CLINICAL PHARMACY TRAINING PROGRAM                                        BATCH 40 (CPTP 01-17) 

Case Presentation

​Date of Presentation ​(24 ​April ​2017)

Team : Oncology
Members : Abalos, Malala, Sardona
Covered Period : March 4, 2017- March 8, 2017
Patient Demographics

Patient Initials SOT PIN 1202174585

Unit 5 Main A Room No. 5117
Age 62 years old Sex Female
Wt. 52.5 Kg Ht. (length for babies) 155 cm

Chief Complaint (CC)

Abdominal Pain
History of Present Illness (HPI)
Patient is diagnosed with Colon cancer stage 4 (Lung Metastasis) Breast cancer stage 4 (Brain metastasis) Status Post
Bilateral Mastectomy, Status Post Colostomy creation of Status Post FOLFOX who came in due to bleeding for colostomy.
Few hours prior to admission, the patient had an episode of nausea and vomiting. At 0000H, the caregiver seen a bleeding
per colostomy described as bright red. Hence, consult.
Review of Systems (ROS)
Gastroinstestinal

Abdominal pain/Nausea/Vomiting/Hematochezia
Past Medical History (PMH)
STANDING MEDICATION (FOR CHEMOTHERAPY)
DAT FD LD NAME SD STRENGTH ROUTE FREQUENCY INDICATION
E
6/16 1400H 1600H ALERT 100mg 150mg IV X 2 hours Protocol treatment of
Oxaliplatin advanced colorectal
(Oxalee) cancer combination
with Folinic acid and 5
Fluorouracil
1400H 1600H ALERT 50mg 500mg IV X 2 hours Protocol treatment of
Folinic acid advanced colorectal
(DBL) cancer combination

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CLINICAL PHARMACY TRAINING PROGRAM                                        BATCH 40 (CPTP 01-17) 

with Oxaliplatin and 5

Fluorouracil
1600H 6/18 ALERT 500mg 3000mg IV X 46 hours Protocol treatment of
1410H 5-Fluorouracil advanced colorectal
(DBL) cancer combination
with Folinic acid and
Oxaliplatin
6/18 1415H 1545H ALERT 100mg 263mg IV X 90 minutes Treatment in
Bevacizumab Colorectal cancer in
(Avastin) combination with
Folinic acid, Oxaliplatin
and 5 Fluorouracil
PRE-CHEMOTHERAPY
6/16 125mg 6/18 Aprepitant 80 mg PO X 2 doses Prevention of
1330H 0600H (Emend) 125mg then Once a day moderate
chemotherapy-induced
nausea and vomiting
Palonosetron (Aloxi) 250 mg IV Prevention of
moderate
1330H chemotherapy-induced
nausea and vomiting
Dexamethasone 10 mg IV Prevention of
(Cordex-5) ​5 mg moderate
chemotherapy-induced
nausea and vomiting
Ranitidine (Ulcin) 50 mg IV Prevention of stomach
acid formation to
reduce indigestion and
heartburn which can
sometimes lead to
nausea and vomiting
Diphenhydramine 25 mg IV Prevention of
(Benadryl) hypersensitivity
reactions in
chemotherapeutic
agents

MEDS PRIOR TO ADMISSION Last dose taken

3/6 PM 3/2 Calcium carbonate + 2 tablets PO 3x a day Calcium supplement
Vitamin D3 (Caltrate and stimulate strong
Plus) bones; reduce cell
proliferation in the
lining colon.
PM 3/2 Ursodeoxycholic acid 300 mg PO 2x a day Treatment to reduce
(Udcacid) progression of liver
2
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An International Affiliate of:
New York-Presbyterian Hospital
Columbia University College of Physicians and Surgeons
Weill Cornell Medical College of Cornell University
CLINICAL PHARMACY TRAINING PROGRAM                                        BATCH 40 (CPTP 01-17) 

