Post on 14-Apr-2017
Responding to Symptoms in
Community pharmacy
Dr Siham Gafer Altayib Bpharm Khartoum University
MSc Community pharmacyQueenrsquos University Belfast
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
3To enable the student to identify major diseases that should be referred to the doctor
4To equip the student with the necessary skills and knowledge to manage minor ailments presenting in the pharmacy
Impact of pharmacy on patient care
In the United Kingdom the Pharmacy identified five mainareas in which pharmacy makes major contributionsto health outcomes
1 Management of prescribed medicines
ndash dispensing of medicinendash counseling
2 Management of chronic conditions
ndash repeat prescribingndash monitoring therapeutic outcomesndash improvement in quality of life
3 Management of common ailments
ndash counselingndash recommendation of line of action
4 Promotion and support of healthy lifestyles
ndash health educationndash health screening
5 Advice and support for other healthcare professionals
ndash provision of information on clinical and technical aspects of use of medicinesndash participation in research and development programs to transfer science into practice
Why
the
pharmacist
Community pharmacists are the health professionals most accessible to the public
They supply medicines in accordance with a prescription or when legally permitteddispense them without a prescription
In addition to ensuring an accurate supply ofappropriate products
their professional activities also cover
1- counseling of patients at the time of dispensing of prescription and non-prescription drugs2- drug information to health professionals patients and the general public3- and participation in health promotionprograms
They maintain links with other health professionals in primary health care
Responding To symptoms
in community pharmacy
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
bull 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
bull It was also criticized that the pharmacists do not employ a safe and structured approach when responding to patientsrsquo 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
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
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
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
bull Use of a mnemonic will minimize the risk of missing important information about the patientrsquos condition
bull There are three such methods which have been suggested
1048686 AS METHOD 1048686 WHAM 1048686 ENCORE
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
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
Advantages -
Establishes presenting compliant
Disadvantages -
1- fails to consider general appearance of the patient 2- no social life style factors taken into account3- no family history 4- no history of previous symptoms
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)
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
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
3To enable the student to identify major diseases that should be referred to the doctor
4To equip the student with the necessary skills and knowledge to manage minor ailments presenting in the pharmacy
Impact of pharmacy on patient care
In the United Kingdom the Pharmacy identified five mainareas in which pharmacy makes major contributionsto health outcomes
1 Management of prescribed medicines
ndash dispensing of medicinendash counseling
2 Management of chronic conditions
ndash repeat prescribingndash monitoring therapeutic outcomesndash improvement in quality of life
3 Management of common ailments
ndash counselingndash recommendation of line of action
4 Promotion and support of healthy lifestyles
ndash health educationndash health screening
5 Advice and support for other healthcare professionals
ndash provision of information on clinical and technical aspects of use of medicinesndash participation in research and development programs to transfer science into practice
Why
the
pharmacist
Community pharmacists are the health professionals most accessible to the public
They supply medicines in accordance with a prescription or when legally permitteddispense them without a prescription
In addition to ensuring an accurate supply ofappropriate products
their professional activities also cover
1- counseling of patients at the time of dispensing of prescription and non-prescription drugs2- drug information to health professionals patients and the general public3- and participation in health promotionprograms
They maintain links with other health professionals in primary health care
Responding To symptoms
in community pharmacy
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
bull 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
bull It was also criticized that the pharmacists do not employ a safe and structured approach when responding to patientsrsquo 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
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
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
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
bull Use of a mnemonic will minimize the risk of missing important information about the patientrsquos condition
bull There are three such methods which have been suggested
1048686 AS METHOD 1048686 WHAM 1048686 ENCORE
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
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
Advantages -
Establishes presenting compliant
Disadvantages -
1- fails to consider general appearance of the patient 2- no social life style factors taken into account3- no family history 4- no history of previous symptoms
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)
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
3To enable the student to identify major diseases that should be referred to the doctor
4To equip the student with the necessary skills and knowledge to manage minor ailments presenting in the pharmacy
Impact of pharmacy on patient care
In the United Kingdom the Pharmacy identified five mainareas in which pharmacy makes major contributionsto health outcomes
1 Management of prescribed medicines
ndash dispensing of medicinendash counseling
2 Management of chronic conditions
ndash repeat prescribingndash monitoring therapeutic outcomesndash improvement in quality of life
3 Management of common ailments
ndash counselingndash recommendation of line of action
4 Promotion and support of healthy lifestyles
ndash health educationndash health screening
5 Advice and support for other healthcare professionals
ndash provision of information on clinical and technical aspects of use of medicinesndash participation in research and development programs to transfer science into practice
Why
the
pharmacist
Community pharmacists are the health professionals most accessible to the public
They supply medicines in accordance with a prescription or when legally permitteddispense them without a prescription
In addition to ensuring an accurate supply ofappropriate products
their professional activities also cover
1- counseling of patients at the time of dispensing of prescription and non-prescription drugs2- drug information to health professionals patients and the general public3- and participation in health promotionprograms
They maintain links with other health professionals in primary health care
Responding To symptoms
in community pharmacy
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
