PWDT FORM

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

X

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

Parkinson’s 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

X

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 25

10 year risk (%) 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

10＾3/uL

Monocyte

3.4 – 9.0

%

RBC

4.7 – 6.1

10＾6/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

10＾3/uL %

Renal Profile Normal range Na+

136 – 145 mmol/L

K+

3.5 – 5.0 mmol/L

9

%

8/7

Urea

2.5 – 6.7 mmol/L

Creat

53-115 μmol/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