Osce Tips

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OSCE TIPS
In order for a student to perform efficiently in OSCE, he should be well aware

about CPS and Patient Self-Care in addition to Therapeutic Choices. However with
regard to the last reference, he will not use it as in MCQ exams where one has to
know all details that are in the test.
The student should know how to use CPS efficiently. By efficiently we mean to
skim and scan the informatic accurately (to avoid any miss information) and within
1.5 -2 minutes, and not more than that. In order to do that, the student must know
what CPS contains, and how to search for the information with a minimum time
period. For example, all the information, regarding the administration of the
medication is found under the dosage in each individual monograph, and at the
same time, they are found in lilac pages under Clin-info. Which part should the
student follow easily and efficiently?
We will go through the CPS step by step and systematically in order to make the
student be familiar in grasping the information from CPS, and how to deliver that
information to the patient (since the student should paraphrase the information
written in CPS to the patient languages, and not to use technical terminology).
The first few pages of the CPS list us some of discontinue products and not all the
discontinue products are included. So the student should know that in CPS, he
might find some products, or there might be a handout on the table of any
discontinue product, if the station was on a new product that is substituting a
discontinue one due to side effect are due to some risks or precautions. The student
should know that the list on CPS is in alphabetical order, and the year that the
prodect was discontinued is indicted at the end of each listing. Also the student
should know that the products are listed according to their brand name, and not
scientific name. Discontinue medications should be kept in mild especially in noninteractive stations when the student sees the Rx is accurate in all its requirements,
like name of the patient, name of doctor, with the address, strength and directions,
and nothing is missed. So before indicating that the Rx is correct, check what the
product is discontinue or not.
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EXAMPLE:
Rx
Tylenol cold and Flu (Night time relief) 1x4 Age: 16 years old
considering all other information are correct.
For the first instance, the student might think that the Rx is correct, and actually
there is a monograph of Tylenol Flu (Night time Relief). However, Tylenol Cold
and Flu (Night time Relief) is discontinue according to CPS 2007 since 2004 and
the medication Tylenol Flu (Night time Relief) is not the same as the above one.
So by being familiar with at least knowing that in CPS, there is a list of products,
one might have a glance to scan whether the product is discontinue or not, so that to
choose the correct answer.
When the student comes to the blue pages, which contain the Brand and Generic
Name Index, one thinks that these pages are not important, since one only can go to
these pages to refer to the indicated individual medication monograph. However,
the student should familiarise himself with a lot of things mentioned in the blue
pages in order to interact efficiently with the patient and to solve the station
accurately. For instance, if he doesnt see the name of the medication, whether in
brand or generic is not underlined, and then he should expect that there is no
monograph for that medication and there is no need to waste time, looking for it, in
the CPS. Sometimes the medication is seen in the blue pages in bold letters that are
not underlined, which means that you may see only the supplied of that medication,
and thus not complete information.
EXAMPLE:
Rx
Novo- Hylazin
When you go to blue pages, Novo- Hylazin is not underlined, but is written in bold
letters, so I expect to get only supplied as information from CPS with respect to
the above medication, which is not sufficient for me to solve the station. Hence I
should go to the brand name of the above medication which is Hydralazine and is
underlined to get all the information that I want.
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EXAMPLE:
Rx
Apo- Terazocin
The medication in CPS is written in bold letters and if you look for it in CPS you
see the supplied only and thus you can not gain the information that you need to
solve the station if counselling was required to solve it. So, the student in this case
should go to the blue pages, and he will see Hytrin underlined where he can pick out
all the information he wants, since a complete individual monograph is available.
So, in general whenever one sees generic names i.e. those medications that are
preceded with Apo, ratio, Novo etc. It is important to go to the brand in order to
get the complete information, and not to lose anytime.
Sometimes one might see such kind of prescriptions:

Rx
222 tablet
Or another prescription such as:
Rx
3TC
These prescriptions contain numbers, so how we can find their monographs, taking
into consideration that both are underlined. There is no index in CPS for any
number, and therefore you might lose time if you dont know the strategy of finding
such kind of medications. If we take 222 tablet which contain ASA/Caffeine
citrate/codeine phosphate, we can know the location of that medication in this way.
222 tablet means two hundreds and twenty two, thus this should come
alphabetically after Twinrex since Two can come after TWI. Similarly, 3TC which
contains lamivudine, we say 3 means Three, thus if should come after thiopental.
thr comes after thi in CPS and prior to thymogloburin.
If the blue pages I may see beside the name of the medication that is underlined,
this word CPHA, this is an abbreviation of the Canadian Pharmacist Association,
and it includes comprehensic monographs including similar things like the other
individual monographs except the supplied. So if one wants the supplied
information, the student should go to the corresponding individual monograph that
is available in CPS, and if not available, the student should search in the CPHA
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monograph at the front pages, since sometimes they mention some tables with the
strength all route of administration.
EXAMPLE:
ACE inhibitor contains comprehensive monograph for all ACE inhibitor
medications. However, if I want to know the supplied of ramipril, in that case I
should go to the individual monograph of ramipril which is Altace in order to
know the supplied.
Other important information that one can get from the blue pages is that, sometimes
the change in salt of some medications results in a drastic, change in the
pharmacological activity and hence in its indication. For example, a prescription
written in this way:
Rx
Ciclopirox Olamine
In that prescription, the student might go and look in CPS for Ciclopirox which is
Penlac in CPS, while the prescription is for Ciclopirox Olamine which is Loprox
or Stieprox. Loprox is topical antifungal, which Penlac is for nail management
onychomycosis.
Another important thing which should be considered, when we use the blue pages,
is that certain medications can be found in different dosage forms, but not in the
same monograph. For example potassium. Potassium in its different dosage forms
is seen in different individual monograms. So if I want liquid potassium chloride, I
should go to K-10 SR tablet potassium chloride, I should go to K-Dur. Powder of
potassium chloride, I should go to K-Lyte/Cl. Effervescent powder potassium
citrate, I should go to K-Lyte.
This is very important to be well known especially when a doctor, a nurse or a
medical student wants to change a dosage form from liquid to solid or to an
effervescent, the student should be aware that the potassium dosage forms are in
different separated monographs.
Another point to be considered when one has a look on these blue pages is that
sometimes the abbreviation of the medications mentioned in these blue pages does
not refer to the expected medication and thats why one has to confirm whatever he
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is looking for. For example: M.O.S. one might tell the patient when he is
counselling him that this medication is morphine sulphate since S may indicate
sulphate while really the medication is Morphine HCl.
Another point worth to be noticed when one is using the blue pages is that if the
student is dealing with a steroid whether it is eye, ear or nasal drop, or with inhaled,
systemic or topical corticosteroid and he fan not find an individual monograph for
that medication, then he can simply use the CPHA monographs of corticosteroids
namely: corticosteroids inhaled, corticosteroids systemic, corticos eye, ear, nose
and corticosteroid topical.
The lilac pages or the Clin- Info are also important for the student to familiarize
himself. They contain treatment regimen for Bacterial Endocarditis Prevention, and
preoperative management of medications with routine Immunization schedule.
EXAMPLE:
A doctor wants to share your opinion about the use of the following medications to
discontinue them since the patient is going to do major cardiac surgery.
Altace 2.5mg BID
Chlorpropamide 200mg daily
Here, it is in vain to go to the individual monograph to pick out the information to
solve this station, since you will lose too much time in searching for the
information, in addition you may not find the use of these medications before
surgery in their individual monographs. However you can find the relevant
information in Clin- info easily and with a short time.
So:
Altace: may be discontinue since it is a major cardiac surgery to avoid thpertension
Flecainide: Adm. approximately (2 hours) preoperatively with sips of water
Chlorpropamide: should be discontinuing 1 day before surgery since oral agents are
withhold on the morning before surgery and it is a long acting agent.
So it is important to have a look on these pages of perioperative management of
medication and to keep in mild that the use of medications before or during surgery
should be instructed from these pages.
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o The CYP 450 Drug Interaction

These pages are well known to the student. However, it is better to consult the
individual monograph for any significant drug-drug or food-drug interaction, since
some of the interactions are clinically insignificant. So all major interaction in the
individual monograph of the medications are either seen under drug-drug interaction
in the same monograph. If there is severe drug-drug interaction which results in
morbidity of the patient, then in that case you may find the interaction when the
contraindication.
o Drug Administration and Food.
This is a very important part for the student, since it gives complete information
about the administration of oral medication, whether with or without food, and
whether to be crushed or not, in addition to other comments which are essential to
be counselled to the patient
It is a very long list. However Im going to list most essential drugs that are given
before meal and those that are given with or after meal, then therest of medication
could be given with or without meal.
Medications before meal
o
o
o
o
o
o
o
o
5 ASA
Alendronate
Captopril
Domperidone
Gemfibrozil
Lanzoprazole
Metoclopromide
Nateglimide and rapiglinide
Empty stomach
o
o
o
o
o
Ampicillin
Dekoral vac.
Cloxacillin
Didanosine
Bisphosphonates
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o
o
o
o
o
OSCE TI PS
Lincomycin
Norfloxacin
Sucralfate
Tetracycline
Zafirlukast
Medications taken with or after meal

o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Acarbose (to avoid irritation)

Acitretin (to enhance absorption)
Antacid
Allopurinol (to avoid diarrhea)
Amoxycillin/ Clavulanate (to avoid diarrhea)
Bromocriptine
Carbamazepine
Carvedilol
Chloroquine
Clarithromycin-tablet XL
Colestipol
All NSAIDs
Doxycycline
Fenofibrate
Galantamine
Ganciclovir
All antidiabetic agents except Nateglinide and rosiglitazone
Hydroxy chloroquine
Itraconazole solid dosage forms (not liquid) and ketoconazole
Lovastatine
Mefloquine
Phenytoin
Olsalazine
Prednisolone
Theophylline (uniphyl)
Venlafaxine XR
Verapamil- SR except Cover- HS
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OTC
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Empty
Stomach
OSCE TI PS
With or without With or Do not

Food
after meal crash
ASA-EC
ASA-plain
Atapulsite suspention
Atapulsite-tab-regular
Bisacodyl tablet
Calcitriol (Vitamin D3)
Calcium salts
Codein
Cyproheptadine
Docusate Na-cap
Docusate Ca
Fever few
Foxofenadine
Folic acid
Guaferessin
Hydroxylxine
Ibuprofen
Iron salts
Drug Administration and Grapefruit Juice

o Grapefruit juice acts as an inhibitor of intestinal isoenzymes, CYP3A4. Separating
the dose of the drug from ingestion of grapefruit juice may not prevent an
interaction. However grape fruit juice in addition to its inhibitory action, it may act
as an inducer for some medications:
With Clopidogrel may decrease plasma levels of active metabolite, thus
weakening its ability to inhibit platelet aggregation.
With Fexofenadine may decrease fexofenadine serum levels.
With Itraconazole and Ketoconazole may decrease serum level.
With Losartan may decrease formation of major active metabolites.
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Latex Allergy
o It is important to realize whenever the patient is using parenteral products, or he is
an in-patient using catheters, cannulae and feeding tubes has the possibility of Latex
allergy. So the student asks about that.
Important things in solving direct counselling stations:
1. Greeting the patient
2. Providing privacy
Communication
3. Indentifying the patient
skills
4. Empathy and sympathy
5. Relevant info gathering
6. life style
7. Efficient listening and responsing
8. Administration of medications
9. Side effect and how to correct them
10. Expectation
Communication
11. Precaution
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12. Monitoring
Solving the station
13. Storage
14. Self care measure
15. Follow up
This is an example for the above points
Pharmacist: Hello Im (
), the pharmacist, how may I help you? (Greeting)
Patient: Im here to pick up my prescription.
(If the patient recalls some pain, tiredness, worried or any other action, then the
pharmacist should express empathy or sympathy before he sits down like:
You look somewhat tired
You must have been in quite a bit of discomfort
It sounds that you have been through a lot of pain
You seem frustrated
You seem disappointed
Sorry to hear that, and I will try my best to help you)
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Pharmacist: Have your seat please.

Patient: Thank you.
Pharmacist: In order to help you better, I would like to ask you a few questions. Is that
ok for you?
Patient: Yes, its ok.
Pharmacist: Is that Rx for you? (Identifying the patient)
Patient: Yes, for me.
Pharmacist: Would you like to sit here or in a more private area? (Or simply the
pharmacist can say that this is a private area that is offering privacy)
Patient: Thank you.
Pharmacist: I would like to reassure you that whatever information I gather, will remain
confidential (Confidentiality).
So what the student does in the first minute is to do the following:
Greeting, expressing empathy, identifying the patient offering privacy and
confidentiality and this makes the student to act professionally with the patient and
gives some self confidence to the student.
The next step is Gathering relevant information.
The relevant information gathering starts by going directly to the patient profile first, if
the patient does have a profile, otherwise the student should establish a profile which is
done by well known MAMA. So in case if the patient has a profile, I go to the profile
and confirm the allergy if he has. If I ask on allergy that he has, I should ask him about
the nature of that allergy, and what happened to him namely signs and symptoms like
rash, short of breath, hypotension or other type of allergy or intolerance, since the
patient can not differentiate between different types of allergies and even sometimes, he
thinks that a simple side effect like a diarrhea is an allergy. So confirming the allergy is
important followed by asking him other kinds of allergies like food allergies, or
environmental allergies (pets, pollens, dust, ragweed, grass.etc), till the patient says
no I dont have any other kind of allergy.
Then the next step in the profile is to look for the medication that he is taking asking the
patient one by one about each medication, how is he taking them (dose) and is he taking
them regularly or not. This information is important since, if the patient is not taking the
medication regularly, then there is a compliance problem, and in that case the
pharmacist should tell the patient, I should call the doctor if you didnt tell your doctor
about that. The doctor might request not to dispense the new medication, if a
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compliance problem existed. Then you go to the next medication in the profile and next,
till there is no other prescription medication.
After that ask the patient about his medical combinations starting from the existing
problem say hypertension, then tell him what other medical conditions, like diabetes or
asthma till he says no.
Then go to non-Rx-medications, herbal products and vitamins and whether he is using
them regularly or not.
Then if the patient is female, ask whether she is pregnant and breast feeding (if that is
applicable).
Thus going through the profile stepwise with make you do MAMA.
Then go to lifestyle and say.
Pharmacist: As you know lifestyle may affect how the medication works. May I ask you
if you smoke, drink alcohol, hows your diet and exercise?
Any one of the above, if the patient was practicing it in an abnormal way i.e. if the
patient was smoking, drinking too much alcohol and diet not following the regular
Canadian guidelines (or not healthy diet) and with sedentary life then these should be
circled in order to address them later on. This is applied also for medications in the
profile which may interact with the new medication; they also should be addressed later
on. The addressing should prior to give the tips of self care measures. The gathering of
information with the first introductory greetings should not last more than 3 minutes.
Then in order to respond to what you have listed and information that were gathered
from the patient. Then the pharmacist to continue the dialogue should say:
Pharmacist: Before I go to my reference book, do you have any concern or question?
(This is important to ask it, since you can check any concern of patient or question by
going to the reference book, better them to be surprised by a question or concern from
the patient after it makes you to check book, since it makes you to check back again and
to lose more time)
Patient: Just counsel me on the medication.
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References:
It is better to start with the hand outs or prints that are available on the table, and if these
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are not sufficient, then I should go to CPS to pick out the information that I want. In
order to counsel the patient, this should not last more than 1-1.5 minutes. So tell the
patient before you go to the reference books.
Thank you for sharing the information with you. If you dont mind, I will check my
reference book and I will get back to you within a few minutes.
What are the informations that should be picked out?

The students should familiar himself in picking out the information form the CPS. This
should be done in this way.
1. Go and look at the indication and paraphrase the information. For example, Aless
21 in CPS it is mentioned that it is used for conception control then I paraphrase it
to: it help to prevent pregnancy.
o Atovent: indication in CPS: As a bronchodilator for the maintenance
treatment of bronchospasm.
Paraphrase: It will help to open the airways in your lung and to keep
maintain youe lung airways.
o Paxil: Is indicated for symptomatic relief of depressive disorders.
Paraphrase: It will help to relieve your mood swinging
o Amoxicillin: Is indicated for the treatment of bronchitis.
Paraphrase: It will help to treat your infection in your lung airways (or
bronchial airways).
o Coumadin: For the prophylaxis and/or treatment of venous thrombosis.
Paraphrase: If will help prevent and treat any clot formation in your veins.
Or we simply can say it is a blood thinner.
o ASA: Paraphrase: It will help prevent clot formation
o Antipsychotic: It will help treat and maintenance of any psychotic disorder
like bad thoughts or any social withdrawal.
So, paraphrasing would male the pharmacists to be away from any technical phrasing,
and using his simple language that is easily understood bu the patient which results in
better compliance and better instructing the patient
o After indication, the student should go to the administrate of the medication. Here,
there is no need to check the dose whether it is correct in the Rx or not if the task of
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the student is just to counsel the patient or if the station states that the prescription is
ready for pick up, or it states that the Rx was already checked by the pharmacist. So
these notes make the student anticipate, what the station iswhether it is direct
counselling, or DRP (Drug Related Problem). Thus, if it is direct counselling, it is
better to go quickly to the lilac pages to pick out whether the medication is taken
with or without food, or not chewed or crushed, in addition to the other relevant
information that are mentioned. Actually, going into these pages, spares time for
looking to these specific information under the dosage part, since you have to read
longer paragraphs and to skim and skin.
o After the administration, the student should tell the expectation beyond that
treatment. By expectation, we dont mean the onset and the duration, but the partial
effect after how many days, and this is very important to know when to see the
doctor. So the student should say you should see a partial or a marginal effect
after___days and optional effect after ___days or weeks.
Most of the expectations are seen under the dosage however sometime under the
Pharmacology and sometimes between the lines. Because sometimes, it is not easily to
pick out that information, and in order the student to behave in a professional way with
the patient, it is important to search these information in advance and to know them.
However if one can not find the expectation of the medication, the student may tell the
patient When is your next visit to your doctor then when you visit him say after 4
weeks or 6 weeks, tell your doctor about the response to your medication, so that the
doctor assess your condition, you may need dose adjustment, keep you on same dose or
might switch you to another medication.
To make it simple, here is a list of some expectation of well known medications.

Medication
Expectation
*Max effect 4-6 weeks CPS 2007 Pg. 375
Thyroid (Synthroid, Levothyroxine)
*Max after 3-6 weeks CPS 2007 Pg. 631
Cozar (losartan potassium)
* We can apply this to all antihypertensives. If not, we may say when your next visit is
to your doctor. Your doctor may keep you on the same dose, adjust the dose.
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Crestor: Maximum within 2-4 weeks, and is maintained during chronic therapy.
CPS 2007 Pg. 634
Crixivan: Viral suppression was observed thru 24 weeks.
Dovonex for psoriasis: Clinical improvement in itchiness and scale usually occurs
within 2 weeks. Optimal effect 6-8weeks (improvement in plaques) CPS 2007 Pg.
769
DDAVP (Antidiuretic hormone) spray: effect within one hour, peak in 1-5 hours.
CPS 2007 Pg. 678
Donepezil: Initial response 4-6 weeks. Therapy is maintained for several months and
several years. CPS 2007 Pg. 212
Carbolith (Lithium Carbonate): Acute phase 1week should be controlled. Then
maintenance which should occur by 2weeks, and continue long-term treatment for
the expected duration of the main phase, since early withdrawal lead to relapse. CPS
2007 Pg. 437
All antidepressants and Antipsychotics: Partial response (improvement in appetite,
sleeping, reduction in aggressiveness and positive signs and symptoms in 2 weeks
and maximal response 4-6 weeks in depression and 8 weeks in antipsychotics.
Quvar (and all steroid inhalers): Improvement in asthmatic symptoms within the
first or 2nd week if starting treatment. CPS 2007 Pg. 1968
Salisylic acid 40% for warts: Visible improvement in 2-4 weeks. Complete
improvement in 6-12weeks.
Nitroglycerin pump, ASA (81-325mg), Plavix: You should expect a control in your
angina (clot formation for ASA) as long as you are using it.
Coumadine tablet: Anticoagulation after 24 hours. Peak after 72 hours. The therapy
should be continued until the risk if thrombosis or clot formation has passed. CPS
2007 Pg. 617
For Rosacea: Significant effect in 1 month. Continuing improvement in 12 weeks.
Adapulene and Clindamycin(for *acne): Patient responding to clindamycin should
show improvement in 8weeks
* For Acne, if we are giving au OTC as Benzo-gel, the partial response after 4-8 weeks.
Maximal response should be seen sfter 8-12 weeks.
* Antibiotics: Partial response after 3 days, full response after the end of therapy. No
interruption in treatment unless, there is treatment failure.
Antiulcer agents (except for H-pylori): Partial response after 4 weeks. Then your
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doctor might put you on maintenance dose.

Cortenema: Maximum effect in 5-7 days.
Herbals: Therapy should not exceed 3 months. However, if after 2 months no
improvement, discontinue.
Colchicine: Within 12-48 hours. You should see an effect.
Prolopa: Effect seen within 3-6 weeks.
Corticosteroid Nasal Drops: There may not become evident until 2-3 days of
treatment have been completed. Full therapeutic benefit requires regular use. CPS
2007 Pg. 2070
Strattera (for ADHD): Initial improvement within 1-4weeks. CPS 2007 Pg. 2244
Sulfonyl urea (antidiabetics): The response is evident in 1week. Nevertheless,
treatment should be attempted for 4 weeks before determining whether the patient is
responding or not. CPS 2007 Pg. 2259
Bisphosphonates: Initial effect after 4 weeks for *osteoporosis which results in
inhibition of bone resorption (in case in bone mass). However the treatment could
be maintained for one year or more.
* For Pagets disease, full effect after 6 months.
1- adrenergic Blocking agents (Alfuzosin, doxazosin, tamsulosin and terazosin).

Over a period of days to weeks, this may improve urinary flow rates. Therapeutic
Choices Pg. 780
Metformine: Maximum response in 4 weeks otherwise, the doctor would adjust the
dose. CPS 2007 Pg. 1048
Nateglinide: To control fasting blood glucose, usually fasting blood glucose drops
after one month of regular use. However for postprandial control, early decrease in
post prandial glucose level.
Avandia: Adequate control of blood glucose in seen in 8-12 weeks. CPS 2007 Pg.
267
Methotrexate(MTX): Full effect after 6-8 weeks for rheumatoid arthritis, therapeutic
response begins after 3-6 weeks.
Phenytoin: A period of 7-10 days is required to achieve a therapeutic level. CPS 207
Pg. 736
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o After expectation, the student should go to the relevant side effect that could be
corrected by the patient and telling the patient how to manage the side effect. For
example, it is not relevant to say the side effect of warfarin are nausea, vomiting and
diarrhea since these side effect are general to most medications. However, it is
important to mention the more relevant (specific) side effect, for instance in this
case of coumadine, we may say, bleeding (may warrants diagnostic investigation so,
tell the patient to see his doctor since within the therapeutic range, bleeding should
not occur, and investigation, here, is important since it may unmark a previously
unsuspected lesion for example, tumor, ulcer, etc. Other side effect like cold
intolerance, so wear protective clothings, headache (use Tylenol) and fatigue (take
sore rest). So picking out (3 or 4) side effect that are relevant and telling the patient
how to one of the precautions and warnings, telling the patient to be aware of that
and monitoring it, and if it happens to contact his doctor.
o After picking the side effect and precaution, then know storage of the medication.
After that (this should rest from 1-11/2 min) then face the patient, and tell him Thank
you for your patience.
o Your doctor prescribed this medication for you_____
o Mention the trade name and ingredients and strength.
o Then say this medication will help ____ (indication with paraphrasing).
o Then the administration (use future tense, or continuous future tense; like you are
going to use this medication, or you will be using this medication, or you will use
this medication) continuous future tense and future tense avoids you from
paternalism. Dont say you must use, or take this medication 3 or 4 times (that is
paternalism). State clearly the administration if it is two times, say it morning and at
night i.e. 12 hours apart. If it is a pill say, you put the pill in your mouth. If the pill
doesnt have water coat, or not solubilized by saliva, then say it put the pill in your
mouth and swallow it with a full glass of water, and mention whatever indicated in
lilac pages under Clin-information about dont chew or crush or anything when the
comment corresponding to that medication. The administration is important part
and a crucial part in counselling the patient because if the administration is not clear
to him, then the patient can not take the medication properly and would not be
effective.
o After that tell him: You should see a partial response within ___days or weeks and
you should see an optimal response within ___days or weeks. (Expectation)
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o Then tell him 3 or 4 side effect with the management of these side effecs, and with
one precaution that should be monitored and reported to doctor immediately if it
occurs.
o In case if you cant find any precaution or warning you can tell the patient if a
hypersensitivity reaction happens like short of breath, swelling of lips and dizziness
then you discontinue the medication and contact your doctor.
o Then tell him the storage of the medication.
o After that address any issue whether in the patient profile where there might be any
drug-drug interaction, or addressing any issues between OTC, herbal products and
the new Rx medication, or any issue with life style of the patient regarding his
general health or with respect of the effect of life style on the new Rx medication.
End up the dialogue by saying: Do you have any question so far? to address it and
provide the patient with the information sheet, if the medication is new to the
patient.
o Then tell the patient: Some self care measures are important to be practiced along
with the medication. It is important to mention relevant or more specific selfcare
measures for that conduction, and not the general ones like good diet, and physical
exercise. The priority is always to the specific ones, and then to the general
measures.
o Lastly, the following: If you dont mind, I will call you after 3 days or 2 days to see
if you are experiencing any side effect like (mention only one side effect), and after
1 week or 2 weeks or 3 weeks to see if there is any improvement in your condition
or health status or signs and symptoms.
o End the interview: Thank you for coming in, have a nice day.
We will take some examples of direct counselling where the Rx is ready for pick up, or
the Rx has been checked. Some of those examples are with patient profile, others
without. Some there might be something of drug interaction, where the patient should
be told to monitor his condition or to the pharmacist should confirm that with the
doctor. In all of these cases, complete counselling should be provided to the patient
o Any concern or question raised by the patient should addressed either immediately,
or you can tell the patient that you will answer him after checking in your reference
book guide to double check, or to confirm that.
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o Try to be active listener i.e. not to repeat pardon me, or sorry ..etc.
o Dont repeat the thing that you have counselled the patient unless you feel that the
patient is not comprehending the information.
o Dont ask a question to the patient, if the patient has already given you the answer,
or has raised it to your previousy.
o When you go to selfcare measures, dont say things like dont drink alcohol if the
patient didnt tell you that he drinks alcohol, or eat a well balanced food, if the
patient is already eating good diet. So, the self care measures are not general tips,
but information given to the patient, if he is not practicing them which helping
enhancement of the effectiveness of the medication.
o In case if the case is direct counselling to the child. In this condition, there is no life
style but mention, whether the child has taken allhis vaccines, regularly or not.
o Certain conditions like skin disease (fungal infections) or skin infestation like lice or
scabies. It is irrelevant to say do you drink alcohol or well balanced diet on physical
exercise in gathering the information. Here, you should spare time to more
mentioning the non-pharmacological measures to avoid reinfection and more time to
educate the patient. So you should realize which stations require more time to
counsel and educate the patient which stations require less gathering information as
in the above examples. Another example, like when you face a station counselling a
medication for controlling cholesterol level, then emphasize on diet and exercise.
Same thing to Diabetics. However if the rtcteen is concerned with allergic rhinitis,
then stress more on environmental allergies like pets, pollens, ragweed, grass and
dust, and the OTC medication that are used, and non- pharmacological management
by the patient, so that to educate the patient more about these and address other
issues.
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Case: 1
Patient name: John Smith
Patient profile
Rx
ASA 81mg 1x1
Coumadin 2.5mg tablet 1x1
First stroke attack
Allergy- Sulfonamide
Age: 65 years old
Weight: 90 kg
Pharmacist:
Hi, my name is ( ). I am the pharmacist in duty today. How may I

help you?
Patient:
I am here to pick up my Rx.
Pharmacist:
This is a private area (Privacy), please have your seat. Or, please have
your seat.
Patient: Thank you.
Pharmacist:
Is the Rx for you? (Identifying the patient)
Patient: Yes, it is for me.
Pharmacist:
In order to help you better, may I ask you a few questions?
Patient: Sure.
Pharmacist:
I would like to reassure you that whatever information I collect will
remain confidential. (Confidentiality)
Pharmacist:
Would you mind to check your profile first?
Patient: Sure.
Pharmacist:
I can see from your profile that you are using aspirin 81mg. Are you
still using it?
Patient: Yes, I am still using it.
Pharmacist:
How many times per day?
Patient: One time per day in the morning after breakfast.
Pharmacist:
Are you using it regularly?
Patient: Yes, everyday.
Pharmacist:
So, could you please tell me what happened recently that made your
doctor to Rx this new medication for you?
Patient:
Well, I had a stroke attack, and I was admitted to the hospital in ICU,
and stayed for 6 days in the hospital and now the doctor discharged
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me, and wrote this medication for me.

Pharmacist:
Oh, that must be hard for you or you must have been in quite a bit of
discomfort. (Empathy)
Patient: Yes. It was distressful time, but now I am ok.
Pharmacist:
So what did the doctor tell you about this new medication?
Patient: He told me that this will help to prevent further stroke attacks.
Pharmacist:
Are you using it for the first time?
Patient: Yes, I am using it for the first time.
Pharmacist:
So, what did the doctor tell you about the use of the previous
medication along with this new one?
Patient: I dont remember that he mentioned anything.
Pharmacist:
Any other medication that you are using currently?
Patient: No.
Pharmacist:
Any other medical conditions apart form stroke like diabetes, asthma?
Patient: No.
Pharmacist:
According to your profile you have sulfa allergy.
Patient: Thats right.
Pharmacist:
Could you please explain to me the nature of that allergy? I mean was
there short of breath, swelling of lips, rash?
Patient: Yes, there was rash, short of breath.
Pharmacist:
Any other allergy to medication?
Patient: No.
Pharmacist:
To food?
Patient: No.
Pharmacist:
To environmental like hay fever?
Patient: No.
Pharmacist:
Any over the counter medications you are using currently?
Patient: Yes, Tylenol for my headache.
Pharmacist:
Do you use it occasionally?
Patient: Yes, sometime one tablet per week.
Pharmacist:
Any herbal product or vitamines?
Patient: No herbal product but I use Centrum 1 pill per day.
Pharmacist:
Sometimes life style may affect the way the medications work, do you
mind if I ask you do you smoke?
Patient: No I dont smoke.
Pharmacist:
Do you drink alcohol?
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Patient: Yes, I drink two pints of beer every day.

Pharmacist:
Do you eat a well balanced diet?
Patient: Well I dont have time. I mostly eat in restaurants and processed food.
Pharmacist:
Do you have time to practice some physical exercise?
Patient: I do that occasionally.
Pharmacist:
Before I go to my reference book, do you have any question or
concern?
Patient: Just counsel me on my medication.
Pharmacist:
Sure. Thank you for sharing information with you. If you dont mind
I will check in my reference book and I will get back to you.
Notes: This gathering information should not last more than 2.5-3 minutes. Reference
book should not last more than 1-1.5 minutes. So the total time spent till the start of
counselling should be 3.5-4 minutes.
Pharmacist:
Patient: Yes.
Pharmacist:
Thank you for your patience. Sir, your doctor Rxed for you a
medication called Coumadine, it contains warfarin sodium. This
medication is a blood thinner and will help to prevent any further clot
formation as long as you are using it. (Indication) You are going to use
this medication one tablet per day in your mouth with a full glass of
water with or without food. Please avoid abrupt changes in diet, and
dont eat green leafy vegetables, since they may decrease the effect of
the medication. Does that make sense to you?
This medication starts to work within 24 hours. However, the
maximum effect may be delayed 72-96 hours. You should continue
using your medication regularly as directed by your doctor.
(Expectation)
Patient: Ok.
Pharmacist:
Some patients may or may not experience some side effect like
bleeding, if frequently happens or severe, contact your doctor
immediately to adjust the dose or for other assessments. If headache
(use Tylenol), fatigue take some rest. If cold intolerance (protective
clothing). If you experience a dark, purplish color of the toes, contact
your doctor immediately. (Monitoring)
Patient: Does that happen immediately?
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Pharmacist:
It usually occurs between 3-10 weeks or later.
Patient: Ok, I will watch my toes.
Pharmacist:
I can see that you are fat, and its important to reduce your weight by
reducing your calories intake, and physical exercise. Have you talked
to your doctor about that?
Patient: Yes, my doctor told me to reduce my weight and I will try that.
Pharmacist:
Also try to reduce your alcohol to 1 glass of beer and only in
weekends, and your diet should be well balanced diet, avoid Na (dont
say salts, if you say salt, patient might think table salt while he should
avoid or limit sodium in his diet). Dont eat green leafy vegetables too
much, since they reduce the effect of the medications and make it less
effective (addressing life style). With regarding to your aspirin, could
you please tell me if you have done any heart surgery, or of you have
any prosthetic heart valves replacement?
Patient: No.
Pharmacist:
In that case discontinue, you previous aspirin since it is no more
effective because you had a stroke attack and aspirin couldnt prevent
that. Moreover, using it with coumadine will increase bleeding.
(However if the patient has a prosthetic valve replacement or heart
surgery, it is better to tell the patient that I would call the doctor to
confirm with him whether you will be using ASA 81mg along with
coumadine or not.) Do you have any question so far?
Patient:
No, you gave me a lot of information.
Pharmacist:
This is an information sheet about the medication.
Patient: Thank you.
Pharmacist:
Some selfcare measures are good to practice along with your
medication like try to mobilize yourself, and drink plenty of water and
you may use graduated support stocking to prevent any clot formation
in your ankle or leg. Dont forget to keep your appointments with
your doctor and to do the blood work.
Patient: Thank you. I will do that.
Pharmacist:
If you dont mind I will call you within 5 days to see if there is any
side effect like bleeding and I will call you every 2weeks at the
beginning of therapy to see how well you are doing with your new
medication. Thank you for coming in. Have a nice day.
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Case: 2
John Rex Age=50 years
Rx
MS contin 60mg tablet 20tab
MS IR 10mg tablet
40tab
1x2
1tab PRN Q6H
Pharmacist:
Hi my name is (
), I am the pharmacist in duty today. How may I
help you sir?
Patient:
I am here to pick up my Rx (if he complains from pain at this moment
from his appearance, or is bothered some, express your empathy like
you have been through a lot of pain), otherwise express empathy after
questioning him and reveals his pain.
Pharmacist:
Please have your seat. Or this is a private area. (Privacy)
Patient: Thank you.
Pharmacist:
Is this Rx for you? (Identifying the patient)
Patient: Yes for me.
Pharmacist:
In order to help you better, I would like to ask you a few questions. Is
that ok for you sir?
Patient: Sure.
Pharmacist:
I would like to reassure you that whatever information I gather will
Patient: Thanks.
Pharmacist:
What did the doctor tell you this medication is for?
Patient:
He told me it is for my wrist pain, which was broken when I fell on it
during a hockey game yesterday morning.
Pharmacist:
Oh, that must be hard for you.
Patient: Yes, it is really hurting me a lot.
Pharmacist:
Patient: Yes, I am using it for the first time.
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Note: Always these two questions are asked when you receive a new prescription
1. What did the doctor tell you this medication is for?
2. Are you using it for the first time?
If there is a profil, go through the profile and ask then the above two questions as in
case 1.
Pharmacist:
Patient: No.
Pharmacist:
Patient: No.
Pharmacist:
Patient: No.
Pharmacist:
Patient: No.
Do you have any medical condition apart from this pain like diabetes
or asthma?
Do you have any allergy to medications?
To food?
To environment like hay fever?
Note: Dont say all together. Do you have allergy to food and medications? Say it one
by one because the patient can not answer more than one question, so be patient with
the patient.
Pharmacist:
Any Rx medications apart from this?
Patient: No other prescription medication.
Pharmacist:
Any over the counter medication like Tylenol?
Patient: No.
Pharmacist:
Any herbal product?
Patient: No.
Pharmacist:
Sometimes lifestyle may effect how the medication works. Would you
mind if I ask you do you smoke.
Patient: No.
Pharmacist:
Do you drink alcohol?
Patient: Yes, I drink of alcohol at night everyday.
Pharmacist:
Do you eat balanced diet?
Patient: Yes.
Pharmacist:
It seems to me you are a sportsman.
Patient: Yes, I am a hockey player.
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Pharmacist:
Before I go to my reference book, do you have any question?
Patient: Just counsel me on my medications.
Pharmacist:
Sure I do. Thank you for sharing the information with you. Please
give me a few minutes to check in my reference book.
Thank you for your patience sir, your doctor has prescribed two
medications for you.
One is called MS contin which contains
morphine sulphate that has a prolonged action, which you are going to
take it as one pill in the morning in your mouth, and make it 12 hours
a part with full glass of water. It is important sir that not to chew or
crush the tablet and you may take them with or without food. The
other medication sir that your doctor prescribed for you is the same as
the first one, however it acts rapidly, and therefore the first doses of
these two medications should be taken simultaneously, since the first
medication MS contin will take sometime (a few hours) till it works,
and therefore the MSIR could be used simultaneously to cover the
time till the first medication starts to work. The 2nd medication is
taken by mouth, with or without meal, with glass of water. Then the
2nd medication which is MSIR is taken afterward in just in case if you
have a break through pain which mostly occurs before your next MS
contin dose. Make sure ir that when you take the MS IR pills, you
should space apart 6 hoursbetween the MS IR pills. These pills will
help to relief your pain (indication), and as far as you are taking them,
you will not experience any pain (expectation). If you see yourself
that you are using the immediate release form more frequently and
more than instructed by your doctor, then it is important in that case to
call your doctor, he might increase the dose of your first medication
MS contin, and you may not need the MSIR on the breakthrough pain
dose (monitoring). Does that make sense for you?
Patient: Yes it does.
Pharmacist:
You may or may not experience some side effect like constipation
(increase fibre in take like whole grain or bran or you may use a
laxative). You may feel sedated or groggy so dont drive a car while
you are using this medication, and take care when you change your
position from lying down to standing up. If you feel nausea and
vomiting, then use it after food. In case these signs and symptoms are
severe, then repeat that to your doctor. (Monitoring)
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Notes: Mentioning withdrawal symptoms after discontinue is optional and the

medication should be tapered.
Pharmacist:
In case if you see any visual disturbance which is rare then contact
your doctor.
Patient: Ok.
Pharmacist:
Store it at room temperature.
Patient: Ok.
Pharmacist:
Is there any question so far?
Patient: No, thanks.
Pharmacist:
Some self care measures are important to be practiced along with your
medication like take some rest, and for the first day use cold
compresses, then after 24-48 hours use hot compressers. Elevate your
wrist above the heart to reduce edema.
Patient: Ok, I will do that.
Pharmacist:
If you dont mind, I will call you after three days to see if you are
experiencing any side effect like sedation, and after one week to see if
there is any improvement.
Patient: Ok.
Pharmacist:
Thank you for coming in. Have a nice day.
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Case: 3
Name: John Smith
Age: 45 years old
Doctor: James Glaxo
Rx
Uremox 100mg tablet, one tablet. single dose
On the table
Combination of different dosage forms
Piperative Syrup
Pyranted Rammocte Syrup.
Pharmacist:
Hello, my name is (
). I am the pharmacist in duty today. How
may I help you?
Patient: Im here to pick up my prescription.
Pharmacist:
This is a private counselling area. Please have your seat. (Privacy)
Patient: Thank you.
Pharmacist:
In order to help you better, may I ask you a few question?
Patient: Sure.
Pharmacist:
Patient: Yes, it is for me.
Pharmacist:
I would like to reassure you whatever information I gather will remain
confidential. (Confidentiality)
Patient: Thank you.
Pharmacist:
What did the doctor tell you this medication is for?
Patient:
He told me that this medication is for my pin worm, I have some kind
of itchiness and some stomach pain.
Pharmacist:
Oh, you must have been in quite a bit of discomfort. (Empathy)
Patient: Oh, yes. Pin worm are bothering me.
Pharmacist:
Patient: Yes, for the first time.
Note:
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1. When you gather the information now, and because the case is about pin worm, then
the student should ask MAMA not only for the patient but all other family member
so that not to lose time, and ask them back again.
2. Because the doctor is prescribing it for him only and not for other family members,
then we can anticipate that this case is not a resistant case, otherwise the doctor
would have prescribed this medication to all family members.
3. We must provide OTC medication against pin worm to other family members, and
to start treatment the whole family simultaneously to avoid reinfection.
4. Calling the doctor to prescribe other family members, Uermox is not needed since,
there is other OTC available.
5. Doctor prescribed Uremox, since he diagnosed the pin worm, and he has been
infested. It is an Rx medication, and the pharmacist can recommend the OTC for
pinworm.
6. If the patient said that I used pyrautel previously several times, or pinworm is
frequently occurring to him. In that case, it is important to call doctor for Rx
uermox to all other family members.
Pharmacist:
Patient:
Pharmacist:
Patient:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
How many family member, are you?

