SUMMARY OF OSCE CASES The Pharmacy Examining Board of Canada

*************November 2003

Case 1. A father of a child come to your pharmacy asking for hydrocortisonecream because his child have diaper rash. (No patient profile)

Case 2. A young lady come to the pharmacy asking for canesten cream for fungal infection. (No patient profile)

Case 3. An old lady about 65 yrs. old come to the pharmacy complaining of dry cough. She is one of your regular customer. Her profile include the following for her hypertension: 1. hydrochlorothiazide (5 years) 2. enalapril ( 3 weeks)

Case 4. A patient about 45 yrs. old come to your pharmacy to drop his new prescription for prednisone 20mg, once daily for 5 days. He have some concerns about the prednisone. The patient profile include: 1. Flovent 125mcg 1 puff BID 2. Ventolin Inhaler 1-2 puffs QID prn

Case 5. A healthy muscular young man about 25 yrs. old come to your pharmacy requesting syringe 3 cc. No patient profile. How are you going to handle the situation?

Case 6. A 25-30 y.o. healthy patient (lady) come to your pharmacy. She lookstired and dizzy. She complains that since she refilled her medication a week ago, she always feel drowsy, tired and dizzy. Profile include only Loxapine 5mg tablet. Counsel her.

Case 7. A physician come to your pharmacy asking you about what could bethe most suitable oral preparation for his patient. Patient profile include: 1. HCTZ 2. KCL 3. Enteric coated ASAHe is asking for forms of this medication. What will be your recommendation?

Case 8. Non-interactiveYou received 5 prescriptions. Verify, identify the problem & your recommendation. 1. Uniphyl tab. 600mg 2 tabs. TID 2. Famcyclovir 125mg tab. 1 tablet daily for 7 days. 3. Mevacor tablet 1 tab. once daily HS 4. Flovent 125 ug ii puffs BID 5. Pulmicort 400ug i puff BID

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Case 9. Non-interactiveYou are give 5 prescriptions, 5 vials, 5 original bottles prepared by technician.Read, verify and check correctness.Recommend some corrections if any.

Case 10. Assessor and PhysicianA prescription for Carbamazepine 200mg TID for trigeminal neuralgia. Patient profile contain Tylenol#3. You have to discuss with the physician the case, thedose and the course of treatment.

Case 11. A patient have diabetes (type 1) and is using Insulin. She is going toArizona where the temp. reach 40 degree celsius. She is asking about how to store her insulin. Counsel the patient regarding proper handling of her meds. Patient profile include: 1. Humulin regular 2. Humulin NPH 3. Glucotest

Case 12. A patient 50 y.o. have angina. His doctor prescribed him Nitroglycerin patches. He wants to know more about it. Patient profile include:1. Nitroglycerin Spray PRN. Should he continue using the spray? Counselling.

Case13. A 35 y.o. lady complaining that her 2 kids have head lice. She needs treatment for her kids ages are 9-12 y.o. Provided: Nix cream rinse 1% Kwellada shampoo R & S 5%Counsel the patient/s.

Case 14. A 35 y.o. lady complaining of heartburn. Profile include: 1. Tamoxifen 2. Naproxen

Case 15. Non-interactiveAsthmatic patient dropped a new prescription. The prescription is for propranolol 40mg BID. Patient profile: 1. Flovent 2. SalbutamolVerify the prescription. Inform the patient regarding drug interaction and record it on the sheet provided in the station.Record your recommendation on how to remedy the drug interaction.

Case 16. A 30 y.o. lady come to your pharmacy looking tires and light-headed. She is having migraine and was using Imitrex and Tylenol#3. Now she has a baby and is breastfeeding. Counsel the patient regarding what she needs to know about her medications, its efffect on breastfeeding.

GOODLUCK!!!!!!

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************May 2003

Case 1. Non-interactive. 5 prescriptions + answer sheet. Choose either to dispense each prescription, or there is a problem and your suggestions. Make sure that you perform the 7 point check to assure correctness. Don't forget toopen each container to check that the contents are correct.

Case 2. Patient with parkinson's disease. Profile provided + CPS, Rx, a copy ofdrug interaction. Patient profile include: Sinemet, Selegeline & Tylenol#3. He comes to pick up his prescription for meperidine (demerol). Discuss with the patient the interaction between meperidine and selegeline. You may look at the CPS for info. regarding interaction. Convince the patient why not to take it.

