CHAPTER

7 Therapeutics Planning

LEARNING OBJECTIVES
• L ist the components of the therapeutics planning • L ist the steps involved in the selection of specific
process. therapeutic regimens.
• List the steps involved in patient problem identification. • Select patient-specific therapeutic regimens.
• Identify subjective and objective patient parameters. • Describe the SOAP (Subjective, Objective, Assessment,
• List the steps involved in problem prioritization. Plan) format.
• Prioritize patient problems.

E ffective planning facilitates the selection of appro-

priate drug and nondrug interventions (including
patient education) for specific patient problems and pro-
the patient for the patient’s medication history. Review all
relevant data resources, including data from the current
patient chart (hard copy and electronic), data from past
vides a framework for monitoring a patient’s response to charts (e.g., previous hospital admissions), data obtained
the drug and nondrug interventions. from patient interviews or interviews with relatives or
The planning process consists of problem identifica- significant others if the patient is not capable of provid-
tion, problem prioritization, selection of patient-specific ing information, and uncharted data available from team
drug and nondrug interventions for each problem, and members. Seeking out and then identifying relevant data
development of an integrated monitoring plan (Box requires patience and methodical scrutiny. Note that the
7-1). Planning also incorporates well-thought-out alter- patient’s story may vary depending on who interviewed
native treatment regimens. Successful planning requires the patient and when the patient was interviewed. Some
expert knowledge of pharmacotherapeutics, human dis- data may be contradictory. But it is important to gather
ease, physical assessment, and laboratory and diagnostic and then consider all available data.
tests (Figure 7-1). Planning incorporates consideration of Patient factors that by themselves appear unimport-
patient factors that influence therapeutic regimens (e.g., ant may be important when considered in the context of
history of nonadherence to medication regimens, prior other patient data. Pertinent positive data (abnormal find-
experience with prescription and nonprescription medi- ings) include abnormal laboratory results such as a serum
cations, concurrent medical conditions, other medication potassium level that exceeds the upper limit of the ref-
regimens) as well as consideration of the way in which erence range (e.g., serum potassium level of 5.8 mEq/L),
medications influence patients (e.g., adverse effects such abnormal signs and symptoms described by the patient
as drowsiness or dizziness, cost of therapy). This chapter (e.g., the patient’s description of the signs and symptoms
describes the processes for problem identification, prob- of her migraine headache), and abnormalities noted on
lem prioritization, and selection of patient-specific drug physical examination (e.g., a blood pressure of 160/110
and nondrug interventions for each problem; monitoring mm Hg), and are relatively easy to identify. Pertinent nega-
is discussed in Chapter 8. tive data (findings that are normal but, given the patient’s
disease or condition, would have been expected to be
abnormal) are more difficult to recognize, and identifying
1. IDENTIFY THE PROBLEMS them requires a good understanding of human disease and
pharmacotherapeutics. For example, many patients with
Seek out patient data from all sources; consider all avail- longstanding type 1 diabetes mellitus develop diabetic
able patient data. Look for relationships among the data, retinopathy. The fact that a patient with longstanding
then group the related subjective and objective data type 1 diabetes mellitus does not have diabetic retinopa-
together to determine the specific patient problems. thy is important negative data. A patient who is adherent
Assess each patient problem. to diuretic therapy but is not taking potassium supple-
ments would be expected to have a low serum potassium
STEP 1—OBTAIN PATIENT DATA level. The fact that such a patient has a serum potassium
level within the reference range is pertinent negative data.
Consider all available patient data. Review all previously Create a working list of the data. Experienced clini-
charted data (history, physical examination findings, cians work from mental lists of patient data, but students
results of laboratory and diagnostic tests) and interview and less experienced clinicians may find that taking the

132
 Chapter 7 Therapeutics Planning 133

time to create a written list of the patient data minimizes quantified (Box 7-2). Some clinicians view all data obtained
the risk of overlooking problems that may impact the directly from the patient (i.e., the chief complaint, the his-
decision-making process. Experienced clinicians who tory of the present illness, the past medical history, the
work with very complicated patients (e.g., critically ill family history, the social history, the medication history,
patients) often create written data lists to avoid overlook- the review of systems) to be subjective data, because the
ing important issues. data are not verifiable by an independent observer and
Subdivide the data into lists of subjective data and objec- must be considered just a story. For example, a patient may
tive data. Subjective data, such as coughing, pain, and itch- report that he or she had an oral temperature of 102.5°F
ing, are describable but cannot be precisely measured or (39.2°C). The temperature reported by the patient is con-
sidered to be subjective data because of the uncertainty as
Box 7-1 The Planning Process to whether it is accurate (e.g., Did the patient drink hot
or cold liquids a few minutes before taking the tempera-
1. Identify the problems ture? Was the thermometer placed in the mouth correctly?
Step 1—Obtain patient data Did the patient read the thermometer correctly? Did the
Step 2—Group-related data patient really take his or her temperature?). A patient may
Step 3—Determine each problem report that he or she is taking a specific dose of a medi-
Step 4—Assess each problem cation, but without verification from the prescriber and/
2. Prioritize the problems or pharmacy, the patient’s report is subjective. Patient rat-
Step 1—Identify the active problems ing scales (e.g., the 10-point pain rating scale) are designed
Step 2—Identify the inactive problems to objectify subjective data but are based on individual
Step 3—Rank the problems patient interpretation of subjective descriptors.
3. Select patient-specific drug and nondrug interventions Objective data, such as blood pressure, heart rate, and
Step 1—Determine short-term and long-term goals of temperature, are data that can be precisely measured
therapy or quantified (Box 7-3). By convention, data that are
Step 2—Create a list of options obtained by the health care professional by direct obser-
Step 3—Eliminate options based on patient-specific vation of the patient or are obtained during the physi-
and external factors cal examination (e.g., crackles, edema, muscle atrophy,
Step 4—Select appropriate drug and nondrug pain) but that cannot be precisely quantified are consid-
interventions ered objective data because the data were obtained by an
• Select drug dosage, route, interval, and duration objective, trained clinician. Data documented by other
of therapy health care professionals (e.g., a list of prescribed medica-
Step 5—Identify alternative interventions tions and dosages, description of biopsy results, identifi-
4. Develop a monitoring plan cation of wheezing) are considered objective data.
Step 1—Determine specific monitoring parameters
• Select specific target outcomes STEP 2—GROUP-RELATED DATA
• Select monitoring intervals for each parameter
Step 2—Integrate the monitoring plan Evaluate the list of objective and subjective data for pos-
Step 3—Obtain data sible relationships among the data. This step requires
Step 4—Assess the response to therapy comprehensive knowledge of the signs and symptoms of

Se
me lect Problem Problem
io
re dica n o identification prioritization
gim tio f
Pr en n
s
iden oblem
tific
atio
n
Monitoring
plan
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pla orin
nit

Selection of
Mo

medication
m regimens
ble n
Pro izatio
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p

Figure 7-1 Components of Therapeutic Planning.

134 Clinical Skills for Pharmacists: A Patient-Focused Approach

disease and pharmacotherapy and becomes easier with not shigellosis). The problem list is refined as more data
experience. For example, subjective complaints of fever, become available. Patient problems include current medi-
one episode of chills, and productive cough combined cal problems such as hypertension, pneumonia, asthma,
with objective data of leukocytosis with an increased per- diabetes, and gastrointestinal bleeding; past medical
centage of bands, a chest radiograph showing right middle problems such as a history of migraine headache, hip
lobe consolidation, and sputum positive for gram-positive fracture, deep vein thrombosis, and myocardial infarc-
encapsulated cocci in pairs are related. A less experienced tion; past surgeries such as appendectomy, tonsillectomy,
clinician should be able to recognize that the patient has coronary artery bypass grafts, and transurethral resection
some kind of lower respiratory tract bacterial infection. of the prostate; and issues such as nonadherence, obesity,
A more experienced clinician may strongly suspect pneu- illicit drug abuse, alcohol use, tobacco use, and allergies.
mococcal (Streptococcus pneumoniae) pneumonia. Some pharmacists consider medication-related issues
Work through the list of patient data making sure that such as corticosteroid dependency, long-term anticoagu-
every piece of patient data is considered. Note that it only lation therapy, drug interactions, adverse drug reactions,
takes one piece of data to identify a patient problem. For or incorrect dosage (too high a dose, too low a dose) to be
example, a patient may smoke tobacco but have normal identifiable problems and list them as separate problems
physical examination findings and normal laboratory distinct from the medical condition for which the medi-
results. The patient’s self-identification of the smoking cation was prescribed (e.g., steroid-dependent asthma,
history is enough to categorize the patient as a smoker. recurrent thrombophlebitis). Other pharmacists prefer to
Some data may belong with more than one group of include these medication-related issues with the medical
data. For example, a blood pressure of 160/110 mm Hg condition.
belongs with data related to the patient’s diagnosis of
hypertension, but if the patient had been prescribed anti- STEP 4—ASSESS EACH PROBLEM
hypertensive drug therapy but missed many doses, the
blood pressure of 160/110 mm Hg also belongs with data Each problem is then assessed in terms of each of the
related to patient nonadherence. Some data are of histori- ­following characteristics:
cal interest only but must still be identified and consid- • Acuity (acute or chronic)
ered in the context of the rest of the patient data (e.g., a • Severity (mild, moderate, or severe)
patient history of appendectomy 10 years ago). • Symptom level (symptomatic or asymptomatic)
• Treatment status (treated or untreated)
STEP 3—DETERMINE EACH PROBLEM • Degree of control (controlled or uncontrolled)
• Classification (staging of disease)
Evaluate each group of related subjective and objective
data items to determine the specific patient problem or
issue. The problem is not always a specific diagnosis but Box 7-3 Common Objective Parameters
may be a preliminary identification of the issue pend-
Height and weight
ing acquisition of additional data (e.g., acute diarrhea,
Vital signs: temperature, blood pressure, heart rate,
respiratory rate
Blood chemistry: sodium, potassium, chloride, carbon
Box 7-2 Common Subjective Parameters
dioxide content, glucose, creatinine, aspartate
Anxiety Headache Palpitations aminotransferase, alanine aminotransferase, bilirubin,
Bloating Heartburn Pounding pulse calcium, magnesium, cholesterol, triglycerides, alkaline
Blood-tinged Heat intolerance Rash phosphatase, lactate dehydrogenase, uric acid, urea
sputum Impotence Seizures nitrogen
Blurred vision Indigestion Shortness of Blood gases: pH, arterial partial pressure of carbon
Breast Insomnia breath dioxide, arterial partial pressure of oxygen, bicarbonate
tenderness Incontinence Slurred speech concentration
Chills Itching Sneezing Blood proteins: total protein, albumin, complements,
Cold intolerance Joint pain Sore throat immunoglobulins
Confusion Loss of appetite Syncope Hematology: hemoglobin, hematocrit, mean corpuscular
Constipation Loss of libido Thirst volume, mean corpuscular hemoglobin concentration, red
Cramps Muscle aches Tingling blood cell count, white blood cell count and differential
Decreased Muscle weakness Tinnitus Urinalysis: specific gravity, cellular content, protein
appetite Nasal congestion Tremor Culture and sensitivity findings: blood, urine, sputum,
Depression Nasal itching Vertigo tissue
Diarrhea Nausea Weakness Serum drug concentrations
Difficulty Nervousness Wheezing Specific organ systems: peak expiratory flow rate, forced
concentrating Numbness expiratory volume in 1 second, forced vital capacity,
Dry skin ratio of the forced expiratory volume in 1 second to the
Dysuria forced vital capacity, ejection fraction, triiodothyronine
Fatigue level, thyroxine level, thyroid-stimulating hormone
Flatulence level, creatinine clearance
 Chapter 7 Therapeutics Planning 135

Knowing these characteristics is useful when prioritiz- kidney disease), and lifestyle modification recommenda-
ing patient problems and when planning patient-specific tions (e.g., exercise 30 minutes a day most days of the
drug and nondrug interventions. For example, a patient week).
for whom step 1 identifies asthma that is treated and well
controlled does not need any change in drug therapy, STEP 2—IDENTIFY THE INACTIVE PROBLEMS
whereas a patient for whom step 1 reveals asthma that
is untreated and uncontrolled does need drug and/or Inactive problems are problems that do not require any
nondrug intervention. Management of a patient’s acute, kind of drug or nondrug intervention and are of histori-
severe, uncontrolled, untreated asthma exacerbation will cal interest only. Examples of inactive problems include a
take precedence over treatment of any of the patient’s history of an appendectomy at age 12, a history of pneu-
other chronic and controlled problems. Because histori- monia 2 years ago, a history of smoking two packs of ciga-
cal problems (e.g., a history of a broken leg) cannot be rettes per day until quitting 10 years ago, a history of illicit
assessed for these characteristics, by convention these drug use 20 years ago, and a history of sulfa-­associated
problems are simply documented as “S/P” (meaning “sta- rash. Although inactive problems do not require plan-
tus post” or “a history of”). ning for current drug or nondrug therapy interven-
tions, inactive problems are still identified and listed on
the patient problem list so that they can be considered
2. PRIORITIZE THE PROBLEMS when planning drug and nondrug interventions for
active problems. For example, a patient with a history of
The second step in the planning process is prioritization splenectomy is at increased risk of infection with S. pneu-
of the patient problems. Prioritization means ranking the moniae, Haemophilus influenzae, Neisseria meningitides, and
patient problems with the most urgent problems at the some gram-negative bacteria. Knowledge of this risk will
top of the list and the least urgent problems at the bottom help in planning patient-specific antibiotic therapy in the
of the list. Prioritization is a way of ordering the relative event that the patient has signs and symptoms consistent
need for intervention and is not meant to imply a rank with infection. A patient with a history of narcotic addic-
ordering of importance or significance to the patient’s tion should not be prescribed narcotics unless there are
overall health care needs. Problems of equal urgency no other alternatives, and then only with an awareness
are still listed in a rank order although the plans docu- of the patient’s history of narcotic addiction and close
ment the need to address each problem simultaneously. monitoring.
Historical (inactive) problems are not ranked but are sim-
ply listed at the bottom of the problem list. Problem lists STEP 3—RANK THE PROBLEMS
are dynamic lists that evolve and are modified as new
data become available. Rank-order the active patient problems. One approach to
Problem prioritization helps clinicians plan their work- ranking patient problems is to identify the problem that
load and patient interventions. For example, an acutely needs the most immediate attention and then rank the
ill patient may also be obese. The acute care pharmacist remaining active problems in order of need for interven-
needs to be aware of the patient’s obesity (some drugs tion. The number one problem is the problem that if left
are dosed based on actual body weight, some drugs are untreated will cause the most harm to the patient in the
dosed based on lean body weight, and some drugs are shortest amount of time. For example, consider a patient
dosed based on adjusted body weight), but the problem with bacterial meningitis, obesity, and a history of a bro-
of obesity is a long-term issue that is best addressed once ken leg as a child. The bacterial meningitis is the patient’s
the patient has recovered from the acute problem and is number one problem because it is a life-threatening prob-
discharged home. lem that requires immediate intervention. The patient’s
other active problem is the obesity. But obesity is not
STEP 1—IDENTIFY THE ACTIVE PROBLEMS as immediately life-threatening as the meningitis and is
therefore ranked as the patient’s number two problem.
Active problems are problems that require some kind of The history of a broken leg as a child is an inactive problem
drug or nondrug intervention to resolve and/or man- and is ranked at the bottom of the list. Another approach
age the problem. Examples of active problems include is to work from the bottom of the list up by determining
pneumonia, asthma, congestive heart failure, dyslipid- the problem requiring the least attention. This problem
emia, osteoporosis, diabetes mellitus, trauma, anxiety, is ranked as the least important problem. The pharmacist
cerebrovascular accident, hypertension, renal failure, repeats the ranking process with the remaining problems
hepatitis, leukemia, migraine headaches, and myocardial until all are ranked. Regardless of the approach, the active
infarction. problems are placed at the top of the list, inactive prob-
Most clinicians who interact with patients in the lems are at the bottom of the list, and active but less acute
ambulatory setting add a “primary disease prevention” problems are in the middle. As noted previously, the rank
problem to the active patient problem list for the pur- ordering is rather arbitrary if the problems all have rela-
poses of planning and documenting routine immuniza- tively equal need for intervention.
tions (e.g., annual influenza vaccine, tetanus/diphtheria Clinicians given the same list of patient data may
booster vaccine every 10 years), screening (e.g., blood develop different prioritized lists. This is not unexpected;
pressure assessment every 2 to 3 years, annual urinaly- no one list is correct. Lists are developed based on the
sis for microalbuminuria for patients at risk of chronic clinical judgment and experience of the practitioner.
136 Clinical Skills for Pharmacists: A Patient-Focused Approach

