2009 Local Case and Answer Key

2009
ASHP National Clinical Skills Competition
LOCAL CASE
2009 ASHP Clinical Skills Competition
LOCAL COMPETITION CASE
Directions to Clinical Skills Competition Participants

Identify the patients acute and chronic medical and drug therapy problems. Recommend interventions to address the drug therapy
problems using the forms supplied (Pharmacists Patient Data Base, Drug Therapy Assessment Worksheet [DTAW], and
Pharmacists Care Plan).
IMPORTANT NOTE: Only the Pharmacists Care Plan will be used for evaluation purposes. The Drug Therapy Assessment
Worksheet is simply a tool to assist you in the decision-making process.
ASHP CLINICAL SKILLS COMPETITION 2009
PHARMACISTS PATIENT DATA BASE FORM

Demographic and Administrative Information
Name: SC
Address: 2087 Bentley Ave
Charlotte, NC
Date of Birth: 12/17/1973
Height: 163cm (54)
Weight: 54 kg
Gender: Female
History of Present Illness
You are on rounds with the Internal Medicine team on 4/5/09 outside
the patients room. Dr Graham, the attending physician, has diagnosed
this patient with Pneumocystis jirovecii pneumonia and esophageal
candidiasis. Dr Graham believes SCs pneumonia is improving. SC
will not be started on antiretroviral medications at this time. Nurse
Jones steps out of the patients room and informs the team that the
patient has become increasingly anxious overnight. Dr Graham would
like recommendations from the pharmacist for SC. The information
below contains the patient's history, physical exam, laboratory data,
and other information up to this point.
Patient ID: 2989031

Room & Bed: Room 1064/General Medicine
Physician: Graham
Pharmacy: n/a
Race: African American
Religion: None specified
Vitals & Other Tests
Vitals & Other Tests
4/4/09
4/5/09
BP mmHg
170/95
BP mmHg
165/92
Pulse bpm
130
Pulse bpm
120
Temp
Tmax 102.2F Temp
Tmax 99 F
RR breaths/min 26
RR breaths/min 26
O2 Sat
84% RA
O2 Sat
92% RA
ABG:
pH
7.45
PaCO2 mmHg 35
PaO2 mmHg
65
HCO3 mmol/L 24
SC presented to the emergency department on 4/4/2009 @ 10PM with

a cc of cough and chills and panic-like agitation. She was also
experiencing moderate hand tremor, diaphoresis, nausea and itching
with a sensation of bugs crawling on her skin. She has known HIV
disease but is currently not on prophylaxis or antiretroviral therapy.
Two weeks prior to admission she began to note the onset of a dry,
nonproductive cough, intermittent chills, anorexia, and then
progressive exertional dyspnea. She also complains of severe mouth
and throat pain, as such she refuses to eat or drink. She was admitted
her to the general medicine service, from the emergency department,
for further inpatient management.
This form is to be used ONLY in the ASHP Clinical Skills Competition. Any other use of this form requires permission from ASHP.
2
ASHP CLINICAL SKILLS COMPETITION

PHARMACISTS PATIENT DATA BASE FORM (Cont.)
Past Medical History
HIV diagnosed in 2006
AIDS
Hepatitis C
Alcohol withdrawal related seizures (4/2006 & 12/2008)
Polysubstance abuse
Gravida 4 Para 0
Chemistry and CBC

