RTS - Lecture Notes PDF

lOMoARcPSD|33607052 RTS - lecture notes The Role of a Pharmacist (Kingston University) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052 Skin conditions Eczema Symptoms:  Red and cr...

lOMoARcPSD|33607052 RTS - lecture notes The Role of a Pharmacist (Kingston University) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052 Skin conditions Eczema Symptoms:  Red and cracked  Dry and flaky  Undergoing lichenification  Change in skin pigmentation  in folds of elbows, joints, knees, neck and wrists Treatments:  First line = greasy emollient  second line = topical corticosteroids (hydrocortisone – mild potency (10+) or clobetasone – moderate potency (12+)) Max 7-day use Non-pharmacological:  Do not scratch/itch  Avoid aggrevating clothing  Moisturise 2-3 times per day  Replace soap with emollients  Wear protective clothing, e.g. when out in the sun  Avoid triggers  Keep cool  Not too many hot baths  Apply emollients after baths Refer:  If current management strategy is not controlling flare ups  Adverse reaction to emollients  Signs of infection  Psychological implications (insomnia, depression, anxiety)  Severe fissures (cracks) in skin/broken skin (skin cannot repair itself)  Differential diagnosis suspected  Under 10 years  Pregnant  Application to face, anogenital region Contact dermatitis Irritant (contact with substance) Redness, burning, stinging, soreness of affected area only (contact areas) Onset usually within 48 hours of contact Allergic (contact with allergen) Redness, itch, scaling of affected areas Delay of hours to days within contact of allergen Usually areas in contact with allergen develop rash but other areas show symptoms if true allergy Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052 TREATMENT Avoid irritant or allergen 1st Line: Emollient (same as atopic eczema) 2nd Line: Topical Corticosteroid 3RD Line: Oral Corticosteroids (severe cases) [referral] Psoriasis Symptoms:          Raised plaques Skin, joints and nails affected Inflamed areas of skin Red and scaly in appearance Scale are white/silvery Itchy Painful Symmetrical can appear on trunk and genital areas Treatments:     1st Line: Emollient (same as atopic eczema) 2nd Line: Topical Corticosteroids 3RD Line: Topical Vitamin D preparations (e.g. calcipotriol, calcitriol) – POM Use OD –BD Coal Tar Preparations (shampoo):  Helps to remove loose scales  Messy to apply  May stain clothing and bedding Dithranol:  Ideal for chronic scaly psoriasis in selected areas  Apply sparingly  Stains clothing and may irritate skin (can cause dermatitis) Vitamin A analogues (e.g tazarotene):  Not to be used on face or skin folds Salicylic Acid preparations:  Reduces excessive scaling Scabies Symptoms:         Infestation by the scabies mite Intense itching, worse at night-can lead to loss of sleep Burrows can sometimes be seen as small thread-like grey lines Lines are raised, wavy and about 5-10mm long Common sites infested- web space of fingers and toes, wrists, armpits, buttocks and genital area Rash- patchy and diffuse or dense and erythematous Rash commonly found around midriff, underarms, buttocks, inside the thighs and around ankles Transmitted by skin-to-skin contact Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052 Treatment:           Permethrin cream [5%]- left on skin for only 8-12 hours before being washed off. For 2 months + Malathion- lotion left on for 24 hours, 6 months + Eurax cream if it is really itchy If hands are washed cream/lotion should be reapplied 2 applications- 7 days apart for both permethrin and malathion Aqueous lotions are used in preference to alcoholic versions- sting and irritate excoriated skin Treatment is applied to entire body, from neck downwards but not the neck, face and scalp in adults However, in children under 2 and elderly, the advice is now to include the scalp, neck and face [avoiding eyes and mouth] and ears Itching may persist for up to 2-3 weeks until the allergenic mite material is cleared from the skin- Patients should therefore be reassured and offered symptomatic relief if necessary All those who have been in close contact with infected person should be treated Referral:     Weeping yellow discharge or yellow crusts- infected skin Suspected infestation in babies and children Treatment failure- if itching hasn’t stopped after 3 weeks or if new areas of itching are continuing to appear 7-10 days after treatment Unclear diagnosis Ringworm Symptoms:  Red  Macerated from dampness  Odorous  Raised red edges with a lighter centre Treatment Options: Topical Imidazole or Oral Terbinafine (FIRST CHOICE)    Examples: clotrimazole (ok in pregnancy and breastfeeding), miconazole (ok in pregnancy and breastfeeding), econazole, terbinafine, itraconazole Treat topically for 14 days In some case, an additional 14 days will be recommended to prevent re-infection Non-drug treatments: Follow lifestyle measures - So drying yourself properly, don’t pick on it, don’t share stuff coz it is contagious Acne vulgaris OTC OPTIONS 1st line = Benzoyl peroxide     3 actions – antibacterial, reduces inflammation and helps to unplug blocked pores 2.5%, 4%, 5% and 10% strength. Wash the skin 20-30 minutes before use. May bleach hair, bed linen, or clothes. Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052      If your skin does become irritated, then stop using it until the irritation goes. Then try again with a lower strength or reduce the time it is left on your skin before washing off. Use a water-based preparation (rather than an alcohol-based one). Apply once daily at first and wash off after several hours. Gradually increase the length of time left on the skin. Aim to put on twice daily when you get used to it. 2nd line = Nicotinamide products e.g. Freederm. Applied twice a day, acts as an anti-inflammatory, reducing swelling, redness and tenderness of the spots. Or in case of severe acne, refer to doctors and they can prescribe topical or oral antibiotics Salicylic acid  Keratolytic drug that has some anti-comedone activity  Less effective than the topical retinoids Scarlet fever Symptoms:  Flu-like symptoms  high temperature  Sore throat or swollen neck glands  Strawberry tongue Drug treatment:  Serious infection so might require antibiotics from GP – ask GP first before going in because they might prefer to do a phone consultation with you instead because of how contagious it is Non-drug treatment:  drinking cool fluids  eating soft foods if you have a sore throat  taking painkillers like paracetamol to bring down a temperature (do not give aspirin to children under 16)  using calamine lotion or antihistamine tablets to stop itching Refer:  have scarlet fever symptoms  do not get better in a week (after seeing a GP), especially if your child has recently had chickenpox  are ill again weeks after scarlet fever has cleared up – this can be a sign of a complication, such as rheumatic fever  are feeling unwell and have been in contact with someone who has scarlet fever Impetigo Symptoms:    