OSCE OTC Red Flags - Year 4 PDF

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Introduce self, nature of station, confidentiality, consent Name/Age/appearance (picture may be displayed) Self or someone else? (if someone else, take their age/allergies) Medication (are you currently taking any medications? If yes  changes in doses? Recently started or stopped?) Extra medication (did you try anything for this) Time persisting (how long has it been going on for?) History (has this ever occurred in the pasted? If yes, ask how they treated it last time? What might have triggered it?) Other symptoms (are you experiencing any other symptoms?) Danger symptoms (state all the danger symptoms that may result for referral – red flags below) Refer/sell appropriately Explain the reason for refer/sell Counselling (dose, duration, if not improving?) Thank the patient

Gout red flags  Uncertain diagnosis or underlying systemic illness (eg. RA or connective tissue disorder) •Pregnancy or 1 hr - Vomiting, constipation, diarrhoea PLUS persistent abdominal pain - Blood in stools/vomit - Mild/moderate pain lasting on/off for 7 days - Over 55 years with persistent dyspepsia or >45 + 1st time dyspepsia - Babies: projectile vomiting + constipation/diarrhoea/fever/screams from pain - Abdominal pain with chronic back pain - Recent weight loss - Swelling (hernias)

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Oral Thrush - Babies 1 ulcer

- Diabetic or immunosuppressed - Infection - Pregnant/BF - Recurrent ulcers - No improvement after 3 weeks - ADR  BMS drugs etc  Medication to give:  Topical local anaesthetics/analgesics: Anbesol Liquid, Bonjela, Rinstead Contact Pastilles - Limited use, short duration of action, should not be taken before a meal  Benzydamine HCl: Difflam Oral Rinse and Spray – can numb and/or sting, dilute with equal amount of water if stings. Can use every 1.5 to 3 hours prn, max 7 days. Rinse NOT to be used on children under 12 years  Antiseptic mouth washes – chlorhexidine: Corsodyl Mouthwash – Reduces incidence of secondary infection, accelerates healing process 

Dyspepsia - Persistent vomiting - Bleeding of GIT - Loss of appetite - Lump in mouth/throat - Age?  >45 + 1st time unexplained dyspepsia  ≥55 + persistent unexplained dyspepsia (>5 days) - Difficulty swallowing - Unintentional weight loss - Suspicious barium meal result  Medication to give:  Antacids: o Magnesium salts: Milk of Magnesia liquid or tablets (can cause diarrhoea) o Aluminium salts: Alu-Cap capsules (can cause constipation) o Bismuth salts: Pepto-Bismol (avoid if aspirin sensitive, pregnant or 2 weeks - Symptoms changed - Pregnant  Medication to give: DO NOT GIVE UNLESS DIAGNOSED BY DOCTOR Medication for major presenting symptom Anti-diarrhoeal -- Loperamide: Imodium; decreases bowel motility, reduces stool frequency and urgency, poor penetration of BBB Bulking agent -- may improve constipation and diarrhoea - Ispaghula husk: Senokot High Fibre

Anti-spasmodic -- Intestinal smooth muscle relaxants (C/I paralytic ileus) - Peppermint oil: Colpermin, Mintec; Mebeverine: Colofac IBS Hyoscine butylbromide: Buscopan IBS Food diary - identify trigger, try not to rush meals, eat balanced diet with plenty of fluids, take regular exercise 

Constipation - Fever/night sweats - Illness/unable to walk in children and adults - N/V - Diarrhoea - Self-medication not effective after 4 days - Severe pain for >2 days - Blood in stools - Weight loss  Medication to give: 1st line - alter diet and lifestyle and increase fluids  Bulk laxatives -- ispaghula husk, slow action (24 to 72 hours), take plenty of water, not to be taken before bedtime, not for frail elderly, can alter absorption of medication  Stimulant laxatives (C/I in pregnancy/BF) -- stimulate the nerve endings in the bowel wall Anthraquinones - Senna: Senokot, Syrup of Figs, Exlax  acts within 8-12 hrs Diphenylmethane derivatives - Bisacodyl: Dulcolax tablets/supps. Sodium Picosulphate: Dulcolax-Pica, Dulcolax Perles. Caster oil - not recommended  Osmotic laxatives -- retain fluid in the bowel so stimulating peristalsis and forming a loose stool, more powerful than bulk laxatives. Magnesium salts: Epsom salts, Milk of Magnesia - effective within 3 hrs Lactulose/macrogol (BEST for pregnancy): Glycerol supps. Effects within 1-2 hrs; longer action up to 72 hours, sweet tasting; C/I in patients’ lactose/galactose intolerant and use with caution with diabetics  Faecal softeners -- Docusate sodium: Dioctyl caps, little if any straining required, effect within 1-3 days  Faecal lubricant -- Liquid paraffin - NOT advised OTC  Improve diet, exercise, increase fluids, do not take laxatives regularly, do not take bulk laxatives at bedtime  Babies: breast-fed: should not be constipated, bottle-fed are they making feed with sufficient water?  Elderly: increase fluids, possibly dehydrated, bulk laxatives first choice, HOWEVER care in bed bound or inactive patients

