PHARMACIST WORKUP OF

DRUG THERAPY IN
PHARMACEUTICAL CARE

Date: 12/12/13

Department: Parenteral Nutrition

Case : Parenteral Nutrition (PN) for Post Laparotomy of Subacute

Intestinal Obstruction

Ward: 3A

Reg. No: 1229888

Name of Students:
TAZQIRAH BT MUHAMAD (2010285624)
ZARITH NADIA BINTI MOHAMAD ZULKIFLI (2010663642)

PROBLEM ORIENTED
PHARMACIST RECORD
Department of Pharmacy Practice
Faculty of Pharmacy
Universiti Teknologi MARA
CASE 1
A. Patient Description
Name : CNL Age : 77
Reg. No : 1229888 Gender : Male [ ] Female [ / ]
Admission : 19/12/11 Weight : 49.7 kg
Race : Malay [ ] Chinese [ / ] Indian [ ] Height : 150 cm

B. Chief Complaint (CC)

Patient was admitted to Ward 3A, Hospital Tengku Ampuan Rahimah (HTAR) Klang on
19/12/11 due to abdominal pain for 1 day with nausea and vomiting for 5 times.

C. History of present illness (HPI)

Patient was diagnosed with hypertension for more than 30 years ago. She had undergone
cholecystectomy 10 years ago.

D. Family & Social History

She is taken care by her daughter. She was an ex-smoker.

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/ Schedule/ Indication Start Date Prescriber Indication
Strength/Route Frequency (and stop issues,
of Use date if effectiveness,
applicable) safety,
compliance
and cost
Tab. Losartan OD Anti-hypertensive
potassium/hydro agent
chlorothiazide
100/25 mg
Tablet OD Anti-hypertensive
Amlodipine agent
besylate 5mg

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

nutritional, etc.)

Name/Dose/ Schedule/ Indication Start Date Prescriber Indication

Strength/Route 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? Nil

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?
Never___________________________________________________________________
Everyone has problems with following a medication regimen exactly as written.
What are the problems you are having with your regimen?
No problem______________________________________________________________
Compliance rate: Compliant [ / ] Moderate/partial compliant [ ] Noncompliant [ ]

I. Social History
Smoking:
Do you use tobacco?
 / Yes No If yes, what type? Packs/day ________ years.

If no, Never consume [ ], stopped [ ] 30 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
_________________

Diet Routine Exercise/Recreation Daily Activities/Timing

- - -
 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: Alert, conscoius, colicky abdominal pain, nausea,

Date 19/12 Date 19/12 vomiting_______________________________________________
Height(cm) 150 Na+ 139
Vital Signs: BP: 142/82 mmHg, PR: 88 beats/min, RR: 13 beats/min,
Weight(kg) 49.7 K+ 3.4
Temp(C°) 37 BUN 15.5 T: 37°C ___________________________________ ___________
Bp(mmHg) 142/82 Creatinine 259 KUT: _____ _______
Pulse(bpm) 88 Urine output -
HEPATIC: _____________________________________ ______
RR/VENT 13 I/O -
Peak Flow - Uric acid/Mg 0.64 CVS: __________ ____ __________
PH - Ca2 1.86 CHEST: _____________________ ________________________
Osat - PO4 1.11 BLOOD: _____________________________________ ________
PCO2 - FBS/RBS - ABDO: _______________________________________________
HCO - BMI 22.09
LDL - LDH - SKIN/MUSCLE: _______________________________________
HDL - CPK - NEURO/MENTAL: _____________________________________
TG - INR - HEENT: _____________________________________ ________
T.Choles. - PT/aPTT -
GIT: ________________________________________ _________
WBC 4.06 TT/FDP -
Hgb 13.1 BLI Bili -
Platelet - ALT/AST -
Chest X-ray - Alk Phos -
Echocardio - Total P/Alb -
ECG - TSH -
- CrCl(ml/min) 12.57
 Vital Signs

19/12 21/12 23/12 25/12 27/12 28/12

T (oC) 37 37 36.6 37 37 37

BP (mmHg) 142/82 137/53 150/65 120/75 140/80 142/58

HR (beat/min) 88 75 80 93 66 -

I/O: Input/Output - 2082.5/3510 2672.5/4360 3083/3105 2647.5/2183 3100/1637

Balance - -1427.5 -1687.5 -22 464.5 1463

Renal Profile

Normal range 21/12 23/12 25/12 27/12 28/12

Na+ 135 – 145 mmol/L 139 135 136 138 140

K+ 3.5 – 5.0 mmol/L 3.1 ↓ 3.5 4.5 4.3 4.2

Urea 1.7 – 8.3 mmol/L 16.2 ↑ 22.9 ↑ 28.4 ↑ 31.8 ↑ 21.0 ↑

Creat 57-130 μmol/L 232 ↑ 245 ↑ 195 ↑ 101 63

Clcr 75 – 125 ml/min 14.0 13.2 16.6 32.2 51.69

PO4- 0.81-1.45 mmol/L 1.4 1.45 1.34 1.39 1.16

Mg 0.66-1.30 mmol/L 0.65 1.3 1.01 1.22 1.16

↓: Lower than normal range

↑: Higher than normal range

9
 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)

