Hospital Internship - OSCE Guide

CONTENT:
Nursing mothers - back pain – ibuprofen 400 mg
Vaccination advice (MMR) - Scenario 5.8 Drug Choice in Nursing Mothers
- Scenario 4.4 Vaccination Advice
Hypercalcemia – bendroflumethiazide 2.5mg – alfacalcidol – labs: sodium,
Glucose Monitoring potassium,calcium,phosphate
- Scenario 2.5 Monitoring blood glucose - Scenario 5.7 Drug-induced hypercalcaemia

Betahistine (serc) Warfarin – mechanical mitral valve replacement – anticoagulant – hypertension –

type 2 diabetes – Ischemic heart disease
Drug History taking/drug queries from health professional (scenario: hospital) - Scenario 5.6 Initiating Warfarin Therapy
- Scenario 1.7 Drug History
Depression history – sertraline – ibuprofen 200mg
Lifestyle advice following a heart attack - Scenario 5.5 Managing interactions (Ibuprofen)
Medications: aspirin 75mg, ramipril 5 mg, simvastatin 40mg, bisoprolol 2.5, glyceryl
trinitrate sublingual spray Meningitis – child – allergic to penicillin
- Scenario 6.1 Lifestyle advice following a ‘heart attack’ - Scenario 5.4 Choosing antibiotic therapy

Managing therapy (ciprofloxacin) Cough-wheeze -st john's wort – uniphyllin continus (Theophylline)
Aspirin, ramipril, simvastatin, sodium valproate - Scenario 5.3 Managing interactions (St John’s Wort)
- Scenario 5.11 Managing Therapy (Ciproloxacin) Co-amilozide – lisinopril – potassium level – heart failure
- Scenario 5.1 Managing interactions (hyperkalaemia)
Clopidogrel for percutaneous coronary intervention, patient with stents
- Scenario 5.10 Clopidogrel for percutaneous coronary SOAP: Diabetes
intervention SOAP: Hypertension
CALCULATION:Paper tablets
Warfarin and clarithromycin Creatinine clearance: using Cockroft-Gault equation case scenario
- Scenario 5.9 Managing interactions (Warfarin) Reducing dosage
Dobutamine infusion rate in ml/hr

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Vaccination advice (MMR)

Vaccine Name Measles-Mumps-Rubella Vaccine

Indication It is indicated for the routine immunization of children, and children and adolescents who have not been immunized on a regular
schedule.

Population & All children get two doses of MMR (measles-mumps-rubella) vaccine, starting with the
Frequency ● 1st dose at 12 through 15 months of age, and the
● 2nd dose at 4 through 6 years of age.
Children can receive the second dose earlier as long as it is at least 28 days after the first dose.

Dosage The dosage for MMR is 0.5 mL.

Direction of Use It is administered subcutaneously or intramuscularly. The preferred injection sites are the anterolateral area of the thigh in younger
children and the deltoid area in older children, adolescents, and adults.

MOA The MMR vaccine works to stimulate the immune system to protect against measles, mumps, and rubella. This vaccine is live
attenuated and thus is a harmless, less virulent version of the infectious agents of which it provides protection. Since the MMR
vaccine is live attenuated, it has excellent efficacy but requires more than one dose to achieve this immunity.

Side effects Adverse events tend to occur with the first dose. 1 to 3 weeks following vaccination, 5% of immunized children experience malaise
and fever, which can present with or without a rash that lasts up to 3 days.

Contraindications ● Pregnancy
● Hypersensitivity
● Immunosuppression
● Moderate or Severe Febrile Illness
● Active Untreated Tuberculosis

Interactions ● Corticosteroids and Immunosuppressive Drugs

(drug/food) ● Immune Globulins and Transfusions
● Use with Other Live Viral Vaccines

Special Precautions/ ● Febrile seizure

Warnings ● Hypersensitivity to eggs
● Thrombocytopenia
● Family history of Immunodeficiency

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Important Counselling Since the MMR vaccine is a live vaccine, it can cause mild measles, mumps or rubella infections. It should not be given if you:
Notes ● are pregnant
● have a severe weakness of the immune system
● have had a severe allergic response (anaphylaxis) to this vaccine or part of this vaccine before
● have had another live vaccine within the past 4 weeks.

If your child develops a rash without other symptoms, no treatment is needed. The rash should go away in several days. Check with
your doctor to see if you can give either acetaminophen or ibuprofen for pain or fever and to find out the appropriate dose.

Sample Case Scenario 4.4 Vaccination Advice

You are working as a community pharmacist when a male customer approaches you. He has been sent notification that his
12-month-old baby is scheduled to receive the first MMR (measles, mumps, rubella) vaccination in two weeks’ time. He is concerned
about the effects of the MMR vaccine, having read in the newspaper that there is a link with autism.

In this type of scenario, it is appropriate to acknowledge the man’s concerns. That is, to show that you know there has been a lot of
information in the media about this issue. You should have then looked in the BNF for information relating to MMR. You should have
identified a statement advising that there is no evidence of a link between MMR vaccination and autism. This is key in this scenario.

You should then have:

● explained the meaning of ‘no evidence of a link’, that is, it cannot be proven that the MMR vaccine causes autism
● discussed the benefits and risks of MMR vaccination, in terms of the consequences of the illnesses versus the possible
side-effects of the vaccine. This might seem a lot to discuss in the short timeframe of the OSCE, so keep to main
messages.
In interactive stations it is always sensible to check whether the person is satisfied with the information given. It is also important to
avoid jargon and unexplained acronyms, that is, say things in lay language.

Glucose Monitoring

Recommended Target
Ranges
> 180 mg/dL Too high; considered unhealthy

80-130 mg/dL Good range for most people

< 70 mg/dL Too low; considered unhealthy

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Device Use & Glucose meter or glucometer measures how much sugar is in the blood sample.
Direction of Use
How to Use a Blood Sugar Meter?
1. Prepare your supplies and clean your hands.
2. Turn on your glucometer and insert a test strip.
3. Prick your finger and squeeze a drop of blood.
4. Place the drop to the edge of the test strip.
5. Wipe away any remaining blood.

Frequency ● For people with type 1 diabetes, frequent blood glucose testing is the only way to safely and effectively manage blood
glucose levels. People with type 1 diabetes may use blood glucose monitoring (BGM) with fingersticks and a glucose meter,
or continuous glucose monitoring. Continuous glucose monitoring (CGM) is a way to monitor your blood glucose levels
every 5 to 15 minutes, 24 hours a day.
● For people with type 2 diabetes, the recommendations for how often to test blood glucose are based upon individual factors
such as type of treatment (oral medications, insulin, and/or lifestyle changes), A1C level, risk of hypoglycemia (when blood
glucose is too low), and treatment goals.

Side effects There were only minor local adverse events: hypersensitivity, itching, pain, redness, burning, subcutaneous hemorrhage.

Contraindications ● Severe Dehydration

● Hypotension
● Shock
● Peripheral Circulatory Failure
● Diabetic Ketoacidosis

Important counselling Every time you check your blood glucose, write down your result. Also write down any notes about things that may be affecting your
notes blood glucose, such as your diet and exercise for the day. This information can help you and your health care provider:
- Look for patterns in your blood glucose over time.
- Adjust your diabetes management plan as needed.

If you have type 1 diabetes:

● Check your blood glucose 4 or more times a day if you are on intensive insulin therapy with multiple daily injections (MDI) or
if you are using an insulin pump.
● You may need to check your blood glucose more often, 6–10 times per day, if:
- You have diabetes that is not well controlled.
- You are ill.
- You have a history of severe hypoglycemia.
- You have hypoglycemia unawareness.

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If you have type 2 diabetes:

● Check your blood glucose 2 or more times a day if you take insulin or other diabetes medicines.
● Check your blood glucose 4 or more times a day if you are on intensive insulin therapy.
● You may need to check your blood glucose more often if:
- Your medicine is being adjusted.
- Your diabetes is not well controlled.
- You are ill.

Sample Case Scenario 2.5 Monitoring blood glucose

A 55-year-old woman has asked to have her blood glucose levels assessed. You are required to perform this procedure.

Prior to carrying out this procedure, all necessary equipment should be checked, this should also involve the calibration of your
particular blood glucose monitor with the corresponding blood test strips. This procedure must be carried out prior to the test being
undertaken as both measuring tool and strip must be compatible. (Please refer to manufacturers’ instructions.) Glucose monitoring is
an invasive technique that requires the client’s consent prior to the procedure being undertaken.

Did you follow the procedure below?

● Even if the client is used to this procedure, you should still explain it to them.
● Turn on the glucose monitor and ensure it is calibrated.
● Clean the client’s finger with an alcohol wipe and allow it to dry
● Prepare the test strip, making sure it is in date and in good
● condition.
● Prick the client’s finger with the lancet and dispose of the lancet into the sharps bin.
● Squeeze the finger gently and then position the finger over the test strip so that the blood drops on to the test strip.
● Give the client a cotton wool ball and press firmly on the pricked site to stop any further bleeding.
● Note the reading from the glucometer.
● Inform the client of the reading.
● Document the reading and take appropriate action according to the result.

Rx Betahistine (Serc)

Generic Name / Betahistine

Device Name

Therapeutic Category Antivertigo

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Indication/Uses For vertigo, tinnitus and hearing loss associated in patients with Meniere’s disease.

Dosage Initially, 8-16 mg tid or 24 mg bid, adjusted according to individual response.

Maintenance: 24-48 mg daily.
Max: 48 mg daily.

Direction of Use May be taken with or without food.

Side effects Nausea, dyspepsia. Rarely, vomiting, bloating, abdominal distension or pain. Rarely, ventricular extrasystoles, hypotension (including
orthostatic hypotension), tachycardia. Hypersensitivity reactions.

Contraindications Hypersensitivity to the active substance or to any of the excipients.

Phaeochromocytoma - a rare, usually noncancerous (benign) tumor that develops in an adrenal gland.

Interactions Drug interactions:

(drug/food) ● Serum concentration may be increased by MAOIs (e.g. selegiline). Therapeutic effects may be decreased by
antihistamines. May decrease the bronchodilator effects of β2 agonists.
Food interactions:
● Delayed absorption with food.

Special Precautions/ Patients with bronchial asthma, CV disease, active or history of peptic ulcer disease. Hepatic impairment. Pregnancy and lactation.
Warnings

Important counselling Overdose

notes Symptoms: Nausea, somnolence, abdominal pain, convulsion, pulmonary or cardiac complications.
Management: Supportive treatment.

Drug History taking/drug queries from health professional (scenario: hospital)

Steps on Drug History Introduce yourself

Taking Inform patient the importance of maintaining a current medication list in chart
Confirm the patient's information (Name, age, birthday)
What medications are they taking?
(you may ask these questions)
● Name of medication
● What is the medication for

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● Dosage form
● Amount or dose
● How do you take the medication (by which Route)
● How often do you take the medication
● When did you begin taking the medication
● What prescription medication are you taking on a regular basis or as needed?
● What over-the-counter medication are you taking on a regular basis or as needed?
● What herbal or natural medicines are you taking on a regular or as needed basis?
● What vitamins or other supplements are you taking?

If medication list available:

- Review each medication with patient
- Confirm that it is current

Other questions:
● Have you recently started any new medications?
● Did a doctor change the dose or stop any of your medications recently?
● Did you change the dose or stopped any of your medications recently?
● Are any of the medications causing side effects?
● Have you changed the dose or stopped any medications because of unwanted effects?
● Do you sometimes stop taking your medication whenever you feel better ? or when it makes you feel worse?

Important counselling Balanced open-ended questions (what, how, why, when) with yes/no questions
notes Avoid medical jargon - Keep it simple
Avoid judgemental comments

Sample Case Scenario 1.7 Drug History

You are the pharmacist on a hospital ward. You are approached by a doctor whom you know well. He asks you whether selegiline
can cause vertigo. What questions would you ask the doctor before the query can be answered?

You are not expected to state whether the drug causes the side-effect. The purpose of the task is for you to identify what information
you need before you are able to find out whether the drug can cause the side-effect.

To enable you to target your search for information to address the question posed by the doctor, you need to ask questions to
establish some information:
● Relevant patient details (e.g. age), as some patients, including the elderly, may be more susceptible to
● side-effects.
● How long has the patient had vertigo? Or, when did the vertigo appear in relation to the initiation of selegiline? This question

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would help you to establish whether there may be a link between starting the treatment and the development of the
side-effect.
● Describe the vertigo (signs, symptoms, severity, is it getting better or worse?).
● How long has the patient been taking the selegiline?
● What dose, and for what indication?
● What other medication is the patient taking and at what dose(s), including over-the-counter, herbal or homeopathic
medications? This question is asked so that you can ascertain whether there may be other causes for the symptom
experienced.
● Has any other medication been started or stopped during this time? Again, this is asked in order to eliminate causes of the
symptom.
● Any other pre-existing medical problems/conditions/drug allergies of relevance (that may have caused the vertigo)?
● Has any action already been taken to address the problem?