damage based on
elevated SGOT/AST
(55 unit/L), Low
albumin (0.6) and
elevated conjugated
bilirubin (0.25 mg/dL).
AM 3/4 ALERT 30 units SQ Every 24 hours Maintenance medicine
Insulin Glargine to prevent
(Lantus) hyperglycemia due to
Type II DM of patient
AM 3/4 Salbutamol sulfate 2 puff INH Every 8 hours Prevention of
(Ventolin MDI) 120 bronchial asthma
mcg/INH exacerbation.
PM 3/2 Multivitamin (Propolis e PO 2x a day Multivitamin
zinc) supplement to boost
immune system
PM 3/2 Essence of Mushrooms PO 3x a day Herbal multivitamin
Supplement to boost
immune system
PM 3/2 Dexamethasone 4 mg PO Every 8 hours Prevention of emesis
(Decilone Forte) due to chemotherapy
and reduce withdrawal
symptoms caused by
steroids.
AM 3/2 Vitamin D3 (Healthy PO Once daily Prevent development
options) of cancer by promoting
cell differentiation;
stimulate strong bones
and help absorb
calcium.
AM 3/2 Vitamin C (Poten Cee) 500mg PO Once daily Vitamin supplement to
boost immune system,
and antioxidant to
combat free radicals.
AM 3/2 Vitamin B complex PO Once daily Vitamin supplement to
(Meganerv 1000) maintain nerve
function and boost
immune system.
Radiotherapy therapy for Colorectal cancer 28 sessions with chemotherapy Capecitabine (Xeloda) (2012), mFOLFOX x 6
cycle (2014), Status post (Bevacizumab) Avastin and Capecitabine (Xeloda) x 2 cycle for Breast and Colorectal Cancer
(2015), Radiotherapy for brain cancer (11/11/2016)
Past Surgical History
Colectomy (2012), Colostomy (2012), Abdominoperineal Resection and Pelvic exenteration (2012), Total Abdominal

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An International Affiliate of:
New York-Presbyterian Hospital
Columbia University College of Physicians and Surgeons
Weill Cornell Medical College of Cornell University
CLINICAL PHARMACY TRAINING PROGRAM                                        BATCH 40 (CPTP 01-17) 

Hysterectomy Bilateral Salpingo Oophorectomy (TAHBSO) (2012), and Bilateral Mastectomy (2012)
Smoking and Alcohol (and any other substance abuse)
(-) Smoker, (-) Alcohol beverage drinker
Social/Work History
Unemployed and living with family
Family History
(-) Hypertension, (+) Diabetes Mellitus Type II, (+) Bronchial Asthma
Physical Exam/Labs/Other Tests
Vital Signs
RESULTS REFERENCE RANGE
Blood Pressure 140/96 mmHg 120/80 mmHg - 90/60 mmHg
Pulse Rate 82 beats per minute 60 to 100 beats per minute
Respiratory Rate 20 breaths per minute 12 to 18 breaths per minute
Temperature 36.9 ‘C (36.5°C to 37.3°C)
Pain Scale Mild Pain
Laboratory Results
March 5, 2017 0541H
Complete Blood Count
TEST RESULTS REFERENCE RANGE REMARKS
Hemoglobin 8.1 g/dL 11.6 – 15.5 g/dL Low
Hematocrit 24.6 % 36.0 – 47.0 % Low
Red Blood Cell 2.61 mil/mm^3 4.20 – 5.40 mil/mm^3 Low
White Blood Cell 5870 mm^3 4800 – 10800 mm^3
Differential count
Neutrophils 76% 40 – 74% High
Lymphocytes 2% 19-48% Low
Monocytes 1% 3-9% Low
Stabs 21% 2-6% High
Platelet Count 155,000/mm^3 150,000-400,000 mm^3
Mean Corpuscular 94 Fl 82-98 FL
Volume

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An International Affiliate of:
New York-Presbyterian Hospital
Columbia University College of Physicians and Surgeons
Weill Cornell Medical College of Cornell University
CLINICAL PHARMACY TRAINING PROGRAM                                        BATCH 40 (CPTP 01-17) 

Mean Corpuscular 31 Pg 28-33 Pg

Hemoglobin
Mean Corpuscular 33% 32-38%
Hemoglobin
Concentration
Red blood cell Distribution 17% 11.0-14.0% High
Width
Chemistry
TEST RESULTS REFERENCE RANGE REMARKS
Creatinine 0.38 mg/dL 0.56-1.02 mg/dL Low
Blood Urea Nitrogen 12 mg/dL 7-18 mg/dL
Serum Glutamic Pyruvic 53 unit/L 12-78 unit/L
Transaminase / Alanine
Aminotransferase
Serum Glutamic 55 unit/L 15-37 unit/L High
Oxaloacetic
Transaminase / Aspartate
Aminotransferase
Bilirubin 0.60 mg/dL 0.20-1.00 mg/dL
Conjugated Biliburin 0.25 mg/dL 0.00-0.20 mg/dL High
Unconjugated Biliburin 0.35 mg/dL 0.00-0.80 mg/dL
Alkaline Phosphatase 98 unit/L 46-116 unit/L
Total Protein 4.50 g/dL 6.40-8.20 g/dL Low
Albumin 1.60 g/dL 3.40-5.00 g/dL Low
Globulin 2.90 g/dL 2.30-3.50 g/dL
Albumin/Globulin Ratio 0.6 1.5-2.5 Low
Sodium 139 mmol/L 136-145 mmol/L
Potassium 4.3 mmol/L 3.5-5.1 mmol/L
Chloride 105 mmol/L 98-107 mmol/L
Bicarbonate 23 mmol/L 21- 32 mmol/L

