Final objectives

Question 1

List symptoms or situations in which you would refer a patient complaining of ear or eye problems to his or her primary care provider.

Answer 1

Refer EYE: Blunt trauma; foreign particles trapped/embedded in eye; ocular abrasions; infections of eyelid/eye surface; eye exposure to chemical splash/solids/fumes; thermal eye injury (welder’s arc); viral conjunctivitis; chlamydial conjunctivitis.
Refer EAR: signs of infection; pain assoc with ear discharge; bleeding/ signs of trauma; presence of ruptured tympanic membrane; ear surgery within last 6 wks; tympanostomy tubes present; incapable of following proper instructions; hypersensitivity to recommended agents;

Question 2

excessive/impacted cerumen

Answer 2

want to soften/remove. Sense of fullness or pressure; gradual hearing loss, can lead to decreased cognition in elderly; dull pain; vertigo; tinnitus; chronic cough.

Question 3

water-clogged ear

Answer 3

(NOT swimmer’s ear – external otitis) – remove the water. Feeling of wetness/ fullness; accompanied by gradual hearing loss; itching; pain; inflammation – may lead to infection.

Question 4

Dry Eyes

Answer 4

may be caused by eyelid defects, aging – postmenopausal women, corneal defects, drugs with anticholinergic properties, diuretics, beta-blockers, allergens. Signs/symptoms: white/mildly red eye, sandy/gritty feeling, excessive tearing.

Question 5

Allergic conjunctivitis

Answer 5

often seasonal. Red eye with water discharge, ITCHING!! Usually no vision impairment – may be blurred due to excessive tearing.

Question 6

Diagnosed Corneal Edema

Answer 6

may be due to overwear of contacts, surgical corneal damage, inherited corneal dystrophies. Often edema is confined to epithelium – may distort optical properties of cornea causing HALOS OR STARBURSTS AROUND LIGHTS (with or without reduced vision).

Question 7

Loose Foreign Substance in Eye

Answer 7

excessive tearing, no abrasion on eye surface, not embedded.

Question 8

Minor Eye Irritation

Answer 8

non-allergic, may be caused by loose foreign substance, exposure to sun/wind/too much contact wearing.

Question 9

Chemical Burns

Answer 9

refer – emergent treatment only: irrigate with copious amounts of sterile saline or tap water

Question 10

Artificial Eyes

Answer 10

clean with sterile isotonic solution

Question 11

Contact Dermatitis

Answer 11

affects eyelid, reaction to allergen or irritant. Potentially caused by cosmetics, soap, exposure to meds, contact with foreign particles; Both eyelids suggest allergies. Signs/Symptoms: swelling, scaling, redness of eyelid, UV burns of cornea , profuse itching.

Question 12

non-pharmacological treatment for cerumen

Answer 12

Use a wet wrung out washcloth draped over a finger and wipe out cerumen – not effective once cerumen impacted

Question 13

non-pharmacological treatment for water clogged ears

Answer 13

Tilt affected ear down and manipulate auricle to try to expel water; use a blow dryer on low heat to help dry out ear after swimming/bathing (don’t blow directly into ear); water-absorbing ear plugs.

Question 14

non-pharmacological treatment for dry eye

Answer 14

Avoid environments that that increase evaporation of tear film (dry or dusty places). Use humidifier, reposition work stations away from heating/cooling systems. Avoid prolonged use of computer screens, wear eye protection in windy/sunny environs. Use a white petrolatum/ mineral oil ointment on eye.

Question 15

non-pharmacological treatment for allergic conjunctivitis

Answer 15

removing/ avoiding allergen exposure; applying cold compress to eyes for 3-4 times/day to reduce redness and itching. Check pollen count, stay indoor, keep windows shut, use air filters.

Question 16

non-pharmacological treatment for loose foreign substance in eyeball

Answer 16

irrigate/flush the eye with water/ sterile saline

Question 17

non-pharmacological treatment for minor eye irritation

Answer 17

flush eye, use an eye lubricant.

Question 18

instructions for installation of otic products

Answer 18

Wash hands and outside of ear – dry. Warm drops to body temp. Tilt head to side with affected ear directed upwards, position dropper near but not inside ear canal opening. Pull ear auricle backwards and upward (if less than 3 yo pull back and down), place proper number of drops in ear, press skin flap (tragus) over ear to hold in medication. Stay in this position for instructed amount of time, and wipe away excess.

Question 19

instructions for instilling ophthalmic products

Answer 19

wash hands and around eye(s), if wearing contacts – remove them, tilt head back, grab lower eyelashes and pull out lower lid, put dropper directly over eye (don’t touch dropper to eye), Look up before you drop in medication, once medication placed – close eyes for several minutes with face parallel to floor, place finger on tear duct. Blot excess from around eyes. Wait at least 5 mins before reapplying. For ointments, follow same initial steps. Instead of dropping med into eye(s), place thin ¼-1/2” strip of ointment in lower lid. Close eye(s), vision may be blurred

Question 20

Recommend appropriate follow up for self-treatment of ear and eye conditions

Answer 20

If it gets worse or doesn’t improve after 72 hrs, go see a dr.

Question 21

Describe the 3 layers of tear film and the role their roles in maintaining ocular lubrication

Answer 21

epithelium: (outer) lipophilic (keeps tear film layer) – maintains optical properties and reduces evaporation
- stroma: (middle) hydrophilic – wetting properties of the tear film
- Endothelium: (inner mucinous layer) hydrophilic – allows outer and middle layers to maintain constant adhesion across cornea and conjunctiva

Question 22

Describe common causes of hearing and visual impairments and their impact on hearing and vision

Answer 22

Aging, traumas, diabetes, HTN, cataracts, glaucoma, macular degeneration; congenital defects, noise exposure, presbycusis. Impacts: reduction in hearing/vision

Question 23

Identify causes and risk factors for development of specific types of hearing and visual impairments

Answer 23

Diabetes, congenital defects, traumas, noise exposure, aging, being black (glaucoma), being white (macular degeneration)

Question 24

Assess and address barriers to communication with hearing impaired and visually impaired individuals

Answer 24

Hearing: face the person so they can see your face, be sure the lighting is good, eliminate background noise, avoid chewing or covering mouth, speak loud/don’t shout, don’t exaggerate sounds, clue person about the topic, rephrase with shorter, simpler statements, avoid crowded/noisy areas. Sight: ?? Read directions to them?

