Nasal Congestion Protocol



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Minor Ailment Pharmacy Enhanced Service

Pharmacy Protocol

Updated March 2015 (CJL)

Cough Protocol

|Definition |

|A reflex action to clear the airways of mucus and irritants, such as dust or smoke. Cough may be classified as: |

| |

|Productive cough: |

|Described as “chesty or loose” |

|Brings up mucus (also called sputum or phlegm) |

|This cough is helpful, as it clears the phlegm from lung passages. |

| |

|Unproductive cough: |

|Described as “dry, tight or tickly” |

|No mucus is produced |

|Happens when throat and upper airways become inflamed (swollen) |

|The common cold or flu causes a dry cough because the brain thinks the inflammation in the throat and upper airways is a |

|foreign object and tries to remove it. |

|Description of symptoms |

|Type of cough |

|Colour and consistency of any sputum |

|Presence of other symptoms. |

|Investigative questions |

|Cough worse at any particular time of day? |

|How long have you had the cough? |

|Previous remedies tried? |

|Any regular prescribed or OTC medicine? |

|Do you smoke? |

|How does the cough sound? |

|Criteria for inclusion |

|Troublesome cough requiring soothing. |

|Criteria for exclusion |

|NOTE - Patients under 6 years should not be provided with medication |

|Thick yellow, green, brown or foul smelling sputum |

|Blood stained sputum |

|Pink, frothy sputum |

|Cough of sudden onset |

|Chest pain |

|Shortness of breath, chest tightness, wheeze |

|Painful calf |

|Unexplained weight loss |

|Cough exceeding 2 weeks without improvement |

|Recurrent coughs |

|Asthmatics presenting with wheeze / reduced PEFR |

|Failure of OTC remedy to improve symptoms |

|Gastro-oesophageal reflux disease is suspected cause of cough. |

| Precipitating factors |

|Adverse drug reactions |Infection |

|Air pollution |Serious conditions (e.g. lung cancer) |

|Allergy |Temperature changes |

|Asthma |Smoking (active or passive) |

|Dry atmosphere | |

|Advice to be given |

|Reassure patient that coughs are usually self-limiting. If symptoms persist beyond 3 weeks with no improvement or if cough gets|

|progressively worse see GP |

|Treatment isn't usually necessary, but a home remedy containing honey and lemon may help ease a short-term cough |

|There’s little evidence to suggest that cough medicines will be any more effective but cough medicine may be supplied |

|OTC medication |

|Non-productive cough |

|Simple linctus SF 200ml |

|Paediatric simple linctus SF 200ml |

|Pholcodine linctus 5mg/5ml SF 200ml |

| |

|Productive cough |

|Ammonia & ipecacuanha mixture 200ml |

|Guaifenesin linctus 200ml |

|Non pharmaceutical treatment |

|A home remedy containing honey and lemon may help ease a short-term cough. |

|Referral criteria |

|Consider supply, but patient should be advised to make a routine appointment to see GP |

|A cough lasting 3 weeks or more or a cough that gets gradually worse |

|Unsuccessful treatment with OTC medicines of more than 3 weeks |

|A persistent dry, night time cough in children / elderly |

|A dry cough in a patient prescribed an ACE inhibitor |

|Discoloured or bloodstained sputum (green sputum is common in viral infections and may not warrant referral) with no other |

|symptoms. |

|Rapid referral |

|Very high temperature or shortness of breath accompanied by a cough, particularly in patients aged over 65 or under two years |

|Chest pain other than solely with coughing |

|Difficulty breathing/wheezing |

|If chest pain related to exertion |

|‘Pink and frothy’ or blood stained sputum (especially if accompanied by breathlessness and swollen ankles) |

|Blood stained sputum associated with chronic fever and night sweats |

|Suspected whooping cough or croup. |

|References |

|CPPE: Responding to Minor Ailments, 2008. |

|() |

|NHS Choices: Cough |

|() |

Conjunctivitis Protocol

|Definition |

|Redness and inflammation of the thin layer of tissue that covers the front of the eye (the conjunctiva). |

|Conjunctivitis can be caused by an irritant, such as chlorine or dust, an allergy (for example, to pollen), or an infection. |

| |

|Description of symptoms |

|Allergic conjunctivitis - usually affect both eyes and is intensely itchy |

|Viral conjunctivitis - tends to affect one eye first (which becomes watery), with redness developing in the second eye a few |

|days later. Most cases of viral conjunctivitis occur along with a common cold |

|Bacterial conjunctivitis - usually causes a sticky discharge from the eye and crusting around the eyelids. |

| |

|General Symptoms: |

|Itchiness and watering of the eyes |

|Red eye |

|Burning sensation in the eyes |

|Feeling of grit in the eyes. |

|Investigative questions |

|Duration of symptoms? |

|Previous remedies tried? |

|Concurrent medication? |

|Criteria for inclusion |

|Treatment with eye drops is only required in bacterial (infective) conjunctivitis and ONLY after self-care methods have been |

