Diagnosis & Management Flashcards

Question

What is the lifestyle advice given for IBS?

Answer 1

Have regular meals and avoid missing meals Have at least 8 cups of fluid per day, especially non-caffeinated drinks Avoid fizzy drinks Considering limiting the intake of high fibre foods, lots of green leafy vegetables Reduce the intake of resistance starch, often found in processed foods Limit fresh fruit to 3 portions per day Daily oats

Answer 2

- Heartburn/reflux/discomfort/pain - Vague abdominal discomfort - Nausea/vomiting - Early satiety - Bloating/Flatulence/Belching - Feeling of fullness - Pain, ranging from after eating to several hrs after eating

Answer 3

Pregnancy On other medicines Smokers overweight/obese Family history

Answer 4

- Anaemia (Gastrointestinal bleeding) - Loss of weight (unexplained) - Anorexia (loss of appetite) - Recent onset of progressive and recurrent symptoms (including change of bowel habit) - Melena (blood in stools)

Answer 5

- Identification of the cause (including any medicines) - Consider stress, anxiety and depression - Dietary modifications - Smoking - Weight loss - Alcohol & caffeine intake - Posture

Answer 6

- They raise the pH of gastric secretions - Aluminium salts can cause constipation, magnesium salts can cause diarrhoea - There are a wide range of products available that vary in their efficacy based on the metal salt

Answer 7

- First line for heartburn symptoms - When swallowed, the alginate comes into contact with the acid in the stomach, precipitating out and forming a sponge like matrix which floats on the stomach contents

Answer 8

- Very effective for heartburn symptoms - Available OTC – omeprazole and esomeprazole - Works by suppressing acid secretion at the proton pump in the parietal cells

Answer 9

- Severe abdominal pain - Dehydration - Blood in vomit - Duration/recurrent symptoms - Recent foreign travel - Pregnancy, especially if hyperemesis is suspected

Answer 10

Oral rehyrdation therapy

Answer 11

- Prochlorperazine (migraine related) - Anti-histamines (for travel sickness) - Anticholinergics (for travel sickness)

Answer 12

- Minor - Small (less than 1cm in diameter) , white/grey in colour, painful, shallow with a raised red rim - Causes pain when eating or drinking - Rarely occur on the gingival mucosa - Major - Larger ulcers (greater than 1cm) - Numerous, occurring in groups of 10 or more - Can merge to form many ulcers - Herpetiform - Pinpoint and can occur in crops of up to 100 - Often occurs in the posterior part of the mouth

Answer 13

If theres any possibilty of oral cancer A single lesion lasting longer than 3 weeks Larger than 1cm In crops of 5-10 or more Duration Painless ulcers Multiple site involvement – Behcet disease

Answer 14

Antibacterials – chlorhexidine mouthwash – a number of RCTs have shown they can reduce pain and also severity of symptoms Analgesic – choline salicylate – studies have shown this to be significantly better than placebo for relieving pain. Over 16’s only. Lidocaine and benzocaine products available for under 16’s Local corticosteroid – hydrocortisone buccal tablets – reduce inflammation, pain and promotes healing – over 12’s only

Answer 15

- Stress - Trauma - Nutritional deficiencies (iron, zinc, vitamin B12) - Infection - Food sensitivities - Genetics

Answer 16

- Drink plenty of water, avoid alcohol - Avoid intercourse till symptoms resolve - Avoid perfumed cosmetics/bubble bath etc - Avoid ignoring call to urinate - Hygiene - Urinate following sex/use of lubricants - Cotton underwear and avoid tight fitting clothes

Answer 17

- Dysuria (painful urination, burning, stinging) - Urinary frequency & urgency but only passing small amounts of urine - Nocturia - Urine appearance – cloudy/smelly/change of colour - Haematuria (urine might be dark and strong smelling) - Suprapubic pain/tenderness

Answer 18

- Increasing age - Pregnancy - Prior infections of the upper urinary tract/anatomical or neurological abnormalities - Catheters - Undiagnosed diabetes - Sexual activity - Lifestyle

Answer 19

- Thrush - Pyelonephritis – signs of systemic infection – fever, loin pain, rigors - Vaginitis - STI’s - Medicine induced cystitis - NSAIDs - Oestrogen deficiency – post menopause – frequent cases

