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.

B.

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

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

Parkinsons disease

Diverticulitis

Dizziness

Liver disease

Past stroke

Gallbladder problems

Fainting

Pancreatitis

Depression

Other:

Anxiety
Other:

DO YOU HAVE:
High blood pressure

LUNG PROBLEMS
/

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
Diabetes

Other:

F.

Medication history

F.S.1
Current Prescription Medication Regimen
Name/Dose/
Strength/Route

Schedule/
Frequency
of Use

Tab. Losartan
potassium/hydro
chlorothiazide
100/25 mg
Tablet
Amlodipine
besylate 5mg

OD

Anti-hypertensive
agent

OD

Anti-hypertensive
agent

F.S.2
Name/Dose/
Strength/Route

Indication

Start Date
(and stop
date if
applicable)

Prescriber

Indication
issues,
effectiveness,
safety,
compliance
and cost

Current Nonprescription Medication Regimen (OTC, herbal, homeopathic,

nutritional, etc.)
Schedule/
Frequency
of Use

Indication

Start Date
(and stop
date if
applicable)

Prescriber

Indication
issues,
effectiveness,
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 (%)

<9

<1

10

11

12

13

14

15

16

17

10

18

11

19

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:

Date
Height(cm)
Weight(kg)
Temp(C)
Bp(mmHg)
Pulse(bpm)
RR/VENT
Peak Flow
PH
Osat
PCO2
HCO
LDL
HDL
TG
T.Choles.
WBC
Hgb
Platelet
Chest X-ray
Echocardio
ECG

19/12
150
49.7
37
142/82
88
13
4.06
13.1
-

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)

19/12
139
3.4
15.5
259
0.64
1.86
1.11
22.09
12.57

Alert, conscoius, colicky abdominal pain, nausea,

vomiting_______________________________________________
Vital Signs: BP: 142/82 mmHg, PR: 88 beats/min, RR: 13 beats/min,
T: 37C ___________________________________ ___________
KUT:

_____ _______

HEPATIC: _____________________________________ ______

CVS:

__________

____ __________

CHEST: _____________________ ________________________

BLOOD: _____________________________________ ________
ABDO: _______________________________________________
SKIN/MUSCLE: _______________________________________
NEURO/MENTAL: _____________________________________
HEENT:

_____________________________________ ________

GIT: ________________________________________ _________

Vital Signs

19/12

21/12

23/12

25/12

27/12

28/12

37

37

36.6

37

37

37

142/82

137/53

150/65

120/75

140/80

142/58

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

T (oC)
BP (mmHg)
HR (beat/min)

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 mol/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

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

= 186 x (SCr / 88.4)

-0.203

x (age)

-1.154

x (0.742 if female) x (1.210 if black)

-0.203

= 186 x (259 / 88.4)

x (77)
= 16.53 ml/min/1.73m

x (0.742)

Stage

Description

GFR ml/min/1.73m2

Kidney damage with normal or GFR

90

Kidney damage with mild GFR

60 89

Moderate GFR

30 59

Severe GFR

15 29

Kidney failure (ESRD)

<15 (or dialysis)

Patients CKD stage

16.53 ml/min/1..173 m2

Cardiac Enzymes
Normal range
CK
LDH
Aspartate Transaminase

30 - 200
135 - 225
5-34

Others
Normal range
RBS

4-11mmol/L

21/12

23/12

25/12

27/12

28/12

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 +
cilastatin) 500mg
IV Fluconazole 200mg

TDS

20/12/11

21/12/11

OD

21/12/11

27/12/11

Surgical prophylaxis
-broad spectrum bactericidal agent
Treatment of fungal infection

IV Tazocin (Piperacilin +
Tazobactam) 4.5g
IV Meropenem 1g

OD

21/12/11

23/12/11

First line of intra-abdominal sepsis

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

40mg
T. Amlodipine 5mg
T. Simvastatin 40mg
IV Frusemide 40mg

OD

20/12/11

28/12/11

STAT & OD
ON
Run 1mg/hour

19/12/11
19/12/11
21/12/11

Continue
Continue
Continue

TDS
STAT
TDS
OD

21/12/11
21/12/11
19/12/11
21/12/11

29/12/11
Continue
20/12/11
Continue

Prophylaxis of deep vein

thrombosis
Hypertension
Prevention of cardiovascular events
Treatment of resistant hypertension
and prevention of fluid overload
Treatment of potassium deficiency
Treatment of potassium deficiency
Prophylaxis of stress ulcer
Treatment of anemia (off label
used) and neutropenia

TDS
BD
BD

22/12/11
22/12/11
21/12/11

24/12/11
Continue
26/12/11

T. Folate/ B complex
40mg
T. Esomeprazole 40mg

OD

28/12/11

Continue

OD

27/12/11

Continue

IV Vit K 10mg
IV N-Acetyl Cysteine

STAT

22/12/11
25/12/11

Continue
26/12/11

Mist KCl 15ml

IV KCl 1g
IV Ranitidine 50mg
IV Filgastrim 300mcg/ml
[recombination human
granulocyte-colony
stimulating factor (GCSF)]
IV Bromhexine 8mg
IV Tramadol 25mg
IV Pantoprazole 40mg

11

Mucolytic agent
Relief of moderate to severe pain
Proton pump inhibitor
Prophylaxis of stress ulcer
To provide energy
Treat anemia
Proton pump inhibitor
Prophylaxis of stress ulcer
Correct any clotting defect
Mucolytic agent

Patients progress report in the ward

Date
General

19/12
Alert, conscious, lethargic looking,
mildly dehydrated, pink (not
jaundiced)

20/12
General condition same, a febrile,
calcified uterine fibroid noted

21/12
General condition same,
Gangrenous bowel 2 to internal
herniation

142/82
88
37
Colicky abdominal pain
-

139/67
103
13
37
Colicky abdominal pain
-

137/53
75
17
37
No pain
6.2

Vital signs
BP
PR
RR
T
CVP
O2Sat
Lungs
Abdomen
CVS
DXT (mmol/L)
Plan
-

Start T. Amlodipine 5mg

stat & od
Start T. Simvastatin 40mg
on
Start IV Ranitidine 50mg tds
Monitor BP 2 hourly
KIV to add another
antihypertensive if
persistently high
Keep patient NBM
Start IV drip 4pins (normal
saline and dextrose 5%)

12

Off IV Ranitidine 50mg tds

Start T. Pantoprazole 40mg
bd
Monitor vital signs
Inform stat if bp> 100/90
mmHg or PR > 120
beats/min
Start IV Imipenem 500mg
tds
Start S/C. Enoxaparin
Sodium 40mg od
Laparotomy on 10.30 p.m.

Off IV Imipenem 500mg tds

Start IV Fluconazole 200mg
od
Start IV Piperacilin 4.5g od
Start T. Metoprolol 50mg bd
Start IV Frusemide 40mg run
1mg/hour
Start IV KCl lg stat then
convert to Mist. KCl 15ml tds
Start IV Filgastrim
300mcg/ml
Start TPN

Patients progress report in the ward

Date

22/12
General condition same,
decompensated metabolic
acidosis

23/12
General condition same,
respiratory distress

24/12
General condition same, pupil
sluggish bilaterally, poor GCS

Lungs

150/55
68
23
37
-

150/65
80
13
36.6
-

135/70
102
18
37
-

Abdomen

No pain

No pain

No pain

CVS

6.4

7.4

7.4

General
Vital signs
BP
PR
RR
T
CVP
O2Sat

DXT (mmol/L)

Plan
-

Start IV Tramadol 25mg

bd
Start IV Vit K 10mg stat
to correct any clotting
defect

Off IV Piperacilin 4.5 g

od

13

Start IV Meropenem 1g
tds
Off IV Bromhexine

Patients progress report in the ward

Date

25/12
General condition same, sepsis

26/12
General condition same

27/12
Alert, not tachypnea, GCS
improved

120/75
93
14
37
-

143/83
101
20
37
-

140/80
66
22
37
-

No pain
6.9

No pain
9.9

No pain
9.7

General
Vital signs
BP
PR
RR
T
CVP
O2Sat
Lungs
Abdomen
CVS
DXT (mmol/L)

