Keypoint Summaries for 320 0T6

Pediculosis Key Point Summary

Common Communication Issues
There is often a social stigma associated with this condition, reassure patients that this
is a common condition that can happen to anyone.
Recognize that there may be a need for privacy as the patient may feel embarrassed;
offer counseling in a private area.
Be empathetic and address patients according to where they are in their knowledge
(i.e. age of patient, if it is a child or parent).
Be aware that some ethnicities do now allow for sexual discussions (may be
important in stressing treatment in contacts for body and pubic lice).
Prompts in History Taking
Has the patient had previous episodes of lice?
Is the patient allergic to ragweed or chrysanthemum?
Does the patient have a history of seizures or epilepsy?
Is the patient pregnant?
If the patient has pubic or body lice it may be necessary to ask if recent sexual
contacts are experiencing similar signs and symptoms.
Assessment
Location

Head Lice
Scalp back & sides

Signs &
Symptoms

Papules
secondary infection
crusts &
excoriations

Transmission

Hair to hair contact

Fomites

Body Lice
Trunk (waist &
axillae)
Papules
secondary infection
crusts &
excoriations
Nocturnal pruritus
Infected clothes,
bedding,
Poor hygiene

Pubic Lice
Pubic area
Papules
Blue-gray pigments
secondary infection
crusts & excoriations
Eyelashes, beards &
eyebrows may also be
infected
Sexual contact

Non-Pharmacologic Treatment
infected fomites: dry clean or wash in hot (60 C) water then dry in hot cycle
store unwashable items in plastic bags for 10 days
soak combs/brushes in hot water for 5-10 min or wash in pediculicide shampoo
After treatment with pediculicide shampoo remove nits using fine tooth nit comb

Pharmacologic Therapy

Treat all contacts

Re-treat in one week

Pharmacological treatment of body lice is unnecessary. Hygiene measures such as

bathing, laundering of infested clothes and linens in water at 60 C or storage in a bag
for 10 days are sufficient methods of treatment.

An oral antihistamine may be recommended for immediate relief of itch caused

by body lice.

If eyelashes are infected with pubic lice, lice can either be manually removed with
tweezers followed by application of white petrolatum 4 times daily for 3 days to
suffocate remaining nits and lice.
OTC: Permethrin
1%

Brand Name - Nix Cream

Rinse
-Kwellada-P Cream
Rinse

Contraindications
and
Cautions

-caution in ragweed,
chrysanthemum
allergies
-caution in children
< 2 months old

Convenience

- drug of choice
because low toxicity
and high ovicidal
activity
-apply to towel
dried hair
-leave on for 10
minutes

Instructions
for Use

OTC: Pyrethrins
with piperonyl
butoxide

OTC: Lindane

OTC: White
vinegar
Formic acid

Rx: Ivermectin

- Pronto Lice
Control System
-R & C II Shampoo/
Conditioner
-RID
-caution in ragweed,
chrysanthemum
allergies
-caution in
petrolatum allergies

-PMS Lindane
- Hexit
Shampoo

-Step 2

Stromectol

-contraindicated in
seizure disorders
-caution in
pregnancy,
nursing, elderly,
children < 2
years, inflamed
skin
-not first line
treatment

- apply before
lice treatment

- safety not
proven in
children, nursing
or pregnant
women2

- can be made
at home

-available by
special access
program

-apply for 4
minutes to dry
hair

- soak hair
-wrap hair in
towel for 30 to
60 minutes

- 200g/kg PO

-apply to dry hair

Notes: Permethrin demonstrates the best ovicidal activity amongst all available
treatments with 70-80 % efficacy. Efficacy increases to 96-100% with re-treatment.
Therefore it is imperative to stress to the patient the importance of re-treatment in 7 to 10
days.
References
1. Patient Self Care
2. American Academy of Family Physicians. Ivermectin Use. http://www.aafp.org

KEY POINT SUMMARY: SCABIES

Pathophysiology
Scabies is infestation of the skin with the human mite Sarcoptes sacbiei var
hominis
o impregnated female burrows into the stratum corneum and lays 2-3 eggs
daily
o eggs hatch into larvae 3-4 days later
o larvae move to skin surface and mature into adult mites within 14-17 days
o mites separated from the host die in 2-4 days
Transmission
close personal or sexual contact
fomites transmission is rare
no transmission of scabies from pets
Risk Factors
female > male
children < 2 years old
institutions, armies, prisons
Communication Challenges
shyness or embarrassment
History Taking Issues & Relevant Questions
medical history
o pregnancy? (consider precipitated sulphur)
o seizures? (caution with lindane)
allergies
o ragweed or chrysanthemum allergy? (caution with permethrin)
medication history
o topical steroids? (consider Scabies incognito)
Signs and Symptoms
intense pruritis that worsens at night due to sensitization to mites, eggs, or feces
burrows (silvery lines) on finger/toe webs, wrists, genitalia, axillae, buttocks and
nipples
head and neck involvement found in children, elderly, bedridden and Norweigian
scabies
erythematous papules on the trunk due to immune response to the mites

o features? face and scalp are spared in adult, but not in infants and young
children
excoriations due to scratching
residual itch
o itching will continue for 4-6 weeks after treatment due to hypersensitivity
reaction
o do NOT retreat patient for residual itch

Differential Diagnosis
scabies
atopic dermatitis
contact dermatitis
impetigo
pediculosis pubis
lichen simplex chronicus
lichen planus
Crusted or Norwegian Scabies
atypical, hyperkeratotic and more contagious form of scabies
infestation on the order of millions compares to 20 mites in classic scabies
people at risk?
o immunocompromised
o institutionalized
o pregnant women
signs and symptoms?
o scaling of hands and feet or generalized scaling
o minimal pruritis
o burrows and erythematous papules are less common
Scabies Incognito
topical steroids can cause atypical presentation due to anti-inflammatory effects
o result? scabies mite remains localized and does not migrate
Non-Pharmacologic Therapy
clothes / linens should be cleaned with soap and hot water or stored in bags for 57 days
vacuum all surfaces (rugs, furniture)
avoid body contact with others
Pharmacologic Therapy
treat infested individuals and all close physical contacts with topical scabicide
o scabicide is applied to entire body including face and scalp
o scabicide must be washed off after 12 hours
o retreat in 7-14 days to prevent ping-pong effect

permethrin 5%
o drug of choice in treatment of adults and children >2 months old
o efficacy? 96-100%
o low systemic absorption
o caution individuals with ragweed chrysanthemum allergy
precipitated sulfur 6% in petrolatum
o drug of choice in pregnancy, lactation, and children <2 months old
o efficacy? 82%
o dosing? apply BID x 10 days
o disadvantage? unpleasant odour and local irritation
lindane 1%
o efficacy? 67-92%
o risk of convulsions when used in children or patients with skin disease

Common DRPs
ping pong effect
failure to retreat
unnecessary treatment of residual itch
failure to treat contacts
failure to clean fomites
improper applicatioin of drug
use of wrong drug
scabies incognito due to steroid use

ACNE Key Point Summary- Group 3A

Communication Challenges
Patient may be embarrassed or sensitive about their condition. Go to a private area if
possible.
Patient may perceive the condition to be untreatable and thus may not be eager to take your
advice. Be patient and reassuring and use empathy.
History
Family History
Do any family members have a history of acne?
Is there a history of other dermatologic conditions such as rosacea, atopic dermatitis?
These conditions can be masked by acne
Medical Conditions (Determine the kind of acne)
Does the patient have any underlying skin conditions?
Where are the acne lesions located? Common areas include face, neck, chest, upper arms,
back
What type of lesions? Inflammatory ( papules, nodules, pustules) vs. Non-inflammatory
(open/closed comedones)

Is the skin type oily, dry, normal, or combination? This will affect the choice of vehicle
for the drug, i.e. gel for oily skin
Quantity (# of lesions), severity (scaring or pigmentation), duration of acne?
Allergies
To topical acne preparations? (benzoyl peroxide, salicylic acid)
To cinnamon or Peruvian balsam (sensitizers)? These may cross-react w/ benzoyl
peroxide.
Other drug allergies?
Medication History
Previous or current use of medications to treat acne? Rx or OTC, topical or systemic
Currently taking other medications? Some may cause drug-induced acne (i.e.
anticonvulsants, hormones, oral contraceptives, tuberculostatics)
Other Factors
Cosmetics use (moisturizers) water-based?
Any aggravating factors, such as stress, humidity, seasonal variations, pre-menstrual flare
up, occupational hazards, irritants, mechanical friction?
Common DRPs
Patient is experiencing signs and symptoms of acne and requires drug therapy (Rx or OTC)
Patient is taking a drug that may be causing symptoms of acne drug-induced acne.
Patient is taking the wrong/ineffective drug and requires alternate therapy (i.e. higher or
lower dose)
Patient may experience secondary infections from picking and scratching acne
Patient may be using the medication incorrectly e.g. improper application of topical
Patient may experience an ADR with treatment (i.e. sensitivity to benzoyl peroxide, oral
antibiotic)
Patient is experiencing recurrence of acne (noncompliance due to stopping treatment too
early)
Nonpharmacological Options:
Use oil-free cosmetics (use infrequently if possible), oil-free sunscreens (after cleansing and
before acne meds) and oil-free moisturizers
Wash face no more than twice daily with a mild soap or a non-abrasive soapless cleanser (i.e.
Cetaphil) and pat dry. Do not rub, pick or scrub skin.
Minimize environmental irritants such as coal tar, mineral oil, petroleum oil, humidity, heat
Use relaxation techniques since stress can exacerbate acne
Avoid manipulation of acne-like lesions
Shampoo hair regularly and keep from falling into the face. Reduce use of hairspray and gel.
Keep nails short and clean
Treat acne as soon as it appears to avoid complications such as scaring
Men: shave in the direction of hair growth (try electric and manual razor for best comfort)
Eliminate mechanical friction: headbands, violins, chinstraps, orthopaedic braces etc
Eat a healthy balanced diet (although foods are usually not aggravating factors)
Pharmacological Options:
Active
Brand Examples
ingredient
Benzoyl
Solugel, Neutrogena on-

Strength
available
2.5 5%

Dosage Forms
available
Lotions, gels,

Drug Action

Dosing

Exfoliant, antisebum,

Daily or

Peroxide

the-spot vanishing formula,

pastes, washes,
antibacterial,
Panoxyl Pain 5, Benzagel 5
creams
antiinflammatory
Salicylic
Oxy Daily Face Wash, Oxy 0.5 - 2% Gels, pads,
Keratolytic and
Acid
Medicated Pads,
lotions, creams,
exfoliant
Neutrogena Skinclearing
toners, washes,
Moisturizer, Clearasil Deep
astringents,
cleansing astringent
cleansers, sticks
Sulfur
Acnomel, Clearasil acne
2 - 10%
Cream, soap,
Exfoliant
treatment cream
lotion
Symptoms will usually get worse (reddening and irritation) during early stages of therapy,
allow 6-8 weeks for improvement

BID
Daily or
BID

Daily or
BID

Benzoyl Peroxide is usually the treatment of choice!!

