Concise On Managing Symptoms In A Community Pharmacy Author And Book Designer:
Ahmed Almokashfi Almansi
- Faculty Of Pharmacy, University Of Khartoum - Regional Projects Subcommittee of IPSF EMRO - Pharmacy Education Subcommittee Member Email: ahmedabdlla97@gmail.com Phone And Whatsapp Number: +249 967682893
Supervised by:
The Regional Projects Officer (RPO), of the Eastern Mediterranean Regional Office (EMRO), of the International Pharmaceutical Students Federation (IPSF).
Preface:
The main idea of this book is to be both concise and informative at the same time. It aims to improve the abilities of a community pharmacist to respond to symptoms regarding different systems in the body as well as improving his/ her counseling skills, but at the same time being easy to read and not time consuming, so as to attract as many pharmacists as possible to improve their clinical abilities. The increasing deregulation of medications from Prescription Only Medicine (POM) list to Over The Counter (OTC) has put additional responsibilities on the pharmacists, which is being able to deal with common conditions and choose the best OTC medication available for each. The book provides the pharmacist with knowledge about the signs and symptoms of common conditions, differentiating between similar conditions and the ability to recognize the more serious conditions that require referral to a doctor. The book also supplies the pharmacist with the appropriate medications for each case, their doses for different age groups and their contraindications.
References:
1- Symptoms In The Pharmacy: A Guide To The Management Of Common Illness: - Fifth Edition -By: Alison Blenkinsopp, Paul Paxton, and John Blenkinsopp. 2- Community Pharmacy: Symptoms, Diagnosis And Treatment: -Third Edition -By: Paul Rutter. 3- British National Formulary (BNF). 4- Websites: Mayoclinic.com and Drugs.com.
Contents General Approaches 1
Bacterial Skin Conditions:
Cough Cold And Flu Sore Throat
Acne Corns And Calluses Scabies Napkin Rash
Section One: Respiratory Problems
2 3 5
Section Two: Gastrointestinal Problems Heartburn Dyspepsia (Indigestion) Nausea and Vomiting Constipation Diarrhoea Irritable Bowel Syndrome Haemorrhoids (Piles) Mouth Ulcers Oral Thrush Threadworms (Pinworms)
Section Three: Skin Conditions Topical Dosage Forms Eczema/Dermatitis Urticaria Fungal Skin Infections
-Athlete’s foot (Tinea Pedis) -Ringworms (Tinea Corporis) -Tinea Cruris -Tinea faciei -Pityriasis versicolor -Dandruff
Fungal Nail Infection Psoriasis Viral Skin Conditions
-Warts And Verrucae -Chickenpox -Cold Sores -Measles -Roseola Infantum -Rubella (German Measles)
6 6 7 7 9 10 10 11 12 12
13 13 14 14 14 15 15 15 16
16 16 17 18 19 19 19 19
-Scarlet Fever -Impetigo
20 20
21 21 22 22
Section Four: Central Nervous System Headache 24 Insomnia 26
Section Five: Eye And Ear Problems Conjunctivitis Dry Eye Ear Wax Inflammations Of The Ear -Otitis Externa -Otitis Media
Section Six: Muscloskeletal Problems Muscle Pain Back Pain Bruising Painful Joints (Arthritis) First Aid Treatment For Strains And Sprains
Section Seven: Women’s Health Cystitis Dysmenorrhea (Period Pain) Vaginal Thrush Emergency Hormonal Contraception
27 28 28 29 29
31 31 31 32 32
33 33 34 34
General Approaches General Steps For Responding To Symptoms:
1
1- Information-gathering: by developing rapport and by listening and questioning to obtain information about symptoms, e.g. to identify problems that require referral; what treatments (if any) have helped before; what medications are being taken regularly; what the patient’s ideas, concerns and expectations are about their problem and possible treatment. 2- Decision-making: is referral for a medical opinion required or not? 3- Treatment: the selection of possible, appropriate and effective treatments (where needed); offering options to the patient and advising on use of treatment. *Medications mentioned in the ‘management’ part of each condition, are OTC medications (given without a prescription) in most countries, please check the OTC list of your country to be sure. 4- Outcome: telling the patient what action to take if the symptoms do not improve.
Referral To A Doctor:
the following indicate a higher risk of a serious condition and should make the pharmacist consider referring the patient to the doctor: 1- Long duration of symptoms. 2- Recurring or worsening problems. 3- Severe pain. 4- Failed medication (one or more appropriate medicines used already, without improvement). 5- Suspected adverse drug reactions (to prescription or OTC medicine). 6- Danger symptoms.
Privacy In The Pharmacy:
The pharmacist should always bear the question of privacy in mind and, where possible, seek to create an atmosphere of confidentiality if sensitive problems are to be discussed. Using professional judgement and personal experience, the pharmacist can look for signs of hesitancy or embarrassment on the patient’s part and can suggest moving to a more quiet part of the pharmacy to continue the conversation.
Patient Point Of View:
Patients are not blank sheets or empty vessels. They are experts in their own and their children’s health. The pharmacist should take into account the patient point of view, he might have experienced this condition before, might have tried different medications already, might prefer certain treatment approaches, so the pharmacist should enable the patient to participate by actively eliciting their views and preferences.
Section One
Respiratory Problems
Cough: Common Causes Of Cough:
1- Viral infection: eg. Flu, cold, and croup. 2- Bacterial infection eg. Tuberculosis, pneumonia. 3- Gastroesophageal Reflux Disease: Acid passes into oesophagus and enters the throat and irritate the airways. 4- Congestive Heart Failure. 5- Chronic Bronchitis. 6- Asthma. 6- Medications: most commonly ACEI, NSAIDs, and B-Blockers. -The Pharmacist should ask to know if any of the above mentioned are causing the cough.
Asthma:
Classical asthma symptoms include Cough (that is worse at night) with wheezing, shortness of breath and chest tightness, and usually the disease is present in the family tree.
Acute Bronchitis:
2
cough with colored mucus or blood, fever, chills, and difficulty breathing. Like acute bronchitis, can also last for several weeks.
Croup:
Viral infection that usually occurs in infants. Cough is associated with difficulty and noise while breathing.
Tuberculosis:
Bacterial infection, classical symptoms include cough with haemoptysis (bloody cough) with fever and night sweats. - The type of cough being dry or wet (productive), depends on the cause. Dry cough is mostly associated with viral infections, allergies, and acid reflux. While productive cough is caused by infections (viral or bacterial), asthma, congestive heart failure, and chronic bronchitis. *Note: Some asthma patients may experience dry rather than productive cough. - Viral infections are mostly treated using OTC medications to relieve symptoms, while bacterial infections are referred to the doctor to prescribe a suitable antibiotic. - The color of sputum produced from the productive cough can help in determining the cause.
Inflammation of the bronchi of the lung which can be caused by viral or bacterial infection, causing cough with mucus (which Sputum color indications: can be clear or colored), wheezing, Colored sputum: Green,yellow or rust shortness of breath, chest discomfort, colored indicates bacterial infection, very slight fever and fatique, it can last several slightly yellow (mucopurulant) indicates weeks. viral. infection, pink or red colored indicates TB Pneumonia: or pneumonia. Pneumonia is an infection that inflames *Infections are usually associated with the air sacs in one or both lungs caused by other symptoms such as fever. viral, bacterial or fungal infection, causing
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Respiratory Problems
Non-Colored sputum (Mucoid): Can result from asthma, heart failure, or chronic bronchitis.
combination of multiple ingredients. - It’s better to use natural herbal remedies to manage children below 6 years cough.
Management:
When to refer?
For Dry cough:
Cough Suppressants (Antitussives): They act on the CNS and suppress cough. 1- Dextromethrophane (DM): Most widely used antitussive, but has abuse potential if taken in high doses, because it acts on opioid receptors like morphine. Should not be given for children below 6 years, and it is contraindicated for asthmatics and best avoided in 3rd trimester of pregnancy. 2- First Generation Antihistamines: (For age above 2 years) Diphenhydramine and Chlorpheniramine work as antitussives. Pharmacist should warn not to use 1st generation oral antihistamines before driving (because of sedation) and should know it’s contraindicated in benign prostatic hyperplasia (BPH) and closed angle glaucoma.
For Productive cough:
1- Expectorants: Work by loosening mucus so it can be easily coughed. Guaifenesin: Most widely used expectorant. Ammonium chloride is a common expectorant as well. Expectorants are safe in pregnancy and breastfeeding. 2- Mucolytics: Work by breaking down mucus. Ambroxol Hydrochloride and Bromhexine Hydrochloride. Expectorants and Mucolytics should not be used for children below 2 years unless by medical advice. -The dosage of these cough medications depends on the product which is mostly a
1- Green, yellow, rusty, pink or red sputum. 2- Chest pain (sign of heart failure). 3- Asthma, TB or croup symptoms. 4- Failed cough medication. 5- Suspected adverse drug reaction. 6- Cough lasting more than 2 weeks.
