Patient Self CareCondensed

Niamh MonePEBC NO: 100644

PEBC Qualifying Exam ISUMMER 2014

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Contents

Insomnia 3Depression 5Smoking Cessation 7Headache 11Fever 15Heat Related Disorders 17Vertigo 19Tinnitus 21

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Insomnia

AGE SYMPTOMSMore common in women, elderly and psychiatric illness

May be due to1. Rumination2. Physiological factors

MEDICATION EXTRA MEDICATIONA lot of medication can cause insomniae.g. hormones, alcohol, antiepileptics, hypertension meds, methylphenidate

TIME HISTORYOccurs at least 3 times a week and has been a problem >1monthTransient (2-3 days)Short term (4-21 days)Chronic (>21 days)

If needed for >14 days or crap after 3 days, refer

Primary – no medical cause (stress, death etc.)Secondary - comorbid

OTHER SYMPTOMS DANGER SYMPTOMSIf due to comorbidity or medication, refer

Therapy

Non-pharmacologic Therapy (Chronic Insomnia)

Sleep hygiene

Personal habits

1. fix a bedtime and an awakening time

2. exercise regularly, but not right before bead

3. avoid nicotine before sleep and awakening

4. avoid caffeine, alcohol, sugar and spice 4-6 hours before bed

Sleeping Environment

1. comfortable bed2. temperature and

ventilation are good3. block all noise

Getting ready for bed

1. light snack such as warm milk or tryptophan

2. pre-sleep ritual3. relaxation techniques4. get into fav sleeping position5. don’t take worries to bed

stimulus control therapy, relaxation

training, CBT

sleep restriction therapy,

multicomponent therapy, biofeedback, paradoxical intention

Sleep hygiene (not as effective as

monotherapy)

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Stimulus Control TherapyAssociate the bedroom with sleep1. go to bed only when tired2. use bedroom only for sleep3. get up at same time q am4. avoid napping5. if still not tired, read a

book in a different room for 15-20mins

Relaxation techniquesGood where hyper arousal the cause of insomnia1. progressive muscle

relaxation(muscles tightened and relaxed in certain order)2. biofeedbackincrease slow brain wave activity using EEG3. imagery trainingsubstitute pleasant thoughts with worrying ones

Paradoxical IntentionReduces performance anxiety by forcing patient to stay awake with eyes open in dark room

Sleep RestrictionControlling amount of time in bed but increasing time asleep

MulticomponentMay combine cognitive behavioral and sleep hygiene components

CBTAimed at creating at new attitude towards sleep

Pharmacologic therapy

Drug Dose Side Effects CIsValerian 400-900mg 30-60mins

before bedDizziness, nausea, headache, GI, high doses cause hangover.Hepatotoxicity and withdrawal reported.

Pregnancy

Melatonin Fatigue, headache, dizziness, irritability and abdominal cramps

Diphenhydramine

12,5-50mg 30-60mins before bedtime

Morning drowsiness, dizziness, grogginess, AC side effects

May lower seizure threshold, glaucoma, prostate, heart disease, AC problems

Doxylamine 25mg, 30 mins before bedtime

Tired in morning, hangover, AC May lower seizure threshold

On these meds….1. sleep hygiene2. avoid alcohol3. avoid operating machinery and driving4. keep a sleep diary

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Depression

AGE SYMPTOMS1/3 suffer from bipolar – so see if they have had any manic episodes in the past

Major depressive disorder: >5 or more symptoms with at least one of first 2:

1. depressed mood2. markedly decreased interest/pleasure3. weight loss/gain4. insomnia/hypersomnia5. restlessness/lethargy6. fatigue7. worthlessness or guilt8. cant conc or make decisions9. suicidal thoughts, plans, actions

Dysthymia: 2y of depressed mood plus 2 or more of:1. increased/decreased appetite2. insomnia/hypersomnia3. low energy4. low self esteem5. poor conc6. hopelessness

MEDICATION EXTRA MEDICATIONBeta blockers, steroids, oral contraceptives

TIME HISTORYBidirectional with CV disease poorer outcomesMore likely with a first degree relative (1.5-3X)Reoccurrence1- 60% 2 – 70% 3 – 90%Edinburgh Postnatal Depression Scale for postpartum

OTHER SYMPTOMS DANGER SYMPTOMSPHQ-9: if yes to either, refer

1. over past month, have you been feeling down, depressed or hopeless

2. over past month, have you had little interest in doing things?

Non-Pharmacological Therapy

PsychotherapyGood for mild to moderate, but not for crazy or suicidal people.Counseling, CBT, IBT, self help books etc.

Exercise Light therapy10,000n lux light pointed at face for 30 mins. Difference seen in 1-3 weeks. Good for “SAD” may cause irritability, eye strain, headache, insomnia. Can start with 15 minutes and work up if bad side effects.

Electroconvulsive therapyReserved for more severe. Induced seizures in anaesthetized patient.

rTMSSofter than ECT, non invasive.

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OTC medications

Drug Dose Side effects CIsSt johns wort 300mg TID Photosensitivity, GI, dizziness,

insomnia, restlessness, agitation, mania and hypomania

Inducer; Reduce effectiveness of drugs, can cause serotonin syndrome with SSRIsPregnancy, breastfeeding

SAMe 400-1600mg dy in divided doses

Insomnia, AC effects Serotonin syndrome, pregnancy and lactation

Omega 3 1-2g day Fishy aftertaste, nausea Additive bleeding risk with anticoagulants,Pregnancy and lactation

Prescription Meds

Symptom improvement in 2-4 weeks. If no improvement after 6-8 weeks, see doctor.Overall good outcome in 2 months.Patient should stay on meds for 6-9 months after remission if first episode. Longer than 1 year is not unreasonable.

Monitoring:Weekly for 4 weeks, biweekly for 4 weeks, than at 3 months. Pediatric and severe patients should be monitored more often

Serotonin SyndromeMental status changes, agitation and tremor, hyperthermia, rhabdomyolosis, seizures, arrhythmias and respiratory arrest!

