OSCE, Pharmacy First Year

constipation The passage of hard stools (faeces) less frequently than the patient's own normal pattern Diarrhoea definition and its types The passing of watery stools more than three times a day Diarrhoea can either be: acute: diarrhoea that comes on suddenly, and lasts for five to 10 days, or chronic: diarrhoea that lasts for more than two weeks Diarrhoea symptoms Watery, frequently passed stools with or without Abdominal cramps Flatulence Weakness Nausea, vomiting, fever Headache, loss of appetite Fluid loss with subsequent dehydration may lead to electrolyte loss - Na+, K+, Mg2+, Cl- Causes of diarrhoea Acute diarrhoea usually caused by a bacterial or viral infection food poisoning or contaminated food or water side effect from some drugs Chronic diarrhoea may be a symptom of a more serious condition e.g. Crohn's disease, irritable bowel syndrome laxatives, poor diet Diarrhoea often goes away after a few days without treatment Drink fluids to avoid dehydration rehydration drinks 1 / 34 Diarrhoea treatment Eat as soon as you can food high in carbohydrates Anti-diarrhoea medicines loperamide Painkillers to treat fever or headache Home made treatment of diarrhoea WHO recommendation Half a small spoon of salt and six level small spoons of sugar dissolved in one litre of water or Lightly salted rice water What is dioralyte Powder for reconstitution Directions: dissolve one sachet in 200ml of fresh drinking water and drink after each loose motion Each sachet contains: sodium chloride 470mg potassium chloride 300mg disodium hydrogen citrate 530mg glucose 3.56g Dioralyte relief Powder for reconstitution Each sachet contains: sodium chloride 350mg potassium chloride 300mg sodium citrate 580mg cooked rice powder 6g Antidiarrhoeals Slow transit time through the GI tract which increases water and electrolyte absorption Loperamide 2mg tablets adults and children over 12 years 2 capsules initially then one after each loose motion to max 8 in 24 hours Not a preferred treatment 2 / 34 When to refer patients with diarrhoea Blood or mucous in motions - bright red is ok in small amounts Signs of dehydration - lethargy, headache, dry mouth Long period of time - >5 days? Vomiting for more than one day High fever Recent change in bowel habit or travel abroad Constipation symptoms Change in stool frequency Stools can become unusually hard, lumpy, large or small Stomach ache and cramps Feeling bloated, nauseous, loss of appetite Chronic problems - hemorrhoids, faecal impaction Causes of constipation Poor diet - lack of fibre and/or fluids Lack of mobility Medication antidepressants, antiepileptics, iron supplements Pregnancy Medical conditions diabetes, Parkinson's, underactive thyroid Constipation alternating with diarrhoea Blood or mucous in motions - bright red is ok in small amounts Weight loss When to refer patient with constipation Abuse of laxatives Vomiting Fever Angina Increase intestinal motility Onset of action 8-12 hours usually night time administration 3 / 34 Side effects include abdominal cramps, Stimulant laxatives, how they work, on- excessive fluid loss, electrolyte imbalset of action, side effects, examples ance Examples include senna, bisacodyl Bulk- forming laxatives Stimulates peristalsis in a similar way to dietary fibre Onset of action 24-36 hours Important to drink plenty of water to avoid impaction Side effects include flatulence and abdominal bloating Examples include bran, ispaghula husk Osmotic laxatives Retain fluid in the bowel by osmosis so important to drink plenty Onset of action up to 3 days Side effects include flatulence, abdominal pain, colic Examples include lactulose and magnesium salts Haemorrhoids Abnormal swelling or enlargement of the anal vascular cushions Symptoms of haemorrhoids Bright red rectal bleeding: blood is seen on the surface of the stool, not mixed in Pruritus: due to chronic mucus discharge and irritation Soiling: due to impaired continence or mucus discharge Rectal fullness or an anal lump Large prolapsed haemorrhoids can thrombose: very painful purple/blue, oedematous, tense, and tender perianal mass Excessive straining (from chronic constipation) Increasing age Raised intra-abdominal pressure, such as: 4 / 34 Causes of haemorrhoids pregnancy chronic cough Ascites Less common: pelvic/ abdominal masses, family history, cardiac failure, or portal hypertension Haemorrhoids treatment Treat the constipation Creams, ointments and suppositories these will treat the symptoms but not cure the hemorrhoids Local anaesthetic, astringent and barrier cream Short-term treatment (5-7 days) When to refer patients with haemorrhoids Exclude other causes of rectal bleeding such as: - malignancy - inflammatory bowel disease - diverticular disease. Indigestion (Dyspepsia) a persistent or recurrent pain or discomfort in the upper abdomen due to a disorder of digestive function" Heartburn ( GORD) a digestive disorder involving the lower oesophageal sphincter (LOS) causing the reflux of gastric contents particularly acid into the oesophagus" When to refer patients with indigestion Anyone can be affected by indigestion but if First time is > 50yrs old - REFER If more than 5 days - REFER Recurrent symptoms - REFER Differential Diagnosis (not exhaustive) Ulcer Gallstones Gastric cancer Angina Heart attack (MI) 5 / 34 Dangerous signs of dyspepsia Persistent abdominal pain Anorexia Unexplained weight loss Blood in vomit (looks like coffee grounds) or stools (black tarry appearance) Severe pain - in upper or lower abdomen Vomiting with or without blood, along with other danger symptoms Difficulty swallowing NSAIDs, iron, erythromycin, steroids, oeWhat medication can exacerbate indistrogens, oral contraceptives - will aggragestion symptoms vate symptoms. Work by physically neutralising stomach acid Variety of formulations - liquids, tablets patient preference Occasional use How antacids work, when to use them, Best 1 hour after meals as gastric emptypes and side effects. tying slowed Sodium salts - avoid when sodium intake restricted, fast acting short duration Aluminium salts - constipating Magnesium salts - diarrhoeal Calcium salts - fast acting, long duration. Deflatulents, how do they work, exam- Break up and release trapped wind ples. Dimethicone, simeticone, peppermint oil How do histamines H2 antagonists help Reduce the amount of acid produced in patients with indigestion? Examples? the stomach - ranitidine, famotidine Why are currently all otc H2 antagonists (rantidine, nizatidine, famotidine) unavailable due to a contamination issue, but are expected to return to market in the near future How do proton pump inhibitors (PPIs) work to help indigestion? Examples? A specific inhibitor of the acid pump in the parietal cells - inhibits the enzyme H+K+ATPase - the final stage in the production of hydrochloric acid in the stomach. 6 / 34 omeprazole, pantoprazole, esomeprazole H2 histamines antagonists: Rapid onset of action and relatively long duration of Compare between H2 histamines antag- action - up to 12 hours onists and proton pump inhiinhibitors in Proton pump inhibitors: Inhibition of acid terms of onset of action secretion within 1 - 2 hours and have a long duration of action (24hours) hence once daily dosing. Small meals often - as eating too much or too fast aggravates Eat with mouth closed*, drink after rather than during meals Non pharmacological advice for patients Lose weight with indigestion Reduce alcohol consumption Stop smoking Avoid trigger factors e.g. spicy foods etc - keep food diary to identify Try and avoid stressful situations GORD( heartburn) symptoms Burning pain in the chest between the stomach and throat with or without :Pain Flatulence When to refer patients with GORD? Anyone can be affected by GORD but if First time > 50yrs old - REFER If more than 1 week - REFER Recurrent symptoms - REFER Severe radiating pain - REFER Differential Diagnosis Tumour Heart disease such as atypical angina, heart attack (MI) Dangerous signs of heartburn Danger symptoms Difficulty swallowing - dysphagia Severe pain radiating to back and arms Pain aggravated by exercise 7 / 34 Causes of GORD Dietary habits - large portions, certain foods or drinks , eating before bed Lifestyle habits - overweight, smoking, tight fitting clothes/belts, lying down or bending over esp after eating , stress Medical causes - pregnancy, hiatus hernia, certain medications Advice for patients with heartburn As for indigestion in addition Avoid bending Raise head of bed Dietary Health promotion Heartburn treatment Rafting agents Work by floating on top of stomach contents i.e. alginates - Gaviscon to protect the lining of oesophagus if reflux does occur. Causes of irritable bowel syndrome Abnormal GI motility Psychological Factors - anxious patients who worry excessively. Some may be obsessed with bowel function and have taken purgatives regularly. Luminal compounds which may irritate the bowel - food allergens, bile acids Altered serotonin levels - role in motility Patient support - reassurance to alleviate anxiety, often there is an underlying fear of cancer. Dietary modification - for constipation, high fibre diet, laxatives. For diarrhoea, Treatment of irritable bowel syndrome avoidance of fresh fruits and salads, loperamide Antispasmodic (e.g. dicyclomine) Antidepressants/hypnotherapy (strong 8 / 34 brain-gut component to IBS). Brain imaging is a new investigative tool. Newer 5-HT receptor targeted drugs may prove beneficial. MULTIDISCIPLINARY APPROACH! Causes of cold Caused by rhinoviruses (40% of colds) and coronaviruses (10% of colds) cold symptoms Tingling in nose/throat/eyes Rhinorrhoea (+/- sneezing) Nasal congestion Sore/inflamed throat Cough may develop Children may present with pyrexia Cold: Gradual onset of symptoms Low-grade fever if present Body aches, fatigue, cough, sore throat are mild Runs its course in approx 1 week Can lead to mild inner ear infections. Compare the symptoms of cold and flu Flu Faster onset of symptoms Higher & sustained fever Body aches, fatigue, cough, sore throat are more severe Symptoms persist for 2 weeks or more Can lead to pneumonia, bronchitis, & other colds or infections Congestion Sneezing Body aches