assignment on various diseases

Assignment on diseases

Assignment topics:

Cough Rhinitis Sore Throat Diarrhoea Dyspepsia Oral Thrush Motion Sickness Constipation Headache Insomnia

Submitted To: Mr. Rashid Hussain

Submitted By: Zameer-ul-hassan Roll no. 143 6th semester Self support

Faculty of Pharmacy University Of Sargodha, Sargodha.

1. Cough 1


A protective reflex action caused when the airway is being irritated or obstructed. The majority of coughs presenting in the pharmacy associated with other symptoms of a cold. The evidence to support the use of cough suppressants and expectorants is not strong but some patients report finding them helpful.

Cough Symptoms :

Associated signs and symptoms are important factor in determining the cause of the cough is whether it is acute or chronic.

Acute coughs have been divided into infectious and noninfectious causes.Signs and symptoms that point to an infection include fever, chills, body aches, sore throat, nausea, vomiting, headache, sinus pressure, runny nose, night sweats, and postnasal drip. Sputum, or phlegm, sometimes indicates an infection is present, but it is also seen in noninfectious causes.Signs and symptoms that point to a noninfectious cause include coughs that occur when a person is exposed to certain chemicals or irritants in the environment, coughs with wheezing.

The signs and symptoms of the chronic cough can be hard for doctors to assess, because many causes of chronic cough have overlapping signs and symptoms.

o If a cough is related to environmental irritants, it will worsen when exposed to the offending agent. If a person has an environmental allergy, the cough may improve when using allergy medications. If a person has a smoker's cough, it may improve if they stop smoking and worsens with increased smoking.

o If a person has a chronic lung disease such as asthma, emphysema, or chronic bronchitis, they may have a persistent cough or a cough that worsens with certain locations or activities.

o If a cough is associated with medications, such as angiotensin converting enzyme (ACE) inhibitors, the cough often begins after starting the medication in question, but can come on at any point during the use of the medication. The cough is often dry and improves when the medication is stopped.

o A cough associated with GERD is often associated with a sensation of heartburn. This type of cough worsens during the day or when lying flat on the back. Furthermore, a sizable minority of people with a cough caused by GERD will note no symptoms of reflux, but most people will report improvement in their cough when GERD is treated properly.

Etiology:

Receptors are located mainly in the pharynx, larynx, trachea and bifurcations of the large bronchi are stimulated via mechanical, irritant or thermal mechanisms. Neural impulses are carried out along afferent pathways of the vagal and superior laryngeal nerves, which terminate at the cough centre in the medulla. Efferent fibers of the vagus and spinal nerves carry neural activity to the muscles of the diaphragm, chest wall and abdomen. These muscles contraction followed by the sudden opening of the glottis that creates the cough.

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Role of pharmacist :

The most common causes of an acute cough are infection, allergies and postnasal drip. Viral infection is the most common cause of an acute cough at all ages. Recurrent viral bronchitis is more prevalent in pre-school and young school-aged children and is the most common cause of persistent cough in children of all ages. It is the pharmacist’s responsibility to differentiate other causes of cough from viral causes and also refer those cases of cough that might have more serious pathology. Asking symptom-specific questions will help the pharmacist to determine if referral is needed.

Question Relevance Sputum colour Yellow, green or brown sputum normally indicates infection. However,

mucopurulent sputum is probably is caused by a viral infection and does not require automatic referral.

Haemoptysis can be rust coloured (pneumonia), pink coloured (left ventricular failure) or dark red (carcinoma).

Nature of sputum Thin and frothy suggests left ventricular failure.Thick, Mucoid to yellow can suggest asthma.Offensive, foul-smelling sputum suggests either bronchiectasis or lung abscess.

Onset of cough A cough that is worse in the morning suggests postnasal drip, bronchiectasis or chronic bronchitis.

Duration of cough Cough lasting longer than 3 weeks should be viewed with caution because they might indicate a more sinister pathology.

Periodicity Adult patient with recurrent cough might have chronic bronchitis, especially if they smokeCare should be exercise in children who present with recurrent cough and have a family history of eczema, asthma or hay fever. This might suggest asthma and referral would be required for further investigation and pulmonary function tests (e.g. peak expiratory flow assessment).

Age Children will most likely be suffering from an upper respiratory tract infection but asthma, especially if the cough is non-productive and at night, should be consideredWith increasing age conditions such as bronchitis, pneumonia and carcinoma become more prevalent

Smoking history Patient who smoke are more prone to chronic and recurrent cough. Over time this might develop into chronic bronchitis and emphysema

What you need to know

Management:

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Pharmacists are well aware of the debate about the clinical efficacy of the cough remedies available OTC However, many people who visit the pharmacy for advice do so because they want some relief from their symptoms and, while the effectiveness of cough remedies remains unproven, they can have a useful placebo effect.The choice of treatment depends on the type of cough. Suppressants (e.g. pholcodine) are used to treat unproductive coughs, while expectorants such as guaifenesin (guaiphenesin) are used in the treatment of Productive coughs. Demulcents like Simple Linctus that soothe the throat are particularly useful in children and pregnant women as they contain no active ingredients. The BNF gives the following guidance.

Expectorants: A simple expectorant mixture may serve a useful placebo function and is inexpensive.

Suppressants: Where there is no identifiable cause (underlying disorder), cough suppressants may be useful; e.g. if sleep is disturbed.

Demulcents : Paediatric simple linctus is particularly useful in children, and sugar-free versions are available. Productive coughs should not be treated with cough suppressants because the result is pooling and retention of mucus in the lungs and a higher chance of infection, especially in chronic bronchitis.

Codeine/pholcodine: Pholcodine has several advantages over codeine in that it produces fewer side-effects and pholcodine is less liable to be abused. For these reasons, codeine is best avoided in the treatment of children’s coughs and should never be used in children under 1 year. Both pholcodine and codeine can induce drowsiness, although in practice this does not appear to be a problem. Nevertheless, it is sensible to give an appropriate warning. Codeine is well known as a drug of abuse and many pharmacists choose not to recommend it. Sales often have to be refused because of knowledge or likelihood of abuse. Pholcodine can be given at a dose of 5 mg to children over 2 years of age (5 mg of pholcodine is contained in 5 ml of pholcodine linctus BP). Adults may take doses of up to 15 mg three or four times daily. The drug has a long half-life and may be more appropriately given as a twice-daily dose.

Dextromethorphan : Dextromethorphan is less potent than pholcodine and codeine. It is generally non-sedating and has few side-effects. Occasionally, drowsiness had been reported but, as for pholcodine, this does not seem to be a problem in practice. Dextromethorphan can be given to children of 2 years and over. Dextromethorphan was generally thought to have a low potential for abuse. However, there have been rare reports of mania following abuse and consumption of very large quantities, and pharmacists should be aware of this possibility if regular purchases are made.

Demulcents :

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Preparations such as glycerin, lemon and honey or Simple Linctus are popular remedies and are useful for their soothing effect. They do not contain any active ingredient and are considered to be safe in children and pregnant women.Their pleasant taste makes them particularly suitable for children but their high syrup content should be noted. Expectorants Two mechanisms have been proposed for expectorants.

Guaifenesin (guaiphenesin):

Guaifenesin is commonly found in cough remedies. In adults, the dose required to produce expectoration is 100–200 mg, so in order to have a theoretical chance of effectiveness, any product recommended should contain a sufficiently high dose.Some OTC preparations contain sub therapeutic doses.

Antihistamines :

Examples used in OTC products include diphenhydramine and promethazine. Theoretically these reduce the frequency of coughing and have a drying effect on secretions, but in practice they also induce drowsiness.Combinations of antihistamines with expectorants are illogical and best avoided. A combination of an antihistamine and a cough suppressant may be useful in that antihistamines can help to dry up secretions and, when the combination is given as a night-time dose if the cough is disturbing sleep, a good night’s sleep will invariably follow.

Interactions .

Traditional antihistamines should not be used by patients who are taking phenothiazines and tricyclic antidepressants because of additive anticholinergic and sedative effects

Sympathomimetics:

Pseudoephedrine is the most commonly used oral decongestant included in cough and cold remedies for its bronchodilatory and decongestant actions. It has a stimulant effect that may lead to a sleepless night if taken close to bedtime. It may be useful if the patient has a blocked nose as well as a cough and an expectorant/ decongestant combination can be useful in productive coughs. Oral sympathomimetics should be used with caution in patients with diabetes coronary heart disease (e.g. angina) hypertension hyperthyroidism Interactions. Sympathomimetics should be avoided by patients taking monoamine oxidase inhibitors (e.g. phenelzine) reversible inhibitors of monoamine oxidase A (e.g. moclobemide) beta-blockers tricylic antidepressants (e.g. amitriptyline); a theoretical interaction which does not seem to cause problems in practice.

Theophylline:

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Theophylline is sometimes included in cough remedies for its bronchodilator effect. OTC medicines containing theophylline should not be taken at the same time as prescribed theophylline since toxic blood levels and side-effects may occur. The action of theophylline can be potentiated by some drugs, e.g. cimetidine and erythromycin. Levels of theophylline in the blood are reduced by smoking and drugs such as carbamazepine, phenytoin and rifampicin that induce liver enzymes, so that the metabolism of theophylline is increased and lower serum levels result. Side-effects include GI irritation, nausea, palpitations, insomnia and headaches. The adult dose is typically 120 mg three or four times daily. It is not recommended in children. Before selling any OTC product containing theophylline, check that the patient is not already taking the drug on prescription.

Case study:

Mrs Patel, a woman in her early twenties, asks what you can recommend for her son’s cough. On questioning you find out that her son, Dillip, aged 4, has had a cough on and off for a few weeks.He gets it at night and it is disturbing his sleep although he doesn’t seem to be troubled during the day. She took Dillip to the doctor about 3 weeks ago, and the doctor explained that antibiotics were not needed and that the cough would get better by itself. The cough is not productive and she has given Dillip some Tixylix before he goes to bed but the cough is no better. Dillip is not taking any other medicines. He has no pain on breathing or shortness of breath. He has had a cold recently.

View of the pharmacist :

This is a 4-year-old child who has a night-time cough of several weeks’ duration. The doctor’s advice was appropriate at the time Dillip saw him. However, referral to the doctor would be advisable because the Cough is only present during the night. A recurrent cough in a child at night can be a symptom of asthma, even if wheezing is not present. It is possible that the cough is occurring as a result of bronchial irritation following his recent viral URTI. Such a cough can last for up to 6 weeks and is more likely to occur in those who have asthma or a family history of atopy (a predisposition to sensitivity to certain common allergens such as house dust mite, animal dander and pollen).

2.Rhinitis

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Rhinitis is a medical term for irritation and inflammation of the mucous membrane inside the nose. In rhinitis, the inflammation of the mucous membrane is caused by viruses, bacteria, irritants or allergens

Types of Rhinitis :

There are two types of rhinitis: Allergic non-allergic.

Allergic Rhinitis: Seasonal allergic rhinitis (hay fever) is most often caused by pollen carried in the air during different times of the year in different parts of the country.Allergic rhinitis can also be triggered by common indoor allergens such as:

the dried skin flakes, urine saliva found on pet dander, mold, droppings from dust mites cockroach particles.

This is called perennial allergic rhinitis, as symptoms typically occur year-round.

Non-allergic Rhinitis: At least one out of three people with rhinitis symptoms do not have allergies. Nonallergic rhinitis usually afflicts adults and causes year-round symptoms, especially

runny nose nasal congestion.

This condition differs from allergic rhinitis because the immune system is not involved.

Symptoms :

Allergic rhinitis symptoms include: Post nasal drip Itching in the nose, roof of the mouth, throat, eyes Sneezing Stuffy nose (congestion) Runny nose Tearing eyes Dark circles under the eyes Hay fever symptoms tend to flare up in the spring and fall. Perennial allergic rhinitis symptoms

are year-long.

Role of pharmacist:

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It is not difficult to diagnose. Within the community pharmacy setting the majority of patients who present with rhinitis will be suffering from cold or hay fever.Diagnosis is largely dependent upon the patient having a family history of atopy,clinical symptoms and worsening symptoms at a particular time of year.Asking symptom-specific questions will help the pharmacist to determine the cause and whether referral is needed.

Questions Relevance Seasonal variation

Symptoms in the summer months suggest hay fever: year –round suggest perennial rhinitis

History of asthma, eczema or hay fever in the family

If a 1st degree relative suffers from atopy then hay fever is the most likely cause of rhinitis

Triggers Pollen is the main allergen in hay fever, therefore symptoms are worse when pollen counts are high

Infective rhinitis will be unaffected by pollen count; patient with perennial rhinitis might suffer from worsening symptoms but symptoms should persist when indoors, unlike hay fever sufferers who usually see improvement of symptoms when away from pollen.

Treatment and management :

OTC medication: Avoiding pollen is almost impossible but if he follows few rules then exposure to pollen can be diminished. E.g.:

Patient should remain indoors when pollen count is high and windows should be closed. Using allergen impermeable bed linen and acarcidal sprays can reduce house-dust mite.

Loratadine should be recommended as 1st line therapy if the patient suffers from general symptoms such a snasal itching, sneezing, rhinorrhea and associated ocular symptoms. A range of topically administered medication is available to combat nasal congestion and ocular symptoms, including; antihistamines, mast cell stabilizers and decongestants.

Practical prescribing and product selection :

Medicine Use in children

Recommended dose

Side effect Drug interactio

Care in patients

Pregnancy

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nsSystemic antihistamines Acrivastine >12 yrs One capsule

TIDSedation but least likely with Loratadine

None None Ok but all manufacturers advise avoidanceCetrizine >6 yrs 2.5 ml bid

children over 2 yrs , 1 tab. Daily in adults

Loratadine >2 yrs 1 tab dailyNasal antihistaminesAzelastine >5 yrs 1 spray in

each nostril bid

Nasal irritation 5%, bitter taste 3%

None None Ok

Levocabastine 12 yrs One drop in each eye, 2 sprays in each nostril bid

Nasal irritation, headache

Severe renal impairment

Case study :A young man presents in late May. He asks what you can recommend for hay fever. On questioning, he tells you that he has not had hay fever before, but some of his friends get it and he thinks he has the same thing. His eyes have been itching a little and are slightly watery, and he has been sneezing for a few days. His nose has been runny and now feels quite blocked. He will not be driving, but is a student at the local sixth-form college and has exams coming up next week. He is not taking any medicines.

The pharmacist’s view: This young man is experiencing the classic symptoms of hay fever for the first time. The nasal symptoms are causing the most discomfort; he has had rhinorrhoea and now has congestion so it would be reasonable to recommend a corticosteroid nasal spray providing he is aged 18 or over. If he is under 18, an oral or topical antihistamine could be recommended, bearing in mind that he is sitting for exams soon and so any preparation that might cause drowsiness is best avoided. His eyes are slightly irritated, but the symptoms are not very troublesome. You know that he is not taking any other medicines, so you could recommend acrivastine, loratadine or cetirizine. If the symptoms are not better in a few days, he should see the doctor.

3.Sore throat

Most sore throats that present in the pharmacy will be caused by viral infection (90%), with only one in ten being due to bacterial infection, so that treatment with antibiotics is unnecessary in most cases.

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Symptoms: The main symptom is a sore throat:

Fever Headache Joint pain and muscle aches Skin rashes Swollen lymph nodes in the neck

Etiology:

Pharyngitis is caused by swelling (inflammation) of the pharynx, which is in the back of the throat, between the tonsils and the voice box (larynx).Most sore throats are caused by a viral infection, such as the cold or flu.Some viruses can cause specific types of sore throat, such as coxsackie infection or mononucleosis.Bacteria that can cause Pharyngitis include Group A streptococcus, which leads to strep throat in some cases.Other, less-common bacteria that cause sore throats include corynebacterium, gonorrhea, and Chlamydia.Most cases of Pharyngitis occur during the colder months. The illness often spreads among family members.

Role of pharmacist:

Pharmacist must try to differentiate between viral infection and other causes of sore throat. When examining the mouth, pay particular attention to the fauces and tonsils- are they red and swollen? Is any exudate present? Is there any sign of ulceration?

Question Relevance Age The likely cause of sore throat is influence by the age of patient. Although viral

causes are the most common causes, Streptococcal infections are more prevalent in school-aged children.

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Viral causes are the most common cause of sore throat in adults Glandular fever is most prevalent in adolescents Oral thrush affects the very young and very old.

Tender cervical glands

On examination, patient suffering from glandular fever and streptococcal sore throat often have markedly swollen glands. This is less so in viral sore throat.

Presence of tonsillar exudates

Marked tonsillar exudates is more suggestive of a bacterial cause than a viral cause.

Ulceration Herpetiform and herpes simplex ulcers can also cause soreness in the mouth, especially in the posterior part of the mouth.

Treatment :

OTC medication:

The majority of sore throats are viral in origin and self limiting

Antibacterial and antifungal agents should not be routinely recommended because the vast majority of sore throats are caused by viral infections, against which these agents have no action.

Benzydamine (anti-inflammatory agent) has proven efficacy in relieving pain with sore throat. There is good evidence to show that simple systemic analgesia

; paracetamol, Aspirin ibuprofen, is effective in reducing the pain associated with sore throat. Flurbiprofen lozenges have shown to be significantly more effective than placebo in reducing pain

associated with sore throat.

Practical prescribing and product selection:


Recommended dose

Side effects Drug interactions

Patient in whom care should be exercised

Pregnancy

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Local anestheticsLidocaine >12 yrs 6 spray of

Dequaspray & 10 spray of covonia throat spray

Can cause sensitization reactions

None None Neonatal respiratory depression in large dosesAvoid in 3rd trimester

BenzocaineLozengespray

>3 yrs>6 yrs

8 lozenges for adults in 24h

Anti-inflammatory agentsBenzydamineRinseSpray >12 yrs

>6 yrs

Oral rinse may cause stinging

None None Ok

Symptoms for direct referral:

Hoarseness Dysphagia Thrush Glandular fever

Case study:

A woman asks your advice about her son’s very sore throat. He is 15 years old and is at home in bed. She says he has a temperature and that she can see creamy white matter at the back of his throat. He seems lethargic and hasn’t been eating very well because his throat has been so painful. The sore throat started about 5 days ago and he has been in bed since yesterday. The glands on his neck are swollen.

The pharmacist’s view:It would be best for this woman’s son to be seen by the doctor. The symptoms appear to be severe and he is ill enough to be in bed. Glandular fever is common in this age group and is a possibility. In the meantime you might consider recommending some paracetamol in soluble or syrup form to make it easier to swallow. The analgesic and antipyretic effects would both be useful in this case.

4. Diarrhoea Diarrhoea is defined as an increased frequency of bowel evacuation, with the passage of abnormally soft or watery faeces. The basis of treatment is electrolyte and fluid replacement; in addition, antidiarrhoeals are useful in adults and older children.

Symptoms:

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Some sufferers may pass slightly watery stools and have brief episodes of stomachache, while others may pass very watery stools and have more severe stomach cramping. The most common symptoms include: Abdominal cramps

Abdominal pain Vomiting Nausea Temperature (fever) Headache Loss of appetite Fatigue Loose, watery stools Bloating Blood in stool

Etiology:

The etiology of diarrhoea depends upon its cause.

Acute gastroenteritis, the most common cause of diarrhoea in all age groups, is usually viral in origin. Commonly implicated viruses are the rotavirus the Norwalk virus and the Norwalk-like virus.

Rotaviruses are the most common cause of diarrhoea in children under the age of 2.

The fecal-oral route transmits all three types of virus. Viral replication results in blunting of the villi of the upper small intestine decreasing the absorptive surface.Bacterial causes, for example: Shigella and Salmonella species are invasive,penetrating the mucosa of the small intestine normally a result of eating contaminated food or drink.

Role of Pharmacist :

suitable available home fluids immediately upon onset of diarrhoea in a child Treat dehydration with ORS solution (or with an intravenous electrolyte solution in cases of

severe dehydration) Emphasize continued feeding or increased breastfeeding during, and increased feeding after

the diarrhoeal episode

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http://www.medicalnewstoday.com/articles/73936.php


Use antibiotics only when appropriate, i.e. in the presence of bloody diarrhoea or shigellosis, and abstain from administering anti-diarrheal drugs

Questions to be asked :

Questions Relevance Frequency and nature of stools

Patient with acute, self-limiting diarrhoea will be passing watery stools more frequently than normalDiarrhoea associated with blood & mucous require referral to eliminate invasive infection, such as Shigella, and conditions such as inflammatory bowel disease (IBS)

Periodicity A history of recurrent diarrhoea of no known cause should be referred for further investigation

Duration A person who present with a history of chronic diarrhoea should be referred. The most frequent causes of chronic diarrhea are IBS, inflammatory disease and colon cancer

Onset of symptoms

Ingestion of bacterial pathogens can give rise to symptoms in a matter of a few hrs after eating contaminated food (toxin-producing bacteria) or up to 3 days later. It is important to ask about food consumption over the last few days, establish if anyone else ate the same food and to check the status of his or her health

Timing of diarrhoea

Patient who experience diarrhoea first in the morning might have pathology of IBSNocturnal diarrhea is often associated with IBS

Recent change of diet

Change in diet can cause changes in bowel function, e.g. when away on holiday. If the person has recently been to a non-Western country then giardiasis is possibility

Management:

Oral rehydration therapy:

The risk of dehydration from diarrhoea is greatest in babies, and rehydration therapy is considered to be the standard treatment for acute diarrhoea in babies and young children. Oral rehydration sachets may be used with antidiarrhoeals in older children and adults. Rehydration may still be initiated even if referral to the doctor is advised.

Drugs that may cause diarrhoea:

Antacids: magnesium salts Antibiotics Antihypertensives: guanethidine (common side-effect but rarely prescribed); Digoxin (toxic levels) Diuretics (furosemide (frusemide)) Iron preparations

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Misoprostol

Other therapy:

Loperamide: Loperamide is an effective antidiarrhoeal treatment for use in older children and adults. When recommending loperamide the pharmacist should remind patients to drink plenty of extra fluids. Oral rehydration sachets may be recommended. Loperamide may not be recommended for use in children under 12 years.

Kaolin: Kaolin has been used as a traditional remedy for diarrhoea for many years. Its use was justified on the theoretical grounds that it would absorb water in the GI tract and would absorb toxins and bacteria onto its surface, thus removing them from the gut.

Diarrhoea in practice:

Mrs Robinson asks what you can recommend for diarrhoea. Her son David, aged 11, has diarrhoea and she is worried that her other two children, Natalie, aged 4, and Tom, aged just over 1 year, may also getit. David’s diarrhoea started yesterday; he went to the toilet about five times and was sick once, but has not been sick since. He has griping pains, but is generally well and quite lively. Yesterday he and chips from the local takeaway during his lunch break at school. No one else in the family ate the same food had pie. Mrs Robinson has not given him any medicine, but has some kaolin and morphine mixture at home and wants to know if David could take some, and also if the other children could take it if necessary.

The pharmacist’s view:It sounds as if David has a bout of acute diarrhoea, possibly caused by the food he ate yesterday during lunchtime. He has vomited once, but now the diarrhoea is the problem. The child is otherwise well. He is 11 years old, so the best plan would be to start oral rehydration with some proprietary sachets, with advice to his mother about how they should be reconstituted. Kaolin and morphine mixture should not be given to children under 12, and in any case is not considered first-line treatment for diarrhoea. If either or both the other children get diarrhoea, they can also be given some rehydration solution. David should see the doctor the day after tomorrow if his condition has not improved.

5.Dyspepsia

Dyspepsia, also known as upset stomach or indigestion, refers to a condition of impaired digestion It is a medical condition characterized by chronic or recurrent pain in the upper abdomen, upper abdominal fullness and feeling full earlier than expected when eating.Dyspepsia is an umbrella term generally used by heath care professionals to refer to a group of upper abdominal symptoms that arise from five main conditions.

Non-ulcer dyspepsia (indigestion)

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http://en.wikipedia.org/wiki/Abdomen

http://en.wikipedia.org/wiki/Pain

http://en.wikipedia.org/wiki/Digestion


Reflux (heartburn) Gastritis Duodenal ulcers Gastric ulcers

These five main conditions represent 90% of dyspepsia cases that present to the GP.

Symptoms:

Pain worsened by exertion and associated with nausea and perspiration may also indicate angina.

The presence of gastrointestinal bleeding (vomit containing blood), difficulty swallowing, loss of appetite, unintentional weight loss, abdominal swelling and persistent vomiting are suggestive of peptic ulcer disease or malignancy urgent investigations.

Etiology: Lower esophageal sphincter incompetence is the principle cause of reflux oesophagitis. Increase acid production results in the inflammation of the stomach (gastritis) and is usually attributable to Helicobacter pylori infection, NSAID or acute alcohol ingestion. The presence of H. Pylori is central to duodenal and gastric ulceration as H. Pylori is present in nearly all individuals. The mechanism with which it affects is unknown, but the bacteria are thought to secrete certain chemical factors that result in gastric mucosal damage.

Role of community pharmacist:

Patient who present with dyspepsia are likely to be suffering from reflux, gastritis or non-ulcer dyspepsia. Despite this, a thorough medical and drug history should be taken to enable the community pharmacist to rule out serious pathology and diagnose dyspepsia. A no. of dyspepsia specific questions should always be asked of the patient to aid in diagnosis.

Questions Relevance Age The incidence of dyspepsia decreases with advancing age and therefore young adults

are likely suffer from dyspepsia with no specific pathological condition.Location Dyspepsia is experienced as pain above the umbilicus and centrally located (epigastric

area). Pain below the umbilicus will not be due to dyspepsia.Pain experienced behind the sternum (breast bone) is likely to be heartburn

Nature of pain Pain associated with dyspepsia is described as aching or discomfort. Pain described as gnawing, sharp or stabbing is unlikely to be dyspepsia

Radiation Pain that radiates to other areas of the body is indicative of more serious pathology and the patient must be referred. The pain might be cardiovascular in origin.

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http://en.wikipedia.org/wiki/Vomiting

http://en.wikipedia.org/wiki/Dysphagia

http://en.wikipedia.org/wiki/Gastrointestinal_bleeding

http://en.wikipedia.org/wiki/Angina

http://en.wikipedia.org/wiki/Perspiration

http://en.wikipedia.org/wiki/Nausea


Associated symptoms

Persist vomiting with or without blood is suggestive of ulceration or even cancer and must be referred

Social history Bouts of excessive drinking are commonly implicated in dyspepsia. Likewise, eating food on the move or too quickly is often the cause of symptoms.

Management :.



Recommended dose


Care in patients

Pregnancy

AntacidsSodium only

>12 yrs None None Patient with heart disease

Ok

Mg only Diarrhoea TCAs, quinolones, imidazole, phenytoin, penicillamine.

None Ok

Alginates Gaviscone >6 yrs

(advance liquid >12 yrs)

None None Patient with heart disease

Ok

AsiloneHeartburn

>6 yrs

H2-antagonistsPepcid AC

>16 yrs

1 tab. And repeat after 1h.

Diarrhoea, constipationheadache None None

Not recommended

Case study :

Mrs Mohsin daska, a 35 yrs old woman, asks to speak to the pharmacist because she wants something for stomach ache. You find out that the pain is located in the upper and lower left quadrants, but mainly the upper quadrant.

a. From which conditions might she be suffering?

Possible conditions are: reflux, non-ulcer dyspepsia, gastritis, primary dysmenorrhoea, endometriosis, IBS, pancreatitis, renal colic, MI and herpes zoster.Questioning reveals that patient to be suffering with describes as ‘an ache’.

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b. From which likely conditions could she know be suffering?

The word ‘ache’ means you can rule out those conditions that present with severe, stabbing, burning or gnawing pain:

Pancreatitis, renal colic; severe Reflux; burning Herpes zoster; severe, lancing

But it could still be any of: non-ulcer dyspepsia, gastritis, primary dysmenorrhoea, IBS, endometriosis, and, possibly, MI.

c. What symptoms-specific questions you are going to ask to differentially diagnose he condition?Questions to be asked are:

o Periodicityo Aggravating factorso Radiationo Associated symptoms

d. which body systems ca abdominal pan originate? And also describe its relevant cause?

The body systems and relevant cause of pain are:GI tract: non-ulcer dyspepsia, gastritis, primary dysmenorrhoea, endometriosis, IBS, pancreatitis, renal colic, MI and herpes zoster CVS: myocardial ischemiaMusculoskeletal: muscle strainReproductive: ectopic pregnancy, ovarian cyst Before any course of action is taken, you ask if she take any medication from GP. Her response is as:Paracetamol prn: she has taken for 6 months for knee painAtorvastatin 40mg od: she has taken for last 3yrs for familial hyperlipidaemiaNaproxen 500mg bd prn: she has taken for 6 months for knee pain

6.Oral thrush

Thrush (candidosis) is a fungal infection, which occurs commonly in the mouth (oral thrush), in the nappy area in babies and in the vagina. Oral thrush in babies can be treated by the pharmacist.

Significance of questions for pharmacist:

Age:

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Oral thrush is most common in babies, particularly in the first few weeks of life. Often, the infection is passed on by the mother during childbirth. In older children and adults, oral thrush is rarer, but may occur after antibiotic or inhaled steroid treatment. Affected areas:Oral thrush affects the surface of the tongue and the insides of the cheeks.

Appearance:

Oral thrush: When candidal infection involves mucosal surfaces, white patches known as plaques are formed, which resemble milk curds; indeed, they may be confused with the latter by mothers when oral thrush occurs in babies. The distinguishing feature of plaques due to Candida is that they are not so easily removed from the mucosa, and when the surface of the plaque is scraped away, a sore and reddened area of mucosa will be seen underneath, which may sometimes bleed.

Napkin rash: In the napkin (nappy) area, candidal infection presents differently, with characteristic red papules on the outer edge of the area of nappy rash, so-called satellite papules. Another feature is that the skin in the folds is nearly always affected. Candidal infection is now thought to be an important factor in the development of nappy rash.

Management: Antifungal agents:

Miconazole: The only specially formulated product currently available for sale OTC to treat oral thrush is miconazole gel. Preparations containing nystatin are also effective, but are restricted to prescription-only status.Miconazole gel is an orange-flavored product, which should be applied to the plaques using a clean finger four times daily after food in adults and children over 6 years, and twice daily in younger children and infants. For young babies, the gel can be applied directly to the lesions using a cotton bud or the handle of a teaspoon. The gel should be retained in the mouth for as long as possible. Treatment should be continued for 2 clear days after the symptoms have apparently gone, to ensure that all infection is eradicated..Practical points:

Oral thrush and nappy rash: If a baby has oral thrush, the pharmacist should check whether nappy rash is also present. Where both oral thrush and candidal involvement in nappy rash occur, both should be treated at the same time. An antifungal cream containing miconazole or clotrimazole can be used for the nappy area.

Breastfeeding: Where the mother is breastfeeding, a small amount of miconazole gel applied to the nipples will eradicate any fungus present. For bottle-fed babies, particular care should be taken to sterilize bottles and teats.

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Case study:

Helen Jones, a young mother, brings her daughter, Jane, to see you. Mrs. Jones wants you to recommend something for Jane’s mouth, which has white patches on the tongue and inside the cheeks. Jane is 8 years old and is not currently taking any medicines. She has not recently had any antibiotics or other prescribed medicines. Jane does not have any other symptoms.

The pharmacist’s view:

Jane should be referred to her doctor, since thrush is rare in children other than infants. There is no apparent precipitating factor such as recent antibiotic therapy and Jane should see her doctor for further investigation.

The doctor’s view:Helen Jones should be advised to take Jane to the doctor. The description is certainly suggestive of oral thrush. If there were any doubt as to the diagnosis, a swab could be taken for laboratory examination. If Jane did have thrush, then treatment such as miconazole oral gel or nystatin oral suspension might be prescribed. Treatment is enhanced by cleaning the white plaques off with a cotton bud prior to application.The next concern would be to determine a precipitating cause. General enquiries about Jane’s health would be necessary. The doctor would be in a good position to know of previous medical history including any transfusions and family history. A general physical examination would be carried out, looking, in particular, for signs of anaemia, any rashes or bruising, enlargement of lymph nodes (glands), enlargement of abdominal organs (e.g. liver or spleen) or any other masses. The doctor would be looking for signs of a malignancy such as leukaemia or lymphoma. Almost certainly blood tests would be arranged. The doctor would also make an assessment of any HIV risk factors and counsel Helen and Jane accordingly before initiating any further action.

7. Motion sickness

Motion sickness is thought to be caused by a conflict of messages to the brain, where the vomiting centre receives information from the eyes, the GI tract and the vestibular system in the ear. Effective prophylactic treatments are available OTC and can be selected to match the patient’s needs.

Symptoms: The most common signs and symptoms of motion sickness include:

Nausea Pale skin Cold sweats

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Vomiting Dizziness Headache Increased salivation Fatigue

Etiology:

It is widely believed that motion sickness results from the inability of the brain to process conflicting information received from sensory nerve terminals concerning movement and position, the eyes and vestibular system of the ear.

Role of community Pharmacist :

Most people who have had motion sickness in the past ask their healthcare provider, how to prevent it next time? Conventionally accepted medical approaches of assessment for this condition may include questions about the individual's symptoms as well as the event that typically causes the condition (such as riding in a boat, flying in a plane, or driving in car). Laboratory tests are generally not necessary to establish a diagnosis of motion sickness.

Management: Prophylactic treatments for motion sickness, which can be bought OTC, are effective and there is usually no need to refer patients to the doctor. Anticholinergic activity is thought to prevent motion sickness and forms the basis of treatment by anticholinergic agents.

Antihistamines:

Antihistamines include cinnarizine, meclozine and promethazine. Anticholinergic effects are thought to be responsible for the effectiveness of antihistamines in the prophylaxis of motion sickness. All have the potential to cause drowsiness and promethazine appears to be the most sedative. Meclozine and promethazine theoclate have long durations of action and are useful for long journeys since they only need to be taken once daily. Cinnarizine and promethazine theoclate are not recommended for children younger than 5 years, whereas meclozine can be given to those over 2 years. The manufacturers of products containing these drugs advise that they are best avoided during pregnancy.

Anticholinergic agents:

The only anticholinergic used widely in the prevention of motion sickness is hyoscine hydrobromide, which can be given to children over 3 years. Anticholinergic drugs can cause drowsiness, blurred vision, dry mouth, constipation and urinary retention as side-effects, although they are probably unlikely to do so at the doses used in OTC formulations for motion sickness. Children could be given sweets to suck to counteract any drying of the mouth. Hyoscine has a short duration of action (from 1 to 3 h). It is

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therefore suitable for shorter journeys and should be given 20 min before the start of the journey. Anticholinergic drugs and antihistamines with anticholinergic effects are best avoided in patients with prostatic hypertrophy because of the possibility of urinary retention and in glaucoma because the intraocular pressure might be increased.

Case study:

Mr and Mrs Mehmood and their two children akram aged 5 and jasmin aged 12 are going on their summer holidays. They want to know what travel sickness tablets they should take.a. What information do you need to know before recommending a suitable product?

You need to know: Who is affected by travel sickness? This will influence recommendation, especially if it

affects one of the parents who might be driving. The length of the trip. This will influence which product will be most appropriate. It is

sensible to match up the length of the journey with a medicine that has the same duration of action as the trip.

Medication history: parents who are taking medicine for glaucoma or prostate enlargement should avoid taking OTC medications. Additionally medicine with anticholinergic side effects will potentiate the side effect of OTC medication.

Past medication for similar journeys: it is likely that the family has bought such product in the past. It is worth finding out what they were and how well tolerated they were before potentially recommending the same product.

.

b. What would be the best drug regimen for the family?It appears total journey time is relatively short and a hyoscine-based product would be the most suitable product for two children and their father. Junior kwells could be used by every children; Mr mehmood would have to take two tablets, Jasmin one tablet and akram half a tablet. As Jasmin has narcolepsy, it is necessary to se if she takes any medication to help with the condition. If she does then checks have to be made to ensure that she could still take hyoscine

8.ConstipationConstipation is a condition that is difficult to define and is often self diagnosed by patients. Generally it is characterized by the passage of hard, dry stools less frequently than the person’s normal pattern.

Etiology:

In case of constipation, intestinal transient time is increased, which allows greater water resorption from the large bowel leading to harder stools that are more difficult to pass. This is most frequently caused by a deficiency in dietary fiber; a change in life style and/or environment and medication. Occasionally, patients ignore the defecatory reflux because it might be inconvenient for them to defecate.

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Symptoms:

Besides the inability to defecate, patient might also have abdominal discomfort and bloating. Children are more irritable and have decreased appetite. Specks of blood in toilet pan might also be present. Other associated symptoms are; malaise, abdominal distension.


Question Relevance Change of diet or routine

Constipation usually has a social or behavioral cause.

Pain on defection

Associated pain when going to the toilet is usually due to a local anorectal problem. Constipation is often secondary to the suppression of defecation because it induces pain. These cases are best referred for physical examination.

Presence of blood

Bright red specks in the toilet or smears on toilet tissue suggest hemorrhoids or a tear in the anal canal (fissure). However, if blood is mixed in the stool then referral to GP is necessary. A stool that appears black and tarry is suggestive of an upper GI bleed.

Acute or chronic

Constipation lasting 6 weeks or more is said o be chronic.

Lifestyle changes

Changes in job or marital status can precipitate depressive illness that can manifest with physiological symptoms such as constipation

.

Management:

Constipation that is not caused by serious pathology will usually respond to simple measures, which can be recommended by the pharmacist: increasing the amount of dietary fibre; maintaining fluid consumption; and taking regular exercise. In the short term, a laxative may be recommended to ease the immediate problem. Stimulant laxatives (e.g. senna, bisacodyl) Bisacodyl tablets are enteric-coated and should be swallowed whole because bisacodyl is irritant to the stomach.

Bulk laxatives :(e.g. ispaghula, methylcellulose, sterculia)

Bulk laxatives are those that most closely copy the normal physiological mechanisms involved in bowel evacuation and are considered by many to be the laxatives of choice. Such agents are especially useful where patients cannot or will not increase their intake of dietary fiber. Bulk laxatives work by swelling in the gut and increasing fecal mass so that peristalsis is stimulated.

Lubricant laxatives (e.g. liquid paraffin):

Liquid paraffin works by coating and softening the faces; it prevents further absorption of water in the colon. Long-term use can result in impaired absorption of fat-soluble vitamins (A, D, E, K). Leakage of liquid paraffin through the anal sphincter may occur, causing embarrassment and unpleasantness. If

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liquid paraffin is inadvertently inhaled into the lungs, lipid pneumonia can develop. Inhalation could occur during vomiting or if acid reflux (regurgitation) is present. The unpleasant and dangerous effects of liquid paraffin have led to restrictions in the UK on the pack size that can be sold. Pharmacists have an important role in discouraging the use of liquid paraffin, which has little valid therapeutic use.Constipation in children:Parents sometimes ask for laxatives for their children. Fixed ideas about regular bowel habits are often responsible for such requests. Numerous factors can cause constipation in children, including a change in diet and emotional causes.

Constipation in pregnancy:Constipation commonly occurs during pregnancy; hormonal changes are responsible and it has been estimated that one in three pregnant women suffers from constipation. Dietary advice concerning the intake of plenty of high-fibre foods and fluids can help. Oral iron, often prescribed for pregnant women, may contribute to the problem. Stimulant laxatives are best avoided during pregnancy; bulk forming laxatives are preferable, although they may cause some abdominal discomfort to women when used late in pregnancy..Case Study:A man comes into the pharmacy and asks for some good laxative tablets. Further questioning by the pharmacist reveals that the medicine mis for his dad who is aged 72. He does not know many details except that his dad has been complaining of increasing constipation over the last 2–3 months and has tried senna tablets without any benefit.

The pharmacist’s view:Third-party or proxy consultations are often challenging because the person making the request may not have all of the relevant information. However, in this case the decision is quite clear. The patient needs to be referred to the doctor because of the long history of the complaint and the unsuccessful use of a stimulant laxative

9.HeadacheThe most common types of headache that the community pharmacist is likely to encounter are tension headache, migraine and sinusitis. Careful questioning can distinguish causes that are potentially more serious so that referral to the doctor can be advised.

Aetiology :

Pain control systems modulate headaches of all types, independent of the cause. However, etiology of tension headache and migraine are still to be fully elucidated. Tension headache is commonly referred to as muscle contraction headache, as electromyography has shown pericranial contraction, which is often exacerbated by stress. However, similar muscle contraction is noted in migraine sufferers.

Associated symptoms:

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.

Migraine:Migraine affects about 10% of the UK population (6% of men and15% of women). In 2001 over £60m. was spent on prescription medication in the UK. There are two common types of migraine: migraine without aura (common migraine), which occurs in 75% cases, and migraine with aura (classic migraine) in up to one-third.

Migraine without aura: (common migraine): Attacks lasting 4–72 hAt least two of the following headache characteristics:

Pulsating/throbbing Pain of moderate to severe intensity Pain aggravated by movement:

Migraine with aura: (classic migraine):

At least three of the following characteristics: One or more transient focal neurological aura symptoms Gradual development of aura symptoms over 4 min or several symptoms in succession Aura symptoms lasting 4–60 min Headache following or accompanying aura within 60 min


Most patient with headache mostly self-medicate, any patient requesting advise should ideally be questioned by the pharmacist, as it is likely that headache has either not responded to OTC medication or is troublesome enough for patient seek advice. A no. of headache-specific question should be asked. In addition, the pharmacist should also enquire about the person’s social history because social factors-mainly stress-play a significant role in headache. Ask about the person’s work and family status to determine if the person is suffering from greater levels of stress than normal.



Recommended dose


Care in patients

Pregnancy

Migraleve >10 yrs Initially 2 pink tab. Then if necessary 1 or 2 yellow tab after every 4h

Dry mouth, sedation and constipation

Increased sedation with alcohol, opioid analgesics, anxiolytics, hypnotics and antidepressants

Glaucoma, prostate enlargement

Avoid in 3rd trimester

Midrid >12 yrs Initially 2 Dizziness, Avoid Control of Avoid

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capsules then one after every hr until relief. Max. 5 capsules in 12 hrs

rash concomitant use of MAOIs and moclobemide due to risk of hypertensive crisesAvid in patients taking Beta-blockers and TCAs

hypertension and diabetes might be affected, although a short course is unlikely to be clinically important

Case Study:

Wei Lin, a woman aged about 30, has asked to speak to you. She tells you that she would like you to recommend something for the headaches that she has been getting recently. You ask her to describe the headache and she explains that the pain is across her forehead and around the back of the head. The headaches usually occur during the daytime and have been occurring several times a week, for several weeks. There are no associated GI symptoms and there is no nasal congestion. The pharmacist’s view:

From the information obtained, it sounds as though this woman is suffering from tension headaches. The location of the pain and lack of associated symptoms lead towards this conclusion. The timing of the headaches indicates that this woman’s recent move and change of employment are probably responsible for the problem. This patient is worried that the headaches may signal a serious problem, but the evidence indicates this would be unlikely. The pharmacist could recommend the use of a combination of paracetamol and doxylamine, warning about the possibility of drowsiness being induced by the antihistamine. If the headaches do not improve within 1 week, she should see her doctor.

10.InsomniaIt is estimated that over 8 million people in the UK have problems sleeping. Temporary insomnia is common and can often be managed by the pharmacist. The key to restoring appropriate sleep patterns is advice on sleep hygiene. OTC products to aid sleep (the antihistamines diphenhydramine and promethazine) can help during the transitionperiod and can also be useful in periodic and transient sleep problems.

Symptoms :

The main symptom of insomnia is trouble falling or staying asleep, which leads to lack of sleep. If you have insomnia, you may:

Lie awake for a long time before you fall asleep Sleep for only short periods Be awake for much of the night

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Feel as if you haven't slept at all Wake up too early

Aetiology:Insomnia reflects disturbances of arousal and/or sleep system in the brain. Their relative activities determine the degree of alertness during wakefulness and depth and quality of life. Therefore insomnia may be caused by any factor, which increases activity in arousal systems or decreases activity in sleep systems. Some causes of insomnia are;

Medicines Environmental noise Altered patterns; shifts Psychological stress Mental healthg:depressions Poor saleep hygeine Behsavioral;children Aging pregnanacy Underlying medical conditions


Pharmacists, in collaboration with physicians, are in a unique position to assist the many patients who complain of disturbed sleep and/or impaired daytime functioning. Suggestions are made for pharmacist involvement in patient evaluation, education, and monitoring, and for other possible roles of the pharmacist in dealing with the insomniac patient and the appropriate use of hypnotics. Two key features of insomnia needed to determine; the type of insomnia and how it affects the person. Asking symptom-specific questions will help the pharmacist to determine if referral is necessary.

Question RelevancePatterns of sleep

An emotional disturbance (predominantly anxiety) is commonly associated in patients who find it difficult to fall asleep; patient who fall asleep but wake early and can’t fall asleep again, or who are then restless, are sometimes suffering from depression

Daily routine

Has there been any chance to the work routine—changes to shift patterns, additional workload resulting in longer working hrs and greater day time fatigue

Underlying medical conditions

Medical conditions likely to cause insomnia are GORD, pregnancy, pruritic skin conditions, asthma, Parkinson’s disease. Osteoarthritis and depression

Recent travel

Time zone changes will affect the person’s normal sleep pattern and it can take a no. of days to re-establish normality.

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Antihistamines (diphenhydramine, promethazine):

Antihistamines reduce sleep latency (the time taken to fall asleep) and also reduce nocturnal waking. They should be taken 20–30 min before bedtime and can be recommended for adults and children over 16. Tolerance to their effects can develop and they should not be used for longer than 7–10 consecutive nights. Diphenhydramine has a shorter half-life than promethazine (5–8 h compared with 8–12 h)

Benzodiazepines:

Despite the UK CSM statement on the use of benzodiazepines, recommending that these drugs are for short-term use only and should not be used for longer than 3 weeks, pharmacists are well aware that patients continue to be on these drugs for long periods of time. Research shows that success rates in weaning patients off benzodiazepines can be high. This is an area where pharmacists and doctors can work together and discussions with local doctors can initiate this process.

Complementary therapies:

Aromatherapy:

Aromatherapy is effective in aiding relaxation. Lavender oil in particular has been shown to induce a sense of relaxation, as has camomile. One or two drops of the essential oil sprinkled on a pillow, or three or four drops in a warm (not hot) bath can be recommended.

Nasal plasters for snoring:

These adhesive nasal strips work by opening the nostrils wider and enabling the body to become accustomed to breathing through the nose rather than the mouth. A plaster is applied each night for up to 1 week to retrain the breathing process. The strips have been suggested for use in night-time nasal congestion during pregnancy. Practical pointsSleep hygieneKey points are:

establish a regular bedtime and waking time consciously create a relaxation period before bedtime no meals just before bedtime no naps during the daytime no caffeine after lunchtime reduce extraneous noise (use earplugs if necessary)

Insomnia in practice:

Chris Jenkins, a 20-year-old student, comes into the pharmacy requesting some tablets to help him sleep. He says that he has had problems sleeping ever since he returned from Indonesia 10 days ago. He says that he cannot get off to sleep because he does not feel tired. When he eventually does fall asleep, he

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sleeps fitfully and finds it difficult to get up in the morning. He has never suffered from insomnia before. He is otherwise well, is not taking any medicines and does not have any other problems or difficulties.

The pharmacist’s view:Long-haul travel can result in disruption of the sleep pattern and some people are more affected by it than others. It would be reasonable to recommend that Chris take an antihistamine (diphenhydramine or promethazine) for 4–5 days until the problem resolves. An alternative would be one of the herbal products to aid sleep. He should find thathis normal sleep pattern is re-established within 1 week.

References

Community pharmacy by Paul Rutter Symptoms in the pharmacy by Alison & Johan Blenkinsopp, Paul Paxton www.google.com www.ncbi.nih.gov/pubmedhealth www.uspharmacist.com

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http://www.uspharmacist.com/

http://www.ncbi.nih.gov/pubmedhealth

http://www.google.com/

Health & Medicine

assignment on various diseases