4/4/09
Na mmol/L
136
K mmol/L
3.5
Cl mmol/L
103
CO2 mmol/L
24
BUN mg/dL
4
SCr mg/dL
0.8
Gluc mg/dL 143
Ca mg/dL
8.4
Mg mg/dL
2.0
Phos mg/dL 0.9
WBC K/L
3.4
Hgb gm/dL 10.0
HCT %
28.6
Plts K/L
260
Neut %
87
Lymph %
2
Mono %
3
Bands %
8
Eos %
0
Baso %
0
Total Protein g/dL 7.0
Albumin g/dL 3.1
Alk Phos units/L 205
AST units/L 158
ALT units/L 113
Tot bili mg/dL 0.5
hCG
negative
LDH International Units/L
460
Blood EtOH mg/dL 200
4/5/09
Na mmol/L
138
K mmol/L
3.6
Cl mmol/L
104
CO2 mmol/L
27
BUN mg/dL
5
SCr mg/dL
0.9
Gluc mg/dL 109
Ca mg/dL
-Mg mg/dL
-Phos mg/dL
-WBC K/L
3.0
Hgb gm/dL 10.4
HCT %
29.7
Plts K/L
240
Albumin g/dL 2.7
Alk Phos units/L 206
AST units/L 128
ALT units/L 124
Tot bili mg/dL 0.4
Urine Drug Screen
Amphetamines Negative
Barbiturates Negative
Benzodiazepines Positive
Cocaine Negative
Marijuana Positive
Opiates Negative
Blood EtOH mg/dL 0
Family History
Unknown
3

Social History (from outpatient chart)
Tobacco: denies
ETOH: drinks approximately twelve 12 oz cans of beer per day, she
reports that she has not had any beer in the 12 hours before presenting
to the emergency department due to severe mouth and throat pain and
difficulty swallowing.
Illicit Drugs: Past history of occasional marijuana, last used about 2
weeks ago; crack cocaine, last used about 1
month ago
Caffeine: denies
Occupation: unemployed
Status: divorced/has boyfriend who is HIV negative (last HIV test 1
month ago).
Children: None (states she can not afford her birth control)
Physical Activity: denies
Diet: Nothing notable
Procedures
Cultures
4/5/09
Blood Culture X2 No Growth

AFB Smear X 3 No Growth
AFB Culture No Growth
Fungus Culture No Growth
Stool Culture No Growth
Sputum Gram Smear: <10 epithelial cell seen/LPF;
<10 PMN/LPF, 1+ Gram Positive Cocci; 2+ Gram
Positive Rods, 1+ Gram Negative Rods, 1+ Yeast
Pneumocystis DFA Stain 1+ Pneumocystis
jirovecii
Immunology 4/5/09
Hep A
Reactive
Hep B Surface Ag
Nonreactive
Hep B Core Total Ab
Nonreactive
Hep C Virus Ab, Riba 3.0 Positive
HIV 1 RNA
3,531,673 copies/ml
CD4
2 cells/mm3
PPD 4/5/09 @ 0800
Pending
X-ray
Chest (taken in emergency department on 4/4/09)
Reading: diffuse interstitial hilar infiltrates with ground glass
appearance most prominent in the right mid lung field
Interpretation: consistent with Pneumocystis jirovecii
pneumonia
Chest (4/5/09) unchanged.
Physical Exam 4/5/09

General: Thin female in acute distress with shortness of breath and obvious agitation
Skin: Moist; no lesions, tumors or moles; no palmar erythema
HEENT: Normocephalic; atraumatic; deferred remainder of exam due to agitation; sclerae are anicteric
Chest: Tachypneic, labored breathing; decreased breath sounds in the right middle lung field
CV: Regular rhythm; tachycardic; no murmurs, gallops, or rubs
Abd: Soft, tender to palpation, moderately distended; (+) bowel sounds; liver span enlarged at 2 cm below right costal margin; no
splenomegaly; no spider angiomata
Ext: Moves all extremities; (+) tremor in both hands
4