Fatigue What the common symptoms between flu and cold? Sore throat Cough Fever 9 / 34 Sore throat Cough Fever What are the symptoms of COVID? Loss of sense of taste/smell Cough is new and continuous High risk groups with flu: need care Prolonged severe symptoms relating to cough, sputum volume/colour, breathWhen to refer patients with cold or flu? lessness, fever, general malaise. Exacerbation of Asthma/COPD worsening of condition. Earache - Otitis media (children). Will Flu and Covid vaccines prevent the No, Flu and Covid vaccines will not precommon cold vent the common cold. Non drug advice for people with cold Rest: will help with symptoms Increase fluid intake Eat plenty of fresh fruit/vegetables to help maintain body's vitamins and minerals What is used for (runny nose or sneezing) in patients with cold? Decongestants Side effects of antihistamines Dry mouth, sedation and constipation, blurred vision, urinary retention What Patients care should be exercised Patients with Glaucoma and men with when prescribing antihistamines enlarged prostate For nasal congestion Cold: Decongestants like xylometazoline or pseudoephedrine. What treatment is recommended for Cold and Hypertension: Saline nasal nasal congestion for patients who have spray and steam inhalation are used for cold, cold and hypertension, hay fever? nasal congestion. Hay fever: Beclometazoline nasal spray, along with antihistamines if needed. 10 / 34 Productive cough - expectorant to loosen phlegm/catarrh Expectorants include guaifenesin, Ipecacuanha Evidence base poor, but large placebo effect Treatment for productive and non pro- Non-productive cough -suppressant ductive cough Pholcodine or Dextromethorphan Evidence base poor at OTC doses, but large placebo effect Demulcents - Glycerin/Simple Linctus and Simple Linctus Paediatric. Pharmacy 1st options. Again, evidence base is poor but large placebo effect If the patient has sore throat for more than 14 days If the patient has dysphagia. If the patient has ulcer, blisters in mouth When to refer a patient with sore throat If the patient has in their neck large tender lymph nodes If the patient has extreme pain and no improvement. • what does these symptoms mean in children. Adolescents . Tonsil exudate (white patches on the tonsils) • Fever • Swollen glands (enlarged lymph nodes) Children: streptococcal throat - refer Adolescents: glandular fever_ refer Difference between urge incontinence and stress incontinence stress incontinence involves leakage of urine during physical activities or movements that increase abdominal pressure such as laughing, sneezing, coughing, exercising. while urge incontinence involves sudden and intense urges to urinate, often resulting in involuntary urine loss. 11 / 34 Management of stress incontinence pelvic floor muscle training duloxetine (women) selective serotonin and noradrenaline reuptake inhibitor relaxes detrusor muscle increases external sphincter activity topical vaginal oestrogen therapy (post-menopausal women). Management of urge incontinence pelvic floor muscle training reduction of excessive fluid intake topical vaginal oestrogen (female) to reverse atrophy (prescribed) M3 muscarinic receptor antagonist (males), e.g. solifenacin (prescribed) Incontinence absorbent materials Incontinence pads, pull-up pants, bedding - wide range Hydrophobic layer draws urine from surface, keeps skin dry Sanitary pads - cheaper but stay damp, can irritate skin Washable bed pads, sit on top of the mattress, useful for travelling Tampons for stress incontinence Large size tampons in vagina exert pressure on bladder neck, (not recommended by NICE) Appliances: sheath, urinals, drainage system for men. 12 / 34 Management of incontinence Lifestyle: reduce caffeine intake, reduce alcohol intake, reduce weight, stop smoking, drink plenty of water, avoid food that irritates bladder (spicy, acidic e.g. curries, citrus fruits) Physical therapy: pelvic floor muscle training, avoid lifting Behavioural therapy: bladder training Conservative management: absorbent devices and catheters, preventative training (pregnancy) Pharmacological treatment: antimuscarinics (oxybutynin, solifenacin), intravaginal oestrogens (postmenopausal vaginal atrophy), treat constipation promptly Invasive procedures (e.g. Botulinum toxin A) Surgical approaches (e.g synthetic mid-urethral tape procedure) Why is tamsulosin used? It belongs to a group of medicines called alpha blockers. It's used to treat men with symptoms of an enlarged prostate (benign prostate enlargement) Tamsulosin hydrochloride is a P medicine. When can it be supplied over the counter 45-75 years old, symptoms for 3 months or more. no symptoms of infection or blood in urine no diabetes, heart, liver or kidney disease no postural hypotension no previous allergy or sensitivity to tamsulosin no previous prostate surgery no plans for cataract surgery (risk of intraoperative floppy iris syndrome) 13 / 34 How does Tamsulosin work? Tamsulosin hydrochloride is an alpha1-adrenoceptor blocker (also terazosin, alfuzosin, doxazosin) inhibits contraction of prostatic and bladder neck