Osce Revision

OSCE REVISION Legal prescription requirements (Standard NHS, Private): 1. Signature of prescriber – Must match the prescribers name 2. Address of prescriber 3. Date on prescription – valid for 6 months or 28 days if CD sch. 1,2,3,4 4. Particulars of prescriber – particulars that indicate the type of appropriate practitioner e.g. Dr. and GMC number 5. Name of patient 6. Address of patient – including house number/name and full postcode, if homeless NFA, not required for EEA 7. Date of birth or age of the patient if under 12 years – if it says Mr./Mrs. then assume patient is over 12 years but check age in case elderly Legal prescription requirements (EEA or Switzerland): 1. Patient details – full name and date of birth 2. Prescriber details – prescribers name, professional qualifications, direct contact details including email address, telephone/fax number with international prefix, work address including the country in which they work 3. Prescribed medicines details – name of the medicine (brand name where appropriate), pharmaceutical form, quantity, strength, and dosage details 4. Prescriber signature 5. Date of issue – valid for up to six months from the appropriate date, schedule 4 CD for 28 days - EVEN IF WRITTEN IN DIFFFERENT LANGUAGE, STILL LEGALLY ACCEPTABLE - PHARMACIST NEEDS TO HAVE ENOUGH INFORMATION TO ENABLE SAFE SUPPLY OF MEDICINES, CONSIDERING PATIENT CARE AND WELL BEING - SCHEDULE 1, 2 AND 3 CDs AND MEDICINAL PRODUCTS WITHOUT MARKETING AUTHORISATION VALID IN THE UK CANNOT BE DISPENSED IN THE UK WHEN PRESCRIBED BY A PRESCRIBER IN AN EEA COUNTRY OR SWITZERLAND Prescription requirements of Schedule 2 and 3 Controlled Drugs: 1. Signature of prescriber 2. Particulars of prescriber – particulars that indicate the type of appropriate practitioner e.g. Dr. and GMC number 3. Prescribers address 4. Date of prescription 5. Dose – must be clearly defined 6. Formulation – must be stated, abbreviations are acceptable 7. Strength – only needs to be written on prescription if more than one strength exist 8. Total quantity – must be written in both words and figures e.g. tablets, capsules, ampoules, millitres 9. Quantity prescribed/duration – max 30 days 10. Name of patient

11. Address of patient – if patient doesn’t have a fixed address (e.g. homeless or witness protection scheme) ‘no fixed abode’/’NFA’ is acceptable 12. Dental prescriptions – ‘for dental use only’ 13. Instalment direction – where the prescription is intended to be supplied in instalments a valid instalment direction is required Categories of Veterinary Medicines - POM-V – Prescription-only medicines that can only be prescribed by a veterinary surgeon and supplied by a veterinary surgeon or pharmacist with a written prescriptions - POM-VPS – Prescription-only medicines that can be prescribed and supplied by a veterinary surgeon, a pharmacist or a suitably qualified person or an oral or written prescription - NFA-VPS – A category of medicine for non-food animals that can be supplied by a veterinary surgeon, a pharmacist or a suitably qualified person; a written prescription is not required - AVM-GSL – An authorised veterinary medicine that is available on general sale Veterinary Cascade - Where available it is a legal requirement to: supply a licensed veterinary medicine - Only where above is not possible: an existing licensed veterinary medicine for another species or different condition can be considered - Only where above is not possible: a licensed human medicine or an EU-licensed veterinary medicine can be considered - Only where the above is not possible: extemporaneous or specifically manufactured medicines can be considered Prescription requirements for POM-V, POM-VPS and medicines supplied under the veterinary cascade: 1. Name, address, telephone number, qualification and signature of the prescriber 2. Name and address of animal owner 3. Identification and species of the animal and its address (if different from owner’s address) 4. Date – valid for 6 months or shorter if indicated by the prescriber (Sch 2, 3 and 4 CDs are valid for 28 days) 5. Name, quantity, dose and administration instructions of required medicine 6. Any necessary warnings and if relevant the withdrawal period 7. Where appropriate a statement highlighting that the medicine is prescribed under the veterinary cascade 8. Where Sch 2 or 3 CDs have been prescribed a declaration that the item has been prescribed for an animal/herd under the care of a veterinarian 9. If prescription is repeatable the number of times it can be repeated Clinical check: - Check drug is suitable for indication

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Correct dose, correct frequency Suitable formulation Suitable quantity Suitable duration Drug is suitable for age of patient Dose is suitable for age of patient Drug is suitable for ethnicity of patient Contra-indications or cautions Any interactions Any warnings required To be taken before/after food

Accuracy check: 1. Label against prescription 2. Product against prescription 3. Label against product 1. Label and Prescription a. Name of patient – prefix e.g. Mr./Mrs./Miss. Etc b. Name of the medicine c. Dose d. Strength e. Formulation f. Quantity g. Duration h. Directions i. Label warnings/specific medicine warnings 2. Product and Prescription a. Name of medicine b. Correct product inside the box c. Correct PIL inside box d. Strength e. Formulation f. Drug release type g. Correct quantity h. Expiration date i. Spoon if liquid dosage form 3. Label and Product a. Name of medicine b. Strength c. Formulation d. Quantity e. Duration f. Drug release type g. Direction h. Expiration date

