Revised 1/2011

UAMS College of Pharmacy

OFFICE OF EXPERIENTIAL EDUCATION

Longitudinal Achievement Based Assessment Form (The student and preceptor each complete one copy of this form in E*Value at the mid-point and end of the APPE)

Student Name Starting Date APPE Site Preceptor's Signature Student's Signature Assessment Guidelines:

1. At midpoint and on the last day of the APPE, the preceptor reviews the student’s performance including any related documentation to assess development of skills in each of the competency areas. The preceptor completes the Longitudinal Achievement Based Assessment Form by entering a proficiency score for each item listed under the competency areas that is applicable to the APPE. The final page of the assessment includes written comments on strengths and areas in need of improvement with a suggested plan for continued student development. These assessments are formally reviewed with the student at a midpoint and final meeting.

2 The student completes midpoint and final self-assessments using the Longitudinal Achievement Based Assessment Form and reviews these documents with the preceptor during the midpoint and final meetings to discuss any discrepancy between the student’s and preceptor’s assessments.

3. By the last day of the APPE, the assessments are documented in E*Value to be used as a tool for continuing student development in the remaining experiences.

4. At the beginning of the next APPE, the student will review past assessments with the preceptor and discuss the APPE activities on which the student will focus to further develop proficiency in the competency areas.

5. Preceptor and student assessments are reviewed by the Office of Experiential Education. If the student is not demonstrating adequate proficiency as outlined in the Longitudinal Achievement Based Assessment Procedure for APPEs, the student will be contacted by the Assistant Dean for Experiential Education, and a remediation plan will be coordinated, as appropriate.

6. For successful completion of the APPEs, Doctor of Pharmacy candidates must achieve and maintain a proficiency score of “4” for each of the items.

Proficiency Score 5 - Meets requirement at a level beyond that expected for a new graduate 4 - Meets requirement with minimal or no prompting and intervention from the preceptor 3 - Meets requirement with moderate prompting and intervention from the preceptor 2 - Meets requirement with extensive prompting and intervention from the preceptor 1 - Does not meet requirement even with prompting and intervention from the preceptor 0 - Though opportunities existed, student did not engage in requirement; therefore not able to assess NA – Not applicable to experience or not observed

Revised 1/2011

UAMS COP Competencies Domain 1: Patient Care-Ensuring Appropriate Pharmacotherapy and Therapeutic Outcomes The graduate will provide patient-centered care in cooperation with patients, prescribers, and other members of an inter-professional health care team based upon sound pharmacotherapy principles and evidence.

1.1 Collect and evaluate data 1.2 Conduct a systematic review of the patient prior to recommending any drug or non-drug therapy 1.3 Design and implement an individual patient-centered pharmacotherapy plan to maximize desired effects and

minimize undesired effects. 1.4 Document patient care activities

Domain 2: Dispensing and Pharmacy Resource Management The graduate will manage and use resources of the health care system, in cooperation with patients, prescribers, and other health care providers and administrative and supportive personnel to promote health and to provide, assess, and coordinate safe, accurate, and time-sensitive medication distribution.

2.1 Demonstrate accurate, safe, and time-sensitive preparation, dispensing, and administration of pharmaceuticals 2.2 Manage pharmacy resources to optimize pharmacotherapy outcomes 2.3 Educate patients and healthcare providers about requirements for effective therapy

Domain 3: Health Improvement, Wellness, and Disease Prevention The graduate will promote improved health, wellness, and disease prevention.

3.1 Demonstrate skills needed to participate in or provide preventive services 3.2 Apply research processes to inform pharmaceutical policy 1.5, 2.4, & 3.3 Demonstrate professional citizenship in the delivery of patient care, in the distribution of medications, and

to promote wellness & prevent disease

Revised 1/2011

Patient Care 1.1 Obtains appropriate patient information from patient (medical and medication history, financial, social, cultural,

quality of life indicators (ADLs, ADEs), and physical assessment data) to incorporate into assessment.

1.1 Obtains appropriate patient information from records (medical and medication history, financial, social, cultural, quality of life indicators (ADLs, ADEs), and physical assessment data) to incorporate into assessment.

