PPAS Exam 2

NEUROLOGIC EXAMINATION → 13

1. mental status

2. cranial nerves

3. motor fx

4. cerebellar fx

5. sensory fx

6. reflexes

7. gait

8. headache

9. cognition

10. delirium

11. depression

12. anxiety

13. tardive dyskinesia

CRANIAL NERVES

1. I olfactory → smell

2. II optic → visual acuity, visual fields

3. III oculomotor, IV trochlear, VI abducent → eye muscles, pupil size, response to light

4. V trigeminal → face/jaw

5. VII facial → raise eyebrows, clench eyes, smile/frown, puff out cheeks

6. VIII acoustic/vestibulocochlear → inner ear (whisper, scratch, tuning fork)

7. IX glossopharyngeal, X vagus → gag reflex, swallowing

8. XI accessory → shrug shoulders, turn head to side

9. XII hypoglossal → stick out tongue

Cranial nerve symptoms & diagnoses → STROKE (4)

1. vision

2. facial asymmetry

3. slurred speech

4. difficulty swallowing

Cranial nerve symptoms & diagnoses → BELL’S PALSY (2)

1. facial paralysis

2. lower eyelid drooping

Cranial nerve symptoms & diagnoses → MYASTHENIA GRAVIS (2)

1. eyelid drooping

2. double vision

MOTOR FUNCTION: ASSESSING COORDINATION & BALANCE

FINE MOVEMENTS → 4

1. rapid finger tapping

2. finger to nose

3. alternate pat with hand & palm

4. observe at rest

MOTOR FUNCTION: ASSESSING COORDINATION & BALANCE

BALANCE

1. _____________, semi-tandem, tandem

2. Romberg test →

1. standing feet together

2. stand still & close eyes 20s

MOTOR FUNCTION: ASSESSING COORDINATION & BALANCE

GAIT → 4

1. standing

2. walking

3. turning

4. TUG (timed up and go test)

1.     Stand with your eyes closed	A. Cranial Nerve II Optic
2.      Stick out your tongue	B.  Cranial Nerve VII Facial
3.     Tap your thumb and finger together fast	C. Cranial Nerve VIII Vestibulocochlear
4.     Tell me the number I whispered	D. Cranial Nerve XI Accessory
5.     Smile	E. Cranial Nerve XII Hypoglossal
6.     Walk fast like you are catching a bus	F. Balance
7.     How many fingers am I holding up?	G. Fine motor movements
8.     Shrug your shoulders	H.  Gait

Match the technique/request to the nerve/function

1. F

2. E

3. G

4. C

5. B

6. H

7. A

8. D

MOTOR: REFLEXES classification

1. -

2. -

3. -

4. Altered with disease states → 5

1. 2+ normal

2. 0 absent

3. 4+ hyperreflexia, may also have clonus

4. stroke, PN, ALS, MS, Thyroid disease

Timed Up and Go Test (TUG)

1. normal health elderly complete in _______

2. Score _____ = HIGH RISK FOR FALLS

1. </= 10s

2. >14

Stroke or TIA s/s

1. Balance

2. Eyes

3. Face (one side droop/numb)

4. Arms (one arm weak/numb)

5. Speech (slurred, unable)

6. Time (CALL 911! check clock to know what time sx first appeared)

HEADACHE reasons for emergent referral →

1. S → systemic s/s

2. N → neurologic

3. O → onset (thunderclap)

4. O → older (new onset >50 yo)

5. P → progression of existing headache disorder

Mental/Cognitive Status Screening Tools: MINI-COG

1. Orientation and registration: time, place, person, ___________, or items

2. Recall:

3. Perform task:

1. recognize words

2. 3-5 words given, then after 5 min ask what they were

3. clock draw

MINI MENTAL STATE EXAM (MMSE)
Max score is 30

1. Mild AD →

2. Moderate AD →

3. Severe AD →

1. 21-24

2. 10-20

3. <10

DELIRIUM

1. MUST have … 2

2. then have either or … 2

1. acute/fluctuating, inattention

2. disorganized thinking, altered level of consciousness

HELPFUL QUESTIONS TO USE WITH CAM

1. Acute/fluctuating →

2. Attention →

3. Disorganized thinking →

4. Altered level of consciousness →

1. confusion → What day is it?

2. distraction, trouble keeping track → repeat the days of the week backwards

3. illogical, incoherent

4. drowsy, sleep, agitated, trying to escape

Which feature of the CAM did Mr. Williams exhibit when he was agitated and trying to “get out of here”?

A. Acute onset and fluctuating course

B. Inattention

C. Disorganized thinking

D. Altered level of consciousness

D

When Laura had delirium, she wanted to let the birds out of the wall with a hammer. Which feature of the CAM does this provide?

A. Acute onset and fluctuating course

B. Inattention

C. Disorganized thinking

D. Altered level of consciousness

C

COMPLEXITIES OF TRANSITIONS IN CARE

1. Multiple _________

2. Multiple (ever-changing) ____________

3. Multiple _________

4. Various _____

5. __________________

6. __________________

7. Lack of _____________

8. Inadequate ________ and __________

1. providers

2. therapeutic plans

3. comorbidities

4. EMRs

5. med discrepancies

6. poor communication

7. patient/family education

8. planning, goal setting

COMPLEXITIES OF TRANSITIONS IN CARE AFTER DISCHARGE

1. __________ for patients and their family about how and who should manage their care

2. Medication issues →

3. ______________

1. misunderstanding

2. misunderstanding of instructions, adherence, DDIs, duplicate or omitted Rx

3. poor follow up w PCP

3 C’S OF MED RECS →

1. COLLECT best possible med hx

2. COMPARE what pt is actually taking w what is prescribed (identify discrepancies)

3. CORRECT any med discrepancies

PHARMACY RX REFILL INFORMATION

Advantages

1. Often _________ for medications

2. Provides information about _________

Disadvantages

3. Can be ______ to obtain

4. May be ________ (multiple pharmacies, OTCs)

1. only source

2. adherence

3. difficult

4. incomplete

OUTPATIENT EMR MEDICATION LIST

Advantages

1. May be easy to obtain and ______, especially if integrated EMR

Disadvantages

3. Cannot exchange their data ___________

4. Doesn’t work if patients are from practices that ___________

1. integrate

2. outside their own private network

3. dont use that EMR

HEALTH INFORMATION EXCHANGES

Advantages

1. May allow access to data from a _________ of healthcare systems

2. Data may be in a coded form that’s relatively _________

Disadvantages

3. _________ with a robust system in place

4. Most useful if ____________ the network

5. Only as accurate as the ________

1. variety

2. easy to use

3. few regions

4. everyone contributes

5. source it comes from

DISCHARGE MED LIST FROM RECENT HOSPITALIZATION

Advantages

1. If from same hospital, ________

2. May be easy to _________ into current chart

3. At one point in time, _________

Disadvantages

4. May be _________

5. Access limited to discharges from the ________

1. easiest to access

2. integrate

3. was accurate

4. out of data

5. same hosp

PATIENT/CAREGIVER’S VERBAL REPORT

Advantages

1. May be easy to obtain if patient ________ or family/caregiver available

2. Assesses patient/caregiver ________ of medications

Disadvantages

3. May be very _________ or _______

4. Not _______ in some cases (ex. delirium, family/caregiver not available)

1. communicative

2. knowledge

3. inaccurate, incomplete

4. available

MED LIST ON PAPER FROM PATIENT/CAREGIVER

Advantages

1. _____ to obtain

2. A bridge to a _________

Disadvantages

3. May be very ________ or ______

4. Often ___________

1. easy

2. long-term solution

3. inaccurate, incomplete

4. not available

TYPES OF MEDICATION DISCREPANCIES

Intended →

purposeful addition or omission of med(s)

TYPES OF MEDICATION DISCREPANCIES

Unintended →

1. omission

2. commission

3. diff dose/route/freq

4. therapeutic dup

Warfarin or aspirin held for a procedure

Example of …

intended

Metformin held at admission (use SSI while inpatient)

Example of …

intended

PPI continued at discharge for stress ulcer prophylaxis while pt was intubated

Example of …

unintended - commission

Patient requires 5 more days of prednisone for COPD exacerbation, not added to discharge med reconc

unintended - omission

Patient takes enalapril at home for BP but is substituted lisinopril upon admission per hospital formulary. His discharge instructions list both lisinopril & enalapril.

Example of …

unintended - duplication

Catapres TTS 0.1mg patch (patient was NPO during admission) continued at discharge instead of clonidine 0.1 mg tablet.

Example of …

unintended - diff dose/route/freq

PAIN CLASSIFICATION

1. Acute

2. Subacute

3. Chronic

1. <1m, identifiable cause, tx aimed at underlying cause

2. 1-3m

3. >3m, not always identifiable, tx aimed to improve fx

1. NOCICEPTIVE PAIN

2. NEUROPATHIC PAIN

1. somatic → to body tissues, sharp/localized, visceral → arising from organs, dull/aching

2. PNS, CNS

PAIN ASSESSMENT

1. Past … hx

2. →

3. →

4. Query _________

5. ___________ risk screening

6. ___________ screening

7. ___________ risk screening

8. ________

1. med, social, family, psychiatric

2. ROS, basic 7 questions, QISS TAPED

3. phys exam

4. PDMP

5. substance abuse risk

6. mental health

7. rsp disease

8. pain

PAIN INTENSITY SCALES

1. A

2. B

3. C

4. D

1. visual analog scale

2. numeric rating scale

3. verbal scale

4. faces rating scale

_____________: brief, self-reported screening tool designed to help providers assess patients’ risk of opioid abuse before starting opioid therapy

opioid risk tool ORT

_______________: 17-item self report assessment of aberrant behavior for current opioid therapy

COMM assessment

PHARMACOTHERAPY BASED ON TYPE OF PAIN

1st line therapy → considerations for opioid use

1. Nociceptive

2. Neuropathic

3. Central sensitization

1. NSAIDs → only when other inadequate

2. TCA/SNRIs, antiseizure → ^

3. TCA/SNRIs, antiseizure → AVOID; often worsen

POPULATIONS AT GREATEST RISK FOR HARM FOR OPIOIDS → 6

1. sleep apnea/other

2. renal/hepatic insuff

3. older adults

4. preg women

5. depression/other

6. personal/family hx of AUD/SUD

When starting opioid therapy for acute or chronic pain, clinicians should prescribe _______ opioids

