Patient Care Plan D’Youville College School of Pharmacy Pharmaceutical Care Plan and SOAP Note Student Name Date Date of History Angela Kumar 10/16/18 10/16/18 85090116205000 COLLECT Subjective Patient Initials

Patient Care Plan D’Youville College School of Pharmacy
Pharmaceutical Care Plan and SOAP Note
Student Name Date Date of History
Angela Kumar 10/16/18 10/16/18
85090116205000
COLLECT
Subjective
Patient Initials: BP
Age:
57 Gender:
Male Race:
White Data Source(s):
patient
CC (or reason for visit, if none): Elevated blood pressure
HPI for CC ; other pertinent problems (include symptom analysis when relevant): BP came in stating that he was to undergo an endoscopy but was cancelled due to his elevated blood pressure. The patient stated that on presentation to colonoscopy, his blood pressure was 246/140 and was treated with nitropaste. He was then referred to his primary care physician who referred him to the ED. He states that last week at a checkup, his blood pressure was normal (126/88). Patient claims that he was initially okay and has not felt any symptoms of being hypertensive until today where he conveyed a dull pressure in his chest that radiates to the left arm.

Medical History (illnesses and surgeries, check ‘past’, ‘active’, or both):

Past Active Past Active ? ?Hypertension ? ?? ?Hypercholesterolemia ? ?? ?? ?? ?? ?? ?? ?? ?? ?? ?? ?? ?? ?Drug Allergies/Sensitivities (circumstances and type of reaction): zinc (patient states he just felt the zinc go through his body)
Vaccinations Date administered Vaccinations Date administered
? Influenza n/a ? _________________ ? Pneumococcal n/a ? _________________ ? Shingles n/a ? _________________ Barriers to Adherence/Medication Use Behaviors:
? Medication preferences/beliefs/attitudes? Limited access to health care facilities/pharmacy
? Health literacy/knowledge (patient or caregiver)? Lack of family/social support
? Lack of accessibility (eg, cost, insurance)? Unstable living conditions, homelessness
? Burdensome regimen? Other: ______________________________? Cognitive impairment
Comments: n/a
Meds Admin by:
Medication List
Source of medication list: ? patient ? medical record ? pharmacy (please list): ___________________
List of Active/Current Home Medications
Start Date Drug Name/Strength/Regimen (RX and OTC) Indication Date last taken
Past two years Simvastatin 20 mg po qdHigh cholesterol 10/16/18
10/15/18 Amlodipine 10 mg p po qdHTN 10/16/18
10/15/18 Aspirin 81 mg po qdantiplatelet 10/16/18
List of Active/Current Supplements (e.g., vitamins, herbals) or other Complementary Treatments
Start Date Product Name/Strength/Regimen Indication Date last taken
If patient has been admitted to the hospital, please list new inpatient medications below:
Start Date Drug Name/Strength/Regimen (RX and OTC) Indication Date last taken
10/16/18 15:35 Labetalol 20 mg IVP over 2 minutes HTN- appropriate due to rapid onset of action (five minutes or less) 10/16/18
10/16/18 19:46 Clonidine 0.1 mg once HTN- appropriate dude to indication in resistant hypertension 10/16/18
Home medications recently d/c’d, held or dose changed (due to hospitalization, toxicity, etc)
Medication Date d/c’d or held(if applicable) Reason for d/c or hold Dose changed to: (if applicable) Reason for dose change
Family Medical History
Father: n/a Mother: Siblings
Children: Other:
Social History:
Residence: At home Family/Social Environment: married, lives with spouse
Smoking: never smoked Alcohol: Social drinker (does not drink more than 3 drinks/day) Illicit drugs: denies
Diet: n/a Physical Activities: n/a
Education: n/a Occupation: n/a
Review of Systems
Constitutional: Negative for chills/ fever
Cardiovascular: Positive for chest pain
Respiratory: Negative for cough, SOB
Abdomen/GI: Negative for abdominal pain, N/V
GU: Negative for urinary symptoms
Objective
Objective Parameter Value
Vital Signs
Date: 10/16/18 14:58 15:32 16:05 17:58 19:00
T: 98.2 98.2 – – – –
HR: 77 74 72 77 79 97
RR: 20 18 18 19 18 17
BP:198/106 180/128 158/101 168/121 174/94 141/58
Physical Examination Date: 10/16/18
Weight: 98.88 kg
Pertinent findings on physical exam (+/-):
General: Appears in no apparent distress. Behavior is appropriate for age, cooperative, pleasantHEENT: atraumatic normal cephalic, intact eye movements, oral mucosa is moist (no deficits)Respiratory: No signs of distress, breath sounds clearCardiovascular: Positive for chest pain. Quality is heaviness, located in anterior and radiates to left arm.Gastrointestinal: Bowel sounds active, palpation- soft, non-tender in all quadrantsGenitourinary: CVA tenderness absent Musculoskeletal/extremities: extremities all grossly normal, ROM normalSkin: pink, warm temperature, dryNeurologic: orientation is normal, moves all fours
Pain Assessment
(if applicable) Date: 10/16/18
Pain Scale: 1 2 3 4 5 6 7 8 9 10
Pain Assessment: Complains of heaviness in chest anteriorly that radiates to left arm with breathing or movement (pain is dull)
Pertinent Laboratory Values
(if available)
Lab Value Normal Range 10/16/18 Calculated CrCl88-128 mL/min 112 mL/min WBC 4.0-11.0 3.6 (low) Glucose 74-100 132 (high) Platelets 145-450 138 (low) Creatinine 0.6-1.2 0.88 Calcium 8.6-10.3 8.6 Chloride 98-107 108 Potassium 3.6-5.1 3.3 Sodium 136-145 141 CO2 21-31 27 Mag 1.7-2.5 2.3 Hgb 14.0-18.0 15.7 Hct40-54 44.7 Platelets 138 145-450 WBC 3.6 4.0-11.0 Other Pertinent Diagnostic Tests ; Results
Date Diagnostic Summary of Results
10/16 A1C 5.2 (Within normal limits)
10/16 Chest X-ray No active infiltrates are seen
10/16 Troponins 0.01 (0.00-0.04)- No evidence of myocardial necrosis
Medication Review
Medication Appropriateness Effectiveness Safety Adherence Is there a drug-related problem that requires further assessment and intervention? *(any yes in row)
Is this medication inappropriate for the condition for which it is being given†? Is there a therapeutic duplication which may be inappropriate? Is a more effective medication available that could be used for this condition? Is this dose inappropriate to achieve the goals of treatment? Is the patient experiencing any adverse effect from this medication? Is the dose of this medication high enough to be toxic to the patient? Is there a physiologic contraindication for this medication? Is the patient unable to take this medication as intended? Is the patient unwilling to take this medication as intended? Is there a barrier, cost or otherwise, to acquiring this medication? Is a formulary alternative a more cost effective choice? Amlodipine 10 mg ? Yes
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Simvastatin 20 mg ? Yes
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Aspirin 81 mg ? Yes
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Is there an untreated indication for which a medication may be appropriate? ? Yes ? No ? Yes
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† select “yes” if medication has no known/accepted indication * if “yes” is selected, include problem in the prioritized “Assessment, Plan and Follow-Up Evaluation” grid in the next section
546100444500lefttop00ASSESSMENT, PLAN ; FOLLOW-UP
Assessment, Plan and Follow-Up Evaluation (Prioritized List)
DRP: Uncontrolled Hypertension (Hypertensive Emergency)
Type of DRP: Appropriateness, safety
473710011557000Description/Supporting Evidence of DRP
Patient BP is a 57-year-old white male who presents to the ED with an elevated blood pressure. He came in stating that upon presentation to a colonoscopy, his blood pressure was 246/140 and was treated with nitropaste. He was then referred to his primary care physician who referred him to the ED. He states that last week at a checkup, his blood pressure was normal (126/88) and today, has not felt any symptoms of being hypertensive. Complaints of anterior chest pain radiating to the left arm emerged while in the ED. BP was only chronically on simvastatin for his high cholesterol (past two years) and was started on amlodipine and aspirin by his PMD yesterday (10/15/18). In treating acute changes in blood pressure, it is important to differentiate between hypertensive emergency ; urgency. Because this patient’s SBP >180 mmhg & DBP > 120 mmHG and exhibits signs of end organ dysfunction (chest pain), he is classified as hypertensive emergency.
Therapeutic goals
First hour: Reduce MAP by 25% (while maintaining goal DBP ? 100 mmgHg)
Hours 2-6: SBP 160 mgg Hg and/or DBP 100-110 mmHg
Hours 6-24 (maintain goal for hours 2-6 during the first 24 hours)
Prevent CVD disease
Improve symptoms of chest pain
Plan
Non-Pharmacologic
Promote weight loss with a goal of at least 1 kg reduction in body weight to reduce blood pressure by 1mm hg.

Implement DASH diet (diet rich in fruits, vegetables, whole grains and low fat dairy products with reduced content of saturated and transfats.
Decrease dietary sodium and potassium intake
Increase aerobic activity (90-150 min/week)
Reduce alcohol consumption
right3852300
Pharmacologic
Upon initial presentation to the ED, was given a dose of labetalol 20 mg via IV push followed by PO clonidine 0.1 mg at which his blood pressure was still elevated. BP was then admitted to the hospital for hypertensive emergency. Medications that can be used to initially treat emergency include vasodilators (hydralazine, nitroglycerin, sodium nitroprusside), Calcium channel blockers (clevidipine, nicardipine), (Enalaprilat), alpha antagonists (phentolamine), and D1 receptors (fenoldopam). Per the guidelines, preferable agent for treatment is sodium nitroprusside which is a potent arterial and venous vasodilator with favorable PK parameters. It is a nitric oxide donor that leads to smooth muscle relaxation and reduces afterload and preload, giving it wide applicability for various hypertensive emergencies. However, adverse effect profile (Increased ICP, cyanide accumulation) and cost prevent regular use of this agent. Beta blockers (such as labetalol) are potent in reducing blood pressure and have a rapid onset of action (5 minutes). Labetalol is preferred over the other beta blockers due to its alpha and beta antagonistic properties (esmolol and metoprolol are only beta selective). Due to this fact, labetalol has direct vasodilatory effects on top of blood pressure control via ionotropic and chronotropic effects. Clonidine is an alternative agent used in hypertensive emergency, indicated for use in lowering blood pressure over a short period of time. It is not to be used for long term therapy. Because patient has no contraindications and is currently on a calcium channel blocker (Amlodipine 10 mg qd), he should continue CCB and start on another blood pressure lowering agent for long- term management. Thiazide-like diuretics are preferred due to effectiveness in preventing all types of CV morbidities and mortality. Lower dose thiazide-like diuretics (typical of modern antihypertensive treatment regimens) also have more evidence from RCTs demonstrating reductions in CV events and mortality, when compared with lower dose thiazide diuretics. Chlorthalidone 12.5 mg qd is a good choice in this drug class because it is shown to have a prolonged half-life and reduction of risk for CVD. Dose can be titrated based on patient response to 50 mg daily and up to 100 mg/day. Along with being more potent, chlorthalidone is also useful due to longer duration of action and effectiveness in lowering the relative risk of cardiovascular events by 12 percent and heart failure by 21 percent.
Follow Up: Monitor and evaluate
Chlorthalidone
Monitor for hyponatremia, hypokalemia, uric acid, calcium levels
Blood pressure
Home BP is the average of all BP readings performed with a semiautomatic, validated BP monitor, for at least 3 days and preferably for 6–7 consecutive days before each clinic visit, with readings in the morning and the evening, taken in a quiet room after 5 min of rest, with the patient seated with their back and arm supported. Two measurements should be taken at each measurement session, performed 1–2 min apart
Assessment of Therapeutic Management Options and Rationale for Recommendation
Patient is an adequate candidate for treatment with Chlorthalidone because he does not meet any of the contraindications (history of gout, renal disease or sulfonamide allergy). Should treatment not be efficient, and patient’s hypertension is resistant, the addition of an ACE inhibitor should be considered. The preferred three-drug regimen consists of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), a long-acting calcium channel blocker such as amlodipine, and a long-acting thiazide-like diuretic, preferably chlorthalidone.

Chest Pain
Type of DRP: Appropriateness, safety
Description/Supporting Evidence of DRP
Patient BP presents to the ED with a dull, aching chest pain anteriorly that radiates to the left arm and left chest arm. His blood pressure on admittance was 198/106. Aside from chest pain, patient exhibits no other symptoms such as SOB, nausea, diaphoresis, weakness, palpitations, neck/jaw pain. Vitals/ O2 saturation and electrolytes are within normal limits. Chest x-ray also shows no active infiltrates ; is also insignificant. Per algorithm, a 12-lead EKG should be obtained and troponins should be assessed. In the case of BP, troponins and EKG show insignificant findings, therefore ACS can be ruled out.

Therapeutic goals
Treat underlying cause (hypertension)
Reduce ASCVD risk
Improve blood pressure/ QOL
Plan
Because the etiology of this patient’s chest pain is non-cardiac in origin, and is underlying to his hypertension, treating the cause (hypertension) should be appropriate to relieve BP’s chest pain. Based on presentation, his current 10-year ASCVD score is 22.6%, with a lifetime risk of 69%. He can reduce this risk with HTN management, lifestyle changes (exercise/ reduction in alcohol intake) and with adherence to his medication regimen.

References
2018 ESC/ESH Guidelines for the Management of Arterial Hypertension. Eur Heart J 2018; Aug 25
Journal of the American College of Cardiology Volume 68, Issue 10, September 2016DOI: 10.1016/j.jacc.2016.03.513
Buch V, Ralph H, Salas J, Hauptman PJ, Davis D, Scherrer JF. Chest Pain, Atherosclerotic Cardiovascular Disease Risk, and Cardiology Referral in Primary Care. J Prim Care Community Health. 2018;9:2150132718773259.

-22860030035500
IMPLEMENT
Execute care plan in collaboration with other health care professionals and the patient or caregiver
? Counseling/patient education Home BP is the average of all BP readings performed with a semiautomatic, validated BP monitor, for at least 3 days and preferably for 6–7 consecutive days before each clinic visit, with readings in the morning and the evening, taken in a quiet room after 5 min of rest, with the patient seated with their back and arm supported. Two measurements should be taken at each measurement session, performed 1–2 min apart
Patient should be aware that goal BP should be around 130-135/ 85-89 mmHg

? Device teaching/demonstration ? Medication reconciliation Aspirin 81 mg
Aspirin 81 mg qd was prescribed to patient to patient one day prior to admission. Patient’s 10-year ASCVD risk should be re-evaluated following new hypertensive regimen and aspirin should only be continued of patient presents a moderate-high risk of a CVD event.

For low-risk patients (ie, men and women whose 10-year absolute risk of a first CHD event is <10 percent), the absolute benefit of a reduction in cardiovascular events is unlikely to exceed the absolute risk of major bleeding.

For moderate- and high-risk patients (ie, men and women whose 10-year absolute risk of a first CHD event is ?10 percent), randomized data on benefits and risks are sparse. As a result, clinical decision making should be done on an individual basis for those individuals in whom the benefits of aspirin to prevent a first MI are likely to exceed the risk of major bleeding.

Atorvastatin
If patient is experiencing any unexplained muscle pain, tenderness or weakness (particularly if accompanied by malaise or fever) a doctor should be consulted.

Large quantities of grapefruit juice should not be consumed
This patient should make lifestyle changes and increase exercise regimen to aid in hypertension. However, he should be cautioned not to engage in Unaccustomed vigorous exercise due to the increase the risk for muscle injury.
? Contact prescriber about medication regimen changes If patient notices that blood pressure isn’t controlled on current regimen, contact MD immediately to add/adjust medication regimen.

? Adjust medication regimen If patient’s BP is not controlled on regimen, doses should be titrated to max possible dose followed by addition of third antihypertensive agent. If patient’s blood pressure is not controlled on three primary agents, then patient’s HTN is resistant and further evaluation should be completed. Patient should contact MD to change regimen and should not attempt to change/ modify it on his own.