Academic ServiceUpdated: 11-20-24
APPE Patient Care Interventions Tracking
| Date: | 11/20/2024 |
| Rotation Type: | APPE Ambulatory Care |
| Comments: | ? |
| Diagnostic Codes: | C50.912 | Malignant neoplasm of unspecified site of left female breas C77.3 | Sec and unsp malig neoplasm of axilla and upper limb nodes |
| Patient Age: | 44 Years |
| Patient Sex: | F |
| Drug therapy recommendations provided: | Initiation of monitoring |
| Drug-related problems identified: | Adverse drug reaction |
| If you interacted with health care team member(s), indicate the healthcare team members you directly interacted with during this intervention: | Pharmacist Physician Nurse |
| Interaction: | Healthcare Team Member(s) |
| Method of Communication: | Written: Electronic messaging system |
| Patient Education Provided?: | Yes |
| Patient intervention - SBAR Summary: Provide a short summary of this intervention in an SBAR format: | The situation is JP is a 44-year-old female who wants to start semaglutide for weight loss. The background is she is currently on abemaciclib for treatment of breast cancer and wants to know if there is an interaction before she proceeds to obtain a prescription from her PCP. My assessment is that there are no pertinent drug/disease interactions between cancer treatment and GLP-1 medications. However, the patient should monitor for increased GI side effects as both medications have overlapping GI side effects that may be additive. The plan is to inform the patient that there are no pertinent drug/disease state interactions but to initiate monitoring of GI side effects, including abdominal pain, constipation, diarrhea, nausea, and vomiting. Continue supportive care treatment for cancer medication, including loperamide and antiemetics. However, if symptoms do not resolve with supportive care or worsen, let the clinic and her physician know. |
APPE Patient Care Interventions Tracking
| Date: | 11/18/2024 |
| Rotation Type: | APPE Ambulatory Care |
| Comments: | ? |
| Diagnostic Codes: | C67.8 | Malignant neoplasm of overlapping sites of bladder L20.9 | Atopic dermatitis, unspecified |
| Patient Age: | 86 Years |
| Patient Sex: | F |
| Drug therapy recommendations provided: | Change in medication |
| Drug-related problems identified: | Needs different drug product |
| If you interacted with health care team member(s), indicate the healthcare team members you directly interacted with during this intervention: | Pharmacist Physician |
| Interaction: | Healthcare Team Member(s) |
| Method of Communication: | Written: Electronic messaging system |
| Patient Education Provided?: | N/A |
| Patient intervention - SBAR Summary: Provide a short summary of this intervention in an SBAR format: | The situation is AH is a 86 YO F who has chronic atopic dermatitis. The background is AH is undergoing treatment for bladder cancer with enfortumab since April 2024. She was previously on pembrolizumab but got switched due to disease progression and possible rheumatoid arthritis onset. She has been experiencing ongoing rash on her body and has been exacerbated by pembrolizumab in January 2024 which she was prescribed Clobetasol, Protopic and tried phototherapy. She presented to dermatology late October for uncontrolled atopic dermatitis and the dermatologist is inquiring about prescribing Dupixent. My assessment is Dupixent is not an appropriate choice for this patient based on the side effect profile of Dupixent and Enfortumab. Based on the EV-301 trial that investigated the use of enfortumab in patients with advanced bladder cancer, 47% of patients (N=296) experienced all-grade skin reactions. Although less common, Dupixent has also been documented to have exacerbations of atopic dermatits (SOLO-1/2, CHRONOS trials). My recommendation is to not proceed with Dupixent and have the patient try prophylactic topical treatments and oral prednisone and consider Dupixent or dose reduction as a last resort. Initiate triamcinolone 0.1% AAA QD to BID x 4 weeks then PRN if symptoms improve to Grade 1 Continue to monitor, if no resolution/worsening then can consider oral corticosteroid regimen or dose reduction. |
APPE Patient Care Interventions Tracking
| Date: | 10/29/2024 |
| Rotation Type: | APPE Ambulatory Care |
| Comments: | ? |
| Diagnostic Codes: | C61 | Malignant neoplasm of prostate |
| Patient Age: | 70 Years |
| Patient Sex: | M |
| Drug therapy recommendations provided: | Initiation of monitoring |
| Drug-related problems identified: | Needs drug therapy Adverse drug reaction |
| If you interacted with health care team member(s), indicate the healthcare team members you directly interacted with during this intervention: | Pharmacist Physician Nurse Nurse Practicioner |
| Interaction: | Healthcare Team Member(s) |
| Method of Communication: | Written: Chart note |
| Patient Education Provided?: | Yes |
| Patient intervention - SBAR Summary: Provide a short summary of this intervention in an SBAR format: | The situation is CP is a 70-year-old M who is inquiring about a drug information question in regards to his oral chemotherapy regimen and over-the-counter Advil (ibuprofen). The background is that he is currently taking abiraterone for his oral chemotherapy regimen for treatment of his prostate cancer diagnosis. He reached out to the healthcare team to ask if it is ok to take ibuprofen while on abiraterone. My assessment is there are no significant drug interactions between the patient's chemotherapy along with his other medications (prednisone, bupropion, gabapentin, and tadalafil) and ibuprofen. However, some overlapping side effects between abiraterone/prednisone and ibuprofen should be monitored. My recommendation is that the patient can take ibuprofen when needed but should be monitored for increased GI upset, easy bruising/bleeding, and blood pressure. The healthcare team should also monitor labs, including serum creatinine and platelets. The patient should also limit his ibuprofen intake to 1.2 g/day per OTC labeling and inform his care team if his pain persists or worsens. |
APPE Patient Care Interventions Tracking
| Date: | 08/29/2024 |
| Rotation Type: | APPE Community Pharmacy |
| Comments: | |
| Diagnostic Codes: | A53.9 | Syphilis, unspecified J45.20 | Mild intermittent asthma, uncomplicated Z29.81 | Encounter for HIV pre-exposure prophylaxis |
| Patient Age: | 46 Years |
| Patient Sex: | M |
| Drug therapy recommendations provided: | Initiation of monitoring |
| Drug-related problems identified: | Adherence |
| If you interacted with health care team member(s), indicate the healthcare team members you directly interacted with during this intervention: | Pharmacist |
| Interaction: | Healthcare Team Member(s) |
| Method of Communication: | Verbal: In person |
| Patient Education Provided?: | N/A |
| Patient intervention - SBAR Summary: Provide a short summary of this intervention in an SBAR format: | The situation is this patient had an STI screening a few days ago and there are 3 labs that are flagged as abnormal. The background is RG is a 46 YO with NKDA and a PMH of asthma which he uses albuterol and HIV PrEP which he takes Truvada. Other medications include Zyrtec, Vitamin D, creatine and protein power, and montelukast. The patient also had syphilis in 2016 which was treated with doxycycline x 14 days. The patient's syphilis screening as of this month shows RPR titer as 1:1, antibody positive and the RPR with flex titer as reactive. The patients past titers since 2023 have been 1:1. My assessment is that the labs of this month indicate that antibodies to the bacterium treponema pallidum which causes syphilis was found in the blood sample. This could be because of the patient's past infection with syphilis. Based on the patients past titers of 1:1, I am not concerned of a re-infection with syphilis unless this increases 4-fold. My plan is to continue monitoring this patient's antibodies to ensure that there is no re-infection and follow up with results at the next appointment. |
APPE Patient Care Interventions Tracking
| Date: | 08/27/2024 |
| Rotation Type: | APPE Community Pharmacy |
| Comments: | |
| Diagnostic Codes: | E11.9 | Type 2 diabetes mellitus without complications N52.9 | Male erectile dysfunction, unspecified Z29.81 | Encounter for HIV pre-exposure prophylaxis |
| Patient Age: | 61 Years |
| Patient Sex: | M |
| Drug therapy recommendations provided: | Initiation of monitoring |
| Drug-related problems identified: | Dosage adjustment needed |
| If you interacted with health care team member(s), indicate the healthcare team members you directly interacted with during this intervention: | Pharmacist |
| Interaction: | Healthcare Team Member(s) |
| Method of Communication: | Verbal: Phone Call |
| Patient Education Provided?: | N/A |