Plan
-

Start IV N-Acetyl
Cysteine
Continue IV Fluconazole
200mg tds
Continue IV Meropenem
1g tds
Continue T. Metoprolol
50mg bd
Continue S/C Enoxaparin
Sodium 40mg od
Continue Mist KCl 15ml
tds
Continue IV Pantoprazole
40mg bd

Off T. Metoprolol 50mg

bd, then convert to T.
Metoprolol 100mg bd
Off IV Pantoprazole
40mg bd
Off IV N-Acetyl Cysteine

14

Off IV Fluconazole 200mg

od
Continue IV Meropenem
1g tds
Continue T. Metoprolol
100mg bd
Continue S/C Enoxaparin
Sodium 40mg od
Start IV Esomeprazole
40mg od
Off TPN, allow oral
feeding

N. DRUG THERAPY PROBLEM LIST (DTPL)

Date

DRP (medication related)

Recommendation

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 patients 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.
Incorrect dose of tab. Simvastatin 40mg when
prescribed with tab. Amlodipine.

19/12/11

15

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 patients blood count because she cannot
tolerate oral feeding yet.
Suggest to give IV potassium chloride, KCl 1g stat to
correct patients 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

prescribed to the patient.

Suggest to give ferrous fumarate, folic acid and

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 27/12/11

TPN bag 5 (total energy: 1000 kcal) has been selected

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. PHARMACISTS CARE PLAN MONITORING WORKSHEET (PMW)

Pharmacotherapeutic
Goal (based on the above
DRP)

Monitoring
Parameter

Desired
Endpoint

Monitoring
Frequency

1. Treat the underlying

cause that lead to
hypoalbuminemia.

Serum albumin
level

To correct hypoalbuminemia before

albumin replacement can be done

Every day

2. Treat anemia.

i)RBC count
ii) Hemoglobin
count
iii) Hematocrit
count
i) Random blood
glucose level
ii) Fasting blood
glucose level

4.5 5.5 10 12 /L
13 17 g/dL

Every day

4. Maintain the blood

pressure within desired
range.
5. Monitor patients
condition closely to ensure
that TPN given provides
adequate amount of fluid,
nutrients, etc.

3. Control the blood

glucose level.

40 50 %
< 10 mmol/L

Upon admission

< 7 mmol/L

Every 2 days

Blood pressure

< 120/80 mmHg

Every 6 hours

Patients hydration
status, serum
electrolytes level,
blood glucose,
other nutrients

To ensure the patient received adequate Every day on TPN

amount of nutrients and fluid needed
from TPN bag given as similar as when
she takes oral feeding

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 patients 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 patients
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

Yes

No

Do not
know

1. Are there previous conclusive reports on this reaction?

+1

2. Did the adverse event appear after the suspected drug

was administered?

+2

-1

3. Did the adverse reaction improve when the drug was

discontinued or a specific antagonist was administered?

+1

4. Did the adverse reaction reappear when the drug was

readministered?

+2

-1

5. Are there alternative causes (other than the drug) that

could on their own have caused the reaction?

-1

+2

6. Did the reaction reappear when a placebo was given?

-1

+1

7. Was the drug detected in the blood (or other fluids) in

concentrations known to be toxic?

+1

8. Was the reaction more severe when the dose was

increased, or less severe when the dose was decreased?

+1

9. Did the patient have a similar reaction to the same or

similar drugs in any previous exposure?

+1

10. Was the adverse event confirmed by any objective

evidence?

+1

20

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, and weight in kg and serum creatinine mg/dl
If serum creatinine is expressed as mol/liter instead of mg/dl, calculation is based on:
88.4 mol/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 mol/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

22