PHARMACIST WORKUP OFDRUG THERAPY IN PHARMACEUTICAL CARE Date: 12/12/13 Department: Parenteral Nutrition Case : Parenteral Nutrition (PN) for Post Laparotomy of Subacute Intestinal Obstruction Ward: 3A Reg. No: 1229888 Name of Students: TAZQIRAH BT MUHAMAD (2010285624) ZARITH NADIA BINTI MOHAMAD ZULKIFLI (2010663642) PROBLEM ORIENTED PHARMACIST RECORD Department of Pharmacy Practice Faculty of Pharmacy Universiti Teknologi MARA CASE 1 A. B. Patient Description Name : CNL Age : 77 Reg. No : 1229888 Gender : Male [ ] Female [ / ] Admission : 19/12/11 Weight : 49.7 kg Race : Malay [ ] Chinese [ / ] Indian [ ] Height : 150 cm Chief Complaint (CC) Patient was admitted to Ward 3A, Hospital Tengku Ampuan Rahimah (HTAR) Klang on 19/12/11 due to abdominal pain for 1 day with nausea and vomiting for 5 times. C. History of present illness (HPI) Patient was diagnosed with hypertension for more than 30 years ago. She had undergone cholecystectomy 10 years ago. D. Family & Social History She is taken care by her daughter. She was an ex-smoker. E. Medical History Interview HEART PROBLEMS: URINARY/REPRODUCTIVE: Chest pain (angina) Urinary or bladder infection Past heart attack Prostate problems Heart failure Hysterectomy Irregular heartbeat Chronic yeast infections Heart by-pass surgery Kidney disease Rheumatic fever Dialysis Other: Other: EYES, EARS, NOSE & THROAT MUSCLES AND BONES Poor vision Arthritis Poor hearing Gout Glaucoma Back pain Sinus problem Amputation Bladder disorder Joint replacement Other: Other: GASTROINTESTINAL NEUROLOGICAL Heartburn Headache Ulcer Seizures or epilepsy Constipation Parkinson’s disease Diverticulitis Dizziness Liver disease Past stroke Gallbladder problems / Fainting Pancreatitis Depression Other: Anxiety Other: DO YOU HAVE: High blood pressure LUNG PROBLEMS / Asthma Low blood pressure Emphysema High cholesterol Bronchitis Diabetes Other: Cancer Anaemia Bleeding disorder DO YOU HAVE OR USE…? Hay fever Glasses Sleeping problems Hearing aid Other: Other: DO YOU HAVE A FAMILY HISTORY OF: High blood pressure Heart disease Diabetes Other: . Medication history F. safety. compliance and cost Current Nonprescription Medication Regimen (OTC.) Schedule/ Frequency of Use Indication Start Date (and stop date if applicable) Prescriber Indication issues. effectiveness.S.2 Name/Dose/ Strength/Route Indication Start Date (and stop date if applicable) Prescriber Indication issues.S. herbal. effectiveness. compliance and cost .1 Current Prescription Medication Regimen Name/Dose/ Strength/Route Schedule/ Frequency of Use Tab. safety. Losartan potassium/hydro chlorothiazide 100/25 mg Tablet Amlodipine besylate 5mg OD Anti-hypertensive agent OD Anti-hypertensive agent F.F. nutritional. homeopathic. etc. Allergies: History of allergies: Yes [ ] No known allergies [/ ] Are you allergic to any prescription drugs. What are the problems you are having with your regimen? No problem______________________________________________________________ Compliance rate: Compliant [ / ] Moderate/partial compliant [ ] Noncompliant [ ] I. 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 [ / ] No If yes. Medication Compliance assessment Base questions on history obtained to this point. How often would you estimate that you miss a dose? Never___________________________________________________________________ Everyone has problems with following a medication regimen exactly as written. Social History Smoking: Do you use tobacco? .G. Your medication regimen sounds complex and must be hard to follow. over-the-counter medication. please list the medications and the reaction experienced: What environmental allergies do you have? Nil H. herbals or food supplements? Yes / No. what type? Packs/day ________ years. Never consume [ ]. Alcohol : Do you drink alcohol? Chronic alcoholic Yes / No If yes. stopped [ ] year(s) ago. what type? Drinks/day/week. If no. Drug/substance abused: Never consumed [ / ] . stopped [ ] 30 year(s) ago. Never consume [ ] ./ Yes No If yes. Stopped __ year(s) ago. Other Drug use: Caffeine intake: Never consumed [ / ] drinks per day . If yes What type _________________ Diet Routine Exercise/Recreation Daily Activities/Timing - - - . If no. 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 Female Point total 10 year risk (%) Point total 10 year risk (%) 0 1 <9 <1 1 1 9 1 2 1 10 1 3 1 11 1 4 1 12 1 5 2 13 2 6 2 14 2 7 3 15 3 8 4 16 4 9 5 17 5 10 6 18 6 11 8 19 8 12 10 20 11 13 12 21 14 14 16 22 17 15 20 23 22 16 25 24 27 >17 >30 >25 >30 . J. WBC Hgb Platelet Chest X-ray Echocardio ECG 19/12 150 49. conscoius. nausea.09 12.06 13.1 - 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) 19/12 139 3.11 22.4 15. RR: 13 beats/min.57 Alert. Pharmacologic review of system: Lab investigation General: Date Height(cm) Weight(kg) Temp(C°) Bp(mmHg) Pulse(bpm) RR/VENT Peak Flow PH Osat PCO2 HCO LDL HDL TG T. T: 37°C ___________________________________ ___________ KUT: _____ _______ HEPATIC: _____________________________________ ______ CVS: __________ ____ __________ CHEST: _____________________ ________________________ BLOOD: _____________________________________ ________ ABDO: _______________________________________________ SKIN/MUSCLE: _______________________________________ NEURO/MENTAL: _____________________________________ HEENT: _____________________________________ ________ GIT: ________________________________________ _________ . vomiting_______________________________________________ Vital Signs: BP: 142/82 mmHg.64 1.Choles.7 37 142/82 88 13 4.86 1. colicky abdominal pain.5 259 0. PR: 88 beats/min. Physical examination / laboratory for initial and follow-up. 2 51.01 1.5 4.3 4.45 mmol/L 1.16 Mg 0.45 1.0 13.66-1.5 -1687.4 1.5/4360 3083/3105 2647.4 ↑ 31.6 37 37 37 142/82 137/53 150/65 120/75 140/80 142/58 88 75 80 93 66 - I/O: Input/Output - 2082.5/2183 3100/1637 Balance - -1427.2 Urea 1.81-1.7 – 8.3 mmol/L 16.5 1463 T (oC) BP (mmHg) HR (beat/min) Renal Profile Normal range 21/12 23/12 25/12 27/12 28/12 Na+ 135 – 145 mmol/L 139 135 136 138 140 K+ 3.5/3510 2672.22 1.0 mmol/L 3.9 ↑ 28.1 ↓ 3.16 ↓: Lower than normal range ↑: Higher than normal range 9 .30 mmol/L 0.5 -22 464.39 1.3 1.65 1.34 1.Vital Signs 19/12 21/12 23/12 25/12 27/12 28/12 37 37 36.69 PO4- 0.2 16.6 32.5 4.5 – 5.8 ↑ 21.2 ↑ 22.0 ↑ Creat 57-130 μmol/L 232 ↑ 245 ↑ 195 ↑ 101 63 Clcr 75 – 125 ml/min 14. 742 if female) x (1.4) -0.73m2 1 Kidney damage with normal or ↑GFR ≥90 2 Kidney damage with mild ↓GFR 60 – 89 3 Moderate ↓GFR 30 – 59 4 Severe ↓GFR 15 – 29 5 Kidney failure (ESRD) <15 (or dialysis) Patient’s CKD stage 16.Evaluation of renal function (Please choose at what stage of renal impairment that the patient is having based on your calculated creatinine clearance.203 x (age) -1.73m² x (0.203 = 186 x (259 / 88.200 135 .210 if black) -0.4) x (77) = 16.173 m2 Cardiac Enzymes Normal range CK LDH Aspartate Transaminase 30 .9 9.7 6.Diagnoses/Provisional Dx / Acute / Chronic medical Problems - Subacute intestinal obstruction obstruction 2° to adhesion colic - Hypertension (>30 years ago) - Cholecystectomy (>10years ago) 10 . Formula is given at the appendix) Estimated GFR using MDRD equation -1.225 5-34 - Others Normal range RBS 4-11mmol/L 21/12 23/12 25/12 27/12 28/12 6..7 K .53 ml/min/1.4 6.154 = 186 x (SCr / 88.53 ml/min/1.2 7.154 x (0.742) Stage Description GFR ml/min/1. Simvastatin 40mg IV Frusemide 40mg OD 20/12/11 28/12/11 STAT & OD ON Run 1mg/hour 19/12/11 19/12/11 21/12/11 Continue Continue Continue TDS STAT TDS OD 21/12/11 21/12/11 19/12/11 21/12/11 29/12/11 Continue 20/12/11 Continue Prophylaxis of deep vein thrombosis Hypertension Prevention of cardiovascular events Treatment of resistant hypertension and prevention of fluid overload Treatment of potassium deficiency Treatment of potassium deficiency Prophylaxis of stress ulcer Treatment of anemia (off label used) and neutropenia TDS BD BD 22/12/11 22/12/11 21/12/11 24/12/11 Continue 26/12/11 T. Parental. Inhaler and others) Drug Name Prescribed Duration Indication Schedule Start Stop IV Tienam (imipenem + cilastatin) 500mg IV Fluconazole 200mg TDS 20/12/11 21/12/11 OD 21/12/11 27/12/11 Surgical prophylaxis -broad spectrum bactericidal agent Treatment of fungal infection IV Tazocin (Piperacilin + Tazobactam) 4.5g IV Meropenem 1g OD 21/12/11 23/12/11 First line of intra-abdominal sepsis TDS 24/12/11 29/12/11 Intra-abdominal infection T. Amlodipine 5mg T.L. Drug treatment in the ward Current Drug Therapy (Oral. Metoprolol 100mg BD 26/12/11 Continue Hypertension S/C Enoxaparin Sodium 40mg T. Esomeprazole 40mg OD 28/12/11 Continue OD 27/12/11 Continue IV Vit K 10mg IV N-Acetyl Cysteine STAT 22/12/11 25/12/11 Continue 26/12/11 Mist KCl 15ml IV KCl 1g IV Ranitidine 50mg IV Filgastrim 300mcg/ml [recombination human granulocyte-colony stimulating factor (GCSF)] IV Bromhexine 8mg IV Tramadol 25mg IV Pantoprazole 40mg 11 Mucolytic agent Relief of moderate to severe pain Proton pump inhibitor Prophylaxis of stress ulcer To provide energy Treat anemia Proton pump inhibitor Prophylaxis of stress ulcer Correct any clotting defect Mucolytic agent . Metoprolol 50mg BD 21/12/11 26/12/11 Hypertension T. Folate/ B complex 40mg T. Pantoprazole 40mg bd Monitor vital signs Inform stat if bp> 100/90 mmHg or PR > 120 beats/min Start IV Imipenem 500mg tds Start S/C. Enoxaparin Sodium 40mg od Laparotomy on 10. Gangrenous bowel 2° to internal herniation 142/82 88 37 Colicky abdominal pain - 139/67 103 13 37 Colicky abdominal pain - 137/53 75 17 37 No pain 6. Simvastatin 40mg on Start IV Ranitidine 50mg tds Monitor BP 2 hourly KIV to add another antihypertensive if persistently high Keep patient NBM Start IV drip 4pins (normal saline and dextrose 5%) - - 12 Off IV Ranitidine 50mg tds Start T. pink (not jaundiced) 20/12 General condition same. - Off IV Imipenem 500mg tds Start IV Fluconazole 200mg od Start IV Piperacilin 4. a febrile. KCl 15ml tds Start IV Filgastrim 300mcg/ml Start TPN . mildly dehydrated.5g od Start T.2 Vital signs BP PR RR T CVP O2Sat Lungs Abdomen CVS DXT (mmol/L) Plan - - Start T.Patient’s progress report in the ward Date General 19/12 Alert. Metoprolol 50mg bd Start IV Frusemide 40mg run 1mg/hour Start IV KCl lg stat then convert to Mist. lethargic looking. conscious. Amlodipine 5mg stat & od Start T.m.30 p. calcified uterine fibroid noted 21/12 General condition same. 5 g od - 13 Start IV Meropenem 1g tds Off IV Bromhexine .4 General Vital signs BP PR RR T CVP O2Sat DXT (mmol/L) Plan - Start IV Tramadol 25mg bd Start IV Vit K 10mg stat to correct any clotting defect - Off IV Piperacilin 4. decompensated metabolic acidosis 23/12 General condition same.4 7. pupil sluggish bilaterally. poor GCS Lungs 150/55 68 23 37 - 150/65 80 13 36. respiratory distress 24/12 General condition same.4 7.6 - 135/70 102 18 37 - Abdomen No pain No pain No pain CVS 6.Patient’s progress report in the ward Date 22/12 General condition same. 9 No pain 9. allow oral feeding . Metoprolol 50mg bd.9 No pain 9. then convert to T. not tachypnea. Metoprolol 100mg bd Off IV Pantoprazole 40mg bd Off IV N-Acetyl Cysteine - 14 Off IV Fluconazole 200mg od Continue IV Meropenem 1g tds Continue T. Metoprolol 50mg bd Continue S/C Enoxaparin Sodium 40mg od Continue Mist KCl 15ml tds Continue IV Pantoprazole 40mg bd - - Off T. Metoprolol 100mg bd Continue S/C Enoxaparin Sodium 40mg od Start IV Esomeprazole 40mg od Off TPN. GCS improved 120/75 93 14 37 - 143/83 101 20 37 - 140/80 66 22 37 - No pain 6. sepsis 26/12 General condition same 27/12 Alert.Patient’s progress report in the ward Date 25/12 General condition same.7 General Vital signs BP PR RR T CVP O2Sat Lungs Abdomen CVS DXT (mmol/L) Plan - Start IV N-Acetyl Cysteine Continue IV Fluconazole 200mg tds Continue IV Meropenem 1g tds Continue T. . DRUG THERAPY PROBLEM LIST (DTPL) Date DRP (medication related) Recommendation 20/12/11 Uncorrected hypoalbuminemia (low serum albumin) which can be caused by malnutrition. 19/12/11 15 Serum albumin level is an important prognostic indicator. The U. Incorrect dose of tab.S. Amlodipine. 