hospital pharmacy

hospital pharmacyOrder DescriptionAs part of your role with the hospital you have been asked to undertake a medication review for a recently admitted patient Mr JD within the Hospital.Upon checking his records you find out the following informationAge 85 yearsWeight 73kgHeight 160cm.His Medical History indicates that he suffers from Hypertension, Type 2 Diabetes, Gout, Osteoarthritis, GORD and COPDHis charted medications are listed belowMedication
Dose
Allopurinol 300mg
1 at 0800Amlodipine 10mg
1 at 0800Digoxin 250mcg
1 at 0800Glicazide SR 30mg
1 at 0800Esomeprazole 20mg
1 at 0800Paracetamol 665mg
2 tablets 0800, 1400 and 2100Salbuatamol 100mcg MDI
1-2 prnAllergies were noted be for Metformin and Mr JD was noted to have suffered from developed itchy skin rashes upon prescribing of this medicationHe is a non smokerHis Pathology results indicated that his serum creatinine was 114 micromol/LHis liver function tests and serum creatinine levels were indicated to be within the normal rangeHis last record BP that morning was 150/85As part of of your role to speak to Mr JDs wife to check and confirm the charted medications and you are told the following information inregards to his medicationCurrent medicationAllopurinol 300mg 1 mane for Pain in feetAmlodipine 10mg 1 mane for blood pressureDigoxin 250mcg 1 mane for the heartEnalapril 10mg 1 mane for blood pressureGliclazide SR 30mg 1 mane for diabetesOmeprazole 20mg 1 mane for indigestionParacetamol 500mg 1-2 prn for painArthri-Relief 1500mg 1 daily prn for painSalbutamol 100mcg/dose MDI prn for breathingBased on the information that you have discovered identify potential and actual medication related issues and suggest how these could be aIDressed or monitored?