#Paracetamol Bp

[g0refield]

I told the doctor that i have chronic joint pain, and suspect EDS. I also told her that i pass out when standing still for five minutes and that my BP is normal, so i wanna get a tilt test.

i walked out of there crying with nothing but a prescription for paracetamol.

i know i’m young and that my symptoms aren’t super bad but i’m so scared that it’ll only get worse. i also know that hypersomnia, the only diagnosis i have, is very common in people with EDS and/or POTS. mainly i just wanna get taken seriously.

[faofinn]

Day 29 - Head Injury

A follow on from a Whumptober fic - here

@mediwhumpmay

Fao’s head spun as they settled him inside. At least it was warmer, though he was still cold. He gripped Sheila’s hand tightly as they fussed, though he could feel himself slipping. He didn’t want to pass out, but it was beginning to feel inevitable, his vision blurring into black. 

Fao drifted in and out of consciousness throughout the trip to hospital, struggling to stay with it, despite the people talking to him. When he was aware, he fought against the people touching him but he didn’t have much energy to do anything. Everything hurt, he felt so weak, and every jolt made the dizziness worse. They weren’t far from the hospital, though, and Fao fought to stay awake as they got him inside and transferred across onto their bed, groaning as they moved him. 

This is Fao, he's 23 years old. He was playing rugby when he was tackled at his shoulders around half an hour/forty minutes ago. Took a significant hit to the head and was knocked unconscious on impact, though came to quickly, initially GCS 12 rising to GCS 14. Obviously deformed collarbone so query fracture there. No c-spine tenderness, but boarded for MOI. He's been agitated with us, but lost consciousness again during transport, GCS 3 for about four minutes. Became unable to maintain his own airway and had a respiratory arrest. We ventilated him for about 2 minutes before a spontaneous return, tolerated OP and NP during. He's had a gram of IV paracetamol - has a 20 in left ACF. Obs are as follows - Resp at 18, Heart rate 134, sats 97% on air, now 100% on 15L. Bp 103/62, did drop to 89/45 during his unresponsive episode. BM was 5.1, GCS as before, pupils equal but sluggish. He is allergic to morphine, but other opiate derivatives are okay. Do you need anything else from us?”

The consultant shook her head. “That’s great, thank you.” She said, then moved to speak to Fao. “Hi Fao, I’m Grace, I’m one of the doctors here. Looks like you’ve taken a bit of a hit. There’s going to be loads of people around you for a minute, whilst we get you all set up and make sure we know all of what’s going on, alright? It can be disorienting, try not to worry. We’ll tell you what we’re doing as we do it.”

Fao struggled to listen, but just about managed, trying to focus on the doctor’s face. “‘Kay.” He mumbled. “My mum?”

"She's around, just letting us do our checks first."

“Can I have her? Please?” He whimpered. 

Sheila pushed through, her son's request breaking through her want to follow the rules. She gripped his hand, squeezing in to press a kiss to his forehead, trying to avoid the blocks and tape. 

"I'm here, sweetheart. I'm right here."

He managed a smile. “Mum.”

"I'm not going anywhere, okay? I'm staying with you, I'm just gonna let them do their things they need to."

“Headache.” He complained. 

"I'm not surprised."

“Feel shit.”

"Again, not surprised. Was a shitty tackle."

“Don’t remember.”

"Illegal, they knocked you clean out."

“Oh.”

"Yeah, that's why they're a bit busy around you."

“Feel… fuzzy.”

She swallowed thickly. It was just the concussion, that was all. "You will, you're gonna be fine."

“Yeah. Gonna be fine.”

"Course you are."

“Got you, but don’t feel well.”

"These lovely people are gonna fix you up."

“Mm.” He was quiet for a moment, part of him trying to understand what they were saying. He wanted to know what was going on. His brows pulled together as he focused, but didn’t manage to get anything useful to register in his brain. 

Sheila recognised the look in his eyes. "Hey. They're wanting to take you for a scan, see if any damage is there."

“No thanks.”

"You don't have a choice." She said gently. 

“I don’t want it, though.”

"You need it. You might have hurt yourself more than we can see." Sheila murmured softly. 

“No thank you.”

"Fao, you've got to. You currently can't make that decision."

He whined, and although he protested endlessly, he didn’t have a choice. They took him through to the scanner, and he wasn’t sure if he was tired or they’d given him something, but it was harder to focus and stay awake. About halfway through the scan, he’d drifted a little, but almost jolted awake in fear, nausea suddenly overwhelming him. 

“‘M gonna be sick.” He said, panic rising. 

"We're nearly done, Fao. Take some slow deep breaths." The tech said.

"If he's said he's going to be sick, he's going to be sick." Sheila snapped. "He's not stupid."

“Gonna be sick.” Fao repeated, swallowing thickly. “Help?”

They finally listened to him, and staff came in, helping him onto his side as he was sick. He felt so horribly out of control, held up and in pain, trying desperately to breathe through the nausea. Everything was hazy and horrible, the room spinning, and once he’d finally finished they settled him back on his back. They’d need to do the scan again now, but at least they’d given him some antiemetics. 

They’d started to help and he was able to drift again whilst the scan happened, letting the hazy darkness pull him under. They got through the whole thing without any drama this time, and then he was moved back to resus to await the results. 

They let him and Sheila know quite quickly that they couldn’t see any significant head injury like a bleed or fracture, that it was likely nothing more than a severe concussion, but they’d need to wait for the more detailed scan report. They could, however, get him out of the blocks and sat up a little, which helped him to feel more awake and oriented. He still struggled to keep his eyes open, and his collarbone was absolutely killer, the painkillers hadn’t really touched it. But at least he was okay.

[kaydoespharmacy]

Cold

Symptoms – sore throat, sneezing, runny/blocked nose, cough, mild fever, pressure in ears, headache, myalgia (pain in muscles)

Duration – 1-2 weeks, symptoms peak 2-3 days, incubation period 10-12 hrs

Referral criteria – suspected flu, earache not responding to analgesia, sinus pain not responding to decongestants, no improvement after 10-14 days self-medication

Complications - immunocompromised, who smoke, and with comorbidities such as diabetes mellitus, congestive heart failure, asthma, chronic obstructive pulmonary disease, cystic fibrosis, and sickle-cell disease

Sinusitis – prolonged nasal congestion and facial pain

LRTI - acute bronchitis, acute exacerbation of asthma or chronic obstructive pulmonary disease (COPD), and community-acquired pneumonia

Acute otitis media – common in younger patients

Differential diagnosis

Meningitis – high fever, drowsiness, blank expression, vomiting, loss of appetite, high pitched screaming, non-blanching rash, photophobia, severe headache, malaise

Upper airway obstruction – noisy breathing, drooling, inability to swallow.

Nasal foreign body – persistent discharge from 1 nose with no other symptoms

Management – paracetamol or ibuprofen for headache, muscle pain or fever – only continue use if distressed, change to other agent if not alleviated, don’t give both together

Paracetamol contraindicated in – liver/kidney problems, epileptic

Ibuprofen contraindicated in – pregnancy, perforated stomach, increased bleeding, severe HF, kidney or liver problems, high BP, asthma, hay fever

Intranasal decongestants – improve breathing and promote sleep and has fewer S/E than oral decongestants. Ephedrine HCL 0.5% nasal drops for 12 and older p 1-2 drops 4x daily for 1 week – contraindicated – diabetes, hypertension, hyper thyroidism, CVD, high BP, MAOI in last 2 weeks

Oral decongestants – relieve nasal congestion (phenylephrine) – max 1 week

Antitussive (cough) – dextromethorphan

Expectorants (guaifenesin)

Chlorphenamine or Beecham’s (contains phenylephrine and paracetamol) (Sedating antihistamine – dries up secretions)

Counselling points

Go to GP if

fever for more than 3 days

symptoms worsening after 5 days

symptoms not better after 10 days

follow up meeting

risk and complicated patients within the week

young children – 1 week

Headaches

Types of headaches

Primary – not associated with other conditions – migraines, tension types, cluster

Secondary – associated with other conditions – trauma/injury, vascular disorders, hyper-tension, withdrawal such as opioids, analgesics, or alcohol. Bacterial or viral infection.

Features of serious headache – referral

New severe or unexpected headache – sudden onset reaching max intensity 5 mins and new onset in over 50s

Progressive or persistent headaches that changed dramatically

Associated features – fever, impaired consciousness, seizure, stiffness, photophobia, neurological deficit, cognitive dysfunction, atypical aura (greater than 1 hour) or aura 1st time in patients using combined oral contraceptives.

Dizziness, visual disturbance, vomiting. Head trauma up to 3 months prior, triggered by coughing, sneeze, or physical exertion. Worsened by standing or lying down.

Compromised immunity

Diagnosis

Migraine without aura – at least 5 attacks lasting 4-72 hrs with unilateral location (half the face), pulsating, moderate to severe pain and aggravated by or causing avoidance of routine physical activity. Attack comes with nausea and/or vomiting, photophobia and phonophobia

Migraine with aura – 2 attacks with visual aura (zigzag lines or blind spots), pins and needles, speech/language symptoms, motor weakness, vertigo.

One aura spreading gradually for 5 mins and 2 or more occurring after

Each aura lasts for 5-60mins which is unilateral

Management – stop combined oral anticontraception – contraindicated

Ibuprofen 400mg, paracetamol 1g, advise med to be taken at start of attack – follow up 2 weeks

Tension type – recurrent episodes lasting 30 mins – 7 days with NO nausea or vomiting. May have phot/phono phobia

Bilateral (across head landscape), pressing or tight (not pulsating), mild to moderate pain, not aggravated by physical activity

Management – simple analgesia – paracetamol or NSAID

Identify comorbidities such as stress, mood disorders, chronic pain, sleep disorders to manage

Cluster headache – 5 attacks of severe/very severe unilateral orbital (around ONE eye), forehead or temporal pain lasting 15 mins to 3 hrs with nasal congestion, runny nose, eyelid oedema, sweating, facial slushing, fullness in ear or restlessness

Attacks occur between one every other day and 8 per day for more than half the time the disorder is active

Management – REFER

Advise to avoid triggers and risk of medication overuse, identify and manage comorbidities – insomnia, depression, and anxiety

Medication – occurs 15 days per month and have a pre-existing headache disorder. Regular overuse of drugs for 3 months

Management – withdrawal from medication and advice around this

Sinusitis

Sinusitis usually follows a cold and lasts less than 12 weeks

If over 12 weeks becomes chronic – risk groups are allergic rhinitis, asthma, immunosuppression

Symptoms

Adults

Nasal blockage (obstruction/congestion), nasal discharge, facial pain/pressure, frontal headache, loss, or reduction of smell, altered speech indicating nose blocked. Tenderness, swelling. Redness over cheekbone, cough, headache worse when bending or lying down. Toothache.

Children

Nose block, discoloured nasal discharge, facial pain, pressure and or cough at day or night-time

Bacterial sinusitis

More than 10 days, discoloured, pussy discharge (from 1 nose), severe local pain (1 side), fever over 38 degrees, deterioration after milder sickness

Refer to hospital immediately

If they have symptoms of acute sinusitis and;

Severe systemic infection

Intraorbital or periorbital complications, including periorbital oedema or cellulitis, displaced eyeball, double vision, or new reduced vision

Intracranial complications, including swelling over frontal bone, symptoms or signs of meningitis, severe frontal headache, or focal neurological signs

Refer to GP

Severe symptoms, painkillers don’t work, symptoms worsen, symptoms don’t improve after 1-week, recurrent infection, sudden worsening, antibiotic failure, unusual or resistant bacteria, recurrent episodes, immunocompromised, allergic cause

Treatment

Acute with symptoms less than 10 days

DON’T OFFER ANTIBIOTIC, assure that it usually self resolves without bacterial complications. Symptoms managed

Paracetamol or ibuprofen for pain, headache, and fever

Use nasal saline spray or decongestants spray

Clean nose with saltwater solution (boil 1 pint of water and add 1 teaspoon of salt and bicarbonate soda. Wash hands, stand over sink, cup the palm of 1 hand and pour small amount of solution into it. Sniff water into 1 nostril at a time, breath through mouth and allow water to pour into sink, don’t let it go into your throat. Do 3x daily)

Acute for 10 days or more with no improvement

High dose nasal corticosteroid for 2 weeks for over 12s (mometasone 200mcg 2x daily)

Counsel that It may improve symptoms but won’t make the infection any shorter, could have systemic effects, may be difficult to use correctly.

Symptoms should get better 3-5 days of treatment – REFER if not

1st line antibiotic for adult

If not life threatening - phenoxymethylpenicillin 500 mg four times a day for 5 days.

Is systemically unwell, symptoms of more serious illness or high risk of complications - co-amoxiclav 500/125 mg three times a day for 5 days.

