Project Report
On
CLINICAL PHARMACY CLERKSHIPIn
HAYAT SHAHEED TEACHING IN KHYBER TEACHING HOSPITAL
PESHAWAR, N-W.-F.-P.
Submitted By:
ziaullah zahid ali
Doctor of Pharmacy September, 2007
Department of Pharmacy University of Peshawar
Submitted By: Zahid ali
This project is submitted to the Department of Pharmacy in Partial fulfillment of the requirements for the degree of doctor of pharmacy
(Pharm. D Condensed Course)
(Morning Shift)
DEPARTMENT OF
Department of PharmacyUniversity of Peshawar
DEDICATED TO MY PARENTSThis Effort is dedicated to My Lovely Parents
who took pains to educate me.
Project approval
This project entitled malaria in the specialty of pulmonalogy ward in Khyber teaching Hospital Peshawar, prepared by zahid ali submitted to the Department of Pharmacy for the fulfillment of the requirements for the degree of Doctor of Pharmacy is hereby approved for submission.
Hospital Chief Pharmacist: ______________________________
Approved & Supervised by: ______________________________ Prof. Dr. Raza khan Department of Pharmacy, University of Peshawar.
Chairman: _____________________________ Prof. Dr. Zafar Iqbal Department of Pharmacy, University of Peshawar.
External Examiner: ______________________________
Table of contentsS.No Contents Page No
1. Title page
2. Summary of the project
3. Aims & Objectives
4. Methodology
5. Result / Finding
6. Clinical pharmacy
7. Conclusion
8. Acknowledgment
9. References
CLINICAL PHARMACY
UNIVERSITY OF PESHAWAR
Introduction
The term “clinical pharmacy” has been developed principally in the
field of Hospital Pharmacy where it is widely used.
Definitions
A number of definitions have been put forward but there does not
appear to be a structured practice that can be called as clinical
pharmacy.
Some of these definitions are:
United Kingdom Clinical Pharmacy Association
Clinical pharmacy is the knowledge skills, and attitudes needed to
contribute to patient care or to deliver pharmaceutical care.
OR
Clinical pharmacy is a health science discipline in which pharmacist
provides patient care that optimizes medication therapy and
promotes health, wellness, and disease prevention.
The Clinical Recourse and Audit Group of Scottish Office Department
of Health:
Clinical pharmacy is a discipline concerned with the application of
pharmaceutical expertise to help maximize drug efficiency and
minimize drug toxicity and expenditure.
American College of Pharmacy
Clinical pharmacy is a health science specialty which embodies the
application, by the pharmacist, of scientific principles of
pharmacology, toxicology, pharmacokinetics and therapeutics to the
care of patient.
OR
The area of the pharmacy concerned with the science and, practice of
rational medication use
However as an essence of all those definitions, clinical pharmacy
involves pharmacists playing a role in a way that medicines are used
to treat patients rather than to merely supplying medicines to
patients according to the prescriptions of other health care
professionals (such as doctors).
The Emergence of Clinical Pharmacy in Advance Countries
The concept of clinical Pharmacy arose as a result of a number of
different factors including:
Development of sub disciplines n hospital pharmacy since the
1920’s.
The growth of clinical pharmacology since the 1940’s.
Innovative. Teaching programs.
The decline of pharmacology instructions in medical schools.
To some extent, pharmacy ‘took over an aspect partially
abandoned by physicians. .
Over burdened by patients dad and explosion of new drugs,
physicians turned to pharmacists more and
more for drug information, especially with in institutional settings.
Clinical Role of Pharmacist in Advance Countries
Clinical pharmacy works in collaboration with the doctors, nurses and
other health care professionals to help ensure that medicines are
used safely, effectively and in cost-effective manner.
Some of his roles are:
I Dispensing of Medications
i) Receipt and interpretation of prescription.
ii) Performance / supervision of the dispensing.
2. Prescription Monitoring for:
i) Medication errors. *
ii) Drug interactions.
iii) Side effects and d drug reactions.
iv) Allergic manifestations and hypersensitivity
v) Contraindications.
3. Prescribing Advice to Medical Staff in
i) Choice of medicine and use.
ii) .Method/route of ministration.
iii) Possible side effects.
iv) Interaction with other medication and with food.
v) Pharmacokinetic monitoring.
vi) Drug therapy monitoring.
vii) Parenteral Nutrition.
4. Drug History Taking
i) Obtaining information on all medication, a patient is t
ii) Assessment of patient compliance with prescribed
treatment.
5. Patient Counseling on Medicines
i) Helping patient to understand the method of taking
their medicines.
ii) Answering any other questions.
iii) Supply of aid to patients, to take their medicines
correctly.
6. Answering Medicines Information Queries
i) Being expert on & dug, pharmacist can answer more
complicated queries.
ii) Provide references for the prescriber.
iii) May run a telephonic help line.
7. Treatment Guidance
Collaborate with other health professionals to produce guid on
more appropriate use of medicines.
8. Medicines Management
Work with budget holders and senior clinicians to ensure that
resources for medicines are efficiently used.
9. Clinical Audit
i) Contribute to the audit program of medicines.
ii) Also collaborate in multidisciplinary audits.
10. Education and Training of Staff
Contribute to the education and training of students and staff
within pharmacy and
from other health care disciplines.
CONCLUSION:
The clinical pharmacist does not make decisions concerned with
diagnosis. Although, the doctor will determine the drug therapy, the
pharmacist can help particularize the medication to be used. The
senior medical practitioners are expected to know more about the
range of drugs used within their own specialty the pharmacist can
contribute to the choice of drug regimen, particularly in a position
when more than one condition is being treated. The ph can help
decide about the dosage form and the best route of administration of
a medicine which the clinician has prescribed. The pharmacist is also
expected to take the specific responsibility for dosage calculation.
In none of these aspects, the. pharmacist is practicing the clinical role
of the doctor. On contrary, the presence pf pharmacist permits the
doctor to use the pharmacist’s knowledge & experience to be better
informed in prescribing decisions. Thus, the contribution of the
pharmacist is additive to, and not a substitute for that of a doctor.
It has been shown from the study that clinical pharmacist can
incorporate his valuable comments in avoiding the Irrational drug
prescribing, irrational drug usage, irrational dispensing, the practices
of poIypharmacy, interactions of drugs with other drug moity,
appropriate drug the in cases of antibiotics to enhance patient
compliance and to correct the pharmacy problems in-the prescribed
drugs. It is therefore suggested that specialized pharmacist in clinical
pharmacy practice should be provided to each unit to prevent such
types of problems. There pharmacist should be handed over the
duties of management of drug therapy provision of drug —drug and
drug food interactions, improve patient compliance through patient
counseling and patient education although the senior practioner are
expected to know more about the range of drug used with their own
specialty, the pharmacist can contribute to the choice of drug
regimen, practical in a position in which more than one conditions are
being treated. The pharmacist can help about the dosage form and
the best route of administration, which the clinician has prescribed.
the pharmacist is also expected to take the specific responsibility for
dosage calculation. In none of these aspects, the pharmacist is
practicing the clinical role of the doctor. On contrary the presence of
pharmacist permits the doctor to use the pharmacist knowledge and
presence to be better informed in prescribing decisions.
SUMMERY OF THE PROJECT
Clinical pharmacy includes II performed by pharmacist practicing in
hospital, community pharmacies, nursing homes, clinics and any
other settings. Where medicines are prescribed and used.” The
purpose of this clinical clerkship is to ensure the safe, effective and
economic use of medicines. These studies were conducted. Under the
supervisor of chief pharmacist. There is direct interaction of trainee
clinical pharmacist with the doctors and patients.
This project was assigned to find out various level in Govt. Hospital
where the clinical pharmacist can play a vital role for the
improvement of health care setting. For this purpose, data was
collected and evaluated by stud various books of pharmacology and
clinical medicine.
The Clinical Pharmacy clerkship is designed to integrate the
knowledge from previous didactic courses in pharmacology, clinical
chemistry & pathophysiology for application encountered in Clinical
practice.
At the completion of this clerkship the student would be able to;
Appropriately and effectively communicate with other health
care professionals and patients to assure complete and
accurate information concerning drug therapy and patient’s
response.
Effectively’ obtain the necessary information from the patients
and other health care providers to ensure appropriate drug
treatment
Correctly interpret the disease state, signs, and Symptoms.
Utilize laboratory data for both diagnosis and monitoring of drug
therapy.
Identify therapeutic end points.
Formulate a rational drug treatment plan.
Consistently demonstrate proper documentation of
pharmaceutical care activities.
Interpret, describe and apply pathophysiology and therapeutics
of the minimum knowledge based on diseased states into
patient care activities.
Understand, interpret, critically’ evaluate and apply in clinical
context primary literature encountered during the Clinical
Pharmacy clerkship.
The studies reveal that in about 30% of patient are malarial
Infected.
WHAT IS MALARIA
Malaria is an infectious disease caused by the parasite called
Plasmodium. There are four identified species of this parasite causing
human malaria, namely, Plasmodium vivax, P. falciparum, P. ovale
and P. malaria. It is transmitted by the female anopheles mosquito. It
is a disease that can be treated in just 48 hours, yet it can cause fatal
complications if the diagnosis and treatment are delayed. It is re-
emerging as the # 1 Infectious Killers and it is the Number 1 Priority
Tropical Disease of the World Health Organization.
MALARIA IS A MAJOR GLOBAL HEALTH PROBLEM
Malaria affects more than 2400 million people, over 40% of the
world's population, in more than 100 countries in the tropical
countries. The tropics provide ideal breeding and living
conditions for the anopheles mosquito, and hence this
distribution.
Every year 300 million to 500 million people suffer from this
disease (90% of them in sub-Saharan Africa, two thirds of the
remaining cases occur in six countries- India, Brazil, Sri Lanka,
Vietnam, Colombia and Pakistan etc).
WHO forecasts a 16% growth in malaria cases annually.
About 1.5 million to 3 million people die of malaria every year
(85% of these occur in Africa), accounting for about 4-5% of all
fatalities in the world.
One child dies of malaria somewhere in Africa every 20 sec.,
and there is one malarial death every 12 sec somewhere in the
world.
Malaria kills in 1 year what AIDS killed in 15 years.
Malaria ranks third among the major infectious diseases in
causing pneumococcal acute respiratory infections and
tuberculosis. It is expected that by the turn of the century
malaria would be the number one infectious killer disease in the
world.
Every year 30000 visitors to endemic areas develop malaria.
Estimated global annual cost (in 1995) for malaria: US$ 2 billion
(direct and indirect costs, including loss of labour).
Estimated annual expenditure on malaria research, prevention
and treatment: $ 84 million.
Malaria was nearly eradicated from most parts of the world by the
early 60's, owing largely to concerted anti malarial campaigns world
over under the guidance of the World Health Organization.
HISTORY OF MALARIA
Malaria is probably one of the oldest diseases known to mankind that
has had profound impact on our history. But for malaria, the
outcomes of many a wars and destinies of many a kings would have
been different. It has been responsible for the decline of nations and
crushing military defeats, often having caused more casualties than
the weapons themselves. For centuries it prevented any economic
development in vast regions of the earth. It continues to be a huge
social, economical and health problem, particularly in the tropical
countries. History of malaria and its terrible effects is as ancient as
the history of civilization, therefore history of mankind itself.
Malaria was linked with poisonous vapors of swamps or stagnant
water on the ground since time immemorial. This probable
relationship was so firmly established that it gave the two most
frequently used names to the disease malaria, later shortened to one
word malaria, and paludisme. The term malaria (from the Italian mala
“bad” and aria “air”) was used by the Italians to describe the cause of
intermittent fevers associated with exposure to marsh air or miasma.
The word was introduced to English by Horace Walpole, who wrote in
1740 about a “horrid thing called malaria that comes to Rome every
summer and kills one.” The term malaria, without the apostrophe,
evolved into the name of the disease only in the 20th century. Up to
that point the various intermittent fevers had been called jungle
fever, marsh fever, paludal fever, or swamp fever.
DIAGNOSIS OF MALARIA
Diagnosis of malaria involves identification of malaria parasite or its
antigens/products in the blood of the patient. Although this seems
simple, the efficacy test of the diagnosis is subject to many factors.
The diagnosis of malaria is confirmed by blood tests and can be
divided into microscopic and non-microscopic tests.
MICROSCOPIC TESTS
For nearly a hundred years, the direct microscopic visualization of the
parasite on the thick and/or thin blood smears has been the accepted
method for the diagnosis of malaria in most settings, from the clinical
laboratory to the field surveys. The careful examination of a well-
prepared and well-stained blood film currently remains the "gold
standard" for malaria diagnosis.
The microscopic tests involve staining and direct visualization of the
parasite under the microscope.
1. Peripheral smear study
2. Quantitative Buffy Coat (QBC) test
Non-Microscopic Tests
Several attempts have been made to take the malaria diagnosis out
of the realm of the microscope and the microscopist. These tests
involve identification of the parasitic antigen or the antiplasmodial
antibodies or the parasitic metabolic production.
Rapid Diagnostic Tests (RDTs)
1. Para Sight F test
2. OptiMal Assay
3. The immuno chromatographic test (ICT Malaria P. f. test)
4. Polymerase Chain Reaction
5. Detection of antibodies by Radio immuno assay,
immunofluorescence or enzyme immuno assay
The simplest and surest test is the time-honoured peripheral smear
study for malarial parasites. None of the other newer tests have
surpassed the 'gold standard' peripheral smear study.
Remember this:
Ask for MP test in all cases of fever and related symptoms and
also whenever there is high level of suspicion.
MP test can be done at any time. Do not wait for typical
symptoms like chills, vomiting and high grade fever.
A negative test DOES NOT rule out malaria. Repeated tests may
have to be done in all doubtful cases. Duration of the illness,
level of parasitemia, expertise of the technician and the method
of examination may all have a bearing on the result of the M.P.
test.
Peripheral smear study for malarial parasites - The MP test
Peripheral smear study for malarial parasites is the gold standard in
diagnosing malarial infection. It involves collection of a blood smear,
its staining with Romanowsky stains and examination of the Red
Blood Cells for intracellular malarial parasites.
Thick and thin smears are usually prepared. Thick smears are used to
identify the parasites and thin smears for identifying the species.
Staining methods:
An experienced technician can detect as few as 5 parasites/µl in a
thick film and 200/µl in a thin film.
CLINICAL FEATURES OF MALARIA
Malaria is a febrile illness characterized by fever and related
symptoms. However it is very important to remember that malaria is
not a simple disease of fever, chills and rigors. In fact, in a malarious
area, it can present with such varied and dramatic manifestations
that malaria may have to be considered as a differential diagnosis for
almost all the clinical problems! Malaria is a great imitator and
trickster, particularly in areas where it is endemic.
