1. A Case Presentation on RTA
SUBMITTED TO:-
Dr. Akhilesh Patel
Assistant Professor
Department of Pharmacy Practice
NIMS Institute of Pharmacy
SUBMITTED BY:-
Bhavya Jindal
Doctor of Pharmacy
II Year
NIMS Institute of Pharmacy
3. REASON FOR ADMISSION
● Fracture in left temporal bone
● Injury in head,shoulder and leg
● Ear discharge
● Vomitting
● GCS-E4V5M6
● S1S2+ve
4. PATIENT HISTORY
● MEDICAL HISTORY:NAD
● MEDICATION HISTORY:NAD
● FAMILY HISTORY:No relevant family history
● SOCIAL HISTORY:History of cigarette smoking since last 1 year
● DIET: vegetarian
● OCCUPATION-student
7. LAB ADVICES
● USG
● CT-Spine
● CT-Face
● CT- head
● X-RAY- PBH
● X-RAY-Chest PA view
8. LAB REPORTS
TEST VALUE NORMAL RANGE
NEUTROPHILS 80.5 (H) 45-75%
LYMPHOCYTES 15.9(L) 25-45%
EOSINOPHILS 0.1(L) 1-6%
TRBC 4.29(L) 4.50-5.50 millions
MCH 32.5(H) 26-30 pg
RDW-CV 15.6(H) 10-15%
MPV 12.4(H) 7.5-12 fl
TEST VALUE NORMAL RANGE
PROTHROMBIN TIME 17.8(H) 9-14.9
CONTROL(MNPT) 13.5 13.5 sec
INR. 1.34(H) 0.9-1.1
RATIO 1.32
9. Co-Complaints
● Left high parietal scalp edema noted.
● Fracture of left temporal bone extending upto the mastoid air cells.
● Deviated nasal septum S shaped with bilateral inferior turbinate hypertrophy.
15. SUBJECTIVE EVIDENCE
● A 16 year old male was admitted in Emergency
Medicine Dept./unit-1 on July,30,2023 around
9:45pm with injuries on head,shoulder and left
foot.
● Blood mixed with discharge from left ear was
noticed along with vomiting.
16. OBJECTIVE EVIDENCE
● All vitals were normal at the time of examination.
● CT scan showed left high parietal scalp edema with fracture
of left temporal bone extending upto the mastoid cells.
● Minor external injuries were noted on left foot and shoulder.
18. Assessment of current therapy-Rationality of each drug:
●MONOCEF:Monocef 1mg injection is an antibiotic belonging to the cephalosporin
group,which is used to treat bacterial infections in the body.It is effective in infections of the
brain(e.g.,meningitis),ear etc.
●AMIKACIN:Amikacin is used for bacterial infections.Includes joint infection ,intra
abdominal infections,meningitis and UTIs.
●METROGYL:Helps in infections caused by bacteria and parasites. Treat infection of
liver,stomach,intestines,vagina,brain,heart,lungs.
●PANTOP:Reduces the amount of acid in tomach.
●PARACETAMOL:Treat mild to moderate pain(headache,menstrual
pain,toothaches,backaches).
●DIAMOX:A diuretic medication that treats swelling caused by heart disease.
●LACTULOSE:Used by mouth or rectally to treat or prevent complication of liver diasease.
●GRILINCTUS:Treat cough,thins mucus in nose, windpipes and lungs.Relieves runny
nose,watery eyes,throat irritation.
19. RESPONSE TO THERAPY
[patient responded well to the therapy,symptoms were reduced]
● ADRs/DRUG INTERACTIONS
● No ADRs/drug interaction were identified
20. THERAPEUTIC GOAL
PATIENT SPECIFIC
● To prevent any kind of infection.
● To stop ear discharge.
● To heal the fracture.
● To relieve pain .
● To keep patient in stable condition.
21. PATIENT COUNSELLING [By Clinical Pharmacist]
PATIENT SPECIFIC-
● Take proper rest.
● Wounds should be disinfected and bandaged properly.
● Patient should not put any pressure on his left ear.
● Physical work like lifting weights should be avoided.
DISEASE SPECIFIC-
● Patient should take light and healthy meals.
● Fluid intake like juice,coconut water should be increased.
