Introduction
This placement handbook has been prepared to support your learning during your clinical placement for PY3060B Clinical Pharmacy. It also acts as your diary/log book and should be completed and submitted for assessment. Some sections are required to be signed by the pharmacist supervising you and the case presentation/patient medication review presentation will be marked by the pharmacist.
The handbook should be read in conjunction with the student handbook previously used during the clinical visits to Lewisham, Royal Marsden and St. George’s Hospital. As well as providing guidance on patient management plans, presentations, etc., it also contains the Standards for Professional Conduct which continue to apply, irrespective of whether the clinical placement was organised by yourself or by the University.
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Placements will be two week placements in hospital, community or PCT pharmacy. Your placement provider should confirm your start and end date. The first week should be used to collect data for the placement activities. You need to attend every day from 9am – 5pm on the first week of your placement. The next week should be used to complete the handbook, make sure it is signed and retrieve any missing information. The period during which the placements will occur is from Monday 29th March to Friday 16th April. Your placement provider should confirm your start and end date.
You should complete the section for each activity. There are 5 activities in all that you have to carry out during the clinical placement. You must not use the same patient and/or activity for more than one record. Each record must refer to a different patient or activity. In addition to recording the information, you should provide evidence of reflective learning. Reflection is an integral part of the case presentation and Patient Management Plan (PMP) process and is included in the proforma. For the other activities there is a reflective learning sheet to complete. This should be familiar to you as it is similar to the record for your PDP and similar to the RPSGB preregistration records.
The handbook should be completed; the appropriate sections signed by the supervising pharmacist. The completed patient management plan should be handed by Tuesday 6th April for students who started their placement on Monday 29th March and on Tuesday 13th April for students who started their placement on Tuesday 6th April and on Tuesday 20th April for students who started their placement on Monday 12th April. Other placement activities should be handed in on Friday 9th or Friday 16th April or Friday 23rd April depending on your start date. Case presentations will be assessed On Monday, Wednesday or Friday week beginning 19th, 26th April or 3rd May.
You must ensure that all the activities are signed off by your supervisor or other member of staff. The supervisor may wish to make comments and there is a space for these on each worksheet. The reflective learning sheets should be completed and these also require to be signed by a supervisor or member of staff. Failure to complete these will mean that no marks can be obtained for that activity.
Spare copies of all forms and worksheets are available on StudySpace.
Learning Outcomes
This handbook will support you in achieving the following learning outcomes
Demonstrate and apply knowledge of the concept and implication of ADRs.
Outline the characteristics of some drug-induced disorders and the drugs associated with them.
Relate the selection of therapy to treatment guidelines/evidence base, drug properties and the patient
Understand the use of commonly used medical abbreviations. (Complements knowledge gained in Professional Practice 5)
Use data from commonly requested biochemical and haematological laboratory tests to monitor drug treatment and disease progression. (Complements knowledge gained in Professional Practice 5)
Provide appropriate pharmaceutical advice to potential patients to manage some minor conditions encountered in community pharmacy.
Provide appropriate pharmaceutical advice to potential patients and healthcare professionals on the management of a number of common disease states.
Produce a structured reflective diary of placement experience
Practice activities to be completed during the placement
Activities to be undertaken in placement
Core
Community
Hospital
PCO
1. Prepare a Patient Management Plan (PMP)
3. Public Health activity, such as
Provision of smoking cessation advice/products
Emergency hormonal contraception
Advice on cardiac health
Provision of healthy lifestyle advice
3. Patient Medication History
3. Analyse prescribing data and prepare summary report
2. Counsel a patient on how to obtain optimum benefit from their medicines
4. medication use review
4. Discharge Plan
4. Prescription review
5. Presentation of medication use review and recommendations to community pharmacist
5. Case presentation
5. Case presentation
6. Deal with a request for OTC medicines or minor ailment treatment
6. Shadow prescribing visit
1. Patient Management Plan: Page 1
Patient initials: J.W
Name of Pharmacy: Sainsbury Pharmacy
Name of GP: Dr Khan
Sex: M
Weight/Height if available:108 kg /1.74m
Age:75
Date:9th June 2010
Presenting Complain (PC): Patient had a cold and temperature and he was currently taking Sudafed. He came in the pharmacy because it was not working and wanted to buy another OTC product. He also had muscle weakness and felt dizzy.
