Download Problem 4: Mixed Anemia

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Faculty of Pharmacy
University of Santo Tomas
Anti- psychotic drugs Anti- psychotic drugs Anti- psychotic drugs Anti- psychotic drugs Anti- psychotic
Anti- psychotic drugs Anti- psychotic drugs Anti- psychotic drugs Anti- psychotic drugs Anti- psychotic
Mr. jay p. jazul
Clinical & pharmacotherapy
Clinical & pharmacotherapy
Clinical & pharmacotherapy
Clinical & pharmacotherapy
Principles of Documentation
The ability of HC providers to evaluate and plan the
patient’s immediate treatment and monitor his/her
health care
Communication and continuity of care among providers
involved in the patient’s care
Canaday et al
Clinical & pharmacotherapy
Principles of Documentation
Accurate and timely claims review and payment
Appropriate utilization review and quality of care
evaluations
Collection of data that may be useful in research and
education
Canaday et al
OVERVIEW
Problem Oriented Approach
Allows auditing of care to assure
quality.
OVERVIEW
Pharmacist’s Role
 Should learn the problem oriented method of
health care so that a systematic, disciplined
approach to each patient is used and no
important
therapeutic
considerations
are
missed.
OVERVIEW
Pharmacist’s Role
 The approach should always be the
same regardless of the simplicity or
complexity of the problem.
OVERVIEW
Pharmacist’s Role
 He or she should not ignore other
problems including social,
psychological and financial problems.
PROblem oriented approach
TWO (2) MAIN
COMPONENTS
Problem List
SOAP Notes
Problem list
Problem
A problem is defined as a patient concern, or a
concern of both the patient and health care
professional.
Problems are not confined to diagnoses.
Identified as generally or as specifically as
possible based on available information.
Problem list
Problem
The problem maybe:
Symptom – patient complaint
Sign - abnormal results from the
laboratory test or abnormal finding from a
physical examination
Problem list
Problem
The problem maybe:
Social or financial situation
Psychological concern or physical
limitation
Problem list
SIGNS & SYMPTOMS
SIGNS
Obtained from interviewing the patient or
caregiver.
HERFINDAL TEXTBOOK OF THERAPEUTICS 2004
Problem list
SIGNS & SYMPTOMS
SYMPTOMS
May become a sign after the physical
examination is completed
This may lead to a diagnosis after the
completion of the appropriate diagnostic tests.
HERFINDAL TEXTBOOK OF THERAPEUTICS 2004
Problem list
Problem List
Definition
The table of contents of medical
record and framework for patient
care.
OVERVIEW
The Problem List
Things to know:
The problem list should be
rearranged into hierarchical order
with the most serious problem
listed first
OVERVIEW
The Problem List
Things to know:
Problems must be considered in the
treatment of any other problem, and
the treatment of a given problem is
affected by the presence of all of the
other problems.
Problem list
EXAMPLES of SYMPTOMS
Patient may complain of cough, fever, and
sputum production.
Physician hears rales and rhonchi on chest
auscultation and orders a sputum culture and
chest radiograph, which leads to the
diagnosis of pneumococcal pneumonia.
Problem list
EXAMPLES of SYMPTOMS
Patient may complain of cough, fever, and
sputum production.
Penicillin is administered and the pneumonia is
cured.
problem
DEVELOPMENT OF THE PROBLEM
Chief complaint
History of the Present Illness
Past Medical History
Family History
pROBLEM
DEVELOPMENT OF THE PROBLEM
During history
Review of Systems
Results of Laboratory Tests
Diagnostic procedures
Physical Examination
SOAP NOTES
Overview
For each problem, the subjective and objective
data assessed or interpreted in order to
develop a plan.
The plan may be to gather more data or to treat.
SOAP and farm
Difference between SOAP and FARM
SOAP NOTES
Subjective
Findings
Objective
Assessment
Assessment
Recommendation
Plan
Plan
Monitoring
SOAP NOTES
We will start to
the basic…
OVERVIEW
SOAP NOTES
Summary
SECTION
Subjective (S)
DEFINITIONS
What client tells you
What pertinent others tell you
about the client
Basically, how the client
experiences the world
Objective (O)
Factual
What the counselor personally
observes/witnesses.
Quantifiable (what was seen,
counted, smell, heard or
measured)
Examples
Client’s feelings, concerns,
plans, goals, and thoughts
Intensity of problems and
impact on relationships
Pertinent comments by
family, case managers,
behavioral therapists, etc.
