CASE PRESENTATION ON PANCYTOPENIA based on soap formet

Case presentation on pancytopenia ,it contains patient details,lab investigation, assessment, plan and pharmacist comments etc
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1. CASE PRESENTATION ON PANCYTOPENIA SUBMITTED BY : YUVRAJ ROLL NO :29 SCS COLLEGE OF PHARMACY

2. PATIENT INFORMATION Patient Name : XYZ Age :40yrs Gender :Male Ward :Male emergency

3. REASON FOR ADMISSION c/o easy fatigability since 15 day PAST MEDICAL HISTORY No known comorbidities

4. PAST MEDICATION HISTORY NIL SOCIAL HISTORY SMOKER : No ALCOHOLIC: Alcoholic since 15 years USE OF TOBACCO :No MARRIED :Yes

5. PHYSICAL EXAMINATION CVS :S1S2 heard ,no murmur CNS :Clinically normal RS :NVBS heard P/A :Soft , non tender Skin :No rashes GIT :Soft , n on distended , no organomegaly

6. VITAL SIGNS VITALS VALUE BLOOD PRESSURE 130/85 mmHg PULSE RATE 80 bpm RESPIRATORY RATE 18bpm TEMPERATURE afebrile SPO2 98%

7. LABORATORY INVESTIGATION TEST ABNORMAL VALUE NORMAL VALUE HEMOGLOBIN 8.5 g/dl 14-18 g/dl RBCs 2.54x10^6/ mm³ 4.3-5.9x 10^6/mm³ WBCs 4400g/dl 4500-11000g/dl HCT/PCV 15.6 % 39-49% MCV 92.5µm³ 76-100µm³ SERUM CREATININE 1.42mg/dl 0.6-1.2mg/dl BILIRUBIN DIRECT 0.81mg/dl 0-0.2mg/dl ALBUMIN 3.94g/dl 3.4-5.4g/dl

8. DIAGNOSIS The patient was diagnosed with Pancytopenia, 2◦ Alcoholism

9. GOALS OF TREATMENT To normalise the Hb level . To reduce the hospitalisation . Prevent disease progression . Relieve symptoms .

10. TREATMENT CHART BRAND NAME GENERIC NAME ROUTE , FREQUENCY INDICATION Inj . Pan Pantoprazole 40mg ; 1-0-0 Proton pump inhibitor Inj . Optineuron Thiamine+Vitamin B6+D-Panthenol 1amp; 1-0-1 Nutritional Supplement NS 100 ml 1ꙩ PRBC Transfusion Tab . Vitamin b complex Vitamin B complex 0-0-1 Vitamins

11. DRUG- DRUG INTERACTION No drug – drug interaction found. POSSIBLE ADVERSE EFFECT

12. PATIENT COUNCELLING ABOUT DISEASE PANCYTOPENIA A condition in which there is a lower than normal number of red and white blood cells and platelets in the blood . Anemia symptoms include fatigue , dizziness , shortness of breath , arrhythmia Leukopenia symptoms include fatigue , fever and chill ,sore throat , diarrhea . Thrombocytopenia symptoms include blood in urine , bruising, heavy bleeding

13. PATIENT COUNCELLING ABOUT LIFESTYLE MODIFICATION Drink plenty of water . Consume green leafy vegetables , beans , nuts, etc in diet to improve RBS production. Do not do heavy lifting or exercise Take iron and Vitamin E Containing food . Eat a healthy diet . Get enough sleep and rest . Maintain healthy body weight . Avoid food like beverages as it block the iron absorption .

14. PATIENT COUNSELLING ABOUT DRUG Take vitamin b complex tablet with a full glass of water .

15. PHARMACIST COMMENT THE PRESCRIPTION IS RATIONAL . PATIENT COUNSELLING Patient counselling about disease ,drug and life style modification is done .

16. THANK YOU