introduction lecture about responding to symptoms in the community pharmacy

1. Responding to symptoms
in
Community phaRmaCy
Dr. : Siham Gafer Altayib
B.pharm. Khartoum University
MSc. Community pharmacy
Queen’s University Belfast

2. CouRse objeCtives :
1- To outline structured approach to responding to
symptoms
2- To enable the student to identify common minor
illnesses that can be treated in the pharmacy.

3. 3.To enable the student to identify major diseases
that should be referred to the doctor.
4.To equip the student with the necessary skills and
knowledge to manage minor ailments presenting in
the pharmacy.

4. Impact of pharmacy on patient care
In the United Kingdom, the Pharmacy identified five main
areas in which pharmacy makes major contributions
to health outcomes:

5. 1 Management of prescribed medicines:
– dispensing of medicine
– counseling
2 Management of chronic conditions:
– repeat prescribing
– monitoring therapeutic outcomes
– improvement in quality of life

6. 3 Management of common ailments:
– counseling
– recommendation of line of action
4 Promotion and support of healthy
lifestyles:
– health education
– health screening

7. 5 Advice and support for other healthcare
professionals:
– provision of information on clinical and technical
aspects of use of medicines
– participation in research and development programs
to transfer science into practice

8. Why
the
phaRmaCist ?

9. Community pharmacists are the health professionals
most accessible to the public.
They supply medicines in accordance with a
prescription or, when legally permitted,
dispense them without a prescription.
In addition to ensuring an accurate supply of
appropriate products,

10. their professional activities also cover:
1- counseling of patients at the time of dispensing of
prescription and non-prescription drugs
2- drug information to health professionals, patients
and the general public
3- and participation in health promotion
programs.
They maintain links with other health professionals in
primary health care.

11. Responding to
symptoms
in
Community phaRmaCy

12. Responding to symptoms is a major activity for the
community pharmacist.
Pharmacist receives every day loads and loads of requests
for advice about symptoms and the pharmacist supervises
a much greater number of over the counter (OTC) medicine
sales.
This role has always been important for the community
pharmacist.

13. • It was argued that in many cases pharmacists were not
asking enough or appropriate questions and therefore had
insufficient information to advice optimally the patient
about their symptoms.
.

14. • It was also criticized that the pharmacists do not
employ a safe and structured approach when
responding to patients’ symptoms and they fail to
differentiate between a symptom that might
suggest a more serious pathology or one which
can be easily managed with an OTC product.

15. For all these reasons, guidelines were issued
outlining a structured approach when dealing
with a patient requesting advice on symptoms.
It is essential for all pharmacists to be familiar
with these guidelines.

16. Approaches to differential diagnosis:
Acronyms :
This is a traditional way developed for
the community pharmacist to help them
remember what questions to ask to the
patient

17. In a busy pharmacy, interruptions may interfere with
dialogue between pharmacist and patient and the use of a
mnemonic to remind the pharmacists of the critical steps
involved in assessing the clinical significance of symptoms is
helpful.
• Use of a mnemonic will minimize the risk of missing
important information about the patient’s condition.

18. • There are three such methods which have been
suggested.
􀁮 AS METHOD
􀁮 WHAM
􀁮 ENCORE

19. 1 WHAM :
The WHAM mnemonic was developed mainly for
use by counter assistants when responding to
symptoms.
It is shorter than the other techniques. The basis
of this mnemonic is:

20. W Who is the patient and what are the symptoms?
H How long have the symptoms been present?
A Action taken: what medicines have been tried?
M Medicines being taken for other problems?

21. Advantages :-
Establishes presenting compliant
Disadvantages :-
1- fails to consider general appearance of the
patient
2- no social life style factors taken into account
3- no family history
4- no history of previous symptoms

22. 2 ASMETHOD :-
The AS METHOD mnemonic identifies some of the main
questions which should be asked of each patient requesting
advice on symptoms. AS METTHOD translates as:
D Danger symptoms (which require referral to the doctor)?

23. A Age of the patient?
S Self or for someone else?
M Medicines the patient is taking?
E Extra medicines tried for the current symptoms?
T Time or duration of the symptoms?
T Taken anything for it or seen the doctor?
H History of any disease or condition?
O Other symptoms being experienced?

24. Advantages :-
establishes the nature of the problem & if the patient
has suffered from previous similar episodes
Disadvantages :
1- exact symptoms and severity not fully established
2- no social / life style factors taken into account
3- no family history

25. 3/ ENCORE :
ENCORE was developed as a structured approach to responding to
symptoms, in response to perceived shortcomings of community
pharmacists in this area of activity.
-Deficiencies highlighted by several surveys have included:
- Inadequate knowledge about specific therapies and products
- Suboptimal exploration with the patient of the symptoms
- Insufficient attention given to drug-drug interactions
- Omission of advice about referral to other experts when justified
- Generally insufficient communication with the patient.

26. 2ENCORE :
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain

27. Advantages :
“ Observe “ section suggests taking into account the
appearance of the patient , does he or she looks poorly
Disadvantages :
1- section (no medication ) or ( refer ) add little to the
differential diagnosis process
2- no social / life style factors taken into account
3- no family history

28. The most popular Structured approach to responding to
symptoms is ENCORE :
Explore
Nature of symptoms
Obtain identity of patient
Concurrent medication or treatment
Exclude possibility of serious disease
Other associated symptoms

29. No medication
Remember that in many instances
medication is not necessary
Care
Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women

30. Observe
Other tell tail signs
Demeanor of patient
Dramatization by patient
Refer Potentially serious cases
Persistent symptoms
Patient at increase risk
Explain
Discus with the patient why a
particular course of action is
suggested

31. E XPLORE
A)Nature of symptoms
The exact nature & site of the symptoms will often need clarification.
Dyspepsia and indigestion are used by patients to explain diverse non-
specific complaints.
Establishing the exact site of the gastric pain or discomfort would be
important.
1- Pain in the region of the abdomen just below the sternum usually
indicates that its origin is the upper elements of the GIT (oesophagus,
stomach and upper small intestine).

32. 2- A burning pain in this region radiating towards the throat
would be indicative of oesophagus.
3- “Sharp” may indicate a precisely-located pain, originating
from a gastric or peptic ulcer.
4- “Burning” may refer to gastric or oesophagitis.
5- Symptoms felt in the central region of the abdomen are
indicative of a condition further down the gut such as
gastro-enteritis and constipation

33. B) Obtain identity of patient
• It is always necessary to establish who the request is for. Assuming
the person asking for advice is the person suffering the symptoms is
not always correct.
For example, a wife may be requesting advice on a symptom which her
husband is experiencing, or vice versa. Although their ages are similar,
the symptoms of gastritis would be of greater concern in a male since
he will have a greater chance of suffering from coronary heart disease
than his wife. Conversely, gallstones conditions.
• Parents or grandparents will report the symptoms on behalf of a child.
It is important to be aware of this if a medicine is to be recommended,
since many preparations are contraindicated in children.

34. C) Concurrent Medication
• It is essential to establish if the patient is taking any medicines, whether
prescribed by a doctor or purchased OTC.
• There are four obvious reasons for this:
1- A medicine may be causing the symptoms
2- A medicine may indicate a disease state which could have a bearing on
management
3- The patient may already be taking a medicine the pharmacist is about to
recommend and which is not providing relief.
4- Medications that are recommended may interact with existing treatment.

35. D) Exclude possibility of a serious disease
Knowing if the patient has a history of disease may give important information.
Obese patients tend to suffer more frequently from gastritis than non-obese
people. This is often due to physical pressure on the stomach.
Large meals can cause symptoms due to the physical distension of the stomach.
Hiatus hernia is a condition in which the lower oesophagus or part of the stomach
slides through the diaphragm. This situation leads to more reflux of gastric acid.

36. E) Other Associated symptoms
• Other symptoms being experienced can help in the verification or
rejection of a ‘working diagnosis’.
• An ‘upset stomach’ may be a complex array of symptoms which
include: epigastric discomfort, pain, bloating, belching, feeling of
fullness, heartburn and nausea.
It may also be associated with vomiting but care must be taken in such
situations where vomiting is present since this may indicate a blockage
or, if the vomit is found to contain blood; it might indicate a bleeding
ulcer. Both of these conditions would require referral.

37. • The severity of pain must be established. Pain which
awakens the patient out of sleep is indicative of peptic ulcer
for example.
• Discomfort on swallowing food or drinks may be
experienced in gastritis. When a real difficulty in
swallowing (dysphagia) is experienced, the patient must
be referred to the doctor. This may indicate a physical
blockage due to carcinoma or due to the production of
scar tissue from repeated gastric reflux.

38. • Loss of weight in someone suffering from an ‘upset stomach’ must be
concerned as it may indicate carcinoma or bleeding ulcer.
Blood produced from bleeding ulcer can lead to the production of ‘tarry’ stool
which is difficult to pass.
• The aggravation of symptoms when bending down or on some sudden
physical exertion is usually indicative of dyspepsia.
Lying down allows acid to enter the oesophagus and aggravate the symptoms
which is why patients are sometimes recommended to raise the head of the bed.
•

39. The severity of pain must be established. Pain which awakens the patient
out of sleep is indicative of peptic ulcer for example.
• Discomfort on swallowing food or drinks may be experienced in gastritis.
When a real difficulty in swallowing (dysphagia) is experienced, the patient
must be referred to the doctor. This may indicate a physical blockage due to
carcinoma or due to the production of scar tissue from repeated gastric
reflux.

40. N O MEDICATION
If over indulgence of specific foods or alcohol can be identified as a possible
cause, then advice to avoid them may be all that is necessary.
C ARE
Special Care Group
Certain groups of patients, because of their vulnerability to the complications
of disease or their susceptibility to adverse drug reactions, will require special
consideration before a management strategy is decided. The four main groups
are:

41. The four main groups are:
1.The Geriatric Patient
They suffer from many more diseases than younger people and
therefore receive more medication than other groups of patients.
85 %of the elderly suffer from at least one chronic condition and the
average number of drugs taken by an elderly patient is 3.2.

