“Community pharmacy” summary — Paul Rutter

Introduction

You face daily challenges in community pharmacy practice when patients present with acute symptoms without you having access to their full medical records. You must make rapid clinical decisions regarding over-the-counter medicine management, patient triage, and the need for immediate medical referral.

Paul Rutter provides a clinical handbook in Community Pharmacy to help you safely assess symptoms and differentiate minor self-limiting conditions from serious pathology. Structured patient history taking and systematic clinical reasoning form the foundation of safe practice throughout this guide.

The book covers major body systems across seven core areas to help you answer key clinical questions.

How do you differentiate viral infections from bacterial complications?
Which red flags require urgent medical referral for eye and ear conditions?
What protocols govern urinary and menstrual health evaluations?
How do you screen for alarm symptoms in gastrointestinal presentations?

1. Respiratory System Conditions

Chapter 1 focuses on the respiratory system, addressing anatomy, examination techniques, and cough management. Upper structures filter, warm, and moisten air, while the lower respiratory tree uses upward-beating cilia to expel foreign bodies and excess secretions.

You must differentiate self-limiting upper respiratory viral infections from bacterial complications and persistent coughs requiring medical referral.

Coughs are classified as acute or chronic based on duration, with any cough lasting longer than three weeks requiring medical evaluation for serious pathology. The British Thoracic Society defines acute cough as lasting less than 3 weeks and chronic cough as lasting more than 8 weeks, leaving a grey area between 3 and 8 weeks where persistent symptoms demand GP referral. These presentations account for 12 million GP visits per year for acute cough, alongside 24 million visits per year in community pharmacy for cough.

Refer any cough lasting longer than 3 weeks to a medical practitioner for further investigation.
Check sputum colour, onset, duration, periodicity, age, and smoking history to assess severity.

Clinical evidence for over-the-counter cough medicines is generally weak, making guaifenesin the only expectorant with modest trial support, while antitussives show limited efficacy in acute viral cough. The largest guaifenesin study included 239 participants showing reduced cough frequency, while a smaller trial tested 65 participants.

Avoid using cough and cold mixtures in children under 6 years of age.
Limit cough and cold mixtures in children aged 6 to 12 to a maximum of 5 days on professional advice.
Advise parents of children under 6 to offer increased fluids and non-pharmacological demulcents like simple linctus.

Common Colds and Sore Throats

The common cold is caused predominantly by rhinoviruses spread through direct hand contact and contaminated surfaces, requiring pharmacists to differentiate self-limiting colds from influenza. More than 200 virus types cause colds, with rhinoviruses accounting for 30 to 50 percent of all cold cases. Children experience 5 to 6 colds per year on average, while adults experience 2 to 4 colds per year.

Wash hands frequently and use disposable tissues to reduce direct contact transmission.
Administer nasal drops with the head in a downward position facing the floor to prevent swallowing.

Most sore throats are viral, self-limiting infections, but clinical evaluation must identify bacterial streptococcal infections or danger signs like dysphagia and suspected agranulocytosis. Viral infections account for 70 to 90 percent of sore throat cases, with 40 percent of people symptom-free after 3 days and 85 percent symptom-free after 1 week.

Inspect the pharynx, fauces, tonsils, and cervical glands using a good light source and tongue depressor.
Refer patients experiencing dysphagia, duration over 2 weeks, or signs of agranulocytosis.

Sore throat symptom relief relies on local lozenges, topical anti-inflammatories, and systemic analgesics like paracetamol and ibuprofen taken regularly. Strefen lozenges contain 8.75 mg of flurbiprofen to reduce pain.

Recommend lozenges or pastilles instead of gargles to ensure longer contact time with inflamed mucosa.
Instruct patients taking systemic analgesics for sore throat to take them regularly rather than on an as-needed basis.

