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Community Pharmacy - 5 Mark Answers

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1. Selection of Site and Space for Community Pharmacy

• Proximity to hospitals/clinics: A pharmacy near a hospital, doctor's clinic, or health centre ensures a steady flow of prescriptions.
• Population density: High residential areas, busy markets, or localities with a large elderly population provide more business.
• Accessibility: The site should be easily reachable by foot, vehicle, or public transport. Ground floor locations are preferred.
• Competition: The number of existing pharmacies in the vicinity must be assessed. Avoiding over-saturated areas is important.
• Visibility: The pharmacy should be visible from the road, with good signage.
• Safety and security: The area must be safe with low crime rates.
• Parking space: Adequate parking for customers adds convenience.
• Rental/ownership cost: Should be economically feasible relative to expected revenue.

• Minimum floor area recommended is generally 10 sq. meters (as per many state pharmacy council norms in India), though larger spaces are preferred.
• The space should accommodate:
  • Dispensing counter (front area)
  • Storage area (shelves, refrigerator for temperature-sensitive drugs)
  • Prescription area (consultation/counselling zone)
  • Record-keeping area (registers, computer)
  • Patient waiting area
• Adequate ventilation, lighting, and sanitation are mandatory.

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2. Use of Computers in Community Pharmacy

1. Prescription Processing: Computerized dispensing software reads, stores, and processes prescriptions quickly, reducing manual errors.
2. Patient Medication Records (PMR): Detailed records of each patient's medication history, allergies, and drug interactions can be maintained and retrieved instantly.
3. Drug Interaction Checking: Software automatically flags dangerous drug-drug, drug-food, or drug-disease interactions at the time of dispensing.
4. Inventory Management: Stock levels are tracked in real time. Automatic reorder alerts prevent stockouts and reduce overstocking.
5. Billing and Invoicing: Automated billing speeds up the cash counter, generates GST invoices, and maintains purchase/sales records.
6. Label Printing: Accurate, legible medication labels with dosage instructions are printed, reducing dispensing errors.
7. Expiry Date Management: Software alerts for drugs approaching expiry, helping reduce wastage and legal liability.
8. Reporting and Audit Trail: Sales reports, Schedule H/H1/X drug reports, and narcotic registers can be generated for inspection.
9. Communication: Email/messaging for placing orders with wholesalers, communicating with prescribers, and patient counselling reminders (SMS/app alerts).
10. Barcode/QR Code Scanning: Ensures the correct drug is dispensed and aids in track-and-trace compliance.

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3. Legal Requirements in Community Pharmacy

A. Drugs and Cosmetics Act, 1940 (and Rules, 1945)

• Pharmacy must obtain a Drug License (Form 20 and 21) from the State Licensing Authority.
• A registered pharmacist must be in charge (Rule 65).
• Premises must meet minimum area, equipment, and storage standards.
• Separate records must be maintained for Schedule H, H1, and X drugs.

B. Pharmacy Act, 1948

• Only a person registered with the State Pharmacy Council can practice as a pharmacist.
• A B.Pharm or D.Pharm qualification with registration is mandatory.

C. Narcotic Drugs and Psychotropic Substances (NDPS) Act, 1985

• Narcotic and psychotropic substances require special licenses.
• Strict record-keeping in separate registers with details of purchase, sale, and stock balance.

D. Drugs (Prices Control) Order (DPCO)

• Maximum Retail Price (MRP) cannot be exceeded.
• Essential medicines listed under the National List of Essential Medicines (NLEM) must be sold at controlled prices.

E. Consumer Protection Act

• Pharmacist is liable for deficiency in service or supplying substandard/spurious drugs.

F. Other Requirements

• Shop and Establishment Act registration
• GST registration
• Trade license from local municipal body
• Maintenance of purchase/sale registers, prescription files

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4. Need of Registers in Community Pharmacy

1. Legal Compliance: The Drugs and Cosmetics Act mandates maintenance of specific registers for Schedule H, H1, and X drugs. Failure to maintain them is a punishable offence.
2. Traceability: Registers allow tracking of every drug purchase and sale, which is critical during drug recalls, inspections, or investigations.
3. Narcotic Control: NDPS Act requires strict registers for narcotic drugs showing stock, purchase, dispensing, and balance - preventing diversion and misuse.
4. Prescription Records: Maintains a file of all prescriptions dispensed, useful for legal protection of the pharmacist.
5. Audit and Inspection: Government drug inspectors verify registers during routine inspections. Proper registers avoid legal action.
6. Inventory Management: Stock registers help in monitoring stock levels, identifying slow-moving or expired items.
7. Patient Safety: If a dispensing error is suspected, registers help trace what was dispensed, to whom, and when.
8. Financial Accounting: Purchase, sales, and cash registers provide a financial audit trail for taxation purposes.