Relevant Past Medical History (PMH)
Diabetes
Osteoporosis
Allergies:nkda
Patient previous prescribed/OTC medication from PMR
Indication in this patient
How long on it?
Patient previous prescribed/OTC medication:
Indication in this patient
How long on it?
1.Sudafed
2.Gaviscon
3.
4.
5.
Nasal decongestants
Gastro-oesophageal reflux disease
7 days
6.
7.
8.
9.
10.
Patient current prescribed/OTC medication
Drug and dosing details
1.Ramipril(10mg) capsules-take one capsule each day
2.Metformin (500mg) tablets-Take one tablet with or after evening meal
3.Aspirin(75mg)
Dispersable tablets
Take one tablet once each day after food
4.Simvastatin(40mg)tablets-Take one tablet at night with food.
5.Omeprazole
(20mg) capsules-Take one capsule each day
6.Alendronic acid (70mg)tablets-Take one tablet each week
7.Cal D3 chewable tablets-take one tablet twice each day
Indication
Hypertension
Type 2 diabetes
Prevention of an atherosclerotic event
Lowering cholesterol
Gastro-oesophageal reflux disease
Osteoporosis
Osteoporosis
Duration
Summary of monitoring parameters
Measure blood pressure and liver function tests.
Measure blood sugar glucose level and HB1ac.
Measure cholesterol levels.
Patient Management Plan: Page 2
Tests if available e.g. BP, glucose or cholesterol (normal range)
Date 9th June 2010
1.Blood pressure (130/85 mmhg ) – 164/83 mmhg
2.Pulse rate (60-80 beats p/min) – 67 beats p/min
3.Total cholesterol (3-5mmol/l) – 8.21mmol/l
4.Cholesterol (HDL)(>1mmol/l) – 0.8 mmol/l
5.Blood glucose (<7mmol/l) -11.2 mmol/l
6.
7.
8.
9.
10.
11.
12.
Significance of results outside normal range if available:
The blood pressure is very high, cholesterol levels are high especially the total cholesterol levels. The HDL levels are slightly low The glucose levels are out of range and are high.
Other considerations (social issues, compliance);
The patient is very old and forgets to take his medication regularly and has been advised on the MUR to have a dossete box made for him and delivered which will ensure he takes his medication regularly.
Medical Problems
1.Diabetes
2.Hypertension
3.High cholesterol
4.Osteoporosis
Pharmaceutical problem list prioritised (max 4 problems)
1.Management of diabetes
2.Management of hypertension
3.Management of high cholesterol
4.Management of osteoporosis
Patient management Plan: Page 3
SOAP NOTES (max. 2 pages in font size 11 Arial line spacing 1.5)
PHARMACEUTICAL PROBLEM management of diabetes
Subjective
Patient is overweight
Objective
Blood sugar levels were measured in the MUR by the pharmacist using the finger prick test. The result of this test was 11.2mmol/l.
Patient weighed 108 kg and had a BMI of 30 kg/ m².
Blood pressure was high: 164/83.
Pulse rate: 68 beats per/minute
Analysis
The patient is overweight and this is indicated by his BMI of 30kg/m².The blood sugar levels on examination showed to be very high. Normal blood glucose levels range from 4-8mmol/l throughout the day, therefore his blood glucose level of 11.2mmol/l is well out of the normal range. The patient’s high blood sugar levels can lead to micro vascular complications e.g. nephropathy or macro vascular complications e.g. stroke and especially since he has other cardio risk factors e.g. he is obese and has hypertension.
NICE Guidelines recommends that if the person is overweight (body mass index greater then 25kg) oral anti-diabetic treatment should be started. If metformin is not tolerated or is contraindicated, then consider starting a sulfonylurea. NICE also recommends rechecking HbA1c within 2-6months to reassess blood glucose control.
Currently this patient is on monotherapy on metformin .His blood glucose levels are still very high.
If blood glucose control is not being achieved NICE guidelines recommends that a second drug can be added if the person is already taking the optimum dose. If patient is taking metformin one of the following options can be considered:
Add a sulfonylurea
If the person has an erratic lifestyle add a rapid acting insulin secretagogue(nateglinide or repiglinide)
If there is significant risk of hypoglycaemia (or its consequences) with sulfonylurea, or is sulfonylurea is contraindicated add a gliptin or glitazone.
