Responding to symptos lecture 1

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