CASE ANALYSIS:

Student/Pharmacist:

Patient’s name: P.M.

Date of admission: 12/09/2022 Date of discharge: ongoing case
Age: 64 years old
Sex: Male
Height: 181cm
Weight: 74kg
Srcl = 0.78
Crcl= 100 ml/min
BMI= 22.6 kg/m^2
CC (Chief Complaint):
Left big toe inflammation and necrotic tissue with fever and chills post-surgery
(ingrown toe nail removal)

HPI (History of Present Illness):

64 years-old male patients presented with left big toe inflammation with the presence
of necrotic tissue and pus.

History goes back to one week ago when the patient had an ingrown nail surgery at
another hospital. Post-surgery, the
Patient started having increasing pain in the site of surgery. The pain was accompanied
by inflammation and low-grade fever.

The wound site started to appear necrotic and oozing foul smelling pus prompting the
family (his wife) to bring him to the hospital.
Patient denies any dyspnea, abdominal or chest pain but he had chronic cough upon
admission.

PMH & PMT (Past Medical History & Past Medical Treatment):

The patient is diagnosed from 12 years ago with type II diabetes mellitus in which he
takes Janumet (50/1000) PO BID (50 mg sitagliptin +1000 mg of metformin).

PSH (Past Surgical History):

Toenail removal

FH (Family History):
N/A

SH (Social History):
He is a smoker he smokes 2 packs per day => 40 packs/year
Immunization:
Took 3 shots of COVID-19 vaccine. Took the third shot 3 months ago.

Allergies:
No known drug allergy (NKDA)

PE (Physical Examination)

VS:

Vital signs: On
admission
T (oC) 38.8C
BP 129/81
mmHg
RR 20
beats/min
Pulse 100 bpm

GA (General Appearance):
Conscious, cooperative, alert, well-oriented, pain-free. Ambulated with help and can
move all his limbs.
Not in distress

ROS (Review of Systems):

Heart: normal sinus rhythm. No peripheral edema, no murmurs.
Lungs: no dyspnea or cough, GBAE ( Good bilateral air entry), clear
GI: bowel movement is positive, soft abdomen (non-distended, nontender). On regular diet, well
tolerated. No nausea
GU ( Genitourinary): voiding freely, no complaints
HEENT: Normal, no LAD ( left anterior descending artery )
Neurological: cranial nerves intact, no sensory or motor deficit, motor power intact.

Laboratory values

Hematology:
 Normal
values
CBC automated:
WBC 6.19 4-9.7
RBC 5.68 4.4-5.7
Hb 15.7 12.9-
16.6
Hct 46.8 39-50
MCV 82.5 81-95
MCH 27.6 26.5-
31.5
MCHC 33.4 31.4-
34.7
RDW 12.4 12-15
WBC differential:
Polymorphs 41-67
Bands
Lymphocytes 16-44
Monocytes 2.6-7.9
Eosinophils 0-1.4
Basophils
Blasts 0.2-2
Other:
Nucleated RBC
Platelet count

Bacteriology: N/A

13/09/2022
Date

Specimen
Pending results

Microscope
finding

Culture finding

Chemistry:
 Estimated Normal values
GFR
Glucose,
fasting
Uric acid 29 18-43 mg/dL
BUN
Creatinine 0.78 0.7-1.3 mg/dL
Bilirubin T.
Bilirubin D.
Protein total
Albumin
Globulin
Cholesterol
HDL-C
LDL-C
TG
Chol/HDL
Na+ 139 135 - 145 mmol/L
K+ 4.6 3.5 - 5 mmol/L
Cl- 102 98 - 107 mmol/L
CO2 23 22 - 30 mmol/L
Mg++
Ca++
Phosphorous
ALP
SGOT (AST)
SGPT (ALT)
GGT
LDH
CPK
CK-MB
Amylase
CRP 1.3 HIGH 0-0.7
Troponin T

Drug serum concentrations: N/A

Digoxin
Theophylline
Gentamycin
Tobramycin
Vancomycin
 Phenytoin

Blood bank:
N/A

Parasitology: N/A

Urinalysis:
Color
pH
SG
LE
Nitrite
Proteins
Glucose
Ketones
Bilirubin
Urobilinogen
Hb qual.
Others:
WBC
RBC
Epithelial cells
Casts
Crystals
Other

