RTS- Pain

Question 1

List 3 pharmaceutical analgesics available.

Answer 1

1) paracetamol

2) non-steroidal anti-inflammatories (NSAIDs)
- e.g ibuprofen, diclofenac, naproxen, aspirin and its derivatives
- reduces release of inflammatory and pain mediators.
- N.B diclofenac tablets have been reclassified for P to POM

3) opioids - low dose codeine and dihydrocodeine
- reduces neural transmission of pain.

Question 2

List the symptoms of acute and chronic pain (3, 3)

Answer 2

Acute

1) sudden pain
2) swelling and tenderness in affected area
3) weakness

Chronic pain

1) pain when playing or exercising
2) dull ache at rest
3) swelling

Question 3

List 3 types of pain.

Answer 3

1) neuropathic (nerves)
2) visceral (organs/tissues)
3) somatic (bones/muscles)

Question 4

Outline the dose, side effects, formulation, counselling and action of paracetamol. (8)

Answer 4

1) analgesic and antipyretic action
2) action not fully understood
3) adult dose 500-1000mg four time daily
4) children’s dose depends on age
5) tablets, capsules, soluble tablet, liquid & suppositories
6) side effects are rare
7) counsel max dose,do not take other paracetamol containing products
8) max 100 tablets as a P medicine at pharmacists discretion if justifiable reason.

Question 5

Outline the dose, side effects, formulation, counselling and action of ibuprofen. (9)

Answer 5

1) ant-inflammatory, analgesic & antipyretic action
2) adult dose 200-400mg three times daily
3) children’s dose depends on age.
4) tablets, capsules, orodispersible tablets, liquid & gel.
5) care in elderly, respiratory, GI, renal disease, pregnancy & breast feeding
6) counsel max dose & take with or after food.
7) other OTC NSAIDs diclofenac & naproxen
8) can cause asthma attacks, ensure patient has taken it before.
9) side effects go disturbance, dyspepsia, hypersensitivity

Question 6

Outline the dose, side effects, formulation, counselling and action of mild opioids. (11)

Answer 6

1) analgesic action
2) codeine and dihydrocodeine available OTC and only in combination with paracetamol
3) tablets, dispersible tablets and capsules
4) adult dose (8-12.6mg codeine per tablet) 2 tablets QDS
5) children’s dose- not recommended for children under 12 years
6) take care in asthma, COPD, elderly, head injury, kidney/liver impairment, pregnancy and breastfeeding
7) side effects- constipation, drowsiness
8) counsel max dose and may cause drowsiness could affect driving avoid alcohol. side effects may be worse in elderly patients
9) indication for short term treatment of acute moderate pain, not relieved by paracetamol, ibuprofen and aspirin
10) max OTC supply = 32 both solid and effervescent
11) labelling requirements- can cause addiction . For 3 days only

Question 7

Outline the dose, side effects, formulation, counselling and action of caffeine. (6)

Answer 7

Often listed as an active ingredient in analgesic preparations

1) supposed to enhance pain relief, especially in headache.
2) improves absorption of the analgesic by lowering gastric pH.
3) dose generally 130mg- about a cup of coffee/tea
4) side effects- sleep disturbance, hypertension, peptic ulcer disease
5) some users may find the extra alertness unpleasant
6) risk of dependence and misuse

Question 8

Outline the use of analgesics in elderly patients and children (4, 1)

Answer 8

Elderly

1) paracetamol 1st line
2) increased risk of GI toxicity with NSAIDs
3) increased risk side effects from opioids
4) increased risk of fractures

Children
1) no aspirin under 16 years

Question 9

Outline the use of analgesics in patients with cardiovascular & renal disease and GI conditions. (3, 2)

Answer 9

Cardiovascular & renal disease

1) caution with NSAIDs in heart failure
2) NSAIDs may impair renal blood flow leading to sodium and water retention oedema & hypertension
3) sodium content - effervescent contains lots of sodium

GI conditions

1) NSAIDs contraindicated in history of, or active GI ulceration
2) caution with NSAIDs in inflammatory bowel disease

Question 10

Outline the use of analgesics pregnant in and breast feeding and hepatic impairment patients (1, 2)

Answer 10

Pregnancy and breastfeeding
1) paracetamol 1st line

Hepatic impairment

1) increased risk of GI bleeding with NSAIDs
2) paracetamol generally safe at normal doses

Question 11

List the common musculoskeletal ailments seen in the community. (9)

Answer 11

1) bruising
2) lower back pain ( lumbago)
3) arthritis, rheumatism
4) activity/sports related injuries
5) minor soft tissue (muscle, tendons, ligaments) injuries can be treated OTC
6) severe soft tissue damage and hard tissue (bone, cartilage) damage needs referral and investigation
7) sprains- over stretching or twisting of ligaments, may rupture blood vessels
8) strains- muscle or tendon injury with swelling and pain
9) bruising - damage to capillaries causing blood leaking in tissue
Refer:dislocation-of bones at joints ,fracture- break in bone or cartilage

Question 12

Order the injuries from most likely to least likely, for the following:

1) ankle-Achilles’ tendon injury, sprain, stress fracture or plantar fasciitis.
2) knee- stress fracture, chrondromalacia ( runners knee), ligament damage.
3) Elbow- tennis elbow/ golfers elbow, bursitis (students elbow)/ stress fracture.
4) shoulder- frozen shoulder, other types of RSI, injury caused by overhead work (RSI)

Answer 12

Most likely - likely - unlikely

Ankle- sprain , Achilles’ tendon injury, plantar fasciitis or stress fracture

Knee- ligament damage , chrondromalacia ( runners knee) , stress fracture

3) Elbow- tennis elbow/ golfers elbow, bursitis (students elbow)/ stress fracture.
4) shoulder- frozen shoulder, injury caused by overhead work (RSI), other types of RSI

Question 13

In order to minimise recovery time following a sports/ activity related injury it is essential to treat with PRICE and avoid HARM to minimise swelling and secondary tissue damage. Explain what the acronym PRICE & HARM stand for.

Answer 13

Protect 
Rest
Ice 
Compression 
Elevation 

Heat
Alcohol
Running
Massage

Question 14

Describe phase one of the process of healing after an activity/sports related injury (5)

Answer 14

1) phase one - inflammation
2) blood and tissue fluids accumulate causing swelling
3) symptoms such as redness, heat , swelling and pain
4) potential formation of blood clots
5) lasts approximately 72 hours

Question 15

Explain the following: tennis elbow, golfers elbow , bursitis, runners knee. (4)

Answer 15

1) Tennis elbow- pain above elbow joint, may spread to upper arm
2) Golfers elbow- pain on inner side of elbow, may radiate down forearm.
3) bursitis- swelling of joint, tenderness and pain e.g. Students elbow, housemaids knee
4) runners knee- knee pain on movement and impact ( mainly in novice runners)

Question 16

Describe phase two of the process of healing after an activity/sports related injury (5, 2)

Answer 16

Phase two

1) takes up to six weeks
2) blood clots gradually removed
3) tissue repaired- scar tissue may form
4) analgesia may be required
5) continues support may be useful - gradually reduced

Phase three:

1) change of scar repair fibres info more ordered arrangement
2) process is promoted by gradual activity, especially gentle stretching and increasing normal movement.

Question 17

Describe the points to consider for an activity/ sports related injury (5)

Answer 17

1) onset and duration can affect course of action
2) should improve after a few days depending on cause of problem
3) important to establish events leading up to the injury to confirm type of injury
4) can influence choice if treatment
5) some drugs can mask pain, increase chance of fractures etc.

Question 18

Outline the referral criteria for a activity/sports related injury. (13)

Answer 18

1) severe/ prolonged pain/ swelling
2) unable to bear weight
3) bone or joint visibly out of place
4) bone or joint visually out of place
5) limb, hand, foot, finger or toe is immobilised
6) old injury hurts, aches or swells
7) joints feel abnormal or unstable
8) elderly ( especially females )
9) suspected fracture
10) head injury
11) fevers, chills, malaise - signs of infection
12) treatment failed or no improvement after 5 days
13) pins and needles or numbness ( sign of nerve damage)

Question 19

Explain the difference between strains and sprains.

Answer 19

Strains- do not immobilise injured joint.

Sprains- immobilise injured muscle for first few days

Question 20

Explain what rubefacients are and what they do. (6)

Answer 20

1) Rubefacients = redness and warming of skin by causing local vasodilation ( deep heat)
2) masks perception of pain
3) act of massage enhances effect & disperses pain mediators
4) little evidence to support use - not for use in acute phase
5) take care to avoid eyes/ mucous membranes / broken skin
6) sensitisation may occur.

Question 21

Outline the WWHAM-O for bruising.

Answer 21

Who- adult/child (abuse) elderly?
What- bleeding below skin after fall, trauma , blow, recurring, unexplained?
How long - pain should subside after a few days, skin will be discoloured for 2-3 weeks
Action- already taken?
Medication- any other medications
Other- clotting, liver or heart problems, pregnant?

Question 22

Describe the symptomatic management of an activity/sport related injury. (2, 3, 1)

Answer 22

Practical advice:

1) PRICE and HARM in first 72 hours
2) if injury result of frequent activity e.g. Sporting injury - prevent recurrence

Treatment options
oral analgesia:
1) paracetamol in combination with topical NSAIDs
2) NSAIDs 
3) avoid aspirin - can affect clotting 

Topical analgesia:
1) NSAIDs ( not to be used with oral NSAIDs) 72 hours after injury: Heat and rubefacients/ counter irritants

Question 23

Outline the referral criteria for bruising. (4)

Answer 23

1) unexplained, frequent, excessive
2) known clotting problems
3) hepatic impairment
4) taking warfarin, MSAIDs, steroids, carbimazole ect.

Question 24

Outline the symptomatic treatment of bruising. (3, 3, 1)

Answer 24

Treatment options: 
Heparinoid and Hyaluronidase 
1) help disperse oedema 
2) may help reduce swelling and bruising 
3) avoid if possibility of infection 

Arnica

1) traditional herbal medicinal product
2) some evidence to support efficacy
3) can also be used homeopathically but little evidence to support use

Witch Hazel
1) acts as astringent and anti-inflammatory

Question 25

List the causes of lower back pain (6)

Answer 25

From most likely to least likely:

1) strain due to bad posture/ activity - lifting, bending, gym etc
2) degenerative disease (e.g. Osteoarthritis)
3) trapped nerve- sciatica ( shooting lower back pain radiating to upper leg) , slipped disc, pregnancy
4) compression fractures
5) osteomyelitis (bone infection)
6) malignancy (cancer)

Question 26

Outline the points to consider for a patient with lower back pain. (4, 3)

Answer 26

Age can help identify cause:

1) less than 15 years - should be specific cause of injury
2) 15-30 years - trauma, injury, prolapsed disc, malignancy
3) over 50 years - osteoporosis, metabolic bone disorders (pagets), malignancy
4) women: period pain? Urinary tract infection?

Onset and duration can affect course of action:

1) is there a causative factor? ( gardening, lifting)
2) getting better or worse?
3) usually an acute condition- starts to improve within a week, resolved within a month

Question 27

Outline the referral criteria for lower back pain. (10)

Answer 27

1) pain following major trauma e.g. Car accident (fracture?)
2) new pain in patient aged under 20 or over 50 years
3) worse at rest, better after exercise (ankylosing spondylitis- chronic inflammatory condition affecting spine)
4) gait disturbance ( prolapsed/ slipped disc, ankylosing spondylitis)
5) bladder/ blowed problems
6) widespread or worsening weakness in legs
7) sciatica- back pain radiating down one or both legs/ numbness/ tingling ( prolapsed disc affecting sciatic nerve)
8) fever
9) long standing back pain- especially if middle of upper back
10) no response to treatment

Question 28

Explain the symptomatic management of back pain (3, 1)

Answer 28

Treatment options: 
Oral analgesia 
1) NSAIDs 1st line if no contraindications 
2) Paracetamol 2nd line 
3) avoid aspirin - can affect clotting 

Topical analgesia
1) NSAIDs (should not use with oral NSAIDs)
Heat and rubefacients/counter irritants as for activity/sports related injuries

Question 29

What is rheumatism / arthritis (4)

Answer 29

1) Names are used interchangeably by patients
2) painful joints, swelling, inflammation, stiffness, limitation of movement, joint deformity.
3) terms used by patients that covers many disorders:osteoarthritis, rheumatoid arthritis, gout, infection
4) can be difficult to distinguish so best to refer.

