‘Experience is the best teacher” Now, at the end of Hospital Training, I am pleading to say that NIRMA UNIVERSITY has intellectually included Hospital Training as part of B.Pharm. Hons. ‗S academic curriculum (Semester X). This hospital training has given me a chance to get exposed to practical work. What I have studied in semester 9, I have able to implement it in semester X hospital training. I have already completed B.Pharm. And have studied subjects like Pharmaceutics, Pharmacognosy, etc. But in this course, I have been exposed to clinical field, not only theoretical aspect, but practical aspect as well which, according to me, the most exciting experience of my field is. According to my merit rank (calculated on the basis of semester 9 marks); I have got a chance to get trained in Shrey Hospital under the guidance of Dr. Chirag Joshi sir. He is the one who holds and manages the Intensive Coronary Care Unit (I.C.C.U) on one hand alone. It has been great experience to obtaining under such qualified and experienced person. On the first day of my training, I along with fellow members was introduced to medical staff and have been introduced to different departments like ICCU, Operation theatre, dialysis unit, Radiology department, Pathology Lab, Lithotripsy, Pharmacy and various wards and these sessions were included in week one schedule. During second week, I was allocated to pharmacy. I got exposed to the way to handle prescription and reading as well. I came to know the arrangement of medicines. Different medicines of same company were kept in one shelf and were arranged according to their alphabetical order in the same shelf. I also came to know about medication handling & storage, dispensing, ADR and medication order identification while handling prescription. By this pharmacy experience I came to know about extreme use of antibiotics i.e. irrational use we can say. Pharmacists here in pharmacy have overcome the mistakes done by doctor in hurry e.g. dose, freq.etc. Our case studies began third week onwards and were continued till the end of training. Herein I studied different cases pertaining to most of the system of body. Dr. Chirag sir explained us the format of presenting the case like Patient demographics,chief complains, past history, past medication history, vital signs, systemic examination, laboratory investigation, other diagnostic tests (X-ray, USG, and MRI), medications, adverse reactions and then other related discussions. Sir explained us how to take history of patient and assigned me the case along with other fellow members which we have to present before him on the next day by preparing in the format what he had taught to us. Sir fully explains us the case according to format and carries on interaction as well. This include why a particular treatment is preferred (based on patient‘s economic status), how to overcome drug interactions and ADRs. He fully explains the treatment along with the available options of medicines e.g. Cephalosporins. He gives us a brief introduction over different class of the same along with brand names and the spectrum they cover. He explained all the part of case from entering in the hospital to discharge from hospital, every reason for single treatment. And I also saw some cases of particular of my interest like poisoning, alcoholic patient, renal failure. During this practical training I also involved in ward round participation. I used to go with Chirag sir and learn the way treat the patient and maintain patient history notes. I used to check drug dose and dosing frequency. I also used to take patient history which is also critical in understanding patient‘s case. During ward round participation, I came to real practice experience as I was in front of the patient and use knowledge in dealing with patient. All in all, it was the best experience that I have undergone in my field. This would be greater than anything in clearing my future registered pharmacist exam i

1. [SHREY HOSPITAL]
A PROJECT REPORT OF
CLINICAL PHARMACY PRACTICE EXPERIENCE
Carried out at Shrey Hospital, Ahmedabad,
SUBMITTED TO
NIRMA UNIVERSITY
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF
DEGREE OF
Bachelor of Pharmacy (Hons.)
By
Mr. PARTHKUMAR.D.DHANANI (10BPW618)
Semester X
UNDER THE GUIDANCE OF
Mr. Bhavik Shah, M.Pharm
INSTITUTE OF PHARMACY
NIRMA UNIVERSITY
SARKHEJ-GANDHINAGAR HIGHWAY
AHMEDABAD-382481,
GUJARAT, INDIA
SEPTEMBER 2010
[Parth Dhanani] Page 1

2. [SHREY HOSPITAL]
Certificate
This is to certify that Mr.PARTH KUMAR DHANANI
(10BPW618) of Semester X of B. Pharm (Hons.), 5-year
Integrated Programme, Institute of Pharmacy, Nirma
University, Ahmedabad, has undergone training at SHREY
Hospital from 25/05/2010 to 08/09/2010 and has satisfactorily
completed 400 hours in the Pharmacy Practice Experience.
Date: 9/9/2010
Shri Dharmanshu Chhaya
Manager
Shrey Hospital Ltd.
Near AMCO Bank,
Stadium Circle, Navrangpura,
Ahmedabad - 380 009
Phone: 26468616 to 20, 40017777
Mobile No. - 98250-23371.
EMail: shreyhospitals@yahoo.co.in
Seal of the Hospital
Professor In charge Head of Department Seal of the Institute Director
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3. [SHREY HOSPITAL]
Index
Chapter No. Topic Page No.
Introduction
Clinical Pharmacy Practice 5–6
1.
Importance of Clinical Pharmacy
Practice Training
2. Objectives 7 – 10
Introduction and Overview of Training
Training Site
3. 11 – 16
Training Site Features
Training Duration
Training Schedule
4. Overview of Routine Activities at Hospital 17 – 27
5. Case Studies 28 – 99
6. Results and Discussion About Learning Experience 100 – 106
7. Other Activities and Participation 107 – 123
8. Summary 124 – 125
9. References 126 - 127
10. Annexure 128 – 136
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4. [SHREY HOSPITAL]
ACKNOWLEDGEMENT
This project has been prepared to give brief knowledge to ―Clinical experience in
Shrey Hospital of 400 hours ‘‘.this project has to be undertaken and completed as per
the direction of the syllabus.
I am very thankful to Mr.Dharmanshu Chhaya, for his constant, restless guidance
through his busy schedule .and for his warm welcoming to the Shrey Hospital family.
Also I would be thankful to Dr.Chirag Joshi(M.D) who guided me in all the clinical
doubts and also gave us his personal attention to better understanding of the practical
connection of clinical aspects to my theoretical knowledge as well as his incites to
better development of my clinical experience in Shrey.
I would also like to convey my gratitude to Mr.Bharathai Mahant, The Director of the
Shrey Hospital, for allowing us to use the resources of the hospital, which were
helpful in completion of my thesis.
At this stage I, specially, thank professors Incharge Mr. Bhavik Shah of Institute of
Pharmacy, Nirma University, for the moral support and constant encouragement in
the accomplishment of my project work in semester: X of B.Pharm honors.
Thanking you,
Mr. PARTHKUMAR DHANANI (10BPW618)
[Parth Dhanani] Page 4

5. [Chapter 1]
CHAPTER 1:
Introduction to Pharmacy Practice Experience:
Pharmaceutical care is defined as ―a patient-centered, outcomes oriented
pharmacy practice that requires the pharmacist to work in concert with the patient
and the patient's other healthcare providers to promote health, to prevent disease,
and to assess, monitor, initiate, and modify medication use to assure that drug
therapy regimens are safe and effective.‖
The potential for medication therapy management services provide an
additional career opportunity for pharmacy graduates. Pharmacists usually rotate
between different pharmacy services offered by shrey hospital. These may include:
 clinical pharmacy
 medicines information
 medicines management
 aseptic/technical service
 dispensary services
 community pharmacy services
 primary care
 Importance :
 Pharmacy student‘s main focus on patient cares and emphasizes the
pharmaceutical care model.
 Pharmaceutical care is ―the responsible provision of drug therapy for the
purpose of achieving definite outcomes that improve a patient's quality of life.‖
 Pharmacy practice‘s aim is to guide pharmacy educators in pharmacy practice,
to educate pharmacy students and to guide pharmacists in practice to update
their skills.
 Role of pharmacist is to ensure that a patient‘s drug therapy is appropriately
indicated, the most effective available, the safest possible, and convenient for
the patient.
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6. [Chapter 1]
 Purpose of training and expectations that a clinical pharmacist looks
forward:
 Counseling patients on the effects, dosage and route of administration of their
drug treatments, particularly those who require complex drug therapy.
 Communicating effectively with patients' relatives, community pharmacists,
general practitioners etc.
 Communicate with physician and discuss the cases which enrolled in shrey
hospital.
 Ensuring medicinal products are stored appropriately and securely to ensure
freshness and potency.
 Ensuring medication reaches the patient in the correct form and dose - this may
include tablets, capsules, ointments, injections, inhalers and creams.
 Liaising with physicians, nurses and other fellow health care professionals to
ensure the delivery of safe, effective and economic drug treatment.
 Monitoring every stage of medication therapy to improve all aspects of delivery
and reporting patient side effects.
