Community Pharmacy Symptoms, Diagnosis & Treatment PDF

Community Pharmacy This page intentionally left blank Community Pharmacy Symptoms, Diagnosis and Treatment Paul Rutter FFRPS MRPharmS PhD Professor of Pharmacy Practice, School of Pharmacy and Biomedical Sciences, University of Central Lancashire, Preston, UK FOURTH...

Community Pharmacy This page intentionally left blank Community Pharmacy Symptoms, Diagnosis and Treatment Paul Rutter FFRPS MRPharmS PhD Professor of Pharmacy Practice, School of Pharmacy and Biomedical Sciences, University of Central Lancashire, Preston, UK FOURTH EDITION Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2017 © 2017 Elsevier Ltd. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the publisher (other than as may be noted herein). First edition 2004 Second edition 2009 Third edition 2013 Fourth edition 2017 ISBN 978-0-7020-6997-0 Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. For Elsevier: Content Strategist: Pauline Graham Content Development Specialist: Helen Leng Project Manager: Andrew Riley Designer: Christian Bilbow Illustration Manager: Karen Giacomucci Illustrator: PCA Creative Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1 Contents Useful websites vii Preface ix Introduction xi How to use the book xv 1 Making a diagnosis 1 2 Respiratory system 9 3 Ophthalmology 53 4 Ear conditions 79 5 Central nervous system 93 6 Women’s health 121 7 Gastroenterology 151 8 Dermatology 217 9 Musculoskeletal conditions 283 10 Paediatrics 305 11 Specific product requests 333 Abbreviations 357 Glossary of terms 359 Index 361 This page intentionally left blank Useful websites Updated July 28th, 2015 The Nursing and Midwifery Council http://www.nmc.org.uk/ Health and care Professions Council http://www.hpc-uk.org/ Evidence-based Medicine National Institute for Health and Care Excellence http:// UK Pharmacy Organisations and Trade Bodies www.nice.org.uk/ National Pharmaceutical Association http://www.npa. Bandolier http://www.medicine.ox.ac.uk/bandolier/ co.uk/ Centre for Reviews and Dissemination http://www.york. Pharmaceutical Services Negotiating Committee http:// ac.uk/crd/ psnc.org.uk/ Midlands Therapeutics Review and Advisory Committee Guild of Healthcare Pharmacists http://www.ghp.org.uk/ http://www.centreformedicinesoptimisation.co.uk/ UK Clinical Pharmacists Association http://www.ukcpa.org/ mtrac/ Association of the British Pharmaceutical Industry http:// Regional Drugs and Therapeutic Centre http://rdtc.nhs.uk/ www.abpi.org.uk/ Health Services Technology Assessment Texts (US site) The Proprietary Association of Great Britain http://www. http://www.ncbi.nlm.nih.gov/books/NBK16710/ pagb.co.uk/ King’s Fund http://www.kingsfund.org.uk/ British Pharmaceutical Students Association http://www. bpsa.com/ Medicines Information & Regulation UK Medicines Information http://www.ukmi.nhs.uk/ International Healthcare Organisations Electronic Medicines Compendium http://www.medicines. International Pharmaceutical Federation (FIP) http://www. org.uk/emc/ fip.org/ NICE Clinical Knowledge Summaries http://cks.nice.org. World Health Organisation http://www.who.ch/ uk/#?char = A Medicines & Healthcare products Regulatory Agency Pharmacy Journals Pharmaceutical Journal http://www.pharmj.com/ https://www.gov.uk/government/organisations/ medicines-and-healthcare-products-regulatory- Chemist and Druggist http://www.chemistanddruggist. agency co.uk/ European Medicines Agency http://www.ema.europa. The Pharmacist http://www.thepharmacist.co.uk/ eu/ema/ International Journal of Pharmacy Practice http:// US Food and Drug Administration http://www.fda.gov/ onlinelibrary.wiley.com/journal/10.1111/ (ISSN)2042-7174 Therapeutic Goods Administration (Australian) https:// www.tga.gov.au/ International Journal of Clinical Pharmacy http://www. springer.com/medicine/internal/journal/11096 Professional Bodies and Regulators Royal Pharmaceutical Society http://www.rpharms.com/ Wider Healthcare Journals of Interest to Community home/home.asp Pharmacy Journal of SelfCare http://www.selfcarejournal.com/ General Pharmaceutical Council http://www. pharmacyregulation.org/ British Journal of General Practice http://www.bjgp.org/ Pharmaceutical Society of Australia http://www.psa. British Medical Journal http://www.bmj.com/ org.au/ Health Services Research http://www.hsr.org/ The British Medical Association https://www.bma.org.uk The Lancet http://www.thelancet.com/ The General Medical Council http://www.gmc-uk.org/ Nursing Standard http://journals.rcni.com/journal/ns viii Useful websites General Health Sites for Healthcare Workers http://www.healthfinder.gov/ Medscape http://emedicine.medscape.com/ http://www.mayoclinic.com/index.cfm? Selfcare forum http://www.selfcareforum.org/ http://www.evidence.nhs.uk http://www.bbc.co.uk/health/ General Health Sites for Patients http://www.patient.co.uk Preface Demand on healthcare professionals to deliver high-­ 2015, over 90 Prescription-Only medicines have been re- quality patient care has never been greater. A multitude classified as Pharmacy medicines. More recent switches of factors impinge on healthcare delivery today, including have included products from new therapeutic classes, al- an aging population, more sophisticated medicines, high lowing community pharmacists to manage and treat a patient expectation, health service infrastructure as well as wider range of conditions. adequate and appropriate staffing levels. In primary care Further deregulation of medicines to treat acute illness the medical practitioner role is pivotal in providing this from different therapeutic areas seems likely, especially as care and they remain the central member of the healthcare healthcare professional opinion to acute medicine deregu- team, but demands on their time mean other models of lation is broadly positive and the impact on general prac- service delivery are being adopted in the UK and in other tice workload associated with dealing with minor ailments developed countries that utilise other types of healthcare is high (and represents 100–150 million GP consultations professionals. per annum). Pharmacists, more than ever before need to This is leading to a breaking down of the traditional demonstrate that they are competent practitioners and can boundaries of care between doctors, nurses, and pharma- be trusted with this additional responsibility. Therefore cists. In particular, certain activities once seen as medical pharmacists require greater levels of knowledge and un- practitioner responsibility are now being performed by derstanding about commonly occurring medical condi- nurses and pharmacists as their scope of practice ex- tions. They will need to be able to recognise their signs pands. The traditional role of supplying medicines safely and symptoms, and use an evidence-based approach to and efficiently through community pharmacy still exists treatment. but greater patient-facing cognitive roles are now firmly This was, and still is, the catalyst for this book. Although established. Health prevention services are now routine, other books targeted for pharmacists on diagnosis are pub- for example, smoking cessation, weight management and lished, this book aims to give a more in-depth view of vaccination programmes. The pharmacy is now seen (by minor conditions and how to differentiate them from more many governments) as a place where the general pub- sinister pathology that may present in a similar way. The lic can be managed for everyday healthcare needs with- book is intended for all non-medical healthcare staff, but out visiting a doctor. The most notable long-term global especially for pharmacists, from undergraduate students to healthcare policy, which directly affects pharmacy, is experienced practitioners. the reclassification of Prescription-Only medicines to It is hoped that the information contained within the non-prescription status. In the UK between 1983 and book is both informative and useful. This page intentionally left blank Introduction Community pharmacists are the most accessible health- e­ xercise), moving through to managing their own ill health care professional. No appointment is needed to consult a (e.g., self-medicating) either on their own or with help. As pharmacist and patients can receive free, unbiased advice people progress along the continuum, more facilitation by almost anywhere. A community pharmacist is often the others is required until a person needs fully managed care. first health professional the patient seeks advice from and, as such, provides a filtering mechanism whereby minor self-limiting conditions can be appropriately treated with What is self-medication? the correct medication and patients with more sinister ­pathology referred on to the GP for further investigation. Self-medication is just one element of self-care and can be On a typical day a pharmacist practising in an ‘average’ defined as the selection and use of medicines by individu- community pharmacy can realistically expect to help be- als to treat self-recognised illness or symptoms. How