Patient Self Care Condensed Niamh Mone PEBC NO: 100644 PEBC Qualifying Exam I SUMMER 2014

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

Insomnia
AGE
More common in women, elderly and psychiatric illness

SYMPTOMS
May be due to 1. Rumination 2. Physiological factors

MEDICATION
A lot of medication can cause insomnia e.g. hormones, alcohol, antiepileptics, hypertension meds, methylphenidate

EXTRA MEDICATION

TIME
Occurs at least 3 times a week and has been a problem >1month Transient (2-3 days) Short term (4-21 days) Chronic (>21 days) If needed for >14 days or crap after 3 days, refer

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

OTHER SYMPTOMS
If due to comorbidity or medication, refer

DANGER SYMPTOMS

Therapy Non-pharmacologic Therapy (Chronic Insomnia)

stimulus control therapy, relaxation training, CBT

sleep restriction therapy, multicomponent therapy, biofeedback, paradoxical intention

Sleep hygiene (not as effective as monotherapy)

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 bed 2. temperature and ventilation are good 3. block all noise Getting ready for bed 1. light snack such as warm milk or tryptophan 2. pre-sleep ritual 3. relaxation techniques 4. get into fav sleeping position 5. dont take worries to bed

Stimulus Control Therapy

Associate the bedroom with sleep 1. go to bed only when tired 2. use bedroom only for sleep 3. get up at same time q am 4. avoid napping 5. if still not tired, read a book in a different room for 15-20mins

Relaxation techniques
Good where hyper arousal the cause of insomnia 1. progressive muscle relaxation (muscles tightened and relaxed in certain order) 2. biofeedback increase slow brain wave activity using EEG 3. imagery training substitute pleasant thoughts with worrying ones

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

Sleep Restriction
Controlling amount of time in bed but increasing time asleep

Multicomponent
May combine cognitive behavioral and sleep hygiene components

CBT
Aimed at creating at new attitude towards sleep

Pharmacologic therapy
Drug Valerian Dose 400-900mg 30-60mins before bed Side Effects Dizziness, nausea, headache, GI, high doses cause hangover. Hepatotoxicity and withdrawal reported. Fatigue, headache, dizziness, irritability and abdominal cramps Morning drowsiness, dizziness, grogginess, AC side effects CIs Pregnancy

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

Doxylamine

25mg, 30 mins before bedtime

Tired in morning, hangover, AC

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

On these meds. 1. sleep hygiene 2. avoid alcohol 3. avoid operating machinery and driving 4. keep a sleep diary

Depression
AGE SYMPTOMS 1/3 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 mood 2. markedly decreased interest/pleasure 3. weight loss/gain 4. insomnia/hypersomnia 5. restlessness/lethargy 6. fatigue 7. worthlessness or guilt 8. cant conc or make decisions 9. suicidal thoughts, plans, actions Dysthymia: 2y of depressed mood plus 2 or more of: 1. increased/decreased appetite 2. insomnia/hypersomnia 3. low energy 4. low self esteem 5. poor conc 6. hopelessness MEDICATION Beta blockers, steroids, oral contraceptives TIME EXTRA MEDICATION HISTORY Bidirectional with CV disease poorer outcomes More likely with a first degree relative (1.5-3X) Reoccurrence 1- 60% 2 70% 3 90% Edinburgh Postnatal Depression Scale for postpartum DANGER SYMPTOMS PHQ-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?

OTHER SYMPTOMS

Non-Pharmacological Therapy Psychotherapy Good for mild to moderate, but not for crazy or suicidal people. Counseling, CBT, IBT, self help books etc. Electroconvulsive therapy Reserved for more severe. Induced seizures in anaesthetized patient. Exercise Light therapy 10,000n 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.

rTMS Softer than ECT, non invasive. 5

OTC medications Drug St johns wort Dose 300mg TID Side effects Photosensitivity, GI, dizziness, insomnia, restlessness, agitation, mania and hypomania Insomnia, AC effects Fishy aftertaste, nausea CIs Inducer; Reduce effectiveness of drugs, can cause serotonin syndrome with SSRIs Pregnancy, breastfeeding Serotonin syndrome, pregnancy and lactation Additive bleeding risk with anticoagulants, Pregnancy and lactation

SAMe Omega 3

400-1600mg dy in divided doses 1-2g day

Prescription Meds

bupropion, mirtazepine, moclobemide, SNRIs, SSRIs

quetiapine, trazodone, tcas

maois

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 Syndrome Mental status changes, agitation and tremor, hyperthermia, rhabdomyolosis, seizures, arrhythmias and respiratory arrest! Withdrawal syndrome Malaise, headache, dizziness, nausea, diarrhea, mood, electric shocks and vivid dreams, almost like flu symptoms

Other counseling tips: 1. avoid alcohol 2. do not use illegal drugs 3. tell your doctor if you are taking herbal products 4. rest plenty 5. exercise regularly 6. eat regularly 7. keep socially active DO NOT MAKE ANY MAJOR LIFESTYLE CHANGES! May give suicidal ideations at first 1 week or so

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

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

MEDICATION

EXTRA MEDICATION

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

HISTORY

OTHER SYMPTOMS
We can assess dependence via Fagerstrom Tolerance scale

DANGER SYMPTOMS
1. ci to NRT 2. very high nicotine dependence

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

precontemplation

relapse

contemplation

maintenance

preparation

action

FAGERSTROM SCALE Question How soon after you wake up do you have your first cig? Do you find it hard refraining in smoking in places where it is forbidden? Which cig would be the hardest to give up? How many cigarettes do you smoke? Do you smoke more in the morning than rest of day? Do you smoke even when ill? <5 = low 5 = 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 Acupuncture Laser therapy Needles in nose and ear, no Similar to acupuncture. No evidence evidence. Aversion Therapy Association 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! Pharmacological therapy In order of best to worst: 1. Champix 2. Nicotine patch plus PRN 3. bupropion and patch 4. inhaler 5. bupropion 6. patch 7. lozenge 8. gum Hypnotherapy No evidence Clove and herbal cigarettes May contain up to 70% tobacco. Also tar, CO and other toxins. 0 >60mins No Any other than first in the morning <10 No No 1 31-60mins Yes First in the morning 11-20 Yes Yes 21-30 >31 2 6-30mins 3 <5mins

Drug Gum

Dose Nicorette 2mg if <6 4mg if >7

Side effects Jaw throat and mouth soreness

1. depression, insomnia, dizziness, headache 2. Taste 10-12 pieces per disturbances, day, up to 20. May nausea and vom decrease by 1 gum 3. hypertension per day each week 4. rash over 3 months, up to 5. cough 6 months max Thrive 2mg if <25 4mg if >25

Contraindications 6. life threatening arrhythmia 7. severe angina 8. history of recent stroke 9. 2ks following MI relative ci: 1. pregnancy 2. smoking while using 3. <18 yrs

Comments 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. DO NOT SWALLOW OR CHEW! Suck only. Move from one side of mouth to other periodically Same as above w/ acidic foods and drinks

Lozenges Thrive 1mg if <20 (max 25 per day) 2mg >20 (max 15 per day) Nicorette 2mg if >30mins 4mg if <30mins weeks 1-6: q1-2h weeks 7-9: q2-4h weeks 10-12: 4-8 discontinue when loz are 1-2 times per day, do not use for >6months Inhaler Initial: use 6-12 per day for 3-6 weeks and taper over next 6-12 weeks D/C if use is down to 1-2 times per day. Not >6months Apply to non-hairy, clean, dry site in upper arm or hip. Dont use the same site >1 per week 6wks>2wks>2wks

Same as above

Same as above

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

Same as above and rash

generalized skin problems severe eczema or psoriasis

If patient still smoking in first 2 weeks, refer Check monograph with strenuous exercise Do not cut patches

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 Bupropion Side effects Dry mouth, insomnia Hypertension, muscle/joint pain, dizziness, tremor, sleepy, rash, taste CI Seizures Anorexia/bulimia Concurrent MAOI therapy

Varenicline

Can be used in combination and Can cause agitation caution in pregnancy psychiatric patients Nausea, vomiting, headache, insomnia, Pregnancy abnormal dreams and dizziness Do not use in combo as increased side Psychological assessment important effects and no increased efficacy

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

Special Considerations
1. Pregnancy Use 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 patients physician. 2. Lactation Use IR products. Breastfeed before using the product to minimize exposure. 3. CV disease Safe with stable CV disease. Transdermal patch preferable as it is consistent. 4. Children Counseling best. No evidence that NRT works best, should be done under physicians care. 5. Smokeless tobacco no conversion for NRT products. Counseling best or refer. DRUG INTERACTIONS Enzyme inducer so increases clearance of drugs in smokers. Fluvoxamine Rasagiline Olanzapine Warfarin Nifedipine Estrogens Diazepam Theophylline Trifluoperazine Methadone Clozapine Caffeine Reduce caffeine intake to reduce side effects 10

