Clinical Pharmacy and Pharmacotherapy
Patient assessment and monitoring
Clinical questions reward a systematic approach: subjective and objective data, assessment, and plan (SOAP). Build a problem list, then link each problem to guideline-based therapy, goals of therapy, and monitoring parameters. Know how to estimate renal function with the Cockcroft-Gault equation: CrCl = [(140 − age) × weight]/(72 × SCr), multiplied by 0.85 for women. Know when to use actual, ideal, or adjusted body weight. Recognize common monitoring traps: CBC for clozapine and methotrexate, LFTs for methotrexate and statins, TSH for amiodarone, digoxin levels for toxicity, and vancomycin AUC rather than trough alone.
Therapeutics and safety
High-yield areas include anticoagulation (INR for warfarin, anti-Xa for heparins), heart failure, diabetes, asthma/COPD, infectious disease, and pain management. Apply the Beers criteria for older adults and deprescribing principles. Evaluate adverse drug events with causality tools such as the Naranjo scale. Drug interactions, duplication, and adherence barriers are common question stems.
Drug information
Use primary, secondary, and tertiary literature appropriately; appraise study design, bias, and generalizability. Off-label use requires evidence and documentation.
Traps
Do not adjust doses for renal function using serum creatinine alone without considering age, weight, and sex. Do not confuse trough and peak levels. Do not assume a sliding-scale insulin regimen is basal insulin.
Worked example
A 70-year-old woman weighs 60 kg and has SCr 1.2 mg/dL. CrCl = [(140 − 70) × 60]/(72 × 1.2) × 0.85 ≈ 41 mL/min. Use this to select renally adjusted doses and avoid nephrotoxic combinations.