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Chapter Twenty-Two
Prescribing for minor ailments
Paul Rutter
22
STUDY POINTS
*
The growth of self-care and the increased access
to medicines
*
The key skills required to arrive at a working
diffential diagnosis for a minor ailment
*
Getting information from patients who present at
the pharmacy with symptoms or conditions
*
Techniques to make questioning more effective
and how to pick up on non-verbal cues
*
Full assessment of patient’s symptoms in order to
provide treatment and/or advice for minor ailments
Introduction
The community pharmacist plays an essential role in
providing patient care. In most western countries, a
network of pharmacies allows patients easy and direct
access to a pharmacist without an appointment. Without pharmacists, general medical services would be
unable to cope with patient demand. In effect, pharmacists perform a vital triage role for doctors by filtering those patients who can be managed with
appropriate advice and medicines and referring cases
which require further investigation. This has been a
central role of community pharmacists for many decades, but over the last 20 years the role has taken on
greater significance as there has been a shift in global
healthcare policy to empower patients to exercise
self-care. For pharmacists to safely, effectively and
competently manage minor ailments requires considerable knowledge and skill. It involves having the underpinning knowledge on diseases and their clinical
signs and symptoms, the ability to apply this knowledge to an individual patient and use problem solving
to arrive at a working differential diagnosis. This has to
be combined with good interpersonal skills such as
picking up on non-verbal cues, asking appropriate
questions and articulating clearly any advice which is
given. This chapter attempts to provide the contextual framework behind the growing prominence of
the pharmacist in managing minor ailments and the
key skills required to maximize performance.
The concept and growth of self-care
The concept of self-care is not new. People have always treated themselves for common illnesses and
pharmacists have always provided an avenue for people to practise self-care. Self-care does not mean individuals are left on their own and means more than just
looking after themselves. It includes all the decisions
and actions people take in respect of their health and
covers recognizing symptoms, when to seek advice,
treating the illness and making lifestyle changes to
prevent ill health. The expertise and support provided
by healthcare professionals, such as pharmacists, is
crucial to making self-care work. The profile of selfcare has dramatically increased in recent years and is
largely government driven, consumer fueled and professionally supported.
Government policy
The creation of national healthcare schemes, such as
the NHS has encouraged the general population to
become more reliant on institutional bodies to look
SECTION THREE Pharmacy prescribing and selection of medicines
after their health. This has led to increased demand on
services provided by these bodies, including the management of minor illness. For example, more than one
in three GP consultations are for minor illnesses and
an estimated 20–40% of GP time could be saved if
patients exercised self-care. Similar findings have
been recorded for patients attending hospital emergency departments. This dependence by patients on
bodies such as the NHS has led to government policies which encourage and facilitate self-care. In the
UK, the government agenda for modernizing the
NHS was spelled out in its White Paper The NHS
Plan (2000). Within this document the government
made its intention clear to make self-care an important part of NHS health care. It stated that the front
line of health care was in the home. Since that time
the government has published numerous papers detailing why and how maximizing self-care can be
achieved. The prominence placed on this government
strategy is evidenced by the Department of Health
having a dedicated website on self-care (http://www.
dh.gov.uk/en/Policyandguidance/Organisationpolicy/
Selfcare/index.htm). Included in these policy docu-
ments are specific papers looking at the role of pharmacy (e.g. A Vision for Pharmacy in the New NHS,
2003; Choosing Health through Pharmacy, 2005). It is
clear that UK government policy centres on patient
empowerment and utilizing all healthcare professionals to encourage patient self-care.
this can be achieved by encouraging patients to practise self-care themselves or by making better use of
other healthcare professionals’ skills.
NHS walk-in centres and
telephone help lines
The UK government has been proactive in facilitating
self-care, most obviously by the formation of NHS
walk-in centres and the telephone help lines NHS
Direct (England and Wales) and NHS 24 (Scotland).
The aim of walk-in centres is to improve access to
health care that supports other local NHS providers.
