PWDT FORM

2012Edition TUTORIAL CASE STUDY FOR PWDT©

2012 Edition Yahaya Hassan©

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 ORIENTEDPHARMACIST RECORDDepartment of Pharmacy Practice

Faculty of PharmacyUniversiti Teknologi MARA

CASE 1

A. Patient Description

Name : Mr RA Age : 31

Reg. No : 494725 Gender : Male [X ] Female [ ]

Admission : 30/11/2015 Weight : 62 kg

Race : Malay [ ] Chinese [ ] Indian [X] Height : - cm

B. Chief Complaint (CC)

- 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: 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: Appendicitis X Anxiety

Other:

DO YOU HAVE: LUNG PROBLEMS

High blood pressure 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 Other:

Diabetes

F. Medication history

F.S.1Current Prescription Medication Regimen

Name/Dose/Strength/Route Schedule/Frequency of

Use

Indication Start Date (and stop

date if applicable)

Prescriber Indication issues, effectiveness,

safety, compliance and

cost

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 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?

X

Yes NoIf 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

_________________

Diet

Routine

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

Lab investigation

Date 1/12/2015 DateHeight(cm) Na+Weight(kg) 62 kg K+Temp(C°) 37 o C BUNBp(mmHg) CreatininePulse(bpm) Urine outputRR/VENT I/OPeak Flow Uric acid/MgPH Ca2

Osat PO4PCO2 FBS/RBSHCO BMILDL LDHHDL CPKTG INRT.Choles. PT/aPTTWBC TT/FDPHgb BLI BiliPlatelet ALT/ASTChest X-ray Alk PhosEchocardio Total P/AlbECG TSH

CrCl(ml/min)

Pharmacologic review of system:

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 8/7

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 10＾3/uL Lymphocyte 19 – 48 %

Neutrophils 40 – 74 %

Renal Profile

Normal range

Na+ 136 – 145 mmol/L

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K+ 3.5 – 5.0 mmol/L

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 Description GFR ml/min/1.73m2 Patient’s CKD stage

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)

Cardiac Enzymes

Normal range

CK 30 - 200

LDH 135 - 225

Aspartate Transaminase 5-34

Others

Normal range

RBS 4-11mmol/L

10

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

Schedule

Duration Indication/safety/efficacy

start Stop

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 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5

am noon pm midnight

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Patient’s progress report in the ward

Date

General

Vital signs

BPPRRRT

CVPO2Sat

Lungs

Abdomen

CVSLimbs

ReflometPlan

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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 () COMMENTS

1) Correlation Between DrugTherapy & Medical Problem

Any drugs without a medical indication?Any unidentified medication?Any untreated medical conditions?Do they require drug therapy?

YES ? NOYES ? NOYES ? NOYES ? NO

2) Appropriate Therapy Comparative efficacy of chosenmedication (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 oroutcomes?Is therapy tailored to this patient?

YES ? NO

YES ? NO

YES ? NO

YES ? NO

YES ? NO

3) Drug Regimen Are dose and dosing regimen appropriateand/ or within usual therapeutic rangeand/ or modified for patient factor?Appropriateness of PRN medications?Is route dosage from mode ofadministration appropriate, length orcourse of therapy considering efficacysafety, convenience patient limitationlength or course of therapy and cost?

YES ? NO

YES ? NOYES ? NO

4) Therapeutic Duplication / Polypharmacy

Any therapeutic duplication? YES ? NO

5) Adverse Drug Reaction Are symptoms or medical problem druginduced? What is the like hood the problem is drug related?

YES ? NO

6) Interactions: Drug-Drug. Drug- disease, Drug-Food, Drug-herbal

Any drug-drug interaction with clinicalsignificance?Any relative contraindications givenpatient characteristic and current/ pastdisease state?Any food interactions with clinicalsignificance?Any drug-lab test interactions withclinical significance?

YES ? NO

YES ? NO

YES ? NO

YES ? NO

DRUG RELATED PROBLEM QUESTION ANSWER () COMMENTS

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7) Drug Allergy Or Intolerance Allergy or intolerance to any medicationcurrently being taken. Is patient using a method to alert healthcare provider of the allergy/intolerance?

YES ? NO

YES ? NO

8) Risk And Quality of Life Impact

Is patient at risk for complications with an existing disease state?Is patient on track for preventivemeasures (immunizations, mammograms)Is Therapy adversely impacting patient’squality of life? How so?

YES ? NO

YES ? NO

YES ? NO

9) Social Or Recreational Drug Use (Drug Abuse)

Is current use of social drug problematic?Are systems related to suddenwithdrawal or discontinuation of socialdrugs?

YES ? NOYES ? NO

10) Financial Impact Is therapy cost-effective?Does cost of therapy represent a financialhardship for the patient?

YES ? NOYES ? NO

11) Patient knowledge Of Therapy Does patient understand the role of theirmedication, how to take it and potentialside effect?Would patient benefit from educationtools?Does the patient understand the role ofnon drug therapy?

YES ? NO

YES ? NO

YES ? NO

12) Adherence/ compliance Is there a problem with non adherence todrug or non drug therapy?Are there barriers to adherence or factorshindering the achievement of therapeuticefficacy?

YES ? NO

YES ? NO

13) Self Monitoring Does patient perform appropriate self-monitoring?Is correct technique employed?Is self-monitoring performed consistently,at appropriate times and with appropriatefrequency?

YES ? NO

YES ? NO

YES ? NO

14

N. DRUG THERAPY PROBLEM LIST (DTPL)

Date DRP(medication related) Recommendation

15

O. PHARMACIST’S CARE PLAN MONITORING WORKSHEET (PMW)

PharmacotherapeuticGoal (based on the above

DRP)

Monitoring Parameter DesiredEndpoint

MonitoringFrequency

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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.

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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 NoDo not know

1.  Are there previous conclusive reports on this reaction? +1 0 0

2.  Did the adverse event appear after the suspected drug was administered?

+2 -1 0

3.  Did the adverse reaction improve when the drug was discontinued or a specific antagonist was administered?

+1 0 0

4.  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.  Did the reaction reappear when a placebo was given? -1 +1 0

7.  Was the drug detected in the blood (or other fluids) in concentrations known to be toxic?

+1 0 0

8.  Was the reaction more severe when the dose was increased, or less severe when the dose was decreased?

+1 0 0

9.  Did the patient have a similar reaction to the same or similar drugs in any previous exposure?

+1 0 0

10. Was the adverse event confirmed by any objective evidence?

+1 0 0

If score is then, ADR is:

< 0 doubtful

1 to 4 possible

5 to 8 probable

> 9 definite

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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 µmol/liter instead of mg/dl, calculation is based on:

88.4 µmol/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 µmol/liter

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Q. REFERENCES

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