Cold And Flu: Both conditions are caused by viral infection, and they are usually mixed up with each other, due to similar symptoms.
In-Common Symptoms:
Rhinorrhea (runny nose) , sneezing , cough, congestion , sore throat.
Differing Symptoms:
Flu: Muscle aches, high temperature, fatigue,loss of appetite. Cold: Headache (due to sinusitis, page 24), usually complicated by earache (otitis media, page 30). Other differences: - Low grade fever can accompany cold symptoms. - The cough regarding flu is usually dry, while in common cold it’s productive. - In flu, the symptoms develop rapidly while cold symptoms develop gradually. - Flu patient, unlike in common cold, would usually send someone to get the medication that he needs from the pharmacy, due to fatique and more severe symptoms. - Flu and cold can be both complicated by acute bronchitis or pneumonia.
Allergic Rhinitis:
- This is caused by an inflammatory
response to an allergen in certain seasons, the allergen can be grass pollens, tree pollens, dust, fungal mould spores etc... Symptoms are similar to that of common cold and management is almost the same, However in allergic rhinitis the patient usually suffers also from eye symptoms, more frequent sneezing and nasal itching. The symptoms last as long as the person is affected by the allergen, while cold continues for about 4-7 days.
Management:
1- Antihistamines: -First Generation (Sedative): Chlorpheniramine: Effective for rhinorrhea, sneezing and cough but ineffective in treating congestion unless a topical antihistamine such as azalastine is used. - Child 1–23 months: 1 mg twice daily. - Child 2–5 years: 1 mg every 4–6 hours; maximum 6 mg per day. - Child 6–11 years: 2 mg every 4–6 hours; maximum 12 mg per day. - 12 years & above: 4 mg every 4–6 hours; maximum 24 mg per day. -Second Generation (Non-sedative): Effective for rhinorrhea, sneezing but ineffective for cough and congestion. Cetirizine: - Child 2–5 years: 2.5 mg twice daily. - Child 6–11 years: 5 mg twice daily. - 12 years and above: 10 mg once daily. Loratidine: - Child 2–11 years (body-weight up to 31 kg): 5 mg once daily. - Child 2–11 years (body-weight 31 kg and above): 10 mg once daily. - 12 years & above: 10 mg once daily. 2-Sympathomimetics: These agents are used for congestion (known as decongestants), they are not recommended for children below 6 years. - Oral Sympathomimetics: Oral forms should not be taken near bed
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Respiratory Problems
time because it causes excitation, also contraindicated in hypertension, heart diseases, diabetes, and not to be used with MAOI and Antidepressants. Pseudoephedrine: Above 12 years: 60 mg orally every 6 hours as needed. 6-12 years: 30 mg orally every 6 hours. Phenylepherine is also a known oral decongestant. - Topical Sympathomimetics: -All topical decongestants should not be used for longer than 5 days, because rebound nasal congestion can occur. Xylometazoline and Oxymetazoline: 1 or 2 drops into each nostril once or twice daily as needed. 3- Analgesic and Antipyretic agents: Paracetamol: 15mg/kg for children every 8 hours, 1g for adults every 8 hours. Ibuprofen can be used too. 5 mg/kg for children every 8 hours, 400mg every 8 hours for adults. Both used to relieve the headache and earache (in Cold) or muscle aches, and fever (in Flu). - If earache doesn’t settle with analgesics, then refer to doctor to prescribe a suitable antibiotic. 4- Cough medications: Mentioned earlier in Cough. 5- Levocabastine eye drops: Used for relief of eye symptoms which is experienced more in allergic rhinitis. Can be used in children over 12 years of age and adults. 6- Sodium Cromoglycate: This can be used for prevention of allergic rhinitis, available as nasal spray. The dose for adults and children is one spray into each nostril two to four times daily. Safely used for all patient groups. Combinations of multiple ingredients for Flu or Cold symptoms can be found, for example a combination including
Paracetamol, Chlorpheniramine, and Pseudoephedrine.
Sore Throat: Viral infections account for 70% to 90% of sore throat cases, remaining are mostly bacterial, commonly streptococcus pyrogens. Differentiation between viral and bacterial sore throat cases is extremely difficult from just clinical symptoms. A patient who presents with pharyngeal or tonsilar exudates (white spots, pharmacist can inspect the mouth), swollen anterior cervical glands, high grade fever (39-40C) and absence of cough is more likely to be bacterial rather than viral.
Hoarseness:
Hoarseness is caused when there is inflammation of the vocal cords in the larynx (laryngitis). Laryngitis is typically caused by a self-limiting viral infection. It is usually associated with a sore throat and a hoarse, diminished voice. Antibiotics are of no value and symptomatic treatment (see ‘Management’ below) and advices like resting the voice, should be given. The infection usually settles within a few days and referral is not necessary. *Hoarseness can be caused by some medications such as inhaled corticosteroids.
Dysphagia (Difficulty in swallowing):
Usually associated with severe sore throat (such as in glandular fever) and does not require referral. Dysphagia requires referral only if it is not associated with
sore throat.
5
Respiratory Problems
Glandular fever:
Viral throat infection, occurs most commonly between the age of 14-21 years. A severe sore throat may follow 1 or 2 weeks of a general malaise, throat may become very inflamed with cream exudates, glands in the neck (lymph nodes) may be enlarged. Management is symptomatic (see below).
Management:
Oral Analgesics: Paracetamol, Ibuprofen, and Aspirin, taken as needed. -Antibiotics in case of bacterial infection were shown to only reduce the infection duration by one day, it’s not recommended.
Section Two
Gastrointestinal Problems
Heartburn
after 1 hour if the pain didn’t resolve. (Max 2 tablets per day).
Caused when there is acid reflux into the oesophagus, burning pain is felt in the upper stomach and tends to move upward, maybe even till the throat. Can be aggravated by bending or laying down, overweight or pregnancy and it is more likely to occur after a large meal. Some medications can cause heartburn, including drugs with anticholinergic effects such Hyoscine, TCAs, CCBs, Nitrates, Theophylline, Aminophylline and Caffeine.
Proton Pump Inhibitors (PPIs): Licensed for this indication for patients over 18 years. Omeprazole: Taken 20mg after a meal as initial dose then reduced to 10mg once symptoms improve. All PPIs Should not be crushed or chewed! and Omeprazole should not be taken during pregnancy. Safer PPIs can be used during pregnancy and have less drug-drug interactions than Omeprazole, such as Pantoprazole.
Referral is required if pain is radiating to the shoulder and arm or worsens on effort. (signs of angina).
If any of these medications fail, then referral is required.
Management:
1- Antacids: Preferably in combination with alginates (alginates work by increasing mucus adherence to the oesophagus), they are usually available in the form of liquid or chewable tablets. They are taken whenever the pain is experienced. Sodium Bicarbonate: Fast acting antacid, avoided in hypertension, heart diseases, and renal failure due to sodium content. Can cause belching and metabolic alkalosis. Aluminum Hydroxide and Magnesium Hydroxide: Are usually used in combination because Aluminum causes constipation while Magnesium causes diarrhoea, thus neutralizing their adverse effect. 2- H-2 antagonists: Licensed for patients over 16 years. Ranitidine 75mg taken one tablet straight away after occurrence of pain and 1 tablet
6
Dyspepsia (Indigestion) Upper abdominal discomfort which can be caused by food or medications such as NSAIDs. Also can be the symptom of an underlying disease such as Gastric or Duodenal ulcer, pain of gastric ulcer is aggravated by food, while duodenal ulcer pain most likely occurs when the stomach is empty, that is 2-3 hours after a meal, and especially at night.
Management:
1- Antacids. 2- H-2 Antagonists. 3- Proton Pump Inhibitors (PPIs).
When To Refer?
1- Pain is very severe. 2- Medication failed. 3- Blood in vomit or stools.
4- Pain worsens on effort or radiates to arms and shoulders.
Nausea and Vomiting Common Causes:
1- Infection, Gastroenteritis (caused by Rotavirus) being the most common, with diarrhoea associated. 2- Migraine. 3- Pregnancy. 4- Chemotherapy. 5- Motion Sickness. 6- Medications such as opiates, iron, NSAIDs, SSRIs. And other causes such as middle ear diseases or alcohol intake.
