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Upon completion of the chapter and exercises, the student pharmacist will be able to

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  1. Recognize the role of deductive reasoning in the drug-monitoring process.

  2. Know what a patient database is and how it is used to monitor drug therapy.

  3. Be able to extract appropriate patient information and integrate it with drug information to formulate a process for monitoring drug therapy.

  4. Understand the utility of common calculations used in monitoring drug therapy in a patient, for example, creatinine clearance, modification of diet in renal disease (MDRD), body mass index (BMI).

  5. Discuss the importance of a chief complaint (CC) and history of present illness (HPI) in monitoring drug therapy.

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Back at the hospital the attending pharmacist has collected additional information.

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One week since his accident, the patient is in the ICU and mechanically ventilated. You are preparing for rounds with the ICU service and notice in the chart an order for levofloxacin 500 mg IV q24h, first dose stat. You obtain the following information from the chart:

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Height 70 in

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Weight 70 kg

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Scr 1.7 (baseline on admission 1.0 mg/dL)

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WBC = 12% neutrophils

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Tmax =101°F

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BP = 100/60

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HR = 85

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Patient Encounter: Discussion

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There are a number of questions that the student should ask about the patient's medication regimen.

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  1. Is the drug being used for an appropriate diagnosis or indication? Knowing the diagnosis establishes a basis for selection of an appropriate medication.

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  • You determine from the chart that the patient is being treated empirically for ventilator-associated pneumonia (VAP).

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  1. Is the dose of the medication appropriate for this specific patient? Take into account patient characteristics such as age, weight, sex, ethnic background, and allergies as well as concurrent disease states and medications used.

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  • You know nothing about VAP or how to treat it. What resources should you access to determine if the treatment with levofloxacin 500 mg IV q24h is appropriate?
  • How will you determine if the dose of levofloxacin is appropriate for patient X, especially since his Scr is increasing? What calculation should you use to determine patient X's renal function?

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  1. What are the most likely adverse effects caused by this medication? Does the patient exhibit any of these adverse effects?

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  • What if your patient began to experience an erythematous rash 2 days after starting levofloxacin? What would you do?

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  1. Are there any patient-specific barriers to taking this medication?

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  • How would you address the family's concerns about withholding antibiotics?

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  1. What proof do you have that the medication is effective?

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  • What objective measures will you follow to determine if the antibiotic is working?

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The purpose of this chapter is to provide some direction primarily for the student ...

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