DOCTOR-PATIENT COMMUNICATION

EXERCISES

Edition 1

Department of Pharmacology, JIPMER

Copyright: Department of Pharmacology, JIPMER, 2020

 CONTRIBUTORS

Faculty

Dr. Jayanthi. M. Additional Professor & Head

Dr. Raveendran. R, Professor (Senior scale)
Dr. Manikandan. S, Additional Professor
Dr. Girish. C, Associate Professor
Dr. Kesavan. R, Associate Professor
Dr. Harivenkatesh. N, Assistant Professor
Dr. Priyadharsini. R, Assistant Professor
Dr. Mirunalini. R, Assistant Professor
Dr. Suganthi. S, Assistant Professor
Dr. Anusha. N, Assistant Professor

Senior residents
Dr. Kiruthika. S
Dr. Dharam Prasad. D
Dr. Suja Xavier
Dr. Ilanthamizhan. J

Junior residents
Dr. Vivek Raj. N
Dr. Priyadarshini. B
Dr. Niveditha. K. Gowda
Dr. Ranjan. K. M.
Dr. Sathya. V
Dr. Lakshmi. B
Dr. Subhiksha. S
Dr. Shanmugarajan. D
Dr. Shravan. V
Dr. Muthumeera. R
Dr. Sridevi. R
Dr. Balaga Hemalatha
Dr. Reka. D
Dr. Vishnu Eriyat
Dr. Hemamalini. R
Dr. Surya. S
Dr. Kalaimani. S

Compiled by

Dr. Vivek Raj

Dr. Suja Xavier
Dr. Suganthi. S
Dr. Mirunalini. R
 Contents

S.No Case scenarios Page

no
1. Isosorbide dinitrate for angina 1
2. Nitroglycerin transdermal patch for angina 3
3. Low dose aspirin for ischemic heart disease 6
4. Clopidogrel for ischemic heart disease 9
5. Warfarin for deep vein thrombosis 11
6. Hydrochlorothiazide for hypertension 13
7. Enalapril for hypertension 15
8. Atenolol for hypertension 17
9. Furosemide for heart failure 19
10. Metoprolol for heart failure 21
11. Salbutamol dry powder inhaler for bronchial asthma 23
12. Salbutamol metered dose inhaler for bronchial asthma 26
13. Salbutamol metered dose inhaler with spacer for bronchial asthma 29
14. Carbamazepine for trigeminal neuralgia 32
15. Sodium valproate for generalized tonic clonic seizures 34
16. Phenytoin for generalized tonic clonic seizures 36
17. Oral contraceptive pills for contraception 38
18. Propranolol for hyperthyroidism 41
19. Levothyroxine for hypothyroidism 43
20. Insulin for type 2 diabetes mellitus 45
21. Bisacodyl for constipation 48
22. Oral rehydration solution for diarrhoea 50
23. Antitubercular therapy for newly diagnosed tuberculosis 52
24. Doxycycline for malaria chemoprophylaxis 55
25. Metronidazole for amoebic dysentery 57
26. Ferrous sulphate for iron deficiency anaemia 59
27. Folic acid for megaloblastic anaemia 61
28. Ibuprofen and methotrexate for rheumatoid arthritis 63
29. Topical betamethasone for psoriasis 65
30. Nicotine gum for smoking cessation 67
 General instructions to be followed by the
doctor in doctor-patient communications

A doctor should adhere to the following criteria, which is commonly

referred to as ‘GATHER’ approach for better and effective
communication with the patient.
 Greet the patient

 Ask about complaints

 Tell them about treatment options available

 Help patients to decide

 Explain the use of medication

 Return visit plan

Apart from these general instructions, every doctor should try to
employ additional criteria to cater to the needs of the patients in
specific scenarios.
 Scenario 1

Isosorbide dinitrate for angina

1
Give instructions for a 45 year old patient with a history of acute angina attacks regarding the
use of Tab. ISOSORBIDE DINITRATE 10 mg

 You have been diagnosed with a condition called angina which is a chest pain that happens
due to reduced oxygen supply to your heart muscles.

 I’m prescribing you a tablet, isosorbide dinitrate at a dose of 10 mg. It is used for prevention,
not treatment.

 The tablet works by widening veins, bringing less blood back to the heart from the rest of
the body thus reducing the strain on the heart and increasing the blood supply to the heart.

 Take the tablet 3 times a day. Take the last dose before 6 pm. Do not take 2 doses together
even if you missed the previous dose.

 Timing of intake is very important for this drug. If you take this drug at frequent intervals,
it may not work as expected. There should be a minimum of 14 hours “nitrate-free" period
each day to avoid tolerance.

 You may experience headache and flushing for 1-2 weeks, it will subside with time. You
may experience lightheadedness on standing, especially just after rising from a lying or
seated position.

 Do not take this along with any medicine for erectile dysfunction as it can produce a
dangerous fall in your blood pressure.

 If you experience chest pain during the course of therapy, take sublingual nitroglycerin 0.4
mg immediately and repeat up to three tablets in a 15 minutes interval, if chest pain persists.
Report to the emergency department at the earliest.

 It should be stored in a cool place, away from direct sunlight.

 Review after two weeks.

2
 Scenario 2

Nitroglycerin transdermal patch for angina

3
Give instructions for a 50 year old male with chronic stable angina regarding the use of
NITROGLYCERIN transdermal patch

 You have been diagnosed with a condition called angina which is a chest pain that happens
due to reduced oxygen supply to your heart muscles.

 I’m prescribing you an adhesive patch that delivers the medicine called nitroglycerin
through the skin and into the bloodstream.

 Nitroglycerin is used to prevent or reduce the frequency of angina attacks (chest pain or
discomfort).

 You will have to apply a patch once each day, usually in the morning.

 You should remove the patch at bedtime and put a new one on when you wake up in the
morning. This "patch off" period may make the medicine more effective.

 It must be applied in an area of clean dry skin that has no sores, cuts, or rashes. The chest
area is most preferred. Other sites you may apply the patch are upper arm, back, abdomen
and thigh. You should avoid applying to regions like below knee and elbow, and skin folds.