Cornflakes stuck to your skin Starts with red sores or blisters get bigger Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052    spread to other parts of your body be itchy sometimes be painful Drug treatment:    Crystacide cream (1% hydrogen peroxide) is the only OTC treatment Apply two to three times daily for a maximum of three weeks. Refer to Gp for other antibiotic treatment Practical advice:  Care with personal hygiene is necessary to avoid transmission  wash hands after contact with the lesion, keep fingernails short  do not share flannels and towels  do not scratch the skin  children should not go to school/nursery whilst being treated  Do not go to the gym  The lesions should be soaked in warm, soapy water and washed away prior to treatment. Referral: had treatment for impetigo but the symptoms change or get worse had impetigo before and it keeps coming back Fifth disease/slapped cheek syndrome Symptoms:  bright red rash on both cheeks  a high temperature of 38C or more  a runny nose and sore throat  a headache Drug treatment:  self-limiting  paracetamol/ibuprofen for a high temperature, headaches or joint pain  antihistamines for itchy skins Non-drug treatment:  rest  drink plenty of fluids to avoid dehydration – babies should continue their normal feeds  use moisturiser on itchy skin Refer:       very pale skin shortness of breath extreme tiredness fainting pregnant weakened immune system Chicken pox Symptoms: Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052      Small red clear fluid filled spots Aches and pain Itchy Fever When the spots crust over it is no longer contagious Pharmacological:  Paracetamol- for fever  Avoid Ibuprofen in chicken pox as it causes increase skin reactions  Chlorphenamine- Piriton for itching: 1+ for the syrup and 6+ for tablets  calamine lotion for itching Non-pharmacological:  Plenty of fluids  Rest  Stay off from school until the spots crust over  Baggy clothes- to reduce abrasion  Mittens to stop itching  Keep nails short to avoid itching Refer:       If it does not improve in 1 week Unsure of the diagnosis Painful blisters Dehydrated If the patient is pregnant, is exposed to chicken pox and they have not had it before If the patient is immunocompromised or has HIV and has not had chicken pox before Measles Symptoms:  Small pink/red spots on the on the trunk area (chest/abdomen)  Fever  Kolpik spot- white spots in the inside of your mouth inner cheeks and mouth  Sensitivity to light  Red eyes  Runny nose Pharmacological/non-pharmacological:  Ibuprofen/paracetamol for the fever  Close the curtains to help with sensitivity to light  Rest  Increase consumption of fluids Refer:     Fever for more than 3 days Cough worsens Difficulty breathing Earache Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052 Rubella Red/pink skin rash- small spots, swollen glands around head & neck, fever, cold like symptoms- cough & runny nose, aching/painful joint. REFER ALL CASES! Meningitis small red pin prick spots that turn purple- non blanching rash, cold hands and feet, seizures, stiff neck, sensitive to light, confused- EMERGENCY REFFERAL!!! Cellulitis Broken skin, redness, pain, heat, swelling, fever, weeping rash- REFER! Bites/stings Treatment - Paracetamol/ibuprofen for pain - Topical local anaesthetic - Antihistamine (topical / oral) - Hydrocortisone 1% cream/ointment Non-drug treatment:  Wash area with soap & water  Cold compress (reduce swelling)  Do not scratch  Wear light coloured clothing  Apply insect repellent  Cover exposed skin  Wear shoes when outdoors  Avoid products with strong perfumes  Do not disturb insect nests  Avoid camping near water, e.g. ponds/swamps  Keep food/drink covered  Keep doors/windows closed (thin netting)  Mosquito net (impregnated with insecticide)  Spray room with insecticide  Burn pyrethroid coils / heat insecticide impregnated tablets Repellents  DEET (di-ethyltoluamide) – Jungle Formula®  Eucalyptus oil / citronella oil – Mosi Guard®  Formulations: liquids, creams, lotions, pump sprays  On skin (30-50%); On clothes (100%) Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052 Childhood conditions Colic Symptoms:     Child screams regularly (3 hrs a day more than 3 days a week for more than 3 weeks). Cannot be comforted. Roughly at the same time (late afternoon). Baby draws knees up to chin, tight fist, red face (Clinically because of bowel pains) in some cases can hear stomach rumbling & they produce a lot of wind. May also have rigid abdomen. Mild pain- restless Strong pain – rhythmically crying, loud scream then quiet. Then loud then quiet and that continues. Treatment:   Infacol (simethicone) = 1 month and over Gripe water = 1 month and over Non-drug treatment:      Wrap/swaddle baby to give them comfort as they’ve just come out of womb Massage gut in circular motion Burp baby often Drink milk slowly etc. try hypoallergenic formula milk Refer:    Overanxious parents Medication failure Baby isn’t putting on weight Nappy rash Symptoms: Mild:  Small part of Babies skin become irritated covered in pink/red spots of blotches.  Only feel pain while passing faeces or urine. Severe:  Bright red spots  Dry/cracked broken skin  Swellings/ulcers on skin  Covers large part of nappy area. May spread to abdomen & down the legs  Baby cries more often Weeping + yellow crusting = bacterial infection Small dark red lesions near perimeter of nappy area = secondary fungal infection due to candidia. Treatment:   1ST line = Barrier cream (Zinc cream/zinc oxide ointment or something petroleum based, sudocrem) 2nd line = clotrimazole cream (for severe nappy rash). Apply 2/3 times a day for 7-10 days after the rash has healed. Non-drug treatment: Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052     Leave nappy off for as long as possible No soaps, water is enough Change nappy frequently Avoid plastic tight fitting pants (they keep moisture) Refer:     If the condition has been present for more than 2 weeks Broken skin Severe rash (weeping, yellow crusting etc) Other parts of the body are affected. Teething Symptoms:       Restless & irritable, disturbed sleep Sore red gums Flush cheeks No food wanted Lots of dribbling Want to chew everything Treatment:  Paracetamol/ibuprofen – for pain Paracetamol susp SF 120mg/5ml(100ml)    2.5ml qds (3-6 months)  5ml qds (6-24 months)  7.5ml qds (2-4yrs) Local anaesthetics or mild antiseptics – bonjela teething gel Never give one containing choline salicylate as that causes Reyes Syndrome. (brain damage) Non-drug Treatment:      Lightly massage the gum with clean fingers Give the baby teething rings (can refrigerate but not freeze as this burns baby’s gums) Can chew on chilled fruit of veg Avoid teething biscuits, contains sugar, can cause decay Usually a nappy rash is seen when the baby is teething Refer: - High fever, or rashes that are not confined to the face (with temperature greater than 38 oc or above). Child is systemically ill Difficulty in swallowing or breathing Persistent pain reported Ulceration on muscosal surfaces