What happened?

While I was working at the Smithton Pharmacy, a 25 years old

male came into our pharmacy asking for a pack of Nurofen Plus.
Murray (the pharmacist) asked me to talk to that man. Murray told
me he is our regular customer and he was using Nurofen Plus for
his migraine. I was aware from the lecture of migraine given by
Angus that opioids should only be used as absolute last resort in
treatment of migraine. This is because the risk of dependency and
medication overuse headaches is very high. In addition, it can
cause nausea, vomiting and slow down the gut motility which in
term increases the onset time of the medication, so it is usually
not welcome for many migraineurs.
What if anything happened subsequently?
Murray introduced me to that man and I asked him a couple of
questions. His migraine was diagnosed by GP three months ago.
He is otherwise healthy and not taking any medication. Nurofen
Plus helps him to reduce the pain associated with migraine but it
does not resolve his nausea and vomiting. Nurofen Plus was
recommended by his friend who also suffers from headache.
I explained this to Murray and he agreed to let me recommend
Anagraine which contains 5 mg metoclopramide and 500 mg
paracetamol. Anagraine is indicated for the symptomatic relief of
headache, nausea and vomiting associated with migraine. I
recommended him to take 2 tablets three times a day once the
headache started and try to avoid noise and light when headache
started. Murray also recommended him to write a migraine diary
and come back to discuss the efficacy with us.
What did you learn?
I learnt that the role of pharmacist in supplying combination
analgesics containing codeine is not just preventing the
diversion and abuse of the opioids, it is also important to
access the appropriateness of the medication.
I also learnt the importance of history taking especially
when the product is not recommended by health care
professional, without a proper history taking we can never
provide the best recommendation to our patient.
I learnt the non-drug intervention is as important as the
medication, in this case if he can identify the trigger of his
migraine and try to avoid it, it can lead to significant
improvement of his quality of life.
I understood why S3 products should involve pharmacist and
we are expected to exercise professional judgment to
different circumstances.
Follow up after recommendation is important, it can make
sure the medication is appropriate and effective to the
patient and we can refer the patient if OTC treatment is not
adequate to treat patient.
What would you do differently in the future?

If I come cross product request of analgesics containing codeine in

the future. I will always take full histories of the patient, access the
appropriateness of the product for their condition and recommend
other product if possible to reduce the risk of dependence. In
addition I will always provide non-drug recommendation whenever
possible. I will also record the sale of S3 medications in dispensing
system so everyone know what is going on and follow up.
What further learning needs did you identify?
I revised the guidance for provision of combination analgesics
containing codeine from PSA

What happened?
Middle aged woman travelling to Thailand requesting information
for vaccination 1 month prior departure to the country. She asked
the pharmacist about the necessary vaccinations that she should
take and the stock made available before she speaks to the GP.
She mentioned that she will be travelling to Thailand for few
weeks and she was wondering if there is any specific vaccine that
she should be on beforehand. She said she will be back later as
she was hurrying to her appointment with her client. Then Murray
has asked me about what I knew about the immunization for
travellers after the customer left.
What if anything happened subsequently?
I have tried to find the answers from the immunization handbook
but there isnt any information made available for vaccination
before travelling to Thailand. Murray then mentioned that there is
a CDC (Centers for Disease Control & Prevention) website by US
can provide some information regarding the vaccination for
travelling to different country.
When I looked up the website, I found there are recommendations
for different types of travellers. They recommended all travellers
should up-to-date on routine vaccines including MMR vaccine,
diphtheria-tetanus-pertussis vaccine, varicella vaccine, polio
vaccine, and flu shot.
They also recommended Hepatitis A and Typhoid for most
travellers as they can be infected through contaminated food or
water. There are some vaccines that may be needed for some
travellers. For example, if the traveller planning to get a tattoo or
piercing, then hepatitis B is also recommended.
I reported these findings to Murray and he said there is
information that I missed which is important to the patient. Then I
realised that I did not find out the schedule of the vaccination.
Hepatitis A is recommended to start the vaccine series at least
one month before travelling which is feasible in this case. If
travellers cannot get the vaccine one month before travelling,

they can get a shot called immunoglobulin in order to provide an

immediate but temporary protection.
What did you learn?
I learnt that the knowledge of pharmacist should not restrict
to medication, our roles are expanded exponentially, and
therefore self-directed learning is very important for every
pharmacist.
I learnt how to find the resources of vaccinations and other
related information for travellers and discuss the options
with them
I also learnt some lifestyle recommendation for travellers
such as food and water safety can help avoid unnecessary
use of antibiotics.
I understood the recommendation provided should be
individualise for every patient. For instance, immunoglobulin
is recommended if patient leaving Australia after few days.
What would you do differently in the future?
In the future, I would keep myself updated with traveller
information for vaccination whenever a patient came into the
pharmacy. This is to ensure the patient would be protected from
the local pandemic when they travel to overseas country. At the
same time allows them to enjoy their travel without hassle of
bringing disease back to Australia when they travel back.
What further learning needs did you identify?
I browse through the travellers health section of CDC
website (http://wwwnc.cdc.gov/travel/), making sure I can
locate the correct information in a timely manner.
I decided to revise some common infectious disease which
can prevent by vaccination. I decided to spend one hour
each week on one disease; there is much information
available on CDC website.
I chat with many friends whose travel frequently to different
country to see if they need any information about
vaccination.