In addition, because the focus of the pharmacist is on Box 7-4 Factors to Consider When Selecting
therapeutic issues rather than on differential diagnosis, a Specific Therapeutic Regimen
the pharmacist-generated patient problem list may be
similar although not necessarily identical to the problem PATIENT-SPECIFIC FACTORS
list generated by physicians, nurses, or other health care What regimens have effectively managed the problem in
professionals. the past?
What regimens have not effectively managed the problem
in the past?
3. SELECT PATIENT-SPECIFIC DRUG How might other patient problems influence the proposed
AND NONDRUG INTERVENTIONS regimen?
How might the proposed regimen influence other patient
Once the prioritized patient problem list is developed, the problems?
next step is to select patient-specific drug and nondrug Does the patient have any culturally based needs?
interventions for each patient problem, including initial
and alternative drug and nondrug interventions. EXTERNAL FACTORS
Determine appropriate nondrug interventions, includ- State-of-the-art therapeutics (e.g., current guidelines)
ing patient education. For example, an important part Cost of the proposed therapy
of the management of allergic rhinitis is avoidance of Formulary limitations
allergens; patients may benefit from education regarding
allergen avoidance. Exercise is important to maintaining
a healthy body weight; patients may benefit from rein-
forcement of the message and suggestions for how much problems and medications, social habits, cultural beliefs,
and what type of exercise is important given their other and willingness to commit to a course of therapy, as well
medical conditions. Dietary interventions are important as external factors such as insurance coverage and access
for the management of many chronic diseases such as to refrigeration for storage of refrigerated medications
diabetes mellitus, chronic renal failure, and hypercho- (Box 7-4). Consider interventions that have and have
lesterolemia; patients may benefit from reinforcement not worked for the patient in the past, the influence of
of the need to maintain the prescribed dietary practices. other patient problems on the proposed medication regi-
Nondrug interventions include reminders for routine men, the influence of the proposed regimen on all other
vaccines (e.g., annual influenza vaccine) and screenings patient problems, and any cultural-specific medication-
(e.g., fasting lipid panel every 5 years starting at 20 years related issues. For example, a patient who has responded
of age). well to a specific decongestant in the past will most likely
Determine an appropriate medication regimen for respond well to the same decongestant in the future.
each patient problem that can be treated and/or man- A patient with renal insufficiency is at risk of develop-
aged with medications. For each medication selected, ing seizures from the accumulation of normeperidine, a
include the dosage (e.g., 50 mg, 1 g, a pea-sized drop of renally eliminated metabolite of meperidine. A drug with
lotion, one teaspoonful, two puffs), the dosage formula- negative inotropic effects may worsen a patient’s conges-
tion (e.g., tablet, capsule, liquid, suppository, ointment, tive heart failure.
dry-powder inhaler), the route of administration (oral, Consider external factors, including the state-of-the-
topical, ophthalmic, otic, intravenous, rectal, inhaled), art therapeutics for managing the specific problem, cost
dosing interval (e.g., daily, two times a day, four times a considerations, and limitations imposed by institutional
day, every 8 hours, once a month), duration of therapy and state formularies, when selecting an optimal thera-
(e.g., 7 days, one time only, long term), and rationale peutic regimen. Rarely is any single therapeutic regimen
(the evidence-based reason for selecting the patient-­ the only possible appropriate regimen; many different
specific therapeutic intervention). The general approach regimens may be equally effective for the patient. The
is to develop the therapeutic plan for each problem and choice between equally effective regimens is based on
then integrate the individual plans, with care taken to experience, personal preference, and consideration of
ensure that each component of the plan is appropriate external limitations such as restrictive drug formularies
given the other plans and that the overall integrated plan or out-of-pocket expenses.
is achievable for the patient. For example, when consid-
ered individually, plans for therapeutic interventions for STEP 1—DETERMINE SHORT-TERM
a patient with multiple chronic medical conditions may AND LONG-TERM GOALS OF THERAPY
seem reasonable and appropriate, but when considered
together they may not be doable if the multiple medica- All drug and nondrug interventions should be in the
tion regimens require the patient to adhere to multiple context of the specific short-term and long-term goals of
sets of complicated instructions (e.g., take with food, therapy, which may or may not be the same depending
take 2 hours before eating, take every 4 hours around the on the specific patient problem. For example, the short-
clock, take every 8 hours around the clock, do not take term goal for a patient being treated for a hypertensive
within 2 hours of taking another medication, etc.). emergency is to reduce the diastolic blood pressure to
Selection of a specific regimen requires assessment 100 to 105 mm Hg within 2 to 6 hours of presentation
of each patient problem in the context of everything with a maximum reduction of 25% or less of the initial
that is known about the patient such as other patient diastolic blood pressure. The long-term goal is to reduce
 Chapter 7 Therapeutics Planning 137