Question 25

Compare the prevalence of acute bronchitis, flu, and pneumonia in different populations.

Answer 25

Old and young people are most likely to be susceptible, or those with compromised immune systems.
Pneumonia more likely in old ppl or people who have a lot of hospital/ health care setting exposure.
Flu: old peeps
Bronchitis: Patients with COPD have it a lot.

Question 26

Describe the etiology and pathogenesis of acute bronchitis, flu, and pneumonia.

Answer 26

Flu: Viral. Transmitted through particle droplets; contaminated surfaces. Most often in winter
Bronchitis: Most often due to virus; occasionally bacterial. Most often in Winter.
Pneumonia: bacterial more often than viral – most treated as bacterial.

Question 27

List risk factors associated with the development of acute bronchitis, flu, and pneumonia

Answer 27

Bronch-a-donk: COPD, smoking, prev exposure to flu or URI

Flu: >65 yo,

Question 28

Identify signs and symptoms of acute bronchitis, flu, and pneumonia

Answer 28

Bronch: persists more than 5 days (1-3 wks), inflamed bronchi, productive cough, wheezing, NOT Fever, chills, nausea
Flu: fever, nonproductive cough, myalgia, malaise, headache, sore throat, rhinitis possible, usually lasts 3-7 days
Pneumonia: productive mucopurulent/rust colored cough mucus, fever, chills, dyspnea, chest pain, malaise, headache, confusion, lung buildup, consolidation (no sound from lung due to build up, popping sound).

Question 29

Describe complications that arise from acute bronchitis, flu, and pneumonia

Answer 29

Honk-a-bronch-a-losis: worsening of chronic conditions
Flu: Can lead to bronchitis, pneumonia, sinusitis, ear infections, worsening of chronic conditions
Pneumonia: death

Question 30

Apply prevention and treatment guidelines for acute bronchitis, flu, and pneumonia

Answer 30

BRONCHITIS: [symptomatic]warsh yo hands, expectorants, cough suppressants, beta-2 agonists if wheezing, possible high dose inhaled corticosteroid, echinacea for prevention? pelargonium for cough suppressant/reduce duration? Honey?
FLU: [antivirals]vaccination. antivirals (tamiflu), avoid sick ppl, warsh yo damn hands!, avoid touching mucous membranes (eyes, nose, mouth), cover face orifices when sneezing/coughing
PNEUMONIA: [antibiotics] vaccination for the elderly and children. Anti-bacterials - macrolides (azithromycin).
viral, self limiting: flu, bronchitis
bac: pneumonia
vaccine, fever: flu, pneumonia

Question 31

Describe the etiology and pathogenesis of asthma and COPD

Answer 31

Asthma: bronchoconstriction, excess mucus production, periodic shortness of breath; inflammation of lung; narrowing or airflow way. Childhood onset: more likely to be allergy based (possible genetic predisposition to IgE mediated response to aeroallergens). Adult onset: more often nonallergic; negative family history; possibly due to environ exposures - tobacco exposure
COPD: airflow limitation and obstruction; progressive; assoc with chronic inflammatory responses in airways and lungs to noxious particles or gases. Smoking #1 risk factor

Question 32

Compare the prevalence of asthma and COPD in different populations

Answer 32

Asthma:7.3% of population (1 in 13 Americans); ~3600 annual deaths (trending down); most common chronic disease in children
COPD: smoking #1 risk factor, ppl over 40

Question 33

List risk factors associated with the development of asthma and COPD

Answer 33

Asthma: aspirin, NSAIDS, exposure to environ pollutants, allergies, genetic predisposition to IgE mediated response to aeroallergens
COPD: Having the Flu, recurrent URI, smoking, exposure to environ pollutants, genetic antitrypsin-1 deficiency, having chronic asthma

Question 34

Identify signs and symptoms of asthma and COPD

Answer 34

Asthma: coughing, wheezing, chest tightness, shortness of breath, emotions
COPD: decreased expiratory ability, wheezing, cough, (antibiotics should only be given to someone with COPD if they have the three cardinal symptoms of increased dyspnea, increased sputum volume, increased sputum purulence).

Question 35

Describe complications that arise from asthma and COPD

Answer 35

xacerbations, death. More death. Breathing = not good, exercise intolerance.

Question 36

Identify asthma medications that are considered long-term control medications and quick relief medications. Describe appropriate use of each in ASTHMA management.

Answer 36

Short acting - SABA (albuterol, levalbuterol, isoetharine; inhaled anticholinergic (has longer onset of action, may not be best for rescue) - ipratropium.
Controller drugs - Inhaled corticosteroids (ICS), mast stabilizers, leukotriene modifiers,
Long acting bronchodialators (LABA) - inhaled beta agonist (salmeterol) - often used in combination with inhaled corticosteroids.

Question 37

Describe the role of spacers and nebulizers in the management of asthma

Answer 37

Spacers allow for more of the active drug to be appropriately inhaled deep into the lung without getting stuck in the mouth.
Nebulizers: Nebulizer – vaporize meds, breathe in. Often for breathing treatments for people who don’t respond as well to other treatments (inhalers). Takes several minutes to breathe it all in. Slow process. Breathe normally. May take 5-10 minutes to get all drug. Can be better for elderly, ppl with COPD. There are handheld portable nebulizers.

Question 38

Assess a patient who seeks assistance with breathing trouble. Determine if self-treatment is appropriate, or it referral is necessary.

Answer 38

Self-Treatment OK: symptoms mild, intermittent, short duration OR prior diagnosis of intermittent asthma AND individ knows warning signs and symptoms indicating need for urgent care AND individ does not have any concurrent diseases that impair oxygen intake or breathing (COPD, CAD) AND patient is older than 5yo AND not pregnant AND current asthma symptoms are consistent with previous symptoms AND nonRx meds are for short-term (

Question 39

Teach a patient how to use a peak flow meter and instruct on its role in asthma management

Answer 39

Breathe in and out fully, then breathe in a deep breath, and exhale into the PFM with as much force as you can; do this three times. The highest number reached is the patient’s “personal best” - use this number to determine if they’re in the green zone (within 80% of personal best - lung function is ok); if they’re in the yellow zone (50-79% of personal best - lung function is decreasing, may need to reevaluate treatments, how they’re being used); If they’re in the red zone (below 50% of personal best - they need to seek medical help). Can be a useful tool in tracking lung function

Question 40

List symptoms or situations in which you would refer a patient complaining of stomach discomfort to his or her primary care provider.