bull 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
bull It was also criticized that the pharmacists do not employ a safe and structured approach when responding to patientsrsquo 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
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
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
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
bull Use of a mnemonic will minimize the risk of missing important information about the patientrsquos condition
bull There are three such methods which have been suggested
1048686 AS METHOD 1048686 WHAM 1048686 ENCORE
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
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
Advantages -
Establishes presenting compliant
Disadvantages -
1- fails to consider general appearance of the patient 2- no social life style factors taken into account3- no family history 4- no history of previous symptoms
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)
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
Impact of pharmacy on patient care
In the United Kingdom the Pharmacy identified five mainareas in which pharmacy makes major contributionsto health outcomes
1 Management of prescribed medicines
ndash dispensing of medicinendash counseling
2 Management of chronic conditions
ndash repeat prescribingndash monitoring therapeutic outcomesndash improvement in quality of life
3 Management of common ailments
ndash counselingndash recommendation of line of action
4 Promotion and support of healthy lifestyles
ndash health educationndash health screening
5 Advice and support for other healthcare professionals
ndash provision of information on clinical and technical aspects of use of medicinesndash participation in research and development programs to transfer science into practice
Why
the
pharmacist
Community pharmacists are the health professionals most accessible to the public
They supply medicines in accordance with a prescription or when legally permitteddispense them without a prescription
In addition to ensuring an accurate supply ofappropriate products
their professional activities also cover
1- counseling of patients at the time of dispensing of prescription and non-prescription drugs2- drug information to health professionals patients and the general public3- and participation in health promotionprograms
They maintain links with other health professionals in primary health care
Responding To symptoms
in community pharmacy
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
bull 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
bull It was also criticized that the pharmacists do not employ a safe and structured approach when responding to patientsrsquo 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
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
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
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
bull Use of a mnemonic will minimize the risk of missing important information about the patientrsquos condition
bull There are three such methods which have been suggested
1048686 AS METHOD 1048686 WHAM 1048686 ENCORE
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
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
Advantages -
Establishes presenting compliant
Disadvantages -
1- fails to consider general appearance of the patient 2- no social life style factors taken into account3- no family history 4- no history of previous symptoms
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)
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
1 Management of prescribed medicines
ndash dispensing of medicinendash counseling
2 Management of chronic conditions
ndash repeat prescribingndash monitoring therapeutic outcomesndash improvement in quality of life
3 Management of common ailments
ndash counselingndash recommendation of line of action
4 Promotion and support of healthy lifestyles
ndash health educationndash health screening
5 Advice and support for other healthcare professionals
ndash provision of information on clinical and technical aspects of use of medicinesndash participation in research and development programs to transfer science into practice
Why
the
pharmacist
Community pharmacists are the health professionals most accessible to the public
They supply medicines in accordance with a prescription or when legally permitteddispense them without a prescription
In addition to ensuring an accurate supply ofappropriate products
their professional activities also cover
1- counseling of patients at the time of dispensing of prescription and non-prescription drugs2- drug information to health professionals patients and the general public3- and participation in health promotionprograms
They maintain links with other health professionals in primary health care
Responding To symptoms
in community pharmacy
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
bull 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
bull It was also criticized that the pharmacists do not employ a safe and structured approach when responding to patientsrsquo 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
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
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
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
bull Use of a mnemonic will minimize the risk of missing important information about the patientrsquos condition
bull There are three such methods which have been suggested
1048686 AS METHOD 1048686 WHAM 1048686 ENCORE
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
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
Advantages -
Establishes presenting compliant
Disadvantages -
1- fails to consider general appearance of the patient 2- no social life style factors taken into account3- no family history 4- no history of previous symptoms
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)
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
3 Management of common ailments
ndash counselingndash recommendation of line of action
4 Promotion and support of healthy lifestyles
ndash health educationndash health screening
5 Advice and support for other healthcare professionals
ndash provision of information on clinical and technical aspects of use of medicinesndash participation in research and development programs to transfer science into practice
Why
the
pharmacist
Community pharmacists are the health professionals most accessible to the public
They supply medicines in accordance with a prescription or when legally permitteddispense them without a prescription
In addition to ensuring an accurate supply ofappropriate products
their professional activities also cover
1- counseling of patients at the time of dispensing of prescription and non-prescription drugs2- drug information to health professionals patients and the general public3- and participation in health promotionprograms
They maintain links with other health professionals in primary health care
Responding To symptoms
in community pharmacy
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
bull 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
bull It was also criticized that the pharmacists do not employ a safe and structured approach when responding to patientsrsquo 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
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
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
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