Case 3. A young woman comes to pick up her refill of Prozac & asking how it may affect her baby as she is pregnant. You are provided with the following: CPS, patient profile (includes Fluoxetine; Materna), a copy of drug risk in pregnancy. Her doctor doesn't know that she is pregnant. Look up the effect of this medication on the fetus. Advice her to see the doctor and ask him if she should stop the medication or reduce the dose, as you'll find that it's under category C (contra-indicated to pregnancy). Therefore the doctor should weigh the benefits versus risks.

Case 4. A lady over 50 y.o. complaining of heartburn. You are provided with CPS, patient profile (Fosamax a week ago), some antacids. Ask usual questions about heartburn, gather as much information as you neeed. Upon gathering info., you found out that her symptoms started about a week ago and that she lies down after taking it in the morning. Counsel her about the proper way of taking Fosamax and its side effects if not taken properly. Check blue pages of CPS. Note: don't give her antacids.....you should know why.

Case 5. A man in his 40's complaining of heart pounding. Patient profile: Ramipril & Lovastatin for one year and Nicotine patches a week ago. While gathering info., you found out that he smokes sometimes. Counsel him about how the patch works, nicotine overdosage and the proper use of the patch. (Consult blue pages of CPS)

Case 6. Non-interactive. You are provided with: CPS, prescription for clarithromycin and the patient profile. (Warfarin, Digoxin & Simvastatin w/c are discontinued a month ago). On the answer sheet, explain the interaction between Clarithromycin and warfarin, digoxin and simvastatin. State the problem, intervention needed (lab. monitoring of the blood), effects, etc.,etc.

Case 7. A woman come to your pharmacy asking for canesten for her yeast

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infection. It was her 1st time to use canesten. Gather info. Ask if she has vaginal discharge. If patient says yes, and the discharge is grayish with foul odor, advice her to see a doctor to find out what kind of infection and the medication/s to be used. Check if she has other medical condition, taking other medications ( Rx, OTC or herbals), have any allergies?, and other symptoms (fever, abdominal pain...). Counsel her on non-pharmacological measures she can take.

Case 8. A young man complaining from stuffy nose. He used a decongestant spray for a while but it didn't help. Upon gathering info., you found out that he has no other symptoms that indicate flu or colds (fever, runny nose, cough, aches) He is healthy , no medical condition, not taking any medications (OTC, herbals) no allergies (pollen, animal dander.....) Counsel him about the situation w/c appears to be rebound congestion due to the prolonged used of nasal spray.

Case 9. A nurse came to pick up a prescription for Nix 1% for an old lady with head lice. Patient profile shows she had Nix 1% four days ago. Don't dispense the prescription. Advice the nurse to tell patient to wait from 7-10 days beforea second application and only if she still have them. Can still use the narrow toothed comb for picking nits. Advise her on non-pharmacological measures.

Case 10. No patient. The station is provide with: CPS, Therapeutic Choices, patient profile, a prescription (with an empty space to indicate the problem and alternative). The assessor is the prescribing doctor. Rx was for H. pylori treatment (Amoxicillin, Clarithromycin, Losec). Patient profile tells that he is allergic to penicillin. Discuss the problem with the doctor and suggest an alternative. After consulting the T.C., you found out that the other alternative is Metronidazole instead of Amoxicillin. Discuss the concentration, dose, and treatment period for each medicine in the system. Write it all down in the space next to Rx.

Case 11. Old lady. Patient profile: Ipratropium Inh., Ventolin Inh., for her COPD, Nitroglycerin spray for angina. Her doctor advise her to take a flu shot.The lady is worried it will make her get a flu or be contagious to her grandchildren whom she is living with. Explain to her the benefits of getting aflu shot. Tell her that it won't give her a flu and that it should be taken every year (in Oct. or Nov.) When you have eased up her concerns, counsel her on the proper use of her inhalers.

Case 12. Non-interactive. Station is provided with: CPS, Th.Choices, patient profile, Rx for clarithromycin for pneumonia (fax Rx). In his profile, you found out that he is allergic to Erythromycin. Check the Th. Choices for the alternative with same mech. of action (e.g.: Doxicycline (both act on protein synthesis), write down the problem, suggest changes, name and dose of alternative and the no. of days treatment accdg. to Th. Choices.

Case 13. An old man came to pick up his refill of Lorazepam. Profile tells you that about 16 days ago, he got 30 tabs. of lorazepam taken 1 tab. before

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bedtime. Doctor gave one refill at 30 day interval. Patient says i tablet is not working that's why he is taking 2 tabs. now he ran out of it. He drinks coffee after dinner. Don't release the refill. Verify with doctor or refer patient to walk in clinic. Explain to him how lorazepam may be causing addiction and advise him to lower coffee consumption especially at night.

