2012Edition TUTORIAL CASE STUDY FOR PWDT©

PHARMACIST WORKUP OF
DRUG THERAPY IN
PHARMACEUTICAL CARE

Date : 9/6

Case : NSTEMI

Ward : 7B

Bed No: 12

Reg. No : 405358

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

2012 Edition Yahaya Hassan©

CASE 1

A. Patient Description
Name : MM Age : 35
Reg. No : 405358 Gender : Male [/ ] Female [ ]
Admission : 9/6 Weight : 69 kg
Race : Malay [ / ] Chinese [ ] Indian [ ] Height : 168 cm

B. Chief Complaint (CC)

Right sided chest pain

C. History of present illness (HPI)

Right sided chest pain since 8/6 after break fast, on and off in onset
Pain score 6/10
Burning non radiating
Bury
Vomitted 3 times
Took Gaviscon to relief pain, was not relieved
D. Family & Social History
Mom past away because of heart problem
Mom has diabetes mellitus, hypertension and ischemic heart disease
Patient works as prison guard, married with 3 children
Active smoker since 15 years old
Active person, plays futsal and football
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: 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.1
Current Prescription Medication Regimen

Name/Dose/Strength/Route Schedule/ Indication Start Date Prescriber Indication issues,

Frequency of (and stop effectiveness,
Use date if safety,
applicable) compliance and
cost

F.S.2 Current Nonprescription Medication Regimen (OTC, herbal, homeopathic, nutritional,

etc)

Name/Dose/Strength/Route Schedule/ Indication Start Date Prescriber Indication

Frequency (and stop issues,
of Use date if effectiveness,
applicable) 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? 1 packs/day 20 years.

If no, Never consume [ ] , stopped [] 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 Daily Activities/Timing

Diet Exercise/Recreation
 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. CrCl(ml/min)

Lab investigation
Date 10/6 (in ED) Date 10/6 (in ED)
Height(cm) 169 Na+ 138 mmol/L
Weight(kg) 68 K+ 3.7 mmol/L Pharmacologic review of system:
Temp(C°) 37 BUN
Bp(mmHg) 168/100 Creatinine 72 umol/L
Pulse(bpm) 49 Urine output General: ___________________________________________
RR/VENT I/O Vital Signs: ___________________________________ _____
Peak Flow Uric acid/Mg 0.78 mmol/L
KUT: _____ ___
PH Ca2 2.28 mmol/L
Osat PO4 0/58 mmol/L HEPATIC: _____________________________________ ___
PCO2 FBS/RBS CVS: __________ ____ ________
HCO BMI CHEST: _____________________ _______________________
LDL 1.73 LDH
BLOOD: _____________________________________ _____
HDL 0.87 CPK
TG 1.36 INR ABDO: _____________________________________________
T.Choles. 3.22 PT/aPTT SKIN/MUSCLE: ____________________________________
WBC TT/FDP
NEURO/MENTAL: ___________________________________
Hgb 15.6 g/100ml BLI Bili 17 umol/L
Platelet 189 x10/L ALT/AST HEENT: _____________________________________ _____
Chest X-ray Alk Phos 60 u/L GIT : ________________________________________ ______
Echocardio Total P/Alb 70 g/L
42 g/L
ECG RBBB TSH
ST aVR
ST I,II,v2-
v4
 Vital Signs

10/6 11/6 12/6 13/6 14/6

T (oC) 37 37 37 37 37
BP (mmHg) 145/94 123/87 132/84 150/110 134/87
HR (beat/min) 51 66 72 75 77
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 15.6 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 189 Lymphocyte 19 – 48 %

Neutrophils 40 – 74 %

Renal Profile

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 Normal range

Na+ 136 – 145 mmol/L 144

K+ 3.5 – 5.0 mmol/L 3.1

Urea 2.5 – 6.7 mmol/L 1.9

Creat 53-115 μmol/L 69

Clcr 50 – 110 ml/min 108.66

Cl- 98 – 107 mmol/L 101

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 ≥90 108.66
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 11/6 12/6
RBS 4-11mmol/L 6.2 6.2

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

L. Drug treatment in the ward

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Current Drug Theraphy(Oral,Parental,Inhaler and others)

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Drug Name Prescribed Duration Indication/safety/efficacy
start Stop
Schedule
Tablet Isosorbide TDS 10/6 Withheld Treatment of angina
Dinitrate 10 mg on 12/6
Tablet Trimetazidine TDS 10/6 14/6 Prophylactic treatment of
20 mg PO episodes of angina pectoris
Tablet Bisoprolol OD 10/6 14/6 Treatment congestive cardiac
Fumarate 2.5mg PO failure
IV GTN 2.5mcg/min 0.15ml/H 10/6 11/6 Treatment angina
Tablet Alprazolam ON 10/6 13/6 Sedation
0.5mg PO
Tablet Simvastatin ON 10/6 14/6 Reduce cardiac events
20mg PO
Tablet Clopidogrel OD 11/6 14/6 Prevention of myocardial
75mg PO infarction,stroke or peripheral
arterial disease
Tablet Cardiprin OD 11/6 14/6 Antiplately
100mg PO
S/C Fondaparinux OD x 5/7 11/6 14/6 anticoagulant
2.5mg
IV Ranitidine TDS 11/6 13/6 Prevent ulcer
50mg
Tablet Paracetamol STAT 11/6 11/6 Reduce headache
1g At 5pm
Tablet Paracetamol STAT and 12/6 at 13/6 Reduce headache
QID
1g 4pm
Mist KCL 15ml TDS x 5/7 13/6 14/6 Correct phosphate level
PO
Perindopril 2mg OD 13/6 14/6
PO
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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13
Patient’s progress report in the ward