Lifestyle advice following a heart attack

Nonpharmacologic ● Try to avoid or limit foods that have very few nutrients and a lot of calories as often as possible.
Treatment/Practices - Limit saturated fat, trans fat, sodium, red meat, sweets, and sugar-sweetened beverages.
- Eating a low-sodium diet
- Try to reduce the amount of — or eliminate — processed foods, which tend to be high in sodium and sugar, and
consume alcohol in moderate amounts.
- Instead, when available, eat more fruits and vegetables, whole grains, lean proteins, and healthy fats and oils.

Heart healthy foods

● leafy, green veggies

● whole grains, such as whole wheat, brown rice, oats, rye, and quinoa
● berries
● avocados
● fatty fish, such as salmon, mackerel, sardines, and tuna
● nuts and seeds, such as almonds, walnuts, flaxseeds, and chia seeds

● Cardiovascular exercise can seem like a miracle potion. It strengthens your heart and helps lower your blood pressure and
cholesterol levels. It also acts as a stress reliever and mood enhancer.
- The American Heart AssociationTrusted Source recommends at least 150 minutes per week of moderate exercise,
at least 75 minutes per week of vigorous exercise, or a combination of both.

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- Whether you decide to walk, run, swim, ride your bike, or even engage in some types of household chores, you
can improve your health. There are cardio fitness plans for all levels, including beginners.
- Be sure to get the all-clear from your doctor before lacing up your running shoes.
● Maintaining good mental health can benefit you in many ways.
- If you’re able to have a positive outlook about your treatment after a heart attack, including any lifestyle changes,
this can help reduce your risk for heart problems.
- After a heart attack, you’ll likely experience a wide range of emotions, including depression and anxiety. These
emotions can make it more difficult to implement and maintain habits that will greatly improve your health.
- That’s why it’s important to discuss mental health concerns, as well as physical ones, that you may have with your
doctor.
● Smoking negatively affects your cardiovascular system in a number of ways.
- It can damage your heart functionTrusted Source and blood vessels, and prevent oxygen-rich blood from getting to
your organs and other body parts.
- As a result, smoking is a major risk factor of heart disease, which can lead to a heart attack.
- If you’re a smoker, consider quitting. Talk with your doctor about finding a plan to help you quit.
- If you have friends or family who smoke, try to also avoid breathing in secondhand smoke.

Monitoring Attending regular check-ups is a must.

Blood pressure monitoring.
(Necessary tests depends on the condition of px) Some tests conducted are the following:

● Blood tests. Certain heart proteins slowly leak into your blood after heart damage from a heart attack. Emergency room
doctors will take samples of your blood to check for these proteins, or enzymes.
● Electrocardiogram (ECG). This first test done to diagnose a heart attack records electrical signals as they travel through
your heart. Sticky patches (electrodes) are attached to your chest and limbs. Signals are recorded as waves displayed on a
monitor or printed on paper. Because injured heart muscle doesn't conduct electrical impulses normally, the ECG may show
that a heart attack has occurred or is in progress.

Some additional test may be performed: (ff)

● Chest X-ray, Echocardiogram, Coronary catheterization (angiogram), Cardiac CT or MRI

Special Precautions/ The px condition must be stable for at least 3 weeks before you're allowed to drive again. Your doctor will likely advise you to hold off
Warnings on sex and other physical activities for at least 2 to 3 weeks after your heart attack.

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Important counselling ● Encourage the patient to change lifestyle as much as possible and take the prescribed medications as directed by their
notes physician.
● Avoid doing heavier housework, such as sweeping, vacuuming, or mowing the lawn until your doctor says it's ok to do so.
You can build up by gradually adding other activities as you feel able. Make sure you're free from pain or discomfort as you
add new activities. You should aim to sit less each day.

Medications: aspirin 75mg, ramipril 5 mg, simvastatin 40mg, bisoprolol 2.5, glyceryl trinitrate sublingual spray

If these drugs are taken together? Medications: aspirin 75mg, ramipril 5 mg, simvastatin 40mg, bisoprolol 2.5, glyceryl trinitrate sublingual spray

Indication Simvastatin + Aspirin: beneficial in coronary heart disease across a broad range of cholesterol levels.
Simvastatin + Ramipril: treatment in hypercholesterolemic patients. Hypertension.
Bisoprolol + Aspirin: (low-dose aspirin) reduces blood pressure and decreases symptoms of anxiety during bereavement.
Bisoprolol + Ramipril: two medications commonly used to treat high blood pressure.

Non-pharmacological Alcohol consumption

Therapy ● Reduce the amount of alcohol consumed to recommended limits. Men should not regularly drink more than 21 units/week
and women should not regularly drink more than 14 units/week.
● Avoid binge drinking, and preferably have a minimum of two alcohol-free days every week.
Diet
● Eat a ‘Mediterranean’ diet; at least five portions of fruit and vegetables, plenty of nuts, fibre and (oily) fish and limit meat,
saturated fat, and salt intake.
● Reduce fat intake (animal fats, fatty foods, e.g. chips, try grilling or baking instead of frying).
● Vitamin supplementation in most people is unnecessary.
Exercise
● Move a little more (i.e. increase the amount of appropriate exercise). Ask the customer whether they have tried to exercise
and what they think they can fit into their daily routine.
● Take regular physical activity of moderate intensity for at least 30 minutes per day or 3 × 10 minutes per day or at least five
times a week.
● Maintain body weight within a normal range of BMI 18.5–24.9 kg/m2.

Contraindication blood pressure may fall following the increase in beta-blocker dose, and as a result she may feel a little dizzy or lightheaded

Drug-Drug Interaction Glyceryl trinitrate sublingual spray +Aspirin: may make your angina worse.
Glyceryl trinitrate sublingual spray +Ramipril: can increase the risk of first-dose hypotension

Important Counselling Follow the above advice with regard to losing weight/reducing BMI.

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Notes ■follow the advice with regard to reducing alcohol consumption

■ follow the advice with regard to stopping smoking. As he has attempted and failed to quit several times before, a referral to a GP
or individual or group service may be appropriate. Options should be discussed with the patient.

Sample Case Scenario 6.1 Lifestyle advice following a ‘heart attack’

Read the notes below after listing the questions you would ask. If you asked the appropriate questions, the patient would have told
you that he is a 66-year-old white male. The patient recently had a heart attack (six weeks ago). Current BMI is
27 kg/m2. He takes the following medication supplied by the hospital:
● aspirin 75 mg daily
● ramipril 5 mg daily
● simvastatin 40 mg at night
● bisoprolol 2.5 mg daily
● glyceryl trinitrate sublingual spray 400 micrograms – one or two puffs as required for chest pain.
Other information you may have elucidated about the patient.
The patient:
● smokes (20 a day) and has tried to quit several times
● drinks alcohol often (3 beers and a whisky each night)
● knows his diet needs improving
● does not do much exercise
● has a stressful job.

Questions to be asked/issues clarified before providing advice

● Establish a few basic facts about the individual, including age, ethnic status, weight.
● Establish details of ‘heart attack’ and medical conditions:
○ When did he experience the ‘heart attack’?
○ Are any other medical conditions present (including other cardiovascular conditions such as hypertension)?
○ Are any current regular, as required and OTC medicines taken (including complementary medicines)?
● Establish some lifestyle factors:
○ Daily and weekly alcohol consumption (in units). If the patient is unsure about units then clarify using appropriate
verbal or written comparisons
○ Does the patient ever binge drink (clarify definition of binge drinking)?
○ Ask the patient to describe a typical weekly intake of food and drink.
○ Ask about smoking/tobacco consumption status. If the patient is a smoker/tobacco consumer then ask what is
smoked/consumed and how often per day. When does the patient have the first smoke/tobacco product of the
day?
○ Current weight/BMI is important. Target advice at overweight or obese.
○ Current exercise regimen.
● Establish previous advice:

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○ Ask about advice already received from secondary or primary care with regard to healthy lifestyle and patient’s
level of compliance with such advice. If poor compliance, attempt to establish reasons. By asking these questions
you are ensuring the advice can be tailored to the individual’s needs.

What lifestyle advice should someone follow after a heart attack?

There are a number of lifestyle changes advised to prevent further problems. Did you cover the following?
Alcohol consumption
● Reduce the amount of alcohol consumed to recommended limits. Men should not regularly drink more than 21 units/week
and women should not regularly drink more than 14 units/week.
● Avoid binge drinking, and preferably have a minimum of two alcohol-free days every week.
Diet
● Eat a ‘Mediterranean’ diet; at least five portions of fruit and vegetables, plenty of nuts, fibre and (oily) fish and limit meat,
saturated fat, and salt intake.
● Reduce fat intake (animal fats, fatty foods, e.g. chips, try grilling or baking instead of frying).
● Vitamin supplementation in most people is unnecessary.
Exercise
● Move a little more (i.e. increase the amount of appropriate exercise). Ask the customer whether they have tried to exercise
and what they think they can fit into their daily routine.
● Take regular physical activity of moderate intensity for at least 30 minutes per day or 3 × 10 minutes per day or at least five
times a week.
● Maintain body weight within a normal range of BMI 18.5–24.9 kg/m2.
Other
● Try to give up smoking. The benefits of stopping smoking are considerable. The patient should be offered the various NHS
options on support services to aid their attempt to quit smoking. See also Scenario 6.3.
● Try to reduce stress; suggest stress management techniques.

What advice would you give to this patient?

As this patient has experienced a ‘heart attack’ recently, it is a good time now to reinforce advice that they will have received. Many
NHS secondary care Trusts have cardiac rehabilitation nurses employed to provide advice before discharge and to follow up patients
for a while after discharge. This patient should:
● follow the above advice with regard to losing weight/reducing BMI
● follow the advice with regard to reducing alcohol consumption
● follow the advice with regard to stopping smoking. As he has attempted and failed to quit several times before, a referral to
a GP or individual or group service may be appropriate. Options should be discussed with the patient. Exercise advice is
needed but in view of their age and recent ‘heart attack’ this needs careful evaluation and a principle of starting gently and
building up gradually should be followed.

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Rx Aspirin 75 mg

Generic Name / Aspirin/Acetylsalicylic acid (Zorprin)

Device Name

Therapeutic Category Anticoagulants, Antiplatelets & Fibrinolytics (Thrombolytics) / Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Indication/Uses ● Acute ischaemic stroke, Angina pectoris, Myocardial infarction

● Fever, Mild to moderate pain
● Rheumatic disorders
● Prophylaxis of cardiovascular events in high-risk patients

Dosage ● Acute ischaemic stroke, Angina pectoris, Myocardial infarction

- Adult: For primary prevention:
- Loading: 150-300 mg.
● Fever, Mild to moderate pain
- Adult: Initially, 300-900 mg, repeated 4-6 hourly according to clinical needs.
- Max: 4 g daily.
● Rheumatic disorders
- Adult: 4-8 g daily in divided doses for acute disorders. 5.4 g daily in divided doses for chronic conditions.
● Prophylaxis of cardiovascular events in high-risk patients
- Adult: Long term: 75-150 mg once daily.
- Short term: 150-300 mg daily.

Direction of Use Should be taken with food.

Side effects ● Salicylate sensitivity, Tinnitus, Dyspepsia, Gastric irritation, Nausea, Vomiting, Rash, Urticaria.
● Potentially Fatal: Paroxysmal bronchospasm and dyspnoea. Coma, CV collapse, resp failure, severe hypoglycaemia.
Rarely, Reye’s syndrome. Hypersensitivity reactions (e.g. Stevens Johnson syndrome, angioedema), gastrointestinal
bleeding and perforation.

Contraindications ● Hypersensitivity to aspirin or other NSAIDs.

● Peptic ulcer, haemorrhagic disease, coagulation disorder (e.g. haemophilia, thrombocytopenia), gout.
● Severe hepatic and renal impairment. Children <16 years and recovering from viral infection.
● Pregnancy (doses >100 mg daily during 3rd trimester) and lactation.
● Concomitant use with other NSAIDs and methotrexate.

Interactions ● Increased risk of GI bleeding with alcohol.

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(drug/food) ● Increased risk of GI bleeding and ulceration with other NSAIDs.

● Increased risk of haematological toxicity of methotrexate.

Special Precautions/ ● Patients with dyspepsia or lesion of the GI mucosa, asthma or allergic disorders, anemia, dehydration, menorrhagia,
Warnings uncontrolled hypertension, G6PD deficiency, thyrotoxicosis.
● Patients undergoing surgical procedures.
● Moderate hepatic and renal impairment.
● Pregnancy.

