RTS - Respiratory Conditions

Question 1

List the common respiratory conditions you may come across in community pharmacy

Answer 1

1) the common cold
2) influenza
3) coughs
4) Hayfever
5) asthma and COPD
6) pneumonia and other bacterial and viral infections
7) drug induced cough
8) more serious diseases :TB , lung cancer etc

Question 2

outline the difference between the common causes for cold and influenza, explain the transmission of the disease and state whether there is a vaccine.

Answer 2

colds:
1) viral infection by over 100 causative viruses (40% rhino-viruses, 10% coronaviruses)
2) affects nose, nasopharynx and upper respiratory tract
3) immunity specific to each virus so no vaccine
4) transmission: droplet inhalation or touching surfaces where droplets have landed.
influenza:
1) viral infection of the whole respiratory tract by 3 types of myxovirus
2) vaccine is available - reformulated each year
3) transmission by droplet inhalation- highly contagious

Question 3

Describe the symptoms of a cold

Answer 3

1) gradual onset
2) initial discomfort of eyes, nose, throat
3) sneezing, rhinorrhoea, congestion, sore throat , dry tickly cough, headache
4) mild fever in children , although uncommon in adults
5) colds last 4-7 days
- common - average adult has 2-4 a year , all year

Question 4

Describe the symptoms of influenza

Answer 4

1) rapid onset
2) initially fever, shivering , headache , myalgia, vertigo, nausea, back pain
3) may also get symptoms of cold
4) anorexia and depression for up to few weeks after
- can affect up to 15% population and causes epidemics and pandemics periodically, usually in winter.

Question 5

Outline when you would refer a cold or influenza

Answer 5

1) asthmatics -not always
2) night time cough in children
3) persistent cough
4) dyspnoea (SOB) /wheezing
5) stiff neck and/or non-blanching rash
6) severe pain on coughing
7) earache
8) facial pain
9) treatment failure
10) nasty sputum

Question 6

Describe the Non-pharmacological counselling advice given to patients suffering from cold and influenza

Answer 6

1) caused by virus so no paint going to GP!
2) rest, keep warm, plenty of fluids
3) eat plenty of fresh fruits and vegetables to help maintain body’s vitamins and minerals and therefore immune system
4) should improve within 7-10 days
5) influenza vaccine advice to at risk groups
6) steam inhalation, inhalants etc.
7) sweets to ease throat

Question 7

List the complementary medicine for colds and influenza

Answer 7

1) zinc
2) menthol
3) vitamin c
4) vitamin E
5) echinacea
6) garlic

Question 8

Describe the possible likely and unlikely diagnosis of a sore throat

Answer 8

1) most likely :viral infections and self limiting (7-10 days )
2) likely: streptococcal infection “strep throat” may require referral
3) unlikely: glandular fever, thrush, herpes simplex
4) very unlikely - carcinoma, medicines

Question 9

Explain how the choice of treatment for a person with a sore throat is influenced by who the person is.

Answer 9

Who: age affects choice of medicine and the likely cause of symptoms, especially in children so you may need to refer
- babies or infants- croup, difficulty breathing
- children <12 years at school- likely to be bacterial
- teenagers - if persistent could be glandular fever
Smokers - increased risk of infection , chronic bronchitis, emphysema, COPD, lung cancer
Diabetic, asthmatic, heart problems, pregnant, immunosuppressed?

Question 10

Outline the symptoms of a sore throat and state when you need to refer

Answer 10

1) runny/ blocked nose
2) runny eyes
3) cough
4) temperature
5) severity of pain
Referral:
1) observation: ulceration, redness, white patches, exudate, inflammation
2) swollen lymph glands - if very painful/ not improving for 5-7 days
3) difficulty swallowing (dysphagia) /drinking / breathing
4) over one week consider referral , over 2 weeks refer
5) severe pain with no other symptoms and no improvement 24-48 hours should be referred

Question 11

Explain why it is important to check if a patient is on any medication before recommending a product for a sore throat

Answer 11

1) some medication can cause sore throats e.g. Inhaled steroids - advice
2) for others it is a sign of immunosuppression as a result of taking: carbimazole, carbamazepine, sodium valproate, azathioprine, oral steroids, cytotoxic drugs including chemotherapy- refer
3) interactions with recommended products
4) allergies to medication
5) other conditions they have not shared? Asthma, diabetes , heart problems?

Question 12

outline the difference between the common causes for cold and influenza, explain the transmission of the disease and state whether there is a vaccine.