We are three; me, my wife and my 6 year old son.
He is 35 kg weight and my wife is 70kg.
Is your wife pregnancy?
No.
Do all family members have any medical condition?
No.
Do all family members have any allergy to medications?
No.
To food?
No.
To environment like hay fever?
No.
Does any family member use an OTC like Tylenol or vitamine?
Sometimes my wife uses Tylenol occasionally.
Does any family member use herbal product?
No.
Pharmacist: With regard to life style, do you and your wife smoke, drink alcohol, how
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Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
OSCE TI PS
about diet, exercise?

Thank you for sharing information with you. Please give me a few
minutes to check in my reference book.
Ok.
Thank you for your patience. Your doctor has prescribed for you Uremox
which contains mebenduzole. This medication will help and in your pin
worms. (Indication) You must chew the tablet and you can take it with or
without food in the morning. This medication is going to kill the pin
worms, however since reinfection may be frequent, then it is important to
repeat it after 2 weeks to eradicate the pin worm. (Expectation) Does that
make sense to you?
Yes, it does.
You may experience some side effect like nausea, vomiting and diarrhea,
and in that case take it with food. Sometimes you may experience
headache (take Tylenol). Also you may experience dizziness. In that case,
slowly change your position from lying down to sitting position or
standing position. In rare conditions, sometimes rash, short of breath and
swelling of lips will take place. If that happens, contact your doctor
immediately.
Ok.
Because pin worms are conditions, I recommended all family members
should be treated. I have here combantrin in different dosage forms and I
have also piperazine which is also effective in treatment of pin worms,
which medication and dosage form they like.
Anything you recommend.
Note: If patient says why the doctor didnt Rx Uermox for them and insists on that. In
that case, tell him I will call the doctor for that. (Doctor may fax or Rx verbally
Uremox)
Pharmacist: I recommend syrup combantrin, it contains 45ml which is sufficient for
your wife and your son. Your wife is going to use 20mg and your son
10ml. Just shake it before use, and start all of you using medications at
the same time to prevent reinfection. Side effects are almost similar to
your medication, and manage them as I told you.
Patient:
I will do that.
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Pharmacist: Do you have any question so far?

Patient:
No thanks.
Pharmacist: Some self care measures are important to be practiced along with the
medication like;
1. Wash your hand frequently
2. Cut your finger nails
3. Change under wear everyday
4. Wash the clothes with hot water and soap
Patient:
Ok.
Pharmacist: If you dont mind, I will call you after 3 days to manage any side effectct
like dizziness and I will call you after 2 weeks to see the improvement in
your pin worms.
Patient:
Ok.
Pharmacist: I will give you this information sheet about Uremox since you are using it
for the first time. Also I will give you information sheet about conbantrin.
Patient:
Thank you.
Pharmacist: Thank you for coming in. Have a nice day.
Case: 4
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A patient comes to pick up his prescription for his stomach ulcer. He has stomach upset
and hyperacidity. The Rx is ready for pick up. Counsel him as you do in your
pharmacy.
On the table: Famotidine (pepcid AC 10mg), Zantac75mg tablet, Tums, Gaviscon tablet,
Maalox susp.
Rx
Patient profile
HP-PAC 1x2 for 14 days
Patient: John Smith
Age: 40 years
Allergy: Unknown
Medications: Tagamet 200mg tablet 1x2 since 1 month ago
Pharmacist: Hi, my name is (
). How may I help you?
Patient:
I am experiencing stomach pain, and my doctor prescribed some
medications for me.
Pharmacist: Oh, you must have been in a quite a bit of discomfort. (Empathy)
Patient:
Yes, a lot of discomfort.
Pharmacist: Why dont you have your seat?
Patient:
Thank you.
Pharmacist: Is this Rx for you sir? (Identifying the patient)
Patient:
Yes.
Pharmacist: In order to help you better, may I ask you a few questions?
Patient:
Sure.
Pharmacist: I would like to reassure you that whatever information I collect will
Patient:
Thank you.
Pharmacist: Would you mind if I check your profile?
Patient:
Sure.
Pharmacist: According to your profile, you are using Tagamet 20mg. Are you still
using it?
Patient:
Yes.
Pharmacist: How many times?
Patient:
Twice a day before meal.
Pharmacist: Are you using it regularly?
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Patient:
Yes.
Pharmacist: So, what happened recently that made your doctor prescribed this
medication for you?
Patient:
Well, I had vomiting with streaks of blood, and severe pain and stomach
upset.
Pharmacist: That must be hard for you. (Empathy)
Patient:
Yes, it was really hard.
Pharmacist: What did the doctor tell this new medication is for?
Patient:
He told me that this will help to relieve my stomach ulcer.
Pharmacist: Are you using it for the first time?
Patient:
Yes.
Pharmacist: So, what did the doctor tell you about the use of the previous medication,
along with this new one?
Patient:
I dont remember that he told me anything.
Pharmacist: Beside Tagamet, are you using any other Rx medications?
Patient:
No.
Pharmacist: In addition to stomach ulcer, do you have any medical condition?
Patient:
No.
Pharmacist: Do you have any allergy to update your profile for any medication.
food. environment like hay fever?
Patient:
In each question, he says no.
Pharmacist: Are you using any herbal product. over the counter medication like
aspirin or Tylenol, any multivitamine?
Patient:
No for each question.
Pharmacist: Sometimes life styles affect the way, the medication works. May I ask you
if you smoke?
Patient:
No.
Pharmacist: Do you drink alcohol?
Patient:
Once per month.
Pharmacist: Do you eat well balanced food?
Patient:
Yes, I follow the Canadian guidelines for healthy eating but I sometimes
eat on the run.
Pharmacist: Do you have time to do any physical exercise?
Patient:
Yes, I do 3-4 times per day for an hour.
Pharmacist: Before I go to my reference book, do you have any concern or question?
Patient:
Just gove me the medication, counsel me, and should I continue the
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Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
OSCE TI PS
previous medication along with this one or not.

Sure, I will tell you everything after I look in my reference book. Thank
you for sharing the information with you sir. Please give me a few
Thank you.
Thank you for your patience. First of all and because you told me that
now you have some stomach upset and hyperacidity. I would like to give
you an over the counter antacid to help lessen your signs and symptoms
now. We have different dosage forms of antacid, which one do you
prefer?
Thank you for your help; anything that you think, it will resolve my
stomach upset now.
Tums are good. You can chew one or two tablets now. They work
immediately within 15 minutes. They help lessen your stomach upset, till
you use, your prescription medication.
Thank you.
Your doctor has Rxed for you HP-PAC. It contains lansoprazoleclarithromycin and Amoxycillin. These three medications will help to
eradicate the bacteria that are called H pylori that are causing this stomach
ulcer, and will help to prevent recurrence (Indication). You see the blister
pack; it contains 2 opaque pink capsul. You take one in the morning and
the other at night, 12 hours apart, in your mouth with a full glass of water.
Dont chew or crush the capsule. Also you see these two yellow tablets.
Take it as you take the capsule twice daily. However you can use them
with or without meal. You have also in this blister 4 opaque, scarlet and
yellow caps. So you take two in the morning with the other previous
medications i.e. 12 hours apart with or without food. So everyday you are
going to take four pills in the morning (3 capsuls and 1 tablet) and four at
night. Does that make sense to you?
Yes, everyday 4 in the morning and 4 at night.
You should take 2 packs; use them regularly for 14 days.
After 1 week, I will come to pick up my refill.
You should see maximal relief in your signs and symptoms like pain,
vomiting and bleeding after fourteen days. However before that you may
see some improvement and also you may use the Tums along with this
medication concomitantly if you need it. (Expectation)
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Patient:
Thank you.
Pharmacist: You may or may not experience some side effect like with opaque cap like
headache (use Tylenol), dizziness (slowly change your position from lying
down to standing up). With the other two i.e. the pill and the capsule, both
of them you might experience nausea, vomitin and diarrhea. So in that
case take them after meal. In rare conditions, an allergic reaction may
occur but this is very rare, like rash, short of breath and lowering in your
blood pressure. If that occurs, discontinue the medication and contact
your doctor immediately. (Monitoring) According to your profile,
(discontinue Tagamet) because it has no added benefit to your current
regimen. (There is no need to call the doctor for that, and this applies for
all H2RA and PPI. However you can say, after the treatment i.e. after 14
days, your doctor may put you on this medication or on another
medication or not at all; so you can discuss with your doctor before you
finish the two packs, or you can call me to discuss that with your doctor)
Do you have any question so far?
Patient:
No thanks, you provided me with efficient information.
Pharmacist: Some self care measures are important to be used along with the
medication, like avoiding any triggering diet that worsens the signs and
symptoms. Keep on your healthy diet, but remember that coffee, orange
juice, spicy foods, fatty foods, large meals or eating on the run may
provoke these signs and symptoms. Keep your appointment with your
doctor.
Patient:
Yes, my next visit is after two weeks.
Pharmacist: If you dont mind, I will call you after 3 days to manage any side effect
like vomiting (Dont say to see if there is and side effect but say to
manage any side effect.). I will also call you after two weeks to se the
improvement in your stomach ulcer.
Patient:
No problem.
Case: 5
Patient comes with a new Rx. She has severe acne. The Rx is ready for pick up.
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Counsel her as you are in your pharmacy.

Name: Jean Carl
Age: 20 years
Doctor Gaucher
Patient Profile
Tricyclen 28 tablet 1x1
Benzpyl gel 4% Apply 1x1 at night
Allergy: Unknown
Rx
Diane-35 1x1
Refills: 3
), I am the pharmacy in duty today. How may I help
you?
Patient:
Pharmacist: This is a private area, please have your seat. (Privacy)
Patient:
Thank you.
Pharmacist: Is this Rx for you? (Identifying the patient)
Patient:
Yes, for me.
Patient:
Ok.
Pharmacist: I would like to reassure that whatever information I collect, will remain
Patient:
Thank you.
Pharmacist: What I did the doctor tell you, this medication is for?
Patient:
It is for my severe acne which is bothering me a lot.
Pharmacist: I can see you are concerned about that, and you are in a quite a bit
discomfort. I will try my best to help you Jean. (Mention the name)
(Empathy)
Patient:
Thanks.
Pharmacist: Would you mind to check your profile?
Patient:
Sure.
Pharmacist: I can see in your profile you are taking Tri-cyclen-28 is it to prevent
pregnancy?
Patient:
Yes, I use this medication as an oral contraceptive.
Pharmacist: I also can see you are using Benzoyl gel. Are you still using it?
Patient:
Yes, I am using it still, but I couldnt find any benefit from it, and thats
why I went to my family doctor.
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Patient:
Yes, I do.
Pharmacist: So, what did the doctor tell you about the use of tri-cyclen and Benzoyl
gel along with this new medication?
Patient:
I dont remember. He told me sometimes, but I forgot.
Pharmacist: Are you using this medication for the first time.
Patient:
Yes.
Pharmacist: Are you using any other Rx medication beside these?
Patient:
No.
Pharmacist: Do you have any medical condition like asthma or diabetes?
Patient:
No.
Pharmacist: Do you have any allergy to medical.food.. environment?
Patient:
No. No. No.
Pharmacist: Any over the counter medication beside benzoyl gel?
Patient:
Sometimes Tylenol, on need basis.
Pharmacist: Any herbal product. multi vitamin?
Patient:
No. No.
Pharmacist: Are you pregnant or planning to be pregnant?
Patient:
No, I have just done my pregnancy test and it was negative.
Pharmacist: Do you breast feed?
Patient:
No.
Pharmacist: Do you drink alcohol. smoke?
Patient:
No. No.
Pharmacist: How is your diet?
Patient:
I eat spicy food, I like it. I also eat sweets.
Pharmacist: Do you have time to practice physical exercise?
Patient:
Yes, I do that 5 days a week for 1 hour.
Pharmacist: Thats great.
Patient:
Thank you.
Pharmacist: Before I go and check my reference book, do you have any question or c
concern?
Patient:
Yes, should I continue use my Benzo-gel and my Tri-cyclen?
Pharmacist: Sure, I will tell you about that after I check in my reference book. Thank
you for sharing information with you. Please give me a few minutes to
check in my reference book.
Patient:
Sure.
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Pharmacist: Thank you for your patience.

Pharmacist: Jean, your doctor has Rxed for you Diane 35 which contains cyproterone
acetate and Ethinyl estradiol. This medication will help treat your severe
acne. You are going to take one pill each day at the same time for 21 days,
in your mouth, with or without meal with a full glass of water. But make
sure to take it everyday at the same time for 21 days beginning on the 1 st
day of your menstrual cycle. Withdrawal bleeding occurs during the off
period, which means after your period 4 days. You begin taking your
tablet 7 days after discontinue, regardless of whether or not withdrawal
bleeding is still progress. If you miss a menstrual period, or suspect
pregnancy, medication should be discontinuing. Does that make sense to
you?
Patient:
Yes, that makes sense to me.
Pharmacist: Treatment should be continued for several months since improvement may
not be seen with 4 to 5 cycles after signs have completely resolved.
Patient:
Ok.
Pharmacist: Some some effect you may or may not experience like headache and
breast tenderness (Tylenol use), spotting (this goes away with continued
use), nausea and vomiting (after meal take it), and in case of dizziness
(postural change do it carefully). In rare conditions, you might see pale
stools, this is very rare, if that happens contact your doctor immediately.
(Pale stool which is a sign of hepatitis, elevation in blood pressure, severe
headache which could be due to clot formation, visual disturbance,
migraine and vaginal bleeding, all these are side effect and precautions of
oral contraceptives and hormonal replacement therapy so the student
should memorize them in advance).
Patient:
Ok.
Pharmacist: It is important to discontinue Benzo-gel, since, it has no benefit and also
discontinues, Tri-cyclen-28tablet, since Diane can act as anti acne and
prevent pregnancy at the same time. If you miss any dose, call me and I
will tell you what to do. (Dont call the doctor)
Patient:
Ok.
Pharmacist: This is an information sheet about your medication.
Patient:
Thank you.
Pharmacist: Some self care measures are important to practice along with your
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medicationlike,
1. Avoid oily based make up and use non-oily ones.
2. Dont remove up roof of your blister to avoid 2-infection.
3. Dont squeeze your pimple.
4. Tie your hair to the back to avoid any irritation to the face.
5. Avoid foods that trigger your acne. For example, if spicy food and
pasties or sweets exacerbate your acne, then try to avoid them.
Patient:
Ok, I will do with your advice.
like headache and I will call you after 2 weeks to look for any
improvement in your acne. (Follow up)
Patient:
Ok.
Pharmacist: Thank you for coming in, have a nice day.
Case: 6
Patient- Katty Mark
Age: 35 years old
Patient profile
Unknown
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Pregnant
He comes with a new Rx for depression, and he requests an OTC medication. Counsel
him for his new Rx and solve her concern.
Rx
Effexor XR 37-5 mg 1x1
Mitt: 30 tablet
Refills (3)
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Hi, my name is (
). I am the pharmacy in duty, how may I help you?
Hi, I am here to pick up my prescription. My mood is down nowadays.
Oh really, that must be hard for you. (Empathy)
Yea, it is bothering me a lot.
This is a private area. Please have your seat. (Privacy)
Thank you.
Yes, it is for me.
In order to help you better, may I ask you a few questions?
Sure.
I would like to reassure you, that whatever information I gather will
Thats great.
Ok, Katty, what did the doctor tell you this medication is for?
He told me it may help to control my mood swinging.
Sure, it does and are you taking it for the first time?
Yes.
Besides, mood swinging, do you have any medical condition like diabetes
or asthma?
No.
In addition to this medication are you using any Rx medication?
No.
Any non-Rx medication. herbal product. vitamin?
No. No. No.
Sometimes life style may affect the way the medication work, may I ask
you if you smoke. Alcohol. Diet. physical exercise?
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Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
OSCE TI PS
No smoke. 1 glass of wine everyday at night. eating too much. no

physical exercise.
May I ask you a personal question? Are you pregnant, or planning to be a
pregnant?
Yes, I am pregnant.
Congratulation.
Thank you.
In which month are you pregnant?
Three months.
Have you told your doctor about pregnancy?
Yes, I told him.
Before I go and check in my reference book, do you have any concerns or
questions?
Yes, I do. Could you please tell me is the medication compatible in
pregnancy, and also I have a dry cough and I want you to give me the big
bottle of Benylin Syrup.
Ok, Katty I will give you the Benylin after I check in my reference book.
This also applies to your concern about the use of your medication in
pregnancy. So thank you for sharing information with you. Please give
me a few minutes to check in my reference book.
Sure.
Thank you for your patience. Ok, Karry, with regard to your request of
Benylin Syrup for your dry cough. I dont recommend to give you
Benylin, since this medication contain a substance called
dextromethorphan which interacts with your medication Effexor
resulting in rise in your body temp, increase in rigidity, profused sweating,
irregularity in blood pressure, and rapid heart rate. So please dont use
Benylin. Because the importance of your Rx medication to treat your
mood swinging which is our objective, I recommend not to use any cough
syrup to prevent the drug-drug interaction, and you can drink water only, it
may help to reduce your cough. Also inhaling water vapour will help to
soothe your cough. With respect to the use of medication in pregnancy.
Definitely, your doctor outweighed the benefits against the risk when he
prescribed to you this medication. More over, untreating conditions of
mood swinging affect your health, in addition to the health of your child.
You may deliver the baby in a prematured time, under weight, and may be
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some defects in his body organ, if you dont treat yourself. In addition, it
is very hard for a depressed lady to interact with her child after delivery, if
not treated. More over, the statistics shows, high percentage of healthy
new born, children were delivered from people using this medication, in
comparison with healthy women that are not using any medication.
Note: Always solve al the concerns as we did above before counselling the patient.
Pharmacist: Does that make sense to you?
Patient:
Yes, it makes sense to me.
Pharmacist: Ok, Katty, your doctor Rxed to you Effexor XR which contains
Venlafaxine. This medication will help solve your mood swinging and
control your appetite since you told one you eat too much. You are going
to use this medication as one cap by mouth in the morning regularly
everyday swallow whole, dont chew or crush the capsule with a full glass
of water and use it with or after meal. (Administration) Does that make
sense to you?
Patient:
Yes, it does.
Pharmacist: You should see improvement in your control of appetite after two weeks.
However optimal effect i.e. control of your mood swinging after 4-6
weeks. (Expectation) Is that ok?
Patient:
Ok.
Pharmacist: You may or may not experience some side effect like nausea, vomiting
and diarrhea (if you can not tolerate that, contact your doctor). If you
experience headache (take Tylenol). If you experience dry mouth (you
can suck on a candy). If you have any bad thoughts or thoughts of give
up, contact your doctor immediately (precaution). You told me you eat
too much, this should be improved as you continue using the medication
regularly. You should see improvement in your appetite. Also, eat more
fibre and reduce your calorie intake and do physical exercise like walking
or jogging. So that to control your weight and counteract too much eating
by burning the calories that you take (Addressions and life style). Store
your medication at room temperature. (Store)
Patient:
Ok I will do that.
Patient:
No thanks.
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OSCE TI PS
Pharmacist: Some self care measures are important to be followed along with the
medication:
1. Increase your lesure time
2. Enjoy your hobbies
3. Increase your vacationing time
4. Warm showers and listen to music
5. Relaxation exercises like yoga
Patient:
I will do that
Pharmacist: If you dont mind I will call you after 3 days to manage any side effect
like vomiting and after 6 weeks, to see the improvement in your condition.
Within this time feel free to call me any time, you like.
Patient:
Thanks. You did a lot of good thing with me.
Pharmacist: This is our job, thank you for coming in. Have a nice day.
Case: 7
Name: Jean Kimbel
Age: 30 years
Doctor Smith (Gynecologist)
Patient profile
Comid 50mg tablet 1x1 for 5 days
Unknown
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Rx
Clomid 100mg tablet
1x1 for 5 days
Pharmacist: Hello, my name is (
), I am the pharmacy in duty today, how may I help
you?
Patient:
I am here to pick up my prescription.
Pharmacist: This is a private area. Please have your seat. (Privacy)
Patient:
Thank you.
Pharmacist: Is this Rx for you Jean. (Identifying the patient)
Patient:
Yes, it is for me.
Pharmacist: I can see you are concerned about your medication, and I will try my best
to help you. (Empathy)
Patient:
Thank you.
Pharmacist: In order to help you better may I ask you a few questions?
Patient:
Sure.
Pharmacist: I would like to reassure you that whatever information I collect, will
Patient:
Thank you.
Pharmacist: What did the doctor tell you this medication is for?
Patient:
My doctor told me this will enhance ovulation and make me pregnant.
Pharmacist: Ok, are you taking it for the first time?
Patient:
Yes, for the first time.
Pharmacist: I can see from your profile, you used a lower strength of this medication
which was 50mg tablet. Am I right?
Patient:
Yes, you are right, I used the 50mg and it wasnt effective and so my
doctor told me to use the 100mg now.
Pharmacist: Have you used any Rx medication beside that?
Patient:
No.
Pharmacist: Do you have any medical condition like diabetes or high blood pressure?
Patient:
No.
Pharmacist: Do you have any allergy to food. medication. environmental?
Patient:
No. No. No.
Pharmacist: Do you use any over the counter medication. herbal products.
vitamine?
Patient:
No. No. No.
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Pharmacist: Life style; ask for alcohol, smoking, diet, and exercise.
Patient:
Ok with life style.
Pharmacist: Before I go and check in my reference book, do you have any question or
concern?
Patient:
Yes, I was wondering if this medication can cause multiple pregnancies.
Pharmacist: I will check that in my reference book and I will tell you about it.
Patient:
Thank you.
Pharmacist: Thank you for sharing information with you. Please give me a few
Note: Solving the concern first.
You asked me mum about multiple pregnancies. I checked in my reference book, that
the incidence of multiple pregnancies (2, 3, only) is high when clomid is used. I
appreciate your interest that, and it is your decision whether to take it or not.
Patient:
Ok, I will take it. I have no children.
Pharmacist: Have you repeated your pelvic examination before taking the 2 nd course of
treatment?
Patient:
Yes, I did that, and it was normal.
Pharmacist: Thats great. Ok mam, your doctor Rxed to you Clomid which contains
clomiphen citrate. This medication will help induce ovulation and you
may be pregnant (indication). Do you have menstruation or not?
Patient:
Yes, I have menstruation.
Pharmacist: So, you are going to use this pill by mouth with a full glass of water with
or without food, staring from the 5th day of your cycle for consecutive
days (administration). In most patients, ovulation appears to occur from
6-12 days after completion of therapy, where coitus/ intercourse everyday
or every two days is greatly important (expectation) follow your basal
body temperature. If you record a sudden rise i.e. recording two different
body temperature, which indicates occurring of ovulation and if you dont
have menses after that, these are signs of pregnancy, and it is important to
do pregnancy test, to make sure you are pregnant, and also is of benefit so
that not to start the third subsequent course without excluding pregnancy.
Does that make sense to you?
Patient:
Yes, it does.
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Pharmacist: Some patients may or may not experience some side effect like headache
(Tylenol), back pain (Tylenol), anxiety (increase your relaxation time). In
rare conditions visual defects may occur (so dont drive your car) and if it
is severe discontinue medication and contact your doctor. Do you have
any question so far?
Patient:
Can I repeat the course several times or can my doctor prescribe to me a
higher strength, in case if I dont be pregnant?
Pharmacist: No, your doctor cannot increase the dose more than 100mg and it should
not be beyond 5 days because it causes some bad outcomes to your health.
Also the course of treatment is 3 courses only and of you dont get
pregnant, your doctor will do further more investigations and assessments
to know the reason.
Patient:
Thank you for this information.
Pharmacist: Some self care measures are important
1. Healthy diet starting from now because of possibility to be
pregnant
2. Physical exercise
3. Keep your appointments with your doctor.
4. Dont use it beyond 5 days
Patient:
Thank you.
Pharmacist: If you dont mind I will call you after 5 days to manage any side effect
like back ache and I will call you after 1 month to see the effect of the
medications.
Patient:
Ok, you can call me.
Case: 8
Patient name: Chad Russel
Patient profile
Rx
Eryc (Erythromycin) 333
Glis (Tadalafil) 10mg
1x1 for 14 days
Sig. 1tb/prn/od
Diabeta (Glyburide) 5mg
Mitte: 3blisters x 4
(1) t.i.d.
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Refills: (3)
OSCE TI PS
Age: 47years
Gender: male
Allergy: Unknown

), I am the pharmacist in duty today, how may I help
you?
Patient:
Pharmacist: Ok, sir, this is a private area, please have your seat. (Privacy)
Patient:
Thank you.
Pharmacist: Is the Rx for you? (Identifying the patient)
Patient:
Yes, for me.
Patient:
Sure.
Pharmacist: I would like to reassure you whatever information I collect will remain
Patient:
Thank you.
Pharmacist: If you dont mind Chad I would like to check first your profile, is that ok
for you?
Patient:
Sure.
Pharmacist: I can see that you are using Eryc, could you please tell me why you are
using it?
Patient:
I am using it because I have infection in my respiratory system.
Pharmacist: Are you using it 4 times daily?
Patient:
Yes.
Patient:
Yes.
Pharmacist: I can see you are using Diabeta, twice daily.
Patient:
Yes, I had diabetes since 10 months ago.
Patient:
Yes.
Pharmacist: You must have been in quite a bit of discomfort (Empathy) due to your
infection and controlling your diabetes.
Patient:
Yes, what one can do?
Pharmacist: So, could you please tell me what happened recently that made your
doctor prescribe this new medication for you?
Patient:
Well, I have some sexual weakness.
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Pharmacist: That is common among diabetic people. (Empathy) Are you using it for
the first time?
Patient:
Yes.
Pharmacist: When are you planning to take it? (This question is very important to
avoid any drug-drug interaction between Tadalafil which is a substrate of
CYP450 3A4 and Ery which is enzyme inhibitor of 3A4).
Patient:
My doctor told me to use it on need basis.
Pharmacist: I will tell you when to use it after I check in my reference book.
Note: You can address or answer the question or any concern if you are quite sure from
the answer. Otherwise it is better to check in the reference book before you answer or
address any concern or question.
Patient:
Ok.
Pharmacist: Any other medical condition beside that. any other Rx medication
beside that?
Patient:
No. No.
Pharmacist: Any known allergy to drug. Food. environment?
Patient:
No. No. No.
Pharmacist: Sometime lifestyle may affect, the way the medication work may I ask
you if you smoke. Alcohol. Diet. exercise?
Patient:
No smoking. 2 glasses of wine everyday. diet, I follow the
instructions of my doctor regarding diet and exercise because I am
diabetic.
Pharmacist: Ok sir. Before I go and check in my reference book, do ou have any
question or concern?
Patient:
Just counsel me on the use of this medication.
Pharmacist: Sure, thank you for sharing the information with you. Please give me a
few minutes to check in my reference book.
Patient:
Sure.
Pharmacist: Thank you for your patience. Your doctor has Rxed to you, Cialis which
contain Tadakafil 10mg, this will help in enhancing the erection of the
penis (dont say your penis) (indication). Cialis has been shown to be
effective within 30 minutes of taking the tablet, and up to 36 hours later.
Patients may start sexual activity at any time relative to dosing.
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Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
OSCE TI PS
(Expextation) Sir, because there is a drug-drug interaction between Eryc

that you are using it and Cialis, I prefer to end up your Eryc medication
then start to use Cialis avoid any augmentation in side effect like dizziness
and lowering in your blood pressure and flushing.
Ok.
So how many days are left to finish your Eryc?
I have been using it since 10 days ago.
Ok, then continue for 4 days i.e. till you finish your antibiotic and after 24
hours start taking Cialis if you need it.
Ok.
You are going to take only one pill prior to anticipate sexual activity. It
may be taken with or without food in mouth with a full glass of water.
Dont take more than one tablet per day as it is recommended by your
doctor. Avoiding grapefruit juice since it increases the conc. of Ciais an
augment, the side effect. Does that make sense to you?
Yes, it does.
You may or may not experience some side effect like headache (use
Tylenol), body pain (Tylenol).
Flushing (avoid alcohol and hot
beverages). In rare case you may experience persistent erection for more
than 4 hours. If that happen, and sometimes it happens in rare cases,
contact your doctor immediately. (Precausion)
Ok.
Store it at room temperature (Storage), not in bathroom away from
children.
Ok.
You told me, you drink alcohol, two glass of wine everyday.
Yes.
Pharmacist: I would like to tell you Mr. Russel, that alcohol consumption may
decrease the ability to attain an erection and may also temporality
decrease blood pressure. Cialis may augment the blood-pressure lowering
effect of alcohol. So it is important to use alcohol while you are using
Cialis. (Addressing the issues)
Patient:
Ok, I will do that.
Patient:
You were generous with me about providing me with your information.
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Pharmacist: It is important to use condom to avoid any sexually transmitted diseases.

Also it is important not to use nitro glycerine with this medication. Keep
controlling your diets and dont forget your doses of the antibiotic and of
Diabeta. Keep your appointments with your doctor. (Self care measures)
Patient:
Thank you.
Pharmacist: IF you dont mind, I will call you after a week to manage any side effect
like dizziness and to see the improvement in your infection. Feel free to
call me anytime you like.
Patient:
Ok, you can call me anytime you like.
Case: 9
Name of patient: Amita Clark
Age: 40 years
Doctor: S. Wilson
Gender: Female
Allergies: Penicillin
Comments: Schizophrenia
Rx
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Ativan 2mg PO
1tab/t.i.d.
Mitt: 30
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
OSCE TI PS
Zyprexa Zydis 10mg tablet

sig 1 tablet/OD
Mitt: 30
Hi, my name is (
), how may I help you?
I am here to ick up my Rx.
Thank you.
Is this prescription for you mum? (Identifying the patient)
Yes, it is for me, I am experiencing some kind of aggressive behaviour and
bad thoughts and my doctor Rxed this for me.
Oh really, that must be hard for you. I can see that you are a little bit
bothered. (Empathy)
Yes, I am really frustrated.
In order to help you better may I ask you a few questions?
Sure.
Thank you.
You said your doctor Rxed for you these medications for your some
strange behaviour. Is that correct? (Confirmation the diagnosis)
Yes.
Are you using them for the first time?
Yes.
Beside, strange behaviours, do you have any medical condition, like
asthma or diabetes?
No.
Beside these medications, do you have any medical conditions?
No.
Do you have any allergy to a medication?
Yes, to Penicillin.
Could you please tell me the nature of that reaction?
Rash, swelling, short of breath.
Are you using any non-Rx medication. any herbal product. any
vitamin?
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Patient:
Pharmacist:
Patient:
Pharmacist:
No. No. No.