Date
10/6 3pm 11/6 5pm 12/6 7pm 13/6 3pm
General
Vital signs
BP 131/76 133/84 128/74 140/94
PR 54 76 68 69
RR 20 20 20 20
T 37 37 37 37
CVP
O2Sat
Lungs

Abdomen

CVS
Limbs
Reflomet
Plan

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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 Drug Any drugs without a medical indication? YES ? NO /
Therapy & Medical Problem Any unidentified medication? YES ? NO /
Any untreated medical conditions? YES ? NO /
Do they require drug therapy? YES ? NO /
2) Appropriate Therapy Comparative efficacy of chosen YES / ? NO
medication (s)?
Relative safety of chosen medication (s)? YES / ? NO
Is medication on formulary?
Is non drug therapy appropriately used YES ? / NO
(e.g diet & exercise)?
Is therapy achieving desired goals or YES ? / NO
outcomes?
Is therapy tailored to this patient? YES / ? NO

3) Drug Regimen Are dose and dosing regimen appropriate YES / ? NO

and/ or within usual therapeutic range
and/ or modified for patient factor?
Appropriateness of PRN medications? YES / ? NO
Is route dosage from mode of YES / ? NO
administration appropriate, length or
course of therapy considering efficacy
safety, convenience patient limitation
length or course of therapy and cost?
4) Therapeutic Duplication / Any therapeutic duplication? YES ? NO /
Polypharmacy
5) Adverse Drug Reaction Are symptoms or medical problem drug YES ? NO /
induced? What is the like hood the
problem is drug related?
6) Interactions: Drug-Drug. Drug- Any drug-drug interaction with clinical YES ? NO /
disease, Drug-Food, Drug-herbal significance?
Any relative contraindications given
patient characteristic and current/ past YES ? NO /
disease state?
Any food interactions with clinical YES ? NO /
significance?
Any drug-lab test interactions with YES ? NO /
clinical significance?

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DRUG RELATED PROBLEM QUESTION COMMENTS
ANSWER ()
7) Drug Allergy Or Intolerance Allergy or intolerance to any medication YES ? NO /
currently being taken. Is patient using a
method to alert health YES / ? NO
care provider of the allergy/intolerance?
8) Risk And Quality of Life Is patient at risk for complications with YES ? / NO
Impact an existing disease state?
Is patient on track for preventive YES ? / NO
measures (immunizations, mammograms)
Is Therapy adversely impacting patient’s YES ? / NO
quality of life? How so?
9) Social Or Recreational Drug Use Is current use of social drug problematic? YES ? / NO
(Drug Abuse) Are systems related to sudden YES ? / NO
withdrawal or discontinuation of social
drugs?
10) Financial Impact Is therapy cost-effective? YES / ? NO
Does cost of therapy represent a financial YES ? NO /
hardship for the patient?
11) Patient knowledge Of Therapy Does patient understand the role of their YES / ? NO
medication, how to take it and potential
side effect?
Would patient benefit from education YES / ? NO
tools?
Does the patient understand the role of YES ? / NO
non drug therapy?
12) Adherence/ compliance Is there a problem with non adherence to YES ? NO /
drug or non drug therapy?
Are there barriers to adherence or factors
YES ? NO /
hindering the achievement of therapeutic
efficacy?
13) Self Monitoring Does patient perform appropriate self- YES ? / NO
monitoring?
Is correct technique employed? YES ? / NO
Is self-monitoring performed consistently,
at appropriate times and with appropriate YES ? / NO
frequency?

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 N. DRUG THERAPY PROBLEM LIST (DTPL)

Date DRP(medication related) Recommendation

10/6 Dual antiplatelet therapy- risk of bleeding Monitor risk of bleeding- risk assessment of
bleeding

13/6 ACE-I can increase SCr Dose must be reduced or stopped within 2 weeks after
initation if SCr increase 30% from baseline. Follow up
after 2 weeks.
10/6 Statin can cause elevation of serum alanine Monitor elevation to not exceed 3 times the upper
aminotransferase (ALT) limit

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 O. PHARMACIST’S CARE PLAN MONITORING WORKSHEET (PMW)
Pharmacotherapeutic Monitoring Parameter Desired Monitoring
Goal (based on the above Endpoint Frequency
DRP)

Correct persistent high 1)Monitor blood 140/90 mmHg Every 4 hour

blood pressure pressure level
2)Monitor
hypertension
symptoms like
headache

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 P. DISCHARGE SUMMARY AND COMMUNICATION

Patient was discharged with:

1) Tablet Perindopril 2mg OD
2) T. Bisoprolol 1.25mg OD
3) T.Cardiprin 100mg OD
4) T. Clopidogrel 75mg OD x 1/12
5) GTN 0.5mg PRN
6) T.Simvastatin 20mg ON
7) T. Trimethazidine 20mg TDS
8) Mist KCL 15ml TDS x 3/7

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

Do not
Yes No
know
1. Are there previous conclusive reports on this reaction? +1 0 0
2. Did the adverse event appear after the suspected drug
+2 -1 0
was administered?
3. Did the adverse reaction improve when the drug was
+1 0 0
discontinued or a specific antagonist was administered?
4. Did the adverse reaction reappear when the drug was
+2 -1 0
readministered?
5. Are there alternative causes (other than the drug) that
-1 +2 0
could on their own have caused the reaction?
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
+1 0 0
concentrations known to be toxic?
8. Was the reaction more severe when the dose was
+1 0 0
increased, or less severe when the dose was decreased?
9. Did the patient have a similar reaction to the same or
+1 0 0
similar drugs in any previous exposure?
10. Was the adverse event confirmed by any objective
+1 0 0
evidence?
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
Ministry of Health Malaysia. (2011). Clinical Practice Guidelines UA/NSTEMI. Retrieved from
http://www.moh.gov.my

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