2012Edition

TUTORIAL CASE STUDY FOR PWDT

PHARMACIST WORKUP OF
DRUG THERAPY IN
PHARMACEUTICAL CARE

Date :
Case : Post Laparatomy for Perforated
Supravenous Appendicitis with
Generalized Peritonitis
Ward :
Bed No:
Reg. No : 494725

PROBLEM ORIENTED
PHARMACIST RECORD
Department of Pharmacy Practice
Faculty of Pharmacy
Universiti Teknologi MARA

2012 Edition Yahaya Hassan

CASE 1
A.

Patient Description
Name

: Mr RA

Age

: 31

Reg. No

: 494725

Gender

: Male [X ] Female [ ]

Admission

: 30/11/2015

Weight

: 62

Race

: Malay [ ] Chinese [ ] Indian [X]

Height

: - cm

kg

Chief Complaint (CC)

B.

Pain over abdominal is tolerable (Pain score: 1/10)

C.

History of present illness (HPI)

Undergone post exploratory laparotomy for perforated supravenous appendicitis
with generalized peritonitis at Hospital KPJ and referred to Hospital Kajang to
continue TPN

D.

Family & Social History

-

E.

Medical History Interview

HEART PROBLEMS:
Chest pain (angina)
Past heart attack
Heart failure
Irregular heartbeat
Heart by-pass surgery
Rheumatic fever
Other:
EYES, EARS, NOSE & THROAT
Poor vision
Poor hearing
Glaucoma
Sinus problem
Bladder disorder
Other:
GASTROINTESTINAL
Heartburn
Ulcer

URINARY/REPRODUCTIVE:
Urinary or bladder infection
Prostate problems
Hysterectomy
Chronic yeast infections
Kidney disease
Dialysis
Other:
MUSCLES AND BONES
Arthritis
Gout
Back pain
Amputation
Joint replacement
Other:
NEUROLOGICAL
Headache
Seizures or epilepsy

Constipation
Diverticulitis
Liver disease
Gallbladder problems
Pancreatitis
Other: Appendicitis

DO YOU HAVE:
High blood pressure
Low blood pressure
High cholesterol
Diabetes
Cancer
Anaemia
Bleeding disorder
Hay fever
Sleeping problems
Other:
DO YOU HAVE A FAMILY HISTORY OF:
High blood pressure
Heart disease
Diabetes

Parkinsons disease
Dizziness
Past stroke
Fainting
Depression
Anxiety
Other:
LUNG PROBLEMS
Asthma
Emphysema
Bronchitis
Other:
DO YOU HAVE OR USE?
Glasses
Hearing aid
Other:
Other:

F.

Medication history
F.S.1

Current Prescription Medication Regimen

Name/Dose/Strength/Route

Schedule/
Frequency of
Use

Omeprazole 4 mg IV

OD

Tramal 50 mg IV

TDS

Maxolon 10 mg IV

TDS

Cefaperazone 1 g IV

BD

Metronidazole 800 mg IV

TDS

Tazosin 40 mg IV

TDS

F.S.2

Indication

Start Date
(and stop
date if
applicable)

Prescriber

Indication issues,
effectiveness,
safety,
compliance and
cost

Current Nonprescription Medication Regimen (OTC, herbal, homeopathic, nutritional,

etc)

Name/Dose/Strength/Route

Schedule/
Frequency
of Use

Indication

Start Date
(and stop
date if
applicable)

Prescriber

Indication
issues,
effectiveness,
safety,
compliance
and cost

G. Allergies:

History of allergies:

Yes [ ]

No known allergies [X ]

Are you allergic to any prescription drugs, over-the-counter medication, herbals or food
supplements?
Yes

No.

If yes, please list the medications and type of

allergic reaction experienced:

Are there any medications that you are not allergic but cannot tolerate?
[ ] Yes

[X] No

If yes, please list the medications and the reaction experienced:

What environmental allergies do you have?

Nil

H. Medication Compliance assessment

Base questions on history obtained to this point.
Your medication regimen sounds complex and must be hard to follow;
How often would you estimate that you miss a dose?
______________________________________________________________________
Everyone has problems with following a medication regimen exactly as written.
What are the problems you are having with your regimen?
______________________________________________________________________
Compliance rate : Compliant [ X ] Moderate/partial compliant [ ] Noncompliant [ ]
I. Social History (Soc.Hs)

Smoking: Do you use tobacco?

Yes

No If yes, what type?

packs/day ________ years.

If no, Never consume [ ] , stopped []

17

year(s) ago.

Alcohol : Do you drink alcohol? Chronic alcoholic

Yes

No

If yes, what type?

Drinks/day/week.

If no, Never consume [ ] , stopped [ ]

year(s) ago.

Other Drug use : Caffeine intake : Never consumed [ ]

drinks per day , Stopped __ year(s) ago.

