msc clinical pharmacy pharmaceutical care plan...mortality rates for alcoholic liver disease (ald)....

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MSC CLINICAL PHARMACY PHARMACEUTICAL CARE PLAN

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A . P A T I E N T B A C K G R O U N D A N D M E D I C A T I O N L I S T

Reason for selecting this patient

The hospital at which I work has one of the highest rates of emergency admissions for alcohol-related liver disease in the UK, and one of the worst

mortality rates for alcoholic liver disease (ALD). Combined with the fact that ALD is a topic in this semester’s MOT unit, I have decided to base my care plan

on a patient presenting with variceal bleed secondary to portal hypertension in ALD. As I am currently in a non-patient-facing rotation, I have accessed the

patient notes remotely, and presented this care plan from a hypothetical point of view.

Patient Details

Initials: AR Age: 77 years Female

Weight: 61.2 kg Height: 142 cm BMI: 28.7 kg/m2

Patient History

Presenting Complaint:

Vomiting blood

Black stools

History of presenting complaint:

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Patient History

Started coughing and vomiting fresh red blood last night at midnight and has continued to vomit blood this morning

Also started with black stools yesterday

o Opening bowels more than usual but no signs of fresh blood in stool

Reports feeling dizzy on standing when mobilising to toilet and an exercise tolerance on the level of 15 metres.

Denies abdominal pain, collapse, syncope, shortness of breath, chest pain, chest tightness, palpitations

No stigmata of chronic liver disease, and does not have ascites.

Not eating or drinking much over the last 4 – 5 days

Has noticed her abdomen become slightly distended over the last 12 months – non-tender with no palpable masses

Last had alcohol yesterday

Obs on admission: BP 128/55 mmHg; GCS 15/15; RR 16 resp/min; HR 94 bpm; T 36.9 °C; SpO2 96 % on RA

Past Medical/Surgical/Mental Health History:

Depression

Chronic alcohol excess (ongoing for 8 years)

o Drinking 1 – 2 bottles of white wine (18 units) daily for the last 18 months

Osteoporosis

o History of left radial distal fracture

Chronic lower back pain

Social History:

Lives alone in ground floor flat (widowed)

“Doesn't get out of the house much”

Nil carers and independently mobile

Never smoked

Impression/Diagnosis:

Upper gastrointestinal (GI) bleed

o Identified contributory factors include chronic excess alcohol intake, and use of ibuprofen

Plan:

Medicines reconciliation

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Patient History

Stop ibuprofen and start IV omeprazole

Gastroscopy (OGD)

Alcohol withdrawal pathway (CIWA-Ar scoring and chlordiazepoxide PRN)

Check haematinics

Abdominal ultrasound scan (USS) in light of chronic alcohol intake

Medication History

Medication List Indication and Evidence

Adcal-D3 caplets - TWO caplets BD PO Combination product containing calcium carbonate and colecalciferol, used

as adjunctive therapy for the management of osteoporosis.(1) Dietary

calcium and vitamin D intake may be deficient in patients with poor

nutritional status secondary to alcohol misuse.

Thiamine tablet 50 mg QDS PO Vitamin B1 supplement for treatment of deficiency, often associated with

poor nutritional intake secondary to alcohol misuse.(1)

Mirtazapine tablet 15 mg ON PO

(switched from citalopram 20 mg OD in February 2017)

Antidepressant licensed for the treatment of depressive episodes.(2) NICE

guidance states that mirtazapine is considered an appropriate alternative to

SSRIs for treatment of patients taking concomitant NSAIDs, or if response to

initial antidepressant choice is inadequate.(3,4)

Zopiclone tablet 3.75 mg ON PRN PO Hypnotic for short-term treatment of insomnia.(2)

Co-codamol 8 mg/500 mg tablet – ONE or TWO tablets QDS PRN PO Compound analgesic preparation.(2)

Ibuprofen 400 mg TDS PRN PO (buys over-the-counter) NSAID for lower back pain.(5)

Poor concordance – patient says she does not take her tablets very often. Infrequency of dispensing, and dates and counts of PODs corroborate this.

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Medication History

Medication List Indication and Evidence

Allergies/Sensitivities No known drug allergies or intolerances.

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B . P R O G R E S S N O T E S A N D M E D I C A T I O N C H A N G E S

Progress Notes

Date Notes

19/04/17 Patient admitted with haematemesis and melaena. Medicines reconciliation completed – patient is not adherent with her prescription

medications. USS abdomen was not done as a recent one from January exists. This scan reports fatty/cirrhotic changes to her liver and

some evidence of portal hypertension.

OGD was abandoned due to vomiting of blood and fear of aspiration. This has been rescheduled for the next day, but she may need to

have emergency scope overnight if there is any deterioration.

Patient has also been reviewed by the gastroenterology team – varices seen but obviously cannot be positively identified as the source

of bleeding. Their plan is to transfuse with target Hb of 8-9 g/dL, and start terlipressin, co-amoxiclav, phytomenadione, and

omeprazole IV.

Overnight the patient has had ongoing melaena but no haematemesis.

21/04/17 AR has been relatively well overnight – she isn’t encephalopathic or tremulous, and her melaena has settled. OGD today has confirmed

variceal bleed, and 4 oesophageal varices have been banded. CIWA-Ar scores have been 0 or 1, and she has not needed any doses of

chlordiazepoxide.

Patient has also been seen by a psychiatry consultant – no signs of severe depression or suicidal ideation reported. His plan is to restart

mirtazapine 15 mg ON, and refer her to community drug and alcohol recovery services (Achieve Salford).

24/04/17 Patient has been transferred to a specialist GI/hepatology ward. She has been stable over the past few days, with no further bleeds,

not signs of withdrawal, or encephalopathy. She has been started on loperamide for loose stools, and injectable medicines have been

converted to oral formulations/alternatives.

A beta-blocker (carvedilol) has been initiated for treatment of portal hypertension, and terlipressin therapy discontinued. A repeat USS

liver was done today to look for changes since January – a coarse texture of the liver was observed in keeping with cirrhosis. The

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Progress Notes

Date Notes

hepatic portal vein was poorly visualised so an outpatient USS will be needed for portal vein assessment.

27/04/17 Blood tests have shown mild hypokalaemia which is being treated with a short oral replacement course. Subjectively, AR appears low

in mood with very flat affect so a second mental health liaison team referral was made. She has also been commenced on rifaximin by

the gastro consultant for prophylaxis of hepatic encephalopathy.

The patient has been seen by a different psychiatry consultant; their plan is to continue mirtazapine and refer her for follow-up by a

named community psychiatry consultant. Mirtazapine was never prescribed following the initial psychiatry assessment, so this has

been corrected.

01/05/17 AR was finally been by seen by the inpatient alcohol specialist nurse on 28/04/17. She was assessed, counselled, and referred back to

Achieve Salford alcohol recovery services in the community. She is motivated to aim for abstinence on discharge, but obviously needs

to engage with Achieve for psychosocial support and relapse prevention. Pharmacological interventions for alcohol dependence e.g.

acamprosate have not been utilised at this point.

AR is medically fit for discharge.

Medication Changes

Medication List Dose Frequency Route Indication Start/Continued

Date

Stop Date

Pabrinex Intravenous High Potency

injection

TWO pairs TDS IV Vitamin prophylaxis of Wernicke’s

encephalopathy in at-risk patients.(1,6)

19/04/17

(new on

admission)

23/04/17

Chlordiazepoxide capsule 10 - 30 mg Every 1 to PO Treatment of alcohol withdrawal.(2) Dose 19/04/17 On discharge

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Medication Changes


Date

Stop Date

4 hours

PRN as per

CIWA-Ar

score

guided by symptom-triggered CIWA-Ar

score as per trust policy.(6)

(new on

admission)

Omeprazole injection 40 mg BD IV Treatment of major upper GI bleed,

although guidance advises that this

shouldn’t be started before gastroscopy,

and little evidence exists to support use of

PPIs in variceal haemorrhage.(7–9)

19/04/17

(new on

admission)

23/04/17

Terlipressin (Variquel) injection 1 mg Every 6

hours

IV Treatment of variceal bleeding in line with

marketing authorisation, trust guidance,

an d BSG guidelines.(8–10)

19/04/17

(new on

admission)

24/04/17

Phytomenadione injection 10 mg BD IV Vitamin K injection for correction of raised

INR secondary to fat malabsorption in

hepatic disease.(1)

19/04/17

(new on

admission)

20/04/17

(3 doses given)

Co-amoxiclav injection 1.2 grams Every 8

hours

IV Antibiotic therapy for variceal bleed in line

with BSG guidelines.(8)

19/04/17

(new on

admission)

20/04/17

Adcal-D3 caplets TWO

caplets

BD PO Adjunctive therapy in the management of

osteoporosis, as discussed above.(1)

19/04/17 Continued

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Medication Changes


Date

Stop Date

(pre-admission)

Metoclopramide injection 10 mg Every 8

hours PRN

IV Treatment of nausea and vomiting in

actively vomiting patient.(2)

20/04/17 23/04/17

Piperacillin/tazobactam injection 4.5 grams Every 8

hours

IV First line antibiotic therapy for acute

upper GI bleed in cirrhotic patients

according to trust antibiotic policy, and

BSG guidelines on management of variceal

haemorrhage.(8,11)

20/04/17 23/04/17

Loperamide capsule 2 mg PRN after

each loose

motion

(max. 16

mg daily)

PO Antimotility agent licensed for treatment

of acute diarrhoea.(7)

23/04/17 On discharge

Omeprazole capsule 40 mg BD PO Oral conversion from IV omeprazole.

Needs reviewing if ulceration not found on

scope.(8)

23/04/17 Continued

Metoclopramide tablet 10 mg TDS PRN PO Oral conversion; antiemetic for

management of nausea and vomiting.(2)

23/04/17 On discharge

Co-amoxiclav tablet 625 mg TDS PO Oral step-down from Tazocin for

treatment of acute upper GI bleed in

cirrhotic patients according to trust

policy.(11) To complete recommended 7

23/04/17 27/04/17

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Medication Changes


Date

Stop Date

day course.

Vitamin B compound strong tablet TWO

tablets

TDS PO Vitamin prophylaxis of Wernicke’s

encephalopathy. Evidence for use in

addition to thiamine is poor, and does not

form part of update trust guidance.(6)

23/04/17 04/05/17

Thiamine tablet 50 mg QDS PO Oral vitamin prophylaxis for Wernicke’s

encephalopathy in line with trust policy.(6)

To complete recommended 10 day

course.

23/04/17 04/05/17

Carvedilol tablet 3.125 mg BD PO Beta-blocker used for treatment of portal

hypertension, as prophylaxis of further

variceal bleeding.

24/04/17 Continued

Sando-K effervescent tablet TWO

tablets

TDS PO Oral potassium preparation for correction

of mild hypokalaemia.(1)

26/04/17 29/04/17

Rifaximin tablet 550 mg BD PO It is unclear from the notes what the

indication for rifaximin is, and should be

reviewed (see below). It is approved by

NICE for prevention of recurrence of overt

hepatic encephalopathy.(12)

27/04/17 Continued

Mirtazapine tablet 15 mg ON PO Appropriate choice of antidepressant

therapy in patient with history of GI bleed,

and advised by two separate psychiatry

27/04/17 Continued

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Medication Changes


Date

Stop Date

consultants.(2,4)

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C . M O N I T O R I N G P L A N

Monitoring Plan

Parameter Justification Frequency Result(s) and Action Plan

Urea & electrolytes Routine monitoring for all

hospital inpatients.

Raised urea may indicate renal

impairment alongside raised

creatinine, although variceal

haemorrhage will cause raised

urea as well.

Omeprazole is known to cause

electrolyte abnormalities

including hyponatraemia and

hypomagnesaemia. (7)

Antidepressants are also

associated with hyponatraemia,

and may be additive with PPIs,

but the risk is highest with SSRIs

than other antidepressants.

Monitoring of hypokalaemia and

treatment with Sando-K.

Monitoring of serum calcium

levels is advised with Adcal-D3

therapy.

On admission

and every 2 –

3 days.

19/04 20/04 24/04 25/04 28/04 30/04 02/05

Na+

(133 -146

mmol/l)

140 143 138 138 136 140 139

K+ (3.5 –

5.3

mmol/l)

3.9 3.6 3.0 H 3.2 3.2 3.6

Urea (2.5

– 7.8

mmol/l)

5.5 7.2 8.6 8.8 7.1 5.4 5.0

Corrected

Ca2+ (2.2

– 2.6

mmol/l)

NA NA 2.32 2.25 2.42 2.44 2.49

Mg2+ (0.7

– 1

mmol/l)

NA NA 0.83 0.81 NA NA NA

PO43- (0.8

– 1.5

mmol/l)

NA NA 0.70 H 0.70 0.96 1.05

Patient mildly hypokalaemic which was corrected following a three day course of

Sando-K. Raised levels of serum urea are most likely due to variceal haemorrhage.

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Monitoring Plan


Creatinine / eGFR /

ClCr

Routine monitoring for hospital

inpatients – allows identification

of renal pathology e.g. AKI which

may result secondary to hepatic

disease, blood loss, or

antihypertensive medication like

carvedilol.

Drugs (or drugs with metabolites)

cleared by renal excretion will

need dose adjustments in renal

impairment.

On admission

and every 2 –

3 days.

19/04 20/04 24/04 25/04 26/04 28/04 30/04 02/05

Creatinine

(44 – 97

µmol/l)

85 73 72 82 83 97 95 98

eGFR

(ml/min/1.73

m2)

56 67 68 59 58 48 49 48

ClCr (ml/min) 47.2 54.9 55.7 48.9 48.3 41.3 42.2 40.9

Renal function mildly impaired, and creatinine clearance according to Cockroft &

Gault formula has fluctuated slightly. No dose adjustments were necessary.

Liver function tests

including INR & PT

Liver screen

Routine bloods for newly

admitted inpatients. Patient has

presented with possible variceal

bleed and history of alcohol

dependence so assessment of

degree of hepatic impairment is

indicated.

Raised ALT and GGT in particular

are indicative of alcoholic liver

disease. Bilirubin and ferritin are

often also raised.

Albumin and INR/PT are

On admission

and every 2 -

3 days.

19/04 20/04 21/04 24/04 25/04 28/04 30/04 02/05

ALP (30

– 130

U/l)

144 104 89 88 73 104 106 103

ALT (7 -

40 U/l)

36 29 33 46 46 69 66 61

Bilirubin

(0 – 20

µmol/l)

53 67 88 101 90 85 69 67

GGT

(<73 U/l)

NA NA 253 NA NA NA NA NA

Albumin

(35 – 50

34 29 28 31 30 28 26 25

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Monitoring Plan


measures of synthetic function of

the liver. Low albumin levels are

indicative of chronic liver disease

due to its long circulating half-

life. Low levels of plasma proteins

including albumin will increase

the free fraction and thus

systemic exposure to highly

protein bound drugs.

Significantly deranged LFTs may

necessitate dose adjustment or

discontinuation of drugs which

are hepatically metabolised or

are known to be hepatotoxic.

The liver screen allows

identification of potential causes

of any observed derangement in

hepatic function including

malignant and viral causes.

g/l)

INR (0.8

– 1.1)

1.6 1.5 NA 1.4 NA NA NA NA

PT (9.2 –

12.7

seconds)

19.5 18.3 NA 16.5 NA NA NA NA

CEA (0 – 3 µg/l) 3

Serum ferritin (10 – 291 µg/l) 1281

Alpha-1-antitrypsin (0.8 – 2.0 g/l) 1.8

Ceruloplasmin (0.17 – 0.34 g/l) 0.17

Viral serology (hepatitis A,B,C) NAD

USS abdomen/liver Discussed above

Results from standard LFTs and liver screen alongside patient history and USS are

indicative of alcoholic liver disease. Raised INR and low albumin indicate impaired

synthetic function which may result in reduced clearance of hepatically-

metabolised drugs. ALT and ALP are not significantly raised. Malignant/viral

causes are unlikely.

Full blood count Routine monitoring for all

inpatients. Hb monitoring is

On admission

and every 2 - 19/04 20/04 24/04 25/04 26/04 28/04 30/04 02/05

Hb (130 – 119 108 84 83 85 94 86 89

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Monitoring Plan


required in patients with active

bleeding, and for patients

receiving blood transfusions

(target in this patient was 80 – 90

g/l).

Raised neutrophils and WCC are

usually indicative of systemic

infection.

MCV allows for identification of

micro- or macrocytic anaemia,

which may arise in patients with

alcohol dependence as a result of

poor nutritional intake.

Thrombocytopenia is a risk factor

for bleeding so a platelet count is

indicated.

3 days. 180 g/l)

WCC (4.0 –

11.0 ×109/l)

12.9 11.7 10.0 9.8 9.8 12.4 10.9 10.2

Neutrophils

(1.8 – 7.5

×109/l)

11.2 9.3 8.3 7.7 7.9 10.2 8.2 7.9

Platelets

(150 – 450

×109/l)

150 122 90 100 132 228 226 189

MCV (84 –

105 fl)

106.7 107.5 112.6 111.9 109.0 110.9 113.1 112.4

Falling Hb observed due to blood loss from variceal haemorrhage. Hb

subsequently maintained within target range of 80 – 90 g/l. Platelet count dipped

slightly and recovered – this may be related to resolving haemorrhage.

WCC and neutrophils are slightly raised but patient was apyrexial throughout

admission so systemic infection is unlikely.

Raised MCV indicates there may be underlying macrocytic anaemia in this patient.

Active bleeding makes interpretation of Hb more difficult. The most common

causes of macrocytic anaemias are vitamin B12 and thiamine deficiency but these

were not specifically tested for. Such deficiencies are more common in patients

dependent on alcohol due to poor nutritional intake.

B12 and folate To screen for deficiency in light of

low Hb, raised MCV, and alcohol

As needed Not done unfortunately.

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Monitoring Plan


dependence and poor diet.

CIWA-Ar Symptom-triggered monitoring

for the signs of alcohol

withdrawal in a patient with 18

month history of drinking 2

bottles of wine per day.

Every 1 – 4

hours based

on CIWA

score.

Patient was scoring 0 -1 during this admission, and not requiring any doses of

chlordiazepoxide.

AUDIT-C Assessment of severity of alcohol

use or dependence.

Once, during

admission.

Total score of 24 - indicating possible dependence on alcohol.

Temperature Routine monitoring as part of

NEWS scoring. Indicative of

systemic infection if pyrexial.

Frequency

adjusted as

per NEWS

Apyrexial throughout admission.

OGD To look for source of GI bleed e.g.

varices or peptic ulcer.

As needed. Varices seen and variceal source of bleeding confirmed – 4 varices were

endoscopically banded.

USS To visualise fatty or cirrhotic

changes to the liver and assess

the hepatic portal vein.

As needed. Results discussed above.

ECG

Routine for patients on

admission. Patient had brought in

a box of citalopram which she

may still have been taking, and

which is known to cause QT

prolongation.

On admission

and as

needed.

No abnormalities detected.

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Monitoring Plan


SpO2 Routine monitoring as part of

NEWS scoring.

Frequency

adjusted as

per NEWS

Oxygen saturations maintained within target range of 94 – 98 % on room air

Respiratory rate (RR) Routine monitoring as part of

NEWS scoring.

Frequency

adjusted as

per NEWS

Within the normal range of 15 – 20 breath/min throughout admission.

Blood pressure (BP) Routine monitoring as part of

NEWS scoring. Blood loss and

carvedilol can both cause a drop

in BP and thus needs to be

monitored.

Frequency

adjusted as

per NEWS

BP was 128/55 mmHg on admission. During her inpatient stay, the patient’s

systolic BP peaked at 170 mmHg, and her lowest recorded diastolic BP was 45

mmHg. On average her BP before initiation of carvedilol was approx. 140/70

mmHg, which dropped to approx. 125/60 mmHg following initiation of the beta-

blocker.

Heart rate (HR) Routine monitoring as part of

NEWS scoring. Beta-blockers

such as carvedilol affect HR in

particular and monitoring of HR is

required.

Frequency

adjusted as

per NEWS

HR was 94 bpm on admission. Her peak recorded HR was 122 bpm, and the

minimum recorded was 59 bpm. On average her HR was around 80 bpm before

initiation of carvedilol, which then dropped to approx. 70 bpm after carvedilol

was started.

Vitamin D Patient has osteoporosis, poor

nutritional intake, and has stated

that she does not leave the

house very much. She is

therefore at risk of deficiency

which in turn is a major

modifiable risk factor for

osteoporosis.

As needed. Results from last month showed serum 1,25-dihydroxyvitamin D3 and 1,25-

dihydroxyvitamin D2 levels in normal range.

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Monitoring Plan


Pain score Routine monitoring as part of

NEWS scoring. Patient takes

ibuprofen and co-codamol on a

PRN basis

Frequency

adjusted as

per NEWS

Scoring 0-1 out of 3 throughout admission.

Bristol stool chart Routine observation for

inpatients. Patient presented

with melaena and increased

frequency of passing stools.

Frequency

adjusted as

needed. Each

movement

should be

recorded.

More frequent type 6 or 7 stools during the first few days of admission.

Frequency and type settled after a few days, and after starting PRN loperamide.

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D & E . I D E N T I F I C A T I O N O F C L I N I C A L P R O B L E M S A N D A C T I O N P L A N

Analysis of Clinical Problems

Clinical Problem Assessment Priority Action Taken and Outcome

Variceal bleed Main reason for presentation and

high risk of morbidity/mortality.

Likely secondary to chronic alcohol

excess and possibly OTC ibuprofen

use.

High Four oesophageal varices were banded.

Ibuprofen was stopped and the patient was

advised to avoid using prescription or OTC

NSAIDs.

An alcohol specialist nurse referral was made,

who assessed and counselled the patient, and

has made a referral to the community drug

and alcohol team (Achieve Salford). AR seems

motivated to aim for abstinence on discharge

but will need strong psychosocial support.(13)

Drug interventions were not opted for in this

case.

Antibiotics were initiated as per BSG guidance,

but the initial choice of IV co-amoxiclav is not

in line with Trust policy, so she was changed to

Tazocin very shortly afterwards, before step

down to oral co-amoxiclav as appropriate to

complete 7 day course.(8,11)

Patient was started on omeprazole but this

should be reviewed as the OGD did not exhibit

any peptic ulceration. The source of bleeding

was confirmed as oesophageal varices.(8)

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Portal hypertension Portal hypertension secondary to

ALD results in oesophageal varices

and ultimately leading to current

presentation.

High Carvedilol initiated for the unlicensed

indication of prophylaxis of further variceal

bleed due to portal hypertension. This is the

routine choice of beta-blocker in the trust for

this indication and there is building evidence of

superior efficacy to others e.g.

propranolol.(14)

Small but acceptable dips in HR and BP were

observed.

Risk of alcohol withdrawal, and

Wernicke’s and hepatic

encephalopathy

Patient at risk of alcohol withdrawal

due to excessive daily alcohol intake.

Poor nutritional intake and ALD are

risk factors for Wernicke’s and

hepatic encephalopathy respectively.

High Patient placed on the alcohol withdrawal

pathway as per trust policy.(6) Her CIWA-Ar

scores were low (between 0 and 1) so she did

not require any PRN doses of chlordiazepoxide.

Pabrinex was prescribed for vitamin

prophylaxis of Wernicke’s encephalopathy

although the dose of this was too high (2 pairs

TDS is recommended for fulminant Wernicke’s

rather than those at low risk) and our policy is

to restrict use in these cases to 3 days rather

than 5.(6) Oral thiamine and vitamin B co-

strong were prescribed for the recommended

period of 10 days, but the evidence for use of

vitamin B above thiamine monotherapy is poor

and it is not advised in updated guidance.

Rifaximin was initiated by the gastro consultant

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but the indication for this is unclear, as it is not

specified at the point of initiation, and the

patient was not overtly encephalopathic.

The only licensed and NICE/GMMMG-

approved indication at this dose is for

prevention of recurrence of hepatic

encephalopathy. All other unlicensed

indications e.g. prophylaxis of SBP would need

an individual funding request (IFR).

Alcohol dependence AUDIT-C score of 24 – indicative of

possible dependence. Alcohol

dependence will be contributing to

worsening chronic liver disease, and

is the main cause of the variceal

bleed.

High Alcohol specialist nurse referral made, as

discussed above.

Low mood Patient has been treated for

depression previously. Current low

mood may be related to recent loss

of husband, alcohol dependence, and

poor physical health. It is recognised

that unmanaged depression is

associated with worse outcomes for

co-existing physical health

problems.(4)

Medium Mental health liaison team (MHLT) referral

made and the patient was reviewed by two

separate psychiatry consultants. She has been

re-started on mirtazapine and is to be

followed-up by a named community psychiatry

consultant.

Mirtazapine was unfortunately not initiated for

many days despite pharmacist intervention

and two MHLT reviews advising it. Mirtazapine

has a lower bleed risk vs SSRIs so is an

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appropriate choice of antidepressant.(2,4)

Poor adherence to medications Patient identified as being non-

concordant with her medications and

admits that she does not take her

tablets very often

Medium The patient should be counselled about the

importance of taking her medications regularly

as prescribed. There are likely multiple factors

contributing to her poor adherence, such as

alcohol dependence and depression. Regular

and multi-source follow-up and psychosocial

support e.g. from her GP, community

psychiatrist, Achieve Salford, community

pharmacists will be key to improving her

concordance.

If consenting, the patient could be referred for

post-discharge Medicines Use Review with her

community pharmacy.

VTE risk assessment All patients should be assessed for

risk of hospital-acquired VTE on

admission and whenever the clinical

picture changes, as mandated by

NICE guidelines and the NHS

standard contract.(15)

Medium Done on admission and LMWH not indicated,

but AR was not reassessed following banding

and cessation of active bleeding. Her INR

remained raised but liver disease is generally

pro-thrombotic so the reassessment should

have taken place.

Loose stools Presented with melaena and

increased frequency of loose stools.

Low C. difficile PCR and antigen tests were not

taken. Resolution of bleeding and loperamide

appear to have settled her bowel symptoms

but she still received metoclopramide, a

prokinetic, concurrently. I would have advised

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considering an alternative antiemetic with less

of a prokinetic effect e.g. cyclizine.

Chronic lower back pain Patient has a documented chronic

lower back pain on GP record.

Low Pain scores of 0 – 1 throughout admission so

not requiring analgesic medicines as inpatient.

Patient should be counselled on discharge

about avoiding NSAIDs like ibuprofen, and

using lowest effective doses of paracetamol

and/or codeine in light of her liver impairment.

Osteoporosis Past medical history of osteoporosis.

Has numerous risk factors for the

disease as discussed previously.

Low Poor nutritional intake and not leaving the

house very much means she is at risk of

vitamin D deficiency although recent serum

vitamin D levels were in normal range. Adcal-

D3 compliance is important for this patient and

this should be re-affirmed – if she is not

tolerating this particular formulation,

alternatives can be offered.

I would be cautious about advising oral

bisphosphonates like alendronic acid due to

the risk of oesophageal irritation.

Anaemia Patient presented with low Hb

(confounded by concurrent

haemorrhage) but also high MCV.

Medium Unfortunately vitamin B12 and folate levels

were not taken to investigate macrocytic

anaemia further. These could be done as an

outpatient and any deficiencies corrected e.g.

with hydroxocobalamin IM or oral folic acid 5

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mg daily.

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F . F O L L O W - U P A N D F U T U R E P L A N

Follow Up Plan (including discharge requirements, future planning and ongoing assessments)

Follow Up Requirement Action Taken/Future Plan

Patient counselling regarding her new medications – mirtazapine, carvedilol,

omeprazole, rifaximin.

Mirtazapine - this can be sedating so it is best taken at night, and the sedating

effects lessen with time. It can take up to 6 weeks to see any change in mood,

so adherence is important, and sudden cessation might trigger

discontinuation symptoms. She will be reviewed in the community and the

dose may be increased, and courses usually last at least 6 months to have the

best overall effect. She should also be aware of the signs of serotonin

syndrome e.g. agitation and muscle twitching, and to seek medical help if

these are experienced.

Carvedilol – a beta-blocker to lower the pressure in a vein supplying the liver.

This will help reduce the risk of the varices re-bleeding so again, adherence is

important. The patient should be advised not to abruptly stop taking this

medicine as it can cause serious rises in blood pressure, and to report if she

feels dizzy particularly when standing.

Omeprazole – reduces stomach acid to help with symptoms of reflux. See

comments above about whether this is indicated for GI bleed.

Rifaximin – side effects are largely gastrointestinal and mild as it is poorly

absorbed from the GI tract, it may discolour urine red but this is unlikely.

Whether this is indicated or need IFR is discussed above, as the indication is

not clearly documented within the patient’s notes.

Avoid NSAIDs such as ibuprofen as these may have aggravated the bleed.

Refer to the New Medicines Service is the patient consents as she is eligible

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Follow Up Plan (including discharge requirements, future planning and ongoing assessments)

Follow Up Requirement Action Taken/Future Plan

due to initiation of carvedilol.

Management of alcohol dependence Reviewed by alcohol specialist nurses as an inpatient and referred to Achieve

Salford community alcohol recovery services. She appears motivated to aim

for abstinence on discharge but will need to engage with Achieve for

psychosocial support and relapse prevention in order to maximise her

chances of succeeding.

Pharmacological management options have not been chosen.

Mental health follow-up Counselling about mirtazapine as above.

Signs of re-bleed Haematemesis and melaena are the key signs of variceal bleed. This can be

life-threatening and she should emergency medical assistance if she suspects

re-bleeding.

Investigation of possible macrocytic anaemia GP can arrange for vitamin B12 and folate levels to be taken in the community

to ascertain underlying cause of low Hb and raised MCV.

Gastroenterology follow-up Patient has been referred for a further USS liver as an outpatient to examine

the hepatic portal vein and blood flow. She should be followed up by

gastroenterology as an outpatient, and may be referred back to the Well

Liver Clinic.

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G . C O N T I N U I N G P R O F E S S I O N A L D E V E L O P M E N T

Learning Plan

Learning Need Identified Action Taken Completion Date

Unfamiliar with variceal bleed guidelines. I was not aware of any national guidelines regarding variceal bleed

management, and I was up to date with my local trust policy either. I have

since read these guidelines and applied them to this case and will apply them

in future cases. Of particular note, I have learned that proton pump inhibitors

are not indicated following variceal bleed as little evidence exists to support

their use

08/05/17

Roles and structure of the inpatient alcohol

specialist nurse services, and community alcohol

recovery services.

I have asked if I could spare some time to shadow an alcohol specialist nurse

one morning or afternoon. In particular I would like to ask about role of

hospital and community pharmacists in managing patients with alcohol

dependence, structure of the services in the area, and criteria and protocols

for pharmacological management.

In progress

Evidence for carvedilol vs propranolol in portal

hypertension.

Find reviews and primary evidence regarding the use of carvedilol for portal

hypertension. I will also contact our gastroenterology/hepatology specialist

pharmacist for assistance in locating this evidence.

12/05/17

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H . E V I D E N C E A N D R E F E R E N C E S

Reference List

1. Joint Formulary Committee. 9 Nutrition and blood. In: British National Formulary. 72nd ed. London: BMJ Group and Pharmaceutical Press; 2016.

2. Joint Formulary Committee. 4 Central Nervous System. In: British National Formulary. 72nd ed. London: BMJ Group and Pharmaceutical Press; 2016.

3. National Institute for Health and Care Excellence. Depression in adults: recognition and management (CG90). London; 2009.

4. National Institute for Health and Care Excellence. Depression in adults with a chronic physical health problem: recognition and management (CG91). London; 2009.

5. Joint Formulary Committee. 10 Musculoskeletal and joint diseases. In: British National Formulary. 72nd ed. London: BMJ Group and Pharmaceutical Press; 2016.

6. Brown R, Pennington H. Management of alcohol withdrawal including the symptom triggered CIWA score. Salford Royal NHS Foundation Trust; 2016.

7. Joint Formulary Committee. 1 Gastrointestinal system. In: British National Formulary. 72nd ed. London: BMJ Group and Pharmaceutical Press; 2016.

8. Tripathi D, Stanley AJ, Hayes PC, Patch D, Millson C, Mehrzad H, et al. UK guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut. 2015;64(11):1680–704.

9. Conlin A. A Guideline for the Management of Acute Upper Gastrointestinal Bleeding. Salford Royal NHS Foundation Trust; 2015.

10. Joint Formulary Committee. 6 Endocrine System. In: British National Formulary. 72nd ed. London: BMJ Group and Pharmaceutical Press; 2016.

11. Antibiotic Steering Committee. Antibiotics Guidelines: Gastrointestinal Infections. Salford Royal NHS Foundation Trust; 2016.

12. National Institute for Health and Care Excellence. Rifaximin for preventing episodes of overt hepatic encephalopathy (TA337). London; 2015.

13. National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (CG115). London; 2011.

14. Li T, Ke W, Sun P, Chen X, Belgaumkar A, Huang Y, et al. Carvedilol for portal hypertension in cirrhosis: systematic review with meta-analysis. BMJ

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Reference List

Open. 2016 May 4;6(5).

15. National Institute for Health and Care Excellence. Venous thromboembolism: reducing the risk for patients in hospital (CG92). London; 2010.

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I . P R O F E S S I O N A L F R A M E W O R K M A P P I N G

RPS Foundation Framework

Cluster 1 Patient and Pharmaceutical

Care

Cluster 2 Professional Practice Cluster 3 Personal Practice Cluster 4 Management and

Organisation

1.1 Patient Consultation 1.2 Need for Medicine 1.3 Provision of Medicine 1.4 Selection of Medicine 1.5 Medicine Specific Issues 1.6 Medicines Information and

Patient Education 1.7 Monitoring Medicine Therapy 1.8 Evaluation of Outcomes 1.9 Transfer of Care

2.1 Professionalism 2.2 Organisation 2.3 Effective Communication Skills

2.4 Team Work 2.5 Education and Training

3.1 Gathering Information 3.2 Knowledge 3.3 Analysing Information 3.4 Providing Information 3.5 Follow Up 3.6 Research and Evaluation

4.1 Clinical Governance 4.2 Service Provision 4.3 Organisations 4.4 Budget and Reimbursement 4.5 Procurement 4.6 Staff Management

RPS Advanced Pharmacy Framework

Cluster 1 Expert

Professional Practice

Cluster 2 Collaborative

Working Relationships

Cluster 3 Leadership Cluster 4 Management Cluster 5 Education,

Training and

Development

Cluster 6 Research and

Evaluation

1.1 Expert Skills and Knowledge AS1 AS2 M

1.2 Delivery of Professional Expertise AS1 AS2 M

1.3 Reasoning and Judgement

2.1 Communication AS1 AS2 M

2.2 Teamwork and Consultation AS1 AS2 M

3.1 Strategic Context AS1 AS2 M

3.2 Governance AS1 AS2 M

3.3 Vision AS1 AS2 M

3.4 Innovation AS1 AS2 M

4.1 Implementing National Priorities AS1 AS2 M

4.2 Resource Utilisation AS1 AS2 M

4.3 Standards of Practice AS1 AS2 M

4.4 Management of Risk

5.1 Role Model AS1 AS2 M

5.2 Mentorship AS1 AS2 M

5.3 Conducting Education and Training AS1 AS2 M

5.4 Professional

6.1 Critical Evaluation AS1 AS2 M

6.2 Identifies Gaps in the Evidence Base AS1 AS2 M

6.3 Develops and Evaluates Research Protocols

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RPS Advanced Pharmacy Framework

Cluster 1 Expert

Professional Practice

Cluster 2 Collaborative

Working Relationships

Cluster 3 Leadership Cluster 4 Management Cluster 5 Education,

Training and

Development

Cluster 6 Research and

Evaluation

AS1 AS2 M 1.4 Professional

Autonomy AS1 AS2 M

3.5 Service Development AS1 AS2 M

3.6 Motivational AS1 AS2 M

AS1 AS2 M 4.5 Managing

Performance AS1 AS2 M

4.6 Project Management AS1 AS2 M

4.7 Managing Change AS1 AS2 M

4.8 Strategic Planning AS1 AS2 M

4.9 Working Across Boundaries AS1 AS2 M

Development AS1 AS2 M

5.5 Links Practice and Education AS1 AS2 M

5.6 Educational Policy AS1 AS2 M

AS1 AS2 M 6.4 Creates Evidence

AS1 AS2 M 6.5 Research Evidence

into Working Practice AS1 AS2 M

6.6 Supervises Others Undertaking Research AS1 AS2 M

6.7 Establishes Research Partnerships AS1 AS2 M

msc clinical pharmacy pharmaceutical care plan...mortality rates for alcoholic liver disease (ald)....

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