1.1 Conducts patient-specific physical assessment (BP, blood sugar, Coaguchek, etc) as appropriate

1.2 Assesses patient-specific signs/symptoms of adverse effects of drug therapies

1.2 Assesses patient-specific signs/symptoms of disease control/severity

1.2 Assesses patient-specific signs/symptoms therapeutic effects of pharmacotherapeutic recommendations (pharmacologic and non-pharmacologic)

1.2 Assesses potential drug-drug, drug-diet, and drug-disease interactions

1.2 Assesses barriers to health care (cultural, social, financial, literacy, etc)

1.2 Prioritizes problems related to self-care interventions

1.2 Prioritizes problem list based on patient and health care provider collaborative relationships

1.2 Anticipates changes in patient needs based on emerging differences in patient’s signs/symptoms of disease control or barriers to optimal therapy

1.3 Knows drug categories and indications.

1.3 Knows factual content of steps necessary for proper medication/device use.

1.3 Compares and contrasts the pros and cons of interventions useful in preventing or remedying non-adherence or drug related consequences.

1.3 Defines plan to monitor pharmacotherapy effectiveness.

1.3 Addresses relevance of patient factors (cultural, social, financial, literacy, etc) to select appropriate pharmacotherapy.

1.3 Evaluates desired outcome of non-pharmacologic, lifestyle, and preventive care interventions based on needs of individual patients.

1.3 Recommends/modifies non-pharmacologic, lifestyle changes, and preventive care interventions based on individual needs of a patient.

1.3 Selects/modifies patient-specific medication therapy and defines individual patient treatment goals and plan to optimize pharmacotherapy outcomes.

1.3 Conducts individually tailored patient education based on an understanding of the patient’s needs/preferences and situation (cultural, social, economic, & education). Education includes verification of patient understanding.

1.3 Evaluates the current level of adherence to a treatment plan (pharmacologic and non-pharmacologic) and drug related consequences.

1.3 Implements intervention individually tailored to the patient to prevent or remedy non-adherence or drug related consequences and follows up with patient.

Revised 1/2011

Documentation

1.4 Documentation is easy to read and understand.

1.4 Terminology is written on the appropriate level for the patient or healthcare providers.

1.4 Records information clearly and accurately with no typographical or numerical errors.

1.4 Records information completely (all required elements of area norm such as SOAP note, patient profile, etc).

1.4 Documentation is well organized and easy to follow with no extraneous information included.

Medication Distribution, Processing, and Dispensing 2.1 Identifies brand and generic drugs

2.1 Verifies all parts of a legal prescription

2.1 Accurately transcribes verbal and written prescriptions

2.1 Dispenses prescription drugs in appropriate packaging

2.1 Generates an accurate prescription label

2.1 Dispenses and administers prescription drugs including basic compounding. (ex. Compounding done in any community or hospital pharmacy)

2.1 Verifies accuracy using a multiple check system

2.1 Verifies pertinent patient information is correct

2.1 Demonstrates proper immunization administration technique

Resource Management

2.2 Demonstrates knowledge of personnel necessary to ensure delivery of pharmacotherapy to patients in light of

regulatory constraints

2.2 Demonstrates knowledge of management techniques related to ensuring appropriate personnel and fiscal resources necessary to deliver pharmacotherapy

2.2 Demonstrates knowledge of distribution systems and other technology used in the delivery of pharmacotherapy to patients

2.2 Optimizes pharmacotherapy delivery to the patient within the constraints of fiscal and human resource

Revised 1/2011

Communication 2.3 Incorporates basic components of patient counseling (Prime Questions; open vs. closed ended questions) and

maintains control of the interaction

2.3 Demonstrates positive interactions with patients/caregivers/ healthcare providers

2.3 Includes required patient counseling information (OBRA ’90)

2.3 Develops rapport with patients and healthcare professionals

2.3 Communicates specific drug therapy recommendations (including purpose of medications, potential adverse drug reactions, and other relevant information) to healthcare providers

2.3 Communicates a clear follow up plan with patients and healthcare providers to monitor therapeutic outcomes

Public Health

3.1 Participates in a variety of health and wellness screenings and “brown-bag” events (applies basic drug therapy and monitoring parameters to specific patients)

