We acknowledge that your medical records (lab data and diagnostics) are kept confidentally and are also limited in sharing with other healthcare professionals. Our clinic has a distinct plan to overcome this obstacle. We, the clinical pharmacists, need to know the medications that you are taking and interview you for some other medical information or ask you complete a form of questionaires. Based on your medication and disease information, we will draft an indepth report of our medication treatment plan for you and then we will send it to your physician. Upon receiving our report, your physician will response in a time frame depending on the seriousness of the treatment.
Here is a sample counsultation report prepared by a clinical pharmacist. It is a pharmacotherapeutic case exerpted from a textbook of a Doctor of Pharmacy program (Textbook: Physical Assessment: A Guide for Evaluating Drug Therapy by R. Leon Longe (PharmD) and Jon C. Calvert (MD, PhD) )
PHARMACOTHERAPEUTIC CASE ILLUSTRATION
Jon, a 67-year-old male, complained of "weakness, cough, and difficulty breathing, especially if I walk." Jon said he had visited his physician two weeks ago and had his blood pressure medication changed. The shortness of breath has been awakening him at night. He stated that he felt better when he sat up in bed. He had occasional nausea and loss of appetite.
Past medical history revealed appendectomy at age 15, myocardial infarction at age 59, history of peptic ulcer disease (PUD), angina pectoris, and hypertension. The family history disclosed that his father died of a stroke at age 71, his mother died of pneumonia at age 82, and two brothers are alive (one has diabetes mellitus). Two sons are in good health. He has smoked cigarettes 1 to 2 packs per day for 35 years. Furosemide 40 mg PO QD, propranolol 80 mg PO BID, and hydralazine 50 mg PO TID are his current medications. He has no known drug allergies. No significant findings except as outlined in present complaint are reported in the review of systems.
Jon appeared to be a 67-year-old, well-developed and well-nourished male in moderate distress. His vital signs (VS) were as follows: blood pressure (BP) 180/128 mm Hg (supine); pulse 120 beats/min and regular; respiratory rate 20/min with Cheyne-Stokes pattern; temperature 97.8° F (oral). Examination of the heart revealed: apical impulse (PMI) at the 6th intercostal space at the anterior axillary line; S3 gallop heard at apex, accentuated with inspiration; no murmur or rubs. Auscultation of the lungs revealed the following: bilateral diffuse, moist crackles with a wheeze in the left lung. Examination of the abdomen revealed the following: nontender, normal bowel sounds, hepatomegaly, jugular vein distention (JVD), and positive hepatojugular reflux (HJR). Jon's extremities were cyanotic, and he displayed pitting, pretibial edema to knees.
Chest x-ray presented in Figure 11.12 revealed hilar congestion and increased vascular markings with cardiomegaly (compare with normal chest x-ray). Electrocardiogram (ECG) in Figure 11.13 showed sinus tachycardia with left ventricular hypertrophy. Serum chemistries were normal except for elevation of liver enzymes.
Fig. 11.12 A. Chest radiograph, taken at the time the patient was first seen, demonstrating marked cardiomegaly, pulmonary congestion, pleural effusion (e.g., pleural fluid in the costophrenic angles), and vascular engorgement. B. Chest radiograph of the same patient taken several days after therapy was initiated. Pulmonary congestion is gone, as is pleural effusion (i.e., no fluid in the costophrenic angles). Cardiomegaly remains, but is greatly reduced.
Fig. 11.13 Electrocardiogram (ECG) demonstrating normal sinus rhythm with evidence of left ventricular hypertrophy.