CLINICAL PHARMACY CLERKSHIP

GUIDE & WORKBOOK

BY

Dr. Syed Saqlain Shah Pharm.D.

Student

Department of Pharmacy

University of Peshawar

(2008)

CONTENTS

TOPIC PAGE NO.

1. Introduction………………………………………………………….............01

2. Goals & Objectives of Clinical Pharmacy Clerkship…………………….…..01

3. Job Description/ Routine Activities of Students During The Clerkship……..02

4. Taking Case History………………………………………………………….04

5. Management of Drug Related Problems (DRPs)………………………….... 08

6. Clinical Pharmacy Project………………………………………………..…. 09

7. Appendix 1

Clinical pharmacy Thesis Outline and Sequence of Chapters/ Sections….…14

8. Appendix 2

Sample of “Title Page # 1 of Thesis”………………………………………. 15

9. Appendix 3

Sample of “Title Page # 2 of Thesis”……………………………………..…16

10.Student Work Book…………………………………………………….…...17

11.List of Cases…………………………………………………………...…….18

12.Cases Recorded by the Students & Work-up on Drug therapy………….......19 onward

INTRODUCTION

Clinical Pharmacy clerkship is a closely supervised experiential learning program in which

the pharmacy students receive clinical pharmacy training and experience in clinical setting.

The importance of experiential learning program cannot be overemphasized in the profession

of pharmacy. Understanding the principles of proper patient care is essential if pharmacy is to

grow as a profession. In this program, particular emphasis is placed on the careful and

systematic approach to the assessment of the patient’s medication therapy to identify actual &

potential medication related problems, evaluate these problems and work with other health

care team members to manage there problems.

GOALS & OBJECTIVES OF CLINICAL PHARMACY CLERKSHIP

The fundamental goal of the clinical pharmacy clerkship is to provide a structured, practical

and closely supervised professional experience that enables the students to better assume their

future role as a competent clinical pharmacist. This goal include the development of

professional judgment, pharmaceutical care practice competencies and technical skills. At the

completion of clerkship the students should be able to demonstrate competencies in the

following areas:

• To obtain accurate medication histories & gather other relevant patient’s data.

• To learn medical terminologies commonly used by health care professionals in the

patient care areas.

• To learn interpretation of common clinical laboratory tests.

• To perform effective drug regimen reviews and identify actual and potential

medication – related problems.

• To develop a pharmaceutical care plan for the patient.

• To recommend a therapeutic drug monitoring plan, including drug concentration

monitoring and indicators of efficacy and toxicity.

• To assess drug therapy regimen in a patient with alter renal or hepatic function.

• To demonstrate an awareness of the assessment skills in areas necessary to monitor

medication outcomes.

• Communicate effectively with health care professionals and others both orally and in

writing.

• To perform complete and accurate patient counseling and enhance patient education

and compliance.

• To provide drug information to health care professionals and patients and to

demonstrate competencies in the following areas:

o Indication – specific prescribing practice

o Appropriate drug dosage selection

o Appropriate dosage – form selection

o Drug use in pregnency

o Drug use in pediatrics

o Drug use in geriatrics

o Dosage adjustment in renal impairment

o Dosage adjustment in hepatic impairment

o Management of drug interactions

o Detection & management of adverse reaction & drug induced diseases.

o Brand names of commonly used drugs

• To demonstrate professional attitude, motivation and ethics.

• To demonstrate the fundamental knowledge of pharmacotherapeutics in the areas

necessary to provide the service.

• To provide the student opportunities to engage in scholarly activities (i.e, special

projects, presentations, research activities ,etc.)

DESCRIPTION / ROUTINE ACTIVITIES OF STUDENTS

DURING THE CLERKSHIP

Student will perform the following activities during clerkship rotations;

• Taking history from the patient with special emphasis on medication history.

• Participation in Medical Rounds to learn how health care professionals;

Assess/ identify patient’s disease and medication related problems

Treat/ resolve actual disease and medication related problems

Prevent potential disease and medication related problems

Learning medical terminologies commonly used by health care professionals

in patient- care areas.

