]

UNIVERSITY OF GHANA
SCHOOL OF PHARMACY
DEPARTMENT OF PHARMACY PRACTICE
DANSO JEPHTHAH KWASI

Personal Information

Patient Initials O.T. Gender MALE Age

16 YRS

Date: 19TH JANUARY , 2024 Height : N/A Weight; N/A

BMI : N/A

Ward: TAMAKLOE WARD Ethnic Origin ; N/A

Presenting complaint: History of Presenting Complaint:

Abdominal pain
Constipation Patient who has no chronic illness was apparently well
Vomitting until a week prior to presentation when he started to
experience a gradual onset of an intermittent colicky
central abdominal pain which had no relieving or
exacerbating factors, graded as 8/10. It was associated
with about two episodes of vomiting since last Thursday
which contained food previously eaten and streaks of
dark-colored blood. There has been constipation,
gradual abdominal distention & a facial
hyperpigmentation from the onset of the pain. He was
sent to a peripheral hospital where an abdominopelvic
ultrasound was done with a suspicion of an amoebic
abscess.

Social History: Family History:

He is a student N/A

Past Medical History: On Examination :

1
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No previous surgical history Young patient who looks acutely ill, in obvious pain,
not in any respiratory distress, anicteric, mildly
dehydrated; hyperpigmentation of the face from the
Vital Signs : forehead
TEMP: 37.3 degree celsius
PULSE: 90 bpm
RR: 22 cpm ODQ:
BP: 121/68 mmhg Fever+, Hematemesis+, Previous trauma
SPO2: 96%
Abdominal exams:
CNS: Full, mwr, grossly distended
Grossly intact No visible & palpable cough impulse
Soft, central/periumbilical tenderness with rebound
tenderness
Percussion tympanic Bowel sounds: low pitch

CVS:
Heart sound 1&2 present No murmurs Pulse regular of
good volume

Respiration:
Air entry adequate, vesicular breath sounds, no added
sounds

Risk Factors
N/A

Differential diagnosis (if any)

Medication History [Past Six Months ]

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Prescription Medications
Medication Name / Dosage/ Start Stop Reason for use Comment
strength/route Frequency Date Date

N/A N/A N/A N/A N/A N/A

Non-Prescription Medications/Remedies/Products - Please list any additional non

prescription medications, herbal products, or nutritional supplements used by patient pre-
admission.
Medication Name / Dosage/ Start Stop Reason for use Comment
Strength/Route Frequency Date Date

N/A N/A N/A N/A N/A N/A

Allergies - Please specify what patient is allergic to and the nature of reaction to the
allergen
No known allergies

Lifestyle Information- please ask questions which are relevant and appropriate to the
patient
(e.g., exercise, use of: tobacco, alcohol, recreational drugs). Quantify information where
possible (e.g., units of alcohol, frequency of exercise).

Does pt self-monitor at home? NO known information

Blood  Yes Peak  Yes Blood  Yes Ketones  Yes
Pressure  No Flow  No Glucose  No  No

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Immunisation Information- Has patient had relevant vaccinations and/or does patient
require any additional vaccinations based on disease history?
No Known information

Additional Information

Who organises the patient’s medications at home?

 Patient
 Carer
 Other:
_______________________________________________________________________
_

Suspected adherence concerns? Please describe.

INVESTIGATIONS
Parameter Reference Range Dates
Urea (SI) 19/01 / Flag Flag
24
Sodium 135 - 150 mmol/L 136 N
Potassium 3.5 - 5.5 mmol/L 4.5 N N
Chloride 95 - 110 mmol/L 98 N N
Bicarbonate 23-29 mmol/L 26 N N
Anion Gap with 18- 23 mmol/L 17 L N
K+
Urea (SI) 2.6- 6.7 mmol/L 4.9 N N
Creatinine (SI) 53- 97 umol/L 46 N 80 N
Urea / 10 - 20 26 H 18 N
Creatinine ratio
eGFR Stage 1 : > 90 272.4 N 92 N
ml/min/1.73m2

Stage 2 : 60 - 89
ml/min/1.73m2

Stage 3A : 45- 59
ml/min/1.73m2
Stage 3B : 30 - 44
ml/min/1.73m2
Stage 4 : 15 - 29
ml/min/1.73m2

Stage 5 : < 15
ml/min/1.73m2
Uric Acid 155 - 357 umol/L N/A N/A

4
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Haematology
Parameter RESULTS Dates
19/01/ Nor Flags
24 mal
rang
UNIT e
RBC 4.03 10^6? 3.8 - N
UL 6.5
HB 10.7 G/dL 13 - N
18
HCT 30.3 % 36.0 L
- 54
MCV 75.2 fL 80- L
100
MCH 26.6 pG 27 - L
32
MCHC 35.3 g/dL 32 - H
36
RDW_SD 38.5 fL 37 - N
54
RDW_CV 14.0 % 11 - N
16
PLT 429 10^3/ 150 H
UL -
400
MPV 10.3 fL 6- H
11
PDW 11.2 Fl 9_ N
17
WBC 9.79 10^3 / 3.5 _ N
uL 10.5
NEUT% 78.2 % 40_ H
75
LYMPH% 14.5 % 21 _ N
40
MONO% 6.8 % 2_ N
10
EO% 0.1 % 1-6 L
BASO% 0.4 % 0.0 - N
1.0
NEUT# 7.65 10^9/L 2-7 H
LYMPH# 1.42 10^9/L 1- 3 N
MONO# 0.67 10^9/L 0.2 - N
1
EO# 0.04 10^9/L 0.04 N
- 0.4

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BASO# 0.02 10^9/L 0.02 N
-
0.04

Reference Range Dates

LIVER UNIT RES FLA
FUNCTION S UL G
TEST TS
7/11
/23
Parameter [3 to 40] U/L 29 N

Women [< 34 ], U/L 14 N

Men [ < 45 ]
Children 1 - 30 Days
[ < 25 ], 2 - 12
Months [ < 35 ], 1 - 3
Years [ < 30 ], 4 - 6
Years [ < 25 ], 7 - 9
Years [ < 25 ], 10 -
18 Years [ < 30 ]

Adults Women [ 35 - U/l 90 N

105 ],Men [ 40 -
130 ] Children
(Female) 1 - 30 Days
[ 48 - 406 ], 1month -
1 Year [ 124 - 341 ],
1 - 3 Years [ 108 -
317 ] , 4 - 6 Years
[ 96 - 297 ] , 7 - 9
Years [ 69 - 32 Years
[ 51 - 332 ], 13 - 15
Years [ 50 - 162 ] ,
16 - 18 Years [ 47 -
119

Women [ < 38 ] Men U/L 33 N

[ < 55 ] Children /
Adolescents
(Female) 1 day - 6
Months [ 15 - 132 ],
6 Months - 1 Year [ 1
- 39 ], 1 - 12 Years
[ 4 - 22] , 13 - 18

6
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Years [ 4 -24]
Children /
Adolescents (Male) 1
day - 6 Months [ 12 -
122 ] , 6 Months - 1
Year [ 1 - 39 ],

Neonates Day 1 [ <

150 ], 2nd Day [ 22 - 9 N
193 ], 3rd Day [ 12 - umol/l
217 ], 4th - 6th Day [
1.7 - 216 ] Children
> 1 Month [ 3.4 -
17 ] Adults [1.7 - 21]

[0.0 - 5.2]

3.3 N
[0.0 - 19.0] umol/l

5.7 N
Adults( > 18 Years umol/l
Female) [66 - 88],
Adults( >18 Years 74 N
Male) [66 - 88] g/l
Children (Female) 1
- 30 Days [42 - 62], 1
- 6 Months [44 - 66],
6Months - 1 Year [56
- 79], 1 - 18 Years
[57 - 80] Children
(Male) 1 - 30 Days
[41 - 63], 1 - 6
Months [47 - 67],
Months - 1 Year [55
- 70], 1 - 18 Years
[57 - 80]

36 N
g/l
[35 - 52] 38.0 N
g/l

7
 ]
[25 - 45]

Current Medications (on ward)

Medication [name/ Dosage Start Date End Date Reason for use Comment
strength Route] /Frequency

Ringer-Lactate Infusion 1L Once for one 19th N/A For electrolyte

500ml ( SINGLE ) day January,2024 imbalance and It is
fluid appropriate
19th resuscitation
Dextrose Infusion 5% 2L Once for one January,2024 N/A For electrolyte It is
(500ml) ( SINGLE ) day imbalance and appropriate
fluid
resuscitation It is
appropriate
Metronidazole infusion 19th 21st January, Prophylaxis
(Workhardt) 500mg 3 Times January,2024 2024 against
( SINGLE ) daily anaerobic
infection
CIPROFLOXACIN For prophylaxis It is
INFUSION,2MG/ML 19th 21st January, against gram appropriate
IN 100ML 400mg 2 Times January,2024 2024 negative
Daily infections

