPECIFIC DIRECTIONS

PRESCRIBING CONTROLLED DRUGS FROM SCHEDULES 2–5 BY INDEPENDENT NURSE AND PHARMACIST PRESCRIBERS

AUTHORITY TO COMPOUND MEDICINES

PRESCRIBING CONTROLLED DRUGS BY OTHER INDEPENDENT PRESCRIBERS

STANDARD OF PRESCRIBING

PRESCRIBER’S DUTY OF CARE

RESPECTING PATIENT AUTONOMY

THE PROPRIETY OF TREATMENT

ELEMENTS OF A REAL CONSENT

FULL CONSENT

FREELY GIVEN CONSENT

REASONABLY INFORMED CONSENT

TRESPASS TO THE PERSON

NEGLIGENCE

OBTAINING CONSENT

SUMMARY

ACTIVITY

REFERENCES

CASE LAW

LEGISLATION

FURTHER READING

WEBSITES

CHAPTER 4: The Ethics of Prescribing

DEONTOLOGY

UTILITARIANISM

FOUR PRINCIPLES OF BIOETHICS

AUTONOMY

BENEFICENCE

NON‐MALEFICENCE

JUSTICE

MAKING ETHICAL DECISIONS

CONSCIENCE, CODES AND LAW

ETHICS AND THE INDIVIDUAL

ETHICS AND PROFESSIONAL CODES

ETHICS AND THE LAW

EXAMPLE OF AN ETHICAL PROBLEM IN PRESCRIBING

SUMMARY

ACTIVITY

USEFUL WEBSITES

REFERENCES

FURTHER READING

CHAPTER 5: Prescribing in Practice

INDEPENDENT AND SUPPLEMENTARY PRESCRIBING

SUPPLEMENTARY PRESCRIBING AND THE CMP

WHAT INFORMATION MUST A CMP INCLUDE?

SHOULD I USE INDEPENDENT OR SUPPLEMENTARY PRESCRIBING?

PRESCRIBING IN PRACTICE

PERSONAL PRESCRIBING FORMULARIES

PRESCRIBING FOR PATIENTS

INTERPRETING AND APPLYING CLINICAL GUIDELINES TO PRESCRIBING

LOCAL GUIDELINES

DRUGS AND DRIVING

COMMUNICATING PRESCRIBING DECISIONS WITHIN THE TEAM

ORGANISATIONS AND EMPLOYERS

SUMMARY

ACTIVITY

REFERENCES

FURTHER READING

USEFUL WEBSITES

CHAPTER 6: Public Health Issues

WHAT IS PUBLIC HEALTH?

CONTRIBUTIONS TO PUBLIC HEALTH

EFFECTIVE APPROACHES TO PROMOTING PUBLIC HEALTH PRESCRIBING

GOLD STANDARDS: HEALTH‐PROMOTING SETTINGS

KEY PRIORITY AREAS FOR PUBLIC HEALTH

MAKING EVERY CONTACT COUNT

LONG‐TERM CONDITIONS

HEALTHCARE‐ASSOCIATED INFECTIONS

MEDICATION ERRORS

SUMMARY

ACTIVITY

REFERENCES

USEFUL WEBSITES

SECTION 2: Pharmacology

CHAPTER 7: General Principles of Pharmacology

HOW DO DRUGS EXERT THEIR EFFECTS ON THE BODY?

TARGET MOLECULES

THERAPEUTIC INDEX

SUMMARY

ACTIVITY

REUSABLELEARNINGOBJECTS

FURTHER READING

CHAPTER 8: Pharmacokinetics 1: Absorption and Distribution

HOW DO DRUGS GET INTO THE BODY?

DRUG ABSORPTION

DRUG DISTRIBUTION

SUMMARY

ACTIVITY

USEFUL WEBSITES

REUSABLELEARNINGOBJECTS

FURTHER READING

CHAPTER 9: Pharmacokinetics 2: Metabolism and Excretion

DRUG ELIMINATION

DRUG METABOLISM

DRUG EXCRETION

DRUG CLEARANCE

HALF‐LIFE

SUMMARY

ACTIVITY

FURTHER READING

USEFUL WEBSITES

REUSABLELEARNINGOBJECTS

CHAPTER 10: Routes of Administration

LOCAL VERSUS SYSTEMIC DRUG EFFECT

ORAL ADMINISTRATION

SUBLINGUAL ADMINISTRATION

RECTAL ADMINISTRATION

TRANSDERMAL ADMINISTRATION

OCULAR ADMINISTRATION

INHALATION

INTRAMUSCULAR INJECTION

SUBCUTANEOUS INJECTION

INTRAVENOUS INJECTION

SUMMARY

ACTIVITY

FURTHER READING

CHAPTER 11: Variations in Drug Handling

PHARMACOKINETIC VARIABILITY WITH AGE

PHARMACODYNAMIC VARIABILITY

SUMMARY

ACTIVITY

REFERENCES

FURTHER READING

CHAPTER 12: Polypharmacy and Medicines Optimisation

WHAT IS POLYPHARMACY?

WHICH PATIENT GROUPS ARE MOST IMPACTED?

WHAT ARE THE IMPLICATIONS FOR HEALTHCARE SERVICES?

WHICH DRUGS ARE MOST PROBLEMATIC?

MEDICINES OPTIMISATION

MEDICINES OPTIMISATION TOOLKITS AND DEPRESCRIBING

SUMMARY

ACTIVITY

REFERENCES

GUIDANCE

CHAPTER 13: Adverse Drug Reactions and Interactions

ADVERSE DRUG REACTIONS: SOME DEFINITIONS

CLASSIFICATION OF ADRS

SUSCEPTIBLE PATIENT GROUPS

MECHANISMS OF ADRS AND EXAMPLES

PHARMACOKINETIC CAUSES

PHARMACODYNAMIC CAUSES

IDENTIFICATION AND MANAGEMENT OF ADRs

DRUG INTERACTIONS

MANAGEMENT OF INTERACTIONS

SUMMARY

ACTIVITY

REFERENCE

FURTHER READING

USEFUL WEBSITES

CHAPTER 14: Introduction to the Autonomic Nervous System

THE NERVOUS SYSTEM

THE AUTONOMIC NERVOUS SYSTEM

ACTION OF THE AUTONOMIC NERVOUS SYSTEM ON BODY ORGANS

NEURON STRUCTURE

NEURON FUNCTION

CHOLINERGIC TRANSMISSION

NORADRENERGIC TRANSMISSION

SUMMARY

ACTIVITY

FURTHER READING

CHAPTER 15: Clinical Application of the Principles of the Autonomic Nervous Systems

DRUGS WHICH TARGET THE PARASYMPATHETIC NERVOUS SYSTEM AND CHOLINERGIC TRANSMISSION

DRUGS WHICH TARGET THE SYMPATHETIC NERVOUS SYSTEM AND NORADRENERGIC TRANSMISSION

SUMMARY

ACTIVITY

FURTHER READING

CHAPTER 16: The Gastrointestinal System

DYSPEPSIA

PHARMACOLOGICAL BASIS OF MANAGEMENT

NAUSEA AND VOMITING

PHARMACOLOGICAL BASIS OF MANAGEMENT

DIARRHOEA

CONSTIPATION

SUMMARY

ACTIVITY

REFERENCE

FURTHER READING

GUIDANCE

CHAPTER 17: Cardiovascular Drugs and Diseases

REGULATION OF BLOOD PRESSURE

HYPERTENSION

DRUGS THAT AFFECT THE RAAS

DIURETICS (SEE CHAPTER 19)

β‐ADRENOCEPTOR ANTAGONISTS (β‐BLOCKERS)

α‐ADRENOCEPTOR ANTAGONISTS

DRUGS TARGETING THE RAAS

ISCHAEMIC HEART DISEASE

SUMMARY

ACTIVITY

REFERENCES

FURTHER READING

USEFUL WEBSITE

CHAPTER 18: Haemostasis and Thrombosis

HAEMOSTASIS

ANTICOAGULANT DRUGS

PHARMACOKINETICS

ROLE OF PLATELETS IN THROMBOSIS AND HAEMOSTASIS

ANTIPLATELET DRUGS

SUMMARY

ACTIVITY

REFERENCES

FURTHER READING

GUIDANCE

CHAPTER 19: The Renal System

STRUCTURE AND FUNCTION OF THE KIDNEYS

THE PRINCIPLES OF GLOMERULAR FILTRATION

DRUG USE IN PATIENTS WITH RENAL IMPAIRMENT

DRUG DOSING IN RENAL IMPAIRMENT

USE OF DIURETICS IN RENAL FAILURE

SUMMARY

ACTIVITY

REFERENCES

FURTHER READING

USEFUL WEBSITES

REUSABLE LEARNING OBJECTS

CHAPTER 20: The Respiratory System

THE REGULATION OF AIRWAY TONE

THE ROLE OF INFLAMMATION IN RESPIRATORY DISEASE

GUIDANCE

SUMMARY

ACTIVITY

REFERENCES

FURTHER READING

CLINICAL GUIDELINES

CHAPTER 21: Introduction to the Central Nervous System

CENTRAL NERVOUS SYSTEM

PARTS OF THE BRAIN

NEURONAL STRUCTURE AND FUNCTION

PRINCIPAL NEUROTRANSMITTERS OF THE CNS

SUMMARY

ACTIVITY

FURTHER READING

USEFUL WEBSITE

CHAPTER 22: Neurodegenerative Disorders

PARKINSON’S DISEASE

ALZHEIMER’S DISEASE

SUMMARY

ACTIVITY

REFERENCES

FURTHER READING

USEFUL WEBSITES

CHAPTER 23: Depression and Anxiety

DEPRESSION

ANXIETY DISORDERS

SUMMARY

ACTIVITY

REFERENCES

FURTHER READING

CLINICAL GUIDELINES

CHAPTER 24: Schizophrenia

DESCRIPTION AND EPIDEMIOLOGY

AETIOLOGY OF SCHIZOPHRENIA

PATHOGENESIS OF SCHIZOPHRENIA

TREATMENT OF SCHIZOPHRENIA

OTHER USES OF ANTIPSYCHOTIC MEDICINES

SUMMARY

ACTIVITY

REFERENCES

FURTHER READING

USEFUL WEBSITES

CHAPTER 25: Epilepsy and Antiseizure Drugs

INTRODUCTION AND DEFINITIONS

SEIZURE TYPES AND EPILEPSIES

COMMON ANTISEIZURE MEDICATIONS: MECHANISMS AND USE

PRACTICE APPLICATIONS WITH COMMON SCENARIOS

SPECIAL GROUPS

HOLISTIC CARE

SUMMARY

ACTIVITY

USEFUL WEBSITES

REFERENCES

CLINICAL GUIDELINES

CHAPTER 26: Pain and Analgesia

WHAT IS PAIN?

PAIN PHYSIOLOGY

ANALGESIC PHARMACOLOGY

OPIOIDS

OTHER ANALGESICS

WORLD HEALTH ORGANIZATION PAIN LADDER

GUIDANCE

SUMMARY

ACTIVITY

REFERENCES

USEFUL WEBSITES

CLINICAL GUIDANCE

FURTHER READING

CHAPTER 27: Drugs of Misuse

CLASSIFICATION OF DRUGS OF MISUSE

ADDICTION, DEPENDENCE AND TOLERANCE

CANNABINOIDS

OPIOIDS

COCAINE

KETAMINE

LYSERGIC ACID DIETHYLAMIDE

AMPHETAMINES

‘ECSTASY’, 3,4‐METHYLENEDIOXY METHAMPHETAMINE

SOME OTHER THERAPEUTIC DRUGS SUBJECT TO POTENTIAL ABUSE

ALCOHOL

NICOTINE

PERFORMANCE‐ENHANCING DRUGS

TREATMENT OF DRUG ADDICTION

SUPPORT FOR OPIOID ABUSE

NICOTINE THERAPY

ALCOHOL DEPENDENCE

SUMMARY

ACTIVITY

REFERENCES

FURTHER READING

CLINICAL GUIDELINES

USEFUL WEBSITES

CHAPTER 28: Antibacterial Chemotherapy

GENERAL PRINCIPLES OF ANTIMICROBIAL CHEMOTHERAPY

MECHANISM OF ACTION OF ANTIBACTERIAL DRUGS

SUMMARY

ACTIVITY

REFERENCES

FURTHER READING

USEFUL WEBSITES

REUSABLE LEARNING OBJECTS

CHAPTER 29: Antibiotic Resistance

and Clostridioides Difficile

BACTERIA AND THE HUMAN BODY

ANTIBIOTIC RESISTANCE

ANTIBIOTIC‐ASSOCIATED DIARRHOEA AND

CLOSTRIDIOIDES DIFFICILE

SUMMARY

ACTIVITY

REFERENCES

FURTHER READING

CHAPTER 30: Antifungal and Antiviral Drugs

MYCOLOGY AND CLASSIFICATION

ANTIFUNGAL DRUGS

VIRUSES

SUMMARY

ACTIVITY

REFERENCES

USEFUL WEBSITES

FURTHER READING

CHAPTER 31: The Endocrine System

THE ENDOCRINE SYSTEM

MECHANISMS OF HORMONE ACTION

GLUCOSE HOMEOSTASIS AND DIABETES MELLITUS

DIABETES MELLITUS

TREATMENT OF DIABETES

TYPE 2 DIABETES MANAGEMENT

THE THYROID GLAND

HYPOTHYROIDISM

HYPERTHYROIDISM

SUMMARY

ACTIVITY

REFERENCES

FURTHER READING

USEFUL WEBSITE

CLINICAL GUIDANCE

CHAPTER 32: Contraception and Reproductive Health

ENDOCRINE REGULATION OF THE FEMALE REPRODUCTIVE SYSTEM

MECHANISM OF ACTION OF OESTROGEN AND PROGESTERONE

FORMULATIONS OF OESTROGENS AND PROGESTERONES

HORMONAL CONTRACEPTION

COMBINED HORMONAL CONTRACEPTION AND THE PROGESTOGEN‐ONLY PILL

DRUG INTERACTIONS

EMERGENCY CONTRACEPTION

NON‐CONTRACEPTIVE USES OF OESTROGEN AND PROGESTERONE

SUMMARY

ACTIVITY

REFERENCES

FURTHER READING

USEFUL WEBSITES

CLINICAL GUIDANCE

CHAPTER 33: Cancer Pharmacotherapy

CANCERS

CANCER PHARMACOTHERAPY

MYELOSUPPRESSION

REGIMENS

TARGETED CANCER THERAPY

GUIDANCE

PRACTICE POINTS

SUMMARY

ACTIVITY

USEFUL WEBSITES

FURTHER READING

CHAPTER 34: Musculoskeletal Disease

RHEUMATIC AND MUSCULOSKELETAL DISORDERS

OVERVIEW OF PREVALENT RMDs

PHARMACOLOGICAL MANAGEMENT OF INFLAMMATORY ARTHRITIS

SUMMARY

ACTIVITY

REFERENCES

USEFUL WEBSITES

Pharmacology Glossary

The Patient Glossary

Activity Answers

CHAPTER 1

CHAPTER 2

CHAPTER 3

CHAPTER 4

CHAPTER 5

CHAPTER 6

CHAPTER 7

CHAPTER 8

CHAPTER 9

CHAPTER 10

CHAPTER 11

CHAPTER 12

CHAPTER 13

CHAPTER 14

CHAPTER 15

CHAPTER 16

CHAPTER 17

CHAPTER 18

CHAPTER 19

CHAPTER 20

CHAPTER 21

CHAPTER 22

CHAPTER 23

CHAPTER 24

CHAPTER 25

CHAPTER 26

CHAPTER 27

CHAPTER 28

CHAPTER 29

CHAPTER 30

CHAPTER 31

CHAPTER 32

CHAPTER 33

CHAPTER 34

Index

End User License Agreement

List of Tables

Chapter 3

Table 3.1 Nonmedical prescriber summary of prescribing authority

Table 3.2 Key areas of medicines law covered by the Human Medicines Regulat...

Table 3.3 High‐level principles for remote prescribing

Chapter 5

Table 5.1 Reasons for local guidelines

Chapter 6

Table 6.1 The three domains of public health activity

Chapter 7

Table 7.1 Examples of commonly used drugs (grouped by BNF chapter) which ac...

Table 7.2 Examples of drugs in clinical use which act as agonists, competit...

Table 7.3 Examples of drugs in clinical use which act as reversible and irr...

Chapter 8

Table 8.1 Terms used to describe lipid solubility

Table 8.2 Key facts concerning the degree of ionisation of drugs that are w...

Table 8.3 Examples of commonly used drugs that are either acidic or basic i...

Table 8.4 Examples of drugs that bind to the plasma proteins albumin and ac...

Table 8.5 Examples of drugs across the range of plasma protein concentratio...

Chapter 9

Table 9.1 Examples of drugs that are substrates for individual cytochrome P...

Table 9.2 Examples of drugs, foodstuffs and herbal supplements that either ...

Table 9.3 Examples of common pro‐drugs and their active metabolites

Table 9.4 Examples of polymorphisms in cytochrome P450 isoforms, prevalence...

Table 9.5 Effect of modulation of urinary pH on the renal excretion of weak...

Table 9.6 Examples of drugs that undergo mainly renal clearance

Chapter 10

Table 10.1 Examples of different routes of drug administration

Table 10.2 Routes of administration available and whether they are routinel...

Table 10.3 Examples of enteral and parenteral routes of drug administration...

Chapter 11

Table 11.1 Pharmacodynamic changes in the elderly

Chapter 13

Table 13.1 Characteristics of type A and type B adverse drug reactions

Table 13.2 Susceptible patient groups

Table 13.3 Types of ADRs to be reported to the Medicines and Healthcare pro...

Table 13.4 Drug interactions caused by alterations in elimination

Chapter 14

Table 14.1 Opposing actions of the parasympathetic and sympathetic nervous ...

Table 14.2 Actions of the sympathetic nervous system on body functions that...

Table 14.3 Action of the parasympathetic nervous system on body functions

Table 14.4 Drug groups that can be used clinically to modulate cholinergic ...

Table 14.5 Drug groups that can be used clinically to modulate noradrenergi...

Chapter 15

Table 15.1 Groups of drugs used clinically that target the action of the pa...

Table 15.2 Effect of the parasympathetic nervous system on body organs

Table 15.3 Effect of muscarinic antagonists on body organs and associated p...

Table 15.4 Clinical effect of overstimulation of muscarinic receptors by an...

Table 15.5 Effect of the sympathetic nervous system on the body and the spe...

Table 15.6 Some side effects of the different forms of adrenoceptor antagon...

Chapter 17

Table 17.1 Examples of drugs in the main subclassification of calcium chann...

Chapter 18

Table 18.1 Drug interactions with warfarin which occur through modulation o...

Chapter 19

Table 19.1 Functions of the kidneys

Table 19.2 Examples of substances filtered and not filtered by the kidneys...

Table 19.3 Examples of drugs that need careful dose adjustment in renal fai...

Table 19.4 Drugs that cause predictable nephrotoxicity

Table 19.5 Actions of the three classes of diuretic drugs

Chapter 20

Table 20.1 Examples of short‐ and long‐acting bronchodilators commonly used...

Table 20.2 Some important potential interactions of methylxanthines with ot...

Table 20.3 The HIGH STAKES mnemonic for identifying adrenal insufficiency

Chapter 21

Table 21.1 Principal neurotransmitters in the central nervous system and th...

Chapter 22

Table 22.1 Dopamine agonists

Table 22.2 Genetic predisposition (familial risk) and gene linkage in relat...

Table 22.3 Stages of dementia

Table 22.4 Available acetylcholinesterase inhibitors

Chapter 23

Table 23.1 Some pathological anxiety disorders

Chapter 24

Table 24.1 Positive psychotic symptoms

Table 24.2 Negative psychotic symptoms

Table 24.3 Receptor targets of typical antipsychotic drugs

Table 24.4 Receptor targets of atypical antipsychotic drugs

Table 24.5 Other uses of antipsychotic drugs

Chapter 25

Table 25.2 Antiseizure medication side effects and interactions

Chapter 26

Table 26.1 Physiological functions of prostaglandins

Table 26.2 Functions of different forms of COX enzyme

Table 26.3 Opioid classification

Table 26.4 Opioid receptor subtypes

Chapter 28

Table 28.1 Bacterial classification by Gram stain, shape and aerobic/anaero...

