OTC Table

Lloydy and Rachelles
5-Minute OTC Consult for Trainee Pharmacists
Foreword: Hope this helps everyone. Ive intentionally avoided reviewing every treatment available for each condition and focused on the ones with the most evidence and which are most commonly available seeming as though you only need to know two treatments for each in the Board Exam. Please feel free to email me any additional information I could include in this table regarding either topics already covered or else any additional ones.
Michael Lloyd and Rachelle Downie 2007
Cheers, Lloydy lloydy_m@hotmail.com
DERMATOLOGY Head Lice Scabies Eczema/Dermatitis Psoriasis Nail infection Acne
5 6 7 8
Fungal skin infections (Athletes foot, tinea, jock itch)

9 10
Chickenpox Warts Corns/calluses Dandruff Sunscreen/Sunburn

Hair loss
11 11 12 13 13
14
Hydrocortisone Topical Cream 15 Shingles 15

German Measles (Rubella) Measles 16

ORAL HEALTH Cold Sores Dry Mouth (Xerostomia) Aphthous (mouth) ulcers Gingivitis Oral thrush Toothache
16
17 18 18 19 20 20
Oral Hygiene
20
GASTROENTEROLOGY & GENITOURINARY Haemorrhoids 21 Heartburn 22 Diarrhoea and Vomiting 22 Motion Sickness 23 Constipation 24 Irritable bowel 24
Threadworm
25
PAEDIATRICS Teething 26 Febrile Convulsions/Fever in Children Gastroenteritis & Dehydration Colic 27 Nappy rash 28 Cradle Cap 29
26 27
EYE DISORDERS
Dry Eye Syndrome Viral Conjunctivitis Bacterial Conjunctivitis Allergic Conjunctivitis Stye Chalazion Contact Lens Care Blepharitis Red Eyes Vasoconstrictor eye drops Antihistamine eye drops Ocular lubricants EAR, NOSE & THROAT Ear Ache 30 31 31 31 32 33 33 33 34 36 36 36
38
Ear Wax Otitis Externa Allergic rhinitis Sore Throat Intranasal Decongestants Nasal corticosteroids Nasal antihistamines
38 39 39 40 41 41 42
RESPIRATORY
Cough Cold and Flu Asthma inhalers 43 45 46
WOMENS HEALTH
Period pain (primary dysmenorrhoea) 47
PMS
Vaginal Thrush Cystitis
48
48 49
PREGNANCY/BREASTFEEDING Nutrition & General Health advice during Pregnancy Back pain in pregnancy 51 Constipation 51 Reflux 51 Nocturnal muscle cramps in legs 52 Pruritis in Pregnancy 52 Morning Sickness 52 Breast & Nipple Thrush 53 Problems with lactation 53 Mastitis 54
50
PAIN
Musculoskeletal pain Headache Insect bites Bruising 54 55 55 56
Tennis elbow
56
57 59 60 61 63 64
MISCELLANEOUS Nicotine Replacement Therapy Orlistat Emergency Contraception Travel Health Sleep Antihistamines
Patient Problem
Treatment
Children (ok in)
Pregnancy
Lactation
Other Check and treat other family members if infected. Clean sheets and clothes in hot water, sun dry). Repeat treatment 7 days after. Children can be sent back to school after first treatment. Itch may continue up to 1 week post eradication.
P (permethrin) for pregnancy Avoid natural alternatives in pregnancy as may contain essential oils which are contraindicated
DERMATOLOGY
Head Lice
Itch (rash): back of scalp, neck and behind ears. Eggs (nits): white specks stuck to hair near the scalp Lice
**shampoos not as good as diluted by water to subtherapeutic conc. Permethrin (Quellada lotion 1%, Pyrifoam liquid) Apply to clean, damp hair after washing towel drying. Leave in for 10 minutes, rinse out and dry then comb with a fine tooth comb. Repeat in 7 days. Maldison (Lice Rid lotion 0.5%, KP 24 lotion 0.5%) Apply 20-40mL to dry hair, leave in overnight, wash out in the morning and comb out dead lice Pyrethrin/piperonyl butoxide (Banlice) Apply to dry hair, leave in for 10 mins, wash out with normal shampoo, remove lice and eggs with fine tooth comb. Wet combing Apply conditioner to dry hair from tip to root. Comb with a fine tooth comb from scalp to tip in sections. Clean comb with tissue and repeat each section 5 times. Repeat every 2 days until no head lice seen for 10 consecutive days Resistant Lice Retreat with a different chemical treatment Or Wet Combing
Not < 2
Preferred
Safe
Not < 2
No
No
1. Head lice present? 2. Used lice tx before? Did it work? Used properly? 3. Under 2y.o? 4. Pregnant or breastfeeding? 5. Swollen glands, weeping/crusty rash? Infectn? 6. Tx head lice regularly? 7. Want to know more about head lice prevention?
Not < 2
No
No
preferred when < 2
Self Care Card: Head Lice Must reapply 7 days after 1st application! Treat all family members and people with close contact. Hot washing/drying of clothing/bedding required (similar to head lice) Scabies treatments may actually CAUSE skin irritation!
Scabies
Mite infestation. Intense itching which is worse at night. Scratching of the skin can lead to changes in its appearance. Commonly effects web space of the fingers and toes, wrists, armpits, buttocks and genital area. May cause rash around the midriff, underarms, inside of thighs and around ankles.
Shower and dry thoroughly. Apply to whole body starting from the neck down (include neck, face and scalp when treating children <2 and elderly). Allow to dry and put on clean clothing. Leave for at least 8 hours* and then clean off thoroughly. Repeat in 7 days. Pay attention to skin folds, belly button and groin. Wash off thoroughly. If hands washed during treatment, should be reapplied. *Increase contact time to 24 hours in treatment failure. Permethrin 5% (Lyclear cream, Quellada Scabies Lotion) 30 mg tube Dose: 1-2 tubes for adults. tube for children 5-12. tube 1-5 years Refer <2y.o. (TG: >6 months) Treat neck, face and scalp Preferred Preferred
Flaking skin is infective to others. Itching can continue for several days/weeks after successful treatment, i.e. not a sign of treatment failure. 1. Confirm dx? 2. HOPC other family members affected? 3.Check for burrows? small, raised bumps under skin, may appear as thread-like grey lines 4. Age refer children 2. Symptoms; commonly affects web space fingers, toes, writs, armpits, buttocks, genital area 5. Signs of infection 6. Medication Benzyl benzoate (Ascabiol 25%) Lotion Apply with a new paint brush. diluted with an equal quantity of water for children under 12 years of age, and with 3 parts of water for babies B2 No
May use an antihistamine to help relieve itch P (permethrin) for pregnancy Refer: o babies and children o infected skin (weeping yellow discharge) o treatment failure o unclear diagnosis Self Care Card: Scabies
Eczema/Dermatitis
Smx: -red, scaly itchy rash -degree of itch varies: day to day, bw individuals, under stress, at night, heat etc Cause: -depends on the TYPE of eczema being experienced
TYPES *Exogenous contact with external agents eg. allergic contact dermatitis, photoallergy dermatitis *Endogenous internal predisposition eg. seborrhoeic dermatitis, atopic eczema, varicose eczema ATOPIC ECZEMA = typical eczema/dermatitis
Treatment 1.Emollients/Moisturisers/Bath oils & washes: - acute management & prevent relapse - aqueous or sorbolene cream (QV, Dermaveen) or liquid paraffins (bath oils) - oatmeal bath oils & moisturisers also very soothing - apply after bath/shower (3 min window) - creams, washes safe to use in infants & applied to the face - FREQUENT application is important

Advice: - avoid environmental or any precipitating irritants Non-drug management: * Wet Wrap Treatment - soak towels in tepid water (or Burrows solution if area infected) to create a wet wrap treatment -applied after hydration (ie bath) & emollients/CSs applied leave on for 15-60mins to enhance topical therapy abosorption -reserved for SEVERE/recurrent cases *Other advice: -avoid over-warm clothes or temperature in the home -avoid using detergents aggrevate eczema -identify & eliminate environmental irritants or allergens -?food link potential if so avoid -routine moisturisation via humectants, occlusive moisturiers = mainstay of preventative treatment -AVOID SOAP!! * Ecezma Referral: - secondary bacterial infections Abx - patch testing for allergens - treatment of warts & molluscum contagiosum is difficult in eczema - herpes simplex 000 - ? fungal infection In children common aggravating factors include: -sand, dust -rough clothes, abrasive surfaces like carpets -calamine lotion
Bath oils & washes QV bath oil, Hamiltons, Dermaveen oil, Oilatum Bath oil Bath: 10-15mins once a day qid when flare-ups occurs Moisturisers Face & Body Dermeze, Hydraderm, QV cream, Dermaveen lotion qid
Humectants - glycerin, PEGs, urea, propylene glycol - attract & retain water in the skin Emollients: eg. soft paraffin, dimethicone, liquid paraffin, lanolin, vegetable oils - sooth roughened skin, reduce water loss, Dermaveen Cleansing Bar: colloidal oatmeal Dermaveen Shower & Bath Oil: colloidal oatmeal, paraffin oil Dermaveen Eczema Cream: colloidal oatmeal QV Bar: Dimethicone QV Bath Oil: Liquid Paraffin QV Cream: WSP, Liquid Paraffin, Glycerol
- ?unknown cause - common in ectopic people - Red, scaly eruption: *acute weeping, crusted *chronic thickened, dry & cracked (scratching can lead to lichenification Sites vary with age: - Infants: face & nappy area
- Children: flexures of elbows, knees, hands, feet - Adults: flexures of elbows, knees, hands, feet and face
QV Skin Lotion: WSP, Glycerol Hamiltons Dry Skin Cream: Urea Hamiltons Dry Skin Lotion: Liquid Paraffin, Glycerol Hamiltons Oil: Liquid Paraffin Creams & Ointments are MORE effective than lotions. Use lotion when eczema is mild 2. Corticosteroids - when moisturers dont provide enough relief - use least potent to bring eczema under control - strength, amt, frequency depends on age, area, disease extent - Sigmacort 1% - face, body, groin, flexures Directions: - apply sparingly to the side affected - avoid prolonged use due to risk of SEs - may apply the less potent ones (eg. Sigmacort) bd
-extremes in heat
Psoriasis
Well defined, red papules coalescing to erythematous plaques. Red plaques often covered by a silvery scale. Can occur anywhere on the body but often appear on the extensor areas such as the elbows, knees or the trunk or scalp, in the flexors (perianal, submammary or axillary regions). Commonly get pitting of the fingernails.
Moisturisers/Emollients Where scaling or irritation are prominent features, the soothing action of emollient creams or ointments offer prompt relief. Best if applied after a shower. Q.V. Moisturising Lotion, DermaDrate, Dermaveen, Cetaphil glycerol 10% in sorbolene cream It is also beneficial to use soap substitutes such as QV Bath Oil as dry skin conditions often exacerbated by soaps and detergents. Keratolytics Salicylic acid and sulphur are used to lift and soften thick scale in psoriases. salicylic acid 2% to 10% in sorbolene cream, emulsifying ointment or white soft paraffin Coal Tar Tars are anti-inflammatory and antipruritic. Although considered first-line therapy, use is limited by patient acceptability due to colour and smell. LPC 2% to 10% cream or ointment topically, apply twice daily
Refer cases of suspected but undiagnosed psoriasis.
Ok
Ok
Ok
Tar, dithranol and salicylic acid can be irritating on the skin and should not be used in acute inflammatory psoriasis, on the face or in the flexures.
Ddx: eczema, seborrhoeic dermatitis, and tinea. Atopic
salicylic acid 2-4% can be included in coal tar preparation
eczema occurs on the flexor aspects of the limbs rather than the extensor aspects, as in psoriasis. Avoid trauma (e.g. scratching, sunburn), frequent use of soaps and detergents, and alcoholic beverages.
Hydrocortisone (DermAid, Sigmacort) 0.5%, 1% Apply thin layer to affected area 2-4 times/day; reduce frequency as condition improves. Good for flare ups but prolonged use can cause skin atrophy see TOPICAL CORTICOSTEROIDS Dithranol Aantiproliferative effect on psoriatic skin; useful in thick plaque psoriasis. dithranol 0.1% to 2% with salicylic acid 2$ to 5% (to prevent oxidation of dithranol and remove scale) in yellow soft paraffin, apply topically to lesions each day then wash off 10-30 minutes later with lukewarm water
>2
Ok
Ok
Avoid
Avoid
Avoid
Fungal skin infections (Athletes foot, tinea, jock itch)

Creams preferred Lotions for large/hairless areas Powders on feet, groin (inside socks and shoes)
Clotrimazole (Canestan, Clonea) 1% cream Miconazole (Daktarin) 2% cream, lotion, dusting powder Apply 2-3 times a day until infection clears and for 2 weeks after.
Ok
Ok
Continue treatment for 2 weeks after symptoms resolve. Fungus thrives in warm, moist conditions good personal hygiene is important: *dry between toes *use a separate towel for infected area(s) *wearing thongs in public showers and change rooms *change socks (preferably cotton) daily *avoid tight, synthetic shoes *dust shoes with fungicidal powder Refer: o diabetic patients o severe, treatment resistant infection o sx of bacterial infection o involvement of nails
Bifonazole (Canestan Once Daily, Mycospore) 1% cream Apply once at night until infection clears and for 2 weeks after. B3: Avoid Ok
Terbinafine (Lamisil) 1% cream Apply once a day for 1-2 weeks * Athletes foot: 2-4 weeks * Jock itch: 1-2 weeks
*does not require further course once symptoms relieved as do other topical antifungals as fungicidal (faster acting) aids compliance
Ok
Ok
1. Symptoms? Itchy,
erythematous, flaky white skin, plaques 2. Severity? Inflammation, weeping, puss, yellow crust (bacterial infection) 3. Previous treatment? 4. Diabetic, immunocompromised?
Instructions: - clean & dry affected areas thoroughly - apply to affected area and surrounding area apply a thin layer - regular use is required for successful treatment - Smx should resolve within a few days - Tm shouldnt extend beyond 4 weeks
Self Care Card: Tinea
Nail infection
Amorolfine (Loceryl) nail lacquer
No
No
No
Apply once or twice a week for 6 (finger nail) to 12 (toe nail) months. Amorolfine is the only topical antifungal which can penetrate the nail, i.e. Daktarin (miconazole) tincture is useless. For more severe/resistant fungal nail infections refer to the Dr for systemic oral treatment or removal of nail. 1. 2. 3. 4. 5. 6. 7. File down infected areas on an infected nail (dont use file on a healthy nail afterwards) clean nail surface with a cleaning pad dip spatula into lacquer paint over the entire nail surface close bottle tightly allow 3-5mins for nails to dry clean spatula and neck of bottle with same cleaning pad use: once or twice weekly continue until infected nails are completely cured and regrown us takes about 6 months for fingernails and 9-12months for toenails be careful not to let lacquer contact skin Refer young children Ok Ok Gradual improvement over time with treatment, usually within 8-12 weeks after beginning therapy. Do not squeeze or pick the acne lesions (pimples). Avoid wearing heavy oil based makeup and clean makeup off thoroughly each night. Exercise regularly and eat a healthy diet with lots of fresh food and water. This will improve general health and be reflected in the skin condition. UV light can be helpful acne usually gets better during summer
Refer: o severe acne
Acne
Before applying, wash affected area with mild soap or soap substitute and warm water; gently pat dry. Wash hands after application.
Benzoyl Peroxide (Benzac, Oxy, Panoxyl) 2.5,5,10% - antibacterial activity and is mildly comedolytic Apply once or twice a day, begin treatment with lower strengths (2.5 or 5%) then change to 10% after 3-4 weeks if tolerated and acne resistant.
Counselling: Can cause skin irritation including reddening and soreness, especially at beginning of treatment. Can bleach hair, clothing and bedding. Avoid contact with eyes, mouth and other mucous membranes. Usually takes between 8-12 weeks of treatment to experience benefit. Inactivates topical tretinoin; apply 12-24 hours apart.
Acne is an androgenically stimulated, inflammatory disorder of the sebaceous glands caused by increased sebum production, abnormal follicular keratinisation and proliferation of Propionibacterium acnes.
Triclosan face-wash solution (pHisoHex) Use as a face wash three times daily. How old? How long have had acne for? Previous treatment? Successful? How was previous treatment used? Counselling:
Wash hands thoroughly with pHisoHex. Wet face and apply enough pHisoHex into palm to cover a 20 cent coin. Gently massage over the face, concentrating on problem areas and avoiding the eye area. Rinse and repeat. Rinse thoroughly and pat dry with a clean towel. Discontinue use if irritation develops.
Ok
Ok
Azelaic acid (Finacea gel, Acnederm lotion) Apply morning and night. Less irritating than benzoyl peroxide but may cause hypopigmentation, use with caution in patients with dark complexions.
B1 no data
Data lacking
o o o o o
failed medication suspected druginduced or rosacea very young children or older adults occupational acne mild acne not responsive to treatment for 8 weeks
Self Care Card: Acne
Chickenpox
Crops of teardrop vesicles on erythematous bases. Starts with small red lumps (papules) fluid containing blisters (vesicles) rupture, forming crusted spots. Areas commonly affected: Trunk, face and scalp. Can occur on mucous membranes. Prodromal symptoms: Fever, malaise, anorexia, headache Symptomatic treatment (self limiting, usually clears in 7-14 days) and good hygiene to avoid secondary infection.
Paracetamol for fever. Solugel (amorphous hydrogel) applied liberally to lesions provides a soothing effect and accelerates healing place in fridge Pinetarsol or Dermaveen bath products for bathing (emollient, antipruritic, and anti-inflammatory). Take care not to slip when stepping out of bath. Phenergan(promethazine, 10-25 mg n for kids) or Vallergan(Trimeprazine) at night to avoid night time scratching. Keep child well hydrated even if doesnt want to eat (prodromal symptom). Keep skin cool, cold compresses to reduce itching. Cut childs nails short (scratching increases the risk of secondary bacterial infection and scaring). Anti-itch creams (e.g. Paraderm, Eurax) may be useful. AVOID calamine lotion as dries out skin causing further irritation and resultant scaring when itched.
Pt infectious from 48 hours before appearance of rash until the all lesions have crusted. Incubation time (time btwn contact and development of rash) is usually ~2 weeks. Kids can return to school when lesions have scabbed over, temp is normal and sense of well-being returned. Spread by respiratory droplets, direct contact with varicella vesicles. Self Care Card: Chicken Pox
Warts
Human papilloma virus (HPV). *Usually asymptomatic, i.e. no itch or pain (unless knocked or rubbed). *Appear mostly on hands, knees and elbows (feet) *Discrete edge and have raised/roughened, skin-coloured surface & raised Duofilm Gel (salicylic acid 27%) Duofilm (lactic acid, salicylic acid) Wart-off stick (salicylic acid) Using applicator, apply once at night. Allow to dry and cover with occlusive dressing. Continue until wart is completely removed 1st line preferred in children Ok Ok
Self-limiting infection usually disappear spontaneously within 6 months to 2 years. Treatment may take up to 3 months.
*Separate skin lines rather than skin lines running over the top of them. *Warts supplied by a network of capillaries. When pared (e.g. with pulmus stone) thrombosed, blackened capillaries or bleeding points appear. *cauliflower appearance *plantar warts usually not raised & grow up into the foot Preparing infected area for Tm: Pre-soak affected area in warm water for 5-10 mins to soften and hydrate skin, then remove dead skin from surface of wart by gently rubbing with a pumice stone. Protecting surrounding skin: Mask healthy, surrounding skin with vasciline or nail varnish or a bandaid with holes cut out. Apply treatments with applicator (not finger) 1. Diabetes? Refer 2. Age? Common in children 3. Appearance? Wart vs
corn/callous
Pasafilin paint (podophyllum resin, salicylic acid) As above.
No
No
No
DDx: Corns/calluses (See below)
Wartner (dimethyl ether, propane) Hold applicator to lesion for 20 secs; repeat every 15 days as necessary (max 3 times)
Avoid < 4
Avoid
Avoid
Diswart (glutaraldehyde) will stain skin brown but will fade after treatment complete Apply twice a day.
No
No
No
Alternative method: Easiest and least expensive. Cover wart with waterproof tape (e.g. duct tape) and leave on for 6 days, then soak, pare with pumice stone/emery board, leave overnight then reapply tape cyclically for 8 cycles
4. Location? Refer facial or

anogenital
Refer: o diabetic pts o anogenital warts o non-responsive to Tx o multiple and widespread o lesions on the face o > 50 y.o. o warts that change colour or shape o bleed/itch without provocation
5. Duration?
Corns/calluses
White or yellowish hyperkeratinised/thickened areas of skin which occur on pressure areas such as the top of toes and along the side of feet (i.e. over bony prominences of the feet). Hard and circular-shaped with a polished or central translucent core. DDx from warts: Do not have black dots/spots
Treatment should be aimed at relieving pressure can use circular corn pad or other forms of padding to relieve friction and absorb pressure.
Encourage pts to wear open shoes such as thongs and sandals. MUST address the underlying issue to resolve the problem & prevent reoccurrence
Treated with keratolytics same as for warts if required. E.g. Scholl corn pads/foam * Feet should be clean and dry * Remove medicated disc from backing and place adhesive surface of disc over corn and cover with pad * Repeat treatment daily until corn removed Caution/Precautions
but rather expose layers of white keratin when pared. Do not separate the skin lines on the sole of the foot
* DO NOT use for diabetics Refer to Dr * DO NOT use on broken or inflamed skin * Check for any circulation problems before using Refer * Avoid use in <16yrs * If corn remains after 2 weeks seek medical advice note: no evidence for coal tar shampoos in the treatment of dandruff Dandruff should improve within 1 2 weeks of beginning treatment. Ok Ok Ok
Shampooing on a daily basis with a mild, hypoallergenic, nonmedicated shampoo helps prevent dandruff. Ensure to thoroughly wash out shampoo. Use a conditioner to moisturise your scalp. Avoid using hair gels and other products that contain alcohol, which tend to dry out skin.
Dandruff
Hyperproliferative skin condition Greyish-white flakes or scales on an itchy scalp. Visible dead cells (flakes) can often be seen on the patients clothing. Condition associated with the yeast Pityrosporum ovale. Treatments are either antifungal or cytostatic (reduces rate of cell turnover). DDx: seborrhoeic dermatitis (scales are yellowish and greasy-looking and there is usually some inflammation with reddening and crusting of the affected area; typically affects centre of face, eyebrows, nasolabial folds and midchest) treated same way as dandruff psoriasis (scales are silvery-white and associated with red, patchy plaques and inflammation; typically affects the knees and elbows, face rarely being affected) contact dermatitis (use of new hair products?) Ketoconazole (Nizoral 1%, 2%) Apply to wet scalp, lather, then leave for 5 minutes; rinse thoroughly. Use twice a week until treated, then once every 1 or 2 weeks for prevention. Ok Ok ok
Zinc pyrithione (Head and Shoulders, Fongitar) Apply to wet hair, lather, then leave for 5 minutes; rinse thoroughly. Use 2-3 times a week until treated then once a week for prophylaxis. *antifungal and cytostatic
Selenium sulphide (Selsun Blue) Lather into wet hair for 5 mins, repeat and rinse thoroughly; initially twice weekly, then as necessary *cytostatic: avoid if patient has inflamed or broken skin. May stain jewellery and alter the colour of hair dyes.
>5
Ok; avoid 1st trimester
Ok
Refer: o treatment resistant dandruff o suspected psoriasis o signs of infection Self Care Card: Dandruff
Sunscreen/Sunburn
Prevention is better than treatment.
Application of sunscreen: use an SPF 30+ broad-spectrum, water resistant sunscreen apply liberally to clean, dry skin 30 mins before going outside reapply sunscreen every 2 hours, more often if swimming or playing sport
SPF 30+ has greatest protection. Slip on a shirt, slop on some sunscreen, slap on a hat and slide on some sunnies.
Treatment of sunburn includes: systemic analgesia - Solugel (propylene glycol, sodium chloride); Apply liberally prn. Store in fridge for extra relief on application.
SOOV Burn Spray (cetrimide, lignocaine, phenoxyethanol) Hold the bottle 10 cm from the affected area and spray until skin is wet. For treating the face, spray onto fingers and then apply gently. Apply up to four times daily.
Self Care Card: Sense in the Sun
Hair loss
Male-pattern baldness (androgenic alopecia) is the most common form of hair loss presenting in pharmacy. Thinning of the hair and a frontal receding hairline; often accompanied with hair loss at the crown.
Minoxidil (Rogaine) 20mg/mL, 50mg/mL Apply 1 mL twice a day to area where hair regrowth/stabilisation is required. Apply to clean, dry scalp and allow to dry naturally. Do not wash hair for 4 hours. Counselling: Continuous treatment is required to maintain response. Response may not be seen until about 4 months of treatment. Wash hands well after application. Do not wear a wig, scarf or hat for at least 1 hour after application as this may increase the amount absorbed through the skin causing unwanted effects. Side effects may include mild dermatitis or unwanted hair growth above eyebrows and on cheeks.
>18
No
No
Response is best when many thin, miniature hairs still remain before starting treatment. No benefit is seen where there is no visible hair. Noticeable hair growth occurs by 34 months with maximal response after 12 months of continuous treatment (discontinue treatment if no response by 6 months). Benefit of treatment is lost within 612 months of stopping. Self Care Card: Male Pattern Hair Loss
Hydrocortisone Topical Cream

S2 0.5% S3 1% (30g or less) S4 1% 50g Temporary relief of symptoms associated with acute and chronic corticosteroid responsive conditions including minor skin irritations, itching and rashes due to eczema, dermatitis, contact dermatitis (such as rashes due to
Hydrocortisone cream 0.5% or 1% (Dermaid, Sigmacort, Cortic-DC) Apply thin layer to affected area 1-3 times daily (0.5%) or 1-2 times daily (1%).
>2 unless under supervision of pharmacist /doctor
Ok
Ok
Topical hydrocortisone should not be used where the cause of the skin condition is unknown. In particular, should not be used where a viral or bacterial cause is suspected.
Should not be applied to broken skin.
cosmetics and jewellery), psoriasis, anogenital pruritus and sunburn. Used any other cream/ointment? Have acne, cold sore, chicken pox, or shingles? Unsure if rash is infected? For an infant? Nappy rash? Rash on the face? Have diabetes or arthritis? Pregnant or breastfeeding? Already used for 7 days or more? Recurrent problem? Skin broken? Dry skin? Where skin is dry, should apply an emollient first to the entire area of dry skin before the application of topical hydrocortisone to the targeted area(s).
Shingles
(Herpes Zoster) -Antiviral tx should be initiated in the 1st 72hrs of attack (Chickenpoxshingles) Smx: - prodromal general malaise (headache, fever, sore throat etc) - blistering rash us trunk, back (along a nerve) - extreme pain - lesions erupt over a week & heal within 2 weeks
Drug Treatment: Aciclovir, Famciclovir (250mg q8h for 7/7), Valiciclovir within 72hrs (reduces pain, viral shedding, duration of rash & ophthalmic complications) Tm: 7 days Non-drug Treatment: - bathe lesions in saline tds to soothe and remove the crusts - rest & fluids - cover lesions with non-adherent dressing (melonin) - Analgesia for pain (aspiring/ paracetamol/ paracetamol extend) others: prednisolone & amitriptyline
Reactivation of varicellazoster Post-herpatic neuralgia severe in adults If child affected refer!
German Measles (Rubella)

Rubella Virus Vaccination available SMx: *blotchy flat rash (cf chickenpox which is rased) * pink on face/neck/body * tender glands
Presentation NOT as common due to vaccination Infectious: 7 days BEFORE rash until 7 days after Treatment: fluids & rest fever: paracetamol Problem for pregnant women defects in unborn child (hearing, mental speech etc) Prodrome: - fever, runny nose, mailaise, reduce appetite & Kopliks spots in mouth (2448hrs before the appearance of a rash) Rash: - non-itchy, starts behind ears, spreads to trunk & extremities in 24hrs, blotchy flat rash & coincides with high fever Recovery: - cough for 1-3 weeks
Measles
Parmyxovirus HIGHLY CONTAGIOUS!!! Vaccine available RARE in Aust Smx: * initially cold Smx * incubation prodrome Rash Recovery
Treatment: - rest & fluids - fever: paracetamol
Patient Problem
Treatment
Children (ok in)
Pregnancy
Lactation
Other Spread by contact & very contagious. Advice: -use sunscreen (sun can reactivate virus) -use moisturising lip balm to prevent drying out and cracking which can lead to 2o infection -avoid astringent cold sores
ORAL HEALTH
Cold Sores
4 main stages: Tingle few hours preceeding Blister days Weeping spreads Scab healing (week)
Aciclovir 5% (Zovirax) Apply at first sign of lesion 5 times a day for 5 days (q4h when awake)
Refer
Idoxuridine (0.5%) with lignocaine (Virasolve) Apply thin layer at first sign of lesion hourly on 1st day then every 4 hours until lesion disappears Good for MILD attacks
B3; can use but preferably avoid B1 ; No
No
No
*HSV infectious from tingle stage until blisters have healed
Povidone(10%)-iodine lotion (Betadine) Apply qid for 5 days * Aciclovir and idoxuridine should be applied early during tingling stage to duration and severity. * Povidone iodine may dry weepy cold sores and prevent 2o infection. (skin staining one SE)
No
No
-avoid contact -dont touch eyes after touching coldsore -use separate towel to dry hands after applying and avoid touching eyes.
Refer: o lesions affecting the inside of the mouth, eye or genitals o large area >10cm piece o persistent & recurrent o secondary infection o very young person (child) o painless without itch/tingling
1. Taking any other meds? 2. Pregnant or breastfeeding? 3. Child or infant? Refer 4. Have eczema? Refer 5. Tinging, blisters or pain? If not, may be impetigo (yellow crust) or school sores. Refer 6. Eye irritation? Refer 7. Duration? >2 weeks, refer
Self Care Card: Cold Sores
Dry Mouth (Xerostomia)

? Reason elderly, drug (TCAs, anticholingerics, chemoTx, palliative-care ?mouth breathing ? diuretics ?beta blockers ?oxygen therapy ? Severity ? Diet ? Treatments already tried Presentation: -dry cracked lips -teeth stuck to lips -dry, cracked, furrowed tongue -difficulty swallowing & speaking -sore or burning mouth - saliva that is ropy and scant
MANAGEMENT: mouthwashes bicarbonate/plain water q2h gentle brushing of teeth with soft tooth brush artificial salivas Biotene, Oralube, Oralbalance qh Sugar-free lollies Regular drinks, adequate hydration, ice cubes, water q30h Vaseline to lips Room humidifier Reduce causative meds Rx: pilocarpine eye drops to mouth (SE: sweating)
Aphthous (mouth) ulcers

White or yellowish centre with an inflamed red outer edge appearing
Orabase (Carmellose dental paste) forms protective mechanical barrier over ulcer(s) Apply prn.
Refer < 10
Ok
Ok
Apply after food. Normally resolve within 714 days
on the tongue margin and inside the lips and cheeks. Often reoccurring.
Kenalog in Orabase (Triamcinalone 0/1% in carmellose paste) Dab small amount onto ulcer and hold in position until paste becomes sticky and forms a think film. Apply at night; 2-3 times daily if required. C/I: fungal, bacterial, viral infection of mouth/throat
Cat C - No
No Nutritional deficiencies (B12, iron and folic acid), trauma to mouth, hereditary, stress.
More common in females. Duration? Painful or sore? Age? Trauma related? No. of ulcers? More than 10? Lesion size >1cm in diameter? Any other medications? ? cause ? ulcers anywhere else on other parts of your body ? changed diet, describe diet Common medication causes of mouth ulcers: -cytotoxics, NSAIS, thiazides, tetracycline, anticholinergics, diuretics DDx: *herpes simplex: us on lips, outside mouth, fever, tingling *Bechets syndrome: more extensive and resistant to treatment OTC Vitamin B2 supplementation: - mouth ulcers may be due to Vit B2 deficiency - take: Vit B2 15mg tds for 1st week then 25mg/d SM33 (Lignocaine and salicylic acid) gel reduce pain/inflammation Apply to affected area every 3 hours as required. (can use this product > 6 months) ?? Ok Ok
Chlorhexidine 0.2% mouthwash (Sepacol) for prevention of secondary infection. Use 10mL held in the mouth for 1 minute twice daily. caution; can cause STAINING of the teeth and tongue when used for continuous periods of time
Ok
Ok
Refer: o duration greater than 14 days o painless mouth ulcer(s) o children <10 o ulcers in crops of five to ten, or more o ulcers >1cm in diameter o associated weight loss Self Care Card: Mouth Ulcers
Gingivitis
Inflammation of the gums caused by plaque and calculus deposits on the teeth. Sx: bad breath, gum swelling (often painless), gum bleeding when flossing or brushing Tm: Requires removal by dentist and good oral hygiene: brushing and flossing, chlorhexidine mouthwash to inhibit plaque formation.
Chlorhexidine 0.2% mouthwash (Sepacol) Use 10mL held in the mouth for 1 minute twice daily.
Continual use may lead to brown staining of tongue and teeth.
Refer
Ok
Ok
Oral thrush
Oral thrush is common in babies, particularly in the first few weeks of life. Affects surface of the tongue and inside of cheeks. White plaques form which, when wiped away, leave a sore and reddened area of mucosa which may sometimes bleed. Presents differently to candidal nappy rash infection which presents as red papules (satellite papules) on the outer edge of the area of nappy rash.
Miconazole (Daktarin Oral Gel) 2% Drop gel on tongue; keep in mouth for as long as possible before swallowing. For infants, divide dose into several portions and place into front of mouth (prevent obstruction). Adults, children: 1/2 spoonful using provided measuring spoon 4 times daily Infants < 1 year: 1/4 spoonful using provided measuring spoon 2 times daily Administration instructions: spoon should NOT be used for administering the gel use a clean finger, apply sm amts of gel at a time to the inside of cheeks and over the tongue Continue treatment for at least 48 hours after the symptoms have totally disappeared. Nystatin (Nilstat) 1 mL (100,000 units) four times daily. The dose should be administered under the tongue or in the buccal cavity and held in the mouth as long as possible before swallowing. Treatment should be continued for at least 48 hours after symptoms have resolved.
Ok
Ok
Ok
Use treatments after food and avoid taking food or drink for one hour after the dosing. If baby has oral thrush should check for nappy rash. Treat both at a time. For bottle-fed babies, sterilize bottles and teats. Refer: o all except babies o recurrent infection o failed medication o diabetics o immunocompromised patients o painless lesions
OK
OK
OK
Toothache
Reason: - ? infection, ?wisdom teeth/molars cutting through, ? tooth extraction, ?braces Ask about dental hygiene how frequently brush teeth, types of mouthwashes used, last time saw dentist Dental therapy is best option for pain relief provide symptomatic relief and refer
Symptomatic relief options: 1. Analgesics - paracetamol: 1-2 tabs q4-6h prn - Ibuprofen: 200-400mg q6-8h prn Max: 1200mg/d 2. Nyal Toothache drops (ethanol, phenol & benzocaine) Directions: moisten cotton bud with 1-2 drops and place in cavity of aching tooth for about 1 minute. Max qid
Oral Hygiene
AVOID mouthwashes! Most commercial mouthwashes contain large amounts of alcohol which are carcinogenic to oral membranes. Brush with a soft toothbrush after each meal. Floss teeth regularly. Soak dentures in white vinegar overnight.
Patient Problem
Treatment
Children (ok in)
Pregnancy
Lactation
Other Treat after stools and lubricate applicators. Avoid soap products, rough toilet paper (can wash instead of wipe), nylon clothing.
GASTROENTEROLOGY & GENITOURINARY Anusol (Zinc Oxide, Benzoyl Benzoate, Balsam-peru) ointment/suppositories Haemorrhoids Supps, insert morning and night and after each bowel motion Itching, burning, pain, swelling and Oint, Insert/apply bd to perirectal area and the mucosa of the rectal canal to a point discomfort in perianal area and about 1 cm above the anal sphincter. anal canal. Uncomfortable and feeling of incomplete evacuation Astringents thought to precipitate surface proteins thus producing a protective coat over the on defecation. Bright red blood on haemorrhoid. toilet paper.
Refer children <12
Ok
Ok
Ok
Ok
Proctosedyl (Cinchocaine 5mg, Hydrocortisone 5mg) ointment/suppositories Insert tds for 1st week, bd for 2nd week then d for 3rd week.
Do not use when bleeding present. May exacerbate candidiasis. SE: stinging, burning at site. Prolonged/overuse: skin atrophy/infection CI: uncontrolled infections, STDS, viral infections
Treat cause; i.e. constipation by increasing fluids and fibre (fruit, bulking agent) in diet and exercising regularly, stool softener Suggest pelvic floor exercise for pregnant woman.
Refer: o blood mixed in with stool or large qty o abdominal pain o fever o dark-coloured blood o leakage of mucous o sharp stabbing pain on defecation o >3 weeks, not resolve with treatment o need to be manually reduced
Ok Rectinol (Cinchocaine, Zinc Oxide) ointment/suppositories Insert into rectum morning and night and after each bowel motion. (Lotion: smear small qty over anal region) No 1. Take any other meds? (May be
causing constipation/diarrhoea)
Ok
No
Rectogesic (GTN) for treatment of anal fissures by promoting healing via vasodilation Insert 1-1.5 cm strip of ointment into anal canal tds
Constipation can cause/aggrevate anal fissures so it is also a good idea to offer a stool softener if constipation is problem. SE: may cause headaches & facial flushing in some patients
2. Pregnant or breastfeeding? 3. Diagnosed by a doctor? 4. Constipation or altered bowl habit? 5. Blood or pain? 6. Recurring problem? >1week,
refer
7. Swelling or itching?
Self Care Card: Haemorrhoids
Heartburn/Indigestion
Indigestion (dyspepsia) is poorly localised upper abdominal pain which may be brought on by particular foods, excess food, alcohol or medications. Heartburn (reflux oesophagitis) presents as a burning sensation in stomach and passing upwards behind breastbone. May cause acidic taste in back of throat and is often associated with precipitating factors (certain foods, too much food, alcohol, bending or lying down) and more common in overweight patients. 1. aggravating/relieving factors? 2. previous history/treatment? 3. other medications? NSAIDs etc 4. severe pain, difficulty swallowing? Radiating pain down arm? CVD 5. blood in vomit or black tarry stools? bleeding ulcer 6. pregnant or breastfeeding? 7. symptoms dont go away or keep coming back? 8. smoker? alcohol? 9. under 18 or over 50? refer children as unusual and ppl > 50 incase gastric cancer 10. unexplained weight loss? possible gastric carcinoma
Non drug measures: o eat small, frequent meals o avoid large meals and fatty/spicy foods o avoid alcohol, caffeine and chocolate as can all relax lower oesophageal sphincter o cease smoking o dont eat late in the day o posture avoid bending, stooping and lying flat. Elevate bedhead o weight reduction o avoid tight, constrictive clothing o avoid NSAIDs where possible Antacids Mylanta Original (AlOH, MgOH, Simethicone) 10-20mL prn up to 4 times daily
*contain high amounts of Na so avoid in patients on sodium-restricted diet or with HT, CCF,
Heartburn common in pregnancy due to raised progesterone levels causing smooth muscle relaxation of oesophageal sphincter; also increased upwards pressure on stomach. Refer when: Failure to respond to Tx Pain radiating to arms Difficulty swallowing Regurgitation Long duration Increasing severity Children
refer
Ok
Ok
renal impairment etc

**Al salts tend to cause constipation whilst Mg causes diarrhoea
H2 antagonists Ranitidine (Zantac) 150 mg bd or 300 mg d
refer
B1: safe to use
Ok
Self Care Card: Heartburn and Indigestion
Diarrhoea and vomiting

refer if longer than 48 hours
1st line Gastrolyte, Repalyte (NaCl, KCl, citrate, glucose) Two effervescent tablets or the contents of one powder sachet should be made up with 200mL of fresh drinking water. Refrigerate and discard after 24 hours.
Ok but when in doubt refer in case something else wrong
ok
Avoid dairy products for duration of the diarrhoea, particularly in children

Continue to breastfeed infants offer more feeds
correction of dehydration and electrolyte disturbance is the priority in all cases
Loperamide (Gastrostop, Imodium) 2mg capsules 2 stat, then 1 after each loose bowel action; max 8/day *ONLY recommend when px needs to be at work etc in adults should let gastro run its course*
>12 yrs
No B3
Safe for occasional short term use
and oral rehydration solutions in between feeds. Stop formula for 6-24 hours or until condition improves.
note: antidiarrhoeals should not be used in children, treat with fluid and electrolytes
Diphenoxylate+atropine 2.5mg/25mcg (Lomitil) 2 tabs 2-4 times a day; max 8/day

*may have an additive effect with drugs which act on the CNS, avoid combination **although ADEC Category B3 is preferred treatment for diarrhoea during pregnancy; avoid in later stage of pregnancy
> 12yrs
No
Taking any other medications? Antibiotics recently? Pregnant or breastfeeding? Blood in stools? Black stools? Hight temperature? Child or older person? Duration? Longer than 48 hours? History of recurrent diarrhoea/constipation? Bad pain or vomiting? Kidney, liver or heart disease? Glaucoma or bladder problem? Recent travel overseas? Recent food history?
Safe for occasional short term use
Refer: o diarrhoea with n/v o signs of dehydration; dry mouth/mucous membranes, sunken eyes, tiredness, irritability, deep breathing, rapid pulse, low blood pressure, decreased urination o blood or mucus in stools o drug-induced o diarrhoea for >1 day in infants; 2 days in children under 3 and elderly pts; 3 days in adults and older children Self Care Card: Vomiting and Diarrhoea
Motion sickness
caused by excessive vestibular stimulation Tips: o sit in middle of plane or boat o avoid alcohol and decrease oral intake, take frequent small meals o fix vision 45o angle above horizon o avoid reading while actively travelling o take first dose 30 mins before travel
>2 Dimenhydrinate (Dramamine, Dramamine Junior) 2.5mg/mL, 25mg, 50mg Adult: 1 2 tablets (50-100mg) every 46 hours as needed. Max: 400mg/day
SE: drowsiness
Ok
Ok monitor baby for sedation Ok
>2 Hyoscine hydrobormide (Kwells, Travacalm HO) 0.3mg Adult: 12 tablets, repeat every 4-6 hours as needed; max 4/day tablets >5 Pheniramine 45.3mg (Avil) sedating antihistamine Adults: - 1 tab up to tds 5-10yrs: tab up to tds
Ok
Ok, use only if strictly indicated
Ok, use only if strictly indicated
Constipation
Caused by inadequate dietary fibre, fluid intake and activity/exercise as well as inappropriate bowel habit. Isaghula granules (Fybogel) 1 teaspoon/sachet, 1 to 2 times daily.
*Requires adequate hydration. C/I in bowel obstruction
Bulk forming
Time to onset Usually 24 hours; 2-3 days for full affect 6-12 hours
adult dose
Ok
Ok
Non-drug therapy: increase dietary fibre increase exercise ensure adequate fluid intake toilet after meals Normal bowel habit can range from 3 times a day to 3 times a week. Reassure patients.
Hormonal changes and direct pressure on the bowel causing decreased mobility common cause of constipation during pregnancy bulk forming, osmotic and stool softener preferred
Stool softener + stimulant Coloxyl (docusate 50mg) with Senna Take 1-2 tablets daily. 1. Sx? Normal bowel frequency? 2. when was the last bowel movement? 3. taking any other medications? 4. pregnant or breastfeeding? 5. elderly or children? 6. recent surgery? 7. any bleeding from the rectum? pain on defecation? 8. alternating constipation and diarrhoea? 9. intense pain? 10. taking laxatives often? 11. heart or kidney problems?
*avoid laxatives containing Na and Mg salts
Osmotic laxatives Lactulose (Actilax, Duphalac) Take 30mL daily in one or two divided doses. *Ok in diabetes as not absorbed Simulant laxatives Biscodyl (Durolax, Bisalax) Take 1-2 tablets daily. OR Use one suppository daily. Glycerin suppositories Insert 1 suppository well up in the rectum as required
1-2 days
poloxamer (Coloxyl Drops) preferred for children <3 years; 10-25 drops in bottle or with fruit juice 5-15mL d with fruit juice, water or milk
Ok (senna
only short term)
Ok
Ok
Ok
Oral: 6-12h Supp: 1560mins 15 30 minutes
>4
Ok; avoid in late stage -
Ok
Refer: o blood in stools o abdominal pain, vomiting, bloating, weight loss o age o failure of OTC medicines Self Care Card: Constipation Avoid trigger factors including stress, large meals, fatty foods, caffeine and exacerbating medications.
Keep a diary of; when you experienced symptoms and what you were doing before
Irritable Bowel Syndrome

Chronic abdominal pain associated with alteration in bowel habit (between constipation and diarrhoea) and without apparent aetiology. Pain often accompanied by abdominal distension/bloating.
Antispasmodics act on smooth muscle in the gut, causing relaxation and thus reducing abdominal pain and distension. Peppermint oil (Mintec) 0.2mL caps Swallow whole 1 capsule three times a day before meals. Mebeverine HCl (Colese, Colofac) 135mg Take 1 tablet three times a day before meals. Refer <16 Avoid Avoid
Bulking agents are recommended regardless of predominant symptom. Rome II criteria: 12 weeks or more in past 12 months of abdominal pain or discomfort that has 2 of 3 features of; relieved by defecation, onset associated with change in frequency of stool, onset associated with change in form of stool. More commonly reported by females and often develops in young adult life. Treatment is aimed at symptomatic relief of predominant symptom(s) and avoidance of trigger factors. Isaghula granules (Fybogel) 1 teaspoon/sachet, 1 to 2 times daily. Psyllium powder (Metamucil, Mucilax) 1 teaspoon 1 to 3 times daily see CONSTIPATION see DIARRHOEA Refer <16 Ok Ok
they started, what you were eating or drinking before symptoms began, how you were feeling at the time (e.g. stressed) and any medications you were taking.
Refer: o children under 16 o patients over 40 with recent change to bowel habit and no previous history of IBS o pregnant women o blood in stools o unexplained weight loss o signs of bowel obstruction o unresponsive to appropriate treatment Self Care Card: IBS Constipation Vomiting and Diarrhoea
Threadworms
Common in young children. Nighttime perianal itching (female lays eggs at night) and consequent sleep disturbance, tiredness and daytime irritability; teeth grinding; nose picking, abdo pain, loss of appetite.
Pyrantel (Anthel/Combantrin tablets 125, 250mg; Combantrin/Early Bird 100mg chocolate squares) Dosage based on bodyweight 10mg/kg as a single dose (M=750mg) Combantrin suspension 1mL/5kg Mebendazole (Combantrin-1, Vermox, Banworm; 100mg tablets/squares) One (100mg) tablet stat regardless of age.
>6 months. Refer if <1 y/o
B2: can use but avoid in 1st trimester.
Ok: avoid if can
Perianal itching may continue for several days after treatment. Repeat drug treatment in 2-4 weeks.
>2 y/o
B3: Avoid
Ok: avoid if can
Refer: o Infection other then threadworm suspected
Dx: need to sight worms (white thread-like objects ~5-10mm long); found in faeces or protrude from anus at night. Sticky tape over anus in morning eggs stick to tape. 1. Pregnant or breastfeeding? 2. Recent travel abroad? Other type
of worm infestation
Infection is common and not a sign of poor hygiene or parental neglect of children. Treat all family members even if asymptomatic as may be in early stages of infection (sensitisation to irritant substances surrounding eggs may take several days). Cut fingernails short and thorough clean hands and brush nails after going to the toilet and before handling food to prevent transmission.
o o o o
travel abroad medication failure persistent symptoms pregnant family member children >6 months
P (pyrantel) for pregnancy
3. Unsure if threadworms present? 4. Less then 2 y.o? 5. Liver disease? LFT abnormalities
with pyrantel/mebendazole Patient Problem
Wash and iron bed linen, sleepwear, clothes and towels. Showering/bathing in morning to wash away eggs laid previous night.
Treatment Children (ok in) Pregnancy Lactation
Self Care Card: Threadworms Other *AVOID: PainStop NIGHT bc poor ratio may not control pain*
PAEDIATRICS Teething
Infants first teeth usually erupt at age ~ 4 months and teething completed by 2-3 years of age. Excessive drooling, chewing on fingers, restlessness, irritability, disturbed sleep/feeding patterns, rubbing at cheeks etc
Reassure parents. Suggest teething ring, clean cloth or pacifier for gumming. Gentle massage of gums with fingers. Cool fluids although avoid frozen foods or objects as may cause thermal damage Teething biscuits in older children Paracetamol 15 mg/kg q3-6h Ibuprofen 5 - 10 mg/kg q6-8h with food (>3 months) Bonjela (choline salicylate) children >4 months Apply 0.5 cm to the gums every 3 hours; max 6 times/day Counselling: -normal occurrence in children who are concurrently ill with a fever -dont cause long-term problems -should stop by 6yrs Treatment/Management: 1. Paracetamol should manage the fever with paracetamol 15mg/kg q4-6h prn (however, antipyretics may not reduce the chance of a seizure occurring) 2. Convulsion management: -place child on side, chest down, head turned to size. DONT lie on back. -ensure child cool cool washes, undress to child to their singlet - get medical attention Treatment 1. ORT - replace loss of electrolytes with Gatroylte/Hydralyte - frequent small volumes - ensure adequately rehydrated! Hydralyte NaCl, K citrate, Citric acid, Glucose
Febrile Convulsions/Fever in Children

-convulsions associated with a high fever >38oC -NOT epilepsy -brief, generalised, occur within 24hrs of fever -in children 6months-5yrs -30-50% risk of recurrent febrile seizures but LOW risk of developing chronic epilepsy
The treatment of febrile seizures: - rectal/IV diazepam for children who have suffered from it before may use diazepam rectal/oral at the onset of fever for prevention of recurrence
Gastroenteritis & Dehydration

viral gastro bug Smx: - diarrhoea, vomiting, abdo pain, crying, fever, reduced appetite,
DO NOT GIVE ANTIDIARRHOEALS! Always recommend that if the vomiting/diarrhoea DOESNT improve see Dr or Hospital
irritability, Duration: 2-3 days Problem: infants/children incr risk of dehydration treat cautiously! Check 1.?Age 2. ?Duration of symptoms 3. ?Worse or improving 4. ?keeping any fluids down 5. ?degree of dehydration v.impt in determining whether to treat vs refer 6. ?blood in vomit or stools 7. ?fever & other Smx 8. ?food causes 9. ?anyone else in the family affected
Directions: <12 months: 100ml every 90 mins 1-3yrs: 100ml every 90 mins 3-6yrs: 100ml every 60mins 7-12yrs: 100ml every 30mins Seek advice if diarrhoea persists for more than: <6months: 6hrs 6months-3yrs: 12hrs 3-6yrs: 24hrs 6yrs-Adult: 48hrs Gastrolyte NaCl, KCl, Na citrate, glucose Directions: dissolve 1 sachet into 200ml of water drink freshly & frequently may be stored in fridge for 24hrs Directions: Volume to be taken in 6hrs 5kg: 150-210ml 10kg: 300-420ml 15kg-450-630ml 20kg -600-840ml 30kg 900-1260ml 2. Other foods - bland/dry foods (avoid dairy, spicy & irritant foods) - breastfeeding and bottle feeding SHOULD be continued during illness - complex carbos well tolerated
immediately Stress how children can become dehydrated VERY quickly * Mild-Moderate Dehydration: - urine concentrated - hx of vomiting & diarrhoea - ORT should be suffice *Severe dehydration: -REFER to hospital -impaired peripheral perfusion -dry mucous membranes -sunken eyes -not urinating -increased pulse -low blood pressure
Colic
Colic is defined as excessive crying in an otherwise healthy baby. Wessel criteria or the rule of three: crying last for >3 hours a day, >3 days a week, and persist >3 weeks.
General Measures: o sooth by holding and rocking the baby o use pacifier o use of gentle rhythmic motion (e.g. strollers, infant swings, car rides) o place near white noise (e.g. vacuum cleaner, clothes dryer) o burp baby after meals o employ 5 Ss (need to be done concurrently): 1) Swaddling tight wrapping with blanket 2) Side/Stomach laying baby on side or stomach 3) Shushing loud white noise 4) Swinging rhythmic, jiggling motion 5) Sucking sucking on anything (e.g. nipple, finger, pacifier)
Reassure parents that colic is not the result of bad parenting. Prevent caregiver burnout by advising parents to get proper rest breaks, sleep, and help in caring for infant.
Predominantly occurs between 2 weeks and 4 months of age. Intense crying, high-pitched screams, inconsolability, flushed face, fish clenching, back arching, drawing up legs to abdomen with periodic extension of legs, arms stiff tight and extended, symptoms may occur more often in late afternoon and evening. Diet o avoid under- or over-feeding o check feeding technique as underfeeding can result in excessive sucking resulting in air being swallowed and leading to colic-like symptoms o teat size of the bottle should be checked so that when the bottle is turned upside down the mil should drop slowly from the bottle o if formula feeding, consider a one-week trial of switching to hypoallergenic formulas (if breastfeeding, continue to do so as switching to formula will not help) o switching to soy formula may be beneficial If suspected that crying is due to excessive wind caused by air swallowing during crying or feeding then can use: Simethicone (Infacol Wind Drops) Infants 1 month-2 years: add 0.2 mL to bottle or give orally immediately before breastfeeding (> 2 years: 0.4 mL 4 times/day (after meals and at bedtime); max. 12 doses/day)
Usually subsides 3-6 months of age. Colic has no bearing on babys intelligence or future development.
Refer: o infants that are failing to put on weight o medication failure o over anxious parents
Self Care Card: Infant Colic
Nappy rash
Erythematous rash on the buttock and groin area caused by contact of urine and faeces with skin, wetness and maceration of skin due to infrequent nappy changes and inadequate skin care
- Frequent nappy changing. - Nappy-free periods where possible. - Use mild detergents to wash nappies and ensure thoroughly rinsed. - Breathable nappy liners or change to disposable nappies (Huggies most absorbent) - Avoid plastic/waterproof pants. - Cleanse skin between each nappy change with warm water or olive oil/dilute bath oil using cotton balls or a warm face washer & apply barrier cream at EACH nappy change - AVOID: soap, talc, wipes that may irritate skin - Oatmeal bath oil can help soothe the irritated area Apply a barrier cream with each nappy change. Zinc (Zinc cream, Sudicream, Amolin, Desitin, RCH nappy goo) is soothing. Lanolin (Alpha Keri lotion) hydrates skin. Castor oil/cod liver oil provides a water-resistant layer on skin. Hydrocortisone 1% (Dermaid, Sigmacort, Cortic-DC) Applied sparingly to inflamed area 1-3 times daily after bath. For short term use only. To minimise systemic absorption, use highly absorbent disposable nappies, change nappies more frequently and maximise nappy-free periods.
If non-responsive to OTC treatment after 1 week should be referred.
Broken or unbroken skin? Infection? Bacterial (weeping or yellow crusting), fungal (satellite pustules) Duration? >2 weeks, refer Previous Hx?
If fungal infection also present, apply clotrimazole (Canestan, Clonea) cream to affected area d or bd after bath. Continue for 1 week after symptoms cease. Apply antifungal first and then steroid. Can use Hydrazole (hydrocortisone/ clotrimazole) initially but revert back to clotrimazole cream for
If signs of candidal involvement, can use: Miconazole + zinc oxide (Daktozin) Apply without rubbing at each nappy change to water cleaned (do not use soaps) dry skin; continue until cleared or for greater than or equal to 7 days.
rest of course once inflammation resolved Self Care Card: Nappy Rash a.k.a infantile seborrhoeic dermatitis Reassure parents cradle cap is a common, self limiting condition and will clear spontaneously i.e. NOT contagious, child WILL grow out of it, usually DOESNT need any treatment, NOT due to hygiene Recurrent cases may be due to proliferation of yeast in the scalp and may respond to ketoconazole shampoo (Nizoral)
Cradle Cap
Greasy, yellow scaling and crusts on the scalp and face. Rash does not itch and rarely irritates infant (impt for DDx) Age of onset usually ~1 month and resolves by 8-12 months.
Remove thick scale by massaging warm olive or mineral oil gently into scalp leave on for several hours/overnight wash off with a mild soap and a soft bristle toothbrush or terry cloth washcloth. Frequent shampooing with a mild, non-medicated shampoo. Failing this: Severe Cases: Egozite Cradle Cap Lotion (salicylic acid, olive oil, castor oil) Ensure scalp is dry and apply to crust only twice daily for 3-5 days without washing hair, then wash with a gentle shampoo. Repeat for remaining crust. * AVOID: contact with eyes & non-crusted areas*
Treatment
Children
Pregnancy
Lactation
(ok in) EYE DISORDERS Dry Eye Syndrome (keratoconjunctivitis sicca or keratitis sicca xerophthalmia) * Smx: -dry, itchy, gritty, irritated, watering eyes Reasons; - drug causes: anticholinergics, diuretics, OCP, retinoids, HRT, propranolol -evnviro: AC, smoke, dry air, air pollution, computer use -contact lenses -medical conditions: Sjoegrens syndrome, Steven-johnson;s, chronic conjunctivitis, post-herpes zoster WHY? Aqueous tear deficiency lack of tears of production of tears of poor quality Check: 1. Age of px common in elderly 2. Other Smx - ?redness, pain, pus/discharge, uni/bilateral, blurred vision, flashing lights Refer 3. Occupation 4. Current medications/medical conditions Treatment: EYE LUBRICANTS many different artificial tear supplements available Main types: preserved, preservative free, drops, ointments, gels Dose: 1 drop every 1-12hrs as required lubricants may be used as often as required Ointment: reserved for night as can cause some blurring in the vision Products available: - Polytears (hypromellose, dextran) & Genteal (hypromellose) contain least-irritant preservative - Systane (PEG, Propylene Glycol) - slightly more viscous thus more lubricating - actually helps in the healing process - Genteal Gel (hypromellose, carbomer 980) & Viscotears Liquid gel (carbomer 980, PAA) - good for night-time use Products suitable to be worn with contact lenses OK A A Advice in regards to management: - avoid precipitating factors eg. AC, smoke - regular use of eye lubricants (drops during day & ointment at night) -reduce evaporation by wearing wrap-aroudn glasses or humidifying air Directions to insert eye drops: -wash hands and ensure clean -unscrew/twist off container -tilt head back -with one hand create a pouch with the lower lid -position bottle directly above pouch & drop -close eye -press on nose for 12minutes -repeat process in a few mins if >1 drop needed Remember: -never share eye drops -d28 -avoid touching the tip of the bottle with the eye Self Care Card: Dry Eyes Viral Conjunctivitis (aka pink eye) Smx: - very watery, itchy, irritated eye -bilateral, mild discomfort -foreign body sensation -redness Self-limiting condition 1-3 weeks to resolve SYMPTOMATIC Treatment ONLY cold compress artificial tear supplements hourly use if needed analgesics paracetamol avoid bright light HIGHLY Contagious appropriate hygiene essential
Refresh Contacts (carmellose) Bion Tears (preservative-free single use containers)
My usual recommendations: Mild: Polytears/Refresh/Genteal during the day and Genteal Gel at night Mod: Systane during the day & Genteal at night Preservative free for anyone prone to allergies/contact lens wearers
Discard all eye makeup/cosmetics
Bacterial Conjunctivitis Smx: - red, spreads quickly to other eye, irritated - sticky discharge that reforms during the day/overnight - mucopurulent discharge increase over 1-2days - gritty feeling Check: ? duration of Smx ? changes in vision ? deep seeded pain, flashing lights, headaches, neurological changes ? Hx of URTI/cold ? child possible blocked tear ducts rather than bacterial conjunctivitis ? Ddx: viral, allergic, foreign body Cause: G+ve & G-ve Allergic Conjunctivitis Smx: - red, itchy, watery eye - conjunctivial oedema - shouldnt be discharge
COMMENTS: * self-limiting resolves in 5-14 days * contagious good hygiene is essential * recurrent infections may be associated with abnormalities in lacrimal drainage system Treatment:
Contagious appropriate hygiene is essential (ie. washing hands, facecloths & towels) Not in infants Safe Safe Discard all eye-makeup and cosmetics
Propanimide (Brolene) drops & oint o for MILD conjunctivitis o 1-2 drops tds-qid for 5-7 days o Should have noticeable improvement within 2 days o SE: burning, irritation, stinging Sulfacetamide (Bleph-10) drops only o For MILD conjunctivitis o 1 drop q2-4h for 2 days, then if there is improvement, 1 drop qid for 5 days o initial improvement within 24hrs o SE: irritation & redness (due to sulphur)
> 2 months
CAT C AVOID!
? Potential for infant absorption
TREATMENT REGIMENS: Mild Symptoms: irrigate with NaCl 0.9% - bd Cold compress prn/regularly Artificial tear supplements: 4-8times/day Safe Safe Safe
Make sure to carefully check the PREGNANCY Cats & what AGE these drops can be used in!
Check: -pollens, dust mites, cosmetics, contact lenses/solutions -?visual acuity -?papillae or lumps under the lid (follicles) - drugs/medications
Mod Symptoms: Oral antihistamine may be useful Topical drugs: o Levocabastine (Livostin) Antihistamine Dose: 1 drop bd incr to tds/qid if needed SE: stinging, mild eye irritation o Ketotifen (Zaditen) Antihistamine-mast-cell stabiliser! FAST onset of action within 15mins Dose: 1 drop bd Lodoxamide (Lomide) Mast-Cell stabiliser
> 6yrs
AVOID B3
Suitable if needed
> 3YRS
? B1
Suitable if needed
> 4yrs
B1 limited data
Limited data
Long term use of topical vasoconstrictors (Naphazoline, Phenylephrine, Tetrahydrozoline) + Antihistamine combinations eg. Naphcon-A NOT recommended bc of rebound conjunctivitis o Napchon-A, Antistine-Privine (Naphazoline & pheniramine) Dose: 1 drop q6-12 hr (good short term to reduce redness)
Severe Symptoms: Seek specialist advice Topical CSs may be required Recurrent Symptoms: Refer to a specialist Oral Antihistamine may also be useful Mast0cell stabiliser is effective as a preventive measure o Eg. Zaditen Ketotifen 1 drop bd
o
Stye (Internal & External Hordeolums) Smx: - slightly painful lump near lid - us able to see a small white head - swelling and redness around the area Chalazion (Meibomian cyst blockage of one of the Meibomian glands in the upper or lower lids) Smx: - looks similar to a stye
Eg. Lomide - Lodoxamide Ddx: -chalazion -acute dacryocystitis -blepharitis -eye lid trauma
Treatment: Warm compress to aid drainage 10-20mins qid until drains Lid hygiene LidCare If internal Refer may require Abx
TREATMENT/Management may rupture spontaniously, however severe cases may require surgery. Self-limiting Blepharitis = risk factor Likely to suffer from recurrent chalazions so good lid hygiene is essential
DDx: stye
- BUT: no head & painless lump - develops over weeks Check: - other eye conditions - ?blepharitis - ?eye make-up Contact Lens Care Caring for Contact Lenses requires: cleaning, disinfecting, soaking, wetting, lubricating some products have 1 solution to cover most of these steps WHY? protein builds up on contacts this should be removed daily with a clearer Disposable/daily contacts less risk of developing eye infections but $$ Advice:
-
wash hands thoroughly before touching contacts (In/out of eye) do NOT use water to wash contacts (risk of infection) do no moisten/clean with saliva caution before using drops not compatible
Blepharitis - CHRONIC inflammation of the margins of the eyelids Smx: -crusting of the eyelids, soreness, greasy appearance -flaking, irritation, foreign body sensation, some discharge Main 3 causes: 1) Seborrhoeic Blepharitis 2) Rosacea Blepharitis 3) Staph Blepharitis Red Eyes MANY possible reasons why someone develops a RED eye!! Questions: ? how long ? other Smx (discomfort, blurred vision, pain, discharge) ? had before ? injury ?irritants ? contacts or glasses
MANAGEMENT 1) Eyelid hygiene - essential due to the CHRONIC nature of the condition - removal of crusts and debris daily with warm water or a 1 in 10 dilution of baby shampoo - daily or twice daily (if severe) - or LidCare product may be used - avoid wearing eye make-up/discard old makeup 2) Control Cause - treat the underlying cause - eg. Control scalp seborrhoea 3) Symptomatic management -artificial tear supplements relieve dry eyes & itching Possible Causes: - conjunctivitis bacterial, allergic, viral - allergy, hay-fever, irritation - dry eyes - foreign body irritation, redness, tearing, foreign body sensation - contact lens problem associated with contact lense use - ? glaucoma (rare) - hormonal changes menopause - trauma burn - ? iritis (sometime more sinister ) Questioning: ? pain type, severity, intensity ? loss of vision ? sensitivity to light ? alleviating & aggrevating factors ? ocular conditions ? ocular swelling/ protrusion Main Issue: make the correct diagnosis! If no apparent sinister cause can treat short term with decongestant eye drop but make sure refer to doctor if doesnt clear within a few days.
? medication/medical conditions ? allergies ? reason for redness
Pain Vision Lacrimation or discharge Pupils Response to Light
Conjunctivitis Burning NOT severe NORMAL Mucous or mucopurulent NORMAL NORMAL
Iritis Moderately severe PHOTOPHOBIA Moderately decreased Lacrimation Small, irregular Minimal
Glaucoma Very SEVERE Nausea, emesis Considerable decreased Lacrimation Mild-dilated Unreactive Minimal
Episcleritis/Scleritis Episcleritis: irritation Scleritis: severe pain NORMAL Lacrimation NORMAL NORMAL Self Care Card: Red Eyes
Counselling It is important to write the date you open the eye preparation on the bottle or tube and to discard it 28 days later (unless told otherwise). Some people find it easier if they have someone help them or if they use a mirror. Wash your hands then sit or lie down. Tilt your head back, look up and gently pull down your lower eyelid to form a pouch. Avoid letting the tip of the dropper or tube touch your eyes, skin or any other surface. Use a clean tissue to mop up any excess. Drops Shake suspensions (cloudy liquids) gently before use. Put 1 drop into the pouch (see above). If you think that the first drop missed your eye, put in another. Try not to blink after putting in a drop. Close your eyes and gently press against the inner corner of your eye with your finger (over the tear duct) for at least 3 minutes. This increases the effectiveness of the eye drop and helps reduce the amount of medicine that gets into the rest of your body where it may cause side effects. The eye pouch will be full after a single drop. If you need to use another eye drop at the same time of day, wait several minutes before using it. If you find it difficult to tell whether a drop has gone into your eye and you don't have someone to help, try storing your eye drops in a refrigerator, so you can feel when the cold drop goes in your eye. Ointments Squeeze a small amount (about 1 cm length) along the pouch (see above) then blink several times to spread the ointment. If you need to use drops at a similar time of day, use the ointment last. Children Hold the child's eyelids open between the index finger and thumb of one hand and put drops in with the other. If this is difficult, put a couple of drops onto the skin at the inner corner of the eye and wait for the eyes to open. Infants and toddlers may need to be held still while the eye preparation is given. If you don't have someone to help you may need to swaddle the child with a sheet or lay them on the floor and gently hold their head still between your knees. Contact lenses Do not wear contact lenses when using eye ointments. Wearing soft contact lenses is generally not recommended while using eye drops. They may be removed before using an eye drop, then reinserted after a period of at least 5 minutes. If drops are used twice daily you can insert the lens after putting in the morning drop and remove the lens before the evening drop. If drops are used accidentally while lenses are in, remove them and rinse well with an appropriate solution before reinsertion. Soft (hydrogel) lenses can be stained by some drugs (check with your pharmacist). Disposable lenses can still be worn. Some drugs may make your eyes feel dry.
Vasoconstrictor (decongestant) eye drops
Indications: mild ocular congestion, i.e. allergic conjunctivitis, red eye Adverse effects: rebound hyperaemia, stinging on instillation Counselling: do not use for more than 5 days and seek medical attention if symptoms dont improve within 48 hours although advertised for minor irritations, a cool compress is beneficial and is safer if used for too long these eye drops will cause symptoms similar to red eye (i.e. rebound congestion/hyperaemia) Naphazoline (Murine Clear Eye, Albalon, Naphcon Forte) 1-2 drops up to 4 times daily. Tetrahydrozoline (Visine) 1-2 drops up to 4 times daily.
No
Safe to use short term (up to 5 days)
Safe
Antihistamine eye drops
Indications: allergic conjunctivitis Adverse effects: stinging on instillation (more than others), mild eye irritation, headache Counselling: Shake before use. You may feel drowsy and the effects of alcohol may be increased; do not drive or operate machinery if you are affected. Levocabastine (Livostin) eye drops 1 drop into each eye twice daily, increasing to 3-4 times daily if necessary.
>6
B3, avoid use
Ok if indicated
Avoid combinations of vasoconstrictor and antihistamine as doubtful benefit and should not use vasoconstrictor for longer than 5 days whereas antihistamine use may be indicated indefinitely.
Ocular Lubricants
see DRY EYE
Patient Problem
Treatment
Children (ok in)
Pregnancy
Lactation
Other
EAR, NOSE & THROAT Deafness Ear wax Otitis externa Pain
Irritation/ itching
Tinnitus/ vertigo

Discharge
Upper respiratory tract infection

Comments Ear discomfort, feeling of fullness and slight gradual hearing loss. Associated with cotton bud use. Initially irritation alone, progressing to pain and discharge. If oedema, can get conductive hearing loss. Can be precipitated by swimming, warm weather and dermatitis. Ear pain tends to be throbbing/aching. Pain is relieved on rupture of the tympanic membrane, which releases a mucopurulent discharge. Most common in children 3-6 years. If recurrent, otitis media may develop into glue ear, which is sticky fluid that has not drained from the middle ear. Treatment of glue ear is usually surgical drainage and insertion of grommets. Usually caused by viral infection.
Otitis media
Inner ear problem Refer: - foreign body - generalised inflammation of outer ear may require antibiotics - otitis externa may require antibiotics - otitis media if no improvement after 24-48 hours usually treated with symptomatic analgesia/decongestants for first 24-48 hours unless child has ever & vomiting - children under 6 years with ear pain or hearing impairment - tinnitus/vertigo underlying inner ear problem
Ear Drop Administration: o to make insertion more pleasant, hold the bottle in your hands for a few minutes prior to administration to warm solution o tilt your head to one side, with ear pointing to the ceiling (can suggest resting head on arm of couch whilst watching tv) o straighten the ear canal with one hand by pulling the ear upwards (adults)/ downwards (children) and back o with the other hand, use the dropper to instil the correct number of drops into the ear holding the dropper as close as possible to the ear canal without touching it o keep the head in the tilted position for several minutes o return head to normal position and use a clean tissue to wipe away any excess solution. Ear Ache
1. Age 2. Type of pain? 3. Severity of pain? ?radiation 4. Other Smx? 5. Hearing difficulties? Vertigo?
General: - can be caused by infection, foreign body, dermatitis, ear plugs, referred pain from teeth, jaw, sinuses - chronic infections hearing damage/loss Common causes: Otitis media:
Dizziness? 6. Travel? Swimming? Loud music concert? Etc 7. Mx? - ?ototoxic meds 8. Discharge? 9. Associated trauma? If cant identify a CAUSE for the ear ache refer!
-inflammation of the middle ear -most common in children Glue ear: -type of chronic otitis media -long term build up of thick, sticky, fluid in the middle ear & behind the ear drum -hearing loss/difficulties is common Ear Wax: -hearing problems requires wax removal & softening Swimmers Ear: -water accumulation bacterial growth, inflammation, swelling pain Self Care Card: Ear Problems
Ear Wax Wax is normal part of the ear, protective role History of gradual hearing loss usually reported on presentation to pharmacy with ear wax impaction.
MANAGEMENT: avoid using cotton buds, pushing plugs into the ear sometimes clears without treatment in 5 days often use cerumenolytic agents before Syringing
>12 yrs Refer: o Associated traumarelated conductive deafness o Dizziness or tinnitus o Foreign body in the ear canal o OTC medication failure o Pain originating from middle ear
if severe REFER: may need gentle syringing by doctor to loosen wax

drops should be warmed before use (hold in hands for several minutes) Tilt head and instill 5 drops into one ear. Repeat twice a day.
Common in the elderly. Associated with hearing aids/cotton bud use
Cerumenolytics Waxol Ear Drops Docusate aqueous based or Cerumol Ear Drops (dichlorobenzene + chlorbutol) - oil based Dose: warm dropper bottle in hands for several minutes and then instil 5 drops in affected ear(s) twice daily for a few days OR 10-30mins before syringing by doctor SEs: irritation Cerumol C/I in patients with peanut allergy
Self Care Card: Ear Problems > 12yrs Isopropyl alcohol helps reduce moisture. Acetic acid increases acidity of the ear canal to create an inhospitable environment for bacteria. Swimming related: regular use of drying agents after swimming careful/meticulous cleaning ear plugs/cap for swimming
Otitis Externa
- itching, inflammation, irritation of the external ear canal - may be due to dermatitis, local trauma, foreign objects, Usually bacterial but can be fungal.
Management: If inflammation is present: Refer to Dr (possibly need antibacterial/CS combination) Avoid use of antiseptic/drying agents when inflammation present will cause pain To prevent recurrence can use OTC Antiseptic/Drying Agents such as: Aquaear (acetic acid, isopropyl alcohol) or Ear Clear Dry & Clear (isopropyl alcohol, glycerol) *less irritating Dose: Instil 4-5 drops into each ear after swimming or bathing
avoid swimming while have infection
Self Care Card: Ear Problems
Allergic rhinitis
Seasonal or perennial. Common allergens: grass/tree pollen, fungal mould spores, house-dust mite and animal hair.
Oral antihistamines (non-sedating) Loratadine (Claratyne) 10mg tabs, 1mg/mL Take one tablet daily. Children: 2-12yo, 5mg d 1-2yo, 2.5mg d Steroid nasal spray seasonal allergic rhinitis Budesonide (Rhinocort) 32, 64mcg 1-2 sprays into each nostril daily
>1
Prefer sedating agents but can use (Cat B1)
Safe to use
>6 > 12
Ok Ok
Ok Ok
Sx: rhinorrhoea (runny nose), nasal congestion, nasal itching, itchy roof of mouth, itchy/watery eyes, sneezing.
Fluticasone (Beconase Allergy and Hayfever) 50mg/dose Initially 2 sprays daily then 1 spray daily **Regular use (only in adults, C/I in ppl <18) is essential for full benefit and should be used each day during hay fever season. Onset of action takes 3-4 days (i.e. not for immediate relief of symptoms, can use decongestant (e.g. oxymetazoline) in the interim). Nasal decongestant Oxymetazoline (Dimetapp, Drixine, Logicin nasal sprays) 0.05%, 0.025% 1-2 sprays into each nostril up to tds Do not use for longer than 5 days. Ophthalmic antihistamines Livostin (levocabastine) eye drops 1 drop into each eye twice daily Nasal antihistamines Azep (azelastine HCl) One spray into each nostril twice a day. Suitable for long term use.
>2
1. Onset and duration 2. Symptoms 3. Previous History - Seasonal vs

perennial allergy
Refer: o wheezing, SOB, tight chest o painful ear/sinuses o purulent conjunctivitis o failed treatment or prolonged symptoms
4. Wheezing, chest tightness, SOB, coughing? Possible exac. of

asthma
>6
Avoid
Ok if indicated No Self Care Card: Hay fever, Sinus Problems
5. Secondary infection earache,

facial pain, purulent conjunctivitis
6. Previous treatment?
>5
No
Sore Throat
Majority caused by viral infection (90%); bacterial infection (streptococcal), glandular fever, herpes simplex, candidiasis and varicella accounting for the rest. Questions about associated symptoms will often help in making differential diagnosis. Viral sore throat often associated with generalised malaise, fever, headache and cough. Streptococcal infections are more prevalent in school-aged children. Sore throat usually accompanied by fever, marked tonsillar exudate, tender cervical glands and no cough. Paracetamol and ibuprofen provide rapid and effective relief of pain in sore throat and should be used first line. Benzydamine (Difflam) anti-inflammatory lozenges spray solution 1 lozenge every 1-2 hours as required; max 12 loz/day 4 sprays onto sore/inflamed area every 1 -3 hours as necessary 15mL gargled/rinse for 30 secs every 1 -3 hours as needed; expectorate >6 Cat B2: Ok Ok
Usually self-limiting.
Benzocaine (Cepacaine) mouthwash Gargle or rinse 10-15 mL for 10-15 secs and expel liquid; repeat every 2-3 hours as necessary.
Caution with hot food and drinks after use.
>6
Ok
Ok
Refer: o duration of more than 2 weeks o signs of bacterial infection (i.e. marked
tonsillar exudate accompanied with a high temp. and swollen glands)
o o o o o
hoarseness >3 weeks difficulty swallowing recurrent bouts of infection associated skin rash adverse drug reaction (e.g.
clozapine, sulfasalazine, drugs causing agranulocytosis, inhaled corticosteroids)
Itch/sneeze Nasal discharge Nasal blockage Impaired smell Intranasal corticosteroids +++ +++ ++ + Oral/intranasal antihistamines ++ ++ +/ Intranasal decongestants +++ Cromoglycate + + +/ Ipratropium +++ +++ very effective, ++ moderately effective, + marginally effective, +/ little or no effect, ineffective Indications: relief of nasal congestion associated with acute and chronic rhinitis, Intranasal Decongestants
common cold and sinusitis. Cause local vasoconstriction and therefore decrease nasal blood
Safe
Safe
Safe
Caution with: MAOI, avoid in infants <6 months as rebound congestion can cause
flow and congestion.
breathing difficulty. Adverse effects: local burning, stinging, rebound congestion with prolonged use, i.e. > 4-5 days Oxymetazoline (Drixine/Dimetapp 12 hour/Logicin Drixine Paediatric drops) Adults, 1-2 sprays into each nostril up to tds Adults, 1-2 drops into each nostril up to tds
Nasal corticosteroids
Produce local anti-inflammation, decrease capillary permeability and mucus production and vasoconstriction.
Indications: allergic rhinitis, nasal polyps Caution with: bleeding disorder (may cause nose bleeds), recent nose surgery or trauma. Adverse effects: local nasal stinging, itching, sneezing, sore throat, dry mouth Budesonide (Rhinocort) 32, 64mcg 1-2 sprays into each nostril daily Fluticasone (Beconase Allergy and Hayfever) 50mg/dose Initially 2 sprays daily then 1 spray daily >6 > 12
Safe
Safe
Onset within 3 7 hours, optimal effect after several days of use use regularly for seasonal rhinitis.
Nasal antihistamines
Indications: allergic rhinitis Caution with: local irritation, nosebleeds Adverse effects: local nasal stinging, itching, sneezing, sore throat, dry mouth Azelastine (Azep) 1mg/mL nasal spray 1 spray bd Levocabastine (Livostin) 0.5mg/mL nasal spray 2 sprays bd increased to qid prn
>6
B3; avoid
Should be safe
In allergic rhinitis, intranasal antihistamines are as effective as oral antihistamines but less effective than regularly used intranasal corticosteroids. You may feel sleepy and the effects of alcohol may be increased whilst using this medication, do not drive etc if you are affected.
Patient Problem
Treatment
Children (ok in)
Pregnancy
Lactation
Other Most dry coughs are caused by a viral infection and are self limiting. Most coughs resolve within 7 10 days. Cough suppressants may cause drowsiness, constipation, n/v and are C/I in respiratory failure, asthma, COPD Caution in recommending syrups to diabetics due to high sugar content.
Refer:
RESPIRATORY
Cough
Coloured sputum (green or yellow thick mucus) is suggestive of a chest infection and should be referred. Do not treat productive cough with cough suppressant as results in pooling and retention of mucus in the lungs and higher chance of infection. Postnasal drip often causes a cough and is characterised by sinus or nasal discharge that flows behind the nose and into the throat. Signs include patient having to swallow mucous or notice they are clearing their Bromhexine (Bisolvon) 4mg/5mL 10-20 ml tds Guaifenesin (Robitussin EX) 100mg/5mL 10-20mL q4h
Expectorants (productive cough) >1 Ok Ok
>2 Cough Suppressants (non-productive cough)
Ok
Avoid
Demulcents (simple linctus, sucrose and glycerol syrups), which sooth the throat by forming a protective layer over sensory receptors in the pharynx, are particularly useful in children and pregnancy. Caution high syrup content in patients with diabetes. Pholcodine (Duro-Tuss Regular) 10 - 15mg 3-4 times daily
> 2 y.o. children 25 years: 2.5-5mL
Ok
Ok
throat more often. Usually worse at night. Treat with antihistamine/ sympathomimetic. A recurrent night-time cough can indicate asthma, especially in children. Ddx from cough caused by post-natal drip. Avoid cough suppressants in children < 2
>2 Dextromethorphan (Bisolvon, Benadryl Dry) 10 - 20mg every 4 hours or 30mg every 6-8 hours
* Dextromethorphan is C/I within 14 days of treatment with a MAOI and should not be combined with drugs that may contribute to serotonin syndrome.
Ok
Ok
o o o o
>2 Dihydrocodeine (Rikodeine) 1.9mg/mL Take 5 - 10mL every q4-6h
Ok
Ok
o o o o o
cough lasting 2 weeks or more and not improving coloured sputum chest pain SOB wheezing whooping cough or croup recurrent nocturnal cough suspected adverse SE failed treatment persistent nocturnal cough in children
Duro-Tuss Range:
Bisolvon Chesty:
Self Care Card:
Dry Cough: Pholcodine cough suppressant centrally acting, shouldnt cause sedation but may in sensitive individuals o Forte: 15mg Phocodeine/5ml Dose: 5ml q6h prn o Regular: 15mh Pholcodine/15ml Dose: 10-15ml q6h prn Chesty Cough Liquid Forte expectorant & mucolytic o Bromhexine 8mg & Guaiphenesin 200mg/10ml o Dose: 10ml q4-6h prn Chesty Regular Liquid Regular: Bromhexine o Bromhexine 12mg/15ml o Dose: 15ml q8h prn Expectorant: Pholcodine, Bromhexine o Pholcodine 15mg, Bromhexine 12mg/15ml o Dose: 10-15ml q6h prn
Bromhexine 4mg per 5ml (mucolytic) Adult: 10ml tds, may be increased up to 20ml tds for the first 7 days
Dimetapp ADULT Range: DM Cold & Cough Elixir: o Brompheniramine maleate 2mg, phenylephrine 5mg, dextromethorphan 10mg per 5ml o Adult: 10ml q4h prn Elixir: o Brompheniramine 2mg, Phenylephrine 5mgper 5ml o Adult: 10ml q6-8hr prn Chesty Cough Elixir: o Guiphenisin 200mg, Bromhexine 8mgper 10m o Adult: 10ml q8h prn INFANT Range: Infant Drops o Brompheniramine 4mg, phenylephrine 5mg per 5ml o For: >1 month old o Dose: 0.15ml/kg q6-8h DM Cold & Cough Elixir: o Brompheniramine 2mg, phenylephrine 5mg, dextromethorphan 10mg per 5ml o For: > 1 year but really cough suppression in infants NOT advisable! Chest Congestion: o Guaiphenesin 100mg per 5ml (expectorant) For: > 1 year but really cough suppression in infants is NOT advisable
Robitussin Range: DX Dry Cough Forte: Cough Suppressant: o Dextromethorphan 30mg per 10ml o Adult: 10ml q6-8hr prn DM Cough & Chest Congestion: Cough Suppressant & Expectorant: o Dextrometyhorphan 30mg & Guaiphenesin 200mg per 10ml o Adult: 10ml q6-8hr prn ME Chesty Cough Forte: Mucolytic & Expectorant: o Guaiphenesin 200mg & Bromhexine 8mg per 10ml o Adult: 10ml q8h prn
Benadryl Range:
Original: Diphenhydramine 12.5mg, Ammonium Cl 125mg, Sodium Citrate 50mgper
5ml o Adult: 10ml q4h prn
Dry Forte: Dextromethorpan 15mg per 5ml o Adult: 10ml q6-8hrs prn Chesty Forte: Bromhexine 3mg, Guaiphenesin 100mg per 5ml o Adult: 10-15ml q6h prn Nightime: o Dextromethorphan 10mg, diphenhydramine 12.5mg per 5ml o Adult: 10ml q4h prn SYMPTOMATIC Treatment: Analgesia paracetamol, ibuprofen, paracetamol/codeine Nasal decongestants pseudoephedrine, phenylephrine, oxymetazoline Cough suppressants dextromethorphan, codeine Antihistamine doxylamine, triprolidine HCl, chlorpheniramine see COUGH see SORE THROAT Sympathomimetics - constrict the dilated blood vessels in the nasal mucosa. C/I: heart disease, hypertension, hyperthyroidism, diabetes, MAOI use saline nasal sprays (e.g. Fess) for relief of symptoms for patients in these groups. Oral Sudafed Sinus Pain Relief (Paracetamol 500mg, Pseduoephedrine 30mg) > 12 B2; avoid Avoid use 2 tabs 3-4 times daily (max 8 tabs/day) use if not if not neccessary necessary Sudafed Day and Night (Day: as above, Night: as above + Triprolidine 1.25mg) 2 daytime tabs twice daily, 2 nightime tabs at bedtime Codral products contain codeine. *No evidence for efficacy of phenylephrine* Rest and increase fluid intake. Cough may persist after worst of the cold is over. Use paracetamol for headaches and pain.
Cold and Flu

Symptoms of common cold: runny/blocked nose, sore throat, cough, sneezing, headaches, earache Condition specific qns: What symptoms are you experiencing? Which are most troublesome? How long have you had these symptoms for? High temperature for 3 days of more? Child or older person? Severe earache? Nature of cough? Sputum colour? Chest pain, sore throat or cough that wont go away? Treatment specific qns:
Taking any other medications? High blood pressure, diabetes? Pregnant or breastfeeding? Liver, heart or thyroid disease? Asthma, stomach problems, glaucoma, prostate or constipation? Differential Diagnosis: FLU - persistent temperature of >38oC at least one respiratory symptom present - at least one constitutional symptom present (headache, malaise, myalgia, sweats/chills, prostration) rapid onset with sweats/chills, muscular aches and pains in limbs, a dry sore throat, cough and high temperature bed bound, delirious
Nasal Sprays Oxymetazoline (Dimetapp, Drixine, Logicin) 0.5 mg/mL 1-3 sprays in each nostril twice daily Nasal sprays should not be used for longer than 5 days as can cause rebound congestion. Nasal Drops Drixine Paediatric Nasal Drops 0.25 mg/mL 1-3 drops in each nostril twice daily The head should be tilted backwards; this is best achieved by lying on a bench or bed. After instillation of drops in the nostrils, the head should be slowly moved from side to side to enable the solution to flow over the total area of the nasal lining. <6 >6 B2; avoid use if not neccessary Avoid use if not necessary Refer: o symptoms lasting greater than 10-14 days o dry cough develops into productive cough o severe earache (child) o facial pain/frontal headache (sinusitis) o very young or old o heart or lung disease o persistent fever and productive cough o delirium o asthma, COPD
Fess Nasal Spray (isotonic NaCl) Max 8 sprays per nostril every 2-3 hours as needed. Fess Little Noses (Nasal drops)
Ok
Ok
Ok
Self Care Card: Cold and Flu Taking any other medications? Have you seen your doctor (Re: asthma) in last 12 months? How often are you finding you need to use your inhaler? More than usual? How long does one inhaler last you?
Asthma Inhalers
Record sale in patients history to enable monitoring of their use of reliever medications which may indicate a worsening of their asthma.
Salbutamol (Ventolin, Asmol CFC-free inhalers) 100mcg/dose, 200 doses Shake well and inhale 1 - 2 puffs as required, or 5-15 minutes before exercise; repeat 3-4 times a day as necessary.
o o o o o o o o o
remove cap and shake MDI exhale place mouthpiece in mouth and tilt head back slightly start to breathe in slowly and deeply at the same time as breathing in press down on canister to actuate 1 puff continue to breathe in hold breath for at least 10 seconds breathe out slowly if a second dose is required repeat above
Terbutaline (Bricanyl turbuhaler) 500mcg/dose, 200 doses Inhale 1 - 2 puffs as required, or 5-15 minutes before exercise; repeat 3-4 times a day as necessary.
o o o o o o o o remove cap hold upright while turning base once to the right, and then back to the left until a click is heard (dose ready for inhalation) exhale away from device place mouthpiece in mouth and breathe in forcefully and deeply hold breath for at least 10 seconds remove from mouth before exhaling if a second dose is required, repeat above after use rinse mouth thoroughly with water and expel
How is your asthma control at the moment? Is it affecting your exercise or sleep? Are you using a preventative inhaler? How often? How are you using it? Have you got an Asthma Action Plan? Self Care Card: Asthma, Asthma medications
Patient Problem
Treatment
Children (ok in)
Pregnancy
Lactation
Other
WOMENS HEALTH
Period pain (primary dysmenorrhoea)

Pelvic pain occurring at or around the time of menses. Age Usually occurs during teens and 20s Suffered this type of pain before? How treated? When is she expecting her period Taking any other medications? Already using an NSAID? Pregnant or breastfeeding? Ectopic pregnancy? Other symptoms? Medical conditions? Have stomach problems, asthma, heart, kidney or liver disease, high blood pressure, arthritis or gout? Type of pain? L lower pelvic/abdomen or back I mild-severe N crampy, spasmodic, ache, dragging D 1-24 hours O occur at beginning of menses C n/v, constipation, backache, headache, fatigue etc A - stress R local heat, drugs R lower back, inner thighs F every month
NSAIDs can be given 1-3 days before expected menstruation and continued through first day of period.
Cat C, avoid in late pregnancy
Ok
Ibuprofen (Nurofen, Panafen, Advil) 200mg 400 mg initially at the first sign of pain or menstrual bleeding, then 400mg every four to six hours. Max 1,200 mg/day (6 tablets).
Relieving acute pain: Massage the lower back and buttocks. Lie flat on your back and put a pillow under your knees or lie on your side and bring your knees to your chest. Place a hot water bottle/heat pack on your stomach or lower back. Rest and warm baths Lifestyle modifications: Reduce stress Exercise regularly Smoking cessation Diet: vegetarian diet low in fat, dairy products and eggs with increased vegetables, raw seeds, and nuts shown to significantly decrease pain. Keep a diary of symptoms so you can plan for monthly periods.
Refer: o abnormal vaginal discharge o abnormal bleeding o symptoms suggestive of 2o dysmenorrhoea o severe intermenstrual pain and bleeding, wrong time o failure of medication o pain with a late period (possibility of eptopic preg) o fever
Naproxen sodium (Naprogesic) 275mg 550 mg stat, then 275 mg q6-8h as required. Max 5 tablets/day.
Mefenamic acid (Ponstan) 250mg Two capsules (500 mg) three times daily with food.
*Mefenamic acid blocks production of prostaglandins as well as the action of already formed prostaglandins may be useful in period pain resistant to treatment with ibuprofen and naproxen.
Care with NSAIDs: -asthma, PUD, allergies -Li+, anticoagulants, Warfarin, MTX, Digoxin, Antihypertensives
Mersyndol Night Strength (Paracetamol 450mg/Codeine 9.75mg/Doxylamine 5mg) relax & assist in sleeping 1-2 tabs every 4-6 hours as needed; max. 8 tabs/day
> 12 y.o.
Cat A
Ok
Self Care Card: Period Problems PMS -poorly defined complex set of psychological & physical Smx
MANAGEMENT: - refer if severe - educate/treat mild MPS: - explain that NORMAL, lifestyle changes, tell partner (so more accepting), adequate
-relieved during menstruation -us ~ 2weeks -av age: late 20s ? due to change in E2:P ratio Smx: -mood changes -fluid retention, odema (abdo) -bloating, breast tenderness -headache, back pain/heaviness -other: eye/skin/respiratory complaints
excerise, healthy diet, self-help Consider possible DDx: - renal/adrenal cause fluid retention - mammary dysplasia breast swelling - thyroid, PCOS, Psych disorder TREATMENT: requires referral to Dr 1st line OCP higher doses 50mcg, progestogens For Mild-Mod PMS OTC treatment & self-help may be enough:
Vit B complex/Mineral supplement for 3 cycles, then Evening Primrose Oil (2x500mg bd 3caps bd after 3/12) then, Refer to Dr if still no improvement Safe as a single dose Safe as a single dose
Self-diagnosis is unreliable; advise the woman to seek medical advice if symptoms persist or recur within 2 months after using selfprescribed treatment Treatment of sexual partner is not necessary as vaginal candidiasis is not sexually transmitted Vaginal antifungals may be used during pregnancy; use a 1-week course; vaginal applicators may be used with care in late pregnancy but digital insertion may be preferable. They may also damage contraceptive diaphragms and latex condoms (but not polyurethane condoms). Refer: o first time infection o pregnant o diabetic o >2 attacks in previous 6 months o contact/history of STD
Vaginal Thrush
Common in women of childbearing age. Pregnancy, diabetes, antibiotics, oral corticosteroids and OC are strong predisposing factors. Signs and symptoms: Intense itchiness or soreness around vagina. Vaginal discharge that is thick, white (curd-like) and odourless. Dysuria (burning around outside of vagina wen passing urine). Dyspareunia (painful intercourse). Erythema and/or oedema of vulva. DDx: Bacterial Vaginitis Unpleasant musty or fishy vaginal odour, exacerbated immediately after intercourse. Thin grey-white vaginal discharge. Taking any other medications? Diabetes? Fluconazole (Diflucan One) 150mg tablet Take one capsule orally as a single dose. Onset of symptom relief may be expected within one day, with complete relief possible in 2 days. Diflucan Duo contains 1 capsule and a tube of antifungal cream which can be applied twice daily, morning and night, to vulvovaginal and perianal area for external vaginal itch or irritation.
Clotrimazole Canesten Pessary (6 Day), 100mg Insert one pessary into the vagina at night for 6/7 Canesten Pessary (1 Day), 500mg Insert one pessary into the vagina at night The tablets should be inserted as deeply as possible into the vagina once daily, preferably in the evening. Canesten Cream (6 Day), 1% Insert one applicator full into the vagina at night for 6/7 Canesten Cream (3 Day), 2% Insert one applicator full into the vagina at night for 6/7 Canesten Cream (1 Day), 10% Insert one applicator full into the vagina at night for 6/7 One applicator should be filled with cream and inserted as deeply as possible into the vagina with the patient lying on her back. Can be applied externally as well. Canesten Clotrimazole Thrush Treatment Once Pessary + Cream (Combination pack)
Safe
Safe
Pregnant or breastfeeding? Pelvic or lower back pain? More than 2 attacks in last 6 months? Yellow, green or smelly discharge? First time infection? Diagnosed by a doctor? Patient <16 or >60? Self Care Card: Thrush
Keep genital area clean; use plain, unscented soap. Take showers rather than baths Wear cotton underpants with a cotton crotch. Avoid synthetic and nylon underwear and tight-fitting jeans or pants. Sleep in loose gown without underpants. Thrush thrives in warm, moist environment avoid prolonged wear of wet clothing, especially a wet bathing suit or exercise clothing. After urinating or bowel movements, cleanse by wiping from front to back (vagina toward anus). Lose weight if obese, and maintain euglycaemia in diabetic patients. Delay sexual relations until the symptoms clear/discomfort resolves. Drink Yokult. Non-pharmacological 1. 2. 3. 4. drink large amounts of water (5L/day) to help encourage bladder voiding and flush out bacteria in bladder void bladder immediately before and following sexual intercourse reduce coffee and alcohol intake as tend to irritate bladder in some people ensure bladder is completely empty by waiting 20 seconds after passing urine and then train to empty final drops; after each bowel movement toilet paper should be wiped from front to back to minimize transfer of bacteria from the bowel into the vagina and urethra drinking unsweetened cranberry juice may help prevent and treat UTIs by inhibiting bacterial adherence to the bladder epithelium Refer -
o o o o o o
patients <16 or >60 abnormal or irregular vaginal bleeding blood staining of vaginal discharge vulval or vaginal sores, ulcers or dysuria no improvement within 7 days of treatment suspected bacterial cause, i.e. vaginal discharge has an unpleasant odour or is yellow or greenish.
Cystitis
Inflammation of the bladder mucosa. Signs and symptoms: Burning during urination Pain during urination Urgency Frequency Sensation of incomplete bladder emptying Blood in urine Lower abdominal pain/cramping Cloudy, odorous urine Nocturia Itching/pricking sensation of urethra
OTC treatments should only be used for mild cystitis of short duration (<2 days) or until patient can consult a doctor.
5.
Ural (sodium citrotartrate) 4g Dissolve 1-2 sachets in cold water 4 times daily.
Urinary alkalinizers can help relieve the symptoms of mild cystitis. *avoid in patients with hypertension, heart disease, renal impairment or pregnant women
No
Avoid
Refer: o men, children, elderly o pregnancy o diabetic o fever, nausea/vomiting o loin pain, tenderness o haematuria o vaginal discharge o duration of longer than 2 days o recurrent cystitis o failed medication
Patient Problem
Treatment
Children (ok in)
Pregnancy
Lactation
Other Many pregnancy multivitamins available. Elevit or Blackmores is recommended
PREGNANCY /BREASTFEEDING Pre-conception & During pregnancy: Nutrition & General Health - folic acid 500mcg before conception and for first three months of pregnancy (reduces advice during Pregnancy
risk of neural tube defects eg. Spinda-bifida) - ? any medications discuss plans to become pregnant with dr - consider a change of lifestyle if smoker, alcoholic, heavy caffeine consumer - healthy lifestyle & food recommendations - careful when starting any new mx always check with Dr/pharmacist Pregnancy: Foods to AVOID: - soft cheeses eg. Brie, Camember, Ricotta Listeria - cold meats eg. From Delis/supermarkets - Listeria - uncooked or smoked seafoods & shellfish Mercury, Listeria, almonella - precooked or prepared cold foods e.g. salads, deli meats - dried/fermented sausages eg salami - soft-serve ice cream - pate - raw meat, eggs Salmonella - caffeine safe in moderation - alcohol - unwashed vegetables Toxoplasmosis - high sources of vitamin A Listeria: a bacteria found in some foods. In pregnancy listeria can cause miscarriage, stillbirth or premature labour. Early signs of listeria: fever, flu-like Smx. Mc aches, general malaise Should eat: well balanced & healthy diet fruit, veges, grains, fats, protein etc May need Fe supplementation: mane best absorption & with vit C after food to reduce GIT upset constipation problem in pregnancy (need to manage)
Back pain in pregnancy

Common complaint, caused by strain on the muscles of the back as the uterus enlarges and grows forward.
Paracetamol is treatment of choice, 1-2 tablets qid prn Can use codeine but avoid close to term as may depress respiration in the newborn, and exacerbate any constipation. Non-pharmacological treatment: o do not stand or sit in same position for too long o rest when pain is severe, sitting or lying with the legs raised o support the back with a pillow when sitting o wear flat shoes o when picking up anything heavy (incl. children) take the strain on the legs instead of the back o combination of appropriate exercises to strengthen back, and sufficient rest
Avoid NSAIDs during pregnancy, especially in 3rd trimester as there is increased risk of closure of fetal ductus.
o o o o o
a heat pack or massage may be helpful soak in a warm bath some women wear maternity belts may wish to consult a physiotherapist watch weight gain -
Constipation
Common esp in later pregnancy Due to baby pressing on the bowel, dehydration, need of Fe supplementation Check: ? blood in stools ? haemorrhoids ? antacids (Ca2+) excessive use may be contributing to constipation
Non-Drug Options - plenty of fluid and exercise - increase amt of fibre (however ONLY after acute bout of constipation has been relieved) - healthy food: high fibre, whole grains, apples/pears, kiwi fruit (good to eat skin) - fibre supplementation: Metamucil, psyllum Drug treatment: 1st line Coloxyl (stool softener) or Lactulose (Lactulose takes 1-2 days onset of action, need to take regularly, Dose: 15-45ml for 3 days then reduce dose may be used as maintenance dose) Note: -sennosides (e.g. senna) should be avoided! (stimulation of labour) - bulking agents cause bloating and wind only use after bowel actions have returned back to normal Antacids Cat A 1st line choice safe & effective Mylanta Original (AlOH, MgOH, Simethicone) 10-20mL prn up to 4 times daily *contain high amounts of Na so avoid in patients on sodium-restricted diet *Al constipation, Mg diarrhoea *Avoid use within 2 hrs of taking other medications *NB:// some pxs are concerned about the Al & Alzeheimers claim reassure that the results of the study were later proven incorrect. Safe to use* Ranitidine Cat B1 ONLY if Dr has prescribed it!!!! DONT recommend
Reflux
WHY? -foetus pressing on stomach loosen sphincter stomach contents reflux up burning sensation = reflux When questioning, exclude any other causes of indigestion ? pain in arms ? vomiting
Refer
Cat A
Ok
Other measures: -smaller meals -remain upright during & after eating -avoid spicy foods that may ppt reflux -raise bed head -avoid fizzy rinks -avoid eating before bed
Nocturnal muscle cramps in legs

- common later in pregnancy due to electrolyte imbalances
Recommendations 1. Increase fluid intake mc cramps could be due to dehydration 2. Heat packs and massage the legs before bed time 3. Stretching, loose clothing, flat shoes 4. Magmin: 1-2 tablets daily (Cochrane review) nb:// Mg may cause constipation!
Pruritis in Pregnancy
-develops from 3rd month onwards -due to oestrogen cholistasis
Management: 1) Shower oils/soap alternatives see eczema section 2) Moisturisers eg. QV, Dermaveen, Sorbolene cream see eczema section
build up of bilirubin pruritis
3) HC 1% (Dermaid, sigmacort) to relieve itching 4) Sedating antihistamine: - Dexchlorpheriamine (Polaramine) Cat A - Chlorpheniramine (Avil) Cat A - Cyproheptadine (Periactin) Cat A Ginger: MAX: 1g daily high doses increases coagulation of blood Monitor mum for symptoms of dehydration (e.g. rapid pulse, low BP, sunken eyelids, reduced skin turgor, cool skin, deep/increased respirations). Can recommend a rehydration solution if patients feels they can stomach it.
Morning Sickness
Persistent vomiting in a pregnant woman that interferes with fluid and electrolyte balance, as well as nutrition. Particularly bad in first trimester and effects 70-80% of women. Symptoms usually begin ~ 2 weeks after first missed period.
Pyridoxine (Vitamin B6); 50mg bd-tds. Max: 100-150mg/d (exceeding this max dose can lead to peripheral neuropathy tell px NOT to incr dose even if not helping) Acupressure bands (e.g. Sea-band) worn on the wrist may be of benefit and are unlikely to be harmful. Changes to dietary or daily habits can help relieve morning sickness (the idea is to keep the stomach neither too full or too empty, both of which can exacerbate nausea): o eat small frequent meals (4-6 daily) to maintain blood sugar levels- dont wait until you are hungry o eat a diet high in carbohydrates & protein (fruit, cheese, eggs, beef, poultry, veges, toast, rice) and low in fat o avoid large meals and greasy, highly spicy meals o for nausea in the mornings- keep sweet biscuits by bedside to eat when you first wake and after eating one or two, rest for about 20 mins before getting up o drink plenty of water & fruit juices but avoid alcohol and large quantities of tea, coffee or milk o suck barley sugar, boiled sweets or peppermints when travelling o drink liquids between rather than with meals to avoid bloating which can trigger vomiting o slowly sip a fizzy drink when feeling nauseated, or eat ice chips o ginger or peppermint tea may be helpful o if nausea is worse late in the day, prepare the main meal in the morning (or the night before) o keep rooms well ventilated and odour free o relax, rest and get into the fresh air as much as possible
Breast & Nipple Thrush

- Overgrowth of candida on nipples/breast - significant amount of pain Smx: Nipple: burning, itching, pain, stinging, pink, dry, flaky Breast: shooting, stabbing, deep
If confirmed by dr that nipple thrush: Nipples: miconazole gel or nystatin cream applied after each feed Oral treatment for mother: nystatin 500,000 U/tab 2 tab tds Babys mouth: miconazole gel qid for 7 days then once daily Possible SEs: Mother: gel may irritate the skin Baby: gel may cause babies to gag or vomit consider changing to nystatin drops
aching breast pain. Uni/bi lateral pain
Problems with lactation
Herbal preparations used to increase breast milk production (galactagogues) - caffeine, hops, fenugreek, fennel seek, blessed thistle, alfalfa traditionally reported to increase breast milk BUT little data support their efficacy & safety - be cautious when recommending herbal preps Drug S4 therapy: - Metoclopramine & Domperidone
Mastitis
-inflammation of the breast may be an infective cause Smx: Breast: erythema, pain, odema, swelling, lump General: fever, lethargy, nausea, anxiety, headache
Early management: maintain breastfeeding analgesia: paracetamol In this situation REFER in case of infection
Patient Problem
Treatment
Children (ok in)
Pregnancy
Lactation
Other Pain not relieved within 5 days of OTC treatment should be referred to Dr. Topical analgesics should be kept away from the eyes, mouth and mucous membranes and should not be applied to broken skin. Refer: o suspected fracture o possible adverse drug reaction; falls in elderly, unexplained bruising
PAIN Musculoskeletal pain

RICE Rest; avoid activity promoting
bleeding and blood flow Ice; to reduce swelling and pain, apply every 2 hours for 20mins for the first 48 hours. Not directly on skin but in wet towel, plastic bag etc Compression; reduces pain and swelling as well as providing support for injured part Elevate; reduces bleeding, swelling and pain raise above level of the heart.
Ibuprofen (Nurofen) 200 mg tabs, 5% gel oral: 1 2 tablets three times a day before food, max 6 tablets (1200mg) daily topical: rub 4 10 cm of gel into affected area until absorbed every 4 hours prn, max. 4 applications/day Diclofenac (Voltaren Rapid 25, 50) oral: 100-150 mg/day in 2-3 divided doses. Take with food. topical: rub gel gently into affected area 3-4 times daily. Do not use for longer than 2 weeks
Have asthma? Stomach ulcers? Other meds?
5-10mg/kg q6-8h
Cat C;
avoid use as may cause closure of fetal ductus arteriosus
Avoid use as excreted in breast milk
Children >12 months; 1mg/kg tds
Avoid any HARM Heat; increases bleeding
Alcohol; increases swelling Running; avoid exercising too soon Massage; or use of heat rubs in first
48-72 hours increases swelling and bleeding
Deep Heat (methyl salicylate, menthol) Apply and massage 2-3 times daily; or before, during and after sporting event.
Avoid contact with eyes or mucous membranes. Do not apply to broken skin or sensitive areas
>5
Ok
Ok
o o o o
Paracetamol (Panamax, Panadol) 500mg Avoid NSAIDS within 48 hours of injury as increases bleeding and swelling. Adult/Child >12, Child <12, 1 2 tablets every 4-6 hours prn, max. 8 per day. 15 mg/kg every 46 hours (max 60 - 90 mg/kg daily)
Ok, reduced dose
Ok
Ok
head injury medication failure arthritis severe, persistent back pain back pain (and/or pins and needles/numbness) radiating down legs
Self Care Card: Pain Relievers, Sprains and Strains
Headache
Most common are tension headache, migraine and sinusitis. Tension headache; bilateral feeling of heaviness, pressure or tightness that extends like a band around the head. Can affect upper part of neck also. Migraine; recurrent episodes of throbbing head pain, often unilateral (frontal, occipital or
Paracetamol (Panadol, Panamax, Panadeine-15) 500mg Take 1 - 2 tablets qid prn (max. 4g daily)
Refer <12
Ok
Ok
Ibuprofen (Nurofen, Panafen) 200mg Take 1 - 2 tablets tds (max. 1200mg daily)
Refer <12
No
No
Avoid trigger factors: stress, tension, anxiety caffeine, alcohol, smoking fasting, delaying or missing meals bright or flickering lights strong fumes/smells anything else associated with onset Self care:
Anagraine (metoclopramide 5mg, paracetamol 500mg) Take 1-2 tabs at first sign of migraine; repeat every 4 hrs if needed, max 6 tabs in 24 hrs. ( adult dose for children 12-17yo)
Refer <12
Ok
Ok
keep a headache diary detailing times migraines occur, drugs and dosages used,
hemicranial). Swaps sides btwn attacks. Pain is severe and limits or stops activity and is usually associated with nausea, vomiting and/or photophobia. Relieved by lying in a dark quiet room. May be preceded by aura (usually visual disturbances such as flickering lights, zigzag lines, loss of part or all vision). Initiate treatment at first signs of migraine. Sinusitis; associated with an upper respiratory tract infection Cluster; orbital pain often worse at night and associated with conjunctivitis and nasal congestion on the same side of the head as the headache refer
Mersyndol (paracetamol 450mg, codeine 9.75mg, doxylamine 5mg) Take 1 - 2 tablets every 4-6 hours prn (max. 8 tabs/day)
Refer <12, ok if >12
Ok
Ok, watch for sedation in child
response to treatment and what may have triggered attack practice relaxation exercise exercise regularly eat a well balanced, regular diet drink plenty of water get adequate sleep
Age? Nature? Duration? Other medications/medical problems? Trauma? Previous history/treatment? LINDOCARRF
Refer headache: o children <12 and adults with new sx >50 o assoc. with injury/trauma o severe and last >4hrs o severe occipital headache (across back of head) o worse in morning then improves o associated drowsiness, visual disturbance or vomiting o neck stiffness o frequent migraines o OTC treatment resistant o medication induced (e.g. pill) o starts after exercise, sex, straining or coughing
Self Care Card: Headache, Migraine, Relaxation Techniques, Pain Relievers, Sinus Problems For a mild reaction: o wash the area with soap and cool water o apply ice in a cool, wet cloth to reduce swelling o apply an anti-itch preparation (see below); can use an antihistamine for additive relief from itch Eurax (Crotamiton) cream 1st line Apply gently to affected area 2-3 times a day. Stingose (Aluminium sulfate) solution Apply promptly and liberally to affected area(s) prn. Soov Bite (Cetrimide, lignocaine) Dab onto affected skin up to 4 times a day. -
Insect bites
Often present as an itchy wheal that develops into a firm, itchy papule. Mild reactions can be treated successfully with OTC products whereas moderate-severe (including those with sx of bacterial infection) require referral to doctor.
Ok Ok > 2yrs
Ok Ok Ok
Ok Ok Ok
Paraderm Plus (chlorhexidine 0.1%, lignocaine 1%, bufexamac 5%) - antisepetic, anaesthetic, anti-inflammatory & soothing - apply tds/qid Bruising Determine reason i.e. injury, warfarin (?over-anticoagulated) Need a FULL medical Hx Arnica Ointment - Treatment of bruises, sprains and assoc swelling. Apply freely to affected areas Tennis Elbow Cause: - Over use of the muscles and tendons in the forearm. To Dx: Get them to make a fist - if it hurts in the forearm, then it is tennis elbow! Management/Treatment: Elastic support bandage Relative rest with reduction of aggravating activities Ice area for 10 minutes twice a day NSAIDS for short term relief Hirudoid (cream) & Lasonil (oint) Herparinoid - for bruises, swelling, treatment of scars and various inflammatory conditions of the viens - Dose: thin layer to affected area bd or tds prn - DONT apply to open wounds or use when bleeding occurs or infected -
Cat A
Patient Problem
Treatment
Children (ok in)
Pregnancy
Lactation
Other
MISCELLANEOUS
Nicotine Replacement Therapy
Patches 16-hour patches (Nicorette)

*preferred if sleep disturbance is troublesome
5 mg/16 hours, 10 mg/16 hours, 15 mg/16 hours NRT relieves nicotine withdrawal symptoms (craving, anxiety, agitation, irritability and hunger) allowing the smoker to concentrate on psychological aspects of quitting. 24-hour patches (NicabateCQ, Nicabate CQ Clear, Nicotinell, QuitX)
*best for morning cravings
Counselling: Tell pharmacist if experience any unpleasant side effects as it may mean that dose adjustment is necessary. Store and dispose of products carefully and out of the reach of children as can be fatal. In particular patches still contain nicotine and are dangerous to children and pets. Do not continue smoking whilst using these products as increased amount of nicotine can produce toxic effects, such as feeling sick, vomiting, palpitations and chest pain Non-drug Counselling: contact support services such as Quitline or community based groups for extra support and tips avoid situations which were previously associated with having a cigarette carry a pen or gum for hand-to-mouth movement carry small snacks such as carrot sticks or lollipops regular exercise and may help you quit and also avoid putting on weight smokers who plan before they quit and set a date are more successful when you get the urge remember the 4 Ds; so something else, delay, deep breathe, drink water if you have a cigarette it is not the end of your quit attempt but rather a setback Practice points: Severe addiction or continual NRT failure use patch and 2mg gum together. Strict dosing reduces cravings more than prn doses.
7 mg/24 hours, 14 mg/24 hours, 21 mg/24 hours Moderate-high nicotine dependency: Apply 1 patch daily of either 21 mg/24 hours OR 15 mg/16 hours. Stop within 12 weeks Low-moderate nicotine dependency: Apply 1 patch daily of either 14 mg/24 hours OR 10 mg/16 hours. Stop within 12 weeks
High dependence: waking at night to smoke or smoking within first 5 minutes of waking, usually >30 cigarettes a day Moderate: smoking within 30 minutes of waking, usually 20-30 cigarettes per day Low-moderate: not needing to smoke within the first 30 minutes of waking, usually 10-20 cigarettes Low dependence: no needing to smoke withing the first 30 minutes of waking, usually <10 cigarettes a day
Apply to a different skin site each day, on a non-hairy, clean, dry site on the upper body or outer part of the arm. Recommended progression: Step 1 (21mg/24 hours) for 6 weeks, then Step 2 (14mg/24 hours) for 2 weeks, then Step 3 (7mg/24 hours) for 2 weeks May cause local irritation (can be treated with topical corticosteroid). C/I in patients with eczema. Lozenge (NicabateCQ) 2 mg, 4 mg Moderate-high nicotine dependency, use 4 mg lozenges; low-moderate nicotine dependency, use 2 mg lozenge Weeks 1-6: 1 every 1-2 hours, up to 15 in 24 hours Weeks 7-9: 1 every 2-4 hours Weeks 10-12: 1 every 4-8 hours Weeks 12-24: take when needed to maintain abstinence Dissolve lozenge in your mouth when feel urge to smoke, do not chew or swallow it. It takes half an hour to dissolve; do not eat or drink in this time.
Note: can use sublingual tablets (Nicorette Microtab, 2 mg) in same way
1. Number of cigarettes smoked a day? 2. When they are smoked (how soon after wakening? 3. Previous attempts to quit? 4. Confidence and motivation to quit? 5. Recent MI, cerebrovascular event, arrhythmias?
Gum (Nicorette, Nicotinell, QuitX) 2 mg, 4 mg Hgh nicotine dependency, chew 10 15 pieces daily. Avoid use of >1 piece/hour. After 4-8 weeks reduce to 2 mg, then stop or taper use over a further 4 weeks. Moderate nicotine dependency, chew 8 12 pieces of 2 mg gum daily Chew gum until tingling or peppery/bitter taste and then park it between the cheek and upper gum. When tingling stops, rechew and park; repeat for total of 30 minutes. Avoid swallowing saliva/gum (can cause indigestion) and eating or drinking whilst using gum.
*max. 20 x 2 mg or 10 x 4 mg per day
Continue for 12 weeks (6-8 weeks for most people), including the taper period. May require longer for some. C/I: recent MI, cerebrovascular event, arrhythmias Pregnancy/breastfeeding: Try behavioural therapy first. NRTs are category D or C but often level of nicotine is less than from cigarettes refer for doctor to calculate risk/benefit ratio.
NRT only indicated for people >16 years of age.
C/I in patients with dentures. Note: microtabs Microtabs (Nicorette) 2 mg Place 1 or 2 tablets under the tongue every 12 hours according to craving or withdrawal symptoms, for 8 12 weeks. Then gradually reduce use over next 4 weeks to zero. Maximum dose 40 tablets (80 mg) daily. Place 1 or 2 tablets under the tongue and let them slowly dissolve over about half an hour. Avoid chewing or swallowing the tablet.
Gum and lozenges contain large amounts of Na+ so use with care in patients on sodium reduced diets. Self Care Card: Smoking, Nicotine Replacement Therapy
Orlistat
Lifestyle changes including increased physical activity, eating behavioural modification and fat and calorie restricted diet are first line and must accompany treatment with orlistat. Only indicated in obese patients with BMI >30 or >27 with other risk factors e.g. hypertension, diabetes, hyperlipidaemia. Tried lifestyle changes? BMI? Take any other medications?
warfarin, amiodarone
Xenical Take one (120 mg) capsule with, or within 1 hour, your 3 main meals. Do not take a dose if you miss a meal or if it does not contain any fat. Counselling: this medication may cause fatty stools (flatus, faecal urgency, loose oily stools); more likely to occur when your diet is too high in fat it is important that whilst taking this medication you continue to practice caloric restriction with a diet high in fruit and vegetables, increase physical activity and eating behaviour modification whilst taking this medication, it is recommended that you take multivitamin supplements containing the fat-soluble vitamins A, D, E, K supplement should be taken 2 hours apart from orlistat
Important for patients to have realistic goals. Average weight loss of 10% in one year which is great for cardiovascular health etc. but often not satisfactory for those seeking cosmetic sliming. Not appropriate in pregnancy or breastfeeding. D/I: For patients on warfarin, may increase INR as reduces the absorption of vitamin K monitor INR closely. Decreases plasma concentrations of cyclosporine and amiodarone. C/I: pancreatic enzyme deficiency, major GI surgery, malabsorption syndrome, cholestasis
Increased risk of disease associated with a waist circumference of 102 cm in men and 88 cm in females. Meal replacementhypocaloric preparations
Pancreatic problems? Gallstones? Stomach problems or vitamin deficiency? Recent GI surgery? Kidney stones? Diabetes, high blood pressure or
cholesterol? Pregnant or breastfeeding? Under 18?
(eg Optifast) may cause weight loss in the short term, but weight is usually regained when treatment is stopped.
Self Care Card: Weight & Health Emergency Contraception

