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New patient presents with shopping list of his 'usual' medications

Harry Painter, 58, registered

at the surgery today and asked for an appointment. His presenting problems are a persisting cough and painful knees. He tells you he needs

a repeat of his usual medications and hands you a four-page list that includes four inhalers, two analgesics, an anti-inflammatory, antidepressants, two major tranquillisers, a proton pump inhibitor and two laxatives.

Dr Richard Stokell advises.

What are the possible responses to his request?

 · Rebook the patient within two or three days for a longer appointment.

 · Attempt to assess the need for each medication and prescribe during this consultation.

 · Find out which medications are actually needed today and deal with just these.

 · Ask the patient if he really uses and needs all the items listed.

 · Look for interactions which are clearly dangerous and then provide a prescription for perhaps four weeks.

 · Decide which items are to be issued today, then involve another member of staff in adding and issuing the prescription while the patient waits in the waiting room.

Clearly, a combination of the above responses is appropriate. Assessment of compliance, drug safety and time management are essential elements.

What should be done next?

A first priority is to find out as much as possible about this patient before his next visit. Old notes can be requested urgently in the usual way or obtained informally from the previous GP. You may not be too impressed with his prescribing for this patient, but most practices have one or two similar patients and his GP will know him very well and will usually be happy to share his insight into the patient's problems.

Nurse-run new patient checks can be useful in identifying complex problems and starting the process of organising the patient's complaints.

What constitutes an effective management strategy?

A key to understanding this patient and improving his management is to generate an active problem list and try to tailor his medication to this. Summarising his notes, looking to see which of his problems are being managed in secondary care and looking for evidence to support or refute diagnoses are important tasks. In this case, psychiatric follow-up was ongoing and a long-standing diagnosis of asthma seemed to have no evidence to support it.

What should be the focus of the next consultation?

In this consultation assess each active problem and begin the process of rationalising prescribing. However, because the patient is likely to feel threatened by this, a gradual approach is usually preferable.

The patient will guide you to the areas he is unhappy with. Obvious areas for improvement such as analgesics with laxatives or anti-inflammatories with proton pump inhibitors can be tackled. Gaining control of this patient's symptoms and medication has to be seen as a long-term goal arrived at by negotiation over a series of consultations.

What other sources of help are available?

 · Pharmacists Increasingly, community pharmacists are happy to review patients with prescribing issues. They can look for safety issues, assess compliance and offer alternatives.

 · Secondary care The patient is already attending psychiatric review, so a request to rationalise those drugs in the consultant clinic is worthwhile. Also, when questioning the validity of a long-term diagnosis such as asthma, there may be merit in involving secondary care, as a consultant opinion can carry added weight, especially if backed up by more sophisticated investigations.

 · Non-drug alternatives Pain management should aim at improving pain tolerance and increasing activity. Physiotherapy, osteopathy, aromatherapy and more formal rehab clinics are valuable referral pathways.

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