Management:
1- Domperidone: - Below 12 years: 250 micrograms/kg up to 3 times a day; maximum 750 micrograms/ kg per day. - 12 years & above: 10 mg up to 3 times a day; maximum 30 mg per day. It’s safety in pregnancy has not been established but there are no reports of it being teratogenic. 2- Prochlorperazine: Patients 12 years & above: 5-10 mg twice or three times daily. Not recommended for children below 12 years. Use in pregnancy is questioned, but can be used if necessary. 3- Hyoscine: For prevention of motion sickness. - Child 4–9 years: 75–150 micrograms, dose to be taken up to 30 minutes before the start of journey, then 75–150 micrograms every 6 hours if required; maximum 450 micrograms per day. - Above 10 years: 150–300 micrograms, dose to be taken up to 30 minutes before the start of journey, then 150–300 micrograms every 6 hours if required; maximum
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Gastrointestinal Problems
900 micrograms per day. As it is an anticholinergic drug, should be avoided in BPH and glaucoma. Also not be taken with other drugs with anticholinergic effects, such as TCAs. 4- Cinnirarizine: An antihistamine used for motion sickness. - Child 5–11 years: 15 mg 3 times a day. - 12 years & above: 30 mg 3 times a day. 5- Ginger: Some years ago it was found that ginger powder (Zingiber officinale) could effectively reduce motion sickness, as well as being safe (few side effects). 6- Oral Rehydration solution (ORS): If needed (Details in Diarrhoea topic).
When to refer?
1- Blood in vomit. 2- Moderate to severe abdominal pain. 3- Failed medication.
Constipation Normal bowel movement range from one movements per day to 3 per week, less than that,it is considered to be constipation.
Common Causes:
1- Eating and lifestyle habits. 2- Pregnancy. 3- Irritable Bowel Syndrome. 4- Depression. 5- Hypothyroidism. 6- Medications, including Opiates, Aluminium salts, Hyoscine, Antidepressants, Chlorpheniramine.
Management:
Patients (especially children) can be advised to increase exercise, fibre intake
(fruits, vegetables and cereals) and adequate fluid intake. Chronic use of laxatives should be avoided, because it can result in loss of muscular tone of the intestines due to dependence. 1- Stimulant Laxatives: This is the type of laxatives that causes dependence the most, so should not be used for long term at all (not longer than 1 week) and should be avoided in pregnancy, and not recommended for children, because it can lead to dehydration. Its effect appear 6-12 hours when taken orally. Bisacodyl: - Child 4–17 years: 5–20 mg once daily, adjusted according to response, dose to be taken at night. - Adult: 5–10 mg once daily. Increased if necessary up to 20 mg once daily, dose to be taken at night. Senna: Should not be continued more than a week, because it causes brown pigmentation of stool. - Child 6–17 years: 7.5–30 mg once daily, adjusted according to response. - Adult: 7.5–15 mg daily (max. per dose 30 mg daily), dose usually taken at bedtime; initial dose should be low then gradually increased, higher doses may be prescribed under medical supervision. Glycerol Suppository: Usually given when bowel movement is desired quickly, should work within 15-30 mins. - 1g suppository for infants. - 2g suppository for children (below 12 years). - 4g suppository for 12 years & above. *All taken whenever a bowel movement is required. Castor oil also available in pharmacies as
8
Gastrointestinal Problems
stimulant laxative. Usual dose for patients above 12 years is 15-30 ml once daily and 5-10 ml for patients between 2-12 years. 2- Bulk Laxatives: Considered laxative of choice because it closely copy the normal physiology of bowel evacuation which leads to less dependence. It’s the type of laxatives preferred in pregnancy. Its effect appear after 12-36 hours. *Pharmacist should tell the patient to increase fluid intake while taking bulk laxatives. Isphagula: - Child 6–11 years: 2.5–5 ml twice daily, dose to be given as a half or whole level spoonful in water, preferably after meals, morning and evening. - 12 years & above: 1 sachet twice daily, dose to be given in water preferably after meals, morning and evening Methylcellulose: Adult dose: 3–6 tablets twice daily. Each dose should be taken with at least 300 ml of liquid. 3- Osmotic Laxatives: Effect may take 1-2 days to appear. Lactulose: *This is the most common laxative used for constipation in children. - Child 1–11 months: 2.5 ml twice daily, adjusted according to response. - Child 1–4 years: 2.5–10 ml twice daily, adjusted according to response. - Child 5–17 years: 5–20 ml twice daily, adjusted according to response. - Adult: Initially 15 ml twice daily, adjusted according to response. Epsom Salt (Magnesium sulphate): for rapid bowel evacuation, within 2-4 hours. Adult: 5–10 g, dose to be mixed in a glass of water, taken preferably before breakfast.
4- Stool Softeners: Such as Docusate.
Diarrhoea Causes:
1- Viral infections: most commonly Rotavirus gastroenteritis, which resolves in 2-3 days spontaneously, but can persist longer due to ingestion of milk because of the inactivation of digestive milk enzymes during diarrhoea. 2- Bacterial Infections: Staphylococcus, Campylobacter, Salmonella, Shigella, E.coli, Bacillus cereus. 3- Protozoal: Giardia lamblia and Amoebiasis. 4- IBS, Crohn disease, Ulcerative Colitis. 5- Medications: Opioid, Iron, Antacids (Magnesium hydroxide), NSAIDs (almost all) , Antibacterials (almost all), SSRIs, Misoprostol, Diuretics.
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Gastrointestinal Problems
Age
milliters given after each watery stool
Below 1 year
50 ml after each watery stool
1-5 years
100 ml after each watery stool
6-12 years
200 ml after each watery stool
Above 12 years
400 ml after each watery stool
boiled then left to cool before using it to make the solution. The solution can be kept for 24h if stored in a refrigerator. Home made salt and sugar solutions can be used for adults, in which the electrolyte concentration is less crucial, unlike in infants and young children. Patients shall ask how much of the ORS should be taken, it is as follows:
Table 2.1
2- Antidiarroeal drugs: Loperamide: - Child 4–7 years: 1 mg 3–4 times a day for up to 3 days only. Management: - Child 8–11 years: 2 mg 4 times a day for - Patient should be advised not to have up to 5 days. milk or dairy products when experiencing - 12 years & above: 4 mg immediately then diarrhoea, because digestive milk enzymes 2 mg after each further bout of diarrhoea, are deactivated during diarrhoea. max 16 mg per day. 1- Rehydration: Important especially in babies and young children. It is initiated even if referral to doctor is advised. Oral Rehydration Solution: Sachets of powder for reconstitution are available; these contain sodium as chloride and bicarbonate, glucose and potassium. It is essential that appropriate advice be given by the pharmacist about how the powder should be reconstituted. Patients should be reminded that only water should be used to make the solution (never fruit or fizzy drinks) and that water should be
Kaolin: Adult dose: 10–20 ml every 4 hours. Has been used as a traditional remedy in the past but its use these days is limited. Should not be used for children below 12 years age.
When to refer?
1- Fever with vomiting is present (Indicates bacterial infection). 2- Diarrhoea lasting more than 2 days. 3- Blood, or mucus in stool. 4- Failed antidiarrhoeal medication.
10 Irritable Bowel Syndrome Symptoms:
1- Left lower quadrant abdominal pain, which is usually relieved by stool or wind passage. 2- Mucus in the stool. 3-Bowel habit change (Diarrhoea, constipation, or both alternating). *Diarrhoea mostly comes on wakening and shortly after meals. 4- Bloating.
Possible Aggravating factors:
1- Stress. 2- Caffeine. 3- Sorbitol and Mannitol. 4- Milk, dairy products, chocolate, and onions. - So patient should be advised to avoid any of the aggravating factors.
Management:
- Diet and lifestyle changes are important for effective self-management of IBS, including increasing water intake, as well as limiting caffeine, alcohol and fizzy drinks. Patients should be encouraged to increase physical activity, and advised to eat regularly, without missing meals or leaving long gaps between meals. 1- Antispasmodics: Mebeverine: Taken 1 tablet (150 mg) 3 times a day, 20 mins before a meal. Can be given to patients above 10 years. Alverine: Taken 1-2 capsules 3 times daily before food. Only for patients above 12 years. Peppermint oil: One capsule 3 times a day before food. For patients above 15 years.
Gastrointestinal Problems
Hyoscine: One tablet 3 times a day before food. For patients above 12 years. 2- An antidiarrhoeal or/and laxative (preferably bulk laxative) can be used to manage bowel habit changes.
When To Refer?