Any lump, thickening or red or white patches Signs of bleeding or infection of the mouth or area surrounding the mouth or the throat Child with digestive tract disorders, diarrhoea or rash Child with oral thrush Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052 Headlice Symptoms: itchy scalp – because of allergy to their saliva Detection methods: Wet hair method:  Wash hair as normal  Put lots of conditioner  Comb out tangles  Using detection comb into roots of hair touching scalp draw down to tips of hair  Comb all parts of scalp  Check for lice after each stroke (wipe/rinse if seen)  Rinse out conditioner  Repeat procedure Dry hair method:  Straighten untangle hair with comb  Switch to detection comb  Comb each section 3/4x  Look for lice each time  Trap lice with thumb, avoids risk of lice being repelled by static electricity as comb withdrawn from hair  Continue into full head covered Treatment:     dimeticone = hedrin. Leave for 8 hours/overnight and repeat after 7 days. Permethrin = lyclear. Wash hair with mild shampoo then apply this and leave for 10 mins then rinse. Repeat after 7 days. malathion = derbac = do not give to children with eczema or asthma. Apply to wet hair and leave on for 12 hours. Coconut, anise and ylang ylang spray – apply and leave for 15 mins and repeat after 7 days. Non-drug treatment:     Wet combing – similar to detection method but need to repeat at 4 times every 4 days. dry combing – similar to above send children to school family treated only if they have lice as well – not prophylaxis Threadworms Symptoms:    Nighttime perianal Itching (due to an allergic reaction caused by the mucus released when laying eggs) Loss of sleep = tiredness and irritability Diarrhoea may be present in severe cases Treatment:     Mebendazole (ovex) = 2 years and over, taken as a single dose = higher compliance Piperazine = has senna, 3 months+ Both are CI in epileptic and pregnant and renally impaired treatment (give hygiene measures) Give treatment to the whole family and repeat after 14 days Non-drug treatment:  Aim to clear eggs from body and home and prevent eggs being swallowed Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052        Wash sleep wear, bed linen, towels toys Vacuum and damp dust home Wear close fitting underpants/knickers at night Every morning shower to wash off eggs Wash hands and scrub under nails first thing in morning + after using loo each time and eating Avoid biting nails Avoid sharing towels Refer:     Recent travel abroad (so other types of worms can be considered) Medication failure Infection other than threadworm suspected Broken skin or signs of weeping Cradle cap Harmless. Unknown to the child (no pain in child) Symptoms:     Yellow/greenish patches Scales & flakes on the scalp Not contagious Usually starts on scalp and can spread behind the ears Treatment: Eventually clears up however there are things that can be done to help: 1. Dentinox shampoo 2. Gently wash baby’s hair & scalp to prevent build-up of sebum 3. Loosen crust by massaging baby oil/ petroleum jelly on scalp at night. This helps loosen the scales. Then by morning gently remove the loose particles then wash hair. 4. Shampoo that contain ground nut oil or peanut oil are best avoided in children under five years. 5. If the above methods do not work, use a mild shampoo. Refer:    swelling spreads to other parts infection Seborrhoeic dermatitis/dandruff TREATMENT  Regular use [at least twice weekly] of an ordinary mild detergent shampoo will effectively control dandruff by removing scales  A wide range of medicated treatments are available, containing:  Pyrithione zinc and Selenium sulphide – use twice weekly and leave on for around 3 mins  Ketoconazole [2% shampoo] - can apply the lather behind the ear, chest etc and wash it off after 3-4 mins  Coal tar - (apply once or twice weekly). not much evidence for this  Salicylic acid – loosens and sloughs off dead cells from scalp  head and shoulders – ok to use daily Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052 Women's health Vaginal thrush Symptoms: - Cream coloured, thick curdy (cottage cheese) discharge - redness, itching - pain/discomfort Treatment:  Topical azoles o Clotrimazole, econazole, miconazole o Single dose, multiple dose, combination packs (pessary with a cream) o Pessaries, intra-vaginal creams o Quick initial relief - vehicle o May exacerbate burning o Cream for external application to vulval area may help  Oral fluconazole o 150mg single dose o Potential for interactions - warfarin  “Natural” remedies o Application of live yogurt intra-vaginally on tampon or to vulval area o Adding vinegar or bicarbonate of soda to bath to change vaginal environment o Tea tree oil impregnated tampons o May have soothing effect o No evidence for efficacy Non-drug treatments:   Correct use of vaginal products – incorrect use can lead to treatment failure (for example, if pessary is not inserted high enough then it has no use) Prevention if recurring problem o Avoid tight fitting clothing – tights, jeans o Cotton underwear, rather than nylon o Avoid perfumed products around vaginal area – soaps, bath foams, shower gels – irritation & strip vaginal protective layer o Avoid vaginal douches -strip vaginal protective layer o Do not use “feminine itching” products o Wipe from front to back after defecation – prevents transfer of Candida from bowel to vagina Refer:                 Aged 60 For > 60 year olds, sometimes better off with a lubricant because it can be due to menopause First occurrence Pregnancy or suspected pregnancy >2 attacks in previous 6 months (recurrent) Further investigation needed bc it can be a sign of diabetes Previous history of STD Exposure to partner with STD Abnormal/irregular vaginal bleeding Blood stained discharge Vulval/vaginal sores, blisters or ulcers Lower abdominal pain or dysuria Known hypersensitivity to vaginal antifungals Redness, irritation, swelling due to treatment No improvement within 7 days of treatment Diabetics Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052  Immuno-compromised patients Bacterial vaginosis Symptoms: Whitish-grey discharge, thin (fishy odour). REFER Trichomoniasis Symptoms: Green-yellow frothy discharge. Strong odour. REFER Menorrhoea Heavy period Treatment: Tranexamic acid 500mg tablets ◦ take 2 tablets 3 times a day for up to 4 days. Max 4g. ◦ aged 18 years and over, ◦ with regular 21-35 day cycles, ◦ with no more than 3 days individual variability in cycle duration. [so regular periods] Refer: - Women under 18 and those over 45 years [menopause] - Patients who have been taking tranexamic acid for three menstrual cycles without a reduction in bleeding - Breastfeeding women - Patients who are obese or diabetic [at risk of CVD] - Patients with polycystic ovary syndrome or a history of endometrial cancer in a first degree relative. - Women taking unopposed oestrogen* or tamoxifen - Patients taking medicines that interact with tranexamic acid ◦ Tranexamic acid will counteract the thrombolytic