All the clinical features of malaria are caused by the erythrocytic
schizogony in the blood. The growing parasite progressively
consumes and degrades intracellular proteins, principally hemoglobin,
resulting in formation of the 'malarial pigment' and hemolysis of the
infected red cell. This also alters the transport properties of the red
cell membrane, and the red cell becomes more spherical and less
deformable. The rupture of red blood cells by merozoites releases
certain factors and toxins (such as red cell membrane lipid, glycosyl
phosphatidyl inositol anchor of a parasite membrane protein), which
could directly induce the release of cytokines such as TNF and
interleukin-1 from macrophages, resulting in chills and high grade
fever. This occurs once in 48 hours, corresponding to the erythrocytic
cycle. In the initial stages of the illness, this classical pattern may not
be seen because there could be multiple groups (broods) of the
parasite developing at different times, and as the disease progresses,
these broods synchronise and the classical pattern of alternate day
fever is established. It has been observed that in primary attack of
malaria, the symptoms may appear with lesser degree of parasitemia
or even with submicroscopic parasitemia. However, in subsequent
attacks and relapses, a much higher degree of parasitemia is needed
for onset of symptoms. Further, there may be great individual
variations with regard to the degree of parasitemia required to induce
the symptoms.
The first symptoms of malaria after the pre-patent period (period
between inoculation and symptoms, the time when the sporozoites
undergo schizogony in the liver) are called the primary attack. It is
usually atypical and may resemble any febrile illness. As the disease
gets established, the patient starts getting relapse of symptoms at
regular intervals of 48-72 hours. The primary attack may
spontaneously abort in some patients and the patient may suffer from
relapses of the clinical illness periodically after 8-10 days owing to the
persisting blood forms of the parasite. These are called as short
term relapses (recrudescences). Some patients will get long
term relapses after a gap of 20-60 days or more and these are due
to the reactivation of the hypnozoites in the liver in case of vivax and
ovale malaria. In falciparum and malariae infections, recrudescences
can occur due to persistent infection in the blood.
MANIFESTATIONS OF ACUTE MALARIAL ILLNESS
While most of the clinical manifestations of malaria are caused by the
malarial infection per se, high grade fever as well as the side effects
of anti malarial therapy can also contribute to the clinical
manifestations. All these may act in unison, further confusing the
picture. In some cases, secondary infections like pneumonia or
urinary tract infection can add to the woes. All these facts should
always be kept in mind.
Typical features: The characteristic, text-book picture of malarial
illness is not commonly seen. It includes three stages viz. Cold stage,
Hot stage and Sweating stage. The febrile episode starts with shaking
chills, usually at mid-day between 11 a.m. to 12 noon, and this lasts
from 15 minutes to 1 hour (the cold stage), followed by high grade
fever, even reaching above 1060 F, which lasts 2 to 6 hours (the hot
stage). This is followed by profuse sweating and the fever gradually
subsides over 2-4 hours. These typical features are seen after the
infection gets established for about a week. The febrile paroxysms are
usually accompanied by head aches, vomiting, delirium, anxiety and
restlessness. These are as a rule transient and disappear with
normalization of the temperature.
In vivax malaria, this typical pattern of fever recurs once every 48
hours and this is called as Benign Tertian malaria. Similar pattern may
be seen in ovale malaria too (Ovale tertian malaria). In falciparum
infection (Malignant tertian malaria), this pattern may not be seen
often and the paroxysms tend to be more frequent (Sub-tertian). In P.
malariae infection, the relapses occur once every 72 hours and it is
called Quartan malaria.
ATYPICAL FEATURES:
In an endemic area, malaria often presents with atypical
manifestations
Atypical features are more common in the following situations:
Falciparum malaria
Early infection
Patients at extremes of age
Patients who are immune-compromised (extremes of age,
malnourished, AIDS, tuberculosis, cancers, on
immunosuppressive therapy etc.)
Patients on chemoprophylaxis for malaria
Patients who have had recurrent attacks of malaria
Patients with end stage organ failure
Last but not the least, pregnancy.
Atypical fever: In an endemic area, it is rather unusual to find cases
with typical fever pattern. Some patients may not have fever at all
and may present with other symptoms listed below. Many present
with fever of various patterns - low grade to high grade, with or
without chills, intermittent to continuous, or even as cases of
prolonged fever. In the initial stages of the illness, fever may be
quotidian, with more than one spike per day and this is due to the
development of multiple broods of the parasite. As the disease
progresses, these broods get synchronized and the fever tends to be
more uniform. However in cases of P. falciparum malaria and mixed
infections, this pattern of multiple spikes may continue.
Headache: Headache may be a presenting feature of malaria, with
or without fever. It can be unilateral or bilateral. Some times the
headache could be so intense that it may mimic intra-cranial
infections or intra-cranial space occupying lesions. It may also mimic
migraine, sinusitis etc. Presence of projectile vomiting, papilloedema,
neck stiffness and focal neurological signs would suggest other
possibilities.
Body ache, back ache and joint pains: These symptoms are fairly
common in malaria. These can occur even during the prodromal
period and at that stage these are generally ignored and diagnosis of
malaria is impossible owing to lack of peripheral parasitemia. They
are also common accompaniments of the malaria paroxysm.
Sometimes, malaria may present only with these symptoms,
particularly in cases of recurrent malaria.
Dizziness, vertigo: Some patients may present with dizziness or
vertigo, with or without fever. They may also have associated
vomiting and/or diarrhoea. This may mimic labyrinthitis, Menniere's
disease, vertebro-basilar insufficiency etc. Rarely patients may
present with swaying and cerebellar signs. Drugs like chloroquine,
quinine, mefloquine and halofantrine can also cause dizziness,
vertigo, and tinnitus.
Altered behaviour, acute psychosis: Patients may present with
altered behaviour, mood changes, hallucinosis or even acute
psychosis, with or without fever. Malaria may be detected
accidentally in such cases and they improve completely with anti
malarial therapy. Altered behaviour may also be due to high grade
fever or drugs. Antimalarial drugs like chloroquine, quinine,
mefloquine and halofantrine can cause restlessness, hallucinations,
confusion, delirium or even frank psychosis.
Altered sensorium: Patients with P. falciparum malaria may present
with altered sensorium due to severe infection, hypoglycemia,
electrolyte imbalance due to vomiting or diarrhoea (particularly the
elderly), hyperpyrexia, subclinical convulsions etc. Differential
diagnosis will include acute encephalitis, meningitis, metabolic
encephalopathy etc. As a rule of the thumb, malaria should be
considered a possibility in all cases of acute neuropsychiatric
syndromes and in cases of proven malaria, other possibilities should
be considered in the presence of papilloedema, increasesd ICT, neck
stiffness and focal deficits.
Convulsions, coma: Patients with cerebral malaria present with
generalised seizures and deep unarousable coma. Sometimes one
single fit can precipitate deep, unarousable coma. These could also
be due to hypoglycemia and all patients presenting with these
manifestations should be administered 25-50% dextrose immediately.
Drugs like chloroquine, quinine, mefloquine and halofantrine may also
trigger convulsions.
Cough: Cough may be a presenting feature of malaria, particularly P.
falciparum infection. Patient may have pharyngeal congestion and
features of mild bronchitis. Patients who have persistent cough and/or
fever even after clearance of parasitemia should be evaluated for
secondary bacterial pneumonias/ bronchopneumonia and bronchitis.
Breathlessness: In severe falciparum malaria, patients may present
with history of breathlessness, due to either severe anemia or non-
cardiogenic pulmonary oedema. Secondary respiratory tract
infections and lactic acidosis are other rarer causes for tachypnoea
and/or breathlessness in these patients. Patients with pre-existing
cardio-vascular or pulmonary compromise may deteriorate or even
die if they suffer from severe malaria.
Chest pain: Acute retrosternal or precordial pain may be presenting
feature of malaria. It may radiate to the left or right shoulder tips or
arms. It is due to rapid increase in the splenic size and perisplenitis.
This pain may mimic acute myocardial infarction, pleurisy, neuralgia
etc. Coupled with breathlessness, sweating and hypotension (algid
malaria), the picture will very closely resemble that of acute MI.
Acute abdomen: Patients can present with acute abdominal pain,
guarding and rigidity, mimicking bowel perforation, acute
appendicitis, acute cholecystitis, ureteric colic etc.