Paracetamol 1g IV 19th For the relieve It is

(Pharmalgan) ( Single ) January,2024 N/A of abdominal appropriate
1g 4 Times Daily pains

Potassium Chloride 19th It is

Injection 20meq/10ml 60mmol daily January,2024 N/A For electrolyte appropriate
( SINGLE ) balance and
fluid
resuscitation

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 ]

Medical Problems/ Diagnosis being managed as a case of

1. Appendicitis ( Perforated Appendix)

PHARMACEUTICAL CARE PLANS (SOAPO)

Pharmaceutical care issue / problem 1

OPTIMIZING THE TREATMENT OF APPENDICITIS ( PERFORATED
APPENDIX)

SUBJECTIVE DATA - abdominal pain that migrates to the right iliac fossa , vomiting,
constipation

OBJECTIVE DATA
Considering the Intra operation findings:
( 1.gangrenous preileal appendix with autoamputation of tip of appendix
2.offensive purulent fluid about 1l mL
3.ischemic but viable small bowel with fibrinous adhesions) there is an evidence of a
perforated appendix.

Assessment
Diagnosis :
The appendix is a worm-like structure attached to the caecum and is notable for morbidity
when the inner lining of the vermiform gets inflamed, this inflammation is liable to spread
to surrounding structures. Most patients present with right lower quadrant pain. This right
lower quadrant (RLQ) pain begins as either generalized, periumbilical or epigastric pain

9
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before manifesting as RLQ pain. Appendicitis mostly affects males within the age range of
10-30 years, with a male to female ratio of 1.4:1. Current guidelines clearly focus on early
appendectomy with the exception of appendiceal masses . Also, in appendicitis patients
experience nausea and vomiting. Appendicitis is the most frequent cause of an abdominal
abscess. 1
Acute appendicitis is considered a surgical emergency. The appendix is viewed as a
vestigial organ and is well-known for its tendency to be inflamed. However, the states that
appendicitis is a rare side effect of Gemfibrozil, a Fibrate, used in the management of
hyperlipidaemia. A select few complications include inflammatory bowel syndrome (IBS)
and bladder/urinary tract infection. Below is a table showing the ALVARADO scoring
system in the diagnosis and the need for surgery in Appendicitis.2

Scores of 1-4 indicate "discharged home", scores of 5-6 signify being "observed", and
scores of 7-10 indicate the need to "undergo emergency surgery" 3
Furthermore, other scoring systems exist with the inclusion of the
Appendicitis Inflammatory Response Scoring System. Some diagnostic indirect signs
include; the Rovsing sign, the Dunphy’s sign (cough test), the Markle’s test (heel-drop
jarring test) etc. Pertaining to surgery, the laparoscopic method of appendectomy is
associated with faster recovery and lesser cost as compared to performing an oblique
incision at the McBurney’s point and subsequent removal of the inflamed appendix .4

Confirmation of Diagnosis.
Considering the subjective findings - TEMP: 37.3 degree celsius, PULSE: 90 bpm ,RR:
22 cpm , BP: 121/68 mmhg , SPO2: 96% and Intra operation findings:
1.gangrenous preileal appendix with autoamputation of tip of appendix
2.offensive purulent fluid about 1l mL
3.ischemic but viable small bowel with fibrinous adhesions there is appendicitis which led
to the autoamputation of the tip of the appendix ( perforated appendix)

Appropriateness of Therapy

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 ]
Ringer-Lactate Infusion 500ml ( SINGLE )

