Pharmacy Practice-VB

(Clinical Pharmacy-I) Lab

LAB MANUAL
8TH SEMESTER
PH4851

Faculty of Pharmacy

Capital University of Science and Technology, Islamabad

 Pharmacy Practice-VB

(Clinical Pharmacy-I) Lab

LAB MANUAL

8TH SEMESTER

PH4851
Supervision and Coordination

Sohail Riaz

Lecturer

Faculty of Pharmacy, C.U.S.T.

Prepared by

1. Rimsha Muzaffar-BPH203002
2. Areeba Noor-BPH203003
3. Fallah Anjum-BPH203013
4. Nooran-ul Ain-BPH203016
5. Noor ul Eman Khan-BPH203030
6. HafsaShabbir- BPH203032
7. Malaika Hamid- BPH203037

(Students, 8th Semester)

Faculty of Pharmacy, C.U.S.T.

Sign: ______________________

Name: ______________________

Reg No.: ______________________

 INDEX

Serial Case name Page No. Signature

No.

1 Recurrent Pericardial Effusion due 2

to Pulmonary TB

2 Cardiac Emergency 10

3 I Can’t Stop Coughing 14

4 I Feel So Dizzy 16

5 My Chest Hurts… 23

6 I Should Be In ICU! 27

7 Why Do I Have Stomach Ache? 37

8 Why Is There Blood In My Stool? 42

CARDIOLOGY WARD

1
Lab 01:

Recurrent Pericardial Effusion due to Pulmonary TB

Lab Values INT, Dose & Disease Management, Patient Profile, Rationale of Therapy

Case #: 01 Diagnosis: Recurrent Pulmonary Effusions

Patient Age: 69 Years Gender: Female

HOPI:

A 69 years old female patient presented to the hospital on 9th Marchwith SOB since last 3 days.

Past Medical History

 Hypertension since 30 years (compliant to Eziday 25 mg OD)

 Pulmonary TB since 2 months (compliant to ATT)
 Recurrent Pericardial Effusion (last admission in hospital in January)
 Pulmonary embolism and LV thrombus (compliant to Xcept)

O/E:

 Pulse rate (90 beats/min)

 BP (120/80 mm of Hg)
 PO2 (92%)
 BSR (102 microg/dl)
 2D Echo showed Massive Pericardial Effusion causing Cardiac Tamponade (EF 50%)
 CVS (S1+S2+O)
 B/L lung air entry (reduced)

G/C:

Stable, oriented, conscious

Plan:

 Pericardioceutesis
 Rx Optimization
 Pulmonary review needed for Tubercular pleural effusion (Pleural Biopsy + Rx Optimization)
 CECT CAP
 Pericardial Fluid RE
 Culture, ADA, Cytology, Genexpert (for MTB)

2
 PERICARDIOCEUTESIS

DAY 1: 250ML Pericardial fluid aspirated, followed by catheter flushing by heparinised saline. Fluid
samples send for ADA, Cytology, Genexpert and PCR for TB. Post-care admissionto ward.

Post care check-up:

 PO2 (96%)
 Vitals (normal)
 Air entry (still less)
 Echo (stable)

DAY 2: After 24 hours, 110ml aspirated, followed by catheter flushing by heparinised saline. Pt felt
nausea on aspiration, for which Onset I/V Statwas given.

Post care check-up:

 Pulse rate(92 beats/min)

 PO2(91%)
 Air entry (less)
 Echo (stable)

DAY 3: 110 ml aspirated, followed by catheter flushing by heparinised saline.

Post care check-up:

 Pulse rate (80 beats/min)

 PO2 (96%)
 RR (23)
 Echo (mild pericardial effusion)
 LFT’s slightly raised

DAY 4: 110 ml aspirated, followed by catheter flushing by heparinised saline.

Post care check-up:

 Vitals (normal)
 PO2 (97%)
 Air entry enhanced

DAY 5: 60ml aspirated, followed by catheter flushing by heparinised saline.

3
Post care check-up:

 Vitals (normal)
 PO2 (97%)
 Lung air entry enhanced
 BP (120/80 mmHg)
 CT (normal)
 Temperature (normal)
 G/C (stable)

LAB VALUE INTERPRETATION

Tests Reference Value with Test Interpretation

units Result

Blood Tests

Hemoglobin (Hb) 14-16 g/dl 14.3 Normal

Hematocrit 36-42 % 42.3 Normal

MCV 80-95 fl 81.3 Normal

MCH 27-32 pg 27.5 Normal

MCHC 31.5-34.5 g/dl 33.8 Normal

Leukocytes – 4-10 x 109/L 6.42 Normal

4
Total

Platelets 150-400×109/L 223 Normal

LFTs

Bilirubin (serum) 3-17umol/l 26 High

(Acute hepatitis due to ATT)

ALT (SGPT) <41u/l 59 High

(Acute hepatitis due to ATT)

Albumin (serum) 35-50 g/L 38 Normal

Cardiac Biomarkers

Creatinine kinase- ˂25 u/L 164 High

MB
(Tissue damage resulting from Cardiac

Tamponade)

Troponin T ˂0.001 ug/L 0.10 High

(Tissue damage resulting from Cardiac

5
 Tamponade)

Renal Function Tests

Urea 3.3-8.3 mmol/L 9.3 High

Creatinine 60-120 umol/L 114 Normal

(serum)

Pleural Biopsy

The pleural biopsy showed fragments of fibrous tissue. The patient was recommended to take the
ATT modified therapy (days a week)

ATT Modified Therapy

Drug Dose (mg) Dosing Frequency

Tab Ethambutol 400 OD

Tab Leflox 500 OD

IV Amikacin 500 OD

CECT CAP

The Contrast-Enhanced Computed Tomography indicated LymphangitisCarcinomatosis. The patient

was told to consult an oncologist.

Pericardial Fluid RE

6
Colour Reddish

Proteins ++

(Fluid Retention)

Neutrophils Raised

(Inflammatory condition)

Gram +/- Bacteria Negative

AFB Negative

MTB Culture tests

The Mycobacterium tuberculosis culture test showed no growth of the bacteria.

Other Tests

Other test conducted such as ADA test, Cytology, GeneXpert and PCR were all negative.

RATIONALE OF THERAPY

S.No Drug Prescribes Frequency Possible side Justification of

Dose(mg) effects selected drug

1 Tab Ethambutol 400 OD Abdominal pain, ATT

confusion,
headache, loss of
appetite, nausea
and vomiting

2 Tab Leflox 500 OD Nausea, ATT

headaches, sun
(Levofloxacin) sensitivity,
diarrhoea and

7
 insomnia

3 INJAmikacin 500 OD Agitation, black, ATT

tarry stools,
bloody or cloudy
urine, bluish lips
or skin, blurred
vision, burning,
crawling, itching,
numbness

4 SypHepamerz - BD Nausea, stomach For acute hepatitis

pain, bloating,
(L-Omithine-L- diarrhea and
Aspartate + constipation
Nicotinamide +
Ribaflavin sodium
Phosphate)

5 Tab Domflash 10 BD Headache, dry For treating N&V

mouth, diarrhea, caused by other
(Domperidone) or abdominal drugs
cramping,
drowsiness

6 Tab Xcept 20 OD Back pain, To prevent

bleeding gums, emboli/thrombus
(Rivaroxaban) bloody stools, formation
numbness,
coughing up
blood,dizziness.

7 INJ Rocephin 2000 BD Swelling, redness, For TB

pain, a hard lump,
(ceftriaxone) or soreness, loss
of appetite,
nausea, vomiting,
upset stomach,
diarrhea,
headache

8
8 Tab Prednisolone 5 TD Weight gain, Steroidal drug to
Blurred vision, reduce pain,
Dizziness, inflammation and
Fractures, Mood swelling
Changes,
Abdominal pain,
Acne

FINAL COMMENTS

Pericardioceutesis resolved cardiac tamponade and other associated problems. Patientwas discharged
with Rx optimisation. Modified ATT was told to continue even after TB was resolved so as to
completely eradicate MTB and to prevent any relapse. Syrup Hepamerzwas given for hepatitis.

The patient was told to refer oncologist and pulmonologist.

9
Lab 02:

Cardiac Emergency
Lab Values INT, Dose & Disease Management, Patient Profile

Case #: 02 Diagnosis: Acute myocardial infarction-Cardiogenic Shock

Age: 60 Years Gender: Female

HOPI:

Patient admitted to hospital with centralized chest pain, shortness of breath, cough and apprehension
from 2 weeks.

O/E:

 ETT (7.5cm) (9/3/24)

 SpO2= 97%, Chest= B/L crepts, RR= 17/min
 BP: 158/83 mmHg, HR= 96/min, S1+S2+O, MAP= 107 mmHg
 Afebrile - JVP – Pedal Edema
 IP/OP: 1300ml/1400ml
 SNT, BS+BSR= 91 mg/dl
 CVP 9/3/24, Foley 8/3/24

G/C:

Better, Weaned off vent (process of reducing patient’s dependency on ventilator as they recover and
regain ability to breath)

Plan:

 Keep CVP 8-10 cm of H2O

 Continue vasopressors to maintain MAP> 65
 Strict I/O charting, urine output should be > 0.5ml/kg/hr.
 Attendants counselled regarding disease prognosis
 CXR
 Prescribed medicines
 Echo

LAB VALUE INTERPRETATION

10
Test Normal Values Value with Interpretation Correction
units

Blood Test

Due to kidney issue there is

issue with the production of
M14-16g/dl Erythropoietin which is
Hemoglobin(Hb) 15.63g/dl Slightly high
F12-14g/dl required for the production
of RBCs.

Hematocrit F36-42% 14.2% Low Due to less production of

erythropoietin
M42-46%

LFTs

ALT(SGPT) <45u/l 338 u/l High May be due to Liver is not

working properly.

Coagulation Tests

APTT 30-34second 27.1 sec Low Disseminated intravascular

coagulation

INR Upto1.5 1.05 Normal -

Prothrombintime(PT). 12-14second 11.3 sec Normal -

Renal Function Tests

Creatinine 3.3-8.3mmol/l 18.7mmol/l High Kidney affected due to

impaired perfusions

RATIONALE OF THERAPY

11
 Medicationas
S.No ordered: Prescribe Possible side Justification of selected
d dose Frequency effects drug
Name/Class/
Dose

1. Meronem inj 1g TDS Headache; nausea Meropenem is an

, Vomiting, diarrh antibiotic that is
Broad ea, constipation; r used to treat severe
spectrum ash; or anemia.
antibiotic Infections
of the skin or stomach

HEPARIN 5000 IU TDS Trouble Those treated with

inj breathing, fast heparins had
breathing or a decreased risk of
Anti- wheezing. Balanc myocardial infarction
coagulant e issues or and a higher incidence
confusion. of minor bleeding.
Problems seeing
2. or hearing.
Headaches.

DISPRIN tab 300mg ½ OD Vomiting, It has been shown to

dehydration, limit infarct size,
NSAID’s tinnitus, vertigo, improve ventricular
deafness, function, and decrease
sweating, warm mortality in suspected
3. extremities with evolving myocardial
bounding pulses, infarction (MI).
increased
respiratory rate
and
hyperventilation.

12
 LIPIGET tab 40mg HS Muscle pain. Atorvastatin is an
Muscle pain is HMG-CoA reductase
Anti- one of the most inhibitor used to lower
lipidemic commonly side lipid levels and reduce
4.
effects. It the risk of
happens most cardiovascular
often in the disease including
calves and thighs. myocardial infarction
Joint pain is and stroke.
another possible
atorvastatin
side effect.

ULCENIL 40mg OD Anxiety,blistering Ulcenil is used to treat

tab , peeling, or stomach ulcers, erosive
loosening of the esophagitis, and
Histamine skin.blood in the gastroesophageal
H2 Receptor urine or reflux disease.
antagonist stools.bloody,
black, or tarry
5. stools. Difficulty
in breathing.

Ca 10ml BD Constipation. The role of calcium

GLUCONAT This is not a gluconate in treating
E inj complete list of hyperkalemia is
side effects and to stabilize cardiac cell
Calcium salt others may occur. membranes. Calcium
6. should promptly be
administered to any
patient presenting with
hyperkalemia with
EKG changes,
indicating a
hyperkalemic
emergency.

13
 RISEK inj 40ug Stomach pain, gas; Risek works
nausea, vomiting, by decreasing the amoun
substituted diarrhea; or t of acid made by the sto
benzimidazole headache. mach, to give relief of
s symptoms and allow
healing to take place.
7.

Final Comments

In this case a patient was admitted via emergency to CCU and CRP intubation done in CCU. Shifted
to ICU afterrevived, weaned off went. A patient K/C of HTN for 16 years, Old CVA for 16 years
partially recovered, NSTMI e- LVF EF 25%. She was ex hukka smoker, wood burning + Naswar
addict. Now COPD, SOB, centralized chest pain, apprehsension, cough since 2 weeks. Initially on
admission she was advised for CXR and kept on ventilator support for 42 hours after 24 hours of
admission she was weaned off as her general condition was stable.

14
PULMONOLOGY WARD

15
Lab 03:

I Cannot Stop Coughing

Lab Values INT, Dose & Disease Management, Patient Profile, Rationale of Therapy

Case #: 03 Diagnosis: Bronchiectasis

Age: 64 years Gender:Female

Co morbidities

 Hemorrhoids (from 12 to 14 years)

 TB in 2017 (treated for 09 months)
 8 to 10 episodes of hemoptysis in 2016; diagnosed as TB

History

The patient has been treated for tuberculosis (TB) in 2017. For the past 1 year, the patient has
been presenting with shortness of breath (SoB), productive cough, and haemoptysis on and off.

Past Surgical History: NX

 AllergyHistory: NX
 Transfusion History: 1 red cell concentrate (RCC)
 Family History: HTN+, DM+, TB-
 Personal History: anorexia (reduced appetite), insomnia (lack of sleep), quitting of
dipping tobacco 6 months ago,

O/E

Thin lean lady sitting comfortably. She was pallor and had koilonychia (spoon nails). The JVP
(jugular venous pressure) was elevated.

 Chest: B/C Crepts

 Abdomen: BS+
 Vitals

Blood Pressure 110 / 70 mmHg

16
Pulse 105 bpm

SpO2 97%

Respiratory rate 20 br/min

Active Complaints on Presentation

1. Productive cough of whitish colour(more at night) -from 5 to 6 days

2. SoB (at rest)-from 5 to 6 days; mMRC scale grade 2
3. Haemoptysis (5 days prior to admission)
4. Orthopnoea
5. Right sided chest pain elevated on coughing
6. Epigastric pain

Examination

1. HRCT (high resolution computed tomography) of chest

HRCT chest was performed with 10 mm thick contiguous axial slices from lungs apices to below
the level of diaphragm. Coronal and sagittal reformatting was performed later.

Findings from HRCT

 Moderate bilateral pleural effusion

 Increased cardiac size with interlobular septal thickening
 Calcification in splenic artery
 Calcification in descending aorta
 Patchy areas of ground glass haze in lower lobes of both lungs
 Calcification in some lymph nodes
 Enlarged mediastinal right hilar lymph nodes

Impression

 Cardiomegaly with patchy ground glass haze, interlobular septal thickening and bilateral
pleural effusion; suggestive of pulmonary Edema
 Right hilar lymphadenopathy

2. ECG

ST depression in V6.