the diastolic blood pressure to 85 to 90 mm Hg over the STEP 3—ELIMINATE OPTIONS BASED ON
next 2 to 3 months to reduce the long-term morbid- PATIENT-SPECIFIC AND EXTERNAL FACTORS
ity and mortality associated with the elevated diastolic
blood pressure. The short-term goals for a patient who Once all therapeutic options are identified, eliminate
smokes tobacco and wants to stop smoking is to set a quit options based on the comparative effectiveness of the
date, arrange for the patient to join a support group, and drugs; the suitability of the drug for the patient given
discuss drug therapy options (i.e., transdermal nicotine the other patient medical conditions and drug therapies;
patch, nicotine gum/lozenge/inhaler/nasal spray, bupro- the ability of the patient to adhere to the proposed regi-
pion, varenicline). The long-term goal is for the patient men; and other factors such as the effectiveness of previ-
to successfully stop smoking and not resume smoking in ous treatment regimens, cost, and formulary restrictions.
the future. Consider the impact of the therapeutic option on other
Determine specific goals and outcomes of therapy patient problems (e.g., the potential adverse effect of
before doing any other planning. Set specific goals for beta-adrenergic blocking antihypertensives on patients
each patient problem and for the overall therapeutic out- with asthma) and the influence of other patient problems
come in general. When setting therapeutic goals, consider on the therapeutic option (e.g., the need to reduce the
long-term factors such as the impact of the therapeutic drug dosage in a patient with chronic renal insufficiency).
regimen on the patient’s quality of life and survival. For
example, a long-term weight reduction plan is not appro- STEP 4—SELECT APPROPRIATE DRUG
priate for a patient with a short life expectancy. Select AND NONDRUG INTERVENTIONS
target therapeutic ranges for all objective parameters
(e.g., systolic blood pressure between 110 and 130 mm Decisions about appropriate drug and nondrug interven-
Hg; serum potassium level between 3.5 and 4.5 mEq/L; tions are based on past patient experiences, assessment
weight between 120 and 130 lbs and define specific val- of the severity of the problem, drug-specific factors such
ues that indicate potential toxic effects [e.g., heart rate as the therapeutic index of the drug, and specific patient
<50 beats/min], plasma phenytoin concentration >20 factors such as the presence of chronic renal or hepatic
mg/L). Select specific subjective outcomes for all subjec- disease that may influence the elimination or metabo-
tive parameters (e.g., sleeping through the night without lism of the drug. Determine the best drug and nondrug
wheezing; no nocturnal leg cramps; anorexia). regimen, including each specific drug to be used, dosage,
Consider the severity of disease and the short-term route, duration of therapy, and rationale for the selection
or long-term nature of therapy when setting therapeutic of each drug and nondrug component of the regimen. For
goals. For example, consider the differences in the goals example, if a patient failed to stop smoking because the
of insulin therapy for a young patient with newly diag- patient developed varenicline-associated side effects and
nosed type 1 diabetes mellitus and an elderly patient with stopped taking the medication, then the patient should
a 50-year history of type 1 diabetes mellitus and signifi- not be prescribed varenicline the next time the patient
cant cardiovascular and peripheral vascular disease. Evi- attempts to quit smoking. If a patient’s prescription
dence suggests that tight control of blood glucose levels medication insurance no longer covers a specific branded
may delay the onset and decrease the severity of the com- product, then every effort should be made to find an
plications of diabetes. Therefore the target blood glucose equivalent medication, generic or otherwise, that is paid
level for the young patient with newly diagnosed diabetes for by the prescription medication insurance plan.
is lower and has a narrower acceptable range than that for The rationale, the reason why the specific interven-
the elderly patient with diabetes and longstanding dis- tion was selected, should be patient specific and based
ease who has already developed complications from the on current published evidence. The rationale should be
disease and is at risk of hypoglycemia-related falls. documented in the SOAP note in the patient chart even
if verbally discussed with the prescriber. For example, the
STEP 2—CREATE A LIST OF OPTIONS recommendation to initiate antihypertensive drug ther-
apy with hydrochlorothiazide 12.5 mg daily for a patient
Identify all classes of drugs and possible therapeu- with newly diagnosed uncomplicated hypertension is
tic approaches for each problem; do not eliminate any based on the recommendations of the Seventh Report of
option at this stage of planning. The options list is usually the Joint National Committee on Prevention, Detection,
a mental list, although students and inexperienced clini- Evaluation, and Treatment of High Blood Pressure.1 The
cians may find it helpful to create and then work from a recommendation to vaccinate or not vaccinate a person
written list. Depending on how familiar the pharmacist is with the influenza vaccine is based on current Centers for
with the management of the medical condition, this step Disease Control and Prevention recommendations.2
may require review of current pharmacotherapeutics and
human disease textbooks, literature searches of the cur- STEP 5—IDENTIFY ALTERNATIVE
rent pharmacy and medical literature, review of current INTERVENTIONS
treatment guidelines, or consultation with colleagues.
This step becomes easier and more time efficient with An important part of the planning process is anticipation
practice and experience. As the member of the health care of potential patient problems with the prescribed and/or
team with the most knowledge of pharmacotherapy, it recommended drug and nondrug interventions (“what
is the pharmacist’s responsibility to identify all possible if”). A well-thought-out plan includes alternative medica-
drug therapy options. tion regimens for common potential problems, such as the
138 Clinical Skills for Pharmacists: A Patient-Focused Approach

development of an allergy or adverse reaction to the initial documenting patient problems and the plans for man-
therapeutic regimen, lack of desired therapeutic response aging the patient problems. Each problem is SOAPed
to the initial therapeutic regimen, and identification of individually, although some clinicians prefer to integrate
additional patient problems that may influence the effec- all data and plans into a single lengthy and potentially
tiveness or pharmacokinetic profile of the initial therapeu- complex SOAP note. Some patients may have only one
tic regimen. Anticipation of these potential issues allows or two problems; in complex cases patients may have 20
the creation of well-thought-out alternative therapeutic or more problems. Regardless of the number of problems,
plans instead of therapeutic plans hastily chosen when each problem is documented with the relevant subjec-
unanticipated patient problems suddenly appear. For tive and objective data, problem assessment, and plan for
example, therapeutic planning for a patient with newly managing the problem. A new SOAP note is created with
diagnosed hypertension should include plans for what to every patient interaction, although typically no more fre-
do if the initial treatment fails to lower the blood pressure quently than daily, even for acutely ill patients; however,
or has to be discontinued because of the development of multiple SOAP notes per day may be written if significant
intolerable side effects (both very common issues). new patient data become available.

4. DEVELOP A MONITORING PLAN APPLICATION ACTIVITY

Refer to Chapter 8 for discussion of monitoring of drug This activity may be worked on individually or in groups
therapies. of three or four. Read the “Useful Information for Iguana
Bites” before working on the case. Working individually
or as a group use the case on pg 143 to do the following:
SOAP FORMAT 1. List the patient data.
2. List the subjective and objective data.
The process of identifying the subjective and objective 3. Group related objective and subjective data together
data, assessing the problem, and developing a specific and identify the likely problem.
therapeutic and monitoring plan is called “SOAPing the 4. List and prioritize the problems.
problem.” The term SOAP is an acronym for Subjective, 5. Create a plan for problem No. 1 (refer to the “Useful
Objective, Assessment, Plan. Information for Iguana Bites”). Include nondrug
The SOAP format is the formal and universally rec- therapy and drug therapy (drug, dosage, duration,
ognized organizational structure for identifying and rationale).

Patient Case Example—Integration and Application

The steps involved in therapeutics planning (problem of oral steroids in the past but hasn’t taken any for several
­identification, problem prioritization, and selection of years. She tries to avoid steroids because they make her
patient-specific drug and nondrug interventions) are diabetes hard to control. She denies fever, sore throat,
­illustrated in the following patient case example. cough, vomiting, or diarrhea.
PMH: Type 2 DM × 10 yr controlled with oral medications
Patient Case and diet; S/P appendectomy age 16 yr
Date: Late August SH: Married, four children (sons 8 and 10 and daughters
Location: Outpatient clinic 4 and 5). Lives in a two-story house in the suburbs. No
CC: “There has to be something you can do for my tobacco, no alcohol, no illicit drugs. Elementary school
allergies” teacher (teaches first grade).
HPI: Louisa Sorensen is a 31 y/o F with a 20+ yr history of FH: M↑ (50, + SAR, + asthma), F↑ (51, + SAR); two siblings
seasonal allergic rhinitis (SAR) and type 2 diabetes mel- + SAR; all four of her children + SAR
litus (DM). She is allergic to ragweed and has symptoms ROS: As per history of present illness
every fall but claims that this fall is much worse than
usual. She complains of multiple bouts of sneezing, runny Medication History
nose, fatigue, irritability, and itchy eyes, nose, and throat. Current prescription medications:
Her symptoms are worse when she is outside and better metformin (Glucophage) 1000 mg twice daily × 5 yr
when she is inside air-conditioned buildings. She’s had to Past prescription medications:
trade out of recess duty at work and has not been able to Has tried “every prescription antihistamine available.”
attend her children’s soccer games. She has taken every She says that they “sort of work” but are not as effec-
available prescription antihistamine but feels they are not tive as the nonprescription antihistamines. Has taken
as effective as the nonprescription antihistamines. How- several different medications for the type 2 DM but
ever, nonprescription antihistamines make her too drowsy cannot remember their names. Has had to use insulin
to work or drive, so she doesn’t take many doses. She a couple of times while taking prednisone.
started taking nasal cromolyn sodium four times a day a Takes prednisone for a few days “when my allergies are
couple of weeks ago. She has taken several short courses really bad”; cannot remember exact dosages or dates
 Chapter 7 Therapeutics Planning 139

Patient Case Example—Integration and Application—cont’d

Current nonprescription medications: • Traded out of recess duty
diphenhydramine (Benadryl Allergy) 25 mg once or twice • Unable to attend children’s soccer games
a day, mostly in the evenings or at night; started about • Has taken all available prescription antihistamines but
2 wk ago not as effective as nonprescription ­antihistamines
cromolyn sodium (NasalCrom) one spray each nostril four • Nonprescription antihistamines make her too drowsy
times daily during fall allergy season × 2 yr; started to work or drive, which limits their use
about 2 wk ago • Started nasal cromolyn four times daily 2 wk ago
Current complementary and alternative medicines: • Has taken several courses of oral steroids in past
No ­current alternative medicines • Avoids steroids (make her DM hard to control)
Past complementary and alternative medicines: Has tried • No fevers, sore throat, cough, vomiting, or diarrhea
devil’s claw, pollen extracts, and echinacea for her aller- • S/P appendectomy age 16 yr
gies without noticeable benefit (unknown dates, dosages, • + FH for SAR (parents, siblings, and children)
durations) • Diet: Low fat (<200 mg cholesterol/day), high fiber
Immunizations: Had all the usual childhood vaccines; (30 g/day), low sodium (<2.4 g/day) with moderate
last tetanus/diphtheria booster was 5 yr ago; gets the carbohydrates (about 50% of total daily caloric
­influenza vaccine every fall intake)
Drug allergies: NKDA • Glucophage 1000 mg twice daily × 5 yr
Adverse drug reactions: None • Used several different medications for her DM but
Adherence: Takes her medications as prescribed or cannot remember their names
­recommended • Has had to use insulin a couple of times while ­taking
Diet: Low fat (<200 mg cholesterol/day), high fiber (30 g/ prednisone
day), low sodium (<2.4 g/day) with moderate carbohy- • Prednisone for a few days in past
drates (about 50% of total daily caloric intake) • Benadryl Allergy 25 mg 1-2×/day for about 2 wk
• NasalCrom one spray each nostril four times daily for
Physical Examination Findings about 2 wk
General: LS is a pleasant but uncomfortable-appearing • Tried devil’s claw, pollen extracts, echinacea in the past
woman. She is 5′1″ tall and weighs 180 lb (BMI 34). for her allergies without noticeable ­improvement
Vital signs: Afebrile; BP 114/74 mm Hg; HR 72 beats/min, • Had all the usual childhood vaccines
RR 10 breaths/min • Last tetanus/diphtheria booster was 5 yr ago
HEENT: PERRLA, EOMI, TM intact; + conjunctival injection; • Gets the influenza vaccine every fall
+ chemosis; + rhinorrhea (clear watery secretions); pale, • Takes her medications as prescribed or ­recommended
swollen nasal mucosa; oropharynx clear except for some
postnasal drip; + periorbital edema; + allergic shiners; Objective data:
+ allergic crease • 5′1″
Chest and lungs: CTAP • 180 lb
CV: RRR; + S1, + S2; PMI 5ICS MCL; no m/r/g • BMI 34
Abdomen: NABS; NTND; appendectomy scar RUQ • + Conjunctival injection
Extremities: Strength 5/5 UE and LE; reflexes 2+ UE and LE • + Chemosis
Neuro: A×3; cranial nerves II-XII intact • + Rhinorrhea (clear watery secretions)
• Pale, swollen nasal mucosa
Laboratory Tests and Diagnostic Procedures • Oropharynx clear except for postnasal drip
Today’s labs: Random fingerstick blood glucose 110 mg/dL • + Periorbital edema
Labs from last visit 5 mo ago: Hb A1C 6.5% • + Allergic shiners
• + Allergic crease
1. IDENTIFY THE PROBLEMS • Appendectomy scar RUQ
Step 1—Obtain Patient Data • Random fingerstick glucose 110 mg/dL
Subjective data: • Hb A1C 6.5% 5 mo ago
• “There has to be something you can do for my allergies.”
• 20+ history of SAR Step 2—Group Related Data
• Type 2 DM × 20 yr Allergy Group
• Allergic to ragweed Subjective data: “There has to be something you can do for
• Allergy symptoms every fall but are worse than usual my allergies”; 20+ yr history of SAR; allergic to ragweed;
• Multiple bouts of sneezing allergy symptoms every fall but are worse than usual;
• Runny nose multiple bouts of sneezing; runny nose; fatigue; irritabil-
• Fatigue ity; itchy eyes, nose, and throat; allergy symptoms are
• Irritability worse outside; feels better inside air-conditioned build-
• Itchy eyes, nose, and throat ings; traded out of recess duty; unable to attend chil-
• Allergy symptoms are worse outside dren’s soccer games; has taken all available ­prescription
• Feels better inside air-conditioned buildings antihistamines but not as effective as nonprescription
140 Clinical Skills for Pharmacists: A Patient-Focused Approach

Patient Case Example—Integration and Application—cont’d

a­ ntihistamines; nonprescription antihistamines make her 2. PRIORITIZE THE PROBLEMS
too drowsy to work or drive, which limits their use; started Step 1—Identify the Active Problems
nasal cromolyn four times daily 2 wk ago; has taken sev- • SAR
eral courses of oral steroids in past; avoids steroids (make • Type 2 DM
her DM hard to control); no fevers, sore throat, cough, • Obesity
vomiting, or diarrhea; + FH for SAR (parents, siblings, and • Primary disease prevention
children); Benadryl Allergy 25 mg 1-2×/day for about 2
wk; NasalCrom one spray each nostril four times daily for Step 2—Identify the Inactive Problems
about 2 wk; has tried devil’s claw, pollen extracts, echina- • S/P appendectomy
cea in the past without noticeable improvement; takes her
medications as prescribed or recommended Step 3—Rank the Problems
Objective data: + conjunctival injection; + chemosis, + Active Problems That Need Immediate Therapeutic
nasal congestion; + rhinorrhea (clear, watery secretions); Intervention
pale, swollen nasal mucosa; oropharynx clear except for • SAR
postnasal drip; + periorbital edema; + allergic shiners;
+ allergic crease Active Problems Requiring Less Immediate Therapeutic
Intervention
Diabetes Group • Type 2 DM
Subjective data: Type 2 DM 10 yr; prednisone increases her • Obesity
blood glucose level; diet: low fat (<200 mg cholesterol/ • Primary disease prevention
day), high fiber (30 g/day), low sodium (<2.4 g/day) with
moderate carbohydrates (about 50% of total daily caloric Inactive Problems of Historical Interest
intake); has used several different medications for her DM • S/P appendectomy
but cannot remember their names; had to use insulin in Of the patient’s active problems, her SAR is causing her
the past when taking prednisone; Glucophage 1000 mg the most immediate discomfort; interventions are needed to
twice daily for 5 yr. improve the quality of her life. Her type 2 DM and obesity
Objective data: 5′1″; 180 lb; BMI 34; random fingerstick are active problems, but both are stable and do not need
glucose 110 mg/dL; Hb A1C 6.5% 5 mo ago immediate intervention. She has not received some of the
recommended vaccines and disease screenings for a woman
Obesity Group her age with DM. Therefore, this patient’s prioritized patient
Subjective data: None problem list is as follows:
Objective data: 5′1″; 180 lb; BMI 34 1. SAR
2. Type 2 DM
Appendectomy Group 3. Obesity
Subjective data: S/P appendectomy age 16 yr 4. Primary disease prevention
Objective data: Appendectomy scar RUQ 5. S/P appendectomy

Primary Disease Prevention Group 3. SELECT PATIENT-SPECIFIC DRUG AND NONDRUG

Subjective data: Had all the usual childhood vaccines; INTERVENTIONS
last tetanus/diphtheria booster was 5 yr ago; gets the Step 1—Determine Short-Term and Long-Term Goals
influenza vaccine every fall of Therapy
Objective data: None Problem No. 1: Seasonal Allergic Rhinitis
Short-term goal: Reduce patient symptoms
Step 3—Determine Each Problem Long-term goal: Initiate preventive therapy before
• SAR ­symptoms develop
• DM
• Obesity Problem No. 2: Type 2 Diabetes Mellitus
• Appendectomy Short-term goal: Control blood glucose level on a daily
• Primary disease prevention basis
Long-term goal: Prevent morbidity and mortality by
Step 4—Assess Each Problem ­keeping the Hb A1C value at <7%
• SAR: Acute, severe, symptomatic, treated, uncontrolled
• DM: Type 2, chronic, moderate, asymptomatic, treated, Problem No. 3: Obesity
controlled Short-term goals: Refer the patient to a nutritionist for
• Obesity: Class I, chronic, moderate, asymptomatic, dietary counseling; initiate an exercise program
untreated, uncontrolled Long-term goal: Lose 1-2 lb/wk until goal weight
• Appendectomy: S/P appendectomy achieved; reduce morbidity and mortality by
• Primary disease prevention: Up-to-date with vaccines; ­maintaining goal weight
missing other recommended gender- and age-based
screenings
 Chapter 7 Therapeutics Planning 141

Patient Case Example—Integration and Application—cont’d

Problem No. 4: Primary Disease Prevention examination every 1-3 yr, optional monthly self-breast
Short-term goal: Bring patient up to date with all examination, annual cervical cancer screening (every
­recommended vaccinations and screenings 2-3 yr after three consecutive negative test results),
Long-term goal: Reduce morbidity and mortality human papillomavirus DNA testing every 3 yr
by ­prevention of preventable diseases and early
­identification of other diseases Step 3—Eliminate Options Based on Patient-Specific
and External Factors
Problem No. 5: S/P Appendectomy Problem No. 1: Seasonal Allergic Rhinitis
Short-term goal: Not applicable According to the current practice guidelines, the recom-
Long-term goal: Not applicable mended treatment for moderate to severe SAR consists of a
nasal corticosteroid plus an oral nonsedating antihistamine
Step 2—Create a List of Options with or without an oral decongestant; short courses of oral
Problem No. 1: Seasonal Allergic Rhinitis corticosteroids may be required.3 The patient has nasal, ocu-
• Antihistamines lar, and systemic symptoms. Therefore eliminate single-drug
• Systemic, nonsedating (cetirizine, fexofenadine, therapy with an ocular or nasal drug. Although the patient
loratadine, desloratadine) has not had an adequate trial of nasal cromolyn sodium, it is
• Systemic, sedating (clemastine, diphenhydramine, unlikely to be effective for severe SAR. Therefore discontinue
tripelennamine, brompheniramine, chlorpheniramine, the nasal cromolyn. The patient feels that nonsedating anti-
hydroxyzine, azatadine, cyproheptadine, histamines are ineffective but experiences dose-limiting side
phenindamine, azelastine) effects with sedating antihistamines. Antihistamines are more
• Ocular (azelastine, olopatadine, levocabastine) effective if taken regularly, and the patient cannot tolerate
• Nasal (azelastine) the sedating antihistamines. Therefore eliminate the sedat-
• Decongestants ing antihistamines. Nasal decongestants are not intended
• Systemic (pseudoephedrine, phenylephrine) for long-term use. Therefore eliminate nasal decongestants.
• Nasal (phenylephrine, epinephrine, ephedrine, Systemic decongestants may elevate blood glucose levels
naphazoline, xylometazoline, tetrahydrozoline, in patients with diabetes and are to be used with caution.
oxymetazoline) The patient is not congested. Therefore eliminate systemic
• Corticosteroids decongestants.
• Systemic (prednisone, cortisone, dexamethasone)
• Nasal (beclomethasone, budesonide, flunisolide, Problem No. 2: Type 2 Diabetes Mellitus
fluticasone, triamcinolone, mometasone, ciclesonide) The recommended treatment for type 2 diabetes consists of
• Anticholinergics dietary intervention, exercise, and oral hypoglycemics; some
• Nasal (ipratropium bromide) patients require short-term or long-term insulin.4 The drugs
that increase insulin release are most effective for patients
Problem No. 2: Diabetes Mellitus who are of normal weight or just a little overweight; the
• Drugs that increase insulin release (sulfonylureas patient is obese. Therefore eliminate the drugs that increase
[glipizide, glyburide], meglitinides [repaglinide]) insulin release. The drugs that increase insulin sensitivity
• Drugs that increase insulin responsiveness (biguanides are expensive, often cause weight gain, and are no more
[metformin], thiazolidinediones [pioglitazone]) effective than biguanides alone or in combination. Therefore
• Drugs that modify intestinal carbohydrate absorption eliminate the drugs that increase insulin sensitivity. Drugs
(alpha glucosidase inhibitors [acarbose, miglitol]) that modify intestinal carbohydrate absorption have addi-
• Exogenous insulin tive effects when combined with oral hypoglycemics but
are associated with significant gastrointestinal side effects
Problem No. 3: Obesity (flatulence, diarrhea), so do not consider them at this time.
• Sympathomimetics (phentermine, diethylpropion, The patient has good long-term control of her diabetes,
ephedra) so do not consider insulin unless she is going to take oral
• Drugs that inhibit fat absorption (orlistat) corticosteroids.