Table 28.2 A summary of the major antibiotic classes with example drugs and...

Table 28.3 Clinical uses of semisynthetic penicillins

Table 28.4 Cephalosporins in current UK practice

Table 28.5 Clinical uses of common cephalosporins

Table 28.6 Clinical uses of erythromycin and doxycycline, both of which act...

Table 28.7 Clinical uses of ciprofloxacin and metronidazole, both of which ...

Table 28.8 The relative potency of dihydrofolate reductase (DHFR) inhibitor...

Table 28.9 Clinical uses of trimethoprim

Chapter 29

Table 29.1 Examples of antibiotic classes and their risk of CDI

Chapter 30

Table 30.1 Clinical uses of nystatin

Table 30.2 Clinical uses of antifungal drugs that act by inhibiting ergoste...

Table 30.3 Clinical uses of aciclovir

Table 30.4 Clinical uses of Paxlovid

©

(nirmatrelvir with ritonavir)

Chapter 31

Table 31.1 The function of each of the three cell types located in the endo...

Table 31.2 The different formulations of insulin available

Table 31.3 Examples of rapid‐, short‐, intermediate‐ and long‐acting insuli...

Table 31.4 The main groups of antidiabetic drugs

Table 31.5 Potential molecular mechanisms of metformin action

Table 31.6 Summary of thyroid effects within the body

Chapter 32

Table 32.1 Summary of the main effects of oestrogens

Table 32.2 Physiological functions of progestogens

Table 32.3 Drugs which induce the metabolism of ethinylestradiol

Table 32.4 Effect of combined oral contraception on co‐administered drugs

Chapter 33

Table 33.1 Summary of the key pharmacological targets for cytotoxic antican...

Table 33.2 Key side effects associated with a range of cytotoxic agents (si...

Table 33.3 Examples of chemotherapy combination regimens

Chapter 34

Table 34.1 The breadth of rheumatic and musculoskeletal disorders (condition...

Table 34.2 Disease‐modifying antirheumatic drugs used for inflammatory arth...

Table 34.3 Pre‐treatment screening tests aiming to minimise adverse events ...

List of Illustrations

Chapter 2

FIGURE 2.1 Model of accountable practice (Plant and Pitt 2010). DHSC, Depart...

Chapter 6

FIGURE 6.1 The main determinants of health (Dahlgren and Whitehead 1991, wit...

Chapter 7

FIGURE 7.1 The importance of shape in determining the specificity of interac...

FIGURE 7.2 The agonist binds to the receptor and induces a cellular response...

FIGURE 7.3 (A) At this end of the concentration–response curve there is only...

FIGURE 7.4 Comparison of the concentration–response curves of a full agonist...

FIGURE 7.5 Visual analogy for competitive antagonism. (A) An agonist binds t...

FIGURE 7.6 Difference in the concentration–response curve of a full agonist ...

FIGURE 7.7 The maximum response of a full agonist is reduced in the presence...

FIGURE 7.8 Site of action of a non‐competitive antagonist.

Chapter 8

FIGURE 8.1 The lipid bilayer that makes up the cell plasma membrane.

FIGURE 8.2 Diffusion through a lipid.

FIGURE 8.3 A drug crossing a cell membrane using a carrier molecule.

FIGURE 8.4 Saturation of a carrier protein and its impact on drug absorption...

FIGURE 8.5 The relative proportions of drug compartments in the body.

FIGURE 8.6 (A) A normal plasma protein concentration with 50% of drug free a...

FIGURE 8.7 Different patterns of drug distribution in the body and examples ...

Chapter 9

FIGURE 9.1 The phases of, and enzymatic processes involved in, drug metaboli...

FIGURE 9.2 Possible effects of cytochrome P450 induction and inhibition on t...

FIGURE 9.3 The metabolism of paracetamol and production of toxic metabolite....

FIGURE 9.4 Changes in absorption and first‐pass metabolism affect different ...

FIGURE 9.5 Example of enterohepatic recycling involving a drug conjugated to...

FIGURE 9.6 The change in concentration of drug in plasma with time and a det...

FIGURE 9.7 Concentration of drug in plasma. The half‐life of the drug is 2 h...

Chapter 12

FIGURE 12.1 Medicines optimisation based on the NHS England medicines optimi...

Chapter 14

FIGURE 14.1 The divisions of the nervous system.

FIGURE 14.2 Typical structure of a neuron, or nerve cell, the fundamental co...

FIGURE 14.3 Chemical transmission across the synapse.

FIGURE 14.4 Receptor types and neurotransmitters of the autonomic nervous sy...

FIGURE 14.5 Acetylcholine transmission is turned off by the action of the en...

FIGURE 14.6 Noradrenergic transmission is turned off by the reuptake of nora...

FIGURE 14.7 The relationship between dopamine, noradrenaline and adrenaline....

Chapter 15

FIGURE 15.1 Production of noradrenaline from L‐Dopa.

Chapter 16

FIGURE 16.1 A parietal cell and stimulation of gastric acid secretion via ac...

FIGURE 16.2 The sites of action of histamine H

2

‐receptor antagonists (to com...

FIGURE 16.3 The sites of action of the four main classes of antiemetic drugs...

Chapter 17

FIGURE 17.1 Outline of the role of the renin‐angiotensin‐aldosterone system ...

FIGURE 17.2 Summary of the NICE guidelines (2019) for the treatment of hyper...

FIGURE 17.3 The action of calcium channel inhibitors to inhibit entry of cal...

FIGURE 17.4 The renal nephron showing the main sites of diuretic action in t...

FIGURE 17.5 Statins inhibit 3‐hydroxy‐3‐methyl‐glutaryl CoA (HMG‐CoA) as the...

FIGURE 17.6 Mode action of glyceryl trinitrate (GTN) via the release of nitr...

Chapter 18

FIGURE 18.1 A simplified diagram showing the extrinsic and intrinsic pathway...

FIGURE 18.2 Sites of action of Factor X and thrombin inhibitors (direct oral...

FIGURE 18.3 (a) The platelet adhesion reaction. As the blood vessel is damag...

FIGURE 18.4 Action of aspirin to inhibit both endothelial and platelet cyclo...

FIGURE 18.5 Mechanism of action of thrombolytic drugs.

Chapter 19

FIGURE 19.1 Frontal cross‐section of the human kidney.

FIGURE 19.2 The basic functional unit of the kidney, the nephron.

FIGURE 19.3 Accumulation of drug in renal failure.

FIGURE 19.4 Effect of increased dosage interval in renal failure.

FIGURE 19.5 Effect of decreased dose in renal failure.

Chapter 20

FIGURE 20.1 The human airways or bronchial tree created using Biorender.

FIGURE 20.2 Stimulation of bronchodilation by β

2

‐adrenoceptor agonists and t...

FIGURE 20.3 Schematic diagram summarising the action of corticosteroids acti...

FIGURE 20.4 Production and consequences of leukotrienes in the airways.