1- Pain in the upper abdomen, rarely happens in IBS. 2- Blood in stool, this indicates other conditions such as Crohn Disease, Ulcerative Colitis, and Peptic Ulcer.
Haemorrhoids (Piles) These are swollen vessels in the perianal area and anal canal that is most commonly formed due to constipation. It can be internal (Protrude into the anal canal) or external (hang outside the anus).
Symptoms:
1- Anal itching and irritation. 2- Dull ache pain in the perianal area and can be worse when having a bowel movement. 3- Presence of severe, sharp, pain on stool passage may indicate presence of anal fissure (tear in the skin of the anal canal), which requires referral to the doctor. 4- Rectal bleeding can be present, and in this case the blood appears to be bright red. If blood is black in color (meaning it was extensively mixed with stool) that means it comes from the higher GIT, like in Inflammatory bowel disease (Ulcerative Colitis and Crohn disease), and requires referral. *Symptoms of haemorrhoids remain local to the anus and do not cause abdominal pain or vomiting. *Pregnant women are susceptible to
haemorrhoids than non-pregnant women due to increased pressure and hormonal changes.
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Gastrointestinal Problems
Mouth Ulcers Causes:
1- Infection. Management: 2- Trauma: Biting tongue or cheek. - Patient should be told to avoid any 3- Drug allergy: NSAIDs, Cytotoxic drugs, medications that cause constipation (eg. and sulfasalazine. Morphine) or that increase blood fluidity 4- Food allergy. (eg. Warfarin). 5- Nutrition deficiency (Especially Zinc and - Also should be told to increase fibre and Vit B12). fluid intake and exercise, to avoid constipa- The ulcer appears inside the mouth and tion. also on the outer lips as white or yellow centre with inflamed red outer edge that The following medications can be found as ranges from 5mm (minor) to 30mm (major) Ointments or/and suppositories: in diameter, but the minor is more common, 1- Local Anaesthetics: and can be numerous. Benzocaine and Lidocaine: They are used twice a day for maximum 2 weeks (because they can cause sensitization.) 2- Topical steroids: Hydrocortisone: Used twice a day, and should only be given for patients 18 years & above and discontinued after 1 week of use. A combination including a local anaesthetic and a topical steroids, for example a combination of Lidocaine and Hydrocortisone can be found.
Mouth Ulcers Management:
1- Chlorohexidine mouthwash: Reduces the severity of ulceration, it acts as an antibacterial to prevent secondary bacterial infections with the ulcer. Used twice daily, rinsing 10 ml in the mouth for 1 minute for all patients groups. Patient should be advised to brush teeth 4- Skin protectors (eg. Zinc oxide and Kaolin) and Counter-irritants (eg. Menthol) after using the mouthwash because it can cause brown staining of teeth. can also be used. 3- Laxatives: To relieve constipation, stimulant laxative (eg. Bisacodyl) can be used for 1-2 days then increase dietary fibre and fluid or continue on a long term laxative (bulk laxative).
*Suppositories are preferred in the management of internal haemorrhoids.
2- Topical corticosteroids: Hydrocortisone pellet and Triamcinolone paste used 3-4 times daily. 3- Benzydamine mouthwash: 15 ml rinsed for 1 minute 3 times daily.
4- Choline Salicylate gel (NSAID): used to relieve the pain, when needed.
Oral Thrush Caused by the fungus Candida. Common in children at early age (first weeks of life), because it affects immunosuppressant patients. Immunosuppression can also be due to the effect of drugs, such as inhaled steroids, or broad spectrum antibiotics (which kill the normal flora). It affects the surface of the tongue and inside of cheek, appears as white patches.
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Gastrointestinal Problems
Threadworms (Pinworms) This disease is caused by Enterobius vermicularis worm. Occurs commonly in children.
Signs And Symptoms:
1- Child itching his bottom, which is caused by perianal itching (caused by eggs being laid in the anus). The itching is worse at night because that’s the time the female lay eggs at. Itching can lead to secondary bacterial infection. 2- The worms appear clearly as white threadlike objects in the feces. 3- Diarrhoea can be present.
Management:
Oral Thrush Management:
Miconazole oral gel: 4 times daily after food for patients 6 years & above, 2 times daily for patients below 6 years. The gel can be applied directly to the lesions using a cotton bud or the handle of a teaspoon. The gel should be retained in the mouth for as long as possible. Treatment should be continued 2 days after the infection has appeared to be over. - The patient should be referred if no apparent cause is known for the immunosuppression.
1- Mebendazole: Dose for all patients above 6 months: 100 mg for 1 dose, if reinfection occurs, second dose may be needed after 2 weeks. BNF states that is the treatment of choice for all ages. - It is also active against whipworm, roundworm and hookworm. 2- Piperazine (Paralyses worms) + Laxative (To expel worms with the feces), preferably a stimulant laxative. - Pharmacist should ask if any other family members are infected, and treat all, to prevent re-infection.
Section Three
Skin Conditions
Topical Dosage Forms Firstly, we need to know when to use each of the following topical dosage forms: 1- Ointments: Used for dry skin conditions (eg. Psoriasis), as it can keep skin moist for longer. They typically stay on the skin and trap moisture, and allow greater penetration of the active ingredient. Because of their longer time of contact with skin, most antibiotics are available as ointments. Also it causes less allergic reactions as it contains less preservatives, so it is better for sensitive skin. 2- Creams: Used for wet skin conditions (which involve a discharge) as it can wash away this discharge eg. Eczema, and if a lot of skin needs to be covered, as it is easier to be spread and can be washed easily unlike ointment which is greasy. It’s easier for application in the face, unlike ointment. 3- Lotions: This is the same as creams but contain more water, thus it is thinner and easier to use and spread than creams. The more greasy the preparation, the less it allows the evaporation of moisture from the skin (evaporation is preferred in hot conditions) so creams are prefered in cold, while lotions in hot temperature. 4- Gels: Gel doesn’t contain oil at all, it is used in hairy areas mostly because of their good penetration capability, and also in oily skin types.
Eczema/Dermatitis
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and sometimes becomes thickened. The rash is irritating and can be extremely itchy. The lesions have very poorly defined edge, unlike in fungal infections. The neck, the backs of the hands,the wrist, the groin, around the anus, the ankles and the feet are the most common sites. *Eczema term is used usually when the rash is caused by a genetic factor (atopic) while Dermatitis is used when the cause is external.
Possible aggravating factors:
1- Genetic allergy. 2- Metals, especially nickel. 3- Cigarette smoke. 4- Factors that cause dryness of skin, like soap, detergents and cold wind. 5- Topical medications, including Neomycin, and component of medications such as Lanolin (An ointment base) and Cetyl Stearyl Alcohol (A preservative).
Eczema Management:
The pharmacist should try to know what A rash that typically presents as dry flaky factor is causing eczema for the patient, if skin that may be inflamed and have red spots. The skin may be cracked and weepy there’s no identifiable factor, then referral
to a dermatologist is advisable to perform a patch test to identify the cause. 1- Topical Corticosteroids: Hydrocortisone: Applied twice daily on the affected area. It is contraindicated when the skin is infected, in acne, on the face, and on the anogenital area. The course should not exceed 1 week, and can only be used for patients above 10 years. Clobetasone: Also applied twice daily. Can only be used for patients above 12 years.
Skin Conditions 14 Fungal Skin Infections
1- Athlete’s foot:
Itchy flaky skin in the spaces between toes caused by the fungus Tinea pedis. If the skin gets broken, this may lead to development of secondary bacterial infection, If there are indications of bacterial involvement such as weeping, pus or yellow crusts, then referral to the doctor is needed. When other areas of foot are involved, it can be confused with eczema 2- Antipruritics (Relieve itching): but in eczema the areas between toes are Aqueous Calamine lotion can be used for not involved. this indication, as well as Crotamiton. *The itching of eczema is not histamine related, so using antihistamine is senseless. When To Refer: 1- Toenails are involved (requires systematic antifungal treatment). *Referral is required if there’s evidence of 2- Signs of secondary bacterial infection. infection, which includes weeping, 3- Immunocompromised patients (eg. presence of pus, and spreading. Diabetics , HIV patients, drugs effects such as ciclosporin)
Urticaria
Eczema can be mistaken with Urticarial rashes, which are caused by food allergies, food additives, medicines, grass etc... Urticarial rash is histamine related and respond well to systematic antihistamines.
Management:
Cetirizine: - Child 2–5 years: 2.5 mg twice daily. - Child 6–11 years: 5 mg twice daily. - 12 years & above: 10 mg once daily.
