Practical Prescribing for Medical Students


Edited by: Helen Bradbury, Barry Strickland-Hodge, Judy McKimm & Kirsty Forrest

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  • Copyright

    Foreword from the Series Editors

    The Learning Maters Medical Education Series

    Medical education is currently experiencing yet another a period of change, typified in the UK with the introduction of the revised Tomorrow's Doctors (General Medical Council, 2009) and ongoing work on establishing core curricula for many subject areas. Changes are also occurring at Foundation and postgraduate levels in terms of the introduction of broader non-technical competencies, a wider range of assessments and new revalidation requirements. This new series of textbooks has been developed as a direct response to these changes and the impact on all levels of medical education.

    Research indicates that effective medical practitioners combine excellent, up-to-date clinical and scientific knowledge with practical skills and the ability to work with patients, families and other professionals with empathy and understanding; they know when to lead and when to follow and they work collaboratively and professionally to improve health outcomes for individuals and communities. In Tomorrow's Doctors, the General Medical Council defines a series of learning outcomes set out under three headings:

    • Doctor as Practitioner;
    • Doctor as Scholar and Scientist;
    • Doctor as Professional.

    The books in this series do not cover practical clinical procedures or knowledge about diseases and conditions, but instead cover the range of non-technical professional skills (plus underpinning knowledge) that students and doctors need to know in order to become effective, safe and competent practitioners.

    Aimed specifically at medical students (but also of use for junior doctors, teachers and clinicians), each book relates to specific outcomes of Tomorrow's Doctors and other relevant documents, providing both knowledge and help to improve the skills necessary to be successful at the non-clinical aspects of training as a doctor. One of the aims of the series is to set medical practice within wider social, policy and organisational agendas to help produce future doctors who are socially aware and willing and prepared to engage in broader issues relating to healthcare delivery.

    Individual books in the series outline the key theoretical approaches and policy agendas relevant to that subject, and go further by demonstrating through case studies and scenarios how these theories can be used in work settings to achieve best practice. Plenty of activities and self-assessment tools throughout the book will help readers to hone their critical thinking and reflection skills.

    Chapters in each of the books follow a standard format. At the beginning a box highlights links to relevant competencies and outcomes from Tomorrow's Doctors and other curricula, if appropriate. This sets the scene and enables readers to see exactly what will be covered. This is extended by a chapter overview which sets out the key topics and learning outcomes.

    Each chapter typically includes at least one case study which illustrates how theory can be used in practice from different perspectives. Activities are included which include practical tasks with learning points, critical thinking research tasks and reflective practice/thinking points. Activities can be carried out by readers or with others and are designed to raise awareness, consolidate understanding and enable students to improve their practice by using models, approaches and ideas. Each activity is followed by a brief discussion on issues raised. At the end of each chapter a chapter summary provides an aide-mémoire of what has been covered.

    All chapters are evidence-based in that they set out the theories or evidence that underpins practice. In most chapters, one or more ‘What's the evidence?’ boxes provide further information about a particular piece of research or a policy agenda referenced in books, articles, websites or policy papers. A list of additional readings is set out under the ‘Going further’ section, with all references collated at the end of the book.

    The series is edited by Professor Judy McKimm and Professor Kirsty Forrest, both of whom are experienced medical educators and writers. Book and chapter authors are drawn from a wide pool of practising clinicians and educators from around the world.

    Author Biographies

    David Alldred formerly of the University of Leeds, now Senior Lecturer in Pharmacy Practice at the School of Pharmacy, University of Bradford. David is a clinical pharmacist who has research and practice experience in primary and secondary care. His teaching and research focus on the quality and safe use of medicines, particularly in older people.

    Helen Bradbury Senior Lecturer at the University of Leeds. Helen's post at Leeds spans education and healthcare. She is the programme leader for the Master's in Clinical Education and has published on reflective practice and e-learning. Helen worked in the NHS for 20 years as a hospital pharmacist before commencing her academic career.

    Natalie Bryars Principal Pharmacist at York Teaching Hospital NHS Foundation Trust, where she leads on Clinical Governance. Natalie's teaching focuses on medicines management and patient safety and she contributes to the training programmes for medical, nursing and pharmacy staff within the Trust. She also teaches on prescribing at the Hull and York Medical School and her research has focused on how prescribing can be taught more effectively to medical students.

