Boaz Gobera (NsambyaHospitalReport2021)

MBARARA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Faculty of medicine, Department of pharmacy
STUDENT’S NAME: GOBERA BOAZ

REGISTRATION NUMBER: 2017/PHA/020/PS
A REPORT OF THE HOSPITAL TRAINING AT ST. FRANCIS HOSPITAL

NSAMBYA SUBMITTED TO THE DEPARTMENT OF PHARMACY,
MBARARA UNIVERSITY OF SCIENCE AND TECHNOLOGY, IN
PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD
OF BACHELORS DEGREE OF PHARMACY
HOSPITAL SUPERVISOR: Dr. ANN NABACWA
UNIVERSITY SUPERVISOR: Dr. NUWAGIRA PETER
PERIOD OF TRAINING: FOUR WEEKS, JAN/FEB 2021

DECLARATION
I GOBERA BOAZ declare that the content of this report is entirely based on my Hospital training
experience at St. Francis Hospital Nsambya and it has never been submitted to any university or
institution of learning for any academic purpose.
GOBERA BOAZ
Name: …………………………… Signature: …………………………
Date: ……………………………….
This report has been submitted for examination and approval by the following supervisors.
HOSPITAL PHARMACIST, NSAMBYA

Dr. ANN NABACWA
Name: …………………………………… Signature: …………………………
Date: ……………………………….
UNIVERSITY SUPERVISOR
Dr. NUWAGIRA PETER