For inflammatory and non-inflammatory lesions
Bactericidal effects, anti-sebum effects, anti-inflammatory effects, AND a weak peeling
agent
Solugel4 OTC- hydrophase base, well absorbed and does not leave a film
Start with once daily application: Wash face and pat dry with towel. Apply to the
affected area (not just lesions) for 15 mins and wash it off. This will allow the skin to get
used to the med and reduce potential drying and irritation. For each subsequent night,
double the time you leave the med on, until it is left on for about 4h. Thereafter, it can be
left on over night. Twice daily application may be started after 1-2 weeks of usage (apply
once in the morning and once at night).
Avoid eyes and mucus membranes
May stain/ bleach clothing, fabrics, hair etc and has a slight odour
Different strengths available up to 5% is OTC and above 5% is prescription
May cross-react with other sensitizers (e.g. Peruvian balsam and cinnamon)
Antibacterials
Antibacterials
Antisebum
Antiinflammatory
(topicals)
(systemic)
Isotretinoin
Isotretinoin
Minocycline
Benzoyl peroxide
Antibiotics
High estrogen, low
Tetracycline
Benzoyl peroxide
Erythromycin
androgen BCP

Erythromycin
Nicotinamide
Spironolactone,
Clindamycin
cyproterone
acetate
Combinations:
Benzoyl peroxide
1) Benzoyl per. + clindamycin
2) Benzoyl per. + erythromycin
3) Retinoic acid + erythromycin
4) Neomycin +
methylprednisolone avoid
Side effect issues: dryness, redness, gastric upset, diarrhea, photosensitivity, staining
Interaction issues: DRUG-FOOD (calcium-tetracycline, fat-isotretinoin), DRUG-DRUG
(antibiotics-OCPs, retinoic acid/benzoyl peroxide)
Counseling
Acne is a disorder of the pilosebaceous unit with sebum production, +/- P.acnes, and
obstruction of the follicles
Acne is most common between the ages 12-25
Self-limiting, treatable, more severe in men but more persistent in women

4 stages: HyperkeratinizationSebum ProductionMicrobial

ProliferationInflammation
Patient may be concerned about the length of time for their appearance to return to
normal and if scarring will be present. Offer follow-up to ensure that the treatment is
working for the patient.
Hydroquinone or alpha hydroxy acid can be used to reverse pigmentation
Patients may want to hide their acne during treatment. Educate patients in order to
prevent potential exacerbation of their condition through such measures.

Key Point Summary for Psoriasis

Communication Issues:
-the patient may be embarrassed or have low self esteem due to their condition
-the patient may be desperate for treatment
-the patient may be discouraged or frustrated due to the unrelenting relapses that occur
and they may believe that any further treatment will prove useless
Patient History Issues and Relevant Questions with Specific Prompts:
-pts family history.since approx. 30 % of pt have a positive family history and there is
a 70 % chance of pt having psoriasis if both patients are positive
-past / present medications i.e.) Rx, non-Rx, herbals?....some drugs can either initiate a
psoriatic occurrence (-blockers) while other medications can aggravate an existing
condition (antimalarials, NSAIDS, lithium, alcohol, etc)
-allergies
-medical conditions i.e.) does pt suffer from psoriatic arthritis
-what are the onset / frequency / duration of condition
-where are the lesions located
-describe signs and symptoms
-is patient pregnant.since this will limit our therapy choices
-age of patient....since incidence peaks occur between ages 16-22 (Type 1) and
57-60 (Type 2)
Common / Relevant Drug Related Problems:
-pt may be in need of treatment
-patient may be using inappropriate treatment that have no added benefits for the pts
condition or they may be using a product that is aggravating their condition
-patient may not be using a recommended product properly
Therapeutic Plan Options:
Non-Pharmacological Options:

-avoid triggers i.e.) stress, obesity, alcohol, infections (Streptococcal, viral, etc), trauma,
sunlight (usually beneficial, but unfortunately 10 % of pts experience a worsening of
their condition when exposed to sunlight)
-do not remove scales..may result in bleeding (Auspitzs sign)
-avoid harsh soaps
-avoid rough, tight-fitting clothes such as fabrics made of nylon or wool
-take tepid baths instead of showers
-use a cool air humidifier
-use an emollient to keep skin hydrated and to increase absorption of other products
Pharmacological Options:
-since psoriasis results from an immune-mediated acceleration of epidermal
proliferation, resulting in palpable, erythematous eruptions with a silvery, loose scale, the
following options would be optimal:
immuno-modulating agent > anti-mitotic agent > anti-inflammatory agent > emollient
Initially, the patient should try topical agents, such as topical corticosteroids, steroid
sparring agents, calcipotriol, tarazotene, anthralin, coal tar, etc (see chart). If these
prove ineffective, the patient could try light therapy (UVB or PUVA). If the condition still
does not resolve, the patient could try systemic therapy such as sulfasalazine,
methotrexate, acitretin, or cyclosporine.
Topical OTC Products Commonly Used For Psoriasis:
Drug Name
Coal Tar

Mechanism of Action
-anti-mitotic
-anti-pruritic
-use once daily at night

Anthralin

-anti-mitotic
-use for 8-12 hrs
overnight

Salicylic Acid

-keratolytic (softens
scales and helps
increase penetration of
other products)
-use 1-2 times / day
(cream)

Dosage Form and

Strengths
-0.5 % - 10 %
-available as cream,
gel, and shampoo
-available as crude coal
tar or tar distillate (LCD)

-1%, 2% in stiff paste

-0.1, 0.2, 0.4 % in
cream formulation

-3 % 5 %
-available as a cream
or ointment

Side Effects

Contraindications

-irritating
-messy, stains clothes
-smells bad
-photosensitizer (may be
beneficial in combo with
UVB- Goeckerman
Routine)
-may cause acne,
folliculitis
-burning, stinging
-stains skin / clothes
purple (therefore, should
be compounded with
salicylic acid to prevent
this reaction)
-photosensitizer (may be
beneficial in combo with
UVB-Ingrams Routine)
-redness
-peeling
-drying

-do not use on face, in

flexural areas or on groin
due to irritation
-do not use on open,
inflamed wounds

-do not use on face, in

flexural areas or on groin
due to irritation
(pt can apply petrolatum
ointment around the
lesion to prevent
perilesional irritation)

Hydrocortisone

-anti-inflammatory
-apply 2 -3 times/day

Petrolatum

-emollient
-very weak anti-mitotic
activity

- 0.5 %
-available as cream,
ointment, lotion

-irritation
-skin thinning

-ointment

-may increase absorption

of other products due to
occlusive effect
-greasy

-only use on the face and

in flexural areas
-do not use for longer
than 2 weeks to prevent
tachyphylaxis

RX Therapy Product Review

Drug

Mechanism Of Action

Dosage Form and

Strength
-cream
-ointment
-lotions
-oral (severe cases or
unresponsive to
topicals)
require more potent
steroids for extremities
and trunk
-bid for 6-8 weeks
-cream
-ointment
-scalp solution

Corticosteroids

-anti-inflammitory
-antipruritic
-immunomodulatory
anti-proliferatie

Calcipotriol

-anti-proliferative
-immunomodulatory
-vitamin D3 analogue

Tazarotene

-anti-proliferative
-receptor selective
retinoid
-modifies inflammatory
infiltrate

-0.05 -0.1%
-applied nightly only to
lesions for 8 weeks
-cream
-gel

Acitretin

-oral retinoid
-inhibits leukocyte
migration

-for pustular or
erythrodermic psoriasis
-oral
-10 or 25 mg capsules
-treat until resolution
occurs

Side Effects

Contraindications

-irritation, burning, itching,

redness, dryness, hypopigmentation
-tachyphylaxis

-not for pustular or mild

psoriasis
-salicyclic acid and LCD
decrease potency
-not for use longer than 2
weeks

-burning, dryness,
swelling, redness,
peeling, pruritis
-hypercalcemia,
hypercalciuria
-potential to worsen
psoriasis
-irritation, pruritis,
burning, peeling
-plaques turn red before
clearing
-photosensitizing
-teratogenic
-teratogenic
-skin peeling, scaling,
pruritis, rash, dry mouth,
rhinitis

-safe for pregnancy

-monitor calcium urine
and serum levels
-not for face or folds

-pregnancy
-not on thin skin
-not in seborrhea and
sensitivity to retinoids
-avoid sunlight
-pregnancy
-no alcohol
(reesterification back to
etrtinate life time risk of
teratogenicity)
-use contraception
-monitor lipid and
triglycerides monthly for
3-6 months then every 36 months

Counseling:
-treatment is only 50 % effective and it takes approx 12 weeks to see any improvements
(first, scales improve then thickness of lesions decreases then redness resolves)
-to avoid relapse, pt must be persistent with treatment
-use low-potency products for face and flexural folds
-use steroid-sparring agents intermittently to avoid tachyphylaxis

Keypoint Summary: Pinworm

Communication/Emotional Aspects

Embarrassment - Patients or caregivers may feel embarrassed because of the social connotations of being infected
by worms. Ensure patients that this is a common infection, especially in school year children.

Age-related communication In addition to educating caregivers, pharmacists should also try to communicate
with the young patients since the implantation of nonpharmacological measures require the awareness and
cooperation of patients themselves.
Privacy/Counselling Respect patients privacy and offer to counsel in a private counselling room.

Pathophysiology
- infection of the large intestine by
Enterobius vermicularis
- humans are the only natural host
and human GI tract is where a
pinworms entire life cycle occurs.
- life cycle: larvae mature in the large
intestine (1-2 mo) mature female
pinworm migrates to the anus at
night to deposit eggs on the perianal
skin eggs transferred to night
clothes and bedding

Mode of Transmission
hands and under fingernails through
scratching anal areas or handling
contaminated clothing , bedding or
other environmental objects

ingestion of eggs by the host or by

another person

Risk Groups
- children 5-10 years of age
(uncommon in < 2 yrs)
- overcrowded living
- lack of person hygiene
- homosexual man
- institutionalized patients
- travelers to areas of high incidence

Signs and Symptoms

Many people are asymptomatic

Most common: nocturnal perianal or paerineal itching

Insomnia (caused by itching)

Migration to female genital area: vulvovaginitis, vaginal discharge

Heavy infestation: anorexia, irritability, abdominal pain

Due to Scratching: skin irritation, eczematous dermatitis, bleeding or 2 0 bacterial infection

Diagnosis

Visual
identification of
either the ova or
the worm

Inspection of the anal

area at night
Scotch-tape test

Confirmation of
diagnosis by
physicians

Initiation of non-PCL
measures and
pharmacological Tx

Nonpharmacological Measures

Maintenance of personal hygiene

o handwashing & fingernail cleaning before meals and after using the bathroom or scratching the perianal
area
o regular cleaning and changing of linen/ pyjamas/ underwear/ towel/ toilet seat

Change night clothes and bed linen at the beginning of each treatment course

During the week following treatment, all family members wear cotton underpants that have been washed in hot,
soapy water and change BID.

