Otc Summary

OTC Summary for Intern Pharmacists
Abbz Gayed
Abbz Gayed, 2015

Glossary
Pediatrics- Page 3
Oral Health- Page 10
Women’s Health- Page 17
Pregnancy and Breastfeeding- Page 22
Dermatology- Page 33
Gastroenterology- Page 51
Eye Disorders- Page 59
Respiratory- Page 69
Pain- Page 73
Ear, Nose and Throat- Page 78
Miscellaneous- Page 84
2
Pediatrics
1. Teething- Page 4
2. Fever/Febrile Convulsions- Page 5
3. Gastroenteritis and Dehydration- Page 6
4. Colic- Page 7
5. Cradle Cap- Page 8
6. Nappy Rash- Page 9
3
1. Teething
 Usually erupt at 4 months and full teeth at 2-3 years
Symptoms
 Drooling
 Irritability
 Swollen gums
 Clingy behavior
 Disrupted sleeping patterns
 Rash around chin from drooling
Questions to ask?
 Fever?
 Any other Sx
 How old
Non-pharmacological measures
 Teething ring (silicone based as liquid filled can rupture and leak)
o Can put in fridge but NOT freezer as can get ice burn
 Rub baby’s gums
 Let baby suck on dummy or chew on clean, damp cloth
 Dry biscuits to chew on
Treatment
Treatment Directions/Strength
Paracetamol 15mg/kg every 4-6 hours, MAX 60mg/kg
Ibuprofen 5-10mg/kg every 6-8 hours with food, >3 months, MAX
3 doses in 24 hours
Bonjela (Choline 8.7%, 0.5cm strip to the baby’s gums every 3 hours, >4
salicylate) months due to Reye’s Syndrome, MAX 6 doses per day)
Orabase Protective Paste Take a small dab of ORABASE Paste and coat the
(gelatin, involved area of the mouth with a thin film. Hold in
carboxymethylcellulose) position until it becomes sticky. Do not attempt to rub it
in)
2. Fever/Febrile convulsions
4
 Temperature greater than 37 degrees
 Treat symptoms not the fever
 Fever itself is not harmful
Symptoms
 Temp >37
 Irritability
 Fatigued
 Tired
 Dehydrated
o Low urine output
o Sulken eyes
o Skin turgor
 Not eating well
Questions to ask?
 Duration?
o More than 5 days needs referral
 Age?
o <3 months needs referral
 Any other symptoms?
 Are their day to day habits disrupted?
Non-pcol measures
 Dress in damp clothes
 Drink plenty of fluids
Treatment
Paracetamol 15mg/kg every 4-6 hours, MAX 60mg/kg
Ibuprofen 5-10mg/kg every 6-8 hours with food, >3 months, MAX
3 doses in 24 hours
Referral points
 <3 months old
 More than 5 days
 Fever and no other Sx
 Dehydration
 Stiff neck
 Non-blanching rash (reddish rash)
 Febrile convulsion experienced
o Lay child on side with head on side
o Cool washes and undress to singlet
o Seek medical attention
3. Gastroenteritis and Dehydration
5
 Diarrhoea in infants
 NO ANTI-DIARRHOEALS
Symptoms
 Vomiting
 Diarrhoea
 Abdominal pain
 Cramping
 Dehydration
 Reduced appetite
Questions to ask?
 Age?
 Duration?
 Dehydrated?
 Can they keep fluids down?
 Blood in vomit or stools?
 Fever or other Sx?
 Worse or improving?
Non-pcol measures
 BRAT diet
o Bread, rice, apples, toast
 Avoid irritating foods eg. Dairy, spicy foods
 Continue to breastfeed or bottle feed
Treatment
Hydralyte (combo of 0-3 years= 100mL every 90 mins
electrolytes) 3-6 years= 100mL every 60 mins
6-12 years= 100mL every 30 mins
12-adult= 200mL every 30 mins (MAX 4000mL in adult)
 Sip slowly. Refrigerate after opening and discard after
one month
 Liquid, sachets, icy poles, effervescent tabs
Referral points
 <6 months= diarrhoea for >6 hours
 6 months – 3 years= diarrhoea for > 12 hours
 3-6 years= diarrhoea for >24 hours
 6 years – adult= diarrhoea for >48 hours
 Failure to gain weight
 Severe signs of dehydration (no urine output)
 Blood in vomit or stools
4. Colic
6
 Crying and screaming for 3x3x3 (>3 hours, >3 days per week, >3 weeks)
Symptoms
 Crying for 3x3x3  Irritable
 Clenched fists  More common in
 Pulled up legs up to belly and evening/night
periodic flexing
Questions to ask?
 Duration?  Any other Sx?
Non-pcol measures
 Sooth baby  Can try a one week trial of
 Swaddle in blankets hyperallergenic formula for
 Rock baby back and forth colicky babies
 White noise eg. Vacuum  Can try soy formula
cleaner  If already breastfeeding, don’t
 Check sucking technique (air in switch to formula
babies tummy could cause  Burb baby after meals
colic)  Warm baths
 Check teet on bottle (should  Assure parents that they are
slowly drip when tipped upside NOT bad parents
down)  Take breaks and have someone
 Don’t under or over feed else supervise baby
 Switching to formula is unlikely
to help
Treatment
Treatment Dosage/directions
Infacol drops (Simethicone) 6 months-2 years= 0.2mL into bottle or into baby’s
mouth before feeds
> 2 years= 0.4mL qid after foods
MAX: 12 doses per day
Brauer Baby and Child Colic -Camomilia and others
<6 months= 0.5mL every 30 mins up to 4 doses
then q4h thereafter
>6 months= 1mL every 30 mins up to 4 doses then
q4h thereafter
AVENT Natural Anti-colic Vent pushes air into bottle NOT the baby’s tummy
system (bottle)
Referral
 Failure to put on weight  Over anxious parents
 Lactose intolerant  Signs of systemic infection
 > 4 months old
5. Cradle cap
7
 Form at about 1 month and subside at 8-12 months
 Not itchy and not contagious
 Recurrent cases could be fungal infections
Symptoms
 Thick yellow and greasy scales on scalp and face
 Baby is otherwise normal and happy
Questions to ask?
 Age?
 Duration?
 Any other Sx?
 Family Hx of dermatitis (generally there is no family history associated with
seborrhoeic dermatitis whereas in psoriasis and atopic dermatitis family
history is more likely)
Non pcol measures

 Self limiting
 Can leave
 Daily shampooing
Treatment
Treatment Dosage/Instructions
Olive oil BP -Massage scalp with olive oil and leave in overnight
-wash the next morning with gentle shampoo and soft
bristle toothbrush
-DO NOT TRY AND PICK OFF CRUSTS
Egozite Cradle cap -salicylic acid 6% in castor oil and olive oil
lotion -apply BD to dry scalp (only to crusts) for 3-5 days WITHOUT
washing scalp
-then wash with gentle shampoo
-repeat for remaining crusts
-some hairs may loosen and fall out. They will grow back
Referral points
 OTC Tx failure
 Crusts that appear in warm weather
6. Nappy Rash
 Caused be skin contact of urine and faeces and skin maceration
8
Symptoms
 Red rash at buttock and groin area
 If bacterial, weeping or yellow crusting with fever
 If fungal, well defined edge and may have bumpy texture
Questions to ask?
 Duration
 Types of nappies used
 How do you wipe baby?
 Signs of bacterial or fungal infection?
 Spread outside of nappy area?
 Tried any previous Tx? Did it work?
Non pcol measures

 Nappy free time
 Frequent nappy changes
 Barrier cream with each nappy change
 Use disposable nappies (Huggies is most adsorbent)
 Avoid soap and wipes (irritants)
 Wash area with soap substitute eg. Cetaphil
 Bath baby in Dermaveen (colloidal oatmeal) as soothes babies skin
Treatment
Treatment Dosage/Directions
Hydrocortisone 1% -apply bd-tds until rash resolves (MAX 7 days)
Miconazole 2% -bd until fungal infection resolves and then for 7 days
after
Barrier Cream -apply after every nappy change
-Sudocrem (Zinc oxide)
Paracetamol 15mg/kg q6-8 hrs
NOTE: Order of application:
1) cortisone
2) anti-fungal
3) barrier cream
-can use combo products
-once inflammation subsides, CEASE cortisone
-can use clotrimazole 1% tds until Sx resolve
Referral points
 Signs of bacterial infection (broken skin, fever)
 Rash spreads outside nappy area
 No improvement seen after 5 days
 Persists beyond 2 weeks
Oral Health
9
1. Cold Sores- Page 11
2. Dry Mouth- Page 12
3. Aphthous Ulcers- Page 13
4. Gingivitis- Page 14
5. Oral Thrush- Page 15
6. Dental Caries- Page 16
1. Cold sores
Symptoms
10
 Initial tingling- hours preceding  Itchy
 Blister- days  Painful
 Weeping  On lips and generally unilateral
 Crusts over (in about 1 week)
Questions to ask?
 Age (refer young children)  Lesions anywhere else in body?
 Duration  Pregnant or breastfeeding
 Had before? How many times? (refer)
Non pcol measures

 Get Tx as soon as sign of  Use separate towel to wash
tingling face
 Avoid triggers (sun, stress,  Don’t touch eyes after
illness etc) touching cold sores
 Don’t share towels, cutlery etc  Use sunscreen
 Don’t pick scab
Treatment
Aciclovir 5% 5 x d for 5 days (5x5x5)
-at tingle stage
- >2 years
Famciclovir 500mg 3 tabs stat with plenty of water
-at tingle stage
Virasolve (idoxuridine and Hourly for day 1 then qid thereafter until lesions clears
lignocaine) -use once Sx have appeared
- >12 years
Hydrocolloid patch 8 hourly until lesion clears
-can give to pregnant women but still refer!!!!!
Referral points
 Pregnant or breastfeeding  Painless
 Young child  Lesions in other places of body
 Immunosuppressed  Large lesion
 Hx of eczema  More than 3 episodes a year
 More than 14 days  Signs of infection
2. Dry Mouth (Xerostomia)

 Generally has an underlying cause
 Drugs eg. TCAs, anticholinergics, diuretics etc
11
Symptoms
 Dry, cracked lips
 Teeth stuck to lips
 Sore or burning throat
Questions to ask?
 Duration?
 Any meds taking?
Non pcol measures

 Frequent sips of water
 Suck ice cube
 Sugar free gum
 Sugar free lollies
 Brush with soft toothbrush
 Lip balm
Treatment
 Artificial saliva products
 Eg. Biotene mouth spray (Water, glycerin, sorbitol prn)
Referral points
 Medicine induced
3. Aphthous ulcers (mouth ulcers)
Symptoms
 White/yellow centre with red, inflamed border
12
 On tongue or inner lip and cheeks
 Painful
Questions to ask?
 Duration
 Other meds?
 Been stressed lately?
 Braces/dentures?
Non pcol measures

 Avoid irritants
 Avoid hot/spicy foods
 Ice cubes can help sooth ulcer
 Stress management
 Apply all pastes after food to increase contact time
 Soft tooth brush
 Should resolve in 1-2 weeks
Treatment
Bonjela (choline salicylate) -0.5cm strip q3h (max 6 applications d)
Orabase (carmellose) -barrier on ulcer
-safe in all age groups
-dab on, NOT rub on
-prn
-SAFE in pregnancy
SM-33 Gel (lignocaine and -q3h prn
salicylic acid) -SAFE in pregnancy
Kenalog in Orabase -dab a 1cm strip on ulcer and hold in place until film
(Triamcinalone 0.1% in forms
orabase) -use nocte but can use up to tds after meals
-CAT C (AVOID)
Referral points
 More than 2 weeks  Drug induced
 < 10 years old  Painless
 Crops of more than 5  Fever
 >1 cm  Tingling
 Immunocompromised  Nutritional deficiency
4. Gingivitis
Symptoms
 Red inflamed gums due to plaque build up
13
Questions to ask?
 When was last dental visit?
 Reg meds?
 Smoking?
Non pcol measures

 Visit dentist for plaque removal
Treatment
 Chlorhexidine mouthwash 0.2% to prevent secondary infection
 10mL swirled in mouth for 1 min BD for 1 days
o Can discolour teeth
o Separate from teeth brushing by one hour
Referral points
 Drug induced (eg. NSAIDs, warfarin)
 Hypertrophy involved
5. Oral thrush
Symptoms
 White creamy plaques on tongue
14
 When wiped away, show red inflamed mucosa
 Common in babies in first few weeks of life
Questions to ask?
 Duration
 Recent antibiotic use?
 Any ICS?
 Ill fitting dentures?
 Painful
Non pcol measures

