CASE STUDY 1
Mrs T, aged 35, comes to your pharmacy to ask for advice on her father’s care, Mr I. Her father who is 66 years old, retired and otherwise generally healthy, is at home in bed and too unwell to come to the pharmacy. He has been unwell for the last 2 days and Mrs T has been looking after him. Mr I has been bedridden for the past day, can hardly sit up, has a runny nose, sneezes a lot, has a headache, muscle ache, fever (39oC) and chills. Mr I also has a sore throat and a dry, chesty cough. He received his free seasonal influenza vaccine one month ago. Influenza is not currently in circulation.
1. What is he likely to be suffering from and what healthcare advice should you, as the pharmacist, give to Mrs T regarding her father? Include any recommendations you might make for OTC medicines, taking into account the evidence-base for their use.
Mr. I is most likely to be suffering from a rhinovirus infection, which is also known as the common cold. The common cold is self-limiting and there are self-measures that can be taken. However, since the common cold is a viral infection, there are no treatments available that will cure the common cold but there are treatments available to help relieve the symptoms and that it usually lasts from two to 14 days but that most people recover within a week (NHS.uk, 2016).
The most appropriate management during the course of Mr. I’s illness are symptom relief and rest. Mr. I should have plenty of rest, drink plenty of fluids and eat healthy food. Treatment options for Mr I’s symptoms include:
1. Aches, pains and fever can be treated with painkillers such as aspirin, paracetamol or ibuprofen.
2. Cold and flu can be soothed with an oral decongestant such as pseudoephedrine (e.g. Lemsip Cold).
3. Blocked nose can be remedied with a nasal decongestant (e.g. Otrivine Nasal Spray). Sinuses can be eased with an inhalant or vapour rub (e.g. Olbas oil, Vicks vaporub).
4. Cough suppressants such as pholcodine, codeine and dextromethorphan (e.g. Robitussin Dry Cough) can be used to treat Mr I’s dry, chesty cough as it aids by blocking the natural coughing reflex.
5. Sore throat can be relieved by sucking on a pastilles or lozenges (e.g. Strepsils Original, Tyrozets) to help lubricate the throat, reduces the irritation and prevent the throat from feeling dry and scratchy.
Mr. I can try some self-care tips to relieve his symptoms by inhaling steam to help loosen and bring up the phlegm, he can also gargle with salt water to relieve his sore throat by adding a teaspoon of salt to a glass of warm water and spitting it out after gargling. Mr. I should drink plenty of fluids such as warm drinks containing lemon juice and honey to soothe his throat. He can also prevent the virus from spreading by using tissues and by washing his hands frequently, and should not be sharing drinks or cutlery with others (Boots Counter Intelligence Plus, 2016).
2. What should Mr I be monitored for at home? What complications could there be?
Common complications that may occur after a common cold would be sinusitis, chest infections – such as acute bronchitis, chronic obstructive pulmonary disease (COPD) or pneumonia – and ear infections such as acute otitis media. Mr. I should have a follow up appointment if his symptoms worsen after 3-5 days or if his symptoms persists after 7-14 days. However, Mr. I should immediately refer to his pharmacist or GP if he coughs mucus that isn’t clear or white, coughs up blood, is experiencing chest pain, is wheezing, has shortness of breath, still coughing after three weeks, has difficulty swallowing or breathing or if his sore throat lasts for more than 5 days (NICE CKS, 2016).
References
Boots Counter Intelligence Plus. (2016). London: Tim Langford, pp.40-44.
Nhs.uk. (2016). Common cold – NHS Choices. [online] Available at: http://www.nhs.uk/Conditions/Cold-common/Pages/Introduction.aspx [Accessed 18 Oct. 2016].
NICE CKS. (2016). Common cold. [online] Available at: http://cks.nice.org.uk/common-cold#!topicsummary [Accessed 18 Oct. 2016].
CASE STUDY 2
A physician is called to see a 78-year-old woman, Ms CD, recovering from a partial colectomy in a community hospital 3 days post-hospital discharge. The patient has a temperature of 38.5°C, has frequent episodes of diarrhoea, abdominal cramps and her stool has a ground coffee appearance and smells very offensive. She is tolerating oral fluids but has nausea and is weak. You are the community pharmacist who supplies Ms CD’s regular medication and make regular visits to the nursing home. According to your PMR the patient is currently prescribed:
Ibuprofen 200mg TDS
Codeine phosphate 30mg QDS
Is on day 3 of a 7-day course of co-amoxiclav, started on the day of discharge from the hospital
A full blood count and analysis of urea and electrolytes has been requested by the GP to ascertain leukocytosis (presence of infection) and dehydration. Blood cultures are requested from the laboratory and a faecal sample is sent for investigation. The patient’s blood count, urea, electrolytes and blood cultures are all normal. The patient is diagnosed with a moderate C. difficile infection (CDI) and administered fluids intravenously to augment her oral intake.
1. What additional information would the doctor require to make a definitive diagnosis of C. difficile and what are other potential causes of her symptoms?
As Ms CD has frequent episodes of diarrhoea, a stool test should be done to check for the presence of Clostridium Difficile toxins in the stool. The toxins are used to diagnose antibiotic-associated diarrhoea and pseudomembranous colitis caused by C. diff (Labtestsonline.org.uk, 2016).
Clostridium difficile is a gram positive; spore-forming rod and it is part of the flora neonates. It contains 3 types of toxins- Toxin A, Toxin B and binary toxins. Toxins A and B are proinflammatory and cytotoxic, they are the primary markers for the identification of C. difficile as they cause the disturbance of actin cytoskeleton and impairment of tight junctions in human epithelial cells, resulting in fluid build-up and extensive damage to the large intestine (Carter, Rood, and Lyras, 2010).
A White Cell Count (WCC) test and albumin test should also be done. The WCC test is usually performed as part of the full blood count but also can be tested separately. This test is used to detect any underlying infection or inflammation as the number of white blood cells in the bloodstream will often be elevated if there is a serious infection somewhere in the body (HealthEngine, 2016). The albumin test is used to detect if the kidneys or liver are working properly. Abnormal albumin levels may indicate otherwise. Another potential indication of the diagnosis would be that Ms CD had developed diarrhoea within few days of coming out of the hospital. Lastly, the most common clinical representation of C. Difficile is associated with the history of antibiotics usage (Clinical Infectious Diseases, 2016).
Ms CD is likely to have gotten C. difficile due to several reasons. Firstly, she had just gotten out of a partial colectomy surgery, which is the removal of a diseased or damaged part of the colon or the rectum, this increased her risk of getting infected with C. difficile. Furthermore, as stated on her PMR, Ms CD was being prescribed Co-amoxiclav right after her surgery (Ratini, M., 2016). These broad-spectrum antibiotics are used against a range of bacteria however can also destroy the natural bacteria in the bowel, leading to the overgrowth of C. difficile. Another factor, which has to be taken into account, is MS CD’s age; there is an increased risk of getting infection in people aged 65 and above. Additionally, the environment in which Ms CD was staying was in a healthcare setting where so many elderly patients are unwell, in close contact, vulnerable and at risk of getting an infection (Bupa.co.uk, 2016).
2. What treatment is Ms CD likely to receive for the diagnosis in addition to IV fluids, and what other changes to her medications should have been made?
As Ms CD has been diagnosed with moderate C. Difficile, the appropriate treatment would be to stop the treatment of her current antibiotics immediately. Ms CD should be advised against the use of any anti-diarrhoeal medication that can be bought over the counter as this slows down the diarrhoea and increases the time of her colon being exposed to the toxins, which will further inflame and damage her colon (Patient, 2016). Since Ms CD is dehydrated, fluids should be given through a drip in her arm. Ms CD stays in a community hospital, so it is recommended that she move into her own room during her treatment to reduce the risk of spreading her infection to people living around her (CDC.gov, 2016).
In order to prevent anymore C. difficile infection, Ms CD should wash her hands with soap and water regularly and should not just depend on hand gel as it is not an alternative to hand-washing and that it may not be able to kill any C. difficile spores. These spores are resistant cells that survive for a long period especially on hands and surfaces, objects and clothing unless they are thoroughly cleaned (NHSChoices, 2016). Ms CD also shouldn’t use any antibiotics unless prescribed by her doctor or GP.
As part of the antimicrobial stewardship, streamlining and IV to Oral Switch should be applied to Ms CD’s case. Streamlining is when an initial antibiotic regimen is changed to a result-based therapy in response to a laboratory result for the patient. This helps avoid any lengthy usage of broad-spectrum antimicrobials; it targets the infecting organism, stops the inappropriate use of antimicrobials and also reduces the risk of any secondary infection. Since Ms CD could not tolerate fluids that well as she had nausea when taking her medicines, she was given a parenteral therapy in the hospital. This may be time prolonging and inappropriate, therefore switching the route of administration of her medications to an oral route as many medications has good oral bioavailability and is also cost saving (Antimicrobial Stewardship, 2016).
References
Antimicrobial Stewardship: “Start Smart, – Then Focus’. (2016). 1st ed. [ebook] London: Carole Fry, pp.11-12. Available at: https://www.bb.reading.ac.uk/bbcswebdav/pid-3063526-dt-content-rid-5104798_2/courses/PM3A-16-7A/StartSmartThenFocus.pdf [Accessed 19 Oct. 2016].
Bupa.co.uk. (2016). Clostridium Difficile Infection | Bupa UK. [online] Available at: http://www.bupa.co.uk/health-information/directory/c/clostridium-difficile-infection [Accessed 19 Oct. 2016].
Carter, G., Rood, J. and Lyras, D. (2010). The role of toxin A and toxin B in Clostridium difficile-associated disease. Gut Microbes, 1(1), pp.58-64.
Cdc.gov. (2016). Patient information about C. difficile infection | HAI | CDC. [online] Available at: http://www.cdc.gov/HAI/organisms/cdiff/Cdiff-patient.html [Accessed 19 Oct. 2016].
Clinical Infectious Diseases – Oxford Journal. (2016). Clostridium Difficile. [online] Available at: http://cid.oxfordjournals.org/content/46/Supplement_1/S12.long [Accessed 19 Oct. 2016].
Health Engine. (2016). White Cell Count Test. [online] Health Engine. Available at: https://healthengine.com.au/info/White-Cell-Count-Test [Accessed 19 Oct. 2016].
NHS Choices. (2016). Clostridium difficile. [online] Available at: http://www.nhs.uk/Conditions/Clostridium-difficile/Pages/Introduction.aspx [Accessed 19 Oct. 2016].
Labtestsonline.org.uk. (2016). Clostridium difficile toxin: The Test. [online] Available at: http://labtestsonline.org.uk/understanding/analytes/cdiff/tab/test/ [Accessed 19 Oct. 2016].
Ratini, M. (2016). C. diff: Causes, Symptoms, and Treatments. [online] WebMD. Available at: http://www.webmd.com/digestive-disorders/clostridium-difficile-colitis#2 [Accessed 19 Oct. 2016].
Patient. (2016). Clostridium Difficile. C Diff; Symptoms and information | Patient. [online] Available at: http://patient.info/health/clostridium-difficile-leaflet [Accessed 19 Oct. 2016].
CASE STUDY 3
Mr DM is a 68yr old male who you see regularly in the pharmacy. He is overweight and suffers from diabetes with poor glycaemic control. He currently takes the following medications: Metformin (500 mg TDS), Ramipril (10 mg od), Aspirin (75 mg od), Atorvastatin (10mg od). He came to you in the pharmacy several weeks ago about a painful, itchy sore on his foot between his toes and you told him to see his GP, who diagnosed a venous leg ulcer. Despite self-care measures, on follow-up with the GP the ulcer had become infected (cellulitis) and he was prescribed antibiotics.
1. Why is this common in diabetic patients?
2. What is the likely action, advice and treatment given by the GP (a) on Mr DM’s first visit and (b) his second visit and why?
CASE STUDY 4
Mr P is a 40-year-old male patient, who has had asthma since childhood for which he has a salbutamol inhaler (100 micrograms, 2 puffs, QDS PRN) and Symbicort Turbohaler (400/12, 2 puffs BD). His condition is managed effectively through meetings with an asthma nurse. He has recently quit smoking from a 30-a-day habit. He lives alone. 5 days ago he began to have ‘flu-like symptoms, including a runny nose and sore throat. 2 days ago he became short of breath with a productive cough (green sputum) and chest pain when coughing. He was having to use his inhaler more often and found he was unable to sleep and went to the emergency department. His recent observations were: pulse 115 beats per min, temperature 39oC, BP 130/80, respiratory rate 40 breaths per min and PEFR 230 litres per min.
1. What are the general investigations that should be performed for Mr P following being admitted into hospital?
2. What infection is Mr P most likely to have and what are the most common respiratory pathogens?