Case presentation on pneumonia and renal calculi

1. PRESENTED BY
K. Pavani
PharmD
VIth year
15dr1t0005
NCPER

3. INTRODUCTION
An inflammation of the lung parenchyma (the respiratory bronchioles
and the alveoli) is known as PNEUMONIA, which is caused by
microorganisms and

4. PHYSICAL EXAMINATION
. Chest X-ray.
Gram stain and culture and sensitivity tests of sputum.
Blood culture.
Immunologic test to detect microbial antigens.
CT Scan thorax.
Transtracheal aspirate.
Fiberoptic bronchoscopy or transcutaneous needle aspiration /biopsy.
Transcutaneous oxygen level analysis or ABG.

5. NAME:- Mrs. X AGE:- 60 yrs
SEX:- F IPNo:- 117093
DOA: 15/11/2019
DOD: 26/11/2019

6. Chief Complaints:
C/o fever since 1 month, high grade, intermittently evening in off temp+,
chills and rigors+ associated with cough with expectoration(yellowish) since
10 days, SOB II –III since 10 days and pain in Flank region since 10 days
with decreased urine output and swelling of limbs.
History of present Illness:
H/O Chest pain diffuses(dull aching pain)
Past Medical History:
k/c/o Type II DM, HTN since 10 yrs not on medication.
Past medication history
Pt is on insulin for Diabetes since 4 years

7. Family history:
No significant information
Social History:
General appearance:
She is conscious, coherent and oriented
Marital Status :- Married Appetite :- Normal
Bowel & Bladder:- Normal Micturition :- Normal
Education:- Uneducated Alcohol:- No
Occupation :- House-wife Tobacco :- No
KNOWN ALLERGIES:- No known allergies

8. PHYSICAL EXAMINATION
GENERAL
Ht:- 142 CM Wt:- 51 Kgs BMI:- 26 kg/m2 BSA:- 1.4 m2
VITALS 1 2 3 4 5 6 7 8 9 10 11 12
Blood Pressure(mmHg)
150/
80
150/
80
120/
70
130/
90
130/
90
130/
80
120/
70
120/
90
130/
90
120/
90
120/
90
120/
90
Heart Rate (bts) 79 79 81 98 83 85 78 79 81 79 80 80
Temperature(0F) 101 100 100 101 100 100 98 98 98 98 98 98
Respiratory rate(cpm) 20 20 20 20 20 20 18 22 20 22 22 22

9. SYSTEMIC EXAMINATIONS
A.CARDIO VASCULAR SYSTEM – Nil Significant
1.Thrills: No 2. Cardiac Sounds: S1S2+ 3.Cardiac murmurs: No
B.RESPIRATORY SYSTEM – Nil Significant
1.Dyspnea- Yes 2.Wheeze- No
3.Position of Trachea- Central 4. Breath Sounds:- Vesicular
C.CENTRAL NERVOUS SYSTEM – Nil Significant
1.Level of consciousness:- Alert 2.Speech:- Normal
Systemi
c
1 2 3 4 5 6 7 8 9 10 11 12
CVS S1S2+ S1S2 + S1S2 + S1S2 + S1S2 + S1S2 + S1S2 + S1S2 + S1S2 + S1S2 + S1S2 + S1S2 +
RS:B/L Clear Clear Clear Clear Clear Clear Clear Clear Clear Clear Clear Clear
P/A Soft Soft Soft Soft Soft Soft Soft Soft Soft Soft Soft Soft

10. LAB INVESTIGATIONS
DAY 2 DAY 3
Hb 8.1% -
S. Cr 8.3mg/dl 3.7mg/dl
S. Phospahtes 3.5 mg/dl -
S. Na+ 137 mmol/lit 133mmol/lit
S. K+ 5.0 mmol/lit 4.3 mmol/lit
S. Urea - 65 mg/dl
Uric acid 40mg/dl
G.F.R 12ml/min
OTHER INVESTIGATIONS
Chest X-ray:-
 An x-ray examination revealed patient is having right upper lobe Pneumonia (
Infection is confined to upper lobe by the horizontal fissures)
USG Abdomen:-
 Crystals visualized at the upper calye of both kidneys