Question 30

List the conditions headaches may be a symptom of as well as the different types of headaches. (5)

Answer 30

Most likely to least likely

1) tension headache, migraine , cluster
2) URTI (e.g.cold) sinusitis
3) migraine, eye strain
4) cluster headache, trigeminal neuralgia, depression
5) Meningitis, subarachnoid haemorrhage, glaucoma, raised intracranial pressure( e.g brain cancer)

Paracetamol can cause rebound headaches if taken for 5 days.

Question 31

Outline the symptoms, longevity and patient group for tension headaches. (3)

Answer 31

Symptoms:

1) pain mild/ moderate, generalised dull ache. Feels like a band of heat, or pressure on head.
2) bilateral, come aching eyes.

Patient:
3) most age groups can be affected , accepts choice of treatment

• action taken? Medication? Some can trigger headaches e.g nitrates open blood vessels which can cause headaches, the contraceptive pill and HRT.
• other medical conditions, pregnancy/breastfeeding , recent trauma? Other symptoms start at the same time?
• trigger factors, symptoms in migraines can start after certain foods, activity, situation, e.g stress, tiredness, caffeine, chocolate, alcohol , hormones.

Question 32

Outline the symptoms, longevity and patient group for migraines. (4)

Answer 32

Symptoms:
1) mild/ moderate (severe), throbbing, worse moving, unilateral. Some have an aura- blind spots, flashing/ zig zagging lights
2) photophobia, nausea, vomiting
Patient:
3) women more likely than men 1st time in over 50years - refer
Longevity:
4) can last hours to UK to 3 days. Recurring

• action taken? Medication? Some can trigger headaches e.g nitrates open blood vessels which can cause headaches, the contraceptive pill and HRT.
• other medical conditions, pregnancy/breastfeeding , recent trauma? Other symptoms start at the same time?
• trigger factors, symptoms in migraines can start after certain foods, activity, situation, e.g stress, tiredness, caffeine, chocolate, alcohol , hormones.

Question 33

Outline the symptoms, longevity and patient group for cluster headaches. (3)

Answer 33

Symptoms:
1) intense, unilateral, orbital pain, runny nose/ eye same side as pain
Patient:
2)men more likely than women
Longevity:
3) 10 minutes -3 hours tends to be the same time if the day. Recurring

• action taken? Medication? Some can trigger headaches e.g nitrates open blood vessels which can cause headaches, the contraceptive pill and HRT.
• other medical conditions, pregnancy/breastfeeding , recent trauma? Other symptoms start at the same time?
• trigger factors, symptoms in migraines can start after certain foods, activity, situation, e.g stress, tiredness, caffeine, chocolate, alcohol , hormones.

Question 34

Describe the referral criteria for headaches (12)

Answer 34

1) ingoing severe pain over 4 hours
2) very sudden onset
3) suspected depression
4) signs of meningitis
5) recent trauma
6) cluster headaches
7) migraines for the first time in over 50 year olds
8) eye strain / severe eye pain
9) failed treatment
10) severe pain with vomiting and/ or confusing and/ or malaise
11) glaucoma, trigeminal neuralgia, sinusitis, subarachnoid haemorrhage , raised intracranial pressure
12) medication e.g pill

Question 35

Outline the symptomatic treatment for general and tension headaches. (6)

Answer 35

1) remove cause ( dehydration, lighting , rest)
2) paracetamol 1st line
3) ibuprofen 2line
4) combination product if necessary
5) alternate cooling preparations, menthol preparations
6) herbal: feverfew- conflicting clinical evidence

Question 36

Outline the symptomatic treatment of migraines (5)

Answer 36

1) start treatment immediately at onset, 1st line is simple analgesia, liquid/soluble or preparations can act quicker.

Specific OTC products for migraine:

2) migraleve duo: pink and yellow tablets contain paracetamol and codeine.
3) sumatriptan- helps constrict blood by vessels. Licensed for patients who have a history of migraines. ,use fill out a form only pharmacist can agree to sell.
4) buccastem M : contains buccal anti- emetic
5) for frequent attacks more than two a month, patient may be prescribed prescription only ,educations by their doctor.