17
3. CXR

Patch of consolidation at lower zone.

LAB VALUE INTERPRETATION

Test Name Reference Range Result Interpretation

Haemoglobin (Hb) M 14-16 g/dL 10 Normal

F 12-14 g/dl

WBC 4.5 to 11.0 × 109/L 7.67 Normal

Platelet count 150 to 400 × 109/l 344 Normal

Urea 3.3-8.3 mmol/l 6.6 Normal

Creatinine 60-120 umol/L 74 Normal

Troponin I 0 to 0.04 0.41 High

Pro BNP < 125 pg/Ml > 5000 High

Ejection fraction 50 to 70% 40% Low

The patient was diagnosed with bronchiectasis.

RATIONALE OF THERAPY

18
S. Drug Dose Frequency Side Effects Justification of
No Selected Drug

InjFortum Ceftazidime injection

1. (Ceftazidime) Diarrhea, is used to treat
Injection site bacterial infections in
reactions, many different parts
Stomach pain, of the body.
500 ½ BD Dizziness,
mg Headache,
Seizure,
Bloating, Fast
heartbeat, Loss
of appetite

InjSolucortef It is used to reduce

2. (Hydrocortiso Acne, inflammation (pain,
ne Sodium Headache, swelling, redness and
Succinate) Dizziness, heat).
Anorexia,
100 ½ BD Nausea,
mg Weight gain,
Anxiety,
Blurred vision,
High blood
pressure

3. Atem (Ipratropium Dizziness, It is used for

Bromide) + Clenil nausea, controlling and
(Beclomethasone - Every 8 stomach upset, preventing symptoms
+ Salbutamol) ours dry mouth, or of lung
constipation disorders/obstruction
such as wheezing,
shortness of breath,
and feeling of
tightness.

19
 stomach Omeprazole is used
4. cramps, alone or with other
bloated medications to treat the
feeling, watery symptoms of
and severe gastroesophageal
diarrhea which reflux disease
InjRisek 40 mg ½ OD may also be (GERD).
(Omeprazole) bloody
sometimes,
fever, nausea
or vomiting, or
unusual
tiredness or
weakness.

5. SypHydryllin It is indicated in the

(Aminophylline) symptomatic treatment
2 Tsp TDS Irregular of productive and
heartbeat, high unproductive cough.
blood pressure
and
restlessness.

6. Tab Ascard 75 mg - Upset It is used to prevent the

(Aspirin) stomach, formation of blood
clots.
Heartburn,
Headache,
Diarrhea,
Drowsiness.
Nausea,
Xerostomia,
Fainting,
Fever

20
7. Tab Lowplat 75 mg - Easy Lowplat is indicated
(Clopidogrel bleeding/bruisi for the prevention of
bisulphate) ng, stomach ischemic events,
upset/pain, myocardial infarction,
diarrhea, and stroke and
constipation cardiovascular death in
patients with Acute
Coronary Syndrome
(ACS)

8. Tab Lipiget 20 mg HS constipation, Atorvastatin is used

(Atorvastatin) flatulence, together with a proper
dyspepsia, diet to lower
abdominal cholesterol and
pain, triglyceride (fats)
headache, levels in the blood.
nausea This medicine may
myalgia, help prevent medical
asthenia, problems (eg, chest
diarrhea and pain, heart attack, or
insomnia. stroke) that are caused
by fats clogging the
blood vessels.

9. Tab Nebil 2.5 mg OD Swelling in the For treatment of

(Nebivolol) legs, essential hypertension,
Dizziness, stable, mild and
Fatigue, moderate chronic heart
Headache, failure in addition to
Shortness of standard therapies in
breath, elderly patients
Bradycardia,
Vomiting,
Cold hands or
feet,

Diarrhea

21
 10. Inj Lasix 20 mg OD Tinnitus Lasix is used to treat
(Furosemide) swelling of the ankles,
Headache feet, legs or even the
brain or lungs. This
Constipation swelling is called
oedema and can occur
Blurred vision
in some heart, lung,
Muscle liver or kidney
cramps conditions.

Painful or
difficult
urination

Thirst

Diarrhea

Dizziness

11. Tab Myteka 10 mg HS headache, This medicine is used

(Montelukast fever, cough, to control and prevent
sodium) and stomach symptoms caused by
pain asthma.

Final plan:

The patient is under supervision, yet, following plan is to be followed:

Continuation of medications (Rx)

22
Lab 04:

I Feel So Dizzy
Lab Values INT, Dose & Disease Management, Patient Profile

Case#: 04 Diagnosis: unstable Angina, COPD

Age: 77 years Gender: Female

HOPI

The patient has a history of Hypertension for 25 years. She is also suffering from COPD (Gold
stage II) and has left bundle branch block for the past one year. The patient also complaints
several blackouts and dizziness while changing position which may points out the presence of
syncope. The patient also has osteoarthritis.

P/C

The patient was admitted to hospital with complaints of unstable angina, palpitations and
apprehensions. She is suffering from dyspnea which may be the main cause of syncope. She was
having drycough with associated vomiting and also complaints chest pain for 1 day.