Estimated GFR using MDRD equation

-1.154 -0.203
= 186 x (SCr / 88.4) x (age) x (0.742 if female) x (1.210 if black)
-1.154 -0.203
= 186 x (259 / 88.4) x (77) x (0.742)
= 16.53 ml/min/1.73m²

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 16.53 ml/min/1..173 m2
5 Kidney failure (ESRD) <15 (or dialysis)

Cardiac Enzymes
Normal range
CK 30 - 200 -
LDH 135 - 225 -
Aspartate Transaminase 5-34 -

Others
Normal range 21/12 23/12 25/12 27/12 28/12
RBS 4-11mmol/L 6.2 7.4 6.9 9.7 6.7

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

- Subacute intestinal obstruction obstruction 2° to adhesion colic
- Hypertension (>30 years ago)
- Cholecystectomy (>10years ago)

10
 L. Drug treatment in the ward
Current Drug Therapy (Oral, Parental, Inhaler and others)
Drug Name Prescribed Duration Indication
Schedule Start Stop
IV Tienam (imipenem + TDS 20/12/11 21/12/11 Surgical prophylaxis
cilastatin) 500mg -broad spectrum bactericidal agent
IV Fluconazole 200mg OD 21/12/11 27/12/11 Treatment of fungal infection
IV Tazocin (Piperacilin + OD 21/12/11 23/12/11 First line of intra-abdominal sepsis
Tazobactam) 4.5g
IV Meropenem 1g TDS 24/12/11 29/12/11 Intra-abdominal infection
T. Metoprolol 50mg BD 21/12/11 26/12/11 Hypertension
T. Metoprolol 100mg BD 26/12/11 Continue Hypertension
S/C Enoxaparin Sodium OD 20/12/11 28/12/11 Prophylaxis of deep vein
40mg thrombosis
T. Amlodipine 5mg STAT & OD 19/12/11 Continue Hypertension
T. Simvastatin 40mg ON 19/12/11 Continue Prevention of cardiovascular events
IV Frusemide 40mg Run 1mg/hour 21/12/11 Continue Treatment of resistant hypertension
and prevention of fluid overload
Mist KCl 15ml TDS 21/12/11 29/12/11 Treatment of potassium deficiency
IV KCl 1g STAT 21/12/11 Continue Treatment of potassium deficiency
IV Ranitidine 50mg TDS 19/12/11 20/12/11 Prophylaxis of stress ulcer
IV Filgastrim 300mcg/ml OD 21/12/11 Continue Treatment of anemia (off label
[recombination human used) and neutropenia
granulocyte-colony
stimulating factor (G-
CSF)]
IV Bromhexine 8mg TDS 22/12/11 24/12/11 Mucolytic agent
IV Tramadol 25mg BD 22/12/11 Continue Relief of moderate to severe pain
IV Pantoprazole 40mg BD 21/12/11 26/12/11 Proton pump inhibitor
Prophylaxis of stress ulcer
T. Folate/ B complex OD 28/12/11 Continue To provide energy
40mg Treat anemia
T. Esomeprazole 40mg OD 27/12/11 Continue Proton pump inhibitor
Prophylaxis of stress ulcer
IV Vit K 10mg STAT 22/12/11 Continue Correct any clotting defect
IV N-Acetyl Cysteine 25/12/11 26/12/11 Mucolytic agent

