【正文】 : WNL Chest xray: Clear, no signs of pneumonia,第五十二頁，共七十一頁。,P: Begin fluoxetine 20 mg qd q am or at noon. Continue therapy for 6 months. Monitor changes in appetite, sleep pattern, interest in life, mood, quality of life, and suicidal thoughts. Physiologic signs and symptoms should improve in 1 week, while mood will take 24 weeks to respond. Also monitor for headaches, anxiety, insomnia, nausea, somnolence, dizziness or anticholinergic side effects. Advise patient to take fluoxetine in the morning or at noon to help prevent insomnia. Antacids may help with nausea. This drug may cause drowsiness or dizziness, so caution is advised when driving or operating machinery. It will take several weeks for this drug to work or side effects to develop.,第五十八頁，共七十一頁。,PHARMACEUTICAL DIAGNOSIS 1. Suboptimal Response to Bronchodilators D. G. has a symptomatic exacerbation of his chronic bronchitis that requires further treatment. The reversible airway obstruction would probably be amenable to additional bronchodilators. A theophylline level of 12 mg/L is within the therapeutic range and pharmacokinetically consistent with his dosage. The use of antibiotics in this situation is controversial, although recent evidence suggests a benefit. 2. Adverse Drug Reaction to Doxycycline K.H. has developed a rash probably due to the doxycycline started 9 days ago. The usual drug rash is maculopapular and commonly occurs after 710 days of therapy. Avoid antihistamines unless K.H. is itching, because they are sedating and have anticholinergic effects.,第六十四頁，共七十一頁。 refer him to a smoking cessation clinic. 2. Educate patient that he has an allergy to doxycycline and possibly other tetracyclines. 3. Advise patient to take fluoxetine in the morning or at noon to help prevent insomnia. Antacids may help with nausea. This drug may cause drowsiness or dizziness, so caution is advised when driving or operating machinery. It will take several weeks for this drug to work or side effects to develop.,第六十九頁，共七十一頁。藥師應(yīng)不僅確定其過去用藥方案中的劑量詳情，更應(yīng)考察該方案效果如何、是否發(fā)生不良事件以及為何后來停用了該方案等細(xì)節(jié)。ix237。,PATIENT COUNSELING AND EDUCATION 1. Assess K.H.39。,Rash K.H. does not complain of itching. He has a maculopapular rash on trunk and thighs. His eosinophiles are in the normal range. Depression The five symptoms mentioned under patient introduction and their duration of over six weeks are consistent with a major depressive episode. However his breathing problem may be contributing to the mood disorder. The patient does not appear to be suicidal at this point. Deep Vein Thrombosis Patient injured his right leg in a fall seven months ago. Deep vein thrombosis in the calf developed a week later. The measurements of INR have shown wide swings over the last seven months. Presently the INR has stabilized around 3.0 for the last two months. No known Allergies,第六十二頁，共七十一頁。,PROBLEM 2. DRUG ALLERGY S: K.H. complains of a rash that began yesterday, but does not complain of itching. O: K.H. has maculopapular rash on trunk and thighs, his eos is 1.2. A: K.H. has developed a rash due to the doxycycline started 9 days ago. The usual drug rash is maculopapular and commonly occurs after 710 days of therapy. Avoid antihistamines unless K.H. is itching, because they are sedating and have anticholinergic effects. P: Discontinue Vibramycin. A veeno baths for a soothing effect may be needed. Label K.H. allergic to doxycycline. Monitor for resolution of the rash. Educate patient that he has an allergy to doxycycline and possibly other tetracyclines.,第五十六頁，共七十一頁。7“ HEENT: Normal COR: Normal S1 and S2。,五、藥歷舉例(jǔ l236。每一種監(jiān)測指標(biāo)應(yīng)列出其相應(yīng)的監(jiān)測時間、監(jiān)測頻率，必要時應(yīng)注明特殊的監(jiān)測者。,O〔Desired Outcome，理想結(jié)果〕 設(shè)定特定的治療目標(biāo)或終點。) 臨床情況不完善 臨床檢查數(shù)據(jù)不完善 臨床檢查數(shù)據(jù)過多 尚需進一步觀察,第四十二頁，共七十一頁。,藥物治療評價相關(guān)問題 未處置問題 是否有必要(b236。要使用、調(diào)整和停用某種藥物，都應(yīng)該討論其效益和風(fēng)險。 藥師