College of Pharmacy & Nursing

College of Pharmacy & Nursing School of Pharmacy

PHARMACOTHERAPY-III LAB (PHCY510L)

Clinical Lab Manual Summer Semester 2016/2017

Faculty: Dr. Sabin Thomas Assistant Professor in Pharmacy Practice

Student ID:

Collecting and Organizing Pertinent Patient‐Specific Information

What is the problem? • Patient demographics, medical history, lab investigation, medication history etc.

• These subjective and objective information should be obtained directly from patients, family or health care professionals as needed.

• Information gathered by the pharmacist should be recorded in the patient’s medical re-cord so that it can be shared with other health care professionals.

SOAP Module

SOAP (subjective, objective, assessment and plan) module may be used to process any pharmacotherapeutic case.

• Subjective data explain the reason for the main complaint that the patient reports concerning symptoms, and medications adverse effects encountered. They are considered immeasurable data because it is based on the patient's interpretation and recall of past events.

• Objective data from physical examination, laboratory results, diagnostic tests, medications and all histories. They are measurable, e.g blood pressure, temperature, serum drug levels, pulse rate PR, respiratory rate RR, etc.

• Assessment is a brief but complete description of the problem, including a conclusion or therapeutic needs that are supported logically by the above subjective and objective data.

Example: in case your patient is hypokalemic, you may assess the reason of low potassium. Is it because of organic disease or because of a drug that patient is using and how serious it is (risk assessment?)

• Plan is a detailed description of recommended or intended action: Drug therapy (pharmacological and non-pharmacological), Workup/refer (laboratory, radiology, consultation), Diet, physiotherapy, surgery Patient education: self-care, goals of therapy, medication use Monitoring, and follow-up relative to the above assessment. Document and/or present the plan as a table

Case Scenario-1 Meningitis

J.K., a 67-year-old white woman with a history of orthotopic liver transplant was brought to the emergency room by her family because of a decreased level of consciousness. The patient was taking mycophenolate 1.5 g PO BID, prednisone 10 mg daily and tacrolimus 2 mg PO BID. Associated symptoms were headache, nausea, vomiting, and diarrhea for 3 days. J.K. has experienced fatigue, chills, headache, difficulty with speech, watery diarrhea and neck stiffness. On admission to the ED, J.K. had a temperature of 39.4◦C.

Her weight is 50 kg. Blood cultures were also obtained. Lumbar puncture revealed cloudy spinal fluid, white blood cell count of 2,400/mm3; with 65% polymorphonuclear leukocytes, total protein 225 mg/dL and glucose 41 mg/dL consistent with bacterial meningitis. The cryptococcal antigen was negative. The Gram stain of the CSF was positive for gram-positive rods. The patient is started empirically on ceftriaxone 2 g IV Q 12 hours and vancomycin 1 g IV Q 8 hours and ampicillin 2 g IV Q 4 hours. Blood cultures are positive 24 hours later with a gram-positive rod.

1. Apply SOAP module to this scenario.

2. What are the important features of Listeria meningitis?

3. Justify the continuation of empirical treatment given to the patient.

Case Scenario -2 Empiric Treatment for Meningitis

Mathew is an 70-year-old man who is taken to the Emergency Department complaining of fever, “stiff neck” and splitting headache for 3 days that is not relieved by acetaminophen or ibuprofen. He had undergone a surgery for a recent head injury.

Over the past 24 to 36 hrs, he is been increasingly lethargic and has not been making sense when speaks. The medical team performs a lumbar puncture and the findings support the initial diagnosis of meningitis, but the medical team wants to begin empiric antibiotic therapy.

1. What are the likely pathogens that would have caused meningitis?

2. Suggest suitable empiric treatment for the patient.

Case Scenario -2 Antibiotic Use in Respiratory Illness

Wafa is a 25-year-old marketing executive. She is worried about her cough and hoarse voice, as she has to give a presentation to her company board next week. Wafa says that she developed symptoms of cough with thick mucus sputum, running nose, mild fever and tiredness 5 days ago. She used ‘cough lozenges’ for her symptoms and felt ‘a bit better. She denies any sputum production or wheeze, or contact with anyone suffering from pertussis (whooping cough). Wafa is single and lives with her parents. She is a non- smoker and drinks alcohol only at social functions. She underwent a tonsillectomy at age 13. She denies any history of asthma. She has no history of renal or hepatic disease and no known drug allergies. Her family history is unremarkable. Currently, she is not taking any medication. On examination, she looks anxious. Her blood pressure is 126/84 mmHg, pulse 90 beats/min, respiratory rate 15/min and temperature 37.8 ºC. There is no cervical lymphadenopathy or cyanosis. Throat examination reveals no exudates. Respiratory examination reveals no chest wall tenderness and auscultation reveals normal breath sounds. There were no other significant findings.

2. Wafa is worried about her symptoms and requests an antibiotic prescription. She says she was prescribed an antibiotic for similar symptoms in the past and felt better after taking it.

Would you recommend an antibiotic for Wafa at this visit? Why/why not? If yes, please specify:

3. Would you recommend any over-the-counter medication(s) for Wafa’s symptoms? Why/why not? If yes, please specify:

4. What advice will you give Wafa about non-pharmacological strategies to manage her current condition?

Case Scenario -3 Empirical Antibiotic Use in Animal Bites

Mrs Lee presents with her 11-year-old grandson, Justin (45 kg) who is staying with her during his school holidays. Justin was bitten by her cat an hour ago because he pulled the cat’s tail while playing with it in the backyard.

Mrs Lee cleaned Justin’s wounds with tap water, used some tissues to stop the bleeding, and brought Justin to see you. On examination, Justin sustained scratches and obvious puncture wounds on his right hand, and scratches on his right lower arm.

You attempt to irrigate the wounds with normal saline and where necessary, debride the wounds. On your request, Mrs Lee rings Justin’s mother for further information.

Justin has asthma, but it is well controlled on fluticasone/salmeterol 50/25 micrograms (two puffs twice daily) and he rarely needs to use his ‘Ventolin’. Justin has received all his childhood vaccinations based on the recommended schedule.

The last ‘triple antigen’ was given at four years of age. Justin’s mother is unsure if Justin is allergic to any medications.

2. Is an antibiotic required for Justin? Please state why OR why not. If ‘yes’, please provide details of the antibiotic(s) required.

3. Is tetanus toxoid and/or immunoglobulin indicated for Justin? Please state why OR why not: