physical examination/assessment has a place in...

© 2015 American College of Apothecaries.

Physical Examination/Assessment Has A Place in Community Pharmacy

Practice

Roger S. Klotz, R.Ph.,FASCP, FACA,

FCPhA

Associate Professor of Pharmacy

Practice and Administration

Western University of Health Sciences


DisclosuresI declare that I have no conflicts of interest, real

or apparent, and no financial interests in any

company, product, or service mentioned in this

program, including grants, employment, gifts,

stock holdings, and honoraria.”

2

The American College of Apothecaries is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.


Learning ObjectivesAt the conclusion of this program, the participating

pharmacist or technician will be able to:

– Objective #1: Prepare an initial observation of a patient to

assess the present status.

– Objective #2: Utilize basic physical exam steps to assess

the patient’s present health status.

– Objective #3: Apply a basic physical exam to access the

patient response to their present therapeutic plan.

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Definition of Physical Examination

• Examination of the body by

auscultation, palpation,

percussion, inspection, and

smelling.

• I would add by sight and sound.

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Why Should The Pharmacist do a Physical Assessment/Exam?

• Determine if the patient has health risks and

should be referred to a medical practitioner.

• Determine if the patient is responding to

their to medication therapy.

• Determine if the patient has adverse

reactions to their therapy.

• Determine the patient’s concerns during the

exam.

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Initial Assessment is Visible and Auditory

• Watch the patient as they approach.

- Stride and body stance

- Facial expression

- Skin color

- Appearance

- Eyes

- Speech/response as you greet them

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Physical Assessment/Exam Steps• Take blood pressure and pulse – listen to

heart sounds (stethoscope & blood pressure cuff of appropriate size).

• Lung sounds for certain patients

– Which patients?

• Eye and ear exam for certain patients

- Which patients?

• Tendon reflex determination for certain patients

– Which patients?

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Physical Assessment/Exam Steps• Heart sounds – Why?

• Skin color (look for rashes, blemishes, skin discoloration) – Why?

• Waist circumference (Male < 90 cm, Female < 80 cm) – Why the different values?

• Waist- Hip Ratio (Male <0.9, Female < 0.8) – Why the different values?

• Height and Weight – Why?

• Respiratory rate – 15 to 20 per minute -Why?

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Physical Assessment/Exam Steps• Body Density Determination – Why?

• Body Temperature – Why?

• Observation throughout the visit – Why?

• Interview questions are very important – Why?

• Patient’s response including body positioning

during their response – Why?

• Collecting data and documenting it is Critical

• Appropriate note taking – Why?

• Follow-up with the patient and physician(s)

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CLIA Waived Testing Can Be Part of Your Assessment/Exam Services

• Lipid profile - fasting

• Glucose - fasting

• INR (Coaguchek, INRatio)

• AST/ALT – via Cholestec device

• HgA1c

• Many More (Check the FDA Web Site)

• More Waived tests will be coming

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Tests Designated as Waived By The FDA: 2000 To The Present

• FDA Web Site for the list:

http://www.accessdata.fda.gov

/scripts/cdrh/cfdocs/cfClia/test

swaived.cfm

• Pharmacy can and must be a

licensed laboratory - Great

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http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfClia/testswaived.cfm


New Technology Continues to be Developed

•Non-invasive Central

Venous Pressure

Measurement

•Why?

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A Pharmacy Practitioner’s Thoughts and Actual Experiences

• Actual Case Studies:

Experienced By A

Pharmacist in A

Community Pharmacy.

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Case #1• A women in her late fifties came into the pharmacy on a

Monday afternoon and wanted to know if taking Ginkgo

Balboa really improved brain function of individuals. She

was interested in taking Ginkgo Balboa to improve her

memory. I explained that there was no scientific evidence

that it really did improve memory.

• Since Ginkgo Balboa has platelet inhibiting properties I

was concerned if she was taking in medications. She

stated that she presently was not taking any medications,

so theoretically we could assume that there was no risk to

this patient taking Ginkgo Balboa daily.

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Case #1 - Ask For Details• It is extremely important to obtain a full

understanding of the patient present health

status.

• Keeping this in mind I asked the patient if

she was seeing a physician presently on a

regular basis. When I asked her this

question she responded, yes that she had

been seeing a physician regularly. In fact

she informed me that she was going to have

surgery next Tuesday.