Allergies/Intolerances
No known drug allergies
Current Scheduled Drug Therapy

Drug Name/Dose/Strength/Route
Prescription Coverage
Insurance: None
Copay: not applicable
Cost per month: not applicable
Home Pharmacy: none known
1.
Ceftriaxone 1gm IV
Q24 hours
Duration StartStop
Dates
4/4/09 present
2.
Azithromycin 500mg PO
Q24 hours
4/4/09 present
3.
Sulfamexthoxazole/Trimethoprim
800-160mg PO (1 tab)
Nystatin suspension 500,000 units PO
Enoxaparin 40mg SQ
Omeprazole 20mg PO
Multivitamin 1 tab PO
Drospirenone/Ethinyl estradiol 1 tab
Q12 hours
4/4/09 present
Q8 hours
Q24 hours
Daily
Daily
Daily
4/4/09 -- present
4/4/09 -- present
4/4/09 -- present
4/4/09 -- present
4/4/09 -- present
Empiric for community acquired

pneumonia
Empiric for community acquired
pneumonia
Treatment of Pneumocystis jirovecii
pneumonia
Treatment for esophageal candidiasis
Venous Thromboembolism prophylaxis
-Vitamin replenishment
Birth control
Once
Once
Once
Once
Once in ED
Once @ 4AM 4/5/2009
Testing for Tuberculosis

Agitation
Agitation
Q4 hours prn
pain/fever
Q4 hours prn
Q4 hours prn moderate
to severe pain
Q4 hours prn
Q6 hours prn nausea
Q6 hours prn nausea
Q6 hours prn anxiety
4/4/09 -- present
Mild pain/fever
4/4/09 -- present
4/4/09 -- present
Dyspnea
Moderate to severe pain
4/4/09 -- present
4/4/09 -- present
4/4/09 -- present
4/4/09 -- present
Dyspnea
Nausea
Nausea
Agitation
4.
5.
6.
7.
8.
PO
9. Tuberculin PPD 0.1ml ID
10. Lorazepam 1mg PO
11. Lorazepam 1mg IV
Current PRN Drug Therapy
1. Acetaminophen 500mg PO/PR 1-2 tabs
2. Albuterol Inhaler 1-2 puffs
3. Hydrocodone 5mg/Acetaminophen
500mg 1-2 tabs
4. Ipratropium Inhaler 2 puffs
5. Ondansetron 4mg IV
6. Ondansetron 4mg PO
7. Lorazepam 1mg PO
Prescribed Schedule
Indication
Medication History
Patient is non-adherent with medicine at home. She has a prescription for Yaz (drospirinone/ethinyl estradiol) at home but can not afford
this medicine, and thus does not take it.
5
Drug Therapy Assessment Worksheet (DTAW)

The Drug Therapy Assessment Worksheet (DTAW) will serve as a guide to identify any drug-related problems that your patient may have. You may make notes on the DTAW. However, the Drug Therapy Assessment Worksheet will not be scored. As you proceed through all the questions on the DTAW, you will
accumulate a list of drug therapy problems. All of these problems should be assessed on your Pharmacists
Care Plan. Drug-related problems may be listed as separate items on your Pharmacists Care Plan or addressed in your recommendations for therapy of the acute or chronic disease states that the medicines are
being used to treat. Teams will be evaluated on identifying and making appropriate recommendations for
drug-related problems in the following areas below:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Correlation between drug therapy and medical problems

Appropriate drug selection
Drug regimen
Therapeutic duplication
Drug allergy or intolerance
Adverse drug events
Interactions: drugdrug, drugdisease, drugnutrient, and druglaboratory test
Social or recreational drug use
Failure to receive therapy
Financial impact
Patient knowledge of drug therapy
15
6
Not evaluated
for Competition

DRUG THERAPY ASSESSMENT WORKSHEET (DTAW)
Type of Problem
Assessment
Presence of Drug-Related Problem
Correlation between Drug

Are there drugs without a medical
1.
Therapy and Medical
indication?
Problems
2.

Are any medications unidentified (are any

unlabeled or are anyprior to admission/
3.

clinic visitunknown)?

Comments/Notes
A problem exists.
More information is needed for a determination.
No problem exists or an intervention is not
needed.
Are there untreated medical conditions?

Do they require drug therapy?
Appropriate Drug
What is the comparative efficacy of the
1.
Selection
chosen medication(s)?