Problem No. 4: Primary Disease Prevention Problem No. 3: Obesity

• Recommended vaccines for the patient’s age group: Dietary intervention and exercise are considered first-
tetanus/diphtheria every 10 yr, annual influenza line treatments for obesity; pharmacologic intervention is
• Recommended vaccines for patients with DM: not indicated at this time. Therefore do not consider drug
pneumococcal pneumonia polysaccharide, herpes zoster therapy at this time.
• Recommended screenings for the patient’s gender and
age group: visual every 2 yr, dental every 6-12 mo, Problem No. 4: Primary Disease Prevention
weight each visit, cholesterol (fasting lipid profile) The patient should receive the annual influenza and sched-
every 5 yr starting at age 20 yr, annual urinalysis for uled tetanus/diphtheria boosters. As a patient with diabetes,
albuminuria, annual serum creatinine and estimated she could receive one or two doses of the pneumococcal
glomerular filtration rate (eGFR), clinical breast pneumonia polysaccharide vaccine and the herpes zoster
142 Clinical Skills for Pharmacists: A Patient-Focused Approach

Patient Case Example—Integration and Application—cont’d

vaccine; discuss with the patient’s physician. The rest of the Step 5—Identify Alternative Therapeutic Interventions
recommended screenings are appropriate for the patient. Problem No. 1: Seasonal Allergic Rhinitis
The patient may need a short course of oral corticosteroids
Step 4—Select Appropriate Drug and Nondrug if her symptoms have not improved after a 2-wk trial of nasal
Interventions corticosteroids and nonsedating antihistamine. Consider a
Problem No. 1: Seasonal Allergic Rhinitis 10-day course of prednisone (40 mg/day on days 1 and 2;
Given the patient’s DM and past history of requiring insulin 30 mg/day on days 3 and 4; 20 mg/day on days 5 and 6;
when taking prednisone and antihistamine-associated drows- 10 mg/day on days 7 and 8; 5 mg/day on days 9 and 10).
iness, a conservative initial approach is best. Once-daily Insulin may need to be added if prednisone is prescribed.
therapy may improve patient adherence. Initiate therapy
with a nasal corticosteroid and a nonsedating antihistamine. Problem No. 2: Type 2 Diabetes Mellitus
There is little difference among the marketed nasal corti- If prednisone is added to her regimen, instruct the patient to
costeroids except for fluticasone, which is better absorbed check her blood glucose level before regularly scheduled
than other nasal formulations and potentially associated meals and to treat elevated blood glucose levels with short-
with more systemic steroid-related side effects. Aqueous acting regular human insulin (1 unit of regular insulin for
dosage formulations may cause less nasal mucosa irritation each 50 mg/dL glucose above 150 mg/dL); instruct the patient
than other dosage formulations. Initiate therapy with triam- to call the clinic if her blood glucose level is >400 mg/dL.
cinolone acetonide (Nasacort AQ) two sprays (220 mcg)
each nostril once daily. There is little difference among the Problem No. 3: Obesity
marketed nonsedating antihistamines except for cetirizine, Consider adding orlistat (Xenical) 120 mg three times daily
which is more sedating than other nonsedating antihista- with meals containing fat (during or up to 1 hour after the
mines. Initiate therapy with loratadine (Claritin) 10 mg once meal) if the patient has not lost weight after several months
daily on an empty stomach. Advise the patient to avoid of diet and exercise.
outdoor activities and to keep her car and house windows
closed. Patient should return to the clinic in 2 wk to evaluate Problem No. 4: Primary Disease Prevention
the effectiveness of the regimen. If the patient gets influenza, recommend oseltamivir (Tami-
flu) 75 mg twice daily × 5 days if therapy can be initiated
Problem No. 2: Type 2 Diabetes Mellitus within 48 hours of the onset of symptoms to reduce the
The patient’s DM is well controlled on her current regimen. severity and duration of symptoms.
Continue metformin (Glucophage) 1000 mg twice daily.
The patient should continue her current diet but reduce the Initial Treatment Regimen
number of calories (see obesity plan). Encourage moderate The following nondrug and drug interventions are
exercise. ­recommended for the patient:
• Initiate therapy with triamcinolone acetonide (Nasacort
Problem No. 3: Obesity AQ) two sprays (220 mcg) in each nostril once daily and
The patient is obese (BMI 35) and at risk for cardiovascular loratadine (Claritin) 10 mg once daily.
complications. The goal of therapy is to lose 0.5-1.0 kg/wk • Advise the patient to avoid outdoor activities and keep
for the first 3 mo. Although drug therapy could be initiated car and house windows closed.
(her BMI is >30), the conservative approach is to try a few • Instruct the patient to return to the clinic in 2 wk for
months of dietary restrictions and moderate exercise. Refer reassessment.
the patient to a nutritionist and encourage the patient to • Continue metformin (Glucophage) 1000 mg twice daily.
adhere to the recommended dietary plan. Encourage the • Refer the patient to a nutritionist.
patient to start a walking program with a target of 30 min • Advise the patient to start a walking program with a
of walking 5 days/wk. Encourage the patient to find a “diet target of 30 minutes of walking 5 days/wk.
buddy” or join a weight loss support group. • Encourage the patient to make appointments with her
ophthalmologist, gynecologist, and dentist.
Problem No. 4: Primary Disease Prevention • Discuss the recommendations for the pneumococcal
Schedule the influenza vaccine for November. Encourage pneumonia polysaccharide and herpes zoster vaccines
the patient to schedule appointments with her ophthalmolo- with the patient’s physician.
gist, dentist, and gynecologist. Request a fasting lipid profile, • Schedule the influenza vaccine for November.
urinalysis, and serum creatinine level.

other animals. Close follow-up for signs of infection is

Useful information for Iguana Bites essential.
Iguanas, increasingly popular as pets, are frequent car- Treatment
riers of unusual subtypes of fecal Salmonella organisms. Superficial scratches and bites:
Iguanas inflict injury by scratching, tail whipping, Nondrug therapy: Clean the wound as quickly as
and biting, which can cause significant lacerations. ­possible with soap and water. Cover with bandages.
Bite wound care is similar to that for bites inflicted by Drug therapy: None.
 Chapter 7 Therapeutics Planning 143

Deep puncture wounds or lacerations: Ampicillin side effects: Rash, itching, insomnia,
Nondrug therapy: Clean the wound as quickly as agitation, hyperactivity, nausea, diarrhea, con-
possible with soap and water. Irrigate the wound fusion, dizziness, ↑ aspartate aminotransferase,
with copious amounts of saline. Suture all wounds ↓ hemoglobin, ↓ platelets, ↓ hemoglobin, ↓ red
except hand wounds. Apply 1% povidone-iodine blood cell count, ↓ hematocrit
to wounds that are going to be sutured. Cover with Ciprofloxacin side effects: Nausea, diarrhea, vomit-
bandages if sutured; otherwise, do not bandage. ing, abdominal discomfort, headache, restless-
Povidone-iodine side effects: irritation, redness, ness, rash, nightmares, seizures, ↑ blood glucose,
rash ↑ serum potassium, ↑ serum creatinine, ↑ alanine
Prophylactic antibiotics: Ampicillin 500 mg orally four aminotransferase, ↑ aspartate aminotransferase,
times daily for 5 days. Give ciprofloxacin 250 mg ↑ alkaline phosphatase, ↑ lactate dehydrogenase,
twice daily for 5 days if allergic to penicillin. ↑ serum bilirubin

Application Activity - Patient Case

Time: 9 am Current or past complementary and alternative therapies:
Location: Outpatient urgent care clinic None
CC: “Iggie bit me” Immunizations: Had all the usual childhood vaccines.
HPI: Marcus, a 29 y/o man, states that Iggie, his 4-yr-old Last tetanus/diphtheria vaccine was 3 yr ago. Gets the
pet iguana, bit him on his right hand this morning as he ­influenza vaccine every fall.
reached into Iggie’s cage to feed him. Marcus says that Drug allergies: Allergic to penicillin. Was given penicillin
the wound didn’t bleed much but that it really hurts. He when his tonsils were removed. Doesn’t remember what
describes the pain as throbbing and rates the pain as 6 on happened, but his mother told him he almost died and
a 10-point scale (10 being the worst possible pain). His that he should never take penicillin.
hand feels better when he holds it up. He washed the bite Adverse drug reactions: None
wound with soap and water, wrapped a towel around his Adherence: Says he gets heartburn if he doesn’t take the
hand, and called his doctor, who told him to go to the Nexium so he is careful to take the doses.
outpatient urgent care clinic. Diet: Avoids tomatoes and tomato-based foods
PMH: GERD for 2 yr. His symptoms include heartburn and
belching and are worse if he eats tomato-based foods or Physical Examination Findings
lies down right after eating. HTN first diagnosed last year. General: Pleasant, cooperative man in obvious distress.
He exercises regularly and avoids salty foods. He takes no 6′2″, 82 kg
medication for the HTN. S/P tonsillectomy age 5 yr. Vital signs: BP 140/90 mm Hg, HR 140 beats/min,
SH: Works as a computer programmer. Lives in own three- RR 12 breaths/min, T 98.6° F (oral)
story home. Started drinking alcohol when he was HEENT: PERRLA, EOMI, NCAT
18 yr and is currently drinking about a six-pack of beer Chest and lungs: CTAP
on weekends. Does not smoke tobacco and denies the CV: + S1, + S2; II/VI systolic murmur at the apex; no rubs or
use of illicit drugs. gallops
FH: Married with two small children (aged 3 yr and 6 mo). Abdomen: NABS, NTND
M&F A&W. Both parents have HTN. Extremities: Deep puncture wound on dorsal surface of right
hand near thumb. Hand is red and swollen. Unable to
Medication History feel radial pulse on right.
Current prescription medications: Esomeprazole (Nexium) Neuro: A×3; reflexes 2+ throughout; cranial nerves not
20 mg daily × 2 yr for the GERD tested
Past prescription medications: None Labs: Panel-7 WNL; CBC WNL.
Current or past nonprescription medications: None

SELF-ASSESSMENT QUESTIONS d. Objective

e. Oppose
1. What does the A in the acronym SOAP stand for? 3. Which one of the following is not a component of
a. Active the planning process?
b. Appraisal a. Problem identification
c. Assessment b. Problem prioritization
d. Acquire c. Selection of specific initial and alternative
e. Attainment treatment regimens
2. What does the O in SOAP stand for? d. Development of an integrated monitoring plan
a. On the whole e. Patient counseling
b. Opportunity
c. Overall
144 Clinical Skills for Pharmacists: A Patient-Focused Approach

4. Which one of the following is not a step involved in Problem No. 1 Problem No. 2 Problem No. 3
the identification of patient problems? a. Hypertension Penicillin Congestive
a. Identification of subjective and objective patient allergy heart failure
data b. Hypertension Congestive Penicillin
b. Creation of a working list of all patient data heart failure allergy
c. Prioritization of patient data c. Congestive Hypertension Penicillin
d. Creation of sets of related problems heart failure allergy
e. Determination of each specific patient problem d. Congestive Penicillin Hypertension
5. Which one of the following is a subjective ­parameter? heart failure allergy
a. Serum creatinine level e. Penicillin allergy Congestive Hypertension
b. Weight heart failure
c. Height
d. Dysuria 11. Which of the following is not a step in the ­selection
e. Peak expiratory flow rate of specific therapeutic regimens?
6. Which one of the following is not a subjective a. Creation of a list of therapeutic options for each
­parameter? problem
a. Anxiety b. Selection of an appropriate therapeutic regimen for
b. Indigestion each problem
c. Respiratory rate c. Identification of alternative regimens
d. Insomnia d. Creation of a monitoring plan and monitoring of
e. Pain patient response to treatment
7. Which one of the following is an objective e. Identification of objective and subjective patient
­parameter? parameters
a. Blurred vision 12. A patient with a dry, hacking cough asks the pharma-
b. Temperature cist to recommend a cough medication. The pharma-
c. Headache cist, who does not know the patient, recommends a
d. Tinnitus popular nonprescription cough suppressant without
e. Fatigue checking the patient’s medication profile. What error
8. Which one of the following is not an objective did the pharmacist commit?
­parameter? a. The pharmacist should have considered other
a. Vertigo patient problems.
b. Urine output b. The pharmacist should have recommended an
c. Bilirubin level expectorant.
d. Hemoglobin level c. The pharmacist should have advised the patient to
e. Ejection fraction see a physician.
9. A patient arrives in the emergency room with a seri- d. The pharmacist should have recommended a
ous head injury. Laboratory tests identify mild hyper- decongestant.
lipidemia. The patient is S/P hernia repair. Which of e. The pharmacist should have obtained a
the following is an appropriate prioritization of the prescription for a cough suppressant from the
patient’s problems? patient’s doctor.

Problem No. 1 Problem No. 2 Problem No. 3

a. Head injury Hyperlipidemia S/P hernia
repair
b. S/P hernia Hyperlipidemia Head injury http://evolve.elsevier/Tietze
repair
c. Hyperlipidemia S/P hernia Head injury Audio glossary terms
repair
d. Hyperlipidemia Head injury S/P hernia
repair
e. Head injury S/P hernia repair Hyperlipidemia REFERENCES

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tention, and a displaced point of maximal impulse. and management of rhinitis: an updated practice parameter.
Blood pressure is 120/78 mm Hg. She has a penicillin J Allergy Clin Immunol 122(2 suppl):S1–S84, 2008.
allergy. Which of the following is an appropriate pri- 4. Executive summary: standards of medical care in ­diabetes—
oritization of the patient’s problems? 2009. Diabetes Care 32:S6–S12, 2009.