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. |
|() |
|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. |
|() |
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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