Your SlideShare is downloading. ×
0
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Formal case ( 5 problems duodenal ulcer , hypertension , anemia , smoking , headache )

1,551

Published on

team work

team work

Published in: Health & Medicine
0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,551
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
23
Comments
0
Likes
2
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. King Saud University College of Pharmacy Clinical Pharmacy Dept PHCl 429 Formal Case Presentation Code: 04 Facilitator: T.A. Ghadah Assiri, MSc Presenting students: Aya Kamel Malak Algamdi Najwa AlOtaibi Salma Alsalman Dec-18-2013
  • 2. Patient Information › Name: A.S › Age: 55 years › Gender: male › Race: African American › Height: 172 cm › Weight: 73 Kg › BMI:
  • 3. Chief Complaint (CC) › A.S present to clinic complaining of “epigastric abdominal pain, vague abdominal discomfort and dizziness”
  • 4. History of Present illness (HPI) › Epigasteric abdominal pain, vague abdominal discomfort and dizziness. His pain started 1 year ago he took OTC antacid with no improvement the pain come between 1-3 am and relived by food He describes it of being moderately to severe. › He complains of postprandial bloating and darkening of stool one week ago.
  • 5. History of Present illness (HPI) › Also he suffers from moderate throbbing head pain unilateral and temporal , the pain stay for 2 hours in the morning. › The patient had hypertension 5 years ago which is uncontrolled due to issue of non-compliance.
  • 6. Past Medical History (PMH) › Hypertension (Stage 1)  diagnosed 5 years ago.
  • 7. Medication History › Current prescribed medication :1. Furosemide 40 mg orally twice daily started × 5 years › Current non-prescribed medications:1. Ibuprofen 200 to 400 mg orally qid , prn 2. Maalox 30 ml orally after meal and at bed time 3. Bismuth subsailcylate occasional use (1-2 times a week )
  • 8.  Medication History a- Current prescribed medications: Drug Dose Route Frequency Indication Furosemide 40 mg orally BID HTN b- Current Non-prescribed medications: Drug Dose Route Frequency Indication Ibuprofen 200 to 400 mg Orally QID PRN Headache Maalox 30 ml Orally BID Duodenal Ulcer **after meal and at bed time Bismuth subsailcylate Not known c- Supplements: None Orally 1-2 times/week Duodenal Ulcer
  • 9. Allergies › NKA
  • 10. Family History (FH) › His father died at age of 59 of shock due to severe GI bleeding 2ry to untreated PUD. › The Mother died in a motor vehicle accident 4 years ago.
  • 11. Social History (SH) › He is a manger in a stress job, married with two grown children. › He smokes 1ppd of cigarettes for 10 years .
  • 12. Physical Examination (PE) GEN VS Slightly pale , thin male in moderate distress BP average 185 96 , HR 90 , RR 20 , T 37 C , Wt 73 Kg , Ht 172 cm HEENT WNL Chest WNL Abd Mild tenderness , no masses Rect Non-tender, melenic stool found in rectal valut , stool heme +ve Ext WNL Neuro ECG Memory intact ; no nystagmus ; no tremor ; or ataxia ; (-) Romberg : CN II-XII INTACT ; SENSORY INTAVT ; DTRs : 2+ throughout : babinski (-) bilaterallly . Normal
  • 13. Laboratory Data: Na 137 mg/dL WBC 9 Th/mm3 K 4.0 mEq/dL RBC 4.23 Mil/mm3 Cl 106 mEq/dL Hgb 11.0 mg/dL HCO3 26.8 mEq/dL Hct 33 Cr 1.4 mg/dL MCV 79 BUN 32 mg/dL MCH 26 Glu 100 mg/dL
  • 14.  General overview about the case The patient has 5 main problems , almost all of them are untreated .
  • 15.  General overview about the case Problem list: 1. Untreated Peptic Ulcer. 2. Untreated Anemia. 3. Untreated Headache. 4. Uncontrolled Hypertension. 5. Untreated Smoking.
  • 16. NSAID Induced Duodenal Ulcer
  • 17. SOAP Assessment › Subjective :• He complains clinic of epigasteric abdominal pain, vague abdominal discomfort and dizziness. • He noticed darkening of stool one week ago. • The pain come between 1-3 am and relived by food, he describes it of being moderately to severe. • Manager of stressful job. • His father died at age of 59 of shock due to severe GI bleeding 2ry to untreated PUD.
