SUPPLEMENTARY COURSE IN DISPENSING AND RATIONAL …pei-cme.com/prime/uploads/Patient Assignment 1...(ii) Volume 1 Course Manual: Chapter 1: Basics Of Applied Therapeutics; Sections

Pharm-Med Education International © 2014 Enhancing Patient Lives Through Training Excellence

Page 1 Supplementary Course in Dispensing and Rational Prescribing ISBN:0-620-33652-8 May 2013: 5th

Edition

PHARMACY EDUCATION INTERNATIONAL© 2013: Enhancing Patient Lives through Training Excellence

Supplementary Course in

Dispensing and Rational Prescribing

PRACTICAL COMPETENCY ASSESSMENT

PATIENT ASSIGNMENT 1:

CONDUCT A CASE ANALYSIS

ON A PROBLEMATIC PATIENT CASE

EXAMPLE WRITE UP __________________________

PATIENT ASSIGNMENT #1 __________________________

CASE ANALYSIS: ADAM M.

__________________________



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Assignment Brief: Conduct a Clinical Audit on a Problematic Patient Case where

the therapeutic management has been unsuccessful because it has consistently

failed to achieve satisfactory Clinical Targets and Therapeutic Outcomes.

Before commencing this assignment you need to:-

1) Review and be familiar with the content material in:

(i) Module 2 of the Online Dispensing Course Material: Assessment of the Prescription

(ii) Volume 1 Course Manual: Chapter 1: Basics Of Applied Therapeutics; Sections 3 to 7: pages 3

to 13 and Section 10: pages 20 - 30 (making effective use of the SAMF).

(iii) The case study of George M (Section 3 page 3) and its preliminary work up as laid out in the

above references as well as the model write-up for George M's case (see below)

(iv) The Formative Competency Assessment for the case study of Patient Xolile Mguni.

2) Think carefully about the type patient case that is likely to fulfill the criteria for this assignment. The

most suitable patients to choose for these assignments are those with coexisting morbidities.

Therefore you are required to IDENTIFY A PATIENT WITH TWO OR MORE CHRONIC CONDITIONS

THAT HAVE NOT BEEN EFFECTIVELY CONTROLLED.

3) Ensure that you select an appropriate case which enables you to systematically review the patient’s

medical and clinical history to establish how well the conditions have been controlled and whether

or not medical treatment of the conditions has been effective or ineffective. Therapeutic problems

that are lifestyle related and that present problems with patient education and adherence as well as

problems related to drug therapy (choice of inappropriate medications, incorrect doses or dose

intervals, adverse drug reactions and drug interactions) are common in patients with Chronic

Diseases of Lifestyle (Cardiovascular Disease, Diabetes, Respiratory – including HIV and TB;

Gastrointestinal etc) and other chronic conditions (especially Thyroid disorders, Epilepsy, Mood

disorder etc).

4) As a template and a guide to what is expected in this assignment, refer to the Model Write Up that

you can download (from the Online component of Module 2 of the Dispensing Course: Assessment

of the Prescription) or which you have received for the Patient Case Analysis of George M. His case

is presented in the Volume 1 Course Manual: Chapter 1: Section 3 (p3 – 5)

5) Make sure your case has sufficient clinical information and detail to fulfill the Assignment

requirements laid out below

To complete this assignment successfully the following criteria must be met:

In the process of undertaking this assignment, you will:

(A) Need to have official permission from the facility manager / responsible pharmacist to obtain the

folder of a patient who case fulfills the criteria of Points (1) and (2) above.

(B) Learn how to apply the process we referred to SPIPA (Structured Procedure In Pharmacotherapy

Assessment: Volume 1 Course Manual: Chapter 1: Sections 5(i) and (ii); pages 9 and 10). In this

process you will learn how to ‘tease out' a patient case by following exactly the same principles

embodied in the example given in George M's case and in Xolile Mguni's case



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(C) Adhere to the following procedure in completing your Clinical Audit Assignment report:

1) Record the Folder number and Demographic data of the patient concerned (Section 4 (i) p 6)

2) Summarize the patient’s Personal details, Family history details Social History and Lifestyle

details (choose a patient where this information is available) Section (Section 4 (i) p 6)

3) Record the patients Medical Condition History – give a short summary (2 – 3 lines) for each of the

diagnosed or reported conditions you identify (Section 4 (i) p 7)

4) Make sure you record the patient’s RELEVANT clinical and medication history data clearly and

systematically on your Assignment form, by GROUPING SIMILAR READINGS TOGETHER IN A

SEQUENTIAL AND CHRONOLOGICAL ORDER. For example systematically group your patients

Body Mass records together, blood glucose values together, BP readings together etc so that it is

easy to follow the trends of how these clinical parameters vary. Record data for the following:

(i) Systematically record the patients Clinical Measurements (Body Mass; BMI; BP; ECG

results; Peak Flow etc) (Section 4 (i) p 7)

(ii) Systematically record the patients Laboratory data (HGT; Serum Creatinine; TSH; Uric

Acid; K+; CD4 count and Viral Load etc.) (Section 4 (i) p 7)

(iii) Systematically record the patients Medication History (Section 4 (i) p 8)

5) Because of the volume of clinical data in that is often present in patient cases of this nature – it is

important to be selective in the data you include in your case write-up. Do not include data that

have no bearing on the problems being addressed.

6) Compile a patient Problem List and arrange these problems in your order of priority (Section 4 (ii)

p 8). NOTE: Each of the patients Chronic Conditions become part of your Problem List

7) APPLY the SPIPA process (Sections 5(i) and (ii)) and follow it as applied in Xolile Mguni's case.



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8) Systematically analyse the patients REGIMEN HISTORY and assess the APPROPRIATENESS of the

MEDICATIONS PRESCRIBED for EACH of the patient’s MORBIDITIES.

9) Compile a S O A P NOTE for EACH OF THE PATIENTS CHRONIC CONDITIONS and discuss the

problems you identify (Section 6 page 11).

10) Your discussion of Medication Appropriateness should be:

o in terms of your own understanding of what you consider to be the advantages or

disadvantages of each prescribed medication and why they have, or have not, been

effective.

o Where you feel that interventions, in terms of changes in therapy or treatment options,

would benefit the patient – have no reservations to discuss these.

o Always consider Polypharmacy and whether, in your opinion, it is possible to decrease the

number of medications prescribed.

o Be aware that the prescription of more medications, at higher doses, is often the

consequence of unsuspected or undetected Non-adherence.

o NOTE THAT YOU WILL BE REWARDED FOR SHOWING CRITICAL THINKING SKILLS IN THESE

ASPECTS. YOU WILL NOT BE PENALISED FOR ERRORS OF JUDGEMENT DUE TO LACK OF

EXPERIENCE IN THESE ASPECTS.

o REMEMBER THIS IS A LEARNING PROCESS

11) Compile a Case Summary and set realistic Therapy Targets to suit the particular circumstances of

your patient’s case. These include Lifestyle, Adherence and Pharmacotherapy Targets (Section 7

page 12)


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PATIENT ASSIGNMENT # 1

PATIENT CASE ANALYSIS – EXAMPLE REPORT

PRACTITIONER NAME: Sr. Florence Nightingale PROF. REG NO: SANC 0123456 DATE 3rdMarch 2015 PRACTITIONER SIGNATURE: F Nightingale PRACTITIONER CONTACT ADDRESS: 1 Meyer Street; PLUMSTEAD COMMUNITY HEALTH CENTRE BONTEHEUWEL CHC TELEPHONE: 021-7825116 // 082-393-1170

RESPONSIBLE OFFICER (Print): MICHAEL F PERKIN DATE: : : : 3rdMarch 2015 SIGNATURE: M.F. Perkin TELEPHONE 021-7977306 // 082-372-6873

Patient Demographic data Patient General Information

Family Name Mitchell Marital Status Married Single X Sex M X F Date of Birth 25/06/1979 First Name Adam Mass (Kg) 85 Height (m 1.62 BMI(m/h2) 32 Waist (cm) Hip (cm) Waist:Hip

Folder No PEI CDC 777-77-7 Patient Chronic Conditions

# Condition Date Dx # Condition Date Dx

1 HYPERTENSION 2010 (Jan) 4 HIV (+) 2013 (Sept) 2 OSTEOARTHRITIS 2012 (May) 5 RENAL IMPAIRMENT 2014 (Feb)

3 GORD 2012 (Dec) 6 DIABETES 2015 (Feb)

Other Dx / Conditions: Record of CHRONIC NON-ADHERENCE as well as ETHANOL ABUSE and generally UNHEALTHY LIFESTYLE.

SUMMARY PATIENT SOCIAL HISTORY

Tobacco: Started smoking in senior high school at age 15 years. ± 10 Pack years.

