Dr. Afreen Nasir, PharmD Pharmacotherapeutics 3

1. CASE PRESENTATION
Presented by
Afreen Nasir
4th PHARM.D
REG NO. 17QO902
ABMRCP

2. PATIENT DEMOGRAPHY
IP No. : 11902391 DOA : 24/1/2020 DOD : 1/2/2020
Age : 30 YEARS Ward/ Bed : 4th /22 Department : Medicine
Sex : Female

3. SUBJECTIVE DATA
COMPLAINTS ON ADMISSION:
• C/o yellowish discoloration of eye & epistaxis , bleeding & ulcer in oral cavity since 1 month ,
abdomen distension since 10 days , lower limb swelling since 4 days. Patient complained of
worrying thoughts ,chest discomfort , palpitation , irritability , confusion since 2 weeks.
HISTORY OF PRESENT ILLNESS :
• Patient was apparently well , then she developed yellowish discoloration of eyes which was
insidious in onset & gradually progressive along with epistaxis , abdomen distension. H/o
lower limb swelling – pitting type , gradually increasing , present up to knee (grade iii). No
H/o vomiting , loose stools etc. H/o confusion.

4. PATIENT HISTORY:
• Past medical History - No H/O HTN , T2DM , COPD
• Family History – Nothing significant
• Allergy - NKA
• Medication history - Nothing significant
• Social History -
Appetite: Reduce Sleep: disturb Bowel-Bladder: Normal &regular Diet: Mixed
Alcohol: Yes ; since 3-4 years (1-2 glasses of whiskey per day) ; last drunk: 19/1/2020

5. OBJECTIVE DATA
• VITAL SIGNS : (24/1/2020)
BP : 110/70mmHg HR: 78 breaths /min SPO2=98% Wt: 50.4Kg Ht: 158cm
• GENERAL EXAMINATION: Patient is moderately built , well nourished , conscious , cooperative
PICCKLE : Pallor + ,Icterus +, Cyanosis/ Clubbing/Koilonychia / Lymphadenopathy - Absent , Oedema + (pitting
type).
• SYSTEMIC EXAMINATION
HEENT – normal
CNS- altered sensorium
RS - B/L normal breath sound +
Par abdomen – soft , Tenderness, hepatomegaly + 14cm below costal margin
CVS- S1 S2 sound +

6. LABORATORY EXAMINATION:
Tests Performed 24/1 26/1 31/1 Normal values
Hemogram
Hgb 6.2 9.5 10.4 F= 12.3-15.5 g/dL
PCV 38 38 37 F = 36-45%
RBC 3.6 3.58 3.5 F = 4.1 – 5.1 × 10⁶ cells / microLitre
Platelets 88,000 87,000 90,000 1.5-4.5 lakhs/mm³
MCH 30 31 29 27-32 pg / cell
MCV 103 105 103 80-96 fL
MCHC 34.9 34 33 33 – 35.5 g/dL
ESR 39 F= 1-20 mm /hr
RDW 15.6 11.5% - 14.5%
WBC 5900 6100 5300 4000-11000/mm³
Neutrophils 82 78 74 45-73%
Eosinophils 2 1.5 2 0-4%
Lymphocytes 9 11 12 20-44%
Basophils 00 00 0.8 0-1 %
Monocytes 7 8 14 2-10%

7. Tests Performed 24/1 26/1 31/1 Normal values
VitB12 118 121 150 180- 914 pg/ml
Folate 10 10.5 10 5-25 mcg/L
Ferritin 305 305.8 304 F= 11-307 ng/ml
Sr.Iron 38 38.4 37 F= 37- 145 microgram / dL
Transferrin 220 219 220 200 – 300 mg/dL
UIBC 234 236 234 112-346 microgram/dL
TIBC 321 324 324 250-450 microgram/dL
Lipid Profile : LDL 224 <130mg/dL
RFT
S. creatinine 0.3 F= 0.5-0.9 mg/dL
BUN 5 7-20 mg/dl
Sr. Sodium 124 135 136-145 mEq/L
Sr .Potassium 3.0 3.6 3.5 – 5.1 mEq/L
Sr. Chloride 91 97 96-106 mEq/L
S. Calcium 7.1 7.9 8.5-10.8mg/dl
LFT

