Current medicines

Taken as directed?

Comments

Doxycycline 100mg po BD for 5/7 in total

N/A

Completed course

Prednisolone 40mg po OM for 7/7 in total

N/A

Completed course

Fluoxetine 20mg po OM

YES

Mr Wells has been depressed lately. Doctors in the hospital decided to treat this.

Bendroflumethiazide 2.5mg po OM

YES

For hypertension

Ramipril 10mg po OM

YES

For hypertension. Raj notices that, under ‘clinical narrative’ on the discharge, that Mr Wells was experiencing a non-productive cough

Fostair 100/6 2 puffs BD

NO

Doesn’t like the taste and prefers his original Symbicort. Wants to know why it was swapped and whether he can go back on it

Bricanyl 500mcg 2 puffs PRN 

NO

Has been using this frequently up to four times a day

Main action points

Issue
New antidepressant medication - fluoxetine

Recommendation
Raj advises that it is common for those with long-term chronic conditions to feel depressed. Although there are non-drug treatments available such as cognitive behavioural therapy, the doctors in the hospital thought drug treatment would be better because it can be initiated immediately.

Raj advises that Mr Wells should not stop taking fluoxetine abruptly but only do so on his GP’s advice due to the risk of experiencing withdrawal effects, which can be severe and may include headaches, anxiety, dizziness and sleep disturbance.

Raj ascertains that Mr Wells no longer drives but nevertheless advises him that this medicine may affect his driving ability.

Raj also advises that the full effect of this medicine may take several weeks and that he should see his GP after about four weeks for a review on whether the medicine is working. He tells Mr Wells that he will probably be on the medicine for a long time and that, even when he feels better, this medicine may be continued for 12 months to ensure no relapse.

For consideration by
Patient
Raj advises Mr Wells that if he feels unwell in any way or experiences any unusual symptoms to either come in to the pharmacy for advice or see his GP.

• Not to stop taking fluoxetine except on GP advice
• To make an appointment to see his GP in a month’s time
• Check for any unusual symptoms that may be an indication of a side effect

Issue
Mr Wells was experiencing a non-productive cough before admission

Recommendation
Mr Wells does not smoke. Could this cough therefore be a result of ramipril or something more sinister such as cancer? Raj advises Mr Wells to monitor his cough and if it persists for more than three weeks to see his GP.

For consideration by
​Patient

• To monitor his non-productive cough and see GP if it persists for more than three weeks

Issue
Does not want to use the Fostair inhaler, wants to return to Symbicort

Recommendation
Raj explains that the hospital and the wider NHS community are adopting similar, equally effective but cheaper, inhalers to reduce the NHS medicines bill. Mr Wells refuses to use the new inhaler and comments that he has paid his taxes for long enough.

Raj explains that, although Mr Wells wants to be restarted on his old inhaler, it is in his interest to continue using the Fostair inhaler until a replacement is available.

For consideration by
​Patient

• To put a prescription request for Symbicort in at his surgery
• Continue using Fostair until replacement inhaler issued​

• To issue a prescription for Symbicort to improve patient compliance

Issue
Overuse of Bricanyl inhaler

Recommendation
The maximum dose for this is one puff (500mcg) QDS PRN. One dose (puff) should give three hours’ relief. Failure to provide this relief may be evidence of deterioration of asthma or underuse/misuse of the combination steroid/B2 agonist inhaler. In this case, the latter is most probably the issue  and Raj has already advised Mr Wells of the importance of using the combination inhaler.

The dose on Mr Wells’ prescription needs to be changed to one puff QDS PRN.

Raj reads through the patient information leaflet because it is vital that Mr Wells follows the manufacturer’s instructions.

For consideration by
​Patient​

• Not to use more than QDS. If not gaining three hours’ relief from one dose to seek medical advice
• Follow manufacturer’s directions on how to use inhaler

GP 

• Change dose from 2 puffs PRN to 1 puff QDS PRN

Nurse

• Ensure Mr Wells has an annual date for his asthma review

Issue
Healthy living advice

Recommendation
Raj advises Mr Wells not to start smoking or drinking alcohol and to continue with a healthy diet and pattern of food consumption (small amounts regularly). He also tells Mr Wells to continue walking to ensure he gets adequate exercise.

For consideration by
​Patient

• Continue with his pattern of healthy living 
• Visit the pharmacist in a few weeks when the inhaler issues are resolved