Class 7 Flashcards
Your next patient is a 60 year old man who is a known case of IHD. He has come to you for a medication review. He is on simvastatin, paracetamol, allopurinol, aspirin, and temazepam. His cardiologist recently added diltiazem.
Tasks:
Take history from his son for 3 minutes
Request report from pharmacist
Explain the report and required actions to his son
Open-ended question
Explore Ischemic Heart Disease
D: When was your father diagnosed with heart disease?
D: Is he compliant with his medications and taking them regularly?
D: Has he noticed any side effects of these medications?
D: Does he have any chest pain or shortness of breath on exercise?
Key point: Geriatric Screening (medication compliance)
D: Does he have any memory problems?
D: Who does he live with at home?
D: Does he have enough support?
D: Any recent falls or head injuries?
D: How’s his mood been lately?
Statins
D: Does he have any muscle aches?
D: Has he had any weakness?
D: Does he have dark urine?
Diltiazem
D: Do you know why the specialist added the diltiazem?
D: Does he have swelling in the legs?
D: Does he have constipation?
Aspirin
D: Does he have any heart burn or abdominal pain?
Temazepam
D: How long has he be on temazepam?
D: Why was he started on this medication?
D: Has he increased the dose recently to get the same effect?
D: Has he ever tried to stop taking the medication?
D: Did he have any symptoms like sleep problems, anxiety, nausea, seizure?
Gout History
D: Is he drinking alcohol?
D: Can you describe his diet for me?
D: Is he taking a lot of red meat, seafood?
D: Has he had any rash? (SJS as side effect)
Report from Pharmacist:
Diltiazem can elevate simvastatin and cause liver damage and rhabdomyolysis
Temazepam
D: Thank you for answering my questions. I have read the pharmacist report.
The main interaction is with the new medication diltiazem and the fat lowering medication simvastatin. This interaction increases the risk of damage to the liver and a serios condition called rhabdomyolysis which is a severe inflammation and breakdown of the muscle tissue.
Simvastatin is an essential medication for people who have heart disease as it lowers the fat in the blood and prevents future heart attacks and worsening of the heart disease.
Diltiazem is a medication that mainly affects the blood pressure. I will need to talk to his cardiologist and ask why he started his medication. In case it was started because of a high blood pressure, we have better options like ACE inhibitors.
I will arrange a meeting with you and your father, the specialist and me to talk about this.
Temazepam is a sleeping pill from a group called benzodiazepines. This medication can cause dependence and the body gets used to it. If we want to stop it, we would have withdrawal symptoms such as sleep problems, anxiety, nausea, and the most severe form a seizure.
We will plan to stop it:
I will change to another medication for the same group called diazepam. Stopping this tablet will give him less withdrawal symptoms (diazepam is long-acting)
We will do tapering of the dose, meaning we will decrease the dose every 1 - 2 weeks by 15-25%.
We will do a supervised review plan: get script from one doctor, one pharmacy, and we will do small scripts
I’ll refer him to a psychologist for cognitive behavioral therapy to help him with sleep hygiene
I will give you a sleep hygiene fact sheet
Allopurinol is used for gout. I will check his uric acid level to make sure that it is in the target range of below 0.36. I also want him to avoid red meat, seafood, sugary drinks, alcohol especially beer, and to be well hydrated to decrease the chance of a flare up
Aspirin irritates the food pipe and the stomach and we need to use this medication lifelong. For this reason, I’ll give him pantoprazole to decrease the acid production in his stomach.
I will give him a Webster pack. This is a medication pack that the pharmacist places the tablets needed in each day in one compartment. This improves the compliance to the medication. Since he’s taking more than 5 medications, it may be difficult for him to remember all his medications.
If you get extra time: Lifestyle Modification for IHD
Your next patient is a 28 year old lady who has come to your GP. She had a seizure 4 months ago and was diagnosed with epilepsy. Her neurologist has started her on antiepileptic medication and she has come to you today to discuss about her driving license.
Tasks:
Take history from patient for 4 minutes)
Counsel the patient accordingly
Open-ended question
D: Hi, my name is ____. I’ll be taking care of you today. How may I help you?
D: Are there any specific concerns that you want to address today?
D: I understand your concern. But is it okay if I just ask you a few questions
Explore the Epilepsy
D: When were you diagnosed with epilepsy?
D: When was the last time that you had a seizure? (key point 1)
D: What treatment are you taking?
D: Are you compliant with your medications? Are you taking it regularly and on time? (key point 2)
D: Why are you not taking this medication?
D: Have you had any side effects with this medication? Any weight gain, headache, nausea?
D: Are you seeing your specialist regularly?
Risk factors (key point 3)
D: Do you drink alcohol? How much and how often?
R: I drink 5-6 glasses of wine on the weekends?
D: Do you use any drugs?
D: Are you using any other medications or supplements?
D: Do you have regular and adequate sleep every day?
Key point 4:
D: Do you drive a private vehicle or a commercial vehicle?
D: May I know your occupation?
Psychosocial
D: How is your mood?
D: How are you coping with your diagnosis?
Counselling
I understand that you are having a tough time using the public transport. The reason we have asked you stop driving is concerns about public safety and your own safety in case you have a seizure while you are driving.
Once we start treatment for a patient diagnosed with epilepsy for the first time:
We need to wait for 6 months to allow enough time to make sure that the medication is working properly
And there has been no seizure episode in the past 6 months
Being compliant to your treatment and medication is critical. We will not be able to approve a conditional license if you are not compliant to your medication
In your case, you are eligible for a conditional license if you have been treated for 6 months and you have been compliant to treatment and there has been no seizures in the last 6 months. I’ll book another appointment for you in 2 months’ time.
You will need annual reviews.
There are some triggers that increase the risk of having a seizure:
Please avoid alcohol as much as possible. If you will drink, drink less than 4 standard drinks
Avoid drugs
Have a regular sleeping pattern and schedule as lack of sleep increases the risk of another seizure
Always tell your GP and pharmacist that you are taking epilepsy medications
I will give you some reading material from the Fit to Drive website. I will also discuss this with your neurologist and get an opinion from him. In case you continue not taking your medication regularly, the driving license authorities might ask you to do regular tests to check the medication level in your blood.
*if they change the case:
Epilepsy diagnosed in childhood, well-controlled. Had an episode of seizure recently.
Ask the patient not to drive for 4 weeks (if there is a triggering factor) before reassessment
If there is NO triggering factor, assess in 3 months
Your next patient is a 25 year old lady who has presented to your GP complaining of severe headaches. She has had 8 episodes in the last 12 months. The headaches are one sided and accompanied by nausea and photophobia. She give history of getting the headaches after drinking wine. There is no history of blurring of vision, no loss of weight and no vomiting. She has done a brain MRI which is normal.
Tasks:
No further history
Explain diagnosis to the patient
Explain your management plan to the patient
Open-ended question
D: Hi, my name is ___. How can I help you today?
Address concern
D: I’m so sorry that you’re going through this.
D: Is there any concern that you want me to address today?
Diagnosis
You are having a condition called migraine headache. This is a type of headache which usually happens on one side, with nausea, light sensitivity, see sparkling/flashing lights.
We are not sure about the exact cause, but we believe it happens because of dilation of the blood tubes in your brain.
As you had a long-term and severe headache, we made sure there are no brain tumors by doing a scan called an MRI, which in your case it is normal.
Management
To treat this condition:
I can give you some medications.
We usually do a step-wise treatment.
I want you first to try to take simple painkillers like ibuprofen
I can also add some medications to help with the nausea and these medications also increase the absorption of the painkiller. We can give you metoclopramide or ondansetron
If these medications don’t help, we can do a special painkiller from a group called triptans like rizatriptan or sumatriptan. These medications come in different forms like tablets, a wafer or a nasal spray. It might make you a little bit dizzy, just be careful with this
Non-pharmacological options
When you get the headache:
Sleep in a dark, quiet room
Neck stretching exercise might help
You can put cold pack on your forehead and hot compress on your neck and shoulders
We also need to find and avoid the triggers. A migraine headache is usually triggered by some certain events or food. Please make a migraine diary. Write down everything about the day you get a migraine and in time we will be able to find your triggers. There are some common triggers:
In your case, I can see wine is triggering your headaches, please avoid this.
Food: cheese, banana, garlic
Drinks: coffee, tea, alcohol, dehydration
Missing meals, irregular sleep
Stress
Periods
General treatment advice:
Have a regular meal and sleep time
Avoid excessive caffeine
Drink a lot of water
Relaxation techniques for stress like yoga, meditation, mindfulness
Prophylaxis
If your migraine headache happens frequently and happens more than 2-4/month, please come back to me to consider preventive medications. We have different options like propranolol, pizotifen, amitryptiline.
Just in case, if you ever want to go on contraception, please tell your GP that you have migraine as we are unable to give you combined oral contraceptive pills.
If your headaches change, are getting worse or no longer responding to treatment, or you start having blurring of vision, numbness, pins and needles, weakness, come back to me for reassessment
I want you to avoid using the simple painkiller more than 15 days per month and the triptans more than 10 days per month, because it can cause another type of headache called medication overuse headache.
Support and review services
I’ll give you reading material
I’ll refer you to a support group called Migraine Australia