Withdrawal syndromeMalaise, headache, dizziness, nausea, diarrhea, mood, electric shocks and vivid dreams, almost like flu symptoms

Other counseling tips:1. avoid alcohol2. do not use illegal drugs3. tell your doctor if you are taking herbal products4. rest plenty5. exercise regularly6. eat regularly7. keep socially active

DO NOT MAKE ANY MAJOR LIFESTYLE CHANGES!May give suicidal ideations at first 1 week or so

bupropion, mirtazepine, moclobemide, SNRIs,

SSRIs

quetiapine, trazodone, tcas maois

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Smoking Cessation

AGE SYMPTOMSQuitting before the age of 50 results in at 50% reduction in risk of death in next 15 years

Withdrawal symptoms include depression, anxiety, irritability, difficulty concentrating, restlessness, increased appetite, GI symptoms, headache, insomnia

MEDICATION EXTRA MEDICATION

TIME HISTORYSymptoms of cigarette withdrawal usually peak 24-72 hours and subside after 2 weeks.Cravings can continue for years

OTHER SYMPTOMS DANGER SYMPTOMSWe can assess dependence via Fagerstrom Tolerance scale

1. ci to NRT2. very high nicotine dependence

MythsAll types of tobacco have harmful effects including non-cigarette forms“Light” cigarettes may deliver same amount of nicotine regardless of package

pre- contemplation

contemplation

preparation

action

maintenance

relapse

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FAGERSTROM SCALE

Question 0 1 2 3How soon after you wake up do you have your first cig?

>60mins 31-60mins 6-30mins <5mins

Do you find it hard refraining in smoking in places where it is forbidden?

No Yes

Which cig would be the hardest to give up?

Any other than first in the morning

First in the morning

How many cigarettes do you smoke? <10 11-20 21-30 >31Do you smoke more in the morning than rest of day?

No Yes

Do you smoke even when ill? No Yes

<5 = low5 = moderate>6= high – REFER

Non-pharmacologic therapy

Refer everyone to behavioral modification programs. Light smokers may be able to do this alone.e.g. smokershelpline.ca, cancer.ca, camh.net “on the road to quitting” is a 40 page self help guide

AcupunctureNeedles in nose and ear, no evidence

Laser therapySimilar to acupuncture. No evidence.

HypnotherapyNo evidence

Aversion TherapyAssociation with an unpleasant sensation with smoking. E.g., electric shocks. Rapid smoking has shown most promise but not recommended due to heart and lung problems!

Clove and herbal cigarettesMay contain up to 70% tobacco. Also tar, CO and other toxins.

Pharmacological therapy

In order of best to worst:1. Champix2. Nicotine patch plus PRN3. bupropion and patch4. inhaler5. bupropion6. patch7. lozenge8. gum

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Drug Dose Side effects Contraindications CommentsGum Nicorette

2mg if <64mg if >7

Thrive2mg if <254mg if >25

10-12 pieces per day, up to 20. May decrease by 1 gum per day each week over 3 months, up to 6 months max

Jaw throat and mouth soreness

1. depression, insomnia, dizziness, headache

2. Taste disturbances, nausea and vom

3. hypertension4. rash5. cough

6. life threatening arrhythmia

7. severe angina8. history of recent

stroke9. 2ks following MI

relative ci:1. pregnancy2. smoking while

using3. <18 yrs

Do not chew like normal gum!!

Bite one piece in the mouth, and park between teeth and gums for 1 mins, repeat when desire arise again, up to once a min for 30 mins then discard piece.

Avoid acidic beverages and foods while chewing and 15 mins before.

Lozenges Thrive1mg if <20 (max 25 per day)2mg >20 (max 15 per day)Nicorette2mg if >30mins4mg if <30mins

weeks 1-6: q1-2hweeks 7-9: q2-4hweeks 10-12: 4-8

discontinue when loz are 1-2 times per day, do not use for >6months

Same as above Same as above DO NOT SWALLOW OR CHEW! Suck only. Move from one side of mouth to other periodically

Same as above w/ acidic foods and drinks

Inhaler Initial: use 6-12 per day for 3-6 weeks and taper over next 6-12 weeksD/C if use is down to 1-2 times per day. Not >6months

Transient and decrease with use. Irritation, cough, headache, nausea

same as above Puff like cig (5-10 mins at a time)

Cartridges can be used for 24h once punctured

Patch Apply to non-hairy, clean, dry site in upper arm or hip. Don’t use the same site >1 per week

6wks>2wks>2wks

Same as above and rash

generalized skin problems – severe eczema or psoriasis

If patient still smoking in first 2 weeks, referCheck monograph with strenuous exerciseDo not cut patches

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21-40 cigs per day can use 35mg nicotine>40 cigs per days can use 40mg nicotine

with insomnia, remove patch at night and use immediate release product first thing in the morning.

Prescription Therapy

Drug Side effects CIBupropion Dry mouth, insomnia

Hypertension, muscle/joint pain, dizziness, tremor, sleepy, rash, taste

Can cause agitation – caution in psychiatric patients

SeizuresAnorexia/bulimiaConcurrent MAOI therapy

Can be used in combination and pregnancy

Varenicline Nausea, vomiting, headache, insomnia, abnormal dreams and dizziness

Psychological assessment important

Pregnancy

Do not use in combo as increased side effects and no increased efficacy

Clonidine can also be used but is generally not due to side effects

Special Considerations

1. PregnancyUse non-pharmacologic methods where possible. If moderate to heavy smoker, use NRT. Start within first 16 weeks. Use IR products, and if not, use 16-hour patch. Should involve patient’s physician.

2. LactationUse IR products. Breastfeed before using the product to minimize exposure.

3. CV diseaseSafe with stable CV disease. Transdermal patch preferable as it is consistent.

4. ChildrenCounseling best. No evidence that NRT works best, should be done under physicians care.

5. Smokeless tobaccono conversion for NRT products. Counseling best or refer.

DRUG INTERACTIONSEnzyme inducer – so increases clearance of drugs in smokers.