Developing written and oral communication skills i.e. how to communicate

effectively with health care professionals and others, both orally and in

writing.

Monitoring patient compliance statue & adherence to drug therapy and to

identify the factors responsible for non-compliance.

Patient education and counseling to improve compliance during patient stay at

the hospital and at the time of discharge.

Reviewing patient medication therapy in the ward in order to learn how health

care professionals diagnose/ detect/ identify & manage he following

medication related problems;

o Untreated conditions(s)

o Drug(s) without indication(s)

o Improper drug selection/ taking wrong drug

o Sub therapeutic dose

o Excessive dose

o Improper duration

o Drug(s) not administered/ Failure to receive medication

o Drug interactions

o Adverse drug reactions/ intolerances

o Requiring dose adjustment in renal impairment

o Requiring dose adjustment in hepatic impairment

o Therapeutic duplication

o Pregnancy/ lactation related problem(s)

o Inappropriate dosage-form/ route of administration

o Non-compliance

o Use of narrow therapeutic index drug(s) without monitoring

o Poly-pharmacy

o Cost related problems

o Miscellaneous medication related problems

• Developing pharmaceutical care plan for the patient.

• Learning how to provide Drug information to the patients and health care

professionals.

• Any other activity which the supervisor considers necessary to be preformed by the

students.

TAKING CASE HISTORY

Patient case-history is the information gained by healthcare professionals by asking specific

questions, either from the patient or patient’s attendant, with the aim of obtaining information

useful to diagnose the disease.(s) and to identify health related problems of the patient. The

information obtained in this way, together with clinical examination and laboratory

investigations, enable the physician to diagnose the disease(s) and to formulate a medical care

paln for the patient. Clincal pharmacist will use the information collected in patient history

along with relevant positive findings of clinical examination and laboratory investigations in

order to identify patient’s drug related needs and to formulate a pharmaceutical care plan for

the patient.

A proforma is given in workbook section that will be found very useful by the students for

taking the history and recording other relevant information (clinical examination and

laboratory investigations) in an organized form. The proforma may also be used to document

pharmaceutical care process on continuous basis. In the following section only “case history”

will be discussed, while the remaining parts of the proforma will be discussed in the

proceeding sections.

Case history outline

• Patient information

• Chief complaint(s)

• History of present illness

• Past medical history

• Past surgical history

• Family history

• Social history

• Personal history

• Medication history

• Allergies

• Immunizations

• Review of systems

• Other relevant histories

Patient information

Patient’s identification and demographics are recorded i.e name, address, gender, age, hieght,

weight, occupation, etc.

Chief comlaint(s) (CC)

This is a brief statement of the reasons, why the patient consulted the physician, stated in the

patient own words. In order to convey patient’s symptoms accurately, medical terms are

generally not used. These are arranged in chronological order i.e. complaint that developed

first is written at the top followed by other complaints in sequence of occurrence.

History of Present Illness (HPI)

Details about the complaints enumerated in the CC section are recorded. It is a more

complete description of patient’s symptom(s). it usually includes the following:

• Date of onset

• Precise location

• Nature of onset, severity and duration

• Presence of exacerbations and remissions

• Effect of any treatment given

• Relationship of presenting complaints to other symptoms, body functions or activities

• Degree of interference with daily activities

Past Medical History ( PMH)

The PMH includes serious illness that the patient has experienced in the past. It also includes

any previous admission in hospital.

Past Surgical History ( PSH)

PSH includes information about surgical procedures and injuries, blood transfusion etc. that

the patient has experienced in the past.

Family History (FH)

The FH includes the age and health of the parents, siblings, and children. For deceased

relatives, the age and source of death are recorded. In particular, heritable disease in those

with a hereditary tendency are noted (e.g. Diabetes Mellitus, Cardio vascular disease,

Malignancy, Rheumatoid Arthritis, obesity, etc.)

Social History (SH)

Social history includes living arrangements, occupations, economic status, educational

background, marital status, number of children, hobbies, physical activities, drug use

(including tobacco, alcohol, and other recreational drug use), recent foreign travel and

exposure to environmental pathogens through recreational activities or pets.

Personal Histories (PH)

PH includes collection of information about sleep, bowl habits, hours & regularity of meals,

etc.

Medication Histories (MH or Meds)

The medication history (also called drug history, DH) should include the following:

• An accurate record of the patient’s past ( prior to admission) and current prescription

& nonprescription medication use

• Home remedies and other types of health products used

• Drug allergies & intolerances

• Patient’s compliance status & barriers to take medications as prescribed

• Response to previous and current drug therapy

• Pertinent health beliefs: etc.

Because pharmacists possess extensive knowledge of the thousands of prescription &

nonprescription drug products available, they can perform a valuable service to the health

care team by obtaining a complete medication history.

Allergies

Allergies to food, pets, environmental factors (e.g. grass, dust, pollens, seasonal) are

recorded. An accurate description of the reaction that occurred should also be included.

Immunizations

Information about immunization is collected in case of pediatric-patients case-history. Type

and time of immunization should be recorded.

Review of System (ROS)

In the review of system ( also called systemic review), the examiner questions the patient

about the presence of symptoms related to each body system. The purpose of ROS is to

evaluate the status of each body system and to prevent the omission of pertinent information.

In a complete ROS, body systems are generally listed starting from the head and working

toward the feet and may include the skin, head, eyes, ears, nose, mouth and throat, neck,

cardiovascular, respiratory, gastrointestinal, genitourinary, endocrine, musculoskeletal and

neuropsychiatric systems. In many cases only pertinent positive and negative findings are

recorded. Information that was included in the HPI is not repeated in the ROS.

Other relevant histories

Main format of case-history has been described in the above paragraphs but there will be

variations in some areas e.g. in case of pediatric and obstetrical/ gynecological histories.

in these cases all relevant information should be recorded.

MANAGEMENT OF DRUG RELATED PROBLEMS (DRPs)

A drug related problem or medication related problem is an event or circumstance involving

the drug therapy that actually of potentially interferes with desired health outcomes e.g.

• Untreated condition(s)

• Drug(s) without indication(s)

• Improper drug selection/ taking wrong drug

• Sub therapeutic dose

• Excessive dose

• Improper duration

• Drug(s) not administered/ failure to receive the drug\

• Drug interactions

• Adverse drug reactions/ intolerances

• Requiring dose adjustment in renal impairment

• Requiring dose adjustment in hepatic impairment

• Therapeutic duplication

• Pregnancy/lactation related problem(s)

• Inappropriate dosage-form / route of administration

• Non-compliance

• Use of narrow therapeutic index drug(s) without monitoring

• Poly-pharmacy

• Cost related problems

• Miscellaneous medication related problems

In order to identify DRPs, Clinical pharmacist use the information collected in patient’s

history along with relevant positive findings of clinical examination and laboratory

investigation (see work book section). After identifying the DRPs, clear and concise

recommendations are suggested and then the intervention are documented. Different

formats can be used for documentation, among them use of SOAP format is very

common.

SOAP format is use to document the pharmacist’s intervention/recommendation in

patient’s medical charts in an organized way. Written SOAP notes include Subjective &

Objective data, Assessment of problem, and appropriate Plans. Subjective data is obtained

by interviewing the patient and it includes the patient’s chief complain, histories of

present illness, past medical history, past surgical history, family history, social history,

personal history, medication history, history of allergies, etc. Objective data include all

pertinent patient vital sign, physical examination notes and clinical laboratory values. The

Assessment portion includes primary and secondary diagnosis, which encompasses a

comprehensive and relevant explanation of DRPs, therapeutic alternatives and the rational

for the recommended therapeutic plan. The Plan portion contains a description of the

desired clinical and pharmatherapeutic outcomes. The plan is develop based on the

subjective and objective information and the final assessment of each problem. The

therapeutic plan should include a detailed monitoring plan for each DRPs in future patient

occupation initiatives. Written recommendation are then incorporated into the patient’s

chart, which is a legal document.

CLINICAL PHARMACY PROJECTS

Structured projects or research activities in the field of clinical pharmacy are very important

aspects of this discipline. These activities will advance both practice and knowledge in

pharmacy especially in the area of clinical pharmacy.

While conducting clinical pharmacy projects, students should identify and define a problem

or issue related to clinical pharmacy practice of pharmacotherapy that will be studied or

addressed. Therefore, clear objectives for the project should be developed that address the

specified problem or issue. To achieve the project objectives, the protocol is developed that

demonstrates a systematic approach to data collection, analysis, and interpretation. Finally a

thesis/ dissertation or written report is prepared in a format that is suitable for publication.

Students must be able to confidently present and defend there project.

PROJECT PROPOSAL

Before conduction the study, project-proposal must be prepared submitted that will make the

study structure, organized and beneficial for the student as well as for the profession and

community. Following is the outline with helpful hints that will help the students to prepare

project-proposal.

1. Introduction and background:

Historical background of the problem or issue, finding from preliminary literature

search that summarize what is known about this problem and importance of the study

is stated. Following are useful online resources to systematically search the literature

for the preparation of the project- proposal as well as thesis.

• Scopus: http://www.scopus.com

• PubMed: http://www.pubmed.gov

• PubMed central: http://www.pumedcentral.nih.gov

• ISI Web of Knowledge: http://www.isiknowledge.com

• HighWire Press: http://www.highwire.stanford.edu

• Elsevier (Science Direct): http://www.sciencedirect.com

• Springerlink: http://www.springerlink.com

• Blackwell Synergy: http://www.blackwell-synergy.com

• Scirus: http://www.scirus.com

• General Search Engine: http://www.google.com

2. Aims and objective:

Specifically stat what you want to achieve or discovered with your study.

3. Methodology:

In this section it is clearly described how the study will conducted. It should include,

type study, design of study, involvement of other departments or healthcare

professionals (be sure appropriate approval have been obtained), method of data

collection, evaluation criteria/statistical analysis, proposed time line, etc.

4. References:

A standard referencing format should be used (see under final thesis).

5. Appendices:

Include charts, graphs, drawings or other material as necessary to support the project

proposal.

FINAL THESIS/ DISSERATATION OR WRITTEN REPORT

Thesis usually consists of the following sections (see also appendix 1)

1. Title Page (see also appendix 2 & appendix 3)

The title includes the title of the thesis, name of the author and his/her position, name of

institution & statement about the submission of thesis in partial fulfillment of the

requirements for a degree (Pharm.D., M.S., etc).

2. Acknowledgements

This section is an opportunity for the researcher to thank anyone who helped in the study

i.e. people who provided supervision, guidance or advice, anyone who assisted in the data

collection & thesis preparation, any administrative & funding body for the provision of

facilities or financial support, etc.

3. Summary of abstract

It provides a brief overview of the whole study/thesis usually in one or two pages. It

appears at the beginning of the report but it is often one of the last sections to be written.

It includes a brief description of the background & introduction of the study, the

objectives methodology, results/ findings, and major conclusions or recommendations.

4. Introduction

It describe the problem and/ or needs that led to the study/ project, and summarizes other

literature on the topic ( Also see “Introduction & Background” under Project Proposal)

5. Objectives

It clearly state what the researcher wants to achieve or discover with the study.

6. Methodology

It clearly describes the procedures and methods used such that someone else could

reproduce the project. It questionnaires or interviews are used in the study, these items

should be mentioned as part of the methodology section.

7. Results

In this section results are presented objectively with no interpretation or explanation.

Usually tables, graphs and charts are used to present the results.

8. Discussion

The discussion section is one of the largest and most important components of the thesis.

It should include an interpretation and/ or explanation of the results. Findings are related

to the literature. It should also include a critique analysis of the study, its limitations and

the areas of weakness.

9. Conclusion

It is a brief summary usually one to two paragraphs, on the outcome of the study related

to the original objectives. Recommendations may also be made for further research.

Extrapolations or inferences not supported by the findings should be avoided.

10. References

It is better to use a standard referencing format right from the start, such as Harvard or

Vancouver systems.

In the Harvard system, name of the author(s) and date of publication are mentioned in the

text. Then the full citations are listed alphabetically in the reference section. In case of

more that two authors, generally only the first is mentioned in the text followed by et al.

Then the names of all authors are mentioned in the reference section. Where there is

reference to more than one publication in any year by an author ( or the same authors), the

suffix a, b, c, ets. Follows the date in the text and also in the reference section.

The Vancouver system is a numbering system. In the text, numbers are used sequentially

at each point to be referenced. The reference section then lists in numerical order the full

references in order of appearance in the text.

All references should be listed in a systematic & organized manner in the “References”

chapter of the thesis. The consistency and completeness of all cited references are of great

importance. Following or any other appropriate format may be followed for listing

references from different types of literature resources.

Journal Articles

• Baird JK; Effectiveness of ant malarial drugs, N Engl J Med 2005; 352; 1565

• Hazier TK, Lee TA, Hansten PD, Horn JR; Performance of community Pharmacy

drug interaction software, Jam Pharm Assoc 2001; 41; 200-204

Books

• Books with editor(s) & author (s) names:

Duffull S B, Woods D J, Drug in pregnancy & Lactation. In: Walker R

Edwards C (editors): Clinical Pharmacy & therapeutics, 3rd ed., Churchill

Livingstone, London, 2003.pp. 707-716.

• Book without editor(s):

Danish M I, Infectious Diseases, In: Short textbook of Medical Diagnosis and

Management, 8th ed., Johar Publisher, Pakistan, 2006, pp. 718-720.

Internet

• OTC facts figures. www.chpa-info.org. Accessed March 26, 2002

11. Appendices:

This section includes data collection forms, consent forms, questionnaires, approval

certificate granted by ethical committee, etc.

APPENDIX 1

Clinical pharmacy thesis Outline and Sequence of Chapters / Sections

While organizing different chapters & sections of the thesis, usually the following sequence

is followed:

• Title Page # 1(It appears on the outer hard cover of the thesis)

• Title Page # 2(It contains a formal thesis statement)

• Optional Pages i.e. Dedication etc. ( Not compulsory)

• Certificate of Approval (Departmental format should be followed)

• Acknowledgments

• Contents

• List of Abbreviations

• List of Tables

• List of Figures

• List of Appendices ( if any)

• Summary

• Introduction

• Aims and objectives

• Methodology

• Results

• Discussion

• Conclusion

• References

• Appendices ( if any)

APPENDIX 2

Sample of “ Title Page # 1 of Thesis”

APPENDIX 3

Sample of “ Title Page # 2 of Thesis”

ROLE OF CLINICAL PHARMACIST IN

IDENTIFICATION AND MANAGEMENT OF DRUG RELATED PROBLEMS

BY

FINAL PROFESSIONALDOCTOR FO PHARMACY

(Pharm.D.)

ROLL NO. 2760

DEPARTMENT OF PHARMACYUNIVERSITY OF PESHAWAR

PESHAWAR, PAKISTAN(SESSION 2007-08)

ROLE OF CLINICAL PHARMACIST IN

IDENTIFICATION AND MANAGEMENT OF DRUG RELATED PROBLEMS

BY

AZHAR ZAFEER

THESIS SUBMITTED TO THE DEPARTMENT OF PHARMACY IN PARTIAL FULFILLMENT OF THE

REQUIRMENTS OFR THE DEGREE OF DOCTOR OF PHARMACY (Pharm.D.)

(Pharm.D.)