effects of fibrinolytic agents. Primary dysmenorrhoea Painful periods Treatment: 1st line –therapy NSAIDs o Take after food  Ibuprofen (max daily OTC dose 1200mg (200 - 400mg qds/tds))  Diclofenac 12.5mg (25mg initially, then 12.5–25mg q4-6h max 75mg/d)  Naproxen 250mg (50mg initially, then 25mg 6-8 hours later if required, max daily dose 750mg, for max 3 days) Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052     Paracetamol Alone or in combination with NSAID or codeine, useful when NSAID C/I Aspirin Hyoscine (co-combined usually with paracetamol or something but in a very small amount to have an effect) Caffeine (Some evidence of additive effect with ibuprofen) Non-drug treatment    Warmth – (hot water bottle and warm bath are soothing) TENS machine (emits electrical pulses that interfere with pain signals – receipt/perception) Some evidence but effectiveness is not clear for acupuncture, fish-oils, herbal remedies, exercise & supplements Practical points  Exercise during menstruation is beneficial - it raises endorphin levels, reducing pain and promoting a feeling of well-being.  There is some evidence that a low-fat, high-carbohydrate diet reduces breast pain and tenderness. For women taking analgesics for dysmenorrhoea:  Take the first dose as soon as your pain begins, or as soon as the bleeding starts, whichever comes first.  Take the tablets regularly, for 2–3 days each period, rather than ‘now and then’ when pain builds up.  Take a strong enough dose (ask if this is the maximum allowed dose you can take)  Side-effects are uncommon if you take an anti-inflammatory for just a few days at a time, during each period. Refer:         Presence of abnormal vaginal discharge Abnormal bleeding Symptoms suggest secondary dysmenorrhoea Severe intermenstrual pain (mittelschmerz) and bleeding Failure of medication (if it doesn’t work after 2 cycles of treatment) Pain with a late period (possibility of an ectopic pregnancy) Presence of fever Taking oral contraceptives Cystisis/UTI Symptoms:  Abrupt onset- attacks begin with an itching or pricking sensation in the urethra  Frequent desire to urinate-although only a few drops may be passed  Dysuria-painful or difficult urination  Urine may be dark and cloudy and have an unpleasant ‘fishy’ odour  may have raised temperature or fever  may have pain in the suprapubic area or lower back Treatment: o Sodium/potassium citrate – can raise BP, use in caution with acei or anything else that increase potassium (for the potassium one as it can hyperkalaemia) o Avoid in patients taking lithium as the effectiveness of lithium is reduced o Paracetamol/ibuprofen for pain PRACTICAL MEASURES  - - To avoid the possibility of attacks: Void the bladder completely-wait for 20 secs once the bladder feels empty then strain to squeeze out the final drops Avoid delay in emptying the bladder- pass urine at least every 3 hours After excreting-wipe from front to back to minimise transfer of faecal organisms to the vagina and urethra Cystitis is often associated with sex. If it seems to be a trigger- wash the perianal skin beforehand and empty the bladder before and after. Use a lubricant to prevent trauma and soreness. Or just don’t have sex till you’re better as it can make the condition worse Avoid tight underwear made from synthetic materials and tight trousers Thoroughly rinse out detergent after washing clothes Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052 - Avoid perfumed bath additives and vaginal deodorants as they may be irritant Reduce coffee and alcohol intake as these act as bladder irritants in some people Evidence that drinking cranberry juice regularly is prophylactic. Refer:          All males Pregnant women Children Haematuria [blood in urine]- doesn’t necessarily have serious implications Vaginal discharge- indicates vaginal infection of fungal or bacterial origin Loin pain and tenderness- may indicate infection in kidneys or ureters Fever Symptoms persisting for more than 2 days Recurrent attacks EHC Hormonal contraceptives = COC & POC COC = missed pill is if they missed 2 or more pills in week 1 or the pill free interval. One pill missed= take as soon as they remember/next day and its fine. Take precautions for next 7 days. POC = missed pill is missed or late pill of > 12 hours. Take precautions for next 2 days. Missed pill + UPSI = NEED EHC EHC = Levonogestrel OR ulipristal (Ella one) Levnonogestrel:  within 72 hours  16+ but can be given to under 16s by pgd  if BMI>26 or >70kg then double dose  double dose if taking enzyme inducing drugs (carbamazepine, griseofulvin, phenytoin, barbiturates including primidone, rifabutin, rifampicin, ritonavir, herbal medicines containing St.John’s wort)  not suitable in severe liver dysfunction, risk of ectopic pregnancy or have inflammation of the fallopian tubes  COC.= 7 days precaution after  POC = 2 days precaution after Ulipristal:  within 120 hours  to anyone of childbearing age  not allowed to supply if taking enzyme inducing drugs – if sex was more than 72 hours and they are taking enzyme inducers then IUD is the best option  the effectiveness reduces if taken progesterone (from the normal pill) 7 days before or take it 5 days after taking the ella one  Not suitable for use in those who have asthma controlled by oral glucocorticoids  COC = 12 days precaution. after  POC = 7 days precaution after Downloaded by H. 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([email protected]) lOMoARcPSD|33607052 instructions on use: - if vomit in 3 hours = take another tablet - With or without food - Next period might be early or late Chlamydia Symptoms women:      lower abdominal pain dysuria purulent vaginal discharge Inter menstrual bleeding inflammation of the neck of the womb Symptoms men:     dysuria painful swelling of the testicles urethral discharge proctitis Screening      Using the clamelle chlamydia service test kits bought from the pharmacy and posted off to lab need to wait 2 weeks after the upsi before testing if tested positive = partner can get a slip and can be treated without the test to check that you are clear from it, wait another 6 weeks after treatment Treatment:      Azithromycin For 16+ 1 g (so 2 tablets) for asymptomatics POM = doxycycline 100mg BD x 7 days Non-drug treatment:   provide advice on emergency or regular contraception partners should avoid sex until 7 days after the last person has been treated Foot Verruca/warts Warts:    Raised lesions with a roughened surface Flesh coloured Common on the palm or back of hands, area around finger nails, face and genital areas. Verruca’s:   Found on the sole of the foot, usually in weight- bearing areas. Owing to constant pressure grow inwards instead of outwards Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052   Painful because of pressure exerted on nerve endings Have black headed spots Treatment: 1)      2) Salicylic acid combined with lactic acid – BAZUKA (lactic acid allows salicylic acid to penetrate) Soak skin and file skin surface prior to application Localise application to affected area (ring with petroleum jelly) Treatment may take up to 12 weeks Occlusion with plaster/collodion Avoid naked flames! Cryotherapy – dimethyl ether/propane mixture (wartner). It freezes verruca. One time thing but may be repeated after 2 weeks Non-drug treatment:    Easily spread through direct contact and shed skin Do not pick/scratch: viral shedding » multiple lesion Usually resolve spontaneously after 2 years Refer:        Diabetics Circulatory issues Compromised immune system due to disease (HIV) or medication (ciclosporin) Bleeding Failed OTC treatment Changed appearance of lesion (size and colour) Genital or facial warts Corns/calluses Formations of thick, horny skin (hyperkeratinisation) on the feet due to friction or inappropriate foot-ware Differential diagnosis: Rule out bunions! Refer if bunion Treatments:  Epidermabration  Hydrocolloid plasters  Keratolytic agents  salicylic - given to remove the dead skin. Apply Vaseline around the corn/callus Non-drug treatment:    Correctly fitting footwear Padded inserts/shields around affected area Rich moisturising cream Refer: - Elderly Diabetics Peripheral vascular disease patients If it is infected Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052 Athletes foot Symptoms:  Itchy  Dry and scaly skin or moist and weeping skin between the toes  May occasionally involve sole and instep of foot  Very resistant to heat/washing-high risk of re-infection Treatments (antifungals):  Imidazoles – apply 2 or 3 times daily and continue for 7-10 after cleared. Can be used for children + adults  Terbinafine – brand: Lamisil, cream and spray, 12+  Tolnaftate – apply twice daily and continue for up to 6 weeks after. Has the least  Benzoic acid  hydrocortisone – if inflammation present and only for 7 days Non-drug treatments:  Keep skin clean and dry, esp. between the toes and before applying the antifungal preparations  Keep your own towel  Change socks frequently  Avoid non-breathable shoes (trainers, tight, shoes)  Don’t forget to treat pets  Avoid walking barefoot in public areas because it is easily spread (verruca socks/flipflops)  Shoes should be dusted with fungicidal dusting powder (as a prophylactic measure) Refer:  Severe, affecting other parts of the foot  Signs of bacterial infection (pus, yellow crusting etc.)  Unresponsive to appropriate treatment  Diabetic patients  Involvement of the toenails Fungal nail infection/onychomycosis Can only treated in the pharmacy if it is affecting up to two nails and if it is not too deep (at least has some healthy area). Symptoms:     The nail has thickened and turned yellow/white at the tip Changes to the nail appear to have spread along the length of the nail towards the nail base Debris has accumulated under the nail, causing scaling and distortion of the nail The nail has become brittle and/or some of the nail broken away Treatment: Amorolfine 5% nail lacquer Counselling points      Apply regularly (weekly) for up to 9-12 months for toenails and 6 months for fingernails File down as far as is comfortable using one of the disposable nail files supplied Clean and degrease using alcoholic cleaning pads Discard the disposable nail files and not to be used on healthy nails Apply it using one of the reusable applicators supplied Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052                Dip the applicator into the nail lacquer without wiping off any of the lacquer on the neck of the bottle. Touch the nail with the end of the applicator and the lacquer will flow over the nail surface. Allow the lacquer to dry. After use, clean the applicator with the cleaning pad used earlier for nail cleaning. Keep the bottle tightly closed. Before repeat applications of the lacquer, residual lacquer should be removed (using the pads) and the affected nails should be filed down again as required. Treatment should be continued without interruption until the nail is regenerated and the affected areas are finally cured. Patients should not expect to see much difference in the first three months – this is a long-term treatment. Failure to complete the treatment or follow the instructions correctly can result in a recurrence of symptoms. Remind patients to avoid allowing the lacquer to come into contact with eyes, ears and mucous membranes so use gloves when applying it (Cautions) Don’t use artificial nails or nail polish Occasionally patients have a slight, transient, burning sensation in the areas of the nails after the application of the lacquer. It is safe to continue to use the product Nail disorders (e.g. nail discoloration, broken nails, brittle nails) may occur. These reactions can also be linked to the onychomycosis itself. Debris from infected nails can be a source of reinfection for skin. Keep skin cool and dry as far as possible and use a topical fungicidal treatment such as terbinafine at the first sign of infection Co-existent athlete’s foot should be treated with an appropriate antimycotic cream Damaged nails are more likely to become infected than healthy, intact nails CONTRA-INDICATIONS  Hypersensitivity to the ingredients  Pregnancy and breast-feeding  Under 18 Refer     Peripheral circulatory disorders diabetes mellitus immunosuppression People with nail dystrophy and destroyed nail plates Eye Dry eye Medicine-induced dry eyes       Diuretics Isotretinoin Hormone replacement therapy Cardiac arrhythmic drugs Beta blockers Drugs that have an anticholinergic effect e.g. tricyclic antidepressant Treatment    Hypromellose 0.3%, 0.5%, 1% (always start with the lower strength and the work your way up) Carbomer E.g. GelTears Lubricants E.g. Lacri-Lube Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052 Red eye/subconjunctival haematoma      Broken blood vessels in sclera, eye appears red and bloodshot No pain or visual disturbance Sudden onset Rupture of small blood vessels, maybe as a result of temporary increase in pressure such as sneezing, coughing No treatment, but refer if a result of trauma, or if patient is diabetic Conjunctivitis Viral conjunctivitis - treatment    Watery discharge It is self-limiting so goes away on its own Very contagious – hygiene measures are important o Do not share towels o Wash hands after touching eye Allergic conjunctivitis - treatment    Avoidance of allergen Sodium cromoglicate (Mast cell stabiliser) Prophylactic agent – given continuously during hay fever season Bacterial conjunctivitis   Mucopurulent discharge gritty feeling Treatment:  chloramphenicol eye drops/ointment aged two years and over. Not recommended in pregnancy/breastfeeding ◦ Apply one drop into the infected eye every two hours for the first 48 hours and four hourly thereafter for 5 days ◦ Sleep need not be interrupted in order to administer eye drops. ◦ If using chloramphenicol ointment, apply ointment 3-4 times daily. ◦ When both drops and ointment are being used, drops should be used during the day and ointment once at night. Refer:   if symptoms worsen no improvement after 48 hours of use Counselling points  Remove discharge from the eye using water  Do not share towels, facecloths etc.  