10.3 Patient Data Collection
Key Takeaways
- A complete patient history includes chief complaint, HPI via OLDCARTS (Onset, Location, Duration, Character, Aggravating, Relieving, Timing, Severity), past medical history, medication history (prescription, OTC, supplements, allergies with reaction), social history, family history, and review of systems.
- Medication reconciliation at admission, transfer, and discharge — collect, compare, resolve discrepancies (omission, duplication, wrong dose, wrong route), and document — is a pharmacist-led safety practice that prevents medication errors across transitions of care.
- Pharmacy-relevant physical assessment spans vital signs (BP, HR, RR, temperature, SpO2, pain), heart sounds (S1-S4, murmurs), lung sounds (wheeze, crackles, rhonchi), abdominal and neurologic exams, and anthropometrics (BMI, waist circumference).
- Core laboratory panels include CBC (WBC, RBC, Hgb, Hct, platelets, differential), CMP (electrolytes, BUN, creatinine, glucose, liver enzymes), coagulation (PT/INR, aPTT, anti-Xa), cardiac (troponin, BNP/NT-proBNP, lipid panel, hs-CRP), endocrine (HbA1c, TSH, free T4, cortisol), and inflammatory markers (ESR, CRP, procalcitonin).
- Therapeutic drug monitoring guides dosing of vancomycin (trough or AUC24 400-600 mg·h/L), aminoglycosides (peak and trough), and anti-epileptics (phenytoin, valproate, carbamazepine); point-of-care testing enables rapid bedside decisions for glucose, INR, rapid strep/flu/COVID, and urinalysis.
Patient History
A structured patient history is the foundation of clinical assessment and pharmacotherapy decisions. The chief complaint (CC) is a single phrase in the patient's own words. The history of present illness (HPI) is explored using OLDCARTS: Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity. Additional history elements include past medical history (PMH), medication history (prescription, OTC, herbal and dietary supplements, allergies with specific reaction type and severity), social history (tobacco, alcohol, illicit drugs, occupation, sexual activity, functional status), family history (cardiovascular disease, diabetes, cancer, psychiatric illness), and review of systems (ROS) to screen for symptoms across organ systems.
Medication Reconciliation
Medication reconciliation is the formal process of creating the most accurate possible list of all medications a patient is taking and comparing it against medication orders at every transition of care — admission, transfer, and discharge. The steps are collect (best possible medication history from patient, family, pharmacy, prior records), compare (against current orders), resolve (discrepancies including omission, duplication, wrong dose, wrong route, wrong frequency, drug interaction), and document. Pharmacists play a central role; unresolved discrepancies are a leading cause of preventable adverse drug events.
Physical Assessment Relevant to Pharmacy
Vital Signs
Blood pressure (BP), heart rate (HR), respiratory rate (RR), temperature, oxygen saturation (SpO2), and pain (numeric or behavioral scale) constitute the standard vital signs. Trends matter as much as absolute values.
Heart Sounds
S1 (mitral and tricuspid valve closure) and S2 (aortic and pulmonic closure) are normal. S3 suggests heart failure (volume overload); S4 suggests a stiff ventricle (HTN, hypertrophic cardiomyopathy). Murmurs are characterized by timing (systolic vs diastolic), location, intensity, radiation; a new murmur may signal endocarditis or valvular dysfunction.
Lung Sounds
Wheeze indicates bronchoconstriction (asthma, COPD); crackles suggest pulmonary edema, pneumonia, or fibrosis; rhonchi reflect larger airway secretions; pleural rub indicates pleural inflammation.
Abdominal, Neurologic, and Anthropometric Assessment
Abdominal exam evaluates bowel sounds, hepatosplenomegaly, tenderness, and ascites. Neurologic exam covers mental status (Glasgow Coma Scale, orientation), cranial nerves, deep tendon reflexes, motor strength, sensation, and coordination. Body mass index (BMI) and waist circumference quantify obesity and central adiposity, guiding cardiometabolic risk and drug dosing.
Laboratory Values
Complete Blood Count (CBC)
White blood cells (WBC) elevate with infection, inflammation, leukemia; red blood cells (RBC), hemoglobin (Hgb), and hematocrit (Hct) define anemia and polycythemia; platelets assess thrombocytopenia or thrombocytosis. The differential (neutrophils, lymphocytes, monocytes, eosinophils, basophils) localizes infection, allergy, or hematologic malignancy.