Allergic Rhinitis and Treatments

Allergic rhinitis is classified by symptom timing into intermittent or persistent categories, driven by an IgE-mediated immune response to allergens like pollen and house dust mites. The condition affects 10 to 25 percent of adults in the UK and 40 percent of children.

Ask patients about seasonal variation, family history of atopy, and specific environmental triggers.
Advise allergen avoidance strategies such as closing windows during high pollen counts and using dust mite control measures.

Second-generation non-sedating antihistamines and intranasal corticosteroids form the cornerstone of effective allergic rhinitis treatment in community pharmacy. Systemic antihistamines have an onset of action of 30 minutes to 1 hour, whereas intranasal corticosteroids require 2 weeks to reach maximum clinical efficacy.

Recommend loratadine as first-line therapy for mild intermittent general symptoms.
Instruct patients using corticosteroid nasal sprays to shake the suspension bottle before use and maintain regular daily dosing for full therapeutic benefit.
Restrict topical nasal decongestants to a maximum of 5 to 7 days to prevent rhinitis medicamentosa.

2. Ophthalmology and Ear Conditions

Simple physical examinations using pen-torches and otoscopes allow you to identify minor eye and ear ailments while spotting sight-threatening or infectious red flags.

Chapter 2 covers ophthalmology, detailing eye anatomy, examination procedures, and the differential assessment of red eye. Chapter 3 addresses ear conditions, centering specifically on ear anatomy, patient assessment, and ear wax impaction.

Ocular Examinations and Red Eye

Community pharmacists should perform a simple eye examination in good light to help differentiate between minor self-limiting and serious sight-threatening ocular conditions. Red eye is a common presenting complaint with both non-serious and serious causes, requiring pharmacists to separate conditions manageable with OTC products from those needing immediate referral. Eye problems account for 2-5% of GP workload, and a UK community pharmacy study found an average of 2 cases of red eye per week.

You must follow specific procedural steps during the examination:

Wash your hands.
Ask the patient to look straight ahead to view the pupil, cornea, and sclera.
Gently pull down the lower lid and ask the patient to look upwards and to both the left and the right.
Gently lift the upper lid and ask the patient to look downwards and to both the left and right.
Ask the patient to look directly into a near light using a pen-torch and then look back at you to examine pupil reaction.
Assess visual acuity by asking the patient to read small print with the affected eye.

Subconjunctival haemorrhage presents as a bright red segment or whole eye caused by a ruptured blood vessel, requiring reassurance rather than active treatment. It can be precipitated by coughing, straining, or lifting, and resolves spontaneously in 10 to 14 days without treatment in the absence of trauma.

Reassure the patient that symptoms will resolve in 10 to 14 days without treatment if there is no history of trauma.

Bacterial conjunctivitis is largely self-limiting, and routine antibiotic prescribing offers only marginal benefits over no treatment. A study by Rose et al. in The Lancet in 2005 found no significant difference in cure rates after 7 days in children treated with chloramphenicol versus placebo, recording 86% versus 83%. Overall, 65% of people have clinical cure in 2 to 5 days with no treatment.

Bathe the eyelids with lukewarm water to remove any discharge.
Use tissues to wipe the eyes and throw them away immediately.
Avoid wearing contact lenses until symptoms have resolved.
Practice regular hand washing and avoid sharing pillows and towels.

Eyelid Disorders and Dry Eye

Eyelid disorders such as blepharitis and styes are frequently encountered in community pharmacy and respond well to conservative hygiene measures rather than systemic or topical antibiotics. Blepharitis accounts for 5% of primary care ophthalmic consultations, and bacterial staphylococcal infection causes 90-95% of cases of styes.

Clean the eyelids using a warm compress for 5 to 10 minutes.
Apply a diluted mixture of baby shampoo (1:10) with warm water to the eyelids using a cotton bud twice a day initially.

Dry eye syndrome is a chronic, incurable condition caused by a reduction in tear volume or alteration in tear composition, managed primarily through artificial tears and lubricating ointments. Almost 3% of older adults develop dry eye each year.

Enquire whether the patient was instructed by a GP or optician to buy artificial tears or if it is a self-diagnosis.
Use hypromellose as a first-line treatment due to low cost, dosing up to hourly or half-hourly initially.
Administer carbomer last if other eye drops need to be instilled due to its high viscosity.

Ear Anatomy and Wax Management

Proper physical examination of the external ear requires understanding anatomical features and following a precise inspection sequence along the 3 cm external auditory meatus. Ear wax is naturally cleared by migratory skin from the eardrum, but impaction often results from misguided cleaning attempts or physiological factors. Between 2-6% of the general population suffer from impacted wax.

First, wash your hands
Next inspect the external ear for redness, swelling and discharge
Then apply pressure to the mastoid area which is directly behind the pinna
Next move the pinna up and down and manipulate the tragus
You should finally examine the EAM using an otoscope or pen torch while manipulating the pinna

Clinical trials show that simple water and oil-based softeners are as effective as proprietary cerumenolytics for ear wax removal, though evidence quality is limited. Practical product selection involves specific dosing regimens.

Cerumol Ear Drops: five drops into the affected ear two or three times a day for up to 3 days, retained with a cotton wool plug
Cerumol Olive Oil Drops: two to three drops twice a day for up to 7 days, retained with a cotton wool plug
Earex: four drops twice a day for up to 4 days, retained with a cotton wool plug
Peroxide-based products: five drops once or twice daily for 3 to 4 days without plugging the ear

Otitis Externa and Media

Otitis externa is a generalized inflammation of the ear canal strongly associated with swimming, heat, and moisture. The lifetime prevalence of acute otitis externa is 10%, and swimmers are 5 times more likely to contract it than non-swimmers. Acute otitis media involves rapid fluid accumulation behind the tympanic membrane in children aged 3 to 6 years, but over three-quarters of episodes resolve within 3 days without treatment.

Manage uncomplicated cases with paracetamol or ibuprofen
Refer children under 2 years with discharge or systemically unwell patients for GP consideration of antibiotics

Over-the-counter management of otitis externa is limited to pain relief, local analgesics, and acetic acid sprays for mild superficial infections.

Choline salicylate: completely fill the EAM and plug with soaked cotton wool every 3 to 4 hours for adults and children over 1
Acetic acid spray: one spray into the affected ear at least three times a day, up to one spray every 2 to 3 hours for adults and children aged 12 and over

Pharmacists must identify specific warning signs and symptoms that necessitate immediate medical referral rather than over-the-counter treatment.

Refer patients presenting with dizziness or tinnitus for further investigation
Refer children with fever, general malaise, or pain originating from the middle ear
Refer cases of suspected foreign bodies, trauma-related conductive deafness, or OTC medication failure

3. Central Nervous System and Women's Health

Careful neurological history taking helps you classify headaches and manage short-term insomnia, while specific protocols govern urinary and menstrual health evaluations.

Headache Classification and Migraines

Headaches are classified into primary and secondary disorders using the International Headache Society system, where secondary headaches indicate underlying pathology requiring referral. Between 80 and 90 percent of patients present with tension-type headache in a community pharmacy. Episodic tension-type headaches last from 30 minutes to 7 days, feel like a tight band or weight pressing on the head, and are not typically accompanied by nausea or vomiting.

Maintain a regular sleep pattern
Take regular exercise
Modify work environment and use relaxation techniques like yoga
Maintain a food diary to identify reproducible food triggers occurring within 6 hours of ingestion
Eat regularly and do not skip meals

Insomnia and Nausea Management

Insomnia is classified by duration into transient, short-term, or chronic forms, and should primarily be managed through sleep hygiene education rather than long-term medication. First-generation sedating antihistamines serve as the primary OTC pharmacological treatment for short-term insomnia, though tolerance can develop with continuous use.