The service is nurse led but some employ doctors
to work at particular times. The first NHS walk-in
centre opened in 2000 and there are now approximately 90 operating in England. The Department of
Health states that over 5 million people have used a
walk-in centre with the main users being young
adults. NHS Direct, launched in March 1998, has
seen remarkable government investment and rapid
and widespread expansion. It is a 24-hour nurse led
service that receives over 500 000 calls per month.
Although originally designed as a telephone help line
service, NHS Direct now also offers an online service
and direct interactive digital TV plus the publication
of its self-help guide.
Widening access to self-care
The guiding principle of NHS modernization is to
provide services that are best suited to the needs
and convenience of patients. With regard to self-care,
Table 22.1 Chronological history charting prescription only medicine (POM) to pharmacy (P) and P to general sales list (GSL) deregulation
Year POM to P Examples P to GSL Examples
1983 3 Oral ibuprofen 0
Loperamide
Terfenadine
1984–86 0 0
1987 3 Hydrocortisone 0
1988 2 0
1989 2 0
220
1
Deregulation of medicines
Less obvious, but arguably more important, has been
the expansion of medicines available without prescription (Table 22.1). This has direct impact on
Continued over
Prescribing for minor ailments CHAPTER 22
Table 22.1 (Continued )
1990 0 0
1991 2 Nicotine gum 0
1992 8 Vaginal imidazoles 0
Nicotine patches
1993 5 0
1994 17 H
1995 7 2 Oral ibuprofen
1996 3 2 Clotrimazole
1997 3 8 Loperamide
1998 5 3
1999 3 2 Nicotine gum
2000 4 Terbinafine 2 Famotidine
2001 5 Emergency hormonal contraceptives 5
2002 2 0
2003 1 5 Minoxidil
2004 3 Omeprazole 3 Terbinafine
2005 2 Chloramphenicol 3
2006 2 Sumatriptan 1
antagonists 2 Effervescent aspirin and lidocaine
2
Minoxidil
Beclometasone nasal spray
Prochlorperazine
Beclometasone nasal spray
Simvastatin
Amorolfine
Total 82 38
2007 5 5
2008 3 7
1
Terfenadine reverted back to POM control in 1997 following serious adverse events in America and was subsequently withdrawn by the
manufacturers.
community pharmacists and represents one of the
major ways in which pharmacy can contribute to
self-care. Widening access to medicines previously
only available via prescription supply is a global phenomenon and not unique to the UK.
The switching of prescription only medicines
(POMs) to pharmacy (P) status is now well established. Loperamide and ibuprofen were the first
POMs to be switched in 1983. The rate of POM to
P deregulation after the initial two switches was slow,
with only nine medicines deregulated between 1984
and 1991 (see Table 22.1). This was in part due to the
bureaucratic process in place at the Medicines Control Agency (MCA; now known as the Medicines and
Healthcare products Regulatory Authority, MHRA).
In 1992 the MCA changed the process by which
221
SECTION THREE Pharmacy prescribing and selection of medicines
medicines were deregulated. Under the new system,
changes to the product’s legal status could be made
without requiring amendments to the POM Order,
thus speeding up the process. This change was effective, with no fewer than 30 medicines being deregulated over the next 3 years.
Further streamlining took place in 2002 to encourage manufacturers to switch medicines from both
POM to P and P to general sales list (GSL). At approximately the same time, the White Paper Building
on the Best (2003) set a target of 10 medicine
switches each year (both POM to P and P to GSL)
which was endorsed in The NHS Improvement Plan
(2004). Between 1983 and 2008, over 80 POM to
P and 40 P to GSL switches were made, although,
the target of 10 switches per year from 2004 has yet
to be met.
More recent POM to P switches have seen new
therapeutic classes deregulated (e.g. proton pump
inhibitors, triptans) and further deregulation of medicines from different therapeutic areas seems likely.
The profession has played its part in this process, with
the Royal Pharmaceutical Society of Great Britain
(RPSGB) producing a consultation document on future candidates for POM to P switching (2002), some
of which are now deregulated or being considered
(e.g. tranexamic acid in 2007). Perhaps the largest
area for future growth of deregulation centres
on chronic disease management. Government policy
toward self-care now embraces both acute and
chronic illness (Supporting People with Long Term
Conditions to Self Care: A Guide to Developing
Local Strategies and Good Practice, 2006) and in
2004, the deregulation of simvastatin paved the
way for further medicines to be available to manage
chronic illness. This now enables UK consumers to
purchase a medicine which government agencies
have declared too low a priority to fund on the
NHS (coronary heart disease risk of 10–15% over
10 years). This move therefore puts the emphasis
squarely on the shoulders of the consumers to decide for themselves whether they want to initiate
primary prevention.