FluvoxamineRasagilineOlanzapineWarfarinNifedipineEstrogensDiazepamTheophyllineTrifluoperazineMethadoneClozapineCaffeine

Reduce caffeine intake to reduce side effects

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Headache

AGE SYMPTOMSTemporal arteritis >50 years, fatal

Refer if onset >40 years

Tension – mild- moderate tight band in both sides of the head. May have photo/phonophobia (1 or the other)Migraine – moderate/severe pulsating headache, usually on one side of the head. May have aura with photo/phonophobia with nausea or vomiting.Cluster – excruciating penetrating, usually unilateral at temple/above eyebrow. May have, at same side of headache, NO VOMITING

1. lacrimation2. red eyes3. nasal congestion or running4. constriction of pupil “miosis”5. dropping of eyelid “ptosis”6. facial sweating7. eyelid edema8. some photophobia (mild)

MEDICATION EXTRA MEDICATIONIntracranial hypertensionAntibioticsCorticosteroidsCimetidine, isotrenitoin, tamoxifenHeadacheHypertensivesH2 antagonistsNitratesNSAIDSHRT, Oral contraceptivesSSRIS

TIME HISTORYTension – can last 30 mins to 7 daysMigraine – 4-72hCluster – 15-180mins

Chronic - >15 days a monthChronic cluster headache: attacks repeatedly for more than a year with less than 14 days remission. Can attack 8 times a day to once every other day

Onset if wakening in morning or woken by it – refer as may be brain tumor

Onset with exercise –may be benign or serious

MOH: use of analgesics on 15 days/months for 3 months

Pregnant?Any medical conditions? E.g. diabetes, epilepsyHave you had this before?

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OTHER SYMPTOMS DANGER SYMPTOMS1. Chronic headache >15 days a month2. First or worst headache3. Sudden headache4. One sided weakness5. Changes in vision, mental status,

consciousness, sensation6. Fever7. Progressive with a change in pattern8. >3 migraines a month for prophylaxis9. Medication overuse headache10. Stiff neck, focal signs, consciousness11. Fail to achieve benefit from OTC12. Vomit in 20% migraines and severe disability

in 50% attacks

MOHAnalgesics (apart from NSAIDS) can not be used >15 days/moTriptans and ergotamines – only use 10 days/mo

Treatment1. complete removal of implicated drugs2. relieve withdrawal symptoms3. treating headaches with migraine specific medication4. initiate prophylactic therapy

Triggers

Foods that contain nitrites MSG Aspartame or

neurotransmitter precursorsE.g. cheeses, cured meats, chocolate, alcohol, caffeineALSO MISSED/DELAYED MEALS

Environmental Weather Loud noises Flickering lights Strong odors Cig smoke Travel across time zones

Chemical Benzene Insecticides perfumes

Hormonale.g. periods, menopause

Stress, anxiety, sex, sleep cycle

TREATMENT OF HEADACHE

Drug Dose Side effects Interactions Pregnancy CommentsAcetaminophen

1000mg Q4H prn x2 doses (no more than 4g daily)Child: 10-15 mg/kg q4h prn

Liver or kidney dysfunction

Warfarin – increased bleeding (1.3g dy for >1 week more likely)

First choice Less effective than NSAIDs

ASA Same as aboveChild (>12 y) 500-650mg single dose

GI upset, ulceration or bleed

Warfarin Safe in first and second trimesters, NOT 3RD! – hypertension

Do not use in viral or fever in children. Avoid EC as this prolongs

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of newborn, prolonged preg and labor

onset. Effervescent 100mg ASA similar to sumatriptan 50mg for migraine.

Ibuprofen 200-400mg Q6H x2 doses PRNChild: 5-10mg/kg up to QID

Same as ASA Same as ASA Same as ASA Pain free at 2h

Naproxen 220mg q8-12h x2 doses PRN

Same as ASA Same as ASA Same as ASA

Codeine 1-2 tabs q4h PRN (can be used in adolescents)

Sedation, dependence, tolerance, constipation

Additive sedation with other sleepy tabs.Enzyme inhibitors antagonize effect

No! Cleft palate abnormalities

Use less than <10 days per month

If vomit in 20% migraines and severe disability in 50% attacks = prescription meds!!

Prescription Medication

TRIPTANS - MOST EFFICOUS SC injection oral tabs orally disintegration nasal

DIHYDROERGOTAMINE NASAL/INJECTION FORMSOral ergots do not have much evidence but this is proven. Used with opioids or antiemetics in emergency room

CLUSTER HEADACHERequires O2 and rapid onset triptans e.g. nasal, subcutaneous triptans or DHE

Antiemetics

Oct. – dimenhydrinate

RX- domperidone, metoclopramide and prochlorperazine

PROPHYLAXIS required in following circumstances >3 attacks per month that fail to respond adequately to acute therapies severe attacks than significantly impair qol Optimal acute therapies have failed, CI or serious side effects MOH

2-3 month trial period on prophylactic agentlow dose and titrated upwardwithdrawn gradually to prevent rebound headachesmay be continued for months or years

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Drug Dose Side effects

Interactions Pregnancy Comments

Feverfew 125mg per day

Mouth ulcers

Anticoagulants Avoid – uterine contractions

Avoid if contact dermatitis from plants in Asteraceae family

butterbur 75mg BID GI – burping

None ? Good evidence. Do not use unless commercially prepared as a carcinogenic

Coenzyme q10

100mg tid GI <1% Additive blood pressure lowering effects, may reduce AC effects of warfarin, may lower efficacy of chemo

? May take up to 3 months for benefit

Magnesium 300mg BID Diarrhea, GI

Separate doses by 2h for doxy ETC

Safe Conflicting evidence

Riboflavin 400mg/day

Yellow urine

None High doses teratogenic

Small trial in adults show efficacy

Prescription

Migraine

Bblockers w/o intrinsic sympathomimetic activity e.g. propranolol, metoprololTCAsCCBsSerotonin receptor antagonists e.g. pizotifenValproic acid/divalproexTopiramateNSAIDS

Cluster

Verapamil/Lithium/Valproic acid at onset&Steroids (e.g. prednisolone 60-80mg/day for 2-3 days, then reduce)ORErgotamines (not within 24 hours of triptan)

A 50% reduction in migraines is considered good! Keep a diary and record migraines

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Fever

AGE SYMPTOMSFever in children is rectal temperature >38Adults – circadian highest between 4-6pm, lowest at 6am.>37.2 morning>37.8 any time define feverHigh fever >40.5

Refer<6moRefer >40.5 everyone elseRefer – distressed child

MEDICATION EXTRA MEDICATIONNew drug that causes hypersensitivity?

TIME HISTORYFEVER LONGER THAN 3 DAYS – refer24h with no cause - refer

Travelled abroad?Surgery?Raw food?

OTHER SYMPTOMS DANGER SYMPTOMS1. Stiff neck, seizures, localized pain,

redness, swelling or heat2. Wheezing and cough3. Rash

Temperatures

Rectal 0.6 higher than…OralArmpit 0.5-1 lower than…

Mercury thermometers no longer recommended as they may break, up to 10 minutes for glass thermometers. Digital only need 10 seconds.

Rectal is most accurate, good for <4-5 years oldOral >5yrs. Do not bite thermometer. No hot food or bev 10 mins before.Auxiliary less reliable. Confirm via another route if >37.2

Non-pharmacological Therapy Removal of excess clothing and bedding Increased fluid intake Avoid physical exertion Ambient temps around 20-21 degrees

Sponging – no additional benefit. But take antipyretics 30 mins before. ONLY DO WITH WATER!

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Pharmacological TherapyReduce hypothalamic set point.Use at regular intervals to avoid shivering

Ibuprofen – avoid in diarrhea and vomiting

Combination of paracetamol and ibuprofen NOT GOOD – one or the other

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Heat Related Disorders

AGE SYMPTOMSYounger patients – exertional heat strokeOlder patients – classical heat stroke

Infants and elderly at risk

Heatstroke – body temp >40 and changes in mental status. Two types

1. Classical – poor environment. Hot dry skin and less pronounced increase in core body temp. occurs over several days

2. Exertional – physical activity. Occurs over few hours

MEDICATION EXTRA MEDICATION1. Blockage of sweat production

alcohol, anticholinergics, antihistamines, hypertension drugs

2. Vasoconstrictionalpha agonists, MAOIs, sympathomimetics

3. Disrupted hypothalamusantipsychotics, amphetamines

4. Increase in heat productionexcessive thyroid, sympathomimetics

Also any meds that alter a person’s perception to stay hydrated

TIME HISTORYFew hours – exertionalFew days – classical

If recovery does not occur within 20-30mins refer

Outdoor laborers and athletes at riskDehydration

OTHER SYMPTOMS DANGER SYMPTOMS1. Loss of consciousness2. Confusion/hallucinations3. Convulsions4. Altered mental status5. Sob6. Vomiting7. Little or no urine8. Skin that is hot and dry with no sweat9. If recovery does not occur within 20-

30mins10.Heat stroke

The hypothalamus regulates heat. Body eliminates heat by four different mechanisms:1. EVAPORATION e.g. sweating2. RADIATION – electromagnetic waves. 65%3. CONDUCTION – physical contact with a cooler object. Least effective4. CONVECTION – transfer to air. E.g. vasodilation

Reduction in these can increase risk of heat related illness. CV system can collapse with multiple organ failure.

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Prevention Methods

1. Move at risk individuals to air conditioned location to partake in social activities (FIRST LINE) 2. Be hydrated before activity and during (500ml to IL per hour of activity)3. 10 to 20 mins break from sun per hour4. Avoid strenuous activity from 10am-3pm5. Wear light coloured, light weight clothing including wide brimmed hat6. Acclimatize. 10-14 days!

Heat Rash Heat edema Heat Cramps Heat Syncope Heat Exhaustion

Heat Stroke

Prickly heat due to increased sweatingBreasts (under)Elbow creasesGroinUpper ChestNeck

Vasodilation of blood vessels, sodium and water retentions and prolonged standing

Water and sodium depletion.Stomach, arms and legs.Common in athletes – warning sign of heat exhaustion.

Dizziness and fainting

Weakness , n&v, hypotension, fatigue, dizziness, headache, increased body temp

Similar to heat exhaustion but with altered mental status

Go to cooler area and keep dry

Elevate feet or handsPrevent with acclimatization

Stop activity! And rest for a few hours- see physician if not better in 1 hourORSStretch and massage

Stop and rest – get up slowly

AcclimatizationCan lead to heat stroke if untreated.

Stop and rest.ORS.recovery in 2-3 hif no improvement in 20-30 mins - refer

Call 911Stop and rest.ORSRemove excessive clothingIce packs

Pharmacologic Therapy

Acetaminophen won’t workBenzos and barbiturates for seizuresMannitol promotes osmotic diuresis and prevents or treats renal failure

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Vertigo

AGE SYMPTOMSDizziness – light headednessVertigo – sense of movement when there is none

Can include nausea, vomiting, pallor and sweating

MEDICATION EXTRA MEDICATIONOtotoxic drugs

TIME HISTORYCan be acute, chronic and recurrent CV

Endocrine – anemia, diabetesMigraine, head injury

OTHER SYMPTOMS DANGER SYMPTOMSRefer everyoneNumbness, tingling, weakness, visual disturbances, difficulty speaking – 911!