Is there any chance to be pregnant or planning to be pregnant?
No.
Sometimes life style may affect, the way the medication work, may I
know if you smoke.. Alcohol. Diet.. Physical exercise?
Patient:
No smoke. 1 glass of wine everyday. eat on the run. no physical
exercise.
Pharmacist: Before I check in my reference book, do you have any question or
concern?
Patient:
When should I take both medications?
Pharmacist: Sure I will counsel you after I check in my reference book. Thank you for
sharing information with you. Please give me a few minutes to check in
my reference book.
Patient:
Sure.
Amita, your doctor has prescribed two medications for you, one is called
Ativan 2mg which contains Lorazepam which works quickly to calm your
condition, till the other one will which is Zyprexa Zydis tablet
(olanzepine) works. Ativan is quicker in its action than Zyprexa Zydis.
Both of them will help to control your strange behaviours like bad
thoughts, aggressiveness and your withdrawal from society. You should
see some improvement in your sleep pattern and appetite after 2 weeks.
However maximal effect of controlling your strange behaviours and bad
thought may take 8 weeks. (Expectation) Ativan you are going to use it 3
times daily, every 8 hours by mouth with a full glass of water with or
without food. Also taken simultaneously at night, you are going to take
Zyprexa Zydis by mouth. It is a disintegrating tablet. It begins
disintegrating in mouth within seconds, allowing its content to be
swallowed subsequently with or without liquid. The oral disintegrating
tablet breaks easily and should be handled carefully with dry hands. One
blister cell must be separated from the strip prior to peeling the blister
backing. The blister backing should be carefully peeled back and the
orally disintegrating tablet. Pushed out and placed directly in the mouth.
The oral disintegrating tablet may also be stirred into 125mg of water,
milk, coffee, orange juice or apple juice and the contents quickly
consumed. Does that make sense to you?
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Patient:
Yes, it does.
Pharmacist: Some side effect you may or may not experience like both medications
may cause sedation and drowsiness (so dont drive a car or operate
machinery). Both may cause constipation (so fibre intake). Zyprexa
may cause in weight (so monitor your weight gain and reduce your
caloric intake and physical exercise). Also may cause lowering in blood
pressure when you change your position (Be careful and do it slowly
when you change your posture from lying down to standing position). In
rare condition a rise in body temperature, and rigidity, rapid heart beat
with irregular pulse and professed sweating. This rarely happens.
However if it happens, discontinue medications and contact your doctor.
Patient:
Yes, it does.
Pharmacist: You told me you drink 1 glass of wine everyday. It is important to avoid
that, since alcohol increases sedation and dizziness. Dont eat run, you
should watch your caloric intake, since the medication enhances your
appetite and increase your weight, and thats why physical exercise is
important to practice along with reduction of calories in your diet.
(Addressing the life style issues)
Patient:
Ok, I will do that.
Pharmacist: Store Zyprexa Zydis in the original package in a dry place at room
temperature while Ativan store in at room temperature. (Storage)
Patient:
I will do that.
Pharmacist: Do you have any questions so far?
Patient:
No.
Pharmacist: Some self care measures are important to be followed along with the
medication like;
1. Social supporting group
2. Try to resume your social activities with your family and friends
and communicate with them
3. Be physically active
4. Relaxation exercises (yoga)
5. Watch your calories
6. Keep your appointments with your doctor
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Patient:
Thank you for these tips.
Pharmacist: If you dont mind, I will call you after a week tomanage some side
effectlike izziness and I will call you after 2 weeks to see if there is any
improvement in your condition.
Patient:
Ok.
Case: 10
Patient: John Hirtz
Age: 40 years
Allergies: Unknown
Gender: Male
Patient Profile
Pulmicort turbohaler 200g 1x2
Serevent Diskus 50g 1x2
Ventolin inh 1-2 puff prn
Rx
Advair Diskus 250g
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1x2
60 blisters
Pharmacist: My name is (
), I am the pharmacist in duty today. How may I help
you?
Patient:
I am here to pick up my Rx for asthma.
Pharmacist: Oh really then you must have been in a quite a bit of discomfort.
(Empathy)
Patient:
Not a lot.
Patient:
Thank you.
Pharmacist: Sir, is this Rx for you? (Identifying the patient)
Patient:
Yes, it is for me.
Pharmacist: In order to help you better, I would like to ask you a few questions. Is that
ok?
Patient:
Certainly.
Patient:
Thank you.
Pharmacist: Would you mind to check your profile?
Patient:
Sure.
Pharmacist: From your profile, I can see that you are using pulmicort 200 g
turbohaler, isnt it?
Patient:
Yes, I am using it twice daily.
Pharmacist: Regularly?
Patient:
Yes, regularly.
Pharmacist: Same thing for Serevent?
Patient:
Yes, regularly.
Pharmacist: Ventrine inh you are also using?
Patient:
Yes, I use 1-2 puffs twice a week and once before exercise.
Pharmacist: Is your asthma controlled?
Patient:
Yes.
Pharmacist: So, what happened recently that made your doctor Rx this new medication
for you?
Patient:
Well, sometimes I forgot to use one of the puffs since they are 3, my
doctor told me that this new medication contain 2 in 1.
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Pharmacist: Sure, correct as your doctor told you, and is used to maintain your
asthmatic relief. Are you using it for the first time? Beside these Rx
medications are you using other medications?
Patient:
No.
Pharmacist: Beside asthma do you have any medical condition like high blood
pressure or Diabetes?
Patient:
No.
Pharmacist: Do you have any allergy to medication. food. environmental?
Patient:
No. No.. to cat and pollen.
Pharmacist: Any over the Counter medication.. Herbal product. Vitamins?
Patient:
No. No.. No..
Pharmacist: Life style; Alcohol. Diet. Smoking. Exercise?
Patient:
No. Good. No. Yes.
Pharmacist: Before I go and check in my reference book, do you have any concern or
questions?
Patient:
Should I continue the other medications or not?
Pharmacist: Sure, I will tell you after I check in my reference book. Thank you for
sharing information with you. Please give me a few minutes to check in
my reference book.
Pharmacist: Thank you for your patience. Your doctor, sir, ahs prescribed Advair discs
for you which contains Salmeterol and Fluticaseone. As your doctor told,
these contain two medications in one device. It is cheaper and to make it
easy for you for compliance, and not to forget your medication. So
discontinue Pulmicort turbohaler and Serevent Diskus, and keep using
Advait Diskus 230g twice daily 12 hours apart, regularly everyday. Do
you know, then, how to use it?
Pharmacist: IF you have any concern you can call me.
Patient:
Ok.
Pharmacist: Some side effect, you may or may not experience like irritation, horseness
of voice, cough (suck a candy), rinse your mouth with water to avoid
fungal infection.
Note
1. Here we didnt mention the expectation since the patient was already on these two
ingredients.
2. With inhalers and due to their slow systemic absorption, mention the local side
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effect. If you went to mention the systemic side effect due to prolong use of inhaler;
mention first the local, then the systemic.
3. There is no need to call the doctor for discontinuing of the Serevent and Pulmicort
since the doctor already told him, this will help with compliance. However, if the
doctor didnt say that or if the patient said I dont remember when the doctor told
me about the Serevent and Pulmicort. Then you should tell him that you are going
to call the doctor to confirm for Pulmicort and not for Serevent since if Serevent
used, this will increase the adrenergiz dose, resulting in arrhythmia and tremor.
While for steroids systemic effects are seen after 2000g. So there is still a chance
that the doctor may tell the patient to use Pulmicort and Advair. In either way if the
patient says the doctor didnt tell me, then it is better to confirm. Does that make
sense to you?
Patient:
Yes, it makes sense to me.
Pharmacist: If you feel that you have sortness of breath use your blue puffer and use it
also before exercise. (Addressing) IF you use this blue puffer more than 3
days perweek until except that one before exercise or you see the
effectiveness of theblue puffer (Ventolin) is less than 3 hours, then your
asthma is not under control. It is better to see your doctor (Monitorning).
It is also important to avoid cat at home and wear a mask or avoid pollen
by not exposing yourself to it (Addressing his environmental allergy).
Patient:
I will follow your advice.
Patient:
No thanks.
Pharmacist: Some self care measures are important to follow along with your
medication.
(1) No cat at home and in your bedroom.
(2) Keep yourself in air conditioning room.
(3) Take influenza vaccine to avoid complications.
(4) Take a shower after you come back from outdoors, to get rid of pollen.
Patient:
Ok.
Pharmacist: If you dont mind, I will call you after three days to manage any side
effect like cough, and I will call you after 10 days to see how you are
doing with your medication.
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Patient:
OK.
Corticosteroid inhalers
1 - Beclomethasone (Qvar)
MDI: 100-800mcg/day divided BID
2 - Ciclesonide (Alvesco)
MDI: 100-800mcg/day divided BID
3 - Fluticasone (Floveat HFA, Floveat Diskus)
MDI/DPI: 200-1000mcg/day devided BID
4 - Budesonide (Pulmicort)
MDI: 100-800 mcg/day up to
2400 in divided BID
Tiotropium
DPI: 18mcg/puff: 1puff once daily
Ipratropium
MDI: 20mcg/puff: 2 puffs q 6-8 hours
Maximum 240mcg/day
Salbutamol
MDI: 100mcg/puff: 1-2 puffs tidqid prn
Maximum 8 puffs (800mcg).
For refills
It is important to ask the patient are you run out of your medication, since
sometime, the patient comes to the pharmacy before his due date (early refer).
Sometimes the patient by chance come across the pharmacy and asks for his refill.
Checking the profile is important to know whether he has refills or not, or he came
for earl refills. If the patient has no refills, we either tell the patient to see the
doctor. (if he refuses, then we request authorization from doctor)
In refills, it is very important to question the patient, since early refills does not
necessarily mean that he is using over dosage. Sometimes the doctor tells the
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patient by telephone to increase the dose. Sometimes the patient comes early since
he is going to travel, and wants a travel supply. Sometimes the doctor reduces the
dose, which makes the patient to come after the due date. So, this does not mean
non-compliance.
When a patient comes for a refill, Discuss with the patient, about the disease and the
medication. Regarding the disease. Have you seen an improvement in your signs
and symptoms? Is it partial or complete? How is your assessment by your doctor?
How is your blood work (if applicable)? Is your medical condition controlled or
not. Regarding the medication ask him if he experienced any side effect, whether
using it regularly or not (compliance); ask if he has any concern with the
medication. Confirm with him administration and remind the patient about the
precautions. Also ask him about any change in his life style, or is he using any OTC
or herbal product. Up date any allergy. In general we ask him half Mama, and in
this way.
- Discuss about disease
- Discuss about medication
- Up date any recent allergy
- Ask any change in life style or pregnant, breast feeding (if lady)
- Ask any OTC or herbal product
- Then Confirm administration and dosage.
Remind him about precautions and storage.
Review with the patient self care measures.
Case: 11
Patient comes to pick up his refill 2 weeks before his due date.
Patient: Mathew
Age: 18 years
Gender: Male
Patient Profile:
Dexedrine 10mg cap 1x3
90 tablets each 30 days
Refills: (3) last refill 2 weeks ago
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Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
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you?
Oh, hi, I am here to pick up my refills.
Sure, Are you run out of your medication?
Yes, last pill I consumed it yesterday night.
Please have your seat.
Thank you.
Is it for you? (Identifying the patient)
Yes, it is for me.
In order to help you better, I would like to ask you a few questions.
Sure.
I would like to reassure you that whatever information. I collect will
Thank you.
Would you mind to check your profile, and to see your refills?
Sure.
According to our profile Mathew, you are coming for early refills; may I
know the reason why?
Well, I am not feeling well, my attention is not good, I feel I am not strong
enough as other people, so I wanted to be more stimulated and active so, I
am using 4 pills instead of 2 pills; two in the morning and two at night.
Have you talked to your doctor about using more than he has directed
you?
No, but I feel that my mood is up when I use higher dose.
I can see that you have some problems with your activity attention, and I
will try my best to help you. (Empathy)
Thank you.
Havent you tried to talk to your family, teacher in the school about being
less active?
No, but I have a friend using this medication and he doesnt have any
disease (ADHD), and his mood is up and he doesnt feel tired.
Have you experienced any side effect?
Yes, constipation, loss in appetite, euphoria and sleeplessness.
How long have you been using it in high dose?
Since a week ago.
How is your performance at school and at home?
Still the same thing as before but I feel my mood is up.
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Note: from the above dialogue, the pharmacist discussed about the disease and the
medication and now he will go to ask half MAMA questions and life style.
Pharmacist: Do you have any new allergy to update it.
Patient:
No.
Pharmacist: Are you using currently any over the counter medication, any herbal
product or vitamin? (These questions are mandatory, as the life style
questions to recognise whether there is any drug-drug infection which is
affecting his health)
Patient:
No.
Pharmacist: Is there any change in your life style regarding alcohol, smoking, diet and
exercise?
Patient:
Nothing now, except I eat less now, and less sleeping hours.
Pharmacist: Thank you for sharing information with you, please give me a few min to
check in my reference book.
Patient:
Sure.
Pharmacist: Thank you for your patience. Dear Mathew, I know you are increasing the
dose because you think this might result in better attention, and to be
stronger. However, this thing if you want to get it, it should be by your
doctor who is in a best position to assess your condition and to see if there
is any improvement or not. You cant do that by yourself by increasing
the dose since this will result in toxicity and severe side effect as ou
mentioned, and also euphoria where you feel our mood is up, and this will
definitely end up with addiction and dependence and further increase in
the dose resulting in destroying your body and your mental health. You
will not respond to your brain, and this will result in craving which means
seeking for the medication and abusing the medication which will affect
more your medical condition and your general health. As you see your
appetite is less, and you will lose weight and be less energetic, and also
you cant sleep because of high dose, and this will affect your daily
activity.
Patient:
Oh, really.
Pharmacist: So, what I recommend now is to go and see your doctor, and tell him that
you are doubling the dose, and mention to him, how long you have been
using it in this way, and the side effect that you are experiencing currently.
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OR, if you like, I can call the doctor and discuss this issue with him.
Patient:
No, I will go and see the doctor.
Pharmacist: I will also give you a few pills to prevent any rebound effect which may
affect your mood or make ou feel tired, until you see your doctor. Is that
ok for you? I would also like to emphasize to eat well balanced food rich
in vegetables and fruits, and limit sweet intake and dont forget to eat your
breakfast before you go to school, and continue on your physical exercise,
but dont do strenuous exercise since this will affect on your heart. Also, I
would like to remind you about following good sleep, hygiene, use sound
proofed room and take a warm shower before you sleep. Make your
sleeping room just for sleep and not for studying.
Patient:
I will follow our advice.
Pharmacist: If you dont mind, I will call you after a week to see what you have done
with your doctor. (Follow up)
Patient:
Ok.
Case: 12
Patient: Rosemary Khan
Age: 33 Years
Gender: Female
Diagnosis: Grand Maleilepsy
The patient is coming for her refill with a concern. Solve her concern as you are in your
pharmacy. (She is pregnant)
Patient Profile
Epival (Divalproex Na) 250mg tablet 1x1
Mitt: 30 tablet
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Refills (5)
Last refill 30 days ago
Pharmacist: Hi my name (
you?
Patient:
I am here to pick up my refills.
Pharmacist: Please have your seat.
Patient:
Thank you.
Pharmacist: Is the refill for you? (Identifying the patient)
Patient:
Yes, for me.
Pharmacist: Are you run out of your medication?
Patient:
Yes.
Pharmacist: In order to help you better, I need to ask you a few questions, is that ok for
you?
Patient:
Yes it is ok.
Pharmacist: I would like to reassure you, whatever informations. I gather with remain
Patient:
Thank you.
Pharmacist: Would you mind to check your profile? (This is mandatory to see early
refills, compliance, or if there is any refill left)
Patient:
Sure.
Pharmacist: How do you feel now? (Empathy)
Patient:
My seizures are controlled.
Pharmacist: You mean you havent experienced any attack. (Talking about the disease)
Patient:
No.
Pharmacist: Are you following your monthly assessment and blood work with your
doctor? (Talking about the disease)
Patient:
Yes, I do.
Pharmacist: Have you experienced any side effect? (Talking about the medication)
Patient:
Some mild dizziness, and more sleepy hours.
Pharmacist: Oh, that must be hard for you. (Empathy)
Patient:
They are tolerable.
Pharmacist: Are you using the medication regularly? (Talking about the medication)
Patient:
Yes, once every day.
Pharmacist: Have you missed any dose?
Patient:
No.
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Note: (Now if the pharmacist talked about the disease and medication, will go and ask
about half MAMA question, ask since she is female whether she is pregnant or not, then
any change in life style, since life style change may affect the way the medication
works.)
Pharmacist: Have you experienced any allergy since last month to update against
food. medication environment?
Patient:
No.. No.. No..
Pharmacist: Are you using any over the counter medication herbal product.
vitamins?
Patient:
No.. No.. No..
Pharmacist: Are you pregnant, or planning to be pregnant?
Patient:
Yes, I have checked in my pregnancy test and I am 1 month pregnant.
Pharmacist: Have you talked to your doctor about that?
Patient:
Not yet.
Pharmacist: Is there any change in your life style regarding alcohol, smoking diet
exercise?
Patient:
No change. It is the same as before.
Pharmacist: Do you have any question before I go and check in my reference book?
Patient:
Yes, should I discontinue my medication?
Pharmacist: Sure, not. Just give me a few minutes to check in my reference book and I
will tell you whatever information you want about the medication in
pregnancy. Thank you for sharing the information with you.
Patient:
Thank you.
Pharmacist: Thank you for your patience. Dear Rosemary, it is very important to keep
you treatment of epilepsy, since discontinue of treatment has a risk on
your health and also to the child. The child may have low birth weight,
you may have premature baby or some defeats in his organs if any seizure
takes place during pregnancy. Therefore, therapy of your epilepsy is of
great importance. However, this should be considered by your doctor,
who is in best position to out weight the benefits against the risk since
there are some margined risk, when one takes this medication during
pregnancy. I would also like to tell you that the statistics reveal that
women treated with antiepileptic medication, their delivered children are
healthy and good outcome when compared with these healthy women who
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Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
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have delivered healthy children and dont use any antiepileptic

medication. So, what I recommend is to continue use the medication, and
dont discontinue your medication, and see your doctor ASAP. I will also
give you an over the counter Folic acid 1mg, since antiepileptic
medication reduce Folic acid in your body, and thus in children. So, to
avoid any neural tube defect (a defect in brain and spinal chord due to low
level of Folic acid) Folic acid is important. Please, tell your doctor that
you are using Folic acid 1mg. Your doctor may keep you on this strength,
he may give you a higher prescription strength. Is that ok?
Yes, ok.
Do you have any question or concern so far?
No, thank you, I will soon see my doctor.
Some self care measures are important to follow along with the
medication.
(1) Eat well balanced food rich with vegetables and fruits.
(2) Increase your intake of dairy products since you need calcium and
vitamin D. Discuss that with your doctor. I will give you maternal
which contain multi vitamin and gin can start one tablet every day
with or without meal, and you can tell your doctor about using
maternal.
(3) Avoid sleep deprivation, since it may enhance the chances of
000000
Is that ok?
Yes, ok.
If you dont mind, I will call you within a week to see what you have done
with your doctor.
Ok.
Thank you for coming in, have a nice day.
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Case: 13
Patient: Linda Burton
Age: 35 years
Gender: female
Diagnosis: Anxiety
Migraine attack
Allergy: Unknown
The patient is coming with a concern.

Solve her concern, she is breast feeding, she has some pills from her previous filled Rx.
Patient Profile
Fiorinal C1/2 50mg 1x4
40 tablets last fill
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1 month ago
Pharmacist: Hi, my name is ( ), I am the pharmacist in duty today, how may I help
you?
Patient:
Oh, I have severe headache and I want to ask you if I can use Fiorinal
C1/2 50mg which I have 3 pills left at home from my previous Rx when I
had a lower limb sprain.
Pharmacist: Oh, that must be difficult for you. (Empathy, identifying the patient)
Patient:
Yes, it is hard for me.
Patient:
Thank you.
Pharmacist: In order to help you better may I ask you a few questions?
Patient:
Sure.
Pharmacist: I would like to reassure you that whatever information, I collect will
Patient:
Thank you.
Pharmacist: How long have you had this attack of migraine?
Patient:
Since 2 hours ago, I have headache with nausea and vomiting.
Pharmacist: How often does this happen to you?
Patient:
Every 6 months approximately and after I am severely exhausted.
Pharmacist: Have you tried any medication?
Patient:
No, but I have some Fiorinal C1/2 tablets Rxed for me by my doctor last
month for my wrist sprain. Can I use them?
Pharmacist: I will come across your question after I double check in my reference
book. But for the time being, I would like to know some more
information about your medication and general health. Is that ok?
Patient:
Yes, ok.
Pharmacist: Have you been diagnosed by doctor that you have migraine.
Patient:
Yes.
Pharmacist: What did he describe for you at that time?
Patient:
Also Fiorinal C1/2 6 pills, and he told me to use 1 prn.
Pharmacist: Do you have any medical condition that I should be aware of?
Patient:
No.
Pharmacist: Any Rx medication that you are using currently?
Patient:
No.
Pharmacist: Any allergy to medication.. food. environment?
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Patient:
No.
Pharmacist: Any OTC. herval .. vitamins in life style?
Patient:
Tylenol occasionally. No.. No.. life style good. (No A/C smoky,
good diet, moderate exercise)
Pharmacist: Are you pregnant?
Patient:
No.
Pharmacist: Do you breast feed?
Patient:
Yes, I have a baby 1 month old, I breast feed him, and also I give him
some formula milk.
Pharmacist: Do you have in the fridge any collection of your breast milk?
Patient:
No, I havent. Can I collect now?
Pharmacist: No, Mom, you cant collect now since this will increase your stress and
aggravate your signs and symptoms.
Patient:
What should I do then?
Pharmacist: (After checking reference book) As you told me, that your doctor has
Rxed previously Tylenol#3 for your migraine previously, and a month ago
for your wrist pain and was effective in both conditions and since you
have a few pills of Fiorinal C1/2 left, then you can use Fiorinal C1/2 pill
on need basis, as now, provided that is not expired. If you see a partial
relief or a relief and mother attack of migraine, then you can use it after 4
hours, not more than two doses. However, if no relief, see your doctor.
Patient:
What about my child can I breast feed him?
Pharmacist: No, you cant breast fee him for that day that you take the medication
since the medication is excreted in breast milk and because you dont have
any collection of milk in the fridge, then, I recommend giving him
formula milk for today, as you usually give him as a support to your breast
milk. Meanwhile, try to express your breast at the same time you breast
feed to prevent accumulation of milk in your breast and to get rid of the
medication, that is excreted in your breast milk, so that next day when you
are relieved, you can breast feed the child since there is no medication left
or accumulated in your breast milk after discarding the milk in every
expression.
Patient:
Thank you for this information.
Pharmacist: Do you have any question or concern so far?
Patient:
No.
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Pharmacist: Some self care measures are important to follow along with your
medication like:
1. Avoid stress and severe exercise
2. Avoid any triggering factors like sweets, chocolates
3. Stay in a dark room and avoid strong noises and strong odours
4. Cold compressor on your head 3-4 times daily
5. Avoid irregular meals
6. Relaxation exercise
Patient:
Thank you.
Pharmacist: If you dont mind, I will call you tomorrow to see how you are doing with
your migraine, and if there is any
Patient:
Sure.
OTC Stations
In OTC stations, the student should take more details from the patient, since here he is
working as a triage. So he may refer the patient only or refer the patient plus some OTC
till he sees the signs and symptoms. So, after greeting the patient, privacy and
confidentiality and empathy as in Rx stations, the stud cut should ask the patient the
following questions in order to evaluate, and assess the signs and symptoms of the
patient (Dont say the medical condition of the patient, since medical conditions are
assessed by doctors like hypertension, asthma, diabetes mellitus. etc. Here we are
dealing with simple signs and symptoms which could be treated for short time.
However if they persist, the patient should see the doctor.)
1. Describe to me a little more your signs and symptoms (open-ended
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question).
2. How long have you had these signs and symptoms (specify for instance
diarrhea, constipation, cough, fever. etc).
3. How often or how frequently does this happen for you.
The above question are very important, since if the signs and symptoms were for
a long time and frequently occurring, then definitely the patient requires referral.
4. Have you tried any medication for that.
5. Have you been seen by the doctor to treat these signs and symptoms.
6. Does it affect your daily activity and any disruption of your sleep (if it does
then refer)?
7. Red flags
a. Fever
b. Ng and Diarrhea
c. Bleeding
d. Drowsiness
e. Severe and unfamiliar headache
Ask the red flags which are systemic signs and symptoms relevant to the case. After
that ask MAMA question, pregnancy or breast feeding, then life style. After that take
permission to check in reference book or any handout available in the station. You
should be clear in asking and gathering the questions, listen carefully to the patient and
address any concern either directly and immediately, if you know the answer or tell the
patient that you will address the question or concern after you check in your reference.
After gathering the station, then you should counsel the patient by telling him, the
administration, expectation, side effect management of side effect. Dont mention
directly the precaution since it is an OTC, but you can mention it in directly as it is
started below. Always start with the negative.
Dear Sir, you are going to use this medication once, twice, three time daily, no more
than (
) days, within this time period you should see a response or improvement in
your signs and symptoms like (
). (Expectation) However, if your signs and
symptoms get worse, or if the signs and symptoms exceed one week or two weeks
(relevant to the case), then you should see your doctor (Monitoring and Precaution). So
that administration, expectation, monitoring and precautions and this fulfills what is
required from each station. Then say as in Rx counselling some side effect may have,
may not have like (
), (
), (
), three side effect are enough until their
management. Then go to non-pharmacological and following up as usual and here are
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some of the example.
Case: 14
25 years patient comes with a concern, requesting an OTC product for his condition.
He has been diagnosed as having scabies by his doctor.
). How may I help you?
Patient:
I went to my doctor for my itchiness all over my body, and he told me that
I have scabies, and he told me that I can buy it from the pharmacist.
Pharmacist: Sure, we have. You must have been in a quite a bit of discomfort.
(Empathy) This is a private area. Please have your seat. (Privacy)
Patient:
Thank you.
Patient:
Sure.
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Pharmacist: I would like to reassure you whatever information. I gather will remain
Patient:
Thank you.
Pharmacist: So, you told me that your doctor diagnosed your signs a symptom as
scabies, isnt that correct? (Confirming the diagnosis and identifying the
patient)
Patient:
That is correct.
Pharmacist: Could you please tell me how many family members that are living
together? (This is an essential question, so that to gather information from
all family member, and not only the infested patient, since we are going to
treat all family member just like pin worms, and also so that not to repeat
the gathering information for each family member and not to lose time.
Patient:
Me, my wife and we have a baby 1&1/2 month old.
Pharmacist: Does any family member have any medication condition?
Patient:
No.
Pharmacist: Does any one have any allergy to food. medication. environment.
Rag weed?
Patient:
No. No. No. No..
Pharmacist: Does any family member use any medication OTC. Herbal product
vitamine?
Patient:
No. Tylenol occasionally. No. No.
Pharmacist: Is your wife pregnant?
Patient:
No.
Pharmacist: Does she breast feed?
Patient:
No.
Pharmacist: For you and your wife, do you smoke. Alcohol (There is no need to
ask for diet and exercise it is irrelevant to the case).
Patient:
No. No.
Pharmacist: Before I got to my reference book, do you have any concern or question?
Patient:
Do all family members should use?
Pharmacist: Definitely you and your wife, you should use one medication and the child
he became he is 1 and half month old, I will give him a different
medication. So, thank you for sharing information with you. Please give
me a few minutes to check in my reference book.
Patient:
Sure.
Pharmacist: Thank you for your patience. I am going to give you and your wife
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permethrin 5% cream (Nix Dermal Cream), and Sulfur 5% for your child.
Nix Cream you and your wife are going to massage into all skin areas.
From the neck down to the sole of the feet; every bit of the skin must be
treated, including the finger nails, waist and genitalia. Leave the cream on
for 8-14 hours without interruption, then wash off (shower may be the best
way).
You personally should see a relief in your itching and
disappearance of lesions after 1 week. If you personally see appearance of
new lesions or live mites, then consult your doctor for confirmation and
the therapy may be repeated for another 7 days (Expectation).
Note: Pharmacist can not repeat the medication for scabies, since it could be treatment
failure and all treatment failure should be assessed by the doctor. In addition, in
Therapeutic Choices Pg. 1095 it is mentioned that second administration 1 week after
first often routinely prescribed. (Prescribed mean by doctor whether written or verbal,
while the pharmacist doesnt prescribe but suggest or recommend)
Pharmaicst: For your child, use Sulfur5%. Apply to the skin of the child to all areas
from the head (since it is a child) down to the soles of the feet; every bit of
skin must be treated, including the finger nails, waist and genitalia at bed
time daily for 5-7 days. Does that make sense to you?
Patient:
Yes it does.
Pharmacist: Some people may or may not experience side effect like for
permethrin5%, redness, itchiness, and for Bulfur5% some local irritation,
malodour, and stains clothing. Sometimes its patients with scabies,
itching may persist for weeks after mites are irradiated. In that case see
your doctor. He might prescribe for you medium potency topical
corticosteroid which requires an Rx. Its not OTC (monitoring)
Patient:
No.
Pharmacist: Some self care measures are important to follow along with the
medication.
1. Wash all your clothes with soap and hot. Unwashable items could
be put in a sealed plastic container for 7 days.
2. Avoid sex.
3. Use antiseptics to wash the toilet seat.
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Is that ok?
Patient:
Yes, ok.
Pharmacist: If you dont mind, I will call you within a week to see if there is any
improvement.
Patient:
Ok.
Pharmacist: Thank you for coming. Have a nice day.
Other tips regarding skin infestation

1. If the wife was pregnant, she should be given Sulfur10% and not Sulfur5% for
5-7 days.
2. If the patient comes to the pharmacy and says I have itching over all my body,
red-brown, bilateral, well-demacrated rash covering the thighs and public area.
You should refer him to the doctor for diagnosis.
3. For a pregnant lady with lice and child 2 months of age, you can give R&C
shampoo.
4. Patient for scabies or lice hypersensitive to chrysanthemum or rag weed give
him Lindane1% lotion for scabies.
5. Lindane is not first live treatment.
6. Do not retreat with Lindane. It is important to consult the physician.
7. In case of chrysanthemum or rag weed allergy give result shampoo or Lindane
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shampoo (these have chemical salts)

8. In case if live lice was seen after one day, 2 days, 3 days. etc. in the hair, then
this indicates either treatment failure, or failure in non-pharmacological i.e.
reinfection. Dont wait, till 1 week passes. Go to a different class of shampoo.
Case: 15
A young man approaches you requesting smokeless tobacco. He heard from his friend
that smokeless tobacco reduces cancer and lung diseases.
On the table: Nicotine gum, Nicotine patches, Nicotine inhaler, Nicotine gargle, herbal
products for smoking cessation.
Address his concern and solve the problem as you are in your pharmacy.
). I am the pharmacist in duty today, how may I help
you?
Patient:
Well I want to quit smoking, and my friend told me that he read in a
magazine that smokeless tobacco reduces cancer and lung diseases if one
uses it instead of smoking cigarettes.
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Pharmacist: Congratulation, I can see you are greatly concerned about that, and I will
try my best to help you. (Empathy)
Patient:
Thank you.
Patient:
Yes, I want to avoid smoking by smokeless tobacco if you can provide me.
Pharmacist: Ok, Sir, in order to help you better, I would like to ask you a few questions.
Is that ok?
Patient:
Ok.
Pharmacist: Sir, your friend is correct that smokeless tobacco reduces cancer and lung
diseases to the negative smokers, since they would not inhale any smoke,
however those who use it would certainly continue suffer from its
drawbacks. According to statistics kills approximately 48,000 Canadians
every year (Therapeutic Choices Pg. 146), primarily from heart disease,
lung cancer and lung diseases like COPD. So it is better to avoid tobacco
and thus smoking to get rid of any disease that they carry to the persons
who use them. In our pharmacy we have patches for nicotine, inhaler,
lozenges, gums, and all of them help to quit smoking, and the
concentration that will be released in your body after using them will help
you to quit smoking, and has no bad effect on your body Do you like to
chose any one of these medications that help you to quit smoking?
Patient:
Sure, any one you recommend I will take.
Pharmacist: Before recommend I need to ask you a few questions and I would like to
reassure you whatever information I collect will remain confidential.
(Confidentiality)
Sir, how many cigarettes do ou smoke per day?
Patient:
1 pack per day.
Pharmacist: Have you tried to quit before?
Patient:
No.
Pharmacist: Are you using any prescription medications?
Patient:
No.
Pharmacist: Any allergies to food, medications. environment?
Patient:
No. No. No.
Pharmacist: Are you using any OTC. Herbal product Vitamins?
Patient:
No. No. No.
Pharmacist: May I ask you a few questions about your life style?
Patient:
Sure.
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Pharmacist: Alcohol. Diet. Exercise. Coffee?

Patient:
No alcohol, apetite low. No time for physical exercise. 4 cups of
coffee.
Pharmacist: Do you have any question or concerning about?
Patient:
Just give anything that helps me quit smoking.
Pharmacist: Sure, thank you for sharing information with you. Please give me a few
Patient:
Sure.
Pharmacist: Thank you for your patience. I am going to give you nicoderm patches
14mg. You are going to use them every day for 6 weeks, then you use
7mg patch for two weeks. (Administration & Expectation) You should
start on the quit date. You should not smoke while you use the patches,
since this will result in overdosage and sometimes intoxication like
nausea, vomiting, rapid heart beat, dizziness, and profuse sweating. The
patch should be applied only once a day to a non-hairy, clean, dry skin site
on the upper body or outer upper arm. Does that make sense to you?
Patient:
Sure.
Pharmacist: Sometimes you may or may not experience side effect like skin sensitivity,
sleeplessness, nausea and stomach upset. These are tolerable and go away
as you continue using the patch. However, if the symptoms wore severe
and persistent, discontinue the patch, and wash the area with water
without soup, since soup enhances absorption of nicotine and report that
to your doctor. In rare case, rash or sweating occurs with severe redness at
the area where the patch is applied. This is an allergic reaction to the
patch and rarely occurs. In that case, also discontinue the patch, and
remove it, and wash the area with water only, not soup. (Monitoring) Do
you have any question or concern?
Patient:
No, thank you.
Pharmacist: Some self care measure, are important to follow as an adjunct to the
therapy.
1. Try to occupy your head with a clipper or pen
2. Eat well balanced food, and your appetite will be improved, after
quitting smoking and you may gain 4-5 lbs weight, so avoid high
caloric diets.
3. You told me you drink four cups of coffee and I think, this will
also stimulate smoking, so try to replace coffee with tea.
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4.
It is important to do physical exercise whenever you feel urge for

smoking, in addition to regular physical exercise for 1/2 an hour a
day for your general health.
5. Relaxation exercises like Yoga.
Patient:
I will try to do all of these.
like sleeplessness and each week to see your performance in smoking
cessation. Feel free to call me any time you like.
Patient:
Thank you so much, you provided me with a lot of information.
Note: For empathy, in this station, you can also say I appreciate your deep concern
about your health
Other tips regarding smoking cessation

1. If the person smokes more than 20 cigarettes then start with step one (21mg/24
hours)
2. If a pregnant lady wants to quit smoking, give her the tips of nonpharmacological.
3. If a patient has cardiac disease or has MI or recent stroke, and he want to quit
smoking, refer hi to his doctor.
4. A patient with hypertension and wants to quit smoking, refer him to doctor.
Dont start with 14mg/24 hours or 2nd step. This could be done by his doctor and
not you as a pharmacist since hypertension are a systemic disease or the doctor
may prescribe Zyban or Champix for him as prescription medications.
5. If patient is worried especially girls from quitting smoking, since they think they
might gain weight. Advice them that the gain in weight is mild from 4-5lbs,
shortly after quitting smoking, and then this levels off. Tell them they can help
not to gain weight by taking fibres, and reduces the number of calories in their
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diet and by physical exercise.

6. If one says I tried several times and I couldnt quit. Encourage him to repeat
that and learn from the failure of quitting.
7. Emphasize on correct use of sum (administration) like biting it once or twice
each minute. Park it under tongue or between gum and check for 1 min repeated
for 30 minutes. Avoiding coffee, tea, juices and cola when he is using the gum
since they interact and reduce the effect of Nicotine gum.
8. If smokers using the patch complain of unmanageable cravings and smoke
cigarettes, add nicotine gum or inhaler as a breakthrough medication.
Note: How to apply other patches (not nicotine patches)

1. Evra patch (Hormonal Contraceptive) The patch should be applied to a clean,
dry intact healthy skin on the buttock, abdomen, upper outer arm or upper torso,
in a place where it wont be rubbed by tight clothing. Not on a breast. Half of
the clear protective liner is peeled away. The patient should avoid touching the
sticky surface of the patch. The patch is positioned on the skin and the other
half of the liner is removed. The patient should pres down firmly on the patch
with the palm of her hand for 10 seconds, making sure that the edges stick well.
The patch is worn for 7 days. On the Patch Change Day; Day 8, the used
patch is removed and a new one is applied immediately.
2. Estalis and Estalis Sequi Patch (HRT) Immediately after removal of a patch
from the pouch, and removal of the protective liner, the adhesive side of the
Estalis or Vivelle patch should be placed on a clear, dry area of intact skin and
peel off the remaining one-half of the protective liner. The site selected should
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also be one at which little wrinkling of the skin occurs during movement of the
body (buttocks and lower abdomen). The waist should be avoided, since tight
clothing may dislodge the patch. Patches should not be applied to the same skin
site for at least 1 week. Not on breast.
3. Nitro Dur patch Apply it on arm or chest. Application site should be rotated.
A suitable area may be shaved if necessary. Dont put it on the distal part of
extremities. Hands should be washed thoroughly after application.
4. Duragesic Patch Apply on chest, back, flank, or upper arm every 3 days.
Case: 16
22 year woman come with a concern, and she wants an OTC product. She has white
flakes on the shoulders of her black sweater after she brushes her hair. Her hair is clean,
and the scalp is itchy.
Available: Ketoconazole2% shampoo, Selsun shampoo, Zinc Pyrithione (Head and
shoulders), salicylic and sulphur bar and lotion and coal tar shampoo.
Pharmacist: Hi, my name is ( ), I am the pharmacist on duty today. How may I help
you?
Patient:
I am here with a concern.
Patient:
Thank you.
Pharmacist: May I know your concern.
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Patient:
I have white flakes on my shoulders when I brush my hair. Although my

hair is clean, the scalp is itchy.
Pharmacist: I appreciate your concern in your health, and I acknowledge your concern,
and I will try my best to help you. (Empathy)
Note: When the patient says I have white flakes, she already identified herself.
(Identification)
Patient:
Thank you.
Pharmacist: In order to help you better, I need to ask you a few questions. I would like
to reassure you that whatever information I collect will remain
confidential. (Confidentification)
Patient:
Thank you.
Pharmacist: How long have you had these flakes appear on your shoulder when you
comb?
Patient:
Since two weeks ago. I used regular shampoo with no benefit.
Pharmacist: Did this thing appear before? (Frequency)
Patient:
No, it is for the first time.
Pharmacist: Have you tried anything for it?
Patient:
No.
Pharmacist: Have you been seen by doctor for this purpose?
Patient:
No, I have just come here, I think you can give me something.
Pharmacist: Sure, I will. Is the itchiness severe and bothering you a lot?
Patient:
Not so severe.
Pharmacist: Have you seen any live lice in your hair?
Patient:
No.
Note: You cant ask you on red flags have, since the problem is local, and doesnt affect
her daily activity. Also if you dont have time ask only on Allergy, since the other
questions of MAMA are irrelevant. Same thing to life style, if you dont have time just
ask her if her diet is good and about physical exercise only.
Pharmacist: Do you have any question or concern about anything before I go to my
reference book?
Patient:
No, thanks. Just give me any medication.
Pharmacist: Sure, I will. Thank you for sharing information with you. Please give me
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Patient:
Pharmacist:
Patient:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
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a few minutes, to check in my reference book.