 Wash mouth after using ICS
 Probiotics with anti’s
 Fit dentures properly
 Brush and floss daily
 Use anti-fungal on dentures
 DON’T SOAK IN WATER OVERNIGHT
Treatment
Nystatin drops (100, -1mL qid under the tongue after food
000 units/mL) -hold in mouth for as long as possible then swallow
-continue for 7-14 days after Sx resolve
Miconazole 2% gel -birth – 1 year= 1.25mL (1/4 of measuring spoon) qid, place
in front of mouth in small portions
->1 year= 2.5mL (1/2 a measuring spoon) qid
-hold in mouth for as long as possible before swallowing
-Manufacturer CI use in less than 6 months age. This is
because children have choked because parents place spoon
in mouth. It is only used to measure out required amount
-continue for 7-14 days after Sx resolve
Referral points
 Recurrent
 >3 weeks
 Diabetic
 Plaques that cannot be removed
 Painless
6. Dental caries
Symptoms
 Tooth pain when biting down or eating sweet, hot or cold foods
15
 Visible holes in teeth
Questions to ask?
 Recent dental visit
 Recent extractions?
 Wisdom teeth coming out?
 Gum involvement?
Non-pcol measures
 Dentist
Treatment
Nyal toothache drops (phenol, ethanol, Soak cotton bud with 1-2 drops and hold
benzocaine) in cavity for 1 minute, MAX qid
Ibuprofen 200mg 1-2 tabs q4-6 hours with food prn (MAX
6 tabs d)
-AVOID IN PREGNANCY
Referral points
 Refer all patients to dentist as Tx is symptomatic
Women’s Health
16
1. Period Pain- Page 18
2. Premenstrual syndrome- Page 19
3. Cystitis- Page 20
4. Vaginal Thrush- Page 21
1. Period pain (primary dysmenorrhea)
Symptoms
17
 Lower abdo pain  Nausea
 Lower back pain  Crampy
 Fainting  Moody
Questions to ask?
 Had before?  Severity of Sx?
 Age?  Pain before, during, post cycle?
 Duration?  Pregnant? (PV bleeding while
pregnant is NOT normal)
Non pcol measures

 Warm baths  Lie on back with pillow under
 Stress management knees
 Pelvic floor exercises  Lie on side with knees pulled
 Hot water bottle on lower up to chest
abdomen  Keep a diary of Sx
Treatment
Treatment Dosage/Duration
Mefanamic acid 250mg 2 tds with food for duration of pain (MAX 7 days)
-general NSAID counseling
-MAX 1500mg d
Naproxen 275mg 2 tabs stat then 1 tab q6-8 hours with food
-MAX 5 tabs d
-general NSAID counseling
Paracetamol 500mg 2 qid prn
-MAX 8 tabs d
Mersyndol night 1-2 tabs q4-6 prn
Para= 500mg -MAX 8 per day
Codeine= 9.75mg -Label 1
Doxyalmine= 5mg -anti-SLUD
Referral points
 <12 years  Heavy bleeding
 >30 years  Late period with pain
 Disabling Sx  Period pain not occurring
 Recent EC use (could be during cycle
ectopic)  Fever
 Pain that starts and subsides  Malaise
before cycle  Painful sex
2. Premenstrual Syndrome (PMS)
 Begin about 7-14 days before menses and subside a few hours after cycle
 Psychological and physical Sx
Symptoms
18
 Mood changes  Depression
 Irritability  Bloated feeling
 Insomnia  Breast tenderness
 Headache
Questions to ask?
 Age?
 Duration?
 Psych and physical Sx?
 Psych Sx alone?
 Severity of Sx?
Non pcol measures

 Healthy diet  Let partner know
 Lifestyle measures  Relaxation techniques
 Exercise
Treatment
1st Line: REFER
Treatment for MILD- Dosage/Directions
MODERATE
Pyridoxine (Vit B6) 50-100 mg d for prevention of Sx
- doses >500mg can lead to toxicity (eg. Peripheral
neuropathy)
Elemental calcium 1200mg d
-MAKE SURE PATIENT IS RECEIVING ELEMENTAL
CALCIUM
-SEs: nausea, flatulence
-C: renally impaired
Evening Primrose Oil 500mg 500mg bd
-Natural product
-poor evidence to support
Referral points
 REFER ALL PATIENTS
 <30 years
 PMS Sx that worsen or remain same after onset of menses
 Psych Sx alone
 Sever or disabling Sx
3. Cystitis (UTI)
 Inflammation of the bladder
Symptoms
 Painful urination  Urgency
19
 Frequency  Nocturia
 Blood in urine  Rapid onset
Questions to ask?
 Onset? (gradual onset suggests STI- refer)
 Age
 Duration
 Diabetic? (refer)
Non pcol measures

 Drink plenty of fluids (5L in 24 hours)
 Wipe from front to back
 Avoid OH and caffeine
 Wear cotton undies
 Respond to urge to urinate
 Avoid constipation
 Urinate before and after sexual intercourse
Treatment
Ural (sodium -1-2 sachets dissolved in cold water up to QID, MAX 2 days
citrotartate) 4g use
sachets -caution in pts with HTN, HF and those with salt restricted
diets
-NOT to be used with nitrofurantoin
Hexamine Hippurate -poor evidence
-cannot be used with ural as hexamine needs acidic
environment to work and ural is alkaline
Referral points
 Diabetic  Sx lasting longer than 7 days
 Immunocompromised  Vaginal discharge
 Man  Fever
 >70 years  Pregnancy
 <16 years
4. Vaginal Thrush
 Caused by Candida albicans
Symptoms
 Cottage like discharge  Itching/Burning
20
 Painful urination  Painful intercourse
 No odour  Acute onset
Questions to ask?
 Age?  Immunosuppressed?
 Recent Antibiotic use?  Blood in urine/discharge?
 Diabetic?  First time?
 Pregnant?  Frequency of episode?
Non pcol measures

 Wipe from front to back  Avoid irritants like soap,
 Wear loose fitting cotton detergents, douches, perfumes
undies  Eat low fat natural yoghurt
 Blot dry (rubbing can irritate  Drink Yokult
vagina)  Avoind intercourse
Treatment
Treatment Dosage/Treatment
Butaconazole 2% -1 applicatorful at bedtime until tube is finished
cream -SEs: local irritation
Clotrimazole cream & -10% cream- once -100mg pessary- 6 days

pessary -2% cream- 3 days -500mg pessary- 1 day
-1% cream- 6 days -Use cream and pessary at bedtime
-use until tubes are finished
Miconazole 2% cream -1 applicatorful at bedtime for 7 days
Fluconazole 500mg tab -ONE tab Tx
-GI upset
-relief within 1 day of Tx, MAX relief seen after 2 days
Nystatin 100, 000 units -1 applicatorful 2-bd at bedtime for 14 days
NOTE: - Azoles damage condoms and diaphragms. Do not use while using azoles
-wear sanitary pad as creams may leak out
-relief should be seen within 3 days of local/topical Tx
Referral points
 > 4 episodes a year  <16 years old or >60 years old
 Diabetic  Blood in urine/discharge
 Immunocompromised  First time infection
 Odour  No improvement within 7 days
 Green/yellow discharge of Tx
 Pregnancy
Pregnancy and Breastfeeding

1. Back Pain- Page 24
2. Constipation- Page 25
21
3. Reflux- Page 26
4. Nocturnal muscle cramps in pregnancy- Page 27
5. Pruritis in pregnancy- Page 28
6. Breast and nipple thrush- Page 29
7. Mastitis- Page 30
8. Lactation Problems- Page 31
9. Morning sickness- Page 32
General health and advice during pregnancy

 Pregnancy multivitamin
o Elevit with I or Fefol
 Folic acid supplement (500mcg) 1 month before becoming pregnant and
during the first three months of pregnancy
22
 Iron supplement if doctor recommends
 High in iron foods include:
o Spinach, broccoli, cabbage
o Eggs
o Fish
o Poultry
 Foods to avoid:
o Processed meats eg. salami
o Raw meat eg. In sushi
o Raw seafood
o Soft cheeses eg. Ricotta
o Soft serve ice cream
o Unpasteurized milk
o Pre-packaged salad
 Eat a healthy well balanced diet
 Golden rules of food safety:
o Put food that needs to be cold in fridge straight away
o If its been left out of the fridge for 2 hours or more, don’t eat it!
o Defrost and marinate food in the fridge
o Wash and dry hands thoroughly before and after preparing a meal
o Keep kitchen clean
o Separate raw and cooked foods and use separate knives and cutting
boards for each
o Cook foods until they’re steaming hot
o Make sure foods are fully cooked
1. Back pain in pregnancy

 Common as the uterus grows and moves forward
Symptoms
23
 Lower back pain
Questions to ask?
 Happened before pregnancy?
 How many weeks?
 Try anything to treat?
 Any Hx of muscoskeletal disorders?
Non pcol measures

 Pelvic floor exercise
 Don’t sit or stand in the same position for too long
 Swimming
 Flat shoes
 Massages
 Sit with a pillow behind back
 Heat pack
 Maternity belt
 Physio
 Weight loss
Treatment
 Paracetamol 1g qid prn (MAX 4g d)
 NO NSAIDs unless under specialist advice
Referral points
 Hx of muscle pain
 Pain started before pregnancy
2. Constipation
 Common in pregnancy as uterus pushes down on bowel
 Could be due to Fe supplementation, dehydration etc
24
Symptoms
 Constipation (esp in end stages of pregnancy)
Questions to ask?
 How long?
 Any dietary changes?
 Any Fe supplements?
 Any opioids?
 Excessive antacid use?
 Could it be hemorrhoids?
Non pcol measures

 Increase fluids
 Increase fibre in diet- fruits with skin, veggies, whole grain breads etc
 Respond to urge to defecate
 Increase exercise and mobility
Treatment
Treatment Dosage/Instructions
Docusate (stool -50-150mg d-bd
softener) -takes 1-3 days to work
-MAX 500mg d in divided doses
-SEs: abdominal cramping, diarrhoea
Lactulose -15-45mL d in 1-2 doses
-Mercy guidelines: 20mL bd
-need to take regularly to work
NOTE: NO STIMULANTS (eg. Senna) IN PREGNANCY AS THEY CAN STIMULATE
CONTRACTIONS
Referral points
 Blood in stools
 >2 weeks
 Pain on defecation
3. Reflux
 Common in pregnancy
Symptoms
 Feeling of acid coming up the throat
 Heart burn
25
 Indigestion
Questions to ask? (Remember MARY REMEDY)

 Radiating pain?  Burning pain?
 Triggered/alleviated by  Any other Sx? Eg coughing up
anything? blood
 Vomiting?  Any other meds?
 Chest pain?
Non pcol measures

 Eat smaller meals  Remain upright during and
 Avoid spicy and irritant foods after eating
 Put your pillow up at night  Avoid eating right before bed
Treatment
Mylanta Original (Al, -2-4 tabs chewed up to qid prn
Mg, Simethicone) -no more than 14 days use
-best taken after meals and at bedtime but prn really
Mylanta double -1-2 tabs up to qid prn
strength (Al, Mg, -5-10mL up to qid prn
Simethicone) -no more than 14 days use
-best taken after meals and at bedtime but prn really
Antacids -combo of Al, Mg, Na and Ca
-caution of Na if on a salt restricted diet
-Al and Mg together in the one product balance the
diarrhoea and constipation so it isn’t experienced
eg. Gaviscon (Ca and Na) 20mL qid prn
NOTE:
 Constipation- exacerbated by antacids containing Al and Ca
 Diarrhoea- exacerbated by antacids containing Mg
 LABEL 4 if using other applicable meds
 DON’T give OTC PPIs or ranitidine (B1). Only under doc advice
Referral
 Coughing up blood  Dysphagia
 Radiating pain  Vomiting
 Anemia  Treatment failure
 Failure to gain weight
4. Nocturnal muscle cramps in pregnancy

 Common late in pregnancy due to electrolyte imbalance
Symptoms
 Muscle cramps esp. at night
Questions to ask?
26
 Exercising?
 Dehydrated?
 Duration?
Non pcol measures

