Introduction To Pharmacy Practice and Simulation: PHAR456

Introduction to Pharmacy
Practice and Simulation

PHAR456
Beirut Instructors: Dr. Marwan Akel; Dr. Jihan Safwan; Dr.
Ahmad Dimassi; Dr. Maya Khoury; Dr. Siham Kanaan
Bekaa Instructor: Dr. Rasha Jbara
Lebanese International University
School of Pharmacy
Spring 2020-2021
1
4.A RED EYE
4.B HEADACHE
2
Learning Outcomes
• Identify the most likely etiology when patients present with headache
or red eye, through history, diagnostic tests, and patient findings on
examination, to enable the pharmacist to recommend effective
treatment or refer the patient to an appropriate provider
• Perform appropriate physical assessment for eye (red eye) and head
3
4.A RED EYE
4.B HEADACHE
4
Red Eye
• Patients routinely present to the pharmacy with eye complaints
• Since there are few eye conditions that can be successfully treated
with over-the-counter (OTC) products, the pharmacist will end up
referring most patients to the physician
• Causes of red eye can be:
1. Infectious (viral most common, bacterial)
2. Allergic (most common)
3. “Nonspecific” (including irritative)
• There are other conditions that can be confused with conjunctivitis,
including some that need urgent or emergent management
5
Eye Anatomy
6
Eye Anatomy
• Conjunctivitis: inflammation of the conjunctiva (singular) or
conjunctivae (plural)
• The conjunctiva is usually described as having three parts, all of which
are thin, transparent layers of mucous membrane:
1. Bulbar or ocular conjunctiva: the most external and easily observable
portion as it overlies the white portion (sclera) of the eyeball itself
2. Palpebral or tarsal conjunctiva: visible if the eyelids are inverted, covers
the inner linings of both upper and lower eye lids (the palpebrae)
3. Conjunctival fornices: difficult to visualize, because of its anatomic location
at the fornix, which is the communication between the palpebral and
bulbar conjunctivae
7
Eye Anatomy
• Note the following:
1. Bulbar Conjunctiva
2. Palpebral Conjunctiva
3. Sclera
4. Cornea 1
5. Limbus 2
4
3
5
8
Eye Anatomy
• Conjunctivitis can be bulbar (the lining over most of the eyeball) or
palpebral (the linings inside the eye lids) or both
• When the bulbar conjunctiva is normal (not inflamed), it cannot be
differentiated from the sclera beneath it, because it is clear
• The pink or red coloration is due to increased visualization of blood vessels in
the conjunctivae due to vasodilation of the vessels
• Vasodilation in general is due to inflammation or irritation
• Keratitis: Inflammation of the surface of the cornea
• Keratoconjunctivitis : inflammation of both the conjunctiva and the
corneal surface
9
Symptoms in Inflamed Eye Requiring Immediate
Referral
• Some patients present to the pharmacy to attempt to self-treat eye
problems that may cause permanent loss of vision without immediate
referral and treatment
• It is very important that pharmacists are aware of signs and
symptoms that indicate serious eye problems
• The following findings (table) should always be a reason to advise the
patient to see an eye-care specialist, usually on an emergent basis
• These are findings that are not caused by simple conjunctivitis or
other non-sight-threatening conditions
10
Referral
Symptoms in Inflamed Eye Requiring Immediate Referral (May incur visual loss if not
seen immediately)
Pain in the eyeball itself (true eyeball pain)
Significant change in vision (decreased visual acuity)
Photophobia (extreme sensitivity to light)
Severe foreign body sensation
Limbal or ciliary flush
Any corneal irregularity
History of trauma to the eye
Cutaneous vesicular eruption on the face or near the eye
Soft tissue swelling near the eye or eyelids
Hyphema or hypopyon
Contact lens wearers
11
Referral
• Limbal or ciliary flush:
• The limbus is the border between the cornea and the sclera and is usually
devoid of visible vessels or redness
• When a problem causes inflammation of either the cornea (keratitis) or the
anterior portion of the uveal tract (iritis), a limbal flush occurs
• The flush means that there are visible (dilated) blood vessels concentrated at
the border of the cornea and the sclera (limbus), and often the area
immediately surrounding the limbus is deep pink or red
• Any corneal irregularity (i.e., anything except a perfectly clear cornea)
12
Anterior uveitis. Marked conjunctival injection and perilimbal hyperemia (“ciliary flush”) are seen in this
patient with recurrent iritis. Source: photo contributor: Frank Birinyi, MD: Reproduced with permission from Knoop KJ , Stack LB, Storrow AB,
