OBJECTIVE:To probe into the treatment of patient with acute pulmonary thromboembolism ( PTE) and hepatic renal insufficiency and the entry point of provision of pharmaceutical care by clinical pharmacists .METHODS:The clinical pharmacists did deeply research in clinic , aimed at a patient with acute PTE and hepatic renal insufficiency , pharmaceutical knowledge was applied into the pharmaceutical care in respect of the patients'liver and kidney function , INR values and drug interactions etc .RESULTS:According to the patient's creatinine clearance rate ( CCR) , the clinical pharmacists can determine the initial dose of fondaparinux sodium , by which the dose didn't need to be adjusted .During the process , INR values changed since the interactions between anti-cold medicine and warfarin; the clinical pharmacists found this situation timely and formulated treatment regimen with the physician , which made the INR value fluctuated at about 2. CONCLUSIONS: The clinical pharmacists provide entire pharmaceutical care for the patient , which play an important role in the process of medication .%目的：探讨临床药师参与急性肺血栓栓塞症伴肝、肾功能不全患者的治疗、提供药学监护的切入点。方法：临床药师深入临床，针对1例急性肺血栓栓塞症伴肝、肾功能不全患者，应用药学知识对该患者肝、肾功能与国际化标准比值（ INR）及药物相互作用等方面进行药学监护。结果：临床药师根据患者的肌酐清除率确定磺达肝癸钠使用初始剂量即可不需调整剂量；患者用药过程中，因抗感冒药与华法林的相互作用而引起INR值发生波动，临床药师及时发现并与医师商讨拟定治疗方案，使患者INR值波动在2左右。结论：临床药师对该患者进行了全程药学监护，在药物治疗过程中发挥了一定的作用。
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