Dr. Afreen Nasir, PharmD Pharmacotherapeutics 3

1. CASE PRESENTATION
Afreen Nasir

2. PATIENT DEMOGRAPHY
IP No. : 121901740 DOA : 20/12/19 DOD : 31/12/2019
Age : 20 YEARS Ward : 4th Department : Medicine
Sex : Female

3. COMPLAINTS ON ADMISSION
• C/o giddiness & weakness since last week (from date of admission ) , c/o heavy
menstrual bleeding , joint pain, oral ulcer.
HISTORY OF PRESENT ILLNESS :
• H/o amenorrhea – 2 months ago , gum bleeding , weight loss + ( 10 kg lost in 6
months) , rashes on upper – lower limbs 1 day back.
• Menstrual history – 28-35 days cycle , 3-4 pad change.

4. PATIENT HISTORY
• Past medical History -
No H/O HTN , T2DM , hypothyroidism , epilepsy
H/o dengue 1 yr back
• Family History – Nothing significant
• Allergy - NKA
• Medication history – 3 pint PRBC transfusion
• Social History –Nothing significant
• Appetite: Reduce Sleep: N Bowel-Bladder: Normal &regular Diet: veg

5. GENERAL PHYSICAL EXAMINATION
• Vital signs :(20/12/19)
BP : 140/70mmHg HR: 90 beats/min SPO2=98% RA
• Patient is moderately built , well nourished , conscious , well oriented to TPP
• PICCKLE : absent
SYSTEMIC EXAMINATION
• HEENT – normal
• CNS- HMF +
• RS- normal breath sound +
• Par abdomen – soft N/T
• CVS - S1 S2+

6. PROVISIONAL DIAGNOSIS
• Δes menorrhagia

7. LABORATORY EXAMINATION
Tests Performed 20/12 23/12 26/12 28/12 Normal values
Hemogram
Hgb 4.2 4.2 4.9 6.0 F= 12.3-15.5 g/dL
PCV 17 F = 36-45%
RBC 2.6 2.4 F = 3.5 – 4.5 × 10⁵ / mm³
Platelets 21000 5000 4000 1000 1.5-4.5 lakhs/mm³
MCH 18 19 27-32 pg / cell
MCV 75 72 80-96 fL
MCHC 22 24 33 – 35.5 g/dL
ESR 110 110 F= 1-20 mm /hr
WBC 3920 3900 3990 4201 4000-11000/mm³
Neutrophils 64 63 59 62 45-73%
Eosinophils 02 1 02 01 0-4%
Lymphocytes 29 27 24 31 20-40%
Basophils 00 00 00 00 0-1 %
Monocytes 9 7 4 3 2-8%

8. Tests Performed 20/12 23/12 26/12 28/12 Normal values
VitB12 183 180- 914 pg/ml
Ferritin 10 F= 11-307 ng/ml
Sr.Iron 35 F= 37- 145 microgram / dL
Transferrin 310 200 – 300 mg/dL
Transferrin Saturation 18 20-50%
Reticulocyte count 3.0 0.5 – 2.5 %
UIBC 115 112-346 microgram/dL
TIBC 252 250-450 microgram/dL
Lipid Profile : HDL 24 > 65 mg/dl
RFT
S. creatinine 0.5 0.5 0.4 F= 0.5-0.9 mg/dL
BUN 10 10 10 7-20 mg/dl
Sr. Sodium 140 140 139 136-145 mEq/L
Sr .Potassium 4.4 3.8 3.8 3.5 – 5.1 mEq/L
Sr. Chloride 112 111 105 97-114 mEq/L

9. Tests Performed 20/12 23/12 26/12 28/12 Normal values
LFT
Albumin 4.4 4.8 3.5-5.5g/dL
Globulin 3.0 2.7 2.5-4.5 g/dL
ALP 126 119 30-120 unit/L
SGOT/AST 21 21 10-35 U/L
SGPT /ALT 11 10 <35 U/L
T. Bilirubin 0.6 0.7 Up to 1.2 mg/L
Sr. Direct bilirubin 0.6 0.5 0.2 mg/dL
GGT 42 44 1-94 U/L
PT 12.4 11.1 – 13.1 sec
S . Total protein 6.9 6.6 – 8.7 g/dl
INR 0.91 0.9-1.1
Biochemistry
LDH 256 265 F = 135 – 214 U/L
ANA +