8. Tests Performed 24/1 26/1 31/1 Normal values
Globulin 2.8 2.8 3.2 2.5-4.5 g/dL
ALP 168 166 154 40-140 unit/L
SGOT/AST 279 278.9 267 12-38 U/L
SGPT /ALT 71 71 68 7-41 U/L
T. Bilirubin 21.1 20 19 Up to 1.3 mg/L
Sr. Direct bilirubin 22 20 18 0.1 – 0.4 mg/dL
GGT 522 512 502 1-94 U/L
PT 19.8 12.2 11.1 – 13.1 sec
INR 1.76 1.5 0.9-1.1
aPTT 42 40 30-40 sec
Impression – Macrocytic (Vitamin B12 deficiency) anemia with thrombocytopenia.
OTHER TESTS (25/1/20)-
• Cytology report : Specimen – Ascitic fluid
Report – No atypical / malignant cells seen in smear
• Bacteriology report : Specimen – ascitic fluid
Report – No pus cells , no organisms , no growth after 2 days of ascitic incubation.
• Serology – Anti HCV : negative , HBsAg : negative

9. • P/A Ultrasound scan : Mild ascites , fatty hepatomegaly , mild splenomegaly , feature of portal hypertension,
portal vein dilated 14mm.
• Endoscopy : Oesophageal candidiasis
• Blood group : AB +ve

10. ASSESSMENT
FINAL DIAGNOSIS:
From subjective & objective data patient is diagnosed with decompensated liver disease
secondary to alcohol with coagulopathy , ascites , grade I encephalopathy , oesophageal
candidiasis ,vitamin B12 deficiency anemia.

11. TREATMENT CHART :
• Medicine
• prescribed
• Generic name
• Dose
• Freq
• Route
• Indications
• Start date
• Stop date
Medicine
prescribed
Generic name Dose Freq Route Start date Stop
date
Inj. Vit K PHYTONADIONE 1 amp 1-0-0 IV 24/1 27/1
Inj . Pan PANTOPRAZOLE 40mg 1-0-0 IV 24/1 1/2
T. Udiliv URSODEOXYCHOLIC ACID 150 mg 1-0-1 PO 24/1 1/2
Inj. Optineurin Thiamine (Vit B1)100mg + Pyridoxine ( Vit
B6) 100mg + Cyanocobalamin(Vit B12)
1000mcg + Riboflavin (Vit B2) +
Nicotinamide ( Vit B30 100 mg + D-
Panthenol ( Vit B5) 50mg
1 amp 1-0-0 IV 24/1 29/1
Inj. Xone CEFTRIAXONE 1g 1-0-1 IV 24/1 28/1
Syp. LACTULOSE LACTULOSE 15ml 1-1-1 PO 27/1 1/2
T. Aldactone SPIRONOLACTONE 50mg 1-0-0 PO 24/1 1/2
Inj Lasix FUROSEMIDE 40mg 1-1-0 IV 26/1 31/1
Syp. Potklor POTASSIUM CHLORIDE 15ml 1-1-1-1 PO 24/1 30/1
Zyte gel L/A CHOLINE SALICYLATES & LIDOCAINE 10ml 1-0-1 24/1 1/2
T.
FLUCONAZOLE
FLUCONAZOLE 150mg 1-0-0 PO 25/1 27/1

12. Medicine
prescribed
Generic name Dose Freq Route Start
date
Stop
date
T. RIFAXIMINE RIFAXIMINE 550mg 1-0-1 PO 25/1 29/1
Inj. MEROPENEM MEROPENEM 1g 1-1-1 PO 31/1 1/2
C. Bifilac Streptococcus faecalis 30 million , Clostridium butyricum
2 million ,Bacillus mesentericus 1 million , lactic acid
bacillus ( Lactobacillus sporogenes – 50 million spores)
1mg 1-1-1 PO 31/1 1/2
Inj. Lorazepam LORAZEPAM 1mg 1-0-1 IV 27/1
MONITORING PARAMETERS :
DRUGS PARAMETERS TO BE MONITORED
Inj. Vit K (PHYTONADIONE) INR , PT, Sr.K level
Inj. Optineurin Sr.VitB12
SPIRONOLACTONE +FUROSEMIDE Dehydration, ↓Na /Mg/Ca