Sure.
Thank you for sharing information with you. I can assure that you have
dandruff in your hair. You said that you used regular shampoo with no
benefit. Isnt that right?
Then, it is important now, at this step to use an antifungal shampoo, we
have here in our pharmacy Ketoconazole, Selsum and Head and shoulders.
All of them work well. Which one do you prefer?
Any one you recommend.
I recommend Ketoconazole2% shampoo to be used 2-4 times weekly, you
can apply topically to your scalp. Its application is very simple. Wet the
hair and part a small section. Rub some of the shampoo into scalp at
roots. Repeat until the entire head has been treated. Leave the shampoo
on for at least 5 minutes. Rinse it out. Repeat if necessary. It requires 2-4
weeks and follows prophylaxis treatment one treatment every 1 or 2
weeks (administration and expectation). Avoid eye areas. Does that make
sense to you?
Yes.
Some side effect you may or may not experience like mild itchy, stinging
and irritation (these are tolerable). Do you have any question so far?
No thanks.
Some self care measures are important to follow along with the use of
shampoo like avoiding harsh soaps and detergents. Use warm water to
bathe and remove scale each day. Avoid stress and dryness (use
humidifiers).
If you dont mind, I will call you after two weeks to see if there is any
improvement in your dandruff (no need to cal after couple of days to
manage the side effect since the side effect are local and mild).
Ok.
Other tips with respect to skin and scalp condition

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1. If there is a triggering factor like soap, detergent, water or any allergen resulting
in dermatitis that is generalized, not local, with a history of asthma, allergic
rhinitis (always ask for family history of asthma, allergic rhinitis and psoriasis
and in tolerant to wool clothes).
2. If the triggering factors like soap, detergent, water or any chemical scab
resulting in local dermatitis, then that may be contact dermatitis.
3. First generation antihistamine and Hydrocortisone 0.3% are good medications to
treat acute or chronic contact dermatitis or atopic dermatis. First severities are
good to relieve allergy and sedate itchiness.
4. Dont use antihistamine and Hydrocortisone 0.3% more than 1 week, since it
requires monitory.
Case: 17
38 year male patient with a wart or a corn, he doesnt know at the sole of a foot. It has
been steadily getting worse for last week. He is wearing sandals to avoid rubbing it.
Approaches the counter for an OTC product.
Available
Formalin 3%
Lactic acid 10% & 16.7%
Salicylic acid 16.7% & 25% & 40%
you?
Patient:
Well, I have a thickened area of skin on bottom of my sole. At the
beginning was slightly painful, not the pain is getting more and cant walk
easily.
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Pharmacist:
Patient:
Pharmacist:
Patient:
OSCE TI PS
That must be hard for you sir. (Empathy)

Yes, it is bother me a lot.
Thank you.
Note: There is no need to identify the patient since he is saying I am the one who is
experiencing the signs and symptoms.
Pharmacist: I wonder to help you better, I would like to ask you a few questions, is that
ok?
Patient:
Ok.
Pharmacist: I would like to reassure you that whatever information, I gather will
Patient:
Thank you.
Pharmacist: How long have you had this?
Patient:
Since a week ago.
Patient:
First time.
Patient:
Just wearing sandals to avoid rubbings.
Pharmacist: Have you been seen by your doctor for this purpose?
Patient:
No.
Pharmacist: Are there skin ridges overlapping the thickness area?
Patient:
No.
Pharmacist: Is there any black dot in centre of lesion?
Patient:
Yes, at the beginning it was much clear.
Pharmacist: Does it affect your daily activity or sleep?
Patient:
Not too much. But I cant walk steadily like before.
Pharmacist: Do you have any fever? (Red flags)
Patient:
No.
Pharmacist: Pain?
Patient:
Yes, pain at the beginning when pushed, as when walking, but now is
getting more painful in comparison with my first day. (Red flag)
Pharmacist: Do you have any medical condition like diabetes? (It is important to ask
this question)
Patient:
No.
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Pharmacist: Any allergies to medication. food. environment?

Patient:
No. No. No.
Pharmacist: OTC. Herbal. Vitamins.? (Ask if you have time since, the effect of
any medication is local), and as you know the patient will be referred with
no OTC.
Patient:
No.
Pharmacist: Life style? (If you have time, since you will refer the patient)
Patient:
Ok.
Pharmacist: Before I go and check in my reference book, do you have any questions or
concern?
Patient:
No.
Pharmacist: Please give me a few minutes to check in my reference book.
Patient:
Ok.
Pharmacist: Thank you for your patience. I can assume the pain and the thickness area
in your sole foot is a plantar wart, and because, it is getting worse, I can
not recommend any OTC product now for you. It is important to see your
doctor for assessment.
Patient:
You mean I should see my doctor?
Pharmacist: Yes, sir and in the mean time, avoid walking barefoot to avoid spread of
the virus, since this is transmitted via contact with another lesion or
contaminates surfaces. Also change socks and shoes every day. Keep feet
clean and dry.
Patient:
Pharmacist: If you dont mind, I will call you after a week to see what you have done
with your doctor. (Follow up)
Patient:
Thank you.
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Case: 18
Patient 10 months old, bottle fed infant who has stuffy nose, cranky, and somewhat
feverish and cant feed properly. One of his teeth is erupting.
Available:
Saline infants drop, temperature drop, Benylin Syrup for kids, Otrivin 0.025% drop,
Benylin Dm-D for children, Benylin Dm for children, Benylin DM for children 12
hours. (Bedtime), Benzocain gel.
). I am the pharmacist in duty today, how may I help
you Mam?
Care Giver: Well my son who is 10 year old has stuffy nose, cranky and has mild fever
since yesterday. I also saw one of his teeth is erupting.
Pharmacist: you must have been in quite a bit of discomfort. (Empathy)
Care Giver: Yes, I do.
Pharmacist: This is a private area. Please have your seat Mam. (Privacy)
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Care Giver:
Pharmacist:
Care Giver:
Pharmacist:
Care Giver:
Pharmacist:
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Care Giver:
Pharmacist:
Care Giver:
Thank you.
Is he your son? (Identifying the patient)
Yes.
In order to help you better, I need to ask you a few questions.
Sure.
Thank you.
How long our son was in these signs and symptom?
Since yesterday.
You said Mam that he has mild fever. Could you please tell me, whether
you have measured that a thermometer or not, and how much was the
fever?
I measured it by a thermometer, rectally and it was 38.
How often does this happen to him.
First time.
Pharmacist:
Care Giver:
Pharmacist:
Care Giver:
Pharmacist:
Care Giver:
Pharmacist:
Care Giver:
Pharmacist:
Care Giver:
Pharmacist:
Care Giver:
Pharmacist:
Care Giver:
Pharmacist:
Care Giver:
Pharmacist:
Care Giver:
Have you tried any medication for him?

No.
Has he been seen by doctor for his condition?
No.
Does that affect his sleep? (Red flag)
No.
Any vomiting or diarrhea? (Red flag)
No.
Does your son have any medical condition like kidney disease?
No.
Any Rx medication?
No.
Any allergy to Medication. Food. Environment?
No. No. No.
Have you given him any OTC. Herbal. Vitamins?
Only multivitamin drop. (5 drops/day)
Is he taking his vaccine regularly?
Yes he does.
Care Giver:
Pharmacist:
Care Giver:
Pharmacist:
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Pharmacist:
Care Giver:
Pharmacist:
Care Giver:
Pharmacist:
Care Giver:
Pharmacist:
Care Giver:
Pharmacist:
Care Giver:
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You told me that he can not feed properly. Do you breast feed him?
Yes.
Do you also give him formula milk?
No.
Do you have any question or concern?
Just give me some medication to treat his fever and stuffy nose so that he
can be breast feed properly.
Ok, Mam, thank you for sharing information with you. Please give me a
Sure.
Thank you for your patience. Mam, I can assure your child has common
cold. He is too small, he is under two years of age and thats why it is
important to see his doctor to assess his condition. I will give a saline drop
to use 4 times daily by instilling 2 drops for his stuffy nose. You can use
some cold compresses and dress him in layers till you take him to his
doctor.
Is the case serious?
Pharmacist: It is not serious if you can take your son as soon as possible, to be
assessed and diagnosed. As I told you he is under 2 years of age, and
medication for cold and cough under this age should be carried out by the
family physician.
Care Giver: Thank you for your advice.
Pharmacist: I will call you after 3 days to see what you have done with his doctor.
Care Giver: Sure.
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Case: 19
An elderly man with glaucoma that suffers from sneezing mild fever and stuffy nose,
approaches the counter asking for OTC medication to treat his signs and symptoms.
Available: Otrivine 0.5% drop, Saline nasal drop, Sudafed Syrup, Benadry1 Syrup, Cd
artin Syrup, Claritin tablet and Aerium tablet 10mg, Tylenol 500mg.
you?
Patient:
Well, I want you to help me in choosing and OTC medication for my
stuffy nose and sneezing, I think I caught cold. I have also mild fever, I
checked it by mouth and it was 38.5 C.
Pharmacist: Oh, really then you must have been in a quite bit of discomfort. (Empathy)
Patient:
Yea, I am bothered a little.
Pharmacist: Why dont you grab your seat?
Patient:
Thank you.
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Patient:
Certainly.
remain confidential.
Patient:
Thank you.
Note: Identifying the patient here, there is no need since the patient is telling you, I have
sneezing and stuffy nose and privacy is not required for this case.
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
How long have you had these signs and symptoms?

Since yesterday.
How often does this happen?
Every year at the beginning of winter.
Have you had flu shot?
Yes, sir, 2 weeks ago.
Have you tried anything for your cold?
No, sir.
Does it affect your daily activity and disrupt your sleep? (Red flag)
No.
In addition to mild fever, do you have nausea and vomiting? (Red flag)
No.
Do you have severalized pain in your body? (To exclude flu)
No.
Do you have any medical condition?
Glaucoma.
That must be hard for you. (Empathy)
Well, at the beginning it was hard, then my doctor Rxed for me Timolol
drop and I am feeling well with it.
In addition to glaucoma, do you have any medical condition such as
asthma or diabetes?
No.
Any allergy to Medication.. Food.. Environment?
No. No. No.
Life style; Alcohol. Smoking. Diet.. Exercise?
No alcohol. No smoking. Well balanced. I do exercise
Before I got and check in my reference book, do you have any question or
concern?
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Patient:
Just give me any medication.
Pharmacist: Sure I will after I check in my reference book. Thank you for sharing
information with you. Please give me a few minutes to check in my
reference book.
Patient:
Sure.
Pharmacist: Thank you for your patience sir, I can assume your signs and symptoms
are related to common cold. I recommend taking Arius 10mg tablet which
is good for your sneezing and at the same time for you congested nose
(stuffy nose) and it doesnt cause any dizziness.
Patient:
Thats fine because of work on the computer system and I want to be alert.
Pharmacist: You are going to use this medication no more than 1week, within this
week, you should see an improvement in your stuffy nose and sneezing.
However, if you see that your signs and symptoms are getting worse, or
you need to use them more than 1 week, then it is important to see your
doctor. Also I am going to give you Tylenol 300mg, 1tablet on need i.e.
when you have mild fever only and not more than 3 days. If your fever
persists more than 3 days, then it is better to see your doctor.
(Administration, Precaution, Expectation, Monitoring and When to see the
doctor) Does that make sense to you?
Patient:
Yes it does.
Pharmacist: You may or may not experience some side effects like dryness of mouth
(suck on a candy) and headache (Tylenol).
Patient:
These are mild and tolerably.
Patient:
No, thank you.
Pharmacist: Some self care measures are important to be followed along with
medication like:
1. Sip some chicken soup
2. Drink plenty of water
3. Bed rest
4. Relaxation exercise
Patient:
Ok.
Pharmacist: If you dont mind, I will call you within 3 days to manage any side effect
like headache.
Patient:
Sure.
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Case: 20
Pregnant women in her first trimester having mild fever, general body aches, stuffy nose
and cough. She approaches the counter with her hands otrivine drops and benylin
tablet.
Available: Benylin tablet and syrup, Benylin Night, Tylenol 500mg tablet, Otrivine
0.5% drop, Saline drop for adult, different lozenges, Echinacea, Claritin tablet.
), I am the pharmacist in duty today, how may I
help you?
Patient:
Well, I want to purchase these two medication otrivine drop 0.5% and
benylin tablet since I have stuffy nose and cough. I have also some fever
and body aches but I have at home Tylenol 500ml to manage it.
Pharmacist: You must have been in quite a bit of discomfort. (Empathy)
Patient:
Yes that is true.
Patient:
Thank you.
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Note: Patient said the medication for me. (Identifying)

Pharmacist: Before I give you these two medications and in order to provide you with
the proper therapy, I need to ask you a few questions. Is that ok?
Note: Here although the patient picked up the OTC from the patient selected area, the
pharmacist has the right to intervene since they are not unscheduled medication to be
taken from any retail outlet.
Patient: Sure.
Pharmacist: I would like to reassure you that whatever information I gather will
Patient:
Thank you.
Pharmacist: How long have you been experiencing stuffy nose, muscle ache and
cough?
Patient:
Since two days ago.
Pharmacist: How often does this happen?
Patient:
Every year, at the beginning of winter.
Pharmacist: Have you taken your flue vaccine?
Patient:
Yes, I did.
Pharmacist: Have you tried anything for your signs and symptoms?
Patient:
Not yet.
Pharmacist: Have you been seen by doctor for that purpose?
Patient:
No.
Pharmacist: You said you have mild fever. Have you measured it by which route?
(Red flag)
Patient:
38.5C by mouth.
Pharmacist: Is their any nausea or vomiting? (Red flag)
Patient:
No.
Pharmacist: Does these signs and symptoms affect you daily activity or disrupt your
sleep?
Patient:
No.
Pharmacist: In addition to these signs and symptoms do you have medical condition
treat I should be aware of?
Patient:
No.
Pharmacist: Are you using any Rx medication?
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Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
OSCE TI PS
No.
Do you have any allergy to medication food environment?
No. No. No.
Do you use any OTC. Herbal product. Vitamins?
No. No. Materna.
Are you pregnant?
Yes in my 3rd month.
Congratulations.
Thank you.
Life style: smoking. Alcohol. Diet. Exercise?
No. No. Canadian guideline. Yes.
Before I go and check in my reference book, do you have any question or
concern?
No.
Pharmacist: Thank you for sharing information with you. I can assume Mam that you
have common cold. You can use Tylenol 500mg tat you have at home as
one pill on need basis if you have fever not more than one day, and for
pain also on need basis till you see your doctor. It is very important to see
your doctor since you are pregnant, because you are pregnant then you are
not a good candidate for over the counter medication, since these
medications with the exception of (Tylenol and some external
medications) should be done under supervision of doctor. So I dont
recommend taking otrivin 0.5% drop or Benylin tablet when you see your
doctor. You may saline drop 4 times daily.
Patient:
Thank you for all these information.
Pharmacist: It is important to follow for the time being till you see your doctor, those
are:
1. Inhale water vapour and place a towel over your head.
2. Bed rest.
3. Wash your hands with soap and water more frequently.
4. Shouldnt share your towel with the other to prevent the spread of
the infection.
Do you have any question?
Patient:
No, thanks.
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Pharmacist: If you dont mind, I will call you after 3 days to see what you have done
with your doctor.
Patient:
Ok.
Case: 21
30 years old patient approaches the counter, he is experiencing allergic rhinitis with bad
breath.
Available: Claritin tablet and Syrup, Aerius tablet and Syrup, Benadryl Tablet and
Syrup, N.S. drop, otrivin 0.5% drop, lozenges, Benylin tablet and Syrup, Tylenol,
terostine eye drop and Echinacea, different gargles.
), I am the pharmacist in duty today, how my I help
you?
Patient:
I have allergic rhinitis, this happen to me every year, start from September
till the end of November and also I feel some bad breath from my mouth.
So could you please give me something?
Pharmacist: That must be hard for you. (Empathy) This is private area, please have
your seat. (Privacy)
Patient:
Thank you.
Pharmacist: In order to help you better, I need to ask you a few questions, is that ok for
you?
Patient:
It is ok.
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Pharmacist: I would like to reassure you, whatever information I gather will remain
Patient:
Ok.
Pharmacist: Is your allergic rhinitis was diagnosed by doctor previously?
Patient:
Yes, I experience sneezing, water and eye, itching and now I have bad
breath too.
Patient:
Every year from September to November. However bad breath I felt once
only 3 days ago.
Pharmacist: Have you eaten any garlic or drink something different from your usual
diet or drink?
Patient:
No, I havent eaten outside and I eat my usual diet.
Pharmacist: How long have you been with your allergic rhinitis?
Patient:
Since 3 days ago.
Pharmacist: Have you tried anything?
Patient:
No.
Patient:
No.
Pharmacist: Does it affect your daily activity and disrupt your sleep? (Red flag)
Patient:
A little bit, but I am bothered from it. Could you please give whatever
OTC that is suitable for me?
Pharmacist: Sure, I will help you in therapy, however after checking in my reference
book.
Patient:
Ok.
Pharmacist: Do you have any fever? (Red flag)
Patient:
No.
Pharmacist: Any nausea or vomiting? (Red flag)
Patient:
No.
Pharmacist: Any phlegm or coloured discharge? (Red flag)
Patient:
No.
Pharmacist: Any medical condition beside these sign and symptoms?
Patient:
No.
Pharmacist: Any Rx medication?
Patient:
No.
Pharmacist: Any allergy to food. Medication. Environment?
Patient:
No. No. grass and pollen.
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Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
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So what do you use usually when you have this allergy?

I use Claritin tablet, one tablet need basis.
Any OTC. Herbal product. or Vitamins?
No. No. No.
Life style: alcohol smoking. Diet. Exercise?
No. No Yes good diet. Yes.
concern?
No.
Thank you for your patience. As you mentioned Mam, you have been
diagnosed of having allergic rhinitis, and your signs and symptoms now, I
can assume they are consistent with that. However, you have a bad breath
and this could be an early infection. It could be in your mouth, throat as
sore throat or infection in sinuses which may cause this bad breath. So
what I recommend is to see your doctor to assess and diagnose your signs
and symptoms. You said you always use Claritin tablet on need basis and
is effective whenever you have these signs and symptoms and I can give
you that but to use it just only till you see your doctor i.e. as soon as
possible.
Thats ok.
Some self care measures are important to follow till you see your doctor:
1. Avoid grass and pollen.
2. Take shower when you are out doors.
3. Sit in an air conditioning room at times when pollen is high.
Is that ok, Mam?
Ok.
If you dont mind, I will call you within 3 days to see what you have done
with your doctor.
Thank you.
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Case: 22
Alcoholic patient with mild fever, general malaise and headache.
His age: 44 years.
Available:
ASA in different strength, Advil 200 & 400, Tylenol with different strength, Tylenol
No.1, 222S, Centrum
help you?
Patient:
Well, I have mild fever. I feel tired and I have some kind of headache.
Pharmacist: Oh, really, then you must have been in quite a bit of discomfort.
(Empathy)
Patient:
Thank you.
Patient:
Thank you.
Pharmacist: In order to help you better, I need to ask you a few questions.
Patient:
Sure.
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Pharmacist: I would like to reassure you that whatever I gather will remain
confidential.
Patient:
Thank you.
Pharmacist: How long have you had these signs and symptoms?
Patient:
Since two days ago.
Pharmacist: How often this happens to you?
Patient:
Last year also happened to me.
Pharmacist: Have you used any medication for that?
Patient:
No.
Patient:
No.
Pharmacist: How feverish you are?
Patient:
My fever is 38.5C orally measured.
Pharmacist: Does these signs and symptoms affect your daily acitivity and sleep
distruption?
Patient:
No.
Pharmacist: Is there any nausea or vomiting?
Patient:
No.
Phram:
MAMA.
Pharmacist: Llife style: Alcohol. Smoking. Diet. Exercise?
Patient:
Drinks, 2-3 drinks alcohol every day. No smoking. Good. Good.
Pharmacist: Do you have any question or concern before I go to my reference book?
Patient:
If you can give me any medication.
Pharmacist: Please give me a few minutes to check in my reference book, before I can
recommend any therapy for you.
Patient:
Sure.
Pharmacist: Thank you for your patience. Sir, I can assume, you have common cold.
However, I cant give you Tylenol since you are chronic drinker, which
may result in your liver damage. Same thing for Advil, it cant be given
with alcohol. 222S or ASA can not be given with alcohol too. So what I
recommend is to see your doctor ASAP to assess your condition. In the
mean time, and till you see your doctor you can use some self care
measures like:
1. Inhalation of wet vapour (humidifier)
2. Bed rest.
3. Eat well balanced food.
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4. Wash your hand more frequently with soup and water to avoid
spread of infection.
Patient:
No, thanks.
Pharmacist: If you dont mind, I will call you with in couple of days to see what you
have done with your doctor.
Patient:
Ok.
Pharmacist: Thank you for coming in.
Case: 23
A 50 year old man is experiencing back pain. Lifting is part of his job, and he cant
avoid it. He needs pain killers to help him get through his day. He has also fecal
incontinence.
Available: Tylenol extra strength, 222S, Tylenol No.1, Tylenol regular, Advil 200 &
400, Capsaicin cream, ASA 650mg tablet.
), I am the pharmacist on duty today, how may I
help you?
Patient:
I need some pain killer for my lower back pain.
Patient:
Yes, it is hurting me a lot.
Patient:
Thank you.
Pharmacist: Before I give you a pain killer, I would like to ask you a few question, is
that ok for you?
Patient:
Certainly.
Pharmacist: I would like to reassure you that whatever in formation I collect will
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Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
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remain confidential.
Thank you.
Could you please explain more about your signs and symptoms?
I have lower back pain because in my work, I lift some objects and today I
feel the ain is more and I even experiencing urgency in defecation.
How long have you been in these signs and symptoms?
Since two months ago.
Have you tried anything for it?
I have at home Tylenol extra strength, and I use it on need basis, but I am
feeling now, Tylenol is less helpful. Could you please give me something
that is stronger?
Sure, I will after I gather more information and check in my reference
book, so that I can give you the adequate therapy or recommendation.
Thank you.
How often does this happen to you?
Well, last year, it happened with me whenever I lift heavy objects.
Have you been seen by a doctor for this purpose?
No.
Does it affect your daily activity and sleep disruption?
Well, as you know I have to work, we are 5 family members, and I combat
the pain at work by taking Tylenol, and at night I drink two shot of whisky
to combat the pain, so that I can sleep.
Sorry to hear that. That is hard for you.
Yes, it is hard.
Beside urgency for defecation, do you have any other signs and symptoms
like urine urgency or weakness in your legs? (Red flag)
No.
Any nausea and vomiting? (Red flag)
No.
MAMA
No Rx medication, no other medication, not known allergy, OTC only
Tylenol.
Life style: Alcohol. Smoking. Diet. Exercise?
2 drinks alcohol. No smoking. Good diet. Now cant do exercise
due to the pain.
Please give me a few minutes to check in my reference book.
Copyright 2000-2009 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is100
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Patient:
Sure.
Pharmacist: Thank you for sharing information with you. As you said Sir, you have a
lower back pain since 2 months ago, and now you have incontinence for
defecation, so it is very important to see our doctor to assess your
condition. Taking pain killer or any other medication without monitoring
the signs and symptoms by your doctor would carry more risk to your
health like more side effects and the disease may progress more, thats
why seeing your doctor will dispose your condition, and gives you the
proper therapy. You may need a physiotherapist or any other secondary
sitting. I can give you for the time being Tylenol No.1 till you see your
doctor. You use this medication as one tablet on need and space at least 4
hours between two doses. I t is good for acute or chronic cases f low back
pain. But again, I emphasize to see your doctor as soon as possible and
this medication is just a pain killer till you see your doctor. You may
experience some constipation (increase fibre intake), sedation (dont drive
when you use it). Take it with full glass of water by mouth. Does that
make sense to you?
Patient:
Yes, it does.
Pharmacist: It is important for you to follow some self care measures like:
1. Physical exercise
2. Heat massage
3. Avoid unnecessary bed rest
Patient:
I will follow that.
with your doctor.
Patient:
Ok.
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Case: 24
30 years old female has outbreaks of acne after years of no acne.
Available: Solugel 4% & 5%, Glycolic acid 2%, 10% gel and lotion
Pharmacist: Hello, my name is ( ).
Patient:
I have some pimples spread as red spots over my face. I havent
experienced that since I was 18 years old.
Pharmacist: That must be hard for you. (Empathy)
Patient:
Certainly hard.
Patient:
Thank you.
Patient:
Sure.
Pharmacist: I would like to reassure you, that whatever information I get will remain
Patient:
Thank you.
Pharmacist: How long have you had these pimples and red spots spread over your
face?
Patient:
Since 5 days ago.
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Pharmacist: How often does this happen for you?

Patient:
This is the first time. I remember when I was 18 years old, I experienced
acne.
Patient:
No.
Pharmacist: Do you have any eye irritation or dry eye?
Patient:
Yes I feel something like a foreign body in my eye.
Pharmacist: What is your work, Mam?
Patient:
I supervise labourers working in construction in the field.
Pharmacist: So you work is in the field making you exposed to sun light.
Patient:
Yes.
Pharmacist: Any other signs and symptoms?
Patient:
No.
Pharmacist: MAMA
Patient:
No medical condition, No known allergy, No Rx medication, no OTC or
herbal.
Pharmacist: Lifestyle: Alcohol smoking coffee. Diet exercise?
Patient:
No alcohol, no smoking, 5 cups of coffee, spicy and I use vinegar with
salad, I do physical exercise.
Pharmacist: Thank you for sharing information with you Reference.
Pharmacist: Thank you for your patience. I can assume from what you have just
mentioned that you are experiencing what we call Rosacea, these are
pimples that appear and provoked with certain triggers. In your condition,
I assume your occupation outside in the sun light and eating spicy food
with vinegars, all these are triggering factors for Rosacea. I recommend
seeing your doctor as soon as possible to assess your condition. He might
prescribe some Rx medication. In the meantime try to reduce No. of
coffee since hot beverages enhance Rosacea and avoid vinegar and spicy
food. Wear protective clothing and wear sun cream SPF30 to protect your
face from sunlight. Does that make sense to you?
Patient:
Yes.
Pharmacist: Some self care measures, in addition to what I have already addressed you.
It is also important to avoid any stressed up condition since it is a
triggering factor. Also you can use green-tinted foundation which works
well at camouflaging the redness of Rosacea.
Patient:
Thank you.
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Pharmacist: I will call you after 3 days to see what you have done with your doctor.
Case: 25
A mother that wants to know which is the preferred vehicle to choose when picking an
acne preperation, and how to use topical preps.
help you?
Patient:
I am here to ask you about the preferred vehicle to choose when picking
acne prep for my son and how to use them.
Care giver: Thank you.
Pharmacist: To whom do you want acne prep, so that you are asking the preferred
vehicle to choose for acne? (Identifying)
Care giver: To my son who is 18 years old.
Care giver: Sure.
Care giver: Thank you.
Pharmacist: Your son must have been in a quite a bit of discomfort from his acne.
(Empathy)
Care giver: Sure, he is.
Pharmacist: Does he have any allergy to medication. food. environment?
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Care giver:
OSCE TI PS
No. No. No.
Note: Here, there is no need to ask MAMA questions since she hasnt brought any Rx or
she isnt asking any OTC. She wants just to have some information about that; maybe
to talk with the doctor or to make her chose the best medication from the patient
selected area. We asked about allergy since any base vehicle may or may not cause
allergy. So it is better to ask about allergies. Also life style questions are not necessary
in this particular case for the same reasons above.
Pharmacist: First of all I would like to know your sons skin type so that I provide you
with the proper recommendation.
Patient:
My son has an oily skin face.
Pharmacist: Ok, Mam, in case of patients with oily skin often prefer vehicles with
higher proportions of alcohol i.e. solutions and gels. Also these vehicles
can be more easily applied to larger areas such as back, if back is
involved. However, those with dry or sensitive skin prefer non-irritating
lotions and creams. Also lotions can be used with any skin type, and
spread well over hair bearing skin, but will burn or dry if they contain
propylene glycol. So for your son, solutions, gels and lotions can be used.
Care Giver: Thank you for this information, could you please tell me how to use the
topical preps?
Pharmacist: Sure, topical preparations should not be applied to individual lesions but
to the whole area affected by acne (contrary to psoriasis, in psoriasis only
on the lesion) to prevent new lesions from developing, using care around
the eye rid, mouth and cheek, which chafe easily. Lotions should be
applied with a cotton swab once or twice a day after washing or at bedtime
if they leave a visible residue. Also I would like to caution you against the
use of a circular or rubbing motion that might increase irritation, and tell
him to use single, gentle, continuous strokes on each side of the face, from
the mild lineout towards the ears.
Care giver: Thank you for your information.
Pharmacist: I appreciate your deep concern in the health of your son. Feel free to call
me or visit me in the Pharmacy any time you like.
Patient:
Thank you.
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Case: 26
60 years old woman that has burned leg with boiling hot water. The affected covers
4cm2 and is painful, red and moist, and itching.
Available: ASA325, Tylenol 500mg, Advil 200mg, 400mg, Benzocaine oint, Tetracaine
oint, Pramoxine cream, Benadryl tablet, Syrup, Aloe Vera.
). I am the pharmacist in duty today, how may I
help you?
Patient:
Boiling water burned my leg while I was making coffee. It is a small area
that was burned, but it is painful, red, moist and itching.
Pharmacist: That must be hard for you sir. (Empathy)
Patient:
Yes, of course.
Pharmacist: This is a private counselling area, please have your seat. (Privacy)
Patient:
Thank you.
Pharmacist: In order to help you better I need to ask you a few questions. I would like
Patient:
Thank you.
Pharmacist: Since when this has happened?
Patient:
Since 2 hours ago.
Patient:
No.
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Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
OSCE TI PS
Do you have any fever? (Red flag)

No.
Is their any Nausea and Vomiting? (Red flag)
No.
Do you feel dizzy?
No.
Do you have any medical condition like diabetes or asthma?
No.
Are you using any Rx medication?
No.
Any allergies to medication food. environment?
No. No. No.
Life style: alcohol. Smoking.. Diet. Exercise?
No. No. good. Yes.
Before I go and check my reference book, do you have any questions or
oncern?
No.
Thank you for sharing information with you. Please give me a few
minutes to check in my reference book and I will get back to you.
Sure.
Thank you for your patience. Sir, you have a burn wound in your leg
which should be assessed by your doctor because you are not young to say
that the area involved is small. You are 60 years old and even for small
burns, you should be assessed by your doctor. In addition to that, you
burn is moist, red and painful. I just can give you Tylenol 500mg, on need
bases and not to exceed 8 tablets per day as a pain killer till you se your
doctor as soon as possible. Does that make sense for you?
Yes, Sir.
Some self care measures are important to follow now like
1. Cooling and cold compresses 4-6 times per day.
2. Backing soda baths may provide relief of itching.
3. You may put a dressing on the wounded area.
Can I put n multi biotic cream or ointment on it?
There is no need since it is not an open wound. See your doctor as soon
as possible and he will tell you what you need.
Thank you.
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with your doctor. In the meantime, feel free to call me anytime.
Patient:
Thank you so much.
Pharmacist: Thank you for coming in.
Patient:
Have a nice day.
Note: Here there is no need to ask for tetanus vaccine, whether the patient has been
vaccinated or not since it is a small burn. There is no need to give local anesthetise. We
should give time for the doctor to assess the condition of the burn. Tylenol alone is
enough. ASA can not be given since it enhances anti coagulating and aspirin also
enhances histamine release which increases the itching of the patient.
Case: 27
Name: Janne, Joh
Age: 44 years
Patient Profile
Inderal 40mg PO 1x2
Patient approaches your counter requesting an OTC for his wasp sting which happened
30 minutes ago and he has mild symptoms of flushing, some itchiness and restless.
Available: Dibucaine cream, lidocaine cream, pramoine, EmCa patches, Calamine
lotion, Benadryl tablet and Syrup, Menthol Hydrocortisone 0.5% cream, Tylenol 500mg
tablet.
you?
Patient:
I had a sting bite and I want any remedy for it.
Pharmacist: Oh, you must have been in quite a bit of discomfort. (Empathy)
Patient:
Yes, I have some itchiness and flushing and I feel somewhat restless.
Patient:
Thank you.
Patient:
Sure.
Pharmacist: I would like to reassure you that whatever information that I gather will
Patient:
Thank you.
Pharmacist: Ok, sir when did that happen?
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Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
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Half an hour ago.

Have you tried anything?
I just put a tooth paste on the bite to cool it.
Thats good. Do you have mentioned like dizziness, Nausea and
Vomiting? (Red flags)
Until now, no.
Do you have any medical condition?
Hypertension.
Is it controlled?
Yes, it is controlled.
What do you use for it?
Inderal 40mg orally twice a day.
Do you use it regularly?
Yes, I do.
Do you have any allergy to medication. food. environment?
No No. No.
Any other medical condition?
No.
Any other Rx medication?
No.
Are you using any OTC. herbal. Vitamins?
No. No. No..
Life style: alcohol. Smoking. Diet. Exercise?
No.... No. good. Do exercise.
Do ou have any question or concern?
Just give me any mediation for the sting bite.
Sure, sir, I will provide you with the proper therapy after I check in my
reference book. Thank you for sharing the information with you. Please
give me a few minutes to check in my reference book.
Sure.
Thank you for your patience. Sir, according to my reference book, you
should go immediately to emergency room.
Is my case serious?
Yes, your case is serious since you are using Inderal 40mg for your
hypertension. This medication masks most of the signs and symptoms of
the allergy reaction that may occur with sting bites. In addition, it makes
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the treatment harder since higher doses of adrenaline are needed to treat
your allergy reaction if it happens. So, Sir, I greatly recommend to go
now to ER to assess your condition, and to be treated immediately so that
to manage any allergic reaction if it does occur from the sting bites.
Patient:
I will go now to the ER.
Pharmacist: If you dont mind, I will call you tomorrow to see how your condition was
managed. Do you want me to call a taxi for you?
Patient:
No, thanks.
Case: 28
A teenager that stepped on a nail white working with a carpenter in his shop. It went
through his boot and let a puncture wound on the outside of his foot. It is quite painful
and he can not step fully on that foot. He has taken a tetanus shot within the last 5
years.
Available: ASA 35mg, Tylenol 500mg & extra strength, Pramoxine cream, Polysporin
cream, Elma patch, Xylocain gelly, Ethanol 70% & 95%, H 2O2 5%, Different sizes of
bandages.
Pharmacist: Hi, my name is ( ), I am the pharmacist in duty today. How may I help
you?
Patient:
Well, while I was walking in a carpenter shop, a nail vent through my boot
and left a puncture wound on the outside of my foot. I can not step on it
and it is hurting me.
Patient:
Yes, it is painful.
Patient:
Thank you.
Patient:
Sure.
Patient:
Thank you.
Pharmacist: When did that happen?
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Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
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2 hours ago.
No.
No.
Any Nausea and Vomiting? (Red flag)
No.
Have you taken any tetanus shot?
Yes, 5 years ago, 3 doses.
Do you have any signs and symptoms other than these?
No.
MAMA?
No medical condition, no Rx medication, no known allergy, no OTC, or
herbal product.
Life style: alcohol. Smoking. Diet Exercise?
No. No. Good. Good.
concern?
Any medication to treat my condition.
Sure, after I check in my reference book to provide you with a therapy.
So, thank you for sharing information with me. Please give me a few
Sure.
Thank you for your patience. Sir, it is important to see your doctor since
you can not step properly on your foot, and is quite painful.
But I had tetanus shot 5 years ago and I received 3 doses.
Thats good to protect you from tetanus and it is still active. But still
because you have quite pain and you can not step your foot on the ground,
then you should see your doctor. I am going to give you Tylenol 500mg
just as a pain killer to help you tolerate the pain till you see your doctor.
Thank you.
Do you have any questions so far?
No.
Some self care measures are important to follow.
1. Immobilize the area, and keep the area rested for now.
2. Keep the wound moist to promote healing so you can put a
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dressing for it.

Patient:
Thank you.
with your doctor.
Patient:
Ok.
Case: 29
A young couple has encountered poison ivy on a camping trip and are itchy and
miserable.
Available: Hydrocortisone cream 5%, Benadryl Syrup, tablet 25mg & 50mg, Claritin
Syrup, tablet 10mg, Aericin Syrup, tablet 10mg, Xylocain oint, Benadryl oint,
Neutrogena cream.
you?
Patient:
I am here looking for a medication for poison ivy. I was on a camping trip
yesterday where I came in contact with ivy plants and now my legs are
itchy and eczematous with some blisters.
Patient:
Patient:
Thank you.
Pharmacist: In order to help you better, I need to ask you a few questions. Is that ok?
Patient:
Yes, ok.
Patient:
Thank you.
Pharmacist: You said since yesterday you have this? (Confirming how long)
Patient:
Yes.
Pharmacist: How often did this happen to you in the past?
Patient:
It is the first time.
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Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
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No.
Have you visited a doctor for this purpose?
No.
No.
Any Nausea and Vomiting? (Red flag)
No.
Any dizziness? (Red flag)
No.
Does it affect your daily activity and disrupt your sleep? (Red flag)
No.
MAMA?
No medical condition, no known allergy, No Rx medication, No OTC or
herbal.
Life style: Alcohol. Smoking. Diet.. Exercise?
No No. Good. Yes.
Do you have any question or concern?
Just give me any remedy for this thing.
Sure, I will, after checking in my reference book. So, thank you sir, for
sharing the information with you. Please give me a few minutes to check
in my reference boo, and I will get back to you.
Sure.
Thank you for your patience, sir. I can assume you are experiencing
contact dermatitis due to poison ivy. I am going to give you Benadryl.
Which one do you prefer, tablet or Syrup?
Anything that is good.
Both dosage forms work the same however the pills are easier to carry
them, so I am going to give you Benadryl tablet 25mg and use them as
one tablet on need basis i.e. just when you feel you have itchiness. You
are going to use it one tablet on need basis for no more than 2 weeks,
within these two weeks you should see a relief in your itchiness.
However, if you dont see any relief, or your itchiness is getting worse
after the first dose, or you need to use it more than 2 weeks, then
discontinue the medication and see your doctor. You can use it with or
without food with a full glass of water. (Administration, precaution,
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Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
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expectation and monitoring) Also, Hydrocortisone 5% cream I am going

to give you. You are going to apply it 2 or 3 times also whenever there is
itchiness and redness. You are going to use it, no more than a week,
within this time period you will see a relief in your leg redness and
itchiness. However if the itchiness became more after the first application
or if you should use it more than 1 week, then you should discontinue the
medication and see your doctor.
I have at home petrolatum, can I use it?
Sir, Petrolatum has the tendency to irritate particularly sensitized skin as
in your case now. It is best avoided.
Ok.
Some side effect you may or may not experience from Benadryl like
dizziness (dont drive car), constipation (increase fibre intake) and from
Hydrocortisone 0.5% cream, you may or may not experience some kind of
irritation which is tolerable. Do you have any question so far?
No.
Some self care measures are important to follow like:
1. Use moisturizers like Neutrogena cream.
2. Oatmeal baths.
3. Avoid touching the blisters and unroot them.
Thank you.
If you dont mind, I will call you within 3 days to manage any side effect
like dizziness to see how you are improving.
Thank you.
Thank you for coming, have a nice day.
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Case: 30
A woman was scratched by her pet during her vacationing 3 days ago in the green parks
of Ohio. The wound is now red, slightly inflamed and still painful.
Available: Benadryl Syrup, tablet 25&50mg, Polysporin cream, Xylocain cream, Elma
cream, Different sizes of bandages, Benadryl oint, Mupirocin oint, Polymyxin oint.
you?
Patient:
Could you please give me something for my super facial wound? I was
scratched by my pet during my vacationing in one of the parks of Ohio.
Pharmacist: Oh, you must have been in quite a bit of discomfort. Please have your
seat. (Empathy)
Patient:
Thank you.
Pharmacist: Before I recommend any thing for you, I need to ask you a few questions.
Is that possible for you?
Patient:
Sure.
Patient:
Thank you.
Pharmacist: Could you please describe to me your wound?
Patient:
Well the scratch is now red. It is still painful with slight swelling.
(Inflamed)
Pharmacist: Since when this happened?
Patient:
3 days ago.
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Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Is this the fist time that this happens to you?

Yes, it is the first time. It is a friendly cat.
Have you tried anything for it.
No.
No.
Can you sleep well?
Yes.
Does it affect your daily activity?
No.
No.
Any dizziness? (Red flag)
No.
MAMA?
No medication, No Rx medication, no allergy, no OTC or herbal.
Have you been vaccinated by Tetanus toxoid as a primary immunization?
Yes, and complete doses.
concern?
Patient:
No.
Pharmacist: Please give me a few minutes to check in my reference book. Thank you
for sharing the information with you.
Patient:
Sure.
Pharmacist: Thank you for your patience. According to my reference book, it is
important in your case to see your doctor as the scratch was out door in an
open environment which could be contaminated by certain microbes, like
tetanus since you said you were in a green park during the scratch. I know
you have been vaccinated completely by tetanus. But still in your
condition since as I told you the scratch was in a place which could be
contaminated then it is important to be assessed by your doctor. You may
need a toxoid vaccine.
Patient:
Is that serious?
Pharmacist: Taking a toxoid vaccine if your doctor recommends will boost your
protection more toward any infection.
Patient:
Ok, then.
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Patient:
No.
Pharmacist: Keep the wound clean and cover it with a bandage to enhance healing and
to avoid dryness.
Patient:
Ok.
Pharmacist: If you dont mind, I will call you after three days to see what you have
done with your doctor.
Patient:
Thank you.
Case: 31
A 2 year old child who has crusty discharge in his eyes upon waking the last two days.
He has no fever. He is crying. His eyelids are stuck together in the morning.
Available: Polysporin eye drop, Polysporin eye oint, Visine drop, Mydfrin drop,
Neosporin drop, Opticrom drop, Alocvil drop, refresh tears and Systane.
Solution:
The patient in this case should be referred to his doctor. We can not recommend any
OTC for the patient since he is a child. (We can not offer OTC for 48 hours. Patient
Self-Care Pg. 152) Some self care measures like, eyelids that are stuck together in the
morning should be soaked with a warm compress and opened carefully. The family
need to pay attention to personal hygiene to avoid transmitting the infection.
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Case: 32
A woman approaches the counter asking for an OTC product for her both children
having chicken pox. One is 2.5 years old and the other 4.5 years old. They have mild
fever, rash on the body with liquid blisters on top.
Available: Aveeno, Tylenol Syrup, ASA 80mg, Benadryl, Calamine lotion, Caladrcyl
lotion.
Solution:
The infection is a viral infection, and should be diagnosed first by doctor. So referring
the Patient to doctor for diagnosis is important. In the meantime till the patient sees his
doctor, oat meal baths, like Aveeno, help soothe the rash and ease the itch. For mild
fever and pain relief, Tylenol is a good choice. Not aspirin 80mg (Reyes syndrome)
Caladryl Potion may be given. This product combines the drying agent of calamine
lotion with a topical anti-itch formation of Benadryl. The bottle should be kept cool in
the fridge. Some self care measures are important to follow like Baths in cool water
with baking soda. Wet compresses can provide also quick relief of itching. Trimming
the finger nails short can prevent scratching. Keeping those scars to a minimum.
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Case: 33
A mother approaches the counter, and says that the doctor said her young son is lactoseintolerance and thats why causing her smelly diapers. She is one year old. Is there
something to give her?
Solution:
If the lactose intolerance is mild, and in this condition because the child is one year old,
the desire for milk product is not strong, so avoiding milk and eliminating lactose
containing foods from the diet. Soy milk may provide a good alternative, some are even
fortified with extra vitamins and calcium for those who have a great desire for milk like
under 1 year of age. (Milk should be recommended by the paediatrician since the patient
has lactose intolerance.) For mild cases, and when mild is the only source for children,
in addition to soy milk recommended by doctor, the patient may use the ordinary
formula milk, and then adding the enzyme lactase directly to mild products. This
typically decreases the diarrhea and gas experienced with lactose intolerance.
Examples: Lactaid, Dairy Ease, Surelac
Case: 34
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A mother approaches the counter requesting an OTC medication for pain, for her 6 year
daughter has some sprain in her wrist after she fell down from a ladder, yesterday.
Available: ASA 325mg tablet, Tylenol 325mg tablet, 500mg Tylenol #1, Tempra drop,
Tylenol Suspension, childrens Motrin or Childrens Advil susp, chewable or Junior
tablet.
Solution:
In this particular case, since the age is above 4 years, we can ask the patient to rate the
pain from one to five. One for mild pain, and five for worst pain. Best medication to be
given for the child is Advil suspension, since it acts as a pain-killer and as an antiinflammatory agent. Tylenol alone will not help as Advil. Follow the dose according to
weight on label of advil. Tell the mother that: Your child is going to use this medication
as ( ) no more than 1week, within this week he should see a relieve in his pain and
swelling. However if the pain was getting worse after the first dose or the patient
requires to use the advil suspension more than 1week, then contact his doctor.
Self care measures: RICE
Case: 35
A lady approaches the counter and she is embarrassed. She wets herself when she is
hurrying to get somewhere, or when she laughs.
Solution:
1. Provide privacy and empathy (you must have been in a quite a bit of discomfort or
frustrated).
2. Since it is occasional, educate her about kegel exercises to strengthen muscle tone of
vagina.
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3. Offer incontinence pads that absorb both urine and odor.

4. This takes up to three months to see an optimum respone (Expectancy).
5. In case if the condition is not occasional i.e. persistent, or no optimal response after
three months, then it is important to see the doctor. (When to see the doctor.)
Non-pharmacological
1. Avoid caffeinated products like coffee and tea
2. Avoid citrus juices since they irritate the bladder
Case: 36
A person approaches the counter. He wants something to his ear and to all family
members, since their ear hurt terribly whenever they fly in an airplane. They have no
allergy, or medical conditions. John is 48 year old, his wife is 46 years old. His son is 8
months and the other one is 3 years old.
Available:
Infants Tylenol cold drop, Dimetapp childrens Decongestant drop, Otrivine drop, 4way spray and Pseudafed Syrup
Solution:
1. After gathering all the information and MAMA and life style; then educate the
patient that this happens due to blockage of the eustachian tube of the ear by
congestion which results in a vacuum and the fluid presses painfully against the ear
drum
2. Under 1 year give Infants Tylenol Cold drop. The dose is according to weight on
the label. The child who is over two years give him, Dimetapp Childrens
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Decongestant.
3. For adults give Otrivine drop
If the patient says after asking him all the above OTC that he has tried that before with
no benefit, then tell him to see their doctor.
Self Care Measures
1. Drinking water chewing gum or yawning
2. Feeding a bottle of milk or breast feeding is also sufficient for infants and children.
Case: 37
40 year old person approaches the counter, with his hand multivitamin (Centrum tablet).
He asks whether Centrum can treat his restless-leg syndrome which he heard from his
friend.
Solution:
1. If this happens occasionally mild ting ling, and twitching of the legs, and the
insomnia is for few nights in a mouth. Then OTC could be given, like:
Ualerian herbal product which is an effective sleep aid (150-300mg in capsule form)
taken half an hour before sleep.
Tell him Centrum is good since many who suffer from RLS also have been shown to
have lower than normal iron levels.
Nytol (Diphenhydramine 25mg tablet) is good when short-term sleep aid is needed.
2. If the condition of insomnia is persistent, or the condition is continuous, then refer
to doctor.
Self Care Measures:
1. Avoid any alcohol, smoking and caffeinated beverages
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2.
3.
4.
5.
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Avoid stressful conditions

Physical exercise
Relaxation exercise
Sleep hygrene
Case: 38
Someone approaches the counter of your pharmacy asking if there is any OTC drug to
stop baldness.
Available:
Rogain shampoo
Solution:
1. If the person is asking an OTC for baldness, and he is not having any baldness, or if
he wants it just in case for prevention since he has a family history of baldness, then
dont give Rogain. Follow self care measures, since he is not losing hair.
2. However, if the person is having continuous baldness and losing the hair, the drug
Rogain (minoxidil 20%) has been shown to slow down baldness in some men. It
should be used twice a day, everyday, for 3-4 months before you see the results.
Self Care Measures:
1. Avoid hair from exposing to severe cold. Wear a hat to keep it warm.
2. Avoid curling the hair
3. Avoid harsh soaps
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Case: 39
A patient 25 years old asks for an OTC for Jock itchy. He has some rash in the area
with small, red, rising like bumps that cover the groin area and the external genitalia.
Solution:
1. Give Miconazole or Clotrimazole cream ointment or tolnaftate twice daily for 1
week.
2. You can give powders of antifungals for places where sweating is a problem,
like in folds of skin. Apply for 1 week.
3. If itchying becomes severe, applying a light coating of Hydrocortisone 5%
cream or ointment to the rash with the antifungal cream or ointment for another
week may help.
4. If the condition persists after 2 weeks or becomes worse after adding
Hydrocortisone 5% cream or oint, then discontinue Hydrocortisone 5% cream
and contact your doctor.
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Drug-Related Problems
1. If there is a DRP in the Rx i.e. a drug-drug interaction, food-drug interaction,
disease-drug interaction, high dose, low dose, warnings or precautions and your
task is to counsel a patient, mentioned that the Rx is ready for pick up then in
that case, ou should counsel the patient on the medication(s), and at the end
before you go to non-pharmacological, you should say I want to double check
with the doctor or to confirm this thing with the doctor since there is a drugdrug, food-drug, low dose etc. and then I will call you back today. However,
dont use that dose till I call you back.
2. Sometimes there are certain DRP that depends on your professional judgement,
and in that case there is no need to call the doctor. But just either space apart or
discontinue one medication in profile or you can just say monitor your condition
in profile, see any warning sign and symptom contact your doctor immediately.
Examples:
Sildenafil 25, 50, 100
Vardenafil
Tadalafil
Enzyme inhibitors (Erythromycin PI,

Cimetidine, Valproic acid. etc)
You can ask this question at the beginning of counselling after you check in your
reference book like, when are you going to plan to take this new medication which is
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Sildenafil and Vardenafil or Tadalafil since it is a prn and especially when you see that
the ofter medication, its dose will end up after few days if it is an antibiotic. The
patient can finish the antibiotic course and then take Sildenafil course to prevent any
interaction. However, if the case is persistent for example, he is using Valproic acid for
epilepsy and now he is using either one of sexual dysfunction medication, in that case
we can not discontinue either drug, and we can tell the patient to monitor his dizziness,
fussiness or drowsiness. Also in certain cases for example, if in patient profile there is
Omeprazole or HP-PAC, then there is no need to call the Dr, you just tell him to
discontinue the previous medication in the profile. Also is any statin with enzyme
inhibitor like Erythromycin or Clarithromycin or Cimetidine used shortly, we can tell
the patient to discontinue the statin medication which is acting an enzyme inhibitor is
finished and the patient can compensate that by diet and physical exercise. Also there
are cases of non compliance with several devices for asthma or COPD; Doctor may
prescribe two medicaton in one device like symbicort or advair to make the patient
easier for him to comply with the medication; in this type of condition there is no need
to call the doctor to discontinue the other medication, you can just tell the patient that
you drug of mediacation gave you advantage to make it easier for you and less costly.
Similar conditions when shifting within the same class like Ipratropium to Tiotropium,
you dont expect the patient to use both. However there are certain condition to ex. in
case of steroid puffer for example, advair and the patient profile contains flovent. In this
condition it is important to call the doctor since in certain conditions both could be
given since such a combination may not exceed 2,000ug/day. Also Ritalin with
concentra, both could be given, since Ritalin (methylphenidate) could be used for
breakthrough doses while concentra for maintenance doses, and therefore it is better to
call the doctor. So always use your knowledge and professional judgement in these
conditions.
So when not to counsel the patient about the medication. This happens when your
reference book tells you that these medication are contraindicated. So any
contraindication, you should not counsel the patient, and explain that to the patient and
tell him I should call the doctor to discuss with him about certain issues with respect to
medication(s), the contraindication is a DRP, high dose or very low dose or severe drugdrug interaction of clinical importance or food-drug interaction which results in severe
morbidity or lethal dose or hypersensitivity reaction, or non compliance. So when you
want to tell the patient that there is a DRP and how to correct it is by tell him.
Mr. or Mrs. (name), your medication that your doctor Rxed may
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interact is overdosage with milk, food

underdosage
medication, herbal
should suggest to space apart
monitory our condition
call the doctor
avoid using this
OTC and herbal product
OSCE TI PS
resulting in bad effects so I
Case: 40
Name: Joha Smith
Patient Profile
Age: 65 years old
Sandimmune 320mg/day given I.V
Condition: Inflammatory bowel disease
for 30 days. (20 left on hand)
Weight: 80kg
Rx
Andriol (testosterone undecanoate) 80 mg BID
Mitt 120 capsule
Refills: (3)
Solution:
1. Gather the information(MAMA + life style including the patient profile)
2. Tell the patient after checking in CPS that there is a Drp between the new
medication which is Andriol and the previous medication in his profile that is
used for inflammatory bowel disease namely sandimmune injection since there is a
drug-drug interaction between the two medications resulting in potentiation of
cyclosporine and in more kidney side effects, and therefore I have to call the doctor
to discuss this issue with him. So sorry for not the filling the Rx now until I discuss
this issue with your doctor. You may use it after you finish the course of
Sandimmune, but in either case I have to call the doctor, Dont counsel the patient
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here since there is a contraindication in CPS, and a 20 days on hand is considered a

long period to wait and then to use the new medication.
Case: 41
Name: Carl Glaxo
Age: 70 years
Weight 80kg
Gender: Male
Patient Profile
Creatinine clearance: 20ml/min
Glyburide 5mg PO QD
Rx
Glucobay (acarbose) 100mg PO tid
Mitt: 100
Refills: (2)
Solution:
1. Gather the information as usual
2. Then go to CPS and check. Tell the patient that because your kidney does not
function well as it is indicated on your profile. In such a case this medication is not
recommended. I should call the doctor to discuss this issue with you. He might put
you on another medication. (Dont say I cant dispense it.) In case of creatinine
clearance is below 25ml/min, Glucobay (Acarbose) is not recommended.
3. Counsel him on self care measure of how to manage his diabetic condition currently
till you discuss with his doctor namely complying with the previous dose, Diet and
physical exercise.
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Case: 42
Patient name: Mary Glaxo
Age: 35 years
Gender: Female
Rx
Clomid 50mg tablet
Sig: tablet BID
For 5 days
Refills: (2)
Solution:
1. Gather the information from the patients. Including MAMA questions as usual.
2. Then after checking in CPS tell the patient If you dont mind I would like to call
the doctor to double check with him about the dose since the usual dose for the first
time is with one pill (50mg) daily and not two pills daily for 5 days, and to increase
the dose only in those patients who do not respond to the 1 st course. You have told
me that this is your first course and thats why I want to confirm this with the
doctor.
3. Dont counsel on medication but educate the patient that after we get confirmation
from the doctor about the dose, therapy may be started at any time if the patient has
no recent uterine bleeding. However if the doctor intends to do progesteroneinduced bleeding or planning to do that, or of spontaneous uterine bleeding occurs
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before therapy, the regimen of 1 pill (50mg) daily for 5 days should be started on or
about 5th day of the cycle.
4. Educate the patient that if pregnancy has not been achieved after 3 ovulatory
responses to clomiphene, further treatment is not recommended.
5. Advice the patient of the possibility of multiple pregnancy and its potential hazards
if conception occurs during a cycle in which clomiphene is given, and thats why the
patient should check using pregnancy test before using the medication.
6. Inform the patient the possibility of multiple pregnancies when one uses this
medication.
Case: 43
Name: Johnson Bird
Age: 50 years
Allergy: Unknown
Patient Profile
ASA 650 mg QID
Altace (Ramipril) 5mg PO QD
Betaloe (Metoprolol) 100mg PO BID
Warfarin 2.5mg PO QD
Rx
Naproxene 500mg PO T.I.D
Mitt: 30
In this particular case, as a first glance one thinks that there are 3 DRPs here. Firstly is
that ASA and Naproxene (two NSAIDs) are not recommended together. Secondly, ASA
causes bleeding and naproxene may induce that. Thirdly, warfarin may augment
bleeding more especially if the patient is taking two NSAIDs.
Here the student must be prudent before he says, I should call the doctor or I can not
counsel since these medications are not recommended together. So if the task is to
counsel, I should counsel, which means that there is no DRP, and if there is something
to address during counselling as due to the drug-drug interaction or disease-drug
interaction should be addressed by monitoring or cautioning the patient Also the student
should be aware of the medical condition of the patient He should read and asl proper
questions with respect to the profile of the patient, and therefore he should ask whether
the patient was in the hospital or not, since from the profile, one can predict that the
patient has a post-MI condition, and when was his last myocardial infarction. So, if the
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patient has recently been in the hospital and discharged then this case is related to post
MI and the doctor is intending to give these medications together to treat symptomatic
pericarditis, and it appears that ASA is in effective, and therefore the doctor added and
NSAID, or he might have added a corticosteroid.
Solution:
1. As far as the task is to counsel, then counsel the patient and ask adequate questions
to confirm his condition is a post-MI, pericarditis.
2. Address other issues by monitoring the patient and caution the patient about the
bleeding from any site and to contact his doctor immediately.
3. Discontinuction or contimuction of warfarin depends on period of pericarditis had
occurred. If it occurred early, then there is no need to call the doctor. However call
the doctor if pericarditis presents weeks or months following MI (Dresslers
syndrome) due to risk of pericardial bleeding and tamponade. (Therapeutic Choices
Pg. 451)
4. In form the patient about gradual mobilization, if he had recent MI, and to keep his
appointments with his doctor for ECG and monitoring his condition.
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Case: 44
Age: 45 years
Allergy: Unknown
Rx
Advir 250 inhalation aerosol
One inhalation twice daily
Solution:
1. Gather all the information including MAMA.
2. Check in CPS. Inform the patient that you are going to call the doctor to double
check with the doctor about the dose of the inhaler, since this dose is for Advair
Diskus and not for Advair inhalation aerosol which has a different dose which is two
inhalations twice daily. (CPS 2008 Pg. 61)
3. Counsel the patient about non-pharmacological only.
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Case: 45
Patient name: Lynett Kimbey
Patient Profile
Age: 42
Agenerase Capsule (Amprenavir)
Allergy: Unknown
150mgx4 BID
Weight: 80 kg
Ritonavir 100mg tablet BID
Rx
Agenerase oral sol. 15mg/ml
40ml. BID
help you?
Patient:
I am here to pick up my prescription.
Pharmacist: Comment: The pharmacist should know that the Rx is for Agenerase, and
should offer privacy. This is a private area, please have your seat.
(Privacy)
Patient:
Thank you.
Pharmacist: Is this Rx for you sir? (Identifying the patient)
Patient:
Yes, sir.
Patient:
Sure.
Pharmacist: What did the doctor tell you this medication is for?
Patient:
Actually I had this medication before, as you can see from profile, but it
was inform of capsule, and I have some difficulty in swallowing, and I
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told the doctor for that, actually they are big capsules not like the other
pills and thats why he prescribed a liquid for me which is easier for me to
be swallowed.
Pharmacist: That must be hard for you sir. (Empathy)
Patient:
Yes, it was hard for me.
Pharmacist: Continue asking MAMA and life style. Then check in reference book.
Pharmacist: Sir, I should call your doctor since Agenerase capsule and solution. Are
not inter changeable on mg-mg basis. This liquid form is about 14% less
effective if given in that dose. So I should call the doctor to correct the
dose, so that you may gain the maximum benefit from your medication.
Patient:
Ok.
Pharmacist: Counsel on non-pharmacological only and not the medication, since there
is a DRP, and the doctor in such a condition may not correct the dose, he
may switch him to a different medication, especially if he thinks that
increasing the dose may increase the side effect.
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Case: 46
Patient name: Angela Crist
Patient Profile
Age: 23 years
Insulin NOVO ge. Regular 20 BID
Allergy: Unknown
Insulin NPH 50/70 30 BID
Rx
Ovral 21 (EE 50g/norgestrel 0.25mg)
1 tablet PO for 21 days
Mitt: 3 packs
Refills: (3 packs)
Solution:
1. Offer privacy
2. Gather information including MAMA and life style and ask about the control of her
diabetes
3. Go to the reference book and check. Inform her that there is a DRP and you should
call the doctor since she is a diabetic patient and this pill contains high conc. of
medications that may result in loss of control of her diabetes, So I am going to call
your doctor to discuss this issue with him (Dont worry say to double check with the
doctor) and tell the patient that your doctor may Rx low dose medication or another
method of preventing pregnancy which is safer for her diabetes.
4. Counsel on non-pharmacological of her diabetes. Dont counsel on that medication,
since the doctor will definitely switch her to another method.
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Case: 47
Patient Profile
Age: 55 years
Lactulose 30ml for barium enema tomorrow
Allergy: Unknown
Rx
Asacol (5-ASA) 400mg tablet
2 tablet PO BID
Mitt: 100
Refills: (3)
Solution:
1. Gather the information including MAMA and life style and check in CPS.
2. Inform the patient that you should call the doctor since the laxative that he is going
to take tomorrow for his barium enema which is lactulose is an acidic substance.
Its action may last (1) or (2) days, and because the medication that he is taking
namely Asacol can not disintegrate in acidic medium since it is an enteric coated
tablet a part will have no benefit since the onset is 24-48 hours. So your doctor may
prescribe for you another laxative for your colonoscopy so that it may not interact
with your medication that you are taking.
3. Counsel the patient on non-pharmacological like advising the patient not to limit his
food group and social supporting group is important.
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Case: 48
Patient name: Nancy Herald
Age: 37 years
Allergy: Unknown
Rx
Avelox 400mg tablet PO Od for 14 days
Mitt: 14
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pham:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Hi, my name is (
Sure, this is a private area please have your seat. (Privacy)
Thank you.
Yes, it is for me.
In order to help you better, I need to ask you a few questions, and I would
like to reassure you whatever information I gather will remain
Thank you.
What did the doctor tell you about the use of this medication?
He told me it is for my urinary tract infection.
Oh, really, you must have been in quite a bit of discomfort. (Empathy)
Oh, yea.
Yes.
No.
Any allergy to medication.. food. environment?
No. No. No.
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Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Any Rx medications?
No.
Any over the counter. herbal product. or vitamins?
No. No. No.
Are you pregnant?
No.
Do you breast feed?
Yes, I breast feed my child who is 6 months old.
Do you give him additional formula milk?
No, only I give my breast milk.
Asking on life style. Alcohol, smoking, diet, physical exercise?
No. No . good diet and good physical exercise.
Thank you for sharing the information with you. Please give me a few
Patient:
Ok.
Pharmacist: Ok, Nancy, I need to call your doctor about your medication since it is
mentioned in my reference book (CPS) a serious warning and precaution
for those patients who breast feed and take this medication. If you dont
mind I will call the doctor to discus this issue with him (dont say to
double check with doctor since it is a serious warning, and a possible risk
to the baby taking into consideration that there are other alternatives) since
Avelox is excreted in the breast milk, and because of the potential of
unknown effects from this medication, a decision should be made by your
doctor to switch you to another medication or discontinue breast feeding,
because there are other good alternatives).
Patient:
Ok, no problem, call the doctor, please.
Pharmacist: Counsel on non-pharmacological like increasing water intake, and drink
cranberry juice.
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Case: 49
Patient name: James Ford
Patient Profile
Age: 60 years
Cimetidine 200mg
Allergy: Unknown
1x2 since a month ago
Refills: (3)
Rx
Apo-metoprolol 50mg tablet
1x2
Mitt: 60
Refills: (3)
Solution:
1. Ask about MAMA questions and life style
2. Check in reference book
OK, sir, I should call the doctor since it seems that a drug-drug interaction may
occur between your previous medication and the new medication. I wont do double
check with your doctor. (Here double check should be said and not an issue since
the condition could be monitored.) Your doctor may give you an alternate
medication within the same class like atenolol or nadolol (this is optional to
mention) since they are not metabolized in the liver and not be affected by your
previous medication, or he may just monitor the combination. Does that make sense
to you?
3. Go to non-pharmacological of hypertension and gastric ulcer and offer follow up.
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Case: 50
Age: 20 years
Allergy: Sulfe
Patient Profile
Clavulin- 500F tablet
1x3 for 10 days
Rx
Clavulin- 100
4.7ml. T.I.D
In this scenario the doctor switched the patient after the third day of treatment from
tablet to oral suspention, because the patient can not swallow the tablet, easily in both,
the tablet and the suspention. The total dose is 1500. However there is a DRP.
Solution:
1. Gather all the information including MAMA and life style.
2. Check in the reference book and tell the patient I should call your doctor since I
went to discuss with him some issues regarding the dose of your medication since
these two medications are not interchangeable.
Optional: Clavulin-500F is 4:1 while the new one is 7:1
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Case: 51
Name: Jack Petty
Patient Profile
Age: 60 years
Condarone (Amiodarone) 200mg tablet
Allergy: Penicillin
1x1
Refills: (3)
Rx
Digoxin 0.25mg tablet PO
1x1
Mitt: 30
Refill: (4)
Solution:
1. Gather the required information (MAMA and life stye)
2. Check in reference book and tell the patient I should call the doctor to double
check with him about the dose of the new medication, since a drug-drug interaction
between the previous medication which increases the concentration level of the new
one and may result in toxicity. So you may require a reduction in the dose of the
new medication to more than one-half this dose or close monitoring by your doctor.
3. Give him the non-pharmacological and follow up.
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Case: 52
Name: Cavl Smith
Age: 50 years
Allergy: Unknown
Rx
Covera-HS (verapamil HCl) 240mg
PO QD a.m.
Solution:
1. Gather all the information required including MAMA and life style
2. After checking in the reference book, tell the patient that you are going to call the
doctor about the medication, since this medication should be given at night and not
in the morning as it is written in the Rx. Peak values in the morning when the drug
is given at night.
3. Counsel the patient completely with non-pharmacological.
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Case: 53
Patient name: Cal Brimton
Age: 60 years
Allergy: Unknown
Patient Profile
Glucophase (metformin Hcl 830mg 100 tablet)
Refills (6)
Last filled 1 month ago
Fist filled 3 months ago
Patient approaches the counter with nausea, vomiting, and diarrhea since yesterday.
Available: ORS, Attapugite, Gravo 1 tablet, Kaopccutate suspention, B6 tablet,
Immodium capsul.
Solution:
1. Gather all the information including MAMA
2. After checking in the reference book, tell the patient that it is important to see doctor
to assess his condition immediately, since these might be signs and symptoms of
what we call in medical terminology as lactic acidosis. (The possibility of having
irritation before or after meal is lessened since he was using it since 3 months ago
and also adjusting the dose for side effect occurs at the initiation of treatment. So
the possibility of lactic acidosis is great after excluding any food poisoning and tries
to know whether he is using any OTC or herbal product or any change in his life
style like alcohol resulting in that.
3. Non-pharmacological gives him ORS only and tells him to increase by water intake
but to see doctor immediately for assessment since his condition is serious.
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Case: 54
Name: Smith Elaxo
Age: 25 years
Patient Profile
Insect bite allergy
Rx
Inderal LA 60mg tablet 30 tablets
LX1
Nitro-glycerine pump
1puff prn
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Hello, my name is (
Please have your seat.
Thank you.
Is the Rx for you? (Identifying the patient)
Yes, for me.
What did the doctor tell you these medications are for?
They are for angina.
Oh, that must be hard for you. (Empathy)
Doctor told me I will do well with my angina if I use them properly.
Sure. In order to help you better, I need to ask you a few questions.
Sure.
I would like to reassure you whatever information I gather will remain
Patient:
Thank you.
Pharmacist: According to your profile, it sounds that you have an insect bite allergy.
Patient:
Yes, I have allergy to some insects like wasps.
Pharmacist: Could you please tell me what do you experience when you have any sting
bite?
Patient:
Well, rash, short of breath, swelling in my lips and last time I was severely
dizzy and my blood pressure went down and I was in the emergency room
for one day.
Pharmacist: Oh, thats a real allergic reaction that you should be aware of.
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Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
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Sure.
In addition to Angina, do you have any other medical condition?
No.
In addition to these medications, do you use other Rx medication?
No.
Any other kind of allergy to Food. medication. environment?
Only sting bite.
Do you use any over the counter medication herbal products.
Vitamins?
Only Tylenol occasionally when I have some headache.
Do you mind if I ask you a few questions about your life style?
Sure.
Alcohol. Smoking. Diet. Exercise?
No. No. Good. Good.
concern?
Just give me my medication.
Sure, thank you for sharing the information with you. Please give me a
Sure.
Thank you, Sir, for your patience. According to my reference book, for
those who are allergic to sting bite, it is better not to take Inderal, if
belongs to a class called B6 Blockers which make the therapeutic
management harder for you, in case if you experienced any allergic
reaction to sting bite. So if you dont mind, I would like to call your
doctor to discussion issue with him and give you an alternative medication
to Inderal which does not make the management of insect bite hard and
doesnt mask the signs and symptoms as does this one. Is that ok?
Thats ok.
It is important to avoid in future from sting bite because you are allergic to
them by avoiding spraying any perfumes, and avoiding eating out doors in
open parks.
Ok, thank you.
Pharmacist: I will call you today about the discussion with your doctor and I will
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provide you with the medications that he will Rx. Would you like to come
in for pick up or have it delivered to you? In case if I have it delivered to
you, I will call you to counsel you about the medications and to set a date
for follow up, and managing any side effect of the medications like
dizziness.
Patient:
Thank you.
Pharmacist: It is important to join in a medic alert program and to wear a bracelet
indicating that you are allergic to sting bite.
Patient:
Ok.
Case: 55
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Name: John Wayne

Age: 44 years old
Allergy: Peanut
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Patient Profile
Kayexalate (Sodium Polystyrene Sulfonate)
60gm two times daily
+
Kleve = 6.5 mmeg/L
Normal value 3.3-5meg/L
Patient approaches the counter asking for Magnesium Sulphate (Milkof Magnesia) as a
laxative, because he is using Kayexalate powder for his hyperkalemia and making him
more constipated.
Solution:
1. Gather all the information from the patient including MAMA and life style.
2. Tell the patient that Magnesium Salfate can not potassium only, it can take the
Magnesium too and therefore the laxative will not have any effect. More over,
Magnesium Sulfate may reduce the effectiveness of the resin to potassium since the
resin will take Magnesium out with the potassium or reducing the efficacy of the
resin. I can give you Micro lax containing Glycerine Sorbitol as a microenema.
You can use recfally 5ml which is usually sufficient. A second tub may be eneded in
severe cases.
3. Non-pharmacological
Avoid now Bananas, tomatoes and citrus juices since they have potassium.
Case: 56
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Patient Name: Martin Grand

Age: 40 years
Allergy: Unknown
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Patient Profile
Lamisil (Terbinative Hcl) cream
for autancouse candidiasis for 2 weeks (2 tubes)
A patient approaches the counter requesting Clotrimazole cream for his skin candidiasis,
because he used Lamisil with a partial benefit after 2 weeks, and still the area between
his groins is red and itching.
Solution:
1. Gather all the information including MAMA.
2. Tell the patient tat with regard to Lamisil he should wait for 2-4 weeks more after
cessation of treatment since relief continues with lamisil even if it is discontinue. So
I dont recommend Clotrimazole cream now or any other cream until he wait for 2-4
weeks and then decide whether there is treatment failure or not.
3. Give self care measures.
Keep the area well cleaned and dry.
Avoid sweating wince warmth and humidity are good environment for fungal
growth.
Use mild soap.
Avoid any perfumes on the area since they are irritant.
4. Follow up the patient if there is no optional cure after 2-4 weeks of treatment
cessation, the patient should consult his doctor.
Case: 57
Patient approaches the counter, requesting scopolamine patch for all the family since
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they are travelling a long journey which lasts two days.

Pharmacist: Hello, I am the pharmacist in duty today. My name is (
), how may I
help you?
Patient:
We are going a trip for pleasure. I, my wife and my 10 year old son to
Colorado which takes me two days and I want scopolamine patch since I
heard is used for prevent nausea and vomiting when one experiences
during travelling and since it is easy to be used.
Pharmacist: Wow, that must be a nice trip, but I would like to ask you a few questions
so that I can provide you with the proper therapy.
Patient:
Sure.
Pharmacist: Does any one of family member has any medical condition?
Patient:
No.
Pharmacist: Any family member has any allergy to medication. food.
environment?
Patient:
No. No. No.
Pharmacist: Does any family member uses any medication?
Patient:
No.
Pharmacist: Does any family member uses over the counter medication, herbal
product vitamins?
Patient:
No. No. No.
Phram:
Would you mind to ask you about your life style of yours and your wife?
Patient:
Sure.
Pharmacist: Alcohol. Smoking. Diet. Exercise?
Patient:
No. No. Good. Good.
Pharmacist: How old is your child?
Patient:
10 years old.
Pharmacist: Before I go and check in my reference book, do you have any question or
concern?
Patient:
No.
Pharmacist: Thank you for sharing the information with you. If you dont mind, I will
check in my reference book and get back to you.
Patient:
Thank you.
Pharmacist: Sir, you and your wife can take and use scopolamine patch. You can apply
it behind the ear 12 hours before you travel. You can apply the patch for
72 hours on a dry, hairless skin behind the ear. However Scopolamine
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patch is not recommended for children at this age group, and I recommend
to give him Gravol 25mg on need or you can give him 25mg tablet every
4-6 hours. Does that make sense to you?
Patient:
Ok, yes.
Pharmacist: Some self care measures
Drinking water.
Avoiding heavy meals before traveling.
Avoiding salt.
Passengers should look at the horizon.
Patient:
Ok.
Pharmacist: After you come back from the trip, call me to see how you were doing
with the medication.
Patient:
Ok.
Case: 58
Name: Glexo Carl
Age: 55 years
Patient Profile
HIV protocol
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Allegy: Unknown
OSCE TI PS
Sporanox Capsule 100mg b.i.d. for 3 months
Rx
Sporanox oral solution
10ml b.i.d.
Mitt: 300ml
Patient tells the pharmacist that his doctor switched him from capsule to solution since
he finds some kind of difficulty in swallowing the capsule.
Solution:
1. Gather the information (MAMA + life style)
2. After checking in the reference book, tell the patient that you have to call the doctor
since capsul and solution are not changeable. Sporanox capsul are used in fungal
infection is in blood especially in HIV patient while the solution is not used for that
purpose so theres a DRP and ou are going to discuss this issue with the doctor.
3. Dont counsel the patient since this is considered a wrong medication.
4. Counsel the patient on self-care measure, like
Safe sex (use condoms)
Good nutrition & good hygiene
Keeping appointment with the doctor.
Case: 59
Patient Name: Gerald Fugeson
Age: 55 years
Allergy: Unknown
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Rx
Tiazac XC (Diltiazem Hcl) 240mg PO QD.a.m,
Mitt: 90
Solution:
1. Gather the information (MAMA + life style)
2. Tell the patient that you are going to call the doctor since there is a DRP. This
medication should be given at night. IT is designed for night time administration
since it has a special delivery system with maximum effect in the morning. Tell the
patient that you are going to cal him back after you discuss with his doctor about
time of administration.
3. Counsel the patient on the medication.
4. Counsel him on non-pharmacological of blood pressure like
Reduction in salt intake
Increase in fibre intake
Avoid diet rich with saturated fat.
Regular use of medication.
Regular monitoring of blood pressure.
Case: 60
Patient Name: Jack Smith
Age: 66
Allergy: Unknown
Patient Profile
Carbolith 30mg tablet (lithium carbonate)
1 tablet POQD (3 refills)
Achlorhydria
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Rx
Tryptan (1-tryptopham) 1gm tablet.
Take 1tab PO QID
Mitt: 120 (3 refills)
Patient:
I am here to pick up my Prescription.
Pharmacist: This is a private area, please have your seat. (It is important to offer
privacy here, since you are dealing with CNS disorders)
Patient:
Thank you.
Pharmacist: Is this Rx for you? (Identifying the patient)
Patient:
Yes, for me.
to reassure you that all the information I collect will remain confidential.
(Confidentiality) What did the doctor tell you this medication is for?
Patient:
He said it is for my mental disorders.
Pharmacist: Oh, really, you must have be in a quite a bit of discomfort. (Empathy)
Patient:
Yes, I do.
Pharmacist: So, could you please tell me what happens recently that made you doctor
Rx this medication?
Patient:
Well, I am responding partially to the previous treatment.
Pharmacist: So, what did the doctor tell you about the use of the previous medication,
along with this new one?
Patient:
He told me to use both of them regularly.
Pharmacist: Are you using the new one for the first time?
Patient:
Yes, I do.
Pharmacist: If you dont mind, I need to ask you a few more questions to provide you
with the proper therapy and more information regarding your condition.
Patient:
Sure.
Pharmacist: In addition to your medical condition, do you have any other one?
Patient:
Yes, I have some stomach disorders, my doctor told me once that I have
what they call Achlorhydria, which means less acid secretion from my
stomach.
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Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
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Yes, it makes me susceptible to infections.