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Case #1- Using Fundamental Sciences

• I tried to explain the significance of Ginkgo

Balbo’s effect on her platelets, which could

cause significant bleeding.

• This would be a greater risk for her, since

she would be having surgery next week. I

informed her that her surgeon want not be

happy with me if I allowed her to take a

platelet inhibitor. She thanked me and said

she would talk to me after her surgery.

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Case #1- Using Fundamental Sciences

• It is also important to know the type

and extent of the surgical intervention

if you are going to provide any

medication (prescription, OTC, or

herbal) to a patient. Also, knowing the

mechanisms of action of all

medications is critical to safe and

appropriate medication therapy.

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Facilities – Treatment Room

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CASE #2• A women came into the pharmacy with her 7 year

old son. She stated that her son has an ear ache

and she was unable to get an appointment with

their physician until next week.

• She wanted to know if there is a OTC medication

that would help reduce the pain until she can see

their physician.

• I took my ototoscope to check the boy’s ear . The

boy was placed on a treatment table to make it

easier to view and deal with squirming.

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Case #2 The boy’s tympanic membrane was clear and there was no

bulging, so it is unlikely that the cause would be related to

an ear infection.

I did notice that when boy spoke that he had serve nasal

congestion.

I recommended pseudoephedrine oral liquid and asked the

mother what was her son’s weight. I need the boys weight

to calculate the appropriate dose.

The mother was instructed to contact me tomorrow if the

boy does not improve by the morning.

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Case #3A woman came to the pharmacy wanting to

ask me about her son’s sore throat. She

wanted to know if I could recommend an

OTC lozenge to relieve her son’s throat

pain.

I explained that I wanted to check her son’s

throat, so I took them into the treatment

room and asked the boy to sit on the

treatment table.

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Case #3Using a pen light flash light I inspected the

back of the boy’s throat paying particular

attention to the tonsil area.

I found that the were a significant number of

white patches in the patient’s throat.

I also took the patient’s temperature and

found that the boy had an elevated

temperature.

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Case #3• I explained to the mother that she should take her

son to their physician, because it is a good

possibility that her son has a throat infection, which

would require medical diagnosis to determine if

antibiotic therapy was appropriate.

• I explained that I would call their physician to

explain my observations and recommendation to

see the physician for a full medical assessment.

• The use of OTC lozenges at this time would be

inappropriate.

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Case #4• A woman in her sixties came into the pharmacy

with her five year old granddaughter. Grandma

explained that her granddaughter has a cough,

which is particularly bad at night. Grandma

wanted my recommendation regarding an

appropriate pediatric cough syrup.

• I asked Grandma, has the coughing accord more

recently. She explained that her granddaughter

has had the coughing occurrences for quite a

while, and the usual remedies did not work.

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Case #4• A very common symptom in the

patients with asthma is a chronic

cough particularly at night. This is a

result of airway obstruction and

increased mucus production in the

patient’s airway. A cough associated

with a viral infection will generally be

for a relatively short period of time and

not recurrent.

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Case #4• I took Grandma and her granddaughter

into the treatment room so that I could set

the child on the treatment table to prevent

squirming, which makes it difficult to listen

to the child’s lung sounds. Using the

stethoscope I placed the diaphragm of the

stethoscope on the patient’s upper back

and asked the patient to breath in.

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Case #4• I heard severe airflow resistance in the bronchioles known as Rhonchi,

which are common occurrences in the patient with asthma. I explained

my thoughts to Grandma and recommended that she take her

granddaughter to her pediatrician. If she couldn’t make an appointment

in the near future I recommended that she take her granddaughter to

the emergency room.

• I explained that it was important to have a diagnostician assess her

granddaughter’s present problem. I explained that I would not

recommend a cough syrup, because the general cough syrup would

not deal with the problem. It is important that a full diagnosis of the

reason for the cough be made. I explained that I was concerned that

her granddaughter has asthma and it is important to have a physician

evaluate your granddaughter. Grandma said that she would contact the

pediatrician today to make an appointment.

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Case #5• A gentleman came into the pharmacy

complaining that he has had a

problem for the last 2 days with

breathing and coughing.

• He wanted to know if there is a

product available to relieve the

breathing difficulty and the coughing.

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Case #5• I took the gentleman into the treatment

room and listened with my

stethoscope on the gentleman’s back

at four points.

• I heard crackling sounds (“Rales”) as

if there was fluid in the lung.

• I also took the gentleman’s

temperature and found that he did

have an elevated temperature.

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Case #5• I explained to the gentleman that I was

very concerned about the lung sounds I

heard and the presence of an elevated

temperature.

• The pharmacist explained that most OTC

medications would not improve this

symptoms.

• The pharmacist instructed the gentleman

to see his physician as soon as possible.

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Case #5• I told the patient that he would call the his

physician to explain my findings and

concerns.

• I explained that I would make sure that the

physician new it was important to see him

as soon as possible.

• I have found with experience talking

directly to the patient’s physician allows the

patient to be given a priority.

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Case #6• A woman in her early forties came into the pharmacy

seeking advice. Her husband recently transferred to

California from out of state. She explained that tonight they

were having a dinner party for people working with her

husband in his new position in the company. She stated

that she was washing the kitchen floor on her hands and

knees.

• She used a piece of carpeting rolled up to protect her

knees. She was using a paring knife to scrap heavy and

gummy dirt off the floor. She placed the knife on the carpet

and when she scooted forward the paring knife was driven

into her right thigh penetrating fairly deep.

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Case #6• Patient explained that she did not have a primary care

physician yet and did not know where the closest hospital

could be found.

• I asked her about the wound and she showed me her

thigh, which had four bandages applied to the wound site.

• I took her into the pharmacy treatment room so that I

could palpate the wound area. The site was hot, swollen,

discolored, and very firm. It appeared that she was

bleeding into the tissue. I asked her what health

insurance plan did she have. She informed me that her

husband’s firm provided them with Illinois Blue Cross

and Blue Shield health insurance.

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Case #6• I explained that I was going to refer her to the primary

care medical group in the same shopping center.

• I called the primary care medical group and explained my

observations of the patients wound and informed them

that she did not a physician in the area. I also informed

them that she had Illinois Blue Cross and Blue Shield as

her insurance plan. The medical assistant told me to bring

the patient over now.

• I asked one of my technicians take the patient to the

medical practice office across the parking lot.

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Case #6• The technician on returning said as they walked

in the front door the medical assistant at the

desk said take the patient to treatment room #3.

• There were a number of patients waiting, but

they gave the new patient priority, because of

the information the pharmacist provided.

• The medical office called after about an hour

and gave the me a prescription for an antibiotic.

They informed me that the physician after

assessing the wound stitched the site up with

four stitches

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Case #6• The patient at the end of the week came into the

pharmacy to thank the pharmacist. That she was

doing well and the wound healed nicely.

• This is an example of how the pharmacist can act

as a referrer to physicians and help improve

patient outcomes.

• It also increases the pharmacist’s creditability with

physicians in the local medical practices. The

physician reacted in the fact that a trained

professional had referred the patient and they

sensed an immediate patient need.

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Case #7• A patient of mine with a seizure disorder was a

student at UCLA. Fall to spring she lived on

campus, but in spring of very year should would

come home to spend the summer with her family.

• In spring the Student Health Center pharmacy

would transfer her sodium phenytoin prescription

to my pharmacy. In the fall of 2001 the student

was going to return to living on campus.

• The student and her mother as usual came in to

get her sodium phenytoin prescription refilled

just before returning to campus.

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Case #7• While her prescription was being

refilled her mother asked me if I

would look at her daughter’s rash

which she developed recently. The

mother stated that it was all over her

body and it worried her.

• I took the patient and her mother into

a pharmacy treatment room and

looked at the rash.

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Case #7• This is what he saw:

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Case #7• Using one of my standard RX/communication forms:

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Case #7• The form allowed him to put physical

assessment comments on the form and

there was a place for me to sign the

prescription.

• I used this approach quite often to share

my assessments and recommendations to

physicians in the area.I wrote on the form

that I was concerned about the patient’s

skin rash, particularly since she was taking

sodium phenytoin.

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Case #7• I had seen this rash many times when I was in

acute medicine (hospital) practice and was

concerned that the patient had developed the

Stevens-Johnson Syndrome, which can be fatal if

unrecognized.

• I asked the physician to review the rash and

make a diagnostic assessment. I signed the form

and gave it to the mother. I told her to take her

daughter to their physician today. If her

physician was not available I instructed her to

take her daughter to the Emergency Room

immediately.

•

•42


Case #7• The mother returned to the pharmacy a few

days letter and thanked me for intervining.

• She informed me that they had gone to the

emergency room and given the note to the

physician.