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5. Steps Involved in Selection of Site for Community Pharmacy

• Study the local population - size, age distribution, socioeconomic status.
• Identify areas with high footfall such as near hospitals, clinics, bus stands, or markets.

• Survey the number of existing pharmacies in the locality.
• Assess whether the area is underserved or saturated.

• Estimate potential revenue based on prescription volume and OTC demand.
• Calculate operating costs (rent, salaries, utilities, licenses).
• Determine break-even point and profitability.

• Check available floor space (minimum area as per drug licensing norms).
• Assess ventilation, lighting, water supply, drainage, and sanitation.
• Verify electricity connection and load capacity (for refrigerators, computers, AC).

• Check zoning regulations - commercial land use must be permitted.
• Verify ownership/lease documents are clear.
• Confirm the premises meets all structural requirements for drug license.

• Check road access, public transport proximity, and parking availability.
• Ensure the shop is visible and has space for signage.

• Negotiate rent/purchase price.
• Sign a proper lease/sale agreement.
• Proceed with drug license, trade license, and GST registration.

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6. Layout of Community Pharmacy

• The workflow should flow logically: receive prescription → verify → retrieve drugs → dispense → counsel → billing.
• Storage must comply with temperature, humidity, and light requirements.
• Controlled substances must be stored in a locked cupboard/safe.
• Emergency drugs should be kept in an accessible, designated location.

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7. Legal Requirements About Community Pharmacist

Qualification and Registration

• Must hold a D.Pharm or B.Pharm degree from a recognized institution.
• Must be registered with the respective State Pharmacy Council under the Pharmacy Act, 1948.
• Registration must be renewed periodically as prescribed.

Drug License

• The pharmacy must hold a valid retail drug license under the Drugs and Cosmetics Act, 1940 (Form 20 for allopathic drugs, Form 21 for Schedule C and C1 drugs).
• A registered pharmacist must be physically present (or his/her name must appear on the license).

Dispensing Obligations

• Schedule H drugs must be dispensed only on prescription; records must be kept for 2 years.
• Schedule H1 drugs (e.g., certain antibiotics, anti-TB drugs) require the patient's name, address, and prescriber's registration number to be recorded.
• Schedule X drugs (psychotropics) require a separate register with purchase/sale entries verified against prescriptions.
• Narcotic drugs are governed by NDPS Act and require separate licenses and registers.

Labeling

• Every dispensed drug must have a label showing: patient name, drug name and strength, dose, route, frequency, expiry date, and pharmacist/pharmacy details.

Patient Counselling

• It is a professional and ethical duty to counsel patients on correct use, storage, and side effects of their medications.

Other Duties

• Maintain registers, purchase bills, and prescription records.
• Cooperate with drug inspectors during inspections.
• Not supply spurious, adulterated, or misbranded drugs.

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8. Computers and Software in Community Pharmacy

Key Software Functions

• Integrates billing, inventory, purchasing, and patient records in one platform.

• Digitally stores and retrieves prescriptions.
• Tracks refills and identifies patients who miss chronic disease medications.

• Alerts pharmacist to drug-drug, drug-allergy, and drug-disease interactions before dispensing.
• Reduces adverse drug events significantly.

• Auto-generates purchase orders when stock falls below minimum level.
• Tracks batch numbers, expiry dates, and FIFO/FEFO dispensing.
• Prevents expired drug dispensing and reduces wastage.

• Generates GST-compliant invoices.
• Maintains daily sales reports, payment records, and credit accounts.

• Prints clear, standardized labels automatically after prescription entry.

• Generates reports required by law - Schedule H/H1/X drug sales records, narcotic statements.
• Supports government drug regulatory audits.

• Modern systems receive e-prescriptions from hospitals and telemedicine platforms.
• Enables home delivery and remote dispensing services.

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9. Maintenance of Various Registers in Community Pharmacy

Types of Registers

• Records all drugs purchased: date, supplier name, invoice number, drug name, batch number, quantity, expiry date, price.
• Purchase bills must be retained for at least 2 years.