The patient has high cholesterol levels and is currently taking simvastatin for this which is also recommended by NICE as 1st line treatment for the management of blood lipid levels in people with type two diabetes. The patient is on a dose of 40mg taken once daily at night. This could be increased to the maximum dose of 80mg since his total cholesterol levels are high.
The patient is also on antihypertensive medication and should maintain a blood pressure below 140/80 mmhg since he is diabetic. NICE recommends an ACE inhibitor should be first line treatment here. His blood pressure is currently 164/83mmhg which is above the target blood pressure an according to CKS guidelines if the blood pressure does not meet the target blood pressure referral to a specialist maybe required.
Plan
The plan is firstly make sure the patient knows the lifestyle interventions he can take to reduce all risks of complications of his diabetes. This patient is obese and has a BMI of 30. He should be encouraged to lose weight and be given appropriate dietary advice, i.e. reduce fat intake, eat more fruits, vegetables and carbohydrates. Since he has a BMI of 30, he may be referred to a dietician for weight loss medication. This weight management advice will help reduce his risk factors for diabetic complications as well as other cardiovascular complications he has a risk of. Currently he is taking metformin to control his blood glucose levels. The dose of Metformin could be increased gradually to the maximum dose of 2g.if this does not control the blood glucose then Sulfonyureas should be added as a combination therapy according to NICE guidelines since his blood glucose levels . He should also be made aware that he can test his blood glucose levels at home using the finger prick test to make sure his blood glucose levels are controlled. Blood pressure should be monitored at least every 1-2 months until it reaches the target blood pressure and to ensure patient does not turn hypotensive.
Patient management Plan: Page 3
SOAP NOTES (max. 2 pages in font size 11 Arial line spacing 1.5)
PHARMACEUTICAL PROBLEM management of hypertension
Subjective
NIL
Objective
On examination blood pressure was 164/83
Pulse :67 beats/min
Total cholesterol:8.21
HDL:0.8
Glucose:11.2mmol/l
BMI:30kg/m
Analysis
From examination the patient’s blood pressure has elevated from his previous blood pressure shown on the patient medication record which was 158/84.The patient had a cold and came in for alternative decongestants to Sudafed which he was currently taking for his cold symptoms that he was experiencing. Sudafed should not be taken since he is a patient on anti hypertensive medication. All decongestants should be stopped. Patient should be advised of alternative regimes he can take to combat his cold symptoms such as olbas oil inhaler, vick’s rub and paracetamol to lower his temperature.
According to NICE guidelines in hypertensive patients aged over 55 or black the 1st choice for initial therapy should be calcium channel or thiazide diuretics.
Step 2 is adding an ACE inhibitor if the initial therapy was a calcium channel blocker or thiazide diurectic.if initial therapy was an ACE inhibitor add a calcium channel blocker or diuretic.
Step three in the guidance recommends using combination of three drugs:
Use combination of ACE inhibitor, calcium channel blocker and thiazide type diuretics should be used.
Step four in the guidance recommends adding an alpha blocker, spironolactone or another diuretic. If the blood pressure remains uncontrolled on adequate doses of four drugs and expert advice has not been obtained this should now be sought. Currently the patient is on the maximum dose of Ramipril which is 10mg for hypertension. His blood pressure is still elevated and step 2 therapy would be essential and if after regular monitoring if the blood pressure has not been lowered step 3 may need to be put into the drug regime. Since the patient is also diabetic his target blood pressure needs to be for a diabetic patient needs to be considered and should be aimed at less than 140/85.
Plan
The patient needs to moved to step two of NICE guidelines and therefore be on a combination of an ACE inhibitor and calcium channel blocker or thiazide diurectis.If the combination of ACE inhibitor (Ramipril) and a thiazide diuretics(furosemide) is chosen then careful monitoring of his electrolytes, urea and creatine should be done.
The patient’s blood pressure should be monitored regularly i.e. – once every four weeks to assess treatment response.
