OSCE

Step 1: Identifying self and checking with the caller who they are

• Hi, good morning, I am Anne, the pharmacy intern here. How may I help you today?

(question → identify category)

• Before we proceed, may I check who I am speaking to please?

  • Lay person: for themselves or for someone else?

  • Doctor/Nurse: where are you calling from?

    • For patient information: NRIC, name, gender, age, (height, weight), NKDA

• Where are you calling from?

• How may I address you?

Step 2: Checking background information and active listening

Step 3: Categorise question

Availability/ Identification/ Administration/ Compatibility/stability/Cost/Dosage/Drug Safety/Adverse reaction

Drug interactions/Choice of therapy/Pharmaceutical/Pharmacology/indications/Supply of literature/ Poisoning/overdose

Step 4: Search Strategy

Micromedex, LexiComp/UpToDate, MIMS, BNF, PIL/HSA infosearch, PubMed

Saying bye bye and thank you

**Readback

Okay, that's all I have to clarify, I will check back with you in about 10 minutes.

How may I contact you?

Thank you, byebye

Step 5,6,7: Evaluate/Analyse/Synthesise, Response, F/U & document

NIL

DI category 1

Resources

Pregnancy + Lactation

PREGNANCY

1. Briggs → Drugs in pregnancy and lactation

2. Micromedex → 1st choice bc of thorough information, useful to obtain FDA and ADEC pregnancy risk

3. OTIS mother to baby

4. Lexicomp (2nd choice)

PBMO

** want to use the lowest effective dose for as short a period as possible

LACTATION

1. Hales (medications and mothers’ milk)

2. LactMed → Database

3. Briggs → For drugs in pregnancy and lactation

4. Micromedex → to obtain AAP rating and amount that crosses into breastmilk

LHBM

Others: PIL (cautious side), BNF (too generic), MIMS (too little info)

Availability + identification

1. Product insert in HSA →check if drug is available in SG

2. MIMS online → Companies pay premium to get drugs listed hence useful to identify brands, Use image database (local) first, Access to overseas products for patients with medications from other countries

3. Mediview → search for drugs carried by local practices

Martindale?

Dosing + choice of therapy

DOSING

1. AHFS DI,

2. Lexicomp,

3. Micromedex (core database)

CHOICE OF THERAPY

1. Lexicomp,

2. micromedex,

3. Guidelines from MOH or specific guidelines like GINA for asthma, AHA for HTN, GOLD for COPD, KDIGO for CKD

4. Pharmacotherapy textbooks

Parenteral ADMINISTRATION

1. HSA Product Insert: to see formulations & excipients, also to check what exact constitutions are req

2. AHFS Handbook on Injectable Drugs (“trissels”): inform how certain common drugs in US are adminstered here

3. Paediatric Injectable Drug teddy bear book: fluid restriction in neonates; maximum conc allowed for various drugs in children (only for IV)

Parenteral COMPATIBILITY

1. AHFS Handbook on Injectable Drugs (“trissels”): provides context on the concentrations, diluents, conditions used on reactivity studies

2. King’s guide

ADR, DDI

ADR ^^

1. Initiating the session

2. Building RS with patient

Involving patient

*Actively encourages patient to share concerns and to seek clarifications

Uses appropriate non-verbal behaviour

*Dresses appropriately for professional encounter

*Demonstrates eye contact and appropriate facial expression

Demonstrates appropriate posture, position, movement

Uses appropriate verbal cues eg volume, tone, pace of speech

Demonstrates appropriate confidence

Developing rapport

Uses non-judgmental tone of communication

*Acknowledges patient’s concerns

Engages in empathic, compassionate and respectful conversation with patient about her condition and concern(s)

3. Communicate information about new medicine

1. Diagnosis (NOT IN RUBRICS?)

2. Dose + strength

3. Purpose/benefit/onset

4. Dosing/administration

5. Duration + quantity

6. If non-adherence..

7. Advice on missed dose

8. Appropriate storage

9. Side effects + management

10. Rare but serious SE’s that require immediate attention

11. Interactions with DDIs/supplements/foods

12. Monitoring parameters

13. Non-pharmacological (NOT IN RUBRICS?)

4. Steps in effective patient counselling

*Avoids jargons and/or uses plain language to explain medical terms if use is unavoidable

*Use of demo sets to demonstrate techniques (where relevant)

Organises information into chunks to aid retention and recall of information

*Performs teach-back to validate patient’s understanding at appropriate times or important sections of information (eg dosing, monitoring parameters) (_____, do you mind if i ask you some questions to check if you remembered the important points that we discussed today please?)

Actively solicits patient’s questions and concerns before moving on

5.Communication Skills to Encourage Behaviour Change (Technique)

Uses open-ended questions to assess current behaviours and motivation to change (where relevant)

Praises and provides affirmation on efforts made to change (where relevant)

Demonstrates reflective listening (where relevant)

Provides summary of the discussion (where relevant)

Rolls with resistance to SP’s wish for information/change (where relevant)

Address patient’s concerns

6. Closing the session

*Actively solicit patient’s questions and concerns (last opportunity before closing)

*Summarises the session (Okay so in this session, we have gone through….)

*Contracts with patient regarding next steps (eg calling pharmacy for drug enquiries)

*Thank patient for time and attention

Condition

Explanation/Cause

Medication given

Administration/Dosing/Device use/Counselling

** teach back

Non-pharmacological

Monitoring

Acute bacterial conjunctivitis

1. Caused by certain bacterias

2. Inflammation of eyelid base

- could be from previous infected individuals with directed hand-eye contact, oculogenital spread..

- Patient’s own sinus/mucus

Signs and symptoms:

- Hyperaemia (Red eye)

• inflammation of Bulbar conjunctiva

1. Lack of itching

2. Chemosis (swelling of conjunctiva)

3. Yellow Purulent or mucopurulent discharge

   1. (present in the morning) ⇒ eyelids stuck together

4. Clear cornea

5. No history

1. Fluoroquinolone (levofloxacin),

polymyxin (typically gentamicin),

fusidic acid (Fucithalmic)

1. Dont wear contact lens for the meantime

2. Administration of eye drops

Viral conjunctivitis

1. Inflammation of eyelid base

2. Caused by certain viruses

- sick contacts, recent history of URI

Signs and symptoms:

1. Hyperaemia (Red eye)

2. Itching (less of an intense itch)

3. Foreign body sensation → (“I feel like I have something in my eye e.g. sandy, gritty…”)

4. Watery discharge (not mucousy)

5. Typically starts in 1 eye then followed by the other a few days later (bilateral usu.)

6. 1st eye is severely more affected

7. History of recent URI or sick contact

1. Antihistamine for itching

1. Don't wear contact lens for the meantime

2. Administration of eye drops

1. Supportive with artificial tears and cool compress

2. Exposure precautions as extremely contagious

Allergic conjunctivitis

1. Hypersensitivity to allergens

ACUTE: Exposure to known allergen eg cat dander

SEASONAL (or ALLERGIC RHINO-CONJUNCTIVITIS (ARC)): Outdoor airborne pollens e.g. pollens ; develops over days and weeks

PERENNIAL: Environmental exposure e.g. indoor allergens like dust mites, animal dander and mould

1. Hyperaemia (Red eye)

2. INTENSE itch →risk of getting secondary infection !!!

3. Chemosis (swelling of conjunctiva) - various levels

4. Watery and nonpurulent discharge

5. Swelling (oedema) of lower eyelid

6. Usually bilateral

7. Mild photophobia?

8. Burning sensation

9. Eye pain is NOT characteristic

10. Clinical history: of atopy, seasonal allergy/specific allergy

RED FLAGS:

• Intense inflammation

• Pain

• Reduced visual acuity

• Unilateral

• Progressive disease

First-gen antihistamines: Competitively and reversibly block histamine receptors in the conjunctiva. Lipophilic, crosses blood-brain barrier and causes sedation

Alosyn: Antazoline - immediate but temporary relief.