Name: …………………………………………. Signature: …………………………
Date: ……………………………….
I
ACKNOWLEDGEMENT
First and foremost, I dedicate this report to the glory of my Lord Jesus Christ who has blessed me
beyond anything I could ever have imagined and has loved me beyond my comprehension.
I appreciate my parents, Mr. Bampama Job and Mrs. Nandudu Fatuma who have tirelessly
provided for all my needs during the Hospital training.
I also appreciate the pharmacy department, Mbarara University of science and technology, which
has availed knowledge to me through lectures, seminars and practical sessions and endeavored to
allocate me for the hospital training.
I would like to thank St. Francis Hospital Nsambya for allowing me to have my training there.
This is such an inspiring Hospital I love to work for and/or make in future! May God bless St.
Francis Hospital abundantly above that which she can ever think or imagine!
I greatly thank my supervisors, the University supervisor, Dr. Nuwagira Peter and the Hospital
Pharmacist, Dr. Ann Nabacwa, who have tirelessly and continuously guided me through my
training.
I thank all the Nurses and Doctors of St. Francis Hospital Nsambya who allowed me to benefit
from their experience in their respective departments of the hospital. May God bless you.
I thank my group members (Ainembabazi Clinton, and Mafabi Pius Timothy) and the Intern
pharmacists with whom we worked and were able to complete the Hospital training.
Special thanks are conveyed to the Mbarara University pharmacy student’s association
(MBUPSA) which also contributed to the success of this Hospital training by availing students’
log books which were used during the training.
Finally, I dedicate this report to my beloved spiritual father Apostle Grace Lubega, who has taught
me the word (of God) and the application thereof; through which I have been able to manifest the
promises of God, including academic success and excellence. How could I excel without that word
you preach to me, which is from the very mouth of God?
II
TABLE OF CONTENTS
DECLARATION ............................................................................................................................. I
ACKNOWLEDGEMENT .............................................................................................................. II
TABLE OF CONTENTS .............................................................................................................. III
ABBREVIATIONS AND ACRONYMS .................................................................................. VIII
CHAPTER ONE: INTRODUCTION ............................................................................................. 1
1.1DESCRIPTION OF HOSPITAL PLACEMENT ................................................................................ 1
1.2DESCRIPTION OF PLACEMENT SITE ........................................................................................... 1
1.3TRAINING OBJECTIVES .................................................................................................................. 2
1.4TRAINING METHODS AND PROCEDURES USED ...................................................................... 2
CHAPTER TWO: STORES DEPARTMENT ............................................................................... 4
2.1 ORDERING OF SUPPLIES ............................................................................................................... 4
2.2 PROCUREMENT PROCESS............................................................................................................. 5
2.3 GOODS STORAGE PRACTICES ..................................................................................................... 5
2.4 INVENTORY MANAGEMENT ....................................................................................................... 6
2.4.1 Documentation/record keeping .................................................................................................... 6
2.4.2 Stock cards ................................................................................................................................... 7
2.4.2.1 Parts of a stock card .............................................................................................................. 7
2.4.3 ABC analysis ............................................................................................................................. 10
2.4.4 The physical count ..................................................................................................................... 10
2.4.5 What to do with expired stock ................................................................................................... 11
CHAPTER THREE: PHARMACY .............................................................................................. 12
3.1 ISSUING OF ITEMS FROM THE STORE ..................................................................................... 12
3.2 DISPENSING OF DRUGS............................................................................................................... 12
3.2.1 Steps involved in dispensing ...................................................................................................... 12
CHAPTER FOUR: WARDS AND CASE WRITEUPS .............................................................. 14
4.1 CASE STUDY 1: SEVERE MALARIA AND BILARTERAL ACUTE OTITIS MEDIA ............. 14
4.1.1 Introduction ................................................................................................................................ 14
4.1.1.1 Malaria ................................................................................................................................ 14
4.1.1.2 Otitis media ......................................................................................................................... 14
4.1.2 Patient demographics ................................................................................................................. 14
4.1.3 Subjective information ............................................................................................................... 14
4.1.4 Past medical history (subjective) ............................................................................................... 15
4.1.5 Objective information ................................................................................................................ 15
4.1.5.1 Vitals ................................................................................................................................... 15
III
4.1.5.2 Hemo parasites tests ............................................................................................................ 15
4.1.5.3 Urinalysis ............................................................................................................................ 16
4.1.5.4 Haeme studies (only derangements are indicated) .............................................................. 16
4.1.6 Current medication plan ............................................................................................................. 17
4.1.7 Current Pharmaceutical care plan .............................................................................................. 17
4.1.8 Pharmacology of the drugs used in case study 1........................................................................ 19
4.2 CASE STUDY 2: SEVERE BRONCHOPNEUMONIA ................................................................. 21
4.2.1 Introduction ................................................................................................................................ 21
4.2.1.1 Causes of pneumonia .......................................................................................................... 21
4.2.1.2 Predisposing factors ............................................................................................................ 21
4.2.1.3 Pneumonia in a Child of 2 months-5 years ......................................................................... 21
4.2.4 Subjective Information ............................................................................................................... 22