Ok, any other prescription medications beside what you are taking?
No.
Any allergy to food medication. environment?
No. No. No.
Any over the counter medication herbal. Vitamins?
Only Tylenol occasionally.
Would you mind if I ask you some questions on your life style?
Sure.
Alcohol smoking caffeinated beverages diet exercise?
No No 4 cups of coffee, 4 cups of tea and 2 coke. Diet good.
Exercise good.
Do you have any question or concern before I go and check in my
reference book?
No.
Ok.
Thank you for your patience. I need to call your doctor sir, because you
have a condition of Achlorhydria and according to my reference book, this
means higher conc. of bacteria in your stomach which is assist in
conversion to a metabolite which may result in accumulation of water in
your lung (Pulmonary edema) which all of us dont want that to happen.
Ok.
I will discuss this issue with your doctor. He might switch you to another
medication. So, for the time being I will not dispense the medication for
you till we hear from your doctor today and I will call you back.
Ok.
Also, I would like to inform you that caffeinated beverages inform of coke,
coffee or tea reduce the effectiveness of your Carbolith (lithium) that you
are taking, since they enhance its excretion, so I would like to advice you
to limit these caffeinated beverages.
Ok, I will do that.
I will call you today. Thank you for coming in to our pharmacy. Have a
nice day.
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Case: 61
Name: Linda Class
Age: 30 years
Allergy: Penicillin
Patient Profile
Sulfatrim DS PO EX2
Mitt: 60 tablets
Rx
Yasmin 21 (Drospirenone Ethinyl Estradiol) tablet
1 tablet PO QD for 21 days
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Mitt: 3 packs
Solution:
1. Gather the information including MAMA and life style.
2. Tell the patient that you should call the doctor since the previous medication
increases potassium level and the new one too. Tell the patient that he may need
monitoring for his potassium level.
3. Counsel the patient
4. Give self care measure,
Avoiding bananas and citrus juice.
Safe sex
5. Provide follow up with the patient
Concern Stations
In concern stations, it is just like one asking you for an OTC product, you should probe
more by asking the following questions:
How long have you been in this conditions (or signs and symptoms)?
Have you been seen by doctor for this purpose?
Does it affect your daily activity, or your sleep?
Red flags
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MAMA
Life style
Then solve the concern as a triage either give OTC, OTC + non-pharmacological, nonpharmacological only, or refer to doctor with some non-pharmacological.
If the concern was asked by the patient and he is having an Rx; if you can solve the
concern immediately, try to solve it. Otherwise, the permission from the patient that
you will answer him, after you go to the reference book, but for now, you need to gather
some more information. (Never forget the concern or ignoring it)
Case: 62
Patient Name: Carlo Lewis
Age: 20 years
Allergy: Unknow
Patient Profile
Benzamycin (Erythroanycin Benzoyl Peroxide)
Apply to the affected area twice daily
Pharmacist: Hello, I am the pharmacy in duty today, my name is (

). How may I
help you?
Patient:
Well, I purchased this medication 4 weeks ago. I dont feel any
improvement in my pimples.
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Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Phram:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
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Oh, that must be hard for you. (Empathy)

Yea, it is really hard for me.
This is a private area, please have your seat. (Private)
Thank you.
In order to help you better, I need to ask you a few questions.
Sure.
So you purchased this medication 4 weeks ago. (Confirming how long)
Yes.
Have you tried anything beside that medication?
No.
Have you been seen by dotor to explain to him about not having any
response?
No.
Does these pimples disrupt your sleep or daily activity?
No.
Do you have itching and redness in the face? (Red flag)
No.
How many times are you using it?
Twice daily.
Are you applying it on the pimples only or on the whole area?
On the whole area.
Where do you store the medication?
In my bed room in the drawer.
No.
Are you using any Rx medication beside that?
No.
According to your profile, you have no allergy. Is that correct?
Yes, I dont have.
Are you using any over the counter medication, herbal product or
vitamins?
No.
May I ask you a few questions about your life style?
Sure.
Alcohol Smoking.. Diet. Exercise?
No.... No. good. Good.
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Pharmacist: Thank you for sharing the information with you. Please give me a few
Patient:
Sure.
Pharmacist: Thank you for your patience. Mr. Lewis, your medication which is called
Bezamycin is not working on your pimples because you didnt store it
properly. You should store it in the fridge, and thats why is not working.
So what I recommend is to bring another Rx from your doctor or if you
dont mind I can call your doctor and tell him about that so that to release
a verbal Rx. Didnt the pharmacist tell you to store it in the fridge?
Patient:
Yes, he told me but I forgot to do that.
Pharmacist: Dont forget next time, I am going to call your doctor about that. Do you
want to wait or have it delivered to ou?
Patient:
Please deliver it to me.
Pharmacist: Ok, some self care measures are important like,
Dont squeeze the pimples
Avoid food that triggers
Avoid harsh soap
Dont let your hair come on your face to irritate the pimples
Patient:
Ok, I will do that.
Pharmacist: If you dont mind, I will call you after 2 weeks to see how you are doing
with your medication.
Patient:
Thank you.
Case: 63
Patient approaches the counter with a concern. He had palpitation and tachycardia in
the morning. Now he is ok. He is asking the reason behind that.
Name: John Smith
Age: 44 years
Allergy: Peanut
Patient Profile
Dexedrine (Dextroamphetamine sulphate) 15mg
1tab PO QD 30 tablet
Refills 30 tablet every month for 3 months
Pharmacist: Hi, I am the pharmacist in charge today, my name is (

help you?
), how may I
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Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
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Well, I have a concern about my health.

Please have your seat, this is a private area. (Privacy)
Thank you.
Could you please tell me your concern?
Today, morning after I went to the gym, I felt severe palpitation, and rapid
heart beats which happen to me for the first time.
How long did it last?
Around 30 minutes and then was less and after 1 hour I was ok.
This is the first time.
That must be hard for you. (Empathy)
Yes.
In order to help you better, I need to ask you a few questions, and I would
like to reassure you that whatever information I collect will remain
confidential.
Thank you.
Have you tried anything for that?
No.
No.
Have you experienced any Nausea, vomiting? (Red flag)
No.
Any dizziness?
Yes, some dizziness with the palpitation.
How do you fell now/
I am ok now.
Do you have any medical condition like asthma or high blood pressure?
No, but I use Dexedrine, because more often I feel sleepy during the day
which affect my daily activity and my work.
What kind of work do you work?
I am a business man.
Beside Dexedrine, do you use any other medication?
No.
Any allergy to food. drug. Environment?
No. No. No.
Do you use any over the counter medication. herbal product
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Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Pharmacist:
Patient:
Pharmacist:
Patient:
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vitamins?
No. No. No.
Do you mind if I ask you a few questions about your life style/
Sure.
Do you drink alcohol. Smoking. Diet. Exercise?
No. No. I have less appetite with regard to exercise, I do exercise
when I go to the gym.
Do you have any other questions?
No.
Thank you for your patience. I appreciate your deep concern about your
health. I would like to tell you sir, is that I can assume that what you have
experienced from palpitation and rapid heart beat, and made you dizzy is
because of the severe strenuous exercise that you were practicing, and
along with the medication Dexedrine that you are taking every day. When
you use this medication, you should avoid strenuous exercises since it
cause these signs and symptoms. Didnt the pharmacist caution you about
that?
Maybe, I forgot.
So, next time, dont do strenuous exercises. Just normal ones.
Ok.
Pharmacist: Regarding your appetite, it is important to discuss with your doctor that
your appetite is reduced, and I can say, it is most probably due to the
medication and therefore eating a healthy diet rich with vegetable and fruits
and following Canadas Food Guide for Healthy Eating is important, and you
can discuss with your doctor if you need any vitamin supplement.
Patient:
I do that.
Pharmacist: If you dont mind, I will call you tomorrow to just make sure that
everything is ok regarding your health.
Patient:
Sure.
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Case: 64
Patient approaches the counter and has a concern about his medication.
experienced nose bleeding in the morning.
Name: Ronald Sing
Age: 62 years
Allergy Erythromycin
He has
Patient Profile
Synthroid 100mg PO QD 1 week ago
Warfarin 2.5mg PO QD since 6 months ago
Solution:
1. Gather the information (MAMA + life style and how severe the bleeding)
2. Tell the patient that you can assume that the bleeding is now due to the new
medication that he is using since both Thyroxine and Warfarin enhances the
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bleeding and therefore he should see his doctor immediately to measure INR and to
adjust the dose accordingly.
3. Give him self care measures like avoiding strenuous exercises, and limiting green
leafy vegetables.
4. Follow up after couple of days to see what he has done with his doctor.
Case: 65
Patient Name: Carlos Algine
Age: 55 years
Allergy: Unknown
Patient Profile
Gluconorm (repaglinide) 2mg tid
since 12 months ago
Lopid (Gemfibrozil) 300mg PO QD 7 days ago
Patient approaches the counter. He has a concern. He is diabetic and he experienced in

the morning shivering, sweating and some numbness in the lips. He says that he hasnt
changed the dose of Gluconorm.
Solution:
1. Gather all the information (MAMA + life style) and stress is his diabetes under
control (by asking the following question: how many times do you use your
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medication, regularly or not, how many times per day do you measure your glucose
level, ask about his diet, exercise and whether he is using alcohol or not).
2. After excluding all the above, then tell these signs and symptoms may be related to
hypo glycaemia (lowering of your blood glucose) due to the interaction between the
new medication that is used to reduce his triglycerides in blood and the Gluconorm.
The new medication increases the level of the Gluconorm which results in
hypoglycaemic signs and symptoms like hunger, headache, shivering, profused
sweating and numbness of lips. Therefore if he is still experiencing the symptoms
right now, give him lit saver (3-5 tablets of glucose). If not tell him, It is important
to see your doctor before you use the next dose of lopid, in order to adjust the dose
of Gluconorm.
3. Give him self care measures:
Compliance with the medications after the doctor adjusts the dose.
Reduce simple sugar and increase fibre intake
Limit alcohol
Avoiding strenuous exercises
4. Follow up after couple of days to see what he has done with his doctor.
Case: 66
Patient Name: Carl Lewis
Age: 25 years
Allergy: Food
Patient Profile
Nalcrom (Sodium Cromoglycate) 100mg cap 1x3
Patient approaches the counter and he says that his doctor prescribed for him Nalcrom
since he has allergy to wheat and his doctor told him to use this medication and he can
eat bread without diarrhea, and loss in weight.
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Greeting the patient

Takes his private place. (Privacy)
Oh, you must have been in quite a bit of discomfort (Empathy)
Thank you.
Whatever information I father will remain confidential.
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Patient:
Thank you.
Pharmacist: MAMA + life style, and stress on how he uses the medication.
Patient:
I am swallowing the medication after eating, but still I have diarrhea with
food immediately after eating.
Pharmacist: Checking in his reference book.
Sir, actually to administer as a solution is probably the method of choice
in food allergy and should be taken 15 minutes before meal, not after
meal. The contents of the capsule should be dissolved in a small quantity
of very hot water, then after dissolving you can dilute the contents with
cold water to drink. Didnt the pharmacist tell you that?
Patient:
Maybe I forgot.
Pharmacist: If you dont see any difference when you follow my advice, then it is
important to see your doctor to discuss with him this issue.
Patient:
Ok.
Pharmacist: If you dont mind I will call you after two days to see how your condition
is.
Patient:
Thank you.
Case: 67
Patient approaches the counter, asking some information to Pollinex-R (Modified
Ragweed Adsorbate) vaccine and he always experiences allergic rhinitis which is
seasonal due to ragweed.
Patient Name: Steven John
Age: 33 years
Allergy: Ragweed
Patient Profile
Benadryl 25mg GID
Flonase sprays in each nostril BID
Contac Cold12 60mg Q6H
Pharmacist: Greeting the patient, empathy, identifying the patient

Patient:
I am using certain medications like Benadryl, Flonase and Contac cold
every year during the ragweed allergy i.e. from mid of august till the end
of October and I am experiencing many side effects from these
medications like dizziness, blurred vision, and sometimes hoarse voice.
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Pharmacist: That must be hard for you.

Patient:
Sure, it is hard for me.
Pharmacist: Did you talk about your signs and symptoms of allergic rhinitis with your
doctor?
Patient:
Sure, I did but recently, I read about this vaccine in the internet and I want
to use it now instead of using my regular medication of allergic rhinitis.
Pharmacist: Gathering information (MAMA + life style) and after checking in
reference book.
Sir, you cannot take this vaccine now since Pollinex-R is not administered
during ragweed season which is not (since he is using his medications of
allergic rhinitis). Next time you can start prior to ragweed season. So, the
course of the vaccine therapy should start toward the end of June and be
given such the last injection is received about the first week in August.
Also Polline x-R vaccine is expected in many patients. To reduce their
dependence on the medication on other medication, such as Benadryl and
other cough/cold over-the-counter medication that you are taking do
improve your signs and symptoms. There is also evidence that the use of
nasal steroids as you are using it now (Flonase spray) is reduced in
patients who have received a course of Pollinex-R.
Patient:
Yes, it does. So next year I can take the vaccine.
Pharmacist: Sure, some self care measures are important to follow along with the
medication, such as try to shower after you come back home from out
doors to get rid of pollen, try to sit in air conditioning room, avoid dust
too.
Patient:
I will do that.
Pharmacist: IF you dont mind, I will call you after a week to manage any side effects
like dizziness and to see how you are doing with your medication.
Patient:
Thank you.
Pharmacist: It is also important to discuss with your doctor about this vaccine and
whether it is suitable for your condition or not, for the next seasonal
allergic rhinitis.
Patient:
Sure, I will do.
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Case: 68
Patient Name: Norma Baham
Age: 22 years
Allergy: Sulfa, insect bite
Patient Profile
Twinject 0.3mg Auto injector
Patient approaches the counter with a concern of using Twinject in case if he has an
insect bite since he read in a magazine that it contains Sulfite and he is also allergic to
Sulfa.
Pharmacist: Greeting the patient with Privacy, Identifying the patient with Empathy.
Patient:
My concern is that I read that this medication contains Sulfite, and I am
allergic to Sufla.
Pharmacist: I appreciate your deep concern about your health and medication.
Patient:
Thank you.
Pharmacist: Gather information (MAMA + life style) and check in reference book.
Sir, I would like to tell you that there are no known contraindications to
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Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
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the use of this medication in a life-threatening allergic reaction. The

presence of Sufite(s) in this product should not prevent administration of
the medication for treatment of serious allergic or other emergency
situations, even if the patient is Sulfite allergic.
Ok, so I can use it.
Sure. Do you know the demonstration of the device?
Yes, the pharmacist explained to me everything yesterday.
It is important not to use it in buttock, and try to be careful so that not to
touch the concealed needle, and try to avoid adding perfumes, or eat in
park since perfumes and eating in parks attracts insects. Always check the
expired date.
I will do.
Feel free to call me whenever you like if you have any question about the
medication or how to use.
Thank you.
Case: 69
Patient Name: Sam Henry
Age: 50 years
Allergy: Peanut
Patient Profile
Altace (Ramipril 2.5mg) PO QD
Metformin 500mg BID
Lipitor 10mg PO QD
Rx
Micardis plus (Felmisartan/HCT) 1x1
Mitt: 60 tablet
A medical student asking the pharmacist that his senior doctor wrote an Rx for his
patient to treat his hypertension, and he left the hospital and he cant contact him. The
medical student is asking whether there is duplicate of medications for hypertension
regarding Telmisartan in Micardis and Altace that he is taking.
Solution:
1. Greet the medical student and acknowledge his concern.
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2. Gather all the information (MAMA + life style) and check in reference book.
3. Tell the medical student that Altace is given in low dose, so most probably is as
prophylactic for coronary artery diseases or to preserve the kidney, since he is
diabetic and that dose of Ramipril can not treat hypertension but only for
prophylaxis.
4. Follow up with the patient every day.
Case: 70
(Dispensing Error)
A patient approaches the counter with a concern about this medication. He was using
Zyprexa Zydis in the previous month. However, now after he used the pill which he
bought it 4 days ago, he feels dizzier than when he used to have previously.
Patient Profile
Zyprexa Zydis 10mg PO QD
Pharmacist: Hello, I am the pharmacist in duty today, my name is (
), how may I
help you?
Patient:
(A little bit Fussy) I bought this medication from you yesterday, and I feel
dizzier than I used to be when I use this medication.
(It is important to offer privacy in all dispensing error ones.)
Patient:
Thank you.
Pharmacist: You said you are dizzier today, and that must be hard for you. (Empathy)
Patient:
Not only today but since 4 days ago when I purchased this medication
from your pharmacy.
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Pharmacist: Ok, Mam I need to ask you a few questions, so that I can solve your
concern. I would like to reassure you whatever information I gather will
Patient:
You said that you are dizzy since 4 days ago. (Confirming the signs and
symptoms)
Pharmacist: Yes.
Pharmacist: How often does his happen to you?
Patient:
It happens mildly because as I told you, I am suing Zyprexa Zydis and this
makes me dizzy but nowadays, I am feeling dizziness more than before.
Patient:
No.
Patient:
No.
Pharmacist: Do you have any medical condition beside that?
Patient:
No.
Pharmacist: Are you using any Rx medication beside that?
Patient:
Any herbal product or over the counter product?
Pharmacist: Any allergy to medication?
Patient:
No.
Pharmacist: Ask only about alcohol because we dont have here direct counselling and
just to exclude that alcohol is not aggravating the dizziness.
Patient:
No.
Pharmacist: Could you please give me the medication to check the label, the content
and the expired date?
Patient:
This is the medication.
Pharmacist: After checking the label and inside the vial.
Oh, it appears an error has been happened. This because of the same
name, same colour of the pill (yellow) and same shape (round) but the
strength is different. Instead of giving you Zyprexa Zydis 10mg, it was
given Zyprexa Zydis 15mg. I apologize for that, Mam. I am responsible
for this error.
Patient:
Will that make me under high risk?
Pharmacist: I can tell you that the medication is the same, but we gave you higher
strength which makes you taking higher dosage and experiencing more
dizziness. Please, Mam, give me a few minutes to check in my reference
book.
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Patient:
Sure. (Worried about her condition)
Pharmacist: After checking in my reference book, it seems that you have taken over
dosage, and I again apologize for that, and it is important to see your
doctor or to go to emergency room to assess your condition and to
evaluate that.
Patient:
Oh, my God, emergency room. Do I need that?
Pharmacist: I am telling you that just to assess and evaluate the over dosage. It might
not be serious and you will be discharged immediately and just in case if it
is serious, they will take all the measurements to counteract any risk.
Patient:
Yes, ok.
Pharmacist: I would like to tell you that your case is an isolated case in my pharmacy,
and I will take every measure to make this thing not to happen again. I
will make a meeting with all my pharmacy team to discuss with them this
dispensing error and how to prevent that in the future. I will also call your
doctor about this dispensing error and telling him about your dizziness
after consuming higher dose. I will also fill an incident Rx form, and
inform the regional pharmacy operation about that.
Patient:
Ok.
Pharmacist: If it is convenient for ou, could you please give me the wrong medication
to replace it with the new one.
Patient:
Ok.
Pharmacist: This is your new one, and dont take the ext dose till your doctor tells you
when to take it to avoid any higher dose.
Patient:
Ok.
Pharmacist: I will call you for a taxi to take you to your doctor or to the hospital.
Which one do you prefer?
Patient:
My doctor.
Pharmacist: Ok, I will. Keep in touch with you till your condition is stabilized.
Patient:
Thank you.
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Case: 71
Name: Christina Johns
Age: 22 years Female
Patient Profile
Ampicillin 500mg QID Ftd
Started 2 days ago.
Rx
Alesse 28
S: UD
M: 3PK
Patient approaches the counter for counselling and he has a concern whether the
antibiotic that he is using for his chest infection will interact with the birth control.
help you?
Patient:
I am here to pick up my Rx and I have a concern whether the antibiotic
that I am using Ampicillin interacts with my birth control pill or not.
- It is important to offer privacy when you dispense birth control pill.
Patient:
Thank you.
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Pharmacist: Is it for you? (Identifying the patient)

Patient:
Yes.
Pharmacist: I appreciate your deep concern, about your health and medication.
(Empathy) I acknowledge your concern and I will answer your concern
after I check in my reference boo, but for a while I need to ask you some
questions to provide you with the proper treatment. Is that ok?
Patient:
Yes, ok.
Patient:
Thank you.
Pharmacist: According to your profile you are using an antibiotic called Ampicillin.
How many times are you using it?
Patient:
4 times per day.
Pharmacist: Regularly?
Patient:
Yes, regularly.
Pharmacist: Since two days ago have you seen any improvement in your cough and
fever?
Patient:
Yes, to some extent.
Pharmacist: In addition to this medication, are you using any other medication?
Patient:
No.
Pharmacist: Any allergy to Drug. Food environment?
Patient:
No. No. No.
Pharmacist: Life style: Alcohol. Smoke. Diet. Exercise?
Patient:
No. No. good diet. Good in exercise.
Pharmacist: After checking in my reference book, it shows that there is a drug-drug
interaction between your antibiotic Ampicillin and the birth control pill
which results in the reduction of the effectiveness of the medication, and
may make you pregnant, and this thing which you dont want to be, right?
Patient:
Right.
Pharmacist: So, what I recommend is to use another additional birth control method in
addition to the birth control pills like condom for the whole period of
antibiotic use till the antibiotic is finished. I mean for the rest of five days.
Patient:
Yes it does.
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Note: The pharmacist solved the concern first and now moves to counselling.
Pharmacist: This is a birth control pill call Alesse. It contains estrogen and
progesterone, it helps to prevent pregnancy. It contains 28 pills. (21) pills
are active and the rest (7) are inactive pills. Could you please tell me
which day you prefer to take them (I mean 1st day menstruation or OST
Sunday or any other day within the first five day of menstruate). If is
usually effective it is taken in first day of menstruation. However, if taken
any other day within the first five days, you should use back up method
which is a condom because you are going to use the matter if you take 1st
to fifty day. However for next month if you dont use it from the first day
of menstruation, you should use a back up method for 7 days. Does that
make sense to you?
Patient:
Yes, it does.
Pharmacist: You are going to take one pill before you sleep by mouth with a full glass
of water with or without meal and try to swallow the pill at the same time
every day for 11 days. Then till day 28, within these days after the 21
days, ou period may arrive. Continue to take these inert pills till day 28
and in day 29 start your new pack, is that ok?
Patient:
Yes, ok.
Pharmacist: Some side effect you may or may not experience like nausea, vomitting
and dearrhea (use after meal), headache (Tylenol), spotting (goes with
time). If you see any bleeding, contact your doctor. (Precaution)
Patient:
Ok.
Pharmacist: If you miss a pill use another additional pill the next day (i.e. double dose).
If you miss more than two, you can call me to tell you what to do.
Patient:
Ok.
Patient:
No.
Pharmacist: Some self care measures:
Safe sex to avoid any infections disease.
Always keep more than one pack at home to compensate for the
missing pill.
Eat well balanced food.
Avoid smoking areas.
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Patient:
Ok.
Pharmacist: If you dont mind, I will call you after 1 week to manage any side effect
like headache.
Patient:
Thank you.
Case: 72
Name: James Broadway
Age: 50 years
Allergy: Unknown
Patient Profile
Tylenol#3 Po QID for 21 days
last fill 5 days ago
Available: -Imodium tablet (different dosage forms)

ORS
BSS (different dosage form)
Kaopectit suspention
Attapulgite suspention
Patient comes to requesting Imodium for his diarrhea.
Solution:
1. Gather the information including MAMA and life style
2. Dont give Imodium, this is codeine withdrawal diarrhea which requires Rx
medication like Clonidine.
3. Tell him to see the doctor as soon as possible.
4. Give him ORS and non-pharmacological.
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Doctor Stations
In doctor stations try to interact with the doctor using the scientific language as much as
you can. Avoid the lay language that you use with patient. Recommend every thing to
the doctor except the non-pharmacological. So what you should do is this.
Read whatever is mentioned in the profile in front of the doctor, and whatever he
wants to prescribe now.
Gather MAMA without life style.
Recommend what the doctor wants after checking in the reference book, and
mention the name of the reference.
Tell the doctor that you are going to monitor the major side effect or cautions.
Mention the follow up that you are going to do with the patient.
Be clear and concise.
At last document the important points.
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Case: 73
Patient Name: Carl Smith
Age: 60 years
Allergy: Acetaminophen
Patient Profile
Nardil 30mg/day PO
for 6 weeks
Rx
222S
100mg Q4Hx 2 doses
Doctor:
I have a patient with atypical depression using Nardil 30mg/day for 6

weeks, and now he has an attack for migraine and I want to Rx for him
(222S). Is that ok for him; if not please recommend anything that you
believe is of benefit to my patient. I am here for any question.
Note: First read whatever in the profile and in the prescription. Look at the age of the
patient and the allergies. Look at the reference books. Is there are any handouts or only
CPS and Therapeutic Choices. Then read in front of doctor in this way.
Pharmacist: Ok, doctor, I can see you want to Rx 222S for your patient who is 60 years
old and allergic to acetaminophen, and using an antidepressant medication
which is Nardil. Is that correct?
PharmacyPrep.
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Doctor:
Yes, that is correct.
Pharmacist: May I know the nature of his allergy, and what he experienced when he
used acetaminophen?
Doctor:
Rash, short of breath and hypotention and the patient was transferred to
ER, and that was 5 years ago.
Pharmacist: May I know doctor, if he has any other allergy?
Doctor:
No.
Pharmacist: May I know if he is using any medication other than that?
Doctor:
No.
Pharmacist: Does he have any other medical condition?
Doctor:
No.
Pharmacist: Is he using any OTC or herbal?
Doctor:
You can ask him, I dont know.
Pharmacist: Ok, doctor, please give me a few minutes to check in my reference book.
Doctor:
Sure.
Pharmacist: Ok, doctor, according to my reference book which is CPS 2008, (222S)
contains codeine and so, there may be a big chance for drug-drug
interaction between 222S and Nardil resulting in serotonin syndrome
which means the patient would be under risk of harm due to this
interaction, which both of us doesnt want it to hyper.
Doctor:
So, what do you recommend?
Pharmacist: I can recommend Relpax (Eletriptan HBr) which is very good medication
to abort migraine and at the same time does not have any drug-drug
interaction with Nardil.
Doctor:
Could you please give me the dose?
Pharmacist: Sure. It is 20mg (dont say 20-40mg) stick to one dose. So it is 20mg
initially, and the patient may take an additional 20mg in 2 hours,
maximum 40mg/24hrs.
Doctor:
Ok.
Pharmacist: I will monitor the condition of the patient if he experiences any chest pain,
drowsiness or paresthesia. I will also follow up the next day with the
patient to manage any side effects like fatigue.
Doctor:
Thank you.
Pharmacist: Do you want me to document that?
Doctor:
Yes
Pharmacist: Document.
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Case: 74
Name: Joh Carlos
Patient Profile
Age: 55 years
- Trizivir (abacavir Sulfate- lamivudine-Zidovudine)
Allergy: Unknown
PO BID
- CD4= 180
- CrCl= 40ml/min
Rx
Cotrimoxazole (SMT/TMP)
15mg/kg/day PO QID for 21 days
Doctor:
Hello, I want to Rx cotrimoxazole for my patients who is HIV infected

and to give him a prophylactic medication against pneumogastric jerovici
since his CD4 is less than 200. So is it possible to give him cotrimoxazole with Trizivir protocol of HIV.
Pharmacist: I can see doctor, you want to Rx co-trimoxazole for your HIV patient
using Trizivir to protect him (prophylaxis) from pneumocystic jerovici
since his CD4 is 180.
Doctor:
Thats right.
Pharmacist: May I know doctor, if he is using any other prescription medication?
Doctor:
No, only Trizivir.
Pharmacist: Any other medical condition beside that?
Doctor:
No.
PharmacyPrep.
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Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
OSCE TI PS
Any allergy to medications, food, environment?

No.
Please give me a few minutes to check in my reference.
Ok.
Ok, doctor, according to my reference book CPS 2008, administration of
trimetheprim, a constituent of co-trimoxazole, causes a 40% increase in
lamivudine plasma levels, and because he has renal impairment since his
CrCl is 40ml/min, then the patient should be carefully assessed.
OR we can give alternatives such as Mepron (atovaqucm) 750mg BID
since it doesnt contain pyrinethamine or pimaquine 30mg/day +
clindamycin 300mg Q8H.
Note: Mentioning one or two alternatives is sufficient although in this case pentamidine
aerosol 300mg/mo could be given, and is easy for compliance.
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Oh, I didnt realize that. So, ok I will give him atovaqucm and
clindamycin.
I will monitor his condition if any side effect like headache, rash or GIT
effect.
Oh, thank you.
I will continue follow up with him every week for monitor his condition
and to elevate his CD4.
Thank you so much.
Do you want doctor, any more information?
No, thanks a lot.
Doctor, do you want me to document these information?
Yes, thank you.
Thank you.
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Case: 75
Name: Johnson Monka
Age: 86 years
Allergy: Unknown
Diagnosis: Pseudomenmbranous
Colitis.
feeding
Patient Profile
- uses Nasogastric tube for
Rx
Vancomycin capsule 500mg PO QID for 10 days.
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Doctor:
Pharmacist:
Doctor:
Hello, my patient has pseudomembranous colitis due to Clindamycin

previous use for a skin infection. I want to Rx for him Vancomycin
capsule 500mg QID. But he cant swallow the capsule and he uses
Nasogastric tube for feeding. So what do you recommend?
Ok, doctor, I can see that your patient is using a Nasogastric tube for
feeding and you want to Rx Vancomycin cap for him to treat his
pseudomembranous colitis. Does he have any other medical condition?
No.
Any known allergy?
No.
Any medication is he using?
No.
Ok, doctor, please give me a few minutes to check in my reference book.
Ok, doctor, according to my reference book CPS 2008, Vancomycin cap
could be given orally to treat that condition, but the problem is that
Vancomycin capsules are formulated in a matrix gel that prevents
administration by a nasogastric tub.
I recommend I.V. dosage form should be used orally. So we can give one
vial which contain 500mg of Clindamycin HCL and reconstitute it in 20ml
water four tiems daily by the N.G. tube.
Oh, thats fine.
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Pharmacist: I will monitor the condition of your patient to look for the improvement in
his diarrhea and if there is any stomach upset due to the antibiotic.
Doctor:
Thank you.
Pharmacist: I will continue follow up with the patient every 3 days till his condition is
stabilized.
Doctor:
Thank you so much.
Pharmacist: Doctor, do you want any other information?
Doctor:
No, thank you.
Pharmacist: Do you want me to document this information?
Doctor:
Yes, thank you.
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Case: 76
Name: Carl Smith
Age: 69 years
Allergy: Unknown
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Patient Profile
- Ceftazidime 2gm I.V. Q8h
- Gentamicin 7mg/kg once daily I.V.
- Neutrophils 0.9x109/L
Hello, I have a patient who is under low risk of neutropenia and currently
he is using ceftazidime and Gentamicin I.V. and I want to switch him to
oral medications. So could you please recommend something for me?
I can see doctor that your patient is taking ceftazidine 2gm I.V. Q8h and
Gentamicin 7mg/kg once daily I.V. May I know the reason for that?
Well, he is a cancer patient and a low risk neutropenia and he developed
some sort of chest infection. But we did culture and sensitivity tests for
him. It was found he is not MRSA, so I started to give him the above
medication, and I want to switch him now to oral so that I can discharge
him.
Does your patient have any other disease? Fever
No.
Does he use any other medication?
No.
Ok.
Thank you doctor for your patience. Your patient, we can give him oral
Amoxicillin Clavulanate 875/125mg tablet PO BID plus ciprofloxacin
750mg PO BID for 7 days this is what mentioned in Therapeutic Choices
Pg. 1431 since he is a febrile.
No, he has no fever. So thank you for that, I will prescribe what you have
mentioned.
Ok, doctor, I will monitor his condition, and see if he develops any
diarrhea or infection.
Thank you.
I will continue follow up with him every 3 day till his condition is
stabilized.
Thank you.
Doctor, do you want any more information?
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OSCE TI PS
Doctor:
No, thanks.
Pharmacist: Do you want me to document that?
Doctor:
Oh, yes please.
Case: 77
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Name: Jack Isac

Age: 44 years
Allergy: Unknown
OSCE TI PS
Patient Profile
Prozac (Fluoxetine) 10mg Po QD
since 2 months ago, refills (3)
Rx
Duralith (lithium carbonate) CR 900mg Po QD
Mitt: 30
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Hi, my patient is having acute depression is Bipolar disorder, and I want to

add Rx Duralith 900mg per day for him. He is using Prozac 10mg. Is that
ok? I am here if you have any question.
Doctor, I can see that your patient is using Prozac 10mg since 2 months
ago and now you want to add Carbolish to his regimen because he is
experiencing acute depression in Bipolar Disorder. Is that correct, doctor?
Yes.
Ok, doctor, does your patient have any other medical condition?
No.
Any other medication?
No.
Does you patient has any allergy?
No.
Sure.
Ok, doctor, according to my reference book, adding Lithium to long acting
SSRI will switch the patient to mania and this thing both of us dont want
it to happen. In addition to great possibility of serotonin syndrome. So
what I recommend is to add Olanzepine (Zyprexa) 5mg/day to treat his
condition without the risk of switching the patient to mania or serotonin
syndrome.
Thats fine.
I will monitor the patient for weight gain and for movement disorders.
Thank you.
Also, doctor, I will follow up the patient every week to see the
improvement in his condition and to manage any side effect like dizziness
or sedation.
PharmacyPrep.
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Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
OSCE TI PS
Thanks a lot.
Doctor, do you need any further information?
No, thanks.
Do you want me to document that?
Yes, please.
Case: 78
Name: Kamal Zia
Patient Profile
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Age: 33 years
Allergy: Penicillin
OSCE TI PS
Prozac 10mg tablet PO QD

since 6 weeks, refills (3)
Rx
Codeine 60mg Po G6H
Mitt: 30
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
I want to Rx Codeine 60mg for my patient who has depression and now
he is under Prozac 10mg everyday. My patient fell down on his wrist
during playing Hockey and thats why I am Rxing Codeine for him. I
want to take your opinion. Is that possible or not?
Ok, doctor, I can see that you want to Rx Codeine as an analgesic
medication (use scientific terminology with the doctor) for your patient
who is using Prozac for his depression.
No.
Any medication other than Prozac?
No.
Any allergy?
No.
Ok, doctor, please give me a few minutes to checking my reference book.
Ok.
According to my reference book, Therapeutic Choices, the Prozac is an
enzyme inhibitor of 2D6 and this will prevent the conversion of codeine to
morphine, so Prozac may antagonize codeines analgesic effect which
both of us doesnt want that to happen.
Yes, of course.
What I recommend is to give morphine as M.O.S. 10mg PO Q6H, or
meperidine 100mg/dose I.V. or if you want the analgesia for a short period
of time for less than 1week you can use Toradol Ketololac 30mg/dose IV.
or I.M.
Thank you for all these alternatives.
I will monitor the patient for dizziness and constipation.
Thank you.
I will also continue follow up every 3 days to see his improvement and to
manage any side effect like dizziness.
Thanks a lot.
PharmacyPrep.
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Pharmacist:
Doctor:
Pharmacist:
Doctor:
OSCE TI PS
Doctor, do you need any further information?

No thanks.
Doctor, do you want me to document that?
Yes, please.
Case: 79
Name: Joerse Brown
Age: 40 years
Patient Profile
Ziagen (abacavir) 300mg BID
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Wight: 70kg
Videx EC 400mg PO QD
Allergy: Unknown
Vivaimune 200mg BID
CD4= 190
Rx
Z-pack 500mg 1st day
Then 250 mg x 4 days
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
I have an ambulatory patient who is an HIV, taking a protocol for HIV as

is indicated in his Profile. He came today to my clinic and he is
experiencing pneumonia with cough, short of breath, chest pain, fever and
haemoptysis. Is Z-pack ok for him?
Ok, doctor, I can see that your patient is an HIV patient using Ziagen,
Videx and Viraimune and now his CD4 is below 200 and experiencing
pneumonia. Is that correct, doctor?
Yes.
Ok, doctor. Does he have any other medical condition?
No.
Any know allergy to food, drug, or environment?
No.
Ok. Please give me a few minutes to check in my reference book.
Ok.
According to my reference book (Therapeutic Choices), your patient is
experiencing pneumonia and the most probable pathogen. When CD4 is
below 200 is pneumocystic carinil (jerovivii), and Azithromycin is not
helpful against pathogen.
Well, in that case, the most effective antibacterial agent is contrimoxazole
20mg/kg/day orally in divided doses every 6 hours for 21days.
Ok, thank you. I will prescribe that.
Pharmacist: Ok, doctor, I will monitor his condition, if there is any fever, and to keep
his appointments with you for check up or any blood work. I will also
continue follow up every week to look for managing any side effect like
nausea and vomiting to see the improvement in his condition.
Doctor:
Thank you.
PharmacyPrep.
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Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
OSCE TI PS
Doctor, do you need any more information?

No.
Do you want me to document this information?
Yes, please.
Documenting the information.
Case: 80
Name: Carl Smith
Age: 65 years
Gender: Male
Patient Profile
- COPD
- currently he has heart failure.
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Allergy: Unknown
Rx
Altace (ramipril) 12.5mg BID
Monocor (Bisoprolol) 1.25mg PO QD
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
I want to Rx these medications to my patient who has COPD as a patient

history and currently he has heart failure. Do you agree with me, or if not
could you please recommend any other alternatives?
Ok, doctor. I can see that your patient has COPD and heart failure, he is
65 years of age and no know allergy to medications. Isnt that correct?
Yes.
Doctor, does your patient have any other medical condition beside that?
No.
Does your patient use any other medication (no need to say prescription
medication and then OTC or herbal products in Doctor Stations, just say
does he use any medication)
No.
Ok.
Ok, doctor, according to my reference book (Therapeutic Choices) these
two medication as initial therapy to treat heart failure is the best regimen,
and the age is not a contraindication to the -blocker since you have a
compelling evidence for use which is heart failure (In hypertension over
60, -blockers are not recommended). However, he has COPD and Blockers should be used cautiously (in asthma they are contra-indicated),
and requires close monitoring esp. he is 65 years old.
But I am giving him Monocor which is a selective medication to the heart.
It is not non-selective -blocker).
Pharmacist: You are correct doctor Monocor. It is selective, but as you know, you are
going to fit rate the dose, since this dose is an initial dose, and as you
know when we fit rate the dose, selectivity is lost.
Doctor:
Ok, so, what do you recommend?
Pharmacist: Well, doctor, according to (Therapeutic Choices) it is mentioned to
consider using ACE inhibitor/ARB combination therapy to prevent
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Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
OSCE TI PS
disease progression in patients with minimal to moderate symptoms who

can not tolerate -blockers as in this patient since he has COPD. So what
I recommend is Atacand (Candasartan 4mg tablet) once daily orally and
you can titrate the dose till 32mg once daily according to the best response
that you can get.
Ok, thank you, I will Rx candesartan 4mg PO QD initially.
I will monitor your patient for his weight, edema, dizziness and to keep
his appointments with you for blood potassium since both medications
candesartan and Altace cause potassium retention.
Oh, thats great.
I will continue to follow up with your patient every week to look for the
improvement and to manage any side effect like dizziness.
Thank you a lot.
Doctor, do you want any more information?
No, thanks.
Doctor, do you want to document this information?
Yes, please.
Document.
(In general the dialogue with the doctor and solving the station with those of reference
book properly usually doesnt exceed 5 minutes, and the student has plenty of time to
solve the station.)
Case: 81
Name: Minass Smith
Age: 55 years
Sex: female
Allergy: Unknown
Patient Profile
HCT 25mg PO QD
since 2 months
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Rx
HCT 50mg PO QD
Mitt: 30 tablet
Refills: (3)
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
This is the Rx that I want to prescribe for my patient who has

hypertension of 155/96. He was using HCT 25mg PO QD, and still his
blood pressure was not under control, and thats why I doubled the dose to
control his blood pressure. So, I want to take your opinion about that, if it
is ok so that I recommend that dose for him.
Ok, doctor. I can see your patient have being using HCT 25mg PO QD
since 2 months ago, and his blood pressure was not under control, and you
want to double the dose for him. Is that correct, doctor?
Doctor, does your patient have any other medical condition?
No.
Does he use any other medications?
No.
Does your patient have any allergy?
No.
Ok.
Ok, doctor, according to my reference book; in case if there is no response
or partial response in the previous two months, it is better to add another
medication from a different class and from group 2 since HCT, and
dihydropyridine and non-dihydropyridine are group if so either adding
ACE inhibitor/ARB or -Blocker is much useful to potentiate the effect.
In addition to that increasing the dose of HCT increases the risk of side
effect since most of side effect are dose related like more potassium
depletion, electrolyte imbalance, increase in blood glucose and dizziness.
Can I give Methyldopa for her?
Well, doctor, as you know methyldopa is given in cases of pregnancy
(compelling evidence), and since she is 55 year old and her hypertension
is not a complicated one, so I dont see any reason for prescribing it for
her.
PharmacyPrep.
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Doctor:
Pharmacist: What I recommend is to add ACE inhibitor like Altace start initially with
5mg/day and titrate the dose till you reach a controlled blood pressure.
After that you can Rx vaseretic (enalpril/HCT) for maintenance dose.
Also this is combination of Altace which preserves potassium, and HCT
depletes potassium, makes the potassium level balanced.
Doctor:
Ok, I will recommend adding enalpril 5mg/day orally.
Pharmacist: I will monitor your patient for any side effect like cough, infection and
dizziness. I can tell him to visit the pharmacy whenever he likes to
measure his blood pressure and to see his control in blood pressure. I will
also continue follow up with the patient every week, and to remind him to
visit your clinic for check up and if he needs any blood work.
Doctor:
Thank you.
Pharmacist: Doctor, do you need any more information?
Doctor:
No, thanks.
Pharmacist: Do you want me to document this information?
Doctor:
Yes, please.
Pharmacist: Documents.
Case: 82
Name: Real Clark
Age: 55 years old, Weight: 85kg
Sex: Male
Allergy: Unknown
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Rx
NTG SL tablet 0.6mg SL Q5min prn
Minitran patch (Nitrogrlycerin Transdermal)
0.2mg/h patch applied and removed daily.
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
I want to Rx these two medications to my patient. He has stable Angina.

I would like to share your opinion whether I can or you would like to
modify the regimen.
Well doctor, can see that you want to Rx NTG tablet Sublingual and
Nitroglycerin patch for your patient who has stable Angina. He is 55
years old and 85kg weight. Is that collect, doctor?
Doctor, does your patient have any other medical condition beside stable
Angina?
No.
Does your patient use any other medication?
No.
Does he have any allergy?
No.
Ok.
Ok, doctor, according to my reference book (Therapeutic Choices), the
medications that you recommended are used to help treat and prevent
stable Angina. However, in addition to these, it is mentioned in
(Therapeutic Choices) to start with antiplatelet like (ASA 81mg) and ACE
inhibitor like Altace (Ramipril) 40mg PO QD. Also, statins are added if
nonfasting total cholesterol is normal to prevent the comorbidity and
mortality associated with this disease.
His Cholesterol level is normal. I will recommend Altace and ASA as you
said.
I will monitor your patient for any side effect like dizziness or if any chest
pain, also monitor for tolerance, so I will remind the patient for not using
the patch for more than 12 hours/day to avoid tolerance. I will follow up
the patient to manage any side effect like dizziness and to keep his
appointments with you.
Thanks a lot.
PharmacyPrep.
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Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
OSCE TI PS
Do ou need any more information?

No thanks.
Do you want me to document this information?
Yes, please.
Documents.
Case: 83
Name: Jeanny Clark
Age: 70 years
Gender: Female
Allergy: Unknown
Patient Profile
- Breast Cancer
- Radiotherapy
- Ca- Protocol of Breast Cancer
- Anzemet (dolasetron) 100mg PO Pre chemotherapy
and then 1x2 for 5 days
PharmacyPrep.
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Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
OSCE TI PS
I have a lady with breast cancer, I am giving her medication for breast
cancer (protocol) every 3 weeks, and she is also under radiotherapy and
experiences nausea and vomiting. I am giving her Anzemet which is a
potent medication for nausea and vomiting twice daily but still she vomits
at the end of doses i.e. just before the next dose. I would like to share
your opinion of what should I do. Should I change the treatment regimen
for nausea and vomiting? I dont want to change the protocol, and
radiotherapy is very important for her.
Ok, doctor, I can see that your patient has breast cancer and she is under
breast cancer protocol and using chemotherapy, and you are giving her
currently Anzemet 100mg pre chemotherapy and then twice daily for 5
days but she experiences nausea and vomiting at the end of doses. Isnt
that correct?
Yes, it is correct.
Does she have any other medical condition beside her Antineoplastic
Protocol and Anzemet 100mg tablet.
No.
Any allergy?
No, allergy.
Ok.
Ok, doctor, according to my reference book which is Therapeutic Choices,
Prochlorperazine, it is usually used as rescue medication i.e. in the end
dose effect, in addition to the regular use of Anzemet.
Doctor:
Ok, that is helpful since I am not going to change Anzemet, I just add
prochlorperazine at the end of doses as a rescue dose. Could you please
tell me the doses of Prochlorperazine?
Pharmacist: You can give Prochlorperazine 10mg orally on need basis or rectally also
10mg.
Doctor:
Oh, thats fine.
Pharmacist: I will monitor the patient for any side effect like sedation, dry mouth and
blurred vision. I will also continue follow up the patient every week to
see his improvement and to keep his appointments regularly for the
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OSCE TI PS
radiotherapy.
Doctor:
Thank you.
Pharmacist: Doctor, do you want any other information?
Doctor:
No, thanks.
Pharmacist: Ok, doctor, do you want to document that?
Doctor:
Yes, please.
Miscenancous Stations
Case: 84
Female patient comes for a refill of her medication as antiyeast syrup which was put on
hold a year ago.
Name of Patient: Linda Barton
Age: 33 years
Patient Profile
Terazol 0.4% vaginal cream
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Allergy: Unknown
OSCE TI PS
(terconazole) for 7 days.
Patient:
Hi, there.
Pharmacist: Hi, I am the pharmacist in duty today, how may I help you?
Patient:
Well, I have a refill here which was put on hold since a year ago. It was
about a vaginal cream for my yeast infection which I used it a year ago
and now same signs and symptoms appear so could you please give me
that cream since my Dr. had already prescribed it to me.
Patient:
Thank you.
Pharmacist: You must have been in a quite a bit of discomfort. (Empathy)
Patient:
Yes.
Patient:
Thank you.
Pharmacist: How long have you been having this yeast infection?
Patient:
Since 3 days ago.
Pharmacist: Does this happen frequently?
Patient:
No, last time was a year ago and I used this medication and it was ok with
me.
Pharmacist: Have you used anything for it?
Patient:
No.
Pharmacist: I can guess you havent gone to doctor since you are ordering your
medication that is on hold.
Patient:
That is true.
Pharmacist: You told me the signs and symptoms were just like before. Could you
please describe to me your signs and symptoms?
Patient:
White colour discharge, with no odour, and some itchiness during
urination.
Pharmacist: Do you have any fever? (Red flag)
Patient:
No.
Pharmacist: MAMA and life style.
Pharmacist: After checking in the reference book:
Ok, mam, this medication was on hold and at that time your doctor
prescribed it for you to be used for 7 days and a refill for another 7 days.
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OSCE TI PS
Patient:
Pharmacist:
Patient:
Pharmacist:
However, you were recovered after 7 days and you didnt take it at that tie.
Now you are telling me you have same signs and symptoms, and you want
your medication on hold. I would like to tell you mam, that we are here
for the best benefit of the patient. This medication now you may need it
or you may need another one or could be an over the counter medication.
I would like to tell you that this is an Rx medication, and was given for
you after assessment by the doctor, and diagnosis so for the time being if
you want the same medication, because it is a 14 medication and
antibiotic, it is better to consult your doctor to assess your condition.
Because you may need it or you may not, or may be only OTC.
Oh, so I have to see my doctor.
Yes, it is better to do that since you havent used it since a year ago and it
is a prescription medication not an OTC.
Thank you.
Some self care measures:
Eat yogurt
Clean the area with mid soap and water
Avoid tight clothing
Avoid sex till you are treated
Thank you.
If you dont mind, I will call you after 3 days to see what you have done.
Thats ok.
Thank you for coming in. Have a nice day.
Case: 85
(Dosette)
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient profile
- ASA 81mg chewable PO QD
- Glyburide 5mg PO BID
- Glucophaye 500mg PO BID
- Lipitor 40mg PO QD
- Zyprexa Zydis 10mg/day
Patient comes with a concern that he doesnt know how to use the medications.
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OSCE TI PS
Pharmacist: My name is (
). I am the pharmacist in duty today. How may I help
you?
Patient:
Yesterday, I brought an Rx for you and you dispensed to me 5 different
medications, and I am confused how to use them.
Pharmacist: Let me check your profile. Oh, it is really a confusing schedule.
(Empathy) I will try to simplify it for you by drawing a chart for you.
Note: Dont ask MAMA here, since she has already been here since yesterday.
Morning
ASA 81mg
Glyburide 5mg
Glucophaye 500mg
Lipitor 40mg
Patient:
Noon
Supper
Bedtime
So, mam, take your heart protection pill in the morning with the food to
avoid stomach upset, and Glyburide and Glucophaye, these two
medications to control your diabetes; take the Glyburide in the morning
and the other dose at supper with food. Take Glucophaye at noon with
food and the other dose at bed time, so that these two medications for your
diabetes should not be taken together and space them apart according to
this schedule to avoid low glucose level. The other pill Lipitor, always
take it at supper with or without food since it has more optimal effect.
However Zyprexa Zydis, you should take them at night since it causes
drowsiness. Mam, if the table does not clarify everything for you, I can
give you a dosette free of change telling you the day and time of
administration except Zyprexa Zydis which I can not put it in dossette,
since I can not pull the tablet and put it in dossette since it is affected by
the environment.
Thank you, I think the table is enough.
Note: Dont go to interaction. The case here is to look for compliance. Any interaction
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OSCE TI PS
could be monitored unless there is a control-indication.

Pharmacist: If you dont mind, I will call you after three days to see how you are doing
with your medication, and to manage any side effect like stomach upset.
Patient:
Thank you.
Case: 86
(Doctor-Station)
Name: Carl Glaxo

Age: 25 years
Allergy: Unknown
Patient Profile
- Schizophrenia (Acute)
- Ativan (Lorazepam) 1mg I.M.
Rx
Zyprexa 10mg I.M. inj 1x1
Doctor:
I have a patient with Acute Schizophrenia. I gave him Ativan 1mg inj
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Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
OSCE TI PS
I.M., and still not under control. I want to share your opinion to add
Zyprexa 10mg I.M. inj to his regimen. Do you think that this will help in
controlling his signs and symptoms of Schizophrenia?
Ok, doctor, I can see that you have a case of uncontrolled Schizophrenia
under Ativan 1mg inj I.M., and you want to add Zyprexa 10mg I.M. inj to
his regimen in order to control his condition.
That is right.
May I know, doctor, if your patient has any other medical condition beside
that?
No.
May I know if your patient has any allergy?
Not that I know.
Does he use any medication beside Ativan inj?
No, this is his first episode of Schizophrenia.
Ok, and if you have any questions, I am here ready to answer your
questions.
According to my reference books, Therapeutic Choices and CPS 2008,
Zyprexa inj can not be given together with Ativan inj since this may cause
respiratory failure and severe drowsiness. I believe both of us dont want
the patient to suffer from these side effects.
So what do you recommend?
I recommend Haloperidol 2mg or Haloperidol 4mg inj to be given with
Lorazepam inj I.M. Although it causes dizziness and drowsiness but they
dont cause respiratory failure as in case of Zyprexa inj with Ativan.
Ok, I will take your recommendation.
I will monitor the patient for management of any side effect like dizziness
or drowsiness and I will continue follow up with the patient every week to
see his improvement in his condition and to keep his regular appointments
with you.
Thank you.
Do you want, doctor, any more information?
No, thanks.
Doctor, do you want me to document those information?
Yes, please.
Document.
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Case: 87
Patient Name: Clark Cable
Age: 58 years
Weight: 77kg
Allergy: Peanut
Patient Profile
- Lanoxin (Digoxin) loading 1mg PO
in divided doses
- Maintenance: Digoxin 0.25mg mg/day PO
- Supra ventricular fibrillation
- Warfarin 5mg PO for 3 weeks
Rx
Cordarone 200mg PO TID x 2 weeks then 200mg daily
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Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
OSCE TI PS
I have a patient in my word was taking the loading dose of Digoxin and
then I kept him on maintenance dose of Digoxin to control his supra
ventricular fibrillation. Now, I want to add Cordarone 200mg TCD to do
the rhythmic control by adding Cordarone 200mg TID for 2 weeks and
then 200mg daily. He was on Warfarin 5mg for the last 3 weeks.
Ok, doctor, I can see that our patient is experiencing supra ventricular
arrhythmia and he is currently started with a rate control medication
namely Digoxin, then Warfarin for 3 weeks, then now you want to control
his rhythms by adding Cordarone which you want to start with a loading
dose of Cordarone, then a maintenance dose of Cordarone.
Exactly.
Ok, doctor, does your patient have any other medical condition?
No.
Does your patient have any allergy?
Yes, to peanut which resulted in rash, redness, itchiness and shortness of
breath.
Does he use any other medication beside these mentioned?
No.
Thank you doctor, please give me a few minutes to check in my reference
book.
Ok.
Pharmacist: Ok, doctor, according to my reference book, Therapeutic Choices, and in

order to avoid dysrhythmic that may happen due to drug interaction of
Digoxin with Amiodarone due to the increase in level of Digoxin, it is
recommended to reduce the dose of maintenance of Digoxin by 25-50%.
Doctor:
Ok, thank you, you are correct, I will reduce the dose.
Pharmacist: Also, I would like to remind you doctor, to give him Warfarin
for 4 weeks since after rhythmic control, his heart will be pumping
efficiently, so in order to prevent any hidden clot, it is important to give
Warfarin.
Doctor:
Oh, you are right, thank you for that.
Pharmacist: Doctor, do you want any more information?
Doctor:
No, thanks.
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Pharmacist: Doctor, do you want to document that?

Doctor:
Yes, please.
Case: 88
Patient Name: Hasan King
Age: 67 years
Sex: Male
Allergy: Unknown
Patient Profile
- Warfarin 3mg PO QD since 3 months ago
patient developed hyperthyroidism
- Inderal (Propranolol 40mg BD) a week ago
Patient comes with a concern.

Pharmacist: What brings you here Mr. King? Three days ago, I gave you Inderal for
your thyroid. Have you experienced any side effect?
Patient:
Well, I have some nose bleeding and some red blood in my stool.
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Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
Pharmacist:
Patient:
OSCE TI PS

This is a private area, please have your seat. (Privacy)
Thank you.
In order to help you better, I need to ask you a few questions. I would like
Thank you.
If you dont mind, I want to check your profile.
Sure.
I can see that you are on Warfarin since 3 months ago. Have you
experienced any side effect from that medication?
No, but only in last two days, I have nose bleeding and blood in my stool.
Are you using it every day and regularly?
Yes, regularly.
I can see you are using Inderal 40mg.
Yes.
Are you using it regularly?
Yes, regularly.
For what purpose are you using it?
My doctor prescribed to me for my hyperthyroidism and he said to try this
medication first, and if I need other medications, he will Rx them to me
later on.
So, you have hyperthyroidism diagnosed recently.
Yes.
Well, I have a stent made for me in my heart and the doctor prescribed
Warfarin for me.
What other medical condition?
Nothing else.
Any allergy to medication. food. environment?
No. No. No.
Any other Rx medication?
No.
Any herbal product. vitamin. over the counter medication?
No. No. No.
Any change in your life style food. alcohol. smoking. exercise?
Good food. no alcohol. no smoking. good exercise.
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Pharmacist: Thank you for sharing the information with you. Please give me a few
Patient:
Thank you.
Pharmacist: Thank you for your patience. According to my reference book, if a patient
has hyperthyroidism, then the body will destruct important factors which
prevent bleeding like Vitamin K. So, in your case, Vitamin K is
destructed in your body due to your disease condition (increase in thyroid)
which result in bleeding. So it is important to see your doctor
immediately to reduce the dose of Warfarin, and to adjust the dose and
INR according to your new condition.
Patient:
Is it serious?
Pharmacist: Yes, it is serious now, so that to do the adjustment of the dose of Warfarin
to prevent any further bleeding, so that your condition will be stabilized
after that, and you wont experience any nose bleeding or blood in stool.
OR, your doctor may skip a dose to prevent bleeding and adjust the dose
accordingly.
Patient:
Thank you for your advice.
Pharmacist: It is important to avoid contact exercises and not to change your life style
which may interfere with the efficacy of Warfarin.
Patient:
Thank you.
Pharmacist: If you dont mind, I will call you in two days to see how your condition is.
Patient:
Thank you.
Pharmacist: Thank you for coming. Have a nice day.
Case: 89 (Medical Student)
A medical student comes to ask you about a diabetic patient in the ward, is experiencing
hyperglycemia in the morning, although his dose at night was increased in the previous
3 nights by 5u increments. The medical student wants to share your opinion. His senior
doctor is on vacation.
Patient Profile
Novolin 30/70 Insulin 40u BID Today
Novolin 30/70 Insulin 35u BID Jan 30
Novolin 30/70 Insulin 30u BID Jan 24
Fasting Glucose level mg/dl = 8.2mmol per L
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Pharmacist:
Medical Student:
Pharmacist:
Medical Student:
Pharmacist:
Medical Student:
Pharmacist:
Medical Student:
Pharmacist:
Medical Student:
Pharmacist:
Medical Student:
Pharmacist:
Medical Student:
Pharmacist:
OSCE TI PS
Hi, my name is (
). I am the pharmacist in duty today.
How may I help you?
Well, my doctor is on vacation now, and I just want to share
your opinion about my patient who is diabetic and his blood
glucose level in the morning is high although we are
increasing his insulin Novolin 30/70 by 5 increments in the
consecutive nights. Does this mean that my patient is
resistant to Insulin?
Thank you for sharing my opinion, which is or aim to work
collaboratively. I would also want to know, whether your
patient has any infection or any other medical condition that I
should be aware of.
Nothing, only diabetes.
Any allergies to medication?
Not that I know.
Any other medication?
No other medication.
How is his life style (Diet, alcohol, exercise, and smoking)?
He follows our direction and is compliant.
Sure.
According to my reference book, the patient might be
experiencing Somogyi phenomena since as you increase the
dose, the Blood glucose level in the morning is increasing due
to the counter regulatory hormones that are acting. What is
happening is that as I are increasing the dose of insulin,
hypoglycaemia occurs in the early morning between 3am and
4am which results in secretion of the counter regulatory
hormones like Growth hormone, ACTH hormone and results
in hyperglycaemia in the morning.
Oh, that might be a possible thing.
What I recommend is to decrease the dose of insulin in the
evening or shift the evening dose to the night dose. You can
share my opinion with other doctors in the hospital. It is
important to measure his Blood glucose levels at late nights to
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Medical Student:
Pharmacist:
Medical Student:
Pharmacist:
OSCE TI PS
confirm the hypoglycaemia occurring in the early morning to

confirm Somogyi phenomena.
Thanks a lot.
I will call you tomorrow to see how your patient is doing.
Thanks a lot.
Have a good day.
Case: 90
Patient Name: David James
Age: 25 years
Sex: Male
Allergy: Unknown
Doctor:
Patient Profile
- Risperidone 5mg PO QD (9 months ago)
- Zyprexa Zydis tab 20mg QD (7 months ago)
- Clozapine 600mg PO QD (4 months ago)
(Dose was increased gradually by increments
within period of two months)
- Clozapine 900mg PO QD for the last two months
I want to share your opinion about my patient, who is experiencing

schizophrenia, and he is resistant to Risperidone, Zyprexa, and for the last
4 months I tried Clozapine by increasing the dose in increments with only
partial benefits. Could you please provide me with your opinion about
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Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
OSCE TI PS
any other medication, or any other useful regimen to treat this patient? I
am here to answer ay question if you would like to ask.
Thank you doctor, I can see that you have a resistant case of schizophrenia
and your patient has been using Risperidone and Zyprexa previously
without any benefit and now he has some partial benefit from Clozapine
which you use it for the last 4 months.
Exactly.
Doctor, does your patient have any other medical condition?
No.
Does he have any allergy to any medication?
No.
Does he use any Rx medication other than those mentioned?
No.
Sure.
Well, doctor, according to my reference book (CPS), Clozapine should be
given an adequate trial of (6 months) to see the optimal effect, and since
you have tried that for 4 months, it is important to wait for further two
months.
Oh, thank you for that advice; I will wait for further 2 months more.
Doctor, do you want any other information?
No, thanks.
Doctor, do you want me to document that?
Yes, please.
Document.
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Case: 91
Non-duteractive station
Prescription errors:
Three prescriptions have errors. Identify the errors.
Rx (1)
Avaxim inject I.V. (Hepafitis A Vaccine Inactivated)
0.5ml, Single dose, Booster dose after 6-12 months
Mitt: 1
Rx (2)
Alvesco (GKlesonide) inhaler
Shake well and inhale 1 puff twice daily
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Mitt: 1
Rx (3)
Depo-Provera 100mg inj Every 3 months
Solution:
Rx (1) Inappropriate route of administration. (It should be I.M.)
Rx (2) Inappropriate directions (The patient should not shake)
Rx (3) Inappropriate strength (It should be 150mg)
Case: 92
Patient Name: Caroll Elias
Age: 79 years
Allergy: Unknown
Patient Profile
Apo-omeplazole 20mg BID
Terazosin 2mg QD
Novo-metoprolol 25mg BID
Glyburide 2.5mg BID
Metformin 500mg BID
Calcium Decussate 100mg 2/day
HCT 25mg PO QD
Syathroid 88mcg PO QD
Palafer PO QD
Patient:
I have a confusing schedule.
Pharmacist: Yes, I know it is a confusing schedule. I will clarify that for you, mam, by
drawing a table for you indicating the day and time of administration.
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Patient:
Thank you.
Pharmacist: If you like, we offer a free dossette or blister packs to make you remember
when to take pills.
Patient:
No thanks. Just draw me a table and I follow that.
Breakfast
Omeprazole 20mg
BID
Lunch
Dinner
Bedtime
With or without food,

dont crush or chase
Terazocin QD
Notes
With or without food,

dont crush or chase
Metolprolol 25mg BID
With or without food
Glyburide 25mg BID
After meal
Metformin 500mg
BID
Calcium Decussate
2/day
After meal
with plenty of water
HCT 25mg
Syathroid 88mcg
Empty stomach space

from iron at least 2hrs
Palafer
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Patient:
Phamacist:
Patient:
OSCE TI PS
Thank you for the table.

I will call you after two days if you dont mind to see how you are doing
with your medication and to manage any side effect like stomach upset.
Thank you.
Note: You can go to life style, if you have time.
Case: 93
Patient Name: Dr. Douglas, C
Age: 35 years
Sex: Male
Allergy: Unknown
Medical Condition: Social anxiety
Rx
Zyban (Bupropion SR)
Sig: 1 tab QD x3 then BID
Mitt: 60 tabs
Solution:
Sorry doctor, in order to dispense it, it should be by your family physician. I know you
are a doctor and you can prescribe any medication you want, but that privilege that you
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have is for your patients, and not for yourself. The college of physicians and surgeons
urges members not to obtain drugs for their own needs, or for their family except in an
emergency medication, so it is advisable to have an Rx from the family physician and to
monitor your condition as you do with your pts.
Case: 94
This is from pharmacy connection July/August 1995.
How to handle narcotic and controlled drugs returned to the pharmacy on behalf of a
deceased patient.
Solution:
These medications are not considered pharmacy inventory, since they have already been
legally dispensed. Hence, prior written authorization to destroy them from the Bureau
of Drug Surveillance is not required. However, a pharmacist could potentially be
challenged later about what he/she did with the returned drugs (possibly by the executor
f the deceaseds estate).
Therefore, the College recommends that a pharmacist:
o Prepare a list of drugs at the time of return
o Carry out the destruction ideally in the presence of the person making the return (or
subsequently in the presence of another pharmacist)
o Have the person returning the drugs sign the list and receive a copy of an Estate
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Destruction Form. The Estate Destruction Form was prepared by the Bureau of
Drug Surveillance to facilitate documentation.
Case: 95
Patient Name: James, Evil
Patient Profile
Age: 62 years
(PUVA) oxsoralen (methoxsalen)
Sex: Male
Soak in aq. Sol. for 10 mins before UVA
Allergy: Unknown
exposure. 100mg/75L bath water for 10 days.
Medical condition: Psoriasis
Patient approaches the counter asking for St. Johns Wort to treat his mood fluctuation.
Pharmacist: Hi James, what brings here today?
Patient:
Well I am looking for St. Johns Wort to treat my fluctuation in mood. My
friend told me it is good for that purpose.
Pharmacist: You must have been in quite a bit of discomfort.
Patient:
Yea.
Patient:
Thank you.
Pharmacist: Yes, St. Johns Wort is used for that reason, but as I know you are using a
certain medication for your Psoriasis, so would you mind to check your
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OSCE TI PS
profile to see the medication that you are using since St. Johns Wort
interects with many medications.
Patient:
Sure.
Pharmacist: Sir, according to my reference book, St. Johns Wort is not recommended
with therapeutic UV treatment due to the risk of photosensitivity. You are
using a medication with light wave exposure which may result in
photosensitivity. So, I dont recommend St. Johns Wort for your
condition for that reason. It is better to see your doctor and treat your
condition.
Patient:
Sure, I will do that.
Pharmacist: If you dont mind I will call you after a week to see what you have done
with your doctor.
Patient:
Thank you.
Pharmacist: Have a nice day.
Note: There is no need to go to MAMA questions since you are not going to dispense
anything for the patient due to the contraindication of St. Johns Wort with PUVA.
Case: 96 (Medical Student)
Patient Name: Gelald Ovin
Patient Profile
Age: 37 years
Altace (Ramipril) 5mg PO QD
Medical Condition: Hypertension
since 6 weeks ago.
Family History: Stroke
HCT 12.5mg PO QD
Allergy: Unknown
since 12 weeks ago.
Pharmacist:
Medical Student:
Pharmacist:
Medical Student:
Hi, I am the pharmacist in duty today, my name is (

).
How may I help you?
Well I have a patient using Altace 5mg tablet and HCT
12.5mg tablet for his hypertension. He has a family history of
stroke. He is going to be discharged today. My senior doctor
is not available right now, and I want to share your opinion to
give him ASA 50mg or Clopidogril 75mg for prophylaxis
from stroke.
Thank you for sharing my opinion. As you know we should
work collaboratively for the best benefit of the patient.
Sure.
PharmacyPrep.
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Pharmacist:
Medical Student:
Pharmacist:
Medical Student:
Pharmacist:
Medical Student:
Pharmacist:
Medical Student:
Pharmacist:
Medical Student:
Pharmacist:
OSCE TI PS
Does your patient have any other medical condition beside

hypertension?
No.
Does he use any Rx medication in addition to what is
mentioned in his profile?
No.
Does he have any allergy to medications?
No.
Please give me a few minutes to check in my reference book
(asking life style of patient with medical students is optional).
Sure.
According to my reference book (Therapeutic Choice)
Antiplatelets
(ASA,
cloidogre,
ticlopidine
and
dipylidamole/ASA are not indicated for primary prevention of
ischemic stroke due to the increased risk of adverse effect.
They are extremely effective for secondary prevention. So
controlling his hypertension, with life style modification if
there is any risk of them is recommended at this stage.
Oh, I didnt realize that. Ok, thank you, I will discharge the
patient without giving him ASA.
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Case: 97
Patient Name: Jeany Chriss
Age: 38 years
Gender: Female
Pregnant, 2nd trimester
Allergy: Unknown
Rx
Insulin lantus (glargine) 15u per day
Doctor:
Hi, I want to prescribe Insulin lantus for my pregnant lady. She has
8.8mmol/L glucose level, I want to give her 15u of that Insulin. Do you
think that dose is sufficient?
Pharmacist: Ok doctor, I can see that you want to prescribe Insulin lantus to your
pregnant lady who is experiencing diabetes due to her pregnancy. She is
in her 2nd trimester of pregnancy. Ok doctor, may I ask you a few other
questions?
Doctor:
Sure.
Pharmacist: Does she have any medical condition like diabetes before pregnancy?
PharmacyPrep.
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Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
Doctor:
Pharmacist:
OSCE TI PS
No, just family history of diabetes.

Does she use any prescribed medications?
No.
Any allergies to medication?
No.
Please, doctor, give me a few minutes to check in my reference book.
Sure.
Well doctor, according to my reference book (CPS), Insulin glargine is not
recommended due to concerns that it may affect fetal growth.
So, what do you recommend in pregnancy?
According to my reference book, Insulin lispro is recommended since
others are information lacking. You can give the dose according to the
blood glucose level and carbohydrate consumption.
Oh, thanks a lot. I will prescribe Insulin lispro instead of Glargine.
Do you want any other information doctor?
No thanks.
I will keep in touch with the pregnant lady to monitor her blood glucose
level and to follow up with her to manage if any hypoglycaemia or hyper
glycemia that may occur.
Thanks a lot.
Do you want me to document that?
Yes, please.
Document.
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Station: 98
Patient 30 years of age approaches the counter and wants to take plan B in advance.
Solution:
Pharmacists should consider supplying plan B in advance of need if the woman
demonstrates a good knowledge of its use. There are no apparent contraindications and
the supply is deemed appropriate (for example, a woman who regularly used condoms
requesting an advance supply in case a condom breaks). Plan B is more efficacious, the
earlier it is taken after an unprotected intercourse or contraceptive failure.
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Station: 99
A mother of a new born child approaches the counter and she says that the child has an
allergy to her breast mil after he takes small amount of breast milk. He develops rash,
redness and itchiness.
Solution:
This is mostly cows milk allergy. The mother should be asked whether she is drinking
cows milk or not which passes by breast milk to the feeding child, and is not due to
breast milk. So the mother should stop taking cows milk or formula based on cows
milk, given to the baby. Most babies that react to cows milk protein. Any allergy to
milk should be diagnosed by the doctor to avoid a reduction in nutrients and calcium.
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Station: 100
Patient approaches the counter asking about Insulin requirements in pregnancy. She is
pregnant now in her first month.
Solution:
Insulin requirements usually fall in the first trimester, and increase subsequently during
the second and third trimester. After delivery, insulin requirements normally return
rapidly to pre-pregnancy values. Patients with diabetes who are lactating may require
adjustment in insulin dose, meal plan or both. So it is important to see her doctor to
monitor her blood glucose levels and to take insulin lispro if needed and to control her
diet and exercise.
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Dose Adjustment
Examples of a prandial insulin dosage adjustment
Anticipated carbohydrate intake 60gm
Insulin-to-CHO ratio = 1:12 (1 unit to 12g CHO)
Prandial insulin is Aspart
Insulin scasitivity: 1 unit lowers BG by 2mmole/L
Pre-meal BG is 11mmole/L (Target value 7mmole/L)
The patient should administer a total of 7 units of Aspart: 5 units to cover the CHO
content and an extra 2 units to correct for premeal hyperglycemia.
Adjustments of routine doses

Time of blood glucose test and responsible insulin inj
Pre-breakfast ----- Basal insulin given previous evening
Post-breakfast ---- Pre-breakfast prandial insulin
Pre-lunch ----------Pre-breakfast regular insulin and/or pre-breakfast NPH
Pre-supper -------- Pre-breakfast NPH; also pre-lunch regular insulin
Post-supper ------- Pre-supper prandial insulin
Bedtime ----------- Pre-supper regular insulin and/or pre-supper NPH
2 am --------------- Pre-supper NPH
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Patient Self-Care
TIPS to how to read the book
The first five chapters of the book deals with how to communicate with patients
and patient centered care which depend largely on the pharmacists ability to
develop trusting relationships with patients and to help patients reach the
therapeutic goals that both the patients and their health care providers endorse.
The pharmacist should act as a good sender and as a good receiver of messages.
As a sender, you are responsible for ensuring that the message is transmitted in
the clearest form, in terminology understood by the other person, and in an
environment conductive to clear transmission. To check whether the message
was received as intended, ask for feedback from the receiver and clarify any
misunderstandings. As a receiver, you have the responsibility of listening to
what is transmitted by the sender. To ensure accurate communication, you
should provide feedback to the sender by describing what you understood the
message to be.
Chapter 6 deals with Insomnia. The chart of assessment of patients with
insomnia reveals clearly that OTC medications are considered when insomnia is
in a predictable pattern, and also when patients expectations may be achieved
and should be given for 2-3 nights. The patient should be referred if OTC
sedative ineffective after 3 evenings or if it is required for more than 14
consecutive days. The chapter emphasizes on the non-pharmacological (sleep
hygiene) and it is important to recommend the patient the sleep diary indicating
the usual bedtime, time of arising, the timing and quantity of meals, use of
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alcohol, exercise, medications and descriptions of the duration and quality of

sleep. If we look at non-prescription drug therapy of Insomnia, we see only
three medications namely Diphenhydramine, Doxylamine and Valerian. The
latter is an herbal product, it has a Din number but still limited data available.
When counselling a patient experiencing insomnia by giving him an OTC or Rx
medication, you should counsel him on:
1. Sleep hygiene
2. Medication cause sedation and should not be used with alcohol
3. They may cause dizziness and the patient should not drive or operate
machinery while under the effect of the medication.
4. Tell the patient if medication is not effective for 3 days or if it requires
more than 14 consecutive days, then see doctor.
5. Insomnia is not a disease but a sign and symptom of an underlying disease
if it occurs in a chronic manner (more than 3 weeks).
6. Monitoring should be after 3 days to see the effect on insomnia, and how
to manage side effect like dizziness or hang over.
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Depression
1. All cases of depression require referral.
2. Avoid alcohol with antidepressants.
3. Monitoring after two weeks to see for the vegetative effects (increase or
decrease in sleep, improvement in appetite), and after 6 weeks to look for
improvement in mood swinging.
4. St. John Wort may be appropriate for the individual who is unwilling to seek the
attention of a physician.
5. Patients experiencing their fist episode of depression should be maintained 6-9
months after remission of symptoms.
6. Non-pharmacological are important in depression like relaxation exercises,
physical exercise, social support grouping. Keep socially active and enjoy your
hobbies.
7. Tell the patient to avoid alcohol absolutely.
8. Take the medication regularly.
9. Withdrawal symptoms of antidepressants are flu-like feelings of malaise and
muscle aches, stomach or bowel upset, anxiety and irritability, fatigue,
headaches and electric should like feelings.
10. Stopping of antidepressant is by doctor.
Headaches
For migraine headaches, keep a diary of food taken 24 hours before the attack.
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Patient education is very important to reassure patient about his headache.

