A soape note on uncontrolled hypertensionRomit Subba
This was our SOAPE note on Uncontrolled HTN. SOAPE S Stands for Subjective O stands for Objective A for Assessment P for Plan and E for Education . Patient have Uncontrolled HTN for which we being a pharmacist giving our rationale depending upon his/her SOAPE. Suggestions and comments are appreciated.
PHARM-D INTERNSHIP ANNUAL REPORT PRESENTATION UNDER THE GUIDENCE OF DR.R.GO...DR. METI.BHARATH KUMAR
PHARM-D final Internship Report Presentation Under the Guidance of DR.R.Goutham Chakra
If Anyone need this they can contact me via
dr.m.bharathkumar@gmail.com
Case Presentation in SOAP format on Ischemic Heart Disease with Acute Coronar...Umme Habeeba A Pathan
Heart diseases are major reason for mortality and morbidity. This is the case on how depression and stress can lead to Heart disease and worsen the QOL of patient. Little changes in food style and your attitude towards your health can save your heart.
A soape note on uncontrolled hypertensionRomit Subba
This was our SOAPE note on Uncontrolled HTN. SOAPE S Stands for Subjective O stands for Objective A for Assessment P for Plan and E for Education . Patient have Uncontrolled HTN for which we being a pharmacist giving our rationale depending upon his/her SOAPE. Suggestions and comments are appreciated.
PHARM-D INTERNSHIP ANNUAL REPORT PRESENTATION UNDER THE GUIDENCE OF DR.R.GO...DR. METI.BHARATH KUMAR
PHARM-D final Internship Report Presentation Under the Guidance of DR.R.Goutham Chakra
If Anyone need this they can contact me via
dr.m.bharathkumar@gmail.com
Case Presentation in SOAP format on Ischemic Heart Disease with Acute Coronar...Umme Habeeba A Pathan
Heart diseases are major reason for mortality and morbidity. This is the case on how depression and stress can lead to Heart disease and worsen the QOL of patient. Little changes in food style and your attitude towards your health can save your heart.
viral hepatitis is one of the chronic disease and can cured with proper treatment and care .Here is the case study on viral hepatitis for pharmacy students .
SOAP notes are a highly structured format for documenting the progress of a patient during treatment and is only one of many possible formats that could be used by a health professional. They are entered in the patients medical record by healthcare professionals to communicate information to other providers of care, to provide evidence of patient contact and to inform the Clinical Reasoning process.
SOAP is an acronym for:
Subjective - What the patient says about the problem / intervention.
Objective - The therapists objective observations and treatment interventions (e.g. ROM, Outcome Measures)
Assessment - The therapists analysis of the various components of the assessment.
Plan - How the treatment will be developed to the reach the goals or objectives.
Here i am presenting a meningitis case in the form of soap note.
patient counseling: Patient counseling is defined as providing medication information orally or in written form to the patients or their representatives on directions of use, advice on side effects, precautions, storage, diet and life style modifications.
Focal seizures begin in one area of the brain, but can become generalized and spread to other areas
This powerpoint deals with the SOAP analysis of Pneumonia, suffered by a girl, how the disease was diagnosed & appropriate treatment measures given & patient counselling tips given.
Regards,
@ RxVichu!! :)
viral hepatitis is one of the chronic disease and can cured with proper treatment and care .Here is the case study on viral hepatitis for pharmacy students .
SOAP notes are a highly structured format for documenting the progress of a patient during treatment and is only one of many possible formats that could be used by a health professional. They are entered in the patients medical record by healthcare professionals to communicate information to other providers of care, to provide evidence of patient contact and to inform the Clinical Reasoning process.
SOAP is an acronym for:
Subjective - What the patient says about the problem / intervention.
Objective - The therapists objective observations and treatment interventions (e.g. ROM, Outcome Measures)
Assessment - The therapists analysis of the various components of the assessment.
Plan - How the treatment will be developed to the reach the goals or objectives.
Here i am presenting a meningitis case in the form of soap note.
patient counseling: Patient counseling is defined as providing medication information orally or in written form to the patients or their representatives on directions of use, advice on side effects, precautions, storage, diet and life style modifications.
