case study

1. CASE PRESENTATION
ATYPICAL PNEUMONIA ALONG
WITH ESRD
Submitted by : Amar Prasad Chaudhary
III PHARM-D
Department of clinical practice,
MALLIGE COLLEGE OF PHARMACY,Silvepura,Bangalore-90

2. ATYPICAL PNEUMONIA
 Pneumonia is an inflammatory illness of the lung. Frequently, it is described as lung
parenchyma/alveolar inflammation and abnormal alveolar filling with fluid (consolidation
and exudation).
 The alveoli are microscopic air-filled sacs in the lungs responsible for absorbing oxygen.
Pneumonia can result from a variety of causes, including infection with bacteria, viruses,
fungi, or parasites, and chemical or physical injury to the lungs.
 . Early investigators distinguished between typical lobar pneumonia and atypical (e.g.
Chlamydophila) or viral pneumonia using the location, distribution, and appearance of
the opacities they saw on chest x-rays.
 People with infectious pneumonia often have a cough producing greenish or yellow
sputum, or phlegm and a high fever that may be accompanied by shaking chills.
Shortness of breath is also common, as is pleuritic chest pain, a sharp or stabbing pain,
either experienced during deep breaths or coughs or worsened by them.

3. DEMOGRAPHIC DETAILS
Patient name : ABC
Age : 81yrs
Sex : Female
Date of admission : 14-01-2018
Date of discharge : 18-01-2018

4. SUBJECTIVE EVIDENCE
COMPLAINTS ON ADMISSION
c/o cough along with expectoration yellowish
sputum
c/o fever since 4 days
c/o shortness of breath since today which worsened
at night

5. Past medical history
 Diabetes mellitus – II
 Hypertension
 Ischemic heart disease (IHD)
 End stage renal disease (ESRD)
Medication history
BRAND
NAME
GENERIC
NAME
DOSE FREQU
ENCY
INDICATION Route TIME
Betaloc Metoprolol 25mg 1-0-1 antihypertensive PO After food
Monotrate sr Isosorbide 5-
mononitrate
30mg 1-0-0 Anti-anginal PO After food
Cilacar clinidipine 5mg 1-0-0 Anti hypertensive PO After food
Ecospirin AV Aspirin +
arovastatin
75mg +
12.5mg
0-0-1 IHD PO After food
Inj.H.actripid H.Insulin(sc) 4-4-4 1-1-1 DM SC

6. Social history
Appetite : normal
Sleep : normal
Bowel and bladder : normal
Diet : mixed

7. General physical examination
 PICCLE : Edema +ve
 BP: 130/90 mm hg
 RR : 24cpm
 Temp: 104F
 Pulse : 94 bpm

8. Systemic examination
 CVS : S1 S2 +ve
 RS : B/L NVBS –ve , ronchi +ve
 Pelvic abdomen : soft
 CNS : conscious , oriented
Provisional diagnosis
Lower respiratory tract infection

9. OBJECTIVE EVIDENCE
 RENAL PROFILE TEST ( 16 JAN)
 Liver function test
Liver function test
Bilurubin (D) : 0.4mg/dl (0.0-0.3)
Alb/Glb : 1.00 (1.10-1.80)
 Dialysis performed on 14 – jan and removed 1.5-2lt of fluid
CONSTITUENT OBSERVED VALUE NORMAL VALUE
Sr.creatinine 5.00mg/dl 0.6-1.5mg/dl
Urea 76mg/dl Adult 13-43
>60 17-50
Bicarbonate 21.8mmol/lt 23-30mEq/L
Uric acid 3.70mg/dl 3.5-7.2mg/dl
Calcium 8.4mg/dl 8.5-10.5
eGFR 10ml/min/1.73m2 >90ml/min/1.73m2
phosphorus 2.1mg/dl 2.5-4.5mg/dl

10. Arterial blood group
PCO2: 24.70 mm hg
X-RAY REPORT
mild cardiomegaly
reticulonodular opacities in bilateral lungs fields
HEMATOLOGY
Constituents Observed value Normal value
RBC 3.1million cells / cumm 4.6-5.4 millcells/cumm
Neutrophils 87% 40%-80%
Lymphocytes 05% 20%-40%
Heamoglobin 9.5gm/dl 11.5-15.5 gm/dl
PCV 30% 34%-46%
ESR 60 mm hr 0-20mm hr

11. Random blood sugar : 179mg/dl
 Urine analysis
 Serum parathyroid hormone and serum calcium concentration
Parathyroid hormone : 184.6ng/dl (10-65ng/dl)
vitD 1,2,5 dihydroxy : 19.2ng /dl (20-64ng/dl)
Echo
LV : concentric Left ventricular hypertrophy
Sputum test :
few epithelial cells, many inflammatory cells , gram +ve cocci and gram –ve bacilli bacteria present
constituent Observed value Normal value
RBC 12-15cells/hpf Nil
Protien Positive ( +++) Nil
Epithelial cells 2-4cells / hpf 2-3 cells