March 6, 2016 1156H

Examination: Bedside abdomen – (Kidney & Urinary Bladder)

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Columbia University College of Physicians and Surgeons
Weill Cornell Medical College of Cornell University
 CLINICAL PHARMACY TRAINING PROGRAM                                        BATCH 40 (CPTP 01-17) 

Findings:
Colostomy tube is noted in the left lower abdomen with paucity of the descending colon, distal to the splenic
flexure, there are lucencies noted in the sac filled colon. This may be attributed to retained fecal material and
possible of pneumatosis intestinalis cannot be ruled out.
Further evaluation with CT scan may be done or if recommended. Tip of nasogastric tube is noted in the left upper
abdominal quadrant. Flank and psoas shadows are intact the visualized osseous structures are unremarkable.
March 6, 2016 0130H
Blood Cross Match
Test Result
Blood Group A
RH Factor +
Result: 1 unit filtered PRBC available cross-matched valid until March 7, 2017.
March 6, 2016
Test Result
Blood Type A-Rh D(+)
Antibody Screening -

Allergies
No Known Allergy
DIAGNOSIS
Colorectal Cancer stage 4 metastasized on lungs, Breast Cancer stage 4 metastasized on brain and bone, Type 2
Diabetes Mellitus, Cushing syndrome steroid induced dysglycemia.

Medications (Patient Medication Profile)

STANDING MEDICATION
Date FD LD Name Strength Route Frequency Remarks Indication
3/4 0105 3/6 Omeprazole 40 mg IV Once daily While on Treatment to reduce the
H 0800 (Omepron) NPO secretion of gastric acid
H Shifted to that may intensify
abdominal pain due to
Prevacid
patient’s bleeding colon
while patient is on NPO
1705 3/6 Dexamethasone 5 mg IV Every 8 hours While on Prevention of emesis
H 0600 (Cordex-5) NPO due to chemotherapy
H Shifted to prior to admission and

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An International Affiliate of:
New York-Presbyterian Hospital
Columbia University College of Physicians and Surgeons
Weill Cornell Medical College of Cornell University
 CLINICAL PHARMACY TRAINING PROGRAM                                        BATCH 40 (CPTP 01-17) 

Decilone to reduce the

Forte withdrawal syndrome
of steroids.
1742 3/6 Levetiracetam 500 mg IV Every 12 While on Prevent seizure
H 0800 (Keppra) hours NPO caused by the
H radiation therapy for
brain metastasis.
(11/11/16)
3/6 3/7 3/10 Lanzoprazole 30 mg NGT Once daily Prevention of too
0600 0600 (Prevacid) much secretion of acid
H H in the stomach to
reduce abdominal pain
due to bleeding colon.
3/8 ALERT Conc:10mcg IV Demand 10mcg/ml Treatment for
0309 PCA Fentanyl /ml Dose: in 50 ml intolerable pain due to
H (DBL) 10mcg/bolus PNSS colon cancer that
Basal Rate: Lock-out Norgesic cannot
Zero interval: 15 address. (Request by
mins the family)
Patient’s Own Medication
Date FD LD Name Strength Route Frequency Remarks Indication
3/6 1500 0800 Calcium 2 tablets NGT 3x a day Calcium supplement
H H carbonate + and stimulate strong
Vitamin D3 bones; reduce cell
(Caltrate Plus) proliferation in the
lining colon.
1500 0800 Ursodeoxycholic 300 mg NGT 2x a day Treatment to reduce
H H acid (Udcacid) progression of liver
damage based on
elevated SGOT/AST
(55 unit/L), Low
albumin (0.6) and
elevated conjugated
bilirubin (0.25 mg/dL).
1500 0800 Multivitamin NGT 2x a day Multivitamin
H H (Propolis and supplement to boost
zinc) immune system
1500 1400 Essence of NGT 3x a day Herbal multivitamin
H H Mushrooms Supplement to boost
immune system
1500 0800 Vitamin D3 1000 units NGT Once daily Prevent development
H H (Healthy of cancer by promoting
Options) cell differentiation;
stimulate strong bones
and help absorb

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______________________________________________________________________________________
An International Affiliate of:
New York-Presbyterian Hospital
Columbia University College of Physicians and Surgeons
Weill Cornell Medical College of Cornell University
 CLINICAL PHARMACY TRAINING PROGRAM                                        BATCH 40 (CPTP 01-17) 

calcium.
1500 0600 Vitamin C 500mg NGT Once daily Vitamin supplement to
H H (Poten cee) boost immune system,
and antioxidant to
combat free radicals.
AM 1900 Levetiracetam 500mg NGT Every 12 Prevent seizure
H (Keppra) Syrup hours caused by the
radiation therapy for
brain metastasis.
(11/11/16)
1500 1400 Dexamethasone 4 mg NGT Every 8 hours Prevention of emesis
H H (Decilone Forte) due to chemotherapy
and reduce withdrawal
symptoms caused by
steroids.
3/7 1008 2105 Orphenadrine 35mg + NGT Every 12 Treatment to alleviate
H H Citrate + 450mg hours Discontinu pain and muscle
Paracetamol e spasm due to
(Norgesic Forte Ordered abdominal pain
) Paracetam caused by colorectal
ol IV cancer.
PRN MEDICATION
Date FD LD Name Strength Route Frequency Remarks Indication
3/4 Paracetamol 300 mg IV For fever Used to reduce body
(Aeknil) Every 6 hours temperature (>37.8
degree celsus)
3/7 Morphine sulfate 10 mg give NGT For pain Used as a rescue dose
(Plain) ½ tablet as Every 4 hours for the patient
needed 4 abdominal pain score
over 10 pain 4/10.
scale Dr
Tinglao
NEBULIZATION

IV FLUIDS
3/4 PNSS 1L X 80 ml/hr IV
D5NSS 1L X 60 ml/hr IV
PNSS 1L TFR:100 IV
ml/hr
3/6 PNSS 1L 10 ml/hr IV While on
NGT
PARENTERAL NUTRITION
3/4 ALERT 1250 ml IV X 24 hours While on Supply nutrients the
Nutriflex 1000 NPO body needs while the

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An International Affiliate of:
New York-Presbyterian Hospital
Columbia University College of Physicians and Surgeons
Weill Cornell Medical College of Cornell University
 CLINICAL PHARMACY TRAINING PROGRAM                                        BATCH 40 (CPTP 01-17) 

patient should not

received feedings by
mouth.
STAT MEDICATION
Date FD LD Name Strength Route Frequency Remarks Indication
3/4 1515 Hyoscine-N-But 20 mg IV Treatment to relieve
H ylbromide cramps in the stomach
(Buscopan) that causes abdominal
pain.
3/5 1035 Lactulose 30 ml NGT Treatment as
H (Duphalac) premedication for plain
SD:3.3g/5ml X ray procedure.
3/6 3/6 Paracetamol 500 mg NGT Prevention of fever
0830 (Biogesic) due to blood
H transfusion caused by
acute transfusion
reaction.
3/7 0300 Aluminum+Mag 10 ml NGT Treatment for
H nesium abdominal pain due to
hydrochloride too much acid
(Gaviscon) secretions.
SD: 500 mg/267
mg/160 mg
TREATMENT
Date FD LD Name Strength Route Frequency Remarks Indication
3/7 2200 Monobasic Treatment as
H sodium premedication for
phosphate colostomy procedure.
(Fleet enema)
SD: monobasic
sodium 19 g,
dibasic sodium
7 g in 118ml
3/8 c/o pt. Deproteinized Sufficient Apply in Treatment to fasten
Calf Blood amount mouthsores the healing due to
Extract 3x a day dryness of mouth
(Solcoseryl) caused by mouth
Jelly sores.
SD: 2g/20g
1930 Nystatin Sufficient Swab Treatment for mouth
H (Afunginal) amount 2x a day ulcer caused by fungal
SD: 100,000 infection.
units
IV INCORPORATIONS

9
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An International Affiliate of:
New York-Presbyterian Hospital
Columbia University College of Physicians and Surgeons
Weill Cornell Medical College of Cornell University
 CLINICAL PHARMACY TRAINING PROGRAM                                        BATCH 40 (CPTP 01-17) 

Date FD LD Name Strength Route Frequency Remarks Indication

3/4 ALERT IV Treatment to increase
40 meqs in X1 cycle the Potassium levels
250ml PNSS X 31.25 due to lab result taken
Potassium ml/hr on March 3, 2017 (3.2
Chloride X 5 meq/hr mmol/L)
INSULIN
Date FD LD Name Strength Route Frequency Remarks Indication
3/5 ALERT Sliding SQ Treatment for patients'
Insulin Glulisine Scale type 2 DM due to
(Apidra) sudden increased of
SD: 3.49 mg/mL CBG by 212 mg/dL
(100 units/mL) caused by Steroid
induced dysglycemia
CBG ​ > ​180 2 units SQ
mcg/dL
>​220mg/dL 6 units SQ
8 units SQ
>​260mg/dL
Refer
>300mg/dL