 Rink plenty of fluids
 Massage legs before going to bed
 Heat packs
 Stretching
 Loose clothing
 Flat shoes
Treatment
 Mag-Min 500mg 1-2 tabs d (Cochrane review), may cause diarrhoea
Referral points
 OTC Tx failure
5. Pruritis in pregnancy
 Due to bilirubin build up
Symptoms
 Rash
 Itch
27
Questions to ask?
 Weeks?
 Duration?
 Any open, weeping wounds?
 Allergies?
 Other meds?
Non pcol measures

 Avoid irritants eg. Soap, perfumes, etc
 Cold packs
Treatments
Moisturisers QV, Dermaveen, Cetaphil prn
Hydrocortisone 1% -Apply sparingly bd for 7 days MAX
-1 FTU covers the space of 2 hand palms
Sedating antihistamines -Dexchlorpheniramine (Polaramine): 2mg qid
for itch -Cyproheptadine (Periactin): 4mg tds
-Pheniramine (Avil): up to 45.3mg tds
-SEs: sedation (label 1a), anti-SLUD, confusion
Referral
 OTC Tx failure
 Open, weeping wounds
6. Breast and nipple thrush

 Overgrowth of candida on nipples
Symptoms
 Burning
 Itching
 Stinging
 Painful
28
 Cracked nipples
 Pink
 Dry
 Shooting and stabbing pain (in breast)
Questions to ask?
 Recent antibiotic use?
 Odour?
 Open or weeping wounds?
Non pcol measures

 Keep nipples dry
 Wash towels
 Wash bras
 Wash nursing pads
 Px antifungal for baby if breastfeeding
Treatment
Miconazole 2% -thin layer bd-qid and continue for 2 weeks when Sx
resolve
-don’t need to wipe off before feeding (helpful to baby)
-use after feeds to maximize contact time
Nystatin 100, 000 units -bd-tds and continue for 2 weeks after Sx resolve
-don’t need to wipe off before feeding (helpful to baby)
-use after feeds to maximize contact time
Paracetamol 1g qid (MAX 4g d)
Referral points
 Suspected bacterial infection
 OTC Tx failure
7. Mastitis
 Inflammation of the breast
 Generally infective cause
Symptoms
 Pain
 Oedema
 Swelling
29
 Erythema
 Lump
 Fever
 Malaise
 Lethargy
 Nausea
Questions to ask?
 Duration?
 Systemic Sx?
 Any abscess present?
Non pcol measures/Treatment

 ALWAYS REFER
 Paracetamol 1g qid prn (MAX 4g d)
 Continue to breastfeed (not harmful to baby)
 Massage under hot shower before a feed
 Use cold packs after a feed to keep you feeling comfortable
8. Lactation problems
 Not enough breast milk
 Could be due to hormonal reasons, hot weather etc
Symptoms
 Not enough breast milk
 Irritable baby
Questions to ask?
30
 Duration?
 Any meds?
 Are you dehydrated?
 Have you tried expressing?
 Increasing fluids?
 Taking stimulants?
Non pcol measures

 Massage breast
 Sit up right (not too far back)
 Warm compress
 Consider a breast pump
 When feeding, drain both breasts completely regardless of whether the baby
is still feeding or not
 Do not recommend herbal supps as evidence is lacking
Treatment
 REFER if non-pcol measures fail
9. Morning sickness
 Common between 6 and 14 weeks gestation
 Can occur anytime throughout day and pregnancy
Symptoms
 Nausea
 Vomiting
 Dehydration
 Weight loss
 Unable to tolerate food or fluids
31
 Reflux
Questions to ask?
 Duration?
 Anything aggravates?
 Weight loss?
 Dehydrated?
 How many times a day throwing up?
 Can you tolerate any food/fluids?
Non pcol measures (evidence is lacking)

 Smaller meals throughout the day
 Eat a dry cracker before getting up outta bed
 Soups compared to solids
 Avoid triggers
 Cold drinks and foods are better tolerated
 Rest as fatigue makes nausea worse
 Meals high in protein
Treatment
Ginger 1g d
Pyridoxine (Vit B6) 50-100mg tds
-doses >500mg can lead to toxicity (eg. Peripheral
neuropathy)
Blackmores Morning -1 tds
Sickness (ginger and B6)
Referral points
 Suspected hyperemesis
 Weight loss
 Dehydration
Dermatology
1. Head Lice- Page 34
2. Scabies-Page 35
3. Eczema/Dermatitis- Page 36
4. Psoriasis- Page 37
5. Fungal Skin infections- Page 38
6. Nail fungal infections- Page 39
7. Acne Vulgaris- Page 40
8. Chickenpox- Page 41
32
9. Corns/calluses- Page 42
10. Warts- Page 43
11. Dandruff- Page 44
12. Sunscreen/Sunburn- Page 45
13. Wound management- page 46
14. Hair Loss- Page 47
15. Shingles- Page 48
16. German Measles (Rubella)- Page 49
17. Measles- Page 50
1. Head lice
Symptoms
 Itch (not always present) esp at back of scalp, neck and behind ears
 Live lice (dark sesame seed like)
 Eggs (white and stuck at hair shaft
Questions to ask?
 Current breakout at school?  Anyone else in family affected?
 Seen live lice? (can only start  Any open lesions?
Tx if see live lice)
33
Non pcol measures
 Don’t share hats, towels and girls to tie long hair back
 Wash combs, brushes etc in hot water
 Clean bed linen, towels, clothes etc and anything that can’t be cleaned, needs
to be tied in an air tight bag for 2 weeks
 Wet combing technique (use for Dx or Tx)
o Apply condition to dry hair from tip to root & divide in 2-3cm sections
o Comb each section at least twice and wipe on white paper and see if
live lice are present
o Repeat every 2 days until no live lice are seen for 10 consecutive days
Treatment
Quellada -Apply to clean, damp hair. Leave on for 10 minutes then wash off
(Permethrin 1%) thoroughly with water. Remove dead lice with a comb.
-don’t wash hair with shampoo for 2 days post
-PREFERRED IN PREGNANCY AND CHILDREN >2 YEARS
Hedrin -lotion or spray
(Dimeticone -apply to all hair
4%) -leave in for at least 8 hours (overnight maybe?) then wash out
-SAFE IN ALL POPULATIONS
KP 24 lotion -apply 20-40mL for at least 12 hours and then wash out
(maldison 0.5%) -use wet combing
-DO NOT USE IN PREGNANCY, SAFE > 2 YEARS
NOTE: -itch may persist for 1 week post eradication
-repeat Tx in 7 days and repeat wet combing technique every 2 days in between Tx
-can return to school after 1st Tx
Referal
 Pregnancy, <2 years
 OTC Tx failure (itch present 10 days post Tx)
 Signs of infection (swollen glands, weeping, crusting)
2. Scabies
 Mite infestation
Symptoms
 Intense itch (worse at night and after bathing)
 Rash in webbed areas (in between toes and fingers), buttocks, wrists, armpits
and genital areas
 Burrows (small raised bumps under skin)
Questions to ask?
 Describe rash
34
 Itchy?
 Worse at night and after bathing?
Non pcol measures

 Wash all clothes, linen, toys etc and anything that can’t be washed needs to
be tied in an air tight bag for 2 weeks
 Limit close contact with others until Tx is started
 Do not share towels, clothes etc
Treatment
Lyclear (Permethrin -shower and dry thoroughly
5%) -apply to neck down, paying attention to skin folds, belly
button and groin, wait to dry and then wear clean clothing
-apply to neck, face and ears in <2 years and elderly
-leave on overnight and clean off the next morning
-treat all family members and people with close contact
-REPEAT IN 7 DAYS
1-2 tubes for adults

½ tube for 5-12 years old
¼ tube for 1-5 years
Others -Dermaveen colloidal oatmeal bath
-Polaramine for itch
-cortisone 1% for intense itch and inflammation
NOTE: Itching can continue for several days/weeks post Tx
-Can return to school after successful Tx
Referral points
 Pregnant/breastfeeding
 < 2 years
 OTC Tx failure
 Itch present for 3 weeks post Tx
3. Eczema/Dermatitis
Symptoms
 Red/itchy rash  Dry and scaly
 Weeping  Papules/blisters
 Poorly defined edge  Generally in skin folds ie inner
 Hot skin elbow, inner knees
Questions to ask?
 Duration?
 Any signs of infection (fever, warmth, purulent smell)
 Occupation?
35
 Have you come in contact with anything that may have sparked it off?
 Location
 Hx of eczema, asthma, hayfever
 Are you allergic to detergents in the wash?
Non pcol measures

 Avoid irritants  Wear damp clothes (soothing)
 Avoid scratching  Shower with lukewarm water
 Avoid soaps (dry out skin)  Pat dry
 Keep skin moisturized  Keep fingernails short
Treatment
Emollients Eg. QV, Dermaveen (colloidal oatmeal, paraffin oil), Cetaphil,
Dermeze (White soft paraffin, liquid paraffin)
-use prn
-use bath lotions
-apply n before bed
Steroid Hydrocortisone 1%: bd for 7 days (>2 years)
Clobetasone 0.05%: d-bd for 7 days? (>12 years)
NOTE: -emollient can be applied 30 mins after steroid
-use FTU for steroids
Referral points
 < 2 years in need of corticosteroid
 OTC Tx failure
 Face lesions unresponsive to emollients
 Widespread or severe
4. Psoriasis
 Hyperproliferation of skin
Symptoms
 Pink lesions with silvery white scales
 Well defined border
 Symmetrical
 Not normally itchy
 Generally on knees, elbows, scalp and trunk
 Redness extends beyond hair margin in scalp psoriasis
 Hairloss suggests fungal infection
36
Questions to ask?
 Description  Itchy?
 Duration  Family Hx?
 How long?  Signs of infection?
Non pcol measures

 Avoid irritants  Pat dry
 Avoid scratching  Keep fingernails short
 Avoid soaps (dry out skin)  Wear gloves
 Keep skin moisturized  Stress Mx
 Shower with lukewarm water  Sun exposure may help
improve psoriasis
Treatment
Emollients Eg. QV, Dermaveen (colloidal oatmeal, paraffin oil), Cetaphil,
Dermeze (White soft paraffin, liquid paraffin)
-use prn
-use bath lotions
-apply n before bed
Cortisone Hydrocortisone 1%: bd for 7 days (>2 years)
Psor-Asist (Salicylic -Apply bd (softens and lifts scale)
acid 2%, coal tar -SEs: stains skin and clothes photosensitivity
5%, sulfur 3%) -safe in pregnancy and children
Referral
 No Hx of psoriasis and presents with psoriasis like lesions
 Severe lesions
 Signs of infection
 Pustular lesions
5. Fungal skin infections

 Tinea pedis (athlete’s foot)
 Tinea corporis (skin)
 Tinea cruris (jock itch)
Symptoms
 Itchy  Well defined border
 Red  In pedis, in tow webs
 Flaky  In corporis, well defined border
 Dry with clear centre
Questions to ask?
37
 Duration?
 Lifestyle? Eg. Been swimming lately?
 Diabetic/immunocompromised? (REFER)
 Nail involvement?
 Bleeding? Odour?
Non pcol measures

 Wear thongs when swimming or in communal showers
 Dry in between toes
 Use separate towel to toes and rest of body
 Wear loose fitting shoes
 Wear cotton socks
 Change socks frequently
Treatment
Terbinafine 1% -ONCE d for 7 days ONLY
- >12 years old
-B1, don’t recommend in pregnancy
Bifonazole 1% -n until infection clears and then for 2 weeks after
-B3, don’t recommend in pregnancy
Clotrimazole 1% -tds until infection clears and then for 2 weeks after
-safe in pregnancy
Miconazole 2% -bd until Sx resolves and continue for 2 weeks after
-safe in pregnancy
Referral points
 OTC Tx failure
 Diabetic if have signs of infection
 Immunocompromised
 Recurrent infections
 Nail involvement
6. Nail fungal infections
Symptoms
 Dull/yellow nail like appearance
 Thick brittle nails
Questions to ask?
 Trauma to nail?
 Immunocompromised?
 Diabetic?
Non pcol measures
38
 Keep area clean
 Change socks regularly (if on toe nail)
 Avoid trauma to nails
 Avoid sharing towels
Treatment
Miconazole -evidence is lacking
tincture -don’t recommend
Amorolfine 5% nail -applied once to twice WEEKLY (just as effective as each other)
lacquer -pack contains: nail file, cleaning pad, lacquer, reusable spatula
1. File nail own before each application (don’t use on healthy
nail afterwards)
2. Clean nail surface with cleaning pad
3. Dip spatula into lacquer (provides measured dose) and paint
entire nail surface
4. Close bottle tightly
5. Allow 3-5 mins for nail to dry
6. Clean spatula and neck of bottle with same cleaning pad
NOTE: Above process must be used before each application
-6 months for fingernails
-9-12 months for toenails
-careful not to get it on skin
-wear gloves when applying Tx
-skin irritation has been reported
-DO NOT GIVE TO CHILDREN, PREGNANT OR BREASTFEEDING
Referral
 Too expensive for patient
 Suspected poor compliance
 Matrix involvement
7. Acne vulgaris
 Hormone influenced inflammatory condition
Symptoms
 Open and closed comedones  Pustules with erythema
(black and white heads)  Can be painful
 Generally on face, chest, back
and shoulders
Questions to ask?
 Age? (common in puberty)  Severity?
 Duration?  Any meds? (could be drug
 Occupation? induced)
39
 Cosmetics?
Non pcol measures

 Avoid irritants  Clean makeup thoroughly off
 Health balanced diet/Exercise  Use Cetaphil cleanser each
 Stress Mx (stress can make night (Avoid oily cleansers)
worse)  Keep hair tied back so its not
 Don’t squeeze or pick lesions oily on face
(scarring)  Acne improves during summer
Treatment
Benzoyl -always start with 2.5 or 5% strengths
peroxide 1. Wash and dry hands before use
2.5, 5, 10% 2. Wash area with skin cleanser (eg. Cetaphil) and pat dry
gel 3. Apply gel ONCE d, leave on for 2 hours then wash off with water and
pat dry
4. After 3 days, if no discomfort is felt, apply n and leave on all night
5. After 7 days, can use bd
NOTE: duration of Tx is about 8-12 weeks, assess after 6 weeks
-SAFE IN PREGNANCY, Can cause acne flare
Azelaic acid -bd for 12 weeks
15% gel -step 1-2 as above
-DO NOT RECOMMEND IN PREGNANCY, can cause hypopigmentation
Referral
18. Moderate to severe acne 22. Patients over 25 presenting for
19. Occupational acne the first time
20. Failed OTC meds 23. Rosacea (flushed cheecks)
21. PCOS Sx 24. < 12 years
8. Chickenpox
 Caused by varicella zoster virus
 Transmitted by droplet particles
Symptoms (begin 1-3 weeks after infection)

 Initially patient has mild headache, moderate fever, sore throat and generally
unwell for up to 3 days
 Rash develops a day or so later
 Small red lumps appear that rapidly turn into vesicles
 Vesicles then crust over in 3-5 days
 New lesions continue to appear for up to 5 days
 Extremely itchy
40
 Contagious from a few days before the onset of rash until all lesions have
crusted over
Questions to ask?
 Describe Sx?
 Duration?
 How was the patient feeling before the onset of the rash?
Non pcol measures

 NO CALAMINE LOTION (dries  Wear light weight cotton
out skin) and NO CORTISONE clothing
 Stay hydrated  Avoid contact with people
 Cool compresses to reduce  Tell children to smack lesions
itching instead of scratching
 Cut child’s nail short
Treatment
Paracetamol 15mg/kg q4-6 prn (MAX 60mg)
Solugel (propylene Prn (can keep in fridge for cooling effect)
glycol and NaCl)
Pinetarsol (wool tar-shake before use
2.3%) -add 15-30mL to a warm bath and bathe for 5-10 mins once d
-pat skin dry
Dexchlorpheniramine -2mg QID
(Polaramine) -normal sedating antihistamine counseling
Referral points
 Pregnant
 Immuncompromised
 Joint pain
 Initial Sx persisting
9. Corns and calluses
 Due to pressure and friction
Symptoms
 Corns:
o Usually on tops, sides and tips of toes
o Grey hard core of skin with a yellow raised ring of inflammation
around
 Calluses:
o Flattened yellow/white thickened skin
o Usually on balls of feet, heel
o Burning sensation
41
Questions to ask?
 Footware?
 Location? (plantar surface is probably a wart)
 Relieving factors? (when shoes are removed, pain should subside whereas
pain in a plantar wart remains)
 Any tiny black dots?
Non pcol measures

 Properly fit shoes
 Wear open toes shoes such as thongs or sandals to relieve pressure on corns
 Corns and calluses become more painful when the skin is dry and hard.
Applying a moisturiser to these areas daily will help to keep the skin soft and
help make them less painful.
 PREVENTION IS THE KEY!!!!
Treatment
Scholl Corn shield -apply to corn
gel plaster
Scholl foam cushions -apply to corn
Scholl corn removal -apply to corn d for MAX 2 weeks
pads 40% salicylic -caution in diabetics, allergy, <16 years (don’t use)
acid
Wart Tx See wart section
Referral points
 Soft corns
 Tx failure
 Impaired peripheral circulation (as in diabetics)
 Difficulty walking
10. Warts
 Human papilloma virus spread by direct skin-skin contact
Symptoms
 Cauliflower appearance  Single or in crops
 Black dots on surface  Hands and knees and sole of
foot (plantar)
Questions to ask?
 Age  Associated Sx?
 Location
42
 Has the wart grown and
changed overtime?
o Cover wart with
Non pcol measures waterproof tape (eg.
 Contagious so avoid skin to Duct tape) and leave on
skin contact with others or for 6 days, soak, pare
other parts of body with pumice stone,
 Don’t pick at wart leave overnight
 Usually disappear with 6 o Reapply tape and
months – 2 years repeat for 8 cycles
 Duct tape occlusion therapy
Treatment
Duofilm Solution -once d until removed (Refer at 12 weeks if not effective)
(16.7% salicylic acid, -Before application, clean affected area, soak wart in warm water for 5
16.7% lactic acid) minutes, remove loose tissue with a pumice stone and dry thoroughly.
Scholl corn removal -apply to wart d for MAX 12 weeks
pads 40% salicylic -caution in diabetics, allergy
acid -CAN USE IN CHILDREN, PREGNANCY AND B/F
Wartner (dimethyl -hold applicator to lesion for 20 seconds
ether, propane) -repeat every 15 days prn (MAX 3 doses)
-DO NOT USE IF PREGNANT, B/F, <4 YEARS
Diswart -apply bd
(glutaraldehyde -use pumice stone every 1-2 days
10%) 3 month Tx
-SAFE IN PREGNANCY AND B/F
NOTE: Paint normal skin with nail polish or cover with tape with a hole left for the
wart. Apply substance to wart. Apply more tape to increase occlusion. Remove tape
the following day, file with a pumice stone.
Referral points
 Pain or bleeding without  Multiple and widespread
provocation  Anogenital and facial warts
 >50 years  Lesions that have grown or
 Diabetic changed colour
11. Dandruff
 Hyperproliferative skin condition
 Could be fungal
Symptoms
 Dry, itchy, flaky scalp
 Dead cells on patients clothing
 More common in winter
 Confined to scalp (DIAGNOSTIC CRITERIA)
Questions to ask?
43
 New hair products?
 Any associated hair loss?
 Inflammation, bleeding scalp?
Non pcol measures

 Avoid hair products containing OH as these dry scalp out
 Use conditioner or leave in conditioner
 Dandruff does not cause balding and is not contagious
 Shampoo daily eg. Dermaveen Oatmeal shampoo
 Wash hair after exercise
Treatment
Head and shoulders -use daily until dandruff clears
(Zinc pyrithione 0.5%) -SAFE IN ALL PATIENT GROUPS
-SEs: dermatitis (Avoid if have pre-existing dermatitis)
Selenium sulfide 1% -twice weekly for 2 weeks then once weekly for 2 weeks
-apply to wet hair, leave for 2-3 mins then wash out
-SEs: skin irritation, hair and jewellery discolouration
-avoid if patient has broken or inflamed skin,
Nizoral 1, 2% -twice weekly for 4 weeks
(Ketoconazole) -apply to wet hair, massage into scalp, leave for 5 minutes.
Wash and then repeat
-SEs: skin irritation, hair discolouration
-AVOID IN PREGNANCY
Referral points
 OTC Tx failure
 Suspected fungal Infection
12. Sunscreen and sunburn

 Prevention is key
Symptoms
 Pain
 Redness
 Peeling
Questions to ask
 Age  Any photosensitive meds?
 Duration  Recent sun exposure?
44
Non pcol measures
 Prevention:
o Slip on some sun protective clothing
o Slop on some SPF 50+ sunscreen 20 mins before exposure and reapply
every 2 hours
o Slap on a broad brimmed hat
o Seek shade between 10am and 2pm
o Slide on some sunnies
o Lip balm sunscreen
 Treatment
o Avoid further sun exposure
o Drink plenty of fluids to avoid dehydration
o Take cool showers and apply cool compresses
o Wear loose, soft clothing to avoid irritation to burned skin
o Apply moisturizer to burnt area
Treatment
Paracetamol prn
Solugel Prn (can keep in fridge for cooling effect)
Soov Burn Spray -qid
(cetrimide, lignocaine, -hold spray 10cm from affected area and spray until skin is
phenoxyethanol) wet
-for face, spray onto fingers and then apply to face
Referral points
 Melanoma like lesions (think ABCE)
o Asymmetry (not usually round)
o Border (often irregular)
o Colour (varying shades)
o Diameter (>6mm)
o Evolution (itching/ulcerating)
13. Wound management
Symptoms
 Vary depending on wound
 Open
 Cut skin
 Weeping
 Odour if infected
Questions to ask?
45
 How did the wound come about?
 Any NSAIDs, anti-coagulants, anti platelets use?
Treatment
 DON’T USE GAUSE
 Keep moist
 Clean an acute wound with: sterile 0.9% NaCl vials
 If the wound is contaminated: Betadine 1% solution (povidone-iodine) for 4
mins then wash off
 Stop bleeding by pressure or alginate dressing
 Close a laceration with steri strips
 Dress with Tegaderm with Pad (island film dressing). Change every 5 days or
sooner if exudate moves towards edges of island
14. Hair loss
Symptoms
 Receding hair line
 Hair thinning out
 No other Sx
 Redness and patchy hair loss (fungal)
Questions to ask?
 Gradual onset?  Age?
46
 Meds?  Iron deficient?
 Stressed?  Itchy?
Non pcol measures

 Wear a hat as skin can burn
 Stress Mx
Treatment
Iron -2 month trial if suspected deficiency in women
-empty stomach (can have with food if causes tummy upset)
-swallow whole, label 4
Minoxidil 2, 5% -apply 1mL bd to dry hair and do not wash hair for 4 hours
-let hair dry naturally
-wash hands before use
-may initially have increased shedding
-some response should be seen at 4 months
-if no response seen at 12 months, refer
-do not use a wig, hat or scarf for at least 1 hr after applying
-SEs (due to systemic absorption): rapid HR, chest pain,
dizziness
-can get hair growth above eyebrows and cheeks, skin
irritation
-best used when some hair is already on scalp
-NOT IN PREGNANCY, <18, >65
Referral points
 <18 years
 Sudden onset
 Suspected iron deficiency
 Diabetes
 Hypothyroidism
 Fungal infection
15. Shingles
 Caused by reactivation of varicella zoster
Symptoms
 Prodromal phase: general malaise, headache, fever, sore throat
 Blistering rash on trunk (on ribcage side)
 Extreme pain
 Lesions erupt over a week and heal within 2 weeks
Questions to ask?
 Had before?
47
 Where did lesions start?
 Immunocompromised?
Non pcol measures

 Bath lesions in saline tds to soothe and remove crusts
 Rest
 Plenty of fluids
 Cover lesions with non-adherent dressing (eg. Melolin)
Treatment
Paracetamol 15mg/kg q4-6 prn (MAX 60mg)
Solugel (propylene Prn (can keep in fridge for cooling effect)
glycol and NaCl)
Zostrix (capsaicin -for post hepatic neuralgia
0.025%) -tds-qid
-rub in thoroughly and wipe off excess
-wash hands thoroughly after
-wear gloves when applying if burns
-don’t use during an acute attack as may make worse
-can cause chemical burns
-see doc if neuralgia persists after 14 days
Referral
 Child
 Immunocompromised
 Pregnant
16. German measles (Rubella)
Symptoms
 Cold like Sx and swollen glands preceeding rash
 Blotchy itch rash (NOT RAISED as in chickenpox)
 Pink on whole body
 Infectious 7 days before rash appears
Questions
 Age?
 Had before?
48
 Fluids and rest
 Paracetamol
Referral points
 Pregnant women
17. Measles
Symptoms
 Prodrome phase (24-28 hours before rash): fever, runny nose, malaise,
reduced appetitie, Koplik’s spots in mouth
 Non-itchy rash that starts behind the ears and spreads to the trunk and
extremities in 24 hours
 Blotchy flat rash and coincides with a high fever
 Cough for 1-3 weeks
Questions to ask?
 Where did the rash start?
49
 Any spots in mouth?
 Any other family members affected?

