Kwame Nkrumah University of Science and Technology

Faculty of Pharmacy and Pharmaceutical Sciences

Department of Clinical & Social Pharmacy
[Pharmaceutical Care Plan Documentation]

ADVANCED PATIENT PROFILE

Personal Information

DO 70Y 5M 30D MALE

Patient Initials Age Gender
23/11/18
Date Ethnic Origin Height
Weight
Bandoh A
Ward

Presenting complaint: History of Presenting Complaint:

Right sided weakness Patient with no known chronic medical condition

Pain in the right lower limb
woke up complaining of right leg pain. Later in the
day he was working in his provision store when he
developed sudden onset of right sided weakness
about 4 hours before presentation. The right sided
weakness is constant, and has not improved or
retrogressed since it occurred.

Social History:

Lives at Dome
Runs a provision store with his wife
Married for 35 years with 6 children
 Kwame Nkrumah University of Science and Technology
Faculty of Pharmacy and Pharmaceutical Sciences
Department of Clinical & Social Pharmacy
[Pharmaceutical Care Plan Documentation]

Past Medical History: Relevant Signs:

none Temperature: 37.2ºC

Pulse rate: 101bpm
RR: 24cpm
SPO2: 94
BP: 130/90mmHg
RBS: 9.4mmol/l

Coronary Risk Of 6 (0-4)

Medication History
Medication name Comment
and strength Dose/Frequency Reason for use

Gebedol (Paracetamol Not stated For pain

500mg+Diclofenac
50mg)

Paracetamol 500mg Not stated For pain

 Kwame Nkrumah University of Science and Technology
Faculty of Pharmacy and Pharmaceutical Sciences
Department of Clinical & Social Pharmacy
[Pharmaceutical Care Plan Documentation]

Does pt. self-monitor at home?

Blood  Yes Peak  Yes Blood  Yes
Pressure No Flow No Glucose No

INVESTIGATION
Lipid profile

Parameter Results Reference range

Total cholesterol 4.6 mmol/l 3.5-5.2
Triglyceride 1.6 mmol/l 2.3-4.5
HDL 0.79 mmol/l 1.02-3.90
LDL 3.07 mmol/l 3.0-4.1
VLDL 0.73 mmol/l 0.05-0.7
Coronary Risk 6 0-4

Haematology
Parameter Reference Date
Range 24/11/18
WBC 2.5-8.5×103/uL 20.95
RBC 3.50- 4.42
5.50×106/uL
HGB 11.0-18.0g/dL 12.2
HCT 36.0-54.0% 35.3
MCV 80.0-100.0fL 79.9
MCH 27.0-30.0pg 27.6
MCHC 31.0-37.0g/dL 34.6
PLT 150.0- 215
400×103/uL
RDW-SD 37.0-54.0fL 42.7
RDW-CV 11.0-16.0% 14.6
PDW 9.0-17.0fL 12.5
 Kwame Nkrumah University of Science and Technology
Faculty of Pharmacy and Pharmaceutical Sciences
Department of Clinical & Social Pharmacy
[Pharmaceutical Care Plan Documentation]

MPV 9.0-13.0fL 11.7

NEUT 25.0-75.0% 67.0
LYMPH 20.0-60.0% 23.1
MONO 2.0- 9.2
10.0×103/uL
EO 1.0- 0.2
0.6.0×103/uL
BASO 0.0-0.1×103/uL 0.5

Liver function test

Parameter Results Unit Normal range
SGOT (AST) 28 U/L 3 to 40
SGPT (ALT) 33 U/L < 34
Alkaline 129 U/L 0-258
phosphatase
GGT 45 U/L 8-61
Total Bilirubin 11.8 umol/l 3-21
Conjugated 5.0 umol/l 0.0-5.2
Bilirubin
Unconjugated 6.8 umol/l 0.0-17.6
Bilirubin
Total Protein 77 g/l 64-85
Albumin 38 g/l 35-52
Globulin 39 g/l 25-45
Troponin 1
Parameter Results Reference
Troponin 1 0.012 ng /ml Up to 0.034 pmol/l

Pro BNP
Parameter Results Reference
NT-pro BNP 16.2 pmol/l 0-27.1 pmol/l

ESR
Parameter Results Reference
ESR 98 mm fall/hr 1-7mm
 Kwame Nkrumah University of Science and Technology
Faculty of Pharmacy and Pharmaceutical Sciences
Department of Clinical & Social Pharmacy
[Pharmaceutical Care Plan Documentation]

Current Medications (on ward)

Medication Comment
name and Dose/Frequency Start End Reason for use /
strength Date Date change
Aspirin Tab 75mg 75mg once daily 23/11/18 Ongoing Prevention of stroke