Urticarial Rash
Athlete’s foot - Athlete foot can be caused by footwear that doesn’t allow moisture to escape giving the appropriate environment for fungus to grow. It is also easily spread from one person to another, for example in changing rooms. - To prevent re-infection after treatment, ensure socks and shoes are washed and kept free from fungus.
15
Skin Conditions
period of 1 week, only for patients over 16. 2- Topical Azoles: (Antifungals) Can be used for all patients groups. Itchy pink or red scaly slightly raised patch- Miconazole, Clotrimazole: Used twice daily, es with a well defined inflamed border,over- for the period of 2 weeks, for all ages. Ketoconazole: Used twice daily for the time the centre of the lesion becomes period of 1 week, for all ages. clear. It takes place in major skin surfaces that do not include the face,hands, feet, or Azoles are also effective as antibacterials, so it can be useful in preventing secondary scalp, neither genital area. bacterial infection. 3- Hydrocortisone: Used to reduce inflammation, but should not be used alone, but in combination with antifungals. The dose would be twice daily for a period of no longer than 1 week, and only for patients over 10 years old.
2- Ringworms (Tinea Corporis):
5- Pityriasis versicolor Ringworm before central clearing
The lesions exhibit fine superficial scale and are located on the upper trunk. The lesions are usually small (less than 1 cm) but can join together to form larger plaques. Appear to be brown to pink to white colored. The rash does not itch significantly and the face is usually spared.
Management: Ringworm after central clearing
Ketoconazole Shampoo: For 12 years & above, apply once daily for maximum 5 days, leave preparation on for 3–5 minutes before rinsing.
3- Tinea Cruris:
Presents as itchy red area with a well defined edge in the genital region often spreads to the inside of the thighs.
4- Tinea faciei:
Same as corporis but in the face.
Management Of Tinea Infections:
1- Topical Allylamines: (Antifungals) Terbinafine cream, used twice daily, for the
Pityriasis Versicolor Rash
6- Dandruff:
In dandruff, the scalp will be dry, itchy and flaky. Greyish or white Flakes of dead skin are usually visible in the hair close to the scalp and are visible on the shoulders and collars of clothing. Diagnosis is straight forward.
Management:
1- Ketoconazole Shampoo: For ages above 12 years, apply twice weekly for 2–4 weeks, leave preparation on for 3–5 minutes before rinsing 2- Selenium Sulphide Shampoo: Adults and children over age 5 use it twice weekly for the first 2 weeks then followed by weekly use for the next 2 weeks; then it can be used as needed. The hair and scalp should be thoroughly rinsed after using selenium sulphide shampoo, otherwise discoloration of blond, grey or dyed hair can result. - Patients need to understand that the treatment will not cure their dandruff permanently and that it will be sensible to use the treatment on a less frequent basis to prevent their dandruff coming back.
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Skin Conditions
Management:
Amorolfine Nail Lacquer 5%: For ages 12 years & above, applied 1–2 times a week for 6 months to treat finger nails and for toe nails 9–12 months (review at intervals of 3 months), apply to infected nails after filing and cleansing, allow to dry for approximately 3 minutes. If more than 2 nails are affected, then systematic treatment is preferred (eg. Terbinafine), thus referral is required.
Psoriasis Raised, large, red scaly patches/plaques, over the extensor surfaces of the elbow and knee. The patches are symmetrical and sometimes a patch is present over the lower back area, the scalp is often included. Lesions tend not to itch unlike fungal infections and eczema. Nail biting marks takes place with time, which is a useful diagnostic guide. The exact aetiology of psoriasis still remains unclear but it is known that inherited factors are important.
- There is debate amongst experts as to whether dandruff is caused by infrequent hair-washing. However, it is generally agreed that frequent washing (at least three times a week) is an important part of managing dandruff.
Fungal Nail Infection (Onychomycosis) The nail takes on a dull opaque and yellow appearance. Overtime the nail becomes brittle and crumbles away or falls off. Eczema and psoriasis can also affect the nail but the skin should also be affected.
Knee Psoriasis
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Skin Conditions
reduce the itching.
Scalp Psoriasis Pityriasis Rosea However, psoriasis can present with differing patterns that can be confused with other skin disorders. In guttate psoriasis a widespread rash of small, scaly patches develops abruptly, affecting large areas of the body. This most typically occurs in children or young adults and may be triggered by a streptococcal sore throat. This can be mistaken with Pityriasis Rosea(see below).
Management Of Psoriasis:
1- Dithranol Cream: Dithranol has been a traditional, effective and safe treatment for psoriasis. Proprietary creams (0.1–2%) are more acceptable, especially when used for one short contact (30min) period each day and removed using an emollient. Some people are very sensitive to Dithranol as it can cause quite severe skin irritation. It is usual to start with the lowest concentration and build up slowly to the strongest that can be tolerated. 2-Topical Vitamin D derivatives: Calcipotriol and Tacalcitol.
Guttate Psoriasis
Pityriasis rosea:
A rash that usually begins as a large circular or oval spot on your chest, abdomen or back. It can cause itching, and can be severe. It’s self limiting and usually settles down within 8 weeks. Over-the-counter topical medications, such as calamine lotion or zinc oxide, can help
Viral Skin Conditions 1- Warts And Verrucae (Human Papilloma Virus)
Caused by viral infection of skin, common in children more than adults. Warts appear as raised lesions with rough surface that are usually flesh colored.
Warts have capillaries, if pared, thrombosed, black points will be seen in the wart. Warts can be found in the palm or back of the hand, and usually in the fingers near the nails. If present in the face or anogenital area, referral is required. Plantar warts (verrucae) occur in the weight bearing areas of the sole and heels, they differ from normal warts in being not raised, because the weight pushes the lesions inward producing pain while walking.
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Skin Conditions
The surrounding healthy skin should be protected by application of layer of petroleum jelly (Vaseline). And it should be applied using a stick. Dosage depends on the formulation and concentration of salicylic acid. - Pads containing Salicylic acid can be found in the pharmacy, used for verrucae , and warts that are not so highly raised. A single pad should be changed every 48 hours. 2- Formaldehyde and Glutraldehyde gels are also effective for warts. -The treatment of warts can take up to 3 months, ‘patient’ should be advised to be ‘patient’.
When to Refer?
Wart
1- Bleeding. 2- Itching. 3- Genital and facial warts. 4- Immunocompromised patient (eg. Diabetics).
2- Chickenpox (Varicella Zoster)
Verruca (Plantar Wart) Management:
1- Salicylic Acid Gel/Ointment: Considered to be the treatment of choice for warts. Works by destruction of the raised skin.
Most common in children below 10 years but can also occur in adults. Incubation period is about 2 weeks. The disease starts with malaise, fever, then the rash appears as small red lumps that develop into minute vesicles then burst forming crusted spots. Mainly occurs in the face and trunk, can also occur in mucous membrane of the mouth. It’s contagious only before appearance of rash. It’s self-limiting and it would be gone within 1 week.
Management:
1- Paracetamol or Ibuprofen: for fever. 2- Calamine lotion: for the itching.
3- Promethazine (Systematic): For itching.
Chickenpox Rash
(Shows the stages of the spots)
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Skin Conditions
groups. Applied 5 times a day, for 5 days. Patients who experience cold sores frequently can be told that they should use treatment as soon as they feel the characteristic tingling or itching which precedes the appearance of a cold sore, because it is said to be more effective before appearance of the cold sore. Penciclovir Cream: Suitable for all patient groups. Applied every 2 hours for 4 days. 2- Antiseptic: eg. Benzalkonium Chloride can be used to avoid secondary bacterial infection. - Patients should be aware that cold sore is contagious and transmitted by direct contact.
When to Refer?
3- Cold Sores: (Herpes Simplex)
Symptoms of discomfort, tingling occur 6-24 hrs before cold sore develops, starts with development of minute blisters on top of inflamed red raised skin, and my be filled with white matter. They are extremely painful. Occur most often on the lips or face Doesn’t last more than 2 weeks. Cold sores can be aggravated by sunlight, wind and fever.
Cold Sore Management:
1- Antivirals: Acyclovir Cream: suitable for all patient
1- Painless sore (can be a sign of oral cancer). 2- Sore lasting more than 2 weeks. 3- Eyes affected. 4- Babies and young children. 5- Immunocompromised patient.
4- Measles:
This viral infection along with Mumps and Rubella has a combined vaccine (MMR vaccine) that is usually given between 1215 month of age. Incubation period is 10 days, symptoms start with cold, cough, conjunctivitis, and fever. Then small white spots appear then the rash follows, appears as small red spots which will blanch if pressed. The rash starts behind the ear then spreads to face and trunk. Symptoms disappear within 3 days. (Image on next page.)