| Patient intervention - SBAR Summary: Provide a short summary of this intervention in an SBAR format: | The situation is this patient does not seem to have seen their PCP in some time but the most recent PCP the patient saw is the new one but we need to obtain contact information to ensure it is ok to continue HIV PrEP treatment. The background is JC is a 61 YO M with NKDA, PMH of T2DM which he takes Ozempic and Metformin, erectile dysfunction which he takes tadalafil and HIV PrEP which he takes Descovy. The patient was seen by PCP to discuss renal function decline but did not ask if PCP was okay with continuing Descovy. The patient has had some difficulty establishing a new PCP due to some staff changes at the clinic he goes to. My assessment is that the patient should continue Descovy for now but we need to finalize this with the PCP because if the patient's CrCl does get below <30 mL/min, PrEP cannot continue. My recommendation is that we need to get the PCP info as soon as possible in order to make sure the current treatment of Descovy is safe for the patient along with ensuring that his diabetes is well controlled which can reflect his renal function decline. |
APPE Patient Care Interventions Tracking
| Date: | 08/28/2024 |
| Rotation Type: | APPE Community Pharmacy |
| Comments: | |
| Diagnostic Codes: | F99 | Mental disorder, not otherwise specified Z29.81 | Encounter for HIV pre-exposure prophylaxis |
| Patient Age: | 28 Years |
| Patient Sex: | M |
| Drug therapy recommendations provided: | Initiation of monitoring |
| Drug-related problems identified: | Adherence |
| If you interacted with health care team member(s), indicate the healthcare team members you directly interacted with during this intervention: | Pharmacist |
| Interaction: | Patient |
| Method of Communication: | Verbal: Phone Call |
| Patient Education Provided?: | Yes |
| Patient intervention - SBAR Summary: Provide a short summary of this intervention in an SBAR format: | The situation is this patient has been on HIV PrEP for just over a year and would like to continue but has expressed difficulty with adherence. The background is RK is a 28 YO M who has NKDA, PMH includes HIV PrEP which he is taking Descovy for. The patient has had a recent diagnosis of depression and anxiety which he is taking sertraline for and will be starting bupropion. As of the most recent encounter in July, he missed 4 tablets in the last month while backpacking but he expresses a concern about missing tablets more sporadically since the last visit in April. He notes that his difficulty with adherence may be due to the recent diagnosis of depression and anxiety. My assessment is overall RK is compliant with his medication but has missed some doses and it sounds like he wants to continue treatment for both HIV PrEP and depression/anxiety but is concerned about how his recent diagnosis of depression and anxiety might be affecting his adherence. My recommendation is to have the patient continue the pill case he uses and maybe offer a different pill case depending on his current one that will make medication administration more easier depending on the dosing of his medications. When I was starting to take medications daily, I certainly missed doses even with a pill container. Something that helped me was setting reminders on my phone depending on when I need to take medications along with a weekly reminder for filling up my pill container, this could be a suggestion. Also, if backpacking or traveling is something the patient does often enough, there are smaller pill containers designed for on-the-go travel that are discreet that the patient can take along in a hiking backpack or travel luggage. Another recommendation I have is to counsel the patient on the importance of taking medications as prescribed. If the underlying reason for missing doses occasionally and unintentionally is due to depression and anxiety which could definitely have an impact on daily tasks, making sure you are taking the sertraline and bupropion as prescribed to help control those symptoms of depression and anxiety can help improve adherence. |
APPE Patient Care Interventions Tracking
| Date: | 08/27/2024 |
| Rotation Type: | APPE Community Pharmacy |
| Comments: | |
| Diagnostic Codes: | A56.3 | Chlamydial infection of anus and rectum Z20.2 | Contact w and exposure to infect w a sexl mode of transmiss Z29.81 | Encounter for HIV pre-exposure prophylaxis |
| Patient Age: | 20 Years |
| Patient Sex: | M |
| Drug therapy recommendations provided: | Addition of medication |
| Drug-related problems identified: | Needs drug therapy |
| If you interacted with health care team member(s), indicate the healthcare team members you directly interacted with during this intervention: | Pharmacist |
| Interaction: | Healthcare Team Member(s) |
| Method of Communication: | Verbal: Phone Call |
| Patient Education Provided?: | Yes |
| Patient intervention - SBAR Summary: Provide a short summary of this intervention in an SBAR format: | The situation is this patient had STI labs collected 6 days ago and one of the labs has an abnormal result indicating an active STI. The background is AC is a 20 YO M who has NKDA, PMH includes HIV PrEP which he is taking Truvada for. The patients most recent STI screening as of this month show that chlamydia trachomatis is detected based on a rectal collection. My assessment is treatment for chlamydia should be initiated based on detection of chlamydia in the rectum. My recommendation is to initiate doxycycline 100 mg PO BID x 7 days which is the preferred regimen based off of CDC STI guidelines. |
APPE Patient Care Interventions Tracking
| Date: | 08/23/2024 |
| Rotation Type: | APPE Community Pharmacy |
| Comments: | |
| Diagnostic Codes: | K21.00 | Gastro-esophageal reflux dis with esophagitis, without blee |
| Patient Age: | 88 Years |
| Patient Sex: | F |
| Ethnicity (as reported by patient or through patient medical record): | Other |
| Drug therapy recommendations provided: | Discontinuation of medication |
| Drug-related problems identified: | Unnecessary drug therapy |
| If you interacted with health care team member(s), indicate the healthcare team members you directly interacted with during this intervention: | Pharmacist Physician Nurse |
| Interaction: | Healthcare Team Member(s) |
| Method of Communication: | Written: Chart note |
| Patient Education Provided?: | Yes |
| Patient intervention - SBAR Summary: Provide a short summary of this intervention in an SBAR format: | The situation is this patient is taking medications for treatment of GERD. The background is this patient was taking two medications in the same class, PPIs (pantoprazole and omeprazole) for the past few months. My assessment is one taking both of these medications is unnecessary and could lead to more harm. My recommendation is to discontinue the omeprazole based on the patients current GERD management and symptoms. |
APPE Patient Care Interventions Tracking
| Date: | 08/14/2024 |
| Rotation Type: | APPE Community Pharmacy |
| Comments: | |
| Diagnostic Codes: | M51.26 | Other intervertebral disc displacement, lumbar region M54.41 | Lumbago with sciatica, right side |
| Patient Age: | 52 Years |
| Patient Sex: | F |
| Drug therapy recommendations provided: | Change in medication |
| Drug-related problems identified: | Needs different drug product |
| If you interacted with health care team member(s), indicate the healthcare team members you directly interacted with during this intervention: | Pharmacist Physician Nurse |
| Interaction: | Healthcare Team Member(s) |
| Method of Communication: | Verbal: Phone Call |
| Patient Education Provided?: | Yes |
| Patient intervention - SBAR Summary: Provide a short summary of this intervention in an SBAR format: | The situation is this patient was prescribed gabapentin post-op spinal surgery and to help manage sciatic nerve pain. The background is the patient was prescribed gabapentin 300 mg TID and gabapentin 100 mg TID for TDD 1200 mg. My assessment is the patient was getting concerned with the amount of pills she takes each day and was taking them incorrectly. My recommendation is to switch the patient to gabapentin 400 mg TID instead of taking two different strengths to lessen the pill burden for the patient and she would still be taking the same TDD of 1200 mg. |
APPE Patient Care Interventions Tracking
| Date: | 08/12/2024 |
| Rotation Type: | APPE Community Pharmacy |
| Comments: | |
| Diagnostic Codes: | B96.81 | Helicobacter pylori as the cause of diseases classd elswhr |
| Patient Age: | 30 Years |
| Patient Sex: | M |
| Ethnicity (as reported by patient or through patient medical record): | Other |
| Drug therapy recommendations provided: | Change in medication |
| Drug-related problems identified: | Needs different drug product |
| If you interacted with health care team member(s), indicate the healthcare team members you directly interacted with during this intervention: | Pharmacist Physician Nurse |
| Interaction: | Healthcare Team Member(s) |
| Method of Communication: | Verbal: In person |
| Patient Education Provided?: | Yes |
| Patient intervention - SBAR Summary: Provide a short summary of this intervention in an SBAR format: | The situation is this patient was prescribed an oral regimen for treatment of H. pylori. The background is the initial regimen the patient was prescribed was the clarithromycin triple-based therapy. My assessment is based on current 2023 guidelines from the IDSA that this regimen may not be effective based on resistance patterns of clarithromycin. My recommendation is to switch from the clarithromycin triple-based therapy to the bismuth quadruple therapy based on recommendations from the IDSA and Sanford guide. |
APPE Patient Care Interventions Tracking
| Date: | 06/12/2024 |
| Rotation Type: | APPE Inpatient/Health Systems |
| Comments: | |
| Diagnostic Codes: | A41.51 | Sepsis due to Escherichia coli [E. coli] N39.0 | Urinary tract infection, site not specified |
| Patient Age: | 80 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Ethnicity (as reported by patient or through patient medical record): | Other |
| Drug therapy recommendations provided: | Increase dose |
| Drug-related problems identified: | Dosage adjustment needed |
| If you interacted with health care team member(s), indicate the healthcare team members you directly interacted with during this intervention: | Pharmacist Physician |
| Interaction: | Healthcare Team Member(s) |
| Method of Communication: | Verbal: In person |
| Patient Education Provided?: | N/A |
| Patient intervention - SBAR Summary: Provide a short summary of this intervention in an SBAR format: | The situation is this patient needs a dose adjustment to treat a bacteremia. The background is this patient had a positive blood culture for E. coli and was started on Ceftriaxone 1 gram IV Q24H. My assessment is the medication choice of ceftriaxone is ok but should be increased due to the bacteremia and the patients increasing WBC. My recommendation is to increase to Ceftriaxone 2 grams IV Q24H. |
APPE Patient Care Interventions Tracking
| Date: | 06/07/2024 |
| Rotation Type: | APPE Inpatient/Health Systems |
| Comments: | |
| Diagnostic Codes: | L03.311 | Cellulitis of abdominal wall Z96.642 | Presence of left artificial hip joint Z96.653 | Presence of artificial knee joint, bilateral |
| Patient Age: | 72 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Ethnicity (as reported by patient or through patient medical record): | Caucasian |
| Drug therapy recommendations provided: | Discontinuation of medication |
| Drug-related problems identified: | Unnecessary drug therapy |
| If you interacted with health care team member(s), indicate the healthcare team members you directly interacted with during this intervention: | Pharmacist Physician |
| Interaction: | Healthcare Team Member(s) |
| Method of Communication: | Verbal: In person |
| Patient Education Provided?: | N/A |
| Patient intervention - SBAR Summary: Provide a short summary of this intervention in an SBAR format: | The situation is this patient was started on empiric antibiotic therapy upon admission to the ER which included vancomycin 2 grams IV Q24H and ceftriaxone 2 grams IV Q24H. The background is this patient has probable cellulitis of his abdominal wall with pertinent physical exam findings including increased redness over the lower abdomen and lower quadrant abdominal pain. Also notable, the patient has had bilateral knee joint replacements and left hip replacement within the past 15 years. The patient had 2 sets of positive blood cultures for gram positive cocci in chains suggestive of streptococcal species based on the DNA panel. My assessment is, based on the blood cultures and the patients presentation, vancomycin can be discontinued. My recommendation is to discontinue the vancomycin, continue ceftriaxone 2 grams IV Q24H and follow up with repeat blood cultures as well as follow up with the provider about further physical exam findings regarding the hardware from the joint replacements. |
APPE Patient Care Interventions Tracking
| Date: | 05/23/2024 |
| Rotation Type: | APPE Inpatient/Health Systems |
| Comments: | |
| Diagnostic Codes: | G93.41 | Metabolic encephalopathy I69.891 | Dysphagia following other cerebrovascular disease J17 | Pneumonia in diseases classified elsewhere |
| Patient Age: | 78 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Ethnicity (as reported by patient or through patient medical record): | Caucasian |
| Drug therapy recommendations provided: | Discontinuation of medication |
| Drug-related problems identified: | Unnecessary drug therapy |
| If you interacted with health care team member(s), indicate the healthcare team members you directly interacted with during this intervention: | Pharmacist Physician |
| Interaction: | Healthcare Team Member(s) |
| Method of Communication: | Verbal: In person |
| Patient Education Provided?: | N/A |
| Patient intervention - SBAR Summary: Provide a short summary of this intervention in an SBAR format: | The situation is this patient was started on metronidazole 500 mg IV Q8H and ceftriaxone 2 grams Q24H for aspiration pneumonia. The background is this patient has a history of recurrent aspiration pneumonia secondary to dysphagia from a CVA that occurred in June of 2023. My assessment is anaerobic coverage is not recommended for aspiration pneumonia unless a lung abscess or empyema is suspected per the ATS/IDSA 2019 guidelines for the diagnosis and treatment of adults with CAP. My recommendation is to discontinue the metronidazole and continue the ceftriaxone. |
APPE Patient Care Interventions Tracking
| Date: | 05/20/2024 |
| Rotation Type: | APPE Inpatient/Health Systems |
| Comments: | |
| Diagnostic Codes: | B96.4 | Proteus (mirabilis) (morganii) causing dis classd elswhr N39.0 | Urinary tract infection, site not specified R78.81 | Bacteremia T83.511A | I/I react d/t indwelling urethral catheter, init |
| Patient Age: | 69 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Ethnicity (as reported by patient or through patient medical record): | Caucasian |
| Drug therapy recommendations provided: | Increase dose |
| Drug-related problems identified: | Dosage adjustment needed |
| If you interacted with health care team member(s), indicate the healthcare team members you directly interacted with during this intervention: | Pharmacist Physician |
| Interaction: | Healthcare Team Member(s) |
| Method of Communication: | Verbal: In person |
| Patient Education Provided?: | No |
| Patient intervention - SBAR Summary: Provide a short summary of this intervention in an SBAR format: | The situation is that this is a 69-year-old male who presents to the ED with hematuria after a same-day catheter change. The background is that this patient has a chronic Foley catheter because of his BPH and was started on Ceftriaxone 1 gram IV Q24H for suspected UTI. Final blood cultures showed Proteus Mirabilis. My assessment is that due to the positive blood cultures, the dose of ceftriaxone should be increased to adequately treat the bacteremia. My recommendation is to increase the dose from 1 gram Q24H to 2 grams Q24H. |
APPE Patient Care Interventions Tracking
| Date: | 05/15/2024 |
| Rotation Type: | APPE Inpatient/Health Systems |
| Comments: | |
| Diagnostic Codes: | A41.9 | Sepsis, unspecified organism R65.21 | Severe sepsis with septic shock |
| Patient Age: | 81 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Ethnicity (as reported by patient or through patient medical record): | Caucasian |
| Drug therapy recommendations provided: | Change in medication |
| Drug-related problems identified: | Needs different drug product |
| If you interacted with health care team member(s), indicate the healthcare team members you directly interacted with during this intervention: | Pharmacist Physician |
| Interaction: | Healthcare Team Member(s) |
| Method of Communication: | Verbal: In person |
| Patient Education Provided?: | N/A |
| Patient intervention - SBAR Summary: Provide a short summary of this intervention in an SBAR format: | The situation is this patient had an initial diagnosis of sepsis and possible pneumonia. The background is this patient came in with shortness of breath, altered mental status, and a history of pneumonia. There were also findings of infiltrates on the chest X-ray and, notably, the patient has a prosthetic valve s/p TAVI from 2018. The patient was started on ceftriaxone and azithromycin while cultures were pending. Blood culture results came back showing staph aureus present in the blood. This is also MSSA because there was no MRSA detection on the PCR. My assessment is the patient's current therapy of azithromycin is ok to continue for the pneumonia treatment, but ceftriaxone does not have the best coverage for MSSA and has been shown to have higher rates of treatment failure after 90 days and should probably be switched to a different cephalosporin with better MSSA coverage for treatment, especially with the prosthetic valve. My recommendation is to change ceftriaxone to cefepime for MSSA coverage and follow up with repeat blood cultures within 48 hours to monitor for safety and efficacy. |
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