PH1122- reasons to refer Flashcards
What are reasons to refer oral thrush ?
DIABETIC PATIENTS May indicate poor diabetic control- Refer As soon as practicable
DURATION > 3 WEEKS Unlikely to be thrush and needs further investigation by a doctor- Refer as soon as practical
treatment hasn’t worked after 1 week
IMMUNOCOMPROMISED PATIENTS- Likely to have severe and extensive involvement; outside community pharmacist’s remit- Urgent possible same-day referral
PAINLESS LESIONS- Sinister pathology- Urgent possible same-day referral
What are reasons to refer Headlice
No obvious reasons unless parent really doesn’t want to pay the price for headline treatment
What are reasons to refer a sore throat
AFTER 2 WEEKS - refer as soon as practicable
TONSILLAR EXUDATE with high temperature and swollen glands - possible bacterial cause
MEDICATION that interferes with immune response (e.g., immunosuppressants, disease-modifying antirheumatics)- refer as soon as practicable
DYSPHAGIA (can’t swallow) - Urgent referral
What are reasons to refer a red eye ?
CLOUDING OF THE CORNEA or
ASSOCIATED VOMITING- Suggests glaucoma- Refer Immediately to emergency department
REDNESS CAUSED BY A FOREIGN BODY- Requires removal of body (but outside the remit of community pharmacist)- Urgent same-day referral to an optician
IRREGULAR-SHAPED PUPIL OR ABNORMAL PUPIL REACTION TO LIGHT
PHOTOPHOBIA
TRUE EYE PAIN
DISTORTION OF VISION
REDNESS LOCALIZED AROUND THE LIMBAL AREA Suggest sinister pathology- all of which - Urgent same-day referral to an optician
What are reasons to refer dry eye ?
ASSOCIATED DRYNESS OF MOUTH AND OTHER MUCOUS MEMBRANES- Sjögren’s syndrome? As soon as practicable
OUTWARD TURNING LOWER EYELID - Requires medical intervention- Refer as soon as practical
What are reasons to refer a cough ?
CHEST PAIN
HAEMOPTYSIS
PAIN ON INSPIRATION
WHEEZING AND/OR SHORTNESS OF BREATH - All symptoms suggest possible sinister pathology or severe cases of simple viral infection- Urgent same-day referral.
Depending on severity, may mean referring to hospital rather than GP
DURATION > 3 WEEKS
COUGH THAT RECURS ON A REGULAR BASIS- Suggests nonacute cause of cough and requires further investigation-Refer As soon as practicable
DEBILITATING SYMPTOMS IN OLDER ADULTS (making them feel weak)- This patient group at greater risk of complications- Urgent same-day referral
PERSISTENT NOCTURNAL COUGH IN CHILDREN Suggests possible asthma- Refer as soon as practicable
younger than 3 months suffering from croup or symptoms don’t improve after 48 hours
What are reasons to refer for the common cold ?
ACUTE SINUS INVOLVEMENT THAT FAILS TO RESPOND TO OTC DECONGESTANT THERAPY- Possible need for nasal steroids or antibiotics- As soon as practicable
MIDDLE EAR PAIN THAT FAILS TO RESPOND TO ANALGESIA- possible need for antibiotics- Refer as soon as practicable
PATIENTS WITH SYMPTOMS INDICATIVE OF FLU; VULNERABLE PATIENT GROUPS, SUCH AS THE VERY OLD- Need an assessment of symptom severity by physician - Same-day referral
What are reasons to refer rhinitis ?
FAILED MEDICATION
MEDICINE-INDUCED RHINITIS- Requires discussion with a doctor for alternative treatment- Refer as soon as practicable
NASAL BLOCKAGE THAT FAILS TO CLEAR- Suggests polyp
UNILATERAL DISCHARGE, ESPECIALLY IN CHILDREN POSSIBLE TRAPPED FOREIGN BODY - Same-day GP referral
What are reasons to refer for ear wax ?