Answer 12

colds:
1) viral infection by over 100 causative viruses (40% rhino-viruses, 10% coronaviruses)
2) affects nose, nasopharynx and upper respiratory tract
3) immunity specific to each virus so no vaccine
4) transmission: droplet inhalation or touching surfaces where droplets have landed.
influenza:
1) viral infection of the whole respiratory tract by 3 types of myxovirus
2) vaccine is available - reformulated each year
3) transmission by droplet inhalation- highly contagious

Question 13

Describe when you would refer a patient suffering from a sore throat

Answer 13

1) babies or infants, especially if associated with difficulty breathing
2) bacterial infections
3) suspected glandular fever
4) difficulty swallowing and/or breathing
5) ulceration
6) white patches/ plaques in throat and/or mouth and tongue
8) patient is immunosuppressed , especially if sore throat is associated with a fever
9) extreme pain with no other symptoms and no improvement after 24- 48 hours
10) treatment failure

Question 14

What is tonsillitis and outline the treatment options

Answer 14

1) tonsillitis is the inflammation of the tonsils and often the cause of a sore throat
2) can be viral
3) if bacterial, often streptococcal and known as “strep throat”
4) signs of streptococcal infection include white patches on tonsils, fever and malaise
5) if recurrent may consider having them removed
6) drinking can be difficult, cannot swallow saliva

Question 15

Explain what glandular fever is and list the symptoms

Answer 15

1) a viral infection usually affecting adolescents and young adults
2) sore throat, swollen lymph glands, fever
3) recovery from symptoms usually in 6 weeks
4) patient may be tired or become depressed for several months

Question 16

Explain what oral thrush is and list the symptoms and treatment

Answer 16

1) a fungal infection caused by candida (yeast)
2) mouth and throat may be very sore
3) presence of white patches/ plaques on mucosal surfaces that cannot be wiped/ brushed off
4) common in babies and asthmatics using steroid inhalers
5) diabetics (undiagnosed/uncontrolled)
6) refer if patient is/ could be immunocompromised
7) if simple cause - Tx OTC with oral miconazole gel

Question 17

Outline the symptomatic management of sore throats

Answer 17

1) demulcents- soothes and moisturises throats e.g. Glycerol syrup or pastilles, simple linctus
2) lozenges : antiseptic (e.g. Cetylpridinium), antibacterial? ( deaualium, tyrothricin), antifungals ( dequalium)
3) local anaesthetics: as lozenges or sprays ( benzocaine, lidocaine)
4) anti- inflammatory : gargle/ spray benzydamine , asprin gargle/ lozenges flurbiprofen (NSAID) - Cl in <12 year old, patient on NSAIDs, asthma , peptic ulcer , allergy to aspirin or NSAIDs
5) oral analgesics - paracetamol

Question 18

Outline what a fever is and list the common symptoms and treatment

Answer 18

1) an increase in body temperature . A fever is a common symptom associated with coughs, colds, flu , sore throats etc
2) manage using anti-pyretics
3) if lasts for > 48 hours and not responsible to anti-pyretics - refer
4) occasionally may be febrile convulsions -refer to A&E
5) febrile convulsions most common in children

Question 19

What is a cough?

Answer 19

1) a reflex action
2) symptom Of many conditions including being in 40-50% of upper respiratory tract infections (URTIs)
3) can be productive or non productive
4) could be acute or chronic
5) pneumonia and other bacterial and viral infections

Question 20

Explain the difference between a productive and non productive cough

Answer 20

Productive: 
1) chesty 
2) sputum being produced in the lungs 
3) sputum may or may not be coughed up 
4) if sputum does come up if is known as expectoration
Nonproductive: 
1) tickly 
2) can be dry 
3) no sputum from lungs, inflammation and irritation of pharynx 
4) may be phlegmy 
5) difficult to stop at times 
6) may be iatrogenic

Question 21

Describe the symptoms of a cold

Answer 21

1) gradual onset
2) initial discomfort of eyes, nose, throat
3) sneezing, rhinorrhoea, congestion, sore throat , dry tickly cough, headache
4) mild fever in children , although uncommon in adults
5) colds last 4-7 days
- common - average adult has 2-4 a year , all year

Question 22

Outline what a cough could be a sign of

Answer 22

Most likely: viral infection I.e. Cold
Likely: postnasal drip, allergy, asthma
Unlikely: croup, chronic bronchitis, bronchiectasis, pneumonia, drug-induced
Very unlikely- heart failure, tuberculosis , cancer, lung abscess

Question 23

Explain why the choice of treatment for a patient suffering from a cough may be influenced by who the person is

Answer 23

1) age affects choice of medicine
2) children are more prone to coughs and colds, night time cough may indicate asthma
3) elderly are at greater risk of bronchitis, pneumonia, even cancer
4) pregnant and breastfeeding, asthmatic, diabetic , heart problems?
5) smokers - increased risk of infection, chronic bronchitis , emphysema, COPD, lung cancer?

Question 24

Describe the symptoms of influenza

Answer 24

1) rapid onset
2) initially fever, shivering , headache , myalgia, vertigo, nausea, back pain
3) may also get symptoms of cold
4) anorexia and depression for up to few weeks after
- can affect up to 15% population and causes epidemics and pandemics periodically, usually in winter.

Question 25

Describe the different appearances of sputum,explain what it indicates and state whether to refer.

Answer 25

1) white and clear: viral infection - referral not always
2) yellow/green coloured: bacterial infection - referral not always
3) clear but thick : asthma - refer
4) rust coloured : pneumonia - refer
5) pink tinged and/or frothy - left ventricular heart failure - refer
6) dark red : lung cancer - refer
7) offensive, smelly: bacterial infection, lung abscess or worse - refer
8) blood present : tuberculosis - refer

Question 26

Outline when you would refer a cold or influenza

Answer 26

1) asthmatics -not always
2) night time cough in children
3) persistent cough
4) dyspnoea (SOB) /wheezing
5) stiff neck and/or non-blanching rash
6) severe pain on coughing
7) earache
8) facial pain
9) treatment failure
10) nasty sputum

Question 27

Explain how the duration of a cough could indicate what the disease is

Answer 27

1) > 3 days -likely to be a virus
2) > 1 week, with nasty sputum- bacterial infection
3) > 3 weeks - bronchitis
4) > 3 months - chronic bronchitis, TB, cancer?
5) did onset coincide with anything else ?

Question 28

Explain why you need to ask patients about their medication before you recommend a treatment for a cough

Answer 28

1) interactions with recommended product
2) allergies to medication
3) drug induced cough e.g. Ace inhibitors
4) other conditions? Diabetes , asthmatic , heart problems ?

Question 29

Outline when you would refer a cough

Answer 29

1) chest pain
2) chronic cough- greater than 3 weeks
3) recurring cough
4) haemoptysis ( blood in sputum)
5) persistent night time cough in children
6) pain on inspiration (breathing in)
7) wheezing, shortness of breath
8) weight loss
9) suspected adverse drug reactions
10) treatment failed

Question 30

Outline the symptoms for the following:
Heart failure
Spontaneous pneumothorax
Bronchiectasis

Answer 30

Heart failure : particularly elderly.
-shortness of breath, difficulty breathing
- productive, frothy , pink tinged cough
Spontaneous pneumothorax - collapsed lung, especially in young, tall thin men : sudden chest pain, family history
Bronchiectasis - permanent widening of the bronchi
- nasty sputum

Question 31

Outline the difference between day nurse and night nurse

Answer 31

Day capsules: paracetamol, pseudoephedrine, pholcodine.

Night capsules: paracetamol, promethazine, dextromethorphan

Question 32

Outline the active ingredients in cough and cold products

Answer 32

pain relief- paracetamol
Nasal congestion - decongestant
Cough :
1) demulcents - soothes and moisturises throats e.g. Glycerol, simple linctus
2) expectorants- loosens phlegm e.g. Guaifenisen, ipecacuanha, squill, ammonium salts
3) opioids - depress the cough reflex, acts in brain e.g. Pholcodine, dextromethorphan, (codeine not for under 18 years)
4) antihistamines- anti-cholinergic action results in antitussive effects but can cause drowsiness e.g. Diphenyhydramine, triprolidine

Question 33

Name two decongestants

Answer 33

1) pseudoephedrine - one box containing no more than 720mg at any one time without a prescription
2) ephedrine - no more than 180mg at any one time without a prescription
- unlawful to sell them together

Question 34

Outline the management of coughs in children

Answer 34

1) OTC cough and cold medicines no longer recommended for children under 6
2) manufacturers still in the process of updating
3) only products for under 6 to be used in coughs and colds now are paracetamol and ibuprofen on their own , simple linctus and glycerol
3) for children over 6, products similar to adults are available but with clear advice (but not codeine for under 18 years)

Question 35

What is allergic rhinitis?

