The document presents a case study of a 25-year-old male patient diagnosed with tonsillitis, exhibiting symptoms such as fever, throat pain, and difficulty swallowing. The treatment plan includes the administration of azithromycin, paracetamol, ranitidine, and vitamin B complex, along with patient counseling on symptomatic relief methods. The physician confirmed the diagnosis based on both subjective and objective evaluations, while the pharmacist noted no adverse drug interactions.

1. • CASE STUDY BASED ON DISEASE
• { TONSILLITIS }
PREPARED BY
MARTIN SHAJI
Pharm D

2. • Patient name –Ms. x OP no. –145028
• Admission date- 30-2- 19
• Age-25
• Sex-M
• Department- General medicine
PATIENT DEMOGRAPHY

3. 1. Physical examination: patient conscious and coherent
Vital signs:
Temperature (oF): 100
Pulse rate (/min): 76beats
Blood Pressure (mm of Hg):120/80mm of Hg
2. Systems Examination:
CVS: S1, S2 +
RS: Clear
GENERAL EXAMINATIONS

4. SUBJECTIVE EVALUATION
A 25 years old male patient was consulted with the complaints of fever for
few days at frequent intervals along with throat pain, sore throat, difficulty
swallowing, and cough with sputum. Inflamed tonsils are noticed .
OBJECTIVE EVALUATION
On Examination, the patient was conscious & coherent.
ASSESSMENT:
Based on subjective & objective evaluation the physician
confirmed it as Tonsillitis.
SOAP NOTES

5. CONFIRMATORY
DIAGNOSIS
TONSILITIS

6. • From the examination the patient was noticed with inflamed tonsils
hence, he is advised to use salt gargle thrice a day , also avoiding cool
food items .
• Considering the severe inflammation the patient should provided
with penicillin's, or antibiotics . Past medication history of the patient
has shown that penicillin sensitivity in the subject , hence
Azithromycin and Metronidazole has to provided.
• Along with paracetamol [ analgesic & antipyretic] , here the patient
having elevated temperature.
PLANNING

7. Sl.
No.
Drug
Indication ROA Frequency and dose.Brand Name Generic Name
1. ZITHROMAX AZITHROMYCIN ANTIBIOTIC
ORAL BID 250 MG/ 7 DAYS
2. T. PCT PARACETAMOL ANALGESIC &
ANTIPYRETIC
ORAL
OD 500MG/ 7 DAYS
3. RANTAC RANITIDINE H2 - BLOCKER
ORAL BID 25 MG/ 7 DAYS
4. T. B ACTIVE B COMPLEX VITAMIN
SUPPLEMENT
ORAL OD / 7 DAYS
DRUG CHART

8. REGARDING MEDICATION
AZITHROMYCIN ;
250 mg BID is used orally for 7 days, Azithromycin
is an antibiotic used for the treatment of a number of bacterial infections.
Paracetamol
650mg BID is used as an anti-pyretic. It act as a pain killer and also as
temp lower. Given for 7 days
RanitidinE
25mg BD is used as an anti-ulcerative drug which reduce stomach irritation
,donot take more than two weeks given for 7 days .
B. COMPLEX
The B vitamins are eight water-soluble vitamins that play important roles in
cell metabolism. Supplements containing all eight are generally referred to as
a vitamin B complex. Suggested for 7 days , so as to ensure the patients
health and improve the resistivity to the infection.

9. PHARMACIST INTERVENTIONS
1.The prescription was rational.
2. No DDI or ADRs were found.

10. DISCUSSION
Tonsillitis is inflammation of the tonsils, two oval-shaped pads of
tissue at the back of the throat — one tonsil on each side. Signs
and symptoms of tonsillitis include swollen tonsils, sore throat,
difficulty swallowing and tender lymph nodes on the sides of the
neck.

13. PATIENT COUNSELING- Instructions for patient
Easing the pain of a sore throat: Suck on a throat lozenge, hard
candy or popsicle; take acetaminophen (Tylenol or ibuprofen (Advil);
(Advil); gargle with warm salt water (1/4 tsp. salt per glass of
of water); drink plenty of liquids; and eat soft, bland foods. Throat
Throat sprays (Chloraseptic) can also provide pain relief
• Gargle with warm salt water
• Drink warm tea
• Suck on popsicles