OSCE Case Study

This is gastroenteritis. It is due to bacteria or viruses. We usually call it bacterial gastroenteritis. It is a self_limiting condition, the patient gets better by its own. Your body tries to expel any toxins. Recommendation: A 21 years old-patient. She has watery stools and abdominal cramps_ she has these symptoms since yesterday afternoon. She has not taken any action, she used energy drinks. She has not used any medication, no medical condition. Hydration (dioralyte sachets), to replenish lost fluids and electrolytes. Loperamide (Imodium) might be useful if you are travelling, if you are a student, you want to slow the cramps of the GI tract. For abdominal pain is due to the body is trying to expel the toxins so paracetamol might be useful. Encourage her to drink plenty of fluids and stick to a bland diet consisting of easily digestible foods like rice, bananas, and toast. if the blood is mixed with stool, then it is sometimes that we need to worry about but in this scenario the blood is red on toilet paper and not mixed with stool. This bleeding is due to superficial bleeding of blood vessels of rectum. When someone A patient suffers from piles. He has pain when he passes motion (has bowel is straining at stool. movement), red blood in the tissues. He has these symptoms for five days; he has The patient is using co-codomol which not done any action. He has no medical caused constipation. He should use bulk_ forming laxative (stimulation of peristalsis in a similar way to a dietary fibre. It is important to drink plenty of water to avoid impaction. 1 / 54 Advice:.He should have a diet rich in fibre. Increase his exercise, increase his fluid intake. conditions, but he is using co_codamol Instruct him to apply the cream or oint(codeine and paracetamol). ment to the affected area after each bowel movement and to gently cleanse the area with warm water. sitting in warm water for 10-15 minutes can also help alleviate discomfort. A child has had diarrhoea since last night. The patient is a child, 3 years old. using toilet 3 times at night and once in morning. The motions are very watery. Has these symptoms since last night, no medication, no medical history. Symptoms of dehydration (Gastroenteritis). Due to bacteria or viruses. Hydration salts (dioralyte) one sachet in 200 ml of water, water from the tap is ok. Any fresh water, if you are on holiday where water is not Suitable, use boiled water. Symptoms of dehydration: dry mouth, dark urine, headache, feeling dizzy. If the patient is a baby (lack of tears, less wet nappies). It is a self-limiting situation. Non-pharmacological advice: do not go to school. Plenty of water, Antibiotics are not recommended for children. dry mouth, dark urine, headache, feeling dizzy. If the patient is a baby (lack of tears, less wet nappies). Persistent constipation lasting longer than a week may indicate an underlying medical issue that requires evaluation.Bloating accompanied by constipation could be a sign of an underlying gastrointestinal problem, especially if it's persistent or severe. 2 / 54 laxative: Senna laxative ( works 8 to 12 hours) stimulates intestinal movement. Thomas has been constipated for over a week. Advice: Instruct him to increase fibre intake through foods like fruits ( strawberThe patient is Thomas. He suffers from ries, apples, pears, oranges). vegetables constipation for over a week. He has (leafy greens like spinach, lettuce and bloating. broccoli) and whole grains ( bread, pasNo medication, no medical history. He is ta, rice). Dried fruits ( apricots, figs) , not active. Studies at college. legumes( beans, peas, chickpeas) can help. Drinking plenty of water and staying physically active can also help. Ensure that Alex is effectively managing his asthma with his inhaler as prescribed by his healthcare provider. Poorly controlled asthma can sometimes exacerbate gastrointestinal symptoms. Other reasons for wind can be: fast food, Scenario 5 Alex has been experiencing chewing gums, fizzy drinks. Beans, cabterrible wind over the last week. bage, onions, broccoli. The patient is Alex, he is suffering from terrible wind, bloating over a week. Has Using deflatulent such as Simeticone (or asthma and using inhaler. simethicone) dimethicone. It breaks up trapped wind. There is no strong evidence for these products but if the patient insists to have something, recommend them Irritable bowel syndrome: bloating, constipation or diarrhoea, it could be linked to stress, depression, It is a life- long condition. It might go and come back again. Advice: dietary modifications, stress management techniques, regular exer3 / 54 cise, and medication options tailored to her specific symptoms and needs. Additionally, keeping a food diary to identify triggers and avoiding foods that exacerbate symptoms can be helpful. low FODMAP diet might help. This includes certain meats, fish, eggs, lactose-free dairy, gluten-free grains, and select fruits and vegetables with lower FODMAP content Jane's irritable bowel syndrome has been giving him problems. It is a cold because there is no significant pain or fever. For aches and pains: paracetamol. For sore throat, strepsils or benzydamine hydrochloride (difflam spray). A 48-year-old man, who is a taxi driver. He has a blocked-up nose - find it difficult to breath through your nose. Nose is also runny. You have a sore throat - generally sore, no sharp pain or spots on your throat when you check in the mirror. You've had this for the last 2-3 days. You've not got any allergies that you know of. You've never had hay fever. You have high blood pressure and take Atenolol tablets, 50mg one daily For blocked nose: saline spray because he has high blood pressure and he is on atenolol. Using steam inhalation with menthol crystals can be an effective way to relieve nasal congestion and soothe irritated nasal passages. For runny nose: loratadine non drowsy. If you have a combination product, let them know that is product has paracetamol so do not use paracetamol. Advice: get rest, hydration, good diet, hand hygiene to prevent spread the virus. we should check pharmacy first to see if he is eligible for vaccine. 4 / 54 Oxymetazoline and pseudoephedrine. They work by constricting blood vessels in the nasal passages, reducing swelling and congestion, and providing relief from symptoms of nasal congestion due to colds, allergies, or sinusitis. Nasal decongestant sympathomimetics It's important to use oxymetazoline and examples and how does they work? pseudoephedrine nasal sprays as directed and not to exceed the recommended dosage to avoid side effects. Pseudoephedrine is commonly found in oral decongestant medications such as Sudafed. It seems that this lady has flu because she cannot get out of bed. We are concerned because she is type 1 First consultation diabetic - she is unwell- she has to adjust You are a 23-year-old woman. You phone insulin for her low food intake - she might your local community pharmacy. not be eating well because of the flu. You work in a car show room as a secre- We are concerned about her diabetic tary control. We need to know if she can ad"I feel terrible; I have aches and pains just her insulin for her lower intake. If no in my muscles. I also feel feverish and refer her to the G.P. have a dry sore throat and cough. Can you help?". For her symptoms: Your symptoms have got worse over the For aches and pains: paracetamol. last 2 days. If you have diabetes and are concerned You find it difficult just getting out of bed about your kidney health, avoid ibupro- all aches. fen. You have diabetes type 1 so want to For cough: simple linctus sugar free avoid anything with sugar. For sore throat: benzydamine hydrochloYou've taken ibuprofen - 2 x200mg three ride sugar free. times a day for last two days but it's not Advice: rest, good diet so that she can made much difference. take insulin properly, hydration. It is important to keep in contact with this lady (diabetic). If your symptoms get worse, If you have symptoms of bacterial 5 / 54 infection, see you GP. If not you should expect her to get better in one week. The patient returns after one week, her symptoms have not resolved - what action will you take? It is now 7 days later and you're not really feeling any better so you return to the pharmacist. You had followed their advice and are now looking to try something else. PCR test was negative. She needs to wait for two weeks because flu can last up to two weeks. If she come after two weeks saying that she is feelings worse, productive cough, higher temperature, this sometimes indicates chest infection, pneumonia . she has a bacterial secondary infection post flu, we ask her to call her GP. She said she usually had these symptoms before at the same of the year.This means this is hay fever. Other questions that we need to ask her to ensure that she is suffering from hay fever and nothing else. Questions like when do you have these symptoms? Is It is the start of June it at the exact time every year? Is there You are 23 years old. a specific season? Trigger factors like You work as a nursery teacher grass, pollen, fungal spores, animals, do "Can I buy something to treat this annoy- you have hay fever history? What have ing 'summer cold'?" you been doing recently, moving to a new "I have a stuffed-up nose, which is also house, having a new pet? very runny" "My eyes are itchy too and I'm sneezing In addition to nasal congestion, runny all the time." nose, sneezing, and itchy eyes, do you You've had the symptoms for the last 5 experience any other symptoms such as days but you are prone to getting sum- coughing, wheezing, or difficulty breathmer colds around this time nearly every ing? year. Allergic asthma Treatment by antihistamines such as loratadine it is good because it is not sedating_ to help relieve your runny nose, sneezing, and itchy eyes. These medications can be taken once daily and are effective for managing allergy symptoms. 6 / 54 She takes it once a day. This means she does not need to take medication to her work. She should take loratidine regularly (everyday) at the time when she gets allergies. Pollen time: morning and evening avoid being out at these times. I usually take decongestant lemon drinks Eye drop: sodium cromoglicate eye but they haven't worked this year. drops You have no other medical conditions Symptoms in the nose and back of and take no other medicines. throat: You are a non-smoker and non-drinker. Nasal corticosteroid sprays: BeclometasoneAdvice Keep the windows and the door shut. Wear sunglasses do not touch your eyes, to prevent pollen enter her eyes. Smear Vaseline around the inside edges of the nostrils - it helps stop pollen from getting through Beclometasone nasal spray (a corticosteroid): works by reducing inflammation in the nasal passages. It helps relieve symptoms such as nasal congestion, runny nose, sneezing, and itching by targeting the underlying inflammation associated with hay fever. It is effective Difference between decongestants such for long-term management of hay fever as xylometazoline and nasal corticos- symptoms and is safe for daily use when teroids sprays such as beclometasone used as directed. 2. Xylometazoline and phenylephrine nasal sprays (decongestants): Xylometazoline and phenylephrine are nasal decongestants that work by constricting blood vessels in the nasal passages, which helps reduce swelling and congestion. 7 / 54 Since you have a known allergy to cats and anticipate experiencing symptoms when visiting your aunt, you can consider purchasing an over-the-counter antihistamine medication to help alleviate your symptoms. Piriton (chlorphenamine) is a You are 27 years old common antihistamine that is often used Work as an admin assistant in a bank. to relieve symptoms of allergies, includ"Can I buy something to stop my allergy ing itching, runny nose, and sneezing. to cats? I am going to visit my aunt for the first time in years and she has two cats." You can continue using Piriton if it has I have no symptoms just now - but I know worked well for you in the past. AlternaI'll get all itchy and get runny eyes and all tively, there are other antihistamine opsneezy when I visit my aunt. tions available over-the-counter, such as I take no other medicines. I have no other loratadine (Claritin), cetirizine (Zyrtec), medical conditions. which may also provide effective relief for When I was younger I used to take Piriyour allergy symptoms. ton when I visited my aunt. Advice avoid close contact with the cats, wash your hands frequently, and keep windows closed to prevent allergens from entering the house. Nurse is in her 60s and retired 10years ago Child is next door neighbour's son - she can't get out because he isn't well and nurse volunteered to get something for her. Not been well for 3-4 days but seems worse yesterday and today so is being kept off nursery. Has "sniffles, a bit of a temperature that comes and goes and is a bit lethargic. Has a bit of an occasional, productive cough" Hasn't been given anything for it yet Family is on a bit of a budget. Government suggested that not to provide products containing decongestants and antihistamines under the age of six. Because there is no evidence that they are beneficial. From six to 12, very limited products under the supervision of pharmacist. For cough: simple linctus paediatric For temperature: ibuprofen or calpol (paracetamol) Make sure to supply the correct strength. In terms of they are on the budget, free supply from pharmacy first. It is viral infection. It is self- limiting, rest, 8 / 54 Just the mum, dad and kid in the family good diet. Hydration. No other medical conditions, medicines, At the age over two, they are eligible for otc medicines or vitamins/supplements flu vaccine. 58 years old plasterer Third time this week been in a pharmacy. Has had this cough for about a month but was just toughing it out until this week Got Benylin Non-drowsy a week ago, it didn't work so he then got Broncho-Stop and it's not made any difference either No other medical conditions or medicines or otc or vitamins Smokes 20 a day since 16 years old Drinks 3 or 4 pints on three or four nights a week Cough is productive with some yellow mucus, particularly in the mornings He's also a bit breathless most of the time since developing the cough and is finding managing carrying bags of plaster as being difficult and also finding stairs difficult. .We are worried about this patient. we usually refer the patient if they have cough more than 3 weeks. Red flags: He has cough for a month. It might be covid, lung cancer, chest infection, COPD. He is a smoker. He is plasterer, he has exposure to dust. He is a bit breathless. He is 58 years old. In this case, go to your G.P as soon as possible. I would not supply him with cough medicine, to force him to see the G.P. . 78 year old woman. Recent diagnosis of hypertension. Just started ramipril 2.5mg once daily at start of this week Has developed an annoying cough - just dry and irritating nearly all the time, constant tickle in the throat Has osteoporosis and has Calcium with Vitamin D prescribed for this by her GP Has no other medical conditions Takes paracetamol sometimes if has a headache. Takes cod liver Oil capsules every day for her joints Lives with her husband and stays fairy She is using ramipril (ACE inhibitor). angiotensin converting enzyme The cough is a side effect of ACE inhibitors. She needs to see her G.P to change her medication. They can explore alternatives. 9 / 54 active - does some gardening, does some line dancing once a week at old folk's club, likes going for short walks with her husband. Non smoker, non drinker It is important to talk to Andrew directly if that is possible. Based on his sore, swollen gums and noticing blood when eating an apple, it sounds like he may be experiencing symptoms of gum inflammation, which could be due to several factors: Poor oral hygiene: Inadequate brushing and flossing can lead to the buildup of plaque, causing inflammation and bleeding gum. Patient 15 yr. old Andrew Watt, who has It can also be influenced by factors such Down Syndrome as hormonal changes, certain medications, and medical conditions like diSymptoms Sore swollen gums and noabetes. Aggressive brushing, using a tices blood when eats an apple. hard-bristled toothbrush, or eating hard or sharp foods can irritate the gums Duration For the past 2 weeks and lead to inflammation and bleeding_ . Dental appliances: Ill-fitting dentures or Treatment Not done anything - hoped it braces can irritate the gums and lead to would get better soreness and bleeding. Drugs None Other info No other medical conditions Symptoms: 1. Swollen, red gums 2. Bleeding gums, especially when brushing or eating 3. Soreness or tenderness in the gums 4. Bad breath 5. Receding gum Treatment options: 1. Improved oral hygiene: Encourage Andrew to brush his teeth gently twice a day and floss daily to remove plaque and prevent gum inflammation. Using a soft-bris10 / 54 tled toothbrush and a fluoride toothpaste is recommended. 2. Dental cleaning: Suggest that Andrew visit a dentist for a professional cleaning to remove plaque and tartar buildup from his teeth and gums. 3. Mouth rinses: Recommend using an antimicrobial mouthwash to help reduce bacteria in the mouth and promote gum health. Andrew is becoming very aware of the 4. Dietary modifications: Advise Andrew soreness in his gums and is stopping to avoid hard or sharp foods that may eating certain foods further irritate his gums and contribute to soreness and bleeding. 5. Dentist visit: Encourage Andrew and his caregivers to schedule a dental appointment for a thorough evaluation and treatment plan. If Andrew is experiencing discomfort, over-the-counter pain relievers like acetaminophen or ibuprofen may help alleviate some of his symptoms. However Patient 15 yr. old Andrew Watt, who has Down Syndrome Symptoms Sore swollen gums and notices blood when eats an apple. Gingivitis. Refer to the dentist to prescribe mouthwash ( chlorhexidine) to Duration For the past 2 weeks reduce bacteria that causes gum inflammation. Non steroidal inflammatory Treatment Not done anything - hoped it drugs like ibuprofen or naproxen can help would get better reduce swelling and inflammation in the gums. Drugs None Other info No other medical conditions Andrew is becoming very aware of the 11 / 54 soreness in his gums and is stopping eating certain foods These are minor aphthous ulcers. They should go away by their own but they are quite irritating and annoying. They are linked with stress and lack of sleep (trigger reasons). They are two, three in number. These have been for 8 days. If they are more than three weeks , we will refer her. I would recommend that Mary consider using over-the-counter topical treat36 yr. old Mary Bell, bank manager in the ments that relieve the pain, can help local bank. numb the pain like lidocaine and benzocaine. Very painful sores in mouth - 2-3 small ulcers inside cheeks and floor of mouth Duration For the past 8 days, and gets worse when drinks coffee Treatment Not done anything - hoped it would get better No other medical conditions . Mary has been working long hours at the bank. She is a non-smoker. Advice: avoid coffee, acidic food, spicy food irritate them, avoid alcohol, smoking. Maintaining good oral hygiene practices, including gentle brushing and rinsing with a mild saline solution, can also help promote healing and prevent infection. If Mary's symptoms persist or worsen despite these measures, or if she experiences difficulty eating or drinking due to the ulcers, she should consult the dentist. If they are large clusters, large numbers, we will be worried about the patient. In this case we are not worried 12 / 54 No other medical conditions Faisal has exams coming up and is quite stressed - He is a non-smoker. Cold sores, also known as fever blisters, are typically caused by the herpes simplex virus (HSV), I would recommend that Faisal consider using an antiviral medication like aciclovir to help treat his cold sores. Aciclovir works by inhibiting the replication 20 yr. old Faisal Shah, accountancy stu- of the herpes virus, which can help redent. Saw advert for aciclovir last night duce the duration and severity of outbreaks. It's important for Faisal to start Symptoms Yellow crusts around top lip, treatment as soon as possible, ideally dry and crusty around nostrils within the first 24 hours of symptoms appearing, for maximum effectiveness. Duration For the past 3 days In addition to using aciclovir, Faisal should avoid picking or scratching at the Treatment Tried dabbing aftershave on cold sores to prevent further irritation and the area - seems to be getting worse and potential spread of the virus. He should more itchy also keep the affected area clean and Action? moisturized to promote healing. Drugs None , no medical conditions, Given that Faisal has exams coming up he has exams coming up, he is quite and is experiencing stress, it's essential stressed. He is non smoker. for him to take care of his overall health and well-being. Managing stress through relaxation techniques, getting plenty of rest, and maintaining a healthy diet can help support his immune system and potentially reduce the frequency of cold sore outbreaks. It is really infectious. Do not touch your face. Advice: wash your hands after applying the cream. 13 / 54 Drugs A blue and a brown inhaler Other info Has had asthma since childhood This is oral thrush (candidiasis) which is a fungal infection caused by Candida yeast. Symptoms: sore tongue, Irritation, different taste. White patches on the tongue, it could be anywhere in the mouth. Steroid 40 yers old Simon Collins. Sore tongue inhalers infect the immune system within and noticed white patches on cheeks the mouth. people using steroid inhaler and tongue. Has a bad taste in mouth are the most susceptible for oral thrush. Simon has asthma and is using inhalers, Duration it's essential for him to rinse his mouth For the past 3 days with water after using his inhalers to help reduce the risk of developing oral Treatment Used Listerine mouthwash thrush as a side effect of inhaled corticosteroids. Drugs A blue and a brown inhaler Recommendations: using miconazole He has asthma since childhood. gel. It's important for Simon to follow the directions provided with the medication and complete the full course of treatment to ensure that the infection is adequately treated. If Simon's symptoms persist or worsen despite using antifungal medication, or if he experiences difficulty swallowing or breathing, he should see your doctor. If it was an elderly man, you need to tell the patient to to remove and clean their dentures thoroughly after each meal and before bedtime. Dentures should be soaked in a denture cleaning solution overnight and rinsed well before wearing 14 / 54 them again. Also maintain oral hygiene and regular dentist checkups, avoid risk factors such as smoking, excessive alcohol consumption, and prolonged use of antibiotics. Based on her symptoms of pain when eating cold or hot food/drinks and the sensation of her tongue feeling larger than normal, it sounds like she may be experiencing symptoms of oral discomfort or altered sensation, which could have several potential causes. 46 yr. old Pawla Adamik Pain when eating cold or hot food/ drinks, tongue feels larger than normal - is this my new toothpaste? This has been getting steadily worse for the last 2 weeks. Has not tried any medication to date. Enalapril 5mg tablets, started last week High blood pressure, recently diagnosed Causes: 1. Oral irritation: may be due to irritation of the mouth tissues, possibly from certain foods, beverages, or oral care products like toothpaste. 2_ Medication side effect: Since Pawla recently started taking enalapril for high blood pressure, it's important to consider whether her symptoms could be related to this medication. Enalapril is used to treat high blood pressure. While it's not common, some individuals may experience side effects such as oral discomfort or taste disturbances with this medication. Treatment: 1. Discontinuation of potential irritants, she may consider discontinuing use and switching to a different product to see if her symptoms improve. 2. Oral hygiene: Encourage her to maintain good oral hygiene practices, including gentle brushing with a soft-bristled toothbrush and fluoride toothpaste, as well as regular flossing and rinsing with 15 / 54 a mild mouthwash. 3. Moisturising oral products: like saliva substitutes or oral lubricants to help alleviate dry mouth symptoms and promote oral comfort. 4. Advice her to see her GP to see if these symptoms are side effects of the medication _ regular dental check_up. Based on her symptoms of bad breath, an acid taste at the back of her throat, and a burning sensation when bending down, it sounds like Carla may be experiencing symptoms of gastroesophageal reflux disease (GERD), also known as acid reflux. 32 yr. old Carla Owens . Was out with for a few drinks and one of her friends commented on her bad breath Not sure how long going on for - friend just told her I would recommend that Carla consider addressing the underlying cause of her bad breath and other symptoms by managing her acid reflux. Mints and chewing gum are just masking the problem. They do not solve the issue. some recommendations: Nothing - though about mints and chewing gum. 1. Lifestyle Modifications: Encourage Drugs: Cerazette Carla to make lifestyle changes to help reduce her acid reflux symptoms. This Last few weeks noticed an acid taste may include avoiding trigger foods and at back of throat and burning sensation beverages such as spicy foods, caffeine, when bends down. She is overweight. and alcohol, eating smaller, more frequent meals, and avoiding lying down or bending over after eating. 2. Weight Management: Since Carla is overweight, losing weight through a combination of diet and exercise may help reduce pressure on her stomach and decrease the severity of her acid reflux symptoms. 16 / 54 3. Over-the-Counter Antacids: Recommend over-the-counter antacids or acid reducers to help neutralize stomach acid and provide temporary relief from heartburn and acid reflux symptoms. Examples include gaviscon. treatment plan for her acid reflux symptoms. If her symptoms persist or worsen despite these measures, see your G.p. POM anti_emetics needed_1st trimester is too high risk to give anything over the 1.Female in 1 st trimester of pregnancy counter. suffering from nausea and vomiting. Sips of water, small amounts of food, avoid foods that cause aversion. See your GP. Constipation: baby pushing bowels upwards, iron supplements, lack of movement (static). Increase of progesterone hormone which causes relaxation of muscles hence not much movement. Bulk_forming laxatives e.g ispaghula husk ( Fybogel sachets mixed with water_ take it quickly after reconstituting it. Female in 3 rd trimester of pregnanAvoid spicy foods, increase fibre in diet cy suffering from constipation and com( whole fruits/ veg) to stimulate gastric plaining of haemorrhoids. emptying , a little movement required. ( not a lot during trimester 3 ) Senna can not be used as it is stimulant laxative _ can stimulate uterine contractions. Haemorrhoids: pressure, consequence of pregnancy Anusol cream, witch hazel 17 / 54 Indigestion: reduced gastric emptying, hormones relax muscle tone in stomach ( hence reducing gastric emptying) baby pushing bowels upwards causing acid reflex 3. Female in 2 nd trimester of pregnancy Gaviscon can be given _antacid with alwho is complaining of indigestion ginate _ protective neutral layer which prevent acid moving upwards ,frequent small meals, avoid spicy food, elevation on top of bed. Peptac or Gaviscon dose: 10 ml (2 spoonfuls) after meal. Same as before 4. Female in 3 rd trimester of pregnancy Can be given PPI _opemrazole (POM) with symptoms suggestive of acid reflux. but the first line should be antacids Hormones can change the pH of vagina, become more acidic, need to ask if she has thrush before, need diagnosis by GP 5. Female in 2nd trimester of pregnancy , likely to be prescribed treatment that with symptoms suggestive of Thrush is better than topical application. ( oral treatment) Natural remedies: yoghurt application to the area. May help. Treatment with antibiotics _ not allowed on pharmacy first for UTI treatment for pregnant women. Female in 3 rd trimester of pregnancy Trimethoprim __ harmful to foetus as it with symptoms suggestive of a Urinary affects the levels of folic acid essentially Tract Infection. during the first months. Nitrofurantoin_ can cause jaundice in the foetus Anaemia symptoms:tiredness, pale, blood test shows low blood count, shortness of breath. If she has iron deficiency then she is on iron supplements. Otherwise, she can strart folic acid tablets before pregnancy. 18 / 54 Foetus is likely to have defects during anaemia, consider taking vitamin D supFemale with anaemia who is actively try- plements. ing to get pregnant. Physically fit_ lose weight if you are overweight. Exercise, stop smoking, reduce alcohol intake, reduce caffeine intake. 3 rd trimester , need to prepare for delivery, going to go through blood loss, hence important to increase the mother 8. Female in 3 rd trimester of pregnanblood count so she is ready to give birth. cy whose doctor/blood tests confirm that Treatment until three months after delivshe is anaemic. ery Iron tablets, Eat iron_rich food (leafy veg), plenty of water. we can not supply another one in the same cycle. The argument for supplying it (it could disturb the lady cycle). we can sell it but not supply over the counter A 29 years old woman is requesting because It is not licensed. EHC. She has received a previous sup- Advice on Use a long_ term contracepply within her current menstrual cycle. tion like progesterone only pill_ suggest access to sexual clinic. Either refer them to sexual clinic or double the dose. you could prescribe her and take the responsibility. A lot of pharmacists shut on Sunday. We can not supply her because she doesn't fit the criteria, she did not have sex. If she is responsible. If she understands A 19 years old woman is requesting how to use it and because the pharmacy EHC. She is going to a party tonight (Satis shut on Sunday, you could sell EHC. urday) and she may need it tomorrow. Advice: use a barrier method (condom for free) prevent sexual transmitted diseases which EHC can not do. Chat about longer_ term contraception. 19 / 54 She is under 16, we can not sell her over the counter because it is not licensed. But we can supply her under PGD if she understands how to use it, consequences of sex. Patient 3 (aged 14 years) is requesting Advice to access sexual clinic. EHC. She is in the pharmacy on her own. We need to get information about the partner (child protection, sex is permitted if her boyfriend is 16) if her partner is over 16, it is a crime. We do not need parents' consent if she's over 13. We need to ask safety questions about her cycle to supply her. If her cycle is regular or not . When was her last period? Sometimes women can not come to pharmacy (exceptional circumstances Male customer (early 20s) is requesting like covid) but this situation is not excepEHC for his girlfriend. She cannot come tional. to the pharmacy. We need to speak to the woman on phone. We need to know the girl age, why she can not come in person, is there any assault taking place if there is no harmful consequences, we can supply her boyfriend. The most effective one is the copper coil at sexual clinic. Ella one (ulipristal acetate can be used if she was unable to Patient 4, (aged 29 years) is requesting get an appointment for copper coil. EHC on a Monday morning. She had There is reduced effectiveness in that, unprotected sex on Thursday afternoon advice her that the best is to take EHC last week. within the first 24 hours after unprotected sex. Needs to do pregnancy test if her cycle was delayed. Female aged 35yrs is requesting EHC. No problem at all. Advice on use and long She had unprotected sex the night be_term contraception. fore. 20 / 54 Antihistamines are effective for relieving symptoms such as itching, sneezing, and watery eyes associated with allergies, they are not typically effective for treating a blocked and runny nose caused by congestion. You are working in a community pharA decongestant is recommended, which macy and a patient/customer asks for works by reducing swelling in the nasal an antihistamine for a blocked and runpassages, thereby relieving congestion ny nose. After counselling you establish and helping to alleviate a blocked and that the appropriate medication would runny nose. be an OTC decongestant and need to explain why an antihistamine would not .Antihistamines primarily target histabe appropriate.How do you handle this mine receptors to block the effects of scenario? histamine, which is released during an allergic reaction and leads to symptoms such as itching, sneezing, and watery eyes. However, they do not directly address nasal congestion caused by swollen blood vessels in the nasal passages. Advantages Tablet advantages: • Convenient and easy to handle • Accurate dosing • Cost-effective • Stable with a longer shelf life A 30-year-old man comes into a pharmacy for a light headache and would like Disadvantages: to have a paracetamol-containing medicine to be taken orally. Discuss the ad- • Some people may find them difficult to vantages and disadvantages ofA: tablets swallow • May take longer to dissolve and be absorbed • Potential for stomach irritation Capsules Advantages: 21 / 54 • Easier to swallow • Faster onset of action • Reduced risk of stomach irritation • Customizable formulations, coloured formulations, easy to identify. formulation of paracetamolB: capsules formulation of paracetamol. Disadvantages: • Less portable • Limited dosing flexibility • Higher cost compared to tablets Paracetamol Suspension advantages: A 2-year-old toddler has a small fall at the nursery and was prescribed paracetamol suspension. Her mother is concerned that her daughter, who is very difficult, won't swallow the medicine and is looking for an alternative formulation. Discuss the advantages and disadvantages ofC: paracetamol suspensionD: paracetamol suppositories • Easy oral administration, suitable for children who have difficulty swallowing pills • Palatable taste, often flavored to improve acceptance • Flexible dosing based on weight and age • Rapid absorption for faster onset of action Disadvantages: Risk of caking . Suspensions must be shaken for even distribution of the drug Precision of dose can't be achieved Prone to contamination Paracetamol Suppositories Advantages: • No swallowing required, suitable for children who refuse oral medication • Predictable absorption for consistent dosing. Avoids first pass effect. • Less messy compared to liquid formu22 / 54 lations • No risk of vomiting up the medication Dose not affected by gastric emptying. Disadvantages: • Inconvenient and uncomfortable for both child and caregiver during insertion • Limited availability in some pharmacies • Potential for rectal irritation. . Not acceptable in some cultures Analgesic Patches: Advantages: Good patient compliance. • Long-lasting relief over several hours or days ( long duration of action) • Convenient application with localized delivery • Minimal systemic absorption, reducing risk of side effects • May provide targeted relief to specific 53-year-old man often suffers from back areas of pain pain due to his frequent plane journeys. He generally uses Ibuprofen gel to alle- Disadvantages: viate the pain, but has heard about analgesic patches and would like to switch to • Potential for skin irritation or allergic this formulation. Discuss the advantages reactions and disadvantages ofE: patchesF: topi- • Limitation of movement, especially in cal gels joints • Higher cost compared to topical gels Topical Gels: Advantages: • Quick absorption for rapid pain relief • Ease of application with no residue • Variety of formulations available for customization • Less risk of skin irritation compared to 23 / 54 patches Disadvantages: • Need for frequent reapplication throughout the day • Potential for skin sensitivity with certain formulations • Provides less targeted relief compared to patches A woman comes in with her 4-year-old son asking for something to "treat Adam's cough and cold". He has a dry, tickly cough, runny nose and is flushed and sweaty. He has had these symptoms for the last two days since he started his new nursery. She has given him Calpol, which has helped to reduce his temperature. Calpol has an analgesic effect. Tell the mother that Calpol not treat the cough or cold. It is for the fever and muscle aches. For cough: simple linctus paediatric. Placebo effect_ no evidence. Saline nasal drop for runny nose. Advice: hydration, rest, good diet. A 23-year-old woman presents saying "I feel terrible; I have aches and pains in my muscles. I also feel feverish and have a dry sore throat and cough. Can you help?" Her symptoms have been getting worse over the last two days and today she found it difficult to get out of bed. She has diabetes so needs to be careful about sugar in any medicines that she takes. She has tried ibuprofen but that didn't seem to work. The diagnosis might be a flu or covid. Self- limiting. We need to question how she is using ibuprofen, is she using the correct dose for the correct time? We can offer paracetamol for muscle pain. Sugar free cough suppressant. Sugar free Simple linctus. Sore throat: sugar free difflam spray (benzydamine hydrochloride ) A customer comes into your pharmacy on a Friday afternoon and describes symptoms of nasal congestion and headache. She presents you with an old prescription she had received for the same symptoms last year and asks if she could buy the same products over-the-counter as she doesn't want to Hay fever or allergy. Desloratadine is POM. We can offer an alternative as loratatidine does the same thing. Paracetamol is fine but she is asking for Beechams which contains paracetamol 24 / 54 wait for a GP appointment the following week. The following were prescribed: Desloratadine 10mg daily for 5 days Paracetamol 1-2 tablets when required, max 8 tablets in 24 hours Ephedrine hydrochloride 0.5% nasal drops She also asks if she can buy Beechams cold and flu capsules. and she is already using paracetamol and also Beechams is for cold and flu, she is unlikely that is going to help her symptoms. For nasal congestion: nasal spray can be offered. We need to ask her What were your Initial symptoms? Advice: pelvic floor muscle training to strengthen the area muscles. reduce caffeine and alcohol. do not drink if you want to go out or sleep. Use continence pads. Mrs Gh, a 55 year old female with ask your GP to prescribe them. topical urge incontinence due to prolapse of the vaginal oestrogen (female) prescribed. uterus. Medication: anti- muscurinic (oxybutynin) by doctor. 4 weeks to work. side effects: dry mouth, constipation, There is an online course (bladder training) 6-week course strengthening muscles of bladder, information about when to drink. We need to ask her what symptoms of chlamydia? It is a sexual transmitted disease. pain in tummy or pelvis, pain when Miss ER, a 27 year old who thinks she urinating and during sex. unusual dismay have chlamydia. charge, some bleeding between periods and after sex, uncomfortable, Why she thinks she had chlamydia? Chlamydia is a bacteria treated with antibiotics. 25 / 54 Refer her to Sandyford clinics. Advice the patient that it is an infection disease, tell your partner to get treatment. It has a long-term consequence. It might affect fertility. To prevent it, wear condoms What symptoms do you have? Patient can not empty the bladder fully, difficulty in starting urinating. urinate more frequently, pain when urinate, urine continence problems. urinate at night (when does not have the problem in the past) Advice: reduce caffeine intake, reduce fluids before sleep or going out. • Tamsulosin 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 3. Mr JL, a 65-year-old patient with be- or PSA (Prostate Specific Antigen) nign prostatic hypertrophy. Tamsulosin P medicine can be supplied over the counter if the patient. • 45-75 years old, symptoms for 3 months • 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) The pharmacist is able to supply it for two weeks. If the patient was beneficial 26 / 54 from that, the patient can get a four-week supply from the pharmacy. Ask if she suffers from stress, vitamin deficiency b12 or iron deficiency, or hormone imbalance, bleaching hair, medication. Are you on chemotherapy? when it starts, how long? What do you 4. Ms TW, 35 years old very concerned mean by a lot of hair? It is about 100 hair with unexplained hair loss. is normal to lose this every day. Does it come out in clumps? Do you have hair patches? If rapid hair loss, refer to GP. There are some of substances that causes that like cocaine. In most cases the reason is hormones. Is it for yourself, how long? Age (night sweats are common at 50s menopause) when at night? or day? How frequently? family history, are you stressed? Worried about something? Diabetes, pre-diabetes, medication side Mrs LP who asks for advice on the maneffects, started new medication recently? agement of excessive sweating. change dose of medication? Leukaemia. Cancer? is it after exercise? Advice: Wear loose clothes, stay hydrated, sleep hygiene measure (room cool, taking shower, lighter duvets) foot powders, good type of shoes, armpits shields worn under clothes. 27 / 54 6. Mrs JD 45 years old complaining of rectal bleeding. Mrs SK who asks for advice regarding her problem with bad breath. Ask about the blood colour? If the bleeding is closer to the anus (bright red blood) and bleeding higher up in the digestive tract (darker or tarry stools) Inquire about pain or discomfort during bowel movements can indicate conditions such as hemorrhoids, anal fissures, or inflammatory bowel disease. Conditions that cause rectal bleeding: cancer, anal fissures, haemorrhoids. If the patient has weight loss, this might indicate cancer. How long do you have the symptoms, other symptoms? It could be (haemorrhoids). We need to ask more questions to make sure that it is haemorrhoids. Symptoms of haemorrhoids: Itchy, accompanied with constipation, large lump, the blood is not mixed with stools. advice: creams, explain how to use it, keep the area clean, sit in warm water, treat the constipation. Ask if she has gum swelling, gum bleeding, signs of infection? Wobbly teeth, pain? Wear dentures? Do you have good denture hygiene? Clean it every day? Soak it in appropriate fluid over night? Rinse it? What kind of smell (sweet smell indicates ketones - diabetes) is it recent? Is it going on problem? is it after eating certain foods? Oral hygiene: brush teach gently twice a day with appropriate toothbrush, do not brush excessively, use mouth wash, flossing, stop smoking, brushing the tongue, bacteria on tongue, spit out rather than rinse out, Mouth spray. 28 / 54 Ask how long the symptoms, frequency, how you feel. what is going on? Have you had it before? Are you stressed? How is life with you? Stress. Causes: (medication such as diuretics), disease such as CV disease, diabetes, cyclists might have this problem. if they stop cycling, that might be resolved. Advice: reduce alcohol and caffeine, hydration, check if they use blood pressure 8. GK, 57 years old male experiencing medication, overweight, if it is not psyerectile dysfunction chological, if it is urinary infection, refer. If they need medication, viagra helps. Double check that the patient is uncontrolled hypertension before prescribing viagra. prescribe testosterone hormone (check his hormone level first) It is preferred to speak to a male pharmacist. It is acute pain. The pain is because of mechanical injury. self-limiting ,hot water bottles to the lower Patient T, (aged 48) has a dull pain in his back may provide some relief, get rest. lower back. ibuprofen or paracetamol. Topical medthe last couple of days. Just moved ication can be used if the patient prefers house and has been lifting a lot of fairly it. heavy boxes - no medication. If the pain is travelling, if the patient has problems with urine, if the patient is fifty then refer. She had chicken pox, but it is not related to these symptoms. (Red and swollen Patient U (aged 3) has toothache- moth- gum). er tells you that she is crying a lot with the We are concerned about patient if there pain and rubbing her mouth. The symp- is a sign of infection (fever), then refer to dentist. If the cheeks are swollen, there is bleeding then refer. 29 / 54 This pain by teething or tooth decay, tooth cavities. The patient should see the dentist. toms started about two days ago. Gums In the meantime, you can give the child appear very red and swollen - tried a over-the-counter children's pain relievers teething ring. - has had chicken pox 6 like ibuprofen syrup or paracetamol. The months ago. appropriate dose depends on the child's weight, so follow the dosing instructions. Lidocaine gel can be used (topical gel). the pain is cramping pain usually at the beginning of the period, the pain is in the abdomen and the back, headache (normal). We call this pain primary dysmenorrhoea. Who is it for - Patient V, 17 yrs - painful She is on salbutamol and beclometaperiods - Pain in the abdomen and back sone inhalers for asthma. we usually do which begins before the period starts not recommend any NSAIDs like ibuproand can last for a couple of days. Other fen, but only 10 percent of asthmatic peosymptoms include headaches and tenple are affecting by NSAIDs, you can ask der breasts. her if she has used NSAIDs before and - for the past 3 months - started regular had issues with it. periods about 6 months ago. Then you recommend using paracetaShe uses salbutamol and beclometamol or ibuprofen. If they do not help, use sone inhalers.- has asthma Naproxen (POM) can be taken at a dose of 250 mg every 6 to 8 hours as needed. Buscapon (hyoscine butylbromide) can be used. If they do not help, then refer. Hot water bottle, hot bath, rest, staying hydrated may also provide relief Patient X (aged 39) needs help to get to sleep, feels very tired in the morning and irritable at work as well as finding it hard to concentrate at work. Very stressful at work just now as redundancies are to be announced next month and half the he drinks coffee at night (it might be the reason why he can not sleep) you can ask if he has stress. Relaxation strategies can help. Start with establishing a regular bedtime routine such as creating a comfortable sleep environment, gentle exercise (go to gym). 30 / 54 Sleep hygiene (Last meal three hours workforce will be out of a job. before sleep, last drink two hours before, - for the past 2 weeks- drinking hot coffee screens one hour before sleep). Do not at night - heard that hot drinks were good drink caffeine at night. to get to sleep. No Medication. He does not need sleep medication because he is not tired. You have to ask if the pain is on one side, or where exactly. The pain is might because of sinuses. If it is a headache, we should know what kind of headache ( tension headaches like a tight band on Patient Y, 29 yrs- dull throbbing pain the head, if the pain is on one side then in the cheekbones and forehead. Face it is a cluster headache, if it is migraines, feels a bit puffy you should ask if they have blurred vision, vomiting, light sensitivity) . How long - just 3-4 days, just getting over for this scenario it is tension headache, a really bad dose of the cold.- Hay fever we recommend paracetamol, if it does and allergies when younger but nothing not work use codeine ( cause sedation, recently. constipation) . You can use ibuprofen as a second line. His face feels a bit puffy, this might because of sinus infection. (Sudafed) Non pharmacological advice: maintain a good hydration, rest, Patient Z (aged 28) suffers from migraines but wants something for the nausea that accompanies the migraine. - severe headache with throbbing pain at one side of the head. Feel very nauseous and would like to treat this just now suffers migraines for the last 8 years, this one has just started as feeling very sick. Medication - insulin Medical History - diabetes since 10yrs For nausea accompanying migraines, over-the-counter anti-nausea medications like (hyoscine bromide is reasonable choice). Prochlorperazine be helpful. Buccastem is a brand name of prochlorperazine buccal medicine is good for patients who have vomiting. • 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, par- 31 / 54 ticularly red wine or foods that contain nitrates • Maintain good sleep hygiene Check /correct posture. A 25 year old woman, who weighs 65 kg, admits to ingesting the contents of Optimal sampling time 4 - 15 hours post a "box" of paracetamol 1 hour ago. The dose. paracetamol concentration is 30 mg/L. The sample has been taken too early - further absorption can occur and the What advice would you give regardresult could be misinterpreted - we need ing the interpretation of the paracetamol a further sample concentration measurement and why? We can use the information to estimate the dose of paracetamol The friend produces a box of 32 tablets Assuming 22 tablets have been taken, which still contains 10 tablets. Why is this the dose of paracetamol is = 22 x 500 mg information important? = 11000 mg / 65 kg = 169 mg/kg If the dose exceeds 150 mg/kg over an hour, could administer activated charcoal 1. How the patch works: The patch releases both estrogen and progestin through the skin, which inhibits ovulation by providing negative feedback on the pituitary gland, preventing the release of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). A young woman (approx. 30yrs) has read 2. The pill: Birth control pills contain about a new contraceptive patch called synthetic hormones, and they work by Evra. She preventing ovulation, thickening cervical wants to know 'how it works and is it mucus to inhibit sperm penetration, and better than taking the pill?' thinning the uterine lining. They are taken orally every day at the same time to maintain hormone levels. 3. Skin irritation: While some people may experience skin irritation with the patch, it's not a universal side effect, and many individuals tolerate it well. 4. Risk associated with the patch: The 32 / 54 patch, like other hormonal contraceptives, carries a risk of blood clots, especially in individuals who smoke. Smoking increases the risk of cardiovascular side effects, including blood clots, due to its effects on blood vessels. 5. Consistency of hormone levels: The patch delivers hormones steadily through the skin, resulting in consistent hormone levels throughout the week. In contrast, hormone levels can fluctuate with oral contraceptive pills, especially if a pill is missed or taken at different times. One of your elderly customers (approx. 80yrs) asks you if she should take calcium and Vitamin D supplements - she is confused by the different strengths of Vit D/calcium in the various products and wants to know which one she should take. 1. Sunlight exposure: Vitamin D synthesis in the skin requires UV light, which may be limited during winter months or for individuals who spend less time outdoors. Since the woman is 80 and may not be as active or spend as much time outdoors, vitamin D supplementation becomes especially important. 2. Post-menopause: After menopause, women are at a higher risk of bone loss due to hormonal changes. Vitamin D is crucial for calcium absorption and bone health, especially in older individuals. 3. Mechanism of action: Vitamin D stimulates the uptake of calcium from the diet and increases its absorption in the intestines by regulating the expression of calcium transporters. Without sufficient vitamin D, calcium uptake is compromised, leading to weakened bones. 4. Advice: While supplementation is important, encouraging the woman to try to go outside when possible and consume a diet high in calcium can also support her overall bone health. For pregnant D is important for her. 33 / 54 Without vitamin D, stimulating calcium uptake from intestines leads to bones without calcium. She might try to get pregnant or trying to avoid pregnancy. How ovulation predictor kit. It measures LH levels (stimulates ovulation) LH is protein hormone and the kits contains antibodies. When antibodies bind to LH hormone in the urine sample, the antibodies react, causing a visible change 3. A female customer asks you to explain in the test result, such as a colour change 'how an ovulation predictor kit works'. or a line appearing on the test strip. This change indicates the peak fertility window for conception. The pregnancy kit has the same idea contain antibodies against HCG. If the woman wants to get pregnant, we can advise taking folic acid, stop smoking, reducing alcohol intake. Diabetes: based on the age of the patient (type one diabetes). Around 10 to 14 years old. Caused by lack of insulin. Diabetes type 2: in fifties or sixties. The patient needs GlucoGel to make his blood glucose level higher (low blood glucose (hypoglycaemia) Hypoglycaemia: tiredness, Rapid heartbeat, paleness, hunger, Irritability or moodiness? Difficulty concentration, Weakness or fatigue, Headache. 1. Blood sugar regulation: After eating, carbohydrates are broken down into glucose, which enters the bloodstream. Elevated blood glucose levels signal the pancreas to release insulin. 34 / 54 2. Insulin function: Insulin acts as a key that unlocks cells, allowing glucose to enter and be used for energy. It also helps convert excess glucose into glycogen for storage in the liver and muscles. 3. Lowering blood sugar: When insulin levels are sufficient, it helps lower blood sugar levels by facilitating the uptake of glucose into cells. This process keeps Grandparents want to purchase 'Gluco- blood sugar levels within a healthy range. Gel' for their grandson. They ask about the role of insulin Now, regarding GlucoGel, it's important in the body as they aren't very sure how to note that it's a brand name for a gluthe Gluco-gel works. cose gel used to treat hypoglycemia, or low blood sugar levels. In cases of hypoglycemia, where blood sugar levels drop too low, immediate treatment is needed to raise them back to a safe range. Glucose gel, like GlucoGel, provides a quick source of glucose that is rapidly absorbed into the bloodstream, raising blood sugar levels and preventing or resolving hypoglycemic symptoms. It is used to alleviate menopausal effects (night sweats and hot flashes) Some evidences around using soya_ based. Treatments show they have effect A female customer (approx. 55yrs) has on some people. It is different from perread about soya-based treatments for son to person. menopausal It binds to oestrogen receptors but with symptoms and asks your advice/opinion lower affinity than oestrogen. on their usefulness. It could have interactions with other medications. Check medical history. Registration of herbal remedy. You should check THR logo, product licence. 6. A patient is collecting his usual prescription for 'thyroxine' but notices it is Levothyroxine is the name of medication, levothyroxine is a synthetic form of thy35 / 54 labelled as levothyroxine- and the tablet is bigger than normal. He usually gets the 25mcg tablet but this is 100mcg. You check the prescription and it is correct. He asks you to explain why the tablets aren't called thyroxine and why the dose has been increased. roxine used to treat thyroid conditions, while thyroxine is the active hormone produced by the thyroid gland. You should ask if the patient had blood test, ask about the results if he has lower thyroxine levels. just contact the GP. Thyroxine is amine hormone, the conversion of T4 to T3 can make the cell more sensitive. The receptor in the nucleus Symptoms of hypothyroidism: depression, fatigue, weight gain. It might be child abuse, domestic abuse, sexual abuse, child neglecting because of postnatal depression. Child abuse: you can contact the department of social services. You should contact them again if they contact you. Signs of child abuse: the baby is not clean, ill, cuts, the baby in the same clothes. Poor hygiene, unexplained inA regular female customer tells you she juries, finger's bruises, emotional abuse. is concerned about a neighbour's child e. who she can hear Physical abuse: bruises in arms, legs, sobbing at various times throughout the markers in back, face. day. A raised male voice can also be heard at certain times in the night alMother abuse: the mother might be very though there is only the baby and its defensive, does not want you to interact young single mother who live there. She with her. asks you if she should do something You can tell the neighbour to contact about it - if so, what? them and check on them to make sure that they are really abused. If you want to report abuse, you do not need consent. If there are injures blamed on a little brother or kicked by a horse. If you have older children suspecting sexual abuse, you should report your concerns. You can refer to the child EB, you can call NHS and get advice, you can contact child 36 / 54 line, Children under the age of 13 (sexually) you should report. One of your regular patients is collecting their medication (2 months' supply of fluoxetine). You notice that they do not make eye contact with the counter staff, seem flat in mood and look quite dishevelled. Should you do anything about this- if so, what? Fluoxetine is for depression. OCD , anxiety, mental health issues. Maybe his depression is getting worse. Is the patient is taking the medication as prescribed. Some patients are not adhering (not compliance). Some forget to take medication. Talk to the patient in a consultation room. Do you mind if we have a chat about your medication. The patient needs the medication to be reviewed monthly. Antidepressants are on repeat. Find out if things have changed. You can contact the GP about your concerns A middle aged overweight female who recently purchased a blood pressure monitoring device from your pharmacy tells you that her BP readings have been 'high' every time she uses it. She asks you if this means that she has 'high blood pressure' and will she die of a stroke? Her husband is also overweight and is taking tablets called amoldipine (she found his empty packet in the bin ) and she wants to know why he is taking them You should tell her that high blood pressure can lead to stroke, but we should ask her about the reading. The acceptable reading for middle_aged women is 130/90. We need to check if she is using the device correctly, the position (sitting, your feet should be flat on the floor, clothes around the arm affecting, the arms should be at rest, legs are not crossed, do not put pressure on the heart) Lifestyle interventions: weight management (this increases your medical condition and smoking) BMI under 29, good diet, exercise, We can measure blood pressure ourselves, you do three readings over a couple of months 37 / 54 Elderly man, he may does not need laxatives. we are worried about bowel cancer, when you turn fifty, you should get a stool sample and test it for bowel cancer. We need to ask questions about bowel cancer: If he has blood in stool, he has pain An elderly male asks for a laxative, in the anus, brown or black pits in the something to soften the stools- he also stool. Change in bowel habits, if there ask for 'pads' that he is constant change of bowel habits, uncan use to prevent his clothes getting explained weight loss. Abdominal pain stained. What is the best course of action (how severe). You could feel a mass. in this situation? If it is deficiency anaemia: lethargy, tiredness and lack of energy shortness of breath? noticeable heartbeats (heart palpitations), pale skin If we are on doubt, we refer him to the doctor. Memory loss is natural process and does not always mean dementia. regular customer asks you to explain to We should ask to see her husband and her what dementia is as she thinks her have dementia test. Is this because of husband has it'. work stress, because of difficult period How would you respond to this? She he has, we could refer to the GP. doesn't feel that she is coping with him Explain to the lady about dementia to very well. help her, support groups for people who have dementia, or relatives of patient. Alzheimer's Scotland Scenario 1 -Young person J.S. is a 15-year-old male. Smokes approx. 10 cigarettes per day and has been smoking since he was 12. He only smokes after he has left for school and can go long periods during classes where he doesn't smoke at all. He does not smoke in the late evening or at night. He is currently using his pocket money to He is under 18 years old. ( dilemma) where he buys them ? He was caught by his parents. They will ask where do you get the money from? When you smoke , you smell bad. You will have bad breath and Yellow teeth. His CV system is still developing. He might not want to quit. Peer influence. 38 / 54 buy cigarettes but runs out fairly quickly and then has to borrow from friends. Started smoking because all his friends were doing it but has recently been caught by his parents who are insisting he stop. They have told him to come to the pharmacy and sign up for the smoking cessation service and this will be his first quite attempt. Use your money for something better. Your parents will be proud of you. If his parents are smokers, involve them in the program. Products: NRT: gum, patch. Pom are not licensed for under 18. If he doesn't want to tell his parents. Advice: encouragement from parents Refer to support group. She is pregnant. She craves cigarettes when she gets up 5 min (addiction). Degree of dependence on it. J.S is 32 years old and has discovered Barriers: weight gain , stress she is 8 weeks pregnant with her 3rd For pregnant woman, it is better to stop child. Her other two children are aged smoking without using NRT. But if you 2 and 4. J.S. did not stop smoking with can not, you can use NRT. either of her other two children as she For immediate relief: lozenges, gum ( found it too hard but feels determined to goes straight to blood supply). Patches stop this time. can be used but remove them at night. J.S. smokes roughly 20 per day and has Advice : Engage with other support one within 5 minutes of waking up. She health lines (other counselling). has been referred by her midwife for additional support due to her two previous nicotine will cross the the placenta barriunsuccessful attempts to stop. er, will be in breast milk . POMs are not recommended in pregnancy. B.D. is 52 years old and is being admitted for a planned operation in 4 weeks. He smokes around 35 per day, has smoked since he was 12 and states he loves having a cigarette, especially after his meals. However, his surgeon is keen for him to have stopped smoking prior to his admission. B.D. had not considered stopping until his surgeon mentioned it. He particularly enjoys a cigarette after meals and does not have his first one Reason: he will be admittted to hospital.( surgery) Barriers: he enjoys it Nicotine increase the risk of blood clotting during surgery. Products: NRT (no gum because of dentures). Advice: 39 / 54 until after his breakfast. He also wears dentures. A.C. 61 year old man who has a diagnosis of coronary heart disease. He smokes around 15 per day, has his first cigarette upon waking and has never tried to stop before. He has had a recent medication change as his condition is worsening and feels it is time to try and stop after having smoked for 40 years. He lives with his wife who is also a smoker but she does not want to stop at present as she has tried and been unsuccessful a number of times. L.W. is a 27 year old female with a history of depression and anxiety. She is currently prescribed fluoxetine 40mg daily with her dose having recently been increased due to her low mood. She is feeling better and has decided she would like to stop smoking, is keen to succeed this time after a few unsuccessful attempts and is sure she can do it this time. L.W. currently smokes over 20 per day but does not have a cigarette until after her morning coffee. She does not like chewing gum and some patches can irritate her skin. T.D. is a 40 year old man who smokes around 10 cigars per day. He has had multiple quite attempts over 15 years and switched from cigarettes to cigars thinking they would be easier to stop, were better for your health and he actually likes them better. He has tried cold turkey, cutting down, patches and gum on separate occasions. He has only ever purchased products himself and Concerns: diagnosis of coronary heart disease. Barriers: his wife is a smoker. He has been smoking for 40 years. Products: Husband: NRT Wife: POMs only ( unsuccessful trials) Advice: engage both of them for stopping. Concerns: she has anxiety. Barriers: anxiety, fear of failure Products: lozenges Do not recommend veranicline can excacevate mental health issues. . Advice: Nicotine stimulate HCl in parietal cells and causes more reflux. Multiple unsuccessful attempts . Cravings cigarettes in the morning. Products: lozenges, inhaler. Veranicline (POM). 