Symptoms in the Pharmacy :introduction
ASMETHOD
was developed by Derek
Balon, a community pharmacist in London:
A: Age and appearance
The appearance of the patient can be a useful indicator of whether a
minor or more serious condition is involved. If the patient looks ill,
e.g. pale, clammy, flushed or grey, the pharmacist should consider
referral to the doctor. As far as children are concerned, appearance is
important, but in addition the pharmacist can ask the parent whether
the child is generally well. A child who is cheerful and energetic is
unlikely to have anything other than a minor problem, whereas one
who is quiet and listless, or who is fractious, irritable and feverish,
might require referral.
The age of the patient is important because the pharmacist will
consider some symptoms as potentially more serious according to
age. For example, acute diarrhoea in an otherwise healthy adult
could reasonably be treated by the pharmacist. However, such symptoms
in a baby could produce dehydration more quickly; elderly
patients are also at a higher risk of becoming dehydrated. Oral thrush
is common in babies, less common in older children and adults; the
pharmacist’s decision about whether to treat or refer could therefore
be influenced by age.
Age will play an important part in determining any treatment offered
by the pharmacist. Some preparations are not recommended at all for
children under 12 years, e.g. loperamide. Hydrocortisone cream and
ointment should not be recommended for children under 10; aspirin
should not be used in children under 16; corticosteroid nasal sprays and
omeprazole should not be recommended for those under 18. Others
must be given in a reduced dose or as a paediatric formulation and the
pharmacist will thus consider recommendations carefully.
Other OTC preparations have a minimum specified age, e.g. 16
years for emergency hormonal contraception and nicotine replacement
therapy (NRT), and 18 for treatments of vaginal thrush.
Pharmacists are used to assessing patients’ approximate age and
would not routinely ask for proof of age here, unless there was a
specific reason to do so.
S: Clarification as to who is the patient
M:Medication regularly taken, on prescription or OTC
E: Extra medication tried to treat the current symptoms
T: Time, i.e. duration of symptoms
H: History
There are two aspects to the term ‘history’ in relation to responding to
symptoms: firstly, the history of the symptom being presented and
secondly, previous medical history. For example, does the patient have
diabetes, hypertension or asthma? PMRs should be used to record
relevant existing conditions.
Questioning about the history of a condition may be useful; how
and when the problem began, how it has progressed and so on. If the
patient has had the problem before, previous episodes should be asked
about to determine the action taken by the patient and its degree of
success. In recurrent mouth ulcers, for example, do the current ulcers
resemble the previous ones, was the doctor or dentist seen on previous
occasions, was any treatment prescribed or OTC medicine purchased
and, if so, did it work?
In asking about the history, the timing of particular symptoms can
give valuable clues as to possible causes. The attacks of heartburn that
occur after going to bed or on stooping or bending down are indeed
likely to be due to reflux, whereas those that happen during exertion
such as exercise or heavy work may not be.
History-taking is particularly important when assessing skin disease.
Pharmacists often think, erroneously, that recognition of the
appearance of skin conditions is the most important factor in responding
to such symptoms. In fact, many dermatologists would argue that
history-taking is more important because some skin conditions resemble
each other in appearance. Furthermore, the appearance may be
altered during the course of the condition. For example, the use of a
topical corticosteroid inappropriately on infected or infested skin may
substantially change the appearance; allergy to ingredients such as
local anaesthetics may produce a problem in addition to the original
complaint. The pharmacist must know therefore which creams, ointments
or lotions have been applied.
O: Other symptoms
Patients generally tend to complain about the symptoms that concern
them most. The pharmacist should always ask whether the patient has
noticed any other symptoms, or anything different from usual because,
for various reasons, patients may not volunteer all the important
information. Embarrassment may be one such reason, so that
patients experiencing rectal bleeding may only mention that they
have piles or are constipated.
The importance or significance of symptoms may not be recognised
by patients; for example, those who have constipation as a side-effect
from a tricyclic antidepressant will probably not mention their dry
mouth because they can see no link or connection between the two
problems.
D: Danger symptoms
These are the symptoms or combinations of symptoms that should
ring warning bells for pharmacists because immediate referral to the
doctor is required. Blood in the sputum, vomit, urine or faeces would
be examples of such symptoms, as would unexplained weight loss.
