University of the Western Cape
School of Pharmacy
Pharmacology & Clinical Pharmacy
Therapeutic Work-Up Notes (2020)
Student Name: _____________________________________
Student #:
_________________________________________
A. PATIENT ASSESSMENT
PAST MEDICATION HISTORY
MEDICAL HISTORY
REASON FOR ENCOUNTER
DEMOGRAPHICS
PATIENT
Name:
Admission Date:
Dwayne Morrison
Age (years):
59
Birth Date:
Weight (kg):
83
Height (m):
Pregnancy:
No
Breast Feeding:
Occupation:
Manager at his company
Living
arrangements:
He lives with his wife who is a nurse
Gender:
Male
1.68
BMI(kg/m^2)
29.41
No
CrCl (ml/min)*:
68.31
Allergies:
N/A
MY WIFE SAYS I NEED TO GET MY LUNGS CHECKED. EVER SINCE WE MOVED , I AM HAVING A HARD TIME BREATHING
Drug eluting stent 2years ago. Coronary artery disease and myocardial infection 7 years ago. Normal echocardiogram and stress test 3
months ago. Had a Chronic bronchitis 8years and has increased over last 12 months.
Medication
Dosage
Asprin
81mg PO once
Start Date
Stop Date
Indication
daily
Budesonide/formoterol
80mcg/4.5mcg
two inhalation
twice a day
OTC naproxen
220mg every 12
hours PRN
Rosuvastatin
20mg PO twice a
day
1
* CrCl = (140 – age[years]) X weight[kg] / serum Cr[umol/L] If female, multiply with 0.85
SOCIAL DRUG USE
Substance
History of Use
Substance
History of Use
Tobacco per day
5 to 6 cigarettes per day
Alcohol per day
2 beers most nights of the workweek and 2 to 3
glasses of wine on weekends
Caffeine cups per day
Other
N/A
,
Laboratory investigations (only list, don’t provide results)
Diagnostic investigations
Liver function test
INVESTIGATIONS
Full blood count
1.White blood cell
2.Haemoglobin
3.Hematocrit
4.Platelet
Kidney function test
REVIEW OF SYSTEMS
Pulmonary function test
CNS:
Muscle: Sharp pain, tingling neck muscle
ENT:
CVS:
Resp: decreased breath sound, chronic cough
Urology:
GIT:
Endo:
Skin: warm, dry
Other:
Day:
0
1
2
3
4
5
6
7
8
9
10
VITAL SIGNS
Date:
Blood Pressure:
110/68
Heart Rate:
Respiratory Rate:
16
Temperature:
37
Prioritize according to importance:
DIAGNOSIS
Mr Morrison has Chronic Obstructive Pulmonary Disease due to the shortness of breath, chronic cough, results from spirometry test (
FEV1-FVC ratio is less than 0.7),
Chronic obstructive pulmonary disease . This is highly supported by family history , chronic cough, cervical radiculopathy.
2
Medication
Dosage
0
1
2
3
4
5
6
7
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9
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Indication
CURRENT MEDICATION (POST ADMISSION
Date:
Medicine X
X gm PO, TDS
Medicine S
S mg IV, TDS
B. THERAPEUTIC PLAN
Unnecessary Drug Therapy
Needs Additional Drug Therapy
1.
Dosage too Low
Adverse Drug Reaction
Dosage too High
Alternative Drug Therapy
Non-adherence
Other
Description of Drug Related Problem
Mr Dwayne will experience less therapeutic effects due to inefficient dose of Budesonide/formoterol administered.
DRUGS THERAPY PROBLEM (PRIORITIZE YOU DRPS)
Therapeutic Alternatives (medicine, dose, duration). List all possible alternatives. Rationalize your decision.
Mr Dwayne should use a dose of Budesonide/formoterol of 160mcg/4.5mcg 12hrs daily. This will improve drug effect as the previous
dose of 80mcg/4.5mcg was less effective.
2.
Description of Drug Related Problem
Mr Dwayne will experience adverse reactions when administering aspirin this is due to
Aspirin having a small therapeutic index with irreversibly inhibition(due to high protein binding) of inflammatory
mediators(prostaglandin) cause reduced mucus that reduce immune response and is highly reactive with alcohol.
Therapeutic Alternatives (medicine, dose, duration). List all possible alternatives. Rationalize your decision.
Mr Dwayne should use naproxen 220mg PO 12hrs PRN. This is because the drug performs similar function as aspirin is of the same
pharmacological class of nonsteroidal anti-inflammatory drug and this drug is a reversible inhibitory of inflammatory mediators
unlike aspirin.
3.
Description of Drug Related Problem
Therapeutic Alternatives (medicine, dose, duration). List all possible alternatives. Rationalize your decision.
3
4.
Description of Drug Related Problem
Therapeutic Alternatives (medicine, dose, duration). List all possible alternatives. Rationalize your decision.
Goal of Therapy (Parameter/Value/Time-frame)
1. We want to reduce shortness of breath from moderate to mild within 7 days.
2. We want to improve the ratio of force expiratory volume and force vital capacity from 0.6 to above
GOALS OF THERAPY
0.7 within 7 days.
3. We want to reduce COPD severity from moderate to mild within 6 weeks.
4.
5.
6.
4
We Recommend that Mr Dwayne must start to join community support groups or visit a psychologist to help
him reduce or quit tobacco use.
We advice that Mr Dwayne must have an annual influenza vaccine since he has an immunocompromised
system.
DISEASE GOALS
We advice that Mr Dwayne must avoid any dusty or smokery area at work as this exacerbates his condition.
We advice that Mr Dwayne must have a musk on when ever he is doing his hobbies ie gardening so as to
reduce any allergic response that may be triggered.
If Mr Dwayne has an option he must consider returning back in his previous house or avoid being outdoors as
the area is in high altitude, so inhaled air is cold which triggers bronchoconstriction of airway.
NON-PHARMACOLOGICAL THERAPY & PATIENT EDUCATION
Patient Education Points (pharmacologic and non-pharmacologic):
We are going to educate Mr Dwayne about various types of inhalers and recommend a suitable inhaler with a large volume
spacer so as to improve drug delivery to the lungs. We also going to educate him about the proper techniques of using the
inhaler. We also going to advice him on how to hygienically take care of the volume spacer by washing it with cool water and
soap.
C. FOLLOW-UP AND MONITORING
5
Meds.
Effectiveness Monitoring
Safety Monitoring (side effects/ADR)
(Physical assessment/Laboratory investigation)
(Physical assessment/Laboratory investigation)
Formoterol
Hypersensitivity to the active ingredients or any of its
Regular check up on blood glucose levels as this drug can
excipients. Closely monitor wheezing as the drug has
alter the blood glucose.(confirm how changes are measured)
exacerbating effects.
and also monitor the levels of potassium serum.
Naproxen
Measure of creatine to monitor glomerular function as the
FOLLOW-UP EVALUATION
drug affect the kidney and hepatic function.
Budesonide/formoterol
We are going to measure the increase of force
expiratory volume using a spirometry to check whether
an increase from 50% to 80% is achieved.
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Notes/Remarks
PROGRESS NOTES
Date:
D. LABORATORY RESULTS
HAEMATOLOGY
REFERENCE
RANGE
White Blood Cells (WBC)
Red Blood Cells (RBC)
Haemoglobin (HB)
Hematocrit (HCT)
MCV
MCH
Platelets (PLT)
C-Reactive Protein (CRP)
INR
PTT
Fibrinogen
PT
D-Dimer
Iron Serum
Ferritin
Vitamin B12
Folic Acid
4 – 11 /L
3.8 – 4.8 /L
14 – 18 gm/L
0.368 – 0.473 L/L
77.1 – 91.5 fl
25.8 – 31.7 pg
140 – 440 /L
0 – 10
1.0 – 1.2
35 – 45 sec
1.8 – 3 g/L
10 –12 sec
< 250
10 – 30 umol/L
10 – 120 ug/L
200 – 1100
2 – 15
ARTERIAL BLOOD GAS
REFERENCE RANGE
pH
PO2
PCO2
Base Excess
HCO3
Oxygen Saturation (O2 Sats)
7.35 – 7.45
75 – 90 mm Hg
35 – 45 mm Hg
-2 to +2
20 – 25 mmol/L
95 – 98 %
CEREBROSPINAL FLUID
REFERENCE RANGE
Protein
Glucose
Chloride
0.1 - 0.45g/L
2.5 – 5.5 mmol/L
120 – 130 mmol/l
DATE
7
CSF – ADA
< 6 u/L
CHEMISTRY
REFERENCE RANGE
Na
K
Cl
Urea
Creatinine
Phosphates
Calcium
135 – 147 mmol/L
3.5 – 5.3 mmol/L
95 – 105 mmol/L
2.6 – 7.0
Mmol/L
0.80 – 1.60 mmol/L
2.20 – 2.56 mmol/L
LIVER FUNCTION TEST
REFERENCE RANGE
Total Protein
Albumin
Total Billirubin
ALP
AST
ALT
GGT
Total Cholesterol
LDL
HDL
60 – 85 g/L
40 – 60 g/L
3.42 – 25.7 umol/L
40 – 120 u/L
5 – 40 u/L
5 – 40 u/L
0 – 60 u/L
3.87 – 5.17 mmol/L
<4.1 mmol/L
>1.04 mmol/L
OTHER TESTS
REFERENCE RANGE
8