Integrated Pharmacy Practice Lab #1

4TH Pharm DPharmacy Practice Dep.,

Unizah College Of Pharmacy2015-2016

Patient Interview

Active listening Empathy Building rapport Open-ended questions Close-ended question Leading questions Silence “why” Non verbal communications cues

Communication skills

It is a dynamic process that include both hearing what is being said as well as interpreting the complete words that are spoken to understood the message that is being delivered.

You have to be concious enough to the patient to give the patient attention and concentration away of external and internal distractions and interuptions

Active listening

Is defined as intellectual identification with feelings, thoughts and attitudes of another.

Empathy ways depends on the particular patient and situations.

For example, nodding head, making a statement, or asking a follow up questions.

Don’t say” I know what you are feeling”But “how are you feeling”

Empathy

It sets the tone of the interview and allow the patient to feel comfortable with you, there by making the lines of communication more open and honest.

“ hello Mrs., my name is Nouf. I am a clinical pharmacist I am a part of your medical team, and I am here to ask you a few questions about what brought you to the hospital and discuss the medications that you have been taking at home.”

“ I have a few questions for you , Mrs. Amal. Is it okay for me to speak to you with your family/friends in the room or would you prefer to be alone while we talk?”

Building rapport

Require the patient to answer with more than a simple yes or no in as exploring symptoms

What symptoms are you experiencing?

How you are feeling today ?

How are you taking your medication?

Open And Closed Ended Question

Open-ended quis. ……? Close-ended quis……?

Play a role in communicationg with

patient to collect data

Did you take your blood pressure medication this morning?

Are you feeling well today?

Do you take your medication as directed by the physician?

Leading questions:To obtain an accurate response to your questions,

leading questions should be avoided.“why””Why“ may get the patient may feel the need to

defend his or herself but what he may thought that you may offer judgment

Why do you miss your doses?What causes you to miss your doses?

What is the question to be avoided during an interview?

Lock & Comment

Silence in interacting with your patient is more significant than you may realize.

Length of silence is definitely an art. Long enough but not so long to get the

patient feeling uncomfortable

Silence

Tone of voice Choice of language Facial expressions Body posture and position Gestures/movements Eye contact

Non vebal communication

It Is The Role Of Medical Student, Resident, Physician

Height Weight Vital Signs Inspection & OBSERVATION

PHYSICAL EXAMINATION

It will help you to identify, prevent, and or resolve any active or potential drug-related problems.

We have to obtain accurate MH.Why?1. Ruling in or out a drug-related adverse effect2. Preventing drug-drug, food-drug, drug-disease

interactions.3. Monitoring for clinical signs that may be masked due

to a drug.4. Evaluating laboratory finding, as certain drug may

affect the results.5. Preventing prescriping errors

MEDICATION HISTORY

It verify correct OTC or herbal agents selection and administration.

It gives you the opportunity to assess for any drug-drug or drug-disease interaction that may occur due to OTC or herbal agents.

gives you the opportunity to councel and educate about OTC medications and herbal agents.

MEDICATION HISTORY (cont.)

Medication name Strength and dose Frequency Timing Indication Adverse reactions Past medication history Medication history Adherence allergies

Medication History Components

Close the interview It have to include: Assessing the patient’s understanding Providing an opportunity for the patients to ask you questions. Discussing any follow up plan

You may use the teach-back methods Thank you for all the information you have give me. I will

be sure to document this in your medical record. Before you go I just want to make sure that we discussed how to take your medication properly. Would you mind showing me how will you use your inhaler when you grt home?

What question do you have for me? Well, it was great meeting you, please call the pharmacy if

you have any question. Our number is on you label.”

Close the interview

doctor will use various techniques to assess the symptom: Anemia. These will include a physical examination and possibly diagnostic tests. (Note: A physical exam is always done, diagnostic tests may or may not be performed depending on the suspected condition) Your doctor will ask several questions when assessing your condition. It is important to openly share any pertinent information to help your doctor make an accurate diagnosis.

Dietary historyWhy: e.g. including vegetarianism, lack of red meat, animal products and green leafy vegetables - may indicate dietary deficiency of iron , folate or B12 as cause of anemia.

Are you pregnant?Why: pregnancy causes increased physiological requirements of iron and folate.

Alcohol history?Why: Alcohol can cause anemia by several mechanisms e.g. Gastrointestinal blood loss due to oesophageal varices, peptic ulcer; folate deficiency and sideroblastic anemia.

Past medical historyWhy: Chronic disease can cause anemia e.g. connective tissue disease, malignancy , thyroid disorders , Addison's disease.

Surgical historyWhy: e.g. previous stomach or small bowel surgery can cause Vitamin B12 deficiency; any recent surgery can cause blood loss.