Medical opinion on deregulation
Medical opinion is important in non-prescription
use of medicines by patie nts. Doctors may advise
patients to take them, pre scribe them or dissuade
their patients f ro m using them. Relatively few studies have been conducted over the period of deregulation in the UK to ascertain GPs’ attitudes to wards
themoveforgreateraccesstopreviouslyPOMs.
Around th e time of the first deregulated POM,
loperamide, M orley et al (1983) found GPs were
generally against potential switches. Not until
1992 was further work published on GPs’ attitudes to deregulation of medicines. Spencer &
Edwards asked respondents their opinion on pharmacists managing 14 conditions treated at the time
with POM medicines. Mixed results were found,
ranging from the majority of doctors (87%) in agreement for pharmacists to use co-dydramol for toothache to almost no support (11%) for cimetidine to
be given for dyspepsia. Erwin et al in 1996 a nd
Bayliss et al in 2004 repeated the same questions.
Over this 20 year period there is evidence that the
attitudes of British GPs towards greater availability
of medicines have become more positive. Bayliss
et al hypothesized that this change in attitude is in
part due to the length of time a product has been
available without prescription and is supported by a
1999 Finnish study that found doctors were moderately positive, but more reserved towards those
drugs only recently given over the counter (OTC)
status. Results from all studies, except Bayliss et al,
only considered acute conditions. When GPs were
asked about management of chronic conditions,
their opinions were strongly a gainst such a move,
yet opposition to the management of chr onic illness
might lessen in time, as it has with acute conditions.
Minor ailment schemes (MAS)
One barrier to patient self-care is the NHS system
itself. Over 85% of prescriptions dispensed are exempt from the prescription charge (NHS statistics
2004). Therefore patients entitled to free prescriptions are likely to seek a doctor when they have minor
illness, as any prescription issued will be free of charge
in contrast to purchasing potentially the same product
from the pharmacy. In response to this, a scheme
dubbed ‘Care at the Chemist’ was established in Merseyside in 1999. It involved eight pharmacies and one
GP practice and allowed patients free access to medicines through the pharmacy to treat 12 self-limiting
conditions. Of the 1522 patients who used the
scheme, only 21 patients were referred back to the
GP. A 30% reduction in GP workload was observed
for the 12 conditions included in the scheme. The
scheme was subsequently replicated elsewhere and
similar findings were observed. Consequently, the
government called for widening participation of
222
Prescribing for minor ailments CHAPTER 22
MAS, and the new pharmacy contract for England
and Wales has seen MAS incorporated into the enhanced service specification and in Scotland it is included as a core service. MAS are designed to meet
the needs of the local patient population. Consequently, different models exist throughout the country although many bear much similarity to the ‘Care
at the Chemist’ scheme. However, there are some
primary care trusts and health authorities that now
use a common scheme and there is growing support
for a national scheme to be implemented in England.
In some schemes, patient group directions (PGD)
have been incorporated to allow pharmacists to
prescribe POMs to treat conditions such as urinary
tract infections and impetigo. A useful resource is
the National Prescribing Centre (NPC) website
(http://www.npc.co.uk/mms/SIGs/minor_ailments/
#HELP).