11. Right upper lobe pneumonia WITH B/L RENAL CALCULI

12. TREATMENT CHART
S.N
O
TRADE NAME GENERIC NAME DOSE FREQ START
DATE
END
DATE
1. Tab. Dolo Acetaminophen 650mg TID 15/11/19 20/11/19
2. Tab. Pantop Pantoprazole 40mg OD 15/11/19 17/11/19
3. Tab. Telma Telmisartan 40mg OD 15/11/19 17/11/19
4. Inj. H.
Actrapid
Insulin 16/11/19 26/11/19
5. Tab. Telma -
CH
Temisartan +
Chlorthalidone
20/6.25
mg,
OD 17/11/19 26/11/19

13. S.NO TRADE
NAME
GENERIC
NAME
REGIME
N
FREQ START
DATE
STOP
DATE
7 Tab. Shelcal Calcium
supplements
500mg OD 17/11/19 26/11/19
8 Tab.Lasix Furosemide 20mg BD 18/11/19 26/11/19
9 Tab. Nodosis Sodium
bicarbonate
500mg BD 18/11/19 26/11/19
10 Tab. Ketoadd Alpha-
ketoglutarate
BD 18/11/19 26/11/19
11 Syp. Potrate –
SF
Potassium
citrate
100ml TID 18/11/19 26/11/19
12 Tab. Amaryl Glimepiride 0.5 mg OD 22/11/19 26/11/19
13 Tab. Pantocid
- DSR
Pantoprazole/
domperidone
20mg OD 24/11/19 26/11/19
14. Inj.Zosyn Piperacillin /
tazobactam
2.5gm TID 15/11/19 26/11/19
15 Inj. Levotos levofloxacin 500mg BD 15/11/19 26/11/19

15. SUBJECTIVE
C/o fever since 1 month, high grade, intermittently evening in off
temp+, chills and rigors+ associated with cough with
expectoration(yellowish) since 10 days, SOB II –III since 10 days.
OBJECTIVE
 Fever- 101
 Yellowish expectoration
 Chest x-ray
S-O-A-P ANALYSIS-I

16. ASSESSMENT
1. Diagnosis
On the basis of subjective and objective evidence the final diagnosis is
RIGHT UPPER LOBE PNEUMONIA
2. Etiology
It may be due to bacteria like streptococcus pneumonia, life style.
3. NEED FOR THERAPY ( EVALUATE CURRENT OR NEW THERAPY):-
RIGHT UPPER LOBE PNEUMONIA
Yes patient needs therapy to
1. Alleviate symptoms and prevent further complications like Pleural effusions,
Empyema, Respiratory failure.
2. To decrease the infection.
3. To Eradicate bacteria.

17. 11. Brand name:- Inj. Levotos
Generic name:- Levofloxacin
Class:- Quinolones
M.O.A :- Exerts anti-bacterial action by inhibiting bacterial topoisomerase IV and DNA gyrase,
the enzyme required for DNA replication, transcription repair and recombination.
A.D.R :- Nausea, diarrhoea, constipation, headache, insomnia, Inj. Site reactions, Ophthalmic:-
transient decrease in vision, ocular burning, ocular pain or discomfort.
C/I :- Hypersensitivity to levofloxacin or other quinolones
2. Brand name:- Inj. Zosyn
Generic name:- Piperacillin + Tazobactam
Class:- Pencillins
M.O.A :- Piperacillin has an antimicrobial activity against a wide range of gram-ve organisms
including K. Pneumonia, P. aeruginosa, Enterobacteriaceae and against gram +ve organisms like
E.faecalis and B. fragilis.
Tazobactam is a pencillanic acid sulfone derivative with beta- lactamase inhibitory properties. In
combination tazobactam enhances the activity of piperacillin against beta-lactamase producing
bacteria.
A.D.R :- Diarrhoea, skin rashes, occasionally platelet mediated bleeding, rigors, malaise, ulcerative
stomatitis, inj. Site reactions sucha s pain
C/I:- Hypersensitivity
ASSESSMENT OF CURRENT THERAPY