Counselling Dispensing a prescription overall: 1. Introduction and confirm the correct patient 2. What is the medicine and why they are taking it 3. Dosage 4. Medicine related advice – side effect, cautions, best way to take 5. Lifestyle – habits contributing to health, exercise, diet, smoking, alcohol 6. Any questions Dispensing a prescription in detail: 1. Introduce yourself as the pharmacist 2. Explain the purpose of the consultation 3. Confirm identity of patient by asking name and address or date of birth 4. Ask about allergies 5. Ask if they take any other medicines 6. Ask if they have taken the medication before 7. Explain why they are taking the drug 8. Any specific medicine related points 9. Explain correct dosing 10.If you forget to take a dose, miss the dose and continue as prescribed the next dose, DO NOT take a double dose 11.If there are any changes see your doctor or pharmacist 12.Side effects – at least 3 – inform doctor 13.State if they need to take with water/before or after food etc. 14.Explain any warning side effects which need to be reported or looked out for 15.Suggest healthy lifestyle advice – exercise, diet, smoking, alcohol 16.Refer patient to PIL 17.Do they understand 18.Ask if the patient has any questions Responding to symptoms: 1. Introduce yourself as the pharmacist 2. Recap and confirm the symptoms 3. Explain the diagnosis 4. Explain the proposed cause of symptoms 5. Explain type of treatment and how to use it 6. Explain what the type of treatment does 7. Suggest one preparation 8. Propose additional advice 9. Other specific condition related advice

10. 11. 12. 13. 14.

Maintain eye contact Build rapport Speak clearly Use appropriate, patient friendly language Logical flow

Chicken Pox Observed behaviours 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0

Introduction as the pharmacist Recaps and confirms the child’s symptoms – flu like symptoms, fever, fatigue, aching body, headaches, loss of appetite Explains what diagnosis – CHICKEN POX Explains proposed cause of symptoms - viral Explains type of treatment and how to use – cooling gels/mouses/lotions, antihistamines, pain relief Explains what treatment does Suggestions of one of the following – calamine lotion, cooling gels, poxclin, chlorphenamine, paracetamol, DO NOT GIVE NSAIDS Drink plenty of water – keep hydrated Avoid scratching to prevent scarring – keep fingernails clean and short Loose-fitting clothes, smooth, cotton fabrics are best and will help skin from becoming sore and irritated To prevent spreading the infection, keep children off nursery or school until all spots crust over Keep away from public areas because can expose to risk groups such as pregnant women, new-born babies and people with weakened immune systems IF BLISTERS BECOME INFECTED REFER – surrounding skin becomes red and sore IF CHILD HAS CHEST PAIN, DIFFICULTY BREATHING REFER FEVER THAT LASTS LONGER THAN 24HRS Communication skills – maintains eye contact Communication skills – builds rapport Communication skills – speaks clearly Communication skills – uses appropriate, patient-friendly language Communication skills – consultation had a logical flow

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Cradle Cap Observed behaviours 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5

Introduction as the pharmacist Recaps and confirms the child’s symptoms – yellow or brown, greasy scaly patches on scalp, affected part of skin appears red Explains what diagnosis – CRADLE CAP Explains proposed cause of symptoms – overactive sebaceous glands, too much sebum causes flakes to stick to scalp Explains type of treatment and how to use – shampoos, oils Explains what treatment does Suggestions of one of the following – Dentinox Shampoo, Capasal Therapeutic shampoo Avoid using shampoos based on peanut oil or groundnut oil allergies Do not scratch or pick at it so an infection doesn’t develop Gently wash your baby’s hair and scalp with baby shampoo can help prevent the build up of scales Massaging baby oil or natural oil, such as almond or olive oil into their scalp at night can help loosen the crust, gently remove loose crust with soft cloth or baby rush in morning WASH AWAY ANY REMAINING OIL with baby shampoo – leaving any oil on the head could clog pores and cause flakes to stick REFER IF BABY NOT RESPONDING TO TREATMENTS INFLAMED OR INFECTED REFER IF ANY ITCHING/SWELLING REFER

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1 6 1 7 1 8 1 9 2 0

Communication skills – maintains eye contact Communication skills – builds rapport Communication skills – speaks clearly Communication skills – uses appropriate, patient-friendly language Communication skills – consultation had a logical flow

Colic Observed behaviours 1 2

3 4 5 6 7 8 9

Introduction as the pharmacist Recaps and confirms the child’s symptoms – excessive frequent crying, occurs in evening and the same time each day, baby becomes flushed, clench their fists, draw their knees up and arch their back Explains what diagnosis – COLIC Explains proposed cause of symptoms – no specific reason, doesn’t mean baby is unwell or unhealthy Explains type of treatment and how to use – simeticone: break up gas bubbles in GI tract, removing cows milk, lactase drops – break down lactose, hypoallergenic formula Explains what treatment does Suggestions of one of the following – Simeticone, Lactase drops, Hypoallergenic formula Removing cows milk if not tolerating cows milk, mother have a dairy free diet whilst taking calcium supplement. Make sure baby does not have Soy milk – hormones disrupt sexual