Administer diphenhydramine at a dose of 50 mg approximately 20 minutes before bedtime for adults and children over 16
Advise patients taking sedating antihistamines to avoid concurrent CNS depressants or alcohol due to potentiation of sedation
Screen patients for contraindications including glaucoma and prostate enlargement before recommending antihistamine sleep aids

Cystitis and Vaginal Thrush

Cystitis is primarily caused by bowel flora ascending the urethra, and acute uncomplicated cases present with typical urinary symptoms. Over-the-counter options for cystitis are limited to alkalinising agents and fluid intake advice.

Spooner in 1984 concluded that an 80 percent symptomatic relief was gained in patients treated with a 2-day course of Cymalon.

Ask about symptom duration; refer if symptoms last longer than 5 to 7 days due to pyelonephritis risk
Refer children and elderly female patients over 70 years old
Refer patients presenting with fever, vaginal discharge, or loin pain

Menstrual Disorders

Primary dysmenorrhoea involves painful uterine cramping caused by prostaglandin overproduction during menstruation. Heavy menstrual bleeding significantly impacts quality of life and can be treated non-hormonally with tranexamic acid if abnormalities are excluded.

Use NSAIDs like ibuprofen or naproxen as first-line therapy for two to three cycles
Apply warmth to the lower abdomen using hot water bottles for pain relief
Refer women over the age of 30 with new or worsening symptoms

4. Gastroenterology and Oral Conditions

Gastrointestinal and oral presentations require systematic screening for alarm symptoms to separate benign self-limiting disorders from serious pathology.

Chapter 6 covers gastroenterology, examining gastrointestinal tract anatomy, assessment methods, and oral cavity conditions such as mouth ulcers. The chapter highlights localized oral health problems, detailing how to evaluate and treat conditions affecting the oral cavity.

Oral Health and Ulcers

Minor aphthous ulcers are the most common presentation in community pharmacy, but pharmacists must identify specific referral warning signs to rule out serious pathologies like oral carcinoma. The majority of patients presenting with mouth ulcers have minor aphthous ulcers, which are roundish, grey-white, painful, less than 1 cm in diameter, and heal in 7 to 14 days. 1 in 5 of the general population is affected by minor aphthous ulcers over their lifetime, and 80 percent of patients presenting in a community pharmacy have them.

Ask about the number of ulcers, as minor aphthous ulcers occur singly or in small crops while numerous ulcers indicate major or herpetiform types.
Check the location; ulcers toward the back of the mouth or on the gingival mucosa are less consistent with minor aphthous ulcers.
Inspect for irregular shapes or large sizes which may indicate trauma or serious pathology.
Always refer any patient presenting with a painless ulcer to exclude leukoplakia or carcinoma.

Oral thrush is an opportunistic mucosal infection unusual in healthy adults and requires identifying underlying predisposing factors or referral for prolonged lesions. Oral thrush presents as creamy-white soft elevated patches that can be wiped off to reveal underlying erythematous mucosa. Daktarin oral gel containing miconazole is the primary OTC treatment, achieving cure rates between 80 and 90 percent.

Hold the miconazole gel in the mouth for as long as possible to increase contact time with the infection.
Continue treatment for up to 2 days after symptoms have cleared to prevent relapse and reinfection.
Use a spacer and wash the mouth out after using inhaled corticosteroids to minimize the risk of thrush.

Gingivitis is inflammation of the gums caused by plaque accumulation and can be prevented and managed through proper oral hygiene and antibacterial mouthwashes. Plaque forms when oral bacteria and food particles adhere to the pellicle coating on teeth. 50 percent of the UK population is estimated to be affected by gum disease, and 85 percent of people over 40 experience gingival disease.

Brush teeth twice daily with a fluoride toothpaste, preferably after eating.
Floss approximately three times a week using a C-shape curve around each tooth to remove plaque from spaces a toothbrush misses.
Rinse with 10 mL of 0.2 percent chlorhexidine mouthwash around the mouth for about 1 minute twice a day.

