MJ, a 73-year-old male was admitted in a primary care urgent unit due to weakness and lethargy. He experienced these sym

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MJ, a 73-year-old male was admitted in a primary care
urgent unit due to weakness and lethargy. He experienced these
symptoms approximately 2 months prior to clinic visit. He had a
history of seizure disorder since MVA 2 years ago and DJD in knees
and hips.
The patient does not smoke, however he became a heavy
drinker since the death of his wife 4 months ago.
Medications:
Phenytoin 300mg PO q HS
Aspirin 650 mg PO QID and PRN
Patient claimed to be compliant with medication
regimen.
Allergies: NKA
Physical Examination:
General: Well developed, well nourished male in no acute
distress
Vital Signs: BP 120/80. RR 20, T 37oC. Wt 62 kg, Ht
180cm
HEENT: Pale mucous membranes and skin; no
nystagmus
Coronary: Normal S1 and S2, no murmurs, rubs, or
gallops
Chest: Clear to auscultation and percussion
Abd: Soft, non-tender, no masses or
organomegaly
Genitourinary: Normal male genitalia
Rectal: Guaiac-positive stool
Ext Pale nail beds, tenderness of both knees but no
signs of inflammation
Neuro: Alert and oriented x 3; No seizures in 6
months
Laboratory Examination Results: (SI UNITS)
Hct 0.32 MCV 80 μm3 TIBC 91 μmol/L
Hgb 100 mmol/L MCHC 280
Plts 320 x 109/L Serum Fe 6.7 μmol/L
Stool guaiac test: Guaiac-positive stool
Peripheral blood smear: Normocytic red blood
cells
I. General Activity Instruction: Pharmacist Work-up of
drug therapy
Analyze the case properly
Fill-in the table below.
Identify principal problems from the scenario, create
problem list and prioritize identified problems
Create systematic documentation (SOAP Note) following
the SOAP format
B. Drug therapy problems: Assess the patient’s current
medication therapy and evaluate if there are any drug therapy
problems.
Drug Therapy Problem
Correlation between drug therapy and medical
problems
Unnecessary Drug therapy
Needs Additional Therapy
Appropriate drug selection
Drug regimen
Wrong Drug
Dose too high/too low
Therapeutic duplication
Adverse Drug Reaction (ADR)
Medication
Classification
ADR caused to the patient
Drug Interactions
Object
Precipitant
Mechanism of toxicity (MOT)
Failure to receive therapy
Financial impact
Patient’s knowledge of drug therapy