• The physician after assessing the rash

turned to the mother of the patient and said

that the pharmacist has saved your

daughter’s life.

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Case #7• The daughter was admitted and the sodium

phenytoin was stopped. Fortunately, the

daughter came home the following summer so

the pharmacist got to see her and see she was

doing well.

• One thing I learned working in acute care is the

importance of writing progress notes

and signing them indicating that you

are taking responsibility.

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Case #7• When physicians see that pharmacists put

their assessment and recommendations in

writing and sign the note this really gives

the pharmacist’s thoughts creditability,

since the pharmacist was taking the

responsibility.

• This approach also gets physicians to react

rapidly and take the pharmacist’s

assessment and recommendations

seriously.

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Case #8• A gentleman came into the pharmacy to ask for

the pharmacist’s help.

• The gentleman wanted to know if I could suggest

something to remove the oblong brown spot on

his LEFT temple. It was relatively large and

because he has fair skin it shows up and many

people committed on the spot.

• I inspected the brown spot and immediately

became concerned.

• I asked the gentleman if spent a good deal of time

in the sun or drove a great deal?

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Case #8• The gentleman responded that he drives a

long haul truck and so he is usually inside

the cab.

• This resulted in significant concern for me

because of the possiblity that it was a

superficial skin cancer.

• The pharmacist during his physical

assessment training had been shown

pictures of patients with facial skin cancer.

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Case #8

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Case #8 I explained to the gentleman that it would not be

appropriate to use something like a bleaching

cream because it really needed to be assessed

and evaluated by a dermatologist.

I said that I could refer the gentleman to a local

dermatologist.

I also would be glad to talk with the dermatologist

regarding the my observations and concerns.

The patient agreed to see the dermatologist.

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Case #8• The gentleman return to the pharmacy a week later to

thank and let the me know that he saw the dermatologist.

• The dermatologist examined his left temple closely and

then informed him that the brown spot was a superficial

facial cancer.

• The dermatologist removed the tissue by using nitrogen

oxide freezing technique.

• The pharmacist checked his right temple and was pleased

that it looked normal.

• The gentleman told the pharmacist that he would have a

follow up visit with the dermatologist in 6 months.

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Case #9• A gentleman came into the pharmacy about

mid-day and wanted to know if I could

provide him with something that can stop a

nose bleed. Observing the gentleman it

was obvious that it was not for him. I asked

him why he was requesting something to

stop nose bleeds. He informed me that a

good friend of his had significant bleeding

from his nose so he wanted to get

something to stop the bleeding.

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Case #9• I showed him some sterile dressings that could be

used as packing to help stop the nasal bleeding. I

explained how to use the dressing and told him

that he should bring his friend to the pharmacy as

soon as the bleeding could be stopped. I

explained that I wanted to take his friends blood

pressure, because significant nasal bleeding is

quite often see in individuals with hypertension

and these bleeds happen spontaneously. He said

that he would bring his friend to the pharmacy as

soon as possible.

52


Case #9• About one hour late the gentleman

brought his friend to the pharmacy. I

took his friend into the treatment room

and asked about any medical

problems that he may have. He denied

having any serious medical problems,

but said he does get headaches and

nose bleeds periodically.

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Case #9• I then took his blood pressure. I

measured his blood pressure by

using a stethoscope and

sphygmomanometer and got a

reading of 210/105.

• I measured his blood pressure in

both arms. This method is an indirect

measurement of the patient’s arterial

blood pressure.

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Case #9• A blood pressure this high puts the patient at risk of not

only bleeding, but of having a stroke. I informed the patient

and his friend that they should immediately go to the

emergency room for a full medical assessment.

• The patient was admitted to the hospital. Again the

pharmacist really must assesses all patients and the

situations that they are presently dealing with, especially

when patient or family member explain a significant

potential problem. This patient was at very high risk of

serious medical problems and obviously this situation

should be brought to the attention of a diagnostician

immediately.

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Case #10• The 41 year old woman who had been referred to

us for warfarin management. We had previously

referred her to the emergency and she was then

hospitalized. She came for her INR determination

visit a couple of months later. She complained that

she had significant bleeding after have a uterine

biopsy. We did her INR and it was in goal range. I

did notice that when she walked a relatively short

distance she was breathing hard. I decided to take

her up to see a provider in our Patient Care Center.

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Case #10• When walking from the elevator to the waiting room she

again had difficulty breathing. Her primary care physician

was not present, so they called in a Physician Assistant. I

explained the situation to the PA and explained I was

concerned about her serum hemoglobin and could they

check it.

• About 20 minutes later I looked out of the pharmacy front

door and noticed that there were firemen in the lobby. I

went out and asked the security guard what was

happening. He indicated that the clinic called 911 because

a patient was having difficulties. There was a fire engine

and an fire ambulance in front of the clinic. I walked out

and looked into the ambulance and there was my patient in

the ambulance.

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Case #10• I was later informed that she was taken to

the hospital where 2 liters of blood were

administered because of her severe anemia.

Her Hemoglobin had been 4.0.

• We continue to provide anticoagulation

services to this patient and she continues to

be in goal range. She is doing very well and

is very thankful for my concern.

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Case #10• She continues to make her visits and has not had

the problem again. Again when the pharmacist

takes responsibility and so to say signs off their

assessment and recommendations are given

serious consideration by other health care

professionals. At her last visit she drove herself to

the visit. Obviously all of our observations,

assessments, and recommendations are shared

with her primary care physician so that they know

exactly what is happening. Our progress notes are

faxed to the physician shortly after each visit or

entered into the EMR.

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Billing Invoice Care Partners Pharmacy

• Care Partners Pharmacy

• Service & Product Documentation

2593 C Chino Hills Parkway, Chino Hills, Ca. 91709

909-393-3080 Fax # 909-393-8856

Patient:

Physician: Phone #:

Pharmacist Signature: ______________________

Date: .

60


Billing Invoice Continued• The following products & services were

provided:

• Services: Quantity: Price:

• “Fat Loss”:

• Personalized Weight Control Program:

• a. Initial, Assessment and Menu Preparation

($200.00

• b. Initial Program (3 mos. – Bi-Monthly)

$395.00

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Billing Invoice Continued• c. Extended Program (3 mos. – Bi-Monthly) ( ) $295.00

• d. Maintenance Program (6 mos. – Monthly) ( ) $195.00

• Laboratory Testing (CLIA Waived Tests:

• CLIA Exempt Laboratory Tests:

• a. Total Cholesterol & Glucose ( ) $ 15.00

• b. TC, HDL, Glucose Panel ( ) $ 25.00

• c. Lipid Profile & Glucose ( ) $ 35.00

• d. Capillary Tube ( ) $ 1.00

• e. Lancets ( ) $ 1.00

• F. Mini-Pet Pipette ( ) $ 12.00

• g. Glucose & Fructosamine ( ) $ 15.00

• h. Prothrombin Time (INR) ( ) $ 25.00

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Billing Invoice Continued• i. H. Pylori Test ( ) $ 35.00

• j. Liver function (ALT) ( ) $ 35.00

• k. Mini-Pet Pipette ( ) $ 12.00

• l. Glucose & Fructosamine ( ) $ 15.00

• m. Prothrombin Time (INR) ( ) $35.00

• n. H. Pylori Test ( ) $ 35.00

• o. Liver function (ALT) ( ) $ 35.00

• Smoking Cessation Program (8 wKs) ( ) $265.00

• Smoking Cessation Assessment ( ) $45.00

63


Billing Invoice Continued

• Assessment monitoring

• a. Blood pressure ( ) $ 10.00

• b. Per cent body fat (Tanita) ( ) $ 35.00

• c. Body composition measurement (Futrex) $ 65.00

(with risk assessment report).

• Pharmacokinetic Consult ( ) $130.00

• Drug: .

• Nutritional Analysis ( ) $ 65.00

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Billing Invoice Continued• Products:

• 1. Duet-Glucose Monitoring system ( ) $399.00

• - Glucose sticks 50’s ( ) $ 67.50

• - Glucose & Fructosamine sticks 8’s ( ) $ 12.00

• 2. Tannta’s Body Fat Monitor/Scales ( ) $450.00

• 3. Personalized food scale ( ) $ 5.95

• 4. Senior Compliance Pack–monthly ( ) $ 25.00

• Effective: 9/08/98

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We Are Finished.

•Questions?

•Discussion?

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Need More Information?

Name: Roger Klotz

Title: Associate Professor of Pharmacy Practice

Company: Western University of Health Sciences

Contact Information:

Office: 909-496-5539 or Cell: 714 396-9275

E-Mail: [email protected] or

[email protected]

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