The public’s view on self-care
and access to deregulated
medicines
The public’s attitude toward self-care and its actual
actions are contradictory. A King’s Fund study (2004)
found that almost 90% of respondents believed they
were responsible for their own health and a Mintel
report (2004) found that 8 out of 10 people said they
had to be ‘really ill’ to visit a doctor. However, it is
estimated that upwards of 40% of GP time is spent
dealing with patients who present with minor illness
and only 25% of people who suffer minor illness selftreat with a purchased non-prescription medicine. It
appears then that the government’s message on promoting self-care is understood by people but is not
being translated into action. Of some comfort to the
government are findings from 2003 and 2004 Mintel
lifestyle surveys that show increasing numbers of people consulting a pharmacist while the number of GP
consultations is slowly falling. These latter studies cite
convenience as a major contributory factor to pharmacy consultation rather than waiting for a GP
appointment. However, patient attitudes over being
questioned before medicines are sold are seen as a
barrier. A study by Morris (1997) found most consumers had a degree of awareness of why pharmacy staff
might require information but almost two-thirds had
expected to make their most recent purchase without
being questioned. Cantrill et al (1997) also found that
pharmacists reported more than 10% of consumers
unwilling to answer questions.
It appears that some sectors of the public are unhappy to be questioned by pharmacy staff. This group
poses difficulty for pharmacy staff but asking questions ensures responsible purchasing of OTC medicines by consumers. There is also a small body of
research both in the UK and USA that indicates that
the public regards OTC medicines as inherently
‘weaker’ than prescription medicines. OTC status in
itself may lead to a perception that the medicine
cannot be harmful. For example, 40% of people in a
US study believed that OTC medicines were ‘too
weak to cause any real harm’ (Roumie & Griffin
2004). That doses of medicines switched from
POM to P may be lower than those used on prescription is likely to reinforce such beliefs and could influence why people believe that they should not be
questioned.
Getting information from the patient
As healthcare professionals, community pharmacists
are in a unique position. Patients have free and easy
access to their advice. Not only do patients take advantage of this but they value it. Surveys have shown
that the general public believes pharmacists to be
one of the most trusted occupations. It is important
that the faith the general public has in pharmacists
is maintained and enhanced. Ensuring that you are
competent to handle minor ailments is one way to
do this. The following steps highlight the key considerations you should think about when someone asks
for your advice about a particular symptom or condition they have.
First impressions
It is said that you never get a second chance to make a
first impression. When we meet somebody for the
first time we make assumptions about that person.
We often put people into categories and the assumptions lead to expectations of their behaviour, jobs and
character. This initial judgment of a person is often
based purely on what we see and hear and includes
appearance, dress, age, gender, race and physical
disabilities. It is important that we are aware of these
assumptions in order to avoid stereotyping people. For
example, the impression we have of a person wearing
a denim jacket may be very different from our impression of the same person wearing a suit. As you get
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SECTION THREE Pharmacy prescribing and selection of medicines
to know a person better, initial impressions are either
reinforced or discarded, but in the context of dealing
with patients who want advice about minor illness,
this could be the first and last time you see them. This
first impression works both ways and pharmacists
who create a friendly approachable impression are
more likely to find patients receptive to what they say.
From the perspective of deciding what the
patient’s problem is, this ‘first impression’ can be very
helpful in giving you clues to their state of health.
Assessment of the patient begins the moment the
patient enters the pharmacy. Most pharmacists will
probably do this at a subconscious level but what is
important is to bring this to the conscious level and
build it into your consultations. Many visual clues will
be apparent if they are actively looked for. How old
are they? Many conditions are age-related and this will
help narrow down the number of conditions that need
to be differentiated from one another. What is their
physical appearance? Is the patient overweight or
showing signs of being a smoker? Are there any signs
of confusion, pain or systemic illness? For example,
does the patient look well or poorly? For people who
appear in discomfort or look visibly poorly, this might
influence your decision to treat or refer – they might
have a self-limiting condition such as viral cough
but have marked systemic upset which necessitates
referral. How did the person present to the pharmacy
counter? Did they walk over in a normal manner or
did they appear nervous, shy or reluctant? It might
mean that the person who appeared nervous wants
advice but is embarrassed to ask or they are intimidated by the environment and atmosphere. These
‘cues’ can be picked up by the pharmacist and appropriate action taken to make the person more at ease.
The key is to observe your patient. Take time to assess
what they look like, how they move and how they
behave. This initial assessment will provide useful
information which shapes your thinking and actions
and is the first step to reaching a differential diagnosis.
