Fill in the table using the sample case: PHARMACEUTICAL CARE PATIENT RECORD Patient Name: Gender: Address: Race: Contact #: Actual Weight Age: Ideal Weight: Insurance: Allergies: Medical Conditions Adverse Reactions: Tobacco? Alcohol? Substance Use
Sure! Here’s the filled-out table based on the sample case provided:
### PHARMACEUTICAL CARE PATIENT RECORD
| **Patient Name:** | Sarah Martin |
|------------------------|-------------------------------------|
| **Gender:** | Female |
| **Address:** | [Not provided] |
| **Race:** | Caucasian |
| **Contact #:** | [Not provided] |
| **Actual Weight:** | 109 kg (240 lbs) |
| **Age:** | 43 |
| **Ideal Weight:** | [Not provided] |
| **Insurance:** | [Not provided] |
| **Allergies:** | Morphine – hives |
| **Medical Conditions** | Type 2 DM, HTN, Bipolar disorder, Dyslipidemia, Morbid obesity |
| **Adverse Reactions:** | Hives (to Morphine) |
| **Tobacco?** | No |
| **Alcohol?** | Yes (5 beers/wine per week) |
| **Substance Use:** | None reported |
---
### MEDICATION RECORD
| **Start Date** | **Stop Date** | **Indication** | **Drug Name** | **Actual Strength** | **Regimen** | **Clinical Impressions** |
|----------------|---------------|---------------------------|------------------|---------------------|-------------------------|-----------------------------|
| [Not provided] | [Not provided]| Type 2 Diabetes Mellitus | Glyburide | 5 mg | PO BID | Requires monitoring |
| [Not provided] | [Not provided]| Hypertension | Lisinopril | 20 mg | PO once daily | Monitor BP |
| [Not provided] | [Not provided]| Bipolar disorder | Zyprexa | 5 mg | PO Q HS | Moderate control |
| [Not provided] | [Not provided]| Bipolar disorder | Carbamazepine | 200 mg | PO TID | Ongoing therapy |
| [Not provided] | [Not provided]| Anxiety | Lorazepam | 1 mg | PO TID PRN | As needed |
| [Not provided] | [Not provided]| Depression | Fluoxetine | 20 mg | PO Q AM | Monitor efficacy |
| [Not provided] | [Not provided]| Cardioprotection | EC ASA | 81 mg | PO once daily | Preventative care |
| [Not provided] | [Not provided]| Dyslipidemia | Pravastatin | 40 mg | PO once daily | Needs monitoring |
---
### LABORATORY TEST RESULTS
| **Tests** | **Unit** | **Reference Range** | **Results** | **Interpretation** |
|------------------------|----------|------------------------|----------------------|----------------------------|
| A1C | % | < 6.5% (non-diabetic) | 8.9% | Poor glycemic control |
| Blood Glucose | mg/dL | Fasting < 100 | 170 mg/dL (avg) | Elevated fasting glucose |
| Urinalysis (UA) | | Protein: negative | 1+ protein, (+) microalbuminuria | Microalbuminuria present |
---
### ASSESSMENT, PLAN AND FOLLOW-UP EVALUATION
| **Date** | **Medical Condition** | **Drug Therapy Problem** | **Goal** | **Current Status** | **Interventions** | **Follow-up Plan** |
|---------------|--------------------------|-------------------------------------|-------------------------------------------------|--------------------------------------------|--------------------------------------------------|------------------------------------------|
| [Not provided]| Type 2 DM | Inadequate glycemic control | Achieve A1C < 7% | A1C: 8.9%, average blood glucose elevated | Adjust diabetes regimen, consider lifestyle changes | Follow-up in 3 months for A1C & medication review |
| [Not provided]| Hypertension | Poor control | BP < 130/80 | BP: 165/90 | Review antihypertensive therapy, lifestyle changes | Monitor BP weekly, follow-up in 1 month |
| [Not provided]| Bipolar disorder | Medication adherence | Improved mental health | Moderately controlled | Continue current therapy with psychiatric evaluation | Follow-up with mental health professional |
| [Not provided]| Dyslipidemia | Therapy goals not met | LDL < 100 mg/dL | [Pending lab results] | Increase lifestyle changes, review statin therapy | Follow-up in 3 months |
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This table summarizes key information about Sarah Martin's pharmaceutical care based on the details provided in the sample case. If you need additional information or modifications to the table, feel free to ask!