Headache AGE
Temporal arteritis >50 years, fatal Refer if onset >40 years

SYMPTOMS
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. lacrimation 2. red eyes 3. nasal congestion or running 4. constriction of pupil miosis 5. dropping of eyelid ptosis 6. facial sweating 7. eyelid edema 8. some photophobia (mild)

MEDICATION
Intracranial hypertension Antibiotics Corticosteroids Cimetidine, isotrenitoin, tamoxifen Headache Hypertensives H2 antagonists Nitrates NSAIDS HRT, Oral contraceptives SSRIS

EXTRA MEDICATION

TIME
Tension can last 30 mins to 7 days Migraine 4-72h Cluster 15-180mins Chronic - >15 days a month Chronic 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

HISTORY
Pregnant? Any medical conditions? E.g. diabetes, epilepsy Have you had this before?

11

OTHER SYMPTOMS
1. 2. 3. 4. 5.

DANGER SYMPTOMS
Chronic headache >15 days a month First or worst headache Sudden headache One sided weakness Changes in vision, mental status, consciousness, sensation 6. Fever 7. Progressive with a change in pattern 8. >3 migraines a month for prophylaxis 9. Medication overuse headache 10. Stiff neck, focal signs, consciousness 11. Fail to achieve benefit from OTC 12. Vomit in 20% migraines and severe disability in 50% attacks

MOH Analgesics (apart from NSAIDS) can not be used >15 days/mo Triptans and ergotamines only use 10 days/mo Treatment 1. complete removal of implicated drugs 2. relieve withdrawal symptoms 3. treating headaches with migraine specific medication 4. initiate prophylactic therapy Triggers Foods that contain Environmental nitrites Weather MSG Loud noises Aspartame or Flickering lights neurotransmitter precursors Strong odors E.g. cheeses, cured meats, Cig smoke chocolate, alcohol, caffeine Travel across time zones ALSO MISSED/DELAYED MEALS Hormonal e.g. periods, menopause Chemical Benzene Insecticides perfumes

Stress, anxiety, sex, sleep cycle

TREATMENT OF HEADACHE
Drug Dose Acetaminophen 1000mg Q4H prn x2 doses (no more than 4g daily) Child: 10-15 mg/kg q4h prn ASA Same as above Child (>12 y) 500-650mg single dose Side effects Liver or kidney dysfunction Interactions Pregnancy Warfarin First choice increased bleeding (1.3g dy for >1 week more likely) Warfarin Safe in first and second trimesters, NOT 3RD! hypertension Comments Less effective than NSAIDs

GI upset, ulceration or bleed

Do not use in viral or fever in children. Avoid EC as this prolongs 12

of newborn, prolonged preg and labor

Ibuprofen

Naproxen Codeine

200-400mg Q6H x2 doses PRN Child: 510mg/kg up to QID 220mg q8-12h x2 doses PRN 1-2 tabs q4h PRN (can be used in adolescents)

Same as ASA

Same as ASA

Same as ASA

onset. Effervescent 100mg ASA similar to sumatriptan 50mg for migraine. Pain free at 2h

Same as ASA Sedation, dependence, tolerance, constipation

Same as ASA Additive sedation with other sleepy tabs. Enzyme inhibitors antagonize effect

Same as ASA 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

Antiemetics
Oct. dimenhydrinate RX- domperidone, metoclopramide and prochlorperazine

DIHYDROERGOTAMINE NASAL/INJECTION FORMS Oral ergots do not have much evidence but this is proven. Used with opioids or antiemetics in emergency room CLUSTER HEADACHE Requires O2 and rapid onset triptans e.g. nasal, subcutaneous triptans or DHE 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 agent low dose and titrated upward withdrawn gradually to prevent rebound headaches may be continued for months or years

13

Drug Feverfew

Dose 125mg per day 75mg BID

Side effects Mouth ulcers GI burping

Interactions Anticoagulants

Pregnancy Avoid uterine contraction s ?

Comments Avoid if contact dermatitis from plants in Asteraceae family Good evidence. Do not use unless commercially prepared as a carcinogenic May take up to 3 months for benefit

butterbur

None

Coenzyme q10

100mg tid

Magnesium Riboflavin Prescription

Additive blood pressure ? lowering effects, may reduce AC effects of warfarin, may lower efficacy of chemo 300mg BID Diarrhea Separate doses by 2h Safe , GI for doxy ETC 400mg/day Yellow None High doses urine teratogenic

GI <1%

Conflicting evidence Small trial in adults show efficacy

Migraine
Bblockers w/o intrinsic sympathomimetic activity e.g. propranolol, metoprolol TCAs CCBs Serotonin receptor antagonists e.g. pizotifen Valproic acid/divalproex Topiramate NSAIDS

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

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

14

Fever
AGE
Fever in children is rectal temperature >38 Adults circadian highest between 4-6pm, lowest at 6am. >37.2 morning >37.8 any time define fever High fever >40.5 Refer<6mo Refer >40.5 everyone else Refer distressed child

SYMPTOMS

MEDICATION
New drug that causes hypersensitivity?