Questioning
Arriving at a diagnosis is a complex process. In medicine it is based on three kinds of information: patient
history; physical examination; and the results of investigations. Currently, physical examination and using
diagnostic tests are rarely used in community pharmacy practice. Pharmacists rely almost exclusively on
questioning patients when deciding whether to offer
treatment or perhaps refer the patient for further
evaluation. Studies have shown that an accurate patient history (gained from asking questions alone) is a
powerful diagnostic tool. Supplementary examinations and diagnostic testing do improve the odds of
reaching a correct diagnosis, but only by 10–15%.
The pharmacist’s diagnosis will, in many cases, be a
differential one; the signs and symptoms are suggestive of a particular condition but it is difficult with
absolute certainty to label the exact cause. For example, someone who presents with acute cough is likely
to have a viral self-limiting cough but it could possibly
be bacterial in origin. Advice and treatment might
well be the same but an exact diagnosis cannot be
made. Of course, in certain circumstances this can
be done, for example head lice, eczema caused by a
watchstrap or psoriasis on a knee, etc.
The ability to ask good questions to gain the appropriate information is therefore critical. The type of
question and the way in which it is asked will dictate
the level of response given.
Use of open and closed questions
There are two main types of questions: open and
closed. A closed question is one which is direct and
close-ended. It requires the respondent to give a single
word reply such as ‘yes’ or ‘no’. They can be very
useful when asking for specific information or to test
understanding. Examples of closed questions are:
*
Are you taking any medicines from the doctor?
*
Have you ever had this rash before?
*
Do you suffer from hay fever?
*
Have you changed your washing powder?
*
Is the pain worse in the mornings?
Open questions are open ended and allow people to
respond in their own way. They do not set any ‘limits’
and generally allow the person to provide more detailed information. Open questions encourage elaboration and help people expand on what they have
started to say. Examples of open questions include:
*
Describe your symptoms to me.
*
Tell me where the pain is.
*
How do you relieve the symptoms of headache?
*
What do you do when that sensation occurs?
The above examples show that open questions are
often built around words like ‘what’ and ‘ how’ and
generally allow an element of ‘feeling’ to be introduced by the patient in the reply. Open-ended questions are not without their problems. Some patients
when asked an open-ended question will launch into a
detailed explanation of their symptoms and it can be
224
Prescribing for minor ailments CHAPTER 22
difficult to pick up on the important information that
is mixed in with irrelevant facts. This can be timeconsuming, which can make pharmacists reluctant to
use open questions.
Choosing the correct type of question can prove to
be difficult, particularly in a busy pharmacy where
other patients are waiting for prescriptions or advice.
It is tempting to ask a number of closed questions
which will provide information, albeit limited to what
can be gleaned from one word answers. However, this
could result in the patient being ‘bombarded’ with
many questions and make them feel as if they have
been through an interrogation. Pharmacists must
learn to develop good questioning skills to enable
them to build up an accurate picture of the patient’s
condition. In most consultations a mixture of closed
and open questions will be needed. It also allows
patients time to elaborate certain points and builds
their confidence in the pharmacist.
As previously mentioned, how patients react to
being asked questions in the pharmacy has been subject to some research. Findings have shown that some
people feel it is not the legitimate business of pharmacy staff to ask what they may view as ‘personal’
questions about why the medicine is needed. It is
therefore important to ensure that those people
who are less responsive to being asked questions
are dealt with in an appropriate way. This is usually
done by explaining why questions have to be asked
and using non-verbal communication. Position, posture and eye contact are important to give a relaxed,
open appearance. Avoid using a counter or desk as a
barrier or getting too close and invading a patient’s
‘intimate zone’ (see later).
Drawing together information
It is important that pharmacists are sensitive to the
needs of their patients when asking questions. If the
patient indicates they wish to speak privately or you
notice they appear uncomfortable, then every effort
should be made to provide a quiet area for conversation. With the new community pharmacy contract
now in place, most pharmacies have consultation
rooms which provide areas for this purpose. The pharmacist must tailor their questioning strategy to each
patient. It is also important that each question is asked
with a purpose. There is little point asking a question
if nothing is done with the answer. A number of
techniques have been advocated to maximize information gathering from patients. These include the use
of acronyms, the funnelling technique and clinical
reasoning.
Acronyms
Acronyms have been developed to help pharmacists
remember which questions should be asked.
WWHAM (Who is the patient? What are the symptoms? How long have the symptoms been present?
Action taken? Medication being taken?) is the best
known and simplest acronym to remember and has
been advocated by many as a useful tool in gaining
information from patients. Other acronyms have been
subsequently developed and include ENCORE,
ASMETHOD and SIT DOWN SIR. The difficulty
with using acronyms is that they are rigid and inflexible – a ‘one size fits all’ approach. In addition, there is
a tendency to ask questions for no reason – it is part of
the acronym so the question has to be asked even
though there might be no relevance or underpinning
reasoning for asking the question. This is especially
true of WWHAM, and because it is simple to remember it also means it provides the least information.
Other acronyms do provide more information but
because they are longer they become almost impossible to remember. Acronyms can be helpful in gaining
some information from the patient but pharmacists
should not rely solely on them. Each patient is different and it is unlikely that an acronym can be fully
applied, and more importantly, it might miss vital
information.
Current prescription workload and staff skill mix
in most pharmacies makes pharmacist intervention in
requests for advice or product selection impossible
on every occassion. Up to 75% of patients are first
seen by a counter assistant. The standardization of
their questioning by using an acronym via a standard
operating procedure (SOP) might be appropriate to
ensure basic information is obtained from all patients.
The funnelling technique
A funnelling technique can be used to allow direction
and focusing of ideas on a specific topic. This involves
initially asking background open questions to provide
basic information, then asking specific closed questions to provide specific detail and clarify points. In
these circumstances, it can be useful to paraphrase
comments made, to ensure that the understanding
of the information being obtained from the patient
is accurate. This checking procedure allows the
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SECTION THREE Pharmacy prescribing and selection of medicines
pharmacist to check understanding and minimizes
misinterpretation. It is possible during any one conversation to use more than one ‘funnel’, e.g. establishing a patient’s current medical condition, then going
on to suggest appropriate action or medication available. In a pharmacy setting, where time can be a
limiting factor, using the funnelling technique can be
useful for directing and focusing a conversation to
enable an end point to be achieved more quickly.
Clinical reasoning
Clinical reasoning relates to the decision-making processes associated with clinical practice. It originates
from medicine in determining the best way physicians
solve diagnostic problems. It is a thinking process directed towards enabling the practitioner to take appropriate action in a specific context. Based on these
principles, the encounter with a patient in a community
pharmacy is no different. It fundamentally differs from
using acronyms or the funnel approach in that it is built
around clinical knowledge and skills which are applied
to the individual patient. Various models have been
used to explain the process and include hypotheticodeductive reasoning and pattern recognition.
Hypothetico-deductive reasoning
This is a process in which a number of hypotheses are
generated which are then used to guide subsequent
information retrieval from the patient. Each hypothesis can be used to predict what additional findings
ought to be present if it were true. Very early in a
clinical encounter and based on limited information,
practitioners will arrive at a small number of hypotheses. The practitioner then sets about testing these
hypotheses by asking the patient a series of questions.
The answer to each question then allows the practitioner to narrow down the possible diagnosis by either
eliminating particular conditions or confirming their
suspicions. Hypothesis generation and testing involves
both inductive (moving from a set of specific observations to a generalization) or deductive reasoning (moving from a generalization to a conclusion in relation to
a specific case). Therefore, induction is used to generate hypotheses and deduction to test hypotheses.
Pattern recognition
Pattern recognition relies more on inductive processes
than deduction. For example, take a newly qualified
pharmacist and a very experienced pharmacist who
has been qualified 25 years. If they both see the same
patient with the same problem, they both might arrive
at the same conclusion, but how this was achieved will
probably be different. This is because not all cases
seen by more experienced practitioners will require
applying a hypothetico-deductive model. For example, impetigo has a very characteristic appearance.
Once a pharmacist has seen a case of impetigo, it is
a relatively straightforward task to diagnose the next
case by recalling the appearance of the rash. Therefore
much of daily practice will consist of seeing new cases
that strongly resemble previous encounters. For this
reason, expert reasoning in non-problematic situations tends to be drawn from pattern recognition from
previous stored knowledge and clinical experience.
