Only $2.99/month

OSCE- Explaining medications/ management plan

Terms in this set (17)

1. Full name & role
2. Confirm patient details
3. Today I will be.... as I can see from your notes you have been prescribed a Salbutamol (reliever inhaler blue inhaler )/ beclomethasone (preventer inhaler brown inhaler)
4. What do you know so far about the inhalers? And have you used them before?
5. For Salbutamol:is a reliever. This is useful to help relieve sudden asthma attacks. It works by relaxing the airways so that you can breathe more easily. You shouldn't need this more than three times a week if your asthma is well controlled. Ask your GP for a review if you are using this more frequently. I would like you to inhale 1-2 puffs when you feel short of breath.
6. For is a preventer - it helps to reduce the swelling in the airways and stops them from tightening up. You use this inhaler to reduce the risk of having asthma attacks. I would like you to inhale 2 puffs 2 times a day. It's really important that you don't miss doses, as regular use is key to keeping your asthma under control."
7. To make sure you've understood everything I've said could you tell me what type of inhaler you have and when it should be used? Don't worry if you can't remember everything right away, we can always go back over the important information.
8. Now I will demonstrate to you how to use it:
(pressurised metered-dose inhaler (pMDI), which is most commonly used in OSCE scenarios)
Device test

If the inhaler hasn't been used for 5 days or more, the patient should be advised to test the device before using it:

1. Remove the cap and shake the inhaler well.

2. Point the mouthpiece away from you and press the canister to release a puff into the air.

Dose counter:
Some pMDI's have a dose counter which shows the number of remaining doses left in the inhaler. Advise the patient to check the inhaler is not empty and to seek a replacement whilst they still have several doses left.
Advise the patient to seek a replacement in advance of their inhaler expiring and to avoid using it after the expiry date.

9. Preparation

1. Hold the inhaler upright.

2. Remove the cap from the inhaler and inspect to make sure there is nothing inside the inhaler mouthpiece.

3. Shake the inhaler well.

Inhalation

4. Sit or stand up straight and slightly tilt your chin up. This position helps the medication to better reach the lungs.

5. Breathe out gently and slowly away from the inhaler until your lungs feel empty.

6. Put your lips around the mouthpiece of the inhaler to create a tight seal.

7. Start to breathe in slowly and steadily whilst at the same time pressing the canister on the inhaler once.

8. Continue to breathe in slowly until your lungs feel full.

9. Remove the inhaler from your mouth and seal your lips.

10. Hold your breath for 10 seconds, or as long as you are comfortably able to.

11. Breathe out gently, away from your inhaler.

Final steps

12. Once you have finished using your inhaler, replace the cap. If you've used an inhaler that contains steroids, rinse your mouth with water to reduce the chance of side effects.

Multiple doses

If you've been prescribed a second puff, wait 30 seconds to a minute for repeating steps 3-12.
10. Ask patient to use their own inhaler and demonstrate (Point out the positives..."You are doing X&Y very well"... then introduce room for improvement ..."but doing A&B may help your inhalers work more effectively for you.)
11. Can use spacer Spacers are used to improve drug deposition in the lungs. They are also useful for reducing the side effects of high dose inhaled corticosteroids by decreasing the amount of drug deposited in the mouth.
12. Spacer should be:washed with detergent (washing up liquid is fine) once a month and left to air-dry. Not wiped dry as it can cause static
13.Check if the patient has any questions
14. Explain the potential side effects they may experience when using their inhalers:

Palpitations and tremor: salbutamol can cause tachycardia and tremor, particularly at higher doses.
Oral thrush: steroid inhalers can cause candidiasis, particularly if the patient doesn't wash their mouth out effectively after each use.
Advise that if the patient has an asthma attack that does not respond to their salbutamol inhaler after 10 puffs (with 30 seconds between each puff) they should call 999 for urgent medical assessment.

Provide an information leaflet for the relevant inhaler device.

Arrange a follow-up appointment to re-assess the patient's inhaler technique.