Focal seizures begin in one area of the brain, but can become generalized and spread to other areas
This powerpoint deals with the SOAP analysis of Pneumonia, suffered by a girl, how the disease was diagnosed & appropriate treatment measures given & patient counselling tips given.
Regards,
@ RxVichu!! :)
Obesity and hyperlipidemia is international /worldwide problem causing heart disease leading to major predisposing factor for morbidity and death. Conventional medicine used in allopathy include statins, fibrates, niacin and resins but are going to defame due to their adverse effects. Herbal medicine ginger has proved itself as one of the potent anti hyperlipidemic and anti obesity herb with least adverse effects. We did try to compare its hypolipidemic effects with placebo effects when used in mild to moderate hyperlipidemic patients. It was placebo-controlled single blind research study. Research was conducted at National hospital, Lahore, from July to November 2016. Consent was taken from sixty hyperlipidemic patients age range from 25 to 60 years. Both gender male and female patients were enrolled. Patients were randomly divided in two groups, 30 patients were on drug ginger pasted-powder advised to take 5 grams in divided doses with their normal diet for the period of three months. Thirty patients were on placebo pasted-wheat powder, with same color as of ginger powder, advised to take 5 grams in divided doses with their normal diet for the period of three months. Their base line lipid profile and body weight was recorded at start of treatment and were advised to come for check-up, fortnightly.
International Journal of Medical Science in Clinical Research and Review Vol 03, Issue 02,April – 2020 Page |
229
When duration of study was over, their lipid profile and body weight was measured and compared statistically with pre-treatment values. Three months treatment with 5 grams of ginger decreased total cholesterol from 233.11±1.53 mg/dl to 198.44±1.23 mg/dl, LDL cholesterol reduced from 202.21±1.88 mg/dl to 187.72± 1.98 mg/dl, reduced body weight from 76.01±2.66 kg to 72.80±1.87 kg. Both plasma total cholesterol and LDL cholesterol reduction was statistically significant, but body weight decrease was non-significant when analyzed biostatistically.
For this Discussion, review the case Learning Resources and the .docxevonnehoggarth79783
For this Discussion, review the case Learning Resources and the case study excerpt presented. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs.
Case: An elderly widow who just lost her spouse.
Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications:
•
Metformin 500mg BID
•
Januvia 100mg daily
•
Losartan 100mg daily
•
HCTZ 25mg daily
•
Sertraline 100mg daily
Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP: 132/86
By Day 3 of Week 7
Post
a response to each of the following:
• List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
• Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
• Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
• List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
• List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
• For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?
• Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.
Respond to the these discussions. All questions need to be addressed.
Discussion 2 Me
Treatment of a Patient with Insomnia
The case presented this week, is that of a 75-year-old widow who just lost her spouse 10-months ago. Th patient presents with chief complaints of insomnia. Past medical history of DM, HTN, and MDD is reported. Since the passing of her husband, she states her depression has gotten worse .
Just an attempt to promote pharmacy practice in India. It helps for the students and professionals of pharmacy in healthcare, especially Doctor of Pharmacy and Pharmacy Practice students
A Little Bit of Everything, Quick & Snappy: Probiotics to Advances in the Car...PASaskatchewan
As pharmacists, you are rarely faced with a consistent patient population with similar problems and questions. More likely, each patient you interact with has unique and varied concerns that you must be ready to address in an instant. This session reflects the diversity of patients a pharmacist will face in day-to-day practice and covers a range of topics in a quick and snappy format. This session will cover the evidence as it relates to concurrent probiotic and antibiotic use, second line treatment for patients with type 2 diabetes, and explore new utilization strategies of using drugs traditionally used in the treatment of type 2 diabetes for patients with type 1 diabetes.
A presentation by Dr. Swamy Venuturupalli, MD, FACR from Lupus LA's annual patient education conference at Cedars Sinai Medical Center in Los Angeles, CA.
Dr. Swamy Venuturupalli is a board-certified rheumatologist practicing in Los Angeles. He is Clinical Chief of the Division of Rheumatology at Cedars Sinai Medical Center and Associate Clinical Professor of Medicine at UCLA as well as being Editor-in-Chief of Current Rheumatology Reports.
