Non Medical Prescribing: Case Study Reflection Template

Non medical prescribing1
Case Study Reflection Template
(please submit via turnitin and as a signed paper copy in Evidence Profile)
Prescribing Framework
(NPC Principles of Good Prescribing Framework 1999)
1 - Consider the Patient
(NPC Principles of Good Prescribe Framework 1999)
Patient name and dob/age Mr Jone Williams
68 years old
Dob 00/00/0000
Presenting Complaint (PC) Admitted to hospital for complain of
coughing, fever and dyspnoea from last 1
week.
History of presenting complaint
(HPC) (use appropriate
assessment tool eg. PQRST)
P- Patient noticed droplet of blood in cough.
Felt sick and difficulty in breathing.
Q-Feeling uneasy and heaviness in chest.
R-experienced severe right chest pain
S- The chest pain scales 7/10 and patient
was not able to mobilise.
T- The pain started on the day of admission
in morning. Experienced harsh cough from
last 7 days.
Clinical findings and observations
(signs and symptoms, clinical
Upper abdominal pain, nausea, vomiting,
high fever, harsh coughing, thick blood in

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observations, wound assessment
etc)
sputum.
Body temperature: 38.5°C
BP: 152/90
RR -24 breaths/min
HR- 112/minute
Past medical history Patient has lost 14lbs over past few days
however did not lose any appetite. Past
history tells that he was chronic smoker for
15 years and suffers fro hypertension.
Past surgical history Had operation for appendicitis at age of 35
years.
Prescribed Medication history
(Name, Dose, Frequency, Reason
Started, whether effective)
Lisinopril: 80 mg through oral administration
once in a day for the condition of
hypertension
Paracetamol 500 mg-oral administration
Metolazone for hypertension
Over the counter products
(complementary, herbal and illicit
etc.)
None
Allergies
(To what and state nature of
reaction)
None
Adverse reaction
(To what and state nature of
None

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reaction)
Family history: Wife- diabetic
Son – 30 years, type 2 diabetic
Any other issues:
(e.g. hepatic impairment, renal
impairment)
No
Social History
Home Situation Live with his wife and son in country side.
Needs community help to access the
hospital service
Occupation Retired government employee.
Hobbies Gardening
Pets Dogs
Recent Travel Went in 3 days trip to Australia
Alcohol No
Smoking Yes, 4-5 cigarette per day
Recreational Drugs Never
Sexual History Normal, celibate from few years
Systems Enquiry
(Provide details where appropriate, or state nothing of note, but only if this is
the case)
Cardiovascular Has hypertension, take Metolazone
prescribed by GP.
Respiratory Difficulty in breathing
Gastrointestinal Nil

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Genitourinary Nil
Nervous system Nil
Endocrine Nil
Musculoskeletal Nil
Skin hair & Nails Berated
Other Patient became low in appetite.
Working diagnosis
(pathophysiology and evidence to
support diagnosis)
Patient showed major symptom of
pneumonia as he looks tried and
underweight. He coughs continuously and
while sitting he leans to his right side for
chest pain. He showed high blood pressure
152/90, high body temperature of 38.5°C. In
pneumonia bacteria infects the lungs that
causes high number of WBC and
inflammation of air sacs resulting in high
fever, chest pain and shortness of breath.
Prescribing Considerations
2 - Consider the appropriate strategy: consider your competence to
prescribe, legal, ethical and professional issues.
Prescription Decision
By considering the sign and symptoms of the patient and in consultation with GP,
he was diagnosed with pneumonia.
Prescription- Amoxicillin oral capsules 500 mg two time per day for 2 weeks and