|used for at least 48 hours with no improvement in symptoms. |

|Self-care for conjunctivitis involves following the below advice: |

|Avoid touching the eye and spreading any infection to the other eye |

|Bathe eye(s) with cool boiled water for 48hrs, to soothe and cleanse |

|Do not wear make-up or contact lenses until the conjunctivitis has cleared |

|Do not share towels, flannels and pillow cases with others in the home |

|Call back to pharmacy after 48 hours (2 days) if no improvement in symptoms to be supplied with eye drops /ointment. |

|Criteria for exclusion |

|Children less than two years of age |

|History of hypersensitivity to chloramphenicol or to any other ingredient within the preparation |

|Pregnant or breastfeeding |

|Unresponsive / insufficient response to active episode of treatment |

|Eye surgery or laser treatment in the past six months |

|Recently returned from abroad |

|Family history of a severe blood disorder |

|Precipitating factors |

|Old or young: more common in children and the elderly, possibly because children come into contact with more infections at |

|school and elderly people may have a weaker immune system, |

|Recent upper respiratory tract infection, such as a cold, |

|Diabetes or another condition that weakens the immune system, |

|Concomitant medication, such as corticosteroids |

|Blepharitis (inflammation of the rims of the eyelids) |

|Advice to be given |

|Self-care for conjunctivitis involves following the below advice: |

|Avoid touching the eye and spreading any infection to the other eye |

|Bathe eye(s) with cool boiled water for 48hrs, to soothe and cleanse |

|Do not wear make-up or contact lenses until the conjunctivitis has cleared |

|Do not share towels, flannels and pillow cases with others in the home while you have conjunctivitis |

|Call back to pharmacy after 48 hours (2 days) if no improvement in symptoms to be supplied with eye drops /ointment. |

| |

|IF eye drops /ointment are supplied (after 48hous of self-care): |

|Eye drops should be stored in a refrigerator (2-8oC) |

|Eye ointment should be stored in a cool, dry place, away from direct heat and light |

|May experience transient burning or stinging sensation in the eye when applying eye drops |

|Gently clean away sticky discharge using cotton wool soaked in water |

|Do not wear contact lenses until the symptoms have cleared up (where applicable) |

|Wash hands regularly. |

|OTC medication |

|Chloramphenicol 0.5% eye drops, 10mL |

|Chloramphenicol 1% eye ointment, 4g |

| |

|Maximum treatment is 5 days. |

|Non pharmaceutical treatment |

|Self-care for 48 hours before medication (see above advice) |

|Referral criteria |

|If symptoms do not improve after 48 hours of self-care then advise return for medication |

|If symptoms do not improve after 48 hours of treatment with medication |

|Where conjunctivitis may be related to wearing contact lenses |

|Already using other eye drops or eye ointment |

|Intense redness in one or both eyes. |

|Rapid referral |

|Newborn baby with conjunctivitis |

|Severe pain in the eye(s) |

|Blurred vision |

|Sensitivity to light. |

|References |

|NHS Choices: Conjunctivitis |

|() |

|Practice guidance: OTC chloramphenicol eye drops, Royal Pharmaceutical Society of Great Britain |

|() |

Fever Protocol

|Definition |

|A body temperature over 37.5oC |

|Description of symptoms |

|Feeling hot (often with sweating) or cold (often with shivering) |

|Often accompanied by headache and aching muscles. |

|Investigative questions |

|Has the temperature been measured? |

|Normal body temperature (when taken in the mouth) 36.5-37.5oC. |

|Criteria for inclusion |

|Body temperature over 37.5oC |

|Criteria for exclusion |

|Children less than 3 months old |

|Temperature above 40oC. |

|Precipitating factors |

|Infection – upper respiratory tract / ear / urinary |

|Teething in infants |

|Common childhood illnesses, such as chicken pox |

|Tonsilitis |

|Post-vaccinations |

|Overheating due to excessive bedding or clothing. |

|Advice to be given |

|Treatment should provide relief of symptoms and avoid febrile convulsions (fits) in infants |

|Enquire about concurrent analgesic usage. |

|OTC medication |

|Paracetamol 500mg tablets, 32 pack |

|Paracetamol suspension, 120mg/5mL SF 100ml |

|Paracetamol suspension 250mg/5mL SF 200ml |

| |

|Ibuprofen 200mg tablets, 24 pack |

|Ibuprofen 400mg tablets, 24 pack |

|Ibuprofen suspension, 100mg/5mL SF, 100ml |

|Do NOT supply ibuprofen if patient has asthma or GI problems. |

| |

|Advise patient to take with/after food to limit GI side effects |

|Avoid in patients sensitive to aspirin |

|Avoid in patients taking lithium |

|Contra-indicated in patients with congestive heart failure or renal impairment. |

