Dr. Afreen Nasir, PharmD Pharmacotherapeutics 2

2. PATIENT DEMOGRAPHY
IP No. - 071900715 DOA- 6/12/19 DOD-11/2/2020
Age - 47 YEARS Ward- 4th Department-Medicine
Sex- F
SUBJECTIVE DATA
Chief complaints:
• C/o cough since 1month, fever since 15days, headache since 4 days, vomiting since 2 days,
slurring of speech since 2 days.
History of present illness :
• Patient was apparently well 1 month back, then she developed cough gradual in onset &
progressive, with scanty expectoration –mucoid, nonblood tinged, fever –intermittent during
evening with chills ,rigor, myalgia, headache-holocranial throughout the day.
• H/O weight loss, vomiting (projectile, non bolus , contain food particles), chest pain.

3. • No H/O bleeding manifestation
Past medical history:
• Not k/c/o HTN, T2DM, COPD
• K/C/O retroviral disease
Family history:
• Nothing significant
Social history:
Appetite- ↓ Sleep- ↓ Bowel Bladder- Normal &regular Diet- Mixed
Vital signs :(6/12/19)
BP : 140/80mmHg RR: 90 breaths /min SPO2=96%

4. • .
General physical examination :
• Patient is moderately built , well nourished
• Pallor + ,Icterus / Cyanosis/ Clubbing/Lymphadenopathy/Oedema – Absent
Systemic examination :
• HEENT – normal
• CNS- conscious , well oriented to time /place/person ,HMF +
• RS- normal breath sound
• Par abdomen – soft
• CVS- S1 S2 sound +, Tachycardia
• Power- 5/5 5/5 Tone – N N Plantar - ↓
5/5 5/5 N N
• Post menopausal : 2 years
• Neck stiffness + Kernig's sign + Brudzinski's sign +

5. • . PROGRESS REPORT
DATE BP
(mmHg)
PULSE
(Beats/min)
SPO2 COMPLAINTS
17/12 110/70 84 97% Neck stiffness + PLHA ( person living HIV –
AIDS) to rule out Opportunistic
infection, oral candidiasis
30/12 110/70 92 98% Drowsiness
31/12 130/80 70 93% Drowsiness , neck stiffness + Retroviral disease +
1/1 90/60 90 95%
2/1 90/60 100 94% Fever (100.4º) with headache , 1 epi
vomiting
3/1 100/60 98 94% 1 epi fever, 2 epi vomiting
9/2 120/80 88 ” 1 epi vomiting
13/1 110/70 98 98% Headache
16/1 120/70 98 96% Nausea , headache
22/1 100/80 90 97% Headache, 1epi vomit
23/1 180/70 112 96% Headache, 2 epi vomit with blood
tinged
26/1 110/70 94 94% headache

6. DATE BP(mmHg) PR( beats /Min) SPO2 PROCEDURE DONE COMPLAINTS
28/1 130/80 110 97% headache
30/1 100/80 118 99% SOB- shortness of breath
1/2 110/70 110 96% 1 pint PRBS transfusion ( O +ve)
2/2 120/80 116 96% ” fatigability
3/2 120/80 120 96% ”
4/2 ” 114 98% ” headache
8/2 130/90 124 ” ”
10/2 110/70 120 ” ”
11/2 100/70 100 ” ”

7. .Lab examination: ( Results date wise)
TESTS PERFORMED 7/12 18/12 11/1 4/2 7/2 NORMAL VALUES
Hb 6.9↓ 10.4 6.6 6.9 9.5 F=11.5-16.5 gm/dl
Packed cell vol 22↓ 20.4 20.2 21.1 30.2 F=36-46%
Platelet 3.3 3.7 3.8 3.3 3.8 1.5-4.5 lakhs/mm³
RBC 3.56 2.54↓ F=3.5 - 4.5×10^5/mm³
MCH- Mean corpuscular Hb 30 27.6 29 27-32 pg
MCV-mean corpuscular vol 92.7 84.8 90.8 78-98 fl
MCHC 34.9 30.4 ↓ 31 32-36 g/dl
ESR 135↑ 110 F= 0-20 min in 1 hr
WBC 5900 6100 5300 7900 5710 4000-11000/mm³
Neutrophils 50 59 48 65 70 40-75%
Eosinophils 12↑ 8 8.6 7 12 1-8%
Lymphocytes 29 27 24 31 29 20-45%

8. • .
TESTS PERFORMED 7/12 18/12 11/1 4/2 7/2 NORMAL VALUES
Basophils 00 00 0.8 00 00 <1%
Monocytes 10 8 14↑ 12 10 2-10%
LDL 224↑ 72 23 <130mg/dl
GRBS-general random blood sugar 133 Upto 140mg/dl
S. creatinine 1.2 ↑ 1.3 1.0 1.2 0.8 F= 0.5-0.9mg/dl
Blood urea 33↑ 27 22 21 20 7-20mg/dl
Sodium 124 ↓ 135 129 132 137 136-145 mEq/L
Potassium 5.3 ↑ 5.5 5.0 5.2 4.9 3.5 – 5.1 mEq/L
Chloride 95↓ 103 96↓ 98 95↓ 97-114 mEq/L
S. Total proteins 8.9 ↑ 6.4↓ 8.6 6.6-8.7 g/dl
S.Albumin 3.4↓ 5.0 4.2 3.5- 5.2 g/dl
S . globulin 5.5 ↑ 5.3 2.4 ↓ 2.5- 4.5 g/dl

9. TESTS PERFORMED 11/1 7/2 NORMAL VALUES
Alkaline phosphate (ALP) 179 ↑ 130 F= 35- 104 U/L
SGOT/AST 52 ↑ 54 F= 10-35 U/L
SGPT/ALT 36 ↑ 32 <33U/L
S. Total Bilirubin 1.2 1.3↑ Upto 1.2 mg/dl
S. Direct bilirubin 0.3 ↑ 0.2 0.2 mg/dl
GGT- gamma glutamyl transferase 44 ↑ 21 F= 6 - 42 U/L
VitB12 118↓ 180- 914 pg/ml
Ferritin 694↑ F= 11-307 ng/ml
Iron 206↑ F= 37- 145 microgram
Transferrin 196↓ 200 – 300 mg/dl
Absolute eosinophilic count 660 ↑ 40-440 / mm³
 Impression – Microcytic hypochromic anemia with eosinophilia

10. ASSESSMENT
From the subjective and objective data it is assessed that patient is suffering
from cryptococcal meningitis & Oral Candidiasis associated with HIV

11. Medication Chart :
Medicine
prescribed
Generic name Dose Freq Route Indications Start
date
Stop
date
Inj .
CEFTRIAXONE
Ceftriaxone • 1g
• 17,30/12
(2g)
1-0-0
1-0-1
7/1 (1-0-1)
IV Antibiotic to treat
respiratory
infection
16/12 10/1
Inj. PAN Pantoprazole 40mg 1-0-0 ” Proton pump inh –
Treat acid reflex
’’ 6/2
Inj .EMESET Ondansetron 4g • 1-0-1
• 28/1 (1-1-1)
’’ antiemetic ’’ ’’
Inj.
PARACETAMOL
Acetaminophen • 1g
• 6,7/1-
500mg
SOS ’’ Analgesic,
antipyretic
’’
10/2
16/1
C.
FLUCONAZOLE
Fluconazole • 150mg
• 300mg
 (1-0-0)
• 7/1 (1-0-1)
 18/1 (1-1-1)
• 19 , 20/1 (1-1-1-
1)
p/o Antifungal for
meningitis
16/12 -
10/1
28/1
- 6/2

12. Medicine
prescribed
Generic name Dose Freq Route Indications Start
date
Stop
date
Inj . MANNITOL Mannitol 1-0-1
• 31/12(1-1-1)
IV Osmotic diuretic –
Treat meningitis
30/12 4/1
T. SEPTRAN DS (
ART)
Trimethoprim/sulfa
methoxazole
100mg 1-0-0 p/o Antibiotic - 30/12
20/1
10/1
11/2
T. CANDID V3 Clotrimazole 200mg 0-0-1 ’’ Antifungal – oral
candidiasis
4/1
Inj .
AMPHOTERICIN
. B. LIPOSOMAL
Amphotericin B 240mg
• 8/1
(45mg/d)
1-0-0 in 5% D flush
NS
IV Antifungal –treat
cryptococcal
meningitis
4/1
20/1
16/1
6/2
T. PCT Paracetamol-
Acetaminophen
500mg 1-1-1 P/O Antipyretic ,
analgesic
11/1
24/1
26/1
31/1
3/2
21/1
29/1
6/2
9/2
Neb . ASTHALIN Salbutamol
sulphate
10mg 1-1-1 P/N Bronchodilator for
SOB ( shortness of
breath)
13/1

