Diagnosis and history taking in the pharmacy History taking  very important but not difficult to learn Required Skills: Differential diagnosis of minor ailments Not easily distracted or feel pressured The ability to ask the ‘right’ questions The ability to give the correct advice

General Rules-1 Who is the patient? You or absent? Why absent? If absent- uncertain about severity and nature of disease self-treatment unwise Child? Open-ended: ‘What is the problem?’ ‘How do you feel?’ Observe: ‘does the patient look ill?’ (body language, esp. babies)

General Rules-2 SIT DOWN SIR! Any current or recent medicines? (OTC and Rx) Later in the interview: Personal or family history, occupational or social habits (e.g. drinking, smoking, and exercise) The description of the illness can be expanded by asking more specific and structured questions SIT DOWN SIR!

A reminder of questions to ask about symptoms Site or location I Intensity or severity T Type or nature D Duration O Onset W With (other symptoms) N aNnoyed or aggravated by Spread or radiation Incidence or frequency pattern R Relieved by

Site/Location e.g. Abdominal pain:  ???appendicitis (Central pain, moving to the right iliac fossa)  ????Renal colic (pain in the right or left loin or iliac fossa)  ???Peptic ulcer (central or epigastric)  ???Biliary colic (right hypochondrium)

Appendicitis pain

Biliary Colic pain

Renal Colic

Site/Location e.g. Headache Unilateral migraine Frontal  migraine, sinusitis or tension Occipital tension, muscle spasm, or subarachnoid hemorrhage e.g. skin rash Localised reaction to a watchstrap Whole body allergy to an antibiotic subarachnoid hemorrhage= heamorage into the subarachnoid space  a space between the arachnoid membrane and the pia mater which contains the CSF.

Papule pimple whiteheads blackheads pustule

Descriptive Dermatologic Terms

Intensity/severity Of e.g. skin rash, pain or bleeding from a wound Gives information not only about the likely diagnosis but also about the urgency of situation (monitor, give OTC or refer to doctor)

Type or nature e.g. abdominal pain e.g. skin rash Flat or raised Cramp like or colicky involvement of a hollow organ bowel or ureter ‘gnawing’ peptic ulcer Throbbing stabbing e.g. skin rash Flat or raised Single or multiple Blistering or dry Help to differentiate certain conditions

Skin

Duration Helps to differentiate conditions: e.g. migraine (few hours) from tension HA (few days or weeks) Helps to decide when to refer: e.g a baby with 3 days diarrhea doctor. A baby with few hours diarrhea may respond adequately to hydration with a simple electrolyte mixture

Onset Provides clues to its likely cause E.g. abdominal pain or diarrhea that starts soon after overindulgence in a restaurant E.g. Headache occurs on awakening after a long night  reassurance, empathy and OTC drug

Accompanying symptoms Usually not volunteered by the patient Crucial to differentiate many symptoms e.g. productive cough with/without blood e.g. diarrhea with/without blood e.g. red eye with itching or with pain and photophobia

Aggravating Factors Valuable for some conditions: e.g. pain of peptic ulcer can be worsened by a heavy meal or alternatively by fasting- while pain of gallstones worsened by fatty meal e.g. headaches: raised ICP worse by lying down (mornings) while tension headaches maybe better in the mornings but worsen as the day goes by

Spread or radiation e.g. referred pain Appendicitis (central, radiates to the right iliac fossa), angina (radiates to arm or jaw), biliary colic (pain in the upper abdomen that is referred to the back and felt between the shoulder blades) Skin rash- single discrete lesion in one part of the body before spreading elsewhere, while others present in more generalized way

Incidence or frequency Sometimes the pattern is characteristic e.g. classic migraine: rarely occurs twice in same week, whereas cluster migraine occurs everyday, same time of the day for several weeks e.g. hayfever versus common cold: differentiate by months of the year

Relieving Factors e.g. pain of peptic ulcer-> relieved by small snacks e.g. migraine attack can be terminated by vomiting e.g. medicines relieve/diagnose: GTN can relieve anginal attack, while antacid can relieve reflux dyspepsia but NOT VICE VERSA!

Other factors also play a role in efective history taking: experience. Never use negative words like cancer, tumor etc. (see cartoon)

Why clinicians must be familiar with OTC products? Many OTC products are effective in treating common ailments and at less cost, Many active ingredients contained in OTC drugs may worsen existing medical conditions or interact with prescription medication. E.g. antacids bind many drugs, thus reduce absorption. Cimetidine inhibits hepatic microsomal drug-metabolizing enzymes. Misuse or abuse of OTC products may actually produce significant medical complications

Note: Many of the more potent OTC ingredients are hidden in products where their presence would not ordinarily be expected: Examples: Alcohol (% ethanol) in cough syrups, cold preparations, and mouthwashes Antihistamines in analgesics, menstrual products, sleep aids, Aspirin & other salicylates: in antidiarrheals, cough/allergy preparations Caffeine in analgesics, menstrual products and stimulants

5. Benzocaine in antitussives/lozenges, dermatologic preparations, hemorrhoidal products, toothache, cold sore and teething products 6. Sodium in analgesics, antacids and laxatives 7. Sympathomimetics in analgesics, asthma products, cough, cold and allergy preparations, hemorrhoidal products and sore throat products