BPPV Meniere’s disease Vestibular neuritis Central vertigoMost common type (20%)CausesViral neuritisSurgeryInfectionTrauma

2nd most common type Due to viral infection of vestibular portion of the 8th cranial nerve

5%due to vascular disorders e.g. stoke

Small crystals of CaCO3 in semicircular canals

Distention of endolymphatic compartment of inner ear

Brief bouts of vertigo when change head positionHearing loss and tinnitus usually not present

Fluctuating hearingRoaring tinnitusAural fullnessvertigo

Sudden onset vertigo, nausea, ataxia and nystagmus.No hearing impairment.If this is present – it is labyrinthitis

May disappear in a few weeks but may recur

Acute – 30 mins to several hours

2-3 days

Epley manoeuvreAntiemetics

AcuteVestibular suppressants with or without antiemeticsProphylaxisSalt, caffeine and smoking restrictionBetahistidineAvoid VS

Excellent prognosisAvoid movement

- vestibular suppressants

- antiemeticsfor 2-3 daysMethylprednisolone?Bppv may occur in 15%

Treat underlying cause

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OTC Medication

Drug Dose Side Effects CommentsDimenhydrinate (Gravol)

25-50mg Q6H or 100mg Q8H

Drowsiness, AC Avoid with CNS depressants

CI in angle closure glaucoma, prostatic hypertrophy and urinary retention

Scopolamine Patch – apply one for 72hours

Local reactions, see above

Promethazine 25mg Q6-8H for nausea only

EPS, same as above

Prescription therapy

Benzodiazepines, betahistine, flunarizine. Only treat for a week or less

Other points:Avoid drivingAvoid alcohol with therapy

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Tinnitus

AGE SYMPTOMSLess common in children and more in the elderly Objective – vascular, mechanical or spontaneous

Subjective – otologic, neurologic, infectious, drug

MEDICATION EXTRA MEDICATIONLoop diuretics, salicylates, aminoglycosides

TIME HISTORYRefer if >24 hours

OTHER SYMPTOMS DANGER SYMPTOMSRefer if >24 hours

Non-pharmacologic therapy

1. Avoid loud noises or use noise protectors2. Avoid caffeine or smoking3. Use masking techniques or devices4. Hearing aids in hearing loss5. Stress management and biofeedback6. Tinnitus retaining therapy

Acupuncture not found to be a benefit

Pharmacologic Therapy

Antidepressants – no evidenceGingko biloba –evidence is lacking.

Drug Side Effects CommentsGingko GI

HeadacheDizzinessPalpitationsAllergic skin reactions

Bleeding and seizures!

Avoid in warfarin or antiplatelets

Vitamin A and zinc have been used, but no evidence.

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Eyelid Conditions

Hordeolum Chalazion BlepharitisPathophys Stye (most common)

Glands of ZeisSmall/superficialExternal – towards the skin

Meibomian GlandsLargerInternalPoint to skin or conjunctivaMore prolonged courseUsually staph aureus

Chronic inflammation of meibomian gland. Painless, localized swelling.

Most point towards conjunctiva.

More common in- blepharitis- rosacea- seb dermatitis

With recurrent, refer.

ChronicBilateral eyelidsCan be mixed, anterior and posteriorCan be associated with skin conditions.Can result in permanent damage e.g. scarring and damage to cornea

See next page

Assessment Unilateral, localized lid swelling, tenderness and redness. May occur with blepharitis.

May resemble stye, but without acute inflammatory signs. May press on eyeball for visual distortion

Irritation, burning and itching of the lid margins. Foreign body sensation, worst in mornings.

Time 48h Improvement – a few days. Complete can take weeks to months

Chronic

Prevention Avoid touching the eye and rash hands afterwardsChange compresses and towels after each useDo not let eye drops touch eye/lashes

Good eyelid hygiene Lid hygiene

Lifestyle Warm compresses 10-15 mins, tid/qid.Massage afterwards.Hard boiled eggsUsually drains in 2 days. If longer, refer.

Same 1. warm compresses2. eyelid scrub with baby

shampoo3. mechanical expression

my ophthalmologistUse once or twice daily at outbreak, or twice weekly when under control

OTC Not recommended Same NonePrescription After incision –

Antibacterial e.g. bacitracin or erythromycinIf cellulitis, erythromycin, cloxacillin or tetracycline

Steroid injections in lesion or incision. Topical steroids or antibacterials good.

Ointments after eyelid cleaning – bacitracin and erthyromycinSteroids and antibacterials at breakoutPosterior – systemic tetra, doxy or minocycline. Erthyromycin when CI

Refer If >2 days If recurrentIf large/painfulNo improvement within a few days

Eye painPhotophobiaImpaired visionTraumaChemical exposure

Foreign bodyHeat exposureEye protrusionContact lens wearer>48 hours and no improvement

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Blepharitis

ANTERIOR POSTERIORSTAPYLOCOCCAL BLEPHARITISs. aureus and s. epidermitisinflammation and redness along anterior portion of eyelid. Scaly, crusts and ulceration in eyelids. Loss of lashes in chronic, recurrent styes

MEIBOMIAN SEBORRHEAExcessive glandular secretions.Photophobia, burning, oily and frothy tear film. Few signs of inflammations.

SEBORRHEIC BLEPHARITISNon-ulcerativeMore oily and greasy, less scaly.Will have sebborrheic dermatitis in other areas.

MEIBOMIANITISInflammation and obstruction of glands.Can be diffused or localized.Soft cheesy substance expressed

CHALAZION ARE1. LARGER2. MAY NOT HURT

Compared to styes

SEE MINOR AILMENTS BOOK REGARDING PUTTING IN EYE DROPS

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Conjunctivitis

SymptomsForeign body sensation, scratching or burning sensation, fullness around the eyes and mild photophobia. Redness, crusty after sleeping.

Viral Bacterial AllergicItching Minimal Severe

Redness GeneralizedDischarge Profuse, serous Moderate, white Moderate, serous or

white

Acute Bacterial Hyperacute Bacterial

Chronic bacterial

Viral Allergic

Self limiting, resolves in 2 weeks. Can be reduced to 1-3 days.S aureusS pneumoniaeH influenzae

Neonates/sexually active young people. V serious, sight threatening.Neiserria G and MYellow green discharge. Bilateral in neonates

4 weeksusually with other condition e.g. blepharitiss aureusMoraxella lacunata (makeup)

Subconjunctical haem.UrtiWatery dischargeMay spread from one eye to the other.AdenovirusHerpes (keratitis)2-4 weeks

Itching, tearing, red eye

HandwashingWarm compressSaline irrigationReplace eye drops

Refer Lid hygieneWarm compresses

Infectious 2 weeks after 2nd eye infectedChildren out of school for 1 week

Avoidance strategies, cold compresses

Polysporin QID for 5-7 days, treat 2 days after it has resolved

Refer immediately Refer Antihistamines, lubricants

Oral antihistamines

Trimethoprim / polymixin BErythromycinBacitracinSylfacetamide sodium – cheap and toleratedAminoglycosides good for gram neg – toxicity and allergic reactionsChloram – aplastic anaemiaFluoroquinolones (oxacins” for more serious infections e.g. keratitis

Antibacterials (after gram staining) and irrigation.

