Opener a. Introduce yourselves as a team of student pharmacists and then each say your name b. “How would you like us to address you?” c. “Do you have a preferred name and/or pronouns?”
II. Chief Complaint
a. “What brings you in today?” i. Urinary Incontinence ii. Dementia (she probably won’t tell us) iii. Insomnia
III. History of Present Illness – Urinary Incontinence (Amanda)
a. Have you been experiencing any leakage or accidents?
b. How long has this been occurring? c. How would you describe the symptoms? (ASK these: any Pain, burning, back pain, changes in color of urine, urgency to go?) d. Do you experience urinary leakage when you cough, sneeze, or laugh? e. Do you wake up during the night often to urinate? How does that affect your sleep? f. Is there a certain time in the day where it gets worse or better? g. What treatments have you tried? h. Have you had these symptoms before?
IV. History of Present Illness – Insomnia/Dementia (I feel like we can tie this together) (Caitlin) a. Can you tell me about your day-to-day routine? What kinds of things do you do during the day? b. Do you feel fatigued or drowsy during the day? c. How has your sleep been lately? Do you find it hard to fall or stay asleep? d. How long does it usually take you to fall asleep at night?" e. How many hours of sleep do you get at night? f. How long has this been going on? g. What treatments have you tried? V. Review of Systems – Can be Yes/No questions (Amanda) a. Gen: Fever? Fatigue? Changes in energy level? Changes in appetite? Difficulty concentrating?
b. HEENT: Headaches? Vision changes?
c. Resp: Cough? Shortness of breath? Difficulty breathing? Wheezing? Phlegm or
mucous? Chest tightness? Changes in exercise capacity?
d. CV: Palpitations? Fainting? Chest pain?
e. GI: Diarrhea? Abdominal pain? Nausea? Vomiting? Heartburn?
f. Extremities: Swelling? Joint pain? Arthritis?
g. Skin: Rashes? Dryness? Bruises?
h. Neuro: Dizziness? Confusion? Forgetfulness?
VI. Medical History (Caitlin)
a. What (other) (medical) conditions do you have if any? b. Have you had any previous surgeries? c. How often do you see your primary care doctor? d. What specialists do you see if any? e. How often do you test your blood sugar? What is your usual reading? f. How often do you check your blood pressure? What is your usual reading?
VII. Family History (Caitlin)
a. Are there any medical conditions that you know about that run in your family? b. Do you have any siblings? c. What medical conditions did/do your siblings have? VIII. Medication/Vaccine History? (Amanda) a. “What medications are you currently taking?” (We have her list, we might need to go over it with her, because of the dementia)
Medication Dosage Frequency Indication
Lisinopril (Zestril) 10 mg Daily Hypertension Circle pink
Amlodipine (Norvasc) 10 mg Daily Hypertension Circle
white
Aspirin 81 mg Daily Pain Circle
yellow
Apixaban (Eliquis) 2.5 mg Twice Anticoagulati Circle
Daily on yellow
Carvedilol (Coreg) 25 mg Twice Heart Failure Football
Glimepiride (Amaryl) 2 mg Daily Diabetes Green oval
Insulin Glargine (Lantus) 30 units QHS Diabetes Gray/
purple pen
Albuterol (ProAir HFA) 0.09 QID Asthma/COP Red
mg/actuation D inhaler
Tiotropium (Spiriva 2.5 mcg Daily COPD Green gray
Respimat) container
Fluticasone/Vilanterol 100 mcg/25 Daily Asthma/COP Blue
(Breo Ellipta) mcg D container
Paroxetine (Paxil) 20 mg Daily Depression Circle
white
Diazepam (Valium) 5 mg Twice Anxiety yellow/
Daily orange circle Acetaminophen/Diphenhy 500 mg/25 mg Q PM Pain Blue dramine (Tylenol PM)
Oxybutynin (Ditropan) 10 mg Daily Overactive Pink circle
Bladder
Calcium 2000 units Daily Osteoporosis Big
Carbonate/Vitamin D3 pink/white (Caltrate) tablet
Esomeprazole (Nexium) 20 mg Daily GERD Purple
capsule
b. What do you take your___________ for?
c. What side effects are you experiencing, if any? d. What over the counter medications do you use either regularly or as needed? e. What herbal supplements or vitamins do you use? f. Do you know if you are up to date on all your vaccinations? g. What allergies do you have to medications, foods or supplements? h. Have you ever had a bad reaction to your medication(s)? i. What barriers do you have to accessing your medications? j. Everyone misses medication doses from time to time, in a typical week how many medication doses do you estimate you might miss? IX. Social History (let them know they can skip any questions that make them uncomfortable) (Caitlin)
a. What is your current living situation? (may need to prompt further – living alone, living with a partner, have a caregiver) b. How do you feel about tasks, like cooking a meal or paying bills? Is it easy to keep track of what needs to be done next? c. Do you have any dietary restrictions? d. How often do you get in physical activity or exercise? e. What types of physical activity do you enjoy? f. Do you have any pets at home? g. Do you use any adaptive equipment, such as a cane or walker? h. Do you smoke? i. How often do you have alcoholic beverages? (if yes get details) j. Do you have any concerns with taking medications or receiving vaccines?