Therapeutic Management/Summary
DAY 1
March 4, 2017
Prior this admission, the patient was admitted from St Luke’s Medical Center on June 16, 2016 for chemotherapy
and as an Ambulatory patient for the sessions. For her pre medications, Dr Dy ordered Palonosetron (Aloxi) 250mg
IV, Dexamethasone (Cordex 5) 10mg IV, Aprepitant (Emend) 125mg per tab one tablet PO then, 80mg per tablet
one tablet once daily pre breakfast for 2 days to prevent nausea and vomiting while undergoing chemotherapy,
Ranitidine 10mg IV to prevent heartburn and Diphenhydramine (Benadryl) 25 mg PO for prevention of
hypersensitivity in chemotherapeutic agents.
On her first cycle of her Chemotherapy (June 16, 2016), the patient was given Oxaliplatin (Oxalee) 150 mg in D5W
250mL for 2 hours, Folinic acid (Leucovorin) 500 mg in D5W 250 mL for 2 hours as side drip to Oxaliplatin
(Oxalee), 5-Fluorouracil (DBL) 3,000 mg in PNSS 1 L for 46 hours then Bevacizumab (Avastin) 263 mg in PNSS
200 ml for 90 minute. For the second cycle (July 16, 2016), third cycle (July 27, 2016), fourth cycle (August 17,
2016) and last cycle (September 7, 2016) the patient was given the same pre medications and chemotherapeutic
agents.

➢ On March 4, 2017 at 1235H the patient was admitted to the Emergency Room complaining of abdominal pain. Few
hours prior to admission patient had an episode of nausea and vomiting and the caregiver notice blood in the
colostomy bag described as bright red, hence the family consult.
➢ Dr. Carlos Dy examined the patient and ordered Omeprazole (Omepron) 40 mg IV once daily while on NPO,
Paracetamol (Biogesic) 500 mg one tablet every 4 hours as needed for temperature >37.8 C and PNSS 1L to run
at 80 mL/hr. Dr. Carlos Dy advised the Clinical nutritionist for possible Nasogastric tube feeding (NGT).

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An International Affiliate of:
New York-Presbyterian Hospital
Columbia University College of Physicians and Surgeons
Weill Cornell Medical College of Cornell University
CLINICAL PHARMACY TRAINING PROGRAM                                        BATCH 40 (CPTP 01-17) 

➢ The patient was transferred to Cancer unit (5 Main A) under the service of Dr. Carlos Dy (Medical Oncology).
➢ While on Cancer Unit (5 Main A), the patient was still on NPO until the Surgical Oncology service requested to start
NGT feeding. The CBG of patient was 96 mg/dL. IV fluid was shifted to D5NSS 1L to run at 60mL/hr and ordered
to continue Omeprazole (Omepron) 40 mg IV once daily.
➢ At 1500H, Medical Oncology ​Service ordered CBG monitoring every 4 hours while still on NPO,
Hyoscine-N-Butylbromide (Buscopan) 20 mg IV stat for abdominal pain and shifted the Paracetamol (Biogesic) 500
mg one tablet every 4 hours as needed for temperature >37.8 C to Paracetamol (Aeknil) 300mg IV every 6 hours
as needed for pain or fever >37.8C. The patient’s potassium level was 3.2 mmol/L based on March 3, 2017
laboratory result. For this reason, Medical Oncology service ​ordered to start Potassium Chloride 40 mEqs in 250
mL NSS to run for 5 mEqs/hr (31.5 mL/hr) for one cycle.
➢ At 1620H, Medical Oncology service ​ordered to start Nutrifex 1000 Kcal 1250mL for 24 hours and ordered
Dexamethasone (Cordex 5) 5 mg IV every 8 hours for withdrawal syndrome of steroids (hypoglycemia) and
Levetiracetam (Keppra) 500mg IV every 12 hours.
➢ At 1840H, Dr Que (Neuro) ordered to shift D5NSS 1L to run at 60mL/hr to PNSS 1L to run at 100mL/hr.

DAY 2
March 5, 2017

➢ On March 5, 2017 0430H, Dr Que ordered Insulin Glulisine (Apidra) 3 units SQ stat.
➢ At 1029H, the patients CBG is 212mg/dL while on Dexamethasone medication. Dr Toledano considered
Dexamethasone as one of the possible inducer for sudden increase of patient’s CBG and ordered to start Apidra
Sliding Scale: 2 units for CBG ​> 180 mg/dL SQ; 6 units for CBG ​> ​220 mg/dL SQ; 8 units for CBG ​> 260 mg/dL SQ
and refer if CBG is ​>​ 300mg/dL.

