Sample feedback report
What a marked prescription looks like
One student attempt at a practice scenario, marked by the same rules engine that marks every real attempt on Oskela. The renal bands and interaction records come from the live drug reference. Nothing on this page is typed in as a result.
The scenario
- Patient
- Patient C-104, 74, Female
- Weight
- 58 kg
- Creatinine
- 1.9 mg/dL
- eGFR
- 24 mL/min/1.73m²
- Diagnosis
- Non-valvular atrial fibrillation, CHA2DS2-VASc 5, CKD stage 4
- Allergies
- Penicillin (Anaphylaxis, 2009)
- Current medicines
- Clarithromycin 500 mg twice daily, day 3 of 5; Amlodipine 5 mg once daily
A 74-year-old woman on day three of clarithromycin for community-acquired pneumonia is found to be in atrial fibrillation at 104 beats per minute. She is haemodynamically stable. Bloods: creatinine 1.9 mg/dL, eGFR 24 mL/min/1.73m2, haemoglobin 12.1 g/dL, platelets 230. Liver function normal. She has pleuritic chest pain that is keeping her awake.
Task. Prescribe anticoagulation for stroke prevention and something for the pleuritic pain. Her current medicines continue.
What the student wrote
1. Apixaban 5 mg · PO · BD
- Instructions
- Take at the same time every day. Long-term treatment.
- Monitoring
- none written
2. Ibuprofen 400 mg · PO · TDS · 5 days
- Instructions
- Take with food.
- Monitoring
- none written
Three mistakes students really make are in here. The report on the right finds all three and says why each one matters.
Not passed
Score 45 / 115 (39.1%)
A single critical finding fails the attempt whatever the score, exactly as an unsafe prescription would be pulled on a ward.
The drug choice was right. The dose for this kidney function, the analgesic, and the monitoring were not: the weak domain is safety, and that is where the next practice points.
Apixaban 5 mg · PO · BD
- Correct: Apixaban is the anticoagulant of choice here: non-valvular AF with a high stroke risk, and the direct oral anticoagulant with the most renal data at this eGFR.+35
- Correct: Dose within the recommended range (2.5–5 mg).+10
- Correct: Appropriate route.+5
- Correct: Appropriate frequency.+5
- Critical: She meets two of the three dose-reduction criteria (weight 58 kg, creatinine 1.9 mg/dL), so apixaban must be 2.5 mg twice daily. 5 mg twice daily at eGFR 24 roughly doubles her exposure.
- Minor: Instructions should mention: bleeding, bruising, black stools.
- Correct: Key instruction included.+5
- Moderate: RENAL (eGFR 24): For atrial fibrillation, reduce dose to 2.5 mg twice daily. For other indications, use with caution.
- Major: INTERACTION (major): Apixaban + Clarithromycin. Avoid co-prescription if possible. If combined use is essential, reduce the apixaban dose (for example, from 5 mg twice daily to 2.5 mg twice daily) and monitor the patient closely for signs of bleeding. Consider alternative antibiotics that are not strong CYP3A4/P-gp inhibitors.
Ibuprofen 400 mg · PO · TDS · 5 days
- Critical: An NSAID is contraindicated: eGFR below 30 and a newly started anticoagulant. Ibuprofen would accelerate the kidney injury and add a second bleeding risk on top of apixaban.-10
- Critical: RENAL (eGFR 24): Avoid use in severe renal impairment (eGFR < 30 mL/min/1.73m2); if deemed essential, use the lowest effective dose for the shortest duration and monitor renal function closely.
- Major: INTERACTION (major): Ibuprofen + Apixaban. Avoid co-prescription where possible. If an NSAID is required, use the lowest effective dose for the shortest duration and consider a gastroprotective agent such as a proton pump inhibitor. For patients with a high bleeding risk, consider alternative analgesics such as paracetamol or a weak opioid.
Across the whole prescription
- Major: Paracetamol is the analgesic for this patient: regular 1 g up to four times daily, with a review at 48 hours.-5
- Moderate: Monitoring should include: renal function, eGFR, creatinine, haemoglobin, full blood count.
- Allergy cross-check · clearAgainst penicillin allergy, including class cross-reactivity
- Pregnancy · clearNot applicable to this patient
- Renal dose bands · 2 flaggedEvery prescribed drug at eGFR 24
- Drug interactions · 2 flaggedPrescribed lines against each other and against current medicines
These run against the drug database whether or not the case author wrote a rule for them. They are rules and data, not a language model, so the same prescription always gets the same marks.
- Apixaban monographThe dose-reduction criteria and the renal bands the checker applied.
- Ibuprofen monographWhy NSAIDs are contraindicated below eGFR 30 and with anticoagulants.
- Prescription writing practiceMore renal-impairment scenarios to write and have marked.
Write your own and have it marked
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