18. Goals of therapy :
 GENERAL GOAL
 To improve patients quality of life
 To prevent from further complications
 Slow progression of disease
 Provide end-of-life-care if emerges.
 PATIENT SPECIFIC GOAL
 Eradicate bacteria
 Assess severity of pneumonnia
 Relieve symptoms:
- fever, cough, pleuritic chest pain, sputum, dyspnea.
 Promptly recognize and minimize complications:
- Empyema, cavitation, pneumothorax, septic shock, respiratory failure.
 Improve clinical s/sx

19. Monitoring parameters:
 WBC
 Vitals, Respiratory Rate
 SpO2
 Chest X ray
 RS:B/L
 Platelets
Therapeutic Monitoring:
 Levofloxacin:- Monitor for blood glucose
 Salbutamol:- monitor blood sugar levels regularly because salbutamol may cause
blood sugar to raise.

20. SUBJECTIVE
C/O pain in Flank region since 10 days with decreased urine output and
swelling of limbs.
OBJECTIVE
 Hb:8.1g
 S.Phosphates – 3.5 mg/dl
 Na+ - 137 mmol/lit
 K+ - 5.0 mmol/lit
 Uric acid- 4.0
 S.Cr – 8.3mg/dl
 Sr.Urea- 60mg/dl
 G.F.R – 12ml/min
S-O-A-P ANALYSIS-II

21. ASSESSMENT
1. Diagnosis
On the basis of subjective and objective evidence the final diagnosis is
B/L RENAL CALCULI
2. Etiology
It may be due to dehydration, diet that have high protein, sodium and sugar.
3. NEED FOR THERAPY ( EVALUATE CURRENT OR NEW THERAPY):-
B/L RENAL CALCULI
Yes patient needs therapy to
1. Alleviate symptoms and prevent further complications like blockade of
urinary tract, urinary tract infection etc..
2. To decrease the levels of urea.
3. To normalize physiological functions of kidney.

22. Brand name:- Inj. Telma
Generic name:- Telmisartan
Class:- Angiotensin receptor blockers
M.O.A :- Angiotensin II receptor blocker ; inhibits vasoconstriction and aldosterone-secreting
effects of angiotensin II
A.D.R :- Dizziness, fainting, hyperkalemia, muscle weakness, rash, itching,
C/I :- Hypersensitivity( anaphylaxis, angiooedema), pregnancy ( 2nd & 3rd trimester), bilateral
renal artery stenosis
Brand name:- Tab. Lasix
Generic name:- Furosemide
Class:- Diuretic
M.O.A :-It works by blocking the absorption of sodium, chloride and water from the filtered
fluid in kidney tubules causing profound increase in the output of urine (Diuresis)
A.D.R :- Hypotension, dehydration, electrolyte depletion, rash, pancreatitis, nausea,
abdominal pain, dizziness.
C/I :- Hypovalemia, anuria, hypotension
ASSESSMENT OF CURRENT THERAPY

23. Goals of therapy :
GENERAL GOAL
 To improve patients quality of life
 To prevent from further complications
 Slow progression of disease
 Provide end-of-life-care if emerges.
 To maintain health related quality of life.
 Maintain near normal lab values
PATIENT SPECIFIC GOAL
 To control blood pressure.
 To prevent progression and secondary complications of CKD.
 To reduce the swelling of lower limbs.
 To increase the urine output.

24. Monitoring parameters:
 Hemoglobin
 S. Phosphates
 Serum Sodium
 Serum Potassium
 Uric acid
 Serum Creatinine
 Serum Urea
Therapeutic Monitoring:
 Furosemide:- Monitor for potassium levels
 Telmisartan:- Monitor for potassium levels, because ARB’S cause
Hyperkalemia

25. PATIENT COUNSELLING
About Drugs
Tab. Torsemide:
 Take the tablet once daily in the morning.
 Take low-sodium or low-salt diet, potassium supplements, and potassium-
rich foods like bananas, raisins, and orange juice in your diet.
Tab. Ca. Acetate:
 Avoid taking antacid or other calcium supplements unless prescribed by the
physician.
 Take the tablet twice daily.
Tab. Pantoprazole:
Take it 30min before meals.

26. Life style modifications
 Eat meals that are low in fat and cholesterol.
 Get regular exercise.
 Extra iron in the diet, iron pills, iron given through a vein (intravenous iron)
special shots of a medicine called erythropoietin and blood transfusions to
treat anemia.
 Limiting fluids.
 Eating less protein.
 Restricting salt, potassium, phosphorous, and other electrolytes.
 Getting enough calories to prevent weight loss.

27. DRUG THERAPY PROBLEM WORK SHEET
DRPs identified Recommendations Monitoring
Parameters
Frequency inappropriate Inj. Furosemide 10mg IV
BD, can be changed to
TID. To reduce the
swelling of lower limbs.
• Monitoring Scr, urea
levels, and Electrolyte
levels
• Monitoring urine output
ratio.
Untreated condition Ferrous sulfate or
gluconate can be given at a
dose of 38 to 65 mg of two
or three times daily.
• Hemoglobin levels
 Dialysis should be performed to patient as G.F.R is <15ml/min

28. 1. Drug therapy problem: Untreated condition (Anaemia).
Therapy goals/ Therapy end points: To improve haemoglobin levels.
Therapy recommendations: Ferrous sulfate at a dose of 38 to 65 mg of two or
three times daily can be given.
2. Drug therapy problem: Un Prescribed dose of a drug (Alpha ketoglutarate)
Therapy goals/ Therapy end points: To treat renal problem
Therapy recommendations: The drug Alpha ketoglutarate should be given at a dose of
300mg
3. Drug therapy problem: Un Prescribed dose and frequency of a drug (Inj.H.Actrapid)
Therapy goals/ Therapy end points: To treat diabetes mellitus
Therapy recommendations: Inj. H. Actrapid should be given at a dose of between o.3 to 1.0
IU per kilogram body weight per day at a frequency of BD (30 minutes before meal)

29. DRUG-DRUG INTERACTIONS
INTERACTION SEVERITY MECHANISM OF INTERACTION ACTION REQUIRED
Insulin + Levofloxacin Major Levofloxacin can affect blood glucose
levels where hyperglycemia or
hypoglycemia will be reported.
Need dose adjustment or
more frequent monitoring of blood
glucose levels to safely use both
medications.
Potassium Citrate +
Telmisartan
Major Combining these medications may
significantly increase potassium levels in
blood.
Need dose adjustment or more
frequent monitoring for potassium
levels.
Glimepiride + Levofloxacin Major Levofloxacin can affect blood glucose
levels where hyperglycemia or
hypoglycemia will be reported.
Need dose adjustment or more
frequent monitoring of blood
glucose levels to safely use both
medications.
Furosemide + Pantoprazole Moderate Combining pantoprazole with furosemide
increase the risk of hypomagnesaemia.
Need dose adjustment or frequent
monitoring and do not use the
medication more frequently or for
a longer time than recommended.
Calcium acetate +
Levofloxacin
Moderate Calcium may interfere with the
absorption of levofloxacin in the blood
stream and reduce it’s effectiveness.
Co- administration of the drugs
should be avoided. A gap period of
4 to 6 hours should me maintained
between the two drugs
administration.

30. http://www.chpnet.org/BIEM_Res/lectures.asp
http://www.emedicine.com/emerg/topic501.html
 http://g.msn.com/9SE/1?http://www.irishhealth.com/in
dex.html?level=4&id=538&&DI=293&IG=6f0f1fd0f6
854d928d14d6e96915e742&POS=22&CM=IMG&CE=
22&CS=AWP&SR=22
http://http://www.medonline.com.br/med_ed/med1/iran
ejm.html
www.auburn.edu/~deruija/renal_part3/sld001.html