Responding to Symptoms

Introduction

Every day, community pharmacists have to respond to symptoms presented by patients and make some clinical decision for the minor ailments.

However, there are some factors that make this particularly challenging for us.

Poor knowledge and skill in differential diagnosis
Lack of access to patient's medical history or full medications profile
Some patients did not disclose sufficient history of presenting illness, due to poor health literacy, perceived lack of privacy, stigma and embarrassment, language barrier, fear of discrimination, cultural beliefs and practices or past negative experiences with healthcare.
Unavailability of diagnostic testing
The symptoms may be presented on behalf of another people
A detailed conversation needs to be initiated

Pharmacist Consultation

A typical process shall involve:

Patient assessment based on the obvious information provided by the patient themselves.

What the problem appears to be?
How bad and how long the symptoms are?

Questioning the patient to determine specific information that will assist the differential diagnosis and also eliminate more serious conditions.

Including patient-specific characteristics such as age, comorbidities, pregnancy or breastfeeding status, and medication history (including non-prescription medicines and herbal remedies).
Action taken, medicines tried?

Offering an OTC medicine/advice and reassurance or referral to doctor.

Remember, patients are more likely to follow health advice if they participate in conversations about their health decision making.
A red flag is a symptom or patient characteristic that alerts the pharmacist that there could be a more severe underlying problem and often referral to another health-care practitioner is required.
One should also be mindful of patients who frequently request OTC medicines for symptomatic relief, because they may be used to hide symptoms.
Another reason to refer would be due to the failure of OTC medicines to control or relieve a condition.

NOTE: Depending on the patient, you may need to use a mix of open-ended and short-ended questions to gather the information.

Use of Mnemonics

Some of the commonly used mnemonics used in practice are

WWHAM

W - Who is the patient?
W - What are the symptoms?
H - How long have the symptoms been present?
A - Action taken?
M - Medication being taken?

LICEF

Lifestyle - How is the problem affecting you day-to-day?
Ideas - What do you think might be causing the problem?
Concerns - What is your biggest worry about this?
Expectations - What are you hoping we can do today?
Feelings - How are you feeling today?

SCHOLAR

S - Symptoms
C - Characteristics
H - History
O - Onset
L - Location
A - Aggravating factors
R - Remitting factors

ENCORE

E - Explore
N - No medication
C - Care
O - Observe
R - Refer
E - Explain

ASMETHOD

A - Age, appearance
S - Self or someone else
M - Medication
E - Extra medicines
T - Time persisting
H - History
O - Other symptoms
D - Danger symptoms

SIT DOWN SIR

S - Site or location
I - Intensity or severity
T - Type of nature
D - Duration
O - Onset
W - With (other symptoms)
N - Annoyed or aggravated
S - Spread or radiation
I - Incidence or frequency pattern
R - Relieved by

However, these mnemonics are rigid, inflexible and often inappropriate (vital information can be missed or not all questions will be relevant to every symptom assessment).

On the other hand, we should use clinical reasoning to arrive a differential diagnosis.

Summary

Critical for pharmacists is the need to learn from uncertainty. When referrals are made, we should attempt to follow up the outcome of the referral.

Knowing what a more experienced doctor believed what the diagnosis was allows you to build up experience and, when faced with similar presenting symptoms, have a better idea of the cause.
Without this feedback, pharmacists reach a 'glass ceiling', where the outcome is always the same - referral - which might not be necessary.

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