2.

What is the relative safety of the chosen

medication(s)?
3.

Has the therapy been tailored to this

individual patient?
A problem exists.
Drug Regimen
Are the prescribed dose and dosing
1.

frequency appropriatewithin the usual

therapeutic range and/or modified for
2.

patient factors?

3.

Is pm use appropriate for those

medications either prescribed or taken

that way?
A problem exists.
Is the route/dosage form/mode of

administration appropriate, considering
efficacy, safety, convenience, patient
limitations, and cost?
Are doses scheduled to maximize

therapeutic effect and compliance and to
minimize adverse effects, drug interactions,
and regimen complexity?
Is the length or course of therapy

appropriate?
Therapeutic Duplication
Are there any therapeutic duplications?

needed.

needed.
1. A problem exists.
2. More information is needed for a determination.

3. No problem exists or an intervention is not
needed.
Drug Allergy or
Intolerance

Is the patient allergic to or intolerant of

any medicines (or chemically related
medications) currently being taken?
Is the patient using any method to alert

health care providers of the allergy/ needed.
intolerance (or serious medical problem)?
2009, American Society of Health-System Pharmacists, Inc. All rights reserved.
This form is to be used ONLY in the ASHP Clinical Skills Competition.

Any other use of this form requires permission from ASHP.
(continued)
16
7
Not evaluated
for Competition

DRUG THERAPY ASSESSMENT WORKSHEET (DTAW)
Type of Problem
Assessment
Presence of Drug-Related Problem
Adverse Drug Events

Are there symptoms or medical problems
1.

that may be drug induced? What is the

likelihood that the problem is drug
2.

related?

3.

A problem exists.
Interactions: Drug-Drug,
Are there drug-drug interactions? Are they
1.
Drug-Disease, Drug-
clinically significant?
Nutrient, and Drug-
2.
Laboratory Test
Are any medications contraindicated

(relatively or absolutely) given patient
3.

characteristics and current/past disease

states?
A problem exists.
Are there drug-nutrient interactions? Are they

clinically significant?
Are there drug-laboratory test interactions?

Are they clinically significant?
Social or Recreational Drug

Is the patients current use of social drugs 1.
Use
problematic?

2.

Could the sudden decrease or

discontinuation of social drugs be related
3.

to patient symptoms (e.g., withdrawal)?
Failure to Receive
Therapy

Has the patient failed to receive a

medication due to system error or
noncompliance:
Financial Impact
Is the chosen medication(s) cost effective?
Comments/Notes

needed.

needed.
A problem exists.
needed.
Are there factors hindering the

achievement of therapeutic efficacy? needed.

Does the cost of drug therapy represent a

financial hardship for the patient?

needed.
Patient Knowledge of
Drug Therapy

Does the patient understand the purpose

of his or her medication(s), how to take it,
and the potential side effects of therapy?
Would the patient benefit from education

tools (e.g., written patient education needed.
sheets, wallet cards, and reminder
packaging)?
2009, American Society of Health-System Pharmacists, Inc. All rights reserved.
This form is to be used ONLY in the ASHP Clinical Skills Competition.

Any other use of this form requires permission from ASHP.
17
8
19A
Priority
Therapeutic Goals
2007,American
American Society
Health-System
Pharmacists
, Inc.
All
rights
2009,
Societyofof
Health-System
Pharmacists
, Inc.
Allreserved.
rights reserved.
Health Care Problem
Recommendations for Therapy
*Please note, there should be only a 1, 2, or 3 listed in the priority column, and the number 1 should only be used once.
A. List all health care problems that need to be addressed in this patient using the table below.
B. Prioritize the problems by indicating the appropriate number in the Priority column below:
1 = Most urgent problem (Note: There can only be one most urgent problem)
2 = Other problems that must be addressed immediately or during this clinical encounter; OR
3 = Problems that can be addressed later (e.g. a week or more later)
Problem Identification and Prioritization with Pharmacists Care Plan
ASHP Clinical Skills Competition - Pharmacists Care Plan
Monitoring Parameters and