Thank the patient for their time.
1. Full name and role
2. Confirm patient details
3. Explain reason for consultation- today I have been asked to discuss your warfarin therapy in regards to your DVT, is that okay?
4. Ask patient what they know so far about warfarin therapy
5. Explain warfarin:Warfarin helps to prevent the clots from forming.
Warfarin stops your blood from clotting within the blood vessels. It is also used to stop existing clots getting bigger (as in DVT) and to stop parts of clots breaking off and forming emboli (as in Pulmonary Embolism or PE). It is often common to refer to the delay in clotting as 'thinning' the blood.
6. Explain it is taken once a day and the dose required may differ on different days depending on the INR (measures how long it takes your blood to clot- blood test)
7. Treatment will be monitored in an anticoagulation clinic by blood tests to check INR level as warfarin increases the INR
They will get a yellow book where INR levels are recorded in and their warfarin dosage
8. On the first few days a higher dose called loading dose is given
9. INR would need to be 2-3 and the dose of warfarin will be adjusted by nurse/doctor
10. Possible side effects: bleeding, skin necrosis (death of cells/tissues), alopecia, jaundice
11. Over anticoagulation is possible and to seek medical help if: epistaxis (nose bleed), coughing up blood, bleeding gums, excessive bruising (need 3 for full marks)
12. Explain lifestyle changes: decrease alcohol intake, diet decrease food with vitamin K (green vegetables), avoid contact sport (rugby)
13. Warn patient about getting pregnant while on warfarin- birth defects and may cause bleeding of fetus
14. Alert health care professionals and read all drug instructions leaflets before taking warfarin with other meds example antibiotics or NSAIDs
15. Do not double take dose if you miss one and don't suddenly stop taking it without consulting a doctor
16. If any dental work or surgery should inform them they're taking warfarin
17. Suggest that medical alert bracelet may be worn
Medical history, drug history, smoking alcohol
18. Summarise and next steps thank patient

Patient question: side effects of warfarin and heard they have ingredient they use in art poisoning

SF mentioned above, not something I heard about but I can look it up for you and provide further details.
1. Full name and role
2. Confirm patient details
3. What do you already know about HRT?
Is there anything that worries you about HRT?
What were you hoping we'd discuss today?
4. Hormone replacement therapy, often referred to as HRT, is an effective treatment for menopause-related symptoms. HRT can also have a positive influence on other long-term health problems associated with the menopause, such as reducing the risk of osteoporosis, cardiovascular disease and stroke. The aim of HRT is to restore the low levels of hormones that occur as a result of menopause."1
5. There are many ways in which you can take HRT, with the most common way being tablets (oral HRT). Other forms of HRT include skin patches, gels and implants such as the Mirena coil. You can try different forms and find the ones that work best for you
6. Menopause occurs when your ovaries stop producing eggs. As a result of the menopause, there are reduced levels of the hormones oestrogen and progesterone in your body. This can result in symptoms such as hot flushes, weakened bones and vaginal dryness. HRT works by replacing these hormones to varying degrees with the hope of reducing the symptoms and health problems associated with menopause
7. Who can take it:women with early menopause until the age of natural menopause (around 51 years), even if they are asymptomatic, women under 60 years who are at risk of an osteoporotic fracture in whom non-oestrogen treatments are unsuitable
8. HRT comes in different formulations: gel, cream, pills, monthly (Oestrogen is taken daily and progestogen is given at the end of the cycle for 10-14 days) , every 3 months (Oestrogen is taken daily and progestogen is given for 14 days every 13 weeks) or continues (Oestrogen and progesterone are taken daily without any breaks suitable for post menopausal)
9. If it is okay with you, I'd like to tell you about the benefits and disadvantages of HRT, then hopefully you will have enough information to make a decision
Effectual at reducing frequency of hot flushes, vaginal dryness, helps prevent thinning of the bones and therefore help reduce the risk of fractures, reduces CVD risk, and in some cases also improves low mood symptoms that arise from menopause (need atleast 3 for full marks)
10. Side effects of HRT vary, depending on the type of HRT used. If the HRT contains oestrogen, you may experience breast tenderness, leg cramps, bloating, nausea and headaches. If the HRT contains progestogen you may experience breast tenderness, backache, low mood and pelvic pain. Breakthrough bleeding is common in the first 3-6 months with continuous combined HRT
11. HRT increases the risk of developing blood clots in the legs and lungs. These conditions can be treated with blood-thinning medication, however, they are serious medical conditions that can be life-threatening- HRT delivered through your skin carries less risk of blood clots, so that is something we will consider.
12. Oral forms of HRT slightly increase the risk of developing a stroke. HRT preparations that are delivered through the skin do not carry this increased risk of stroke.
13. Some research suggests that HRT may increase the risk of breast cancer. The overall risk when taking combined oral HRT is thought to be small. Once you stop taking HRT, your risk of breast cancer returns to that of someone who has never taken HRT.
14. Oestrogen-only HRT significantly increases the risk of developing cancer in the lining of the womb. We can provide some other medication to help reduce this risk
15. Contraindications of breast cancer: breast cancer, breast feeding, DVT/PE, undiagnosed vaginal bleeding, pregnancy
16. Contraception should still be continued for 1 year after last period
17. Can you just repeat back to me what we've just discussed regarding...
18. Do you have anything else that is concerning or you were expecting from todays consultation
19. Give patient time to think and make decisions
20. Past medical history: Current, past, or suspected breast cancer, Undiagnosed vaginal bleeding, Untreated hypertension, Pregnancy, DVT/PE , surgical history?
21. Medication history and allergies
Social history: alcohol, drugs, smokinh
22. Explain next steps - leaflet and websites. Summarises and thanks patient

Patient question: wants to know whether she needs to be on it long term or not?