➢ At 1135H, Dr Cortez ordered Lactulose (Duphalac) 50 mL as a pre medication for plain abdominal x-ray as needed
NGT now while patient is on NPO.
➢ At 1840H, Dr Toledano ordered to stat Nutriflex 1000Kcal to run 24 hours.

DAY 3
March 6, 2017

➢ On March 6, 2017 0727H, Dr Cortez ordered to resume NGT feeding and to consume the last TPN ordered.
➢ At 0800H, the patient undergo blood transfusion (BT) because of excess bleeding (8.1 g/dL), Medical Oncology
service ordered to transfuse 1 unit Packed RBC for 4 hours duration, keep vein open for IV Fluids and Paracetamol
(Biogesic) 500mg PO as pre medication for blood transfusion to prevent fever >37.8 C.
➢ At 1030H, Medical Oncology service ordered to resume oral medications and to continue patient’s own
medications. Shifted Omeprazole (Omepron) 40 mg IV once daily to Lansoprazole (Prevacid) one tab PO once
daily while NGT and shifted Dexamethasone (Cordex 5) 5mg IV every 8 hours to Dexamethasone (Decilone Forte)
4mg PO every 8 hours while on NGT.
➢ At 2300H as a rescue dose, the patient was given Udcacid 300 mg BID via NGT, Multivitamins 1 cap NGT BID
twice a day and CBG every 6 hours while on NGT feeding.
➢ At 1700H, the Medical Oncology service ordered to give patient’s own medications: Leviteracetam (Keppra) Syrup
5ml via NGT every 12 hours.

Day 4

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An International Affiliate of:
New York-Presbyterian Hospital
Columbia University College of Physicians and Surgeons
Weill Cornell Medical College of Cornell University
CLINICAL PHARMACY TRAINING PROGRAM                                        BATCH 40 (CPTP 01-17) 

March 7, 2017

➢ On March 7, 2017 0040H, Medical Oncology service hold the feeding temporarily and informed the Surgical
Oncology for evaluation of colostomy. The patient experienced abdominal pain. Medical Oncology service ordered
Gaviscon one sachet stat via NGT.
➢ At 0600H, Dr. Dy resumed NGT feeding.
➢ At 0835H, Dr Cortez ordered to prepare 1 red robinson catheter, 1 fleet enema, 1 KY Jelly and clean gloves. The
patient has positive bowel movement.
➢ At 0925H, Fellow under Dr Cortez referred to Dr Ting Lao for pain management.
➢ At 1000H, Dr Ting Lao ordered to continue patient’s own medication: Norgesic Forte 1 tablet every 12 hours via
NGT. She ordered to give rescue dose of Morphine Sulfate plain 10 mg per tablet ½ tablet 5 mg as needed for pain
score 4 over 10 and may be taken as often as every 4 hours via NGT.
➢ At 1600H, patient is asleep and had a (-) Bowel Movement. Dr Bongalon ordered to give fleet enema for
colonostomy once patient is awake.
➢ At 2200H, Colonostomy surgery done. Fleet enema was given.
➢ At 2312H, the family inquired for faster pain relief of abdominal pain of the patient. Pain service resident under Dr
Ting Lao explained regarding the use of PCA.
➢ At 2319H, resident under Dr. Ting Lao ordered PCA Fentanyl. Concentration: 10 mg/mL; Volume: 50mL; Diluent:
PNSS; Basal Rate: 0; Demand Dose: 10 mcg/bolus, Lockout Interval: 15 minutes. Maintain the following patient
medication box: Naloxone 1 ampule, 1 50 mL PNSS solution, 2 10mL syringe. Hold patient’s own medication
Morphine Sulfate Plain 10mg per tab once PCA started. Do not use the following drugs once PCA started:
Tramadol, Nalbuphine, Butorphanol and Meperidine. Hook the patient for pulse oximeter for 24 hours once PCA
started. Referred to Opioid side effect treatment sheet for guidance.

Day 5
March 7, 2017

➢ March 8, 2017 at 0309H, PCA fentanyl was started.