 If the skin is very hairy, you can clip the hair (do not shave it) so that the patch sticks well
and will not be hard to remove.

 Use a different area of skin each day. Wait several days before using the same area again.

 Press the patch firmly in place with the palm of your hand for 10 to 20 seconds. The patch
needs the pressure and heat of your hand to stick well.

4
 Common side effects reported are headache, dizziness, light-headedness and fainting due
to decreased blood supply to the brain. If you use any pill for erectile dysfunction together
with this medicine, your blood pressure may fall to a dangerously low level.

 If you experience chest pain during therapy, take sublingual nitroglycerin 0.4 mg
immediately and repeat up to three tablets in a 15 minutes interval, if chest pain persists.
Report to the emergency department at the earliest.

 Review after two weeks.

5
 Scenario 3

Low dose aspirin for ischemic heart disease

6
Give instructions for a 55 year old patient with ischemic heart disease who is prescribed
Tab. ASPIRIN 150 mg

 You have been diagnosed with a condition called ischemic heart disease, commonly known
as heart attack, where the risk of clot formation is high in the blood vessels of the heart. It
leads to the reduced blood supply to the heart leading to chest pain.

 I’m prescribing you a tablet aspirin at low dose of 150 mg. It is blood thinner that brings
down the risk of heart attack by reducing chances of clot formation.

 Take one tablet each day with a full glass of water after food; Do not crush or chew these
tablets as they are specially coated.

 This drug can cause gastrointestinal mucosal irritation, causing upper abdominal pain and
could aggravate gastric ulcer. Do not take over the counter painkillers, which also have
similar side effects.

 You would have increased risk of bleeding, and thus it is vital to take increased care in case
of injuries /bruises.

 It is very important to inform any doctor/nurse about the intake of this drug (aspirin) before
any medical/surgical procedures.

 If you experience any unusual bleeding, report to the hospital immediately.

 Do the regular exercise of mild to moderate intensity (150 minutes/week approx.). Do not
engage in unaccustomed heavy work.

 Avoid smoking and alcohol consumption.

 Have a diet rich in vegetables, fruits, legumes, nuts, whole grains, fish, polyunsaturated fatty
acids. Reduce salt, trans fat intake. Minimize consumption of processed meat, refined
carbohydrates and sweetened beverages. Have adequate sleep.

7
  Do not stop the drug without consulting your physician.

 Review after 2 weeks

Note:

For asthmatic patients: Taking aspirin may worsen your asthma symptoms. If you develop asthma
exacerbation, please report to the hospital immediately.

8
.

Scenario 4

Clopidogrel for ischemic heart disease

9
Give instructions for a 65 year old male patient with ischemic heart disease who is
prescribed Tab. CLOPIDOGREL 75 mg

 You have been diagnosed with a condition called ischemic heart disease, commonly
known as heart attack, where the risk of clot formation is high in the blood vessels of the
heart. It leads to the reduced blood supply to the heart leading to chest pain.

 I’m prescribing you tablet clopidogrel at dose of 75 mg. It is blood thinner that brings
down the risk of heart attack by reducing chances of clot formation.

 Take one tablet every day at the same time.

 Since you would have increased risk of bleeding, it is vital to take increased care in case
of injuries /bruises.

 It is very important to inform any doctor/nurse about the intake of this drug (aspirin) before
any medical/surgical procedures.

 If you experience any unusual bleeding (bleeding in gums, bloody stools, blood in urine
etc), report to the hospital immediately

 Do not take over the counter medications like pain killers.

 A gastric ulcer drug, omeprazole, will decrease the effect of clopidogrel. Hence, it should
not be taken without doctor's advice.

 Do not stop the medication without consultation.

 Review after 1 month.

10
 Scenario 5

Warfarin for deep vein thrombosis

11
Give instructions for a 60 year old patient with venous thromboembolism who is
prescribed Tab. WARFARIN 2 mg
 You have been diagnosed with a condition called venous thromboembolism wherein the risk
of clot formation is high in the deep veins of your legs. If left untreated, it can lead to serious
complications. The clots can dislodge and block the blood supply to your lungs.

 I’m prescribing tablet warfarin at the dose 2 mg which will increase the time for your blood
to clot in your blood vessals.

 Take one tablet every day at a fixed time of the day. Do not take more than the prescribed
dose even if you have missed the dose as it can increase serious bleeding risk.

 The dose of the tablet will be adjusted based on a test report called INR. This test has to be
done frequently to adjust the dose so as to make sure the drug works properly without
increasing the bleeding risk.

 Since you would have increased risk of bleeding, it is vital to take increased care in case of
injuries /bruises.

 It is very important to inform any doctor/nurse about the intake of this drug (aspirin) before
any medical/surgical procedures.

 If you experience any unusual bleeding (bleeding in gums, bloody stools, blood in urine etc),
report to the hospital immediately

 Avoid eating more than one serving of green leafy vegetables per day since it may decrease
the activity of the drug

 Review after 2 days with INR report for follow-up.

Note:
For reproductive-age women: Avoid pregnancy while on warfarin as it can harm the fetus. If
you take birth control pills while on warfarin, the contraceptive action may be lost. Use
alternate methods of contraception.

12
 Scenario 6

Hydrochlorothiazide for hypertension

13
Give instructions for a 50 year old patient with hypertension who is prescribed Tab.
HYDROCHLOROTHIAZIDE 12.5 mg.

 You have been diagnosed with hypertension, a condition where your blood pressure remains
high. If left untreated, it can lead to heart disease and kidney problems.

 I am prescribing you a tablet called hydrochlorothiazide 12.5 mg, which will excrete excess
water and sodium from your body and will keep your blood pressure under control.

 Take one tablet of hydrochlorothiazide 12.5 mg every day, once in the morning.

 You might notice that you urinate more frequently. It is normal. Take your dose at maximum
before 4 PM so that you will not be disturbed in your sleep.