Other parameters: N/A

INR
aPTT control
aPTT patient
PT control
PT patient

ABG (Arterial Blood Gases):

pH
pCO2
pO2
HCO3
TCO2
 O2 saturation 97%
Base excess

Serology:
N/A

Other:
PCR Swab test: COVID-19 negative
Chest X-ray: clear
X-Ray for left ankle: no significant findings for bone involvement, no fractures

Impression/Diagnosis:
Left big toe cellulitis with the presence of necrotic tissue and pus.
Needs debridement and antibiotics.

Problem list plus medication list:

Problems Medications
1. Toe cellulitis Zermacin ( Vencomycin) 1000 mg IV
q8hr
Meropenem 1g IV every 8h
2. Type II DM Janumet 50/1000 PO BID
3. SUP Omeperazol 20mg one tablet orally daily
4. Pain Management Perfalgan 1g IV once daily
5. Hydration NaCl 0.9% 1000mL Q 24hr

6. Nicotine dependence None

 SOAP 1: Toe Cellulitis

S: Subjective
O: Objective
A: Assessment
P: Plan

Collect subjective and objective signs and symptoms

Subjective: fever, left big toe inflammation, necrotic tissue and pus from wound

Objective: fever 38.8C, high CRP reading. Normal Blood pressure, conscious,
cooperative, alert, well-oriented, pain-free. .
He was started empirically on admission on Vancomycin and Meropnem waiting for a
debridement.

A: Assessment of the medical problem

1. Brief Pathophysiology and Definition of the Disease
Skin and soft tissue infections (SSTIs) are clinical entities of variable presentation,
etiology and severity that involve microbial invasion of the layers of the skin and
underlying soft tissues. result from microbial invasion of the skin and its supporting
structures. Management is determined by the severity and location of the infection and by
patient comorbidities.
Cellulitis is a common bacterial skin infection that causes redness, swelling, warm to
touch, and pain in the infected area of the skin. Cellulitis usually affects the skin on the
lower legs, but it can occur in the face, arms and other areas. It could be purulent or non-
purulent.
If untreated, it can spread and cause serious health problems. Good wound care and
hygiene are important for preventing cellulitis.
Pathophysiology:
Cellulitis usually follows a breach in the skin, such as a fissure, cut, laceration, insect
bite, or puncture wound. In some cases, there is no obvious portal of entry and the breach
may be due to microscopic changes in the skin or invasive qualities of certain bacteria.
Organisms on the skin and its appendages gain entrance to the dermis and multiply to
cause cellulitis. Facial cellulitis of odontogenic origin may also occur. Patients with toe-
web intertrigo and/or tinea pedis —as well as those with lymphatic obstruction, venous
insufficiency, pressure ulcers, and obesity—are particularly vulnerable to recurrent
episodes of cellulitis.
The vast majority of cases of cellulitis are likely caused by Streptococcus pyogenes and,
to a lesser degree, by Staphylococcus aureus.

2. Clinical presentation
 Erythema and edema
 Pain at site and possibly in surrounding area
 Swelling
 Warmth
 Purulent/non-purulent
  Severe infection: Malaise, chills, fever, and toxicity. Pain disproportionate to
examination findings

3. Diagnosis
 Blood cultures
 CBC with differential
 Levels of creatinine, bicarbonate, creatine phosphokinase, and C-reactive protein
(CRP)
 If necrotizing fasciitis is a concern, CT imaging is typically used in stable
patients; MRI can be performed, but MRI typically takes much longer than CT
scanning
 Strong clinical suspicion of necrotizing fasciitis should prompt surgical
consultation without delay for imaging
 Skin biopsy is not routine but may be performed in an attempt to rule out a
noninfectious entity
The IDSA recommends considering inpatient admission in patients with hypotension
and/or the following laboratory findings
 Elevated creatinine level
 Elevated creatine phosphokinase level (2-3 times the upper limit of normal)
 CRP level >13 mg/L (123.8 mmol/L)
 Low serum bicarbonate level
 Marked left shift on the CBC with differential

4. Risk factors
 Injury. Any cut, fracture, burn or scrape gives bacteria an entry point.
 Weakened immune system. Conditions that weaken your immune system —
such as diabetes, leukemia and HIV/AIDS — leave you more susceptible to
infections. Certain medications also can weaken your immune system.
 Skin conditions. Conditions such as eczema, athlete's foot and shingles can cause
breaks in the skin, which give bacteria an entry point.
 Chronic swelling of your arms or legs (lymphedema). This condition
sometimes follows surgery.
 History of cellulitis. Having had cellulitis before makes you prone to develop it
again.
 Having a condition, such as diabetes that cause poor blood flow
 Obesity. Being overweight or obese increases your risk of developing cellulitis.

5. Staging
- Mild infection: for purulent SSTI, incision and drainage is indicated.
- Moderate infection: patients with purulent infection with systemic signs of
infection.
- Severe infection: patients who have failed incision and drainage plus oral
antibiotics or those with systemic signs of infection such as temperature >38°C,
tachycardia (heart rate >90 beats per minute), tachypnea (respiratory rate >24
breaths per minute) or abnormal white blood cell count.
Infections are classified as:
- Non-purulent infections
- Purulent infections; drainable abscess
- Purulent infections; non-drainable abscess
The patient here has a moderate infection with drainable abscess.

6. Complications
Recurrent episodes of cellulitis may damage the lymphatic drainage system and cause
chronic swelling of the affected limb.
Rarely, the infection can spread to the deep layer of tissue called the fascial lining.
Necrotizing fasciitis is an example of a deep-layer infection. It's an extreme emergency.

A: Assessment of Medication therapy problem

1. Guidelines
According to the “Practice Guidelines for the Diagnosis and Management of Skin and
Soft Tissue Infections” IDSA (2014): incision and drainage are a must in the treatment
of cellulitis.
The algorithm on next page outlines the IDSA approach to initial empiric antibiotic
therapy and abscess management of patients with skin abscesses or skin infections with
purulent drainage. It includes various appropriate antibiotic options depending on the
patient presentation. The choice among them further depends on factors such as patient,
expected toxicities, drug interactions, cost, side effects, co-morbidities, and convenience
of administration.
Time for performing incision and drainage depends on whether the administration of
antibiotic will be delayed or not.
We will follow this algorithm in order to determine whether the treatment regimen of the
patient was chosen correctly.
Patients with purulent infection should be managed with empiric therapy for infection
due to MRSA, pending culture results. Empiric therapy for infection due to beta-
hemolytic streptococci is usually not necessary. Empiric therapy selection should be
tailored to culture and susceptibility results when available and cultures were taken and
results were not out at the time I took the information for the case.
 2. Indication and effectiveness
The patient presented with cellulitis of the left toe and purulent drainage. If we follow the
algorithm, it is noted that the patient has signs of systemic infection (fever) and a
surrounding cellulitis. Thus, empirical antibiotic therapy is initiated without any delay.

 How to determine if antibiotics are given PO or IV?

 Patients with mild infection may be treated with oral antibiotics. Treatment with
parenteral antibiotics is warranted in the following circumstances:
- Systemic signs of toxicity (eg, fever >100.5°F/38°C, hypotension, or sustained
tachycardia)
- Rapid progression of erythema
- Progression of clinical findings after 48 hours of oral antibiotic therapy
- Inability to tolerate oral therapy
- Proximity of the lesion to an indwelling medical device (eg, prosthetic joint or vascular
graft).
Based on the patient presentation: fever 38.8°C, more than 38 as specified in the
guidelines so he will be treated with IV antibiotics.

 How to choose empirical antibiotics to use?

Look at algorithm and conclude that the patient is presenting with prominent skin
necrosis and thereby treatment to be initiated is:
One of the following: vancomycin or daptomycin PLUS one of the following:
- Ampicillin-sulbactam
- Piperacillin-tazobactam
- Ticarcilin-clavulanate
- Ceftriaxone PLUS metronidazole
- Ciprofloxacin PLUS metronidazole
- Levofloxacin PLUS metronidazole
The patient was given empirically:
 Vancolon 1000mg (vancomycin); IV every 8 hr
 Meronem 1g (meropenem); IV 1000mg every 8h
The choice of vancomycin was done correctly. The physician went for meropenem
instead of the options listed above. This is not a wrong antibiotic to be added to
vancomycin since it provides the coverage of microorganisms necessary: broad-spectrum
carbapenem antibiotic with excellent activity against many pathogens associated with
complicated skin and soft tissue infections. Covers many Gram-positive and Gram-
negative pathogens, including many potentially resistant strains such as Pseudomonas
aeruginosa, as well as anaerobic organisms. The change of this antibiotic to match the
exact options mentioned in the guidelines could be further discussed with the physician.

Vancomycin dose: for severely ill patients, a loading dose (20 to 35 mg/kg) is
appropriate; the loading dose is based on actual body weight, rounded to the nearest 250
mg increment and not exceeding 3000 mg. Within this range, we use a higher dose for
critically ill patients. The initial maintenance dose and interval are determined by
nomogram (typically 15 to 20 mg/kg every 8 to 12 hours for most patients with normal
renal function). Subsequent dose and interval adjustments are based on AUC-guided or
trough-guided serum concentration monitoring. Thereby dose is correct.
.
( correct the vancomycin trough levels )
The criteria to check when do we shuld check the peakor the trough levels of
vancomycin

How often should I check => do the calculation

Then, IV regimen can be switched to PO tailored to culture and susceptibility data once
signs of infection are resolving. However, we didn’t reach this point yet in the treatment
of the patient, he is still taking IV antibiotics.

3. Duration of treatment
The duration of therapy should be individualized depending on clinical response. In
general, five days of therapy is appropriate for patients with uncomplicated cellulitis
whose infection has improved within this time period.
Extension of antibiotic therapy (up to 14 days) may be warranted in the setting of severe
infection, slow response to therapy, or immunosuppression.
Thereby, treat patient for up to 14 days

4. Monitoring for safety and efficacy, side effects and DDIs

Drug Monitoring Efficacy/ Side effects (Most Drug-drug
Safety common and most interactions, drug
serious) food interaction,
drug lab
interaction:
Zermacin (vancomycin) E: Resolution of signs and Anaphylaxis None
symptoms Clostridioides (formerly
S: Periodic renal function Clostridium) difficile
tests (BUN, CrCl, GFR,
electrolytes), CBC, serial
infection
auditory function testing Drug-induced immune
may be helpful to minimize thrombocytopenia
risk of ototoxicity, serum Hypersensitivity reactions
trough vancomycin (delayed)
concentrations (Draw at
least one steady-state
Infusion-related reaction
trough concentration; Nephrotoxicity
repeat as clinically Neutropenia/pancytopenia
appropriate) Ototoxicity
AUC monitoring once
weekly
Signs and symptoms
of allergy or
anaphylaxis (red man
syndrome)
Meronem E: Resolution of signs and CNS effects Probenecid: May increase
 (meropenem) symptoms
S: Perform culture and
sensitivity testing prior to
initiating therapy. Monitor
for signs of anaphylaxis
during first dose. During
prolonged therapy, monitor
renal function, liver
function, CBC. During
outpatient use, monitor for
neuromotor impairment
and mental alertness.
Clostridioides (formerly the serum concentration
Clostridium) difficile of Meropenem. Risk X:
Avoid combination
infection
Hypersensitivity reactions Sodium Picosulfate:
(immediate and delayed) Antibiotics may
diminish the
therapeutic effect of
Sodium Picosulfate.
Carbapenems may
decrease the serum
concentration of
Valproate Products

5. Assess for adherence and compliance

Since the patient is still at the hospital, there is no concern about medication compliance
because nurses are responsible of taking care that medications are taken properly.
However, when the patient will be discharged, his wife needs to make sure that their her
husband is taking the medications properly and for the appropriate duration prescribed.