 Fluids and rest
 Paracetamol
 Vaccine available and effective if given within 2-3 days of Sx appearing
Referral points
 Pregnant women
Gastroenterology
1. Haemorrhoids- Page 52
2. Heartburn- Page 53
3. Diarrhoea and vomiting- Page 54
4. Motion sickness- Page 55
5. Constipation- Page 56
6. Irritable bowel syndrome- Page 57
7. Threadworm- Page 58
50
1. Haemorrhoids
 2 types: internal and external
Symptoms
 Bleeding  Perianal itching
o Spotting around toilet  Mucus discharge
pan  Pain
o Streaking on toilet  Internal: more pain during
tissue bowel motion
o Blood on SURFACE of
stool
51
 External: pain AFTER bowel
motion, pain on
pressure/contact
Questions to ask?
 Symptoms  Recurrent?
 Had constipation lately?  Occupation? (associated with
 Do you strain? lifting and sitting?) diet?
 Type of bleeding? Colour?  Pregnant? (common in
Where? Volume? pregnancy)
Non pcol measures

 Avoid straining  Use annusol wipes (soothing)
 Respond to urge to defecate not toilet paper
 Avoid constipation (laxative?)  Avoid long periods of
 Warm baths for 15 mins daily standing/sitting
 Increase fluid and fibre in diet  Don’t try and initiate
defecation
Treatment
Anusol ointment -bd, wash area before application, load applicator and insert into rectum
(ZnO, benzoyl -wash applicator in hot water and detergent and then dry
benzoate) -SAFE IN PREGNANCY
Proctosedyl -tds (after bowel motions if possible) for 1 week MAX
(cinchocaine, -wash area before use
hydrocortisone) -use finger for external and nozzle for internal
-squeeze while withdrawing nozzle from rectum
-wash nozzle with warm soapy water, -SAFE IN PREGNANCY
Rectogesic (0.2% -FOR ANAL FISSURES ONLY
GTN) -apply to anal canal tds for 2-4 weeks, caution: headache, dizziness, facial
flushing, can give stool softener as well, nitrate free period needed, B2
Referral
 Abdo pain  Persistent changes in bowel
 Blood IN the stool habits
 Fever  >3 weeks
 Unexplained rectal bleeding  <12 years old
2. Heartburn and indigestion

 REFER TO REFLUX IN PREGNANCY, PAGE 26
Additional treatment
Ranitidine 150mg -1 bd
-diarrhoea, constipation
->12 years old
52
OTC PPI -1 d
-Pantoprazole 20mg -normal PPI counseling
-Rabeprazole 10mg -MAX 2 WEEKS
- >18 years
NOTE: all antacids, MAX 2 WEEKS
Additional Referral points

 Medicine induced heartburn
 Dark stools
 Debilitating pain
 Radiating pain
 >50 years
3. Diarrhoea and vomiting

 REFER TO GASTROENTERITIS AND DEHYDRATION, PAGE 6
Additional Treatment
Loperamide 2mg -2 stat then 1 after every bowel motion (MAX 8 d)
-SEs: abdo pain, N&V, flatulence
-ideally, let gastro run its course
53
-B3, >12 years
Lomotil -2 tabs qid (MAX 8 tabs)
(Diphenoxylate -label 1
2.5mg, atropine -SEs: as above, anti-SLUD
25mcg) -C, >12 years
If nauseas, offer -1 tds

Blackmores Morning
Sickness (ginger, B6)
Additional Referral points

 >50 years and change in bowel habits
 Recent travel overseas
 Drug induced (eg. C. diff)
4. Motion sickness
Symptoms
 Weakness
 Nausea
 Pallor
Questions to ask?
54
 Had before?
 Severity of Sx?
Non pcol measures

 Sit in middle of boat, plane wing, car front
 Avoid OH
 Decrease oral intake
 Frequent small meals
 Fix vision on horizon
 Avoid reading while travelling
Treatment
Pheniramine 45.3mg -half-1 tab 30 mins before travel, up to tds
-5-10 years: half tab 30 mins before travel, up to tds
-label 1, normal sedating antihistamines counseling
-SAFE IN PREGNANCY
-Promethazine HCl -HCl- 25mg night before or 2 hours before travel, >2 y/o
-Promethazine theoclate -theoclate: 25mg 1-2 hours before travel, >5 years
- normal sedating antihistamines counseling
-CAT C
Kwells (Hyoscine -1-2 tabs 30 mins before travel (MAX 4 tabs)
hydrobromide 0.3mg) -label 12
-normal sedating antihistamines counseling
- >6 years, B2
5. Constipation
 REFER TO CONSTIPATION IN PREGNANCY, PAGE 25
Additional Treatment
 Refer to ‘LAXATIVES’ in AMH summary for extra information
Psyllium Husk -1 spoonful in 250mL water tds, drink asap
(Metamucil) -take with EXTRA FLUID to ensure laxative effect
-2-3 days for full effect, starts working in 1 day
55
-safe in heart disease
Docusate with -1-2 n, then 1 prn, up to 4 tabs
senna 50/8mg -6-12 hours to work
Lactulose -15-45mL d in 1-2 doses
-Mercy guidelines: 20mL bd
-need to take regularly to work (1-3 days)
Movicol - 1 sachet in 125mL prn, MAX tds
(polyethylene -can keep in fridge for 24 hours
glycol) - >2 years, use movicol half
Additional referral points

 Weight loss
 Medicine induced
 Alternative diarrhoea and constipation
 >14 days
6. Irritable bowel syndrome (IBS)
Symptoms
 Chronic abdo pain
 Diarrhoea and constipation alternating
 Pain relieved by defecation or wind
Questions to ask?
 Change in diet?
56
 Stressed?
 Depressed?
 New meds?
Non pcol measures

 Stress relief
 Avoid trigger factors (Eg. Certain foods, stress, caffeine)
 Exercise
 High fibre diet
 Keep a diary
Treatment
Psyllium Husk -1 spoonful in 250mL water tds, drink asap
(Metamucil) -take with EXTRA FLUID to ensure laxative effect
-2-3 days for full effect, starts working in 1 day
Buscopan -1-2 tabs qid
(hyoscine -SEs: sedation, anti-SLUD
butylbromide -AVOID IN PREGNANCY
10mg)
Iberogast -2 different plant extracts
-20 drops tds
-SAFE IN ALL PATIENT GROUPS
Referral points
 <16 years
 >40 with changing bowel habits
 Pregnant
 Blood or fat in stools
 Weight loss
 Bowel obstruction
 Systemic Sx eg. Fever
7. Threadworms
Symptoms
 Itchy bottom, esp at night
 Irritability
 Sleep disturbances
 Tiredness
 Loss of appetite
57
Questions to ask?
 Have you seen actual worms?
 Have you performed the sticky tape test?
o Apply sticky tape to the anus at night and remove in the morning and
look for eggs.
 Recently travelled?
 Duration?
 Age of patient?
Non pcol measures

 Wash hands after meals and after toilet
 Nails to be short and clean
 Bed linen should be frequently washed
 Shower mane and clean around anus properly
Treatment
Pyrantel -10mg/kg as a single dose, with food, (MAX 1g)
(Combantrin -repeat in 2 weeks
100mg squares) -itching may continue for several days after Tx
-PREFERRED in all patient groups
-for other worms, 10mg/kg/day for 3 days.
Mebendazole -1 tab stat regardless of age/weight
(Combantrin-1 - >2 years
100mg) -repeat in 2 weeks
NOTE: TREAT ALL FAMILY MEMBERS
Referral points
 OTC Tx failure
 Secondary infection due to itch
 Recent travel
 <6 months
 Pregnant (no Tx is totally safe)
Eye
1. Dry eye- Page 61
2. Red eye- Page 62
3. Contact lens care- Page 63
4. Viral Conjunctivitis- Page 64
5. Bacterial conjunctivitis- Page 65
6. Allergic conjunctivitis- Page 66
58
7. Stye- Page 67
8. Chalazion- Page 67
9. Blepharitis- Page 68
General Eye
*REFER TO APF FOR ADMINISTRATION OF DROPS AND OINTMENTS*
Questions to ask ALL patients that present with any eye disorder:
 Wear contacts?  Pain?
 Drug induced?  Photophobia?
 Occupation?  Visual field disturbances?
 Dry mouth as well?
59
Referral points for ALL patients that present with an eye disorder:
 True eye pain  Vision loss
 Photosensitivity  Foreign body in eye
 Drug induced eye problem  Redness away from pupil
 Visual field disturbances
Symptom Treatment Dosage/Direction

Itchy eye Antihistamine Livostin (Levacobastine 0.05%)
(Levacobastine) or -1 drop bd-qid
Mast cell stabilizer -label 1
(ketotifen) -shake before use
-B3 (not in pregnancy)
Zaditen (Ketotifen 0.025%)

-1 drop bd
-B1
-may cause drowsiness
Red eye Vasoconstrictor Naphcon Forte (Naphazoline 0.1%)
(naphazoline or -1 drop bd-qid
phenylyephrine)
Prefrin (phenylephrine 0.12%)
-1 drop q3-4 prn
SEs: rebound hyperaemia, stinging on instillation

NOTE: do not use more than 5 days, see doc if no
improvement after 2 days, cool compress is just as effective
and safer
Dry eye REFER TO ‘DRY EYE’
NOTE: DO NOT RECOMMEND VASOCONSTRICTOR-ANTIHISTAMINE COMBO
PRODUCTS AS CAN LEAD TO OVERUSE eg. Naphcon-A
1. Dry eye
 Lack of tears or poor quality tears
Symptoms
 Dry, itchy, gritty, watery eyes (watery because of overproduction)
Questions to ask?
 Wear contacts?  Occupation?
 Drug induced?  Dry mouth as well?
60
 Pain?  Visual field disturbances?
 Photophobia?
Non pcol measures

 Avoid irritants  Boost humidity in air by placing
 Consciously blink bowls of water to evaporate
 Good contact lens care  If wear contacts, use
 Wear shades if its sunny or preservative free eye drops
windy  Discard 28 days after opening
Treatment
Genteal eye drops (hypromellose 0.3%) -prn (1 drop every 1-12 hours prn)
-counsel on eye drop administration
-SEs: transient stinging and burning reported
Liquifilm Tears (1.4% polyvinyl alcohol) -prn (1 drop every 1-12 hours prn)
-SEs: transient blurred vision
PRESERVATIVE FREE DROPS FOR CONTACT LENS WEARERS
Poly Gel (carbomer 0.3%) NOTE: Eye drop but has ‘gel’ in brand name
-prn (1 drop every 1-12 hours prn)
-NOTE: use last if other drops are also being used
Refresh (polyvinyl alcohol 1.4%, -prn (1 drop every 1-12 hours prn)
povidone 0.6%) -counsel on eye drop administration
GELS/OINTMENTS
Genteal Gel (hypromellose 0.3%, 0.2% -nocte
carbomer) -counsel on eye ointment
-transient blurring of vision
Refresh Night time (paraffin) -nocte
-counsel on eye ointment
-transient blurring of vision
Referral points
 Drug induced dry eyes  Associated dry mouth
 Bottom lid turns outward  Child as rare
 Persistent Sx
2. Red eyes
Symptoms
 Red eye
Questions?
 REFER TO PAGE 60
 New cosmetics?
61
Non pcol measures
 Reassure patient it is self limiting
 Wear shades
 Avoid irritants eg. New cosmetics?
 Don’t rub eyes
 If infectious cause, discard cosmetics used in this period
 Avoid contacts during and for 48 hours after infection clears
 Wash hands before and after instilling drops
 Avoid touching eye, sharing towels ets
 Cold compress (cold towel on eye for 10 mins on, 10 mins off- prn)
Referral
 ONE red eye
3. Contact lens care
1. When to clean contact lenses? At night as soon as you remove them – not in
the morning. Do not change brand of solution without first consulting your
optometrist
2. Steps in cleaning:
62
(a) Preparation and washing hands – wash hands before removing contact
lenses, and make sure you rinse off all the soap first. Dry the hands with a lint
free tissue/cloth
(b) Cleaning (Rubbing) – Place a few drops of multi-purpose cleaning solution
(eg. Optifree Ever Moist (thicker than standard Optifree and has greater
contact time)) in the palm of your hand. Place the lens on the tip of your
index finger of you other hand and rub it into the solution for 30 seconds.
Turn the lens inside out and repeat for the other side. Turn the lens back the
correct way again.
(c) Rinsing – hold the lens between the thumb and the index finger again and
rub the lens under a stream of multipurpose solution again to rinse off the
original solution *DO NOT USE TAP WATER.
(d) Storage and disinfection – Place the lens in the appropriate side of the case
and cover with fresh solution. Screw the lid on and shake to mix the solution.
(e) Rinse before re-insertion – in the morning, remove the lens from the case
and rinse with the solution before putting it into the eye. Discard the solution
in the case, rinse with hot water and dry with a tissue.
4. Viral conjunctivitis
Symptoms
 Watery
 Irritated
 Foreign body sensation
 Both eyes
63
 Generalized redness
 Associated with cough and cold Sx
Questions to ask?
 Any other Sx?
 Recently been sick?
Non pcol measures