 If you notice any muscle cramps or excessive fatigue or dyspnoea, please report
immediately.

 You will have to take the medication life long as hypertension requires long term treatment
and stopping the treatment will result in complications.

 Reduce the amount of salt intake up to 2 grams per day in your food. Avoid pickles, papads
or noodles. Have a diet rich in vegetables, fruits, legumes, nuts, whole grains, fish,
polyunsaturated fatty acids. Minimize consumption of processed meat, refined
carbohydrates, and sweetened beverages.

 Do regular exercise of mild to moderate intensity (150 minutes/week approx.).

 Avoid smoking and alcohol consumption. Have adequate sleep.

 Maintain a diary recording of your blood pressure either at home or in the nearest health
care facility for the next month.

 Review after one month.

14
 Scenario 7

Enalapril for hypertension

15
Give instructions for a 55 year old hypertensive patient who is prescribed Tab.
ENALAPRIL 5 mg

 You have been diagnosed with hypertension, a condition where your blood pressure
remains high. If left untreated it can lead to heart disease and kidney problems.

 I am prescribing you a tablet called enalapril which will keep your blood pressure under
control

 Take one tablet of enalapril 5 mg every day once in the morning after food.

 Do not stop medication on your own, as hypertension requires long term treatment and
stopping the treatment will result in complications.

 If you experience dry cough, dizziness or skin rash which might occur in some patients,
you need to report immediately.

 Reduce the amount of salt intake up to 2 grams per day in your food. Avoid pickles, papads
or noodles. Have a diet rich in vegetables, fruits, legumes, nuts, whole grains, fish,
polyunsaturated fatty acids. Minimize consumption of processed meat, refined
carbohydrates, and sweetened beverages.

 Do regular exercise of mild to moderate intensity (150 minutes/week approx.).

 Avoid smoking and alcohol consumption. Have adequate sleep.

 Maintain a diary recording of your blood pressure either at home or in the nearest health
care facility for the next one month.

 Review after one month.

Note:
For reproductive-age women: Avoid pregnancy while on warfarin as it can harm the fetus.

16
 Scenario 8

Atenolol for hypertension

17
Give instructions for a 35 year old patient with hypertension who is prescribed Tab.
ATENOLOL 25 mg

 You have been diagnosed to have hypertension, a condition with increased blood pressure

 I am prescribing this drug, atenolol to control your blood pressure (BP), so that your BP
can be in the optimal range to maintain vital organ function

 You must take one tablet of atenolol 25 mg in the morning daily for one month

 The effect of the drug may take 4 to 6 weeks to become evident

 Do not stop medication on your own, as hypertension requires long term treatment and
stopping the treatment will result in complications.

 This drug may cause sedation, sleeplessness, and tiredness as side effects.

 Reduce the amount of salt intake up to 2 grams per day in your food. Avoid pickles, papads
or noodles. Have a diet rich in vegetables, fruits, legumes, nuts, whole grains, fish,
polyunsaturated fatty acids. Minimize consumption of processed meat, refined
carbohydrates, and sweetened beverages.

 Do regular exercise of mild to moderate intensity (150 minutes/week approx.).

 Avoid smoking and alcohol consumption. Have adequate sleep.

 Maintain a diary recording of your blood pressure either at home or in the nearest health
care facility for the next one month.

 Review after one month.

18
 Scenario 10

Furosemide for heart failure

19
Give instructions for a 50 year old patient with mild congestive cardiac failure who is
prescribed Tab. FUROSEMIDE 20 mg

 You have been diagnosed with heart failure, a condition where your heart does not pump
blood effectively

 I am prescribing you tablet furosemide which will excrete excess water and sodium from
your body by increasing urine production and thereby will help your heart to function
better

 Take one tablet of furosemide 20 mg every day, twice, once in the morning and once in
the afternoon along with meals.

 You might notice that you urinate more frequently. It is normal. Take your evening dose
before 4 PM so that you will not be disturbed in your sleep.

 If you notice muscle cramps, excessive fatigue, oedema or dyspnoea, report

immediately

 Do not stop medication on your own, as heart failure requires long term treatment and
stopping the treatment will result in problems.

 Maintain a diary recording of your weight every day at the same time before breakfast.
If you notice any sudden increase or decrease in weight, report immediately.

 Reduce the amount of salt intake in your food and restrict your fluid intake. Do not take
pickles, papads or cheese.

 Avoid smoking or consuming alcohol and eat more green leafy vegetables. Avoid high
calorie fatty diet

 Do regular exercise of mild to moderate intensity until you tolerate.

 Review after 2 weeks

20
 Scenario 10

Scenario 10

Metoprolol for heart failure

21
Give instructions for a 50 year old patient with heart failure who is prescribed Tab.
METOPROLOL 50 mg

 You have been diagnosed with heart failure, a condition where your heart does not pump
blood effectively.

 I am prescribing you tablet metoprolol which will help your heart function better. Take one
tablet of metoprolol 50 mg every day, once in the morning.

 Do not crush the tablet. Take it orally.

 If you experience muscle cramps, excessive fatigue, difficulty in breathing, abnormal

heartbeat, dizziness, report immediately.

 Do not stop medication on your own, as heart failure requires long term treatment and
stopping the treatment will result in problems.

 Maintain a diary recording of your weight every day at the same time before breakfast. If
you notice any sudden increase or decrease in weight, report immediately.

 Reduce the amount of salt intake in your food and restrict your fluid intake. Avoid pickles,
papads or noodles. Have a diet rich in vegetables, fruits, legumes, nuts, whole grains, fish,
polyunsaturated fatty acids. Minimize consumption of processed meat, refined
carbohydrates, and sweetened beverages.

 Do regular exercise of mild to moderate intensity until you tolerate.

 Avoid smoking and alcohol consumption. Have adequate sleep.

 Review after 1 month.