Tetrahydrozoline - vasoconstrictors for redness

Newer-gen antihistamines:

Levocabastine

Olopotadine

Preventative - avoid allergen

Non-pharmaceutical - Avoid rubbing eyes, cool compress, artificial tears, saline rinses,

Dry eye disease

It is a multifactorial disease of the ocular surface, loss of homeostasis of tear film

“Eyes can’t produce enough tears

Signs and symptoms: dry eyes, red

Cause/ Etiology:

- Sjogren syndrome (Autoimmune)

o Primary and secondary

- Non-Sjogren syndrome

o Systemic drugs (antihistamine drug e.g. Chlorphenamine)

o Lacrimal deficiency

o Obstruction of the lacrimal gland duct

o Reflex

B. Evaporative (lipid layer)

Etiological causes:

Intrinsic

o Meibomian oil deficiency

o Drug action e.g. Accutane to treat acne vulgaris

o Low blink rate (naturally)

Extrinsic

o Contact lens wearer

o Ocular surface disease e.g. allergy

o Topical preservatives e.g. BAK

o Vitamin A Deficiency

C. Environment

- Air con workplace

- Computer use -> low blink rate

Risk Factors:

- Aging

- Female

- Asian

- Contact lens

Goal of treatment: restore homeostasis of ocular surface/on the cornea

1. Ocular lubricants (replenish tear vol, stabilise tear film)

E.g. Tears Naturale, Hypotears

1. Device use for eye drops

2. Ointment → might have blurry vision at night

1. Education on: local environment, lid hygiene, lid massage, warm compresses, using the computer less/more short breaks, take a break from wearing contact lenses

2.

Blepharoconjunctivitis

1. Antibiotic containing ointment (Gentamicin, also known as Gentamicin POS)

2. Topical antibiotic eyedrops (levofloxacin hydrate, also known as Cravit Ophthalmic Solution)

3. Corticosteroids (dexamethasone sodium phosphate and gentamicin sulfate, also known as Dexa-Gentamicin

Blepharitis

1. Inflammation of the eyelids due to eye glands being clogged

2. Posterior (tear film instability) or anterior (infection of the base)

3. Caused by some conditions like rosacea, seborrheic dermatitis, eczema, psoriasis, infections, certain irritants (contact blepharitis), certain Medications

4. Associated with dry eye disease, red and swollen eyelid, itchy eye, irritation, scales on eyelids

1. Heat

- Bring turbid lipid material to melting point

- Use of warm compress

2. Clean

- Remove scruf, collarettes, crusting

- Use of warm washcloth

Hordeolum (stye) ≠ cyst

1. Bacterial infection

2. Causes acute inflammation of the oil gland on the eyelid

3. Small yellow-pus filled lesion may be visible

- can be internal or external, developed over a few days

- self-limiting

→ signs and symptoms:

Red eyelid, swollen eyelid, pain and sensitive to the touch

NIL

NIL

Apply a warm compress to relieve the pain and discomfort of the stye (around 5-10 minutes several times a day and gently massage the eyelid)

- Ensure you have good and proper hand hygiene

Chalazion

1. Blocked zeis or meibomian glands causing accumulation of material ont he eyelid

2. May be from a previous stye after 10 days to 2 weeks

3, NOT PAIN, bump, slightly red eyelid, no head

Consider incision + curettage or glucocorticoid injection

NIL

Self limiting but can Apply warm compress – soften the cyst and facilitate drainage to the eyelid for 10 to 15 minutes, 4 to 6 times a day for several days.

Primary open-angle Glaucoma

normal appearing anterior chamber angle + raised IOP

- Due to clogging of drainage canals

- Gradual loss of peripheral visual field

Goal of treatment: Prevent further deterioration of vision from disease progression → so lower IOP

Targeted for IOP >25 to 30% below initial IOP (for normal pressure and high pressure)

Prostaglandins (e.g Latanoprost, Bimatoprost) > beta-blockers (timolol) > alpha-adrenergic agonists (Brimonidine) > carbonic anhydrase > cholinergic

Condition

Explanation/Cause/Signs and symptoms

Medication given

Administration/Dosing/Device use/Counselling/SE

** teach back

Non-pharmacological

Monitoring

Acne

Atopic dermatitis

Disruption of the outer layer of the skin/skin barrier caused by irritants or allergens

→ from a gene mutation?

- dry, itchy skin w/ redness, swelling, crusting, oozing

- common on hands and feet in adults

→ personal/family hist of atopic dermatitis

→ is there any atopic triad?

1. Topical corticosteroids

→ Hydrocortisone 1% (cream, ointment or lotion)

=

1. 1 tube 15g (30 FTU) → Use 1 FTU (0.5g) → treats an area of skin the size of 2 hands

2. Avoid application on thinner region of the skin like face, eyelids and genital areas

3. Use for shortest possible duration + apply a thin layer → otherwise increase the risk of getting side effects

4.Do not bandage or cover the area unless instructed otherwise → may lead to more being absorbed and increase side effects

5. Common side effects: Redness, Steroid telangiectasia →dilation of capillaries (into clusters), Tinea faciei

6. If dose if missed, apply as soon as you remember. If it is near the time for the next application, only apply the usual amount. DO NOT apply extra ointment or cream to make up for missed application

● Aim to reduce the discomfort and restore the skin barrier

● Avoid any known allergens (food, cosmetics, dust mite etc)

● Avoid potential pollutants

● Loose-fitting clothes

● Advise against scratching that may increase risk of infections

● Use of emollients (Cetaphil) → Baseline: Basic therapy

- morning before the flare, 2x a day at the peak, morning after the flare

○ Avoid the use of aqueous cream as it contains irritants

○ Using non drying, soap free products in the shower or moisturiser after showering

○ 2-3 times a day

○ Should use even when AD is dormant

○ Avoid irritants such as sodium lauryl sulfate (found in aqueous cream)

● Use of Suu Balm Menthol Cream to maintain skin barrier and reduce itch

Cold sores

Caused by herpes simplex virus

- prodromal symptoms of itching, burning, pain or tingling symptoms 6-48 hours

- trigger factors: stress, ill health, sunlight, viral infection and menstruation

