1. Integrative Approaches to Pharmacotherapy—A Look at Complex Cases
Chapter 60:
Integrative Approaches to Pharmacotherapy—A Look at Complex Cases

2. Managing Multiple Problems in a Single Patient
The practitioner must evaluate possible medication therapies and select the best patient-specific option.
This level of complexity is reflective of real-life situations and requires a systematic approach to the patient to manage the complexities.

3. Issues Affecting Medical Conditions
Economic
Social
Emotional
Cultural

4. Issues Related to Medication Therapy
Cost of medications
Selection of treatment options
Emotional reminder of illness association with chronic medication-taking behavior
Culturally accepted treatment options

5. Problem-Oriented Medical Record (POMR)
Each of the patient’s medical problems is identified and prioritized in order of importance.
The order of the problems depends on the acuity and severity of the situation.
Typically, the most severe and acute problems are listed first, followed by the chronic conditions, and then problems requiring preventive measures (e.g., smoking cessation).
SOAP note technique is used.

6. SOAP Note Technique
(S)ubjective
(O)bjective
(A)ssessment
(P)lan

7. Subjective versus Objective Data
The subjective and objective components are the data that support the identification of the prioritized problem.
Subjective data: refer to information provided by the patient (or other individual) that cannot be independently verified.
Objective data: often are laboratory data or health assessments (e.g., blood pressures) performed or observed by the practitioner.

8. Question
A practitioner is examining a patient who grimaces when his leg is moved. What type of data is the patient displaying?
Objective
Subjective
Objective and subjective
This does not qualify as data

9. Answer
A. Objective
Rationale: The objective data often are laboratory data or health assessments (e.g., blood pressures) performed or observed by the practitioner. The grimace denotes pain upon movement of the limb. The subjective data refer to information provided by the patient (or other individual) that cannot be independently verified, for example, if the patient stated that he had pain but was not physically displaying signs of pain.

10. Information Contained in SOAP Note Assessment
Chief complaint
History of the present illness
Past medical history
Family and social history
Medication history
Results of review of systems
Physical examination and laboratory results

11. SOAP Note—Therapeutic Plan
Additional diagnostic tests necessary to confirm or rule out the suspected diagnosis
Referral to other practitioners as necessary
Information about changes in therapeutic plans
Adding or discontinuing drug therapy
Identifying therapeutic goals
Establishing monitoring parameters

12. Question
In which section of the SOAP note does the practitioner delineate the potential diagnosis related to the problem?
Subjective data
Objective data
Assessment
Plan

13. Answer
C. Assessment
Rationale: The assessment section of the SOAP note integrates the subjective and objective information and is where the practitioner delineates the potential diagnosis related to the problem. The last portion of the note is the therapeutic plan. In this section, the practitioner may include additional diagnostic tests necessary to confirm or rule out the suspected diagnosis.

14. Anticipating Problems
Patient noncompliance
Adverse reactions
Interacting drugs

15. Other Information Needed Before Prescribing
Assessment of specific information related to drug therapy
Inventory of patient-reported allergies including an assessment of drug allergies
Prescription medication use
Nonprescription medication use and complementary and alternative product use

16. Case Study Parameters Specific goals for treatment
Specific goals of therapy
Type of drug therapy chosen
Parameters for monitoring success of the therapy
Specific patient education based on the prescribed therapy
Adverse reactions for selected agent that would cause a change in therapy

17. Case Study Parameters (cont.)
Second-line therapy
Appropriate over-the-counter and/or alternative medications
Recommended lifestyle changes
Drug–drug or drug–food interactions related to chosen agent

18. Summary
When managing multiple problems in a single patient, the practitioner must evaluate possible medication therapies and select the best patient-specific option.
This level of complexity is reflective of real-life situations and requires a systematic approach to the patient to manage the complexities.
One of the more common methods for organizing medical information is the problem-oriented medical record (POMR), which uses the SOAP note for organizing patient information.