Chapter 21

FIGURE 21.1 The major anatomical areas of the brain.

FIGURE 21.2 Anatomy of a neuron showing the pathway of electrical transmissi...

FIGURE 21.3 The influence of excitatory and inhibitory inputs on a nerve cel...

FIGURE 21.4 Ionic components of the action potential showing the roles of so...

Chapter 22

FIGURE 22.1 Synthesis and breakdown of dopamine. COMT, catechol–O‐methyltran...

FIGURE 22.2 The role of peripheral DA metabolism inhibitors in raising dopam...

Chapter 23

FIGURE 23.1 Target sites for selective serotonin reuptake inhibitors and tri...

FIGURE 23.2 Mechanism of action of moclobemide (from http://www.cnsforum.com...

FIGURE 23.3 The GABA

A

receptor with representations of the exogenous drugs t...

Chapter 25

FIGURE 25.1 Classification of seizure types.

FIGURE 25.2 The decision‐making process in epilepsy. EEG, electroencephalogr...

Chapter 26

FIGURE 26.1 Physiology of pain.

FIGURE 26.2 Synthesis of prostaglandins.

FIGURE 26.3 Pain transmission.

FIGURE 26.4 Gate control theory.

FIGURE 26.5 Paracetamol metabolism in liver. CYP450, cytochrome P450; NAPQI,...

FIGURE 26.6 World Health Organization analgesic ladder. NSAID, non‐steroidal...

Chapter 28

FIGURE 28.1 The differences in cell wall structure between a Gram‐positive a...

FIGURE 28.2 An example of a drug concentration against time graph for three ...

FIGURE 28.3 Structure of peptidoglycan.

FIGURE 28.4 Antibiotic classes that inhibit protein synthesis and where they...

FIGURE 28.5 Action of antibiotics on bacterial folate synthesis.

Chapter 29

FIGURE 29.1 The effect of using narrow‐ and broad‐spectrum antibiotics to tr...

FIGURE 29.2 About every one in 10

7

bacteria will have a mutation (green). If...

FIGURE 29.3 Mechanisms of resistance employed by bacteria.

Chapter 30

FIGURE 30.1 Polyene antifungal molecules combine with ergosterol to form a h...

FIGURE 30.2 Many drugs interfere with ergosterol biosynthesis with actions a...

FIGURE 30.3 The structures of guanosine and acyclovir.

FIGURE 30.4 Reproduction cycle of the influenza virus.

Chapter 31

FIGURE 31.1 Location of the major glands and endocrine hormones (www.commons...

FIGURE 31.2 The differing actions of (A) circulating, (B) paracrine and (C) ...

FIGURE 31.3 Regulation of blood glucose by the endocrine pancreas.

FIGURE 31.4 The structure of the insulin receptor.

FIGURE 31.5 Mechanism of insulin action at a cellular level. GLUT4, glucose ...

FIGURE 31.6 Demonstration of glycosuria.

FIGURE 31.7 Mechanism of action of sulphonylureas.

FIGURE 31.8 Feedback regulation of thyroid hormones. TRH, thyrotrophin‐relea...

Chapter 32

FIGURE 32.1 Endocrine regulation of the female reproductive system. FSH, fol...

FIGURE 32.2 Production of oestrogens, progesterone and testosterone from cho...

FIGURE 32.3 Cellular mechanism of action of oestrogen and progesterone.

FIGURE 32.4 Mechanism of action of the oral contraceptives. By providing an ...

Chapter 33

FIGURE 33.1 Key pharmacological targets in cytotoxic chemotherapy, showing i...

FIGURE 33.2 The human epidermal growth factor receptor 2 is overexpressed in...

FIGURE 33.3 (a) The epidermal growth factor (EGF) receptor is expressed in s...

Chapter 34

FIGURE 34.1 Radiographic appearance of knee osteoarthritis. Posteroanterior ...

Part 2

FIGURE 1 ‘Drugs' which may be used by patients but may not be recognised or ...

Guide

Cover Page

Table of Contents

Title Page

Copyright Page

List of Contributors

Foreword

Preface

Acknowledgements

Begin Reading

Pharmacology Glossary

The Patient Glossary

Activity Answers

Index

WILEY END USER LICENSE AGREEMENT

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The New Prescriber

An Integrated Approach to Medical and Non‐medical Prescribing

SECOND EDITION

Edited by

Joanne Lymn BSc PhD NTF

Professor of Healthcare Education, University of Nottingham

Alison Mostyn BSc Biomedical Sciences (Pharmacology) PhD PGCHE SFHEA

Professor in Pharmacology Education for Health, University of Nottingham

Roger Knaggs BSc BMedSci PhD EDPM FHEA FFRPS FRPharmS FFPMRCA

Professor of Pain Management, University of Nottingham;

Specialist Pharmacist in Pain Management;

Primary Integrated Community Solutions

Michael Randall MA PhD FBPhS SFHEA

Professor of Pharmacology, University of Nottingham

Dianne Bowskill RN DPSN(DN) BSc DHSci

Associate Professor of Prescribing Education, University of Nottingham;

Professor of Healthcare Education, University of Nottingham

This edition first published 2024© 2024 John Wiley & Sons Ltd

Edition HistoryJohn Wiley & Sons Ltd. (1e, 2010)

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.

The right of Joanne Lymn, Alison Mostyn, Roger Knaggs, Michael Randall, and Dianne Bowskill to be identified as the authors of the editorial material in this work has been asserted in accordance with law.

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Limit of Liability/Disclaimer of WarrantyThe contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.

Library of Congress Cataloging‐in‐Publication Data applied for:

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List of Contributors

Alison Mostyn, Professor of Pharmacology Education for Health, School of Health Sciences, University of Nottingham

Anna Soames, Sexual Health Nurse Training Lead Nottingham University Hospitals Nurse Representative FSRH Practice Learning and Development Board

Christina Giavasi, Consultant Neurologist, Nottingham University Hospital Trust

Daniel Shipley, Senior Clinical Pharmacist

David Kendall, Professor Emeritus of Pharmacology, University of Nottingham

David Andrew Walsh, Professor of Rheumatology, School of Medicine, University of Nottingham

Dianne Bowskill, Associate Professor of Prescribing Education, School of Health Sciences, University of Nottingham

Frank Coffey, Consultant in Emergency Medicine, Nottingham University Hospitals NHS Trust; Clinical Consultant to the Postgraduate Clinical Skills Programme, School of Health Sciences, University of Nottingham

Helen Boardman, Associate Professor in Pharmacy Practice, School of Pharmacy, University of Nottingham

Joanne Lymn, Professor of Healthcare Education, School of Health Sciences, University of Nottingham

Katharine Whittingham, Associate Professor, School of Health Sciences, University of Nottingham

Matthew Boyd, Professor of Medicines Safety, School of Pharmacy, University of Nottingham