bull Use of a mnemonic will minimize the risk of missing important information about the patientrsquos condition
bull There are three such methods which have been suggested
1048686 AS METHOD 1048686 WHAM 1048686 ENCORE
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
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
Advantages -
Establishes presenting compliant
Disadvantages -
1- fails to consider general appearance of the patient 2- no social life style factors taken into account3- no family history 4- no history of previous symptoms
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)
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
5 Advice and support for other healthcare professionals
ndash provision of information on clinical and technical aspects of use of medicinesndash participation in research and development programs to transfer science into practice
Why
the
pharmacist
Community pharmacists are the health professionals most accessible to the public
They supply medicines in accordance with a prescription or when legally permitteddispense them without a prescription
In addition to ensuring an accurate supply ofappropriate products
their professional activities also cover
1- counseling of patients at the time of dispensing of prescription and non-prescription drugs2- drug information to health professionals patients and the general public3- and participation in health promotionprograms
They maintain links with other health professionals in primary health care
Responding To symptoms
in community pharmacy
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
bull 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
bull It was also criticized that the pharmacists do not employ a safe and structured approach when responding to patientsrsquo 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
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
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
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
bull Use of a mnemonic will minimize the risk of missing important information about the patientrsquos condition
bull There are three such methods which have been suggested
1048686 AS METHOD 1048686 WHAM 1048686 ENCORE
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
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
Advantages -
Establishes presenting compliant
Disadvantages -
1- fails to consider general appearance of the patient 2- no social life style factors taken into account3- no family history 4- no history of previous symptoms
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)
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
Why
the
pharmacist
Community pharmacists are the health professionals most accessible to the public
They supply medicines in accordance with a prescription or when legally permitteddispense them without a prescription
In addition to ensuring an accurate supply ofappropriate products
their professional activities also cover
1- counseling of patients at the time of dispensing of prescription and non-prescription drugs2- drug information to health professionals patients and the general public3- and participation in health promotionprograms
They maintain links with other health professionals in primary health care
Responding To symptoms
in community pharmacy
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
bull 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
bull It was also criticized that the pharmacists do not employ a safe and structured approach when responding to patientsrsquo 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
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
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
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
bull Use of a mnemonic will minimize the risk of missing important information about the patientrsquos condition
bull There are three such methods which have been suggested
1048686 AS METHOD 1048686 WHAM 1048686 ENCORE
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
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
Advantages -
Establishes presenting compliant
Disadvantages -
1- fails to consider general appearance of the patient 2- no social life style factors taken into account3- no family history 4- no history of previous symptoms
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)
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
Community pharmacists are the health professionals most accessible to the public
They supply medicines in accordance with a prescription or when legally permitteddispense them without a prescription
In addition to ensuring an accurate supply ofappropriate products
their professional activities also cover
1- counseling of patients at the time of dispensing of prescription and non-prescription drugs2- drug information to health professionals patients and the general public3- and participation in health promotionprograms
They maintain links with other health professionals in primary health care
Responding To symptoms
in community pharmacy
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
bull 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
bull It was also criticized that the pharmacists do not employ a safe and structured approach when responding to patientsrsquo 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
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
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
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
bull Use of a mnemonic will minimize the risk of missing important information about the patientrsquos condition
bull There are three such methods which have been suggested
1048686 AS METHOD 1048686 WHAM 1048686 ENCORE
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
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
Advantages -
Establishes presenting compliant
Disadvantages -
1- fails to consider general appearance of the patient 2- no social life style factors taken into account3- no family history 4- no history of previous symptoms
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)
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
their professional activities also cover
1- counseling of patients at the time of dispensing of prescription and non-prescription drugs2- drug information to health professionals patients and the general public3- and participation in health promotionprograms
They maintain links with other health professionals in primary health care
Responding To symptoms
in community pharmacy
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
bull 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
bull It was also criticized that the pharmacists do not employ a safe and structured approach when responding to patientsrsquo 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
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
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
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
bull Use of a mnemonic will minimize the risk of missing important information about the patientrsquos condition
bull There are three such methods which have been suggested
1048686 AS METHOD 1048686 WHAM 1048686 ENCORE
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
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
Advantages -
Establishes presenting compliant
Disadvantages -
1- fails to consider general appearance of the patient 2- no social life style factors taken into account3- no family history 4- no history of previous symptoms
