Patient:

Date:

Pharmacist:

PHARMACISTS PATIENT DATABASE FORM

Patient Name: Address: Date of Birth: Height: Date of Admission/Initial Visit: Allergies/ADRs No known drug allergies/ADRs Not known/inadequate information Drug: Reaction: Patient ID: Physician: Pharmacy: Race: Weight: Occupation: Prioritized Medical Problem List Location:

Sex:

Medication Profile

HPI, PMH, FH, SH, etc.

Patient:

Date:

Pharmacist:

VITAL SIGNS, LABORATORY DATA, DIAGNOSTIC TEST RESULTS

Date Wt Temp BP Pulse Resp Na (135-145 mEq/L) K (3.3-4.9 mEq/L) Cl (97-110 mEq/L) CO2/HCO3 (22-30 mEq/L) BUN (8-25 mg/dL) Creat (M: 0.7-1.3 mg/dL, F: 0.6-1.1 mg/dL) Creat Clear. (85-135 mL/min) Glucose (fasting) (80-110 mg/dL) H/H (M: 13.8-17.2/40-50, F: 12.1-15.1/36.1-44.3) MCV (80-98) WBC (4000-10,000) Diff Platelet (140-440K) Albumin (3.5-5 gm/dL) T bili (0.3-1.1 mg/dL) D bili (0-0.3 mg/dL) AST (11-47 IU/L) ALT (7-53 IU/L) Alk phos (38-126 IU/L) Total Ca (8.6-10.3 mg/dL) Mg (1.3-2.2 mEq/L) PO4 (2.5-4.5 mg/dL) Other labs, diagnostic info, notes

DRUG THERAPY PROBLEM WORKSHEET

Type of Problem
Correlation between drug therapy and medical problems Need for additional drug therapy

Possible Causes
Drugs without obvious medical indications Medications unidentified Untreated medical conditions New medical condition requiring new drug therapy Chronic disorder requiring continued drug therapy Condition best treated with combination drug therapy May develop new medical condition without prophylactic or preventative therapy or premedication Medication with no valid indication Condition caused by accidental or intentional ingestion of toxic amount of drug or chemical Medical problem(s) associated with use of or withdrawal from alcohol, drug, or tobacco Condition is better treated with nondrug therapy Taking multiple drugs when single agent as effective Taking drug(s) to treat an avoidable adverse reaction from another medication Current regimen not usually as effective as other choices Current regimen not usually as safe as other choices Therapy not individualized to patient Medical problem for which drug is not effective Patient has risk factors that contraindicate use of drug Patient has infection with organisms resistant to drug Patient refractory to current drug therapy Taking combination product when single agent appropriate Dosage form inappropriate Medication error PRN use not appropriate for condition Route of administration/dosage form/mode of administration not appropriate for current condition Length or course of therapy not appropriate Drug therapy altered without adequate therapeutic trial Dose/interval flexibility not appropriate Dose/frequency too low to produce desired response in this patient Serum drug level below desired therapeutic range Timing of antimicrobial prophylaxis not appropriate Medication not stored properly Medication error

Problem List

Notes

Unnecessary drug therapy

Appropriate drug selection

Wrong drug

Drug regimen

Dose too low

DRUG THERAPY PROBLEM WORKSHEET (CONT.)

Type of Problem
Dose too high

Possible Causes
Dose/frequency too high for this patient Serum drug level above the desired therapeutic range Dose escalated too quickly Dose/interval flexibility not appropriate for this patient Medication error Receiving multiple agents without added benefit History of allergy or ADE to current (or chemicallyrelated) agents Allergy/ADE history not in medical records Patient not using alert for severe allergy/ADE Symptoms or medical problems that may be druginduced Drug administered too rapidly Medication error, actual or potential Effect of drug altered due to enzyme induction/inhibition from another drug patient is taking Effect of drug altered due to protein binding alterations from another drug patient is taking Effect of drug altered due to pharmacodynamic change from another drug patient is taking Bioavailability of drug altered due to interaction with another drug or food Effect of drug altered due to substance in food Patients laboratory test altered due to interference from a drug the patient is taking Patient did not adhere with the drug regimen Drug not given due to medication error Patient did not take due to high drug cost/lack of insurance Patient unable to take oral medication Patient has no IV access for IV medication Drug product not available The current regimen is not the most cost-effective Patient unable to purchase medications/no insurance Patient does not understand the purpose, directions, or potential side effects of the drug regimen Current regimen not consistent with the patients health beliefs

Problem List

Notes

Therapeutic duplication Drug allergy/adverse drug events

Interactions (drug-drug, drugdisease, drug-nutrient, druglaboratory test)

Failure to receive therapy

Financial impact Patient knowledge of drug therapy

PHARMACEUTICAL CARE PLAN

Medical Problem List Diabetes Militus tipe 2 (8 tahun yang lalu) Drug Therapy Problems Hanya dapat menunkan 1-2 % HbA1C sehingga dibutuhkan terapi tambahan obat OAD Lisinopril tidak cocok untuk DM tipe 2 tetapi DM tipe 1 sehungga penggunaan Lisinopril digantikan dengan Ramipril. HCTZ penggunaanny a kurang tepat karena ClCr Pasien <30 sehinnga diganti golongan loop diuretik Therapy Goals, Desired Endpoints HbA1C > 7 Therapeutic Recommendations Tambahkan tiazolidinediones (pioglitazone dengan dosis 15-30 mg 1 kali sehari & rosuglitazone 4-8 mg 1-2x sehari) Memberi obat yang cocok untuk pasien CKD Lisinopril digantikan dengan Ramipril 10 mg 1x sehari dapat mengurangi resiko neprophati Rational e Therapeutic Alternatives

Current Drug Regimen Metformin 1000 mg 2 x sehari

Monitoring

CKD (3 tahun yang lalu) Hipetensi (2 tahun)

Digunakan obat yang tidak memperparah CKD Lisinopril 10 mg 1x sehari HCTZ 12,5 mg 1x sehari

Mempertahanka n fungsi renal pasien Tekanan darah < 130 mmHg/80mmH g

Enapril 5 mg 1x sehari Penggunaaan ramipril 0untuk DM tipe 2 dilakukan selama kurang lebih 3,5 tahun

Hiperlipidemi a (2 tahun yang lalu)

Simvastatin 10 mg 1x1

Total kolesterol <170 LDL <110

Karena LDL > 130 mg/dL maka dapat digunkan TLC + dosis rendah statin

TLC + max dosis statin

Dimonitorin g kadar kolesterol,

yaitu Total kolesterol tinggi (<170); Kadar HDL Rendah (>45) ; Kadar Tc tinggi (> 125) Nyeri kaki akibat terkilir 1 minggu yang lalu

HDL >45 Dan trigliserida <125

LDL, HDL dan trigliserida.

Paracetamol 500 mg 6 x sehari Norco (Acetaminophen/Hidrokodo n) 500/5 mg 4-6 sehari Naproxen 500 mg 4 xehari

Batuk Kering

Tidak terdapat obat untuk mengobati batuk kering

Dikhawakan terjadi dosis yang terlalu tinggi sehingga dapat meningkatkan efek samping. Penggunaan Paracetamol dapat dihentikan cukup dengan Norco dan Naproxen karena Norco sudah mengandung Analgetik opiod sehingga cukup efektif untuk menghilangka n nyeri karena penggunaan ACEI tetap digunakan maka untuk mengurangi batuknya pasien dapat

Nyeri kaki dapat hilang

Penggunaan Paracetamol 500 mg 6 x sehari dapat dihilangkan, dan penggunaan yang tetap digunakan adalah Norco (Acetaminophen/Hidrokodo n) 500/5 mg 4-6 sehari dan Naproksen dosis diturunkan menjadi 300 mg (275-550 mg) 2 kali sehari

Dapat digunakan kodein dengan dosis 5-10 mg 3 kali sehari

Morphin dengan 5 mg setiap 4 jam atau dekstromethorpha n

Kadar PPS tinggi Kadar HbA 1C tinggi karena kadar gula darah px juga tinggi Kadar Albumin rendah

diberikan obat batuk non produktif (karena bbatuk ini kemungkinan disebabkan karena efek samping) Berhubungan dengan DM Berhbungan dengan DM

Kadar PSS <180

Kadar HbA1C <7% Kadar 4-6 g/dL

Terapi dengan OAD (diatas) Terapi dengan OAD (diatas)

Menurunnya kadar ini kemungkinan disebabkan karena efek samping dari Lisiniprol.

PHARMACEUTICAL CARE PLAN (CONT.)

Medical Problem List Current Drug Regimen Drug Therapy Problems Therapy Goals, Desired Endpoints Therapeutic Recommendations Therapeutic Alternatives

Rationale

Monitoring

PHARMACEUTICAL CARE PLAN (CONT.)

Medical Problem List Current Drug Regimen Drug Therapy Problems Therapy Goals, Desired Endpoints Therapeutic Recommendations Therapeutic Alternatives

Rationale

Monitoring

Patient:

Date:

Pharmacist: Lauren Bartoli

PATIENT EDUCATION SUMMARY