Goal of treatment: aim to resolve the condition

1. Topical acyclovir (Antiviral) cream

1. 5x daily every 4 hours, 5 days

Psoriasis

Condition

Explanation/Cause

Medication given

Administration/Dosing/Device use/Counselling

** teach back

Non-pharmacological

Monitoring

Oral ulcers

1. Single or small crops of ulcers that are typically found in the cheek, mouth or lips

Oracort E paste, apply liberally 2-3 times a day

Xerosstemia

1. Dry mouth from reduced or absent saliva flow

2. Could be caused side effects from drugs, disease

3. Signs and symptoms: difficulty swallowing, eating and wearing dentures, taste disorder, painful tongue..

Hydroxyethyl cellulose solution

This medication will help to replace the moisture and lubricate the mouth

PUD

1. PUD is where your stomach lining has an ulcer caused by an ulcer called H.pylori (an infection by bacteria that weakens the protective mechanisms of the stomach, allowing acid to get to the sensitive lining) /NSAIDs (when you take too much, it can cause damage to the lining and unable to be repaired)

Common cause: NSAIDs and H.pylori

Signs and symptoms: pain wakes patient up at night

Goal of treatment: Eradicate the bacteria, relieving the ulcer disease, healing ulcer, preventing recurrence, reducing complications

2 weeks:

PPI triple therapy (PPI OD/BD, amoxicillin 1g BD/metronidazole 500mg BD, Clarithromycin 500mg PO BD

Or

Bismuth quadruple therapy

(PPI or H2RA OD/BD, metronidazole 250-500mg QDS, Bismuth Salicylate, Tetracycline 500mg QDS)

Or

Non-Bismuth Quadruple

(PPI BD/OD 10-14 days, Amoxicillin, Clarithromycin, Metronidazole days 1-10)

Goal of treatment for NSAID prone:

Heal ulcers

1. STOP the NSAIDs

2. Omeprazole 20mg daily

Bismuth, tetracycline Omeprazole: take 30 min before food (just on an empty stomach), sawllow whole

Amoxicillin and clarithromycin: take tgt after food

Avoid drinking milk tetracycline

N/V, diarrhea

Amoxicillin, tetracycline

Metallic taste in mouth

Clarithromycin, metronidazole

Nausea, vomiting, diarrhea or constipation

Levofloxacin

Urine or stool discoloration, constipation

Bismuth

Abdominal pain, passing of gas, diarrhea, constipation

PPIs

N/V: take with, or after food except for tetracycline

Diarrhea: drink more water

Metallic taste: reversible upon discontinuing medication

Constipation: take more fibre/fruits and drink more water

Urine/stool discoloration: reversible upon discontinuing medication

1. Emphasise on the importance of taking the medications in its full course to kill the bacteria otherwise the infection might return or the bacterial resistance could occur such that the antibiotics won't work anymore. Ulcers also take time to heal hence you should not stop taking the medications even when the pain goes away.

2. Stress reduction

Smoking cessation

Dietary: avoid spicy foods, caffeine and alcohol

Urea breath

Follow up in 2 weeks

GERD

1. Symptoms or complications arising from refluxed stomach contents into the distal oesophagus or beyond into the oral cavity

2. The lower esophageal sphincter relaxed, irritates the esophagal mucosa, increase pressure in the abdomen

3. (acid keeps flowing back into the esophageal or oral area giving you that burning sensation)

Signs and symptoms: Heartburn, acidic sour taste in the mouth, regurgitation

Complications; esophagitis, barette’s oesophagus, strictures, chronic cough..

Goal of treatment: alleviate or eliminate symptoms, decrease frequency of recurrence, promote healing of injured mucosa, prevent complications

If frequent heartburn >2 days per week:

1. PPI (omeprazole 20mg OD)

If episodic heartburn,

2. Antacids (Gavison liquid 2 5mL spoonfuls 4x a day, PRN)

3. H2RAs (Famotidine 20mg BD)

1. For PPI, this medicine helps to reduce the acid production in your stomach. For side effects, you may experience headache, fatigue, dizziness, constipation? Take with water 1h before food and sit upright

1. For H2RAs, it aims to reduce acid production in the stomach. Same side effects .take it AT NIGHT this is when histamine production is the highest

2. For Gaviscon, it aims to to chemically neutralise the acid and may lead to flatulence, bloatedness and constipation.

Try elevating the head of the bed,

avoid certain foods that can cause lower esophageal relaxation,

avoid foods that may have a direct irritant effect,

stop smoking,

eat smaller meals

avoid sleeping immediately after meals

Up to 2 weeks, follow up after 4 weeks for PPIs

Dyspepsia (indigestion)

1. Symptoms in the gastroduodenal area (upper area or around the chest)

2. Usually followed by a sense of heaviness in the stomach after eating, epigastric pain or burning (location above the umbilicus)

3. Can be caused by many things e.g. H.pylori (have they been tested)?, spicy foods

Trigger points: anorexia, loss of weight, persistent pain..

Goal of treatment: relieve the symptoms

1. Alginates

2.Antacids (Magtasil magnesium trisilicate → slightly slower. Constipation..?, Gaviscon tabs, liquid, double action + liquid)

3. H2 receptor antagonists (H2RAs) (Ranitadine - 150mg)

4. Proton Pump inhibitors (PPIs)

*liquids will have faster onset of action

*take note if CVS patient cause sodium content to be known (like the double action one)

1. To be taken after food

More than 2 weeks

Nausea + vomiting

1. Symptoms usually just include patient feeling queasiness or discomfort

1. Dimenhydrinate tablets 50-100mg every 4-6h PRN **ASSOCIATED WITH SEDATION

2. Domperidone 10mg TDS

3. Scopolamine patch but POM ONLY

1. May experiences drowsiness, constipation, dry mouth

○ Changes in diet

Restricting oral intake

Rating small meals

Avoiding spicy foods

Eating bland foods

Behavioural interventions

Acupuncture

Ginger and pyridoxine (especially for pregnancy)

Biofeedback, chewing gum?, hypnosis, relaxation, yoga

Constipation

1. Uncomfortable, infrequent bowel movement (<3x per week), feeling of incomplete defecation, straining..

2. Likely caused by lifestyle choices i.e. poor diet, low fibre intake, lack of exercise, medications (Calcium carbonate, aluminium hydroxide, NSAIDs, antihistamines)

(functional, slow-transit, pelvic floor dysfunction)

Goal of treatment: relieve symptoms, reestablish normal bowel habits, improve QOL

1. Bulk forming agents (Methylcellulose)

2. Lactulose

3. Glycerin (suppository)

1. For bulk forming agents, it aids in increasing the water content of the stool. Some side effects would include diarrhoea.

Lifestyle modifications: Dietary management (foods like whole grain, eat plenty of fresh fruits… prunes..replacing white rice with brown rice) , adequate hydration, fibre supplements, laxatives, exercise, timed bowel management

Diarrhoea

1. Increase in frequency of stools for more than 3 times a day. Stools often appear pasty and liquidy

2. Can be acute, prolonged, persistent, chronic. Chronic can be caused by IBD, malabsorption syndrome.. Drugs like laxatives, NSAIDs, PPI

3. Or could also be caused by food poisoning which will have vomiting, a temperature..

Goal of treatment: Manage the diet, prevent excessive water/electrolyte/ acid-based disturbances, provide symptomatic relief, treat curable causes, manage secondary disorders

1. Loperamide (4mg, max 16mg/day + 1mg/5ml for liquid)

2. Diphenoxylate (2.5 - 5mg 3-4x daily)

3. Adsorbants (charcoal?)

1. Loperamide works by slowing down the contraction of the gut and allowing more water to be absorbed. Side effects would include dizziness and constipation

2. Diphenoxylate also slows down the contraction of the gut and helps to increase residence time that allows more water to be absorbed. Side effects include dizziness, constipation..