|Non pharmaceutical treatment |

|Avoid dehydration by increasing intake of cool water |

|Try to keep room at a comfortable temperature, about 18oC |

|Keep child cool if the environment is warm, for example, cover with a lightweight sheet, but ensure they are still |

|appropriately dressed for their surroundings. |

|Referral criteria |

|Temperature above 40oC |

|Cyclical fever – questions should be asked to ascertain whether patient has recently returned from foreign travel or works in |

|a medical laboratory |

|Young babies and elderly patients that appear to be very unwell - these patients easily become hyper – or – hypothermic |

|respectively. |

|Rapid referral |

|Under three months old and temperature of 38oC or above |

|Aged between three and six months old with a temperature of 39oC or above |

|Over six months old and has other signs of being unwell, such as floppiness and drowsiness. |

| |

|Suspected meningitis – telephone surgery |

|References |

|NHS Choices: Fever in children () |

Hay Fever Protocol

|Definition |

|Seasonal allergic reaction by exposure to pollens, grass, flowers or trees |

|Description of symptoms |

|Typically early spring to late autumn when the pollen count is over 50 |

|Frequent sneezing |

|Runny or blocked nose |

|Itchy, red or watery eyes (also known as allergic conjunctivitis) |

|Itchy throat, mouth, nose and ears |

|Cough, usually caused by postnatal drip. |

|Investigative questions |

|Family history of hay fever / other allergies? |

|Previous diagnosis? |

|Which symptoms are the most troublesome? |

|Previous remedies tried? |

|Concurrent medication? (Antihistamines contra-indicated in patients with Glaucoma, patients taking anti-arrhythmic drugs). |

|Criteria for inclusion |

|Typical symptoms of hay fever where other possible causes have been excluded (see referral criteria) |

|Criteria for exclusion |

|Patients under age of 6 |

|Pregnancy. |

|Precipitating factors |

|Exposure to allergens |

|Pollution. |

|Advice to be given |

|If possible, stay indoors when the pollen count is over 50 |

|Keep windows and doors shut. If it gets too warm, draw the curtains to keep the sun out and temperature down |

|Avoid fresh flowers in the house |

|Regularly damp dust the house |

|Where possible, avoid drying clothes outside as this will help prevent bringing pollen inside the house |

|Change your clothes when you have been outside |

|Wear wraparound sunglasses to prevent pollen getting in the eyes (also dark glasses may help if photophobia a problem |

|Have pollen filters fitted to car air inlet system and also on vacuum cleaner |

|Check pollen count daily on weather forecast |

|With respect to antihistamines – beware of drowsiness, do not exceed maximum doses |

|If no improvement is noted after 5 days*, refer to GP. |

|OTC medication |

|Chlorpheniramine 4mg tablets, 28 pack |

|Chlorpheniramine 2mg/5mL liquid, 150ml |

|**see BNF for interactions - avoid in patients with prostatic hypertrophy, glaucoma and epilepsy |

|Cetirizine 10mg tablets, 30 pack |

|Loratadine 10mg tablets, 30 pack |

|Otrivine-Antistin (antazoline sulphate 0.5%, xylometazoline 0.05%) eye drops, 10ml |

|Sodium cromoglicate 2% eye drops, 10ml |

|Beclomethasone 50 micrograms/metered dose nasal spray, 100 doses |

|Non pharmaceutical treatment |

|Cold compress applied to eyes may offer symptomatic relief. |

|Referral criteria |

|If symptomatic treatment is unsuccessful / persists beyond September |

|Pregnancy |

|Patients who are breathless / wheezing heavily / chest tightness |

|Asthma suffers who still have difficulty breathing despite using their prescribed medicines |

|Patients who may have a secondary infection, such as otitis media or sinusitis |

|Purulent, rather than clear, discharge from the eyes, which may indicate infection. |

|Rapid referral |

|Asthmatics (as mentioned above) |

|Seasonal asthmatics. |

|References |

|NHS Choices: Hayfever |

|() |

|Symptoms in the Pharmacy: A guide to the management of common illness. Alison Blenkinsopp & Paul Paxton, 3rd ed.* |

|The Pharmaceutical Journal, Vol 270, no. 7242, 29 March 2003 |

Headache Protocol

|Definition |

|Pain anywhere in the region of the head or neck |

| |

|Headaches have many different causes but can generally be split into two types: |

