Dr. Afreen Nasir, PharmD Pharmacotherapeutics 3

1. CASE PRESENTATION
Afreen Nasir

2. PATIENT DEMOGRAPHY
IP NO. : 101901765 Age/sex : 42 years female Department : unit M 1
Ward : 4th DOA : 21/10/19 DOD : 25/10/19

3. COMPLAINTS ON ADMISSION
• C/o high grade fever since 3 days , involuntary movement since 1 day , generalized weakness
since morning, seizure 1 episode in morning , fever since yesterday.
HISTORY OF PRESENT ILLNESS
• H/o fever with regur , chill from past 3 days , headache since 3 days , associated with blurred
vision
• multiple joints pain since 6 years , deviation of angle of mouth ,ulceration in mouth
• Bluish / black discolouration of digits on exposure to cold
• Cheat pain , breathlessness , palpitation, cough yellowish sputum
• H/o fall & LOC 2 hrs back , H/o 1 episode of GTCM today 23 min ago – attenders found her
unconscious at 6 am .
• H/o tongue bite +

4. PATIENT HISTORY
• Past medical history : Not K/C/O HTN , hypothyroidism ,k/c/o mixed connective tissue
disorder since 6 years with Raynaud’s phenomenon.
• Family history : Nothing significant
• Medication history :
• Social history : Diet – Mixed Sleep : N Appetite : N Bowel-Bladder : N
• Allergy : NKA
Drug Route Dose Frequency Duration Indication
T. Methotrexate P/O Not specified Not specified Not specified Treat MCTD
T. Prednisone P/O 10mg Once daily ’’ ’’

5. GENERAL PHYSICAL EXAMNATION
• Vital signs ( 21/10/19)
BP: 150/90 mmHg HR : 100 bpm RR : 20 breaths/min SPO₂ : 99% RA
• Patient is conscious oriented to T/P/P
• PICCKLE : absent
• Muscle tenderness +
SYSTEMIC EXAMINATION (12:30 pm)
CVS : S1S2 +
CNS : drowsy , pupil : 2mm (both R &L ) , Patellar Tendon Reflex(PTR) : 2 + , HMF : + , Plantar :↓,
Reflex : 2+ 2+ Power of both limbs : 5 5 Plantar B/L withdrawal
2+ 2+ 5 3/5
RS : B/L NVBS +
PA : soft non tender

6. PROVISIONAL DIAGNOSIS
• Δes Cholelithiasis

7. LABORATORY EXAMINATION
Tests performed 21/10/19 22/10/19 Normal values
Hemogram
Hgb 8.9 9.1 F= 12.3-15.5 g/dL
PCV 28.5 29 F = 36-45%
RBC 4.21 F = 3.5 – 4.5 × 10⁵ / mm³
Platelets 2.5 2.89 1.5-4.5 lakhs/mm³
Reticulocyte Count 0.321 0.5 – 2.5 %
MCH 21 27-32 pg / cell
MCV 70 80-96 fL
MCHC 30 33 – 35.5 g/dL
ESR 45 F= 1-20 mm /hr
CRP 5.9 3 mg/L
WBC 16000 10530 4000-11000/mm³
Neutrophils 90 89 45-73%
Eosinophils 01 01 0-4%
Lymphocytes 04 08 20-40%

8. Tests performed 21/10/19 22/10/19 Normal values
Basophils 00 00 0-1 %
Monocytes 05 02 2-8%
Folate 20.8 5 - 25 mcg/L
Vit B12 134 180- 914 pg/ml
Ferritin 21.7 F= 11-307 ng/ml
Transferrin Saturation 6.47 20-50%
Transferrin 289 200 – 300 mg/dL
UIBC 313 112-346 microgram/dL
TIBC 334 250-450 microgram/dL
Sr.Iron 21.4 F= 37- 145 microgram / dL
TFT
TSH 1.81 0.25 – 6.7 milli unit /L
FT3 1.38 2.3-4.1 pg/mL
FT4 0.75 2.45 – 4.25 pg/ml
LFT
ALP 59 30-120 unit/L

9. Tests performed 21/10/19 Normal values
GGT 14 1-94 U/L
Total bilirubin 0.4 Up to 1.2 mg/L
Direct bilirubin 0.1 0.2 mg/dL
SGOT/AST 29 10-35 U/L
SGPT /ALT 26 <35 U/L
Albumin 8.9 3.5-5.5g/dL
Globulin 3.2 2.5-4.5 g/dL
A/G ratio 1:1 1 – 5:1
T. Protein 6.7 6.6 – 8.7 g/dL
RFT
S. creatinine 0.9 F= 0.5-0.9 mg/dL
BUN 2.9 7-20 mg/dl
Sr. Sodium 134 136-145 mEq/L
Sr .Potassium 3.4 3.5 – 5.1 mEq/L
Sr. Chloride 102 97-114 mEq/L
Sr. Calcium 8.3 8.5 – 10.5 mg/dL

10. Tests performed 21/10/19 22/10/19 Normal values
Biochemistry
FBS 115 75-110 mg/dL
LDH 28 F= 135 -214 U/L
GRBS 133 108 <200 mg/dL

11. FINAL DIAGNOSIS
• Patient is diagnosed with MCTD , hypothyroidism ,hypertension, seizure disorder ( new onset
, generalized tonic clonic seizure ) , cholelithiasis , microcytic hypochromic anemia of chronic
disease with neutrophilia.

12. TREATMENT GOALS
• Patient specific –
-Improve QOL
-Selecting cost effective medicine & minimizing side effects of medicines
• Disease specific –
- Achieve normal thyroid function
- Prevent progression of edema in brain before it damage brain
- To bring electrolytes level to normal
- To reduce breathlessness , chest pain , abdomen pain , body pain , headache
- To normalize the raised body temp.
- Reduce episodes of seizure.

13. TREATMENT CHART
Medicine
prescribed
Dose Freq Route 21/
10
22/
10
23/
10
24/
10
25/
10
26/
10
Indications
T. Amlong ( AMLODIPINE) 5mg 0-0-1 P/O + + + + + + CCB: antihypertensive
T. PREDNISOLONE 40mg 1-0-0 ’’ + + + + 60
mg
60
mg
Treat breathlessness
Inj. Dexoma
(DEXAMETHASONE
PHOSPHATE)
10mg/
ml
1-1-1 IV + + + + 1-0-
1
1-0-
1
Corticosteroid – treat cerebral
edema
Inj . PANTOPRAZOLE 40mg 1-0-0 IV + + + + 1-0-
1
80
mg
1-0-
1
80
mg
PPI
T. Thyronorm ( THYROXINE
SODIUM)
50mcg 1-0-0 P/O + + + + + + Treat hypothyroidism
T. SILDENAFIL 20mg 1-1-1 ’’ + + + + + + Treat Raynaud’s phenomena
Inj. Xone (CEFTRIAXONE) 1g 1-0-1 IV + + + + + + Antibiotic for respiratory inf.
Inj. MANNITOL 100ml 1-0-1 ’’ + + + + + + Diuretic – treat cerebral edema
Inj. Levipil (LEVETIRACETAM) 500ml 1-1-1 ’’ + + + + + + Antiepileptic

14. Medicine
prescribed
Dose Freq Route 21/
10
22/
10
23/
10
24/
10
25/
10
26/
10
Indications
T. Chymoral Forte (TRYPSIN-
CHYMOTRYPSIN)
1,00,000
armour
units (T&C
ratio 6:1)
1-0-1 P/O + + + Anti-inflammatory,
analgesic
T.CETIRIZINE 10mg 0-0-1 ’’ + + + Antihistimine
T. FERROUS SULPHATE &
FOLIC ACID
200mg /
5mg
1-0-1 ’’ + + + Iron & folic acid
supplement to treat anemia
Inj. VitB12 (
METHYLCOBALAMINE)
1500mcg OD IV + + + Vit B12 supplement to treat
anemia
T.Cal vitD3 (CALCIUM
CARBONATE &
CHOLECALCIFEROL)
250mg/12
5 IU
0-1-0 P/O + + Calcium supplement , treat
hypothyroidism
T. METHOTREXATE 15mg Once
weekly
P/O + Treat MCTD
T. NAPROXEN 500mg Stat P/O + NSAID : Analgesic

