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The Pharmacotherapy Patient Case Presentation . Purpose of the Patient Case Presentation. Patient cases are presented to colleagues on a daily basis, for three primary reasons.
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Purpose of the Patient Case Presentation • Patient cases are presented to colleagues on a daily basis, for three primary reasons. • First, one practitioner needs another to assume responsibility for a patient when leaving a shift, taking a vacation, or sharing responsibilities. • Second, a practitioner needs advice from a colleague concerning the care of a patient. • Third, and most frequently in the case of student practitioners, to present patient cases to a mentor/practitioner when learning to care for patients. • You will be expected to present numerous patient cases, so it is important to learn the skills to do this properly as early in your career as possible.
for the pharmaceutical care practitioner. The case presentation format in pharmaceutical care practice is structured to present patient information for the purpose of identifying, resolving, and preventing drug therapy problems.
During a case presentation your decisions are described and your rationale is explained. • Drug therapy problems as anexample. • During the presentation of your patient's case, you will need to describe • which drug therapy problem your patient has • and how you decided to resolve it. • You have already completed the assessment, • identified drug therapy problems, • constructed care plans, • and may have evaluated your patient's outcomes. • The case presentation tells the story of what you found, what you did, and what happened.
Some case presentations are designed for the purpose of obtaining assistance from a colleague. • You might need help in determining what your patient's drug therapy problem is or what might be the best approach to achieving the goals of therapy. • In either situation, your presentation should inform your colleague what help you need.
Assessment of the Patient's Drug-Related Needs • Brief Description of the Patient • This provides your colleagues with a mental picture of this individual. • Practitioners need to see the patient to care for him or her. • This should be simple, straightforward, and include how the patient appeared to you (physically, emotionally, and health-wise). • Your introduction of the patient should include age, gender, and physical description (height, weight, and ethnic origin if it is germane to the care this patient).
Example • M.J. is a 23-year-old female who is 5 ft 3 in tall and weighs 132 lb. • Mr. W. is a 71-year-old Caucasian male who is approximately 6 ft tall and of average weight. • B.L. is a 55-year-old, 6 ft 3 in 220 lb male construction worker who appears very uncomfortable due to his recent work-related injury to his right hand.
Reason for the Patient Encounter • Your description should focus on the patient's initial request or the precipitating event. • It is most helpful to use the patient's own words. • direct quotations from the patient describing his or her perceptions of need. • This might include items the patient does not understand, expressed concerns, or expectations that are unrealistic. • Using the patient's own words avoids adding your own bias or interpretation onto the patient's description of his/her primary concern.
You may also need to include the patient's presenting signs, symptoms, or illness behavior and a description of the patient's general health. • Example M.J. presented to our pharmaceutical care clinic with a cough that has "kept me awake for the past two nights." • Mr. W. was referred to me by Dr. Samuelson for assessment and continued follow-up of his anticoagulant therapy. Mr. W. explained that he has "been taking these pills for over 6 years, and I don't know why they keep taking blood samples." • B.L. asked us to contact his primary care physician and obtain "a new drug that will work" to relieve the pain and inflammation in his injured right hand.
In order to fully understand your patient's drug-related needs, you may need to describe his/her employment, family support, and socioeconomic status. • Lifestyle, living conditions, occupation, and family (or other care-givers affected by the person's illness) can all impact the patient's medication taking beliefs, behaviors, and outcomes. • A patient's functional capacity (physical, emotional, and social) should also be included here.
a description of any special needs the patient has. Language barriers, physical limitations (hearing or sight, walking restrictions), • or diverse cultural backgrounds (beliefs, religion, traditions) should all be noted if they impact the drug therapy decisions that will be made. • It is important to be respectful of individual differences and sensitive when describing patient characteristics that represent beliefs or lifestyles that differ from your own.
Example M.J. has a history of animal allergies and has recently begun taking care of her partner's three cats. • Mr. W. lives alone in a gated retirement community. He uses a cane to assist with walking and requires large print books and newspapers to read due to his failing eyesight. • B.L. recently moved from Mexico and speaks very little English. His oldest daughter accompanied him to help as an interpreter.
Medication Experience Reported by the Patient • a summary of the relevant events in a patient's lifetime that involve drug therapy. • include the patient's attitudes, beliefs, and preferences about drug therapy that have been shaped by the patient's experiences, traditions, religion, and culture. • presented in the patient's own words. • The focus of this portion of your presentation is to describe how your patient makes decisions about using medications.
This information helps you to understand the whole person and will be necessary as you try to identify common ground on which to develop the care plan. • Example M.J. explained that this type of cough has occurred "at least three or four times in the past, whenever my partner brings her cats to my apartment. I think it is because of the cats, but I really like animals." • Mr. W. has been meticulously observant of all his appointments to have his INR measured and his warfarin dosage adjusted. He keeps a record of all his past INR results in his wallet. • B.L. asked his daughter to ask why he had to see a physician, just to get some more pain medication. In his hometown in Mexico, that was not required. He could purchase most medications his family needed at any pharmacy.
