pINFORMATION

Name:c.swamireddy Age/Sex:40/m DOA:19.10.17 DOD:24/10/

Place:chittoor IP No:20171209 BMI:-
ward:msw
Edu. Qualification: Occupation:cooli
Presenting complaints:pain
and swelling in anal region
Painful defecation from 5 yrs
Cold and cough for 12 days

Diet taken on previous day:

PATIENT MEDICATION HISTORY INTERVIEW

Recent hospitalization: Yes No √ If yes, how long back:

Duration of most recent hospitalization:
Past Medical History: Hdrocele surgery-10years ago
Spine surgery-5years ago

Social history Duration Diet Gynaeic and Obstetric

History (For Females)
Smoking (pack/years) √ (20/days) 20years Vegetarian
Alcohol habits Mixed diet
Tobacco chewing
Snuff
Others
No habits

medication history of OTC Drugs: Yes/ No√

OTC medication Vaccination Nutritional Alternate Reason
Drugs Indication Duration status supplement system of
s/vitamins Ayurveda
medicine
Hepatitis A Homeopathy
Hepatitis B Unani
Tetanus Siddha
Pneumonia Herbal
Others: supplements

Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor Page 1

Medication History Chart For previous Medications:

Date Medications Indication Duration Last Age drug

Drug Dose Freq dose related
taken on problems/
ADR/ADE

Data sources referred to:

Patient Patient Prescriptions Patient’s Case file Discharge summary

√ party medication √

Comment on patient opinion about medication:

satisfactory

Assessment of compliance behavior:

compliance

Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor Page 2

 TREATMENT CHART REVIEW

PROVISONAL DIAGNOSIS: FINAL DIAGNOSIS:

Fissure in anal with bronchitis
Anal fissure

TREATMENT:

DAY OBJECTIVE LAB INVESTIGATIONS TREATMENT

FINDINGS
19/10 A febrile vitals HB-11.6gm/dl Inj.diclo 50mg IV BD
stable RBS-92mg/dl Inj.ambroxol IV BD
GC fair Sr.creatinine-0.9mg/dl T.cetrizine 5mg po OD
PR-70/min T.count-6500cells/cum.m T.cifran 500mg po BD
BP-112/68mmhg N-75% T.dulcolex 5ml BD
SPO2-100% L-17%
CVS-S1 S2+ E-03%
RS-B/L harsh M-05%
VBS+ B-00%
PLATELETS-4.17Lakkh/cum.m

20/10 A febrile Bleeding time 1hour 20 min Inj.Diclo 50mg IM BD

GC fair Clotting time 4hour 35 min Tab.PCT 500mg PO BD
Vitals stable HCV ╞ Tab.cifran 500mg PO BD
BP:100/70mmHg HBS Ag ╞ NEGATIVE Tab pantop 40mg PO BD
PR:70bpm HIV ╞ Tab dulcolex 2 po HS

21/10 PR:70/min Chest X-ray -bronchitis Inj.deriphyllin IV OD

BP:110/60mmHg Inj Amoxycillin 500mg OD
SPO2-100% Tab.deriphyllin OD
CVS-S1S2+ Tab cetrizine OD
RS-B/L Harsh Inj.Ambroxylene TID
VBS+

Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor Page 3

22/10 GC fair Inj.ceftriaxone IV BD
Vitals stable Inj.metrogyl IV BD
BP-130/80 Inj Diclo IM BD
PR-70bpm Inj.pantopIV BD
Inj.Ethamsylate IV BD
Inj.deriphylline IV BD
Syp Ambroxyl 10mlOD
Tab PCT 500mg PO BD
Tab serratiopeptidase PO BD
23/10 GC fair Inj.deriphylline IM BD
A febrile Inj.ceftriaxone IV BD
Vitals stable Inj.metrogyl IV TID
BP-120/80 Inj.diclo 50mg IM BD
PR-72 bpm Tab.pantop 40mg OD
P/A-soft Tab.serratiopeptidase BD
Tab dulcolex BD

24/10 GC fair Syp Ambroxol PO TID

Vitals stable Inj.ceftriaxone IV BD
A Febrile Inj.metrogyl IV TID
Inj.deriphylline IM BD

BP-100/70mmHg Inj.Diclo 50mg IM BD

PR-72bpm Tab.pantop 40mg PO OD
P/A-soft Tab.serratiopeptidase PO BD
Tab.dulcolex PO BD
Syp Ambroxol PO TID

Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor Page 4

 Assessing of therapeutic goals

Cure of the disease: Yes / No√

Reduction/elimination of signs and symptoms: Yes √/ No

Drug-food interactions: Yes√ / No

Drug + Food Interaction Adjustment

Cetrizine + Alcohol Alcohol can increase nervous side Avoid or limit the use of
effects of cetrizine such as dizziness alcohol while being treated
and drowsiness with cetrizine

Ciprofloxacin +daily products Make the medication less effective Interrupt feeding for 1 hr
before and 2hrs after drug
dose

Theophylline+caffeine Smoking and excessive caffeine Avoid smoking and limit

consumption alter blood levels of Caffeine consumption
drug,which may affect dosing

Drug-drug interactions: Yes √/ No

Drug + Drug Interaction Adjustment

Ciprofloxacine+dulcolax Ciprofloxacin can cause an irregular Do not exceed dose and duration of
heart rhythm the risk is increased if use of bisacodyl
have low blood levels of magnesium
or potassium which occur with
bowel cleaning preparations

Theophylline+pantopraz Using together may increase effects Dose adjustment

ole of theophylline and cause nausea
,vomiting,insomnia,tremors,uneven
heartbeats restlessness

Reference:WWW.DRUGS.COM

WWW.CLINIREX.COM

WWW.MEDSCAPE.COM

Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor Page 5

Medication errors:

Patient identity and record number

2017120932

Any allergies noted

NO

Short forms written on the medication chart

YES

Dose clear Y/N? Explain

YES

Route of administration

IV, IM, per oral

Date and time of drug administration

22/10/2017

Confusion in writing of the drug

YES

STANDARD TREATMENT:
lignocaine jelly or ointment( 5%) applied locally 3-4 times a day
Tab.metronidazole(400mg) for 5days twice a day
Tab.Ibuprofen(400mg)one tablet 8hours
Sitz bath(warm water with potassium permanganate 1:10000 or povidone iodine) twice a day
Isapghula husk 1-2 teaspoon in water one or two times a day for control of constipation and straining
during defecation
Liquid paraffin (5-15ml) at bed time for one month,if no relief with local lignocaine application
Surgical treatment:
Aim of therapy is to cause complete relaxation of the anal sphincter that will relieve pain and slowly heat
the fissure
Anal dilation under general anesthesia
Fissureectomy & sphincterotomy if needed
Bronchitis:
Mucolytic syrup containing acetyl cysteine 10ml 8hrly-if thick viscid sputum
Salbutamol,inhaled (via aerosol)100microgram 12hrly and as needed or
Ipratropium bromide , inhaled 20micrograms(2puffs) 12hrly and as needed
Antibiotics for secondary infection
Amoxicillin ,oral 500mg 8hrly for 7 days or
Azithromycin, oral,500mg daily for 3 day

Reference:www medscape.com
Pharamacotherapeutics 9th edition joseph T.Dipiro and goodman & gillman’s pharmacology 9thE

Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor Page 6

Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor Page 6
Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor Page 7
 PATIENT COUNSELING DOCUMENTATION FORM

DISCHARGE MEDICATION:
Tab.Deriphyllin 300mg po od 15 days
Tab.cifran 500mg po od 4days
Tab.Rantac 150mg PO OD 7days
Tab.serratiopeptidase po TID 10 days

