Clinical Pharmacy Practice Experience


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‘Experience is the best teacher”
Now, at the end of Hospital Training, I am pleading to say that NIRMA UNIVERSITY has intellectually included Hospital Training as part of B.Pharm. Hons. ‗S academic curriculum (Semester X). This hospital training has given me a chance to get exposed to practical work. What I have studied in semester 9, I have able to implement it in semester X hospital training.
I have already completed B.Pharm. And have studied subjects like Pharmaceutics, Pharmacognosy, etc. But in this course, I have been exposed to clinical field, not only theoretical aspect, but practical aspect as well which, according to me, the most exciting experience of my field is. According to my merit rank (calculated on the basis of semester 9 marks); I have got a chance to get trained in Shrey Hospital under the guidance of Dr. Chirag Joshi sir. He is the one who holds and manages the Intensive Coronary Care Unit (I.C.C.U) on one hand alone. It has been great experience to obtaining under such qualified and experienced person.
On the first day of my training, I along with fellow members was introduced to medical staff and have been introduced to different departments like ICCU, Operation theatre, dialysis unit, Radiology department, Pathology Lab, Lithotripsy, Pharmacy and various wards and these sessions were included in week one schedule.
During second week, I was allocated to pharmacy. I got exposed to the way to handle prescription and reading as well. I came to know the arrangement of medicines. Different medicines of same company were kept in one shelf and were arranged according to their alphabetical order in the same shelf. I also came to know about medication handling & storage, dispensing, ADR and medication order identification while handling prescription. By this pharmacy experience I came to know about extreme use of antibiotics i.e. irrational use we can say. Pharmacists here in pharmacy have overcome the mistakes done by doctor in hurry e.g. dose, freq.etc.
Our case studies began third week onwards and were continued till the end of training. Herein I studied different cases pertaining to most of the system of body. Dr. Chirag sir explained us the format of presenting the case like Patient demographics,chief complains, past history, past medication history, vital signs, systemic examination, laboratory investigation, other diagnostic tests (X-ray, USG, and MRI), medications, adverse reactions and then other related discussions. Sir explained us how to take history of patient and assigned me the case along with other fellow members which we have to present before him on the next day by preparing in the format what he had taught to us. Sir fully explains us the case according to format and carries on interaction as well. This include why a particular treatment is preferred (based on patient‘s economic status), how to overcome drug interactions and ADRs. He fully explains the treatment along with the available options of medicines e.g. Cephalosporins. He gives us a brief introduction over different class of the same along with brand names and the spectrum they cover. He explained all the part of case from entering in the hospital to discharge from hospital, every reason for single treatment. And I also saw some cases of particular of my interest like poisoning, alcoholic patient, renal failure.
During this practical training I also involved in ward round participation. I used to go with Chirag sir and learn the way treat the patient and maintain patient history notes. I used to check drug dose and dosing frequency. I also used to take patient history which is also critical in understanding patient‘s case. During ward round participation, I came to real practice experience as I was in front of the patient and use knowledge in dealing with patient.
All in all, it was the best experience that I have undergone in my field. This would be greater than anything in clearing my future registered pharmacist exam i

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Clinical Pharmacy Practice Experience

  2. 2. [SHREY HOSPITAL] CertificateThis is to certify that Mr.PARTH KUMAR DHANANI(10BPW618) of Semester X of B. Pharm (Hons.), 5-yearIntegrated Programme, Institute of Pharmacy, NirmaUniversity, Ahmedabad, has undergone training at SHREYHospital from 25/05/2010 to 08/09/2010 and has satisfactorilycompleted 400 hours in the Pharmacy Practice Experience.Date: 9/9/2010Shri Dharmanshu ChhayaManagerShrey Hospital Ltd.Near AMCO Bank,Stadium Circle, Navrangpura,Ahmedabad - 380 009Phone: 26468616 to 20, 40017777Mobile No. - 98250-23371.EMail: Seal of the HospitalProfessor In charge Head of Department Seal of the Institute Director[Parth Dhanani] Page 2
  3. 3. [SHREY HOSPITAL] Index Chapter No. Topic Page No. Introduction Clinical Pharmacy Practice 5–6 1. Importance of Clinical Pharmacy Practice Training 2. Objectives 7 – 10 Introduction and Overview of Training Training Site 3. 11 – 16 Training Site Features Training Duration Training Schedule 4. Overview of Routine Activities at Hospital 17 – 27 5. Case Studies 28 – 99 6. Results and Discussion About Learning Experience 100 – 106 7. Other Activities and Participation 107 – 123 8. Summary 124 – 125 9. References 126 - 127 10. Annexure 128 – 136[Parth Dhanani] Page 3
  4. 4. [SHREY HOSPITAL] ACKNOWLEDGEMENTThis project has been prepared to give brief knowledge to ―Clinical experience inShrey Hospital of 400 hours ‘‘.this project has to be undertaken and completed as perthe direction of the syllabus.I am very thankful to Mr.Dharmanshu Chhaya, for his constant, restless guidancethrough his busy schedule .and for his warm welcoming to the Shrey Hospital family.Also I would be thankful to Dr.Chirag Joshi(M.D) who guided me in all the clinicaldoubts and also gave us his personal attention to better understanding of the practicalconnection of clinical aspects to my theoretical knowledge as well as his incites tobetter development of my clinical experience in Shrey.I would also like to convey my gratitude to Mr.Bharathai Mahant, The Director of theShrey Hospital, for allowing us to use the resources of the hospital, which werehelpful in completion of my thesis.At this stage I, specially, thank professors Incharge Mr. Bhavik Shah of Institute ofPharmacy, Nirma University, for the moral support and constant encouragement inthe accomplishment of my project work in semester: X of B.Pharm honors.Thanking you,Mr. PARTHKUMAR DHANANI (10BPW618)[Parth Dhanani] Page 4
  5. 5. [Chapter 1] CHAPTER 1: Introduction to Pharmacy Practice Experience: Pharmaceutical care is defined as ―a patient-centered, outcomes oriented pharmacy practice that requires the pharmacist to work in concert with the patient and the patients other healthcare providers to promote health, to prevent disease, and to assess, monitor, initiate, and modify medication use to assure that drug therapy regimens are safe and effective.‖ The potential for medication therapy management services provide an additional career opportunity for pharmacy graduates. Pharmacists usually rotate between different pharmacy services offered by shrey hospital. These may include:  clinical pharmacy  medicines information  medicines management  aseptic/technical service  dispensary services  community pharmacy services  primary care Importance :  Pharmacy student‘s main focus on patient cares and emphasizes the pharmaceutical care model.  Pharmaceutical care is ―the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patients quality of life.‖  Pharmacy practice‘s aim is to guide pharmacy educators in pharmacy practice, to educate pharmacy students and to guide pharmacists in practice to update their skills.  Role of pharmacist is to ensure that a patient‘s drug therapy is appropriately indicated, the most effective available, the safest possible, and convenient for the patient. [Parth Dhanani] Page 5
  6. 6. [Chapter 1] Purpose of training and expectations that a clinical pharmacist looks forward:  Counseling patients on the effects, dosage and route of administration of their drug treatments, particularly those who require complex drug therapy.  Communicating effectively with patients relatives, community pharmacists, general practitioners etc.  Communicate with physician and discuss the cases which enrolled in shrey hospital.  Ensuring medicinal products are stored appropriately and securely to ensure freshness and potency.  Ensuring medication reaches the patient in the correct form and dose - this may include tablets, capsules, ointments, injections, inhalers and creams.  Liaising with physicians, nurses and other fellow health care professionals to ensure the delivery of safe, effective and economic drug treatment.  Monitoring every stage of medication therapy to improve all aspects of delivery and reporting patient side effects.  Provide help to main pharmacist of hospital for writing guidelines of drug use within the hospital, preparing bulletins and implementing hospital regulations.  Providing information to individual wards on budgets and expenditure on drugs.  Participating in ward rounds, taking patient drug histories and contributing to the treatment decision-making process - this includes highlighting a drugs potential side effects, identifying harmful interactions with other drugs and assessing the suitability of treatments for patients with particular health conditions.  Preparing and quality-checking sterile medications under special conditions.  Provide help to pharmacist and pharmacy assistant for the accurate dispensing and timely distribution of drugs and medicines for inpatients or outpatients.  Provide help and supervising the work of other staff.  Responding to medication-related queries from within the hospital, other hospitals and the general public and if needed then communicate with physician about the queries. [Parth Dhanani] Page 6
  7. 7. [Chapter 2]CHAPTER 2: OBJECTIVES: Pharmacy profession has entered doctor‘s clinics and hospitals as the ―clinicalpharmacist‖. Clinical pharmacy is a branch of pharmacy where the pharmacist role isto provide patient care. Clinical pharmacist is an important part of the healthcareteam. The pharmacist works in coordination with the doctors for the better patienthealthcare. They have some very specific roles which aim at assuring patient safety. Some of the roles are as follows:  Patient medication history interview.  Medication order review.  Patient counseling regarding safe and rational use of drug.  Adverse drug reaction monitoring.  Drug interaction monitoring.  Therapeutic drug monitoring.  Participating in ward rounds.  Providing drug information at the drug information and poison information centre. Build upon drug literature evaluation skills and engage in evidence-based medicine approaches. Drug information is utilized in all pharmacy practice settings, and research is no exception. Publish and present results of the research project at a national meeting. One of the essential tenets of research is being able to conduct research and present the research results to other healthcare professionals. Attend grand rounds and other seminars in order to further enhance the educational experience. Clinicians and other researchers from both inside and outside the institution present interesting topics on a weekly basis, and there are many ongoing lectures that present topical cutting-edge material in a variety of subject areas. These sessions will be used to further enhance the educational process. Participating in ward rounds, taking patient drug histories and contributing to the treatment decision-making process - this includes highlighting a drugs potential[Parth Dhanani] Page 7
  8. 8. [Chapter 2] side effects, identifying harmful interactions with other drugs and assessing the suitability of treatments for patients with particular health conditions. Counseling patients on the effects, dosage and route of administration of their drug treatments, particularly those who require complex drug therapy. Monitoring every stage of medication therapy to improve all aspects of delivery and reporting patient side effects. Communicating effectively with patients relatives, community pharmacists, general practitioners etc. Preparing and quality-checking sterile medications under special conditions. Ensuring medicinal products are stored appropriately and securely to ensure freshness and potency. Ensuring medication reaches the patient in the correct form and dose - this may include tablets, capsules, ointments, injections, inhalers and creams. Provide help to pharmacist and pharmacy assistant for the accurate dispensing and timely distribution of drugs and medicines for inpatients or outpatients. Provide help and supervising the work of other staff. Responding to medication-related queries from within the hospital, other hospitals and the general public and if needed then communicate with physician about the queries. Provide help to main pharmacist of hospital for writing guidelines of drug use within the hospital, preparing bulletins and implementing hospital regulations. Providing information to individual wards on budgets and expenditure on drugs. Communicate with physician and discuss the cases which enrolled in shrey hospital. Collaborate with other research professionals both on and off site to expand research experience. Current research projects involve co-researchers at independent sites, and the clinical pharmacist will be interacting with, and responding to healthcare professionals at these sites. The development of the ability to work with others both on and off-site will be strengthened and communications skills will be solidified in this environment. In addition, networking opportunities for the fellow are possible.[Parth Dhanani] Page 8
  9. 9. [Chapter 2] Integrate the fellow within the research process. Clinical pharmacist will actively participate in ongoing research that relates to pharmacy practice. These will include grants that are related to adverse drug events, medication prescribing and patient safety as it relates to pharmacy issues. He/she will be encouraged to think critically and input his/her opinion regarding the direction of the research projects. As the they will be actively engaged in the research process, the insights that the fellow can provide can become instrumental in the research process and lead to educational growth for the fellow. Build upon drug literature evaluation skills and engage in evidence-based medicine approaches. Drug information is utilized in all pharmacy practice settings, and research is no exception. Clinical pharmacist will interact with faculty in both the Department of Pharmacy Practice and Department of Pharmaceutical Sciences. He/she fellow will be encouraged to seek opportunities to collaborate with colleagues who share similar teaching and research interests. Within the system of health care, clinical pharmacists are experts in the therapeutic use of medications. They routinely provide medication therapy evaluations and recommendations to patients and other health care professionals. Clinical pharmacists are a primary source of scientifically valid information and advice regarding the safe, appropriate, and cost-effective use of medications. Clinical pharmacists are also making themselves more readily available to the public. In the past, access to a clinical pharmacist was limited to hospitals, clinics, or educational institutions. However, clinical pharmacists are making them available through a medication information hotline, and reviewing medication lists, all in an effort to prevent medication errors in the foreseeable future. In some states, clinical pharmacists are given prescriptive authority under protocol with a medical provider (i.e., MD or DO), and their scope of practice is constantly evolving. In the United Kingdom clinical pharmacists are given independent prescriptive authority.Basic components of clinical pharmacy practice: 1. Prescribing drugs[Parth Dhanani] Page 9