• Records OTC and prescription drug sales: date, drug name, quantity, batch number, price.

• Separate register for all Schedule H drugs dispensed.
• Contains: date, patient name, address, prescriber's name, drug, quantity, and signature.
• Must be retained for 2 years.

• Similar to Schedule H register but also includes the prescriber's registration number and patient's ID proof details.
• Mandatory for drugs like second-line antibiotics, certain steroids.

• Maintained for psychotropic substances.
• Includes stock received, dispensed quantity, balance, and prescription details.
• Verified by drug inspectors.

• Maintained under NDPS Act for narcotic drugs (morphine, codeine, fentanyl, etc.).
• Separate inward (purchase) and outward (dispensing) registers.
• Balance must tally at all times.
• Subject to regular inspection by Narcotics Control Bureau/State authorities.

• All dispensed prescriptions are retained and filed chronologically.
• Retained for 2 years (Schedule H), 5 years (Schedule X).

• Records refrigerator temperature twice daily to ensure cold chain maintenance.

• Entries must be made in ink (no pencil).
• No overwriting - corrections must be initialed with date.
• Pages must be serially numbered.
• Registers must be produced on demand during drug inspector visits.

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10. Coding and Decoding in Community Pharmacy

Purpose of Coding

• To mark the cost price (purchase price) of each drug in a secret code so that the actual profit margin is not visible to customers or staff.
• Helps in quick inventory taking and stock auditing.
• Assists in calculating profit, discount, and pricing decisions.

Coding Methods

• A code word of 10 letters (no letter repeated) is selected, where each letter represents a digit (0-9).
• Example: Code word = "MISCHGUARDS" (but practically any 10-letter word without repetition is chosen)
  • M=1, I=2, S=3, C=4, H=5, G=6, U=7, A=8, R=9, D=0
• If the purchase price of a drug is ₹45, it is coded as "CH" and written on the stock label.
• The pharmacist and owner know the code word; customers cannot read the cost price.

• Numbers are transposed using a fixed offset (e.g., add 3 to each digit): price ₹12 becomes "45" in code.

• Combination of letters, numbers, and symbols.

Decoding

• The reverse process - converting the coded price back to the actual cost price using the known code key.
• Used during billing to calculate profit, or during stock audits to value inventory.

Other Coding in Pharmacy

• Drug shelf codes/bin numbers: Each drug is assigned a bin location code (e.g., A-12, B-04) to locate it quickly in the dispensing area.
• Batch/Lot coding: Every batch of drugs has a manufacturer's code for traceability.
• Expiry coding: Some older stock uses coded expiry dates; pharmacists must decode the manufacturer's batch code to determine expiry.

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GI Disturbances - 5 Mark Answers

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1. GI Disturbances - Detailed Explanation

Classification of GI Disturbances

1. Upper GI: Peptic ulcer disease (PUD), GERD, gastritis, hiatus hernia
2. Small intestinal: Malabsorption syndromes, celiac disease, Crohn's disease
3. Large intestinal: Irritable Bowel Syndrome (IBS), ulcerative colitis, diverticulitis, colorectal carcinoma
4. Hepatic/Biliary: Hepatitis, cirrhosis, gallstones, cholecystitis
5. Pancreatic: Pancreatitis, pancreatic carcinoma
6. Infections: Gastroenteritis, food poisoning, worm infestations
7. Functional: No structural cause found (IBS, functional dyspepsia)

Common Causes

• Dietary indiscretion (spicy food, alcohol, overeating)
• Infections (bacterial, viral, parasitic)
• Drugs (NSAIDs, antibiotics, steroids)
• Stress and psychological factors
• Motility disorders
• Obstruction (mechanical or functional)

General Principles of Management

• Dietary modification - bland, low-fat, easily digestible diet
• Hydration and ORS (especially in diarrhea/vomiting)
• Symptomatic drug therapy (antacids, antiemetics, antidiarrhoeals, laxatives)
• Specific treatment of the underlying cause
• Referral to gastroenterologist for persistent or alarm symptoms

Sleisenger and Fordtran's Gastrointestinal and Liver Disease; Frameworks for Internal Medicine

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2. Diarrhea

Definition

Types

Mechanisms (Pathophysiology)

1. Secretory diarrhea - Increased secretion of fluid/electrolytes into the intestinal lumen (e.g., cholera toxin, VIPoma). Persists even with fasting.
2. Osmotic diarrhea - Non-absorbable solutes in the gut lumen draw water osmotically (e.g., magnesium antacids, lactose intolerance). Stops with fasting.
3. Exudative/Inflammatory diarrhea - Mucosal damage causes blood and pus in stools (e.g., ulcerative colitis, dysentery).
4. Dysmotility diarrhea - Hypermotility reduces transit time, preventing fluid reabsorption (e.g., IBS, hyperthyroidism, diabetic autonomic neuropathy).