13. Medicine Prescribed Generic name Dose Freq Route Indication Start
date
Stop
date
K. BIND SACHET Calcium Polystyrene
sulfonate
15g 1-1-1 P/O Treat
hyperkalaemia
15/1
T. N . ACETYL CYSTEINE Acetylcysteine 600mg 1-1-1 p/o Mucolytic 16/12 2/2
T. ART Antiretroviral therapy p/o Antiviral 19/1
26/1
21/1
11/2
CANDID MOUTH 1% PAINT Clotrimazole Antifungal – treat
oral thrush
16/12
2/1
31/12
11/1
Inj. OPTINEURON Cyanocobalamin (B12),
D-Panthenol (Vit B5),
Pyridoxine (Vit B6),
Riboflavin (Vit B2),
Thiamine(vit B1),
Nicotinamide (vit B3)
1 amp in
100 ml NS
• 1/2
(2amp
)
0-1-0 IV Treat VitB12
deficiency- vit
supplement
20/1
1/2
11/2
21/1
T. Fe Ferrous Sulphate • 200mg 0-1-0 p/o Treat anemia 1/2 11/2
T. BIFILAC Lactobacillus+
Streptococcus faecalis +
Clostridium butyrcum +
Bacillus mesentericus
2-2-2 ’’ Probiotic ’’ ’’

14. Med Prescribed Generic Name Dose Freq Route Indication Start date Stop
date
Syp.
AMBROLITE
Ambroxol+Guaifene
sin + Terbutaline +
Methanol
10mg – 2tsp 1-1-1 p/o Mucolytic 5/2 8/2
T. PAN Pantoprazole 10mg 1-0-0 ’’ Proton pump inh-
reduce gastric acid
secretion
7/2 11/2
IVF .NS
RL
Normal saline
Ringer lactate
1 pint
1 pint
• 19/1 ( 100mg/L)
1-0-0 IV Electrolyte
replenisher
16/12
19/1
17/1
2
IVF .DNS Dextrose , Sodium
chloride
• 1 Pint @ 75 ml/hr
• 1 pint @ 100ml /hr
’’ ’’ • 3/1
• 30/12 8/1
IVF. NS Normal saline –
sodium chloride
2 Pint @75 ml/Hr ’’ ’’ 2/1
16/1
IVF .NS
RL
Normal saline
Ringer lactate
2pint
2pint
• 1pint RL @ 200ml/
hr
• 1pint NS
’’ ’’ • 20/1
• 26 /1
• 2/2
11/2
1/2
11/2

15. PLAN
PROBLEM PLAN
Fever & headache , myalgia • Inj Paracetamol 1g,
• T. PCT 500mg
Vomiting • Inj. Emeset 4g
SOB • Neb. Asthalin 10mg
• Syp. Ambrolite
• T. N . Acetylcysteine 600mg
Hyperkalaemia K bind Sachet
Oral candidiasis • T.Candid V₃ 200mg
• Candida mouth paint
Anemia & Vit B 12 deficiency • Inj Optineuron 1amp /2amp in 100ml NS
• T.Fe 200mg

16. MONITORING PARAMETERS
Medication Monitoring parameters
• T. Ceftriaxone Hypersensitivity reaction, wbc count, urinalysis, BUN, SCr
• T. Fe RBC count, sr. ferritin, total iron – binding capacity, Hb .
• Inj . Pan Hypersensitivity reaction
• Inj PCT Body temp, pain intensity by pain scale , Liver function,
Hypersensitivity reaction
• Inj Ondansetron ECG ( QT prolongation ), Sr. Potassium ,Sr. Mg, ↓bowel
activity, hypersensitivity reaction
• C. Fluconazole LFT ( AST, ALT , ALP ) , RFT , Potassium
• Inj Mannitol Sr. Electrolytes (K , Na) , RFT, infusion site, urine I&O
• Trimethoprim/
sulfamethoxazole
CBC with differential , platelet count , liver enzyme test,
bilirubin, Sr K, Sr Creatinine, BUN
• Inj.Amphotericin B
Liposomal
RFT , Sr electrolyte ( Mg, K) , blood count , Hb ,LFT, Temp,
CBC,cardiac function

17. : Medications
Specific monitoring parameters
• T. Clotrimazole LFT
• K bind sachet Sr K , Ca, Na, Mg, ECG
• Inj Optineuron Level of vit b12
Clinical pharmacist intervention ( Drug interaction)
1) Serious –
• Fluconazole + ondansetron - ↑ QTc interval
2) Monitor closely-
• Pan ↓ effect of ferrous sulphate by ↑ gastric pH
• Fluconazole & Trimethoprim ↑ QTc interval
• Fluconazole & Sulfamethoxazole ↑ QTc interval

19. •CONDITION ON DISCHARGE-
Pallor +
Power, tone, reflex –N
BP- 140/80mmHg
SPO₂ - 96%
PR- 90BPM
CVS – S1S2 ,Tachycardia +
RS- NVBS
CNS – Conscious, Kernig's + , Brudzinski's + , Neck stiffness +
ADVICE TO DOCTOR-
Since the patient’s discharge condition is not stable as sign –symptoms of meningitis is still
present , and there is no discharge medicine prescribed for that, may be her conditions can
improve if C. FLUCONAZOLE 250 mg is included in her discharge medicine.

20. •
• T. SEPTRAN DS -100mg – 1 time in morning after breakfast – for 1 week- it is antibiotic
which treat infection by Cryptococcus in HIV
→ Side effect : diarrhea – so drink lot of water or take ORS
2) Eat food which boost your immune system –curd, sweet potato, papaya, beans, green
leafy vegetables , sea food (fish),dry fruits (almonds) , citrus fruits ( tomato, orange).
• Use of turmeric , garlic in food
DURING DISCHARGE-
• Take all the medications regularly with plenty of water on time. If skipped any med. take
it immediately when remembered, but if it is time to take next dose don't take the skip
dose , which can cause high dose of med.
• Swallow whole tab don't chew. Store medicines in dry , clean container, away from heat &
sunlight , children ,don't freeze.
1) You were diagnosed with CRYPTOCOCCAL MENINGITIS which means inflammation in
covering of brain by fungus. In your case it is HIV AIDS – associated .
IN WARD - Most of the medicines are given through IV , if there is swelling, irritation, in site
of injection ; inform to nurse incharge . You can apply ice pack in site if injection to reduce
swelling

21. 4) T. PAN -45 mg – take 1 time in morning – 1 week – it will reduce acid production in
stomach , hence reduce stomach pain , chest burn which happen because of eating
medicines.
• Side effect- vomit, constipation, gas formation in stomach, loose motion, fast heart beat.
• Eat –Green leafy veg, ginger, egg white, soft meals ( khichadi)
• Don'ts- Tea, coffee, soft drinks, spicy food
5) T. OPTINEURON- take in afternoon , after food- 1 week – it will increase Vit B12 (
vitamin supplement)
• Eat- chicken, liver, milk, eggs, tuna fish
6) T. Fe -200mg- take in afternoon after lunch- 30 days- treat anemia ( low hemoglobin in
blood) .
• Side effect- constipation/ loose motion , dark color stool
• Side effect - stomach pain , ulcer in mouth
• You apply wet cloth over head when you have fever
3) T. PCT is paracetamol- 500mg – it will reduce fever- take for 1 week
• Use of turmeric , garlic in food

22. 7) T. N. ACETYLCYSTEINE -600mg-take 3 times a day – for 30 days-it will make cough loose
& you can remove is easily. You can breath easily.
• Side effect- Vomit, mouth sore.
• Eat- Hot water, ginger, veg-pepper soup
• Don'ts- cold drinks, ice creams
• Take steam inhalation ( In hot water in a tub add balm and inhale by covering yourself
with blanket)
• Don’t sleep straight ,you will have more breathing difficulty, sleep on one side, raise your
head using more pillows.
8)Visit to physician after 1 week , inform him if you get any side effects after eating medicine
,so that he can change the medicine or dose.
9) Continue ART which is medicine for retroviral infection (HIV)
• Wash & cook food, keep yourself clean to maintain personal hygiene( wash hand, take
bath)
• Eat - citrus fruits (lemon, tomato, orange) , iron which you are eating in form of tablet will
be easily taken by your body, green leafy veg( spinach, drum stick leaves), meat, liver,
seafood, beet root, amla, pomegranate