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Diarrhoea - Weight loss - Blood in stools - Fatigue/pain >2 days - Alternating with constipation - Travelled recently - Symptoms change/worsen - Chronic (>3wk)/recurrent diarrhoea - Age?  24hrs  6 mo–2 yrs + Sx >48 hrs  Elderly + Sx >48hrs  Adult + Sx >72hrs - Mucus persistently in stools  Medication to give:  No treatment - usually self-resolves, maintain fluid intake  Oral rehydration sachets: Dioralyte, mix with recommended amount of water, will keep for 1 hr or 24 hrs if kept in fridge, sip little and often  Babies: ensure bottles are properly sterilised and making the feeds properly

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Nausea/Vomiting

Blood in vomit Age?  24hrs  6 mo–2 yrs + Sx >48 hrs - Weight loss - Diabetic - Severe vomiting - Digoxin - Projectile vomiting  Medication to give:  Offer electrolyte replacement  Drink plenty of fluids, sip water/little and often, avoid dairy products + greasy foods for 24 hrs. Reintroduce light diet when hungry  Pregnancy: morning sickness: frequent small meals, ginger, sea-bands  Haemorrhoids - Failed treatment after 1 week - Lots of blood - Internal anal pain - Recurrent - Dark red blood in stool - Duration of more than 3 weeks  Medication to give:  Topical preparations: Anusol, Preparation H, Germoloids  Addition of Hydrocortisone: do not use for more than 7 days, do not use in pregnancy/BF, >18 yrs, not to be used if broken skin/infection  Maintain good hygiene, diet, do not scratch area, avoid straining, increase exercise, laxatives (faecal softener) -

Respiratory red flags  -

Common cold + Flu CV disease/Chest pain Lung disease Asthmatic Painful earache Coloured sputum Dyspnoea Pregnant with FLU Diabetic with FLU Elderly or baby with FLU Persistent fever Ear tugging Noisy breathing/wheezing Persistent nocturnal cough Croup/whooping cough

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Cough >2 weeks Coloured sputum Recurrent nocturnal cough ACEI (new or dose change) (ADRS) Whooping cough/croup Chest pain/SOB/wheeze Smoker + recurrent cough

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Sore throat Medication (signs of bone marrow suppression)  DMARDs  Carbimazole  Sulfasalazine - >1-week sore throat - >3 weeks persistent hoarseness - Tonsillitis history - Dysphagia - Smoking heavy -

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Allergic Rhinitis - Breathless/wheezing - Coloured nasal discharge - Purulent conjunctivitis - Earache (otitis media?) - Facial pain (ask if hurts bending down due to potential sinusitis) - 5 days of tx failure

Dermatology red flags 

Eczema - Migration to eye - Psoriasis suspicion or herpetic complications (widespread lesions) - Fever - Red blisters - Infection (weeping, broken skin, flares) - Tx failure after multiple drugs - Sudden/severe worsening of eczema

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Psoriasis: ALWAYS REFER! (unless very mild, in which case give emollient) Dandruff - Signs of infection - Psoriasis suspicion - ALL otc treatment failed

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Seborrheic dermatitis - All otc treatment failed

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Acne - Moderate-severe acne (lesions; not just black/whiteheads) - Failed tx

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Cold sores - Affecting eye - Young infants - Frequent/severe attacks - Lesions in mouth or genitals - Immunosuppressed/Pregnant

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Rosacea: ALWAYS REFER Shingles – ALWAYS REFER Scabies (YS) - Younger than 6 months - Still itching after 3 weeks of tx Pubic lice – no red flags other than the obvious ones Warts/Verrucae - PVD - Elsewhere on body (i.e. not on hands or feet) - ALL otc tx failed – but ask compliance - Change in wart colour or appearance - Eczema near the wart - Diabetic Corns, Callouses, and Bunions - Diabetic - PVD - 2 (2 max) - Crumbled/damaged nail - Infection of proximal nail (bottom of nail) - Diabetic

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Fungal skin infections refer only in signs of infection: hot/red, weeping sores, broken skin

CNS red flags 

Headache - Meningitis Sx: neck stiffness, petechial rash, visual disturbances - Injury/trauma association - Contraceptives + migraine - ADR suspicion - Severe headache >4hrs - Frequent migraine / Failed tx - Children 5 days of symptoms

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Vaginal thrush Sores/ulcers/blisters on vagina/vulva Pregnant/BF Younger 60 Blood in discharge Foul smelling or coloured discharge STI history or partner STI No improvement from OTC tx after 7 days

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Diabetic First time or >2 attacks in 6 months

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Primary Dysmenorrhoea Vaginal discharge/fever (PID) Irregular bleeding/pain @ any time of cycle Pain on sex Chronic/dull pain (instead of spasmodic pain) Breastfeeding

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Menorrhagia First time getting heavy period (not normal for them) Blood in urine Pain on sex Age 45 Tranexamic Acid tried for 3 menstrual cycles with no effect Renal insufficiency (even if mild!) Inter-menstrual/irregular bleeding Obese Thrombotic event history Drugs: oral contraceptives, warfarin/anticoagulants Allergic to Tranexamic Acid Diabetic Post-coital bleeding Pregnant/BF Tamoxifen

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give tranexamic acid, Cyclo F tablets Take 2 three times a day for as long as needed, maximum of 4 days. No more than 8 in a day. 18-45 only, CHD/irregular bleeds/anticoagulants/COC/POP/renal issues/seizures/obese/pregnant        

Amenorrhoea – ALWAYS REFER! Bacterial vaginosis – ALWAYS REFER! Stress incontinence – ALWAYS REFER! Ectopic pregnancy – ALWAYS REFER! PID – ALWAYS REFER! PCOS – ALWAYS REFER! STIs – ALWAYS REFER – UNLESS: asymptomatic chlamydia in both partners + over 16 yrs (=azithromycin 500mg, 2 tabs only once – 2 hrs after food or before bed – see doctor if vomiting occurs) EHC red flags - Possibly already pregnant - Severe liver dysfunction - Ectopic pregnancy risk - Taking enzyme inducers  CBZ  PHY  Barbiturates  Rifampicin  Rifabutin  Ritonavir  St John’s Wort - EllaOne only: Severe asthma and on a glucocorticoid

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Menopause red flags - Unusual bleeding

Men’s Health red flags 

BPH -

Fever Pain on urination in the last 3 months Urinary incontinence Bloody/cloudy urine

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Alopecia (CHAD) - Chunks of hair falling out - Hypothyroidism suspicion (fatigue, weakness, weight gain) - Anaemia suspected (fatigue, dizziness, SOB) - Drug induced hair loss suspected  Warfarin  Lithium  CBZ  Sodium valproate  Beta-Blockers  Colchicine  Allopurinol

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Snoring - Headache + fatigue the next day

Travel Health red flags 

Travel Sickness - Pregnant/BF - Children < 2 yrs - Glaucoma - Liver or Kidney disease - Urinary retention - Epilepsy

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Traveller’s Diarrhoea - Age?  24 hrs  1-3 or 75+ with Symptoms >48hrs  3-75 with Symptoms >96 hrs - Dehydration - Blood/mucus in stools - Severe vomiting or Fever

Ear – Red Flags -

Perforation of tympanic membrane (previously/now/suspected/grommets) Earache internally / discharge Recurrent otitis externa/chronic middle ear disease Foreign body / trauma Cholesteatoma – mastoid skin erosion + smelly discharge Skin conditions – atopic dermatitis, seborrheic dermatitis, psoriasis, dermatophytosis Surgery of middle ear/mastoid previously Deafness (severe)

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Neoplasm: ear canal bleeds easily on contact + crusty lesions Associated symptoms:  N/V  Tinnitus  Dizziness  Persistent vertigo  MENINGITIS SYMPTOMS  Neck stiffness  Photophobia  Confusing headache + earache Failed treatment/persistent wax Abnormal lesions/blisters/ulcers Mastoiditis (Swelling + painful mastoid, pt feels unwell, hearing loss) Barotrauma (common in divers/recently flown/trauma) Referred pain – pain originating from: Sphenoidal sinuses, Teeth, Neck, Throat Otitis media – purulent, smelly discharge

Eye – Red Flags -

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Moderate to severe eye Pain Severe, unexplained Photophobia Trauma/injury causing redness Visual acuity loss Ciliary injection – blue ring around coloured part of eye with redness around it Marked Redness of eye Patient: o Taking anticoagulants or antiplatelets o Has bruising/bleeding elsewhere o Has HPT No improvement w/in 48 hours of antibiotics >2 weeks of symptoms Conjunctivitis less than 2 years

Paediatric Red Flags  -

Pyrexia (fever)...