13. PROGRESS CHART:
Date BP (mmHg) Pulse
(Beats/min)
SPO2 Complaints Notes
25/1 120/80 84 98% Lower limb swelling ,
difficulty walking
CVS : S1S2+ RS : NVBS PA : hepatomegaly +
10:30 am blood transfusion B+ve
CNS: altered sensorium
26/1 130/90 92 98% Fatigue , headache CVS : S1S2+ RS : NVBS PA : hepatomegaly +
27/1 130/80 101 99% Worrying thoughts ,
palpitation , excess
sweating
CVS : S1S2+Tachycardia RS : NVBS PA :
hepatomegaly +
CNS : confusion
28/1 124/82 90 99% Lower back pain CVS : S1S2+ RS : NVBS PA : hepatomegaly +
CNS : HFM
29/1 122/80 101 96% Sleep disturbance ,
palpitation
CVS : S1S2+ Tachycardia RS : NVBS
30/1 180/80 98 98% Sleep disturbance CVS : S1S2+ RS : NVBS
31/1 110/70 98 98% Neck stiffness+ CVS : S1S2+ RS : NVBS
1/2 120/70 103 98% CVS : S1S2+ Tachycardia RS : NVBS

14. PLAN
TREATMENT GOALS:
• Patient specific –
-Improve QOL , prevent complications related to bleeding
-Selecting cost effective medicine & minimizing side effects of medicines
- To avoid morbidity & mortality associated with disease
• Disease specific –
-Manage symptoms associates with portal hypertension ( ascites , encephalopathy , thrombocytopenia)
-To prevent progression of liver disease
-To bring electrolytes , hemogram / liver proteins or enzymes abnormalities to normal level
-To prevent the progression of sign & symptoms of grade 1 encephalopathy like euphoria , anxiety , mild
confusion , agitation , sleep disturbance etc.

15. CLINICAL PHARMACIST INTERVENTIONS
• Drug – drug interaction :
• Prescription audit :
Use of standard abbreviation – Yes
Use of Capital letters – No
Drug interaction – Yes
Therapeutic duplication – No
Legibility – Legible
Reference – Drugs.com
Interaction Range Reason
Potassium chloride <> Spironolactone Major Combination of these drugs ↑es K level in blood, which
causes kidney failure , irregular heart rhythm
Spironolactone <>Lactulose &
Furosemide <> lactulose
Moderate Both drugs has laxative effect which increase risk of
dehydration
Furosemide <> Pantoprazole Moderate Cause hypomagnesemia

16. CONDITION ON DISCHARGE-
• Pallor + BP- 120/70mmHg SPO₂ - 98% PR- 108 bpm CVS – S1S2 ,Tachycardia + RS- NVBS
• CNS – Conscious oedema – present but reduced
DISCHARGE MEDICATION :
Medication prescribed Dose/Route Frequency /Duration Possible side effects
T. FLUCONAZOLE 200mg PO 1-0-0 × 7days Headache, abdomen pain ,rash
Syp. LACTULOSE 15ml PO 1-0-1 × 7 days Vomiting, flatulence
T. PANTOPRAZOLE 40mg PO 1-0-0 vomit, constipation, gas formation in
stomach, loose motion, fast heart
beat
Zyte gel L/A (CHOLINE SALICYLATES
& LIDOCAINE)
10ml Finger Tip Unit
(FTU)
1-0-1 Burning sensation, itching
T. Udiliv (URSODEOXYCHOLIC ACID) 150mg PO 1-0-1 × 7 days Abdomen pain, itching, hair fall
T. Aldoloc ( FUROSEMIDE +
SPIRONOLACTONE)
50/20mg PO 1-0-0 × 7 days Headache, stomach pain
T. RIFAXIMINE 550mg PO 1-0-1× 5 days Flatulence , constipation

17. • ADVICE TO PHYSICIAN TO ADD DRUG IN MEDICATION CHART – CALCIUM SUPPLEMENT must be added
as it also help in treating coagulopathy.
• ADVICE TO PHYSICIAN ON DISCHARGE MEDICATION-
- Since the patient’s discharge condition is satisfactory but vit B12 levels is low and no discharge medicine is prescribe
for that, may be this parameters come to normal if T. OPTINEURON is included in her discharge medicine.
- T. PHYTONADIONE must also be added in discharge medication because PT, INR values are still abnormal , which may
further increase bleeding problems.
• MONITORING & FOLLOWING UP : After 1 week patient is asked to revisit hospital to the checkup whether there are
any improvement in her condition after the course of medicine or to monitor the side effects if she complaints.
- Monitor if there are improvement in levels of Hgb , PCV , platelets , vit B12, sr. iron, liver proteins /enzyme,
PT/INR/aPTT, sr.Ca.
- Enquire for any episodes of anxiety attacks after discharge .
PATIENT COUNSELLING :
• Disease
• Medication
• Diet
• Lifestyle modification

18. THANK YOU