Diagnosis & Management Flashcards
What are the common causes of constipation?
- Simple constipation – poor diet (especially fibre), low fluid intake, reduced mobility, drugs
- Specific condition/presentation - IBS, pregnancy, elderly
What are the 5 red flags for constipation?
- Anaemia
- Loss of weight
- Anorexia
- Recent onset (sudden change)
- Melaena (blood in stools)
What are the 4 referral symptoms for constipation?
- Treatment failure
- Suspected faecal impaction
- Suspected anal fissure/fistula/undiagnosed haemorrhoids
- Any symptoms that sit outside of your area of competence
What is first line treatment for constipation?
- lifestyle advice (water, diet)
What is recommended order of the 3 laxatives?
- bulk-forming (not to be taken if caused by meds)
- osmotic
- stimulant (firstline for opioid)
How do bulk forming laxatives work?
- Mimic increased fibre intake, which swells in the bowel and increases faecal mass. They also promote the proliferation of faecal bacteria
- Must be accompanied by increased fluid intake
- Slower to work and can take up to 72 hours for effect to be seen
- Side effects include bloating and abdominal distension
How do osmotic laxatives work?
- They act to retain fluid in the bowel by osmosis
- Take up to 48hrs to see effect
- Side effects include flatulence and cramps
- Requires lots of water
How do stimulant laxatives work?
- Increase GI activity by directly stimulating colonic nerves
- Quick acting – generally seeing an effect within 6-12 hours
- The main side effect seen is abdominal pain
- Should be avoided in pregnancy
How do stool softeners work?
- Docusate is the most commonly used and is a non-ionic surfactant that allows penetration of water into the faecal mass
- They also have weak stimulant properties
- Do not supply or recommend liquid paraffin
What is the new safety advice for stimulant laxatives?
- now a third line treatment
- max pack size of 20 for GSL
- age restricted to 18+
- P sale to 12-17s, under 12s to GP
What are the 4 common causes of acute diarrhoea?
- Bacteria
- Viruses
- Protozoa
- Drugs
What are the 8 referral symptoms for diarrhoea?
- Blood/mucus in stools
- Dehydration/associated vomiting (tiredness, weakness)
- Weight loss
- Recent hospital stay or use of antibiotics
- Diarrhoea following recent foreign travel
- Failed treatment
- Symptoms lasting > 2-3 days in children and elderly (24 hours in diabetics)
- Medicine induced diarrhoea
What is the first priority of diarrhoea treatment?
oral rehydration therapy containing glucose, sodium chloride, potassium chloride and disodium hydrogen citrate
available in different flavours
What are the 2 anti-motility drugs and how do they work?
Loperamide - works by acting on mu-opiate receptors to increase the tone of both the small and large bowel, hence increasing intestinal transit time and reabsorption
Bismuth subsalicylate (Pepto-Bismol) – more traditional treatment which remains popular by some – thought to improve symptoms but less effective than loperamide
What advice is given to patients with diarrhoea?
- Drink plenty of clear fluids
- Avoid very sugary drinks
- Avoid milky drinks
- Eat depending on appetite, consider avoiding if exacerbates diarrhoea
- Avoid contact with food till better/stay off work
- Careful hygiene
What are the 3 common causes of haemorrhoids?
- Constipation and straining
- Family history
- pregnancy
What are the 3 common symptoms of haemorrhoids?
- Blood on stools/toilet paper
- Pain on defecation
- Itching
What are the 7 referral symptoms for haemorrhoids?
- First presentation
- Blood in stools
- Patients who have to reduce haemorrhoids manually–3rd or 4th degree haemorrhoids
- Severe pain/stabbing/sharp pain associated with defecation
- Rectal symptoms with associated signs of infection
- Symptoms that don’t resolve within 7 days/get worse with treatment
- Any symptoms that sit outside of your area of competence
What are the 4 degrees of haemorrhoids?
1st degree – project into the lumen but don’t prolapse
2nd degree – prolapse on straining but return to the lumen spontaneously
3rd degree – prolapse on straining and must be returned manually
4th degree – prolapsed and cannot be returned to the anal canal
What are the treatments for haemorrhoids?
- Dietary changes – essential for all patients to reduce straining and resolve the possible cause. Consider a bulk forming laxative if needed or address constipation
- Local anaesthetics (Lidocaine) – temporary relief from pain and itching
- Astringents (eg bismuth, zinc) – coats the haemorrhoids to provide a protective layer
Anti-inflammatories (eg hydrocortisone) – reduce inflammation
Protectorants (eg shark liver oil) – forms a protective layer hence relieves pain and associated itching
What is the lifestyle advice for haemorrhoids?