3.1 Provides public health education and disease prevention information

3.1 Organizes a health and/or wellness screening or “brown-bag” event

3.1 Demonstrates formal presentation skills on public health/disease prevention topics

Drug Information and Evidence-Based Medicine

3.2 Collects basic data from primary literature (population, methods, etc)

3.2 Conducts a literature search using appropriate keywords and databases

3.2 Describes a variety of drug benefit designs regulated by third party administrators or institutional P&T committees

3.2 Includes appropriate information for evaluation from literature search

3.2 Evaluates drug literature for efficacy factors

3.2 Evaluates drug literature for safety factors

3.2 Evaluates drug literature for cost factors

3.2 Describes how drug benefit design and process influence drug therapy

3.2 Describes how the institutional formulary management process affects drug therapy

3.2 Recommends alternative therapy based on plan specification

Revised 1/2011

Professionalism 1.5, 2.4, 3.3 Demonstrates appropriate grooming and professional dress

1.5, 2.4, 3.3 Displays proper respect for all individuals

1.5, 2.4, 3.3 Maintains strict confidentiality

1.5, 2.4, 3.3 Acknowledges limitations in therapeutic knowledge

1.5, 2.4, 3.3 Places patient’s welfare above personal self interest and is accountable and responsible for patient care

1.5, 2.4, 3.3 Understands and complies with all state and federal regulations concerning prescription competencies

1.5, 2.4, 3.3 Asks questions, independently seeks to increase knowledge, seeks constructive criticism

1.5, 2.4, 3.3 Behaves ethically in all aspects of practice

1.5, 2.4, 3.3 Is punctual

1.5, 2.4, 3.3 Uses personal technology (cell phone, text device, Facebook, etc) appropriately

Revised 1/2011

Describe student strengths:

Describe competency areas that need improvement:

Describe a plan of action for continued student competency development:

NPM Case Presentation Evaluation (Competency 1.1, 1.2, 1.3, 1.4, 1.5, & 2.3)

I. Preparation 1. Patient Presentation ______/15

Soap Note, results clearly presented All Rx and NPM medications listed All data needed for necessary points Appropriate triage questions (i.e., pregnancy status,

age, other disease states)

II. Knowledge 1. Drug therapy ______/30

Understands patient’s drug therapy. Links problems with drug therapy ( including appropriateness)

Discusses alternate NPM choices available and rationalizes choice of product Understands mechanisms of drugs’ action Anticipates common or serious drug interactions and ADRs Pertinent pharmacokinetics/dosing considered Cost of therapy justified

2. Monitoring ______/15

Appropriate parameters to assess efficacy and toxicity presented Defines endpoints of therapy (what to monitor, how often, when to seek

emergent help or see physician) 3. Follow-up ______/10

When to f/u, what to f/u (must discuss) F/U was completed, or attempt documented

4. Patient information/counseling ______/10

How to explain purpose(s) of drug therapy Important instructions for drug use Side effects/precautions that should be communicated Use of devices, equipment, etc. for delivery of medication Other (eg, blood glucose testing, PEFR)

III. Style of presentation/delivery/organization ______/10 -- Well organized -- Pertinent information -- Diction -- Voice projection

-- Personal appearance -- Distracting mannerisms -- Reliance on notes IV. Response to questions ______/10

Responses appropriate and straightforward 100 points possible ______

At-Risk Case Presentation Evaluation (Competency 1.1, 1.2, 1.3, 1.4, 1.5, & 2.3)

III. Preparation Patient Presentation

Soap Note, results clearly presented ______/10 Chronological course adequately detailed All data needed for necessary points

IV. Knowledge (Pt. Specific therapy and Topic Discussion) ______/3

Discussion of disease state/pathophysiology Pertinent sequelae, mechanisms presented Signs and symptoms reviewed

Drug therapy ______/17 Understands patient’s drug therapy. Links problems

with drug therapy ( including appropriateness) Understands mechanisms of drug action Anticipated common or serious drug interactions and ADRs Pertinent pharmacokinetics/dosing considered

Monitoring ______/15 Appropriate parameters to assess efficacy and

toxicity presented Defines endpoints of therapy (what to monitor, how often,

when to seek emergent help or see physician) Patient information/counseling ______/10

How to explain purpose(s) of drug therapy Important instructions for drug use Side effects/precautions that should be communicated Other (eg, blood glucose testing, PEFR)

V. Primary LIT: Review ______/12 Study design Statistics (in handout with assessment of appropriateness) Results Conclusions (Authors and students) Place in therapy

IV. Style of presentation/delivery/organization ______/10 -- Well organized -- Pertinent information -- Diction -- Voice projection -- Personal appearance -- Reliance on notes -- Distracting mannerism -- Eye/contact w/audience

V. Handout (also include visual aids if applicable) ______/8 Handout referenced throughout and with appropriate citations. Organization of handout

VI. Response to questions ______/15 Responses appropriate and straightforward

100 points possible

____________

Non‐Prescription Medication 1.1 Collect and evaluate data 

• OTC SOAP notes 1.2 Conduct a systematic review of the patient prior to recommending any drug or non‐drug therapy 

• OTC SOAP notes 1.3 Design and implement an individual patient‐centered pharmacotherapy plan to maximize desired effects and minimize undesired effects. 