Levonorgestrel (Postinor-2) The effectiveness of EC decreases with the time taken since unprotected intercourse: <24 hours = 95% 24-48 hours = 85% 48-72 hours = 58%
note: the overall failure rate when EC is taken within 72 hours is <2%
1. 2.
When did you last have unprotected sexual intercourse? Within previous 72 hours? Already pregnant or previous unprotected intercourse >72 hours earlier in same menstrual cycle?
Should not be taken due to a lack of benefit rather than any risk to the pregnancy (i.e. will not terminate an existing pregnancy). Patient should consider a urine pregnancy test if unsure.
3. 4.
5. 6.
Unexplained vaginal bleeding? Current/history of breast cancer?
Patient Counselling o The first tablet should be taken as soon as possible after unprotected intercourse. Take the second tablet 12 hours later (if safe can delay first dose if necessary for convenience)
o
Refer
Severe liver disease? High blood pressure, diabetes, heart disease or history of stroke/DVT?
Refer
o
Refer
If vomiting occurs within 2 hours of taking a tablet, an additional tablet will need to be taken You need to use a barrier method of contraception until the onset of your next period Your next period should occur around the anticipated date but can occur one week before or after that time consult your doctor if menstruation does not occur within one week after the anticipated date (or 3 weeks after taking EC) or if the period is lighter than normal or intermittent If pregnancy occurs after taking EC, consult your doctor and let them know that you used the EC (increased risk of ectopic pregnancy) Common side effects include nausea and vomiting, breast tenderness, vaginal bleeding and headache
Taking any other medications?

o
Drugs including anticonvulsants (phenytoin, carbamazepine), St Johns wort, rifampicin, griseofulvin may reduce the efficacy of EC. May interact with warfarin to raise INR. Refer
7.
Stomach problems?
Diarrhoea, vomiting or other causes of malabsorption (Crohns disease, IBS etc) may reduce absorption and thus efficacy of EC. Refer
8.
Pregnant or breastfeeding?
ADEC category D and should not be used during an existing or expected pregnancy. Levonorgestrel is excreted in small amounts into breast milk and should be fine in breastfeeding but for those concerned, can avoid breastfeeding child for 3 days (continue to express to keep up the milk supply but discard the milk).
o
C/I: current pregnancy (last period was late or lighter than usual), unexplained vaginal bleeding, current breast cancer, allergy to levonorgestrel
9.
Under 16?
Refer
10. Used emergency contraceptive before?

Need to discuss regular long-term methods of contraception with their doctor.
o
Travel Health
Some simple precautions include:
seek specialist travel health advice before travelling
Deep Vein Thrombosis (DVT) DVT is the formation of clots in the deep veins of the leg which Prevention: may result in life-threatening embolisms. Exercise ankles and calf muscles every half hour. Symptoms (usually post flight): often no symptoms leg pain, swelling and redness a mild ache or tenderness in one or both legs, particularly in the calves Keep legs straight, do not sit cross-legged. Drink plenty of water or juice but AVOID alcohol and caffeinecontaining drinks.
Visit the
www.smartraveller.gov.au
website for travel information.
Take a spare pair of glasses. If you are planning to carry medications overseas contact the embassy of the country(s) you will be visiting to ensure your medicines are legal there. Carry a letter from your doctor listing the medicines, how much you will be carrying and that they are for your personal use. Leave in original packaging. Consider purchasing health and travel insurance. Always carry a first-aid kit. Wear a Medic Alert bracelet or necklace if you have a serious medical condition or allergy. Whether or not you are male or female take condoms with you rather than relying on those bought locally. Always follow
Consider using pressure stockings. Risk factors: sitting or lying still for long periods of time without moving legs (e.g. flying) taking hormone therapy (OC, HRT) personal/family history of DVT or blood clotting disorder smoking pregnancy obesity >40 y.o Jet Lag An upset of a persons biological clock caused by travelling Prevention: across several time zones in a short period of time and is If possible break the trip up by including stopovers. dependent on how many time zones crossed and which Try and plan for arrival at destination around bedtime direction travelled, east or west(better). Set your watch to the local time of the destination and eat/sleep according to this destination time during the flight. Symptoms include: Eat light, healthy meals and drink plenty of water. Limit alcohol being alert, sleepy and hungry at the wrong times and caffeine-containing beverages. anxiety, feeling disorientated Wear loose, comfortable clothing during the flight and try to forgetfulness, poor concentration sleep during longer legs of the flight a mild sleeping tablet headache may help. weakness, irritability, tiredness, disturbed sleep Travellers Diarrhoea (TD)
safe sex practices. Remember that the pill does not protect against STDs and that medicines used to treat travellers diarrhoea and prevent malaria can reduce effectiveness of OC. Avoid contact with animals. Choose safe modes of transport Wear shoes and sandals. Avoid getting tattoos or body piercing. Avoid illicit drugs.
Illness caused by consuming contaminated food/water. Commonly causes stomach cramps, pain or bloating, frequent runny diarrhoea, nausea and vomiting, fever, bloodied stools.
Prevention: Drink small amounts of fluid often. Drink only boiled, canned or bottled drinks do not add ice. Avoid shellfish and cold cooked meats. Dont eat fresh salads, raw vegetables or cut fruit if you cant peel it, cook it or boil it, dont eat it! Avoid eating anything washed in local water. Avoid unpasteurised dairy products Wash your hands before meals and dry them with your own towel or allow to air dry. Can use a chlorhexidine gel. Use bottled water to brush teeth and avoid swallowing water whilst showering or bathing. Treatment: Symptomatic treatment as appropriate. May include use of a rehydration agent (Gastrolyte), antidiarrhoeal drug (loperamide), antiemetic (metoclpramide) or antispasmodic (hyoscine). If symptoms severe or last longer than 48 hours, seek medical advice.
Malaria Prevention: Avoid exposure to mosquitoes from dusk to dawn use mosquito nets treated with insecticide (e.g. Symptoms often occur several weeks after returning permethrin), air-conditioning, mosquito coils etc from/leaving affected areas and typically include; wear light-coloured clothing covering arms, legs and ankles fever, malaise, chills, headache nausea when outdoors and especially after sunset use a DEET insect repellent at regular intervals Patient presenting with febrile illness within 12 months of travel in endemic areas should be referred for immediate medical attention. Prophylaxis: Doxycycline 100mg daily; taking 2 days before entering, and continue for 24 weeks after leaving, an endemic area. Maximum recommended course 6 months. Malaria is a serious disease caused by a parasite that infects red blood cells. Ensure you have enough medication to last full trip
Self Care Card: Travel Health, First Aid, Vomiting and Diarrhoea, Sense in the Sun, HIV/AIDS
Sleep
Important to differentiate between different types of sleep problems; difficulty falling asleep, waking during the night, early morning waking, poor sleep quality, snoring Duration? Previous history? Treatment? Contributing factors? Recent stress? Taking any other medications?
Advice on sleep hygiene

Encourage address underlying causes regular bedtime and waking time regular daytime exercise creating a comfortable temperature and quiet environment for sleep taking a hot bath before bedtime having a warm milk drink before bedtime get up if you cant sleep and sit in another room until feel more sleepy Avoid avoid large meals, excessive alcohol, smoking and drinking caffeine-containing beverages close to bedtime daytime napping strenuous exercise close to bedtime use bedroom for sleeping and sexual activity only pets and clocks in the bedroom
Sedating antihistamine should not be used to aid sleep for longer than 7-10 days. Commonly cause anticholinergic sideeffects (dry mouth, constipation, blurred vision, tinnitus).
note: sedating antihistamines can cause paradoxical excitement, restlessness or nervousness especially in children or elderly
> 12 Diphenhydramine (Unisom Sleepgels) 50mg 1 capsule at bedtime Questions when supplying sedation antihistamines: Recommended by a doctor? Used them before? Taking any other medications? Glaucoma, prostate or thyroid problems? Peptic ulcers or epilepsy? Liver disease? Pregnant or breastfeeding? Child or elderly? >2 Promethazine (Phenergan) 10mg, 25mg, 5mg/5mL adults 25-75 mg at night children 6-12 yrs: 10-25 mg at night; 2-5 yrs: 5-15 mg at night. > 12 Doxylamine (Restavit) 25 mg One or two tablets twenty minutes before bed. Restavit should not be used for more than ten days consecutively. Avoid Valerian (Blackmores Valerian Forte) 1 tablet before bedtime Nasal plasters for snoring
Ok
Ok
No
No
Cat A; but avoid use
No
Refer: o suspected depression o chronic problem (longer than 3 weeks duration) o children <16 o irrational insomnia
Avoid: no trials -
Avoid Self Care Card: Sleeping Problems
ORAL ANTIHISTAMINES
Contraindications: in children < 2 because of link with SIDs (sedating antihistamines) Adverse effects: sedating sedation, dizziness, blurred vision, n/v, constipation, dry mouth, incoordination i.e. Anti-SLUD non-sedating drowsiness, fatigue, dry mouth, headache, nausea
Less-sedating
Used only for allergic disorders (allergic rhinitis and conjunctivitis, chronic urticaria). They penetrate the bloodbrain barrier poorly and so have a reduced incidence of sedation; anticholinergic adverse effects are reduced due to poor affinity for muscarinic receptors. They have similar efficacy to the sedating antihistamines but are often better tolerated. Most are long acting and can be taken once daily.
Safe to use
Zyrtec (cetirizine) most likely of less-sedating antihistamines to cause sedation.
Loratadine (Claratyne) 10mg tabs, 1mg/mL Take one tablet daily. Child 2-12yo, 5mg d 1-2yo, 2.5mg d Fexofenadine (Telfast) 30 (child), 60, 120 (rhinitis), 180 (urticaria) mg Take one tablet daily. Child 6-11, 30mg bd
B1, prefer sedating anti-Hs
Sedating Antihistamines
Used in allergic disorders, motion sickness, vertigo, itch associated with skin disorders, nausea, and for sedation including premedication. They commonly have anticholinergic and CNS adverse effects (drowsiness). Many are short acting but some, eg promethazine, act for up to 12 hours. Dexchlorpheniramine (Polaramine) allergy only 2mg tablets 2 mg qid 6mg CR tablets 6 mg bd, swallow whole 0.4mg/mL syrup 0.04mg/kg/dose tds Promethazine (Phenergan) sedation, allergy and nausea 10, 25mg tablets 25 75mg daily OR 10 25mg 2-3 times daily 1mg/mL elixir >2 yrs: 0.125mg/kg tds
>2
Cat A 6 - 12; 1mg qid 2-6 >2 Cat C
Short term
This medication may make you sleepy; don't drive or operate machinery if this happens. Avoid alcohol and other medication which may cause sedation.
Short term

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Lloydy and Rachelles

5-Minute OTC Consult for Trainee Pharmacists

Cheers, Lloydy lloydy_m@hotmail.com

DERMATOLOGY Head Lice Scabies Eczema/Dermatitis Psoriasis Nail infection Acne

Fungal skin infections (Athletes foot, tinea, jock itch)

Chickenpox Warts Corns/calluses Dandruff Sunscreen/Sunburn

Hydrocortisone Topical Cream 15 Shingles 15

German Measles (Rubella) Measles 16

Michael Lloyd and Rachelle Downie 2007

Michael Lloyd and Rachelle Downie 2007

Children (ok in)

preferred when < 2

Michael Lloyd and Rachelle Downie 2007

Michael Lloyd and Rachelle Downie 2007

Refer cases of suspected but undiagnosed psoriasis.

Ddx: eczema, seborrhoeic dermatitis, and tinea. Atopic

salicylic acid 2-4% can be included in coal tar preparation

Michael Lloyd and Rachelle Downie 2007

Fungal skin infections (Athletes foot, tinea, jock itch)

Self Care Card: Tinea

Amorolfine (Loceryl) nail lacquer

Michael Lloyd and Rachelle Downie 2007

Michael Lloyd and Rachelle Downie 2007

Self Care Card: Acne

Michael Lloyd and Rachelle Downie 2007

Pasafilin paint (podophyllum resin, salicylic acid) As above.

DDx: Corns/calluses (See below)

4. Location? Refer facial or

Michael Lloyd and Rachelle Downie 2007

Ok; avoid 1st trimester

Michael Lloyd and Rachelle Downie 2007

Self Care Card: Sense in the Sun

Hydrocortisone Topical Cream

>2 unless under supervision of pharmacist /doctor

Should not be applied to broken skin.

Michael Lloyd and Rachelle Downie 2007

Reactivation of varicellazoster Post-herpatic neuralgia severe in adults If child affected refer!

German Measles (Rubella)

Michael Lloyd and Rachelle Downie 2007

Treatment: - rest & fluids - fever: paracetamol

Children (ok in)

B3; can use but preferably avoid B1 ; No

Michael Lloyd and Rachelle Downie 2007

*HSV infectious from tingle stage until blisters have healed

Self Care Card: Cold Sores

Dry Mouth (Xerostomia)

Aphthous (mouth) ulcers

Apply after food. Normally resolve within 714 days

Michael Lloyd and Rachelle Downie 2007

Michael Lloyd and Rachelle Downie 2007

Michael Lloyd and Rachelle Downie 2007

Children (ok in)

Refer children <12

Self Care Card: Haemorrhoids

Michael Lloyd and Rachelle Downie 2007

renal impairment etc

H2 antagonists Ranitidine (Zantac) 150 mg bd or 300 mg d

B1: safe to use

Self Care Card: Heartburn and Indigestion

Diarrhoea and vomiting

Ok but when in doubt refer in case something else wrong

Avoid dairy products for duration of the diarrhoea, particularly in children