Note:
Do not change the brand of the medicine on your own as it may affect the effectiveness of the
treatment.(Metoprolol succinate zero order prolonged release should be used in heart failure)

22
 Scenario 11

Salbutamol dry powder inhaler

for bronchial asthma

23
Give instructions for a 30 year old bronchial asthma patient regarding the use of dry
powder inhaler (Rotahaler)

 You have been diagnosed to have asthma which is the attacks of breathing difficulty due to
severe airway narrowing in your lungs.

 To treat this condition, I have prescribed you a drug called salbutamol in a capsule and a
dry powder inhaler called rota-haler.

 Salbutamol reverses the airway narrowing and helps you to breathe at ease. Hence it is very
important to take this drug whenever you are having an attack.

 This device is called rota-haler. It has a mouthpiece, drug powder chamber and a hole to
insert the capsule. The whole device can be dismantled into two parts for the ease of
cleaning

 You should hold the rota-haler vertically and put the capsule into the square hole. While
inserting the capsule, the clear (transparent) end of the capsule should get in first. Make sure
that the top of the rotacap is level with the top of the hole.

 If there is a capsule already in the device, then that should be pushed into the shell with a
new one. Now hold the rota-haler horizontally and twist the barrel sharply forwards and
backwards. This will help to split the capsule into two parts, and you can see the broken
parts and powder in the chamber.

 Now breathe out gently and keep the mouthpiece of rota-haler between the upper and lower
front teeth and seal with lips. Breathe in the powder quickly and deeply. Remove rota-haler
from the mouth and hold breath for about 10 seconds. If any powder is left repeat the same
procedure. Open the rota-haler and discard the empty capsule.

 After taking this drug, you can perceive the improvement in breathing and wheezing sound
will decrease. The effort of the breathing will become easy. This will assure that the drug
is working, and you are improving.

24
 You should hold the breath for at least 10 seconds. If you can also try to hold the breath
more than 10 seconds to 45 seconds. Wait for 5 minutes and if you feel you are not
improving then take another capsule.

 You should call emergency service at the third doses if you are still not better and
meanwhile trying the fourth dose.

 Sometimes you may develop fine tremors, elevated heart rate. These are usually harmless
and will subside in due course. If you develop any severe cough during drug inhalation
and you cannot tolerate then report immediately.

 Clean the rota-haler frequently and dry it before its next usage. Always gargle the mouth
as soon as you feel better after an attack. It will help to remove drugs deposited in the
throat and prevent unwanted side effects.

 Ask the patient to demonstrate the usage of rota-haler.

 Review after 2 weeks.

25
 Scenario 12

Salbutamol metered dose inhaler for

bronchial asthma

26
Give instructions for a 22 year old with bronchial asthma regarding the use of metered
dose inhaler

 You have been diagnosed to have asthma which is the attacks of breathing difficulty due to
severe airway narrowing in your lungs

 To treat this condition, I have prescribed you a drug called salbutamol as a metered dose
inhaler(MDI).

 Salbutamol reverses the airway narrowing and helps you to breathe at ease. Hence it is very
important to take this drug whenever you are having an attack

 This device is called metered dose inhaler which will deliver the drug directly to your lung.

 It has a mouthpiece and drug canister which can be pressed to deliver the drug.

 You should hold the MDI vertically. Now gently shake the MDI for 3-4 times. Now breathe
out gently and keep the mouthpiece of MDI between the upper and lower front teeth and
seal with lips. Press the canister once while taking the breath. Try to hold your breath for at
least 10 seconds

 After taking this drug, you can perceive the improvement in breathing and the wheezing
sound will decrease. The effort of the breathing will become easy. This will assure that the
drug is working, and you are improving.

 You should hold the breath for at least 10 seconds. If you can also try to hold the breath
more than 10 seconds to 45 seconds. Wait for 5 minutes and if you feel you are not
improving then take another dose. You should call emergency service at the third doses if
you are still not better and meanwhile trying the fourth dose.

27
 Sometimes you may develop fine tremors, elevated heart rate. These are usually harmless
and will subside in due course. If you develop any severe cough during drug inhalation
and you cannot tolerate then report immediately.

 Clean the MDI frequently and dry it before its next usage. As soon as you feel better after
an attack, do gargling of the throat with plain water. It will help to remove the drug
deposited in the throat and prevent unwanted side effects.

 Please always have an extra fully loaded canister with you in case of emergency use. You
can check the remaining medicine in the canister by viewing the dose counter or you can
use calendar methods.

 Ask the patient to demonstrate the usage of MDI.

 Review after 2 weeks.

28
 Scenario 13

Salbutamol metered dose inhaler with

spacer for bronchial asthma

29
Give instructions to the parent of a 5 year old child with bronchial asthma regarding the
use of metered dose inhaler with a spacer

 Your child has been diagnosed as having asthma which involves the attacks of breathing
difficulty due to severe airway narrowing in the lungs.

 To treat this condition, I have prescribed your child a drug called salbutamol as a metered
dose inhaler (MDI). Since it is slightly difficult for your child to use this, I have advised an
additional aiding instrument called spacer.

 Salbutamol reverses the airway narrowing and helps you to breathe at ease. Hence it is very
important to take this drug whenever you are having an attack.

 This device is called metered dose inhaler which will deliver the drug directly to your lung.
It has a mouthpiece and drug canister which can be pressed to deliver the drug. The other
one is called spacer.

 Your child is too young to have proper coordination for breathing the drug in and out with MDI.
The spacer will help to store the drug temporarily and your child can breathe easily with that.
Spacers can make it easier for medication to reach the lungs, and mean less medication gets
deposited in the mouth and throat, where it can lead to irritation

 You should hold the MDI vertically and gently shake it for 3-4 times. Remove the cap from
your inhaler, and from your spacer. Inhaler’s mouthpiece should be fixed into a spacer. Ask
your child to breathe out.

 Now bring the spacer to your child’s mouth, put the mouthpiece between his teeth and ask
him to close his lips around it. Press the top of the inhaler once. Ask him to breathe in very
slowly until he can reach the maximum. Ask him to hold his breath for about ten seconds
and then breathe out into the spacer. He can repeat this several times.

30
 After taking this drug, your child can perceive the improvement in breathing and the
wheezing sound will decrease. The effort of the breathing will become easy. This will assure
that the drug is working, and your child is improving.

 Wait for 5-10 minutes and if you feel your child is not improving then give another dose.
You should call emergency service at the third doses if your child is still not getting better
and meanwhile try the fourth dose.

 Sometimes your child may develop fine tremors or elevated heart rate. These are usually
harmless and will subside in due course.

 Clean the MDI and spacer frequently and dry it before its next usage. The spacer should not
be wiped with a towel or other clothes during cleaning. Better to dry it by air only.

 As soon as your child recovers from an attack, ask him to do gargling of the throat with
plain water. It will help to remove the drug deposited in the throat and prevent unwanted
side effects.

 Please always have an extra fully loaded canister with you in case of emergency use. You
can check the remaining medicine in the canister by viewing the dose counter or you can
use calendar methods.

 Ask the patient to demonstrate and ask to come for review after 2 weeks

31
 Scenario 14

Carbamazepine for trigeminal neuralgia

32
Give instructions for a 28 year old who is prescribed Tab. CARBAMAZEPINE 100 mg
for trigeminal neuralgia

 You have been diagnosed with trigeminal neuralgia, which is a condition that causes
recurring severe pain in parts of your face due to affliction of the trigeminal nerve.

 I’m prescribing you tablet carbamazepine 100 mg that acts by inhibiting the impulses
generated in the trigeminal nerve.

 It may take 1 to 2 days for the symptoms to ease.

 A low dose is started and built up gradually until a dose is reached that stops the pain.

 You should then take it regularly to prevent pain from returning.

 You must take carbamazepine until about a month after the pain has stopped. The dose
may then be reduced gradually and stopped if possible.

 Common side-effects are drowsiness or tiredness which are only temporary. You may
sometimes experience disturbances in eyesight and balance; report to your physician if
you develop these symptoms.

 Report immediately, if you develop any of the following: fever, sore throat, rashes,
yellowing of your skin, abdominal pain.

 The drug should not be taken with other medications like phenytoin, phenobarbitone
and valproate as they induce each other’s metabolism.

 Review after 2 weeks.

33
 Scenario 15

Sodium valproate for generalized tonic clonic

seizures (GTCS)

34
Give instructions for a 50 year old patient with generalized tonic clonic seizure who is
prescribed Tab. SODIUM VALPROATE 200 mg
 You have been diagnosed with generalised tonic-clonic seizure (GTCS). A seizure is a short
episode of symptoms caused by a burst of abnormal electrical activity in your brain.

 I am prescribing you a tablet called valproate that works by stabilising the electrical activity
of your brain, which prevents the seizures from occurring.

 You need to take tablet valproate 200 mg three times a day every day after food.

 Try to take your doses of valproate at the same time each day. This will help you to avoid
missing any doses.

 If you forget to take a dose, take it as soon as you remember unless it is nearly time for your
next dose, in which case leave out the missed dose. Do not take two doses together to make
up for a missed dose.

 Common side-effects are loss of appetite, vomiting, heartburn, drowsiness, loss of balance
and shakiness.

 Long-term use of valproate may cause weight gain and metabolic adverse effects. Maintain
a healthy lifestyle. Eat a balanced diet, and do regular exercise.

 You should immediately report if you experience abdominal pain, dark urine or jaundice
which are suggestive of liver problems.

 Do not stop the drug even if you do not have seizures for a long time. Stopping the drug
suddenly can aggravate seizures.

 Do not change the brand of the medicine on your own. As it can cause variations in drug
levels leading to enhanced toxicity or reduced effectiveness.

 Review after 2 months with LFT reports.

Note: Avoid pregnancy while on valproate as it can cause fetal anomalies.

35
 Scenario 16

Phenytoin for generalized tonic clonic

seizures (GTCS)

36
Give instructions for a 50 year old patient with generalized tonic clonic seizure who is
prescribed Tab. PHENYTOIN 100 mg
 You have been diagnosed with Generalised tonic-clonic seizure (GTCS). A seizure is a
short episode of symptoms caused by a burst of abnormal electrical activity in your brain.

 I'm prescribing you tablet phenytoin at the dose of 100 mg which works by stabilising
the electrical activity of your brain, which prevents occurrence of seizures. You need to
take it every day regularly to control seizures.

 Take one tablet three times a day regularly. Try to take your doses of phenytoin at the
same times each day. This will help you to avoid missing any doses.

 If you forget to take a dose, take it as soon as you remember unless it is nearly time for
your next dose, in which case leave out the missed dose. Do not take two doses together
to make up for a missed dose.

 Some common adverse effects seen with this drug are dizziness, increased sleepiness,
change in taste, gum hypertrophy, increased male-pattern hair growth in females,
coarsening of facial features and acne.

 At toxic doses, it affects your brain and ear-balancing components causing dizziness,
double vision, and imbalance. Report immediately, if you develop any of the above
symptoms.

 Do not stop the drug even if you do not have seizures for a long time. Stopping the drug
suddenly can aggravate seizures.

 Do not change the brand of the medicine on your own. As it can cause variations in drug
levels leading to enhanced toxicity or reduced effectiveness.

 Review after 1 month for follow-up.

Note: For reproductive-age women: if you take birth control pills along while on
phenytoin, the contraceptive action may be lost. Use alternate methods of contraception.
Avoid pregnancy while on phenytoin as it can harm the fetus.

37
 Scenario 17

Oral contraceptive pills for contraception

38
Give instructions for a 25 year old newly married woman regarding the use of oral
contraceptive pills

 I am prescribing these birth control pills as a method of contraception since you are planning
to avoid pregnancy for one year.

 You must start taking this pill from 5th day of your menstrual cycle

 Start from the arrow shown in the tablet strip. Take one pill in the night daily till you finish
all 28 pills.

 Take the pill regularly at the same time of the day. Last 7 pills are hormone free pills, during
this time you will get breakthrough bleeding.

 Start the new strip from 8th day onwards irrespective of your periods. You can continue the
same as long as if you wish to avoid conception.

 It is important that you take these pills every day without fail to provide effective
contraception.

 Suppose, if you miss a pill one day, then take the missed pill as soon as you remember or
take the missed pill along with the next dose. However, if two or more pills are missed, then
take only the most recently missed pill and continue from the next dose in the usual time.

 In such situations, you need to use back-up contraception (e.g., condoms) or avoid
intercourse until hormonal pills have been taken for 7 consecutive days.

 In addition to birth control, this will also reduce blood loss during periods. Taking pills will
not prevent sexually transmitted infection.

 You may experience nausea, breast tenderness, headache, intermittent bleeding in the
initial period. This will settle after continued use.

39
 There is also a lesser chance of developing serious side effects like blood clots in veins,
hypertension and cervical cancer on long term use

 Whenever you want to conceive you can stop this pill and fertility will be returned from
the subsequent 2-3 menstrual cycles.

40
 Scenario 18

Propranolol for hyperthyroidism

41
Give instructions for a 55 year old hyperthyroidism patient who is prescribed Tab.
Propranolol 40 mg

 You have been diagnosed to have hyperthyroidism caused by thyroid hormone excess, a
condition with increase heart rate (palpitation) and tremors due to increased thyroid
hormone activity

 I am prescribing this tablet propranolol only to control your symptoms. It is important that
you continue other antithyroid drugs along with this medication.

 You must take one tablet of propranolol 40 mg three times daily for one month.

 This drug may cause sedation, sleeplessness / tiredness as side effects. It can also worsen
asthma attacks.

 Do not stop taking the drug without doctor’s advice as this may produce a rebound increase
in symptoms.

 Report immediately if you develop any untoward reactions like dizziness, difficulty in
breathing, abnormal heartbeat.

 Avoid seafoods and iodised salt.

 Review after one month.

42
 Scenario 19

Levothyroxine for hypothyroidism

43
Give instructions for a 45 year old hypothyroidism patient who is prescribed Tab.
LEVOTHYROXINE 50 mcg

 You have been diagnosed with hypothyroidism, a condition with weight gain, lethargy,
depression and intolerance to cold due to decreased thyroid hormone activity

 I am prescribing this drug, levothyroxine to replace the deficient thyroid hormone in your
body.

 You have to take one tablet of levothyroxine 50 mcg every day on an empty stomach
preferably before your morning tea or breakfast.

 It may take few weeks to see the response of the treatment.

 It may cause increased heart rate, agitation, nervousness and on long term it can lead to
bone weakness as possible side effects.

 Don’t stop taking the drug without doctors consultation. This may produce a rebound
increase in symptoms.

 Consume iodised salt in your diet.

 Avoid cabbage, soy, cauliflower as they may affect your thyroid hormone synthesis.

 Review after two months with TSH report.

44
 Scenario 20

Insulin for type 2 diabetes mellitus

45
Give instructions for a 50 year old with type 2 diabetes mellitus uncontrolled on oral
hypoglycemic drugs who is prescribed insulin

 Since your diabetes is not controlled with glucose lowering tablets, you will need insulin
to lower blood glucose effectively. Hence, I have started insulin for you.

 I have prescribed two forms of insulin. The one which looks like a clear liquid is called
regular insulin. It decreases blood glucose fast. The other one which appears cloudy is
called isophane insulin and it acts slowly.

 In diabetes, strict blood sugar control is very important in avoiding the complications like
vision defects, kidney damage and nerve related side effects . These two types of insulin
will control your blood glucose effectively and prevent these complications.

 I am starting you on both these insulins in low normal dose and I’m planning to increase
the dose gradually till your blood glucose level stabilizes at the recommended level.

 You must take this insulin every morning and evening just 25-30 mins before your food
intake. Always remember to take the insulin before food. Never miss it. If you have
forgotten to take insulin before food, do not take insulin after food. It is not going to help
and may cause low blood glucose later. Just take the next dose at the usual time.

 You need a special syringe called an insulin syringe which is labelled as units and a special
needle which is very thin and short. Please remember that insulin syringes and other
syringes are different. Please do not think that both ml and units are the same. Always use
an insulin syringe to load insulin in prescribed amounts. If you use another syringe with
ml to load insulin, it may lead to large insulin dose delivery and can cause unconsciousness
immediately.

 Take these two vials and clearly identify which is clear and which is cloudy. Do not shake
the vial but gently rotate it with both your palms. For your ease of administration, you can
take both insulins in the same syringe. First, take the prescribed amount of clear insulin
followed by a cloudy one.

46
 These two insulins should be given as an injection into the fat layer just below your skin.
Pinch the skin and make a fold. Inject the insulin perpendicular to the skin and leave the
fold before completing the injection.

 You can inject it into your abdomen, outer upper arm, buttocks, hip, and the front and side
of the thigh. Always make the habit of rotating the injection sites. Never rub the site of
injection as it may cause insulin entry into your blood fast.

 Insulin acts by decreasing blood glucose. Sometimes blood glucose may fall to very low
levels. In that situation, you may feel an elevated heart rate, sweating, tremors, and
giddiness. If not attended, it may cause unconsciousness. So have candy with you always
and take one immediately if you feel these symptoms.

 Exercising for 20 mins a day with small and frequent meals are strongly recommended.

 Avoid carbohydrate and fat rich diet, and foods with added sugar. Eat whole grains, fresh
fruits and vegetables.

 Do not alter the dose of insulin by yourself.

 Always store the drug in the refrigerator but do not freeze it.

 Review after 2 week with blood glucose report. Regular visit to the clinic may be needed
for optimising your insulin dose.

47
 Scenario 21

Bisacodyl for constipation

48
Give instructions for a 25 year old who is prescribed Tab.BISACODYL 10 mg for
constipation

 This drug is given to treat your constipation. It acts by increasing your bowel movements.

 Take one tablet orally at night. It causes the bowel movements within 6 to 12 hours after
ingestion. Do not take this tablet within 1 hour of antacids, milk, or dairy products.

 Do not take more than one tablet (10 mg)per day and don't continue for more than a week.
These may make you dependent on laxatives and cause your bowel to lose normal
activity.

 In some patients, it can cause skin rash and itching. It can cause stomach discomfort,
faintness or bloody diarrhoea. Report if you develop any of the above symptoms.

 Take high-fibre diet and drink plenty of liquids (eight glasses) each day.

 If your complaint does not subside after taking these tablets, you can come to review
again.

49
 Scenario 22

Oral rehydration solution

for diarrhoea

50
Give instructions to the mother of a 3 year old child suffering from viral diarrhoea
regarding the preparation and use of ORS solution

 Your child is suffering from mild dehydration because of diarrhoea.

 I’m prescribing oral rehydration solution powder which can improve your child’s
hydration.

 It comes in a powder form in a sachet. To use it, you have to add the entire contents of
the sachet to the one litre of boiled, cool water and shake it for 2 to 3 mins till the powder
is dissolved completely.

 It should be used within 24 hours after preparation. Discard the unused solution at the end
of the day. Prepare a fresh solution every day.

 This solution should be given to the child after every episode of diarrhoea. It should be
given slowly, in small amounts, as often as possible during the first 24 hours of diarrhoea.

 You can continue giving the normal bland diet. Avoid oily, spicy and fried foods.

 If your child has persistent diarrhoea, vomiting, not taking oral feeds, and lethargy, please
report back immediately.

51
 Scenario 23

Antitubercular therapy for newly diagnosed

tuberculosis

52
Give instructions for a 32 year old newly diagnosed tuberculosis patient who is prescribed
antitubercular therapy

 You have been diagnosed to have tuberculosis. This is a bacterial infection of the lungs
which can lead to serious complications if left untreated. This bacterial grows very slowly
inside the cells. Hence, longer treatment duration i.e., minimum of 6 months is required to
get complete cure.

 It is important that you take these medicines regularly every day. Otherwise, your disease
will progress and cause more complications or you will develop resistance to the therapy.
In that case, only few drugs will be able to treat your disease and those drugs will produce
more side effects.

 The course of therapy takes a minimum of 6 months. For the first two months, I am
prescribing you a fixed-dose combination of four medicines (HRZE).

 You should take 3 tablets every day before food. Along with this, I am prescribing you a
vitamin tablet which has to be taken daily at night to prevent nerve related side effects
caused by these drugs.

 Follow the arrow shown in the package and after taking three tablets, call the toll-free
number which is given at the back of the phone symbol displayed in the package.

 Depending on the sputum reports, your further course of treatment will be decided.

 In the second part of the treatment, even if your sputum result comes negative for TB, you
will be given a combination of two tablets that have to be taken daily for the next 4 months.

 Take more fruits, vegetables and protein-rich diet which will improve your health.

53
 These drugs can cause jaundice, numbness, pins & needle sensation, pain abdomen, fever,
chills, headache, joint pain etc. If you develop these side effects, report immediately

 Your sweat and urine might turn orangish to red in colour which is harmless.

 These medicines are known to interact with plenty of other drugs. Do not take any other
medicine without doctor’s advice.

 Do not discontinue the treatment even if you get relieved of the symptoms.

 Avoid smoking and alcohol.

 Follow strict personal hygiene. As this infection can spread by airborne droplets to others,
always wear a face mask when you are in close contact with someone. Follow cough
etiquettes like coughing in a tissue/ napkin or into your elbow and dispose of the
napkin/tissue in a covered bin. Wash your hands often.

 Review after 1 month.

54
 Scenario 24

Doxycycline for malaria chemoprophylaxis

55
Give instructions for a 28 year old who is prescribed Tab. DOXYCYCLINE 100 mg for
malaria chemoprophylaxis

 I'm prescribing you an antibiotic, doxycycline, to prevent malaria as you are travelling to a
malaria endemic region.

 The dose of this medication is 100 mg of doxycycline daily. Take these capsules 1 hour
before or 2 hours after food preferably on the same time of the day.

 Start taking this capsule 2 days before travel to malaria endemic areas. It should be taken
daily during your stay at the malarious area and continued for 4 weeks after leaving that
area.

 Take plenty of fluids. Avoid taking this capsule with milk, iron supplements, antacids and
should not lie down for 1hr after taking these capsules.

 Also use mosquito repellent, mosquito nets, clothing covering the whole body, and staying
in well-screened areas, especially from early night time until dawn. This will offer further
protection from infective mosquitoes

 If you develop skin rash, hives, difficulty breathing or swallowing, redness of the skin,
itching, loss of appetite, stomach pain, nausea, vomiting, diarrhoea, headache, blurring of
vision, confusion, decreased urination, report to the nearest health care facility.

 Avoid prolonged exposure to sunlight. Use sunglasses, sunscreen to avoid skin reactions.

56
 Scenario 25

Metronidazole for amoebic dysentery

57
Give instructions to 35 year old who is prescribed Tab METRONIDAZOLE 400 mg for
amoebic dysentery

 You have been diagnosed to have amoebic dysentery which is a gut infection caused by a
parasite.

 I'm prescribing you antibiotic metronidazole at the dose of 400 mg. You must take this tablet
three times a day for 5 days. This drug should be taken after food.

 Do not skip the dose. Complete the course of antibiotics even if your symptoms improve. If
you don't complete the course, it may increase your risk of further infection that is resistant
to antibiotics.

 This medicine can cause loss of appetite, vomiting sensation, stomach upset, metallic taste,
diarrhoea, mouth or tongue irritation, numbness or tingling of hands or feet

 If you develop rash, itching, stuffy nose, fever or joint pain, report immediately.

 Avoid alcohol intake while you are taking metronidazole and for at least 3 days after you
stop taking the drug, because it will produce serious side effects like dizziness, palpitations,
sweating etc.

 Maintain personal hygiene.

 If your symptoms do not subside report back.

