F- findings, A- assessment, R- resolution, M- monitoring. A systemic method for recording the pharmacist's examination of patient pharmacotherapy and subsequent modification of medication related problems

1. INTERNSHIP CASE PRESENTATION
RHEUMATOID ARTHRITIS & LOWER
RESPIRATORY TRACT INFECTION
VINEETH VIDHYASAGAR.P,
I17060036
PHARM.D – Intern,
Department Of Pharmacy,
MEDICINE – M2 UNIT
14.10.22
DEPARTMENT OF PHARMACY

2. CHIEF COMPLAINTS:
Patient came to casualty with c/o cough with expectoration for 1 week, not associated with fever, cold.
HISTORY OF PRESENTING ILLNESS:
• No h/o chest pain/palpitation/breathlessness
• No h/o abdominal pain/decreased urine output/loose stools
• No h/o headache /LOC/weakness
PAST HISTORY:
• K/C/O rheumatoid arthritis 7 to 8 years and not on regular medications.
• N/K/C/O DM/SHTN/BA/TB/CAD/CKD/thyroid disorders
ON EXAMINATION:
• Patient conscious, oriented, afebrile, hydration.
• No P/I/C/C/L/E
S/E:
CVS: S1S2 CNS: NFND
RS: BAE no added sounds P/A: soft, BS no organomegaly
NAME: XXX AGE/SEX: 65/M IP.NO: 921312
UNIT/ WARD: MII/6 D.O.A: 04/08/2022 D.O.D: 12/08/2022

3. INVESTIGATIONS OBSERVED RANGE NORMAL RANGE UNITS
CBC
Hemoglobin 13.7 13-17 mg/dl
Total cells 10400 4500-11000 Cells/cu.mm
Platelets 2.24 1.5-4.5 Lakhs/cu.mm
Lymphocytes 19 20-40 %
URINE ROUTINE
Albumin, sugar,
RBC’s
Nil Nil -
Pus cells 4 – 6 0-5 /HPF
Epithelial cells 2 – 3 0-5 /HPF
RFT with Sr. Electrolytes
Urea 42 5-20 mg/dl
Creatinine 1.2 0.8-1.3 mg/dl
Sr. Na+ 134 135-145 mmol/L
Sr. K+ 3.6 3.5-5 mmol/L
Sr. Cl- 97 95-105 mmol/L
LABORATORY INVESTIGATION

4. LFT with Sr. Proteins
Bilirubin(T)
(D)
0.9
0.2
0.1-1.2
0.1-0.3
mg/dl
SGOT 41 8-45 IU/L
SGPT 33 7-56 IU/L
ALP 103 44-144 IU/L
Total proteins 5.9 6-8.3 g/dl
S. Albumin 3.1 3.4-5.4 g/dl
S. Globulin 2.8 2-3.5 g/dl
CULTURE SENSITIVITY OF SPUTUM:
Few pus cells of gram-negative bacilli seen
Klebsiella- high RESISTANT SENSITIVE
Tetracyclines Ciprofloxacin
Ceftriaxone Amikacin&
piperacillin/tazobactam
Co-trimoxazole Gentamicin& Imipenem
Gentamicin& Imipenem

5. DIAGNOSIS
Rheumatoid Arthritis
Lower Respiratory Tract Infection

6. DRUGS D1 D2 D3 D4 D5 D6 D7
Inj.Diclofenac 1amp IM (sos)       
Inj. 1NS with MVI over 4 hrs       
Inj. Dexamethasone 2cc IV OD       
Inj.Deriphylline 1amp IV BD       
Inj. Cefotaxime 1g IV BD (ATD)       
Inj. Vit B1, B6, B12 1 amp IM OD       
IVF 1DNS over 12 hrs       
Inj. Amikacin 500mg IV OD - - - - - - 
Neb Budecort Q8th hrly
Duolin
      