• OTC SOAP notes 1.4 Document patient care activities 

• OTC SOAP notes • Project 

 2.1 Demonstrate accurate, safe, and time‐sensitive preparation, dispensing, and administration of pharmaceuticals 2.2 Manage pharmacy resources to optimize pharmacotherapy outcomes 

• Management discussion 2.3 Educate patients and healthcare providers about requirements for effective therapy  

• CE presentation  • OTC in the news topic discussion  

3.1 Demonstrate skills needed to participate in or provide preventative services • Herbal topic discussion • Project • OTC in the news topic discussion 

3.2 Apply research processes to inform pharmaceutical policy • Herbal topic discussion • Project • Formulary 

 1.5, 2.4, 3.3 Demonstrate professional citizenship 

• OTC SOAP notes • Overall presentations 

   

Medication Therapy Management 1.1 Collect and evaluate data 

• At‐risk patient presentation 1.2 Conduct a systematic review of the patient prior to recommending any drug or non‐drug therapy 

• At‐risk patient presentation 1.3 Design and implement an individual patient‐centered pharmacotherapy plan to maximize desired effects and minimize undesired effects. 

• At‐risk patient presentation 1.4 Document patient care activities 

• At‐risk patient presentation • Project 

 2.1 Demonstrate accurate, safe, and time‐sensitive preparation, dispensing, and administration of pharmaceuticals 2.2 Manage pharmacy resources to optimize pharmacotherapy outcomes 

• Management discussion 2.3 Educate patients and healthcare providers about requirements for effective therapy  

• CE presentation   

3.1 Demonstrate skills needed to participate in or provide preventative services • Herbal topic discussion • Project 

3.2 Apply research processes to inform pharmaceutical policy • Topic presentation • Literature review • Herbal topic discussion • Project 

 1.5, 2.4, 3.3 Demonstrate professional citizenship 

• At‐risk patient presentation • Overall presentations 

   

Jane Doe DSM At‐Risk Patient #1  S:    MH is a 65 y/o WF who is in no apparent distress.  MH was diagnosed with diabetes 

within the last 6 months and also suffers from hypertension.  Patient states that she feels that “my blood pressure and blood glucose levels are under control.”  Yet she does not know what the goals of therapy are for her disease state.  She visits with her primary care physician only once a year. She has had no signs or symptoms of hypotension/hypoglycemia or excessive thirst/increased frequency of urination since starting therapy. 

  PMH:  Diabetes Mellitus‐ Type 2 (2010)               Hypertension (1990’s)   PSH:  Not of significance   SH:  She is a retired widow.  She denies smoking, alcohol, or illicit drug use.   FH:  Mother and Father deceased – HTN   Allergies:  NKDA   Current Medications:      Prescription Rx:       Valsartan 160 mg (one po daily)       Atenolol 50 mg (one po daily)       Hydrochlorothiazide 50 mg (one po daily)       Metformin 500 mg (one po daily)       Glipizide ER 10 mg (one po qam)       Sertraline 100 mg (one po daily)          OTC:       Prilosec OTC 20mg (one po daily)       Ibuprofen 200mg (four po three times daily)  O:  Vitals:  Ht:  5’2’’ (157) Wt: 150 lb (68.2 kg)     BP: 160/75  BG:  Before breakfast: 150                  Bedtime:  140   HgA1c:  around 8 (six months ago)  A:   

1. DM‐2 Goals of Therapy: 

• Preprandial blood glucose of 90‐130 mg/dL • Bedtime glucose of 100‐140 mg/dL • HgA1c of <7 • Prevent microvascular and macrovascular complications 

 2. HTN 

Goals of Therapy: • BP: 140/90 mm Hg • Prevent further complications 

P: 1. DM‐2 

• Educated patient on goals of BG • Counseled patient on need for more frequent doctor’s visits 

