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Page 1 of 30
MSC CLINICAL PHARMACY PHARMACEUTICAL CARE PLAN
Please edit and format this template where necessary to add additional lines to the tables. Each table will generate automatic headings over additional pages.
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
Medication List Dose Frequency Route Indication Start/Continued
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
Medication List Dose Frequency Route Indication Start/Continued
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
Medication List Dose Frequency Route Indication Start/Continued
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
Medication List Dose Frequency Route Indication Start/Continued
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
Parameter Justification Frequency Result(s) and Action 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
Parameter Justification Frequency Result(s) and Action 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
Parameter Justification Frequency Result(s) and Action 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
Parameter Justification Frequency Result(s) and Action 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
Parameter Justification Frequency Result(s) and Action 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
Parameter Justification Frequency Result(s) and Action 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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Analysis of Clinical Problems
Clinical Problem Assessment Priority Action Taken and Outcome
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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Analysis of Clinical Problems
Clinical Problem Assessment Priority Action Taken and Outcome
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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Analysis of Clinical Problems
Clinical Problem Assessment Priority Action Taken and Outcome
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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Analysis of Clinical Problems
Clinical Problem Assessment Priority Action Taken and Outcome
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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Analysis of Clinical Problems
Clinical Problem Assessment Priority Action Taken and Outcome
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