ROLL NO. 2760

DEPARTMENT OF PHARMACYUNIVERSITY OF PESHAWAR

PESHAWAR, PAKISTAN(SESSION 2007-08)

List of cases

Case No: Title ( Final Diagnosed) Page No0102030405060708091011121314151617181920212223242526

CASE NO……..……. Final Diagnosis:

Patient Information

Patient Name: ……… Ward: ……. ……. Bed#: ……

Address: ……………… Occupation: ……… ………

Gender: …… ….… Age: …. … DOA: ……… DOD: ………….…

Height: … …. … Weight: …………. TOA: …… ….. MOA: … …

Chief Complaint (s):

History of Present Illness:

Past Medical History:

Past Surgical History:

Family History:

Personal history:

Social history:

Medication History:

Allergies:

Immunizations:

Other Relevant Histories:

Review of Systems:

Physical Examination (only relevant positive findings)

General: Vital Signs:

T F , BP mmHg , HR , PR /m , RR

Systemic:

Cardiovascular:Pericardium = S1 + S2+0 = Inspection = palpitation =

Gastrointestinal:

Respiratory:

Nervous system:

Moter system = Sensory system =Skin:

Genitourinary:

Other:

Tests Ranges Data / Result

CB

C/F

BC RBC

Hb testESRPCV/HctMCVMCHMCHCRetic.countWBC/TLCNeutrophilsLymphocytesMonocytesEosinophilsBasophilsANCPLTPTAPTTINR

LF

Ts Bilirubin total

Direct/conj.ALT/SGPTAST/SGOTALPGGTAlbuminGlobulinTotal Serum Prot.

RF

Rs BUN

Crs

Clcr

EL

EC

TR

OL

YT

ES Na

ClKHCO3/CO2

CaMgPO4

BL

OD

D G

LU

CO

SE

& H

bA

Ic &

OT

HE

R T

ES

TS RBS

FBSHbAIc

Results of Relevant Laboratory Tests

Culture Sensitivity Tests

Date Source Microbe Resistant to Sensitive to

Results of other relevant Tests (Chest X-Ray, ECG, U/S ABD, CT –Scan, MRI, etc….)

Liver R/E Liver biopsy Typhi dot

DIAGNOSIS:

Date- Wise Daily Progress Report (DPR) & Response Assessment

Vital Sign Date/Time

T(F) ͦBP(mmHg)HR(per min)PR (per min)RR (per min)

TREARMENT HOSPITAL

Start- Date Brand (Generic), Dose, Route, Frequency & duration Stop-Date

DISCHARGE MEDICATIONS

CASE ANALYSIS

• Indication (s) of prescribed medications (case specific)

• Identification and management of Drug Related Problems (DRPs

• Overall comments (if any)

Indication (s) of Prescribed Medications (Case Specific):

Identification and Management of Drug Related Problems

Analyze/review the case for Actual & Potential Drug Related Problems (DRPs) and suggest/ recommend appropriate Management. Report (if possible) Outcome / follow up with Physician and/ or Patient.

Daily Medication Therapy Review & DRPs Checklist

Drug Related Problems Date/Frequency

Untreated conditions

Drugs without Indications

Improper Drug Selection

Sub therapeutic Dose

Excessive Dose

Improper duration

Drugs not administered

Drug Interactions

Adverse Drug Reaction/Intolerance -

Requiring Dose Adjustment in Renal Impairment

Requiring Dose Adjustment in Hepatic Impairment

Therapeutic Duplication

Pregnancy/Lactation Related problems

Inappropriate Dosage-Form/ Route of administration

Non-compliance

Use of narrow Therapeutic Index Drugs without monitoring

Poly-pharmacy

Cost related Problems

Miscellaneous Problems

Management Plan for each DRP (Use SOAP or other relevant format):

A. Untreated condition.

a. Subjective:

b. Objective:

c. Assessment:

d. Plan:

B. Cost related problems:

Recommendation:

Recommendation: