CASE PRESENTATION

S.Navya Pharm-D 4thyear

HT.NO:13117D1007Vaagdevi College of

Pharmacy,Hanamkonda.

CASE PROFILE• A male patient of age 28 years was admitted in

general medicine male ward of MGMH with ip.no:21301 on 13/6/16.

• The patient case profile was explained in soap format.

SUBJECTIVE FINDINGS:• Severe pain in both upper and

lower limbs since four days• Pain in both knee joints since four days.

• Fever of low grade associated with chills and rigours since four days.

• Bone pain(osteolgia) since five days.PAST MEDICAL AND MEDICATION

HISTORY:• Patient is a known case of sickle cell

anemia since two years.• NO PAST SOCIAL AND

FAMILY HISTORY WAS FOUND.

OBJECTIVE FINDINGS COMPLETE BLOOD PICTURE:17/6 Haemoglobin:7.3gm%Total RBC:3.2million cells/mmTotal WBC :12,3000cells/cmmNeutrophils:76% Eosinophils:9% Lymphocytes:12% monocytes:3%Pcv:23%, mcv:71%,mch:21pg,mchc:30gm/dl impression:microcytic hypochromic eosinophilia.

• 16/6 LIVER FUNCTION TESTS: Total bilirubin:9.65mg/dl Direct bilirubin:5.46mg/dl SGOT:69.4U/L Alkaline phosphate:160U/L SGPT:47.1U/L15/6 SERUM CALCIUM:5.8mg/dl16/6 Ultrasound of abdomen: impression:mild hepatosplenomegaly13/6 BLOOD UREA:45mg%

• PHYSICAL EXAMINATION:• On examination patient was conscious and coherent. Generalized weakness.Pallor+Icterus+

PROVISIONAL DIAGNOSIS: • Based on chief complaints, past medical history the patient was diagnosed with

ABOUT DISEASE;Sickle cell anemia is a hereditary disease in which a mutated form of haemoglobin Distorts the red blood cells into a cresent shape at low oxygen levels.

‘SICKLE CELL ANEMIA’

• Etiology:genetic inheritence called autosomal recessive inheritence;a variant of sickle cell anemia have HbS.HbS has valine substituent for glutamic acid as the sixth amino acid in the beta polypeptide compared with normal hemoglobin.

• Symptoms:Chest pain,pale skin,swelling in hands and feet,severe pain of joints and bones,severe infections etc.

Assessment of standard treatment

PLANs.no

Drugs Dose ROA

Freq Category

1. IVF 3 pint NS,1 pint RL Electrolyte replinesher

2. Inj.Ceftriaxone 1amp/IM BD 3rd gen cephalosporin

3. Inj.Diclofenac 1 amp/IM BD analgesic

4. Tab.Hydroxyurea 200mg/PO BD Antimetabolite

5. Tab.Pantoprazole 40mg/PO OD Proton pump inhibitor

6. Tab.Paracetamol 500mg/PO TID Antipyretic

7. Tab.Calcium 500mg/PO OD Calcium supplement

8. Tab.Ursodeoxycholic acid 300mg/PO OD Liver protective

9. Inj.Ketorolac 1amp/IM BD NSAID

Lifestyle modifications• Take folic acid supplements daily, and

choose a healthy diet. • Drink plenty of water. • Avoid temperature extremes. Exposure to

extreme heat or cold can increase your risk of a sickle cell crisis.

• Exercise regularly, but don't overdo it.