(do not take with alcohol)

Fluid/electrolyte replacement (Repalyte)

Drink more water

Eat soft and more plain food

BRAT diet - bland so doesn't aggravate the digestive system

Avoid eating spicy/fatty food

Ulcerative Colitis

- Autoimmune-mediated intestinal inflammation where the inflammation is distributed continuously, involves the rectum and limits itself to colon

Risk Factors:

- Family history

- Infection

- NSAIDs

- Stress

- antibiotics

S&S:

- fever

- Uveitis (Iritis/conjunctivitis)

- Mouth ulcer

- Abdominal pain

- Large joint arthritis (asymmetrical)

- Skin Rash (Erythema nodosum and/or Pyoderma gangrenosum)

- Blood in stools + Anaemia

Complication:

- Pseudopolyps → regeneration of cells, but in a weird way

- Toxic Megacolon

- Perforation

- Massive haemorrhage

- Strictures

- Carcinoma of the colon

Goals of treatment:

-Resolve acute inflammation

-Relive extraintestinal symptoms

-Resolve and prevent complication

-Maintain in remission

Algorithm:

IF distal mild: oral sulfasalazine ↓dose(3-4wks)

IF extensive mild/moderate: oral mesalamine/budesonide↓

IF moderate: budesonide MMX/prednisone ↓dose(8wks)

IF no response: infliximab + azathioprine (good for remission)

IF severe: methylprednisolone/hydro prednisone(8wk) + AZA

IF no response: infliximab/cyclosporine IV PO +AZA/6MP

IF INF cannot: vedolizumab

-Low in FODMAPs food

-Avoid wheat, diary products, artificial sweeteners

Chron’s disease

Condition

Explanation/Cause

Medication given

(the doctor has prescribed you with… this is to help you (goal of treatment))

Administration/Dosing/Device use (Have you used the device before? Do you mind if I teach you how to use it?) /Counselling

** teach back

Non-pharmacological

Monitoring

HTN

1. HTN is when there is an increase in your blood pressure in your blood vessels

2. Is mostly asymptomatic but severe cases can have some symptoms of headache, visual changes, blurred vision..

3. There are some risk factors like sedentary lifestyles, diabetes, stress

4. If poorly controlled, can lead to bad consequences such as stroke, visual loss, heart attack..

Goal of treatment: BP goal of <130/80 mmHg or <140/80 mmHg (if >65)

1a. ACEi e.g. Lisinopril 10mg OD

1b. ARB e.g. Valsartan 80mg OD

2. CCB e.g. Amlodipine 2.5mg OD or Nifedipine

3. Diuretics (DHPs) e.g. Hydrochlorothiazide

ACEi counselling:

1. Dry cough as a side effect may be observed - please see a doctor if so

2. Side effects include

CCB counselling:

1. Edema/Swelling may be observed which should go away after 2 weeks. Can elevate legs with a pillow or so.

Diuretics counselling:

1. May have to go to the toilet more often because of its effects, it works by helping you pee out more water so that it reduces blood pressure

1. Restrict sodium intake which is cutting down foods like processed foods, fast foods and increase potassium intake like eating bananas and mango

2. Decrease alcohol intake to under 1/2 drinks a day

3. Would be beneficial to have moderate exercise of 150 mins a week

4. Measure BP 2x daily (see below)

5. Note if your BP exceeds >180/110 mmHg please go AnE

6. Some of these drugs may lead to hypotension so do note to stand up slowly to prevent fainting

ACEi: 1-2w, renal panel (SCr,K), follow Q4 monthly

• Check for cough

CCB: 2-4 weeks, PR control

Diuretic: Monitor SCr and K, weight

HF

1. Heart failure is a condition whereby your heart is unable to function optimally, and unable to pump out sufficient blood to meet the demands of your body or is only able to do so when the blood pressure increases

2. However, this leads your heart to work too hard, and overtime it will make your heart muscles become stiffer and harder, therefore it is less efficient in pumping out your blood.

3. Risk factors: Hypertension, AF..

4. Some signs and symptoms: increased swelling of legs.., sudden weight gain in a short period of time, dry hacking cough

Goal of treatment: Improve QOL, relieve symptoms, reduce or prevent hospitalisations, slow progression of disease, increase survival

TARGET HR: 50-70

1. ARNi > ACEi > ARBs

2. BB (+ivabradine if PR not at goal // +digoxin if concomitant AF) e.g. Bisoprolol, Carvedilol, Metoprolol, Nebivolol

3. MRA e.g. Spironolactone

4. SGLT2i e.g. Dapagliflozin or Empagliflozin (10mg OD - take note if diabetes then 25mg)

5. (if needed) Diuretics e.g. Frusemide (20mg BD), Bumetanide

ACEi counselling:

1. Dry cough as a side effect may be observed - please see a doctor if so

2. Side effects include the dry cough

ARNi counselling:

1. Monitor BP, may experiences dizziness, cough, lightheadedness

BB counselling: BB work by reducing your heart rate and slows down the heart contraction. You may experience side effects of tiredness, fatigue and shortness of breath. You may also not see the effects until 3-6 months but it will get better!

CCB counselling:

1. Edema/Swelling may be observed which should go away after 2 weeks. Can elevate legs with a pillow or so.

Diuretics counselling:

1. May have to go to the toilet more often because of its effects, it works by helping you pee out more water so that it helps to treat fluid retention and reduces blood pressure.

2. May experience dehydration - avoid by consuming the amount of fluid specified by your doctor.

3. May also experience dizziness or lightheadedness - get up slowly from sitting or lying down to prevent this

MRA counselling:

1. Side effects include gynaecomastia

SGLT2i counselling: side effects of

1. Daily weight check (before breakfast)

2. Fluid restriction (1.2L bottle)

3. Sodium intake and salt substitution

4. As some of your medications cause an increase in potassium levels, eat less high K foods, can boil your veggies.

5. Take note of any sudden weight gain of 2-3kg in a day (pls inform doctor)

6. Use all drugs at the same time!! These are to ensure that you achieve the goals of treatment

7. Monitor BP

8. If you experience sudden weight gain, new worsening of dizziness, sudden increased swelling please go to the doctor (but dont worry these are rare SEs)

At your next checkup in about 2-4 weeks, he will have to draw blood to ensure that the medications are working safely and effectively for you.

(if given ARNI after ACE, wait 36h for wash out period)

ACEi: 1-2w, renal panel (SCr,K), follow Q4 monthly

• Check for cough

CCB: 2-4 weeks, PR control

Diuretic: Monitor SCr and K, weight

BB: BP, PR, clinical status. TCU in 2-4 months

SGLT2i: SCr, BP. Follow up 2-4w (take note if any euglycemia ketoacidosis if diabetic)

MRA: SCr, K, urea. Check 1w then 4w

Monitoring is to ensure that the medications are working safely for you

Hyperlipidemia (statins)

1. Hyperlipidemia is when you have high levels of cholesterol in your blood

2. This may be caused by family history (pri dyslipidemia) or others like obesity, diabetes, hypothyroidism, alcoholism (sec dyslipidemia)

3. Risk factors (overweight, obesity, DM, metabolic syndrome)

4. Poorly controlled hyperlipidemia can put you at risk of heart attack or stroke so it’s very important to take your medications even if you dont feel any symptoms

Goal of treatment:

Control blood cholesterol levels

Medications:

1. Statins (Rosuvastatin 10mg ON or OM > atorvastatin ON or OM > Simvastatin > Lovastatin)

!. Rosuvastatin or atorvastatin can be taken any time of the day

1. Statins: May experience some SEs like mild muscle aches, tenderness or weakness. , … please take note of more serious SEs (but are rare) if the muscle aches become more pain.

2. DDIs: Amiodarone, colchicine.. Please don’t eat any grapefruit, gemfibrozil, red yeast rice?

3. If you observe any severe muscle aches, and your urine is brown or tea coloured, light coloured stools, loss of appetite then please seek medical help immediately. Rare side effects

4. You can also lower your cholesterol levels

4 weeks TCU (will take 6-8w for effect)

Baseline CK, lipid panel, LFTs

Atrial Fibrillation

1. This is an when your heart has abnormal heart rhythms which means that the

Goal of therapy:

Rate control:

Class II (BB e.g. atenolol, bisoprolol) OR Class IV (non-DHP CCB e.g. diltiazem, verapamil),

Digoxin,

Ivabradine

Rhythm control:

Class I and class III (amiodarone)

Amiodarone: TFT, LFT, chest x ray, ECG and physical exam required @ baseline + !6 monthly

Angina pectoris

1. Occurs when there are fat deposits in your blood vessels → forms what is called a ‘fatty plaque’. This narrows the blood vessel and reduces the supply of blood to the heart muscles.

2. Some risk factors: family hist, high cholesterol levels, diabetes, hypertension

3. May have experienced some signs and symptoms like squeezing chest pain, pain radiating to jaw, neck, shoulder, pain is relieved after rests of nitrates

Goal of therapy: Reduce angina symptoms, reduce exercise-induced ischaemia, prevent CV events/stroke/death

TARGET HR = 55-60

1. Sublingual GTN

2. (first line) BB (atenalol, bisoprolol 2.5-20mg or carvedilol) + DHP CCB (nifedipine 30mg-180mg OD) OR

non DHP **not in HFrEF (verapamil 30mg-120mg TDS/QDS)

3. Nitrates e.g. Isosorbide mononitrate 60mg OD

4. Ivabradine (add on therapy if target HR not achieved) 5mg or max 7.5mg BD

5. Antiplatelet therapy (Aspirin 75-100mg/day or clopidogrel 75mg/day)

1.. BB/NDHP help to reduce your heart rate and muscle contraction to slow down overworked heart. They will also increase your oxygen supply through dilation of your blood vessels. (if verapamil - might have constipation, bradycardia, headache..)

(DHP CCB will have vasodilated related)

2. Nitrates help by helping to increase the blood and oxygen supply. It helps to prevent or relief your angina symptoms. Some common side effects are headache, dizziness and hypotension. You may treat the headache with paracetamol if necessary.

3. Sublingual GTN:

Use this medicine when there is a sign of angina attack. Preferably eat it while you are sitting. Place under your tongue and allow it to dissolve completely - this allows the drug to absorb faster and have a faster onset of action (5 mins) than your other medicines. Do not swallow or eat. If you still feel chest pain after 5 mins, please call 995 and use it otw. As for storage, keep it in a cool dry place and carry it with you where you go in a bag or purse to avoid keeping it near your body. Please only keep the bottle within 8 weeks of opening and then after that obtain a fresh supply. You can date the bottle if needed.

- Diet: reduce intake of salt, reduce saturated fat intake, increase fruits and vegetables, less high in sugar food, less alcohol

- exercise

- weight reduction

- smoking cessation

(other management: influenza vax, body weight, diet, smoking cessation, hypertension, hyperlidpidemia)

Condition

Explanation/Cause (Layman terms)

Medication given

Administration/Dosing/Device use/Counselling

** teach back

Non-pharmacological

Monitoring

Asthma

1. Having asthma means that your airways are inflamed so are more sensitive than the regular.

2. Signs and symptoms: Shortness of breath, cough, wheezing

Risk factors: family members have asthma, eczema or allergic rhinitis

- respiratory infections

- Environmental factors

Goals of treatment:

(long term) → symptom control, risk reduction (minimise future risk of asthma-related mortality)

1. Maintenance “Controller” medications

a. Low dose ICS-formoterol (Symbicort Turbuhalor - Budesonide + formoterol → 1-2 puffs BD with additional reliever doses up to max 12 puffs/day)

OR

Beclomethasone-formoterol (100mcg/6mcg) → 1 puff BD for maintenance and 6 puffs additional for reliever. Max 8 puffs per day

2. Reliever medications

a. Rapid-acting inhaled B2-agonists (Ventolin MDI - containing salbutamol, 2 puffs PRN)

B. ICS - formoterol

C. ICS-SABA

1. This medication is called the controller medication which will help provide symptomatic relief and reduce the risk of exacerbations. You may experience symptoms of change in voice, different taste in your mouth, dry mouth or throat. It is important to take the required maintenance even if you miss the dose.

2. This second medication is supposed to provide your relief when you feel a flare up occurring. Do remember to take this with you wherever you go. You may experience some symptoms such as tachycardia, palpitations, headache and restlessness. The headache and dizziness should subside over time. Do check with your doctor if these symptoms do not go away.

Avoidance of tobacco, physical activity (general health benefits , if aware that you have exercise-induced bronchospasm then you can use your ICS-formoterol 5-20mins before exercising), occupational asthma (work history), avoid medications that may worsen asthma (NSAIDs + beta blockers can exacerbate), vaccinations, remediation of dampness or mould

Cerumen impaction

1. An accumulation of earwax in the ear

2. Risk factors (genetics, elderly, skin conditions like eczema, dermatitis, wearing hearing aids, inadequate bod hygiene)

3. Signs and symptoms: feeling of pressure/fullness, ear discomfort, NO PAIN!!

1. Docusate sodium 0.5% w/v apply 5-10 drops into the ear 1 time a day

2. Hydrogen peroxide 3%

1. It works by breaking down the ear wax and disperse it. May experience some hypersensitivity or allergy

2. Releases oxygen when exposed to oxygen and loosens the ear wax

1. Can use an isotonic seawater sp ray/wash??

Should resolve in 4 days

Water-clogged ears

1. Accumulation and retention of water in your ear canals that leads to gradual hearing loss and sensation of fullness

2. Trapped moisture could weaken your immune system and increase risk of infection

More likely if you have a lot of contact with water

1. Ear drops containing Isopropyl alcohol (95%) and glycerin

Reduce water exposure

-Wear shower/swimming cap

-Wear ear plugs while showering

-Tilt affected ear downwards and gently shake water from ears

Should resolve in 4 days

Common cold

1. Presented with cough, sore throat, nasal congestion…

Explain + Cause:

-Viral infection of upper airways by various viruses e.g. rhinovirus

Transmission:

- Hand contact

- Breathing in large particle droplets from close contact with an infected person

- Small particle droplets from airborne particles that stays in the air for 5hrs

Patho:

- Virus attaches to receptors found along your airway, they could cause damage to your hair-like structures on your cells. This releases signals to cause inflammation in your airways.