Answer 20

- Duration and recurrent cases (2 in 6 or 3 in 12) - Abnormal vaginal discharge or other signs of an STI - Red flag, signs of sepsis (check vitals) - Children under 12 - Diabetics - >65s - Immuno-compromised patients - Men - Pregnancy - Indwelling catheter

Answer 21

- Alkalising agents? - Cranberry juice? - Fluids + simple analgesia - Antibiotics if confirmed and more severe

Answer 22

- Oestrogen exposure - Immunocompromised - Antibiotic use (broad spectrum) - Poorly controlled diabetes - Irritants - Sex

Answer 23

- Diabetes - Discharge with abnormal smell/consistency/colour - OTC medicine failure - Pregnant women - Recurrent attacks - Women under 16 and over 60 - Diagnosis is inconclusive or physical examination is needed - Possibilty of STI - Similar symptoms showing in Men

Answer 24

Systemic triazole antifungal oral capsule 150mg stat dose (fluconazole 1st line) Clotrimazole 500mg intravaginal pessary 2nd line if fluconazole is not indicated (NICE) Consider a topical imidazole if vulval symptoms are present Treatment failure is defined as symptoms not resolving within 7-14 days

Answer 25

Probiotic yoghurt can be effective, either topically or orally Avoid tight clothing, perfumed soaps etc Symptoms should start to resolve within 3 days, see GP if no improvement within 7 days Treat partner if appropriate (Balanitis or asymptomatic with recurrent cases for ♀) How to insert pessaries Avoid douching

Answer 26

All internal preparations should be used at night Preparations might affect latex contraceptives Fluconazole can cause GI disturbances and there are possible drug-drug interactions. Treatment OTC should not be used in pregnancy or where there is a chance patient is pregnant

Answer 27

- Wash your hands - Ask the patient to sit down and look straight ahead - Gently pull down the lower lid and ask the patient to look left, right, up & down - Check the patients reaction to light - Check visual acuity by asking the patient to read small print with the affected eye - Perform for both eyes - Wash your hands

Answer 28

- True eye pain - Loss of vision - Vomiting - Clouding of cornea - Susepected herpes infection - Distortion of vision - Irregular shaped pupil - Photophobia - Foreign body - Any kind of haemorrhage - Keratitis

Answer 29

- Most cases are self limiting and will resolve within 5-7 days - Using an anti-infective should be reserved for severe cases - ‘Brolene and Golden Eye’ preparations are not recommended due to lack of evidence - Distinguishing between bacterial and viral infections is not possible in the community pharmacy - Self help methods are thought to be the preferred option unless symptoms are severe or last longer than 3 days/rapid resolution is needed

Answer 30

- Bathe the eyelids with lukewarm water or saline to remove any discharge - Use tissues to wipe the eyes then discard - Avoid contact lenses till symptoms have cleared - Wash hands, avoid sharing towels, good hygiene etc. - Chloramphenicol - Chloramphenicol drops – 1 drop every 2hrs for 48hrs then 1 drop every 4hrs duration waking hours only. Maximum of 5 days treatment - Chloramphenicol ointment – Apply three to four times daily, or once at night if used in conjunction with the eye drops

Answer 31

Allergen avoidance, cold compress, avoid eye rubbing, consider artificial tears Sodium cromoglycate eyes drops (Opticrom allergy) Mast cell stabiliser Works prophylactically so must be used continuously when exposed to the allergen One to two drops in each eye four times daily Sympathomimetic/antihistamine combination (Otrivine Antistin) Sympathomimetic reduces redness – does not treat underlying pathology. Antihistamine aims to reduce allergic response Short term use only to prevent rebound effects Avoid in patients with glaucoma One to two drops three to four times daily

Answer 32

Styes are self limiting and should resolve once ruptured Topical antibacterial agents will not speed up healing Warm compress application for 5-10 minutes, 2-4 times daily will bring stye to a head quicker Referral is only needed if symptoms don’t resolve or are severe/get worse Don’t recommend picking or squeezing

Answer 33

Blepharitis – chronic and intermittent condition which can be managed by self care measures Advise the patient that good eyelid hygiene is the mainstay of treatment. The eyelids should be cleaned in a stepwise manner twice daily initially, then reduced to once daily as symptoms improve Apply a warm compress to the closed eyelids for 5–10 minutes once or twice daily Baby shampoo diluted 1:10 with warm water, and wiped on eye lids with cotton bud or cloth twice daily, reducing to once daily Advise the person not to use a compress that is too hot as they may burn the skin. Treat any dry eyes as needed

