Pharmacy Practice-VA

(Clinical Pharmacy-I) Lab

LAB
MANUAL 8TH
SEMESTER

PH4861

Faculty of Pharmacy
Capital University of Science and Technology, Islamabad Pharmacy
 Practice-VA

(Clinical Pharmacy-I) Lab

LAB MANUAL
8TH SEMESTER
PH4861

Supervision and Coordination

Sohail Riaz
Lecturer
Faculty of Pharmacy, C.U.S.T.

Prepared by
1- M Yasir Ghaffar Bph193039

2- Tania khalid Bph203006

3- Warda jawad Bph203004

4- Maida bint-e-tahir Bph203027

5- Azeen shoukat Bph203008

6- Iqra Batool Bph203005

7- Ali Hassan 203101

(Students, 8th Semester)

Faculty of Pharmacy, C.U.S.T.

Sign: ______________________
 Index

Serial Cases Page Sign

No.
1 Hepatic encephalopathy
2 Acute Gastroenteritis
3 Bladder CA
4 Colon CA
5 ulcerative colitis
6 Active Pulmonary TB
7 NSTEMI
8 STEMI
 Medical Ward

In patient Case Profile (Gastro Ward)

Case #: 1 Diagnosis: hepatic encephalopathy

Age: 61 year Gender: female

Diagnostic tests Findings

• Ultrasound abdomen is soft, non-distended
• X-Ray low air entry into the right side
(chest)
• CT scan massive pleural effusion
• MRI
Lab Value Interpretations:

Value with
Tests Interpretation Correction
units

Blood Test

Hematocrit 38.4% normal

Hemoglobin (Hb) 13.5g/dl normal

Sedimentation rate (ESR) 39

Mean corpuscular volume (MCV) 97 high

LFTs

Albumin (serum) 36 g/l

Bilirubin (serum) 95 micromole/l high

ALT (SGPT) 56 µ/l high

Phosphatase, alkaline (serum)

Coagulation Tests

aPTT 52.1/27.1 sec

 INR 1.34 low

Prothrombin time (PT) 14.5/10.8 sec

Lipid Profile

Low density lipoproteins (LDL)

422 µ/l
(recommended range)

Serum Electrolytes

Sodium (serum or plasma) 139 mmol/l normal

Potassium (serum) 4.8 mmol/l normal

Chloride (serum) 102 mmol/l normal

Dose & Disease Management

S.No Drug Brand Active Prescribed Dose Frequency

1 rocephine cephalosporine 1g IV BD

2 risek omeprazole 40 mg OD

3 tab xifaxan Rifaximin 55 mg BD

5 syp lilac lactulose

6 tab calamox co amoxiclav 625 mg

7 syp hepamer Lornithine L

aspartate

Major Lab Deviations:

• bilirubin is high due to hepatic encephalopathy

• ALT is high due to hepatic encephalopathy

• INR is low due to hepatic encephalopathy, as liver secrete coagulation factors

 Rationale of Therapy

1. Adverse
1. Therapeutic reaction /
Normal effects side effects
Medication as dose expected possible
S. Action of
ordered: range. 2. Why is 2. Patient
No drug
Name/Class/Dose Safe patient Counselling
dose? receiving 3. Patient’s
medication? response to
Medication
use to treat patient have
rocephin yes bacterial infection in liver
• (antibiotic) infections

for stomach due to taking

yes disturbance antibiotics patient
have stomach
•
risek issue

for liver because patient

Yes preventing it has hepatic
•
heparin from harmfull encephalopathy
chemicals

for patient has

Yes constipation abdominal pain
• lilac syrup and constipation

xifaxan for abdominal patient has

• yes pain abdominal pain
 antibiotic
yes
•
calamox

• Evaluation of DRPs:
• Did the patient have any DRP?
• Yes ☐ No
 In patient Case Profile (Gastro Ward)

Case #: 02 Diagnosis: Acute Gastroenteritis

Age: 16 years Gender: Female
Symptoms: foul smelly loose motions, vomiting, high grade fever, and loss of appetite.
Co-morbidities: Nil

Examination Findings
1. Chest B/L clear
2. Abdoman Soft, non-tender, non-distended
3. GCS 15 / 15

Lab Value Interpretations:

Tests Value with units Interpretation Correction

Blood Test

Hematocrit 33.5 % Low 36-42%

Hemoglobin (Hb) 11.2 g/dl Low 12-14 g/dl

Mean corpuscular volume (MCV) 74.6 fl Low 80-95 fl

Leukocytes - Total 19.42 x 109/l High 4-10 x 109/l

Platelet count 252 x 109/l Normal 150-400 x 109/l

Diabetes Related

Glucose (Random) (plasma or serum) 5.4 mmol/l Normal <11.1 mmol/l

LFTs

Albumin (serum) 42 g/l Normal 35-50 g/l

Bilirubin (serum) 22 umol/l High 3-17 umol/l

 ALT (SGPT) 24 u/l Normal <45 u/l

Phosphatase, alkaline (serum) 167 u/l Normal <300 u/l

Coagulation Tests

APTT 36.9/27.1 High 30-34 Seconds

INR 1.20 Low Upto 1.5

Prothrombin time (PT) 13.0/12.8 Normal 12-14 Seconds

Serum Electrolytes

Sodium (serum or plasma) 138 mmol/l Normal 136-145 mmol/l

Potassium (serum) 4.2 mmol/l Normal 3.4-5 mmol/l

Chloride (serum) 103 mmol/l Normal 98-106 mmol/l

Renal Function Test

Creatinine (serum) 85 umol/l Normal 60-120 umol/l

Urea (plasma or serum) 4.3 mmol/l Normal 3.3-8.3mmol/l

Dose & Disease Management

S.No Drug Brand Active Prescribed Dose Frequency

1. Inj. Flagyl (IV) Metronidazole 500 mg TDS

2. Inj. Provas (IV) Paracetamol 1g OD

3. Inj. Novidat (IV) Ciprofloxacin 200 mg BD

4. Tab. Ulcenil (PO) Famotidine 20 mg BD

5. Inj. NS (IV) NaCl 70 ml /hr

6. Inj. R/L (IV) NaCl, KCl, 1000 ml OD

CaCl2H4O2
7. Inj. Onset (IV) Ondansetron 8 mg SOS

8. Syp. Zincat (PO) Zinc-Sulphate 20 mg BD

Monohydrate (2 TSP)

9. Enflor Saccharomyces 1 Sachet TDS

boulardii
Major Lab Deviations:

1. Low Hb

2. Low hematocrit

3. High WBCs

4. High bilirubin

5. High APPT

6. Low INR

Rationale of Therapy

1. Adverse reaction /
1. Therapeutic effects
Normal dose side effects possible
Medication as ordered: expected
S. No range. Action of drug 2. Patient Counselling
Name/Class/Dose 2. Why is patient
Safe dose? 3. Patient’s response to
receiving medication?
Medication
Flagyl 500 mg/100 ml Metronidazole is a 1. To treat infections 1. Dizziness, headache, metallic
(Metronidazole) 500 mg Yes medicine used to like trichonomiasis, taste, anorexia etc.
treat different dysentery etc. 2. To prevent stomach upset,
1.
types of bacterial 2. For loose stools. take this medication with food
and parasitic or a glass full of water.
infections by 3. Reduces diarrhea.
 inhibiting protein
synthesis by
interacting with
DNA, and causes
a loss of helical
DNA structure
and strand
breakage.
Provas 500 mg – 1 g Paracetamol has a 1. To reduce pain and 1. Nausea, vomiting,
(Paracetamol) 1g every 4 – 6 hours central analgesic fever. constipation, sore throat,
Yes effect that is 2. To treat fever loss of appetide etc.
mediated through 2. Remember to leave at least
activation of four hours between doses
descending and do not take more than
serotonergic four doses of paracetamol in
2.
pathways by any 24-hour period.
inhibition of 3. Reduce fever.
prostaglandin
synthesis or
through an active
metabolite
influencing
 cannabinoids
receptors.

Novidat 100 – 400 mg Ciprofloxacin is a 1. To treat urinary tract 1. Headache, dizziness,

(Ciprofloxacin) 200 mg Yes bactericidal infections, sexually phototoxicity, tachycardia,
antibiotic of the transmitted nausea etc.
fluoroquinolone infections, 2. Avoid taking ciprofloxacin
drug class. It gastrointestinal with dairy prducts (eg; milk
3. inhibits DNA infections. or yogurt) or calcium
replication by 2. To reduce diarrheal fortified juices alone.
inhibiting onset and for 3. Decreased diarrheal onset.
bacterial DNA vomiting.
topoisomerase and
DNA-gyrase.

Ulcenil 10 – 40 mg Famotidine is a 1. Acts as anti-emetic 1. Headache, anorexia,

(Famotidine) 20 mg Yes H2 receptor and prevent acid abdominal discomfort,
antagonist. It regurgitation, heal hematuria etc.
decreases the peptic ulcers. 2. Take 15 – 60 minutes before
4.
amount of gastric 2. To relieve vomiting. eating foods or having drinks
acid secretion by that may cause heartburn.
blocking 3. Reduce vomiting.
histamine
 receptors on
parietal cells.

Onset 16 mg/dose Ondansetron is a 1. Treat or prevent 1. Constipation, headache,

(Ondansetron) 8 mg Yes serotonin nausea and vomiting hiccups, fits etc.
antagonist, it especially in pregnant 2. It works best on empty
5. works by blocking ladies and cancer stomach, an hour before
serotonergic patients. food, or two hours after
receptors in CTZ. 2. For treating meal.
vomiting. 3. Effective for vomiting.
Zincat 10 – 20 mg Zinc sulphate 1. Fulfill zinc 1. Headache, lethargy,
(Zinc Sulphate Yes treats diarrhea by deficiency in children heartburn, nausea, vomiting,
Monohydrate) 20 mg inhibiting three and prevent diarrhea. abdominal pain etc.
intracellular 2. For diarrheal 2. Avoid taking it with foods
pathways of treatment. that are high in calcium or
6.
intestinal ion phosphorus which make
secretions, harder for body to absorb
including cAMP, zinc sulphate.
calcium and nitric 3. Reduce diarrhea.
oxide
Enflor 500 – 1000 mg Boulardii inhibits 1. Used for acute 1. Bloating, flatulence,
7. (Saccharomyces boulardii) Yes toxin A mediated diarrhea, IBD, constipation, increased thirst
250 mg diarrhea, intestinal antibiotic associated etc.
inflammation, and diarrhea and other 2. Take any time in a day, with
histological conditions. or without food and
damage by 2. For treatment of alongside antibiotics.
reducing toxin A- infectious diarrhea. 3. Effective for diarrhea.
receptor binding.
Boulardii releases
52kDa protease
which digests
both toxin A and
its receptor
binding site.
(6) Evaluation of DRPs:
I. Did the patient have any DRP?
No
 In Patient Case (Gastro Ward)

