Part 1
Mr Jiten Chavda is a 27- year-old man. He has had 2 appointments in the last two months. The following notes are on his records:
15/12/2020– Telephone consultation
Problem: Asthma Exacerbation
Presenting Complaint: Recurrent cough for 4/52, occasional breathlessness, productive sputum, tiredness – (night time cough keeping him awake?)
3 RCP Questions: Yes to all
History: Asthma from childhood – well controlled in the past
Examinations: N/A as telephone
Social: Works in a sewing factory, non smoker, drinks occasionally
Medication: Terbutaline Turbohaler 500mcg 1 puff PRN
New Medication: Budesonide Turbohaler 100mcg BD
Comment: Likely asthma exacerbation, step up treatment, currently on SABA only so addition of ICS BD, to contact if symptoms do not improve or other concerns. Advised will take a couple of weeks for new inhaler to work.
15/01/2021 – Telephone consultation
Problem: Asthma follow up
Presenting Complaint: Still has recurrent cough for 2/12, no improvement, productive, sputum purulent – occasional blood in cough, feeling more tired, temperature, sweating/shivering. Still working as needs the money, ICS recently added not helping, using SABA 8x daily – helps with breathing.
New Medication: Amoxicillin 500mg TDS for 5/7
Comment: Patient asked to come this AM for face to face so can conduct examinations but unable to make it as at work, explained importance but worried manager might sack him, discussion re Sick note but not interested – CAP likely – prescribe Antibiotics and follow up, safety netted. No allergies. Finish course. Continue with ICS.
The GP Practice Pharmacist has contacted today to arrange a face-to-face consultation with him to complete an asthma medication review and to check his inhaler technique. Over the telephone, she also gathers the following information:
Presenting complaint:
Cough now for nearly 3/12
Coughing up phlegm – yellow, brown in colour – thinks it blood
Breathlessness worse, find it difficult to speak, climb stairs, feeling weak
Night sweats – wakes up drenched sometimes
High temperature
Lack of appetite, when asked about weight loss – his housemates mentioned that he had lost weight, so he weighed himself yesterday – Current weight 65kg
Tiredness but trying his best to work
Social History: Non smoker, drinks alcohol 6 units per week, used to go to gym but has stopped since not well, single, lives with other workers from the factory – 6 in total in rented accommodation. Housing conditions are good generally, no damp/ mould, a cleaning rota to ensure dust free to help with his asthma. He would like his own space, currently sharing a room with 3 others, overcrowded but not enough money. His housemates are all well.
Came back from India 4 months ago – hasn’t been right. Went home to visit family – was there for 1/12.
Medication: Always just had the blue inhaler and rarely uses it but the last 4 months has seen him use it at maximum dosage. Been using Pulmicort BD every day since he has been prescribed that but not helping. Thinks his technique is good – uses ICS in the same way as his blue inhaler. The antibiotics finished yesterday and they helped a little bit but he still feels unwell.
The GP Practice Pharmacist suspects tuberculosis and decides to discuss this further with the GP.
a) Based on the signs and symptoms and the patient’s social history define the main five key points that aided the GP Practice Pharmacist to arrive at this diagnosis? (5 marks)
There are nine GPhC standards that every pharmacy professional is accountable for meeting. Pharmacy professionals are personally accountable for meeting the standards and must be able to justify the decisions they make.
b) With reference GPhC standard 8 explain what the best course of action would be, how you would communicate this and identify steps that can be taken to prevent this situation from happening again. (10 marks)
c) Tuberculosis is a notifiable disease in the UK. Why is this and what process is involved? (5 marks)
d) Describe below the different tests that will need to be carried out to confirm the active TB diagnosis? (10 marks)
e) Identify any potential close contacts of this patient and how they should be tested for latent TB. Include in your answer what the test involves and how the results are interpreted to confirm a diagnosis of TB. (5 marks)
f) Discuss why tuberculosis is a difficult condition to treat with reference to its cellular pathophysiology and the bacterial cell wall. (10 marks)
Part 2 – Treatment
Mr Chavda is to be started on medication for tuberculosis. He will be taking his medication without supervision.
a) What are the aims of using combinational therapy for TB treatment? (3 marks)
b) With reference to the NICE Guidance NG33 and the BNF, propose a suitable starting and maintenance regime for Mr Chavda. Include your calculations, counselling points for each of the medications and the monitoring requirements that may apply. (15 marks)
c) Mr Chavda is struggling with his tablet burden and it is affecting his compliance. Would he be a candidate for Directly Observed Therapy? Discuss the advantages and disadvantages of Directly Observed Therapy Vs Unsupervised Therapy. (10 marks)
d) With reference to NICE Guidance NG33 discuss three strategies healthcare professionals can employ to encourage patients with TB to follow their treatment plan. (6 marks)
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e) Suggest and discuss an alternative to solid oral dosage forms for the delivery of tuberculosis medication. Include in your discussion the pros and cons of your choice. (10 marks)
Part 3 Asthma Control
5 months later Mr Chavda attends the Asthma Clinic for an asthma medication review. He has been doing really well considering the challenges and the medication burden. He is continuing to take his medication as prescribed for now and will complete his 6-month course next month.
He is still using the following two inhalers:
Terbutaline 500mcg Turbohaler 500microgram 1 puff PRN
Budesonide 100mcg Turbohaler 1 puff BD
During the review, Mr Chavda’s inhaler technique was checked using the In-chek device. During the review it becomes apparent that Mr Chavda doesn’t have a high inspiratory flow rate to use his inhalers correctly.
a) Explain how you assess Mr Chavda’s asthma control? (5 marks)
b) Suggest alternative delivery devices and justify your decisions using your knowledge on inhaled dosage design. (6 marks)