Dyspepsia and Reflux Management

Dyspepsia is an umbrella term for upper abdominal symptoms that require careful evaluation to screen for serious pathology using established ALARM symptoms. 25 to 40 percent of the general population in Western society suffer from dyspepsia. 95 percent of duodenal ulcers and 80 percent of gastric ulcers are associated with Helicobacter pylori.

Assess whether pain is centrally located in the epigastric area above the umbilicus rather than below it.
Identify relieving or aggravating factors, such as food or antacids relieving ulcer pain.
Screen for ALARM symptoms to identify patients requiring urgent endoscopy or medical referral.

Over-the-counter management of dyspepsia includes antacids, alginates, H2 antagonists, and proton pump inhibitors, each with distinct onset profiles and clinical indications. Proton pump inhibitors like omeprazole offer superior efficacy for moderate to severe symptoms but require referral if symptoms persist beyond 2 weeks or continuous use exceeds 4 weeks.

Take antacids after food because gastric emptying is delayed, allowing antacids to exert their effect for up to 3 hours.
Take famotidine 10 mg at the onset of symptoms, repeating after 1 hour if necessary, up to a maximum of 20 mg in 24 hours.
Take omeprazole initial dose of two 10 mg tablets once daily for reflux-like symptoms in adults over 18.

Bowel Habits and Abdominal Pain

Acute diarrhoea is primarily managed by preventing dehydration using oral rehydration solutions, while antimotility agents serve as useful adjunctive symptom relief. The current WHO oral rehydration solution has a reduced osmolarity of 245 mmol/L containing 75 mmol/L of sodium.

Administer oral rehydration solution by sipping small volumes every 5 to 10 minutes rather than drinking large quantities at once.
Give adults 2 L of oral rehydration solution in the first 24 hours, followed by normal fluids and 200 mL per loose stool.
For loperamide in adults, take two capsules immediately, followed by one capsule after each further bout of diarrhoea up to a maximum of 16 mg daily.

Constipation is characterized by hard stools and difficult defecation, and is primarily managed by increasing dietary fibre and fluids alongside targeted laxative selection. 25 to 40 percent of all people over the age of 65 experience constipation.

Increase dietary fibre intake to approximately 30 g per day through fruit, vegetables, cereals, and wholemeal bread.
Ensure an adequate fluid intake of 2 L per day when following a high-fibre diet or taking bulk-forming laxatives.
For ispaghula husk, adults should take 1 sachet or 2 level 5 mL spoonfuls twice a day mixed with water.

Irritable bowel syndrome is a common functional bowel disorder featuring abdominal pain and bloating associated with altered bowel habits, diagnosed largely by exclusion. 10 to 20 percent is the reported adult prevalence rate of IBS in Western countries.

Exclude suspected food triggers by removing them from the diet for a minimum of 2 weeks before gradually reintroducing them.
Take peppermint oil capsules one capsule three times a day before food, increasing to two capsules three times a day for severe symptoms.
Refer any patient under 16 or patients over 45 presenting with a recent change in bowel habit.

Haemorrhoids involve prolapsed anal cushions and are commonly managed with lifestyle modifications and topical products, while persistent bleeding requires urgent referral. 1 in 2 people will experience at least one episode of haemorrhoids during their lives.

Increase dietary fibre and fluid intake to produce softer stools and eliminate straining during defecation.
Apply topical haemorrhoid treatments twice daily and after each bowel movement.
Refer any patient who has to manually reduce their haemorrhoids or patients over 40 with unexplained persistent rectal bleeding.

Abdominal pain can stem from numerous conditions ranging from self-limiting disorders to life-threatening emergencies, requiring pharmacists to screen for symptom clusters and red flags. Abdominal pain lasting longer than 6 hours suggests underlying pathology.

Determine the precise anatomical location of abdominal pain to differentiate between upper and lower abdominal pathologies.
Assess whether pain is colicky, cramp-like, burning, or sharp, and check if it radiates to the back, shoulder, or jaw.
Immediately refer any patient presenting with abdominal pain accompanied by fever, vomiting, or suspected pregnancy.

5. Dermatological Disorders and Infestations

Skin turnover rates and barrier integrity dictate how you manage inflammatory plaques, fungal infections, parasitic infestations, and viral lesions.

Skin Turnover and Psoriasis

The skin consists of an outer epidermis and inner dermis, with a continuous epidermal cell turnover rate that drives barrier function and lesion formation. The basal layer actively undergoes cell division, forcing new cells to move up through the epidermis to form the outer keratinised horny layer. This continual process takes approximately 35 days in normal skin, but in hyperproliferative disorders like psoriasis and dandruff, cell turnover can be ten times faster, taking only 3 to 4 days. Dermatological disorders account for 15 percent of the UK GP workload.

Plaque psoriasis classically presents with well-defined boundaries and diagnostic pinpoint bleeding when scales are gently removed, known as the Auspitz' sign. Psoriasis has a 1 to 3 percent worldwide prevalence and affects 1 to 2 percent of the UK population. There is a 25 to 30 percent chance of developing psoriasis if one parent has it, and a 50 to 60 percent chance if both parents suffer from the condition, alongside a 70 percent concordance rate in identical twins. OTC treatment is limited to mild to moderate cases using emollients, keratolytics, coal tar, or dithranol, while severe forms or specific variants require prompt medical referral.

Tham et al. (1994) compared calcipotriol 50 micrograms twice daily versus 15 percent coal tar solution daily, showing both were effective but calcipotriol was significantly better. Harrington (1989) found Psorin containing 0.11 percent dithranol was significantly more effective than Alphosyl.

Reassure patients about the benign, non-contagious nature of psoriasis while emphasizing its chronic and long-term relapsing nature.
Apply emollients regularly and liberally.
Exercise care when getting out of the bath due to slippery emollient bath additives like oilatum.

Fungal Infections and Hair Loss

Dermatophyte infections invade the keratinised layers of skin and nails, causing symptoms like macerated toe webs in athlete's foot or dull, opaque, yellowing nails in onychomycosis. Over 10 percent of the general population suffers from onychomycosis, with prevalence reaching up to 50 percent in people aged over 70 years. Athlete's foot affects 15 percent of the UK population. Allylamines like terbinafine and imidazoles serve as first-line treatments for skin infections, while 5 percent amorolfine lacquer is used weekly for mild toenail infections.

Zaug (1992) showed amorolfine produced clinical cure in 37 percent of toenail infections in an open-label trial, while Reinel (1992) reported 46 percent cure rates with weekly application.

Soak and dry the affected area, then apply topical terbinafine or imidazole according to product instructions, continuing treatment for 1 to 2 weeks after lesions clear.
File and clean the nail using provided disposable pads and files before evenly applying amorolfine lacquer weekly.

Parasites, Warts, and Dermatitis

Female scabies mites burrow and lay eggs, leaving faecal pellets that trigger a delayed cell-mediated hypersensitivity reaction and severe nocturnal itching. Permethrin cream is the first-line treatment of choice with high cure rates, requiring careful whole-body application and simultaneous treatment of all close contacts to prevent reinfection.

Apply permethrin cream to the whole body including the scalp, neck, face, and ears, and wash thoroughly 8 to 12 hours later.
Repeat the treatment after 7 days.
Machine-wash clothes, towels, and bed linen at 50 degrees Celsius or above after the first application.

6. Musculoskeletal Conditions and Soft Tissue Injuries

Acute low back pain and soft tissue injuries are predominantly self-limiting and respond best to staying active, structured analgesia, and physical care protocols.

You encounter musculoskeletal conditions frequently, with Chapter 8 of the text focusing extensively on acute low back pain. Most patients present with acute, self-limiting problems that resolve spontaneously. You must establish the cause, severity, and whether the condition requires professional referral.

Find out when the injury occurred and what precipitated it
Assess the level of discomfort and any restriction in range of motion
Determine whether the injury appears to be worsening
Establish what expectations the patient has regarding treatment

Over 90% of patients get better within 6 weeks, though up to two-thirds of patients have a recurrence within one year. Fewer than 5% develop chronic back pain persisting for more than 12 weeks. In the UK, 7-8% of all adult GP consultations in the low back pain area resulted in 4.5 million working days lost in 2004-2005, while 60 to 90% of adults experience an episode of low back pain at some point in their adult lives.

Acute Low Back Pain Evaluation

Specific trigger points and symptoms act as danger signs that mandate immediate referral of a back pain patient to a GP or specialist.

Refer patients presenting with fever due to suspected infection
Refer patients with pain radiating away from the lower back area indicating sciatica
Refer young people under 20 and older people over 55 reporting numbness, persistent worsening pain, weight loss, or feeling unwell
Refer patients showing bowel or bladder incontinence for suspected cauda equina syndrome
Refer patients if symptoms fail to improve after 4 weeks duration for symptom failure before referral

A systematic review identified 401 patients across two trials showing improvements in pain relief and functional status when staying active.

Encourage patients with acute low back pain to keep active rather than rest in bed

Systemic and Topical Analgesics

Systemic analgesics and specific adjuvants like caffeine have varying evidence bases for treating acute low back pain over the counter.

Recommend paracetamol as a first-line choice for most people due to fewer side effects
Advise patients taking systemic NSAIDs to limit use to 7 to 10 days duration for systemic NSAID use
Recommend caffeine-containing analgesic products only if they contain 100 mg or more of caffeine for analgesic enhancement

A Cochrane review of 19 studies involving 7238 participants found a small but statistically significant benefit with caffeine used at doses of 100 mg or more. Topical NSAIDs achieve 50% pain relief compared to 43% for placebo across 47 studies comparing topical NSAIDs to placebo.

Recommend topical NSAIDs for patients needing minimized systemic side effects, such as the elderly or those with previous GI issues
Check lower age limits for rubefacients before use in children, noting many require users to be over 12 while some can be used from 5 or 6 years old
Consider standardized herbal remedies such as Devil's Claw, White Willow Bark, or Cayenne plasters as viable alternatives for back pain

Sports Soft Tissue Injuries

Non-drug treatment plays a major role in managing soft tissue injuries, governed by the standard RICE protocol.

Rest the injured part to allow immobilisation, enhance healing, and reduce blood flow
Apply ice while the injury feels warm to the touch until the skin becomes numb, repeating at hourly intervals
Apply compression using an elastic bandage or support like a crepe bandage
Elevate the injured part ideally above the heart to help fluid drain away

Refer acute injuries showing immediate swelling and severe pain
Refer children under 12 years old and elderly patients
Refer patients exhibiting a decreased range of motion in all directions involving the shoulder
Refer patients with an excessive range of movement in any joint suggesting major ligament disruption
Refer patients unable to bear any weight on an injured ankle or foot
Refer any cases of suspected fracture or treatment failure

7. Paediatrics and Specific Pharmacy Requests

Special patient groups require tailored clinical approaches, ranging from risk stratification in children to specialized pharmacy reclassifications and preventive health products.

Paediatric Care and Fever Assessment

You must rely on parents or caregivers to gather history when assessing paediatric conditions because children struggle to articulate symptoms. While parents know when a child is unwell and assess general well-being based on liveliness, you should always refer visibly ill children to a GP.

Fever in children indicates an adjusted higher hypothalamic set point. You must evaluate the overall appearance of the child alongside structured risk stratification systems:

Take temperature under the arm in children under 5 years using an electronic or chemical dot thermometer.
Encourage children to drink additional fluids to prevent dehydration from sweating.
Administer paracetamol or ibuprofen as monotherapy if the child is unwell or distressed.

