This Study Resource Was: Activity #1: The Patient'S Medical Chart Micaella Anne T. Manuela Bs Pharmacy4 Questions

Activity #1: THE PATIENT’S MEDICAL CHART
MICAELLA ANNE T. MANUELA

BS PHARMACY4
QUESTIONS:
1. Define or describe a medical chart.
2. Give the purposes or uses of a medical chart.
3. How do doctors communicate with one another when treating the same patient of different
ailments in order to avoid interactions or untoward effects of drugs?
4. Why should pharmacist be familiar with patient’s medical chart?
5. Why are not all forms present in a patient’s medical chart?
ANSWERS:
1. A medical chart is a complete record of a patient’s key clinical data and medical history, such
as demographics, vital signs, diagnoses, medications, treatment plans, progress notes,
problems, immunization dates, allergies, radiology images, and laboratory and test results.
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A medical chart is comprised of medical notes made by a physician, nurse, lab technician or
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any other member of a patient’s healthcare team. Accurate and complete medical charts
ensure systematic documentation of a patient’s medical history, diagnosis, treatment and
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care.
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A medical chart includes:
 Surgical history (e.g., operation dates, operation reports, operation narratives)
 Obstetric history: (e.g., pregnancies, any complications, pregnancy outcomes)
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 Medications and medical allergies

 Family History (e.g., cause of death, common family diseases)
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 Social History (e.g., community support, close relationships, past and current
occupation)
 Habits (e.g., smoking, alcohol consumption, exercise, diet, sexual history)
 Immunization Records (e.g., vaccinations, immunoglobulin test)
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 Developmental History (e.g., growth chart, motor development, cognitive/intellectual

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development, social-emotional development, language development)

 Demographics (e.g., race, age, religion, occupation, contact information)
 Medical encounters (e.g., hospital admissions, specialist consultations, routine
checkups)
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2. The purpose of a medical chart is to serve as both a medical and legal record of an
individual's clinical status, care, history, and caregiver involvement. The specific information
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contained in the chart is intended to provide a record of a person's clinical condition by
detailing diagnoses, treatments, tests and responses to treatment, as well as any other
factors that may affect the person's health or clinical state.
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3. Medical chart is a vital instrument for all providers involved in a patient’s care and for any
subsequent new provider who assumes responsibility for the patient. In disciplinary or peer
review matters, medical charts can justify (or refute) the need for a particular treatment. In
reimbursement and utilization disputes, medical records can document what services were
rendered and whether they were medically necessary. Medical charts are the single most
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important evidence for the provider whenever a malpractice claim, or other inquiry, arises
concerning patient care.
4. Information is key to reducing medicine errors, improving medicines adherence and
delivering safe and more effective care to patients. Access to the patient health record will
allow pharmacists to make more informed clinical decisions, in partnership with patients,
about the pharmaceutical care that patients receive. This will improve medicines adherence,
supporting improvement in the treatment of individual patients.
5. The medical record excludes health records that are not official business records such as
personal health records managed by the patient.
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Activity #2: LABORATORY AND DIAGNOSTIC TESTS
BS PHARMACY4
QUESTIONS:
1. Give the importance of laboratory and diagnostic tests.
2. What are the different specimens used for laboratory tests?
3. What factors affect the values and interpretations of laboratory tests?
4. Discuss the role of a clinical pharmacist in interpreting and analyzing laboratory and
diagnostic tests.
ANSWERS:
1. Clinical laboratory testing plays an essential part in the delivery of quality health care. A
physician or other clinician orders lab tests to diagnose, treat, manage, or monitor a patient’s
condition. The process begins with the collection of a sample of blood, tissue, or other
biological matter from the patient, which is then sent to the laboratory where it is uniquely
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identified and examined to make certain that it is appropriate for the testing ordered by the
health care provider.
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2. Serum, Plasma, Urine are some of the specimens used.
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3. The following factors can affect the results obtained from samples and should be taken into
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consideration when interpreting results.
 Collection-to-Test Time
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 Temperature
 Sample collection time
 Appropriate sample
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 Appropriate collection container

 Patient’s age
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 Biological Rhythms
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 Pregnancy
 Menstrual Cycle
4. Pharmacists usually monitor laboratory tests to:
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 Ensure that the drug and the dose ordered is appropriate for each patient
 Monitoring for adverse effects to ensure patient safety.
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 Assess the need for additional or alternative drug therapy

