1
Q
Primary Headaches: Episodic
A
- Tension Headache
- Migraine Headache
- Sinus Headache
- Rebound Headache (chronic daily headache)
2
Q
Secondary Headaches
A
- Head Trauma
- Vascular deficit (aneurysm, bleed, etc.)
- Substance Abuse
- Infection (meningitis)
3
Q
Don’t treat a headache that…
A
- Severe, “worst of my life”
- Going on for longer than 10 days
- Pregnancy, especially 3rd trimester
- could be sign of preeclampsia
- Kids
- Infection, fever, secondary HA’s
- ETOH abuse, caution with acetaminophen
- can use, just dose appropriately
- Non-diagnosed migraine
4
Q
Tension Headache
A
- Symptoms
- myofascial pain (muscle pain)
- bilateral
- diffuse
- radiating
- tight
- pressing
- **cap’s too small **
- Duration: minutes to days
- Onset: **gradual **
- Secondary to:
- Stress
- Anxiety
- Depression
- Emotional Conflicts
- Fatigue
- More in women than in men
- Treat with APAP, NSAIDs, salicylates
- Right when starts
- Physical therapy and relaxation exercise
5
Q
Migraine
A
- Complex interaction of neuronal/vascular systems
- Symptoms:
- With or without **aura **
- wavy/flashing lights
- Unilateral/bilateral
- Throbbing
- Hours-Days
- With or without **aura **
- Lots of triggers
- Rx:
- Abortive: triptans, aspirin/caffeine, ergots
- for now and again headache
- Prophylactic: TCA’s (tricyclic antidepressant), ß-blocker, CCB (calcium channel blocker), etc.
- more frequent
- Symptomatic: Aspirin, APAP, NSAIDs, opiates, sedatives, anti-emetics
- Need medical diagnosis before treating
- Avoid giving shot of morphine
- Go to bed and lie down
- Treat at early onset
- Abortive: triptans, aspirin/caffeine, ergots
- Non-Pharmacologic
- Sleep, nutrition, cope with stress
- Avoid Mg supplements, nitrates, tyramin, phenylalanine, MSG, caffiene
6
Q
Sinus Headaches
A
- Nasal passageway and sinus opening swelling/obstruction due to trauma, allergies, infection
- Location
- Face, forehead, periorbital area
- Due to trauma, allergies, sinus infection
- Pseudoephedrine works best to relieve this headache
7
Q
Rebound Headache
A
- AKA: Chronic Daily Headache
- Occurs after 3 mo. of analgesic use (any analgesic)
- Notice in the morning > rest of day
- Tapered decrease in analgesic use
- Small dose of tricyclic so they sleep well at night and get over it
8
Q
Lower Back Pain
Goals of Therapy
A
- Decrease pain and discomfort
- Prevent ongoing damage
- Don’t do any harm
- Get back to normal routines
- Back pain from out of shape
- Don’t let them just lie around
- Back pain from out of shape
9
Q
Lower Back Pain: Exclusions
A
- Chronic (>2 weeks)
- 3rd trimester of pregnancy
- Kids <7 yo
- Fever/infection
- Numbness/Tingly
- Loss of bowel/bladder function
- need to elimate spinal cord injury
- Limited time to deocmpress w/o permanent damage
- Severe pain
- Pain that continues 10 days after treatment
- Increased intensity or change in character
- Pelvic/Abdominal pain
- Visually deformed joint, abnormal movement, weakness in limb, suspected fracture
10
Q
Lower Back Pain: Red Flags
A
- Numbness/Tingling
- Referred pain from internal organs
- Cancer: weight loss; over 50 yo/under 16yrs; night pain or at rest; failure to improve; persists>6 weeks
- Infection Related: Fever, IVDA (intravenous drug abuser), recent infection, immunocopromised
- Cauda Equina Syndrome:
- Note: waiting >72 hours to decompress risks permanent neurological deficit
- Vertebral Fracture: Steroids, mild trauma at >50yo, >70 yo, osteoporosis, significant trauma
- Acute Abdominal Aortic Aneurism: abdominal pulsating mass, ASCVD (ateriosclerotic cardiovascular disease), pain at rest or noctural pain, >60 yo, smoker
11
Q
Pain Types
A
- Acute Pain:
- Pain that comes on quickly, can be sever, bust lasts a relatively short time
- Chronic Malignant Pain:
- Associated with advanced, progressive disease (often fatal) such as cancer, MS, AIDS, and terminal kidney disease
- Chronic Non-Malignant:
- Begins as acute pain, but it continues beyond the typical time expected for resolution of the problem or persists, or reocurrs for other reasons
