Pharmacist intervention by pharm.D student

1. Done by,
sri sharika kumar
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3. 3
Butterfly shaped
gland surrounded by
veins and arteries

4. A 67 year old Asian women was admitted in our KMCH hospital on 6th
September 2019 with a complaints of neck swelling. Her past history reveals that she
is a known case of hypertension , hyperlipidemia (overweight BMI) and vertigo for
the past 4 years (regularly on treatment) medications for HTN (Tab. Arbitel-AM then
changed to Tab. Telma 40mg) ,for hyperlipidemia (Tab.Novastat 10mg), for vertigo
(Tab.Vertin 24mg for 2 months course was given) And nodules presence were found
on 17th April 2019.
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5. 5

6. IP NO: F11086(1).
REG NO: 1066698.
AGE/SEX: 67yr/female.
MARRITAL STATUS: Married.
DATE OF ADMISSION: 6/8/19.
DATE OF DISCHARGE: 9/8/19.
DATE OF READMISSION: 11/8/19.
DATE OF STABLE DISCHARGE: 20/8/19.
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7. PRESENT DIAGNOSIS: Bilateral Thyroid Nodules.
PRESENT SURGICAL PROCEDURE: Total Thyroidectomy I.
PAST DIAGNOSIS: HTN Since 2015, VERTIGO since 2015, and Hyperlipidemia for the past 4 years
on regular treatment.
PRESENT COMPLAINTS: Giddiness, syncope.
DATE OF
CONSULTATIONS
INVESTIGATIONS TREATMENT REGIMENS
2/6/2015 BP: 170/80mmHg.(HTN)
LDL:170mg/dL.(Hyperlipidemia)
Vertigo were found
Tab. Arbitel-AM (1-0-0-1)
Tab. Novastat 10mg (0-0-0-1)
Tab. Vertin 24mg(1-0-0-0)
Tab. Lonazep 0.25mg(0-0-0-1)
X 2months
7/8/2015 BP: 120/80 Tab. Arbitel-AM(0-0-0-1)
Tab. Novastat 10mg (0-0-0-1)
Tab. Pregabid NT (0-0-0-½)
X 2months
5/11/2015 LDL: 150mg/dL
Total cholesterol: 242g/dL
Tab. Telma -40mg (0-0-0-1)
Tab. Novastat -10mg(0-0-0-1) 7

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9. PAST INVESTIGATIONS :
On 17th April 2019
USG Neck: No cyst or calcification seen.
IMPRESSION: TI-RADS 4 category nodules in both lobes of thyroid as
detailed.
suggested FNAC of largest nodule in right lobe.
BP: 170/100 mmHg.
WEIGHT:75.6kgs.
HEIGHT: 164cm.
BMI: 28.1(overweight).
On 15th July 2019
WEIGHT: 75.4kgs.
BP: 140/90 mmHg.
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11.  On 6th September 2019 (first date of admission)
INVESTIGATIONS PATIENT VALUE REFERENCE RANGE
Blood glucose random 111mg/dL 75 to 125mg/dL.
Creatinine 0.8mg/dL 0.5 to 0.9mg/dL.
eGFR More than 60ml/minute/1.73m2
Potassium 4.3mEq/L 3.7 to 5.4mEq/L.
Sodium serum 142mEq/L 132 to 146mEq/L.
Hemoglobin 12.2g/dL 12 to 15g/dL
PCV 35% 35% to 47%
Total WBC count 7600cells /cumm. 4000 to 11300cells /cumm.
Platelet count 279000cells/ µL 150000 to 450000cells/ µL. 11

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INVESTIGATIONS PATIENT VALUE REFERENCE RANGE
Polymorphs 66% 45-75%
Lymphocytes 30% 20-40%
Monocytes 02% 2-10%
Eosinophils 02% 2-6%
Basophils 00% Upto1%
Total RBC count 4.13 mil/µL 4-5.1mil/µL
MCH 29.6pg/cell 27-34pg/cell
MCHC 35g/dL 31-36g/dL
MCV 84.8µm3 80-96µm3
RDW 12.1% 11.5-14.5%

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Evidence based reference
ranges

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DATE TIME HEART RATE RESP RATE BP SpO2%
6/8/19 8pm
10pm
84beats/min
80beats/min
20breaths/min
20breaths/min
130/70mmHg
130/60mmHg
97%
97%
7/8/19 2am
6am
10am
88beats/min
86beats/min
82beats/min
20breaths/min
20breaths/min
20breaths/min
130/70mmHg
110/70mmHg
110/80mmHg
97%
98%
98%
VITALS ON POST OPERATIVE CONDITION: (OPERATION TIMINGS: 10:45 TO 12:45 on 7/8/19)
TIME TEMP PULSE
RATE
RESP RATE BP O2 SATURATION
1:30pm 98.6°F 80beats/min 18breaths/min 140/90mmHg 98%
2:00pm 98.4°F 84beats/min 20breaths/min 130/70mmHg 95%
3:00pm 94.6°F 86beats/min 20breaths/min 150/90mmHg 95%
4:00pm 96.8°F 84beats/min 20breaths/min 140/70mmHg 96%
5:00pm 94.6°F 86beats/min 20breaths/min 130/70mmHg 97%
6:00pm 98.4°F 84beats/min 22breaths/min 120/80mmHg 96%
VITALS ON POST OPERATIVE CONDITION: (OPERATION TIMINGS: 10:45 TO 12:45PM ON 7/8/19)

