PWDT-FORM

2012Edition

TUTORIAL CASE STUDY FOR PWDT©

PHARMACIST WORKUP OF DRUG THERAPY IN PHARMACEUTICAL CARE

Date : Case : Ward : Bed No: Reg. No :

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

2012 Edition Yahaya Hassan©

CASE 1 A.

Patient Description Name

:

Age

:

Reg. No

:

Gender

: Male [ ] Female [ ]

Admission

:

Weight

:

Race

: Malay [ ] Chinese [ ] Indian [ ] Height :

B.

Chief Complaint (CC)

C.

History of present illness (HPI)

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 Constipation Diverticulitis Liver disease Gallbladder problems Pancreatitis

kg

cm

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 Parkinson’s disease Dizziness Past stroke Fainting Depression

Other: 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

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

F.S.2

Schedule/ Frequency of Use

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 [ ]

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

[ ] No If yes, please list the medications and the reaction experienced:

What environmental allergies do you have?

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 [ ] 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

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