Whilst on drug therapy patient needs to be given lifestyle intervention advice to take alongside the drug therapy. The patient needs to be advised to have a low fat and low saturated fat diet which will help reduce his weight since he has a high BMI of 30mg/m, reduce his salt diet intake (less 6g salt per day), increase fruit and vegetable consumption and reduce cardiovascular risk by stopping smoking and increasing oily fish consumption. Dynamic Exercise would also help the patient as part of his lifestyle intervention, although since he is very old this is not ideal for the patient.His glycaemic control should be optimised as he is a diabetic (HBA1c of less than 7%) and regular blood sugar levels should be monitored.
2. Patient Counselling
Patient initials:
Sex: M / F
Age:
Location of Counselling (e.g. community pharmacy, counselling room, ward type, out -patient)
Current medical problem(s) (if known):
Patient’s needs ( other considerations):
Current medication (drugs and doses)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Main Counselling points to cover
Supervisor’s signature:
Student signature:
Date
2 Patient Counselling: reflective learning
Date
Brief summary of the nature of the activity
What were you trying to achieve?
What happened / what was the outcome?
What have you learnt as a result?
What do you want / need to learn more about?
Tutor/Supervisor Comments
Tutor/Supervisor Name
Tutor/Supervisor Signature
Date
3. Public Health Activity:
Patient ID (init)
DOB/age:
M/F
Current problem(s)
Relevant past medical history:
Current Medication (if known)
(Drug, dose, frequency)
1.
2.
3.
4.
5.
Activity:
Source
Patient
Pharmacist
Referred by GP
Other ……………..
Reason
Describe activity and how the situation was dealt with.
Advice/information provided
Product supplied or sold
Other issues and comments (patient hard of hearing, mobility, who manages medicines at home, etc)
Further action if needed and outcome
Tutors Comments
Signature
Date
3. Public Health Activity: reflective learning
Date
Brief summary of the nature of the activity
What were you trying to achieve?
What happened / what was the outcome?
What have you learnt as a result?
What do you want / need to learn more about?
Tutor/Supervisor Comments
Tutor/Supervisor Name
Tutor/Supervisor Signature
Date
4. Patient medication use review Page 1
Patient:
DoB
Conditions/diagnosis
MEDICINE
(include dosage details)
MODE OF ACTION
INDICATION
(Appropriateness)
MONITORING (EFFICACY/SAFETY)
PARAMETERS
COUNSELLING POINTS
4. Patient medication use review Page 2
Issues and Recommendations
Issues
Contribution/recommendation
Outcome
For the attention of…
1.
2.
3.
4.
Reflection on Significant Events:
References Used:
Supervisor’s Comments & signature:
Name:
Date:
4 Patient medication use review: reflective learning
Date
Brief summary of the nature of the activity
What were you trying to achieve?
What happened / what was the outcome?
What have you learnt as a result?
What do you want / need to learn more about?
Tutor/Supervisor Comments
Tutor/Supervisor Name
Tutor/Supervisor Signature
Date
5. Patient medication review presentation
Clinical Pharmacy Module
PY3060B
Patient Medication Use Review Presentation Feedback
Name of Presenter: Assessors:
Title: Date:
Presentation start time: Presentation end time:
Duration:
Comments
Mark
Presentation Style
Clarity
Eye Contact
Use of Language
Rapport
20
Resources
Quality of slides
Quantity of slides
Used well?
Appropriate
20
Content
Introduction
Discussion
Understanding
Explanations
Scientific
40
On questioning
Manner
Attitude
Knowledge
Confidence
20
Overall Mark
100
Comments
Tutor/Supervisor
Date
6. OTC request/treatment of a minor ailment
Patient ID (init)
DOB/age:
M/F
Current problem(s)
Relevant past medical history:
Current Medication (if known)
(Drug, dose, frequency)
1.
2.
3.
4.
5.
Request
Source
Patient
Pharmacist
Referred by GP
Other ……………..
Describe activity and how the situation was dealt with.
Potential problems and how solved
Product supplied or sold
Advice/information provided
Other issues and comments (patient hard of hearing, mobility, who manages medicines at home, etc)
Further action if needed and outcome
Tutors Comments
Signature
Date
6 OTC request/treatment of a minor ailment: reflective learning
Date
Brief summary of the nature of the activity
What were you trying to achieve?
What happened / what was the outcome?
What have you learnt as a result?
What do you want / need to learn more about?
Tutor/Supervisor Comments
Tutor/Supervisor Name
Tutor/Supervisor Signature
Date
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