msc clinical pharmacy pharmaceutical care plan€¦ · myocardial infarction (mi) – aug 2015...

Student ID Number:

of 24

MSC CLINICAL PHARMACY PHARMACEUTICAL CARE PLAN

Please edit and format this template where necessary to add additional lines to the tables. Each table will generate automatic headings over additional pages.

A . P A T I E N T B A C K G R O U N D A N D M E D I C A T I O N L I S T

Reason for selecting this patient

I chose this case as I had little previous hands-on experience with acutely unwell diabetic patients but, having recently covered the diabetic theory in my

Diploma, I was keen to apply my knowledge in practice.

Patient Details

Initials: RR Age: 78 years Male Female

Weight: 90.2 kg Height: 1.7 meters BMI:31.2kg/m2

Patient History

Presenting Complaint: Slurred speech. Unsteadiness. Fatigue. Nocturia

Past Medical/Surgical/Mental Health History: Intermittent Claudication. Myocardial Infarction (MI) – Aug 2015 (bypass). Cataracts (removed). Hypertension

(HTN). Atrial Fibrillation (AF). Chronic Kidney Disease (CKD) Stage 3B. Gastro-oesophageal reflux disease (GORD).

Social History: Independent – lives with wife. Smoked 25/day for 20yrs – stopped 35yrs ago. Drank 20pints beer/weekend – stopped 10years ago. Father

deceased – MI in his 60s. Mother deceased – Stroke in her 80s. Brother – Diabetes/Cardio Vascular disease. Both Sisters – previous MIs. Gets medication in a

Comment [AM1]: and improve patient care?

Comment [AM2]: ?PVD

Comment [AM3]: angina not mentioned but listed as having stable angina in the medication history

Student ID Number:

of 24

Patient History

Blister Pack.

Impression/Diagnosis: Diabetic Ketoacidosis (DKA)/Hyperosmolar Hyperglycaemic state (HSS). Stroke? Sepsis (urinary)?

Plan: Urine Dip. Blood Glucose. Venous Blood Gas (VBG). Ketones.

Medication History

Medication List Indication and Evidence

Atorvastatin tablet 80mg ON. Secondary prevention of cardiovascular events following MI. (1)

Bisoprolol tablet 5mg OM. Secondary prevention of cardiovascular events following MI (1).

Carbomer 980 0.2% eye gel – Both eyes PRN. Symptomatic relief of dry eyes. (2)

Glyceryl Trinitrate 400mcg Oral Spray – 1 to 2 sprays sublingually PRN. Prevention and treatment of episodes of (stable) angina (3).

Isosorbide Mononitrate M/R tablet 60mg OM. Treatment of stable angina (3).

Lansoprazole capsule 30mg OM. GORD (4).

Nicorandil tablet 30mg BD. Treatment of stable angina (3).

Paracetamol tablet 0.5g to 1g QDS. Mild to moderate pain relief (2).

Ramipril capsule 2.5mg OM. Secondary prevention of cardiovascular events following MI (1).

Rivaroxaban tablet 15mg OM. Prophylaxis of stroke and systemic embolism in non-valvular atrial fibrillation

(5).

Comment [AM4]: Bicarb?

Comment [AM5]: does this also have a role in the patients AF?

Comment [AM6]: not in PMH

Comment [AM7]: how long has the patient been on this higher dose? is it still indicated.

Comment [AM8]: does this also have a role in the patients HTN? would this be first line if they hadn't had an MI - discuss

Student ID Number:

of 24

Medication History

Medication List Indication and Evidence

Allergies/Sensitivities NKDA

Student ID Number:

of 24

B . P R O G R E S S N O T E S A N D M E D I C A T I O N C H A N G E S

Progress Notes

Date Notes

31/10/16 Admitted to A&E department following GP referral. Patient had a three-week history of; not sleeping due to nocturia,

unsteadiness/stumbling with a recent history of slurred speech, blurred/double vision, nausea/vomiting and forgetfulness.

Point of care (POC) blood gases for rapid identification of pH, Bicarbonate, Sodium, Potassium and Glucose (58.3mmol/L).

Ketone levels (0.5mmol/L).

Laboratory bloods taken: Full blood count (FBC), International normalised ratio (INR)/Prothrombin time (PT), Renal Profile including

estimated glomerular filtration rate (eGFR), Lipid profile, Liver profile, C reactive protein (CRP), Glucose levels.

Swabbed for MRSA (nose and groin).

Dysphagia screen.

Computerised Tomography (CT) head.

Diagnosis: HHS.

Initiation of IV fluids (Sodium Chloride 0.9%).

Insulin (sliding scale) commenced.

Diabetic referral.

1/11/16 Pre-breakfast BMs: 16.0mmol/L. Ketones: 0.1mmol/L

POC blood gases.

Comment [AM9]: redundant terminology. Be specific VRII? FRII?

Comment [AM10]: what time was this started? guidelines recommend not starting at time zero if ketones are <1.0mmol/L. Why did this patient’s treatment differ to the guidelines - or can you clarify what time this infusion was started after admission and diagnosis with HHS. This is also misleading as a fixed rate intravenous insulin infusion is recommended for HHS not a variable rate infusion.

Comment [AM11]: DO NOT use BMs - it is not an accepted medical abbreviation

Student ID Number:

of 24

Progress Notes

Date Notes

Bloods: Renal profile (including eGFR). Liver profile. INR/PT.

Stroke referral due to continued slurred speech.

Medicines reconciliation performed by pharmacist. No OTC. Good concordance established

Medication history communicated to medical team who prescribed regular medication omitting nephrotoxics (Ramipril) due to Acute

kidney injury (AKI). Rivaroxaban held due to raised INR (2.1) on admission and awaiting CT-head results to rule out (haemorrhagic?)

stroke. I noticed the patient had not been prescribed VTE prophylaxis (patients in HHS have an increased risk of venous thrombosis)

and suggested (after first confirming CT results rule out a bleed and ensuring INR now below 2.0 - a contraindication (12) to LMWH)

enoxaparin be commenced at the renal dose of 20mg od.

Sliding scale (SS) insulin stopped. Started on Novomix 30.

2/11/16 Pre-breakfast BMs: 17.8mmol/L. Ketones: 0.2mmol/L.

Bloods: CRP, Liver profile. Renal profile (including eGFR), FBC, HbA1c. INR/PT.

Current medication to continue.

Stroke review – Speech still slurred so started on Aspirin 300mg/day antiplatelet therapy. OPD appointment made for review and

Carotid Doppler.

Dietician referral.

Diabetic foot check – NAD.

Novomix dose increased as blood glucose levels elevated.

Comment [AM12]: PT?

Comment [AM13]: why not just restart NOAC? Why measure INR here when you could measure parameters associated with rivaroxiban?

Comment [AM14]: what caused this presentation?

Student ID Number:

of 24

Progress Notes

Date Notes


IV fluids ceased

Bloods: Renal profile. Liver profile. Bone profile. Parathyroid hormone (PTH). FBC.

Insulin dose increased.

Upon further research, I established Rivaroxaban is known to give false high INR readings (6). I communicated this to the medical team

who took this in to account alongside the CT result of ‘subacute infarct’ (with no haemorrhagic transformation) and speech

improvement and it was decided to restart Rivaroxaban. Aspirin ceased. Enoxaparin ceased.


Novomix dose increased – patient counselled on administration, blood sugar monitoring and hypoglycaemia (‘hypo’) warning signs.

Renal function slowly improving - Ramipril restarted (Blood Pressure at 131/77mmHg).

Discharge prescription filled, ensuring provision of needles and sharps bin. Insulin passport provided as per NPSA alert (7) and

completed to contain patient’s insulin details, ‘hypo’ treatment and all regular medicines. Confirmed that patient had been provided

with the means to self-test blood glucose levels after discharge.

Patient discharged.

Comment [AM15]: what else needs to be considered in order to restart the NOAC? has the patients renal function improved at this point?

Student ID Number:

of 24

Medication Changes

Medication List Dose Frequency Route Indication Start/Continued

Date

Stop Date

Actrapid 50units in 50ml 0.9%

sodium chloride.

Sliding

scale

Hourly dose

titration.

IV Blood glucose control. 31/10/2016 01/11/2016

Aspirin tablet 300mg OD PO Acute antiplatelet treatment of stroke/TIA

(8)

2/11/16 03/11/16

Atorvastatin tablet 80mg ON PO Secondary prevention of cardiovascular

events

1/11/16 Continue

Bisoprolol tablet 5mg OM PO Secondary prevention of cardiovascular

events

1/11/16 Continue

Glyceryl Trinitrate spray 400mcg PRN SL Angina 1/11/16 Continue

Isosorbide Mononitrate MR tablet 60mg OD PO Angina 1/11/16 Continue

Lansoprazole capsule 30mg OM PO GORD 1/11/16 Continue

Nicorandil tablet 30mg BD PO Angina 1/11/16 Continue

Novomix 30 Flexpen 20units BD (9am,

6pm)

SC Diabetes Mellitus (9) 1/11/16 2/11/16

Novomix 30 Flexpen 22units BD (9am,

6pm)

SC Diabetes Mellitus (9) 2/11/16 3/11/16

Novomix 30 Flexpen 28 units BD (9am,

6pm)

SC Diabetes Mellitus (9) 3/11/16 Continue

Comment [AM16]: The recommended insulin dose is a fixed rate intravenous insulin infusion (FRIII) given at 0.05 units per kg per hour It would have been good to see a table here of the dose titrations this patient received along side blood glucose results

Student ID Number:

of 24

Medication Changes

Medication List Dose Frequency Route Indication Start/Continued

Date

Stop Date

Novomix 30 Flexpen 6units OD (12pm) SC Diabetes Mellitus (9) 4/11/16 Continue

Novorapid Flexpen 4units STAT (12:14) SC Diabetes Mellitus (10) 2/11/16 2/11/16

Novorapid Flexpen 6units STAT (15:16) SC Diabetes Mellitus (10) 2/11/16 2/11/16

Ramipril capsule 2.5mg OD PO Secondary prevention of cardiovascular

events

2/11/16 Continue

Rivaroxaban tablet 15mg OD PO AF stroke prophylaxis. 3/11/16 Continue

Sodium Chloride (NaCl) 0.9% 1000ml Over 1st hour. IV Replace fluid loss. Normalise osmolality. 31/10/2016 31/10/2016

Sodium Chloride 0.9% 1000ml Every 4-6

hours.

IV Replace fluid loss. Normalise osmolality. 31/10/2016 01/11/2016

Sodium Chloride 0.9% 1000ml Every 6-8

hours.

IV Replace fluid loss. Normalise osmolality. 01/11/2016 03/11/2016

Comment [AM17]: why were these two stat doses given?

Comment [AM18]: was any potassium given? recommended in guidelines to give in first 24 hours even if in normal range. https://www.diabetes.org.uk/Documents/Position%20statements/JBDS-IP-HHS-Adults.pdf

Student ID Number:

of 24

C . M O N I T O R I N G P L A N

Monitoring Plan

Parameter Justification Frequency Result(s) and Action Plan

Glucose levels Diagnostic indicator of HHS (11). To monitor

improvement.

4 hourly

On Adm 01/11 02/11 03/11 04/11

58.3 Pre-breakfast

BMs

(mmol/L)

16.0 17.8 14.3 9.9

mmol/L Post-

breakfast

BMs

(mmol/L)

23.1 24.2 16.2 12.9

The current NICE Type 2 diabetes mellitus (T2DM) guidelines do

not contain blood glucose targets. However, Diabetes UK council

of healthcare professionals (CHP) have advised that the glucose

targets from NICE T2DM (2008) can be utilized (12). This is target

levels of 4-7mmol/L pre-prandial and <8.5mmol/L two hours

after meals, which the patients’ levels far exceeded. The

administration of both NaCl and Insulin would precipitate a fall in

glucose levels.

Ketone levels Diagnostic indicator of HHS, to rule out Diabetic

Ketoacidosis (DKA). (11)

4 hourly

Comment [AM19]: According to the HHS guidelines the target glucose is different in the acute phase of treatment. 'A target blood glucose of between 10 and 15 mmol/L is a reasonable goal. Complete normalisation of electrolytes and osmolality may take up to 72 hours'. There is also an hourly recommended reduction rate which has not been discussed or shown in the table. A fall of glucose at a rate of up to 5 mmol/L per hour is ideal and once the blood glucose has ceased to fall following initial fluid resuscitation, reassessment of fluid intake and evaluation of renal function must be undertaken. Insulin may be started at this point, or, if already in place, the infusion rate increased by 1 unit/hr. As with DKA, a FRIII is preferred, though generally lower doses are required.

Student ID Number:

of 24

Monitoring Plan


Date 31/10 01/11 02/11 03/11 04/11

Blood

Ketones

(mmol/L

0.5

0.1

0.2

0.1

0.0

Consistently below 3mmol/L suggesting this is not a case of DKA.

Residual insulin (In type 2 diabetes) is a key factor in preventing

lipolysis and subsequent ketone production.

Acidosis Diagnostic indicator of HHS, to rule out DKA. (11) Day 0, Day

1.

pH reading >7.3 (7.33) and bicarbonate > 15mmol/L

(20.1mmol/L) further confirming diagnosis of HHS rather than

DKA.

Osmolality Diagnostic indicator of HHS (11) Day 0. Calculated using the formula 2Na + Glucose + Urea =

240+58.9+17.2 = 316.1 mosmol/kg. Although not

>320mosmol/kg as suggested in diabetes guidelines (11) this is

significant enough to indicate HHS, especially when taken in to

account with low Ketone and acidity levels. IV NaCl prescribed.

Blood Pressure (BP),

Heart Rate & ECG.

Can be an indicator of hydration/dehydration. To

monitor whether medication changes (i.e. holding

Ramipril, IV fluids) had any detrimental effect on

blood pressure.

Indicator of cardiac activity.

4 hourly

Systolic BP peaked, on admission, at 140mmHg but then

remained consistently between 119 – 130mmHg.

Heart rate ranged between 67 – 83 bpm.

ECG result verified AF. No other concerns.

Comment [AM20]: good

Comment [AM21]: patient has HTN/prev MI/AF

Comment [AM22]: what is the target BP for this patient (MI, HTN, ?new diabetes diagnosis)

Comment [AM23]: what is the target HR

Student ID Number:

of 24

Monitoring Plan


U&Es To determine electrolyte levels and kidney

function. Creatinine and Urea are a good indicator

of dehydration as are Sodium and Potassium.

Electrolyte monitoring required whilst receiving IV

NaCl. It is also important to monitor renal response

to treatment.

Daily

Serum Range 31/10 01/11 02/11 03/11

Sodium

(mmol/L)

136-

145

120 130 131 134

Potassium

(mmol/L)

3.5 –

5.4

4.6 3.8 4.1 4.7

Creatinine

(mmol/L)

62 -

115

237 208 175 170

Urea

(mmol/L)

2.5 –

6.7

17.2 17.1 11.7 9.8

Initial low Sodium levels were indicative of hypovolaemic

hyponatraemia. Potassium levels remained within safe

parameters. Raised Creatinine & Urea are conducive with

dehydration and AKI/CKD. Gradual improvement seen as IV fluids

continued.

eGFR Need to determine current renal function matched

against baseline to establish whether function has

deteriorated due to dehydration and/or other

factors.

Marker of improving renal function.

Daily

Baseline 31/10 01/11 02/11 02/11

eGFR

(ml/min)

35 22 26 31 32

Comment [AM24]: see note about potassium above

Comment [AM25]: also needed for dose adjustments

Student ID Number:

of 24

Monitoring Plan


Patient had baseline eGFR of 35ml/min (CKD3) but the further

deterioration is indicative of AKI. This was likely caused by

hyperglycaemic dehydration. Nephrotoxic medicine (Ramipril)

held and rehydration with IV NaCl (already administered for HHS)

used to improved renal function.

FBC Raised WBCs can (alongside CRP) be an indicator of

infection. Simple test for anaemia. Platelet levels

required to assess suitability of low molecular

weight heparin (LMWH) therapy.

Daily No abnormality detected (NAD).

INR/PT Routine INR check on admission returned result of

2.1 - patient taking the anticoagulant Rivaroxaban.

Every day

until

returned to

normal.

Rivaroxaban was held on admission and INR soon returned to

normal (1.0 on 2/11/16). It was later established Rivaroxaban is

known to cause erroneous INR readings so Rivaroxaban was

restarted.

Lipid profile Hyperlipidaemia is one of the primary causes of

stroke so needed to establish current medication is

maintaining acceptable levels.

One off. NAD - all lipid levels within acceptable limits.

Liver profile To establish liver function. Especially important as

patient on high dose Atorvastatin which can

effect/be affected by the liver. Also, used to

establish whether hepatic disease could have been

a cause of raised INR.

One off. NAD – Liver enzymes, bilirubin & albumin all within acceptable

limits.

CRP Can be used as an indicator of infection which is

especially important to establish early in acutely

Daily NAD – levels consistently below 10mg/L

Comment [AM26]: INR – a good parameter to monitor NOACs?? - Xa levels? PT/APTT?

Comment [AM27]: doesn't need to be done daily if not suspecting infection/clincal picture does not change also monitor temperature to look for signs of infection

Student ID Number:

of 24

Monitoring Plan


unwell patients.

Glasgow Coma

Score (GCS)

Neurological scale to determine conscious state. Daily NAD.

HbA1c Indicator of long-term glucose control. ONE off. 127mmol/mol. Although this is usually interpreted as two

consecutive results, a reading this high (usual range 20-

41mmol/mol) would allow a confident diagnosis of Type 2

Diabetes. A further test can be performed after 8-12 weeks to

assess control.

Dysphagia screen To establish whether patient has a safe swallow. On

admission.

NAD.

MRSA screen Prevent spread of MRSA infection. One off Swabs of nose and groin both showed nil growth of MRSA.

CT head Rule out Cerebrovascular Accident (CVA) One off Hypodensity right posterior frontal – old/subacute infarct. Small

hypodensity left parietal lobe. Chronic small vessel ischaemia.

Nil acute. Nil haemorrhage.

Comment [AM28]: so the patient did not have a stroke? it was not that clear in the progress notes.

Comment [AM29]: Fluid balance?

Student ID Number:

of 24

D & E . I D E N T I F I C A T I O N O F C L I N I C A L P R O B L E M S A N D A C T I O N P L A N

Analysis of Clinical Problems

Clinical Problem Assessment Priority Action Taken and Outcome

Osmolality/Hypovolaemia Osmolality approx. = 2Na +

glucose + urea.

Hypovolaemia secondary to raised

osmolality.

High Medium Low Rapid changes in osmolality can be harmful so NaCl 0.9%

is recommended to restore volume and reverse

dehydration. Good response to treatment seen and

osmolality reduced.

Hyperglycaemia Blood glucose levels High Medium Low Fluid replacement with NaCl 0.9% will lower glucose

levels and subsequently reduce osmolality. In this

instance (sliding scale) Insulin was started before

adequate fluid replacement which is contrary to current

HHS Diabetes Society guidelines. This was fed back to the

medical team but as the patient was responding

positively therapy was maintained, albeit with constant

monitoring to prevent cardiovascular collapse (as water

moves out of intravascular space). Monitoring showed a

rapid initial drop in glucose levels followed by a more

gradual decrease (except for a small rise when SS insulin

was switched to Novomix). Although glucose levels didn’t

reach the desired range during inpatient stay, they

showed positive improvement with safety nets in place

for continued monitoring/care on discharge.

Stroke risk CT head High Medium Low Aspirin commenced whilst querying stroke. This was

continued even after CT showed ‘nil acute’ due to

continued slurred speech. Once bleed risks ruled out

Comment [AM30]: What was the response/outcome more specifically


Comment [AM32]: did you also feedback that a fixed rate insulin infusion is recommended rather than a variable rate?

Student ID Number:

of 24



(repeat CT and INR fall confirmed) rivaroxaban was

restarted. Aspirin stopped. OPD appointment for carotid

Doppler.

AKI eGFR High Medium Low Although the patient is known to have CKD his

dehydration put further strain on his kidneys resulting in

AKI. The patient was rehydrated with IV fluids and his

nephrotoxic medication was held awaiting return to

baseline renal function. His other regular medication was

also screened for need of AKI adjustment – none

required. Upon sufficient renal function improvement,

Ramipril was restarted with request for GP to recheck

renal function in one week and then monitor.

Raised INR Pathology data. High Medium Low Initially Rivaroxaban was held but further research

established that the INR values are only calibrated and

validated for coumarins and should not be used for any

other anticoagulant (6). Once bleed risk had been ruled-

out, Rivaroxaban was restarted (at prior renal dose). I

also took the time to re-educate the patient on use of

Rivaroxaban including how it can increase the risk of

bleeding and what the warning signs are.

VTE prophylaxis Mobility. eGFR. INR. High Medium Low Enoxaparin was not originally prescribed as

contraindicated when INR > 2.0 (13). Also, needed to

rule out the presence of any bleed using CT. Once these

factors had been addressed enoxaparin was prescribed

Comment [AM33]: was the slurred speech put down to the HHS?

Comment [AM34]: if the patients INR was over 2.0 then enoxaparin still shouldn’t be given. we just don’t dose rivaroxaban/NOACs using INR as theoretically it shouldn’t be affected although in practice you see that it is often raised in patients taking NOACs.

Comment [AM35]: what about the dose of rivaroxaban? did you consider calculating the CrCl?

Comment [AM36]: you have not prioritised; not everything can be high priority

Student ID Number:

of 24



at renal dose of 20mg (13). This was subsequently

ceased on re-introduction of Rivaroxaban.

Comment [AM37]: Other clinical problems: Potassium not given as per guidelines Management of previous MI - why is the patient not taking aspirin, did you investigate? Management of AF - critique the patients management against current guidelines Management of HTN - is the patient on the correct medications as per guidelines taking into account other co-morbidities? Are the targets being met. Management of GORD - how long has the patient been on lansoprazole, could they trial a dose reduction to 15mg daily Intermittent claudication - are they diagnosed with vascular disease? Should they be on an antiplatelet agent for this - were there any clinic letters or just managed by GP? Management of stable angina - this was not mentioned in the patients PMH - are they on the correct treatment for this? What has the patient’s diet been like, are they are a risk of refeeding syndrome?

Student ID Number:

of 24

F . F O L L O W - U P A N D F U T U R E P L A N

Follow Up Plan (including discharge requirements, future planning and ongoing assessments)

Follow Up Requirement Action Taken/Future Plan

Advice on insulin therapy. Provided with advice from both the diabetic specialist nurse and pharmacist including:

Injection technique.

Provision of completed insulin passport.

Discussed significance of insulin brand, dose, timings and missed doses.

What to do if hypoglycaemia (hypo’s) occur.

Sick day rules. For example: keep testing BMs, keep using insulin (may require higher doses), keep

hydrated (and eating where possible), check ketones. Inform medical professional if illness continues.

Storage of insulin.

Monitoring techniques/requirements.

Requirement to inform the DVLA of diagnosis.

Also, raise the likelihood that insulin will be regularly reviewed and when stabilized his GP may change

him over to oral hyperglycaemics.

Reiterate advice on Rivaroxaban therapy. Provision of Rivaroxaban alert card.

How/when to take.

Common side effects.

Comment [AM38]: what advice was

given? Be specific


Student ID Number:

of 24



When to contact health care provider.

Monitoring requirements.

Advice on healthy eating/lifestyle. Recommended to increase amount of vegetables, fish & fibre in diet whilst cutting down on sugar,

processed food, alcohol.

Encourage exercise and weight loss.

Stress importance of flu vaccine.

Advice on avoiding AKI. Patient education:

What is AKI? – aka acute renal failure.

Why is AKI important? – maintain kidney function. Prevent hospital admission.

How to reduce chance of AKI? a) Avoid NSAIDs. b) Sick day rules – if unwell (vomiting, diarrhea, infection)

maintain fluid intake. Avoid alcohol. Temporarily stop taking Ramipril until symptoms settle (if >48hrs

contact GP).

Transfer of care. Ensure all diagnosis are documented on the discharge paperwork as well as making sure they’re

communicated to the patient. Even though there were no changes to the patients’ oral medication a

copy of the discharge prescription was faxed through to the patients’ pharmacy as he was using a blister

pack (on admission) and the pharmacy would need to be aware that the patient may also need a supply

of insulin/needles/lancets/test-strips etc. delivering with his regular medication.

Renal profile GP to monitor patients renal function in relation to recent AKI.

Student ID Number:

of 24



Diabetic review Appointment made in outpatients diabetic clinic in six weeks’ time for review of current therapy to

ensure glycaemic control. Also, as this patient had no previous diagnosis of diabetes, switching from

insulin to an oral hypoglycaemic should be considered after several weeks/months (11)

Diabetic checks Annual eye, foot and kidney screens to manage long term effects of diabetes.

Review in outpatient stroke/TIA clinic. Follow up appointment made for carotid doppler and to discuss (sub-acute) infarct, implications and

treatment/prevention regimes.

Signpost to support groups and other sources of

information.

Diabetes UK; website and membership.

Stroke association; website, helpline.

Local support groups

Comment [AM40]: NMS/MUR

Comment [AM41]: further HbA1c monitoring? BP control? how often and what targets

Student ID Number:

of 24

G . C O N T I N U I N G P R O F E S S I O N A L D E V E L O P M E N T

Learning Plan

Learning Need Identified Action Taken Completion Date

Review Diabetic policy re : HHS protocol. Read current Trust policies on Diabetic emergencies such as DKA and HHS to

ensure there are clearly defined treatment pathways for the separate

conditions. Discuss with diabetic team and emergency care pharmacist as

appropriate.

31/12/2016

Research regarding mechanism of action of

current anticoagulants and interpretation of

relevant data.

Further research required in to how NOACs effect pathology data and how this

should be interpreted. I can speak to our Medicines Information Pharmacist

and may also need to source articles and speak to relevant manufacturers.

31/12/2016

I would like to find out about the different types

of stroke/TIA; how they are diagnosed (i.e. How

to interpret imaging data) and what the different

outcomes are.

Discuss with Stroke Pharmacist.

Visit Stroke ward to shadow/speak to specialist health care providers.

Review imaging data.

31/01/2017

I would like to find out how Dysphagia is assessed. Discuss/liaise with ward dieticians and (with consent) witness an assessment

taking place.

31/01/2017

Comment [AM42]: CPD cycle?

Student ID Number:

of 24

H . E V I D E N C E A N D R E F E R E N C E S

Reference List

1. National Institute for Health and Care Excellence (NICE). NICE Clinical Guidelines CG172. Myocardial Infarction: cardiac rehabilitation and prevention

of further cardiovascular disease. November 2013.

2. British National Formulary (BNF) 72. British Medical Association and The Royal Pharmaceutical Society. 2016.

3. National Institute for Health and Care Excellence (NICE). NICE Clinical Guidelines CG126. Stable angina: management. August 2016.

4. National Institute for Health and Care Excellence (NICE). NICE Clinical Guidelines CG184. Gastro-oesophageal reflux disease and dyspepsia in adults:

investigation and management. November 2014.

5. National Institute for Health and Care Excellence (NICE). NICE Clinical Guidelines CG180. Atrial fibrillation: management. August 2014.

6. Bayer plc. Summary of Product Characteristics: Xarelto® 15mg tablets. Available at: https://www.medicines.org.uk/emc/medicine/25592 (Accessed

15th December 2016).

7. National Patient Safety Agency Alert PSA003: The adult patients passport to safer use of insulin. March 2011.

8. National Institute for Health and Care Excellence (NICE). NICE Clinical Guidelines CG68. Stroke and transient ischaemic attack in over 16s: diagnosis

and initial management. July 2008.

9. Novo Nordisk Ltd. Summary of Product Characters: NovoMix 30 Flexpen. Available at: https://www.medicines.org.uk/emc/medicine/8591 (Accessed


10. Novo Nordisk Ltd. Summary of Product Characters: Novorapid Flexpen. Available at: https://www.medicines.org.uk/emc/medicine/25033 (Accessed

Comment [AM43]: although well referenced, you don’t always critique management against guidelines well

https://www.medicines.org.uk/emc/medicine/25592



Student ID Number:

of 24

Reference List


11. Joint British Diabetes Societies Inpatient Care Group: The management of the hyperosmolar hyperglycaemic state (HHS) in adults with diabetes.

(August 2012)

12. Diabetes UK Council of Healthcare Professionals (CHP). Available at: https://www.diabetes.org.uk/Guide-to-diabetes/Managing-your-

diabetes/Testing/ (Accessed 15/12/2016).

13. Pennine Acute Hospitals NHS Trust. Policy for the prevention of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in

patients 18years of age and over admitted to hospital. Version 3.1. April 2016.

https://www.diabetes.org.uk/Guide-to-diabetes/Managing-your-diabetes/Testing/

https://www.diabetes.org.uk/Guide-to-diabetes/Managing-your-diabetes/Testing/

Student ID Number:

of 24

I . P R O F E S S I O N A L F R A M E W O R K M A P P I N G

RPS Foundation Framework

Cluster 1 Patient and Pharmaceutical

Care

Cluster 2 Professional Practice Cluster 3 Personal Practice Cluster 4 Management and

Organisation

1.1 Patient Consultation 1.2 Need for Medicine 1.3 Provision of Medicine 1.4 Selection of Medicine 1.5 Medicine Specific Issues 1.6 Medicines Information and

Patient Education 1.7 Monitoring Medicine Therapy 1.8 Evaluation of Outcomes 1.9 Transfer of Care

2.1 Professionalism 2.2 Organisation 2.3 Effective Communication Skills

2.4 Team Work 2.5 Education and Training

3.1 Gathering Information 3.2 Knowledge 3.3 Analysing Information 3.4 Providing Information 3.5 Follow Up 3.6 Research and Evaluation

4.1 Clinical Governance 4.2 Service Provision 4.3 Organisations 4.4 Budget and Reimbursement 4.5 Procurement 4.6 Staff Management

Student ID Number:

of 24

A P P E N D I X

Submitted as separate file.

MARKER 1 This was a complicated patient with multiple co-morbidities and management of HHS which was not as per guidelines. Although elements of this deviation were briefly mentioned I would expect over all a more detailed critique of all aspects of the patients management and a more holistic approach. The follow up section was on the whole good but again lacked some detail. Please see comments on the submission for more information. Background and medication list: 2 Progress notes and changes: 3 Monitoring: 3 Identification of issues: 2 Action: 3 Follow-up: 3 CPD: 4 Evidence: 2 55% MARKER 2

This a complicated and complex patient which you seem to manage well. You tackle the PC well, but this takes the main focus away from the wider co-morbidities. You must compare new treatments with guidelines and evaluate the rationale. Background and medication list: 3 Progress notes and changes: 3 Monitoring: 3 Identification of issues: 2 Action: 3 Follow-up: 4 CPD: 4 Evidence: 3 62.5% OVERALL MARK: 58.75