12. Final diagnosis
 From subjective and objective evidence it is confirmed that patient is
suffering from
 DM Type 2
 Primary hypertension
 Chronic IHD
 ESRD
 Unspecified acute LRTI with septicemia
 ?allergic bronchitis

13. Assessment of current drug therapy
DATE BRAND
NAME
GENERIC NAME INDICATION DOSE
(MG)
ROUTE FREQUENCY TIME END TIME
14-1-018 Inj.magnex
forte
Cefeperazone +
sulbactum
Antibiotic 1.5gm Iv BD 18-1-018
14-1-018 Inj.dolo Acetaminophen Antipyretic 1gm Iv SOS 18-1-018
14-1-018 iv.Pantodac Pantoprazole PPI 40mg Iv 1-0-1 18-1-018
14-1-018 T.Betaloc Metoprolol Antihypertensive 25mg Po 1-0-1 AF 18-1-018
14-1-018 T.Monotrate sr Isosorbide
mononitrate
Anti anginal 30mg Po 1-0-0 AF 18-1-018
14-1-018 T.Cilicar Clinidipine CCB 5mg Po 1-0-0 AF 18-1-018
14-1-018 T.Ecospirin AV Aspirin + atorvastatin Hyperlipidemia 75mg Po 0-0-1 AF 18-1-018
14-1-018 H.Actripid Regular insulin DM 4IU s/c 1-1-1 BF 18-1-018

14. DATE BRAND NAME GENERIC NAME INDICATION DOSE
(MG)
ROUTE FREQUENCY TIME END TIME
14-1-018 Duolin neb Levosalbutamol +
ipratropium
Bronchodilator Neb 1-1-1 18-1-018
15-1-018 t.Azee Azithromycin Antibiotic 500mg Po 0-1-0 AF 18-1-018
15-1-018 T.Montec Lc Montelucast +
levocitrizine
Dysponia Po 0-0-1 AF 18-1-018
15-1-018 C.Antiflu Oseltamavir Antiviral 75mg Po OD AF 18-1-018
15-1-018 Budecort neb Budesonide anti-
inflammatory
Neb 1-0-1 18-1-018
16-1-018 T.Shelcal Cal with vit D3 VitD deficiency 500mg Po 1-0-1 AF 18-1-018
17-1-018 Syp.lupitus levocloperastine antitusssive 20mg/5
ml (2ts)
Po BD AF 18-1-018

15. PROGRESS CHART
PARAMETER DAY1 DAY2 DAY3 DAY4 DAY5
BP (mmhg) 130/80 130/70 140/80 130/70 130/80
Creatinine (mg/dl) - 3.61 5.00 - -
eGFR (ml/min) - 14.90 10 - -
Pulse 84 86 84 88 92
Sputum - Gram –ve and
gram +ve
Normal flora - -
X-RAY
(reticulonodular
opacities)
High
opacities
Mild reduced
opacities
- Low opacity -
FBS 146 141 124 206 139

16. PLANNING
Discharge medication
BRAND NAME GENERIC NAME DOSE FREQUENCY TIME DAYS
Inj.H.actripid Regular insulin 4units 1-1-1 BF Continue
T.Pantodac Pantoprazole 40mg 1-0-1 BF 5days
t.Ecospirin AV Aspirin + atorvastatin 75mg+12.5mg 0-0-1 AF Continue
T.Azee Azithromycin 500mg 0-1-0 AF 2days
T.Cilacar Clinidipine 5mg 1-0-0 AF If BP>150/90
mmhg
T.Montek LC Montelucast +
levocitrizine
10mg+5mg 0-0-1 AF 5days
T.Shelcal Cal.+vitD3 500mg 1-0-1 AF Continue
T.Betaloc Metoprolol 25mg 1-0-1 AF Continue
Syp.lupitus levocloperastine 2ts BD AF 3 days

17. Pharmacist intervention
 All drugs were screened and no drug interactions were found.
 ADVERSE EFFECTS OF DRUGS
1. Cefeperazone/sulbactum: diarrhea, nausea, vomiting , rashes
2. Acetaminophen: hepatotoxicity ,headache, GI irritation , ulcer
3. Pantoprazole: GI irritation, diarrhea, nausea
4. Metoprolol: impotence, bradycardia , tiredness
5. Isosorbide nitrate: dizziness , flushing ,headache
6. Clinidipine: flushing, peripheral edema, malaise
7. Aspirin+atrovastain: hepatotoxicity, GI irritation
8. Azithromycin : diarrhea, nausea, abdominal pain
9. Oseltamivir: abdominal pain, conjunctivitis, Ear disorder

18. Patient counselling
 Shouldn't take fluid more than 500ml
 Take salt free diet and low potassium diet
 If you have any breathing difficulty consult to your physician
 Do dialysis at proper time
 Take rest as much as possible
 Take less fluid containing food
 Take low sugar diet food or sugar less food .
 Take low cholesterol containing food , try to avoid red meat
 Don’t go in the air pollution area while going use mask
 Take pantoprazole 30min before food