• Calgery and Cambridge consultation model was used
• Nitrofurantoin 100mg m/r capsule twice a day for three days antibiotic was prescribed for a 33 year old female with lower urinary tract infection with no health issues apart from asthma and migraine
• Prescribed by pharmacist independent prescriber
• Use NICE guidelines for evidence based treatment on lower urinary tract infection but also journals to critically analyse therapy
(Urinary-tract infections | Treatment summary | BNF content published by NICE)
• Harvard referencing and in text reference
1. Case study (table)
Your role Pharmacist prescriber
Setting General Practice
Prescribing type Independent prescriber
Consultation Model The Calgary Cambridge model is used. It is a comprehensive model that provides both doctor and patient centred consultation. It is evidence based and it identifies the skills and behaviours using 5 easy framework to promote collaborative partnership.
(consultation models and csa frameworks – Bradford VTS, 2021)
Consent The patient consents to the assessment and understands my role as a supervised student practitioner.
Confidentiality statement Consent was obtained from the patient to use in this case study as an example of my prescribing practice. All names (patient, other healthcare professionals and the organisation) changed in compliance with the GPhc guideline.
(GPhC , In practice: guidance on confidentiality, 2021)
Patient Overview • Mrs Taylor 33 years old female
• Married
• Not pregnant or breastfeeding
• No other sexual partner
• None smoker
• Drinks 4-5 units a week
• Working as a teacher and trying to keep healthy
• No procedure or catheter inserted
• Not diabetic or not hypertensive
• Mother suffers from asthma and father has diabetes
Presenting Complaint Mrs Taylor complaining of the following symptoms for the past three days:
• burning when passing urine(dysuria) with strong smell
• no temperature
• lower abdominal pain
• no vaginal discharge
Medical History
• migraine , 2015
• asthma , since childhood
Allergy Status Mrs. Taylor has no known drug allergies
Current Medications
• Sumatriptan 50mg for migraine attacks only (one or two ta
• Paracetamol 500mg tablets (one or two tablets when required for migraine and headaches)
• Salbutamol 100mcg inhaler (one- two puffs up to four times daily when needed)
• No other OTC, herbal or recreational drugs
(Excellence, 2021)
Assessment (physical) • Vital signs were normal , temperature was 36.4֯ C
• Heart rate 81 beats per minute
• Oxygen saturation 95%
• Respiratory rate 13 breath per minute
• Blood pressure 122/80mmhg
• Genital area was examined and was all normal
• On examination of abdomen , it was soft with mild suprapubic tenderness but no abdominal mass or renal angel tenderness.
• Urine sample(mid stream urine) was requested from the patient to be performed and brought back to the surgery to perform a dip test to detect presence of nitrates and leukocyte esterase (Clarke & Kumar ,2007)
Investigation Results • The test results showed positive nitrates and 2+ moderate leucocytes.
Differential Diagnosis • Pyelonephritis/ renal angel tenderness or kidney stones , was excluded as the patient had no backpain or Ioin pain, nausea / vomiting, and no fever.
• STD was excluded as the patient had one sexual partner and had no vaginal discharge, itching, or irritation around vaginal area nor blood discharge
• Genital herpes, excluded as there is no itching by patient or blisters when genital area was examined.
• Sepsis was excluded as all other vital signs were normal and no fever present
Definitive diagnosis • Prescence of nitrates and leukocyte from the urine dipstick confirms acute UTI (NICE, 2021).
Medications Considered • None pregnant women with no underlying conditions and uncomplicated UTI can be Nitrofurantoin 100mg modified- release twice a day for three days or nitrofurantoin 50mg, four times a day for three days. If there is a risk of resistance, prescribe Trimethoprim, 200mg twice a day for three days (NICE, 2021).
Medication Prescribed
• Nitrofurantoin 100mg capsule m/r, take one capsule twice a day for three days. (Excellence, 2021)
Key pharmacology of prescribed medication Pharmacokinetic of Nitrofurantoin:
Absorption
Each Macrobid capsule contains two forms of nitrofurantoin. 25% of the dose is macrocrystalline nitrofurantoin which has slower dissolution and absorption than nitrofurantoin microcrystals. The remaining 75% of the dose is microcrystalline nitrofurantoin contained in a powdered blend which on exposure to gastric and intestinal fluids forms a gel matrix resulting in a modified release of active ingredient over time. Combined these systems provide a clinically effective bactericidal urine concentration at therapeutic doses.
Distribution
Plasma nitrofurantoin concentrations at therapeutic doses of the Macrobid capsule are low, with peak levels usually less than 1 mcg/ml. Nitrofurantoin is highly soluble in urine to which it may impart a brown colour. Unlike many drugs the presence of food or agents delaying gastric emptying increases the bioavailability of the Macrobid capsule.
Elimination
Approx. 20-25% of the total single dose of nitrofurantoin is recovered from the urine unchanged over 24 hours.
