Pharmacy Preceptors Guild of the Philippines

HOSPITAL PHARMACY VIRTUAL INTERNSHIP PROGRAM

CLINICAL PHARMACY – Patient Education prior to discharge
ACTIVITY ASSIGNMENT - 39

Instructions:

1. Your patient is ready for discharge (see case below).

2. Attending Physician requested for patient counseling and medication education by a Pharmacist
before patient may go home (as seen in the picture below):

3. You are the Pharmacist(s) assigned during that time.

4. Create a medication list and include information you will provide to your patient as part of your
patient counseling/patient education/medication education based on the current medication list
created.
5. Submit the accomplished Medication List prior to Discharge Form

Case:
Mr. TR, a 54-year-old man, presented with sudden-onset of epigastric pain that started the previous
night and “felt like trapped wind”. This radiated through his back, up to his neck and into both
shoulders/arms. He was extremely flatulent.

The patient was referred for coronary angiogram/percutaneous coronary intervention (PCI), which was
carried out on site the same day. It showed the presence of a thrombus in the obtuse marginal coronary
artery. The distal left anterior descending coronary artery and the right coronary artery were 80% and 6-
70% stenosed, respectively.

Echocardiogram: Normal left ventricular function

Two drug-eluting events were inserted into the obtuse marginal coronary artery. The following drugs
were prescribed post-PCI:
- Aspirin 75mg tablet daily
- Clopidogrel 75mg tablet daily
- Bisoprolol 2.5mg tablet daily
- Ramipril 1.25mg tablet at night
- Atorvastatin 40mg tablet at night
- Lansoprazole 30mg tablet daily

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 Pharmacy Preceptors Guild of the Philippines
HOSPITAL PHARMACY VIRTUAL INTERNSHIP PROGRAM
CLINICAL PHARMACY – Patient Education prior to discharge
ACTIVITY ASSIGNMENT - 39

Mr. TR is for discharge after 3 days of admission after an uneventful stay in the hospital with the
drugs listed above and a Glyceryl trinitrate (GTN) spray to be used sublingually. Arrangements were
made for an exercise tolerance test (ETT) in 6 weeks to determine whether further PCI is indicated,
and for Mr. TR to enter the local cardiac rehabilitation program.

Justification:
Diagnosis: The most likely diagnosis was confirmed by angiogram, which identified thrombosis and
stenosis in the coronary arteries obtuse marginal, LAD & RCA, requiring development of drug-eluting
stents. Also, echodiagram shows normal LV function.

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