Endpoints
Team # _______
Evaluated for
competition
19B
10
Priority
Therapeutic Goals
2007, American
American SSociety
ociety ofof
HeHealth-System
alth-System PharPharmacists
macists, Inc
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eservedreserved.
.
2009,
, Inc.
Health Care Problem

Endpoints
Team # _______
E v a l u a te d f o r
c o m p e ti ti o n
19B
11
Priority
Therapeutic Goals
2007, American
American SSociety
ociety ofof
HeHealth-System
macists, Inc
.A
ll rigAll
hts rrights
eservedreserved.
.
2009,
, Inc.
Health Care Problem

Endpoints
Team # _______
c o m p e ti ti o n
19B
12
Priority
Therapeutic Goals
2007, American
American SSociety
ociety ofof
HeHealth-System
macists, Inc
.A
ll rigAll
hts rrights
eservedreserved.
.
2009,
, Inc.
Health Care Problem

Endpoints
Team # _______
c o m p e ti ti o n
19B
13
Priority
Therapeutic Goals
2007, American
American SSociety
ociety ofof
HeHealth-System
macists, Inc
.A
ll rigAll
hts rrights
eservedreserved.
.
2009,
, Inc.
Health Care Problem

Endpoints
Team # _______
c o m p e ti ti o n
19B
14
Priority
Therapeutic Goals
2007, American
American SSociety
ociety ofof
HeHealth-System
macists, Inc
.A
ll rigAll
hts rrights
eservedreserved.
.
2009,
, Inc.
Health Care Problem

Endpoints
Team # _______
c o m p e ti ti o n
19B
15
Priority
Therapeutic Goals
2007, American
American SSociety
ociety ofof
HeHealth-System
macists, Inc
.A
ll rigAll
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eservedreserved.
.
2009,
, Inc.
Health Care Problem

Endpoints
Team # _______
c o m p e ti ti o n
16
17
2009
ASHP National Clinical Skills Competition
LOCAL CASE ANSWER KEY
Evaluated for
competition

Team # _______
A. List all health care problems that need to be addressed in this patient using the table below.
B. Prioritize the problems by indicating the appropriate number in the Priority column below:
1 = Most urgent problem (Note: There can only be one most urgent problem)
2 = Other problems that must be addressed immediately or during this clinical encounter; OR
3 = Problems that can be addressed later (e.g. a week or more later)
*Please note, there should be only a 1, 2, or 3 listed in the priority column, and the number 1 should only be used once.
Health Care Problem Priority
Acute Alcohol
Withdrawal
Therapeutic Goals

Endpoints
Prevent acute alcohol

induced delirium tremens
Prevent Wernickes
encephalopathy
Prevent autonomic
instability
Lorazepam 1mg IV q6 hours

Lorazepam 0.5mg IV q2 hours
prn (adjunctive tx to Lorazepam)
Enalaprilat 1.25mg IV q2 hours
prn SBP > 175 (change to
Clonidine 0.1mg PO)
Haloperidol 2mg IV q2 hours
prn severe agitation or
hallucinations (adjunctive tx to
Lorazepam)
Initiate maintenance fluid (1 liter
bag daily) with Dextrose
5%/0.45% NS 1 liter with
Thiamine 100mg-200mg/Folic
Acid 1mg/MVI/Magnesium 2gm
x 3 days
Follow Management of alcohol
withdrawal delirium. An
evidence-based practice
guideline. (2004)
Change to oral therapy when

thrush pain subsides
Vitals (BP/HR) q 4 hours x
72 hours then q shift
Monitor for signs/symptoms
of withdrawal:
tremor,diaphoresis,nausea/
vomiting, fever, agitation,
confusion, sleeplessness,
hallucinations, seizure
(Severity Assessment Scale,
American Journal of Critical
Care, January 1995, Vol.
4(1), 67 OR-- Revised
Clinical Institute Withdrawal
Assessment for Alcohol
(CIWA-Ar) Scale. Br J
Addict 1989;84:1353-7)
Chem 7, Magnesium,
Phosphorus daily x 72 hours
Pneumocystis jiroveci
pneumonia
Therapeutic Goals

Endpoints
Prevent mortality
Appropriate treatment for
opportunistic infection
Decrease hypoxemia
Trimethoprim/Sulfamethoxazole
16ml (256mg TMP/1280mg
SMZ) IV q6 hours
(19mg/kg/day TMP adjusted for
ease of compounding)
Discontinue oral TMP/SMZ
subtherapeutic dosing.
Recognizing the need for IV
medication is key here.
Discontinue Ceftriaxone and
Azithromycin
Prednisone oral solution 40mg
PO BID x 5 days then 20mg PO
BID x 5 days then 20mg daily
for 11 days OR
Methylprednisolone 32 mg IV
BID X 5 days (~64mg daily)
with taper.
Follow Guidelines for
Prevention and Treatment of
Opportunistic Infections in HIVInfected Adults and Adolescents
- April 10, 2009 (p.6)

Test for G6PD deficiency
Chem 7 (potassium, BUN,
creatinine) daily
CBC daily (w/ ANC)
LFTs daily
Signs/symptoms of allergic
reaction (rash, pruritis)
Maintain adequate hydration
Urine output, q shift
O2 Saturation q shift
GI upset, emotional
instability, glucose w/
Steroid
Severe oral and

esophageal thrush
Therapeutic Goals

Endpoints
Appropriate treatment of
candidiasis

Pain assessment, including

pain Score (1-10 scale), pain
intensity, pain relief, daily
Quality of life measurement
daily
Pain Management
Improve pain
relief/minimize pain
Prevent Acetaminophen
toxicity
Electrolyte
Management
Replenish electrolytes
Prevent re-feeding
syndrome
Convert all medicine to IV

therapy when possible
(solutions/suspensions may be
appropriate)
Fluconazole 200mg IV daily x
14-21 days
Discontinue Nystatin
Follow Guidelines for
- April 10, 2009 (p.46)
Viscous Lidocaine/Maalox 10ml
po q6 hours prn pain
Morphine 2mg IV q6 hours as
needed for mild to moderate
(esophageal) pain.
Morphine 6mg IV q6hours as
needed for severe (esophageal)
pain.
Discontinue
Hydrocodone/Acetaminophen
and Acetaminophen products
Replace phosphate with Sodium
Phosphate 0.24mmol/kg over 6
hours 13 mmol Sodium
Phosphate in 250ml 0.9NS IV
over 6 hours. Repeat x 1 if
needed
Chem 7, Magnesium,
Phosphorus daily x 72 hours
Discharge
Planning/Patient
Education
2
OR
3
Opportunistic Infection
Prophylaxis
Therapeutic Goals
Ensure patient can obtain

medicine
Establish a pharmacy home
Prevent inpatient
readmission due to nonadherence
Ensure all discharge
medications have an
indication
Appropriate primary and

secondary prophylaxis for
opportunistic infections

Endpoints
Contact social worker to enroll

patient in NC Medicaid
Determine pharmacies that are in
close proximity to patients home
and give patient options for a
pharmacy home
Contact chosen community
pharmacist for continuity of
care, medication reconciliation
and comprehensive medication
review.
Patient needs primary
prophylaxis for MAC and
Toxoplasmosis: Azithromycin
1200mg q week. TMP/SMZ
will cover Toxoplasmosis
prophylaxis.
PCP prophylaxis TMP/SMZ 1
DS tab daily (after 21 days of
treatment therapy)
Follow Follow Guidelines for
- April 10, 2009
Chem 7, CBC q 3 months
Contraception/Safe
sexual practices
Therapeutic Goals
Assure pregnancy is
prevented
Assure education of safe
sexual practice

