Patient work up answer key

Pharmacy Case Based Exam I
Directions: Review the following Subjective and Objective findings and then, complete the
SOAP note by writing an Assessment, Goals, and Plan. Also complete prepare pharmacokinetic monitoring forms for each anticonvulsant. Make sure you accurately complete these forms. Weighting of Items: Assessment , Goals, and Plan = 63 points;
Monitoring Forms = 25 points
Case Information:
November 9, 1999 14:00
S: This 20 year old patient presented to the pharmacy looking very anxious. When asked if there is a
problem she indicated, “ I…know I am pregnant. I don’t know what to do…I know my seizure medicationcan harm a baby….I’m not married either.” Upon further questioning, she indicated she just can’t tell herparents. She said, “Maybe an abortion is the best thing, but I just can’t bring myself to do it.” Seizure Activity: Patient states her seizures have been well controlled – in fact she has had no seizures
since Vigabatrin was added 2 years ago (it was investigational at that time). She states until then she had at
least one seizure daily since her accident at age 9.
Description of Seizures: She states that she initially smelled something similar to bacon before the seizure
began. When the seizure begab, she would start picking at her arm as if lint was on it. She would
repetitively pick at her arms for about 2 minutes. Her family told her that during the seizures they call her
name but even though she was conscious, she did not hear them.
PMH: S/P Severe head trauma at age 9 (1988)
SH/FH: Patient is a college student majoring in engineering at Auburn University. She lives with two
other female friends. She has been dating her boyfriend only a brief time and states he doesn’twant to marry her and is pressuring her to get an abortion. He does not know she takes seizuremedications. She is from Cullman where her parents are well known in their community.
Both parents are alive and well with no chronic illnesses. Grandparents are also alive and wellwith no major illnesses.
Med Hx:
Ovcon 35 1 q am (Ethinyl estradiol 0.35mg and norethindrone 1mg)
Phenytoin 350 mg q am (100mg Kapseals & 50mg chewtab)
Depakote 750mg TID (breakfast, 2PM, and bedtime)
Vigabatrin 1gm BID (breakfast and bedtime)
Diamox 250mg BID 4 days before, during, and 4 days after menstrual cycle
OTC products – only uses Motrin about once a month for headache or menstrual cramps
Insurance – Covered under parent’s BCBS – Alabama policy (generics cost $5/prescription and tradename
products are $15/prescription)
Pt. Education – patient is knowledgeable about why she is taking each medication.
Adherence – patient admits to having some difficulty remembering to take the 2PM VPA dosage. Misses
the dose several times a week she usually takes the dosage she forgot at supper.
Allergies – Carbamazepine, phenobarbital
Smoking – neg Alc - neg
O: Temp – 98.6 BP – 110/72 HR – 81 Ht = 5ft 4in Wt = 115 lbs
Neuro – EOMI Nystagmus – negative Ataxia - negative Romberg – negative Mini Mental Status Exam – oriented x 3 recalled 3 items, could subtract 7 from 100 backwards, recall was intact, language appropriate.
Mood/affect: patient appears depressed, but she says it is just because she doesn’t know what todo.
Head - Visual changes – complains that she sometimes has trouble seeing the board; has not been to an opthamologist in 5 years. H/A – neg Changes in taste – negHayfever –negative Sore throat – negative – Eyes – clear sclera GERD/Heartburn & Dyspepsia – negative; Nausea and vomiting – neg Constipation – negDiarrhea – neg Pt has not seen dark, tarry or bright red stools Rheum – Joints – no joint pains No muscle painsLMP: July 1, 1999 (Patient has used an OTC Pregnancy Test 3 different times and it is clearly positive).
Patient remembers having unprotected sex on July 17, 1999. She was told by her MD to also use adiaphram.
Ext - EEG – Per MD, continues to be abnormal – last EEG was 1-5-99.
