KAPS Patient Assessment and Evaluation 2 — Questions and Answers
Question 1: A pharmacist reviews a patient's medication list and finds they are taking warfarin and newly prescribed trimethoprim-sulfamethoxazole. What assessment finding warrants immediate follow-up?
- Increased bleeding risk due to CYP2C9 inhibition elevating warfarin levels (Correct answer)
- Decreased warfarin efficacy due to enzyme induction
- Reduced renal clearance of trimethoprim only
- Additive antiplatelet effects unrelated to INR
Correct answer: Increased bleeding risk due to CYP2C9 inhibition elevating warfarin levels
Trimethoprim-sulfamethoxazole inhibits CYP2C9, reducing warfarin metabolism and significantly raising INR and bleeding risk.
Question 2: When assessing a patient's medication history, the BEST source for reconciling home medications in an unconscious patient is:
- The patient's pharmacy dispensing records and pill bottles (Correct answer)
- The admitting physician's memory
- The patient's insurance formulary
- A standard drug reference database
Correct answer: The patient's pharmacy dispensing records and pill bottles
Pharmacy dispensing records and pill bottles provide the most accurate, objective documentation of recently dispensed medications.
Question 3: A 68-year-old patient with CKD stage 3b (eGFR 35 mL/min) is prescribed metformin. The most appropriate pharmacist assessment is:
- Recommend dose reduction and close monitoring for lactic acidosis risk (Correct answer)
- Confirm the dose is acceptable since eGFR is above 30 mL/min
- Suggest immediate discontinuation without further evaluation
- Advise switching to insulin without reviewing current glycemic control
Correct answer: Recommend dose reduction and close monitoring for lactic acidosis risk
At eGFR 30–45 mL/min, metformin can be continued at a reduced dose with close monitoring, but lactic acidosis risk is elevated.
Question 4: During a SOAP note review, the 'O' (Objective) section should include which of the following?
- Vital signs, laboratory values, and physical examination findings (Correct answer)
- Patient's description of pain and self-reported symptoms
- The pharmacist's drug therapy problem identification
- Recommended medication adjustments and follow-up plan
Correct answer: Vital signs, laboratory values, and physical examination findings
Objective data includes measurable, reproducible findings such as vitals, labs, and physical exam results.
Question 5: A patient presents with new-onset confusion, hyponatremia (Na 118 mEq/L), and has been on hydrochlorothiazide for 6 months. The pharmacist's assessment should prioritize:
- Thiazide-induced SIADH as the likely cause and recommend holding the diuretic (Correct answer)
- Increasing the thiazide dose to restore volume balance
- Adding fludrocortisone to correct sodium
- Initiating 3% saline without further evaluation
Correct answer: Thiazide-induced SIADH as the likely cause and recommend holding the diuretic
Thiazide diuretics are a common cause of SIADH-like hyponatremia; holding the agent and correcting sodium gradually is the first step.
Question 6: Which tool is MOST appropriate for systematically identifying drug therapy problems during a comprehensive medication review?
- The Pharmacist's Patient Care Process (PPCP) assessment framework (Correct answer)
- The Beers Criteria alone
- A random drug interaction checker
- The patient's self-reported satisfaction survey
Correct answer: The Pharmacist's Patient Care Process (PPCP) assessment framework
The PPCP provides a structured collect-assess-plan-implement-follow-up cycle specifically designed to identify and resolve drug therapy problems.
Question 7: A patient taking lithium for bipolar disorder starts ibuprofen for knee pain. The most critical assessment concern is:
- NSAIDs reduce renal lithium clearance, risking lithium toxicity (Correct answer)
- Ibuprofen will reduce lithium's therapeutic effect
- The combination increases QT prolongation exclusively
- NSAIDs accelerate lithium metabolism via CYP450
Correct answer: NSAIDs reduce renal lithium clearance, risking lithium toxicity
NSAIDs inhibit prostaglandin-mediated renal lithium excretion, causing lithium accumulation and potential toxicity.
KAPS Patient Assessment and Evaluation 2
A pharmacist reviews a patient's medication list and finds they are taking warfarin and newly prescribed trimethoprim-sulfamethoxazole.
What assessment finding warrants immediate follow-up?