 Provide help to main pharmacist of hospital for writing guidelines of drug use
within the hospital, preparing bulletins and implementing hospital regulations.
 Providing information to individual wards on budgets and expenditure on drugs.
 Participating in ward rounds, taking patient drug histories and contributing to the
treatment decision-making process - this includes highlighting a drug's potential
side effects, identifying harmful interactions with other drugs and assessing the
suitability of treatments for patients with particular health conditions.
 Preparing and quality-checking sterile medications under special conditions.
 Provide help to pharmacist and pharmacy assistant for the accurate dispensing
and timely distribution of drugs and medicines for inpatients or outpatients.
 Provide help and supervising the work of other staff.
 Responding to medication-related queries from within the hospital, other
hospitals and the general public and if needed then communicate with physician
about the queries.
[Parth Dhanani] Page 6

7. [Chapter 2]
CHAPTER 2:
OBJECTIVES:
Pharmacy profession has entered doctor‘s clinics and hospitals as the ―clinical
pharmacist‖. Clinical pharmacy is a branch of pharmacy where the pharmacist role is
to provide patient care. Clinical pharmacist is an important part of the healthcare
team. The pharmacist works in coordination with the doctors for the better patient
healthcare. They have some very specific roles which aim at assuring patient safety.
Some of the roles are as follows:
 Patient medication history interview.
 Medication order review.
 Patient counseling regarding safe and rational use of drug.
 Adverse drug reaction monitoring.
 Drug interaction monitoring.
 Therapeutic drug monitoring.
 Participating in ward rounds.
 Providing drug information at the drug information and poison information
centre.
 Build upon drug literature evaluation skills and engage in evidence-based
medicine approaches. Drug information is utilized in all pharmacy practice
settings, and research is no exception.
 Publish and present results of the research project at a national meeting. One of
the essential tenets of research is being able to conduct research and present the
research results to other healthcare professionals.
 Attend grand rounds and other seminars in order to further enhance the
educational experience. Clinicians and other researchers from both inside and
outside the institution present interesting topics on a weekly basis, and there are
many ongoing lectures that present topical cutting-edge material in a variety of
subject areas. These sessions will be used to further enhance the educational
process.
 Participating in ward rounds, taking patient drug histories and contributing to the
treatment decision-making process - this includes highlighting a drug's potential
[Parth Dhanani] Page 7

8. [Chapter 2]
side effects, identifying harmful interactions with other drugs and assessing the
suitability of treatments for patients with particular health conditions.
 Counseling patients on the effects, dosage and route of administration of their
drug treatments, particularly those who require complex drug therapy.
 Monitoring every stage of medication therapy to improve all aspects of delivery
and reporting patient side effects.
 Communicating effectively with patients' relatives, community pharmacists,
general practitioners etc.
 Preparing and quality-checking sterile medications under special conditions.
 Ensuring medicinal products are stored appropriately and securely to ensure
freshness and potency.
 Ensuring medication reaches the patient in the correct form and dose - this may
include tablets, capsules, ointments, injections, inhalers and creams.
 Provide help to pharmacist and pharmacy assistant for the accurate dispensing
and timely distribution of drugs and medicines for inpatients or outpatients.
 Provide help and supervising the work of other staff.
 Responding to medication-related queries from within the hospital, other
hospitals and the general public and if needed then communicate with physician
about the queries.
 Provide help to main pharmacist of hospital for writing guidelines of drug use
within the hospital, preparing bulletins and implementing hospital regulations.
 Providing information to individual wards on budgets and expenditure on drugs.
 Communicate with physician and discuss the cases which enrolled in shrey
hospital.
 Collaborate with other research professionals both on and off site to expand
research experience. Current research projects involve co-researchers at
independent sites, and the clinical pharmacist will be interacting with, and
responding to healthcare professionals at these sites. The development of the
ability to work with others both on and off-site will be strengthened and
communications skills will be solidified in this environment. In addition,
networking opportunities for the fellow are possible.
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9. [Chapter 2]
 Integrate the fellow within the research process. Clinical pharmacist will actively
participate in ongoing research that relates to pharmacy practice. These will
include grants that are related to adverse drug events, medication prescribing and
patient safety as it relates to pharmacy issues. He/she will be encouraged to think
critically and input his/her opinion regarding the direction of the research projects.
As the they will be actively engaged in the research process, the insights that the
fellow can provide can become instrumental in the research process and lead to
educational growth for the fellow.
 Build upon drug literature evaluation skills and engage in evidence-based
medicine approaches. Drug information is utilized in all pharmacy practice
settings, and research is no exception.
 Clinical pharmacist will interact with faculty in both the Department of Pharmacy
Practice and Department of Pharmaceutical Sciences. He/she fellow will be
encouraged to seek opportunities to collaborate with colleagues who share similar
teaching and research interests.
 Within the system of health care, clinical pharmacists are experts in the
therapeutic use of medications. They routinely provide
medication therapy evaluations and recommendations to patients and other health
care professionals.
 Clinical pharmacists are a primary source of scientifically valid information and
advice regarding the safe, appropriate, and cost-effective use of medications.
 Clinical pharmacists are also making themselves more readily available to the
public. In the past, access to a clinical pharmacist was limited to hospitals, clinics,
or educational institutions.
 However, clinical pharmacists are making them available through a medication
information hotline, and reviewing medication lists, all in an effort to prevent
medication errors in the foreseeable future.
 In some states, clinical pharmacists are given prescriptive authority under protocol
with a medical provider (i.e., MD or DO), and their scope of practice is constantly
evolving. In the United Kingdom clinical pharmacists are given independent
prescriptive authority.
Basic components of clinical pharmacy practice:
1. Prescribing drugs
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10. [Chapter 2]
2. Administering drugs
3. Documenting professional services
4. Reviewing drug use
5. Communication
6. Counseling
7. Consulting
8. Preventing Medication Errors
Scope of clinical pharmacy:
Drug Information
Drug Utilization
Drug Evaluation and Selection
Medication Therapy Management
Formal Education and Training Program
Disease State Management
Application of Electronic Data Processing (EDP)
[Parth Dhanani] Page 10

11. [Chapter 3]
CHAPTER 3:
Introduction and Overview of Training
Introduction and overview
of hospital training include
visit to various departments
of Shrey Hospital that are
as follows:
Figure 1 Layout of shrey hospital
1) Intensive coronary care unit (ICCU):
 An intensive coronary care unit (ICCU) is a hospital ward specialized in the
care of patients with heart attacks, unstable angina and various other cardiac
conditions that require continuous monitoring and treatment.
 All rooms have dialysis capabilities, and one is equipped with negative air
flow. The nurse's station is designed for direct observation of the patients and
houses the central monitors.
 The Intensive Coronary Care Unit (ICCU) is located on the 4th floor of the
shrey hospital. It is a single hall unit, with no through traffic. All rooms are
private, and equipped with individual monitors, wall oxygen, suction, and an
emergency power system.
 There are two emergency code carts maintained in the ICCU with portable
monitoring equipment. Supplies and other equipment are centralized. A
waiting room is adjacent to the unit.
Equipment & Facility:
 ICCU is managed by highly trained doctors.
 10 Bedded Well Equipped ICCU with Central Station.
 All Beds equipped with Multi Para Monitors with
- ECG
- SPO2
[Parth Dhanani] Page 11

12. [Chapter 3]
- NIBP
- RESP
- Invasive BP
- Temperature
 Bed side multi Para monitors with invasive pressure monitoring, Infusion
pumps, pacemakers, defibrillators, ultrasonic nebulizers, bed side oxygen,
vacuum, air lines.
2nd Invasive Line
 Availability of Pacemaker.
 Bedside Oxygen, Vacuum Line.
 Bedside Digital X- Rays.
 10 State of art ventilators.
 Capnography Monitor Available.
 Defibrillator (BPL)
 Facility for Bedside Dialysis.
 ICCU Managed Round the Clock by Qualified Intensivists.
 Intra Aortic Balloon Pump.
 Infusion Pumps----Syringe Pumps, Volumetric Pumps.
 Latest Crasn Carts.
 Muscle Pulsator to Prevent DVT.
 Multiple Parameter central Station
 Ultrasonic nebulizer.
Activities performed in ICCU:
Counseling to patients
Exercise:
 In an exercise program is to determine patient‘s risk of complications from
exercise. This is usually done by performing an exercise test on a treadmill.
 Patients can also build exercise into their daily routine by taking a brisk walk
.Over time most people can gradually increase the intensity of exercise in their
workout.
