229 Exam

Which of the following is an appropriate documentation tip?

- Include as much information as possible

- Use lots of abbreviations to shorten reading time

- Avoid point form

- Do not just state a problem, include the solution

Do not just state a problem, include the solution

Which is not one of the 7 C's of documentation?

- Courteous

- Concrete

- Concise

- Conclusive

- Coherent

- Correct

- Clear

- Complete

Conclusive

True or false. Never alter or delete a previous note.

True

If you make an error, create a new note and cite the date of the previous note and add further information

When are unstructured (free form) notes typically used?

When general impressions are noted but no action or recommendation is required

What does a SOAP note stand for?

Subjective

Objective

Assessment

Plan

Which of the following does NOT go in the Subjective portion of a SOAP note?

- Chief complaint

- Patient's handwritten glucose log

- Patient declared substance use

- Pharmacy med list

Pharmacy med list

Which of the following goes in the Objective portion of a SOAP note?

- Allergies

- Serum creatinine

- Family history

- Monitoring plan

Serum creatinine

Which is incorrect about the Assessment portion of a SOAP note?

- Problems should be numbered

- Each problem should begin with a one sentence description of the problem

- Each problem should have a recommendation attached

- Relevant subjective and objective findings included

Each problem should have a recommendation attached

This goes in "Plan"

Each numbered point in the Plan portion of a SOAP note should include:

- Therapy needed (eg. meds)

- Specialist referral or consult if required

- Information provided to the patient

- Monitoring recommendations

- All of the above

All of the above

What is true about the initial admission note (H&P) in a patient's chart?

- Typically unstructured, free-text

- Tends to be the shortest note in the patient's chart

- Usefulness decreases with time of admission

- Specific to just one of the patient's issues

Usefulness decreases with time of admission

Consult notes are typically ________ (less/more) focused than H&P

More

Which type of documentation tends to have the least amount of new information?

- H&P

- Imaging results

- Progress notes

- Consult notes

Progress notes

Often outdated copy and paste from previous notes and just a few relevant alterations in the Assessment & Plan component

Which is more accurate for seeing medications on a patient's chart? The MAR or the Orders tab

The MAR. It is what has actually been administered to the patient

Which of the following methods of conflict resolution includes high concern for maintaining the relationship?

- Compete

- Withdraw

- Compromise

- Accomodate

Accomodate

Which of the following methods of conflict resolution includes high concern for substance?

- Accomodate

- Compromise

- Collaborate

- Withdraw

Collaborate

Which of the following is the "worst" way to resolve an important conflict while maintaining a relationship?

- Compete

- Compromise

- Accomodate

- Withdraw

Withdraw

Match the conflict resolution strategy to the description

a) Compete

b) Withdraw

c) Compromise

d) Collaborate

e) Accommodate

i) Split the difference

ii) Problem solve creatively so everyone wins

iii) Give in to maintain friendly relationships

iv) Be a winner at any cost

v) Take whatever you can get

a) Compete and iv) be a winner at any cost

b) Withdraw and v) take whatever you can get

c) Compromise and i) split the difference

d) Collaborate and ii) Problem solve creatively so everyone wins

e) Accommodate and iii) Give into maintain friendly relationships

Which of the following is incorrect about tobacco?

- The burning of tobacco releases more than 7,000 chemicals

- Releases carcinogens

- Derived from a synthetic compound

- Kills up to half of its users

Derived from a synthetic compound

Tobacco comes from the tobacco plant

True or false. It is illegal for Ontario community pharmacies to sell cigarettes

True

It is illegal in all provinces but B.C

What is the main psychoactive component of tobacco?

Nicotine

Which is NOT an effect of nicotine binding to nicotinic receptors?