Counseling aids used: Yes /No√

If so, specify 
Time taken to counsel
Less than 2 min 2-5
min
√ 5-10 min More than 10 min
Counseling steps followed:
√Case sheet reviewed √ Self introduction done
√Purpose of counseling done √ Patient was warned about taking
√medication Actual counseling done √ Patient’s understanding
√gained towards therapy Counseling points summarized was
ascertained
Counseling given to
√Patient
Representative
If representative, give reason:
Patient is weak or unable to speak Paediatric
patient Language
Hearing impaired Geriatric patient
Points covered during counseling Any Barriers involved Yes / No√
√Name and purpose of medication Lack of time
√Dosage and administration Lack of interest of patient
√Advice on missed dose Language
√Potential side effects Lack of counseling aids
√Precaution to be taken Lack of pharmacist’s knowledge
√Storage recommendations Others [Mention]
√Benefits of completing the course
√Drug/food interactions
√Life style modifications
Others [Mention]

COUNSELLING GIVEN ON:FISSURE IN ANAL REGION AND BRONCHITIS

DISEASE SPECIFIC: Get enough rest because even after healing the surgery the anal fissure still has to
heal on it own

Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor Page 8

After surgery ,probably have difficulty controlling
Hatulence and may also have minor fecal incontinence
The fissure may actually return if it does not heal properly
Bleeding from the area of surgery may occur until the fissure is fully healed so avoid strenuous exercise
Get adequate sleep and rest to let your body heal
Drink plenty of water to help prevent hard stools and aid in healing
Keep well hydrated
Give humidified air if possible
Avoid exposure to allergens
Smoking cessation

DRUG SPECIFIC:
Take theophylline with a full glass of water on an empty stomach at least 1 hour before or 2 hours after a
meal
Ciprofloxacine is a fluoroquinolone antibiotic to treat infection
Ranitidine is an acid suppressor that should be taken 30min before meal
Complete the drug therapy even feel better that prevents reoccurrence
Do not miss the dosage of any drug

REGARDING LIFE STYLE MODIFICATIONS:

Eat enough fibre –fibre rich foods include cereals ,fruits, whole-meal bread and vegetables
Drink plenty of fluids (10-12glassess of water)
Wipe gently after going to toilet
Fiber supplement such as Metamucil
Don’t take painkillers that contain codeine may cause constipation
Clean the anus cautiously with water
Exercise regularly
Relieving soreness and discomfort warm baths

Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor Page 9

Evaluation of Patient Counseling
√Appropriate introduction Time factor and privacy
√Assessment of symptoms
√Thorough assessment of medication history including current medications
√Determine allergy status Provide non-drug options for
√the patient Recommends correct pharmacological therapy Discussion of side
effects, interactions Summarize key points Check
whether patient understood Checks to see if the patient has seen a doctor or other
healthcare professionals
√Thanks for the patient for their time

GRADES: A= 10-12; √B= 6- 9; C= 4- 6; D= < 4

Name: Signature of the counselor:

Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor Page

10
 INTERVENTION DOCUMENTATION FORM

Patient demographic details:

Age:40 Sex: Male √ Female Hospital No: I/P No:2017120932

Unit:msw
Provisional/final diagnosis:FISSURE IN ANAL REGION with BRONCHITIS

Current drugs:
Inj.ceftriaxone IV BD
Inj metrogyl IV BD
Inj.diclo 50mg IM BD
Inj.pantop 40mgIV BD
Inj.Ethamsylate IV BD
Inj.Deriphylline 10ml OD
Tab.PCT 500mg PO BD
Tab.serratiopeptidase PO BD

Intervention identified during:

√Ward rounds Special visits Telephonic Patient counseling

Problem identified during the drug therapy and a brief description of the problem:

Patient was identified to have uneven heart beats after subsequent administration of theophylline
and pantoprazole

Suggestions made:

Drug withdrawal √ Drug dose modification

Drug re-administration New drug to be added

Suggestions accepted: √ Yes No
If No, give reason:

Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor Page 10

 Drug therapy changed:
√Yes No

Follow-up:

Intervention category

Untreated indication Overdose

Sub therapeutic dose Failure to receive the drug

ADR Drug use without indication

√ Drug interaction Drug duplication

Dosage adjustment in special population Spelling of drug/prescription

Dosage adjustment in hepatic failure Dosage form

Dosage adjustment in renal failure Incompatibility

Inappropriate drug selection Others

References:
Text books(mention):

Journals (mention):

√Websites:

www.medscap.com

Micromedex: IDIS (with article no.):

Intervention made by: Signature:
Others (specify):
Date of Intervention:

Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor Page 11

 ADVERSE DRUG REACTION REPORTING &

DOCUMENTATION FORM

Known Allergies:

Date of onset of Reaction:

Drugs used prior Batch Date Dose Route and Tick Indication Date
to Reaction number started Frequency suspected stopped
Drug (s)

MANAGEMENT OF ADVERSE DRUG REACTION:

Drug withdrawn Dose altered No change

TREATMENT GIVEN:

Specific Symptomatic Nil

OUTCOME: Fatal Recovery Continuing

Unknown Other

DECHALLENGE: RECHALLENGE:

No dechallenge No rechallenge

Definite improvement Recurrence of symptoms

No improvement No occurrence of symptoms

Unknown Unknown

Patient interviewed: Yes No

Thank you note provided: Yes No N/A

Alert Card provided: Yes No N/A

Suspected Drug (s):

Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor Page 12

CAUSUALITY:

A) Naranjo’s Scale
Define Possible
Probable Unlikely
B) WHO Probability Scale
Certain Unassessable/Unclassifiable
Probable Unlikely
Possible Conditional

SEVERITY (HARTWIG ET.AL.SCALE):

Mild: Moderate: Severe:

Level 1 Level 3 Level 5

Level 2 Level 4 (a) Level 6
Level 4 (b) Level 7

PREDICTABILITY:
Predictable Non-predictable

PREVENTABILITY (MODIFIED SCHUMOCK AND THORNTON’S SCALE):

Definitely preventable probably preventable Not preventable

PREDISPOSING FACTORS:

Age Gender Genetic

Intercurrent Disease Multiple drug therapy Others (specify)

REFERENCES CONSULTED:

Name of the attending Pharmacist Signature

Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor Page 13

 SRI VENKATESWARA COLLEGE OF PHARMACY,
RVS NAGAR, CHITTOOR

DRUG INFORMATION QUERY FORM

Date: Name of the Enquirer:

Time: Unit/ Tel no:

Query:
Tab dulcolex mechanisum of action

Mode of receipt:
O Direct access Telephone Ward rounds E-mail

Patient Data:
Age: Sex: M/F Diagnosis:

Current Drug therapy:

Any other Information:

Answer needed:
Immediately Within 2-4 hours Within a day Within 1-2 hours

Processional status of the enquirer:

Physician PG Intern Nurse

Patient/relatives/Friends Pharmacy Others

Department:

Purpose of enquiry:
To update knowledge For better patient care Education Others (specify)

Attending Pharmacist name and signature:

Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor Page 14

 SRI VENKATESWARA COLLEGE OF PHARMACY,
RVS NAGAR, CHITTOOR.

DRUG INFORMATION QUERY FORM

Question category: (Please Underline)
Drug therapy: ADR: Interaction: PK: PD:
Indication: Dosage/ Administration: Availability /Cost:
Pregnancy/Lactation: Others (specify):
Details of answer:
Bisacodyl works by stimulating enteric nerves to cause colonic contractions. It is also a contact
laxative it increases fluid and salt secretion
It is stimulant laxatives mainly promote evacuation of the colon
ADR: abdominal discomfort (colic, cramps)

Answer given:
Immediately √ Within 2- 4 hours Within a day Within 1-2 days

Mode of reply:
Verbal Written√ Postal Printed literature E-mail

Reasons for delay if any:

Reference:
Text book (specify) KD Tripathi Micromedex
IDIS Website (specify) Journals
Others
Follow-up:

Attending Pharmacist (S) name: Signature:

Reference No: Date: