November 23 Survey Questions
Question 1:
(Your submission) TL is a 49 yo male who presents with a prescription for Arexvy from his family doctor. He asks if the pharmacy can give the injection? It is officially only indicated for patients 60 years and older and there are no NACI guidelines yet. (ACIP (US) recommends Adults 60+ may receive a single dose of licensed RSV vaccine using shared clinical decision making.) TL has no allergies, medical conditions or medications.
How should a pharmacist respond?
Question 2:
Last time the following situation was presented: HT is a 62 yo female on celecoxib 200mg bid for arthritis for years. Her arthritis pain was not controlled but is tolerable on this dose so HT wants to continue as is. HT is not on anything for gastro protection and said she had discussed this before but it was not initiated and her stomach is "strong as a horse". HT has no allergies to medications. Her only other medication is atorvastatin for dyslipidemia.
What questions would you like to ask or factors would you consider before providing care?
Your questions:
- Confirm no OTCs. What other medications/treatments has she tried for arthritis? Assess other factors for GI risk and explain risk to patient.
- Kidney function. Cardiovascular Risk. Look at trial of once a day instead of BID.
- Any bleeding incidents recently,mainly in stool ? Any stomach pain ? Bloodwork ? Kidney function , HA1C? Any other risk factors for heart disease?
- What had she tried in past for arthritis pain? Would possibly try Acetaminophen CR 650mg since less risk of stomach issues if patient was willing.
- Are you taking tylenol? Do you check your BP? How are your kidneys? Have you ever had an ulcer?
- History of GI issues like ulcers that would put her at higher risk
- Assess Blood Pressure, Assess kidney function, Smoking history, Any CVD? DM2?
- I would consider prescribing a PPI if she remains on celecoxib.- any OTC used, other options for pain control previously tried, any GI symptoms such as heartburn/signs of bleeding/pain, other cardio risk factors such as BP/blood work for lipids/hx, kidney function.
- I would likely think about her “HAS-BLED” score for bleeding risk. I would also be curious about joints affected and impact on QoL to see if changing to an alternate regimen would be preferred
- What service is she looking for? Renewal, additional therapy?
HT has rheumatoid arthritis, she tried Tylenol in the past and found it to be ineffective. It primarily affects her hands and has limited the time she can spendgardening and doing crafts. She's only takes a multivite. eGFR > 90,LFTs WNL, no hematemesis or blood in the stool, BP 126/81, No history of GI disturbances, Non-Smoker. She has only used Celebrex for her arthritis. She is looking for a refill on her Celebrex.
How should a pharmacist respond?
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November 9 Survey Questions
Question 1:
(Your submission) TD is a 45 y/o female who receives B12 injections for a history of 'B12 deficiency' - no other medical conditions. Shepreviously received injections through her MD, who retired in August. Atthat time, her MD gave her a new rx for 1cc q 4weeks. She had her first dose at our clinic in September, and at that time noted that she was overdue because her last dose was at the start of August. She booked infor her second dose in October, 3 weeks later. It was noticed that she was 1 week early for her injection, and the pharmacist proceeded to check SHARE for blood levels. She hasn't had any bloodwork in 5+ years. The dosing interval (3 vs 4 weeks) was brought up with the patient - she stated she always had it injected every 3 weeks at her doctor's office (despite allrxs always being written for every 4 weeks). She acknowledged that she hadn't had bloodwork done for many years. Since B12 is available without a prescription, she could not understand why there would be any concernwith administering it on a different schedule than ordered or why there was concern about lack of bloodwork. TD refused to have bloodwork done(pharmacist at clinic able to provide lab req).
How should a pharmacist respond?
Question 2:
HT is a 62 yo female on celecoxib 200mg bid for arthritis for years. Herarthritis pain was not controlled but is tolerable on this dose so HT wants to continue as is. HT is not on anything for gastro protection and said she had discussed this before but it was not initiated and her stomach is "strong as a horse". HT has no allergies to medications. Her only other medication is atorvastatin for dyslipidemia.
What questions would you like to ask or factors would you consider before providing care?
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October 19 Survey Questions
Question 1:
(Your submission) RK, a 37-year-old male books an appointment at your pharmacy for renewal prescribing. He does not have a primary care provider. He requests a refill for valacyclovir which he last had 2 years ago. He states that he is experiencing a recurrence of genital herpes starting last night with papules forming in the pubic area and on his genitals. He has experienced acute flares 5 times in the last 12 years for which antivirals have been filled at your pharmacy. Other than local lesions he reports no other symptoms and his medical background is not remarkable.
How should a pharmacist respond?
Question 2:
Pharmacists often refer patients to other healthcare providers. This may include non-urgent issues that require medical attention, semi-urgent issues or even a trip to the Emergency Department. For funded prescribing by protocol (e.g. Uncomplicated Cystitis) there is clear documentation for the referral. As care has been provided to a patient and referral is an important part of that care, do you document referrals in other situations?
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October 12 Survey Questions
Question 1:
(Your submission) TJ a 47-year-old male books an appointment at theclinic for a renewal on olanzapine. He does not have a family doctor andhas been getting refills from walk-in clinics. Based on your assessment you determine that the therapy should continue but you notice that hehasn't had a lipid panel done in 2 years. You have the ability to order labs.
How should a pharmacist respond?
Question 2:
When assessing appropriateness of ongoing therapy, a pharmacist willcheck Control (Efficacy), Adverse Effects, Adherence and Complications(2 C's, 2 A's). This assessment process occurs when doing ChronicDisease Management, Advanced Medication Reviews and most oftenduring Renewal Prescribing.
Please indicate your agreement with each of the following regarding renewal prescribing for depression.