21/12/11 Potassium level was below than normal range. KCl 1g stat to correct patient’s hypokalemic status. Food and Drug Administration (FDA) recommended limiting the use of simvastatin with certain drugs due to increased risk of myopathy/rhabdomyolysis.N. 21/12/11 Patient had anemia due to surgery and was prescribed with IV Filgastrim 300 mcg to correct patient’s anemic status. there was no fungal infection has been reported and antifungal prophylaxis was not indicated for the patient. Among hospitalized patients. Suggest to give IV potassium chloride. Simvastatin 40mg when prescribed with tab. Filgastrim is indicated more on treating neutropenia rather than anemia (off label use). Recommend to stop antifungal therapy for the patient in order to prevent any use of unindicated medications in patient. treatment should focus on treating the underlying cause of hypoalbuminemia first before giving IV Human Albumin 5% to the patient. impaired digestion and edema. Thus. lower serum albumin levels correlate with an increased risk of morbidity and mortality. However. Therefore. The maximum recommended dose for simvastatin in conjunction with amlodipine is 20 mg per day. it is recommended to transfuse 1 unit packed cell to correct patient’s blood count because she cannot tolerate oral feeding yet. 21/12/11 Patient was started on antifungal IV Fluconazole 200mg od. it is recommended to start and stop TPN slowly to prevent re-feeding symptom and to meet total nutrition required for the patient. 21/12/11 27/12/11 TPN bag 5 (total energy: 1000 kcal) has been selected on the first day while for the rest 6 days of total duration. TPN bag 6 (total energy: 1400 kcal) was given to the patient. High dextrose level can lead to hyperglycemia which is one the metabolic complication of TPN. Suggest to give ferrous fumarate. 26/12/11 DXT showed high dextrose level on 26/12/11 and 27/12/11.28/12/11 Untreated anemia even though IV filgastrim has been prescribed to the patient. Based on the guideline. total energy required for the patient is 1445 kcal. Thus. 16 . Based on customized calculation. folic acid and hematinic since the patient can already tolerate enteral feeding. it is recommended to monitor dextrose level closely and suggested for intensive insulin therapy if necessary. nutrients. Treat the underlying cause that lead to hypoalbuminemia. Maintain the blood pressure within desired range. Control the blood glucose level. 5. Monitor patient’s condition closely to ensure that TPN given provides adequate amount of fluid. 40 – 50 % < 10 mmol/L Upon admission < 7 mmol/L Every 2 days Blood pressure < 120/80 mmHg Every 6 hours Patient’s hydration status.O. other nutrients To ensure the patient received adequate Every day on TPN amount of nutrients and fluid needed from TPN bag given as similar as when she takes oral feeding 17 . blood glucose. i)RBC count ii) Hemoglobin count iii) Hematocrit count i) Random blood glucose level ii) Fasting blood glucose level 4. Treat anemia. Serum albumin level To correct hypoalbuminemia before albumin replacement can be done Every day 2. etc.5 10 12 /µL 13 – 17 g/dL Every day 4.5 – 5. 3. serum electrolytes level. PHARMACIST’S CARE PLAN MONITORING WORKSHEET (PMW) Pharmacotherapeutic Goal (based on the above DRP) Monitoring Parameter Desired Endpoint Monitoring Frequency 1. Should advice and counsel the patient appropriately in order to enhance the patient adherence to medication to improve the quality of life. Need to monitor the side effects of the medication. B. For healthcare professionals: The healthcare professionals need to follow up the patient’s condition and should reminds the patient to come for a follow up appointment according to the date stated. Based on the above discharge medication. However. DISCHARGE SUMMARY AND COMMUNICATION We have been clerking a retrospective case.P. please provide a summary of the changes that happened in the hospital based on the DRP detected and your recommendation given. Thus. COMMUNICATION: Please provide the communication aspects that you would give to other healthcare