Most women stop taking it once their menopausal symptoms pass, which is usually after a few years.
1. Full name and role
2. Confirm patient details
3. Past medical history
Drug history: allergies
Social history: job, alcohol, smoking, recreational drugs
4. Today I've been asked to talk to you about your medication that you will take in regards to your recent chest infection. Are you aware of this?
5. A chest infection is are infections of the lungs or large airways causing you to have symptoms like cough/sob/ wheezing. Usually it's caused by a bacteria so antibiotic will be prescribed
6. In this case it is it is co amoxiclav which will work by killing off the bacteria that has caused the infection.
7. Are you allergic to penicillin or have you had a previous penicillin reaction
8. Dose will be 625mg 3 times a day (every 8 hours)
9. To take with a a meal/snack as it will make you less sick
10. SF: upset stomach, diarrhoea, vomiting- like all medicines but not all people experience it. Keep taking the medicine but talk to your doctor or pharmacist if these side effects bother you or don't go away:
11. Co-amoxiclav doesn't stop contraceptive pills working, including the combined pill or emergency contraception. However, if co-amoxiclav makes you vomit or have severe diarrhoea for more than 24 hours, your contraceptive pills may not protect you from pregnancy. So use other forms of contraception
12. Seek medical advice if serious SF: blood in stool, as this may signify patient is suffering from colitis (inflammation of the lower end of your digestive system) explain both points to get full marks
13. Advise patient to stop taking the medication and seek immediate medical attention if they develop itchy rash, swollen face/mouth, having difficulty breathing
14. Patient must complete full course even if they think symptoms have improved as failure will cause bacterial resistance
15. ICE?
16. Can you repeat back to me what we just discussed
17. Summarise, next steps, thank patient
1. Full name and role
2. Confirm patient details and consent
3. Today I have been asked to discuss with you the combined oral contraceptive pill. ICE:
Have you heard of this before?
Is there anything that worries you about the combined oral contraceptive pill
What are you hoping the combined oral contraceptive pill can do for you?
4. It is a pill that contains two hormones - progesterone and oestrogen. These hormones are similar to the natural hormones produced by your ovaries
5. Past medical history?
Check for contraindications: PMHx or FMHx of blood clots, pregnant? Unexplained vaginal bleeding? Severe liver disease? Sickle cell anaemia?
6. Allergies? Smoking? Alcohol? Drugs? Work?
7. The pill prevents you from getting pregnant by stopping your ovaries from producing an egg every month."

"It also works by thickening the mucus around your cervix which stops sperm from entering your womb."

"It can also make the lining of your womb thinner, which makes it less likely that a fertilised egg would be able to implant in the womb
8. If you take the combined pill at the appropriate time each day and don't miss pills, it is 99% effective at preventing pregnancy
9. If it is okay with you, I'd like to tell you about the benefits and disadvantages of the pill, then hopefully you will then have enough information to make a decision
10. Advantages:
-does not require an invasive procedure like some other forms of contraception
-is 99% effective when taken correctly.
-Your periods may become more regular, lighter and less painful
-You can run the pill packets back-to-back if you want to control the timing of your period for holidays or certain events
-In some people, the pill can improve acne
-The pill reduces the risk of ovarian, uterine and colon cancer however it may slightly increase risk of cervical and breast cancer and patients with PMHx should not use it
11. SF: (nausea, sore breast, changes in sex drive, mood changes, rise in bp
-To start off with, you may experience some side effects such as a headache, nausea, mood changes or breast tenderness.
-Especially in the first few months, you might experience bleeding on the days you are taking the pill. This is called breakthrough bleeding
-Unfortunately, the COCP does not protect you from sexually transmitted infections (STIs). Barrier contraception (e.g. condoms) is the only form of contraception to provide protection from STIs.
-This contraceptive method relies on you remembering to take it daily. Sometimes it is helpful to set a reminder on your phone or in your diary.
-long term possible risks:
There is a small increase in the risk of developing clots in your legs and lungs. There is also a small increase in the risk of having a heart attack or a stroke"

"If you have had any of these conditions in the past, then you should not use the pill. Seek medical advise if severe migraines, swollen legs or chest pain