11
Patient’s progress report in the ward

Date 19/12 20/12 21/12

Alert, conscious, lethargic looking, General condition same, a febrile, General condition same,
General mildly dehydrated, pink (not calcified uterine fibroid noted Gangrenous bowel 2° to internal
jaundiced) herniation
Vital signs
BP 142/82 139/67 137/53
PR 88 103 75
RR - 13 17
T 37 37 37
CVP - - -
O2Sat - - -
Lungs - - -
Abdomen Colicky abdominal pain Colicky abdominal pain No pain
CVS - - -
DXT (mmol/L) - - 6.2
Plan
- Start T. Amlodipine 5mg - Off IV Ranitidine 50mg tds - Off IV Imipenem 500mg tds
stat & od - Start T. Pantoprazole 40mg - Start IV Fluconazole 200mg
- Start T. Simvastatin 40mg bd od
on - Monitor vital signs - Start IV Piperacilin 4.5g od
- Start IV Ranitidine 50mg tds - Inform stat if bp> 100/90 - Start T. Metoprolol 50mg bd
- Monitor BP 2 hourly mmHg or PR > 120 - Start IV Frusemide 40mg run
- KIV to add another beats/min 1mg/hour
antihypertensive if - Start IV Imipenem 500mg - Start IV KCl lg stat then
persistently high tds convert to Mist. KCl 15ml tds
- Keep patient NBM - Start S/C. Enoxaparin - Start IV Filgastrim
- Start IV drip 4pins (normal Sodium 40mg od 300mcg/ml
saline and dextrose 5%) - Laparotomy on 10.30 p.m. - Start TPN

12
Patient’s progress report in the ward

Date 22/12 23/12 24/12

General condition same, General condition same, General condition same, pupil
General decompensated metabolic respiratory distress sluggish bilaterally, poor GCS
acidosis
Vital signs
BP 150/55 150/65 135/70
PR 68 80 102
RR 23 13 18
T 37 36.6 37
CVP - - -
O2Sat - - -
Lungs - - -

Abdomen No pain No pain No pain

CVS - - -
DXT (mmol/L) 6.4 7.4 7.4
Plan
- Start IV Tramadol 25mg - Off IV Piperacilin 4.5 g - Start IV Meropenem 1g
bd od tds
- Start IV Vit K 10mg stat - Off IV Bromhexine
to correct any clotting
defect

13
Patient’s progress report in the ward

Date 25/12 26/12 27/12

General condition same, sepsis General condition same Alert, not tachypnea, GCS
General improved
Vital signs
BP 120/75 143/83 140/80
PR 93 101 66
RR 14 20 22
T 37 37 37
CVP - - -
O2Sat - - -
Lungs - - -
Abdomen No pain No pain No pain
CVS - - -
DXT (mmol/L) 6.9 9.9 9.7
Plan
- Start IV N-Acetyl - Off T. Metoprolol 50mg - Off IV Fluconazole 200mg
Cysteine bd, then convert to T. od
- Continue IV Fluconazole
Metoprolol 100mg bd - Continue IV Meropenem
200mg tds
- Continue IV Meropenem - Off IV Pantoprazole 1g tds
1g tds 40mg bd - Continue T. Metoprolol
- Continue T. Metoprolol - Off IV N-Acetyl Cysteine 100mg bd
50mg bd - Continue S/C Enoxaparin
- Continue S/C Enoxaparin Sodium 40mg od
Sodium 40mg od - Start IV Esomeprazole
- Continue Mist KCl 15ml
40mg od
tds
- Continue IV Pantoprazole - Off TPN, allow oral
40mg bd feeding

14
 N. DRUG THERAPY PROBLEM LIST (DTPL)
Date DRP (medication related)
20/12/11 Uncorrected hypoalbuminemia (low serum albumin)
which can be caused by malnutrition, impaired
digestion and edema.
21/12/11 Patient had anemia due to surgery and was prescribed
with IV Filgastrim 300 mcg to correct patient’s anemic
status.
21/12/11 Potassium level was below than normal range.
21/12/11 Patient was started on antifungal IV Fluconazole
200mg od. However, there was no fungal infection has
been reported and antifungal prophylaxis was not
indicated for the patient.
19/12/11 Incorrect dose of tab. Simvastatin 40mg when
prescribed with tab. Amlodipine.
15
Recommendation
Serum albumin level is an important prognostic
indicator. Among hospitalized patients, lower serum
albumin levels correlate with an increased risk of
morbidity and mortality. Therefore, treatment should
focus on treating the underlying cause of
hypoalbuminemia first before giving IV Human
Albumin 5% to the patient.
Filgastrim is indicated more on treating neutropenia
rather than anemia (off label use). Thus, it is
recommended to transfuse 1 unit packed cell to
correct patient’s blood count because she cannot
tolerate oral feeding yet.
Suggest to give IV potassium chloride, KCl 1g stat to
correct patient’s hypokalemic status.
Recommend to stop antifungal therapy for the patient
in order to prevent any use of unindicated medications
in patient.
The U.S. Food and Drug Administration (FDA)
recommended limiting the use of simvastatin with
certain drugs due to increased risk of
myopathy/rhabdomyolysis. The maximum
recommended dose for simvastatin in conjunction
with amlodipine is 20 mg per day.
28/12/11 Untreated anemia even though IV filgastrim has been Suggest to give ferrous fumarate, folic acid and
prescribed to the patient. hematinic since the patient can already tolerate enteral
feeding.