10. Impression : Severe microcytic hypochromic iron deficiency anemia with leukopenia & severe
thrombocytopenia.

11. FINAL DIAGNOSIS
• Patient is diagnosed with Systemic lupus erythematosus ( non renal).

12. TREATMENT GOALS
• Patient specific –
-Improve QOL
-Selecting cost effective medicine & minimizing side effects of medicines
• Disease specific –
- Control the acute symptom of SLE & protect organs by decreasing inflammation
- Decreasing autoimmune activity in body
- Bringing the abnormal blood parameters to normal

13. TREATMENT CHART
• Medicine
• prescribed
• Generic name
• Dose
• Freq
• Route
• Indications
• Start date
• Stop date
Medicine
prescribed
Dose Freq Route 20 21 22 23 24 25 26 27 28 29 30 31
T. HCQ HYDROXYCHL
OROQUINE
200mg 1-0-1 P/O + + +
T.
MYCOPHEN
OLATE
MOFETIL
500mg 1-0-1
29 (1-1-1)
’’ + + + + +
Inj.
METHYLPRE
DNISOLONE
1g in
100 ml
NS
1-0-0 IV + +
T. Wysolone PREDNISOLON
E
30mg OD PO + + + + + + + + +
T. Fe + FA FERROUS
SULPHATE +
FOLIC ACID
200mg
/5mg
1-0-1 p/o + + + + + + + + + + + +
T. PCT ACETAMINOP
HEN
500mg 1-1-1 P/O + +
Zytee Gel CHOLINE
SALICYLATE
1 FTU 1-1-1 Topical + + + + + + + + + + + +

14. Medicine
prescribed
Generic name Dose Freq Route 27 28 29 30 31
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
B1-100mg
B2 -5mg
B3- 100mg
B5- 50mg
B6-100mg
B12- 1000mcg
OD IV + + + + +

15. PROGRESS CHART
Date BP (mmHg) Pulse
(Beats/min)
SPO2 % Complaints Notes
21/12/19 100/70 80 97 Rashes over limbs CVS: S1S2 + , CNS : HMF + , PA : soft NT , RS :
B/L NVBS +
22/12/19 110/70 82 95 ’’
23/12/19 100/80 80 Fever , headache ’’ Temp: 38° C ( Febrile)
24/12/19 110/70 80 97 ’’
25/12/19 110/70 83 98 ’’
28/12/19 100/70 81 98 Fever ’’ Temp : 38° C
31/12/19 100/70 79 98 ’’

16. CLINICAL PHARMACIST NOTES / INTERVENTION
• Drug – drug interactions :
• Drug – food interactions :
• Advice to Physician : Since patient is on steroid therapy which may cause Osteoporosis so
shall we include CALCIUM & VITAMIN D supplement in the prescription
RANGE INTERACTIONS REASON
Major Ferrous sulphate + Mycophenolate Ferrous sulphate ↓ effect of
mycophenolate by inhibiting GI
absorption
Major HCQ + Mycophenolate Both ↑ immunosuppressive effects
RANGE INTERACTIONS REASON
Moderate HCQ + Grape fruit Grape fruit ↑ blood level of HCQ causing irregular
heart beat

17. DISCHARGE MEDICATION
Medicine prescribed Generic name Dose /
Route
Frequency/ Duration Possible side effects
T. MYCOPHENOLATE
MOFETIL
500mg
P/o
1-1-1 × 1 month Headache , fever, abd pain
T. HCQ HYDROXYCHLOROQUIN
E
200mg
P/O
1-0-1 × 1 month Nausea , taste disturbance
T.PCT PARACETAMOL (
ACETAMINOPHEN)
500mg p.r.n × 1 week stomach pain , ulcer in mouth
T. Fe + FA FERROUS SULPHATE +
FOLIC ACID
200mg
+ 5mg
1-0-1 × 30 days constipation/ loose motion , dark color
stool

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