"The risk of developing these conditions is increased if you smoke regularly, have a high BMI or if you are immobile for a long period of time."
-Research has shown that there is a small increased risk of breast cancer compared to people who are taking non-hormonal contraception.The risk reduces with time after stopping the pill.
-Research has also shown that there is a small increased risk of developing cervical cancer with longer use of the combined oral contraceptive
12. Use additional contraception if they have diarrhoea/ vomiting or if taking antibiotics for infections as pill may not be effective
13. Advise to tell doctor they they are on the pill or having surgery or starting new medication
14. Can't take the pill if: are pregnant
* are a smoker and over 35 years old
* are over 35 years old and stopped smoking less than one year ago
* have a BMI of greater than 35kg/m2
* suffer from migraine with aura
* are breastfeeding up to 6 weeks
* have cardiovascular and venous thromboembolism risk factors
* have a family history of breast cancer
15. You can start the pill at any time if you are sure you are not pregnant. You will need to use condoms for the first seven days of taking the pill.
16. Take pill same time each day for 21 days stop for 7 days (withdrawal bleed) . Restart and follow same regimen even if you have not finished bleeding
17. If missed 1 pill <12 hrs from usual time then just take the missed pull and continue as normal. No extra contraception needed and you may end up taking 2 pills in 1 day which is fine.
18. If missed pill was >12 hrs take 1 pill as soon as you remember but not all missed pills.
19. If missed 2 or more pills . Only take 1 not all. Use condoms or abstain from sex for the next 7 days. If you have had sex in the previous seven days you need to seek advice for emergency contraception
20. If there are seven or more pills left, then you should finish the pack and have the usual 7-day break."
21. If there are less than seven pills left in the pack: "If there are less than seven pills left in the pack then the pack should be finished and a new pack should be started the next day. This means taking the pills back to back.
22. Can you just repeat back to me what we've just discussed regarding...".
23. Summarise, questions, leaflets/websites, thank patient
1. Full name and intro
2. Confirm patient details and consent
3. Ask what do they already know about steroids? (If they say tell them it's used for medical reasons and not the same preparation or type of steroids used for bodybuilder
4. Explain why prescribes steroids: reduce inflammation and swelling which should reduce the pain
5. Tablet taken once a day
6. Being on steroid for their condition is long term
7. Serious side effects: risk if peptic ulcer, gastritis, hypertension, diabetes, osteoporosis, increased risk of infection and decreased immune response
8. Less seriously sf: mood change, weight gain, acne, skin thinning
9. In order to prevent serious side effects from occurring vitamin D and calcium supplements may be given to prevent osteoporosis and an anti acid tablet (proton pump inhibitor) is also given to prevent ulcer disease
10. If they start feeling thirsty and are passing increasing amounts of urine then to see GP for testing for diabetes
11. Don't suddenly stop medication at any point without consulting a doctor as this can cause a severe reaction which may need hospitalisation (an Addisonian crisis)
12. Don't take additional NSAIDS while on steroids and alert doctors if they start to develop severe stomach pains or vomit any blood
13. Main side effects do occur but patient will be started on low dose of steroids first
14. PMH: peptic ulcer disease, osteoporosis, hypertension)
15. Medication history: NSAIDS and allergies
16. Social: work? Alcohol? Smoking? Recreational drugs?
17. ICE, next steps, summarise and thank patient
1. Full name and role
2. Confirm patient details and consent
3. Reason for consultation
4. ICE: What do you know so far about what has happened, concerns about diagnosis/procedure, expectations of todays consultation
5. Age since started smoking? Amount? Frequency?
6. Have tried to quit in past? How they did this?
7. Say that it was good for him to attempt it before? What caused him to start again
8. Patients feelings/ motivation regarding to stop smoking
9. Benefits of stopping smoking: saving money, better health, less stigmatization
10. Dangers of continuing: increased risk of lung/throat/ stomach cancer, CVD complications such as heart attack/stroke
11. Assure patients it's never too late to give up and benefits are still seen in those who give up after smoking for many years
12. Suggest option for either cutting down gradually or going in cold turkey
13. Suggest referral to stop smoking clinic where a specialist nurse can monitor progress
14. Side effects of initially stopping smoking: cravings, weight gain/eating, irritable, frustrated
15. Identifies where the temptation arises and methods to avoid this example keeping busy, more exercise, avoid social settings where more likely to smoke
16. Advise to enlist support from family or friends
17. Offer variety of nicotine replacement therapies example patches, gum, lozenges inhalator and discuss sf example headache, nausea, palpitations
18. Medication available to alleviate cravings example bupropion and its side effects increase seizure threshold if epileptic
19. Acknowledge difficulty in giving up smoking and negotiates a goal date to stop which does not interfere with stressful events in their life
20. Arrange follow up with nurse to monitor progress
21. Any questions
22. Summarise and thank patient
1. Full name & role
2. Confirm patient details
3. Explain reason for consultation: Today I have been asked to speak to you in regards to the nee medication Metformin that the doctor has prescribed for your diabetes
4. Ask patient how much do they know so far about diabetes and metformin
5. Diabetes is the condition in which the body does not properly process food for use as energy.

Type 1 diabetes mellitus: results from the body's failure to produce sufficient insulin.

Type 2 diabetes mellitus: results from resistance to the insulin, often initially with normal or increased levels of circulating insulin.

6. Metformin works by reducing the amount of sugar your liver releases into your blood. It also makes your body respond better to insulin. Insulin is the hormone that controls the level of sugar in your body respond better to insulin. Insulin is the hormone that controls the level of sugar in your blood.
7. One daily with breakfast to reduce side effects. (May be increased to twice daily)
8. Take tablet with or right after meal same time each day
9. To be taken lifelong if it works
10. Test U&E before starting and then annually
11. Side effects: nausea, diarrhoea, abdo pain, weight loss
12. Complications: lactic acidosis
13. If miss dose take one as soon as you remember unless it's close to next dose time. Diabetes. Org. Uk
14.Your doctor will check your blood sugar levels regularly and may change your dose of metformin if necessary.

When you first start taking metformin standard-release tablets, you'll be advised to increase the dose slowly.
15. Call 999 or go A&E if you take too many tablets or you get a skin rash that may include itchy, red, swollen, blistered or peeling skin
you're wheezing
you get tightness in the chest or throat
you have trouble breathing or talking
your mouth, face, lips, tongue or throat start swelling
1. Full name & role
2. Confirm patient details
3. Explain reason for consultation: today I've been asked to discuss the management in regards to Helicobactor pylori (H pylori)
4. How much do you know so far
5. H pylori is occurs when H. pylori bacteria infect your stomach. common type of bacteria that grows in the digestive tract and has a tendency to attack the stomach lining.
6.
7. you'll usually be prescribed a course of 2 antibiotics, which each need to be taken twice a day for a week.
8. The antibiotics most commonly used are amoxicillin, clarithromycin and metronidazole.
9.
10. The side effects of these antibiotics are usually mild and can include:
* feeling and being sick
* diarrhoea
* a metallic taste in your mouth
1. You'll be retested at least 4 weeks after finishing your antibiotic course has been completed to see whether there are any H. pylori bacteria left in your stomach.
2. If there are, a further course of eradication therapy using different antibiotics may be given.

Proton pump inhibitors (PPIs)
PPIs work by reducing the amount of acid your stomach produces, preventing further damage to the ulcer as it heals naturally. They're usually prescribed for 4 to 8 weeks.
Omeprazole, pantoprazole and lansoprazole are the PPIs most commonly used to treat stomach ulcers.
Side effects of these are usually mild, but can include:
* headaches
* diarrhoea or constipation
* feeling sick
* tummy (abdominal) pain
* dizziness
* rashes
1. These should pass once treatment has been completed.
2. If you forget to take a dose take it as soon as you remember
3. Allergy?
-Levothyroxine is a medicine used to treat an underactive thyroid gland (hypothyroidism).


underactive thyroid) is a condition in which your thyroid gland doesn't produce enough of certain crucial hormones
-The thyroid gland makes thyroid hormone which helps to control energy levels and growth. Levothyroxine is taken to replace the missing thyroid hormone.

Levothyroxine is only available on prescription. It comes as tablets or as a liquid that you drink.

-Levothyroxine starts working straight away, but it may be several weeks before your symptoms start to improve.

-Before you start taking levothyroxine, your doctor will do a blood test to see what dose you need. Once you start taking the medicine you'll have regular blood tests to see how well it's working.

-Check with your doctor before taking levothyroxine if you have:

a heart problem including angina, heart disease or heart failure
high blood pressure
had a heart attack
diabetes - the dose of your diabetes medicine may need to change because levothyroxine can raise blood sugar levels

Take levothyroxine once a day in the morning, ideally at least 30 minutes before having breakfast or a drink containing caffeine, like tea or coffee.

Food and caffeinated drinks can both stop your body taking in levothyroxine properly so it does not work as well.

If you stop taking levothyroxine your symptoms are likely to come back.


If you forget to take a dose, take it as soon as you remember, unless it's almost time for your next dose. In which case just skip the forgotten dose. Do not take 2 doses together to make up for a missed dose.


Taking an extra dose of levothyroxine by accident is unlikely to harm you.

Speak to your doctor if:

you accidentally take more than 1 extra dose
you get side effects such as a racing heart beat or chest pain - these may not happen straight away, it can be several days before they come on

Your doctor will do regular blood tests to check the levels of thyroid hormones in your body before and after starting levothyroxine.

These will allow your doctor to adjust the dose to suit you.

Common side effects are the same as the symptoms of an overactive thyroid. Talk to your doctor or pharmacist if these side effects bother you or do not go away.

Feeling sick
Being sick (vomiting) or diarrhoea
Headaches
Feeling restless or excitable, or problems sleeping
Flushing or sweating
Muscle cramps
Shaking, usually of the hands

It happens rarely, but some people may have serious side effects when taking levothyroxine.

Call a doctor straight away if you get:

chest pain
fast or irregular heartbeats, or palpitations
Serious allergic reaction

In rare cases, it's possible to have a serious allergic reaction (anaphylaxis) to levothyroxine.

Immediate action required: Call 999 or go to A&E now if:
you get a skin rash that may include itchy, red, swollen, blistered or peeling skin
you're wheezing
you get tightness in the chest or throat
you have trouble breathing or talking
your mouth, face, lips, tongue or throat start swelling
You could be having a serious allergic reaction and may need immediate treatment in hospital.
Coeliac disease is a condition where your immune system attacks your own tissues when you eat gluten. This damages your gut (small intestine) so you are unable to take in nutrients.

Coeliac disease can cause a range of symptoms, including diarrhoea, abdominal pain and bloating.

Coeliac disease is caused by an adverse reaction to gluten, which is a dietary protein found in 3 types of cereal:

wheat
barley
rye

Gluten is found in any food that contains those cereals, including:

pasta
cakes
breakfast cereals
most types of bread
certain types of sauces
some ready meals

Coeliac disease is usually treated by simply excluding foods that contain gluten from your diet.

This prevents damage to the lining of your intestines (gut) and the associated symptoms, such as diarrhoea and stomach pain.

If you have coeliac disease, you must give up all sources of gluten for life. Your symptoms will return if you eat foods containing gluten, and it will cause long-term damage to your health.

This may sound daunting, but your GP can give you help and advice about ways to manage your diet. Your symptoms should improve considerably within weeks of starting a gluten-free diet. However, it may take up to 2 years for your digestive system to heal completely.

Your GP will offer you an annual review during which your height and weight will be measured and your symptoms reviewed. They'll also ask you about your diet and assess whether you need any further help or specialist nutritional advice.

When you're first diagnosed with coeliac disease, you'll be referred to a dietitian to help you adjust to your new diet without gluten. They can also ensure your diet is balanced and contains all the nutrients you need.

Even if you only consume a small amount of gluten, such as a spoonful of pasta, you may have very unpleasant intestinal symptoms. If you keep consuming gluten regularly, you'll also be at greater risk of developing osteoporosis and cancer in later life.

If you have coeliac disease, you can eat the following foods, which naturally do not contain gluten:

most dairy products, such as cheese, butter and milk
fruit and vegetables
meat and fish (although not breaded or battered)
potatoes
rice and rice noodles
gluten-free flours, including rice, corn, soy and potato
Salbutamol is used to relieve symptoms of asthma and chronic obstructive pulmonary disease (COPD) such as coughing, wheezing and feeling breathless. It works by relaxing the muscles of the airways into the lungs, which makes it easier to breathe.

Salbutamol comes in an inhaler (puffer). Salbutamol inhalers are usually blue.


If you need to use your salbutamol inhaler more than 3 times a week, it could be a sign that your breathing problem is not well controlled. Talk to your doctor, pharmacist or nurse.

Only use your salbutamol when you need it. This may be when you notice symptoms, such as coughing, wheezing, shortness of breath and tightness in the chest or you know that you are going to do an activity that can make you breathless, for example climbing stairs or sport. You should feel a difference to your breathing within a few minutes.

The normal way for adults and children to use their inhaler is:

1 or 2 puffs of salbutamol when you need it
up to a maximum of 4 times in 24 hours (regardless of whether you have 1 puff or 2 puffs at a time)

In a sudden asthma attack you can use your inhaler more and take up to 10 puffs. Wait 30 seconds and always shake the inhaler between doses. You can repeat this dose 10 minutes later.

Immediate action required: Call 999 or go to A&E now if you or your child:
are struggling to breathe
have asthma symptoms that are not getting better
Asthma attacks can get worse very quickly.

If you or your child find it difficult to use an inhaler, your doctor may give you a spacer to use with it.

Salbutamol is a safe and very effective medicine if you use it properly. It has very few side effects.

Common side effects

More than 1 in 100 people have these side effects after taking 1 or 2 puffs of their inhaler:

feeling shaky
faster heartbeat for a short while (but no chest pain)
headaches
muscle cramps
These side effects are not dangerous and they should gradually improve as your body gets used to salbutamol.

Contact your doctor or pharmacist if these or any other side effects bother you or do not go away.

Call a doctor straight away if you get:

muscle pain or weakness, muscle cramps, or a heartbeat that does not feel normal - this can be a sign of low potassium levels
very bad dizziness or you pass out
chest pain, especially if you also have a fast heartbeat or your heartbeat does not feel normal
a very bad headache


Serious allergic reaction

It is possible to have a serious allergic reaction (anaphylaxis) to salbutamol.

Immediate action required: Call 999 or go to A&E if:
you get a skin rash that may include itchy, red, swollen, blistered or peeling skin
you have trouble breathing or talking
your mouth, face, lips, tongue or throat start swelling
You could be having a serious allergic reaction and may need immediate treatment in hospital.
They are known as "preventer" inhalers and are often brown or beige. If you have asthma or COPD, they help stop you getting symptoms.

Beclometasone (sometimes written as "beclomethasone") is a type of medicine known as a corticosteroid (or steroid).