  10. 10. [Chapter 2] 2. Administering drugs 3. Documenting professional services 4. Reviewing drug use 5. Communication 6. Counseling 7. Consulting 8. Preventing Medication ErrorsScope of clinical pharmacy: Drug Information Drug Utilization Drug Evaluation and Selection Medication Therapy Management Formal Education and Training Program Disease State Management Application of Electronic Data Processing (EDP)[Parth Dhanani] Page 10
  11. 11. [Chapter 3]CHAPTER 3:Introduction and Overview of Training Introduction and overview of hospital training include visit to various departments of Shrey Hospital that are as follows: Figure 1 Layout of shrey hospital1) Intensive coronary care unit (ICCU):  An intensive coronary care unit (ICCU) is a hospital ward specialized in the care of patients with heart attacks, unstable angina and various other cardiac conditions that require continuous monitoring and treatment.  All rooms have dialysis capabilities, and one is equipped with negative air flow. The nurses station is designed for direct observation of the patients and houses the central monitors.  The Intensive Coronary Care Unit (ICCU) is located on the 4th floor of the shrey hospital. It is a single hall unit, with no through traffic. All rooms are private, and equipped with individual monitors, wall oxygen, suction, and an emergency power system.  There are two emergency code carts maintained in the ICCU with portable monitoring equipment. Supplies and other equipment are centralized. A waiting room is adjacent to the unit.Equipment & Facility:  ICCU is managed by highly trained doctors.  10 Bedded Well Equipped ICCU with Central Station.  All Beds equipped with Multi Para Monitors with - ECG - SPO2[Parth Dhanani] Page 11
  12. 12. [Chapter 3] - NIBP - RESP - Invasive BP - Temperature  Bed side multi Para monitors with invasive pressure monitoring, Infusion pumps, pacemakers, defibrillators, ultrasonic nebulizers, bed side oxygen, vacuum, air lines.2nd Invasive Line  Availability of Pacemaker.  Bedside Oxygen, Vacuum Line.  Bedside Digital X- Rays.  10 State of art ventilators.  Capnography Monitor Available.  Defibrillator (BPL)  Facility for Bedside Dialysis.  ICCU Managed Round the Clock by Qualified Intensivists.  Intra Aortic Balloon Pump.  Infusion Pumps----Syringe Pumps, Volumetric Pumps.  Latest Crasn Carts.  Muscle Pulsator to Prevent DVT.  Multiple Parameter central Station  Ultrasonic nebulizer.Activities performed in ICCU: Counseling to patients Exercise:  In an exercise program is to determine patient‘s risk of complications from exercise. This is usually done by performing an exercise test on a treadmill.  Patients can also build exercise into their daily routine by taking a brisk walk .Over time most people can gradually increase the intensity of exercise in their workout.[Parth Dhanani] Page 12
  13. 13. [Chapter 3]  This program will consider patient‘s fitness level, heart health, any physical limitations, the amount, intensity and duration of exercise needed to improve heart health, and the need for supervision.  The exercise should use large muscle groups and include aerobic exercise. Walking, jogging, swimming, cycling, rowing, and stair climbing are some examples.Supportive care:  Manage diabetes — People with diabetes are at an increased risk of developing complications after a heart attack. Tight control of blood sugar can help to reduce the risk of these and other types of complications. Tight control can be achieved by losing weight, managing your diet, exercising, monitoring blood sugar levels regularly, and taking oral medications (for people with type 2 diabetes) or insulin (for people with type 1 and sometimes type 2 diabetes).  Stop smoking — Cigarette smoking markedly increases your risk of coronary heart disease and heart attack, and stopping smoking can rapidly reduce these risks. One year after stopping smoking, the risk of dying from coronary heart disease is reduced by about one-half, and the risk continues to decline with time.  Treat high cholesterol — Medicine to lower blood cholesterol levels is also recommended after a heart attack.  Treat high blood pressure — Medicines to control high blood pressure are often recommended after a heart attack. It is important to take these medications exactly as prescribed.Healthy Diet for Heart:  Diet counseling is helpful for people who need to lose weight or reduce cholesterol levels. A registered dietitian is the best person to consult about foods that are helpful, appropriate portion sizes, total calorie recommendations, and realistic ways to change bad eating habits.  Fruits And Vegetables - These foods decrease the risk of cardiovascular diseases including coronary heart disease (CHD) and stroke. Cruciferous vegetables (i.e., broccoli, cabbage, cauliflower, brussel sprouts), green leafy[Parth Dhanani] Page 13
  14. 14. [Chapter 3] vegetables, citrus fruits, and vitamin C-rich fruit and vegetables may lower the risk of cardiovascular disease to the greatest extent.  Fibers - Eating a diet that is high in fiber can decrease the risk of coronary heart disease and stroke by 40 to 50 percent. Eating fiber also protects against type 2 diabetes, and eating soluble fiber (such as that found in vegetables, fruits, and especially legumes) may help control blood sugar in people who already have diabetes. The recommended amount of dietary fiber is 20 to 35 grams of fiber per day.  Fat - High blood cholesterol levels increase the risk of coronary heart disease. Eating foods lower in certain types of fat and cutting back on foods that contain cholesterol can lower cholesterol levels and reduce the risk of coronary heart disease. Saturated fats and Trans fats should be avoided.  Sodium – Sodium restriction is also very necessary for heart disease patients.2) Neurology Department:Description:  The department of Neurology provides Routine outdoor, indoor and dedicated emergency and neuro-intensive care especially, after surgery and stroke.  Besides management of patients with all neurological disorders, outdoor speciality clinics are set up for the following neurological conditions: Movement disorders, headache, epilepsy, neuro-muscle diseases, neuropsychiatry, pediatric neurology and pain.Facility and Services:  Emergency neurosurgery services round the clock on all days.  Intensive Care facility for critically ill patients.  Routine out-door and in-door neurosurgery services.  Sophisticated equipment available in the department to carry out the following electro diagnostic procedures for example, electroencephalography (EEG) and video telemetry, electromyography (EMG).Common Neurosurgical Procedures:  Craniofacial surgery  Endoscopic surgery[Parth Dhanani] Page 14
  15. 15. [Chapter 3]  Radio surgery and Stereotactic radiotherapy  Surgery for spasticity  Spinal surgery  Surgery for aneurysms/arteriovenious malformations  Surgery for movement disorders  Surgery for complex brain tumors  Skull base surgery  Stereotactic surgery  Surgery for Epilepsy3) Continuous Ambulatory Peritoneal Dialysis Unit (C.A.P.D):  Automated Peritoneal Dialysis Machines are also available. Patients are trained in ambulatory peritoneal dialysis in the department. This form of dialysis for chronic renal failure can be done easily at home and does not require any machine.4) Renal Care department:  3 Latest Dialysis Machine available on 3rd floor of shrey hospital for CRF and ARF patients.  Round The Clock Availability of Dialysis Technician facility and also Bed Side Multi-Para Monitors Available in Dialysis Department.  There are Doing SLED in Critically ill Patients and also available Separate Double RO Filtration Plant of Dialysis Water.  Water used in dialysis is Bacteria Free, Zero TDs, Periodically cultures clone for removing contamination.Facilities and services:  The Department takes care of all types of nephrology cases, e.g. acute renal failure, chronic renal failure, acute and chronic nephritis, nephrotic syndrome, renovascular hypertension, collagen disorders involving kidneys etc.  Facility for CRRT (continuous renal replacement therapy) for critically ill patients requiring dialysis and MARS (molecular adsorptive regenerative system) for liver failure is also available.[Parth Dhanani] Page 15
  16. 16. [Chapter 3]  Renal TransplantHaemodialysis:  Plasmaphoresis for renal as well as non-renal cases  Short term dialysis prior to transplantation  To reduce incidence of hepatitis B and C rigorous precautions are taken and such patients are dialyzed on separate machines.  Haemodialysis for acute as well as chronic renal failure patients  Haemodalysis is also done in cases of drug over dosage[Parth Dhanani] Page 16
  17. 17. [Chapter 4]CHAPTER 4:Overview of Routine Activities at HospitalWeek: 1 Introduction to Hospital departments  ICCU: Intensive Cardiac Care Unit  10 beds  Computer showing all present vitals of all patients in ICCU.  Advanced life supporting instruments  Nursing and Medical officers Figure 2 ICCU staff  24 hr running air conditioner  Ventilators near all beds  Dialysis Unit  Services - Hemodialysis - Hemofilteration - Plasma Exchanges - Continuous Ambulatory peritoneal Dialysis Figure 3 Dialysis Unit  Charges per sitting  OT: Operation Theater  Live video recorder of all operations.  All measure operations except cardiac surgery performed in Hospital. Figure 4 Operation Theatre[Parth Dhanani] Page 17
  18. 18. [Chapter 4]  Assembly of Operation Theatre  Pathology Department:  ABGA  Blood glucose meters (Wards, departments, GP surgeries and ambulance services)  Sweat Conductivity meter (Paediatrics)  Blood gas analysers  Bilirubinometer (SCBU)  Nutritional Analysis  HbA1c analyser in Paediatrics  Lithotripsy Centre  Ambulatory Lithotripsy facilities  TMT ( Tread Mill Test ) for cardiac evaluation of the patients Figure 5 Lithotripsy Centre  Wards  Doctors take round at each ward Figure 6 ICCU ward regularly  Combined Ward all on the first, second and third floor, separated by the facilities provided like, Deluxe, Super Deluxe, Special, Figure 7 General ward and Semi Special  Nurshing staff and consulting offices available at each floor.[Parth Dhanani] Page 18
  19. 19. [Chapter 4]  OPD (Out Patient Department)  All departmental specialists with interns are available at OPD site.  It is very affordable to patient compare to other private hospitals.Week: 2  Pharmacy: Figure 8 Shrey Pharmacy Store  Delivery of emergency medicines to the ICCU by Pharmacist.  Pharmacy manager teaches that how to manage the stoke of all medicines.  Arrangement of medicine by Company name or by disease.  Software like ―VISUAL‖ to dispense medicine  Option of Indoor Accommodations:  Various options are available for indoor accommodation suiting to the need & budget of the patients.  Each floor has a specious nursing station supervised by Figure 9 Indoor Accommodation medical officer round the clock[Parth Dhanani] Page 19
  20. 20. [Chapter 4] and services of physician (MD) are available whenever required.  Hospital has sitting space for visitors and waiting area have kiosks of TV, Telephone, Tea, Coffee and mineral water.Week: 3 & 4Cardiovascular System  Hypertension  Heart failure  ECG  Arrhythmia and Pacemaker  RHD and Infective Endocarditis  IHD  Stable Angina  Unstable Angina  Prinzmetal Angina  MI  CPR  Basic Life Support (BLS) -Airways -Breathing -Circulation  Advanced Cardiac Life Support (ACLS) -Defibrillation -Emergency Medication with Adrenalin, Dopamine, Atropine.  Drugs[Parth Dhanani] Page 20
  21. 21. [Chapter 4]Week: 5 & 6Respiratory System  Pneumonia  COPD  Drugs  Tuberculosis  Asthma  Tracheotomy  We have seen the live Tracheotomy in ICCU.  Ventilation  Catheter  Tracheostomy  Respiratory Failure  Hypoxia  Hypercapnea  ABGA Analysis  Mixed Respiratory Acidosis  Mixed Respiratory AlklosisWeek: 7Renal System  ARF  Pre renal ARF  Intrinsic ARF  Post Renal ARF  CRF  GFR Classification  Causes  Pathology  Intervention  Electrolyte imbalance[Parth Dhanani] Page 21
  22. 22. [Chapter 4]  Na/K/Mg/Ca/Hco3 imbalance  Dialysis  Heamodialysis  Peritoneal DialysisWeek: 8 & 9GI Disorder and Liver Dysfunction  Ascities  Cirrhosis  Hepatitis  Hepatic Encephalopathy  IBD, IBS (Inflammatory bowel disease/Syndrome)  Jaundice  Portal Hypertension  Typhoid feverWeek: 10 &11CNS Disorder  Coma  Epilepsy -Types -Drugs -Drug Interaction  EEG/CT scan  GBS  Migraine  MRI  Neuro surgery  Stroke -Hemorrhagic Stroke -Ischemic Stroke[Parth Dhanani] Page 22
  23. 23. [Chapter 4]  ShockWeek: 12Endocrine disorder  Diabetes Mellitus  Hormones -Anterior Pituitary Hormone • ACTH: Adrenocortico Trophic Hormone • GH: Growth Hormone • LH / FSH: Luteinizing hormone/Follicle Stimulating Hormone • PRL: Prolactine • TSH: Thyroid Stimulating Hormone -Posterior Pituitary Hormone • Vasopressin & oxytosinWeek: 13 & 14Infectious Disorder  Dengue  Fever and it several types  Malaria  Tuberculosis  Viral Infections  UTIWeek: 15Poisoning  Alcohol poisoning  Carbon monoxide poisoning  Chemical poisoning  Drug poisoning[Parth Dhanani] Page 23
  24. 24. [Chapter 4]  Food Poisoning  Heavy metal poisoning  Organo phosphorous Poison with case presentation  Radon poisoningParticipation in Ward round with Clinician:  Ward round is an integral part for pharmacists during hospital training. Participation in ward rounds and meetings with the patient is of benefit to the pharmacist as well as the patients.  A clinical pharmacist as we know is the third pillar of the healthcare team following the doctor and the nurse. Goals of ward round participation :  Optimize drug treatment by influencing therapy selection, implementation and monitoring  Provide information on pharmacology, pharmacokinetics and other aspects of the patient‘s therapy.  Gain an improved understanding of the patient‘s clinical details, planned investigations and therapeutic goals. Activity during ward rounds :  Assimilate additional information about the patient which may be relevant to their drug therapy  Contribute information regarding the patient‘s drug therapy e.g.; suggestions for monitoring, information on new drugs  Communicating with physician about changes in drug therapy.  Considering the impact of changes to the care plan, and making necessary alterations.  Discussing alterations to therapy with the patient where appropriate. Detect ADRs and interactions[Parth Dhanani] Page 24
  25. 25. [Chapter 4]  Follow up outstanding issues afterward round and discuss with physician and pharmacist  Investigate unusual orders or doses  Participate in discharge planning  Responding to any enquiries generated. Ward round performance :  Introduction: Introduce our self to patient and their relative and specify the purpose of ward round.  Keeping notes: Always keep notebook and pen during ward round and sketch down the important information during the ward round like the vital sign of patient during ward round.  Making queries: When wanting to make a query, wait till the consultant makes his assessment regarding the patient and plan out the management as disturbing at this time might not be a good idea. Following this, indicate your intension to ask a question and if allowed you can pose a question which is relevant to that patient.  Recording a discussion: Discuss with physician about our quires and make record in notebook about that discussion. Refer this note on next ward round.  Making summary: At the end of the ward round, make a summary of what was discussed and list out the areas needing further reading or practice to perform better as a clinical pharmacist.PHARMACY STORE:  Shrey hospital have a Pharmacy department (Medical Store) located on ground floor. Arrangement of Medicine:  The medicines in Shrey Pharmacy are arranged in shelves according to the company they belong. In that particular company shelf, the drugs are arranged in alphabetical order.[Parth Dhanani] Page 25
  26. 26. [Chapter 4] Figure 10. Drugs’ arrangementDispensing:  The team provides medicines for many areas both on and off site. They provide services to in-patients and out-patients from every clinical area.  The Pharmacy ensures that there is a round the clock availability of a sufficient quantity of drugs. Figure 11 Dispensing of drugs Storage of Medicine:  The medicines are stored in the Pharmacy at room temperature.  Special medicine such as insulin and certain injectables which degrade at room temperature are kept in the refrigerator and the temperature of the refrigerator is checked every morning by the ATO.[Parth Dhanani] Page 26
  27. 27. [Chapter 4]  Shrey Pharmacy does not have the license for Narcotics so no locked storage is required. Figure 12 Storage of medicinesRecords Maintenance:  The inventory list is printed every morning and that is done by the ATO.  The expiratory is done in the starting of every month by computer as well as manually. Figure 13 Record maintenance[Parth Dhanani] Page 27
  28. 28. [Chapter 5]CHAPTER 5: Case studiesCASE STUDY 1: ECLAMPSIA Patient details:  Patient name: XYZ  Age: 23 years  Sex: Female  Weight: 48 kg  Height: 5‘3‖  Date Of Admission: 20/07/10  Date of Discharge: 22/03/10 Chief complaints:  Generalized tonic clonic convulsion after delivering first child  Edema on lower limb since 4 days  Low U/O since 2 days  Fever since 1 day  Unconsciousness since 1 day Past history:  No significant past history Past medication:  No past medication history Family History:  Low socio-economic class  No disease running in family  Delivered first child Social History:  Married  Normal diet & sleep  No tobacco  No alcohol[Parth Dhanani] Page 28
  29. 29. [Chapter 5] On admission vital data:  Temperature: 101 oF  Pulse : 140 / MIN (N:60-90 / MIN)  B.P. : 900/50 mmHg (N: 140 / 90mmhg)  R.R. : 16 / MIN (N: 14 – 18 / MIN)  SPO2: 98% Normal Systemic examination:  CVS: S1S2 Normal  CNS: Unconscious  R.S. : Normal  P/A : Soft Lab investigations:Table 1 Lab investigation of Eclampsia patientINVESTIGATION DAY 1 DAY 2Hb 6.3 8.5TC 26,200 26,000DC 68/17/1/12/2 73/20/2/5/0PC ↓se 82,000 1,66,000PT ↑se Total 24 sec --- Control 13.2 secRBS 120 mg/dL --- (75-115mg/dL)Urea ↑se 193.47 --- (10-20mg/dL)Creatinine ↑se 8.88 (<1.5mg/dL) ---Sodium 135.26 142.37Potassium 4.7 4.1S.Bilirubin ↑se 1.41 (0.3-1mg/dL) ---[Parth Dhanani] Page 29
  30. 30. [Chapter 5]SOPT ↑se 138.5 (0-35U/L) ---S.Ammonia 39.59 ---LDH ↑se 2835 (14-26%) ---pH ↓se 7.21 (7.38-7.44) ---pCO2 ↑se 52 (35-45mmhg) ---PO2 ↑se 67 (80-100mmhg) ---Bicarbonate ↓se 11 (20-30mE/L) --- X – Ray : Normal USG (Abdomen): - Retain products - ARF CT Scan (Brain): Bilateral ischaemia Diagnosis: - ECLAMPSIA (leading cause of death) - POST PARTAL ENCEPHALOPATHY - SEPTICAEMIA - ARF - LIVER INJURY BACKGROUND: • Ten percent of all pregnancies are complicated by hypertension (HTN).Eclampsia and preeclampsia account for about half of these cases worldwide. • In 1619, Varandaeus coined the term eclampsia in a treatise on gynecology.[Parth Dhanani] Page 30
  31. 31. [Chapter 5] • DEFINITION: Eclampsia is defined as the clinical presentation of an unexplained seizure, convulsion, or altered mental status in the setting of the signs and symptoms of preeclampsia. It is considered a complication of severe preeclampsia. • A woman with preeclampsia develops: --- High blood pressure (>140 mmHg systolic or >90 mmHg diastolic) --- Protein in the urine --- Swelling (edema) of the legs, hands, face or entire body. PATHOGENESIS:In eclampsia, placenta does not form a normal system of arteries[Illness (diabetes or high blood pressure), genetic (inherited) factors and the way themothers immune system reacts to the growing placenta] ↓Placenta does not anchor itself as deeply as expected within the wall of the uterus ↓As the pregnancy progresses, a placenta creates an abnormal balance of enzymes(proteins) called growth factors (VEGF)(Placental production and secretion of antiangiogenic factors such as protein liketyrosine kinase 1 and activin a that antagonizes VEGF) ↓ ANGIOGENESIS IMPEDANCE ↓Changes the way that arteries in the mother and the placenta function-  Arteries throughout the body can tighten (become narrower), ↑se BP[Parth Dhanani] Page 31
  32. 32. [Chapter 5]  Become "leaky" allowing protein or fluid to seep through their walls, which causes tissues to swell →Edema  Also react to the abnormal growth factor balance by forming clots  Abnormal cerebral blood flow in the setting of extreme hypertension. Vessels become dilated with increased permeability and cerebral edema occurs and results in ischemia and encephalopathy → Seizures  Many uterovascular changes occur due to the interaction between fetal and maternal allografts and result in systemic and local vascular changes. These system changes contribute to the brain pathology in eclampsia by inhibiting the regulation of cerebral perfusion. Medications:Table 2 Medications of Eclampsia patient DRUG DOSE ROA DURATION GENERIC D D NAME 1 2 Inj. Pipzo 4.5 mg in i.v. 12hrly Piperacillin + √ √ 100ccNS tazobactam Inj. Metrogyl 100ml i.v. 8hrly Metronidazole √ √ Inj. Pantodac 40mg i.v. OD Pantoprazole √ √ Inj. Levepil 500mg in i.v. 8hrly Levetiracetam √ √ 100ccNS Inj. Lasix 2amp i.v. BD Furosemide √ √ Inj. FFP 250ml i.v. 8hrly Fresh frozen √ √ plasma[Parth Dhanani] Page 32
  33. 33. [Chapter 5] Inj. Dopamine 2@ in i.v. 6hrly Dopamine √ √ 50ccNS Inj. Febrinil 1@ i.v. sos Paracetamol √ √ Inj. Falcigo 60mg i.v. OD Artesunate √ √ Inj. D25% 500ml i.v. 10ml/hr Dextrose √ √ Inj. Sodium (0.6*wt*HC i.v. 13@ straight Bicarbonate √ √ bicarbonate O3 def.) & 0.6*48*9 = 13@ 6hrly 259.2mEq Inj. Duphalac 15ml i.v. 8hrly Lactulose √ √ Inj. Vit K1 1@ in i.v. OD Vit K1 √ √ 100ccNS Inj. Norad 2@ in i.v. 6hrly Nor adrenaline - √ 50ccNS Pipzo Dose Calculation:Table 3 Pipzo dose calculation Creatine Dose Dose interval Clearance 20-80 4/0.5 8 <20 4/0.5 12  Cl cr = (140 – age yr) * Body wt. = (140-23) * 48 = 8.78 72 * 72 * 8.88[Parth Dhanani] Page 33
  34. 34. [Chapter 5] DRUG RELATED ISSUE:Table 4 Drug interactions DRUGS INTERACTIONS MANAGEMENT lactulose ↔ Electrolyte loss and increase the The recommended dosage Artesunate risk of torsade de pointes and duration of use should ( moderate) ventricular arrhythmia. not be exceeded. Electrolye Electrolyte disturbances including supplements needed to be hypokalemia and administered. hypomagnesemia. Artesunate The mechanism is decreased Avoid the consumption of ↔ food clearance of Artesunate due to grapefruits and grapefruit (moderate) inhibition of CYP450 3A4- juice. To ensure maximal mediated first-pass metabolism in oral absorption, artemether- the gut wall by certain lumefantrine should be taken compounds present in grapefruits. with food. Furosemide Potentiate the pharmacologic In general, laxatives should ↔ lactulose effects of diuretics. Laxatives can only be used on a short- (Moderate) cause significant losses of fluid term, intermittent basis in and electrolytes recommended dosages. Contact physician if they experience signs and symptoms of fluid and electrolyte depletion such as dizziness, lightheadedness, dry mouth, thirst, fatigue, weakness, decreased urination, postural hypotension, and tachycardia.[Parth Dhanani] Page 34
  35. 35. [Chapter 5]CASE STUDY 2: CIRRHOSIS OF LIVER Patient details:  Patient name: XYZ  Age: 20 years  Sex: Female  Weight: 35 kg  Height: 5‘1‖  Date Of Admission: 28/07/10  Date of Discharge: 3/08/10 Chief complaints:  Abdominanal pain  Distension of abdomen  Decreased appetite  Fever Past history:  No history of HTN/DM/CAD/Asthma Past medication:  No past medication history Family History:  No significant family history Social History:  Single  Normal diet & sleep  No tobacco  No alcohol On admission vital data:  Temperature: N  Pulse : 120 / MIN (N:60-90 / MIN)  B.P. : 124/70 mmHg (N: 140 / 90mmhg)  R.R. : 16 / MIN (N: 14 – 18 / MIN)[Parth Dhanani] Page 35
  36. 36. [Chapter 5]  SPO2: 99% Normal Systemic examination:  CVS: NAD (No Abnormality Detected)  CNS: Unconscious  R.S. : Normal  P/A : Soft Lab investigations:Table 5 Lab investigation of Liver cirrhosis patient INVESTIGATION DAY 1 DAY 2 DAY 3 Hb 8.9 7.9 7.6 TC 14,100 3070 3980 DC 83/5/0/11/1 64/18/1/14/3 72/11/1/15/1 PC ↓se 66,900 42,400 45,900 PT ↑se Total 24.8 sec --- --- Control 13.4 sec INR 2.17 Creatinine 0.36 --- --- (<1.5mg/dL) Sodium ↓se 107.31 122.02 114.2 Potassium 3.93 4.1 --- S.Bilirubin ↑se 1.41 (0.3- --- --- 1mg/dL) SOPT ↑se 142.7 (0- --- --- 35U/L) Alkaline Phosphatase ↑se 173.51 (70- --- --- 120) S.Ammonia 39.59 --- ---[Parth Dhanani] Page 36
  37. 37. [Chapter 5] Gamma-glutamyl 156.73 (1-94 --- --- transferase U/L) Albumin 2.61 (3.5-5.5 --- --- g/dL) Globulins 12.96 (2-4.1 --- --- g/dL) Smear MP not seen --- --- Arterial blood gas analysis (ABGA): PH -- 7.54 pCO2 -- 27 HCO3 -- 114 BA -- 23 O2 -- 99 % TO2 -- 24 USG (Abdomen): - Shrunken right lobe - Moderate spleenomegaly - Small and nodular liver with increased echogenicity with irregular appearing area Endoscopy: Gastroscopy: Exclude the possibility of esophageal varices. Diagnosis: - Cirrhosis of liver / Wilson‘s disease - Ascites/SBP recovered - Marked Icterus - No GI bleed pro encephalopathy Pathophysiology:[Parth Dhanani] Page 37
  38. 38. [Chapter 5] - Figure 14 Liver cirrhosis  Macroscopically, the liver is initially enlarged, but with progression of the disease, it becomes smaller. Its surface is irregular, the consistency is firm and the color is often yellow (if associates steatosis).  Depending on the size of the nodules there are three macroscopic types: micronodular, macronodular and mixed cirrhosis. In micronodular form (Laennecs cirrhosis or portal cirrhosis) regenerating nodules are less than 3 mm. In macronodular cirrhosis (post-necrotic cirrhosis), the nodules are larger than 3 mm. The mixed cirrhosis consists in a variety of nodules with different sizes.  However, cirrhosis is defined by its pathological features on microscopy: 1. The presence of regenerating nodules of hepatocytes and 2. The presence of fibrosis, or the deposition of connective tissue between these nodules.  The pattern of fibrosis seen can depend upon the underlying insult that led to cirrhosis; fibrosis can also proliferate even if the underlying process that caused it has resolved or ceased.  The fibrosis in cirrhosis can lead to destruction of other normal tissues in the liver: including the sinusoids, the space of Disse, and other vascular structures, which leads to altered resistance to blood flow in the liver and portal hypertension. Medications:[Parth Dhanani] Page 38
  39. 39. [Chapter 5]Table 6 Mediation of Liver cirrhosis patient DRUG DOSE ROA DURA GENERIC D D D D TION NAME 1 2 3 4 Inj. Magnex 1.5 mg i.v. 8hrly Cefoperazone+ √ √ √ √ Forte in salbectam 100cc NS Inj. Vit K1 1@ i.v. OD Supplement √ √ √ √ Tab. Cilamin 250mg i.v. TID Penicillamine √ √ √ √ Inj. Famocid 20mg i.v. BID Famotidine √ √ √ √ Inj. Zentax i.v. TID Gentamysin √ √ √ √ Inj. FFP 2@ i.v. Fresh frozen -- √ -- √ plasma Tab. Shelcal 500 mg i.v. OD Calcium √ √ √ √ carbonate + Vit B3 Tab. Becosule Oral OD Vit B Complex √ √ √ √ Tab. Udiliv 300 mg Oral BID Ursodeoxycholic √ √ √ √ acid Inj. H.Alb 20% 20% i.v. 4hrly Supplement √ √ √ √ Tab. Dynapar Oral Sos Diclofenac -- √ -- √ plus Proctodesyl Enema Ethyl -- -- √ √ aminobenzoate/Ec osulide[Parth Dhanani] Page 39
  40. 40. [Chapter 5] Liq. Looz 2@ i.v. 6hrly Lactulose -- -- √ √ Inj. Dytor 1/2 @ i.v. 6hrly Torasemide -- -- √ √ Drug related issue:Table 7 Drug interactions DRUGS INTERACTIONS MANAGEMENT Gentamicin Coadministration of parenteral Use of aminoglycoside ↔ aminoglycoside antibiotics or antibiotics in combination Torasemide oral neomycin in combination with loop diuretics should with loop diuretics may generally be avoided. (Major) potentiate the risk of oto- and Serial, vestibular, nephrotoxicity due to additive or audiometric, and renal synergistic pharmacologic function tests should be effects of these drugs. performed before and during therapy if coadministration is necessary. Gentamicin Coadministration of The lowest effective ↔ aminoglycoside and dosages of aminoglycosides Cefoperazone cephalosporins may increase the and cephalosporins should risk of nephrotoxicity. be used when they are (Moderate) prescribed in combination. Renal function should be monitored closely. Diclofenac ↔ 1. Concomitant use of Avoiding dehydration and Torasemide nonsteroidal anti-inflammatory carefully monitoring the drugs (NSAIDs) and diuretics patients renal function and (Moderate) may adversely affect renal blood pressure. If renal function due to NSAID insufficiency or inhibition of the renal synthesis hyperkalemia develops, of prostaglandins that help both drugs should be[Parth Dhanani] Page 40
  41. 41. [Chapter 5] maintain renal perfusion in discontinued until the dehydrated states. condition is corrected. 2. Hypotensive effect of the diuretics may be reduced because inhibition of prostaglandins can lead to unopposed pressor activity and, consequently, elevation in blood pressure. Penicillamine : Oral administration of Mineral supplements or ↔ Calcium aluminum, copper, iron, zinc, other products containing carbonate magnesium, and possibly other polyvalent cations should minerals such as calcium may be administered at least two (Moderate) decrease the gastrointestinal hours before or two hours absorption of penicillamine, and after the penicillamine dose. vice versa. The proposed mechanism involves chelation of penicillamine to polyvalent cations, which leads to formation of a nonabsorbable complex. Discharge Medications: - Inj. Tazect [Piperacillin + Tazobactam (2.25)] in 100ml NS 8hrly ---------------------------------------------------------- 2 days - Tab. Tarivid [Ofloxacin (200)] (0-0-1) ------------------ 15 days - Tab. Famocid (20) (1-1) - Tab. Shelcal (500) (0-0-1) - Tab. Udiliv (300) (1-1) - Tab. Cilamin (250) (1-1-1) - Tab. Zintate [Gentamicin] (1-1-1) - Tab. Dytor plus [Torasemide] (5+50) (0-0-1)[Parth Dhanani] Page 41
  42. 42. [Chapter 5]CASE STUDY 3: MYOCARDIAL INFARCTION (MI) Patient details:  Patient name: XYZ  Age: 62 years  Sex: Male  Weight: 59 kg  Height: 5‘9‖  Date Of Admission: 17/07/10  Date of Discharge: 22/07/10 Chief complaints:  Chest pain  Difficulty in breath Past history:  No significant past history Past medication:  No past medication history Family History:  Low socio-economic class  No disease running in family Social History:  Normal diet & sleep  Smoking  Alcoholic  No tobacco On admission vital data:  Temperature: N  Pulse : 92 / MIN (N:60-90 / MIN)  B.P. : 144/94 mmHg (N: 140 / 90mmhg)  R.R. : 16 / MIN (N: 14 – 18 / MIN)  SPO2: 98% Normal Systemic examination:[Parth Dhanani] Page 42