Thurman RJ. The Atlas of Emergency Medicine, 3rd ed. McGraw-Hill, Inc; 2010. Fig. 2-27. Copyright © McGraw-Hill Education LLC.
Citation: CHAPTER 14 Inflamed (Red) Eye, Herrier RN, Apgar DA, Boyce RW, Foster SL. Patient Assessment in Pharmacy; 2015. Available at:
https://accesspharmacy.mhmedical.com/content.aspx?bookid=1074&sectionid=62364160 Accessed: February 05, 2021
Copyright © 2021 McGraw-Hill Education. All rights reserved 13
Referral
• Hyphema/hypopyon:
• Under normal circumstances fluid is not visible in the anterior chamber
• A visible meniscus of blood, cloudy fluid or purulent material in the anterior
chamber is an ocular emergency
• Blood in the anterior chamber due to trauma or over-anticoagulaltion is called
a hyphema
• Cloudy or purulent fluid is a hypopyon, caused by inflammation or infection of
the internal structures of the eye
• Most patients will also usually have other cardinal signs, i.e. visual
impairment, eyeball pain, photophobia, limbal flush
14
Hypopyon in acute anterior uveitis (iritis). (Reproduced with permission, from Riordan-Eva P, Cunningham ET, eds. Vaughan & Asbury’s
General Ophthalmology. 18th ed. McGraw-Hill, Inc; 2011:60. Fig. 3-4. Copyright © McGraw-Hill Education LLC.)
Irritative Conjunctivitis
Causes • Chlorine from swimming pools, smoke, intense light (snow blindness),
dry windy conditions
Assessment • Patients should be asked about specific details of recent exposure to
any of the common irritants, use of prescription eye drops, recent
changes in eye cosmetics, or contact lens solutions
• Patients with new or long-term glaucoma medication, contact lens
wearers, and suspected allergic reactions to eye products should be
referred to an eye-care specialist
Treatment • Best treated by avoidance of the irritant and preventive measures
(wearing goggles or sunglasses)
• Topical OTC products may provide temporary relief until preventive
measures can be fully implemented
16
Allergic Conjunctivitis
• Acute episode of allergy affecting the eyes
Definition
• Often becomes either frequently recurring or chronic
Types • Two basic types:
1. Seasonal allergic conjunctivitis (SAC)
2. Perennial allergic conjunctivitis (PAC)
Symptoms • Most common symptoms of SAC/PAC: (symptoms usually bilateral)
1. Itching of the eye: can be intense
2. Watering of the eye: usually clear, rarely mucoid, but never purulent
(rarely does the wateriness obstruct vision to any significant degree)
3. Redness of the conjunctiva: usually mild to moderate and generalized
throughout the visible bulbar and palpebral conjunctivae
• Sometimes there is a mild foreign body sensation in the eye
17
Allergic Conjunctivitis
SAC PAC
Cause • SAC is most typically caused by Cause • PAC is usually caused by allergens
seasonal plant pollens to which the patient is exposed
year-round (most commonly the
house dust mite, animal dander,
and components of the
Presentation • SAC can even be chronic during cockroach)
the patient’s “season,” which may
extend for up to 6 months.
However there is clearly an Presentation • PAC is sometimes thought of as
extended period of time (months) chronic but most patients present
when the patient is virtually with episodes of acute
without allergic conjunctivitis exacerbations as opposed to
symptoms having symptoms constantly
Allergic conjunctivitis commonly coexists with allergic rhinitis and less frequently with
other atopic diseases (asthma and/or atopic dermatitis) 18
Allergic conjunctivitis. Conjunctival injection, chemosis, and a follicular response in the inferior palpebral
conjunctiva in this patient with allergic conjunctivitis secondary to cat fur . Source: photo contributor: Timothy D. McGuirk, DO.
Reproduced with permission from Knoop KJ, Stack LB, Storrow AB, Thurman, RJ. The Atlas of Emergency Medicine, 3rd ed. McGraw-Hill, Inc; 2010. Fig.
2-8. Copyright © McGraw-Hill Education LLC.
https://accesspharmacy.mhmedical.com/content.aspx?bookid=1074&sectionid=62364160 Accessed: January 26, 2021
Other Subtypes of Allergic Conjunctivitis
• Patients suspected of having any one of these three subtypes of allergic
conjunctivitis should be referred to an eye-care specialist:
1. Vernal keratoconjunctivitis (VKC)
2. Atopic keratoconjunctivitis (AKC)
3. Giant papillary conjunctivitis (GPC)
• All three may involve the cornea (cause keratitis), and progression could
cause serious, possibly vision-threatening damage to the cornea
Compared to SAC/PAC Similar to SAC/PAC
• VKC, AKC, & GPC are more severe, chronic, have • VKC, AKC, & GPC also share the
additional symptoms of keratitis or photophobia, symptom of itch (VKC may cause
often associated with stringy ocular discharge very intense itching)
• Photophobia: common in VKC and less common in
AKC and GPC
20
Other Subtypes of Allergic Conjunctivitis
VKC • Common in male children with other atopic diseases and begins
from ages 4 to 10 years and disappears after puberty
AKC • Occurs often in young adult males and continues into the fifth
decade, atopic dermatitis on the eyelids and face is very common
GPC • Occurs predominately in contact lens users, but can occur following
surgery as a reaction to sutures
21
Viral Conjunctivitis
Clinical • Usually begins on one side, but may spread to the other eye
Presentation • Discharge ranges from a thin, clear, watery discharge to a mucoid
and/or mucopurulent discharge (overlapping in appearance with the
discharges of both allergic conjunctivitis and bacterial conjunctivitis)
• May be associated with other symptoms of upper respiratory viral
infectious disease, such as rhinitis, scratchy or mildly sore throat, mild
malaise, possibly a low-grade fever, and possibly cough
• Itching might occur (much less marked than allergic)
• May be associated with lymphadenopathy in the periauricular area
• Follicles, especially on the palpebral conjunctivae, may occur with
either viral or allergic conjunctivitis (more common in allergic)
22
Viral conjunctivitis. Note the characteristic asymmetric conjunctival injection. Symptoms first developed in
the left eye, with symptoms spreading to the other eye a few days later. A thin watery discharge is also seen .
Source: photo contributor: Kevin J. Knoop, MD, MS. Reproduced with permission from Knoop KJ, Stack LB, Storrow AB, Thurman, RJ. The Atlas of
Emergency Medicine, 3rd ed. McGraw-Hill, Inc; 2010. Fig 2–4. Copyright © McGraw-Hill Education LLC.
Viral Conjunctivitis
Cause • Major cause: one of the adenoviruses (no treatment available)
Incubation • Incubation period (5-12 days) and infectious period (10-12 days) continuing while the
Period & eye is red and symptomatic
Infectious • Patients remain infectious during the symptomatic phase of the disease, regardless
Period of whether or not they are being treated with an ocular anti-infective (antibacterial
drugs are not effective on virus)
Treatment • Most patients with pink eye are started on a broad spectrum anti-bacterial agent
(hard to differentiate between viral and bacterial)
• Pharmacists can recommend symptomatic treatment:
• Cold compresses
• Topical wetting agents (artificial tears)
• Topical OTC antihistamine/mast cell stabilizer (ketotifen)
• Topical decongestants
24
Viral Conjunctivitis (Herpes Simplex C.)
Severity • Herpes simplex virus can cause a progressive, serious, and potentially
sight-threatening type of viral conjunctivitis
• It usually includes involvement of the cornea, making it a viral
keratoconjunctivitis or pure viral keratitis
Symptoms • Significant irritation (severe foreign body sensation), photophobia, in
addition to redness, watery discharge, visual blurring, and sometimes
vesicles on the skin of the eyelids or around the eye
Treatment • Suspect herpes simplex keratitis and refer the patient to an
ophthalmologist immediately when: vesicles are present on or near the
eyes in a patient with other manifestations of a red eye, especially if
there is any corneal abnormality, a limbal flush or any of the four
findings that indicate referral (eye pain, visual impairment,
photophobia, or severe foreign body sensation)
25
Herpes simplex keratitis. A large dendritic lesion after fluorescein staining. The patient had been diagnosed
with “pink eye” in a prior visit . Source: photo contributor: Kevin J. Knoop, MD, MS. Reproduced with permission from Knoop KJ, Stack LB,
Storrow AB, Thurman, RJ. The Atlas of Emergency Medicine, 3rd ed. McGraw-Hill, Inc; 2010. Fig. 2-37. Copyright © McGraw-Hill Education LLC.
Viral Conjunctivitis (HZO)
Severity • Herpes zoster ophthalmicus (HZO) is the other potentially sight-
threatening cause of viral conjunctivitis or keratoconjunctivitis
• HZO is a type of shingles
Symptoms • Stinging, burning, and sometimes itching occur before the
development of any visible lesions
• The initial lesion is a vesicle, which progresses through the stages
of pustule, ulcer, and crust
• Both the signs and symptoms of HZO occur in the pattern of a
dermatome
Treatment • Immediate referral to an ophthalmologist: any suggestion of HZO
by symptoms (including eye pain, visual disturbance,
photophobia, severe foreign body sensation) or a dermatomal
distribution of lesions on the face or near the eye or nose
27
Herpes zoster ophthalmicus (HZO)
Herpes zoster rash follows a dermatomal

distribution
28
Bacterial Conjunctivitis
Severity • Less common than viral and allergic but easier to differentiate
Causes • S. aureus, S. pneumoniae, H. influenza (adults) and S. pneumoniae, H. influenzae, and M.
catarrhalis (children)
Symptoms • Commonly causes matting of the eyelids, especially upon awakening in the morning
• Discharge is usually purulent (more often than viral or allergic)
• Begins in one eye, can become bilateral (similar to viral)
• It is not associated with other manifestations of upper respiratory infection (limited to eyes)
• Lack of ocular itching (which can occur in allergic/viral)
Treatment • Visual blurring due to purulent discharge: this blurring should clear completely with removal
or cleansing of the discharge from the eye
• If visual abnormalities persist after cleaning the discharge from the eye, refer patient
immediately
• Patients suspected of having a true bacterial conjunctivitis should be referred to a primary
care provider
• The best thing a pharmacist could suggest other than referral would be warm compresses
for the discomfort
29
Bacterial conjunctivitis. Mucopurulent discharge, conjunctival injection, and lid swelling in a 10-year-old
with H. influenzae conjunctivitis. Source: photo contributor: Frank Birinyi, MD. Reproduced with permission from Knoop KJ, Stack LB, Storrow
AB, Thurman, RJ. The Atlas of Emergency Medicine, 3rd ed. McGraw-Hill, Inc; 2010. Fig. 2-2. Copyright © McGraw-Hill Education LLC.
Bacterial Conjunctivitis/Less Common
Causes
Hyperpurulent or hyperacute conjunctivitis
Causes • Usually due to N. gonorrhea, usually Sexually transmitted illness “STI”
Symptoms • Discharge is purulent, copious, and continuous: almost as soon as the
discharge is cleared, it reaccumulates
• Other symptoms are similar to the more common types of bacterial
conjunctivitis but perhaps more severe
• Eyelid swelling, conjunctival edema (chemosis), and periauricular
lymphadenopathy may occur
Treatment • If untreated, corneal ulceration and perforation can occur (photophobia or
severe foreign body sensation may be an indication of corneal
involvement)
• In all cases, immediate referral is indicated, usually for systemic therapy of
gonorrhea and patient should be advised that sexual contacts are at risk of
some type of gonococcal infection
31
Bacterial Conjunctivitis/Less Common
Causes
Inclusion conjunctivitis
Causes • Certain serotypes of Chlamydophila trachomatis
Symptoms • Appears more like viral conjunctivitis (with more pronounced redness, and there
may be follicles on the palpebral conjunctiva)
• The discharge is mucoid and usually not profuse, but can progress to have a more
purulent nature
• Itch is not a common feature but there may be a significant degree of foreign body
sensation
Treatment • If this disease is even suspected, immediate referral should be advised
• This is necessary for both appropriate systemic anti-microbial therapy and sexual
contact follow-up (as it is also usually an STI in adults)
Follicles
32
Miscellaneous Eye Conditions (FYI)
Blepharitis • Inflammation of the eyelids, usually manifest as redness Blepharitis
and swelling of the margins (outer edges) of the eyelids
• It may be allergic or bacterial in etiology
• It may occur along with allergic conjunctivitis
Chalazion • Chronic inflammation due to plugging of a meibomian

gland in an eyelid
• It is a benign process, which is often asymptomatic,
except for the patient noticing a lump on the eyelid
Hordeolum • An acute inflammation due to plugging of one of several

(or stye) different glands in the eyelid
• Many become acutely infected usually with bacteria
from the skin
33
Miscellaneous Eye Conditions (FYI)
Subconjunctival hemorrhage
Causes • Is due to a broken or leaking vessel in the conjunctiva, which results in
deposition of a contiguous area of blood under the conjunctival membrane
Symptoms • It is asymptomatic and most commonly caused by rubbing the eye,
especially in response to itching, and may be due to a sudden sneeze or
cough
• Patients usually become aware of the process by seeing their eye in a mirror,
or by having somebody else point it out to them
Treatment • It is a self-limiting, completely benign process that resolves in several days
34
4.A RED EYE
4.B HEADACHE
35
Headache
• Headaches are very common, with over 95% of patients suffering from at least one
headache in their lifetime
• Headaches can occur as part of a systemic illness, such as influenza, or as a single
symptom
• Causes
• Multiple and at times complex in pathophysiology
• Classification
• Can be classified as primary (most common type) and secondary HA
• Can be classified by seriousness or urgency:
• Acute onset headaches are mostly secondary, are more serious, and can be life threatening, requiring
immediate diagnosis and intervention
• Chronic or recurrent headaches, which include all the primary headaches and have a much more
benign prognosis
36
Vise-like
Primary Headaches/ Tension Type HA

Epidemiology • Most common form of HA but has unclear pathophysiology
Symptoms • Bilateral, nonpulsating, HA with mild-moderate pain intensity
• The pain is constant and typically described as dull, pressure, vise-like
• Associated with muscle tenderness in the head, neck, and shoulders, which can
be elicited by palpation of the muscles and rotation of the head and neck
ROS • Neurological examination is normal and the overall physical examination is
unremarkable except for some palpable muscle tenderness
• Physical activity has little effect on the pain intensity
Causes • Precipitating factors: stress, tension, and head/neck movements
Treatment • Refer when:
• More than 15 HA/month
• Patients with increasing frequency of headaches
• Those that do not exactly fit the diagnostic criteria
• In whom standard treatments with analgesics are ineffective
37
Primary Headaches/ Migraine HA
Epidemiology • Second most common primary headache (more common in women)
Types • 18 types: most common are migraines without aura or common migraines
(64%), and migraine with aura or classic migraines (18%)
Symptoms • Moderate to severe pain that is incapacitating, unilateral, pulsating, or
throbbing and is made worse by physical activity
• Nausea, vomiting, photophobia, or phonophobia may occur
• 10-30 % will have an aura before and/or during the headache: flashing lights,
scotoma, visual disturbances, paresthesias, or a prodrome of tiredness, fatigue,
mood changes, or GI symptoms
• Migraine headaches typically last 4 to 72 hours
ROS • A neurological examination will be normal
Treatment • Difficult to diagnose, might need a neurologist who specializes in headaches to
accurately diagnose and effectively treat
38
Simplified Diagnostic Criteria for Migraine
39
Primary Headaches/ Migraine HA
• Etiology: controversial
1. Old theory: changes in neurotransmitter activity in the brain lead to a
vasoconstriction followed by rebound vasodilation in intra- and extracranial
blood vessels, which causes headache
2. New Theory: Gene Based Disease
• Decreased or destabilized serotonin activity in the brain stem that lead to the
release of inflammatory, vasodilator neuropeptides such as CGRP (calcitonin
gene-related peptide), PACAP (pituitary adenylate cyclase activating peptide),
and nitric oxide (NO)
• Those neuropeptides cause an inflammation of the vessels and tissue in the
midbrain that leads to the pain and eventual vasodilation
40
Primary Headaches/ Cluster HA
Epidemiology • Relatively uncommon (primarily in men in a ratio of 5:1)
Symptoms • Severe pain (worse than migraine) in the orbital, supraorbital, or temporal
region that is unilateral and pulsating, lasting 30 to 180 min if untreated
• Attacks occur in clusters from once every other day to eight times/day with
headache-free periods lasting days to months
Diagnosis • One or more autonomic symptoms ipsilateral (same side) to the location of the
pain
• These include: nasal congestion or rhinorrhea, conjunctival injection
(redness) or lacrimation, miosis and/or ptosis, forehead and/or facial
sweating, or eyelid edema
ROS • A neurological examination will be normal (other than the eye findings)
Treatment • Patients with cluster headaches need to be seen by a neurologist or headache
specialist for management
41
Primary Headaches Summary
A. DIAGNOSTIC SCHEMATA FOR COMMON PRIMARY HEADACHES
• Migraine Headache
• Episodic Tension Headache
• Cluster Headache
B. DIFFERENTIAL DIAGNOSIS OF COMMON PRIMARY HEADACHES
SUBJECTIVE Migraine Tension Cluster
a. Location Unilateral in 60% to 75%. Remaining are global or Bilateral Unilateral usually starting around eye or temple
frontal
b. Onset Builds quickly over an hour or so to peak Relatively sudden onset. Acute sudden onset over minutes
c. Quality Pulsating Dull, squeezing ache like band around Piercing, deep
head
d. Quantity Severe, incapacitating Lasts 4 to 72 hours Mild to moderate. May be off and on More painful than migraine Lasts 30 to 180 minutes
e. Setting Family history common. More common in females Stress or mental tension Occurs in “clusters” daily for several days then
remission. More common in males
f. Associated 20% have aura (classic migraine). Also nausea, Stiff/painful neck muscles Ipsilateral (same side as pain) nasal congestion or
symptoms vomiting, photophobia, or phonophobia are rhinorrhea, conjunctival injection or lacrimation, eyelid
common edema, facial sweating, other autonomic signs
g. Modifying Exercise makes it worse, lying down makes it Analgesics Physical activity may help
factors better, dark room makes it better
42
Secondary Headaches
• Secondary headaches usually have more serious consequences that require
immediate intervention
• Any patient presenting with what seems like a primary HA but has an
abnormal neurological examination requires a workup for a secondary HA
• New headaches in patients over 50 or any severe headache requires
immediate further diagnostic testing
• Imaging:
• CT scans are the initial choice and are accurate in identifying acute hemorrhage,
trauma to bony structures, and sinus disorders
• MRIs are used to rule out infarction, mass occupying lesions, brain abscesses, and
craniocervical junction abnormalities
43
Secondary HA = SNOOP4
S • S stands for systemic and includes immunosuppressed patients,
infectious meningitis, brain abscess, and metastatic tumor
N • N indicates neurologic abnormality, which would relate to infarcts or
mass occupying lesions
O • The first O is for sudden onset that indicates cerebrovascular accident
(CVA), subarachnoid hemorrhage, or arterial dissection
O • The second O is for onset of new headache over age 50, which considers
temporal arteritis, neoplastic, or vascular issues
P4 • P stands for pattern change with 4 potential causes including
progressive headache and papilledema
44
Temporomandibular Joint Dysfunction Syndrome
• One of the symptoms of TMJ dysfunction can be a

headache (mainly migraine HA more than tension HA)
• Suspicion of TMJ disorders as a cause of headache can
be confirmed with a careful history and limited
physical examination
History • Patients with TMJ disorder headaches commonly will
awaken with their headache and many have a history of
bruxism (grinding the teeth at night) or regular jaw
clenching
• Many patients have occlusal disorders with underbites
more common than overbites
• In some patients, chewing gum is associated with the
headache
45
Temporomandibular Joint
Dysfunction Syndrome
Physical • Place the palmar surface of the fingers of both hands over each TMJ
Examination • Have the patient open their mouth wide. A palpated clicking sensation or
audible click confirms the potential for a TMJ disorder
• In addition, simultaneously observe the opening and closing of the mouth.
Normally, the jaw opens vertically straight up and down
• Any jerky, sideways or angled movement during opening and/or closing
may be indicative of TMJ disorder
Treatment • Patients suspected of headaches secondary to TMJ disorders should be
referred to a dentist initially for evaluation of TMJ disorders
46
Medication Overuse/OTC Headaches
• Patients with episodic migraines and women are the most frequent
patients to develop this type of headache
• Occurs also in patients with both tension and migraine headaches
Diagnosis • There are three criteria for diagnosis:
1. A chronic daily HA for more than 15 days/month
2. A 3-month overuse of ergotamine, triptans, opioids, or combination analgesics (including those with
butalbital) for more than 10 days/month. Alternatively analgesics or any combination of ergots,
triptans, opioid analgesics for more than 15 days/month without overuse also meet the criteria
3. There must be a history of recent development or markedly worsened HA during medication
overuse
Treatment • Patients who you suspect of this problem should be referred to a neurologist or headache specialist for
diagnosis and treatment
• Treatment involves tapering the causative medication or discontinuing it while providing other medication
for pain relief
• Elimination or marked reduction in headache frequency after 60 days is diagnostic
47
Hypertensive Emergency
(Malignant Hypertension)
Causes • Patients who present with blood pressures
>220/120 are at risk for hypertensive
encephalopathy, as well as intracerebral and
subarachnoid hemorrhages
Symptoms • Moderate to severe headache
• In hypertensive encephalopathy, cerebral edema
occurs, causing the headache and potential
changes in behavior and cognitive function
Diagnosis • Blood pressure
• Funduscopic examination of the eye many times
reveals papilledema, a swelling and blurring of the
optic disc
Treatment • Treating the blood pressure reduces the risk of
those complications and the patient’s symptoms
including the headache
48
Tumor/Mass Occupying Lesion
Causes • Malignant tumors • Nonmalignant • Primary • Metastatic lesions