26/12/11 DXT showed high dextrose level on 26/12/11 and
27/12/11.
21/12/11 - TPN bag 5 (total energy: 1000 kcal) has been selected
27/12/11 on the first day while for the rest 6 days of total
duration, TPN bag 6 (total energy: 1400 kcal) was
given to the patient.
Based on customized calculation, total energy required
for the patient is 1445 kcal.
High dextrose level can lead to hyperglycemia which
is one the metabolic complication of TPN. Thus, it is
recommended to monitor dextrose level closely and
suggested for intensive insulin therapy if necessary.
Based on the guideline, it is recommended to start and
stop TPN slowly to prevent re-feeding symptom and
to meet total nutrition required for the patient.

16
 O. PHARMACIST’S CARE PLAN MONITORING WORKSHEET (PMW)

Pharmacotherapeutic Monitoring Desired Monitoring

Goal (based on the above Parameter Endpoint Frequency
DRP)
1. Treat the underlying Serum albumin To correct hypoalbuminemia before Every day
cause that lead to level albumin replacement can be done
hypoalbuminemia.

2. Treat anemia. i)RBC count 4.5 – 5.5 10 12 /µL Every day

ii) Hemoglobin 13 – 17 g/dL
count
iii) Hematocrit 40 – 50 %
count
3. Control the blood i) Random blood < 10 mmol/L Upon admission
glucose level. glucose level
ii) Fasting blood < 7 mmol/L Every 2 days
glucose level
4. Maintain the blood Blood pressure < 120/80 mmHg Every 6 hours
pressure within desired
range.
5. Monitor patient’s Patient’s hydration To ensure the patient received adequate Every day on TPN
condition closely to ensure status, serum amount of nutrients and fluid needed
that TPN given provides electrolytes level, from TPN bag given as similar as when
adequate amount of fluid, blood glucose, she takes oral feeding
nutrients, etc. other nutrients

17
P. DISCHARGE SUMMARY AND COMMUNICATION

We have been clerking a retrospective case. However, we were only provided with the
CP2 form and there was no discharge summary provided. Thus, we were unable to
provide a summary upon her discharge from HTAR.

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.

For healthcare professionals:

 The healthcare professionals need to follow up the patient’s condition and

should reminds the patient to come for a follow up appointment according to
the date stated.
 Should advice and counsel the patient appropriately in order to enhance the
patient adherence to medication to improve the quality of life.
 Need to monitor the side effects of the medication.

For the patient upon discharge:

 Advices the patient to take the right medicine at the right time stated with the
right dose and right route of administration.
 Advices the patient to store the medication at the suitable place and suitable

18
 temperature or condition and keep out of reach of children.
 Reminds the patient for not too simply change or substitute any of the
medication prescribed.
 Explains the usefulness or benefit of taking the medication and the patient must
comply all the medication to improve the quality of life and improve patient’s
condition.
Advices, counsels and educates the patient about his drug therapy which includes
the importance of compliance to the therapy as well as identify any undesired effect
caused by the therapy.

19
 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

20
 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, and 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

21
Q. REFERENCES

1) Drug Information Book, 22nd Edition

2) Handbook Of Medication Dosing In Renal Failure For Healthcare Professionals
3) Dipiro Pharmacotherapy Handbook
4) British National Formulary (2012)
5) NICE Guidelines On Nutrition Support For Adults: Oral Nutrition Support, Enteral Tube
Feeding And Parenteral Nutrition (2006)
6) ESPEN Guidelines On Parenteral Nutrition: Surgery (2009)
7) ESPEN Guidelines On Parenteral Nutrition: Adult Renal Failure (2009)
8) HKL Handbook Of Clinical Nutrition (2011)
9) Notes, P. (2009). Stress Ulcer Prophylaxis In The Intensive Care Unit, 75246(4), 373–
376
10) Singer, P., Berger, M. M., Van den Berghe, G., Biolo, G., Calder, P., Forbes, A., &
Pichard, C. (2009). ESPEN guidelines on parenteral nutrition: intensive care. Clinical
Nutrition, 28(4), 387-400
11) McClave S et al. JPEN J Parenteral Enteral Nutrition 2009 May-June;33(3):277-316
12) ASPEN Board of Directors. Guidelines for Use of Parenteral Nutrition in the
Hospitalized Adult Patient. Journal of Parenteral and Enteral Nutrition 26(1):1S-525,
2002
13) US Food and Drug Administration. (2013). FDA Drug Safety Communication: New
restrictions, contraindications, and dose limitations for Zocor (simvastatin) to reduce the
risk of muscle injury. Silver Springs, MD: US Department of Health & Human Services

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