Case #: 03 Diagnosis: Bladder CA

Age: 53yrs Gender: Female

Lab Value Interpretations:

Tests Value with units Interpretation Correction

Blood Test
Hematocrit 21.7 Low -
Hemoglobin (Hb) 7.6 Low
Mean corpuscular volume (MCV) 83.3 Normal
Mean corpuscular hemoglobin
29.4 Normal
(MCH)
Mean corpuscular hemoglobin
concentration (MCHC) 35.2 High

Platelet Count 34 Low

LFTs

Bilirubin (serum) 4 Normal -

ALT (SGPT) 26 Normal

Coagulation Tests

APTT 27.1 Low

INR 1.0 Low
Prothrombin time (PT) 10.8 Low -
Serum Electrolytes

Sodium (serum or plasma) 133 Low -

Potassium (serum) 3.9 Normal -

Chloride (serum) 103 Normal -

Renal Function Tests

Creatinine (serum) 298 High -
Urea (plasma or serum) 15.9 High -
Urine Tests
Protien +ve
Specific Gravity 1.005
RBCs 15-20
Pus cells 15-20
Color Yellow

Dose & Disease Management

Sr. No Drug Brand Active Prescribed Dose Frequency

Inj Sulzone cefoperazone sodium 2gm BD Inj Sulzone (IV)

(IV)
Inj Thiamine OD Inj Neurobion
Neurobion Hydrochloride (IV)
(IV) (100mg), Riboflavin
Sodium Phosphate
(5mg), Pyridoxine
Hydrochloride
(100mg),
Cyanocobalamin
(1000mcg),
Nicotinamide
(100mg), D-panthenol
(50mg)
3 Inj Cycin (IV) Ciprofloxacin HCl 20 mg BD

4 Inj Flagyl metronidazole 400 mg TDS

5 Inj Risek Omeprazole, 40 mg OD

6 Inj Onset ondasteron 6 mg BD

7 Inj Provas Paracetamol 1 mg TDS

8 Inf N/S Carvedilol 50ml

9 Inj Serenace Haloperidol 0.5 mg, SOS

Major Lab Deviations:
Hemoglobin (Hb): 7.6 g/dl (Low) - Normal range: 12-14 g/dl
Platelet count: 34 x10^9/L (Low) - Normal range: 150-400 x10^9/L
APTT (Activated Partial Thromboplastin Time): 27.1 sec (Low) - Normal range: 30-34 sec
Creatinine: 298 umol/l (High) - Normal range: 60-120 umol/l
Urea: 15.9 mmol/l (High) - Normal range: 3.3-8.3 mmol/l

Rationale of Therapy

1. Therapeutic 1. Adverse reaction /

Medication as Normal dose
effects expected side effects possible 2.
ordered: range.
S. No Action of drug Patient Counselling
2. Why is patient
Name/Class/Dose Safe dose? receiving medication? 3. Patient’s response to

Medication

1. Inj Sulzone (IV) 1 to 2 g IV Inj acts by killing the To treat bacteria • bleeding,
bacteria responsible • abdominal pain,
for infections
• diarrhea,
•
hemoptysis,
2. Inj Neurobion (IV) One ampoule is to be Used for the help manage symptoms Gastrointestinal disturbance,
given 2-3 times diagnosis or related to neuropathy Allergic skin rash,
weekly. treatment of Anemia, Tingling sensation.
Tingling,
Neurological
disorders, Vitamin B6
deficiency.
3. Inj Cycin (IV) 500 mg PO q12hr or acts against the kills the infection- Diarrhea
400 mg IV q12hr for 10 bacteria by binding to causing bacteria
days the 50S subunit of the Chest pain
bacterial ribosome
• Painful or difficult
(site of protein
urination pain
synthesis).

Inj Flagyl 15 mg/kg IV; not to It works by killing treating bacterial • Dizziness
4. exceed 4 g/day bacteria or preventing infections,
their growth. • Headache

• Nausea

Inj Risek IV is 40mg It inhibits secretion acid reflux, heartburn, nausea,

5. of gastric acid by or gastritis vomiting
irreversibly flatulence
blocking the
enzyme system of
hydrogen/potassium
adenosine
triphosphate
Inj Onset 0.15 mg/kg per dose Antiemetic medicine. used to treat and constipation,
6. for 3 doses prevent nausea and headache
vomiting caused by dizzines
surgery, cancer
medicines
Inj Provas 7.5 mg/kg or 0.75 provides onset of pain To treat pain Bloating
7. ml/kg relief Anorexia,
Constipation
,Acute toxicity
 Inf N/S IV. Upto it treats hypovolemia To treat dehydration hypervolemia
8. 10 kg:
100
ml/kg/day
Inj Serenace 0.5-2 mg q8-12hr antipsychotic To lower vomiting sedation
9.
(6) Evaluation of DRPs:

I. Did the patient have any DRP?

 No Yes
 In Patient Case (Gastro Wards)

Case #: 04 Diagnosis: Colon CA

Age: 45yrs Gender: Female

Diagnostic tests Findings

CT scan CA colon, growth at the cecum and hepatic flexure

Lab Value Interpretations:

Tests Value with units Interpretation Correction

Blood Test
Hematocrit 29.8% Normal -
Could be because of
gastrointestinal hemorrhage

Hemoglobin (Hb) 9.7g/dl Low caused due to a tumor that

lowers RBC levels.

