CLINICAL CASE STUDY

PATIENT

DEMOGRAPHICS:

Name: JJ Age: 15/M

Ward/ Bed Number: 11/26 Case Number: 0007

HISTORY OF PRESENT ILLNESS:

Patient JJ is apparently well until…

2weeks PTA: Patient JJ had a high grade fever with a Temperature of 400C temporary lysis with Paracetamol 500mg/tab
accompanied by easy fatigability and upper mid back pain described as heavy with bilateral pleuritic pain.The patient
was brought for consult at a local hospital where in CBC is started with results of low levels and advise to go to a
tertiary hospital. The patient was discharged with paracetamol as needed for fever.
In the interim, the patient had an on and off fever with a Tmax of 390C usually once or twice a day 12-24 hrs apart
still with fatigability and pleuritic chest pain.

9 days PTA: Still with fever with Max Temp of 400C with lysis with Paracetamol but fever will recur every 3hours. This was
accompanied by chest pain on deep aspiration 10/10 pain scale. A BHW was sent to their house to examine. Noted
hypotension with a BP of 60/30mmHg the patient was brought to the hospital. Upon arrival at the hospital, a chest x-
ray was done to have cavity Koch’s, a CBC was done noted diagnosis with pancytopenia and aplastic anemia. The
patient was transfused with whole blood. Treated with antibiotics, initially with Co-amoxiclav then shifted to
Levofloxacin and Ceftriaxone. The patient was also managed with Dopamine drip and digoxin.

During the condition the patient was initially brought to PGH but no room available
brought to Makati Medical Center but due to financial constraints the patient was
transferred to PGH.

LIFESTYLE:
 Not known

PAST MEDICAL HISTORY

o Admitted to Makati Medical Center diagnosed with Pancytopenia and Aplastic Anemia
o A> with Fungal Sepsis with Pneumonia (Resolved)

FAMILY HISTORY
 Not known

REVIEW OF SYSTEMS
(+) Loss of Appetite and Weight Loss

PRESENT WORKING IMPRESSION:

o Acute Leukemia, Aplastic Anemia and Pancytopenia
o Disseminated TB (Lung Pericardium)
o Staphylococcus homunis infection in the bone marrow
 To Note: Chylothorax s/p Thoracentesis
 Lung Nodule r/o Metastasis
 Sp/ IP drain 20 to Cardiac Tamponade
 DEMOGRAPHICS AND ADMINISTRATIVE INFORMATION
Patient’s Name: MB Age/Sex: 36/F Ward/Bed No: 1/21
Weight: Date of Admission:
Doctor-In-Charge Height Case No: 0006

History of Present Illness Lifestyle

Patient JJ is apparently well until…  Not known

2weeks PTA: Patient JJ had a high grade fever with a temperature

of 400 C temporary lysis with Paracetamol 500mg/tab
accompanied by easy fatigability and upper mid back pain
described as heavy with bilateral pleuritic pain. The patient
was brought for consult at a local hospital where in CBC is Family Medical History
started with results of low levels and advise to go to a  Not known
tertiary hospital. The patient was discharged with
paracetamol as needed for fever.
In the interim, the patient had an on and off fever with a
Tmax of 390C usually once or twice a day 12-24 hrs apart
still with fatigability and pleuritic chest pain.
Review of Systems
9 days PTA: Still with fever with Max Temp of 400C with lysis with (+) Loss of Appetite and Weight Loss
Paracetamol but fever will recur every 3hours. This was
accompanied by chest pain on deep aspiration 10/10 pain
scale. A BHW was sent to their house to examine. Noted
hypotension with a BP of 60/30mmHg the patient was
brought to the hospital. Upon arrival at the hospital, a chest
x-ray was done to have cavity Koch’s, a CBC was done
noted diagnosis with pancytopenia and aplastic anemia. The
patient was transfused with whole blood. Treated with
antibiotics, initially with Co-amoxiclav then shifted to
Levofloxacin and Ceftriaxone. The patient was also
managed with Dopamine drip and digoxin.

During the condition the patient was initially brought to

PGH but no room available brought to
Makati Medical Center but due to financial
constraints the patient was transferred to
PGH.

Past Medical History Present Working Impression

o Admitted to Makati Medical Center diagnosed o Acute Leukemia, Aplastic Anemia and
with Pancytopenia and Aplastic Anemia Pancytopenia
o A> with Fungal Sepsis with Pneumonia o Disseminated TB (Lung Pericardium)
o Staphylococcus homunis infection in the
(Resolved)
bone marrow
 To Note: Chylothorax s/p
Thoracentesis
 Lung Nodule r/o Metastasis
 Sp/ IP drain 20 to Cardiac
 Tamponade
Date
HEMATOLO NORMAL VALUES 8/28 Interpretation
GY
RBC 4-6 X1012 /L 3.67 Acute Leukemia, Aplastic Anemia and
Pancytopenia
TB
Hgb 120-180 g/L 106 Acute Leukemia, Aplastic Anemia and
Pancytopenia
TB
HCT 0.37-0.54 % 0.33 Acute Leukemia, Aplastic Anemia and
Pancytopenia
TB
MCV 80-100 fL 89.3
MCH 27-31 pg 28.8
MCHC 320-360 g/L 323
WBC 4-11 x 109 /L 6
NEUT 50-70% 0.72 TB
Acute Leukemia
Chylothorax
LYMPH % 20-44% 0.16 TB
Acute Leukemia
Chylothorax
MONO% 2-9% 0.10 TB
Acute Leukemia
Chylothorax
EOSIN% 0-4% 0.10 TB
Acute Leukemia
Chylothorax
BASO% 0-2% 0.01

PRO/MYL/JV (0) 0.01

PLT 150-450 X109/L 467
RETIC 5-15 X103 15.7
DAT
PROTHROMBIN TIME E
8/28
Control 12-15 secs 12.5
Patients Value - 13.5
Activity - 79.4
INR (1.0) 1.08
APP 8/28
T
Control 25-45 sec 28.2
Patients Value - 28.3
DAT
ARTERIAL BLOOD GAS E
8/28
pH 7.35-7.45 7.47 TB
Chylothorax
PCO2 35-45 mmHg 40.1
PO2 90-100 mmHg 48 TB, Cardiac
Tamponade,
Chylothorax
HCO3 22-26 mmol/ L 29.5 TB,Cardiac
Tamponade
Chylothorax
BE 0-2 mEq/L 6
 %O2 STAT - 85
BLOOD DAT
CHEMIST NORMAL VALUES E
RY 9/1
Creatinine 53-115 µmol/L 32 Acute Leukemia,
Aplastic Anemia and
Pancytopenia
TB
Sodium 140-148 mmol /L 139 Acute Leukemia,
Aplastic Anemia and
Pancytopenia
TB
Chylothorax
Potassium 3.6 -5.2 mmol/L 4.1
Calcium (Ca2+) 2.2 -2.62 mmol/L 2.16 Acute Leukemia,
Ionized (Ca2+) Aplastic Anemia and
Pancytopenia

1.1 -1.35
Phosphorus 0.81-158 mmol/L 2.1
LDH 100 -190.0 µ/L 836 TB
cardiac tamponade
Uric Acid 0.110-0.430 mmol/L 0.627 TB
cardiac tamponade
AFP Quanti 0.74-0.78 0.86 Acute Leukemia,
Aplastic Anemia and
Pancytopenia

CRP >12
CULTURE AND
SENSITIVITY TESTING
DATE SPECIMEN GROWTH ORGANISM RESU
LT
Sensi: Gentamycin,
8/26 Sputum Acinetobacter Vancomycin, Colistin & Linezolid
baumani Interm: Ceftazidime
8/28 Bone Marrow S. hominis Sensi: Vancomycin& Linezolid
2D ECHO
Date:
Impression:
Aplastic Anemia, Cardiac Tamponade
Conclusion: Minimal organized pericardial effusion left ventricular enlargement

BONE SCINTIGRAPHY
Date: 9/7 Impression:
Increase tracer activity in the left iliac wing may be inflammatory and metastatic in nature and suggested radiologic colleration and
scintigraphy monitoring
 DRUG THERAPY PLAN
DRUG PRESCRIBED INDICATION
Vancomycin 500mg/10mL q8h Bone marrow infection
HRZE 2 tabs OD Disseminated TB (Lung Pericardium)

Digoxin 0.25mg/tab ½ tab BID

Vitamin B-Complex 1 tab PO OD For anemia
Zinc Sulfate 1 tsp OD
Multivitamins 1tsp OD
PRN
Paracetamol 500mg 1 tab q4h For fever
Tramadol + Paracetamol 37.5/325mg q8h For pain

PRBLEM AND MANAGEMENT INTERVENTION AND ACTION STATUS

 Vancomycin + Digoxin  Use caution/monitor Moderate
Vancomycin will increase level/effect
vof digoxin

 Rifamnpicin + Digoxin  Use caution/monitor. Reduced Moderate

Rifampicin will decrease level /effect of digoxin serum concentration.
digoxin
 Use caution/monitor.
 Rifampicin +Tramadol Moderate
Rifampicin will decrease level /effect of
tramadol.
 Use caution/monitor.
 Isoniazid + Tramadol/ Moderate
Acetaminophen
Isoniazid will increase level /effect of
tramadol and acetaminophen.

PHARMACIST CARE PLAN

HEALTH PHARMACO- RECOMMENDATIONS MONITORING DESIRED FREQUENCY
CARE NEED THERAPEUTIC & INTERVENTION FOR PARAMETERS ENDPOINT
GOAL THERAPY

Dessiminated
TB
Acute Leukemia

PHARMACISTS NOTES

 Recommendation ______________________________________
Discussion_____________________________________________
Reference: ________________________________________________

 Recommendation ______________________________________
Discussion_____________________________________________
Reference: ________________________________________________
DRUG PRESCRIBED Monitoring End Point Frequency
Parameters
Vancomycin
HRZE
Digoxin
Vitamin B-Complex
Zinc Sulfat
Multivitamins
PRN
Paracetamol
Tramadol + Paracetamol