Atorvastatin Tab 40mg once daily 23/11/18 Ongoing Prevention of

20mg cardiovascular
diseases
Ceftriaxone IV 1g 2g once daily for 2 24/11/18 25/11/18 Treatment of cellulitis
days
Clindamycin Tab 300mg 4 times daily 24/11/18 29/11/18 Treatment of cellulitis
300mg for 5 days
Paracetamol Tab 1g 3 times daily for 24/11/18 27/11/18 Pain management
500mg 3 days

Medical Problems/ Diagnosis

Ischemic stroke
Cellulitis in the right lower limb

Pharmaceutical Care Issues

Inadequate prophylactic therapy for stroke
Inappropriate choice of antibiotic for the treatment of cellulitis
 Kwame Nkrumah University of Science and Technology
Faculty of Pharmacy and Pharmaceutical Sciences
Department of Clinical & Social Pharmacy
[Pharmaceutical Care Plan Documentation]

PHARMACEUTICAL CARE PLAN (SOAPO)

Pharmaceutical Care Issue/Problem 1 Ischemic Stroke
SUBJECTIVE DATA: weakness in right side of body

OBJECTIVE DATA: Face deviated to the left, patient has expressive aphasia, also not
obeying commands, no eye movement, reflexes present in both upper limbs but reduced in
right lower limb

ASSESSMENT
Confirmation of Diagnosis
Ischemic stroke is characterised by the sudden loss of blood circulation to an area of the brain
resulting in a corresponding loss of neurologic function. They are caused by either a local
thrombus formation or by embolic phenomenon, resulting in occlusion of a cerebral artery.
On clinical presentation of stroke, the patient may not be able to reliably report the history
owing to cognitive or language deficits (Dirnagl et al, 2006). A reliable history may have to
come from a family member or another witness. The patient may complain of weakness on
one side of the body, inability to speak, loss of vision, vertigo, or falling. Aphasia is seen
commonly in patients with anterior circulation strokes. This sign was seen in patient D.O. CT
scan of the head will be normal or hypo intensive (dark) in infarction. A dark area was seen
on patient’s CT scan. The signs and symptoms therefore confirm the diagnosis.

Appropriateness of Therapy
The initial approach to the patient with an acute stroke is to ensure that the patient is supported
from a respiratory and cardiac standpoint and to clearly determine whether the lesion is
ischemic or haemorrhagic based on a CT scan. Ischemic stroke patients presenting within
hours of the onset of their symptoms should be evaluated for reperfusion therapy.

Aspirin
Aspirin is an antiplatelet which exerts its effect by irreversibly inhibiting cyclo-oxygenase,
which, in platelets, prevents conversion of arachidonic acid to thromboxane A2 (TXA2), which
is a powerful vasoconstrictor and stimulator of platelet aggregation. Aspirin also inhibits
prostacyclin (PGI2) activity in the smooth muscle of vascular walls. The optimal dose of
aspirin is still under study, but it should be a dose that inhibits TXA2 with the least amount of
PGI2 inhibition. It has been shown that an aspirin dose of 325mg/day will inhibit TXA2, but
will not significantly inhibit PGI2 production. There is probably a point at which lower doses
of aspirin do not completely block TXA, however recent studies indicate that the lowest
effective may be in the range of 50mg/day. (FDA Talk paper, 2001)
All patients who have had an ischemic stroke should receive long term antiplatelet therapy for
secondary prevention (Sacco et al ,2006)
Aspirin given to this patient was appropriate as well the dose.
 Kwame Nkrumah University of Science and Technology
Faculty of Pharmacy and Pharmaceutical Sciences
Department of Clinical & Social Pharmacy
[Pharmaceutical Care Plan Documentation]

Atorvastatin
This is an HMG-CoA reductase inhibitor; inhibits the rate limiting step in cholesterol
biosynthesis by completely inhibiting HMG-CoA reductase. Statins have been shown to
reduce the risk of stroke by approximately 30% in patients with coronary artery disease and
elevated plasma lipids. (Herbert et al, 2008). The National Cholesterol Education Program
(NCEP) considers ischemic stroke or Transient Ischemic Attack (TIA) to be a coronary
‘equivalent’ and has recommended the use of statins to achieve a low-density lipoprotein
(LDL) concentration of less than 100 mg/dl. (NCEP guidelines, 2001). Statin therapy is an
effective way to reduce stroke risk and should be considered in all ischemic stroke patients.
Atorvastatin 40mg was given to this patient and this is appropriate. His lipid profile showed
that he has a high coronary risk, thus making it important to start statin therapy.

Pharmaceutical Care Issue

Inadequate prophylaxis against stroke.

Recommendation
Dipyridamole should be added to Aspirin for dual effect.

PLAN
Patient is currently on Aspirin 75mg daily, Dipyridamole 200mg twice daily and Atorvastatin
40mg daily

Goals of therapy
 To limit the area of brain damage
 To protect patients from the dangers of unconsciousness and immobility
 To prevent aspiration
 To treat the underlying cause if possible
 To identify and manage modifiable risk factors (hypertension, high cholesterol,
diabetes mellitus)
 To support and rehabilitate patients who survive with residual disability
 To minimise adverse effects of drug therapy

Monitoring
Aspirin
 Kwame Nkrumah University of Science and Technology
Faculty of Pharmacy and Pharmaceutical Sciences
Department of Clinical & Social Pharmacy
[Pharmaceutical Care Plan Documentation]

Efficacy: normalised INR

Toxicity: dyspepsia, haemorrhage, headache, hearing impairment
Dipyridamole
Efficacy: prevention of atherothrombotic events, normalised INR
Toxicity: gastrointestinal effects, dizziness, myalgia, throbbing headache, hypotension, hot
flushes, tachycardia.

Atorvastatin
Efficacy: decrease in LDL
Toxicity: epistaxis, hyperglycaemia, hypersensitivity, joint disorders, laryngeal pain

Counselling
 You have been diagnosed with stroke. During a stroke, blood stops flowing to part of
your brain and this can damage areas in the brain that control other parts of the body.
 Take your medications exactly as directed.
 Reduce fat and cholesterol intake
 Increase your intake of fresh vegetables and fruits
 Begin an exercise program such as walking or gardening
 Limit alcohol intake.
 Keep your medical appointments because follow ups are important
 You may be at risk of falling. Make changes to your home to help you walk more easily
 Atorvastatin tablets should be taken at night.
 Avoid foods rich in vitamin K such as green leafy vegetables when taking aspirin.

OUTCOME
The patient’s condition has improved and was discharged home on oral medications to
continue treatment.
 Kwame Nkrumah University of Science and Technology
Faculty of Pharmacy and Pharmaceutical Sciences
Department of Clinical & Social Pharmacy
[Pharmaceutical Care Plan Documentation]

PHARMACEUTICAL CARE PLAN (SOAPO)

Pharmaceutical Care Issue/Problem 2 Cellulitis of the right lower limb
SUBJECTIVE DATA: Ankle swollen, pain in the right lower limb

OBJECTIVE DATA: Right leg swollen (36cm) more than left (32cm), high WBC count of
20.95x103/ul and elevated ESR of 98 mmfall/hr

ASSESSMENT
Confirmation of diagnosis
Cellulitis is a deep dermal and subcutaneous infection that occurs when pathogens gain entry
into the dermis through breaks in the skin. The most common infective organisms in adults
include Streptococci pyogenes and Staphylococcus aureus. The leg is the most common site
and there may be an identifiable portal of entry. Cellulitis is nearly always unilateral (Dupuy,
2007). Bilateral leg cellulitis is rare.
It presents as the acute and progressive onset of a red, painful, hot, swollen and tender area of
skin. The edge of the erythema may be well demarcated or more diffuse and typically spread
rapidly. Fever and malaise occurs in most cases. Blistering, superficial haemorrhage into
blisters, dermal necrosis, lymphangitis and lymphadenopathy may occur. (CREST guidelines,
2005). In this patient, there was swelling of the right leg, pain, rubor as well as increase in
WBC and ESR values.

Appropriateness of therapy
Most of cases of cellulitis are caused by beta-haemolytic streptococci or S. aureus. Empiric
antimicrobial therapy should therefore provide adequate cover for these micro-organisms.

Ceftriaxone 2g
Ceftriaxone is a third-generation cephalosporin with broad-spectrum, gram-negative activity;
it has lower efficacy against gram-positive organisms. Bactericidal activity results from
inhibiting cell wall synthesis by binding to one or more penicillin-binding proteins. It exerts
its antimicrobial effect by interfering with synthesis of peptidoglycan, a major structural
component of the bacterial cell wall. However, since cellulitis is mostly caused by Streptococci
and S. aureus which are gram positive organisms, it would be appropriate to give an antibiotic
which has a high efficacy against gram positive organisms. Thus, the antibiotic of choice is
inappropriate.