NICE guidelines recommend using a traffic light system to assess the risk of serious bacterial illness in children under 5.

Childhood Infections and Parasites

Childhood infectious conditions present unique diagnostic rashes and symptoms. You can treat head lice using physical agents like dimeticone or isopropyl myristate rather than resistant insecticides:

Apply dimeticone 4% lotion to dry hair and scalp, ensuring full coverage from root to tip.
Leave the lotion on for a minimum of 8 hours or overnight before washing out with shampoo.
Repeat the treatment after 7 days to kill emerging nymphs from surviving eggs.

A 2007 study comparing 4% dimeticone lotion applied for 8 hours or overnight against 0.5% malathion liquid applied for 12 hours or overnight found dimeticone significantly more effective, curing 30 out of 43 participants (70%) compared to 10 out of 30 (33%) using malathion.

Specialized Product Requests

Targeted requests require precise clinical screening and product matching. Emergency hormonal contraception containing levonorgestrel prevents 95 percent of expected pregnancies if taken within 24 hours, 85 percent between 24 and 48 hours, and 58 percent within 48 to 72 hours. Nicotine replacement therapy increases rates of quitting smoking by 50 to 70 percent.

For benign prostatic hyperplasia, you can supply tamsulosin following specific safety criteria:

Supply an initial 14-day supply of tamsulosin for men aged 45 to 75 with functional symptoms.
Refer the patient to a doctor for confirmation of symptoms within the supply period.
Provide a further 28 days treatment if doctor confirmation is pending.
Stop treatment and refer to a doctor if symptoms have not improved or worsened within 14 days.

Conclusion

Patient history taking, clinical reasoning, and pharmacological evidence integrate to transform your daily practice from simple product supply into advanced clinical care. You synthesize symptoms, identify red flags, and select evidence-based treatments while maintaining patient safety as your primary objective. Knowing when to refer patients to general practitioners protects public health and establishes your role as an essential healthcare provider.

Conduct structured consultations by gathering detailed symptom histories before recommending any pharmacological intervention.
Screen every patient systematically for red flags and alarm symptoms that require immediate medical referral.
Apply evidence-based guidelines to select appropriate treatments and dosages tailored to individual patient profiles.
Advise patients on expected recovery timelines and self-care measures to manage expectations and encourage active healing.
Recognize your clinical limits and refer patients promptly when presentations exceed the scope of self-care.

10 Key Ideas

Refer any cough lasting longer than 3 weeks to a medical practitioner for further investigation of potential serious pathology.
Perform structured physical examinations of the eye using a pen-torch to check the pupil, cornea, sclera, and visual acuity.
Remove impacted ear wax using water and oil-based softeners or proprietary cerumenolytics like Cerumol, Earex, or peroxide-based products.
Screen patients presenting with headaches for secondary causes and manage tension-type headaches with lifestyle adjustments, sleep patterns, and relaxation techniques.
Refer patients with cystitis if symptoms last longer than 5 to 7 days, if they are children or elderly women over 70, or if they present with fever, vaginal discharge, or loin pain.
Inspect mouth ulcers for irregular shapes, large sizes, or painless presentations to differentiate minor aphthous ulcers from leukoplakia and oral carcinoma.
Manage mild to moderate psoriasis with emollients, keratolytics, coal tar, or dithranol while recognising that cell turnover takes 3 to 4 days instead of the normal 35 days.
Encourage patients with acute low back pain to keep active rather than rest in bed to improve pain relief and functional status.
Assess fever in children under 5 years by taking temperatures under the arm and evaluating overall appearance using a traffic light risk stratification system.
Supply an initial 14-day course of tamsulosin for men aged 45 to 75 with functional benign prostatic hyperplasia symptoms while referring them to a doctor for confirmation.

Book summary “Community pharmacy”: summary

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