Michael F O’Donoghue, Neurology Consultant, Nottingham University Hospital Trust and Honorary Assistant Professor in Neurology, University of Nottingham

Michael Randall, Professor of Pharmacology, School of Life Sciences, University of Nottingham

Michael Watson, Trustee, Institute of Health Promotion and Education

Richard Griffith, Senior Lecturer in Law, School of Health & Social Care, University of Swansea

Richard Roberts, Associate Professor and Lecturer in Pharmacology, School of Life Sciences, University of Nottingham

Roger Knaggs, Professor of Pain Management, University of Nottingham; Specialist Pharmacist in Pain Management; Primary Integrated Community Solutions

Sana Awan, Assistant Chief Pharmacist & Head of Operations, Sherwood Forest Hospitals NHS Foundation Trust

Stephanie Bridges, Associate Professor, Clinical Pharmacy Practice, School of Pharmacy, University of Nottingham

Tim Hills, Senior Pharmacist ‐ Microbiology & Infection Control, Nottingham University Hospitals NHS Trust

Yvonne Mbaki, Associate Professor in Medical Physiology, School of Life Sciences, University of Nottingham

Foreword

Sincethe publication of the first edition of The New Prescriber in 2010, more allied health professionals, including paramedics and dieticians, have gained independent or supplementary prescribing rights, expanding the variety of practitioners who can prescribe and ensuring patients have timely access to medicines.

This second edition of The New Prescriber has been fully updated and restructured to meet the needs of all clinicians who are new to prescribing. New chapters on polypharmacy and medicines optimisation, cancer pharmacotherapy, drugs of misuse and musculoskeletal prescribing have been included to address these common challenges. The book remains focussed on the new prescriber, with a friendly and clear tone to develop confident and safe prescribers.

Alison Mostyn

As a Paramedic Advanced Clinical Practitioner, I felt a lot of pressure to do well, and using The New Prescriber textbook as a key text made the journey even better. The New Prescriber contains all the information you will need to successfully compete the course and to succeed in practice. Since completing the non‐medical prescribing course, my role has become more exciting and more autonomous, giving me all the skills and knowledge to practice at a high level.

Craig Prentice

Preface

While there are a number of current textbooks that deal with individual aspects of prescribing, this book uses an integrated approach providing important information across the broader aspects of prescribing.

The book is divided into two sections dealing with the patient, and pharmacology and therapeutics. The initial section, on the patient, explores the consultation and outlines the legal, professional and ethical frameworks that guide medical and non‐medical prescribing. The second section is concerned with pharmacology. Here, the reader is introduced to the basic concepts of pharmacodynamics and pharmacokinetics, adverse drug reactions and variability of response. These concepts are important as the reader progresses through the rest of the section exploring the therapeutic use of drugs for the treatment of disease.

Throughout the text, the reader will find ‘Stop and think’ and ‘Practice application’ boxes. These are intended to help the reader link theory to practice but in different ways. The ‘Stop and think’ boxes are designed to do exactly what they say and encourage the reader to stop and reflect on the knowledge gained and how this might be applied in practice, thus developing greater understanding. Ideal answers to the questions in these boxes are not presented in the book but should be drawn from an integration of all the relevant information presented within the chapter itself, previous chapters of the book and clinical practice. ‘Practice application’ boxes take a more factual approach by providing a direct link from theory to clinical practice.

Definitions of key terms used in the book can be found in the relevant section glossary.

Acknowledgements

We would like to thank everyone who has contributed to both the first and this second edition of The New Prescriber. The breadth of clinical and academic expertise that we have been able to call on across both editions has been tremendous and means we have been able to ensure a contemporary output.

In addition to these contributors, we would like to thank Lianne Nachmias for her support with the initial development of this edition.

Perhaps most importantly we would like to thank Sue Evans, who has been our key administrative support, managing the production of this edition for us. She has kept us all on track, helped with editing, formatting and proof‐reading, and liaising with the publishers. This edition has been possible only because of Sue’s ongoing support. Thank you, Sue.

Jo, Alison, Roger, Michael, and Dianne

SECTION 1The Patient

1

The Consultation

Frank Coffey and Dianne Bowskill

2

Accountability and Prescribing

Matthew Boyd, Stephanie Bridges, and Helen Boardman

3

Prescribing and the Law

Richard Griffith

4

The Ethics of Prescribing

Matthew Boyd, Stephanie Bridges, and Helen Boardman

5

Prescribing in Practice

Dianne Bowskill and Daniel Shipley

6

Public Health Issues

Michael Watson and Katharine Whittingham

SECTION INTRODUCTION

In this first section we focus on the practical aspects of prescribing for patients. As a new prescriber you will find there are many factors specific to your patient, your profession and your employer that influence both your decision to prescribe and the prescribing decisions you make. Throughout this section you will be encouraged to think about prescribing in practice and we begin with the consultation, the starting point for prescribing. All prescribers must practice within the law and in a manner consistent with the professional and public expectations of a prescriber. The legal framework of medical and non‐medical prescribing is defined in this section and new prescribers are encouraged to think about their prescribing role in relation to these aspects. Your actions as a prescriber will reach far beyond the patients you prescribe for, and this section encourages you to explore the ethical and public health issues associated with prescribing authority. As your prescribing experience grows, you will find it useful to revisit the definitions and questions raised in this section.

The term non‐medical prescriber is used throughout the book and refers to nurses, pharmacists and allied health professionals who, following successful completion of a programme of formal prescribing education, are on the professional record as a prescriber.

CHAPTER 1The Consultation

Frank Coffey and Dianne Bowskill

LEARNING OUTCOMES

By the end of this chapter the reader should be able to:

recognise and analyse the important elements of a consultation

identify the components of the traditional medical history

appreciate the diagnostic process and distinguish between the treatment of symptoms and the treatment of a disease or condition

identify the elements of the consultation essential for safe prescribing (bottom liners)

refine their professional assessment/consultation for the prescribing role

have insight into the impact of technological advances on assessment, diagnosis and treatment.

As you begin your prescribing education you already have a wealth of professional experience in your own area of practice. The assessment and consultation skills learnt as part of professional registration are well practised but may need to be refined as you take on prescribing. We are not suggesting that you need to adopt a new or medical model of consultation, although this might be desirable in certain advanced practice roles. For the majority of new prescribers, the focus will be on analysing their current framework of assessment or consultation and identifying adaptations required to support prescribing decisions. In this chapter we will ask you to think about the elements of the consultation that you may need to adapt or work on. We will give practice tips and point out common errors that can affect the quality of a consultation.

Prescribing inherently brings with it a greater requirement to make a diagnosis. This responsibility may be new and quite daunting. Prescribers need to understand the diagnostic process. In most circumstances, the key factor for accurate diagnosis is eliciting a good history. For this reason, we will look in detail at the elements of a history. Examination and investigations are directed by and supplement the history. The depth and focus of the history and examination will vary depending on the setting and your role. Wherever you work, however, it is essential to be thorough and systematic, and above all to know the bounds of your competence. History taking, examination and clinical decision making are skills that need to be continuously practiced under expert supervision.