Answer 35

1) inflammatory disorder of the nose which offers when membranes lining the nose become sensitised to allergens
2) an allergen is something that causes an allergic inflammatory response
3) pollen, dust mites, animal hair, latex, foods etc
4) a compound called histamine is released if a person is exposed to an allergen
5) histamines can act on the cells of the nasal membranes to intimate an inflammatory response
6) this results in symptoms of runny, itchy nose, sneezing, congestion

Question 36

Explain the three main types of allergic rhinitis

Answer 36

1) seasonal allergic rhinitis - symptoms tend to occur at the same time each year e.g. Allergy to pollen
2) perennial allergic rhinitis- symptoms occur throughout the year e.g. Allergy to house dust mites or pets
3) occupational allergic rhinitis - symptoms are due to exposure to allergens at work e.g. Animal dander , wood dust
- allergic rhinitis is often associated with allergic conjunctivitis, eczema and asthma

Question 37

Compare and contrast allergic rhinitis and the common cold?

Answer 37

Allergic rhinitis: 
1) nasal discharge is clear, takes longer to become purulent 
2) sneezing frequent 
3) nasal itching 
4) eye symptoms common 
5) symptoms continue for as long as sufferer is in contact with allergen 
6) sudden onset of symptoms 
7) occurs same time each year 
8) affects isolated individuals
Common cold 
1) initially clear but may thicken and become purulent within a few days 
2) sneezing less frequent 
3) normally no nasal itching 
4) normally no eye symptoms 
5) symptoms last 4-7 days 
6) gradual onset of symptoms 
7) usually occurs in winter, but could be any time of the year 
8) contagious

Question 38

What is hay fever?

Answer 38

1) Hayfever describes seasonal allergic rhinitis and conjunctivitis caused by pollen
2) patients may be allergic to all types of pollen or just certain types e.g. Tree pollen, grass pollen , a particular type of plant or fungal spores
Tree pollen - symptoms from spring
Grass pollen- symptoms from late spring to early summer
Weed pollen- symptoms from early spring to early autumn
Fungal spores- symptoms in autumn

Question 39

Describe the symptoms of allergic conjunctivitis

Answer 39

1) watery eyes - discharge is clear
2) redness
3) itching of eye and/or eye lids
4) eye area may puff up

Question 40

Outline the symptomatic treatment of Hayfever

Answer 40

1) oral antihistamines- sedative
- chlorphenamine - adult dose 4mg every 4-6 hrs max 24mg in 24 hours
- loratadine & cetirizine- non drowsy -long acting so once daily dosing
- acrivastine - non drowsy only for ages 12-65 , dose 8mg TDS, max 24mg in 24 hours
2) topical antihistamines :
- (azelastine and levocabatine) rapid onset of action (15 mins) can cause temporary location irritation

Question 41

Outline the side effects of anticholinergic antihistamines

Answer 41

Cl- narrow closed angle glaucoma, prostatism
1) dry mouth
2) blurred vision
3) urine retention
4) constipation
5) palpations
(Can’t see, can’t pee, can’t spit , can’t shit)

Question 42

Describe the Non-pharmacological counselling advice given to patients suffering from cold and influenza

Answer 42

1) caused by virus so no paint going to GP!
2) rest, keep warm, plenty of fluids
3) eat plenty of fresh fruits and vegetables to help maintain body’s vitamins and minerals and therefore immune system
4) should improve within 7-10 days
5) influenza vaccine advice to at risk groups
6) steam inhalation, inhalants etc.
7) sweets to ease throat

Question 43

Describe the symptomatic treatment of Hayfever

Answer 43

May need to use a combination of products

1) corticosteroids nasal sprays- fluticasone (once daily) and beclometasone (twice daily) . From 18 years only, acts as a preventative so should use every day even if there are no symptoms. Takes up to 7-10 days to start taking effect
2) mast cell stabiliser - sodium cromoglicate, available as a nasal spray
3) sympathomimetic decongestants - systemic and locally as nasal sprays

Question 44

Explain the non-pharmacological advice given to patients suffering from Hayfever

Answer 44

1) avoidance of pollen
- avoid goi no outdoors if possible , especially when pollen count is at its peak I.e. Morning and evening
- keep doors and windows shut
- if eyes affected close fitting, wrap round sunglasses can help
2) removal of pollen-
- damp dust surfaces in house , in particular bedroom
- shower and wash hair after being outdoors
3) barrier preparations- nasal sprays /balms coat nostrils to prevent pollen from making contact with mucosal membrane and initiating inflammatory response
4) nasal saline washouts - flushes out pollen