This was my case presentation in 5th year of Pharm.D (clerkship) on Left Lower Lobe Pneumonia.

1. 5.4 CLERKSHIP
EXAMINATION – MAY
2021
REG. NO: I16060004
NAME: S. R. CHATHREIAN
PROGRAMME: V PHARM. D
DEPARTMENT OF PHARMACY
ANNAMALAI UNIVERSITY

2. 1. PATIENT DETAILS:
• Name: Mr. X
• Age: 21 Years
• Sex: Male
• IP NO: 879123
• Department: Medicine
• Weight: 58 Kg
• Height: 165 cm
• DOA: 19/01/2021
• DOD: 27/01/2021

3. 2. REASON FOR ADMISSION:
Patient had C/O:
• Cough for 2 weeks
• Pleuritic chest pain for 2 weeks
• Headache (occurred 2 weeks back and lasted for 5 hours)
• No H/O other comorbidities
3. PAST MEDICAL HISTORY: N/K/C/O DM/ SHTN/ TB/ BA/ CAD/ Thyroid
4. FAMILY HISTORY: Not significant
5. SOCIAL HABITS:
• Non smoker
• Non alcoholic
6. KNOWN ALLERGIES: Nil
7. FOOD HABITS: Non Vegetarian

4. ON EXAMINATION:
1. VITALS CHART:
DATE 19/01 20/01 21/01 22/01 23/01 24/01 25/01 26/01 27/01
TEMP 100 99 N 99 N N N N N
B. P 120/70 130/80 110/70 130/90 120/70 120/70 130/90 120/90 110/90
PULSE 88 90 106 80 84 88 86 90 92
RBS 115
RR 22 20 20 20 24 22 20 24 24

5. 2. BLOOD COUNTS:
• Hb: 12 g/ dl
• ESR: 15 mm/ hr
• Platelet Count: 2.47 lakhs
• WBC: 10,140 cells/ cu. mm
• DLC:
i. Neutrophils: 80.5%
ii. Lymphocytes: 13.5%
iii. Monocytes: 5.2%
iv. Eosinophils: 0.5%
v. Basophils: 0.2%

6. 3. LFTs:
• Total Bilirubin: 0.30 mg%
• Direct Bilirubin: 0.01 mg%
• Albumin: 3.72 mg/ dl
• ALP: 48 IU/L
• SGPT: 10 IU/ L
• SGOT: 18 IU/ L
• Total Protein: 6.74 mg%
• Globulin: 3.02 mg%

7. 4. RFTs:
• Urea: 17.03 mg%
• Uric Acid: 4.28 mg/ dl
• Serum Creatinine: 1.03 mg%
5. ELECTROLYTES:
• Sodium: 135 mEq/ L
• Potassium: 4.0 mEq/ L
• Calcium: 9.6 mEq/ L
6. OTHERS:
• Coarse creps (+ve) in infrascapular & interscapular area
• CNS: WNL (Within Normal Limits)
• GIT: Soft, Non - tender

8. 7. CHEST X-RAY:
• Obscuration of the left hemidiaphragm associated with air bronchograms
• Loss of the normal darkening of the thoracic spine inferiorly
DIAGNOSIS: “Left Lower Lobe Pneumonia”

9. MEDICATION:
1. INJ. XONE (CEFTRIAXONE); 1gm i.v; Q12H
2. T. ZITROBACT (AZITHROMYCIN), 500 mg P/O, OD
3. T. PAN (PANTOPRAZOLE); 40 mg, OD
4. T. DOLO (ACETAMINOPHEN); 650 mg, P/O, OD
5. INJ. PIPZO (PIPERACILLIN + TAZOBACTAM); 4.5 gm, i.v, Q8H
6. CAP. DIPEP (PEPSIN + CELLULOSE + FUNGAL DIASTASE + PAPAIN);
10mg, 1 Capsule per day
7. T. MOXIF (MOXIFLOXACIN); 400 mg, P/O, BD

10. SOAP ANALYSIS ON
PNEUMONIA

11. 1. SUBJECTIVE EVIDENCE:
Patient had C/O:
• Cough for 2 weeks
• Pleuritic chest pain for 2 weeks
• Headache (occurred 2 weeks back and lasted for 5 hours)

12. 2. OBJECTIIVE EVIDENCE:
• Temperature: 100 Degree Fahrenheit
• Coarse creps:
(+ve) in infrascapular & interscapular area
• Chest X-Ray:
Obscuration of the left hemidiaphragm associated with air bronchograms
Loss of the normal darkening of the thoracic spine inferiorly

13. 3. ASSESSMENT:
1. DIAGNOSIS: “Left Lower Lobe Pneumonia”
2. ASSESSMENT, IF THERAPY INDICATED:
• To alleviate signs and symptoms
• To avoid complications
• To reduce ADRs, associated with therapy
• To improve HRQoL

14. 3. ASSESSMENT OF CURRENT THERAPY:
Drugs given to the patient involve:
1. INJ. XONE (CEFTRIAXONE); 1gm i.v; Q12H (D1 & D4):
• 3rd generation cephalosporin, bactericidal in nature, by working against cell wall
synthesis.
• Covers major spectrums of GRAM NEGATIVE ORGANISMS.
2. T. ZITROBACT (AZITHROMYCIN), 500 mg P/O, OD (D1 – D4):
• Initial drug of choice, as it covers most of pneumonia etiological agents, including
MYCOPLASMA SPECIES.
• Has lesser ADRs, compared to other drugs used under this disease.

15. 3. T. PAN (PANTOPRAZOLE); 40 mg, OD (D1 – D9):
• Proton pump inhibitor.
• Has been used to act GI parietal cells to prevent damage to GI epithelium due to
excess acid production, as a tantamount of antibiotics used in the patient.
4. T. DOLO (ACETAMINOPHEN); 650 mg, P/O, OD (D1 – D9):
• Helps to reduce fever and to alleviate pain (justifiable by the patient having
slightly raised temperature in initial days of admission, along with the chest pain
and head ache).
5. INJ. PIPZO (PIPERACILLIN + TAZOBACTAM); 4.5 gm, i.v, Q8H (D4 – D9):
• Effective, since it is ANTI-PSEUDOMONAL, coupled with BETA-LACTAMASE
INHIBITOR.

16. 6. CAP. DIPEP (PEPSIN + CELLULOSE + FUNGAL DIASTASE + PAPAIN); 10mg,
1 Capsule per day (D5 – D9):
• Has many implications, but here it is used to improve digestion and enhance
affinity towards having good meals.
7. T. MOXIF (MOXIFLOXACIN); 400 mg, P/O, BD (D3 – D9):
• Fluoroquinolone antibiotic (4th generation) bactericidal, that disrupts bacterial
DNA replication.

17. 4. PLAN (TREATMENT CHART)

18. DRUG
NAME DOSE 19/01 20/01 21/01 22/01 23/01 24/01 25/01 26/01 27/01
INJ.
XONE
1g i.v
Q12H Y Y
T.
ZITRO
BACT
500 mg
P/O,
OD
Y Y Y Y
T. PAN 40 mg
P/O Y Y Y Y Y Y Y Y Y
T.
DOLO
650 mg
P/O,
TID
Y Y Y Y Y
INJ.
PIPZO
4.5g,
i.v
Q8H
Y Y Y Y Y Y
C.
DIPEP
1 Cap,
OD Y Y Y Y Y
T.
MOXIF
400
mg,
P/O,
BD
Y Y Y Y Y Y Y

19. PROGRESS CHART:
1. 19/01/2021:
• Patient was febrile
• Chest showed coarse creps on left interscapular & intfrascapular areas
2. 20/01/2021:
• Temperature slightly reduced
• Patient had c/o consistent cough
3. 21/01/2021:
• Febrile
• No fresh complaints
4. 22/01/2021:
• No fresh complaints

20. 5. 23/01/2021:
• No fresh complaints
6. 24/01/2021:
• No fresh complaints
7. 25/01/2021:
• No fresh complaints
8. 26/01/2021:
• No fresh complaints
9. 27/01/2021:
• No fresh complaints, the patient felt better and was discharged appropriately…

21. PHARMACIST INTERVENTION:
DRUGS TO BE MONITORED:
1. PIPERACILLIN + TAZOBACTAM:
• Monitor for LFTs, (AST & ALT levels)
• Perform urinalysis and BUN and Creatinine levels measurements during therapy
2. MOXIFLOXACIN:
• Use, with caution, for PROLONGED THERAPY, since they are associated with
SUPERINFECTIONS with prolonged/ repeated therapy
• May also cause TENDONITIS/ MUSCLE RUPTURES

22. CRITICAL EVALUATION OF PRESCRIPTION:
S.NO TYPES INTERVENTION
SUGGESTED
1 Needing pharmacotherapy and not
receiving it (a drug indication)
No
2 Taking or receiving the wrong drug No
3 Taking or receiving too little of the
content drug
No
4 Taking or receiving too much of the
content drug
No
5 Experiencing an ADR or drug-drug
interaction
No
6 Not taking or receiving the drug
prescribed
No
7 Taking or receiving a drug for no valid
indication
No

23. DRUG – DRUG INTERACTION:
AZITHROMYCIN + MOXIFLOXACIN:
1. Severity: Major
2. Interaction effect:
Concurrent use may lead to increased risk of QT-interval prolongation
3. Clinical Management:
Concurrent use should be avoided (for elderly)
Do not exceed the recommended dose (If unavoidable)
4. Monitoring parameters:
Changes in the QT - interval

24. DISEASE – RELATED COUNSELLING:
• Take deep breaths (Proper breathing techniques).
• Cough several times each hour to loosen up mucus and get it out of your lungs.
• Wash your hands with soap and water or use an alcohol based hand rub after
blowing your nose.
• Cough or sneeze into a tissue or into your elbow or sleeve.
• Take full body check up every 6 months.
• Stop smoking.
• Exercise regularly.
• Eat a healthy diet.

25. FOOD – RELATED COUNSELLING:
Focus on the following remedies:
1. Cayenne pepper
2. Turmeric
3. Black pepper
4. Garlic
5. Ginger
6. Sesame seeds
7. Fenugreek seeds

26. DISCHARGE SUMMARY:
“A 21 year old male, with no other co morbidities, presented with COUGH,
PLEURITIC CHEST PAIN (for 2 weeks) and HIGH GRADE FEVER (for 2 days). On
observation – Patient was conscious, oriented, febrile, creps (+ve), chest x ray done.
Patient was treated with i.v antibiotics. Patient was found to improve
symptomatically. CT – Thorax was planned. Patient was found to be better and was
discharged appropriately.”

27. THANK YOU