EXTRA MEDICATION

TIME
FEVER LONGER THAN 3 DAYS refer 24h with no cause - refer Travelled abroad? Surgery? Raw food?

HISTORY

OTHER SYMPTOMS

DANGER SYMPTOMS
1. Stiff neck, seizures, localized pain, redness, swelling or heat 2. Wheezing and cough 3. Rash

Temperatures Rectal 0.6 higher than Oral Armpit 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 old Oral >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!

15

Pharmacological Therapy Reduce 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

16

Heat Related Disorders

AGE
Younger patients exertional heat stroke Older patients classical heat stroke Infants and elderly at risk

SYMPTOMS
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
1. Blockage of sweat production alcohol, anticholinergics, antihistamines, hypertension drugs 2. Vasoconstriction alpha agonists, MAOIs, sympathomimetics 3. Disrupted hypothalamus antipsychotics, amphetamines 4. Increase in heat production excessive thyroid, sympathomimetics Also any meds that alter a persons perception to stay hydrated

EXTRA MEDICATION

TIME
Few hours exertional Few days classical If recovery does not occur within 20-30mins refer

HISTORY
Outdoor laborers and athletes at risk Dehydration

OTHER SYMPTOMS
1. 2. 3. 4. 5. 6. 7. 8. 9.

DANGER SYMPTOMS
Loss of consciousness Confusion/hallucinations Convulsions Altered mental status Sob Vomiting Little or no urine Skin that is hot and dry with no sweat If recovery does not occur within 2030mins 10. Heat stroke

The hypothalamus regulates heat. Body eliminates heat by four different mechanisms: 1. EVAPORATION e.g. sweating 2. RADIATION electromagnetic waves. 65% 3. CONDUCTION physical contact with a cooler object. Least effective 4. 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. 17

Prevention Methods 1. 2. 3. 4. 5. 6. Move at risk individuals to air conditioned location to partake in social activities (FIRST LINE) Be hydrated before activity and during (500ml to IL per hour of activity) 10 to 20 mins break from sun per hour Avoid strenuous activity from 10am-3pm Wear light coloured, light weight clothing including wide brimmed hat Acclimatize. 10-14 days! Heat Rash Prickly heat due to increased sweating Breasts (under) Elbow creases Groin Upper Chest Neck Go to cooler area and keep dry Heat edema Vasodilation of blood vessels, sodium and water retentions and prolonged standing Heat Cramps Water and sodium depletion. Stomach, arms and legs. Common in athletes warning sign of heat exhaustion. Stop activity! And rest for a few hours- see physician if not better in 1 hour ORS Stretch and massage Heat Syncope Dizziness and fainting Heat Exhaustion Weakness , n&v, hypotension, fatigue, dizziness, headache, increased body temp Heat Stroke Similar to heat exhaustion but with altered mental status

Elevate feet or hands Prevent with acclimatization

Stop and rest get up slowly

Acclimatization Can lead to heat stroke if untreated. Stop and rest. ORS. recovery in 2-3 h if no improvement in 20-30 mins refer

Call 911 Stop and rest. ORS Remove excessive clothing Ice packs

Pharmacologic Therapy Acetaminophen wont work Benzos and barbiturates for seizures Mannitol promotes osmotic diuresis and prevents or treats renal failure

18

Vertigo
AGE SYMPTOMS
Dizziness light headedness Vertigo sense of movement when there is none Can include nausea, vomiting, pallor and sweating

MEDICATION
Ototoxic drugs

EXTRA MEDICATION HISTORY

CV Endocrine anemia, diabetes Migraine, head injury

TIME
Can be acute, chronic and recurrent

OTHER SYMPTOMS

DANGER SYMPTOMS
Refer everyone Numbness, tingling, weakness, visual disturbances, difficulty speaking 911!

