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The Railway Recruitment Board (RRB) inducts pharmacists since 1962 when the Furnishing Division was inaugurated on 2nd October that year. Inaugurated by the first Prime Minister of independent India Pt. Jawaharlal Nehru on 2nd October 1955, the Integral Coach Factory is one of the earliest production units. Later, the production of fully furnished coaches steadily spread over nearly 511 acres. It has had about 10,408 employees, more than 2000 coaches every year which includes conventional and self propelled coaches.

RRB Pharmacist Verification

All stages of the recruitment process shall require proper documents. Only after the candidates have qualified in all the stages of examinations are shortlisted for document verification and RRBs conduct verification of eligibility conditions with reference to original documents only and is liable to be removed from service summarily if not matched. Signatures of the candidates on all documents should be identical, in all stages of the recruitment process and must be in running hand and not in block/capital or disjointed letters. Signatures in a different style at the time of Document Verification as applicable may result in cancellation of candidature. E-Call letters for Document Verification along with dates of examinations are displayed on the official websites of participating RRBs accordingly on websites of the RRBs concerned. No communication from the RRBs will be done with the candidate through the post. Candidates should ensure that they have requisite educational/technical/professional qualifications from recognized Board/University/Institute. Candidates’ Name, Father’s Name and Date of Birth are of utmost importance and should resemble as recorded in the Matriculation/SSLC/High School Examination Certificate or an equivalent certificate only. Gazette Notification or any other legal document should be submitted at the time of Document Verification (DV) as applicable for such cases. RRB holds the right to introduce additional interviews and/or additional Document Verification etc., without assigning any reason.

Hence, what we can see is that Certificates & Documents Verification for the posts of RRB pharmacists is mandatory and without proper verification, the service can even be terminated. On this note, anyone applying for the posts of RRB pharmacist has to keep a serious attitude on this ground. Hope you have got clear idea on RRB Pharmacist Certificates & Documents Verification Requirements .

Pharmaceutical companies have a monster share of market in Bangalore and its outskirts. As a whole, the state of Karnataka contributes 8% to the country’s revenue in the pharmaceutical sector. It ranks 5th in pharmaceutical Exports, 10th in the number of Pharmaceutical manufacturing contributing 12% to country’s exports. The pharmaceutical policy of 2012 aimed to develop infrastructure, foster R&D and attract mega projects in the Karnataka sector. With 26% contribution from the Government and Initiatives like Venture capital fund of INR 50 crore the formation of Karnataka Pharmaceutical development council including The Vision group and promotional activities have been introduced in the Policy.

Karnataka owns its exclusive pharma SEZ’s in Hassan and Yadgir. Being home to 221 formulation units and 74 bulk drug units its exports result in 40% of its pharma production. Here we will go through the surface of Yellahanka-Whitefield pharmaceutical base. Yellahanka is a suburb of Bangalore, older than the city and lies to the north of Bengaluru which has now overgrown engulfing many of its neighboring villages and towns. Whitefield is a neighborhood of Bengaluru named after George Whitefield and now a major part of Greater Bangalore. There is a driving distance of 35 kms between Whitefield and Yellahanka and it takes 42 minutes to travel from Whitefield to Yellahanka by car. One part of the industry includes pharmaceutical sectors apart from other major thriving industries. Therefore there prevail some pharmaceutical companies like Astra Zeneca Pharmaceuticals, Ranflex India Pvt. Ltd, R L FINE CHEM etc.

Peenya Pharmaceutical Companies

• Bangalore Genei Private Limited,

6, Bda Industrial Suburb, VI Main, Peenya, Near Srs Road, Bangalore. Phone 080 2837 8057.

• Karnataka Antibiotics and Pharmaceuticals Limited,

2nd Main Road, Nalagadderanahalli, Peenya Industrial Area, Bangalore. Phone 080 2357 7680.

• Madhur Pharma & Research Laboratories Private Limited,

292 & 294, Peenya Industrial Area, 4th Phase, Bangalore. Phone 080 2839 4504.

• Mahendra Labs Private Limited,

371 & 372, 4th Phase, Peenya Industrial Area, Bangalore. Phone 080 2225 2639.

• Remidex Pharma Private Limited,

B-249, 2nd Stage, Peenya Industrial Area, Bangalore. Phone 080 2332 7452.

