Referring consumers in pharmacy

June 2014

Referral

Appropriate referral is an essential component of appropriately treating patients in a community pharmacy.

This is an area that many PHRM2011 students find challenging, and is often raised by tutors as an area that needs work.

The following brief notes are intended to help you think through referral for some of the conditions we have discussed. These notes don’t contain all the referral points that you need to consider

Referral and over-the-counter requests

  1. Ask the patient to describe what they have been experiencing in their own terms. This should be done early with an open question: Can you describe your symptoms?
  2. Use targeted questions to confirm that the patient has a condition that can be treated in the pharmacy, and
  3. Rule out symptoms that suggest the patient should be reviewed by a medical practitioner
  4. If you treat, ensure that the patient knows what to expect from treatment. Provide information on when they should seek further assistance.

You should work through each of these in every interaction.

Step 2 and 3 are checking the “differential diagnoses” and done during information gathering. Step 4 should be incorporated into counselling on the treatment

Referral points often depend on context

Example: Coloured mucus may be a referral point in the common cold if the patient has other signs of infection, e.g. the patient also has symptoms that have not resolved within 2 weeks and have a persistent raised temperature.

Coloured mucus is not a referral point in the absence of other signs of infection.

General referral points

Chest Gastrointestinal Musculoskeletal
Chest pain Difficulty swallowing Severe impact
Wheezing Blood in vomit Inability to weight bear
Blood in sputum Bloody diarrhoea Impaired range of movement
Palpitations Inexplicable weight loss
Persistent cough Alternating bowel habit
Whooping cough Vomiting with constipation

Blenkinsopp, Symptoms in the pharmacy (available online via the UQ Library) has an appendix that lists many of these and more.

Common cold—differential diagnoses

Common cold Bacterial bronchitis Influenza Other conditions
Duration 7–10 days May last > 7 days 7–14 days Acute otitis media
Worse then gets better Stable or worsening Worse then better Sinusitis
Few systemic symptoms Pronounced cough Systemic symptoms (more)
Mainly upper-respiratory Protracted cough Fatigue
Might start after cold Refer very young/old

GORD—alarm symptoms

GORD Alarm symptoms Endoscopy indication*
Retrosternal discomfort Chest pain > 55 and first symptoms
Responds to therapy Lack of treatment response Family history of GI cancer
Typically worse after meals Dysphagia/odynophagia
Anaemia
Suspected GI bleeding
Unexplained weight loss

*In addition to alarm symptoms

Summary