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DATE TIME HR RR BP SpO2%
7/8/19 10pm 84beats/min 26breaths/min 130/80mmHg 96%
8/8/19 2am
6am
10am
2pm
10pm
82beats/min
84beats/min
82beats/min
84beats/min
80beats/min
20breaths/min
20breaths/min
20breaths/min
18breaths/min
20breaths/min
130/70mmHg
130/90mmHg
120/60mmHg
110/70mmHg
130/70mmHg
96%
96%
97%
97%
96%
9/8/19 2am
6am
10am
89beats/min
84beats/min
74beats/min
20breaths/min
20breaths/min
20breaths/min
120/80mmHg
120/80mmHg
110/80mmHg
97%
98%
98%
Pre operative intake and output chart:
on 6/8/19 – Total intake = 280ml.
Total output =400ml. Was normal.

16. DIAGNOSTIC PARAMETERS USED:
PATHOLOGY REPORT ON (16/7/19):
Nature of the specimen: FNAC from right thyroid nodule.
IMPRESSION: Suspicious for papillary carcinoma
(Bethesda category V) FNAC Right thyroid nodule.
ECHOCARDIOGRAPHY REPORT:
Normal LV systolic function with diastolic dysfunction.
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Treatment
diagnostic
step wise
approach
for nodules.

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20.  Bilateral thyroid nodules.
Thyroid neoplasm (benign tumor).
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PROCEDURE DETAILS :
1) Total thyroidectomy.
2) Para thyroid dissection under General Anaesthesia on 7/8/19.
Procedure:
 10 cm horizontal skin crease incision ,subplatysmal
flaps.
 1.5 cm left tubercle.
 2mm right nerve.
 2mm left nerve.

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Total thyroidectomy: horizontal skin crease incision ,subplatysmal flaps.

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23. 0n 7th august 2019 On 8th august 2019 On 9th august 2019
Total intake=2300ml Total intake=2850ml Drain=28.5ml.
IVF=1500ml. IVF=1500ml.
oral=800ml. Oral=1350ml.
Total output=1222ml Total output=1228.5ml
Urine=1200ml. Urine=1200ml.
Drain=22ml . Drain=28.5ml.
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DATE ALBUMIN CALCIUM
8/8/19 3.6 8.5 mg/dL
9/8/19 3.6 8.1 mg/dL
On 8/8/19
Corrected calcium = 8.5 + 0.8 (4-3.6)
= 8.5 + 0.8 (0.4)
= 8.5 + 0.32
= 8.82.
On 9/8/19
Corrected calcium= 8.1 + 0.8 (4-3.6)
= 8.1 + 0.8 (0.4)
= 8.1 + 0.32
= 8.42.

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26.  To remove the nodules from the right thyroid gland(total thyroidectomy)
should be done.
To prevent the tetany like symptoms (calcium + vitamin D supplements)
should be prescribed by reviewing the calcium levels.
To prevent from infection acquired during hospitalization after surgical
incision, Prophylaxis of antimicrobials (or to treat) Antibiotics should be
given.
oThese all should be done in order to avoid the risk.
To replace thyroid gland function , synthetic thyroxine like levothyroxine
should be prescribed.
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27. ON THE DAY OF OPERATION:
 Tab. Pan – 40mg 5:30am (oral)
 Tab. Anxit - 0.5mg 5:30 am (oral)
 Inj. Paracetamol -1gram 10:05am (IV)
 Inj. Tramadol - 25mg 12pm (IV)
POST OPERATIVE INSTRUCTIONS:
Oral diet after 7pm
IV fluids RL 70cc/hr.
Inj. Paracetamol 1gm IV (QID)
Inj. Tramadol 50mg IV (TID)
Inj. Emeset 4mg IV (SOS)
Serum calcium and albumin level need to check .
If there is any twitching ,numbness of lips or finger
THERAPY : GIVE IV CALCIUM.
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28. DRUGS
(DOSE/FREQ)
ROUTE TIME 6/8/19 7/8/19 8/8/19 9/8/19
Tab. Telvas
(40mg/OD)
Oral 9pm    Discharged
Tab. Novastat
(10mg/OD)
Oral 9pm    Discharged
Tab. Tramadol
(50mg/TID)
Oral 9am
2pm
10pm