|Primary – not due to another underlying health problem |

|Secondary – have a separate cause, such as illness. |

|Description of symptoms |

|Tension-type headache |

|due to stress or tension |

|commonly episodic (occur less than 15 times per month) |

|usually bilateral, pressing/tightening (non-pulsating) |

|can last 30minutes or more. |

|Investigative questions |

|Nature of pain? |

|Site of pain? |

|Previous history of headaches? |

|Current medication? It is important to identify possible ADR e.g. nitrates. Identify potential interactions with OTC |

|medication. |

|Criteria for inclusion |

|Patients requiring pain relief for tension headache. |

|Criteria for exclusion |

|Children under the age of 12 |

|Patients with headache following injury or trauma to the head |

|Patients with suspected ADR |

|Migraine. |

|Precipitating factors |

|Psychological, social and emotional factors |

|Advice to be given |

|Treatment with analgesics (particularly those containing codeine) can give rise to rebound headaches. For this reason treatment|

|should be restricted to 7 days or less |

|Enquire about other concurrent analgesic usage |

|If the headache does not respond to OTC analgesics within a day, referral is advisable. |

|OTC medication |

|Paracetamol 500mg tablets, 32 pack |

|Paracetamol 250mg/5mL suspension SF, 200ml |

| |

|Ibuprofen 200mg tablets, 24 pack |

|Ibuprofen 400mg tablets, 24 pack |

|Ibuprofen 100mg/5mL suspension SF,100ml |

|**Do NOT supply ibuprofen if patient has asthma or GI problems. |

| |

|Advise patient to take with/after food to limit GI side effects, |

|Avoid in patients sensitive to aspirin, |

|Avoid in patients taking lithium, |

|Contra-indicated in patients with congestive heart failure or renal impairment. |

|Non pharmaceutical treatment |

|As the most frequently reported trigger factors for headache are stress (mental or physical), irregular or inappropriate meals,|

|high intake of coffee and other caffeine-containing drinks, dehydration, sleep disorders, too much or too little sleep, reduced|

|or inappropriate exercise and psychological problems, identity which factor affects your patient and advise on appropriate |

|action. |

|Rest, try to relax and avoid stress |

|Improve posture |

|Consider hot or cold packs |

|Headaches associated with reading or other close work may be due to deteriorating sight. An eye test to see if spectacles are |

|needed would be advisable. |

|Referral criteria |

|Worsening headache with fever |

|Sudden-onset headache reaching maximum intensity within 5 minutes |

|New-onset neurological deficit |

|New-onset cognitive dysfunction |

|Change in personality |

|Impaired level of consciousness |

|Recent (typically within the past 3 months) head trauma |

|Headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked) or sneeze |

|Headache triggered by exercise |

|Orthostatic headache (headache that changes with posture) |

|Symptoms and signs of acute narrow-angle glaucoma |

|Substantial change in the characteristics of their headache |

|Cluster headache. |

|Referral criteria continued |

|Refer a person who present with new-onset headache and any of the following: |

|Compromised immunity, caused, for example, by HIV or immunosuppressive drugs |

|Aged under 20 years and a history of malignancy |

|History of malignancy known to metastasise to the brain |

|Vomiting without other obvious cause. |

| |

|Refer a person over 60 who present with sudden development of: |

|A severe headache |

|Jaw pain when eating |

|Blurred or double vision |

|A sore scalp. |

|Rapid referral |

|Paralysis or weakness in one or both arms and/or one side of the face |

|Slurred or garbled speech |

|Sudden agonising headache resulting in a blinding pain unlike anything experienced before |

|Headache along with a high temperature, stiff neck, mental confusion, seizures, double vision and a rash |

|Headache accompanied by other focal or non-focal neurological symptom, such as blackout, change in personality or memory. |

|References |

|Wikipedia: Definition of headache. |

|() |

|NICE guidance: Headache, CG150, September 2012. |

|() |

|NHS Choices: Headache |

|() |

|NHS Choices: Migraine |

|() |

|GP Notebook: Headache (adult, criteria for urgent referral) |

|() |

|GP Notebook: Headache (features when it is suggested that investigation or referral is required) |

|()) |

|Bendtsen, L. ‘Drug and nondrug treatment tension-type headache’. Ther Adv Neurol Disord, May 2009; 2(3): 155-161. |

|()) |

Head Lice Protocol

|Definition |

|Head lice are tiny insects that feed on blood from the human scalp. To confirm an active head lice infestation, a louse must |

|be found through a reliable, accurate method, such as detection combing. |

|Description of symptoms |

|Head lice are whitish to grey-brown in colour, and smaller than the size of a pinhead when first hatched. |

|When fully grown they are the size of a sesame seed. |

|The female head louse lays eggs by cementing them to hairs (often close to the root), where they’re kept warm by the scalp. |

|After 7 to 10 days, the eggs hatch and the empty eggshells remain glued in place (known as nits). |

|Nits are white and become more noticeable as the hair grows and carries them away from the scalp. |