 Glucophage: 

• Educated on how to take medication • Educated on s/s of lactic acidosis • Educated patient on need of SrCr level 

Glucotrol XL: • Educated patient on how to take medication 

 2. HTN 

• Educated patient on goals of BP for diabetics • Educated patient on need to take weekly BP readings 

 Hydrochlorthiazide: 

• Educated patient on how to take med in morning • Educated patient on hypokalemia s/s 

 Valsartan 

• Educated patient on how to take medication  

Atenolol • Educated patient on how to take medication • Educated patient on adverse effects (fatigue, depression) • Educated patient not to stop medication suddenly • Educated patient on orthostatic hypotension  

Jane Doe SOAP note #1  S:  DH is a 29 y/o WM who presented to the pharmacy with a CC of a “burning sensation” in 

his chest. Patient states the burning sensation developed about 3 weeks ago.  On questioning, the patient states this sensation follows after eating heavy meals usually once or twice a week.  Symptoms usually last 2 hours following eating.   

  PMH: Not significant   Meds: None   OTC: Tums Regular Strength (2 tablets) for 1 week prn without relief    SH: Reports 2‐3 drinks/day. No tobacco use.  O:   Ht: 5’10’’ Wt: 210 lbs  BP: 116/76  HR:  54  A:  Heartburn treated unsuccessfully with Tums 

• Relieve symptoms and discomfort  • Prevent meal‐related symptoms • Improve quality of life • Prevent complications by using the most cost‐effective therapy 

 P:  1. Recommended famotidine 20 mg to be taken 30‐60 minutes prior to a meal that 

precipitates symptoms with a full glass of water.  Educated patient that taking famotidine before meals will result in a prevention of symptoms.  Famotidine can be taken for relief at the onset of symptoms as well with relief expected within 30‐45 minutes. 

   2.  Educated patient that side effects of famotidine are uncommon but some patients do 

report headache, dizziness, diarrhea, or constipation with its use.      3. Educated patient on dietary and lifestyle risk factors that may contribute to 

heartburn.  Patient was willing to make lifestyle modifications such as eating smaller meals and reducing caffeine and alcohol intake. 

   4. Instructed to see a physician if symptoms occur despite appropriate use of famotidine 

and or if alarm symptoms occur.  Follow‐up:  Called patient one week later.  Patient stated that he took the famotidine before 

meals as directed, but with no relief.  Instructed patient to see his physician due to 2 weeks of failed non‐prescription therapy. 

   

Example OTC SOAP Notes SOAP Note #1 S: 40 y/o WM presented to the pharmacy with complaints of cold and flu symptoms, including “hacking, coughing, aching everywhere and sometimes I fell like I have a fever.” He reports that he had to take the day of from his construction job but needs to feel better soon so he can get back to work.    PMH: Not significant PSH: Not significant FH/SH: Nonsmoker, occasional alcohol use.  Works construction. Current medications: None  O: WM with cough and rhinorrhea  A: 40 y/o WM with a cold.   Goals of therapy: Fast, effective relief of symptoms  P: Cold symptoms Recommended a combination product for relief of symptoms.  Recommended Advil Cold and Sinus.  Educated the patient about the contents of the product: ibuprofen and pseudoephedrine and about some common side effects of these drugs.  Advised patient to take 1 tablet every 4‐6 hours as needed.  F/u: Spoke with the patient 3 days later.  He reports he is still “hacking  a little but is starting to feel better.” He reports wearing a mask at his work on a new school building where there is lots of drywall in the air.       

SOAP Note #2 S: Patient AR 45 year old WM presents to the pharmacy asking “Where are your Rolaids?” He states that he has frequent heartburn that is worse at night and after meals.  Upon further questioning he explains he has never tried anything other than short acting antacids.    O: Overweight in appearance.  A: AR has recurrent heartburn/reflux that is uncontrolled.  P: Recommend non‐pharmacological alternatives. 

• No alcohol or tobacco 

• No spicy, greasy, hot, or acidic foods 

• Eat smaller meals while drinking less with meals 

• Eat dinner earlier in the day, if occurring at bedtime stay more upright. 

Medication recommendation: • Pepcid 20mg twice daily 

• If no change in 2 weeks may switch to Prilosec 20mg once daily 30 minutes prior to breakfast.   

