Unaizah College of Pharmacy

Internship Case report submission

Rotation No 3
Rotation description Cardiology
Student Name Meshal Sulaiman Almutairi 
Student I.D. 351115668
Case Topic Pneumonia
Supervisor Dr.Muhannad
Date (English/Arabic) 21/10/2021 – 15/03/1443
Year (English/Arabic) 2021-1443
 PROGRESS NOTE FORM
(SOAP)
Department of Pharmacy Practice
Email: Ucp-internship@qu.edu.sa Unaizah College of Pharmacy, Qassim Unive
Kingdom of Saudi Arabia

Serial No: ______________ Student Name : Meshal sulaiman almutairi

Date: 14/10/2021 I D: 351115668

PATIENT DATA COLLECTION PROFORMA

DEMOGRAPHIC DATA:

Patient name: #### In- Patient no: 276512

Admission date: 14 October 2021 Discharge date: 21 October 2021

Post admission Ward: pediatric ward Prior discharge ward: pediatric ward
Age: 12 Years Gender: male
Weight: 43 kg Nationality: Saudi
Education: N/A
Occupation:N/A
SUBJECTIVE DATA:

CURRENT COMPLAINT (C.C):

Shortness of breath(chest infection : pneumonia) And DIARRHEA

HISTORY OF PRESENT ILLNESS( H.P.I):

14 Years male Saudi obese CP Patient brought to ER female with respiratory clearance
complaints of cough and SOB, HYDROCEPHALUS WITH AP SHUNT EPILEPSY ON 3
AEDS ADMITTED WITH Shortness Of Breath and DIARRHEA, Vitals are taken and recorded
in triage .both upper limb edema and redness.

PAST MEDICAL HISTORY (P.M.H):

1-EPILEPSY
2- Cerebral palsy patient

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Patient Data Collection Form - Example
3-asthma

PAST MEDICATION HISTORY (P.MD.H):

 ATROVENT - IPRATROPIUM 500 MCG/2 ML/ VIAL
 AzoMycin - AZITHROMYCIN 200 MG/5 ML SUSPENSION
 Paracetamol

Description Remarks

Marital status single

Smoking Not assessed

Alcohol intake Not assessed

Drug abuse Not assessed

Diet Not assessed

Appetite Not assessed

Sleep: Not assessed

Exercise Not assessed

Habits Not assessed

SOCIAL HISTORY (S.H):

HISTORY OF ALLERGIES:
 Known allergy towards
 No allergy reported:
 Unknown: ✓

OBJECTIVE DATA

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Patient Data Collection Form - Example
PHYSICAL EXAMINATION:
General: patient Look illness

VITAL SIGNS:

Vital sings Day 1 Day2 Day3 Day4 Day5 Day6 Day7 Day8

Temperature 36.6 37 37 37 37 36.8 36.9 37

BP 103/78 R - - - - - - -
– 121/72
L
PR 121 115 123 129 122 101 111 124

RR 36 32 34 30 28 26 30 28

O2 85- 98% 87- 96% 90- 96% 91- 85- 94-

98%with
saturation o2 5l face 98% 98% 98% 98%
mask

P I C C L E
( Pallor ) ( Icterus) (Cyanosis ) (Clubbing ) (Lymphadenopathy) (Edema)

REVIEW OF SYSTEMS:

-Patient is afebrile, not maintained saturation on room air, no tachypnea and not in distress
were noted.

PROVISIONAL DIAGNOSIS:

pneumonia and diarrhea

RADIOGRAPHIC DATA:

N/A

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Patient Data Collection Form - Example
LABORATORY DATA:
Normal Value/
Lab. Test Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Unit
136-145 mmol/L ￬121 ￬122 ￬121 ￬132 ￬133 ￬132 ￬134
SODIUM

POTASSIUM 3.5-5.1 mmol/L ￬2.8 ￬3.1 ￬2.2 4.8 ￬2.3 4.4 4.5
CHLORIDE 96-110 mmol/L ￬90 100 ￬93 103 110 98 ￬95
BUN 2.1-7.1 mmol/L 2.8 3 2.1 ￬0.9 ￬1.5 ￬1.9 2.4
CREATININE 58-110 umol/L ￬15 ￬13 ￬16 ￬14 ￬13 ￬25 ￬13
CRP 0-9.9mg/L ⭫59.3 - - - - - -
BILIRUBIN 3-22umol/L 3.1 - - - - - -
(TOTAL)
BILIRUBIN 0-6.8umol/L 0 - - - - - -
(CONJUGA
TED)
ALT (GPT) 0-50U/L 32 – - - - - -