Ceftriaxone 1-2g IM in adultsSpectinomycin or oral cipro can be used in penicillin allergic

Topical antibacterials.

Doxy/erythro for meb gland dysfunction or severe acne rosacea.

Topical metronidazole for rosacea

NOT antivirals or steroids in adenovirus

Herpes zoster – topical trifluridine and oral antivirals

Levocabastine and emedastine – rapid onset.OlopatadineNedocromin and lodoxamide.

Ketorolac can decrease itching and redness

Severe may need steroids

Contact lens wearersIf symptoms have not improved after 2 days with treatmentChildren

Refer all Refer all Refer all Refer moderate to severeThose who do not respond in 72h

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Dry Eye

AGE SYMPTOMSFemales Discomfort, visual disturbance, tear film

instability with potential damage to ocular surface. Increased osmolarity of tear film and inflammation of ocular surface

1. aqueous tear deficient DE2. Evapourative dry eye

May overlapHard to diagnose – signs and symptoms may not concordSandy foreign body experience. Worsens over day. Tired, difficulty moving lids, photophobiaIncreased tearing in some circumstances e.g. reading

MEDICATION EXTRA MEDICATIONAnticholinergic drugsAmiodoroneAntiandrogenicB blockersDiureticsinterferonIsotrenitonHRTBenzalkonium chloride as a preservative in drops

TIME HISTORYWorsens over course of the dayRefer if last more than 3-5 days

Environmental – keeping eyes openDiet low in Vitamin A or omega 3 fatty acidsParkinsons

OTHER SYMPTOMS DANGER SYMPTOMSComplications:

1. ocular surface erosions2. epithelial damage3. ocular surface keratinization4. ulceration5. perforation6. scarring7. reduced vision

Refer anyone with autoimmune diseaseSymptoms to do resolve in 3-5 days or worsenComplicationsIf preservative burn patients eyes

Prevention

Remind patients about AC drugsContact lens wearers – clean lensesBlink more during concentrated tasksBlepharitis – lid hygiene

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Non Pharmacologic OTC RXAvoid smoking and smoky roomsHumidifiersMoisture chamber spectacles, ski masksMoist washcloth over closed lids

Tear duct occlusion (by eye care practicioner)

Trial and error approach1-2 week trial of everything

with meibomian gland dysfunction, use omega 3

for factors to think about, see below

Opthalamic cyclosporine and loteprednolSjogren – oral pilocarpine

OthersTopical acetylcysteine, methylprednisolone, estradiol, periorbital IM injections of botulium toxin

Factors for OTC choice

1. ELECTROLYTE COMPOSITION Potassium – maintains corneal thicknessBicarbonate – aids recovery of epithelia barrier function in damaged cornea. May also maintain mucous layer of tear film

2. CRYSTALLOID OSMOLARITY Hypo-osmotic tears used to counteract increased ions with people who have DED

3. COLLOIDAL OSMOLALITY High osmolality stabilizes the volume of corneal epithelial cells. Solutes are taken up by cells so they don’t have to do this internally

4. VISCOSITY AGENTS High viscosity is good – carboxymethylcellulose, hypromellose, PVA, PEG, glycol 400 and propyleytylene glycol.HP-Guar forms bioadhesive gelCastor/mineral oil restore lipid layerSodium hyaluronate – viscosity 500,000x salineCarbomer – 940 resembles an ointment, but less blurred vision than petroleum

5. CYTOTOXIC AGENTS EDTA – can damage corneal epithelial cellsLanolin – irritation to those intolerant to sheeps wool

6. PRESERVATIVES If application more than 4x day then use preservative freeBenzalkonium chloride- toxic to corneal epitheliumOxidative preservative better e.g. polyquad, purite or sodium chlorite (‘vanishing”)OINTMENTS USUALLY DO NOT REQUIRE PRESERVATIVES

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Contact Lens Care

Rigid Glass Permeable (RGP) and softLongetivity:

1. conventional >1 year2. planned replacement (2 weeks, 1 month or every 3 months)3. daily disposable

Rigid Gas Permeable Soft LensesCombines optical qualities and durability with PMMA (hard lens) with oxygen permeability and comfort of soft lenses.

Usually PMMA w silicone, flurosilicone acrylateHydrophobic

Sufficiently high o2 permeability to prevent corneal edema

Good for 5 y

Flexible polymer (HEMA) with high water absorption.Increased comfort due to:

flexibility soft thin edges hydrophilic

however, has an open matrix which can trap dirt which can lead to irritation.More common to leave deposits = higher risk for keratitis

SILICONE – new standard to care. Better 02 permeability – longer wear (>30 days) and decreases deposits

GOOD FOR 1D-1Y

Combination LensThese are also available. Indicated for keratoconus and other corneal dystrophies. Soft lens solns used with these.

Wear SchedulesConventional – 1Y – but due to compliance, planned replacement programs (PRPs) developedDaily – thrown away at end of day. Good for people who are not compliant.Extended wear – use for >24 h. more bacterial keratitis. Do not use for more than 7 days for cleaning or disposal. Silicone ok for up to 30 days.

