How to Approach Clinical Scenarios

Here is how you should approach every scenario question:

• Step 1: What is the question asking? Does it even ask for anything scenario-specific? → If not scenario-specific, just answer the question. DO NOT read the scenario!

• Step 2: What do I know about the topic the question is asking about? Signs/symptoms? Side effects? Contraindications/Black box warnings? Teratogenicity? REMS? Labs/Tests? → This is basically Top 300 + RxPrep chapter info. If you are struggling with this, you should review that section and redo the quiz on RxPrep.  

• Step 3: What about the patient case that stands out regarding the topic being asked? Any symptoms/side effects? Duplicate/antagonistic therapy? Labs/Tests? Allergies? Gender? Age? → Once you get Step 2, you should be able to have enough info to look for relevant information for Step 3. With Step 2 and "key drugs guy/study tip gal" you should be able to eliminate a lot, even if you aren't completely confident about the topic.  

Sample Clinical Questions: -- The way I word the questions are oversimplified compared to how they may be presented on the Naplex due to space constraints. I also am not giving you any actual details. This is simply a practice of how you should approach these scenario questions BEFORE you actually read the scenario. For the case questions, you should look at each drug/disease state and ask yourself what kinds of "cases" they can ask of you, kind of like I did in my post. Also, you should definitely go through all the "labs and tests" associated with each disease state, since that is something you definitely need to memorize for the case questions. RxPrep has a great chapter on that. To go about this, think, if a patient was on a certain drug already, or if you tweaked the labs/test results, how would it affect your recommendation? Best way to study for this is to make flashcards/tables of each disease state with the possible treatment options, disease symptoms/drug MOA and side effects (including black box warnings/contraindications/teratogenicity/etc.) to look for, max doses, and labs/tests associated with the disease state and/or drug (some drugs require certain labs/tests too!).--

• A patient comes in looking to fill a medication for erectile dysfunction (they will likely just give you the name of the drug). Is it alright to dispense it? (They may give more information such as a list of medications they take from a different pharmacy). → You may notice that the patient normally has medications filled elsewhere and/or you notice that their past medical history mentions angina. It is always a good thing to ask the patient for their entire med list. In this case, if you had noticed any of that, you should look for any nitrates that they may be taking as they are contraindicated with your typical erectile dysfunction drugs.

• A female patient comes in wanting to get treatment for acne (they may describe the severity here). What would you recommend for this patient? → Notice the patient is FEMALE. You should always look to see if they are pregnant, especially if there are possible treatments that are teratogenic. Also, isotretinoin has REMS, so they may ask about that.

• A patient presents at the clinic with new onset lower back pain. They describe it as a deep "aching" pain. What would you recommend for this patient? → You may notice that this patient has a history of hyperlipidemia and/or is taking a statin. This may be either new to them, or they may have had a recent dose change. Either way, a deep "aching" pain in the large muscle of the lower back is usually a side effect of statins. A very elevated CK or CPK level would indicate a very strong intolerance to the statin. In this case, either you would lower the dose of the statin or change the statin to something more tolerable (i.e. The less lipid soluble a statin, the less likely it is to have this side effect. For example, atorvastatin is more lipid soluble and more likely to have this side effect than rosuvastatin. But for this reason, rosuvastatin tends to be more "expensive", and sometimes a PA needs to be sent to get a more expensive drug covered by insurance). A lot of the time, they will opt to just lower the statin dose since it is easier and less expensive. However, if the patient needed to increase their statin dose because their lipid levels were still not controlled with the previous lower dose, switching statins may be worth it along with potentially adding a different drug. For example, if you notice their triglyceride level was > 5000 mg/dl, you absolutely need to add a fibrate (fenofibrate is the safest option. Pretty much never choose gemfibrozil since it has a lot of problems, including intolerance) to prevent pancreatitis.

• A patient presents with myocardial infarction (MI) and was treated at the hospital. The provider asks you what you recommend discharging the patient with. → You may notice that this patient has already taken an ACE inhibitor and Beta blocker prior to being hospitalized to control their blood pressure. Perhaps they have even had an MI previously. You want to make sure that when you discharge, you go through their med list to reconcile it all. If they need to increase the dose or change their regimen, make sure the previous lower dose/medication is discontinued and replaced with the newer dose/medication.

• A patient comes in with Pneumocystis Pneumonia (PCP). The doctor needs help recommending a treatment for them. → You may notice this patient has an allergy to sulfa- drugs. Generally, the treatment for PCP is Bactrim. Therefore, you need to think of an alternative treatment for this patient.

You can find more "practice" online, although it can be hard to find. Here is some that might help:

• Dr. Bosnak’s Drug Detective: https://drugdetective.net/?fbclid=IwZXh0bgNhZW0CMTEAAR0sNdi2yww-sgwr8FNcILXMkqwBq5iBhfrDIS8fLNwyHSiozIt20fOY0AY_aem_AWZYSGoGDLtv9qMhWudYDPz8Dt36FQPBS6QMURSaaaYGMRPB1dr0RtJ7eu6IxDaw46DKkKzg_M0iFUz1i6Q4INzf 

• TrueLearn: https://www.youtube.com/watch?v=oWxSQ4L90UE 

• Pharmacy Times → Click the search bar and type "Interactives: Case Studies": https://www.pharmacytimes.com/search?pharmacytimes_sanity_data%5Bquery%5D=Interactives%3A%20Case%20Studies

• Pharmacy House: https://www.youtube.com/@pharmacyhouse/search?query=clinical%20case%20study

SUMMARY - AFTER READING THE QUESTION FIRST, pay attention to the following info for ALL patient cases:

• • Allergies → NEVER skip this!

  • Signs/Symptoms → Can give you a clue what the problem is

  • Gender → If female, MUST look for a pregnancy test

  • Medication list → Note the following information for each drug listed:

    • Contraindications

    • Black Box Warnings

    • Teratogenicity

    • MOA

    • Side effects

    • REMS

    • Max doses, if applicable

  • Labs/Tests → DO NOT skip these! The exam does not allow you to move on to the next question until you have physically scrolled through everything anyways. It is helpful to know the “average” normal value of each lab (particularly electrolytes, liver panel, and kidney panel). Note that if the exam gives you an abnormal value they want you to see, it will most likely be an EXTREME value, not just “barely” outside the range. Also, note that some drug therapies require you to look for different tests prior to starting or to discontinue treatment, such as pregnancy test or HLA-B*5701 screening.