DIZZINESS OR TINNITUS Suggests inner ear problem; requires further investigation- refer as soon as practicable
FEVER AND GENERAL MALAISE IN CHILDREN - Middle ear infection?
ASSOCIATED TRAUMA-RELATED CONDUCTIVE DEAFNESS
FOREIGN BODY IN THE EAR
OVER-THE-COUNTER (OTC) MEDICATION FAILURE Requires further investigation by a doctor
What are reasons to refer otitis ?
GENERALIZED INFLAMMATION OF THE PINNA
MUCOPURULENT DISCHARGE
SYSTEMICALLY UNWELL- Possibly indicates perichondritis - Otitis media? Same-day referral for all
IMPAIRED HEARING IN CHILDREN NOT ASSOCIATED WITH EARWAX- development of glue ear? As soon as practicable
SLOW-GROWING GROWTHS ON THE PINNA IN OLDER ADULTS POSSIBLY indicate malignancy
What are reasons to refer for a headache ?
HEADACHE IN CHILDREN <12 YEARS OLD WHO HAVE A STIFF NECK, HIGH TEMPERATURE OR SKIN RASH Meningitis? Immediate referral to general practitioner (GP) or A&E
HEADACHE AFTER RECENT (1–3 MONTHS) TRAUMA OR INJURY Haematoma?
NAUSEA AND/OR VOMITING IN THE ABSENCE OF MIGRAINE SYMPTOMS
NEUROLOGICAL SYMPTOMS, IF MIGRAINE IS EXCLUDED, ESPECIALLY CHANGE IN CONSCIOUSNESS
VERY SUDDEN AND/OR SEVERE ONSET OF HEADACHE All can suggest sinister pathology and require further investigation.
NEW OR SEVERE HEADACHE IN PATIENTS > 50 YEARS
PROGRESSIVE WORSENING OF HEADACHE SYMPTOMS OVER TIME - As soon as practicable to GP
HEADACHE UNRESPONSIVE TO ANALGESICS SIMPLE ANALGESIA IS EFFECTIVE; IF THIS HAS NOT WORKED, THE PATIENT’S SYMPTOMS REQUIRE FURTHER INVESTIGATION.
Suspect medication overuse headache.
What are reasons to refer insomnia ?
DURATION >4 WEEKS; CHILDREN Outside the remit of community pharmacists; likely to be associated with underlying causes and requires investigation Soon as practicable
INSOMNIA FOR WHICH NO CAUSE CAN BE ASCERTAINED
SYMPTOMS SUGGESTIVE OF ANXIETY OR DEPRESSION INSOMNIA IS one of the cardinal symptoms of depression and anxiety and needs investigation - refer as soon as practicable
What are reasons to refer nausea and vomiting ?
Early-morning vomiting in women of childbearing age Suspect pregnancy Perform test as soon as practicable
Vomiting in children <1 year lasting >24 hours; children who fail to respond to OTC treatment Risk of dehydration Same-day referral
Unexplained nausea and vomiting in any age group Identifiable causes account for the vast majority of presentations Unknown causes should be viewed with caution Same-day referral to GP
Moderate to severe abdominal pain Requires further and fuller investigation
What are reasons to refer cystitis ?
CHILDREN <16 YEARS Cystitis unusual in this age group As soon as practicable
PATIENTS WITH DIABETES- More likely to develop complications from a UTI
DURATION >7 DAYS- Does not suggest an uncomplicated UTI
or
IF THE SYMPTOMS HAVEN’T IMPROVED AFTER 3 DAYS
VAGINAL DISCHARGE- May indicate vaginitis
WOMEN >70 YEARS- More susceptible to complicated UTIs and pyelonephritis; also, symptoms may be indicative of atrophic vaginitis
PREGNANCY Pressure on the urinary tract caused by an infant makes management of UTIs more difficult and can increase the risk of pyelonephritis
HAEMATURIA- Blood may indicate a stone or a tumour Immediate to GP
IMMUNOCOMPROMISED- More likely to develop complications from a UTI
PATIENTS WITH ASSOCIATED FEVER AND FLANK PAIN Suggestive of a complicated UTI and/or pyelonephritis
IF 2 or more of dysuria, cloudy wee, and New nocturia
What are reasons to refer thrush ?
DISCHARGE THAT HAS A STRONG SMELL Thrush has no or little odour and therefore this suggests other causes, such as bacterial vaginosis or trichomoniasis As soon as possible
WOMEN <16 AND >60 YEARS Thrush is unusual in these age groups
PATIENTS WITH DIABETES Might suggest poor diabetic control As soon as practicable
OTC MEDICATION FAILURE- hasn’t resolved after 7 days
PATIENTS PREDISPOSED TO THRUSH
RECURRENT ATTACKS- Suggests underlying problem or misdiagnosis - four or more episodes a year
for all refer as soon as practicable
What are reasons to refer dysmenorrhoea?
HEAVY OR UNEXPLAINED BLEEDING Possibly dysfunctional uterine bleeding As soon as practicable
PAIN EXPERIENCED DAYS BEFORE MENSES
PAIN THAT INCREASES AT THE ONSET OF MENSES
WOMEN >30 YEARS WITH NEW OR WORSENING SYMPTOMS- possibly secondary dysmenorrhoea
Accompanying systemic symptoms, such as FEVER AND MALAISE Suggests possible infection or pelvic inflammatory disease refer as soon as practicable.
VAGINAL BLEEDING IN POSTMENOPAUSAL WOMEN Suggests potentially more sinister cause, such as carcinoma- refer Urgent same-day
What are reasons to refer menorrhagia ?
INTERMENSTRUAL BLEEDING, POSTCOITAL (after sex) BLEEDING, PELVIC PAIN POSSIBLY a sign of cervical or endometrial cancer Urgent same-day referral
TREATMENT FAILURE May indicate alternative diagnosis or more serious pathology As soon as practicable
What are reasons to refer an ulcer ?
CHILDREN < 10 YEARS- MAUs rare; hand, foot, and mouth disease possible in this age group- refer As soon as practicable
ULCERS > 1 CM IN DIAMETER
ULCERS IN CROPS OF 5–10 OR MORE
ASSOCIATED EYE INVOLVEMENT
DURATION LONGER THAN 14 DAYS Suggests other causes of ulceration outside scope of community pharmacist
PAINLESS ULCER Possible sinister pathology As soon as possible
What are reasons to refer oral thrush ?
DIABETIC PATIENTS May indicate poor diabetic control As soon as practicable
DURATION > 3 WEEKS Unlikely to be thrush and needs further investigation by a doctor
IMMUNOCOMPROMISED PATIENTS Likely to have severe and extensive involvement; outside community pharmacist’s remit Urgent possible same-day referral
PAINLESS LESIONS Sinister pathology- urgent same day referral
What are reasons to refer dyspepsia ?
ALARM signs and symptoms
• A naemia (signs include tiredness, pale complexion, shortness of breath)
• L oss of weight
• A norexia
• R ecent onset of progressive symptoms
• M elaena, dysphagia, and haematemesis
Symptoms requiring further investigation Urgent referral to GP
PAIN DESCRIBED AS SEVERE, DEBILITATING OR THAT AWAKENS THE PATIENT AT NIGHT
PERSISTENT VOMITING Suggests ulceration As soon as practicable
REFERRED PAIN Possible cardiovascular or biliary cause
What are some reasons to refer diarrhoea ?
DURATION LONGER THAN 2–3 DAYS IN CHILDREN or 1 day in 1 year old AND OLDER ADULTS
PATIENTS UNABLE TO DRINK FLUIDS At risk of dehydration and associated complications - Same-day referral
DIARRHOEA FOLLOWING RECENT TRAVEL TO TROPICAL OR SUBTROPICAL CLIMATE Giardiasis? As soon as practicable
CHANGE IN BOWEL (LONG-TERM) HABIT IN PATIENTS >40 YEARS
PRESENCE OF BLOOD OR MUCOUS IN THE STOOL Sinister pathology?
SUSPECTED FAECAL IMPACTION IN OLDER ADULTS
SEVERE ABDOMINAL PAIN Outside scope of community pharmacist - refer as soon as practicable
STEATORRHOEA- excess fat in faeces (very foul smelling, hard to flush) Malabsorption syndrome?
What are some reasons to refer constipation ?
PATIENTS >40 YEARS WITH A MARKED CHANGE IN BOWEL HABITS WITH NO OBVIOUS CAUSE Suspect rectal carcinoma Same-day referral
LONGER THAN 14 DAYS’ DURATION, WITH NO IDENTIFIABLE CAUSE This requires further investigation to rule out more sinister causes As soon as practicable
TIREDNESS Check for anaemia or thyroid dysfunction
PAIN ON DEFECATION THAT MIGHT CAUSE THE PATIENT TO SUPPRESS THE DEFECATION REFLEX Check for anal fissure
What are some reasons to refer IBS ?
BLOOD IN THE STOOL The presence of blood in the stool is unusual in IBS and can suggest inflammatory bowel disease As soon as practicable
FEVER
NAUSEA AND/OR VOMITING
Severe abdominal pain Not usually associated with IBS; suggests origin of symptoms from other abdominal causes
CHILDREN < 16 YEARS
PATIENTS > 45 YEARS WITH RECENT CHANGES TO BOWEL HABIT IBS is unusual in these age groups. Refer for further investigation
STEATORRHOEA Associated with malabsorption syndromes
What are some reasons to refer haemorrhoids ?
PERSISTENT OR MARKED CHANGE IN BOWEL HABIT IN PATIENTS >40 YEARS
UNEXPLAINED RECTAL BLEEDING Sinister pathology? Urgent to doctor
BLOOD MIXED IN THE STOOL
FEVER Suspect GI bleeds or inflammatory bowel disease
PATIENTS WHO HAVE TO REDUCE THEIR HAEMORRHOIDS MANUALLY OTC treatment will not help As soon as practicable
SEVERE PAIN ASSOCIATED WITH DEFECATION Anal fissure? - as soon as practicable
ANY PERSON COMPLAINING OF PROLAPSING HAEMORRHOIDS(LEAVING THE ANUS), which need reducing by the patient, should be referred because these patients might require nonsurgical intervention with sclerotherapy or rubber band ligation.
SYMPTOMS SUCH AS NAUSEA, VOMITING, LOSS OF APPETITE AND ALTERED BOWEL HABITS SHOULD BE VIEWED WITH CAUTION and underlying pathology suspected. Referral would be needed.
PATIENTS WITH SYMPTOMS THAT HAVE BEEN CONSTANTLY PRESENT FOR > 3 WEEKS should be referred.
GOOD PRACTICE DICTATES THAT PEOPLE UNDER 20 YEARS SUSPECTED of haemorrhoids should be referred.)
What are the reasons to refer eczema ?
Referral Undiagnosed atopic eczema Other eczema types Infection evidence Severe condition (fissured, bleeding) Failed treatment No identifiable cause Dermatitis duration longer than two weeks Unusual rash features Accompanying symptoms
What are the reasons to refer back pain ?
NUMBNESS
FEVER
PERSISTENT AND PROGRESSIVELY WORSENING PAIN
WEIGHT LOSS
SYSTEMICALLY UNWELL Possible sinister spinal pathology Immediate to general practitioner
BOWEL OR BLADDER INCONTINENCE Cauda equina syndrome (rare and very unlikely to be seen by a pharmacist)
PAIN THAT RADIATES AWAY FROM LOWER BACK AREA Sciatica As soon as practicable
BACK PAIN FROM STRUCTURES ABOVE THE LUMBAR REGION OUTSIDE scope of community pharmacist
FAILURE OF SYMPTOMS TO IMPROVE AFTER 4 WEEKS Requires further investigation as pain that becomes subacute/chronic requires medical intervention
YOUNGER AND OLDER PEOPLE (55 YEARS OLD) WITH NO IDENTIFIABLE CAUSE Suggests more sinister pathology
What are the reasons to refer a soft tissue injury ?
ACUTE INJURIES THAT SHOW IMMEDIATE SWELLING AND SEVERE PAIN Suggests fracture or complete ligament tear- Consider direct referral to emergency department
MARKED DECREASE OR EXCESSIVE RANGE OF MOVEMENT IN ANY JOINT May suggest major ligament disruption or complete tear
PATIENTS UNABLE TO BEAR ANY WEIGHT ON AN INJURED ANKLE OR FOOT
CHILDREN <12 YEARS AND OLDER ADULT PATIENTS Fractures more likely
What are the reasons to refer threadworm ?
MEDICATION FAILURE Possible misdiagnosis As soon as practicable
SECONDARY INFECTION OF PERIANAL SKIN DUE TO SCRATCHING Need for assessment and possible systemic antibiotics
What are the reasons to refer colic ?
The infant is not thriving, or symptoms are not starting to improve or are worsening after 4 months of age This may indicate GORD or intolerance to cow’s milk As soon as practicable
Overanxious parents Parents might need further reassurance
What are the reasons to refer atopic dermatitis ?
CHILDREN WITH MODERATE OR SEVERE ATOPIC DERMATITIS
MEDICATION FAILURE – PATIENT SUFFERS TWO OR MORE FLARE-UPS PER MONTH Outside scope of community pharmacist; patient probably needs corticosteroid therapy As soon as practicable
PRESENCE OF SECONDARY INFECTION (WEEPING AND CRUSTING LESIONS) Potentially needs systemic antibiotics Same day referral to GP
What are the reasons to refer fever in a child ?
ANY FEVERISH CHILD <3 MONTHS OLD
FEVER ACCOMPANIED WITH NO OTHER SYMPTOMS
FEVER OF 5 DAYS OR LONGER
FEBRILE CONVULSIONS, SEIZURES Outside scope of community pharmacist; person requires further assessment Immediate to GP
STIFF NECK
OBVIOUSLY ILL CHILD OR CHILD WHO FAILS TO RESPOND TO STIMULI SUGGESTS meningitis Immediate to E&D
SIGNS OF DEHYDRATION THAT FALL IN ‘AMBER’ OR ‘RED’ CATEGORIES (see https://www.nice.org.uk/guidance/ng143 ) Oral rehydration may be inadequate; intravenous fluids may be needed Immediate to GP
immunocompromised- refer to a&e
What are some reasons to refer nappy rash ?
INVOLVEMENT OF RASH AWAY FROM NAPPY AREA Suggests other causes such as psoriasis As soon as practicable
OTC TREATMENT FAILURE
SEVERE RASH Requires prescription-only treatments
When would you refer chicken pox ?
Children less than 4 weeks old
High temperature, vomiting or develop chest pain
Infected lesions
Children with poor immune system that: are taking medicines such as steroids, immune suppressants and are in contact with people with chicken pox
pregnant mothers whose child has chickenpox.
When would you refer impetigo ?
Always - needs fusidic acid to treat it
Or crystacide but still recommended to get on prescription
When would you refer eczema ?
Undiagnosed atopic eczema
Other eczema types
Infection evidence
Severe condition (fissured, bleeding)
Failed treatment
No identifiable cause
Dermatitis duration longer than two weeks
Unusual rash features
Accompanying symptoms