professional and to patients upon discharge. we were unable to provide a summary upon her discharge from HTAR. Advices the patient to store the medication at the suitable place and suitable 18 . For the patient upon discharge: Advices the patient to take the right medicine at the right time stated with the right dose and right route of administration. we were only provided with the CP2 form and there was no discharge summary provided. Explains the usefulness or benefit of taking the medication and the patient must comply all the medication to improve the quality of life and improve patient’s condition.temperature or condition and keep out of reach of children. counsels and educates the patient about his drug therapy which includes the importance of compliance to the therapy as well as identify any undesired effect caused by the therapy. Advices. Reminds the patient for not too simply change or substitute any of the medication prescribed. 19 . et al. Are there previous conclusive reports on this reaction? +1 0 0 2. Did the adverse reaction improve when the drug was discontinued or a specific antagonist was administered? +1 0 0 4. Was the adverse event confirmed by any objective evidence? +1 0 0 20 If score is then. Did the adverse event appear after the suspected drug was administered? +2 -1 0 3. please answer the following questionnaire and give the pertinent score Yes No Do not know 1. Was the drug detected in the blood (or other fluids) in concentrations known to be toxic? +1 0 0 8. ADR is: <0 doubtful 1 to 4 possible 5 to 8 probable >9 definite . or less severe when the dose was decreased? +1 0 0 9. Did the reaction reappear when a placebo was given? -1 +1 0 7. 30:239-5. Busto U. Did the patient have a similar reaction to the same or similar drugs in any previous exposure? +1 0 0 10.A method for estimating the probability of adverse drug reaction (Naranjo CA.) To assess the adverse drug reaction. Clin Pharmacol Ther 1981. Was the reaction more severe when the dose was increased. Sellers EM. Did the adverse reaction reappear when the drug was readministered? +2 -1 0 5. Are there alternative causes (other than the drug) that could on their own have caused the reaction? -1 +2 0 6. 85 if female) (72 * Cr) Where ClCr is expressed in ml/min.4)-1.154 x (Age) -0.203 x (0. Estimated GFR using MDRD Equation 186 x (Creat / 88.4 µmol/liter =1mg/dl b. Cockcroft-Gault GFR (140-age) * (Wt in kg) * (0.210 if black) Where serum creatinine is expressed as µmol/liter 21 . and weight in kg and serum creatinine mg/dl If serum creatinine is expressed as µmol/liter instead of mg/dl. age in years.742 if female) x (1. calculation is based on: 88. Formula creatinine clearance calculation: a.Appendix 1. 75246(4). P. (2009). G. 373– 376 10) Singer. Clinical Nutrition. P.. Enteral Tube Feeding And Parenteral Nutrition (2006) 6) ESPEN Guidelines On Parenteral Nutrition: Surgery (2009) 7) ESPEN Guidelines On Parenteral Nutrition: Adult Renal Failure (2009) 8) HKL Handbook Of Clinical Nutrition (2011) 9) Notes. Guidelines for Use of Parenteral Nutrition in the Hospitalized Adult Patient.Q.. 22nd Edition 2) Handbook Of Medication Dosing In Renal Failure For Healthcare Professionals 3) Dipiro Pharmacotherapy Handbook 4) British National Formulary (2012) 5) NICE Guidelines On Nutrition Support For Adults: Oral Nutrition Support.. JPEN J Parenteral Enteral Nutrition 2009 May-June. MD: US Department of Health & Human Services 22 .. 2002 13) US Food and Drug Administration. Journal of Parenteral and Enteral Nutrition 26(1):1S-525. Van den Berghe.. P. Biolo. Stress Ulcer Prophylaxis In The Intensive Care Unit. (2013). Berger. FDA Drug Safety Communication: New restrictions. and dose limitations for Zocor (simvastatin) to reduce the risk of muscle injury.. Forbes. & Pichard. Silver Springs. 28(4). M.33(3):277-316 12) ASPEN Board of Directors. REFERENCES 1) Drug Information Book. M. (2009). G. C. Calder. ESPEN guidelines on parenteral nutrition: intensive care. contraindications. 387-400 11) McClave S et al. A.