these tween 5 and 15 patients a day who present with various medicines are made available to the public vary from coun- symptoms for which they are seeking advice, reassurance, try to country but all have been approved by regulatory treatment or a combination of all three. agencies as safe and effective for people to select and use Probably of greatest impact to community pharmacy without the need for medical supervision or intervention. practice globally is the increased prominence of self-care. In many countries (e.g., Australia, New Zealand, France, Self-care is not new; people have always taken an active Sweden, Canada, UK) regulatory frameworks support re- role in their own health. What is different now is the atti- classification of medicines away from ­ prescription-only tude towards self-care by policy makers, healthcare organ- control by having a gradation in the level of medicine isations, not-for-profit agencies and front-line healthcare availability, whereby certain medicines can only be pur- workers. Health improvements have been seen in people chased at a pharmacy. These ‘Pharmacy medicines’ usually adopting health-enhancing behaviours rather than just have to be sold either by the pharmacist or under his or her through medical intervention. This has led to self-care be- supervision. Over the last 30 years this approach to reclas- ing seen in a broader context than just the way in which sification has seen a wide range of therapeutic agents made people deal with everyday illness. In the UK the self-care available to consumers, including proton pump inhibitors forum (http://www.selfcareforum.org/), whose purpose is (US, EU-wide), orlistat (EU-wide), triptans (UK, Germany) to promote self-care and embed it in everyday life, was and beta-2-agonists (Singapore, Australia). established. ‘Facilitated self-medication’ So what is self-care? The majority of purchases for non-prescription medicines are by the consumer alone, using product information Fundamentally, the concept of self-care puts responsibility from packaging to make an informed decision on whether on individuals for their own health and well-being. The to purchase. When consumers seek help at the point of World Health Organisation defines self-care as ‘the abil- purchase, this can be termed ‘facilitated self-medication’. ity of individuals, families and communities to promote Where medicines are purchased through pharma- health, prevent disease, and maintain health and to cope cies, staff are in a strong position to facilitate self-care with illness and disability with or without the support of a decision-­making by consumers, as in most pharmacies health-care provider’. the transaction takes place through a trained counter Self-care has been described as a continuum (Fig. 1), assistant or the pharmacist. Limited research has shown starting with individual choices on health (e.g., taking that ­consumer-purchasing decisions are affected by this xii Introduction Pure self care Pure medical care Responsible Professional individual responsibility The self-care continuum Daily Lifestyle Self-managed Minor Long-term Acute Compulsory Major choices ailments ailments conditions conditions psychiatric care trauma Healthy living Minor ailments Long-term conditions In-hospital care Fig. 1 The self-care continuum ‘­facilitation’. Nichol et al. and Sclar et al. both demon- self-care is none better exemplified than by the level of strated that consumers (25% and 43%, respectively) altered consumer self-medication. The use of non-prescription their purchasing decision when proactively approached by medicines is the most prevalent form of medical care in pharmacy students. Furthermore, a small proportion of the world. Sales are huge with the global market, estimated consumers did not purchase anything (13% and 8%) or to be worth 73 billion Euros. were referred to their doctor (1% and 4%). These studies Despite the enormous sums of money spent on non-­ highlight how the pharmacy team are able to positively prescription medicines, approximately only 25% of people shape consumer decisions and help guide them to arguably regularly purchase non-prescription medicines (25% tend better alternatives. to seek medical attention, and 50% do nothing). The extent to which this happens does vary from country to country, Community pharmacy and self-care and in some markets, this is considerably higher, for ex- ample South Africa and the United States where 35% to Increasing healthcare costs, changes in societal lifestyle, 40% of people use OTC medications on a regular basis. improved educational levels and increasing consumer- Many papers and commissioned reports show that ac- ism are all influencing factors on why people choose to cess and convenience shape the purchasing patterns of exercise self-care. Of greatest importance are probably consumers. These factors seem to be unaffected by coun- ­consumer-purchasing patterns and controlling costs. try or time. Reports spanning thirty years have repeatedly concluded that these play an important part in consumer Consumerism decision-making. The element of convenience does have a country context, for example, in Western countries this is Changes in society have led to people to have a differ- primarily due to ease of access that negates the need for ent outlook on health and the way in which individuals doctor seeking that often is associated with higher cost perceive their own health/ill health. Today people have and increased time. In developing countries, ‘convenience’ easy access to information; the creation of the Internet is more associated with ‘need’ due to lower levels of health giving almost instantaneous access to limitless data on all infrastructure and access to medical resources. aspects of health and care means that people across the globe have the means to query decisions and challenge Costs medical opinion. This growing empowerment is also influ- enced by greater levels of education; having information As populations across the globe live longer lives, whether is one thing but being able to understand it and utilise it is through better hygiene, nutrition or advances in medi- another. This has proved challenging to healthcare systems cine, providing medical care is becoming more and more and workers, having to move from traditional structures expensive. In an attempt to control costs many countries and paternalistic doctrines (e.g., ‘doctor knows best’) to a have gone through major healthcare reforms to maximise patient-focused and centred type of care. This heightened existing resources, both financial and staffing, to deliver public awareness about health, in the context of self-care, effective and efficient healthcare. These reforms include allows individuals to make informed choices and recog- integrating self-care into mainstream public health policy, nise that much can be done by themselves. The extent of including the management of long-term conditions.  Introduction xiii Encouraging more people to exercise greater levels on non-prescription medicines is afforded to community of self-care, either for acute or chronic problems, has pharmacists. Although there is a general global move to the potential to shift costs away from professional care. liberalise non-prescription markets, pharmacies in many Figures from the UK give some indication as to the mag- countries still are the main supplier of non-prescription nitude of potential cost savings. Take primary care work- medicines. Pharmacists are therefore in a position to facil- load as an example. It is reported that approximately itate consumer self-care and self-medication, which needs 20% to 40% of general practice (GP) workload consti- to be built on and exploited. tutes patients seeking help for minor illness at a cost of £2 billion. References Faculty for Self-care Contribution of community pharmacy to http://www.collegeofmedicine.org.uk/faculties/ self-care faculty-self-care Community pharmacists are uniquely placed to provide Department of Health self-care week http://socialcarebulletin.dh.gov.uk/tag/self-care-week/ support and advice to the general public compared with Self-care connect other healthcare professionals. The combination of lo- http://www.selfcareconnect.co.uk/ cation and accessibility mean that most consumers have PSNC self-care and links ready access to a pharmacy where health professional http://psnc.org.uk/services-commissioning/essential-services/ advice is available on demand. A high level of pub- support-for-self-care/ lic trust and confidence in pharmacists’ ability to advise This page intentionally left blank  How to use the book The book is divided into 11 chapters. The first chapter Elements included under each condition lays the foundations in how to go about making a diag- nosis. This is followed by 9 systems-based chapters struc- The same structure has been adopted for every condition. tured in the format shown in Fig. 2. The final chapter is This is intended to help the reader approach differential di- product based and has a slightly different