  • 18. SOAP Assessment › Objectives :• Hgb 11.0 mg/dL • Hct 33 • Abd: Mild tenderness, no masses. • Rect: Non-tender ; melenic stool found in rectal valut ; stool heme +ve. • Endoscopy shows multiple gastric ulcer.
  • 19. Assesment A.S 55 year-old African-American male appears slightly pale suffer from epigastric abdominal pain which is releived by food he has many risk factor for peptic ulcer his endoscopy shows multiple gastric ulcer , he tried to releive pain by otc antacid but its not effective in contrast bismuth subsalycilate worsen his case and cause bleeding , his fecal blood test gives positive heme and his hemoglobin level is low He has NSAID induced duodenal ulcer with secondary gasteric ulcer and ulcerative bleeding , he also needs further tests for H.Pylori Patient needs initial treatment by high dose PPI to prevent complication and treat the symptoms .
  • 20. SOAP Assessment › Assessment :• Drug related problem (DRP): Category/Subcategory: Indication / Need Additional Drug Therapy (Untreated condition). • Statement : A.S 55 year-old African-American male who suffers from epigastric abdominal pain 1 year ago which not relieved by using OTC antacid (Maalox & Bismuth subsalicylate ) needs additional drug therapy.
  • 21. SOAP Assessment › Assessment :• Drug related problem (DRP): Category/Subcategory: Safety (Adverse drug reaction) / Undesirable effect. • Statement : A.S 55 year-old African-American male who takes OTC bisthmus subsalicylate for epigasteric abdominal pain , but his condition become worse and develops bleeding as a side effect which increase risk of recuurance. He needs to stop using it.
  • 22. SOAP Assessment • Drug related problem (DRP): Category/Subcategory: Safety (Adverse drug reaction) / Undesirable effect. A.S 55 year-old African-American male who takes Ibuprofen ( Nsaid ) OTC to treat headache which causing undesirable effect a duodenal ulcer and may cause further complication , the drug must be stooped and choose appropriate alternatives.
  • 23. Fig.1.1
  • 24. Therapeutic goal › Short term goals : 1. Prevent complication (perforation, penetration, obstruction, malignancy 2. Promote ulcer healing Stop the ulcer bleeding. 3. Symptoms relive. › Long term goals : 1. Preventing recurrence and avoiding potential complications. 2. Reduce financial cost of treatment .
  • 25. According to blatchford score, patient has high risk of bleeding. Fig.1.2
  • 26. Therapeutic Alternatives › Ranitidine double dose 300 mg q.i.d › Endoscopy treatment › Injection treatment .
  • 27. Pharmacological Intervention › Stop using ibuprofen to prevent further complication. › Stop using bismuth subsalicylate to minimize the risk of bleeding. › Continue using Maalox to relieve symptoms Drug Dose Frequency Rout Dosage form Duration Trade name Aluminum magnesium hydroxide 30 ml After meals and at bed time Orally Suspension 4-6 weeks Maalox Cost
  • 28. Pharmacological Intervention › Start Drug Dose Frequency Rout Dosage form Duration Trade name Cost Omeprazole 20 mg B.i.d 1 hour before meals Orally Capsule 4-6 weeks Gasec 27 S.R
  • 29. Non-pharmacological Intervention › Omega -3 fatty acids has anti-inflamatory effect help to protect the stomach from ulcers. › Acupuncture treatments. › Endoscopy treatment. › Injection therapy. › Yoga practice to manage stress.
  • 30. Monitoring › Efficacy • Symptomatic improvement. › Safety • The appearance of adverse events like: muscle cramps, muscle weakness or limp feeling; seizures
  • 31. Monitoring Testing for H.pylori Patients taking the test should stop taking PPIs for at least 2 weeks (they interfere with the test) and starve for 4 hours before. Fecal Occult Blood Test  CBC & Hemoglobin Blood urea Mg level
  • 32. Follow-up › Assess the adherence. › Assess the signs and symptoms of progression of ulcer › Follow up session should be scheduled 2-4 weeks after initiating the therapy. › If patient is H.pylori positive start eradicating regimen . › Repeat endoscopy to confirm healing at 6 to 8 weeks. › If ulcer healed decrease omeprazole dose gradually to maintenance dose to prevent recurrence.
  • 33. Patient Education › Take omeprazole 1 hour before meals . › Take vitamins and iron supplement 1-2 hours after taking Omeprazole and Antacid . › Avoid spicy food and xanthin containing beverage and, drinks containing caffeine. › Avoid heavy meals before bed time. › Smoking increases the amount of acid produced by the stomach . need smoking cessation plan . › Encourage small frequent low caloric meals. › Avoid ulcerating drug e.g NSAIDs,Corticosteroid. › Eat Magnesium containing food like banana, Avocado and fish.
  • 34. Reffrence : Guidelines for prevention of NSAID-related ulcer complications. Lanza FL, Chan FKL, Quigley EMM, Practice Parameters Committee of the American College of Gastroenterology. Guidelines for prevention of NSAID-related ulcer complications. Am J Gastroenterol. 2009 › Management of patients with ulcer bleeding. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012 Mar;107(3):345-60.
  • 35. Reffrences › Fig.1.1 › Management and Prevention of upper GI Bleeding Guidelines 2009 by ACCP http://www.eguidelines.co.uk/eguidelinesmain/guidelines/summar ies/gastrointestinal/nice_dyspepsia.php?page=3 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1399777/ http://www.medscape.com/viewarticle/545617_3 › Fig.1.2 Management of Dyspepsia 2005 BY ACG Nicholas J. Talley, M.D., Ph.D., Mayo Clinic College of Medicine, 200 First Street S.W., PL6– 56, Rochester, MN 55905.
  • 36. SOAP Assessment › Subjective :• He has noticed slight darkening of his stool and dizziness. › • • • • • • Objectives :Stool heme (+). Hgb 11.0 mg/dL  Low. Hct 33  Low. MVC 79  Low. MCH 26  Normal. Its Microcytic Anemia ( MVC is below 80 Fl ).
  • 37. SOAP Assessment › Assessment :• DRP category and sub- category: Indication/Need Additional Drug Therapy (untreated condition) • Medical problems: Untreated Anemia • Statement: A.S is a 55 years old African male suffering from anemia which need a medical intervention , that due to GI bleeding secondary to untreated PUD.
  • 38. Therapeutic Goals › Short term goals :• Normalized lab value that related to anemia ( Hgb, Hct, MVC). • Alleviate signs and symptoms. › Long term goal :• Prevent recurrence of anemia.
  • 39. Therapeutic Alternatives 1. Ferrous Sulfate 325 mg. 2. Ferrous Gluconate 325 mg. 3. Polysaccharide iron complex 150 mg.
  • 40. Pharmacological Intervention › Start : Drug Dose Frequency Rout Dosage Form Duration Cost Ferrous Sulphate 325 mg Every 12 hours Orally Tablet 3 months 5 SR › The hemoglobin concentration should rise by 2 to 4 g/dl after 3 weeks.
  • 41. Non-Pharmacological Interventions › Advise the patient to eat more foods that are rich in iron. › Avoid Phosphate, Calcium, Tea (tannic acid), Coffee, Colas, Soy protein and Bran/fiber which are inhibit Iron absorption. Figure.2.1 “Iron-Rich Foods” MedScape : http://www.medscape.com/viewarticle/452692_8
  • 42. Monitoring and Follow-up › Iron therapy should cause : • Reticulocytosis in 5 to 7 days. • Raise Hb by 2 to 4 g/dL every 3 weeks. › Once normal, the Hb concentration and red cell indices should be monitored at intervals. • Every 3 month for 1 year, then after a further year, and again if symptoms of anemia develop after that.
  • 43. Patient Education › Advise patient to expect iron to darken stools. › The drug may cause constipation or nausea, to overcome this problem advice the patient to drink water and eat fibers. › Instruct patient to avoid eating eggs, milk, cheese, yogurt, tea coffee within 1 h before or 2h after taking iron supplement. › For maximum absorption take on empty stomach, but may take with or after meals to minimize GI irritation. › Vitamin C may enhance absorption.
  • 44. References › (1) Barbara g. , joseph t. , terry l. , cecily v.. Hematologic disorder. In: cecily v. (eds.)pharmacotherapy handbook . 7th ed. new York : McGrawhill companies ; 2009. p(363-370) › (2) THAD WILKINS, MD; NAIMAN KHAN, MD; AKASH NABH, MD; and ROBERT R. SCHADE, MD, Georgia. Diagnosis and Management of Upper Gastrointestinal Bleeding. http://www.aafp.org/afp/2012/0301/p469.html (accessed 3-april-2013). › (3) Irene Alton, MS, RD. IRON DEFICIENCY ANEMIA. In: Jamie Stang, PhD, MPH, RD (eds.)GUIDELINES FOR ADOLESCENT NUTRITION SERVICES. 1st ed. Minneapolis: University of Minnesota;; 2005. p(101-108) › (4)http://www.oocities.org/hotsprings/falls/4809/meds/ferroussulfate.h tm › (5) http://nassersite.com/drugdb/view.php?id=2207
  • 45. Migraine headache
  • 46.  SOAP Assessment Subjective “Throbbing head pain, unilateral, temporal, occurring in the morning, which lasts for 2 hours, with photophobia and phonophobia” Objective None Assessment A.S is a 55 years old African male. He developed migraine headache without aura, he is receiving Ibuprofen around 3-4 times/week this caused adverse effects on him, he needs different drug therapy since his previous drug therapy is unsafe. Medical Problem Migraine headache without aura Drug Related Problem Category/Subcategory Safety / Adverse drug reaction (undesirable effect)
  • 47. Therapeutic Goals ›Goals for acute migraine treatment: • Treat migraine attacks rapidly and consistently without recurrence. • Restore the patient’s ability to function. • Minimize the use of backup and rescue medications. • Be cost-effective in overall management. • Cause minimal or no adverse effects.
  • 48. Therapeutic Goals › Long term goals : • Reduce migraine frequency, severity, and disability. (Aim for fewer than 5 headache days per month.) • Reduce reliance on poorly tolerated, ineffective, or unwanted acute pharmacotherapies. • Improve quality of life. • Avoid escalation of headache medication use. • Educate and enable patients to manage their disease. • Reduce headache-related distress and psychological symptoms.
  • 49. Therapeutic alternative Drug Dosage Isometheptene65 2 capsules at onset; mg/dichloralrepeat 1 capsule phenazone 100 every hour as mg/ needed acetaminophen 325 mg (Midrin) Other alternative › Sumatriptan › Naratriptan Rout of administration orally Comment Cost (month) Maximum of 6 capsules/day and 20 capsules/month 70 SR
  • 50. Non-pharmacological treatment › Application of ice to the head and periods of rest or sleep, usually in a dark, quiet environment, may be beneficial. › Preventive management should begin with identification and avoidance of factors that provoke migraine attacks.
  • 51. Non-pharmacological treatment › A headache diary that records the frequency, severity, and duration of attacks can facilitate identification of migraine triggers. › Patient also can benefit from adherence to a wellness program that includes regular sleep, exercise, and good eating habits, smoking cessation, and limited caffeine intake. Behavioral intervention such as Relaxation Training, Biofeedback, and Cognitive Behavioral Therapy
  • 52. Non-pharmacological treatment Patient triggers How to manage them Environmental triggers Tobacco smoking Smoking cessation Loud noises Rest or sleep in a quiet environment Glare or flikering lights Rest or sleep in a dark environment Behavioral-physiologic triggers Stress Relaxation Training, Biofeedback, Cognitive Behavioral Therapy
  • 53. Pharmacological Intervention Drug Dosage FIORICET (butalbital, acetaminophen, and caffeine) 1-2 tablet every 46 hours Rout of administration orally Comment Cost (month) Limit dose to 4 tablets/day and usage to 2 days/week 26.5 SR
  • 54. Monitoring and follow up › Patients should be specifically assessed at follow-up visits to determine if their acute migraine medications need to be changed. › Evaluate the effectiveness of therapy through the use of patient diaries that record headache frequency, drug use, and disability levels
  • 55. Patient Education › Educate the patient about Keeping a headache diary that can help identify frequency, severity, triggers, and response to treatment. › Patients should be advised to adjust their lifestyle to avoid exacerbating their migraine (e.g., avoid missing meals; avoid dehydration; maintain adequate, regular sleep). › A general exercise program should be considered part of comprehensive migraine management. › Patient should Learn and use stress management skills (relaxation training, biofeedback and cognitive behavioral therapy). › Patient should know that It may not be possible to eliminate the primary headache completely.
  • 56. Patient Education › About Medication: › Advise patients to take their medication early in their migraine attack, where possible, to improve effectiveness. › Educate the patient of the risk of chronic daily headaches is increased if headache treatment medication are used more than nine days a month. › Fioricet may impair mental and/or physical abilities required for the performance of potentially hazardous tasks such as driving a car or operating machinery. Such tasks should be avoided while taking this product.
  • 57. Patient Education › Alcohol and other CNS depressants may produce an additive CNS depression when taken with Fioricet, and should be avoided. › Butalbital may be habit-forming. Patients should take the drug only for as long as it is prescribed, in the amounts prescribed, and no more frequently than prescribed.
  • 58.  Reference DiPiro, Joseph T. Pharmacotherapy: A Pathophysiologic Approach.  Neurologic Disorder “Headache“. 8th ed. New York: McGraw-Hill Medical, 2011. 106-131.Pages(1066-1075) http://www.topalbertadoctors.org/file/guideline-for-primary- care-management-of-headache-in-adults.pdf https://www.icsi.org/_asset/qwrznq/Headache.pdf http://www.nice.org.uk/nicemedia/live/13901/60854/60854.pdf http://www.nice.org.uk/nicemedia/live/13901/60853/60853.pdf https://www.icsi.org/_asset/qwrznq/Headache.pdf
  • 59. Uncontrolled Hypertension
  • 60. Subjective  55-year-old-African-American male.  HTN (uncontrolled) x5 years.  The patient non-compliance with his medication.
  • 61. Objective            AGE= 55 years old BP= 158/96 mmHg HR= 90 bpm Na= 137 mg/dL K= 4.0 mEq/dL Cr= 1.4 mg/dL BUN= 32 mg/dL WEIGHT= 73 kg HIGHT= 172 cm BMI= 24.67 Furosemide 40 mg orally twice daily, started x5 years
  • 62. CV Risk factor  Smoking  Age ( 55 years)  High stress job  Increase of Systolic Blood Pressure (SBP) > 20 mmHg  Increase of Diastolic Blood Pressure (DBP) > 10 mmHg
  • 63. Assessment The patient is African American in stage I primary hypertension without comorbid disease or drug is responsible for elevating BP. His blood pressure barely controlled due to issues of compliance and effectiveness. So its current therapy Not the best choice even if he compliant with his medication. The Thiazide–type diuretics is first line therapy for this condition and particularly chlorthalidone. The SBP is more than 15 mmHg above the goal and the DBP is more than 10 mmHg above the goal,(the goal is 140/90 mmHg) so the patient need for combination therapy to attain and maintain BP goals, also he needs modification of his lifestyle regarding to diet style, physical activity and restriction regimen.
  • 64. Drug Related Problems (DRP): Effectiveness (Needs Different Drug More effective drug available Product) A.S 55-year-old-African-American male taking Furosemide 40 mg orally twice daily, started x5 years for hypertension management but his BP out of the established range for his specific condition, so he needs more effective drug to reach the desired range <140/90 mmHg.
  • 65. Drug Related Problems (DRP): Compliance (Non-Compliance) Patient forgets to take A.S 55-year-old-African-American male with uncontrolled hypertension due to issues of non-compliance. He is a manager in high stress job and may forget to take within his busy life. He need to improve adherence. In order to this status, he needs fixed-dose combination product
  • 66. Short term goals:  Increase the adherence and compliance of patient  Implementation of life style changes  Involve pharmacotherapy and patient education programe
  • 67. Intermediate term goals:  Achieve desired target BP value (140/90 mmHg). Long term goals:  Prevent CV risk and complications (Cerebrovascular events , heart failure , kidney disease)  Reduce hypertension associated morbidity and mortality  Improve patient’s quality life
  • 68. Therapeutic Alternative  Therapeutic Life Changes (TLC)  Thiazide-Type-Diuretics (Hydrochlorothiazide Esidrix 25mg PO Once daily in the morning)  Angiotensin-Converting Enzyme(ACE) Inhibitors (Captopril Capoten 25mg PO Twice daily)  Calcium Channel Blocker (CCB) (Diltiazm Cardizem 120mg PO Twice daily)
  • 69. Non pharmacotherapy Life style modification:  Maintain normal body weight( body mass index “BMI” = 18.524.9kg/m2)  Dietary Approach to Stop Hypertension(DASH) is a style of diet including consume a diet rich in fruits , vegetables, and low fat dairy products with a reduced content of saturated and total fat.  Reduce daily dietary sodium intake as much as possible, ideally to =65 mmol/day (1.5g/day sodium, or 3.8g/day sodium chloride)  Regular aerobic physical activity at least 30 minutes/day
  • 70. Pharmacotherapy Intervention  Initiate following drug instead of Furosemide. Drug chlorthalidone/ reserpine Regroton® Dose Frequency Rout Dosage form 50 mg / 0.25 mg Once a daily PO Tablet Duration Cost
  • 71. Monitoring the pharmacotherapy plan  Monitor for signs and symptoms of progressive hypertension –associated target –organ disease (palpitation, Dizziness, dyspnea, sudden changes in vision) periodically.  Routine goal BP values should be attained but the actual BP lowering can occur at a very gradual pace over a period of several months to avoid orthostatic hypotension.  Monitoring BP response should be evaluated 2 to 7 weeks after initiating or making a change in a therapy then every 6 to 12 months in stable patient.  For thiazide diuretic the response needs to be monitored 4 to 6 weeks later because it will show better represent steady state BP values.
  • 72. Monitoring the pharmacotherapy plan  Self-measurement of BP or automated BP monitoring can be useful clinically to establish effective 24-hour control; BP at home needs to be measured during the early morning hours.  Monitor the BUN/serum creatinine because of Diuretics use, to prevent any kidney diseases may occur.  Monitor blood magnesium level periodically, because patient is Using omeprazole together with chlorthalidone, this may cause hypomagnesemia.
  • 73. Follow up Evaluation  Check periodically to make sure that the blood pressure is in the recommended range. If it is not, the treatment should be adjusted. Patients with high blood pressure should see their providers at least once per year and more frequently during medication adjustment phases.  Periodically, at the follow-up visits, the patient should be screened for any complications may occur like damage to the heart, eyes, brain, kidney, and peripheral arteries that may be related to high blood pressure  Follow-up visits are a good time to let know about any side effects may the patient is having from his medication. That may needs suggestions for coping with side effects or may change the treatment.
  • 74. Patient Education  Encourage the patient on the home BP monitoring to achieve more adherences, see the prognosis of his disease and how the therapy is effective.  Lifestyle modification should always be recommended to provide additional BP lowering. - Eat less salt. - Exercise. - Follow the DASH eating plan (Dietary Approaches to Stop Hypertension)
  • 75. Patient Education  Educate the patient on importance of compliance. - Use reminder calls, text or emails as needed - Preparing a dosing card containing only the most essential elements of the patient’s medications including the name of the pill, image, indication and time for drug taken. - Give the patient clear instructions about medications - Ask someone in the family or friends to be medication buddy to help reminder him about daily dosing and getting prescription refills.
  • 76. References  DiPiro, Joseph T. Pharmacotherapy: A Pathophysiologic Approach. Cardiovascular Disorder "Hypertension“. 8th ed. New York: McGraw-Hill Medical, 2011. 106131.Pages(106-131)  European Society of Hypertension and of the European Society of Cardiology, ESH-ESC-GUIDELINES FOR THE MANAGEMENT OF HYPERTENSION,2013.Print  Brotman, D. J. "The JNC 7 Hypertension Guidelines." JAMA: The Journal of the American Medical Association 290.10 (2003): 1313-b-314. Print.  Micromedx phone application
  • 77. Untreated Cigarette smoking
  • 78. Subjective A.S smokes 1 ppd of cigarettes.
  • 79. Objective As smokes 1 ppd, this is equal to 20 cigarettes per day, so the patient is nicotine depended because he smokes more than 10 cigarettes per day.
  • 80. Assessment A.S is a 55 years old African-American male, nicotine dependent smoker who smokes 1 ppd of cigarettes x10 years. The patient has Duodenal ulcer , HTN, Anemia and migraine headache He should be started on smoke cessation therapy.
  • 81. Drug Related Problem (DRP) Indication (Needs Additional Drug Therapy) Untreated Condition AS is a70 year old African-American male, nicotine dependent smoker who smoke 20 cigarettes per day. Currently, He don’t use medication for this condition and need to start on smoking cessation drug.
  • 82. Short term goals  Quit smoking
  • 83. Long term goals  Reducing the risks for developing smoke induced diseases (lung cancer, COPD, CHD, stroke, esophageal cancer, and others).  Improving the patient health in general.  Improve the patient life quality.  Increase in life expectancy and reduce smoking induced mortality and morbidity.
  • 84. Pharmacotherapy Alternatives a) Start the patient in a single medication: 1-Nicotine replacement therapy(patch, gum, inhaler, lozenge ,sublingual tablet) Ex: (patch)dose: 21 mg/24 hr or15 mg/16 hr ,for more t2-Varenicline: Dose: 1 mg twice per day following a 1 week titration (risk of cardiovascular events). han 8weeks.
  • 85. Pharmacotherapy Alternatives a) Start the patient in a single medication cont: 3-Bupropion: The dose of bupropion is 150 mg once per day for the first 3 days and then increased to 150 mg twice per day. The patient should stop smoking in the second week of treatment. 4-Nortriptyline: 75 mg/day for 12 weeks. ( risk of arrhythmia in patients with cardiovascular disease.) B) Advice patient for Smoking reduction rather than smoking cessation
  • 86. Non-pharmacological  Apply the smoke cessation treatment algorithm( 5A’s): oAsk – patients about smoking status oAdvise – patients about the health risks of tobacco use and to quit oAssess – patients’ readiness to quit oAssist – patients that are ready to quit Arrange – follow up
  • 87. Non-pharmacological Counseling  Cognitive and behavioral coping strategies: delay, deep breathe, drink water, do something else. Offer written information (eg. Quit Pack) Offer Quit line referral or other assistance Arrange follow up visit, if appropriate.
  • 88. Pharmacological intervention  Start the patient on nicotine replacement therapy as patches Dose: 21 mg/24 hour. 2- Treatment duration should be more than 8 weeks.
  • 89. Monitoring & Follow up  Ask AS to return to clinic soon after the quit date, preferably during the first week to assess and monitor: oQuitting cigarette smoking oThe patient compliance to his medication . oThe development of any drug adverse effects: Skin erythema, skin irritation and sleep disturbance (abnormal dreams).
  • 90.  Monitoring & Follow up  If withdrawal not controlled, consider combination nicotine replacement therapy (oral NTR could be added).  If patient needs extra support, Consider a further follow-up visit.
  • 91. Patient Education  Educate the patient how to use nicotine patches. (Applied directly to the skin once a day, usually at the same time each day. A apply it to clean hairless aria, With the sticky side touching the skin, press the patch in place with the palm of your hand for about 10 seconds. Wash your hands with water alone after applying the patch. If the patch falls off or loosens, replace it with a new one … etc.).  Educate the patient about the possible adverse effects of nicotine patches(skin irritation, sleep disturbance)  Educate the patient about the importance of compliance to his medication and encourage him to complete his therapy for at least 10 weeks.  Encourage the use of support services.  Educate the patient about the importance of the follow-up visits.
  • 92. References:  Supporting smoking cessation: a guide for health professionals. 2011. [e-book] South Melbourne: The Royal Australian College of General Practitioners College House. pp. 1-53. Available through: RACP http://www.racgp.org.au/download/documents/Guidelines/smoki ng-cessation.pdf [Accessed: 27 Oct 2013].  "Treating Tobacco Use and Dependence: A Quick Reference Guide for Clinicians." Treating Tobacco Use and Dependence: A Quick Reference Guide for Clinicians. N.p., n.d. Web. 10 Nov. 2013.  http://www.ahrq.gov/legacy/clinic/tobacco/tobaqrg2.htm
  • 93. Thank you..

×