[Back to Basics] Responding to Symptoms

NOTE: This post is intended for qualified healthcare professionals, specifically pharmacists and pharmacy technicians. For advice on specific medications, please contact the appropriate healthcare professional.

The [Back to Basics] series:

• Screening Prescriptions
• Responding to Symptoms
• Transfer of Care (coming soon)
• Patient Counselling (coming soon)

So you’ve just qualified as a pharmacist — great! But does your brain still freeze when a patient throws a bunch of symptoms at you? I know mine did.

I’d mentally kick myself after they left the pharmacy as I remembered all the points I should have discussed. I’d trained for this after all!

At least as a pre-reg/trainee pharmacist you had your tutor or another pharmacy professional to rely on. Now you’re running the show, and it couldn’t be clearer that you’re ‘faking it till you make it’.

Let’s go through the basics of responding to symptoms — a bread-and-butter skill that every pharmacist or pharmacy technician should have in their arsenal.

Why have I included pharmacy techs? Pharmacy technicians are skilled professionals who are invaluable to the running of a successful pharmacy service. This might be in hospital, community or GP.

Technicians are becoming more upskilled, taking over tasks that have traditionally been pharmacist-led. This includes running their own long-term conditions clinics.

What is ‘responding to symptoms’?

Responding to symptoms (RTS) is a core part of a pharmacy professional’s role. It is the ability to formulate care plans ad-hoc for patients that approach you with symptoms.

You may also have heard it referred to as dealing with ‘minor ailments’.

Patients can ask any healthcare professional about their symptoms. Pharmacy staff are probably the most accessible healthcare professionals, especially if you work in community.

This accessibility is good for patients as they have an easy way to get reliable information. It might not be so good for you if you’re unprepared to deal with what they ask.

There is no shortage of resources for responding to symptoms. Your university or pre-registration course may give you a handbook of all the likely symptoms you might encounter in a pharmacy. These can include mnemonic devices such as WWHAM, ASMETHOD and a bunch of others.

As a highly skilled clinician, try to move away from these mnemonic devices. They can be useful, but they provide a basic level of information. Mnemonics are ideal for a counter assistant or dispenser who may decide to pass a more complex minor ailment on to you.

I want to take you through a common sense approach to develop your clinical reasoning.

Pharmacy professionals are far more clinically involved with patients than they were even ten years ago. Our ability to use our professional judgement, even with ‘minor’ ailments, can massively improve patient outcomes.

Instead of giving you info to memorise, I want you to focus on the skills you want to embed in your practice.

Let’s start with this scenario:

A woman walks into the pharmacy with a little boy in tow. She explains to you that her son has had gunk coming out of his eye for the past few hours. He’s otherwise well and is terrorising the shelf of shampoo bottles in the corner of the store.

1. Gathering information

You might be thinking of course, IT’S CONJUNCTIVITIS! That’d be a valid idea, but let’s not jump ahead of ourselves. We need to gather some more information.

But how do you know what information to gather? Do you need to know the colour of the gunk? The time of day it comes out? Does it have a smell?

… if you’ve read your RTS and OTC guidelines, you know those questions sound a bit weird. That’s because you need to ask questions that are in line with what you suspect.

Use the clinical knowledge you’ve spent years studying to pin down what you think these symptoms might indicate.

What if I don’t suspect a particular diagnosis? That’s normal — not everything will be as cut-and-dry like in a textbook. In fact, most things hinge on a scale of probability.

Start thinking: ‘it’s more likely to be A than B because of xyz’. Many things in healthcare are not concrete and often you’re dancing with probabilities. That’s why it’s important to safety net just in case it’s something you didn’t suspect.

You have a suspected diagnosis in mind — conjunctivitis — but there are other factors to consider.

You can uncover these factors by asking the right questions. These factors will either escalate, exclude or confirm your diagnosis.

What do I mean by this?

Escalate —

(This is where you ask the red-flaggy questions)

• How old is the child? (< 2 years old will need to be seen by a doctor)
• Is there any pain in the eye?
• Any redness in the eye? (severe redness can indicate a worsening condition)
• Have they tried any treatment already? (If it’s a persistent infection, they’re likely to have already tried antibiotic eye drops)
• Any change in sight?
• Any flashing lights or visual disturbances?
• Any headaches?
• Otherwise eating and drinking normally? (Important to ask with children)

Escalate means you may suspect a diagnosis but it is beyond the scope of your practice: you need to refer to another health provider. This might be a GP, NHS 111, urgent care or A&E.