Comprehensive Medication HistoryAllergies and Alerts/Social Drug Use/Immunization Record • describe any allergies (and associated allergens) • or adverse reactions to previously taken drug therapy. • Smoking, alcohol, and recreational drug use • patient's immunization history is an essential aspect of the Pharmacotherapy Workup and case presentation. This is especially true in vulnerable populations such as children, immunocompromised patients, and the elderly.
Example M.J. reports no drug allergies, but is allergic to animal dander and some forms of nuts which manifest as severe itching and rash that respond to benadryl (diphenhydramine) and cool compresses. She has never used tobacco and drinks 1 or 2 alcoholic beverages only on social occasions. • Mr. W. indicated he was allergic to codeine. He reported that he had to go to the emergency department because he developed angioedema shortly after he took his first dose of Tylenol with codeine for a dental procedure in 1998. He quit smoking cigarettes after his wife died in 1991. He reports no use of alcohol of any type. • B.L. reports no history of any drug or food allergies. He describes his alcohol use as two beers after work and does not smoke cigarettes or cigars.
Current Medication Record: Indication–Drug Product–Dosage Regimen–Outcome • patient's current medication record • First the indication is described, • then the specific drug product, • then the dosage regimen the patient is taking and how long he/she has been taking it at that dosage, • and finally the response the patient has exhibited or described that has resulted from that drug therapy.
Example Mr. W. is presently taking warfarin 2.5 mg orally each morning for prevention of a stroke or myocardial infarction secondary to his long-standing atrial fibrillation. His INR last month was 2.2, and no dosage adjustments were made at that time. His heart rate and rhythm have been successfully controlled for the past three years with digoxin 0.25 mg orally every day, furosemide 20 mg each morning, and oral potassium supplement of 20 meq daily. A review of systems revealed that Mr. W. has not experienced any adverse reactions from his drug therapies.
Past Medical History and Associated Drug Therapies • describe the pertinent portions of the patient's past medical history. • Keep in mind that this is a pharmacotherapy case presentation and not the presentation of a patient's complete medical workup. • Therefore, present only the information and experience you used to make current drug therapy decisions. • Past medical history is used most often to describe those experiences in the patient's past that suggest a risk factor or contraindication to drug therapy. • These situations may include: serious illnesses, hospitalizations, surgical procedures, accidents and injuries, pregnancies, deliveries, and complications to any medical treatments.
Example M.J. was diagnosed with exercise-induced asthma at 7 years of age but has not needed any drug therapy or other medical care for that condition for the past 8 years. • Mr. W. had dental surgery last April at which time his warfarin was discontinued for 7 days and then restarted without incident.
Providing any evidence of success or failure of past attempts at treating or preventing an illness can be a very informative portion of your case presentation
Example M.J. is presently treating tendonitis of the right elbow with ibuprofen 600 mg taken three times each day for the past 5 days. She is satisfied with the relief of both the pain and stiffness. The week prior, she attempted to treat her tendonitis by taking 200 mg twice daily but felt no relief. • M.J. also reported that she attempted to treat a similar cough with dextromethorphan last spring, but "that medication did not help much and it upset my stomach." • In 1999, Mr. W. was instructed to take 2.5 mg of warfarin every other day, alternating with 5 mg, but he could not seem to keep track of his dosing schedule. He was seen in clinic on two occasions that year with bleeding from the nose. He reported that his INR was "way too high because I was taking too much medicine."
Review of Systems • There are several situations in which you will need to present positive or negative findings from the review of systems: • To establish the relationship of the finding to the drug therapy the patient is taking. This is either evidence of the presence or absence of a side effect or adverse drug reaction. • "The review of systems revealed that the patient was not nauseous or agitated and has not experienced headache or dizziness and showed no other side effects from her fluoxetine. • " To identify additional drug therapy needs of the patient that were not discovered during your assessment interview. • "The review of systems revealed that the patient has experienced excessive bruising over the past 3–4 months thought to be related to. . . • To present your interpretation of any abnormal or unexpected findings. • "The review of systems revealed that the patient experienced a feeling of fullness in the abdomen, which subsided when she started her ranitidine therapy.
Example The review of systems was unremarkable except for his report of intermittent nausea over the past 2 weeks which the patient feels is a result of his new diet.
Summary of the Assessment • a brief review of your clinical judgment regarding the patient, his/her active medical conditions, associated drug therapies, and any drug therapy problems identified. • Your summary should report your judgment as to whether you think that all of your patient's drug therapy is appropriately indicated, the most effective available, as safe as possible, and whether the patient is taking it as intended. • This summary informs your colleagues where you are in the course of the case presentation.
Example "The summary of my assessment of M.J. is that she is a healthy 23-year-old female who is bothered by coughing in the evening, which is disrupting her sleep and is felt to be a manifestation of her allergies to cat dander. We will need to provide drug therapy to control these symptoms as she will be in contact with cats for the next 2 weeks."