  43. 43. [Chapter 5]  CVS: S1S2 Normal  CNS: NAD  R.S. : Normal  P/A : Soft  Stool: Not passed Lab investigations:Table 8 Lab investigation of MI patientINVESTIGATION DAY 1 DAY 2Hb 12.1 12.9TC 8350 8010DC 95/6/1/0/0 77/9/3/10/1PC ↓se 2,05,000 1,57,000PT ↑se Total 21.3 sec --- Control 13.2 secRBS 120 mg/dL --- (75-115mg/dL)Creatinine ↑se 9.14 (<1.5mg/dL) ---Sodium 141.76 139.11Potassium 5.6 5.34Magnesium 2.47 (1.8-2) 2.39S.Bilirubin 0.54 (0.3-1mg/dL) ---SOPT 31.67 (0-35U/L) ---CPK-MB 46.72 (0-7 ng/L) ---Troponin I 13.25 (0-0.4) ---pH 7.41 (7.38-7.44) ---[Parth Dhanani] Page 43
  44. 44. [Chapter 5]pCO2 39.48 (35-45mmhg) ---PO2 91.93 (80-100mmhg) ---Bicarbonate 27.84 (20-30mE/L) --- 2D ECG: Abnormalities of wall motion 12-lead electrocardiogram: - Anterior wall myocardial infarction. - Low ejection fractions (<40%) Doppler echocardiography: - Ventricular septal defect - Mitral regurgitation Diagnosis: ACUTE MYOCARDIAL INFARCTION Pathophysiology:  The most common triggering event is the disruption of an atherosclerotic plaque in an epicardial coronary artery, which leads to a clotting cascade, sometimes resulting in total occlusion of the artery.  Atherosclerosis is the gradual build up of cholesterol and fibrous tissue in plaques in the wall of arteries (in this case, the coronary arteries), typically over decades.[Parth Dhanani] Page 44
  45. 45. [Chapter 5] Figure 15 Occluded Coronary artery in MI  Blood stream column irregularities visible on angiography reflect artery lumen narrowing as a result of decades of advancing atherosclerosis.  Plaques can become unstable, rupture, and additionally promote a thrombus (blood clot) that occludes the artery; this can occur in minutes. When a severe enough plaque rupture occurs in the coronary vasculature, it leads to myocardial infarction (necrosis of downstream myocardium).  If impaired blood flow to the heart lasts long enough, it triggers a process called the ischemic cascade; the heart cells in the territory of the occluded coronary artery die (chiefly through necrosis) and do not grow back.  A collagen scar forms in its place. Recent studies indicate that another form of cell death called apoptosis also plays a role in the process of tissue damage subsequent to myocardial infarction.  As a result, the patients heart will be permanently damaged. This Myocardial scarring also puts the patient at risk for potentially life threatening arrhythmias, and may result in the formation of a ventricular aneurysm that can rupture with catastrophic consequences.  Injured heart tissue conducts electrical impulses more slowly than normal heart tissue. The difference in conduction velocity between injured and uninjured tissue can trigger re-entry or a feedback loop that is believed to be the cause of many lethal arrhythmias.  Another life threatening arrhythmia is ventricular tachycardia (V- Tach/VT), which may or may not cause sudden cardiac death. However,[Parth Dhanani] Page 45
  46. 46. [Chapter 5] ventricular tachycardia usually results in rapid heart rates that prevent the heart from pumping blood effectively.  Cardiac output and blood pressure may fall to dangerous levels, which can lead to further coronary ischemia and extension of the infarct. Medications:Table 9 Medications of MI patient DRUG DOSE ROA DURA GENERIC D D D D TION NAME 1 2 3 4 Inj. NTG + Ns 50mg i.v. 0.5ml/h Nitroglycerine √ √ √ √ r Inj. Oxprin 0.8mg i.v. Stat Aspirin √ √ √ √ Inj. Pantocid 40mg i.v. Stat Pantoprazole √ √ √ √ Inj. Emeset 40mg i.v. Stat Onadansetron √ √ √ √ Inj. DNS 1@ i.v. --- Dextrose √ √ √ √ Tab. Eldervit 1@ Oral --- Multivitamin √ √ √ √ Tab. Ecosprin 150mg Oral --- Aspirin √ √ √ √ Tab. Clopivas 100mg Oral OD Clopidogrel √ √ √ √ Tab. Dilzem 30mg Oral TID Diltiazem √ √ √ √ Inj. Decil --- Oral Stat Paracetamol √ √ √ √ Inj. Deriphyllin --- Oral 8hrly Theophylline -- √ -- √ Neb. Levolin --- Nasal 6hrly Salbutamol -- √ √ √[Parth Dhanani] Page 46
  47. 47. [Chapter 5] Neb. Budamate --- Nasal 8hrly Budesonide -- √ √ √ Tab. Calpol 500mg Oral TID Paracetamol -- √ √ √ Liq. Cremaffin 3Tsf Oral --- Paraffin -- -- √ √ Tab. Ultrazec --- Oral Sos Tramadol + PCM -- -- √ √ Advice: - Smoking cessation - Regular exercise - Sensible - Limitation of alcohol intake. Drug related issue:Table 10 Drug interactions DRUGS INTERACTIONS MANAGEMENT Theophylline The risk of seizures may be Caution is advised. ↔ Tramadol increased during coadministration of tramadol (Major) with theophylline that can reduce the seizure threshold. Clopidogrel Coadministration with proton Use of Pantoprazole should ↔ pump inhibitors (PPIs) may preferably be avoided in Pantoprazole reduce the cardioprotective patients treated with effects of clopidogrel. The clopidogrel. (Major) proposed mechanism is PPI If gastroprotection is inhibition of the CYP450 2C19- necessary, H2-receptor mediated metabolic antagonists or antacids bioactivation of clopidogrel. should be prescribed whenever possible. Diltiazem ↔ Aspirin may reverse the Close observation for Aspirin antihypertensive effect of prolonged bleeding time[Parth Dhanani] Page 47
  48. 48. [Chapter 5] (Moderate) verapamil. and reduced antihypertensive effect is recommended. Patients should be advised to notify their physician if they experience unusual bleeding, bruising, or petechiae. Aspirin should be discontinued if an interaction is suspected. Theophylline Pantoprazole increases the rate Theophylline levels in the ↔ of theophylline absorption from upper range of normal. Pantoprazole sustained-release formulations. Patients should be advised (Moderate) Chronic use of proton pump to report any signs of inhibitors produce sustained theophylline toxicity hypochlorhydria, which may including nausea, vomiting, enhance peristalsis in the small diarrhea, headache, intestine and antiperistalsis in restlessness, insomnia, or the proximal colon where irregular heartbeat to their theophylline is absorbed. physicians. Discharge medication: - Tab. Diltiazem (30mg) (1-1-1) - Tab. Ecosprin (75mg) 1OD after meal - Tab. Clopivas (2.5mg) (1-1) - Tab. Dytar Plus (10mg) (1-0-1) - Tab. Deriphylline R (300mg) 1 OD - Neb. Levolin 6hrly - Neb. Budamate 8hrly - Liq. Cremaffin 3 TSF TID - Oint. Dicloran (Diclofenac) - Tab. Ultrazec sos for pain[Parth Dhanani] Page 48
  49. 49. [Chapter 5]CASE STUDY 4: PANCREATITIS Patient details:  Patient name: XYZ  Age: 46 years  Sex: Female  Weight: 69 kg  Height: 5‘6‖  Date Of Admission: 12/07/10  Date of Discharge: 15/07/10 Chief complaints:  Abdominal pain since 2 days  NV since 2 days  Fever since 1 day Past history:  Diabetes Mellitus from last 10 years  No past history of HTN/IHD/Drug Allergy/Chest pain Past medication:  Glynase MF (Glipizide 5mg & Metformin 500mg) 1 tab OD before break fast Family History:  No significant family history Social History:  No tobacco  No alcohol On admission vital data:  Temperature: 103 oF  Pulse : 92 / MIN (N:60-90 / MIN)  B.P. : 110/70 mmHg (N: 140 / 90mmhg)  R.R. : 16 / MIN (N: 14 – 18 / MIN)  SPO2: 99% Normal Systemic examination:[Parth Dhanani] Page 49
  50. 50. [Chapter 5]  CVS: NAD  CNS: NAD  R.S. : Clear  P/A : Soft  Vomiting: Yes  Stool: Not passed (Peristalsis movement absent) Lab investigations:Table 11 Lab investigation of pancreatitis patient DRUG NAME DAY 1 DAY 2 DAY 3 Haemoglobin 14.7 12.6 --- Total count 14,900 11,400 --- Platelet count 2,33,000 2,46,000 2,37,000 RBS ↑se 425 (70-110) --- --- Creatinine 0.8 (0.6-1.2) 0.52 --- Urea 13.5 14.2 --- Sodium 137 139.33 --- Potassium ↓se 3.0 2.8 3.1 Calcium --- 8.3 --- SGPT ↑se 125 (0 - 35) --- 80.76 Serum Amylase ↑se 2415(35-120) --- --- Serum lipase ↑se 5580 (0-160) 1520 --- Serum AlkPo4ase --- 71 (70-120) 124.99 X-Ray: Normal USG: Prevalence of minimal fluid anterior to pancreas[Parth Dhanani] Page 50
  51. 51. [Chapter 5] Diagnosis: - PANCREATITIS - DIABETES MELLITUS  PATHOPHYSIOLOGY:Table 12 Flowchart of Pancreatitis Pathophysiology Acute injury Initial Insult * Zymogen activation * Ischaemias * Duct obstruction Release of Generation of Release of vasoactive cytokines active enzymes substances eg. TNF, IL-1,PAF Vascular damage Inflammation Tissue damage and cell death  The premature activation of pancreatic zymogens within the acinar cells, pancreatic ischemia, or pancreatic duct obstruction initiates AP and leads to a series of secondary events that determine the duration and severity of the injury.  Trypsinogen autoactivation and Trypsinogen activation by the lysosomal enzyme cathepsin B account for the intracellular activation of Trypsinogen and the zymogen cascade.[Parth Dhanani] Page 51
  52. 52. [Chapter 5]  The release of active pancreatic enzymes directly causes local or distant tissue damage, or may enhance inflammation by activating the alternate complement pathway.  Trypsin digests cell membranes and leads to the activation of other enzymes within the pancreas.Figure 16 Pancreatitis Figure 17 Pancreatitis  Lipase damages the fat cells, producing noxious substances that cause further pancreatic and peripancreatic injury.  The release of cytokines by the acinar cell or the inflammatory cells directly injures the acinar cell and enhances the inflammatory response.  Injured acinar cells liberate chemoattractants that attract neutrophils, macrophages, and other cells to the area of inflammation.  Vascular damage and ischemia causes the release of kinins, which makes capillary walls permeable and promotes tissue edema.  The release of damaging oxygen-free radicals appears to correlate with the severity of pancreatic injury.[Parth Dhanani] Page 52
  53. 53. [Chapter 5] Medications:Table 13 Medications for Pancreatitis patient GENERIC D D D DRUG DOSE ROA DURATION NAME 1 2 3 Inj. Magnex 3g i.v. 12hrly Cefoperazo √ √ √ forte in ne+ 100ccNS salbectam Inj. H.Actrapid --- S/C i.v. 12 hrly √ √ √ acc Inj. Pantodac 40mg i.v. OD Pantoprazol √ √ √ e Inj. Emeset 1@ i.v. 8 hrly Ondansetro √ √ √ n Inj. Contramol 1@(50m i.v. 8 hrly Tramadol √ √ √ in 100ccNS g) Inj. RL at 1@ (150 i.v. 200ml/hr Ringer √ √ √ ml) Lactate Inj. KCl 1@ in 2@/day Potassium √ √ √ 1NS@ Inj. Febrinil 1@ i.v. Sos Paracetamol √ √ √ DRUG RELATED ISSUE: DRUGS INTERACTIONS MANAGEMENT Ondansetron Concurrent use of 5-HT3 No particular intervention is ↔ Tramadol receptor antagonists may reduce required. However, the the analgesic efficacy of possibility of a diminished Tramadol. The proposed therapeutic response to mechanism is antagonism of Tramadol should be[Parth Dhanani] Page 53
  54. 54. [Chapter 5] serotonin-mediated effects of considered during Tramadol at the spinal level. concomitant therapy with 5- HT3 receptor antagonists. Insulin ↔ The effect of insulin may be If co administered, close lvp solution potentiated, and the risk of monitoring of blood glucose with hypoglycemia increased. level is required. potassium (KCl in NS)  Diclofenac is widely used analgesic. But in this case, tramadol is used as diclofenac being belonging to NSAIDs class, is nephrotoxic, which will further worsen the condition.  Food has to be administered by naso-jejunum route.  When patient begin to recover, he is first given clear water. If tolerated, then switched on to soft diet and finally, when patient begin to consume full diet, he is discharged from hospital.  Right now this patient is on soft diet.[Parth Dhanani] Page 54
  55. 55. [Chapter 5]CASE STUDY 5: ULCERATIVE COLITIS Patient details:  Patient name: XYZ  Age: 39 years  Sex: Female  Weight: 71 kg  Height: 5‘8‖  Date Of Admission: 23/08/10  Date of Discharge: 27/08/10 Chief complaints: - Altered sensorium since 4 days - Abdominal pain since 4 days - Low grade Fever since 3days - Loose motion since 2 days - Uneasiness since 2 days Past history:  No past history of HTN/IHD/Drug Allergy/Chest pain Past medication:  No past medication history Family History:  No significant family history Social History:  No tobacco  No alcohol drinking  No smoking On admissiently on vital data:  Temperature: 99.6 oF  Pulse : 136 / MIN (N:60-90 / MIN)  B.P. : 110/70 mmHg (N: 140 / 90mmhg)  R.R. : 29 / MIN (N: 14 – 18 / MIN)  SPO2: 99% Normal Systemic examination:  CVS: S1S2 normal[Parth Dhanani] Page 55
  56. 56. [Chapter 5]  CNS: Altered sensorium  R.S. : Clear  P/A : Soft  Vomiting: Nil Lab investigations:Table 14 Lab investigation of Ulcerative Colitis TEST OBSERVED NORMAL VALUE VALUE Hemoglobin 6.0 gm/dl 13.5-17.5 gm/dl DC 60/3/0/0/0 65/35/3/3/6 Total Blood Count 4,940/cmm 4,000-11,000/cmm Platelet Count 1,11,000/mm 1,50,000- 4,00,000/mm INR 1.73 0.8-1.2 PT Test: 20.5 11.1-13.1 Conrol:13.5 Sodium 113 mEq/L 135 – 145 mEq/L Potassium 3.87mEq/L 3.5 - 5.0 mEq/L Magnesium 1.1 mEq/L 1.5-2.5mEq/L Calcium 2.8mEq/L 4.5-5.5mEq/L Serum Alkaline 92.28IU/L 20 to 140 IU/L. Phosphates Serum Protein 2.84 gm/dl 5.5- 9.0 gm/dl S.G.O.T 17.39 0 – 42 IU/L Albumin 1.10 gm/dl .4 – 5.4 gm/dl[Parth Dhanani] Page 56
  57. 57. [Chapter 5]  Blood culture: Negative  USG: Right colon is mildly inflamed and moderately large DIAGNOSIS: Ulcerative colitis Pathophysiology:  Ulcerative colitis (UC) usually begins in the rectum. It may remain localized to the rectum (ulcerative proctitis) or extend proximally, sometimes involving the entire colon. Rarely, it involves most of the large bowel at once.  The inflammation caused by UC affects the mucosa and submucosa, and there is a sharp border between normal and affected tissue. Only in severe disease is the muscularis involved. In early cases, the mucous membrane is erythematous, finely granular, and friable, with loss of the normal vascular pattern and often with scattered hemorrhagic areas. Large mucosal ulcers with copious purulent exudate characterize severe disease. Islands of relatively normal or hyperplastic inflammatory mucosa (pseudopolyps) project above areas of ulcerated mucosa. Fistulas and abscesses do not occur.  Toxic or fulminant colitis occurs when transmural extension of ulceration results in localized ileus and peritonitis. Within hours to days, the colon loses muscular tone and begins to dilate. Pseudopolyps Figure 18 Pseudolyps  The terms toxic megacolon or toxic dilation are discouraged because the toxic inflammatory state and its complications can occur without frank megacolon (defined as transverse colon > 6 cm diameter during an[Parth Dhanani] Page 57
  58. 58. [Chapter 5] exacerbation). Toxic colitis is a medical emergency that usually occurs spontaneously in the course of very severe colitis but is sometimes precipitated by opioid or anticholinergic antidiarrheal drugs. Colonic perforation may occur, which increases mortality significantly. Figure 19 Colectomy specimen Figure 20 Tongue, lips, palate and pharynx ulcersFigure 21 Pyoderma gangrenosum on the leg Figure 22 Endoscopic image Medication:Table 15 Medications for UC patientNAME DOSE ROA GENERIC D D D D NAME 1 2 3 4Inj. Ceftop 0.5g + 0.5g i.v. Cefoperazone & √ √ √ √ sulbactam0Inj. Levoflox 500mg/100ml i.v. Levofloxacin √ √ √ √Inj. Metrogyl 500mg/100ml i.v. Metronidazole √ √ √ √Tab. Texim-O 200mg Oral Cefixime -- -- -- --[Parth Dhanani] Page 58
  59. 59. [Chapter 5]Inj. Forcan 2mg/100ml i.v. Fluconazole √ √ √ √Inj. 25% 30mg i.v. 25% dextrose √ -- -- --DextroseInfusionInj. Saline 0.9% 1000 ml i.v. Sodium Chloride √ √ √ √Inj. Calcium 10 %/10 mL i.v. Calcium √ √ √ √Gluconate GluconateInj. 5mg i.v. Magnesium √ √ √ √Magnesium SulphateSulphateInj. Albumin 20% i.v. Human albumin √ √ √ √Infusion PCV i.v. Pack cell volume √ √ √ --Liq. Mesacol 4 mg /60 ml Anal Mesalamine √ √ -- --EnemaTab. Mesacol 400 mg Oral Mesalamine -- -- √ √Inj. Efcorlin 100 mg i.v. Hydrocortisone √ √ √ √ Sodium SuccinateTab. Delsone 40mg Oral Prednisolone -- -- -- √Inj. Nexpro 40mg i.v. Esomeprazole √ √ -- --Tab. Nexpro 20 mg Oral Esomeprazole -- -- √ √Inj. MVI Amp. i.v. B-Complex √ √ -- --Inj. Vitamin K 0.5ml in 1 i.v. Phytonadione √ -- -- -- syringeTab. Becosules Oral B-complex -- -- -- √Inj. Emsetron 2ml i.v. Ondansetron √ √ -- --Inj. 100mg/2ml i.v. Tramadol HCL √ √ -- --[Parth Dhanani] Page 59