Case 14. A lady concerned about her 2 yr. old son who have fever, 39.5. No other symptoms, no allergy, no medicla condition. Provided: Tylenol, Advil, Aspirin. Advice to see a doctor if symptoms persists.

Case 15. A young woman is concerned about her diabetic friend who is actingfunny. She is breathing in a troubled manner, her mouth smells strange, thirsty, urinates a lot and is taking her insulin but didn't take it for a couple ofdays for some reason. Advise her to go to the emergency as these are symptoms that her blood sugar level is very high.

Case 16. A lady comes to drop off a prescription of her husband for Atorvastatin. Station provided with: CPS, Rx written by a dentist (the wife),patient profile (anti-hypertensive and lipitor, atorvastatin (no refill)) Don't release the lipitor w/o Rx. Refer to walk in or fasmily doctor. Dentist can't prescribe Atorvastatin, it's not her specialty.)

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May 2002

Case 1. A 65 y.o. male patient come to your pharmacy with a new prescription for Nitroglycerin patch (Nitrodur). His profile shows that he has been using Nitroglycerin Spray (Nitro Pump). Counsel the patient regarding the proper use of his medication.

Case 2. A lady asking you how to use the Aerochamber for her son. Upon gathering information, you found out that the patient is also taking as maintenance, Flovent and Ventolin. As the pharmacist, counsel the mother onthe proper use of her son's medications. You should stress that the Ventolin will be used first before the Flovent. Explain why.

Case 3. An old lady complaining of dry cough. Checking her profile, you found out that she is on Enalapril (Vasotec) since three weeks. The patient is using Benylin DM for 3 days now w/o improvement. Counsel the patient. Suggest to see her doctor to prescribe alternative antihypertensive. Ace inhibitor such as Enalapril can cause dry cough.

Case 4. A 30 y.o. healthy man comes to the pharmacy to ask you how to store his insulin. Patient will be going on a trip in a tropical country. Inform him on the proper handling/storage of his insulin.

Case 5. A physician come to the pharmacy asking you if he can prescribe Carbamazepine to his patient who is on Warfarin. Explain about

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Carbamazepine being a Cytochrome inducer and how it will decrease INR of his patient.

Case 6. A breastfeeding mother asking you if she can take Imitrex for her migraine. She is also on Tylenol#3. Counsel her regarding the effects of Imitrex (Note: under category C). Check CPS. Suggest that she has to stop breastfeeding for 24 hrs. after taking Imitrex. She may take just the Extra Strength Tylenol.

Case 7. 50 year old lady dropping a new prescription for Lorazepam. Upon checking her profile, you learned that she just filled Lorazepam several days ago. Counsel the patient regarding the addictive effect of the medication. Suggest to avoid drinking coffee especially before going to bed. Suggest proper sleep hygiene.

Case 8. You are the chief pharmacist of the store and a lady comes to you complaining of being so drowsy and sleepy after refilling her prescription. Upon checking, you find no problem on the prescription and the label, but after opening the vial, you found out a different imprint on the medication. This is a dispensing error. Apologize and perform the necessary action regarding this situation.

Case 9. A young man asking about a hydrocortisone cream for his son's diaper rash. Checking the patient profile, you learned that the patient has used ZnO cream twice in the previous attacks, but this time, it didn't work. Gather more info. regarding the rash. Suggest other non-pharmacological management...consult doctor if symptoms persist.

Case 10. A doctor asking you if he could put his patient who has just had a kidney transplant, on Nefazodone for his depression. Patient profile includes: Azathioprine, Cyclosporine and Prednisolone. Upon checking the CPS, you willfind out that Nefazodone is an enzyme inhibitor thus, it will increase the plasma Cyclosporine level. Elaborate.

Case 11. A cancer patient complaining of burning sensation in her stomach. Profile shows she is on Tamoxifen, Indomethacin and Maalox. Counsel the patient regarding proper intake of Indomethacin. It should be taken p.c. and w/ full glass of water. Elaborate. (remember..you have seven (7) minutes!!!)

Case 12. Non interactive. Youo are given five prescriptions. Perform 7 point check. Name of patient, Name of medication, strength, quantity, signa, refill, name of doctor.

Case 13. Non interactive. The station is provided with some documents. One is a letter from Bayer company regarding Baycol, warning statement from Health Canada about Baycol + Gemfibrozil and a prescription for BAycol

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along with Niacin. You will be asked to answer 3 questions. Write your answer on the answer sheet. a. Reason why Baycol is withdrawn from the market. b. What do you suggest as alternative. c. How you will monitor the patient?

Case 14. A man come to the pharmacy claiming to be an inspector. He is asking for a patient profile apparently as court order against the patient. As pharmacist what should you do on this situation. Pls. refer on the notes.