Exercise: Does not exercise regularly. Spends a lot of time watching TV

Alcohol: +++ excessive consumption over weekends with periodic binge drinking.

Diet: Poor dietary lifestyle. High salt, High

Carbohydrate (starch & refined sugar) intake

Caffeine: ± 6 Cups/Day Allergies: None noted Personal: Unmarried Caucasian male with tertiary diploma in business administration. Employment: middle management at position with a leading commercial retailer. Medical Aid: Member of Employers corporate Medical Insurance fund. Patients’ regular Doctor is a private medical practitioner. Social: financially independent with active social life. No committed close personal relationships.


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SUMMARY HISTORY OF DIAGNOSED CONDITIONS

1) HYPERTENSION: Grade 3 (SEVERE) HPT first diagnosed in January 2010 at age 31. Initial Rx Enalapril 10 mg in the morning. Regimen subsequently escalated to 5 agents (Enalapril HCTZ, Atenolol, Amlodipine & Doxazosin) by June 2013 with no noticeable clinical effectiveness. 2) OSTEOARTHRITIS: Diagnosed, with symptoms of chronic joint pain, in May 2012 as a consequence of Obesity resulting in an excessive burden on weight bearing joints (hip and knee). 3) GORD: Diagnosed in December 2012 to as a likely consequence NSAID-induced (Diclofenac) gastric ulceration. 4) HIV POSITIVE: Diagnosed in September 2013. ART therapy initiated with 2 fixed-dose combination (FDC) products; TRAVUDA (Tenofovir 300 mg / Emtrictabine 200 mg) and ALUVIA (Lopinavir 200 mg / Ritinovir 50 mg) 5) RENAL IMPAIRMENT: Diagnosed in February 2014 with estimated GLOMERULAR FILTRATION RATE (eGFR) of 49 mL/min. 6) DIABETES: Newly diagnosed in February 2015. Referred for Oral Glucose Tolerance test (OGT) for confirmation of diagnosis

CLINICAL & LAB DATA RELEVANT TO THERAPY PROBLEMS (e.g. Patient Mass, BMI, BP, HGT / HbA1c; Lipids; PEFR, TSH/T4; Hb; ECG; CD4 / Viral Load; Sputum; Liver and other Enzyme tests; Sr. Creatinine; Electrolytes

TEST DATE RESULT OBSERVATIONS

(include TARGET / NORMAL RANGE for data)

MASS (30.5yr) 26/01/2010 102 Kg Initial Target BMI < 36; Target Mass ± 94 Kg BMI 26/01/2010 38.9 (Optimal Target BMI < 25; Mass ± 65 Kg) MASS (34yr) 24/06/2013 95 Kg Weight loss not associated with diet change BMI 24/06/2013 36.2

MASS (34.5yr) 17/02/2014 89.5 Kg Weight loss not associated with diet change BMI 17/02/2014 34.1 MASS (35.5yr) 23/02/2015 84.8 Weight loss not associated with diet change BMI 23/02/2015 32.3

Blood Pressure: Target <140/90mmHg (Nondiabetics); <130/80mmHg (Diabetics) Blood Pressure 26/01/2010 180/118 Tuesday HR 92: Start HPT Med:Enalapril 10md/d Blood Pressure 29/03/2010 116/53 Monday: HR 72 Blood Pressure 05/07/2010 192/128 Monday: HR 108: HPT + Atenolol 100mg/d

�Enalapril 20mg/d Blood Pressure 16/08/2010 184/112 Monday: HR 96: HPT + Amlodipine 5mg/d Blood Pressure 17/01/2011 165/103 Monday: HR 98: HPT + HCTZ 12.5mg/d Blood Pressure 09/06/2011 170/90 Thursday Blood Pressure 13/02/2012 178/121 Monday: HR 88: HPT � Amlodipine 10mg/d Blood Pressure 14/05/2012 170/100 Monday: HR 92: Start Diclofenac 25mg 3/d Blood Pressure 10/09/2012 214/136 Monday HR 104: HPT � HCTZ 25mg/d Blood Pressure 04/12/2012 225/139 Tuesday HR 106: Admitted defaulting meds


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RELEVANT PHYSICAL MEASUREMENTS / LABORATORY TESTS (Continued)



Blood Pressure 24/06/2013 208/130 Monday: HR 112: HPT +Doxazosin 4mg/d; Stop Diclofenac start Ibuprofen 400mg 3xd

Blood Pressure 20/09/2013 160/85 Friday: HR 82: Begin ARV Therapy Blood Pressure 13/12/2013 156/92 Friday: HR 86: HIV Markers Improved; Add

Amitriptyline for pain control Blood Pressure 17/02/2014 164/88 Monday HR 90: HIV Markers Improve: Blood Pressure 11/08/2014 211/127 Monday: HR 108: HPT � Doxazosin 8mg/d;

HIV Markers deteriorate: Add Tramadol for pain Blood Pressure 23/02/2015 184/124 Monday: HR 104: HIV Markers deteriorate

Renal Function: Use eGFR (MDRD formula) in OBESE (Compare Cockroft-Gault (C-G) Values) Sr. Creatinine 17/01/2011 72mcmol/L 110mL/min/1.73m2 || Age 32 yrs

Age 33 yrs 13/02/2012 82mcmol/L 94mL/min/1.73m2 Age 34 yrs 24/06/2013 94 mcmol/L 79mL/min/1.73m2||C-G Formula: 111 ml/min Age 35 yrs 17/02/2014 118mcmol/L 61mL/min/1.73m2|| C-G Formula: 83 ml/min Age 36 yrs 23/02/2015 142mcmol/L 49mL/min/1.73m2|| C-G Formula: 65 ml/min

Liver Enzymes: Assessment of alcohol abuse: Normal ALT 0-40IU/L: GGT 0-45 IU/L ALT 10/09/2012 58 IU/L Target <40 GGT 72 IU/L Target <45 ALT 20/09/2013 25 IU/L Target <40 GGT 32 IU/L Target <45 ALT 11/08/2014 88 IU/L Target <40 GGT 120 IU/L Target <45 ALT 23/02/2015 76 IU/L Target <40 GGT 108 IU/L Target <45

Blood Lipids: Assessment of Patient Cardiovascular Risk TotCholesterol 09/06/2011 4.8mmol/L Target: < 5.o mmol/L

LDL 09/06/2011 2.6mmol/L Target: < 2.8 mmol/L TotCholesterol 14/05/2012 4.2mmol/L Target: < 5.o mmol/L

LDL 14/05/2012 2.2mmol/L Target: < 2.8 mmol/L TotCholesterol 04/12/2012 3.8mmol/L Target: < 5.o mmol/L TotCholesterol 23/02/2015 4.5mmol/L Full Lipogram ordered

LDL 23/02/2015 2.4mmol/L Target: < 2.8 mmol/L HDL 23/02/2015 0.9mmol/L Target: > 1.0 mmol/L

Triglycerides 23/02/2015 2.6mmol/L Target: < 1.7 mmol/L


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RELEVANT PHYSICAL MEASUREMENTS / LABORATORY TESTS (Continued)

Fasting Blood Glucose: Normal 4.1-5.6; Metabolic Syndrome 5.8-6.9; Diabetes õ7.0 mmol/L HGT 04/12/2012 5.7mmol/L Borderline / Pre-Metabolic Syndrome 23/02/2015 7.6mmol/L Patient probably Diabetic-Retest to confirm



HIV Markers: Target CD4: > 500 cells/Microlitre : Target Viral Load: LDL (< 40 Copies/mL) CD4 20/09/2013 135

Viral Load 20/09/2013 58773 Start ARV Therapy: Tenofivir/Emtricitabine (Truvada) Plus Lopinavir/Ritinovir (Aluvia)

CD4 13/12/2013 175 Viral Load 13/12/2013 17 326

CD4 17/02/2014 248 Viral Load 17/02/2014 42

CD4 11/08/2014 175 Viral Load 11/08/2014 273 000

CD4 23/02/2015 105 Viral Load 23/02/2015 325 723


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MEDICATIONS ISSUED ON THE PATIENTS LATEST CHRONIC PRESCRIPTION

(i.e. The LAST Prescription before you started your review of the Patient Case)

Date Rx Dispensed

1 0 || 0 2 || 2015

Condition Med Rx for Active ingredient (INN name), Dosage

Form and Strength Dose & Dose Interval

Prescribed

HYPERTENSION ENALAPRIL (Pharmapress®) 20mg/d/am

ATENOLOL (TenBloka®) 100mg/d/am

AMLODIPINE (Amloc®) 10mg/d/am

HYDROCHLORTHIAZIDE (Ridaq®) 25mg 1xd

DOXAZOSIN (Adco-Doxazosin®) 8mg/d/am

ANTIPLATELET ASPIRIN (SOLUBLE) 150mg 1xd

OSTEOARTHRITIS (Chronic Joint Pain)

IBUPROFEN (Neurofen®) 400mg 3xd

AMITRIPTYLINE (Trepiline®) 25 mg/d/pm

TRAMADOL (TramaHexal®) 50mg 3xd

GORD OMEPRAZOLE (Losec®) 20 mg/d

HIV Positive TENOFOVIR 300 mg (Travuda®) 300mg 2xd

EMTRICITABINE 200mg (Travuda®) 200mg 2xd

LOPINAVIR 200mg (Aluvia® FDC) 400mg 2xd

RITONAVIR 50 mg (Aluvia® FDC) 100mg 2xd

HISTORICAL RECORD OF MEDICATION REGIMEN CHANGES

Condition Rx for Active ingredient & Trade name Dose /

Frequency Date Start Date Stop

HYPERTENSION ENALAPRIL (Pharmapress) 10mg/d/am 26/01/2010 05/07/2010

20mg/d/am 05/07/2010 Continued-->

ATENOLOL (TenBloka) 100mg/d/am 05/07/2010 Continued-->

AMLODIPINE 5mg/d/am 16/08/2010 13/02/2012


HYDROCHLORTHIAZIDE 12.5mg 1xd 17/01/2011 10/09/2012

25mg 1xd 10/09/2012 Continued-->

DOXAZOSIN 4mg/d/am 23/06/2013 11/08/2014


ANTIPLATELET ASPIRIN (SOLUBLE) 150mg 1xd 29/03/2010 Continued-->


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PATIENT PROBLEM LIST Priority Problem

1 Poor Case Management: Lack of effective Behaviour Change Counseling and failure to deal with Non Adherence, Substance Abuse (Ethanol) & Unhealthy Diet

2 Uncontrolled Hypertension and CV Risk Status: Hypertension has been poorly managed with Inappropriate Prescribing. Patient now manifests Clinical Cardiovascular Disease (CCD) with Renal Failure.

3 Continuous (uninterrupted) use of ASPIRIN in the face of sustained, severely elevated, Blood Pressures

4 Osteoarthritis (Chronic Joint Pain) and Gastro-Osophageal Reflux (GORD): Excess burden on weight-bearing joints with long-term NSAID use needing Omeprazole

5 HIV Positive: Inappropriate regimen prescribed for initiating Anti Retroviral Therapy (ART) - introduces complications for ongoing management

6 Diabetes: Newly diagnosed - approach to management requires careful consideration

7 Lipid Tests and their Interpretation

8 Potential for Multiple Complex Drug Interactions

HISTORICAL RECORD OF REGIMEN CHANGES (Continued if necessary)

Condition Rx for Active ingredient & Dosage Strength Dose /

Frequency Date Start Date Stop

OSTEOARTHRITIS (Chronic Joint Pain)

DICLOFENAC 25mg 3xd 14/05/2012 24/06/2013

IBUPROFEN 400mg 3xd 24/06/2013 Continued-->

AMITRIPTYLINE 25 mg/d/pm 13/12/2013 Continued--> TRAMADOL 50mg 3xd 11/08/2014 Continued-->

GORD OMEPRAZOLE 20 mg/d 04/12/2012 Continued-->

HIV Positive TENOFOVIR 300 mg (Travuda®) 300mg 2xd 20/09/2013 Continued-->

EMTRICITABINE 200mg (Travuda®) 200mg 2xd 20/09/2013 Continued-->

LOPINAVIR 200mg (Aluvia® FDC) 400mg 2xd 20/09/2013 Continued-->

RITONAVIR 50 mg (Aluvia® FDC) 100mg 2xd 20/09/2013 Continued-->


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PROBLEM #

Subjective Data

Objective Data

Assessment of Problem

Plan to manage Problem


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PROBLEM #

Subjective Data

Objective Data




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PROBLEM #

Subjective Data

Objective Data




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PROBLEM #

Subjective Data

Objective Data




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SUMMARY PRACTITIONERS’ COMMENTS AND RECOMMENDATIONS

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PRACTITIONER NAME ____________________________

PRACTITIONER SIGNATURE __________________________ DATE ________________

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SUPPLEMENTARY COURSE IN DISPENSING AND RATIONAL …pei-cme.com/prime/uploads/Patient Assignment 1...(ii) Volume 1 Course Manual: Chapter 1: Basics Of Applied Therapeutics; Sections