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Ambulatory Care Clerkship Goals and Objectives
COURSE GOALS:
Teach the student the rationale of prescribing medication in an ambulatory care setting; Familiarize the student with laboratory tests and diagnostic procedures used in themonitoring of drug therapy; Teach the student both the physical and laboratory parameters for evaluating effectivemedication use in ambulatory patients, Reinforce to students the need for effective instructions to patients in the proper usage inboth prescription medication and non-prescription medication; Teach the student the basis of developing progressive medication treatment plans inpatients with chronic diseases; Show the student how to apply information acquired during previous undergraduatecourses to clinical care, in particular, the areas of therapeutics, pathophysiology,pharmacology, pharmaceutics, biopharmaceutics, and pharmacokinetics; Utilize appropriate and effective communication skills to assure complete and accurateinformation to team members and patients concerning drug therapy and patient response; Function as an educator for patients and health professional colleagues by conductinginservice sessions, compliance counseling, and group discussions; Enhance a positive professional attitude. This includes:a.
A concern for the individual patient.
An appreciation of the impact of illness on the individual patient and recognition ofthe psychosocial factors which affect medical illness.
Developing the philosophy of a team approach to patient care.
An appreciation of the need for and learning habits necessary for life-long learningas a pharmacist.
Acquiring a sense of responsibility for patient outcomes.
COURSE OBJECTIVES:
At the completion of this rotation, the student-pharmacist will be able to: Communication Skills:
a.
Use a knowledge of interpersonal skills to effectively manage workingrelationships.
Address all communication at the level appropriate for the audience.
Effectively communicate patient data base and assessment to peers.
Explain verbally physical parameters and laboratory parameters and theirrelationship to the evaluation of the efficacy of any drug used in any of the patientswhich a student follows during the rotation.
Articulate and justify recommendations.
Effectively counsel any ambulatory patient about any one drug or any combinationof drugs that the patient is prescribed.
Parameters include:• Use correct grammar, punctuation, spelling, style and formattingconventions in preparing all written communications.
Use listening skills effectively in performing clerkship functions.
Provide concise, applicable, and timely responses to requests fordrug informationfrom health care providers and patients.
Demonstrate Techniques to Enhance Patient Compliance.
a.
Communicate to the patient the importance of taking his/her medication regularly,as well as the medical repercussions of noncompliance.
Demonstrate and assess patient understanding of metered dose inhalers, spacers,etc.
Develop individual strategies for enhancing patient adherence.
Chart Review and Patient Monitoring.
a.
Create a patient profile from information available about patient including chartsand patient interviews using format requested by preceptor.
Review a patient's medical chart and obtain information needed to fulfill thepharmacist’s role in monitoring drug therapy.
Understand and evaluate laboratory tests as they relate to drug therapy.
Assess chart and/or computer profile for correct drug, dosage and compliance.
Demonstrate the ability to analyze patient information to assess therapeuticeffectiveness and adverse drug effects.
Identify standards of therapy and alternatives and be able to recommend appropriatetherapy for the individual patient.
Identify drug-induced disease, drug-drug interactions, drug-disease interactions, ordrug-laboratory interactions.
Identify therapeutic end-points for drug therapy as for therapeutic Demonstrate consistent use of a systematic approach to problem solving.
Formulate solutions to complex patient care problems that maximize the achievement of pharmaceutical care.
k.
Determine the presence of any of the following medication therapy problems in a patient’s current medication therapy: medication used with no medical indication medical conditions for which there is no medication prescribed medication prescribed inappropriately for a particular medical anything inappropriate in the current drug therapy regimen (dose, form, schedule, route of administration, method of administration) prescription of drugs to which the patient is allergic presence of potential for adverse drug events presence or potential for clinically significant drug-drug, drug-disease, drug-nutrient, or drug-laboratory test interactions interference with medical therapy by social or recreational patient not receiving full benefit of prescribed medication problems arising from financial impact of medication patient lack of understanding of his/her medication therapy patient not adhering to medication regimen Therapeutic Drug Monitoring.
a.
Utilize biopharmaceutical and pharmacokinetic principles of drug therapy inambulatory patients.
Demonstrate the ability to appropriately adjust dosage regimens by the use ofpharmacokinetic principles and equations.
Display initiative in preventing, identifying, and resolving pharmacy-relatedpatient-care problems.
Literature Evaluation. Demonstrate the ability to critically review the literature and
apply it to the patient care situation.
ADRs. Demonstrate the thought and documentation process for assessment of ADRs.
Drug Interactions. Demonstrate the thought and documentation process for assessment
of drug interactions.
Ambulatory Care
Minimum Knowledge Base Disease States
In order to both ensure standardization and prevent duplication between clerkship sites, there areidentified minimum knowledge base disease states for each clerkship.
Students in the ambulatory care clerkship are responsible for the following disease states andtherapies: Each ambulatory care site and preceptor has the option of requiring additional site specific topics.
While your Therapeutics notebook may be a starting point reference for this information, new datamay be present since your didactic course work. You are responsible for knowing study design,limitations and results for major landmark studies and/or consensus statements for each minimumknowledge base. For example: Hypertension:
The Sixth Report of the Joint National Committee on Detection Evaluation and Treatment of HighBlood Pressure Arch Intern Med, 1997;157:2413-47.
LEARNING OBJECTIVES:
Hypertension
•
Determine the differences between essential and secondary hypertension.
Identify the risk factors of hypertension.
Identify how the major organs of the body are adversely affected by hypertension and howthese adverse affects can be subjectively and objectively monitored.
Be able to list the drugs which might induce hypertension and foods which may precipitatehypertension in a patient on monoamine oxidase inhibitors.
Be able to list the non-pharmacologic treatment of hypertension and when it is indicated.
Be able to list the side effects of antihypertensive medication.
Be able to individualize the management of patients with hypertension Be able to select an oral drug and dose for treatment of hypertensive emergencies andurgencies.
Be able to select the drugs of choice and possible alternatives in hypertensive patient withthe following concomitant diseases: Congestive Heart FailureAnginaCardiac Arrhythmias Chronic Obstructive Pulmonary Disease (COPD) and Asthma Be able to effectively counsel a patient on their antihypertensive therapy.
Arthritis
Compare and contrast the pathophysiologic processes, epidemiology, and clinical course ofrheumatoid arthritis and osteoarthritis.
Recognize and describe lab parameters pertinent to diagnosis and monitoring of rheumaticdiseases.
Explain proposed indications, mechanism of action, dosing, monitoring parameters anddrug interactions of the following: Explain the pathophysiology of uric acid production as it relates to gout.
Discuss the clinical features of gout.
Recommend appropriate pharmacotherapy dosing and monitoring parameters for treatmentof acute gout and hyperuricemia including: Be able to appropriately counsel patients regarding their arthritis therapy.
Peptic Ulcer Disease (PUD)
Describe the epidemiology and incidence of PUD.
Identify the physiologic controls involved in gastric acid secretion.
Explain the underlying causative mechanisms and pathophysiology involved in PUD.
Describe the usual clinical presentation of patients with duodenal or gastric ulcers andesophageal reflux (GERD).
Discuss the various pharmacologic agents including: pump inhibitors, sucralfate, antibiotics, prokinetics used in the treatment of PUD withrespect to their: a. Mechanism of actionb. Efficacyc. Dosing and duration of therapyd. Side effects Discuss treatment regimens for H. pylori Formulate reasonable treatment plans for patients with gastric or duodenal ulcers, andesophageal reflux disease for both acute and chronic management.
Be able to counsel patients on non-drug measures for GERD.
Be able to appropriately counsel patients regarding their PUD therapy.
Congestive Heart Failure (CHF)
Describe the epidemiology, etiology, natural history, and long-term prognosis ofCHF.
Explain the pathophysiologic mechanisms involved in CHF.
Describe the clinical evaluation and usual clinical presentation of patients withCHF.
vasodilators, aceinhibitors, beta blockers and inotropes in the management of CHF Formulate reasonable treatment plans for patients with CHF, including both drug and non-drug measures and their monitoring parameters Identify and explain controversies in the management of CHF.
Be able to appropriately counsel patients regarding their CHF therapy.
Hyperlipidemia
Be able to cite the benefits of lowering serum cholesterol in patients withhypercholesterolemia.
Be able to state the total and LDL serum cholesterol levels which correspond to the NCEPdefinitions of “desirable”, “borderline” and “high risk” serum cholesterol.
Given the results of a lipoprotein analysis, be able to discuss the significance of theseresults.
Be able to discuss the role of triglycerides as a risk factor for CHD.
Be able to recognize those drugs which may have a detrimental effect on serum cholesteroland triglyceride levels.
Be able to list the risk factors for coronary artery disease which must be taken into accountalong with serum cholesterol in determining a patient’s treatment regimen.
Be able to state the goals of antihyperlipidemic therapy in terms of target serumcholesterol.
Be able to discuss the role of diet in the management of hyperlipidemia and be able tocounsel patients on general dietary guidelines.
For each of the major lipid lowering agents, be able to cite their effects on each of themajorserum lipids, magnitude of this effect and their role in drug therapy.
Given a patient situation, be able to outline an appropriate treatment and follow-up plan.
Be able to recognize and solve problems related to the use of each of the lipid loweringagents.
Be able to appropriately counsel patients regarding their antihyperlipidemic drug therapy.
Reactive and Obstructive Airway Disease
Explain the proposed pathophysiologies in patients with reactive airway disease andobstructive airway disease.
Differentiate between asthma, chronic bronchitis, emphysema, and other forms ofobstructive pulmonary disease.
Identify risk factors of developing obstructive lung disease and counsel a person on theserisk factors.
Explain the basics of pulmonary function testing and utility of PFTs.
Make recommendations regarding the initial medication used in the treatment of asthma,exercise-induced asthma, and chronic obstructive airway disease.
Understand the differences between various beta agonists and clinical utility of each.
Explain the advantages and disadvantages of the various dosage forms currently availablein the treatment of asthma.
Make a recommendation regarding initial loading dose and maintenance dose ofTheophylline.
Make a recommendation regarding pharmacologic change in an existing therapeuticregimen.
List the side effect profiles and monitoring parameters of beta-agonists, leukotrieneantagonists, methylxanthines, anti-cholinergic, corticosteroids, and mast cell stabilizers.
Effectively demonstrate the use of metered dose inhalers and peak flow meters.
Be able to cite the NIH guidelines for management of asthma.
Be able to appropriately counsel patients regarding reactive and obstructive airwaydisease.
Thyroid Disease
Be able to draw a diagram showing how TRH, TSH, T4, and T3 interrelate.
Be able to explain the pathophysiology and other features of Graves' disease andHashimoto's thyroiditis.
Given a patient case including pertinent laboratory information, be able to identify the typeof thyroid abnormality.
Given information on a hyperthyroid patient, choose the most appropriate drug or non-drugtreatment.
Given information on a hypothyroid patient, choose a thyroid product and dose.
Given a patient case, identify any drug-disease, drug-drug, or drug-lab test interactionsrelated to thyroid disorders.
Be able to recommend appropriate laboratory monitoring for any hypo- or hyperthyroidpatient.
Be able to appropriately counsel patients regarding their thyroid drug therapy.
Be able to list the medications that interfere with thyroid function.
Coronary Artery Disease
Be able to assess the effectiveness of current antianginal therapy.
Be able to discuss standards of therapy and alternatives for the prophylaxis of angina.
For a given patient, be able to select the most appropriate antianginal therapy.
Be able to monitor and recognize the side effects of antianginal drugs.
Be able to discuss nitrate tolerance and recommend dosing regimens to prevent itsdevelopment.
Be able to counsel patients regarding their antianginal therapy.
Be able to recognize those patients for whom aspirin therapy would be beneficial andrecommend a dosing regimen.
Oral Anticoagulant Therapy
Be able to state the indications for oral anticoagulant therapy, target INR and recommendedduration of treatment.
Be able to discuss the rationale for use of the INR as a monitoring parameter and targetrange for a given indication.
For a given patient, be able to recommend a warfarin dose based on the patient’s INR anddosing history and recommend frequency of monitoring.
Be able to counsel a patient on warfarin therapy.
Be able to recognize and solve common problems relating to warfarin therapy (includingsignificant drug-drug interactions).
Be able to identify risk factors for bleeding.
Diabetes Mellitus
Describe the action of insulin and other counter regulatory hormones on the metabolism ofcarbohydrates, protein and fats.
Describe the two major reasons that current insulin preparations using intensive insulintherapy cannot mimic the physiologic response to endogenous insulin.
Compare the etiology, prevalence, age of onset, and other important characteristics of TypeI and Type II diabetes, impaired glucose tolerance (IGT), and gestational diabetes mellitus(GDM).
Be able to discuss the long term complications of diabetes and their management Discuss current pharmacotherapeutic strategies for type I and type II diabetes includingintensive insulin therapy and combination use of oral sulfonylureas and insulin, metformin,acarbose and trogilitazone.
Identify patients who would benefit from self-monitoring of blood glucose (SMBG) andchoose an appropriate blood glucose monitor.
Recognize morning hyperglycemia and identify a given patient with either the dawnphenomenon, or the Somogyi effect and list methods to manage.
Identify situations where caution is needed before exercise in a patient with Type Idiabetes.
List signs, symptoms, and potential interferences with recognizing of hypoglycemia.
Differentiate diabetic ketoacidosis from non-ketotic hyperosmolar coma.
Explain the rationale and differences between the use of glycosylated hemoglobin,c-peptide, fructosamine, and random blood glucose values.
Recognize the diagnostic criteria for Type I and Type II diabetes, GDM, and IGT anddetermine when a patient is "well controlled" on current therapeutic regimen.
Be able to provide diabetes education to patients and their families Be able to cite the drugs that might aggravate hyperglycemia or interfere with diabetes •Be able to develop an appropriate treatment ant monitoring plan for a patient with diabetes Community-Acquired Infections
•
Recommend appropriate antimicrobial regimens for diabetic foot infections includingmonitoring parameters.
Identify the most likely pathogens associated with acute sinusitis.
Design an appropriate antibiotic regimen, monitoring parameters, therapeutic endpoints,and adjunctive therapies for acute sinusitis.
Describe the pathogenesis of pneumonia.
List the most likely etiologic agents causing pulmonary infection in a given clinicalsituation.
Be able to recommend the treatment of pneumonia given a specific clinical situation.
List the primary infecting organisms in community-acquired urinary tract infections.
Design appropriate therapeutic regimens and monitoring parameters for communityacquired cystitis.
List predisposing factors for urinary tract infections.
Outline the AHA recommendations for bacterial endocarditis prevention in patients.
Pain Management
Be able to discuss the various types of pain including acute, chronic, neuropathic,headaches, malignant, and phantom limb pain Be able to discuss the physiology of the pain response including the anatomy of thenociceptive pathway- nociceptors, ascending nerve fibers, dorsal horn ganglionicjunctions, ascending neuroregulators such as substance P and bradykinins, and thecontinuation of the ascending pathways to the brain.
Be able to discuss the environmental, physical, and psychological factors that determine apatient’s “tolerance” to painful stimuli.
Be able to discuss the “factors that influence selection” including (but not limited to)mechanism of action, onset of action, duration of action, dosage forms available, genericname trade name, routes of administration, starting dose, maintenance dose, andmaximum dose for the following medications Be able to discuss the side effect profiles and beneficial and adverse monitoringparameters for each class of medication listed above.
Be able to make recommendations for initiation of pain management regimens Be able to make recommendations for pain management modifications in a patient withan existing regimen.
Be able to counsel a patient regarding their pain management regimen.
EXPECTATIONS:
The ambulatory care clerkship provides the student with exposure to both patients and health careprofessionals--it is expected that the student maximize this opportunity.
present and actively participate as a responsible and reliable member of the health care team in thisclerkship. The student is expected to: assume responsibility for patient care, assume responsibilityfor independent learning, communicate effectively and be adaptable.
Unprofessional conduct, unexcused absences and unexcused tardy attendance from any singleassigned responsibility (i.e. clinic, rounds, outpatient dispensing, multidisciplinary meeting,lecture) may be grounds for clerkship failure. Students are required to act ethically in the conductof all pharmacy practice activities. It is the student's responsibility to contact the preceptor or theirdesignee for consent for an excused absence. Co-worker health professional and/or staff at thesesites may assist in the enforcement of this policy and in evaluation of student performance. Patientconfidentiality must be respected and maintained at all times.
courteous and considerate of patients and clinic staff at all times.
Learning Activities Provided During Ambulatory Care Rotation
AMBULATORY PHARMACEUTICAL CARE RESPONSIBILITIES MAY INCLUDE
BUT NOT BE LIMITED TO THE FOLLOWING LEARNING ACTIVITIES:
Clerkship Activities/Responsibilities. Site specific activities may vary. On assigned clinic days,
the student pharmacist shall be accountable for the following pharmaceutical care activities:
Patient counseling for clinic patients with a prescription or OTC medicationa.
intended use, expected action and what to do if the expected action doesn't occur route, dosage form, dosage, and administration schedule precautions to observe during administration common side effects, avoidance, and actions if they occur potential drug-drug or drug-food interactions or combination x-ray, lab procedure issues (interface and timing of doses) what to do in case of missed doseso.
any other information unique to patient or drug Written medication information will be provided under request of the physician or patient according to clinic-specific procedures of the clinic.
Medication history (See, Section III -- Assignment Formats) and, when appropriate,perform a visual identification and verification of medications brought to clinic.
Refill authorization -- reviewed by the student to recommend to the physician-in-chargeaccording to the clinic-specific procedure available from your preceptor.
Drug information requests -- from physicians, health care workers, and patients. Using thefollowing procedure in Section III -- Assignment Formats.
Written assignments may include but are not limited to adverse drug reactions (ADR)reports, drug interaction reports, patient specific questions, medication histories, patientinformation sheets, literature evaluation, journal club, or kinetic reports. (See, Section III --Assignment Formats).
Formal case presentations -- a complete work-up on a patient seen in the clinic will berequired twice during the rotation using the PWDT process and P.H.A.R.M.E. format (See,Section III --Assignment Formats). Therapeutic alternatives must be supported by theprimary literature.
Work rounds case presentations -- informal presentations of at least 2-3 patients/week willbe presented orally to the preceptor (See, Section III -- Assignment Formats).
Students must be able to perform vital signs (blood pressure, pulse, temperature, respiratoryrate assessment) as well as blood glucose monitoring.
Student Evaluations and Outcome Measures.
A.
Daily work ethic/responsibilities.
Subjective components to grading include: communication with preceptor, interactions with health care members, participation inhealth professional education, judgment/professionalism, independence/assertiveness,attitude towards rotation.
Journal Club.
Oral clinical case/Oral challenge. Evaluation format based on PWDT format:
establish patient-pharmacist relationship organize patient data into problem format (collect data) relate drug therapy to specific disease states (organize data — create drug identify potential drug therapy problems (therapeutic assessment) develop specific therapeutic goals (rank drug related problems) develop potential therapeutic alternatives (develop specific therapeutic choose most appropriate regimen for each DRP (therapeutic alternatives) state monitoring parameters for each drug (drug recommendation) able to communicate rationale for recommendations in a logical and succinct manner (monitoring parameters (therapeutic efficacy/toxicity))10.
appropriate patient education and follow-up Formal case presentations – educational grand rounds
Written assignments – ADRs, Kinetics, literature evaluations, medication histories, drug
interaction reports.
Documentation of activities/interventions.
Oral presentation (Inservice).
Work round case presentation. Daily work rounds — Students present patients in a
modified grand round format to other students and to preceptors. Discussion is tailored to
the specific cases at hand and may include monitoring, kinetics, philosophy, ethics, and
disease states. Patient data bases and monitoring parameters are to be maintained on a
variable number of individuals are required by the preceptor. Grading for the work rounds
is subjective.
Patient Medication History Taking.
Patient Medication Counseling.
Outpatient Dispensing (may not be applicable at all sites).
Anchor Scale Pharm.D. Clerkship Student Evaluation.
TEXTBOOK:
No textbook is officially required. The student is strongly recommended to have access to druginformation sources necessary for the student to appropriately monitor patients (i.e. AHFS DrugInformation, Facts and Comparisons, Dipiro's Pharmacotherapy, A Pathophysiologic Approach,Drug Interactions, etc.). Patient education resource information will be accessible to the studentfor on-site clinic use.
PATIENT MEDICATION EVALUATIONS:
In the ambulatory care setting, thorough and complete medication evaluations are of primaryimportance along with the patient's medical record in obtaining patient specific data. It is expectedthat the student will interview and obtain medication histories on ALL possible patients during therotation. The purpose of the medication history and evaluation is to obtain information on drug usethat may assist in the diagnosis and or treatment of the patient.
medications, adverse drug reactions and/or drug allergies, screen for potential drug interactions,assess current therapy in terms of therapeutic response or nonresponse, detect patient-specificproblems or issues with current therapy, document previous drug therapy, monitor current drugtherapy for efficacy, safety and cost, determine patient compliance, and potentially recommendmore appropriate drug therapy.

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