PWDT (Pharmacist Workup plan and Therapy

PHARMACIST WORKUP OF DRUG THERAPY IN

PHARMACEUTICAL CARE

Date : 24-06-2021

Case : ST abnormality, Sinus Tachycardia, Hypertension

emergency.

Ward :

Bed No:

Reg. No :
CASE 1

A. Patient Description
Name : Age :
Reg. No : Gender :
Admission : Weight :
Race : Height :

B. Chief Complaint (CC)

C. History of present illness (HPI)

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: 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
Current Prescription Medication
.1 Regimen
Name/Dose/Strength/Rou Schedule/ Indicatio Start Prescribe Indication
te Frequency n Date r issues,
of Use (and effectiveness,
stop safety,
date if compliance
applicab and cost
le)

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

2 nutritional, etc)

Name/Dose/Strength/Rout Schedul Indication Start Prescribe Indication

e e/ Date r issues,
Freque (and effectivene
ncy of stop ss, safety,
Use date if complianc
applicab e and cost
le)
G. Allergies:

History of 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/Recreati
on
 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.
Pharmacologic review of system:
Lab investigation

General:
Vital Signs:

KUT:
HEPATIC:
CVS:
CHEST:
BLOOD:
ABDO:
SKIN/MUSCLE:
NEURO/MENTAL:
HEENT:
GIT :
 Vital Signs

8 9 10
/ / /7
7 7
T (oC)
BP (mmHg)
HR (beat/min)
I/O:
Input/Output
Balance

Haematology: Complete Blood Count

Normal range 8 Normal range 8

/ /
7 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 %

Neutrophil 40 – 74 %
s

Renal Profile
Normal range

Na+ 136 – 145 mmol/L

3.5 – 5.0 mmol/L

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

L. Drug treatment in the ward

Current Drug Theraphy(Oral,Parental,Inhaler and others)
Drug Name Prescribe Duration Indication/safety/efficacy
d start Stop
Schedule

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 1 1 1 1 2 3 4 5 6 7 8 9 1 1 12 1 2 3 4 5
0 1 2 0 1
a p midni
m no m ght
on
Patient’s progress report in the ward

Date

Gene
ral
Vital signs
B
P

P
R

R
R
T
C
V
P
O2
Sat
Lung
s

Abdomen

CVS
Limb
s
Reflomet
Plan
 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 COMMEN
TS
ANSWER (α)
1) Correlation Between Drug Any drugs without a medical indication? Any unidentified medication? YES ? N
O
Therapy & Medical Problem Any untreated medical conditions? Do they require drug therapy? YES ? N
O
YES ? N
O
YES ? N
O
2) Appropriate Therapy Comparative efficacy of chosen medication (s)? YES ? N
Relative safety of chosen medication (s)? Is medication on formulary? O
Is non drug therapy appropriately used (e.g diet & exercise)? YES ? N
Is therapy achieving desired goals or outcomes? O
Is therapy tailored to this patient? YES ? N
O
YES ? N
O
YES ? N
O
3) Drug Regimen Are dose and dosing regimen appropriate and/ or within usual therapeutic range and/ YES ? N
or modified for patient factor? O
Appropriateness of PRN medications? Is route dosage from mode of
administration appropriate, length or course of therapy considering efficacy safety, YES ? N
O
convenience patient limitation length or course of therapy and cost? YES ? N
O

4) Therapeutic Duplication / Any therapeutic duplication? YES ? N

Polypharmacy O
5) Adverse Drug Reaction Are symptoms or medical problem drug YES ? N
induced? What is the like hood the problem is drug related? O

6) Interactions: Drug-Drug. Drug- Any drug-drug interaction with clinical significance? YES ? N
disease, Drug-Food, Drug-herbal Any relative contraindications given patient characteristic and current/ past O
disease state?
Any food interactions with clinical significance? YES ? N
Any drug-lab test interactions with clinical significance? O
YES ? N
O
YES ? N
O
DRUG RELATED PROBLEM QUESTION COMMENTS
ANSWER (α)
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 YES ? NO
Impact with an existing disease state?
Is patient on track for preventive YES ? NO
measures (immunizations,
mammograms) Is Therapy adversely YES ? NO
impacting patient’s quality of life?
How so?
9) Social Or Recreational Drug Is current use of social drug YES ? NO
Use (Drug Abuse) problematic? Are systems related to YES ? NO
sudden withdrawal or discontinuation
of social drugs?
10) Financial Impact Is therapy cost-effective? YES ? NO
Does cost of therapy represent a YES ? NO
financial hardship for the patient?
11) Patient knowledge Of Therapy Does patient understand the role of YES ? NO
their medication, how to take it and
potential side effect?
YES ? NO
Would patient benefit from
education tools?
YES ? NO
Does the patient understand the
role of non drug therapy?
12) Adherence/ compliance Is there a problem with non YES ? NO
adherence to drug or non drug
therapy? YES ? NO
Are there barriers to adherence or
factors 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 YES ? NO
with appropriate frequency?
 N. DRUG THERAPY PROBLEM LIST (DTPL)

Da DRP(medication related) Recommendation

te
 O. PHARMACIST’S CARE PLAN MONITORING WORKSHEET (PMW)
Pharmacotherapeutic Monitoring Desire Monitori
Goal (based on the Parameter d ng
above DRP) Endpoi Frequen
nt cy
 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
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
 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

Q. REFERENCES