Answer 34

Hypromellose, polyvinyl alcohol, carmellose, carbomer, sodium hyaluronate and wool fats Hypromellose lacks trial evidence, but is long established as a dry eye treatment – and is considered first line Carbomer is more expensive, but has better wetting characteristics so used less often

Answer 35

Ear wax has some important functions, and is not a problem unless it impacts Symptoms include ear discomfort, a feeling of fullness in the ear and slight hearing loss More common in elderly patients Arises due to alterations in the normal method of ear wax migration

Answer 36

Hearing loss (most common symptom). Blocked ears. Ear discomfort. Feeling of fullness in the ear. Earache. Tinnitus (noises in the ear). Itchiness. Vertigo (not all experts believe that wax is a cause of vertigo). Cough (rare and due to stimulation of the auricular branch of the vagus nerve by pressure from impacted earwax).

Answer 37

Trauma related deafness or perforated ear drum Previous history of a perforated ear drum or previous chronic ear disorder Foreign body (Most common in children) OTC medication failure Pain originating from the middle ear (ear wax does not often cause ear pain – Dizziness or tinnitus – but give lifestyle advice (avoid driving, stand up slowly) Sudden hearing loss in one ear only (could be a lesion or disease of the inner ear/auditory nerve) Glue ear

Answer 38

Ear drops should not be instilled if there is a perforated ear drum Ask about the patient’s preference for treatment: Otex – oxygen is released on contact with the wax so could help dispersal General drops to soften wax

Answer 39

Generalised inflammation of the ear canal Inflammation can be due to bacterial or fungal infections Common in patients with prolonged exposure to water – swimmers Common in hot and humid climates Characterised by irritation, pain, discharge (thin, watery discharge due to trauma to the ear canal) and conductive hearing loss/muffled hearing

Answer 40

Ear pain in children under 2yrs – often seen by ‘ear tugging’ & associated fever/loss of appetite, or loss of hearing Generalised inflammation of the pinna – perichondritis Pain on palpation of the mastoid area Slow growing growths on the pinna of elderly patients Duration over 7-14 days

Answer 41

1st line - Analgesics – paracetamol or ibuprofen with a warm compress 2nd line - Acetic acid 2% (available OTC as Earcalm spray) is indicated for superficial infections of the ear/otitis externa Suitable when there is pruritus and/or mild discomfort Apply 1 spray every 2-3hrs (at least 3 times daily), continued for 2 days after symptoms have cleared. See GP if symptoms don’t improve or worse within 48hrs, and should not be used for longer than 7 days

Answer 42

Avoid damage to the external ear canal: Troublesome ear wax should be removed safely to avoid damaging the ear canal. Cotton buds or other objects should not be used to clean the ear canal. Keep the ears clean and dry. Avoid swimming and water sports for at least 7–10 days during treatment. Use ear plugs and/or a tight-fighting cap when swimming. Keep shampoo, soap, and water out of the ear when bathing and showering, for example by inserting ear plugs or cotton wool (with petroleum jelly). Consider using a hair dryer (at the lowest heat setting) to dry the ear canal after hair washing, bathing, or swimming.

Answer 43

Depends on the patient/severity of the symptoms – discharge associated with pain, fever/high temperature, high risk of complications May need ABx – especially in children or adult if severely unwell (not covered by pharmacy 1st) Analgesics – for adults (or referral if severe) Paracetamol Ibuprofen

Answer 44

Saline or salt water sprays/rinses Very popular for a range of different conditions - Rhinitis - Congestion - General hygiene - Contraindications to decongestants - Colds - Sinusitis Use as needed 2-6 times daily

Answer 45

Persistent symptoms Persistent or progressive cough Coughing up blood Breathlessness Unexplained weight loss Persistent chest infections Chest pain Difficulty/pain swallowing Fever above 38oc Fingertip changes (clubbing of fingers – round and large)

Answer 46

Children under 10 needing steroids – consider competency Lesions on face unresponsive to emollients – consider competency Treatment failure Suspect pompholyx Widespread and severe Secondary infection

Answer 47

Emollients – Creams, ointments, additives – to hydrate the skin *Shared Care* Topical steroids – Hydrocortisone (mild), clobetasone (moderate) – reduce inflammation during an acute flare Advice Sedating anti-histamines *Shared Care*