Vitals

Blood pressure 139/62mmHg

Pulse 63 bpm

Heart rate 82 bpm

Blood Oxygen Saturation 98%

O/E

 The patient has high systolic pressure while low diastolic pressure(140/62 mmHg)
 Chest: Clear with polyphonic wheeze(different tones simultaneously)
 CVS: normally audible heart sounds.
 CNS: no focal neurological disorder.
 Pulse: 73 bpm
 Abdomen:

23
  Soft and non tender.

ECG

 ST elevated precordial leads

 Old left bundle branch block(lbbb)

Echo

 Ejection Fraction 45%

 Mild aortic regurgitation and mitral valve regurgitation.
 Wall hypokinesia.

Diagnosis

Unstable Angina

 Troponin I test: 0.02 ng/ml which is normal

 CKMB: Raised(70 IU/L) highly specific for myocardial injury.

LAB VALUES INTERPRETATION

Tests Values with Normal Range Interpretation

Unit

RFTs

Urea 48 mg/dL 7-20mg/dL High

Creatinine 68 umol/L 53-97.2 umol/L Normal

LFTs

24
INR 1 1 Normal

ALT 30 Units/L 7-40Units/L Normal

RATIONALE THERAPY

SNo Drug Prescribed Frequency Possible side Justification of

Dose effects selected drug

1 Injclexane 60mg OD Bleeding gums For prevention of

(Enoxaparin and headache blood clot
sodium) formation

2 Tab Nebil 2.5mg BD Dizziness. For treatment of

Hypertension and
(Nebivolol) Shortness of unstable angina.
breath.

Low blood
pressure.

3 Combivair 206 mcg HS Diarrhea. It is used to

trestasthama
(Budesonide and Loss of appetite.
formoterol
fumarate) Vomiting.

4 Cap tiovair 18mcg BD Pharyngitis. For treatment of

asthama and
(Tiotropium Bronchitis. COPD.
bromide)
Sinusitis.

5 Tab Eziday 500mg BD Loss of appetite Antihypertensive

drug.
(Losartan Nausea

25
 Potassium) Dizziness

6 SypLeflox 500mg BD Bloating It is used to treat

several types of
(levofloxacin) Nausea bacterial
infections.
Seizures.

7 Nuberol forte 400mg OD Dryness of Painkiller

mouth.
(Paracetamol and
orphenadrinecitrate) Diarrhea.

Plan

 Stool routine examination for ovarian cyst.

 Stool test for blood.
 Plan for coronary angina.
 Srferitin, folate and B12.
 Workup for anemia.

Final Comments

The patient was suffering from hypertension for past 25 years and also had COPD for 1 year. She
was admitted in cardiac ward due to unstable angina . Her Echo showed low Ejection Fraction i.e
45% and Ecg indicated ST elevated precordial leads. She had several blackouts and felt
dizziness while changing positions.

26
Lab 05:

My Chest Hurts…
Lab Values INT, Dose & Disease Management, Patient Profile, Rationale of Therapy

Case: 05 Diagnosis: Pleural effusion

Age: 40 Years Gender: Female

HOPE

A 40 years old female was brought to pulmonology ward with the complain of fever, dyspnea,
dry cough, pleuritic chest pain and pleural effusion.

Comorbidities

 Cholecystectomy – 8 yrs ago

 TB contact from brother 1 year back

Current Observations

 She was unwell from 3 weeks and having:

 Dry cough from 2 months – no blood/no sputum
 Dyspnea – MMRC III / Orthopnea / Difficulty in lying down sideways
 Fever – 103°F from 20 days daily with Night sweats and chills
 Vomiting – after food intake
 Pleuritic chest pain

Diagnostic Tests

Diagnostic Findings
tests

USG Chest  Moderate Pleural Effusion on Right side of chest.

 Left basal coarse crepts (Low pitched lung sound)
 Decreased vocal resonance ( fluid decreases the transmission of lower frequency
sound vibrations, leading to decreased or absent vocal resonance.)
 Dull percussion (reduced air in chest due to fluid accumulation, indicate
abnormal density of lungs)

27
ECG  Sinus Tachycardia
 R wave progression – showing coronary narrowing

Fluid Culture  Negative

LAB VALUES INTERPRETATION

Tests Reference Value with units Test Result Interpretation

Blood Test

Hemoglobin (Hb) 14-16 g/dl 10.8g/dl Low

Platelets 150-4000 × 109/L 479× 109/L Normal

Leukocytes – Total 4.5-11× 109/L 9.13× 109/L Normal

Differential: Neutrophils 30-75 % 78 High

Lymphocytes 20-30% 10.9% Low

Eosinophils 1-4% 0.1 Low

Blood Gases

PO2 95-100% 94% Low

LDH

Fluid LDH 225-450 u/l 1063 u/L High

Serum LDH 140-280 u/L 574 u/L High

28
Hemoglobin

Hb are low because of the fact that hepsidin,a mediator of inflammation and iron-regulatory
hormone production increases during inflammation and it suppresses erythropoiesis and
depleting iron depot.

Neutrophils

High neutrophil count show that there is an infection in body especially lungs.Helps the body to
fight against infection.

Lymphocytes

Low lymphocytes indicates the infection in the body.

Eosinophils

Indicates acute bacterial infection in the body.

LDH

It is a non-specific test.Lactate dehydrogenase is present in different parts of body including

liver,RBCs,kidneys,muscles etc. Thus high levels show injury/inflammation in body.

RATIONALE OF THERAPY

Drug Prescribed Frequency Possible side effects Justification of

dose Selected drugs

InjRocephin 2g OD Black, tarry stools, chest It was used to treat the

(ceftriaxone pain, chills, cough, fever, bacterial infection in
sodium) painful or difficult urination, the lungs.
shortness of breath, sore
throat, sores, ulcers, or white
spots on the lips or in the
mouth, swollen glands,
unusual bleeding or bruising,
unusual tiredness or
weakness

InjRisek 400mg OD Headache, nausea, vomiting, Used for stomach

(omeprazole) diarrhea, stomach pain, upset
constipation.

29
InjProvas 1g/100ml SOS Flushing, Nausea, Loss of Used for the pleuritic
(paracetamol) appetite, Dark urine, chest pain
Jaundice, Low fever management

SypHydralin 2tsp BD Irregular heartbeat and high Used for the dry
blood pressure, restlessness,
Belly pain, Tiredness, cough
Nausea, Vomiting

Tab Panadol 2 tab SOS Fatigue, headaches, Used for the pleuritic
abdominal pain, diarrhea, chest pain
(paracetamol) weakness, nausea, management
drowsiness, vomit, body
pain, rashes, itchiness,
stomach pain, burning
sensation

Injleflox 500mg OD nausea, vomiting, stomach Used to treat the

(levofloxacin) pain, constipation, heartburn, bacterial infection
diarrhea, vaginal itching
and/or discharge, irritation,
pain, tenderness, redness,
warmth, or swelling at the
injection spot

InjCelaxane 40mg OD Bleeding gums, coughing up Used to stop unwanted

blood, difficulty with blood clots from
(Enoxaparin breathing or swallowing, forming and prevent
sodium) dizziness, headache, further coronary artery
increased menstrual flow or narrowing
vaginal bleeding,
nosebleeds, paralysis,
prolonged bleeding from
cuts, red or black, tarry
stools, red or dark brown
urine, trouble breathing

InjMevem 1g/100ml BD Constipation, redness and Carbapenem-type

swelling at the injection site antibiotic used for the
infection in the lungs

30
Final comments

AfiaZaib, a 40-year-old female, presented with fever, dyspnea, dry cough, pleuritic chest pain,
and pleural effusion. Diagnostic tests revealed lung involvement and inflammation. Lab results
indicated low hemoglobin, high neutrophils, low lymphocytes, and elevated LDH, suggestive of
infection and tissue damage. Treatment included antibiotics (Rocephin, leflox), supportive
medications, and anticoagulation therapy (Celaxane). Pleural fluid is removed at different time
intervals and checked for any growth. Close monitoring and further investigations are necessary
for comprehensive management.

31
Lab 06:

I Should Be In ICU!
Lab Values INT, Dose & Disease Management, Patient Profile, Rationale of Therapy

Case#:06 Diagnosis: TB, Pleural effusion

Age: 42years Gender:Female

HOPI

The patient has a history of developmental delay, achieved late milestone. It is a known case of
Glycogen Storage Disease (Type III) proven by biopsy (1997). She also suffers from Avascular
necrosis of right hip. She has undergone Splenectomy (2007) .She also suffers from Ankylosing
Spondylitis. She has been bed bound for 2 months and has been in contact with TB patient. The
reports showed the patient also suffers from liver cirrhosis.

P/C

The patient was admitted to hospital with complaints of shortness of breath for 2 months. She is
diagnosed with orthopnea and PAD. She was having productive cough with hemoptysis on and
off. She also has epistaxis. She is also suffering from low grade fever.

Vitals

Blood pressure 120/80mmHg

Pulse 111 bpm

Heart rate 28 bpm

Blood Oxygen Saturation 92%

O/E

 The patient is Critical with hemoptysis, Epistaxis and vaginal bleeding. The patient is
sick looking with nasal prongs and Foleys.
 Chest: The entry of air in right lung is less and left basal crepts.
 Pedal Edema

