SASMETHOD
SASMETHOD is our slightly modified form of the ASMETHOD acronym which adds and changes the order of some of the questions to better fit the order they are asked. Consider your rationale for asking these questions as they may not be applicable in every consultation.
Start the consultation and establish if for Self
- At the outset, you should start the consultation with the patient by introducing yourself and your role/job title. As the conversation unfolds, you may need to take the person to a more private area of the pharmacy, so be mindful of this from the outset. Explain that you will need to ask some questions and ascertain that it is okay for you to do so
- Having the patient present in person, can enable them to point to a specific area of the body and/or answer your questions in greater detail than would be the case for a representative, helping you make a differential diagnosis. It could help rule out certain conditions or aid with differentiation (if someone really has the flu, is it likely they will be well enough to present in the pharmacy)? It might be useful when considering potential misuse or abuse of certain OTC medicines
Age and Appearance
- Does the general appearance of the patient or particular clinical features help to differentially diagnose or manage the condition?
- Is the condition more/less prevalent in certain ages?
- Is there an age-limit which would indicate that the patient should be referred?
- Does it influence your choice of OTC product (is there an age-restriction imposed within the product licence)?
Symptoms
- You need to establish all relevant signs and symptoms (clinical features) to help you reach a differential diagnoses
- Sometimes you will need to ask if the person can think of anything that has brought on/caused the symptoms
Medicines and Medical Conditions (including pregnancy and breast-feeding, if relevant)
- Is the patient on any other medicines?
- Think about medications that can cause the condition
- Think about medications that potentially interact with OTC treatment options
- Does the patient have other/existing medical conditions?
- Think about medical conditions that predispose a patient to a condition
- Think about medical conditions that impact on OTC treatment options
- Is the patient pregnant or breast-feeding?
- Does being pregnant predispose her to the condition?
- Does being pregnant affect treatment options and the management strategy?
- Is pregnancy a referral criterion? If she is breastfeeding, then OTC options could also be limited
Extra medicines
- Has the patient taken/tried anything to relieve your symptoms?
- Does it now warrant referral?
- Does it now warrant a step-up approach in terms of treatment offered?
- Is it possible that the patient has self-selected the wrong product (consider the many GSL products for various conditions)? [it may also be appropriate to ask if anything is making the symptoms worse]
Time
- How long has the patient had the symptoms?
- Does the onset of the symptoms (for example, sudden, gradual) or duration of symptoms affect the diagnosis?
- What is the typical duration of the self-limiting condition?
- Is there a time limit after which referral is deemed necessary?
History
- You could ask about medical conditions/establish more about their medical history here
- Some pharmacists will ask about the history of the presenting complaint at this stage, but it is very late in the mnemonic (and somewhat unnatural) to only be thinking about presenting symptoms at this stage in the conversation!
- Consider family history/genetic link (only if relevant)
- If it is a recurrent condition, is the patient experiencing the same clinical features as before? What medication did they use for the previous episode? Was it effective?
- Consider lifestyle/social factors, for example, smoking/alcohol intake, occupation and exercise (where relevant)
- Some OTC medicines (for example, oral NSAIDs) are contraindicated in anyone who has previously had a stomach ulcer. This information will not necessarily be ascertained by solely asking the patient if they have any existing medical conditions
Other symptoms
- You might need to prompt with specific questions if you want to know about particular signs/symptoms. These may not be volunteered by the patient if they seem unrelated to the immediate problem/presenting complaint. One example would be in relation to cystitis or vaginal thrush-like symptoms in a undiagnosed diabetic patient. They may also be thirsty or suffer from unexplianed weight loss. Another example could be constipation, where other symptoms of hypothyroidism or depression might need to be explored to see if these are causing the constipation in the first instance
Danger symptoms and make a Decision
- Danger symptoms are referral criteria that suggest a more serious pathology or the need for a treatment currently only available on prescription (see referral criteria sections in the app for each condition). These are also known as red flags
- After asking questions and gathering information, it is time to make a decision about the management strategy and whether this will involve self-treatment measures or require referral to another healthcare professional
- If referring, the urgency of the referral will need to be considered. For example, suspected agranuloytosis or meningitis will be an urgent referral due to the onset and severity of complications if left untreated. However, a fungal nail infection affecting more than 2 nails of a immunocompetent person will be much less urgent