Avoid constipation
Anal hygiene
Don’t ignore the call
Avoid undue straining
Position
What are the 8 common symptoms of IBS?
- Abdominal pain, located especially in the lower left quadrant of the abdomen
- Pain can be relieved by defecation or passage of wind
- Constipation and/or diarrhoea
- Bloating, distension, tension or hardness
- Altered bowel habit
- Symptoms made worse by eating
- Passage of mucus
- Diarrhoea after eating or on waking
What are the red flag symptoms for IBS?
- Unintentional and unexplained weight loss
- Rectal bleeding
- Recent change in bowel habit
- Persistent or frequent bloating in females (especially if aged over 50 years)
- Abdominal or rectal mass
- Symptoms with a family history of bowel cancer, ovarian cancer, coeliac disease, or inflammatory bowel disease.
- Patients with no history of IBD
- Steatorrhoea (extra fat in faeces)
- Any symptoms that sit outside of your area of competence
What are the 4 treatments for IBS?
Antispasmodics
- Hyoscine – Buscopan
- Mebeverine – Colofac IBS
- Peppermint oil – Colpermin IBS
Laxatives can be recommended (ispaghula), but lactulose should be discouraged
Anti-diarrhoeals – loperamide first line
Probiotics
What is the lifestyle advice given for IBS?
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
What are the 7 symptoms of dyspepsia?
- 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
Which 5 groups are at higher risk of dyspepsia?
Pregnancy
On other medicines
Smokers
overweight/obese
Family history
What are the 5 red flags for dyspepsia?
- 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)
What is the lifestyle advice for dyspepsia?
- Identification of the cause (including any medicines)
- Consider stress, anxiety and depression
- Dietary modifications
- Smoking
- Weight loss
- Alcohol & caffeine intake
- Posture
How are antacids used to treat dyspepsia?
- 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
How are alginates used to treat dyspepsia?
- 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
How are PPIs used to treat dyspepsia?
- Very effective for heartburn symptoms
- Available OTC – omeprazole and esomeprazole
- Works by suppressing acid secretion at the proton pump in the parietal cells
What are the 6 referral symptoms for N+V?
- Severe abdominal pain
- Dehydration
- Blood in vomit
- Duration/recurrent symptoms
- Recent foreign travel
- Pregnancy, especially if hyperemesis is suspected
What is the first line treatment for N+V?
Oral rehyrdation therapy
Which anti-emetics can be used for N+V?
- Prochlorperazine (migraine related)
- Anti-histamines (for travel sickness)
- Anticholinergics (for travel sickness)
What are the 3 types of mouth ulcers?
- 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
What are the referral symptoms for mouth ulcers?
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
What are the 3 treatments for mouth ulcers?
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
What are the 6 possible causes of ulcers?
- Stress
- Trauma
- Nutritional deficiencies (iron, zinc, vitamin B12)
- Infection
- Food sensitivities
- Genetics
What is the lifestyle advice given for cystitis?
- 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
What are the 6 clinical features of uncomplicated cystitis?
- 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
What are the 7 factors that can increase risk of recurring UTIs?
- Increasing age
- Pregnancy
- Prior infections of the upper urinary tract/anatomical or neurological abnormalities
- Catheters
- Undiagnosed diabetes
- Sexual activity
- Lifestyle
What are the possible differential diagnoses for UTI symptoms?
- Thrush
- Pyelonephritis – signs of systemic infection – fever, loin pain, rigors
- Vaginitis
- STI’s
- Medicine induced cystitis - NSAIDs
- Oestrogen deficiency – post menopause – frequent cases
What are the 10 referral symptoms of UTIs?
- 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
How can cystitis be treated in community?
- Alkalising agents?
- Cranberry juice?
- Fluids + simple analgesia
- Antibiotics if confirmed and more severe
What are the 6 risk factors for vaginal candiasis?
- Oestrogen exposure
- Immunocompromised
- Antibiotic use (broad spectrum)
- Poorly controlled diabetes
- Irritants
- Sex
What are the 9 referral symptoms for vaginal candiasis?
- 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
How is vaginal candiasis managed in community?
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
What is the lifestyle advice given for vaginal candiasis?
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
What is the practical advice surrounding vaginal candiasis tretament?
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
How do you conduct a physical examination of an eye?
- 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
What are the 11 red flag + referral symptoms for eyes?
- 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
How is conjunctivitis managed?
- 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
How is bacterial conjunctivitis managed?
- 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
How is allergic conjunctivitis managed?
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
How are styes managed?
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
How is blepharitis managed?
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
What can be given for dry eyes?
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
What is ear wax impaction?
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
How can you screen for ear wax related problems?
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).
What are the referral symptoms for ear conditions?
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
How can ear conditions be managed?
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
What is otitis externa?
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
What are the red flags for otitis externa?
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
What are the OTC treatments for otitis externa?
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
What is the lifestyle advice given for otitis externa?
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.
What is otitis media?
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
How can common nasal conditions be treated?
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
What are the red flags for respiratory referral?
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)
What are the red flags/refferal symptoms for dermatitis and eczema?
Children under 10 needing steroids – consider competency
Lesions on face unresponsive to emollients – consider competency
Treatment failure
Suspect pompholyx
Widespread and severe
Secondary infection
What are the treatments for dermatitis and eczema?
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
What is the lifestyle advice for dermatitis and eczema?
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
Which steroids can be given OTC?
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
What are the red flags/referral symptoms for acne?
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
What are the OTC treatments for acne?
Benzoyl peroxide
Freederm gel (nicotinamide)
What is the lifestyle advice for acne?
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
How are fungal infections managed?
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)
What is the lifestyle advice for fungal infections?
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
What are the red flags symptoms for fungal nail infections?
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
What is the treatment for fungal nail?
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
What is the lifestyle advice for fungal nail?
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
What are cold sores?
Caused by the herpes simplex virus
Prodromal symptoms
Lesion develops
Often have an associated cause – sunlight, run down, stress etc.
How are cold sores treated?
- Aciclovir (apply five times daily for 5 days) or penciclovir (apply every 2hrs for 4 days)
- Pain relief
What are the referral symptoms for warts and verrucas?
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
How are warts and verrucas treated?
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?
Which conditions require immediate referral?
Cellulitis
DVT
Any suspected cancerous moles
What is the lifestyle advice for warts and verrucas?
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
What are the referral symptoms for nappy rash?
Severe rash
Signs of bacterial infection
Treatment failure following 7 days of appropriate treatment
Psoriasis
How is nappy rash managed?
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
What is the advice for nappy rash?
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
How is head lice infestation treated?
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
What are the symptoms of threadworm?
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
How is threadworm managed?
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
What is the lifestyle advice for threadworm?
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
How should a fever in paeds be treated?
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
What are the symptoms of sepsis in children?
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
How are problems related to teething treated?
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
What are the types of vomiting in infancy?
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
What are the referral symptoms for vomiting in infancy?
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
What are the times for referral for diarrhoea in children?
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
What advice is given for colicky babies?
- 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
How is oral thrush treated in infants?
Nipple – miconazole cream after feeds
Mouth – miconazole oral gel >4 months only
What are the general rules for prescribing in pregnancy?
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
What are the most common conditions that pregnant women come in with?
Nausea and vomiting
Pain
Heartburn
Constipation
Haemorrhoids
Vaginal thrush
Others – leg cramps, coughs and colds, threadworms, anaemia
What is the referral criteria for morning sickness?
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
What advice is given for morning sickness?
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 mealslowin carbohydrate andfat 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
What causes pain in pregnancy?
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
How can you manage pain in pregnancy?
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.
How can you treat heartburn in pregnancy + BF?
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
What are the red flag symptoms for heartburn in pregnancy?
Symptoms that are unresponsive to treatments
Patient is unable to eat due to symptoms
Cause unrelated to pregnancy (peptic ulcer, IBS)
Alarm symptoms present
How is constipation treated in pregnancy?
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
How are haemorrhoids treated in pregnancy?
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
How is vaginal trush treated in pregnancy?
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
How are UTIs treated in pregnancy?
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
How are leg cramps treated in pregnancy?
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
How are coughs and colds treated during pregnancy?
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
How are threadworms treated in pregnancy?
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)
How is feeling faint managed during pregnancy?
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
What are the common problems during breastfeeding?
Sore/cracked nipples
Blocked duct
Not enough milk
Too much milk
Engorgement
How are medicine requests dealt with while breastfeeding?
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