It’s important to stress the importance of how urgent this is — is it something that needs to be seen in the next 24 hours? Can it wait a few weeks for a GP appointment?

Exclude —

(These questions will help establish if there are any other diagnoses)

• Is there any history of allergic conditions e.g. eczema, asthma or hayfever? (Possibly allergic conjunctivitis)
• Is the eye itchy?
• Are both eyes affected? (Possibly dry eyes or spreading infection)
• Are the edges of the eyelids swollen or inflamed? (Could be blepharitis)

Depending on the symptoms the patient has, you could have quite a few exclude questions to ask. But that’s good because the more questions you ask to either escalate or exclude, the easier it is to confirm.

Confirm —

• Do the eyelids stick together when waking up?
• Do the eyes feel gritty?

You can see there’s fewer questions as we go down the stages. This is useful because you know a) it’s not something urgent and b) it’s something you can potentially advise on.

This is where your knowledge of OTC treatments and self-care advice comes into play.

You don’t need to memorise these three stages but try and implement them into your questioning process. Think about what you do well in your practice already and what you might need to improve on.

Note: the questions above are just for the purpose of the guide and not an exhaustive list

2. Treat and/or give advice

Before you jump ahead to selling the most expensive brand of eye ointment, establish the patient’s expectations first.

Not everyone will want medication! Some people just want to know what’s happening to them and want to manage it themselves at home.

You can support this by offering self-care advice. But if you think they really ought to have treatment, perhaps explore why they feel reluctant.

On the other side, if someone really wants a medication that you’re hesitant to give, find out why they feel they absolutely need it.

Perhaps what they need is reassurance about the time frame of symptoms. It might be worth explaining the expectations of symptom management. For example, if they don’t feel better after 48 hours, come back to the pharmacy or speak to a GP.

3. Safety netting

A key part of any minor ailment plan is safety netting. Remember you’re not just treating what’s in front of you but you’re also anticipating what might come next.

Safety netting does not mean telling patients to go to A&E if they feel worse! It’s not always the most appropriate place to go (and A&E staff won’t appreciate it either).

Safety netting can mean the patient coming back to you if they don’t get better. For certain minor ailments, the pharmacy might be a better place to get alternative treatments, like for constipation.

Safety netting helps patients ‘identify the need to seek further medical care if their condition fails to improve or change’.

Good safety netting should:

• Establish a time frame
• Be specific about warning symptoms

In this example, you might say to the mum: ‘If the gunk doesn’t clear up after 48 hours of using the eye drops, make an appointment with the GP.’

This is better than saying, ‘If his eye looks worse then you might need to see the GP’.

While we might be weighing uncertainties in our heads, it’s important for patients to feel confident in our advice. This is why being specific is important.

As a freshly baked pharmacist, I often forgot to counsel on this — there was just too much to remember!

An efficient consultation comes with practice, so go easy on yourself and don’t be tempted to rush.

Getting comfortable in the grey area

Real clinical situations are rarely as black-and-white as a pharmacy textbook. Balancing the grey area of minor ailments and being comfortable in your decision-making is a sign of maturing as a clinician.

You’re not just relying on rote learning but on professional judgement.

When I realised this and internalised the concept of ‘working in the grey’, my confidence as a pharmacist grew.

Remember, you’re working with probabilities.

It’s alright if the child didn’t actually have conjunctivitis.

You made a decision based on the evidence at hand and the likelihood that it was an infection.

You can use this guide in any sector of pharmacy, not just community.

You may run triage clinics in a GP practice where patients will present with a range of symptoms.

A ward doctor may ask for your advice on prescribing for minor ailments in hospital.

Try visualising your minor ailments process as a kind of flow chart, like what you might see in the NICE guidelines. You can apply this process to any patient consultation.

Over time you’ll develop your own way of consulting, finding out information and making a decision based on professional judgement.

Don’t be afraid of getting things wrong (though don’t aim for it either!) because we all make mistakes.

What matters is how we learn from our mistakes and change our practice to reflect our experiences.

If you found this guide useful, buy me a coffee!

I’m on a mission to create useful content for pharmacy professionals that is:

• accessible
• empathetic
• easy to digest

It takes time to produce high-quality content so if you think this is worthwhile, please consider buying me a cup of coffee! And of course, share this guide with others who may find it useful 😊