Causes

• Infectious: Bacteria (E. coli, Salmonella, Shigella, Vibrio cholerae), Viruses (Rotavirus, Norovirus), Parasites (Giardia, Entamoeba)
• Non-infectious: IBD, IBS, food intolerance (lactose), malabsorption, drugs (antibiotics - C. difficile, metformin)
• Other: Thyrotoxicosis, radiation enteritis, short bowel syndrome

Clinical Features

• Loose/watery stools, increased frequency
• Abdominal cramps and bloating
• Tenesmus (in dysentery)
• Fever (in infectious causes)
• Dehydration: dry mouth, reduced urine output, sunken eyes, hypotension

Treatment

1. Rehydration: ORS (Oral Rehydration Solution) - first priority; IV fluids in severe dehydration.
2. Dietary advice: BRAT diet (Banana, Rice, Apple, Toast); avoid dairy initially.
3. Antidiarrhoeals: Loperamide (reduces intestinal motility); NOT used in bloody/infectious diarrhea.
4. Antibiotics: Only for confirmed bacterial causes - Cotrimoxazole (traveller's diarrhea), Metronidazole (Giardia, C. difficile), Ciprofloxacin.
5. Probiotics: Lactobacillus supplements help restore gut flora.
6. Zinc supplementation: Especially in children with acute diarrhea (WHO recommendation).

Frameworks for Internal Medicine; The Essentials of Forensic Medicine and Toxicology

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3. Dyspepsia

Definition

Types

• Peptic ulcer disease (PUD)
• Gastroesophageal Reflux Disease (GERD)
• H. pylori gastritis
• Gastric carcinoma
• NSAID use
• Pancreatic/biliary disease

• Postprandial fullness
• Early satiation (feeling full after small amount of food)
• Epigastric pain
• Epigastric burning
• ...in the absence of structural disease

Sub-types of Functional Dyspepsia

• Postprandial Distress Syndrome (PDS): Meal-induced symptoms - fullness and early satiety
• Epigastric Pain Syndrome (EPS): Pain/burning in epigastrium not exclusively with meals

Symptoms

• Bloating and fullness after meals
• Belching and flatulence
• Heartburn and acid regurgitation
• Nausea (with or without vomiting)
• Epigastric discomfort or pain

Alarm Features (Red Flags - Require Urgent Investigation)

• Age > 55 years with new-onset dyspepsia
• Unexplained weight loss
• Persistent vomiting
• Dysphagia (difficulty swallowing)
• GI bleeding or iron-deficiency anemia
• Palpable epigastric mass

Treatment

1. Lifestyle modification: Small frequent meals; avoid spicy/fatty foods, alcohol, NSAIDs, smoking
2. Antacids: Aluminum hydroxide, magnesium hydroxide - for symptomatic relief
3. H2-receptor antagonists: Ranitidine, Famotidine - reduce acid secretion
4. Proton Pump Inhibitors (PPIs): Omeprazole, Pantoprazole - first-line for EPS type functional dyspepsia and PUD
5. H. pylori eradication: Triple therapy (PPI + Amoxicillin + Clarithromycin for 14 days) if H. pylori positive
6. Prokinetics: Domperidone, Metoclopramide - for PDS type; improve gastric motility and emptying
7. Antidepressants: Low-dose tricyclic antidepressants (TCAs) in refractory functional dyspepsia

Goodman & Gilman's Pharmacological Basis of Therapeutics

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4. Common Drug Therapy for Pain

WHO Analgesic Ladder (3-Step Approach)

1. Step 1 - Mild pain: Non-opioid analgesics
2. Step 2 - Moderate pain: Weak opioids ± non-opioids
3. Step 3 - Severe pain: Strong opioids ± non-opioids

Drug Classes

• Codeine (30-60 mg): Also antidiarrheal and antitussive
• Tramadol (50-100 mg): Mixed opioid + SNRI mechanism; less constipating