Discourage nail-biting/finger sucking

PCL Options
Pyrantel Pamoate
(Combantrin)
OTC

Dosage
11mg/kg (base) as a
single dose, up to a
maximum of 1g base
per day.

Adverse Effects
N/V/D, abdominal
cramps, loss of
appetite, H/A,
dizziness, drowsiness

Pyrvinium pamoate
(Vanquin)
OTC

5mg/kg (base) as a
single dose, up to a
maximum of 350mg
base per day.

N/V/D, abdominal
cramps, dizziness
and photosensitivity

100 mg as a single
dose

Minimal side effects

Mebendazole
(Vermox)
Requires Rx

Comments
- should be avoided
if pregnant or if liver
disease is present
- liquid form should
be shaken well
Will stain feces,
vomit, possibly
clothes and teeth (if
tablet not swallowed
whole) red
Not for use in
pregnancy

Notes to Treatment
- All members should
be retreated in 14
days.
- All household
members, whether
symptomatic or
asymptomatic should
be treated
simultaneously to
prevent re-infection.
- PCL Tx for
asymptomatic
pregnant women
should wait until
after delivery.

Common DRPs Related to Pinworm Infection

Failure to retreat in 2 weeks

Failure to treat infected family members or contacts

Failure to carry out concomitant nonpharmacological hygiene measures

Improper use of right drugs

Emergence of skin excoriations secondary to scratching

Use of wrong drug

Case 6 Eye Irritation and Conditions of the Eye

COMMUNICATION ISSUES:
-Embarrassed due to the redness and irritation seen in the eyes (noticeable to the public)
-Anxious/Nervous about the concern that they may be going blind due to blurred vision. This
should be an important issue addressed by the pharmacist when counseling this patient.
-Calm patient and reassure that the condition is common and treatable
RELEVANT PATIENT HISTORY:
- When did the signs and symptoms of the irritation begin? (Symptoms? discharge, itchy, dry,
redness)
-Does the patient have any allergies? (airborne allergens, drugs/herbals of any kind ie
benzalkonium chloride)
-Does the patient have any medical conditions? (glaucoma, psoriasis, seborrhea, rosacea, acne
vulgaris)
-Does the patient wear contact lenses?
-How is the eye affected? (where? eyelid, one eye, both eyes)
-Does anybody they know have a similar condition?
-Has the patient recently shared a face towel or eye product with another person?
-Is the patient taking any medication, herbals or other products? (Accutane)
-Has the patient treated the condition on their own and what have they used ? (drops, creams,
others)
COMMON DRP'S:
-The patient is taking a medication that can cause the signs and symptoms of eye irritation
-The patient is not using the right drug at the right dose by the right method to treat the eye
condition
-The patient may be experiencing an allergic reaction to an ingredient in the medication used to
treat the eye
DIFFERENTIAL DIAGNOSIS OF EYE IRRITATIONS:
Viral Conjunctivitis or (pink eye): red eyes, clear watery discharge, foreign body sensation,
only one eye, systemic symptoms may be present. Risk Factors: upper respiratory tract
infections especially children.
Bacterial Conjunctivitis: caused by S.aureus, S.pneumonia, red/pink eyes, eyelids stick
together especially mornings, discharge is purulent or watery, foreign body sensation, both eyes,
itch and pain Risk Factors: contact lens, schools or institutions infected with conjunctivitis, poor
hygiene, touching eyes, cosmetics.
Allergic Conjunctivitis (seasonal or perennial): red, itchy, teary, watery eyes, effects both
eyes Risk Factors: airborne allergens, genetics, contact lens wearing (traps allergens beneath
lens)
Irritative /Chemical Conjunctivitis: burning, stinging sensation, tearing, mild to severe
redness, foreign body sensation, prolonged exposure to the irritant can lead to permanent damage

Risk Factors: occupational acids or bases, smoke, chlorine, preservatives, personal hygiene
items
Blepharitis: chronic lid margin inflammation due to Staph infection or seborrhea, swollen
crusty eyelids, red eyelids, burning and itching, loss of eyelashes, photophobia, vision is
unchanged Risk Factors: seborrhea on face or scalp, rosacea, cosmetics, rubbing the eye
Hordeolum (STYE): acute infection of the eyelid glands due to occlusion, external
hordeolum caused by hair follicle. Internal Hordeolum caused by the meibomian glands.
Swelling, tenderness, sensitivity to light, tearing pustules Risk Factors: acne vulgaris or
blepharitis
Chalazion: chronic inflammation of meibomian glands, painless local swelling, redness, Risk
Factors: acne, rosacea and seborrhea.
Dry Eye: itchy, red, unable to produce tears, gritty sensation, excessive evaporation of
moisture, photophobia. Risk Factors: aqueous deficiency, lipid or mucin deficiency, altered
corneal surface, impaired lid function, contact lens
DRUG THERAPIES:
Non-pharmacologicals:
- Use warm compresses for hordeolum, chalazion, blepharitis; cold compress for allergic
conjunctivitis
- Blepharitis: practice good eyelid margin hygiene commercial eyelid scrub (Lid-Care) or baby
shampoo
- Avoid allergen/irritant (allergic conjunctivitis/dry eye)
-Irrigate eyes with normal saline (allergic conjunctivitis or to remove crusting in bacterial)
-Avoid scratching/rubbing and touching eyes and wash hands frequently
- Remove contact lenses
Pharmacologicals:
Drug
Topical Antibiotics: Polysporin/Optimyxin (OTC), Ocuflox (Rx),
Gentamicin (Rx)
Systemic: tetracycline, erythromycin, (Blepharitis)
Oral Antihistamines: 1st Generation Benadryl (OTC), Chlor-tripolon
(OTC), 2nd Generation: loratadine, desloradine, cetirizine,
fexofenidine (all OTC)
Ophthalmic antihistamines: levocabastine

Mast Cell Stabilizers: Cromolyn (OTC)

Corticosteroids: Pred Forte/prednisolone (Rx)
Mast Cell Stabilizers/Antihistamines: Vasocon(OTC)
Vasoconstrictors/Decongestants: napthazoline, oxymetazoline

NSAID gtts: ketorolac (Rx)

Lubricants / Artificial Tears: Tears Naturelle II (OTC)

Comments
For bacterial conjunctivitis, Polysporin use bid-qid for 7 to 10 days
For blepharitis: apply qd-qid for 1-2 wks
For allergic conjunctivitis, prophylactic use most effective, takes
longer to reach eye because systemic
Contraindicated in patients with glaucoma, on MAOIs
2nd generation are 24hr preparations, qd dosing
For allergic conjunctivitis: 1-2 gtts q3-4 h prn, up to 4x/day
Rapid onset since local effect
Very effective in relief of itchy, watery eyes, decreasing eye
puffiness, contraindicated in patients with glaucoma, on MAO
inhibitors, can be found in combination with decongestants
For allergic conjunctivitis: 1-2 gtts qid
Prevents histamine release from mast cells; very effective for
prophylactically, regular use will prevent redness, itchy, swollen eyes
For severe allergic conjunctivitis
fast relief and long lasting effect
For allergic conjunctivitis: 1-2 gtts q3-4h prn up to 4x/day
Decrease eye redness and swelling via vasoconstriction, no
improvement of allergic response
Contraindicated in glaucoma and hypertension (systemic), rebound
redness may occur with prolonged use,
For allergic conjunctivitis: for pain and inflammation, no effect on
allergic response
For dry eye and allergic conjunctivitis: 1 gtts 2-4 times/day
Good for allgergen dilution, Some products may contain the
preservative benzalkonium chloride which is an irritant

Relief of itch, 3 types: mucomimetic, hypotonic, preservative-free

**When to refer:
- If patient is a child
- If patient has seasonal allergic conjunctivitis and does not improve in 72hrs appropriate after self-care
- If patient experiencing pain, photophobia, blurred vision, chemical exposure, imbedded foreign body, eye
protrusion
- If patient wears contact lenses; is a risk of developing serious infection
- If hordeolum/chalazion not resolved in 48hrs
- If patient is suspected of having blepharitis; refer for prescription antibiotics or corticosteroids
- If probable viral conjunctivitis (highly contagious)
- If probable bacterial conjunctivitis; refer if no improvement after 48h after self-care
Counselling Tips for using eye drops and eye ointments:
- Make sure product has not been open for longer than one month; do not touch dropper with anything;
wash hands; remove contacts; do not share products; Discontinue med if eye pain, photophobia, visual
changes, irritation or redness continues, self med 48 hrs or 72 hrs for other products without improvement,
or without tx condition lasted longer than 48 days
Eye Ointment -When opening the tube for the 1st time, squeeze out and discard the first 0.25 cm of ung at it
may be too dry; place 0.6 to 1.25 cm of ung into the pouch of the lower lid;Gently close the eye for 1-2
min. and roll the eyeball in all directions; temporary blurring may occur, avoid driving or operating
machinery; if using both ung and eye drop, use eye drop first, wait 5 min before using ung; if different
types of ung are used, wait 10 mins before using the 2nd one;-if applying to outer lid, use sterile cotton swab
applicator
Eye Drops: Carefully remove cap and lay on side on clean dry tissue; tilt head back or lie down; while eyes
are open, gently pull down on lower lid to form pouch; holding bottle almost horizontally
approach eye from side; hold tip near eyelid at least 2.5 cm away. Do not touch opening to lid or
lash; turn eyes upwards to prevent blink reflex when med touches lid;Blot away excess med
around eye with clean tissue before opening eye. Do not rub or blink excessively; Replace cap.
Wash hands;if more than one drop in each eye, wait 3-5 mins before instilling the next drop
(ensures first drop is not washed away and second drop is not diluted); if more than one
medication, wait 5-10 min. between different med

OTITIS EXTERNA
Key Communication Issues:
Patient might be hard of hearing
Patient might be embarrassed (presence of ear wax)
Key Patient History:
Allergies
Medical Conditions: diabetes, immunocompromised malignant OE
Previous Occurrence treatment used
What makes it better / worse?
Water-based activities: swimming, shower vs. bath
Recent trauma to ear
Chronic skin conditions: seborrhea, dermatitis Eczematous OE
Use of hearing aid

Pathophysiology:
OE refers to inflammation of the external auditory canal (EAC) of the ear. The ear
canal is prone to infection because it is moist, dark and warm.
Subtype
Acute Diffuse

Etiology
Signs / Symptoms
Notes
90% bacterial (P. aeruginosa, Pain, pruritus, discharge;
Predisposing factors:
S. aureus); 10% fungal
sometimes fever (fungal infec'n Too much / little cerumen; moisture;
asymptomatic or mild symptoms) trauma; dermatological conditions;
hearing aids; narrow, hairy canals
Acute Localized Localized boil due to infec'n Localized pain, itching, redness, Pain goes away when boil bursts
(S. aureus)
edema, and can form abscess
Chronic
Eczematous

Necrotizing

Infec'n and inflammation lead Itchiness, mild discomfort, dry

to thickening of canal
flaky skin (when little cerumen)
Chronic skin disorders
Lesions on canal, head and neck
(psoriasis, dermatitis,
mild redness and scaling to
seborrhea, etc.)
psoriatic lesions
pruritus; redness; edema; some
crusting and oozing possible
Infec'n of mastoid / temporal
Bone

