2. OBJECTIVE
1. To establish a good and uniformity of our care for patients
in regards with therapeutic issues, resolving, outcome
monitoring and side effects
2. To standardize the current procedure for clinical pharmacy
documentation
3. To bring us together and close a gap by having a same
understanding on dealing with pharmaceutical related care
issues.
7. CASE 1
! Mr John Jones (61 years) is admitted to the emergency assessment unit at his local hospital complaining of
palpitations, breathlessness and dizziness. He has a 5-day history of some dizziness and palpitations. In the last 24
hours he complained additionally of shortness of breath. He collapsed at home and was then admitted to hospital via
the emergency department.
He experienced similar symptoms two months ago but did not seek medical advice at that time and seemed to recover
quickly. On examination and review by the admitting doctor the following information is obtained:
Previous medical history
Hypertension (diagnosed 5 years ago), no previous history of cardiovascular disease. The patient is a regular cigarette
smoker (>20 per day) and drinks approximately 20 units of alcohol per week.
! Drug history
No known allergies. Mr Jones had been prescribed lisinopril tablets 20 mg once daily but was poorly compliant with
treatment.
! Signs and symptoms on examination
a. Blood pressure 100/70 mmHg
b. Heart rate 175 bpm, irregular
c. Respiratory rate 25 breaths per minute
d. No basal crackles in the lungs.
! Diagnosis
Atrial fibrillation.
! Relevant test results
Full blood counts, liver function tests, electrolytes and renal function were all normal at admission and throughout the
admission to discharge.
! Mr Jones is subsequently transferred to the cardiology ward where his continuing atrial fibrillation is later confirmed
as persistent atrial fibrillation. As the ward clinical pharmacist, you are responsible for daily review of drug charts and
advice to medical and nursing staff on all aspects of drug treatment for patients on the ward.
10. Initial Assessment
CP1 form :
1. Medical/Drug History
2. Compliance
Pharmaceutical Risk Factor :
1. Non compliance with lisinopril 20mg od –
Interview patient!
Other significance risk factor:
1. Smoker
2. Alcoholic
11. Prioritize the issue
Starting clerking – CP2
1. Obtain all information pertaining to the case
(patient’s demographic, medical/drug history,
progress, compliance evaluation, allergy and
others.
2. Issue : non compliance
- Non tolerable side effect?
- Other factors contributing to non compliance
- Re-enforce compliance upon discharge
13. Smoker and
alcoholic?
The patient is a
regular cigarette
smoker (>20 per day)
and drinks
approximately 20
units of alcohol per
week
- Incorporated in
pharmaceutical
care plan
(http://
www.rxkinetics.co
m/careplan.html)
14. Smoking :
One pack-year of smoking would mean that
someone had smoked one package of cigarettes
(20 cigarettes) daily for one year.
Number of pack-year is assessed to determine the
risk for lung cancer, DM and peripheral arterial
disease.
Formula :
No of cigarette smoked / 20 (in a pack) x years
15. Alcoholic : Common risk factor for AF (Malaysia
Clinical Practice Guideline On Management of Atrial
Fibrillation 2012)
16. Questions
1 What is atrial fibrillation?
Atrial fibrillation is an arrhythmia in which the electrical activity in the atria is disorganised.
The AV node receives more electrical impulses than it can conduct and most are blocked
resulting in an irregular ventricular rhythm.
2 What are the most common signs and symptoms exhibited by patients with atrial
fibrillation? Indicate which of these signs and symptoms the patient is exhibiting.
a. Symptoms: Breathlessness/dyspnoea, palpitations, syncope or dizziness, chest discomfort
or stroke/transient ischaemic attack.
b. Signs: Irregular pulse, ventricular rate usually 120–180 bpm. ECG shows fine oscillations
of the baseline with no clear P-waves. Rapid and irregular QRS rhythm.
c. Causative factors: This patient’s hypertension is a potential causative factor.
3 What are the two options in terms of treatment strategy that may be employed to manage
atrial fibrillation? Indicate what would be the most appropriate strategy that you could
recommend to the doctor managing this patient and why you think this is the case.
The two options are rate control or rhythm control. Rate control is the most appropriate in
this patient as he is over 65 years. Atrial fibrillation appears to be of long standing and may
have been present two months ago when the patient experienced a similar episode. His
lisinopril should be stopped as he will get blood pressure control with the beta-blocker.
17. 4 Assuming a rate control strategy is to be used what class
of drug should be the first-line treatment for this patient? If the
first-line drug was contraindicated what class of drug could be
used as alternative treatment?
A beta-blocker is suitable first line treatment for rate control. A
rate-limiting calcium channel blocker could be used in those in
whom a beta-blocker is not suitable, such as asthmatics.
5 What patient parameters should be monitored to assess
therapy with the usual first-line treatment and what is an
appropriate treatment target for such parameters?
Titrate dose against heart rate. The target is for a resting heart
rate of <90 bpm (or 110 for those with recent onset atrial
fibrillation) and an exercise heart rate of <110 bpm (inactive) or
200 minus age (active).
18. 6 What are the two options in terms of antithrombotic prophylaxis in this patient and
what are the potential side-effects of each? State which of these is the most appropriate for
this patient and why?
The two options are warfarin or aspirin. The side-effects are listed in following table
Drug Side Effects
Warfarin Haemorrhage
Hypersensitivity
Rash
Alopecia
Diarrhoea
Nausea and vomiting
Skin necrosis
Hepatic dysfunction (e.g. jaundice)
Pancreatitis
Aspirin Mild stomach upset/irritation (e.g. heartburn). Occasionally severe
gastrointestinal side-effects may occur which may lead to stomach ulcers (evidence severe
GI pain, black tarry stools, vomiting blood).
Occasionally ringing or buzzing in the ears.
In very rare cases and only with larger doses, salicylism may occur.
Effects include dizziness, ringing or buzzing in the ears, nausea, headache and confusion.
19. The overall risk of stroke should be assessed for each individual with atrial fibrillation. It
should also be reassessed regularly, as a person’s risk of stroke will change over time. The
individual’s attitude to anticoagulation will strongly influence the cost/benefit of
treatment, and should always be taken into account.
The decision to use warfarin or aspirin should ultimately be based on the balance of an
individual’s overall risk of stroke compared with the risk of adverse effects and their
personal preference.
In this case the patient is 61-years-old with additional risk factors for stroke (hypertension
and smoking). He is at moderate risk and could be offered either aspirin or warfarin.
7 Assuming the patient is to be discharged on a beta-blocker and aspirin, what
counselling does he require?
Mr Jones needs to be advised to take his medication regularly. If he experiences any
problems he should talk to his GP or a pharmacist. As he is poorly compliant it is
worthwhile exploring with him why he did not take his previous therapy (lisinopril)
regularly.
He should be advised to take his aspirin in the morning after food. The tablet may be
dispersed in water or taken whole with some water. The betablocker should be taken
regularly at the time(s) prescribed, at the same time each day, swallowed whole with a
drink of water. Mr Jones should be told that if he experiences side-effects with this
medication, such as dizziness, he should not stop taking it suddenly but should speak with
his GP or pharmacist.