58
 Scenario 26

Ferrous sulphate for iron deficiency anaemia

59
Give instructions for 35 year old female with iron deficiency anemia, who is prescribed
Tab. FERROUS SULPHATE 200 mg.

 You have been diagnosed with anemia caused by iron-deficiency. Iron is needed for the
synthesis of haemoglobin which carries oxygen in the bloodstream to the other organs.
Lack of iron is causing your symptoms of tiredness, breathlessness and palpitations.

 I’m prescribing you iron tablets to correct the deficiency.

 Take one tablet preferably in an empty stomach, one hour before food or 2 hours after
food in the morning. However, if you experience any abdominal pain, heartburn or
stomach upset, you can take the tablet after the meals.

 Take doses at the same time every day. If forgotten to take the dose leave it and continue
the next dose. Do not take two doses at the same time

 Please do not consume antacid tablets/ dairy products at the same time when you
consume iron tablets as these may impair iron absorption.

 This medication can cause darkening of the stool which is not at all harmful. It can
also cause slight stomach pain at times.

 In case, if you have severe abdominal pain or blood in vomitus, please visit hospital
immediately.

 Include iron rich foods in your diet. (vegetarian: green leafy vegetable, dates, peanut
cake with jaggery; non-vegetarian: meat, eggs, fish )

 Follow-up with haemoglobin report after 3 months.

60
 Scenario 27

Folic acid for megaloblastic anaemia

61
Give instructions for a 28 year old who is prescribed Tab. FOLIC ACID 5 mg
Megaloblastic Anaemia

 You are suffering from a condition called megaloblastic anaemia which occurs because
of deficiency of vitamin B12 and folic acid.

 I am prescribing folic acid tablets for you. Take folic acid tablets every day, one tablet
every day at the same time.

 Improve your diet by including milk and meat products if you are a non-vegetarian

 Consume iron rich foods like dates, jaggery and ragi.

 Review after 1 month with complete blood count report.

62
 Scenario 28

Ibuprofen and methotrexate

for rheumatoid arthritis

63
Give instructions for 45 year old woman, a newly diagnosed rheumatoid arthritis patient,
who is prescribed Tab. IBUPROFEN 400 mg and Tab. METHOTREXATE 7.5 mg
weekly

 You have been diagnosed with rheumatoid arthritis, which is causing the pain, stiffness
and swelling in your joints.

 I am prescribing you two medicines, a painkiller called ibuprofen and an antirheumatic

drug called methotrexate, which will help to reduce inflammation in joints and relieve
your symptoms as well long-term problems.

 You have to take tablet ibuprofen 400 mg four times a day preferably after food for 2
weeks.

 As the painkiller tablet ibuprofen can cause gastritis frequently in most of the patients, I
am prescribing you a gastroprotective medicine, tablet pantoprazole 40 mg which has to
be taken 1 hour before breakfast during the course of treatment.

 You have to take tablet methotrexate 7.5 mg weekly once. You can take this tablet every
Sunday in an empty stomach (at least 1 hour before or 2 hours after food or drink except
water) and you have take folic acid 5 mg tablet after two days (Tuesday).

 You may experience mild side effects like headache, nausea, vomiting, pain abdomen or
blurring of vision. If it bothers you very much, report immediately.

 Drug methotrexate may cause decrease in blood counts and liver problem for which
frequent monitoring will be required.

 Do not take any other analgesics over the counter without doctor’s advice.

 Review after 2 weeks with complete blood count, liver function test and ESR report.

64
 Scenario 29

Topical betamethasone for psoriasis

65
Give instructions for a 28 year old who is prescribed Topical BETAMETHASONE 0.05%
for psoriasis

 You have been diagnosed to have psoriasis, a condition that causes excessive scaling of
the skin.

 I’m prescribing you steroid ointment betamethasone dipropionate 0.05% that will
decrease the inflammation, redness, and scaling over the affected areas.

 It must be applied over the lesions twice daily.

 After washing and drying the affected region, apply a small amount of ointment and
gently rub it into the skin until it disappears. After applying wash the hands. Avoid
rubbing in the unaffected area.

 This should not be used on broken skin or in areas of infection. Do not apply bandage or
cover over the treated areas.

 It is a high potency agent so avoid applying in face, eyes, groin, axillae, or diaper area.

 It should never be taken orally.

 Avoid applying a larger amount and frequent application as it increases the side effects.

 It can cause itching, irritation, dryness, infection of the hair follicles, increased hair, acne,
change in skin colour, skin thinning, and stretch marks.

 If you develop burning sensation or flaring of reactions, report immediately.

 Review after 2 weeks.

66
 Scenario 30

Nicotine gum for smoking cessation

67
Give instructions for a 30 year patient who has been prescribed nicotine chewing gum

 It is appreciable that you have resolved to stop smoking.

 I am prescribing this nicotine gum at the dose of 2 mg to reduce the desire/craving for
smoking. It works by providing low amounts of nicotine to your body to decrease the
withdrawal symptoms and helps to reduce the urge to smoke.

 It should be chewed and not to be swallowed. Chew one piece of gum (2 mg) every 1 to 2
hours for the first 6 weeks, followed by one piece every 2 to 4 hours for the next 3 weeks
and then one piece every 4 to 8 hours for 3 weeks. Do not chew more than 24 pieces a day.

 Chew the gum slowly until you can taste the nicotine or feel a slight tingling in your mouth.
Then stop chewing and place the chewing gum between your cheek and gum. When the
tingling is almost gone (about 1 minute), start chewing again; repeat this procedure for about
30 minutes.

 Avoid eating and drinking for 15 minutes before and during chewing of nicotine gum.

 If you have strong or frequent cravings, you may chew a second piece within one hour.

 Do not chew nicotine gum too fast, do not chew more than one piece of gum at a time, and
do not chew one piece too soon after another.

 Chewing one piece of gum after another continuously may cause hiccups, heartburn,
nausea, or other side effects

 You should stop using nicotine gum after 12 weeks of use. If there are any undesirable side
effects, you can opt for other alternatives like nicotine skin patch or lozenges if you are not
comfortable with chewing gum.

 Review after 12 weeks.

68