Morning Case presentation on clerkship attachment

Case presentation

1. P1=MAM+MODERATE STUNTING + COMPLICATED SCAP WITH PARA PNEUMONIC EFFUSION P2 = MODERATE ANEMIA 2 ° TO IDA PEDIATRICS WARD By Tajuddin Mohammed MORNING CASE PRESENTATIONS 1

2. Outline 2 Case identification Subjective findings Objective findings Lab investigations Physician assessment Medications given pharmacist assessment Drug therapy problems identified pharmaceutical care plan and follow up Patient education

3. Case identification 3 Name: N .A Sex : F Age: 1 ½ Years old Address: HARAR Date of admission: 14 /0 5 /2017 E.C Card No: 802909 Ward : peadiatrics ward Bed No: 28

4. Subjective findings 4 C/C: Fast breathing of 7 days duration. HPI: T his is a 1years and 5 month old female child who was last relatively healthy 1 wk back at which time she start to experience fast breathing, HGIF and grunting of 1 wk duration. Associated to this She also has hx of non whooping, non barking cough of 5 days durations. otherwise he has no hx of body swelling, LOC, ABM no hx vomiting and diarrhea, no hx contact with chronic cougher.

5. Objective findings 5 Physical Examination G/A: acute sick looking V/S: BP= PR= 188 RR=58 T = 39.3 SPO2= 94 % on O2 ANTHRO= Wt=8 kg, Ht = 74cm , MUAC = 13 cm , WFA = b/n -2 and -1, HFA = b/n -3 and -2 HEENT : p ale conjun ctivity LGS: no LAP RS: mild ic / sc reversion : course crepitation of 1/3 over the left side of chest and decreased air entry over 2/3 of posterior chest. CVS: S1 and S2 is well heard, no murmur and gallop. MSS: no Edema or deformity Abdomen: full abdominal moves with respiration.

6. Vital sing: 6 Date BP PR RR T ° SPO2 on O2 14/05/2017 180 58 39.3 94 15/05/2017 160 61 38.9 95 16/05/2017 148 56 36.5 94 17/05/2017 138 46 37.3 98 18/05/2017 132 44 36.9 96 19/05/2017 124 36 36.6 98 20/05/2017 138 36 36.7 96 21/05/2017 128 32 36 96

7. Lab investigations 7 CBC 14/05/17 WBC=33.39 RBC=4.55 HCT=31.4 HGB= 9 .6 MCV=69 MCH=21 MCHC=30 Plt =596 BG= O- ve ESR=40 Gene X-pert = Not detected

8. Cont.…. 8 IMAGING Chest x-ray =Rt side massive pneumothorax C HEST U/S = right middle and lower lung consolidations with adjacent small organized pleural cavity collection. CT-Scan= Rt side pneumothorax with mid rt side effusion

9. Cont.…. 9 PROCEDURE DONE * chest tube drainage

10. Physician Assessment 10 P1=MAM+MODERATE STUNTING +COMPLICATED SCAP WITH PARA PNEUMONIC EFFUSION P2 = MODERATE ANEMIA 2 ° TO IDA

11. Medication given 11 14/05/2017 - PUT ON INO2 -Ceftriaxone 75mg/kg/dose 300 mg iv bid -Vancomycin 15mg/kg/day 120mg iv tid Morphine 0.8mg iv tid 15/05/2017 - INO2 -Ceftriaxone 75mg/kg/dose 300 mg iv bid -Vancomycin 15mg/kg/day 120 mg iv tid Morphine 0.8mg iv tid

12. Medication given 12 16/05/2017 -INO2 -Ceftriaxone 75mg/kg/dose 300 mg iv bid Vancomycin 15mg/kg/day 120mg iv tid Morphine 0.8mg iv tid 17 /05/2017 -INO2 -Ceftriaxone 75mg/kg/dose 300 mg iv bid Vancomycin 15mg/kg/day 120mg iv tid Morphine 0.8mg iv tid

13. Medication given 13 18/05/2017 -INO2 -Ceftriaxone 75mg/kg/dose 300 mg iv bid Vancomycin 15mg/kg/day 120mg iv tid Morphine 0.8mg iv tid 19 /05/2017 -INO2 -Ceftriaxone 75mg/kg/dose 300 mg iv bid Vancomycin 15mg/kg/day 120mg iv tid

14. pharmacist assessment 14 Past Medical hx: no Past Medication hx: no Al lergy: No known hx of allergic

15. Drug therapy problems identified 15 NO DTP

16. pharmaceutical care plan and follow up 16 Medical condition DTP identified Goal of therapy Interventions Parameter to be monitored SCAP No To be cure Ceftriaxone Vancomycin Sign and symptoms Liver function test

17. Patient education 17 Drug adherence Child hygiene Balance Diet ( meat,egg,avocado,bean etc )

18. 18 Thank you!