Danger symptoms are included and discussed in each section of this
book so that their significance can be understood by the pharmacist
was developed by Derek
Balon, a community pharmacist in London:
- A Age/appearance
- S Self or someone else
- M Medication
- E Extra medicines
- T Time persisting
- H History
- O Other symptoms
- D Danger symptoms
A: Age and appearance
The appearance of the patient can be a useful indicator of whether a
minor or more serious condition is involved. If the patient looks ill,
e.g. pale, clammy, flushed or grey, the pharmacist should consider
referral to the doctor. As far as children are concerned, appearance is
important, but in addition the pharmacist can ask the parent whether
the child is generally well. A child who is cheerful and energetic is
unlikely to have anything other than a minor problem, whereas one
who is quiet and listless, or who is fractious, irritable and feverish,
might require referral.
The age of the patient is important because the pharmacist will
consider some symptoms as potentially more serious according to
age. For example, acute diarrhoea in an otherwise healthy adult
could reasonably be treated by the pharmacist. However, such symptoms
in a baby could produce dehydration more quickly; elderly
patients are also at a higher risk of becoming dehydrated. Oral thrush
is common in babies, less common in older children and adults; the
pharmacist’s decision about whether to treat or refer could therefore
be influenced by age.
Age will play an important part in determining any treatment offered
by the pharmacist. Some preparations are not recommended at all for
children under 12 years, e.g. loperamide. Hydrocortisone cream and
ointment should not be recommended for children under 10; aspirin
should not be used in children under 16; corticosteroid nasal sprays and
omeprazole should not be recommended for those under 18. Others
must be given in a reduced dose or as a paediatric formulation and the
pharmacist will thus consider recommendations carefully.
Other OTC preparations have a minimum specified age, e.g. 16
years for emergency hormonal contraception and nicotine replacement
therapy (NRT), and 18 for treatments of vaginal thrush.
Pharmacists are used to assessing patients’ approximate age and
would not routinely ask for proof of age here, unless there was a
specific reason to do so.
S: Clarification as to who is the patient
M:Medication regularly taken, on prescription or OTC
E: Extra medication tried to treat the current symptoms
T: Time, i.e. duration of symptoms
H: History
There are two aspects to the term ‘history’ in relation to responding to
symptoms: firstly, the history of the symptom being presented and
secondly, previous medical history. For example, does the patient have
diabetes, hypertension or asthma? PMRs should be used to record
relevant existing conditions.
Questioning about the history of a condition may be useful; how
and when the problem began, how it has progressed and so on. If the
patient has had the problem before, previous episodes should be asked
about to determine the action taken by the patient and its degree of
success. In recurrent mouth ulcers, for example, do the current ulcers
resemble the previous ones, was the doctor or dentist seen on previous
occasions, was any treatment prescribed or OTC medicine purchased
and, if so, did it work?
In asking about the history, the timing of particular symptoms can
give valuable clues as to possible causes. The attacks of heartburn that
occur after going to bed or on stooping or bending down are indeed
likely to be due to reflux, whereas those that happen during exertion
such as exercise or heavy work may not be.
History-taking is particularly important when assessing skin disease.
Pharmacists often think, erroneously, that recognition of the
appearance of skin conditions is the most important factor in responding
to such symptoms. In fact, many dermatologists would argue that
history-taking is more important because some skin conditions resemble
each other in appearance. Furthermore, the appearance may be
altered during the course of the condition. For example, the use of a
topical corticosteroid inappropriately on infected or infested skin may
substantially change the appearance; allergy to ingredients such as
local anaesthetics may produce a problem in addition to the original
complaint. The pharmacist must know therefore which creams, ointments
or lotions have been applied.
O: Other symptoms
Patients generally tend to complain about the symptoms that concern
them most. The pharmacist should always ask whether the patient has
noticed any other symptoms, or anything different from usual because,
for various reasons, patients may not volunteer all the important
information. Embarrassment may be one such reason, so that
patients experiencing rectal bleeding may only mention that they
have piles or are constipated.
The importance or significance of symptoms may not be recognised
by patients; for example, those who have constipation as a side-effect
from a tricyclic antidepressant will probably not mention their dry
mouth because they can see no link or connection between the two
problems.
D: Danger symptoms
These are the symptoms or combinations of symptoms that should
ring warning bells for pharmacists because immediate referral to the
doctor is required. Blood in the sputum, vomit, urine or faeces would
be examples of such symptoms, as would unexplained weight loss.
Danger symptoms are included and discussed in each section of this
book so that their significance can be understood by the pharmacist
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