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Status post–atrial fibrillation with cardioversionStatus post–knee replacementInsufficient patient education regarding purposes and role of specific medicationsWellness, preventive, and routine monitoring issues: calcium/vitamin D supplement, magnesium supplement, depression screening, osteoporosis screening, dosage for daily aspirinDiscussionStrand et al. 1 proposed a systematic method for evaluation of and intervention for a patient’s pharmacotherapy, using a process called the Pharmacist’s Work-Up of Drug Therapy (PWDT).

The PWDT has been modified by subsequent authors,2–4 but the process remains grounded in the following five questions: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?What patient self-care behaviors 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?Outcomes and EndpointsClinical outcomes are distinctly different from therapeutic or interventional endpoints Case Studies in Geriatric Medicine and Patient Care..

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Therapeutic endpoints include the anticipated and desired clinical effects from drug therapy that are expected, ultimately, to achieve the desired outcome(s). As such, therapeutic endpoints are used as surrogate markers for achievement of outcomes.

Commonly, more than one endpoint will be needed to achieve an outcome. For example, near-normal glycemic control and normalization of blood pressure (endpoints) would be necessary to significantly reduce the risk of end-stage renal disease (outcome).

Therapeutic endpoints should be specific, measurable, and achievable within a short period of time. Achievement of clinical outcomes usually cannot be determined except by long-term observation or retrospective analysis.

Outcomes and endpoints for any given patient should be determined collaboratively between patient and provider before selecting or initiating pharmacotherapy or nonpharmacological interventions. Taking the time to identify these components up front (and periodically revise them later on) helps ensure that subsequent medications or strategies are appropriately directed.

It further ensures a common vision and commitment for ongoing patient care and self-management among the care team (including the patient), thus maximizing the potential for optimal disease control and patient satisfaction. The outcomes and endpoints for a patient such as B.

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Therefore, after desired outcomes and endpoints are determined, they should be prioritized according to medical urgency and patient preference.

Implementation and goal setting related to these priorities can then be undertaken, thus establishing a treatment plan for the eventual attainment of the full list Case Study: A Patient With Type 2 Diabetes Working With an Advanced Examples of desired outcomes and endpoints for B.L. are given in Tables 1 and 2..

During ongoing and follow-up visits, this care plan should be reviewed and modified as indicated by changes in patient status, preferences, and medical findings. Examples of desired outcomes and endpoints for B.

For the sake of brevity, these tables are not intended to be inclusive. Medication-Related Problems and Proposed InterventionsWith agreement between patient and clinician concerning desired outcomes and endpoints, the next logical step is to evaluate whether the current treatment plan is likely to achieve those goals, or, if treatment is to be initiated, which therapies or interventions should be selected.

,1 a medication-related problem is any aspect of a patient’s drug therapy that is interfering with a desired, positive patient (therapeutic) outcome or endpoint.

The PWDT proposes a systematic and comprehensive method to identify, resolve, or prevent medication-related problems based on the following major categories:No indication for a current drugIndication for a drug (or device or intervention) but none prescribedWrong drug regimen (or device or intervention) prescribed/more efficacious choice possibleToo much of the correct drugToo little of the correct drugAdverse drug reaction/drug allergyDrug-drug, drug-disease, drug-food interactionsRoutine monitoring (labs, screenings, exams) missingOther problems, such as potential for overlap of adverse effectsOnce problems are identified, resolutions must be developed, prioritized, and implemented Poorly written case studies (for example, those that include confounders such as additional treatment – either by other parties or self-prescribed by the patient .

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Resolutions may result from numerous strategies, including dose alteration, addition or discontinuation of medication, adjunct medications, regimen adjustment, complementary therapies, instruction on medication administration or devices, disease or medication education, development of “cues” as compliance reminders (e. , pill boxes), and identification of ways to avoid, detect, or manage side effects or toxicities. Needless to say, the involvement of patients and family or caregivers is critical for successful implementation of most resolution strategies and for optimal disease management.

’s medication-related problems and potential interventions (Tables 3 and 4), it was agreed to tackle first her asthma exacerbations and high blood glucose levels. was counseled about the role of maintenance asthma medications versus rescue drugs.

The root of her confusion between these agents was easy to understand—because the prednisone and fluticasone were both called steroids, it seemed likely that the tablets were a cheaper and easier way to take the medicine Finally, remember that a case study is primarily a chronicle of a patient's progress, not a story about chiropractic. Editorial or promotional remarks do not belong .

Case study: a patient with type 2 diabetes working with an

Having grasped the concept of asthma prevention, she was willing to convert to a product combining fluticasone and salmeterol (Advair Diskus) for maintenance/prevention and to reserve the albuterol for quick relief of acute symptoms. Free samples of the new product were dispensed, and B.

was enrolled in the manufacturer’s indigent drug program for subsequent supplies.

She was further instructed on the use of a peak flow meter and advised to monitor her readings and symptoms. At the next visit, these data will be used to determine her maximal expiratory effort (“personal best”) and to construct an asthma action plan.

’s insulin was changed to a basal-based regimen utilizing bedtime glargine (Lantus) insulin and premeal lispro (Humalog) insulin.

She and the pharmacist discussed how this regimen can give greater flexibility in dosing, especially for responding to changes in diet, exercise, and disease exacerbations or medications 11 Jan 2016 - This article describes practical and academic insights into writing a A case series is a descriptive, uncontrolled study based on a group of .

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She agreed to test four times daily and to record her blood glucose results, carbohydrate intake, and insulin doses. At the next visit, these data will be used to modify the adjustment algorithm and to construct a prospective algorithm for matching premeal bolus insulin to the anticipated carbohydrate intake (insulin-to-carbohydrate ratio).

The final interventions for this visit were to increase the dose of potassium chloride and change the fluvastatin to atorvastatin (Lipitor) to further reduce B. Medication education for atorvastatin was provided, and patient questions were answered.

Other medication-related problems and interventions identified for B. are listed and briefly discussed in Tables 3 and 4. For the sake of brevity, these lists are not inclusive nor are all pharmacotherapy issues discussed.

Monitoring for Effectiveness, Side Effects, and ToxicityThe last step in the PWDT process is to develop a plan to evaluate the patient’s progress in attaining desired outcomes, therapeutic endpoints, and behavior changes; to assess effectiveness of pharmacotherapy; and to identify side effects, drug interactions, or toxicity issues that need to be addressed Case Studies are common in Health Studies, where patient case notes are will give you some examples of recommendations and practice in writing them..

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For each medication or intervention, key parameters must be identified as markers for effectiveness, for side effects, for drug interactions, and for toxicity. In addition, the time frame and process for assessing those parameters must be determined.

Finally, the desired range for the parameter must be listed or a “decision point” must be identified to signal that additional action will be required. It should be noted that only a limited number of parameters are selected for a given patient.

For example, it is not necessary to list and monitor for every possible side effect with equal intensity and frequency. Selection of the monitoring parameters is based on the positive effects (efficacy) that are most important to the care of that patient, as well as the adverse effects (side effects, toxicity, or drug interactions) that are most important to avoid for the safety of that patient or to which that patient is most prone.

Because the monitoring component is usually extensive, examples listed for B. in Table 5 have been limited to three of the medication or regimen changes that were made at the first pharmacist visit: switching from fluvastatin to atorvastatin; switching from two shots of premixed 75/25 lispro to bedtime glargine with premeal lispro; and substituting the combination inhaler product for her fluticasone and salmeterol MDI prescriptions. Because atorvastatin and fluvastatin differ chemically, the monitoring parameters for this change are similar to those for initiation of a new medication.

Monitoring for the new insulin regimen (basal insulin with premeal bolus) focuses primarily on glycemic control patterns and hypoglycemic episodes. has previously used the two ingredients of her new inhaler product (fluticasone and salmeterol) without adverse effect, monitoring of her new asthma therapy is focused on effectiveness, tolerance of inhalation of its dry powder formula, and use of the administration device.

SummaryDiabetes patients with multiple co-morbidities have concerns about all of their problems, not just the diabetes; therefore, BC-ADM pharmacists must comprehensively explore all the ramifications of comorbidities as well as patients’ feelings, expectations, and concerns for total health. is a good example of this; even though her referral was for “diabetes management,” her greatest concern at this visit was her asthma exacerbations.

As can be seen in this case, each coexisting disease or coprescribed drug has a domino effect, affecting other diseases or drugs and ultimately affecting quality of life. , the pharmacist clinician was able to develop a PWDT that addresses her diabetes as well as her other health care needs.

was able to leave the health center with a few achievable self-care goals and medication changes that address her acute concerns and with the knowledge and confidence that, at each subsequent visit, additional progress will be made toward her personalized health status goals.