Important counselling ● Avoid alcohol. Alcohol increases the risk of gastrointestinal bleeding.
notes ● Avoid herbs and supplements with anticoagulant/antiplatelet activity. Examples include garlic, ginger, bilberry, danshen,
piracetam, and ginkgo biloba.
● Take after a meal. This reduces irritating gastrointestinal effects.
● Take with a full glass of water.

Rx Ramipril 5 mg

Generic Name / Ramipril (Altace)

Device Name

Therapeutic Category ACE Inhibitors

Indication/Uses ● Hypertension
● Diabetic nephropathy, Nondiabetic nephropathy
● Prophylaxis of cardiovascular events in high-risk patients
● Congestive heart failure
● Heart failure post myocardial infarction

Dosage ● Hypertension
- Adult: Dose is individualised based on the patient's clinical response, tolerability and target blood pressure. As
monotherapy or in combination with other antihypertensives: Initially, 2.5 mg once daily, 1st dose preferably given
at bedtime; may be doubled at intervals of 2-4 weeks if needed. Maintenance: 2.5-5 mg once daily. Max: 10 mg
daily given as single or in 2 divided doses.
- In patients at risk of profound hypotension or on diuretics: Initially, 1.25 mg daily then adjust according to response;
if possible, may also discontinue diuretics 2-3 days before initiating ramipril therapy.
- Elderly: Initiate at lower doses then adjust gradually according to response.

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● Diabetic nephropathy, Nondiabetic nephropathy

- Adult: Initially, 1.25 mg once daily; may be doubled at intervals of 2 weeks. Maintenance: 5 mg once daily. Adjust
dose based on patient’s clinical response and tolerability.
- Elderly: Initiate at lower doses then adjust gradually according to response.

● Prophylaxis of cardiovascular events in high-risk patients

- Adult: In patients ≥55 years who have CV disease, stroke or peripheral vascular disease or with diabetes mellitus
and at least 1 CV risk: Initially, 2.5 mg once daily for 1-2 weeks, may increase to 5 mg once daily for the next 2-3
weeks. Maintenance: 10 mg once daily. Adjust dose based on patient’s clinical response and tolerability.
- Elderly: Initiate at lower doses then adjust gradually according to response.

● Congestive heart failure

- Adult: Patients on diuretics: Initially, 1.25 mg once daily; may be doubled every 1-2 weeks. Maintenance: 10 mg
daily in 2 divided doses. Adjust dose based on patient’s clinical response and tolerability.
- Elderly: Initiate at lower doses then adjust gradually according to response.

● Heart failure post myocardial infarction

- Adult: In clinically and hemodynamically stable patients (within 24-48 hours post-MI): Initially 2.5 mg bid for 3 days;
if not tolerated, start at 1.25 mg bid for 2 days, then increase to 2.5 mg bid. May double the doses at intervals of
1-3 days. Maintenance dose: 5 mg bid. Adjust dose based on patient’s clinical response and tolerability.
- Elderly: Initiate at lower doses then adjust gradually according to response.

Direction of Use May be taken with or without food.

Side effects ● Asthenia, Fatigue, Headache, Dizziness, Paraesthesia, Vertigo, Nausea, Vomiting, Diarrhoea, Dry mouth, Gastrointestinal
inflammation
● Potentially Fatal: Rarely, pancreatitis, airway obstruction (due to angioedema of the tongue, glottis or larynx), fulminant
hepatic necrosis, Stevens-Johnson syndrome, toxic epidermal necrolysis.

Contraindications ● History of angioedema (e.g. hereditary, idiopathic, due to previous angioedema with ACE inhibitors or angiotensin II
receptor antagonists [AIIRAs]); extracorporeal treatments resulting to contact of blood with negatively charged surfaces
(e.g. dialysis or haemofiltration with certain high-flux membranes [e.g. polyacrylonitrile membranes] and low-density
lipoprotein apheresis with dextran); hemodynamically relevant bilateral renal artery stenosis or unilateral in the single
kidney; hypotensive or hemodynamically unstable states.
● Concurrent use with aliskiren in patients with diabetes mellitus or moderate to severe renal impairment (GFR <60
mL/min/1.73 m2); concurrent use or within 36 hours of shifting to or from sacubitril/valsartan.
● Pregnancy and lactation.

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Interactions May increase risk of hypotension with acute alcohol intake.

(drug/food)

Special Precautions/ ● Patients with severe hypertension, decompensated CHF; relevant left ventricular inflow or outflow impediment (e.g. aortic or
Warnings mitral valve stenosis), hypertrophic cardiomyopathy with outflow tract obstruction, unstented unilateral or bilateral renal
artery stenosis, volume or salt depletion, liver cirrhosis and/or ascites; transient or persistent heart failure post-MI,
ischaemic heart disease or cerebrovascular disease, uncontrolled diabetes mellitus, hypoaldosteronism, acute cardiac
decompensation, metabolic acidosis, collagen disease (e.g. SLE or scleroderma); history of airway surgery. Dehydrated
patients.
● Patient undergoing major surgery or during anaesthetics. Desensitisation treatment (e.g. hymenoptera venom). Renal and
hepatic impairment. Elderly.

Important counselling This drug may cause dizziness, if affected, do not drive or operate machinery.
notes

Rx or OTC Simvastatin 40 mg

Generic Name / Simvastatin (Simvoget)

Device Name

Therapeutic Category HMG-CoA reductase inhibitors (statins)

Indication/Uses Primary hypercholesterolemia, prevention of coronary events

Dosage Dose range: 5-80mg/day Starting dose: 20-40mg once daily in the evening

Direction of Use Take simvastatin in the evening, on an empty stomach

Side effects constipation, diarrhea, fatigue, gas, heartburn and headache

Contraindications ● Active liver disease or unexplained persistent elevations of serum transaminases.

● Itraconazole, ketoconazole, HIV PIs, erythromycin, clarithromycin, telithromycin, nefazodone
● Pregnancy & lactation

Interactions Alcohol, diltiazem, grapefruit juice, oral anticoagulants

(drug/food)

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Special Precautions/ Severe renal insufficiency. Patients w/ predisposing factors for rhabdomyolysis. Monitor CK levels & liver function test.
Warnings

Important counselling Follow carefully any lifestyle advice you have been given such as stopping smoking, avoiding drinking too much alcohol, eating a
notes healthy diet and taking exercise. These also help to reduce the risk of heart and blood vessel disease. Do not drink grapefruit juice.

Rx or OTC Bisoprolol 2.5

Generic Name / Bisoprolol fumarate (RiteMED)

Device Name

Therapeutic Category Beta-Blockers

Indication/Uses Management of HTN, angina & heart failure

Dosage Individualized dosage: Essential HTN - 5mg once daily

Diastolic BP up to 105 mmHg - 2.5mg once daily if required

Direction of Use May be taken with or without food.

Side effects Bradycardia; worsening of preexisting heart failure, dizziness, headache; GI complaints eg, nausea, vomiting, diarrhea, constipation;
feeling coldness or numbness in extremities, hypotension & asthenia.

Contraindications Hypersensitivity. Acute heart failure, cardiogenic shock, 2nd- or 3rd-degree AV block (w/o pacemaker), sick sinus syndrome, SA
block; symptomatic bradycardia or hypotension; severe bronchial asthma or COPD, severe forms of peripheral arterial occlusive
disease or Raynaud's syndrome, untreated pheochromocytoma & metabolic acidosis.

Interactions Potentiated AV conduction time & increased -ve inotropic effect w/ class I & III antiarrhythmic drugs (quinidine, disopyramide,
(drug/food) lidocaine, phenytoin, flecainide, propafenone, amiodarone)

Special Precautions/ Avoid abrupt withdrawal. May impair ability to drive or operate machinery. Pregnancy & lactation.
Warnings

Important counselling Follow carefully any lifestyle advice you have been given such as stopping smoking, avoiding drinking too much alcohol, eating a
notes healthy diet and taking exercise.

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Rx or OTC Glyceryl Trinitrate Sublingual Spray

Generic Name / Glyceryl Trinitrate

Device Name

Therapeutic Category Anti-Anginal Drugs

Indication/Uses Angina pectoris

Dosage (400 mcg/spray)

Direction of Use 1-2 sprays under the tongue, then close the mouth, dose may be repeated at 5-minute intervals if required. Max: 3 doses.

Side effects Severe hypotension, shock, paradoxical bradycardia, increased intracranial pressure, dose-related headache,
methaemoglobinaemia, drug tolerance, hypoxaemia.

Contraindications Hypertrophic obstructive cardiomyopathy, increased intracranial pressure (e.g. cerebral haemorrhage, head trauma), inadequate
cerebral circulation, severe anaemia, closed-angle glaucoma, severe hypotension (systolic blood pressure <90 mmHg), arterial
hypoxaemia, severe/uncontrolled hypovolaemia

Interactions ● Reduced absorption of sublingual nitrates with drugs that cause dry mouth (e.g. anticholinergics)
(drug/food) ● Enhanced hypotensive effect with alcohol.

Special Precautions/ Patients with cerebrovascular disease, lung disease or cor pulmonale, recent history of MI, hypothyroidism, hypoxaemia or
Warnings ventilation/perfusion imbalance due to lung disease or ischaemic heart failure, hypothermia, malnutrition, volume depletion,
pre-existing hypotension, orthostatic dysfunction.

Important counselling Do not use GTN with medicines used to treat impotence and medicines used to manage high blood pressure in the arteries of the
notes lungs. Seek medical care if symptoms are not resolved after a total of 3 doses.

Rx Managing Therapy (Ciprofloxacin)

Generic Name / Ciprofloxacin

Device Name

Therapeutic Category Fluoroquinolones

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Indication/Uses Treat a variety of bacterial infections

● Urinary Tract Infections (UTI)- most common
● Pneumonia
● Sexually Transmitted Infections (gonorrhea, chancroid)
● Skin, bone, joint infections
● Prostatitis
● Typhoid fever
● Gastrointestinal infection
● Lower respiratory tract infection
● Anthrax
● Plague
● salmonellosis

Dosage UTI (tab)

● For mild to moderate UTI: 250 mg twice daily
● For severe or complicated UTI: 500 mg twice daily
Respiratory tract or skin and soft-tissue infections (tab)
● Mild to moderate: 500 mg twice daily
● Severe: 750 twice daily
IV Dosage (administered by slow infusion over 60 minutes)
● Mild to moderate infections: 200-400 mg twice daily
● Severe: 400 mg every 8 hours
● With severe renal impairment (creatinine clearance = 1.2 L/hour) 50% reduction in daily dosage

Direction of Use When used orally, it should be given with food to minimize gastrointestinal upset.
When administered intravenously, patients should maintain proper hydration and urine output.

Side effects Mild: nausea and diarrhea

Serious: peripheral neuropathy, prolonged QT interval, seizures, and other CNS effects, hyper or hypoglycemia, photosensitivity,
tendonitis

Contraindications ● Patients with hypersensitivity to the drug or components of the formulation

● Concurrent administration of tizanidine for muscle spasms- ciprofloxacin alters the pharmacokinetics effect of tizanidine,
leading to increased tizanidine levels and decreased psychomotor activity, BP, heart rate.
● Patients with myasthenia gravis- may exacerbate muscle weakness

Interactions Drug Interaction

(drug/food) ● Theophylline (with concurrent caffeine use)- raises theophylline levels

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● Cyclosporine
● Antacids- absorption of ciprofloxacin decreases with antacids containing agents such as aluminum and magnesium
Food Interaction
● Calcium-rich food and dairy products (milk, yogurt) or calcium-enriched juice- decreases the effect of ciprofloxacin

Special Precautions/ ● When used in patients with renal impairment, adjust the dose and discontinue any signs and symptoms of hepatitis
Warnings ● Black box warnings
○ Tendinitis
○ Tendon rupture- Achilles tendon rupture

Important counselling ● Use twice daily (every 12 hours preferably morning and evening) for 7-14 days. Avoid missed doses.
notes ● Drink plenty of water when taking the medication
● Avoid using antacids or you may administer ciprofloxacin wether 2 hours before or 6 hours after antacids for both the
immediate or the extended-release formulations
● It is important to monitor patients taking ciprofloxacin for symptoms of tendinitis, altered mental status, complete blood
count, and renal and hepatic function in prolonged therapy.
● The use of ciprofloxacin with nursing mothers is acceptable with monitoring for possible GI adverse effects (diarrhea or
candidiasis)
○ To breastfeeding mothers: consider avoiding breastfeeding three to four hours after dosing

If these drugs are taken together? Aspirin, ramipril, simvastatin, sodium valproate

Indication Aspirin + Ramipril: Often administered together especially in patients with both heart failure and ischemic heart disease
Simvastatin + Ramipril: used as a treatment in hypercholesterolemic
Aspirin + Ramipril + Simvastatin: used as fixed dose triple combination therapy to prevent cardiovascular diseases

Drug-Drug Interaction Sodium Valproate + Aspirin: Aspirin increases the concentration of sodium valproate which could lead to toxicity.
Aspirin + Simvastatin: Metabolism of Aspirin can be decreased when combined with simvastatin.

Important Counselling ● To manage the valproate toxicity when used with other drugs, dose adjustment is necessary. Contact your physician
Notes immediately.
● Low dose aspirin (75 mg a day) is safe to take with ramipril. Do not take more than the dose prescribed to avoid side
effects.
● Avoid taking more than the prescribed dose of Sodium Valproate.

Additional Notes ● Sodium valproate is an antiepileptic, which acts at γ-aminobutyric acid (GABA) receptors. Toxicity manifests by reduced
consciousness and myoclonus or tremor. Its doses should be monitored especially if the patient is taking other drugs.

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Maximum dose of this drug may easily cause toxicity leading to complications.
● Naloxone may be used to reverse features of mild to moderate valproic acid toxicity

Sample Case (In Scenario 5.11 Managing Therapy (Ciproloxacin)

relation to You are in a community pharmacy and receive a prescription for a 65-year-old male patient for ciprofloxacin 500mg to be taken twice
Management Therapy daily for seven days. You note from his patient medication record (PMR) that the patient has previously had numerous courses of
for Ciprofloxacin) trimethoprim. You also note that the patient currently takes the following medicines:
● Aspirin 75mg daily
● Rampiril 5mg daily
● Simvastatin 40mg daily
● Sodiumvalproate (Epilim Chrono®) 300mg daily.
He has no known drug allergies.

1. What is the likely indication for the ciprofloxacin?

There are a number of indications for ciprofloxacin but in this case it is most likely to be urinary tract infections (UTIs); the use of
trimethoprim provides a clue that the patient may be experiencing recurrent UTIs.

2. Which, if any, of his medicines may interfere with ciprofloxacin?

There are no direct drug–drug interactions with ciprofloxacin for this patient

3. What Counselling points are important for this patient?

There are no direct drug–drug interactions with ciprofloxacin for this patient

4. What discussion might you want to have with the patient or his doctor?
Patients with epilepsy should be advised to use ciprofloxacin with caution because there is a risk that the seizure threshold may be
reduced. Any decision needs to be discussed with the patient and ciprofloxacin used after weighing up the risks and benefits to the
patient. The BNF advises that tendon damage, including rupture, has been reported with quinolones. Tendon rupture may occur
within 48 hours of starting treatment, although some cases have been reported months after stopping a quinolone. Quinolones are
contraindicated in patients with a history of tendon disorders related to quinolone use. Prescribers should also be reminded that
patients over 60 years of age are more prone to tendon damage; the risk of tendon damage is increased by the concomitant use of
corticosteroids; and that if tendinitis is suspected, the quinolone should be discontinued immediately.

Suggested revision points

● List the common drug interactions with ciprofloxacin
● List the important counselling points, paying particular attention to any BNF warnings/advice.

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Rx Sodium Valproate

Generic Name / Sodium Valproate

Device Name

Therapeutic Category Anticonvulsants

Indication/Uses It is is used to treat epilepsy and bipolar disorder

Dosage Usual dose

● Adults & older children (12 years old above): 600 mg-2000 mg a day
● Young children (1 month-11 years): depending on child’s weight
For BIpolar Disorder
● Adults: 750 mg to 2000 mg a day as 1 dose or split into two doses
● Children- depending on child’s weight

Direction of Use It may be taken with or without food, but it is best to stick to the same way each time.
For slow release tabs and caps: Swallow whole with a drink of water. Do not chew.
For slow release granules/crushable tablets: Add the granules/crushed tablet to a small drink or any soft food, then swallow. Do
not chew the granules.
For liquid: use a plastic syringe or spoon that comes with the medicine. Do not use a kitchen teaspoon as you will not get the right
amount.

Side effects Common

● Diarrhea
● Stomach pain
● dry /sore mouth
● Tremors
● Tiredness
● Headache
● Weight gain
Serious:
● suicidal thoughts
● yellowing of the whites of your eyes or your skin (sign of liver problem)
● long lasting and severe nausea, vomiting or stomach pain- signs of acute pancreatitis
● Unusual bleeding/bruises

Contraindications Contraindicated to patients that are allergic to sodium valproate and its other components

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Interactions Drug Interaction

(drug/food) ● Carbamazepine
● Warfarin
● Aspirin
● Cimetidine (for stomach ulcers)
● Medicines for depression: Diazepam

Special Precautions/ Not recommended in pregnancy, as it can cause birth defects and problems with the baby’s learning and behaviour
Warnings

Important counselling ● If you are taking sodium valproate twice a day, try to leave a gap of 10-12 hours between doses.
notes ● If you missed a dose, take the forgotten dose as soon as you remember unless it is within a few hours of the next dose. In
this case, skip the missed dose and take the next dose at the usual time. Never take 2 doses at the same time. Never take
an extra dose.
● For patients with epilepsy, it is important to take this medicine regularly. Missing doses can trigger a seizure.
● You may take sodium valproate with or after a meal or snack to avoid stomach pain. Also avoid spicy foods.
● Drink plenty fluids when taking sodium valproate
● Do not drink too much alcohol.

Rx Clopidogrel

Generic Name / Clopidogrel (Plavix)

Device Name

Therapeutic Category Antiplatelet Agent, Cardiovascular Antiplatelet Agent, Hematologic

Indication/Uses *Clopidogrel reduces the risk of death and cardiovascular complications in patients with symptomatic atherosclerotic
disease, in the setting of percutaneous coronary intervention (PCI), and in patients with unstable angina or non-STEMI.

Dosage 300 mg

Direction of Use loading dose of 300 mg at least 6 h before PCI or, if this is not possible, in a dose of 600 mg at least 2 h before.

Side effects Chest pain, Headache, Joint pain, Rash, Diarrhea, Nosebleed, Itching

Contraindications Hypersensitivity
Active pathological bleeding (e.g., peptic ulcer, intracranial hemorrhage

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Interactions Has severe interactions with Ombitasvir/Paritaprevir/Ritonavir, and Dasabuvir

(drug/food)

Special Precautions/ Clopidogrel's antiplatelet activity is dependent on conversion to an active metabolite by

Warnings the cytochrome P450 (CYP) system, principally CYP2C19

Important counselling Take clopidogrel exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor. Clopidogrel
notes will help prevent serious problems with your heart and blood vessels only as long as you take the medication. Continue to take
clopidogrel even if you feel well.

Sample Case Scenario 5.10 Clopidogrel for percutaneous coronary intervention

You are in the dispensary and receive a call from a local GP who has a hospital referral letter for a 60-year-old woman which
recommends prescribing clopidogrel 75 mg to be taken daily. The patient was admitted to hospital for a PCI and had a stent
inserted. The GP is unsure how long the treatment with clopidogrel should be continued for and wants your advice.

1. What types of stents are routinely used in hospitals?

The first thing you will need to find out from either the GP or the hospital is the type of stent that the patient has had inserted. The
common stents are either ‘bare metal stents’ or ‘drug-eluting stents’. Post-procedural management of patients with coronary stents is
focused on prevention of stent thrombosis and secondary prevention of the underlying vascular disease.

2. How does the type of stent affect the length of treatment?

3. What length of course is appropriate for each type of stent?
The duration of clopidogrel therapy is determined by the clinical setting. Patients whose stents – bare metal stents or drug-eluting
stents – were implanted for a non-ST elevation myocardial infarction should be treated for 12 months. Patients with stable angina
treated with a bare metal stent should take clopidogrel for at least one month and patients receiving a drug-eluting stent should
continue clopidogrel therapy for 6–12 months.

Suggested revision points

● Guidance on PCI and use of stents and antiplatelet therapy
● Identify the types of stents commonly used and patient risk factors in terms of when to use them.

If these drugs are taken together? Warfarin and Clarithromycin

Drug-Drug Interaction Increased risk of haemorrhage and elevated INR and prothrombin time with warfarin.

Important Counselling .Clarithromycin can be taken by patients on warfarin if it is the most appropriate treatment, but the INR must be monitored closely.

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Notes

Sample Case Scenario 5.9 Managing interactions (Warfarin)

You are a hospital pharmacist. A junior doctor is asking for your advice. Ideally she would like to prescribe clarithromycin for one of
her patients, however the patient takes warfarin. The junior doctor is aware of the interaction between clarithromycin and warfarin
and would like your opinion on whether treatment could be initiated. What is your advice?

How did you approach this type of scenario? First, you need to find out about the details of the interaction between the two drugs.
Does the interaction mean that you cannot use the two drugs together? If you do use the drugs together what, if any, monitoring may
be required?

Clarithromycin interacts with warfarin, which increases the anticoagulant effect. The importance is established and potentially
serious. The mechanism of action is inhibition of the liver enzymes CYP450. This reduces clearance of warfarin, resulting in
increased levels of warfarin in the blood, resulting in an increase in the INR, and an increased risk of bleeding.

Clarithromycin can be taken by patients on warfarin if it is the most appropriate treatment, but the INR must be monitored closely.
You need to identify through discussion with the prescriber whether clarithromycin is the most appropriate treatment in this case, or
whether there is a safer alternative. If clarithromycin is to be prescribed, you need to offer advice on managing the interaction.

Remember that OSCEs assess your ability to communicate appropriately. Here you are responding to another healthcare
professional, so language and detail must reflect this. It would be inappropriate (and you would lose marks) to simply respond
saying ‘there is an interaction’. You would be expected to offer a solution. In this case you would recommend initiating treatment and
monitoring to reduce risk.

● Did you use the BNF to answer this question?

● Could you answer the question in enough detail using the BNF?

This scenario clearly demonstrates the importance of choosing the most appropriate source of information. BNF Appendix 1 gives
insufficient information to answer this question in detail; Stockley’s Drug Interactions is the most appropriate reference source here.

Suggested revision points

● Are you confident in the use of prothrombin times? What does a raised INR mean? What does an INR of 2 mean, and how
would you explain this to a patient?

Rx Warfarin

Generic Name Warfarin (Coumadin)

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Therapeutic Category Anticoagulants, Antiplatelets & Fibrinolytics (Thrombolytics)

Indication/Uses Prophylaxis & treatment of venous thrombosis, atrial fibrillation w/ embolization, pulmonary embolism, adjunct in prophylaxis of
systemic embolism after MI & in treatment of coronary occlusion.

Dosage Individualized dosage & duration of treatment. Initially 2-5 mg daily. Maintenance: 2-10 mg daily.

Direction of Use May be taken with or without food.

Adverse Reaction Fatal or non-fatal hemorrhage, bleeding, necrosis of skin & other tissues.

Contraindications Hypersensitivity. Hemorrhagic tendency or blood dyscrasias.

Important counselling ● instruct patients to immediately report signs of GI bleeding, including abdominal pain, vomiting blood, blood in stools, or
notes black, tarry stools.
● Remind patients that excessive vitamin K intake negates warfarin's therapeutic effects. Refer a patient to the physician or a
nutritionist regarding appropriate dietary intake of foods rich in vitamin K (leafy green vegetables, dairy products, and so
forth).
● Instruct patients or family/caregivers to report other troublesome side effects such fever, nausea, or stomach cramps.

Rx Clarithromycin

Generic Name / Clarithromycin (Biaxin)

Device Name

Therapeutic Category Macrolide antibiotics

Indication/Uses Clarithromycin is used to treat a wide variety of bacterial infections.

Dosage As conventional tab or oral susp: 500 mg 12 hourly, may continue therapy if clinical response is observed.

Direction of Use Standard Release Tab & Oral Susp: May be taken with or without food.
Xl & Mr Tab: Should be taken with food. Swallow whole, do not chew/crush.

Side effects Diarrhea, nausea, vomiting, headache, and changes in taste may occur. If any of these effects persist or worsen, tell your doctor or
pharmacist promptly.

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Contraindications Hypersensitivity to clarithromycin or any macrolide antibiotics.

Interactions Clarithromycin interacts with warfarin, which increases the anticoagulant effect.
(drug/food)

Special Precautions/ Patient with coronary artery disease, severe cardiac insufficiency, clinically relevant bradycardia or conduction disturbances
Warnings

Important counselling DO NOT double a dose under any circumstances.

notes

Nursing Mothers - back pain - Ibuprofen 400 mg

OTC Ibuprofen 400 mg

Generic Name / Ibuprofen

Device Name

Therapeutic NSAIDs
Category

Indication/Uses Reduction of fever, relief of mild to moderate pain & inflammation w/ dysmenorrhea, headache including migraine, post-op & dental
pain, musculoskeletal & joint disorder e.g ankylosing spondylitis, OA & RA including juvenile idiopathic arthritis

Dosage Adult: 1-2 softgel caps every 4-6 hr. Max: 6 softgel caps.

Direction of Use Should be taken with food: take immediately after meals

Side effects Dizziness; stomach pain; heartburn; constipation; nausea; rash; tinnitus; swelling

Contraindications Hypersensitivity, concurrent with previous history of GI bleeding or ulceration. Pregnancy (last trimester)

Interactions NSAIDs. Anticoagulants. May decrease the effect of aspirin. Increased risk of bleeding w/ SSRIs. Increased plasma conc. of lithium.
(drug/food)

Special Asthma, heart disease, liver cirrhosis, HTN, kidney disease or taking other NSAIDs, Discontinue if severe allergic reaction, including
Precautions/ skin reddening, rash & blisters occur. Increase risk of heart attack or stroke in long-term use. Pregnancy & lactation. Elderly. Children
Warnings <12 yr.

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Important ● Do not use any other product containing paracetamol, ibuprofen or other NSAIDs.
counselling notes ● If you are taking cough and cold preparations, other fever reducers or pain relievers, check if they contain paracetamol (or
acetaminophen), ibuprofen or other NSAIDs. Do not take more than the recommended dose or duration of treatment. This
medicine may cause stomach bleeding if you are 60 years old or older, have stomach ulcers or bleeding problems, taking a
blood thinning (anticoagulant) or steroid drug.

Sample Case Scenario 5.8 Drug Choice in Nursing Mothers

Mrs C, a patient who is known to you, attends the pharmacy wishing to purchase ibuprofen 400 mg t.d.s. to treat back pain. Mrs C gave
birth two months ago.

1. What questions do you need to ask Mrs C? In addition to the standard WWHAM (remind yourself of what this is – see Chapter 1),
you need to ask Mrs C if she is breastfeeding.

2. What advice would you offer Mrs C?

The BNF states that the amount of ibuprofen secreted into breast milk is too small to be harmful. Nevertheless, some manufacturers
advise avoiding ibuprofen, including topical application, while breastfeeding. If you choose to advise that Mrs C does not take ibuprofen,
you need to suggest an alternative analgesic. Paracetamol is considered safe in breastfeeding. This scenario requires you to retrieve a
single piece of information. Many of the marks available will be for how you communicate the information to the patient. A more complex
OSCE may require you to make a decision about a medicine for which there is no obvious alternative, or perhaps a condition which is
more life threatening. In these situations, you may have to consider suggesting that the mother discontinues breastfeeding, particularly if
there is little published evidence that breastfeeding is safe while taking a particular medicine. Alternatively it may be advisable for the
mother to express breast milk and discard for the duration of treatment, then continue once treatment is no longer required. Did you use
the BNF to answer this? The information required to answer this question is available in the BNF. The SPC also contains information
about pregnancy and breastfeeding.

Hypercalcaemia – bendroflumethiazide 2.5mg – alfacalcidol – labs: sodium, potassium,calcium,phosphate

Hypercalcemia

Usual Causes Bones to release calcium into the blood

Digestive tract to absorb more calcium
Kidneys excrete less calcium and activate more vitamin D, which plays a vital role in calcium absorption

● Usually a result of overactive parathyroid glands (hyperparathyroidism)

○ The most common cause of hypercalcemia can stem from a small, noncancerous tumour or enlargement of one or more
of the four parathyroid glands
● Cancer: lung cancer, breast cancer, blood cancer increase the risk of hypercalcemia

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● Other diseases: tuberculosis, and sarcoidosis can raise blood levels of vit. D which stimulates the digestive tract to absorb more
calcium.
● Immobility: people with a condition that causes them to spend a lot of time sitting or lying down can develop hypercalcemia. Over
time, bones that don’t bear weight release calcium into the blood instead.
● Dehydration: a common cause of mild or transient hypercalcemia due to having less fluid in blood causes a rise in calcium
concentrations.
● Medications: certain drugs such as lithium might increase the release of parathyroid hormone
● Supplements: taking excessive amounts of calcium or vit. D supplements over time raise calcium levels in the blood to above
normal.

Manifestation of ● Calcium level is above normal:

the Disease / ○ Normal range reference: 2.2-2.65 or 2.2-2.7 mmol/L
Symptoms Symptoms:
● Kidney: Excess calcium makes kidney harder to filter calcium thus it may cause excessive thirst and frequent urination,
● Digestive Problem: stomach ache, nausea, vomiting, constipation
● Bones and muscles: excess calcium in blood was leach from bones which weakens them, bone pain and muscle weakness
● Brain: confusion, lethargy, fatigue. It can also cause depression,
● Heart: RARELY BUT SEVERE: hypercalcemia can interfere with heart function and may cause palpitations and fainting, an
indication of cardiac arrhythmia and other heart problems.

Recommended ● Bendroflumethiazide 2.5mg= for HTN

Treatment / ● Alfacalcidol 0.25mcg = hypocalcemia
Drugs

Dosage of the ● Bendroflumethiazide 2.5mg tablet = for HTN

Drug ● Alfacalcidol 0.25 mcg = Hypocalcemia

Direction of Use Bendroflumethiazide 2.5mg = for HTN

Once every morning, maybe taken with or without food. Maybe taken with food or milk.
Max daily: 20 mg daily

Alfacalcidol Oral drops/capsule= Hyperparathyroidism/Hypoparathyroidism/renal osteodystrophy

Initial: 1 mcg daily. Adjust subsequent doses according to patient biochemical plasma Ca levels, radiographic or histological response,
Usual maintenance dose: 0.2 mcg-0.5 mcg daily
*dose discontinuation if hypercalcemia occurs

Alfacalcidol 0.25 mcg =Hypocalcemia

Oral: to be taken with food or as prescribed by the physician.

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*may cause sleepiness

Side Effects Bendroflumethiazide 2.5mg = for HTN

● Feeling thirsty with a dry mouth-
● Feeling or being sick (nausea and vomiting)

Alfacalcidol
● Irregular heart beat
● Headache
● Drowsiness
● Constipation
● Nausea and vomiting

Contraindication Bendroflumethiazide
● Addison’s disease (adrenal gland disorder)
● Allergic to sulfonamides

Alfacalcidol
● Unknown interaction with alcohol
● Drug interaction:
○ Hydrochlorothiazide
○ Digoxin
○ Carbamazepine etc.

Laboratory Labs:
● Sodium: (serum)
○ Reference range -(136-145 mmol/L
● Potassium:
○ Typical level (adult)- 3.5 and 5.0 millimoles per liter
○ Hyperkalemia: >5.5 mmol/L
○ >6.5 mmol/L= can cause heart problems- requires immediate medical attention.
● Calcium (serum)
○ Reference range (normal): 2.2 to 2.7 mmol/L
● Phosphate- this fluctuates with age
○ Reference range (adults)- 0.97-1.45 mmol/L
○ Elderly: values slightly lower than adults
○ Child: 1.45-2.1 mmol/L
○ Newborn: 1.4-3.0 mmol/L

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Important Non pharmacological advice:

Counselling Avoid excess intake of calcium supplements and calcium-based antacid tablets.
Notes Drink more fluids
Walk and be active, which can help stop bone from breaking down.

Bendroflumethiazide 2.5mg
Best taken at the same time in the morning. Avoid taking later in the afternoon or at night to prevent waking up to urinate in the middle of the
night

Alfacalcidol 0.25 mcg =Hypocalcemia

*may cause sleepiness.
May recommend to have regular blood test in order for the doctor to adjust dose,
Store medicines at room temperature.

Sample Case Scenario 5.7 Drug-induced hypercalcaemia

On your daily hospital ward visit you come across a patient who has been admitted because of severe nausea and vomiting. The patient has
hypertension and hypoparathyroidism. His current medication is bendroflumethiazide 2.5 mg in the morning and One-Alpha® 1 microgram
daily. The laboratory test results shown in Table 5.1 have just been returned to the ward.

1. Comment on the laboratory test results, identifying any that are of concern.
The calcium level is raised, that is, higher than the upper limit of the normal range

2. What might be the cause of any observations you made in response to question 1?
There are two potential causes:
■ the bendroflumethiazide, a thiazide diuretic, may increase the risk of hypercalcaemia
■ alfacalcidol (One-Alpha®), being converted to 1,25-dihydroxyvitamin D (which regulates calcium metabolism), results in
increased absorption of calcium. Since hypercalcaemia is observed, it is possible that the dose of alfacalcidol is too high.

3. What action(s) would you recommend?

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Stop One-Alpha® treatment until the plasma calcium concentration returns to normal. Then restart alfacalcidol at half the dose, which is 0.5
microgram daily in this patient. In addition, calcium levels should be monitored. Many students panic when they encounter a term with which
they are unfamiliar, such as in this case hypoparathyroidism. Here the term is used to explain the need for One-Alpha®. You will not be
expected to know every clinical condition! Which resource did you use to help you answer the questions? Some relevant information is
available in the BNF, but may be time consuming to find. You will need to look in the side-effects section in the classification part of the
citation. If you are given an SPC for One-Alpha® the information is more easily found, and is particularly useful for what to recommend if
hypercalcaemia occurs during treatment. You can practise OSCE c05.tex V1 - 04/08/2013 5:22 P.M. Page 137 Clinical prescription
management problems 137 looking at SPCs (and Patient Information Leaflets – PILs) at www.medicines.org.uk/emc/ (accessed 6 June
2012).

Rx Warfarin

Generic Name / Coumarin

Device Name Jantoven

Therapeutic Category Anticoagulants

Indication/Uses Mechanical mitral valve replacement

● Oral warfarin is a long-term treatment that is required after heart valve replacement. This treatment can prevent serious
complications, such as embolism, and lower the incidence of bleeding thereby increasing patients' postoperative survival
rates and quality of life.

Anticoagulant
● Warfarin blocks one of the enzymes that uses vitamin K to make some of the clotting factors, and in turn reduces their
ability to work correctly in the blood. As a result, the clotting mechanism is disrupted and it takes longer for the blood to clot.

Hypertension (Not recommended)

● Warfarin can be prescribed for people who are at higher risk of developing blood clots, for example patients with chronic
thrombo-embolic pulmonary hypertension (CTEPH). It will also be recommended for patients suffering from problems of
irregular heartbeats, for example atrial fibrillation (AF), However, Warfarin causes extensive vascular calcification leading to
increased systolic blood pressure and pulse pressure may be associated with increased valvular and coronary
calcifications, and possibly worsens hypertension in high-risk patients, particularly in those with uncontrolled hypertension,
warfarin is not recommended used in patient with hypertension

Type 2 diabetes
● People with type 2 diabetes are at increased risk for atrial fibrillation, an irregular heartbeat that can allow blood to pool and

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clot in the atria. Anticoagulant therapy such as warfarin may be recommended to reduce the risk of stroke for people with
atrial fibrillation in diabetic patients, However, Warfarin can intensify the effects of the diabetes drugs and cause blood
sugar levels to crash.
Ischemic heart disease
● Atherosclerosis is the most common cause of Ischemic heart disease.The plaques that develop in atherosclerosis can
rupture, causing a blood clot. Warfarin an anticoagulant can prevent ischemic heart disease by preventing blood clots from
forming.

Dosage The initial dose of warfarin should be 5 or 10 mg, once a day for most patients,However dose adjustments are needed for a
particular disease, Recommend to contact doctor in terms of dosing adjustments.

Direction of Use Warfarin is a once-daily oral medication. Warfarin administration can be at any time during the day, but recommendations are for
administration in the afternoon or evening.

Side effects ● Bleeding during your period that's heavier than normal.
● Red or brown pee.
● Poops that's red or look like tar.
● Nose or gum bleeding that doesn't stop quickly.
● Brown or bright red vomit.
● A severe headache or stomach ache.
● Unusual bruising.

Contraindications ● Uncontrolled bleeding;

● Open wounds;
● Active ulcer disease;
● Recent brain, eye, or spinal cord injury or surgery;
● Severe liver or kidney disease;
● Uncontrolled hypertension;

Interactions Drug
(drug/food) ● Aspirin or aspirin-containing products.
● Acetaminophen (Tylenol, others) or acetaminophen-containing products.
● Antacids or laxatives.
● Many antibiotics.
● Antifungal medications, such as fluconazole (Diflucan)
● Cold or allergy medicines

Food

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● Kale.
● Spinach.
● Brussels sprouts.
● Collards.
● Mustard greens.
● Chard.

Special Precautions/ Avoid activities that can cause bruising or bleeding. If you take warfarin, some foods can change how your blood clots. Do not make
Warnings major changes to the foods you eat while you are taking warfarin. Warfarin works best when you eat about the same amount of
vitamin K every day.

Important counselling ● Instruct patients to immediately report signs of GI bleeding, including abdominal pain, vomiting blood, blood in stools, or
notes black, tarry stools.
● Remind patients that excessive vitamin K intake negates warfarin's therapeutic effects. Refer a patient to the physician or a
nutritionist regarding appropriate dietary intake of foods rich in vitamin K (leafy green vegetables, dairy products, and so
forth).
● Instruct patients or family/caregivers to report other troublesome side effects such fever, nausea, or stomach cramps.

Sample Case Scenario 5.6 Initiating Warfarin Therapy

A junior doctor has called you for advice regarding a male patient, aged 50 years, for whom the consultant has requested warfarin be
started. The patient has had a mechanical mitral valve replacement inserted and requires anticoagulation. His past medical history
includes hypertension, type 2 diabetes and ischaemic heart disease. He has no known drug allergies and none of his medicines
interacts with warfarin.

1. What dose would you recommend for initiation of warfarin?

There are a number of different warfarin loading dose regimens, ranging from 10 mg, 10 mg, 5 mg on days 1, 2, 3 (Fennerty et al.,
1988) to 5 mg, 5 mg, 5 mg (Tait and Sefcick, 1998; Crowther et al., 1997, 1999). The key is to ensure the INR is tested on day 3 and
the warfarin dose adjusted accordingly.

2. What INR range would you recommend and why?

The recommended INR range is 2.5–4.5 depending on local guidelines, the number of mechanical heart valves and other patient risk
factors. The higher INR is because mechanical mitral valves have a higher risk of clotting so therefore require more anticoagulation.

3. What maintenance dose would you recommend?

The maintenance dose of warfarin is dependent on the INR and, in this scenario, it would be unwise to recommend a specific
warfarin dose. There are a number of nomograms and local guidelines for adjusting doses of warfarin. Patients have different
sensitivities to warfarin so one patient may require a much higher dose of warfarin to achieve the same INR as another patient.
There are also a number of drug interactions and foods that may affect the INR.

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Depression History

Usual Causes Family history

● Though there are no specific genes that we can look at and trace to depression, if your family members have had
depression, you are more likely also to experience depression.
Illness and health issues.
● Physical illnesses or injuries can have a significant impact on your mental health. Chronic health issues, long-term health
issues, or physical health issues that drastically change your lifestyle can cause depression.
Personality
● Some people and personalities are just more apt to experience depression.
Medication,Alcohol,Drugs
● Medication,Alcohol,Drugs can cause depression due to the altercation of different chemicals and receptor in the body

Manifestation of the Persistent depressed (low) mood.

Disease / Symptoms Loss of interest in things you once enjoyed.
Feelings of worthlessness.
Poor concentration.
Thoughts of harming yourself.

Recommended Sertralin
Treatment / Drugs ● Sertraline selectively inhibits the reuptake of serotonin (5-HT) at the presynaptic neuronal membrane, thereby increasing
serotonergic activity. This results in an increased synaptic concentration of serotonin in the CNS, which leads to numerous
functional changes associated with enhanced serotonergic neurotransmission.19,21 These changes are believed to be
responsible for the antidepressant action

Ibuprofen 200 mg
● Ibuprofen is an NSAIDS that is originally used for fever and minor body aches but study of Paul Galagher,2019 found that
anti-inflammatory agents could restrict major symptoms of depression such as low mood, However it is not yet accepted as a
proper treatment for depression hence should not be used.

Interaction of sertraline and Ibuprofen

● Using sertraline together with ibuprofen may increase the risk of bleeding.Serotonin uptake from blood into platelets is
inhibited leading to decreasing serotonin stores in platelets which affects platelet aggregation thus causing bleeding.

Dosage of the Drug Initial dose: 50 mg PO, per day

May increase by 25 mg at weekly intervals; not to exceed 200 mg,per day

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Direction of Use Take this medication by mouth as directed by your doctor, once daily either in the morning or evening.

Side Effects ● Feeling sick.

● Headaches.
● Being unable to sleep.
● Diarrhea
● Dry mouth.
● Dizziness.
● Feeling tired or weak.

Contraindication ● a disorder with excess or inappropriate antidiuretic hormone

● low amounts of sodium in the blood.
● an increased risk of bleeding.
● manic behavior.
● manic-depression.
● suicidal thoughts.

Important Inform parents/guardian to liimit drug access if patient is suicidal to decrease the risk of overdose to cause harm.
Counselling Notes Inform parents/guardians to provide safety measures (e.g. adequate lighting, raised side rails, etc.) to prevent injuries.

Sample Case Scenario 5.5 Managing interactions (Ibuprofen)

You are working in your community pharmacy and are approached by Mr P, a 40-year-old man with a history of depression. Your
records show that he is currently prescribed sertraline 100 mg daily. He has hurt his back while playing rugby. One of his friends has
suggested ibuprofen 200 mg tablets, which helped him when similarly injured. He asks for your advice about dosage. What advice will
you give Mr P?

Mr P is currently prescribed sertraline to treat depression. This is a selective serotonin reuptake inhibitor (SSRI) antidepressant.
Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID). There is an increased risk of bleeding when NSAIDs are given with
SSRIs (‘black dot’ interaction).

Mr P should be advised not to take ibuprofen. Of course Mr P still has a bad back! At this point you should ask questions in order to
determine the severity of pain. Then you could recommend paracetamol 1 g q.d.s. Or co-codamol 8/500 mg, two tablets/capsules
q.d.s.

Did you use the BNF to answer this? BNF Appendix 1 is a quick and easy source of interaction information (Stockley’s Drug
Interactions provides more detailed information). Using Appendix 1 is often dependent on knowing the class of a drug, for example
that sertraline is an SSRI. If you look up the drug in the BNF index and find the main citation, this lists drugs according to the
classification.

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Remember you must ask customers/patients questions about other medicines. In this type of scenario, where information about
prescribed medicines is given, students frequently forget to ask about over-the-counter (OTC) medicines.

Meningitis: Child - allergic to penicillin

Meningitis

Usual Causes A bacterial or viral infection of the fluid surrounding the brain and spinal cord usually causes the swelling. However, injuries, cancer,
certain drugs, and other types of infections also can cause meningitis.

Bacterial Meningitis
- Meningitis caused by bacteria (ex: Neisseria meningitidis, Streptococcus pneumoniae) can be deadly and requires
immediate medical attention. Vaccines are available to help protect against some kinds of bacterial meningitis. The germs
that cause bacterial meningitis spread from one person to another. Certain germs can spread through food.

Viral Meningitis
- Meningitis caused by viruses is serious but often is less severe than bacterial meningitis. People with normal immune
systems who get viral meningitis usually get better on their own. There are vaccines to prevent some kinds of viral
meningitis.

Fungal Meningitis
- Meningitis caused by fungi is rare, but people can get it by inhaling fungal spores from the environment. People with certain
medical conditions, like diabetes, cancer, or HIV, are at higher risk of fungal meningitis.

Parasitic Meningitis
- Various parasites can cause meningitis or can affect the brain or nervous system in other ways. Overall, parasitic meningitis
is much less common than viral and bacterial meningitis.

Amebic Meningitis
- Primary amebic meningoencephalitis (PAM) is a rare and devastating infection of the brain caused by Naegleria fowleri.
Naegleria fowleri is a free-living microscopic ameba that lives in warm water and soil.

Non-Infectious Meningitis
- Sometimes cancers, systemic lupus erythematosus (lupus), certain drugs, head injury, and brain surgery can cause
meningitis.

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Manifestation of the Meningitis is an inflammation (swelling) of the protective membranes covering the brain and spinal cord.
Disease / Symptoms
Signs and symptoms can include:
● severe headache
● stiff or painful neck
● high fever
● avoiding bright light
● drowsy, confused, comatose
● convulsions
● rash
● joint pains
● cold hands and feet
● vomiting

In babies, signs can include:

● poor feeding
● sleepy, difficult to wake, comatose
● irritable, crying when handled
● difficulty breathing, grunting
● fever
● neck rigidity
● bulging soft spot on top of head (fontanelle)
● high pitched cry
● convulsions
● vomiting
● rash
● pale or blotchy skin

Prevention 1. Vaccination
a. H. influenzae type b vaccine (Hib): given as a three or four-part series during your child’s routine immunizations,
starting at 2 months
b. pneumococcal conjugate vaccine (PCV7): recommended by the American Academy of Pediatrics (AAP) for all
children younger than age 2 and children ages 24 to 59 months of age that are at very high risk for pneumococcal
infection. PCV7 can be given along with other childhood vaccines at 2 months, 4 months, 6 months, and 12 to 15
months
c. meningococcal vaccine: for meningococcal meningitis, a very contagious form of bacterial meningitis. This vaccine
is normally given during the routine pre-adolescent immunization visit (at 11 to 12 years).

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2. Antibiotics for prevention (chemoprophylaxis) - Within the meningitis belt, chemoprophylaxis for close contacts is
recommended in non-epidemic situations. Ciprofloxacin is the antibiotic of choice, and ceftriaxone an alternative.

Recommended Managing the airway, maintaining oxygenation, giving sufficient intravenous fluids while providing fever control are parts of the
Treatment / Dosage foundation of meningitis management. There’s no specific antibiotic for bacterial meningitis. It depends on the bacteria involved. A
of the Drug range of antibiotics is used to treat meningitis.

Current Empiric Therapy (refers to antibiotics that are administered during the period prior to the receipt of blood culture and
antibiotic susceptibility test results)
● Neonates - Up to 1 month old
○ Ampicillin intravenously (IV) and
○ Cefotaxime (or equivalent, usually ceftazidime or cefepime) IV or gentamicin IV and
○ Acyclovir IV
● More than 1 month old
○ Ampicillin IV and
○ Ceftriaxone IV
● Adults (18 to 49 years old)
○ Ceftriaxone IV and
○ Vancomycin IV

*Situation: Child - allergic to Penicillin*

An alternative (which may also be chosen if the patient is severely allergic to penicillin) is:
● Chloramphenicol (25 mg/kg orally or IV every 12 hours) plus Vancomycin (15 mg/kg IV every 8 hours)

Other Antibiotics:
Ceftriaxone
- 3rd generation cephalosporin (Cephalosporins are recommended for the treatment of childhood bacterial meningitis)
- Very effective against Streptococcus pneumoniae and Neisseria meningitidis
- Pediatric Dose:
- 100 mg/kg/day IV/IM in single daily dose or divided q12hr for 7-14 days; not to exceed 4 g/day

Cefotaxime
- Third-generation cephalosporin
- Equivalent to ceftriaxone
- Safe for neonates
- Pediatric Dose:
- <12 years or <50 kg: 200 mg/kg/day IV/IM divided q6hr
- >12 years or >50 kg: 2 g IV q4-6hr in combination with other antimicrobial therapy as necessary

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Side Effects Chloramphenicol

- Ototoxicity, Transient stinging and irritation (ophthalmic), optic neuritis (prolonged use), Nausea, vomiting, glossitis,
stomatitis, diarrhoea

Vancomycin
- Diarrhoea, flushing of the upper body (red man or red neck syndrome), anaphylaxis, infusion reactions (e.g. hypotension,
flushing, urticaria), thrombophlebitis.

Cetriaxone
- Diarrhoea, oral candidiasis, Diaphoresis, Headache, dizziness, Stevens-Johnson syndrome.

Cefotaxime
- Fungal or bacterial superinfection; serious bullous skin reactions (e.g. Stevens-Johnson syndrome, toxic epidermal
necrolysis), headache, dizziness, convulsion.

Contraindication Chloramphenicol
- Pregnancy and lactation (oral, IV), concomitant administration of drugs that cause bone marrow depression.

Vancomycin
- Hypersensitivity

Cetriaxone
- This drug may cause dizziness, if affected, do not drive or operate machinery.
- Pregnancy Category B.
- May increase anticoagulant effect of vit K antagonists (e.g. warfarin).
- Premature neonates up to a postmenstrual age of 41 weeks.

Cefotaxime
- History of acute or severe hypersensitivity reaction to penicillin or other β-lactam antibiotics.
- Concomitant use with bacteriostatic antibiotics (e.g. tetracyclines, erythromycin, chloramphenicol).

Important Chloramphenicol
Counselling Notes - Avoid prolonged use.

Vancomycin
- Special precautions in patients with inflammatory disorders of the intestinal mucosa, underlying hearing loss or prior
deafness, acute anuria, cochlear damage. Renal impairment. Children and elderly.

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Cetriaxone
- Diarrhoea, oral candidiasis, Diaphoresis, Headache, dizziness, Stevens-Johnson syndrome.

Cefotaxime
- Special precautions in patients with asthma, allergic diathesis, history of gastrointestinal disease (particularly colitis).

While your child is recovering from meningitis, he or she may also need:
● Bed rest
● Increased fluid intake by mouth or IV fluids in the hospital
● Medicines to reduce fever and headache. Don’t give aspirin or medicine that contains aspirin to a child younger than age 19
unless directed by your child’s provider. Taking aspirin can put your child at risk for Reye syndrome. This is a rare but very
serious disorder. It most often affects the brain and the liver.
● Supplemental oxygen or breathing machine (respirator) if your child has trouble breathing

Sample Case Scenario 5.4 Choosing antibiotic therapy

On your daily ward visit you are approached by a junior doctor who asks about suitability of therapy for a 5-year-old child who has
been diagnosed with meningitis thought to be caused by meningococci. Lumbar puncture cultures have been taken and the infection
is sensitive to benzylpenicillin, which the doctor would like to prescribe. Other microbial sensitivities are not yet known. The child’s
medicine chart notes that the patient is allergic to penicillin. The nature of the allergy is documented as ‘rash (more than 72 hours
after previous administration), no sign of anaphylaxis’.

1. Which antibiotic therapy would you recommend for the patient?

Benzylpenicillin can be given to this patient, although it is a penicillin antibiotic. You can find information about which antibacterials are
recommended for which infection in the BNF.

2. Why would you recommend this choice? Explain your answer with reference to the information you have been given.
It is easy to make decisions based on ‘the patient is allergic, find something else’. This is the type of case that demonstrates the role
of the pharmacist in a clinical team. This patient is seriously ill, with a life-threatening condition. At this stage the only antibiotic that
you know to be effective is benzylpenicillin. A rash that develops more than 72 hours after previous administration does not constitute
an allergic reaction. Your professional judgement should lead you to the conclusion that the risk associated with not starting treatment
with the penicillin antibiotic (as soon as possible) outweighs the benefits of avoiding the drug because of worries around allergy.

3. What advice would you give to the nursing staff about monitoring this patient with reference to allergic reactions?
Nursing staff should monitor for signs of worsening allergy, such as early rash or anaphylaxis. Adrenaline should be available on the
ward, with information on administration readily available to nursing and medical staff. Did you use the BNF to answer this question?
Could you answer all parts of the question using the BNF? You might need to refer to the BNF for Children to confirm information on
paediatric dosage.

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Cough-wheeze - St. John's Wort – Uniphyllin Continus (Theophylline)

Cough-wheeze

Usual Causes The most common causes of wheezing include problems with your:
Lungs:
● Asthma is a chronic condition that causes spasms and swelling in the bronchial tubes. Wheezing in asthma can be triggered
by exposure to airborne allergens such as pollen, mold, animals, or house dust. Viral illnesses can also make asthma
symptoms worse.
● Bronchitis is inflammation of the lining of the bronchial tubes.
● Bronchiolitis is most common in young children.
● COPD is chronic obstructive pulmonary disorder, a long-term inflammation and damage of the bronchial tube lining, most
commonly from smoking cigarettes.
● Cystic fibrosis (CF). In people who have CF, thick mucus clogs the airways and makes breathing difficult.
● Pneumonia is an inflammation of the lungs caused by a virus or bacteria.
● Respiratory Syncytial Virus (RSV) is a seasonal lung infection that can lead to bronchiolitis or pneumonia.
● Aspirating (breathing) a foreign object into the lungs.

Heart conditions:
● Heart failure. Cardiac asthma is from fluid in the lungs caused by left heart failure.

Lifestyle choices:
● Smoking increases your risk of developing COPD and emphysema. Smoking and secondhand smoke makes asthma
harder to control.

Manifestation of the Wheezing is the shrill whistle or coarse rattle you hear when your airway is partially blocked. It might be blocked because of an
Disease / Symptoms allergic reaction, a cold, bronchitis or allergies. Wheezing is also a symptom of asthma, pneumonia, heart failure and more.

Recommended Theophylline - used to prevent and treat wheezing, shortness of breath, and chest tightness caused by asthma, chronic bronchitis,
Treatment / Drugs emphysema, and other lung diseases. It relaxes and opens air passages in the lungs, making it easier to breathe.
Dextromethorphan - used to temporarily relieve cough caused by the common cold, the flu, or other conditions.

If wheezing is caused by asthma, your doctor may recommend some or all of the following to reduce inflammation and open the
airways:
● A fast-acting bronchodilator inhaler - to dilate constricted airways when you have respiratory symptoms (also use if you have
acute bronchitis)
○ Albuterol aka Salbutamol (Proventil HFA, Ventolin HFA)
○ Levalbuterol (Xopenex)

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● An inhaled corticosteroid
○ Fluticasone

Dosage of the Drug Theophylline

- Oral: 5 mg/kg
- IV: 4.6 mg/kg via infusion over 30 minutes.

Dextromethorphan
- 10-20 mg 4 hourly, or 30 mg 6-8 hourly.

Albuterol aka Salbutamol (Proventil HFA, Ventolin HFA)

Tablets:
- Adults: 4 mg (2 tablets) 3 or 4 times per day.
- Children 2-12 years: 2 mg (1 tablet) 3 or 4 times daily.
- Over 12 years: 2 to 4 mg (1 to 2 tablets) 3 or 4 times daily.
Syrup:
- Adults: 10 mL (salbutamol 4 mg)
- Children >12 years: 5-10 mL, 6-12 years: 5 mL, 2-6 years: 2.5-5 mL.
Inhaler:
- Adults: 400 micrograms 3 or 4 times daily.
- Children: 200 micrograms 3 or 4 times daily.

Levalbuterol (Xopenex)
- Nebulizer solution: 3 times daily at intervals of 6-8 hr

Fluticasone
- Adult: Mild asthma: Initially, 100 mcg bid. Moderate and severe asthma: Initially, 250-500 mcg bid
- Child: 4-16 years Initially, 50-100 mcg bid, may be increased up to 200 mcg bid if necessary.

Direction of Use How to use an inhaler:

1. Shake the inhaler well.
2. Hold the inhaler upright with your thumb on the base and your finger on the push button. Press the dosing button down firmly
- once only
3. Breathe out as far as is comfortable. Note: do not blow into the device at any time.
4. Place the mouthpiece in your mouth. Close lips firmly around it (do not bite it)
5. Breathe in through your mouth steadily and deeply, to draw the medicine into your lungs.
6. Hold your breath, take the inhaler from your mouth and continue holding your breath for about 5 seconds.
7. For the second puff, keep the inhaler upright and repeat steps 2-5. Replace the mouthpiece cover.

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Side Effects Theophylline

- Exacerbated cardiac arrhythmias, urinary retention (particularly in elderly males), exacerbated seizures, status epilepticus,
exacerbated peptic ulcer, Abdominal pain, diarrhoea, gastric irritation, GERD, nausea, vomiting, dizziness, tremor.

Dextromethorphan
- Abdominal pain, diarrhoea, gastrointestinal disturbance, nausea, vomiting.

Albuterol aka Salbutamol

- Hypersensitivity reactions (e.g. urticaria, angioedema, rash, bronchospasm, oropharyngeal oedema), hypokalaemia (high
doses), mouth and throat irritation (inhalation).

Levalbuterol
- Headache, viral infection, rhinitis.

Fluticasone
- Adrenal suppression, nausea, vomiting, abdominal pain, diarrhoea, toothache, dyspepsia, fatigue, malaise.

Contraindication *Situation: St. John's Wort – Uniphyllin Continus (Theophylline)*

Dextromethorphan (cough medicine)

- Taking St. John's wort at the same time as dextromethorphan, a cough suppressant found in many over-the-counter cough
and cold medicines, can increase the risk of side effects, including serotonin syndrome.

Uniphyllin Continus (Theophylline)

- St. John's wort can reduce levels of this medication in the blood.
- Theophylline is a xanthine derivative used in the treatment of asthma and stable COPD to relax the bronchial smooth
muscle. It has a narrow therapeutic index; a serum theophylline concentration of 10–20 mg/L is required in the majority of
patients, although some may find lower theophylline levels to be sufficient to control their symptoms.
- Small increases in serum concentrations can result in toxicity, particularly in patients with a level of more than 20 mg/L.
Patients may experience serious symptoms of toxicity, such as convulsions and arrhythmias, before symptoms like nausea
and vomiting appear.

Important ● Recommend the patient to not take St. John’s Wort while taking Theophylline to prevent drug-drug interaction.
Counselling Notes ● St. John's wort is most commonly used for depression and conditions that sometimes go along with depression such as
anxiety, tiredness, loss of appetite and trouble sleeping. However, St. John's wort is a stimulant and may worsen feelings of
anxiety in some people.

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Sample Case Scenario 5.3 Managing interactions (St John’s Wort)

An elderly patient wishes to speak to you about their cough and wheeze, which they have experienced for a few days now. The cough
is ‘dry’ and as they have been feeling wheezy, they have needed to use their asthma inhalers more often than usual over the last few
days. When asked about medication, the patient states that apart from the inhalers, he takes Uniphyllin Continus® (for the last year),
his dose having gone up to 400 mg every 12 hours last month. Also for the last three months he has been taking St John’s Wort, as
he has been feeling ‘low’ since a friend passed away, although that is not a medicine but something ‘natural’ he states.

1. What is the most likely cause of the patient’s symptoms?

There is an interaction between theophylline (Uniphyllin Continus®) and St John’s Wort. This results in a reduction in plasma
concentration of theophylline, allowing symptoms of asthma to reappear/break through. That is, the lower plasma level of theophylline
is not controlling asthma/breathing.

2. What mechanism of interaction could be involved here, and what are the consequences of the interaction?
St John’s Wort is an enzyme inducer, resulting in increased theophylline metabolism and consequently reduced plasma concentration
of theophylline. This lower plasma theophylline level is insufficient to control the patient’s symptoms.

3. Should the patient just stop taking the St John’s Wort? Explain your answer.
No, the patient should contact his GP in order to manage this clinical situation. There is potential for withdrawal symptoms from St
John’s Wort and toxicity from raised theophylline levels if St John’s Wort is stopped suddenly. The patient’s theophylline levels need to
be monitored. (The usual interval is 5 days after adjusting treatment, the plasma level being taken 4–6 hours post dose.) As with
Scenario 5.1, it is easy to lose marks by not mentioning how you will monitor the patient’s response to treatment adjustment. Did you
use the BNF to answer this question? Could you answer all parts of the question using the BNF? The BNF provides basic information
on drug interactions. More detailed information is available in Stockley’s Drug Interactions. You can save time in an OSCE by using
this text first, if it is provided.

Co-amilozide – lisinopril – potassium level – heart failure

Heart Failure

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Usual Causes ● Coronary artery disease - cholesterol and fatty deposits build up in the heart's arteries, less blood can reach the heart
muscle. It can also contribute to having high blood pressure, which may lead to heart failure over time.
● Past heart attack (myocardial infarction) - A heart attack occurs when an artery that supplies blood to the heart muscle
gets blocked. The damaged heart tissue does not contract as well, which weakens the heart's ability to pump blood.
● High blood pressure (hypertension or HBP) - Uncontrolled HBP is a major risk factor for developing heart failure. When
pressure in the blood vessels is too high, the heart must pump harder than normal to keep the blood circulating.
● Abnormal heart valves - Heart valve problems can result from disease, infection (endocarditis) or a defect present at birth.
● Heart muscle disease (dilated cardiomyopathy, hypertrophic cardiomyopathy) or inflammation (myocarditis) - Any
damage to the heart muscle – whether because of drug or alcohol use, viral infections or unknown reasons – increases the
risk of heart failure.
● Heart defects present at birth (congenital heart disease) - If the heart and its chambers don't form correctly, the healthy
parts have to work harder to compensate.
● Diabetes - increases the risk for developing heart failure. People with diabetes tend to develop hypertension and
atherosclerosis from elevated lipid levels in the blood.
● Obesity - It can cause the heart to work much harder than for a non-obese person. Being obese is also a cause of sleep
apnea and can cause cardiomyopathy.

Manifestation of the ● Shortness of breath with activity or when lying down

Disease / Symptoms ● Fatigue and weakness
● Swelling in the legs, ankles and feet
● Rapid or irregular heartbeat
● Reduced ability to exercise
● Persistent cough or wheezing with white or pink blood-tinged mucus
● Swelling of the belly area (abdomen)
● Very rapid weight gain from fluid buildup
● Nausea and lack of appetite
● Difficulty concentrating or decreased alertness
● Chest pain if heart failure is caused by a heart attack

Recommended Furosemide instead of Co-amilozide

Treatment / Drugs

Dosage of the Drug Oral

Hypertension
Adult : Alone or in combination with other antihypertensives: 40-80 mg daily, adjusted according to patient response. Alternatively, a
usual maintenance dose of 20-40 mg daily may be given.
Elderly: Initiate at lower doses.

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Direction of Use ● Furosemide doesn't usually upset your tummy so you can take it whether or not you've eaten recently.
● Swallow the tablets whole with a drink of water.
● If you're taking furosemide as a liquid, it will come with a plastic spoon or syringe to help you measure out the correct dose.
If you don't have one, ask your pharmacist for one. Do not measure the liquid with a kitchen teaspoon as it won't give the
right amount.

Side Effects ● Peeing more than normal

● Feeling thirsty with a dry mouth
● Headaches
● Feeling confused or dizzy
● Muscle cramps, or weak muscles
● Feeling or being sick (nausea or vomiting)
● A fast or irregular heartbeat

Contraindication Hypersensitivity to furosemide and sulfonamides. Anuria, renal failure with anuria not responding to furosemide; renal failure due to
poisoning by nephrotoxic or hepatotoxic agents; renal failure associated with hepatic coma, electrolyte disturbances (e.g. severe
hyponatremia, severe hypokalemia), hypovolaemia, dehydration, hypotension; comatose or pre-comatose states associated with liver
cirrhosis or encephalopathy; Addison’s disease, porphyria, digitalis intoxication. Lactation.

Important There is an interaction between co-amilozide and lisinopril. Co-amilozide is a combination of a thiazide diuretic (hydro- chlorothiazide)
Counselling Notes and a potassium-sparing diuretic (amiloride) which leads to potassium retention. ACE inhibitors also cause potassium retention,
therefore there is a risk of hyperkalemia..

Sample Case Scenario 5.1 Managing interactions (hyperkalaemia)

As a hospital pharmacist you are making your daily visit to a medical ward. You are given a prescription to prepare for Mr S to go
home. Mr S was taking co-amilozide before coming into hospital, for water retention. He has since been started on lisinopril to treat
heart failure. His serum potassium level is 5.4 mmol/L, which has increased from 4.3 mmol/L on admission to hospital. (Normal
potassium range 3.5–5.0 mmol/L.) His prescription for taking home is:
● Co-amilozide 5/50 mg i mane
● Lisinopril 20 mg i mane

1. Is this prescription clinically appropriate? Explain your answer

No, there is an interaction between co-amilozide and lisinopril. Co-amilozide is a combination of a thiazide diuretic
(hydrochlorothiazide) and a potassium-sparing diuretic (amiloride) which leads to potassium retention. ACE inhibitors also cause
potassium retention, therefore there is a risk of hyperkalemia. From the laboratory results it is clear that there is evidence of the
interaction, with the potassium level already exceeding the upper limit of normal.

2. What action(s) would you recommend? Explain your answer

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What are the guidelines for the treatment of heart failure? When an interaction is identified you need to decide which medicine, if any,
to adjust or change. Here, both drugs are recommended for heart failure. In addition the patient is retaining fluid. You know that ACE
inhibitors may cause hyperkalemia,so the most sensible option is not to use a potassium-sparing diuretic. The best solution here is to
choose a loop diuretic only, such as furosemide in place of co-amilozide.

It is important that you mention how to monitor whether your suggestions have solved the clinical problem. Here you would
recommend that serum potassium levels are monitored. Many students lose marks in OSCEs by failing to follow up recommendations
suggested. Your solution can only be considered successful if the patient recovers!

You need to be familiar with Appendix 1 of the BNF (Interactions), especially the subheadings. Here you need to know that
co-amilozide is a combination of amiloride and hydrochlorothiazide (and what type of diuretic each of these is) in order to search for
an interaction with lisinopril, an ACE inhibitor.

You are not expected to know all the guidelines! Brief summaries for many conditions are found in the BNF.

Diabetes

Usual Causes TYPE 1- caused by an autoimmune disorder, meaning that the body's immune system mistakenly attacks cells that make insulin.
TYPE 2- Being overweight/Obese; Inactivity; Family history; Age; Prediabetes; PCOS; HTN
Gestational Diabetes- overweight before pregnancy, family history

Manifestation of the Increased urination (polyuria); increased thirst (polydipsia); increased hunger (polyphagia); fatigue; blurred vision; pain/tingling in
Disease / Symptoms hands and feet/ numbness; slow- healing sores; unintended weight loss; areas of darkened skin usually armpits and neck

Recommended *All are prescription drugs *It also combination/triple drugs depends on the prescriber
Treatment / Drugs Metformin: for initial drug of choice to lower the blood glucose levels and improve body responds to insulin Sulfonylureas: Oral
medications that help your body make more insulin
Meglitinides: Fast-acting, short duration medications that stimulate the pancreas to release more insulin
Thiazolidinediones: make your body more sensitive to insulin
Dipeptidyl peptidase 4 inhibitors: milder medication that help to reduce blood glucose levels
GLP1 receptor agonist: Slow digestion and improve blood glucose levels
SGLT2 inhibitors: help to prevent the kidneys from reabsorbing glucose into blood and sending it out in your urine

Dosage of the Drug Metformin (alone)

● Adult: 500mg BID taken with the morning and evening meals. Maximum: usually not more than 2550mg per day
● Children 10- 16 yrs age: 500mg BID taken with the morning and evening meals. Maximum: usually not more than 2000mg

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per day Sulfonylureas

Chlorpropamide:
● Adult: 250mg daily as single dose in morning (5-7 days after treatment initiation). Maintenance: 100-500mg daily
● Elderly: 100-125 mg daily (5-7 days after treatment initiation).

Meglitinides
Repaglinide
● Adult: Combination with metformin, initially 0.5mg. Patient transfer from another hypoglycemic agent, initial 1mg. All doses
taken 30 mins. Before each main meal. Max. 16mg daily

Thiazolidinediones
Pioglitazone
● Adult: 15/ 30mg once daily. Max: 45 mg/day
DDP4 inhib

Vildagliptin
● Adult: 50mg BID
SGLT2
Dapagliflozin
● Adult: monotherapy/combination therapy: 10mg once daily/ +metformin 500mg once daily. Heart failure: 10mg once daily

Direction of Use May be taken with or without food

Side Effects Hypoglycaemia; weight gain; GIT disturbance; lactic acidosis and fluid retention

Contraindication Diabetic ketoacidosis; severe hepatic impairment; severe heart failure; hypersensitivity (Forxiga)

Important Counseling Subjective:

Notes ● Patient characteristics (eg, age, race, sex, pregnant)
● Characteristics of diabetes (example: type, age of onset, initial presentation)
● Microvascular and macrovascular complications (including retinopathy, nephropathy, and neuropathy)
● Patient history (past medical, family, social-dietary habits, weight history, sleep behaviors, physical activity)
● Current medications (including complementary and alternative therapies) and medication-taking behaviors (eg, adherence,
injection technique)
● Past diabetes treatments, response to therapy, reason for discontinuation

Objective:

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● Physical exam ( height, weight, BMI, blood pressure, heart rate, comprehensive foot exam)
● SMBG results and self-management behaviors
● Laboratory exam (example: glucose, A1C, Scr, BUN, eGFR, fasting lipid panel, urinary albumin/Cr ratio, serum electrolytes)

Assessment:
● Diagnosis and classification (Type 1, Type 2 etc.)
● Appropriateness, effectiveness, safety/tolerability, treatment burden, cost, and adherence to current antihyperglycemic
regimen
● Achievement of weight, lifestyle, and other behavioral goals
● Achievement of goals for comorbidities (eg, blood pressure, lipids, neuropathic pain)
● Screen for depression, anxiety, disordered eating
● Screen for psychosocial problems and barriers to diabetes self management

Plan:
● State which testing is needed and the rationale for choosing each test to resolve diagnostic ambiguities; ideally what the next
step would be if positive or negative (based on age, comorbidities, and other factors)
● Tailored lifestyle modifications (eg, diet, exercise, weight management)
● Drug therapy regimen (including specific antihyperglycemic agent(s), dose, route, frequency, and duration; specify
continuation and discontinuation of existing therapies.
● Patient education and counseling (eg, purpose of treatment, drug administration, dietary and lifestyle modification)
● Referrals to other providers when appropriate (eg, diabetes educator)

Non-Pharmacologic TYPE 1:
Therapy ● Focus more on physiologically regulating insulin administration.
● For those on fixed doses of mealtime insulin, consistent intake of carbohydrates is recommended to improve glucose control
and minimize hypoglycemia.
● For those on flexible insulin dosing regimens (eg, matching insulin doses to carbohydrate intake amounts)
TYPE 2:
● Balanced diet with moderate carbohydrate intake at each meal to minimize glucose excursions.
● Carbohydrate intake from vegetables, fruits, legumes, whole grains, dairy products, and those high in fiber is preferred.
● Discourage bedtime and between-meal snacks, set realistic goals, determine what the patient is willing to change, and
follow-up to see how and whether those changes occurred.

Physical Activity
● Aerobic exercise
● Resistance/strength training is recommended at least two times a week as long as the patient does not have proliferative
diabetic retinopathy.

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Self-Management Education help your kidneys get rid of extra water and salt from your body through your urine.nd Support

Hypertension

Usual Causes Primary hypertension may cause genetic factors to play a role in the development of essential hypertension by affecting sodium
balance or other BP regulating pathways such as unhealthy lifestyle choices.
Secondary hypertension can caused by either a comorbid disease or a drug (or other product) is responsible for elevating BP

Manifestation of the Early morning headaches, nosebleeds, irregular heart rhythms, vision changes, and buzzing in the ears. Severe
Disease / Symptoms hypertension can cause fatigue, nausea, vomiting, confusion, anxiety, chest pain, and muscle tremors.

Recommended Angiotensin-converting enzyme (ACE) inhibitors - Angiotensin II is a potent vasoconstrictor that stimulates aldosterone secretion,
Treatment / Drugs causing an increase in sodium and water reabsorption with accompanying potassium loss. By blocking the ACE, vasodilation and a
decrease in aldosterone occur.
Angiotensin receptor blockers - inhibit the effects of angiotensin II from all pathways
Calcium channel blockers - work by inhibiting the influx of calcium across the cell membrane.
β-Blocker - helps the heart to beat more slowly and with less force, which lowers blood pressure.
Diuretics - help your kidneys get rid of extra water and salt from your body through your urine.

Dosage of the Drug Angiotensin-converting enzyme (ACE) inhibitors

Enalapril
● HTN: Initially 5 mg/day. Usually 10-40 mg/day as a single or 2 divided doses.

Angiotensin receptor blockers

Losartan
● Usual starting & maintenance dose: 50 mg once daily.
● Max: Antihypertensive effect is attained 3-6 wk after therapy initiation. May be increased to 100 mg once daily.

Calcium channel blockers

Amlodipine
● HTN 2.5-10 mg once daily. Angina Initially 5 mg once daily, may be increased to a max of 10 mg.
● Children 6-17 yr 2.5-5 mg once daily. Max: 5 mg daily
Verapamil
● Initial dose: 180 mg
● Lower dose if patient has high response on to verapamil: 120 mg antihypertensive effects of ISOPTIN SR are evident within
the first week of therapy

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β-Blocker
Atenolol
● Adult HTN 50-100 mg daily.

Diuretics
Hydrochlorothiazide
● Usual Initial Adult Dose: 12.5 – 50 mg once daily Maintenance Dose: 25 – 100 mg once daily or, as prescribed by the
physician.

Direction of Use May be taken with or without food.

Side Effects Dizziness, Headache, Cough, Nausea, High or low levels of magnesium or potassium, Fast or slow heart rate

Contraindication Pregnancy; bilateral renal artery stenosis; hyperkalaemia; dyslipidemia; peripheral vascular disease;

Important Counseling Subjective:

Notes ● Patient characteristics (eg, age, race, sex, pregnant)
● Patient history (past medical, family, social—dietary habits, tobacco use)
● Home blood pressure (BP) readings
● Current medications and prior antihypertensive medication use
Objective:
● BP, heart rate (HR), height, weight, and BMI
● Labs (eg, serum electrolytes, Scr, BUN)
● Other diagnostic tests when indicated (eg, ECG)

Assessment:
● Presence of compelling indications (eg, coronary artery disease, chronic kidney disease)
● Current medications that may contribute to or worsen hypertension
● Appropriateness and effectiveness of current antihypertensive regimen

Plan:
● Tailored lifestyle modifications (eg, diet, exercise, weight management)
● Patient education (eg, purpose of treatment, dietary and lifestyle modification, drug therapy)
● Self-monitoring of BP, HR, and weight—where and how to record results

Non-Pharmacologic ● Patients should engage in moderate to vigorous aerobic physical activity three or four times per week for an average of 40
Therapy minutes per session.

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● A diet that emphasizes vegetables, fruits, and whole grains is recommended to lower blood pressure.
● Provide tobacco cessation interventions for those who use tobacco products.
● Self-measured blood pressure monitoring, with or without additional support
● Limiting sodium intake to 2,400 mg per day is recommended to lower blood pressure.
● alcohol consumption should be limited to no more than two drinks per day

CALCULATIONS

Paper Tablets

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Creatinine clearance:
using Cockroft-Gault
equation case
scenario

Reducing Dosage

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Dobutamine infusion
rate in ml/hr

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