• Morphine - gold standard for severe pain; 5-10 mg SC/IV or 10-30 mg oral
• Oxycodone, Fentanyl, Buprenorphine - alternative strong opioids

• Antidepressants (Amitriptyline) - neuropathic pain
• Anticonvulsants (Gabapentin, Pregabalin) - neuropathic, cancer pain
• Corticosteroids - inflammatory pain, tumor-related pain
• Antispasmodics (Dicyclomine, Hyoscine butylbromide) - GI colic/spasm

• For pain from PUD/GERD - PPIs (Omeprazole) are first-line
• Antacids (Aluminium hydroxide + Magnesium hydroxide) for immediate symptomatic relief

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5. Vomiting

Definition

Pathophysiology

• Chemoreceptor Trigger Zone (CTZ): Located in the area postrema (floor of 4th ventricle), outside the blood-brain barrier. Detects circulating toxins, drugs, metabolic abnormalities. Rich in D2, 5-HT3, NK1, and mu-opioid receptors.
• Vagal afferents: From the GI tract (enterochromaffin cells release 5-HT3 in response to irritants)
• Vestibular apparatus: Motion sickness; H1 and M1 receptors
• Cerebral cortex: Emotional, anticipatory vomiting

Causes

Clinical Features

• Nausea preceding vomiting
• Retching (reverse peristalsis without expulsion)
• Actual vomiting - projectile in pyloric stenosis/raised ICP
• Dehydration, electrolyte imbalance (hypokalemia, metabolic alkalosis)
• Mallory-Weiss tear with repeated severe vomiting

Treatment

1. Identify and treat the cause
2. Rehydration - oral or IV fluids
3. Antiemetics (see Q11 below)
4. Dietary modification - small, frequent, light meals; avoid strong smells
5. NG tube - if vomiting is intractable or obstruction is present

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6. Constipation

Definition

Causes

• Inadequate dietary fiber and fluid intake
• Sedentary lifestyle
• IBS-constipation dominant type (IBS-C)
• Slow transit constipation (colonic inertia)
• Pelvic floor dysfunction / dyssynergic defecation

• Structural: Colorectal carcinoma, strictures, anal fissure, hemorrhoids
• Endocrine: Hypothyroidism, hypercalcemia, diabetes mellitus
• Neurological: Parkinson's disease, spinal cord injury, multiple sclerosis
• Drugs: Opioids, antacids (aluminum), anticholinergics, iron supplements, calcium channel blockers
• Metabolic: Hypokalemia, dehydration

Clinical Features

• Infrequent, hard, pellet-like stools
• Straining at defecation
• Feeling of incomplete emptying
• Abdominal distension and discomfort
• Overflow diarrhea (liquid stool passes around impacted feces)

Complications

• Hemorrhoids and anal fissures
• Fecal impaction
• Rectal prolapse
• Stercoral ulcer and perforation (in severe chronic cases)

Treatment

• Increase dietary fiber (25-30 g/day) - fruits, vegetables, whole grains
• Adequate hydration (8 glasses/day)
• Regular exercise
• Respond promptly to the urge to defecate (do not delay)
• Biofeedback therapy (for pelvic floor dysfunction)

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7. Worm Infestations

Introduction

Types of Worms and Their Features

• Schistosoma - bilharzia; enters through skin in contaminated water

Symptoms

• Abdominal pain and cramps
• Nausea, vomiting, diarrhea
• Malnutrition, weight loss, growth retardation (in children)
• Anemia (hookworm)
• Perianal itching (pinworm)
• Intestinal obstruction (heavy Ascaris load)
• Jaundice and cholangitis (if worms block bile duct - Ascaris)

Diagnosis

• Stool examination for ova and cysts
• Scotch tape test (perianal swab) for Enterobius
• Blood: Eosinophilia, raised IgE
• Serology and imaging for tissue helminths

Treatment - Anthelmintic Drugs

Prevention

• Proper sanitation and safe water
• Washing hands before food and after toilet
• Wearing footwear (to prevent hookworm skin penetration)
• Cooking meat thoroughly
• Regular deworming programs (WHO recommends biannual Albendazole/Mebendazole for at-risk children)

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8. Pyrexia (Fever)

