Drug History Recording Form – Patient Name: AB

Patient Name: AB Gender: Male Age: 80 years

Current Prescribed Medicines

(inc. inhalers/drops/creams and ointments)

Drug/route	Dose + Frequency	Date started Save Time On Research and Writing Hire a Pro to Write You a 100% Plagiarism-Free Paper. Get My Paper	Indications	Any problems experienced
Citalopram	20 mg OD	28/7/15	Management of depressive episodes	NA
Lansoprazole	15 mg OD	28/7/15	Management of stomach and intestinal ulcer	NA
Finasteride	5 mg OD	28/7/15	Management of an enlarged prostrate	NA
HYLO Tear	1 drop q.d.s, p.r.n	28/7/15	Management of dry eye symptoms	NA
Ramipril capsule	10mg OD	28/7/15	Management of hypertension	NA
Sodium valproate Gastro-resistant tablet	500mg; the dosage starts at lowest effective dose and should be gradually increased until a control is achieved	28/7/15	Management of epilepsy	Hyperammonaemia
Atorvastatin	20mg nocte	28/7/15	Cholesterol lowering drug	NA
Cobalamine	50 mg OD	28/7/15	Management of low blood levels of the vitamin B12	NA
Linagliptine/Metformin	2.5mg/850mg 1 b.d	24/10/16	Management of type 2 diabetes mellitus	NA
Aspirin DBP	75mg	24/10/16	Control of diastolic blood pressure	NA

None

Drug	Dose + frequency	Indications	Any problems experienced
None

Complementary medicines

(inc. herbal products/homeopathy/Chinese herbs, etc.)

Product	Dose + frequency	Indications	Any problems experienced
None

Allergies/Problems

Is the patient allergic to any medicine?

Comments- NKDA (No known drug allergies)

Social history
i) Units of alcohol a week= Occasionally consumes a glass of wine whiskey
ii) Cigarettes smoked a day = None

iii) Recreational drug use = None

Compliance Assessment

Provide an overview of whether you think the patient takes their medicine as prescribed. Identify any unintentional (e.g. forgot to take, unable to use/open product) or intentional

What concerns about medicines does patient have? What is the perceived benefit of taking medicines or non-adherence?

Comments

The patient last visited the doctor a month ago. The medicines are usually delivered by the pharmacy. The patient feels lethargic and tired most of the time. Symptoms of oversleeping are observed. He takes all medicines, prescribed by the specialist, carefully. The patient often engages in games such as, basketball, tennis and football. This can be attributed to the depressive episodes that he faces. He went for a review a couple of months ago. Diabetic assessments are carried out at an interval of every 3 months. He does not have any dietary restrictions. No compliance issues are identified.

PHARMACIST: …………………….. DATE: …………………………

SIGNATURE: ………………………..

Patient Data Collection

Data Collected 7^th November

Demographic/Administration Information	Patient hospital number	Ward
Initials: AB
Age: 80 years	Ethnicity:	Gender : Male
Height (cm):	Weight (Kg): IBW: 24.4 kg/m2	SA:
Admission Date: 7/11/2017	Occupation: Retired Engineer

History of presenting complaint (HOPC)

Right foot thickened, helix toenail, pain since July 2010, fungal infection

Past Medical History/Surgery (PMH)
Suffered from stroke in 2009
High blood pressure
Type 2 diabetes since 2009
Has been suffering from depression since 2009
Suffered from blackout previously, after which he stopped driving
Strangulated hernia
Underwent a prostate operation more than 20 years ago
Has pain in the left knee; underwent operation in the left knee in November 2015
Family and Social History
Lives with his wife lives in a flat. He used to enjoy gardening before. He finds it difficult to walk alone now. He has 3 children. 1 lives in the UK and 2 others in Australia. He has been suffering from hearing impairment since 2016. He faces difficulty to walk due to severe back pain. He uses a stick to walk and a corset for hernia. He also suffers from poor eyesight. Manifests symptoms of tremor and shiver.
Examination findings	Days 1-3	Day 4 onwards

Medical problems	Acute/chronic	Active Yes / No
Depression	Chronic	Yes
Stomach and intestinal ulcer	Acute	Yes
Enlarged prostrate	Acute	Yes
Essential hypertension	Chronic	Yes
Dry eye	Acute	Yes
Type 2 diabetes mellitus	Chronic	Yes
Epilepsy	Chronic	Yes
High cholesterol	Chronic	Yes
Vitamin B12 deficiency	Chronic	Yes

Drug Serum Concentrations:

Drug	Date

Current Medication & Compliance Problems

Current Drug Therapy
Drug/route	Dose + Frequency	Duration (Start-Stop dates)	Indications/comments
1. Citalopram	20 mg OD	28/7/15; continue	Management of depressive episodes. It should not be given in doses beyond 40mg, and all signs of suicidal ideations and worsening of depression should be immediately reported to the doctor. It is also essential to check blood electrolyte levels regularly.
2. Lansoprazole	15 mg OD	28/7/15; continue	Management of stomach and intestinal ulcer. It should be taken at least 30 minutes before having food. The tablet should not be chewed or crushed inside the mouth. The doctor should be immediately consulted if symptoms of spasm, muscle cramp and seizures appear.
3. Finasteride	5 mg OD	28/7/15; continue	Management of an enlarged prostrate. All kinds of sudden changes in the breast tissues such as, pain and lumos should be immediately reported. The patient package insert should be read before its administration. The doctor should be informed of the medication, if PSA levels are monitored.
4. HYLO Tear	1 drop q.d.s, p.r.n	28/7/15; continue	Management of dry eye symptoms. Sufficient quantity of the eye drop should be slowly administered into the eye. Administration should be immediately stopped if the drop appears discoloured or cloudy. The doctor should be consulted if a dose of HYLO Tear is missed.
5. Ramipril capsule	10mg OD	28/7/15; continue	Management of hypertension. It should be ensured that the patient is adequately hydrated. The medicine cannot be stopped even if normal blood pressure levels are achieved. The entire capsule should be swallowed whole. Symptoms of light-headedness should be immediately reported.
6. Sodium valproate Gastro-resistant tablet	500mg; twice daily; the dosage starts at lowest effective dose and should be gradually increased until a control is achieved	28/7/15; continue	Management of epilepsy. It should be administered once in the morning and once in the evening. The ideal time gap should be between 10-12 hrs. If a dose is missed, it can be given any time within the next 12 hrs. The doctor should be contacted if signs of bleeding or bruising are observed.
7. Atorvastatin	20mg nocte	28/7/15; continue	Cholesterol lowering drug. The dosage can be increased or decreased depending on results of cholesterol tests that should be taken at an interval of 2-4 weeks. Alcohol and intake of grapefruits (whole or juice) should be limited. The TLC diet is recommended. Urgent medical advice should be taken if symptoms of trauma, seizures, and muscle pain are observed.
8. Cobalamine	50 mg OD	28/7/15; continue	Management of low blood levels of the vitamin B12.
9. Linagliptine/Metformin	2.5mg/850mg 1 b.d	24/10/16; continue	Management of type 2 diabetes mellitus. No doses should be missed. The medication should not be stopped even if blood glucose levels are normalized. 2 doses should not be taken at the same time. The doctor should be immediately called if rashes, blisters, peeling skin, tightness in chest and symptoms of pancreatitis are observed.
10. Aspirin DBP	75mg OD	24/10/16; continue	Control of diastolic blood pressure. It should be taken with food or after having meals. Care should be taken that the patient does not become dehydrated. Emergency help should be taken if a swelling in the neck or head, or breathing difficulty is observed.
COMMENTS/NOTES: (Potential compliance problems/compliance needs e.g. ‘What kind of system do you normally use to take your medicines at home?’) Owing to the fact that the patient is on multiple medications, he is predisposed to increased likelihood of drug interactions. The carers should maintain a positive attitude and a light tone of voice while administering him medicines. The carers and nurses should keep their temper in check and should gently ask the reason why the patient is showing noncompliance to the medications. The medicines should be kept in dosette boxes that consists of a plastic system that will help to keep the weekly medicines organized. Using pill organizers may also help him in avoiding cases drug dosage miss. Blister pack kits should be used for packing the medications.

Problem List + Action Plan

Patient: Mr. Ab Student: Date: 9^thNovember

Date	Pharmaceutical problem / Cause of problem	Action/Intervention	Intended outcome/monitoring
	Adherence of Ramipril capsules that are dispensed outside the pill organizers and dosette box	The patient should be given counselling on the necessity of timely administration of the prescribed drugs. The patient also needs to be counselled on the importance of completing the therapy to prevent health complications.	Monitor the blood pressure minutely until it gets stabilized.
	Adherence to sodium valproate gastro-resistant tablets throughout life	The dosage of sodium valproate that is correct for the patient should be worked out. This anti-seizure drug will not be withdrawn at any time (10).	Monitor the presence of complications such as, increased suicidal ideations, anxiety and idiosyncratic abnormalities (11). Regularly monitor for nutritional intake, fluid intake and somnolence.
	Use of lansoprazole in case of ulcers in the stomach and intestine	The patient should be checked for lactose intolerance before administering the medicine. The capsule will be opened and the granules will be mixed with water or juice if he faces difficulty in swallowing it (17).	Monitor for diarrhea, allergic reactions, stomach pain and increased heart rate (8). The dosage will be immediately stopped if such side effects are observed.
	Use of citalopram as an effective therapeutic intervention for depression	This selective serotonin reuptake inhibitor (SSRI) is administered for inducing a feeling of wellbeing and the patient will be administered the drug until symptoms of persistent low mood disappears (3).	Monitor for symptoms of nausea, irritability and headache on withdrawal of the drug (2).
	Evidence for use of metformin and linagliptine to treat type 2 diabetes mellitus	Administer 850 mg metformine or 2.5mg linagliptine twice a day for controlling the blood glucose levels (6). Advise the patient to strictly adhere to the medications to prevent elevation of blood sugar.	The active ingredient metformin hydrochloride lowers the amount of sugar produced by the liver (1). Linagliptine along with exercise and diet lowers the glucose content (15). Monitor for rapid pulse, anxiety and muscle tremor.
	Evidence for administration of lubricating eye drop HYLO Tear, for dry eye sensation	0.1% Sodium Hyaluronate helps in maintaining optimal viscosity (16). The patient should be reminded of taking the drops on a regular basis.	The chemical provides a soothing and long lasting relief to moderate dry eye symptoms (12). Monitor for redness or swelling in eye.
	Adherence to atorvastatin tablets for maintenance of the blood cholesterol levels	Statin or HMG CoA reductase inhibitors reduce bad cholesterol and triglycerides and increase good cholesterol levels (5). The patient should be educated on appropriate use of medicine from his pill organizer, failure to which may cause heart attack.	Monitor for breathing difficulties and swelling of the face and neck. Check for rapid pulse rate if patient misses doses.
	Evidences for use of cobalamine in treating vitamin B12 deficiency	Serum cobalamin levels <200 ng/L are common among the elderly and can be reversed by administration of intramuscular cobalamine therapy (4).	Monitor for cobalamine toxicity and analphylactic reactions (9).
	Adherence to aspirin medications for reducing high blood pressure	The patient should be counselled on the necessity of timely administration of aspirin, which otherwise may increase the risk of suffering from stroke.	Effective prevention of cardiovascular events on administration of low doses of aspirin (13). Monitor for hemorrhagic stroke and gastric bleeding symptoms.
	Adherence to finasteride monotherapy for treating prostate hyperplasia in the patient	Adherence to the medication will result in better urine flow and decrease the urge of the patient to urinate (7). The medication will be continued until enlargement of the prostate gland reduces.	Follow the medication until benefits are noticed after a year or more. Monitor for symptoms of prostate cancer, bloating, cold sweats and rapid weight gain (14).

References

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Devalia V, Hamilton MS, Molloy AM. Guidelines for the diagnosis and treatment of cobalamin and folate disorders. British journal of haematology. 2014 Aug 1;166(4):496-513.
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