Case 15. A 9 yr.old boy taking Accolate as prophylaxis for asthma. As the pharmacist, is it right for this boy to take Accolate? Check CPS for contraindication.

Case 16. Five prescriptions filled by technician. Check correctness.

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November 2002

Case 1. Non interactive. You are to check 3 prescriptions. Check correctness before you released.

Case 2. Patient with Ileostomy is prescribed with Erythromycin tablet. Counselling.

Case 3. A man come to the pharmacy asking you if he can take garlic for his cholesterol. Counsel him.

Case 4. Prescription for Plendil while still on Hydrochlorothiazide. This is a straight forward counselling.

Case 5. You are the pharmacy manager and one day you overheard one of your staff pharmacist recommending imodium for a 2 y.o. girl for her diarrhea.Manage the situation.

Case 6. Doctor prescribed Ciprofloxacin to 8 y.o. child. Patient profile: Ventolin, Budesonide inhaler. Identify the problem if there is any. Establish clinical significance of the treatment.

Case 7. A patient has a new prescription for Cortenema. Ask you what he needs to know about it.

Case 8. An agitated mother come to your pharmacy asking your help for her daughter who is having earache for almost 2 days. Counselling.

Case 9. Non-interactive. Check 3 prescriptions: Famcyclovir for vaginal warts,Celexa, and cannot remember the last one. Write down answers on the

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answer sheet regarding what you need to know about the medications.

Case 10. Prescription for Naproxen written by a doctor from another province. Patient profile includes Advil

Case 11. Patient is prescribed Propranolol for her migraine. Profile: Epipen, Ventolin Inhaler. Counselling.

Case 12. A senior using Tylenol for arthritic pain. Profile: Losec, Antacid. She is still in pain. What will you recommend?

Case 13. A patient is taking Metformin, Glyburide, HCTZ, Xenical, Altace. Sheis confuse as to how to use them. Help the patient.

Case 14. A doctor calls for a repeat for Mr. X who has been using HCTZ for 6 months. The technician took the call. Is it right or not? Station is provided with federal laws but in symbols...

Case 15. A patient come to the pharmacy to buy Maalox for his upset stomach. He has been using Metformin. Counsel the patient.

Case 16. Patient is using Tylenol, Cotrimoxazole and Warfarin. Straight forward counselling on this.

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May 2001

Case 1. You work in a pharmacy that is located in a remote area. You received a prescription for Ciproflaxacin 500mg. The problem is, all forms of Ciprofloxacin in your pharmacy are expired. No other pharmacy at a distance of 20 Km. It will take 3-4 days to order. How are you going to handle the situation?

Case 2. Patient is giving you a prescription for Methotrexate for her arthritis. She needs to know more about her medication. Profile: she is on birth control pills.

Case 3. Patient with arthritis using Tylenol extra strenght but still in pain. Askyou for counselling. What would you recommend?

Case 4. Patient asking you how to treat her heartburn. She is on Metformin. Also complaining of flatulence and stomach aches.

Case 5. No patient. Assessor acted as a doctor. Giving you a prescription for Warfarin and Carbamazepine.Tell him what he needs to know.

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Case 6. Patient was on Nitroglycerin tablet. The doctor shifted her to Nitro spray. Patient says she is not getting any benefit from it. How are you going to counsel the patient?

Case 7. Patient complaining of constipation and hemmorhoids. Patient profile: Verapamil, Tylenol #3.Explain to the patient what's causing his constipation and recommend treatment for hemmorhoids.

Case 8. Patient with acne dropping a new prescription for Differin. Patient profile: Materna Vit.How will you counsel the patient?

Case 9. Patient with breast cancer using Indomethacin. She is suffering from stomach upset. Counsel the patient.

Case 10. Patient with borderline cholesterol level. Asking you about taking garlic.

Case 11. A young athletic person is buying a 3 cc syringe from your pharmacy. Upon gathering info., you found out that he will be using that to inject "deca durabolin" (?) for body building. How will you counsel this man?

Case 12. A patient come to the pharmacy asking your recommendation for vaginal yeast infection.

Case 13. Patient had an Ileostomy procedure. He is prescribed Erythromycin Capsule. Counsel the patient.

Case 14. Proper use of Aerochamber. Patient also taking Flovent and Ventolin.

Case 15. Technician received a prescription of Tylenol#3 over the phone. O.K.or not? Explain.

Case 16. You are the hospital pharmacy manager. You overheard one of your staff pharmacist having conversation with a doctor. The dostor is asking if he can give Vancomycin Oral instead of Injection. Your staff pharmacist approvedof it. How are you going to handle the situation?