Whether we are conscious of it or not, most people
will use a combination of hypothetico-deduction and
pattern recognition when dealing with patients. Neither model provides an error-proof strategy and error
rates of up to 15%, especially in difficult cases in
internal medicine, have been reported in the medical
literature. However, these models of ‘responding to
symptoms’ are more likely to gain the correct diagnosis compared to using acronyms and the funnel method because acronyms and the funnel method tend to
just gather information without having a hypothesis in
mind. Example 22.1 highlights the clinical reasoning
approach.
A furtherhypothesis to test in Example 22.1 would
now be sputum production. Knowledge of the conditions listed indicates that postnasal drip, allergy and
medication are not associated with sputum production. As these are the three conditions which we have
doubts over from the first question, it seems a good
follow-up question to ask if the patient is producing
sputum; if so, then these three conditions can be
eliminated.
The patient tells you that there is a bit of phlegm
but they haven’t really looked at the colour. This now
means you are left with six possibilities. To differentiate between them, further distinguishing questions
need to be asked. Some chronic cough conditions
tend to show periodicity during the day, either being
better or worse in the morning or evening. From our
remaining conditions we know that generally:
*
Chronic bronchitis is worse in the morning
*
Asthma is worse in the evening
*
Bronchiectasis is worse in the morning and evening
*
Tuberculosis shows no variation
*
Cancer shows no variation
*
Nocardiosis shows no variation.
226
Example 22.1
A man in his early sixties (slightly overweight) wants
something for his cough.
Step 1: Visual clues: age, sex and overweight
Step 2: Conditions to consider
Based on epidemiology, the most likely cause of cough in
any age patient is viral infection, yet many other conditions
can cause cough. These can be categorized by their
prevalence within the population and give the pharmacist
clues to the magnitude of likeliness that the person will
have that condition and should be borne in mind during
consultation.
Likely Postnasal drip, allergies, acute bronchitis
Unlikely Croup, chronic bronchitis, asthma,
pneumonia, angiotensin converting enzyme
inhibitor
Very unlikely Heart failure, bronchiectasis, tuberculosis,
cancer, pneumothorax, lung abscess, nocardiosis
In this case our patient is approximately 60 years old so
certain conditions can be eliminated (e.g. croup) and
others are less likely (e.g. pneumothorax tends to occur in
young people, heart failure and lung abscess tend to occur
in the elderly). This leaves a possible 12 conditions which
Prescribing for minor ailments CHAPTER 22
could present to the community pharmacy which have
cough as the primary symptom.
Step 3: Formation of hypotheses
The initial question needs to narrow down the number of
conditions that must be considered. A number of questions
are relatively discriminatory, such as duration of cough,
sputum production and presence of systemic symptoms. If
we take duration (he has had the cough for 4 or 5 weeks)
then this should eliminate acute causes of cough (up to 3
weeks’ duration) and leaves us with a list of nine
possibilities, although three of these, post-nasal drip,
allergy and medication, can be either acute or chronic:
*
Chronic bronchitis
*
Asthma
*
Bronchiectasis
*
Tuberculosis
*
Cancer
*
Nocardiosis
*
Postnasal drip?
*
Allergy?
*
Medication?
Our patient says that the cough is always worse after
getting up in the morning. This therefore tends to
point to a diagnosis of chronic bronchitis. Obviously,
the diagnosis is very tentative and we can now ask
supplementary questions (generally closed questions)
which should support the differential diagnosis. For
example, our hypothesis would be that the person is a
smoker or ex-smoker; we would expect them not to
have any marked systemic symptoms; and we would
expect that the person has a history of repeated episodes of cough. These confirmatory questions should
be all positive and support our initial suspicions. If the
patient responds in a different way to that which we
anticipated then the differential diagnosis would need
to be revised and hypotheses reconstructed to establish the cause of the cough. In this example the patient
has to be referred.