Ideally your prescribing will be effective, but above all it should be safe. The primary dictum of all healthcare practice is ‘primum non nocere’ (above all do no harm). We will outline the elements of the consultation that are essential for safe prescribing, the ‘bottom liners’ of a prescribing consultation.

In the final part of the chapter, we will explore the potential impact of technological and scientific advances on assessment and clinical decision making and outline the increasing emphasis on health improvement and prevention in consultations.

THE CONSULTATION

The consultation is a two‐way interaction between a healthcare practitioner and a patient. Your role will influence the types of patients you treat, the environment in which you see them and your approach to the consultation. As a non‐medical prescriber your focus is on diagnosis. Assessment for diagnosis in a typical consultation comprises the history, examination and investigations. Factors to consider include the urgency and seriousness of the presentation, time constraints and the personalities, culture, language and medical knowledge of both the patient and the clinician. Previous contact with the patient, autonomy, and confidence are further influences on the consultation. Communication and consultation skills are inextricably interlinked. There are many excellent textbooks available for prescribers who wish to enhance their communication skills (Brown et al. 2016; Silverman et al. 1998; Berry 2004).

ELEMENTS OF A CONSULTATION

Although consultations differ in specifics, there are common elements and generic skills that are applicable in varying degrees to any given situation. Numerous consultation models have been developed over the years, for example Neighbour (2005), Pendleton et al. (2003) and Calgary Cambridge in Silverman et al. (1998). Rather than dwelling on the theory underpinning consultations, we will describe a practical framework for the consultation (see Box 1.1). This includes an assessment component (see I to (j) in Box 1.1) and other elements which can be applied in varying degrees to all consultations.

It is important for consultations to have a degree of structure. The skill in consulting is to maintain a structure and system that includes all the vital elements and yet does not feel like a straitjacket for the patient or clinician. In the following section we will analyse the different elements of the consultation in more detail and highlight those that are likely to change or need more emphasis for you as you take on prescribing.

BOX 1.1ELEMENTS OF A CONSULTATION

Preparing for the consultation and setting goals for it.

Establishing an initial rapport with the patient.

Identifying the reason(s) for the consultation.

Exploring the patient’s problem(s) and ascertaining their ideas, concerns and expectations about it.

Focusing questions to obtain essential information.

Gathering sufficient information relating to the patient’s social and psychological circumstances to ascertain their impact.

Coming up with a diagnosis or a number of differential diagnoses in order of likelihood.

Performing a focused physical examination and near‐patient tests to support or refute the differential diagnoses.

Reaching a shared understanding of the problem with the patient.

Interpreting the information gathered and re‐evaluating the problem.

Considering further investigations if necessary.

Deciding what treatment options, pharmacological and non‐pharmacological, are available.

Advising the patient about actions needed to tackle the problem.

Explaining these actions and the time of follow‐up if required.

Inviting and answering any questions.

Summarising for the patient and terminating the consultation.

Making a written record of the consultation.

Presenting your findings to another health professional.

STOP AND THINK

Using Box 1.1 as a framework, reflect on your current consultations and identify elements you are less confident with. Make a note of these to inform learning and development needs.

(A) PREPARING FOR THE CONSULTATION AND SETTING GOALS

Take time to study all the information available to you about the patient prior to the consultation. Study referral letters and available medical records for vital information, including the patient’s past history, medications and allergies. Set goals for the consultation and ensure that the environment is set up appropriately with adequate lighting and privacy.

(B) ESTABLISHING THE INITIAL RAPPORT

First impressions are especially important and will influence your subsequent relationship with the patient. If you have not encountered the patient before, introduce yourself by name and explain your role. Check the patient’s details (name, date of birth, address). Observe the patient’s demeanour and physical appearance. The patient will invariably be feeling nervous. Put them at ease by projecting confidence and warmth, and they are more likely to open up to you during the consultation.

(C) TO (G) HISTORY TAKING/DIAGNOSIS HYPOTHESIS

Elements (c) to (g) in Box 1.1 are primarily concerned with the taking of a history and the consideration of differential diagnoses. The importance of the history cannot be overstated. In the vast majority of cases (>70%) the history will provide an accurate diagnosis or differential diagnosis even before the examination and investigations are performed. A good history will therefore facilitate effective prescribing. Certain minimum information must be elicited to ensure safe prescribing,

The history is a two‐way process. In reality, we do not ‘take’ a history. Rather, we ‘make’ a history with the patient. The result is influenced by both the practitioner’s and the patient’s prior knowledge, experiences and understanding of language. Where understanding of language is a barrier, clinical risk is significantly increased and an interpreter should be considered. There are psychodynamic processes at play during any consultation which the practitioner needs to be aware of. These are explored in detail in other publications (Berry 2004).

The scope and depth of the history will depend on the role of the practitioner and the circumstances surrounding the consultation. Whatever the nature of the history, it is essential to be systematic and as far as possible follow the same sequence of questioning each time. In this way vital information will not be overlooked. This becomes particularly important when the patient has multiple symptoms and/or a complicated medical history.

Most patient histories will contain some or all the elements of a traditional medical history. This structure has limitations and has been criticised for being practitioner rather than patient centred. A full history is too time‐consuming in most situations. However, we believe that it is important for prescribers to understand the elements of the traditional history before considering some of the modified and/or abbreviated versions that are used in practice.

THE TRADITIONAL MEDICAL HISTORY

PRESENTING COMPLAINT (PC)

Consider the symptom(s) or problem(s) that has brought the patient to seek medical attention and its duration. The presenting complaint should ideally be written or presented orally in the patient’s own words, for example ‘tummy ache for 3 hours’ ‘dizzy spells for 2 years’.

Remember that the complaint that the patient seeks medical advice about might not be their main concern, for example a man concerned about impotence might attend on the pretext of back pain. The true presenting problem will be elucidated by an empathetic and skilled interviewer.

HISTORY OF THE PRESENTING COMPLAINT (HxPC)

This is where you clarify the presenting complaint. It is the most important part of the history and is essential for the formulation of a differential diagnosis. Explore the patient’s symptoms and try to build a clear picture of the patient’s experience. Avoid leading questions as far as possible. At some point, however, you will need to move to focused questioning to elicit essential information and fill in gaps in the patient’s story. When there are a number of symptoms, it is important to complete the questioning around each symptom in a systematic fashion before moving on to the next one. Pain is one of the most common presenting symptoms. The following information should be elicited about pain: its onset (gradual or sudden), location, radiation, character, periodicity (does it come and go?), duration, aggravating and relieving factors, and associated features (secondary symptoms). Similar questioning with modifications can be applied to most symptoms, for example for diarrhoea the character (amount, colour, etc.), timing, aggravating and relieving factors, and associated symptoms (e.g., abdominal pain) are all relevant. Several mnemonics have been created as an aide mémoire for symptom analysis (see Boxes 1.2 and 1.3 for examples).

BOX 1.2SYMPTOM ANALYSIS MNEMONIC

PQRST

P –

provocation or palliation

Q –

quality and quantity: what does the symptom look, feel, sound like?

R –

region/radiation

S –

severity scale, may be rated on a scale of 1–10, which is useful for subsequent evaluation and comparison

T –

timing

BOX 1.3SYMPTOM ANALYSIS MNEMONICS

SQITARS

SOCRATES

S

–

site and radiation

S –

site

Q

–

quality

O –

onset

I

–

intensity

C

–

character

T

–

timing

R –

radiation

A –

aggravating factors

A –

associated symptoms

R –

relieving factors

T –

time intensity relationship

S –

secondary symptoms

E –

exacerbating/relieving

S

–

severity

PRACTICE APPLICATION

As a new prescriber using a mnemonic/acronym is an effective approach to remembering key questions to ask in a consultation

Always ask about the cardinal symptoms in any system potentially involved, for example for chest pain, ask about the cardinal symptoms relating to the cardiovascular and respiratory systems. The cardinal respiratory symptoms are cough, dyspnoea, wheeze, chest pain, sputum production and haemoptysis. Include within the history of the presenting complaint the presence of risk factors for conditions that may be the cause of the presenting symptom(s), for example if ischaemic chest pain is in the differential, hypertension, smoking and a positive family history examples of such risk factors. Similarly, oral contraceptive pill (OCP) therapy or prolonged immobilisation would be risk factors for pulmonary embolism.

PAST MEDICAL AND SURGICAL HISTORY (PMHx)

The past medical history, along with medications, drug history and allergies, provides the background to the patient’s current health or disease. Record previous illnesses, operations and injuries in chronological order. Include the duration of chronic conditions, for example diabetes mellitus or asthma, in your record and, where appropriate, the location of treatment and the names of the treating clinicians. Remember that many medical conditions may impact on your choice and/or dose of drug treatment.

FAMILY HISTORY (FamHx)

Information regarding the age and health or the cause of death of the patient’s relatives can be invaluable and provide vital clues in the diagnostic process. Many conditions have a well‐defined mode of inheritance. Enquire specifically about the following common conditions: hypertension, coronary artery disease, high cholesterol, diabetes mellitus, kidney or thyroid disease, cancer (specify type), gout, arthritis, asthma, other lung disease, headache, epilepsy, mental illness, alcohol or drug addiction, and infectious diseases such as tuberculosis. Depending on the clinical area, you may need to explore the family history of sensitive areas such as mental health, drug misuse or sexual health in more detail. The family history may also throw light on the patient’s ideas, fears and expectations, for example a patient whose sibling has died from a brain tumour is likely to be genuinely concerned about a headache that is persisting.

MEDICATIONS, DRUG HISTORY AND ALLERGIES

The drug and allergy history are an extremely important part of the medical history. The presenting symptoms may result from the side effects or complications of drug therapy. Current medications and previous allergies will influence prescribing. Ask the patient to list the medications that they are taking on medical advice or otherwise. Ask to see a recent medication list or prescription. Ideally, you should see the medications. Note the name, dose, route, frequency of use and indications for all medications. It is also important to establish if the patient is taking the medicines prescribed. List over‐the‐counter drugs, and complementary and herbal medicines. The oral contraceptive pill is often not perceived as a medication. Ask specifically about it in women of the appropriate age. Patients may omit to mention medications that are not tablets (e.g., inhalers, home oxygen, creams, eye or ear drops, pessaries, suppositories). Ask specifically about such agents.

Enquire about allergies or adverse reactions to medications, foods, animals, pollen or other environmental factors. If the patient gives a history of allergy, record the exact nature and circumstances of the reaction and the treatment given.

PERSONAL AND SOCIAL HISTORY

The personal and social history is a critical aspect of the history. All illnesses, treatments and rehabilitation must be seen in the context of the patient’s personality, spirituality, and personal and social circumstances. Occupation, habitation, hobbies and lifestyle habits can have a profound impact on health and disease. Where appropriate, do not neglect to ask about recent travel abroad and sexual history. Ascertain whether the patient smokes or has smoked in the past and quantify their smoking. Enquire about alcohol intake and, where appropriate, the use of illicit drugs. Some patients may be reluctant to reveal the full extent of their smoking, alcohol consumption or recreational drug use. Maintain a non‐judgmental attitude to encourage such patients to share information.

SYSTEMS REVIEW

The systems review (SR), which is undertaken at the end of the history, involves a series of screening questions that systematically cover all the body systems. It is usually done in a head‐to‐toe sequence. Its purpose is to elicit any further information that might be relevant to the current illness or to uncover present or past problems that the patient has overlooked. The SR may provide information that leads you to suspect a multisystem disease process such as systemic lupus erythematosus or may demonstrate associated symptoms in another system, for example arthritis associated with inflammatory bowel disease. A comprehensive list of SR questions can be found in Coffey, Wells and Stone (2024).

(H) PHYSICAL EXAMINATION/NEAR‐PATIENT TESTS

The purpose of the physical examination and near‐patient tests is to supplement your findings from the history and to support or refute your diagnostic hypotheses. The extent of your examination will depend on your training and experience. It is not essential to be able to perform a physical examination to be a competent prescriber in a specialised area. Increasingly, however, healthcare practitioners are taking on advanced examination skills. It is important that these are taught and assessed appropriately.

Perform vital signs, including temperature. Consider vital signs in the context of the patient’s age, physical fitness and medication, and always seek a reason for abnormal vital signs. Perform a thorough examination and avoid taking shortcuts. In most cases, your examination will be a focused one, concentrating on a specific area of the body. It is important to expose adequately the area to be examined and always compare limbs with the contralateral one.

Near‐patient tests are tests that produce immediate results, for example electrocardiograms, urinalyses, arterial blood gases and blood glucose. Increasingly other investigations such as the full blood count and urea and electrolytes are becoming available as near‐patient tests. These tests can be invaluable for diagnosis and can also direct or influence the prescription of medications. Remember always to check glucose level in a patient with confusion or altered consciousness.

(I) TO (K) DIAGNOSIS

Diagnosis is the process of ascertaining the nature and cause of a disease. This enables the practitioner to target treatments effectively. The diagnosis is made by evaluating the symptoms, signs and investigation results, which together constitute the diagnostic criteria. The information is considered in the context of the patient’s physical, social and psychological status. A treatment plan is then formulated, ideally in partnership with the patient, who should be kept informed throughout the diagnostic procedure.

Increasingly healthcare practitioners other than doctors are involved in the diagnostic process. The advent of non‐medical prescribing has accelerated this trend. Practitioners moving into the diagnostic arena need to understand the process and be aware of potential pitfalls. The way clinicians diagnose alters as they become more experienced. The word diagnosis comes from the Greek words for ‘through’ (dia) and ‘knowledge’ (gnosis