12
Q
Lower Back Pain: Treatment
A
- RICE
- rest, ice, compression, elevation
- Ice 10 min 3-4x daily
- NICE
- NSAIDs, ice compression, elevation
- Step Approach (adjuncts):
- NSAIDs, capsaicin, anesthetics, TCA, gabapentin, opiates
- Topical methyl salicylate 10% (counter irritant)
- Capsaicin takes 1+ weeks to begin working
13
Q
Osteoarthritis vs. Rhumatoid Arthritis
A
- Osteoarthritis:
- Dull pain, stiffness in knees, hips, spine, hands, weight-bearing joints, and typically uni-lateral (can be bilateral)
- Rheumatoid Arthritis:
- Swollen, tender, warm , symmetrical pain in hands, wrists, fingers
- Aggravated by movement
- Worse in the **morning **
- Needs prescription
- Psoriasis has arthritis associated
14
Q
Joint Pain: Self-Treatment Exclusions
A
Same as those in backpain:
- Chronic (>2 weeks)
- 3rd trimester of pregnancy
- Kids <7 yo
- Fever/infection
- Severe pain
- Pain that continues 10 days after treatment
- Increased intensity or change in character
- Pelvic/Abdominal pain
- Visually deformed joint, abnormal movement, weakness in limb, suspected fracture
15
Q
Joint Pain: Treatment
A
- APAP
- Topical analgesic
- Casaicin: take over a week to begin working
- Topical methyl salicylate 10%: possible counter irritant but immediate effect
- NSAID (only when inflammation is present, prostaglandins needed for healing too)
- Glucosamine
- Very safe, placebo effect
- Kills pancreatic cells, increasing risk of developing diabetes
- SAM-e
- very safe, may be helpful
- less joint space narrowing
16
Q
Tennis Elbow (Tendonitis)
A
- Symptoms:
- warm, swollen, red , tender, pain with extension
- Nonpharmacologic Treatment
- Palm-up lifting-No
- Forearm Band
- RICE, NICE won’t be effective
- Pharmacologic Treatment
- Ibuprofen, but need Rx dose
- Topical Analgesic
17
Q
NSAIDs and inflammatory disease or acute muscle injury
A
- NSAIDs may be preferred for self treatment
- Aspirin must be dosed near the self-care max in order to achieve anti-inflammatory response
- Recommend naproxen to treat swelling and pain, acetaminophen will only treat pain
18
Q
Fever: Symptoms
A
- Temporal greater than 100.1
- Oral greater than 99,7
- Add one degree to oral temperature to get rectal/tympanic temperature
- Subtract one degree from oral temperature to get axillary temperature
- axiallary>oral>rectal/tympanic
- **Don’t Treat Numbers **
19
Q
Fever: Self-Treatment Exclusions
A
- >6 month and 1040
- <6 month and 1010
- Systemic Infection
- Hyperthermia risk
- Impaired oxygen utilization (COPD, resp. distress, heart failure)
- Immpaired Immune function (cancer, HIV)
- CNS damage (head trauma, stroke)
- Children with history of febrile seizures/seizures
- Be more aggresive at treating in order to avoid and have a full work up done
- Children who are vomitting/cannot keep down fluids and are very sleep/irritable/hard to wake up
20
Q
Fever: Non-Pharmacologic Treatment
A
- Adequate fluids to prevent dehydration
- Wear light clothing
- Remove blankets
- Maintain room temperature at 680F
- Increase fluid uptake 50-100 mL/hr
21
Q
APAP dosing/info
A
- Acetaminophen
- Tylenol
- Works in CNS, pain & fever
- NOT anti-inflammatory
- Child
- 10-15 mg/kg q4-6h
- Not to exceed 5 dose in 24 hours
- Adult
- 325-1000 mg q4-6h
- Max 3000 mg
- With moderate drinking, max 1500 mg
- Male <2 a day
- Female <1 a day
- Cautions:
- Liver damage
- Analgesic of choice for warfarin patients
- Best for pregnant women
- Best for elderly and those with hypertension
22
Q
NSAIDS dosing/information
A
- Naproxen (Aleve), Ibuprofen (Advil, Motrin)
- Peripheral COX inhibitors
- Pain, fever, high doses for swelling
- Ibuprofen:
- Child: 5-10 mg/kg q6-8h, not to exceed 4 dose in one day
- Adult: 200-400 mg q4-6h (1200 mg max)
- Naproxen:
- Child not recomended for children less than 12
- Adult: 220 mg q8-12h (660mg max)
- Ibuprofen slightly better for fever…not much difference
- Don’t use if history of ulcer/GI bleed
- Avoid with Gout
- Caution: risk for heart failure, hypertension and stroke.
- Asthma, Nasal polyps, aspirin allergy->AVOID
23
Q
Asprin Dosing
A
- COX inhibitor
- GI ulcer, HBP, CHF, kidney disease, gout, avoid
- Avoid in pregnancy
- Reye’s Syndrome
- Children under 15
- Fever, aches and pains
- Asthma, nasal polyps
- Dosing:
- Children: Not recomended
- Adult: 650-1000mg q4-6h (4000mg)
24
Q
Douching
A
- NOT GOOD
- black, little education, incarcerated adolescents
- Increased risk of PID, reduced fertility, ectopic pregnancy, vaginal infections, STI, low birthweight infants, cervical cancer
- irritation
- disrupt normal flora and pH
- Tactfully discourage
25
Atrophic Vaginits
* **Symptoms:**
* dyspareunia, lack of adequate vaginal lube
* irritation, dryness, burning, itching, leuokrrhea (milky white discharge)
* Incontinence in older
* **Cause**
* Low estrogen levels
* **Treatment:**
* Lubicrant products
* water soluable
* Sexual activity
* Dryness: estrogen
* unopposed estrogen associated with endometrial cancer
* vaginal estrogen very well absorbed
* Exclusions:
* postmenopausal bleeding
* especially if bleeding and on estrogen
* Not relieved by lubricants
* Symptoms that are not localized
* Severe vaginal dryness or dyspareunia
26
PMS
* **Behavioral:** fatigue, irritable, depression, etc.
* **Physical**: bloating, breast tender, acne, appetite changes, headache
* Sign: **bad before period and goes away with start of menses**
* ****Very dramatic, may be PMDD, need referral
* Treatment:
* Charting
* mark days of symptoms and days of period
* Education, diet modification, exercise, stress managment
* **Vitamin B6 and Calcium and Vitmain D**
* Mood
* B=100mg, C and D=1000mg
* **Vitamin E**
* Breast tenderness'
* **NSAIDs**
* Headache
* Midol and Pamprin is a bunch of crap
* diuretics don't work
27
Dysmenorrhea
* Primary: associated with cramp-like abdominal pain without pelic disease
* within 6-12 months of menarche
* less likely after 25 yo
* Severe pain, miss school
* Secondary: associated with pelvic pathology
* IUD can cause
* Secondary needs a cause/source
* **Primary Clinical Presentation**:
* Dull pain and cramping
* N/V/D
* irritability and headache
* at the start of menses
* **Non-Pharmacological Therapy**
* Heat, exercise, massage, sleep
* Omega-3-FA
* **Pharmacological Therapy**
* ****Not aspirin or acetaminophen due to Reyes and CNS
* NSAIDs
* prostaglandins have a short half-life, so can work at onset
* perhaps oral contraceptive pilll
28
Vulvocaginal Candidiasis (yeast)
* Classic Symptoms:
* Thick, white "cottage cheese", no odor discharge
* Normal pH
* redness, **itching**, swelling
* might be from immunosuppresant or antibiotics
* Treatment
* not treat partner
* Non-pharmacological
* Decrease refined sugar, eat yogurt
* Pharmacological
* Avoid 1 day treatments
* Should improve within 2-3 days
* If itch, use cream
* **miconazole**, clotrimazole, butoconazole, tioconozole
* nystatin=yeast only=not good choice
* fluconazole=last a long time in the body
* may need to use another course if on antibiotics
* **Drug interactions**
* warfarin and miconazole
* warfarin and flucanazole
* **Exclusions:**
* Preganancy
* Girls less than 12 yo
* fever and lower belly pain
* uncontrolled/undiagnosed diabetes, HIV infection
* recurrent (\>3 VVC/year or within the past 2 months)
29
Bacterial Vaginosis: BV
* Symptoms:
* **thin, water discharge**
* **off-white or discolored**
* **fishy smell**
* irritation
* **dysuria**
* itch
* Risk Factors:
* new partner, IUD, smoking
* Treatment:
* Requires referral
* No treatment of partner
* change in normal flora, not necissarily an STD