smooth muscle increases urine flow rate (2-3 ml/s), reduces other symptoms of obstruction (urgency, dribbling, incomplete emptying) Does not alter prostate size, growth rate or PSA (Prostate Specific Antigen) Tamsulosin: Dose and Directions Available as 400 microgram modified-release capsule. Tamsulosin can be taken for up to 6 weeks then refer to GP When to refer a patient using Tamsulosin If symptoms worsen or don't improve in 14 days, refer to GP side effects of tamsulosin May have dizziness, fatigue, sweating due to alpha-blockade (fall in BP) after first dose - lie down May cause retrograde ejaculation due to weak sphincter at the base of the bladder 5 alpha- reductase inhibitors (5ARIs): fiUsed if very enlarged prostate, PSA > nasteride, dutasteride ( prescribed med1.4 ng/mL icines). When are they prescribed? inhibit metabolism of testosterone to dihydrotestosterone (DHT) DHT is a more potent driver of prostate 5 alpha- reductase inhibitors (5ARIs): fi- growth than testosterone nasteride, dutasteride ARIs reduce size of prostate (25%), PSA . How do they work ? (50%) symptoms of obstruction, improve urine flow in 6-12 months. May be used in combination with an alpha-blocker (dutasteride + tamsulosin) What are the side effects of 5 alphaAssociate with loss of libido and ejaculareductase inhibitors (5ARIs): finasteride, tory dysfunction dutasteride? 14 / 34 competitive inhibitor of the muscarinic M3 subtype inhibit contraction of the detrusor muscle - particularly useful for patients with deAntimuscarinics: solifenacin succinate, trusor overactivity (polyuria, urgency) oxybutynin ( prescribed drug). Why are provides symptomatic treatment of urge they used? incontinence and frequency may be used in combination with an alpha blocker, e.g. solifenacin and tamsulosin Saw palmetto fruit (Serenoa repens) and nettle root (Urtica dioica) have THR (Traditional Herbal Remedy) MHRA registraWhat herbal remedies can be used for tion to relieve symptoms of urinary tract urinary tract symptoms? Are they effec- discomfort in men who have confirmed tive? diagnosis of BPH - based on traditional use only. no evidence for improvement in LUTS not recommended. Surgical procedures for urinary tract symptoms Transurethral resection of the prostate (TURP) removal of prostate tissue by diathermy retrograde ejaculation results in 90% of men, low risk of impotence and incontinence Who is the patient, (age)? What are the symptoms? Do you have any pain when passing urine - is it a sharp or burning local pain (in the urethra)? Do you have any back or lower abdomiWhat questions do you need to ask for nal pain? patient with Cystitis Do you have any problems passing urine? Do you have any other symptoms - nausea, vomiting, fever? Do you have any vaginal symptoms? How long have the symptoms been pre15 / 34 sent? Action taken? Medication? When to refer a patient with cystitis > 5 - 7 days duration, blood in urine, fever, loin/back pain, vomiting - pyelonephritis? new sexual partner, rash, raised warts or other abnormalities in genital area sexually transmitted disease? thirst, weight loss, nocturia - diabetes? frequent recurrence - diabetes, abnormality of urinary tract? persistent or recurrent symptoms in pregnant woman related to drug therapy male, child or elderly patient Management of cystitis Mild cases usually resolve spontaneously in 2 - 3 days Drink plenty of fluids Avoid delays and empty the bladder completely Wash perianal area with water and unperfumed soap after bowel movement; wipe front to back If symptoms are related to intercourse, empty bladder before and after Paracetamol may be useful for mild pain - don't delay treatment Is this statement true? Mild cystitis can be managed without antibiotics but patients should be referred to the GP if they have symptoms of infection. Yes 16 / 34 Alkalinising agents potassium or sodium citrate mixture or powders alter urine pH, may relieve "burning" sensation avoid in pregnancy, hypertension (excess Na+) avoid in renal disease, with potassium supplements or ACE inhibitors (excess K+) Cranberry juice popular "home" remedy, evidence that it reduces adherence of bacteria to uroepWhat products can be used for cystitis? ithelial cells in bladder and urethra Little evidence of efficacy in treating cystitis, may reduce incidence of infection Antibacterial agent usually requires confirmation of an infection by GP (urine sample) 3 day course of trimethoprim 200 mg 12 hourly or nitrofurantoin 50 mg 6 hourly In some areas: trimethoprim (or a cephalosporin) can be supplied by an accredited pharmacist under a Patient Group Directive (PGD) What the sever form of emesis called during pregnancy and what other accompanied symptoms? hyperemesis gravidarum (nausea that does not 'go away' weight loss, reduced appetite, dehydration, and feeling faint- risk of starvation and dehydration) Increase in hCG hormone ( human choricauses of emesis (vomiting) during preg- onic gonadotropin), decreased gastric nancy and treatment? emptying) 17 / 34 Treatment is by anti-emetics: usually POMs so should refer to GP. Decrease in motility of smooth