Answer 48

Think about the cause???!!!! Decrease levels of house dust mite Avoid drying soaps Avoid perfumed toiletries Avoid abrasive clothing Stress management Wet-wrap technique Sunshine No evidence that dietary manipulation has an effect

Answer 49

Hydrocortisone - mild Apply twice daily for a maximum of seven days Only for >10’s Clobetasone - moderate Apply twice daily for a maximum of seven days Only for >12’s In fingertip units

Answer 50

Moderate or severe acne, especially where there is a risk of scarring Occupational/drug-induced acne OTC treatment failure – after 2 months of acne treatment OTC Rosacea

Answer 51

Benzoyl peroxide Freederm gel (nicotinamide)

Answer 52

Can take 8 to 12 weeks to see an improvement in symptoms Benzoyl peroxide can bleach hair, clothes, towels etc Wash area carefully before application Apply sparingly – a small pea-sized amount is enough for the face Apply to the whole area not just the lesions No evidence that food causes acne Stress does not cause acne, but can make it worse Sunlight can help Avoid greasy, heavy make up, moisturisers etc Avoid squeezing spots

Answer 53

Imidazoles and allylamines as topical preparations are the recommended first line products Other include tolnaftate (athlete’s foot and groin) and undecenoates (athlete’s foot). Both applied twice daily and continued for at least 7 days after lesion heals Clotrimazole cream – apply two to three times daily – normally for at least 2 weeks to see an improvement then another 7-14 once lesion heals Terbinafine cream (Lamisil)

Answer 54

Wash affected area daily and dry carefully Do not share towels Avoid scratching the area since this might spread the infection further Wear non-occlusive footwear to minimise foot perspiration and alternate footwear every 2 to 3 days Wear cotton socks Use flip-flops in communal areas Consider anti-fungal sprays and talcs in shoes to eliminate spores No need for children to miss school

Answer 55

Those with conditions which predispose them to fungal infections Pregnant or breastfeeding women Under 18’s Those with fungal nail infections other than DLSO Those with more than TWO infected nails Nail dystrophy or a destroyed nail Failed treatment or no improvement within 3 months

Answer 56

Amorolfine 5% nail lacquer Topical anti-fungal, works by causing ergosterol depletion and accumulation of ignosterol – cell wall thickening Because nail grows very slowly, treatment is long Apply once weekly – 6 months for finger nails and 9-12 months for toe nails Nail preparation prior to weekly application

Answer 57

Wash and dry feet thoroughly everyday Try to prevent infection spreading to other toes Avoid tight fitting or occlusive shoes Alternate use of shoes Exercise good nail care Use anti-fungal sprays in shoes Visit podiatrist regularly Avoid going bare foot in communal areas Avoid nail varnish and artificial nails

Answer 58

Caused by the herpes simplex virus Prodromal symptoms Lesion develops Often have an associated cause – sunlight, run down, stress etc.

Answer 59

- Aciclovir (apply five times daily for 5 days) or penciclovir (apply every 2hrs for 4 days) - Pain relief

Answer 60

Anogenital warts Diabetics Lesions on the face Multiple and widespread warts Patients over 50 presenting with wart for first time Warts that itch or bleed without provocation Warts that have grown and changed in colour

Answer 61

50% of all warts and verrucas will spontaneously resolve after 2 years Salicylic acid – destructive treatment Is a keratolytic, which acts slowly by destroying the virus containing epidermis, showing modest success rates if used for 12 weeks OTC treatments contain between 12 or 26% salicylic acid applied daily Bazuka or Bazuka extra strength Important discussion points with the patient: Assess motivation and if compliance is likely Is the wart/verucca troublesome to the patient What is the motivator for wanting treatment?