Diagnosis

32
 X ray of chest showed massive pleural effusion.

HCRT

HCRT of chest showed features of TB

LAB VALUES INTERPRETATION

Tests
Normal Range Values with Interpretation
Unit

Blood Test

Hemoglobin(Hb) 14-16g/dL 9.2 g/dL Low due to

glycogen
storage disease

MCV 80-95 fl 95fl normal

LFTs

Bilirubin(serum) 3-17µmol/L 35µmol/L High because of liver

Cirrhosis

ALT(SGPT) 0-35Units/L 85Units/L High because of liver

Cirrhosis

ALP 53-168IU/L 474IU/L High due to liver

33
 cirrhosis

Albumin(serum) 35-50g/L 36g/L Normal

RATIONALE THERAPY

S.No Drug Prescribed Frequency Possible side Justification of

Dose effects selected drug

1 Tab G- 40mg OD Blurred vision For pedal edema

mide(furosemide)
Constipation

Dizziness

2 Inj Meronem 1g BD Rash For bacterial

infections that
(Meropanem) Diarrhoea might occur after
operation.
Headache

3 Tab Movax 2mg HS Abnormal LFT For Ankylosing

Spondylitis
(Tizanidine) Constipation

Vomiting

4 Tab Celbex 100mg BD Diarrhoea For Ankylosing

(Celecoxib) Headache Spondylitis

High blood
pressure

5 SypHydraline 2 tsp BD Loss of appetite For cough

34
 Nausea TB

Dizziness

6 Syp Lilac 2tsp BD Bloating For constipation

(lactulose) Nausea For stomach pain

Cramps

7 Avelox 400mg OD Diarrhoea For infections of

lungs,Airway,sinus
(Moxifloxacin) Cough

Chest pain

8 Tab 400mg OD Hepatotoxicity For TB

Ethambutol Optic neuropathy

Mental confusion

9 Tab Transamine 500mg BD Migraine For excessive

bleeding
Double vision

Swelling

10 Tab Nubral forte 1 tab BD Dryness of mouth For pain relief

Dizziness

tachycardia

Plan

 Avoid all hepatotoxic drugs

 Restrict mobility
 Repeat Coagulation
 Send sputum AFB smear

35
  CTPA awaited
 Plan to shift patient to ICU
 Monitor for active bleeding
 FFP arranged in hand

Final Comments

The patient was suffering from a number of diseases. She was admitted in pulmonology ward
after she had active complains of SOB fever and dyspnoea. She was in contact with a TB patient
and resulted in her having it. She had pleural tap done to remove excess fluid present in her
lungs. Her condition was very critical and will be transferred to the ICU when there will be a bed
available.

36
GASTROENTEROLOGY
WARD

37
Lab 07:

Why Do I Have Stomach Ache?

Lab Values INT, Dose & Disease Management, Patient Profile, Rationale of Therapy

Case#: 07 Diagnosis: Chronic diarrhea and gastroenteritis

Patient Age: 59Years Gender: Female

HOPI

Patient admitted to hospital with chronic diarrhea, abdominal pain, generalized weakness, weight
loss, and arthralgia persisting for the last 1.5 years.

O/E

 Pulse: 73 bpm
 BSR: 8 mg/dl
 BP: 110/70
 CVS: Normal intensity of both S1 and S2
 Chest: B/L clear
 Abdomen: Soft, Non-tender and positive bowl sounds

G/C

Patient was vitally and hemodynamically stable

Plan

 Colonoscopy
 ESR
 Mantoux test
 CECT abdomen and pelvis
 CT

LAB VALUE INTERPRETATION

TestName ReferenceRange Result Interpretation

Haematocrit F36-42% 33.7 Low
M42-46%

38
 Haemoglobin(Hb) M14-16 g/dL 10.4 Low
F12-14 g/dl
Meancorpuscularvolume(MCV) 80-95 fl 62.1 Low
MCH 27-32 pg 19.2 Low
WBC 4.5to11.0×109/L 5.13 Normal
MCHC 31.5-34.5g/dl 30.9 Slightly Low
Plateletcount 150to 400× 109/l 293 Normal
Urea 3.3-8.3 mmol/l 3.8 Normal
Creatinine 60-120umol/L 68 Normal
Sodium(serumorplasma) 136-145 mmol/l 136 Normal
Potassium(serum) 3.4-5 mmol/l 5.0 Normal
Chloride(serum) 98-106 mmol/l 104 Normal

ALT (SGPT) < 45 Units/L 28Units/L Normal

PT 12-14 secs 10.8 Slightly low

INR Up to 1.5 1 Normal

APTT 30-34 secs 27.1 Slightly low

Bilirubin 3-17umol.l 11 Normal

S.Albumin 35-50 g/l 38 Normal
Colour PaleYellow PaleYellow Normal
Appearance Clear Transparent Normal
SpGravity 1.020 1.005 Normal
PUScell Nil Nil Normal
Stool R/E Nil 3-4 pus cells Present

RATIONALE OF THERAPY

S.No Drug Prescribed Frequency Possible Side JustificationofSelected Drug

Dose Effects

1. Inj Flagyl (IV) nausea, It was used target bacterial

vomiting, overgrowth and infection
(Metronidazole) 500 mg TDS diarrhea, associated with chronic
stomach gastroenteritis.
cramps, metallic

39
 taste in the
mouth,
headache,
dizziness, and
vaginal yeast
infection .
nausea, administered to maintain
2. InjRinger vomiting, electrolyte balance and
headache, and hydration status
Lactate
1L OD chills .

3. constipation and Used for anti-diarrheal

Smecta Sachet blockage in the properties, aiming to reduce
3g BD intestines . stool frequency and improve
stool consistency
diarrhea, rash, a broad-spectrum antibiotic,
4. nausea, was administered to target any
vomiting, and bacterial infection contributing
headache . to the patient’s symptoms,
especially in the context of
Inj Oxidil chronic gastroenteritis

(Ceftriaxone
1g BD
sodium)

5. Tab Folic Acid Folic Acid supplementation

was initiated to address
--- O.D ---------- potential deficiencies
associated with chronic
diarrhea and anemia.

6. diarrhea, broad-spectrum antibiotic

nausea, properties to target bacterial
Tab Cyprocin 250 mg BD vomiting, infections associated with
abdominal pain, chronic gastroenteritis and
(Ciprofloxacin) and headache . inflammatory bowel disease.

