Patient Assessment

Pharmaceutical Care
 Pharmaceutical care

• It is the responsible provision of drug therapy for the purpose of achieving

definite outcomes that improve patient quality of life.

• These outcomes are:

- Curing a disease
- Eliminating or reducing symptoms
- Arresting or slowing a disease process
- Preventing a disease symptom
 Pharmaceutical care

The pharmacist important responsibilities:

- Patient medication, the most convenient
(effective, safest, economic
- Prevent DTP
DTP
 Common DTP

• Unnecessary drug therapy-----------

- No indication
- Duplicate therapy
- CI
 Common DTP
• Dose too low or high----------
- Wrong
- Inappropriate frequency,
duration, storage,
administration
 Common DTP

• ADR---------
- Unsafe for patient
- Allergic reaction
- Drug interaction
- Incorrect administration
 Common DTP

• Noncompliance ---------
- Cannot afford drug
- Prefer not to take drug
- Does not understand instructions
Patient Approach
 Elements needed to assess
patient
I. KNOWLEDGE
• Characteristic patterns of signs and symptoms
associated with each disorder
• Characteristic presentation of potential drug-
related problems
• Chronic disease guidelines for diagnosis and
treatment of specific disorder
II. Diagnostic/evaluative criteria (Guidelines for
diagnosis and treatment of most acute and chronic
disorders)
 Elements needed to assess
patient
III. Subjective data
Patient history (70-80% correct diagnosis)
IV. Objective data
Physical examination
Lab test results
Medical imaging
 PROVIDER CENTERED VERSUS PATIENT CENTERED PATIENT
HISTORY

PATIENT CENTERED PATIENT HISTORY

Based on the patient’s feelings regarding

symptoms or disease
The interviewer liberally should use empathy,
plus silence and nodding to get the patient to
tell their story.
 Patient history
PROVIDER CENTERED
are designed to get specific types of information
from the patient to use to make a diagnosis,
with less attention paid to personal, social, and
emotional aspects.
 Physical assessment (check up)
methods
• Observation
• Palpation
• Percussion
• Auscultation
 Physical assessment (check up)
methods
Observation
Note the way the patient walks,
talks, dresses, and behaves
Look more closely at the patient’s
body for symmetry
Look presence of lesions and, if
present, their color, size, shape,
and so on.
Physical assessment (check up)
methods
Physical assessment (check up)
methods
Physical assessment (check up)
methods
 Physical assessment (check up)
methods

• Breathing
problems
• Swallowing
problems
 Physical assessment (check up)
methods
• Observation
• Palpation
• Percussion
• Auscultation
 Physical assessment (check up)
methods
Palpation
Palpation, is touching or feeling with
the hand individual structures on the
surface and within the body cavities,
particularly the abdomen
It is the second step in patient
examination
• Gives crucial clues to the presence of
abnormalities such as enlarged organs
and palpable masses.
• Palpation also may be effective in
assessing fluid within aspace.
Physical assessment (check up)
methods
Physical assessment (check up)
methods
 Physical assessment (check up)
methods
• Observation
• Palpation
• Percussion
• Auscultation
 Physical assessment (check up)
methods
Percussion
• Percussion is a method of tapping body parts with fingers, hands, or small
instruments as part of a physical examination.
• It is done to determine The size, consistency, and borders of body organs
• The presence or absence of fluid in body areas
• The sound is a sign of the type of tissue within the body part or organ.

--------Lungs sound hollow on percussion because they are filled with air.
--------Bones, joints, and solid organs such as the liver sound solid.
Physical assessment (check up)
methods
 Physical assessment (check up)
methods
• Observation
• Palpation
• Percussion
• Auscultation
Physical assessment (check up)
methods
Auscultation
Body sounds created
in the lungs, heart, blood
vessels, and abdominal
viscera.
It is the last technique used
during the examination.
Patient Medical History
PMH
 Complete medical history
Needed when patients admitted to an inpatient
facility
Or new patients to a provider’s practice

or when the patient’s symptoms do not fit the

pattern of a common disease.

CMH can be found in health records

 Complete medical history
A COMPLETE MEDICAL HISTORY consist of five
components:
- History of present illness (HPI)
- Past medical history (PMH)
- Family history (FH)
- Personal/social history (PH)
- Review of systems (ROS).
• CHIEF COMPLAINT HISTORY
• CHRONIC DISEASE FOLLOW-UP VISIT HISTORY
Past medical history
includes past infectious diseases and immunizations, adverse reactions
to medications, and hospitalizations.

Personal history
occupation, marital status, personal habits such as alcohol or smoking,
financial status, and current living arrangements

Family history
significant health events in the lives of parents, siblings, and offspring,

A review of systems
It tends to start at the top of the body (head, eyes, ears, nose and
throat) and move down, e.g., respiratory, cardiovascular,
gastrointestinal, genitourinary tract, etc.
The chief complaint history (HPI)
many times that is all that is needed to
accurately diagnose, with physical examination,
laboratory tests, and medical imaging
confirming the suspected diagnosis
 Structure of the Chief Complaint History
INTRODUCTION
“Hi, I’m ______________ your pharmacist and you are?”

GENERAL BROAD OPEN-ENDED QUESTIONS

“What can I help you with today?”
“Tell me more about your______________.”

FOCUSED OPEN-ENDED QUESTIONS

LOQQSAM

CLOSED-ENDED QUESTIONS

SUMMARIZATION
“So you’ve had a ______________ that started 3 days ago,” etc.

CLOSURE
“Is there anything else we need to discuss today?”
 LOQQSAM
LOCATION
Where is the symptom located? Where it may move
(radiation)

ONSET
When did it start? How long have you had it?

QUALITY
Exactly, how does it feel like?
Which best describes your pain?

e.g., pain. Is it dull, sharp, crushing, aching, or burning?

 LOQQSAM

QUANTITY
How frequently does it happen?
How bad is it? Pain rated on 1-10 scale
How much does it interfere with your usual daily activities?

SETTING
How did it happen?
When do you notice it?
In what circumstances does/did it occur?
What happened just before it started?
 LOQQSAM

“When does your chest pain occur?”

“Oh, only when I’m outside shoveling snow during
the winter”
would likely indicate ………………….?
When does your chest pain occur?”
“Well, last night it started while I was just sitting in
my recliner watching my favorite TV show”
would likely indicate ………………….?
 LOQQSAM
ASSOCIATED SYMPTOMS
What other symptoms do you have?
What else happens?
How else do you feel bad or different around the
time it happened?

MODIFYING FACTORS
What makes it better?
What makes it worse?
What have you tried for this? How did it work?
 LOQQSAM

What do u think caused this problem?

What medications are you currently taking?”

Or
“Let me double-check your medication profile to
make sure that what I’m going to suggest won’t
cause any problems with your existing therapy.”
• Just to make sure I got it all, let me
summarize what you have told me.”
 The chronic disease follow-up visit
history
Follows 3C method
Control
Compliance
Complications
 General Approach to Interviewing Patients
Returning for Chronic Disease Follow-Up
HOW HAVE THINGS BEEN GOING WITH YOUR ______________ SINCE YOUR
LAST VISIT
How have your home blood glucose readings been?
How many times do you get up from bed to go to the bathroom at night?
????????????????????

WHAT KIND OF PROBLEMS HAVE YOU HAD REMEMBERING TO TAKE YOUR

MEDICATION OR HOW ARE THINGS GOING WITH YOUR DIET/EXERCISE?
????????????????????

WHAT KIND OF CHANGES HAVE YOU NOTICED SINCE YOUR LAST VISIT?
What kind of problems have you been having with your medication?
I WANT TO DOUBLE-CHECK AND MAKE SURE YOU ARE NOT HAVING ANY OF
THE FOLLOWING PROBLEMS
????????????????????

TELL ME MORE ABOUT IT followed by LOQQSAM as needed.

 CASE 1

WHAT CAN I DO FOR YOU TODAY?

What do you have that’s good for a cold and runny nose?
TELL ME MORE ABOUT YOUR COLD.
I’ve had it for a while and just can’t seem to get rid of it.
LOQQSAM
LOCATION
N/A.
ONSET
Started about 2 weeks ago, seemed to get better, and now it ’s back
with a vengeance.
QUALITY
Now the discharge is thick and yellow-brown all the time. When it
started it was clear most of the time except
when I woke up it was thick and yellow.
 CASE 1

QUANTITY
Not bad, just annoying.
SETTING
I caught it from the guys at work.
ASSOCIATED SYMPTOMS
Not sneezing, a slight fever, mild headache centered just below my eyes,
mucous tastes and smells terrible.
MODIFYING FACTORS
Pseudoephederine hasn’t helped much.
Bending over makes the facial discomfort worse.
MEDICATIONS/WHAT CAUSED IT
I don’t take any medicines and I don’t know why it got worse.
 CASE 2

WHAT CAN I DO FOR YOU TODAY?

What do you have that’s good for a cough?
TELL ME MORE ABOUT YOUR COUGH.
It’s just a nagging cough that doesn’t seem to go away.
LOCATION
N/A.
ONSET
Started about 1 month ago.
QUALITY
Nagging, dry, no sputum.
QUANTITY
Not too bad, just annoying. I cough two to three times/hour..
 CASE 2

SETTING
Had the flu that went to my chest and was left with this cough.
ASSOCIATED SYMPTOMS
I’m tired because I’m not getting much sleep.
No allergy history.
3 packs/day; smoker up until 9 years ago.
MODIFYING FACTORS
Exercising makes worse, also worse at night.
Cough drops don’t help.
WHAT DO YOU THINK CAUSED IT?
I don’t have any idea what caused it.
WHAT MEDICATIONS DO YOU TAKE?
I take some omeprazole for my heartburn.
 CASE 3

WHAT CAN I DO FOR YOU TODAY?

What do you have that's good for heartburn?
TELL ME MORE ABOUT YOUR HEARTBURN.
I’ve just got this pain that at times makes my stomach seem like it’s on
fire.
LOCATION
Just above my belly button.
ONSET
Started about 1 month ago.
 CASE 3

QUALITY
Burning pain.
QUANTITY
Not too bad, but is getting worse.
SETTING
Get it about 1 to 2 hours after I eat and lately it's been waking me up at
night.
ASSOCIATED SYMPTOMS
A lot of belching and gas, have had loose dark bowel movements the
last few days.
MODIFYING FACTORS
Eating makes it better, Tums have helped a little, margaritas make it
worse.
 CASE 4

WHAT CAN I DO FOR YOU TODAY?

Do you have something that’s good for the flu?
TELL ME MORE ABOUT YOUR FLU.
It’s just the flu. My throat bothers me the most.
LOCATION
Pain is worst in the back of my throat and just under my left ear.
ONSET
Started about 3 days ago.
QUALITY
Just hurts.
 CASE 4

QUANTITY
Sometimes it ’s so bad I can hardly swallow.
Is there 24 hours a day.
SETTING
It ’s been going around at work.
ASSOCIATED SYMPTOMS
Headache, feverish, aches all over, afraid to eat because my stomach
seems real sensitive. No cold symptoms
or dental problems.
MODIFYING FACTORS
Orange juice makes it hurt like the devil.
 CASE 5
WHAT CAN I DO FOR YOU TODAY?
I'm here for a follow-up visit for my blood pressure.
SO HOW HAVE THINGS BEEN GOING WITH YOUR BLOOD PRESSURE
SINCE YOUR LAST
VISIT?
Fine, I had my blood pressure checked at a health fair and it was 130/80
and my home blood pressure
readings are 120-138/78-88.
WHAT KIND OF PROBLEMS HAVE YOU HAD REMEMBERING TO TAKE
YOUR
MEDICATION?
None, the chlorthalidone is working well.
 CASE 5

HOW ARE THINGS GOING WITH YOUR DIET AND EXERCISE?

I've lost another 2 lb and I’m still walking my dog for about 30 minutes
every morning.
WHAT KIND OF CHANGES HAVE YOU NOTICED SINCE YOUR LAST
VISIT?
None really.
SOUNDS LIKE THINGS ARE GOING REALLY WELL.
 CASE 5

BEFORE YOU GO I WANT TO DOUBLE-CHECK AND MAKE SURE THAT

YOU ARE NOT
HAVING ANY OF THE FOLLOWING PROBLEMS:
CHEST PAIN? No
DIZZINESS? No
SHORTNESS OF BREATH? No
MUSCLE WEAKNESS? No
CHANGES IN VISION? No
HEADACHES? No
DIFFICULTY BREATHING? No
 CASE 5

CHANGES IN ABILITY TO WALK OR DO REGULAR ACTIVITIES? No

DIFFICULTY SLEEPING?
Yes, now that you mention it. Recently I’ve been waking up some nights
about midnight, which is unusual for me.
TELL ME MORE ABOUT YOUR WAKING UP.
 CASE 6

HOW HAVE THINGS BEEN GOING WITH YOUR BLOOD GLUCOSE SINCE
YOUR LAST
VISIT?
Not as well as I would have hoped. My morning results have been right
around 200 and my bedtime results are even higher(230-250).

HOW HAVE THINGS BEEN GOING WITH YOUR DIET AND EXERCISE?
The exercise is going pretty well. I take my dog for an hour almost on
weekends and Tuesday and Thursday evenings. The diet is another
thing entirely! It is really hard to remember all the things I'm supposed
to do especially with trying to cook for the family. If asked your family's
big meal is in the evening usually including some type of dessert which
you try and avoid but you can’t resist your favorites.
 CASE 6

WHAT KIND OF PROBLEMS HAVE YOU HAD REMEMBERING TO TAKE

YOUR MEDICATION?
None really. I have a good routine. I keep my metformin in the kitchen
so I remember to take them with
breakfast and dinner.
WHAT KIND OF CHANGES HAVE YOU NOTICED SINCE YOUR LAST
VISIT?
None really.
 CASE 6/control

I WANT TO DOUBLE-CHECK AND MAKE SURE YOU ARE NOT HAVING

ANY OF THE FOLLOWING PROBLEMS?

HOW MANY TIMES DO YOU GET UP TO URINATE DURING THE NIGHT?

Two to three times
GENITAL ITCHING/RASHES? No
PAIN ON URINATION OR INFECTED CUTS/SORES? No
DROWSINESS, DIZZINESS, PALPITATIONS, SWEATING? No
CHEST PAIN? No
DIFFICULTY BREATHING? No
DIFFICULTY SLEEPING? No
CHANGES IN VISION/SPEAKING/CHEWING/MEMORY? No
PROBLEMS MOVING ANY LIMBS? No
 CASE 6/Complications

CHEST PAIN? No
DIFFICULTY BREATHING? No
DIFFICULTY SLEEPING? No
CHANGES IN VISION/SPEAKING/CHEWING/MEMORY? No
PROBLEMS MOVING ANY LIMBS? No
HEADACHES? No
BURNING/TINGLING IN FEET? No
LEG PAIN/CRAMPS? No
NAUSEA/ GI UPSET? No
DIARRHEA? No
CHANGE IN TASTE? No
 CASE 7

SO HOW HAVE THINGS BEEN GOING WITH YOUR ASTHMA SINCE

YOUR LAST VISIT?
Better I think. My albuterol use was about the same, but no ER visits
this month. Only used it about four times/week, once a week at night.
I turned off the swamp cooler function and have thoroughly cleaned up
the bedroom and am remembering to close the bedroom door when we
leave.

The albuterol seems to be working better now that I know how to use it.
On a couple of occasions one
puff has been enough.
 CASE 7

WHAT KIND OF PROBLEMS HAVE YOU HAD REMEMBERING TO TAKE

YOUR MEDICATION?
I did really well the first few weeks with the beclomethasone evening
dose, then things heated up at work and I have been working late and
just forget when I get home some evenings. The morning dose hasn’t
been a problem.

WHAT KIND OF CHANGES HAVE YOU NOTICED SINCE YOUR LAST

VISIT?
Other than the things I mentioned, none.
 CASE 7

BEFORE YOU GO I WANT TO DOUBLE-CHECK AND MAKE SURE THAT

YOU ARE NOT
HAVING ANY OF THE FOLLOWING PROBLEMS:
HEARTBURN? No
CHEST TIGHTNESS? No
SHORTNESS OF BREATH? Yes, about four times a week
COUGHING? Yes, about once a week
WHEEZING? No
TREMBLING/PALPITATIONS? No
EXPOSURE TO DUST/ANIMALS/POLLEN? No
RUNNY NOSE? No
ITCHING SKIN/RASH? No
DIFFICULTY SLEEPING? Yes, one night a week
SORES OR PAINS IN MOUTH? No