case

1

• College of health science school of pharmacy
• Case presentation
• pediatrics ward clerkship case presentation
• By -Shimelis Engida(PG)

2
Out line

• Case identification
• Subjective findings
• Objective findings
• Physician assessment
• Pharmacist assessment
• Current medications
• Pharmaceutical care
• Reference

3
Patient identification

• Name - U.K
• Age 8 years
• Sex- M
• Body weight- 32 kg
• Hight127cm
• Ward paediatrics

• Bed no 703/8
• MRN- IC -219912
• Date of admission 17/04/15 E.C

4
Subjective findings

• C/C- body swelling of 07 month duration
• HPI-these is an 8 years old of child who has
  relatively swell 07 month back at which time he
  began to develop generalized body swelling
  started from face and progressed to the abdomen
  and then bilateral lower extremity associated
  with it , he has history reddish discoloration of
  urine decreased urine output easy fatigability
  and SOB for four month duration other ways there
  no history of productive cough skin rash,
  yellowish discoloration of the eye

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Cont.

• Other ways
• no known drug allergy

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Objective finding

• Physical examination
• G/A stable
• V/S BP-122/73, PR -97 , RR -26, Temp-
  36.3c0 at admission
• HEENT puffy face with bilateral periorbital
  oedema
• sensile pale conjunctiva
• Wet buccal mucosa
• LGS---No LAP
• Resp ---no
• CVS--- S1 and S2 well heard no MG
• Chest--- clear chest good air entry bilaterally.

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Cont..

• Abd..protrobent abdomen which moves with
  respiration
• There is no organ palpable
• Fluid trial shifts dullness positive
• GUS --normal male external genitals
• MSS--- no joint tenderness
• Int ---Grade 3 bilateral petting edema
• no skin rash or palpable purpura
• CNS ..Continues time, place

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V/S
Date BP pR temp RR sao2
3/5/15 104/67 99 36.7 20 91
4/5/15 107/72 97 36.1 20 89
5/5/15 122/92 120 37.1 21 92.6
6/5/15 125/80 121 36.9 24 93
7/5/15 111/80 88 36.7 26 94
8/5/15 102 37 24 94
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Lab investigationCBC
Test name Date Date
Test name 26/12/22 am 26/12/22 pm Normal range
WBC N 12.2 76.6 12.2 76.6 5.5 - 15.5 27-55 ( )
RBC 3.94 3.94 3.9-5.5
Hgb 11.7 11.7 11.2-15.7
HCT 34 34 34.1-44.9
MCV 29.7 86.3 79.4 - 94.8
Platelet 381 381 182.0 - 369.0
RDW Na 15.4
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Serum electrolyte

Serum Date Date Date Date
Serum 26/12/22 01/01/23 03/01/23 12/01/23
p -
K 6.13 6.17 4.59 3.42
Na 138.4 121.2 137 141.5
Mg - -
Cl- 105.6 88.3 103.6 103.6
ca 7 7 6.2 7.05
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RFT
Date Creatinine (0.34-0.53) Urea (16.6-48.5) GFR
27/12/22 5.54 314.3 12.5
01/01/23 5.61 343.8
03/01/23 5.96 396.2
04/1/23 6.52 409.2
05/1/23 4.82 317.8
06/01/23 4.4 241
07/01/23 4.8 249
08/01/23 3.82 164.3
12/01/23 3.71 68.3
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Urine analysis
Urine test 26/12/22 27/12/22 Normal range
SG 1.020 1.02 1.00.1.02
Protein 3 2

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Imaging

• 26/12/22
• U/S
• bilateral pleural effusion,
• massive ascites,
• Bilateral Renomegaly

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Physician assessment

• On the day 17/4/15
• P1 - stage II HTN
• P2-nephrotic/nephritis syndrome
• P3-partially vaccinated
• Revised diagnosis on the day 19/4/15
• P1-nephrotic/nephritis syndrome
• P2-stage II HTN (controlled)
• P3-stage III AKI on CKD

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Current medication
Drug (name, dose, dosage form, frequency) Indication Starting date Stopping date
Prednisolone 60mg po daily 2mg/kg/day Nephrotic syndrome 17/4/15 change to methylprednisolone and start 25/4/15 again 21/4/15 -26/4/15 then cont..
Lasix 3mg/kg/day30mg iv tid Nephrotic edema stage III AKI 17/4/15 21/4/15 22/4/15 Conti..
Nifedipine 40mg po tid (3 mg/kg/day up to 120 mg/day) Stage II HTN 17/04/15 Cont...
hydralazine 0.1mg/kg(3mg iv qid ) Stage II HTN 17/04/15 3/5/15
Atenolol 25mg po BID Stage II HTN 17/04/15 2/5/15 hold
HCT 25mg po daily before 30min iv Lasix Stage II HTN 19/04/15 Conti
Salbutamol puff 6puff qid Hyperkalemia 19/04/15 26/4/15
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Cont.
Omeprazole 20mg/kg bid Stressed induced ulcer prophylaxis 19/04/15 Cont.
Calcium gluconate 0.5mg/kg/dose Hyperkalemia 19/04/15 21/4/15
RI 0.1iu/kg /dose Hyperkalemia 19/04/15 21/04/15
Ondansetron 0.15mg/kg/dose (5mg iv tid) Vomiting 18/04/15 21/04/15and start 26/4/15..
Cotrimoxazole 480mg po daily prevent Pneumocystis infection 20/4/15 25/4/15
Methyl prednisolone 550mg iv tid for 3day Nephrotic syndrome 21/04/15 26/4/15
Heparin 25000iu Hypercoagulation 21/04/15 Cont..
Labetalol 5mg iv qid Stage II HTN 25/04/15 2/5/15
Cyclophosphamide 300mg iv over 1hour Nephrotic syndrome 1/5/15 Cont.
Mensa 200mg iv over 15min Hemorrhagic Cystitis 1/5/15 Cont..
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Pharmacists assessment

• Past medical history
• He has no past medical history
• Past medication history
• starting from 24/3/15
• on prednisolone 2mg /kg/day 30mg po bid
• nifedipine 3mg/kg/day 30mg po tid
• Lasix 3mg/kg/day 30mg/kg/ iv tid

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Identified Drug therapy problem

• Adverse Drug Event
• hydrochlorothiazide cyclophosphamide
• sulfamethoxazole heparin
• sulfamethoxazole increases effects of heparin by
  decreasing metabolism
• sulfamethoxazole increases effects of heparin by
  decreasing metabolism

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Identified drug therapy problem
Medical condition DTP Responsible drug/condition Possible dtp Intervention Acceptance
NS Unnecessary drug therapy Mensa Avoid Cyclophosphamide use and change in to ACEI
NS HTN ADE Cyclophosphamide with HCT HCT increase toxicity of cyclophosphamide AVOID HCT
UIT hypercoagulation ADE sulfamethoxazole with heparin sulfamethoxazole increases effects of heparin Cotrimoxazole change into norfloxacin
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Desired therapeutic outcome

• To improve sign and symptom
• Improve lab
• Improve quality of life
• Prevent complication of nephrotic syndrome and
  HTN
• Complete resolution of proteinuria
• Prevent relapse

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Out come evaluation

• Protein urea
• GFR
• Creatinine level
• BP
• Edema
• Potassium level
• Urine output

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Pharmaceutical care plan

• It is better to start ACEI like captopril
• Stop hydrochlorothiazide
• Stop cyclophosphamide and mesna
• change cotrimoxazole into ciprofloxacin or nor
  floxacillin

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Patient education

• Salt striction until edema subside
• Take medication on time
• Announce caregiver to know the symptoms of
  nephrotic syndrome
• measure weight
• Measure urine output

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References

• Medscape.com
• www.uptodate.com

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• THANKS