 Monitoring patients’ response to therapy
 Prevent misinterpretation resulted from drug interference
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Activity #3: DRUG MONITORING THERAPY
BS PHARMACY4
CASE STUDY #1
Mrs. C is a 62-yo woman with a history of hypertension, atrial fibrillation and type 2 diabetes.
She is a non-smoker and obese. Her current medication comprises flecainide 100 mg twice a
day, aspirin 75 mg daily, simvastatin 40 mg and diltiazem 180 mg daily. Mrs. C is suffering from
a respiratory tract infection and her GP has prescribed a 5-day course of clarithromycin.
MONITORING PARAMETERS:
 Flecainide 100mg, BID
Creatinine, electrolytes incl. Mg at baseline; ECG; serum drug levels
 Asprin 75mg, OD
Creatine at baseline, salicylate testing, LTA, measure of 11-dehydrothromboxane B2 in urine.
 Simvastatin 40mg, OD
Cr at baseline; LFTs at baseline, then as clinically indicated; CK at baseline if myopathy risk, then as
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clinically indicated
 Diltiazem 180mh, OD
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BUN/Cr; LFTs; BP, HR; ECG
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There is potential for interaction between simvastatin and diltiazem and between simvastatin and
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clarithromycin. Some statins, particularly simvastatin and atorvastatin, are metabolized by
cytochrome P450 (CYP3A4) and co-administration of potent inhibitors of this enzyme may
particularly increase plasma levels of these statins and so increase the risk of dose-related side
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effects, including rhabdomyolysis. Current advice is that diltiazem and simvastatin may be given
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together provided the simvastatin dose does not exceed 40 mg daily, so it is reasonable for this
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therapy to be continued.
However, clarithromycin should not be given together with simvastatin. Clarithromycin is a potent
inhibitor of CYP3A4 and diltiazem is a less potent inhibitor.
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Myopathy and rhabdomyolysis have been reported in patients taking the combination. Mrs C
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should be advised not to take her simvastatin while she is taking clarithromycin and to start taking
it again after she has completed the course of antibiotic.
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CASE STUDY #3
A 76-yo woman with depression and Parkinson’s disease was admitted to hospital drowsy,
confused and feverish (temperature 40ºC). There was no evidence of infection. The serum
creatinine kinase level was markedly increased, suggesting muscular disorder. The patient’s
regular medication was co-beneldopa, naproxen, meclobemide and lactulose. Until the day
before admission she had been taking clomipramine 50 mg daily, but this had been changed to
meclobemide 300 mg daily.
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CASE STUDY #3
A 62-yo man takes warfarin 6 mg daily for recurrent deep vein thrombosis. During a routine
check at the anticoagulant clinic he is found to have an INR of 10. He also takes lisinopril 10 mg
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daily for hypertension and occasional co-codamol for pain. His dentist prescribed miconazole
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oral gel (125 mg to be applied to the lesions four times a day) for a suspected fungal infection 6
days ago.
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CASE STUDY #4
An 80-yo woman presented to an outpatient clinic with a history of severe giddiness and a few
episodes of blackouts. She was being treated for angina and hypertension. She had been on
bendrofluazide 2.5 mg once daily and slow-release isosorbide dinitrate 60 mg once daily for a
few years. Her general practitioner had recently commenced nifedipine SR 20 mg twice daily for
poorly controlled hypertension. On examination her BP was 120/70 while supine and 90/60 on
standing up.
CASE STUDY #5
Mrs. F. M., a 70-yo woman with chronic asthma and mild heart failure, has been receiving:
Bendrofluazide, 10 mg each morning
Prednisolone 5 mg daily
Salbutamol inhaler 2 puffs four times daily
Beclomethasone inhaler 2 puffs four times daily
Magnesium trisilicate 10 mL when required
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The patient is breathless at night and kept awake with a painful knee. Her general practitioner
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has prescribed naproxen 250 mg three times daily.
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CASE STUDY #6
Mrs. A. B., a 69-yo woman, has been receiving digoxin 0.25 mg and frusemide 80 mg daily for
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her heart failure for the past 6 months according to your patient records. She now presents the
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following prescription to your pharmacy:

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Enalapril, 10 mg twice daily

Frusemide 80 mg in the morning
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Potassium chloride (slow release) 2 three times daily

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Activity #3: DRUG MONITORING THERAPY
BS PHARMACY4
QUESTIONS:
1. What is meant by drug therapy monitoring? How is this done?

2. State the purposes and goals of monitoring patient drug therapy.
3. List the steps involved in drug therapy monitoring.
4. What drugs are commonly monitored?
ANSWERS:
1.
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Activity #1: THE PATIENT’S MEDICAL CHART

MICAELLA ANNE T. MANUELA

 Medications and medical allergies

 Developmental History (e.g., growth chart, motor development, cognitive/intellectual

development, social-emotional development, language development)

 Appropriate collection container

 Assess the need for additional or alternative drug therapy

following prescription to your pharmacy:

Enalapril, 10 mg twice daily

Potassium chloride (slow release) 2 three times daily

1. What is meant by drug therapy monitoring? How is this done?

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