Dr. Venuturupalli grew up in Bombay, India, the son of two physicians. In 1995, he received his medical degree from the prestigious Topiwala National Medical College in Bombay. Dr. Venuturupalli completed his residency in Internal Medicine, with distinction, at the Upstate Medical University in Syracuse, NY. Following his residency, he was appointed Chief Resident in the department of medicine at Syracuse University, where he was in charge of managing and training 65 residents.
In 1999, Dr. Venuturupalli moved to Los Angeles for a combined fellowship in health services research with UCLA's School of Medicine, the RAND Corporation, and the Greater Los Angeles Veteran's Administration Medical Center. Along with his cohort, he conducted research on complementary and alternative medicine, publishing studies on Ayurvedic medicine, dietary supplements, and mind-body medicine. Dr. Venuturupalli then completed a rheumatology fellowship at the UCLA-Olive View medical program in 2002.
Dr. Venuturupalli's role as research investigator includes over a hundred clinical trials involving conditions such as lupus, rheumatoid arthritis, inflammatory muscle diseases, ankylosing spondylitis, etc. He participates in ongoing rheumatology research with Dr. Daniel Wallace, a leading physician in the field, at the Cedars Sinai Division of Rheumatology. Dr. Venuturupalli lectures frequently to the general public and to the staff and faculty at Cedars Sinai Hospital on various topics in rheumatology, including alternative and complementary medicine. He was also recently invited to give grand rounds at Cedars on topics such as antiphospholipid syndrome and myositis. Dr. Venuturupalli has authored numerous text-book chapters, is published in peer-reviewed journals, and is currently the Editor-in-Chief of the journal Current Rheumatology Reviews.
For the past eight years, Dr. Venuturupalli has held a private practice in association with a group of 4 rheumatologists. Dr. Venuturupalli is highly regarded by his colleagues and is a sought-after teacher in his field of expertise. He has served as the past president of the Southern California Rheumatology Society, a non-profit professional organization of rheumatologists focusing on professional education.
Areas of expertise: Inflammatory Muscle disease, Systemic Lupus Erythematosus, Anti- Phospholipid syndrome, Sjogren's syndrome, Osteoporosis, Vasculitis.
15
FUNDAMENTALS COURSE PROJECT (GROUP)
Introduction
Client name Mr. Brown
Client age: 72yrs
Gender: Male
Religion: Jewish
Ethnic: African American
Illness: T3 burst fracture
Family History: Mr. Brown is from a family of six. He’s the only male child in the family with five siblings. He lost both his parent to high blood pressure when he was at the age of 35. Currently, Mr. Brown has been battling this condition for the past six years. During my assessment, his blood pressure was 165/90 which indicates that he is also experiencing high blood pressure, which is family heredity. Our focus for this project is the disease Mr. Brown is experiencing the T3 disease
Question One
Drug Name Trade & generic name, dose, route & frequency
Pharmacological & therapeutic drug class & Expected action in the body
What medical diagnosis is your patient taking this drug for? How will it help them?
Side Effects & Adverse Reactions/ Complications/Top drug interactions
Nursing Administration Special Instructions and Assessments
Client Education Evaluation of Medication Effectiveness (e.g. Pain Scale)
- Dosage:
5mg
- route:
rectally
-frequency:
3 days daily
- generic:
Bisacodyl
-Trade:
Dulcolax
(Gunnström et al., 2022).
- Therapeutic:
Fluid is altered
that results in colon.
fluid buildup
- T3 burst
Fracture:
-the patient has
agonized injury in the spinal
cord, this
will assist in colon
clearing.
- also the patient has a problem in his
bladder and bowel . This medication
aids in making the bowel soft when he is constipating.
-Anxiety, memory loss, blurred vision, insomnia, depression, fatigue, dizziness,
- interactions:
no
applicable drug
interactions
(Vallerand, 2021).
- Assess for abdominal distention and bowel function
- evaluate
intake and
output ratios in the body.
- Do not take the dose twice or skip the dose as prescribed.