Inj. Paracetamol
(1gm/QID)
IV 4am
10am
4pm
10pm




Stopped
Inj. Emeset
(4mg/SOS)
IV
Tab. P750
(750mg/QID)
Oral 3am
9am
3pm
9pm





Discharged
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29. On 9th august 2019 discharge
Rx
Tab. Shelcal 500mg( BD) (on review of calcium).
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DRUGS DOSAGE MORNING AFTER
NOON
EVENIN
G
NIGHT AFTER/BEFORE
FOOD
DURATIO
N
Tab. P750 750mg 1 1 1 1 After food 8 days
Tab. Tramadol 50mg 1 1 0 1 After food 5days
Tab. fastpan 40mg 1 0 0 0 Before food
(empty stomach)
15days
Tab. Enstrenth 1 0 0 0 After food 15 days
To come for review in 11 days.
When to contact the hospital : If there is any numbness ,tingling ,twitching of lips or fingers(IV calcium
is recommended.

30.  To Prevent the Infection( From hospital acquired )Antibiotics must
be given.
There were no serious Drug-Drug ,Drug-disease ,Drug-food
interaction.
Drain of 20-28.5ml shows the presence of infection.
Should be checked for microbial susceptibility immediately by
collecting the drain fluids.
For replacing the thyroid gland function- need to administer
synthetic thyroxine such as levothyroxine , it must be prescribed.
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33. Patient readmitted with the complaints of swelling and redness
in the surgical site.
On Emergency Admission : (For the swelling complains)
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MEDICATION (STAT) TIME
Inj. Calcium gluconate 9:30am
Inj. Esomac 9:45am
Inj. Para 10:30am
Inj. Augmentin 11:00am
On 13th august 2019:
calcium : 8.8mg/dL.
blood glucose random: 117mg/dL.
glycosylated hemoglobin: 5.5%.

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DRUG/ GENERIC NAME /DOSE ROUTE FREQ START DATE END DATE
Inj. Augmentin
(Amoxicillin &clavulanic acid)
(1.2gm)
IV TID 11/8/19 12/8/19
Inj. Magnex forte
(cefoperazone2gm +sulbactam 1gm)
(3gm)
IV BD 12/8/19 13/8/19
Infection on the surgical site is suspected , so antibiotic culture
susceptibility testing should be done to identify the microbial growth type.
To select the antibiotic therapy for the particular isolated species.
Initially planned treatment with penicillin antibiotics ,cephalosporin and
beta lactamase inhibitors until the culture report arrives.

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36. Sample collected :11/8/19.
Reporting date: 13/8/19.
Culture : positive.
Growth identification : staphylococcus Aureus.
Growth rate: heavy growth (MSSA).
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ANTIMICROBIAL
AGENTS
ISOLATE-1
MIC(mcg/ml) INT
Oxacillin 0.5 S
Gentamicin <=0.5 S
Ciprofloxacin <=0.5 S
Levofloxacin 0.25 S
Erythromycin <=0.25 S
Clindamycin 0.25 S
Linezolid 2 S
Teicoplanin <=0.5 S
Vancomycin <=0.5 S
Tetracycline <=1 S
Co-trimexazole <=10 S

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Drug Time 14/8/19 15/8/19 16/8/19 17/8/19 18/8/19 19/8/19 20/8/19
Inj. Ciprofloxacin
(400mg/BD)
3am
3pm















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Antimicrobial switch criteria

40. MEDICATIONS DOSE MORNING AFTERNOO
N
EVENING NIGHT A/B FOOD DURATIO
N
Tab. Cifran 500mg 1 0 0 1 AFTER
FOOD
5days
Tab. P750 750mg 1 1 1 1 AFTER
FOOD
5days
Tab.Thyronorm 100mcg 1 0 0 0 Empty
stomach
1 bottle
Tab. Calbrit 500/1000 0 0 0 1 A/B food 2months
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Follow up on 4 days.

41. The full replacement maintenance doses of levothyroxine may be less than
1mcg/kg/day.
This elderly patient is needed as maximum as 75mcg/day.
The maximum dose of levothyroxine is not needed as per the geriatric guidelines.
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42. TO AVOID:
Soya foods should be avoided.
OTC drugs should be avoided.
Heavy physical activity should be avoided
for 3-4 days.
Should not skip the medicine.
Food timings should not be often changed
while taking levothyroxine.
To avoid oily fried foods.
To avoid stress and need to take a proper
sleep everyday.
TO CONSUME:
Plenty of water should be taken.
Calcium rich foods should be taken in
order to prevent brittleness of the bones.
Levothyroxine pills should not skip
If skipped due to forgetfulness, as soon as
possible you remember take the dose twice
the next day.
On empty stomach need to consume
levothyroxine pills.
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