Allergic or intolerant to penicillin - clarithromycin 500 mg twice a day for 5 days.

Pregnant or intolerant to penicillin - erythromycin 250 mg to 500 mg four times a day or

Children 1st line

Phenoxymethylpenicillin

1 to 11 months, 62.5 mg four times a day for 5 days. 

1 to 5 years, 125 mg four times a day for 5 days. 

6 to 11 years, 250 mg four times a day for 5 days. 

12 to 17 years, 500 mg four times a day for 5 days.

If very unwell - co-amoxiclav

1 to 11 months, 0.25 mL/kg of 125/31 suspension three times a day for 5 days. 

1 to 5 years, 5 mL of 125/31 suspension three times a day or 0.25 mL/ kg of 125/31 suspension three times a day for 5 days

6 to 11 years, 5 mL of 250/62 suspension three times a day or 0.15 mL/kg of 250/62 suspension three times a day for 5 days. 

12 to 17 years, 250/125 mg three times a day or 500/125 mg three times a day for 5 days.

If allergic or intolerant to penicillin – clarithromycin

Under 8 kg, 7.5 mg/kg twice a day for 5 days. 

8 to 11 kg, 62.5 mg twice a day for 5 days. 

12 to 19 kg, 125 mg twice a day for 5 days. 

20 to 29 kg, 187.5 mg twice a day for 5 days. 

30 to 40 kg, 250 mg twice a day for 5 days. 

12 to 17 years, 250 mg twice a day or 500 mg twice a day for 5 days.

2nd line – if symptoms are still worsening after 1st line treatment for 2-3 days

Adults – co-amoxiclav 500/125mg TD x 5 days

Children – specialist advice

ANTIHISTAMINES can be prescribed for allergic triggered sinusitis

Diabetes type 1

Body stops making insulin and the blood sugar (glucose) level goes extremely high - persistent hyperglycaemia (random plasma glucose of 11mmol/l or more). We must control glucose level with insulin injections, healthy diet and reduce the risk of other health complications. Typically occurs in children and young adults.

Symptoms of T1D- Frequently thirsty, pass a lot of urine, tiredness, weight loss and feeling generally unwell. Develops quite quickly, over days or weeks, as the pancreas stops making insulin.

Pathophysiology of T1D- Autoimmune disease (environmental & genetic factors). Antibodies attach to the beta cells in the pancreas destroying the cells that make insulin (pancreatic islet cells).

Diagnosing T1D- Simple dipstick test to detect glucose in a sample of urine BUT only way to confirm the diagnosis is to have a blood test to look at the level of glucose in your blood (level of 11.1 mmol/L or more in the blood sample indicates that you have diabetes) PLUS a fasting blood glucose level is taken (level of 7.0 mmol/L or more indicates that you have diabetes).

Management- Should be offered multiple daily injection basal-bolus insulin regimens as the first-line choice. Twice-daily insulin detemir should be offered as the long-acting basal insulin therapy. Once-daily insulin glargine may be prescribed if insulin detemir is not tolerated, or if a twice-daily regimen is not acceptable to the patient. Insulin detemir may also be offered as an alternative once-daily regimen. There are multiple types of insulin…

Rapid Acting- Insulin Aspart (Novorapid®), Lispro (Humalog®) and Glulisine (Apidra®)

Short Acting- Soluble insulin (Actrapid®)

Intermediate Acting- Isophane (Insulatard® or Humulin I®) & NPH - neutral protamine Hagedorn

Long Acting- Insulin glargine (Lantus®), detemir (Levemir®)

Combination insulins (biphasic)- e.g., Novomix 30®, Humalog Mix 25®, Humalog Mix 50®, Humulin M3® and Insuman Comb 50®

Diet & Lifestyle- Diet low in fat, salt, and sugar and high in fibre and with plenty of fruit and vegetables. If you are overweight try to lose weight, increase your physical activity even if it’s only going for a walk (community groups)

Other Health Complications- Get regular checks with your GP, podiatrist, and optometrist. Also get the flu jab every year.

Complications – microvascular, macrovascular (MI, stroke), metabolic (diabetic ketoacidosis) and hypoglycaemia (blood glucose less than 3.5mmol/l)

Psychological complications – anxiety, depression, and eating disorders and those at increased risk of developing autoimmune diseases

Suspect DKA in diabetics – greater than 11mmol/L

Increased thirst and urine frequency, inability to tolerate fluids, persistent vomiting, diarrhoea, visual disturbance, lethargy, fruity smell on breath, deep sighing when breathing and dehydrated

Management

HbA1c levels target of 48mmol/mol or lower - Measure 3-6 months but more often if not controlled

Self-monitoring – need glucose monitor, lancet, finger pricking device and testing strips

Taught at diagnosis and review technique 1 yearly.

Before breakfast, 2 hours after meals, during illness, before driving, if they feel hypo – at least 4 times a day including before and after meals and before bed.

More frequency required (up to 10x daily) if

Target HbA1c not achieved, frequency of hypo increases, during illness, before, during and after sports, planning, during and while breastfeeding.

Target glucose readings

Fasting plasma glucose level of 5–7 mmol/L on waking.

Plasma glucose level of 4–7 mmol/L before meals at other times of the day.

For adults who choose to test after meals, plasma glucose level of 5–9 mmol/L at least 90 minutes after eating.

Agree bedtime target plasma glucose levels with the person. This should:

Consider the timing of the last meal and its related insulin dose.

Be consistent with the recommended fasting level on waking.

Provide information of effects of food and drinks – carbohydrate training (match carb quantities to insulin doses)

Educate to be careful of body weight and diets, feasting and fasting, fibre and protein intake, diabetic foods and sweeteners, alcohol intake, matching carbs with insulin and physical activity

Advice on alcohol – avoid drinking on empty stomach, eat carb snack before and after drinking (extra insulin not required). Measure glucose more regularly and maintain it with carb intake. Alcohol can exacerbate or prolong hypoglycaemic effect.

Exercise – lower glucose levels and reduces CVD risk and can help weight

Sick day rules – never stop or skip insulin – dose may need altering seek advice. Check blood more frequently – 1-2 hours including in the night. Check blood or urine ketone levels – 3-4 hours including night and if 2+ or 3mmol/l or higher then contact GP immediately.

Maintain normal meal pattern where possible if not then replace meals with carb rich drinks, milk, fruit juices and sugary drinks. Aim to drink at least 3L of fluid to prevent dehydration.

Offer multiple daily injection basal-bolus insulin regimens as the first-line choice to all adults with type 1 diabetes.

Offer twice-daily insulin detemir as the long-acting basal insulin therapy

Offer a rapid-acting insulin analogue injected before meals for mealtime insulin replacement

If a multiple daily injection basal–bolus insulin regimen is not possible and a twice-daily mixed insulin regimen is preferred

Insulin pump therapy is recommended as a treatment option for adults with type 1 diabetes mellitus if condition isn’t controlled by treatment

Diabetes type 2

The body still makes insulin however, you do not make enough insulin for your body's needs OR the cells in your body do not use insulin properly (insulin resistance means you need more insulin than normal make to keep glucose levels down. Occurs mainly in people aged > 40 but inc diagnosed in younger people, commonly associated with obesity, physical inactivity, raised blood pressure, dyslipidaemia, and a tendency to develop thrombosis (CV risk).

Symptoms of T2D- Gradual (weeks-months) and can be quite vague at first. Frequent thirst, passing large amounts of urine, tiredness, which may be worse after meals. Some people also develop blurred vision and frequent infections, such as recurring thrush.

Management- Metformin HCl 1st choice for treatment of all patients (à weight loss, red risk of hypoglycaemic events and long-term CV benefits). Has an anti-hyperglycaemic effect, lowering both basal and postprandial blood-glucose conc. It does not stimulate insulin secretion and therefore, when given alone, does not cause hypoglycaemia. If metformin contra-indicated/not tolerated trial MR formulation or initial treatment should be a sulfonylurea e.g. gliclazide OR a dipeptidyl peptidase-4 inhibitor e.g. linagliptin OR Pioglitazone.

Insulin- can be added if intensification of treatment needed. If needed, bedtime basal insulin should be initiated, and the dose titrated against morning (fasting) glucose.

Diet & Lifestyle- Avoid foods heavy in saturated/trans fats, beef and processed meats, sugary drinks, high-fat dairy products and salty/fried foods & have fibrous fruits and vegetables, high omega-3 fatty acid food and poly/monosaturated fats. Lose weight and inc physical activity (min 5 x 30 min brisk walk / week) and smoking cessation.  Also see optician regularly in case of damage to retina, GP and podiatrist.

EXTRA INFO FOR BOTH

Holiday- Pack about x3 the amount of insulin needed, test strips, lancets, needles or glucose tablets you would use, in case you need it (take cool bag to avoid insulin getting too hot). Carry your medicine in your hand luggage just in case checked-in bags go missing or get damaged (insulin can freeze and render it unusable). If injecting (i.e. will have needles/sharps) get a letter from your GP that says you need it to treat diabetes. If you use a pump or CGM, check with your airline before you travel about taking it on board as may require paperwork for medical equipment. If you use a pump, pack insulin pens in case it stops working. Take plenty of snacks in case there are any delays. Do not put your pump through the hand luggage scanner – let airport security know so they can check it another way.

<18 & Diabetic- Paediatric diabetes care team until 18 will help w injecting insulin, testing blood glucose levels, and diet. They can give advice on school or nursery and talk to your child's teachers and carers. Initially, every 1 - 2 weeks but will eventually be every 3 months.

Check Ups Needed- Annually get feet checked by podiatrist to check for loss of feeling in your feet, and for ulcers and infections. Get your eyes checked to check for any damage to blood vessels in the eyes, and checks for high blood pressure, heart, and kidney disease by your GP, also ensure to book in annually for a flu jab. Every 3 months have a blood sugar test (HbA1C test) checks your average blood sugar levels and how close they are to normal when newly diagnosed, then every 6 months once you're stable (~48-53 mmol/mol recommended).

Education- free education courses to help you learn more about and manage your diabetes, your GP will need to refer you. Diabetes UK run local charities for extra support, their website plus the NHS website offers a lot of diabetes information and advice. Maybe invest in a medical ID to carry w you.

Extra Lifestyle Advice- Eat a meal w carbs (e.g. pasta) before you drink alcohol and make sure people around you can recognise a hypo, choose diet soft drink mixers where possible, check your blood glucose regularly/before bed/the next day, drink plenty of water the next day. Avoid hypos by eating the right amount of carbs before, during and after exercise, adjust your insulin and check your blood glucose regularly, drink plenty of water. Recommended to have HbA1c <48mmol/mol when pregnant as high blood glucose levels can harm your baby, especially in the first 8 weeks of pregnancy, also a risk of having a large baby, which can cause complications during labour. Speak to your diabetes team If you're planning to get pregnant or if you get pregnant unexpectedly.

Item for disposal

Method of disposal

Needles

Sharps bin

Lancets

Sharps bin

Used blood test strips

Sharps bin

Leftover/expired insulin

Sharps bin/return to pharmacy

DVLA- tell the DVLA you’re diabetic or you could get fined due to hypoglycaemia/low sugar levels crisis. Check your blood glucose no longer than 2 hours before driving, check your blood glucose every 2 hours if you're on a long journey, travel with sugary snacks and snacks with long-lasting carbs, like a cereal bar or banana. If you feel your levels are low: stop the car when it's safe, remove the keys from the ignition, get out of the driver's seat, check your blood glucose, and treat your hypo, don't drive for 45 minutes from when you feel normal again.

Sharps Removal- Patients issued a sharps bin from the diabetes clinic/hospital on first diagnosis. Some pharmacies offer this sharps disposal service, or the diabetes clinic do too. Can arrange w GP/LHB for sharps collection (Cardiff Council does NOT offer kerbside sharps disposal)

Other Technologies- Insulin Pump (attached to skin via tiny tube which is replaced every 2-3 days & pump moved to diff part of body) will deliver a set background amount of insulin into blood day and night, can add your extra mealtime insulin using the pump. Continuous glucose monitoring (CGMs) means you can check your sugar levels at any time (see patterns in your levels, sends an alert if glucose too high/low) but as interstitial fluid sugar readings are a few mins behind your blood sugar levels you'll still need to do finger-prick checks every now and then. It’s a sensor you attach to your abdomen which needs replacing every 7 days, but some models can be worn for months. Free Style Libre is a flash glucose monitoring system measures your glucose levels continuously throughout the day via interstitial fluid (few mins behind). Attach sensor to your arm and a reader will scan to see your sugar levels (can also use a smartphone app to scan the sensor), sensors usually last for 14 days.

Testing blood glucose

Glucose monitor, specific in-date test strips, primed lancing device and cotton wool pad.

PRIMING LANCET

Twist cap off lancing device

Place fresh lancet into device so grooves line up and twist off the cover, so the needle is visible – change lancet every time so you don't get skin infections

Replace device cap - it should click and then adjust the depth metre – how far the needle will puncture – this is personal preference

Pull sliding barrel at bottom of device back to prime the lancet

CALIBRATING MONITOR

Turn on monitor – put new in-date test strip inside it and test it with in-date control solution – to make sure readings are correct

Do this every time you open a new pack of test strips, if you damage your monitor and if you think the readings are wrong.

TESTING process

Wash hands with warm water and soap and dry. Then rub hands for 10 seconds – warms hands to improve blood flow to fingers

Turn on monitor and place strip inside and wait for it say it’s ready for blood

Place device firmly on side of the finger (less nerves so less painful) and press release button then remove device from site. - change fingers regularly to stop hardening of skin.

Wipe first drop of blood away with cotton pad, use second one to test make sure by touching the blood onto the test strip

If successful wipe blood with cotton pad and apply plaster

Note readings

Remove cap of device exposing lancet. Place lancet cover on table and press lancet hard into this blue plastic cover – this will cover the needle and make it easy to remove

Place lancet and cotton pad in bin

Injecting insulin

Inject in stomach, thighs, or buttocks. Inject an inch away from previous site. Prevents lumps – this reduces absorption of insulin.

check that its correct insulin and is in date. Always check manufacturer’s instructions.

Wash hands with soap and warm water

Attach needle to pen – peel back cover, screw cap onto pen, remove white outer cover and the green cover to expose needle – change needle every time

Dial to 2 units and push plunger so you can see insulin coming out – to make sure no air stuck in there – can take multiple goes in new pens

Set correct dose

Press directly into skin and inject slowly – count to 10 

Remove needle straight without bending it

Use the white outer cap to remove the needle and dispose in yellow sharps bin

Asthma

Symptoms – episodic, worse at night/early morning, triggered by exercise, infection and exposure to cold air or allergens. Triggered by emotion and laughter in children. In adults by NSAIDS and BB use.

Common with atopic eczema, dermatitis and allergic rhinitis and family history

ACUTE EXACERBATION OF ASTHMA IN ADULTS

First-line treatment for acute asthma is a high-dose inhaled short-acting beta2 agonist (such as salbutamol) given as soon as possible. For patients with mild to moderate acute asthma, a pressurised metered-dose inhaler and spacer can be used. For patients with acute severe or life-threatening symptoms, administration via an oxygen-driven nebuliser is recommended, if available. If the response to an initial dose of nebulised short-acting beta2 agonist is poor, consider continuous nebulisation with an appropriate nebuliser. Intravenous beta2 agonists are reserved for those patients in whom inhaled therapy cannot be used reliably.

In all cases of acute asthma, patients should be prescribed an adequate dose of oral prednisolone. Continue usual inhaled corticosteroid use during oral corticosteroid treatment. Parenteral hydrocortisone or intramuscular methylprednisolone are alternatives in patients who are unable to take oral prednisolone.

IN CHILDREN OVER 2

First-line treatment for acute asthma is an inhaled short-acting beta2 agonist (such as salbutamol) given as soon as possible. For children with mild to moderate acute asthma, a pressurised metered-dose inhaler and spacer device is the preferred option. The dose given should be individualised according to severity and adjusted based on response. For children with acute severe or life-threatening symptoms, administration via an oxygen-driven nebuliser is recommended, if available. Parents/carers of children with acute asthma at home, should seek urgent medical attention if initial symptoms are not controlled with up to 10 puffs of salbutamol via a spacer; if symptoms are severe, additional bronchodilator doses should be given as needed whilst awaiting medical attention. Urgent medical attention should also be sought if a child's symptoms return within 3-4 hours; if symptoms return within this time, a further or larger dose (maximum of 10 puffs of salbutamol via a spacer) should be given whilst awaiting medical attention.

COPD

Symptoms - persistent respiratory symptoms and airflow obstruction, which is usually progressive and not fully reversible, exertional breathlessness, chronic/recurrent cough, or regular sputum production, wheeze

Treatment – education on condition and risk factors, smoking cessation, pneumococcal and flu vaccination yearly, treatment of associated comorbidities

1st line – SABA or SAMA to relieve breathlessness and improve exercise tolerance – reviewing medication, adherence, and inhaler technique regularly

THEN IF they have NO asthmatic features or no features of steroid responsiveness – offer LABA AND LAMA

If they continue to have day-to-day symptoms, consider 3-month trial of LABA+LAMA+ICS

If NO improvement go back to LAMA+LABA only but if it works continue and review annually

If they have asthmatic or steroid responsiveness features offer LABA+ICS if they have day to day symptoms of 1 severe or 2 moderate exacerbations a year, then offer LABA+LAMA+ICS

WITH ICS DISCUSS RISK OF USING ICS including pneumonia

Acute exacerbation of COPD – triggered by infections, smoking and environmental pollutants

Severe breathlessness, increased cough, increased sputum production and change in colour, increased wheeze, and chest tightness, cold or sore throat, reduced exercise tolerance, ankle swelling, increased fatigue, and acute confusion

FOR SEVERE exacerbation – ADMISSION

FOR non-severe – increase dose or freq of SABA and maybe change to nebuliser for ease of admission

If no contraindications with significant increase in breathlessness – offer 30mg oral prednisolone OD x 5 days or if caused by infection then amoxicillin 500mg TD x 5 days, doxycycline 200mg day 1, 100mg OD x 5 days, or clarithromycin 500mg BD X 5 days

Epilepsy

Cause – abnormal excessive or synchronous brain activity

Symptoms

Short-lived (less than 1 minute), abrupt, generalised muscle stiffening with rapid recovery — suggestive of tonic seizure.

Generalised stiffening and subsequent rhythmic jerking of the limbs, urinary incontinence, tongue biting —suggestive of a generalised tonic-clonic seizure.

Behavioural arrest — indicative of absence seizure.

Sudden onset of loss of muscle tone — suggestive of atonic seizure.

Brief, 'shock-like' involuntary single or multiple jerks —suggestive of myoclonic seizure.

Management

During seizure – protect from injury by placing in recovery position. If tonic-clonic seizure is prolonged (more than 5 mins) or recurrent – emergency buccal midazolam or emergency admission

Annually reviewed – assess seizure control, how it’s affecting QOL, adverse effects and compliance with drug

Women of childbearing age – 13 to 60

Epileptic women not treated with drugs or on non-enzyme inducing antiepileptic (except lamotrigine) – contraceptive options are same as general population

Woman on exyzme-inducing drugs – drug can reduce effectiveness of combined hormonal contraception, progestogen-only pills, transdermal patches, the vaginal ring, and progestogen-only implants. OFFER medroxyprogesterone acetate injections or an intrauterine method (copper intrauterine device or the levonorgestrel-releasing intrauterine system)

Woman on lamotrigine – oestrogen containing contraceptive reduces efficacy of lamotrigine

USE progesterone only instead but educate them to report signs of lamotrigine toxicity

Category 1 (ensure the person is maintained on a specific manufacturer's product) — phenytoin, carbamazepine, phenobarbital, primidone.

S/E – common and usually mild, advise to report and can usually be fixed with dose adjustment or change of drug

Sedation and dizziness, suicidal thoughts and behaviour, acute psychotic reactions, weight gain and loss, skin rashes.

Safe in pregnancies – lamotrigine (Lamictal) and levetiracetam (Keppra) are safest options

Anxiety

Uncontrollable widespread worry and range of cognitive and behavioural symptoms

Slow onset and symptoms don’t usually improve but are better controlled with intervention

Diagnosis – worry associated with restlessness, insomnia and muscle tension, fatigue, poor concentration, irritable. ALWAYS ask about alcohol and drug use including OTC

Treatment

Establish diagnosis and severity of anxiety and any other comorbidities (usually insomnia and depression and whichever is the most pressing is treated first) – explaining the disorder and treatment opportunities and starting them with active monitoring of symptoms either self or through regular meetings

Offer CBT – non-facilitated self-help for 6 weeks, individual guided self-help, educational groups

High intensity CBT, applied relaxation or drug therapy

Drug therapy – 1st line is SSRI (sertraline, paroxetine, or escitalopram) 2nd line SNRI (duloxetine or venlafaxine). If both contraindicated or intolerable then Pregabalin.

Review effectiveness and ADR every 2-4 weeks during first 3 months then every 3 months.

Counsel on common effects during treatment initiation (suicidal thoughts and worsening of anxiety) but importance of reporting this instead of withdrawing from drug

SSRI – don’t take NSAIDS or if prescribed take with PPI

For pregnant women step 3

DO NOT give benzo or antipsychotics in primary care

Benzodiazepines (SCH 3 and 4)

Most commonly used anxiolytics and hypnotics

Short rem relief (2-4 weeks only) of anxiety that is severe, disabling, or causing the patient unacceptable distress

use to treat short-term ‘mild’ anxiety is inappropriate

Sch 4 CDs, apart from temazepam

Sch 3 (CD no register) and midazolam

Pharmacological effects of benzodiazepines

Sedation, sleep induction

sleep, but can still cause arousal

decreased anxiety, amnesia at higher doses

muscle relaxation (both midbrain and spinal effects)

anticonvulsant activity

Reduced aggression

Depression

Persistent low mood and/or loss of pleasure in most activities and range of emotional, cognitive, physical, and behavioural symptoms

Diagnosis

Low mood

Loss of interest/pleasure from normally pleasurable activities (anhedonia)

Reduced energy (fatigue)

Low self-esteem; feelings of guilt

Inability to think/concentrate

Altered psychomotor activity

Sleep disturbance; early morning wakening

Altered appetite

Suicidal thoughts

Diagnosis requires 2 core symptoms plus 2 or more others present for most of the day on most days for the last 2 weeks

Differential diagnosis

Ensure symptoms are not caused by physical illness, alcohol, medication, or illicit drug use

The symptoms aren’t caused by normal grief (death of family) – maybe consider very long grief

Never been a manic (severe levels of high mood) or hypomanic (to a reduced level) episode

Treatment

Dependant on accurate assessment and diagnosis of depression

Psychological

CBT, behavioural activation, interpersonal psychotherapy, problem solving therapy

Social

Identify stressors and work on strategies/signposting to other supporting organisations

Biological – moderate to severe

Antidepressant therapy or antidepressant and antipsychotic combination therapy in psychotic depression

Drug classes

Tricyclic antidepressants (TCAs) e.g., amitriptyline

Selective serotonin reuptake inhibitors (SSRIs) e.g., fluoxetine

Serotonin and NA uptake inhibitors (SNRIs) e.g., venlafaxine

Monoamine oxidase inhibitors (MAOIs)

Irreversible e.g., phenelzine (MAO-A and B)

Reversible e.g., Moclobemide

Atypical antidepressants e.g., Mirtazapine

Noradrenaline reuptake inhibitors (NRIs) e.g., Atomoxetine

TCA - S/E – Short lasting (days) sedation, confusion, and Incoordination in both normal and depressed patients, antimuscarinic effects, dry mouth, blurred vision, decreased mucus production. Dangerous CV effects in OD 

Severe depressive at risk of suicide shouldn’t be given TCA

Interactions – potentiation of the effects of alcohol – alcohol is a depressant and will only compound the depressive effects

SSRI’s - S/E – nausea, anorexia, insomnia, and loss of sexual function

Less anticholinergic side-effects and less dangerous in OD than TCAs. Prolonged QTc – cardiovascular complications risk with citalopram  interactions – NSAIDs, Anticoagulants, triptans

SNRI’s - S/E – significant withdrawal effects – have short half-lives so need to be taken regularly to avoid these effects. Complex nature of TCAs makes them difficult to prescribe to complex patients unlike SNRIs

Interactions – NSAIDs and anticoagulants

MAOIs - S/E – antimuscarinic effects, restlessness as a result of CNS excitation

Interactions – serious food and drug reactions e.g., cheese (tyramine from food such as cheese is broken down by MAO. The lack of breakdown from MAOIs can lead to tyramine actively displacing neurotransmitters such as 5HT, DA, NA – causing hypertensive crisis

VERY IMPORTANT COUNSELLING POINTS

No other drugs or illicit drugs with this

Side effects

Drug and food interactions are unacceptable.

“Cheese reaction”: this occurs when amines that are generated during fermentation, like tyramine, are ingested and absorbed from the gut. (The main danger is ripe cheese, yeast products - Marmite).

Large rise in systemic tyramine indirectly results in a large release

    of catecholamines

Hypertensive crisis characterised by throbbing

            headache, tachycardia & cardiac arrhythmias.

