Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 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 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 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 nti- 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 Thank You!!!