Answer 40

Frequent heartburn for more than 3 months
Heartburn while taking recommended dosages of nonRx H2RA or PPI
Heartburn/dyspepsia that continues after 2 wks of treatment with a nonRx H2RA or PPI
Heartburn and dyspepsia that occur while taking a Rx H2RA or PPI
Severe heartburn/dyspepsia
Nocturnal heartburn
difficulty/pain on swallowing solid foods
Vomiting blood or black material or passing black/tarry stools
Chronic hoarseness, wheezing, cough, choking
Unexplained weightloss
Continous nausea, vomiting, diarrhea
Chest pain accompanied by sweating, pain radiating to shoulder, arm, neck, jaw, shortness of breath
Children 45 with new-onset dyspepsia

Question 41

Recognize gastrointestinal conditions amenable to self-treatment. Describe symptoms and qualities that would differentiate one condition from another

Answer 41

Heart Burn
Usually w/in 1 hour of eating
Especially after over eating/drinking
Regurgitation with bitter/acidic fluid
Occuring 2+ times a week may = GERD (gastresophageal reflux disease)
Dyspepsia
Postprandial fullness (still unusually full feeling long after a meal) → persistance of food in stomach
Early satiation → feeling full after not eating much
Epigastric pain → unpleasant feeling under the sternum
Epigastric burning → feels like an unpleasant sensation by the heart
Bloating, nausea, vomiting, belching
Alarm symptoms: sudden weight loss, anemia, blood loss, dysphagia (trouble swallowing)

Question 42

Recommend appropriate nondrug and nonprescription therapy for heartburn and dyspepsia.

Answer 42

Nonpharmacological
Dietary and lifestyle modifications; move exercise/physical activity and less heavy/greasy/fatty foods
Keep diary of “triggers” and avoid them
Weight loss
Elevating head at bed time 6-8”
Eat smaller meals
Refrain from eating within 3 hrs of laying down
Evaluate Rx and nonRx meds for their likelihood to cause heartburn/dyspepsia
Discourage tobacco use
Limit alcohol/caffeine intake
Pharmacological
Antacids
Neutralize gastric acid
Contain Mg, Ca, Al, Na
Act as buffering agent in lower esophagus → cations react with chloride and form water compounds
Most minimally absorbed systemically
Take at onset of symptoms and 1-2 hrs later if they persist
Should NOT take regularly for more than 2 wks
Aluminum containing compounds assoc with constipation
Ca++ Carbonate ma → belching and flatulence (same with Na+ bicarbonate)
H2RA (Histamine Type 2 Receptor Antagonist)
Cimetidine, ranitidine, famotidine, nizatidine → considered interchangable at low dose
Decrease fasting and food stimulated gastric acid secretion and gastric volume by inhibiting H2Rs
BA not affected by food; reduced a little by antacids
Tolerance builds when taken daily
Preferred to take on as-needed basis
For mild-moderate infrequent/episodic heartburn and for heartburn prevention (prevention = take 30 min to 1 hr before meal)
Most common SEs = HA, dizziness, diarrhea, constipation, drowsiness
Rare thrombotic events, impotence, gynocomastia
PPIs
Antisecretory drugs
Relieve heartburn/dyspepsia by decreasing gastric acid secretion
Inhibit H+/K+ ATPase, irreversibly blocking final step in gastric acid secretion
Relative BA increases with regular dosing
Symptom onset relief may take 2-3 hours, but FULL EFFECT may not be seen for 1-4 days
Ex: omeprazole
Most common SEs = dizziness, HA, diarrhea, constipation
Chronic use may increase risk of infection.
INCREASED RISK FOR OSTEOPOROSIS IN ELDERLY
Risk of rebound acid secretion once stopped
Bismuth Subsalicylate
Believed to have topical effect on stomach mucosa
Not recommended for children
Should be avoided in those with renal failure
Dont use in those with aspirin allergy
Dark tongue and black stools ok

Question 43

Recommend appropriate follow up for self-treatment of heartburn and dyspepsia

Answer 43

If worsens, or continues after two weeks of treatment, go see PCP
If radiating pain or sweating, shortness of breath with pain, go see PCP
Try to limit use
Chronic use of PPI could = rebound acid secretion

Question 44

Describe various pathways and mechanisms for the nausea and vomiting process.

Answer 44

Common disorders: motion sickness, pregnancy, acute viral gastroenteritis, overeating, indigestion
Involves CNS and GI tract
CTZ = chemotrigger zone; outside blood-brain barrier; responds to stimuli from bloodstream or cerebrospinal fluid
VC = vomiting center; in brain stem (medulla oblongata)
Mechanical obstruction (small intestine obstruction)
Motility disorders (gastroparesis)
Infections
Topical GI irritants (Alcohol, NSAIDS, antibiotics)
Vestibular Disorders (motion sickness)
Increased Intracranial pressure (CNS tumor)
Psychogenic (anticipatory vomiting, anxiety)
CNS Disorders (migraine)
Irritation of CTZ (medication induced → chemotherapy, opioids, drug withdrawl)

Question 45

Select medications based on their mechanism of action for specific causes of nausea and vomiting

Answer 45

General Treatment Approach
most cases self-limiting and will spontaneously resolve.
ORS

Question 46

List symptoms or situations in which you would refer a patient complaining of nausea and vomiting to his or her primary care provider

Answer 46

Exclusions for Self Treatment
urine ketones/ high BG in DM patients
suspected food poisoning that doesnt clear after 24 hrs
n/v with fever and/or diarrhea (infectious disease?)
severe upper R quadrant pain, especially after eating fatty foods (pancreatitis?)
blood in vomit
yellow skin/eye discoloration/dark urine (hepatitis?)
stiff neck, no HA, light sensitivity (meningitis?)
Head injury with n/v, blurred vision/ numbness, tingling
ppl with glaucoma, BPH, chronic bronchitis, emphysema, asthma (may have bad reaction to OTC antiemetics)
preggo (severe symptoms)/ breastfeeding
drug induced n/v (opioids, NSAIDS, antibiotics, estrogens, digoxin, theophylline, lithiuim)
psychgenic induced: AN, BN
chronic disease induced : gastroparesis with DM, DKA or HHS with DM, GERD

Question 47

Recognize nausea and vomiting situations amenable to self-treatment.