Do not share the bottles if more than one person is affected  Have 2 bottles if both eyes are affected  Wash and dry hands before and after application  Store the drops in the fridge  Discard remaining after 5 days of use  Do not miss school/work Refer (Urgent referral – A&E): Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052  Contact lens use (refer to doctor, an optometrist or contact lens practitioner - soft contact lenses should not be reused until after 24h of treatment completion)  Patient is already using other eye drops or eye ointment  Suspected foreign body in the eye or Eye injury  Associated pain or swelling around the eye or face or severe pain within the eye  Photophobia  Vision is affected (reduced or blurred or seeing halos around light)  Pupil looks unusual, i.e. torn, irregular, dilated or non-reactive to light  Cornea looks cloudy  Eye movement is restricted or painful  Eye inflammation associated with a rash on the scalp or face  Conjunctivitis in the recent past or history of Glaucoma or Dry eye syndrome (keratoconjunctivitis sicca)  Eye surgery or laser treatment in the past six months  Personal or family history of bone marrow problems  Patient is pregnant or breast-feeding  Patient taking medicine that interacts with chloramphenicol (e.g. other drugs that an cause bone marrow depression)  No improvement is seen after 48 hours of treatment  If viral infection is suspected (symptoms can be associated with an upper respiratory infection and/ or symptom get worse despite using chloramphenicol)  Acute glaucoma  Symptoms get worse despite use of chloramphenicol Eyelid disorders – stye  An eyelash follicle or gland on the eyelid margin becomes infected  Acute pus producing inflammation Treatment:  Antibacterial agent = dibromopropamidine ointment – not sure it actually helps but if they want it!  Usually resolve spontaneously, with or without rupture, after three to four days  Respond well to non-drug treatment – warm compress may open blocked pores, increase blood supply and increase concentration of repair mediators in area.  Inadvisable to squeeze – spread infection.  If treatment failed – refer Eyelid disorders – blepharitis       Inflammation of eyelids Scaly margins Local burning Irritation Skin flakes around eye lashes Vision NOT impaired Blepharitis - Treatment  No cure  Apply a warm (but not hot) compress to your closed eyelids for 5 to 10 minutes Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052  A cloth or flannel warmed  Gently rub your closed eyelid with your finger or a cotton wool bud  Use a cloth or cotton bud with warm water and a small amount of cleaning solution (bowl of water with drop of baby shampoo or teaspoon on bicarbonate of soda), and gently wipe the edge of your eyelids to clean them.  Try to avoid touching your eye  These steps should be carried out twice a day at first, then once a day when symptoms have improved.  If photophobic and oedemic – refer Ear Excess/impacted cerumen Pharmacists can only treat external ear infections. Symptoms:  Temporary deafness  Discomfort  Sensation that ear is blocked  Recent attempt to clean ears OTC treatments: 1) Oil based – almond oil, peanut oil, olive oil. It softens the wax. Cheapest and simplest treatment. Allergy risk with Arachis, peanut and camphor oil (Earex®) 2) Water based - docusate sodium (e.g. Waxsol®) 3) Peroxide based - Otex®, Exterol® How to apply the treatments:  Wash hands  Warm bottle in hands for a few minutes  Tilt head to one side with ear pointing to ceiling.  Instil 5 drops. Remain in position for 5 minutes then treat opposite ear. Repeat 2/3 times a day.  Use cotton wool plug if necessary  Wash hands  Use for 3-4 days or as per manufacturers’ direction  Consider syringing by doctor if not cleared up Practical advice:  Do not insert foreign objects to clean  No ear candling Refer:  Pain (middle ear issue)  Mucinous discharge (middle ear infection)  Trauma-related deafness/redness/swelling  Failure of OTC treatment  Dizziness/tinnitus (inner ear problem)  Foreign body Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052 Otitis externa/swimmer’s ear Symptoms:  Itching and irritation  Depending on the severity, can become intense.  Scratching may result in trauma and pain.  Discharge if present is not mucopurulent (contain both mucus and pus).  Should not present with any systemic symptoms.  On observation the ear canal or external ear appears red, swollen or eczematous OTC treatment:  Oral antihistamines – it is itchy  Dry skin on pinna: emollient (Diprobase, Epaderm®, Aveeno®)  Dry skin in external ear canal: olive oil  To remove water after swimming: Swim-Ear® (glycerin)  Acetic acid (Ear-calm Spray) Practical advice:  Avoid cotton wool buds and scratching  Swimmers should use ear plugs, swimming cap and protective drops  Avoid getting water, soap or shampoo into your ears when you have a shower or a bath  Hairdryer low setting, not corner of towel Refer:  Children  Symptoms persist>7 days after treatment  initiation  Significant/Mucopurulent discharge  Pain in mastoid area  Slow growing growths on pinna (cancer)  Generalised inflammation of pinna  Systemic symptoms-fever Eustachian tube trauma/glue ear Symptoms:  Loss of hearing  Pain OTC treatment:  Adults: Unit dose pump-action decongestant sprays very easy to use, contain xylometazoline (e.g. Sudafed®, Otrivine®)  Children for glue ear: Otovent® Practical points:  Sucking sweets/chewing gum  Swallowing  Valsalva’s manoeuvre Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052 TO INSTIL EAR DROPS IN A CHILD, YOU SHOULD PULL THE PINNA OF THE EAR DOWN AND BACK! Gastro Dyspepsia Symptoms:      Acid reflux/regurgitation Chest pain- no radiation Bloating Nausea and vomiting Drugs: NSAIDs, CCB, nitrates, theophylline Treatments:    Antacids- work by neutralising the acid. Examples include: CaCo 3/Al(OH)3 (can cause constipation), Mg(OH)2 (can cause diarrhoea) Alginates- work by forming a raft above the stomach, preventing acid reflux. Examples include sodium alginate (Gaviscon) PPI- inhibit the proton pump, preventing acid production. Examples include omeprazole 10mg OD (18+)-interacts with clopidogrel Non-drug treatments:        If obese or overweight reduce your weight (exercise/diet/orlistat if eligible) Have light meals Avoid triggers like spicy foods Eat at least 3-4 hours before you sleep Raise head with pillows- gravity prevents acid reflux Reduce alcohol intake/smoking cessation Review drugs Refer:      Children Dysphagia Failure of treatment Unintentional weight loss Blood in vomit- looks like coffee granules Constipation Symptoms:    Inability to defecate completely, can lead to abdominal discomfort or pain May be from changes in diet May be from drugs such as: opioids, antimuscarinics, antipsychotics, antidepressants, CCB or iron. Treatments:  Bulk forming laxatives- increase faecal bulk, increase peristalsis, increases the retention of