What happened?
A 40 years old man came into the pharmacy with a prescription for
irbersartan 150mg for the first time. I have received the
prescription and go through with the legal requirements of the
script, after verified the script, I reviewed the medication history
of him and I noted that patient has been taking venlafaxine
150mg for 12 months. This raises my concern as I was aware from

therapeutic lectures that venlafaxine can cause a raise in blood

pressure and this may be the reason why patient was prescribed
with antihypertensive. With some doubts, I have sought advice
from Murray about this situation; Murray asked me what I would
do with this patient if I were the pharmacist.
I said SNRI is usually not a first line option for depression and
there are plenty of options which are currently recommended by
the Therapeutic Guidelines that will not increase the BP. In this
case, I will contact prescriber and recommend SSRI such as
sertraline to replace venlafaxine for his depression. I will not
dispense irbersartan to the patient as it seems like we are using a
medication to treat a side effect caused by other medication
rather than treating the condition alone. Murray told me that it
may be too quick to jump into conclusions. Then he asked me to
shadow him whilst he asked the customer further questions.
What if anything happened subsequently?
Murray asked the patient whether it is fine to discuss his new
medication. After consented, he asked the patient many question
regarding this medication related problem. The questions include:
Did your doctor aware that you are taking venlafaxine? (yes,
and he said this medication may increase my blood
pressure)
What is your blood pressure? (170/120)
Do you think venlafaxine help your depression? (I had tried
two different antidepressants before and the response was
not good enough, venlafaxine was working quite well on me)
After questioning, he said he was satisfied to dispense his new
medication. He explained to me that sometime it may be
justifiable to use a medication to treat the side effect of other
medication. In this case, doctor had tried different medications to
manage his depression so it may not be appropriate to change his
antidepressant. Apart from that, his BP is quite high which indicate
his hypertension is not entirely due to venlafaxine. However, if the
patient had hypertension in the first place, we will definitely
discourage the use of SNRI as a first choice.
What did you learn?
I learnt that when I identify any potential medication
problem, I shouldnt jump to the conclusion and contact
prescriber too quickly. I should always ask the patient what
they have been told and use our professional judgement to
assess case by case.
I also learnt that although the guideline provide a evidence
base recommendation for majority of patient, but patients
factor should be consider before making recommendation.
We shouldnt blindly follow the guideline without using our
professional judgement.
I also realised that dispensing history in the pharmacy is

often incomplete. In this case, patient previous medication

was dispensed in other pharmacy. Therefore we cant always
assume that we have complete medication history of the
patient until we actually talk to the patient.
What would you do differently in the future?
In the future, I will always talk to the patient before I make
any recommendation to the prescriber.
I will ask the every patient if they have their medication
dispensed in other pharmacy, then I will contact the
pharmacy to collect more information to make a complete
list of medication that they are currently taking.
I would encourage the patient to use the PCEHR to allow the
patient to self record their condition and the medication
they are taking.
What further learning needs did you identify?

What happened?
A male in his early 20 has come into the pharmacy with a
prescription for norfloxacin 400mg twice daily, however Murray
mentioned that the norfloxacin has been out of stock for quite a
while. Therefore, we cannot dispense the norfloxacin for this
patient; Murray spoke to the patient about this issue and
suggested him to buy some Hydralyte before GP has reply. Murray
has asked me to prepare a letter with recommendation for
treatment of travelers diarrhea. After checking the AMH and eTG,
I have made recommendation of azithromycin and ciprofloxacin.
Then Ive asked the pharmacist to check whether the letter is
appropriate before sending to the GP. After checking, Murray
suggested me to check PBS whether they are subsidized and write
down the price of each of the medication. Then he explained that
GP has prescribed norfloxacin on a authority required prescription,
which may imply that GP wish to prescribe the antibiotics at a
lower price. Therefore, listing out the prices may help the GP to
guide his selection of medication for the patient as part of the
factors to be considered in patient centered care.
What if anything happened subsequently?
What did you learn?

What would you do differently in the future?

What further learning needs did you identify?

What happened?
During the placement in Smithton pharmacy, I have encountered a

lot of prescription for indication of acute gout attack. One day I

have come across a script for colchicine with direction of 2 tabs
stat, then 1 tab every 6 hours until the pain has relief or diarrhoea
is intolerable. I wasnt really sure if the direction was appropriate,
therefore I check AMH online for the directions for colchicine. I
realized that direction on AMH is 2 tabs stat then 1 tab after 1
hour. I have raised the issue with Murray and seek for advice
from him. He mentioned that GP has been practicing based on the
traditional approach for a long time and the change of direction for
colchicines has only been made in the past few years. He has
been mentioning this to the prescriber before but the prescriber
insists to practice such way. He also mentioned that there is a
transition period of changing the practice between the prescribers;
therefore he intends to have a conference with the prescriber soon
and do a presentation on recent updates on management of acute
gout attacks. He normally would talk to the patient about the side
effects to be aware about following the instructions written by the
prescriber to ensure the safe use of the medication. Through this I
understand the intention of the pharmacist to maintain the
relationship between the patient and the doctor.
What if anything happened subsequently?
What did you learn?

What would you do differently in the future?

What further learning needs did you identify?