• Meyer Organics Private Limited,

10D, 2nd Phase, Pennya Industrial Area, 3rd Main, Peenya, Bangalore. Phone 080 2839 6048. Anglo French Drugs and Industries Limited, Plot No.4, Phase 2, Peenya Industrial Area, Bangalore. Phone 080 2315 4770.

Yellahanka Pharmaceutical Based Companies

• R L Fine Chem,

Ray House, No.2000, HIG, Next to Yelhanka New Town Police Station, RWF West Colony, Bangalore. Phone 080 2846 1647.

Yeshwanthapur Pharmaceutical Companies

• Theramyt Biologics Private Limited,

Prasad Enclave, Yeshwantpur Industrial Suburb, 5th Main, 118/119, Bangalore. Phone 080 3003 4600.

• Kemwell Biopharma Pvt. Ltd. – Bangalore
• No. 11, Tumkur Road, Yeshwanthpur. Bangalore. Bangalore.

• Jubilant Biosys Limited
• 96 Industrial suburb 2nd stage 560022 08066628400

• Fine Chemicals Laboratories – Bangalore
• No. 7, 1st Main Road, Industrial Suburb, Yeshwathpur, Yeshwanthpur. Bangalore. Bangalore.

• Adhitya Medicals – Bangalore
• No-24/3, 4th B Cross 9th Main Road Yeswanthpur, Yeshwanthpur. Bangalore. Bangalore.

Kemwell Pvt. Ltd. – Bangalore
Door No- 11, Kemwell House, Teppada Begur, Tumkur Road, Yashwantpur, Nelamangala Taluk, Yeshwanthpur. Bangalore. Bangalore.

• Micro Nova Pharmaceuticals Pvt Ltd
• Yeshwanthpur
• 08022370454

Usha Minechem Industries

• Sharadha Medicals
• Yeshwanthpur
• 9886199325

The Pharmaceutical industry in Karnataka inclusive of this Peenya Yellahanka-Whitefield base has been able to generate Rs 8k crore in revenue contributing 8% of the country’s total revenues. The presence of exclusive Pharma SEZ, Pharma industrial areas, R&D Centres & ability to produce quality products makes the region a well developed ecosystem to be ideal destination for pharmaceutical industries. Also, there exist more than 70 medical and dental colleges, which is a large number of educational setups for pharmacy study, add up in creating an ecosystem for collaboration on product development and trials, drug testing laboratories and what not.

Canada as the strongest economy country attracts several international students and it is one of the best countries to pursue higher degrees of Pharmacy. Canada has well developed research facilities with up to date technology which are relevant requirements in the of field Pharmaceutical science. It is a highly demanding field due to ever changing trends that offer many careers with different job roles across the world. Throughout the world, Germany, Canada, and USA are the best places to pursue master’s degrees. Career scope in Pharmacy is plenty in Canada as to fulfill current shortages, there is growing demand of hospitals and diseases and well-developed resources to manage it all.

Top Universities for studying Pharmacy in Canada

• University of British Columbia
• University of Waterloo
• University of Alberta
• Dalhousie University
• Memorial University of New Foundland
• University of Toronto

Canadian University Master Degree in Pharmacy

A Masters degree in Pharmacy encompasses the knowledge of drugs, medical formulations and clinical services with practical experience creating experts in this field. An M.S in Pharmacy degree expounds a multitude of opportunities in the health science sector and Canada providing ample career-based development is much beneficial for the international students. The program is a thesis-based full-time of 2 years course comprising of 2 four-month terms with specializations in Pharmaceutical Sciences/Pharmacy Practice. The option of both part-time and full-time are present there with the coursework includes a minimum of three one-term courses, academic integrity workshop, thesis proposal and defense. Most of the universities offers M.S program with a minimum admission requirement of 75% in the undergraduate course and good TOEFL scores. M.S in Pharmacy offers research in the various areas of Pharmacology, Toxicology, Pharmaceutics and Pharmacokinetics. Funding Opportunities are available for International students through assistantships and awards.

Canadian University Ph.D. in Pharmacy

A doctorate in Pharmacy will allow you to be well versed in this field, provide you with the opportunity to learn from the best in this evergreen and ever changing field of work to create a better living.

Canada with its excellent job opportunities will provide you with chances to use the knowledge gained to produce drugs and medicines to combat a large number of diseases around the world. A doctorate generally has a time span of 4-6 years yet maximum students take 5 years to complete the degree. The first two years are comprised of extensive coursework followed by strict examinations.  In the last years of study there are research-intensive work followed by the preparation of the research thesis, its oral defense from other scientists.

A Ph.D. in Pharmacy covers the arenas of health sciences studies related to drug and formulations, pharmaceutical chemistry, etc. Admissions to the Doctorate programs require a Master’s degree in the relevant field of interest with a minimum grade point average of 3 on 4, resume, statement of purpose, letter of recommendation, research proposal, TOEFL, and GRE. Some Universities require the completion of particular examinations after the Master’s degree by prospective Ph.D. students though some universities offer a combined MS- Ph.D. course. Moreover, PhD students are provided with a stipend during their education making it affordable along with other sources of financial support in the form of tuition fee waivers and awards.

Jobs for Pharmacy students in CANADA

• clinical pharmacist
• community pharmacist
• dispensary department supervisor – hospital
• drug information pharmacist
• druggist
• health care institution pharmacist
• hospital druggist
• hospital pharmacist
• industrial pharmacist
• intern pharmacist
• pharmacist
• pharmacist consultant
• registered pharmacist
• retail pharmacist

Immunization, also called vaccination or inoculation, a method of stimulating resistance in the human body to specific diseases using microorganisms—bacteria or viruses—that have been modified or killed. These treated microorganisms do not cause the disease, but rather trigger the body’s immune system to build a defense mechanism that continuously guards against the disease. If a person immunized against a particular disease later comes into contact with the disease-causing agent, the immune system is immediately able to respond defensively. Vaccines are classified into mainly four categories namely, Whole-Organism vaccines, Purified Macromolecules Vaccines, Recombinant Vaccines and Future Vaccines.

Classification of VACCINES:

I. WHOLE-ORGANISM VACCINES

a. Live attenuated vaccines

b. Killed or inactivated vaccines

II. PURIFIED MACROMOLECULES

a. Toxoids

b. Capsular Polysaccharide vaccines

c. Polypeptide vaccines

III. RECOMBINANT VACCINES

a. Recombinant Protein vaccines

b. Recombinant vector vaccines

c. Subunit Vaccines

d. Polynucleotide vaccines (DNA vaccine)

IV FUTURE VACCINES

a. Multivalent subunit vaccine

b. Anti-idiotype vaccine

c. Plant vaccine

Examples of Vaccines:

Examples of live attenuated vaccines include:

· Measles vaccine (as found in the MMR vaccine)

· Mumps vaccine (MMR vaccine)

· Rubella (German measles) vaccine (MMR vaccine)

· Oral polio vaccine (OPV) (sabin vaccine)

· Varicella (chickenpox) vaccine

· BCG (Bacillus Calmette-Guerin ) vaccine for TB

Examples of inactivated (killed) vaccines:

· Inactivated polio vaccine (IPV), which is the shot form of the polio vaccine

· Inactivated influenza vaccine

· Salk polio vaccine

· Pertussis vaccine used in DPT vaccine

Examples of toxoid vaccines:

· Diphtheria toxoid vaccine (may be given alone or as one of the components in the DTP, DTaP, or dT vaccines)

· Tetanus toxoid vaccine (may be given alone or as part of DTP, DTaP, or dT)

Examples of component vaccines:

· Haemophilus influenzae type b (Hib) vaccine

· Hepatitis B (Hep B) vaccine

· Hepatitis A (Hep A) vaccine

· Pneumococcal conjugate vaccine

Types of Vaccines:

        Scientists have developed two approaches to immunization: active immunization, which provides long-lasting immunity, and passive immunization, which gives temporary immunity. In active immunization, all or part of a disease-causing microorganism or a modified product of that microorganism is injected into the body to make the immune system respond defensively. Passive immunity is accomplished by injecting blood from an actively immunized human being or animal.

Passive Immunization

        Passive immunization is performed without injecting any antigen. In this method, vaccines contain antibodies obtained from the blood of an actively immunized human being or animal. The antibodies last for two to three weeks, and during that time the person is protected against the disease. Although short-lived, passive immunization provides immediate protection, unlike active immunization, which can take weeks to develop. Consequently, passive immunization can be lifesaving when a person has been infected with a deadly organism.

Occasionally there are complications associated with passive immunization. Diseases such as botulism and rabies once posed a particular problem. Immunoglobulin (antibody-containing plasma) for these diseases was once derived from the blood serum of horses. Although this animal material was specially treated before administration to humans, serious allergic reactions were common. Today, human-derived immune globulin is more widely available and the risk of side effects is reduced.

Active Immunization:

        Vaccines that provide active immunization are made in a variety of ways, depending on the type of disease and the organism that causes it. The active components of the vaccinations are antigens, substances found in the disease-causing organism that the immune system recognizes as foreign. In response to the antigen, the immune system develops either antibodies or white blood cells called T lymphocytes, which are special attacker cells. Immunization mimics real infection but presents little or no risk to the recipient. Some immunizing agents provide complete protection against a disease for life. Other agents provide partial protection, meaning that the immunized person can contract the disease, but in a less severe form. These vaccines are usually considered risky for people who have a damaged immune system, such as those infected with the virus that causes acquired immunodeficiency syndrome (AIDS) or those receiving chemotherapy for cancer or organ transplantation.  Without a healthy defense system to fight infection, these people may develop the disease that the vaccine is trying to prevent. Some immunizing agents require repeated inoculations—or booster shots—at specific intervals.
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ISCOMS (immune stimulatory complexes):

Some plant materials have been evaluated, including the soap-like saponins from Quilaja saponaria and the highly purified Quil A extract obtained from saponins which induce the production of cytokines. In common with all saponins these materials have hemolytic activity that limits their direct use in humans although it is used in veterinary medicine. However, combination of Quil A with cholesterol, phospholipids, and antigens forms a human-compatible adjuvant called immunostimulatory complexes (ISCOMs). ISCOMs have an interesting range of adjuvantactivities resulting in an increased Th1 response.

Hypothetical transport route(s) across the intestinal epithelium of antigens incorporated into ISCOMs or delivered with ISCOMATRIX.

•   Uptake and transport of ISCOMs by M cells in the Peyer’s patches;
•   Uptake and intracellular transport of ISCOMs by enterocytes;
•   Paracellular transport of antigen as a result of surfactant-like effects of ISCOMATRIX on the epithelial integrity.

• ISCOMs are 40 nm large particles made up of saponins (Quil A), lipids, cholesterol and antigen, held together by hydrophobic interactions between the first three components.

• Cholesterol is the ligand that binds to saponin forming 12 nm rings.

• These rings are fixed together by lipids to form the spherical nanoparticles. Hydrophobic or amphipathic antigens can be incorporated into this complex.

• They are versatile and flexible delivery systems with increased efficiency of antigen presentation to B cells and uptake by the APC. vaccines are potent inducer of both humoral and cellular (CD4+ and CD8+ T-cell) immune responses.

• The use of saponins in ISCOMs-based vaccines retains the adjuvant activity of the saponin component but with a reduced toxicity.

• The ISCOMATRIX adjuvant is identical to ISCOMs except that it does not contain antigen. This adjuvant can be mixed with antigens and has some of the advantages of ISCOMs such as the preferential targeting of antigen to APC.
• However, the response obtained differed from that of ISCOMs vaccination in that the ISCOMATRIX induced a Th2-like response, whereas the ISCOMs-based vaccine induced a mixed Th1/Th2 response.

Action of ISCOMs

ISCOMs (immune stimulatory complexes) are lipid micelles that will fuse with cell membranes. Peptides trapped in ISCOMs can be delivered to the cytosol of an antigenpresenting cell (APC), allowing the peptide to be transported into the endoplasmic reticulum, where it can be bound by newly synthesized MHC class I molecules and hence transported to the cell surface as peptide:MHC class I complexes. This is a possible means for delivering vaccine peptides to activate CD8 cytotoxic T cells. ISCOMs can also be used to deliver proteins to the cytosol of other types of cell, where they can be processed and presented as though they were a protein produced by the cell.

Liposomes:

• Liposomes are synthetic spheres comprised by lipid bilayers that can encapsulate antigens and act as both a vaccine delivery vehicle and adjuvant.

• The potency of liposomes depends on the number of lipid layers, electric charge, composition and method of preparation

• Depot formation at the site of injection and efficient presentation of antigens to macrophages.

• Both humoral and cell-mediated immune responses have been elicited by liposomes.

• Immunostimulators such as LPS and MDP when encapsulated within liposomes show enhanced adjuvanticity with reduced side effects.

• However, phospholipid liposomes have certain limitations such as sensitivity to host phospholipases, instability on storage, high cost of manufacture and difficulty in scale up of production.