* Common
30
Trichomoniasis
* Symptoms
* **Smelly, yellow-green discharge**
* Pruritius
* Erythema
* Edema
* Risk Factor:
* Multiple Sex partner, new sex partner, unprotected sex, other STI
* Treatment
* Require referral, reportable disease
* **Treat partner**
* Tinadazole
31
Toxic Shock Syndrome (TSS)
* Symptoms:
* **Red rash on palms**
* **low blood pressure**
* cramps
* nausea
* **dizziness**
* Day 2-3: **fever**, vomitting, dizziness
* Within 2 days of menses, using super absorbant tampons
32
Allergic Rhinitis
* Signs and Symptoms
* Watery eyes; itchy nose, eyes or throat, sneezing, nasal congestion, runny nose
* Best is avoidance
* Nasal saline irrigation, HEPA filter
* Recommended OTC
* Antihistamines
* 1st generation: benadryl (diphenhydramine)
* sedative,
* 2nd generation, claratin (loratidine), allegra (fexofenadine), zyrtec (cetirizine)
* non-sedative
* weak, good for mild allgery
* **Inhaled corticosteroids**
* Flonase (fluticasone) and triamcinaclone
* **when taking this, don't need antihistamine**
* Exclusions:
* Signs of otitis media, sinusitis, lower respiratory problems
* history of non-allergic rhinitis
* narrow-angle glaucoma
* \<12 yo
* pregnant or lactating
* Other Info:
* Only treat most prevalent
* itch: require sedating antihistamine, can use zyrtec due to minial sedation
33
Cold
* **Signs and Symptoms:**
* Sore throat, nasal congestion, runny nose, sneezing, low fever, chills, headache, possble cough
* Exclusions
* Fever \>101.5
* Chest pain
* Sign of bacterial infection
* COPD
* Not improve in 7 days
* AID/Immunosuppresed
* Infant \<2 yo
* Frail/elderly
* Nonpharmacologic:
* fluid, rest, toilet
* Echinacea at the 1st signs/symptoms
* Recommended OTC:
* **Jolly ranchers**
* instead of local anesthic like benzocaine
* **Decongestant**:
* pseudophedrine, (systemic) oxymetazoline (LA), ephedrine, pheylephrine (topical)
* AVOID selling phenylephrine (systemic), degraded in liver and not reach nose (ex: sudafed-PE)
* **Antitussive**:
* dextromethorphan: 6-8 hrs, not constipative, not sedative
* codeine: 4-6 hour, constipative, sedative, use for sleep
* (benzonatate (Tessalon perle))
* **Expectorants**:
* Guanisefen: witchcraft
* **Analgesics**
* Not aspirin
* Other Notes
* No cold preps for kids under 4
* Honey works such as well to soothe throats
* Treat symptoms as they come instead of using combo products
* Echinacea not for those on immunosuppressants
34
Influenza
* Signs and Symptoms
* Aches and Pains, myalgia
* Fever
* Sore Throat, cough, fatigue
* Use same method as cold
35
Rhinitis Medicamentosa (Rebound Congestion)
* Signs and Symptoms:
* Stuffy nose due to overuse of decongestants
* Treatments
* Quit cold turkey
* Leversee method
* one nostril at a time
* Long-Term: use steroidal nasal spray for allergies
36
Asthma
* Signs and Symptoms
* Wheezy, cough, shortness of breath
* cough could be only symptom
* Don't sell primatene mist or tablets
* Refer for MDI
37
Cough
* Exclusions
* Fever\>101.5
* history of underlying disease associated with cough
* COPD, chronic bronchitis, CHF
* Suspected drug associated cough
* cough\>7 days
* uninteded weight loss
* drenching nighttime sweats
* OTC
* codeine 10-20 mg q4h
* constipative, sedative
* dextromethorphan 10-20 mg q4h
38
Strep Throat Considerations
* Must have at least two of the three:
1. Sore Throat
2. Tender Lymph Node
3. Pus on tonsils
* If there is a cough, then NOT strep
* 1 to 2 year olds don't get strep
* May be associated with fever
Pharm 558
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