format. A list agnosis from the position of clinical decision-making (see of abbreviations and a glossary are included at the end Chapter 1). To help summarise the information, tables and of the book. algorithms are included for many of the conditions. Arriving at a differential diagnosis Key features of each chapter To contextualise how commonly conditions are seen by community pharmacists, a table listing the likelihood in At the beginning of each chapter there is a short sec- which they are encountered is presented. This is designed tion addressing basic anatomy and history taking spe- to ‘frame’ the questions that should be asked from the cific to that body system. A basic understanding of the point of working from the most likely cause of symptoms. anatomical location of major structures is useful when To help a further table summarising the key questions that attempting to diagnose/exclude conditions from a pa- should be asked for each condition is included. The rele- tient’s presenting complaint. It would be almost impos- vance (i.e., the rationale for asking the question) is given sible to know whether to treat or refer a patient who for each question. This will allow pharmacists to determine presented with symptoms suggestive of renal colic if which questions should be asked to enable a differential one does not know where the kidneys are. However, diagnosis to be reached. this is not intended to replace an anatomy text, and the reader is referred to further reading listed throughout Primer for differential diagnosis the book for more detailed information on anatomical A ‘primer for differential diagnosis’ is available for a number considerations. of conditions covered. This algorithmic approach to differen- tial diagnosis is geared towards nearly or recently qualified Self-assessment questions pharmacists. They are not intended to be solely relied upon in making a differential diagnosis but to act as an aide memoire. Twenty multiple choice questions and at least two case- It is anticipated that the primers will be used in conjunction study questions are presented at the end of each chapter. with the text, thus allowing a broader understanding of the These are designed to test factual recall and applied knowl- differential diagnosis of the condition to be considered. edge. The type of multiple choice questions are constructed to mimic those set in the UK pre-registration examination Trigger points indicative of referral set by the General Pharmaceutical Council. They start with simple traditional multiple choice questions in which the A summary box of trigger factors when it would be pru- right answer has to be picked from a series of five possible dent to refer the patient to another healthcare practitioner answers, and work up to more complex questions which is presented for each condition. In most instances a ration- are interrelated. ale for referral is presented. These trigger factors are not The case studies challenge you with ‘real-life’ situa- absolute and the pharmacist will have to use their profes- tions. All are drawn from practice and have been encoun- sional judgement on a case-by-case basis. For example, a tered by practising pharmacists, but have been modified person with a cough of 3 days’ duration might need refer- for inclusion in the book. ral if they are visibly poorly. xvi How to use the book 1. Respiratory system 2. Ophthalmology 3. Ear conditions 4. The central nervous system 5. Women's health 6. Gastroenterology 7. Dermatology 8. Musculoskeletal conditions 9. Paediatrics 10. Specific product requests Background General overview of eye anatomy History taking and the eye exam Red eye Eyelid disorders Dry eye Self-assessment Red eye Background Prevalence and epidemiology Aetiology Arriving at a differential diagnosis Clinical features of conjunctivitis Conditions to eliminate Evidence base for over-the-counter medication Practical prescribing and product selection Further reading and web sites This hopefully will provide extra information for pharma- Evidence-based OTC medication and cists when faced with queries from pregnant and lactating Practical prescribing and product women and allow them to recommend products when faced selection with manufacturer information stipulating avoidance. These two sections present the reader, first, with an evaluation of the current literature on whether over- the-counter medicine works, and second, with a quick Hints and tips boxes reference to the dose of the medicine and when it cannot A summary box of useful information is provided near be prescribed. This does not replace standard textbooks the end of each condition. This contains information that such as Martindale or Stockley’s drug interactions, but it does not fall readily into any of the other sections but is does allow the user to find basic data in one text without nonetheless useful. For example, some of the hints and tips having to reach for three or four other texts to answer boxes give advice on how to administer eye drops, suppos- simple questions. itories and other forms of medicines. The pregnancy and breast-feeding recommendations in this book are based largely on those from standard texts such as: Briggs’ Drugs in pregnancy and lactation and, Schaefers’ Drugs in pregnancy and lactation. Many man- Further reading and websites ufacturers of over-the-counter medicines advise against their products being used in these groups, but where possi- To supplement the text, at the end of each condition a list of ble, in the summary tables reference is made to the recom- selected references and reading is provided for those who mendations made from these standard and trusted sources. wish to seek further information on the ­subject. Websites  How to use the book xvii are also provided, and all sites have been checked and were active and relevant at the time of writing (Summer 2015). Electronic Resources Finally, all information presented in the book is accu- New to this edition is access to additional material hosted rate and factual as far as the author is aware. It is ac- on Elsevier’s electronic portal. The electronic resource knowledged that guidelines change, products become holds additional material that includes: discontinued and new information becomes available over the lifetime of a book. Therefore if any information in the A chapter on evidence-based medicine book is not current or valid, the author would be grateful Videos on physical examination of any feedback, positive or negative, to ensure that the Additional written case studies next edition is as up to date as possible. More multiple choice questions This page intentionally left blank  Chapter 1 Making a diagnosis In this chapter Community pharmacy performance when dealing Clinical reasoning 3 with patients’ signs and symptoms 1 Summary 4 Current pharmacy training in making a Consultation and communication skills 6 diagnosis 2 Conclusion 7 Global healthcare policy now has a strong self-care focus before. This raises the question as to whether pharma- and various strategies have been put in place to encour- cists are capable to sell these medicines appropriately. age consumers to have a more active role in exercising Early ­research of pharmacist/consumer interactions in self-care. pharmacy practice did not address this but concentrated Pharmacies unquestionably handle and manage large more on auditing questioning behaviour and analysing numbers of consumers who seek help and advice for the advice people received. This body of work did illus- minor illness, and advocates of pharmacy have argued trate the basic nature of performance; types of questions that this will decrease doctor workload regarding minor asked, frequency of advice provided and consumer per- illness, allowing them to concentrate more on ‘complex’ ception to questioning. The findings were broadly critical patient care. of pharmacist performance. Over the same time period, The expansion of non-prescription medicines has un- covert investigation by the UK consumer organisation, doubtedly contributed to the growth seen in the market ‘Which’, also concluded that pharmacists generally per- and given consumers greater choice. It has also provided formed poorly. Further practice research (mainly from community pharmacy with an opportunity to demonstrate developed countries) has sought to determine the out- real and tangible benefits to consumers by facilitating come of these interactions rather than the mechanics of patient self-care. For example, in the UK, Government- the interaction. Findings from all papers raise questions endorsed (and funded) schemes such as Minor Ailment over pharmacist ability to consistently perform at ex- Schemes have shown the positive impact community pected levels. Lamsam et al. (1998), found that in a third pharmacy can have on patient outcomes. However, re- of interactions, the pharmacists made recommendations search data on the impact community pharmacy makes without assessing the patient’s symptoms and in a fur- to patient outcomes through facilitated self-medication ther third of cases, recommendations were poor, which is less convincing. could have potentially caused harm. Horsley et al. (2004) found that the expected outcome was only reached in half of observed cases. Driesen et al. (2009) and Bilkhu et al. (2013) also report poor performance, and in each Community pharmacy performance study (diarrhoea in a baby and allergic conjunctivitis when dealing with patients’ signs and in an adult) suggest that too few questions were asked. symptoms Tucker et al compared pharmacist performance to doctors and nurses across a spectrum of dermatological condi- Regardless what degree of control is placed on medicine tions. Pharmacists performed more poorly than doctors availability in different countries, pharmacists can now and only 40% of pharmacists were able to identify all le- manage and treat a wider number of conditions than ever sions correctly. Data from developing countries is ­limited 2 Making a diagnosis but a review by Brata et al. (2013) also highlighted in- consistent information gathering, leading to inappropri- Meaning of Attributes of the the letter mnemonic ate recommendations. W Who is the patient? Positive points W What are the Establishes presenting Current pharmacy training in making symptoms? complaint H How long have the Negative points a diagnosis symptoms been Fails to consider general present? appearance of patient. The use of protocols/guidelines and mnemonics seem to A Action taken? No social/lifestyle factors have been almost universally adopted by pharmacy. Many M Medication being taken into account; no such mnemonics have been developed as highlighted in a taken? family history sought; 2014 review (Shealy, 2014). The use of these ‘decision aids’ not specific or in-depth seems to have had little impact on improving performance enough; no history of and recent research findings have shown that community previous symptoms pharmacists over rely on using this type of questioning strategy (Akhtar, 2014; Iqbal, 2013; Rutter, 2013). Other examples of mnemonics that have been sug- gested as being helpful for pharmacists in differential Try not to use mnemonics diagnosis are ENCORE, ASMETHOD and SIT DOWN SIR. At best, these tools allow for standardising information Although these are more comprehensive than WWHAM, gained from patients from and between pharmacists and they still are limited. None take into consideration all the wider pharmacy team. The more fundamental and im- factors that might impinge on a differential diagnosis. portant question is not simply asking the questions but All fail to establish a full history from the patient in re- determining how that information is utilised. Having a set spect to lifestyle and social factors or the relevance of a of data still requires interpretation and this inability to family history. They are very much designed to establish appropriately synthesise gathered information is where re- the nature and severity of the presenting complaint. This, search has highlighted pharmacists’ failings. in many instances, will be adequate but for intermittent The use of mnemonics has been taught by many higher conditions (e.g., irritable bowel syndrome, asthma, hay education institutions and adopted by commercial com- fever) or conditions where a positive family history is munity pharmacy organisations. Mnemonics are rigid, important (e.g., psoriasis, eczema), they might well miss inflexible and often inappropriate. Every patient is dif- important information that reduces the chances of gain- ferent and it is unlikely that a mnemonic can be fully ing a correct diagnosis. applied, and more importantly, using mnemonics can mean that vital information is missed, which could shape Meaning of Attributes of the ­decision-making. Some of the more commonly used mne- the letter mnemonic monics are discussed briefly in the next section. E Explore Positive points N No medication ‘Observe’ section suggests WWHAM C Care taking into account O Observe the appearance of the This is the most common mnemonic in use and widely R Refer patient – does he or she taught and used in the UK. It is the simplest to remem- E Explain look poorly? ber but also the worst to use. It gives the pharmacist very Negative points limited information from which to establish a differen- Sections on ‘No medication’ tial diagnosis. If used, it should be used with caution and and ‘Refer’ add little to is probably only helpful to use as a basic information-­ the differential diagnosis gathering tool. WWHAM might be appropriate to allow process. No social/lifestyle for counter assistant staff to gain a general picture of the factors taken into account; person’s presenting complaint but should not be advocated no family history sought as a tool to establish a diagnosis.  Clinical reasoning 3 Meaning of Attributes of the acronym Steps to consider in clinical reasoning 1 the letter 1. Use epidemiology to shape your thoughts A Age/appearance? Positive points What is the presenting complaint? Some conditions S Self or someone Establishes the nature of are much more common than others. Therefore you else? problem and if patient has can form an idea of what condition the patient is likely M Medication? suffered from previous to be suffering from based on the laws of probability. E Extra medicines? similar episodes For example, if a person presents with a cough then T Time persisting? Negative points you should already know that by far the most com- H History? Exact symptoms and severity mon cause of cough is a viral infection. Other causes of O Other symptoms? of social/lifestyle factors cough are possible and need to be eliminated. Your line D Danger symptoms? not taken into account; no of questioning should therefore be shaped by thinking family history sought that this is the ‘default’ cause of the person’s cough and ask questions based on this assumption (see 4. Meaning of Attributes of the acronym Hypothetico-deductive reasoning). the letter 2. Take account of the person’s age and sex S Site or location? Positive points Epidemiological studies show that age and sex will in- I Intensity or severity? Establishes the severity and fluence the likelihood of certain conditions. For exam- T Type or nature? nature of problem and if ple, it is very unlikely that a child who presents with D Duration? the patient has suffered cough will have chronic bronchitis, but the probabil- O Onset? from previous similar ity of an elderly person having chronic bronchitis is W With (other episodes much higher. Likewise croup is a condition seen only in symptoms)? Negative points children. Sex can dramatically alter the probability of N Annoyed or Fails to consider general people suffering from certain conditions. For instance, aggravated? appearance of patient. migraines are five times more common in women than S Spread or radiation? No social/lifestyle factors in men, yet cluster headache is nine times more com- I Incidence or taken into account; no mon in men than in women. Use this to your advantage. frequency pattern? family history sought It will allow you to internally change your thought pro- R Relieved by? cesses as to which conditions are most likely for that person. 3. The general appearance of the patient Does the person look well or poorly? This will shape your thinking as to the severity of the problem. If a Clinical reasoning child is running around a pharmacy, they are likely to be healthier than a child who sat quietly on a chair not Decision-making processes associated with clinical prac- talking. tice are an essential skill and are central to the practise of Taking these three points into consideration, you should professional autonomy. It is a thinking process that allows be able to form some initial thoughts as to the person’s the pharmacist to make wise decisions specific to individ- health status and ideas of what may be wrong with ual patient context. them. AT THIS POINT questions should be asked. Whether we are conscious of it or not, most people will – at some level – use clinical reasoning to arrive 4. Hypothetico-deductive reasoning at a differential diagnosis. Clinical reasoning relates to Based on this (limited) information, the pharmacist the decision-making processes associated with clinical should arrive at a small number of hypotheses. The practice. It is a thinking process directed towards en- pharmacist should then set about testing these hypoth- abling the pharmacist to take appropriate action in a eses by asking the patient a series of questions. Ask: specific context. It fundamentally differs from using ‘The right question, at the right time, for the right reason’ mnemonics in that it is built around clinical knowledge and skills that are applied to the individual patient. It The answer to each question asked allows the pharma- involves recognition of cues and analysis of data. cist to narrow down the possible diagnosis by either 4 Making a diagnosis eliminating particular conditions or confirming his or Many people will present to the pharmacist at an her suspicions of a particular condition. In effect the early stage in the evolution of their illness. This means pharmacist asks questions with knowledge of what the that they may not present with classical textbook answer is expected to be. For example, a confirmatory symptoms or have not yet developed any ‘red flag’-type type of question asked to a patient suspected of having symptoms when seen by the pharmacist. For example, allergic conjunctivitis might be ‘Do your eyes itch?’ In a child may have headache but no other symptoms yet this case the pharmacist is expecting the patient to say later go on to develop a stiff neck and rash and be ‘yes’ and thus helps support your differential diagno- diagnosed with meningitis, or a person may have an sis. If a patient states ‘no’, then this is an unexpected acute cough that subsequently develops into pneumo- answer that casts doubt on the differential diagnosis; nia. Safety netting attempts to manage these situations. therefore further questions will be asked and other di- This should take one of two forms: agnostic hypotheses explored. This cycle of testing and re-testing the hypotheses continues until you arrive at Conditional referrals This should be built into every consultation. It is a differential diagnosis. more than a mere perfunctory ‘If you don’t get bet- Good questioning following these principles will mean ter come back to me or see the doctor’. It has to that you will end up at the right diagnosis about 80% be tailored and specific to the individual and their of the time. symptoms. For example, if a person presents with a 5. Pattern recognition cough of 10 days’ duration, after how many more In addition, clinical experience (pattern recognition) also days would you ask them to seek further medical plays a part in the process. Certain conditions have very help? Three days? Five days? Seven days? Longer? characteristic presentations and, once seen, it is a relatively In this case knowledge on cough duration is im- straightforward task to diagnose the next case by recalling portant. If the differential diagnosis is a viral cough, the appearance of the rash. Therefore much of daily prac- then we know that this symptom typically lasts 10 tice will consist of seeing new cases that strongly resemble to 14 days, but it is not unusual for the symptom to previous encounters and comparing new cases to old. last 21 days. Longer than 21 days suggests that the Pattern recognition is therefore much more com- cough is becoming chronic and requires further inves- monly used by experienced or expert diagnosticians tigation. A conditional referral in this case would be compared with novices. This is generally because there anything between 5 and 10 days – in other words the is a gap between the expert–novice knowledge and clin- person has had the cough for between 2 and 3 weeks, ical experience store. Research has shown that experi- which is starting to become longer than one would enced doctors tend to only use hypothetico-­deductive expect for viral cough. Conversely, if the cough had strategies when presented with difficult cases. been present for just 2 days, then a conditional refer- 6. Physical examinations ral after a further 2 more weeks would be appropriate. The ability to perform simple examinations (e.g., eye, Advise patients on warning symptoms ear, mouth and skin examinations) does increase the It is entirely reasonable to highlight to patients those probability of arriving at the correct diagnosis. Where signs and symptoms that they may develop subse- appropriate (provided pharmacists are suitably trained) quent to your consultation. For example, a child suf- examinations should be conducted. Seeing a rash or fering with diarrhoea is managed by the pharmacist, viewing an eardrum will provide much better data from but the pharmacist highlights the signs of dehydra- which to base a decision than purely a patient descrip- tion to the child’s parents. This would be good prac- tion. Throughout this book, where examinations are tice as the consequence of dehydration is clinically possible, instruction is given in how to perform these more significant than the diarrhoea itself. examinations. Student Consult has some videos on how to perform these physical examinations. 7. Safety netting Summary Even if you are confident of your differential diagnosis, it is important to ‘safety net’. You are not going to get it In practice, family doctors tend to use a mixture of right all the time; making an incorrect diagnosis is inevi- ­hypothetico-deductive reasoning and pattern recognition table. It has been reported that upward of 50% of ­patients augmented with physical examination and, where needed, do not receive a definitive diagnosis at the end of a con- laboratory tests. It can seem to some patients that the doc- sultation with a family doctor (Heneghan et al., 2009). tor asks very few questions, spends very little time with  Summary 5 them and closes the consultation even before they have are going to be caused by the four conditions that are ‘warmed the seat’. In these circumstances the doctor is commonly seen by community pharmacists (tension-type probably exhibiting very good clinical reasoning. Research has shown that, with greater experience, doctors tend to headache, migraine, sinusitis and eye strain). This is not to say that it could not be caused by the other conditions, 1 rely more on non-analytical decision-making (e.g., pattern but the likelihood that they are the cause is much lower. recognition), whereas novice practitioners use analytical 2. STEP TWO: Take account of the person’s age and sex models (hypothetico-deductive reasoning) more frequently. Does age or sex have any bearing on shaping your Most pharmacists will exhibit some degree of clinical thoughts? The person is a woman – and we know mi- reasoning but most likely at a sub-conscious level. The key graines are more common in women compared with to better performance is shifting this activity from the sub- men. So although tension-type headache is the most conscious to conscious. Gaining clinical experience is fun- common cause of headache, the chances of it being damental to this process. Critical for pharmacists is the need caused by migraine needs to be given more prominence to learn from uncertainty. When referrals are made, every in your thinking. Will age affect your thinking? In this attempt should be made to either follow-up with the doctor case probably not as the common causes of headache about the outcome of the referral or encourage the patient do not really show any real variation with age. back to the pharmacy to see how they got on. Knowing what So at this point you should still be considering all another person (usually a more experienced diagnostician) four conditions as likely, but migraine as a cause should believed the diagnosis was allows you to build up experience be now be thought of more seriously alongside the most and, when faced with similar presenting symptoms, have a common cause of headache, the tension type. better idea of what the cause is. Without this feedback, phar- 3. STEP 3: The general appearance of the patient macists reach a ‘glass ceiling’, where the outcome is always Nothing obvious from her physical demeanour is con- the same – referral – which might not be necessary. structive towards your thinking. Her ‘distracted’ state might be as a consequence of the pain from the head- Differential Diagnosis – an example ache and worth exploring. A 35-year-old female patient, Mrs JT, asks to speak to the 4. STEP FOUR: Hypothetico-deductive reasoning pharmacist about getting some painkillers for her head- Each question asked should have a purpose – again, it is ache. She appears smartly dressed and in no obvious great about asking the right question, at the right time and discomfort but appears a little distracted. for the right reason. In this case we are initially consid- 1. STEP ONE: Use epidemiology to shape your thoughts ering the conditions of tension-type headache, migraine, In primary care, headache is a very common pre- sinusitis and eye strain (listed in that sequence in terms senting symptom that can be caused by many condi- of likelihood). It is important that your clinical knowl- tions. Table 1.1 highlights the conditions associated with edge is sufficiently sound to know how these different headache that can be seen by community pharmacists. conditions present so that similarities and differences are From this background information you should already known, allowing questions to be constructed to eliminate be thinking that the probability of Mrs JT’s headaches one type of headache from another. This will allow you to think of ‘targeted questions’ to ask. Table 1.2 highlights associated signs and symptoms of these four conditions. Table 1.1 We can see that location and nature of pain for the four Conditions associated with headache that can be conditions vary as do the severity of pain experienced (al- seen by community pharmacists though pain is subjective and difficult to measure reliably). Incidence Cause A reasonable first question then would be LOCATION of pain. If the patient says, ‘It is bilateral and towards the Most likely Tension-type headache back’, this points towards the tension-type headache (other Likely Migraine, sinusitis, eye strain causes are frontal or unilateral). Given this information if we asked about NATURE of Unlikely Cluster headache, medication overuse pain next, and working on the hypothesis of tension-type headache, temporal arteritis, trigeminal headache, we would be expecting a response from the neuralgia, depression patient of an ‘aching/non-throbbing headache’, which ­ Very unlikely Glaucoma, meningitis, sub-arachnoid might worsen as the day goes on. If patients describe haemorrhage, raised intracranial pressure symptoms similar to our expectation, this further points to tension-type headache as being the correct diagnosis. 