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and hormonal development Parental advice – look after own well being, can be stressful, get family support or friends. Hold your baby, in different positions Use fast flow teat, preventing baby from swallowing air by feeding upright, always burp the baby, gently massage baby tummy Bathe baby in warm water Changes to diet, breastfeeding women should avoid caffeinated and alcoholic drinks. REFER if weak, high pitched continuous cry, seem floppy when picked up, takes less than a third of usual amount of fluids, passes less urine than normal Communication skills – maintains eye contact Communication skills – builds rapport Communication skills – speaks clearly Communication skills – uses appropriate, patient-friendly language Communication skills – consultation had a logical flow

Teething Observed behaviours 1 2

3

Introduction as the pharmacist Recaps and confirms the child’s symptoms – red swollen gums, red flushed face or cheeks, dribbling more than usual, waking more at night, inconsistent feeding, rubbing gums, biting, chewing or sucking Explains what diagnosis – TEETHING

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4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0

Explains proposed cause of symptoms – new teeth Explains type of treatment and how to use – teething rings (place in fridge), paracetamol/ibuprofen, teething gels (local anaesthetic/mild antiseptic), teething granules Explains what treatment does – bonjela: relieves the pain, ibuprofen/paracetamol: relieve pain Suggestions of one of the following – bonjela, ibuprofen/paracetamol, teething rings Gently rubbing over the affected gum with clean finger may ease pain Cool, sugar free drinks Try chilled water in a bottle/cup if can’t eat yet Rash on chin after dribbling? Apply petroleum jelly as a barrier cream REFER if high temperature REFER if diarrhoea

Communication skills – maintains eye contact Communication skills – builds rapport Communication skills – speaks clearly Communication skills – uses appropriate, patient-friendly language Communication skills – consultation had a logical flow

Conditions and treatments: responding to symptoms Constipation - Arises when a patient experiences a reduction in their normal bowel habit with more difficult defecation and/or hard stools - Very common – all age groups, most common in the elderly – 25-40% over 65 have constipation - Women 2-3 times more likely to suffer than men and 40% of women in late pregnancy suffer constipation Symptoms - Discomfort on passing of stools - Abdominal discomfort or cramps - Bloating - Feeling of emptying of rectum - Feeling of obstruction or blockage - Need to manually assist defecation Causes of constipation - Eating habits/lifestyle – most likely o Poor fluid intake o Travel o Deficiency in dietary fibre intake o Pregnancy as hormonal changes slow down gut movements as the baby takes up room and exerts pressure on the bowel o Reduced mobility o Change in lifestyle or environment o Ignoring of reflex to defecate - Medication – likely o Most exert action by decreasing gut motility thereby causing constipation o Opiates o Aluminium salts o Antidepressants o Anti-Parkinson’s medication – should be on laxatives o Anticholinergic – antihistamines o Iron o Phenothiazine – antipsychotics o Laxative abuse - Underlying conditions – unlikely o Irritable bowel syndrome o Pregnancy o Depression o Functional disorders (children - Colorectal cancer/HIV – very unlikely

Diagnosis - Establish the patients current bowel habit compared to normal - This will establish if the patient is suffering from constipation - Then concentrate on determining the cause – blood present? Pain on passing stool? Other symptoms? Changes in diet? Lifestyle?

Specific Questions to ask - Change of diet or routine? o Constipation usually has a social or behavioural cause o Usually some event that has precipitated the onset of symptoms - Pain on defecation? o Usually due to a local anorectal problem – referral - Presence of blood? o Bright red specks in the toilet or smears of blood on the toilet tissue indicate haemorrhoids or anal canal fissure o If blood is mixed in the stool then referral is necessary o A dark stool that is black/tarry is indicative of a bleed higher up in the GI tract - Duration – acute or chronic? o Chronic if it has lasted longer than 6 weeks o Cases of more than 14 days with no identifiable cause or previous investigation by the GP should be referred - Lifestyle changes o Changes in job/marital status can precipitate depressive illness that can manifest with physiological symptoms such as constipation

Trigger points – indicative of referral - Pain on defecation causing patient to suppress the defactory reflex – check for anal fissure - Patients aged 40 years and over with a sudden change in bowel habits with no obvious cause – could be a danger symptom for rectal carcinoma - Greater than 14 days duration with no identifiable cause – suspects underlying cause requiring fuller investigation by GP - Tiredness – check for anaemia or thyroid dysfunction - Blood in the stools - If a child refer Treatment - Should take a stepped care approach - Uncomplicated – non drug treatment is 1st line for all patient groups - Simple dietary and lifestyle modifications will relieve majority of cases - Any possible changes to medication currently on - Lifestyle measures o Increase dietary fibres (30g daily) – fruits, cereal, brown bread, rice, pasta, bran flakes o Increase fluid intake minimum 1.6L (8 glasses) for women and 2L (10 glasses) for men of water a day o Increase in exercise – walking to work, about 30 mins a day if they can – give the patient mobility o Toileting – go when needed, unhurried, establish a regular routine and position - OTC treatment o Bulk forming agents  Increases faecal volume like fibre  Retains fluid in the stool thereby softening the faeces  Must maintain fluids as could potentially cause gut obstruction  Side effects: - flatulence and bloating in the first few weeks  Works in – 12-24 hours  E.g. wheat bran, Isphagula husk (Fybogel), Sterculia, Methylcellulose o Stimulant laxatives  Stimulates nerves in large intestine increasing peristalsis and gut motility  Works in 8-12 hours – take at bedtime to go in the morning  Side effects: - abdominal cramps, diarrhoea, lazy bowel  E.g. senna, bisacodyl, glycerol, sodium picosulfate o Osmotic laxatives  Draw water from intestinal wall into the lumen  Raises intra-luminal pressure increasing volume of contents stimulating peristalsis  Not for chronic use  4-72 hours to work  Side effects: - abdominal pain, bloating

 E.g. lactulose, macrogols and magnesium salts o Faecal softeners/lubricants  Lowers surface tension of intestinal content  Docusate sodium and liquid paraffin

Diarrhoea - An increase in frequency of the passage of soft or watery stools relative to the usual bowel habit for that individual - Acute – less than 7 days - Persistent – more than 14 days - Chronic – more than a month Symptoms - Passing of frequent, soft watery stools - Irritation of stomach lining - Stomach cramps - Nausea - Fever - Loss of appetite - Dehydration Causes of Diarrhoea - Infective causes – most likely o Bacterial  Shingella, Salmonella, E.coli, Bacillus  Contaminated food/drink  Travellers diarrhoea – E.coli o Viral  Acute gastroenteritis  Rotavirus o Protozoa – tropical - Non infective cases o Anxiety o Emotional upset o Medication - likely  Metformin, iron o Alcohol o Coffee o Sweets high in sorbitol content - IBS, giardiasis, faecal impaction – unlikely - Ulcerative colitis and Crohn’s disease, colorectal cancer, malabsorption syndromes – very unlikely Diagnosis and Specific Questions - Frequency and nature of the stools o What does it look like – watery without blood, or is there blood and mucus present? o Watery without blood – shows that it is infective and so self limiting

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o Diarrhoea associated with blood and mucus – referral to eliminate invasive infection o Blood – IBD Periodicity – previous history of recurrent diarrhoea should be referred Duration – refer if greater than 4 days in adult, or 2/3 days in child/elderly Onset of symptoms – any new foods/changes to the diet Abdominal pain? Travel? Signs of dehydration o Unsatisfied thirst o Dry tongue/mouth o Poor urine output o Rapid breathing o Lethargy/confusion o Cold, clammy, wrinkly skin

Trigger points – indicative of referral - Change in bowel habit in over 50s – may have sinister pathology - Following recent travel – rule out giardiasis - Duration longer than 2/3 days in children/elderly – at risk of dehydration and associated symptoms - Presence of blood in stools, faecal impaction in elderly, severe abdominal pain – further investigation by GP - Malaise or fever - More than 4 days in an adult - 12 years – 1 spray into affected ear TDS o Continue 2 days after symptoms have disappeared o No improvement or worsening after 48 hours – Refer o Don’t use for longer than 7 days Earwax impaction - Ear wax is produced in the outer third of the cartilaginous portion of the ear canal by the ceruminous glands - Used for mechanical protection of tympanic membrane, trapping dirt, repelling water and exerting protection against bacterial/fungal infection - Most common external ear problem - Clinical features include – gradual hearing loss, ear discomfort, recent attempts to clean ears, itching, tinnitus and dizziness Specific questions to ask a patient: Ear wax - Course of symptoms o Gradual hearing loss with ear wax impaction

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Associated symptoms o Dizziness and tinnitus indicate inner ear problem so refer o Ear wax impaction rarely causes tinnitus, vertigo or true pain History of trauma o Check if person has recently tried to clean ears o This often leads to wax compaction Use of medicines o If a patient has used an OTC medication correctly this would require referral for further investigation

Referral of Ear Wax Impaction - Dizziness or tinnitus – suggests an inner ear problem - Pain originating from the middle ear - Fever or malaise in children - Associated trauma related conductive deafness - Foreign body in the EAM - OTC medication failure OTC treatments for Ear Wax Impaction - Oil based products – Cerumol Ear drops – (arachis – peanut oil, 57.3%) o 5 drops into affected ear 2/3 times daily for 3 days o In between, administration of cotton wool smeared in petroleum jelly should be applied to retain liquid - Oil based products – Cerumol Olive Oil Drops – (olive oil 100%) o 2/3 drops instilled twice a day for upto 7 days o In between, administration of cotton wool smeared in petroleum jelly should be applied to retain liquid -

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Peroxide based products – exterol and otex Docusate – waxol Sodium bicarbonate Glycerin – earwax advance and earex plus

Colic - Excessive crying usually in the first few weeks of life and usually resolves by age of 3-5

months Defined as crying for more than 3 hours a day for more than 3 days a week for more than 3 weeks Patients parents/carer may not necessarily wait for 3 weeks as it can be very distressing

Symptoms of Colic - Excessive high pitched crying usually in late afternoon/evening (6pm) - Face may appear flushed - May pass gas when crying - Clench their fists - Arching of the back - Drawing up of knees to their tummy - Bloated tummy - Crying outbursts are not harmful – the baby will continue to feed and gain weight as normal Causes

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Unknown but thought to be multifactorial Linked to disorder of GI tract Spasmodic contraction of smooth muscle causes pain and discomfort Allergy to cow’s milk or lactose intolerance Trapped wind Hormonal imbalances

Specific questions to ask patient: Colic - Crying quality o High pitched crying with facial flushing, drawing up of knees, fist clenching are commonly observed in colic - History of crying o Excessive crying is not isolated and will have been present for some time o Acute infections are sudden in onset and baby will not exhibit a long-standing history of excessive crying - Aggravating factors o Hunger, thirst, too hot, cold, trapped wind Trigger points – indicative of - Infants that are failing to put on - Medication failure - Over anxious parents

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Reduced urine output Pale skin High fever

referral weight

Treatments available for Colic - Re-assure the parent that the child is normal, thriving and healthy - Non medical treatment o Comforting the baby while crying – hold them o Wind the baby after feeding, sit upright during feeding to avoid trapped air o Avoid picking up and putting down too many times – overstimulation o Try holding baby in different position o Background white noise may help o If breast feeding – reduce caffeine intake, spicy food, alcohol o Use a fast flow teat - Review the feeding technique – underfeeding can result in excessive suckling and therefore excess air being swallowed resulting in colic like symptoms - Consider removal of cow milk from baby’s and mothers diet or try hypoallergenic milk formula - Medical treatment o Simeticone – Infacol and Dentinox simeticone drops (2.5ml from syringe or to the bottle, max 6 doses in 24 hours)  Pharmacologically inert – no side effects, interactions  Gentle relief of trapped wind or griping pain  Can be safely prescribed to all infants  With or just after each feed  Try for one week, if not improvement, stop treatment and refer o Lactase enzyme – Colief infant drops  Breaks down lactose present in milk to glucose and galactose

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Reported to improve colic symptoms Safe/natural and may help in short term lactose intolerance Bottle - 4 drops to bottle every time the baby is fed Breastfeeding - add few tablespoons of breast-milk and 4 drops of Colief and give to baby – then continue breastfeeding as normal

Chickenpox - Mild, common childhood illness - Caused by the varicella zoster virus - Transmitted by droplet infection – coughing and sneezing and, due to fluid from blisters - Remains dormant in the body for upto 14 days before any symptoms are seen – incubation period - Spotty blistering red rash then appears which can cover the whole body - These normally appear in clusters – behind ears, face, scalp, chest, belly, arms and legs - Appear as small red lumps which turn into fluid filled blisters and then crusted spots - Most infectious period is when red rash appears - When spots have crusted it is no longer contagious

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Before the rash appears there are flu like symptoms – nausea, fever, aching, headache, feeling unwell, loss of appetite Most infectious 1-2 days after the rash appears (1-2 days) until all blisters have crusted over (5-6 days)

Treatments of Chickenpox - No known cures - Clears without the need for treatment - Symptomatic treatments exist – fever, pain and high temperature o Mild painkiller – Paracetamol, Calpol – NSAIDs 2nd line due to potential skin problems o Itching – soothing emollient creams – calamine lotion o Itching – sedating antihistamines – chloramphenamine – piriton General advice - Itching o Ensure the child has short clean fingernails so doesn’t infect or scar from scratching o Put socks on hands overnight - Fever o Wear loose, smooth, cotton clothes o Avoid sponging with cool water – may irritate further - Hydration o Maintain a high fluid intake o Sugar free ice lollies Prevention of spread - Keep at home for at least 5 days - Stay at home until the blister has crusted over - Avoid contact with pregnant women, new borns or those with weak immune systems - Maintain hygiene – wipe down toys, and surfaces - Wash bedding/clothes more regularly Referral of Chickenpox - Suspected meningitis - Signs of infection - Rash for over 2 weeks - Fever lasting longer than 24 hours - Vomiting - Neck stiffness Cradle Cap - Appears as large yellow, greasy scales and crusts on the scalp - This can become thick and cover the whole scalp - Can affect other areas such as the face and napkin area - Common harmless condition – doesn’t usually itch or cause discomfort Causes of Cradle Cap - Characterised by increased cell turnover rate - Cause linked to overactive sebaceous glands

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Babies may also retain their mothers hormones for several weeks/months making the babies glands more active Excessive sebum causes old cells to stick to the scalp instead of drying and falling off It is not contagious and isn’t caused by poor hygiene or allergy

Symptoms - Harmless condition - Doesn’t itch or cause discomfort to the baby - Occurs on scalp, face, nose, groin, ears, neck, skin folds, knees and armpits - Greasy yellow patches on scalp - Scales eventually start to flake and effected area appears red - Hair can come away with the scales/flakes Treatment - Most cases clear in own time - Gently washing with shampoo can help prevent build up - Baby oil, natural oil, almond oil, olive oil can be used to loosen crusts - Wash more frequently, don’t pick as it can cause infection - Stronger shampoos can help loosen it o Dentinox Cradle Cap shampoo – 2 applications repeated at each bath time until scalp is clear – then use as necessary o Contains sodium lauryl sulfate which is a cleaning agent that de-greases the skin o Wash hair 2-3 times a week Referral - Speak to GP in case of uncertain diagnosis - Severe cradle cap - Swelling - Bleeding - On face or body - Inflamed/infected - OTC treatment failure

Teething - Teething is when a baby’s milk teeth come through the gums at around the age of 6 months causing irritation Symptoms of Teething - May have no pain or discomfort - Gum can be sore or red

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Flushed cheeks on the side of face where teething is occurring Gnawing/chewing gums Rubbing of ear on same side as the tooth More frequent dribbling Waking up at night Generally unsettled Inconsistent feeding

Cause of teething is the emergence of new milk teeth through the gums Treatments of Teething - Teething rings o Provide something safe to chew on, easing pain, distraction technique o Can be cooled in a fridge o Can use a wet flannel - Teething gels – bongela teething gel/calgel o Over 4 months old o Sugar free gel can be rubbed on o Contains a mild local anaesthetic which can numb pain o Can contain antiseptic to prevent infection o Rub onto baby’s gums with a clean finger - Can give baby something healthy to chew on – veg/fruit o Stay near by in case they choke o Avoid items with lots of sugar – decay risk - Pain killers - Calpol o If baby is in pain/high temp o Small doses of ibuprofen or Paracetamol o Should be sugar free o No aspirin - Tips o Cool drinks – sugar free o Comfort and play with baby to distract it o Prevent teething rashes by wiping excess dribble from the chin Referral for Teething - Severe symptoms lasting longer than a few days - 18 months and no teeth - Visible signs of tooth decay - Double row of teeth - Small jaw defect - Facial injury

Private Prescription Registers 1. Reference e.g. Book A, Page 8, Item 1 or A/8/1 2. Prescription date 3. Supply date 4. Medicine details a. Name

b. Quantity c. Formulation d. Strength of medicine supplied 5. Prescriber details a. Name and address of practitioner b. GMC number c. Telephone number 6. Patient details a. Name and address of patient Controlled Drugs Register 1. Class - look for drug subtitle in the BNF 2. Name of Drug/Brand – what is written on prescription/BNF 3. Strength 4. Form – drug formulation on prescription 5. Date supplied – today’s date 6. Name and address of person/firm supplied – patient name/address 7. Prescribers details – prescriber name and address 8. Person collecting/representative – patient name/address 9. Proof of identity – yes 10.Proof of identity of person collecting provided – yes 11.Quantity supplied – quantity on the prescription 12.Balance – take away the quantity supplied from total 13.Name of pharmacist – Vivek Patel, UCL SoP, London, WC1 XXX, (GPhC number) 14.If a mistake is made – sign, date and GPhC number

Diabetes - Type 1 diabetes mellitus: the body's failure to produce sufficient insulin - Type 2 diabetes mellitus: resistance to the insulin, often initially with normal or increased levels of circulating insulin - Gestational diabetes: pregnant women who have never had diabetes before but who have high blood sugar (glucose) levels during pregnancy are said to have gestational diabetes

Driving - Drivers with diabetes may be required to notify the Driver and Vehicle Licensing Agency (DVLA) of their condition depending on their treatment, the type of license, and whether they have diabetic complications - If hypoglycaemia occurs, or warning signs develop, the driver should: o Stop the vehicle in a safe place; o Switch off the ignition and move from the driver's seat; o Eat or drink a suitable source of sugar; o Wait until 45 minutes after blood glucose has returned to normal, before continuing journey. Type 2 Diabetes - First line treatment – life style interventions including diet and exercise - If this doesn’t control glucose levels after 3 months – use metformin or sulphonylureas - Metformin is the drug of first choice in overweight patients in whom strict dieting has failed to control diabetes, may also be considered as an option in patients who are not overweight - Sulfonylureas are considered for patients who are not overweight, or in whom metformin is contra-indicated or not tolerated - When combination of strict diet and drug therapy fails – use a combination of metformin and sulfonylurea Metformin - Increases sensitivity of cells to insulin allowing the body to make better use of lower insulin levels - Drug of 1st choice in overweight patients in whom strict dieting has failed to control diabetes, also considered in those who are not overweight - When combination of strict diet and metformin treatment fails – combine with sulfonylurea - Usually once daily with breakfast – may be increased to twice daily - Take tablet with or immediately after a meal at the same time each day - Side effects – nausea, diarrhoea, abdominal pain, weight loss - Complications – lactic acidosis - Contra-indications – renal impairment, ketoacidosis, low BMI - If a dose is missed, take as soon as you remember unless it is close to the next dose time Sulfonylureas – Glibenclamide, Gliclazide, Glimepiride, Glipizide, Tolbutamide - Augment insulin secretion and are only effective when there is some pancreatic beta cell activity present - Considered for patients who are not overweight or in whom metformin is contra-indicated or not tolerated - When combination of strict diet and sulfonylurea treatment fails – combine with metformin