Information

may experience discomfort during first few weeks as eyes adapt, but go to doctor anyway

some meds alter eye dynamics e.g. sedatives and AC effects

Drugs that cause discolouration:1. dopamine2. sulfasalazine3. phenylephrine4. tetraydrozoline5. pyridium6. nitrofurantoin7. rifampicin8. tetracycline

Refer:

1. pain when inserting/wearing/after wearing

2. burning that causes excessive tearing

3. inability to keep eyes open4. severe/persistent haze, fog or

haloes5. redness, irritation, itching6. poor vision 7. painful lid swelling8. photophobia

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There are 2 forms of chemical disinfection: oxidizing agents (hydrogen peroxide) disinfecting

Eye doctor would have recommended one.

Should always be rinsed after dropping them

Always ask about compliance – soft lenses can be recommended

RGP SOFT

Remove lens from eye Remove lens from eye

Clean with surfactant cleaner Clean with surfactant cleaner

Rinse with soaking soln/saline Rinse with rinsing soln

Clean with enzyme cleaner every week then

rinsing soln afterwards

Store overnight in soaking soln Store overnight in disinfectant (look at product

for times)

Rinse with soaking soln Rinse with rinsing soln

Add a few drops of wetting soln to concave lens

Place on eye, rewet if required and discard used

solutionsPlace on eye, rewet if required and discard used

solutions

DO NOT SWITCH BETWEEN BRANDS, can only recommend what eye professional has given. Usually a trial and error approach.

Unpreserved aerosol saline is the only product that can be substituted by the wearer.

Ear Pain28

Condition Pain Itch Discharge Hearing loss

Other comments

Ruptured tympanic membrane

Yes (sudden and sharp)

No Yes Yes (abrupt) Can happen with acute OM and barotrauma

Earwax No (unless infected)

Frequently No (unless infected)

Yes (gradual)

Fulness or pressure

Acute bacterial OE

Yes (acute) Sometimes Frequent Sometimes Pain when chewing, movement of auricle.Excessive moisture, trauma, scratching

Eczemateous otitis externa

Sometimes Yes Sometimes (oozing, crusting)

Sometimes Will have other condition.May become infected

Otitis media Yes (abrupt) No Yes (if TM ruptures)

Sometimes ChildrenURTI to followRelieved with rupture of TM

Foreign Body Yes Sometimes If becomes infected

Yes Fullness and pressure in ear

Barotrauma Yes No Yes if TM Ruptures

Yes Aire travel and diving. Tinnitus and vertigo may be present

Refer: ear surgery in past 6 weeks ruptured TM (acute onset hearing loss with pain) Tympanostomy tubes Ear drainage (except definite EOM) Otitis media Foreign body When flying/scuba diving >24h Other symptoms >2-3days Hearing loss with no reason If hearing loss doesn’t improve following resolution of nasal congestion

Drug Related Ototoxicity

Cisplatin Loop diuretics Quinine AminoglycosidesASA Phosph type 5 Minocycline Macrolides

Otitis Media

Otalgia – ear painOtorrhea – ear drainage

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AGE SYMPTOMSOM most common in children (75% <1 yr)Refer if <6months

Middle ear inflammation (acute ear pain, unilateral and developing over a few hours. Fever and reduced hearing)May occur with URTIPresence of middle ear effusionAcute onset

MEDICATION EXTRA MEDICATION

TIME HISTORYMore present during winter monthsRefer if >72hRefer if chronic or reccurrent

OTHER SYMPTOMS DANGER SYMPTOMSALL CASESOtorrhea<6monthshistory of chronic or reccurentcraniofacial abnormalitiesif lasts longer than 72 hours

“Wait and see” approachUse analgesia for first 48-72 hours, including child >6 months. Oral preferably, topical can cause irritation and hypersensitivity.if antibiotics are used, systemic only.Do not use decongestants or antihistamines.If using warm oils, only warm in palms due to burns. Never use in ruptured TM. Never sleep with hot water bottle.

Otitis Externa

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AGE SYMPTOMSChildren 7-12, declines >50yrs Pain and discharge present. Normally unilateral

Bactererial OE- otalgia, pruritis and tenderness. Especially on movement of ear. Cellulitis of pinna and regional lymphadenopathy may be present.Fungal OE- pruritis and fullness in the ear, usually after antibiotic treatment. May have black, grey, blueish green, yellow or white fungal elements in EACAcute localized: Due to a boil by S aureus. Pain, itch, redness, edema, absessChronic – thickening of skin due to infection and inflammation. Itch and dry flaky skin – allergic contact dermatitisEcsemateous OENecrotizing – diabetic or immunocompromized. Extends to mastoid or temporal bone. Systemic antibiotics required

MEDICATION EXTRA MEDICATION

TIME HISTORY

OTHER SYMPTOMS DANGER SYMPTOMSEdema and debis in EAC – cleansing must be done first by physicianIf no improvement in 3-5 days. May take 1-2 weeks for full resolution

Therapy

Topical acidifying agents, antibiotics alone or antibiotic/steroid combo.

Eye products can be used as less acidic

Topical aminoglycosides can cause ototoxicity, if used for >1 week and after infection has subsided

Instill 3-4 drops 3-4 times daily. Treat for 1 week. Symptoms may last 6 days after treatment begins. If symptoms not completely gone, then treat for up to 2 weeks.

Fungal can be treated by cleansing and acidification alone. If not, compounded topical antifungals can be used.

Also – analgesia can be used. Topical analgesia not recommended.

Polysporin OTC is besEczematiousAvoid offending product

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Apply aluminium acetate solutionre-acidifying with topical steroid

Prevention of re-occurance1. after swimming or bathing, dry EAC with hairdryer on low/instill with acidifying or alcohol drops2. avoid over cleaning and scratching3. avoid cotton swabs4. avoid water sports 7-10days after treatment

Impacted Earwax32

AGE SYMPTOMSMore common in older aged people with hearing aidsRefer if a child

Sensation of fullness in the ear, hearing loss and discomfort

MEDICATION EXTRA MEDICATION

TIME HISTORYHistory of cleaning with cotton swabs

OTHER SYMPTOMS DANGER SYMPTOMSInjuried earPerforated TMRecent ear surgeryTM tubesDrainage from earHearing lossTinnitus or dizzinessChild3-4 days or 5-7 days with oil based product. Should get relief straight after syringing.

