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 : kg
Race : Malay [ ] Chinese [ ] Indian [ ] Height: cm

B. Chief Complaint (CC)

C. History of present illness (HPI)

D. Family & Social History

E. Medical History Interview

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

Renal Profile
Normal range

Na+ 136 – 145 mmol/L

K+ 3.5 – 5.0 mmol/L

9
 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
K .Diagnoses/Provisional Dx / Acute / Chronic medical Problems

Normal range
RBS 4-11mmol/L

10
L. Drug treatment in the ward

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

11
Patient’s progress report in the ward

12
M. Drug therapy assessment/Identifying drug related problem. (Please answer each of the following questions based on your
assessment of the patient)

13
14
 N. DRUG THERAPY PROBLEM LIST (DTPL)

Date DRP(medication related) Recommendation

15
 O.PHARMACIST’S CARE PLAN MONITORING WORKSHEET (PMW)
Pharmacotherapeutic Monitoring Parameter Desired Monitoring
Goal (based on the above Endpoint Frequency
DRP)

16
 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.
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

17
 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 If score is then, ADR
is:
<0 doubtful
1 to 4 possible
5 to 8 probable
>9 definite

18
 +1 0 0 evidence?
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

19
Q. REFERENCES

20