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Case study

Case study. Done by : Ahmed Fahad Basilim clinical pharmacist intern Supervised by: Dr. Muna Filfilan. CASE Record No. : 740051 Bed No. : 556- A.

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Case study

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  1. Case study Done by :Ahmed Fahad Basilim clinical pharmacist intern Supervised by: Dr. Muna Filfilan

  2. CASERecord No. :740051Bed No. : 556- A 17 years old Saudi female . Came to ER. On 25/ 1/ 2009 complained of sore throat, productive cough and fever for 2 days back , also there is L.L edema and abdominal distension. The patient stopped her medication 2 days ago because its finished.

  3. Case cont.. Past history: 1- Sickle cell anemia (SCA) on regular blood transfusion. 2- Old ischemic stroke. 3- Nephrotic syndrome. 4- Hyperlipidemia.

  4. Case cont.. Past medication: 1- Prednisolone 40 mg PO OD. 2- Lasix 40 mg PO OD 3- Aldactone 25 mg PO OD 4- Aspirin 81 mg PO OD. 5- Zocor 20 mg PO OD

  5. Case cont.. Vital sign: Pulse: 105/ minmm/Hg138/ 97:BP RR: 20Temp: 38.6 °C

  6. Case cont.. :Investigation .Abdomen: + ve ascites .Nervous system: conscious L pitting edema..Limbs: L

  7. Case cont.. Primary diagnosis: Recurrent nephrotic syndrome.-

  8. Case cont.. Lab result: 25/1/ 2009 PT: 11.5 ( 10.4-12.6 ) INR: 1 PTT:29.4 ( 25.9-36.6)

  9. Case cont.. Lab result: 25/1/ 2009 PT: 11.5 (10.4-12.6) INR: 1 PTT: 29.4 (25.9-36.6) WBC: 30.7 (4.4- 11.3) RBC: 1.39 (4.3- 5.5) HGB: 6.5 (11.5- 16.5) PLT: 454 (145- 400)

  10. Case cont.. Lab result: 25/1/ 2009 PT: 22.4 ( 18.5 ) INR: 1.8 PTT: 26.5 ( 31.6) WBC: 30.7 (4.4- 11.3) RBC: 1.39 (4.3- 5.5) HGB: 6.5 (11.5- 16.5) PLT: 454 (145- 400) Cr : No reagent. LDL: 169 mg/dl ( 0 – 130 ) AST: 53 u/L ( 15- 37 ) LDH: 313 u/L ( 100- 190 ) AlB: 1.9 g/dl ( 3.4- 5.9) 225 mg /dl ( 0 – 200)Choles :

  11. Case cont.. Plan: 25/1/2009 -Abdo.U/S -Urine analysis-Urine C.S -CXR -PT/PTT -serology - CBC -Chemistry -Septic screen blood C.S

  12. Case cont.. Plan: 25/1/2009 -Abdo.U/S -Urine analysis-Urine C.S -CXR -PT/PTT -serology -CBC -Chemistry -Septic screen blood C.S Prednisolone 40 mg PO OD - ASA 81 mg PO OD – -Zocor 20mg PO OD Losec 20mg PO OD- - Aldactone 25mg PO OD - Folic acid 2mg PO OD - Aranesp 40ug S/C once/week - Perfalgan 1g IV OD - Rocephin 1g IV OD - Lasix 40mg IV OD

  13. Case cont.. - D/C Losec 20 mg PO OD - D/C aldactone. - Human Albumin 100 cc IV OD - Increase Lasix 40 mg IV BID

  14. Case cont.. Urine report: 26/1/2009 - Appearance:yellowish , clear - Protein: +++-PH: 6 - Glucose: --Occult blood: ++ - RBC: 15-20-WBC: 15-25 - Crystal:-- Cast:+ - Bacteria:- Blood report: - No growth after 7 days.

  15. Case cont.. Urine report: 26/1/2009 - Appearance:yellowish , clear - Protein: +++-PH: 6 - Glucose: --Occult blood: ++ - RBC: 15-20-WBC: 15-25 - Crystal:-- Cast:+ - Bacteria:- Blood report: - No growth after 7 days. T: 38 ° C

  16. Case cont.. :Plan: 26/1/ 2009 - Hi stop 4mg PO OD Hs. - Human albumin 100 cc IV OD - Kafosed 10 cc PO TID

  17. Case cont.. Lab result:27/1/2009 WBC: 20.20 RBC: 1.93 PLT: 349 HGB: 5.4

  18. Case cont.. Lab result:27/1/2009 WBC: 20.20 RBC: 1.93 PLT: 349 HGB: 5.4 Cr: 0.7 Ca: 7.8 AST: 54 LDH: 288 Albmin: 2

  19. Case cont.. :Plan: 27/1/ 2009 - Increase Rocephine to 2mg IV OD - Human albumin 100 cc IV OD - Hydroxyurea 500 mg PO OD - Increase folic acid to 5mg PO OD - Transfusion 2 units PRBC

  20. Case cont.. Lab result:28/1/2009 WBC: 30.69 RBC: 3 PLT: 448 HGB: 6

  21. Case cont.. :Plan: 28/1/ 2009 - Human albumin 100 cc IV OD - Chemistry on Saturday

  22. Case cont.. Lab result:31/1/2009 Cr: 0.4 Ca: 8.33 AST: 38 Albumin: 2.3

  23. Case cont.. :Plan: 31/1/ 2009 - Human albumin 100 cc IV OD - Zinnat 250 mg PO OD - Stop Rocephine

  24. Thank you

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