Summary Of The Case

Record_2021-11-12-21-04-43_c37d74246d9c81aa0bb824b57eaf7062.mp3.

Record_2021-11-12-21-04-43_c37d74246d9c81aa0bb824b57eaf7062.mp3.

Record_2021-11-12-21-04-43_c37d74246d9c81aa0bb824b57eaf7062.mp3.

Record_2021-11-12-21-04-43_c37d74246d9c81aa0bb824b57eaf7062.mp3.

Record_2021-11-12-21-04-43_c37d74246d9c81aa0bb824b57eaf7062.mp3.

IMG_74598544.mp3. Review of Systems Weak, tired, and achy. Some shortness of breath (notably increased on exertion). Denies chest pain, cough, or hemoptysis. Denies nausea and vomiting, abdominal pain, and melena. Appetite is very poor. He bruises easily. Vital signs: BP 118/72 mmHg HR 66 bpm RR 18 rpm T 97.2°F Weight 50 kg.

IMG_74598544.mp3. HEENT(Head, eyes, ears, nose, and throat) NC/AT, oral mucosa is clean and dry, no JVD LUNGS: Decreased breath sounds in the right base, he has egophony in the right lower and mid-lung fields with bronchophony, no crackles, left lung field WNL. CV ( Cardiovascular central venous cerebrovascular) Grade 2/6 systolic murmur ABD (Abdomen) Soft, NT/ND, no hepatosplenomegaly EXT(Extremities): Left AV fistula in the upper extremity, good bruits, reduced pulses in lower extremities..

video-1636727654.mp3. Laboratory and Diagnostic Tests Sodium 134 mEq /L Potassium 4.9 mEq /L Chloride 104 mEq /L BUN 58 mg/dL CO2 content 19 mEq /L Serum Creatinine 6 mg/dL Glucose 182 mg/dL Calcium 10.3 mg/dL Phosphorus 6.6 mg/dL Albumin 2.4 g/dL PTH 152 pg /ml Hbg 10.2 g/dL Blood cultures (2) and sputum: pending CXR :Right lower lobe infiltrate consistent with pneumonia EKG: NSR, no evidence of acute ischemia Hct 32% Platelets 218,000/mm3 MCV 89.5 fL MCH 28.8 pg MCHC 32.2 g/dL RDW 19.3% WBC 8900/mm3 with 91.2% PMNs, 2.5% lymphocytes, 5.1% monocytes, 1.2% eosinophils PO2 60.2 mmHg PCO2 42.4 mmHg pH 7.45 O2 sat 92.2% CrCl <10ml/min.

video-1636727654.mp3. Primary Diagnosis Right lower lobe pneumonia Weight loss Secondary Diagnosis End stage renal disease Diabetes.

20211112_231547.m4a. Medical Record 9/15 Levofloxacin 500mg IV x 1 given in ED 9/15 regular insulin sliding scale subcut bid 9/16 Humun N 20 units subcut in AM and 10 units in PM 9/16 Glyburide 1.25mg po q AM 9/16 Claforan 2g IV q 24 h 9/16 Aspirin 325mg po daily 9/16 Centrum multivitamins 1-tab po daily 9/16 Epogen 5,000 units IV with dialysis 9/16 Calcitriol 1mcg MWF with dialysis.

Drug Data Base.

Delfin Albano-Santo Tomas Road.m4a. Patient Name: Birthdate: PIN No. Age/Sex:S4-Male-Rmm No.—Height-1Z4-cm Weight: 50 kg Date of Admissim: 9/15 Allergy: Weine- Precautions: Date of ICIJ Admissim —91.1.6— Medical History: Diabetes for 30 years. Diabetic complicatims irclude diabetic nephropathy {which has to ESRDI. retiropathy with blindæss and peripheral neuropathy. TT been on remodiatysis for 10 years (he is dialyzed 3 times/weekl. Additionally. TT has a history of CAD s/p CABG. MI. PVD and restless leg syndrqme. Diagnosis: Right lower lobe pnuemonia. Weight loss. End stage renal disease. Diabetes Feeding DO ZNGT OOGT cPEG OJ-TUBE cG-TUBE cQT Monitoring OTPN ZHD/SLED OCRRT ZIJ CSC ZMechanical cSWAN Garz.

Part.mp3. Mg Ca I mVdU ALT AST Crea C.' tot' cg MM PATIENT DRUG AND MONITORING PROFILE 6 4 10 02.

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Drug Therapy Assessment Checklist.

slide 18.m4a.

slide 19.m4a.

slide 21.m4a. Adverse Drug Events Is the patent al lergic or intolerant to the present med icatjon/s? Is there a high alert drug prescribed to the patient Ibased on drug watch list ? Drug interaction Are there any sagn ificant drug-food or drug-n utrient interactions's Are there drugs administered as an IV admixture? Are there any sign ficant phvaco- chemical incompatibiliti es No. Not indicated Not in the high alert drug watch list None. there is no food interaction/s Levofloxacin is administere d through IV indicated It Is ina high alert drug watch list None. there is no food interaction Insulin is administer ed through No. indicated It Is in a high alert drug watch list Humun n None. there is no food interaction/s Humun N is administere d through IV No. Not indicated It Is in a high alert drug watch list glyburide None. there is no food interaction's No. glyburide is an oral medication. Not indicated No. Not in the high alert drug watch None. there is no food interaction Claforan is administer ed through No. Not indicated Not in the high alert drug watch list None. there IS no food interaction/s No. Aspirin is an oral med ication. No. Not indicated Not in the high alert drug watch list None. there is no food interaction's No. centrum is an oral medication. Not indicated No, Not in the high alert drug watch None. there is no food interaction/s No. calcium acetate in an oral medication. No. Not indicated Not in the high alert drug watch list None. there is no food interactio n's Epogen is administer ed through IV No. Not indicated No. Not in the high alert drug watch list None. there is no food interactio Calcitriol is administe red through IV indiCi high . drug list None there food inten admi ed th.

slide 22.m4a. use of Is there a request for a non-formuLarv drug? Are there a alternative formulary drugs that can be recommended request for a new drug included in formulary? There is no request for non formulary drug There is no request for new drug included for formulary Compliance and A&lerence is the patient noncompliant based on the Medication Treatment Record (MTH)? there written reason in the patient' s medical chart? Are there any medication orders not followed by the patient and/or the nurse-ln- None. there is no written reason None. Medication orders are followed There is no request for formulary drug There is no request for a new drug uded for the formulary None. there is no reason None. Medicatio n orders followed There is no request for formulary drug There is no request for new drug uded for formulary None. there is no written reason None. Medication orders are follc•wed There is no request for non formu larv drug There is no request for a new drug included for the formulary None. there is no written Medication orders are followed There is no request for non formulary drug There is no request for a new drug Included for the formu larv None. there is no written reason None. Medicatio n orders followed There is no request for non formulary drug There is no request for nea drug incl uded for formu larv None. there is no written reason None. Medication orders are follc•wed There is no request for non formulary drug There is no request for a nev.' drug incl uded for the formulary None. there is no written None. Medication orders are follc•wed There is no request fo,• non formulary drug There is no request for a new drug incl uded for the formulary None. there is no Witten reason None. Medication orders are follc•wed There is no request for non formulary drug There is no request for a new drug included for the formulary None. there is no written None. Medicatio n orders followed There is no request for non formulary drug There is no request for a new drug incl uded for the form la there is no written reason None, Medicati On orders followed There is no request for formulary drug There is no request for a new drug included for the formulary None. there is no written None. Medicatio n orders followed.

slide 23.m4a.

Pharmacist’s Intervention Form.

received_404416437897160.mp3. PHARMACIST'S INTERVENTION FORM PATIENT NAME PIN TRUAX TOM BIRTH DATE (MMIDD[YWY) ROOM No. 1 DATE & TIME- 11/11/2021 at 11 pm SEXØMALE OFEMALE UNIT REMARKS HEALTH CARE PROVIDER NOTES AND ORDER SHEET (Subjective, Objective, Assessment and Plan of Care) > Levofloxacin 500 mg IV xl given in ED > DX Pneumonia > Incomplete drug order of Levofloxacin P > Weigh benefit/risk > Suggest to revise drug order of Levofloxacin to 750 mg IV every 24 hours for 7 days. (To be filled out by the Clinical Pharmacist-in-Charge Type of Intentention: Safer alternative available Recommendation: Switch to more effective agent, Switch to safer alternative, Refer to physician Other remarks: iscussed with Name: OAP/RIC ONIC oted in the PATIENTS CHART eported as a sentinel event e rted as an ADVERSE DRUG REACTION Noted in the Patient Education Form was carried out: YES OPatienUFamily o YES YES o o YES YES Intervention NO NO NO NO NO.

received_404416437897160.mp3. Medication Related Problem I. Drug therapy needed 2. Dose too low 3- Medication monitoring needed 4. Suboptimal drug Subcategory Cl assificati on Assessment Ia. Additional therapy required 1b. Untreated medical condition lc- Other 2a. Dose too low 3a- Monitoring needed to assess effectiveness/response to therapy 3b. Monitoring needed to assess for/prevent potential adverse drug events 3c. Monitoring needed for both 3a and 3b 3d. Other 4b. Not effective 4c- No indication or need for therapy 4d- Physicochemical incompatibility 4e. Potential for drug interaction 4f, Therapeutic duplication 4g. Contraindication to therapy exists Oh. Other Medication Related Problem n Suboptimal regimen 9. Nonadherence Subcategory Classification Assessment 8a. Duration too short 8b. Duration too long 8c. Administration not ideal or correct Bd. Frequency not correct 8e. Other 9a. Misunderstood directions 9b. Could not afford 9c. Fett better 9d. Regimen complex 9e. Felt worse 9f. Fear of adverse events 9g. Patient not aware of medication changes 9h. Disbelief in drug effectiveness.

received_404416437897160.mp3. 5. Dose too high 6. Adverse drug event present 7. More affordabTe alternative available Recommendation 1. Add drug 5a- Dose too high 6a. Moderate 6b. Severe 7a. Generic alternative 7b. Preferred formulary alternative OTC alternative 7d. Drug strength 7e. Combination therapy 7f- Other 10. Medication error 9i, Patient overusing medications 9j. Memory/cannot remember to take medications 9k. Other IOa. Unclear prescription 10b. Failure to administer IOC. Failure to discontinue 10d. Illegible prescription IOe. Incomplete 10f. Incomplete order log. Wrong administration IOh. Wrong documentation 2. Change administration time/route/dosage form 3. Change duration 4. Change frequency 5. Discontinue drug 6. Decrease dose 7. Educate 8. Increase dose 9. Recommend laboratory test 10. Recommend other test 11. Refer to nurse-in-charge 12. Refer to other health Gre professional 13. Refer to physician 14.Switch to preferred formulary agent 15.Switch to generic alternative .Switc to more e ectivea ent 7.Switch to safer alternative 18, Switch to OTC alternative 19. Other.

received_422654572754674.mp3. PHARMACIST'S INTERVENTION FORM PATIENT NAME PIN TRUAX TOM BIRTH DATE (MMIDD[YYYY) ROOM No. 1 DATE & TIME- 11/11/2021 at 11 pm MALE OFEMALE UNIT REMARKS HEALTH CARE PROVIDER NOTES AND ORDER SHEET (Subjective, Objective, Assessment and Plan of Care) > Cefotaxime 22 IV q24h > mechanical ventilator > HR-CAP > Based on National Antibiotic uidelines, Ceftriaxone 2g IV q24h for high risk CAP with no risk of pseudomonal infections P > Suggest to shift cefotaxime to eftriaxone 2g IV q24h and re-assess nce culture results available. (To be filled out by the Clinical Pharmacist-in-Charge Type of Intentention: Safer alternative available Recommendation: Switch to more effective agent, Switch to afer alternative, Refer to physician Other remarks: iscussed with Name: OAP/RIC ONIC oted in the PATIENT'S CHART eported as a sentinel event rted as an ADVERSE DRUG REACTION Noted in the Patient Education Form was carried out: YES OPatienUFamily o YES YES o o YES YES Intervention NO NO NO NO NO.

received_422654572754674.mp3. MedicationRelated Problem I. Drug therapy needed 2. Dose too low 3- Medication monitoring needed 4. Suboptimal drug Subcatego Assessment Ia. Additional therapy required 1b. Untreated medical condition lc- Other 2a. Dose too low Classification MedicationRelated Problem 8 8. Suboptimal regimen drug 9. Nonadherence 3a- Monitoring needed to assess effectiveness/response to therapy 3b. Monitoring needed to assess for/prevent potential adverse events 3c. Monitoring needed for both 3a and 3b 3d. Other . Safer alternative available 4b. Not effective 4c- No indication or need for therapy 4d- Physicochemical incompatibility 4e. Potential for drug interaction 4f, Therapeutic duplication 4g. Contraindication to therapy exists Oh. Other Subcategory Classification Assessment 8a. Duration too short 8b. Duration too long 8c. Administration not ideal or correct Bd. Frequency not correct 8e. Other 9a. Misunderstood directions 9b. Could not afford 9c. Fett better 9d. Regimen complex 9e. Felt worse 9f. Fear Of adverse events 9g. Patient not aware Of medication Cha nges 9h. Disbelief in drug effectiveness.

received_422654572754674.mp3. 5. Dose too high 6. Adverse drug event resent 7. More affordabTe alternative available Recommendation 8. Add drug Sa- Dose too high 6a. Moderate 6b. Severe 7a. Generic alternative 7b. Preferred formulary alternative OTC alternative 7d. Drug strength 7e. Combination therapy 7f- Other 10. Medication error 9i, Patient overusing medications 9j. Memory/cannot remember to take medications 9k. Other IOa. Unclear prescription 10b. Failure to administer IOC Failure to discontinue IOd. Illegible prescription IOe. Incomplete documentation 10f. Incomplete order log. Wrong administration IOh. Wrong documentation 9. Change administration time/route/dosage form 10. 11. 12. 13. 14. Change duration Change frequency Discontinue drug Decrease dose Educate 14. Increase dose 15. Recommend laboratory test 16. Recommend other test 17. Refer to nurse-in-charge 18. Refer to other health care professional 19. Refer to physician 18.Switch to preferred formulary agent 19.Switch to generic alternative . w tc to more e ectvea ent 1. witch fer Iternat 18, Switch to OTC alternative 19. Other.