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Glibenclamide – long acting, greater risk of hypoglycaemia, avoided in elderly, - Gliclazide or tolbutamide – shorter acting alternatives - Can encourage weight gain, avoid in pregnancy and hepatic impairment - Nausea, vomiting, diarrhoea, constipation Hypoglycaemia - Shaky, anxiousness, sweating - Initially 10-20g glucose – either glass of lucozade, coke, 2 teaspoons of sugar or 3 sugar lumps - If necessary repeat after 15 minutes - Then a snack containing carbohydrate – sandwich, fruit, milk biscuits Alendronic Acid – (bisphosphonate) - Treatment of Postmenopausal osteoporosis – 10mg daily/70mg once weekly - Stops break down of bones, but new bones are still made - Tablets should be swallowed whole with plenty of water while sitting or standing - To be taken on an empty stomach at least 30 minutes before breakfast - Patient should stand or sit upright for at least 30 minutes after taking tablets – can do some housework or go for a shower in this time/get ready - Side effects – oesophageal reactions, abdominal pain, distension - If pain when swallowing, severe oesophageal irritation occurs, worsening heart burn then seek medical advice - Likely that you may require some calcium supplement to further strengthen the bone, discuss with the GP - Dental check ups also vital – can occur in the jaw – see dentist regularly, maintain good oral hygiene, report any oral symptoms to your dentist/GP - Life style advice o Quit smoking? – Risk factor o Maintain oral hygiene – brush twice a day, floss o Maintain an adequate dietary intake of calcium/Vit D – milk, yoghurt, cheese or take supplements o Regular exercise – walking/cycling/weight bearing – 30 minutes o Levothyroxine – (thyroid hormone) - Hypothyroidism – over 18 years, initially 50-100 micrograms once daily, maintenance dose 100-200 micrograms once daily - Over 50 – initially 25 micrograms OD and maintenance dose of 50-200 micrograms - Take at least 30 minutes before breakfast or any caffeine containing liquids/other medication - Side effect – diarrhoea, vomiting, anginal pain Doxycycline – (tetracycline) - Acne vulgaris (usually) – 100 mg OD - Capsules should be swallowed whole with plenty of fluid during meals while sitting or standing to avoid reflux/irritation - Avoid using indigestion remedies - Absorption is affected by heavy metals - Side effects – nausea, vomiting, diarrhoea

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Use sun screen (may make skin sensitive to sunlight), wash face regularly, be careful with what products you use in case it aggravates the skin

Benzoyl peroxide (quinoderm cream) – (topical preparations for acne) - Acne vulgaris – apply 1-2 times daily, preferably after washing face with soap and water, start treatment with lower strength preparations - May bleach clothing, hair, avoid broken skin - If first time using the product, patch test - Apply a thin layer - Be careful not to use too many product as to dry the skin out, causing a re-bound effect so the skin produces more oil, aggravating the skin - Side effects – skin irritation (if you get this, reduce the frequency until irritation subsides) - Finish the entire course - Clean sheets, clean towels, don’t keep touching the face Loestrin – (combine oral contraceptive) - Combined oral contraceptive pill – one tablet once daily and the same time every day - If reasonably certain you aren’t pregnant, can be started on any day of the cycle, if not then day 1-5 of the cycle - If the pill is missed, take as soon as possible and carry on with the next pill at the correct normal time - If more than 2 pills are missed, you may not be protected, so abstain from sex or use an additional method of contraception - If you vomit within 2 hours of taking the pill, take another - Continual basis - May have menstrual irregularities - After 21 days there will be a 7 day break – you should have your period in this time - Increased risk of venous thromboembolism – esp. whilst travelling with 3 hours of immobility, risk can be reduced by appropriate exercise during journey and wearing graduated compression hosiery – travel socks Co-beneldopa – (1 part benserazide hydrochloride and 4 parts levodopa) - Parkinson’s disease – 50mg 3-4 times daily initially, maintenance 400800mg daily in divided doses, elderly 50mg once or twice daily, increased by 50 mg every 3-4 days ( - with or after food, with food helps reduce side effects such as nausea - Increases the levels of dopamine in the brain - Co-formulation helps with the side effects - Excessive daytime sleepiness and sudden onset of sleep can occur with co-beneldopa so exercise caution when driving or operating machinery - Side effects – nausea, vomiting, taste disturbances - Read additional information PIL - May colour urine which is completely normal - Join Parkinson’s UK for more information

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Life long medication – meet regularly with GP as tolerance can develop so can discuss dosage changes o Eat healthily – reduce levels of saturated fats, less fried foods, grilled meats etc, include 5 portions of fruit and veg, reduce salt intake o Exercise – gradually increase exercise – brisk walking, climbing stairs etc

Carbamazepine – (anti-epileptic drugs) - Epilepsy, prevents seizures – initially 100-200mg 1-2 times daily, increased slowly to usual dose of 0.8-1.2g daily in divided doses (elderly, initial dose is reduced) - May make you sleepy, do not drive or use tools or machinery - Do not stop taking this medicine unless told to by your doctor - Side effects – headache, drowsiness, nausea - Only allowed to drive if they have been seizure free for one year, subject to attacks while asleep only, if drowsy don’t drive - Avoid drinking alcohol - Avoid drinking grapefruit juice - Make sure every time you collect this medicine it is the same type and brand unless changed by doctor as each brand works differently in the body - Seek immediate medical attention if you experience symptoms such as fever, mouth ulcers, bruising or bleeding - Do not share the medicine with anyone else - Did you know you are exempt for paying for prescriptions as you have epilepsy? Proton Pump Inhibitors – Esomeprazole, Lansoprazole, Omeprazole, Pantoprazole, Rabeprazole - Medicines used to inhibit gastric acid secretion by the blocking of the H+/K+ATPase proton pump of the gastric parietal cell - They are effective short term treatment for gastric and duodenal ulcers - They are often used in combination with antibacterials for the eradication of H. pylori - Used for the treatment of dyspepsia and gastro-oesophageal reflux disease (GORD) - Used for prevention and treatment of NSAID-associated ulcers - Side effects – GI disturbances (nausea and vomiting, abdominal pain, flatulence, diarrhoea and constipation - Rebound acid hypersecretion and dyspepsia may occur after stopping prolonged treatment Simvastatin – (statin) - High cholesterol – lowers cholesterol – 10-20mg daily at night - Before or after food - Don’t drink grapefruit juice as it increases amount of drug in the body

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Seek medical advice in case of unexplained muscle pain, tenderness or weakness Long term medication so take regularly

Glyceryl Trinitrate tablets – Nitrates - A medicine that acts to dilate blood vessels to increase the amount of blood and oxygen reaches the heart - Lasts for only 20-30 minutes - Carry these tablets around at all times - Can take one tablet before physical exertion to prevent anginal attacks/symptoms - Dissolve tablets under the tongue, don’t swallow or chew - Can also be taken when required for treatment of anginal chest pain - Take one tablet and dissolve under the tongue and take a break for 5-10 minutes - If the pain doesn’t ease within a few minutes take another dose - If the pain continues for 15 minutes in total then call an ambulance - 300 microgram tablet most effective when first used - You will need to store tablets in a bottle with the cap tightly and get a new supply within 8 weeks of opening as they have short shelf life - Tolerance may develop - Sublingual: prophylaxis and treatment of angina - Injection: control of hypertension and myocardial ischaemia - Cautions – hypothyroidism - Contra-indications – hypersensitivity to nitrates - Side effects – postural hypotension so get up slowly, throbbing headache, dizziness - Lifestyle o Eat healthily – reduce levels of saturated fats, less fried foods, grilled meats etc, include 5 portions of fruit and veg, reduce salt intake o Moderate exercise – start slowly – keep tablet with you at all times o Consider joining a healthy eating or weight loss group o Consider stop smoking? o Reduce alcohol intake? Aspirin – antiplatelet - Used to reduce the risk of a blood clot in the body by thinning the blood - 75mg OD - Rarely causes stomach irritation - If you need a painkiller, take Paracetamol over NSAIDs such as ibuprofen as they can increase the blood thinning properties - Do not take indigestion remedies 2 hours before or after you take this medicine - Swallow this medicine whole, do not crush or chew - This medicine contains aspirin, do not take anything else containing aspirin

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Long term medication so maintain regular contact with your GP for check ups Lifestyle o Stop smoking? – Greatly increases risk of blood clotting o Eat healthily – reduce levels of saturated fats, less fried foods, grilled meats etc, include 5 portions of fruit and veg, reduce salt intake o Exercise – gradually increase exercise – brisk walking, climbing stairs etc

Angiotensin Converting Enzyme Inhibitors – Captopril, Enalapril, Ramapril - Inhibit the conversion of angiotensin I to angiotensin II - Used in heart failure – usually combined with a beta blocker (must stop potassium supplement/diuretics except for low dose spironolactone) - Hypertension – most appropriate initial drug for hypertension in younger Caucasian, Afro-Caribbean and over 55 year old patients – first dose at bed time - Used in early and long-term management of patients who have had myocardial infarction - Side effects – hypotension, renal impairment and persistent dry cough - If you experience a persistent cough – inform your GP - Lifestyle o Stop smoking? – Greatly increases risk of blood clotting o Eat healthily – reduce levels of saturated fats, less fried foods, grilled meats etc, include 5 portions of fruit and veg, reduce salt intake o Exercise – gradually increase exercise – brisk walking, climbing stairs etc

Beta-adrenoceptor blocking drugs – Atenolol, Bisoprolol Fumarate - Used to slow the heart rate – Hypertension, Arrhythmias, Angina and as an adjunct in heart failure - Fatigue, coldness of extremities, sleep disturbances with nightmares - Do not stop taking this medicine unless your doctor tells you to stop - Lifestyle o Stop smoking? – Greatly increases risk of blood clotting o Eat healthily – reduce levels of saturated fats, less fried foods, grilled meats etc, include 5 portions of fruit and veg, reduce salt intake o Exercise – gradually increase exercise – brisk walking, climbing stairs etc Methadone - Opioid dependence

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Long acting opioid Used for abstinence of heroin Dose will be increased slowly as dose can be cumulative resulting in toxicity May need to come in everyday for supervised administration Tolerance develops If you miss 3 days this tolerance will be lost and dose will need to be reduced as patient is at risk of overdose Supportive care programme may be offered Shouldn’t take any other street drugs Avoid alcohol Stop smoking services?