40
Final Comments

This case highlights the overlapping symptoms of chronic gastroenteritis and inflammatory
bowel disease.The treatment regimen comprising broad-spectrum antibiotics, supportive care,
and nutritional supplementation addresses both infectious and inflammatory components of the
condition.. Close monitoring and further investigations are crucial for optimizing outcomes and
enhancing the patient's quality of life.

41
Lab 8:

Why Is There Blood In My Stool?

Lab Values INT, Dose & Disease Management, Patient Profile, Rationale of Therapy

Case#:08 Diagnosis: Hemoptysis and Melena

Patient Age: 61 Years Gender: Female

HOPI

Patient admitted to hospital with history of Hepatitis C, liver disease, shortness of breath, anemia
and generalized body pain from past 3 years. She was admitted because of vomiting blood.

Systematic History

 GIT: constipation, cramps, abdominal pain

 Renal: Burning micturition, urgency
 CVS; palpitations and tachycardia

Co-morbidities

 Diabetes Mellitus
 Asthma
 TB
 IHD
 CVA

O/E

 Pulse: 60 bpm
 BSR: 8 mg/dl
 BP: 120/90
 Pallor +

G/C

Patient was alert and stable

Plan

 Endoscopy: Grade II varices, severe portal gastropathy

 CT Scan: multiple hepatic lesions, nodules

42
LAB VALUE INTERPRETATION

TestName ReferenceRange Result Interpretation

Haematocrit F36-42% 22.2 Low
M42-46%
Haemoglobin(Hb) M14-16 g/dL 7.2 Low
F12-14 g/dl
Meancorpuscularvolume(MCV) 80-95 fl 83.6 Normal
MCH 27-32 pg 27.3 Normal
WBC 4.5to11.0×109/L 12.2 Slightly high
MCHC 31.5-34.5g/dl 32.6 Normal
Plateletcount 150to 400× 109/l 94 Low
Urea 3.3-8.3 mmol/l 9 High
Creatinine 60-120umol/L 69 Normal
Sodium(serumorplasma) 136-145 mmol/l 140 Normal
Potassium(serum) 3.4-5 mmol/l 4.6 Normal
Chloride(serum) 98-106 mmol/l 102 Normal

Hepatitis C <1.0 +ve +ve

ALT (SGPT) < 45 Units/L 31Units/L Normal

PT 12-14 secs 11.4 Slightly low

INR Up to 1.5 1.06 Normal

APTT 30-34 secs 27.1 Slightly low

Alkaline Phosphate < 300 u/l 162 Normal

Bilirubin 3-17umol.l 6 Normal

S.Albumin 35-50 g/l 42 Normal
Colour PaleYellow PaleYellow Normal
Appearance Clear Transparent Normal
SpGravity 1.020 1.005 Normal
PUScell Nil 1-2 Present

RATIONALE OF THERAPY

43
S.No Drug Prescribed Frequency Possible Side JustificationofSelected
Dose Effects Drug

1. Inj Oxidil Common: diarrhea, a broad-spectrum

rash, nausea, antibiotic often used to
(Ceftriaxone 2g OD vomiting, and treat respiratory
headache . infections, including
sodium) those causing
Rare :allergic hemoptysis, and
reactions, severe gastrointestinal
diarrhea, and infections that may
inflammation of the result in melena.
colon
Common:abdominal It helps in controlling
2. InjTerlip IV cramps, diarrhea, bleeding by
headache, and constricting blood
(Terlipressin) hypertension vessels in the
1mg QID
Rare: Ischemic gastrointestinal tract,
events reducing blood flow to
the area of bleeding.

3. Common :hair loss, It is not directly

Tab Thyroxin weight changes, indicated for
3 tabs OD headache, and haemoptysis or melena
diarrhea but may be used if
(Levothyroxine) hypothyroidism is
contributing to these
symptoms.
Common: a loop diuretic used to
4. dehydration, manage fluid overload
electrolyte and reduce pulmonary
imbalances (such as congestion, which can
low potassium), be beneficial in cases of
Inj 10 mg BD dizziness, and hemoptysis where there's
muscle cramps excessive fluid
Metomide accumulation in the
Rare: kidney
damage, hearing loss, lungs.
and allergic
(Furosemide)
reactions.

44
 5. Inj Risek .

(Omeprazole) 40 mg O.D Common: headache, It can be used to manage

nausea, diarrhea, and gastrointestinal bleeding
abdominal pain. by reducing acidity,
thereby promoting clot
formation and
preventing further
erosion of the
gastrointestinal lining.

Final Comments

The patient's symptoms of hemoptysis and melena are likely due to complications of liver
disease, including portal hypertension and varices. The presence of hepatic lesions and nodules
on CT scan indicates advanced liver pathology. The low hematocrit and hemoglobin levels,
along with high WBC count and other abnormal lab values, suggest ongoing bleeding and
possible infection.Given the patient's complex medical history and the severity of her condition,
a multidisciplinary approach involving gastroenterology, hepatology, and infectious diseases
specialists may be necessary for optimal management. Close monitoring of vital signs,
hemodynamic status, and laboratory parameters is essential to assess treatment response and
guide further interventions.

45