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Description

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

CASE 1 A

Patient Description Name

Admission

: Malay [ ] Chinese [ ] Indian [X]

Chief Complaint (CC)

Pain over abdominal is tolerable (Pain score: 1/10)

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

Family & Social History

Medical History Interview

HEART PROBLEMS: Chest pain (angina) Past heart attack Heart failure Irregular heartbeat Heart by-pass surgery Rheumatic fever Other: EYES,

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

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:

Medication history F

Current Prescription Medication Regimen

Name/Dose/Strength/Route

Schedule/ Frequency of Use

Omeprazole 4 mg IV

Tramal 50 mg IV

Maxolon 10 mg IV

Cefaperazone 1 g IV

Metronidazole 800 mg IV

Tazosin 40 mg IV

Indication

Start Date (and stop date if applicable)

Prescriber

Indication issues,

Current Nonprescription Medication Regimen (OTC,

Name/Dose/Strength/Route

Schedule/ Frequency of Use

Indication

Start Date (and stop date if applicable)

Prescriber

Indication issues,

Allergies:

History of allergies:

Yes [ ]

No known allergies [X ]

Are you allergic to any prescription drugs,

If yes,

please list the medications and type of allergic reaction experienced:

Are there any medications that you are not allergic but cannot tolerate

If yes,

please list the medications and the reaction experienced:

What environmental allergies do you have

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

Smoking: Do you use tobacco

No If yes,

Never consume [ ] ,

Alcohol : Do you drink alcohol

If yes,

Drinks/day/week

Never consume [ ] ,

Other Drug use : Caffeine intake : Never consumed [ ]

Stopped __ year(s) ago

Drug/substance abused : Never consumed [] ,

If yes What type _________________

Routine Diet

Exercise/Recreation

Daily Activities/Timing

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

Female Point total 25

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

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

T (oC) BP (mmHg) HR (beat/min) I/O: Input/Output Balance

Haematology: Complete Blood Count Normal range

Normal range

2 – 12

10^3/uL

Monocyte

4 – 9

7 – 6

10^6/uL

Eosinophil

0 – 7

14 – 18

Basophil

0 – 1

42 – 52

Neutrophil #

5 – 5

5 10^6u/L

80 – 94

Lymphocyte#

9 – 5

2 10^6u/L

27 – 31

Monocyte#

16 – 1

00 10^6u/L

33 – 37

Eosinophil#

0 – 0

8 10^6u/L

5 – 14

Basophil

0 – 0

2 10^6u/L

Platelets

Lymphocyte

19 – 48

Neutrophils

40 – 74

Renal Profile Normal range Na+

5 – 5

0 mmol/L

5 – 6

7 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