40 / 54 has never attended any support groups. He takes omperazole for an ulcer and smokes five minutes after waking. Whilst supervising the consumption of methadone, the patient tells you that he has witnessed a violent crime but doesn't want to go to the Police. He does not know if he should tell anyone - and asks for your advice? Scenario: A 65-year-old man visits the pharmacy, visibly distressed and describing severe pain accompanied by a rash that has developed on one side of his face, extending to his scalp and down his neck. He reports feeling extremely fatigued and mentions experiencing flu-like symptoms such as fever and muscle aches. He states that the pain is excruciating and is making it difficult for him to sleep or carry out his daily activities. He's unsure what might have caused the rash and is seeking urgent assistance. Gather more information, how real is this? when happened? Yes, violent crime. He should tell the police. There is a phone number about crimes. Varicella zoster virus ( chickenpox) herpes zoster virus ( shingles) Causes: stress, chemotherapy, When people get chickenpox, the virus stays in the body. It can be reactivated later and cause shingles if someone's immune system is weakened. Your symptoms, including a painful rash on your face, scalp, and neck, along with flu-like symptoms, strongly suggest shingles, especially considering your age. Treatment typically involves antiviral medications like aciclovir tablets under PGD to reduce the severity and duration of the outbreak. Pain management is crucial like paracetamol. You can prevent getting shingles from avoiding people in the "weeping" phase ( oozing) . Which is the only phase in that it is contagious. Advice Keep the affected areas clean and dry to prevent secondary infections, avoid scratching the rash, and take precautions to avoid spreading the virus to others. Wear loose clothes. Cool compress. pharmacist will be able to give you a vaccine( Zostavax ) 41 / 54 Counselling: Space the doses evenly throughout the day. Keep taking this medicine until the course is finished, unless you are told to stop A 55-year-old woman visits the pharmacy complaining of a painful rash that has developed on one side of her torso. She describes the rash as consisting of small, fluid-filled blisters and mentions that it's causing her significant discomfort. She reports feeling generally unwell and fatigued. The woman is concerned about the rash and seeks advice on how to manage it. Shingles Aciclovir tablets ( antiviral) Same as before **Complicated Lip Lesion Scenario:** A 40-year-old woman visits the pharmacy with recurrent lesions around her lips. She explains that these lesions tend to appear during periods of increased stress, such as during busy work weeks or family challenges. She finds these outbreaks embarrassing and worries about their impact on her social interactions and self-confidence. Despite trying various over-the-counter treatments, she's struggled to find effective relief. She seeks advice on managing these lesions effectively and preventing future outbreaks. "Cold sores, caused by the herpes simplex virus, can be treated with Aciclovir. To prevent spreading the virus, avoid touching the sores, sharing towels, or kissing. It's important to wash hands frequently to reduce the risk of transmission." A 40-year-old woman visits the pharmacy with a red, swollen area on her leg. Diagnosis: - Suspected cellulitis based on red, swollen area on the leg, possibly stemming from an insect bite. Treatment: - Flucloxacillin Dosage: Adults - 500mg four times a day, , recommended for bacterial skin infec- 42 / 54 tions like cellulitis. Advice: - Monitor the affected area for changes. She explains that the area has become - Seek further medical attention if sympincreasingly painful and tender to the toms worsen or persist. touch over the past few days. She's worried that it may be infected and seeks adCause: vice on how to manage it. The pharma- Likely bacterial infection, possibly seccist suspects cellulitis, a bacterial skin inondary to an insect bite. fection, and provides guidance on treatCounselling : Taken 1 hour before or ment options and when to seek further 2 hours after food, Swallow capsules medical attention. whole) Side effects: nausea, vomiting, diarrhoea, swelling on lips, tongue, face, jaundice, hepatitis, breathing difficulties. The first line of treatment is hydrogen peroxide 1% cream. second line would be fusidic acid 2% cream which is applied to the lesion three to four times a day for 5 days. This medication is a POM so can only be supplied when presented with a prescription. and this is given to a patient that is presenting localised non-bullous impetigo A 30-year-old man visits the pharmacy which is when blisters are not present. with concerns about a rash on his face. It can only be supplied once in a 3 month He describes the rash as consisting of period. If symptoms present again within red sores and crusty patches that have then the patient must be referred to the been present for several days and are GP. spreading. He's worried about the apWash hands before applying the cream Where possible remove scabs by bathing with warm water before applying the cream Impetigo is a very infectious condition. Important to prevent infection spreading by using their own flannels and towels (hot wash after use) 43 / 54 Do not scratch or pick spots. If applicable, suggest applying cream three times daily on school days (before school, after school and evening) and four times daily at other times. Inform school of condition. Advise that child should be excluded from school until the lesions are crusted and healed pearance and discomfort of the rash and or 48 hours after commencing antibiotic seeks advice on how to treat it. treatment. Do not share cream with anyone else. Inform of possible side effects and their management. The Drug Manufacturer Patient Information Leaflet should be given. Patients should be informed who to contact should they experience an adverse drug reaction A concerned parent brings their 6-year-old child to the pharmacy due to complaints of ear pain and itching. The child recently went swimming and has been experiencing discomfort in the ear since then. Upon examination, the pharmacist notices redness and swelling in the ear canal, along with discharge. Otitis externa Otomize is used for the treatment of otitis externa Apply ONE spray THREE times a day for children and adults Supply ONE 5ml bottle Continue using Otomize for further 2 days after symptoms have stopped If no improvement after 7 days see GP Do not use more than the recommended dose 44 / 54 : - Suspected contact dermatitis based on symptoms of red, itchy patches on hands and forearms, exacerbated by exposure to construction materials and chemicals. Treatment: - Recommended treatment options include protective gloves, barrier creams, and topical corticosteroids to alleviate symptoms and reduce inflammation. A 40-year-old construction worker visits the pharmacy with complaints of red, itchy patches on his hands and forearms. He explains that the symptoms worsen during the workweek and suspects they may be related to exposure to construction materials and chemicals. He's concerned about the impact on his job and seeks advice on managing the irritation and alleviating the symptoms. Cause: - Likely triggered by frequent contact with irritants and allergens present in construction materials and chemicals, leading to an inflammatory response in the skin. Hydrocortisone: Reduces inflammation, swelling, redness and itchiness Hydrocortisone is a P product that can be bought from a pharmacy and is available on pharmacy first. Should be applied no more frequently than twice daily Topical application applied to affected areas Wash hands after treatment unless treating skin on hands Use for a maximum of 5 days in children and 7 days in adults Right amount for children depends on their age. If a second PGD is required within 2 weeks for the same reasons, refer to GP or specialist Use 0.5% only for these cases 45 / 54 Diagnosis: Suspected allergic contact dermatitis based on symptoms of red, itchy patches on hands and arms following exposure to a new laundry detergent. **Treatment:** Recommended treatment options include avoiding further exposure to the offending detergent, using mild, fraA 35-year-old woman visits the pharmagrance-free soaps and moisturizers, and cy with complaints of red, itchy patches applying topical corticosteroids to reduce on her hands and arms. She explains inflammation and relieve itching. that the symptoms developed after she started using a new laundry detergent **Cause:** to wash her clothes. She's concerned Likely triggered by contact with irritants that she may be allergic to the detergent or allergens present in the new laundry and seeks advice on how to manage the detergent, leading to an allergic reaction irritation and alleviate the symptoms. and inflammatory response in the skin. **Dermatitis Concern from Detergent Exposure:** The pharmacist provides guidance on selecting hypoallergenic detergents and advises the patient to perform a patch test before using new products to avoid future allergic reactions. **Diagnosis:** Suspected eczema based on symptoms of recurrent red, dry patches on the cheeks and elbows in a child. A concerned mother brings her 4-year-old daughter to the pharmacy with complaints of red, itchy patches on her cheeks and elbows. She explains **Treatment:** Recommended treatment options include using gentle, fragrance-free moisturizers to hydrate the skin, applying mild topical corticosteroids to reduce inflammation during flare-ups, and using non-soap cleansers to avoid further drying of the skin. 46 / 54 **Cause:** Likely triggered by factors such as cold weather, dry air, and genetic predisposition, leading to inflammation and irritation of the skin. that the symptoms have been recurring for several months, especially during the winter season. The mother is worried about her daughter's discomfort and seeks advice on managing the condition. The pharmacist provides guidance on proper skincare routines, including moisturizing the skin regularly, avoiding harsh soaps and detergents, and using hypoallergenic products. Additionally, the pharmacist advises the mother to monitor the child's symptoms and seek medical attention if the condition worsens or does not improve with home care measures. **Diagnosis:** Suspected eczema based on symptoms of persistent red, itchy patches on arms and legs in an adult. **Treatment:** Recommended treatment options include using emollients to moisturize the skin, applying topical corticosteroids (hydrocortisone) to reduce inflammation during flare-ups, and identifying and avoiding potential triggers such as stress, harsh soaps, and certain fabrics. A 28-year-old woman visits the pharmacy with complaints of red, itchy patches on her arms and legs. She explains that the symptoms have been persistent for several weeks, especially during stressful periods. She's concerned about the impact on her daily life and seeks advice **Cause:** on managing the condition. Likely triggered by factors such as stress, environmental irritants, and genetic predisposition, leading to inflammation and irritation of the skin. The pharmacist provides guidance on proper skincare routines, stress management techniques, and lifestyle modifications to help manage eczema effec47 / 54 tively. Additionally, the pharmacist advises the patient to keep a diary of symptoms and triggers to better understand and control the condition. **Diagnosis:** Suspected nappy rash (diaper rash) based on symptoms of red, irritated skin in the diaper area of the infant. **Nappy Rash Concern in a New Parent:** A sleep-deprived new parent visits the pharmacy with concerns about their infant's red, irritated skin in the diaper area. The parent explains that despite frequent diaper changes and gentle cleaning, the rash seems to persist and is causing discomfort for their baby. They seek advice on how to manage the rash and alleviate their baby's discomfort. **Treatment:** Recommended treatment options include keeping the diaper area clean and dry, using barrier creams or ointments to protect the skin from moisture and irritation, and allowing the baby's skin to air dry whenever possible. Additionally, avoiding tight-fitting diapers and using fragrance-free wipes and detergents can help prevent further irritation. **Cause:** Likely triggered by factors such as prolonged exposure to wetness, friction from diapers, and sensitivity to irritants in diapers or wipes, leading to inflammation and irritation of the skin in the diaper area. The pharmacist provides guidance on proper diapering techniques, including frequent diaper changes, gentle cleansing with warm water and mild soap, and applying a thick layer of barrier cream or ointment with each diaper change. Additionally, the pharmacist advises the parent to monitor the rash closely and seek medical attention if it worsens or does not improve with home care measures. 48 / 54 Following endoscopic assessment by a paediatric gastroenterologist a 32 month old child weighing 13.2 kg is diagnosed with an erosive oesophagitis due to gastro-oesophageal reflux (GORD). Since the GORD has been resistant to conservative dietary and lifestyle advice the doctor would like to trial a 4 week course of a proton pump inhibitor to see if it improves presenting symptoms. The doctor prescribes 10 mg omeprazole to be taken in the morning and asks you to recommend a suitable medicine. What would your recommendation be? 10 mg dose is a reasonable dose. Dosage Forms: capsule is not good for children (under the age of 8 years) risk of choking. Powder for suspension. The flavour might be a problem. The child might not like the flavour. Another problem is dose uniformity. Are you shaking the bottle. Omeprazole has sodium and potassium in it. We need to check if the child has renal issues. Is there any excipients that the child is allergic to. Dispensable tablet: dissolve the tablet in water. If you dissolve it in 100 ml of water the child might not drink all the water ( not have the right dose) . Water quality issue of the water coming of the tap. You might dissolve the tablet in an another liquid . Think about the ph of the liquid. If you put it in a liquid that is alkali, it might have premature rupture of enteric coat ( dose problem) if you dissolve the tablet in an acid solution like apple juice, orange juice, that's ok. But remember micro particles might sediment at the bottom of the container. Dispensable tablets : dissolve the table in Mary, a previously a fit and active 66 water. year old patient, is admitted to the local Is the tablet soluble in water. Are the hospital as an emergency patient 2 days excipients soluble in water? You usually ago and was diagnosed as having had take 10 ml of water for injection. You flush an ischaemic stroke. She received im- the tube to show that it is clear. You then mediate thrombolysis but has been left administer your tablet solution or suswith limited speech and significant left pension then flush it back through again sided weakness. Since the stroke Mary with another 10 ml of water to show that has been dysphagic and having failed all of that went down into the stomach.if the daily swallow assessment test per- you have enteric tablet. You destroy the coat. If there are lots of little beads that 49 / 54 formed by speech and language therapists has had a nasogastric tube inserted to allow enteral feeding. Past medical history included hypertension for 7 years with the most recent BP prior to the stroke being 145/92 mm Hg and type 2 diabetes mellitus. Mary was overweight before the stroke (BMI = 29.8 kg/m2). The last recorded total cholesterol before the stroke was 4.4mmol/L. Medication reconciliation upon arrival at A&E was: Perindopril 2mg tablet in the morning Amlodipine 5mg tablet in the morning Aspirin 75 mg tablet in the morning Me are more than 3 ml in diameters, they will block the tube. Not good for controlled release. You tend to look for immediate release. If the drug is lipophilic, it might be absorbed into the plastic polymer. Liquid preparation. You need to consider the viscosity of the solution, if it has got a lot of suspended particles there, they might block the tube. If it is viscous, dilute it down. We often manipulate the PH of the liquid. We add solvents such as ethanol or propylene glycol to make things more soluble. Perindopril. Perindopril 2mg tablet in the morning Amlodipine 5mg tablet in the morning Aspirin 75 mg tablet in the morning Metformin 500mg tablet three times a day Simvastatin 40mg tablet at night Immediate treatment was to withhold metformin and control glucose levels over the next 24 hrs with a sliding scale insulin infusion (target 4 - 11 mmol/L) and to dose aspirin 300mg pro rectally. On the morning of day 2, the doctor indicates that he would like to reinitiate all medication that Mary was on during admission, with the aspirin dose increased to 300mg for the next 2 weeks. Mary continues to be dysphagic and has the nasogastric tube in place. What would your recommendations be? Amoldipine is available as liquid. Perindopril: you can dissolve a tablet in water or you can look for something else that in that class. Consider drug interactions and aspirin are available as dispensable tablet. Metformin is available as liquid Simvistatin is available as liquid If you are on Amoldipine, simvastatin dose should be reduced. Highest dose of simvastatin should be 20 mg.Amoldipine prevent the metabolism of simvastatin. This will increase the risk of muscle damage. The mistake it should be pharmacy first A 43 year old female patient presents rather than minor ailment scheme. at your pharmacy and asks if she could Oral therapy: 150 mg miconazole for speak to you privately in the consulta- compliance. Exposure to anti fungal agent. Are they tolerant to it? Are they 50 / 54 tion room where she discloses that she thinks she may be suffering from vaginal thrush. After careful clinical questioning you are able to establish that her initial thoughts were correct. Having established that she has no other medical issues you decide to prescribe an antifungal medicine as part of the Minor Ailments scheme. What would you consider in deciding on a particular treatment to prescribe? happy to accept a local application in vagina ( miconazole or clotrimazole).it might be not comfortable because her vagina is tender. It might be religious or cultural issue. ( does not want to enter things in vagina) vaginal tablets are not comfortable. It might be not convenient (3 times a day application). Pregnancy it can cause foetal toxicity. If her partner uses condom, it might interact with the latex and destroy its barrier property. Her partner might have fungal infection. You might offer a cream for her partner at the same time. Consider drug interactions. John is a 56 year old patient with COPD who has experienced an acute respiratory bacterial exacerbation. Earlier you dispense a prescription for 8 x Doxycycline 100mg capsules, two to be taken as a single dose on the first day before reducing to one to be taken daily. He returns to your pharmacy distressed saying that as a vegan he is unable to take the medicine prescribed since he read in the patient information leaflet that it contains gelatin, an animal product. He asks if you can urgently sort out an alternative to treat his COPD exacerbation that is compatible with his vegan beliefs. What would you do? COPD: large volume of yellow green sputum. Caused by bacteria. Dispersible glycerolized beads 100 mg. Expensive. Drink more water. . The patient, who adheres to a vegan diet, faces difficulty with doxycycline due to its gelatin capsules. One potential solution is the use of a dispersible formulation, such as dispersible glycerolized beads. Alternatively, other antibiotics like erythromycin or azithromycin,Amoxicillin: if they have penicillin allergy. Erythromycin, a macrolide, that's biotic, that can sometimes be associated with cardiac issues. It can cause QT prolongation.jewish and Muslim communities do not accept gelatine. devoid of animal-derived ingredients, could be considered. Counseling on proper administration techniques and adequate fluid intake to prevent esophageal irritation is crucial. 51 / 54 Individuals of African or Asian heritage often experience lactose intolerance, manifesting as symptoms like bloating, flatulence, diarrhea, or constipation after consuming dairy products. Diagnosis involves a lactose challenge test, A 25 year old patient diagnosed with followed by a two-week restrictive diet mild lactose intolerance asks for advice to confirm causality. Milk products typon what would be the most suitable oral ically contain around 5 grams of lacantihistamine to take for the treatment of tose per 100 ml, regardless of the aniitchy insect bites following a holiday in mal source. Lactase enzyme expression Greece. decreases with age, exacerbating intolWhat would you consider in deciding a erance. Lactose-free medication alterparticular treatment recommendation? natives, like antihistamines (e.g. loratadine, cetirizine ) or corticosteroid creams (e.g., hydrocortisone, clovetazone), may be prescribed. Cream formulations, such as Urax with trotamicin, or talamine lotion, can provide relief from symptoms. St. John's Wort Used for low mood, mild anxiety Sleep disturbances Choose a reputable brand for quality and purity. Be aware of potential interactions with other medications. Valerian Avoid driving after taking valerian due to possible drowsiness. Use valerian for short-term relief under medical supervision. Monitor for possible side effects and report any to a healthcare provider. Avoid using it during pregnancy or 52 / 54 breastfeeding. Use te recommended dose Belladonna ( herb and homeopathic remedy) headache, airway obstruction, and irritable bowel syndrome It should be stored out of reach of children or pets due to its toxic nature. Passion Flower Stress, mild anxiety Black Cohosh Hot flushes,night sweats, mood swings Sage Night sweats Red Clover menopausal symptoms Fever few migraine headache Rhodiola Stress, mild anxiety, fatigue, exhaustion Ginkgo Cognition, memory Oats Nerves restorative, tranquilliser, antidepressant Hops Sleep inducing, anxiety, stress Lavender Sleep inducing, has calming effect Angus Castus Breast tenderness, mood swings, menstrual cramps, bloating, PMS Bach flowers emotional problems and pain cold sores treatment Aciclovir cream 5% Shingles treatment Aciclovir 400 mg tablets (PGD) Pack Size 56 Aciclovir 800 mg tablets (PGD) Bacterial skin infection Flucloxacillin 250 mg capsules (PGD) Flucloxacillin 500 mg capsules (PGD) Flucloxacillin 250 mg/5 ml oral solution (PGD) Imetigo Hydrogen peroxide 1% (Crystacide) Fusidic acid 2% cream (PGD Head lice treatment Dimeticone 4% lotion 53 / 54 vaginal candidiasis Clotrimazole 1% cream Clotrimazole 500 mg pessaries Fluconazole 150 mg capsule Fungal skin infection (not nail) Clotrimazole 1% and hydrocortisone 1% cream Miconazole 2% and hydrocortisone 1% cream Miconazole 2% cream travel sickness Cinnarizine 15 mg tablets Hyoscine hydrobromide 150 micrograms tablets Hyoscine hydrobromide 300 micrograms tablets otitis externa Acetic acid 2% solution (Ear Calm) 54 / 54