Community Pharmacy Placement Assessment - Essay Example

Community Pharmacy: Placement Exercise 3 I had a chance to observe and share very closely several cases of patient – pharmacist interactions during my placement in the community pharmacy. The first that I had was the case of Miss J. K., who came to the pharmacy asking for an antibiotic. It was noted that Miss J. K. had her mouth covered by her hand, and she can hardly talk. A creamy white lesion was further observed around her mouth and at the tip of her tongue; however, no blisters or blood was noted. Miss J. K. stated that she came to the pharmacy because she was advised by her friend that she would need an antibiotic to reduce her pain. Unfortunately, she could not get an appointment with her Family Physician not until three days later. The pharmacist promptly answered that the pain caused by the whitish lesion around her mouth and at the tip of her tongue is caused by a fungus. Fungal infection cannot be alleviated by taking antibiotics but rather, instances occur when oropharyngeal Candida infection can be triggered by taking antibiotics. The pharmacist explained that patients with history of dental appliance, diabetes mellitus, exposed to antibiotics, and inhaled steroids are commonly affected with oropharyngeal Candidiasis (Hidalgo, 2008). An oral thrush or oropharyngeal candidiasis, representing the most common form of fungal pathogen in the humans, is an opportunistic pathogen caused by an infection of Candida species and they exhibit the following symptoms: sore, painful, and burning mouth or tongue, dysphasia, and whitish thick patches. The pharmacist further explained that Candida, a broad spectrum disease, causes the simplest and most complicated fungal diseases from the superficial mucocutaneous diseases to invasive ones. The pharmacist recommended Miconazole Oral GEL (Daktarin) to be applied to the area affected four times daily. The pharmacist asked the patient whether she was pregnant, planning to get pregnant, or is currently breastfeeding, because one of the rare side effects of Miconazole is nausea and vomiting. The pharmacist also asked the patient whether she was taking other medications because of its probability that Miconazole Gel may possibly produce drug interaction with warfarin .The pharmacist informed the patient that Miconazole gel (Daktarin) and Nystatin are the drugs of choice in treating Candidiasis, and both drugs are available as an over - the - counter medication. Clinical evidence had shown that nystatin miconazol and fluconazole are more effective in treating oral candidiasis (moderate – quality evidence). Trials on miconazole versus nystatin revealed that the rate of clinical treatment had increased significantly with Nystatin. Adverse effects of miconazole and nystatin were vomiting and on rare occasions, diarrhea. Miconazole, an antifungal agent, is used in the treatment of pharyngeal Candidiasis, dermatophytoses, superficial mycoses, cutaneous candidiasis, and vulvovaginal candidiasis. Data suggest that in neutropenic patients, Miconazole can be used effectively as a prophylaxis for pharyngeal candidiasis (University of Maryland Medical Center, 2008). In the fungal cell membrane, Miconazole acts by binding to the phospholipids that alter the permeability of the cell wall thereby resulting in the loss of elements essential inside the cell (University of Maryland Medical Center, 2008). Patient was advised to hold the gel in the mouth for as long as possible and to increase contact time between the medication and the infection. A print out of CMI was given to the patient, and the pharmacist went through with the patient the proper indication, dosages, and contraindication of the Miconazole Gel (Daktarin). Mr. B. B., the second patient, came to the pharmacy with a complaint of heartburn or painful burning sensation in his chest. No vomiting and changes in the color of stool was reported. Mr. B. was asking for a medication to relieve his pain. When the pharmacist and I interviewed the patient, it was noted that the patient is an alcohol beverage drinker for years. The patient also related that he was recently invited to a birthday party in a famous Indian restaurant by an Indian friend, and he recalled eating curry. The patient reported that he has been taking Ramipril once daily for his blood pressure. The pharmacist advised Mr. B.B. to modify his lifestyle by reducing his alcohol intake and avoid eating spicy foods. The pharmacist instructed the patient to observe for any other signs that would suggest impending heart attack since heartburn and abdominal pain would sometimes mimic the symptoms of a heart attack. The pharmacist also advised the patient to avoid the medications that would induce gastrointestinal symptoms. These include: aspirin, NSAIDs, antibiotics, metronidazole, and theophylline. The patient was also advised to note any changes in his health and to consult any changes to his Family Physician. Instead of giving the patient a couple of medication to choose, the pharmacist suggested that the patient should only take a long acting Zantac. Zantac, an H2 antagonist, is a non – imidazole blocker of the receptor of histamine such as gastric cell receptor that inhibits the secretion of gastric acids (RxList, 2009). In the parietal cells, Zantac is known to block the action of histamine that results to decrease production of acid. Clinical evidence revealed there is no significant difference between the standard proton pump inhibitors (PPIs) and H2 receptor antagonist. Another trial in Korea to study the difference between PPIs versus H2 receptor antagonist has yet to be translated (Jee, et al., 2005). An informative pamphlet was provided to the patient containing information such as the different parts of the gastrointestinal tract, what heartburn is, the causation, precipitating factors, and the controlling factors of heartburn. Data that would suggest the signs and symptoms to observe and when to see a doctor is elaborated in the pamphlet. The last patient was Mr. J.K. who came to the pharmacy with his 12 year old son, Jake, asking for an ear drops. Jake complained of redness, swelling, itching, pain, and dizziness in the right ear after cleaning his ears with cotton sticks. The pharmacist examined the ears of Jake and cerumen was noted in the right ears. The pharmacist explained the anatomy of the ear to the patient, and the mechanism of acquiring pain and infection after cleaning it with cottons. The pharmacist also explained to the patient and to the father that under a normal condition, wax protects the ears from small particles and insects that enters the auditory canal. The ciliated canal serves to propel the wax towards the outer ear where this can be washed off. In some individuals, they use cotton buds to clean the wax. Instead of bringing it out towards the outer ear, the wax is pushed towards the bony part of the ears where it is dried, hardened, and impacted. Impacted cerumen presses against the bony part of the sensitive inner two thirds of the ear canal resulting to pain. Cerumen causes slight pain, dizziness, and hearing reduction because it blocks the sound waves to successfully go through the eardrums (McKinley Health Center, 2008). The pharmacist recommended cerumol ear drops, an agent to soften, dislodge, and remove the impacted ear wax. Cerumol ear drop has a unique oil based formula that eases out the ear wax because of its property to penetrate to the deeper ear tissue that causes cerumen to soften and loose gently. The pharmacist instructed the patient to put 5 drops of Cerumol to his ears in an inclined position. To retain the liquid in the ear, the patient was advised to place a plug of cotton wool moistened with Cerumol (Laboratories for Applied Biology, 2008). The patient was instructed to repeat the procedure two times a day for three days (Laboratories for Applied Biology, 2008). In a general practice, a parallel group, single-blind, randomized study was made to compare the efficiency and tolerability of Audax and Cerumol ear drops in softening the impacted ear wax of 50 adults (Dummer, et al. 1992). Dummer, et al. added that both Audax and Cerumol ear drops are well – tolerated, and have shown its effectiveness in ear wax softening; however, patients who exhibited abnormalities in hearing showed significant improvement following Audax treatment. Dummer, et al., concluded in their study that no significant difference was observed in the overall effectiveness assessment of the patient. The pharmacist demonstrated to the father of Jake the proper administration of Cerumol ear drop by asking the patient to sit down and tilt his head 45 degrees. Five drops of cerumol were instilled in one ear which was subsequently covered with wet cotton containing cerumol. The pharmacist asked the father to do the same procedure to the other ear. A fat card was printed out for the father, and a couple of website address to demonstrate the effective way of instilling an ear drop to a child was provided. I wish that we can have a cartoon type video for Jake as a way of making children understand the procedure, and get their attentions. We need more tools to attract the attention of the children to increase their complaints and reduce their fears of taking their medication. Summary: In the first assessment, it is observed that proper knowledge and dispensing of medication is important. Had the pharmacy assistant agreed to give the patient antibiotics when she was asked for it, the patient could have chances of developing drug resistance later in life. Oral thrust must be treated with an anti – fungal agent and not with antibiotic medication. Therefore, it was learned from this case that it is important to properly address the patients’ concern with proper medication since some patients will just go and buy medicines suggested by their friends, which in many cases, may worsen the medical condition of the patient. The second evidence presented that proper knowledge of medications and its side effect is important. The patient was taking antihypertensive Ramipril, which may cause chest pain or heart burn, and the pharmacist, having the proper knowledge on the side effects of each medication has the authority to advice the patient to stop a certain medication and see the doctor immediately. The last study had shown that proper dissemination of information is important while giving the medication of the client. It was noted in the last scenario that the pharmacist demonstrated the proper way of instilling the medication to the patient, and the father demonstrated his understanding of the pharmacist’s instruction by means of a return demonstration. Every time I go to my placement and externship assignment in the pharmacy, I felt the need to get involve, not just observe. The more I observe the interaction between the pharmacist and the patient; the more I gained the confidence not only to interview the patients but to solicit ideas from the pharmacist as well. I enjoyed every moment I talked with the patient, and as I gained more knowledge from the pharmacist, I began to have the confidence and the boldness to do my assignment freely. During my interactions with the patients, I noted that giving medications alone is not enough in patient – pharmacist relationship. Pharmacist must be knowledgeable enough to inquire from the patient regarding their current medical condition and what led them to come to the pharmacy. Therefore, it is a must that a pharmacist must practice proper history taking. A pharmacist must learn also the disease process of the patient’s complaint, and must explain to the patient the pathophysiology of their disease, and the best medication fitted for the specific illness. I also learned not to enumerate various medications to the patient for this will create confusion on the part of the patient. It is at best that the pharmacist must recommend the best medication for the patient because of the knowledge that he has regarding the medical condition of the patient, and is authorized to dispense medications in accordance to the medical ethics, code, and conduct. I also learned from one of my interactions with the patient that it is important to explain the proper dosages, timing, and side effects of the drug. I learned that the information provided by the pharmacist must be accurate especially that improper intake and dosages may result to deleterious reversible or irreversible side effect. Works Cited 1. Burton, M. and Doree, C. (2007). Ear drops for the removal of ear wax (Cochrane Review. The Cochrane Library, Issue 2, 2007. (Accessed:17 April 2009). 2. Chemist Australia. (2008). Daktarin Cream. Available at : http://www.chemistaustralia.com.au/products/daktarin-cream-2-30g (Accessed: 15 April 2009) 3. Dummer, D., Sutherland, I., and Murray, J. (1992). ‘A single-blind, randomized study to compare the efficacy of two ear drop preparations (‘Audax’ and ‘Cerumol’) in the softening of ear wax’, Current Medical Research and Opinion, 13(1), 26 – 30. 4. Flynn P., Cunningham C., Kerkering T., et al. ‘Oropharyngeal candidiasis in immunocompromised children: a randomized, multicenter study of orally administered fluconazole suspension versus nystatin. The multicenter fluconazole study group’, Journals of Pediatrics, 127 (1995), pp. 322–328. Available at: [PubMed] (accessed 15 April 2009) 5. Goins, R., Ascher, D., Waecker, N., et al. (2002). ‘Comparison of fluconazole and nystatin oral suspensions for treatment of oral candidiasis in infants’, Pediatrics Infectious Diseases Journals 21(2002):1165–1167. Available at: [PubMed] (Accessed: 16 April 2009) 6. Hidalgo, J. (2008). Candidiasis. Available at: http://emedicine.medscape.com/article/213853-treatment (Accessed: 12 April 2009). 7. Hoppe, J. (1997). ‘Treatment of oropharyngeal candidiasis in immunocompetent infants: a randomized multicenter study of miconazole gel vs. nystatin suspension’, Pediatrics Infectious Diseases Journals 199716 (1997), pp. 288–293. Available at: [PubMed] (Accesesed: 15 April 2009) 8. Hoppe, J. and Hahn, H. (1996). ‘Randomized comparison of two nystatin oral gels with miconazole oral gel for treatment of oral thrush in infants. Antimycotics Study Group’, Infection 24(1996):136–139. Available at: [PubMed] (Accessed: 15 April 2009) 9. Jee, S., Seol, S., Kim, H., et al. (2005). ‘A randomized, comparative study of rabeprazole vs. ranitidine maintenance therapies for reflux esophagitis--multicenter study’, Korean Journals of Gastroenterol/Taehan Sohwagi Hakhoe Chi 45(2005):321– 327. Available at: [PubMed] (Accessed: 15 April 2009) 10. .Johnson, M., Guiford, S., Libretto, S., et al. (2002). ‘Patients have preferences: a multicentre, double-blind, crossover study comparing rabeprazole and omeprazole’, Curr Med Res Opin, 18(2002):303–310. Available at: [PubMed] (Accessed: 15 April 2009) 11. Laboratories for Applied Biology (2008). Cerumol Ear Drops. Available at: http://www.cerumol.com/cerspc.htm (Accessed: 14 April 2009). 12. McKinley Health Center. (2008). Cerumen. Available at: http://www.mckinley.uiuc.edu/handouts/cerumen.htm (Accessed: 15 April 2009) 13. Murray, P., Koletar, S., Mallegoli, W., Wu, J., and Moskovitz, B. (1997. ‘Itraconazole oral solution versus clotrimazole troches for the treatment of oropharyngeal candidiasis in immunocompromised patients’, Clinical Therapeutics, 19(3), 471 – 480. 14. Rutter, P. and Newby, D. (2007). Community pharmacy. Available at : Elsevier, Australia 15. RxList. (2009). Zantac. Available at: http://www.rxlist.com/zantac-drug.htm (Accessed: April 2009) 16. Superliving Pharmacy (2009). Daktarin Oral Gel. Available at: http://www.superliving.co.uk/pharmacy/body-health/mouth/oral-thrush/daktarin-oral- gel-15g-p.html (Accessed: 13 April 2009) 17. Uemura, N., Okamoto, S., Yamamoto, S., et al. (2001). ‘Helicobacter pylori infection and the development of gastric cancer’, New England Journal of Medicine, 345(2001):784–789. Available at:[PubMed] (Accessed: 15 April 2009) 18. University of Maryland Medical Center. (2008). Clotrimazole. Available at: http://www.umm.edu/altmed/drugs/clotrimazole-030600.htm (Accessed: 13 April 2009) 19. Woodley, M. and Wheelan, A. (1992). Manual of Medical Therapeutics, 27th Edition. Boston: Little, Brown, and Company. 20. http://clinicalevidence.bmj.com/ceweb/conditions/orh/1304/1304_I4.jsp 21. http://www.amh.hcn.net.au/view.php?page=chapter8/monographmiconazole- skin.html#idxDaktarinmiconazoleidx Read More