muscle caused by increase of progesterone. Food passes through the GIT more slowcauses of constipation during pregnancy ly. Also decrease in activity may be taking iron supplements, consider growth of the baby Treatment of constipation during preg- Laxatives (bulk forming, avoid stimulant nancy laxative esp in later stages) Enlarging uterus exerts pressure, incause of haemorrhoids during pregnan- crease in blood volume leading to vecy nous dilation and engorgement. Itching, protrusion of mass, pain , bleeding Treatment of indigestion during pregnan- Use Antacids with or without an alginate cy. e.g Gaviscon Advance or CaCO3. Thrush is a fungal infection caused by Candida albicans.opportunistic infecWhat causes thrush during pregnancy? tion- caused by hormonal changes during pregnancy as the vaginal environment is altered. Can use topical agents (other formulations not for OTC sale) e.g clotrimazole (canesten cream) BUT best to refer to Treatment of thrush during pregnancy GP - likely to prescribe oral treatment. Natural yoghurt contains probiotic called acidophilus- may insert into vagina Causes of UTI during pregnancy growing foetus can put pressure on the bladder and urinary tract. This traps bacteria or causes urine to leak). Treatment of UTI in pregnancy Do not treat OTC - refer to GP What are the results iron deficiency in pregnancy? Iron deficiency can cause anaemia during infancy, spontaneous abortion, premature delivery, low birth weight infant. 18 / 34 Treatment of anaemia Iron supplements- variety of doses, usually 200mg FeSO4 or other iron salts -depending on tolerability. Also consider diet- leafy veg, cereals. Xerostomia (dry mouth) symptoms discomfort, halitosis, tooth decay xerostomia treatment Drinking, artificial saliva, sugar free sweets/gum. Xerostomia (dry mouth) causes Dehydration, anxiety, medication When to refer a patient with xerostomia? Difficulty swallowing, unknown cause, severe, medication. halitosis (bad breath) causes dental or other heath problems, foods, poor oral hygiene halitosis treatment dental check-up, advice, antiseptic mouthwash When to refer a patient with halitosis unknown origin What are the causes of Gingivitis gum/periodontal disease - plaque, smoking, (diabetes), (medicines Symptoms of gingivitis. gums swollen, sore, bleeding on brushing. When to refer a patient with gingivitis? bleeding, foul taste, severe symptoms. Dental caries causes plaque, damage, sugary foods dental caries symptoms toothache, pain (hot and cold foods/drinks) discolouration small painful sores on tongue, inside of Symptoms of minor aphthous ulcers and cheeks or inner surface of lips treatment Treatment: analgesic, mouthwash. Causes of minor aphthous ulcers Causes are unclear possibly: stress? injury? foods? trauma? genes? nutritional deficiencies? Number: 1 to 5 crops. Size: less than 1 cm. Duration: 7 to 14 days 19 / 34 Appearance: round , white or grey, red How minor aphthous ulcers look like, rim. number, size, duration, is it painful, when Pain: + to refer? Refer: if more than 14 days. How major aphthous ulcers look like, number, size, duration, is it painful, when to refer? Number: crops more than 6. Size: more than 1 cm. Duration: 14 to 40 days. Appearance: round or Ovid, Pain: ++ Refer: always. How herpetiform aphthous ulcers look like, number, size, duration, is it painful, when to refer? Size: pinpoint Number:large crops Appearance: small, irregular, pale Duration:more than ten days Pain:+++ Refer: always Other pathology differentiation of mouth ulcers Size: more than 1 cm. Number: single area Duration: varies Appearance: irregular shape Pain: painless Refer: always Oral Candidiasis (Thrush) symptoms white, irregularly shaped patches, soreness, altered taste, burning tongue Oral Candidiasis (Thrush) treatment miconazole oral thrush causes and prevention Causes: medications, dentures, diabetes, smoking Prevention: hygiene (dentures), smoking cessation, sterilising bottles oral thrush referral 3/52, pain, no risk factors, diabetics, severe, tx failure, immunocompromised When to refer a patient with oral problems Pain Bleeding Swallowing difficulties Dental treatment required 20 / 34 Excessive duration of condition Medications implicated Cold sores are caused by herpes simplex virus Cold sores are blisters around mouth and/or nose. Very contagious Untreated cold sores take days to clear up. around 7-10 days to clear up Common factors of cold sores Stress Fatigue UV light Reduced resistance following illness How do cold sores spread? Can spread by direct touch, kissing, sharing towels/eating utensils. Tingle stage - tingle/itch around mouth or nose Blister Stage - small raised blotch which swells and forms a blister Cold sores stages Weeping stage - blisters collapse and join together to form a large weeping sore Scab stage - scab forms and later falls off. cold sores treatment Antiviral cream ( eg Aciclovir) - apply as soon as the first tingle is felt. DO NOT SELL STEROID CREAM FOR COLD SORES!! Blood pH: Acidosis causes Respiratory acidosis (due to arterial PCO2 rising to a level higher than expected) •An increase in arterial PCO2 can be due to: Increased production of CO2 in the body Decreased alveolar ventilation - Main 21 / 34 cause Presence of excess CO2 in inspired gas A rise in PCO2 is a potent stimulus for ventilation, so respiratory acidosis will rapidly correct unless something is maintaining the hypoventilation •An extremely high PCO2 has anaesthetic actions, which will worsen the situation Results of blood pH (acidosis) Acidosis has a depressant action on cellular metabolism •An increase in arterial PCO2 will increase cerebral blood flow •Acidosis is a negative ionotrope (decreases myocardial contractility) Blood PH( alkalosis). Results of blood alkalosis •A drop in PCO2 would reflexly cause a decrease in ventilation (via chemoreceptor inhibitory input into the respiratory centre What is a formulary? A list of recommended drugs, chosen based on efficacy and safety May include information on pricing Are updated regularly What kind of formularies are likely to be used by health care professionals? UK: British National Formulary (BNF), BNF for Children Global: WHO Essential Medicines List Specialist: Hospital formularies, Palliative Care formulary Which of these formularies are most likely to be used by pharmacists? BNF, BNF children Common features A list of drugs are used in practice. Provide information on dosage, side effects. They are categorised medicines in differ- 22 / 34 ent groups. They are listed based on efficacy, safety and costs. What are the common features of the They have information about clinical different formularies, and what are the guidelines. differences? Why might there be differ- They are reviewed and updated regularences? ly. Differences They are different because of price, regulatory requirements, clinical preferences. Disadvantages They are expensive to produce and require regular updating. Limited access to some medicines beWhat are the advantages and disadvan- cause of price. tages of using medicines formularies? Advantages The lower cost of medicine bill, expenditure (Cost effective prescribing). There is no variation in care. quality. normal blood pressure 120/80 mmHg Systolic over diastolic Pulse pressure = Systolic-Diastolic Mean Arterial Pressure (MAP) Mean arterial pressure is an estimate of ventricular pressure. Mean arterial pressure (MAP) = Diastolic + 1/3 pulse pressure 80mmhg + (40/3) = 93mmHg Normal pulse rate In adults, a typical resting heart rate is generally between 60 and 100 beats per minute (bpm) • Concerns: High BMI for age, slightly elevated blood pressure. Physiological considerations: AdolesFemale, 13 years old, BMI 34, BP 130/80 cence is a period of rapid growth and development, which can affect vital signs. mmHg, HR 69, any concerns? High BMI may indicate overweight or obesity, which can impact cardiovascular health. 23 / 34 • Clinical considerations: Monitoring for potential cardiovascular risk factors and lifestyle interventions to address obesity. Concerns: Elevated systolic blood pressure for age, lower heart rate. • Physiological considerations: Advanced age can lead to changes in vital signs, including increased systolic blood 3. Female, 83 years old, BMI 21, BP pressure and decreased heart rate. 145/78 mmHg, HR 48, any concerns? • Clinical considerations: Assessing for potential cardiovascular conditions such as hypertension in older adults. Monitoring for signs of reduced cardiac function or other age-related health concerns. Concerns: Elevated blood pressure, slightly elevated heart rate. Physiological considerations: Middle-aged adult with relatively normal BMI and slightly elevated blood pressure. A Male, 41 years old, BMI 24, BP 138/86 • Clinical considerations: Blood presmmHg, HR 85. Any concerns? sure monitoring over time to assess for trends and potential hypertension. Lifestyle modifications such as diet and exercise may be recommended to lower blood pressure. A patient group direction is a means to supply or administer a POM medicine to a patient without the need for a prescription. What is PGD? It is different from a prescription - a prescription is a "patient specific direction" which allows the supply of a POM to a named patient only whereas the PGD allows the supply of a POM to any one of a group of patients Can PGD used for long term conditions? Not for long term conditions 24 / 34 Why is PGD used? to ensure timely access to POMs for acute defined conditions where there is a distinct diagnosis with no uncertainty It is a document detailing the conditions under which a named POM can be supplied or administered without a Rx. It will What does information the PGP contain? also detail who can be involved in the PGD e.g. pharmacist, nurse , chiropodist and the conditions of the supply Private - supply for ED (higher strengths than otc) - e.g. Viagra, Cialis, Levitra, Antimalarials, flu vaccine, weight loss, travel PGD can be private or under the NHS. vaccines etc. NHS - smoking cessation , EHC, CPUS, pharmacy first - trimethoprim, nitrofurantoin, aciclovir, fusidic acid, flucloxacillin Suspension A liquid formulation containing solid particles which are not soluble. Types of pain Acute- usually self limiting, activity related (i.e musculoskeletal due to sports injury) 2. Chronic conditions - caused by 'other', largely treated by POMs Questions to ask- (who is patient- age, gender) When did it happen? - might just need First Aid? questions you need to ask when patient What are symptoms? - marked complains about pain swelling/bruising/tenderness? Nature of injury - onset? Force? Range of motion - marked reduction? Nature of pain - sharp, acute?- referred pain suggests nerve root compression) RICE Rest: immobilisation, enhanced healing and reduced blood flow Ice: If injury feels warm- apply until skin 25 / 34 becomes numb (repeat hourly) Compression: crepe bandage/tubigrip Non drug treatment of soft tissue injuries etc Elevation: to help fluid drain away from injury OTC treatments for soft tissue injury NSAIDS - ibuprofen, aspirin (avoid in first 48hrs) Paracetamol - preferably on its own (but public influenced by advertising of combination products) Various formulations oral tabs, melts, solutions, gel/creams, lotions, sprays- be aware of different strengths/doses for OTC and P products. Not for <12yrs, asthmatics Restrictions on pack size (GSL 16, P if more than 32) Dysmenorrhoea causes and nature of pain Essentially overproduction of uterine prostaglandins. Take a detailed history of menstrual cycle i.e frequency, severity etc to exclude pathological cause. Age : 2nd causes more likely in women >30yrs Nature of pain: Cramping - NOT dull continuous or diffuse. Severity: decreases as bleeding occurs Onset: before bleeding (lasts 3-4 days Refer all heavy or unexplained bleeding, When to refer a patient with dysmenorfever, sharp pain or anything unexplainrhea able- refer. NSAIDS (including naproxen 250mg tablets - pack size of 9 tablets) Treatment of dysmenorrhea Buscopan (Antispasmodic- prevents cramping). Complementary Therapies- Vitamins E & 26 / 34 B, Fennel Hot water bottle, rest. Oral and dental pain Tend to be local anaesthetics- mainly Lidocaine/ benzocaine- 'apply to affected area'. Teething in children- usually from 3 months onwards (check individual products). Also used in throat sprays and in conditions which require 'numbing' of the surface i.e back of the throat. Mouth ulcers (usually also an antiseptic) COMT- clove oil, chamomile (Ashtons & Parsons tincture of matricaria) What is a headache? Headache is pain or discomfort in the head or face area. Headaches vary greatly in terms of pain location, pain intensity, and how frequently they occur Headache types tension, migraine, cluster. cluster headache Usually occur in a series that may last weeks or months, and the headache series may return every year or two. Severe pain on one side of the head, usually behind one eye The eye that is affected may be red and watery with a droopy lid and small pupil Swelling of the eyelid Runny nose or congestion Swelling of the forehead People often experience symptoms differently - if suspected - Refer 27 / 34 Secondary Headache Usually another underlying reason for occurring- REFER These can include: Trauma/Injury to neck or whiplash, head knock - concussion? Infection - Infected sinusitis, otitis media, dental abscess, eye infection Secondary to facial pain (sinus/mouth/eyes) Psychiatric disorders - panic attacks Cerebral Vascular disorder i.e haemorrhagic stroke (thunderclap) rapid onset, ADRs -most medicines list headache as a side effect i.e nitrates, sildenafil etc Dehydration - co-morbidity /extreme heat (also hangover) Migraine triggers Stress and other emotions (hormonal component) Environmental conditions, i.e light (glaring or flickering) or smells, noise. Fatigue and changes in one's sleep pattern Weather changes -extreme cold Certain foods and drinks Some people also experience an 'aura'Sensory disturbance that includes flashes of light, blind spots, and other vision changes or tingling in your hand or face Advice to keep a migraine diary to log 'trigger factors' - identify headache management strategies. Migraine with or without Aura Migraine headache is usually frontotemporal (children/adolescents also report it to be bilateral, less in adults. Migraines can last for hours/days (untreated or unsuccessfully treated) More or two of the following characteristics: 28 / 34 1. unilateral location 2. pulsating quality 3. moderate or severe pain intensity 4. nausea and/or vomiting 5. photophobia and phonophobia Paracetamol - acts in inhibition of prostaglandin production in pain pathway. Also in activation of descending serotonergic pathways Ibuprofen - act on COX -1 and COX-2 receptors to inhibit production pf prostaglandins in pain pathway Codeine - acts centrally, limited effectiveOver the counter treatment of pain and ness at doses available OTC, often in accompanied symptoms combination products Buclizine - antihistamine with anti-emetic properties, also sedating Prochlorperazine - anti emetic Triptans - selective 5-HT serotonin receptor agonists (cause cranial vasoconstriction). Sumatriptan is P med with restrictions Non drink plenty of water get plenty of rest if you have a cold or the flu try to relax - stress can make headaches worse Avoid trigger factors e.g alcohol, particularly red wine or foods that contain nitrates Maintain good sleep hygiene Check /correct posture 29 / 34 Hepatitis a term used to describe inflammation (swelling) of the liver. It can occur as the result of a viral infection or because the liver is exposed to harmful substances such as alcohol . cholestasis -is a condition where bile cannot flow from the liver to the duodenum (mechanical vs. metabolic) Cirrhosis - is scarring of the liver as a result of continuous, long-term liver damage ascites abnormal accumulation of fluid in the abdomen. For fluid to be detectable by clinical examination there has to be at least 1500 ml present . Ultrasound can detect much smaller volumes (d 500 ml). Abdominal distension. Weight gain as a result of water retention. Discomfort: tense ascites is very uncomfortable but prior to this stage there is simply abdominal distension with only very mild discomfort. Malignancy related ascites is frequently painful. Nausea and appetite suppression: tense ascites presses on the stomach and bowel. Increasing dyspnoea: due to limited venous return from the lower limbs (pressure on the inferior vena cava) and impaired expansion of the lungs (pressure on the diaphragm). jaundice causes Caused by raised bilirubin (NR 0-20 mmol/l) usually caused by impairment of excretion. 30 / 34 Classification of jaundice 1_Haemolytic or pre-hepatic 2- Hepatocellular 3- cholestasis. Haemolytic or pre-hepatic. Haemolysis of red blood cells resulting in the formation of bilirubin at a rate faster than the liver can excrete. Cause: drugs, infection and enzyme deficiency. Unconjugated > conjugated (Bilirubin, 80mmol/L) Hepatocellular jaundice Due to damage of hepatocytes. Intracellular enzymes are leached into the circulation. Damaged hepatocytes are unable to conjugate and transport bilirubin into the bile. Bilirubin up to 300mmol/L : conjugated and unconjugated. Causes: Causes: infection, drugs and alcohol. Impaired blood supply may cause hepatocellular damage. Cholistasis jaundice Intra-hepatic: failure of bile flow or excretion within the liver. Extra-hepatic: Obstruction of biliary tree outside the liver, e.g. gallstones and malignancy. Bilirubin up to 500mmol/L Why ALT is considered as a specific marker of hepatocellular damage ? because ALT levels are generally only significantly raised in liver disease. What do Low ALT (and AST) levels suggest? vitamin B6 deficiency AST levels are raised in shock. When do AST levels increase? AST levels are also raised in pregnancy and after exercise. It is less specific for liver disease and is not included in liver function profiles by all labs. 31 / 34 Levels are raised in all types of liver and biliary tract disease (acute and chronic) and also in pancreatic cancers. GGT (gamma glutamyl transferase) levMeasuring GGT is most useful in paels tients at risk of liver disease due to alcoholism. GGT, unlike other liver enzymes, raised by alcohol consumption ALP (alkaline phosphatase) Levels raised in diseases of the liver and biliary tract, with highest levels found in obstructive jaundice. ALP is usually raised in cirrhosis and liver cancers. Albumin levels What is the most common cause of chronic liver disease ? Viral hepatitis Long-term excess alcohol consumption Haematochromatosis Malnutrition Paracetamol Metabolism Paracetamol is mainly metabolised by glucuronidation, sulfation, and oxidation in the liver. Conjugates are inactive and nontoxic. The sulfation pathway is capacity-limited. The CYP2E1 isoenzyme generates an oxidative intermediate, NAPQI, which conjugates with hepatocellular stores of glutathione to form cysteine and mercaptopurine conjugates. Paracetamol overdose glutathione synthesis may be insufficient to cope with the generation of NAPQI, leading to NAPQI accumulation. NAPQI binds covalently to hepatocytes leading to necrosis 32 / 34 Timescale of liver damage Phase 1 (0.5 - 24 hours) asymptomatic, anorexia, nausea, vomiting, malaise, pallor, diaphoresis Phase 2 (18 - 72 hours) add right upper quadrant abdominal pain/tenderness tachycardia, hypotension oliguria Phase 3 (72 - 96 hours) "hepatic phase" tender hepatic edge, jaundice, coagulopathy, hypoglycaemia, hepatic encephalopathy possible acute renal failure, death Phase 4 (4 days to 3 weeks) resolution of symptoms and organ failure. liver recovery time from paracetamol overdose clinical recovery up to 21 days; histologic recovery months Smoking cessation -NRT/bupropion/varenicline, are most effective when used with other forms of support •E-Cigarettes - Can be recommended but only those with Marketing Authorisation Both NRT and E-Cigarettes still contain Nicotine but NRT IS less harmful than smoking and E-Cigarettes BELIEVED to be! Cravings •Enjoy smoking •Stress/mood •Coping mechanism •Peer pressure •Fear of failure •Social relationships •Pressure from others •Fear of weight gain Barriers to stop smoking 33 / 34 Health •Financial •Pregnancy •Second hand smoke •Hospital admission •Pressure from others Motivations to stop smoking 34 / 34