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Sofia (Patient Ref. No. L-3308), a 15 years old girl is visited (at home) by Emergency Care Practitioners (ECPs) as her parents approached the practitioners with complaints of recurrent tonsillitis for the girl. According to the medical reports she has been experiencing this problem since her childhood. She suffers from severe tonsillitis every 2-3 months and she requires courses of antibiotics very frequently. The problem was too severe in the last few months as she was affected with tonsillitis 1-3 times a month. The advice of the family physician was to go in for tonsillectomy as the girl was suffering too much with regular episodes of tonsillitis in the past few weeks.

The problems usually start when she eats ice-creams, cold drinks, butter milk curd, bananas and other cool food items. The complaints normally commence with irritation and pain in the throat and trouble during swallowing food. She also gets affected with lower respiratory tract infection as she experience severe cough expelling thick yellowish spit. Pain also starts as it radiates to the ears. The girl also experiences trouble in eating and drinking and often has tiredness and body ache. Occasionally she suffers from fever with extreme throat pain that is severe during morning (and gets away as the day progresses). The girl also suffers from frequent colds, nose block, and breathing difficulty, along with bouts of sneezing. This girl had problems of premature greying and also has dandruff and hair falls for the last three years. The girl does not appear healthy and has few other complaints apart from this. She likes to have fried items, sweets, and other spicy foods and hates to have fruits and vegetables. She has grave thirst and sweats profusely even without doing any physical or mental work. She sparingly drinks water and does not have poor appetite.

Sofia has always been an average student, however, she find it difficult to concentrate on studies since the last academic year. She is unable to properly listen, looses concentration, and finds it tough to sit for more than 15-20 minutes at a stretch. She experience stray thoughts and is often lost somewhere while she is in the class. She is often too much buried in her thoughts, has poor memory, and is often completely inattentive and careless to her surroundings. Even though she likes to be in the company of friends, she has aversion for big crowds. She has always been an obstinate child since her childhood and become angry very easily. She feels hurts easily and refuses to reconcile soon. However she stops talking all of a sudden and prefer to be quiet. She is unable to tolerate anything and lose her temper very easily. She gets good sleep though disturbed by fearful dreams sometimes. She recently developed a fear for darkness. In spite of all this, she has always been a pleasant child who loves to sing and dance.

This girl has problems of asthmatic bronchitis and had also gone through tuberculosis during childhood. For tonsillitis problems, even though ENT doctor recommended tonsils removal, her parents decided not to do it. She has a family history of allergies and other similar troubles (parents, one grandparent and uncle possess allergic problems). When she was examined she was found to possess inflamed and enlarged tonsils (marked throat congestion). Her mother had suffered from cervical and lumbar spondylosis and chronic sinusitis during her early ages. Her uncle suffers from hyperacidity and cervical spondylosis. Her father still has problems with bronchial asthma, diabetes and obesity. Her Grandfather (father�s father) had hypertension and obesity.

Patient Group Directions (PGDs) have engaged Emergency Care Practitioners (ECPs) to visit

the house of Sofia as she required treatment. She was suffering from dry, sore throat and also vomits (though not frequently). She was suffering from fever and sore throat for six days. Her pharynx, tonsils and buccal mucosa appeared red and inflamed. Her tonsils were also found to be studded with white areas of exudate. She was diagnosed as suffering from acute bacterial tonsillitis. The clinical condition of the girl is that she was suffering from bacterial infection of the throat, showing symptoms of acute and consistent tonsillitis.

Clinical examination of the girl revealed throat swab positive to Streptococcus A. This condition confirms bacterial infection (as per the guidelines). All the patients who suffer from this problem for more than one year are confirmed acute Tonsillitis, irrespective of their age, sex, gender and clinical need. Penicillin treatment is recommended in this case unless the patient is having penicillin allergy or he/she is already taking other antibiotics. Phenoxymethylpenicillin is recommended for patients with acute bacterial throat infection. People who are already taking other drugs may have problems with phenoxymethylpenicillin (for example, warfarin, methotrexate). For patients with penicillin allergy, Erythromycin is recommended. This phenoxymethylpenicillin treatment is recommended for patients who are systemically unwell, showing symptoms like, history of fever, absence of cough, purulent tonsils and Cervical adenopathy. Phenoxymethylpenicillin treatment is supposed to alleviate the symptoms that are associated with the bacterial throat infection (British National Formulary, Department of Health, 2005) .

Emergency Care Practitioners (ECPs) who deal with patients are supposed to meet certain criteria and are required to follow several guidelines. All the staff must be professionally qualified (for example, a Registered Nurse (RN)). Nurses must carry out the recommended steps of the treatment. Staffs are also expected to have necessary skills for undertaking this assignment. The registered nurse must have received appropriate training and should be deemed competent to administer or supply this medication under patient group direction. The nurses also must have specialist qualifications, training, experience and the competence that is deemed necessary and important to the clinical condition treated under this direction. Special training, qualifications and experience are mandatory to supply as well as administer the medicines. Nurses must complete the appropriate training package and must be thorough with all medications, dosages, possible side effects etc. Practitioners must be completely aware of any change to the recommended medicine list. They are also responsible to keep themselves up-to-date with their respective profession (British National Formulary, Department of Health, 2005).

Treatment involves giving Phenoxymethylpenicillin tablets (250mg), Phenoxymethylpenicillin oral solution 125mg/5ml (sugar free) or Phenoxymethylpenicillin oral solution 250mg/5ml (sugar free). These drugs need to be obtained only from approved pharmacy. According to the specifications of Patient Group Directions (PGDs), informed consent must be obtained and documented (Informed consent on minor injury card or allergy status). Legal status of the medicines should also be checked (for example, General Sales List (GSL), Prescription only (POM) and Pharmacy only (P)). The doses of the medicine(s) should be accurate. Practitioners must be thorough about the range of dose, the criteria for deciding the dose and other specifications. In this case of acute tonsillitis, the drugs Phenoxymethylpenicillin tablets (250mg), Phenoxymethylpenicillin oral solution 125mg/5ml (sugar free) or Phenoxymethylpenicillin oral solution 250mg/5ml (sugar free) must be given to the patient in the range

� 125mg four times a day for 7 days (1yr - 6 yrs)

� 250mg four times a day for 7 days (6yr � 12 yrs)

� 500mg four times a day for 7 days (for adults over 12 years)

In this particular case since the patient is above 12 years, she must be given 500mg four times a day for 7 days. The total dose of medicine that must be given to given to the patients include

28 or 56 Phenoxymethylpenicillin tablets (250mg, as per the dose), 140ml penoxymethylpenicillin oral solution 125mg / 5ml (sugar free), 140ml Phenoxymethylpenicillin oral solution 250mg/5ml (sugar free). The dose of the medicine is four times a day for all the seven days of the week. Practitioners must be well educated about the number of times treatment must be administered. The minimum and maximum period of administration must be known to the practitioners (Dagnelie et al., 1996) . After the prescribed treatment, follow-up treatment may be required in certain cases (according to the symptoms that follow). For example in the case of Phenoxymethylpenicillin, nurses must be aware about the chance of Glandular Fever that cannot be treated using Phenoxymethylpenicillin (British National Formulary, Department of Health, 2005).

Medical practitioners must give necessary advice the patient or the care taker. They must be given necessary details regarding use of the medicine, doses and other details. In certain cases where the patient is taking any additional medicine (for example contraceptive pill), all supplementary precautions must be taken for avoiding side effects, allergies and other complications. Practitioners must recommend additional symptomatic treatment if needed; for example, simple analgesics, rest.

Patients and care takers must be given instructions for identifying and managing

all possible adverse outcomes (side effects, reactions, allergies etc). Patients must be advised to stop using medicines if they produce opposite effects in him/her. For example, patients must stop taking penicillin if they experience severe vomiting, thrush or diarrhoea. They should also stop taking treatment if they experience skin rash within 48 hours of treatment. Patient and care takers must also be able to make necessary arrangements for medical and referral advices (according to the local facilities available for them). Practitioners must be aware of the details of any follow up action that needs to be taken and the circumstances in which they are to be taken. For example, if symptoms persist in a patient, they must seek necessary medical advice. Nurses and other practitioners must be aware of all sites for treatment; for minor and major injury units. Practitioners must also know the facilities and supplies that are needed in the site where treatment is carried out; for example, lab facilities, basic life support, diagnostic and examination

facilities, major and minor injury units. In the case we discussed, facilities like adrenaline and anaphylaxis cove is necessary. Nurses must also take special precautions about concurrent medication also. For example, it should be ensured that patient is not currently taking any drug/medicine that duplicates or interacts with the recommended medicine (British National Formulary, Department of Health, 2005).

In the case of Sofia, according to the present status and her health history (and her family history), she is recommended Phenoxymethylpenicillin treatment to recover from acute tonsillitis. She is expected to get much relief from her sickness by the end of three months. She is also expected to be saved from chronic tonsillitis episodes even though mild throat pain may continue. She is supposed to have no cough or fever is also told that she no longer need to use antibiotics for temporary relief. Sofia�s general immunity is also expected to improve and she may be able to tolerate foods that created problems for her all these years. Her immunity power also is supposed to improve and has become less liable to fever and cold. She is also expected to become more tolerant to weather changes and associated tonsillitis attacks. She is advised to continue with the treatment for some more months to get rid of this problem fully. She is expected to get well with this treatment.

References

British National Formulary, Department of Health. (2005). Patient Group Direction (PGD).

Dagnelie, C. F, Van Der Graaf, Y, De Melker, R. A. and Touw-Otten F.W.M.M. (1996) �Do patients with sore throats benefit from penicillin? A randomized double-blind placebo-controlled trial with penicillin V in general practice�, Br J Gen Pract, 46, 589-593.

Notes

Patient group directions (PGDs): Patient group directions (PGDs) will be the best way to meet the patients� needs. They give the framework for the supply and administration of medicines without the need for an individual prescription and can be invaluable in some direct access services and certain emergency situations. Health care professionals who give care through PGDs should be appropriately trained and must be fully aware of their responsibilities

Registered Nurse: Registered nurses (RNs), regardless of specialty or work setting, perform basic duties that include treating patients, educating patients and peple about various medical conditions, and giving advice and emotional support to the patients and their family members. Registered nurses record medical histories and symptoms of the patient to perform diagnostic tests and analyze results, administer treatment and medications, operate medical machinery, and also assist the patient for the follow-up and rehabilitation.

Bibliography

National prescribing centre(NPC) (2006) Medicines, http://www.npc.co.uk/, Date accessed 03/03/07.

Department of Health. (2006) Tonsillitis, http://www.dh.gov.uk/Home/fs/en, Date accessed 03/03/07.

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