One such patient presented with pain abdomen and vomiting with low
grade fever, and on examination had tenderness in the right lower
abdomen. He was posted for appendicectomy. Pre operative blood
test revealed P. falciparum malaria and he recovered completely with
anti malarials!
Weakness: Sometimes patients may present with history of
weakness, malaise and prostration. On examination they may have
significant pallor, hypotension, dehydration etc. Algid malaria may
present like this and the patient may not have fever at all.
Chloroquine is also known to cause profound muscular weakness and
a new disease called macrophagic myofaciitis has been described in
patients receiving chloroquine.
Vomiting and diarrhoea: Malaria can present as a case of acute
gastroenteritis with profuse vomiting and watery diarrhoea (Choleraic
form). Vomiting is very common in malaria and is due to high grade
fever, the disease itself or even drugs. Vomiting may pose problems
in administering antimalarial treatment. These could also be due to
drugs like chloroquine and due to secondary bacterial or amebic
colitis.
Jaundice: Patients may present with history of yellowish
discoloration of eyes and urine. Mild jaundice is fairly common in
malaria and may be seen in 20-40% of the cases. Deeper jaundice
with serum bilirubin of more than 3 mg/dL is seen in severe P.
falciparum malaria and is associated with anemia, hyperparasitemia
and malarial hepatitis with elevated serum enzymes. Malaria must be
considered as a differential diagnosis for all cases of jaundice in a
malarious area.
Pallor: Severe anemia can be a presenting feature of malaria. It is
usually normocytic normochromic. It may pose special problems in
pregnancy and in children. Pre-existing nutritional anemia may be
aggravated by malaria.
Puffiness of lids: Occasionally patients may present with puffiness
of lids, with or without renal dysfunction.
Secondary infections: Malaria produces significant immune
suppression and this can result in secondary infections. Common
among them are pneumonia, aspiration bronchopneumonia (in the
elderly), urinary tract infection, colitis etc. Meningitis and enteric
fever have also been reported. In falciparum malaria, severe infection
can lead to septicaemic shock (algid malaria). Persistence of fever,
neutrophilic leucocytosis and focal signs of infection should always
alert the clinician to this possibility of secondary infections.
Hepatosplenomegaly: Patients can present with enlargement of
liver and/or spleen, tender or non-tender, with or without fever. Rapid
enlargement of spleen or liver in malaria can cause acute pain in the
abdomen or chest. Generally, organomegaly is noticed in the second
week of malarial illness. However, in cases of relapse or
recrudescence, it may be present earlier. Also, in immune
compromised patients splenomegaly may be absent. In pregnancy,
particularly second half, splenomegaly may be smaller or an enlarged
spleen may regress in size due to immune suppression. Although
splenomegaly is a cardinal sign of malaria, absence of splenomegaly
does not rule out the possibility of malaria.
Combinations of the above: Patients can frequently present with
various combinations of the above mentioned symptoms and signs,
further confusing the picture.
This list is not exhaustive and malaria may present in many other
ways. In all the above listed situations, patients may not have
associated fever, thus confusing the picture. In some, fever may
follow these symptoms. Therefore, one should not wait for the typical
symptoms of malaria to get a blood test done; it is always better to
do a smear whenever reasonable doubt exists.
CLINICAL FEATURES SUGGESTING P. FALCIPARUM
INFECTION:
1. Presence of any of the complications of P. falciparum malaria
viz. altered sensorium; convulsions; coma; jaundice; severe
anemia; hypotension; prostration; hyperpyrexia; renal failure
etc.
2. Atypical presentation.
3. Not responding to chloroquine therapy within 48 hours.
4. Recurrence within 2 weeks.
TREATMENT OF P. VIVAX MALARIA
Plasmodium vivax malaria is usually more common than P. falciparum
malaria and rarely causes any complications. Also, almost all cases of
P. vivax malaria respond to Chloroquine and resistance to this drug
has been reported only in sporadic cases in Irian Jaya, Myanmar,
Papua New Guinea and Vanuatu. Therefore, P. vivax malaria should
be treated with chloroquine and primaquine ONLY.
However, in areas where P. falciparum malaria is also seen in
significant numbers, there is always a chance of mixed infection.
Further, in some cases, the tests for malarial parasite may reveal only
P. vivax infection. This is particularly important if QBC method has
been used for identifying the infection, wherein species identification
is rather difficult. Therefore, all cases of P. vivax malaria should be
carefully observed during initial stages of treatment and if there are
any signs of not improving or deterioration, a possible co-infection
with P. falciparum should be considered.
After 6 days of treatment, a repeat test for malarial parasites should
be done to confirm clearance of parasitemia.
Treatment of P. vivax malaria: A flow chart
Chloroquine + Primaquine
After 48 hours
Clinical Recovery Status quo / worse
Continue the
treatment
Repeat the MP test
on the 6th day
Suspect P. falciparum, repeat MP test at 48 hrs.
(A thin smear examination is better for species
identification and for assessing parasite count)
NEGATIVE POSITIVE POSITIVE NEGATIVE
Cured See
below
Consider other
causes of fever, may
be in association
with malaria.
P. falciparum P. vivax
Treat as
possibly
chloroquine
resistant
If the patient has
typical malarial
complications, treat
as P. falciparum;
otherwise, wait.
TREATMENT OF P. FALCIPARUM MALARIA
Plasmodium falciparum malaria is the cause of all the mortality and
most of the morbidity in malaria. It can present with atypical features,
it can cause dramatic complications and to add to the woes,
treatment may be rendered difficult by resistance to antimalarial
drugs. Treatment of P. falciparum malaria therefore is different from
that of other types of malaria. It depends on the severity of infection,
status of the host and drug sensitivity pattern in the locality. In view
of the seriousness of the problem and synergistic toxicity of
antimalarial drugs, the drugs should be properly chosen right at the
start of the treatment. Changing the drugs or adding of drugs half-
way through the treatment only complicates the issue and adds to
the adverse effects of treatment.
Although blood schizonticidal drugs like chloroquine are enough to
give a radical cure of the falciparum infection, Primaquine should be
administered to all patients as a gametocytocidal drug to prevent the
spread of this potentially lethal infection. However, primaquine should
not be used concurrently with quinine and mefloquine and it is
contraindicated in pregnancy and lactation.
In cases of severe P. falciparum malaria, only parenteral drugs should
be used. And in all such cases, it is safer to presume drug resistance
and start on drugs other than chloroquine, because waiting for a
response to chloroquine may prove costly for the patient.
In cases of resistant P. falciparum malaria, it is better to use two
antimalarial drugs. Various combinations have been tried, but it is
advisable to use one rapid acting drug and another slow acting drug
in combination.
In places where the QBC test is widely used for diagnosis of malarial
infection, it is better to get a thin smear examined for assessing
parasite count in all positive cases of P. falciparum malaria. This simple
test would help in assessing the severity of the infection, in monitoring response to
treatment, and in identifying cases of resistance.
Treatment of P. falciparum malaria - A flow chart
Uncomplicated and
chloroquine sensitive
Complicated and chloroquine
sensitive
Tab. Chloroquine + Primaquine
single dose
Inj. Chloroquine + Primaquine
single dose
After 48 hours
Better; parasite count reduced
by >75%
Status quo/ worse; parasite
count reduced by <75%
Continue Consider resistance
Drugs for chloroquine resistant malaria
Uncomplicated and Complicated and Chloroquine
Chloroquine resistant resistant
Use any one of the following
combinations:
1. Tab. Quinine + Tab.
Pyrimethamine/ Sulfa.
2. Tab. Quinine + Tetracycline
/doxycycline
3. Tab. Artesunate + Tab.
Mefloquine
4.Tab. Mefloquine +
Pyrimethamine/Sulpha.
1. Inj.Quinine +
Pyrimethamine/Sulphadoxine
2. Inj. Quinine + Tetracycline /
Doxycycline
3. Inj. Artemether / Arteether /
Artesunate + Mefloquine.
MONITORING CASES OF P. FALCIPARUM MALARIA
All cases of P. falciparum malaria, particularly in the non-
immune and high-risk population, should be monitored for
complications.
Clinical
parameters:
Vital signs, hydration, intake/output, level of
sensorium, pallor, jaundice.
Lab. parameters: 4 hourly blood glucose (to detect hypoglycemia);
12 hourly hemoglobin, P.C.V. (to assess
hemolysis); 12 hourly parasite count (to assess
response); 24 hourly S. creatinine, S. bilirubin.
Follow-up MP tests
In all cases of P. falciparum malaria, follow-up MP tests should be
done on the 6th and 28th days after treatment. The 6th day smear is
done to assess clearance of parasitemia and 28th day smear is done
to identify recrudescence.
6th day smear: If the parasite is sensitive to the drugs that have been
used, then the parasitemia should clear within 7 days. However,
gametocytes may be found on the smear and this does not require
any treatment; if primaquine has not been given, it can be given now.
Persistence of ring forms of the parasite indicates incomplete
clearance and hence drug resistance. These cases should be re-
treated accordingly with other anti malarial drugs.
28th day smear: If the parasite is not completely eradicated due to
partial resistance, then the 28th day smear will be positive. All such
cases should be re-treated with other antimalarial drugs. Primaquine
should be re-administered in these cases to destroy freshly formed
gametocytes. The National Malaria Eradication Programme in India
recommends repeat smears on 6-7th , 14th , 21st , and 28th days of
treatment to identify resistance and recrudescence.
Combinations of Antimalarial Drugs
Early and effective chemotherapy for malaria has a pivotal role in
reducing morbidity and mortality especially since a vaccine is unlikely
to emerge within the next decade. Multidrug resistance has been
reported from most parts of the world and as a result, monotherapy
or some of the available combination chemotherapies for malaria are
either ineffective or less effective. New antimalarial regimens are,
therefore, urgently needed and antimalarial combination
chemotherapy is widely advocated. Antimalarial combinations can
increase efficacy, shorten duration of treatment (and hence increase
compliance), and decrease the risk of resistant parasites arising
through mutation during therapy.
Combination therapy with antimalarial drugs is the simultaneous use
of two or more blood schizontocidal drugs with independent modes of
action and different biochemical targets in the parasite. The concept
of combination therapy is based on the synergistic or additive
potential of two or more drugs, to improve therapeutic efficacy and
also delay the development of resistance to the individual
components of the combination.
Artemisinin based combinations are known to improve cure rates, reduce the
development of resistance and they might decrease transmission of drug-resistant
parasites. The total effect of artemisinin combinations (which can be simultaneous or
sequential) is to reduce the chance of parasite recrudescence, reduce the within-patient
selection pressure, and prevent transmission.
Antimalarial Drug Combinations
Artemisinin based combinations
Artesunate + Chloroquine
Efficacy Very high chloroquine failure rates (>60%) and sub-
optimal efficacy of the combination (85% cure rate)
Status Not approved; Not a viable option in areas with pre-
existing moderate to high levels of P. falciparum
resistance to Chloroquine
Artesunate + Amodiaquine
Efficacy and
advantages
Better efficacy than amodiaquine alone (cure rate
>90%); Well tolerated
Disadvantages ?Neutropenia; Pharmacokinetic mismatch
Dose Artesunate 4mg/kg and amodiaquine 10mg base/ kg
once a day 3 days
Status Approved
Artesunate + Mefloquine
Efficacy and
advantages
In use for many years and the first-line treatment in
several parts of SE Asia
Disadvantages Pharmacokinetic mismatch; Mefloquine induced
neuropsychiatric effects, cardiotoxic effects, incidents
of vomiting in children; but combination with
artesunate results in less adverse reactions than the
use of mefloquine alone
Dose Artesunate (4mg/kg once daily) for 3 days +
mefloquine (25mg base/kg) as a split dose of
15mg/kg on Day 2 and 10mg/kg on Day 3.
(Alternatively 8mg/kg mefloquine daily for three
days)
Status Not approved; Not considered a viable option as first-
line therapy in Africa
Artesunate + Sulfadoxine/Pyrimethamine (SP)
Efficacy and
advantages
Well tolerated; Efficacy dependent on the level of pre-
existing resistance to SP
Disadvantages Pharmacokinetic mismatch; adverse effects to SP
Dose Artesunate 4mg/kg once daily for 3 days and SP
single dose of 25mg/kg and 1.25mg/kg respectively
Status Approved (in areas where SP efficacy is high);
Resistance to SP limits the use
Artemether + Lumefantrine (Coartem,TM RiametTM )
Efficacy and
advantages
As effective, and better tolerated, as artesunate plus
mefloquine; No serious adverse reactions
documented
Disadvantages ?Irreversible hearing impairment
Dose Artemether 1.5mg/kg and Lumifantrine 9mg/kg at 0,
8, 24, 36, 48 and 60 hours
Status Approved; Not recommended for use in pregnancy
and lactating women
Non-Artemisinin based Combinations
Sulfadoxine-pyrimethamine based combinations
Sulfadoxine-pyrimethamine (SP)
Efficacy and
advantages
Single dose; Cheap
Disadvantages Drug resistance; Serious adverse effects
Dose Sulfadoxine 25mg/kg and Pyrimethamine 1.25mg/kg
as single dose
Status Not approved; Considered as single drug
SP + Chloroquine
Advantages Cheap; Similar pharmacokinetic profiles, with varied
modes of action on different biochemical targets in
the parasite
Disadvantages Drug resistance; Serious adverse effects to SP
Dose Chloroquine 25mg/kg over 3 days; SP single dose as
above
Status Not approved; an be used where resistance to SP is
not a problem
SP + Amodiaquine
Advantages Similar pharmacokinetic profiles
Disadvantages Adverse effects of amodiaquine and SP
Dose Amodiaquine 10mg/kg daily for 3 days; SP single dose
as above
Status Approved (In areas where efficacy of both
amodiaquine and SP remain high - countries in West
Africa)
SP + Quinine
Advantages Effective where resistance to SP is not a problem
Disadvantages Drug resistance; Serious adverse effects
Dose Quinine 15mg/kg 12 hourly for 3 days; SP single dose
as above
Status Not approved
SP + Mefloquin (FansimefTM )
Advantages Fixed dose pill, single dose
Disadvantages Not an additive or synergistic combination; Each drug
has a different pharmacokinetic profile; Expensive;
Resistance known
Dose Mefloquine 15mg/kg and SP as above single dose
Status Not approved; Not recommended for general use
since 1990
Atovaquone + Proguanil (MalaroneTM )
Advantages Synergistic activity; Good safety and tolerability in
children and adults
Disadvantages High cost; Restricted availability; Contra-indicated in
case of hypersensitivity or renal insufficiency
Dose Atovaquone 20mg/kg and Proguanil 8mg/kg once
daily for 3 days
Status Approved; Highly efficacious against P. falciparum,
including strains that are resistant to chloroquine and
mefloquine, with cure rates of 94-100%
Chlorproguanil + Dapsone (LapDapTM )
Advantages Well tolerated; Efficacious
Disadvantages Dapsone induced methaemoglobinaemia and
haemolysis in G6PD deficiency; Potential cross-
resistance with SP
Dose Chlorproguanil 2mg/kg and Dapsone 2·5mg/kg once
daily for 3 days
Status Approved
Quinine based Combinations
Quinine + Tetracycline
Advantages Efficacious
Disadvantages 7-day course, multiple doses daily; Cinchonism;
Tetracyclines contraindicated in children and
pregnant women; Emergence of resistance
Dose Quinine 10mg/kg 8 hourly and Tetracycline 4mg/kg 6
hourly for 7 days
Status Not approved; Difficult to recommend as a first-line
treatment for uncomplicated malaria
Quinine + Clindamycin
Advantages Good efficacy; Safe in children and pregnant women;
Lesser risk of resistance
Disadvantages Cinchonism
Dose Quinine 15mg/kg 12 hourly and Clindamycin 5mg/kg
12 hourly for 3 days
Status Not approved
New Combinations
Piperaquine + Dihydroartemisinin + Trimethoprim
(ArtecomTM ) and ArtecomTM plus Primaquine (CV8TM ) (CV =
China-Viet Nam)
Advantages Efficacy consistently above 93%
Disadvantages Animal toxicology studies indicate additive toxicity;
No serious adverse events observed in human studies
Status Trials; May prove to be more affordable
Chlorproguanil+ Dapsone + Artesunate (CDATM or Lapdap
plusTM )
Status No adequate data available yet
Fosmidomycin+ Clindamycin
Advantages Both drugs act on the parasite's apicoplast; Rapid
clearance and 100% cure rates reported
Status Trials on
Dose and Administration of Antimalarial Drugs
DRUGS FOR TREATMENT OF UNCOMPLICATED
MALARIA
All cases of P. vivax malaria and uncomplicated cases of P. falciparum
malaria are treated with oral drugs. Chloroquine is the ONLY drug
used for P. vivax malaria, because resistance to chloroquine in P.
vivax malaria is almost unknown (only sporadic reports). Most cases
of P. falciparum malaria can also be treated with chloroquine alone,
however, in areas with known resistance to chloroquine, it is safer to
combine chloroquine with another oral antimalarial like
pyrimethamine/ sulphadoxine. Primaquine should be used in both
types of malaria for radical treatment.
Dose of commonly used antimalarial drugs
Age in
years
Dose of Chloroquine (as
base)
(Each 250 mg tablet contains
150 mg base and
Dose of
Primaquine
Dose of
Pyri/Sulpha
(Of 25+500
each 5 ml of suspension
contains 50 mg base)
mg tablet)1st
dose*
2nd
dose
3rd
dose
4th
dose
P. vivax/
mixed
(for 14
days)**
P.
falciparum
Single
dose
0-1 75 mg37.5
mg
37.5
mg
37.5
mgNil Nil 1/4 tablet
1-5150
mg75 mg 75 mg 75 mg 2.5 mg 7.5 mg 1/2 tablet
5-9300
mg
150
mg
150
mg150 mg5 mg 15 mg 1 tablet
9-14450
mg
225
mg
225
mg225 mg10 mg 30 mg 2 tablets
>14600
mg
300
mg
300
mg300 mg15 mg 45 mg 3 tablets
*1st dose of chloroquine should always be larger to obtain sufficient
blood levels, in view of large volume of distribution.
** The National Malaria Eradication Programme in India recommends a 5 day course
of primaquine instead of 14 days.
Dose spacing for chloroquine 1st dose 2nd
dose
3rd dose4th dose
If the patient comes in the
morning and treatment can be
started by mid-day
Stat.After 6
hours
After 24
hours
After 48
hours
If the patient comes in the
afternoon and treatment is
started by evening
StatAfter 12
hours
After 24
hours
After 36
hours
If the patient is coming from a far
off place and /or if the MP test
report is available only next day
Stat (as
presumpt
ive)
2nd and 3rd doses
together after 24
hours
After 48
hours
Parenteral Chloroquine: Parenteral chloroquine may be needed in
patients with complicated, yet drug sensitive, P. falciparum malaria and
in case of persistent vomiting.
Intravenous
infusion
10 mg / kg (max.600mg) in isotonic fluid, over 8
hours; followed by 15 mg / kg (max.900mg) over 24
hours.
Intramuscular
or
subcutaneous
injections
3.5 mg of base/ kg (max.200 mg) every 6 hours or
2.5 mg of base/ kg (max.150mg) every 4 hours.
(Intramuscular injection can cause fatal
hypotension, especially in children)
Treatment of complicated/ chloroquine resistant P. falciparum
malaria
It is safer to treat cases of severe P. falciparum malaria as
chloroquine resistant, unless one is very certain about the sensitivity.
It is better to use two drugs, one rapid acting and one slower acting.
Severe malaria should always be treated with parenteral antimalarials
to ensure adequate treatment.
Quinine
Intravenous
In intensive care unit: 7mg of salt/kg over 30
minutes., followed immediately by 10mg/kg diluted in
10ml/kg isotonic fluid over 4 hours; after 4 hour
interval, 10mg/ kg over 4 hours, repeated every 8-12
hours until patient can swallow. OR 20mg of salt/kg
diluted in 10 ml/kg isotonic fluid, infused over 4 hrs;
then 10 mg of salt / kg over 4 hrs, every 8-12 hrs until
patient can swallow.
Children: 24 mg of salt/kg diluted in 10 ml/kg
isotonic fluid, infused over 4 hrs; then 12mg of salt/kg
over 4 hrs, every 8-12 hrs until patient can swallow.
Intramuscular
20mg of salt/kg diluted to 60 mg/ml by deep i.m.
injection, (divided into two sites); then 10mg of
salt/kg every 8 hours.
Oral Adults: 600mg of salt 3 times a day for 7 days (max.
of 1800mg/day) Children: Approximately 10mg/kg 3
times a day for 7 days.
In areas where resistance to quinine is known or suspected, add single
dose of pyrimethamine/ sulphadoxine OR Tetracycline or Doxycycline
for 7 days (for non-pregnant adults only)
Artemisinin derivatives
Preparation Dose and administration
Artemether:
(Availability:
80 mg/ml Inj.
and 40 mg
cap.)
IM: 3.2mg/kg as loading dose, followed by
1.6mg/kg daily, until patient is able to swallow or
for 5 days. (Maximum dose: 480 mg in adults and
9.6mg/kg in children.)
Oral: 160mg in two doses on the first day, then 80
mg/day for total 5 days
Arteether:
(Availability:
150mg/2 ml
injection)
Adults: 150mg IM once daily for 3 consecutive days.
Children: 3 mg/kg once daily for 3 consecutive
days.
Artesunate:
(Availability:
60mg powder
with 1 ml of
5% sodium
bicarbonate
Injection: The powder should be reconstituted in 1
ml of 5% sodium bicarbonate and then further
diluted with isotonic saline or 5% dextrose (to a
total of 3 ml for im and 6 ml for iv use).
Dose: 2.4mg/kg on the first day (additional 1.2
mg/kg after 4 hours in case of severe falciparum
ampoule for
injection and
50 mg tablet)
malaria), followed by 1.2 mg/kg daily until patient is
able to swallow or for a maximum of 7 days.
Oral: 100 mg on the first day, followed by 50 mg/
day for 7 days.
Other drugs
Drug Dose
Mefloquine 15-25 mg/kg (max. of 1500 mg), given as two
doses, 6-8 hrs apart
Tetracycline 250 mg 4 times a day for 7 days (for patients > 8
years and non-pregnant)
Doxycycline 100 mg twice a day for 7 days (for patients > 8
years and non-pregnant)
IMPORTANT
Most blood schizonticidal drugs prevent the development of the
forthcoming erythrocytic cycle of parasitic development and hence
have no or little effect on the ongoing cycle that is already causing
fever. Therefore, it would take at least 48 hours for the treatment to
be effective.
In severe P. falciparum malaria, oral antimalarials should not be used.
Vomiting, poor general health, poor compliance, erratic G.I.
absorption due to splanchnic vasculopathy etc. make oral therapy
less reliable. Therefore, use only parenteral antimalarials. This also
means that oral only antimalarials like Mefloquine and Halofantrine
have no place in treating severe falciparum malaria.
In all cases of P. falciparum malaria, the antimalarial drugs should be
chosen depending on the severity of the illness and the sensitivity
pattern in the locality. Changing the drugs or adding the drugs in
between is not advisable.
Most antimalarial drugs have a long plasma half-life. Therefore,
adding similar drugs half way through the treatment will only add to
the adverse effects and not to the therapeutic benefit. The following
combinations should therefore be avoided, concurrently or within a
short interval:
(1.) Chloroquine + Quinine (2.) Chloroquine + Mefloquine (3.) Quinine
+ Mefloquine (5.) Quinine + Primaquine (6.) Quinine + Halofantrine
(7.) Mefloquine + Primaquine (8.) Administration of Primaquine and
Pyrimethamine/sulphadoxine on the same day is also not advisable.
Both sulpha and primaquine can precipitate hemolytic crisis in
patients with Glucose 6-phosphate dehydrogenase deficiency.
Do not exceed the maximum recommended dose of antimalarial
drugs. All antimalarial drugs have a narrow safety range and excess
dose may lead to adverse effects. Moreover, larger dose does not
offer any superior antimalarial effect.
Primaquine should be administered to ALL cases of malaria as radical
treatment except in the following situations where it is
contraindicated: (i.) Pregnancy and lactation (ii.) Infants below one
year of age. In these two categories, chloroquine should be given
every week as a suppressive chemoprophylaxis to prevent relapse of
vivax malaria. When these patients are fit for administration of
primaquine, they should be given full therapeutic dose of chloroquine
as well as primaquine. (iii.) Patients with known Glucose 6-phosphate
dehydrogenase deficiency (iv.) Concurrently with quinine, mefloquine
and halofantrine (v.) It should not be used on the same day with
sulphadoxine. In such cases it can be given the next day.
Do not misuse the newer antimalarial drugs. We need to preserve
them for future. Research into newer antimalarial drugs is scanty and
the parasite is fast developing resistance even for newer drugs. Thus
if we deplete the newer drugs by misusing them, we may not have
anything left for treating ALL DRUG RESISTANT malaria in the not-too-
far-future. Therefore, newer anti malarial drugs should be used only
when definitely indicated and not indiscriminately. These drugs
should be used ONLY when parasite index or other methods PROVE
drug resistant malaria. In addition, artemisinin derivatives can be
used in cases of hyperparasitemia or life-threatening complications
on account of their ability to clear the parasitemia earlier compared
to other anti malarial drugs.
AIMS AND OBJECTIVES
1. To detect, report and follow up drug reactions, drug
interactions and patient compliance.
2. To work with health care professional to minimize the risk
and maximize the clinical effects of medication.
3. To communicate with health care professional to seek
knowledge and to give information about drugs.
4. To educate patient about appropriate administration of the
drug.
5. Consistently demonstrate proper documentation of
pharmaceutical care activities.
6. To encoverage the rational use of drug.
7. To improve the patient disease state by therapeutic drug
monitoring to increase the efficacy of drug.
CASE HISTORY NO.1
Patient Name: Asad Bad Shah s/o Saleem Khan
Age: 18 years
Sex: Male
Bed: 11
Address: Karak
Date of birth: 28-08-2007
Chief complaint
Pain in abdomen 3 weeks
Fever 3 weeks
Vomiting 3 weeks
Burning maturation 5 days
History of present illness
According to the patient he is suffering from high grade fever which is
at different intervals and not associated with chills. Thus is a history
of Abdominal pain and vomiting and burning macturation.
Family history
D.M, H.TN and TB not significance
History of post illness
No surgery, no hospitalization
Socioeconomic status
General physical examination
Anemia (-ve), jaundice (-ve), B.P 120/80, pulse rate 90/mint
temperature 102Fo
Systemic examination
Respiratory system normal
Nervous system normal
G.I.T clear
History based diagnosis
Malaria fever
Investigation
M.P, widal, blood culture etc
Test investigation
Test Result
HBs Ag -ve
HCV -ve
SGPT 38 u/l
Billurbin 0.9 u/l
Hb 12 g / dl
Platelet count 210,000
TLC 9800
DLC
Lymphocytes 35% 25-45%
Esinophil 03% 4-6%
Monocytes 02% 1-6%
Polymorpus 60% 40-75%
Neutrophil 25%
Medication history
Inf. Quinine sulphate 900mg
+ 500ml D/ Saline
+ 5-Hypertence
State give
Inf. Quinine 600 mg in D/ Saline
+ 5 Hypertence
TDS
Inj. Bestrix 2g i/v OD
Inf. D/S IL I/V State thin OD
Inf. Plabolyte i/v State given
Tab paradal 2 805
Result / finding
Drug interactions
No drug interaction is reported
Adverse drug reaction
Loss of epetite
Bad test
Compliance
The patient is complaining with the current drug therapy.
Cautions: Quinine use with caution in patient with cardiac arrhythmia
and myastehmia gravisa
Discussion
The patient is admitted with fever, chills, and vomiting. The prescribe
therapy should improve the patient.
Comments
The patient is vomiting but then is no prescribed the anti – emelic e.g
motilliun etc. for relief.
CASE HISTORY NO2
Patient Name: Basmeena
Age: 30 years
Sex: Female
Bed: 8
Date of birth: 24-08-07
Address: Zargar abad peshawar
Chief complaint
Fever high grade 3 weeks
Continuous 3 weeks
Known epileptic 15 weeks
History of present illness
The patient developed high grade fever 3 days back the patient
developed seizure and pits.
Her whole body shavered and rigid then started vibrating moments
sizne she is un-concious and ptis are occurs every 5-10 minuts.
Family history
D.M, H.TN and TB not significance
History of post illness
Epilepsy from 15 years
Socioeconomic status
Poor
General physical examination
Anemia (-ve), jaundice (-ve), B.P 130/80, pulse rate 85/mint
temperature 100Fo
Systemic examination
Respiratory system normal
Nervous system normal
G.I.T clear
History based diagnosis
Epilepsy and Malaria
Investigation
M.P+ve
Widal –ve
Test
Hbs Ag: -ve
HCV -ve
SGPT 40u/c
BB 0.8g/dl
RESULT / FINDINGS
Drug interaction
No drug interaction is reported
Adverse drug reactions
The moxation tachycardia insomonic depressun hypertension
Epival somnolence lnucesed epatite
thrombcyte
Bestrix pain in injection site GIT disturbance
Compliance
The patient is complaining with current drug therapy
Action : bestirx administered with caution in pencillin ellergy
Discussion:
The patient is admitted iwht high grade fever, pits, and the prescribe
therapy should improve the patient.
Comments
Medication history
Inj epival
2nd day medication
3rd day medication
CASE HISTORY NO. 3
Patient : Malik Aman
Age: 28
Sex: Male
Bed: 17
Address: Charsadda
Date of admission: 30-08-07
Present complaint
Fever 18 days
Loss motion 5 days
Drows ness 2 days
History of present illness
According to the father of patient he will be onset of high grade fever
with chill and reger back in Wazirastan 15 days ago. For the last two
days he become drowzee and disoriented no history of vomiting;
dirrhoea or pain, no history of cough headache and local treatment in
charsadda.
Past drug history
No history of allergy to any drug
Personal history
Herone
General physical examination
BP 120/60; pluserate 80/min; anemia –ve, jaundice –ve, lymphode no
palpable GIT soft smooth.
History based diagnosis
Cerebral malaria;
Investigation
CSF examination, CT-Scan, chest x-ray, blood culture, Blood CP.
Test investigation
Blood sugar 144mg/dl
Blood urea 48mg/dl
Serum creatinine 1.1mg.dl
Sodium 132
Potassium 4.8
Chloride 101
Billuribin 0.7mg/dl
SGPT 24u/L
Alkaline Phosphatase 95 u/l
H.B 12.5gm/dl
Plate let count 2,15,000
TLC 9950
CHEMICAL EXAMINATION
Protein 55
Glucose 50
Prescribed medication
Quinine 600mg i/v TDS
Infusion plabolyte i/v in 100ml
pladox
TDS
Inj. Rocifen 3g i/v OD
Result / finding
Drug interaction
No drug interaction is reported
Adverse drug reaction
No adverse drug reaction are observed
Compliance
The patient is complaining with the current drug therapy
Caution
Ceftriaxone should be avoided in neonate due interference in billurbin
metabolism
Discussion
The patient in admitted with fever loss motion, drowsiness, confusion
the prescribe therapy should improve the condition of patient. The
patient is discharge with good prognosis.
CASE HISTORY NO. 4
Patient : Malik Aman
Age: 70
Sex: Male
Bed: 17
Address: Kabul
Date of admission: 28-08-07
Present complaint
Fever 15 days
Disorientation and confusion – 15 days fits – 15 days
History of present illness
Fever was not associated with chill and regor can not speaked,
confused, unable to walke and there is tremer in his limb. Urinary
incontinence there is post epileptic drowsiness present.
Past history: Was admitted in Kabul hosp for same problem was
relieved for 2 days but aggravated the.
Past drug history
No history of allergy to antibiotic
General physical examination
Pulse rate 100, BP= 130/70 respiratory system deformity
pigmentation none, movement normal, percussion normal breath
should normal.
Alimentary system
Shape scophid, liver, spleen kidney impalpalote ascites not present,
hernia not present.
History based diagnosis
Acute meningitis Cerebral malaria;
Test investigation
CSF examination, CT-Scan, Chest X-ray, Blood culture, Blood CP.
Blood sugar 166mg/dl
Urea 59mg/dl
Creatinine 1.2mg.dl
Sodium 134
Potassium 4.9
Chloride 104
Billuribin 0.6mg/dl
SGPT 21 u/l
Alkaline Phosphatase 90 u/l
Prescribed medication
Dose
Inj. Quinine 600mg i/v 1 x TDS
Inf. plabolite i/v in 100ml pladox BDs
Inj. Zanatc ½ BD
Tab. Panadol Extra 2Xsos
Tab. Tegral 200mg ITDS
Tab. Decadron 2cci/v BD
Result / finding
Drug interaction
No drug interaction is reported with the prescribed drug therapy.
Adverse drug reaction
Vomiting
Compliance
The patient is complaining with the current drug therapy
Caution
Ceftriaxone should be avoided in neonate due interference in billurbin
metabolism
Discussion
The patient in admitted with fever loss motion, drowsiness, confusion
the prescribe therapy should improve the condition of patient. The
patient is discharge with good prognosis.
CASE HISTORY NO. 5
Patient : Sofia Bibi
Age: 25
Sex: Female
Bed: 40
Address: Peshawar
Present complaint
Headache 15
Vomiting 2
Fever 15 days
Pregnancy 5 months
Present History
According to the attendeant of patient she is having headache for the
last 15 days. It is associated with vomiting she is also fever, patient
was very irritable.
She has been coming to gynecology doctor for many times for
therapy. Patient is very irritable to communication.
Past drug history
Pregnant
Past treatment
Antimalerial
Ciproxin
Cefixime
Socio economic states
Satisfactory
Family history
No DM, Hypertension
History base diagnosis
Meningitis
General physical examination
B.P 130/80
Pulse rate 87 /min
Local examination
Neck stiffness
Investigation
CSF examination, CT-Scan, Chest X-ray, Blood culture, Blood CP.
Test investigation
SGPT 41 u/l
Billurbin 0.6U/L
H.B 11.2 mg/dl
Platelete count 210000
TLC 9650
Blood urea 39.5
Creatinine 1.8
Blood sugar 150/u/l
Alkaline Phosphatase 150 mgu/l
Chemical examination
Protein 40mg/dl
Prescribed medication
Inj. Quinine 600mg i/v TDS
Inf. Rociphen 3gm i/v OD
Inj. Dormicum I/V SOS
Result / finding
Drug interaction
No drug interaction Is reported
Adverse drug reaction
No adverse drug reaction was observed
Compliance
The patient is complaining with the current drug therapy
Caution
Ceftriaxone should be avoided in neonate due interference in billurbin
metabolism
Discussion
The patient in admitted with fever loss motion, drowsiness, confusion
the prescribe therapy should improve the condition of patient. The
patient is discharge with good prognosis.
HISTORY NO. 6
Patient Name: Islam Gul
Age: 26
Sex: Male
Bed 15
Address: Bunir
Date of Admission: 21/08/07
Chief complaint
Fever, chills from last 15 days
Dry coiugh from last 2 weeks
Loss of eptits
Nausea
History of present illness
According to the pateitn he has high grade fever and cough from 2
weeks and he cosnet to a doctor and local hospital and use the
following drugs.
d/ saline 1000ml state
artem D.S
2+2+2 for 3 days
syp calpol s.o.s
the patient not re-covered with it and refered to LRH medical B ward.
History of past illness
The patient is suffered from malaria 3 years back.
General physical examination
Anemia = -ve Jaundice –ve
BP 12/80 pulse rate 90 /minte
Temperature 102Fo
Systemic examination
Respiratory system normal
Nervous system normal
GIT Normal
History of based diagnosis
Malaria fever
Test investigation
Test Result
Hbs Ag -ve
HCV -ve
SGPT 35 u/l
Billurubin 0.9 u/l
Hb 13.g /dl
Platelet count 215000
TLC 9700
Medication history
Inj. QUININE 60MG IN 100ml
pladex i/v
TDS
Inf. Rocipin 1g i/v BD
Tab. Posnton Fort SOS
22-08-2007
Inj. Bestrix 1 gm BD
Inf. Quinine 600mg in 500 ml
d/w i/v
TDS
Tab pnadol 2+TDS
RESULT / FINDINGS
Cost effectivness : rociphin 1gm Rs. 477, Macter, Rs. 149
Drug interaction
Quinine increased the risk of ventricular arrythemia when given with
pimozide or thioridazine
Pre – caution
Quieinien in pregnancy with high dose in tetrogenic
Adverse drug reaction or side effect
Quienine: cinchonism = visual disturbance
Hypoglycemia after i/v administrator
Over dose
Rociepin 1 gm is OD according to BNF but in prescription is BD
Compliance
The patient is compliance with given medication
Discussion
The patient improve form fever , chills, etc.
ACKNOWLEDGMENT
REFERENCES
1. British National formulary (BNF)-51st Edition.
2. Clinical Medicine by Kumar and Clark 5th edition.
3. Pharmaceutical practice by A.J Winfield and R.M.E Richards
3rd ed.
4. basic and clinical pharmacology by Bertam G.Katzung 9th ed.
5. Short textbook of pathology by Mohd. Inam Dansih.
6. Pakistan guide, 2006 ed.
7. phrma guide 2006 ed.
8. The practice of community pharmacy in Remington. The
science nad practice of pharmacy 20th national book
foundation.
9. Current medical diagnosis and treatment 2006.
10. Clinical medicine fourth edi.
11. Drug information hand book
Websites
12. www.malariasite.com/malaria
13. www.idph.state.il.us/health/infect/reportids/nmen.htm.
14. www.who.int/entity/esr/resources/publication.
15. www.nytimes.vom.
16. www.freefromhunger.org