• To overcome these problems non-phospholipid liposomes are developed. These non-phospholipid liposome vesicles, composed of   dioxyethylenecetyl ether, cholesterol and oleic acid, were evaluated with human vaccine antigens (tetanus and diphtheria toxoids) in rabbits and mice.

• Tetanus and diphtheria toxoids encapsulated in or mixed with  these liposomes elicited antitoxin levels similar to those elicited by antigens given with FCA or adsorbed onto aluminum adjuvants.

• Recent results have suggested that, by choosing lipid components for liposomes, surface-coupled liposomal antigens might be applicable for the development of tumor vaccines to present tumor antigens to antigen-presenting cells (APC) and induce antitumor responses.
• Liposomes have been used to deliver vaccines and have been observed to have immunostimulant activity. When administered orally liposomes with encapsulated antigens have been claimed to provide protection from the gastric proteolytic enzymes. Liposomes also have potential as mucosal delivery systems since not only are they immunogenic in their own right but physical association of the antigen with the liposomal structure is not a requirement for intranasal immunostimulation.
• Simple mixtures of liposomes with other agents such as chitosan have potential for nasal delivery and have facilitated enhanced responses to vaccines administered orally.
• Cochleate systems consisting of calcium-precipitated protein–phospholipids complexes are stable solid sheets that roll up into a spiral with no internal aqueous space, and the calcium ions bridge adjacent sheets. Oral administration of vaccines in cochlear delivery systems has been shown to induce strong long-lasting circulation and mucosal antibody responses with long-term immunological memory to influenza glycoproteins.

Virosomes:

Another type of liposomes, referred to as virosomes, contain a membrane bound hemagglutinin and neuraminidase derived from influenza virus, and serve to amplify fusogenic activity and therefore facilitate the uptake into APCs and induce a natural antigen-processing pathway.

Virosomes are viral glycoproteins encapsulated in lipid vesicles, which have been shown to be effective as experimental vaccines delivered by both mucosal and systemic routes.

 Viruses and their surface glycoproteins have a high affinity for receptors on mucosal surfaces, especially along the respiratory tract.

EXAMPLE:-

IRIV – contains (Haemaglutinin from influenza virus) which intercalates in to phospholipid bilayer & acts to stabilize liposomal base preventing fusion with the liposome.

• Immune potentiation of IRIV is due to HA1 (SUBUNIT) which binds to sialic acid residues (which are present on the surface of macrophages & other immune competent cells, finally resulting in endocytic uptake.
• Upon exposure to low (p^H=5)- The HA2 SUBUNIT undergoes conformational change exposing the fusogenic peptide resulting in the fusion of IRIV  and endosomal membrane

Alternative therapies (i.e. alternative to licensed products of proven quality, safety and efficacy) span a huge range from frank charlatanry (e.g. products based on unscientific postulates, composed of diluent or of snake oil), through physical therapies such as massage and aroma therapies which certainly please (‘placebo’ means ‘I will please’) and do a great deal less harm than some conventional therapies (e.g. surgery, chemotherapy), through to herbal medications with undoubted pharmacological activity and the potential to cause desired or adverse effects, albeit less predictably than the licensed products that have been derived from them in the past and will no doubt be so derived in the future. Medicine takes an empirical, evidence-based view of therapeutics and, if supported by sufficiently convincing evidence, alternative therapies can enter the mainstream of licensed products. Overall, efforts to test homeopathic products have been negative (Ernst, 2002) and it has been argued that no more resource should be wasted on testing products on the lunatic fringe, even when they come with royal endorsement and (disgracefully) public funding. Here we focus on herbal and nutraceutical products that may cause pharmacological effects.

Herbal remedies include dietary supplements (any product other than tobacco intended for ingestion as a supplement to the diet, including vitamins, minerals, anti-oxidants – Chapter 35 – and herbal products), phytomedicines (the use of plants or plants components to achieve a therapeutic effect/outcome) and botanical medicines (botanical supplements used as medicine). The recent increase in the use of herbal remedies by normal healthy humans, as well as patients, is likely to be multifactorial and related to:

(1) patient dissatisfaction with conventional medicine;

(2) patient desire to take more control of their medical treatment; and

(3) philosophical/cultural bias. In the USA, approximately one-third of the population used some form of complementary or alternative medicine (the majority consuming herbal products) in the past 12 months. At a clinical therapeutic level, it is disconcerting that 15–20 million Americans regularly take herbal remedies, while concomitantly receiving modern prescription drugs, implying a significant risk for herb–drug interactions. In Scotland, some 12% of general practitioners and 60% of general practices prescribe homeopathic medicines! Herbal remedies are particularly used by certain groups of patients, notably HIV and cancer patients. The stereotypical user is a well-educated, career professional, white female. From a therapeutic perspective, many concerns arise from the easy and widespread availability, lack of manufacturing or regulatory oversight, potential adulteration and contamination of these herbal products. Furthermore, there is often little or no rigorous clinical trial evidence for efficacy and only anecdotes about toxicity. Many patients who are highly attuned to potential harms of conventional drugs (such as digoxin, a high quality drug derived historically from extracts of dried foxglove of variable quality and potency) fail to recognize that current herbals have as great or greater potential toxicities, often putting their faith in the ‘naturalness’ of the herbal product as an assurance of safety.

Most commonly used herbal products as Alternative Medicine

Garlic Allium sativum Hyperlipidaemia– hypercholesterolaemia

Ginkgo Ginkgo biloba Dementia and claudication

Echinacea Echinacea purpurea Prevention of common cold

Soy Glycine max Symptoms of menopause

Saw palmetto Serenoa repens Prostatic hypertrophy

Ginseng Panax ginseng Fatigue

St John’s wort Hypericum perforatum Depression (mild)

Black cohosh Actaea racemosa Menopausal symptoms

Cranberry Vaccinia macrocarpon Cystitis and UTI

Valerian Valeriana officinalis Stress and sleeplessness

Milk thistle Silybum marianum Hepatitis and cirrhosis

Evening primrose Oenothera biennis Premenstrual symptoms

Bilberry Vaccinia myrtillus Diabetic retinopathy

Grape seed

Conclusion

Warnings about the toxicity of herbal products such as kava kava (hepatotoxicity), aristocholic acid (nephrotoxicity) and phen phen (pulmonary hypertension) have recently been communicated to prescribers and the public. PC-SPES, which was used by many prostate cancer patients because of anecdotal and uncontrolled studies of evidence of activity in prostate cancer, was withdrawn from sale by its suppliers after the FDA found it contained alprazolam and phytoestrogens.

What is Clinical pharmacy?

Clinical pharmacy comprises a set of functions that promote the safe, effective and economic use of medicines for
individual patients.
• The emergence of clinical pharmacy has allowed pharmacists to shift from a product-oriented role towards direct engagement with patients and the problems they encounter
with medicines.
• The practice of clinical pharmacy is generally an essential component of pharmaceutical care.

Explain Pharmaceutical Care & its key elements?

Pharmaceutical care is a co-operative, patient-centred system for achieving specific and positive patient outcomes from the responsible provision of medicines.
The three key elements of the care process are patient assessment, determining the care plan and evaluating the outcome.The ability to consult with patients is a key process in the delivery of pharmaceutical care and requires regular review and development regardless
of experience.

Why clinical pharmacy is incorporated?

The clinical pharmacy process has been incorporated into a professional development framework that can be used to enhance skills and knowledge.

Mnemonics used in the pharmacy consultation process
WWHAM
Who is it for?
What are the symptoms?
How long has it been going on?
Action taken?
Medicines taken?
AS METTHOD
Age of the patient?
Self or for someone else?
Medicines being taken?

Exactly what do you mean (by the symptom)?
Time and duration of the symptom
Taken any action (medicine or seen the doctor)?
History of any disease?
Other symptoms?
Doing anything to alleviate or worsen the symptom?
ENCORE
Evaluate the symptom, its onset, recurrence and duration.
No medication is always an option.
Care when dealing with specific patient groups, notably the elderly, the young, nursing mothers, pregnant women, those receiving specific medication such as methotrexate and anticoagulants, and those with particular disease, for example, renal impairment.
Observe the patient for signs of systemic disturbance and ask about presence of fever, loss of weight and any accompanying physiological disturbance.
Refer when in doubt.
Explain any course of action recommended.

What are the effective communication behaviours ?

For effective consultation, the practitioner also needs to draw upon a range of communication behaviours

Consultation behaviours
Active listening
Appropriate use of open and closed questions
Respect patient
Avoid jargon
Demonstrate empathy
Deal sensitively with potentially embarrassing or sensitive issues