*TRY TO AVOID COMBINATION OF ER/IR PRODUCTS

IR

__________ should NOT be the 1st choice for an ER/LA opioid

methadone

Opioid Dosage

1. Lowest starting dose for opioid naive _____ MME for single dose

2. ^ or _____ MME/day

3. Be cautious when increasing dosage to _____ MME/day

4. AVOID increasing to _____ MME/day

1. 5-10

2. 20-30

3. >/= 50

4. >/= 90

OPIOID TAPERING

1. ______ of original dose _______

2. For long term opioid uses (>1 year) →

1. 10% / week

2. 10% / month

OPIOID FOLLOW UP

1. Within _________ of starting opioid therapy

2. CHRONIC =

1. 1-4w

2. q 3m

PHARMACIST ROLES IN OPIOID SAFETY MONITORING

1. Screening for _________

2. Review of _______ data

3. Use of _________ or _______

4. Avoid __________

5. Proper utilization of _______

6. Arrangement of _______ for opioid use disorder

1. risk factors

2. PDMP

3. urine drug testing, random pill counts

4. co prescribing BZDs

5. naloxone

6. tx

NALOXONE WHEN FACTORS +RISK FOR OPIOID OVERDOSE

1. hx of _________

2. hx of _________

3. Higher opioid dosages (_____ MME/day)

4. Concurrent ________ use

1. overdose

2. SUD

3. >/= 50

4. BZD

OPIOID USE DISORDER TREATMENT

1. Opioid agonist →

2. Partial agonist →

3. PO or LA injectable →

1. methadone

2. buprenorphine

3. naltrexone

S/S OF INTOXICATION OR OVERDOSE → 6

1. miosis

2. -consciousness/drowsiness

3. -resp

4. bradycardia

5. euphoria

6. slurred speech

S/S OF WITHDRAWAL → 6

1. mydriasis

2. sweating

3. fever

4. NV, cramping

5. HTN, tachycardia

6. agitation

OPIOID CONVERSION FACTORS FOR MORPHINE MG EQUIVALENTS → 6

1. hydrocodone = 1

2. hydromorphone = 5

3. oxycodone = 1.5

4. fentanyl transdermal (mcg/hr) = 2.4

5. oxymorphone = 3

6. tramadol = 0.2

Calculate MME and TDD

Hydrocodone 5/325mg q6H

1. TDD = 20 mg hydrocodone

2. MME = 20

OPIOID TOLERANCE

incomplete cross-tolerance between opioids

reduce NEW opioid dose by ______ to accommodate

25-50%

OPIOID INDUCED HYPERALGESIA → treatment

-opioid dosage or opioid rotation

OA vs RA

both can cause morning stiffness

1. OA = larger joints

2. RA = small joints

All facilities that perform lab testing are regulated by

CLIA

What does CLIA stand for?

A. complete laboratory insurance amendments

B. cruise line international association

C. complete laboratory improvement act

D. clinical laboratory improvement amendments

D

What is a “waived test”?

A. Simple lab exam/procedure with high risk of error

B. Simple lab exam/procedure with low risk of error

C. Complex lab exam/procedure with high risk of error

D. Complex lab exam/procedure with low risk of error

B

Which form must be completed to apply for a CLIA waiver?

CMS - 116

In which setting can POCT be performed?

A. community

B. emergency department

C. home

D. all of the above

D

How much is the Biennial Certificate of Waiver Fee?

$248

Yes or No

Can pharmacists charge for CLIA waived services?

yes

To perform POCT in ANY state, you must

A. have a CLIA certificate of waiver

B. follow manufacturer’s instructions for the test

C. both of these

D. only one of these

C

Which organization approves devices as “CLIA-waived”

A. CMS

B. CDC

C. DHHS

D. FDA

D

T or F:

POCT are classified by their complexity as simple, moderate, or high

T

T or F:

You must obtain additional training to provide POC testing

F

SCOPE OF PRACTICE

3 regulatory entities →

1. state pharmacy practice acts

2. federal pharmacy law

3. PREP Act (public readiness and emergency preparedness act)

What can we do in Arkansas?

1. 2017 → “Statewide Protocol” + Naloxone

2. 2019 → Nicotine Replacement Therapy NRT

3. 2021 → Oral Contraceptive Therapy

4. 2022 → Flu/Strep/COVID Test & Treat

5. 2023 → HIV PrEP/PEP Therapy

1. Act 284

2. Act 651

3. Act 408

4. Act 503

5. Act 314

ACT 408 (ORAL CONTRACEPTIVE THERAPY)

1. Can ONLY prescribe ______ birth control

2. REQUIRED completion of ___________ approved by AR BoP

3. Patient assessment algorithm →

1. PO

2. training program

3. preg, BP, OC eligibility screening

ACT 314 (HIV PrEP / PEP Therapy)

PrEP (PRE EXPOSURE) options → 2

1. Descovy (emtricitabine/TAF)

2. Truvada (emtricitabine/TDF)

ACT 314 (HIV PrEP / PEP Therapy)

PEP (POST EXPOSURE) options → 4

1. Emtriva (emtricitabine)

2. Isentress (raltegravir)

3. Tivicay (dolutegravir)

4. Truvada (emtricitabine/TDF)

5. Viread (TDF)

Which require completion of training program approved by AR BoP? (select all that apply)

A. “Statewide Protocol” + Naloxone

B. NRT

C. Oral contraceptive therapy

D. Flu/Strep/Covid test and treat

E. HIV PrEP/PEP therapy

C, E

ACT 314 (HIV PrEP / PEP Therapy)

PrEP (PRE EXPOSURE)

1. Inclusion criteria → 3

2. EXCLUSION criteria → 4

1. 18+, +risk, -HIV Ag/Ab test result w/in past 7d or -POC HIV test

2. interested in Apretude (cabotegravir IM), s/s acute HIV infxn, CrCL <30, +HIV test

ACT 314 (HIV PrEP / PEP Therapy)

PrEP (PRE EXPOSURE) TX ALGORITHM

Descovy vs Truvada preference

1. Descovy → regular NSAID use, -BMD, NOT approved for female @birth

2. Truvada → preg/breastfeeding, cis-female or trans-male

ACT 314 (HIV PrEP / PEP Therapy)

PEP (POST EXPOSURE)

1. Inclusion criteria → 3

2. EXCLUSION criteria → 4

1. 13+, exposure to +HIV source, exposure to unknown HIV status

2. <13 yo, exposure >72h, +HIV test, -renal fx

ACT 314 (HIV PrEP / PEP Therapy)

PEP (POST EXPOSURE)

1. Adult dosing →

2. PREGNANT patients →

3. Pediatric dosing →

1. Truvada + Tivicay/Isentress

2. Truvada + Isentress

3. >/= 40kg Truvada + Isentress; <40 kg Viread + Emtriva + Isentress

POCT & Treat: Influenza

Documentation must be maintained for _____

2 yr

INFLUENZA & STREP A CRITICAL THRESHOLDS

Critically unstable & refer

1. BP

2. RR

3. O2

1. adult <90 SBP or <60 DBP; age 3-9 <70 + (age x 2) SBP

2. adult >25; <18 yo >20

3. <90%

INFLUENZA ELIGIBILITY CRITERIA TO USE PROTOCOL

1. Age _____

2. ____________

3. Symptoms _______

4. No hx of ______ to influenza tx

5. Has NOT used antiviral therapy for influenza within _____

6. ____________

1. 3+

2. not preg

3. <48h

4. allergic rxn

5. 30d

6. not immunocompromised

Which flu treatment contains milk proteins and is NOT recommended in pts w/ underlying respiratory disease?

zanamivir (Relenza)

TAMIFLU (OSELTAMIVIR)

USE IN CAUTION WITH …

1. Chronic _______ disease

2. Severe ______ impairment

3. ________ impairment (dose adjust)

4. ________ disease

1. cardiac

2. hepatic

3. renal

4. resp

STREP A PHARYNGITIS ELIGIBILITY CRITERIA

1. Age _____

2. ______________

3. Centor score _____

4. Has not used ABx for sore throat or URI within ______

5. _________ is positive

6. ______________

1. 3+

2. not preg

3. 2+

4. 30d

5. GAS POCT

6. not immunocompromised

STREP A PHARYNGITIS TREATMENT

1. 1st line

2. 2nd line (or PCN allergy)

3. 3rd line (if PCN allergy or exclusions to 1st/2nd line)

1. amox, pen V

2. cephalexin

3. azithromycin

MEDICARE (REVIEW)

covers → payment to

1. Part A

2. Part B

3. Part C “Medicare Advantage”

4. Part D

1. hospital/hospice → hospital

2. outpt med → provider

3. outpt med, ± Rx → commercial payer

4. Rx → PDP

PHARMACISTS are not currently recognized as providers under Medicare _______, which limits ability to bill for clinical services

part B

1. ____________ is the process of verifying a healthcare professional’s qualifications

2. ___________ is the process of granting permission to perform specific services within an organization or payer network

These processes are essential for pharmacists to participate in medical billing and payer networks

1. credentialing

2. privileging

Who can we bill medical claims for our clinical services?

AR BCBS

Macule vs Patch

patch (5cm+) > match

PAPULE

small, ______ lesion

raised

PLAQUE

raised, >_____ in diameter

1.5 cm

__________: thickening or roughening of the skin (leather bark like)

lichenification

Nodule

_____ cm in length AND depth

>1.5

1. skin lesion =

2. secondary to ______

3. usually ______

1. wheal

2. edema

3. erythematous

Skin lesion =

Nodule containing liquid

cyst

1. skin lesion =

2. filled with ______ serous fluid

1. vesicle

2. clear

skin lesion =

bulla