- Increased dopamine levels

- Decreased acetylcholine release

- Increased norepinephrine release

- Increased sympathetic nervous system activity

Decreased acetylcholine release

Acetylcholine release is increased

Match the nicotine neurotransmitter to its effect

a) Dopamine

b) Acetylcholine

c) Norepinephrine

i) Improved cognition and attention

ii) Activation of reward system

iii) Stimulation and arousal

a) Dopamine and ii) activation of reward system

b) Acetylcholine and i) improved cognition and attention

c) Norepinephrine and iii) stimulation and arousal

How does prolonged acetylcholine release from smoking lead to withdrawal?

Prolonged nicotine administration causes nicotinic acetylcholine receptors to become desensitized, then receptor levels are increased, increasing withdrawal effects

Nicotine metabolism occurs in the liver largely via this enzyme

CYP2A6

Which of the following is false about nicotine?

- Half life of 2 hours

- Travels to the brain in seconds

- Associated with significant withdrawal effects

- Not addictive on its own

Not addictive on its own

______% of smokers are interested in quitting

75

5 stages of quitting smoking

1. Pre-contemplation

2. Contemplation

3. Preparation

4. Action

5. Maintenance

Which of the following is not a common withdrawal effect of smoking?

- Headache

- Weight loss

- Insomnia

- GI symptoms

- Irritability/restlessness

Weight loss

Increased appetite/weight gain is common after stopping smoking

Which of the following is not a first line agent for smoking cessation?

- NRT

- Buproprion

- Varenicline

- Clonidine

Clonidine

What are 5 A's of smoking cessation?

Ask

Advise

Assess

Assist

Arrange

Order the following by what step they are in the smoking cessation process

- Follow up care

- Recommend the patient quit smoking

- Identify and document tobacco use

- Determine willingness to quit

- Offer medication and refer for counseling

1. Identify and document tobacco use (ASK)

2. Recommend the patient quit smoking (ADVISE)

3. Determine willingness to quit (ASSESS)

4. Offer medication and refer for counseling (ASSIST)

5. Follow up care (ARRANGE)

True or false. You should go through all 5 A's with each patient who is smoking

False

If a patient asks for help, we may not need the 5 A's from start to finish for them - you would start at ASSIST

What two questions are asked when assessing readiness to quit?

Given everything going on in your life right now, on a scale of 1-10, where 10 is the most important thing to do right now, how important is it for you to quit smoking altogether?

Given everything going on in your life right now, on a scale of 1-10, where 10 is the most confident you have felt about anything, how confident do you feel you will be able to quit smoking altogether?

The _____________________ Test for Cigarette Dependence measures physical dependence on smoking

Fagerstrom

These are all questions asked in what test:

- How many cigarettes do you smoke a day?

- Which cigarette of the day is most important to you?

- Do you find it difficult to not smoke in places where you are not allowed?

- Do you still smoke even when you're very sick?

- Do you smoke more in the morning than the rest of the day?

Fagerstrom Test

A patient who finds it more important to smoke in the ________________ (morning/night) is more likely to be physically dependent on cigarettes

Morning

Which is a component of motivational interviewing?

- Expressing empathy

- Supporting self-efficacy

- Developing discrepancy

- Rolling with resistance

- All of the above

All of the above

What does it mean to develop discrepancy?

Establishing the differences between smoking and quitting that the patient may have not noticed yet

The 5 R's in motivational interviewing

Relevance: why is quitting relevant to you

Rewards: benefits of quitting

Risk: acute and chronic

Roadblocks: withdrawal symptoms, fear of failure

Repetition: repeat motivational interviewing every time the patient visits the clinic

True or false. Most people who smoke indicate that they are ready to stop in the next 30 days

False

30-35%

True or false. Substantially cutting down the number of cigarettes someone smokes is almost as beneficial for a patient as quitting

False

There is no safe level of smoking for cardiovascular disease so reduction should not be the end goal

When does nicotine withdrawal peak in terms of quitting?

Within 72 hours and may continue intermittently for several weeks

Why should a nicotine patch be a component of any patient's NRT regimen?

It provides a steady baseline level of nicotine that cannot be achieved with oral nicotine

NRT contraindication

Current or recent ACS

True or false. NRT is not covered by ODB even if part of smoking cessation program

True

It is an OTC product

A nicotine patch helps more with ________________ (withdrawal/cravings) and a nicotine gum helps more with _________________ (withdrawal/cravings)

Withdrawal; Cravings

Approximately how much nicotine is inhaled in one cigarette?

1.1-1.8 mg

We intend to align NRT with this (depending on how many cigarettes a patient smokes)

How should nicotine gum be administered?

PRN for cravings using a chew and park technique

Which of the following is incorrect about nicotine gum?

- Slower onset than smoking

- Nicotine is absorbed in the small intestine

- Peak effects in 20-30 minutes

- Avoid acidic food and drinks before and during

Nicotine is absorbed in the small intestine

It is absorbed bucally which is why it is important to chew and park in the side of your mouth

Nicotine gum initial dosing

4 mg if Fagerstrom is 7+, 2 mg otherwise

To be used PRN, most who abruptly quit will require 10-12 pieces a day (max is 20/day)

Nicotine gum tapering schedule

Aim to reduce by 1 piece per week and aim to stop using by 6 months

Nicotine inhaler initial dosing

1 cartridge as needed with up to 12 per day. Encourage the patient to use at least 6 per day (if they feel they need it) for the first 6-12 weeks.

Nicotine inhaler tapering schedule

Gradual reduction after 6-12 weeks of use. Aim to discontinue when only requiring 1 or 2 a day.

Which is correct about the nicotine inhaler?

- Nicotine is absorbed through the lungs

- Cannot be used in patients with poor oral health

- Cold temperatures do not affect the absorption rate

- Aim to puff in short breaths

- Cannot be used in patients with dentures

Aim to puff in short breaths

Which NRT product has the fastest onset?

Nicotine spray

Each nicotine inhaler lasts about ______ minutes and ____ mg of nicotine is absorbed bucally

20; 2

Where should nicotine spray be used?

In the mouth, under the tongue or into the cheek

Nicotine spray initial dosing

1 cartridge as needed with up to 12 per day. Encourage the patient to use at least 6 per day (if they feel they need it) for the first 6-12 weeks.

same as nicotine inhaler

Nicotine spray tapering schedule

Gradual reduction after 6-12 weeks of use. Aim to discontinue when only requiring 1 or 2 a day.

same as nicotine inhaler

What are the most common side effects of the nicotine inhaler and oral spray?

Local irritation that may decline with continued use

How should you advise patients to use a nicotine lozenge?

Suck on tablet and then move to cheek, and then the other cheek. Biting or chewing can increase nicotine release into the GI tract where it is not absorbed

Nicotine lozenge initial dosing

Start with 4mg if first cigarette of the day is within 30 minutes of waking. Otherwise start with 2 mg

Week 1-6: 1 lozenge Q1-2H PRN (max 15/day)

Week 7-9: 1 lozenge Q2-Q4H PRN

Week 10-12: 1 lozenge Q4-Q8H PRN

Discontinue when dose has been reduced to 1-2 per day

Nicotine lozenge beyond ____ months should be avoided

6

Which of the following should not be recommended to a patient with dentures?

- Nicotine spray

- Nicotine inhaler

- Nicotine gum

- Nicotine lozenge

Nicotine gum

Which is correct about nicotine patches?

- Apply to the same area everyday

- Put the patch on the upper chest, upper arm, shoulder, back, or inner arm

- Should be kept on even during strenuous activity

- Recommend all patients to remove before bedtime

Put the patch on the upper chest, upper arm, shoulder, back, or inner arm

Why may you recommend a patient to remove a nicotine patch before bed?

If nightmares are an issue. But this may cause them to get cravings in the morning

True or false. You should start a nicotine patch a week before your planned quit date

False

Start on the quit date

Which is NOT a side effect of nicotine patches?

- Skin irritation

- Nightmares

- Insomnia

- Sedation

Sedation

True or false. You cannot smoke while on a nicotine patch

False

Advise patients not to smoke on the patch (as you would advise any patient not to smoke) but it is generally safe and does not indicate treatment failure

NRT recommendations for a light smoker (less than 10 per day)

14 mg patch x 1-4 weeks AND one short-acting NRT for cravings as needed

NRT recommendations for a moderate smoker (10-29 cigarettes per day)

21 mg patch x 1-4 weeks and one short acting NRT for cravings as needed

NRT recommendations for a heavy smoker (29+ cigarettes per day)

28 mg patch (21 mg + 7 mg patch) x 1-4 weeks and one short acting NRT for cravings as needed

Pharmacotherapy for smoking cessation is recommended for at least ___ months but NRT may be extended and in some cases used indefinitely

3

____________________ has higher smoking quit rates compared to other agents

Varenicline

True or false. Varenicline is an alpha4, beta2-nicotinic receptor partial agonist

True

How does varenicline reduce smoking satisfaction?

By attaching to the same parts of the brain that nicotine attaches to but without stimulating them as strongly as nicotine

How does varenicline reduce withdrawal symptoms?

Maintaining moderate levels of dopamine

Patients who quit smoking with varenicline will have __________ (less/more) dopamine than patients who go cold turkey

More

True or false. Varenicline is covered by ODB for up to 12 weeks

True

True or false. Pharmacists can prescribe Varenicline only for the indication of smoking cessation (LU code)

True

Varenicline should be taken at least ____ days before the quit attempt

7

Why do we recommend patients titrate up the varenicline dose in the first week and take with food and drink?

Due to the high incidence of nausea

Varenicline dosing

0.5 mg x 3 days

THEN 0.5 mg BID x 4 days

THEN 0.5-1mg BID x 12 weeks

True or false. Varenicline cannot be continued beyond 12 weeks

False

It can be continued for an additional 12 weeks if the patient has benefited but is not ready to go off it. Note that ODB will not reimburse them in this case.

True or false. Tapering off is required with varenicline given its upregulation of alpha 4 and beta 2 receptors

False

What is one way to prevent insomnia/odd dreams while on varenicline?

Take the second daily dose at suppertime instead of night time

What form of Bupropion is used for smoking cessation?

Bupropion SR (Zyban)

Bupropion MOA in smoking cessation

Dopamine and noradrenaline reuptake inhibition and reduces the stimulant effects of nicotine on the nicotinic acetylcholine receptors

True or false. Pharmacists can prescribe Bupropion SR for smoking cessation and depression

False

Only for smoking cessation

True or false. Bupropion and varenicline are both covered by ODB for the same amount of time (12 weeks)

True

Which of the following is true about bupropion?

- Bupropion increases alcohol tolerance

- Not associated with seizures unlike varenicline

- Increases appetite

- Alcohol uses increases risk of neuropsychiatric side effects while on it

Alcohol uses increases risk of neuropsychiatric side effects while on it

Contraindications to bupropion

- Receiving any other medications that contain bupropion

- Current seizure disorder or history of seizures

- Current or prior diagnosis of eating disorder

- Undergoing withdrawal from alcohol, benzos, or other sedatives

True or false. Varenicline has no absolute contraindications

True

This smoking cessation drug has a dose dependent risk of seizures

Bupropion

A patient who is concerned about gaining weight after quitting smoking may get additional benefit from this smoking cessation drug

Bupropion

True or false. Combining varenicline and NRT is approved in Canada and used frequently in practice

False

Not approved in Canada but used regardless. Risk of bad dreams with this combination

Which is the safest smoking cessation option?

NRT

Due to safety concerns, Health Canada advises prescribers to consider the use of NRT prior to prescribing either varenicline or bupropion

ODB patients who consider cost a great concern should NOT be recommended this smoking cessation option:

- Nicotine patch + short acting NRT

- Varenicline

- Bupropion

Nicotine patch + short acting NRT

Extending the use of NRT products to ___ months can significantly and safely improve cessation rates; however, extending the use of NRT beyond this presents no additional benefit

6

When might clonidine be indicated for smoking cessation?

In cases of comorbid uncontrolled hypertension