    Catherine Gill Lecturer and Module Leader Nurse Prescribing, University of Leeds, Lead Partner for Learning and Teaching, Caritas Health Partnership. Catherine has a keen interest in prescribing and holistic practice and was among the first UK nurses to qualify as an independent nurse prescriber. Since then she has combined clinical practice with academia, promoting interprofessional learning and teaching and achieving appointment as an associate GP trainer.

    Daniel Greer Lead Pharmacist for Gastroenterology, Leeds Teaching Hospitals NHS Trust. Daniel's background is in hospital pharmacy, where he has worked since qualifying as a pharmacist in 1994. He joined the University of Leeds as a lecturer practitioner and helped set up a new postgraduate programme in pharmacy practice. He contributes to other pharmacology and therapeutics teaching within the school and wider university as well as supervising MSc student dissertations.

    Greg Heath Specialty Registrar in Medical Ophthalmology, York Teaching Hospital NHS Foundation Trust. Greg has an active role in teaching undergraduate and postgraduate students in medicine. He also lectures optometrists on independent prescribing at City University, London.

    Andy Hutchinson Medicines Education Technical Adviser, Medicines and Prescribing Centre at the National Institute for Health and Care Excellence (NICE). Andy is a pharmacist who has been teaching doctors, pharmacists and nurses about evidence-based medicine for more than 20 years. He is particularly interested in the practical skills that busy health professionals need to make evidence-informed decisions with their patients.

    Monica Murphy Student Education Fellow and Lecturer in Ethics and Law in the School of Healthcare, University of Leeds. Monica is a nurse prescriber with a special interest in adult safeguarding and developing student education on medicines management.

    Barry Strickland-Hodge Director, Academic Unit of Pharmacy, Radiography and Healthcare Science and Senior Pharmacy Lecturer, School of Healthcare, University of Leeds. Barry is a pharmacist and information scientist leading on independent prescribing for pharmacists. He teaches nurses, midwives, radiographers, pharmacists, psychiatrists and medical students. As an apothecary, he also has an interest in the history of pharmacy and medicine.

    Jonathan Underhill Associate Director Medicines Evidence, Medicines and Prescribing Centre at the National Institute for Health and Care Excellence (NICE). Jonathan is a pharmacist with a background in medicines evaluation, education and advice. He is passionate about the practical application of the science and art of evidence-informed decision making to help practitioners ensure the best possible outcomes for their patients.

    Arnold Zermansky retired general practitioner and Honorary Senior Research Fellow in the School of Healthcare, University of Leeds. Arnold's teaching and research focus on the quality and safe use of medicines.



    angiotensin-converting enzyme


    adverse drug event


    adverse drug reaction


    activated partial thromboplastin time


    British National Formulary


    BNF for Children


    controlled drug


    confidence interval


    central nervous system


    creatinine clearance


    drug analysis print


    evidence-based medicine




    Faculty of Sexual and Reproductive Healthcare


    glomerular filtration rate


    General Medical Council


    general sales list


    ideas, concerns and expectations


    international normalised ratio




    low-molecular-weight heparin


    marketing authorisation


    monoamine oxidase inhibitor


    modification of diet in renal disease


    Medicines and Healthcare Products Regulatory Agency


    National Health Service

    NHS IQ

    NHS Improving Quality


    National Institute for Health and Care Excellence


    no known drug allergies


    number needed to harm


    number needed to treat


    National Prescribing Centre


    National Patient Safety Agency


    non-steroidal anti-inflammatory drug


    over the counter


    pharmacy medicines


    Patient Group Direction




    prescription-only medicine


    Patient Specific Direction


    randomised controlled trial


    Scottish Intercollegiate Guidelines Network


    Summary of Product Characteristics

  • Drug Calculations

    Here are ten typical situations where a dose needs to be calculated. None are too difficult. Think carefully, as it can be easy to make mistakes. The answers follow in Appendix 2 so you can check how you did.

    • The dose of tinzaparin for the treatment of pulmonary embolism is 175 units/ kg. You have a patient who weighs 56kg. The tinzaparin preparation is 20,000 units/mL.
      • What is the dose?
      • What volume should be administered?
    • A 25kg child with tuberculosis requires the following oral medicines.
      • What doses should be prescribed?
      • What volumes should be administered?