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)
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
Responding To symptoms
in community pharmacy
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
bull 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
bull It was also criticized that the pharmacists do not employ a safe and structured approach when responding to patientsrsquo 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
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
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
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
bull Use of a mnemonic will minimize the risk of missing important information about the patientrsquos condition
bull There are three such methods which have been suggested
1048686 AS METHOD 1048686 WHAM 1048686 ENCORE
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
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
Advantages -
Establishes presenting compliant
Disadvantages -
1- fails to consider general appearance of the patient 2- no social life style factors taken into account3- no family history 4- no history of previous symptoms
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)
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
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
bull 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
bull It was also criticized that the pharmacists do not employ a safe and structured approach when responding to patientsrsquo 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
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
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
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
bull Use of a mnemonic will minimize the risk of missing important information about the patientrsquos condition
bull There are three such methods which have been suggested
1048686 AS METHOD 1048686 WHAM 1048686 ENCORE
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
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
Advantages -
Establishes presenting compliant
Disadvantages -
1- fails to consider general appearance of the patient 2- no social life style factors taken into account3- no family history 4- no history of previous symptoms
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)
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
bull 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
bull It was also criticized that the pharmacists do not employ a safe and structured approach when responding to patientsrsquo 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
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
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
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
bull Use of a mnemonic will minimize the risk of missing important information about the patientrsquos condition
bull There are three such methods which have been suggested
1048686 AS METHOD 1048686 WHAM 1048686 ENCORE
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
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
Advantages -
Establishes presenting compliant
Disadvantages -
1- fails to consider general appearance of the patient 2- no social life style factors taken into account3- no family history 4- no history of previous symptoms
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)
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
bull It was also criticized that the pharmacists do not employ a safe and structured approach when responding to patientsrsquo 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
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
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
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
bull Use of a mnemonic will minimize the risk of missing important information about the patientrsquos condition
bull There are three such methods which have been suggested
1048686 AS METHOD 1048686 WHAM 1048686 ENCORE
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
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
Advantages -
Establishes presenting compliant
Disadvantages -
1- fails to consider general appearance of the patient 2- no social life style factors taken into account3- no family history 4- no history of previous symptoms
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)
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
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
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
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
bull Use of a mnemonic will minimize the risk of missing important information about the patientrsquos condition
bull There are three such methods which have been suggested
1048686 AS METHOD 1048686 WHAM 1048686 ENCORE
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
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
Advantages -
Establishes presenting compliant
Disadvantages -
1- fails to consider general appearance of the patient 2- no social life style factors taken into account3- no family history 4- no history of previous symptoms
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)
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
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
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
bull Use of a mnemonic will minimize the risk of missing important information about the patientrsquos condition
bull There are three such methods which have been suggested
1048686 AS METHOD 1048686 WHAM 1048686 ENCORE
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
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
Advantages -
Establishes presenting compliant
Disadvantages -
1- fails to consider general appearance of the patient 2- no social life style factors taken into account3- no family history 4- no history of previous symptoms
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)
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
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
bull Use of a mnemonic will minimize the risk of missing important information about the patientrsquos condition
bull There are three such methods which have been suggested
1048686 AS METHOD 1048686 WHAM 1048686 ENCORE
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
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
Advantages -
Establishes presenting compliant
Disadvantages -
1- fails to consider general appearance of the patient 2- no social life style factors taken into account3- no family history 4- no history of previous symptoms
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)
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
bull There are three such methods which have been suggested
1048686 AS METHOD 1048686 WHAM 1048686 ENCORE
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
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
Advantages -
Establishes presenting compliant
Disadvantages -
1- fails to consider general appearance of the patient 2- no social life style factors taken into account3- no family history 4- no history of previous symptoms
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)
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
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
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
Advantages -
Establishes presenting compliant
Disadvantages -