Can lead to secondary infec'n

Diabetic, immunocompromised pts

Prevention
Use ear plugs while swimming or bathing or wear bathing cap
After bathing / swimming gently dry external canal with hair dryer or instill
acidifying drops.
Try switching to baths from showers to minimize water entering the ears
When cleansing ear with cotton swab, be gentle and do not push in too deep
Avoid water activities for at least a week until symptoms clear up
Nonpharmacological Therapy
Cleansing of canal is important and is done by physician
Allows for administration of topical therapy
Pain reduction can be managed with cold packs

Pharmacological Therapy
Treatment of patient depends on:
Cost, convenience of dosing, availability (OTC vs. Rx),
potential damage to tympanic membrane
Class
Topical
Antibiotics

Product
Polysporin (OTC)

Efficacy
Gram + / - organisms

Gentamicin 0.3% (Rx)

Gram + organisms

Ofloxacin 0.3% (Rx)

some gram + / -

Acidifying
Agents

Dosing
Side Effects
1-2 gtts
low risk of allergies
BID - QID sensitization
3-4 gtts TID ototoxcity at high
Doses w/ > 7 day
treatment
1-2 gtts BID

Acetic acid in
Bacterial action
1-2 gtts after slight local
alcohol/H202/
and drying agent
water exposure irritation
propylene glycol (OTC)
Benzethonium Cl
Antibacterial and
2-5 gtts
slight local
0.02%, acetic acid 2% (OTC) antiseptic properties
TID - QID irritation
Aluminum acetate
Antibacterial,
2-3 gtts
burning
0.5%, benzethonium Cl
antiinflammatory
TID - QID
(OTC)
and some antiseptic
& astringent prop.
Combination Ciprofloxacin 0.3%,
Gram + / - organisms 4 gtts q12h Bankruptcy?
Antibiotic & dexamethasone 0.1% (Rx)
x 7 days
AntiFramycetin sulfate 5mg,
Gram + / - organisms
2-3 gtts
inflammatory gramicidin 50mg,
TID - QID
dexamethasone 500ug (Rx)
Topical
Lidocaine, Polymyxin B
Antibiotic with
2-4 gtts
Sensitization to
Analgesics
(OTC)
antipruritic /
TID - QID lidocaine
anesthetic action

Notes
See physician if symptoms
do not improve within 2 days
increasing resistance by
pseudomonas; do not use if
tympanic membrane ruptured
pseudomonas resistance to
fluoroquinolones
Prevents bacterial growth
by making acidic environment
soaps reduce efficacy
Long term use not
recommended for infants

Tympanic membrane rupture

not an issue
Ototoxic with ruptured
membrane; not for use with
fungal / viral infections
Can mask other conditions;
not for use with ruptured
tympanic membrane

This is not an exhaustive list; see Janie Bowles-Jordans list for complete
therapeutic options.
For pain relief, oral analgesics, ibuprofen or acetaminophen are generally
recommended over topical ones.
Counselling Tips:
Administration of Ear Drops:
Wash hands with soap before beginning
Warm drops by holding bottle in hand for a few minutes
Do not touch dropper against ear to avoid contamination of drops
Lie on side while administering drops
Anyone over 3 years: pull top of ear up and back
Under 3 years: pull top of ear down and back

This will help to straighten the ear canal and allow drops to enter
Stay lying down for a few minutes (5-10) to allow drops to run into canal
before getting up or turning over to do other ear
GERD is a common condition because everybody has some degree of gastric reflux, especially after meals.
Typical symptoms include diffuse retrosternal pain, acid or bitter regurgitation, hypersalivation, and
coughing that is often aggravated by bending over, lying down or eating fatty meals.
COMMUNICATION CHALLENGES:
patient may be experiencing discomfort, pain and loss of appetite and want immediate relief
overweight patients may be sensitive about suggestions to weight loss as a non pharmacological
option
PATIENT HISTORY ISSUES:
Patients experiencing any of the following symptoms should be referred to a doctor because they have
suspected upper airway manifestations of GERD or another underlying upper GI disorder:
age < 12
laryngitis
chronic cough for 3+ wks
globus sensation
wheezing
if symptoms persist after 2 weeks of treatment
morning hoarseness
frequency or severity of pain greater than
twice a week
hiccupping
Differential Diagnosis
Esophageal spasms
Gallstones
Acute Pancreatitis
Ischemic Heart Disease
Esophageal / Gastric
Cancer
Peptic Ulcer

Symptoms
aggravated by hot/cold food or drink
feeling of food-sticking
nausea or vomiting
sudden onset
nausea or vomiting
severe penetrating pain that is referred to the back
angina (searing, tight, squeezing or crushing pain in chest)
pain radiating to the neck and arm
age > 50
dysphagia
acute unintended weight loss
pain is continuous and radiates to the back
melena or bloody stools

COMMON/RELEVANT DRPS:
Patient is risk of the recurrence or worsening symptoms of GERD and requires treatment
o If the patient is not receiving drug therapy
Patient is receiving the wrong drug or
Patient is on a drug which is not needed
o If the patient treats GERD with analgesics
Patient is suffering an ADR
o If the patient is taking drugs that decrease lowers esophageal sphincter pressure
THERAPEUTIC PLAN OPTIONS
NON-DRUG OPTIONS:
Lifestyle Modifications
stress reduction

Dietary Modifications

avoid foods which delay gastric

exercise regularly (obtain ideal body weight)

avoid tight-fitting clothes around the waist
elevate head of bed roughly 10 cm
avoid smoking
avoid drugs that decrease LES tone
avoid anti-flatulents (because excessive gas is
not the cause of GERD)

OTC OPTIONS:
Drug
Histamine Receptor
Antagonists (H2RA)
Ranitidine (Zantac):
75 mg bid
Famotidine (Pepcid
AC): 10 mg bid
Antacids:

empting or increase acid exposure

o high fat meals
o chocolate, onions, carminatives (e.g. spearmint,
peppermint)
o excessive alcohol
o carbonated drinks
o reduce caffeine intake
avoid exercising or bending on a full
stomach
eat smaller, more frequent meals
eat slowly and avoid gulping down
food
avoid lying down for 3 hours following
meals or eating before bedtime

Comments
Competitively inhibits H2 receptor stimulation on the parietal cells thereby decreasing
gastric acid secretion
Effective in control and prevention of mild to trivial GERD
Onset: w/in 38 mins 90 mins
Duration of action: 9 h
Drug interactions (DI): phenytoin, theophylline, warfarin, procainamide, digoxin &
ketoconzole
ADRs (uncommon): diarrhea, H/A, drowsiness, fatigue, constipation & muscle pain
Administration: swallowable & unaffected by food
Relieves mild symptoms of GERD in 20% of patients
Onset: variable
Duration of action: 0.5-3 h
May have taste or after-taste

Calcium carbonate
most potent antacid
(Maalox):
DI: absorption of quinolones, tetracylines, digoxin, iron & isoniazide,
- chew 2-3 tabs qid 20
serum concentration of ASA if large dose used
min to 1 h pc or at
hs for max of 12 tabs/d ADRs: constipation, belching & flatulence, high doses cause hypercalcemia,
metabolic acidosis or milk-alkali symptoms (N & V, weakness & decreased
mental status), may stimulate gastrin release and acid production
Sodium bicarbonate
(Alka-Seltzer):
- fully dissolve tablet
into
4 oz. water before
taking
Magnesium hydroxide
(combination product
with Al OH below)
Aluminum hydroxide
(Gelusil):
- chew 2-4 tabs qid

ADRs: flatulence, belching & abdominal distension, metabolic alkalosis in

patients with renal dysfunction, high dose or prolonged use
Contraindication (CI): HTN, CHF, renal dysfunction, edema, cirrhosis &
pregnancy
ADRs: diarrhea, hypermagnesemia in patients with renal dysfunction (N &V,
flushing, drowsiness & muscle weakness), renal stones with trisilicate salt
CI: patients with renal failure, limited use in elderly
ADRs: constipation, hypophosphatemia with prolonged use or high dose,
long-term use in endstage renal disease cause dementia & osteomalacia
CI: patients prone to constipation or bowel obstruction or patients with renal
disease

between meals & at hs

Alginic Acid
(Gaviscon):
- 2-4 tsps qid pc or
at hs to max of 16
tsps/d

forms a foam layer on top of gastric contents to prevent reflux and protect the
esophageal mucosa
no therapeutic advantage over using antacids alone

RX OPTIONS:
Drug
Histamine Receptor Antagonists
(H2RA):
Famotidine, Ranitidine, Cimetidine
and Nizatidine
Proton Pump Inhibitors (PPIs):
Lansoprazole, Omeprazole,
Pantoprazole, Rabeprazole
Prokinetic Agents:
Domperidone, Metoclopramide

Comments
Rx strength is more appropriate for severe GERD
Ranitidine is 5-6 times stronger than cimetidine with less side effects
(see list in OTC options)

inhibit the basal and stimulated gastric acid secretion

for severe GERD when the patient receives no benefit from H2RAs
mild side effects (H/A, diarrhea, abdominal pain, nausea, pruritis)
LES pressure & gastric motility
used in combination with H2RA if excess secretion but still not as
effective as PPI alone
high frequency of ADRs (metoclopramide affects the CNS and
domperidone is a dopamine antagonist)

KEY POINTS SUMMARY ALLERGIC RHINITIS

Communication Issues
Age or language-related communication barriers (use language that the patient can understand)
May be difficult to convince patients that symptoms are not related to other conditions e.g. cold/flu
Sedation/congestion may interfere with patients speech
Emotional Aspects Patients may be emotional due to:
Physical impairment of symptoms (which may include difficulty sleeping, fatigue, reduced
concentration)
Psychological impact due to stress, frustration, inconvenience of having to take medication
Social stigma attached to having allergies, embarrassment, and limitation of activities/work
Key Relevant History Issues
1. Signs and symptoms
Paroxysms of sneezing, nasal and palatal pruritis, congestion and CLEAR rhinorrhea; possibly: allergic
conjunctivitis, itchy throat, ear fullness and popping, feeling of pressure over the cheeks and forehead,
allergic salute, allergic shiners
Complications that require attention: sleepiness, fatigue, headache, difficulty concentrating, sinusitis,
otitis media, dental overbite, high-arched palate due to chronic mouth breathing
Important prompts: Which symptoms are most bothersome? Intermittent (<2mo)/Persistent? Mild or
Moderate-Severe (interferes with sleep/daily activities)?
2. Co-existing medical conditions
Patients with allergic rhinitis may be predisposed to ASTHMA, ATOPIC DERMATITIS; sinusitis, otitis
media, nasal polyposis, lower respiratory tract infection, conjunctivitis, dental occlusion
For patients with narrow-angle glaucoma, bladder neck obstruction, hyperthyroidism, cardiovascular
disease and prostatic hypertrophyuse decongestants under physician supervision
3. Aggravating and risk factors
Exposure to allergens in living, social or occupational environments