Definition

Pathophysiology

1. Exogenous pyrogens (bacteria, viruses, fungi, toxins) stimulate macrophages
2. Macrophages release endogenous pyrogens - mainly IL-1, IL-6, TNF-alpha, IFN-gamma
3. These act on the hypothalamic thermoregulatory centre (anterior hypothalamus)
4. Stimulate production of Prostaglandin E2 (PGE2) via COX-2 enzyme
5. PGE2 raises the hypothalamic set-point
6. Body generates heat through shivering, vasoconstriction, and increased metabolism
7. Result: elevated core body temperature = fever

Causes

Stages of Fever

1. Onset (cold stage): Vasoconstriction, shivering, piloerection ("chills")
2. Fastigium (hot stage): Stable elevated temperature; flushed, dry skin
3. Defervescence (sweating stage): Temperature falls; profuse sweating, vasodilation

Patterns of Fever

• Intermittent (quotidian): Peaks daily, returns to normal - malaria
• Remittent: Fluctuates but does not return to normal - typhoid
• Continued/Sustained: Minimal variation <1°C - lobar pneumonia
• Hectic (septic): Swinging high fever - sepsis, abscess
• Pel-Ebstein: Alternating periods of fever and apyrexia - Hodgkin's lymphoma
• Relapsing: Recurrent bouts - Brucellosis, Borrelia

Clinical Features

• Elevated temperature; flushed face
• Tachycardia (10 bpm rise per 1°C rise in temperature - Liebermeister's rule)
• Rigor (severe chills with chattering teeth)
• Headache, myalgia, malaise
• Sweating during defervescence
• Febrile convulsions (especially in children 6 months - 5 years)
• Dehydration

Treatment

• Tepid sponging
• Adequate hydration
• Rest

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9. Nausea

Definition

Pathophysiology

• 5-HT3 (serotonin) - activated by GI irritants; key target for antiemetics (ondansetron)
• Dopamine D2 - CTZ activation
• H1 (histamine) - vestibular nausea
• M1 (muscarinic) - motion sickness, pregnancy nausea
• NK1 (neurokinin 1/substance P) - delayed nausea from chemotherapy

Causes

• GI: Gastroenteritis, PUD, GERD, hepatitis, pancreatitis, intestinal obstruction
• Drugs: Opioids, cytotoxics (chemotherapy), NSAIDs, antibiotics, digoxin
• Metabolic: Uraemia, DKA, hypercalcemia, Addison's disease
• Pregnancy: Morning sickness (first trimester); Hyperemesis gravidarum (severe)
• Neurological: Migraine, raised ICP, vestibular disorders
• Psychogenic: Anxiety, eating disorders
• Postoperative: Post-anaesthesia nausea and vomiting (PONV)

Clinical Features

• Unpleasant "sick" feeling in the upper abdomen/throat
• Pallor, diaphoresis (sweating)
• Hypersalivation and tachycardia
• Anorexia
• May be followed by retching and vomiting

Treatment

1. Address the cause (stop offending drug, treat infection, etc.)
2. Dietary advice: Small, frequent, bland meals; ginger tea; cold foods (less odor)
3. Hydration: Sips of clear fluids, ORS
4. Antiemetics: (see Q11)
5. Acupressure: P6 (Nei Guan) wristband; evidence for pregnancy nausea
6. Ginger (Zingiber officinale): Evidence shows efficacy equal to metoclopramide for postoperative nausea; dose 0.5-1 g/day

Sleisenger and Fordtran's Gastrointestinal and Liver Disease

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10. Ophthalmic Symptoms (Eye Symptoms)

Definition and Scope

Common Ophthalmic Symptoms

• Causes: Conjunctivitis (bacterial/viral/allergic), subconjunctival hemorrhage, acute angle-closure glaucoma, anterior uveitis, foreign body, corneal abrasion
• Key differential: Vision-threatening causes must be excluded (glaucoma, uveitis)

• Superficial pain: Corneal abrasion, foreign body, conjunctivitis
• Deep aching pain: Acute glaucoma, uveitis, scleritis, optic neuritis
• Headache with eye pain: Raised intraocular pressure (IOP)

• Blurred vision: Refractive errors, cataracts, diabetic retinopathy, macular degeneration, raised ICP, optic neuritis
• Diplopia (double vision): CN VI palsy (petrous apex pathology), CN III or IV palsy, myasthenia gravis, thyroid eye disease. Diplopia on lateral gaze due to VIth nerve involvement is characteristic of petrous apex pathology.
• Loss of vision: Acute - CRAO (central retinal artery occlusion), CRVO, vitreous hemorrhage, retinal detachment; Gradual - glaucoma, cataract, ARMD

• Excessive tearing from overflow due to blocked nasolacrimal duct or reflex lacrimation from corneal irritation.