Pharmacodynamic properties of Nitrofurantoin :
Nitrofurantoin is a broad spectrum antibacterial agent, active against the majority of urinary pathogens. It is bactericidal in renal tissue and throughout the urinary tract. The wide range of organisms sensitive to the bacterial activity include Escherichia coli, Enteroccus faecalis, Klebsiella species, Enterobacter species, Staphylococcus species: (eg S. aureus, S. saprophyticus, S. epidermidis)
(Macrobid Capsules 100mg B.P- Summary of Product Characteristics (SmPC) – (emc), 2021)
Potential Adverse Drug Reactions Common side effects:
• feeling sick (nausea)
• being sick (vomiting) and diarrhoea
• loss of appetite
• headaches
• dizziness or feeling sleepy
Nitrofurantoin may cause your pee to turn dark yellow or a brownish colour. This is normal and not a reason to stop taking the medicine. Your pee will return to normal once you stop taking nitrofurantoin.
Serious side effects
Serious side effects are rare and happen in less than 1 in 1,000 people.
Call a doctor straight away if you get:
• pains in the chest, difficulty breathing, coughing, chills, or a high temperature
• pale poo and dark pee together, yellow skin or the whites of your eyes turn yellow – this can be a sign of liver or gallbladder problems
• pins and needles, tingling sensations, numbness or weakness – these can be signs of nerve problems
• bruising or bleeding you cannot explain (including nosebleeds), sore throat, a high temperature and feeling tired or generally unwell – these can be signs of blood problems
• bad headaches
https://www.nhs.uk/medicines/nitrofurantoin/
If there is any side effects not listed in the patient information leaflet or anaphylaxis can be reported to MHRA via online form http://www.mhra.gov.uk/yellowcard or filling in the Yellow card from GP or pharmacist.
Potential drug interactions • No interactions between current drugs and nitrofurantoin.
Advice • Patient is advised to drink plenty of water and keep rehydrated
• Self hygiene , clean/ wash gentile area include wiping from front to back after defecation.
• Not to delay urination when there is an urgency and wear none occlusive underwear.
• Take Nitrofurantoin with or after food or milk
• Tablets can discolour urine so patient shouldn’t worry as it is harmless
(NICE,2021)
Follow up, hand over and/or referrals Seek medical advise immediately if the following occurs:
• If patient not feeling better after 48 hours of starting the course
• symptoms worsen
• develop other symptoms such as back pain or lion pain
• blood in urine
• nausea and vomiting
• fever
Essay Critical analysis
Analyse your consultation of the patient
• Discuss the consultation process and critically analyse the frameworks that influenced your approach.
• This is NOT an analysis of consultation models (Calgery and Cambridge model) or a description of how you applied the different phases of a consultation process.
• The analysis should be about what elements of your consultation were important to the prescribing episode. This should include reference to appropriate guidelines, expert opinion and research.
• When considering your consultation of the patient:
o How did this assist you in undertaking a comprehensive consultation/assessment, making an informed diagnosis, and selecting the appropriate treatment?
o Make sure this is relevant to this episode, for example how developing rapport and establishing trust improved concordance.
• What factors have influenced your prescribing decision; for example, psychological issues; socioeconomic status; education; concordance etc.
• This section relates to the RPS Framework competencies 1-3. Your experiences completing these elements of the framework may give you ideas about how to approach this part if the essay.
Analyse the pharmacology of the drug(s) you prescribed: (Nitrofurantoin)
• Discuss the relevant pharmacodynamics of the medication that you prescribed, and analyse how this relates to the pathophysiology of the condition that you treated (UTI).
• Only discuss the pharmacokinetics for the prescribed drug if this is relevant to your prescribing decision.
• Discuss why the drug you prescribed was appropriate for this patient and this condition.
• You must consider the influence of recent clinical trials on guidelines and/or local policy and critically evaluate how this has influenced your prescribing decision ( use NICE guidelines)
• Consider how this relates to your own area of practice and how recent evidence may contradict local and national guidelines.
• This section relates to the RPS Framework competencies 4-6. Your experiences completing these elements of the framework may give you ideas about how to approach this part if the essay.
Analyse the clinical governance that underpinned your prescribing decision
• Consider the legal, ethical and professional frameworks which support your practice
• Consider the impact your consultation and prescribing decision has had on the patient. For example, how might autonomy and beneficence relate to the issues of concordance and compliance?
• Discuss the impact of your professional role within the context of this prescribing episode.
• Consider how this episode relates to your specific practice area and how this could be developed for the future.
• Do NOT include a generic analysis of legal/ethical issues. This MUST be relevant to the episode.
• This section relates to the RPS Framework competencies 7-10. Your experiences completing these elements of the framework may give you ideas about how to approach this part if the essay.
• 1900 words
• Harvard referencing and intext reference