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1、 Assessment of Therapy and Pharmaceutical Care( (Ref:AppliedTherapeutics8Ref:AppliedTherapeutics8thth) )新竹馬偕紀念醫院羅凱薰藥師Pharmaceutical Care“TheresponsibleprovisionofdrugtherapytoTheresponsibleprovisionofdrugtherapytoachievedefiniteoutcomesthatareintendedachievedefiniteoutcomesthatareintendedtotoimprove
2、apatientsqualityoflifeimproveapatientsqualityoflife.”.” “ “ 提供藥事照顧是藥師的責任提供藥事照顧是藥師的責任，以提供直接且以提供直接且負責的藥物治療相關服務為宗旨負責的藥物治療相關服務為宗旨，且且以提升病以提升病人生活品質為目標人生活品質為目標 ” ” 1993 1993 American Society of Hospital PharmacistsAmerican Society of Hospital Pharmacists2005/4/203藥事照顧及臨床藥學之差異藥事照顧藥事照顧臨床藥學臨床藥學19801980s s1970
3、1970s s以以病患病患為中心為中心以以藥物藥物為中心為中心病患用藥安全病患用藥安全對藥物治療結果負責對藥物治療結果負責 改善生活品質改善生活品質臨床的功能與活動臨床的功能與活動( (藥物動力學服務藥物動力學服務, ,藥物諮藥物諮詢服務詢服務) )紀錄紀錄紀錄紀錄( (未強調未強調) )積極主動積極主動( (proactive)proactive)較被動較被動( (reactive)reactive)2005/4/204藥事照顧標準作法收集與分析患者基本資料收集與分析患者基本資料分辨目前藥物治療的問題分辨目前藥物治療的問題歸納患者的醫療照顧上的需求歸納患者的醫療照顧上的需求設定藥物治療之目標
4、設定藥物治療之目標訂定藥物治療與監測計劃訂定藥物治療與監測計劃與其他醫療人員討論及修正藥物治療與監測計劃與其他醫療人員討論及修正藥物治療與監測計劃執行藥物治療計劃執行藥物治療計劃監測藥物療效監測藥物療效 再修正藥物的治療及修正藥物治療計劃再修正藥物的治療及修正藥物治療計劃 1996 1996 American Society of Hospital Pharmacists.American Society of Hospital Pharmacists.2005/4/205重新定義n n執業人員需以負責任態度滿足病患與藥物有關執業人員需以負責任態度滿足病患與藥物有關的需求的需求，並對提供服務後
5、的結果予以負責並對提供服務後的結果予以負責n n藥師照顧病患藥師照顧病患所有所有用藥的需求用藥的需求( (醫療問題及藥物醫療問題及藥物問題問題) )，不能只單就一種疾病或藥物為問題不能只單就一種疾病或藥物為問題，因因為病人的健康狀況是為病人的健康狀況是整體性整體性 Strand 1998 Strand 1998 2005/4/206Assessment of Therapy藥師應具備能力Knowledge of diseaseKnowledge of diseaseTherapeutic planning skillsTherapeutic planning skillsKnowledge o
6、f laboratory and diagnosticKnowledge of laboratory and diagnostic testing testingPhysical assessment skillsPhysical assessment skillsKnowledge of drug therapyKnowledge of drug therapyKnowledge of non-drug therapyKnowledge of non-drug therapyDrug information skillsDrug information skillsPatient monit
7、oring skillsPatient monitoring skillsCommunication skillsCommunication skills2005/4/208Assessment of Therapyn nEstablishingthepatientrecord(Establishingthepatientrecord(資料建立資料建立) )n nOrganizingthepatientrecord(Organizingthepatientrecord(整合資料整合資料) )n nSystematicapproachestopatienttherapySystematicapp
8、roachestopatienttherapyassessment(assessment(系統性達到評估系統性達到評估) )2005/4/209Establishingthepatientrecord-1 建立建立patientrecordpatientrecord能提供可得的資訊能提供可得的資訊，進而確定及評估進而確定及評估醫療上問題醫療上問題。n n DirectobservationsDirectobservations (eg(eg.physicalappearance,mentalacuity,.physicalappearance,mentalacuity,insulin-inje
9、ctiontechnique)insulin-injectiontechnique)n n PhysicalexaminationPhysicalexamination (eg(eg.bloodpressure,pulse).bloodpressure,pulse)n n LaboratorytestsLaboratorytests (eg(eg.bloodglucose,cholesterollevels).bloodglucose,cholesterollevels)2005/4/2010Establishingthepatientrecord-2n nKnowledgeKnowledge
10、 包含全盤性藥物治療包含全盤性藥物治療，藥物及疾病的關係藥物及疾病的關係，藥物治療藥物治療 下下所預期應有結果所預期應有結果。n nSourcesofpatientinformationSourcesofpatientinformation 成功評估及監測需匯集相關性資訊成功評估及監測需匯集相關性資訊( (獲得獲得subjectivesubjectivedatadata或是監測或是監測 objectivephysicaldata)objectivephysicaldata)-Data-Richenvironment:hospital,long-termcarefacility-Data-Ric
11、henvironment:hospital,long-termcarefacility-Data-Poorenvironment:clinicianoftenisrequiredto-Data-Poorenvironment:clinicianoftenisrequiredtomakeassessmentwithlimitedinformationmakeassessmentwithlimitedinformation2005/4/2011Establishingthepatientrecord-3n nInterviewingthePatientInterviewingthePatient
12、使用聆聽使用聆聽、肢體語言肢體語言、音調等技巧及音調等技巧及 敘述病史方式溝通敘述病史方式溝通 -open-endedquestions:requirepatienttoexplainandopen-endedquestions:requirepatienttoexplainandelaborateelaborate-close-endedquestions:YesorNo-close-endedquestions:YesorNo 2005/4/2012Organizingthepatientrecord-1 提供提供PharmaceuticalcarePharmaceuticalcare應有
13、標準化格式去紀錄病人資應有標準化格式去紀錄病人資訊訊，病人紀錄病人紀錄( (patientrecord)patientrecord)應涵蓋應涵蓋 theHistorytheHistory ,Assessment,Plan.,Assessment,Plan.n nMedicalHistoryMedicalHistory:isessentialtotheprovisionof:isessentialtotheprovisionofpharmaceuticalcarepharmaceuticalcaren nDrugHistoryDrugHistory:-Drugidentificationandu
14、se-Drugidentificationanduse-Assessmentoftherapeuticresponse-Assessmentoftherapeuticresponse-Assessmentofadverseeffects-Assessmentofadverseeffects - -以上方法能快速評估病人使用藥物的情況以上方法能快速評估病人使用藥物的情況2005/4/2013Organizingthepatientrecord-2n nSocialHistorySocialHistory:病人的生活型態及本身態度通病人的生活型態及本身態度通常能決定藥物治療成功或是失敗常能決定藥物
15、治療成功或是失敗 -Work-Work-Exercise-Exercise-Diet-Diet-Supportsystems(whoelseliveswithu?-Supportsystems(whoelseliveswithu?doseiteverstrainyourrelationship?)doseiteverstrainyourrelationship?)-Attitude-Attitude2005/4/2014Systematicapproachestopatienttherapyassessment1n n系統性評估病人的治療系統性評估病人的治療P Problem-roblem-o
16、 orientedrientedmmedicaledicalr recordecord(POMR)(POMR)approachapproach- -ProblemlistProblemlist-S SubjectiveandubjectiveandOObjectivedatabjectivedata-A Assessmentssessment-P Planlan-DiagnosticPlan-DiagnosticPlan-PharmaceuticalCarePlan-PharmaceuticalCarePlan-TherapeuticObjectives-TherapeuticObjectiv
17、es-PatientEducation-PatientEducation2005/4/2015Problem listProblem listnumberednumberedacuity/priorityacuity/priorityresolved/inactiveresolved/inactiveDatabaseDatabaseCCCCHPIHPIPMHPMHFHFHSHSHMed Med HxHx ComplianceCompliance Allergies AllergiesROWROWPEPELab testsLab testsX-rayX-rayScansScansProcedur
18、eProcedureSOAP NotesSOAP Notes SOAP Notes SOAP NotesImplementation of planImplementation of plandiagnosticdiagnostictherapeutictherapeuticeducationaleducationalFollow-up of progressFollow-up of progress2005/4/2016ElementsoftheProblem-OrientedMedicalRecordSOAPnoteIllustrationofSOAPn nSubjective (Symp
19、toms)Subjective (Symptoms) - Pt feels- Pt feels- Observing how the pt looks, talks, acts, responds subjective - Observing how the pt looks, talks, acts, responds subjective informationinformation n nObjective (Sign)Objective (Sign)- VS, finding on PE, results of Lab tests, finding of diagnostic - VS
20、, finding on PE, results of Lab tests, finding of diagnostic procedures (X-ray, CT, ECG)procedures (X-ray, CT, ECG)n nAssessmentAssessment- Etiology, if therapy is indicated, current therapy and/or new - Etiology, if therapy is indicated, current therapy and/or new therapytherapyn nPlanPlan- Therape
21、utic, drugs to be avoided, goals, monitoring (therapeutic - Therapeutic, drugs to be avoided, goals, monitoring (therapeutic & toxic)& toxic)- Pt education- Pt education, future plan, future plan2005/4/2018SOAPnote-1n nProblemListProblemList-isthetableofcontentsofthemedicalrecordandframe-isthetableo
22、fcontentsofthemedicalrecordandframewarkwarkforpatientcareforpatientcare（問題點列表是這個病患照護之架構問題點列表是這個病患照護之架構） -allnewproblemsareaddedtotheproblemlistwith-allnewproblemsareaddedtotheproblemlistwithsequentialnumberssequentialnumbers（發現的問題點可依序的一一填上發現的問題點可依序的一一填上）-hemostimportantproblemisdiscussedfirst-hemost
23、importantproblemisdiscussedfirst( (最重要的問題點先討論最重要的問題點先討論）-Problemsaredynamic-Problemsaredynamic：problemsareresolvedandnewproblemsareresolvedandnewproblemsdevelopproblemsdevelop（問題是動態的問題是動態的，解決了一個解決了一個，又會產生新的問題又會產生新的問題）-drug-relatedproblemslistedbypharmacist-drug-relatedproblemslistedbypharmacist(與藥有關
24、之問題點與藥有關之問題點) )2005/4/2019SOAPnote-2n nSubjectiveSubjective-Patientcomplaintsofsymptoms-Patientcomplaintsofsymptoms（病患所抱怨之症狀病患所抱怨之症狀）-Observationsofhealthcareproviders-Observationsofhealthcareproviders（醫護人員所觀察到資料醫護人員所觀察到資料）datasdatasgatheredbytalkingtothepatientorreviewofgatheredbytalkingtothepatien
25、torreviewofsystem(ROS)system(ROS)（可經由與病患交談或查詢病歷而得可經由與病患交談或查詢病歷而得）n nObjectiveObjective-vitalsigns-vitalsigns（生命徵象數據生命徵象數據 BPBP、HRHR、RRRR）-resultsoflaboratorytests-resultsoflaboratorytests（檢驗結果檢驗結果）-resultsof-resultsofvariewsvariewsproceduresprocedures（醫療儀器等檢查之結果醫療儀器等檢查之結果）-selectthedatathatnecessary
26、tofollowdrugtherapy-selectthedatathatnecessarytofollowdrugtherapy）（選出需繼續作藥物治療者選出需繼續作藥物治療者）2005/4/2020SOAPnote-3n nAssessmentAssessment1.aproblemisdruginduced(ADR)?1.aproblemisdruginduced(ADR)?（問題是因藥物副作用問題是因藥物副作用所引起的嗎所引起的嗎？）？）2.2.Whetherdrugtherapyisrequired?Whetherdrugtherapyisrequired?（需要藥物治療嗎需要藥物治
27、療嗎？）？）3.3.assessthecurrenttherapyforappropriatenessassessthecurrenttherapyforappropriateness（評估目前評估目前治療之適當性治療之適當性）-Areallthedrugsnecessary?-Areallthedrugsnecessary?（所有的藥都需要嗎所有的藥都需要嗎？）？）-Isthisthedrugsofchoiceforthepatient?-Isthisthedrugsofchoiceforthepatient?（是首選藥物是首選藥物? ?）-Isthisthecorrectdose?Isth
28、isthecorrectdose?（劑量適當嗎劑量適當嗎？）？）-Isthisthecorrectdosageform?-Isthisthecorrectdosageform?（劑型適當嗎劑型適當嗎？ ）- - Isthisthebestschedule?Isthisthebestschedule?（是最好之給藥時間嗎是最好之給藥時間嗎？）？）-Isthedurationoftherapyappropriate?-Isthedurationoftherapyappropriate?（治療期間之長短妥當嗎治療期間之長短妥當嗎？）？）n n 2005/4/2021SOAPnote-44.4.ist
29、heistheresponesresponesisadequate/expected?isadequate/expected?（藥效如預期的嗎藥效如預期的嗎？）？）assessthecomplianceofpatients?assessthecomplianceofpatients?（評估病人之順服評估病人之順服性如何性如何？）？）5.5.assessanydruginteractionsorADR(occurredormayassessanydruginteractionsorADR(occurredormayoccur)occur) （評估是否會有或已有藥物交互作用或副作用評估是否會有或已
30、有藥物交互作用或副作用）TheSOAPnoteshouldcontainallthereasonsforanyTheSOAPnoteshouldcontainallthereasonsforanyactiontakenregardingtherapyactiontakenregardingtherapy（任何之建議或異議皆應註明理由任何之建議或異議皆應註明理由） n nPlan(Suggestion)Plan(Suggestion)-treatment-treatment（治療建議治療建議）-monitoringparameters-monitoringparameters（監測之建議監測之建
31、議）-endpointsoftherapy-endpointsoftherapy（治療終點之設定治療終點之設定）-patienteducation-patienteducation（病患教育內容病患教育內容）2005/4/2022 評估評估藥物治療問題藥物治療問題評估評估藥物治療問題藥物治療問題適應症適應症需增加藥物治療需增加藥物治療 有未治療的狀況或疾病有未治療的狀況或疾病 達到協同達到協同/ /增強療效的目的增強療效的目的 以預防新問題的產生以預防新問題的產生服用不需要的藥物服用不需要的藥物 沒有適應症存在沒有適應症存在 濫用成癮性濫用成癮性/ /娛樂用藥娛樂用藥 此症狀不需藥物治療此症狀
32、不需藥物治療 重複用藥重複用藥 治療不可避免的副作用治療不可避免的副作用安全性安全性藥物不良反應藥物不良反應 對病患不安全對病患不安全 有過敏史有過敏史 給藥方式不正確給藥方式不正確 藥物交互作用藥物交互作用 劑量改變太快劑量改變太快 不期望的藥理反應不期望的藥理反應，特異體質特異體質 劑量過高劑量過高 錯誤劑量錯誤劑量 給藥頻率不適當給藥頻率不適當 治療期限不適當治療期限不適當 因藥物交互作用因藥物交互作用 有效性有效性藥物選擇不適當藥物選擇不適當 劑型不適當劑型不適當 有治療禁忌或配伍禁忌有治療禁忌或配伍禁忌 已產生耐藥或抗藥性已產生耐藥或抗藥性 不適用於此適應症不適用於此適應症 有其他更
33、有效的藥物有其他更有效的藥物劑量過低劑量過低 錯誤劑量錯誤劑量 給藥頻率不適當給藥頻率不適當 給藥期限不適當給藥期限不適當 儲存方式不正確儲存方式不正確 給藥方式不正確給藥方式不正確 因藥物交互作用因藥物交互作用 配合度配合度未遵照指示用藥未遵照指示用藥 沒有獲得此藥物產品沒有獲得此藥物產品 買不起這些藥物產品買不起這些藥物產品 不能吞藥或給藥不能吞藥或給藥 不了解用藥指示不了解用藥指示 病患寧願不吃藥病患寧願不吃藥 其他原因其他原因 沒有藥物治療問題沒有藥物治療問題 2005/4/2023ElementsoftheProblem-OrientedMedicalRecordPharmacist
34、sWorkupofDrugTherapy(PWDT)藥物治療之探討PharmacistsWorkupofDrugTherapy(PWDT)PWDTPWDT的焦點特別在於藥物所引起的相關性問題的焦點特別在於藥物所引起的相關性問題( (drugrelatedproblem)drugrelatedproblem)，有有 66個相關性步驟個相關性步驟: :establishingpatient-specificdata-baseestablishingpatient-specificdata-baseidentifyingpatient-specific,drug-relatedproblemiden
35、tifyingpatient-specific,drug-relatedproblemdescribingdesiredtherapeuticoutcomesdescribingdesiredtherapeuticoutcomeslistingalltherapeuticalternativesthatmightproducethedesiredlistingalltherapeuticalternativesthatmightproducethedesiredoutcomesoutcomesselectingthedrugrecommendationthatmostlikelywillres
36、ultinselectingthedrugrecommendationthatmostlikelywillresultinthedesiredoutcomesthedesiredoutcomesestablishaplanfortherapeuticdrugmonitoringthatdocumentsestablishaplanfortherapeuticdrugmonitoringthatdocumentsthatdesiredeffectoccurandundesiredeffectsareminimizedthatdesiredeffectoccurandundesiredeffect
37、sareminimized2005/4/2025 PharmacistsWorkupofDrugTherapyAssessmentCare plan Follow-up Evaluation2005/4/2026DrugTherapyAssessment-EstablishingPriorities-1-EstablishingPriorities-1-AgeandGender-AgeandGender在小於在小於1212歲小孩及大於歲小孩及大於6565歲老人歲老人，使用藥物劑使用藥物劑量上應考量體重及可能產生藥物清除率不良或量上應考量體重及可能產生藥物清除率不良或會增加藥物敏感性會增加藥物敏
38、感性。- -NumberofMedicationNumberofMedication PrescribedorNumberofPrescribedorNumberofDoseperdayDoseperday研究指出研究指出，併用藥物越多種併用藥物越多種，產生藥物副作用產生藥物副作用及交互作用機率越高及交互作用機率越高。2005/4/2027EstablishingPriorities-2- - DosewithaHighRiskforAdverseDrugEffectorDrugDosewithaHighRiskforAdverseDrugEffectorDrugInteractionInte
39、raction 1.1.Withintriggeramorein-depthreview:Withintriggeramorein-depthreview:egeg.Anticoagulants.Anticoagulants,digoxin,digoxin,metered-doseinhalers,metered-doseinhalers,insulin,orinsulin,orhypoglycemicshypoglycemics, ,aminoglycosideaminoglycoside, ,anticonvulsants.anticonvulsants. 2.2.Withahighpot
40、entialfortriggeringdrugWithahighpotentialfortriggeringdruginterationsinterations: : enzymeinhibitorsandinducersenzymeinhibitorsandinducers,cimetidine,macrolide,cimetidine,macrolide antibioticsantibiotics,fluoroquinolone,fluoroquinolone.-TargetDiseases-TargetDiseases在特定病人中本身潛藏著疾病在特定病人中本身潛藏著疾病，藥物選擇也需考
41、量及持續藥物選擇也需考量及持續監測的監測的。2005/4/2028EstablishingPriorities-3- -High-CostDrugHigh-CostDrug社區藥師當遇到藥物昂貴情況下社區藥師當遇到藥物昂貴情況下，應可建議醫師選應可建議醫師選擇替代藥品擇替代藥品。例如例如 :對於對於 asthmaasthma病人病人，fluticasonefluticasone及及 salmeterolsalmeterol 各一支各一支 可建議醫師處方調整為可建議醫師處方調整為 fluticasonefluticasone/salmeterolsalmeterol( (較便宜且方便使用較便宜且
42、方便使用). ).- -AlteredDrugClearanceAlteredDrugClearance1.1.肝肝，腎功能不全會引響藥物清除率腎功能不全會引響藥物清除率 ( (取決於取決於肝代謝或腎排除肝代謝或腎排除 ) )2.2.治療指數狹窄治療指數狹窄:digoxindigoxin, ,phenytoinphenytoin,vancomycinvancomycin2005/4/2029EstablishingPriorities-4-Allergy-Allergyallergy-cross-reactingdrugsallergy-cross-reactingdrugsmakemedic
43、alorpharmacyrecordmakemedicalorpharmacyrecord- -PrescriberPrescriberContactContact建立於藥師和病人安全建立於藥師和病人安全、方便及時間允許下方便及時間允許下-one-on-oneconsultationone-on-oneconsultation-informforphysician(makesuggestionsforchangecanbemade-informforphysician(makesuggestionsforchangecanbemadebynotes,writteninchart,orbyfor
44、malletters)(bynotes,writteninchart,orbyformalletters)(國外國外) )-communicationwithphysician(communicationwithphysician(國內國內) )2005/4/2030PWDTandSOAPtechniques PWDTPWDTformonitoringcontinuingdrugtherapyformonitoringcontinuingdrugtherapy SOAPSOAPwhencommunicatinginwritingwithotherwhencommunicatinginwriti
45、ngwithotherhealthcareprovidershealthcareproviders“ “ThekeytoboththeThekeytoboththePWDTPWDTandtheandtheSOAPSOAPtechniquesisatechniquesisasystematicsystematic approachtoassessingandmonitoringdrugtherapy.approachtoassessingandmonitoringdrugtherapy.” ”無論是使用無論是使用SOAPSOAP或是或是PWDTPWDT（PharmacistsWorkupofDr
46、ugPharmacistsWorkupofDrugTherapyTherapy），），重要的是經由這個過程能重要的是經由這個過程能解決解決臨床上所遇到的問題臨床上所遇到的問題。 2005/4/2031OtherSOAPn nSOAPSOAP( (subjectivesubjective, ,objectiveobjective, ,analysisanalysis, ,planplan)originallydesigned)originallydesignedbyDr.LawrenceL.Weedformedicaldoctors.byDr.LawrenceL.Weedformedicaldo
47、ctors.n nExpanded-SOAPExpanded-SOAP(add(addgoalsgoals, ,monitoringmonitoringandandeducationeducation) )n nSOAPIERSOAPIER(usedbynurse)(usedbynurse)n nDARDAR(usedbynurse)(usedbynurse)n nFARMFARM(findingfinding, ,assessmentassessment, ,resolutionresolution, ,monitoringmonitoring) )n nPWDTPWDT(Pharmacis
48、tsworkupofdrugtherapy)(Pharmacistsworkupofdrugtherapy)n nPMDRPPMDRP(PharmacistsManagementofDrug-RelatedProblems)(PharmacistsManagementofDrug-RelatedProblems)n nAmericanSocietyofHealth-SystemPharmacistsAmericanSocietyofHealth-SystemPharmacists PCPPCP (pharmacistscareplan)(pharmacistscareplan)From:Ame
49、thodofdocumentingpharmaceuticalcareutilizingpharmaceuticaldiagnosis.StephenC.Hurley.19982005/4/2032以medicaldiagnosis為主強調therapeuticproblemmoredetailthanPWDTmorelengthySOAPExpanded-SOAPFARMPWDTPMDRPPCPFrom:Amethodofdocumentingpharmaceuticalcareutilizingpharmaceuticaldiagnosis.StephenC.Hurley.19982005
50、/4/2033NewModularFormat:“PH-MD-ROME” College of Pharmacy,Idaho State University , College of Pharmacy,Idaho State University , StephenC.Hurley.1998n nP PatientIntroductionatientIntroductionn nH HealthProblemsealthProblemsn nMMedicationsedicationsn nPharmaceuticalPharmaceuticalD Diagnosesiagnosesn nR
51、 RecommendedOrdersecommendedOrdersn nDesiredDesiredOOutcomesutcomesn nMMonitoringonitoringn nPatientCounselingandPatientCounselingandE Educationducation 2005/4/2034SuggestedPharmaceuticalDiagnosesRelatedtotheprescriptionSubtherapeutic doseExcessivedoseExcessive/InsufficientdurationofuseSuboptimaldos
52、agescheduleSuboptimaldosageformorroutePoorcost-effectivenessFinancialburden/UnidentifiedmedicationUnclearorincompleteprescription/NotreceivingRelatedtoevaluationofdrugtherapyUntreatedhealthproblemNeedforprophylactic/preventative/Continuation/ormaintenancetherapySuboptimalresponseQuestionableoruncert
53、ainindication/AlternatedrugofchoiceTherapeuticduplication/PharmacokineticevaluationRelatedtoadverseeffectsofdrugtherapyAdversedrugreactionPotentialcontra-indicationPontentialadversedrug/dietinterationPontentialadversedrug/druginterationPontentialadversedrug/laboratoryinterationRelatedtomonitoringIna
54、dequatecharacterizationofahealthproblemInadequatemonitoringofclinicaldataExcessivemonitoringofclinicaldataUnfinishedtrialofdrugtherapyRelatedtopatientfactorsPoorcomplianceExcessiveutilizationProblematicsubstanceuseDetrimentalphysicaldependenceImproperstorageRelatedtopatientcounselingDeficientcounsel
55、ing2005/4/2035S. O. A. P. 案例研討Case Presentation - 1n nS.S.S.S.為為6363歲女性歲女性，主訴為過去兩天頭昏主訴為過去兩天頭昏、視力模糊視力模糊，在今日在今日(93/2/8)(93/2/8)清晨於浴室昏倒並造成頭部受傷清晨於浴室昏倒並造成頭部受傷。n nMedicalhistoryMedicalhistory:stage:stagecoloncancer(4coloncancer(4個月前作過切除手術個月前作過切除手術，現以化學治療現以化學治療) )，seizuredisorder(generalizedtonicseizuredis
56、order(generalizedtonic-clonic-clonic)since)sincechildhood,childhood,但這但這2525年來並無發生年來並無發生，hypertension,hypertension,近日診斷為憂鬱近日診斷為憂鬱症症( (depression)depression)。n nPhysicalexaminationPhysicalexamination:Wt:58kg,BP:136/85mmHg,pulse:78beats/min,Wt:58kg,BP:136/85mmHg,pulse:78beats/min,RR:16beats/min,temper
57、ature:37RR:16beats/min,temperature:37. .n nNeurologicNeurologicexamexam:sheappearstobesomnolentwithbilateral:sheappearstobesomnolentwithbilateralnystagmusnystagmusandataxicgait.shehasabruiseontheleftsideofandataxicgait.shehasabruiseontheleftsideoftheforeheadandmildgingivaltheforeheadandmildgingivalh
58、yperplasiahyperplasia. .n nLaboratoryresultsLaboratoryresults:unremarkablewithnormalelectrolytes,liver:unremarkablewithnormalelectrolytes,liverandrenalfunctiontest,completebloodcount.(admission)andrenalfunctiontest,completebloodcount.(admission)2005/4/2037Case Presentation - 2n n DilantinDilantin:39
59、.6mcg/mL,Albumin:4.4g/dL(STAT):39.6mcg/mL,Albumin:4.4g/dL(STAT)RepeatRepeatDilantinDilantin:39.4mcg/mL(2hourslater):39.4mcg/mL(2hourslater)6monthsago,6monthsago,DilantinDilantin:10.5mcg/mL:10.5mcg/mL2005/4/2038n nProblemList:ProblemList:1.1.possiblepossiblephenytoinphenytointoxicitytoxicity2.2.Headi
60、njuryHeadinjury3.3.stagestagecoloncancercoloncancer4.4.NauseaandvomitingNauseaandvomiting5.5.depressiondepression6.6.hypertensionhypertension7.7.seizuredisorderseizuredisorder8.8.gingivalgingivalhyperplasiahyperplasia2005/4/2039Problem-1possiblephenytointoxicityn nS S:1.S.S.headinjuryresultingfromfa
61、llsecondarytodizziness:1.S.S.headinjuryresultingfromfallsecondarytodizziness2.2-dayshistoryoffatigueandblurredvision.3.hasnottaken2.2-dayshistoryoffatigueandblurredvision.3.hasnottakenanyextradoses.DeniesuseofanyOTCmedicationsorotheranyextradoses.DeniesuseofanyOTCmedicationsorothernon-prescribeddrug
62、s.non-prescribeddrugs.n nOO:1.Weight:58kg:1.Weight:58kg2.drugallergy:nil2.drugallergy:nil3.PE:Bruiseonleftsideofforehead;mildgingival3.PE:Bruiseonleftsideofforehead;mildgingivalhyperplasiahyperplasia,bilateral,bilateralnystagmusnystagmusandataxicgait,otherwiseandataxicgait,otherwisenonfocalneurologi
63、cnonfocalneurologicexamination;remainingexaminationWNL.examination;remainingexaminationWNL.4.Labs:Admission4.Labs:Admissionphenytoinphenytoinconcentration:39.6mcg/mconcentration:39.6mcg/mL;Albumin:4.4g/dL,Repeatlevel2hourslater:39.4mcg/mL.L;Albumin:4.4g/dL,Repeatlevel2hourslater:39.4mcg/mL.PreviousP
64、reviousphenytoinphenytoinconcentrationon92/8/8,concentrationon92/8/8,DilantinDilantin:10.5:10.5mcg/mL.mcg/mL.2005/4/2041n nMedication:Medication:藥名藥名劑量劑量/ /用法用法timetime relatedproblemrelatedproblem phenytoinphenytoin(100)3#(100)3#qhsqhs2/12/8P1,P2,P7,P82/12/8P1,P2,P7,P8 hydrochlorothiazidehydrochlor
65、othiazide(25)1#(25)1#qdqd/am2/12/8P6/am2/12/8P6 ProchlorperazineProchlorperazine(5)2#Q6h(5)2#Q6hprnprn2/12/8P2,P42/12/8P2,P4 fluoxetinefluoxetine(20)1#(20)1#qamqam2/12/8P52/12/8P5ChemotherapyChemotherapy FluorouracilFluorouracil(5-FU)(250)2.8vialfourthcycleon2/5P3(5-FU)(250)2.8vialfourthcycleon2/5P3
66、 LeucovorinLeucovorin(50)0.7vialfourthcycleon2/5P3(50)0.7vialfourthcycleon2/5P32005/4/2042n nA A:1.S.S.with:1.S.S.withsupratherapeuticphenytoinsupratherapeuticphenytoinlevelsandsymptomslevelsandsymptomsconsistentwithconsistentwithphenytoinphenytointoxicity.toxicity.22.Fluoxetine.Fluoxetineisainhibit
67、orofisainhibitorofcytochromecytochromeP4502C9andtheP4502C9andthetemporalrelationshipbetweeninitiationoftemporalrelationshipbetweeninitiationoffluoxetinefluoxetinefordepressionfordepressionandthenewonsetCNSsymptomssuggestsapossibledrug-drugandthenewonsetCNSsymptomssuggestsapossibledrug-druginteractio
68、n.interaction.n nSuggestionSuggestion: :1.considerdiscontinue1.considerdiscontinuefluoxetinefluoxetineandtemporarilydiscontinuingandtemporarilydiscontinuingphenytoinphenytoin. .2005/4/20432.Consider2.Considercitalopramcitalopram, ,mitrazapinemitrazapine,or,orvenlafaxinevenlafaxinefortheforthetreatme
69、ntofdepression.treatmentofdepression.3.Monitoringserum3.Monitoringserumphenytoinphenytoinevery27daysuntilevery27daysuntilconcentrationfallsbelow15mcg/mLandthenreinstateconcentrationfallsbelow15mcg/mLandthenreinstatephenytoinpophenytoinpo300mg300mgqhsqhs. . 4.Continuemonitoringforfurtherseizureactivity,andfor4.Continuemonitoringforfurtherseizureactivity,andfordizziness,blurredvision,ataxia,anddizziness,blurredvision,ataxia,andnystagmusnystagmus. .2005/4/2044 Thank You !2005/4/2045