- if a dose is
skipped it
ought to be taken immediately and given a duration of 6 hours before the next dosage
(Gunnström et al., 2022).
Trade:
Gablofen,
- route:
Orally.
- dose:
5mg
-frequency:
Daily4 times
- generic:
baclofen
- Therapeutic:
Muscle
skeletal
relaxant
- contains
impulses at the
spine.
Therapeutic
effects:
bladder and bowel purpose may
also be enhanced
(Gunnström et al., 2022).
The patient has a problem in his bowel and
Bladder hence the medication may
help mend his
bowel and bladder
function
(Vallerand , 2020).
Side effects
nasal congestion, insomnia, headache, hypotension,
pruritus, and fatigue,
- interactions:
Hypnotics,
Analgesics, and alcohol
(Vallerand, 2020).
- Assess
- Monitor
patient closely
during test
dose.
-preventive
apparatus
ought to be
present for
unendurable
effects in the body
(Gunnström et al., 2022).
- Advice the patient to take medication as prescribed.
- instruct the patient to avoid continuous usage of alcohol while undergoing medication.
(Vallerand, 2020).
Trade:
Sertraline
Dose: 100mg
Frequency: Daily
Generic: Zoloft
- Therapeutic:
pharma ...
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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Case presentation - SOAP Format
1. CASE PRESENTATION
The Prescriptive role of Pharm.D
Dr. Deepak Kumar Bandari
RPh, PharmD, CGPH, CPPC
Elsevier Student Ambassador – South Asia
Department of Pharmacy Practice
Vaagdevi College of Pharmacy
2.
3.
4.
5. Dr. Palat has also contributed to the development of the curriculum for the Indian Association for Palliative
Care (IAPC) course on palliative care, and has been involved in opioid availability activities though the
IAPC and the Pain and Palliative Care Society, Calicut (a WHO Demonstration Project). She facilitated the
development of the Department of Palliative Medicine and the Diploma in Palliative Medicine, the first of
its kind in the country, at Amrita Institute of Medical Sciences, Kochi. With a special interest in pediatric
palliative care, Dr. Palat has played an important role in developing a unique pediatric palliative care
Dr. Gayatri Palat, MD
Anaesthesiology and Palliative Medicine
Associate Professor,
Pain and Palliative Medicine,
MNJ Institute of Oncology and Regional Cancer Center
Hyderabad.
palliative care, Dr. Palat has played an important role in developing a unique pediatric palliative care
fellowship program at MNJ Institute of Oncology and currently leads the Special Interest Group –
Pediatric Palliative Care of the Indian Association of Palliative Care.
Internationally, through her involvement with the IAEA (International Atomic Energy Agency), Dr. Palat has
participated in the initial planning of palliative care in the National Cancer Control Program for Sri Lanka,
Indonesia and the Philippines. She is a director of the palliative care initiative in SE Asia of Two World
Cancer Collaboration, the Canadian branch of International Network for Cancer Treatment and Research
(INCTR), which works with healthcare professionals in resource-challenged countries to reduce the burden
of cancer in South East Asian and African countries. She has also participated in the development of the
EPEC-India curriculum to facilitate the implementation of palliative care in various institutions throughout
the country.
6.
7. Case Presentation – Patient’s Profile
Patient: Shantha
Age: 56-year-old
Weight: 115 kgs
Height : 155cms
BMI : 56 kg/m2
Date : 13-Jan-2016
Sex: Female
This Case was reported in the Out patient Department of Critical care
unit in Continental Hospitals, Hyderabad
Referred to the Clinical Pharmacist for Pharmacotherapy Assessment &
Diabetes Management
BMI : 56 kg/m2
8. Case Presentation – Patient’s Profile
Multiple medical conditions -
1. Type 2 diabetes diagnosed - 2005
2. Hypertension diagnosed – 2012
3. Hyperlipidemia
4. Asthma
5. Coronary Artery Disease
6. Persistent - Peripheral Edema &
7. Longstanding Musculoskeletal Pain secondary to a motor vehicle accident.
Her medical history includes –
Atrial fibrillation
Anemia
Knee Replacement &
Multiple emergency room (ER)
admissions for Asthma
9. Case Presentation - Patient’s Profile
Her diabetes is currently being treated
with-
(Humalog 75/25)
Premixed preparation
75% Insulin Lispro Protamine
Suspension ( Intermediate acting ) +
25% Insulin Lispro Preparation (Rapid 25% Insulin Lispro Preparation (Rapid
acting)
33 units before breakfast &
23 units before supper
She says she occasionally “takes a little
more” insulin when she notes high
blood glucose readings
10. Case Presentation - Patient’s Profile
Her other routine medications -
1. INSULIN 75 /25 (lispro protamine suspension + lispro preparation)
2. FLUTICASONE - MDI - two puffs twice a day
3. SALMETEROL MDI - two puffs twice a day
4. NAPROXEN - 375 mg twice a day
5. ASPIRIN - Enteric-coated, 325 mg daily
6. ROSIGLITAZONE , 4 mg daily
7. FUROSEMIDE , 80 mg every morning
8. DILTIAZEM , 180 mg daily
9. LANOXIN , 0.25 mg daily9. LANOXIN , 0.25 mg daily
10. POTASSIUM CHLORIDE, 20 meq daily
11. FLUVASTATIN , 20 mg at bedtime.
Medications she has been prescribed to take “AS NEEDED” include
1. NITROGLYCERIN - Sublingual for chest pain (has not been needed in the past month)
2. FUROSEMIDE, additional 40 mg later in the day if needed for swelling (on most days the additional dose is
needed) &
3. ALBUTEROL - MDI , two to four puffs every 4–6 hours for shortness of breath.
She denies use of nicotine, alcohol, or recreational drugs
No known drug allergies
Up to date on her immunizations.
11. Case Presentation – Chief Complaints and History (Hx)
Shantha’s chief complaints now
1. Increasing exacerbations of asthma & the need for prednisone tapers.
2. She reports that during her last round of prednisone therapy, her blood glucose
readings increased to the range of 300–400 mg/dl despite large decreases in her
carbohydrate intake.
3. She reports that she increases the frequency of her fluticasone MDI, salmeterol
MDI, & albuterol MDI to four to five times/day when she has a flare-up.
3. She reports that she increases the frequency of her fluticasone MDI, salmeterol
MDI, & albuterol MDI to four to five times/day when she has a flare-up.
History (Hx):
1. Husband Out of work - Only source of income – State Government Pension.
2. Unable to purchase - fluticasone or salmeterol
3. Has only been taking prednisone & albuterol for recent acute asthma
exacerbations.
12. Case Presentation – Chief Complaints and History (Hx)
Shantha’s chief complaints
• Not been able to exercise routinely because of bad
weather & asthma
• The memory printout from her blood glucose meter for the• The memory printout from her blood glucose meter for the
past 30 days shows a total of 53 tests with a mean blood
glucose of 241 mg/dl - 90% above target.
13. Case Presentation – Subjective Findings
Physical Exam
• Well - appearing but obese
• Weight: 115kgs ; Height 5′1″
• Blood pressure: 130/78 mm Hg
• Pulse 88 beats /min• Pulse 88 beats /min
• Lungs: clear
• Lower extremities - pitting edema bilaterally
Shantha reports that-
1. On the days her feet swell the most, she is active & in an upright position throughout the day.
2. Swelling worsens throughout the day, but by the next morning they are “ skinny again.”
3. She states that she makes the decision to take an extra furosemide tablet if her swelling is
excessive and painful around lunch time;
4. Taking the diuretic later in the day prevents her from sleeping because of nocturnal urination.
16. Case Presentation – Physician’s Plan
1. FLUTICASONE - MDI - two puffs twice a day
2. SALMETEROL MDI - two puffs twice a day
3. NAPROXEN - 375 mg twice a day
4. ASPIRIN - Enteric-coated, 325 mg daily
5. ROSIGLITAZONE , 4 mg daily
6. FUROSEMIDE , 80 mg every morning
7. DILTIAZEM , 180 mg daily
8. LANOXIN , 0.25 mg daily
9. POTASSIUM CHLORIDE, 20 meq daily9. POTASSIUM CHLORIDE, 20 meq daily
10. FLUVASTATIN , 20 mg at bedtime.
11. INSULIN 75 /25 (lispro protamine suspension + lispro preparation)
Medications she has been prescribed to take “AS NEEDED” include
1. NITROGLYCERIN - Sublingual for chest pain (has not been needed in the past
month)
2. FUROSEMIDE, additional 40 mg later in the day if needed for swelling (on most
days the additional dose is needed) &
3. ALBUTEROL - MDI , two to four puffs every 4–6 hours for shortness of breath.
17. SOAP ANALYSIS - PWDT
Pharmacist’s Work Up of DrugTherapy (PWDT)
Desired Outcomes
Therapeutic Endpoints
Medication Related Problems Medication Related Problems
Pharmacist’s Interventions
Monitoring Plans
Patient Education
19. What are reasonable outcomes for this patient?
Based on current guidelines and literature, pharmacology, and
pathophysiology, what therapeutic endpoints would be needed to
achieve these outcomes?
Are there potential medication related problems that prevent
these endpoints from being achieved?
Pharmacist’s Work Up of Drug Therapy (PWDT)
these endpoints from being achieved?
What patient self-care behaviours and medication changes are needed
to address the medication-related problems? What patient education
interventions are needed to enhance achievement of these changes?
What monitoring parameters are needed to verify achievement of
goals and detect side effects and toxicity, and how often should these
parameters be monitored?
20. 1. Mortality outcomes
Avoid respiratory, cardiovascular, thromboembolic,or diabetes-related premature
death.
2. Morbidity outcomes
a. Disease-related:Reduce morbidity resulting from uncontrolled blood
glucose, blood pressure, dyslipidemia, and cardiovascular disease.
• Retard the progression of disease.
• Prevent, recognize, and treat early any complications of chronic conditions,
Reasonable Outcomes
• Prevent, recognize, and treat early any complications of chronic conditions,
such as Neuropathy (autonomic or peripheral), Eye disease (e.g., retinal
vascular narrowing, hemorrhages), cardiac disease (e.g., LVH, CHF, MI),
Nephropathy (e.g., proteinuria), and lower-leg amputation.
• Prevent chronic symptoms of asthma (e.g., coughing or breathlessness at
night, in the early morning, or after exertion).
• Retain recognition of hypoglycemia symptoms.
• Maintain near-normal lung function.
• Maintain normal activity levels (including exercise and physical activity).
• Prevent recurrence of Atrial Fibrillation.
21. b. Drug-related: Prevent, minimize, or manage drug-related morbidity.
• Monitor for side effects or toxicity.
• Monitor for drug-drug, drug-disease, and drug-food interactions.
3. Behavioral outcomes
a. Obtain annual eye exams.
b.Adhere to a medication regimen.
c. Get routine and timely medical examinations and laboratory tests.
d.Avoid stimulants or over-the-counter products that may affect blood glucose, blood
pressure, asthma, or circulation, such as alcohol, caffeine, nicotine, and decongestants.
Reasonable Outcomes
pressure, asthma, or circulation, such as alcohol, caffeine, nicotine, and decongestants.
4. Pharmacoeconomic outcomes
a. Keep drug and treatment costs within patient resources.
b. Make cost-effective and efficient use of health care resources.
5. Quality-of-life outcomes
a. Match, or minimally change, patient lifestyle and activities with treatment.
b.Aim for no interference with work or daily activities because of disease symptoms.
c.Work to ensure patient satisfaction with the pharmaceutical care and health care
team.
22. Therapeutic Endpoints
• LDL cholesterol: <100 mg/dl HDL cholesterol: >55 mg/dl
• Triglycerides: <150 mg/dl Hb A1C: <7.0%
Self-monitoring of blood glucose: mean <140 mg/dl
• No episodes of severe hypoglycemia requiring emergency assistance
• Blood pressure: <130/80 mmHg, with minimal or no signs or symptoms
of orthostatic hypotension
• Biochemical measures, such as potassium, calcium, magnesium, uric acid,• Biochemical measures, such as potassium, calcium, magnesium, uric acid,
serum creatinine, and blood urea nitrogen: within normal levels
• Improvement in or no worsening of peripheral edema
• Daytime asthma symptoms less than twice a week, night time symptoms no
more than twice a month, and symptoms responsive to inhaled β 2-agonist
within 15 min.
• Attain/maintain control of ventricular rate to <100 bpm
• Urinary albumin excretion: <30 g albumin/mg creatinine
• Serum digoxin: 1.5–2.0 ng/ml
23. Case Presentation – MRP’s and PI’s
Medication-Related Problems & Proposed Interventions
1. No indication for a current drug
2. Indication for a drug - but none prescribed
3. Wrong drug regimen prescribed / more
efficacious choice possible
4. Too much of the correct drug
5. Too little of the correct drug
1. FLUTICASONE
2. SALMETEROL
3. NAPROXEN
4. ASPIRIN
5. ROSIGLITAZONE
6. FUROSEMIDE
7. DILTIAZEM
5. Too little of the correct drug
6. Adverse drug reaction/drug allergy
7. Drug-drug, drug-disease, drug-food interactions
8. Patient not receiving a prescribed drug
9. Routine monitoring (labs, screenings, exams)
missing
10.Other problems, such as potential for overlap of
adverse effects
7. DILTIAZEM
8. LANOXIN
9. POTASSIUM CHLORIDE
10. FLUVASTATIN
11. INSULIN
12. NITROGLYCERIN
13. FUROSEMIDE
14. ALBUTEROL
15. PREDNISOLONE
24. Medication Related Problems
1. FLUTICASONE
2. SALMETEROL
3. NAPROXEN
4. ASPIRIN
5. ROSIGLITAZONE
6. FUROSEMIDE
7. DILTIAZEM
8. LANOXIN
9. POTASSIUM CHLORIDE
1. Type 2 diabetes diagnosed in 2005
2. Hypertension
3. Hyperlipidemia
4. Asthma
5. Coronary Artery Disease
6. Persistent - Peripheral Edema &
7. Longstanding Musculoskeletal Pain
No indication for a current drug
9. POTASSIUM CHLORIDE
10. FLUVASTATIN
11. INSULIN
12. NITROGLYCERIN
13. FUROSEMIDE
14. ALBUTEROL
15. PREDNISOLONE
7. Longstanding Musculoskeletal Pain
secondary to a motor vehicle accident.
8. Atrial fibrillation
9. Anemia
10. Knee Replacement &
11. Multiple emergency room (ER) admissions
for Asthma
None
No indication for a current drug
25. Medication Related ProblemsMedication Related Problems
Indication for a drug (or device or intervention) but none prescribed
Peak flow meter
Calcium/vitamin D / HRT supplementation
Corticosteroid therapy
Postmenopausal woman
Furosemide can cause hypocalcemia.
Magnesium Supplementation
1. FLUTICASONE
2. SALMETEROL
3. NAPROXEN
4. ASPIRIN
5. ROSIGLITAZONE
6. FUROSEMIDE
7. DILTIAZEM
8. LANOXIN
9. POTASSIUM CHLORIDE Routine Use Of Magnesium In Diabetes.
Hypomagnesemia - Risk Factor - Atrial Fibrillation,
Hypertension, Insulin Resistance, Glucose Intolerance, Dyslipidemia,
Increased Platelet Aggregation
An added benefit - Constipation
Angiotensin-converting enzyme (ACE) inhibitor
Patients >55 years of age with diabetes & hypertension - ACE inhibitor - indicated
Diltiazem - calcium-channel blocker - addresses several needs
If additional antihypertensive, renal, or cardiac effects are indicated, an ACE inhibitor should be added to
the drug regimen.
9. POTASSIUM CHLORIDE
10. FLUVASTATIN
11. INSULIN
12. NITROGLYCERIN
13. FUROSEMIDE
14. ALBUTEROL
15. PREDNISOLONE
26. Medication Related Problems
Too much of the correct drug
• Patient is using excessive
doses of Salmeterol &
fluticasone as treatment for
1. FLUTICASONE
2. SALMETEROL
3. NAPROXEN
4. ASPIRIN
5. ROSIGLITAZONE
6. FUROSEMIDE
7. DILTIAZEM
8. LANOXIN
fluticasone as treatment for
asthma exacerbations (at
times when she can afford
them).
8. LANOXIN
9. POTASSIUM CHLORIDE
10. FLUVASTATIN
11. INSULIN
12. NITROGLYCERIN
13. FUROSEMIDE
14. ALBUTEROL
15. PREDISOLONE
27. Medication Related Problems
Too little of the correct drug
Potassium Chloride Supplement
1. FLUTICASONE
2. SALMETEROL
3. NAPROXEN
4. ASPIRIN
5. ROSIGLITAZONE
6. FUROSEMIDE
7. DILTIAZEM
8. LANOXIN8. LANOXIN
9. POTASSIUM CHLORIDE
10. FLUVASTATIN
11. INSULIN
12. NITROGLYCERIN
13. FUROSEMIDE
14. ALBUTEROL
33. Pharmacist Interventions
Pharmacist Interventions
ASTHMA
1. Change Fluticasone & Salmeterol prescriptions
to a single combination product
2. Limit use of albuterol inhaler (short-acting beta-
agonist) to rescue only.agonist) to rescue only.
3. Consider addition of Leukotriene Inhibitor if
symptoms are not controlled
4. Begin use of Peak Flow Meter every morning
upon arising.
5. Develop & Implement - Asthma Action Plan
36. Pharmacist Interventions
Pharmacist Interventions
Persistent lower-extremity edema
Elevate Extremities – 20 – 30 minutes,
two to three times / day
Wear Support Stockings - anticipating
being on her feet most of the day
Limit Salt Intake
Minimize use - NSAIDs
37. Pharmacist Interventions
Pharmacist Interventions
HYPOKALEMIA
• Increase potassium chloride
supplement temporarily; reassess
potassium level in 7–10 days.potassium level in 7–10 days.
• Titrate potassium dosage with
decreasing use of Albuterol,
Furosemide & Prednisone to attain
& maintain potassium level of
3.5–5.0 mEq/l
38. Outcomes & Endpoints
Pharmacist Interventions
HYPERTENSION
No changes at this time / consider addition or change to ACE inhibitor
CORONARY ARTERY DISEASE
No changes at this time
OBESITY
Refer - Santha for nutrition counseling & weight loss.
CHRONIC PAIN
Change ongoing pain medications to ACETAMINOPHEN 500–650 mg three times a day.
Minimize use of NSAIDs by limiting it to “breakthrough” pain only
naproxen, 250 mg, or ibuprofen, 200 mg, as needed.
39. Outcomes & Endpoints
Pharmacist Interventions
FINANCIAL CONSTRAINTS
• Apply for manufacturers’ indigent drug
programs and State Health Insurance
Programs for combination asthma productPrograms for combination asthma product
& other expensive medications.
Generic Equivalent
Direct – Manufacturer
Samples
40. Pharmacist Interventions
Wellness , Preventive &
Routine Monitoring Issues
Initiate calcium/vitamin D supplementation
Initiate magnesium supplementation
Reduce daily aspirin from 325 to 81 mgReduce daily aspirin from 325 to 81 mg
Screen for depression
Refer for annual eye exam
Refer for bone density scan
Refer for nutritional counseling
42. References
Textbook of Clinical Skills for Pharmacists, 2nd Edition, Karen J.Tietze.
Textbook of Current Medical Diagnosis andTreatment (CMDT) – 2014.
Textbook of AppliedTherapeutics : 2nd Edition, Koda and Kimble.
British National Formulary (BNF), 61st edition
Glen Lewis Stimmel, Professor, University of Southern California, US.
Dr. Navin Loganathan,Cover story : New SundayTimes, Malaysia.
Prof. Syed Azhar Syed Sulaiman, Dean – University Sains, Malaysia.
Jennifer Pham, University of Illinois, Chicago, US : Short profile.
Dr. Gayatri Palat, Director & Co founder, PRPCS – Two World’s Cancer
Collaboration (TWCC), India.