      

At Risk Patient Note S: SP is 66 y/o WF who is in no apparent distress. She states that she has been diagnosed with diabetes, hypertension, and “a heart problem”. She self monitors her blood pressure daily and her blood glucose twice daily. Patient states that her blood pressure has ranged from 132/78-160/80 over the past week. She also reports that her fasting blood glucose level is usually around 162-172. When questioned about her BP and BG goals, she correctly answered that her BG should be below 120 but concerning her BP goal, she just said that she needs to keep it low like it is now. ED is satisfied with her medical care and feels that her disease states are well controlled. When she feels that she is “getting out of control,” she makes an appointment with her primary care physician. She sees her cardiologist every 6 months. Currently, her chief complaint is her legs. Patient reports swelling and dark color in both legs, but especially in the right leg. She reports having stents implanted in both legs to prevent blood clots. She cannot remember when or how many stents were placed, but the most recent stent was placed in the right leg in August 2010. PMH: Type 2 Diabetes Mellitus (1990’s) Hypertension (1980’s) Coronary Artery Disease Hyperlipidemia (2000’s)

GERD PSH: Appendectomy (1968) Knee Replacement (2001) Coronary Angioplasty and Stents (2000’s) Peripheral Arterial Stents (2000’s) SH: SP is a divorced house worker who lives alone. She avoids sweets, fried foods, salt, and grease. Previously smoked 2 ppd and drank ½ pint whiskey daily but quit both about 18 years ago following physician’s advice. She denies any illicit drug use. FH: Mother- died in her early 50’s from unknown causes Father- presently 86 years old with a history of HTN, seizures, and vision problems Siblings- brother and sister both died of cancer in their early 60’s Allergies: penicillin (hives and facial swelling) Current Medications: Prescription: Potassium Chloride 20mEq (one po BID) Clonidine 0.2mg (one po BID) Isosorbide mononitrate 30mg (one po daily)

Diovan 160mg (one po daily) Furosemide 80mg (one po BID) Metoprolol tartrate 50mg (one po BID) Omeprazole 20mg (one po daily) Simvastatin 40mg (one po daily) Plavix 75mg (one po daily) Novolog Flexpen (15 units subQ TID) Levemir (52 units daily at 7:00pm) OTC: Bayer Aspirin 81mg (one po daily) Famotidine (one po daily in the evening) O: Vitals: Ht: 5’ 6’’ (66 inches) Wt: 262 lbs (119 kg)

BMI: 42.3 (Morbidly Obese) IBW: 130.7 lbs (59.3 kg)

BP: not available BG: not available HbgA1C: not available

Labs:

4-15 10-27 Na 139 137 K 4.1 3.8 Cl 99 99

CO2 26 24 BUN 15 22 SrCr 1.21- H 1.31- H

Glucose, serum 140- H 71 Ca 10.1 9.7

Protein, serum 7.4 7.5 Albumin, serum 4.2 4.3

AST 20 16 ALT 15 11 CrCl 60 55

eGFR (AA) 54 49

A:

1. Diabetes Mellitus Goals of Therapy:

• Control BG o Preprandial BG of 70-130 mg/dL o HbgA1C < 7%

• Prevent microvascular and macrovascular complications • Prevent hypoglycemic events

According to patient reported BG levels, fasting preprandial levels are above goal. HbgA1c level not available for evaluation. Increased serum creatinine indicates renal damage. 2. Hypertension Goals of Therapy:

• BP < 130/80 (since patient also has Diabetes) • Use a drug for HTN that has shown benefit in diabetic patients

o TZD, BB, ACE-I, ARB, CCB • Prevent cardiovascular and renal morbidity and mortality

According to patient BP reports, BP is not always below goal. Lab results show renal end organ damage. Potassium level is within normal range. 3. Coronary Artery Disease Goals of Therapy:

• Reduce symptoms of CAD • Eliminate modifiable risk factors • Prevent complications of CAD

4. GERD

Goals of Therapy: • Relieve symptoms of acid reflux • Increase quality of life

5. Hyperlipidemia

Goals of Therapy: • LDL< 100 or <70 • HDL> 50 • TG< 150 • Prevent CHD events

Patient has CAD and therefore has a >20% risk of a CHD event in the next 10 years. AST and ALT within normal limits.