This example illustrates the principle of hypotheticodeductive reasoning and the process behind it. In this
instance,ifanacronym,forexampleWWHAM,was
used, the same outcome of referral would have been
reached, as the ‘H’ question – how long have symptoms
been present? – would have alerted the pharmacist to
the chronic nature of the cough (all pharmacy text
books on this area recommend referral for chronic
cough). However, the information gained would have
been superficial, which would not give you an idea of its
cause and it would also ask irrelevant questions, such as
who it was for (we already knew) and what medication
they had tried.
For pharmacists, pattern recognition does play a
part in shaping the above process but if the outcome
is referral then clinical experience with the condition
can be limited. Unless the patient returns or you
follow up the case with the doctor, it is rare that
pharmacists get feedback on the outcome of the referral. This therefore means that clinical experience
of that symptom or condition is not consolidated by
being given feedback on the diagnosis. Unfortunately,
this means that if similar cases present again then
pattern recognition can be used, but the level of
knowledge remains at the same level as the outcome
is always referral. Pharmacists should try to find out
the outcome of referrals so that clinical experience
increases and pattern recognition is improved.
Physical examination
Within the confines of a community pharmacy the
type and extent of physical examination that can be
performed is naturally limited and the majority
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SECTION THREE Pharmacy prescribing and selection of medicines
of pharmacists will have received no formal training
on how to conduct physical assessment. Examples of
physical assessments that are suitable within the pharmacy include eye and ear examinations, assessment of
skin disease and general inspection of the oral cavity.
These examinations require little training but will
improve the odds of making a correct diagnosis. This
is one area where pattern recognition is very important – for example looking at a person’s skin rash will
always be better than getting an explanation from the
patient.
Picking up on non-verbal cues
The meaning of what a person says is made up of
several component parts. These are the words which
are spoken, the tone of voice used, the speed and
volume of speech, the intonation and a whole range
of body postures and movements. It is generally
agreed that in any communication the actual words
convey only about 10% of the message. This is called
verbal communication. The other 90% is transmitted
by non-verbal communication which consists of body
language (about 50%) and how it is said (about 40%).
might move their hand over a larger area (e.g. irritable
bowel syndrome).
Gestures are also useful for the pharmacist to use
as they can emphasize or reinforce a point or describe
a particular procedure. However, it is important not
to overuse them, as this can detract from the spoken
word and become a distraction to the listener. Do
some ‘people watching’. It is amazing how much information about people you can pick up just by quietly observing their gestures.
Facial expression
Facial expressions are a very important part of communication. Facial expression says a lot about mood
and emotion, with the eyes and the mouth giving the
dominant signs. As well as ensuring that facial expression is encouraging and welcoming, it is important for
pharmacists to be able to read the meaning of facial
expressions. In this way important points regarding a
patient’s level of comprehension or receptiveness can
be judged.
Eye contact
Body language
Body language can be broken down into several component parts which include gestures, facial expression, eye contact, physical contact, body posture
and personal space. It is the combination of all these
components which gives the overall impression. It is
important to ensure that they are all compatible. If a
mixture of messages is portrayed it will cause confusion to observers.
Gestures
Hand gestures in particular are useful when emphasizing a point or to help to describe something. Used
appropriately, they can greatly enhance communication and improve understanding. Observing the
patient’s gestures can give useful information on
how concerned they might be or where the problem
is. For example, someone presenting with abdominal
pain might say they have stomach ache but point to
the lower abdomen. In these cases, the non-verbal
hand clue is much more informative than the spoken
word. Also the person might point to a specific region,
as the pain is very localized (e.g. appendicitis), or they
Avoiding eye contact is a very successful way of avoiding communication. This can be very well illustrated
by observing a class of students who have just been
asked a question by a lecturer!
The maintenance of eye contact during a conversation is vital to ensure the continuation of the process, because it indicates interest in the subject and is
also useful as a means of determining whose turn it is
to speak. However, care must be taken. Holding eye
contact for too long can be off-putting and will reduce
the success of the communication. Anyone who
has been stared at will know how uncomfortable this
can be.
Body posture
We can usually control the words we say, but it is
more difficult to control our body language. It is
possible, therefore, to send out mixed messages by
having a positive verbal message but a negative body
posture. This will only serve to confuse the patient
and it is likely that the outcome of the interac tion
will be poor. There are several classic body postures
which have been identified as having significant
meanings:
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