Syp. Ascoril ls 10ml TDS       
Syp.Mucaine gel 15ml TDS
10min B/F
- - - -   
T.Monteleukast levocetirizine
(0-0-1)
-      
T. Pulmoclear BD -      
T. BC/Vit C (1-0-0)       
T.FST (1-0-1)       
T
R
E
A
T
M
E
N
T

7. CONDITION ON DISCHARGE:
Patient conscious, oriented, afebrile
CVS: S1S2 CNS: NFND
RS: BAE no added sounds P/A: soft, BS
VITALS:
BP: 120/80mmHg PR:88/min
SPO2:98%@RA RR:16/min
ADVICE ON DISCHARGE:
• T. Cipro 200mg 1-0-1
• T. Pan 40mg (1-0-1) B/F

8. FARM ANALYSIS
Findings Assessment Resolution Monitoring

9. FINDINGS
SUBJECTIVE:
C/o cough with expectorations for 1 week
OBJECTIVES:
Patient was k/c/o rheumatoid arthritis for 7 to 8 years not on regular treatment.
RFT: Urea:42mg/dl
URINE ROUTINE:
Pus cells: 4 to 6 cells/HPF
Epi cells: 2to 3 cells/HPF
CULTURE SENSITIVITY OF SPUTUM:
Few pus cells of gram-negative bacilli seen
Klebsiella - high

10. ASSESSMENT
Based on patient complaints, routine lab investigations and other examinations, the patient was
diagnosed as Rheumatoid arthritis/LRTI.
RESOLUTIONS / RECOMMENDATIONS
RHEUMATOID ARTHRITIS
• Suggest and continue Inj. Diclofenac 1 amp IM, if pain exists.
• Continue Inj. Decadron 2CC IV OD for 7 days.
LRTI
• Inj. Deriphylline 1 amp IM BD was continued for 7 days.
• Continue nebulizer Budecort and Duolin 8 times a day.
• Continue Syp.Ascoril LS 10ml three times a day for 1 week.
• Continue T. Pulmoclear two times a day for 6 days.
• Continue T.Montek LC once a day at bed time for 6 days.
• Continue Syp.Mucaine gel 15ml TDS 10min b/f.

11. MEDICATION RELATED PROBLEMS:
• Diclofenac x Dexamethasone
Use with caution.
Either increase toxicity of other by pharmacodynamic synergism. Increased risk of GI ulceration.
• Dexamethasone x Theophylline
Dexamethasone will increase the level or effect of theophylline by affecting hepatic/intestinal enzyme
CyP3A4 metabolism.
• Diclofenac x Terbutaline
Diclofenac increases and terbutaline decreases the serum potassium level.
MONITORING
• Monitoring of vital signs including blood pressure, SPO2, pulse rate and respiratory rate routinely.
• W/F wheeze
• Monitoring of serum urea level, serum creatinine and serum potassium levels.
• Positive response to Syp.Mucaine gel 10ml to gastric ulceration.

12. GOALS OF THERAPY:
To improve patient quality of life.
OUTCOME:
 Patient condition was symptomatically improved.
 Few drug-drug interactions were noted, and drugs gave positive response to the patient.
 No ADR was occurred.
PATIENT COUNSELLING:
 Rest when needed. Rest is important if joints are painful. Limit your daily activities until
symptoms improve.
 Use ice or heat. Both can help to decrease swelling and pain. Ice may also help to prevent tissue
damage.
 Elevate the joints. Elevation helps reduce swelling and pain.
 Cessation of smoking and avoid other pollutants such as chemical fumes.
 Take the medications regularly, without missing the dose. If missed, don’t double the dose.
 Stay away from people with respiratory symptoms.

13. CRITICAL ANALYSIS OF THE PRESCRIPTION
QUESTIONNARES YES NO
Needing pharmacotherapy and not receiving it - 
Taking or receiving the wrong drug - 
Taking or receiving the too little of drug content - 
Taking or receiving the too much of drug content - 
Experiencing drug-drug or food drug interaction  -
Experiencing any ADR - 
Not taking or receiving the drug prescribed - 
Taking or receiving the drug for no valid indication - 