P: Plan the care plan

1. Recommended therapy plan

According to the guidelines, the patient’s treatment regimen is appropriate and should be
continued:
- Vancolon 1000mg (vancomycin); IV every 8 hr
- Meronem 1g (meropenem); IV 1000mg every 8h

2. Non-pharmacological treatment
Try these steps to help ease any pain and swelling:
 Place a cool, damp cloth on the affected area as often as needed for your comfort.
 Ask your doctor to suggest an over-the-counter pain medication to treat pain.
 Elevate the affected part of your body.
 Ask your doctor whether it might help to wear compression wraps or stockings.

3. Prevention:
If your cellulitis recurs, your doctor may recommend preventive antibiotics. To help
prevent cellulitis and other infections, take these precautions when you have a skin
wound:
 Wash your wound daily with soap and water. Do this gently as part of your
normal bathing.
 Apply a protective cream or ointment. For most surface wounds, an over-the-
counter ointment (Vaseline, Polysporin, others) provides adequate protection.
 Cover your wound with a bandage. Change bandages at least daily.
  Watch for signs of infection. Redness, pain and drainage all signal possible
infection and the need for medical evaluation.
 Protect your hands and feet. Wear appropriate footwear and gloves.
 Inspect your feet daily. Regularly check your feet for signs of injury so you can
catch infections early.
 Moisturize your skin regularly. Lubricating your skin helps prevent cracking and
peeling. Do not apply moisturizer to open sores.
 Trim your fingernails and toenails carefully. Take care not to injure the
surrounding skin.

SOAP: Diabetes

S: Subjective
No specific presentation upon admission
O: Objective
Patient was on Janumet 50/1000 PO BID
A: Assessment
Assess and stage the disease:

Type II Diabetes Mellitus is an impairment in the way the body regulates and uses glucose. High blood
sugar levels can lead to many health problems such as circulatory, nervous and immune system disorders.
The reason behind type 2 diabetes either from that the pancreas is not producing enough insulin which is a
hormone responsible for the uptake of sugar into the cells, or the cells in the body respond poorly to insulin
and cannot store large amount of glucose.

Signs and symptoms of type 2 diabetes often progress slowly. Some patients live a long period of time
without knowing that they have diabetes type II. But when signs and symptoms are present, they may
include: fatigue, frequent infection, numbness r tingling in the hands or feet, slow-healing sores, unintended
weight loss, frequent urination, increased thirst, blurred vision, and areas of darkened skin usually in the
armpits and neck.

Risk factors that might elevate the risk of having type 2 diabetes. Weight, being overweight or obese is a
main risk, fat distribution by having fat accumulating around the abdomen rather than the hips and thighs.
Physical activity helps control weight gain by using glucose as a source of energy and makes cells more
sensitive to insulin, so being inactive increases the risk. Family history of your parent or sibling increases
the risk of type 2 diabetes. Blood lipid levels due to low level of HDL and high levels of triglyceride can
increase the risk. Age, increase the risk after the age of 45 years old.

Besides the complications that might arise due to type II diabetes is the damage of major organs, including
heart, blood vessels, nerves, eyes and kidneys. Managing diabetes and controlling your blood sugar can
lower the risk of these complications or coexisting comorbidities. It might cause, heart and blood vessel
disease increasing the risk of heart disease, stroke, high blood pressure and plaque formation. Nerve
damage in limbs, high levels of glucose in the blood might affect the nerves over time causing tingling,
numbness, burning, pain that usually starts at the top of the toes or fingers Kidney disease, leading to
chronic kidney disease or irreversible end-stage kidney disease, which may require dialysis or a kidney
transplant. Eye damage such as cataracts and glaucoma, and may damage blood vessels of the retina,
potentially leading to blindness. Finally, type II diabetes can lead to Diabetic ketoacidosis (due to the
buildup of ketones in the blood stream) hearing impairment, sleep apnea, and dementia.
Based on the patient he was already diagnosed with diabetes type II and was prescribed on home medication to control his blood
glucose levels.

