Week 20 Flashcards
what is the common ailment scheme?
a free NHS service
patients can access for advice and treatment of 26 conditions through CAS
what does the common ailment scheme service involve?
patient registration with the pharmacy
private consultation with the pharmacist
advice on management and treatment where needed OR referal if needed
who can acces the common ailmemt scheme?
any patient who lives in wales or who is registered to a welsh GP is eligible to access the choose pharmacy service
what are the exclusions to the people that can access the common ailment scheme?
temporary residents whose usual address is not in wales
care home residents
what are the exclusions of the common ailment scheme for some conditions?
age
pregnancy
if they have had the condition multiple times
what are the 26 conditions that can be treated under the common ailment scheme?
- Acne
- Athletes Foot
- Backache (acute)
- Chickenpox
- Cold sores*
- Colic*
- Conjunctivitis (bacterial)
- Constipation
- Dermatitis (acute)
- Diarrhoea*
- Dry eyes
- Haemorrhoids
- Hayfever
- Head Lice
- Indigestion/reflux
- Ingrowing toenail*
- Intertrigo/ringworm
- Mouth Ulcers
- Nappy rash
- Oral thrush
- Scabies
- Sore throat/tonsillitis
- Teething
- Threadworm
- Vaginal thrush
- Verruca
* = advice only conditiond-no treatment available on NHS
what is choose pharmacy?
choose pharmacy is a confidential NHS electronic records system, which community pharmacists use to record details of NHS serices they provide to you
what are cold symptoms?
congestion
itchy/watery eyes
feeling tired
cough
runny/ stuffy nose
sore throat
headache
what are flu symptoms?
cough
runny/stuffy nose
sore throat
headache
fever
body aches
extreme fatigue
what is a cold?
mild, self-limiting, viral, upper repiratory tract infection
how is a cold transmitted?
either direct transmission or aerosol transmission
what are the most common complications of the common cold?
sinusitus
lower respiratory tract infections
acute otitis media
when do symptoms appear in the common cold?
onset of symptoms after infection is sudden, reaching a peak at day 2-3 then decreasing in intensity
when do symptoms tend to last in different people for a common cold?
adults and older children= a week, although can persist for up to 3 weeks
younger children= 10-14 days
smokers=infection is more prolonged
what is the flu?
acute respiratory illness caused by RNA viruses of the family Orthomyxoviridae (influenza viruses)
what are the most common complications from the flu?
acute bronchitis
pneumonia
exacerbations of asthma and chronic abstructive pulmonary disease
otitis media
sinusitis
when do flu symptoms begin to show?
around 2 days after exposure
uncomplicated influenza= coryza, nasal discharge, cough, fever, gastrointestinal symptoms, headache, malaise (discomfort), myalgia(muscle aches), arthalgia, ocular symptoms and sore throat
compliated influenza= require hospital admission,involve the lower respiratory tract, central nervous system (CNS), or cause significant exacerbation of an underlying medical condition.
what are the at risk groups of flu?
those with respiratory, heart, kidney, liver or neurological disease, diabetes mellitus or those who are obese or immunosuppressed
>65 years
women who are pregnant
<6 months
what is the management of the flu?
drink adequate fluid
take paracetamol or ibuprofen to relieve symptoms
rest
stay off work or school until the worst symptoms have resolved
for the flu, when should urgent admission to hospital be considered?
pneumonia
the person has a concomitant disease that may be affected by influenza
suspision of serious illnes
what is a cough?
it is a reflex to airway irritation
it is triggered by stimulation of airway cough receptors, either by irritants or by conditions that cause airway distortion
caused by a viral upper respiratory tract infection (URTI)
what are the different severities of the cough?
acute=<3 weeks
sub-acute= 3-8 weeks
chronic= >8 weeks
what are some of the causes of a cough?
acute bronchitis
pneumonia
acute exacerbations of asthma
environmental or occupational causes
foreign body aspiration
what is the management of cough?
Management of people with cough should be based on treating the underlying cause where it has been identified, or sequential trials of treatment to confirm or refute common causes. Offer self care (e.g. paracetamol or ibuprofen for pain and inflammation, if appropriate), and refer to smoking cessation if relevant.
when should a cough be refered to a respiratory physician?
arranged for people that do not respond to trials of treatment, if the diagnosis is uncertain or is systemically unwell
Emergency referral should be arranged for people with:
* Clinical features of foreign body aspiration.
what is croup?
common childhood disease
usually caused by a virus
what are the symptoms of croup?
sudden onset of a seal-like barking cough
accompanied by a strider
hoarse voice
respiratory distress
symptoms are typically worse at night
who does croup most commonly affect?
6months- 6 years
peak at 2 years old
what are the different severity of croup?
mild =seal-like barking cough, but no strider or sternal/intercostal recession at rest
moderate=seal-like barking cough with stridor and sternal reccesion at rest; no agitation or lethargy
severe=seal-like barking cough with stridor and sternal/intercostal recession associated with agitation or lethargy
what is the management of croup?
all children with mild, moderate or severe croup should receive a single dose of oral dexamethasone
if the child is too unwell to recieve medication, inhaled budesonide or intramuscular dexamethasone are possible alternatives
mild croupo can be managed at home
symptoms usually resolve within 48 hours
what is whooping cough?
a highly infectius disease caused by the bacterium Bordetella pertussis
it is spread by aerosol droplets
released during coughing, and disproportionately affects infants and yough infants
the incubation period is usually 7 days, and the person is infectious for 3 weeks after the onset of symptoms
what are the three phases of whooping cough?
➢The catarrhal phase lasts ~ a week and is characterised by the development of a dry, unproductive
cough.
➢The paroxysmal phase may last for a month or more and is characterised by coughing fits,
whooping, and post-tussive vomiting. The person may be relatively well between paroxysms.
➢The convalescent phase may last an additional 2 months or more, and is characterised by gradual
improvement in the frequency and severity of symptoms.
how is whooping cough managed?
- People who are seriously unwell should be admitted to hospital (a
low threshold is required for children aged 6 months or less). - An antibiotic (usually a macrolide, such as erythromycin or
clarithromycin) should be prescribed to all people with suspected or
confirmed whooping cough with onset of cough within the previous
21 days. - Advice should be given on rest, adequate fluid intake, and the use
of paracetamol or ibuprofen for symptomatic relief. - Children and healthcare workers should be advised to stay off
nursery, school, or work until 48 hours of appropriate antibiotic
treatment has been completed, or 21 days after onset of symptoms if
not treated. - Close contacts may require antibiotic prophylaxis.
what are the different classifications of mouth ulcers?
Aphthous, minor (about 80% of cases)
* Often in groups of up to five
* Small ulcers (<1cm)
* “uncomfortable”
* Heal within 10-14 days
Aphthous, major (about 10% of cases)
* Usually 1-3 ulcers
* Larger than 1cm
* Painful and may affect eating
* Can take weeks to heal
Herpetiform (about 10% of cases)
* Groups of 10-50 small ulcers
* Very painful
* Heal within 10-14 days
what are the different classifications of mouth ulcers?
Aphthous, minor (about 80% of cases)
* Often in groups of up to five
* Small ulcers (<1cm)
* “uncomfortable”
* Heal within 10-14 days
Aphthous, major (about 10% of cases)
* Usually 1-3 ulcers
* Larger than 1cm
* Painful and may affect eating
* Can take weeks to heal
Herpetiform (about 10% of cases)
* Groups of 10-50 small ulcers
* Very painful
* Heal within 10-14 days
what are the causes of mouth ulcers?
Usually unknown, but may sometimes be:
Iron deficiency anaemia
* Vegetarian/vegan diet often implicated
* Heavy menstrual loss
Hypersensitivity
* Preservatives in food (benzoic acid/benzoates)
* Foods (chocolate, tomatoes)
* Sodium lauryl sulfate
Psychological stress
what is the treatment of mouth ulcers?
Saline
* Half a teaspoon of salt in a glass of warm water
* Rinse frequently until ulcers subside
* Any age
Antiseptic (chlorhexidine)
* Rinse (or spray) twice a day
* Not within 30 minutes of toothpaste
* Can cause temporary yellow staining of teeth
* Can be used OTC from age 12
Anti-inflammatory (benzydamine)
* Use every 1.5-3 hours
* Can be used OTC from age 6
Steroid (hydrocortisone)
* One tablet dissolved on ulcer four times a day
* Can be used OTC from age12
when should you refer a mouth ulcer?
Lasts longer than 3 weeks
Keeps coming back
Painless and persistent
Grows bigger than usual
At back of throat
Bleeds or gets red and painful
what is dyspepsia?
a complex of upper gastrointestinal tract symptoms typically present for 4 or more weeks
what are the symptoms of dyspepsia?
Severity varies from patient to patient (most: mild + intermittent)
Upper abdominal pain or discomfort
Burning sensation starting in stomach, passing upwards to behind the breastbone
Gastric acid reflux
Nausea or vomiting
what are the common causes of dyspepsia?
*Gastro-oesophageal reflux disease (GORD)
*Peptic ulcer disease (gastric or duodenal ulcers)
*Functional dyspepsia
* Epigastric Pain Syndrome
* Post-prandial distress syndrome (fullness and early satiety)
*Barrett’s oesophagus
* A premalignant condition
*Upper GI malignancy
what are the causes of gastric-oesophageal reflux disease (GORD)?
- Transient relaxation of lower oesophageal sphincter
- Increased intra-gastric pressure
- Delayed gastric emptying
- Impaired oesophageal clearance of acid
what are some of the risk factors of GORD?
- Smoking
- Alcohol
- Coffee
- Chocolate
- Fatty foods
- Being overweight
- Stress
- Medicines (calcium channel blockers, nitrates, NSAIDs)
- Tight clothing
- Pregnancy
what is peptic ulcer disease?
ulcers may be present in stomach or duodenum
what are the causes of peptic ulcer disease?
- Helicobacter pylori infection
- Medication, mainly NSAIDs (others can cause them)
- Zollinger-Ellison syndrome (rare condition causing high acid secretion)
how can peptic ulcer disease be managed?
Can only confirm ulcers with endoscopy
* H. pylori infection managed with eradication therapy (2 antibiotics and a PPI)
* Therefore wouldn’t be managed OTC
* However, patients frequently present asking for symptomatic relief
what is the management of dyspepsia?
*Most patients have mild or intermittent symptoms which may be
managed through non-pharmacological means and OTC treatments
*Lose weight if overweight
*Eating small, frequent meals rather than large meals
*Eat several hours before bedtime
*Cut down on tea/coffee/cola/alcohol
*Avoid triggers, e.g. rich/spicy/fatty foods
*If symptoms worse when lying down, raise head of bed (do not prop
up head with pillows)
*Avoid tight waistbands and belts, or tight clothing
*Stop smoking
Options
*Non-pharmacological
*Antacids
*Alginates
*H2 receptor antagonists
*Proton pump inhibitors
what are antacids?
compiunds that neutralise stomach acid
what are alginates?
from a raft on top of stomach contents, creating a physical barrier to prevent reflux
what are H2 receptor antagonists?
block H2 receptors in stomack to prevent acid production
what are proton pump inhibitors?
PPIs block proton pumps in stomach wall to prevent gastric acid production
when should you refer dyspepsia?
frequently attending for dyspepdia remedies (sign of gastric cancer)
Red flag signs:
*55 years or over, especially with new onset
*Dyspepsia hasn’t responded to treatment
*Features including bleeding, dysphagia, recurrent vomiting or
unintentional weight loss
what types of people do you need to be aware of when consulting about nausea and vomiting?
*Age: very young and old most at risk of dehydration
*Pregnancy: n&v common, consider in women of childbearing
potential
*Duration: adults >2 days cause for concern, young children (<2
years) any duration
what are some of the associated symptoms of nausea and vomiting?
- diarrhoea – may be gastroenteritis, question about food intake, could be rotavirus in children
- blood in vomit – differentiate fresh blood from that of gastric/duodenal origin
- faecal smell – GI tract obstruction
how can nausea and vommiting be managed?
most established vomiting will require referral
opioids
NSAIDs
antibiotics
oestrogens
steroids
digoxin
lithium
what is constipation?
bowel movement less than three times a week
difficult to pass stools
hard, dehydrated stools
who is more affected by constipation?
women and older people
what are the symptoms of comstipation?
- abdominal discomfort
- cramping
- bloating
- nausea
- straining
what are some of the red flag symptoms of constipation?
- unexplained weight loss
- rectal bleeding
- family history of colon cancer or inflammatory bowel disease
- signs of obstruction
- co-existing diarrhoea
- long-term laxative use
- failed OTC > 1 week
what medication can cause constipation?
- Opioid analgesics
- Antacids – aluminium
- Antimuscarinics (anticholinergics)
- Anti-epileptics
- Anti-depressants
- Anti-histamines
- Anti-psychotics
- Parkinson’s medication
- Calcium-channel blockers
- Calcium supplements
- Diuretics
- Iron
- Laxatives (!)
what non-pharmacological treatment are there for constipation?
increase fibre intake
increase fluid intake
increase excercise
what are pharmacological treatments for constipation?
bulk-forming
osmotic
stimulant
faecal softer
what is diarrhoea?
90% of acute cases associated wit viral or bacterial infection
most cases are short-lived, self-limiting and benign
what are the differnt severity of diarrhoea?
acute: <14 days
persistant: >14 days
chronic: > 4 weeks
what are the symptoms of diarrhoea?
*Three or more lose, watery stools in 24 hours
*Faecal urgency
*Abdominal cramps
*Abdominal pain
*+/- nausea and vomiting
what are the types of questions that should be asked when consulting about diarrhoea?
*Age: very young and old most susceptible to dehydration
*Duration: in infants > 1 day of symptoms would be worrying, in adults
a few days (unless anything else concerning)
*Severity: “explosive”, blood, pus
*Systemic symptoms: fever, nausea and vomiting
*Food intake and fluid intake, esp.in young
*Anyone else in household affected
*Foreign travel
*Any medicines already tried
what are some treatments of diarrhoea?
oral re-hydration therapy
loperamide
kaolin +/- morphine
when should you refer diarrhoea?
- Duration longer than:* 1 day in < 1year old
- 2 days in < 3 year old or in older adults
- 3 days in older children and adults
- Pregnancy
- Severe vomiting
- Fever
- Blood or mucous in stools
- Suspected reaction to prescribed medicine
- Suspected outbreak of “food poisoning”
- Recent foreign travel
- Persistent diarrhoea following antibiotic treatment
what are haemorrhoids?
clusters of vascular tissue, smooth muscle and connective tissue arranged in three columns along the anal canal
what are the risk factors of haemorrhoids?
*Constipation and poor diet
*Increased incidence between ages 45-65yrs
*Pregnancy
*Heavy lifting
*Chronic cough
*Certain toilet behaviours, such as straining or spending more time on
a seated toilet than on a squat toilet
what are the symptoms of haemorrhoids?
External haemorrhoids
* lumps and bumps around the anus
* itchy (irritation from faecal matter not being fully removed by wiping)
* not usually painful unless severely swollen
Internal haemorrhoids
* discomfort/pain
* feeling of fullness in rectum
* when prolapsed, itchy and irritating
* not usually painful unless prolapsed and strangulated
Both may bleed (especially after passing stools)
what is the treatment of haemorrhoids?
*Usually self-limiting and heal within a week or so
*Life-style measure in relation to diet and fluid intake
*Analgesia as needed
*Topical preparation may contain astringents, local anaesthetics,
corticosteroids or a combination
*Can be internal (creams, suppositories) or external (creams, gels,
ointments)
what is teething?
teeth growing through the gums in children around 4-12 months until they have their full set of teeth at around 2-3 years old
what is teething?
teeth growing through the gums in children around 4-12 months until they have their full set of teeth at around 2-3 years old
what are the symptoms of teething?
mild and localised
pain
increased biting
chewing
dribbling
drooling
gum rubbing
sucking
irritability
wakefulnes
ear-rubbing (more serious)
decreased appetite
disturbed sleep
red and swollen gums
when should a referal to a GP happen with teething?
temperature >38 degrees
change in passage of stools
systemically unwell or insevere distress
what treatment is there for teething?
paracetamol 120mg in 5ml sugar-free oral suspension
ibuprofen 100mg in 5ml sugar-free oral suspension
what advice should be given to the patient on how to manage teething?
reassurance that the condition is self-limiting
gentle rubbing of the gums with a clean finger could provide some relief
teething ring
wet flannel
chilled friut or vegetable
avoid objects that can be easily broken because they can be a choking risk
what are threadworms?
threadworms are small, thin, white worms about 12-13mm long
common in children
female worms lay eggs at night around the back passage
what are the symptoms of threadworms?
itching
when shoud you refer to the GP for threadworms?
pregnant
breastfeeding
unwilling to undertake hygiene measures alone
what is the treatment of threadworms?
mebendazole 100mg/5ml suspension (only >6 months)
mebendazole 100mg chewable tablets (only >6 months)
what advice should be given when treating threadworms?
hygeine measures should be undertaken for 2 weeks if combined with mebendazole and for 6 weeks if used alone
what is colic?
self-limiting condition which is defined clinically as repeated episodes of excessive and inconsolable crying in an infant that otherwise appears to be healthy and thriving
may be due to indegestion, trapped wind or with a temporary gut sensitivity
what are the symptoms of colic?
crying that most often occur in the late afternoon or evening and the infant may bring their knees up to their abdomen or arch their back when crying
when shoul a referal to the GP happen when dealing with colic?
weak or high pitched cry
seems floppy when you pick them up
isnt feeding
vomits green fluid
has blood in their stool
has a fever of 38 degrees or above
has a bulging fontanelle
has a seizure
turns blue, blotchy or very pale
has breathing problems
what treatment is offered for colic?
no treatment
advice only
holding the baby on their stmachs when crying may help relieve wind
what is head lice?
small, whitish or grey brown insects that range from the sze of a pinhead to the size of a sesame seed. white eggs or egg cases may be visible in the hair behind the ears or at the back of the neck
what are the symptoms of head lice?
itchy scalp
rash on the back of the neck
feeling as though something is moving through the hair
when should a referal be appropraite for head lice?
people with scalp inflamation
what is the treatment for head lice?
detection comb (first line treatment)
dimeticone 4% lotion (second line treatment
what is a nappy rash?
mild rash restricted to the nappy area
prolonged contact with urine or faeces
candidal fungal infection presenting as sharply marginated redness involving the skin creases
when should you refer when dealing with a nappy rash?
sign of bacterial infection
severe inflamation
baby is sytemically unwell or has a fever
what is the treatment for a nappy rash?
zinc and castor oil (apply a thin layer at each nappy change, do not use if a candidal infection, barrier protection)
if nappy rash is causing discomfort: hydrocortisone 0.5% cream (>1 month old, maximum of 7 days use, apply and wait before putting barrier protection)
if nappy rash persists despite topical hydrocortisone( suspected Candida):
clotrimazole 1% cream (2-3 times a day for after the rash has healed)
what advice would you give the patient on nappy rash?
reduce exposure to irritants
use nappies with the greatest absorbancy
leave nappies off for as long as practically possible
what are the symptoms of oral thrush?
loss of taste or unpleasant taste in the mouth and white patches in the mouth that can be wiped off leaving behind white patches
when should you refer for oral thrush?
symptom not resolved after 7 days
difficulty or pain swallowing
immunocompriised
poorly controlled diabetis
presents with red or white plaque that cannot be rubbed off (could be pre-malignant)
what are the syptoms of acne?
comedones (blackheads and whiteheads) and/or inflammatory lesions (papules) and pus-filled spots (pustules) can develop on the face, back and chest. the skin and hair may appear oily.
when should you refer with acne?
severe acne
oral therapies have previously been used for acne
when OTC have not worked
under 12y/o
what is the treatment for acne?
benzoyl peroxide 5% gel
what advice should be given on how to manage acne?
try not to pick or squeze spots
wash the affected area no more than twice a day with mild soap or cleanser
avoid using too much makeup and cosmetics
apply the gel sparingly 20 minutes after washing and drying the affected area of skin
if irritation occurs it may e useful to reduce the frequency
avoid getting on clothes (bleaching)
avoid sunlight
what are the symptoms of athlete foot?
itchy, white or red, scaly blistering , cracked rash most commonly found between the toes
when should a referal be for athletes foot?
severe or extensive disease
signs of bacterial infection or recurrent episodes
if there has been no improvement after 1 week of treatment or if there id pain and discomfort
immuocompromised or if they have poorly controlled diabetes
what is the treatment of athletes foot?
clotrimazole 1% cream
miconazole 2% cream
hydrocortisone 1% cream (if skin is particularly inflammed)
what advice should be given on the management of athlete foot?
wash and dry the affected skin before applying the treatment and clean your hands afterwards
treatment should be applied to the affected skin and surrounding area
in general:
waer footwear that keeps feet cool and dry
wear a fresh pair of cotton socks every day
dry feet thuroughly
what are the symptoms of cold sores?
small blisters that develop on the lips or around the mouth
self-limiting
when should you refer for cold sores?
pregnant women near term
neonates
immunocompromised
frequent recurrences
condition deteriorates
no improvement after 5-7 days
what is the treatment for cold sores?
no treatment -advice only
what advce should be given to a cold sore patient?
easily transmitable
avoid touching the lesions
avoid kissing until the lesions have completely healed
avoid oral sex
do not share items that come ino contact with lesions
what is ringworm?
common fungal infection that presents with a circular patch of skin, mild redness and more inflamed and scaly than the paler centre
when should we refer for ring worm?
severe or extensice disease
sign of bacterial infection
rash unresponsive to 2 weeks of treatment
immunocompromised
poorly controlled diabetes
if scalp is involved as alternative formulations are available
what is the treatment for ringworm?
clotrimazole 1% cream
miconazole 2% cream
hydrocotisone 1% cream
each has 2 episodes per year (6 months after each other)
what advice should be given for ring worm?
wash the affected skin daily and dry thouroughly afterwards
wash clothes and bed linen frequently to eradicate the fungus
do not share towels
wear loose fitting clothes
take your pet to the vet if they may have ring worm
what are warts and verrucae?
Cutaneous warts are small, rough growths caused by infection of keratinocytes with certain strains of the human papilloma virus. They can
appear anywhere on the skin but are most commonly seen on the hands and feet. A verruca (plantar wart) is a wart on the sole of the foot.
There is a strong case for not treating warts for most people since they may clear spontaneously (usually within 2–3 years) and treatment
may be prolonged or cause side effects (e.g. skin irritation
when should we refer for warts or verrucae?
wart is on face, intertriginous or anogenital regions
uncertain diagnosis
warts with hair growing from them, bleeding or have changed appearance
wart is associated with significant pain
immunocompromised
extensive areas are affected
warts are persistent and unresponsive to salicylic acid
diabetis
poor circulation
what is the treatment for warts and verucas?
salicyic acid 16.7% then followed with salicylic acid 12%
if the lower strength hasnt worked then salicylic acid 50%
what advice should be given for warts and verrucas?
Although unsightly, warts are not harmful, do not usually cause symptoms and resolve eventually without treatment.
Warts are contagious but the risk of transmission is low.
When using salicylic acid - if the surrounding skin becomes sore, stop the treatment for a few days until it settles then re-start treatment.
There is a small risk of skin allergy to the treatment. If this occurs, the surrounding skin becomes red and itchy.
Salicylic acid formulations are flammable – keep them away from flames or ignition sources
It is important to continue treatment until the wart has gone. Seek medical advice if the wart persists longer than 12 weeks of treatment.
To reduce risk of transmission:
* cover with waterproof plaster when swimming
* wear flip-flops in communal showers
* avoid sharing shoes, socks and towels
* avoid scratching lesions, biting nails or sucking fingers that have warts
* keep feet dry and change socks daily.
There is no need to avoid sports or swimming, but take measures to avoid transmission as above
what is dermatitis?
Dry skin has a dull surface with a rough, scaly quality. The skin is less pliable and cracked
Dry areas of skin may become red and itchy; indicating a form of atopic dermatitis has developed40
when should you refer dermatitis?
skin infection
rash failing to respond to therapy
what is the treatment of dermatitis?
cetraben zerobase
doublebase
diprobase cream
hydromol ointment
white soft parafin
hydrocortisone ointment/ cream
what advice should be given for dermatitis?
appropriate usage of emollients
avoid triger factors
not to smoke or to be around naked flames
clothing should be changed regularly
what is scabies?
intesnse itch and rash, often worse at night and when hot, sometimes burrows can be seen in the interdigital web spaaces
when should we refer scabies?
severe rash
secondary infection
systematically unwell
<2 years
suspected crusted scabies
continued treatment failure
what is the treatment for scabies?
permethrin 5% cream
malathion 0.5%
chlorophenamine 4mg tablets
chlorphenamine 2mg in 5ml sugar-free oral solution
when should we refer back pain?
Red Flags9
:
* age over 50 years
* trauma
* history of cancer
* intravenous drug abuse
* immunosuppression (e.g. due to cancer treatment or high doses of oral steroids (see BNF) or other immunosuppressants, or
conditions that reduce immunity)
* diabetes
* tuberculosis or recent urinary tract infection.
Other symptoms that require referral9
:
* No improvement after 3–4 weeks of treatment, or a change (deterioration) in the type of pain.
* Pain that prevents the person doing the usual activities of daily life.
Emergency – seek immediate medical advice as the following symptoms require further investigation9,10:
* Fever of 38ºC (100.4ºF) or above.
* Unexplained weight loss.
* Swelling in the back.
* Constant back pain that doesn’t ease after lying down.
* Pain in the chest or high up in the back.
* Pain down the legs and below the knees (neurological deficit in lower limbs [numbness, weakness]).
* Loss of bladder or bowel control or inability to pass urine.
* Numbness around the genitals, buttocks or back passage.
* Pain that is worse at night.
what is the treatment of back pain?
ibuprofen 400mg tablets
paracetamol 500mg tablets
what advice should be given for back pain?
- What is done in the early stages is very important. Resting for more than a day or two usually does not help and may actually prolong
pain and disability11. - The back is designed for movement: it needs movement – a lot of movement. The sooner a person gets moving and doing ordinary
activities as normally as possible, the sooner they will feel better11. - The people who cope best with back pain are those who stay active and get on with life despite the pain11.
- Local application of heat or cold (ensuring that the skin is protected) may relieve pain and muscle spasm.
what is chicken pox?
the characteristic chickenpox rash: small, red, raised spots on the scalp, face, trunk and proximal limbs which progress
over 12–24 hours to blisters, papules, clear vesicles (which are intensely itchy), and pustules
when should we refer for chicken pox?
If the pharmacist is unsure about the diagnosis, the child should be referred to the GP.
Refer if the child is systemically unwell, their condition deteriorates, they develop complications or their symptoms have not started to
improve within 6 days13.
Neonates are at increased risk of disseminated or haemorrhagic varicella12. For this reason babies less than 4 weeks of age should be
referred to their GP12,13.
Children with chickenpox and parents/carers of young children with chickenpox should be aware of signs/symptoms of:
* skin bacterial superinfection12 – sudden high-grade pyrexia (often after initial improvement), erythema and tenderness surrounding
the original chickenpox lesions
* dehydration12 – reduced urine output, lethargy, cool peripheries, reduced skin turgor
* chest infection13 – persistent cough, difficulty breathing and chest pain.
what is the treatment for chicken pox?
paracetamol oral suspension/ tablets
chlorphenamine oral solution/tablets
what advice should be given for chicken pox?
- Ensure adequate fluid intake to avoid dehydration.
- Dress appropriately to avoid overheating or shivering.
- Wear smooth, cotton fabrics.
- Keep nails short and clean to minimise damage from scratching13.
- Bathe in lukewarm or cool water – dab or pat the skin dry afterwards, rather than rubbing it.
- Calamine lotion, moisturising creams or cooling gels may ease itching.
what is conjunctivitus?
People with conjunctivitis will have a red eye and a discharge which may cause a sticky coating on the eyelid – usually on waking. There may
also be a burning sensation and a feeling of grit in the eye but WITHOUT visual disturbance (in conjunctivitis, any visual disturbance is
cleared by blinking). Bacterial conjunctivitis is usually associated with no or only mild pruritus.
when should we refer conjunctivitus?
Refer urgently to an optometrist or GP if:
* vision is reduced or in any way impaired
* person has significant photophobia
* person has restricted or painful eye movements.
People who have an eye problem that needs urgent attention or people with an apparent eye-related problem are entitled to have a free Eye
Health Examination at an accredited optometrist practice. A list of optometrist practices that are accredited is available at Eye Health
Examination Wales.
Refer people to an accredited optometrist if:
* red eye and no discharge
* eye is painful
* there is redness and swelling around the eye
* there is a history of trauma or foreign body
* contact lenses are worn
* symptoms get worse despite treatment
* there has been no improvement in the person’s signs or symptoms despite treatment.
All Wales Medicines Strategy Group
Page 16 of 67
Refer people to their GP if they:
* are under 2 years old
* are pregnant or breastfeeding and you consider they require treatment
* have a personal or family history of blood dyscrasias
what treatment is for conjunctivitus?
chloramphenicol 0.5% eye drops/ 1% eye ointment
what advice should be given for conjunctivitus?
- Condition is usually self-limiting and will resolve within 1 week.
- Good eye hygiene is essential. Wipe with cooled boiled water.
- Wash hands regularly, particularly after touching infected secretions.
- If symptoms worsen despite treatment, seek medical advice.
- Don’t share pillows or towels.
when should we refer dry eyes?
When the condition of dry eyes is suspected, the person can also be referred to an EHEW accredited optometrist to have a free eye health
examination. Referral is recommended because certain underlying medical conditions can be associated with dry eye syndrome, e.g. allergic
conjunctivitis, Sjögren’s syndrome, facial or trigeminal neuropathy, herpes zoster affecting the eye, chronic dermatoses of the eyelids,
previous ocular or eyelid surgery, trauma, radiation therapy, burns. If acute glaucoma, keratitis or iritis is suspected, refer immediately.
Symptoms include:
* moderate-to-severe eye pain or photophobia
* marked redness in one eye
* reduced visual acuity
what is the treatment for dry eyes?
hypromellose 0.3% eye drops
carbomer ‘980’ 0.2% drops
polyvinyl alcohol 1.4%
liquid paraffin
what advice should be given for dry eyes?
- Good eyelid hygiene to control the blepharitis – present in most people with dry eye syndrome. Eyelids should be cleaned in a
stepwise manner twice daily, then once daily as symptoms improve37. - Limiting the use of contact lenses if these cause irritation (optometrist assessment required).
- Reviewing medication that exacerbates dry eyes, such as topical and systemic antihistamines, tricyclic antidepressants, beta blockers,
diuretics and selective serotonin reuptake inhibitors (SSRIs)37,39. - Using a humidifier to moisten ambient air.
- Stopping smoking.
- If using a computer monitor frequently for long periods, ensure that the monitor is placed at or below eye level. Advise person to avoid
staring at the screen and to take frequent breaks to close or blink the eyes. - Avoid wearing eye make-up.
what is hay fever?
a common seasonal allergy to grass, tree or weed pollen
what are the symptoms of hay fever?
sneezing, rhinitis, conjunctivitis, itchy throat,
mouth, nose, ears, and cough caused by post-nasal drip. Less commonly loss of smell, headache, earache, facial pain or tiredness may
occur. People with asthma may experience worsening of their symptoms
when should we refer hay fever?
- person is pregnant or breastfeeding
- uncontrolled symptoms continue after 2–4 weeks despite correct use of medication45
- urgent resolution of severe symptoms affecting quality of life is required44
- person is a child under 2 years requiring treatment
All Wales Common Ailments Formulary
Page 31 of 67 - there is nasal blockage in the absence of rhinorrhoea, nasal itch and sneezing
- there is unilateral nasal discharge, especially in a young child, to check for a trapped foreign body
what is the treatment of hay fever?
cetirizine
loratadine
chlorphenamine
sodium cromogglicate
beclometasone
what advive should be given for hay fever?
Regular treatment and good nasal spray/eye drop technique are important to control symptoms.
People should be advised to check weather reports for the pollen count and stay indoors when possible when it is high
Non-sedating antihistamines may still cause drowsiness which may affect driving ability especially if combined with alcohol.
Consider buying a pollen filter for car air vents and change at each service.
People who use a steroid nasal spray to control their symptoms should be advised to re-start treatment several weeks before the start of
the pollination season
When the pollen count is high the person should:
* avoid pollen by closing windows, wearing wraparound sunglasses and avoiding grassy areas particularly during early morning,
evening and night44,47
* avoid drying clothes outside
* apply Vaseline® around their nostrils to trap the pollen
* shower and wash their hair after being outdoors to remove pollen
* vacuum regularly and dust with a damp cloth
what is an ingrown toenail?
Ingrowing toenails are a common problem (especially in teenagers and young adults) in which part of the nail penetrates the skin fold
alongside the nail, creating a painful area, often on the big toe. The nail fold may be red, hot, tender, and swollen; occasionally a visible
collection of pus may be present. Granulation tissue may also be seen
when should you refer an ingrown toenail?
infection
co-excisting nail disease
what is the treatment for ingrown toenail?
advice only
what is the advice for an ingrown toenail?
