8.1 Clinical Assessment & Patient History

Clinical Assessment and the Pharmacists' Patient Care Process

The Pharmacists' Patient Care Process (PPCP) provides a consistent framework for delivering patient care: Collect, Assess, Plan, Implement, and Follow-up: Monitor and Evaluate. The foundation of this process lies in the initial clinical assessment and patient history. This requires a systematic approach to gathering subjective and objective information to fully understand the patient's clinical status and medication-related needs.

Subjective vs. Objective Evaluation

Clinical data is traditionally divided into subjective and objective components, forming the basis of the SOAP note format.

Subjective Data: Information provided by the patient, family members, or caregivers. It cannot be directly measured or independently verified by the clinician.

• Chief Complaint (CC): The primary reason for seeking care, typically recorded in the patient's own words.
• History of Present Illness (HPI): A chronological description of the progression of the patient's present illness. The PQRST mnemonic is frequently used for pain or symptom assessment:
  • Provocative/Palliative factors
  • Quality (e.g., sharp, dull, burning)
  • Region/Radiation
  • Severity (scale 1-10)
  • Temporal characteristics (onset, duration, frequency)
• Past Medical History (PMH) and Surgical History
• Social History (SH): Tobacco use (quantified in pack-years), alcohol intake, illicit drug use, occupation, diet, exercise, and living situation.
• Family History (FH): First-degree relatives' medical conditions (e.g., premature cardiovascular disease, diabetes, malignancies) to assess genetic risk.
• Review of Systems (ROS): A systematic inquiry to identify symptoms not related to the primary problem.

Objective Data: Information observed or measured by the clinician or obtained through diagnostic testing.

• Vital Signs: Blood pressure, heart rate, respiratory rate, temperature, oxygen saturation, and pain score (sometimes considered subjective, but often tracked with vitals).
• Physical Examination Findings: Objective signs elicited through inspection, palpation, percussion, and auscultation.
• Laboratory Results: Comprehensive metabolic panel (CMP), complete blood count (CBC), lipid panel, thyroid function, etc.
• Diagnostic Tests: Electrocardiogram (ECG), chest X-ray (CXR), echocardiogram, imaging studies.

The Physical Examination in Pharmacotherapy

While pharmacists do not perform comprehensive physical exams, targeted physical assessments are increasingly important for evaluating drug efficacy and toxicity.

Medication History and Reconciliation

A comprehensive medication history is far more than a list of active prescriptions. It is a critical investigative process.

1. Prescription Medications: Include drug name, dose, route, frequency, and indication. Verify adherence (e.g., "How many times in the last week have you missed a dose?").
2. Over-the-Counter (OTC) Medications: Specifically ask about NSAIDs (risk of GI bleed, AKI, hypertension), antihistamines (anticholinergic effects), and antacids/PPIs (drug interactions, e.g., decreasing absorption of iron or itraconazole).
3. Dietary Supplements and Herbal Products: Often omitted by patients. Identify potential interactions (e.g., St. John's Wort is a potent CYP3A4 inducer and decreases levels of oral contraceptives and statins; Ginkgo biloba increases bleeding risk).
4. Previous Adverse Drug Reactions (ADRs) and Allergies: Differentiate between true IgE-mediated anaphylactic allergies (hives, wheezing, angioedema) and intolerances or side effects (e.g., GI upset from codeine). This directly impacts future prescribing options.

Geriatric Assessment and the Beers Criteria

Clinical assessment in older adults (≥ 65 years) requires specific considerations due to altered pharmacokinetics, pharmacodynamics, and increased vulnerability to adverse effects. The American Geriatrics Society (AGS) Beers Criteria is a critical tool for identifying potentially inappropriate medications (PIMs).

Key Beers Criteria categories include:

• Medications to avoid in most older adults: First-generation antihistamines (highly anticholinergic, risk of confusion and falls); long-acting benzodiazepines (e.g., diazepam, flurazepam) due to prolonged half-life and fall risk; skeletal muscle relaxants (e.g., cyclobenzaprine, carisoprodol).
• Medications to avoid in older adults with specific diseases/syndromes: NSAIDs in heart failure (promote fluid retention); anticholinergics in dementia (exacerbate cognitive decline).
• Medications to use with caution: Aspirin for primary prevention in adults ≥70 years (increased bleeding risk); dabigatran in patients ≥75 years (higher risk of GI bleeding compared to warfarin and other DOACs).
• Drug-drug interactions to avoid: Concomitant use of multiple CNS-active drugs (e.g., opioids + benzodiazepines + gabapentinoids) significantly increases the risk of falls, cognitive impairment, and respiratory depression.

During assessment, the pharmacist must proactively identify "prescribing cascades," where a new medication is prescribed to treat an unrecognised adverse effect of another medication (e.g., prescribing a Parkinson's disease medication like benztropine to treat extrapyramidal symptoms caused by metoclopramide, rather than simply discontinuing the offending metoclopramide).