According to ADA diabetes mellitus type II guideline 2022, during hospital admission oral anti- diabetic agents are stopped and
the patient is switched to insulin since it is easier to monitor the blood glucose level. However, upon discharge the patient will be
switched back to the medication he used to take at home (HBA1C = 5.7%). Based on the stated guidelines, metformin is
considered the first line treatment for diabetes if there was no contraindication and we need to check tolerability. However, the
patient’s ASCVD risk assessment is missing which is needed in order to make the best treatment plan. If the patient has an
established ASCVD, including heart failure, kidney disease a dual combination can be given metformin+SGLT2 inhibitor/ DDP4
inhibitor or GLP1 RA.

The patient is taking a combination of sitagliptin and metformin HCL (a combination of metformin+ DDP4) which is acceptable.

If the patient has no ASVD risk then the patient must use metformin + SGLT2 inhibitor since the decrease
the incidence of cardiovascular events or GLP1 RA only.

Administration:
The patient must be switched into insulin such as Lantus 20u ( glargine) need to cover him during when he
eats in the morning.
Compliance and adherence assessment:
During the patient admission in the hospital there is no need for patient’s compliance and adherence for the
medication since the health care system would take care of that.
However, when the patient will be discharged, his family should make sure that the patient is taking the
medication in the appropriate time and strength.

Duration of therapy
Diabetes is a lifelong condition and therefore requires the patient to take the medication throughout his life
and never skip any dose. Throughout the treatment process changes to the medication regimen could be
adjusted.

Non-pharmacological treatment:

 Eating healthy food, such as food that are low in fat and calories and higher in fiber.

 Getting active such as walking for 30-45 minutes if possible by the patients

 Losing weight is highly important in reducing the risk of diabetes

 All patients should have ongoing access to diabetes self-management education and
support.

Plan:
Continue Janumet 50/1000 PO BID after discharge
Start Lantus in the hospital stay.

Monitor for safety and effectiveness:

Sitagliptin: monitor hepatic and renal function and monitor blood glucose for effectiveness

Metformin: Renal function, lactic acidosis and for the effectiveness monitor blood glucose.

Cost effectiveness :

Implement:

Continue metformin + sitagliptin ( if no ASCVD risk)

Initiate metformin+ Liraglutide ( if ASCVD risk is established)
Call the physician to make sure that the patient’s medication upon discharged is appropriate.
Document the intervention on patient chart
Follow up:

Arrange a follow up plan after 1 months.

SOAP 3: Ulcer prophylaxis

Goals of therapy:
- Decrease risk of Stress ulcer while on therapy
- Decrease risk of GI bleed
- Decrease risk of GI perforation

Complications:
- Ulcers (with signs and symptoms of nausea, heartburn, indigestion….)
- Internal bleeding
- Gastric cancer
- Blockage

Indications of SUP According to the Critical Care ACCP 2020 guidelines:

 Mechanical Ventilation for >48hrs
 PLT<50 or INR>1.5 or PTT> 2 times normal value
 INR>1.5
 Trauma or spinal cord injury
 Major trauma
 Thermal injury affecting more than 20% total body surface area
 Shock
 Medications (Dual/triple antithrombotic therapy) (not DVT prophylaxis)
 Acute or chronic intermitted or continuous Renal-replacement therapy
 Extracorporeal life support
 Acute kidney injury
 Acute hepatic failure
 Severe sepsis
 Hypotension
 Premorbid condition requiring a PPI (GERD, PUD)
 History of GI bleed or gastric ulcer within the past year
 Postoperative transplantation
 Ulcerogenic medications (nonsteroidal anti-inflammatory drugs, aspirin,
corticosteroids)

Having a minimum of 2 from:

 Sepsis
 Hepatic failure
 Renal failure
 Heparin
 Warfarin
 Enteral feeding
 Glucocorticoids with high doses
 ICU stay>1week
 Major surgery
 The patient here is receiving omeprazole 20mg PO every morning.

According to the risk factors, the patient is not eligible for stress ulcer prophylaxis since
the patient has none of the risk factors listed.
Discontinue Omeprazole

Drug Monitoring Efficacy/ Side effects (Most common Drug-drug

Safety and most serious) interactions, drug
food interaction,
drug lab interaction:
Omeprazole E: No GI discomfort – No Headache, Nausea, vomiting, None here
ulcer formation and no Flatulence, Diarrhea
bleeding. Resolution of
GERD/PUD. Long term side effects:
S: Susceptibility testing hypomagnesemia, osteoporosis,
recommended in patients pneumonia, CKD, Vitamin B12
who fail H. deficiency, C. difficile diarrhea
pylori eradication regimen.
Monitor for rebleeding in
patients with peptic ulcer
bleed. For patients expected
to be on prolonged therapy
or who take PPIs with
medications such as digoxin
or drugs that may cause
hypomagnesemia (eg,
diuretics), consider
monitoring magnesium
levels prior to initiation of
treatment and periodically
thereafter.

4. Implement the care

 Document the intervention on patient chart
 Call physician to make sure he/she is update to date on the patient’s case.
 Call physician to make sure he/she de-escalate antibiotics once results of the culture
are out
 Ask the patient to take care of himself and his hygiene
 Counsel patient and his parents of medication use and side effects upon discharge
 Highlight the importance of washing hands and cleaning wound properly
 Counsel the parents on the importance of compliance with medications and reporting
if the symptoms do not subside or return.
 Educate on the non-pharmacological precautions that could be implemented.

5. Follow up with the patient

- Instruct the patient to come back to his physician if he experiences any discomfort
(recurrence…)
- Advise the patient about hygiene.
- Advise the patient to quit smoking gradually

SOAP 4: Pain Management:

Pain is an uncomfortable feeling that tells you something may be wrong. It can be
steady, throbbing, stabbing, aching, pinching, or described in many other ways.
Pain diagnosis:
Pain is measured by doctor's on a numeric scale of 'no pain' to the 'worst ever pain'.
Staging of pain:

Goal of therapy:
Decrease the pain and discomfort as much as possible and eliminate the pain when able.

The patient describes that is his pain is around 4-5 which is moderate to severe pain.
The patient was given:
Perfalgan 1g once daily
So the patients score is 5 than she qualifies for mild painkiller to reduce the pain

Side effects -constipation

-nausea
-vomiting
-dry mouth
- headache
-anxiety
-sweating

Efficacy Monitor pain relief

DDI’s No DDI’s
Monitoring parameters (safety) Respiratory rate
Oxygen saturation
Blood pressure
Heart rate

Non-pharmacological treatment:
Comfort therapy may involve the following:
 Companionship
 Exercise
 Heat/cold application
 Lotions/massage therapy
 Meditation
 Music, art, or drama therapy
 Pastoral counseling
 Positioning

Implement the care plan:

- Document any intervention if needed and follow-up with the patient.
Follow-up with the patient:
Asses the pain of the patient if he is responding with the medication and cable to
tolerate the pain.

SOAP 5: Nicotine dependence:

Collect:

Subjective: A patient presented to the hospital with a social history of smoking 2

packs/day, meaning 40 packs/year

Assess:
Definition: Tobacco use can be characterized as a chronic relapsing substance use
disorder that is sustained by addiction to nicotine

Smoking cessation is very important since it can be the underlying cause of progressing a
lot of chronic diseases such as CAD, HF, and hypertension especially in patients above
the age of 45 years old.

Diagnosis and staging:

The American Psychiatric Association (APA) published the most recent edition of
the “Diagnostic and Statistical Manual of Mental Disorders” (DSM5) in 2013
1. The individual may take the substance in larger amounts or over a longer period
than was originally intended.
2. The individual may express a persistent desire to cut down or regulate substance use
and may report multiple unsuccessful efforts to decrease or discontinue use.
3. The individual may spend a great deal of time obtaining the substance, using the
substance, or recovering from its effects.
4. Craving is manifested by an intense desire or urge for the drug that may occur at any
time but is more likely when in an environment where the substance was previously
obtained or used.
5. Recurrent substance use may result in a failure to fulfill major role obligations at
work, school, or home.
6. The individual may continue substance use despite having persistent or recurrent
social or interpersonal problems caused or exacerbated by the effects of the substance.
7. Important social, occupational, or recreational activities may be given up or reduced
because of substance use.
8. The individual continues to use the substance in situations that could be physically
hazardous.
9. The individual fails to abstain from use despite the knowledge of a physical or
psychological problem likely caused or exacerbated by use of the substance.
10. The individual develops tolerance to the substance, which results in the individual
seeking more of the substance to produce the desired effect.
11. The individual experiences withdrawal, which is the physical condition that occurs
when blood or tissue concentrations of the substance decline in an individual who had
maintained prolonged heavy use of the substance.