[Parth Dhanani] Page 12

13. [Chapter 3]
 This program will consider patient‘s fitness level, heart health, any physical
limitations, the amount, intensity and duration of exercise needed to improve
heart health, and the need for supervision.
 The exercise should use large muscle groups and include aerobic exercise.
Walking, jogging, swimming, cycling, rowing, and stair climbing are some
examples.
Supportive care:
 Manage diabetes — People with diabetes are at an increased risk of
developing complications after a heart attack. Tight control of blood sugar can
help to reduce the risk of these and other types of complications. Tight control
can be achieved by losing weight, managing your diet, exercising, monitoring
blood sugar levels regularly, and taking oral medications (for people with type
2 diabetes) or insulin (for people with type 1 and sometimes type 2 diabetes).
 Stop smoking — Cigarette smoking markedly increases your risk of coronary
heart disease and heart attack, and stopping smoking can rapidly reduce these
risks. One year after stopping smoking, the risk of dying from coronary heart
disease is reduced by about one-half, and the risk continues to decline with
time.
 Treat high cholesterol — Medicine to lower blood cholesterol levels is also
recommended after a heart attack.
 Treat high blood pressure — Medicines to control high blood pressure are
often recommended after a heart attack. It is important to take these
medications exactly as prescribed.
Healthy Diet for Heart:
 Diet counseling is helpful for people who need to lose weight or reduce
cholesterol levels. A registered dietitian is the best person to consult about
foods that are helpful, appropriate portion sizes, total calorie
recommendations, and realistic ways to change bad eating habits.
 Fruits And Vegetables - These foods decrease the risk of cardiovascular
diseases including coronary heart disease (CHD) and stroke. Cruciferous
vegetables (i.e., broccoli, cabbage, cauliflower, brussel sprouts), green leafy
[Parth Dhanani] Page 13

14. [Chapter 3]
vegetables, citrus fruits, and vitamin C-rich fruit and vegetables may lower the
risk of cardiovascular disease to the greatest extent.
 Fibers - Eating a diet that is high in fiber can decrease the risk of coronary
heart disease and stroke by 40 to 50 percent. Eating fiber also protects against
type 2 diabetes, and eating soluble fiber (such as that found in vegetables,
fruits, and especially legumes) may help control blood sugar in people who
already have diabetes. The recommended amount of dietary fiber is 20 to 35
grams of fiber per day.
 Fat - High blood cholesterol levels increase the risk of coronary heart disease.
Eating foods lower in certain types of fat and cutting back on foods that
contain cholesterol can lower cholesterol levels and reduce the risk of
coronary heart disease. Saturated fats and Trans fats should be avoided.
 Sodium – Sodium restriction is also very necessary for heart disease patients.
2) Neurology Department:
Description:
 The department of Neurology provides Routine outdoor, indoor and dedicated
emergency and neuro-intensive care especially, after surgery and stroke.
 Besides management of patients with all neurological disorders, outdoor
speciality clinics are set up for the following neurological conditions:
Movement disorders, headache, epilepsy, neuro-muscle diseases,
neuropsychiatry, pediatric neurology and pain.
Facility and Services:
 Emergency neurosurgery services round the clock on all days.
 Intensive Care facility for critically ill patients.
 Routine out-door and in-door neurosurgery services.
 Sophisticated equipment available in the department to carry out the following
electro diagnostic procedures for example, electroencephalography (EEG) and
video telemetry, electromyography (EMG).
Common Neurosurgical Procedures:
 Craniofacial surgery
 Endoscopic surgery
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15. [Chapter 3]
 Radio surgery and Stereotactic radiotherapy
 Surgery for spasticity
 Spinal surgery
 Surgery for aneurysms/arteriovenious malformations
 Surgery for movement disorders
 Surgery for complex brain tumors
 Skull base surgery
 Stereotactic surgery
 Surgery for Epilepsy
3) Continuous Ambulatory Peritoneal Dialysis Unit (C.A.P.D):
 Automated Peritoneal Dialysis Machines are also available. Patients are
trained in ambulatory peritoneal dialysis in the department.
This form of dialysis for chronic renal failure can be done easily at home and does
not require any machine.
4) Renal Care department:
 3 Latest Dialysis Machine available on 3rd floor of shrey hospital for CRF and
ARF patients.
 Round The Clock Availability of Dialysis Technician facility and also Bed
Side Multi-Para Monitors Available in Dialysis Department.
 There are Doing SLED in Critically ill Patients and also available Separate
Double RO Filtration Plant of Dialysis Water.
 Water used in dialysis is Bacteria Free, Zero TDs, Periodically cultures clone
for removing contamination.
Facilities and services:
 The Department takes care of all types of nephrology cases, e.g. acute renal
failure, chronic renal failure, acute and chronic nephritis, nephrotic syndrome,
renovascular hypertension, collagen disorders involving kidneys etc.
 Facility for CRRT (continuous renal replacement therapy) for critically ill
patients requiring dialysis and MARS (molecular adsorptive regenerative
system) for liver failure is also available.
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16. [Chapter 3]
 Renal Transplant
Haemodialysis:
 Plasmaphoresis for renal as well as non-renal cases
 Short term dialysis prior to transplantation
 To reduce incidence of hepatitis B and C rigorous precautions are taken and
such patients are dialyzed on separate machines.
 Haemodialysis for acute as well as chronic renal failure patients
 Haemodalysis is also done in cases of drug over dosage
[Parth Dhanani] Page 16

17. [Chapter 4]
CHAPTER 4:
Overview of Routine Activities at Hospital
Week: 1 Introduction to Hospital departments
 ICCU: Intensive Cardiac Care Unit
 10 beds
 Computer showing all present
vitals of all patients in ICCU.
 Advanced life supporting
instruments
 Nursing and Medical officers Figure 2 ICCU
staff
 24 hr running air conditioner
 Ventilators near all beds
 Dialysis Unit
 Services
- Hemodialysis
- Hemofilteration
- Plasma Exchanges
- Continuous Ambulatory
peritoneal Dialysis Figure 3 Dialysis Unit
 Charges per sitting
 OT: Operation Theater
 Live video recorder of all
operations.
 All measure operations
except cardiac surgery
performed in Hospital. Figure 4 Operation Theatre
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18. [Chapter 4]
 Assembly of Operation Theatre
 Pathology Department:
 ABGA
 Blood glucose meters (Wards, departments, GP surgeries and
ambulance services)
 Sweat Conductivity meter (Paediatrics)
 Blood gas analysers
 Bilirubinometer (SCBU)
 Nutritional Analysis
 HbA1c analyser in Paediatrics
 Lithotripsy Centre
 Ambulatory Lithotripsy facilities
 TMT ( Tread Mill Test ) for
cardiac evaluation of the patients
Figure 5 Lithotripsy Centre
 Wards
 Doctors take round at each ward Figure 6 ICCU ward
regularly
 Combined Ward all on the first,
second and third floor, separated
by the facilities provided like,
Deluxe, Super Deluxe, Special,
Figure 7 General ward
and Semi Special
 Nurshing staff and consulting offices available at each floor.
[Parth Dhanani] Page 18

19. [Chapter 4]
 OPD (Out Patient Department)
 All departmental specialists with interns are available at OPD
site.
 It is very affordable to patient compare to other private
hospitals.
Week: 2
 Pharmacy:
Figure 8 Shrey Pharmacy Store
 Delivery of emergency medicines to the ICCU by Pharmacist.
 Pharmacy manager teaches that how to manage the stoke of all
medicines.
 Arrangement of medicine by Company name or by disease.
 Software like ―VISUAL‖ to dispense medicine
 Option of Indoor Accommodations:
 Various options are available
for indoor accommodation
suiting to the need & budget of
the patients.
 Each floor has a specious
nursing station supervised by Figure 9 Indoor Accommodation
medical officer round the clock
[Parth Dhanani] Page 19

20. [Chapter 4]
and services of physician (MD) are available whenever
required.
 Hospital has sitting space for visitors and waiting area have
kiosks of TV, Telephone, Tea, Coffee and mineral water.
Week: 3 & 4
Cardiovascular System
 Hypertension
 Heart failure
 ECG
 Arrhythmia and Pacemaker
 RHD and Infective Endocarditis
 IHD
 Stable Angina
 Unstable Angina
 Prinzmetal Angina
 MI
 CPR
 Basic Life Support (BLS)
-Airways
-Breathing
-Circulation
 Advanced Cardiac Life Support (ACLS)
-Defibrillation
-Emergency Medication with Adrenalin, Dopamine, Atropine.
 Drugs
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21. [Chapter 4]
Week: 5 & 6
Respiratory System
 Pneumonia
 COPD
 Drugs
 Tuberculosis
 Asthma
 Tracheotomy
 We have seen the live Tracheotomy in ICCU.
 Ventilation
 Catheter
 Tracheostomy
 Respiratory Failure
 Hypoxia
 Hypercapnea
 ABGA Analysis
 Mixed Respiratory Acidosis
 Mixed Respiratory Alklosis
Week: 7
Renal System
 ARF
 Pre renal ARF
 Intrinsic ARF
 Post Renal ARF
 CRF
 GFR Classification
 Causes
 Pathology
 Intervention
 Electrolyte imbalance
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22. [Chapter 4]
 Na/K/Mg/Ca/Hco3 imbalance
 Dialysis
 Heamodialysis
 Peritoneal Dialysis
Week: 8 & 9
GI Disorder and Liver Dysfunction
 Ascities
 Cirrhosis
 Hepatitis
 Hepatic Encephalopathy
 IBD, IBS (Inflammatory bowel disease/Syndrome)
 Jaundice
 Portal Hypertension
 Typhoid fever
Week: 10 &11
CNS Disorder
 Coma
 Epilepsy
-Types
-Drugs
-Drug Interaction
 EEG/CT scan
 GBS
 Migraine
 MRI
 Neuro surgery
 Stroke
-Hemorrhagic Stroke
-Ischemic Stroke
[Parth Dhanani] Page 22

23. [Chapter 4]
 Shock
Week: 12
Endocrine disorder
 Diabetes Mellitus
 Hormones
-Anterior Pituitary Hormone
• ACTH: Adrenocortico Trophic Hormone
• GH: Growth Hormone
• LH / FSH: Luteinizing hormone/Follicle
Stimulating Hormone
• PRL: Prolactine
• TSH: Thyroid Stimulating Hormone
-Posterior Pituitary Hormone
• Vasopressin & oxytosin
Week: 13 & 14
Infectious Disorder
 Dengue
 Fever and it several types
 Malaria
 Tuberculosis
 Viral Infections
 UTI
Week: 15
Poisoning
 Alcohol poisoning
 Carbon monoxide poisoning
 Chemical poisoning
 Drug poisoning
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24. [Chapter 4]
 Food Poisoning
 Heavy metal poisoning
 Organo phosphorous Poison with case presentation
 Radon poisoning
Participation in Ward round with Clinician:
 Ward round is an integral part for pharmacists during hospital training.
Participation in ward rounds and meetings with the patient is of benefit to the
pharmacist as well as the patients.
 A clinical pharmacist as we know is the third pillar of the healthcare team
following the doctor and the nurse.
 Goals of ward round participation :
 Optimize drug treatment by influencing therapy selection, implementation and
monitoring
 Provide information on pharmacology, pharmacokinetics and other aspects of
the patient‘s therapy.
 Gain an improved understanding of the patient‘s clinical details, planned
investigations and therapeutic goals.
 Activity during ward rounds :
 Assimilate additional information about the patient which may be relevant to
their drug therapy
 Contribute information regarding the patient‘s drug therapy e.g.; suggestions
for monitoring, information on new drugs
 Communicating with physician about changes in drug therapy.
 Considering the impact of changes to the care plan, and making necessary
alterations.
 Discussing alterations to therapy with the patient where appropriate. Detect
ADRs and interactions
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25. [Chapter 4]
 Follow up outstanding issues afterward round and discuss with physician and
pharmacist
 Investigate unusual orders or doses
 Participate in discharge planning
 Responding to any enquiries generated.
 Ward round performance :
 Introduction: Introduce our self to patient and their relative and specify the
purpose of ward round.
 Keeping notes: Always keep notebook and pen during ward round and sketch
down the important information during the ward round like the vital sign of
patient during ward round.
 Making queries: When wanting to make a query, wait till the consultant
makes his assessment regarding the patient and plan out the management as
disturbing at this time might not be a good idea. Following this, indicate your
intension to ask a question and if allowed you can pose a question which is
relevant to that patient.
 Recording a discussion: Discuss with physician about our quires and make
record in notebook about that discussion. Refer this note on next ward round.
 Making summary: At the end of the ward round, make a summary of what
was discussed and list out the areas needing further reading or practice to
perform better as a clinical pharmacist.
PHARMACY STORE:
 Shrey hospital have a Pharmacy department (Medical Store) located on
ground floor.
Arrangement of Medicine:
 The medicines in Shrey Pharmacy are arranged in shelves according to
the company they belong. In that particular company shelf, the drugs
are arranged in alphabetical order.
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26. [Chapter 4]
Figure 10. Drugs’ arrangement
Dispensing:
 The team provides medicines for many areas both on and off site. They
provide services to in-patients and out-patients from every clinical area.
 The Pharmacy ensures that there is a round the clock availability of a
sufficient quantity of drugs.
Figure 11 Dispensing of drugs
Storage of Medicine:
 The medicines are stored in the Pharmacy at room temperature.
 Special medicine such as insulin and certain injectables which degrade
at room temperature are kept in the refrigerator and the temperature of
the refrigerator is checked every morning by the ATO.
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27. [Chapter 4]
 Shrey Pharmacy does not have the license for Narcotics so no locked
storage is required.
Figure 12 Storage of medicines
Records Maintenance:
 The inventory list is printed every morning and that is done by the ATO.
 The expiratory is done in the starting of every month by computer as well as
manually.
Figure 13 Record maintenance
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28. [Chapter 5]
CHAPTER 5: Case studies
CASE STUDY 1: ECLAMPSIA
Patient details:
 Patient name: XYZ
 Age: 23 years
 Sex: Female
 Weight: 48 kg
 Height: 5‘3‖
 Date Of Admission: 20/07/10
 Date of Discharge: 22/03/10
Chief complaints:
 Generalized tonic clonic convulsion after delivering first child
 Edema on lower limb since 4 days
 Low U/O since 2 days
 Fever since 1 day
 Unconsciousness since 1 day
Past history:
 No significant past history
Past medication:
 No past medication history
Family History:
 Low socio-economic class
 No disease running in family
 Delivered first child
Social History:
 Married
 Normal diet & sleep
 No tobacco
 No alcohol
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29. [Chapter 5]
On admission vital data:
 Temperature: 101 oF
 Pulse : 140 / MIN (N:60-90 / MIN)
 B.P. : 900/50 mmHg (N: 140 / 90mmhg)
 R.R. : 16 / MIN (N: 14 – 18 / MIN)
 SPO2: 98% Normal
Systemic examination:
 CVS: S1S2 Normal
 CNS: Unconscious
 R.S. : Normal
 P/A : Soft
Lab investigations:
Table 1 Lab investigation of Eclampsia patient
INVESTIGATION DAY 1 DAY 2
Hb 6.3 8.5
TC 26,200 26,000
DC 68/17/1/12/2 73/20/2/5/0
PC ↓se 82,000 1,66,000
PT ↑se Total 24 sec ---
Control 13.2 sec
RBS 120 mg/dL ---
(75-115mg/dL)
Urea ↑se 193.47 ---
(10-20mg/dL)
Creatinine ↑se 8.88 (<1.5mg/dL) ---
Sodium 135.26 142.37
Potassium 4.7 4.1
S.Bilirubin ↑se 1.41 (0.3-1mg/dL) ---
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30. [Chapter 5]
SOPT ↑se 138.5 (0-35U/L) ---
S.Ammonia 39.59 ---
LDH ↑se 2835 (14-26%) ---
pH ↓se 7.21 (7.38-7.44) ---
pCO2 ↑se 52 (35-45mmhg) ---
PO2 ↑se 67 (80-100mmhg) ---
Bicarbonate ↓se 11 (20-30mE/L) ---
X – Ray : Normal
USG (Abdomen):
- Retain products
- ARF
CT Scan (Brain): Bilateral ischaemia
Diagnosis:
- ECLAMPSIA (leading cause of death)
- POST PARTAL ENCEPHALOPATHY
- SEPTICAEMIA
- ARF
- LIVER INJURY
BACKGROUND:
• Ten percent of all pregnancies are complicated by hypertension
(HTN).Eclampsia and preeclampsia account for about half of these
cases worldwide.
• In 1619, Varandaeus coined the term eclampsia in a treatise on
gynecology.
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31. [Chapter 5]
• DEFINITION: Eclampsia is defined as the clinical presentation
of an unexplained seizure, convulsion, or altered mental status in
the setting of the signs and symptoms of preeclampsia. It is
considered a complication of severe preeclampsia.
• A woman with preeclampsia develops:
--- High blood pressure (>140 mmHg systolic or >90 mmHg diastolic)
--- Protein in the urine
--- Swelling (edema) of the legs, hands, face or entire body.
PATHOGENESIS:
In eclampsia, placenta does not form a normal system of arteries
[Illness (diabetes or high blood pressure), genetic (inherited) factors and the way the
mother's immune system reacts to the growing placenta]
↓
Placenta does not anchor itself as deeply as expected within the wall of the uterus
↓
As the pregnancy progresses, a placenta creates an abnormal balance of enzymes
(proteins) called growth factors (VEGF)
(Placental production and secretion of antiangiogenic factors such as protein like
tyrosine kinase 1 and activin a that antagonizes VEGF)
↓
ANGIOGENESIS IMPEDANCE
↓
Changes the way that arteries in the mother and the placenta function-
 Arteries throughout the body can tighten (become narrower), ↑se BP
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32. [Chapter 5]
 Become "leaky" allowing protein or fluid to seep through their walls, which
causes tissues to swell →Edema
 Also react to the abnormal growth factor balance by forming clots
 Abnormal cerebral blood flow in the setting of extreme hypertension. Vessels
become dilated with increased permeability and cerebral edema occurs and
results in ischemia and encephalopathy → Seizures
 Many uterovascular changes occur due to the interaction between fetal and
maternal allografts and result in systemic and local vascular changes. These
system changes contribute to the brain pathology in eclampsia by inhibiting
the regulation of cerebral perfusion.
Medications:
Table 2 Medications of Eclampsia patient
DRUG DOSE ROA DURATION GENERIC D D
NAME 1 2
Inj. Pipzo 4.5 mg in i.v. 12hrly Piperacillin + √ √
100ccNS tazobactam
Inj. Metrogyl 100ml i.v. 8hrly Metronidazole √ √
Inj. Pantodac 40mg i.v. OD Pantoprazole √ √
Inj. Levepil 500mg in i.v. 8hrly Levetiracetam √ √
100ccNS
Inj. Lasix 2amp i.v. BD Furosemide √ √
Inj. FFP 250ml i.v. 8hrly Fresh frozen √ √
plasma
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33. [Chapter 5]
Inj. Dopamine 2@ in i.v. 6hrly Dopamine √ √
50ccNS
Inj. Febrinil 1@ i.v. sos Paracetamol √ √
Inj. Falcigo 60mg i.v. OD Artesunate √ √
Inj. D25% 500ml i.v. 10ml/hr Dextrose √ √
Inj. Sodium (0.6*wt*HC i.v. 13@ straight Bicarbonate √ √
bicarbonate O3 def.) &
0.6*48*9 = 13@ 6hrly
259.2mEq
Inj. Duphalac 15ml i.v. 8hrly Lactulose √ √
Inj. Vit K1 1@ in i.v. OD Vit K1 √ √
100ccNS
Inj. Norad 2@ in i.v. 6hrly Nor adrenaline - √
50ccNS
Pipzo Dose Calculation:
Table 3 Pipzo dose calculation
Creatine Dose Dose interval
Clearance
20-80 4/0.5 8
<20 4/0.5 12
 Cl cr = (140 – age yr) * Body wt. = (140-23) * 48 = 8.78
72 * S.cr 72 * 8.88
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34. [Chapter 5]
DRUG RELATED ISSUE:
Table 4 Drug interactions
DRUGS INTERACTIONS MANAGEMENT
lactulose ↔ Electrolyte loss and increase the The recommended dosage
Artesunate risk of torsade de pointes and duration of use should
( moderate) ventricular arrhythmia. not be exceeded. Electrolye
Electrolyte disturbances including supplements needed to be
hypokalemia and administered.
hypomagnesemia.
Artesunate The mechanism is decreased Avoid the consumption of
↔ food clearance of Artesunate due to grapefruits and grapefruit
(moderate) inhibition of CYP450 3A4- juice. To ensure maximal
mediated first-pass metabolism in oral absorption, artemether-
the gut wall by certain lumefantrine should be taken
compounds present in grapefruits. with food.
Furosemide Potentiate the pharmacologic In general, laxatives should
↔ lactulose effects of diuretics. Laxatives can only be used on a short-
(Moderate) cause significant losses of fluid term, intermittent basis in
and electrolytes recommended dosages.
Contact physician if they
experience signs and
symptoms of fluid and
electrolyte depletion such as
dizziness, lightheadedness,
dry mouth, thirst, fatigue,
weakness, decreased
urination, postural
hypotension, and
tachycardia.
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35. [Chapter 5]
CASE STUDY 2: CIRRHOSIS OF LIVER
Patient details:
 Patient name: XYZ
 Age: 20 years
 Sex: Female
 Weight: 35 kg
 Height: 5‘1‖
 Date Of Admission: 28/07/10
 Date of Discharge: 3/08/10
Chief complaints:
 Abdominanal pain
 Distension of abdomen
 Decreased appetite
 Fever
Past history:
 No history of HTN/DM/CAD/Asthma
Past medication:
 No past medication history
Family History:
 No significant family history
Social History:
 Single
 Normal diet & sleep
 No tobacco
 No alcohol
On admission vital data:
 Temperature: N
 Pulse : 120 / MIN (N:60-90 / MIN)
 B.P. : 124/70 mmHg (N: 140 / 90mmhg)
 R.R. : 16 / MIN (N: 14 – 18 / MIN)
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36. [Chapter 5]
 SPO2: 99% Normal
Systemic examination:
 CVS: NAD (No Abnormality Detected)
 CNS: Unconscious
 R.S. : Normal
 P/A : Soft
Lab investigations:
Table 5 Lab investigation of Liver cirrhosis patient
INVESTIGATION DAY 1 DAY 2 DAY 3
Hb 8.9 7.9 7.6
TC 14,100 3070 3980
DC 83/5/0/11/1 64/18/1/14/3 72/11/1/15/1
PC ↓se 66,900 42,400 45,900
PT ↑se Total 24.8 sec --- ---
Control 13.4 sec
INR 2.17
Creatinine 0.36 --- ---
(<1.5mg/dL)
Sodium ↓se 107.31 122.02 114.2
Potassium 3.93 4.1 ---
S.Bilirubin ↑se 1.41 (0.3- --- ---
1mg/dL)
SOPT ↑se 142.7 (0- --- ---
35U/L)
Alkaline Phosphatase ↑se 173.51 (70- --- ---
120)
S.Ammonia 39.59 --- ---
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37. [Chapter 5]
Gamma-glutamyl 156.73 (1-94 --- ---
transferase U/L)
Albumin 2.61 (3.5-5.5 --- ---
g/dL)
Globulins 12.96 (2-4.1 --- ---
g/dL)
Smear MP not seen --- ---
Arterial blood gas analysis (ABGA):
PH -- 7.54
pCO2 -- 27
HCO3 -- 114
BA -- 23
O2 -- 99 %
TO2 -- 24
USG (Abdomen):
- Shrunken right lobe
- Moderate spleenomegaly
- Small and nodular liver with increased echogenicity with
irregular appearing area
Endoscopy:
Gastroscopy: Exclude the possibility of esophageal varices.
Diagnosis:
- Cirrhosis of liver / Wilson‘s disease
- Ascites/SBP recovered
- Marked Icterus
- No GI bleed pro encephalopathy
Pathophysiology:
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38. [Chapter 5]
-
Figure 14 Liver cirrhosis
 Macroscopically, the liver is initially enlarged, but with progression of
the disease, it becomes smaller. Its surface is irregular, the consistency
is firm and the color is often yellow (if associates steatosis).
 Depending on the size of the nodules there are three macroscopic
types: micronodular, macronodular and mixed cirrhosis. In
micronodular form (Laennec's cirrhosis or portal cirrhosis)
regenerating nodules are less than 3 mm. In macronodular cirrhosis
(post-necrotic cirrhosis), the nodules are larger than 3 mm. The mixed
cirrhosis consists in a variety of nodules with different sizes.
 However, cirrhosis is defined by its pathological features on
microscopy:
1. The presence of regenerating nodules of hepatocytes and
2. The presence of fibrosis, or the deposition of connective
tissue between these nodules.
 The pattern of fibrosis seen can depend upon the underlying insult that
led to cirrhosis; fibrosis can also proliferate even if the underlying
process that caused it has resolved or ceased.
 The fibrosis in cirrhosis can lead to destruction of other normal tissues
in the liver: including the sinusoids, the space of Disse, and other
vascular structures, which leads to altered resistance to blood flow in
the liver and portal hypertension.
Medications:
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39. [Chapter 5]
Table 6 Mediation of Liver cirrhosis patient
DRUG DOSE ROA DURA GENERIC D D D D
TION NAME 1 2 3 4
Inj. Magnex 1.5 mg i.v. 8hrly Cefoperazone+ √ √ √ √
Forte in salbectam
100cc
NS
Inj. Vit K1 1@ i.v. OD Supplement √ √ √ √
Tab. Cilamin 250mg i.v. TID Penicillamine √ √ √ √
Inj. Famocid 20mg i.v. BID Famotidine √ √ √ √
Inj. Zentax i.v. TID Gentamysin √ √ √ √
Inj. FFP 2@ i.v. Fresh frozen -- √ -- √
plasma
Tab. Shelcal 500 mg i.v. OD Calcium √ √ √ √
carbonate + Vit
B3
Tab. Becosule Oral OD Vit B Complex √ √ √ √
Tab. Udiliv 300 mg Oral BID Ursodeoxycholic √ √ √ √
acid
Inj. H.Alb 20% 20% i.v. 4hrly Supplement √ √ √ √
Tab. Dynapar Oral Sos Diclofenac -- √ -- √
plus
Proctodesyl Enema Ethyl -- -- √ √
aminobenzoate/Ec
osulide
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40. [Chapter 5]
Liq. Looz 2@ i.v. 6hrly Lactulose -- -- √ √
Inj. Dytor 1/2 @ i.v. 6hrly Torasemide -- -- √ √
Drug related issue:
Table 7 Drug interactions
DRUGS INTERACTIONS MANAGEMENT
Gentamicin Coadministration of parenteral Use of aminoglycoside
↔ aminoglycoside antibiotics or antibiotics in combination
Torasemide oral neomycin in combination with loop diuretics should
with loop diuretics may generally be avoided.
(Major)
potentiate the risk of oto- and Serial, vestibular,
nephrotoxicity due to additive or audiometric, and renal
synergistic pharmacologic function tests should be
effects of these drugs. performed before and
during therapy if
coadministration is
necessary.
Gentamicin Coadministration of The lowest effective
↔ aminoglycoside and dosages of aminoglycosides
Cefoperazone cephalosporins may increase the and cephalosporins should
risk of nephrotoxicity. be used when they are
(Moderate)
prescribed in combination.
Renal function should be
monitored closely.
Diclofenac ↔ 1. Concomitant use of Avoiding dehydration and
Torasemide nonsteroidal anti-inflammatory carefully monitoring the
drugs (NSAIDs) and diuretics patient's renal function and
(Moderate)
may adversely affect renal blood pressure. If renal
function due to NSAID insufficiency or
inhibition of the renal synthesis hyperkalemia develops,
of prostaglandins that help both drugs should be
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41. [Chapter 5]
maintain renal perfusion in discontinued until the
dehydrated states. condition is corrected.
2. Hypotensive effect of the
diuretics may be reduced
because inhibition of
prostaglandins can lead to
unopposed pressor activity and,
consequently, elevation in blood
pressure.
Penicillamine : Oral administration of Mineral supplements or
↔ Calcium aluminum, copper, iron, zinc, other products containing
carbonate magnesium, and possibly other polyvalent cations should
minerals such as calcium may be administered at least two
(Moderate)
decrease the gastrointestinal hours before or two hours
absorption of penicillamine, and after the penicillamine dose.
vice versa. The proposed
mechanism involves chelation
of penicillamine to polyvalent
cations, which leads to
formation of a nonabsorbable
complex.
Discharge Medications:
- Inj. Tazect [Piperacillin + Tazobactam (2.25)] in 100ml NS
8hrly ---------------------------------------------------------- 2 days
- Tab. Tarivid [Ofloxacin (200)] (0-0-1) ------------------ 15 days
- Tab. Famocid (20) (1-1)
- Tab. Shelcal (500) (0-0-1)
- Tab. Udiliv (300) (1-1)
- Tab. Cilamin (250) (1-1-1)
- Tab. Zintate [Gentamicin] (1-1-1)
- Tab. Dytor plus [Torasemide] (5+50) (0-0-1)
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42. [Chapter 5]
CASE STUDY 3: MYOCARDIAL INFARCTION (MI)
Patient details:
 Patient name: XYZ
 Age: 62 years
 Sex: Male
 Weight: 59 kg
 Height: 5‘9‖
 Date Of Admission: 17/07/10
 Date of Discharge: 22/07/10
Chief complaints:
 Chest pain
 Difficulty in breath
Past history:
 No significant past history
Past medication:
 No past medication history
Family History:
 Low socio-economic class
 No disease running in family
Social History:
 Normal diet & sleep
 Smoking
 Alcoholic
 No tobacco
On admission vital data:
 Temperature: N
 Pulse : 92 / MIN (N:60-90 / MIN)
 B.P. : 144/94 mmHg (N: 140 / 90mmhg)
 R.R. : 16 / MIN (N: 14 – 18 / MIN)
 SPO2: 98% Normal
Systemic examination:
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43. [Chapter 5]
 CVS: S1S2 Normal
 CNS: NAD
 R.S. : Normal
 P/A : Soft
 Stool: Not passed
Lab investigations:
Table 8 Lab investigation of MI patient
INVESTIGATION DAY 1 DAY 2
Hb 12.1 12.9
TC 8350 8010
DC 95/6/1/0/0 77/9/3/10/1
PC ↓se 2,05,000 1,57,000
PT ↑se Total 21.3 sec ---
Control 13.2 sec
RBS 120 mg/dL ---
(75-115mg/dL)
Creatinine ↑se 9.14 (<1.5mg/dL) ---
Sodium 141.76 139.11
Potassium 5.6 5.34
Magnesium 2.47 (1.8-2) 2.39
S.Bilirubin 0.54 (0.3-1mg/dL) ---
SOPT 31.67 (0-35U/L) ---
CPK-MB 46.72 (0-7 ng/L) ---
Troponin I 13.25 (0-0.4) ---
pH 7.41 (7.38-7.44) ---
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44. [Chapter 5]
pCO2 39.48 (35-45mmhg) ---
PO2 91.93 (80-100mmhg) ---
Bicarbonate 27.84 (20-30mE/L) ---
2D ECG: Abnormalities of wall motion
12-lead electrocardiogram:
- Anterior wall myocardial infarction.
- Low ejection fractions (<40%)
Doppler echocardiography:
- Ventricular septal defect
- Mitral regurgitation
Diagnosis: ACUTE MYOCARDIAL INFARCTION
Pathophysiology:
 The most common triggering event is the disruption of
an atherosclerotic plaque in an epicardial coronary artery, which leads to a
clotting cascade, sometimes resulting in total occlusion of the artery.
 Atherosclerosis is the gradual build up of cholesterol and fibrous tissue in
plaques in the wall of arteries (in this case, the coronary arteries), typically
over decades.
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45. [Chapter 5]
Figure 15 Occluded Coronary artery in MI
 Blood stream column irregularities visible on angiography reflect
artery lumen narrowing as a result of decades of advancing atherosclerosis.
 Plaques can become unstable, rupture, and additionally promote
a thrombus (blood clot) that occludes the artery; this can occur in minutes.
When a severe enough plaque rupture occurs in the coronary vasculature,
it leads to myocardial infarction (necrosis of downstream myocardium).
 If impaired blood flow to the heart lasts long enough, it triggers a process
called the ischemic cascade; the heart cells in the territory of the occluded
coronary artery die (chiefly through necrosis) and do not grow back.
 A collagen scar forms in its place. Recent studies indicate that another
form of cell death called apoptosis also plays a role in the process of tissue
damage subsequent to myocardial infarction.
 As a result, the patient's heart will be permanently damaged.
This Myocardial scarring also puts the patient at risk for potentially life
threatening arrhythmias, and may result in the formation of a ventricular
aneurysm that can rupture with catastrophic consequences.
 Injured heart tissue conducts electrical impulses more slowly than normal
heart tissue. The difference in conduction velocity between injured and
uninjured tissue can trigger re-entry or a feedback loop that is believed to
be the cause of many lethal arrhythmias.
 Another life threatening arrhythmia is ventricular tachycardia (V-
Tach/VT), which may or may not cause sudden cardiac death. However,
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46. [Chapter 5]
ventricular tachycardia usually results in rapid heart rates that prevent the
heart from pumping blood effectively.
 Cardiac output and blood pressure may fall to dangerous levels, which can
lead to further coronary ischemia and extension of the infarct.
Medications:
Table 9 Medications of MI patient
DRUG DOSE ROA DURA GENERIC D D D D
TION NAME 1 2 3 4
Inj. NTG + Ns 50mg i.v. 0.5ml/h Nitroglycerine √ √ √ √
r
Inj. Oxprin 0.8mg i.v. Stat Aspirin √ √ √ √
Inj. Pantocid 40mg i.v. Stat Pantoprazole √ √ √ √
Inj. Emeset 40mg i.v. Stat Onadansetron √ √ √ √
Inj. DNS 1@ i.v. --- Dextrose √ √ √ √
Tab. Eldervit 1@ Oral --- Multivitamin √ √ √ √
Tab. Ecosprin 150mg Oral --- Aspirin √ √ √ √
Tab. Clopivas 100mg Oral OD Clopidogrel √ √ √ √
Tab. Dilzem 30mg Oral TID Diltiazem √ √ √ √
Inj. Decil --- Oral Stat Paracetamol √ √ √ √
Inj. Deriphyllin --- Oral 8hrly Theophylline -- √ -- √
Neb. Levolin --- Nasal 6hrly Salbutamol -- √ √ √
[Parth Dhanani] Page 46

47. [Chapter 5]
Neb. Budamate --- Nasal 8hrly Budesonide -- √ √ √
Tab. Calpol 500mg Oral TID Paracetamol -- √ √ √
Liq. Cremaffin 3Tsf Oral --- Paraffin -- -- √ √
Tab. Ultrazec --- Oral Sos Tramadol + PCM -- -- √ √
Advice:
- Smoking cessation
- Regular exercise
- Sensible
- Limitation of alcohol intake.
Drug related issue:
Table 10 Drug interactions
DRUGS INTERACTIONS MANAGEMENT
Theophylline The risk of seizures may be Caution is advised.
↔ Tramadol increased during
coadministration of tramadol
(Major)
with theophylline that can
reduce the seizure threshold.
Clopidogrel Coadministration with proton Use of Pantoprazole should
↔ pump inhibitors (PPIs) may preferably be avoided in
Pantoprazole reduce the cardioprotective patients treated with
effects of clopidogrel. The clopidogrel.
(Major)
proposed mechanism is PPI If gastroprotection is
inhibition of the CYP450 2C19- necessary, H2-receptor
mediated metabolic antagonists or antacids
bioactivation of clopidogrel. should be prescribed
whenever possible.
Diltiazem ↔ Aspirin may reverse the Close observation for
Aspirin antihypertensive effect of prolonged bleeding time
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48. [Chapter 5]
(Moderate) verapamil. and reduced
antihypertensive effect is
recommended. Patients
should be advised to notify
their physician if they
experience unusual
bleeding, bruising, or
petechiae. Aspirin should be
discontinued if an
interaction is suspected.
Theophylline Pantoprazole increases the rate Theophylline levels in the
↔ of theophylline absorption from upper range of normal.
Pantoprazole sustained-release formulations. Patients should be advised
(Moderate) Chronic use of proton pump to report any signs of
inhibitors produce sustained theophylline toxicity
hypochlorhydria, which may including nausea, vomiting,
enhance peristalsis in the small diarrhea, headache,
intestine and antiperistalsis in restlessness, insomnia, or
the proximal colon where irregular heartbeat to their
theophylline is absorbed. physicians.
Discharge medication:
- Tab. Diltiazem (30mg) (1-1-1)
- Tab. Ecosprin (75mg) 1OD after meal
- Tab. Clopivas (2.5mg) (1-1)
- Tab. Dytar Plus (10mg) (1-0-1)
- Tab. Deriphylline R (300mg) 1 OD
- Neb. Levolin 6hrly
- Neb. Budamate 8hrly
- Liq. Cremaffin 3 TSF TID
- Oint. Dicloran (Diclofenac)
- Tab. Ultrazec sos for pain
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49. [Chapter 5]
CASE STUDY 4: PANCREATITIS
Patient details:
 Patient name: XYZ
 Age: 46 years
 Sex: Female
 Weight: 69 kg
 Height: 5‘6‖
 Date Of Admission: 12/07/10
 Date of Discharge: 15/07/10
Chief complaints:
 Abdominal pain since 2 days
 NV since 2 days
 Fever since 1 day
Past history:
 Diabetes Mellitus from last 10 years
 No past history of HTN/IHD/Drug Allergy/Chest pain
Past medication:
 Glynase MF (Glipizide 5mg & Metformin 500mg)
1 tab OD before break fast
Family History:
 No significant family history
Social History:
 No tobacco
 No alcohol
On admission vital data:
 Temperature: 103 oF
 Pulse : 92 / MIN (N:60-90 / MIN)
 B.P. : 110/70 mmHg (N: 140 / 90mmhg)
 R.R. : 16 / MIN (N: 14 – 18 / MIN)
 SPO2: 99% Normal
Systemic examination:
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50. [Chapter 5]
 CVS: NAD
 CNS: NAD
 R.S. : Clear
 P/A : Soft
 Vomiting: Yes
 Stool: Not passed (Peristalsis movement absent)
Lab investigations:
Table 11 Lab investigation of pancreatitis patient
DRUG NAME DAY 1 DAY 2 DAY 3
Haemoglobin 14.7 12.6 ---
Total count 14,900 11,400 ---
Platelet count 2,33,000 2,46,000 2,37,000
RBS ↑se 425 (70-110) --- ---
Creatinine 0.8 (0.6-1.2) 0.52 ---
Urea 13.5 14.2 ---
Sodium 137 139.33 ---
Potassium ↓se 3.0 2.8 3.1
Calcium --- 8.3 ---
SGPT ↑se 125 (0 - 35) --- 80.76
Serum Amylase ↑se 2415(35-120) --- ---
Serum lipase ↑se 5580 (0-160) 1520 ---
Serum AlkPo4ase --- 71 (70-120) 124.99
X-Ray: Normal
USG: Prevalence of minimal fluid anterior to pancreas
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51. [Chapter 5]
Diagnosis:
- PANCREATITIS
- DIABETES MELLITUS
 PATHOPHYSIOLOGY:
Table 12 Flowchart of Pancreatitis Pathophysiology
Acute injury
Initial Insult
* Zymogen activation
* Ischaemias
* Duct obstruction
Release of Generation of
Release of
vasoactive cytokines
active enzymes
substances
eg. TNF, IL-1,PAF
Vascular
damage
Inflammation
Tissue damage
and cell death
 The premature activation of pancreatic zymogens within the acinar cells,
pancreatic ischemia, or pancreatic duct obstruction initiates AP and leads to a
series of secondary events that determine the duration and severity of the
injury.
 Trypsinogen autoactivation and Trypsinogen activation by the lysosomal
enzyme cathepsin B account for the intracellular activation of Trypsinogen
and the zymogen cascade.
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52. [Chapter 5]
 The release of active pancreatic enzymes directly causes local or distant tissue
damage, or may enhance inflammation by activating the alternate complement
pathway.
 Trypsin digests cell membranes and leads to the activation of other enzymes
within the pancreas.
Figure 16 Pancreatitis
Figure 17 Pancreatitis
 Lipase damages the fat cells, producing noxious substances that cause further
pancreatic and peripancreatic injury.
 The release of cytokines by the acinar cell or the inflammatory cells directly
injures the acinar cell and enhances the inflammatory response.
 Injured acinar cells liberate chemoattractants that attract neutrophils,
macrophages, and other cells to the area of inflammation.
 Vascular damage and ischemia causes the release of kinins, which makes
capillary walls permeable and promotes tissue edema.
 The release of damaging oxygen-free radicals appears to correlate with the
severity of pancreatic injury.
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53. [Chapter 5]
Medications:
Table 13 Medications for Pancreatitis patient
GENERIC D D D
DRUG DOSE ROA DURATION NAME 1 2 3
Inj. Magnex 3g i.v. 12hrly Cefoperazo √ √ √
forte in ne+
100ccNS salbectam
Inj. H.Actrapid --- S/C i.v. 12 hrly √ √ √
acc
Inj. Pantodac 40mg i.v. OD Pantoprazol √ √ √
e
Inj. Emeset 1@ i.v. 8 hrly Ondansetro √ √ √
n
Inj. Contramol 1@(50m i.v. 8 hrly Tramadol √ √ √
in 100ccNS g)
Inj. RL at 1@ (150 i.v. 200ml/hr Ringer √ √ √
ml) Lactate
Inj. KCl 1@ in 2@/day Potassium √ √ √
1NS@
Inj. Febrinil 1@ i.v. Sos Paracetamol √ √ √
DRUG RELATED ISSUE:
DRUGS INTERACTIONS MANAGEMENT
Ondansetron Concurrent use of 5-HT3 No particular intervention is
↔ Tramadol receptor antagonists may reduce required. However, the
the analgesic efficacy of possibility of a diminished
Tramadol. The proposed therapeutic response to
mechanism is antagonism of Tramadol should be
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54. [Chapter 5]
serotonin-mediated effects of considered during
Tramadol at the spinal level. concomitant therapy with 5-
HT3 receptor antagonists.
Insulin ↔ The effect of insulin may be If co administered, close
lvp solution potentiated, and the risk of monitoring of blood glucose
with hypoglycemia increased. level is required.
potassium
(KCl in NS)
 Diclofenac is widely used analgesic. But in this case, tramadol is used as
diclofenac being belonging to NSAIDs class, is nephrotoxic, which will
further worsen the condition.
 Food has to be administered by naso-jejunum route.
 When patient begin to recover, he is first given clear water. If tolerated, then
switched on to soft diet and finally, when patient begin to consume full diet,
he is discharged from hospital.
 Right now this patient is on soft diet.
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55. [Chapter 5]
CASE STUDY 5: ULCERATIVE COLITIS
Patient details:
 Patient name: XYZ
 Age: 39 years
 Sex: Female
 Weight: 71 kg
 Height: 5‘8‖
 Date Of Admission: 23/08/10
 Date of Discharge: 27/08/10
Chief complaints:
- Altered sensorium since 4 days
- Abdominal pain since 4 days
- Low grade Fever since 3days
- Loose motion since 2 days
- Uneasiness since 2 days
Past history:
 No past history of HTN/IHD/Drug Allergy/Chest pain
Past medication:
 No past medication history
Family History:
 No significant family history
Social History:
 No tobacco
 No alcohol drinking
 No smoking
On admissiently on vital data:
 Temperature: 99.6 oF
 Pulse : 136 / MIN (N:60-90 / MIN)
 B.P. : 110/70 mmHg (N: 140 / 90mmhg)
 R.R. : 29 / MIN (N: 14 – 18 / MIN)
 SPO2: 99% Normal
Systemic examination:
 CVS: S1S2 normal
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56. [Chapter 5]
 CNS: Altered sensorium
 R.S. : Clear
 P/A : Soft
 Vomiting: Nil
Lab investigations:
Table 14 Lab investigation of Ulcerative Colitis
TEST OBSERVED NORMAL VALUE
VALUE
Hemoglobin 6.0 gm/dl 13.5-17.5 gm/dl
DC 60/3/0/0/0 65/35/3/3/6
Total Blood Count 4,940/cmm 4,000-11,000/cmm
Platelet Count 1,11,000/mm 1,50,000-
4,00,000/mm
INR 1.73 0.8-1.2
PT Test: 20.5 11.1-13.1
Conrol:13.5
Sodium 113 mEq/L 135 – 145 mEq/L
Potassium 3.87mEq/L 3.5 - 5.0 mEq/L
Magnesium 1.1 mEq/L 1.5-2.5mEq/L
Calcium 2.8mEq/L 4.5-5.5mEq/L
Serum Alkaline 92.28IU/L 20 to 140 IU/L.
Phosphates
Serum Protein 2.84 gm/dl 5.5- 9.0 gm/dl
S.G.O.T 17.39 0 – 42 IU/L
Albumin 1.10 gm/dl .4 – 5.4 gm/dl
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57. [Chapter 5]
 Blood culture: Negative
 USG: Right colon is mildly inflamed and moderately large
DIAGNOSIS: Ulcerative colitis
Pathophysiology:
 Ulcerative colitis (UC) usually begins in the rectum. It may remain
localized to the rectum (ulcerative proctitis) or extend proximally,
sometimes involving the entire colon. Rarely, it involves most of the large
bowel at once.
 The inflammation caused by UC affects the mucosa and submucosa, and
there is a sharp border between normal and affected tissue. Only in severe
disease is the muscularis involved. In early cases, the mucous membrane is
erythematous, finely granular, and friable, with loss of the normal vascular
pattern and often with scattered hemorrhagic areas. Large mucosal ulcers
with copious purulent exudate characterize severe disease. Islands of
relatively normal or hyperplastic inflammatory mucosa (pseudopolyps)
project above areas of ulcerated mucosa. Fistulas and abscesses do not
occur.
 Toxic or fulminant colitis occurs when transmural extension of ulceration
results in localized ileus and peritonitis. Within hours to days, the colon
loses muscular tone and begins to dilate.
Pseudopolyps
Figure 18 Pseudolyps
 The terms toxic megacolon or toxic dilation are discouraged because the
toxic inflammatory state and its complications can occur without frank
megacolon (defined as transverse colon > 6 cm diameter during an
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58. [Chapter 5]
exacerbation). Toxic colitis is a medical emergency that usually occurs
spontaneously in the course of very severe colitis but is sometimes
precipitated by opioid or anticholinergic antidiarrheal drugs. Colonic
perforation may occur, which increases mortality significantly.
Figure 19 Colectomy specimen Figure 20 Tongue, lips, palate and pharynx
ulcers
Figure 21 Pyoderma gangrenosum on the leg Figure 22 Endoscopic image
Medication:
Table 15 Medications for UC patient
NAME DOSE ROA GENERIC D D D D
NAME 1 2 3 4
Inj. Ceftop 0.5g + 0.5g i.v. Cefoperazone & √ √ √ √
sulbactam0
Inj. Levoflox 500mg/100ml i.v. Levofloxacin √ √ √ √
Inj. Metrogyl 500mg/100ml i.v. Metronidazole √ √ √ √
Tab. Texim-O 200mg Oral Cefixime -- -- -- --
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59. [Chapter 5]
Inj. Forcan 2mg/100ml i.v. Fluconazole √ √ √ √
Inj. 25% 30mg i.v. 25% dextrose √ -- -- --
Dextrose
Infusion
Inj. Saline 0.9% 1000 ml i.v. Sodium Chloride √ √ √ √
Inj. Calcium 10 %/10 mL i.v. Calcium √ √ √ √
Gluconate Gluconate
Inj. 5mg i.v. Magnesium √ √ √ √
Magnesium Sulphate
Sulphate
Inj. Albumin 20% i.v. Human albumin √ √ √ √
Infusion PCV i.v. Pack cell volume √ √ √ --
Liq. Mesacol 4 mg /60 ml Anal Mesalamine √ √ -- --
Enema
Tab. Mesacol 400 mg Oral Mesalamine -- -- √ √
Inj. Efcorlin 100 mg i.v. Hydrocortisone √ √ √ √
Sodium Succinate
Tab. Delsone 40mg Oral Prednisolone -- -- -- √
Inj. Nexpro 40mg i.v. Esomeprazole √ √ -- --
Tab. Nexpro 20 mg Oral Esomeprazole -- -- √ √
Inj. MVI Amp. i.v. B-Complex √ √ -- --
Inj. Vitamin K 0.5ml in 1 i.v. Phytonadione √ -- -- --
syringe
Tab. Becosules Oral B-complex -- -- -- √
Inj. Emsetron 2ml i.v. Ondansetron √ √ -- --
Inj. 100mg/2ml i.v. Tramadol HCL √ √ -- --
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60. [Chapter 5]
Tramagesic
Tab. Folvite 5mg Oral Folic Acid √ √ √ √
Tab. Calpol 500 mg Oral Paracetamol √ √ √ --
ADVICE:
- Dietary modification may reduce the symptoms of the disease.
- Lactose intolerance is noted in many ulcerative colitis patients. Those with
suspicious symptoms should get a lactose breath hydrogen test.
- Patients with abdominal cramping or diarrhea may find relief or a
reduction in symptoms by avoiding fresh fruits and vegetables, caffeine,
carbonated drinks and sorbitol-containing foods.
- The use of elemental and semi-elemental formula has been successful in
pediatric patients
DRUG RELATED ISSUE:
Table 16 Drug interactions
DRUGS INTERACTIONS MANAGEMENT
Tramadol ↔ 1. The risk of seizures may be Caution is advised if
Levofloxacin increased during tramadol is administered
coadministration of tramadol with any substance that can
(Major)
with any substance that can reduce the seizure
reduce the seizure threshold. threshold, particularly in
2. Many of these agents also the elderly and in patients
exhibit CNS- and/or with epilepsy, a history of
respiratory-depressant effects, seizures, or other risk
which may be enhanced during factors for seizures.
their concomitant use with
tramadol.
Prednisolone Concomitant administration of Patients should be advised
↔ corticosteroids may potentiate to stop taking the
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