Have you experienced any shortness of breath, palpitations, chest pain, fatigue/tiredness, or headache?Why: These can all be symptoms of anemia.

Have you recently had any ringing in your ears (tinnitus), decreased appetite and weight loss (anorexia),abdominal pain$, indigestion, or change in bowel habit?Why: Whilst these may all appear to be unrelated to anemia, they can be experienced as symptoms.

Have you experienced heavy or prolonged menstrual bleeding recently?Why: Menorrhagia can be a cause of iron deficiency anemia.

Have you noticed any bowel changes recently, particularly darker or more offensive smelling stools?Why: Gastrointestinal bleeding may cause iron deficiency anemia, and may be exhibited by some changes in your stool or bowel habit. Bowel Cancer can also cause iron deficiency anemia, and may cause changes in your bowel habit as well.

Do you suffer from gastrointestinal reflux disease or peptic ulcer disease?Why: These can cause you to experience chronic blood loss and result in iron deficiency anemia.

Do you have hemorrhoids?Why: These can cause you to lose small amounts of blood on a regular basis and can be the cause of anal symptoms, anal swelling, anal itch, and iron deficiency anemia.

To the best of your knowledge, have you ever been diagnosed with diverticulosis/diverticulitis, inflammatory bowel disease or colitis?Why: These are all conditions affecting the large bowel, which can result in acute or chronic gastrointestinal blood loss and thus cause iron deficiency anemia.

Have you ever lived or visited any areas in the topics, and if so where/when?Why: Hookworm can be a cause of gastrointestinal blood loss and iron deficiency anemia, however it is much more common in areas in the tropics.

Can you tell me a bit about your diet and living conditions?Why: Poor diet and living conditions can cause iron deficiency anemia, however this is more likely to be the case in children rather than adults. Additionally certain diets (e.g. vegans) may not consume enough of certain vitamins, and thus cause a type of anemia.

Are there any diseases which run in your family, such as thalassemia or coeliac disease?Why: There are many conditions which can cause malabsorption (such as coeliac disease) and thus cause iron deficiency anemia.

Thalassemia is a genetic and inheritable condition which results in the abnormal formation of hemoglobin in your blood, and may cause iron deficiency anemia in an otherwise healthy person.

Does anyone in your family (even generations ago) come from Mediterranean areas, India, Africa or Southern Asia?Why: There is an increased risk that you may carry one or more genes for Thalassemia if you have genetic family members who are from those areas. Thalassemia can be a cause of iron deficiency 

 these can all be signs of Plummer Vinson Syndrome.

Have you ever been diagnosed with anemia before? If so, what has happened since?Why: Anemia isn't an uncommon diagnosis, and there is some likelihood that you may have been diagnosed with it before. If you have, then it is important for the Health Professional you are currently seeing to know what has transpired since that diagnosis. If you have made any changes, then it is important to evaluate whether or not they are having the desired effect. For example, whether or not you changed your diet or began taking iron supplements.

Have you had any infections?Why: Some infections which last for a long time may cause a type of anemia known as anemia of chronic disease.

Have you ever been diagnosed with Renal Failure?Why: This is a condition which can last for a long time and may cause anemia of chronic disease.

Have you experienced any arthritis, or been diagnosed with rheumatoid arthritis?Why: Rheumatoid arthritis as well as some other Rheumatological conditions can result in anemia of chronic disease as they tend to be experienced for some time.

Do you, or have you had cancer?Why: Cancer and its treatment can have a huge impact on your body, so much so that its effects can result in anemia of chronic disease.

Have you had any illnesses before, particularly ones which have lasted for a long time and which you might still have now?Why: Chronic disease can have long-term effects on other aspects of your health, such as the way in which your body produces blood. These diseases can cause anemia of chronic disease.

Do you drink alcohol, and if so how much?Why: Excessive consumption of alcohol for a prolonged period of time can result in some forms of anemia.

Do you have diabetes, or any liver or heart disease?Why: These can all be caused by some forms of anemia which are the result of the abnormal production of hemoglobin in your blood.

Have you recently experienced any weight gain, lethargy, tiredness, constipation, muscle aches (myalgia) or been particularly avoided being cold?Why: These can all be signs of hypothyroidism, which may also be a cause of anemia.

Is there any possibility that you might be pregnant?Why: Pregnancy can be a cause of anemia, and it is important to consider and rule out this possibility in all women of reproductive age.

If you are pregnant, have you experienced any headache, chest pain, abdominal pain, vomiting, shaking, visual disturbance or experienced pre-eclampsia/pregnancy induced hypertension in any previous pregnancies?Why: Preeclampsia is a very serious condition which in addition to the above listed symptoms, can cause a type of anemia.

Do you or have you taken any medications?Why: Some medications such as azathioprine, phenytoin and trimethoprim can cause some types of anemia.

Do you suffer from diabetes, thyroid disease, Addison's disease or any autoimmune diseases/disorders?Why: Along with pernicious anemia, these can all be associated with one another. Having any one of these autoimmune conditions increases your risk of having (or being later diagnosed with) any other disease in this group.

Have you had any surgery recently?Why: Some surgeries such as a gastrectomy/partial gastrectomy can result in a form of anemia.

Have you noticed any changes or absence in your sense of touch and feeling?Why: Paresthesia can be seen in anemia.

Have you recently thought that your skin or eyes might be more yellow than usual?Why: Jaundice can be noticed as a subtle change in the colour of your eyes and skin, and may be seen with anemia.

Have you noticed any changes or difficult with vision?Why: Some eye problems such as retinal hemorrhages can occur in some types of anemia.

Have you noticed any changes in your hair recently?Why: A subtle but discernable premature graying of your hair may occur with some forms of anemia.

Have you had any fevers?Why: Fever can be a sign of many difference disease processes, but can be associated with a few types of anemia.

Has anyone in your family ever been diagnosed with sickle cell anemia, or do you have any African heritage?Why: Sickle cell anemia is a hereditary condition affecting hemoglobin in blood which can result in anemia, jaundice and episodes of pain in your peripheries. It is more likely to be carried and experienced by those with some or any ethnically African heritage.

Do you know if anyone in your family has ever been diagnosed with any blood disorders or diseases?Why: Apart from the few conditions specifically mentioned above, there are many other inheritable conditions which can affect your blood. These may include Glucose 6 Phosphate Deficiency,Hereditary Spherocytosis, and Pyruvate Kinase Deficiency.

Have you recently received any blood transfusions or any blood products?Why: Contrary to what generally happens blood transfusions can sometimes cause anemia. This may be because the blood/blood product you received was entirely compatible with you.

Do you have any artificial heart valves, any heart disease, or any recent heart problems?Why: Some types of artificial heart valves and some cardiac diseases can cause anemia.

Have you ever been or traveled to anywhere that malaria is known to occur?Why: Malaria can cause anemia. In general, it is vitally important that you tell your Health Professional about any recent or past (up to many years in the past) travel or holidays you have undertaken.

Have you noticed in your urine, particularly at night?Why: Anemia can be sometimes be caused by a condition which causes your blood cells to break apart at night or at times of infection or stress on your body (paroxysmal nocturnal hemoglobinuria).

Have you noticed any ulcers on your legs?Why: These can sometimes be associated with sickle cell anemia.

Have you ever experienced your fingers go white or red and painful?Why: An occurrence called Raynaud's Phenomenon where the fingers/toes may go pale then blue and then finally red. There is much ache and pain associated with this serious of changes, and the condition may be associated with some types of autoimmune anemia.

Have you noticed any changes in your urine, or any purple spots ($purpura)/bruises on your skin?Why: Acute renal failure and unusual bruising can be seen along with anemia in thrombotic thrombocytopenia purpura. There may also be some neurological symptoms which may resemblestroke/transient ischemic attack.

Anemia symptomsWhy: e.g. lethargic, tired, shortness of breath, dizziness, chest pains, palpitations - may indicate if symptomatic or asymptomatic.

Menorrhagia?Why: i.e heavy periods with clotting and flooding - may indicate cause of chronic blood loss and thus anemia.

Peptic ulcer symptomsWhy: e.g. episodic burning pain in upper abdomen below the ribs related to meals - may be cause of chronic blood loss and thus anemia.

Rectal bleeding?Why: may be due to colorectal cancer or polyps, diverticular disease, hemorrhoids , angiodysplasia and thus be a cause of chronic blood loss and thus anemia.

MelaeniaWhy: i.e black tarry stools - indicates bleeding from the upper gastrointestinal tract e.g peptic ulcer or oesophageal varices and thus be cause of anemia.

Coeliac disease symptomsWhy: e.g. intolerance to wheat, bloating, indigestion, diarrhea, bulky frothy stools - causes iron and folate deficiency due to malabsorption.

Ulcerative colitis symptomsWhy: e.g. recurrent attacks of loose stools, bloody diarrhea, mucous in stools - may be a cause of chronic blood loss and thus anemia.

Neurological signs?Why: E.g. paresthesia, loss of vibratory sensation, ataxia and mild dementia - may indicate pernicious anemia.

Jaundice?Why: E.g. yellow skin and sclera, pale stools, dark urine - may indicate Hemolytic anemia; if mild can be due to pernicious anemia or due to chronic liver disease.

Symptoms of Chronic liver diseaseWhy: e.g. jaundice , easy bruising , itchy skin, enlargement of male breasts , loss of body hair , swelling of legs - may indicate cause of folate deficiency and thus anemia.