Based from the sample case analysis below, accomplish the medication reconciliation form required to obtain the patient’s relevant information and identify any drug therapy problems. Sample Case Analysis Patient ABCDE, 68 years of age, retired enginee

**Medication Reconciliation Form** *Patient's Initial: ABCDE* *Age: 68* *Weight: [Data not provided]* *Height: [Data not provided]* *Allergies: [Data not provided]* *Diagnosis: COPD, Hypertension, Atrial Fibrillation* --- ### MEDICATIONS TAKEN: | Name of the Drug (Generic name and Brand name, if applicable) & Dose | Route | Frequency | Specify if (RESUMED, DISCONTINUED OR MODIFIED) (circle one) | SPECIFY MODIFICATION(S) | |-----------------------------------------------------------------------|-------|-----------|-------------------------------------------------------------|------------------------| | Atrovent (Ipratropium) 2 puffs | Inhalation | qid | R | | | Seretide (Salmeterol/Fluticasone) 250mg 2 puffs | Inhalation | BID | R | | | Ventolin (Salbutamol) 2 puffs | Inhalation | prn | R | | | Furosemide 40mg | PO | BID | R | | | Cardizem (Diltiazem) 240mg | PO | OD | R | | | Amiodarone 200mg | PO | OD | R | | | Warfarin 5mg | PO | Daily | D | Withheld due to INR | | Paracetamol prn | PO | prn | R | | | Prednisone 25mg | PO | daily for 7 days | M | Modified to 2 days at discharge | ### CURRENT MEDICATIONS: | Name of the Drug (Generic name and Brand name, if applicable) & Dose | Route | Frequency | Indication | Continue at Discharge (circle one) | |-----------------------------------------------------------------------|-------|-----------|------------|-----------------------------------| | Atrovent (Ipratropium) 2 puffs | Inhalation | qid | COPD | Y | | Seretide (Salmeterol/Fluticasone) 250mg 2 puffs | Inhalation | BID | COPD | Y | | Ventolin (Salbutamol) 2 puffs | Inhalation | prn | COPD | Y | | Furosemide 40mg | PO | BID | Hypertension | Y | | Cardizem (Diltiazem) 240mg | PO | OD | Hypertension | Y | | Amiodarone 200mg | PO | OD | AF | Y | | Prednisone 25mg for 2 days | PO | daily | Inflammation | Y | | Paracetamol prn | PO | prn | Pain | Y | | Warfarin 5mg | PO | Daily | AF | D (withheld) | | Ampicillin 1g IV 6hrly | IV | 6hrly | Infection | D (not listed for discharge) | ### Are there any discrepancies (intentional/unintentional) observed? Give a concrete medication intervention. **Discrepancies Observed:** 1. Warfarin was withheld during the hospital stay due to a high INR (4) and was discontinued on discharge. The patient was not adequately informed about this change. 2. The previous record indicated the continuation of warfarin, which could lead to confusion upon discharge. **Concrete Medication Intervention:** - Contact the prescribing physician to discuss the discontinuation of warfarin given the patient’s history of atrial fibrillation and ensure the patient understands the need for follow-up INR monitoring before resuming warfarin. --- ### Take Home Medications and Providing Patient Counseling **HOME MEDICATIONS:** | Name of the Drug (Generic name and Brand name, if applicable) & Dose | Route | Frequency | Indication | |-----------------------------------------------------------------------|-------|-----------|------------| | Atrovent (Ipratropium) 2 puffs | Inhalation | qid | COPD | | Seretide (Salmeterol/Fluticasone) 250mg 2 puffs | Inhalation | BID | COPD | | Ventolin (Salbutamol) 2 puffs | Inhalation | prn | COPD | | Furosemide 40mg | PO | BID | Hypertension | | Cardizem (Diltiazem) 240mg | PO | OD | Hypertension | | Amiodarone 200mg | PO | OD | AF | | Prednisone 25mg | PO | daily for 2 days | Inflammation | | Paracetamol prn | PO | prn | Pain | --- ### Based on your medication reconciliation and take-home medications, what are the drugs that need to be clarified with a physician? | Drugs | Reason | |---------------|-------------------------------------------------------------| | Warfarin | Need to clarify whether to resume after monitoring INR levels. Discussion needed regarding its importance in preventing stroke in AF patients. | | Prednisone | Verify the tapering plan post-hospital discharge. Four days of therapy (25mg daily) is generally not tapering, and further clarification may be required. | Ensure follow-up appointments and monitoring requirements are communicated to the patient to prevent any medication-related issues in the future.