Ringer's lactate solution, or lactated Ringer's solution, is a type of isotonic, crystalloid

fluid further classified as a balanced or buffered solution used for fluid replacement. The
contents of Ringer's lactate include sodium, chloride, potassium, calcium, and lactate in
the form of sodium lactate, mixed into a solution with an osmolarity of 273 mOsm/L and
pH of about 6.5. In comparison, normal saline (NS) has an osmolarity of about 286
mOsm/L. Ringer's lactate is largely used in aggressive volume resuscitation from blood
loss or burn injuries; however, Ringer's lactate is a great fluid for aggressive fluid
replacement in many clinical situations, including sepsis and acute pancreatitis. This
activity outlines the indications, mechanism of action, methods of administration,
important adverse effects, contraindications, and monitoring, of Ringer's lactate, so
providers can direct patient therapy in treating conditions for which it is indicated as part
of the interprofessional team. Ringer’s lactate solution, or lactated Ringer’s solution, is a
type of isotonic, crystalloid fluid further classified as a balanced or buffered solution used
for fluid replacement. The contents of Ringer’s lactate include sodium, chloride,
potassium, calcium, and lactate in the form of sodium lactate, mixed into a solution with
an osmolarity of 273 mOsm/L and pH of about 6.5. In comparison, normal saline (NS) has
an osmolarity of about 286 mOsm/L. Ringer’s lactate is largely used in aggressive volume
resuscitation from blood loss or burn injuries; however, Ringer’s lactate is a great fluid for
aggressive fluid replacement in many clinical situations, including sepsis and acute
pancreatitis.14

Understanding the metabolism of lactate and briefly reviewing its biochemistry and
physiology is important to recognize the specific benefits of Ringer’s lactate utilization.
Lactate is the compensatory base of lactic acid. Under aerobic physiologic conditions, the
metabolism of glucose leads to the production of pyruvate into cellular respiration.
However, there is always a small state of anaerobic metabolism taking place at any given
time, causing pyruvate to undergo an oxidation-reduction reaction with NADH which
leads to oxidation of NADH to NAD+ and the formation of lactate via the enzyme lactate
dehydrogenase (LDH). This reaction maintains NAD+ levels, even in anaerobic
metabolism, to allow further glycolysis to occur in the absence of oxygen. Normally,
through cellular respiration, there is always a balanced ratio of NADH/NAD+ with the
transfer of protons and electrons to finally make ATP, water (H2O), and carbon dioxide
(CO2) as the final products. If this aerobic system shuts down, the protons have nowhere
to go. Lactate is formed and shuttled out of the cells to keep the NADH/NAD+ ratio
constant. The increased production of lactate, in turn, acts as a buffer system as it takes up
the H+ forming lactic acid. Furthermore, lactate can be metabolized back into pyruvate via
LDH and cellular respiration, forming CO2 and H2O. This CO2 and H2O form carbonic
acid (H2CO3) via carbonic anhydrase, rapidly dissociating to form HCO3. Lactate can
be metabolized to form bicarbonate.14
Administering a liter of Ringer’s lactate does two important things:
1. Volume resuscitation: In that intravascular volume expands, increasing preload and
thus, perfusion
2. Provides the body with sodium lactate: Sodium lactate is a bioenergetic fuel that

11
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the human body is designed to metabolize under ischemic conditions, thus

decreasing cellular death from ischemia.39
Ringer’s lactate is administered most commonly via IV route but may also be safely
administered intraosseously. The goal of administering Ringer's lactate is to replenish the
intravascular volume to permit adequate organ perfusion.14
In clinically stable patients with a diagnosed intestinal obstruction and a history of
abdominal surgery, nonoperative management should be attempted. As soon as acute
intestinal obstruction is suspected, intravenous isotonic fluid should be started, and oral
intake should be restricted. Nasogastric intubation should be performed for decompression
in most patients. Aggressive replacement of electrolytes is recommended after confirming
adequate renal function. Bladder catheterization should be considered to closely monitor
urine output and evaluate the adequacy of fluid resuscitation14
The dosage depends on the age, weight, clinical and biological conditions of the patient
and concomitant therapy.
Recommended dosage:
The recommended dosage is:
- for adults, the elderly and adolescents : 500 ml to 3 litres /24h
- for babies and children : 20 ml to 100 ml / kg / 24 h.
Administration rate:
The infusion rate is usually 40 ml/kg/24h in adults, the elderly and adolescents.
In paediatric patients the infusion rate is 5 ml/kg/h on average but the value varies with
age: 6-8 ml/kg/h for infants, 4-6 ml/kg/h for toddlers, and 2-4 ml/kg/h for schoolchildren.
In children with burns, the dose is on average 3.4 ml/kg/per cent burn at 24 h post-burn
and 6.3 ml/kg/per cent burn at 48 h.
In severely head-injured children the dose is on average 2850 ml/m2.
Infusion rate and total volume can be higher in surgery or in case of need.
The dosage of Ringer's lactate 1L falls within the recommended range of not more than 3L
/ 24 hrs and its recommended for fluid resuscitation in a perforated appendix hence it is
appropriate .14

Dextrose Infusion 5% (500ml) ( SINGLE)

Intravenous sugar solution, also known as dextrose solution, is a mixture
of dextrose (glucose) and water. It is used to treat low blood sugar or water loss
without electrolyte loss. Water loss without electrolyte loss may occur
in fever, hyperthyroidism, high blood calcium, or diabetes insipidus. It is also used in the
treatment of high blood potassium, diabetic ketoacidosis, and as part of parenteral
nutrition. It is given by injection into a vein. Side effects may include irritation of
the vein in which it is given, high blood sugar, and swelling. Excess use may result in low
blood sodium and other electrolyte problems. Intravenous sugar solutions are in

12
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the crystalloid family of medications. They come in a number of strengths including 5%,
10%, and 50% dextrose. While they may start out hypertonic they become hypotonic
solutions as the sugar is metabolised. Versions are also available mixed with saline. 6

Administering a 5% sugar solution peri- and postoperatively usually achieves a good

balance between starvation reactions and hyperglycemia caused by sympathetic activation.
A 10% solution may be more appropriate when the stress response from the reaction has
decreased, after approximately one day after surgery. After more than approximately two
days, a more complete regimen of total parenteral nutrition is indicated.In patients
with hypernatremia and euvolemia, free water can be replaced using either 5% D/W or
0.45% saline. 6

Management of uncomplicated obstructions includes intravenous fluid resuscitation with

correction of metabolic derangements, nasogastric decompression, and bowel rest.
Dextrose infusion 5% is given as a source of energy and also for fluid replacement due to
the emesis associated with intestinal obstruction.

To avoid dehydration in a healthy adult or in patients with no complicating factors such as

fever or excessive fluid losses, daily fluid requirements are 1.5 to 2.5 litres. The volume of
glucose solution needed to replenish deficits will vary with body weight, complementary
treatment, severity of the clinical condition and hydration status of the patient, but in
adults will usually lie between 2 and 10 litres. The pathophysiological response to
dehydration, to electrolyte loss and to glucose infusion will vary with the age of the
patient being treated and this should be taken into account during rehydration
therapy. There is no recommended dose as this is a matter for clinical judgment
and laboratory assessment in each case. The dose range is typically 500 - 3000 ml in a 24
hour period and typical maximum rates are 800 mg/kg/hr or 600 ml/hr.6

The dose that was used for fluid resuscitation wwas 2L which falls withhin the
recommended dose daily of 500 - 3000ml in a 24 hr period hence it is appropriate.

Metronidazole infusion (Workhardt) ( SINGLE )

Metronidazole, sold under the brand name Flagyl among others, is
an antibiotic and antiprotozoal medication. It is used either alone or with other antibiotics
to treat pelvic inflammatory disease, endocarditis, and bacterial vaginosis. It is effective
for dracunculiasis, giardiasis, trichomoniasis, and amebiasis. It is an option for a first
episode of mild-to-moderate Clostridioides difficile colitis if vancomycin or fidaxomicin is
unavailable. Metronidazole is available orally (by mouth), as a cream or gel, and by
slow intravenous infusion (injection into a vein). Common side effects include nausea, a
metallic taste, loss of appetite, and headaches. Occasionally seizures or allergies to the
medication may occur. Some state that metronidazole should not be used in
early pregnancy, while others state doses for trichomoniasis are safe. Metronidazole is
generally considered compatible with breastfeeding.5

Metronidazole is of the nitroimidazole class. It inhibits nucleic acid synthesis by

forming nitroso radicals, which disrupt the DNA of microbial cells. This function only
occurs when metronidazole is partially reduced, and because this reduction usually
happens only in anaerobic bacteria and protozoans, it has relatively little effect upon

13
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human cells or aerobic bacteria. Metronidazole is are indicated in the prophylaxis and
treatment of infections in which anaerobic bacteria have been identified or are suspected
to be the cause. 5

Metronidazole is active against a wide range of pathogenic micro-organisms notably

species of Bacteroides, Fusobacteria, Clostridia, Eubacteria, anaerobic cocci
and Gardnerella vaginalis.
It is also active against Trichomonas, Entamoeba histolytica, Giardia
lamblia and Balantidium coli.
Metronidazole is indicated in adults and children for the following indications:
1. The prevention of post-operative infections due to anaerobic bacteria, particularly
species of Bacteroides and anaerobic streptococci.
2. The treatment of septicaemia, bacteraemia, peritonitis, brain abscess, necrotising
pneumonia, osteomyelitis, puerperal sepsis, pelvic abscess, pelvic cellulitis, and post-
operative wound infections from which pathogenic anaerobes have been isolated.
3. Urogenital trichomoniasis in the female (trichomonal vaginitis) and in the male.
4. Bacterial vaginosis (also known as non-specific vaginitis, anaerobic vaginosis or
Gardnerella vaginitis).
5. All forms of amoebiasis (intestinal and extra-intestinal disease and that of symptomless
cyst passers).
6. Giardiasis.
7. Acute ulcerative gingivitis.
8. Anaerobically-infected leg ulcers and pressure sores.
9. Acute dental infections (e.g. acute pericoronitis and acute apical infections).
Considerations should be given to official guidance on the appropriate use of antibacterial
agents.
The the dose for surgery prophylaxis includes an Initial preoperative dose: 15 mg/kg IV
infused over 30 to 60 minutes and completed about 1 hour before surgery
Followed by: 7.5 mg/kg IV infused over 30 to 60 minutes at 6 and 12 hours after the initial
dose and the maximun dose to be given is 4 g daily. 5
Metronidazole infusion was used for surgical prophylaxis to prevent anaerobic
infections . The dose given was 500 mg three times dailly for ten days which is
appropriate 5

Ciprofloxacin Infusion,2mg/ml in 100ml

Ciprofloxacin is an antibiotic agent in the fluoroquinolone class used to treat bacterial
infections such as urinary tract infections and pneumonia. Ciprofloxacin has FDA
approval to treat urinary tract infections, sexually transmitted infections (gonorrhea and
chancroid), skin, bone, joint infections, prostatitis, typhoid fever, gastrointestinal

14
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infections, lower respiratory tract infections, anthrax, plague, and salmonellosis. In
addition, ciprofloxacin is an appropriate treatment option in patients with mixed infections
or patients with predisposing factors for Gram-negative infections. This activity covers
ciprofloxacin, a broad-spectrum quinolone antibiotic that members of the interprofessional
team need to review its indications, coverage, contraindications, and adverse event profile
to optimally manage patients' infectious diseases.9

Ciprofloxacin is a bactericidal antibiotic of the fluoroquinolone drug class. It inhibits

DNA replication by inhibiting bacterial DNA topoisomerase and DNA-gyrase. Of the
fluoroquinolone class, ciprofloxacin is the most potent against gram-negative bacilli
bacteria (notably, the Enterobacteriaceae such as Escherichia
coli, Salmonella spp., Shigella spp., and Neisseria). Ciprofloxacin also has effectiveness
against some gram-positive bacteria. Ciprofloxacin is the most active
against Pseudomonas aeruginosa among the quinolones. Progressively decreasing
susceptibility among P. aeruginosa has been reported in Europe, North and South
America, predominantly in the hospital or nursing home settings with identifiable risk
factors. Ciprofloxacin is one of the few oral antibiotics to treat P. aeruginosa infections.9
Patients with Hepatic Impairment: In patients with liver cirrhosis, no significant
changes in the pharmacokinetics of ciprofloxacin have been observed. However,
ciprofloxacin's pharmacokinetics are not fully studied in patients with acute hepatic
insufficiency. Additionally, ciprofloxacin has the potential to cause hepatotoxicity. Use
with caution in patients with impaired hepatic function.
An intravenous dosage of 200 to 400 mg twice daily is recommended for mild-to-
moderate infections and up to 400 mg every 8 hours for severe, life-threatening
infections. The recommendation is a 50% reduction in daily dosage for patients with
severe renal impairment (creatinine clearance = 1.2 L/hour). Ciprofloxacin is
administered intravenously by slow infusion over 60 minutes. It is essential to maintain
proper hydration and urine output.9
Ciprofloxacin IV 400mg twice daily was given for a period of seven days as a prophylaxis
for gram negative infections which was appropriate.

Paracetamol 1g IV (Pharmalgan) ( Single )

Paracetamol (acetaminophen or para-hydroxyacetanilide) is a non-
opioid analgesic and antipyretic agent used to treat fever and mild to moderate pain. It is a
widely used over the counter medication and common brand names
include Tylenol and Panadol.

At a standard dose, paracetamol only slightly decreases body temperature; it is inferior

to ibuprofen in that respect, and the benefits of its use for fever are unclear, particularly in
the context of fever of viral origins. Paracetamol may relieve pain in acute
mild migraine but only slightly in episodic tension headache. However,
the aspirin/paracetamol/caffeine combination helps with both conditions where the pain is
mild and is recommended as a first-line treatment for them. Paracetamol is effective for
post-surgical pain, but it is inferior to ibuprofen. The paracetamol/ibuprofen combination
provides further increase in potency and is superior to either drug alone. The pain relief

15
 ]
paracetamol provides in osteoarthritis is small and clinically insignificant. The evidence in
its favor for the use in low back pain, cancer pain, and neuropathic pain is insufficient10

Paracetamol is used for the relief of mild to moderate pain such as headache, muscle
aches, minor arthritis pain, toothache as well as pain caused by cold, flu, sprains,
and dysmenorrhea. It is recommended, in particular, for acute mild to moderate pain, since
the evidence for the treatment of chronic pain is insufficient 10

Usual dosing – For patients without risk factors for paracetamol hepatotoxicity, the
standard regimen is 1g four times a day. ¡ For patients with more than one hepatic risk
factor (old age, weight less than 50kg, poor nutritional status, fasting/ anorexia, chronic
alcohol use) – reduced dose of 500mg four times a day, increased if necessary to a
maximum of 3g per day in divided doses, is advisable. ¡ For patients with severe renal
impairment (eGFR>10 ml/min reduce dose to aximum of 3g/24hrs)

Considering her eGFR values which were greater than 10 ml/min it is appropriate to give
Paracetamol IV 1 gram three times daily for her pain.

Potassium Chloride Injection 20meq/10ml ( SINGLE )

Potassium Chloride for Injection Concentrate, USP, is a sterile, nonpyrogenic,
concentrated solution of potassium chloride, USP in water for injection administered by
intravenous infusion only after dilution in a larger volume of fluid. They are provided in
the following variety of concentrations and sizes comprising a choice of single-dose
containers, all designed to provide the commonly prescribed amounts of potassium
chloride for single-dose infusion after dilution in suitable large volume parenterals. 9

Potassium is the chief cation of body cells (160 mEq/liter of intracellular water) and is
concerned with the maintenance of body fluid composition and electrolyte balance.
Potassium participates in carbohydrate utilization and protein synthesis, and is critical in
the regulation of nerve conduction and muscle contraction, particularly in the heart.
Chloride, the major extracellular anion, closely follows the metabolism of sodium, and
changes in the acid-base balance of the body are reflected by changes in the chloride
concentration. Normally about 80 to 90% of the potassium intake is excreted in the urine,
the remainder in the stools and, to a small extent, in perspiration. The kidney does not
conserve potassium well so that during fasting, or in patients on a potassium-free diet,
potassium loss from the body continues, resulting in potassium depletion. A deficiency of
either potassium or chloride will lead to a deficit of the other. 9

The dosage of Potassium Chloride Injection is Up to 10 mEq/hr IV (max dose of 10

mEq/hr up to 200 mEq/day)
If K is < 2 mEq/L with ECG changes and/or muscle paralysis a max dose of 40 mEq/hr up
to 400 mEq/day
Potassium Chloride Concentrate 20% is used as a source of the potassium cation for the
treatment or prevention of potassium depletion in patients for whom dietary measures or
oral medication are inadequate. Potassium salts may also be used cautiously in those
taking digoxin where potassium depletion may cause arrhythmias. Potassium Chloride
Concentrate 20% must be administered by slow I.V, as a dilute solution.
The dose given was 60mmol which is not more than 200mEq ? day hence it is appropriate

16
 ]
considering her body weight of 65 Kg.9

Care Issue

Nil

Recommendation
Nil

Plan
CURRENT MEDICATIONS
TABS CIPROFLOXACIN 500MG, 12 HOURLY FOR 7 DAYS
TABS METRONIDAZOLE 4OOMG, 12 HOURLY FOR 7 DAYS
TABS PARACETAMOL 1G, 8 HOURLY FOR 7 DAYS

Goals of Therapy
To manage any form of pain associated with the condition, and the surgical wound.
To prevent complications such peritonitis, surgical site infection
To improve the patient’s quality of life
To normalize the WBCs count
To normalize the neutrophil count

Monitoring
Drug Efficacy Toxicity
Ringer-Lactate Infusion Monitoring the patient’s Fluid overload, peripheral
500ml ( SINGLE ) fluid status, electrolyte edema to respiratory
levels, and vital signs distress secondary
during administration pulmonary edema
Dextrose Infusion 5% Monitoring the patient’s Fluid overload, peripheral
(500ml) ( SINGLE ) fluid status, electrolyte edema to respiratory
levels, and vital signs distress secondary
during administration pulmonary edema
Paracetamol 1g IV Effective relief from Hepatotoxicity
(Pharmalgan) ( Single ) abdominal pains
Metronidazole infusion Normal WBC count Cerebral dysfunction,
(Workhardt) ( SINGLE ) altered mental states,
seizures
Ciprofloxacin Normal WBC count Acute kidney injury,
infusion,2mg/ml in 100ml tendinitis, altered mental

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status, complete blood
count,
Potassium Chloride Monitor serum potassium Fatal cardiac arrhythmia
Injection 20meq/10ml and cardiac arrest
( SINGLE )

Counselling
 Patient was counselled on:
1. Partaking in regular exercise
2. Appendicitis in general
3. Adopting a healthy diet
4. Reporting to the healthcare facility when encountered with complications

Role of the pharmacist in the management of the condition:

 To ensure drug adherence.
 To ensure there is no drug-drug interaction.
 To prevent missed doses by ensuring the availability of the needed
medications.
 To provide education and counselling.
 Reviewing the patient’s medications on a daily basis.
 Identification of medication related problems.
To assess and manage patient’s pain via a pain score
Outcome /Evaluation

References
1. Alvarado A: How to improve the clinical diagnosis of acute appendicitis in resource
limited settings. World J Emerg Surg. 2016, 11:16. 10.1186/s13017-016-
0071-8
2. British National Formulary (2022), 84th Edition, BMJ Group and Pharmaceutical
Press. Pages 218, 477, 1132, 1133.
3. Bunces-Orellana, O., Arevalo-Vidal, E., Bustos-Galarza, K., Ferrín-Viteri, M., Oleas,
R., Baquerizo-Burgos, J., & Puga-Tejada, M. (2020). Carbapenems versus
ciprofloxacin/metronidazole for decreasing complications and hospital stay
following complicated acute appendicitis surgery: A prospective cohort in an
Ecuadorian population. Cirugía y cirujanos, 88(3), 297-305.
4. Di Saverio S, Birindelli A, Kelly MD, et al.: WSES Jerusalem guidelines for
diagnosis and treatment of acute appendicitis. World J Emerg Surg. 2016,
11:34. 10.1186/s13017-016-0090-5

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5. "Metronidazole". The American Society of Health-System Pharmacists. Archived from
the original on 6 September 2015. Retrieved 31 July 2015

6. World Health Organization (2009). Stuart MC, Kouimtzi M, Hill SR (eds.). WHO
Model Formulary 2008. World Health.
Organization.p. 491. hdl:10665/44053. ISBN 9789241547659

7. Campoli-Richards DM, Monk JP, Price A, Benfield P, Todd PA, Ward A.

Ciprofloxacin. A review of its antibacterial activity, pharmacokinetic properties and
therapeutic use. Drugs. 1988 Apr;35(4):373-447. [PubMed]

8.Rehman A, Patrick WM, Lamont IL. Mechanisms of ciprofloxacin resistance in

Pseudomonas aeruginosa: new approaches to an old problem. J Med Microbiol. 2019
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9. Potassium Salts, General Monograph. CPS 32ed. Canadian Pharmaceutical Association,

Toronto, 1997: 1258-1259

10. Warwick C (November 2008). "Paracetamol and fever management". J R Soc Promot
Health. 128 (6): 320–
323. doi:10.1177/1466424008092794. PMID 19058473. S2CID 25702228.

11. .Liamis G, Filippatos TD, Elisaf MS. Correction of hypovolemia with crystalloid
fluids: Individualizing infusion therapy. Postgrad Med. 2015 May;127(4):405-
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