Answer 62

Cellulitis DVT Any suspected cancerous moles

Answer 63

Soak affected area prior to treatment The affected skin should then be lightly rubbed with pumice or emery board Application of product should only be made to the affected skin Allow product to dry – many products now form an occlusive layer to stop spread of HPV

Answer 64

Severe rash Signs of bacterial infection Treatment failure following 7 days of appropriate treatment Psoriasis

Answer 65

Whatever the cause, reducing skin irritation from the nappy and its contents will aid healing Barrier preparations - Zinc containing products – protects skin Zinc & castor oil Sudocrem - Titanium containing products Metanium - Dimethicone products – protect against water Conotrane General advice

Answer 66

Avoid coarse towelling materials Use quality nappies to maintain dry nappy/skin interface Change nappies frequently Allow skin to breathe whenever possible Avoid powder preparations – doesn’t prevent nappy rash

Answer 67

Confirm infestation Consider treatment options Three available Wet combing Physical insecticide Chemical insecticide Various factors affect decision making Evidence, contact time, age, pregnancy, previous treatment failure If no response to initial treatment, consider alternative treatment if method of application satisfactory

Answer 68

Night time perianal, ranging from local tingling to acute pain Sleep disturbances may occur due to itching Secondary infection due to severe itching Worms can be present on stools

Answer 69

Mebendazole (Ovex) inhibits the worms uptake of glucose, causing immobility and death Over 2’s only Not for use in pregnancy 1 stat then repeat after 2 weeks if re-infestation is suspected Refer if treatment failure occurs after the two doses, signs of secondary infection

Answer 70

Ensure strict personal hygiene Finger nails should be kept short and clean Careful washing and nail scrubbing prior to meals and after visiting the toilet Bed linen should be washed daily Underwear should be worn at night under bed clothes to help prevent scratching Have a bath or shower on rising All family members should be treated

Answer 71

Normal body temperature of a child is around 36.4c Normal fluctuations can occur Fever occurs when normal processes for maintaining temperature fail A fever is considered >38oc, but also assess how the child appears. Ask the parent to feel the child’s skin A referral must be made to GP/111 if: is under 3 months old and has a temperature of 38C or higher is 3 to 6 months old and has a temperature of 39C or higher

Answer 72

Blue, pale or blotchy skin, lips or tongue, cold skin A rash that does not fade when you roll a glass over it Difficulty breathing, breathlessness or fast breathing A weak, high-pitched cry (or one that’s different to normal) Not responding like they normally do, or not interested in feeding or normal activities Being sleepier than normal or difficult to wake Confusion, slurred speech or not making sense, change of mental state Fit or convulsion High temperature or low temperature High heart rate Low blood pressure

Answer 73

Exclude any other reason for appearing unwell Management Rub gums with a clean finger Allow infant to bite on something Simple analgesics DO NOT GIVE choline salicylate gels Consider teething gels/herbal preparations Lidocaine gel – consider after other options have failed after consultation with pharmacist (MHRA) - Bonjela junior or similar - Apply a little gel to the sore area with either a clean finger tip or swab. This may be repeated after twenty minutes and then every three hours

Answer 74

Gastro-enteritis – with or without diarrhoea – more common in bottle fed infants Posseting (regurgitation) – refer if occurs frequently Gastro-oesophageal reflux – see later slide Nervous vomiting – refer if problematic Projectile vomiting – infants 4-6 weeks of age refer immediately

Answer 75

Gastroenteritis and vomiting More than 24hrs in baby less than 6 months More than 48hrs in infant less than 2yrs A baby who vomits at least half it’s feed on three separate occasions over 24hrs should also be referred

Answer 76

More than 72hrs in older children More than 48hrs in children under 3yrs More than 24hrs in babies under 1yr Babies under 3 months – immediate referral

Answer 77

- Hold or cuddle your baby when they're crying a lot Sit or hold your baby upright during feeding to stop them swallowing air - Wind your baby after feeds - Gently rock your baby over your shoulder - ently rock your baby in their Moses basket or crib, or push them in their pram - Bathe baby in a warm bath - Have some gentle white noise like the radio or TV in the background to distract them - Keep feeding your baby as usual

Answer 78

Nipple – miconazole cream after feeds Mouth – miconazole oral gel >4 months only

Answer 79

Avoid all agents including OTC and herbal supplements unless essential Avoid smoking & alcohol, vit A supplements max. 10,000iu per day, vit D – 10mcg daily Take 400mcg folic acid daily prior to pregnancy and continue to birth (5mg on AEDs) Chronic illness seek early advice Dietary advice – avoid pate, mould ripened soft cheeses, unpasteurised diary products, raw egg products, no more than 200mg caffeine per day Care with raw/rare meats, avoid cured meats (Toxoplasma gondii.) Government advice is that peanuts/nuts should be eaten unless mum allergic to them

Answer 80

Nausea and vomiting Pain Heartburn Constipation Haemorrhoids Vaginal thrush Others – leg cramps, coughs and colds, threadworms, anaemia