Leukocytes - Total 8.32×109/l Normal -

Diabetes Related
Glucose (Random) (plasma or 4.5mmol/l Normal -
serum)
LFTs
Albumin (serum) 37g/l Normal -
ALT (SGPT) 24µ/l Normal -
Coagulation Tests
aPTT 28.3secs Normal -
INR 1.0 Normal -
Prothrombin time (PT) 10.8secs Normal -
Serum Electrolytes
Sodium (serum or plasma) 130mmol/l Low Due to vomiting and loose
stools
Potassium (serum) 4.5mmol/l Normal -
Chloride (serum) 103mmol/l Normal -

Renal Function Tests

Creatinine (serum) 65µmol/l Normal -
Urea (plasma or serum) 3.3mmol/l Normal -

Dose & Disease Management

Sr. No Drug Brand Active Prescribed Dose Frequency

1. Inj. Novidat Ciprofloxacin 200mg BD

2. Inj. Flagyl Metronidazole 500mg BD

3. Inj. Risek Omeprazole 40mg OD

4. Inj. Nospa Drotaverine 1 ampoule BD

Major Lab Deviations: Hemoglobin and Sodium levels

Rationale of Therapy

1. Adverse reaction /
1. Therapeutic effects
Medication as Normal dose side effects possible
expected
S. No ordered: range. Action of drug 2. Patient Counselling
2. Why is patient
Name/Class/Dose Safe dose? 3. Patient’s response to
receiving medication?
Medication
Ciprofloxacin is a
Headache, Dizziness,
bactericidal
To treat urinary tract Phototoxicity, tachycardia, and
antibiotic of the
infections, sexually nausea etc.
fluoroquinolone
transmitted infections, • Take ciprofloxacin before or
drug class. after meals.
1. Inj. Novidat 100-400mg gastrointestinal
It inhibits DNA • Avoid administration of
(Ciprofloxacin) 200mg Yes infections. ciprofloxacin with dairy
replication by
To reduce diarrheal products (e.g., milk or
inhibiting bacterial yogurt) or calcium-fortified
onset and for vomiting.
DNA topoisomerase juices alone.
and DNA-gyrase. • Decreases diarrheal onset.

Inj. Flagyl Metronidazole is a To treat infections like Dizziness, headache, metallic

2.
(Metronidazole) 500mg 500mg/100Ml medicine used to trichonomiasis taste, anorexia etc.
 Yes treat different types dysentery etc. and for • To prevent stomach
of bacterial and loose stools. upset, take this medication
parasitic infections with food or a full glass of
by inhibiting protein water.
synthesis by • Reduces diarrhea.
interacting with
DNA, and causes a
loss of helical DNA
structure and strand
breakage.
Omeprazole is a
specific inhibitor of
H+/K (+) ATPase or
'proton pump' in Constipation, nausea, dry
parietal cells. This mouth.
GERD, benign gastric
enzyme is • Omeprazole should be
3. Inf. Risek (Omeprazole) 40mg ulcer, GI bleeding.
responsible for the ingested 30 minutes before
40mg Yes For epigastric pain.
final step in the meals.
process of acid • Reduces epigastric pain
secretion;
omeprazole blocks
acid secretion in
 response to all
stimuli.

Porphyria, vertigo, constipation,

Drotaverine is a
dry mouth, insomnia etc.
selective inhibitor of
• Should take the drug after
phosphodiesterase 4
To alleviate meals to reduce stomach
(PDE4), which is an
gastrointestinal and irritation.
Inj. Nospa enzyme responsible
40mg/2ml genitourinary smooth • People who are having any
4. (Drotaverine) for the degradation
Yes muscle spasms. allergic reactions or are
1 ampoule of cyclic adenosine
For spasms and pregnant and breastfeeding
monophosphate
epigastric pain. should avoid using this
(cAMP) that leads
medicine.
to smooth muscle
Reduces spasms and epigastric
relaxation.
pain.
(6) Evaluation of DRPs:

I. Did the patient have any DRP?

 No Yes
 In patient Case Profile (Gastro Ward)

Case #: 5 Diagnosis: ulcerative colitis

Age: 33 Years Gender: Female
CLINICAL HISTORY:
Previously diagnosed with ulcerative colitis. She was treated in ICU in lines of PRES.
The presenting complaint of patient

• Fits since evening

• High grade fever
• 40 fits in 1 episode (2-3minutes) including uprolling eyes, frothing mouth, urine fecal
incent
• Tongue bite
• Admitted in ICU for fits
VITALS:
BP: 144/77
SPO2: 91%
PULSE: 116
BSR: 151mg/dl
TEMP: 101F

Diagnostic tests Findings

1. NCS Suggestive of motor axonal neuropathy
2. EEG Suggestive of posterior reversible encephalopathy syndrome characterized by
headache, confusion, seizures, and visual disturbances
3. MRI and Shows mild reduced fronto-parietal-occipital edema
MRV

Lab Value Interpretations:

 Tests Value with units Interpretation Correction

Blood Test

Hematocrit 41.5% normal

Hemoglobin (Hb) 13.1d/dl normal

Sedimentation rate (ESR) 28

Mean corpuscular volume (MCV) 90.4 normal

Platelet count 219x10 normal

Diabetes Related

Glucose (fasting) (plasma or serum) 151mg/dl high

Glucose (Random) (plasma or serum) 5.1mmol/l normal

LFTs

Albumin (serum) 40g/l normal

Bilirubin (serum) 16umol/l Normal

ALT (SGPT) 44u/l normal

Phosphatase, alkaline (serum) 124u/l normal

Coagulation Tests

aPTT 32/27.1 Normal

Bleeding time (Ivy)

INR 1.15 normal

Prothrombin time (PT) 12.4/10.8 normal

Serum Electrolytes

Sodium (serum or plasma) 136mmol/l normal

Potassium (serum) 4.2mmol/l Normal

Chloride (serum) 100mmol/l Normal

Renal Function Tests

Creatinine (serum) 124umol/l high Due to inflammation

Urea (plasma or serum) 5.4 mmol/l normal

Dose & Disease Management

S.No Drug Brand Active Prescribed Dose Frequency

1. Inj rocephin Cephalosporin 2g BD

2. Inj. valium diazepam 2mg SOS

3. Inj. lerace levetirecetam 1g TDS

4. Inj. risek omeperrazole 40mg OD

5. Inj. mannitol mannose 200ml TDS

Major Lab Deviations:

1. Glucose and creatinine level deviations.

Rationale of Therapy

1. Adverse reaction /
1. Therapeutic effects
Normal dose side effects possible
Medication as ordered: expected
S. No range. Action of drug 2. Patient Counselling
Name/Class/Dose 2. Why is patient
Safe dose? 3. Patient’s response to
receiving medication?
Medication
Inj.Rocephin 1-2g Large group of Rocephin is a Nausea
(cephalosporin) bactericidal cephalosporin antibiotic. Vomiting
2g antimicrobials that It works by fighting Lack of appetite, and abdominal
work via their bacteria in your body. pain.
beta-lactam rings. Rocephin is used to treat
The beta-lactam many kinds of bacterial
rings bind to the infections, including
1.
penicillin-binding severe or life-threatening
protein and inhibit forms
its normal activity.
Unable to
synthesize a cell
wall, the bacteria
die.
 2-10mg Diazepam acts by Calm the brain and Confusion
Inj. Valium (diazepam) binding to the nerves. Drowsiness
2mg benzodiazepine Due to episodic seizures Depression
site on the Also effective in reducing dizziness
GABAA receptor inflammation
to enhance the
2.
affinity of channel
opening by the
agonist GABA ,
which leads to
central nervous
system depression
100-1500mg Levetiracetam is a For multiple episodes of Chills
Inj. Lerace medicine used to seizures Unusual weak feeling
(levetirecetam) 1g treat epilepsy. Psychomotor agitation
Seizures are bursts Bleeding gums
of electrical
3.
activity in the
brain that
temporarily affect
how it works.
Levetiracetam
 slows these
electrical signals
down to stop
seizures
20-40mg Omeprazole Has anti-inflammatory Headace
Inj. Risek (omeprazole) effectively inhibits effects Diarrhea
40mg gastric secrection Dizziness
by inhibiting the Stomach pain
gastric H+, K+-
ATPase. This
enzyme is
4.
responsible for
gastric acid
production, and is
located in the
secretory
membranes of
parietal cells.
Inj. Mannitol (mannose) It helps you make To restore intestinal Nausea
200ml more urine and to barrier function Headache
5.
lose salt and Chest pain
hives
excess water from
your body
(6) Evaluation of DRPs:
I. Did the patient have any DRP?
No
Hence, because of weakness in lower limbs due to ulcerative collitis, patient was advised for
physiotherapy. Also, continuous MRI and MRV were also part of plan. CT scan was awaited.
 Pulmonology Ward

In Patient Case (Pulmonology Ward)

Case #: 06 Diagnosis: Active Pulmonary TB

Age: 23 years Gender: Female

Clinical History: Post TB Bronchiectasis (1.5 years back), left lung collapse
C/O:
• High grade fever & chills (2 months)
• Productive cough
• Dyspnea on rest (mmRC-III)
• Central chest pain (inc. upon breathing)
• Wheezing sound upon breathing
A/C:
• Chest pain
• Dizziness
• Lower abdominal pain
Vitals:
• BP: 100/60 mmHg
• Pulse: 120/ min
• SPO2: 98%
Chest: B/L bronchial breathing + scattered wheeze
Plan:
• Echocardiography
• Chest physiotherapy

Diagnostic tests Findings

ABG Normal
Sputum Culture Acinobactor baumanni
CXR Right lower lobe: heterozygous opacity
Air Broncho gram- resolution phase
Left upper lobe cavity
Middle lobe+ base homogeneous opacity
HRCT Collapse consolidation fibrosis & scattered calcification in left lower lobe,
loss of volume, dilated bronchi & architectural distortion in left upper lobe
of lung.

Lab Value Interpretations

Tests Value with units Interpretation Correction

Blood Test
Hematocrit 41.7 % Normal
Hemoglobin (Hb) 12.7 g/dl Normal

Mean corpuscular volume (MCV) 86.4 fl Normal

Mean corpuscular hemoglobin 27.4 pg Normal
(MCH)
Mean corpuscular hemoglobin 31.8 g/dl Normal
concentration(MCHC)
Leukocytes - Total 79.6×109/l High Due to infection.
Platelet Count 660×109/l High Due to infection.
C-reactive protein 19.6 mg/l High Due high level of
inflammation in body.
LFTs
Albumin (serum) 36g/l Normal
ALT (SGPT) 35 U/l Normal
AST 26 U/l Normal
Biomarkers Tests
Trop-I 0.01 ug/l Normal
CK-MB 45 U/l High Due to cardiac muscles
injury caused by TB.
 Dose & Disease Management

Sr. Drug Brand Active Prescribed Dose Frequency

No
1 Inj Solumedrol Methylprednisolone 60 mg BD
succinate
2 Inj Risek Omeprazole 40 mg OD

3 Inj Colistin Colistimethate Sodium 80 mg BD

4 Inj Leflox Levofloxacin 500 mg OD

5 Inj Lasix Furosemide 20 mg OD

6 Sachet Mucolator Acetylcysteine 200 mg BD

7 Tab Panadol Paracetamol 2 tab (1000mg) TDS

8 Neb Atem+ Clenil + Ipratropium bromide, - QID

Ventolin Baclomethasone
dipropionate, Salbutamol
Major Lab Deviations:
1. Leukocytes

2. Platelets

3. C-reactive proteins

4. CK-MB

Rationale of Therapy

1. Adverse reaction /
1. Therapeutic effects
Normal dose side effects possible
Medication as ordered: expected
S. No range. Action of drug 2. Patient Counselling
Name/Class/Dose 2. Why is patient
Safe dose? 3. Patient’s response to
receiving medication?
Medication
1. Inj Solumedrol 20 mg, 40 mg, It suppresses To reduce symptoms • Dizziness, weight gain, fluid
(Methylprednisolone 60 mg, acute and chronic such as swelling, pain, retention and swelling,
succinate) Yes inflammation. and allergic-type hypertension.
60mg reactions. • Take it as prescribed.
• Inflammation was reduced.
2. Inj Colistin 60 mg, 80 mg Colistimethate is a To treat bacterial • Dizziness, numbness, tingling,
(Colistimethate Sodium) Yes surface active infections in many prickling, burning sensation.
80 mg agent which different parts of the • Take it as directed.
penetrates into body. • Treat bacterial infections.
and disrupts the
bacterial cell
membrane.
3. Inj Risek 20 mg, 40mg Omeprazole is a For treatment of GERD, • Constipation, nausea, dry
(Omeprazole) Yes specific inhibitor benign gastric ulcer, GI mouth.
40 mg of H+/K (+) bleeding. • Omeprazole should be
ATPase or 'proton ingested 30 minutes before
pump' in parietal meals.
cells. • Reduces epigastric pain.
4. Inj Leflox 250 mg, 500 mg Levofloxacin For the treatment of • Nausea, headache, sun
(Levofloxacin) Yes promotes the nosocomial pneumonia, sensitivity, diarrhea, insomnia.
500 mg breakage of DNA community-acquired • Take it as prescribed.
strands by pneumonia, chronic • Reduce lung infection.
inhibiting DNA- bronchitis, acute
gyrase, which pyelonephritis.
inhibits the
relaxation of
supercoiled DNA.
5. Inj Lasix 20 mg, Inhibit the Used in treatment of • Feeling thirsty, dry mouth,
(Furosemide) 40 mg sodiumpotassium- edema associated with headaches, dizziness, nausea or
20 mg Yes 2 chloride co- congestive heart failure, vomiting.
transporter located cirrhosis of the liver, and • Complete the course.
in the thick renal disease.
ascending limb of
the loop of Henle
in the renal
tubule.
6. Sachet Mucolator 200mg Acts as an To treat respiratory • Nausea, vomiting, mouth sores
(Acetylcysteine) Yes expectorant by problems such as cough, and runny nose.
200 mg blocking asthma, pneumonia. • Take it as directed.
histamine • Cough was relieved.
receptors and
cough
suppressant.
7. Tab Panadol 500mg, 1000mg Paracetamol has a For the treatment of mild • Diarrhea, increased sweating,
(Paracetamol) Yes central analgesic to moderate pain loss of appetite, nausea or
1000mg effect that is including headache, vomiting, stomach cramps or
mediated through migraine, muscle ache. pain.
activation of • Complete the course.
descending • Fever was reduced.
serotonergic
pathways.
8. Neb Clenil+ Atem+ 50 mcg, 100 mcg, Clenil is synthetic To treat shortness of • Nervousness, shaking
Ventolin 200 mcg, 250 halogenated breath, cough. (tremor), headache, dizziness.
(Baclomethasone mcg inhaled • Follow the prescribed dosage,
dipropionate, Ipratropium Yes glucocorticoid duration.
bromide, Salbutamol) that relieves • Cough was relieved.
QID steroid dependent
asthma.
Atem is
anticholinergic
agent that acts as
bronchodilator.
Ventolin is beta
receotor agonist
that relaxes
smooth muscles
of lungs and
expands airways
to make breathing
easy.
 (6) Evaluation of DRPs:

I. Did the patient have any DRP?

 No Yes

Final Comments
The patient was advised for chest physiotherapy due to which her dyspnea was relieved and
patient’s condition was stabilized
 Cardiology Ward
In Patient Case (Cardiology Wards)

Case #: 07 Diagnosis: NSTEMI

Age: 65yrs Gender: Male

Diagnostic tests Findings

ECG ST segment depression & T wave inversion
Troponin High
CK-MB High

Lab Value Interpretations:

Tests Value with units Interpretation Correction

Blood Test
Hematocrit 36% Normal -
Hemoglobin (Hb) 14.4g/dl Normal

Mean corpuscular volume (MCV) 82.4 fl Normal

Mean corpuscular hemoglobin 28 pg Normal
(MCH)
Mean corpuscular hemoglobin 34 g/dl Normal
concentration(MCHC)
Leukocytes - Total 8.73×109/l Normal -
Platelet Count 309×109/l Normal
Diabetes Related
HbA1c 8.8mmol/l High Uncontrolled Diabetes
LFTs
Albumin (serum) 42g/l Normal -
ALT (SGPT) 17 U/l Normal -
Phosphatase, alkaline (Serum) 179 U/l Normal
AST 50 U/l High In IHD, Cardiac muscles
damage due to insufficiency
O2 supply. In response to
damaging cardiac muscle,
AST enzyme is released in
blood
Coagulation Tests
aPTT 27.1 secs Normal -
INR 1.01 Normal -
Prothrombin time (PT) 10.4secs Normal -
Serum Electrolytes
Sodium (serum or plasma) 136mmol/l Normal -
Potassium (serum) 4.8mmol/l Normal -
Chloride (serum) 100mmol/l Normal -

Renal Function Tests

Creatinine (serum) 101µmol/l Normal -
Urea (plasma or serum) 6.8 mmol/l Normal -
Lipid Profile Tests
Cholesterol 123.5 mg/dl Normal
LDL 96.5 mg/dl Normal
HDL 37.5 mg/dl Normal
Triglycerides 106.5 mg/dl Normal
Biomarkers Tests
Trop-I 0.11 ug/l High Due to cardiac muscles injury
CK-MB 84 U/l High Due to cardiac muscles injury

Dose & Disease Management

Sr. No Drug Brand Active Prescribed Dose Frequency

1 Tab Angisid Nitroglycerin 0.5 mg PRN

2 Inj Risek Omeprazole 40 mg OD

Tab lowplat
3 Aspirin/Clopidogrel 75 mg OD
plus

4 Inj Clexane Enoxaparin 60 mg BD

5 Tab Lipiget Atorvastatin 20 mg HS

6 Tab Xavor Losartan 50 mg OD

7 Tab Cardnit Nitroglycerin 2.6 mg BD

8 Tab Carveda Carvedilol 6.25 mg OD

9 Tab DAPA Dapagliflozin 40 mg OD

Major Lab Deviations:
1- Trop-I levels
2- CK-MB levels
3- AST levels

Rationale of Therapy

1. Adverse reaction /
1. Therapeutic effects
Medication as Normal dose side effects possible
expected
S. No ordered: range. Action of drug 2. Patient Counselling
2. Why is patient
Name/Class/Dose Safe dose? 3. Patient’s response to
receiving medication?
Medication
1. Tab Angised (NG) 0.5 mg Antiplatelet To treat angina. • Dizziness and hypotension.

Yes • Take before exercise or when

pain occurs
2. Tab lowplat plus 75/100 mg Antiplatelet and To reduce Clot and Bleeding, burning sensation in
(Clopidogrel/Aspirin) Yes blood thinner blockage stomach
 Omeprazole is a GERD, benign gastric Constipation, nausea, dry
3. Inf. Risek (Omeprazole) 40mg
specific inhibitor of ulcer, GI bleeding. mouth.
40mg Yes
H+/K (+) ATPase or For epigastric pain. • Omeprazole should be
'proton pump' in ingested 30 minutes before
parietal cells. meals.
• Reduces epigastric pain

Inj Clexane 20, 40, 60,80 mg Binds to To treat thrombosis • Bleeding, swelling and
4.
Yes antithrombin III and itching
(Enoxaparin)
inhibits factor Xa • Avoid simultaneous
administration of aspirin
Tab Lipiget 10, 20, 40 mg Binds to HMG- To Treat CVD and Muscle and joint pain and
5.
(Atorvastatin) Yes CoA and hyperlipidemia diarrhea
decrease
cholesterol
Tab Xavor (Losartan) 20, 50 mg Blocks angiotensin II To treat HTN Dizziness, diarrhea, yellow skin
6.
Yes receptor and chest pain

Tab Cardnit (NG) 2.6, 6.4 mg It reduces preload To treat angina pain Dizziness, fainting and
7.
Yes and is vasodilator by hypotension
activating NO
Tab Carveda 3.125, 6.25, 12.5,25 It is beta blocker To treat HTN Sexual dysfunction, Dizziness
8.
(Carvedilol) mg & depression
Yes
 Tab DAPA 5, 10 mg It is SGLT2 inhibitor To treat diabetes Red patches on skin, cough,
9.
Yes increases urination and dizziness
(Dapagliflozin)
(6) Evaluation of DRPs:

I. Did the patient have any DRP?

 No Yes
 In Patient Case (Cardiology Wards)

Case #: 08 Diagnosis: STEMI

Age: 81yrs Gender: Female

Diagnostic tests Findings

ECG ST segment Elevated and AV block
Troponin High
CK-MB High

Lab Value Interpretations:

Tests Value with units Interpretation Correction

Blood Test
Hematocrit 30.5% Normal -
Hemoglobin (Hb) 10.4g/dl Slightly Low

Mean corpuscular volume (MCV) 89.4 fl Normal

Mean corpuscular hemoglobin 30 pg Normal
(MCH)
Mean corpuscular hemoglobin 34.1 g/dl Normal
concentration (MCHC)
Leukocytes – Total 8.4×109/l Normal -
Platelet Count 125×109/l Slightly Low
Diabetes Related
HbA1c 5.1mmol/l Normal -
LFTs
Albumin (serum) 40g/l Normal -
ALT (SGPT) 138 U/l High Due to Multi-organ
Dysfunction
Phosphatase, alkaline (Serum) 158 U/l Normal
Coagulation Tests
aPTT 27.1 secs Normal -
INR 1.06 Normal -
Prothrombin time (PT) 11.5ecs Normal -
Serum Electrolytes
Sodium (serum or plasma) 136mmol/l Normal -
Potassium (serum) 5.3mmol/l High Hyperkalemia due to
Bradycardia
Chloride (serum) 105mmol/l Normal -

Renal Function Tests

Creatinine (serum) 467µmol/l High Due to AKI
Urea (plasma or serum) 40.8 mmol/l High Due to AKI
Urine Output 10ml/day Low Due to AKI
Lipid Profile Tests
Cholesterol 189.14 mmol/l High Due to Coronary Artery Disease
LDL 96.5 u/l Normal
HDL 30.8 u/l Low Due to Coronary Artery Disease
Triglycerides 193.6 mg/dl High Due to Coronary Artery Disease

Biomarkers Tests
Trop-I 0.11 ug/l High Due to cardiac muscles injury
CK-MB 84 U/l High Due to cardiac muscles injury
 Dose & Disease Management

Sr. No Drug Brand Active Prescribed Dose Frequency

1 Inj. Augmentin Amoxicillin 1.2 g BD

2 Inj. Risek Omeprazole 40 mg OD

Tab lowplat
3 Aspirin/Clopidogrel 75 mg OD
Plus

4 Inf. N/S Normal Saline 50 ml -

5 Tab. Neubrol 35 mg BD

6 Tab Fefan Folic Acid 150 mg OD

7 Inj.Ca-Gluconate Calcium Gluconate 2.6 mg BD

8 Inj.Lasix Furosemide 40 mg BD

9 Tab Alfa-D Vit-D 0.5 mg OD

10 Tab Lophos Calcium 667mg TDS

11 Inj.Atropine Atropine 2 shots of Inj OTD

12 Inj.Nelbin Morphine 10mg OTD

13 Inj. Heparin 5000IU TDS

Major Lab Deviations:
1- Trop-I levels
2- CK-MB levels
3- Cratinine levels
4- Urea levels

Rationale of Therapy

1. Adverse reaction /
1. Therapeutic effects
Medication as Normal dose side effects possible
expected
S. No ordered: range. Action of drug 2. Patient Counselling
2. Why is patient
Name/Class/Dose Safe dose? 3. Patient’s response to
receiving medication?
Medication
1. Inj.Atropine 0.5 mg Anticholinergic To Treat Bradycardia. • Dizziness and Hallucinations.

Yes • Blurred Vision

2. Inj.Nelbin 10mg Painkiller To Treat Chest Pain -

Yes

3. Tab lowplat plus 75/100 mg Antiplatelet and To reduce Clot and Bleeding, burning sensation in
(Clopidogrel/Aspirin) Yes blood thinner blockage stomach
 Omeprazole is a GERD, benign gastric Constipation, nausea, dry
4. Inf. Risek (Omeprazole) 40mg
specific inhibitor of ulcer, GI bleeding. mouth.
40mg Yes
H+/K (+) ATPase or For epigastric pain. • Omeprazole should be
'proton pump' in ingested 30 minutes before
parietal cells. meals.
• Reduces epigastric pain

Inf. N/S 50ml Isotonic Solution To treat Electrolytes -

5. imbalancing
Yes

Tab. Neubrol 35mg Paracetamol Painkiller Orphenadrine

6.
Yes

Tab Fefan 150mg Folic Acid To Treat Anemia -

7.
Yes

Inj.Ca-Gluconate 2.6 mg Calcium Gluconate To trat Cardiac Hypophosphatemia

8. Membrane Stablization
Yes Constipation
 Inj.Lasix Furosemide TO Treat low Urine Allergic Reaction
9. 40
Output
Headache
mg
Blurred vision
Yes
 Tab Alfa-D 0.5 mg Vit-D To meet Deficiency of -
10. Vit-d
Yes

Tab Lophos 667mg Calcium To meet Deficiency of -

11. Calcium
Yes

Inj. Heparin 5000Iu Heparin To Avoid Risk of Bleeding

12. Thrombosis
Evaluation of DRPs:

I. Did the patient have any DRP?

NO Yes

1. Omeprazole + Clopidogrel (SERIOUS): Omeprazole decreases effects of clopidogrel by

affecting hepatic enzyme CYP2C19 metabolism. Avoid or Use Alternate Drug.
Clopidogrel efficacy may be reduced by drugs that inhibit CYP2C19. Inhibition of platelet
aggregation by clopidogrel is entirely due to an active metabolite. Clopidogrel is
metabolized to this active metabolite in part by CYP2C19.
2. Furosemide + Calcium gluconate (Minor): Furosemide decreases levels of calcium
gluconate by increasing renal clearance. Minor/Significance Unknown.