Soak the toe in water for 10 minutes to soften the folds of skin around the affected nail.
* Then, using a cotton wool bud, push the skin fold over the ingrown nail down and away from the nail. Start at the root of the nail
and move the cotton wool bud towards the end of the nail.
* Repeat each day for a few weeks, allowing the nail to grow.
* As the end of the nail grows forward, push a tiny piece of cotton wool or dental floss under it to help the nail grow over the skin and
not grow into it. Change the cotton wool or dental floss each time the foot is soaked.
* Do not cut the nail but allow it to grow forward until it is clear of the end of the toe. Then cut it straight across, not rounded off at the
end.
* Practise good foot hygiene by taking care of their feet and regularly washing them, using soap and water.
* Trimming the nail straight across to help prevent pieces of nail digging into the surrounding skin.
* Wearing comfortable shoes, tights and socks that are not too tight and provide space around their toes.
what is intertrigo?
Intertrigo is an inflammation (rash) of the body folds, commonly affecting the groin, under the breasts and axillae. Skin may become moist
and macerated, leading to fissuring (cracks) and peeling. Intertrigo can be classified as inflammatory (symmetrical; affecting armpits, groin,
under the breasts and the abdominal folds) or infectious (unilateral and asymmetrical; caused by bacteria, yeasts or other types of fungi), but
there is often overlap.
when should you refer for intertrigo?
immunocompromised
severe or extensive disease
bacterial infection
rash unresponsive to treaatment
what is the treatment for intertrigo?
clotrimazole
miconazole
hydrocortisone
what advice should be given for inteertrigo?
- Wash the affected skin daily and dry thoroughly afterwards, particularly in the skin folds.
- Wash clothes and bed linen frequently to eradicate the fungus.
- Do not share towels, and wash them frequently.
- Wear loose-fitting clothes made of cotton or a material designed to move moisture away from the skin.
when should we refer tonsilitis?
Urgent referral (including to A&E if very unwell)69,70:
* respiratory distress
* drooling
* systemically very unwell
* unable to swallow
* difficulty opening mouth
* muffled voice – or making a high pitched sound as they breathe (stridor)
* dehydrated or unable to take fluids
* signs of being systemically unwell and at risk of immunosuppression.
Refer to GP:
* People with persistent symptoms that haven’t started to improve after a week. Refer sooner if symptoms worsen.
* Where there is absence of a cough.
* After 1 week if person has sore throat and lethargy (suggests possible symptoms of glandular fever, especially if 15 to 25 years old).
* People who are immunocompromised (e.g. people receiving cancer treatment or high doses of oral steroids or other
immunosuppressants [see BNF], or those with conditions that reduce immunity).
* If the person is systemically unwell or has symptoms and signs suggestive of serious illness and/or complications.
* If the person has a persistently high temperature over 38o
C.
* If the person is at high risk of serious complications because of pre-existing comorbidity. This includes people with significant heart
disease (including valvular heart disease), history of rheumatic fever, diabetes, lung, renal, liver or neuromuscular disease, cystic
fibrosis and young children who were born prematurely.
* Repeated episodes (5 or more) per year or a lower threshold if other concerns.
* Sore throat in combination with rash, flushed cheeks and swollen tongue could be a sign of scarlet fever. This normally occurs in
children, but can occur at any age.
what is the treatment of tonsilitis?
paracetamol
ibuprofen
what advice should be given for tonsilitis?
Be advised that the condition is self-limiting and is likely to get better within 7 days, with or without antibiotic treatment.
* Seek further healthcare advice if symptoms do not improve within 7 days or worsen.
* Simple analgesics will help temperature and discomfort.
* Take painkillers at regular intervals to relieve pain and fever.
* Adults and older children may find sucking throat lozenges, ice cubes or flavoured frozen desserts (e.g. ice lollies) provides symptomatic
relief.
* People may wish to try medicated lozenges to help reduce pain but their benefit is likely to be small. It is unclear if throat sprays
containing an antiseptic plus local anaesthetic or benzydamine gargles help symptoms.
* Avoiding smoking and smoky environments.
* Drink plenty of cool or warm fluid and avoid very hot drinks that could irritate the throat. Eat cool and soft foods
what are the symptoms of vaginal thrush?
white, odorless discharge with vaginal soreness and vulva itching
when should you refer vaginal thrush?
- people < 16 and > 60 years, pregnant or breastfeeding women and immunocompromised women
- women with poorly controlled diabetes, who have not been reviewed by the GP in the last 3 months
- if woman presents with foul smelling discharge, increased urinary frequency or abnormal vaginal bleeding
- you are uncertain about the diagnosis e.g. patient has had a previous sexually transmitted infection and it may have returned.
what is the treatment for vaginal thrush?
clotrimazole
fluconazole
