CASE PRESENTATION

Presented by
Afreen Nasir
4th PHARM.D
REG NO. 17QO902
ABMRCP
 PATIENT DEMOGRAPHY

IP No. : 071900715 DOA : 6/12/19 DOD : 11/2/2020

Age : 47 YEARS Ward : 4th Department : Medicine
Sex : Female
 SUBJECTIVE DATA

COMPLAINTS ON ADMISSION:
• C/o cough since 1month, fever since 15days, headache for 4 days, vomiting for
2 days, slurring of speech for 2 days.

HISTORY OF PRESENT ILLNESS :

• Patient was apparently well 1 month back, then she developed cough gradual
in onset & progressive, with scanty expectoration –mucoid, nonblood tinged,
fever –intermittent during evening with chills ,rigor, myalgia, headache-
holocranial throughout the day.
• H/O weight loss, vomiting (projectile, non bolus , contain food particles), chest
pain.
• No H/O bleeding manifestation and chest pain.
PATIENT HISTORY:
•Past medical History -
No H/O HTN , T2DM , COPD
K/C/O retroviral disease
Opportunistic infection – oral candidiasis
• Family History – Nothing significant
• Allergy - NKA
• Medication history - Nothing significant
• Social History -
Appetite: Reduce Sleep: disturb Bowel-Bladder: Normal &regular
Diet: Mixed
• Past Menopausal – 2 yr
 OBJECTIVE DATA
• VITAL SIGNS :(6/12/19)
BP : 140/80mmHg RR: 90 breaths /min SPO2=96%
• GENERAL EXAMINATION: Patient is moderately built , well nourished
PICCKLE : Pallor + ,Icterus / Cyanosis/ Clubbing/Koilonychia / Lymphadenopathy/Oedema – Absent
• SYSTEMIC EXAMINATION
HEENT – normal
CNS- conscious , well oriented to time /place/person ,HMF +
RS- normal breath sound
Par abdomen – soft
CVS- S1 S2 sound +, Tachycardia
Power- 5/5 5/5 Tone – N N Plantar - ↓
5/5 5/5 N N
Neck stiffness + Kernig's sign + Brudzinski's sign +
PROVISIONAL DIAGNOSIS:
• Δes PLHA ( person living HIV – AIDS) to rule out Opportunistic infection, oral
candidiasis
• Δes Retroviral disease +
LABORATORY EXAMINATION:
Tests Performed 7/12 30/12 23/1 10/2 Normal values
Hemogram
Hgb 6.2 9.5 10.4 10.2 F= 12.3-15.5 g/dL
PCV 20.4 21.2 30.2 30.1 F = 36-45%
RBC 1.94 3.56 3.60 3.62 F = 3.5 – 4.5 × 10⁵ / mm³
Platelets 3.7 3.34 3.70 3.78 1.5-4.5 lakhs/mm³
MCH 30 31 29 29.2 27-32 pg / cell
MCV 92.7 90 87.5 84.8 80-96 fL
MCHC 34.9 32 30.1 30.4 33 – 35.5 g/dL
ESR 135 110 F= 1-20 mm /hr
WBC 5900 6100 5300 7900 4000-11000/mm³
Neutrophils 50 59 48 65 45-73%
Eosinophils 12 8 8.6 7 0-4%
Lymphocytes 29 27 24 31 20-40%
Basophils 00 00 0.8 00 0-1 %
Monocytes 10 8 14 12 2-8%
Tests Performed 7/12 30/12 23/1 10/2 Normal values
VitB12 118 121 150 178 180- 914 pg/ml
Ferritin 694 630 599 594 F= 11-307 ng/ml
[Link] 206 200 201 200 F= 37- 145 microgram / dL
Transferrin 196 190 189 195 200 – 300 mg/dL
Absolute eosinophilic count 660 590 40-440 / mm³

Transferrin Saturation 81.2 81 79 80 20-50%

UIBC 48 50 50.9 51 112-346 microgram/dL
TIBC 254 255 254 250-450 microgram/dL
Lipid Profile : LDL 224 <130mg/GL
RFT
S. creatinine 1.3 1.0 1.2 0.8 F= 0.5-0.9 mg/dL
BUN 27 22 21 20 7-20 mg/dl
Sr. Sodium 124 129 132 137 136-145 mEq/L
Sr .Potassium 5.5 5.0 5.2 4.9 3.5 – 5.1 mEq/L
Sr. Chloride 95 96 98 95 97-114 mEq/L
Tests Performed 7/12 30/12 23/1 10/2 Normal values
LFT
Albumin 3.4 4.8 4.8 5.1 3.5-5.5g/dL
Globulin 5.5 5.4 5.3 4.6 2.5-4.5 g/dL
ALP 179 175 178 112 30-120 unit/L
SGOT/AST 52 52.1 49 39 10-35 U/L
SGPT /ALT 36 35 36 37 <35 U/L
T. Bilirubin 1.2 1.3 Up to 1.2 mg/L
Sr. Direct bilirubin 0.6 0.5 0.30 0.2 mg/dL
GGT 244 219 117 1-94 U/L
PT 10.3 11.1 – 13.1 sec
INR 0.91 0.9-1.1

Impression – Normochromic, normocytic anemia with eosinophilia

OTHER TESTS (30/12/19)-
• Cytology report : 0.5 ml CSF was collected which was colourless & clear in appearance . 47cells/mm³ cells
were counted in CSF in which lymphocytes were 90% predominantly & neutrophils 10%
• Urine analyses : amorphous granules present
FINAL DIAGNOSIS:
• Patient is diagnosed with Cryptococcal meningitis and oral candidiasis .
TREATMENT CHART :
Medicine Generic name Dose Freq Route Indications Start Stop
prescribed date date
• Medicine CEFTRIAXONE
Inj .Ceftriaxone • 1g 1-0-0 IV Antibiotic to treat 16/12 10/1
• prescribed • 17,30/12 1-0-1 respiratory
(2g) infection
•Generic name 7/1 (1-0-1)
•Dose
C. Fluconazole FLUCONAZOLE • 150mg  (1-0-0) p/o Antifungal for 16/12- 28/1
• 7/1 (1-0-1) meningitis 10/1 6/2
•Freq
•Route • 300mg  18/1 (1-1-1)
• 19 , 20/1 (1-1-1-1)
•Indications
• 150mg  21/1 (1-0-1)
•Start date • 250mg  24 - 27/1 (1-0-1)
•Stop
Inj. PAN date PANTOPRAZOLE 40mg 1-0-0 IV Proton pump inh 16/12 6/2
– Treat acid reflex
Inj .Emeset ONDANSETRON 4g • 1-0-1 IV antiemetic ’’ ’’
• 28/1 (1-1-1)
T. Fe FERROUS • 200mg 0-1-0 p/o Treat anemia 1/2 11/2
SULPHATE
 Medicine Generic name Dose Freq Route Indications Start Stop
prescribed date date
Inj. Paracetamol ACETAMINOPHEN • 1g SOS IV Analgesic, 16/12 16/1
• 6,7/ 1 : (500mg) antipyretic 10/2 -
T. Septran DS TRIMETHOPRIM 1-0-0 p/o Antibiotic 30/12 10/1
(80mg)/SULFAMETHOX 20/1 11/2
AZOLE(400mg)
Inj . Mannitol MANNITOL 1-0-1 IV Osmotic diuretic – 30/12 4/1
• 31/12(1-1-1) Treat meningitis
Inj . Amphotericin . AMPHOTERICIN B 240mg 1-0-0 in 5% D IV Antifungal –treat 4/1 16/1
B. Liposomal • 8/1 (45mg/d) flush NS cryptococcal 20/1 6/2
meningitis
T. Candid V3 CLOTRIMAZOLE 200mg 0-0-1 p/o Antifungal – oral 4/1 -
candidiasis
Candid mouth 1% CLOTRIMAZOLE Antifungal – treat 16/12 31/12
paint oral thrush 2/1 11/1
T. PCT ACETAMINOPHEN 500mg 1-1-1 P/O Antipyretic , 11/1 21/1
analgesic 24/1 -
26/1 29/1
31/1 -
3/2 6/2 -
9/2
 Medicine Generic name Dose Freq Route Indications Start Stop
date date
prescribed
Syp. Ambrolite AMBROXOL+ 10ml– 2tsp 1-1-1 p/o Mucolytic 5/2 8/2
GUAIFENESIN + TERBUTALINE + METHANOL
T. N . Acetyl ACETYLCYSTEINE 600mg 1-1-1 p/o Mucolytic 16/12 2/2
cysteine
Inj. Optineuron Cyanocobalamin (B12)1000mcg, D-Panthenol (Vit 1 amp in 100 0-1-0 IV Treat VitB12 20/1 21/1
B5) 5omg, Pyridoxine (Vit B6) 100 mg, Riboflavin ml NS deficiency- vit 1/2 -
(Vit B2)5mg, Thiamine(vit B1) 100mg, • 1/2 supplement 11/2 -
Nicotinamide (vit B3) 100mg (2amp)
T. Bifilac Lactobacillus 50 million spores+ Streptococcus 2-2-2 p/o Probiotic 1/2 11/2
faecalis 30million+ Clostridium butyricum
2million + Bacillus mesentericus 1 million
IVF .NS NORMAL SALINE 1 pint 1-0-0 IV Electrolyte 16/12 17/12
RL RINGER LACTATE 1 pint replenisher 19/1 -

