MOHAP Pharmacist Exam cheat sheet

Pharmaceutical care is the responsible provision of drug therapy to achieve definite outcomes that improve a patient's quality of life; it requires a direct pharmacist-patient relationship.

The pharmaceutical care process has three core steps: assessment (identify and prioritize drug therapy problems), care plan development, and evaluation/follow-up.

Seven categories of drug therapy problems: unnecessary drug therapy, needs additional therapy, ineffective drug, dose too high, dose too low, adverse drug reaction, and nonadherence.

SOAP note format: Subjective (patient-reported symptoms/history), Objective (labs, vitals, exam findings), Assessment (problem list and drug therapy problems), Plan (interventions and monitoring).

Medication reconciliation is performed at every transition of care (admission, transfer, discharge) and compares the best possible medication history against current orders.

Adherence measurement methods: pill counts and refill records are indirect/objective; patient interview is indirect/subjective; directly observed therapy is the most reliable.

A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm; it is distinct from an adverse drug reaction, which is not preventable by definition.

The Pharmacists' Patient Care Process (PPCP) has five steps: collect, assess, plan, implement, and monitor/evaluate.

Beta-1 selective blockers (e.g., metoprolol, bisoprolol) reduce mortality in heart failure; nonselective agents are avoided because they block beta-2-mediated vasodilation.

ACE inhibitors cause cough via bradykinin accumulation and hyperkalemia via reduced aldosterone; they are contraindicated in pregnancy and bilateral renal artery stenosis.

Warfarin inhibits vitamin K epoxide reductase (VKORC1), reducing factors II, VII, IX, X; effect is monitored by INR, and vitamin K reverses it.

Heparin potentiates antithrombin III, inhibiting thrombin and factor Xa; effect is monitored by aPTT and reversed by protamine sulfate.

Aminoglycosides bind the bacterial 30S ribosomal subunit, are bactericidal, and are nephrotoxic and ototoxic; they require renal dose adjustment and therapeutic drug monitoring.

Macrolides and fluoroquinolones prolong the QT interval; combining them with other QT-prolonging drugs increases the risk of torsades de pointes.

Metformin is first-line for type 2 diabetes; it decreases hepatic gluconeogenesis and is contraindicated in severe renal impairment (eGFR <30) due to lactic acidosis risk.

Levothyroxine is taken on an empty stomach 30-60 minutes before breakfast; calcium, iron, and PPIs reduce its absorption.

First-order elimination: rate is proportional to plasma concentration; half-life t1/2 = 0.693 × Vd / CL, and steady state is reached after approximately 4-5 half-lives.

Bioavailability F = (AUCoral × DoseIV) / (AUCIV × Doseoral); for an IV dose, F is 100% by definition.

Zero-order kinetics (saturation) means a constant amount is eliminated per unit time regardless of concentration; small dose increases can cause disproportionate rises in plasma levels (e.g., phenytoin, ethanol).

The Henderson-Hasselbalch equation: pH = pKa + log([A-]/[HA]) for acids; drug ionization determines lipid membrane permeability and urinary reabsorption.

A prodrug is an inactive derivative that must be biotransformed to release the active drug (e.g., enalapril to enalaprilat); it improves absorption or targeting.

Phase I metabolism involves oxidation, reduction, and hydrolysis (often CYP450-mediated); Phase II involves conjugation (glucuronidation, sulfation) that increases water solubility for excretion.

Excipients include diluents, binders, disintegrants, lubricants, and glidants; they affect tablet hardness, disintegration, and dissolution rate.

Pharmacognosy sources: digitalis glycosides from Digitalis purpurea, morphine from Papaver somniferum, and quinine from Cinchona bark.

A prescription is valid only when it contains the prescriber's name, signature, date, patient identifiers, drug name, strength, dosage form, directions, and quantity.

Controlled substances are classified into schedules based on abuse potential and accepted medical use; Schedule I drugs have no accepted medical use and the highest abuse potential.

Narcotic and controlled drug prescriptions have stricter requirements: limited validity period, no refills in many jurisdictions, and mandatory prescriber identification.

Pharmacists must maintain prescription records for the legally required retention period (commonly 5 years) and must not dispense on an expired or altered prescription.

Ethical principles: autonomy (respect patient choice), beneficence (act in patient's interest), nonmaleficence (do no harm), justice (fair distribution), and confidentiality.

Informed consent requires disclosure of the nature of the treatment, risks, benefits, and alternatives, and voluntary patient agreement.

Generic substitution is permitted only when the law allows it, the prescriber has not prohibited it, and the patient consents; the substituted product must be bioequivalent.

Adverse drug reactions and medication errors must be reported to the national pharmacovigilance authority; serious and unexpected reactions require expedited reporting.

High-alert medications (e.g., insulin, heparin, concentrated electrolytes, chemotherapy) carry a heightened risk of harmful error and require double-checking and standardized labeling.

Look-alike/sound-alike drug names (e.g., hydralazine vs. hydroxyzine) are a leading cause of wrong-drug errors; use tall-man lettering and read-back verification.

The 'five rights' of medication administration: right patient, right drug, right dose, right route, right time (some add reason and documentation).

Root cause analysis is a structured retrospective method for investigating serious adverse events and identifying system-level contributing factors.

The Swiss cheese model describes how multiple layers of defense (checks, protocols, technology) each have gaps that can align to allow an error to reach the patient.

ISMP error-prone abbreviations to avoid: 'U' for units, 'QD'/'QOD', trailing zeros (e.g., 1.0 mg), and the abbreviation 'MS' (morphine sulfate vs. magnesium sulfate).

Medication error reporting systems should be nonpunitive and confidential to encourage reporting; a just culture balances accountability with system improvement.

Antimicrobial stewardship programs aim to optimize antimicrobial selection, dose, and duration to improve outcomes and limit resistance and Clostridioides difficile infection.

The teach-back method confirms patient understanding by asking the patient to restate instructions in their own words rather than asking 'Do you understand?'

Health literacy assessment: use plain language, limit information to 3-5 key points, avoid jargon, and supplement verbal counseling with written or pictorial materials.

Closed-loop communication in healthcare teams requires a sender, a receiver, and read-back confirmation to prevent miscommunication.

SBAR (Situation, Background, Assessment, Recommendation) is a structured handoff communication tool for clinical teams.

Quality improvement uses the PDSA cycle (Plan-Do-Study-Act) and measures structure, process, and outcome indicators.

Nonverbal communication (eye contact, posture, tone) and active listening (paraphrasing, reflecting) are core components of patient-centered counseling.

Documentation of pharmacist interventions should include the problem, intervention, outcome, and follow-up plan to support continuity of care and quality metrics.