Write Your Answer Below:
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The Following is an example of an answer key
A: (24 points total – the student must list at least 8 of the following items)
1. Need for Referral to MD - Based on dates of LMP and patient statements, patient is likely pregnant.
Although patient is on an oral contraceptive, the phenytoin likely induced it’s metabolism. Patient alsoneeds referral to an individual who can appropriate counsel her and allow her to make an informeddecision about whether to continue or terminate the pregnancy.
2. Potential Drug Teratogenicity – There is an increased risk of malformation (2-3 x the general
population rate) in children born to mothers who take chronic AEDs. This increased risk is due notonly to the drug, but may also be related to epilepsy itself and/or the mother’s background history.
ƒ Patients who are on multiple AEDs and at high doses are at greatest risk for teratogenicity. This ƒ Phenytoin is classified as “D” category, valproate is “D” category, and Vigabatrin is “D” category ƒ Based on patient’s history of seizures which were difficult to control. Therefore, it is doubtful that AEDs can be stopped. Since patient may be 10 weeks pregnant, patient has been taking AEDSmost of the first trimester (when malformations are most likely to occur).
ƒ Uncontrolled seizures and hypoxia are a greater risk to the fetus than the AEDs.
ƒ Potential effects on the fetus: Phenytoin may cause lower cognitive abilities and minor 3. Need for Additional Drug Therapy - Patient is not taking any vitamins. Since AEDs can cause folate
deficiency and this may cause malformations, supplemental folate is indicated. Folic acid mayincrease PHT metabolism. Will need to monitor levels.
4. Medication Adherence Issue - Patient is having difficulty remembering to take the noon dose of
5. Potential Drug Induced Disease – vigabatrin has been reported to cause visual field defects. This has
been reported to occur even after several years of therapy.
6. Altered dosing requirements – pregnancy may lead to changes in the pharmacokinetics of AEDs.
Serum levels will need to be monitored closely.
™ Based on population pharmacokinetic parameters, predict the phenytoin is at least in the upper therapeutic range or higher. These parameters will likely change during the pregnancy.
7. Drug Induced Disease in the Newborn – Newborns of mothers who have taken chronic AEDs are at
risk for a Vitamin K coagulopathy which can be prevented by giving mother supplemental vitamin Kduring last month of pregnancy.
8. Needs to follow good health habits during pregnancy and caution patient not to take any medications
9. Need for another drug – Phenytoin induces the metabolism of estrogen. The patient’s contraceptive
dose was too low. (estrogen component should be at least 50mcg/day.) Pharmacotherapy Goals: (15 points – The student must list each of the following goals)
9 Provide appropriate information so that patient can make informed decisions about this pregnancy.
9 Refer patient to physician so that she will have a safe and successful pregnancy, if she decides to continue the pregnancy. Assist MD with pharmacotherapy issues so mother and fetus are notharmed.
9 Maintain seizure-free with minimal drug side effects (optimal quality of life) P: (24 points – the student must list each of the following)
1. Refer patient to the University Women’s Health Clinic; Assisted patient in making the appointment.
2. D/C Birth Control Pills now per discussion with MD via telephone today.
3. Provide appropriate patient education concerning risks to her and fetus during pregnancy so that she is
4. Send MD a complete medication history and information about AEDs and teratogenicity. Discussed possible reduction of phenytoin dose since history indicates vigabatrin may be the primary drugcontrolling the seizures and lower levels may decrease teratogenicity. However, addition of folic acidwill lower the levels. Will therefore start folate therapy nd recheck phenytoin levels in 1 month.
5. Suggest to MD that mid-day valproate dose be stopped since she has been missing doses and has been seizure free (goal for pregnant epileptic is to reduce dosages/drugs if possible). Alternative if MDwants to continue is to have her take with lunch.
6. Encourage patient to each a balance diet, get plenty of rest, and liquids.
7. MD agrees with initiating a multivitamin with 0.8mg – 1mg folate.
8. Refer the patient to the AED Registry at Massachusetts Gen Hospital at 1-888-233-2334. They may provide educational materials and monitor the pregnancy with the patient’s MD. Encourage patient tocall pharmacy for further information.