BPPV Most common type (20%) Causes Viral neuritis Surgery Infection Trauma Small crystals of CaCO3 in semicircular canals Brief bouts of vertigo when change head position Hearing loss and tinnitus usually not present May disappear in a few weeks but may recur Epley manoeuvre Antiemetics

Menieres disease 2nd most common type

Vestibular neuritis Due to viral infection of vestibular portion of the 8th cranial nerve

Central vertigo 5% due to vascular disorders e.g. stoke

Distention of endolymphatic compartment of inner ear Fluctuating hearing Roaring tinnitus Aural fullness vertigo Acute 30 mins to several hours Acute Vestibular suppressants with or without antiemetics Prophylaxis Salt, caffeine and smoking restriction Betahistidine Avoid VS

Sudden onset vertigo, nausea, ataxia and nystagmus. No hearing impairment. If this is present it is labyrinthitis 2-3 days Excellent prognosis Treat underlying cause Avoid movement - vestibular suppressants - antiemetics for 2-3 days Methylprednisolone? Bppv may occur in 15%

19

OTC Medication Drug Dimenhydrinate (Gravol) Scopolamine Promethazine Dose 25-50mg Q6H or 100mg Q8H Patch apply one for 72hours 25mg Q6-8H for nausea only Side Effects Drowsiness, AC Local reactions, see above EPS, same as above Comments Avoid with CNS depressants CI in angle closure glaucoma, prostatic hypertrophy and urinary retention

Prescription therapy Benzodiazepines, betahistine, flunarizine. Only treat for a week or less Other points: Avoid driving Avoid alcohol with therapy

20

Tinnitus
AGE
Less common in children and more in the elderly

SYMPTOMS
Objective vascular, mechanical or spontaneous Subjective otologic, neurologic, infectious, drug

MEDICATION
Loop diuretics, salicylates, aminoglycosides

EXTRA MEDICATION HISTORY DANGER SYMPTOMS

Refer if >24 hours

TIME
Refer if >24 hours

OTHER SYMPTOMS

Non-pharmacologic therapy 1. 2. 3. 4. 5. 6. Avoid loud noises or use noise protectors Avoid caffeine or smoking Use masking techniques or devices Hearing aids in hearing loss Stress management and biofeedback Tinnitus retaining therapy

Acupuncture not found to be a benefit Pharmacologic Therapy Antidepressants no evidence Gingko biloba evidence is lacking. Drug Gingko Side Effects GI Headache Dizziness Palpitations Allergic skin reactions Bleeding and seizures! Vitamin A and zinc have been used, but no evidence. Comments Avoid in warfarin or antiplatelets

21

Eyelid Conditions
Pathophys Hordeolum Stye (most common) Glands of Zeis Small/superficial External towards the skin Meibomian Glands Larger Internal Point to skin or conjunctiva More prolonged course Usually staph aureus Assessment Unilateral, localized lid swelling, tenderness and redness. May occur with blepharitis. 48h Avoid touching the eye and rash hands afterwards Change compresses and towels after each use Do not let eye drops touch eye/lashes Warm compresses 10-15 mins, tid/qid. Massage afterwards. Hard boiled eggs Usually drains in 2 days. If longer, refer. Not recommended After incision Antibacterial e.g. bacitracin or erythromycin If cellulitis, erythromycin, cloxacillin or tetracycline Chalazion Chronic inflammation of meibomian gland. Painless, localized swelling. Most point towards conjunctiva. More common in - blepharitis - rosacea - seb dermatitis With recurrent, refer. May resemble stye, but without acute inflammatory signs. May press on eyeball for visual distortion Improvement a few days. Complete can take weeks to months Good eyelid hygiene Blepharitis Chronic Bilateral eyelids Can be mixed, anterior and posterior Can be associated with skin conditions. Can result in permanent damage e.g. scarring and damage to cornea See next page Irritation, burning and itching of the lid margins. Foreign body sensation, worst in mornings. Chronic Lid hygiene

Time Prevention

Lifestyle

Same

OTC Prescription

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

1. warm compresses 2. eyelid scrub with baby shampoo 3. mechanical expression my ophthalmologist Use once or twice daily at outbreak, or twice weekly when under control None Ointments after eyelid cleaning bacitracin and erthyromycin Steroids and antibacterials at breakout Posterior systemic tetra, doxy or minocycline. Erthyromycin when CI

Refer

If >2 days

Eye pain Photophobia Impaired vision Trauma Chemical exposure

If recurrent If large/painful No improvement within a few days Foreign body Heat exposure Eye protrusion Contact lens wearer >48 hours and no improvement

22

Blepharitis ANTERIOR STAPYLOCOCCAL BLEPHARITIS s. aureus and s. epidermitis inflammation and redness along anterior portion of eyelid. Scaly, crusts and ulceration in eyelids. Loss of lashes in chronic, recurrent styes SEBORRHEIC BLEPHARITIS Non-ulcerative More oily and greasy, less scaly. Will have sebborrheic dermatitis in other areas. POSTERIOR MEIBOMIAN SEBORRHEA Excessive glandular secretions. Photophobia, burning, oily and frothy tear film. Few signs of inflammations. MEIBOMIANITIS Inflammation and obstruction of glands. Can be diffused or localized. Soft cheesy substance expressed

CHALAZION ARE 1. LARGER 2. MAY NOT HURT Compared to styes SEE MINOR AILMENTS BOOK REGARDING PUTTING IN EYE DROPS

23

Conjunctivitis
Symptoms Foreign body sensation, scratching or burning sensation, fullness around the eyes and mild photophobia. Redness, crusty after sleeping. Viral Itching Redness Discharge Acute Bacterial Minimal Profuse, serous Generalized Moderate, white Chronic bacterial 4 weeks usually with other condition e.g. blepharitis s aureus Moraxella lacunata (makeup) Lid hygiene Warm compresses Viral Subconjunctical haem. Urti Watery discharge May spread from one eye to the other. Adenovirus Herpes (keratitis) 2-4 weeks Infectious 2 weeks after 2nd eye infected Children out of school for 1 week Antihistamines, lubricants NOT antivirals or steroids in adenovirus Bacterial Allergic Severe Moderate, serous or white Allergic Itching, tearing, red eye

Hyperacute Bacterial Self limiting, resolves in Neonates/sexuall 2 weeks. Can be y active young reduced to 1-3 days. people. V serious, S aureus sight threatening. S pneumoniae Neiserria G and M H influenzae Yellow green discharge. Bilateral in neonates Handwashing Warm compress Saline irrigation Replace eye drops Polysporin QID for 5-7 days, treat 2 days after it has resolved Trimethoprim / polymixin B Erythromycin Bacitracin Sylfacetamide sodium cheap and tolerated Aminoglycosides good for gram neg toxicity and allergic reactions Chloram aplastic anaemia Fluoroquinolones (oxacins for more serious infections e.g. keratitis Contact lens wearers If symptoms have not improved after 2 days with treatment Children Refer

Avoidance strategies, cold compresses Oral antihistamines Levocabastine and emedastine rapid onset. Olopatadine Nedocromin and lodoxamide. Ketorolac can decrease itching and redness Severe may need steroids

Refer immediately Refer Antibacterials (after gram staining) and irrigation. Ceftriaxone 1-2g IM in adults Spectinomycin or oral cipro can be used in penicillin allergic Topical antibacterials.

Doxy/erythro for meb gland Herpes zoster dysfunction or topical trifluridine severe acne and oral antivirals rosacea. Topical metronidazole for rosacea

Refer all

Refer all

Refer all

Refer moderate to severe Those who do not respond in 72h 24

Dry Eye
AGE
Females

SYMPTOMS
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 DE 2. Evapourative dry eye May overlap Hard to diagnose signs and symptoms may not concord Sandy foreign body experience. Worsens over day. Tired, difficulty moving lids, photophobia Increased tearing in some circumstances e.g. reading

MEDICATION
Anticholinergic drugs Amiodorone Antiandrogenic B blockers Diureticsinterferon Isotreniton HRT Benzalkonium chloride as a preservative in drops

EXTRA MEDICATION

TIME
Worsens over course of the day Refer if last more than 3-5 days

HISTORY
Environmental keeping eyes open Diet low in Vitamin A or omega 3 fatty acids Parkinsons

OTHER SYMPTOMS
Complications: 1. ocular surface erosions 2. epithelial damage 3. ocular surface keratinization 4. ulceration 5. perforation 6. scarring 7. reduced vision Prevention Remind patients about AC drugs Contact lens wearers clean lenses Blink more during concentrated tasks Blepharitis lid hygiene

DANGER SYMPTOMS
Refer anyone with autoimmune disease Symptoms to do resolve in 3-5 days or worsen Complications If preservative burn patients eyes

25

Non Pharmacologic Avoid smoking and smoky rooms Humidifiers Moisture chamber spectacles, ski masks Moist washcloth over closed lids Tear duct occlusion (by eye care practicioner) Factors for OTC choice

OTC Trial and error approach 1-2 week trial of everything with meibomian gland dysfunction, use omega 3 for factors to think about, see below

RX Opthalamic cyclosporine and loteprednol Sjogren oral pilocarpine Others Topical acetylcysteine, methylprednisolone, estradiol, periorbital IM injections of botulium toxin

1. ELECTROLYTE COMPOSITION Potassium maintains corneal thickness Bicarbonate 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 dont 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 gel Castor/mineral oil restore lipid layer Sodium hyaluronate viscosity 500,000x saline Carbomer 940 resembles an ointment, but less blurred vision than petroleum 5. CYTOTOXIC AGENTS EDTA can damage corneal epithelial cells Lanolin irritation to those intolerant to sheeps wool 6. PRESERVATIVES If application more than 4x day then use preservative free Benzalkonium chloride- toxic to corneal epithelium Oxidative preservative better e.g. polyquad, purite or sodium chlorite (vanishing) OINTMENTS USUALLY DO NOT REQUIRE PRESERVATIVES

26

Contact Lens Care

Rigid Glass Permeable (RGP) and soft Longetivity: 1. conventional >1 year 2. planned replacement (2 weeks, 1 month or every 3 months) 3. daily disposable Rigid Gas Permeable Combines optical qualities and durability with PMMA (hard lens) with oxygen permeability and comfort of soft lenses. Usually PMMA w silicone, flurosilicone acrylate Hydrophobic Sufficiently high o2 permeability to prevent corneal edema Good for 5 y Soft Lenses 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 Lens These are also available. Indicated for keratoconus and other corneal dystrophies. Soft lens solns used with these. Wear Schedules Conventional 1Y but due to compliance, planned replacement programs (PRPs) developed Daily 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. dopamine 2. sulfasalazine 3. phenylephrine 4. tetraydrozoline 5. pyridium 6. nitrofurantoin 7. rifampicin 8. tetracycline Refer:

1. pain when inserting/wearing/after wearing 2. burning that causes excessive tearing 3. inability to keep eyes open 4. severe/persistent haze, fog or haloes 5. redness, irritation, itching 6. poor vision 7. painful lid swelling 8. photophobia

27

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 Remove lens from eye SOFT Remove lens from eye

Clean with surfactant cleaner Rinse with soaking soln/saline

Clean with surfactant cleaner Rinse with rinsing soln Clean with enzyme cleaner every week then rinsing soln afterwards Store overnight in disinfectant (look at product for times) Rinse with rinsing soln

Store overnight in soaking soln

Rinse with soaking soln

Add a few drops of wetting soln to concave lens

Place on eye, rewet if required and discard used solutions

Place 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.

28

Ear Pain
Condition Ruptured tympanic membrane Earwax Acute bacterial OE Eczemateous otitis externa Otitis media Pain Yes (sudden and sharp) No (unless infected) Yes (acute) Itch No Frequently Sometimes Discharge Yes No (unless infected) Frequent Hearing loss Yes (abrupt) Yes (gradual) Sometimes Other comments Can happen with acute OM and barotrauma Fulness or pressure Pain when chewing, movement of auricle. Excessive moisture, trauma, scratching Will have other condition. May become infected Children URTI to follow Relieved with rupture of TM Fullness and pressure in ear Aire travel and diving. Tinnitus and vertigo may be present

Sometimes Yes (abrupt)

Yes No

Sometimes (oozing, crusting) Yes (if TM ruptures) If becomes infected Yes if TM Ruptures

Sometimes Sometimes

Foreign Body Barotrauma

Yes Yes

Sometimes No

Yes Yes

Refer: ear surgery in past 6 weeks Otalgia ear pain ruptured TM (acute onset hearing loss with pain) Otorrhea ear drainage 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 doesnt improve following resolution of nasal congestion Drug Related Ototoxicity Cisplatin ASA Loop diuretics Phosph type 5 Quinine Minocycline Aminoglycosides Macrolides

29

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

SYMPTOMS
Middle ear inflammation (acute ear pain, unilateral and developing over a few hours. Fever and reduced hearing) May occur with URTI Presence of middle ear effusion Acute onset

MEDICATION TIME
More present during winter months Refer if >72h Refer if chronic or reccurrent

EXTRA MEDICATION HISTORY

OTHER SYMPTOMS

DANGER SYMPTOMS
ALL CASES Otorrhea <6months history of chronic or reccurent craniofacial abnormalities if lasts longer than 72 hours

Wait and see approach Use 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.

30

Otitis Externa
AGE
Children 7-12, declines >50yrs

SYMPTOMS
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 EAC Acute localized: Due to a boil by S aureus. Pain, itch, redness, edema, absess Chronic thickening of skin due to infection and inflammation. Itch and dry flaky skin allergic contact dermatitis Ecsemateous OE Necrotizing diabetic or immunocompromized. Extends to mastoid or temporal bone. Systemic antibiotics required

MEDICATION TIME OTHER SYMPTOMS

EXTRA MEDICATION HISTORY DANGER SYMPTOMS

Edema and debis in EAC cleansing must be done first by physician If 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 bes 31

Eczematious Avoid offending product Apply aluminium acetate solution re-acidifying with topical steroid Prevention of re-occurance 1. after swimming or bathing, dry EAC with hairdryer on low/instill with acidifying or alcohol drops 2. avoid over cleaning and scratching 3. avoid cotton swabs 4. avoid water sports 7-10days after treatment

32

Impacted Earwax
AGE
More common in older aged people with hearing aids Refer if a child

SYMPTOMS
Sensation of fullness in the ear, hearing loss and discomfort

MEDICATION TIME OTHER SYMPTOMS

EXTRA MEDICATION HISTORY

History of cleaning with cotton swabs

DANGER SYMPTOMS
Injuried ear Perforated TM Recent ear surgery TM tubes Drainage from ear Hearing loss Tinnitus or dizziness Child 3-4 days or 5-7 days with oil based product. Should get relief straight after syringing.

Prevention Olive oil, light mineral oil, hydrogen peroxide, glycerin and sodium biocarbonate Treatment Syringing (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 ONESELF Contraindicated 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.

33

URTI
Symptom Nasal discharge & congestion Fever Sore throat Cough Headache Aches & pain Other Duration Etiology Cold Clear, then mucopurulent Congestion is common Rare Common(mild) dry, scratchy Mod to moderate Dry -> prod Rare, via sinus congestion Mild Sneezing in first few days 5-7 days, up to 14 days Viral Allergic rhinitis Loads clear. Congestion aswell no no Yes if postnasal drip via sinus congestion Earaches (in children) Itchiness, watery eyes, sneezing As long as exposed Not infectious Flu Clear, then mucopurulent CONGESTION IS RARE Yes sudden onset Sometimes Nonproductive Yes Common Sinusitis Persistent rhinorrhea Yellow/green possible no Yes if postnasal drip via sinus congestion Rare Pharyngitis Rare

Yes Severe, sudden onset rare no possible no 3 days Viral>bacterial

Fatigue, Facial weakness, n&V tenderness, toothache 10 days Days to weeks Viral All

Croup is a barking cough, usually unproductive. Inspiratory stridor, dyspnea and fever= refer REFER: 1. Difficulty breathing, wheezing, stridor, chest pain 2. History of respiratory disease 3. Difficulty swallowing 4. Fever >38.5 for >72h 5. Cough>3wks 6. Severe throat pain 7. Severe headache, neck pain 8. Prolonged nasal congestion with mucopurulent discharge Child: 1. Symptoms of croup/ear infection 2. Excessive lethargy/irritability 3. Skin rash 4. Cough with vomiting 5. Dehydration in infant 6. <3months with fever Severe symptoms with reduced fluids intake

34

Allergic Rhinitis
AGE
Children have 30% chance if one parent affected and 50% if both Usually peaks in early twenties/later teens and decreases >45yrs Refer <2 yrs

SYMPTOMS
Seasonal spring to fall Perennial all year Non-Allergic acute and chronic

MEDICATION
Overuse of topical decongestants ACE NSAIDs Bblockers Chlorpromazine Sildenafil Phentolamine Prazosin Reserpine Oral contraceptives Cocaine Methyldopa

EXTRA MEDICATION
Overuse of topical decongestants!!!

TIME
Refer if tried OTC >2weeks and no response

HISTORY
Hypothyroidism and pregnancy can cause it as well as menustration Refer if comorbid illness Refer if allergen not identified

OTHER SYMPTOMS

DANGER SYMPTOMS

Tearing, stuffy or runny nose, itchy face, sneezing Refer if tried OTC >2weeks and no response If allergen not identified Fever Purulent discharge <2yrs old co-morbid illness e.g. asthma can 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

35

Prevention
Pollen Keep windows 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 Outdoor Molds Remain in closed environment for as much as poss Keep air conditioning on indoor cycle (can still be v contaminated) Use face masks when raking leaves etc Indoor molds Use fungiside on 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 House dust mites Animal Avoid carpet Remove pet trial not good. Can take Plastic, leather or 20 weeks for cat wood furniture allergens to be good gone 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 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

36

Treatment Antihistamines Generally do not relieve nasal congestion. 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 Cromoglicate Delayed for up to 4 weeks. Less effective Decongestants Oral 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 Children Pediatric 1st gen antihistamines - >6months Nasal steroids >4yrs Decongestants>6years Pregnancy Nasal steroids ok Antihistamines ok Avoid oral decongestants in 1st trimester Topical decongestant ok

37