Client’s general appearance
Test results
OVERVIEW
SOAP NOTES
Summary
SECTION
Assessment (A)
DEFINITIONS
Summarizes the counselor’s
clinical thinking
Examples
Clinical diagnosis and
clinical impressions
A synthesis and analysis of the
subjective and objective portion
of the notes.
Plan (P)
Describes the parameters of
treatment
Consists of an action plan and
prognosis
Action plan: Interventions
used, treatment progress,
and direction.
Prognosis: include the
anticipated gains from
intervention
SOAP NOTES
SUBJECTIVE (S)
Scopes
Include the patient complaints or symptoms.
Observations of health care providers may be
subjective in nature.
Primary means of gathering subjective data is
by talking to the patient.
Done in a systematic fashion called the review
of systems (ROS).
SOAP NOTES
OBJECTIVE (O)
Scopes
Evaluation of the patient, which may include
apperance, mood, affect and mental status.
Obtained from direct observation (physical
exam) or verifiable sources (lab values,
prescription records).
Should be written in quantifiable forms
Expressed in precise and descriptive terms
SOAp notes
Objective Data
Vital Signs
Results of Laboratory Tests
Findings from a Physical Examination
Results of various procedures
SOAP NOTES
ASSESSMENT (A)
Scopes
Used to assess the patient’s medical and
drug related problems.
Synthesize and analyze data from
subjective and objective data
SOAP NOTES
ASSESSMENT (A)
Scopes
Should contain a statement supporting
your assessment that a problem exists
and should include justification of the
therapeutic goal and brief discussion of
treatment alternatives.
SOAp notes
Assessment
Patient’s current status/behaviour
Evidence of Progress
Response to intervention or medication
Change in functional status
SOAp notes
Assessment of the Clinical Pharmacists
To develop a therapeutic plan
To follow the response to therapy
To document an adverse drug reaction
Workbook for Clinical Pharmacy and Therapeutics by Lloyd, Gourley and
Herfindal, 1988
SOAp notes
Methods of Assessment
A pharmacist should always consider whether a
problem is drug induced.
The pharmacist should consider whether drug
therapy is required; nondrug therapy such as
diet may be a better solution to the problem.
Workbook for Clinical Pharmacy and Therapeutics by Lloyd, Gourley and
Herfindal, 1988
SOAP NOTES
Methods of Assessment
The pharmacist should assess the current therapy for
appropriateness.
a. Are all the drugs necessary?
b. Is this the DOC for this patient?
c. Is this the correct dose?
Workbook for Clinical Pharmacy and Therapeutics by Lloyd, Gourley and
Herfindal, 1988
SOAP NOTES
Methods of Assessment
The pharmacist should assess the current therapy for
appropriateness.
d. Is this the correct dosage form?
e. Is this the best schedule for administration of this
drug to this patient?
f. Is the duration of therapy appropriate?
Workbook for Clinical Pharmacy and Therapeutics by Lloyd, Gourley and
Herfindal, 1988
SOAp notes
Methods of Assessment
The pharmacist should assess the response to
therapy and decide whether the response is
adequate and or the response is that which
was expected.
Workbook for Clinical Pharmacy and Therapeutics by Lloyd, Gourley and
Herfindal, 1988
SOAp notes
Methods of Assessment
The pharmacist should assess any drug
interaction or adverse drug reactions that have
occurred or may occur in this patient.
Workbook for Clinical Pharmacy and Therapeutics by Lloyd, Gourley and
Herfindal, 1988
SOAP NOTES
Methods of Assessment
The pharmacist should
state the reason for selecting this
drug for this patient
the reasons for discontinuing a
drug
the reasons for changing the dose
the reasons for adding a second
Workbook for Clinical Pharmacy and Therapeutics by Lloyd, line
Gourley
and
agent
Herfindal, 1988
SOAP NOTES
PLAN (P)
Scopes
Should recommend your suggested
treatment
Medications: include name, dose,
frequency)
Monitoring / follow up parameters (e.g.
what should be measured, frequency of
measurement, follow up appointment,
etc)
SOAP NOTES
PLAN (P)
Scopes
Interventions or actions taken in
response to assessment
Collaboration with others
Plan for the next session
Change in diagnosis
Documentation of the patient’s
awareness of medications/interventions
SOAP NOTES
PLAN (P)
Scopes
Treatment
Monitoring parameters and endpoints of
therapy
Patient education
Additional studies necessary to evaluate
the problem.
SOAP NOTES
Methods in formulating Plans
The pharmacist MUST:
Decide how therapy will be initiated
Select the appropriate subjective and objective data
Formulate patient education/counseling
Workbook for Clinical Pharmacy and Therapeutics by Lloyd, Gourley and
Herfindal, 1988
Sample Case Analysis
•
An example case will be analyzed
using the SOAP format to illustrate
the method that is to be used.
Sample Case Analysis
•
•
•
•
The information is obtained from the medical
record.
The laboratory data have been reported in
standard units.
Abbreviations have been used less frequently
than they are used in medical charts.
Common abbreviations are used to familiarize
the pharmacists with these abbreviations.
Sample Case Analysis
CC: R.J. is a 74 year old male who
comes to clinic to today with a
complaint of weakness and
lethargy for 2 months
Sample Case Analysis
Past Medical History (PMH)
R.J. has seizures because of a motor vehicle
accident 2 years ago. The seizures have been
well controlled and R.J only suffers one
seizure about every 6 months.
R.J. has suffered from hemorrhoids for 12
years.
R.J. has generative joint disease in his knees
and hips. His complaints are slight pain and
stiffness that do not interfere with his activities.
Sample Case Analysis
•
Medication History
–
–
–
•
Phenytoin, 300 mg p.o qhs
Aspirin, 650 mg p.o. q.i.d.
Over the counter (OTC) hemorrhoid
ointment applied prn
R.J. is a compliant patient.
Sample Case Analysis
•
Social History
–
Tobacco----negative
–
Alcohol----heavy in the last 6 months
since his wife’s death
Sample Case Analysis
Physical Examination (PE)
–
–
–
–
GEN (General): Well-developed, well nourished
male in no distress
VS (Vital signs): BP 120/80 Hr 80 RR 20 T 37
Wt 62 kg (70 kg 6 months
ago) Ht. 6’0’’
HEENT (Head, eyes, ear, nose and throat):
Pale mucous membranes and skin, no
nystagmus
COR (coronary): Normal S1 and S2, no murmurs,
rubs or gallop
Sample Case Analysis
Physical Examination (PE)
–
–
–
–
CHEST: Clear to auscultation and percussion
ABD (abdomen): Soft, nontender, with no
masses or organomegaly
GU ( Genitourinary): WNL (within normal limit)
RECTAL: Guaiac-positive, large inflamed
hemorrhoids
Sample Case Analysis
Physical Examination (PE)
–
–
EXT (extremities): Pale nail beds, tenderness of
both knees but no signs of inflammation,
limited range of motion of both hips
NEURO (neurological): Oriented to time, place
and person; cranial nerves intact; normal
deep tendon reflexes (DTR’s).
Sample Case Analysis
•
•
Results of Laboratory Tests
Hct 32
MCV 80
Hgb 10
RBC 4
Plts 320k
MCHC 28
Serum FE 38
TIBC 510
Peripheral blood smear: microcytic and
macrocytic RBC’s
Sample Case Analysis
•
Problem List
1.
2.
3.
4.
Degenerative joint disease
Hemorrhoids
Seizures
Mixed anemia
Sample Case Analysis
•
The pharmacist analyzing this case should
first rearrange the problem list into
appropriate order for this clinic visit.
Sample Case Analysis
•
•
•
R.J.’s complaint today is consistent with the
problem of anemia and this problem be
discussed first.
The hemorrhoids are contributing to the
anemia and should be discussed second.
The other two problems appear to be well
controlled and are stable.
Sample Case Analysis
•
•
Remember that the number of the problem
does not change although the order may.
The pharmacist then needs to analyze each
of the problems using the SOAP format and
following the systematic approach.
Problem 4: Mixed Anemia
•
S: R.J. complains of weakness and
lethargy. The physician noted
pale mucous membranes and pale
nail beds.
Problem 4: Mixed Anemia
•
O: The Hct, Hgb, MCHC, and serum
Fe are decreased. The TIBC is
increased while iron saturation is
decreased. The MCV is normal but
the smear shows microcytic and
macrocytic cells. The stool is
guiac positive.