Treatment of medication overuse headache involves completely discontinuing
the implicated drag, relieving withdrawal symptoms.
Migrain prophylactic medications should be tried for at least two months to
determine efficacy. It is important to talk to a physician before taking any
preventive medications.
Fever
All feverish people if under 2 months of age, fever >40.5C, or with neck or
seizure, or localized pain, redness, swelling refer to doctor.
If patient having fever after surgery or patient feverish and confused or delirious
or recently received chemotherapy, refer.
If child appearing ill or consistent crying, refer.
Fever persisting more than 24 hours without obvious cause, also refer.
Except the above give Tylenol no more than 3 days, if not relieved, refer. If
relieved drug of choice after 3 days.
Whenever you gathering information about the feverish person, ask about the
temperature, and method of measurement (rectal, oral, armpit, ear) and whether
there is any Tylenol or Tylenol preparation at home. Ask the dose that they are
using it.
If sponging is used to reduce body temperature, administer the antipyretics 30
minutes before sponging to reduce hypothalamic set point.
Recommend avoiding alcohol for adults using Tylenol.
Heat-related Disorders
In preventing heat-related illnesses, athletes should ensure proper hydration as

thirst is an unreliable sign of body fluid loss.
In heatstroke stop activity immediately, and rest in a cool, shaded area,
rehydrate, ensure good air circulation around the patient and take to emergency
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room ASAP.
To monitor the sings and symptoms of heat-related problems, it is important to
let your family and friends know that you may be at risk for this illness. They
can watch over you in case you develop symptoms.
Nicotine addiction
Smoking may affect certain medications, also nicotine replacement therapy

when initiated and when drug of choice.
Intense craving may require additional treatment, for example bupropion.
If symptoms are bothersome, consider increasing dosage, switching or adding an
alternative method of nicotine replacement therapy.
If minor side effect occurs, suggest ways to modify (for example, for belching
and GI upset with gum, advise slower chewing) or consider switching to an
alternative method of nicotine replacement therapy. If serious side effect (for
example, hypertension) consider reducing dose or drug of choice medication,
and switching to alternative, for example bupropion.
If one is taking NRT, he should not continue smoking, as this is very dangerous
for his health.
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Allergic Rhinitis
o First generation antihistamine and oral decongestant are given every 4-6 hours.
o Second generation antihistamine are given once daily except Fexofenadine is
given twice daily.
o Third generation antihistamine desloratidine is given once daily.
o It is better to give second generation antihistamine for allergic rhinitis due to
prolong treatment in allergic rhinitis and to avoid side effect f the first
generation.
o Antihistamines may be given prophylactically before the start of seasonal allergy
or on need basis when the person is exposed to an allergen due to their short
onset of action.
o If seasonal symptoms lasting less than 2 months, allergen avoidance measures
and oral antihistamine with or without decongestant may be given.
o Allergic rhinitis with bad breath refer the patient to a physician, since allergic
rhinitis here might be associated with an infection like sinusitis or sore throat or
any other upper respiratory tract infection.
o Refer patients to a physician if they have already tried appropriate nonprescription therapy for two weeks without an adequate response or if the
allergen responsible for symptoms cannot be readily identified.
o Decongestants are not recommended for use in children.
o All treatments for allergic rhinitis with non Rx therapy is 1-2 weeks, if not
controlled, refer to physician.
o For prophylaxis on need basis, second generation antihistamine should be used
on need basis due to their rapid onset of action. However if for prophylaxis
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before season and if to be taken during the whole season, the therapy should be
under the supervision of the doctor to monitor his condition and side effect.
o In pregnancy, OTC that is used for allergic rhinitis is Nasal cromoglycate, but
should be under the supervision of the physician. However, the pharmacist may
recommend that till the patient sees his doctor.
Upper Respiratory Tract Infections
Single dose on prn basis are moderately effective in relieving nasal congestion,
otherwise rhinitis medicamentosa may occur after prolonged regular use.
Topical decongestants should not be used in children under 6 months of age.
Refer the patients with phlegm with dolour (like green, brown, or any colour) or
if bad odour present, since these could be signs of infection or inflammation
which should be assessed by doctor.
Echinacea is contraindicated in patients with immunosuppression including
AIDS or autoimmune diseases or taking immunosuppressant medication.
Cough and cold remedies should be avoided in children under two years of age.
However in older children, it is your professional judgement to give
dextromethorphan for dry cough since evidence of efficacy is lacking.
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Eye Infection
Self medication with non Rx ophthalmic antibacterial is not necessary and is not
recommended.
Treatment of dermatologic disorders elsewhere in the body such as seborrheic
dermatitis is important in achieving long-term control of blepharitis.
In blepharitis, lid hygiene may be required on a daily basis immediately after
initial diagnosis or during period of exacerbation, but may be reduced to twice a
week once control has been achieved.
In bacterial conjunctivitis in adults, refer to a physician if no improvement
within 48 hours. If children, refer to a physician. Do not recommend selftreatment.
Viral infections are highly contagious and can be spread through respiratory
tract-to-eye, finger-to-eye, or instrument-to-eye (as in physicians offer) and via
contaminated swimming pools.
Children with viral conjunctivitis should be referred and he kept out of school
until there is no ocular discharge (minimum of one week). Ocular decongestants
and/or lubricants are useful in improving patient comforts.
Balanced salt solution, ocular lubricants like methyl cellulose are first line
treatment. Decongestant drops like naphazoline, phenylephrine, oxymetazoline,
and tetrahydrozoline are considered second line treatments.
Second
cromoglycate is considered 2nd line treatment.
If there is unexpected redness, swelling, pain or irritation, stop wearing your
lenses and contact your eye care professional.
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General Ear Conditions
All ear infections refer the patient except if there is hearing loss associated with
URTI; in that case suggest symptomatic treatment for URTI. If hearing loss
does not improve following resolution of nasal congestion, then also refer.
In order for the topical treatment to be effective, the canal of the ear should be
properly cleaned. Cleansing must be done by a physician.
In recurrent otitis externa, for prevention use Aluminium acetate 0.5% (OTC) or
acetic acid 2% (OTC), or use a bathing cap while swimming and ear plugs.
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Nausea and Vomiting
Nausea due to pregnancy, the pharmacist should be aware whether this is Nausea
and Vomiting due to pregnancy which is a normal physiologic thing or is it due
to other diseases associated with pregnancy like UTI. So if Nausea and
Vomiting is occurring in the 2nd trimester, this mostly cause with infection which
requires immediate referral to doctor. However, if is due to pregnancy, the
pharmacist may give B6 tab or Gravol to the patient till the patient sees her
doctor.
In post operative Nausea and Vomiting, this persists for 48 hour, if it continues
refer. This applies too to the Nausea and Vomiting due to viral infection.
In motion sickness, for short trips, give dimenhydrinate, for long trip,
scopolamine patch administered 12 hours before the anticipatory boarding, and
keeping it up to 72 hours behind the external ear lobe.
In Nausea and Vomiting due to medications, try to give the mediation with or
after meal or adjust the dose by calling the doctor as in metformin or Glyburide
or changing the dosage form to enteric counted or melting tablet in saliva, or by
O/C the medication and switching it to another medication, and this also should
be done by the physician, however the pharmacist can play a role by discussing
these things with the doctor and mentioning the doctor the different dosage
forms that are available.
Since dimenhydrinate is recommended by Canadas motherisk program for
augmenting Diclectin therapy in pregnancy and is considered generally safe in
pregnancy, it can be considered for intermittent therapy of motion sickness in
pregnant patients.
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Pin can cause Nausea and Vomiting and therefore increasing the dosage to
control pain, if the pain is controlled by Narcotics, however, with NSAIDs there
is a ceiling to the dose. If the Narcotic medication is not effective, consider
switching to another Narcotic at 75% of the equivalent daily dose.
If the drug is effective but causes paradoxical excitability, try reducing the dose
to find the minimum effective dose.
Constipation
Laxatives may be given by the pharmacist for 1 week on prn basis, if not
effective refer to doctor.
Constipation more than 7 days, refers to doctor since this may result in fecal
impaction.
If the patient complains of hard stool give docusate. Docusate calcium is given
to patients with hypertension. However if patient has hard stools and predicted
constipation, we can give docusate and senna.
Always when counselling patients on laxatives, the onset of action should be
intentioned, and ask the patient whether he prefers immediate action, in that case
we can give glycerine suppository, Bisacodyl suppository sennoside, bisacodyl
or magnesium sulphate. If not immediate we can give lactulose solution which
works within 24-48 hours.
Bulk forming laxatives are best given to pregnant women, and to treat chronic
functional constipation which takes 2-4 months for maximum effect.
Bisacodyl should not be taken with PPI or antacids since it is an enteric coated
tablet.
In cancer patients, stimulate laxatives are the mainstay of therapy with enemas
used intermittently.
In monitoring constipated patients, if full bowel movement has occurred but
bloating and cramping are not relieved, refer to physician.
Laxatives are contraindicate if there is stomach pain, bowel obstruction, Nausea
and Vomiting, and should be spaced apart from other medication with at least
two hours.
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If the laxative was used chronically or for more than 1 month, the pharmacist
may tell the patient to taper the medication and not to discontinue abruptly and
to see his doctor.
Diarrhea
If symptoms of diarrhea persist more than 2 days, refer to doctor.

In children, breastfeeding should be continued during episodes of diarrhea and
ORS should be offered. If a child is not being breastfed, all food and drinks
should be withheld, and ORS given. ORS should start as soon as diarrhea
begins and continue until diarrhea is less frequent.
Early re-feeding should begin within six hours of beginning ORS. For infants
who are formula fed, start with small, frequent feedings of the childs usual
formula. Should the diarrhea persist for five days, switch to a soy-based formula
as lactose intolerance may be suspected. For older children, early re-feeding
with age appropriate, previously tolerated foods is recommended after 24-48
hours, the childs normal diet can resume. It may take 6-7 days for stools to
become completely formed.
In travellers diarrhea, if there is bloody stool, and rectal temperature over 38.9C
with persistent vomiting and the patient is more than 2 years, and the signs and
symptoms moderate to severe, start with antibiotics and loperamide (over 12
years), ORS and non-pharmacological for 48 hours if not responding the refer.
However if the symptoms above are mild-moderate, then start only with
loperamide (caution in children under 12 years) and consider BSS, ORS and
non-pharmacological. If the above symptoms which are mild to severe are for
under 2 years of age, then refer. If the symptoms of child under 2 years of age
are mild then give ORS and non-pharmacological only for 48 hours. If not,
responding refer.
Prior to departure, travellers should see a physician for appropriate antibiotics
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for use in case of diarrhea while travelling.

If symptoms of diarrhea persist longer than 14 days once back form a vacation, a
physician should be consulted.
In case of any abdominal pain whether an adult patient or a child, you should
refer.
Suspect celiac disease in patients with diarrhea, weight loss and tiredness
(anaemia).
Following infections gastroenteritis, it may be a number of months before
lactase activity returns to normal; so after switching to soymilk dont
discontinue that within a short time, tell the patients to take a few months and
should consult the doctor when to restart on the regular formula milk.
Dyspepsia and GERD
In dyspepsia that is due to indulgence of food and/or alcohol; treatment for

therapy should be no more than 2 weeks on regular basis, if signs and symptoms
persist after two weeks, you should tell the patient to see his doctor. In addition
to that, prophylactic therapy is important to advice the patient like to take
famotidine or ranitidine 15-30 minutes before indulging heavy meal which you
eat occasionally or before alcohol when it is taken occasionally. However, if
alcohol is taken or regular basis or eating heavy meal is frequently taken, you
should tell the patient to change his life style.
In case if the patient has stomach upset which is bothering him now; you can
give Famotidine or Ranitidine plus an antacid like Tums or Rolaids in any
dosage form since these antacids work quickly within 15 minutes to subside the
signs and symptoms till the longer acting medications like famotidine or
ranitidine starts working after 1-2 hours.
Liquid antacids should be shaken well and can be taken before or after meals.
Infant Colic
Recommend that care giver maintain a colic diary for 48-72 hours that
documents crying and fussing spells and associated symptoms. Parents should
also log sleeping, playtime and bowel movements in the diary.
When parents use calming techniques, they should use it more than one day,
otherwise the child may get over stimulated, which can make the colic worse.
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Sometimes after breast feeding, the child may get colic. In that case tell the
mother that colic of the child may improve when cows milk is removed from
the mothers diet for one to two weeks. Frequent formula changes to solve the
infant colic are not recommended.
Gripe water, simethicone and sucrose they are either not recommended or
limited data for their benefit. Dicyclomine is contraindicated in infants less than
6 months.
In monitoring infants with colic, after trying all the non-pharmacological and
persists after 3 days of intervention then refer to a physician.
Always give the caregiver a calibrated dropper or an oral syringe instead of
teaspoon.
Haemorrhoids
Haemorrhoids should be diagnosed by doctor and need Rx medication. You can

give which hazel pads or any smoothening cream just to ameliorate the signs and
symptoms till the patient see his doctor.
Any bleeding, rectal pain, protrusion of anal sphincter; you should refer.
Non Rx haemorrhoidal products for external use should be applied sparingly
they should not be inserted into the rectum.
Pinworms
Pregnant lady, children under 12 years of age, patients with renal and hepatic
failure is the priority to be referred.
Dose given according to weight.
All family members should be treated and therefore starting gathering
information (MAMA) from all family members.
Treatment should be repeated after two weeks from its starting dose.
In pregnancy, treatment should be delayed until at least the second trimester.
Caution the patient not to drive or use hazardous machinery until effect of drug
is known.
If itching has not resolved within 7 days of starting medication, repeat treatment.
If itching has not resolved within 7 days of beginning second course refer to
physician.
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Ostomy Care
Ostomy patients with constipation or diarrhea refer.

Enteric coated or tied release formulations should not be given.
Laxatives may result in perforations of colostomies, so give stool softeners like
docusate which are preferred.
Enemas should not be used with colostomies or ileostomies. Avoid laxatives.
Diabetes Care
Look for medication compliance (Dose and administration), diet and exercise.
Always teach patients to recognize early signs of hypoglycaemia like profuse
sweating, shivering, hunger (in hyperglycemia and in hyperglycemia occurs),
numbness of the lips and rapid heart beats, headache and mood changes.
If a diabetic patient regularly approaches your counter requesting analgesic; you
should refer that patient.
Oral decongestants should be avoided.
Diabetic patients with mild heart burn, in digestion or GERO can be treated with
OTC H2-receptor antagonists or with sugar-free antacids. However, if the
condition is more frequent then refer since this could be gastroparesis.
Any increase in physical activity or taking alcohol without prior snack can
increase the risk of hypoglycaemia.
Whenever you dispense metformin, tell the patient to avoid using alcohol
regularly since it may result in lactic acidosis, while occasional ingestion of
alcohol will not result in that.
Cartridges for insulin pen are not interchangeable. Also patients should be
aware if pen requires 150u or 300u, since cartridges of appropriate size would
only fit to the pen.
Needles should only be used once and not left in the insulin cartridge between
injections.
Disposing the needles and syringes should be with friendly hygiene in a
puncture proof container then incinerated by bio-waste companies.
When travelling, the patient should double the amounts of lancets, strips and
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medications taking with him, with a letter from the doctor to be shown in the
customer service. In addition to battery for glucometer measuring device which
should be used more frequently after travelling to the destination area, and
reducing a little bit physical exercise in the destination area to prevent any
traumatic injury.
Opened Insulin more than 28 days, should be discarded.
Infant Nutrition
Healthy breastfed infants require no extra water, even in hot weather, as long as
breastfeeding is readily available to the infant.
Thrush (yeast infection) is another common cause of nipple and breast pain,
usually occurring later in the course of breastfeeding. Prior treatment with
antibiotics predisposes mothers to yeast infections on the breast. If the mother is
diagnosed with thrush on the breast, both mother and baby must be treated,
whether or not the baby has signs of oral thrush. Antifungal creams (for
example, Nystatin, Clotrimatle) should be applied until well absorbed on the dry
nipple and are oral areas after each fed. Therapy for a minimum of 14 days is
usually recommended.
Breastfeeding may continue when the baby has been diagnosed with reflux.
Placing the baby in an upright position during feeds as well as for 30 minutes
after feeding can help prevent mil from refluxing. Burping and small frequent
feeds may also be helpful.
Nicotine patches should be removed at night to reduce infant exposure. Nicotine
gum should be chewed according to directions for moderate blood levels and
mothers should refrain from breastfeeding for two to three hours after using the
gum.
Casein-based formulas, which are more extensively hydrolyzed, are indicated
for feeding infants who have diagnosed cows milk protein or soy protein
allergy.
Soy-based formulas which are all lactose-free are not a routine alternative to
cows milk-based formulas. Appropriate uses include infants fed vegan diets
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and infants with galactosemia.

Infants allergic to cows milk protein can also become allergic to soy protein.
The Canadian Paediatric Society recommends supplement-action for breastfed
infant of Vitamin D (400 I u) daily until weaned in order to prevent rickets in
both healthy and at risk populations. Formula-fed infants receive Vitamin D via
commercial infant formula.
Use a small cup, a tiny spoon or eye dropper to feed a breastfed baby who
refuses to use an artificial nipple.
Nutrition
In anorexia nervosa there is cessation of monthly menstrual period, while in

Bulimia, there is irregular menstrual periods. In anorexia nervosa, there is a loss
of significant amount of weight, while in Bulimia there is preoccupation with
body weight, rigorous exercise, abuse of laxatives and vomiting resulting in
dental problems swollen cheeks or glands, heartburn or bloating.
A reduction of fat without reducing total caloric intake is generally not
sufficient for weight loss. This may result in decrease of cholesterol but not in
body weight.
Long-term eating of less than 100kcal/day to reduce weight is not recommended
as compliance is difficult, and it may cause a reduction in resting metabolic rate,
promoting weight-gain upon cessation of energy restriction.
Best nutrition consists of 30% fat (10% saturator), 55% CHO and 15% protein.
Fasting to control body weight deprives the body of nutrients and results in low
energy, weakness and light-headedness, not real weight loss. Any weight loss is
water and muscle, not fat and weight will be regained when eating is started
again. Ketones can be built up when CHO are not available for energy.
So to control the body weight follows healthy diet and physical exercise and
behavioural change and social support for reinforcement and motivation.
Patients who are underweight can increase nutrient intake by eating at mealtime,
increasing the number and size of servings; increasing nutrient density by adding
extra protein, CHO and fat and by feeding more frequently. Restricting physical
exercise, so there is a positive energy balance can be beneficial as can behaviour
modification.
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For monitoring weight management whether over weight or under weight,

evaluate at six months to determine the success.
Low Back Pain, Osteoarthritis and Sport Injury
Pharmacist should refer patients if not diagnosed, however if patient is not

diagnosed yet, the pharmacist may give Advil (analgesic and anti-inflammatory)
or Tylenol (not more than 4g/day) and for one week only, if not effective within
that week, then the patient should see doctor for Rx medication or for nonprescription like Advil and Tylenol but at this time Tylenol or Advil may be
given. Each one for two weeks and switched to another one for tow weeks
under the supervision of doctor.
If the patient has been already diagnosed by doctor; again he can give a
medication like Tylenol or Advil for no more than one week plus nonpharmacological like warm compresses, and gradient physical exercise plus
message ointments.
A patient can take Tylenol and NSAIDs or cyclobenza prime (skeletal muscle
relaxant) plus NSAIDs. However two NSAIDs are contra-indicated except if
ASA is used for heart protection or stroke prophylaxis since NSAIDs are not a
substitute for ASA.
Skeletal muscle relaxants are useful only for 2-3 days and dispensed by an Rx
from the doctor.
Back pain with red flags like unexplained weight loss problems with urinary
bladder or bowel weakness in leg and severe pain restricting mobility the patient
should be referred. Non-pharmacologic therapy should always be initiated first
or started concurrently with drug therapy.
When giving an herbal therapy like glucosamine to help treat back pain or
osteomyelitis; Gluocosamine therapy, and this may take up to three months to
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see the optimal effect, so the patient should be informed short that before
starting the treatment.
Rubefacients agents are good alternatives for those patients who can not tolerate
pills. They could be used as an adjunct with the systemic medications.
In sport injury, if non-pharmacologic and OTC are not effective, or signs and
symptoms are not resolved in 14 days, then refer to doctor so in sport injury, it is
contrary to back pain and osteoarthritis, we can wait in sport injuries before
referral for 14 days giving the patient analgesics plus RICE (nonpharmacologic).
Using analgesics with codeine for a long period may result in habit forming and
withdrawal symptoms, in case of discontinuation.
Skin Diseases
For athletes food, medication should be applied twice daily to a clear, dry foot
or for 2-4 weeks including one week after the lesion has disappeared. You
should emphasize on completing the course of treatment ever if the symptoms
have subsided.
In athletes foot, do not share personal items such as towels.
If symptoms not improved in 2 weeks, refer the patient.
In corns, calluses and Bunion, salicylic acid 12.6% or 17.6, once or twice daily,
available as liquid. However 40% salicylic acid is used every 24-48 hours, and
is available as pads and plasters. All these preparations should not be used by
individuals with diabetes, or peripheral vascular disease, or impaired circulation.
In warts, avoid touching warts on someone else or on another part of the body.
The ingredient in to all products is salicylic acid in concentration of (11-40%).
If the lesion in warts, or corn or calluses persists after 12 weeks of self treatment
refer the patient to a physician or podiatrist or chiropodist.
In dermatitis, intolerance to wool is a hallmark of atopy (atopic dermatis), also
there is no local lesion, and family history of allergic rhinitis, asthma or any
autoimmure disease which may be triggered by environmental factors. While
contact dermatitis is a delayed or cell mediated hypersensitivity reaction induced
by previously sensitized lymphocytes resulting from exposure of sensitized
individuals to contract allergens.
Moisturizer, first generation antihistamines, and Hydrocortisone 0.5% is the
common treatment, depending on the acute or chronic condition. Taper therapy
in response to resolution; if end points not achieved, refer to a physician for
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further therapy.
In diaper rash, if the rash has been ongoing for more than three days, it is more
likely to be colonized with Candida, and may need preventive anti-yeast therapy.
Do not recommend hydrocortisone 5% for use in children under two years of
age. Taper therapy in response to resolution i.e. taper therapy for anti yeast
agents and Hydrocortisone cream if more than 2 years, but continue giving ZuO
oint. As prophylactic. However treatment should not be more than 2 weeks, if
signs and symptoms persist beyond that; discontinue the medication. In case of
scaly boarder around the lesion, treat by OTC (antifungal), and there is no need
to send to doctor.
In psoriasis, patient should avoid over treatment. Rest periods in treatment with
anti-anxiety measures, emollients, and humidification are required. Antifungal
preparations such as Ketoconazole, selenium sulphide and Zinc phyrithione are
not suitable for psoriatic scalp.
In acne patients and when sunscreen is required, apply sunscreens (SPF>15) in
alcohol or oil-free bases and avoid using benzophenones because they area
acnegenic. The sunscreen should be applied as the first product, or apply
sunscreen during the day and benzoyl peroxide if used at night. OTC should be
used no more than 4 weeks to 8 weeks. If no response, refer.
All viral skin rashes require referral whether for children or adults since all of
them require diagnosis by the doctor. Self-care measures are important to
prevent the spread of the infection. The role of the pharmacist in viral skin
infection is to minimize patients discomfort that can be offered to patients with
viral skin eruption. Mild analgesics like NSAIDs and acetaminophen are
sometimes recommended for the treatment of acute pain associated with herpes;
however, they are often not effective. The pain in acute herpes zoster is
frequently moderate to severe and warrants the use of narcotics. People with
chicken pox are infectious for two days before the rash appears and remain so
until all the blisters have dried up (about 5-10 days).
In drug induced skin reaction, it is important to discontinue the offending agent
and refer the patients.
In patients who are allergic to sulphonamide allergy; it is important to counsel
first degree relatives, and advise them to enrol in Medic Alert program.
In skin infection and infestation, topical antifungal creams or lotions should be
applied to the affected area including 2-3cm beyond its border twice daily for a
minimum of two weeks after the lesion has cleared.
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In pregnant lady R&C shampoo is the best option.

If the lice is alive in the 2nd day or 3rd day, give another trial of a different class
for one week right away (dont wait for one week, till you use the medication).
If not improved, then this is a case of resistance, provided that you reviewed
with the customers the self-care measures of anti-lice and is using then
effectively.
For scabies, the diagnosis is by doctor and when counselling the patient, gather
information from all family members, since all of them are going to use it. Just
in case if new lesions are formed, second treatment if necessary, if no new
lesions are formed, but still itching, give antihistamine preparations and/or
Hydrocortisone 0.5% cream.
Scabies in pregnancy, the preferred treatment is Sulfur 6% in petrolatum for 3
days, same thing for children under two months of age and lactating mothers.
Minor Cuts, Wounds, Burns and Frostbite
Avoid or topical anti-inflammatory drugs such as ibuprofen for acute pain relief
of open wounds. They can interfere with the normal wound healing process.
Acetaminophen or narcotic analgesics (for example, codeine) are preferred.
Tetanus should be given even for patients with apparently minor clean wound
who should be referred to the doctor for a booster dose, if their primary
immunization was not complete (less than three does), or if they are uncertain
about the number of doses that were received.
If the bleeding from the minor cut persists for more than 5 minutes of direct
pressure, then refer to the doctor.
Patients who have burns with minimal blistering should be referred if they
involve this skin areas like the inner surface of the arm, perineum and around
eyes.
Dry, superficial burns where the skin is not broken do not require a dressing. If
there are no blistering or open areas, then there is not need for topical antibiotics.
Patients with frostbite if presented with large blistering areas, especially if the
blister are filed with a milky or blackish fluid, or if they have pain that is not
controlled with usual doses of non-prescription analgesics, should be referred.
Such kinds of patients are prone to develop tetanus.
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Insect bites and Stings
When you get a bite or sting, wash the site with warm water and soap, and apply
ice or cool compresses to relieve the irritation.
Refer to the doctor, any patient with minor signs and symptoms of insect bite, if
he is using -blocker.
Vaginal Candidiasis (Yeast infection)
Ask for red flags to refer like;

- Age, less than 12 years
- Pregnant
- DM
- Immunocompromised
- Less than 2 months since the last vaginal candidiasis and any unprotected
sex since this may result in possible sexually transmitted diseases.
The anti-vaginal products (cream of suppository) are usually administered at
bedtime to increase contact time with vaginal tissue and should be continued
menses if it commences during therapy. The complete course of treatment
should be used even if symptoms resolve before completion of the doses. In
case of vulvular symptoms are significant a topical antifungal can be used
adjunctively.
Whether the anti-yeast is a cream of suppository, containing the ingredient for
one day, three days or six days, the woman should understand that symptoms
should resolve within 7 days of the start of treatment (no matter which regimen
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is used). Also intercourse should be avoided during treatment to avoid affecting

the partner. Also the patient should be aware that the vaginal treatment could
decrease the effectiveness of spermicides, condoms, diaphragms and cervical
caps during treatment and for up to three days after.
Dysmenorrhea, PMS and Menopause
Ibuprofen should be taken during menstruation for 3-6 months, if not

effective patient should see doctor. If ibuprofen is contraindicated refer the
patient.
The diagnosis of PMS is confirmed through prospective monitoring of a
womans symptoms during at least two menstrual cycles.
A woman with mild symptoms of menopause may try to use nonpharmacologic, and then try to pharmacologic therapy that has been shown
to be superior to placebo (for example, Soya supplements, Vitamin E, black
cohosh or Replens). For those who do not respond to such kind of therapy
or who have moderate to severe symptoms should be referred to a physician.
Replens should be instilled into the vagina every 3 days on a continuous
basis. It should not be used prior to intercourse as a substitute for a vaginal
lubricant.
Aphthous Ulcers (Canker Sores)
Aphthous sores are not on the roof of jaw, and are not preceded by fever or
vesicles and occur almost exclusively on movable oral mucosa (inside the
cheeks and lips, tongue, floor of mouth and soft palate).
If the lesion is bordered by a raised margin with red halo around the lesion, then
this is a canker source. However if there is inflammation of the surrounding
tissue, so in that case, it could be oral candidiasis which require referral.
For canker source, benzocain for 3-4 days, with protectants like Zelactin gel and
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analgesics are sufficient to treat signs and symptoms. Mouth washes should be
avoided in canker source, wince they contain alcohol and will Q-tip (cotton
tipped swab) shown be used when applying the local anaesthetic orally before
meal to avoid the spread of the infection.
Prenatal and Postpartum Care
Antihistamines, decongestants, anti-tassives and medications for Nausea and

Vomiting should be given under supervision of doctor. However the pharmacist
can give them like dimenhydrinate B6 tablet, nasal decongestants till the patient
sees her doctor. To any prolonged use of drug therapy greater than 3 days
should be approved by a physician.
Schedule doses of medications in breastfeeding mother, right after breastfeeding
or before the baby is expected to have a long sleep period, in order to allow time
for the medication to pas from breast milk to blood stream.
Topical decongestants should be tried first; normal saline should be tried as a
first-line agent. Systemic decongestants should not be used unless topical
decongestants have failed and the benefits outweigh the risk.
Bromopheniramine is considered as a first-line antihistamine during lactation
while the manufactures cautions against the use of Diphenhydramine are
lactating mother due to increased sensitivity of newborns to antihistamines.
Loratadine (2nd generation antihistamine) is considered first-line antihistamine
during lactation.
Only antacids and aliginic acid may be given to pregnant woman in case of GI
upset.
Nausea and Vomiting in pregnant lady in second trimester, refer to doctor, it
could be due to infection.
Cold Sores
This is different from aphthous ulcers since the patient presents with vesicular oral
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lesions. Petrolatum, zinc-oxide and calamine can be used to prevent craking and
excessive drying of the lesion. Topical antibiotic like polysporin 3-4 times daily is
appropriate to prevent secondary bacterial infection. Tylenol or Advil may be used
orally if their pain from the cold sore.
Halitosis
Allergic rhinitis or any kind of rhinitis that is associated with Halitosis should be
referred because if could be a hall mark for infection like sinusitis, sore throat
and upper respiratory disease.
Regular use of a mouth rinse with high alcohol content can cause drying of the
mucosa and bad breath.
Most commercial mouth rises mask odours and provide antiseptic properties for
a relatively short time period (less than 30 minutes). The duration of action of
mouth rises is probably optimized if they are used prior to going to bed residues
of the mouth rise may remain in the mouth longer because the individual is not
eating or drinking.
Oral Candidiasis
All oral candidiasis requires referral since they need a prescription medication.
Preventive measures for oral candidiasis during steroid inhalation include the
use of a spacer device and rinsing the mouth with water following inhalation.
Dry Mouth
Symptoms of dry mouth that occur only at night are usually not associated with
salivary hypo-function because salivary function normally approaches zero
during sleep.
So for the management of dry mouth recommend frequent sips of water, and
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saliva substituents at night. Lozenges could be administered too.
Guidelines on reading Therapeutic Choices
Therapeutic Choices always start with a simple introduction about the disease,
giving us some general guidelines of the disorder or disease condition, so that
we can establish a goal of therapy. So it is important for the student to grasp
some information from that introduction.
The Goal or Therapy direct you to targets that you should achieve in handling
that situation. For example, I dont expect the goal or my targets in acute
myocardial infarction is to enhance the quality of life; rather my goal should be
to save his life, and after the discharge (post MI) could be to focus to enhance
the patients life by preventing the comorbidity like heart failure.
Then after we know the goal of therapy, we can now do the investigations either
by gathering information from the patient, or from patients history or by doing
some lab tests and clinical tests. Lab tests may be conducted for diagnosis and
sometimes for monitoring which might be different. For example, Rheumatoid
factor-titre is important for diagnosis of Rheumatoid Arthritis, but not for
monitoring. For monitoring and also for screening tests we need non-expensive
tests and simpler tests to be conducted. So, for RA monitoring we may use ESR
or X-ray imaging. This applies for other diseases like asthma etc. So, we can
say that the investigation that is mentioned in Therapeutic Choices could be used
as a tool to diagnose and monitor different disease states and is complementary
to the monitoring parameters for the medications in CPS. For instance, the
investion in Therapeutic Choices is to monitor the disease state; the warning and
precaution is CPS is for monitoring the medications. So, both will be
complementary when correlated together since one can monitor the disease and
the drug, or one can talk about the disease and drug, when he is aware of the
investigations in Therapeutic Choices, and Precautions and warnings in CPS.
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Non-pharmacological choices are a summary for the self-care measures in the

management of the medical condition, and should be well known to the student
because the non-pharmacological is what we inform the patient from the selfcare point of view during the counselling. The student should try to remember
at least the specific measures of the non-pharmacological.
Then we can see the pharmacological choices which are the prescription and the
non-prescription medication mentioned in some details in the text. However,
they are summarized in the table at the end of each chapter, where the dose, side
effect, and interaction with some notes are mentioned. So, the student after
reading the medications in the test should focus more on the summary that is in
the table, so that he is able to know all the mediations that are used to manage
that condition, and also their role when the patient is pregnant or lactating
mother. Also, the table will give you a clue about the different pharmacological
classes that are used to manage the disease condition. So the table may classify
some medications as first line, and others as second line, and so on. Reading
these tables and comprehending the information that are in them will make the
student more confident to deal with each case, since he is aware of medications.
The algorithm or the therapeutic management is the main point that should be
focused on, in order to know how to manage treat a disease condition stepwise
when it is mild moderate or severe and when to switch from one medication to
another in the same class which happens mostly when there is a response to the
medication with severe side effects, or to switch other medications of a different
class when there is no response or to augment by adding another medication
from the same class or from a different class. Also the algorith (flowchart)
indicates the duration of therapy for each medication (regimen) that is expected
to give the optimal response. Comprehending these flowcharts leads the student
to figure out how to deal with each case separately and to solve different
scenario cases, otherwise the therapeutic management can not be efficient and
sometimes wrong or in proper. What is mentioned in the flowchart may be
mentioned in the text, however following the flowchart is much easier since it
summarizes everything and considered as a quick reference but quickly viewing
the flowchart and tracking what is in there. Each disorder has several disease
condition like CNS disorders has anxiety, depression, epilepsy, psychosis,
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bipolar disorder, insomnia and others. Each one has different approach in the
flowchart different from the other that is in the same class, and thats why this is
considered an opportunity to correlate between different flowcharts within the
same disorder since the patient may have more than one disorder like depression
with epilepsy or anxiety with insomnia, or eating disorder with anxiety.
Sometimes the patient has a disorder of one class, and another disorder of a
different class, for instance, patient having depression with heart failure or
psychosis with diabetes, or Parkinson disease with Rheumatoid arthritis. So
multi patient disease conditions require to manage and to follow both flowcharts
or more than one flowchart. So what I want to conclude is that the flowcharts
are then core of managing the disease condition and should be followed and
tracked accurately i.e. the student should understand how to use them efficiently
so that he can solve any case f any disease condition. So now after the patient
has some summarized information about the disease from the introduction of
each chapter, then knowing the goal and the investigation, in addition to the nonpharmacological measures, and the prescription and non-prescription
medications that are used, make you more knowledgeable to use the tables at the
end of the chapter to know the dose, side effect, interactions and the comments
more efficiently which enables you now to use the flowcharts much more easily
and efficiently. This kind of studying comprehensively results in easier
correlation with the different chapters that are mentioned in the Therapeutic
Choices. Since the book summarizes the medication information, in that case,
whenever something is vague or not clear, one may go to the CPS to follow out
more about the dose, administration, monitoring parameters, interactions, the
supplied part and storage of the medication. So the CPS could be a
complementary part to the tables at the end of the chapter or to the flowcharts to
enable the student to know more deep information.
All the end of each chapter in Therapeutic Choices, there are the TIPS which
are important since they are very valuable information regarding the disease or
therapeutic management.
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PharmacyPrep.

In order for a student to perform efficiently in OSCE, he should be well aware

Sometimes one might see such kind of prescriptions:

o The CYP 450 Drug Interaction

Medications taken with or after meal

Acarbose (to avoid irritation)

With or without With or Do not

Calcitriol (Vitamin D3)

Drug Administration and Grapefruit Juice

Pharmacist: Have your seat please.

What are the informations that should be picked out?

To make it simple, here is a list of some expectation of well known medications.

doctor might put you on maintenance dose.

1- adrenergic Blocking agents (Alfuzosin, doxazosin, tamsulosin and terazosin).

Hi, my name is ( ). I am the pharmacist in duty today. How may I

me, and wrote this medication for me.

Patient: Yes, I drink two pints of beer every day.

Notes: Mentioning withdrawal symptoms after discontinue is optional and the

How many family member, are you?

about diet, exercise?

Pharmacist: Do you have any question so far?

previous medication along with this one or not.

Counsel her as you are in your pharmacy.

Pharmacist: Are you using it regularly?

Pharmacist: Thank you for your patience.

No smoke. 1 glass of wine everyday at night. eating too much. no

Pharmacist: Hi, my name is (

(Expextation) Sir, because there is a drug-drug interaction between Eryc

Pharmacist: It is important to use condom to avoid any sexually transmitted diseases.

Zyprexa Zydis 10mg tablet

No. No. No.

Pharmacist: Hi, my name is (

), I am the pharmacist in duty today. How may I help

Diagnosis: Grand Maleilepsy

have delivered healthy children and dont use any antiepileptic

The patient is coming with a concern.

some of the example.

Other tips regarding skin infestation

shampoo (these have chemical salts)

Pharmacist: Alcohol. Diet. Exercise. Coffee?

It is important to do physical exercise whenever you feel urge for

Other tips regarding smoking cessation

diet and by physical exercise.

Note: How to apply other patches (not nicotine patches)

I have white flakes on my shoulders when I brush my hair. Although my

a few minutes, to check in my reference book.

Other tips with respect to skin and scalp condition

That must be hard for you sir. (Empathy)

Pharmacist: Any allergies to medication. food. environment?

Have you tried any medication for him?

How long have you had these signs and symptoms?

Note: Patient said the medication for me. (Identifying)

So what do you use usually when you have this allergy?

Pharmacist: How often does this happen for you?

No. No. No.

Do you have any fever? (Red flag)

Half an hour ago.

dressing for it.

Have you tried anything for it?

expectation and monitoring) Also, Hydrocortisone 5% cream I am going

Is this the fist time that this happens to you?

Pharmacist: Do you have any question so far?

3. Offer incontinence pads that absorb both urine and odor.