• 19/1
( 100mg/L)
IVF .DNS DEXTROSE , SODIUM CHLORIDE • 1 Pint @ ’’ ’’ 3/1 -
75 ml/hr 30/12 8/1
• 1 pint @
100ml /hr
 ASSESSMENT

TREATMENT GOALS:
• Patient specific –
-Improve QOL
-Selecting cost effective medicine & minimizing side effects of medicines
• Disease specific –
- Eradication of microorganism causing infection , reducing sign – symptoms
- Prevention of neurologic sequelae like seizure , deafness, coma, death
- Identifying microbes in CSF & destroying them
PROGRESS CHART:
Date BP (mmHg) Pulse SPO2 Complaints Notes
(Beats/min)
17/12 110/70 84 98% Neck stiffness + CVS : S1S2+
RS : NVBS
PA : soft NT
30/12 110/70 92 98% Drowsiness
31/12 130/80 70 93% Drowsiness , neck stiffness +
1/1 90/60 90 95%
2/1 90/60 100 94% Fever (100.4º) with headache , 1 epi vomiting
3/1 100/60 98 94% 1 epi fever, 2 epi vomiting
13/1 110/70 98 98% Headache
16/1 120/70 98 96% Nausea , headache
22/1 100/80 90 97% Headache, 1epi vomit
23/1 180/70 112 96% Headache, 2 epi vomit with blood tinged
26/1 110/70 94 94% headache
28/1 130/80 110 97% headache
30/1 100/80 118 99% SOB
Date BP (mmHg) Pulse SPO2 Complaints Notes
(Beats/min)
1/2 110/70 110 96% 1 pint PRBC transfusion ( O +ve)

2/2 120/80 116 96% fatigability ’’

3/2 120/80 120 96% ’’
4/2 ” 114 98% headache ’’
8/2 130/90 124 ”
9/2 120/80 88 ” 1 epi vomiting
10/2 110/70 120 ” headache
11/2 100/70 100 ” ’’
CLINICAL PHARMACIST NOTES / INTERVENTION:
• Drug – drug interaction :
1) Serious – Fluconazole + ondansetron - ↑ QTc interval
2) Monitor closely-
Pan ↓ effect of ferrous sulphate by ↑ gastric pH
Fluconazole & Trimethoprim ↑ QTc interval
3) Minor-
Pan ↓ level of cyanocobalamin
Fluconazole ↑ level / effect of sulfamethoxazole
Fluconazole↑ level / effect of pan
 PLAN
CONDITION ON DISCHARGE-
• Pallor +
• Power, tone, reflex –N
• BP- 140/80mmHg
• SPO₂ - 96%
• PR- 90 BPM
• CVS – S1S2 ,Tachycardia +
• RS- NVBS
• CNS – Conscious, Kernig's + , Brudzinski's + , Neck stiffness +
ADVICE TO DOCTOR-
Since the patient’s discharge condition is not stable as sign –symptoms of meningitis are still
present , and there is no discharge medicine prescribed for that, may be her conditions can
improve if C. FLUCONAZOLE 250 mg is included in her discharge medicine.
DISCHARGE MEDICATION :
Medicine prescribed Generic name Dose Frequency/ Duration Possible side effects
T. Septran DS TRIMETHOPRIM 1-0-0 × 1 week diarrhea , skin rashes, headache
(80mg)+
SULFAMETHOXAZOLE
(400mg)
T. PAN PANTOPRAZOLE 40mg 1-0-0 × 1 week vomit, constipation, gas formation in
stomach, loose motion, fast heart beat
[Link] PARACETAMOL 500mg 0-0-1 × 1 week stomach pain , ulcer in mouth
( ACETAMINOPHEN)
T. Optineurin Vit – B 12,B5, B6,B2, 0-1-0 × 1 week Headache , sleepiness, upset stomach
B3, B1
[Link] FERROUS SULPHATE 200mg 0-1-1 × 30 days constipation/ loose motion , dark color
stool

T. N . Acetylcysteine ACETYLCYSTEINE 600 mg 1-1-1 × 30 days Vomit, mouth sore

PATIENT COUNSELLING:
• Disease
• Medication
• Diet
• Lifestyle modification