➢ At 0750H, patient is positive for bowel movement after Fleet Enema 90 mL was given. Patient is negative for
melenal hematochezia.
➢ 0915H, Medical Oncology Service observed no recurrent of melenal hematochezia, positive for abdominal pain, no
edema, soft abdomen, no vomiting, no bleeding on colostomy site, no fever and stable vital signs. positive for
bleeding at right angle of the lip.
➢ At 1300H, Dr Dy diagnosed the patient with Colorectal Cancer stage 4 metastasized on lungs, Breast Cancer stage
4 metastasized on brain, Type 2 Diabetes Mellitus, Cushing syndrome steroid induced dysglycemia​.
➢ At 1810H, Dr Ting Lao ordered Solcoseryl Gel and Nystatin to apply at the right angle of the mouth 3 times a day.
ASSESSMENT AND ACCOMPLISHMENTS (CP notes)
03/04/17 Clinical Pharmacy Notes
1648H
Patient Medication History Done, MIAD accomplished. No known allergies.

12
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An International Affiliate of:
New York-Presbyterian Hospital
Columbia University College of Physicians and Surgeons
Weill Cornell Medical College of Cornell University
CLINICAL PHARMACY TRAINING PROGRAM                                        BATCH 40 (CPTP 01-17) 

P Route of Administration
D/A Paracetamol 500 mg 1 tab every 4 hours PRN for temperature ​>​37.8 degree celsius
The patient is on nothing by mouth and the order is paracetamol tablet as needed for
fever.
A Referred to MROD under Dr. Carlos Dy, Suggest the paracetamol IV as dosage form
recommended dose for ​>​50 kg is 650 mg every hours 1000 mg every 6 hours; maximum
of single dose 1000 mg/dose; maximum daily dose 4 g/day.
R The MROD accepted the recommendation. May give Paracetamol (Aeknil) 300 mg IV
every 6 hours. Endorsed to Bedside nurse and Charge nurse.

P Medication Reconciliation
D/A Unreconciled Medication
Salbutamol (Ventolin) MDI 100mcg/inhalation 2 puffs inhalation every 8 hours
Insulin Glargine (Lantus) 30 units SQ every 24 hours
A Referred to MROD Toledano if the unreconciled medications Salbutamol (Ventolin) MDI
100mcg/inhalation 2 puffs inhalation every 8 hours and Insulin Glargine (Lantus) 30 units
SQ every 24 hours are to be given.
R MD Toledano said to discontinue medicines for now. Patient has no difficulty of breathing
and has low CBG.

P Possible Drug Food Interaction

D/A Dexamethasone (Cordex 5) 5 mg IV every 8 hours vs Food
Steroid (Cordex 5) may cause Sodium and water retention.
Avoid sodium rich food.
A Not referred to MROD Toledano. Patient is on NPO and NGT. Endorsed to Bedside nurse
and Charge nurse.

P Dose of Dexamethasone (Cordex 5)

D/A Dexamethasone Sodium Phosphate (Cordex 5) 5 mg IV every 8 hours
4mg/mL of Dexamethasone (Cordex 5) IV is equivalent to 5mg of Dexamethasone with its
Phosphate salt.
A Referred to Dr. Toledano regarding the 4mg/mL dose of Dexamethasone which is
equivalent to 5mg of Dexamethasone with its Phosphate salt

13
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An International Affiliate of:
New York-Presbyterian Hospital
Columbia University College of Physicians and Surgeons
Weill Cornell Medical College of Cornell University
CLINICAL PHARMACY TRAINING PROGRAM                                        BATCH 40 (CPTP 01-17) 

R Dr. Toledano revised the order of Dexamethasone Sodium Phosphate (Cordex 5) from
5mg/mL to 4mg/mL.

P Route of Administration
D/A Decilone Forte 4 mg PO every 8 hours and Levetiracetam (Keppra) Syrup 500mg every
12 hours
The doctor ordered to continue patient’s own medication Decilone Forte 4 mg PO every 8
hours and Levetiracetam (Keppra) 500mg every 12 hours but the patient is on NPO and
non-NGT.
A Referred to MROD Que regarding the patient’s own medication Decilone Forte 4 mg PO
every 8 hours and Levetiracetam (Keppra) 500mg every 12 hours while patient is on NPO
if to be continue . Suggest Dexamethasone IV and Levetiracetam IV as dosage form.
R MD said discontinue Dexamethasone (Decilone forte) and Levetiracetam (Keppra) syrup
while on NPO. May give Dexamethasone (Cordex 5) 5mg IV every 8 hours and
Levetiracetam (Keppra) IV 500mg every 12 hours
1624H Addendum
Advised the patient to Discontinue the Lantus and Ventolin MDI for now and informed not
to take anything care of patient’s medication for now until instructed. Advised that Keppra
and Decilone Forte were shifted to IV.

1704H No other drug issue noted within the shift.

3/4/17 No other drug issue noted within the shift.

2030H

3/5/17 As per verbally endorsed by Bedside nurse, as per telephone order by Dr Cortez give
1140H Lactulose (Duphalac) 50 ml NGT even on NPO.