Answer 47

Nausea and Vomiting in Preggos
Motion Sickness
Overeating

Question 48

Describe symptoms and qualities that would differentiate one condition from another

Answer 48

Motion Sickness
Does it occur while they’re traveling? In a car, reading while moving, on boats, riding carnival rides?
Overindulgence
Does it occur after eating or drinking too much? Especially if it is a lot of sugary foods
Pregnancy
Morning sickness; are they pregnant? How far along? (mostly seen in first trimester). Is anyone around them sick?
Viral/Bacterial illness
Is anyone around them sick? Accompanied by fever, body aches, diarrhea, other signs of viral or bacterial infection?

Question 49

Recommend appropriate non-drug and pharmacologic treatment approaches for nausea and vomiting related to: motion sickness, morning sickness, overeating, food poisoning, and medications

Answer 49

NonPharmacologic Therapy
ORS for rehydration
Sports drink
avoid reading during travel
avoid XS food/alcohol, especially during/before travel

Avoid N/V in Pregnancy:
fresh air where you sleep
eat some dry crackers before getting out of bed
get out of bed very slowly
eat more, smaller meals throughout day; donot overeat at meals
drink small sips of liquids btwn meals; dont drink a lot at meals or soup
if nauseated, sip carbonated beverage
avoid greasy/fatty foods
eat chilled rather than warm or hot foods
eat high protein, bland foods

Pharmacologic Therapy
Motion Sickness
amtihistamines: Meclizine (may be less sedating), doxylamine, diphenhydramine (use with caution with opiates, psychiatric meds, B-blockers, antiarrhythmics)
may thicken brochial mucus (anticholenergics) → use with caution in asthmatics, COPD, angle-closure glaucoma
dizziness
Food or Beverage
overindulgence, comsumption of disagreeable foods, indigestion
antacid and histamine type 2-receptor agonist (H2RA)
Bismuth subsalicylate
Phosphorated carbohydrate solution (PCS) (theory is that it slows stomach down, like eating something to help nausea)
may cause stomach pain and diarrhea
caution in patients with diabetes
first generation antihistamines are anticholinergic; so second generations like Allegra dont work bc not anticholinergics. (effects on inner ear fluids)

Food Poisoning
Throw it up! Get it out of the system. Stay hydrated. Self-limiting
Medications
May need Risk/Benefit assessment. Can lessen or pull patient off drug/ change meds. May also have patient take med with meals to lessen stomach upset.

Question 50

Know the active ingredients, contraindications, appropriate use, effects, and unwanted effects of nonprescription medications used to treat nausea and vomiting

Answer 50

Cyclizine
Anticholinergic/antihistamine; may cause sedation, dry mouth, dry eyes
Dont use in those under 6
Meclizine
Antihistamine; avoid with alcohol, not as sedating 
Dont use in those under 6
Dimenhydrinate
May cause drowsiness/ paradoxical CNS stimulation, anticholinergic effects, tinnitus, hypotension
Can use in 2-6 yos
Diphenhydramine
Marked drowsiness
Can use in 2-6 yos

Question 51

Recommend appropriate follow up for self-treatment of nausea and vomiting

Answer 51

Stay hydrated with ORS. If it does not clear up after 24 hrs, go see PCP. If symptoms change or get worse, see PCP. If due to overeating, change your eating habits. If medication related, consult with PCP before changing meds.

Question 52

List symptoms or situations in which you would refer a patient complaining of diarrhea or intestinal gas to his or her primary care provider

Answer 52

Exclusions for Self-Treatment (Intestinal Gas)
intestinal gas symptoms that persist more than several months or occur several times a month
severe debilitating symptoms
sudden change in location of abdominal pain, significant increase in the frequency or severity of symptoms, or an onset of symptoms in individuals > 40yo
symptoms accompanied by significant abdominal discomfort or a sudden change in bowel function (diarrhea/constipation)
presence of severe/persistent diarrhea/constipation, GI bleeding, fatigue, unintentional weight loss, frequent nocturnal symptoms

Exclusions for Self-Treatment (Diarrhea)
 or = 6 mo with persistent fever >102.2 F
blood, mucus, pus in stool
protracted vomiting
orthostatic hypotension
severe abdominal pain
risk for significant complications
DM, severe CVD, renal disease; multiple chronic conditions; immunosuppressed patients (AIDS, organ transplant, chemo)
Pregnancy
chronic/ persistent diarrhea
inability of caregiver to administer ORS
suboptimal response to ORS

Question 53

Recommend appropriate non-drug and nonprescription therapy for self-treatable cases of diarrhea and intestinal gas

Answer 53

Nonpharmacological Treatments: (Intestinal Gas)
changes in eating habits and diet
reduce consumption of gas producing foods

CAM (Intestinal Gas)
probiotics
Carminatives (mint, peppermint, spearmint, fennel)
fennel = contraindicated in pregnancy; may cause photosensitivity, cleates with ciprofloxacin lessening its activity

NonPharmacologic Therapy (Diarrhea)
rehydration using ORS

Question 54

now the active ingredients, contraindications, appropriate use, effects, and unwanted effects of OTC anti-diarrheal agents and anti-gas products

Answer 54

Intestinal gas
Pharmacologic Therapy:
Simethicone and activated charcoal = relieve symptoms after intestinal gas has formed.
simethicone: mix of inert silicon polymers
defoaming agent to relieve gas→ reduces surface tension of gas bubbles embedded in mucus of GI tract
FDA approved
Contraindicated in those with simethicone sensitivity or GI perforation and obstruction
Simethicone and loperamide: treatment of nonspecific diarrhea = quick relief
Antacids:many contain antacid and simethicone → efficacy of combo not well founded
Activated Charcoal → purported to eliminate malodorous sulfur-based gases
lactase and alpha-galactosidase may prevent gas formation/ diarrhea oligosaccharides
alpha-galactosidase: hydrolyzes (high fiber foods)
safety remains to be determined
** should not be used in patients with galactosemia
** beware mold allergies
** beware those with diabetes
** haven’t been evaluated for safety in peds
Lactase: break down lactose
no known adverse effects
Special Populations
Peds
ped formulations of simethicone available (40 mg simethicone / 0.6 mL) → used with gas from colic
Not absorbed by GI, considered dafe
Preggos
No reports of congenital defects
Preg Category C
Safe for Nursing moms

Diarrhea
Pharmacologic Therapy
loperamide: synthetic opioid agonist that lacks CNS effects
antidiarrheal effects: stimulates peripheral micro-opioid rececptors on intestinal circular muscles to slow intestinal motility and allow absorption of water and electrolytes
symptomatic relief of acute, nonspecific diarrhea
can use in 6 yo and greater, provides directions for as young as 2 yo
SE: constipation, dizziness; infrequent: abdominal pain, N/V, dry mouth, fatigue
not recommended for invasive bacterial caused diarrhea
Bismuth Subsalicylate
antimicrobial effects and antisecretory effects (reduce fluid and electrolyte loss)
12 yo and older
also for indigestion
may cause black tongue/ stool
tinnitus could = toxicity (from salicylates)
contraindicated in those recovering from chickenpox or flu (Reye’s Syndrome); asthmatics (bronchospasms), dont use with aspirin

CAM
probiotics
daily zinc supplement

Special Populations
children under 5 = self-limiting treatment; ORS; antidiarrheals not recommended
elderly (>65yo) strongly caution against antidiarrheals; diarrhea can be fatal
Preggos = refer

Question 55

Evaluate the role of probiotics in the management of diarrhea

Answer 55

Appropriate for preventing and treating mild acute, uncomplicated diarrhea, especially rotavirus diarrhea in children. Probiotics produce acids that lower stomach pH and inhibit growth of harmful bacteria, enhance immune responses, and compete with pathogenic bacteria for binding sites

Question 56

Recommend appropriate follow up for self-treatment of diarrhea and intestinal gas

Answer 56

If Diarrhea gets more severe or is still an issue after 48 hrs, go see PCP. If it is bloody at all, go see PCP. Stay hydrated!!!!

Question 57

List symptoms or situations in which you would refer a patient complaining of constipation to his or her primary care provider

Answer 57

Exclusions for Self - Treatment
marked abdominal pain, significant distension or cramping
marked or unexplained flatulence
fever
N/V
presence of chronic medical condition that may preclud selfcare laxative treatment (paraplegia or quadriplegia, inflammatory bowel disease, colostomy)
daily laxative use (excluding fiber therapy)
unexplained changes in bowel habits, especially if accompanied by weight loss
blood in stool or dark, tarry stool
marked change in stool character (becomes pencil thin)
any bowel symptoms that last for greater than 2 weeks or recur over at least 3 months
any bowel symptoms that recur after dietary or lifestyle changes or laxative use
inflammatory bowel disease
anorexia
age 2 or less

Question 58

Recognize constipation situations amenable to self-treatment.

Answer 58

Clinical Presentation
decreased frequency or difficulty passing
anorexia
dull  HA
Lassitude
low back pain
abdominal discomfort
bloating/flatulence
psychosocial distress

Question 59

Recommend appropriate non-drug and nonprescription therapy for different causes of constipation

Answer 59

Nonpharmacologic therapy
prevent
eat a balanced diet, increase fruit intake, vegetable intake, half of grains consumed should be whole grain, 14 g dietary fiber per 1000kcal consumed (25 g for women, 38 g for men)
Fiber adds weight and tends to normalize bowel movements
gradually increase intake of insoluble fiber; limit foods with no fiber (cheese, meat, processed foods)
supplement diet with fiber supplement (inulin); bulk forming (psyllium and methylcellulose)
Benefits of adding fiber to diet may not be seen for 3-5 days or longer
significantly increasing dietary fiber in any form may lead to erratic bowel movements, flatulence, and abdominal discomfort for first few weeks
gradually increase fiber intake over 1-2 weeks to improve tolerance
Behavior modification (bowel training)
when you have to go, go!
can try to go first thing in morning and 30 mins after meals when gastrocolic reflexes are strongest
Exercise → low activity levels associated with more constipation

Pharmacologic therapy
Ideal laxative: nonirritating and nontoxic, would act only on descending colon and sigmoid colons, produce normal stool within a few hours
bulk forming agents
things with methylcellulose, polycarbophil, psyllium
recommended for most constipation bc most closely approximate physiologic mechanism in promoting evacuation
dissolve/swell in intestines, forming emollient gels that stimulate peristalsis and facilitate passage
dosage forms = tablets, capsules, powders to be mixed with drinks, fiber chews, wafers, or gummies
NOT systemically absorbed
Action onset 12-24 hours, may be up to 72 hours
Useful for
patients on low fiber diets
postpartum women
older adults
patients with colostemies, irritable bowel syndrome, diverticular disease
prophylactically for patients who should avoid straining in bowel movements
too much could = obstruction if not enough fluid intake or increased flatulence
most common SE = abdominal cramping and flatulence
if not taken with enough fluid, can swell in throat or esophagus and cause choking
AVOID IN THOSE WITH SWALLOWING ISSUES and those with hypersensitivities, and those with intestinal ulcerations, stenosis, disabling adhesions
palliative care patients and opioid induced constipation patient issues
can interfere with medication absorption; should space bulking agents and medications by at least two hours
assess before giving to diabetic patients for sugar content
sugar free ones contain aspartame and should be avoided in those with phenylketonuria
Hyperosmotic agents
polyethylene glycol 3350; glycerin
ions that draw fluid into the colon or rectum to stimulate bowel movement
PEG recommended only for those 17 and older
powder for oral administration (17 g of powder/day mixed in 4-8 oz water)
not realy absorbed or degraded by GI tract → well tolerated
Glycerin suppositoties usually produce a bowel movement in 15-30 minutes of administration
safe and effective, may cause anal irritation if over used
no concern for drug interactions

Question 60

Describe the active ingredients, contraindications, appropriate use, effects, and unwanted effects of laxatives. Know the six different categories of laxatives, their mechanism of action, and the primary ingredients in each category

Answer 60

Bulking agents → adds more bulk/weight, helps push things through your system. Good for those with straining and little bowel movement
Onset = 12-72 hours
Fibers
psyllium
Hyperosmotics → draw liquid into the gut/intestines and helps get things moving
Onset = 15-30 minutes for suppository; Oral PEG = 12-72 hrs
PEG
glycerin
Stimulants → works directly on cilia in the gut, gets them moving faster so things move faster through GI track
Onset = 6-10 hrs, may require up to 24 hrs
Senna compounds
Bicacodyl
Emollients → soften the stool, makes it easier to pass
Onset = 12-72 hours (usually 48 hours)
docusate
Lubricants→ what it says, lubes it up so stool can pass quicker
Onset = oral 6-8 hrs; rectal 5-15 minutes
Mineral oil
Saline solutions → uses ions to pull water from GI track and gets things flushed out
Onset = 30 mins to 6 hrs (oral); 2-15 mins (rectal)
Magnesium sulfate

Question 61

Recommend appropriate follow up for self-treatment of constipation

Answer 61

Staying hydrated can help keep stools soft. Depending on cause of constipation, may want to add fiber (slowly) to the diet. If opioid induced, will want to stay on a regimen of stimulant and emollient (like senna and docusate)

Question 62

Describe the etiology and pathogenesis of osteoarthritis

Answer 62

OA → gradual softening and destruction of cartilage between bones
OA pain
does not directly correlate to degree of joint damage
proximal muscles may be involved if a person with OA guards the affected joint to reduce discomfort
pain often limits patient’s activities of daily living (ADL)
Aka “degenerative joint disease”
Slowly progressive
Characterized by:
Loss of cartilage
Bone remodeling
Inflammation
Bone-on-bone friction pain, stiffness and reduced range of motion in affected joints
•Normal cartilidge is smooth and relatively thick; arthritis gets fibrous, thinner cartlidge, bone on bone rubbing à initiates bone remodeling; but unregulated = additional growths (ostephyte) = inflammation of synovial cap
•Synovium membrane surrounds the joint cavity
•Contains synovial fluid
•Smooth articular cartilage
•Regulated chondrocyte activity
•Compared to OA:
•Inflamed synovium membrane
•Degenerated cartilage from excessive chondrocyte activity
•Growth of osteophytes/ bony spurs
•Pain from activation of nociceptive nerve endings
•Cells found in cartilage – produce and maintain the cartilage matrix
•The more chondrocytes in the cartilage, the more elastic it is:
•Elastic cartilage
•Hyaline cartilage
•Fibro-cartilage
•These cells are able to regenerate to a certain extent, but the process is slow and unable to effectively counteract repetitive stress or injury
•At this point, damage is first seen in the cartilage via imbalance of chondrocytes that eventually affects all other tissues in the joint
•Progression from cartilage à whole joint disease

Question 63

Compare the prevalence of osteoarthritis in different populations

Answer 63

Most common type of arthritis
Age of onset = 45yo; 45 is dividing line ppl with symptoms b4 45 are likely male, after 45 more women than men
F
≥45yo: OA is seen in F>M
Incidence increases with age, most often in elderly
Most common cause of disability among the elderly
Symptoms get worse with age; reduce range of motion
Men are at a greater risk of developing OA early on because they are more likely to have jobs or participate in activities that involve a lot of lifting or repetitive movement
Women on the other hand are more likely to develop OA than men when they are 45 or older

Question 64

List risk factors associated with the development of osteoarthritis

Answer 64

Obesity – preventable, risk associated with weight-bearing joints
Occupation – prolonged activities and repetitive movements
Sports – activity that is done on a pre-existing injury
History of joint trauma
Genetic – still being studied, less likely compared to other factors

Question 65

Identify signs and symptoms of osteoarthritis

Answer 65

Affected joints = hands, knees, hips and spine weight bearing joints
Distal joints > medial joints
Unilateral bilateral with progression; keeping weight off one knee = over compensation
on other knee pain in both
Typical symptoms:
Morning stiffness lasting

Question 66

Describe complications that arise from osteoarthritis

Answer 66

Pain, stiffness, reduced range of motion. May affect ability to work

Question 67

Compare rheumatoid arthritis and osteoarthritis

Answer 67

May be genetic predispositions that are influenced by the environment
2-3x more women affected than men
Pain, stiffness, and swelling in the morning
lasting greater than 1hour
Predominantly, but not exclusively, affects smaller joints (as opposed to weight bearing)
Hands, wrists, feet, ankles
Characteristically affects the first and second joints on the hands. (opposed to OA, which has
something to do with distal joints)
proximal interphalangeal (PIP)
metacarpophalangeal (MCP)
Usually poly-articular
This wont just hurt in the morning, will hurt all the time
Symmetrical

Muscle Weakness and Joint Deformity
	Reduced grip strength
Osteopenia (not osteoarthritis)
	Systemic and focal
Sjogren’s Syndrome
	Oral and ocular dryness
Carpal Tunnel Syndrome (inflammation around nerve that causes pain)
	1-5% prevalence in RA patients
Organ Involvement
	Skin, lung, heart, eyes

Yeah, NSAIDS help with pain, but doesn’t slow down disease progression. Glucocorticoids make you feel better, but complications with long-term therapy à suppresses adrenal system, so if you were to suddenly stop using them you might die (also fat redistribution = round face and buffalo hump)

Question 68

Apply the guidelines to determining appropriate non-drug and pharmacological treatment for osteoarthritis

Answer 68

NonPharmacological options
Weight loss
Exercise
Physical and occupational therapy
OT learning how to do certain activities, tips/tricks to do daily activities with
range of motion you have; PT focused on healing affected joint, getting back range of motion

Thermal treatment
Assistive devices
Acupuncture
Manual therapy - chiropractic
Surgical procedures
Pharmacological Therapy
Topical/ Transdermal Agents
Salicylates – provide topical counter-irritation to distract from symptoms of the
affected joint
Ex. Methyl salicylates (IcyHot, Bengay), trolamine salicylate (Arthricream)
Capsaicin – isolated from hot peppers, releases and depletes substance P from
afferent nociceptive nerve fibers
Apply 2-4x/day, may take up to 2 weeks for full effect
NSAIDs (Rx) – only topical agent on the market is COX-2 selective
Ex. Diclofenac gel/ solution
MAX total body dose for GEL = 32g/day

