TY - CHAP M1 - Book, Section TI - Appendix E - Example Care Plan with Missing Data A1 - Matthias, Kathryn R. A1 - Katz, Michael D. PY - 2023 T2 - Pharmacotherapy Principles and Practice Study Guide, 6e AB - Table Graphic Jump Location|Download (.pdf)|PrintMock Patient Name:Preferred Pronoun:Mock MRN:Age:Sex Assigned at Birth:Height:Race:Gender:Weight:Ethnicity:Preferred Pharmacy:PCP:Insurance:Allergies/Intolerances/ADRsHPI, FH, SH, Social Determinants of Health, Health Literacy□ No known drug allergies/ADRs□ Not known/inadequate informationDrugReactionAdditional Information:Prioritized Medical Problem ListMedication Profile123456Health Maintenance:PMH with no therapy needed:Inadequate Database:Vital Signs, Laboratory Data, and Diagnostic Test ResultsNormal Range or UnitsDayTodayWeightlbs (kg)TemperatureoCBlood PressuremmHgPulseRespiratory RateNa135–145 mEq/L (135–145 mmol/L)K3.3–4.9 mEq/L (3.3–4.9 mmol/L)Cl97–110 mEq/L (97–110 mmol/L)CO2/HCO322–26 mEq/L (22–26 mmol/L)BUN8–25 mg/dl (2.9–8.9 mmol/L)Serum Creatinine (adult)male 0.7–1.3 mg/dl; female 0.6–1.1 mg/dl (male 62–115 m µmol/L; female 53–97 µmol/L)Creatinine Clearance (adult)85–135 mL/min (1.42–2.25 mL/s)Glucose (fasting)65–109 mg/dl (3.6–6.0 mmol/L)Total Ca8.6–10.3 mg/dl (2.15–2.58 mmol/L)Mg1.3–2.2 mEq/L (0.65–1.10 mmol/L)PO42.5–4.5 mg/dl (0.81–1.45 mmol/L)Hemoglobinmale 13.8–17.2 g/dl; female 12.1–15.1 g/dl (male 138–172 g/L; female 121–151 g/L)Hematocritmale 40.7–50.3%; female 36.1–44.3% (male 0.407–0.503; female 0.361–0.443)MCV80.0–97.6 µm3 (80.0–97.6 fL)WBC4–10 × 103/mm3 (4–10 × 109/L)WBC Differential% polymorphonuclear neutrophils (PMN)/eosinophils/basophils/lymphocytes/monocytes///// / / // / / /Platelets140–440 × 103/mm3 (140–440 × 109/L)Albumin3.5–5 g/dl (35–50 g/L)Bilirubin (total)0.3–1.1 mg/dl (5.13–18.80 µmol/L)Bilirubin (direct)0–0.3 mg/dl (0–5.1 µmol/L)AST11–47 IU/L (0.18–0.78 µkat/L)ALT7–53 IU/L (0.12–0.88 µkat/L)Alk phos (adult)38–126 IU/L (0.13–2.10 µkat/L)PH7.35–7.45PO270–95 mmHg (9.3–12.6 kPa)O2Saturation (90–110%)PCO235–45 mmHg (4.7–6.0 kPa)Urine HCGAdditional Notes:DRUG THERAPY PROBLEM WORKSHEETType of ProblemPossible CausesProblem ListNotesCorrelation between drug therapy and medical problemsDrugs without obvious medical indicationsMedication(s) unidentifiedUntreated medical conditionsNeed for additional drug therapyNew medical condition requiring new drug therapyChronic disorder requiring continued drug therapyCondition best treated with combination drug therapyMay develop new medical condition without prophylactic or preventative therapy or premedicationUnnecessary drug therapyMedication(s) with no valid indication or condition is better treated with nondrug therapyCondition caused by accidental or intentional ingestion of toxic amount of drug(s) or chemicalsMedical problem(s) associated with use of or withdrawal from alcohol, drugs, or tobaccoTaking multiple drugs when single agent is as effectiveTaking drug(s) to treat an avoidable adverse reaction from another medicationAppropriate drug selectionCurrent regimen not usually as effective or safe as other choicesTherapy not individualized to patientWrong drugMedical problem for which drug is not effectivePatient has risk factors that contraindicate use of drugPatient has infection with organisms resistant to drugPatient refractory to current drug therapyTaking combination product when single agent appropriateDosage form inappropriate or medication errorDrug regimenPRN use not appropriate for conditionRoute of administration/dosage form/mode of administration not appropriate for current conditionLength or course of therapy not appropriateDrug therapy altered without adequate therapeutic trialDose or interval flexibility not appropriateDose too lowDose or frequency too low to produce desired response in this patientSerum drug concentration below desired goal range for indicationTiming of antimicrobial prophylaxis not appropriateMedication not stored properly or medication errorDose too highDose or frequency too high for this patientSerum drug concentration above the desired goal range for indicationDose escalated too quicklyDose or interval flexibility not appropriate for this patientMedication errorTherapeutic duplicationReceiving multiple agents without added benefitDrug allergy/adverse drug eventsHistory of allergy or ADE to current (or chemically related) agentsAllergy or ADE history not in medical recordsPatient not using alert for severe allergy or ADESymptoms or medical problems that may be drug inducedDrug administered too rapidlyMedication error, actual or potentialInteractions (drug-drug, drug-disease, drug-nutrient, drug-laboratory test)Effect of drug altered due to enzyme induction/inhibition, protein binding alterations, or pharmacodynamic change from another drug patient ... SN - PB - McGraw Hill CY - New York, NY Y2 - 2024/10/10 UR - ppp.mhmedical.com/content.aspx?aid=1198803008 ER -