Clindamycin 300mg
 Kwame Nkrumah University of Science and Technology
Faculty of Pharmacy and Pharmaceutical Sciences
Department of Clinical & Social Pharmacy
[Pharmaceutical Care Plan Documentation]

Clindamycin is a lincosamide used for the treatment of serous skin and soft tissue
staphylococcal infections, including some community-acquired methicillin-resistant
Staphylococcus aureus (CA-MRSA) infections. Clindamycin suppresses toxin production by
group A streptococci, C. prefringens and Staphylococcus aureus
It is also effective against aerobic and anaerobic streptococci. It inhibits bacterial growth
possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent
protein synthesis to arrest.
Patient D.O received a dose of 300mg 4 times daily for 5 days amd this was appropriate.

Paracetamol tab 500mg

Paracetamol is a synthetic non-opioid analgesic and antipyretic [OICPC Therapeutic
Highlights, 2000]. It has no demonstrable anti-inflammatory activity; it is less irritable to the
stomach. Over dosage of paracetamol is dangerous as it may cause hepatic damage which is
sometimes not apparent for 4 to 6 days. The dose for tab Paracetamol is 1g every 4-6 hours. A
dose of 1g 3times daily was given and this was appropriate.

Pharmaceutical Care Issue

Inappropriate choice of antibiotic for the treatment of cellulitis.

Recommendation
Co-Amoksiklav 1g twice daily should be given since it has better activity against Streptococci.

PLAN
Patient is currently on Co-Amoksiklav 1g twice daily for 7 days, Clindamycin 300mg 4 times
daily for 5 days and Paracetamol 1g 3 times daily for 3 days.

Goals of therapy
 To relieve pain
 To control and eradicate the infection
 To treat predisposing conditions
 To prevent complications like ulceration and osteomyelitis

Monitoring
Ceftriaxone
Efficacy: decrease in temperature, decrease in pain
 Kwame Nkrumah University of Science and Technology
Faculty of Pharmacy and Pharmaceutical Sciences
Department of Clinical & Social Pharmacy
[Pharmaceutical Care Plan Documentation]

Toxicity: anaemia, coagulation disorder, granulocytopenia

Clindamycin
Efficacy: decrease in temperature, decrease in pain
Toxicity: abdominal pain, diarrhoea, antibiotic colitis, skin reactions

Paracetamol
Efficacy: decrease in temperature
Toxicity: flushing, skin reactions, tachycardia

Co-Amoksiklav
Efficacy: treatment of infection, relief of symptoms such as pain, swelling
Toxicity: nausea, vomiting, Stevens-Johnson syndrome, exfoliative dermatitis.

Counselling
 You have been diagnosed with cellulitis. It is an infection in the deepest layer of the
skin which is caused by bacteria
 Complete the full course of your antibiotic medication even when you feel well. It
treats the infection and stops it from returning. Not taking all the medicine can make
future infections hard to treat.
 Keep the infected area clean
 Talk to your healthcare provider if you are still in pain
 Wash your hands often to prevent spreading the infection.
 Take Clindamycin with food.

OUTCOME
The patient’s condition has improved and was discharged home on oral medications to
continue treatment.
 Kwame Nkrumah University of Science and Technology
Faculty of Pharmacy and Pharmaceutical Sciences
Department of Clinical & Social Pharmacy
[Pharmaceutical Care Plan Documentation]

References

 British National Formulary (2018), BMJ Group, Royal Pharmaceutical Society of

Great Britain. Pages 121, 439, 520, 526,
 CREST guidelines for wound management in Northern Ireland. October 2005.
 Dirnagl U, Iadecola C, Moskowitz M.A.(2006) Pathobiology of ischemic stroke: An
integrated view. Trends Neurosci 22:391-397.
 Dupuy A, Benchikhi H, Roujeau JC, et al. (2007). Risk factors for erysipelas of the leg
(cellulitis): case control study. BMJ 318 (7198): 1591-1594.
 Food and Drug Administration. FDA Approves New Prescribed Uses of Aspirin. FDA
talk paper (2001). T98-76, www.fda.gov/bbs/topics/ANSWERS/ANS00919.html.
 Herbert PR, Gaziano JM, Chan KS, Hennekens CH. Cholesterol lowering with statin
drugs, risk of stroke and total mortality (2008). An overview of randomised trials,
278:313-321.
 Sacco RL, Adams R, Albers G, et al. (2006) Guidelines for prevention of stroke in
patients with ischemic stroke or transient ischemic attack. A statement for health care
professionals from the American Heart Association/ American Stroke Association
Council on Stroke, 37:577-617
Kwame Nkrumah University of Science and Technology
Faculty of Pharmacy and Pharmaceutical Sciences
Department of Clinical & Social Pharmacy
[Pharmaceutical Care Plan Documentation]