Endpoints
Discontinue YAZ in the hospital

due to risk of hyperkalemia (with
TMP/SMZ)
Medroxyprogesterone (DepoProvera 150mg IM every 3
months.
OR
Ethinyl Estradiol and
Norethindrone 28-tablet package-1
tablet daily without interruption
OR
Ethinyl Estradiol and
Norelgestromin (Ortho Evra) Apply one patch each week for 3
weeks (21 total days); followed by
one week that is patch-free. Each
patch should be applied on the
same day each week (patch change
day) and only one patch should be
worn at a time. No more than 7
days should pass during the patchfree interval.
OR
Ethinyl Estradiol and Etonogestrel
(Nuvaring) - One ring, inserted
vaginally and left in place for 3
consecutive weeks, then removed
for 1 week. A new ring is inserted 7
days after the last was removed
(even if bleeding is not complete)
and should be inserted at
approximately the same time of day
the ring was removed the previous
week.
Hypercoagulability risk
Side effects: menstrual
irregularities, weight
changes, headache
Counsel on proper use of
contraceptives
Patch or Ring products may
be confusing to use for
patient. Close follow-up
necessary.
Polysubstance Abuse
(Alcohol/Cocaine/THC)
Antiretroviral Therapy
Therapeutic Goals
Prevent
alcohol/cocaine/THC
withdrawal
Reduce morbidity/mortality
Psych consult
Suggest counseling at each
follow-up visit
Reduce morbidity/mortalty
from HIV related disease
Although she has AIDS stage

HIV, SC will not likely be
started on antiretroviral therapy
until she has issues such as
substance abuse, adherence, and
reason for her acute inpatient
admission resolved.
Patient should be referred for
HIV follow-up at an appropriate
outpatient setting

Endpoints
HIV viral load and CD4

count every 3 months
CBC w/ diff every 3 months
Chem 7 every 3 months
Tox Screen every 3 months
or PRN
Note to the local judges:

The Pharmacist Care Plan has been constructed to be as exhaustive as possible. Judges for the Clinical Skills Competition are experts in the field of
clinical pharmacy and will have insights into this case that could not be accounted for in a feasible manner. Thus, as a topic expert, if you identify a
drug related problem that we did not account for, please feel free to judge the students responses based on your best judgment. We can envision
industrious students listing level 3 problems such as: outpatient vaccinations, outpatient cancer screenings, patient literacy assessments, domestic
violence assessments, etc. Please use you discretion in judging these points in the context of the larger case.
Optimal Medication Plan for Inpatient Admission

Current Scheduled Drug Therapy
Drug Name/Dose/Strength/Route
1. Lorazepam 2mg IV
2. Fluconazole 200mg IV
3. Sulfamexthoxazole/Trimethoprim 16ml in
500ml D5W (256mg TMP/1280mg SMZ) IV
4. Prednisone solution 40mg PO
5. Enoxaparin 40mg SQ (a change to Heparin
5000 units SQ q8 hours may be
acceptable).
6. Sodium Phosphate 16 mmol/250 0.9NS IV
7. D5W/0.45% Saline IV with Thiamine
100mg/Folic Acid 1mg/MVI
8. Tuberculin PPD 0.1ml SC
Current PRN Drug Therapy
1. Viscous Lidocaine/Maalox 10ml PO
(swish/swallow)
2. Albuterol Inhaler 1-2 puffs
3. Lorazepam 1mg q2 hours
4. Haloperidol 2mg IV
5. Enaprilat 1.25mg IV
6. Morphine 2mg IV
7. Morphine 6mg IV
Prescribed
Schedule
Q6 hours
Q 24 hours
Q6 hours
Duration StartStop
Dates
HD #2 - present
HD #2 - present
HD #2 present
Indication
BID
HD #2 present (x 5
days)
HD #1 -- present
PJP Pneumonia treatment for

PaO2<70 on admission ABG
VTE prophylaxis
HD #2 Once
Phosphate replenishment/prevent
refeeding syndrome
Thiamine/Dextrose Prevent
Wernickes Encephalitis/Vitamin
replenishment
Q24 hours
Once (over 6
hours)
50ml/hour
HD #2 present (x 3
days total)
Once
HD #1 Once
Q4 hours prn
HD #2 present
Q4 hours prn
Q2 hours prn
Q2 hours prn
Q2 hours prn
Q6 hours prn
HD #1 -- present
HD #2 present
HD #2 -- present
HD #2 present
HD #2 -- present
Q6 hours prn
HD #2 -- present
2009, American Society of Health-System Pharmacists, Inc. All rights reserved
Prevent acute alcohol withdrawal/DTs

Severe oral/esophageal thrush
PJP Pneumonia treatment
Pain associated with oral/esophageal

thrush
Wheezing
Mild/Moderate agitation/breakthrough
Severe agitation/hallucinations
SBP > 175
Mild moderate pain associated with
oral/esophageal thrush
Severe pain associated with
oral/esophageal thrush

2009 Local Case and Answer Key

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2009

ASHP National Clinical Skills Competition

2009 ASHP Clinical Skills Competition

LOCAL COMPETITION CASE

Directions to Clinical Skills Competition Participants

ASHP CLINICAL SKILLS COMPETITION 2009

PHARMACISTS PATIENT DATA BASE FORM

Patient ID: 2989031

SC presented to the emergency department on 4/4/2009 @ 10PM with

ASHP CLINICAL SKILLS COMPETITION

Chemistry and CBC

ASHP CLINICAL SKILLS COMPETITION

Blood Culture X2 No Growth

Physical Exam 4/5/09

ASHP CLINICAL SKILLS COMPETITION

Current Scheduled Drug Therapy

Empiric for community acquired

Testing for Tuberculosis

Drug Therapy Assessment Worksheet (DTAW)

Correlation between drug therapy and medical problems

ASHP CLINICAL SKILLS COMPETITION

Presence of Drug-Related Problem

Correlation between Drug

Are there untreated medical conditions?

Is the route/dosage form/mode of

Are doses scheduled to maximize

Is the length or course of therapy

Are there any therapeutic duplications?

More information is needed for a determination.

More information is needed for a determination.

Is the patient allergic to or intolerant of

Is the patient using any method to alert

2009, American Society of Health-System Pharmacists, Inc. All rights reserved.

This form is to be used ONLY in the ASHP Clinical Skills Competition.

ASHP CLINICAL SKILLS COMPETITION

Presence of Drug-Related Problem

Adverse Drug Events

Are there drug-nutrient interactions? Are they

Are there drug-laboratory test interactions?

Social or Recreational Drug

Has the patient failed to receive a

Is the chosen medication(s) cost effective?

More information is needed for a determination.

More information is needed for a determination.

Are there factors hindering the

Does the patient understand the purpose

Would the patient benefit from education

2009, American Society of Health-System Pharmacists, Inc. All rights reserved.

This form is to be used ONLY in the ASHP Clinical Skills Competition.

Health Care Problem

Recommendations for Therapy

Problem Identification and Prioritization with Pharmacists Care Plan

ASHP Clinical Skills Competition - Pharmacists Care Plan

Monitoring Parameters and

Health Care Problem

Recommendations for Therapy

Problem Identification and Prioritization with Pharmacists Care Plan

ASHP Clinical Skills Competition - Pharmacists Care Plan

Monitoring Parameters and

Health Care Problem

Recommendations for Therapy

Problem Identification and Prioritization with Pharmacists Care Plan

ASHP Clinical Skills Competition - Pharmacists Care Plan

Monitoring Parameters and