1300H No drug related problem noted within the shift.

3/5/17 TPN Routine Check

1521H
Nutriflex 1000 Kcal 1250mL x 24h
TCR 1200 Kcal

14
______________________________________________________________________________________
An International Affiliate of:
New York-Presbyterian Hospital
Columbia University College of Physicians and Surgeons
Weill Cornell Medical College of Cornell University
CLINICAL PHARMACY TRAINING PROGRAM                                        BATCH 40 (CPTP 01-17) 

TPR 65g
Infusion rate 52.08mL/h

3/5/17 No other drug related problem noted within the shift.

2030H

3/6/17 P Vague order of Patient own medication

1030H
D/A Calcium carbonate + Vitamin D3 (Caltrate Plus) 2 tablets 3x a day NGT
Ursodeoxycholic acid (Udcacid) 300mg tablets NGT 2x a day
Multivitamin (Propolis and zinc) NGT 3x a day
Essence of Mushroom NGT 3x a day
Vitamin D3 1000 units NGT once daily
Vitamin C 500mg NGT once daily
Vitamin B complex (Meganerv 1000) NGT once daily
Morphine sulfate (plain) 10mg NGT every 4 hours
Norgesic Forte NGT every 12 hours
Levetiracetam (Keppra) Syrup 500mg every 12 hours.
Dexamethasone (Decilone Forte) 4 mg NGT every 8 hours.
Doctor was not able to specify which of the patient’s own medication should be continued.
A Referred to Dr. Salvador which of the patient’s own medication should be continued.
R Dr Salvador ordered to continue all patient’s own medication except Norgesic forte 1 tab
every 12 hours via NGT and Morphine Sulfate plain 10mg per tab ½ tab 5 mg. Patient
instructed and PMAR issued.

P Possible Drug Therapeutic Duplication

D/A Vitamin D3 (with Calcium carbonate) (Caltrate Plus) 2 tablets 3x a day NGT vs Vitamin
D3 1000 units NGT once daily

Multivitamin NGT once daily vs Vitamin B complex (Meganerv 1000) NGT once daily
A Referred to Dr Salvador the drug duplication of Vitamin D3 and Vitamin B.
R MD Salvador acknowledged the referral but opted to continue.

15
______________________________________________________________________________________
An International Affiliate of:
New York-Presbyterian Hospital
Columbia University College of Physicians and Surgeons
Weill Cornell Medical College of Cornell University
CLINICAL PHARMACY TRAINING PROGRAM                                        BATCH 40 (CPTP 01-17) 

1348H No drug related problem noted within the shift.

2030H No drug related problem noted within the shift.

3/7/17 No drug related problem noted within the shift.

1359H
2030H No drug related problem noted within the shift.

3/8/17 P Possible Drug-Drug Interaction

0805H Risk Rating D: Consider Therapy Modification
D/A PCA Fentanyl. Concentration: 10 mg/mL; Volume: 50mL; Diluent: PNSS; Basal Rate: 0;
Demand Dose: 10 mcg/bolus, Lockout Interval: 15 minutes vs Levetiracetam (Keppra)
syrup 500 mg NGT every 12 hours
CNS Depressants (Levetiracetam) may enhance the CNS depressants effect of Opioid
Analgesics (Fentanyl)
If combined limit the dosage to the minimum possible while achieving the desired clinical
effect.
A Referred to Dr. Que. Suggest to lower the dose of Levetiracetam to the minimum possible
while achieving the desired clinical effect. Endorsed to Bedside nurse to monitor for
difficult breathing and sedation.

R Dr. Que acknowledged the referral but opted to continue with the same dose of
Levetiracetam.

3/8/17 P Dosage Form of Solcoseryl Gel

1349H
D/A Solcoseryl gel TID apply to angle of mouth
The available Dosage form for Solcoseryl are jelly and Ointment.
A Referred to MD Salvador that the available Solcoseryl are Jelly for moist wound and
Oinment for dry wound.
R MD Salvador revised the order from Solcoseryl gel to Solcoseryl Jelly TID. Endorsed to
bedside nurse and charge nurse.
2130H No other drug related problem noted within the shift.

16
______________________________________________________________________________________
An International Affiliate of:
New York-Presbyterian Hospital
Columbia University College of Physicians and Surgeons
Weill Cornell Medical College of Cornell University
CLINICAL PHARMACY TRAINING PROGRAM                                        BATCH 40 (CPTP 01-17) 

17
______________________________________________________________________________________
An International Affiliate of:
New York-Presbyterian Hospital
Columbia University College of Physicians and Surgeons
Weill Cornell Medical College of Cornell University