PreventionOlive oil, light mineral oil, hydrogen peroxide, glycerin and sodium biocarbonate

TreatmentSyringing (can se eardrops of soften the wax) at physicians office, emergency department or at home with a caregiver. DO Not TRY TO DO THIS ON ONESELFContraindicated in:

if TM has been perforated in the past or now TM tubes present Ear surgery history Only hearing ear that in affected Children are uncooperative

Water based, oil based and carbamide peroxide equally effective. Instill 15 mins prior to syringing, or use for 3 nights prior to syringing.

URTI

Symptom Cold Allergic Flu Sinusitis Pharyngitis

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rhinitisNasal discharge & congestion

Clear, then mucopurulentCongestion is common

Loads – clear.Congestion aswell

Clear, then mucopurulentCONGESTION IS RARE

Persistent rhinorrheaYellow/green

Rare

Fever Rare no Yes – sudden onset

possible Yes

Sore throat Common(mild) dry, scratchy

no Sometimes no Severe, sudden onset

Cough Mod to moderateDry -> prod

Yes – if postnasal drip

Non-productive

Yes – if postnasal drip

rare

Headache Rare, via sinus congestion

via sinus congestion

Yes via sinus congestion

no

Aches & pain Mild Earaches (in children)

Common Rare possible

Other Sneezing in first few days

Itchiness, watery eyes, sneezing

Fatigue, weakness, n&V

Facial tenderness, toothache

no

Duration 5-7 days, up to 14 days

As long as exposed

10 days Days to weeks 3 days

Etiology Viral Not infectious Viral All Viral>bacterial

Croup is a barking cough, usually unproductive. Inspiratory stridor, dyspnea and fever= refer

REFER:1. Difficulty breathing, wheezing, stridor, chest pain2. History of respiratory disease3. Difficulty swallowing4. Fever >38.5 for >72h5. Cough>3wks6. Severe throat pain7. Severe headache, neck pain8. Prolonged nasal congestion with mucopurulent

discharge

Child:1. Symptoms of croup/ear infection2. Excessive lethargy/irritability3. Skin rash4. Cough with vomiting5. Dehydration in infant6. <3months with fever

Severe symptoms with reduced fluids intake

Allergic Rhinitis

AGE SYMPTOMS34

Children have 30% chance if one parent affected and 50% if bothUsually peaks in early twenties/later teens and decreases >45yrs

Refer <2 yrs

Seasonal – spring to fallPerennial – all yearNon-Allergic – acute and chronic

MEDICATION EXTRA MEDICATIONOveruse of topical decongestantsACENSAIDsBblockersChlorpromazine

SildenafilPhentolaminePrazosinReserpineOral contraceptivesCocaineMethyldopa

Overuse of topical decongestants!!!

TIME HISTORYRefer if tried OTC >2weeks and no response Hypothyroidism and pregnancy can cause it as

well as menustrationRefer if comorbid illnessRefer if allergen not identified

OTHER SYMPTOMS DANGER SYMPTOMSTearing, stuffy or runny nose, itchy face, sneezing Refer if tried OTC >2weeks and no response

If allergen not identifiedFeverPurulent discharge<2yrs oldco-morbid illness e.g. asthmacan not sleep, very dehabilitated

Prevention

Measures can take weeks or months to help.

Avoid smoking, insect sprays, air pollution and fresh tar or paint

Surgery may be required

Prevention

Pollen Outdoor Molds Indoor molds House dust mites AnimalKeep windows Remain in closed Use fungiside on Avoid carpet Remove pet – trial

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and doors closed

Keep air conditioning on indoor cycle

Do not use window or attic fans

Avoid outdoors at high pollen counts

Do not dry clothing outside

Shower or bathe after being outside

environment for as much as poss

Keep air conditioning on indoor cycle (can still be v contaminated)

Use face masks when raking leaves etc

sinks, showers, veg storage areas and garbage pails – or 50:50 bleach in water

Avoid colsole humidifiers and cool mist vapourisers – if used keep clean

Install plastic vapor barrier over exposed soil and keep foundation vents open if crawl space

Remove houseplants

Avoid carpet or furnish the basement if damp or floods

Plastic, leather or wood furniture good

Acarasides – no proven use

Avoid vacuuming or making beds – if so use mask for that and 15 mins afterwards

Vaccum cleaner – double filtration system

Clean while patient not at home

Indoor humidity between 40-50%

Avoid humidifiers

Incase all matresses and pillows

Replace old matresses

Wash bedding at 60 q2w

Avoid stuffed toys that connot be washed

Do not store items under bed

Use window shades – not venetian blinds

not good. Can take 20 weeks for cat allergens to be gone

If not:Put pet in non carpeted area, use heap filter or air purifier or not do put animal in bedroom

Wash cat weekly and dog twice weekly

Eliminate litter boxes or put them in abandoned place

Treatment

AntihistaminesGenerally do not relieve nasal congestion.

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Desloratadine, fexofenadine and cetirizine have modest effects, but only desloratadine is licensed.

Cetirizine most drowsy of 2nd gen.

If tolerance occurs – change to different class. Take for as long as exposed!

Avoid in narrow angle glaucoma, CV disease, chronic lung disease, stenosing peptic ulcer, prostatic hypertrophy

Mast Cell Stabilizers – Sodium CromoglicateDelayed for up to 4 weeks. Less effective

DecongestantsOral have a weaker effect on obstruction. May increase BP. MAOIs – hypertensive crisis!

RX therapy

Steroids – work best. May take a week weeks for max benefit, but 6-8 hours.

Montelukast

Immunotherapy recommended for unavoidable patients

Intranasal ipratropium bromide for rhinnorhea only

Butterbur – natural remedy

ChildrenPediatric 1st gen antihistamines - >6monthsNasal steroids >4yrsDecongestants>6years

PregnancyNasal steroids okAntihistamines okAvoid oral decongestants in 1st trimesterTopical decongestant ok

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