water. Fybogelispaghula husk, takes long time to work. Is suitable for pregnant women and children Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052     Osmotic laxatives- increases water in the large bowel. Lactulose (takes 48 hours to work)- is suitable for use in pregnant women and children, not suitable for those with IBS as it can cause increases bloating Stimulant laxatives- stimulates the colonic nerves- senna, works immediately. Not suitable for use in the 1 st and third trimester Stool softener- works by increasing the penetration of intestinal fluids into the faeces. dioctyl (Docusate sodium), Dulcolax (bisacodyl) Glycerol suppositories- work in 15-30 minutes, contain stool softener and stimulant laxative Non-drug treatments:       Increase fibre Increase fluid intake Exercise Avoid triggers Have sorbitol containing food which soften faeces, like prunes or pear juice. Check drugs Refer:     Failure of treatment Cancer symptoms- weight loss, blood in stools Mucus in stools Worsens Diarrhoea Symptoms:    Abdominal pain/cramps Frequent passing of watery stools May be from antibiotics- kill gut flora, Mg salts, iron, diuretics Pharmacological treatments:    Probiotics- replenish the gut flora should be taken for at least four weeks and assessed for benefit Oral rehydration salts- to replenish the electrolytes and salts lost. Dioralyte OR dioralyte relief for diabetics with is plant based. Loperamide- 2mg (Imodium)- 2 capsules after every loose stool. Maximum 2 capsules four times a day (16mg). 12 + Non-pharmacological:      Avoid triggers, avoid spicy/sugary/fatty food Plenty of fluids/fruit juices to replace that which is lost Increase carbs Personal hygiene Check drugs Refer:     If elderly refer if more than 3 days If younger than 2 refer if more than 2 days If younger than 1 refer if more than 1 day Showing signs of dehydration- dry eye/mouth, sunken eyes, sunken fontanelle (soft part at top of head of babies) Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052 IBS Symptoms:    Changes in bowel habits (diarrhoea/constipation) Mucus passage Abdominal comfort/pain associated with eating Pharmacological treatments:  Probiotics- replace gut flora  Antispasmodics- mebeverine HCL- 135mg TDS (20 mins before food) OR alverine citrate 60mg TDS (20 mins before food)- helps with abdominal pain  Peppermint oil 0.2ml OR 1 or 2 capsules TDS- 15-30 mins before food  Loperamide 2mg for constipation (max 2 QDS)  Ispaghula (Fybogel), senna, docusate sodium, glycerol suppositories (avoid lactulose- causes bloating) 2nd line treatment- need to be referred- Amitriptyline 5-10mg OD (max 30mg), if that does not work then SSRIs, TCAs may be given to treat back pain. Non-pharmacological:  Light meals- do not eat too quickly  Regular meals- do not miss meals  Avoid triggers  Reduce caffeine intake, max 3 cups of tea and coffee a day Refer:  Unintentional weight loss  Family history of ovarian cancer  Rectal bleeding Haemorrhoids Symptoms:  From straining, from constipation  May have rectal bleeding, but blood is on the surface of the stool not mixed with it  May cause discomfort and pain Pharmacological treatments:  Soothing agents- zinc oxide and balsam of Peru (ANUSOL – also comes as anusol HC)  Astringent agents- witch hazel and bismuth- regenerates protein mesh  Local anaesthetics  Topical corticosteroids Non-pharmacological:  Keep the are clean (damp tissue)  Warm baths  Cold compress (ice packs) Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052  Do not pick it Refer:  If they are over the age of 40 and have rectal bleeding for more than three weeks AND have changes in their bowel habits- sign of bowel cancer  If they are over the age of 60 and have rectal bleeding for over 3 weeks OR have changes in their bowel habit Others- Mouth conditions Mouth ulcers Symptoms:   On to five crops of spots on the lips, gums and inside of the cheeks Can be quite painful Pharmacological treatments:  Chlorhexidine gluconate mouthwash- 10ml rinse in mouth for 1 minute. Should avoid brushing teeth straight after as the ingredients in the toothpaste can inactivate the mouthwash, wait at least 30 mins before brushing your teeth  Hydrocortisone +triamcinolone- one pellet QDS, helps to reduce inflammation  Carbenoxolone gel- applied before symptoms appear, it is when you get tingling sensation. Reduces pain and healing time  Benzydamine- spray (12+) or mouthwash (16+) Non-pharmacological:  Have soft foods  Avoid hot foods and have cold drinks  Use soft bristle brush to brush teeth and gums  General good dental hygiene like brushing your teeth twice a day ya nasteh lolz Refer:     Longer than 3 weeks long Treatment failure Rash/ADR Diarrhoea Oral thrush Symptoms:  Fungal infection- white plaques in mouth Pharmacological treatment:  Daktarin 2 % gel (miconazole)- keep in mouth for as long as possible Non-pharmacological:  Rinse out mouth after use of steroids (ICS) Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052  Refer:      Regular good dental hygiene Dentures More than seven days Dysphagia ADR HIV Cold sores Symptoms:  Fluid filled blisters, pop, and crust over  Painful  Is contagious Pharmacological treatment:  Acyclovir 5% cream (zovirax)- five times a day for 5-10 days  Local anaesthetics Non-pharmacological:  Wash hands before use of cream  Do not touch or pick  Do not share anything  Careful applying makeup Refer:      Young children/babies Does not heal in 14 days Multiple sores- painless HIV frequent attacks Fever Kissing disease/Glandular fever Normally gets better without treatment Refer:  a very high temperature or you feel hot and shivery  a severe sore throat  swelling either side of your neck – swollen glands  extreme tiredness or exhaustion  tonsillitis that is not getting better Headaches Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052       Do SOCRATES! Medication overuse headaches- cold turkey for a month Cluster headache- many attacks in a day, may last for 15-30 mins per attack- Refer Chronic daily headache- get headaches on 15 days of the month- Refer Tension- tight band across the head, treat with paracetamol and ibuprofen Migraines- Recurrent, throbbing unilateral pain, may have N & V, with or without aura last 72 hours. Triggers may be lack of water, sleep, diet, weather, and stress. Pharmacological migraine:  Sumatriptan 50mg- 18-65 if migraine is less than 24 hours (only for acute treatment)  If they are over 50 years old, you would need a diagnosis from the doctor of migraines before you can supply  One taken on onset of the migraine- see if you have improvement in 30 minutes, if so but still not complete relief may take another dose in 2 hours (max daily dose of 100mg). If there is no relief or improvement in 30 minutes cannot take another dose.  CI: hypersensitivity to sulphonamides, TIA, hepatic or renal impairment, epilepsy or history of seizures, taking ergotamine/ other triptans or MAOi, atypical migraines.  