of brain tumors of brain tumors from a primary cancer
elsewhere in the body
• Patients previously diagnosed with other malignancies that may metastasize to the
brain who present with a headache should be immediately referred to their
oncologist for further diagnostic evaluation
Symptoms • Typical Presentation: Headaches, cognitive decline, or behavior changes with focal
neurologic deficits
Diagnosis • Some tumors such as benign meningiomas are diagnosed during evaluation of a
primary headache and can be an incidental finding
Treatment • Regardless, unexplained headaches, progressive headaches, or new headaches
with or without neurological deficits should be immediately referred to a
neurologist or headache specialist for further evaluation
49
Meningitis
Definition • Inflammation of the meninges
Causes 1. Viral meningitis is the most common form of meningitis
Also known as aseptic meningitis due to the absence of any organism upon
Gram stain or culture of the cerebrospinal fluid (CSF)
Causes: Enteroviruses (most common) such as coxsackievirus and
echovirus. Others: arboviruses herpes simplex, mumps, and HIV
2. Bacterial meningitis in adults:
Caused primarily by Streptococcus pneumoniae or Neisseria meningitides
Listeria monocytogenes should be suspected in patients who are pregnant,
over 50 years of age or immunocompromised
3. Mycobacterial meningitis should be suspected in areas where tuberculosis
is endemic and in immunocompromised patients such as those with HIV
4. Fungal meningitis is usually found in immunocompromised patients.
Cryptococcus and Aspergillus species are the most common infecting
agents. Candida species also cause meningitis especially in hospitalized
patients
50
Meningitis
Sympto • Symptoms: some combination of headache, fever, neck
ms stiffness (nuchal rigidity), altered mental status,
photophobia, nausea/vomiting, seizures, focal neurological
deficits, and a skin rash, generalized fatigue, malaise,
arthralgias, and myalgias
• The Kernig and Brudzinski signs and nuchal rigidity are
considered weak positive predictive signs
• The classic triad of fever, neck stiffness, and altered mental
status is found in only two-thirds of adults diagnosed with
bacterial meningitis
Diagno • Confirmation of the cause of meningitis depends on
sis examination of the CSF (next table)
• CSF and blood samples are also sent for culture and
susceptibility
51
Meningitis
• CSF Differential Diagnosis:
Examination Bacterial Viral Fungal Mycobacterial
Opening pressure Elevated Usually normal Variable Variable
White blood cell count >1000/mm3 20 to 500/mm3 Variable Variable
Predominant WBC type PMN Lymphocytes/monocytes Lymphocytes Lymphocytes
Protein >100 mg/dL 100 to 500 mg/dL 50 to 200 mg/dL 100 to 500 mg/dL
CSF-serum glucose ratio <0.6 (<40 mg/dL) >0.5 (normal) decreased <40 mg/dL
Other Lactate > 4.2 mmol/L PCR
Serum procalcitonin >0.5

ng/mL
Peripheral WBCs
>10,000+ >80% PMNs
52
Pseudotumor Cerebri (Idiopathic Intracranial
Hypertension)
• A rare disorder (<1.0/100,000) typically seen in overweight females of
childbearing age
Causes • It is due to an imbalance between the production and
reabsorption of CSF, resulting in increased intracranial
pressure and headache
• Can be caused or exacerbated by medications
(tetracyclines, isotretinoin…)
Sympto • Headache, visual disturbances and papilledema can occur
ms • If left unchecked, permanent visual changes can occur
Pharma • Ask patients about new onset headaches and visual
cist Role problems if receiving a medication that can possibly cause
this disorder and make sure patients are not combining it
with another medication that can cause this disorder
53
Acute Trauma/Post-Trauma Headache
Causes • Closed-head trauma
• Special attention should be given to patients on drugs that interfere
with normal coagulation, e.g., aspirin, clopidogrel, warfarin, regular
NSAID use, chronic long-term phenytoin use
Symptoms • A new moderate to severe headache occurring within 12 to 24 hours
after closed-head trauma should be referred to emergent care for
evaluation of subarachnoid or intracerebral bleeding
• HA post trauma can present like all three types of common primary
headaches but tension-type headaches are the most common
• Post-trauma headaches (post-concussion headaches) can last for
weeks after the injury
Treatment • Patients with headaches that might be due to a recent history of
trauma to the head or neck and shoulders should be referred to the
care of a neurologist for evaluation and follow-up
54
Cerebrovascular Accident (Stroke)
Types • Acute cerebrovascular events are divided into two major categories: stroke or CVA, and transient
ischemic attack (TIA)
• Stroke: an infarction of central nervous system tissue
• TIA: transient neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia,
without acute infarction
55
Cerebrovascular Accident
(Stroke) Atheros
clerotic
Plaque
Caus • Two major causes: ischemic and hemorrhagic
es 1. Ischemic events (80% to 88%) are primarily due to
atherosclerosis or embolism
• The atherosclerotic process is associated with a gradual
accumulation of intra-arterial plaque in carotid arteries. If
the plaque is unstable, it may eventually rupture initiating a
platelet-based clot, which may progress to decreased
circulation and a subsequent infarct
• Embolic strokes are due to clots that form in the heart in Embolic
patients with atrial fibrillation or prosthetic cardiac devices strokes
such as a heart valve. A portion of the clot becomes
dislodged and ultimately travels to a part of the circulatory
system of the brain, which is too narrow for it to pass
through. The result is obstruction of the circulation to tissue
past that point
2. Hemorrhagic strokes (12% to 15%) are due to a ruptured
aneurysm or blood vessel
• Uncontrolled hypertension and a combination of
hypertension and atherosclerosis are the primary etiologies Hemorr
in hemorrhagic strokes
hagic
strokes
56
Symptoms • Impaired speech or language, visual disturbances, double vision or visual loss, facial drooping,
trouble swallowing, weakness or numbness/tingling on one side of the body, impaired coordination
of limbs or gait dysfunction, vertigo, dizziness, stiff neck, headache, sudden change in behavior
(often recognized by people other than the patient), seizure, syncope, confusion, or cognitive
impairment
• One simple aid that may help in teaching patient self-recognition skills of the more apparent signs
and symptoms of stroke is the mnemonic FAST (next slide)
Diagnosis • Specific physical findings to confirm the dysfunction could include:
• Dysarthria (trouble speaking), cranial nerve deficits, unilateral weakness, unilateral loss of
sensation, cerebellar dysfunction, and abnormal pupil examination
• Imaging should be done as soon as possible, at least within 24 hours even if the dysfunction lasts less
than 2 hours
• A diffusion weighted imaging MRI (MRI-DWI) is the test of choice due to its sensitivity to detect
small infarctions and distinguish between new and old lesions, and even between ischemic and
hemorrhagic stroke
• MRI is not readily available and CT scan is usually used
• Trans-cranial and carotid Doppler ultrasonography, CT or MR angiography are alternative imaging
tests available
57
“FAST”
F = Face Face drooping and/or asymmetry when
patient smiles.
A = Arms Patient may not be able to raise both arms
evenly.
S = Speech Patient may slur words and may not be able
to repeat a simple sentence correctly.
T = Time If the patient has any of these, call 911
immediately.
58
Pharmacist Role
• Control of comorbid conditions such as hypertension, diabetes,
dyslipidemia, and anticoagulation that can lead to TIA and/or stroke
• Educate patients with those disorders to readily recognize signs and
symptoms of stroke and if present to seek immediate help
• At every visit for these comorbid disorders, the pharmacist needs to
probe for typical symptoms and via neurological examination probe
for typical signs
• By doing this at every visit, it reinforces the patient’s understanding of
self-recognition
59
Thank you…
Questions???
60

Introduction To Pharmacy Practice and Simulation: PHAR456

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Introduction To Pharmacy Practice and Simulation: PHAR456

Uploaded by

Copyright:

Available Formats

Introduction to Pharmacy

Practice and Simulation

• Any corneal irregularity (i.e., anything except a perfectly clear cornea)

Herpes zoster rash follows a dermatomal

Chalazion • Chronic inflammation due to plugging of a meibomian

Hordeolum • An acute inflammation due to plugging of one of several

Treatment • It is a self-limiting, completely benign process that resolves in several days

Primary Headaches/ Tension Type HA

• One of the symptoms of TMJ dysfunction can be a

Causes • Malignant tumors • Nonmalignant • Primary • Metastatic lesions

Predominant WBC type PMN Lymphocytes/monocytes Lymphocytes Lymphocytes

Other Lactate > 4.2 mmol/L PCR

Serum procalcitonin >0.5

You might also like