15. PROGRESS CHART
Date Time PR
(bpm)
BP
(mmHg)
SPo2
%
Notes Complaints
21/10 6 AM 1 epi GTCS ,lasting 2-3 min , LOC
for 10 min, H/o tongue bite
12:30
pm
77 150/90 96 CVS : S1S2 + , RS: B/L NVBS +
CNS: Pupil = 2mm both eyes , Plantar
↓ , PTR : 2+
4:10
pm
90 ’’ 98 Pupil reactive , Muscle tenderness +
Power of both limbs : 5 5
5 3/5
CT brain edema cerebral
Reflex : 2+ 2+
2+ 2+
Plantar B/L withdrawal
1 Epi seizure
22/10 132/80 98 RR: 20 breaths/min , Pupil reactive
Plantar ↓ , Power of limbs 5 5
5 5

16. Date PR
(bpm)
BP
(mmHg)
SPo2
%
Notes Complaints
23/10 70 128/72 98 B/L pupil reactive , B/L plantar reflex
Cytology report : CSF 2ml colourless clear , cell count = 02
cells/mm³
24/10 68 110/80 98 RR: 20 breaths/min , Power : 5 5
5 5
Abdomen pain
25/10 69 110/70 97 Power : 5 5
5 5
26/10 68 120/70 98 RR: 18 breaths/m , CVS: S1S2 + non murmur , CNS : HMF +, Power
of limbs : 5 5
5 5

17. CLINICAL PHARMACIST NOTES / INTERVENTION
Drug – drug interaction :
• Contraindicated – Ceftriaxone + CaCO₃
• Serious(use alternatives) : Naproxen ↑level of MTX by ↓ renal clearance causes
hematologic & GI toxicity
• Monitor closely –
- CaCO₃ ↓ effect of Amlodipine
- Dexamethasone ↓ effect of Sildenafil , Prednisolone
- Pantoprazole ↑level of MTX by ↓ renal clearance
ADVICE TO DOCTOR:
• Patient still has episodes of seizure which may further decrease Ca level in body , so can we
include T. Calcium & Vit D3 in discharge medicine prescribed.

18. DISCHARGE MEDICATION
Medication prescribed Dose Frequency Route Duration Possible side effect
T. PREDNISONE 60 mg 1-0-0 P/O 7 days Weight gain, allergies, vertigo
T. Amlong ( AMLODIPINE) 5mg 1-0-1 ’’ ’’ Skin rash , abd pain , headache
T. Levipil (LEVETIRACETAM) 500mg 1-1-1 ’’ ’’ Headache , lack of energy, fatigue
T. METHOTREXATE 15mg Once
weekly
’’ ↓appetite , gingivitis, skin redness
T. SILDENAFIL 20mg 1-1-1 ’’ ’’ Headache , insomnia, dizziness
T . PANTOPRAZOLE 40mg 1-0-0 ’’ ’’ Headache , abd pain ,facial edema,rash
T. Thyronorm ( THYROXINE SODIUM) 50mcg 1-0-0 ’’ Irregular heart beat, anxiety , diarrhea
T. FERROUS SULPHATE & FOLIC ACID 200mg /
5mg
1-0-1 ’’ Dark colour stool , constipation
Zytee oral 10 ml gel ( CHOLINE
SALICYLATE+ LIGNOCAINE
HYDROCHLORIDE + BENZALKONIUM
CHLORIDE)
9.0%w/v
+
2.0%w/v
+
0.02%w/
v
Itching , burning

19. PATIENT COUNSELLING
• Disease
• Medication
• Diet
• Lifestyle modification