|Head lice take 9 to 10 days to become fully grown and the female may start to lay eggs from 9 days after she’s hatched. |

|To break the cycle and stop the spread, they need to be removed within 9 days of hatching. |

|Itching is caused by an allergy to the lice and not from the lice biting the scalp. |

|As not everyone is allergic to head lice, a head lice infestation may be hard to notice. |

|Even if someone is allergic to head lice, itching can take up to three months to develop. |

|In some cases, a rash may appear on the back of the neck. This is caused by a reaction to lice droppings. |

|Investigative questions |

|Have live lice been detected? |

|Has there been a previous infection recently? |

|Have any treatments been tried already? (Check method of use) |

|Any other contacts? Check close friends/relatives |

|Criteria for inclusion |

|Presence of live head lice identified & verified by healthcare professional before supply made. |

|Criteria for exclusion |

|Treatment failures – second request within one week |

|Family / siblings of patient who are not proven to be infected |

|Children under 6 months |

|Pregnancy / breastfeeding |

|Precipitating factors |

|Not applicable |

|Advice to be given |

|Check & where necessary treat all affected family members at the same time. |

|Inform all close friends/relatives to enable them to check themselves. |

|Conduct regular detection combing, for example on a weekly basis, to find new lice quickly. |

|Only use lotions and sprays if a live louse has been found on someone’s head. |

|Head lice cannot fly, jump or swim and are transmitted by head-to-head contact, climbing from the hair of an infected person |

|to the hair of someone else. |

|Higher incidence in children. |

|Ensure application is per manufacturers instructions. |

|OTC medication |

|Hedrin 4% Lotion, 50ml ONE pack |

|Hedrin 4% Lotion, 50ml TWO packs |

|Hedrin Once 4% liquid gel, 100ml N.B. only one treatment needed |

|Derbac M liquid, 50ml |

|Derbac M liquid, 50ml TWO packs |

|Nit comb. |

| |

|Apply sufficient lotion evenly over dry hair ensuring that the scalp is fully covered and allow to dry naturally (avoid using |

|hairdryers). After recommended time, rinse the hair and comb while wet with a head lice comb. |

|Repeat treatment after 7 days. |

| |

|Alcoholic lotion – normal healthy skin |

|Aqueous liquid – asthmatics and patients with eczema / skin disorders |

|Non pharmaceutical treatment |

|Wet combing |

|Wash the hair using ordinary shampoo and apply plenty of conditioner. Do NOT wash out. |

|Untangle hair with a normal brush. Once the comb moves freely through the hair without dragging, switch to a head lice comb. |

|Slot teeth of head lice comb at the roots, touching the scalp gently. |

|Comb through to the tips of the hair. |

|Check comb after each stroke and clean between each comb. |

|When head has been completely combed, rinse off conditioner. |

|Repeat 3 times at half weekly intervals (a total of 4 sessions in 2 weeks). |

|Referral criteria |

|Treatment failures |

|Children less than 6 months |

|Pregnancy / breastfeeding |

|Signs of secondary bacterial infection of scalp as a consequence of severe infection |

|Rapid referral |

|Not applicable |

|References |

|Mayo Clinic: Head lice. |

|() |

|NHS Choices: Head lice. |

|() |

|Community Hygiene Concern. ‘Welcome to Bug Busting’ () |

|Nasal Congestion Protocol |

| |

|Definition |

|When the tissues lining the nose become swollen. The swelling is due to inflamed blood vessels. It is associated with colds |

|and upper respiratory tract infections. |

|Description of symptoms |

|Blocked nose, |

|Postnasal drip, |

|Runny nose – the discharge is usually clear and runny at first before becoming thicker and darker over the course of the |

|infection, |

|Sneezing, |

|Nasal pain and irritation, |

|Impairment of smell. |

|Investigative questions |

|How long have you had symptoms? |

|Have you tried any other medicines? If so, what and for how long? |

|Criteria for inclusion |

|Congestion where seasonal allergy has been excluded. |

|Criteria for exclusion |

|Recurrent nose bleeds, |

|Chronic sinusitis, |

|Children less than 6 years of age, |

|Pregnant or breastfeeding, |

|Concomitant medications known to interact with recommended medicine(s), |

|Co-existing disease: hypertension, diabetes, hyperthyroidism, arrhythmias, glaucoma, prostatic enlargement, previous allergic |

|reaction to recommended medicine(s), kidney disease. |

|Precipitating factors |

|Local irritation: fumes or particles, allergy, local infection, cold weather. |

|Advice to be given |

|Patients should be advised to put one teaspoon of menthol & eucalyptus in a pint of hot (not boiling) water and use a cloth / |

|towel over the head to trap the steam: |

|Adults and children aged 12 or more: maximum treatment period with a decongestant is 7 days. |