Problem 4: Mixed Anemia
•
A: R.J. is suffering from iron deficiency anemia and
is likely to have folate deficiency as well. The iron
deficiency is due to his blood loss secondary to his
bleeding hemorrhoids perhaps due to
gastrointestinal (GI) blood loss secondary to
bleeding caused by aspirin and alcohol. His diet may
be low in iron and folate due to his drinking and his
recent weight loss may indicate inadequate intake.
Problem 4: Mixed Anemia
•
A: However, because treating a B12 deficiency
anemia with folate can correct the anemia but will
allow the nervous system damage to progress, a
B12 deficiency must be confirmed. Because R.J. is
not in acute distress, the oral route may be used for
iron replacement. Ferous sulfate is the cheapest
form of oral iron.
Problem 4: Mixed Anemia
•
A: The dose of iron required to reverse the sign
and symptoms and to replete his iron sores is about
40 mg/day of elemental iron for 6 months. This may
be achieved with 325 mg FeSO4 t.i.d. R.J. should
avoid aspirin and alcohol. Acetaminophen may be
effective for treating his degenerative joint disease
(DJD) in as much as no inflammation is present.
Problem 4: Mixed Anemia
•
P: Begin FeS04 325 mg p.o. t.i.d. for 6 months.
Obtain a folate and a B12 level and reticulocyte
count. Monitor weakness, lethargy, pallor, and
reticulocyte count (expect an increase in 7 days and
a return to normal in 2-3 weeks), Hct (expect a 6%
increase in 3 weeks and a return to normal in 6
weeks), Hgb (expect a 2% increase in 3 weeks and a
return to normal in 6 weeks) and a peripheral blood
smear.
Problem 4: Mixed Anemia
•
P: R.J. takes an iron on an empty stomach if
possible. If this causes too much GI distress, he
may take the iron with food but the duration of
treatment may need to be longer.
Problem 4: Mixed Anemia
•
He should not take the iron with milk or antacids.
The iron may cause his stools to turn black but this
may distinguished from tarry looking stools that
would indicate GI bleeding. The iron may cause
constipation so he should increase the fiber in his
diet and he should take a bulk laxative such as
psyllium 1 teaspoonful t.i.d. but not at the same time
as the iron.
Problem 4: Mixed Anemia
•
The iron must be kept away from children; iron
poisoning in children may be fatal. R.J. should also
increase the iron in his diet by eating more red meat
liver, and other sources of iron. If the suspicion of
folate deficiency is confirmed, R.J. should begin folic
acid 1 mg p.o q.d for 2-3 weeks to reverse the signs
and symptoms of anemia and to replete his body
stores.
Problem 4: Mixed Anemia
•
Because R.J. is taking phenytoin, he may require
folate supplementation for as long as he requires
phenytoin. R.J should decrease his alcohol intake
and should be referred for appropriate counseling.
The social worker should evaluate R.J.’s need for
help with cooking and housekeeping. In 2 weeks
R.J. should have another stool guaiac test to rule out
other sources of GI bleeding.
Problem 2: Hemorrhoids
•
S: none
•
O: Large inflamed hemorrhoids noted
on physical examination.
Guaiac positive stool.
Problem 2: Hemorrhoids
•
A: His hemorrhoids should be treated to
stop the bleeding. The drugs for treating
hemorrhoids are only useful for treating the
symptoms and the inflammation. Over the
counter preparations do not contain steroids
needed for effective treatment of the
inflammation.
Problem 2: Hemorrhoids
•
P: Refer R.J. to proctologist. Discontinue the
topical hemorrhoidal ointment. Begin Anusol
hydrocortisone (HC) suppositories, 1 rectally b.i.d.
R.J. should remove the foil from the suppository and
insert into the rectum in the morning and at bedtime
for 3-6 days until the inflammation subsides. If the
suppositories cause staining, the stains may be
removed from the fabric by washing. Begin the bulk
laxative as in problem 4 to decrease straining at
stool.
Problem 1: Degenerative
Joint Disease
•
•
S: R.J. complains of slight pain and
stiffness in his knees.
O: Pain in both knees without
evidence of inflammation and
limited range of motion in both
hips were noted on physical
examination.
Problem 1: Degenerative
Joint Disease
•
A: R.J. has pain and stiffness that does not
interfere with his activities and has no signs of
inflammation. The aspirin may be contributing
to his iron deficiency anemia and should be
discontinued. Because the degenerative joint
disease does not appear to involve an
inflammatory process at this time,
acetaminophen may be adequate to treat the
DJD.
Problem 1: Degenerative
Joint Disease
•
A: However large doses of acetaminophen
would be hepatotoxic in this patient with a
history of heavy alcohol intake. If
acetaminophen is ineffective or causes an
adverse reaction, then ibuprofen in analgesic
doses is likely to cause less GI blood loss than
aspirin.
Problem 1: Degenerative
Joint Disease
•
P: Obtain liver function tests. Discontinue the
aspirin. Begin the acetaminophen 650 mg p.o
q.i.d. Do not exceed 4 g/day of acetaminophen.
Avoid any other products that might contain
either acetaminophen or aspirin.
Problem 1: Degenerative
Joint Disease
•
P: Discontinue or limit the ingestion of alcohol
to no more than two drinks per day. Monitor
liver function tests every month for 3 n\month. If
R.J. is unable to tolerate acetaminophen or it is
ineffective, begin ibuprofen 400 mg q.i.d. and
monitor stool guaiac and renal function tests.
Problem 3: Seizures
•
S: None
•
O: R.J. has only one seizure every 6
months. Nystagmus was not
present on physical examination.
Problem 3: Seizures
•
A: R.J.’s seizure appears to be well controlled
and he is not suffering any adverse effects from
his phenytoin therapy other than the
contribution of the phenytoin to his anemia. If
R.J. is given folic acid therapy, his phenytoin
dose may have to be adjusted due to
decreased serum concentrations from this drug
interaction.
Problem 3: Seizures
•
P: Obtain a serum phenytoin level. Monitor for an
increase in seizure frequency or a decrease in
serum concentration if folate therapy is begun.
Monitor for adverse drug reactions to phenytoin
including nystagmus, ataxia, GI distress, skin
reactions, liver function tests, CBC, and sign and
symptoms of hypothyroidism, lymphadenopathy,
and intoxication.
Problem 3: Seizures
•
P: Explain the need for good oral hygiene to
avoid gingival hyperplasia and for regular
dental appointments. Explain that all health
care providers should know about his
phenytoin therapy because of the numerous
drug interactions with phenytoin.
Important Considerations
•
•
The pharmacist who has analyzed this case in
this manner is now in a position to answer
specific questions concerning the case.
For example, the pharmacist could answer
questions about how this patient’s anemia
should be treated or what monitoring
parameters should be followed to assess the
efficacy of the treatment of the anemia.
Important Considerations
•
•
Likewise the student could also answer
questions about the treatment of R.J.’s DJD
(degenerative joint disease) or the efficacy of
the treatment of his seizures.
The pharmacist should anticipate the questions
that are likely to be asked in a clinical setting
concerning this patient’s therapy.
Important Considerations
•
These questions may also predict a phenytoin
level for R.J.
•
The pharmacist who has analyzed the case in
the suggested fashion is unlikely to give
inaccurate or incomplete answers to these
questions because no important therapeutic
considerations have been omitted.
Important Considerations
•
The SOAP format allows a systematic
approach to therapy and is widely used in
pharmacy education and practice.
•
However, each practitioner would analyze a
case slightly different.
Important Considerations
•
In many cases, the correct therapy for an
individual patient will be agreed upon by all
who analyze the case because in these
situations there is only one possible
therapy based upon the contraindications
or other patient’s variables.
Important Considerations
•
In other cases the correct therapy is not so
straightforward and two or three
alternatives may be equally acceptable.
•
In these cases the choice of therapy
frequently rests with the individual
practitioner’s preference.
Important Considerations
•
In other cases there may be one therapy
that would be the best for the patient but
other alternatives may be acceptable
because of extenuating circumstances
such as history of noncompliance.
Important Considerations
•
The therapy and information given in these
cases may become incorrect as new
knowledge is accumulated.
•
In some cases the available literature is
conflicting or controversial and two
practitioners may have different opinions
based on the available information.
Important Considerations
•
In all cases the case analysis and answers
to the questions pertain only to patient
involved.
•
The information may or may not be
applicable to other patients with the same
problem.
Important Considerations
•
Therefore the pharmacists are warned
against memorizing these cases and
thinking that he or she knows the
material and will then be able to pass
examinations.
Anti- psychotic drugs Anti- psychotic drugs Anti- psychotic drugs Anti- psychotic drugs Anti- psychotic
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Anti- psychotic drugs Anti- psychotic drugs Anti- psychotic drugs Anti- psychotic drugs Anti- psychotic
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