During my training in AL Amal psychiatric hospital I found cases that include many medication errors , so I did an analysis for this case and tried to address the medication error and mention the intervention according to the guideline.

1. Schizophrenia
case presentation
Pharmacy professional practice-placement B
Al Amal hospital
12/11/2017 - 7/12/2017
Omkolthoom Mahmoud Weisy
ca

2. Case overview

3. Patient Data Base
name: N.A BMI:26 kg/m2 (Overweight)
age : 49years old Drug allergies: None
Date of admission :3.10.2017 Family history : unknown
B. Case Summary (chief compliant and what happened to the patient
during hospitalization)
Patient (N.A) brought by police to the hospital after bout of aggression and
agitation. (Sever psychosis symptoms)

4. C. History of Present Illness (location, characteristics, aggravating
and alleviating factors, timing, severity):
The Patient was agitated and he refused to answer any question. His Father
stated that the patient became isolated in the last 3 months. (A.N) complains of
hearing wired voices and receives messages from TV and radios inform him that
someone follow him and try to kill him as his father said to doctors. He was
always harm his family members physically .
D. Past Medical History (P.M.H.)/ Surgery
Frequent seizures episodes
Diabetes Mellitus Type 2
Hypertension
schizophrenia

5. E. Family History
Unknown
F.Life style: smoking, diet, caffeine
Not Smoker , not alcoholic
G. Physical Examination (P.E.)
On examination : Patient was restless, had no attention, anxious and
tensed. Patient received diazepam 5 mg 1 ml IV to relive the tension.
Diagnosis :
Diagnosis after clinical assessments : uncontrolled schizophrenia

6. Past medication history

7. Past medication history
Drug Indication Duration
Bisoprolol fumarate (concor ) 5mg tablet Hypertension
Chronic (BID)
1 tab twice daily,
Metformin( Glucophage) 500 mg Tablet
Diabetes Mellitus
Type 2
Chronic , 500 mg twice
daily (BID)
Keprra (Levetiracetam) 100mg Tablets
epilepsy
One tablet in the
morning and one at
night (BID)

8. Vital Signs/ Laboratory Data Interpretation
with normal values

9. InterpretationNormal rangDate
4.10.2017
Date
3.10.2017
UnitLaboratory test
Normal36.1 - 37.23736.8°CTemperature
Slightly high, the normal
BP for diabetic patient
130/80 ( uncontrolled
hypertension )
130/80143/90145/90mmHgBlood pressure
Normal60 - 1006798beats/minPulse
Vital signs

10. InterpretationNormal rang
Date
4.10.2017UnitLaboratory test
Normal4-115.66
Billion cells/L
WBC
Normal3.8-5.24.5
Trillion cells/L
RBC
Normal12-1513.5
grams/dL
Hgb
Normal36-4636.33
percent
%
Hct
Normal80-10083
Femtoliters (fl)MCV
Normal27-3227.33picograms
MCH
Normal31.5-34.533g/dl
MCHC
Normal150-450218billion/L
Platelet
Complete Blood Count (CBC)

11. InterpretationNormal rang
Date
4.10.2017UnitLaboratory test
Normal0.6 – 1.30.8mg/dlSrCr
Normal85 – 135118mg/dlCrCl
Normal10 - 5043mg/dlUrea
General Biochemistry
This lab result show that the kidney function is normal , but according to ADA
2015 :diabetic patient with hypertension should to optimize glucose and
hypertension control to reduce the risk of nephropathy )

12. InterpretationNormal rang
Date
4.10.2017UnitLaboratory test
Normal0.0 - 1.20.1mg/dlBilirubin total
Normal3 – 5.54.7g/dlAlbumin
Normal39 - 190100U/LCK
Normal0 - 2513.7U/LCKMB
liver

13. InterpretationNormal rang
Date
4.10.2017UnitLaboratory test
Normal135 - 225148U/LHDL
Normal50 - 200110
Mg/dl
Total cholesterol
Normal50 - 200150mg/dlTG
highLess than 100120mg/dlLDL
Lipid Profile
Untreated dyslipidemia

14. InterpretationNormal rang
Date
4.10.2017UnitLaboratory test
Normal134 - 146140mmol/LSodium
Normal3.4 – 5.24.4mmol/LPotassium
Normal95 - 110105mmol/LChloride
LOW , because of vitamin D
deficiency ( may be due to
inappropriate diet or
insufficient sun exposure.
51.5 - 11835
ng/ml
Vitamin D
Electrolytes

15. InterpretationNormal rang
Date
4.10.2017UnitLaboratory test
High, uncontrolled
diabetes although he
takes metformin
(antipsychotic antagonize
the effect of antidiabetic
medication )
74 - 126134mg/dlRandom glucose
High, uncontrolled
diabetes although he
takes metformin
(antipsychotic antagonize
the effect of antidiabetic
medication )
4.8 - 77.8Percentage %HBA1C
Blood Glucose

16. Current medication list

17. Drug indication Start
date
Stop
date
Is the drug appropriate? Side effects
Chlorpromazine
tablets 200mg
(Tablets, I tab
daily at night)
Control the
psychotic
symptoms
4.10 Ongoing Not appropriate, according to UpToDate The patient has tried
Chlorpromazine for adequate period with no improvement so
increase its dose will not control the symptoms, according to the
guidelines this medication should be switched to olanzapine or
Risperidone(more safe and effective alternative). Most
Antipsychotic increase seizure threshold but some consider safer
than others during epilepsy( atypical , 2nd generation
antipsychotic ) such as olanzapine or Risperidone.
Extrapyramidal side
effects(e.g., Parkinson-
like symptoms, dystonia,
akathisia, tardive
dyskinesia), drowsiness,
dizziness weight gain
Keprra
(Levetiracetam)
100mg (Tablets, 1
tab twice daily )
anti-
convulsant
4.10 Ongoing Appropriate , To control the epilepsy patient ,Keprra
(Levetiracetam) 100mg, but he should do EEG for more
investigation.
Common side effects
include, psychoneurosis,
drowsiness, weakness,
Hydroxyzine
Hydrochloride
(Atarax) 10
mg(Tablets, 1 tab
at night as needed
)
Insomnia
associate
with
psychosis
symptoms
4.10 Ongoing Appropriate, Hydroxyzine Hydrochloride (Atarax) 10 mg should
be used only if needed not for regular use.
Drowsiness, dry mouth
Metformin.
Glucophage. 500
mg. Tablet. BID
Type 2
diabetes
4.10 Ongoing Appropriate , according to ADA and up to date metformin is first
line therapy for type 2 diabetes .
Heartburn , nausea or
vomiting, weight loss,
Lactic acidosis

18. Drug indication Start date Stop
date
Is the drug appropriate Side effects
Bisoprolol
fumarate
(concor )
5mg twice
per day
hypertension 4.10.2017 Ongoing No , according to JNC8 the first choice for
diabetic patient is ACE inhibitor .beta blocker
are not first line agent
Body aches or pain
chest pain
chills
cough
difficult or labored breathing
ear congestion
fever
headache
loss of voice
nasal congestion
Aspirin
81mg
(jaspirin )
once per
day
Prevention of
CVD specially in
hypertensive
patient .
4.10.2017 Ongoing Appropriate , because aspirin is the first line
drug to decrease the risk of CVD .
Abdominal or stomach pain,
cramping, or burning
black, tarry stools
bloody or cloudy urine
change in consciousness
chest pain or discomfort
confusion
constipation
convulsions, severe or continuing
dark urine
Esomeprazol
e 20 mg (
Nexium)
once daily
before food
To protect the
stomach from
the side effect
of aspirin-
NSAID- ) and
heartburn
4.10.2017 Ongoing Yes , according to BNF and Lexi comp ; proton
pump inhibitor can be given to relieve
heartburn and protect the stomach from the
side effect of aspirin but should be given for
one month (maximum )
bloating
chills
dizziness
darkened urine
indigestion

19. Patient was discharged with
the same medications

20. References :
BNF 66
Pharmacotherapy handbook ( 9 th ) , chapter 69 ( schizophrenia )
Barbra G. Wells , joseph T .dipiro ,Terry L.schwinghammer , Cecily
V.dipiro
Lexicomp
Lippincot Illustrated reviews , pharmacology , sixth edition , chapter 11
BNF 66
Joint National Committee (JNC 8) Guidelines
Practice guideline for the treatment of patient with schizophrenia
(second edition )
Schizophrenia : course over the lifetime by Philip Harvey and Michael
Davidson

21. Drug –Dug interactions

22. drug drug Severity Effect recommendation
metformin chlorproma
zine
Moderate Chlorpromazine may interfere with blood
glucose control and reduce the
effectiveness of metformin and other
diabetic medications
Monitor your blood sugar levels closely. You may need
a dose adjustment of your diabetic medications during
and after treatment with chlorpromazine. It is
important to tell your doctor about all other
medications you use, including vitamins and herbs. Do
not stop using any medications without first talking to
your doctor.
hydroxyzine levetiraceta
m
Moderate Using hydroxyzine together with
levetiracetam may increase side effects
such as dizziness, drowsiness, confusion,
and difficulty concentrating. Some people,
especially the elderly, may also experience
impairment in thinking, judgment, and
motor coordination.
You should avoid or limit the use of alcohol while
being treated with these medications. Also avoid
activities requiring mental alertness such as driving or
operating hazardous machinery until you know how
the medications affect you. Talk to your doctor if you
have any questions or concerns.
chlorpromaz
ine
levetiraceta
m
Moderate Using chlorpromazine together with
levetiracetam may increase side effects
such as dizziness, drowsiness, confusion,
and difficulty concentrating. Some people,
especially the elderly, may also experience
impairment in thinking, judgment, and
motor coordination.
You should avoid or limit the use of alcohol while
being treated with these medications. Also avoid
activities requiring mental alertness such as driving or
operating hazardous machinery until you know how
the medications affect you. Talk to your doctor if you
have any questions or concerns
chlorpromaz
ine
bisoprolol Moderate Chlorpromazine and bisoprolol may have
additive effects in lowering your blood
pressure. You may experience headache,
dizziness, lightheadedness, fainting,
and/or changes in pulse or heart rate.
Avoid activities requiring mental alertness such as
driving or operating hazardous machinery until you
know how the medications affect you, and use caution
when getting up from a sitting or lying position

23. LEXI-COMP
And
BNF 66
Reference :

24. Drug related problems + Pharmacist care
plan

25. Treatment related
problem
Pharmacotherapy goal Recommendation
3/A more effective
drug is available .
(Uncontrolled
Condition
schizophrenia)
Control the psychosis
symptoms and keep the
patient stable
Check the adherence ( educate the patient about the importance of adherence ) ,
Switch chlorpromazine to Risperidone 2mg twice daily.
4/A CURRENT
medication is unsafe
Drug-Disease
interaction
(epilepsy and
chlorpromazine)
Choose safe and appropriate
drug
Chlorpromazine should be avoided in epilepsy
Use safer alternative such as Risperidone and olanzapine.( in this case
Risperidone is the best choice :Initial dose: 2 mg orally per day
Titration dose: May increase in increments of 1 to 2 mg per day at interval of 24
hours or more, as tolerated.
Target dose: 4 to 8 mg orally per day
Maximum dose: 16 mg orally per day)
3/E Duration
inappropriate (
prescribe
Nexium(esomeprazole )
for chronic use )
Correct the duration of proton
pump inhibitor
Prescribe Nexium (esomeprazole ) for maximum 4 weeks then discontinue , or
add calcium supplement with vitamin D because long use of PPI lead to
osteoporosis and fracture, also decrease the acidity of the stomach for long time
and it will be good environment for bacterial growth like C.albican
3/A more effective
medication is available
( bisoprolol )
BP : 130/90
Protect the kidney from
deterioration
Bisoprolol, a beta blocker, is not the drug of choice for hypertensive
patients with diabetes. ACE Inhibitor, Enalapril at 5 mg should be
given and stopping the Bisoprolol. Enalapril has protective advantage to the
kidneys. Maintenance is 20 mg in one or two divided doses daily and maximum
dose is 40 mg daily.
Bisoprolol should be given when QT prolongation occurs. It is allowed in
combination with an ACE Inhibitor.

26. 2/B untreated
condition
Vitamin D: 30 – 40 ng/mL Patient is suffering from Vitamin D deficiency and should be given
supplements of Vitamin D. Example: 50,000 units once a weekly for
at least 8 weeks.
3/B Ineffective Dose HbA1C: 7.8%
RBS: 134mg/dl
Increase the dose of metformin from 500 mg twice daily to 850 mg
twice daily. No need to add a sulfonylurea yet as the maximum dose
of metformin has not been achieved yet. Maximum dose to be taken in one day is
2 g in two divided doses. If hyperglycemia persists, add a sulfonylurea such as
Gliclazide 30 mg MR with breakfast.
6/B Additional
Monitoring needed
To monitor the effect and the
side effect of medication
- More frequent monitoring is required ( I have the lab result of one day only )
Specially for diabetes and hypertension condition .
- Monitor the calcium and parathyroid to have idea about patient bone condition
Because the patient have 49 years old so he is more sensitive to the side effect of
chronic use of esomeprazole ( osteoporosis )
2/B untreated
condition
LDL (mg/dl) = 120 Add atorvastatin 20mg per day to prevent ( CVD ) –according to NICE guidelines -

27. References :
BNF 66
Pharmacotherapy handbook ( 9 th ) , chapter 69 ( schizophrenia )
Barbra G. Wells , joseph T .dipiro ,Terry L.schwinghammer , Cecily
V.dipiro
Lexicomp
Lippincott Illustrated reviews , pharmacology , sixth edition , chapter
11
BNF 66
Joint National Committee (JNC 8) Guidelines
Practice guideline for the treatment of patient with schizophrenia
(second edition )
Schizophrenia : course over the lifetime by Philip Harvey and Michael
Davidson
NICE guidelines
Pathophysiology for the Health Professions, 4th Edition , Ruthanna
Dyer, Barbara E. Gould

28. Medications counselling

29. Counseling PointsMedication
To be taken once daily , medication cause dizziness and drowsiness, patient should
be advised to not drive or operate heavy machinery after daily dose of it avoid
prolong exposure to the sunlight alcohol will increase the side effect .
Chlorpromazine 200mg OD noct
To be taken twice daily , don’t drive or operate heavy machinery as this medication
cause dizziness it cause change in the behavior such as anger, agitation, and
depression.
Levetiracetam 100 mg BID
To be taken once when needed at night cause dizziness and drowsiness, patient
should be advised to not drive or operate heavy machinery after taking this
medication .
Hydroxyzine Hydrochloride 10 MG OD
noct
To be taken twice daily with meals at regular interval swallow the tablets with a
drink of water store this medication at room temperature between 15 – 30
degrees
Metformin 500mg BID
To be taken twice daily check blood pressure regularly never stop
medication without doctor consultation .
Bisoprolol 2.5 mg BID
To be taken once daily with food report any sign of bleeding don’t crush enteric
coated tablet.ODaspirin 81mg
To be taken once daily 30 min – 1 hr before foodEsomeprazole 20 mg OD

30. References
•Taylor, D., Paton, C., Kapur, S., & Taylor, D. (2012). The Maudsley prescribing guidelines in psychiatry. Chichester, West Sussex: Wiley-Blackwell, a John Wiley & Sons, Ltd., Publication,
pages21-22-23-24-34-35-36.
•Schizophrenia: Practice Essentials, Background, Pathophysiology. (2016). Emedicine.medscape.com. Retrieved 2 April 2016, from http://emedicine.medscape.com/article/288259-
overview#a2
•Schizophrenia: Symptoms, Types, Causes, and Early Warning Signs. (2016). Helpguide.org. Retrieved 2 April 2016, from http://www.helpguide.org/articles/schizophrenia/schizophrenia-
signs-types-and-causes.htm#causes
•Schizophrenia. (2016). Mental Health America. Retrieved 2 April 2016, from http://www.mentalhealthamerica.net/conditions/schizophrenia
•Schizophrenia Risk factors - Mayo Clinic. (2016). Mayoclinic.org. Retrieved 2 April 2016, from http://www.mayoclinic.org/diseases-conditions/schizophrenia/basics/risk-factors/con-
20021077
•Schizophrenia Tests and diagnosis - Mayo Clinic. (2016). Mayoclinic.org. Retrieved 2 April 2016, from http://www.mayoclinic.org/diseases-conditions/schizophrenia/basics/tests-
diagnosis/con-20021077
•Schizophrenia : course over the lifetime by Philip Harvey and Michael Davidson
•Practice guideline for the treatment of patient with schizophrenia (second edition )
•Lippincott Illustrated reviews , pharmacology , sixth edition , chapter 11
• Pathophysiology for the Health Professions, 4th Edition , Ruthanna Dyer, Barbara E. Gould
•Pharmacotherapy handbook ( 9 th ) , chapter 69 ( schizophrenia ) Barbra G. Wells , joseph T .dipiro ,Terry L.schwinghammer , Cecily V.dipiro
•Lexicomp
•NICE guidelines
•UptoDate
• JNC8
•ADA 20
•BNF 66
•American Psychiatric Association 2010