Case Study-Clinical pharmacist complete patient's file review

Case Study-Clinical pharmacist complete patient’s file review

40 yrs old Female presented to ER with severe dyspnea, respiratory distress and disturbed level of consciousness. The patient is admitted to ICU with respiratory failure due to acute chest infection require a mechanical ventilator, and has CKD on 3 complete IHD sessions.

Past Medical and Drug History

  • Kidney transplantation for 5 years
  • Last Scr = 2 mg/dl
  • Patient is on
  1. Calcium carbonate 500 mg TID.
  2. Alphacalcidol 0.5 mcg once daily.
  3. Erythropoietin alpha 4000 IU 3 times weekly.
  4. Immunosuppressant therapy.

Vital signs on admission

  • BP        120/80
  • HR        65 b/m
  • Temp     38°C
  • R R       30 b/m

Lab investigation

Lab investigation

Current medication

Current medication

Case management

The first step in our case is medication review and compare each drug with its indication, then review laboratory results and reassess every drug according to this findings.

Then we go to the next step in our case management, which is checking drug-drug interaction, and how to deal with any drug therapy problem related to this interaction.

The next step is medication dose adjustment according to disease and patient kidney and liver functions.

Finally, check the administration method of each drug and give your recommendation to the physician to illuminate it in the medication sheet, and also give some nurse counselling about the right administration method of certain medications.

case maanagement

Medication Review

Every drug in prescription should be according to a certain diagnosis, and our role is reviewing the medication sheet with hospital protocols or guidelines.

In our case, the patient is immunocompromised and comorbid, so we will notice the use of prophylaxis medication to avoid case deterioration, beside the therapeutic medication plan.

medication review

Prophylaxis plan

  1. DVT prophylaxis.
  2. Stress Ulcer Prophylaxis.
  3. Invasive fungal prophylaxis.
  4. Ventilator Associated Pneumonia prevention.
1.DVT prophylaxis:

DVT risk factors

  • Intensive care unit patients

All patients admitted to intensive care units (ICUs) are considered high risk for VTE (both upper and lower extremity venous thrombosis; approximately 10 per cent), even after routine prophylactic anticoagulation.

  • Cancer
  • Stroke

Additional risk factors for VTE that may be present in hospitalized medical patients including:

heart failure, myocardial infarction, and old age (>60 years), as well as previous VTE, prolonged immobility, renal failure, obesity, and inherited or acquired hypercoagulable states.

dvt prophylaxis

2.Stress Ulcer Prophylaxis:

Mortality from stress-related bleeding ranges from 50% to 70% in the critically ill.

   Risk Factors for Stress-Related Bleeding:

  1. Respiratory failure requiring mechanical ventilation for 48 hours or longer.
  2. Coagulopathy (platelet count less than 50,000/mm3, INR greater than 1.5, or aPTT greater than 2 times the control).
  3. Acute kidney injury.

   Risk factors associated with GI bleeding while receiving prophylaxis:

  • All patients on mechanical ventilation.
  • Renal failure.

stress ulcer prophylaxis


PPI prophylaxis is the most effective prophylactic strategy in patients at high risk of developing SUB when compared with using H2RAs.

3.Invasive fungal prophylaxis:


Invasive focal or systemic infections are most often associated with candidemia, which primarily occurs in immunosuppressed patients and those requiring intensive care.

Immunosuppressed patients at special risk for candidemia include:

  • Those with hematologic malignancies
  • Recipients of solid organ or hematopoietic cell transplants

Other factors include:

  • Central venous catheters.
  • Broad-spectrum antibiotics.
  • Acute renal failure, particularly if requiring hemodialysis.
  • Prior surgery, particularly abdominal surgery.
  • Gastrointestinal tract perforations and anastomotic leaks.

Invasive fungal prophylaxis

invasive fungal

4.Ventilator Associated Pneumonia prevention:

“The IHI Ventilator Bundle”

It is a series of interventions related to ventilator care that, when implemented together, will achieve significantly better outcomes than when implemented individually.

VAP prevention bundle

By reviewing every item in this bundle, we found that they did not use Chlorhexidine oral care, and by search in the Cochrane library, we found this systematic review:

Chlorhexidine oral care

Effective oral hygiene care is important for ventilated patients in intensive care. We found evidence that chlorhexidine either as a mouth rinse or a gel reduces the odds of VAP in adults by about 40%. However, we found no evidence that chlorhexidine makes a difference to the numbers of patients who die in ICU, to the number of days of mechanical ventilation or the number of days in ICU.

Recommendation (1)

We recommended adding chlorhexidine mouthwash to patient medication sheet.

Therapeutic plan

This patient is suffering from two medical conditions:

  1. Healthcare-associated pneumonia treatment.
  2. CKD complications management.
  1. Healthcare-associated pneumonia treatment:

According to IDSA guidelines, this patient has two risk factors for a multidrug-resistant pathogen.

Healthcare-associated pneumonia treatment.

Empiric HCAP Therapy

The physician had put this patient on a combination antibiotic therapy, by using one antipseudomonal cephalosporin (cefepime) plus antipseudomonal fluoroquinolone (ciprofloxacin).

antibiotic doses

2.CKD complications management:

To be able to complete our case management, it is the time to give a look on patient laboratory results.

Lab investigation monitoring

Lab investigation monitoring

Corrected Ca level in hypoalbuminemia

In hypoalbuminemia patients, we must calculate the calcium level by this equation to obtain the corrected Ca level.

Corrected Ca level in hypoalbuminemia

Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) – KDIGO guidelines

4.1.1. In patients with CKD stages 3–5, we suggest maintaining serum phosphorus in the normal range (2C). In patients with CKD stage 5D, we suggest lowering elevated phosphorus levels toward the normal range (2C).

4.1.2. In patients with CKD stages 3–5D, we suggest maintaining serum calcium in the normal range (2D).

4.1.5. In patients with CKD stages 3–5D and hyperphosphatemia, we recommend restricting the dose of calcium-based phosphate binders and/or the dose of calcitriol or vitamin D analogue in the presence of persistent or recurrent hypercalcemia (1B).




Erythropoietin Stimulating Agents in CKD patients ON dialysis

  • FDA and the manufacturer state that initiate treatment when haemoglobin is <10 g/dl; reduce the dose or interrupt treatment if haemoglobin approaches or exceeds 11 g/dl)
  • KDIGO Clinical Practice Guideline suggest that ESAs not be used to maintain Hb concentration above 11.5 g/dl in adult patients with CKD. (2C)

CKD Anemia Management

Drug-drug interaction check

There are many websites an mobile applications that we can use to check any medication sheet for drug-drug interaction, as Lexicomp,, Medscape interaction checker

Drug interaction checker

Check two resources to be sure about your intervention.

Recommendation 2

  • Ciprofloxacin + fluconazole

Close monitoring for evidence of excessive QT prolongation and/or Torsades De Pointes (TdP).

Recommendation 3

  • Ciprofloxacin + Prednisone

Monitor for new onset of tendon tender or joint pain.

Recommendation 4

  • calcium carbonate + allopurinol

Monitor closely, Separate by 2 hours.

Medication dose adjustment

Medication dose adjustment in Hemodialysis

Medication dose adjustment in Hemodialysis


ciprofloxacin dose in HD patient


allopurinol dose in HD patient


cefepime dose in HD patient


fluconazole dose in HD patient


Recommendation 5

Ciprofloxacin IV 400 mg every 24 hours

Recommendation 6


  • 1 g on day 1, then 500 mg q 24 h thereafter on hemodialysis days.
  • Or 1 g IV every 24 h; dose after hemodialysis on dialysis days.

Recommendation 7

  • Fluconazole Administer 400 mg after each dialysis period

Recommendation 8

  • Allopurinol 100 mg 48h (give dose after dialysis on dialysis days).

Drug administration review


ciprofloxacin iv adminstration


cefepime iv adminstration


Recommendation 9

  • Ciprofloxacin 400 mg concentrated solution 

N.B. Ciprofloxacin IV present as diluted solution also in 100 ml bottles.

ciprofloxacin administration method

Recommendation 10

cefepime administration method


The clinical pharmacist has an important role as pharmaceutical care practitioner, that in one case he gives 10 recommendations, making this final patient medication sheet.

final medication sheet

Published by

Amin Elkholy

Clinical Pharmacist, PharmD

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