6. Renal Disease Goals of Therapy:

• Slow progression of kidney disease • Stop further damage to kidneys

Patient reports seeing a diabetes specialist about her kidneys about 10 years ago. She describes having a 24 hours urine collection and reports that the finds showed good renal function. Serum creatinine lab values show kidney dysfunction. 7. Leg Problems

Goals of Therapy: • Increase quality of life • Prevent sores, infection, and amputation of lower extremeties • Prevent DVT

P: 1. Diabetes Mellitus

• Educated patient on BG goals and importance of good control of diabetes to prevent complications • Praised patient for participating in daily foot inspections and encouraged continuance • Praised patient for wearing diabetic shoes and not ever going bare footed • Educated patient of diabetic diet • Encouraged daily exercise, weight reduction, and written record of daily self monitoring of BG • Encouraged patient to get yearly eye exam • Counseled patient on s/s of hypoglycemia and how to correct BG level with 15-20g of carbohydrate • Encouraged her to get an influenza vaccine. • Encouraged patient to ask PCP to get a HbgA1C level at next appointment and ask for the results. • Explained that the HbgA1c level show diabetes control of the past 6 months.

Novolog Flexpen • Educated patient on correct administration of insulin • Instructed patient to throw away pen if insulin looks cloudy • Counseled patient to give injection immediately before meals (5-10 minutes) • Encouraged her to call manufacturer if problems arise from insulin pen.

Levemir

• Educated patient on correct administration of insulin • Instructed patient to throw insulin if it looks cloudy • Encouraged her to call manufacturer if problems arise from insulin pen.

2. Hypertension

• Encouraged patient to have healthy lifestyle o Weight Loss o DASH Diet o Continue to avoid salty foods and abstain from alcohol o Exercise- 30 minutes per day

• Encouraged patient to continue daily self monitoring of BP. • Educated patient on goal BP of <130/80 since she has diabetes.

Clonidine • Educated patient on how to take medication correctly. • Counseled patient to not stop taking the medication abruptly especially since she is on metoprolol

Diovan • Educated patient on how to take medication correctly. • This drug is appropriate for diabetic and renal disease patient with HTN. • Counseled patient to avoid salt substitutes. • Emphasized importance of periodic electrolyte panels.

Furosemide/Potassium Chloride • Counseled patient to take furosemide in the morning and early afternoon to prevent nocturia. • Educated patient about need to take potassium with a loop diuretic and the need for monitoring

potassium levels in the blood. Metoprolol

• Educated patient on how to take medication correctly. • This drug is appropriate for diabetic patients with HTN. • Counseled patient to not stop taking the medication abruptly. • Educated patient on orthostatic hypotension, bradycardia, and adverse effect of fatigue. • Educated patient that this drug can mask the s/s of hypoglycemia.

3. Coronary Artery Disease

• Educated patient on role of medications • Emphasized need for lifestyle modifications to eliminate risk factors for CAD

Isosorbide mononitrate • Educated patient to take medication in the morning • Counseled patient on possible side effects of HA and dizziness

Plavix • Educated patient on how to take medication correctly • Counseled patient on increased bleeding risk while taking this medication and s/s of bleeding

4. GERD

• Educated patient on the mechanism of action of both drugs she is taking for acid reflux. • Counseled patient on lifestyle modifications to decrease the symptoms of GERD.

Omeprazole • Instructed patient to take on an empty stomach before breakfast. • Counseled patient on side effects of HA, diarrhea, and N/V.

Famotidine • Educated patient that omeprazole should be sufficient for her symptoms but if she feels like she is

getting relief at night from famotidine, continue to take it OTC. 5. Hyperlipidemia

• Encouraged patient to get a fasting lipid profile at next PCP appt and ask to know her results. • Explained the importance of good cholesterol control.

• Educated patient on Therapeutic Lifestyle Changes in addition to drug therapy. o Exercise- 30 minutes per day o Decrease intake of saturated fats and cholesterol o Increase intake of fiber o Weight Loss

Simvastatin: • Simvastatin is appropriate for diabetic patients

o Heart Protection Study (HPS) Trial • Consider increasing dose if LDL is not at goal • Educated patient to take medication at bedtime • Educated patient on s/s rhabdomyolysis

6. Renal Disease

• Informed patient that labs from last visit indicate renal dysfunction and that she should discuss these results with her PCP at her next appointment. 7. Leg Problems

• Encouraged patient to attend scheduled appointments with podiatrists.