Risk Factors:

-Crowded spaces

-weakened immunity(stress, sleep deprived, underlying medical condition)

- smoking

S&S:

- Sore throat, runny nose, sneezing, nasal congestion, cough

-Last for 7-14 days

-(rare) fever, muscle aches and pain

Complications:

-Acute rhinosinusitis

-Acute otitis media

-LRTI

-Asthma, COPD exacerbation

For symptomatic relief of runny nose:

1. H1 antihistamines e..g chlorpheniramine 4mg tabs, 1 tab 4-6 times a day if needed.

2. 2nd gen H1 antihistamines e.g. Fexofenadine 120mg 1 tab a day or Loratadine 10mg OD

For symptomatic relief of congestion:

1. Topical decongestants nasal spray e.g. Oxymetazoline 0.05% nasal spray 1-2 sprays into each nostril 2-3 times daily

2. Nasal saline

For oral combination:

1. Zyrtec-D cetirizine HCl 5mg Pseudoephedrine HCl 120mg 1 tab BDS (OM, ON)

1. Some side effects you may experience with this are drowsiness, dizziness, confusion, anticholinergic (dry mouth..) … take note if elderly, glaucoma patient. Avoid drinking alcohol.

2. Avoid drinking fruit juice with fenofexadine

3. This medication help you to relieve your congestion by constricting your blood vessels and reduce blood flow so that it reduces the mucus secretion. You may experience some side effects of skin irritation, burning, stinging or some dryness. Just dont use it too often. ALSO do not use for more than 5 days as it can cause rebound congestion whereby your congestion will actually get worse bc it may lead to inflammation of your nasal tissues. ALSO do not share this with others, point away from nasal septum.

To reduce bothersome symptoms and boost immunity:

- Drink more water

- Adequate rest

- Nutritious diet

Prevent transmission of virus:

- Practise good respiratory hygiene e.g. cover your mouth and nose when you cough or sneeze

- Practise Good Hand Hygiene e.g. wash your hands with soap, use hand sanitizers that contain 60-80% alcohol

Acute cough

Non productive cough:

Dextromethorphan or codeine

Productive cough

Fluimucil 600mg

Allergic rhinitis

COPD

Where relevant

Without Spacer

With Spacer

Preparing the device

• Remove cap (demonstrate)

• Hold the inhaler the right way (demonstrate)

• Check the dose counter to ensure that there are doses available (if applicable)*

• Shake the inhaler for 3-5 seconds

*Prime the inhaler before first use, or if not used for several days by spraying 2 puffs into the air

(cont’d from w/o spacer)

• Hold the inhaler the right way & attach it to the end of the spacer (demonstrate)

• If the spacer used for 1^st time, prepare by pressing the inhaler 10x (*check manufacturer instructions)

Administering a puff

• Breathe out all the way (away from the inhaler)

• Place mouthpiece between teeth (without biting) and close lips to form a good seal around the mouthpiece

• Breath in slowly through your mouth & press down firmly on the canister at the same time to release 1 puff

• Continue breathing in slowly & as deeply as you can

• Remove the mouthpiece & hold your breath for ≈10s/ as long as you can

• Breath out slowly away from the inhaler

*If need 2^nd puff, wait ≈1min b4 repeating steps to administer a puff

• If mask is used: place mask securely over mouth & nose. Ensure it fits tightly with no gap btw mask & your face

• If no mask is used: place the spacer mouthpiece in your mouth & seal tightly with your lips.

• Press canister the inhaler down once to release 1 puff of medication into the spacer

• Breath in & out normally through the spacer 5 – 10x. (caregiver can check technique via observing the opening & closing mvt of breathing valve) OR take a deep breath and hold for about 10 seconds then breathe out normally.

*NO NEED to take the spacer out of your mouth to exhale

*If need 2^nd puff, release another puff after 1min. Only one puff into the spacer each time

What to do after administering the dos

• Clean mouthpiece with a dry tissue & replace cap for storage

• Note down no. of doses left/ used if the inhaler does not have a counter, so a new one can be obtained before it runs out

• If you need to use more than 1 type of inhaler, use the reliever first. Wait for 5 minutes before using the next inhaler.

*After using corticosteroid containing inhalers, rinse your mouth with water, gargle and spit (do not swallow the water)

• Remove the spacer from mouth/face

• Clean the mouthpiece/mask with a dry tissue

• Remove the inhaler from spacer and cover with the cap

Cleaning

1. Only wash MDIs w/o dose counters

2. Remove metal canister from external canister holder

3. Soak external canister holder in warm soapy water for ≈30s/ wash under running water

4. Shake off excess water & allow it to air dry

5. Put metal canister back into dry plastic case

6. Test the inhaler by releasing a puff of medication into the air

*Wash 1x/ week

1. Dismantle spacer (if necessary)

2. Soak spacer in lukewarm water with few drops of liquid detergent for ≈15 min (depth of water just enough to submerge spacer w or w/o facemask

3. Shake off excess water & allow it to air dry

*Wash 1x/ month

✗ scrub/ place breathing valve directly under running water

✗ wipe dry with cloth (∵↑static in plastic container, may affect amt of medication received)

✗ rinse spacer as detergent ↓static charges

Preparing the device

• Remove cap (demonstrate) just b4 you are about to use

• Hold the inhaler the right way (demonstrate)

• Check the dose counter to ensure that there are doses available (if applicable)*

*Prime the inhaler before first use, or if not used for several days (Twist base as far as possible in 1 direction, twist it back in the opp direction until u hear a click. Repeat again. Inhaler is now ready for use) 🡪

• Load a dose (*check specific product instructions) twist the base as far as possible in 1 direction, twist it back in the opp direction until u hear a click)

✗ DO NOT shake inhaler

✗ DO NOT invert inhaler aft loading a dose

Administering a puff

• Breathe out all the way (away from the inhaler)

• Place mouthpiece between teeth (without biting) and close lips to form a good seal around the mouthpiece

• Breath in quickly & forcefully

• Remove the mouthpiece & hold your breath for ≈10s/ as long as you can

• Breath out slowly

*If need 2^nd puff, wait ≈ 1min b4 repeating steps to administer a puff

What to do after administering the dose

• Clean mouthpiece with a dry tissue & replace cap for storage

• Note down no. of doses left/ used if the inhaler does not have a counter, so a new one can be obtained before it runs out

*After using corticosteroid containing inhalers, rinse your mouth with water, gargle and spit (do not swallow the water) to avoid oral thrush

✗ wash with water; keep inhaler dry

Condition

Explanation/Cause

Medication given

Administration/Dosing/Device use/Counselling

** teach back

Non-pharmacological

Monitoring

CKD-associated anemia

Goal of treatment:

1. Epoetin Beta (Recormon) → 40 units/kg, 3x per week

1. Expectations: will take about 7-10 days for medicine

CKD-MBD Hyperphosphatemia

[NOT IN RUBRICS] Diagnosis

Your doctor has diagnosed you with anemia, meaning that you have a low red blood cell count in your body. The kidney plays a role in making new red blood cells and when the kidney is damaged, it can no longer make red blood cells. Red blood cells carry oxygen and when you have low amounts of it, you might feel a little more tired than normal. Not to worry, there are treatments for this such as what you have been prescribed.

*Name/dosage form/strength

Your new medication is an injection known as epoetin beta, also known as Recormon. It helps your body produce more red blood cells and you won’t feel as tired as before. The strength is 4000 IU and it is given via SC/IV injection.

*Purpose/benefit/onset

*Dosing/administration instruction

Dosing for HD patients:

• 40 units/kg (IV/SC) 3 times a week

Dosing for PD or pre-dialysis patients

• 20 units/kg (SC) 1-3 times a week

• Common starting dose: 4000 units SC one time a week or IV 3 times a week

To inject it, use your thumb and index finger and pinch about 5cm of skin in your stomach/thigh and inject (number of syringe) into the skin.

*Duration and quantity dispensed

Recormon has been prescribed for 1/2/3 months and there will be (number) syringes in total.

*Assess and address possible non-adherence (as relevant)

It is important to take this medication even if you do not feel anything as production of red blood cells is an ongoing process and this medication helps it

*Advice on missed dose (as relevant)

If you miss your dose or forget to inject your medication, inject it as soon as you can. However, if it is almost time for your next injection, wait until then and skip the missed injection. Do not double your injection to make up for a missed injection.

*Appropriate storage (as relevant)

This should be stored in your refrigerator at 2-8°C but do not freeze and protect from light

Are your following me so far?

*Common SE and ways to manage (as relevant)

Some side effects include increased in BP, stomach upset, vomiting, diarrhea, fatigue, shortness of breath and headaches

• Increase in BP: check BP regularly

• Pain or swelling at injection area: change area of injection frequently to reduce pain and swelling

*Rare but serious SEs requiring immediate medical advice and ways to manage (as relevant)

Painful, swelling redness of legs, slurred speech, vision changes, chest pain: if any of these occurs, seek medication immediately.

These may sound scary, but I would like to assure you that these side effects are very rare

*Interactions (DDI/supplement/food) (as relevant)

Poorly controlled hypertension

*Monitoring parameters (as relevant)

Measure Hgb every 1-2 weeks following initiation/dose change

After target stable Hgb and EPO dose, monitor Hgb at least monthly (HD), every 3 months (other CKD patients) -> this also means that when you come back to see the doctor, you will be doing blood tests

[NOT IN RUBRICS] Non-pharmacological management

No specific ones for anemia, but for CKD:

• Smoking cessation

• Maintain protein intake of 0.8g/kg/day in DM and CKD pts not in dialysis. HD and PD pts should consume 1.0-1.2 g/protein/kg/day

• Na intake of < 2g

• Moderate intensity physical activity (at least 150min a week) or best tolerated -> avoid sedentary lifestyle

Main dispensing label

Title: Brand name, pack size, total quantity dispensed, active ingredients and strength

Body: Dosing instruction (dose, frequency, route, duration), Pertinent administration instructions (e.g. before or after food)

Others:

Patient name (ref. no.)

Date dispensed (expiry date)

External

Internal

For external use only (dermatology)

This medicine may cause drowsiness & may increase the effects of alcohol. If affected do not drive a motor vehicle or operate machinery.

Shake the bottle (suspensions)

Shake the bottle

Store in a cool place (< 30˚C)

Store in a cool place

Not to be taken (non-oral)

Sip & swallow slowly (linctus)

Not to be taken in large quantities (mouth gargle)

For nasal/ rectal/ vaginal use only

Eye drops

Non-oral, gels, creams, suppositories etc.

4 Xalatan 0.005% Eye Drops (2.5mL/ bottle)

Latanoprost 0.005% (1.5mg/ drop)

Instil 1 drop into the RIGHT eye ONCE every night.

Discard unused eye drops 4 weeks after opening.

Name: Kent See Date: 10/02/2022

Ref no.: 103 Expiry date: 08/12/2024

Precaution labels:

1. Refrigerate, do not freeze

2. Not to be taken orally

3. Protect from light

2 Dermasone 0.1% Cream (15g/ tube)

Betamethasone Valerate 0.1% w/w

Apply a thin layer to the affected skin TWO times a day for 2 weeks,

then when necessary (when eczema flares).

Name: Yang Yang Date: 10/02/2022

Ref no.: 103 Expiry date: 10/11/2024

Precaution labels:

1. For external use only

2. Store in a cool place

1 Voltaren (Diclofenac) Emugel 1% gel 50g/tube

Apply and massage on the left knee three times a day, when required to relieve pain.

Name: John Payne                    Date: 20/01/2022

Ref No.: TOP-NSAID-1           Exp Date: 30/01/2024

Precaution labels:

1. For external use only

2. Store in cool dry place

112 KefenTech Plasters (Ketoprofen 30mg/patch)

Apply 1 patch to each knee two times a day when necessary to relieve pain, for 4 weeks.

Name: Yang Yang Date: 10/02/2022

Ref no.: 103 Expiry date: 10/11/2024

Precaution labels:

1. For external use only

2. Store in a cool place

Inhalers

Tablets

1 Ventolin 100mcg Evohaler (200 actuations/ inhaler)

Salbutamol 100mcg/ actuation

Inhale 1-2 puffs by mouth THREE times a day/ every 4-6 hours, when necessary, to relieve shortness of breath

Name: Chin Chia Chuan Date: 15/03/2023

Ref no.: 103 Expiry date: 31/08/2025

60 Singulair 4mg Chewable Tablets

Montelukast (4mg/ tab)

Take 1 tablet by mouth, ONCE every night.

Chew the tablet before swallowing.

Name: Brandon Lee Date: 15/03/2023

Ref no.: 103 Expiry date: 31/09/2026

2 Anoro 62.5/25mcg Ellipta (30 puffs/ellipta)

(Umeclidnium 62.5mcg, Vilanterol 25mcg/Puff)

Inhale 1 puff by mouth once in the morning for 2 months.

Do NOT shake the ellipta.

Name: Beh Chuan Kui Date: 29/03/2025

Ref no.: 90/01 Expiry date: 31/07/2025

Liquids

1 Pulmicort Turbuhaler 100mcg Evohaler (200 actuations/ inhaler)

Budesonide 100mcg/ actuation

Inhale 1 puff by mouth TWO times a day for 2 months.

Rinse mouth with water after each use

Name: Tan Xiao Ming Date: 15/03/2023

Ref no.: 103 Expiry date: 31/10/2025

2 Nurofen suspension Ibuprofen (60mL/bot)

Ibuprofen 100mg/5mL

Take 7.5 mL every 6 hours as required for fever

Name: Xiao Hai Zhi    Date: 20/01/2022

Ref No.: DISP1-Case-4          Exp Date: 30/01/2024

Precaution labels:

1. Store in a cool dry place

2. Shake before use

Abbreviation

Meaning

O/ QD

Once a day

BD

Twice a day

T/ QDS

Three/ four times a day

OM/ N

Every morning/ night

EOD

Every other day

h. s.

At bedtime

a./ p.c

Before/ after meals

(numeric) H

hourly

prn.

When required

o.d./ s.