Answer 81

Hyperemesis gravidarum – can affect 1-3% of pregnancies Severe unstoppable vomiting Inability to keep fluids/food down for 24hrs Very dark urination, or no urination Abdo pain or fever Weakness or feeling faint Blood in vomit

Answer 82

No OTC products available Avoiding any foods or smells that trigger symptoms (for example spicy or fatty foods)/eat anything that doesn’t cause an aversion! Eating plain biscuits or crackers in the morning before getting up. Eating bland, small, frequent meals low in carbohydrate and fat but high in protein. Cold meals may be more easily tolerated if nausea is smell-related. Drinking little and often rather than large amounts, as this may help to prevent vomiting. Ginger biscuits Acupressure Rest and be kind to yourself

Answer 83

Headaches common due to intracranial vascular changes (mediated by P & O) Backache/aches and pains is another common complaint caused by strain on the muscles of the back and weight gain

Answer 84

Minor aches and pains do not require treatment especially in the first trimester Analgesics might be needed for headache, musculoskeletal pain or dental pain Lifestyle advice to reduce back pain Do not stand or sit for too long Rest when painful & ‘put feet up’ Wear flat shoes Stretch tight muscles and soak in warm baths Paracetamol is the analgesic of choice during pregnancy (also for pyrexia) – adult dose – 2 four times daily Aspirin - 3rd trimester warnings – see BNF – avoid (and in BF – absolute avoid) NSAIDs - avoid, including topical - see BNF (caution in BF) Only recommend paracetamol OTC Back care, massage etc.

Answer 85

Common in pregnancy – affects as many as 70% of pregnant women Precipitating factors include posture and eating, and position of the foetus First line - lifestyle (Second line) - simple antacids/alginates can be recommended at any point during pregnancy Avoid PPI’s

Answer 86

Symptoms that are unresponsive to treatments Patient is unable to eat due to symptoms Cause unrelated to pregnancy (peptic ulcer, IBS) Alarm symptoms present

Answer 87

Common later in pregnancy due to reduced GI motility, reduced activity and increased levels of progesterone 1st line - Lifestyle interventions Laxatives Bulk forming laxatives 1st line Osmotic laxatives 2nd line (see previous lectures for details) Avoid stimulant laxatives OTC ….essential to treat to avoid haemorrhoids

Answer 88

Commonly occur for the first time during pregnancy Essential to ensure they have been previously diagnosed prior to treatment – consider your own competency Treat as discussed in previous lectures Avoid hydrocortisone based preparations (pregnancy and BF) ….will usually resolve spontaneously after delivery

Answer 89

Is a frequent problem and can occur up to ten times as often as in non-pregnant women Referral is needed if presentation occurs during pregnancy – clotrimazole is most commonly prescribed topically or intra-vaginally Advice in BF is vague, but not likely to be harmful

Answer 90

Increased risk of pyelonephritis, which in term increases risk of pre-term delivery and low fetal birth weight Refer to GP If BF – standard advice/refer if ongoing despite advice/if symptoms are significant

Answer 91

Painful cramps in the calf common in the third trimester Recommend: Foot exercises to help prevent cramp During an acute attack rub muscles hard and/or pull toes hard towards your ankle

Answer 92

Avoid use of decongestants Care with combination preparations Paracetamol for symptomatic relief Menthol inhalations for congestion Avoid opioid cough suppressants Demulcents have limited efficacy supporting their use but can be recommended Some cough and throat lozenges can be recommended

Answer 93

Common infection in pregnancy since there might be other young children in the household No pharmacological therapies have be proven safe for use in pregnancy for recommendation OTC Strict hygiene must be followed to break the life cycle of the parasite Consider referral if symptomatic (same for BF)

Answer 94

Can be common during pregnancy Often associated with getting up too quickly, after a bath or after lying down Care when getting up Avoid lying flat on back or sleeping on back after 28 weeks of pregnancy

Answer 95

Sore/cracked nipples Blocked duct Not enough milk Too much milk Engorgement

Answer 96

Consider relevant sources (BNF, Briggs, local medicines information, SPC) Timings of medicines (troughs) Consider expressing milk if medicines are to be taken short term ‘Pump and dump’ The recommendation of ‘avoiding breastfeeding’ is not appropriate unless there are no other options