【正文】 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。,3. Untreated Depression K.H. has had his current complaints for more than a month. While he does not appear to be suicidal at this point, he needs treatment. Fluoxetine is as effective, has less side effects, and, when all costs are taken into account, is no more expensive to use than older tricyclic antidepressants such as imipramine and desipramine. 4. Excessive Duration of Warfarin Prophylaxis Since the patient has only had one occurrence of deep vein thrombosis, warfarin therapy is usually discontinued after six months of prophylactic treatment,第六十五頁，共七十一頁。,RECOMMENDED ORDERS 1. Methylprednisolone 45 mg iv stat and continue q 6 h for 72 hours. Aerosolized metaproterenol 4 puffs stat and 1 puff q 5 minutes until relief or side effects, then two puffs every 4 hours while awake. Continue oral theophylline, 600 mg bid. Oxygen 2 liters/minute via nasal prongs. Ampicillin 500 mg po qid for seven days. 2. Discontinue Vibramycin. Label K.H. allergic to doxyclycline. Aveeno baths for a soothing effect as needed. 3. Fluoxetine 20 mg qd in am or at noon. Continue therapy for 6 months. 4. Discontinue warfarin,第六十六頁，共七十一頁。,DESIRED OUTCOMES 1. FEV1 greater than 2000 mL within two days Respiratory rate below 20, within two days ABG should all be within normal ranges within four days 2. Resolution of rash within 5 days 3. Patient’s appetite and sleep moderately improved within one week and mood moderately improved within 4 weeks, with no report of suicidal ideation or side effects listed in monitoring below.,第六十七頁，共七十一頁。,MONITORING While hospitalized 1. Daily, patient’s report of SOB and sputum production Daily, respiratory rate and FEV1 Daily, chest auscultation In 4 days, laboratory to measure arterial blood gases 2. Daily, examine rash 3. Daily, dietary to record percent of each meal eaten, Daily, nursing to record hours of sleep the night before Daily, patient report of mood, interest in life, and suicidal thoughts 1.amp。3. Daily, patient report of adverse effects: headaches, anxiety, insomnia, nausea, dry mouth, constipation, drowsiness, or dizziness,第六十八頁，共七十一頁。,PATIENT COUNSELING AND EDUCATION 1. Assess K.H.39。s ability to use his inhaler correctly and correct any problems. Provide a spacer if necessary. Explain the likely side effects of bronchodilators: nausea, palpitations, anxiety or insomnia. K.H. should discontinue smoking。 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。,謝謝(xi232。 xie)各位！,第七十頁，共七十一頁。,內(nèi)容(n232。ir243。ng)總結(jié),藥歷的類型(l232。ix237。ng)及其書寫。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)。Date 2/24/97。謝謝各位,第七十一頁，共七十