1- fails to consider general appearance of the patient 2- no social life style factors taken into account3- no family history 4- no history of previous symptoms
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)
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
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
Advantages -
Establishes presenting compliant
Disadvantages -
1- fails to consider general appearance of the patient 2- no social life style factors taken into account3- no family history 4- no history of previous symptoms
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)
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
Advantages -
Establishes presenting compliant
Disadvantages -
1- fails to consider general appearance of the patient 2- no social life style factors taken into account3- no family history 4- no history of previous symptoms
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)
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
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)
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
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
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
Advantages -establishes the nature of the problem amp 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
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
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
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
2 ENCORE
Letter meaning of the letter
E Explore
N No medication
C Care
O Observe
R Refer
E Explain
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
Advantages ldquo Observe ldquo 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
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
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
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
No medication Remember that in many
instances medication is not necessary
Care Geriatric patient
Pediatric patient
Lactating mothers
Pregnant women
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
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
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
E XPLORE
A)Nature of symptoms
The exact nature amp 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)
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
2- A burning pain in this region radiating towards the throat would be indicative of oesophagus
3- ldquoSharprdquo may indicate a precisely-located pain originating from a gastric or peptic ulcer
4- ldquoBurningrdquo 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
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
B) Obtain identity of patient
bull 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
bull 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
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
C) Concurrent Medication
bull It is essential to establish if the patient is taking any medicines whether prescribed by a doctor or purchased OTC
bull 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
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
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
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
E) Other Associated symptoms bull Other symptoms being experienced can help in the verification or rejection of a lsquoworking diagnosisrsquo
bull An lsquoupset stomachrsquo 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
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
bull The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
bull Loss of weight in someone suffering from an lsquoupset stomachrsquo must be concerned as it may indicate carcinoma or bleeding ulcer Blood produced from bleeding ulcer can lead to the production of lsquotarryrsquo stool which is difficult to pass
bull 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
bull
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
The severity of pain must be established Pain which awakens the patient out of sleep is indicative of peptic ulcer for example
bull 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
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
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
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
The four main groups are
1The 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 32
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
bull 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
bull Pharmacist should always be aware that prescribing an OTC without proper consideration of the patientrsquos current medication could worsen the condition through drug interaction bull 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
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
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 lsquominor conditionrsquo
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
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
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 childrenrsquos behalf and often in their absence
The assessment will be very subjective reflecting the parentsrsquo anxiety or alternatively a lack of appreciation of the severity of the condition
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
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
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
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
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
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
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
O BSERVE bull A very important rule when dealing with patients presenting with symptoms is to observe their general appearance lsquoDoes the patient look illrsquo This is the most valuable physical sign
bull A patient who is suffering from a bleeding peptic ulcer will look much more ill than a patient who is suffering from simple dyspepsia
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
bull 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
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
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
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
Recurrent and persistent symptoms require referral to the doctor Generally if a symptom has lasted more than 10-14 days the patient will require referralThis 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
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
Example My daughter has diarrhea Can you recommend something I can give her
further information 2 years old has diarrhea for one day ndash 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 donrsquot Know what she ate there
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
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
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
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
Thank you
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
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
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
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
Thank you
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
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
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
Thank you
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
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
Thank you
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
Thank you
Thank you