Use your beclometasone inhaler every day for it to work, even if you do not have any symptoms.
It's important to rinse your mouth or brush your teeth after using a steroid preventer inhaler. This is to prevent infections and a sore mouth.
You may get a blue steroid treatment card if you need high doses of beclometasone to control your symptoms.

Do not change your brand of steroid inhaler without checking with your doctor first.

Children aged 5 years and older can use beclometasone inhalers for asthma.

Adults can use beclometasone inhalers for asthma or COPD.

Beclometasone is not suitable for some people. To make sure it's safe for you, tell your doctor if you:

have had an allergic reaction to beclometasone or any other medicines in the past
cannot have alcohol for any reason (some brands contain a very small amount of alcohol)
have ever had TB (tuberculosis)
are pregnant or trying to get pregnant - your doctor may want to lower your dose
are being treated for viral or fungal infections

The usual dose is 1 or 2 puffs, taken twice a day.

It's important to use your beclometasone inhaler regularly to manage your condition. Keep using it, even if you do not have any symptoms. After using your inhaler, always put the lid back on to keep it clean.

Before using your inhaler, read the information leaflet that came with it. This leaflet contains instructions and diagrams to show you how to use the inhaler, how to keep it clean, and how long to use it before getting a replacement.

It's very important to use your inhaler properly. This is so you get the right amount of beclometasone into your lungs and the most benefit from your medicine.
To get the most from your inhaler, it's important to have your technique checked regularly.

If you or your child find it difficult to use an inhaler, your doctor or nurse may give you a spacer to use with it. Spacers can reduce the risk of side effects affecting your mouth and throat. They are particularly useful for giving beclometasone to young children.

A spacer is a large plastic container with a mouthpiece and a hole for the inhaler. It makes it easier to get the right amount of beclometasone into your lungs.


Use your inhaler as soon as you remember. If it's almost time for your next dose, skip the missed one and take your next dose as usual.

Do not take a double dose to make up for a forgotten dose.

If you forget doses often, it may help to set an alarm to remind you

Taking too much beclometasone by accident is unlikely to harm you.

If you're worried, talk to your doctor or a pharmacist.

Steroid cards

If you are using a steroid inhaler regularly, ask your doctor, nurse or a pharmacist if you need to carry a blue steroid card.


These common side effects may happen in more than 1 in 100 people.

Keep taking the medicine but talk to your doctor if these side effects bother you or do not go away:

oral thrush - a fungal infection that causes white patches, redness and soreness in your mouth
dry or sore throat, or hoarse voice


Side effects are more likely if you're on a higher dose of beclometasone for a long time (more than a few months).

Tell a doctor straight away if you get:

high temperature, chills, a very sore throat, ear or sinus pain, a cough, coughing up more mucus (phlegm) or a change in colour of your mucus, pain when you pee, mouth sores or a wound that will not heal - these can be signs of an infection
"moon face" (a puffy, rounded face), weight gain in the upper back or belly - this happens gradually and can be a sign of Cushing's syndrome
a very upset stomach or you're being sick (vomiting), very bad dizziness or passing out, muscle weakness, very tired, mood changes, loss of appetite and weight loss - these can be signs of adrenal gland problems
changes in your eyesight, such as blurred vision or a cloudy lens in the eye - these can be signs of increased pressure in your eyes (glaucoma) or a cataract
Serious allergic reaction

It happens rarely but it is possible to have a serious allergic reaction (anaphylaxis) to beclometasone.

This is different to an asthma attack. If you or your child have asthma symptoms, such as wheezing or have tightness in the chest or throat, use a reliever inhaler. If the symptoms do not improve or get worse, call 999 or go to A&E.

Immediate action required: Call 999 or go to A&E if:
you get a skin rash that may include itchy, red, swollen, blistered or peeling skin
you have trouble breathing or talking
your mouth, face, lips, tongue or throat start swelling
You could be having a serious allergic reaction and may need immediate treatment in hospital.
The combined oral contraceptive pill is often just called "the pill". It contains artificial versions of female hormones oestrogen and progesterone, which are produced naturally in the ovaries.

If sperm reaches an egg (ovum), pregnancy can happen. Contraception tries to stop this happening usually by keeping the egg and sperm apart or by stopping the release of an egg (ovulation).

When taken correctly, the pill is over 99% effective at preventing pregnancy. This means that fewer than 1 in 100 who use the combined pill as contraception will get pregnant in 1 year.
The standard way to take the pill is to take 1 every day for 21 days, then have a break for 7 days, and during this week you have a bleed like a period. You start taking the pill again after 7 days.

You need to take the pill at around the same time every day. You could get pregnant if you do not do this, or if you miss a pill, or vomit or have severe diarrhoea.
Some medicines may make the pill less effective. Check with your doctor if you're taking any other tablets.

Minor side effects include mood swings, nausea, breast tenderness and headaches - these usually settle down in a few months.
There is no evidence that the pill will make you gain weight.
There's a very low risk of serious side effects, such as blood clots and cervical cancer.
The combined pill is not suitable if you are over 35 and smoke, or if you have certain medical conditions.
The pill does not protect against sexually transmitted infections (STIs), so use a condom as well.
There may be a link between the pill and depression but evidence is mixed and further research is needed.

How it prevents pregnancy

The pill prevents the ovaries from releasing an egg each month (ovulation). It also:

thickens the mucus in the neck of the womb, so it is harder for sperm to penetrate the womb and reach an egg
thins the lining of the womb, so there is less chance of a fertilised egg implanting into the womb and being able to grow

Take your 1st pill from the packet marked with the correct day of the week, or the 1st pill of the 1st colour (phasic pills).
Continue to take a pill at the same time each day until the pack is finished.
Stop taking pills for 7 days (during these 7 days you will get a bleed).
Start your next pack of pills on the 8th day, whether you are still bleeding or not. This should be the same day of the week as when you took your 1st pill.

If you miss a pill or pills, or you start a pack late, this can make the pill less effective at preventing pregnancy. The chance of getting pregnant after missing a pill or pills depends on:

when the pills are missed
how many pills are missed

Can't give to smoker breast cancer overweight other meds

Sometimes intefers with some antibiotics
Cervical screening (a smear test) checks the health of your cervix. The cervix is the opening to your womb from your vagina.
It's not a test for cancer, it's a test to help prevent cancer.
All women and people with a cervix aged 25 to 64 should be invited by letter.
During the screening appointment, a small sample of cells will be taken from your cervix.
The sample is checked for certain types of human papillomavirus (HPV) that can cause changes to the cells of your cervix. These are called "high risk" types of HPV.
If these types of HPV are not found, you do not need any further tests.
If these types of HPV are found, the sample is then checked for any changes in the cells of your cervix. These can then be treated before they get a chance to turn into cervical cancer.
You'll get your results by letter, usually in about 2 weeks. It will explain what happens next.

Cervical screening checks a sample of cells from your cervix for certain types of human papillomavirus (HPV).

These types of HPV can cause abnormal changes to the cells in your cervix and are called "high risk" types of HPV.

If these types of HPV are found during screening (an HPV positive result), the sample of cells is then checked for abnormal changes. If abnormal cells are not treated, they may turn into cervical cancer.

What is HPV?

HPV is the name for a very common group of viruses.

Most people will get some type of HPV during their lives. It is very common and nothing to feel ashamed or embarrassed about.

You can get HPV from any kind of skin-to-skin contact of the genital area, not just from penetrative sex.

This includes:

vaginal, oral or anal sex
any skin-to-skin contact of the genital area
sharing sex toys
Some types of HPV (called "high risk" types) can cause cervical cancer. In most cases your body will get rid of HPV without it causing any problems. But sometimes HPV can stay in your body for a long time.

If high risk types of HPV stay in your body, they can cause changes to the cells in your cervix. These changes may become cervical cancer if not treated.

If you do not have a high risk type of HPV it is very unlikely you will get cervical cancer, even if you have had abnormal cell changes in your cervix before.

Cervical screening checks a sample of cells from your cervix for certain types of human papillomavirus (HPV).

These types of HPV can cause abnormal changes to the cells in your cervix and are called "high risk" types of HPV.

If these types of HPV are found during screening (an HPV positive result), the sample of cells is then checked for abnormal changes. If abnormal cells are not treated, they may turn into cervical cancer.

What is HPV?

HPV is the name for a very common group of viruses.

Most people will get some type of HPV during their lives. It is very common and nothing to feel ashamed or embarrassed about.

You can get HPV from any kind of skin-to-skin contact of the genital area, not just from penetrative sex.

This includes:

vaginal, oral or anal sex
any skin-to-skin contact of the genital area
sharing sex toys
Some types of HPV (called "high risk" types) can cause cervical cancer. In most cases your body will get rid of HPV without it causing any problems. But sometimes HPV can stay in your body for a long time.

If high risk types of HPV stay in your body, they can cause changes to the cells in your cervix. These changes may become cervical cancer if not treated.

If you do not have a high risk type of HPV it is very unlikely you will get cervical cancer, even if you have had abnormal cell changes in your cervix before.

You may have some light bleeding or spotting after cervical screening. This should stop within a few hours.

If abnormal cells are found and you need treatment, there are some risks, such as:

treating cells that may have gone back to normal on their own
bleeding or an infection
you may be more likely to have a baby early if you get pregnant in the future - but this is rare


you do not want to be invited for screening, contact your GP and ask to be taken off their cervical screening list.

You can ask them to put you back on the list at any time if you change your mind.

You'll be sent an invitation letter in the post when it's time to book your cervical screening appointment.

Your letter will tell you where you can go for cervical screening and how to book.

Most cervical screening is done in a GP surgery by a female nurse or doctor.