Can cause drowsiness Refer:                  Pregnant or breastfeeding Longer than 24 hours Outside age range Pain at the back of head- haemorrhage One side weakness/double vision- stroke Clumsiness or uncoordinated movements Rash Reduced consciousness Seizure like movements Deterioration of migraine Treatment failure Do not fully recover in between attacks More than four attack in a month Had fewer than 5 attacks in the past Someone who had their first attack within the last 12 months Taking oral contraceptives- increased risk of stroke Patients with three or more cardiovascular risk factors Sore throat Most sore throats are self limiting and will go within 7-10 days. Associated symptoms:  Cough  fever  cold  aches and pain Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052 Refer:  dysphagia  hoarseness  white spots/pus on the tonsils  Failed medication  lasting longer than 1 week  recurrent bouts of infection Treatment:  Paracetamol/ibuprofen for pain  Benzydamine spray (6+) and mouthwash (12+)  local anaesthetics (benzocaine & lidocaine)  lozenges (iodied lozenges to be avoided in pregnancy because they can affect the thyroid gland of the fetus) Benign prostatic hyperplasia (BPH) Symptoms:     Difficulty when starting to urinate Increased urinary duration and frequency Waking up several times in the night to urinate Symptoms over last three months Pharmacological treatment:  Tamsulosin 400mcg OD- suitable for men aged 45-75 years old  Swallow capsule whole after the same meal each day  Works by relaxing the smooth muscle, increases urinary flow rate and decreases obstructive symptoms  SE: headache, palpitations, rhinitis, constipation, diarrhoea, nausea, vomiting rash, pruiritis, urticaria, abnormal ejaculation, asthenia, dizziness, blurred vision, dry mouth, or oedema  Interactions: increased risk of hypotension with antihypertensives, avoid antimuscarinics like antihistamines which work in opposing way.  Supply: Give initial two-week supply with those with symptoms, if there is improvement in urinary symptoms then a further 4 weeks OTC supply may be made. After 6 weeks of supply patients should see the GP to confirm their symptoms and that they can continue taking tamsulosin. Should see doctor every 12 months for review Non-pharmacological:  Liquids should be avoided 1-2 hours before going to bed  Reduce consumption of alcohol/caffeine (acts as a diuretic)  Increase fruit and fibre- avoids constipation which puts pressure on the bladder  Avoid cold/allergy/decongestants/antihistamines Refer:     CI of tamsulosin Symptoms do not get better or get worse after initial 2-week supply Symptoms ongoing for less than 3 months Potential undiagnosed diabetes (excessive thirst and tiredness) Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052        Patients has problems with their liver, kidneys, or heart Fainting, dizziness, weakness when standing (postural hypotension) Cataract surgery planned or recent cloudy/blurred vision (may be cataracts) On antihypertensives that have alpha blocking properties or on verapamil Pain during urinating/blood in urine Fever- may be UTI Leaking urine- urinary incontinence Obesity    Overweight- 25kg/m2-29.9kg/m2 Obesity 30kg/m2 Weight to height ratio is the best discriminator of CVD risks Pharmacological treatment:  Orlistat 60mg TDS- can be supplied to those who are 18+ and have a BMI of over 28kg/m 2 (contact the GP before supplying if the patient has kidney disease)  Prescribed orlistat 120mg TDS (needs referral to GP to get this), BMI of over 28kg/m 2 +RF or over 30kg/m2  Works by inhibiting GI lipase which prevents the absorption of fat  Must be taken with meal if meal is missed dose should be omitted  Must have a hypocaloric diet- 30% is fat and of this 7% can be saturated fat. So, if daily intake is 2000 calories then you should be consuming 67g of fat.  Should have 5-10% weight loss in three months, do not continue if this is not achieved. Used for max 12 months  No more than 0.5-1kg lost a week  Can cause loss of fat-soluble vitamins (A, K, E &D) s these may be taken 2 hours after the dose of orlistat  Interactions: reduces the effective of oral contraceptives, increases anticoagulant effect or warfarin (or other anticoagulants) by reducing vit K, reduces levels ciclosporin, acarbose (for DM), reduces amiodarone, levothyroxine- increased risk of hypothyroidism, risk of convulsions with antiepileptics.  CI: Chronic malabsorption syndrome, cholestasis, pregnant or breastfeeding, children (˂18) Non-pharmacological:  Exercise at least 150 minutes a week- even if weight is not lost it has health benefits  Increase green vegetables (have 3-5 portions of fruit and veg in a day)  Increase consumption of nuts, seeds, and legumes (4-5 portions a day)  Reduce saturated fats and increase monounsaturated and unsaturated fats.  Whole grain/starchy food  Have two portions of oily fish a week  Low calorie diets- have 600kcal less than what you use  Reduce alcohol consumption  Smoking cessation Motion sickness Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052 Symptoms:  Nausea  discomfort in upper abdomen  feeling of being unwell Treatment:  Hyoscine (tablets or patches). S/E = drowsiness, blurred vision, dry mouth  Antihistamines (promethazine, Cyclizine, cinnarizine) – take 1-2 hrs before journey Non-drug treatments:  Ginger  Acupressure bands  Minimise head and body movement  Lie horizontally  Fix vision on a stable object  Get fresh air  Distractions  Avoid large meals before travelling  Relax Hayfever Symptoms:  Rhinorrhoea [runny nose]  Sneezing  Nasal congestion – blocked nose  Itchy nose/throat  Red, watery eyes  Less common – loss of smell, face pain, headache Pharmacological:  Antihistamines: first line- chlorpheniramine, diphenhydramine, promethazine-sedative (oral) loratadine (2+), cetirizine (6+), acrivastine (12+)- less sedative (oral and topical)  Mast cell stabilisers: Sodium cromoglycate- nasal spray and eye drops. Nedocromil- prophylaxis- has to be administered prior to allergen exposure  Topical anti-inflammatory agents: corticosteroid nasal sprays- beclomethasone, fluticasone it is first line for severe symptoms (2-3 weeks to work- start before season)  Decongestants: Nasal spray, drops or tablets (ephedrine/pseudoephedrine/phenylephrine) Sudafed, otrivine - Short term use only Non-pharmacological:  Avoid allergens  Check Pollen count: >50 is high  Stay indoors Downloaded by H. E. ([email protected]) lOMoARcPSD|33607052  Keep windows and doors shut  Avoid cutting grass, large grassy areas, camping  Shower and wash your hair after being outdoors  Wear wrap-around sunglasses  Keep car windows closed, consider a pollen filter  Vacuum regularly and dust with a damp cloth  Put Vaseline around your nostrils to trap pollen Refer:  Wheezing, breathlessness, tightness in chest - worsening of asthma, seasonal asthma.  If discharge from eyes is purulent [sticky] and not watery- purulent suggests bacterial conjunctivitis  Associated ear pain  Painful sinuses  Severe symptoms unresponsive to therapy – may need short course of oral steroid Downloaded by H. E. ([email protected])