Presented By,

Mr Amol Lavate
M.Pharm 1st year pharmacy practice,
KLE’S college of pharmacy, Belgaum.
CONTENTS
Patient Profile
Subjective Evidence
Objective Evidence
Laboratory Data
Diagnostic Tests
Provisional Diagnosis
Assessment of 1) Therapeutic Goals 2)Therapy indicated
 3) Current Therapy
Therapeutic Monitoring
Toxicity Monitoring
Planning
Patient Counseling
Patient Profile
I.P.# - 332301
Age - 50years
Gender - Female
Date of Admission - 30/09/2009
Date of Discharge - 05/10/2009
Subjective Evidence
Objective Evidence
Subjective Evidence

C/O Fever, nausea and Vomiting

Fever with chills since 3 days, Vomiting since 1day

Objective Evidence

(Test done one day before admission)

Showed weakly +ve for Dengue
Platelet count -- 4000/cu.mm (Decreased)
White Blood Cell -- 3000/cu.mm (Decreased)
Laboratory Data
Date 30/09/09 02/10/09 03/10/09 04/10/09

Haemoglobin 7gm % 7.1gm %

(12 – 14gm %)

Packed cell 20.3% 23.2% 31%

volume (PCV)

(35-45%)
Diagnostic Tests
Provisional Diagnosis
Diagnostic Tests
Malaria parasite (Kit) - +ve for P.Vivax
+ve for P.falciparum
(Gametocyte ring forms & Schizonts seen)
Provisional Diagnosis
Malaria with leucopenia and thrombocytopenia
Assessment of
1) Therapeutic Goals
-To alleviate symptoms
-To prevent relapse and spread
2)Therapy indicated
-Diagnostic tests done
-Rational antimalarial therapy given
Current Therapy
Name, Strength, Route, Date started Date stopped Remarks
Dose
Inj. Ondansetran 4mg 30.09.09 02.10.09 Antiemetic
1-0-1
Inj. Ranitidine 50mg 30.09.09 01.10.09 Antihistamine
1-0-1
Inj. Artesunate 120mg 30.09.09 05.10.09 Antimalarial
1-0-1
Tab. Primaquine 15mg 01.10.09 continued Antimalarial
1-0-0
Tab. Doxycycline 05.10.09 Antimalarial
01.10.09
150mg 1-0-1
Tab. Ranitidine 150mg 01.10.09 05.10.09 Antihistamine
1-0-1
Therapeutic Monitoring
.Symptomatically improved
Toxicity Monitoring

Primaquine  nausea, vomiting, haemolytic

anaemia(G6PD Deficient), Thrombocytopaenia,
leucopaenia
Doxycycline  nausea, GIT upset, haemolytic anaemia,
Thrombocytopaenia.
Planning
Discharge Medication

 Tab Primaquine 15mg 1-0-0 10 days

 Tab Vitamin c (chew) 500mg 1-0-0 10 days
 Tab Paracetamol SOS
 Follow up after 15 days
Patient Counseling
-Disease
-Medication
-Life style
Thank you