    • A patient who is nil-by-mouth requires 200 micrograms of digoxin intravenously. You have 0.5mg in 2mL injection available.
      • What volume should be administered?
    • A 62kg, 80-year-old patient requires a 5mg/kg loading dose of intravenous aminophylline for severe chronic obstructive pulmonary disease. You have 250mg in 10mL ampoules available.
      • What is the dose?
      • What volume is required?
    • A 68.5kg patient with pneumonia requires gentamicin 7mg/kg. You have gentamicin injection 80mg/2mL available.
      • What is the dose?
      • What volume of gentamicin injection is needed?
    • A 70kg patient requires intravenous lorazepam for a severe, acute panic attack at a dose of 30 micrograms/kg. You have lorazepam injection 4mg/mL available.
      • What is the dose?
      • What volume should be administered?
    • A 65kg patient is admitted with a paracetamol overdose and requires an infusion of acetylcysteine at 100mg/kg. You have ampoules of acetylcysteine 2g/10mL available. The infusion needs to be given in 1 litre of glucose 5% over 16 hours.
      • What is the dose?
      • What volume of acetylcysteine is needed?
      • How would you prepare and administer the infusion?
    • A 70kg patient requires dopamine 4 micrograms/kg/min. The pharmacy supplies pre-made syringes containing 200mg in 50mL.
      • What is the dose?
      • What rate in mL/hour needs to be administered?
    • A 25kg child with severe hyperkalaemia requires salbutamol 4 micrograms/kg by intravenous injection. You have 500 micrograms/mL injection available. The injection needs to be diluted with glucose 5% to a concentration of 50 micrograms/ mL prior to administration.
      • What is the dose?
      • How would you prepare the injection?
    • A 2.8kg neonate requires meropenem intravenous infusion 20mg/kg for septicaemia. You have meropenem 500mg injection (dry powder) available. You speak to the on-call pharmacist who says to reconstitute the meropenem with Water for Injection to make 10mL and that meropenem has a displacement value of 0.4mL. Then you need to dilute further with sodium chloride 0.9% to obtain a 10mg/mL solution.
      • What is the dose?
      • How would you prepare the infusion?
      • What volume of meropenem 10 mg/mL needs to be administered?

    Answers to Drug Calculations

    • Dose = 9,800 units
      • Volume = 0.49mL (would round up to 0.5mL)
    • Rifampicin250mg;12.5mL of 100mg/5mL
      Isoniazid250mg;25mL of 50mg/5mL
      Pyrazinamide875 mg;8.75mL of 500mg/5ml
      Ethambutol375mg;9.4mL of 200mg/5mL
    • Volume = 0.5mg in 2mL = 500 micrograms in 2mL
      • 200 micrograms ÷ 500 micrograms × 2mL = 0.8mL
    • Dose = 62 kg × 5mg = 310mg
      • Volume = 310mg ÷ 250mg × 10mL = 12.4mL
    • Dose = 68.5kg × 7mg = 479.5mg (round up to 480mg)
      • Volume needed = 480mg ÷ 80mg × 2mL = 12mL
    • Dose = 70kg × 30 micrograms = 2100 micrograms, 2100 micrograms÷1000 = 2.1mg
      • Volume = 2.1mg÷4mg × 1mL = 0.53mL
    • Dose = 65 kg × 100 mg = 6500mg ≡ 6.5g
      • Volume of acetylcysteine = 6.5g ÷ 2g × 10ml = 32.5mL
      • Preparation/administration = remove 32.5mL from 1L glucose 5% bag and add 32.5mL acetylcysteine 2g/10mL. Run the infusion at 62.5mL/hour (1000mL ÷16).
    • Rate = 4 micrograms/kg/min = 4 × 70kg micrograms/min = 280 micrograms/min Want rate per hour so 280 micrograms/min = 280 × 60 micrograms/hour
      • = 16800 micrograms/hour
      • = 16800 ÷ 1000
      • = 16.8 mg/hour
      • Have 200mg in 50mL, want 16.8mg/hour so (16.8mg ÷ 200mg) × 50mL = 4.2 ml/hour
    • Dose = 100 micrograms (25 kg × 4 micrograms)
      • 100 micrograms ÷ 500 micrograms × 1mL = 0.2mL of injection needed
    • Dose = 20mg×2.8kg = 56mg
      • Infusion preparation = add 9.6mL Water for Injection to the 500mg vial of meropenem. This gives 500mg in 10mL (as displacement value is 0.4mL) i.e. 50mg/mL. Therefore, this needs diluting by a factor of five to obtain a 10mg/mL solution.
      • Take 10mL of the 500mg/10mL solution and add to 40mL of sodium chloride 0.9% . This gives 500mg in 50mL i.e. 10mg/mL
      • Need 56mg dose, so 56mg ÷10 mg × 1mL = 5.6mL
      • Give 5.6 mL over 15-30 minutes. (Could also give over 5 minutes as bolus.)


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