9. Obtain a PHT, CBZ, and VALP level - Monitor serum drug levels through out pregnancy ; adjust to maintain patient seizure free. If possible, maintain levels in the lower end of therapeutic range.
10. Plan on initiating Vitamin K 10mg PO qd to mother during last month of pregnancy.
11. If patient receives oral contraceptives post-pregnancy, the dosage of estrogen needs to be at least 50mcg/day. Other forms of birthcontrol should be used in combination with oral contraceptives inseizure patients receiving AEDs which induced the metabolism.
12. Patient education about: AEDs (Students: I did not detail out this information – but you would, outline specific information as recommended in a patient counseling resource – USP/Macromedex PatientInformation, etc.) , epilepsy, and pregnancy; taking multivitamins with folate; general good healthhabits; need for follow up through out the pregnancy.
PHARMACOKINETIC MONITORING FORM
(15 Points – all Vmax, Km, and Vd calculations must be correct (9 points); form must also be correctlyfilled out (1pt); Cpss calculation must be correct – 5pts) POPULATION PARAMETERS
CLT – CHANGES WITH
T1/2 CHANGES WITH
INTERVAL
ADMINISTRATION
RECOMMENDATIONS
/ NEW REGIMEN
5 STEPS: 1. CALCULATE POPULATION PARAMETERS 2. CALCULATE PATIENT SPECIFIC PARAMETERS 3. COMPARE POPULATION AND PATIENT SPECIFIC DATA 4. CALCULATE NEW REGIMEN IF EFFICACY NEEDS OPTIMIZATION 5. ESTABLISH MONITORING PLANNotes: Population Parameters – Vmax = 365mg/day Km = 4mg/dayPredicted level based on Population Parameters: cpss = Km(S)(F)(Dose) = 4(.92)(1)(350) Vmax – (S)(F)(Dose) = 365 – (0.92)(1)350Cpss = 29.9Pa PT. BIRTHDATE
INSURANCE:
ADDRESS:
PT. LAST NAME
PT. FIRST NAME
TELEPHONE
MD TELEPHONE
PHARMACOKINETIC MONITORING FORM
(5 Points – Clt and t1/2 parameters should be listed (4 points); form must also be correctly filled out (1pt)) POPULATION PARAMETERS
CLT = POP =8ML/HR/KG T1/2
INTERVAL
ADMINISTRATION
RECOMMENDATIONS
/ NEW REGIMEN
5 STEPS: 1. CALCULATE POPULATION PARAMETERS 2. CALCULATE PATIENT SPECIFIC PARAMETERS 3. COMPARE POPULATION AND PATIENT SPECIFIC DATA 4. CALCULATE NEW REGIMEN IF EFFICACY NEEDS OPTIMIZATION 5. ESTABLISH MONITORING PLANNotes: Population Parameters – Clt = 418mL/hrDue to the pe the Clt value for predicting levels. In addition, at higher concentrations, th PT. BIRTHDATE
INSURANCE:
ADDRESS:
PT. LAST NAME
PT. FIRST NAME
TELEPHONE
MD TELEPHONE
PHARMACOKINETIC MONITORING FORM
(5 Points – Clt and t1/2 parameters should be listed (4 points); form must also be correctly filled out (1pt)) POPULATION PARAMETERS
CLT – POPULATION =
T1/2 8-15HRS – SHORTER VD
INTERVAL
ADMINISTRATION
RECOMMENDATIONS
/ NEW REGIMEN
5 STEPS: 1. CALCULATE POPULATION PARAMETERS 2. CALCULATE PATIENT SPECIFIC PARAMETERS 3. COMPARE POPULATION AND PATIENT SPECIFIC DATA 4. CALCULATE NEW REGIMEN IF EFFICACY NEEDS OPTIMIZATION 5. ESTABLISH MONITORING PLANNotes: PT. BIRTHDATE
INSURANCE:
ADDRESS:
PT. LAST NAME
PT. FIRST NAME
TELEPHONE
MD TELEPHONE

Source: http://www.educationscholar.org/ru_area/pdf/050504i_Pharmacy_Essay_I.pdf