 Tobacco smoke, insect sprays, air pollution, fresh tar or paint, alcohol, spicy foods can aggravate
symptoms
4. Family history (of allergic rhinitis, asthma or atopic dermatitis)
5. Allergies
Seasonal (spring-fall, worsening in mornings): pollens and moulds
Perennial (year-round): animal dander, dust mites, moulds, cockroaches
To possible treatments: antihistamines, sodium cromoglycate, decongestants (oral/topical) etc.
6. Product use
Drugs associated with rhinitis: ACE inhibitors, NSAIDs, Beta-blockers, Chlorpromazine, Cocaine,
Guanethidine, Methyldopa, Oral contraceptives, Phentolamine, Prazosin, Reserpine, Topical
decongestants
Interaction between dexchlorpheniramine (first-generation antihistamine)/decongestants and
monoaxmine oxidase inhibitors
Common DRPs
Patient requires avoidance measures (non-pharmacological therapy)
Patient requires pharmacological treatment (e.g. need for a decongestant, an antihistamine)
Patient requires prevention measures (e.g. cromolyn as prophylaxis)
Patient is taking unnecessary drug (e.g. herbals, analgesics)
Patient is experiencing adverse effects (e.g. drowsiness with first-generation antihistamines,
insomnia/high blood pressure with oral decongestants, rhinitis medicamentosa with prolonged use of
topical decongestants)
Inappropriate prn use of 2nd generation antihistamines or intranasal corticosteroids
Treatment
Non-pharmacological: Avoid allergens:
Pollenlimit outdoor exposure when pollen counts are high (sunny, windy days), keep windows closed,
use indoor cycle of A/C, avoid drying clothes outside, shower after outdoor activity
Outdoor Moldsremain inside as much as possible, keep air conditioning on indoor cycle
Indoor Moldskill mold with fungicides/bleach, remove houseplants
House Dust Mitesavoid carpeting/Venetian blinds/toys that cant be washed, minimize use of
humidifiers, clean when the patient is not home, wash bedding in hot water every 2 weeks
Animal Allergensremove pets or keep them remote from patients bedroom, eliminate litter boxes if
possible
Avoid irritants: tobacco smoke, insect sprays, air pollution, fresh tar or paint
Pharmacologicals - Take as directed. Know the dose of the product you are taking and do not exceed
maximum recommended dose. If you experience any discomfort, notify your doctor or pharmacist.
Mild
Saline solutionone level teaspoon of table salt per 200-250mL warm water, instilled using a bulb
syringe or dropper
And/or
Oral antihistamine
Sedating - May cause drowsiness. Do not operate machinery. Avoid alcohol, and report excessive
side effects to your health care provider.
Non-sedating For best results, take on a regularly basis. Avoid grapefruit, orange or apple juice if
taking fexofenedine. Cetirizine may cause sedation in some people (alcohol may increase this
effect).
decongestant
Topical - Do not use for more than 10 days without consulting a health professional. Stop use and
consult your doctor/pharmacist if congestion or runny nose do not improve.

Systemic - A slight increase in heart rate may be noticed with this medication. If congestion does
not improve after 5 to 7 days, consult your doctor or pharmacist. 240mg QD SR pseudoephedrine
take in the morning; 120mg BID SR pseudoephedrine take evening dose 3 to 5 hours before
bedtime.
Topical cromolyn as prophylaxis - Frequent administration may be required (3 times per day). It may
take up to 2 to 4 weeks for this medication to reach its maximum effectiveness. You may experience
some nasal irritation, nosebleeds or headaches.

Moderate: Refer to physician for possible:

Nasal steroid - It may take up to 2 weeks for this medication to reach its maximum effectiveness. To
help reduce the risk of nasal ulceration: spray toward the outer part of the nose; lubricate anterior nasal
septum to reduce bleeding.
Severe: Refer to physician for:
Intranasal steroid antihistamine
Other Rx: options: ipratropium bromide, antileukotrienes, levocabastine, immunotherapy
Nasal Sprays - Gently blow your nose. With your head upright, close one nostril. Spray into the open
nostril, breathing in through your nose while quickly squeezing the bottle. Repeat on the other side. Blow
your nose in 3-5 min. Rinse the tip of the spray bottle with hot water, but try not to get any water in the
bottle.
Nose drops - Have the child gently blow their nose. Lie the child on their back, on a bed with the childs
head hanging slightly over the side. Insert the dropper about 0.8cm (1/3 inch) into a nostril and instill the
recommended number of drops. The child should remain in this position for approximately 5 minutes. Tilt
head from side to side. Repeat to the other nostril. Blow the nose 3-5 min later. Rinse the dropper with hot
water and return it to the bottle. Although hard to do, avoid touching the dropper to the nostril.
Counseling
What It Is: Inflammation of nasal mucosa following contact with an airborne allergen
Prevalence: Allergic rhinitis affects 20% of the population and the prevalence is increasing. Prevalence
peaks in late teens/early twenties.
Cause: Allergens trigger IgE mediated release of histamine and inflammatory mediators from mast cells.
Transmission: No horizontal transmission. Genetic predisposition children have 30% chance of
developing AR if one parent is affected and 50% if both are affected
Recurrence: Recurrence is likely, gradually reduces after age 45
What to expect: Benefits of environmental control may take weeks or months to fully manifest. Most
medications for AR have a quick onset of action (within hours). Resolution of symptoms depends on
severity.
When to see the physician: If the allergen cannot be identified, the patient is under 12, pregnant/breastfeeding, has severe or persistent AR, symptoms of undiagnosed asthma, earache, fever or purulent nasal or
ocular secretions, symptoms unresponsive to appropriate treatment lasting for two weeks or more,
unacceptable side effects of treatment

Key-Point Summary: Cough & Cold

Patient History
Important to determine who is experiencing the signs and symptoms (ie. one person vs. entire
family)

Questions to Ask

How long have you had the S&S? How severe are they? How are they affecting you?
o What kind of cough? (Dry, productive)
o What does the nasal discharge look like? Any congestion?
o Any sneezing? Itching of eyes, nose, mouth? Lacrimation?
o Any general aches & pains; fatigue; weakness; dizziness; GI symptoms?

o Any fever, headache?

o Do you have a sore throat? (scratchy or painful?)
o Was the onset abrupt or progressive?
o Any difficulty to breathe? Wheezing? Stridor?
Other medical conditions (eg. diabetes, hypertension)? History of respiratory disease?
Do you get these S&S regularly? How often? Yearly basis (if yes, could be allergies)?
Are you sleeping well? Do you feel agitated?
Currently taking any medications? OTC products? Herbals (these could cause interactions) ?
What have you tried so far?
Have you had the flu vaccine?
Have your food or fluid intake been significantly reduced?

**if suspect that it is common cold, reassure patient that it is self-limiting and may be gone in 5-7
days.
Pathophysiology:
-viral infection - mainly rhinovirus (common mid-winter/early spring) & coronavirus (common in fall &
spring)
-frequently occurs and is self-limiting
-transmitted via hand-hand contact or contact with a contaminated object (tissue, handrails, doorknobs, etc)
-also transmitted by contact with respiratory droplets
-virus particles come in contact with respiratory mucosa and infection begins
Risk Factors
-exposure to young children
-children (6-10 colds/year)
changes
-adults (2-4 colds/year)
-immunocompromised

-stress
-winter months

-excess fatigue
-extreme temperature

-smoking
-poor hand-washing

-poor nutrition
-crowded areas

Signs & Symptoms

-sore &/or scratchy throat
-nasal congestion with discharge (frequently clear); sneezing
-may have slight fever
-general malaise; headache (not as common); aches & pains
-non-productive cough (may become productive over time)
-may progress to complications:
-Secondary bacterial infections (otitis media in kids under 5 years, sinusitis)
-pneumonia (persistent fever, dyspnea, chest pain, coughing up blood or thick green phlegm, etc.)

Differential Diagnosis
Influenza: high fever (38-40 celcius), sudden onset, chills, fatigue, weakness, sweats, sore throat, myalgia,
nausea, vomiting, diarrhea, usually no nasal congestion, discharge more clear at beginning then mucopurulent,
cough usually unproductive; lasts 10 days
Sinusitis: purulent, often coloured yellow, green thick nasal discharge, fever, headache (pressure, tender,
pain in the front of the face), can lose sense of smell, no cough. A cold may develop into sinusitis; can last
days to weeks.
Allergic rhinitis: copious, watery but clear nasal discharge, congestion, sneezing, watery eyes, itchy eyes
or throat, ear-aches (children especially); seasonal or perennial, can develop secondary to a cold; lasts as
long as exposed to allergen.
Pneumonia: productive cough, blood in sputum (thick green, brown sputum), tightness in the chest,
wheezing, difficulty breathing, fever, easily fatigued, joint and muscle stiffness, pleural chest pain when
taking deep breath.

COPD exacerbation: productive cough, headache, fatigue, wheezing, shortness of breath, dyspnea, weight
loss, ankle, feet and leg swelling, vision abnormalities, smoker
Asthma: mild coughing, wheezing, shortness of breath, chest tightness
Strep throat: possible fever, sore throat (sudden, severe onset, feels like swallowing knives), no cough,
no nasal congestion, swollen lymph nodes (pain in neck)
Croup (children under 3 years of age): bark-like cough, difficulty breathing, strider (inspiratory noise due
to trachea swelling). These children must be referred to a doctor.
Refer to MD if:
Child with any of the following symptoms:
-symptoms of croup or ear infection (otitis media)
-excessive lethargy or irritability
-skin rash
-cough associated with vomiting
Pregnant/breast-feeding women (recommend non-pharms first; if pharm therapy reqd recommend
those w/fewest systemic absorption at lowest possible dose for lowest possible duration. Drug
therapy > 3 days should get MD approval)
Children under 2 years of age (depending on the symptoms---colds often linked with other
complications)
Cough is persistent for > 3 weeks
Fever above 38.5oC
Severe headache or neck pain
Severe symptoms or significant reduction in food/fluid intake (especially older adults)

Non-Pharmacologicals
Treatment
Bed rest
Increased humidity (>50%) humidifier/vaporizer
Increased fluid intake (particularly warm fluids)
Saline nasal spray (or saline drops + nasal aspiration for infants)
Salt water gargle
Prevention
Proper handwashing and avoidance of contaminated materials
Cough/sneeze into tissue then throw tissue away
Pharmacologicals
Antitussives (e.g. dextromethorphan, codeine)
Relief of dry, unproductive cough (if used w/productive cough, mucus retention)
Generally well tolerated, though occasional drowsiness & diarrhea
Patients with chronic lung disease, pregnancy/breast-feeding should consult MD first
Drug interactions with anti-depressants (incl. MAOIs)
Oral Decongestants (e.g. pseudoephedrine, phenylephrine, ephedrine)
Sympathomimetic; relief of nasal congestion via vasoconstriction of blood vessels
Contraindicated in patients with hypertension, diabetes, hyperthyroidism, glaucoma, enlarged
prostate, pregnant/breast-feeding, MAOI use
Mild CNS stimulation (nervousness, restlessness, excitability, insomnia)
Topical Decongestants (e.g. phenylephrine, naphazoline, oxymetazoline, xylometazoline)
Long-acting formulations have less adverse effects than short-acting ones
Can cause local burning, stinging, sneezing, and dryness of nasal mucosa
Rhinitis medicamentosa (rebound congestion) if used for more than 3-5 days

Contraindicated in pregnant/breast-feeding women, as well as children < 6 mos.

Expectorants (e.g. guaifenesin)

Used with productive coughs; loosens chest congestion
Nausea, vomiting, GI upset, drowsiness (rare, at high doses)
Questionable efficacy; good hydration w/oral liquids & humidified air might be better
Antihistamines
Minimal effects on rhinorrhea as common cold is not histamine-induced
First generation antihistamines marginally useful; second generation have no effects
Can worsen stuffy nose after 2-3 days
Antipyretics (e.g. acetaminophen, ibuprofen, ASA)
Can be used to relieve fever, headaches, sore throat which are associated with cold
Combination Products (e.g. DM + guaifenesin, DM + decongestant)
Practical in the sense that they reduce number of meds patient has to take
Not always logical (guaifenesin loosens congestion, but DM suppresses cough)
Lack of flexibility (what happens when one ingredient is no longer indicated?)
Herbals/Natural products (Echinacea, vitamin C, zinc lozenges)
Little evidence to support efficacy in treatment or prevention of cold
Echinacea requires larger doses x 10-14 days; contraindicated in immunosupression
Vitamin C (>1g daily) may cold duration by day, but ADRs (diarrhea, oxaluria, renal stones,
uricosuria)
Zinc lozenges must be used q2h at onset of cold; also have bad taste/poor tolerability
Monitoring Plan:
-patients should monitor daily for cold symptoms (congestion, rhinorrhea, cough, sore throat)
-pharmacist can check up on patient in 2-3 days or upon next visit
-patient should be able to perform daily activities and be able to sleep
-symptoms should subside within 5-7 days (14 days at most)

Vaginitis Key Point Summary

Group 11A (Andrew Armstrong, Mima Caruana, Christina Cella, Gary Jutla,
George Mankarios, Victor Wong)
Pathophysiology
Vaginitis is a non-specific term referring to inflammation of the vagina, due to any
one of a number of causes. Etiology may include infection by microorganisms
such as gonococci, chlamydiae, Gardnerella vaginalis, staphylococci and
streptococci, viral infection, or fungal infections (candidiasis) caused by Candida
albicans. Neoplams of the cervix or vagina, irritation from chemicals used in
douching or from foreign bodies are also possible causes. Parasitic infections,
although rare, may contribute to this condition.
Symptoms
The patient may experience vaginal discharge, which may or may not be
malodorous or stained with blood; irritation or itching; polyuria; dysuria; erythema
or ulceration of vaginal mucosa.

Patient Assessment
Of the possible etiologies of vaginitis, candidiasis (yeast infection, moniliasis) is
the only condition recommended for self-treatment, and only when a positive
diagnosis is confirmed, or if the patient has had previous infections. For all other
causes, or if the diagnosis is uncertain, referral to a physician is necessary for
positive diagnosis. Patients should also be referred if this is their first Candida
infection.
As candidiasis is the only etiology recommended for self-treatment, only it will be
discussed further.
Key Communication Challenges
- Patient may be embarrassed by condition or associated social stigma
- Condition may cause self-esteem issues for patient
- Patient may be frustrated by lifestyle inconveniences
- Necessary to reassure patient, assure that condition is common and easily
treatable
- May be advisable to suggest use of private counseling room
Significant Patient History Issues
- Drug history (use of broad-spectrum antibiotics, high estrogen oral
contraceptives, HRT, corticosteroids, chemotherapy, and tamoxifen may
all contribute to Candida infection by altering normal flora of vagina)
- Medical history or concurrent medical conditions
(pregnant/immunocompromised or patients with Diabetes Mellitus are
more at risk for vaginal candidiasis and physician referral is necessary;
self-treatment in patients <12 yrs inappropriate)
- Does patient have a history of recurrent yeast infections? (infections are
recurrent in 50% of patients)
- Has the patient had a recurrent infection in the past two months? (may be
complications, prescription therapy may be required; refer to physician)
Relevant Questions
- Description of discharge, if any? (if malodorous, creamy, yellow/grey,
suspect bacterial cause, and referral is necessary)
- Presence of concomitant symptoms? (if patient is experiencing fever or
pelvic pain, refer to physician)
- Does patient have a history of unprotected intercourse with multiple
partners? (patient may be at risk for, or have concurrent, STDs; refer to
physician)
- Does patient douche frequently? (predisposes patient for Candida
infection)
- Is patient under stress?
- Does patient wear tight-fitting clothing or synthetic undergarments?
Significant Common/Relevant DRPs

Is yeast infection secondary to medication use?

If so, is the medication therapy appropriate? (ie. inappropriate antibiotic
use; switching from a high-estrogen oral contraceptive to low-estrogen)
Therapeutic Plan Options
Non-Pharmacological
- no effective non-drug therapy for treatment, only prevention
Preventative Measures:
- avoid tight-fitting clothing or synthetic undergarments; use loose-fitting
cotton
- avoid vinegar, saline or yogurt douches or avoid douching entirely
- discourage use of deodorants, soaps or other irritants
- wipe from front to back when toileting
- avoidance of high-sugar foods may be useful
- effectiveness of dietary yogurt in prevention has not been proven
Pharmacological (OTC)
- topical antifungal products are first line treatment for typical uncomplicated
Candida infections (less than 2-3x per year)
- imidazole antifungal products are first choice (70-90% effective) and better
tolerated than other products; one-day and multi-day treatments exist
ie. miconazole (Monistat), clotrimazole (Canesten), tioconazole
(Gynecure)
- boric acid 600mg capsules intravaginally od-bid x 14 days
- nystatin use is not recommended
Pharmacological (Rx)
- generally only warranted for persistent or recurrent cases
- may be necessary in immunocompromised or complicated patients
- prescription oral antifungals are first line
Fluconazole 150mg (Diflucan-150) po as a single dose
- prescription topical antifungals are available, but are second line treatment
Patient Counseling Instructions (OTC)
- Refrain from sexual intercourse during treatment
- For resistant or recurrent infections, it may be appropriate to recommend
male partner use antifungal cream on penis od x 7 days concurrent to
treatment
- If no improvement is noticed after 3 days, or condition not resolved within
7 days, discontinue product use and consult with a physician
- If irritation or sensitization occurs, discontinue use
- Continue treatment through menses if it occurs during treatment
- Do not use tampons during course of treatment
- Products are for vaginal use only not for mouth or eyes; do not ingest
- Apply product vaginally at bedtime to increase contact time

Multiple products, one-day and multi-day treatments exist; refer to

supplied instructions or package insert

Patient Counseling Instructions (Rx)

- fluconazole 150mg supplied as a single dose tablet, to be taken orally
- patient may experience headache (12.9%), nausea (6.7%), abdominal
pain (5.6%), diarrhea (2.7%), dyspepsia, dizziness, taste perversion
(1.3%)
HEADACHES - KEY POINT SUMMARY

COMMUNICATION
Establish a relationship with the patient by addressing communication issues - Offer the use of a private
counseling room to decrease noise level; lower your voice level; listen actively; be empathetic; ask openended questions.

HISTORY
Medical conditions, family hx, allergies; Current medications (OTC, Rx & Herbals); Age, social
& economic status, emotional & physical stress level, diet (caffeine, alcohol, tobacco); Headache
severity (pain scale) & frequency; Aggravating factors? Sensitivity to light, sounds or smells? N
& V? Pulsating or non-pulsating? Bilateral or unilateral? Headaches start upon waking? Pain
around or behind the eye? Eye and/or nose congestion? Febrile?
COMMON DRPs
Patient is experiencing signs and symptoms of a headache and requires drug therapy (Rx or
OTC).
Patient is taking the wrong or ineffective drug and requires an alternate therapy.
PATHOPHYSIOLOGY
Tension-type (TTH): Most common, precipitated by mental stress & tension, exact pathophysiology
unknown, common between ages 12-35 years
Migraine: specific cause unknown, possible genetic factors, neurovascular disorder: dilation of
meningeal blood vessels and activation of trigeminal sensory nerves --> release of vasoactive peptides
& pain signals
Cluster headache: rare, exact pathophysiology unknown, suggested that inflammatory process in
cavernous sinus and tributary veins lead to an attack, vasodilators (nitroglycerin) can induce an attack

SIGNS AND SYMPTOMS

Parameter
Sensation
Severity of Pain
Location
Frequency

Duration
Worsened by
Physical Activity

Tension-type (TTH)

Migraine

Cluster

Tightening/Pressure
Non pulsating
Mild to moderate
Bilateral

Throbbing/Pulsating

Penetrating

Moderate to Severe, mild

Unilateral (usually but can be
bilateral, especially in children)
Episodic (variable)

Excruciating
Always Unilateral
(supraorbital and/or temporal)
Episodic: (last 7 days to 1 yr separated by pain-free period
lasting >= 14 days
Chronic: attacks occur for more than 1 yr or pain-free
intervals < 14 days
15-180 min
No

Chronic >15
days/month
Episodic <15
days/month
30 minutes to a week
No

2-72 hours
Yes

Nausea/Vomiting,
Photophobia,
(Phonophobia)
Other Symptoms

No nausea/vomiting
And
No Photo/Phonophobia
(or only one may occur)
Anorexia may occur

Either nausea and/or vomiting

OR
Photo/Phonophobia may occur
w/ or w/o aura

No vomiting
AND
Mild or No Photo/Phonophobia

On same side of headache, at least one of: Lacrimation,

conjunctival injection, nasal congestion, rhinorrhea, miosis
ptosis, forehead/facial sweating, eyelid edema

RED FLAGS:
Severe/abrupt onset; Increased frequency and/or progressive
Stiff neck, focal signs, reduced consciousness
Systemic signs - fever, unexplained N/V, general weakness

Nocturnal occurrence or when wake in morning

Onset with exercise or intercourse
Onset in middle age or older (i.e. if over 40 years old)

DIFFERENTIAL DIAGNOSIS
Primary Headache Types: paroxysmal hemicrania, idiopathic stabbing headache, cold-stimulus
headache, benign cough headache, benign exertional headache
Infectious: meningitis, encephalitis, sinus headaches only occur in the presence of a sinus infection
Temporal arteritis, subdural hematoma, subarachnoid hemorrhage, stroke, TIA, systemic/CNS
vasculitides, space-occupying lesions

RISK FACTORS
Foods, beverages that contain: Nitrites, MSG, or neurotransmitter precursors - ex. cheeses, cured
meats, chocolate, alcohol and caffeine
Environmental: Weather changes, bright/flickering lights, travel across time zones
Chemical: Benzenes, insecticides
Hormonal: Menstruation, pregnancy, perimenopause
Drugs: Drugs causing intracranial hypertension and drugs causing headaches as a side-effect
Other: Sleep-wake cycle alterations, stress/anxiety, physical and sexual activity, loud noises, strong
smells (ex. cigarette smoke), poor posture, unnatural head or neck position for long periods of time
PATIENT ASSESSMENT
No diagnostic tests for 1 headache disorders - diagnosis after ruling out serious underlying disorders
Patients with TTH, do not need to see MD unless becomes chronic (daily)
Unusual headache (ex. migraine) should be diagnosed by a MD; if red flags appear, refer to ER

NONPHARMACOLOGIC THERAPY
Identification and avoidance of potential risk factors as indicated above
Maintaining a healthy diet, regular sleeping, eating, and exercise schedules
Various techniques to reduce stress and anxiety: biofeedback, relaxation therapy, cognitive-behavioural
therapy
Homeopathy, acupuncture, and aromatherapy - lack evidence for their effectiveness in treatment of
headaches
Drug

PHARMACOLOGIC THERAPY
Dosing
Properties/Onset

Side Effects

Comments

Acetaminophen

Adults: 650-1300 mg q4h x

2 doses PRN, max
4000mg/24hrs.
Children: 10-20 mg/kg/dose
q4h x 2 doses PRN, max 65
mg/kg/24h.

Analgesic and antipyretic agent, no antiinflammatory properties; used for tension

type headaches and mild to moderate
migraine attacks. Onset is 20-30 mins,
duration is 3 to 4 hrs.

Safe at recommended
doses. May cause
hepatotoxicity in doses
> 4 gm/day.

Analgesic of choice during

pregnancy.

ASA

Adults: 650-1300 mg q4h x

2 doses PRN.
Children (age >=12): 500650 mg q4h x 2 doses PRN.

Analgesic, antipyretic, anti-inflammatory,

and anticoagulant properties; effective for
mild to moderate pain with inflammation.
Onset is 30 mins, duration up to 6 hrs.

Many SE involving GI
tract including
ulcerations, heartburn,
nausea, and vomiting.

Avoid use during 3rd

trimester of pregnancy.
Should not be used in
children under 18 yrs in
presence of viral illness or
fever.

Ibuprofen

Adults: 400-800 mg q6h x 2

doses PRN.
Children: 5-10 mg/kg/dose
q6h x 2 doses PRN.
Do not exceed 1200 mg/24
hrs.

Analgesic, antipyretic, anti-inflammatory.

Efficacious for tension type headaches.
Liqui-gel formulations indicated for relief
of mild to moderate migraine headaches.
Onset from 15 to 30 min, duration ranges
from 4 to 6 hrs.

Nausea, constipation,
heartburn, renal
dysfunction. GI side
effects can be reduced if
taken with food.

Avoid use during 3rd

trimester of pregnancy.

Most tension type headaches can be self-medicated with analgesics

Drug therapy:
1) abortive therapy to provide relief during an acute headache attack

Many Rx meds are available for acute migraine attacks: including triptans,
dihydroergotamine, and ergot preparations. The triptans are efficacious for headache pain
as well as migraine symptoms (nausea/vomiting).
2) prophylactic therapy to prevent recurrent headaches
To reduce the frequency and severity of migraines, trial period of 2-3 months is needed to assess the
efficacy of Tx. Pts should keep a log to monitor response to therapy. One agent used at a time, start at low
dose, titrate upwards:
a) Nonprescription: Feverfew, Riboflavin, and Mg have demonstrated efficacy though additional study
needed.
b) Prescription: Beta-blockers, tricyclic antidepressants, calcium channel blockers, NSAIDS, estrogen
gel/patches
MONITORING OF THERAPY
Encourage patient to use a headache diary to determine the frequency, severity, and disability of the
attacks. It helps identify patterns (i.e. association with the menstrual cycle), and helps track treatments
success, or failure.
Associated symptoms may also be surveyed (and treated) such as nausea/vomiting,
photophobia/phonophobia.

Travelers diarrhea
Patient history

Age? very old and very young

allergies? particularly to salicylates
medical conditions? asthma, diabetes,
immunocompromised, hepatic dysfunction, IBD
medications? anticoagulants, salicylcates, probenecid,
methotrexate, doxycycline
Understand that patients may be embarrassed about their
condition and therefore withhold more specific information regarding symptoms
(frequency, colour, presence of blood, consistency)
Reassure that travelers diarrhea is common and self-limiting

Using the wrong medication

Taking too much or too little of the right medication
Experiencing side effects of the medication

Communicatio
n

Common DRPs

Counseling
information

Failure to rehydrate
Pathophysiology:

Enteric infection caused mostly by bacteria (80%), or viruses (10-15%), or

rarely parasites (6%)
Most common enterotoxigenic is E. coli.
Incidence: 20-50 % of 2 wk travelers to developing countries
Risk groups:

Adventurous eating habits

Age: very young and very old

People traveling to high incidence areas: (high risk: Mexico, South and
Central America, parts of Africa, Middle East and Asia)

Patients with gastric hypocholrhydria

Immunodeficent patients
Patients with lack of gut immunity. this is seen in younger individuals
How long will it last? Self limiting usually 3-4 days except in vulnerable patients
(elderly, infants, children, immunocompromised, patients with chronic disease: type
I DM, IBD, chronic renal failure, CHF)
Transmission: Oral fecal Usually in response to contaminated food or water
Signs and symptoms:
3 or more loose stools per day + at least one of the following (signs of enteric
infection):
Fever
Abdominal cramps
Nausea

Drugs that
cause S&S
Prevention

Dysentery: bloody stool occurs in 5-10 % of cases

fecal urgency
- Antibiotics
- Laxatives
- NSAIDs
Safe

Unsafe
boil it, cook it, peel
it, or forget
Poorly
cooked it
meat
Piping hot food
Raw vegetables
Carbonated beverages
(no ice)
Unpasteurized
dairy products
Boiled/bottled water, and
fruit
juices
Cooked food left out in the heat for
Fruits if washed with safeseveral
water and
peeled
hours
Pasteurized milk if properly
storedmousses, mayo, potato salad
Custards,

Seafood
Foods from Street vendor
** acidic environments are bactericidal **
Ice cubes unless you know its made
with safe water
Water melon, strawberries, raspberries
Factors
determining
severity

Refer to MD

Dysentery
Dehydration
Age
Duration of signs and symptoms

Co-morbid diseases (chronic renal failure, CHF, Type 1 DM, IBD,

immunodeficiency)
< 2 yr: with bloody stool, rectal temp > 38.9C, persistent vomiting, or
diarrhea > 48 hrs
Symptoms for longer than 48 hrs
Patients with severe underlying medical conditions: DM, Renal insufficiency
Immunocompromised

Watch out for

dehydration

Nonpharmacologic
al

Pharmacologic
al

Chemoprohylaxis

Goal
Plan

If severe diarrhea and unresponsive for 48 hrs.

Sunken eyes
Absence of tears
Decreased urine output
Greater than 5% loss of body wt
Avoid foods/beverages that will aggravate condition
o Caffeine can increase risk of dehydration, increases GI mobility and
secretions
o Dairy, prune juice, orange juice can make diarrhea worse
Oral Rehydration Therary (ORT) or salts like Pedialyte, gastrolyte carry
with you sachets to make 2-4 L if unavailable use:
1 tsp salt + 8 tsp sugar + 1 L safe water
Avoid high risk foods and beverages
Water purification
Frequent hand washing (soap and water or hand sanitizers)
Bismuth subsalicylate (BSS): (Pepto-Bismol)
o Avoid in people with ASA allergy, renal insufficiency, people taking
anticoagulants
o Caution in children due to risk of Reyes syndrome
o Not to be used in children less than 2 years old
o Can cause black stools. Problem with diagnosis
o Treatment dose: 30mL or 2 tablets q30min (max 8 doses in 24
hours)
Loperamide (Imodium)
o Contraindicated in children less than 2 years of age
o Dose: 2 tablets ( 4 mg) initially, then 1 after each loose bowel
movement (max 8 tablets/day)
Antibiotics
o Fluoroquinolones : ciprofloxacin, norfloxacin, ofloxacin
o Azithromycin (Macrolide)
o Cotrimoxazole (Sulfa) and doxycycline
Cipro avoid in young children
Azithromycin and co trimoxazole used in weight adjusted
doses
Brief illness cannot be tolerated (athletes, business or political travelers)
People at increased risk due to achlorhydria, gastrectomy
Immunocompromised
Chronic illness (i.e. CHF, Type 1 DM, IBD, chronic renal failure)
How??
BSS:QID for up to 3 wks decreases attacks from 40 to 14% or
antibiotics
Reduction of watery stool to < or equal to one per day within 1-3 days; + education
Child- without complications:
- Non-pharmacological + ORT (No Loperamide or BSS)
ORT in children and
elderly
Adult (no fever, no bloody stool, no extensive cramping mild moderate)
- Non-pharmacological + Loperamide (caution with children <12) or BSS + maintain
hydration
Adult (fever or bloody stool or extensive cramping moderate severe)
- Non-pharmacological + Loperamide or BSS + maintain hydration

Hemorrhoids Key Point Summary

Communication Challenges:
Embarrassing situation for patient so be considerate by offering private counselling
Be empathetic
Be reassuring- it is a common and treatable condition
May be difficult to identify the proper signs and symptoms because of sensitive nature of this topic
Patient History Issues
Does the patient have any allergies to medication?
Is the patient currently on any other medication? Herbal medications?
Does the patient have any medical conditions (ie. pregnancy, constipation, diarrhea, obesity)
Important Questions to Ask
How long have you had the symptoms?
Have you previously experienced similar signs and symptoms?
Are you currently taking any medications for the signs and symptoms?
What is your diet like? Do you eat a lot of fast food, spicy food, and fibre? How much liquid do you
consume daily? (ie. alcohol and coffee)
What is your occupation? Does it require you to be sitting for prolonged periods of time or lift heavy
things?
When was the last time you had a bowel movement? Any constipation? Any diarrhea? Do you resist
the urge to defecate?
Is there any mucous or blood in the stool? If there is blood, is it bright red or dark?
Any prolapse? Is it painful? Is there a bump that is bluish in colour? Is there a burning sensation?
Differential Diagnosis
Perianal abscess (bacterial infection)
Anal fissure (tear in the anal mucosa)
Polyps (bright red anal bleeding, abdominal cramps, watery diarrhea)
Anorectal cancer (severe and constant anal bleeding with a constant urge to defecate)
Anorectal abscess (acute infection of mucous glands, pain, swelling mass, fever, chills)
Anal tags (soft, floppy fibroepithelial tags from the anus, itching, burning, irritation)
STDs (pain, discharge, bleeding, ulcer of perianal skin or anal canal)
Common Drug Related Problems
The patient is experiencing signs and symptoms of hemorrhoids and requires therapy.
The patient is experiencing signs and symptoms of hemorrhoids and is using the wrong drug.
The patient is using the appropriate medication incorrectly and requires counselling.
The patient is currently taking a drug, which is causing the signs and symptoms.
Pathophysiology
Anal cushions are normal structures that have a rich arterial blood supply and help seal the upper anal
canal and contribute to continence
Hemorrhoids occur when the anal cushions become engorged and separated from their internal
attachments in the anal canal
External hemorrhoids:
- originate below the dentate line and are generally painful and itchy
- they are located near the anus and covered by a layer of tender anal skin
- blood clot in vessel will lead to a bluish lump or bump
- do not usually bleed
Internal hemorrhoids:

originate above the dentate line, covered by mucous membrane

not painful as there are no innervations above the dentate line
may prolapse and can hemorrhage- patient may see blood on the toilet paper or in the toilet
may cause an infection if left prolapsed (can put back in manually)
Graded from 1-4
1) very little pain and discomfort, swelling of the anal cushions
2) the anal mucosa and anal cushion protrude out upon defecation and return their
normal position
3) the anal mucosa or cushions remain in the prolapsed position and must be put back
manually after bowel movement
4) anal mucosa or the cushion cannot be manually placed back in position and should
be referred to a physician extreme discomfort and pain
Mixed hemorrhoids:
- Both external and internal hemorrhoids.

Risk Factors
pregnancy, increased abdominal pressure
physical exertion, heavy lifting
chronic cough
prostate enlargement
age (usually seen in middle age, with increasing incidence up to 70 yr. old)
loss of rectal muscle tone
constipation, diarrhea
obesity, hepatic disease, prolonged sitting
Signs and Symptoms
Internal hemmorhoids are painless, with bright red rectal bleeding, pruritis, and pain when prolapsed
External hemmorhoids are painful, itchy, and there is a mass felt upon defecation. Pain peaks 48-72
hours after hemorrhoids develop and improves by the 4th day and heals by the 10th day.
Refer
Problem lasts for longer than 7 days
Stool or mucous leaks from rectum between bowel movements
Hemorrhoid does not go back in place after a bowel movement
Rectal bleeding is present and is present in large amounts, is recurrent, is dark in colour
Patients at high risk of colorectal cancer
Patients who experience acute weight loss
Change in bowel habit (chronic constipation, sudden diarrhea)
Non-Pharmacological Treatment
Increase fiber intake, avoid foods that cause diarrhea, drink lots of fluids
Good hygiene
Good toilet habits Avoid straining by spending no more than 1-2 minutes on the toilet
Exercise will strengthen abdominal muscles, increases GI activity and weight loss
Cool pack/ice pack on the area
Anurex This reusable probe containing a cold gel is inserted into the rectum like a rectal suppository
after being cooled in a freezer for a minimum of one hour. It is left in for 6 minutes once to twice
daily. It is used for symptomatic relief of bleeding, pain, irritation, itching, discharge and swelling
both inside and around the anal opening by acting as a vasoconstrictor
Replace prolapsed hemorrhoids with a moist toilet tissue
Sitz bath Sits the entire bottom and hips in warm water and Epsom salts may be added. It is used to
relax the internal anal sphincter and reduce strain. It can be used 3-4 times a day for 10-15 minutes.

Pharmacological Treatment
i) Anti-inflammatory agents - There are no OTC hemorrhoid products that contain hydrocortisone

Cortate 0.5% - applied in the morning and at bedtime and following each bowel movement.
Should not be used for more than 7 days and should be reserved for severed painful cases.
ii) Astringents are used to relieve irritation, itching and burning
Bismuth - applied 6 times daily or after each bowel movement (BM). Can be toxic if absorbed.
Witch Hazel Hamamelis - applied 6 times daily or after each BM. May be sensitizing.
Zinc oxide/sulfate - applied 6 times daily or after each BM. The strength of zinc is usually too low for
astringent properties.
iii) Local anesthetics are used for the temporary relief of itching, irritation, discomfort, and pain but are
contraindicated in pregnancy. There is a potential for allergic reactions (burning, itching) and contact
dermatitis. DO NOT USE in the rectum for lower anal and perianal area only!
Benzocaine1-4.5% - applied 6 times daily. It is not commonly available, is sensitizing, has an onset of
onset of 1 minute and duration of 15-20 minutes.
Pramoxine 1% - applied in the morning, at bedtime and after each BM up to 5 times a day. It has an onset
of less than 5 minutes and duration of 60 minutes.
Dibucaine 0.5-1% - applied in the morning, at bedtime and after each BM up to 3-4 times a day. It has an
onset of 3-5 minutes and duration of 15-45 minutes.
iv) Protectants are used to provide a physical barrier to irritation and prevent excessive water loss from
tissues and they also have lubricating effects. Their duration is approximately 3-4 hours, which is limited
by the length of time on skin (ie. the greasier the better!) They are often used as bases or vehicles for other
active ingredients.
Glycerin 10-45% - applied up to 6 times a day, usually after each BM. Is less greasy than others but should
only be used for external application.
Shark liver oil 3% - applied in the morning, at bedtime and after each BM. Can be used for internal or
external application.
White petrolatum - applied liberally as needed for internal or external application.
Zinc oxide 5-10% - applied up to 6 times a day after each BM for internal or external application.
v) Vasoconstrictors are used to constrict blood vessels and are used temporarily to reduce swelling. They
are contraindicated in pregnancy, hypertension, diabetes, prostatic hypertrophy and thyroid disease. There
is possible systemic absorption if applied to abraded skin. May cause nervousness, tremor, sleeplessness,
nausea and loss of appetite. Risk of hypertensive reactions with monoamine oxidase inhibitors and tricyclic
antidepressants. They are absorbed systemically and therefore should not to be inserted into the rectum.
They have an onset of action of about 10 minutes and their duration varies from 30 minutes to 6 hours.
Ephedrine 0.1-0.31% - applied 4 times daily.
Naphazoline 0.04% - applied in the morning, at bedtime and after each BW up to 4 times a day.
Phenylephrine 0.25% - applied in the morning, at bedtime and after each BW up to 4 times a day.
vi) Antibiotics are used to treat or prevent any type of infections secondary to hemorrhoids.
vii) Oral analgesics such as acetaminophen or ibuprofen may help provide relief from mild discomfort or
pain.

Choice of Vehicle:
External--Wipes Do not deliver sufficient medication to site of action & inconvenient
since must be used often
Internal--Suppositories May slip into rectum and melt, bypassing the site of action
(anal canal)

Both--Ointments effective since occlusive emollient but greasy

Creams less efficacious c.f. ointments but may be more appealing to patient since
less greasy
Gels least occlusive c.f. ointments & creams but may a temporary cooling effect
upon application
Foam difficult to concentrate foam in correct area
Constipation Key Point Summary
Communication:
The patient may feel embarrassed about condition. Assure patient that condition is common to
ease embarrassment. Assure patient that constipation is both treatable and preventable.
Signs and Symptoms:
Hard dry stools
Straining during defecation
Sensation of incomplete defecation
Infrequent bowel movements (less that 3/week)
Abdominal distension (pain)
Risk Factors:
Dehydration
Lack of fiber in diet
Lack of activity
Decreased smooth muscle tone
Increased Age
Pregnancy
Neurologic or endocrine disorders
Medications Anticholinergics, Ca-channel Blockers, diuretics, MAOI, opiate analgesics,
NSAIDS, iron, TCA, chronic laxative overuse, antidiarrheal overuse, chemotherapeutic agents.
Differential Diagnosis:
Colon Cancer presents with bloody stool, pain.
Irritable Bowel Syndrome pain but more frequent BM.
Neurogenic constipation decreased peristalsis due to nervous system.
Colonic obstruction irregularities causing block of colon.
Prevention and Non-Pharmacological
Moderate changes in lifestyle such as increased fluids (2L/day) and fibre (~30g/daily)
Increase exercise to reduce stress and facilitate peristalsis
Avoid aggravating medications
Bowel movement regimes (try to have a consistent time for BM in morning after
breakfast, use footstool, do not strain)
Pharmacologicals:
Stimulant Laxatives (Senna, Cascara sagrada, Bisacodyl, castor oil)
- may cause abdominal pain, diarrhea, hypokalemia, allergic rxns, discoloration of urine to red,
pink, brown, or black

- can be excreted into breast milk

- Cascara sagrada not recommended for children and pregnancy
- Bisacodyl tablets cannot be crushed; should not be used with H+ pump inhibitors or H2 receptor
antagonists
- Melanosis coli: melanotic hyperpigmentation of colonic mucosa from long term use of
anthraquinones; reversable 3-12 months after discontinuation
Lubricants (Mineral oil)
- not recommended for children <1 yr, pts who are bedridden, have difficulty swallowing, gastric
retention, or GERD, due to aspiration risks
- not recommended for use > 1wk
- drug crosses the placenta; accumulates in tissue with repeated use
- can cause lipoid pneumonia, interfere with lipophilic drug absorption
- reduces absorption of vits A,D,E,K; potentiates anticoagulant effect
- do not use with docusate
Osmotics (Hyperosmotic, saline, enemas, lavage)
- pulls water into large instestine to make stool soft
- may cause rectal irritation (Glycerin supp), flatulence, abdominal cramps, diarrhea (lactulose,
sorbitol 70% solution), hypermagnesemia hypokalemia (Mg hydroxide), hyperkalemia (Mg
citrate), hyperphosphatemia (sodium phosphate), risk of mechanical trauma to rectal wall
(enemas)
- may slow absorption of drugs
- may reduce bioavailability of digoxin and tetracyclines (for Mg hydroxide and citrate); potential
for dehydration; not for pts with cardiac or renal disease
- lactulose not for pts with galactose free diet
- sodium phosphate not recommended for pregnant or nursing women, sodium restricted pts;
caution with renal/cardiac pts
- enema not recommended for children <2yrs; phosphate enema not for pts with potential for
prolonged retension, with cardiac or renal disease or with pre-existing electrolyte imbalance
- lavage (polyethylene glycol) usually used before colonscopy
Stool Softeners (docusate sodium, docusate calcium)
- it increases the liquid content of the stool
- not a laxative : does not cause bowel movement
- use < 1 week,
- may lead to dependence, and increase the absorption of medications when taken concomitantly
- contraindicated in pregnancy
Fibre/Bulk Forming Agents (bran products, psyllium mucilloid, methylcellulose sodium)
- bran products most effective in preventing constipation
- for all agents, take with plenty of water ( may lead to further constipation if not taken
with enough water)
- may reduce the efficacy of other drugs
Pharmacological Rankings:
- Stimulant laxatives= osmotics> lubricants = bulk forming agents> stool softeners
Onset/durations:
- Lubricants>osmotics>stimulants>bulk forming agents = stool softeners
Side effects:
- Stimulants>lubricants> osmotics = bulk forming agents > stool softeners
Convenience

- Bulk forming > stool softeners = osmotics = stimulants = lubricants

Cost
- Bulk forming agents > stool softeners > osmotics = stimulants = lubricants
References
Repchinsky, C, ed. Patient Self-Care. Helping patients make therapeutic
choices. Ottawa, ON: Canadian Pharmacists Association, 2002. p. 222-237
Key point summaries (0T3, 0T4, 0T5): URL:http://djs.phm.utoronto.ca/320/Oral
%20Exam/Key%20Point%20Summaries%20for%20Exam%20Topics.htm (Oct 29,2004)