• Mucopurulent: Bacterial conjunctivitis
• Watery: Viral conjunctivitis, allergy
• Stringy/white: Allergic conjunctivitis

• Intolerance to light; associated with: Anterior uveitis, corneal ulcer, migraine, meningitis

• Floaters: Posterior vitreous detachment, vitreous hemorrhage
• Flashes (photopsia): Retinal tear/detachment - requires urgent ophthalmology referral

• Vitamin A deficiency, retinitis pigmentosa

• Diabetes: Blurred vision (fluctuating blood sugar), diabetic retinopathy
• Hypertension: Hypertensive retinopathy (flame hemorrhages, AV nipping)
• Thyroid disease: Proptosis, lid retraction, diplopia (thyroid eye disease)
• Rheumatoid arthritis/SLE: Dry eyes (keratoconjunctivitis sicca), scleritis, episcleritis
• Raised ICP: Papilledema, visual field defects, diplopia (false localizing CN VI palsy)

Treatment Approach

• Infections: Antibiotic eye drops (Chloramphenicol, Ciprofloxacin) for bacterial; antiviral for herpetic
• Allergic: Antihistamine drops (Sodium cromoglycate, Olopatadine), oral antihistamines
• Glaucoma: Timolol (beta-blocker) eye drops, Latanoprost (prostaglandin analogue), Acetazolamide (carbonic anhydrase inhibitor)
• Uveitis: Topical/systemic corticosteroids, cycloplegics (Atropine)
• Dry eyes: Artificial tears (Hydroxypropyl methylcellulose drops)
• Vitamin A deficiency: Vitamin A supplementation

Scott-Brown's Otorhinolaryngology Head & Neck Surgery

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11. Drugs Used in the Treatment of Nausea and Vomiting

Classification of Antiemetic Drugs

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A. 5-HT3 (Serotonin) Receptor Antagonists - "Setrons"

• Chemotherapy-induced nausea and vomiting (CINV) - drug of choice for acute CINV
• Radiotherapy-induced nausea
• Post-operative nausea and vomiting (PONV)

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B. Dopamine D2 Receptor Antagonists

• Mechanism: Blocks D2 receptors in CTZ; also 5-HT3 antagonist and 5-HT4 agonist (prokinetic)
• Uses: PONV, drug-induced vomiting, diabetic gastroparesis, CINV (less effective than ondansetron)
• Dose: 10 mg oral/IV/IM 3 times daily
• Side effects: Extrapyramidal symptoms (dystonia, tardive dyskinesia with long-term use), drowsiness, galactorrhea

• Mechanism: Peripheral D2 antagonist; does NOT cross the blood-brain barrier significantly
• Uses: CINV, nausea of gastroparesis, functional dyspepsia
• Dose: 10 mg TDS before meals
• Advantage over Metoclopramide: Fewer CNS/extrapyramidal side effects
• Side effects: Cardiac arrhythmias (QT prolongation) - avoid in cardiac patients

• Phenothiazine antiemetic
• Uses: Vestibular vomiting, labyrinthitis, PONV
• Dose: 5-10 mg oral/IM; 25 mg suppository

• Butyrophenone; potent D2 antagonist
• Uses: Palliative care for refractory nausea, opioid-induced vomiting
• Dose: 1.5 mg BD oral; 0.5-2 mg SC in palliative care

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C. H1 (Histamine) Receptor Antagonists - Antihistamines

• Motion sickness (first-line)
• Vestibular nausea/vomiting (labyrinthitis, Meniere's disease)
• Pregnancy nausea

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D. Muscarinic M1 Receptor Antagonists (Anticholinergics)

• Motion sickness (Hyoscine transdermal patch behind ear - prophylaxis)
• GI colic and nausea from smooth muscle spasm

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E. NK1 (Neurokinin-1) Receptor Antagonists

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F. Corticosteroids

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G. Cannabinoids

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H. Miscellaneous

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Summary Table of Antiemetics

Sleisenger and Fordtran's GI and Liver Disease; Goodman & Gilman's Pharmacological Basis of Therapeutics; Morgan and Mikhail's Clinical Anesthesiology

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