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Responding to a request for help with
symptoms
• 1 Information gathering
• 2 Decision making
• 3 Treatment
• 4 Outcome
Responding to a request for a named
product
• an expert or a novice user
• The pharmacy patient medication records
(PMRs) are a source of back-up information
for regular customers
 Structuring the consultation
• W – Who is the patient and what are the
symptoms?
• H – How long have the symptoms been
present?
• A – Action taken?
• M – Medication being taken?
 The second mnemonic, ASMETHOD,
was developed by Derek
Balon, a community pharmacist in
London:
• A – Age and appearance
• S – Self or someone else
• M – Medication
• E – Extra medicines
• T – Time persisting
• H – History
• O – Other symptoms
• D – Danger symptoms.
 Outcome
• Resolved
• The patient's desired goals of therapy have been successfully achieved,
and drug therapy can be discontinued. The use of the term resolved is
intended to represent a final positive patient outcome, and is most often
applicable to acute medical conditions or illnesses. The action taken, in
this case discontinuing the drug therapy, should be documented in your
patient's pharmaceutical care records along with the clinical and/or
laboratory evidence of the positive outcome.
• Example Consider the case of a successful treatment of a community
acquired pneumonia in a 53-year male patient with a 10-day course of oral
erythromycin therapy at a dosage of 500 mg four times each day. By the
end of the 10 days of antibiotics, the patient's temperature is back to
normal, he has stopped coughing, his white blood count is no longer
elevated, and the infiltrates originally seen on his chest x ray have cleared.
He does not require any further antibiotics past the original 10-day course
of treatment. No additional follow-up is needed as his pneumonia has
resolved.
• Stable
• The patient's goals of therapy have been achieved, and the same drug
therapy will be continued to optimally manage the patient's chronic
disease. This is most frequently the case when drug therapy is used to
treat or prevent a chronic medical condition or illness. In these cases,
stabilizing the patient's clinical condition and/or improving laboratory test
results were the predetermined desired goals.
• Example In order to stabilize a 63 year old female patient's blood pressure
within a desired range of 110–120/70–80 within 2 months the practitioner
initiates pharmacotherapy with 50 mg of hydrochlorothiazide every
morning, a sodium restricted diet, and a low impact exercise program. At
the 60-day follow-up evaluation, the patient's blood pressure was 112/80
and her hypertension was judged to be stable and no changes in
hydrochlorothiazide dosage regimen were made. The next follow-up
evaluation might be planned to occur in 90 days to reevaluate the
continued success of the entire care plan.
• Improved
• Measurable progress is being realized in achieving the patient's
goals of therapy. Goals have not been completely achieved at this
time; however, no changes in drug therapy will be implemented at
this time because more time will be required to observe the full
benefit from this drug regimen.
• Example Consider a 55-year-old male patient whose depressive
signs and symptoms such as loss of energy and disturbances in
sleep and eating patterns have improved following an initial 3
weeks of drug therapy with 100 mg daily of the antidepressant drug
sertraline (Zoloft). Although his depressed mood and ability to
concentrate have still not fully responded, no changes in his dosage
regimen will be instituted at this time. In this case, an additional
follow-up evaluation would be scheduled for 4 weeks.
• Partial Improvement
• The evaluation indicates that some positive progress is being made
in achieving the patient's goals of therapy, but adjustments in drug
therapy are necessary at this time in order to fully meet all of the
goals of therapy by the next scheduled follow-up evaluation.
• Example A 47-year-old female patient whose arthritic pain has
been somewhat relieved following 2 weeks of therapy with
ketoprofen (Orudis) 12.5 mg four times daily, desires additional
relief from her discomfort. The practitioner's evaluation indicates
that greater effectiveness might be realized by increasing the total
daily dosage of ketoprofen to 75 mg taken as 25 mg three times
daily. The next follow-up evaluation is scheduled to occur in two
more weeks to determine if this adjustment in the dosage regimen
of the nonsteroidal anti-inflammatory medication produces
continued and/or additional relief for the patient without
intolerable stomach irritation, headache, or fluid retention.
• Unimproved
• The practitioner's clinical evaluation is that, to date, little or no positive progress
has been made in achieving the patient's goals of therapy, but further
improvement is still anticipated given more time. Therefore, the patient's care plan
will not be altered at this time. Thus, the unimproved status evaluation is
dependent on the timing of the follow-up evaluation.
• Example An adult male patient who is allergic to penicillin is started on
erythromycin 250 mg orally four times a day for the treatment of a localized soft
tissue infection following a work-related injury to the right forearm. Twenty-four
hours after initiating erythromycin therapy the patient experiences some nausea
from the antibiotic, and the injured area on the arm is still inflamed and slightly
swollen. The practitioner reassures the patient about the nausea and provides him
with a suggestion as to how to minimize this undesirable side effect commonly
associated with erythromycin, and documents an evaluation of the current
effectiveness of therapy. The practitioner reports that although the arm is
unimproved at this early stage in therapy, no dosage changes are indicated, and
that 3–5 days would be an appropriate time to make another evaluation of the
potential effectiveness of the erythromycin therapy.
• Worsened
• The practitioner's evaluation describes a decline in the health of the patient
despite an adequate therapeutic trial using the best possible drug therapy for this
individual. Because the goals of therapy are not being achieved, changes in the
patient's drug therapies are necessary at this time. The drug dosage may need to
be increased and/or additive or synergistic drug therapies might need to be added.
A future follow-up evaluation should be planned to examine the status of the
patient's condition once the changes in the care plan have been instituted.
• Example A 17-year-old athlete whose elbow stiffness and muscle pain have
progressively become more bothersome over the past 4 days despite the use of
acetaminophen 325 mg three times each day and ice packs. This worsening
condition might call for increasing the acetaminophen dosage and/or adding a
topical analgesic such as capsicum. Two days after increasing the acetaminophen
dosage to 1000 mg three times a day and adding topical capsicum, the practitioner
would follow-up again to determine the effectiveness in reducing the pain and
stiffness in this varsity athlete.
• Failure
• The practitioner's evaluation indicates that the present care plan
and associated drug therapies have been given at adequate dosages
and for an adequate amount of time, yet they have failed to help
the patient achieve the goals of therapy. Therefore, the present
therapy should be discontinued and alternate pharmacotherapy
initiated. In these situations, the desired outcomes have not been
realized and the initial treatment is considered to have failed.
• Example A 37-year-old female patient whose symptoms of seasonal
allergic rhinitis have not improved with 2 weeks of
chlorpheniramine therapy at 24 mg per day. Therefore, it will be
discontinued, and new drug therapy initiated such as loratadine
(Claritin) 10 mg daily. The next follow-up evaluation is planned in 5
days to examine the effectiveness of loratadine in controlling the
patient's symptoms of rhinitis.
• Expired
• The fact that the patient dies while receiving
drug therapy is documented in the
pharmaceutical care record. Any important
observations about contributing factors,
especially if they are drug-related, should be
noted