Comprehensive Metabolic Panel (CMP)
Sodium (Na), potassium (K), chloride (Cl), and CO2 (bicarbonate) define electrolyte and acid-base status. BUN and creatinine reflect renal function; estimated glomerular filtration rate (eGFR) guides renally-cleared drug dosing. Glucose screens diabetes. Calcium, ALT, AST, ALP, bilirubin, and albumin assess hepatic and bone status.
Coagulation, Cardiac, Endocrine, Inflammatory
PT/INR monitors warfarin (target INR depends on indication); aPTT monitors unfractionated heparin; anti-Xa monitors low-molecular-weight heparin and direct oral anticoagulants in select situations. Troponin confirms myocardial injury; BNP/NT-proBNP supports heart failure diagnosis; lipid panel (total cholesterol, LDL, HDL, TG) and hs-CRP refine cardiovascular risk. HbA1c reflects 3-month glycemic average (diabetes diagnosis ≥6.5%); TSH with free T4 assesses thyroid function; cortisol (with ACTH) evaluates adrenal axis. ESR and CRP are nonspecific inflammation markers; procalcitonin supports bacterial infection and antibiotic stewardship.
Therapeutic Drug Monitoring
Vancomycin trough (typically 15-20 mcg/mL for serious MRSA infections) or AUC24 (400-600 mg·h/L) guides dosing and nephrotoxicity avoidance. Aminoglycosides (gentamicin, tobramycin, amikacin) use peak (efficacy) and trough (toxicity) targets. Anti-epileptics (phenytoin total or free level, valproate, carbamazepine) narrow the therapeutic window. Other TDM drugs: digoxin, lithium, theophylline, immunosuppressants (tacrolimus, cyclosporine).
| Lab Test | Typical Normal Range | Pharmacotherapy Significance |
|---|---|---|
| Potassium (K) | 3.5-5.0 mEq/L | Hyperkalemia limits ACEI/ARB/MRA, K-sparing diuretics; hypokalemia potentiates digoxin toxicity |
| Serum creatinine / eGFR | 0.6-1.2 mg/dL; eGFR ≥90 | Dose adjustment of renally cleared drugs (vancomycin, gabapentin, DOACs) |
| INR (warfarin) | 2.0-3.0 (mechanical valve 2.5-3.5) | Adjust warfarin dose; assess bleeding vs thrombosis risk |
| HbA1c | <5.7% normal; ≥6.5% diabetes | Titrate metformin, GLP-1 RA, SGLT2 inhibitor, insulin |
| TSH | 0.4-4.0 mIU/L | Adjust levothyroxine (hypothyroid) or thionamide (hyperthyroid) |
| Troponin I/T | <0.04 ng/mL (assay-dependent) | Confirm ACS; triggers antiplatelet, anticoagulant, reperfusion |
| NT-proBNP | <300 pg/mL (age-dependent) | Supports HF diagnosis; guides diuretic, GDMT initiation |
| Vancomycin trough | 15-20 mcg/mL (serious MRSA) | Adjust dose and interval; avoid nephrotoxicity with piperacillin-tazobactam |
| Phenytoin total | 10-20 mcg/mL | Free level preferred in hypoalbuminemia; narrow therapeutic index |
| WBC | 4,000-11,000/mm³ | Neutropenia (febrile neutropenia risk) limits chemotherapy, clozapine |
Point-of-Care Testing (POCT)
Point-of-care testing (POCT) enables rapid bedside decisions. Glucose meters guide insulin sliding scale; INR devices support warfarin self-monitoring; rapid strep, influenza, and COVID-19 assays direct antiviral and antibacterial choices; urinalysis dipstick screens for UTI, hematuria, proteinuria, and glycosuria. Pharmacists verify device accuracy, train operators, and integrate POCT results into therapy decisions. Recognizing normal vs abnormal values and their pharmacotherapy implications — renal dose adjustment, hepatotoxicity monitoring, electrolyte correction, anticoagulation titration, antimicrobial stewardship — is a core competency tested on the FPGEE.
A pharmacist is reconciling medications for a patient admitted with community-acquired pneumonia. The patient's home list includes metoprolol 50 mg twice daily, but the admission orders omit it. Which type of discrepancy is this, and what is the appropriate next step?
A patient on warfarin for atrial fibrillation has INR 5.8 with no bleeding. Which laboratory value, if abnormal, most directly increases the risk of supratherapeutic INR with warfarin?