 Self limiting (1-3 weeks to resolve)
 Highly contagious so don’t share towels, cosmetics etc
 ?discard contacts worn during infection
Treatment
 Cool compress
 REFER TO PAGE 60 and 61 FOR SPECIFIC Sx
 Normal saline eye irrigation
5. Bacterial conjunctivitis
Symptoms
 One eye affected which then  Generalized redness
spreads to the other eye  Crusting in the morning
 Purulent discharge  Waking up with eyelids stuck
 Gritty feeling together
64
Questions to ask?
 Thick, sticky discharge?
 Wake up with eyelids stuck together?
 Anyone else in family affected?
Non pcol measures

 Reassure patient it is self limiting (5-14 days to treat)
 Don’t rub eyes
 Discard cosmetics used in this period
 Avoid contacts during and for 48 hours after infection clears
 Wash hands before and after instilling drops
 Avoid touching eye, sharing towels ets
 Cold compress (cold towel on eye for 10 mins on, 10 mins off- prn)
Treatment
Chloramphenicol eye -1-2 drops, every 2 hours for the first 24 hours, then
drops 0.5% decreasing to 6-hourly until discharge resolves,
-MAX 5 days
-can cause unpleasant taste
-does not need to be kept in fridge once opened
Eye ointment 1%
-nocte or tds for children
both are safe in pregnancy, >2 years

Brolene (Propamidine -for mild cases
0.1%) -1-2 drops 3-4 times d for up to 5-7 days
-If no improvement within 2-3 days, see doc
-safe in pregnancy
Referral
 OTC Tx failure
6. Allergic conjunctivitis
Symptoms
 Both eyes affected
 Watery discharge
 Itchy
 Redness in corners of eyes
 Associated rhinitis
 Seasonal
65
Questions to ask?
 Do you have hay fever? Eczema? Or asthma?
 Any other Sx?
Non pcol measures

 Avoid irritants
 Cool compress
 Avoid rubbing eyes
Treatment
 Oral antihistamines
 Can use prophylactic Tx if known to get as certain times of year
Referral points
 OTC Tx failure
7. Stye/Chalazion
 Stye- inflammation or infection of eyelid margin (anti’s generally not
needed)
 Chalazion- blockage of meibomian gland
Symptoms
 Lump in upper or lower eye lid
 Chalazions are generally on the top lid whereas styes are generally on the
bottom lid
 Swelling and redness around lump
66
 Pain (stye)
 Painless (chalazion)
Questions to ask?
 Recent trauma to eye?
 Painful?
 Recently had blepharitis?
Non pcol measures

 Warm compress 10-20 mins bd-qid
 Self limiting
o Chalazion- few weeks
o Stye- days
 Do not squeeze or rub
 Wash hands frequently
 Wash face daily including eye
 Refrain from using makeup until heals
 Can use ocular lubricant for chalazion (REFER TO PAGE 60)
Referral
 Systemic Sx
 Turning of lower eyelid
 Middle/elderly aged patient with painless lump
8. Blepharitis
 Inflammation of the eye lid margin
 Can be a type of dermatitis
Symptoms
 Bilateral
 Raw red lid margins
 Crusting of eyelashes
 Greasy appearance
67
Questions to ask?
 What other symptoms do you have? (check for scalp involvement)
 Extent of lid involvement? (if localised not likely to be blepharitis)
 Eye involvement? (conjunctivitis is commonly associated with blepharitis)
 How long have you had these symptoms for?
 Other medical conditions? (Looking out for seborrhoeic dermatitis and
rosacea)
 Have you recently changed cosmetics? (can cause sensitisation and contact
dermatitis)
Non pcol measures

 Warm compress for 10-20 mins bd
 Lid hygiene:
o Scrubbing of the eyelid margin with dilute baby shampoo (1 in 10) Lid-
Care or a dilute solution of sodium bicarbonate (1 teaspoon per 250ml
hot tap water)
o Using a cotton bud to apply the shampoo
o Use a downward motion applied to the upper eyelid and an upward
motion for the lower eyelid
o Complete twice daily whilst condition active then once daily for
prophylaxis
 To prepare Lid-Care, moisten one of the cleansing pads with solution, fold
and rub until foam forms. Use a separate pad on the other eye
Referral
 Resistant to OTC Tx
Respiratory
1. Cough- Page 70
2. Cold and Flu- Page 71
3. S3 Asthma relievers- Page 72
NOTE:
68
 NO MEDICATED COUGH AND COLD PRODUCTS TO BE USED IN <6 YEARS
OLD OTC
 Can be given <6 years of age with a prescription but recommended to call
doctor and discuss alternatives (doc may not be aware of new guidelines?)
 Any cough and cold preparation requested for a child between 6-12 years,
should only be given at the discretion of the pharmacist or prescriber
1. Cough
Symptoms
 Dry or chesty cough  Sometimes associated cold Sx
Questions to ask?
 Productive or dry?  Blood? Rust coloured
 Sputum colour? White (viral (pneumonia), pink tinge (left
infection), yellow/green ventricular failure), dark red
(bacterial infection) (carcinoma)
69
 Nature of sputum? Foul  Recent cold / flu? May indicate
smelling (infection), thick post-viral cough (worse at
(asthma) night when lying down)
 Worse any time of day?  Tickle at back of throat and
Asthma (worse at night and recent cold? (postnasal drip)
first thing in the morning)  Sound? Barking sound (croup),
 Wheezing / chest tightness / whooping (pertussis)
shortness of breath?  Any meds / ACEIs?
 Smoker?  Age?
 Duration?
Non pcol measures

 Increase fluids (except in HF)  Wash hands regularly
 Suck sugar free hard lollies  Discard sputum in tissue
 Steam inhalation, vaporisers,  Honey lemon tea for relief
hot showers to loosen sputum  Smoking cessation
 Cover mouth & cough into  Avoid irritants
shoulder
Treatment
Cough Expectorant/ Mucolytic DuroTuss Chesty Cough Liquid (8mg Brom, 200mg Guaif)
Eg. Guaifenesin/ -10mL every q4-6 hours prn (max 4 doses per day)
Bromhexine -SEs: diarrhoea (lax effect of sorbitol), drowsiness
-in B/F, use straight bromhexine 10mL tds
Cough Suppressants DuroTuss Dry Cough Forte (15mg pholcodine)
Eg. Pholcodine, -5mL (15mg) qid
Dextromethorphan, -SEs: drowsiness, constipation, N&V
Dihydrocodeine
NOTE: single products are Cat A
Referral Points
 Cough on its own  Recurrent nocturnal cough
 >2 weeks  Drug induced
 Coloured or smelly phlegm  Failed OTC Tx
 Asthma Sx
2. Cold and Flu
Symptoms
 Cold- stuffy nose, sneezing, sore throat, hacking cough
 Flu- fever, aches and pains, fatigue, extreme exhaustion, slight cough
Questions to ask?
 Symptoms?  Asthma?
 Duration?  Sinusitis?
 Any other medical conditions?  Ear involvement?
70
Non pcol measures
 Assure patient the common cold is self limiting, Tx is only for Sx relief
 Get plenty of rest, stay warm, plenty of water to liquefy mucus
 Steam inhalations
 Blow nose with both nostrils open so don’t force infection into ear
 Wash hands regularly
 Cough into shoulder
 If diabetic, monitor BSLs more closely as BSL increase during infection
 Vitamin C 500mg bd
 Echinacea 2 tabs tds (MAX 8 weeks)
Treatment
Paracetamol/ -Para: 1g qid (MAX 4g d) – safe in pregnancy
Ibuprofen -Ibu: 200-400mg every q6-8h with food (MAX 1.2g d) –NO IN PREGNANCY
Saline Nasal -brands: Fess, FLO
Spray (NaCl 0.9%)-use prn (use 5 mins before medicated nasal spray)
Medicated Nasal -Drixine (Oxymetazoline 0.05%): 1-2 sprays, each nostril tds
sprays -Otrivin (Xylometazoline 0.1%): 1 spray, each nostril tds
SEs: rebound congestion (MAX 5 days use), transient stinging, increased
nasal discharge, theoretical increase in BP
-Not investigated in pregnancy but should be okay, recommend saline
Oral -relief of blocked and runny nose
decongstants -Pseudoephedrine: 60mg q4-6h, MAX 240mg d (CR 120mg bd)
-DON’T RECOMMEND PHENYLEPHRINE AS HAS 2% ORAL BIOAVAILABILITY IE
DOESN’T WORK!!!!!!!!!
?which one to use if hypertensive?
Cough REFER TO PAGE 70 ‘COUGH’
preparation -post viral cough may continue for weeks after cold resolves
NOTE: DO NOT RECOMMEND ANY COMBO PRODUCTS (QUOTE AMH)
Referral
 >10-14 days  Very young/elderly
 Ear and sinus involvement  Persistent fever
 Flu Sx
3. S3 Asthma Relievers
Symptoms (of asthma)

 Wheeze
 Chest tightness
 Shortness of breath
 Worse when exercising
Questions to ask?
 Have you seen your doc to review your asthma in the last 12 months?
71
 How is your asthma control?
 Is your asthma affecting your sleep or exercise?
 How often do you use your preventer?
 Are you using a reliever?
 HOW do you use your asthma devices?
Salbutamol (Ventolin -Device is called puffer
100mcg/dose) -MDI
1. Remove inhaler cap and shake well
2. Exhale away from device
3. Keep head upright and life chin slightly
4. Place mouthpiece between teeth and seal with lips
5. Inhale slowly and deeply, then press puffer to release 1
dose
6. Remove puffer from mouth and hold breath for about 10
seconds
7. Breathe out normally away from the inhaler
8. Repeat above steps for multiple doses
9. Replace cap
Terbutaline (Bricanyl -Device is called a turbuhaler
500mcg/dose) -DPI
1. Unscrew and remove the cap
2. Keep the turbuhaler upright
3. Rotate the grip to the right and then to the left until a
click is heard (dose is ready)
4. Exhale away from device
5. Keep head upright and life chin slightly
6. Place mouthpiece between teeth and seal with lips
7. Breathe in forcefully and deeply
8. Remove puffer from mouth and hold breath for about 10
seconds
9. Breathe out normally away from the inhaler
10. Replace cap
Pain
1. Muscoloskeletal Pain- Page 74
2. Lower back pain- Page 75
3. Insect Bites- Page 76
4. Headache- Page 77
72
1. Musculoskeletal pain
Symptoms
 Pain
 Redness
 Swelling
 weakness
Questions to ask?
73
 LINDOCARF
 How did it happen?
Non pcol measures

 REST- avoid activity
 ICE- apply every 2 hours for 20 mins for first 2 days
 COMPRESSION- compression bandage
 ELEVATE- raise above heart level
 Avoid HARM (heat, alcohol, running, massage (or use of heat rubs in first 2-3
days), NSAIDs within first 2 days
 After 48 hours of RICE, mobilise joint (instead of continuing to rest), can use
heat, massage
Treatment
Ibuprofen 200mg, -1-2 tabs q4-6 hours with food prn (MAX 6 tabs d)
2% gel -rub 4-10cm of gel into affected area qid prn (MAX 4 doses d
for 2 weeks)
-CAT C
Diclofenac 25mg, -1-2 tabs tds with food prn (MAX 200mg d)
1% gel -rub 4-10cm of gel into affected area qid prn (MAX 4 doses d
for 2 weeks)
-CAT C
Paracetamol -500mg: 1-2 tabs qid prn (MAX 8)
500mg, 665mg -665mg: 1-2 tabs tds prn (MAX 6)
Nurofen back pain -non medicated
heat patches -apply every 8 hours
-don’t apply over topical meds
Dencorub Arthritis -MAX qid
Ice Therapy -good if have salicylate allergy
(menthol) -only product suitable if on warfarin
Referral points
 Possible break or fracture  OTC Tx failure after 5 days
 Unable to bear own weight  Drug induced muscle pain
 Pins and needles (nerve  Instantaneous pain, swelling,
involvement) bruising etc
2. Lower back pain
Symptoms
 Aching
 Stiffness
 Localized or more diffuse
 Reduced mobility
 Worse on rest
74
Questions to ask?
 LINDOCARF
 How did it happen?
Non pcol measures

 Keep mobile despite pain
 Hot or cold pack
 Good posture
 Back brace
 Safe lifting
 Flat shoes
 Firm matress
 Lumbar roll
 Avoid same position for long periods
Treatment
 Panadol osteo is first line, then NSAIDs
Referral points
 Fever
 Pain that radiates away from lower back (sciatica)
 Numbness
 Weight loss
 Suspected break or fracture
 No improvement within 4 weeks
3. Insect bites
Symptoms
 Itchy wheal that develops into a firm, itchy papule
 Can sometimes see bite mark in centre
 Can spread to trunk and limbs
Questions to ask?
 Duration?  Do you know what bit you?
75
Non pcol measures
 Avoid being outdoors at dusk or dawn (if need, wear long pants and long
sleeved tops)
 Ensure accommodation has good screens on the window, keep windows shut
and use AC if available
 Wear light coloured clothing
 Avoid wearing aftershaves and perfumes
 Use DEET insect repellant (only apply to exposed skin and clothing)
o NOT recommended in pregnancy but if really need, RWH suggests to
limit exposure to areas that can’t be covered otherwise and spray
onto clothes and surroundings instead of directly onto skin
 Wash area with soap substitute and cool water
 Apply ice to reduce swelling
 Snake, funnel web spider, blue ringed octopus: firm pressure bandage on
whole limb, splint limb, do not wash or apply torniquet
 Do not apply pressure for red back spider as this will make pain worse
Treatment
Stingose (aluminium sulfate) -Apply promptly and liberally after bite tds prn
-unlikely to work if been longer than 30 mins since sting
Soov Bite (lignocaine 3%, -dab onto affected skin qid
cetrimide 0.5%)
Hydrocortisone 1% -Apply sparingly bd for 7 days MAX
-1 FTU covers the space of 2 hand palms
Medi-Quattro (chlorhexedine -antiseptic, anaesthetic, anti-inflammatory
0.1%, lignocaine 1%, -apply sparingly qid prn
bufexamac 5%) SEs: local irritation, skin sensitizer (can cause contact dermatitis)
Referral points
 Anaphylaxis  Poor response to OTC Tx
 Severe pain which does not  Fleas? New pet?
settle  Drug induced
 Worsening Sx  Snake or dangerous spider
4. Headache
Symptoms
 Tension: bilateral, pressure, worse throughout the day, eye strain, hours to
days
 Migraine: unilateral (can swap sides), throbbing, severe pain, N&V,
photophobia, aura comes before, associated with low oestrogen
 Sinusitis: associated with URTI, nasal congestion, pain worse when patient
leans forward (decongestants, maybe Abx)
76
 Cluster: unilateral, worse at night & when lying down, associated with
conjunctivitis & nasal congestion on the same side as the headache, often OH
induced, 2-3 hours, SEVERE TO THE POINT OF SUICIDE
Questions to ask?
 Aura/Sx?  Eye pain?
 Where abouts?  Photophobia?
 Associated N&V?  Stiff neck?
Non pcol measures

 Avoid trigger factors eg. Caffeine, OH, skipping meals, strong smells, smoking
 Keep a headache diary
 Lifestyle measures: relaxation, exercise, eat a well balanced diet, drink plenty
of water, get adequate sleep
 Massage, stretch tight neck, hot packs, water bottles, support pillows
 For migraine, lie down in a quiet, dark room
Treatment
Paracetamol 500mg 2 qid prn
-MAX 8 tabs d
Mersyndol night (Para 500mg, -1-2 tabs q4-6 prn, MAX 8 d
Codeine 9.75mg, Doxy 5mg) -Label 1, anti-SLUD
Ibuprofen 200mg 1-2 tabs q4-6 hours with food prn (MAX 6 tabs d)
Soluble Aspirin 300mg -1-3 tabs stat then repeat in 4 hours prn, MAX 12 d
Metomax (metoclopramide -1-2 tabs stat, repeat in q4h prn (MAX 6)
500mg, paracetamol 500mg) -label 12
Nausetil (prochloperazine 5mg) -20mg stat, 10mg 2hrs later, then 5-10mg tds prn
-label 1, anti-SLUD
NOTE: Soluble preparations are preferred as pts with migraines have impaired drug
absorption
Referral
 Cluster  Rash, fever, stiff neck
 Underlying cause identified  Pain up side of face (trigeminal
 Pain, Fever neuralgia)
 Overuse medicine headache
Ear, Nose and Throat

1. Otitis Media- Page 79
2. Otitis Externa- Page 80
3. Ear Wax- Page 81
4. Sore Throat- Page 82
5. Allergic Rhinitis- Page 83
77
1. Otitis media
Symptoms
 Abrupt
 Pain, fever and irritability (in infants)
 Discharge when eardrum bursts
 Pain relief when eardrum bursts
 Generally follows cold
78
Questions to ask?
 Pain severity?
 Inflammation?
 Any discharge?
 Recently been swimming?
 Hearing loss?
 Age?
 Pain relieved on discharge?
Non pcol measures

 Remind patient that discharge can continue for several weeks after burst
eardrum
 Keep ear dry
 Keep child comfortable
Treatment
 Aimed at symptom relief
 First Line: Paracetamol 15mg/kg q4-6h (MAX 60mg d)
 Ibuprofen: 5-10mg/kg every 6-8 hours with food, >3 months, MAX 3 doses in
24 hours
 NOTE: Don’t ever recommend ‘Auralgan’ as it masks serious causes of pain
Referral points
 Pain continues after burst ear drum
 Hearing loss
2. Otitis Externa
 Water in ear promotes growth of microorganisms
Symptoms
 Itch
 Pain
 Discharge
 Generally post swimming
Questions to ask?
79
 Itchy?
 Painful?
 Discharge?
 Hearing loss?
 Inflammation?
 Swimming lately?
 Systemic Sx?
Non pcol measures

 Dry ears after swimming
 Shake water from ears after swimming
 Ear plugs and caps when swimming
 Avoid swimming if you have an infection
Treatment
Ear Clear for Swimmer’s -4-6 drops into each ear (after shaking water out) after
Ear (acetic acid 1.65%, swimming or bathing
isopropyl alcohol 63.4%)
Vosol Complete Care for -prevention
Swimmer’s Ear (acetic -2 drops bd
acid 2%, benzethonium Cl
0.02%, propylene glycol
2.8%)
NOTE: Don’t ever recommend ‘Auralgan’ as it masks serious causes of pain
Referral
 Ear pain in children under 6
 Generalized inflammation of ear
 OTC Tx failure (Sx present 7 days after starting Tx)
 Systemic signs of infection
 Hearing loss
3. Ear Wax Impaction
Symptoms
 Ear discomfort
 Sense of fullness in ear
 Hearing loss
 Mild discharge
Questions to ask?
 Itchy/pain?
 Hearing loss?
80
 Discharge?
 Dizzy?
Non pcol measures

 Avoid cotton buds in the ear
 Most will resolve untreated within 5 days
 Syringing (by doctor) may be helpful
 NO ear candles
Treatment
Waxsol (Docusate -fill ear canal (about 5 drops) for 2 consecutive nights
sodium 0.5%) before syringing
Ear Clear for Ear Wax -5-10 drops bd, MAX 4 days
Removal (Carbamide - >12 years
Peroxide 6.5%)
Cerumol -5 drops 10-30 mins before syringing OR bd for 4 days and
(Dichlorbenzene with wax will come out unaided
chlorbutol) -contains peanut oil (CAUTION OF PEANUT ALLERGY!!!!!)
Sodium Bicarbonate -5 drops bd for 3-4 days
APF
Referral
 Blood
 Dizziness/Tinnitus
 Fever
 Foreign body
 If pain persists beyond 7 days
4. Sore Throat
Symptoms
 Sore throat
 Difficulty swallowing
 If infection present, associated cough, fever, malaise or rhinitis
Questions to ask?
 Other meds? (agranulocytosis, THINK SMURF)
 Other Sx?
 > 2 weeks
81
Non pcol measures
 Suck an ice cube
 Honey lemon tea for relief
 Salt water gargle
Treatment
Ibuprofen 200mg 1-2 tabs q4-6 hours with food prn (MAX 6 tabs d)
-AVOID IN PREGNANCY
Soluble Aspirin 300mg -1-3 tabs stat then repeat in 4 hours prn, CI: <18
Difflam AAA -1 lozenge prn (MAX 12 d)
(benzydamine, -caution of hot drinks as can make mouth numb
lignocaine, -excess use can have laxative effect
dichlorobenzyl OH) - >6 years, NOT IN PREGNANCY
Bioglan Throat Clear -1 lozenge prn (MAX 8 daily, 5 daily if <6 years)
(Natural)
Cepacaine mouthwash -gargle or rinse 10-15mL for 10-15 seconds and spit out
(benzocaine, -repeat every 2-3 hours prn
cetylpyridinium,
ethanol)
Betadine sore throat -gargle 15mL for 30 seconds and spit out every 3-4 hours
gargle (povidone prn (MAX 8 doses d)
iodine) -if using concentrate, dilute 1:20 before use
Referral points
 If using drugs that cause agranulocytosis
 Associated skin rash
 > 2 weeks
 Difficulty speaking or swallowing
 Signs of bacterial infection (exudate, swollen glands)
5. Allergic Rhinitis
Symptoms
 Runny nose, congestion, sneezing, itching, watery/itchy eyes
 Generally seasonal
Questions to ask?
 Sx? Had before?  Hx of eczema or asthma?
 Seasonal? Or bad all year  Exposed to any allergens
round? recently?
Non pcol measures
82
 Stay indoors  Remove carpets (if persistent)
 Wear shades if outdoors  Wash bed linen frequently
 Avoid triggers  Replace lawn with pavement
 Roll windows up when driving  Wet face to wash pollen
Treatment
Non-sedating Claratyne (loratadine): 10mg d (1st line in pregnancy (NPS))
antihistamines Telfast (fexofenadine): 120mg d or 180mg d
Zyrtec (cetirizine): 10-20mg d
-label 1, anti-SLUD, NOT IN PREGNANCY
Sedating -preferred in pregnancy
antihistamines -Polaramine (dexchlorpheniramine): 2mg qid, 6mg MR bd
-label 1, anti-SLUD
Intranasal Azep (Azelastine 0.1%): 1 spray each nostril bd, B3, >5 years
antihistamines (B3) Livostin (Levacobastine 0.05%): 2 sprays bd, label 1, shake before use
Intranasal -REFER TO COLD AND FLU
decongestants -use until nasal steroid kicks in
Intranasal Steroids -can start 4-6 weeks before expected Sx
-relief in 3-7 hours -Rhinocort (budesonide 32mcg): 1-4 sprays each nostril d
-optimum effect in a -Beconase (beclomethasone 50mcg): 2 sprays each nostril bd
few days -Flixonase (fluticasone 50mcg): 1-2 sprays d
-SEs: nasal bleeding -Nasonex (mometasone 50mcg): 1-2 sprays each nostril d
Other nasal sprays -Atrovent (Ipratropium 22mcg): 2-4 sprays tds (SE: nose bleeds)
-Rynacrom (Cromoglycate 2%): 1 spray up to 6 d (safe in pregnancy)
NOTE: -antihistamine products are preferred in hayfever (compared to oral and
topical decongestants) as they target histamine release
-if eye Sx present, recommend products according to PAGE 60
-in a child, recommend childrens Telfast, Claratyne or Telfast and FESS
-For persistent hayfever, use steroids and cromoglycate
Referral points
 Asthma Sx  Persistent nasal obstruction
 Medicine induced (SSRIs)  Unilateral discharge
Miscellaneous
1. Nicotine Replacement Therapy- Page 85
2. Orlistat- Page 86
3. Emergency Contraceptive- 87
4. Travel Health- Page 88
5. Sleep- Page 89
83
1. Nicotine Replacement Therapy
Questions to ask?
 How soon after waking do you need to smoke?
 How many cigarettes do you smoke daily? (NRT if >10)
 Have you tried to quit before and experiences withdrawal Sx?
 5 A’s: Ask, Assess, Advise, Assist, Arrange (follow up)
Non pcol measures

 4 D’s: Delay, Deep breath (3x),  Avoid associating
Drink water, Do something situations/objects
 Utilize QUIT line  Carry small snacks with you
84
 Exercise to avoid weight gain
Treatment
Gum -6-10 pieces of 4mg gum d OR 8-12 pieces of 2mg gum d
-use park and chew method: chew slowly until bitter taste or tingling comes,
park in b/w gum cheek and upper gum until tingling subsides and then chew
again, lasts 30 mins, MAX: 40mg d
-SEs: throat and mouth irritation, not to be used in denture wearers, jaw pain
Inhalation -10mg cartridges (MAX 12 d), 15mg cartridges (MAX 6 d)
-use prn according to MAX. Each cart lasts 40 mins
-SEs: cough, mouth and throat irritation (do not use in asthmatics)
-good for those who miss hand-to-mouth action
Lozenge -1.5mg (MAX 20 lozenges d), 2, 4mg (MAX 15 lozenges d)
-let lozenge dissolve in mouth (may take up to 30 mins). Do not chew, swallow
or eat in this time
-SEs: throat and mouth irritation
Patch -5,10,15,25mg/16 hours (if sleep disturbances is bothersome)
-7, 14, 21mg/24 hours
-MAX 12 weeks use (can use 2mg gum in combo with patch)
-apply to clean, non-hairy, dry part of upper body or outer arm
-Ses: vivid dreams, nausea (if bothersome, use lower strengths)
Spray -1-2 sprays when craving occurs (4 sprays/hr, MAX 64 sprays d)
-point nozzle at side of cheek or under tongue (avoid lips), hold breath and
release spray. Avoid swallowing for a few seconds
-Ses: lip burning sensation, throat and mouth irritation
Sublingual tablet -1 or 2 tabs under tongue every 1-2 hours (MAX 40 tabs d, 80mg)
-let dissolve slowly over 30 mins, do not swallow, suck or chew
-Ses: throat and mouth irritation
NOTE: -do not smoke while using NRT, use short acting agents (eg. Gum) in
pregnancy, use NRT if >16 years
Referral points
 Pregnancy/Breastfeeding  OTC Tx failure
2. Orlistat
Symptoms
 Patients with BMI >30 or >27 with risk factors eg. HTN, diabetes, cholesterol
 BMI= weight (kgs)/height2 (in metres)
Questions to ask?
 Weight?  Pregnant or breastfeeding?
 Lifestyle?  Medical conditions?
 Meds that cause weight gain?
Non pcol measures
85
 LIFESTYLE MEASURES SHOULD  Low carb, high protein diet
BE TRIALLED FIRST  Reduce sugar, salt, fat etc in
 Healthy balanced diet diet
 Lots of fruit and veggies  3 meals, 3 snacks daily
 Low GI foods  Avoid foods that appear
 Light to moderate exercise (3- healthy but are energy dense
5x weekly) eg. Muesli bars and juices
 Set realistic goals  Smaller portion sizes
(1-4kgs/month weight loss)  Prepare food from night before
if have busy life schedule
Treatment
Xenical (Orlistat) -1 capsule tds with or up to 1 hour after your 3 main meals
120mg - Do not take a dose if you skip your meal or if it doesn’t
contain fat
-CI: malabsorption syndrome, pancreatic enzyme deficiency
state, cholestasis
-do not give in pregnancy (advise on non-pcol meaures)
-take multivitamin with fat soluble vits A, D, E, K while using
orlistat (take 2 hours before orlistat dose or at bedtime)
-SEs: fatty stools, flatulence, fecal urgency, oily stools
-mean weight loss of 1-4kgs yearly
-can affect INR and cyclosporine levels
Referral points
 <18 years
 Medicine induced weight loss
3. Emergency contraceptive
 Delays ovulation and does not prevent implantation of a fertilized egg,
therefore does not interrupt a pregnancy or induce an early abortion
Questions to ask? (CHEAP-M)

 Contraception: What is your usual means of contraception? What is the
reason for the EC Eg. Split condom? Missed OC pills? What is consensual?
 Hours: hours since unprotected intercourse?
o <24 hours= 95% effective
o 24-48 hours= 85% effective
o 48-72 hours= 58% effective
o some evidence suggests efficacy if taken 120 hours post intercourse
 Ectopic pregnancy: history of ectopic pregnancy?
86
 Age: ideally refer if <16 however, pharmacist can give if satisfied patient is
mature enough to understand etc
 Pregnant already: is there a chance you could already be pregnant? Previous
unprotected intercourse in same menstrual cycle? Was your last period
early/short/late? Suggest pregnancy test if unsure
 Medicines: drug interaction unlikely to be of concern
 Medical conditions: CI in breast cancer, unexplained vaginal bleeding,
established pregnancy (WHO does not identify any conditions for which the
risks outweighs the benefits). Malabsorption conditions eg. Crohn’s patients
may need a higher dose (REFER)
Treatment
Levonorgestrel -take NOW
1.5mg -SEs: nausea, vomiting, breast tenderness, vaginal bleeding, headache
-if vomiting occurs within 2 hours of dose, take again
-your next period should be on time but it may be early or late. If it is more than 1
week late or unusually light, you should have a pregnancy test
-if have lower abdo pain or become pregnant after EC, see doc and tell them you had
the EC (increased risk of ectopic pregnancy)
-EC does not protect against STIs!!!!!
-if already taking OC, discard missed pills and pill for day of taking ECP then continue
on as normal on active tablets for the next 7 days (if due for sugar pills skip). Not
covered again until 7 active tablets taken
Referral points (if timely referral is possible)

 > 72 hours since intercourse  Interacting drugs
 <16 years old  Risk of STI
 Breast cancer, unexplained  Sexual assault suspected (also
vaginal bleeding, established offer support, referral to rape
pregnancy, malabsorption crisis centre)
conditions
4. Travel health
 Check immunisations required from smarttraveller website

 If you are planning to carry medications overseas contact the embassy of the
country(s) you will be visiting to ensure your medicines are legal there. Carry
a letter from your doctor listing meds. Leave in original packaging. Get
pharmacy to label OTC meds with your name as well
 Get health and travel insurance, first-aid kit.
 Wear a Medic Alert bracelet or necklace if you have a serious medical
condition or allergy.
 Take condoms with you rather than relying on those bought locally. Always
follow safe sex practices. Remember that the pill does not protect against
87
STDs and that medicines used to treat travellers’ diarrhoea and prevent
malaria can reduce effectiveness of OC.
 Avoid contact with animals, choose safe modes of transport, wear shoes and
sandals, avoid getting tattoos or body piercing, avoid illicit drugs.
Condition Prevention
Deep Vein -Exercise ankles and calf muscles every half hour.
Thrombosis -Keep legs straight, do not sit cross-legged, Consider using pressure stockings
-Drink plenty of water or juice but AVOID alcohol and caffeine-containing
drinks.
Jet Lag -If possible break the trip up by including stopovers.
-Try and plan for arrival at destination around bedtime
-Set your watch to the local time of the destination and eat/sleep according
to this destination time during the flight.
-Eat light, healthy meals and drink plenty of water. Limit alcohol and caffeine-
containing beverages.
-Wear loose, comfortable clothing during the flight and try to sleep during
longer legs of the flight – a mild sleeping tablet may help.
Traveller’s -Drink small amounts of fluid often, drink only boiled or bottled drinks – do
diarrhoea not add ice.
-Avoid shellfish, cold cooked meats, fresh salads, raw vegetables or cut fruit
-Avoid eating anything washed in local water.
-Avoid unpasteurised dairy products
-Wash your hands before meals and dry them with your own towel
-Use bottled water to brush teeth and avoid swallowing water whilst
showering or bathing
-can use ORT, anit-diarrheals, anti-emetics, anti-spasmodics (SEE DOC IF >48
HOURS)
Malaria -Avoid exposure to mosquitoes from dusk to dawn
-use mosquito nets treated with insecticide (e.g. permethrin), air-
conditioning, mosquito coils etc
-wear light-coloured clothing covering arms, legs and ankles when outdoors
and especially after sunset
-use a DEET insect repellent at regular intervals
-speak to DOC about S4 antimalarials eg doxy
5. Insomnia
Symptoms
 Lack of sleep
 Poor sleep quality
 Tired during day
Questions to ask?
 Medicines?  Snoring? Bedwetting?
 Difficulty getting to asleep?  Jetlag?
 Difficulty staying asleep?  Caffeine?
 Poor sleep quality?
88
 Is there something keeping you
up?
Non pcol measures

 TREAT UNDERLING CAUSE  No strenuous mental activity at
 Sleep hygiene (1st line and bedtime (eg. Crossword)
should be trialed for 1 week)  No television in bed
 Regular bedtime and wake up  If can’t go to sleep, get up and
time do something until sleepy
 Avoid sleeping in very warm  Only use bedroom for sleeping
rooms  Avoid heavy meals and OH
 Exercise during the day close to bedtime
 Don’t have daytime naps  Warm bath and milk before
 No sleeping in to catch up on bed
sleep
Treatment
Doxylamine 25mg -1-2 tabs 30 mins before bed
-MAX 10 days in a row
-Label 1a, 12, anti-SLUD, sedation
-cat A, >12 years
Diphenhydramine -1 cap/tab at night
50mg - MAX 10 days in a row
-Label 1a, 12, anti-SLUD, sedation
-cat A, >12 years
Referral points
 < 12 years old  Sx of depression/anxiety
 > 3 weeks  Medicine induced
 Insomnia with no apparent  Underlying medical condition
cause causing insomnia
89

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OTC Summary for Intern Pharmacists

Abbz Gayed, 2015

3. Gastroenteritis and Dehydration

Non pcol measures

Non pcol measures

Non pcol measures

2. Dry Mouth (Xerostomia)

Non pcol measures

3. Aphthous ulcers (mouth ulcers)

Non pcol measures

Non pcol measures

Non pcol measures

1. Period pain (primary dysmenorrhea)

Non pcol measures

Non pcol measures

Non pcol measures

Non pcol measures

Clotrimazole cream & -10% cream- once -100mg pessary- 6 days

Pregnancy and Breastfeeding

General health and advice during pregnancy

1. Back pain in pregnancy

Non pcol measures

Non pcol measures

Questions to ask? (Remember MARY REMEDY)

Non pcol measures

4. Nocturnal muscle cramps in pregnancy

Non pcol measures

Non pcol measures

6. Breast and nipple thrush

Non pcol measures

Non pcol measures/Treatment

Non pcol measures

Non pcol measures (evidence is lacking)

Non pcol measures

1-2 tubes for adults

Non pcol measures

Non pcol measures

5. Fungal skin infections

Non pcol measures

6. Nail fungal infections

Non pcol measures

Non pcol measures

Symptoms (begin 1-3 weeks after infection)

Non pcol measures

Non pcol measures

Non pcol measures

12. Sunscreen and sunburn

13. Wound management

14. Hair loss

Non pcol measures

Non pcol measures

16. German measles (Rubella)

Non pcol measures/Treatment

Non pcol measures

2. Heartburn and indigestion

Additional Referral points

3. Diarrhoea and vomiting

If nauseas, offer -1 tds

Additional Referral points

Non pcol measures

Additional referral points

6. Irritable bowel syndrome (IBS)

Non pcol measures

Non pcol measures