Right/ left eye

Abbreviation

Meaning

3/7

3 days

2/52

2 weeks

7/12

7 months

Action

Dosage form

Take

Tablet/ capsule

Swallow whole, do not chew

Timed/ sustained release

Chew before swallowing

Chewable oral

Put under tongue

Sublingual tablet

Suck

Lozenge

Dissolve … in water before taking

Effervescent tablet

Administer puff/ spray

Oral inhaler/ nasal spray

Instil drops

Eye/ nose/ ear drops

Insert

Suppository/ pessary

Inject

SC insulin

Patient information

Jessica Chan 28y/o Female Chinese

Subjective

Chief complaint (CC): worsening acne vulgaris for the past 2 weeks

History of Presenting Illness (HPI): long standing acne vulgaris on her face since teenagers years with moderate scarring, maintained on EPIDUO. Reported new papules and pustules spreading to her shoulders and back in the last 2 weeks, accompanied by more papules and pustules pn her face. She has been applying EPIDUO to newly affected areas on shoulders and back with minimal improvement. Patient believes to be related to increased stress from starting new job

Past medical history

Acne vulgaris

GERD

Patient medication list

EPIDUO topical gel apply to affected areas once daily

TUMS Regular strength 2 tablets PO PRN

Allergies

NKDA

Social history

Does not smoke or drink alcohol

Family history

NA

Objective

Physical exam is normal except for numerous papules and pustules on face, shoulder and back which appear red and inflammatory

Assessment

1. Acne vulgaris

- Applied EPIDUO to newly affected areas on shoulders and back with minimal improvement (Worsening symptoms on epiduo)

- Starting Doxycycline 200mg PO BD but dose higher than recommended

2. GERD

- Well controlled on TUMS prn

Goals of therapy

Reduce the papules and pustules on the face, shoulders and back

Reduce or minimize scarring on the face

Plan

1. Acne vulgaris

Recommend to start on Doxycycline 100mg PO BD instead of 200mg

Administration: take with water after food

Managing side effects: use sunscreen

Non-pharm: relieve stress by doing breathing exercises, eat less high in sugar food, do not touch or squeeze the papules and pustules, cleanse face 2 times a day

Monitor: improvement in papules and pustules on face, shoulder and back, side effects e.g. photosensitivity of skin

1. GERD

Continue on TUMS Regular strength 2 tablets PO PRN

Non-pharm: eat less spicy/fatty/acidic food, avoid eating food 3 hours going to bed,eat smaller meals and elevate the head end of the bed

Monitor: maintenance of low or no symptoms

Follow-up

Return to clinic in 3 months after starting doxycycline

Patient information

Mr Don Wan Yoke

52

Male

Chinese

Subjective

Chief complaint (CC): Hypertensive emergency – severe headaches and dizziness, raised SCr, presenting BP 180- 200/100mmHg

History of Presenting Illness (HPI): Feeling down due to losing his job. Developed persistent dry cough, looked up the internet and figured it was his ramipril. While at it, looked up on nifedipine LA and saw that it could cause “lower limb swelling”. As he was busy job hunting, he did not want “anything to get in the way of finding another job”. Furthermore, his company doctor prescribed him proprietary Adalat LA and Tritace which he felt was expensive. He stopped both his medicines because he “felt fine” a week back.

Developed headaches and dizziness about 2 days ago and decided to come to A&E because it was affecting his ability to concentrate on driving his two young children around.

Past medical history

Hypertension

Patient medication list

Nifedipine LA tablet 30mg PO OM

Ramipril tablet 5mg PO OM

Allergies

NKDA

Social history

Married, 2 children aged 10 and 12yo, lives in a 5-room HDB flat. Wife works as a personal assistant to a director in an NMC. 52yo technician who has been in events and sound-mixing since graduating from polytechnic. Smoker, and started taking approximately 6 cans of beer a week.

Family history

Nil

Objective

Creatinine was slightly raised

No brain bleed on CT brain scan

BP since admission 180–200/100mmHg

RP SCr 156 micromol/L (elevated) , K 4.0mmoL/L, Ca (total) = 1.80 mmoL/L

Assessment

1. Hypertensive Emergency (presents w v high BP but no organ damage yet - target organ damage starting)

   1. Presented with dizziness, severe headaches, raised SCr

   2. Likely due to non-compliance of medications

   3. Goal BP still not reached

Goals of therapy

• Lower BP to 130/80mmHg (final goal w/ comorbs)

• Start by aiming for <140/90mmHg by next visit

• Next visit in 1 month for reassessment

1. Maintain BP target of 130/80mmHg (52 yo considered young) before going home

   1. dont drop BP so fast → they’ve been on it for a certain amount of time → if drop BP too fast, extent of perfusion decreases [dangerous circulation]

   2. drop by 25% in the 1st hour

   3. 160/120 mmHg within next hour

   4. drop to target BP within the next 24-48 hours

   5. after: maintain at 130/80mmHg

2. Improve adherence to medication (counselling)

Plan

Pharmacological Management:

• Add frusemide 40mg PO OM

  • Consider CCB first

  • Restart ACEi/ARBs only if the SCr and K+ is okay (on discharge)

  • (Parenteral given first in ICU) IV glycerol trinitrate/labetalol - continuous infusion (titrate dose up and down more easily to ensure BP does not drop too drastically) → transit to oral after under control

  • change from proprietary to generic brand (more affordable)

  • Restart Nifedipine LA (dose? frequency?)

  • ACE/ARBs, BB, CCB, thiazide-like Diuretics (nope cuz SCr)

  • Hydralazine 100mg TDS → relatively fast onset but shorter duration of effect → need to take frequent doses, Nitric oxide

Non-pharmacological management:

• Post-discharge: Home BP monitoring

  • 150 mins of moderate exercise per week

  • Quit smoking (smoking cessation)

  • Reduce alcohol

  • Educate patient on purpose of his medications

  • DASH diet

  • Counsel to take his medications diligently can not stop when he “feels fine”

Monitoring parameters: BP, SCr, K

Patient counselling: ensure patient understands what HTN is and complications that can arise from it take note of SDM

Follow-up

Check BP, aim to lower to 140/90mmHg within 1 month

Ensure no significant side effects such as angio-edema

Patient information

Tammy Lim 52 y/o Female Chinese

Subjective

Chief complaint (CC): No chief complaint

History of Presenting Illness (HPI): diagnosed with hyperlipidemia for newly diagnosed hyperlipidemia in nov 2021

then adopted dietary lifestyle modifications, comes today for repeat lipid panel and consultation

Past medical history

Hyperlipidemia

Type 2 Diabetes mellitus

Patient medication list

Metformin tablet 500mg PO TDS

Allergies

NKDA

Social history

do not smoke or drink alcohol

Family history

NA

Objective

LDL is 3.6 mmol/L which is higher than target of 2.6mmol/L

AST and ALT are normal

CK is normal

Physical exam is normal

Assessment

Goals of therapy

Reduce LDL to target of <2.6mmol/L

Plan

1. (condition 1)

2. (condition 2)

Follow-up

Patient information

Subjective

Past medical history

Patient medication list

Allergies

Social history

Family history

Objective

Assessment

Goals of therapy

Plan

1. (condition 1)

2. (condition 2)

Follow-up

Patient information

Subjective

Past medical history

Patient medication list

Allergies

Social history

Family history

Objective

Assessment

Goals of therapy

Plan

1. (condition 1)

2. (condition 2)

Follow-up