Clinical Pharmacy Case Study Report

1. Clinical Pharmacy
Case Study Report
Presented by:

2. Case study
A 39-year old male was brought to the hospital due to complain of weakness on
bilateral lower extremities. The patient is a known case of hypokalemia with a last
occurence in the year 2015. 1 year prior (unrecalled month), he had 1 episode of not
being able to get up from bed, inability to sit down or get up which occurred for an
hour. He just slept it off and upon waking up again, was now able to resume activity.
The patient was well until 1 day prior, upon waking up, was not able to lift bilateral
legs, but able to move feet. He remained lying down for 8hours, at around 5pm, he
was then able to sit up and stand up without weakness. No consultation done. At
around 1am this morning, while walking down the stairs, he suddenly had bilateral leg
weakness, and fell down the stairs. No loss of consciousness, nausea and vomiting,
seizure episodes, chest pain, abdominal pain. Due to persistence of symptoms, hence
subsequently admitted.

3. Age: 39
Gender: Male
Birthday: May 05 1980
Religion:
A. Patient Geographic data
B. History – Medical, family, social
Medical
• (+) Hyperthyroidism
• (-) Hypertension
• (-) Diabetes Mellitus Type 2
• No asthma
• No liver disease
• No kidney disease
• No known allergies
Family History
• No Hypertension
• (+) Diabetes Mellitus Type 2, maternal
• No thyroid diseases
• No heredofamilial myopathies
Personal/ Social History
• 1.5 pack/year Smoker
• Non-Alcoholic
• Occupation: Barangay Official
Catholic
Nationality: Filipino

4. Weakness on Bilateral lower extremities
C. Chief complaint
D. Review of System
• General Ht: 168cm Wt: 72kg BMI 25.53
• Head, Eyes, Ears, Nose Normal
• Neck Normal
• Respiratory Normal
• Cardiovascular Normal
• Gastrointestinal Normal
• Urinary Normal
• Genital Normal
• Peripheral Vascular Normal

5. E. Physical examination
• Bp 120/70 NM
• Hr 99 NM
• Rr 20 NM
• T:36.5C NM
• HEAD, EYES, EARS, NOSE Normal
• NECK Normal BACK Normal
• CHEST Normal
• LUNGS Normal
• CARDIOVASCULAR Normal
• ABDOMEN Normal
• UPPER EXTREMITIES Normal
• LOWER EXTREMITIES Normal

6. F. Diagnosis
• CBC
• Urinalysis
• ECG
• Chest Xray
• Na, K, BUN
• Total CPK, CK-MB
• CKMM
• iCa, TSH, FT4, FT3 c/o
• ABC

7. Executive Summary
2015
Patient was diagnosed with hyperthyroid and was prescribed with Methimazole
(10mg/tab once a day) for 7 months then discontinued. Interim was
unremarkable, no recurrence of bilateral leg weakness, no weight loss (felt to
have gained weight instead), no fever, sore throat nor rashes, no abdominal
pain, nausea, no vomiting, no jaundice, no diarrhea, no excessive sweating, no
heat intolerance.
08/11/2019
Day before the patient was admitted, he was having bilateral leg weakness. It
was only improved after eating 3pcs of banana, then noted recurrence at
midnight. Noted history of increased carbohydrate intake (rice and pasta) one
day prior to onset of symptoms.

8. 08/12/2019
Patient was admitted and conducted several diagnosis. Claims to have
palpitations, no exophthalmos, enlarged thyroid, clear lungs, no edema, good
pulses and tremors both hands. Patient was diagnosed with hyperthyroidism
and hypokalemia probably secondary to increase carbohydrate intake. He
was prescribed with Propranolol(Inderal) 10mg 1tab 2x a day, Potassium
chloride(Kalium durule) 2 durules with meals after 4hrs x 2 dose and
Carbimazole(Neomercazole) 5mg 1tab once a day PO.
Conducted SBAR(Situation, Background, Assessment and Recommendation)
to patient: S- endorsed to next shift; B- patient was managed as a case of
rhabdomyolysis; A- VS stable, still with weakness on bilateral lower
extremities and upper arm; R- for continuity of care

9. 08/13/2019
Patient continued the medications given. VS stable, no more weakness, no
palpitations, slight tremor in left hand only. Hypokalemia resolved. No
objection to discharge. Was given home medications.

10. a) Definition:
Rhabdomyolysis is a pathological condition of skeletal muscle cell damage leading to
the release of toxic intracellular material into the blood circulation.
b) Pathophysiology:
- ATP depletion and or direct muscle injury and rupture of the cell membrane
- Increase intracellular Ca
- Na+/K+ ATPase and Ca+ ATPase pump dysfunction
- Activation of intracellular Ca+
- Mitochondrial dysfunction
- Increased muscle contractility
- Production of free radicals
- MUSCLE DEATH: Leading to release of intracellular muscle constituent
I. BACKGROUND OF THE STUDY

11. I. BACKGROUND OF THE STUDY
c) Etiology:
- Trauma and muscle compression
- Infection
- Metabolic and genetic factors
- Drugs and myotoxins
- Others: Dehydration, use of nutritional supplements, drug use, sickle cell trait, and
malignant hyperthermia
d) Clinical manifestations/Signs and symptoms:
The “classic triad” of rhabdomyolysis symptoms are: muscle pain in the shoulders, thighs, or
lower back; muscle weakness or trouble moving arms and legs; and dark red or brown
urine or decreased urination. Keep in mind that half of people with the condition may
have no muscle-related symptoms.
Other common signs of rhabdomyolysis include:
Abdominal pain
Nausea or vomiting
Fever, rapid heart rate
Confusion, dehydration, fever, or lack of consciousness

12. I. BACKGROUND OF THE STUDY
e) Incidence:
Rhabdomyolysis is a common condition in adult populations and is understudied in
pediatrics. The National Hospital Discharge Survey reports 26,000 cases annually.
f) Definitive diagnostics:
i. Laboratory Examinations:
- Complete blood count (CBC), including hemoglobin, hematocrit, and platelets
- Serum chemistries, including blood urea nitrogen (BUN), creatinine, glucose,
calcium, potassium, phosphate, uric acid, and liver function tests (LFTs)
- Prothrombin time (PT)
- Activated partial thromboplastin time (aPTT) – Thromboplastin released from
injured myocytes can cause disseminated intravascular coagulation (DIC)
- Serum aldolase
- Lactate dehydrogenase (LDH)

13. I. BACKGROUND OF THE STUDY
g) Standard treatment
i. Procedure
- Assess the ABCs (Airway, Breathing, Circulation), and provide supportive care as
needed. Ensure adequate hydration, and record urine output. Insert a Foley catheter
for careful monitoring of urine output. Identify and correct the inciting cause of
rhabdomyolysis (e.g., trauma, infection, or toxins).
ii. Medication
- Medical therapy for rhabdomyolysis focuses on restoring adequate intravascular
volume. Hydration with isotonic sodium chloride solution (0.9% NaCl) is the
cornerstone of rhabdomyolysis therapy. Many clinicians recommend the use of
sodium bicarbonate. Use furosemide or other diuretics (such as mannitol in adults)
with sufficient hydration if urine output is inadequate. Hyperkalemia should also be
addressed.

14. I. BACKGROUND OF THE STUDY
iii. Non-drug therapy
- Dietary modification may help to reduce the symptoms associated with some of the
metabolic disorders and inborn errors of metabolism. Dietary supplementation with
glucose or fructose may decrease the pain and fatigue associated with
phosphorylase deficiency. The muscle pain and myoglobinuria due to carnitine
palmityl transferase deficiency may be reduced with frequent meals and a low-fat,
high-carbohydrate diet. Substitution of medium-chained triglycerides may also be
helpful.

15. G. Treatment (date started, indication, date discontinued, reason)
*may include the MOA, dosage and administration, drug-drug interaction ADR)
Medicine Date started Indication Date
discontinued
reason
CARBIMAZOLE
(NEO-
MERCAZOLE);
TABLET 5MG
AUGUST 12, 2019 It is indicated in
adults and children
in all conditions
where reduction of
thyroid function is
required.
N/A MAINTENANCE
PARACETAMOL -
NAPREX; AMPULE
300MG/2ML
AUGUST 12, 2019 recommended for
the treatment of
most painful and
febrile conditions
AUGUST 13, 2019 AS NEEDED FOR
PAIN
POTASSIUM
CHLORIDE –
(KALIUM
DURULE); TABLET
750MG
AUGUST 12, 2019
11:45AM
used to prevent or
to treat low blood
levels of potassium
(hypokalemia).
AUGUST 12, 2019
20:37PM
RESOLVED
PROPRANOLOL
HCL - INDERAL;
TABLET 10MG
AUGUST 12, 2019
11:00AM
indicated to treat
hypertension.
AUGUST 13, 2019
13:41 PM
DISCHARGED

16. G. Treatment (date started, indication, date discontinued, reason)
*may include the MOA, dosage and administration, drug-drug interaction ADR)
DRUG MOA DOSE AND
ADMINISTRATION
DRUG-DRUG
INTERACTION
CARBIMAZOLE (NEO-
MERCAZOLE); TABLET
5MG
It blocks the
production of
thyroid hormones
through inhibition of
the organification of
iodide and the
coupling of
iodothyronine
residues.
Oral; Adult: Initially,
15-60 mg daily in 2-
3 divided doses.
Maintenance: 5-15
mg daily. Blocking
replacement
regimen: Initially,
20-60 mg in 2-3
divided doses.
Treatment duration:
6-18 months.
Child: 3-17 years
Initially, 15 mg daily
adjusted according
to response.
Hyperparathyroid
patients who
become euthyroid
may have increased
serum
concentration of
digitalis and
increased clearance
of β-blockers.

17. G. Treatment (date started, indication, date discontinued, reason)
*may include the MOA, dosage and administration, drug-drug interaction ADR)
DRUG MOA DOSE AND
ADMINISTRATION
DRUG
INTERACTION
PARACETAMOL -
NAPREX; AMPULE
300MG/2ML
It produces
antipyresis by
inhibiting the
hypothalamic heat-
regulating centre.
Its weak anti-
inflammatory
activity is related to
inhibition of
prostaglandin
synthesis in the
CNS.
Intravenous; 33-50 kg:
15 mg/kg 4-6 hourly if
needed. Max: 3 g
daily.
propranolol may
increase the
pharmacologic
effects of
acetaminophen.
The mechanism
may be related to
inhibition of
acetaminophen
metabolism.

18. G. Treatment (date started, indication, date discontinued, reason)
*may include the MOA, dosage and administration, drug-drug interaction ADR)
DRUG MOA DOSE AND
ADMINISTRATION
DRUG
INTERACTION
POTASSIUM
CHLORIDE -
KALIUM DURULE;
TABLET 750MG
Maintenance of
intracellular tonicity;
the transmission of
nerve impulses; the
contraction of
cardiac, skeletal,
and smooth
muscle; and the
maintenance of
normal renal
function.
2 tablets twice a
day, or more, until
serum potassium is
restored to normal,
then prophylactic
dosage; Should be
taken with food:
Swallow whole w/
½ glass of liqd, do
not
break/chew/crush.
Do not administer
to a patient in a
supine position.
Severe
hyperkalemia w/ K
salts & K-sparing
diuretics like
aldosterone
antagonists (eg,
spironolactone),
amiloride or
triamterene.
Hyperkalemia or
increase in serum K
conc w/ tacrolimus.
Increased K serum
levels w/ ACE
inhibitors.

19. G. Treatment (date started, indication, date discontinued, reason)
*may include the MOA, dosage and administration, drug-drug interaction ADR)
DRUG MOA DOSE AND
ADMINISTRATION
DRUG
INTERACTION
PROPRANOLOL
HCL - INDERAL;
TABLET 10MG
nonselective ß-
adrenergic blocker
that competitively
blocks ß1 and ß2-
receptors resulting
in decreased heart
rate, myocardial
contractility, BP and
myocardial oxygen
demand.
Oral; Adult: As
conventional tab or
oral solution: 10-40
mg 3-4 times daily.
As extended
release cap: 80 mg
once daily, may be
increased to 160
mg daily. Max: 240
mg/day.
Propranolol
increased the half-
life of paracetamol
by 25 +/- 12% (P
less than 0.05) and
lowered its
clearance by 14 +/-
3% (P less than
0.05).

20. H. Therapeutic Monitoring
• Follow up after 1 week with CBC, Na, K, CPK, CKMM, CKMB,
urinalysis
• Follow up after 4 weeks with repeat TSH AND FT4.(Revised into 6
weeks)
• Include ALT (Alanine transaminase) in next blood works
- ALT is an enzyme found mostly in the liver. When liver cells are
damaged, they release ALT into the bloodstream.

21. I. Non-drug/Supportive Therapy
• Eating 3 pieces of bananas to improve with ability to walk, then noted
recurrence at midnight.
• Encourage increase oral fluid intake

22. J. PHARMACY INTERVENTIONS
AUGUST 12, 2019 10:09 AM
• IVF to follow: PNSS 1L at 150mL
AUGUST 12, 2019 10:24AM
• KCl(Kalium Durule) 2 durules / meal every 4h x 2 doses- give 1 dose
now
LATE ENTRY
AUGUST 12, 2019 11:00AM
• 1st dose of Inderal 10mg/tab given after validation
AUGUST 12, 2019 11:45AM
• First dose of Kalium Durule 2 tabs given after validation
AUGUST 13, 2019 14:08PM
• Watch out for fever, sore throat and rashes, if mentioned symptoms
develop STOP carbimazole and request CBC
* Drug Appropriateness Review are done each transaction/revision

23. K. Outcome
With proper monitoring and appropriate intervention, the patient
condition improved with stable vital signs and no further complaints
the patient was cleared for discharge

24. Patient went to the hospital with a chief complain of bilateral leg weakness. The patient is
a known case of hypokalemia with a last occurence in the year 2015. Patient experience
various signs and symptoms such as dizziness, loss of consciousness, chest pain,
dysuria, hematuria and such. Patient also experience hyperthyroidism which was
previously maintained with Methimazole. No signs of of hypertension, kidney disease or
allergies. Patient was hydrated and admitted. On admission, patient was awake, alert, not
in distress. Denies chest pain, dyspnea, weakness, numbness. Potassium chloride was
started. Referred to endocrinology for further management of hyperthyroidism. Thyroid
function tests revealed high thyroid function tests hence Anti thyroid drugs were started.
Patient was monitored with appropriate adjustments to medications and management.
The condition of the patient has improved. On the second hospital day, patient
comfortable, stable vital signs, no new complaints. Patient cleared for discharge. Home
instructions given
L. Summary and conclusion

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