AST (GOT) 0-59U/L 23 - - - - - -

GGT 8-61U/L ⭫263 - - - - - -
TOTAL 63-82g/L 63.58 - - - - - -
PROTEIN
ALBUMIN 35-50g/L ￬33 - - - - - -
ALKALINE 38-126U/L ⭫165 - - - - - -
PHOSPHAT
ASE
CALCIUM 2.1-2.5umol/L 2.1
PH 7.35-7.45 7.43 7.41 - - - - -
PCO2 41-51mmHg ￬36.9 ￬37.6 - - - - -
PO2 80-105 ⭫131 - - - - - -
sO2 95-98 ⭫99 - - - - - -
TCO2 24-29mmol/L 27 27
HCO3 20-26 25.5 - - - - - -
LACTATE- 0.9-1.7mmol/L ￬0.55 - - - - - -
POCT
WBC 4.5-13.5 10^3/uL 7.8 - - - - - -
RBC 4-5.3 10^6/uL 4.8 - - - - - -
HGB 11.5-15.5 g/dL ￬10.5 - - - - - -
HCT 35-45 39.9 - - - - - -
MCV 77-95fL 82.8 - - - - - -
MCH 25-33pg 28.6 - - - - - -
MCHC 31-37g/gl 34.6 - - - - - -

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Patient Data Collection Form - Example
 RDW 11.8-15.6 13.1 - - - - - -
PLATELET 150-45010^3/uL 365 - - - - - -
COUNT
MVP 7.4-10.9fL 10.4 - - - - - -

INTERPRETATION OF ABNORMAL LAB FINDINGS:

No Abnormal finding Interpretation
1 SODIUM Low
2 CHLORIDE Low
3 BUN Low
4 CREATININE Low
5 CRP High
6 GGT High
7 ALBUMIN Low
8 ALKALINE PHOSPHATASE High
9 PCO2 Low
10 PO2 High
11 So2 High
12 LACTATE-POCT low
13 POTASSIUM low
14 HGB low

OTHER DIAGNOSTIC TESTS:

N/A

CONFIRMATORY DIAGNOSIS:

pneumonia and diarrhea

TREATMENT DETAILS:

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Patient Data Collection Form - Example
 Generic Name Dose and
Brand Name Route Indication
& strength Frequency Day no
PERFALGA PARACETAMOL IV 375 mg EVERY SIX Fever Day 1
N
HOURS IV For 3

Day(s)
VENTOLIN SALBUTAMOL NEBULIZATI 0.5 ml EVERY asthma Day1
ON
SOLLUTION FOUR HOURS

NEBULIZATION For

3 Day(s)
Zinacef CEFUROXIME IV 750 mg EVERY diarrhea Day1

EIGHT HOURS IV

For 3 Day(s)
zofran ONDANSETRON IV 3.5 mg once daily IV nausea and Day2

For 1 Day(s) vomiting

Rocephine CEFTRIAXONE IV 1000 mg Q12H IV pneumonia Day3
- DEXAMETHASON IV 7 mg OD IV For 1 EXXECESSI Day4

E SODIUM Day(s) VE

PHOSPHATE SECRETION

WITH

AIRWAY

OBSTRUCTI

ON
AzoMycin AZITHROMYCIN Orall 6.5 ml OD ORALLY upper Day3

EMPTY STOMACK respiratory

For 2 Day(s) tract

infection
ATROVENT IPRATROPIUM NEBULIZA 250 mcg EVERY SIX Asthma Day4

TION HOURS

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Patient Data Collection Form - Example
 NEBULIZATION For

2 Day
DALACIN CLINDAMYCIN IV 300 mg THREE Pneumonia Day2

TIMES DAILY IV

For 3 Day(s)
- methylPREDNISolo IV 12 mg EVERY SIX Pneumonia Day4

n HOURS IV For 2

Day(s)
- CHLORPHENIRAM Orall 4 ml Q12H ORALLY allergic Day7

INE For 3 Day(s) rhinitis

TEGretol CARBAMAZEPINE Orally 15 ml TWICE DAILY epilepsy Day5

ORALLY For 3

Day(s)

DISCHARGE MEDICATION ORDER:

Generic name Dose and Duration of
Brand Name Route
& strength Frequency therapy
Zinacef CEFUROXIME SYP 750 mg EVERY 5days
EIGHT HOURS
- hypertonic saline NEBULIZATIO - 5 houres
N
KeppRA LEVETIRACETAM Orall 7 ml Q12H 30 days
ORALLY
Lioresal  BACLOFEN Orall 5 ml Q12H 30 days
ORALLY

ASSESSMENT

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Patient Data Collection Form - Example
  OUTCOME PATIENT STATUS
- S1S2 NORMAL M0 GOOD PERFUSION
- LAX ABDOMEN NO ORGANOMEGALY PASS URINE AND STOOL
- NO FITS NO SIGNS OF MENINGEAL IRRITATION .
- VITALLY STABLE, oxygen saturation 95% IN room air.

 DRUG RELATED PROBLEMS ( DRPS ) ( should be evidence based)

I-Actual DRPs

Intervention and reference

DRPs / Reference recommendation /
reference
Day 1 Needs additional drug therapy Potassium chloride: The Medsacpe(2021)
(Untreated condition) initial dose is 2-5 mEq/kg
-Decrease in level of potassium. PO in divided doses; not
to exceed 1-2 mEq/kg as
single dose or 20 mEq/kg

Day 2 Needs additional drug therapy Normal salin 0.9% UptoDate(2021)

(Untreated condition)
-Decrease in level of sodium.

Day 3 Needs additional drug therapy ferrous sulfate 25ml/1ml UptoDate(2021)

(Untreated condition) oral drop once daily/
-Decrease in level of HGB

II- Potential DRPs (expected or at risk)

DRPs Intervention and recommendation Reference

Safety

Drug-drug - carbamazepine will decrease the level or effect of (Medscape.,

2021).
interaction between: methylprednisolone by affecting hepatic/intestinal
1 enzyme CYP3A4 metabolism
carbamazepine +
methylprednisolone

2 Dose selection The patient has a low sodium level due to (Naplex,

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Patient Data Collection Form - Example
 “ carbamazepine” carbamazepine 2021).

TREATMENT GOALS

 To resolve clinical signs and symptoms.

 To minimize hospitalization and prevent reinfection.
 Maintain of oxygen saturation.
PLAN

 MONITORING PARAMETERS AND FREQUENCY

- potassium, sodium , and other laboratory test, temperature, adverse drug
reactions and clinical improvement

- EEG

 PATIENT EDUCATION :

a- CONCERNING MEDICATIONS
(Including: instructions, regimen (dose, frequency and duration), expected adverse
effects, potential adverse effects and Medication Contraindications)

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Patient Data Collection Form - Example
Regimen Expected Potential adverse Contraindications
adverse effects effects
Dizziness , drowsiness argatroban , dalteparin , warfarin , heparin
CEFUROXIME Nausea,
(Medscape.com., 2021).
Vomiting,
750 mg EVERY
EIGHT HOURS Diarrhea

b- CONCERNING LIFE STYLE

(Including: diet changes, exercise status, smoking status)

- DO NOT allow anyone to smoke in the house, the car, or anywhere near your
child.
- ADVICE TO FOLLOW UP O2 SATURATION
- washes hands with warm water and soap

c- WARNING SIGNS (for disease or medication).

- epileptic seizures , Fever , headache and pain

 FOLLOW UP VISITS SCHEDULE

We told her to come next week to emergency department

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Patient Data Collection Form - Example
REFRENCES: (should be updated and properly styled)

Boh, L. and Young, L., 2001. Pharmacy Practice Manual. Philadelphia: Lippincott Williams &
Wilkins.

Medscape.com. (2021). Bactrim, Bactrim DS (carbamazepine/methylprednisolone) Dosing,

Indications, Interactions, Adverse Effects, And More.

Uptodate.com. 2021. UpToDate: Evidence-based Clinical Decision Support. [online] Available

at: <https://www.uptodate.com/contents/maintenance-intravenous-fluid-therapy-in-children>
[Accessed 14 October 2021].

Shapiro, K., Bombatch, C., Garrett, S., Drew, A. and Veverka, A., 2020. RxPrep course book.
pp.382-385.

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Patient Data Collection Form - Example
Name of the Supervisor Signature of the Supervisor

___________________ ________________________

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Patient Data Collection Form - Example