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November 2001

Case 1. An old lady, asthmatic, has COPD 2 yrs. ago and is on Nitro spray as well. Her doctor adviced her to take a flu shot but she is afraid to take it. She

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comes to your pharmacy to ask your advice.

Case 2. A lady is on Alendronate, complaining of stomach upset. Counsel thepatient.

Case 3. A man gives you a prescription for Glucocorticoid Enema. Prescription calls for 14 but you only have 7 in stock. What are you going to do?

Case 4. Patient has a new prescription for Lamisil cream for her nail fungal infection. Patient profile states allergy to sulfa drug. Counsel the patient. Howare you going to deal the situation.

Case 5. Patient asking your recommemdation for heartburn which he usuallysuffers at night.

Case 6. A prescription for Zovirax for shingles. Identify what is wrong!

Case 7. A man comes to your pharmacy to order another refill of his Cefetin (antibiotic). There's no refill and the doctor refuse to give him refill. The man is going to Vancouver and he is asking for refill. How are you going to handle the situation?

Case 8. A female patient, asthmatic and is taking Ventolin Spray and Flovent. She found out that she is pregnant. Counsel the patient.

Case 9. A young lady rushed to your pharmacy asking what to do for her friend who is having difficulty breathing, breath smells like nail polish and is always thirsty. Counsel the lady.

Case 10. A patient is on Furosemide and Lanoxin. She recently had deep vein thrombosis, treated in the hospital and comes back to you with a new prescription for Coumadin. Counsel the patient.

Cse 11. A lady is asking you for a refill of Ativan. Checking her profile, you found out that she just picked-up a refill several days ago. How are you going to handle the situation?

Case 12. How are you going to handle a dispensing error? You found out thatyou dispense a different medication than what is actually written on the prescription.

Case 13. Patient suffering from trigeminal neuralgia. Doctor prescribed Tegretol 200mg BID. He has been on Tylenol#3 for the last week but gave no satisfactory result. Handle the situation.

Case 14. Check 5 prescriptions before you release them as the pharmacist.

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Case 15. A lady is asking you for some recommendation, Her son has Otitis media and after days of treatment with Septra he got red spots all over his body. Counsel the patient. Station is provided with Dimetapp syrup for allergy and Cortisone 0.5% cream.

Case 16. A lady coming to pick up an Epinephrine for her son who was foundto be allergic to hazelnut. Show her the proper use of Epinephrine.

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To Our Fellow PEBC Candidates,

The following are some notes regarding the previous cases presented in the last three years of the Objective Structured Clinical Examination (OSCE).Please note that some informations may be incomplete therefore further research is highly recommended. Goodluck to all of us!!!

* There might be 1 or 2 cases that need referral if critical. This includes Corns and Warts for a diabetic patient.* Usually these cases need Non-pharmacological (OTC) recommendations: - heartburn (hyperacidity) - allergy - cough and colds - constipation - pain relief* Always ask or gather more information from the patient prior to giving counselling.* Deca-durabolin - Nandrolone decanoate; a controlled drug - androgenic, anabolic steroid; synthetic derivative of testosterone - adjunctive treatment in senile or post menopausal osteoporosis* Acne is a common condition during pregnancy due to hormonal changes (esp. progesterone). Differin and Accutane are not recommended for pregnant women due to terratogenic effects on the fetus. Use Solugel 4% (non rx) as alternative. It has drying efffect on the acne as well as antibacterial.* Study everything about Fosamax, Epipen, Ventolin, Flovent, Aerochamber, Nitrolingual Spray, Evista* Practice counselling on Metformin, Enemas, Nilstat, Canesten/Monistat, Vaginal Supp.

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* Canker sore is self limiting (7-14 days). Avoid sour subs, spices, chocolate,tomatoes. Review other non pharmacological management like: rinse the mouth w/ warm water or saline or mouthwash as often as possible. Zilactin gel can be applied w/ Q tips for pain.* Cold sores - viral infection, self limiting (3-10 days)* Study everything about Lamisil cream, Warfarin, Garlic for cholesterol* Study Methotrexate uses, Gravol, know some Sleeping aids, antacids, sunblocks* Study everything about birth control pills, lice management, athlete foot management, contact dermatitis.

* Make sure you know the drugs that cause photosensitivity reactions* Practice your dialogue on some complicated situations..always demonstratea concerned and caring attitude.* Know your federal laws, legislation, pharmaceutical ethics. Legal issues.* Be sure you know some useful websites for your counselling techniques. Like: www. cancer.ca - for canadian cancer society www.cbcf.org - canadian breast cancer foundation

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