42. • It is not unusual to see some elderly patient receiving 10 to 12 preparations
and consequently the risk of adverse drug reactions is very much greater
in the elderly.
• Pharmacist should always be aware that prescribing an OTC without
proper consideration of the patient’s current medication could worsen the
condition through drug interaction.
• The aging CNS makes elderly more susceptible to the effect of some
drugs and the physiological changes in various organs reduce the
excretion of drugs from the body

43. 2. The Paediatric Patients
Very young children, especially those in their first months of life are particularly
susceptible to the complications of what in older children would be regarded
as ‘minor condition’.
Neonates have a larger surface area to volume ratio compared to older
children and adults and are for example, at particular risk of dehydration from
diarrhoea.
.

44. Additionally, all children differ from adults in their response to
medicines.
Pharmacist will have difficulties in obtaining accurate information
about the symptoms since this will often be imparted by parents on the
children’s behalf, and often in their absence.
The assessment will be very subjective, reflecting the parents’ anxiety
or alternatively a lack of appreciation of the severity of the condition

45. 3. The Pregnant Patients
All drugs can potentially have an effect on the foetus during pregnancy.
In the first three months of gestation the risk of malformation being
highest from week three to week 11.
During the second and third trimesters, the effects of drugs tends to
be on growth and functional development of the foetus.

46. Drugs taken just before term or during labour can have an effect on the
neonate after delivery.
Many women do take medicines during pregnancy as the condition is often
associated with frequent symptoms.
The pharmacist should inform the patient that there is a lack of information on
the effect of most OTC medicines in pregnancy.
Certain medicines are known to cause definite adverse effects and therefore
should be avoided.

47. 4. Lactating Mothers
All mothers are being actively encouraged to breast-feed their babies.
Toxicity can occur in the infant if drugs are excreted in the breast milk.
Drugs which appear in milk in significant amounts to cause effect include
Aspirin, sedating antihistamines, caffeine, iodides, phenolphthalein and vitamin
A. Products containing these drugs, therefore, should be avoided in breast-
feeding mother.

48. O BSERVE
• A very important rule when dealing with patients presenting with
symptoms is to observe their general appearance. ‘Does the patient
look ill?’. This is the most valuable physical sign.
• A patient who is suffering from a bleeding peptic ulcer will look much
more ill than a patient who is suffering from simple dyspepsia.

49. • Non-verbal dramatisation, such as facial grimacing or the beating of a
clenched fist onto the area where discomfort or pain is being experienced, can
give useful information.
For example, a clenched fist beat onto an area indicates a sharp pain, whereas a
flattened hand rubbed around a general area would indicate discomfort.

50. R EFER
Potentially serious cases such as patients with peptic ulcer disease
(associated with pain) and gastric malignancy
(associated with anorexia) should be referred to a doctor. Tarry stools
may be seen in both conditions.

51. Recurrent and persistent symptoms require referral to the doctor.
Generally, if a symptom has lasted more than 10-14 days, the patient will
require referral.This recommendation will not apply in every case.
Someone suspected to be suffering from a heart condition should be
referred immediately. On the other hand, a patient who is under constant
supervision of a doctor will not need further referral unless there is a clear
condition deterioration.
Patients over the age of 40 are at increased risk of both peptic ulcer disease
and malignancy.

52. Example :
My daughter has diarrhea . Can you recommend something
I can give her ?
further information :
2 years old ,has diarrhea for one day – 4 bowel
movement in past 24 hours ( once a day is normal for
her ) . Stools are so loose but not liquid . No change in
diet at home but went to a party yesterday and don’t
Know what she ate there .

53. Explore :
( nature of symptoms , other associated symptoms , concurrent
medication and treatment , exclude possibility of serious disease )
-Determine how old is the patient
-How bad the diarrhea
-How long it has lasted
-What treatment had been tried
-The appearance of the stool
-If any one else in the family has been affected

54. No medication :
Except for rehydration , no medication is required
Antidiarrheal are contraindicated in infants
Exclude use of laxative
Care :
-As 2 years old dehydration is a real risk and a rehydration fluid
should be recommended particularly if elasticity of the skin
appears abnormally low
-Children under 3 years required referral if the condition
continues for more than 2 days

55. Observe and refer :
-A child who is very drowsy
-Diarrhea ( 3-4 motions ) with vomiting
-Diarrhea with fever may be serious
-Any sign of blood or bile
-persistent-,low grade diarrhea may accompany
amebic or giardial infection

56. Explain :
-Explain why oral rehydration (ORT) is the best treatment
-Why referral is advised
-In particular stress the need to seek medical help if the
condition persist
-ORT sachets should be made up with the correct volume of
water and once reconstituted , must be stored in the fridge and
drunk with in 24 hours

57. Thank
yOu