This patient meets at least 5 criteria which classifies him as having moderate to severe
nicotine dependence.

Goals of therapy:
Smoking cessation
Prevention of chronic diseases in the future.

Pharmacological treatment:
According to the 2014 American association for respiratory care clinician’s guide
to treating tobacco dependence:
Recommended therapy: Nicorette gum 4 mg
Indication: nicotine replacement therapy (NRT). It is used to relieve and/or prevent
withdrawal symptoms and reduce the cravings you get when you try to stop smoking,
or when cutting down the number of cigarettes you smoke. The 2 mg gums are used
for smokers of less than 25 cigarettes per day.
This patient smokes around 40 cigarettes which qualifies him for Nicorette 4 mg.

Dosing:
Weeks 1 to 6: Chew 1 piece of gum every 1 to 2 hours (maximum: 24 pieces/day); to
increase chances of quitting, chew at least 9 pieces/day during the first 6 weeks.
Weeks 7 to 9: Chew 1 piece of gum every 2 to 4 hours (maximum: 24 pieces/day).
Weeks 10 to 12: Chew 1 piece of gum every 4 to 8 hours (maximum: 24 pieces/day).

Administration:
Chew slowly until it tingles, then place gum between cheek and gum until tingle is gone;
repeat process until most of tingle is gone (~30 minutes). Avoid coffee, soda, and other
acidic drinks for 15 minutes before and during use.

Side effects:
Nicotine withdrawal: irritability or aggression, anxiety, restlessness, increased
appetite or weight gain.
Common: headache, throat irritation, nausea

Monitoring for efficacy: number of cigarettes per day

Monitoring for safety:  severe headache, dizziness, mental confusion, disturbed hearing
and vision, abdominal pain; HR.

Cost effectiveness: nicorette fresh mint 4mg costs 257,000LBP for 30 pieces of gum.
This is comparable to the price of one nicotine patch for example. Moreover,
varenicline is very expensive.

Non-pharmacological interventions:
1. Self-monitoring to identify triggers for smoking. Smokers are asked to keep a
real-time record of the times, places, and situations in which smoking occurs
2. Avoiding triggers (e.g., putting away ashtrays, abstaining from alcohol),
altering trigger situations (e.g., taking work breaks in a place in which you
cannot smoke), using substitutes in place of smoking (e.g., gum, candy, a stress
ball, exercise), and refocusing thoughts when cravings arise (e.g., statements of
self-determination such as “I can do this”; delay statements such as “wait a
minute or 2 and the urge will pass”).
3. Instruction and training (e.g., deep breathing, yoga, mindfulness training) for
handling stress and negative emotions that are often linked to smoking urges
4. Support groups to share effective behavior change experiences and challenges

Plan:
Using the 5A’s: Ask, Assess, Advise, Assist, Arrange follow-up
Implement:
Counsel the patient on the importance of smoking cessation using the 5A’s technique
Counsel the patient on incorporating non-pharmacological therapy to assist him with
smoking cessation
Schedule follow-up within the first month of smoking cessation

Follow-up:
Because a smoker’s risk of relapse is highest in the first few days and weeks after making
a quit attempt, a follow-up contact to monitor a patient’s tobacco cessation treatment
should occur within 2 to 4 weeks of the initial visit. Actions that should occur in follow-
up contacts include assessing smoking status, asking about adherence and response to
treatments, providing support and encouragement to remain or become smoke-free

SOAP 5: Hydration

According to the Holliday Segar equation and since the patient is more than 20kg in
weight,
1500ml + 20 mL/kg/day which means that the patient, weighing 74kg, would require
2980 mL/day.
The patient is currently receiving NaCl 0.9% 1000ml for hydration IV, 2000 ml, every
24h (rate 91mL/hr) and since the patient can tolerate oral intake, then this amount is an
adequate amount for hydration for this patient.
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