6 Making a diagnosis Table 1.2 Associated signs and symptoms Duration Timing and nature Location Severity (pain Precipitating Who is score from factors affected? 0–10) Tension- Can last Symptoms worsen Bilateral; Most 2–5 Stress due to All age groups type days as day progresses. often at changes and both headache Non-throbbing back of head in work sexes pain or home equally environment affected Migraine Average Associated with Usually 4–7 Food (in 10% 3 times more attack menstrual cycle unilateral of sufferers); common in lasts and weekends. Family women 24 h Throbbing pain and history nausea. Dislike of bright lights/loud noises Sinusitis Days Dull ache that begins Frontal 2–6 Valsalva Adults as unilateral movements Eye strain Days Aching Frontal 2–5 Close-vision All ages work To further confirm your thinking, you could ask about SEVERITY of pain. In tension-type headache we are ex- Consultation and communication pecting a response that does not suggest debilitating pain. skills Again if we found that the pain was bothersome but not severe, this would point to tension-type headache. The ability of the community pharmacist to diagnose the pa- At this point we might want to ask other questions that tient’s presenting signs and symptoms is a significant chal- RULE OUT other LIKELY CAUSES. We know migraine is lenge given that, unlike most other healthcare professionals, associated with a positive family history. We would ex- community pharmacists do not normally have access to the pect the patient to say there was no family history if our patient’s medical record and thus have no idea about what working differential diagnosis is tension-type headache. the person’s problem is until a conversation is initiated. Likewise, asking about previous episodes of the same type For the most part, pharmacists will be totally dependent of headache would help rule out migraine due to its epi- on their ability to question patients in order to arrive at a sodic and recurrent nature. Similarly, eye strain is closely differential diagnosis. It is therefore vital that pharmacists associated with close visual work. If the person has not possess excellent consultation and communication skills been doing this activity more than normal, it tends to rule as a prerequisite to determining a differential diagnosis. out eye strain. Finally, sinusitis is a consequence of upper This will be drawn from a combination of good question- respiratory tract infection so, if the person has not had a ing technique, listening actively to the patient and picking recent history of colds, this will rule out sinusitis. up on non-verbal cues. So we are expecting certain responses to these ques- Many models of medical consultation and communication tions if the symptoms are a consequence of suffering have been developed. Probably the most familiar model and from a tension-type headache. If the patient answers in most widely used is the Calgary-Cambridge model of consulta- a contrary way, then this starts to cast doubt on your tion. This model is widely taught in both pharmacy and medical differential diagnosis. If this happens, you need to revisit education and provides an excellent platform in which to struc- your hypothesis and test another, – that is, think that the ture a consultation. The model is structured into: symptoms are caused by something else and ‘recycle’ your Initiating the session thought processes to test a hypothesis of a different cause Establishing initial rapport of headache. Identifying the reason(s) for the consultation  Conclusion 7 Gathering information Cantrill JA, Weiss MC, Kishida M, et al. Pharmacists’ Exploration of problems perception and experiences of pharmacy protocols: A step Understanding the patient’s perspective Providing structure to the consultation in the right direction? Int J Pharm Pract 1997; 5:26-32. Consumers’ Association. Counter advice. Which Way to 1 Building the relationship Health? 1999; 3:22-25. Developing rapport Driesen A, Vandenplas Y. How do pharmacists manage acute diarrhoea in an 8-month-old baby? A simulated client Involving the patient study. Int J Pharm Pract 2009; 17:215-220. Explanation and planning Horsley E, Rutter P, Brown D. Evaluation of Community Providing the correct amount and type of information Pharmacists’ Recommendations to Standardized Patient Aiding accurate recall and understanding Scenarios. Ann Pharmacother 2004:38;1080-1085. Achieving a shared understanding: Incorporating Iqbal N, Rutter P. Community Pharmacists Reasoning When the patient’s perspective Making a Diagnosis: A think-aloud study. Int J Pharm Pract Planning: Shared decision-making 2013; 21: S2, 17-8. Closing the session Lamsam GD, Kropff MA. Community pharmacists’ assessments and recommendations for treatment in four case scenarios. For more detailed information on this model, there are Ann Pharmacother 1998; 32:409-16. numerous Internet references available, and the authors of Rutter P, Patel J. Decision making by community pharmacists the model have written a book on communication skills when making an over-the-counter diagnosis in response to (Silverman et al., 2013). a dermatological presentation. SelfCare 2013;4:125–33. Shealy KM. Mnemonics to assess patients for self-care: Is there a need? SelfCare. 2014;5:11-18. Conclusion Silverman J, Kurtz S, Draper J. Skills for Communicating with Patients, 3rd Edition. CRC Press; 2013. Tucker R, Patel M, Layton AM, et al. An examination of the The way in which one goes about establishing what is comparative ability of primary care health professionals wrong with the patient will vary from practitioner to prac- in the recognition and treatment of a range of titioner. However, it is important that whatever method dermatological conditions. SelfCare 2013; 4:87-97. is adopted, it must be sufficiently robust enough to be of Which? Can you trust your local pharmacy’s advice? benefit to the patient. Using a clinical-reasoning approach http://www.which.co.uk/news/2013/05/can-you-trust-your- to differential diagnosis allows you to build a fuller picture local-pharmacys-advice-319886/ Accessed 17 March 2015. of the patient’s presenting complaint. It is both flexible and specific to each individual, unlike the use of mnemonics. Further Reading Heneghan C, Glasziou P, Thompson M, et al. Diagnostic strategies used in primary care. Brit Med J 2009; 338: b946. References Rutter P. Role of community pharmacists in patients’ self-care Akhtar S, Rutter P. Pharmacists thought processes in and self-medication. Journal of Integrated Pharmacy making a differential diagnosis using a gastro-intestinal Research and Practice 2015; 4:57-65 case vignette. Res Social Adm Pharm. http://dx.doi. Schneider C, Gudka S, Fleischer L, et al. The use of a written org/10.1016/j.sapharm.2014.09.003. assessment checklist for the provision of emergency Aradottir HAE, Kinnear M. Design of an algorithm to support contraception via community pharmacies: A simulated community pharmacy dyspepsia management. Pharm patient study. Pharm Pract 2013; 11:127-131. World Sci 2008; 30:515-525. Schneider C, Emery L, Brostek R, et al. Evaluation of the supply Bertsche T, Nachbar M, Fiederling J, et al. Assessment of a of antifungal medication for the treatment of vaginal computerised decision support system for allergic rhino- thrush in the community pharmacy setting: A randomized conjunctivitis counselling in German pharmacy. Int J Clin controlled trial. Pharm Pract 2013; 11:132-137. Pharm 2012; 34:17-22. Watson MC, Bond CM, Grimshaw JM, et al. Factors predicting Bilkhu P, Wolffsohn JS, Taylor D, et al. The management of the guideline compliant supply (or non-supply) of non- ocular allergy in community pharmacies in the United prescription medicines in the community pharmacy. Qual Kingdom. Int J Clin Pharm 2013; 35:190-194. Saf Health Care. 2006; 15:53-57. Brata C, Gudka S, Schneider CR, et al. A review of the information-gathering process for the provision of medicines Lighter Reading for self-medication via community pharmacies in developing Helman C. Suburban Shaman – tales from medicine’s frontline. countries. Res Social Adm Pharm 2013; 9:370-383. Hammersmith Press Limited; Jan 2006. ISBN-10: 1905140088 This page intentionally left blank  Chapter 2 Respiratory system In this chapter Background 9 The common cold 20 General overview of the anatomy of the Sore throats 27 respiratory tract 9 Rhinitis 33 History taking and physical examination 10 Self-assessment questions 44 Cough 10 Background Upper respiratory tract The upper respiratory tract comprises those structures lo- Diseases of the respiratory tract are among the most com- cated outside the thorax: the nasal cavity, pharynx and mon reasons for consulting a GP. The average GP sees larynx. approximately 700 to 1000 patients each year with res- piratory disease. Although respiratory disease can cause Nasal cavity significant morbidity and mortality, the vast majority of conditions are minor and self-limiting. The internal portion of the nose is classed as the nasal cav- ity. The nasal cavity is connected to the pharynx through two openings called the internal nares. The cavity is di- vided into a larger respiratory region and a smaller olfac- General overview of the anatomy of tory region, which senses smells. The respiratory region is the respiratory tract lined with cilia and plays an important part in respiration because it filters out large dust particles. The inhaled air The basic requirement for all living cells to function and circulates, allowing it to be warmed by close contact with survive is a continuous supply of oxygen. However, a blood from the capillaries. Mucous secreted from goblet by-product of cell activity is carbon dioxide, which, if not cells also helps moisten the air. removed, poisons and kills the cells of the body. The prin- cipal function of the respiratory system is therefore the ex- Pharynx change of carbon dioxide and oxygen between blood and The pharynx is divided into three sections: atmospheric air. This exchange takes place in the lungs, where pulmonary capillaries are in direct contact with the nasopharynx, which exchanges air with the nasal cav- linings of the lung’s terminal air spaces: the alveoli. All ity and moves particulate matter towards the mouth other structures associated with the respiratory tract serve oropharynx and laryngopharynx, which serve as a to facilitate this gaseous exchange. common passageway for air and food The respiratory system is divided arbitrarily into the laryngopharynx, which connects with the oesophagus upper and lower respiratory tracts. In addition to these and the larynx and, like the oropharynx, serves as a structures, the respiratory system also includes the oral common pathway for the respiratory and digestive cavity, rib cage and diaphragm. systems. 10 Respiratory system Larynx (voice box) Cough The larynx is a short passageway that connects the phar- ynx with the trachea and lies in the midline of the neck. Background The glottis and epiglottis are located here and act like ‘trap doors’ to ensure that liquids and food are routed into the Coughing is the body’s defence mechanism in attempt to oesophagus and not the trachea. clear airways of foreign bodies and particulate matter. This is supplemented by the mucociliary escalator (the upward beating of the finger-like cilia in the bronchi that move Lower respiratory tract mucous and entrapped foreign bodies to be expectorated The lower respiratory tract is located almost entirely within or swallowed). Cough is the most common respiratory the thorax and comprises the trachea, bronchial tree and symptom and one of the few ways by which abnormalities lungs. of the respiratory tract manifest themselves. Cough can be very debilitating to the patient’s well-being and can also be disruptive to family, friends and work colleagues. Trachea (windpipe) and bronchi Coughs can be described as either productive (chesty) or The trachea lies in front of the oesophagus and extends non-productive (dry, tight, tickly). However, many patients from the larynx to the fifth thoracic vertebra where it di- will say that they are not producing sputum, although vides into the right and left primary bronchi. The bronchi they go on to say that they ‘can feel it on their chest’. In divide and subdivide into bronchioles, and these in turn these cases the cough is probably productive in nature and divide to form terminal bronchioles, which give rise to al- should be treated as such. veoli where gaseous exchanges take place. The epithelial Coughs are either classified as acute or chronic in na- lining of the bronchial tree acts as a defence mechanism ture. The British Thoracic Society Guidelines (2006) rec- known as the mucociliary escalator. Cilia on the surface of ommend that: cells beat upwards in organised waves of contraction, thus expelling foreign bodies. acute cough lasts less than 3 weeks chronic cough lasts more than 8 weeks Lungs The guidelines acknowledge that a ‘grey area’ exists for those coughs lasting between 3 and 8 weeks as it is diffi- The lungs are paired, cone-shaped organs in the thoracic cult to define their aetiological basis because all chronic cavity, protected by the rib cage. Enclosing the lungs (and coughs will have started as an acute cough. For commu- providing further protection) are the pleural membranes; nity pharmacy practice this ‘grey area’ is rather academic, the inner membrane covers the lungs and the outer mem- as any cough lasting longer than the accepted definition brane is attached to the thoracic cavity. Between the of acute should be referred to a medical practitioner for membranes is the pleural cavity, which contains fluid further investigation. and prevents friction between the membranes during breathing. Prevalence and epidemiology Statistics from UK general medical practice show that res- History taking and physical piratory illness accounts for more patient visits than any examination other disease category. Acute cough is usually caused by a viral upper respiratory tract infection (URTI) and consti- Cough, cold, sore throat and rhinitis often coexist, and tutes 20% of consultations. This translates to 12 million an accurate history is therefore essential to differentially GP visits per year and represents the largest single cause diagnose a patient who presents with symptoms of respira- of primary care consultation. These data are echoed else- tory disease. A number of similar questions must be asked where; for example, episodes of URTI are the most com- for each symptom, although symptom-specific questions mon acute condition seen in Australian general practice. are also needed (these are discussed under each heading In community pharmacy the figures are even higher, with that follow). Currently, examination of the respiratory at least 24 million visits per year (or 2000 visits per UK tract is outside the remit of the community pharmacist, pharmacy each year). unless they have additional qualifications (e.g., independ- Schoolchildren experience the greatest number of ent prescriber status). coughs, with an estimated 7–10 episodes per year (compared  Cough 11 with adults with 2–5 episodes per year). Acute viral URTIs Clinical features of acute viral cough exhibit seasonality, with higher incidence seen in the winter months. Viral coughs typically present with sudden onset and associated fever. Sputum production is minimal and 2 symptoms are often worse in the evening. Associated Aetiology cold symptoms are also often present; these usually last A five-part cough reflex is responsible for cough produc- between 7 and 10 days. Duration of longer than 14 days tion. Receptors located mainly in the pharynx, larynx, tra- might suggest ‘postviral cough’ or possibly indicate a chea and bifurcations of the large bronchi are stimulated bacterial secondary infection, but this is clinically diffi- via mechanical, irritant or thermal mechanisms. Neural cult to establish without sputum samples being analysed. impulses are then carried along afferent pathways of the A common misconception is that cough with mucopu- vagal and superior laryngeal nerves, which terminate at rulent sputum is bacterial in cause and requires referral. the cough centre in the medulla. Efferent fibres of the va- This is almost never the case, and people should not be gus and spinal nerves carry neural activity to the muscles routinely referred to the GP for cough associated with of the diaphragm, chest wall and abdomen. These muscles mucopurulent sputum. contract and are followed by the sudden opening of the glottis, which causes coughing. Conditions to eliminate Likely causes Arriving at a differential diagnosis Upper airways cough syndrome (previously referred to The most likely cause of acute cough in primary care for as postnasal drip; also referred to as rhinosinusitis) all ages is a viral infection. Recurrent viral bronchitis is Postnasal drip has been broadened to include a number most prevalent in preschool and young school-aged chil- of rhinosinus conditions related to cough. The umbrella dren, and is the most common cause of persistent cough in term of upper airways cough syndrome (UACS) is being children of all ages. Table 2.1 highlights those conditions adopted. that can be