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October 5 Survey Questions
Question 1:
(Your submission) LY a 46-year-old male books an appointment at the clinic for a strep throat assessment. His symptoms started yesterday and included moderate to severe sore throat, tender lymph nodes, and white/yellowish tonsillar exudates on the left side only. The rest of his household just recovered from a viral URTI. They were positive for strep throat 2 months ago with similar symptoms and recovered successfully, but prior to this never experienced strep before. LY’s swab came backnegative.
Based on the symptoms and specifically the presence of white/yellowish tonsillar exudates how should a pharmacist respond?
Question 2:
When assessing appropriateness of ongoing therapy, a pharmacist will check Control (Efficacy), Adverse Effects, Adherence and Complications(2 C's, 2 A's). This assessment process occurs when doing Chronic Disease Management, Advanced Medication Reviews and most oftenduring Renewal Prescribing.
Please indicate your agreement with each ofthe following regarding renewal prescribing for GERD.
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September 28 Survey Questions
Question 1:
LK is a 42 yo female with taking venlafaxine 75 mg for depression. She has been taking the medication for about 6 months and has run out of refills. The prescription was originally started with a physician from virtualcare as she does not have a family doctor. She indicates that the medication has helped improve her physical symptoms but she still feels down, sometimes has difficulty concentrating and still doesn't take pleasure in activities that she used to enjoy. She denies any thoughts of self-harm. The rest of her medical background in unremarkable. She has tolerated the medication after initial GI discomfort and takes it regularly.
When faced with a renewal how should a pharmacist respond? Your pharmacy is not involved in the Bloom Program.
Question 2:
When assessing appropriateness of ongoing therapy, a pharmacist will check Control (Efficacy), Adverse Effects, Adherence and Complications(2 C's, 2 A's). This assessment process occurs when doing Chronic Disease Management, Advanced Medication Reviews and most oftenduring Renewal Prescribing.
Please indicate your agreement with each of the following regarding renewal prescribing for diabetes.
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September 21 Survey Questions
Question 1:
(Your submission - CPPCC Primary Care Clinic) TX is a 32 yo male requesting a renewal prescription for clonazepam 0.5 mg qid. He alsotakes Suboxone witnessed daily at another pharmacy which has been his home pharmacy for years. His clonazepam has always been dispensed 4 tablets daily with his Suboxone at the other pharmacy. He has come to the clinic monthly for renewals of clonazepam for the past 2 months as his family doctor retired 4 months ago. He was given information on accessing Virtual Care but has had difficulty accessing help electronically. He has taken clonazepam for many years for anxiety. He indicates that he tried sertraline in the past but did not do well with it. While he is aware of long term issues with benzodiazepine use but he would like to continue as he is worried about withdrawal if he stops. Just recently the restriction onproviding 1 month of controlled substances was lifted. He is a Nova Scotia resident with coverage for renewals.
How should a pharmacist respond?
Question 2:
(Any pharmacy, not necessarily a clinic) KT is a 56 yo female taking 36mg of Hydromorph Contin BID for non-cancer neuropathic pain. Her family doctor retired 3 months ago and she has run out of refills for her medication. She has been getting the drug at your pharmacy for the pastfive years although the dose has slowly increased over the past 2 years. She has been on 36 mg bid for the past 8 months.
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September 14 Survey Questions
Question 1:
JW is a 44-year-old female who presents to the pharmacy for an uncomplicated UTI assessment. Her opening statement is - "I've had UTIs before. I've only had 1 in the last 2 years and it was 4 months ago. I have dysuria, I'm peeing all the time. I don't have fever or flank pain. Can you give me Macrobid?" Assuming everything she states is true, how should a pharmacy practitioner respond?
Question 2:
XD is a 56-year-old male who has been prescribed clarithromycin 500mg BID for 7 days to treat Community Acquired Pneumonia. XD does not have a family doctor and obtained the prescription from a walk-in clinic. After taking the first two doses of this medication, XD calls the pharmacy and expresses that he has GI distress and states “I don’t think I can take this medication anymore, my stomach is a mess. I'd rather deal with pneumonia.” When asked about this distress more, XD states that he is not in pain, he's not vomiting and there is no blood in his stool, but he is unable to complete daily activities. How should a reasonable pharmacy practitioner respond?
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August 26 Survey Questions
NL is a 55 yo female who is looking for a recommendation for a hemorrhoidal treatment. She has never been diagnosed with hemorrhoids before. She complains of itching, burning and some blood on the toilet paper. She has experienced increased constipation over the past two weeks (going twice a week (down from daily) with harder formed stools. She also takes levothyroxine 100 mcg daily for hypothyroidism (TSH normal 3 months ago). She has no other medical conditions and no allergies.
How should a pharmacist respond?
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August 19 Survey Questions
HP is a 63 yo male who presents to the pharmacy with a blistering rash in a strip that wraps around the left side of his torso, typical of shingles. He indicates the area was tingling and sore about 10 days ago and the rash developed 6 days ago. There are fluid-filled blisters although some have ruptured. He reports no other symptoms other than pain. He indicates that the pain is sharp and stabbing and is keeping him up at night. On a scale of 1-10 he rates the pain at an 8 at its worst. HP has hypertension, dyslipidemia, glaucoma and acid reflux. His medications include ramipril, amlodipine, atorvastatin, latanoprost and pantoprazole. These medications were started over 6 months ago. He has no allergies. eGFR > 90.
How should a pharmacist respond?
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August 5 Survey Questions
TR is an 18 yo male who comes into the pharmacy looking for assistance with acne products. He has roughly a dozen papules and pustules on his face and roughly the same on his back. He has been using Oxy 5 but it the lesions are persisting. He has no allergies. He has asthma and uses salbutamol occasionally and before hockey and fluticasone regularly. He does not have a family doctor. How should a pharmacist respond?
How do you feel about ordering blood tests?
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July 29 Survey Questions
Have you been trained to give injections for children ages 6 months to 4 years old?
JD calls because his lorazepam 1 mg po bid will run out and he has no refills remaining when he runs out. He wants to know if you will renew it. You did a renewal for a 1-month supply last month and told him he needs to see his doctor. You've spoken to his doctor who wants to see him before giving him more medication. JD can get an appointment with his doctor in 7 days and he has about a 3 days of his medication left. JD tells you he doesn't want to go see the doctor as it's a waste of time and just wants you to renew it. From your assessment, the therapy continues to be appropriate. How should a pharmacist respond?
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July 22 Survey Questions
Pharmacists have noticed some challenges with Lyme Disease Chemoprophylaxis Prescribing. What challenges, if any, are you are experiencing? Use the comment to indicate other challenges or to give tips for handling the challenges you face. Thank you for your feedback as it may help identify key public messages.
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July 8 Survey Questions
TR is a 22 yo male who presents with a tick bite. You are able to confirm that the tick was a deer tick but you do not know how long it was attached. By TR's estimate it could be 24 to 96 hours. How should a pharmacist respond?
Renewal Red Flag Series: When providing renewal prescriptions, it is important that a pharmacist rule out and document any red flags that would warrant an urgent referral. (i.e. Patient reports no signs of …….). This is important not only for the patient’s well-being but to limit the liability of the pharmacist and the pharmacy. When providing renewal prescribing for Spiriva for COPD, what red flags would you document in your assessment?
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June 24 Survey Questions
The PANS prescribing by protocol for Uncomplicated Cystitis indicates that we should refer if the patient has renal dysfunction. At what eGFR should a pharmacist refer?
The manufacturer’s monograph for Macrobid® stated that it was contraindicated in those with an eGFR below 60 mL/min. There is limited data showing it to be safe and effective at 30 – 60 mL/min (Lexi). What is your cut-off for nitrofurantoin regarding renal function?
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June 17 Survey Questions
Part A: DL is a 32 yo female who presents requesting an assessment for birth control. She has not taken birth control before. She is married and is sexually active with her male partner. When trying to rule out pregnancy, she said she had recently had sex 7 days ago and her period was 10 days ago. She was unwilling to take a pregnancy test to confirm she was not pregnant. Her medical history is unremarkable. Should a pharmacist prescribe if the patient was unwilling to take a pregnancy test?
Part B: You subsequently learn that DL just wanted birth control to avoid her menstrual cycle while on vacation with her husband at a resort. Assuming there were no problems regarding the pregnancy test in part A, how should a pharmacist respond?
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June 3 Survey Questions
IG is a 32 yo male who presents looking for Twinrix® as he plans on going to Cuba. His medical background is unremarkable. The pharmacist has not received specialized training and credentials in travel medicine. How should a pharmacist respond?
When providing renewal prescriptions, it is important that a pharmacist rule out and document any red flags that would warrant an urgent referral. (i.e. Patient reports no signs of …….). This is important not only for the patient’s well-being but to limit the liability of the pharmacist and the pharmacy. When providing renewal prescribing for citalopram for major depressive disorder, what red flags would you document in your assessment?
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May 27 Survey Questions
TL is a 45 yo male who presents to the pharmacy looking for assistance for treatment of a discolored toe nail on his left foot. He thinks it’s infected with a fungal infection because it looks similar to the nail he saw on a TV commercial. The commercial indicated that there are products available that could treat it and he wants to know what you would recommend. His medical background is not significant. How should a pharmacist respond?
When providing renewal prescriptions, it is important that a pharmacist rule out and document any red flags that would warrant an urgent referral. (i.e. Patient reports no signs of …….). This is important not only for the patient’s well-being but to limit the liability of the pharmacist and the pharmacy. When providing renewal prescribing for omeprazole, what red flags would you document in your assessment?
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May 20 Survey Questions
TR is an 18 yo male who comes into the pharmacy with his mother looking for assistance with acne products. He has mild acne with several papules and pustules on his face. He has been scrubbing them with Oxy pads but they seem to persist. He hasn’t tried any other products. He has no allergies. He has asthma and uses salbutamol occasionally and before hockey and fluticasone regularly. He’s seeking your assistance because he does not have a family doctor. His prom is in 6 months and wants a noticeable improvement by then. How should a pharmacist respond?
When providing renewal prescriptions, it is important that a pharmacist rule out and document any red flags that would warrant an urgent referral. (i.e. Patient reports no signs of …….). This is important not only for the patient’s well-being but to limit the liability of the pharmacist and the pharmacy. When providing renewal prescribing for latanoprost eye drops, what red flags would you document in your assessment?
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May 13 Survey Questions
If you could increase publicly funded services for all Nova Scotians, which services would you add. Rank the following in your preferred order.
Now that the Standards of Practice for Renewals have been extended for up to 1 year how how often do you provide renewals for a year?
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May 6 Survey Questions
A patient enters your pharmacy complaining that his Victoza® pen has jammed. He would like it replaced. How should a pharmacist respond?
When checking blister packs which of the following is completed by the pharmacist, the technician or assistant each time the pack is filled?
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April 29 Survey Questions
YD is a 42 yo female who presents with a cold sore that started to appear this morning. The last time she had a cold sore was 2 years ago and she was prescribed valacyclovir by the pharmacist as a Minor Ailment. It was filled twice that year. She had 2 other prescriptions for the antiviral 3 years ago and 6 years ago. Her medical background is unremarkable. How should a pharmacist respond?
TR is a 36 yo male who presents requesting an assessment for a cold sore. TR has had 3 or 4 cold sores in the past 10 years and has used valacyclovir. The last one was 2 years ago. Upon inspection there is no lesion on his lip, but he states that he is experiencing a familiar prodromal tingling. His medical background is unremarkable. How should a pharmacist respond?
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April 22 Survey Questions
BH is an 80 yo female, who presents to the pharmacy requesting an assessment for a UTI. She has been experiencing frequency and urgency of urination and has discomfort when voiding. She reports no vaginal symptoms. She also complains of slight flank pain. BH’s spouse is also present and reports that he has noticed an increase in her confusion and agitation over the past couple days. He became less alarmed when she displayed urinary symptoms in the past 24 hours. She had one UTI in the past 14 months, occurring 3 months ago. She was prescribed nitrofurantoin 100mg BID which was changed 2 days later to amoxicillin 500mg TID for 7 days due to treatment failure. BH has diabetes with an A1C two months ago of 9.0. Her eGFR was 62 mL/min and her electrolytes were normal. She is currently taking metformin 250 mg bid and NPH insulin 15 units bid. She is also taking atorvastatin 20 mg daily and candesartan 8 mg daily. BH does not regularly test her blood glucose because she finds it difficult getting a blood sample. THIS IS THE SATURDAY OF THE EASTER WEEKEND. Her family doctor is not in the office until Tuesday. How should a pharmacist respond?
RC is a 32 yo male with anxiety who takes venlafaxine 150 mg once daily and lorazepam 1 mg once daily prn. RC’s venlafaxine prescription is for 3 months and 3 refills but his lorazepam is written for 30 tablets with 5 refills. RC calls to get his third fill of lorazepam refilled but it is 4 days early. He indicates that he had a couple bad days over the past month and took 2 a day and that is why he is early. He normally does not request early refills of lorazepam. The rest of RC’s medical background is unremarkable. It is Saturday and RC’s physician is not accessible until Monday. He has no medication left. How should a pharmacist respond?
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April 15 Survey Questions
How do you feel about cell phone use in the pharmacy?
How concerned are you about the impact of the following for traditional pharmacies over the next 10 years?
- Mail order pharmacies
- Pharmacies owned by drug plans
- Drug pricing reform
- Amazon
- Movement to central fill of all prescriptions
- Preferred provider agreements
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April 8 Survey Question
PT is a 26 yo male taking valproic acid for seizures. His neurologist wishes to start lamotrigine and prescribes and initial dose of 25 mg once daily. There is a Lexi level D interaction as valproic acid may increase the risk of lamotrigine toxicity (Severity Major Reliability Rating Excellent). The recommended dosing initial dosing is 25 mg every other day for 2 weeks. The neurologist thanks you for pointing out the interaction but still wants to start the dose at 25 mg once daily. How should a pharmacist respond?
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April 1 Survey Questions
RT is a 36 yo female who presented with dysuria and frequency 3 days ago. She was assessed by you at that time and based on her history, which included a previous episode of uncomplicated cystitis 4 years prior and no complicating factors, you prescribed a 5-day course of nitrofurantoin. Upon follow-up today she indicates that her symptoms haven’t really changed at all. The rest of RT’s medical background is unremarkable. How should a pharmacist respond?
HG is a 62 yo female with a prescription for sulfamethoxazole/trimethoprim DS for 3 days for uncomplicated cystitis. She is also taking ramipril 5 mg once daily for hypertension. She has no drug allergies. She has no other medical conditions. Her renal function is normal (eGFR>90). Her potassium level is 4.0. How should a pharmacist respond?
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March 25 Survey Questions
Assuming each of the following are clinically appropriate, which of the following would be an appropriate pharmacist renewal for controlled drugs?
- Renew lorazepam 1 mg once daily as previously filled M: 30 tablets with 2 refills.
- Renew 1 week of hydromorphone sustained release 6 mg bid for a patient using it for cancer pain. Has been using it for 4 months. Last fill 30-day supply.
- Renewal of methylphenidate controlled release 27 mg daily as with last prescription M: 60 NR
Too many patients come in with no medication left, no appointment and expect the pharmacist can help in all cases. Or they expect us to prescribe out of our scope? How do you deal with patients that are starting to expect us to help when it's not appropriate? Please share your comments. The posts are anonymous but they are publicly available.
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March 18 Survey Questions
Select the appropriate billing strategies (Bill MSI as an Adaptation, Bill the patient/private plan as an adaptation or Other) for each service:
- Switch olmesartan to candesartan due to a drug shortage for a patient on Seniors Pharmacare
- Adjust drug dose for renal impairment for a senior on the PSHCP
- Change the dose of amlodipine from 5 mg to 10 mg to control blood pressure for a patient on Family Pharmacare.
- Modify the dose of an antibiotic to reflect the child’s weight for a patient on Medavie.
- Cancelling a new prescription for a benzodiazepine due to double doctoring for a patient on Seniors Pharmacare.
- Changing an insulin dose for a patient on Family Pharmacare
KL is a 52 yo male who wants a Renewal on his amlodipine 5 mg. He started the prescription 1 month ago and was supposed to follow up with his family doctor but his appointment was unexpectedly cancelled. His blood pressure is 120/80. He reports no headache, dizziness or edema. His only prescription was for 1 month with no refills. The rest of his medical background is unremarkable. How should a pharmacist respond?
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March 11 Survey Questions
TR is a 46 yo, non-binary with HTN. They seek a renewal on amlodipine 5 mg and when you check their blood pressure it is 100/70 (3 readings, average of last two). TR indicates they check their blood pressure at home, and it usually runs just under 110/75. TR reports no signs of dizziness/orthostatic hypertension/headache/edema. TR’s last prescription was for 90 days with 3 refills. TR has been taking amlodipine for 3 years. It was started after they had a 3 month period of blood pressure readings of 150/85. TR does not have a family doctor. How should a pharmacist respond?
What do you perceive as the upper limit for non-narcotic prescriptions to be renewed if the therapy continues to be appropriate?
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March 4 Survey Questions
TS is a 32 yo male requesting a refill for citalopram for depression. He has been taking the medication for approximately 2 years. His last prescription was 2 months with 2 refills. What factors could be included in the pharmacist’s assessment of therapy?
LT is a 40 yo female requesting a refill for pantoprazole for GERD. She has been taking it for approximately 2 years. Her last prescription was for 90 tablets with 1 refill. What factors could be included in the pharmacist’s assessment of therapy?
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Feb 18 Survey Questions
TW is a 42 yo female with mild symptoms of heartburn daily for the past 4 days. She experienced the symptoms 2 months ago and went to her doctor. He suspected mild GERD and prescribed rabeprazole 20 mg once daily for 2 months. It controlled her symptoms with no adverse effects. She does not have nocturnal symptoms or regurgitation. She ran out 6 days ago and her symptoms returned. She reports no vomiting, dysphagia, signs of blood loss, weight loss or pain when swallowing. She has no other significant medical history. How should a pharmacist respond?
TR is an 8 yo male with asthma taking salbutamol MDI prn (before hockey and 2-3 times per month as a rescue) and fluticasone 50 mcg MDI 2 puffs twice daily regularly. He presents to the pharmacy with a creamy, white patches on his tongue, palate and cheeks. His mother thought he had thrush because he doesn’t rinse his mouth out well after using his steroid and he doesn’t use his Aerochamber®. He has never had thrush before. He takes no other medications, has no allergies and no other medical conditions. He denies burning his mouth in any way. It’s not painful but he says it feels “funny” in his mouth. He reported the patches to his mom today but started noticing it a few days ago. The patches can be scraped off and reveal mild redness underneath but no bleeding. How should a pharmacist respond?
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Feb 11 Survey Questions
FT is a 42 yo male visiting from North Carolina. He states he takes ramipril, atorvastatin and metformin but he forgot it back home. He says he has refills on his prescriptions and would like to transfer them here. He will be staying in NS for another 2 weeks. How should a pharmacist respond?
RA is a 28 yo female discharged from mental health on Friday evening with prescription for Suboxone®. The prescription is not signed and the doctor is not available until Monday. RA was not previously taking Suboxone. How should a pharmacist respond?
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Feb 4 Survey Questions
TH is a 3 yo male who presents with a prescription for amoxicillin for otitis media. His mother indicates that he spiked a fever of 103F in the past 24 hours and has complained of pain in his right ear. TH’s family doctor told his mother that the ear was inflamed with a slight bulge. She did not want to watch and wait as TH was in distress. TH has no allergies, medical conditions or other medications. When you confirm THs weight you calculate the dose to be 20 mg/kg/day. You contact the TH’s physician concerned the dose is sub-therapeutic but he indicates that that’s the dose he wants. “Fill as written.” How should a pharmacist respond?
TH is a 3 yo male with a prescription for amoxicillin for otitis media. His mother indicates that he spiked a fever of 103F in the past 24 hours and complained of pain in his right ear. When you determine TH’s weight you calculate the dose to be 20 mg/kg/day. TH’s doctor has gone for the weekend. You discuss the concern with TH’s mother and inform her that you could adapt the dose but there is a fee for the adaptation. TH’s mother said she just has enough money for the prescription, she can’t afford the adaptation fee. How should a pharmacist respond?
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Jan 28 Survey Questions
KL is a 40 yo male who is indicates that he is travelling to Vancouver in 1 week for a 10-day trip. He indicates that he suffers from terrible jet-lag. Two years ago he was given a blue oval sleeping pill that began with “z” and found that it worked great while he was there and as he adjusted when he got back. You can see he got 14 tablets of zopicline 7.5 mg from a local walk-in clinic two years ago. He was hoping to get a 20-day supply of the medication for his upcoming trip. He indicates he normally does not have problems sleeping. His medical background is unremarkable. How should a pharmacist respond?
DD is a 32 yo female presenting with symptoms of frequency and dysuria. The symptoms began 3 days ago. She denies fever, flank pain, blood in the urine or abdominal pain. She is currently taking Synthroid® 50 mcg once daily. She has no other medical conditions or medications. She breaks out in a rash with amoxicillin. She is currently breastfeeding her 6 month old infant? How should a pharmacist respond?
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Jan 21 Survey Questions
RT is a 48 yo male who has run out of refills on three medications citalopram 20 mg for depression, rabeprazole 20 mg once daily for GERD and amlodipine 10 mg for HTN. He has taken all three medications for the past 4 years. He feels they are working well and control his symptoms. His blood pressure is consistently in the 120s/80s (including the result at your pharmacy). He does not wish to stop any of the medications. His usual quantities are 3 months with 3 refills on citalopram and rabeprazole and 3 months with no refills on his amlodipine. He is a little frustrated that he keeps having to back to the physician for his blood pressure medication when his blood pressure has been well controlled. He can schedule an appointment with his doctor within the next month. How should a pharmacist respond?
HT is a 83 yo female on Seniors Pharmacare with a prescription for cephalexin for cellulitis 500 mg qid for 7 days. Her eGFR is 22 at her most recent blood work 3 months ago. When you click on the button to see the previous 5 and 10 results you can see that this has been consistent for the past 2 years. You calculate her CrCl to be 20 mL/min. How should a pharmacist respond?
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Jan 7 Survey Questions
It is now past Jan 1, 2022 and the updated prescribing standards are in effect. KL is a 53 yo female with hypertension. She requests a renewal on her amlodipine. She has been taking it for 4 years at a consistent dose of 5 mg. Her last prescription was for 3 months and 3 refills. Her BP is 123/81 and that is typical based on her home blood pressure results. She indicates she has an appointment with her physician in 3 weeks. She says it is in-person appointment, but with COVID-19, she was warned it may be switched to virtual. She reports no side effects with amlodipine. The rest of her medical background is unremarkable. How should a pharmacist respond?
LL is a 63 yo male with primary open angle glaucoma. He is currently taking latanoprost 1 gtt ou hs. He has been taking this for the past 6 years. He indicates that the therapy seems to be working well because at his annual check-ups his ophthalmologist indicates his pressure is good and his retina looks fine. He reports no visual disturbances, eye irritation or pain. His last appointment was one year ago when he received a prescription for 1 bottle with 12 refills. How should a pharmacist respond?
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Dec 24 Survey Questions
MJ is a 69 yo female with hypertension. She is looking for a refill on her metoprolol and amlodipine but she has none. Her therapy is metoprolol 25 mg ONCE daily and amlopidine 5 mg once daily. She has been taking this for 2 years. She takes both medication first thing in the morning. Her last prescription was for 90 days with 1 refill. She does not have an appointment with her family doctor. The rest of her medical background is unremarkable. You check her blood pressure at today at noon and it is 135/88. She doesn’t check her blood pressure at home. How should a pharmacist proceed?
KP is a 26 yo male with asthma. He is currently taking salbutamol 1-2 puffs qid prn. He runs out of refills and requests a renewal. He has a family doctor. He has a drug plan. He currently is averaging 1 MDI every two months. His last prescription was for 1 inhaler plus 5 refills. He reports no other symptoms other than some SOB and wheeze which responds well to his salbutamol. The rest of his medical history is unremarkable. How should a pharmacist respond?
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Dec 17 Survey Questions
IT IS NOW 2022 AND THE NEW STANDARDS ARE IN EFFECT. PP is a 34 yo male with asthma. He runs out of refills on his Flovent. He has been taking Flovent 125mcg 2 puffs bid for the past 3 years and finds he rarely needs his salbutamol (2-3 times per month). He reports no problems with Flovent and wishes to continue using it. You renew it for 12 months. Regarding notification of the patient’s family doctor, how should a pharmacist proceed?
IT IS NOW 2022 AND THE NEW STANDARDS ARE IN EFFECT. MJ is a 34 yo female who presents with uncomplicated cystitis. She has two diagnosed UTIs in the past, 5 and 9 years ago. Both were treated with Macrobid. Her symptoms are consistent with uncomplicated cystitis, and you have no reason to refer. There are no alarm symptoms. You prescribe Macrobid. Regarding notification of the patient’s family doctor, how should a pharmacist proceed?
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Dec 10 Survey Questions
TM is a 30 yo male requesting renewal of lorazepam 1 mg once daily prn (2-5x/week) for the treatment of Generalized Anxiety Disorder with panic disorder. He has tried sertraline & another SSRI (he does not recall the name) several years prior and they were discontinued due to side effects (fatigue, sexual dysfunction). TM travels yearly for work (musician) overseas in Europe for months at a time. TM usually gets a 100-tablet supply which seems to last about 1 year. TM is leaving in two weeks. TM’s family doctor retired several months ago. TM went to the ER yesterday as there is no walk-in clinic in the community. After 12 hours, the nurse suggested he leave as he would not be seen within the next 12 hours. How should a pharmacist respond?
TL is a 42 yo female who presents to your pharmacy asking for a renewal for her Synthroid®. She has never been to your pharmacy before. She reports no signs of hyper/hypothyroidism. The rest of her medical background is unremarkable. You check the Drug Information System and see that in the past she had a prescription for 3 months with 3 refills but her last fill was for a two-month supply prescribed by pharmacist at another pharmacy two months ago. It appears that the other pharmacy is her regular pharmacy. You check SHARE and see that the last TSH was two years ago. How should a pharmacist respond? You can choose more than one.
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Nov 26 Survey Questions
OT is a 19 yo male taking methylphenidate SR 54 mg which he has been taking for the past 3 years for ADHD. He has moved to Nova Scotia from Ontario to attend university. His last prescription is on file at a pharmacy in Ontario. The prescription is for 360 tablets, to be released 90 tablets at a time every 90 days and there are 180 tablets remaining. He heard that there were recent federal changes regarding interprovincial transfers of controlled drugs and would like to transfer the 180 tablets to your pharmacy. How should a pharmacist respond?
LK a 70 yo male, who is a regular patient at your pharmacy, shows up for a COVID-19 vaccine. He booked a dose 158 days after his second dose and booked as a patient that is immunocompromised. His medical background includes hypertension, diabetes and dyslipidemia. He does not take immunosuppressant therapy. He states he booked as immunocompromised because A) CanImmunize wouldn’t let him book a booster appointment, B) He states he is 70 years old and has diabetes so he’s at risk and C) He’s flying to Florida in 6 days for 5 months and needs the protection. He says, “If you don’t vaccinate me, it’s your fault if I get sick from COVID.” How should a pharmacist respond? In the comment line, indicate how you would respond to the last statement.
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Nov 19 Survey Questions
LK is a 38 yo male who presents with a sore throat, fever and fatigue for the past 2 days. He had strep throat 2 years earlier treated effectively with penicillin, so he asked his neighbour, a nurse, to take a look. She told him his throat is inflamed with white patches, and she thought it was strep throat. Since he lives in rural Nova Scotia, cannot get an appointment with his family doctor for 2 weeks, would have a 45-minute drive to the nearest ER (with a likely prolonged wait) and has been referred to the pharmacy by the ER in the past, he approaches the pharmacist to see if she could help. The pharmacist can confirm his fever and see the inflammation and exudate on the back of his throat. The rest of his medical history is not remarkable. How should the pharmacist respond?
BL is a 68 yo female seeking a renewal for ramipril and furosemide for HTN and CHF. Her blood work was last completed 1 year ago (1 month after starting furosemide) and her K+ was slightly low (3.4). Other labs are within normal limits. BP – 140/80. BL reports dizziness and polyuria. BL took her last dose this morning. She has an appointment with her family doctor in 2 weeks. The rest of her medical background is not remarkable. Her last prescription was for 3 months and 1 refill. How should a pharmacist respond?
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Nov 12 Survey Question
SH is a 56 yo male with HTN. He is currently taking amlodipine 10 mg od and metoprolol 50 mg bid for the past 6 months (90 days with 1 refill). He took his last amlodipine 10 mg this morning along with one metoprolol. He has one metoprolol left for this evening. He requests a refill because he can't see his doctor for 3 weeks. Would one of the following blood pressure readings cause you to not prescribe and immediately refer to the ER/walk in/911?
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Nov 5 Survey Questions
NM is a 52 yo female who had taken zopiclone 15 mg hs for years for insomnia. Her sleep had improved significantly with no reported adverse effects. She recently went to a walk-in clinic where the physician switched her to Dayvigo to wean her off zopiclone. She does not have a family doctor. She calls the pharmacy because Dayvigo hasn’t worked as well as zopiclone and she hasn’t slept well in the past 3 weeks. She would like a refill of her zopiclone. Her current prescription for Dayvigo is for 30 days with 5 refills. Her last prescription for zopiclone was for 30 days with 5 refills but it was inactivated (Copied) when she switched to Dayvigo. How should a pharmacist respond?
TR is a 38 yo female that has been taking venlafaxine 150 mg for anxiety for years. Over the last year it was tapered down to 75 mg, and she was taking it regularly for about 1 year. She is looking for a refill, but she ran out. Her last fill for a 90-day supply was 200 days ago. She indicates she was trying to taper it further but was struggling with withdrawal symptoms. She says her anxiety has been well-controlled as she has been using other measures to address it and she wants to stop it. The earliest she could see her doctor is sometime late next week, but she is out of capsules, and would like another refill due to withdrawal symptoms. Her last prescription was for a 90-day supply with a refill. How should a pharmacist respond?
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Oct 29 Survey Questions
LK is a 14 yo male who is receiving methylphenidate 27 mg SR daily for ADHD. He has used this dose for the past 18 months and his mother has indicated that it has worked well, and she has noticed a significant improvement at home and at school. She notes no noticeable change in his appetite and he is sleeping well. He is 5’2” and weighs 115 lbs. His last prescription was for 180 tablets dispensed in 30-day intervals by his family doctor. How should the pharmacist proceed?
GG is a 48 yo male taking Kadian for chronic back pain. His dose has been increased over the past 4 years by his family doctor and he is currently taking 200 mg per day. He indicates that he took his last dose this morning and he cannot see his family doctor for 2 weeks. He indicates that drug seems to help his pain for the most part. He normally gets 56 days total filled in weekly intervals. He reports no significant adverse effects. How should a pharmacist proceed?
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Oct 22 Survey Questions
RK is a 21 yo male with ulcerative colitis. He is currently taking Humira®, methotrexate low dose and folic acid. He runs out of refills on his Humira® and doesn’t have an appointment scheduled with his gastroenterologist or his family doctor. He reports that is condition is well controlled. He hasn’t had a flare in years. He reports no blood in the stool, diarrhea, unexplained fever or abdominal pain. His labs which were last completed 1 month ago (he goes 3-4 times per year) all come back within normal limits. His last prescription was for 1 month with 12 refills. How should a pharmacist proceed?
PR is a 48 yo female currently using rabeprazole 20 mg once daily as needed for heartburn. She calls the pharmacy for one of her 2 remaining refills but is told that the refills have expired. She doesn’t have an appointment with her family doctor. She has been taking PPIs for about 10 years. In the past 4 years she tried coming off them with mixed results. Eventually her doctor decided she could just use them prn if her symptoms flared up and she has been dosing so for the past 3 years. She last received a 60-capsule supply 190 days ago. Her previous 60-capsule supply was 270 days before that. She does not have any of the following: abdominal pain, vomiting, blood in stool, dysphagia, regurgitation. Her labs are normal (no signs of bleeding or vitamin deficiency). You talk to her about potentially trying to come off it completely or stepping down further, but she is not interested at this time. How should a pharmacist proceed?
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Oct 15 Survey Questions
TL, a resident in Halifax, comes to your pharmacy in the valley. She’s there for a lovely vacation in wine country. Unfortunately, she forgot her medication (ramipril, citalopram, pantoprazole). She only had a week left so she was due for her prescription but when you called her pharmacy to transfer the prescription there were no refills remaining. She normally gets 3 months and a refill. While she has a family doctor, she did not realize that she ran out of refills and did not set up an appointment. How should the pharmacist proceed?
JC, a 64 yo female calls for a refill of her losartan-hctz 100mg/25mg. She doesn’t have any medication left. The drug has been recalled. JC does not have a family doctor. Her last prescription was for 3 months with 3 refills. How should the pharmacist respond?
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Oct 8 Survey Questions
GM comes into your pharmacy with her blood work printed off. You are surprised but impressed with her initiative. She states in her recent blood work her B12 level was a little low, just below the normal range, so she wanted to take OTC B12 supplements. She wanted to know what dose would be appropriate. How should the pharmacist respond?
TL a 72 yo male, comes to your pharmacy and requests a refill for his ramipril. His blood pressure is 130/84 but when you check his labs on SHARE he hasn’t had blood work in 2 years. His potassium was normal but his eGFR was 45. The previous 3 annual results were 57, 54 and 51. You decide to do a 2-month renewal and request that he go to his doctor and get his bloodwork updated. 2-months later TL shows up at your pharmacy looking for another renewal. He states he "didn’t get around to getting an appointment for more blood work." What should the pharmacist do?
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Oct 1 Survey Questions
KP is a 55 yo female who has just completed a 7-day course of cephalexin for cellulitis. It is Friday and she presents to the pharmacy indicating she just came from her doctor’s office. Her doctor was going to fax in another 7 days of the antibiotic. While the rash significantly improved, there is still some redness, which upon inspection, you can see. While you filled the initial prescription you don’t remember what it looked like initially, but KP said it was three times the size and swollen. You still don’t have the new prescription. You reach out to the physician’s office, but you aren’t able to get in contact with the physician to confirm and the office is closed until Monday. What should the pharmacist do?
TH has been taking Synthroid 88 mcg for the past 3 years. TH has run out of refills on her prescription and requests a renewal. She indicates her family doctor ordered blood work at her last appointment two months ago but she has not followed up since. When you look at SHARE, TSH is high (6.0 mIU/L normal 0.4 – 4.5 mIU/L, T3/T4 not ordered as not advised from Choosing Wisely) suggesting hypothyroidism. When you click on trend for last 5, her results hovered near the top of the normal range for the last 3 years. 4 years ago she her TSH was high which prompted a dose change from 75 mcg to 88 mcg. She noted she currently felt a little tired but didn’t suspect anything unusual. She reports nothing else out of the ordinary and her remaining medical background is unremarkable. She can make an appointment with her doctor in a month. She has no medication left. How should a pharmacist respond?
TD is a 72 yo male with HTN. He is travelling to your town from another part of the province and requests to have his refills transferred. His medications are ramipril 2.5 mg AND telmisartan 40 mg both once daily. He indicates he is using this for HTN and has been doing so for more than 15 years. He states his BP is normally well-controlled and he doesn’t report any adverse effects. He doesn’t regularly monitor his blood pressure. His blood pressure in pharmacy is 135/89. He reports no other medications and no other remarkable medical history. His lab values in SHARE are within the normal range including renal function and potassium. The pharmacist is concerned as “ACEI+ARB combinations often offer no additional outcome benefit, but increased adverse effects when used solely for hypertension. (Limited benefits noted in select patients with nephropathy or heart failure.)” RxFiles (available for PANS members). The data indicated increased risk of renal impairment, hypotension and hyperkalemia. How should a pharmacist respond?
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Sept 24 Survey Questions
RT is a 43 yo male with a history of depression. He has taken citalopram 20 mg for three years with significant improvement in symptoms and no noticeable adverse effects. His other medical history is not remarkable. He does not have a family doctor. He calls the pharmacy and states that he has run out of refills on his medication. He has 2 tablets left. He wants to continue the therapy. You can see that he has filled his prescriptions for citalopram at your pharmacy for the past 3 years. His last prescription was written 6 months ago by one of the pharmacists on your team. The date is Sep 24, 2021. Current COVID practice situations are in effect. How would you respond?
A physician that works in your community contacts your pharmacy and states that while he appreciates your prescribing of renewals when his patients run out of medication, he would like you to only prescribe a 1-month supply as he feels he needs to assess his patients before extending the prescription further. If you have a patient that normally gets 3 months and 1 refill and continuing the therapy is appropriate, how would you respond?
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Sept 17 Survey Questions
How should SHARE be integrated in community pharmacy practice?
TR is a 35 yo female with hypothyroidism. She runs out of refills on her Synthroid and doesn’t have an appointment with her family doctor. She normally gets three months with 3 refills. You check SHARE and the last time she had blood work was 2 years ago which she confirms is probably accurate. She says she’s a little tired but she’s busy. She displays no other signs or symptoms of hypo/hyperthyroidism. Her other medical history in unremarkable. ASSUME A NON-COVID-19 STATE WITH USUAL ACCESS TO BLOOD WORK. What would you do?
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RT is a 62 yo female with hypertension and type II diabetes. She presents to the pharmacy on Friday evening with a prescription for amoxicillin/clavulanic acid for “community acquired pneumonia” diagnosed by her family doctor with no additional testing. When evaluating the therapy, the pharmacist discovers the patient has an allergy to penicillin causing widespread rash. The patient would like to avoid the rash and change therapy. The pharmacist calls the physician, but the office is closed until Monday. The rest of her medical background is unremarkable. How should the pharmacist respond?
LK is a 35 yo male who presents to the pharmacy concerned about a tick bite. He indicates that he was hiking near Lunenburg two days ago and found a tick on his right leg today. By his best estimation the tick was on his leg 37 hours. He presents with a little redness (less than a cm) at the bite area that’s a little itchy. He reports no other symptoms and the rest of his medical history is unremarkable. When you ask about the tick he said he squished it and tossed it in the yard. In addition to meeting the other Standards of Practice (e.g. cautioning the patient about signs/symptoms of Lyme Disease, prevention measures, evidence of treatment/chemoprophylaxis, etc.), how should a pharmacist respond?
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Sept 3 Survey Questions
JT is a 48 yo male with hypertension (HTN). He is currently taking amlodipine 5 mg once daily but has run out tablets and refills. He has a family doctor but cannot get an appointment to see his doctor for 2 weeks. He normally gets a 3-month supply with one refill. You check his blood pressure, and it is 152/93. This is consistent with his home blood pressure readings from his logbook that he brought in. He reports no adverse effects. The rest of his medical background is unremarkable. How should a pharmacist respond?
JT is a 48 yo male with hypertension (HTN). He is currently taking amlodipine 5 mg once daily. He does NOT have a family doctor. His last prescription from a walk-in clinic was for a 3-month supply with 3 refills. You check his blood pressure and it is 152/93. This is consistent with his home blood pressure readings from his logbook that he brought in. He reports no adverse effects. The rest of his medical background is unremarkable. How should the pharmacist respond?
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