Oral Agents
	APAP – inhibits prostaglandin synthesis
		Scheduled for chronic OA = 352-650mg Q4-6hr
	NSAIDs (OTC)– block prostaglandin synthesis via inhibition of COX 1 & 2 enzymes
		Remember standard counseling for NSAIDs: adverse effects, toxicities, etc
	Tramadol – opioid with weak inhibition of norepinephrine and serotonin  reuptake Possible monotherapy for pain: schedule IV Rx Opioids – reduce pain perception by binding to & blocking opioid receptors
Typically 3rd line due to side effects, reserve for chronic OA only
Oxycodone most studied  Duloxetine – SNRI, also indicated for depression and diabetic neuropathy
Takes up to 4 weeks to see effect
No clear recommendation for use, off-label
Reserved as last line/ adjunct for chronic pain Dietary Supplements
	Glucosamine & Chondroitin Sulfate: stimulate anabolic process in cartilage and  thought to have anti-inflammatory activity
Possible supplement or adjunct to prevent/ slow progression of  OA
Glu/CS shown to prevent 1.2% cartilage volume loss in the knee
	May help reduce symptoms long-term for patients; not  recommended as first line or monotherapy Vitamin D: deficiency associated with poor bone health
	No correlation between vitamin D serum levels and incidence of OA 
Intra-articular Injections
	Corticosteroids & Hyaluronic acid

Question 69

Recognize musculoskeletal problems amenable to self-treatment. Describe symptoms and qualities that would differentiate one condition from another

Answer 69

Myalgia - muscle pain; can result from systemic infections (flu), chronic disorders (fibromyalgia), and meds (statins). Can also be result of alcohol abuse or vit D deficiency
Strains - result of injury to muscle or tendon. Can be caused by acute injury, pro-longed over use; can become a chronic condition. caused by eccentric contraction of muscle while muscle is lengthening
Tendonitis - inflammation of tendon. Results from acute injury or chronic repetitive movements. Ex: carpal tunnel (nerve sheaths inflammed and squeeze the nerve)
tennis/golfer’s elbow
swimmer’s shoulder
jumper’s knee
**Medication: fluoroquinolone antimicrobials may cause tendon rupture/tendonitis
Bursitis - common cause of localized pain, tenderness, and swelling worsened by movement of the joint (bursa). results from acute injury/ repetitive action.
Sprains - most common problem with ligaments. → inversion ankle injury
Grade I - result from excessive stretching
Grade II - result from partial tear
Grade III - result from complete tear of tissue
Grades II & III usually = moderate to severe pain, loss of function of affected limb, and inability to bear weight
Tears and ruptures more common in ligaments than tendons
Strain- tendon or muscle; over exertion
Sprains and strains generally treated the same
Low Back Pain - common cause = sedentary life style, poor posture, improper shoes, poor mattress/sleeping posture, excessive body weight, improper technique when heavy lifting
most recover in a few days to a few weeks without needed treatment
if lasts > 3 mo = chronic lower back pain
other causes → congenital abnormalities, OA, vertebral fractures and compressions, spinal TB, pain from kidneys, liver, pancreas, prostate
OA → gradual softening and destruction of cartlidge btwn bones

Clinical Presentation of Musculoskeletal Injuries and Disorders
pain
varying degrees of joint function → limited joint function from a sprain may = (partial) tear → req’s proper workup to rule out fracture or tear
carpal tunnel patients
diminished sense of heat/cold
sense hands are swollen when they’re not
weakness in hands → tendency to drop things
symptoms persist during sleep and when hands not being used → distinguishing factor
OA pain
does not directly correlate to degree of joint damage
proximal muscles may be involved if a person with OA guards the affected joint to reduce discomfort
pain often limits patient’s activities of daily living (ADL)
Low Back Pain
can be neuropathic, involving sciatic nerve → sharp, referred pain in one or both legs
can limit ability to stand, bend, move, sit walk
Untreated pain/injuries may involve
further tissue damage
Bone/cartilage remodeling
disability
work loss
physical impairments (insomnia)

Question 70

Assess a sports injury and counsel on appropriate non-pharmacologic treatment

Answer 70

Nonpharmacological
RICE
rest, ice (not applied for more than 15-20 mins at a time), compression, elevation
promotes healing, helps reduce inflammation
Can prevent sports/exercise injuries by warming up/ stretching muscles before activity, ensuring proper hydration, and wearing appropriate footwear
Muscle cramps → stretch and massage, then immediately rest
electrolyte depletion → oral supplement of electrolytes; fluids containing potassium, sodium, and magnesium
Heat and cold therapy
heat → for noninflammatory in nature injuries; good for acute back pain; hot water bottle, warm wet compress, heating pad
should NOT be used with topical analgesics or over broken skin; should be avoided with inflamed areas; dont use on areas with decreased sensation
Products → (ThermaCare - dont place in knee pit or elbow pit, Precise, generics) can be worn for up to 8-12 hrs
Heat wraps should not be worn during sleep, and should be worn over a towel/article of clothing for those 55yo and up
Cold → 15-20 mins 3-4 times a day
TENS → transcutaneous electrical nerve stimulation
FDA approved
Class II medical device
For sore, aching muscles/joints/chronic intractable pain (may provide temp relief, but wont necessarily take care of problem itself)
SOURCE OF PAIN RELIEF → alteration of pain transmission and release of natural endorphins
used 15-30 mins, up to TID
electrode pad placement is product dependent
AVOID USING ON CHEST, NECK, HEAD, CAROTID ARTERY
AVOID PLACE ON wounds, sores, inflamed areas, sensitive/sensitized areas, cancerous lesions, over topical analgesics
AVOID in ppl with internal or attached devices (pacemakers, insulin pumps, respirators, cardiograms)
AVOID IN PREGGOS
For home use
Proper posture and use of ergonomic controls (seats with back support)
Better fitting shoes
mobilization with PT or exercise
chiropractic manipulation
acupuncture

Question 71

Describe an assessment process for determining whether self-treatment is appropriate for a patient who requests assistance in choosing an external analgesic product.

Answer 71

Exclusions for Self-Treatment
severe pain (pain score >6)
pain that lasts >10days
Pain that continues >7 days after treatment with a topical analgesic
increased intensity or change in character of pain
Pelvic or abdominal pain (other than dysmenorrhea)
Accompanying nausea, vomiting, fever, other signs of systemic infection or disorder
Visually deformed joint, abnormal movement, weakness in any limb, numbness, or suspected fracture
pregnancy

Question 72

Describe the formulations, active ingredients, contraindications, appropriate use, effects, and unwanted effects of nonprescription external analgesics

Answer 72

Topical Products
local analgesic, anesthetic, antipruritic, anti-irritant effects
nonRx topical analgesics are approved specifically for topical treatment of minor-moderate aches and pains of muscles and joints (arthritis, sprains, bruises, strains)
recommened as adjunct to pharmacologic and nonRx therapy of musculoskeletal injuries and disorders
counterirritants → applied to skin to relieve pain. Produce a less severe pain to counter a more intense one → relief more from nerve stimulation than suppression
produce mild, local inflammatory rx → relieves site underlying skin where applied → detract from deep-seated pain in muscles, joints, and tendons
Pain is only as intense as it’s percieved to be.
Cannot be used on those under 2yo
Have been chemical burn reports
products with higher [ ] of menthol: greater than 3% menthol and 10% methyl salicylate
Methyl Salicylate: occurs naturally as winter green oil, etc. Usually combined with other ingredients (menthol, camphor)
rubefacient → causes vasodilation thereby producing hyperemia; supposed to increase temp of skin and produce a counterirritant effect.
Responsible for “hot” aciton in many topical products
inhibit central and peripheral prostaglandin synthesis
direct tissue penetration
Camphor: occurs naturally, but about ¾ available = synthetically made
[ ] of 0.1-3.0% = depresses cutaneous receptors and is used as a topical analgesic, anesthetic, and antipruritic
[ ] > 3.0% , when combined with other counterirritants, induces pain relief by masking moderate-severe deeper visceral pain, with a milder pain
when applied vigorously, acts as rubefacient
Higher [ ]s can cause serious SE and toxicity
CNS toxicity → seizures, can occur w/i 10 mins following ingestion
can cause nausea, vomiting, delirium, convulsion, coma, death
dangerous for kids
Menthol: synthetic or prepped from peppermint oil
can be used in small qty as flavoring agent
[ ] at 1.25% = stimulates cutaneous receptor resonse (acts as counterirritant)
topical menthol activates TRPM8 menthol receptor, triggering sensation of cold, followed by sensation of warmth
Methyl Nicotinate: nicotinic acid is inactive topically, readily penetrates cutaneous barrier.
vasodilation and elevation of skin temp result from low [ ]s with
indomethacin, ibuprofen, aspirin significantly depress skin’s vascular response to methyl nicotinate → vasodilator response affected bc prostaglandin synthesis disrupted
Due to vasodilation effect, may cause drop in BP/pulse rate if applied to large area
Capsicum Preparations: capsaicin, capsicum, capsicum oleoresin → derived from fruits of nightshade family.
contains ~1.5% irritant oleoresin → capsaicin = major component
major pungent ingredient of chili peppers
when applied to normal skin, elicits feeling of warmth through stimulation of TRPV1 receptor.
MOA → depletes substance P (found in slow-conducting, unmyelinated type C neurons that innervate dermis and epidermis)
pain and pruritic stimuli passed along type C neurons
depletion occurs peripherally and centrally
when substance P released = burning sensation
compares with counterirritants
USED TO REDUCE PAIN BUT NOT INFLAMMATION of RA/OA
optimal dose varies btwn patients
pain relief not immediate. USually takes 14 days; may take 4-6 weeks
must use 3-4x/day
wash hands after application
has been assoc with cough, runny nose, sneezing
Additional counterirritants
allyl isothiocyanate, ammonia water, turpentine oil → Category I
rubefaciants
Pharmaceutical Efficacy and Recommendations for Counterirritants
topical rubefascients not supported to be used for acute or chronic pain; compare poorly with NSAIDs
methyl salicylate and menthol patch for moderate-mild muscle strain = effective; only FDA approved analgesic patch
Other Topical Analgesics
Trolamine Salicylate
category III, but several nonRx contain it as primary ingredient. Not supported by evidence
Topical NSAIDs
not available nonRx in US
Rx example → diclofenac
benefits of oral NSAIDs with minial SEs
Product Selection Guidelines
Special Populations
not significant response variability btwn age groups or races
Preggos should be eval-ed by pcp
capsaicin = category B; some list it as C
camphor, menthol, methyl salicylate not categorized
suggested that topical camphor compatible with pregnancy
Patient factors
nonpharm and oral drug therapy often used
consider patient’s history, other meds, allergies
Patient Preferences
dosage forms

Question 73

Demonstrate the proper use of a cane, crutches, walker, and wheelchair

Answer 73

Mobility Aids
- Cane
o Reduce weight or assist with balance
o Opposite hand of affected limb
o Want the handle about wrist height, don’t want them to have to have unusual posture when using it à prevent other injuries
§ A lot are adjustable
- Crutch
o Usually not for older patients
o Usually want an inch or two below arm pit (posture); hand grip should be about wrist height à slight bend in elbow
o Are a lot of problems that can occur with long-term use
- Walker
o Many diff types; assess specific needs
§ Balance issues?
§ Pain/injury issues?
- Wheelchair
o Many different types; assess specific needs
o Foot rests are often a fall hazard
o Prolonged use hazards
§ Pressure sores/ bed sores
§ Loss of circulation
§ Make sure brakes are used
§ Communication issues
§ When they come up to the pharm counter and you cant see them bc they are low and pharmacy counter is really high
- Joint Protection: Splints and Braces
o Immobilize or limit mobility
§ May help with inflammatory conditions
§ Wrist brace for carpal tunnel syndrome
§ Semi-restrictive ankle brace to avoid injury
§ A lot of times people will come in having already been diagnosed with something
- Support Stockings
o Who can support from them?
§ People with edema (CHF)
· With severe edema, size might go down over time
§ Varicose veins
§ People who stand for long periods of time/ sit for long periods of time (lower pressure gradients)
§ Ppl who are likely to develop DBTs (higher gradients)
§ Pregnancy
§ Come in a lot of diff patient gradients; highest at lowest point (near foot); less pressure as you get up
§ NOT for arterial insufficiency
§ Chronic venous insufficiency (higher gradients)
o Should be worn as much as possible (safe to wear all day)
o Some can be machine washed, some have to be hand washed
o Some pharmacies carry, some have to order, some sock stores carry, some athletic stores carry
o Be careful to latex allergies/ components of stockings
o Watch for rashes and reactions
o Don’t use for people who have lesions that might be oozing or weeping