Scenario A (Ears)

Mr RI, a middle-aged man, comes into the pharmacy and asks for your advice. Over the last
couple of weeks, he feels that his hearing, particularly in his left ear has become
‘progressively deaf’, and the ears feel ‘full up’. He has no other symptoms, has not tried
anything already and nor does he take any medication. Upon further discussion, Mr RI
mentions that he had his ears ‘syringed’ a couple of years ago by the nurse at the GP’s
surgery, and thinks he may need to go again, but wonders whether he should use the ear
drops advertised on TV last week as it would save him the trip.
Questions
1a What is the cause of the symptoms?
1b What are the risk factors for developing this condition?
2 What is the general management of this condition in a community pharmacy setting?
3 How do the products generally used to treat the condition work?
4 How can a product’s formulation affect the outcome of treatment for the condition?
5 What advice can you give to help the patient manage this condition?

Scenario B (Conjunctivitis)
Mr JM, a 45-year-old man, comes into the pharmacy on a Friday evening in June, wishing to
speak to you. A couple of days ago, he woke to find that his left eye felt ‘gritty’ and was ‘all
stuck together with whitish pus’. When he cleaned the pus away, he saw that his eye was
‘reddish’ in colour, and noticed a few ‘lumpy’ patches on the lower part of the white of the
eye, which worried him, so he has tried not to touch the other eye. Upon further discussion,
he reveals that his vision is fine and that sometimes he gets ‘hayfever’ in the eyes. He also
takes metformin and gliclazide tablets. He states that his wife had ‘watery red eyes’ last week
and is using the ‘antibiotic eye drops’ recently advertised on the television, and asks if he
should use the drops as well.
Questions
1. What is the cause of the symptoms?
2. What symptoms would necessitate a referral to a medical practitioner?
3 What is the general management of this condition in a community pharmacy setting?
4 What is the goal of therapy and the role of the pharmacist in the management of this
condition? How do the products generally used to treat the condition work? How can a
product’s formulation affect the outcome of treatment for the condition?
5 What advice can you give to help the patient manage this condition?

Scenario C (Hayfever)
It is March and Mr JA, a 20-year-old university student, comes into a community pharmacy
to buy something for a runny nose. On questioning he has had symptoms for the last eight
weeks which he thought was a head cold and has been self-medicating with Vicks Sinex
nasal spray and Sudafed tablets. His runny nose, frequent sneezing and runny eyes are
continuing to be troublesome and he is worried about his forthcoming exams. Mr JA’s
previous medical history includes porphyria and childhood asthma. His past drug history
comprises salbutamol inhaler and beclometasone inhaler for childhood asthma.
Questions
1.What is allergic rhinitis and how does it differ from cold symptoms?
2 What are the trigger factors for hay fever?
3 What are the treatment options for hay fever?
4 What is the management plan for Mr JA’s current symptoms? Four weeks later Mr JA
returns to the pharmacy complaining that his eyes are still running and are now itchy and he
now cannot wear his contact lenses and although the sneezing has improved he is still
suffering from itchy throat and occasional cough.
5 What further treatment options are now available?
6 What are the side-effects of nasal corticosteroids and are there any long-term
complications?
7 Mr JA asks about complementary medicines as he does not want to take medications long
term. What would you advise? 8 What is the long-term management plan for Mr JA?

Scenario D (Sinusitis)
Mr JC, age 21, who has recently changed his job to become a painter and decorator, comes
into your pharmacy and complains of severe nasal congestion, headache and blurred vision
for 3 days. His has recently suffered cold symptoms. He took two paracetamol tablets which
helped briefly. A friend has advised that he takes an antihistamine to treat these symptoms.
And he asks for your advice and recommendations. Mr JC tells you he had childhood asthma
and is allergic to penicillin.
Questions
1.What other questions do you need to ask this patient to help with a working diagnosis?
2 Mr JC has had a greenish yellow discharge for the last 3 days together with facial pain
around the eyes and nose. He complains of a loss of sense of smell and taste since having the
cold symptoms last week. He has not developed a temperature. What is the possible
diagnosis?
3 Due to the presence of a number of the above symptoms you believe Mr JC has acute
sinusitis. What are the predisposing factors for sinusitis?
4 What are the treatment options?
5 Should the patient be given beclometasone nasal spray?
6 A week later Mr JC returns to the pharmacy with a slight improvement of his symptoms
until yesterday when he developed fever and dizziness and slight hearing loss and ear pain.
What would you now recommend?
7 The new junior GP calls you and asks your advice on which antibiotic to prescribe.
8 Mr JC returns to the pharmacy with a prescription for doxycycline 100 mg 2 stat then 1
daily for 7 days. How would you counsel this patient?

Scenario E (Glaucoma)
Mr George Smith, 61 years old, presents you with his repeat prescription. He is concerned
that one of his medications is affecting his vision and asks you to identify the one that is
likely to be causing this. His present medical history includes chronic obstructive pulmonary
disease (COPD) and urinary incontinence. The pharmacy Patient Medication Record (PMR)
includes latanoprost drops for glaucoma which was dispensed six months ago. Mr Smith’s
current and past drug histories are as follows: Current drug history:: ■ Seretide 500
Accuhaler, one puff twice daily ■ salbutamol inhaler two puffs p.r.n. ■ salbutamol nebuliser
solution 5 mg, one 3–4 times daily ■ ipratropium bromide nebulising solution 500
micrograms/2 mL, one four times daily ■ tolterodine 2 mg twice daily ■ tetracycline 250 mg
two twice daily ■ hypromellose 0.3% drops p.r.n. Past drug history: ■ latanoprost 50
micrograms/mL one drop at night ■ tolterodine, first prescribed about six months ago for
urinary incontinence by an urologist consultant. Patient’s COPD seems to be controlled on
combination of inhalers and nebuliser solution. He would use salbutamol and ipratropium
solution 2–3 times a day, but when his COPD got worse, he would increase to 4–6 times
daily. Urinary incontinence appears to be under control at present but he has been
experiencing extreme dry mouth and eyes. In recent weeks, he has noticed significant
deterioration in his vision with slight redness in both eyes. He puts this down to ‘just getting
old’. However he is due to see his eye consultant in six months’ time. The last appointment
was about six months ago. The consultant decided to stop latanoprost eye drops and told him
everything is normal.
Questions
1 What is glaucoma, define different types and why is it important to be treated when
diagnosed?
2 What are the risk factors for developing glaucoma? Identify the possible causes of
worsening of his glaucoma condition.
3 Why are some drugs contraindicated in certain diseases even if they are given as eye drops?
4 How does latanoprost work in the treatment of glaucoma? Discuss the range of drugs and
route of administration that can be used to treat this patient’s glaucoma.
5 What other treatment options are available for treating this patient’s incontinence?