Case presentation on SLE with Pleural effusion (Soap format)

Case presentation on SLE with Pleural effusion ,with typical SOAP format, Pharmaceutical care plan, pharmacist intervention & Critical appraisal of the laboratory datas compared with standard reference values.

1. SLE WITH PLEURAL EFFUSION Presented By: SHARAD CHAND Pharm D (Intern) TVMCP, Bellary.

2. History Taking (SOAP Format ). Patient Demographic Data:- Name :- XYZ DOA :- dd /mm/year Age :- 35 year DOD:- dd /mm/year Sex :- Female I.P no:-692592. Marital Status :- M Income :-Below 1 Lac. Ward :-Female Medicine.

3. Subjective :- Chief Complaints:- C /o easy fatiguability since 1 month C/o cough with mild expectoration. C/o pain in left chest. C/o fever and breathelessness . Mild lumber pain.

4. Past Medical History:- No K/C/o HTN & D/M . Pt. was K/C/O of SLE. Past medication History:- Topical Hydrocortisone ointment 1% .

5. Personal &Social History:- Mixed diet Family History :- Not significant. Nil known Drug Allergy. Allergic History :-

6. OBJECTIVE ON EXAMINATION:- VITALs :- Temperature-100 o F. Pulse rate -90beat/min. R.R -18/min. B.P -90/60 mm of Hg . PICCLE :- Pallor present.

7. SYSTEMIC EXAMINATION R/S:- Trachea shifted to right side, -Dull note on left base of lung region. -↓ sed breath sound.(NAS). - Decreased vocal resonance., stretch 4rth ICS CVS:- -S1 & S2 + ve , No murmurs. P/A:- -Soft, Non-tender, No organo-megally . CNS:- -Oriented & Conscious.

8. OTHER FINDINGS Typical Butterfly rashes on face. Patient was mildly built and nourished.

9. Provisional Diagnosis. SLE with PTB & Pleural effusion

10. ADVICE. -Blood Routine Microscopic Examination. Sputum smear test. RBS Urine proteins. Electrolyte profile test. C-X-Ray.

11. S.No PARAMETERS VALUES (OBSERVED) REFERENCE (A) HAEMATOLOGICAL TEST 1 Haemoglobin 07.02 gm/dl 13-17gm/dl 2 RBC 5 million cells/mm 4.5-6million cells /mm 3 TLC 6700cells/ cumm 4000-11000Cells/mm 3 4 ESR 25mm /1 st hour 0-19 mm/1 st hour. 5 DLC i N 84% 40-70% LAB INVESTIGATION DAY 1

12. C-X-Ray:- Deviated trachea on rt. Side. Pleural effusion seen on left side.

13. OTHER FINDINGS S.N PARAMETER OBSERVED VALUE REFERENCE 1 UREA 16mg/dl 0-45mg/dl 2 s.creatinine 1.0 0.6-1.2mg/dl 3 RBS 66mg/dl 60-160mg/dl 4 ELECTROLYTE PROFILE a Na+ 139 135-147meq/L b K+ 4.5 3.5-5meq/L c Ca ++ 106 88-106meq/L

14. ELEVATED PARAMETERS NORMAL PARAMETERS BLOOD HAEMATOLOGY SPUTUM AFB CHEST X RAY ELECTROLYTE BLOOD C/S PROTEIN RBS

15. FINAL DIAGNOSIS SLE WITH PLEURAL EFFUSION

16. S.No PARAMETERS VALUES (OBSERVED) REFERENCE (A) HAEMATOLOGICAL TEST 1 Haemoglobin 09 gm/dl 13-17gm/dl 2 RBC 5 million cells/mm 4.5-6million cells /mm 3 TLC 6700cells/ cumm 4000-11000Cells/mm 3 4 ESR 25mm /1 st hour 0-19 mm/1 st hour. i N 82% 40-70% ii L 11% 10-30% iii E 2% 1-5% v M - 5-15% Lab investigation DAY 2

17. ELEVATED PARAMETERS NORMAL PARAMETERS BLOOD HAEMATOLOGY SPUTUM AFB LAB INVESTIGATION DAY 4 X –Ray show:- the trachea deviated to rt side,homogenious opacity,mediastinal + ve,whitish effusion on lt side

18. LAB INVESTIGATION DAY 5 c/s report:- show moderate infection with erythromycin senstive species. ELEVATED PARAMETERS NORMAL PARAMETERS Blood C/S Other haematology

19. STANDARD DIAGNOSTIC TEST OF SLE Le cell phenomenon. Previous history of SLE with typical butterfly rashes. Anti nuclear Antibody detection. Anti membrane phospholipid antibody. Antigen and antibody complexes in the circulation.

20. STANDARD DIAGNOSTIC TEST FOR PLEURAL EFFUSION Pleural fluid analysis after thoracocentesis . Biopsy to rule out carcinoma. AFB and C-X Ray to rule out PTB and effusion. Protein analysis (Albumin, Globulin & A/G ratio). Haematology and Blood C/S for infection.

21. DAY VITALS SYSTEMIC FRESH COMP. LAB REPORT Rx 2 T-99f P-88BPM R-N BP-110/70 mmhg GC-fair CVS-S1S2+ve,no murmur R/S-NVBS,NAS CNS- NAD,oriented P/A-soft non tender No new fresh complaints Mentioned in report APC 3 T-99f P-90BPM RR-N BP-110/70 mmhg GC-fair CVS-S1S2+ve,no murmur R/ S-NVBS, ↓chest movement CNS- NAD,oriented P/A-soft non tender No new fresh complaints - APC PATIENT PROGRESS CHART

22. DAY VITALS SYSTEMIC FRESH COMP. LAB REPORT Rx 4 T-99f P-82BPM RR-N BP-96/80 mmhg GC-fair CVS-S1S2+ve,no murmur R/ S-NVBS, ↓chest movement,stony dull on percussion pn lt.side . CNS- NAD,oriented P/A-soft non tender No new fresh complaints X –Ray show the trachea deviated to rt side,homogenious opacity,mediastinal + ve,whitish effusion on lt side APC suggested for pleural tapping. 5 T-98f P-76BPM RR-N BP-110/80 mmhg GC-fair CVS-S1S2+ve,no murmur R/ S-NVBS, ↓chest movement,stony dull persist CNS- NAD,oriented P/A-soft non tender,No organomegaly No new fresh complaints c/s report show moderate infection with erythromycin senstive species. APC, PATIENT PROGRESS CHART

23. PHARMACEUTICAL CARE PLAN. Subjective evidences:- A Female patient of age 35 years admitted in FMW, unit- B with a complaint of easy fatiguability cough with mild expectoration and lt chest pain since last month. fever and breathelesness since 2 days. The pt is K/C/O of SLE and using 1% Hydrocortisone topically, the patient was non-alcoholic and non-smoker.

24. OBJECTIVE On physical examination. vitals - normal. Systemic examination-added sound and stony dull on percusion in lt side, and shift of trachea to the rt side. pt was anaemic , the haematology reveals anaemia and nutrophillia , C-X-Ray reveals pleural effusion . Blood C/S reveals the bacterial infection ( Eyrthromycin senstive strain).

25. ASSESMENT:- On the basis of subjective and objective evidences, the patient was diagnosed as SLE with PLEURAL EFFUSION

26. TREATMENT PLAN S.N Drug Name Dosage form Dose Freq. D 1 D2 D3 D4 D5 1) Tab hydrocortisone Tablet/oral 10mg/5mg 1-0-0 √10mg √5mg √5mg √5mg √5mg 2) Tab Prednisolone Tablet/oral 20mg 1-0-0 √ √ √ √ √ 3) Tab Vit-d+calcium Tablet/oral 500mg 0-0-1 - √ √ √ √ 4) Tab pantoprazole Tablet/oral 40mg 1-0-0 - √ √ √ √ 5) Inj ceftriaxone Inj /IV 1000mg 1-0-1 √ √ √ √ - 6) Inj Pantoprazole Inj /IV 40mg- 1-0-0 √ - - - - 7) T- livogen (IRON) Tablet/oral 152mg 0-0-1 √ √ √ √ √ 8) vita+ Folic acid Tablet/oral 1 tab 0-0-1 √ √ √ √ √ 9) 1pint packed cell transfusion 300ml 2 nd n 3 rd day - √ √ - - 10) Tab Erythromycin Tablet/oral 500mg 1-1-1-1 - - - - √

27. GOAL OF THERAPY To manage active s/s present in pt. To prevent the systemic complication of SLE. To enhance the pt. Quality of life by encouraging to have medical adherence. To prevent the remission of pleural effusion.

28. GOALS ACHIEVED Actual counseling was done regarding disease ,drug and non pharmacological measures. The HB % was Restored to normal. The active sign & symptoms were subside( FEVER,BREATHElESNESS,COUGH,CHEST PAIN).

29. MONITORING PARAMETERS The pt was monitored for the progression of systemic complication of SLE. Hydrocortisone and prednisolone are used for longer duration ,Hence the ADR like gum hyperplasia,hyperglycemia , hirsutism should be monitored.

30. CRITICAL EVALUATION The laboratory parameter suggested for the pt were critically evaluated and as per the results observed it can be concluded that the pt. was anaemic , infective and SLE and pleural effusion.

31. PHARMACIST INTERVENTION. Drugs are checked for interaction ,following interaction found CI -Calcium +ceftriaxone may be form ppt in lungs S -HQ may Decrease lvl of prednisolone. M -Calcium may effect elimination of HQ

32. LABORATORY INTERVENTION. The pleural effusion can be best ruled out by the analysis of the pleural fluid ,which is not done in this patient.

33. DISCHARGE MEDICATION 1)Tab erythromycin 500mg*QID*6 days 2)Tab Livogen 1 Tab*HS*15 Days. 3)Tab Vita+Folic acid 1 Tab*15 Days. 4)Tab prednisolone 20mg 10days, 10mg for next 20days.

34. Non- Pharmacological Management Patient counselling:- - pt , is counselled about importance of light physical exercise with rest. -Using of shades or sunscreen in direct sunlight to prevent the rashes. - Pt is counselled about importance of the drug in SLE.

35. THANK YOU