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Case 4

The document summarizes a 76-year-old female patient's 4-day admission to the general ward for fever, cough, and body aches. Key findings included COPD, UTI, hypertension, and diabetes. The patient was treated with IV fluids, antibiotics including Montaz, Aciloc, and Doxyfic, and oral medications for her comorbidities. Laboratory tests confirmed UTI and elevated blood sugar and lipids. The pharmacist reviewed the patient's medications and therapeutic plan, and provided counseling upon discharge about continuing her treatment regimen.

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Bikash Shrestha
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241 views5 pages

Case 4

The document summarizes a 76-year-old female patient's 4-day admission to the general ward for fever, cough, and body aches. Key findings included COPD, UTI, hypertension, and diabetes. The patient was treated with IV fluids, antibiotics including Montaz, Aciloc, and Doxyfic, and oral medications for her comorbidities. Laboratory tests confirmed UTI and elevated blood sugar and lipids. The pharmacist reviewed the patient's medications and therapeutic plan, and provided counseling upon discharge about continuing her treatment regimen.

Uploaded by

Bikash Shrestha
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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MEDICATION REVIEW OF ADMITTED WARD PATIENT

1. PATIENT DETAILS:

HOSPITAL NO: 75050172 BED NO: GW41


PATIENT NAME KAPIL KUMARI THAKURI
AGE/SEX: 76Y/F
WEIGHT:
HEIGHT:
WARD: GENERAL WARD
ADDRESS KATHMANDU/NUWAKOT
DATE OF ADMISSION 2076/03/19
DATE OF DISCHARGE 2076/03/23
TOTAL STAY 4
DISCHARGE STATUS IMPROVED

VITAL SIGNS:
DATE 2076/03/19 2076/03/20 2076/03/21 2076/03/22 2076/03/23
BP (MMHG) 110/70 120/80 90/60 100/70 110/70
TEMPERATURE (℉) 97.2 98 97 97 98
PULSE RATE (B/Min) 86 84 94 92 86
SPO2 (%) 2 lit/min 94 98 96 98 98
RESPI RATE (B/min) 26 24 27 24 24

2. CHIEF COMPLAINT:

Fever for 20 days associated with chill and rigor. Patient also complained of body ache, decresed
appetite along with nausea and cough. SOB +, chest pain +, K/C/O COPD,

Normal bowel and bladder habit

3. ON EXAMINATION (O/E):

GC: conscious
PILCYCLOD: NIL
VITALS: BP: 110/70 mmHg PR: 86 bpm RR: 22/min T: 97.2 F SPO2: 94% without O2
SYS EXAMINATION:
CHEST:B/Cl decreased air entry
CVS: S1S2M0
PA: soft, non tender, BS+

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4. PRE-MEDICATION HISTORY:

Airtech FB 200 mcg rotacap BD

Tiova 18 mcg OD

Doxofylline 400 mg BD
5. PROVISIONAL DIAGNOSIS:

AE of COPD

UTI

6. MEDICATION AFTER PROVISIONAL DIAGNOSIS:

IV fluid
Inj. Montaz 1.125 gm BD
Inj. Aciloc 50 mg TDS
Tab Paracetamol 500 mg QID
7. INVESTIGATION:

LABORATORY FINDINGS:

Date Test Result


2076/03/17 Urine R/E Color light yellow, reaction-acidic,
sugar-nil, pus cell-6 to 8, RBC-0 to 2,
crystal not seen, bacteria not seen,
mucus thread seen, paracyte not seen,
epithelial cell- 4 to 6, albumin nil
Urine culture 24 hrs incubation No growth of microorganism isolated
CBC TLC-5900, neutrophil-73, lymphocyte-
17, eosinophil-0, hemoglobin-12.5
LFT NAD
RFT NAD
Blood sugar random 239
Blood culture No growth of microorganism isolated
2076/03/18 Lipid profile Total cholesterol-201, TG-215, HDL-
cholesterol-42, VLDL-43
Blood sugar fasting, PP Fasting-178, PP-213
2076/03/20 Urine R/E NAD
CASE RELATED OTHER FINDING (USG, X-RAY, CT-SCAN, MRI ETC.) :

Not done

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8. DIAGNOSIS:

Urinary tract infection

Hypertension

Type II diabetes mellitus

9. MEDICATION AFTER DIAGNOSIS:


SN DRUGS ROA DOSE FREQ. DAYS OF TREATMENT
TRADE NAME GENERIC NAME 3/17 3/18 3/19 3/20 3/21 3/22
1 Montaz IV 1.125g BD √ √
2 Aciloc IV 50 MG TDS √ √ √ √ √
3 Pcm PO 500 MG QID √ √ √
4 Doxyfic IV BD √ √ √
5 Perinorm IV BD √ √ √
6 Tazolin IV BD √ √ √
7 Mylod-LH PO OD √ √ √ √ √ √
8 Siptin-M PO BD √ √ √ √ √ √
9
10

10. RATIONALITY OF PRESCRIPTION/ POSSIBLE DRUG


INTERACTION/MAJOR POSSIBLE ADR

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11. THERAPEUTIC INTERVENTION BY PHARMACIST:

12. DRUG ADVICE ON DISCHARGE:

S.NO. PRESCRIBED GENERIC NAME DOSE ROA DURATION


MEDICINE
1 Montaz IV 1.125g BD
2 Aciloc IV 50 MG TDS
3 Pcm PO 500 MG QID
4 Doxyfic IV BD
5 Perinorm IV BD
6 Tazolin IV BD
7 Mylod-LH PO OD
8 Siptin-M PO BD
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10

13. RATIONALITY OF PRESCRIBING MEDICINE/THERAPEUTIC


INTERVENTION PLAN BY PHARMACIST AFTER DISCHARGE:

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14. DETAILS OF PATIENT COUNSELING:

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