|Child less than 12 years of age: maximum treatment period with a decongestant is 5 days. |

|OTC medication |

|Menthol and eucalyptus inhalation, 100ml |

|Saline nasal drops, 10ml |

|(1-2 drops each blocked nostril before feeds and at night - no more than |

|four times a day) |

|Xylometazoline nasal spray 0.1%, 10ml |

|Xylometazoline nasal drops 0.05%, 10ml |

|Pseudoephedrine 60mg tablets, 12 pack |

|Pseudoephedrine 30mg/5mL liquid SF, 100ml |

|Non pharmaceutical treatment |

|Steam inhalation |

|Special considerations/ Concurrent medication |

|MAOIs |

|Referral criteria |

|Severe sinusitis (pain usually severe and persistent – lasting for longer than 10 days), |

|Rebound nasal congestion – associated with over use of local decongestants, |

|Elderly (over 75) who are of poor health (heart or lung disease), |

|Worsening asthma with no self-management plan, |

|If there is wheezing with breathing. |

|Rapid referral |

|Children under 1 year when the child is unwell and associated with either: |

|High temperature, |

|Poor feeding, |

|Abnormal breathing. |

|References |

|Medline Plus: Stuffy or runny nose – adult |

|() |

|NHS Choices: Cold, common – symptoms |

|() |

|Patient.co.uk: Rhinitis and nasal obstruction |

|() |

|NHS Choices: Non-allergic rhinitis |

|() |

|British National Formulary 66, September 2013-March 2014 |

|Patient.co.uk: Xyometazoline |

|() |

| |

Sore Throat Protocol

|Definition |

|Inflammation of the pharynx |

|Description of symptoms |

|Soreness in the throat |

|Pain on swallowing |

|Hoarseness |

|Fever |

|Headache |

|Malaise |

|Mild cough |

|On examination the back of throat may be red and inflamed |

|Investigative questions |

|How long has throat been sore? Refer if a sore throat has lasted more than one week |

|If sore throat is described as being extremely painful, especially in the absence of cold, cough and catarrhal symptoms, then |

|referral should be recommended if there is no improvement within 24-48 hours. |

|Presence or absence of associated symptoms? |

|Current medication? |

|Criteria for inclusion |

|Sore throat requiring soothing |

|Criteria for exclusion |

|Children less than 16 years of age |

|Dysphagia |

|Oral candidiasis |

|An ‘at-risk’ patient |

|HIV or AIDS |

|Asplenic |

|Has leukaemia |

|Has aplastic anaemia |

|Receiving chemotherapy |

|Taking immunosuppressants |

|Taking anti-thyroid medication |

|Taking a DMARD |

|Precipitating factors |

|Poor immune response (illness/drug related) |

|Advice to be given |

|Sore throats are not usually serious and often pass in 3 to 7 days, |

|Avoidance of smoky or dusty atmospheres, |

|Reduce or stop smoking, |

|If swallowing is painful, consume a light fluid diet. |

|OTC medication |

|Soluble aspirin 300mg tablets, 32 pack |

|As a gargle before swallowing. |

|Use with caution where there is a history of gastric irritation or peptic ulcer disease. |

|Soluble paracetamol 500mg tablets, 24 pack (if aspirin contra-indicated) |

|Ultra Chloraseptic Throat Spray, 15ml (contains benzocaine – local anaesthetic when applied to mucosa) |

|Benzydamine (Difflam) 0.15% Sore Throat Rinse, 200ml |

|Non pharmaceutical treatment |

|Avoid food or drink that is too hot |

|Eat cool, soft food and drink cool or warm liquids |

|Suck lozenges, hard sweets ice cubes or ice lollies |

|Avoid smoking and smoky environments |

|Regularly gargling with a mouthwash of warm, salty water may help reduce swelling or pain |

|Drink enough fluids, especially if you have a fever |

|Referral criteria |

|Persistent sore throat that lasts three to four weeks. |

|Persistent high temperature unchanged after taking medication. |

|Symptoms do not improve within a week. |

|Hoarseness for more than 3 weeks |

|Patients prescribed high dose inhaled steroids – if poor inhaler technique or oral hygiene resulting in hoarseness / oral |

|candidiasis |

|Patients on immunosuppressants/oral steroids/drugs causing bone marrow suppression (e.g. carbimazole) |

|Symptoms suggesting oral candidiasis / tonsillitis / quinsy / glandular fever |

|A second request within 1 month |

|Failed medication |

|Rapid referral |

|Patients especially young children, presenting with severe symptoms (not able to swallow, acute onset and high temperature) |

|Patients known to be immunosuppressed (accompanied by other clinical symptoms of blood disorders) |