Drug/substance abused : Never consumed [] , If yes What type

_________________

Routine
Diet

Exercise/Recreation

Daily Activities/Timing

J. Risk Assessment/Preventive Measures/Quality of Life

Please calculate the 10-year Coronary heart disease (CHD) risk in this patient
according to the Modified Framingham Risk Scores For Men and Women (appendix:
Table 2)
Modified Framingham Risk Scores For Men and Women
Male
Point total
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
>17

10 year risk (%)

1
1
1
1
1
2
2
3
4
5
6
8
10
12
16
20
25
>30

Female
Point total
<9
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
>25

10 year risk (%)

<1
1
1
1
1
2
2
3
4
5
6
8
11
14
17
22
27
>30

J. Physical examination / laboratory for initial and follow-up.

Pharmacologic review of system:
Lab investigation

Date
Height(cm)
Weight(kg)
Temp(C)
Bp(mmHg)
Pulse(bpm)
RR/VENT
Peak Flow
PH
Osat
PCO2
HCO
LDL
HDL
TG
T.Choles.
WBC
Hgb
Platelet
Chest X-ray
Echocardio
ECG

1/12/2015
62 kg
37 o C

Date
Na+
K+
BUN
Creatinine
Urine output
I/O
Uric acid/Mg
Ca2
PO4
FBS/RBS
BMI
LDH
CPK
INR
PT/aPTT
TT/FDP
BLI Bili
ALT/AST
Alk Phos
Total P/Alb
TSH
CrCl(ml/min)

General:

___________________________________________

Vital Signs: ___________________________________ _____

KUT:

_____ ___

HEPATIC: _____________________________________ ___

CVS:

__________

____ ________

CHEST: _____________________ _______________________

BLOOD: _____________________________________ _____
ABDO: _____________________________________________
SKIN/MUSCLE: ____________________________________
NEURO/MENTAL: ___________________________________
HEENT: _____________________________________ _____
GIT : ________________________________________ ______

Vital Signs
8/7

9/7

10/7

T (oC)
BP (mmHg)
HR (beat/min)
I/O: Input/Output
Balance

Haematology: Complete Blood Count

Normal range

8/7

Normal range

WBC

5.2 12.4

103/uL

Monocyte

3.4 9.0

RBC

4.7 6.1

106/uL

Eosinophil

0.0 7.0

HGB

14 18

g/dL

Basophil

0.0 1.5

HCT

42 52

Neutrophil #

1.5 5.5 10^6u/L

MCV

80 94

fL

Lymphocyte#

0.9 5.2 10^6u/L

MCH

27 31

pg

Monocyte#

0.16 1.00 10^6u/L

MCHC

33 37

g/dL

Eosinophil#

0.0 0.8 10^6u/L

RDW-CV

11.5 14.5 %

Basophil

0.0 0.2 10^6u/L

Platelets

130 400

Lymphocyte

19 48

Neutrophils

40 74

103/uL
%

Renal Profile
Normal range
Na+

136 145 mmol/L

K+

3.5 5.0 mmol/L

8/7

Urea

2.5 6.7 mmol/L

Creat

53-115 mol/L

Clcr

50 110 ml/min

Cl-

98 107 mmol/L

Evaluation of renal function

(Please choose at what stage of renal impairment that the patient is having based on your
calculated creatinine clearance. Formula is given at the appendix)
Stage
1
2
3
4
5

Description
Kidney damage with normal or GFR
Kidney damage with mild GFR
Moderate GFR
Severe GFR
Kidney failure (ESRD)

GFR ml/min/1.73m2
90
60 89
30 59
15 29
<15 (or dialysis)

Cardiac Enzymes
Normal range
CK

30 - 200

LDH

135 - 225

Aspartate Transaminase

5-34

Others
Normal range
RBS

4-11mmol/L

10

Patients CKD stage

K .Diagnoses/Provisional Dx / Acute / Chronic medical Problems

L. Drug treatment in the ward
Current Drug Theraphy(Oral,Parental,Inhaler and others)
Drug Name
Prescribed
Duration
Indication/safety/efficacy
start
Stop
Schedule

Time Line: Please circle the actual administration time of the medication. Below it, state the
drugs that the patient is currently on based on decided time.

6
am

10

11

12
noon

pm

10

11

12

midnight

11

3 4 5

Patients progress report in the ward

Date
General
Vital signs
BP
PR
RR
T
CVP
O2Sat
Lungs
Abdomen
CVS
Limbs
Reflomet
Plan

12

M. Drug therapy assessment/Identifying drug related problem. (Please answer each of the following questions based on your
assessment of the patient)
DRUG RELATED PROBLEM

QUESTION

ANSWER ()

1) Correlation Between Drug

Therapy & Medical Problem

Any drugs without a medical indication?

Any unidentified medication?
Any untreated medical conditions?
Do they require drug therapy?
Comparative efficacy of chosen
medication (s)?
Relative safety of chosen medication (s)?
Is medication on formulary?
Is non drug therapy appropriately used
(e.g diet & exercise)?
Is therapy achieving desired goals or
outcomes?
Is therapy tailored to this patient?

YES
YES
YES
YES
YES

?
?
?
?
?

NO
NO
NO
NO
NO

YES

NO

YES

NO

YES

NO

YES

NO

Are dose and dosing regimen appropriate

and/ or within usual therapeutic range
and/ or modified for patient factor?
Appropriateness of PRN medications?
Is route dosage from mode of
administration appropriate, length or
course of therapy considering efficacy
safety, convenience patient limitation
length or course of therapy and cost?
Any therapeutic duplication?

YES

NO

YES
YES

?
?

NO
NO

YES

NO

Are symptoms or medical problem drug

induced? What is the like hood the
problem is drug related?
Any drug-drug interaction with clinical
significance?
Any relative contraindications given
patient characteristic and current/ past
disease state?
Any food interactions with clinical
significance?
Any drug-lab test interactions with
clinical significance?

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

2) Appropriate Therapy

3) Drug Regimen

4) Therapeutic Duplication /
Polypharmacy
5) Adverse Drug Reaction
6) Interactions: Drug-Drug. Drugdisease, Drug-Food, Drug-herbal

13

COMMENTS

DRUG RELATED PROBLEM

QUESTION

ANSWER ()

7) Drug Allergy Or Intolerance

Allergy or intolerance to any medication

currently being taken. Is patient using a
method to alert health
care provider of the allergy/intolerance?
Is patient at risk for complications with
an existing disease state?
Is patient on track for preventive
measures (immunizations, mammograms)
Is Therapy adversely impacting patients
quality of life? How so?

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

Is current use of social drug problematic?

Are systems related to sudden
withdrawal or discontinuation of social
drugs?
Is therapy cost-effective?
Does cost of therapy represent a financial
hardship for the patient?
Does patient understand the role of their
medication, how to take it and potential
side effect?
Would patient benefit from education
tools?
Does the patient understand the role of
non drug therapy?
Is there a problem with non adherence to
drug or non drug therapy?
Are there barriers to adherence or factors
hindering the achievement of therapeutic
efficacy?
Does patient perform appropriate selfmonitoring?
Is correct technique employed?
Is self-monitoring performed consistently,
at appropriate times and with appropriate
frequency?

YES
YES

?
?

NO
NO

YES
YES

?
?

NO
NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

8) Risk And Quality of Life

Impact

9) Social Or Recreational Drug Use

(Drug Abuse)

10) Financial Impact

11) Patient knowledge Of Therapy

12) Adherence/ compliance

13) Self Monitoring

14

COMMENTS

N. DRUG THERAPY PROBLEM LIST (DTPL)

Date

DRP(medication related)

Recommendation

15

O. PHARMACISTS CARE PLAN MONITORING WORKSHEET (PMW)

Pharmacotherapeutic
Goal (based on the above
DRP)

Monitoring Parameter

Desired
Endpoint

16

Monitoring
Frequency

P.

DISCHARGE SUMMARY AND COMMUNICATION

Patient was discharged with:

Based on the above discharge medication, please provide a summary of the changes
that happened in the hospital based on the DRP detected and your recommendation
given.

B. COMMUNICATION:
Please provide the communication aspects that you would give to other healthcare
professional and to patients upon discharge.

17

A method for estimating the probability of adverse drug reaction

(Naranjo CA, Busto U, Sellers EM, et al. Clin Pharmacol Ther 1981;30:239-5.)
To assess the adverse drug reaction, please answer the following questionnaire and give the
pertinent score
Yes

No

Do not
know

1. Are there previous conclusive reports on this reaction?

+1

2. Did the adverse event appear after the suspected drug

was administered?

+2

-1

3. Did the adverse reaction improve when the drug was

discontinued or a specific antagonist was administered?

+1

4. Did the adverse reaction reappear when the drug was

readministered?

+2

-1

5. Are there alternative causes (other than the drug) that

could on their own have caused the reaction?

-1

+2

6. Did the reaction reappear when a placebo was given?

-1

+1

7. Was the drug detected in the blood (or other fluids) in

concentrations known to be toxic?

+1

8. Was the reaction more severe when the dose was

increased, or less severe when the dose was decreased?

+1

9. Did the patient have a similar reaction to the same or

similar drugs in any previous exposure?

+1

10. Was the adverse event confirmed by any objective

evidence?

+1

If score is
<0
1 to 4
5 to 8
>9

18

then, ADR is:

doubtful
possible
probable
definite

Appendix
1. Formula creatinine clearance calculation:
a. Cockcroft-Gault GFR
(140-age) * (Wt in kg) * (0.85 if female)
(72 * Cr)
Where ClCr is expressed in ml/min, age in years, weight in kg and serum creatinine mg/dl
If serum creatinine is expressed as mol/liter instead of mg/dl, calculation is based on:
88.4 mol/liter =1mg/dl
b. Estimated GFR using MDRD Equation
186 x (Creat / 88.4)-1.154 x (Age)-0.203 x (0.742 if female) x (1.210 if black)
Where serum creatinine is expressed as mol/liter

19

Q. REFERENCES

20