Drug Therapy Problem Identification Problem–Drug Therapy–Cause and Effect • If drug therapy problems have been identified, they must be stated clearly during your presentation of the patient's case. • There is a specific format used to describe a patient's drug therapy problems. • (a) the medical condition associated with the drug therapy problem, • (b) the drug therapy involved, and • (c) the relationship (cause and effect) between the medical problem and the drug therapy. • It must be clearly stated so your colleagues can understand your clinical decision.
Example "The patient's ibuprofen dosage of 200 mg twice a day was too low to provide effective relief of her tendonitis." • "The patient requires potassium supplements to prevent diuretic-induced hypokalemia." • "The patient has developed orthostatic hypotension due to the excessive dosage increase of her enalapril." • "The patient prefers not to take his cefuroxime suspension for pharyngitis because of the poor taste."
The Care Plan • Identifying your patient's drug-related needs, as well as resolving and preventing drug therapy problems, requires an organized care planning process. • The care plan should be organized and prioritized by activemedicalconditions being managed with drug therapy. • The problems should be presented in order of risk, severity, and importance to the patient.
For each medical condition, you will need to present your plan • to resolve any drug therapy problems associated with that medical condition, • a clear description of the goals of therapy, • and the interventions you intend to make to achieve the goals of therapy and prevent any drug therapy problems from occurring in the patient.
Example "Our goal is to eliminate the orthostatic hypotension by holding her enalapril for 1 day and then reducing the daily dosage regimen of enalapril to 10 mg twice each day, beginning on Tuesday."
When describing the goals, be certain to include the timeframe in which you expect to achieve each goal. • Example "The goal of therapy is to reduce and then maintain her blood pressure at a systolic of 120–130 mmHg and a diastolic of 70–80 mmHg within the next 4 weeks."
When presenting the therapeutic alternatives considered and the drug therapy selected, be sure to explain the rationale for your choice. • When describing pharmacotherapy rationale always explain both the efficacy and safety considerations for each alternative. • Additional considerations (cost and convenience) can be described here too, but efficacy and safety are always the required minimum.
The final information you will present in your care plan section of the presentation is the schedule for follow-up meetings with the patient. • This plan should also include the parameters you intend to use to evaluate the effectiveness of your plan and the parameters you plan to use to evaluate the safety of your patient's drug therapies.
Example "The patient will take her own blood pressure every morning and record it on her medication diary. She will also record any feelings of dizziness or lightheadedness. I will evaluate these records at the next appointment on August 23. I will evaluate renal function using blood urea nitrogen, serum creatinine, and potassium determinations at that visit. I will also inquire to determine if she has developed a cough from her enalapril therapy."
Follow-Up Evaluation • For presentations of the follow-up evaluation, your focus is on the evidence of success or failure of past care plans and interventions.
The presentation of a follow-up evaluation generally has three sections. • First, briefly review the patient and what you were trying to achieve at previous visits. This generally focuses on resolution of drug therapy problems and achieving goals of therapy. • Second, you will describe what happened to the patient (patient outcome) since the last visit. You will need to compare the patient's outcomes to what was intended (goals of therapy). This comparison is based on clinical and/or laboratory findings used as evidence of effectiveness and safety of drug therapies and patient compliance. • Third, you present your clinical judgment (evaluation) of the patient's progress toward achieving the goals of therapy as of the date of the follow-up presentation being described. It is most useful to be consistent in your use of outcome terminology.
It is most useful to be consistent in your use of outcome terminology. • The terms to describe pharmacotherapy outcome status include • resolved, • stable, • improved, • partially improved, • worsened, • and failure. • It is important to be clear in your use of these outcome status categories
Example "As you will recall, we had reduced this patient's dosage of enalapril 4 weeks ago due to episodes of orthostatic hypotension. I think we have successfully resolved that drug therapy problem. Today, she reports one episode of slight dizziness that diminished within 2 minutes. She has no other complaints including no cough associated with her drug therapy. Her renal function tests have not changed over the past month and all remain within normal limits. Her blood pressure readings over the past month have steadily declined to a daily range of 124–130 over 75–80 mmHg, which are within the planned goal of 120–130 over 70–80 mmHg. My evaluation at this visit is that her blood pressure control has improved, and no changes should be made in her drug regimen at this time. She has no new problems to report at this time. I plan to reevaluate her hypertension pharmacotherapy in 3 months."
Summary of the Case • The case presentation ends with • a brief summary of the most cogent points. • Be sure to summarize the drug-related needs of the patient, • the resolution and prevention of drug therapy problems, • as well as evidence of effectiveness and safety of the patient's pharmacotherapy.
Common Problems in the Case Presentation • Items frequently omitted from student case presentations include • the primary reason the patient sought care, • the original reason for admission to the hospital or clinic, • the nonprescription medications being used as self-care and their indications, • evidence of the patient's ability to understand and adhere to the medication instructions, • and evidence that the drug therapy is being effective • The terminology
The strength of the case presentation format is its simplicity. • Be sure not to negate this by being confusing, long-winded, or making the case appear complex when it is not.