encountered by community pharmacists and UACS is characterised by a sinus or nasal discharge their relative incidence. that flows behind the nose and into the throat. Patients As viral infection is by far the most likely cause of should be asked whether they are swallowing mucous cough in all age groups, it is logical to hypothesise that or notice that they are clearing their throat more than this will be the cause of the cough and questions should usual, as these features are commonly seen in patients be directed to help confirm or refute this assumption (us- with UACS. Allergies are one cause of UACS. Coughs ing ­hypothetico-deductive reasoning – see page 3) Asking caused by allergies are often non-productive and worse symptom-specific questions will help the pharmacist es- at night. However, there are usually other associated tablish a differential diagnosis (Table 2.2). symptoms, such as sneezing, nasal discharge/blockage, conjunctivitis and an itchy oral cavity. Cough of allergic origin might show seasonal variation, for example, hay Table 2.1 fever. Other causes include vasomotor rhinitis (caused by Causes of cough and their relative incidence in odours and changes in temperature/humidity) and post- community pharmacy infectious UACS after a URTI. If UACS is present, it is Incidence Cause better to direct treatment at the cause of the UACS (e.g., antihistamines or decongestants) rather than just treat Most likely Viral infection the cough. Likely Upper airways cough syndrome (formerly known as postnasal drip and includes Acute bronchitis allergies), acute bronchitis Acute bronchitis affects over 4% of adults a year in the UK. Most cases are seen in autumn or winter, and symp- Unlikely Croup, chronic bronchitis, asthma, toms are similar to viral URTI, but patients also tend to pneumonia, ACE-inhibitor induced exhibit dyspnoea and wheeze. The cough usually lasts Very unlikely Heart failure, bronchiectasis, for 7 to 10 days but can persist for 3 weeks. The cause tuberculosis, cancer, pneumothorax, is normally viral, but sometimes bacterial. If bacterial lung abscess, nocardiasis, GORD in origin, symptoms usually resolve without antibiotic treatment. 12 Respiratory system ? Table 2.2 Specific questions to ask the patient: Cough Question Relevance Sputum colour Mucoid (clear and white) is normally of little consequence and suggests that no infection is present Yellow, green or brown sputum normally indicates infection. Mucopurulent sputum is generally caused by a viral infection and does not require automatic referral Haemoptysis can either be rust coloured (pneumonia), pink tinged (left ventricular failure) or dark red (carcinoma). Occasionally, patients can produce sputum with bright red blood as one-off events. This is due to the force of coughing, causing a blood vessel to rupture. This is not serious and does not require automatic referral Nature of sputum Thin and frothy suggests left ventricular failure Thick, mucoid to yellow can suggest asthma Offensive foul-smelling sputum suggests either bronchiectasis or lung abscess Onset of cough A cough that is worse in the morning may suggest upper airways cough syndrome, bronchiectasis or chronic bronchitis Duration of cough Upper respiratory tract infection (URTI) cough can linger for more than 3 weeks and is termed ‘postviral cough’. However, coughs lasting longer than 3 weeks should be viewed with caution, as the longer the cough is present, the more likely a serious pathology is responsible; for example, the most likely diagnoses of cough are as follows: at 3 days’ duration will be a URTI; at 3 weeks’ duration will be acute or chronic bronchitis; and at 3 months’ duration conditions such as chronic bronchitis, tuberculosis and carcinoma become more likely Periodicity Adult patients with recurrent cough might have chronic bronchitis, especially if they smoke Care should be exercised in children who present with recurrent cough and have a family history of eczema, asthma or hay fever. This might suggest asthma and referral would be required for further investigation Age of the patient Children will most likely be suffering from a URTI but asthma and croup should be considered With increasing age conditions such as bronchitis, pneumonia and carcinoma become more prevalent Smoking history Patients who smoke are more prone to chronic and recurrent cough. Over time this might develop in to chronic bronchitis and chronic obstructive pulmonary disease (COPD) day and often recur again the following night, with the Unlikely causes majority of children seeing symptoms resolve in 48 hours. Laryngotracheobronchitis (croup) Warm moist air as a treatment for croup has been used Symptoms are triggered by a recent infection with parain- since the 19th century. This is either done by moving the fluenza virus and account for 75% of cases, although child to a bathroom and running a hot bath or shower, or other viral pathogens include rhinovirus and respiratory by boiling a kettle in the room. However, current guide- syncytial virus. It affects infants aged between 3 months lines do not advocate humidification, as there is no evi- and 6 years and affects 2–6% of children. The incidence is dence to support its use. highest between 1 and 2 years of age and occurs more in Croup management is based on an assessment of sever- boys than in girls; it is more common in autumn and win- ity. Parents should be advised that if the child’s symptoms ter months. Symptoms occur in the late evening and night. persist beyond 48 hours or they exhibit any symptoms The cough can be severe and violent, and is described as of stridor/distress, then medical intervention is required. having a barking (seal-like) quality. In between cough- Standard treatment for those children with stridor would ing episodes the child may be breathless and struggle to be oral or intra-muscular dexamethasone or nebulised breathe properly. Typically, symptoms i­mprove during the budesonide (Russell et al., 2011).  Cough 13 Chronic obstructive pulmonary disease (COPD) patients with reversible airway disease demonstrated no Chronic bronchitis (CB), along with emphysema, is charac- increase in adverse respiratory effects). terised by the destruction of lung tissue and collectively they are known as chronic obstructive pulmonary disease (COPD). In the context of presentations to a community phar- macist, asthma can present as a non-productive cough, 2 The prevalence of COPD in the UK is uncertain. However, especially in young children where the cough is often figures from the Health and Safety Executive (2014) estimate worst at night. In these cases pay particular attention to that over a million individuals currently have a diagnosis of other possible symptoms such as chest tightness, wheeze COPD, which accounts for 25 000 deaths each year. and difficulty in breathing, which may be frequent and Patients with CB often present with a long-standing recurrent, and occur even when the child does not have history of recurrent acute bronchitis in which episodes a cold. become increasingly severe and persist for increasing du- ration until the cough becomes continual. CB has been Pneumonia (community acquired) defined as coughing up sputum on most days for three or Every year between 0.5% and 1% of adults in the UK more consecutive months over the previous 2 years. CB is will have community-acquired pneumonia. Bacterial in- caused by chronic irritation of the airways by inhaled sub- fection is usually responsible for pneumonia and most stances, especially tobacco smoke. A history of smoking commonly caused by Streptococcus pneumoniae (80% of is the single most important factor in the aetiology of CB. cases), although other pathogens are also responsible, e.g., In non-smokers the likely cause of CB is UACS, asthma or Chlamydia and Mycoplasma. Initially, the cough is non- gastro-oesophageal reflux. One study has shown that 99% productive and painful (first 24–48 hours), but it rapidly of non-smokers with CB and a normal chest x-ray suffered becomes productive, with sputum being stained red. The from one of these three conditions. intensity of the redness varies depending on the causative CB starts with a non-productive cough that later be- organism. The cough tends to be worst at night. The pa- comes a mucopurulent productive cough. The patient tient will be unwell, with a high fever, malaise, headache should be questioned about smoking habit. If the patient is and breathlessness, and experience pleuritic pain (inflam- a smoker, the cough will usually be worse in the morning. mation of pleural membranes, manifested as pain to the Secondary infections contribute to acute exacerbations sides) that worsens on inspiration. Urgent referral to the seen in CB. It typically occurs in patients over the age doctor is required to conduct tests such as C-reactive pro- of 40 and is more common in men. Pharmacists have an tein to establish the need for antibiotics. important role to play in identifying smokers with CB, as this provides an excellent opportunity for health promo-