|Difficulty breathing |

|Difficulty swallowing or are not able to swallow enough fluids |

|Severe pain |

|Drooling |

|A muffled voice |

|A high-pitched sound as you breathe |

|References |

|Mayo Clinic: Sore throat. |

|() |

|Patient.co.uk: Sore throat. |

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|NHS Choices: Sore throat. |

|() |

Tinea Pedis (Athlete’s Foot)

|Definition |

|Common fungal infection that usually begins between the toes. |

|Description of symptoms |

|Characteristic macerated, white, cracked lesions which are often itchy, in early stages these are likely to be present in toe |

|webs |

|Lesion spread to plantar or dorsal surface from toes |

|Toe nails may be involved and in time may become dull, opaque and yellow in appearance |

|Investigative questions |

|How long have you had the infection? |

|Previously tried medication? Used for how long? |

|Criteria for inclusion |

|Infection where contact dermatitis and maceration caused by hyperhidrosis and footwear have been excluded. |

|Criteria for exclusion |

|Where inflammation and itching is severe severe and spread beyond toe spaces. |

|Infection present and nails involved. |

|Diabetic patients |

|No improvement within a few weeks after self-treatment |

|Precipitating factors |

|Frequent wearing of damp socks or tight-fitting shoes |

|Weakened immune system |

|Walking barefoot in public areas that may promote spread of infection, such as saunas, swimming pools, communal baths and |

|showers. |

|Advice to be given |

|Treat for one to two weeks after your symptoms have disappeared to ensure the infection has been successfully treated. |

|Wash your feet regularly and thoroughly using soap and water. |

|After washing, dry your feet, paying particular attention to the areas between the toes. |

|Wear clean cotton socks. |

|Change your shoes and socks regularly to help keep your feet dry. |

|Do not share towels and wash your towels regularly. |

|Wear shoes that allow the feet to ‘breathe’. This will help prevent the build-up of moisture in and around the toes. |

|If using sports facilities shower shoes may protect feet from contamination. |

|OTC medication |

|Miconazole 2% cream, 30g |

|Miconazole 2% powder, 100g |

| |

|Make sure that the area is dry before applying the treatment. |

|Apply antifungal medication directly to the rash and surrounding area (4-6cm) of normal, healthy skin. |

|Wash your hands before and after applying the treatment. |

|Non pharmaceutical treatment |

|Attempt to keep the foot cool & dry (see advice), |

|Avoid contact in contaminated areas (see advice). |

|Referral criteria |

|Patient is diabetic, |

|Infection has spread to different areas of the foot apart from the toe spaces, including the upper and lower foot surfaces and|

|the nails, |

|Previous treatment failure with topical anti-fungals, |

|Presence of a secondary bacterial infection as this will be prone to develop if the condition is untreated for some time and |

|the skin is broken. In severe cases, the whole foot may become very sore and painful. |

|Rapid referral |

|Not applicable. |

|References |

|Pharmacists Therapeutic Reference, Medical Tribune Group, 1986 |

|Fungal Feed, Pharmacy Update, Chemist & Druggist, 02.09.2006 |

|Mayo Clinic: Definition of athlete’s foot. |

|() |

|NHS Choices: Athlete’s foot. |

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Threadworm infection

|Definition |

|Infection with Enterobius vermicularis, a species of nematode, within the large intestine of humans. |

|Description of symptoms |

|Intense itching around the anus (or the vagina in girls), particularly at night, |

|Disturbed sleep as a result of the itching, which can lead to irritability. |

| |

|Intact worms may been seen (look like threads of white cotton about 1cm long) on the bed clothes or sheets at night or in the |

|stools. |

| |

|Severe or persistent threadworm infection can cause: |

|Weight loss, |

|Loss of appetite, |

|Skin infection around the anus – bacteria can enter scratches caused by itching, |

|Insomnia, |

|Bedwetting. |

| |

|In extremely rare cases, migration to the vagina can cause irritation and may cause confusion with thrush, vulvovaginitis, |

|enuresis, or urinary tract infection. |

|Investigative questions |

|Do other family members have symptoms? |

|Recent history of symptoms? |

|Concurrent medication? Interactions noted with metronidazole. |

|Criteria for inclusion |

|Patients in whom questioning indicates threadworm infestation. |

|Criteria for exclusion |

|Children under 2 years, |

|Pregnancy and breastfeeding, |

|Previous hypersensitivity to the product or any of its components. |

|Precipitating factors |

|Young children as they often forget to wash their hands regularly, |

|Close contact with a person who has a threadworm infection. |

|Advice to be given |

|Wash hands and scrub nails regularly, particularly after going to the toilet and before mealtimes. Treatment only kills the |

|worms, not the eggs, therefore scrupulous hygiene and cleaning should be continued for at least two weeks, |

|Keep fingernails short and clean, and avoid biting nails or sucking fingers, |

|Do not share towels, |

|Wash all crockery, cutlery and cooking utensils carefully. Thoroughly clean kitchen and bathroom surfaces, |

|Regularly vacuum the house, |

|Wear underwear or pyjamas in bed, |

|Bathe first thing in the morning to wash away eggs laid overnight, |

|Change and wash clothes and bedding frequently to further eliminate ova. |

|• Check for infestation and where necessary treat all household members at the same time. |

|OTC medication |

|Mebendazole 100mg tablet, single dose (one treatment) |

|**Adult and child over 2 years of age: |

|**Repeat after 14 days if re-infection occurs. |

| |

| |

|Mebendazole works by preventing the threadworms from absorbing sugar which means they should die within a few days. |

|Non pharmaceutical treatment |

|Because life span of parasite is only 3-6 weeks, threadworms can be eliminated by hygiene methods. Reinfection is a feature of|

|this condition. Short nails, hand and nail washing after toileting, and again before meals, bathing on waking, changing |

|sheets, pyjamas and underwear daily, and discouraging of scratching. |

|Referral criteria |

|Suspicion of infestation by something other than threadworm, |

|Secondary bacterial infection from scratching, |

|In women if there is increased frequency of urinary tract infections, vaginal bleeding during pregnancy, postmenopausal |

|bleeding or abnormal vaginal discharge, |

|In males if urethral irritation is present. |

|Rapid referral |

|Not applicable |

|References |

|NHS Choices: Threadworms. () |

|Summary of Product Characteristics, Vermox 100mg tablets. Last updated on eMC 30 March 2011. |

|() |

|Patient.co.uk: Threadworms. |

|() |

Vaginal Thrush Protocol

|Definition |

|Infection of the vulva with yeast, usually Candida albicans. |

|Description of symptoms |

|Itching and soreness around the entrance of the vagina |

|Pain during sex |

|Stinging sensation when you urinate |

|Vaginal discharge, although this isn’t always present; the discharge is usually odourless and it can be thin and watery, or |

|thick and white |

|In severe cases, the patient may also present with a red and swollen vagina and vulva, cracked skin around the entrance of the|

|vagina, sores in the surrounding area |

|Investigative questions |

|Age? |

|Have you had a confirmed diagnosis of thrush in the past? |

|Have there been any changes /abnormal menstrual bleeding? |

|Previous use of imidazoles or vaginal antifungals? |

|Criteria for inclusion |

|Women aged between 16 and 60 years of age |

|Confirmed diagnosis of thrush in the past and the patient recognises the symptoms |

|Criteria for exclusion |

|Pregnancy |

|Patient is under 16 or over 60 |

|Failed treatment within the same infectious episode |

|Precipitating factors |

|Prescribed antibiotics |

|Pregnancy |

|Poorly controlled diabetes |

|Weakened immune system |

|Advice to be given |

|Avoid highly perfumed soaps, shower gels, vaginal deodorants or douches |

|Use a regular moisturiser, such as E45 cream, as a soap substitute, then apply a greasier moisturiser to protect the skin. |

|Avoid using latex condoms, spermicidal creams or lubricants if they irritate the genital area. |

|Avoid wearing tight-fitting underwear or tights. |

|Vaginal thrush is not a sexually transmitted disease, but it can sometimes be passed onto partners during sex. Therefore if |

|you have thrush, try to avoid having sex until the affected woman has completed a course of treatment and the infection has |

|cleared up. |

|OTC medication |

|Clotrimazole 500mg pessary, |

|Clotrimazole 1% cream, 20g |

|Clotrimazole 2% cream, 20g |

|Clotrimazole intravaginal 10% cream |

|Canestan Combi (containing clotrimazole 10% vaginal cream and 2% topical cream) |

|Fluconazole capsule 150mg - (BNF lists possible drug interactions also avoid in breastfeeding) |

|Check possible drug interactions as listed in the most current online edition of the BNF |

|Avoid in breastfeeding |

|Non pharmaceutical treatment |

|‘Live’ yoghurt, although recommendation is not evidence based. |

|Referral criteria |

|Patient is under 16 or over 60 years of age |

|Patient has had 2 cases of thrush within the last 6 months - swabs need to be taken for diagnosis to be confirmed. |

|First time sufferer |

|Failed medication – no improvement after 7-14 days |

|The vaginal discharge changes in smell or appearance |

|Known hypersensitivity to available treatments |

|Pregnancy or breastfeeding |

|Previous history of STD / Exposure to partner with STD |

|Abnormal or irregular vaginal bleeding |

|Blood staining within the discharge |

|Vulval or vaginal sores, ulcers or blisters |

|Rapid referral |

|Suspected sexually transmitted disease or vaginitis |

|References |

|Patient.co.uk: Vaginal thrush. |

|() |

|NHS Choices: Vaginal thrush. () |

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