Same can occur with drugs (Pseudoephedrine)

Atypical antidepressants - S/E- sedation, weight gain, increased appetite – good in patients with anorexia or depression causing loss of appetite or weight

Blood disorders – counselling

Withdrawal issues

Can be used with other antidepressants that cause sleep issues

Interactions – alcohol

FDA black box warning – suicide

Treatment

Mild symptoms – psychological therapy

Persistent mild symptoms or moderate to severe symptoms – combination of psychological and drug therapy

1st line treatment usually SSRIs

2nd line switch to alternate SSRI

3rd line switch to different class (normally an SNRI)

Practical issues

Initiating an antidepressant can cause feelings of anxiety consider co-prescribing short course of benzodiazepines to counteract the anxiety

During the first few weeks of antidepressant treatment can have worsening suicidal thoughts with improved motivation so ensure counselling and regular reviews

Consider prescribing limited supply of meds to reduce chance of OD

Side effects often transient and improve with time

Caution when switching antidepressants – table of different half-lives and how to taper them

Treatment approach

If no response to 3 antidepressants, then check concordance, review diagnosis, and consider if social problems are maintaining depression

Consider augmentation – addition of drug to the current therapy

Mirtazapine – sleep

Quetiapine – mood

Aripiprazole

Lithium – mood stabiliser

Lamotrigine – mood stabiliser

Electroconvulsive therapy

Response

2-4 weeks usually for response to be seen (longer in elderly)

Improvement greatest during weeks 1-2

If no response during 2–4-week period, consider first increase in dosage then if again limited efficacy, then switch to alternative

Extended duration if treatment trial will lead to additional benefit in some

Differences between drugs

Mirtazapine, escitalopram, venlafaxine, and sertraline

more efficacious than

duloxetine, fluoxetine, fluvoxamine, paroxetine and reboxetine

Reboxetine less effective overall

Escitalopram and sertraline

better tolerated than

duloxetine, venlafaxine, fluvoxamine, paroxetine and reboxetine

Preventing relapse

Relapse rate 3-6 months post remission is 50% with no drug treatment

A/D treatment reduces absolute risk of relapse by about 50%

After 1st episode continue for 6-9 months

After 2nd episode continue for 12 months

After 3rd episode continue for 2 years

Insomnia – difficulty in getting to sleep or staying asleep long enough to feel refreshed the next morning

Causes

Recreational drugs

caffeine, nicotine, alcohol, cannabis)

Medicinal drugs

anticonvulsants, antipsychotics, b-blockers, SSRIs, MAOIs, steroids, decongestants, Alpha agonists and antagonists, narcotic analgesics

Drug withdrawal

from CNS depressants (eg alcohol, anxiolytics/hypnotics)

Physiological

Diet, late night exercise, shift work (night and evening work)

Environmental

Noise, bright lights, extremes of temperature

Medical conditions

Psychological - anxiety, depression, grief, stress

Non-psychological eg chronic pain, gastric reflux, asthma, sleep apnoea

Types of insomnia

Primary insomnia - insomnia not attributable to a medical psychiatric or environmental cause

Secondary insomnia- insomnia secondary to another condition

Transient (2-3 days) – caused by changes in routine (for eg. change in time zone, alteration of shift work)

Short term (<3 weeks) – may result from temporary environmental stress

Chronic insomnia (>3 weeks) –usually secondary to other conditions

Treatment

FIRST LINE IS ALWAYS NON-DRUG treatments e.g., lifestyle changes and CBT

Drug therapy – Hypnotics

Benzodiazepines

Benzodiazepine-like drugs (Z-class)

melatonin

BEFORE hypnotic is prescribed the cause of insomnia must be established and where possible, underlying factors should be treated

NICE recommends

if hypnotic medicine is the appropriate way to treat one for only short periods of time and strictly according to the licence for the drug. (Usually, 1-2 weeks and max 4 weeks) and should be prescribed on a weekly basis

Benzodiazepines

 Most benzodiazepines

decrease time taken to get to sleep

in individuals who habitually sleep <6hr, the drug increases duration of sleep

Few short-acting BDZs recommended for insomnia (short-term treatment – max 2-4 weeks)

Should only be used when SEVERE, DISABLING or causing EXTREME DISTRESS

Benzodiazepine – like drugs

Z -Hypnotics – Zaleplon, zopiclone, zolpidem (Short acting – t1/2 < 8 hr)

Short term use only (2-4 weeks)

Lack of anxiolytic effects –drowsiness or dizziness - just induce sleep

Melatonin treatment

Prolonged release melatonin available for primary insomnia in over 55yr olds (can be used up to 3 weeks)

Antihistamine gen 1 – can cause drowsiness

Anxiolytics

Kalms, Kalms day, Karma, Karmamood, Potters Newrelax, Relaxherb, Stressless

Hops, valerian, passionflower, passiflora, vervain, St John’s Wort

Sedatives

Kalms night, Kalms sleep, Dormesean, Niteherb, Nytol herbal, Potters Nodoff, sominex herbal

Hops, valerian, vervain, skullcap, wild lettuce, passiflora

Some herbal remedies do contain active ingredients so be careful of interactions

Lifestyle changes – promote sleep hygiene

establishing fixed times for going to bed and waking up

trying to relax before going to bed

maintaining a comfortable sleeping environment avoiding napping during the day

avoiding caffeine, nicotine, and alcohol late at night 

avoiding exercise within four hours of bedtime 

avoiding eating a heavy meal late at night

avoiding watching or checking the clock throughout the night

using the bedroom mainly for sleep if possible

avoid going on phone, looking at screens immediately before bed or whilst in bed

ADHD

Persistent developmentally with inappropriate levels of over reactivity, inattention and/or impulsivity

Diagnosis – based on observation there are no biomed tests

Symptoms – 9 symptoms across 2 domains

Hyperactivity/impulsivity

Inattention

Can be combined type or dominant in one

ADHD – Predominantly inattentive type

Fails to give close attention to details or makes careless mistakes.

Has difficulty sustaining attention.

Does not appear to listen.

ADHD – predominantly Hyperactive/impulsive type

Fidgets with hands or feet or squirms in chair.

Acts as if driven by a motor.

Blurts out answers before questions have been completed.

Difficulty waiting or taking turns.

Interrupts or intrudes upon others.

ADHD – Combined type

Patient meets both sets of inattention and hyperactive/impulsive criteria

ADHD – Differential diagnosis

Sensory impairment – leading to under or over-sensitivity to triggers

Epilepsy and related states – could present as inattention

Effects of head injury

Acute or chronic medical illness

Poor nutrition – linked to poor behavior – not directly linked to ADHD

Sleep disorders – linked to poor behavior – not directly linked to ADHD

Side effects of medication

School or classroom difficulties – bullying or other factors

Large links to exposure to smoking and drinking during pregnancy, childhood illness such as meningitis or other viral infection, low birthweight/prematurity. HIGH heritability

Treatment

Mild-moderate –1st line - parent-training/education programmes with parent and child, group based or individual sessions. Teachers receive ADHD training and offer intervention in schools.

2nd line – CBT or social skills training

3rd line – DRUG THERAPY ONLY FOR SEVERE and should be offered along with psychological, behavioural, and educational interventions

Drug therapy

Methylphenidate – generally first choice

Atomoxetine - if other tics, Tourette's syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion are present

D-amphetamine – ONLY if other drugs ineffective at raised doses – CD2 high risk in addiction and dependence and misuse so used as last resort

Decide which drug treatment to use based on:

their different adverse effects

potential problems with compliance (for example, if a mid-day dose is needed at school)

potential for drug diversion (taken by others) and misuse

preferences of the child or young person and their parent or carer

When a decision has been made to treat children or young people with ADHD with drugs, healthcare professionals should consider: –

methylphenidate for ADHD without significant comorbidity

methylphenidate for ADHD with comorbid conduct disorder

methylphenidate or atomoxetine when tics, Tourette’s syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion are present

atomoxetine if methylphenidate has been tried and has been ineffective at the max dose, or the child intolerant to low or moderate doses of methylphenidate.

Atomoxetine

Closely observe children or young people taking atomoxetine for agitation, irritability, suicidal thinking, and self-harming behavior, particularly during the initial months of treatment, or after a dose change.

Liver damage in rare cases (usually presenting as abdominal pain, unexplained nausea, malaise, darkening of the urine or jaundice).

Treatment of adults

In adults, methylphenidate normally first line treatment

Consider atomoxetine or dexamphetamine if symptoms do not respond to methylphenidate or the person is intolerant to it ~6 weeks.

Selection of appropriate medication

Immediate-release preparations if more flexible dosing is required or during initial titration to using methylphenidate, consider determine correct dosing levels

If there is a choice of more than one drug, use the drug of lowest overall cost

modified-release preparations for convenience…

their pharmacokinetic profile,

improving adherence,

reducing stigma (because the drug does not need to be taken at school)

reducing problems of storing and administering controlled drugs in schools

abuse liability

AUTISM

Symptoms

Socialization

Impaired use of non-verbal behaviors to regulate interactions

Delayed peer interactions, few or no friendships, and little interaction

Absence of seeking to share enjoyment and interests

Delayed initiation of interactions

Little or no social reciprocity and absence of social judgment

 Communication

Delay in verbal language without non-verbal compensation (gestures)

Impairment in expressive language and conversation, and disturbance in pragmatic language use

Treatments

NEED early diagnosis and defined biomarkers

Currently intervention is through family and educational support

Only some specific programs have an evidence base

Aim is to ‘improve the functional status…through skill acquisition in core areas’

Eg developing relationships

Achieving social and environmental milestones through play

Positive reinforcement of social communication

Pharmacological treatments for co-morbidities

Developmental

Hyperactivity/impulsivity (see ADHD)

Psychiatric

SSRIs, other antidepressants for depression

atypical antipsychotics for OCD

SSRI or a2 agonists for anxiety

Behavioural

Atypical antipsychotics (irritability, aggression)

Sensory

Neurological

anticonvulsants and fits, a2 agonists for tics

Gastrointestinal

Sleep disruption

melatonin and clonidine

Dementia

Symptoms –

Higher cognitive function affected

Memory, thinking, comprehension, learning capacity, language (speaking and understanding it)

Daily living activities/emotional behaviour (non-cognitive symptoms)

Behavioural and psychological symptoms of dementia (BPSD) – include agitation, apathy, depression, anxiety, delusions, hallucinations, irritability, and wandering

Treatment -

Acetylcholinesterase (AChE) inhibitors (donepezil, galantamine, and rivastigmine) — as monotherapies for managing mild to moderate Alzheimer's disease.

Memantine (a N-methyl-D-aspartic acid receptor antagonist):

As monotherapy for managing Alzheimer's disease for people with moderate Alzheimer's disease who are intolerant of, or have a contraindication to, AChE inhibitors, or for people with severe Alzheimer's disease.

In addition to an AChE for people with established moderate or severe Alzheimer's disease who are already taking an AChE

For people with non-Alzheimer's dementia the use of AChE inhibitors or memantine is unlicensed, but they may be prescribed by a specialist for people with:

Mild to moderate dementia with Lewy bodies:

Donepezil or rivastigmine are recommended first line.

Galantamine is an option if donepezil and rivastigmine are not tolerated.

Severe dementia with Lewy bodies:

Donepezil or rivastigmine are recommended.

Vascular dementia:

AChE inhibitors or memantine are options if the person has suspected comorbid Alzheimer's disease, Parkinson's disease dementia, or dementia with Lewy bodies.

Risperidone and haloperidol are the only antipsychotics licensed for treating non-cognitive symptoms of dementia, although other antipsychotics are often prescribed off-label for this purpose.

Acetylcholinesterase inhibitors

NMDA receptor antagonist

Cholinesterase inhibitors for mild to moderate AD (eventually stop working)

NMDA receptor antagonist for severe AD and moderate AD in some cases

Treatment must be started only by a specialist clinician

Rheumatoid arthritis

Inflammatory disease causing persistent symmetric joint synovitis

Presents as pain and joint stiffness with heat and swelling progressing at rest and after periods of inactivity with malaise, fatigue, fever, and weight loss

Risk factors – smoking, eating large amounts of red meat, drinks excessive coffee

Symptoms

Joints

Pain

Swelling

Stiffness

Systemic

Fatigue, depression, irritability

Anaemia

Flu-like symptoms, such as feeling generally ill, hot, and sweating

Pain worse in morning

Treatment

Drugs, mild exercise (enhance flexibility of joint and muscle strength), lifestyle changes (rich antioxidant diet, no smoking)

Main types of RA meds

NSAIDs (short term symptomatic relief) – reduce inflammation. OTC (ibuprofen, naproxen). POM (celecoxib, etoricoxib)

S/E – GI irritation, ulcers (use at lowest dose and take with food, use PPI to lessen effects)

Caution – asthmatics and renal impairment and patients with increased CV risk

Disease-modifying anti-rheumatic drugs (DMARDs) – 1ST LINE for active RA (methotrexate, sulfasalazine)

S/E – Nausea, diarrhoea, oral ulceration, alopecia, cough, SOB, bone marrow suppression – CAN BE REDUCED by co-prescribing FOLIC acid 1mg daily

Biological therapies (type of DMARD) – used when DMARDS don’t control RA

Glucocorticoids – short term treatment when starting new DMARD for rapid symprom control  - also used in flares

Analgesics (painkillers)

Drug Treatment Schedule

Start two DMARD regime once diagnosed, using titration regimens

Use anti-inflammatories (NSAIDs), paracetamol with or without corticosteroids until effective

Review after 6 months: increase dose or switch as clinical condition determines.

Patient counselling in RA

Place of drugs in therapy

Onset of action

Side effects

Immunosuppression

Regular painkillers

Regular monitoring including blood tests

Dexterity aids, prescription services

Osteoarthritis

Predominantly non-inflammatory and caused by cartilage loss from synovial joints and bone remodelling due to excessive and repeated overloading on weight bearing joints or stress of a joint over tome and specific injuries

Risk factors – genetic, age, gender, obesity, damage, occupational, and stress

Symptoms

Pain – tends to be worse when using the joint and at end of the day (Worsens on use, resolves at rest)

Stiffness – feel stiff after rest, usually wears off as you get moving

Grating or grinding sensation (crepitus) – joints creak or crunch as you move

Swelling – may be caused by osteophytes (bone outgrowth) or caused by synovial thickening and extra fluid

Muscles around joint look thin/wasted

Unable to use joint normally – doesn’t move as freely or far as normal

Joints give way – muscles have weakened, and joint is less stable

Management

Provide information on sources of advice and support

Advice on self-care strategies such as;

Weight loss, local muscle strengthening exercises and aerobic fitness training

Appropriate footwear, local heat, or cold packs

Odder psychosocial support – career and occupational health assessments if needed

Advice on simple analgesia

Arranging regular reviews to assess response to treatment

MANAGEMENT GOAL – pain reduction and symptomatic relief

First line:

Paracetamol regularly – 4g daily

Topical NSAIDs

Additional treatment:

Oral NSAIDs– not first line

-Start with ibuprofen

-Monitor for side effects

-Possible place for topical therapy

Topical capsaicin – adjunct and helpful in knee and hand – works by stimulating then decreasing the pain sensation

Corticosteroid injection: â pain and inflammation of flare-up

Role of pharmacist

Counselling:

dosage regimen

side effects

warnings

Monitoring for side effects

Weight loss advice

Physiotherapy advice

Compliance aids & living aids

Gout

Type of inflammatory arthritis – causes severe pain and damage to joints

Caused by abnormal high levels of uric acid in blood which deposits urate crystals in joints and tissue

3 phases

Asymptomatic hyperuricaemia – can remain in this stage for life

Acute attack of gouty arthritis – can vary from months to years before another attack

Final period of chronic tophaceous gout – nodules effecting joints

Treatment

Acute

Ice

Rest affected joint

NSAIDs – short term, 7-14 days, high dose, for pain relief and anti-inflammatory

Colchicine (Dose: 500mcg 2-4 x daily until symptomatic relief or SE (stomach cramps, diarrhoea, vomiting)), steroids (used when NSAID and colchine is contraindicated or not useful)

Choice of drug dependant on comorbidities and renal function (NSAID cause fluid retention whereas colchicine doesn’t)

Colchicine use limited as it can have sudden toxicity at higher conc

Combination treatment can be used as well if monotherapy isn’t controlling the attack

Long term treatment to reduce urate

Lifestyle modifications (reduce dietary intake)

Drug therapy: Allopurinol (1st line – offer to all, 100mg od, increased in 100mg increments every 2-3 weeks) S/E – rashes

Febuxostat (2nd line only use when allopurinol intolerant or contraindicated – 60mg OD dose)

Monitor urate level – aim for < 360 μmol/L or 6 mg/dl (critical level)

Muscoskeletal

Sprain

Commonly ankle, wrist, thumb, knees – pain, swelling, tenderness, bruising, disabled use and no weight

Strain

Common in legs and lower back – pain, swelling, bruising, red, and reduced function

BOTH

Self-limiting gets better in 4-6 weeks and full recovery in 12 weeks

Non-pharma advice

PRICE (Protect, Rest (48-72hrs), Ice immediately after, Compression bandages and Elevate to reduce swelling

Reduce HARM (Heat, alcohol, running and massaging for 72hrs.

Avoid NSAIDs for 72hrs

Exercises for sprains

Gently move joint in all directions to increase and maintain flexibility (lack of movement can delay recovery BUT severe sprains with complete lack of movement rest for 10 days first)

Treatment – topical and oral analgesics

Refer – severe pain, possible break or fracture, no alleviation with OTC meds

Lower back pain

Symptoms – pain, tension, soreness, stiffness without underlying cause

6 weeks usual recovery can be up to 12 weeks

Advice

Back exercises, improve posture, yoga, avoid lying or sitting for too long, remain active.

Sleep in different positions, pillows between legs, under knees, hot baths, hot water bottles, ice packs.

Treatment

OTC – topical analgesics or co-codamol if still painful

Refer

No improvement in 3 days, continues for more than 6 weeks, pain travels higher, pain after injury, younger than 20, older than 50, pain affects sleep, unsteady on feet, unexplained weight loss

EMERGENCY

Pins and needles in back, genital, bum, both legs, lose urine or bowel control

Conjunctivitis

Symptoms

Bacterial

Viral

Allergic

Eyes affected

1 or 2

Both

Both

Discharge

Pussy

Watery

watery

Sensation

Gritty

Gritty

Itchy

Co-presenting symptoms

None

Cough/cold

Rhinitis

If pussy, red or gritty it is contagious – allergic ISNT contagious

Advice

Don’t wear contacts, hold cold flannel on eyes for few mins to cool them, use FBC water to gently wipe lashes and clean off crust and clean with cotton wool pad. Use a different one for each eye

Control spread by – reg wash hands with hot soapy water, cover mouth and nose when sneezing, don’t share towels or pillows and don’t rub eyes

Refer

Baby less than 28 days old with red eyes, allergic reaction, or spots on eyelids. For all – symptoms not resolved after 2 weeks

111 - Severe pain, sensitive to light, sudden changes to vision

Treatment

Viral – self-limiting, use hygiene and non-pharma advice

Allergic – Opticrom eye drops (Adults and child – 1-2 drops in each eye up to 4x daily)

Bacterial – over 2, chloramphenicol drops/ointment (Optrex Bacterial Conjunctivitis 1%w/w Eye Ointment) - apply a small amount of ointment in the affected eye 3-4 times daily for 5 days

Blepharitis

Symptoms

NOT contagious, rims of eyelids are inflamed, burning, soreness or stinging in the eyes, crusty lashes that stick together, itchy eyelids

Advice

Clean eyelids at least 1x daily, clean eyes even if symptoms clear, don’t wear contacts, or eye makeup

Cleaning eyes – soak a clean flannel/cotton wool in warm water and place on eye for 10 mins, gently massage eyelids for 30 secs, clean lids using cotton wool. Baby shampoo at 10:1 ratio good.

Refer

No improvement after 2 weeks of cleaning eyes

Treatment OTC

Brolene eye drops – 1-2 drops in each eye up to 4 x daily. If not better in 2 days refer

Dry eyes

Symptoms

Dry feeling, sensation of something in eye, burning, grittiness, itching, light sensitivity, over-blinking, redness, excess tears (randomly tearing)

Causes – over 50, contacts, digital screens, AC, windy/cold/dry/ dusty environment, smoking, alcohol, meds (antidepressants/BP) medical conditions (blepharitis)

Refer

Treatment failure after 2 weeks, change in eyelid shape

111 – severe pain and red, contact wearer with red eyes (could be an infection)

999 A&E – sudden change in sight, bursts of light sensitivity, severe headache/nausea, dark red eyes, injured/pierced eye, something stuck in eye

Advice

Clean eyes daily, take breaks when using screens, use screens below eye level, use humidifier, wear glasses instead of contacts

Treatment 

Light lubricant – Optrex Double Action Drops for Dry and Tired Eyes - Apply 1-2 drops in each eye.

Hyaluronic Acid - Artelac Rebalance Drops, long lasting relief - Place 1 drop into the conjunctival sac 3-5 times daily or more frequently if required.

Hypromellose drops – 1-2 drops 3 x daily

Excessive ear wax

Symptoms – hearing loss, earache, noise/ringing, vertigo, dizziness, and nausea

Causes – narrow/damaged canals, hairy canal, skin condition affecting scalp around ear, inflammation of ear canal

Refer – not cleared in 5 days, badly blocked, severe, complete loss of hearing, likely infection

Advice – don’t use fingers or cotton buds to remove wax

Treatment

Olive oil drops – 2-3 drops in affected ear and massage around outside of ear BD x 7 days

Use dropper when lying down with head to one side to allow oil into ear, over 2 weeks then lumps should fall out, but symptoms should be better within 5 days

Otitis externa

Symptoms - pain, discharge, itch, irritation, external ear/canal appears red, swollen, eczema, deafness, skin swells, tender to touch

Refer – ear pain in children, inflamed pinna, unsuccessful treatment (after 4 days), hearing aids, excessive discharge (wax or pus), high fever, vomiting, fatigue, confusion, dizzy, stiff neck, rash, slurred speech, fits, light sensitivity

Advice – avoid under/over dressing feverish child, lower heating, offer regular fluids, avoid dummies when lying flat, give paracetamol/ibuprofen if child is unwell/distressed (not together)

Treatment

Acute localised (furunculosis) – infected hair follicles in outer-ear causing swelling and irritation

Treatment – hot flannel, oral analgesics, antibiotics if severe

Acute diffuse (over 3 months – more widespread inflammation of skin, bacterial/fungal infection or contact dermatitis due to irritant/allergens

Treatment – earwax plus or EarCalm

Otitis media

Symptoms – earache, discharge, hot, irritable, sleeplessness, ear pulling/rubbing, crying, temporary deafness

Refer – recurrent infections, no improvement in 3 days

Treatment

Self-limiting should be better in 3 days, single analgesics for pain

Hyperthyroidism

Too much thyroid hormones produced naturally

Symptoms

Tremor, warm sweaty palms, weigh loss despite increasing appetite, heat intolerance, diffused alopecia, hair thinning, tachycardia, diarrhoea

Advice

Healthy diet with foods rich in antioxidants, green leafy vegetables (broccoli, cabbage etc)

Vitamin D, omega 3 fatty acids and calcium rich foods. Smoking cessation

Treatment

Carbimazole (adjunct B blocker propylthiouracil for adrenergic symptoms) – block and replace regime

Combo of fixed high dose carbimazole and levothyroxine

Radioactive iodine destroys thyroid cells, surgery to remove some thyroid

Hypothyroidism

Thyroid gland doesn’t produce enough hormones caused by immune system attacking thyroid gland and damaging ait or by damage to thyroid that occurs during treatments for a hyperthyroidism or thyroid cancer

Symptoms

Fatigue, muscle pain, weakness, weight gain, sensitive to cold, dry skin, brittle hair, nails, depression, reduced libido

Advice

Eat antioxidant rich food, seeds and nuts, tyrosine (meat, dairy, legumes)

Avoid – soy, iodine rick food, leafy green vegs, caffeine, alcohol – quit smoking, alcohol.

Inform GP if pregnant (needs treatment and monitoring during)

Treatment

Levothyroxine 1st line – dose depends on blood test and progression – take tablet at same time every day (MORNING) If taking too much causes sweating, chest pain, headaches, diarrhoea, vomiting. Supressing thyroid supressing hormone with high doses causes atrial fibrillation, stroke, osteoporosis

Cold sores

Symptoms

Simplex - Pain, burning, itching, tingling before lesions and lasts 6-48 hrs

Crops of vesicles burst and crust over and heal, commonly on lower lip and ends of mouth

Gingivostomatitis – fever, malaise, sore throat, painful nodules in cervix or under jaw, excessive salivation. Painful vesicles on a red swollen base that rupture to form ulcers inside mouth, covered with yellow/grey membranes

Refer – immunocompromised, unable to swallow, risk of dehydration, severe infection, complication, pregnant, recurrent

Treatment

Paracetamol/ ibuprofen for symptoms

Topical acyclovir/penciclovir OTC – use from onset of symptoms before lesions until lesions heal

OTC topical anaesthetic or analgesics, mouthwashes, or lip barriers – topical analgesics aren’t licensed in children

DON’T prescribe oral antiviral for healthy people

Consider prescribing oral antiviral for healthy people with episode of primary oral herpes simplex, recurrent labialis if lesions are severe, frequent, or persistent and recurrent

And for those who are immunocompromised

Should take at onset and until lesions have healed – minimum of 5 days

Choice of aciclovir or valaciclovir based on preference, dose, regimen, and adherence

Advice

Reassure its usually self-limiting and heals without scarring

Adequate fluid intake

Offer leaflets or websites for more info

Avoid kissing, oral until lesions fully healed, don’t share pillows, makeup, or lip balms. Don’t touch lesions other than when applying treatment – dab instead of rubbing. Wash hands after touching.

Athletes foot

Interdigital — most common; affects the lateral toe web spaces first; usually caused by Trichophyton rubrum.

Moccasin or dry — diffuse chronic scaling and hyperkeratosis affecting the sole and lateral foot; usually caused by Trichophyton rubrum.

Vesicobullous — least common; multiple small vesicles and blisters mainly on the arches and soles of the feet; usually caused by Trichophyton interdigital.

Risk – hot, humid, occlusive footwear excessive sweating, contaminated surfaces, immunocompromised

Advice

Wear well fitting, open footwear that keep feet cool and dry, replace old shoes that may be contaminated. Maintain good foot hygiene – wear different pair of shoes every 2-3 days. Wear cotton, absorbent socks, don’t scratch skin, after washing feet dry then well and between toes, don’t share towels and wash towel freq.

Treatment

Topical antifungal cream in mild, non-extensive disease

Terbinafine 1% cream (12 and over – apply thinly to affected area 1 or 2 daily for 7 days) or clotrimazole 1% cream (2-3 times daily and continue for 4 weeks minimum) okay for kids – OTC for some ages

Additional mild topical corticosteroid if there’s inflammation

Hydrocortisone 1% cream (OD for max 7 days)

Adult severe or extensive – oral antifungal with confirmed fungal infection

1st choice – terbinafine (250 mg once daily for 2–6 weeks, depending on the severity of infection)

2nd – itraconazole, Griseofulvin if not tolerated or contraindicated

Refer

Treatment failure, severe pain, got, painful and red (indicative of serious infection), infection spreads, diabetic patient, immunocompromised

Warts and verrucae

Warts – small, rough growths caused by infection of skin with HPV, form anywhere on skin most commonly on hand and feet

Verruca – (plantar wart) wart on sold of feet

Spread by direct contact, occur and clear spontaneously at any time or may take years

Common warts are firm and raised with a rough surface that resembles a cauliflower (common on knuckles, knees, and fingers).

Periungual warts are common warts around the nails that can be painful and disturb nail growth — nail biting is a risk factor.

Plane warts are usually round, flat-topped, and skin coloured or greyish yellow (common on the backs of hands).

Filiform warts have a finger-like appearance and may have a stalk (more common on the face and neck).

Palmar and plantar warts grow on the palms and the soles of the feet (verrucae). They often have central dark dots (thrombosed capillaries) and may be painful.

Mosaic warts occur when palmar or plantar warts coalesce into larger plaques on the hands and feet.

Not harmful and don’t come with symptoms and resolve with treatment

Advice

Reducing transmission and limit spread, keep feet dry, wear slippers or waterproof plaster in shower and communal areas. don’t share towels, socks, shoes. Don’t scratch lesions, bite nails or suck fingers with warts

Refer

Painful, facial, uncertain diagnosis, immunocompromised, extensively infected

Treatment

Only treated if painful, cosmetically unsightly, or patient request and persistent as the treatment is long and can have side effects.

Topical salicylic acid – up to 12 weeks

Duofilm® (salicylic acid 16.7% plus lactic acid 16.7%) — licensed for plantar and mosaic warts.

Bazuka® extra strength gel (salicylic acid 26%) — licensed for warts and verrucae.

Occlusal® (salicylic acid 26%) — licensed for common and plantar warts.

Salactol® (salicylic acid 16.7% plus lactic acid 16.7%) — licensed for warts, plantar warts, and verrucae.

Apply OD at night, file and soften area by soaking in warm water for 5-10 mins, peel of remaining film before administering next dose, don’t apply on healthy skin

Cryotherapy – every 2 weeks for max 6 treatments

Liquid nitrogen – only for older children and adults

Corns and calluses

Hard or thick areas of skin that can be painful

Corns – lumps of hard skin on knuckles and joints of toes

Callouses – larger patches of rough, thick skin

Both can be tender and painful

Refer

Diabetic, heart disease, circulation issues. Bleeding or puss, treatment failure after 3 weeks, severe pain

Advice

Wear thick, cushioned socks, wear wide, comfortable shoes with low heel and soft sole, use insoles or heel pads, soak corns and calluses in warm water to soften them, use pumice stone regularly or foot file to remove hard skin. Moisturise.

Don’t try to cut them, walk, or stand for long period, wear high heels or tight pointy shoes, go barefoot

Treatment

Heel pads and insoles, OTC products, pain relief

Carnation brand caps for both – adhesive dressing

Fungal nail infection

Caused by dermatophyte and non-dermatophyte moulds and yeasts

Symptoms

Discoloured, abnormal, small flaky white patches and pits on top of nail and becomes rough and eroded. Nail lifted, wite or yellow opaque streaks on one side of nail, scaling, thickening

Refer

Diabetic, severe, treatment failure, spread to other nails

Advice

Keep nails trimmed short and filed, don’t share clippers and files. Well-fitting shoes, cotton socks, maintain good foot hygiene, weak shoes in communal places, avoid nail trauma

Treatment

Not needed if patient not troubled by appearance and infection is asymptomatic

Advise antifungal treatment if – walking uncomfortable, distress, cosmetic, co-morbid complication, or complication

If dermatophyte or candida infection conformed – topical antifungal treatment 0f 50% of nail involved, 2 nails infected, contraindication to oral antifungal

Topical – amorolfine 5% mail lacquer – OTC apply 1 or 2 weekly to affected nail after gentle nail filing – 6 months minimum for fingernails, 12 months for toenails

If dermatophyte nail infection is confirmed:

Prescribe oral terbinafine first-line.

250 mg once a day for between 6 weeks and 3 months for fingernails, and for 3–6 months for toenails

Oral itraconazole if an alternative drug is indicated.

Prescribe as pulsed therapy 200 mg twice a day for 1 week, with subsequent courses repeated after a further 21 days.

If Candida or non-dermatophyte nail infection is confirmed:

Prescribe oral itraconazole first-line.

Prescribe as pulsed therapy 200 mg twice a day for 1 week, with subsequent courses repeated after a further 21 days.

Prescribe oral terbinafine if an alternative drug is indicated.

Prescribe 250 mg once a day for between 6 weeks and 3 months for fingernails, and for 3–6 months for toenails.

[islandpcosjourney]

IVF/ICSI Day 11

2nd October 2023

🥚 Egg collection 🥚

Tonight will be a short one, I'm hoping, as I feel quite spaced out and pretty rubbish if I'm honest.

I have felt so much Grace surrounding today's events and I am told that I was constantly thanking and being grateful to the staff at the unit for it - more of that for a giggle later!

After a disturbed sleep overnight (just clock-watching from around 2am) and some unwelcome, subconscious anxiety surrounding the day's unknowns, I was very grumpy when Mum came into my room at 5.20am asking if I was awake and getting up, when my alarm wasn't meant to be going off until 5.45am 😂 She hadn't realised, or I should say she'd temporarily forgotten, that I wasn't to wear make-up, jewellery or perfume (strong scents can cause harm to the eggs when they're exposed during collection - who knew!) so therefore I wasn't needing my usual "time to get ready". I had packed my essentials already (dressing gown, crocs, needles/sharps box to return, choc brioche treat for after etc) so all I needed to do was get up, get dressed, have a final cup of tea & go - not the usual Màiri routine in the morning I can tell you 🤪 But when I got up, I was apologetic of my outburst and she seemed in very good form considering she'd also been awake most of the night (unfortunately a side-effect from her fibromyalgia so she's permanently exhausted 🥴).

We were very grateful to Calum for also getting up early to drive us up to Dundee because I needed to be there for 8.15am so we had to leave by 6.30am to be safe. We arrived in plenty time and found a new car-park (number 7) where the drop-off area is.

We were in the unit by 8am and clearly before most of the reception staff were around because nobody was able to check us in 😉 Those who know me, I'm never early 😏 but once nursing staff came to call our names out we figured out we were being taken through in order of the surgery schedule, so I was 3rd on the list.

Basics were done such as checking my name, DOB, history, BP, temp, weight (only 0.5kg gained since baseline scan, which is not bad considering how full & bloated I have felt on the hormones - yay!). I didn't have to change into the very fetching gown until nearer the time so I could just sit on the bed/chair and relax in my jumpsuit until I was told to change - very considerate. The nurse seemed very shocked when she asked what and when had I last eaten, that my response was "just a tiny bit of bread at communion last night" as I had attended the evening service at St C's, which was also communion - "aren't you starving?"...... "no, not at all, it was sufficient" 🥰 I'd had my last cup of spearmint tea on the journey up by 6.50am and I was then only allowed sips of water after 7am so she'd get me some water along-with paracetamol and an anti-sickness tablet. I then had to wait on the consultant, embryologist and anaesthetist to see me to sign for consent, discuss procedures and drugs etc. At every point, everyone was so smiley and caring and inclusive of Mum too, making her feel part of the process. I sometimes felt a bit rude being on my phone messaging Kevin but that feeling was always short-lived as he needed to feel part of the process too and being in constant communication was so important for that - plus if I hadn't messaged at the point when I was told things, I wouldn't have remembered later 🤦🏻‍♀️

Having the cannula fitted in my right hand was the usual EXCRUTIATING pain. I know, I sound like a drama queen here but honestly, of all the procedures I've had done over the years, including a 20cm x 8cm lipoma being surgically removed, cannulas are my BIG problem. It's not just when its fitted but it stings and burns constantly afterwards too. Mum was a bit put-off by seeing my feet & legs wiggling, thinking I was cold, but it was just how I dealt with the pain, honestly its the worst part of any hospital admission for me. But as Mum said, if that's the worst part then I never have to worry!

There were more documents to read, processes to learn about, forms to sign & drugs to hear about that it was all a bit over my head sometimes, and Mum's, but I felt so comfortable, supported and cared-for that I had nothing but pure joy running through my veins. Mum and I talked about passages of the Bible (the curtains were shut but conversations were not shut-out, so who knows who was able to hear) & what Dad might've made of all of this (supportive we're sure & no doubt patiently waiting in the car while having a wee norrag (sleep) - definitely 😂). I loved how fascinated Mum was by all of the processes, a very different nursing day from her's since her training over 50yrs ago and she was on the ball - “they haven't brought your paracetamol yet, or your water, or your anti-sickness tablet” 🤪 Once she heard of all the drugs they'd be giving me (an endless list I could not begin to regurgitate, not language I was used to and even Mum who could understand the basics of why each drug was being administered at which point, didn't recognise the names of them as they've changed so much) she was concerned that I was going to be too "out-of-it" to manage public transport on the way home but I assured her that we'd be fine - I knew God wouldn't throw anything my way that I couldn't manage!

Time to go! 1115 came faster than I anticipated, no boredom happened at any point, I mean who could be bored with Mum by their side chatting constantly 😁 and then to be honest I don't remember much after this! I'd been asked earlier to think about what music I'd like to hear in surgery (I hadn't known this was even going to be a thing) and my first reaction was to say ANYTHING. I told them I was a musician and would be happy with any genre (well, that's not entirely true, I cannot stand Kevin's heavy metal music 😵) but not for one second did I think that's what they'd choose to play 😂 - they didn't btw! No, by the time I got into the room I knew what I wanted - Stuart Townend. I wanted God with me in the room, publicly and openly. They didn't bat an eyelid but O don't think the anaesthetist had heard of him as she repeated "Stuart Townsend?" a common error people make about his surname but hopefully one she'll now remember 😏 I told them all that if my favourite Psalm 23 or In Christ alone were to come on, to turn up the volume and they laughed 🤩

"Keep you here" started playing and honestly what happened after that is all a blur.

🎶 For time is given, And time is taken away; The least that we can do Is make the most of every day. And we are given And we are taken away; The best that we can do Is give ourselves away 🎶

(I'm getting a bit weepy writing these lyrics down if I'm honest, for I believe every word and they were so comforting to hear as they put the breathing mask on me and began doing everything around me - that's now another favourite track of mine 🤩)

I wasn't being put to sleep, no, it was conscious sedation so I should've been aware of my surroundings to a certain extent. I do remember chatting away under my mask but I couldn't for the life of me tell you what about 😂 However, afterwards when I was awake again back in the ward, the nurses were having a giggle with us about just how chatty I was and how I kept thanking them all for their skills, their care, the gratefulness I had for all of their help - nice to know I have good manners even in my "sleep" 😇 Somethings coming back to me now, I definitely remember being asked how I felt at some point and responding with "I feel grand, the Lord is with me" - can't say when or who I was speaking to but I definitely remember saying it 🙏🏻

Back on the ward, I was aware of Mum telling me to rest but I was insistent on messaging Kev, reaching for my phone - "I'm ok out darling, I love you" - yeah, I was clearly still groggy and wasn't aware just how much 😂 for I love my grammar and write proper sentences, most of the time! The ACU counsellor came to see me, that was nice of her, I should've been seeing her at 1130 today, an appointment made weeks ago before we obviously knew I'd be in for egg collection and it was nice to meet her in person having only ever seen her online before. I'll see her tomorrow instead, online, once I've properly recovered. Mum had asked me in the waiting room if I'd gotten much out of seeing the counsellor and tbh I hadn't really, it was mostly helpful in the earlier months when we had MAJOR issues with lack of communication, mix ups with info being communicated and working out processes to put our minds at rest. In terms of "during" this actual cycle, I haven't seen her at all and I haven't needed it either for God is guiding me through this, nothing she could say will help that or even enforce that so it hasn't been required. People have talked about "IVF fairies" and the importance in speaking with others going through the same process and aside from having the Fertility Network WhatsApp group popping up in the background and some messages of support from ladies in that group, I haven't really needed to have anyone else to talk to to help me through this. I have Jesus - that’s all anyone should need. I write this blog which is very cathartic, my husband is my best friend & confidante, we’re in this together and our very supportive friends & family are backing us but it’s not what “gets me through”. It's only when your life is all about "WHY?" that one needs to lean on another for their "wisdom" in having gone through a similar process. Once you know the WHY in life - Jesus - you stop needing to look for the answers and instead they are given to you, gracefully.

(Gosh, I thought I'd said I hoped this would be a short one tonight 🤦🏻‍♀️)

Right, onwards! After tea, toast (always THE best tasting toast after surgery, with real butter, none of this "one molecule away from being plastic" margarine nonsense 🤪) and being able to go to the toilet, I could get dressed, learn about the progesterone gel I need to use for the next 20 days and I was ready to go home - yay!

Quick, straight into a taxi, off to the station, Kevin had worked out which trains were best to get, tickets bought, short wait and onto the train we were. Just over an hour later we were back in Edinburgh, Calum had realised he'd be finishing at a school nearby Haymarket around the same time we'd be arriving so he was able to pick us up and off on the last leg we went - Edinburgh road bumps and all 😫 this was where I was most aware of the pain I had while sitting down - ouchie. I was told I'd be tender, almost like a very heavy period for a number of days but this was the first time I'd ever thought that sitting on a doughnut pillow would have been helpful!

I had decided that I was treating myself to a Dominoes pizza tonight so we ordered that on the way home and picked it up on route so we could eat before I needed to rest and before Calum was teaching. It was so tasty! But, shortly after I felt really unwell. I wasn't sure if it was the pizza, the overwhelming feeling of food in my stomach after so long being on juice and being careful what I ate throughout this process but I also felt intense pain in my abdomen and needed quick relief so I had a bath. I was then feeling very sick and was worried that I'd overdone it with the pizza, however, only cloudy, peachy-coloured mucas or bile-like liquid (although that was always green when it happened to me as a child on my period) came out, not a single slice made its way back up my gullet - strange. I did feel some relief afterwards though and Mum did point out how much drugs and poking and prodding I'd gone through so straight to bed with a hot-water bottle it was for me!

I tried a short video call with Kevin around 6pm but it didn't last long for I was clearly falling asleep, was in pain and couldn't sustain the conversation. Mum's been great coming in every so often to check on me, bringing me tea, iced water, painkillers & topping up the hot-water bottle - each 2hr period went by in a flash. Now its after midnight, I'm wide awake and I perhaps need to try to get back to sleep to maintain my body clock’s routine.

In the morning I'll be waiting for a call between 0830-1200 to tell us if any of the 11 eggs (oh yes, I forgot to say, they managed to collect 11 eggs! 🥰) have fertilised overnight. The procedure went according to plan and there were many large follicles alongside some smaller ones, which all produced eggs! Of course I'm delighted as the bigger the number, the more of a chance of fertilisation occurring (about 60-70%) but they have warned that perhaps not all of them will be mature enough and they just won't know that until they go to inject them individually which they were doing this afternoon. I kept saying to each nurse who came to speak to me "It only takes 1" which is true but a very human-minded angle to take. Of course what I mean is that God only needs 1 to create our wee miracle - if it is His intention. 11 eggs have been collected, around half may fertilise, half of those may make it to blastocyst stage, 1 or 2 might make it to a transfer. Or none. There is no way of telling - but God knows.

Whatever happens tomorrow (today now really!) or in the coming days before a potential transfer on Saturday, I know that I've done all that I can, within my power to follow the rules, do as I'm told for this process, but only God has the final say over whether any part of this process is a success or not. So far, he has graced me with his abundant love and graced us with the opportunity to have these final chances at having a family that we so dearly desire. God hears our prayers, our deepest desires, no bargaining is required & certainly no "if I do this, he'll do this" nonsense. If it is His will, He will make it happen. He created medical advances, He created the staff who carry out the medical procedures, He provided the funding for the government to give Scots 3 chances at IVF, He decided that this path was for us and although I questioned it several times, Kevin believed, like the innocence that a child has when they look to their parent for answers.

"Likewise, you who are younger, be subject to the elders. Clothe yourselves, all of you, with humility toward one another, for "God opposes the proud but gives grace to the humble." Humble yourselves, therefore, under the mighty hand of God so that at a proper time he may exalt you, casting all your anxieties on him, because he cares for you." - 1 Peter 5:5-7

Prayer points to consider:

Thank God for the wonders that he has created in our scientific/medical/engineering world.

Thank God for keeping Màiri and Kevin safe & healthy during this challenging process.

Pray for the staff at Ninewells that they may come to rest their weariness, to look to the Lord for strength.

Pray for the eggs taken from Màiri's body today, that they be kept safe overnight and over the following days as they hopefully bond together with Kevin's DNA and develop into healthy embryos.

Pray for the embryologists, that they may see God's wonder of His creation when they look through their microscope. Only he could engineer such amazing cells which one day could grow into a child who walks on this earth.

Pray for Màiri as she recovers and rests in the hope that each day brings encouraging news.

Pray for Kevin who is experiencing this from afar, that he feels close to the process and give him strength in his relationship with his mighty nemesis - patience!

Pray for the 2 other ladies who also went through egg collections today, that their journey may be blessed and anxieties eased.

Pray for other couples, at different stages of their journeys in the unit - embryo transfers and scans/tests that were happening today too.

I pray too for all of you wonderful, supportive people who are reading this, thinking of us, praying for us and hoping with us. WE THANK YOU ALL FROM THE BOTTOM OF OUR HEARTS 💝

Waiting for the train home

"And after you have suffered a little while, the God of all grace, who has called you to his eternal glory in Christ, will himself restore, confirm, strengthen and establish you" - 1 Peter 5:10

[kppanchal]

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[saudade-mayari]

Hello Luna! I’m a shy bean anon who asks tips for upcoming clerkship, internships. I’m nervous to fail please give me tips?

hello!! thank you for asking me anon but i think u asked the wrong person😂 n e ways im going to give you from what ive experienced during my clerkship. i hope it helps 💜

weird coz’ im writing this twenty mins before work hahaha!! This is super long but i hope it helps. It feels nostalgic typing this. It was like two years ago since. 💜

—first off, know and familiarize the hospital you are going to work with. it is important to know what will be your ‘workplace’

—be sure that the hospital and the attending physician knows your basic information. be sure that the data placed in the internship office are correct and updated. trust me it’ll help in the future

—know the dress code. i failed on this the first time of my internship. come 10-20 mins before work. prepare yourself for more than 24hrs of shift. have notebook and tons of extra pen. Be self equipped (e.g steth, index measurements or any measurements, your own bp, watch, first aids like bandaids, paracetamols, neosporon, gums esp on night m and graveyards.) im sure you know why.

—familiarize yourself on the rotations. self learn it. from pre duty, duty, to post duty times. LEARN AND ADAPT TO WORK WITH EVERYONE.

—attitude. whether good (apache) or bad belly, keep your attitude on place. Be professional. Learn to love your least liked rotation. TRUST AND LOVE YOUR DUTY GROUPS 💜💜💜 that’s maintaining and building trust among each other

—i know it is easier said than done... but try your best to apply all laboratory, RetDem and reválida practices on your clerkship.

—it’s hard. especially clinical clerkship. i was nervous as fuck especially on doing the rounds. it took me 3 days and more before i can get myself on a proper shit. ER is a nightmare yes, it is true. all rotations are nightmares. coffee coffee coffee. you become desperate to what keeps you awake and concentrated.

—know the gaps that you could fill. with the little practice we/you had back in university, fill even the small gaps of what needs to be done. it helps. REALLY REALLY HELPS especially the attending physicians.

—DO WHAT YOU ARE TASKED AND ASKED. no task is small. all is important. if senior residents asks you to drain the urine bag, drain it. take a pic of the stool, take it. most of the ‘nasty’ work you’ll consider during clerkship will be worth it.

—ask questions. whether to nurses, interns, fellow, junior and senior residents, pts, rmts, rphs, attending physicians and more. ask question bcoz they have more experience than you have. since we go to different rotation, we handle different people. so it is important to take note from someone who has more time and more used to the circumstances that you are overwhelmed with. your PGIs are your allies, not your enemies

—but.. im not gonna lie, asking questions may be doubled-edged sword. you either get scolded or answered but the tip is before asking a question, know the difference between asking the answers to questions you are not expected to know from asking answers to questions you are expected to know. never ask blindly.

—strong will, thick skin, preparedness to be shouted at bcoz either way YOU will get scolded. thats for sure. every clerks and interns went through that. tip is when your consultant or worse, attending physician told you “why don’t u know this and that? you’re a clerk already you should know this.”

—that’s normal. do not get offended and gather all your will to say “sorry i’ll read on it, doc”. cry afterwards when you reflect on your own bcoz you’ll be hearing things far worse than that.

—one of the most tricky is handling rotations. the hospital has a general rule, but every department has a specific rule to follow. proper execution of rules would mean positive outcome.

—IMPORTANT: know how to correctly take the vital signs. that’s the thing you’ll be doing the most, monitoring patients. so be careful on checking BP, HR, RR, Temp, 02 sat, total fluid intake and total output. Sometimes you have to monitor pain score, BM charting and GCS scoring. You will be even tasked to insert/remove catheter, extract blood and insert IV.

—IMPORTANT 2.0: be vigilant. learn how to properly scrub in during ORs and never ever touch or go near the sterile field while unsterile.

—as clerks, we don’t just monitor. sometimes we get to experience overwhelming circumstances so keep a calm, composed and collected demeanor when handling these kind of situations. you need concentration. panic and anxiety won’t help you, the patient and the guardian. it is also your duty to keep them calm. if you couldn’t calm down, how else would they trust their doctor.

—interact with the patients, doctors and co-clerks most especially when handling diagnosis, critical and confidential paperworks like outpatients and data gathering. (eg. reporting and submitting patient’s case from history to ER admission to its current management) it’ll give you less scolding, less trouble and no errors of datas.

—newbie as it may seems but do not be afraid to give a patient counseling. most especially when they’re the one who asks you and you’re the only health care worker present. it is not just your job to treat but to educate as well. remember to use layman terms. you’re talking with a patient, not a co-clerk or physician.

—i firmly believe to sentiments that “you are not a clerk if you aren’t eating as fast as five minutes in a local fast food chain for decking.” (to my non med moots, decking is taking turns) lol we literally have to eat less than 15 minutes because of the anxiety and nervousness. its normal😂👏🏻

—treat yourself with the dignity that you deserve. getting yourself sick won’t do your duty team, resident doctors and patients any favors. don’t be too hard on yourself.

—it’s okay to make mistakes and errors. we’re in a hospital so try your best to lessen and avoid it.

—keep in your mind that senior residents, attending physicians and consultants gave you that work because they know you are capable of it.

—HAVE FUN WHILE YOU LEARN. my clerkship is full of bloopers but i can confidently say that it is fun and filled with learnings. you’ll definitely experience crying with a dutymate at 3AM and asking yourselves why you chose this profession. NOTE: This is your shameless time to take advantage of being a clerk. take every opportunity to learn and thirst yourself with knowledge (dicks is for later thirst OKAY)

again, no task is small. always remember that entering medschool is like an unknown realm of disease and cures, and every tasks matters.

always keep in your mind that a doctor should be professional. Be kind, take care of yourself, enjoy and remember that learning is always continuous.

at the end of the day (lol joke after 36-48hrs) hospital is a battlefield and no one survives unscathed. you may look like a less of a person (yes LESS of a person😂) but u are glowing in damned spirit and passion.

Endure, learn, have fun and it’ll be over in a blink of eye. You’ll be able to say it to yourself ‘wow i fucking did this shit’.✨

(sike take the board and welcome to residency bitch)

i dunno if this would help, but ive made this post for a moot asking tips in surviving med school

lastly, keep going because your journey is going to be different than mine. pandemic or whatever economic state and crisis you are facing upon clerkship, remember that you are a doctor—a future savior of lives. if the world burns, so is the passion in our hearts. keep going, sweetie. reach that M.D soon!💜✨

[heliophile-oxon]

Paracetamol: do not exceed the stated dose

Even though it’s cheap as chips (assuming the seller isn’t trying to rack up the price!; a tiny bit more if it’s a fancy name brand rather than just paracetamol BP) and even though we’ve had it as an over-the-counter medicine for so long it feels as if it’s been around forever,

paracetamol is very serious shit if you take too much of it. I am glad to say I have no personal experience of this whatsoever, but

“Even taking one or two more tablets than recommended can cause serious liver damage and possibly death. Paracetamol overdose is one of the leading causes of liver failure. Adults can usually take one or two 500mg tablets every 4-6 hours, but shouldn't take more than 4g (eight 500mg tablets) in the space of 24 hours”

It’s the most widely-recommended medicine to alleviate the symptoms of coronavirus, so a lot of people may be taking it or thinking of taking it in the not-too-distant future; I just felt like remembering out loud that cheap and familiar does not mean take extra when/if you’re scared.

[hhjs]

ahhh,,, i'm sure it's already presentable, but you're being too harsh on yourself 🤧 i'm in a weird mood today. my head is hurting, but i also feel that i'm going crazy staying inside, so that's fun. btw! i listened to tamino's music! i quite like his work; it's really nice — 🍑

Ahhh well presentable wasn't literally what i was going for. 😛I want it to be perfect, as horrible as that sounds but I'm busy with coursework now.

Anyways!!! Check ur bp;!! Headaches tend to be a pain in the arse aghhh paracetamol, take it!!! Eat something.

Right??? I love him and his music absolutely.

[priya309]

authorisation of oral medicines containing paracetamol as a single active .... include all relevant BP general monograph/USP General Chapter.

[phroyd]

Members of the multibillionaire philanthropic Sackler family that owns the maker of prescription painkiller OxyContin are facing mass litigation and likely criminal investigation over the opioids crisis still ravaging America.

Some of the Sacklers wholly own Connecticut-based Purdue Pharma, the company that created and sells the legal narcotic OxyContin, a drug at the center of the opioid epidemic that now kills almost 200 people a day across the US.

Suffolk county in Long Island, New York, recently sued several family members personally over the overdose deaths and painkiller addiction blighting local communities. Now lawyers warn that action will be a catalyst for hundreds of other US cities, counties and states to follow suit.

At the same time, prosecutors in Connecticut and New York are understood to be considering criminal fraud and racketeering charges against leading family members over the way OxyContin has allegedly been dangerouslyoverprescribed and deceptively marketed to doctors and the public over the years, legal sources told the Guardian last week.

“This is essentially a crime family … drug dealers in nice suits and dresses,” said Paul Hanly, a New York city lawyer who represents Suffolk county and is also a lead attorney in a huge civil action playing out in federal court in Cleveland, Ohio, involving opioid manufacturers and distributors.

The Sackler name is prominently attached to prestigious cultural and academic institutions that have accepted millions donated by the family in the US and the UK. It is now inscribed on a lawsuit alleging members of the family “actively participated in conspiracy and fraud to portray the prescription painkiller as non-addictive, even though they knew it was dangerously addictive”.

Named in the Suffolk county complaint filed in New York state court are Richard, Jonathan, Kathe and Mortimer David Alfons Sackler, and Ilene Sackler Lefcourt – adult children of deceased brothers Mortimer and Raymond Sackler who developed Purdue Pharma and launched OxyContin in the mid-1990s.

Also named are Theresa and Beverly Sackler, the widows of those two brothers, and David Sackler, son of Richard. Theresa Sackler lives in Londonand the others named lived in the US, mainly in New York and Connecticut.

These eight family members serve or have served on the board of Purdue. Forbes magazine estimates that a core group of 20 Sacklers in the Mortimer and Raymond branches of the secretive family, including the eight named above, are collectively worth $13bn.

Hanly said: “What Purdue Pharma and the Sackler family have done to society through their aggressive peddling of opioids is unconscionable.”

OxyContin was originally widely marketed as a safe wonder drug because of the unique slow-release mechanism of its active ingredient, the narcotic oxycodone. But it turned out to be highly addictive and easily abused.

Suffolk county has already sued Purdue and then filed against the Sacklers in an amended complaint last month.

Now Hanly and other high-profile lawyers working on opioid litigation expect the family members to be sued by name as part of the multi-district litigation in Ohio. In federal court, lawsuits filed by more than 1,200 cities, counties and municipalities across the US, against Purdue and other corporate defendants, have been brought together in the hands of federal judge Dan Polster.

The first trials are due next year in three bellwether cases from two Ohio counties and the city of Cleveland.

Purdue is also being sued by at least 30 states in state court. The first trial in that sequence is expected next spring in Louisiana.

But it is more widely expected that all parties will negotiate a huge global settlement like the approximate $250bn deal agreed in a landmark Big Tobacco case in 1997.

“I’m assuming every single plaintiff’s attorney in the country will copy our complaint naming the Sacklers in the coming weeks,” said attorney Jayne Conroy of Simmons Hanly Conroy, who also represents Suffolk county and is involved in the litigation in Ohio, alongside colleague Paul Hanly.

Hanly said that the economic cost of the opioids crisis in the US, from healthcare to lost productivity, have been put at $1tn between 2002 and 2018, by some leading studies. “Other estimates put the current cost at up to $500bn a year,” he said.

According to a source familiar with the litigation, who cannot be named because they are disclosing confidential information, Purdue Pharma has been arguing behind closed doors to Polster that it can’t afford large-scale damages.

“Of course the company doesn’t have much money left in it because the Sacklers have taken it, they own it, they’ve siphoned it off over the years,” the source said.

Plaintiffs are now determined to make the Sacklers pay, even though their money is scattered in property, charitable foundations, trusts, a multitude of companies and overseas bank accounts.

“I don’t know where it all is yet, but I’ll find it,” Conroy said.

Beyond any civil penalties, some family members could face criminal charges in future.

“I know there are a couple of criminal investigations going on at the federal level, against Purdue, the Sacklers, other defendants, all of them. People are digging, US attorney’s offices are conducting criminal investigations,” said one source.

Purdue and senior executives, but not the Sacklers, was prosecuted and pleaded guilty in federal criminal court in 2007 to misleading regulators, doctors and patients.

A spokesman for John Durham, the US attorney for Connecticut, declined to comment. Prosecutors for the southern and eastern federal districts of New York state did not immediately respond to requests for comment. A spokesman for the northern district of New York said the Department of Justice does not confirm, deny or comment on the existence of any investigation. A spokeswoman for the western district of New York declined to confirm or deny whether the US attorney is conducting a criminal investigation into the Sacklers. A spokesman for Purdue Pharma declined to comment on behalf of the company and the relevant members of the Sackler family.

Those same Sacklers were also sued by name in a lawsuit filed by Massachusetts in June. This alleges that Purdue, its directors and owners “deceived prescribers and patients to get more people to use Purdue’s opioid products, at higher doses, for longer periods” by misrepresenting and downplaying the addictive and deadly risks of the drug. And even claiming that OxyContin, which is derived from opium, was safer than paracetamol or ibuprofen, the common painkillers sold over the counter, the state alleges.

The Massachusetts attorney general, Maura Healey, told the Guardian that experts estimate that the epidemic cost the state almost $15bn in 2017 alone in lost productivity, public safety and healthcare, to say nothing of the human tragedy that has cost thousands of lives in that state alone.

She said she thought the Sacklers were “well aware” of the damage their drug was doing. “But for them it’s greed, it was all about profits over people … I feel very confident naming the family members,” she said.

Asked if Massachusetts was considering a criminal investigation of the company, its executives or owners, Healey said: “I’m focused on using my legal authority to make sure we get restitution for families … damages and penalties for illegal conduct and we are going to continue to pursue this in court.”

She added: To the extent they [the Sacklers] made their fortune on the backs of sick and vulnerable people, then they should turn it over. I have no sympathies for them.”

'I don’t know how they live with themselves' – artist Nan Goldin​ takes on the billionaire family behind OxyContin

Relatives of Arthur Sackler, the older brother of Raymond and Mortimer, who died before OxyContin came to market, are not suspected of any wrongdoing in relation to the drug.

The American art photographer Nan Goldin almost died from an addiction to OxyContin and is now in recovery. She leads a campaign to persuade cultural institutions to reject Sackler donations, and to shame the Sacklers into paying for treatment facilities for opioid dependency instead, not “reputation laundering” as she and other critics dub their philanthropy.

She said the prospect of any criminal charges against family members was “great” and called the family “complicit” in the opioids crisis.

“I’m sick of these people behind the scenes, controlling companies and getting away with murder while their faces are never shown,” she told the Guardian.

The Mississippi lawyer Mike Moore, who helped secure the Big Tobacco settlement and the $20bn settlement against BP for the 2010 Deepwater Horizon oil spill, is involved in the federal case in Ohio and state cases. He said it was right the Sacklers should be targeted.

“They’ve been hiding behind a corporate structure and it’s high time they paid a price,” he said.

Phroyd

[thenetionalnews]

Surprisingly, THIS commonly used drug is linked to the incidence of high BP

Surprisingly, THIS commonly used drug is linked to the incidence of high BP

Acetaminophen is widely used to get relief from low to moderate pain. Also known as paracetamol, it is also used to bring down high temperatures associated with common cold and flu. Though it is widely used, many times even without a doctor’s prescription, health experts have always warned against its overconsumption. High doses of Acetaminophen are toxic to the liver as well. Now the current…

[garethandjude]

Gobbledygook

“language that is meaningless or is made unintelligible by excessive use of technical terms.” 

These are all the new medicines Sam has had today, most of which are probably spelt incorrectly:

Aciclovir - Antiviral, Meropenem - Antibiotic, Amikacin - Antibiotic, Teicoplanin - Antibiotic, Amiloride - Increase Potassium retention and reduce high blood pressure (Hypertension), Amlodopine - reduce high blood pressure - 3 days to take effect, Nifedipine - Immediate reduction of blood pressure. He’s also had paracetamol, morphine, sea water and what ever antibiotics he was infused with overnight. All these medicines come in a syringe or are infused there is no colourful box and safety leaflet. Thankfully Sam wants Jude or I to give the oral medicines so we get an opportunity to google the information on what they do and the side effects (which is quicker than getting them printed out) before he takes them. A lot of trust is placed on the Dr’s and consultants (that are also new today) that this is in Sam’s best interest, but you can’t help wonder whether they are all needed. 

The good news is that one or more or none of these is doing what it should and Sam has been feeling well this afternoon, his BP has come down, HR also seems to have stabilised, no temperature spikes of concern and no ‘fainting’ episodes. Sam has been alert watching movies, doing stickers, Kumon, colouring, and playing on his ipad. His Hickman line dressing was changed and we even managed a botty bath. The cocktail of drugs has affected his tummy though, so we’re probably in for a night of toilet stops, but this is pretty common for Sam after antibiotics.

The Dr’s preferred we stayed put in our room today; 1 because he’s probably infectious, and 2 he may have another fainting moment so Sam only left the room for his MRI. Having spoken with the Dr. this afternoon the MRI showed no signs of concern. The ‘fainting’ could be a hangover from the general anesthetic  which would not have been uncommon yesterday but they ran the MRI today as it is unusual for it to last this long. Hopefully this is now all behind us and fingers crossed we’ll have a good night tonight and can begin discussing plans to come home.

21.07.18

[kppanchal]

Paracetamol Manufacturer in India | Acetaminophen Power and Paracetamol Infusion Supplier – Farmson

Get paracetamol raw materials such as paracetamol Bp, paracetamol Ip, paracetamol crystal, infusion in India with leading pharmaceutical company. Farmson is also manufacturer and supplier of acetaminophen powder and mebendazole powder.

http://www.farmson.com/products

[farmsonpharma]

Paracetamol Products:: Paracetamol BP – USP – PH EUR | Farmson Pharmaceutical

The decision to manufacture single product could be attributed to the reason that Paracetamol is the safest and the cheapest API for analgesic and antipyretic usage with largest volumes. We provide Paracetamol / Acetaminophen in powder form for Tablets, Suspension (liquid syrups), Encapsulation, Suppository and Injectable.

http://www.farmson.com/products#menu1