5- Roseola Infantum:
Occurs most commonly in the first year of life. Similar to Measles rash but occurs mainly in chest and abdomen, but only lasts for 1 day.
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Skin Conditions
doesn’t blanch, this mean can mean that the rash is caused by septicemia from meningitis, which requires immediate referral, or can be caused by a blood leaking, which may be a sign of leukemia.
Bacterial Skin Conditions Measles Rash
6- Rubella: (German Measles)
Incubation period is 12-23 days. It has a characteristic feature which is the enlargement of glands at the back of the neck, then spots which are fine and red are formed. The rash looks similar in appearance to that of measles. It usually starts on the face and spreads to the trunk and limbs. Before the spots are formed, catarrhal symptoms (mild fever,headache,runny nose) occur. Symptoms continue for 3-5 days only.
1- Scarlet Fever:
Scarlet fever is caused by streptococcus pyrogens, almost always accompanied by a sore throat and a high fever (38.3C and above). A red rash that looks like sunburns develops, it typically begins on the face or neck and spreads to the trunk, arms and legs. The rash resembles that of urticaria. The tongue generally looks red and bumpy, and it’s often covered with a white coating early in the disease. Enlarged lymph nodes may also occur. It is more common in children.
Management (Measles, Roseola, Rubella)
1- Paracetamol or Ibuprofen for fever. 2- Calamine lotion or Promethazine for itching. Secondary bacterial infection can compliScarlet Fever Rash cate Measles, can be pneumonia or ear infection, referral is required in this case for the doctor to prescribe a suitable antibiotic, 2- Impetigo: in the meantime pharmacist should Caused most notably by Staphylococcus establish OTC treatments listed above. aurues. A rash starts as a small red itchy patch of inflamed skin that quickly develops into vesicles that rupture and weep. - Chickenpox, Measles, Roseola, and The exudate dries to a brown,yellow sticky Rubella spots all blanch with pressure, crust, it is contagious. a glass tumbler is used to test this, if it
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Skin Conditions
secreting tumour may be responsible. For patients older than teenage years, drug therapy (eg. Lithium, Phenytoin, Progestogens, Levonorgestrol, and Norethinsterol) , oil, grease at work can be the cause.
Management:
Impetigo (See yellow crusts) Management For Scarlet fever and Impetigo: Referral to the doctor to prescribe a suitable antibiotic.
Acne Hormonal changes during puberty, especially production of androgens, and increased keratin and sebum production are thought to cause acne. Excess sebum can induce growth of bacteria propionibacterium acne which is involved in inflammatory acne. Acne is originally formed due to blockade of sebum follicles by keratin forming microcomedones then developing into a noninflammatory lesion (comedone) which maybe closed (whitehead) or open (blackhead due to accumulation of melanin). Affects teenagers more than any other age group. Occurs in the face, neck, centre of chest, upper back, and shoulders. *Acne is extremely rare in young children, and should be referred since an androgen
Benzylperoxide: Available in variable concentrations (2.5%,5%,10%). Has antibacterial and anticomedogenic actions and is the first line OTC agent for both inflammatory and non-inflammatory acne. It is preferred from the beginning to start with the lowest available concentration then increase concentration gradually every 2-3 weeks. Sensitization to Benzylperoxide can occur, skin becomes red, inflamed and sore, in this case treatment should be stopped for a day or two, then started again with the lowest concentration product of Benzylperoxide available. - Acne requires long term treatment, Benzylperoxide requires 6-8 weeks to show results. - Other agents include used for Acne include keratolytics such as Sulphur, Potassium hydroxyquinolone sulphate, and Salicylic acid.
Corns And Calluses Corns and Calluses form due to combination of friction and pressure against one of the bony prominences of the foot. Inappropriate footwear is frequently the cause. Corns appear as white or yellow hyperkeratinized areas of skin unlike verrucas that show black thrombosed capillaries seen as black dots.
Usually occurs in the tops or between toes.
Corn Calluses appear as flattened yellowish white and thickened skin. Occurs in the bottom of the feet, especially balls of the feet and lower border or big toe.
Management:
Aggravating factors such as inappropriate shoes should be avoided. If treatment is necessary then keratolytics such as Salicylic acid can be used. Salicylic acid pads can be used for corns and calluses too. Different sized pads are available to accomodate for the size of calluse.
Calluse
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Skin Conditions
Scabies Scabies mite lays down eggs into the skin under the surface causing red lesions with intense itching, which is worse at night, which is considered a mark symptom for diagnosis. A burrow can be seen as a small thread (1 cm) like lines. Commonly infected sites include web space of fingers toes,wrists,armpits,buttocks and genital area.
Management:
1- Malathion Lotion: Effective for the treatment of scabies and pediculosis (head lice). For one application in an adult, 100ml of lotion should be sufficient. It is applied for the whole body except the head and neck. The lotion is kept on the body for 24 hours without bathing. Medical supervision is needed for patients under 6 months. 2- Permethrin Cream: For a single application in an adult, 30–60g of cream (one to two 30g tubes) is needed. The cream is applied to the whole body (except head and neck) and left on for 8–12h before being washed off. Medical supervision is needed for patients under 2 years. - Hands should be reapplied if it was washed within the treatment period. 3- Benzyl benzoate is also used. 4- Oral Promethazine can be used for itching.
Napkin Rash
Erythromatous rash in babies in the buttock area, probably due to contact with urine and the feces found in the nappies. It can be accompanied by bacterial (yellow crusts) or fungal (small, red lesions) infections which require referral. Also referral is required if the rash
persisted more than 2 weeks.
Management:
Emollients: such as Dimethicone and Lanolin. Soothening agents such as Zinc. - Topical Hydrocortisone is effective for this condition, but it’s only available OTC for patients above 10 years, so it can only be sold when prescribed by a doctor. -Parents should be advised to change nappies as frequently as necessary. Babies up to 3 months old may pass urine as many as 12 times a day.
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Skin Conditions
Section Four
Central Nervous System
Headache Most common types of headaches encountered in the community pharmacy are tension headache , migraine, and sinusitis.
Tension Headache:
Tension headaches are the most common form. It is not associated with any neck stiffness. The pain may be described as a band around the head. Nausea and vomiting are not associated with tension-type headache and rarely causes photo or phonophobia.
Migraine:
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attack. Migraine and tension-type headaches are aggravated by stress. It has been reported that certain food aggravate migraine, such as chocolate and cheese, and it can also be aggravated by hormonal changes eg. in the menstrual cycle.
Sinusitis:
May complicate upper respiratory tract infection, the increased mucus produced within the sinus cannot drain, a secondary bacterial infection develops and the pressure builds up, causing pain. The pain is felt behind and around the eye and usually only one side is affected. The headache may be associated with rhinorrhoea or nasal congestion. The affected sinus often feels tender when pressure is applied. It is typically worse on bending forwards or lying down.
Migraine is a unilateral headache, affecting one side of the head. It’s unusual for patients to present with their first migraine headache over the age of 40, such patients Other types of headache include: should be referred.
Types Of Migraine:
Cluster Headache:
Cluster headaches involve, as their name 1- Classic (With aura): suggests, a number of headaches one Aura is also known as the prodromal after the other. A typical pattern would be phase, which includes seeing flashlights, or daily episodes of pain over 2–3 months, zigzag lines and other alterations in vision after which there is a remission for anyjust before the migraine attack occurs. thing up to 2 years. The pain is usually Patients often get relieved by laying down experienced on one side of the head, in the in a darkened room. eye, cheek or temple. Any recurrent, Peak incidence of this type is 5 years old in persistent or severe headache needs males, and 12-13 years old in females. referral to the doctor for diagnosis, So this 2- Common (Without aura): type requires referral. No aura is associated with this type of migraine. Peak incidence of this type is 10-11 Chronic Daily Headache: years old in males, and 14-17 years old in CDH is defined as headache that is females. present on most days, i.e. more than 15 days a month, typically occurring over a - Both types are associated with symptoms 6-month period or longer. Often associated of nausea and vomiting at the time of the with neck stiffness. This type requires
25
referral.
Central Nervous System
Management:
1- Aspirin: In addition to its use in the symptomatic treatment of headaches, Temporal Arteritis: doses of aspirin on alternate days may be Severe temporal or frontal headache that effective in the prophylaxis of migraine. is caused by inflammation of the arteries It’s contraindicated in children below 16 of the temple, they may appear red, and are painful and thickened to the touch. This years because of its link to Reye’s syndrome. It’s also contraindicated in can cause blindness if not treated, usually asthma, peptic ulcer, and pregnancy. occurs in the elderly. Requires immediate Aspirin can cause indigestion, so it is not referral. recommended before meals. - Headache can also be caused by long 2- Ibuprofen: Cannot be given for children periods of reading, may require eyesight below 1 year. test and the use of glasses. It can cause sodium and water retention, so it is best avoided in patients with - Some drugs can cause headaches, eg. Nitrates. Oral contraceptive pills aggravate congestive heart failure, HTN, and renal failure. Also contraindicated like aspirin in migraine. asthma, peptic ulcer, and pregnancy. Also not recommended before meals. 3- Paracetamol: Analgesic of choice for children less than 12 years and above 3 months. It has little side effects, but can cause liver toxicity at high doses. 4- Caffeine: It is claimed to increase the absorption and effect of analgesics, thus combined with them.
Migraine
Sinusitis
Cluster
Tension
5- Sumatriptan: Used to relieve headache from migraine attack. Patients over the age of 18, but younger than 65, should take a single tablet (50 mg) as soon as possible after the onset of the headache. If the headache clears and then recurs a second tablet can be taken, provided there was a response to the first tablet and more than 2 hours have elapsed between the first and second tablet. (Max 100 mg per day). 6- Prochlorperazine: Used for the nausea and vomiting associated with migraine attack. The dose is one or two tablets twice daily. Available as buccal tablet for migraine,
26
Central Nervous System
pharmacist should counsel on the correct the disease and medication history of the administration method. patient. Buclizine can also be used for nausea and vomiting of migraine.
Management:
*Note: For a migraine attack, medication should be given as a soluble form, or sublingual/buccal tablet, because GIT motion is altered during an attack. For prevention, it’s not necessary.
When To Refer?
1- Headache doesn’t respond to analgesics within 1 day. 2- A steady, dull pain that is deep-sited, severe and aggravated by lying down , since it may be due to raised intracranial pressure from a brain tumour, infection or other cause. 3- A headache that is worse in the morning and improves during the day as particularly serious, since this may be a sign of raised intracranial pressure. 4- Recent trauma (Persistent vomiting after the trauma is also a sign of raised intracranial pressure). 5- Neck stiffness. 6- Any recurrent, persistent or severe headache. (eg. Chronic or Cluster headache) 7- Any elderly patient presenting with a severe frontal or temporal headache that persists and is associated with a general feeling of being unwell should be referred immediately (suggests temporal arteritis).
Insomnia Insomnia can be caused by depression, life and environmental conditions, medications such as decongestants (eg. Pseudoephedrine), Fluxetine, MAOI, Corticosteroids, appetite suppressants, Phenytion and Theophylline. It is important to ask about
Antihistamines: 1- Diphenhydramine: Only licensed for patients 16 & above years old. The dose is 50 mg 20 minutes before bed. 2- Promethazine: 16 years & above: 25-50 mg 20 minutes before bed. Below 16 years and above 2 years: 0.5mg/ kg/dose 20 minutes before bed, but use with caution. - Both should never be given to children below 2 years because of respiratory depression! Both have Anticholinergic side effects, thus contraindicated in BPH and closed angle glaucoma. Also contraindicated in pregnancy and breastfeeding. Should not be used for more than 7 consecutive nights. *Referral is required if depression is suspected.
Section Five
Eye And Ear Problems
27
for patients above 6 years old. 2- Sympathomimetics: Naphazoline: One to two drops should The Conjunctiva can become inflamed due be administered into the eye three or four times a day. to infection (bacterial or viral), or allergy. Sympathomimetics are also combined with Check table 5.1 to know the differences antihistamines, eg. Antazoline+Xylometabetween types of conjunctivitis. zoline, 1 or 2 drops two or three times a Management: day. -Viral Conjunctivitis: -Bacterial Conjunctivitis: There’s no specific OTC preparations avail- Should be referred to the doctor to preable, but patient should be told to follow scribe an appropriate antibiotic. strict hygiene because viral conjunctivitis is extremely contagious. It is better to refer Other indicatives for referral: to the doctor, sometimes an antibiotic is 1- Clouding of the cornea and associated prescribed to prevent secondary bacterial vomiting (suggests glaucoma). infection. 2- Irregular shaped pupil or abnormal pupil -Allergic Conjunctivitis: reaction to light. 1- Mast cell stabilizers eye drops: 3- Photophobia. Sodium cromoglycate is a prophylactic agent and therefore has to be given contin- 4- Severe eye pain. 5- Distortion of vision. uously while exposed to the allergen. One or two drops should be administered in each eye four times a day. It can be used
Conjunctivitis
Bacterial
Viral
Allergic
Eyes Affected
Both, but one eye affected first by 2448 hours
Both
Both
Discharge
Purulent
Watery
Watery
Pain
Gritty feeling
Gritty feeling
Itching
Distribution Of Redness
Generalized and diffuse
Generalized
Generalized but greater in fornices
Associated Symptoms
None mostly
Cough and cold symptoms
Rhinitis only
Table 5.1
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Eye And Ear Problems
1. Wash your hands 2.Tilt your head backwards, until you can see the ceiling. 3. Pull down the lower eyelid by pinching Common Causes: 1- Keratoconjunctivitis Sicca (KCS): This outwards to form a small pocket, and look upwards. accounts for the vast majority of dry eye 4. holding the dropper in the other hand cases. This is caused by underproduction as near as possible to the eyelid without of tears or tears evaporating too quickly, all caused by a problem in parts of the eye touching it. 5. Place one drop inside the lower eyelid responsible for tears production. This then close your eye. condition is chronic with no cure, only 6. Wipe away any excess drops from the artificial tears are used to help on the eyelid and lashes with a clean tissue. dryness. 2- Sjorgen syndrome: Autoimmune disease, causes dryness of eyes and other Instructions for application of eye mucous membranes especially the mouth. ointments: This condition requires referral. 1- Repeat eye drops steps 1,2,3. 3- Blepharitis: Typically, blepharitis is 2- Place a thin line of ointment along the bilateral with symptoms ranging from inside of the lower eyelid irritation, itching and burning of the eyelid 3- Close your eyes and move your eyeballs margins. eyelid margins may appear red from side to side. and raw accompanied with excessive tear4- Wipe any excess ointment from the eyeing and crusty debris or skin flakes around lid by a clean tissue. the eyelashes. Symptoms also tend to be 5- After administration, vision may be worse in the mornings and patients might blurred, but will soon be cleared by complain of eyelids being stuck together. blinking. Requires referral. 4- Medicine induced: Diuretics, drugs with - If more than one eye preparation is to be anticholinergic effects, Isotretinoin, SSRIs, applied at the same time, wait 5 minutes and B-blockers. between each of them. Management: - Patients who wear contact lenses should Artificial Tears: be advised to stop wearing them in the 1- Polyvinyl alcohol Eye drop: The duration of treatment and 48 hours afterstandard dose is four times a day. wards. This is because eye lenses can be 2- Sodium Hyaluronate Eye Drop: The damaged by the preservative contents in dose is on a when-needed basis. the eye preparation.
Dry Eye
When to Refer?
1- Associated dryness of mouth (suggests Sjorgen syndrome). 2- Symptoms of blepharitis (mentioned above).
Instructions for application of eye drops:
Ear Wax Wax blocking the ear is one of the commonest causes of temporary deafness. It may also cause discomfort and a sensation that the ear is blocked.
Management:
The ear can be unblocked by using ear drops such as olive oil and various proprietary drops. The drops should be warmed before use (ideally to body temperature). With the head inclined, five drops should be instilled. A cotton wool plug should be applied to retain the fluid and be kept in for at least 1h or overnight. This procedure should be repeated at least twice a day for 3 days. The use of these drops can worsen the deafness initially and appropriate warning should be given. Cotton wool buds should not be poked into the ear as wax is just pushed further in and it is possible to damage the eardrum. If any wax remains despite this treatment, referral to the doctor is advisable so that the wax can be considered for ear syringing.
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Eye And Ear Problems
and antifungal effects and works by increasing the acidity of the ear canal, making it more difficult for pathogens to grow. However it’s efficacy is far less than antibiotics and other anti-inflammatory agents (Corticosteroids). Acetic Acid can be given to adults and children aged 12 and over. The dose is one spray (60 mg) into the affected ear at least three times a day. Should not be continued for more than 7 days. 2- Analgesics: such as oral Paracetamol can be given to relieve the pain. Local-acting analgesic like Choline Salicylate can be found as a spray.
Inflammations Of The Ear
1- Otitis Externa (OE)
It’s the inflammation of the skin in the ear canal. Symptoms are ear pain only (if the inflammation is localized), and combination of pain,itching, hearing loss, and discharge if the inflammation is diffuse. On examination, the ear canal or external ear, or both, appear red, swollen. The inflammation is mostly bacterial, but can also be fungal. OE can be precipitated by ear trauma, swimming ,chemicals, ear syringing; and skin conditions.
Management:
Referral to the doctor is required so as to prescribe a suitable antibiotic.This antibiotic can be Flucloxacillin. If the patient cannot visit the doctor soon, the following OTC medications can be used: 1- Acetic Acid: Acetic acid 2% spray has both antibacterial
Otitis Externa 2- Otitis Media (OM)
It is inflammation of the middle ear compartment. It typically starts with common cold, due to blockade of Eustachian tube connecting middle ear to nasal cavity causing accumulation of fluid and thus allowing the growth of bacteria. The symptoms of otitis media are pain ,temporary deafness, and usually a high temperature as well as the cold symptoms, unlike otitis externa which is not associated with other systematic symptoms. An examination of the ear should reveal a
red/yellow and bulging tympanic membrane (a thin, cone-shaped membrane that separates the external ear from the middle ear). Pain resolves on rupture of the tympanic membrane, which releases a mucopurulent discharge.
Management:
For otitis media, it’s prefered to manage using analgesics (eg. Oral Paracetamol or Choline Salicylate spray) rather than referring to the doctor for prescribing an antibiotic because most cases resolve within 3 days without the use of antibiotics. The use of antibiotics in such cases would mostly just help in increasing the bacterial resistance. However if the patient is an immunocompromised one (eg. diabetic) or the pain persists for more than 3 days, referral would be essential.
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Eye And Ear Problems
Section Six
Muscloskeletal Problems
Muscle Pain Usually occurs as a result of a tough work such as gardening or exersice.
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problems especially if there’s an accompanying abnormality in passing urine.
Management:
Advices should be given to the patient to exercise and lose weight (if overweight) and always take a good posture. Management: 1- Topical anti-inflammatory agents (Ibu- Managed by oral or topical analgesics and profen, Felbinac, Ketoprofen, Piroxicam, anti-inflammatory agents, sprays are more preferred if the patient prefers topical Diclofenac.) management and is home-alone with no 2- Oral analgesics and anti-inflammatory one to apply it to his back. agents. 3- Counter irritants and rubefacients: Counter-irritants produce mild skin When to refer? irritation, and the term rubefacient refers 1- Middle or upper back pain. to the reddening and warming of the skin. 2- Pain interferes with mobility or radiating Thought to act as analgesics by generating to legs. a sensation of irritation and warming thus 3- Lower back pain that persisted more distracting the nervous system from the than 1 week. pain sensation. Include: Methylsalicylate, Nicotinates, Menthol, Camphor, Capiscum. - Good massage with topical preparations give much better results as it causes increase in blood flow and thus disperse of pain-causing agents.
Back Pain Caused by muscles or other soft structures (ligaments and tendons) strains. Lower back pain that is not too severe or debilitating and comes on after gardening, awkward lifting or bending, is common and managed easily with OTC products, but middle and upper back pain requires referral if it was present for several days, middle back pain can be caused by kidney
Bruising
Bruising is the appearance of blood under the skin, usually occurs as a result of trauma. Easy bruising may be a result of an underlying blood disorder that results from a drug adverse effect or another cause, so patient should be asked if bruising happens frequently or easier than usual, and referred if so.
Management:
1- Arnica gel/cream. 2- Vitamin K topical preparations. 3- Heparinoids and Hyaluronidase which are enzymes, supposed to disperse fluids in swollen areas, reducing swelling and bruising but this is only theoretical and unproven.
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Bruising
Painful Joints (Arthritis) Most common cause is osteoarthritis which is due to wear and tear of the joint. Another cause is rheumatoid arthritis which is caused by body immune system attacking itself.
Management:
1- Glucosamine: Has shown to reduce joint pain in osteoarthritis. 1500 mg once daily, review treatment if no beneďŹ t after 2–3 months 2- Topical or oral anti-inflammatory agents such as Diclofenac and Ibuprofen.
First Aid Treatment For Strains And Sprains 1- Ice/cooling, to lessen the blood flow and thus lessen further swelling. 2- Compression, also to prevent swelling. 3- Elevation of the affected limb to reduce blood flow by the effect of gravity. 4- Rest.
Muscloskeletal Problems
Section Seven
Women’s Health
Cystitis Cystitis refers to inflammation of urethra and bladder, a term used to describe a collection of urinary symptoms including dysuria, frequency and urgency. In 50% of cases the cause is bacteria, which can be E.coli, Staph saprophyticus or Protues mirabilis, and the urine may appear cloudy and foul smelling in this case. Cystitis is more common in women than men, because the urethra of women is shorter, and also it is thought that the prostatic fluid has antibacterial properties. Symptoms of fever, nausea/vomiting, back pain, indicates upper urinary tract infection (kidney and ureter) which can be more serious. About half of cases will resolve within 3 days even without treatment.
Management:
Mostly cystitis requires referral but the pharmacist can help by giving OTC products if the patient can’t see the doctor soon. 1- Paracetamol or Ibuprofen. 2- Potassium/Sodium citrate (Urine alkalanizer): because the pain is caused by acidification of urine by bacteria or any other cause. - One sachet to be taken 3 times a day for 2 days.
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Dysmenorrhea (Period Pain) Can be classified as: 1- Primary: A pain of an unknown cause (no underlying disease). 2- Secondary: Pain caused by an underlying disease such as endometriosis or pelvic inflammatory disease. To differentiate between both: 1- Time Of Occurrence: The primary happens the day before menstruation, but the secondary occurs during other parts of the menstrual cycle, often 1 week before the menstruation. 2- Type Of Pain: The primary dysmenorrheal pain is spasmodic or cramping, but the pain of the secondary is rather aching. Pain of secondary dysmenorrhea may get worse once bleeding starts and the pain may occur during sexual intercourse. - If PID is the underlying disease, then vaginal discharge would be present. - The secondary is more common in old women especially who had children. - The pharmacist can only deal with the primary dysmenorrhea, but should refer the secondary dysmenorrhea.
Management:
This is only for the primary dysmenorrhea, as stated earlier the secondary requires referral. The pain of the dysmenorrhea is thought to be linked to increased production of prostaglandins, so medications that inhibit the synthesis of PGs would be useful.
1- Ibuprofen: Considered to be the treatment of choice of dysmenorrheal pain. 2- Aspirin. 3- Paracetamol: Incase the patient is not allowed to take NSAIDs (eg. Asthmatics).
When To Refer?
1- Failure of medication. 2- Abnormal vaginal discharge. 3- Symptoms suggest secondary dysmenorrhoea. 4- Presence of fever.
Vaginal Thrush Most common causes of vaginal discharge are bacterial vaginosis, vulvovaginal candidiasis (thrush) and trichomoniasis. As thrush is the only condition that can be treated OTC, the text concentrates on differentiating this from other conditions. The dominant feature of thrush is vulval itching. This is often accompanied with discharge (in up to 20% of patients). The discharge has little or no odour and is curdlike. If there’s no discharge accompanied this can be the result of dermatitis, thus it is worth asking whether the patient has recently used any new toiletries (eg Soaps). Symptoms are generally acute in onset. It is common in women of childbearing age, and pregnancy and diabetes are strong predisposing factors, as well as medications such as broad spectrum antibiotics and corticosteroids.
Management:
The patient can be asked whether she prefers a pessary, vaginal cream or oral formulation. 1- Topical Imidazoles: Miconazole or Clotrimazole, A number of formulations
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Women’s Health
are available for local application including creams, vaginal tablets and pessaries. All internal preparations should be administered at night. 2- Oral Fluconazole: Single oral dose treatment that can be taken at any time of the day. - Treatment of partner is important to prevent recurrence, men may be infected with Candida without showing any symptoms. Typical symptoms for men are an irritating rash on the penis, particularly on the glans. This can be managed by an azole cream can be used twice daily on the glans of the penis, applied under the foreskin for 6 days.
When To Refer?
1- Pregnancy or suspected pregnancy. 2- More than two attacks in the previous 6 months. 3- Any blood staining of vaginal discharge. 4- Associated lower abdominal pain or dysuria. 5- Age under 16 and above 60. 6- Discharge that has a foul smell (suggests bacterial vaginosis or trichomoniasis). 7- Diabetics.
Emergency Hormonal Contraception Levonorgestrol taken as a single dose of 1500 microgram as soon as possible after the unprotected sexual intercourse, preferably within 12 hours and not later than 72 hours.