4.2.5 Past medication history(subjective) ........................................................................................... 23
4.2.6.1 Vitals ................................................................................................................................... 23
4.2.6.2 Full Blood Count (only derangements indicated) ............................................................... 24
4.2.6.3 Other tests ........................................................................................................................... 24
4.2.7 Current Medication plan ............................................................................................................ 25
4.3 CASE STUDY 3: ISCHEMIC STROKE [CEREBROVASCULAR ACCIDENT (CVA)] AND
RESOLVING COVID-19 PNEUMONIA .............................................................................................. 28
4.3.1 Introduction ................................................................................................................................ 28
4.3.1.1 Causes of stroke .................................................................................................................. 28
4.3.1.2 Clinical features of stroke ................................................................................................... 28
4.3.1.3 Investigations done ............................................................................................................. 28
4.3.3 Subjective data ........................................................................................................................... 29
4.3.4 Past medical history ................................................................................................................... 29
4.3.5.1 vitals .................................................................................................................................... 30
4.3.5.2 HRCT-chest report (12th/2/2021) ........................................................................................ 30
IV
4.3.5.3 Brain CT scan report (11th/2/2021) ..................................................................................... 30
4.3.5.4 Liver Function Tests (LFTs) ............................................................................................... 30
4.3.5.5 Renal Function Tests (RFTs) .............................................................................................. 31
4.3.5.6 Complete Blood Count........................................................................................................ 31
4.3.5.7 Other tests ........................................................................................................................... 32
4.3.7 Current pharmaceutical care plan............................................................................................... 33
4.4 CASE STUDY 4: SHINGLES, URINARY TRACT INFECTION AND PEPTIC ULCER
DISEASE ................................................................................................................................................ 39
4.4.1 Introduction ................................................................................................................................ 39
4.4.1.1 Cause of Shingles ................................................................................................................ 39
4.4.1.2 Clinical features .................................................................................................................. 39
4.4.3 Subjective information ............................................................................................................... 39
4.4.4 Past medical history ................................................................................................................... 40
4.4.5.1 Vitals ................................................................................................................................... 40
4.4.5.2 Complete blood count (CBC) ............................................................................................. 41
4.4.5.3 Renal Function Tests ........................................................................................................... 41
4.4.5.4 Urine parasites tests ............................................................................................................ 42
4.4.5.5 Other tests ........................................................................................................................... 42
CHAPTER FIVE: CONCLUSIONS AND RECOMENDATIONS............................................. 48
5.1 CONCLUSION ................................................................................................................................. 48
5.1.1 LEARNING EXPERIENCE THROUGH THE TRAINING ........................................................ 48
5.2 CHALLENGES THE DURING TRAINING ................................................................................... 48
5.3 RECOMMENDATIONS .................................................................................................................. 48
5.3.1 To the Hospital ........................................................................................................................... 48
5.3.2 To the University ....................................................................................................................... 49
REFFERENCES ........................................................................................................................... 50
APPENDICES .............................................................................................................................. 51
V
APPENDIX 1: PRESCRIPTION ............................................................................................................ 51
APPENDIX 2: PAYMENT RECEIPT ATTACHED TO A PRESCRIPTION ...................................... 52
VI
ABBREVIATIONS AND ACRONYMS
µL Microliter
ACTs Artemisinin-based Combination therapy
ALP Alkaline phosphatase
ALT Alanine transaminase
AMC Average Monthly Consumption
ARB Angiotensin Receptor blocker
AST Aspartate aminotransferase
BCG Bacille Calmette-Guerin
bd Two times a day
BP Blood pressure
BS Blood sample
bpm Beats per minute
Cap Capsules
CBC Complete Blood Count
CCB Calcium channel blocker
CHF Congestive Heart Failure
CNS Central Nervous System
COVID Coronavirus disease
CrCl Creatinine clearance
CRP C-Reactive protein
CVA Cerebrovascular accident
CYP450 Cytochrome P450
D5 Dextrose 5% solution
DIB Difficulty in breathing
DM Diabetes Mellitus
DNA Deoxyribonucleic acid
DOA Date of admission, Day of admission
FEFO First expiry first out
FIFO First in first out
fL femtoliter
GBW General Body Weakness
GRN Goods Received Note
Gutt. Drops
Hb Hemoglobin
HIV Human Immunodeficiency virus
HMGCoA 3-hydroxy-3-methylglutaryl Coenzyme A
HSV Herpes simplex virus
HTN Hypertension
IM Intramuscular
VII
IU International Units
IV Intravenous
kg Kilogram
L Liter
LFTs Liver function tests
LPO Local Purchase Order
MCH Mean Corpuscular Hemoglobin
MCHC Mean Corpuscular Hemoglobin Concentration
MCV Mean Cell Volume
mg Milligram
MI Myocardial infarction
ml Milliliter
mmHg millimeters of mercury
MPs Malaria parasites
MUST Mbarara University of Science and Technology
NCHE National Council for Higher Education
NMS National Medical Stores
NS Normal saline solution
NSAID Non-steroidal anti-inflammatory drug
OPD Out Patient Department
pg picograms
PNFP Private not for profit
po Orally
PR Pulse Rate
prn As required
PUD Peptic ulcer disease
q4h Every four hours
q8h Every eight hours
qid Four times in a day
RBC Red Blood Cell
RBS Random blood sugars
RDW Red blood cell Distribution Width
RFQ Request for Quotation
RFTs Renal function tests
RH Relative humidity
RHD Rheumatic heart disease
RL Ringers Lactate solution
RNA Ribonucleic acid
RR Respiratory Rate
RTI Respiratory tract infection
SC Subcutaneous
VIII
SCD Sickle cell disease
SpO2 Peripheral capillary oxygen saturation
𝑡1⁄ Half life
2
Tab. Tablet
tds Three times a day
Temp. Temperature
TFI Total Fluid Intake
UBT Urea Breath Test
UTI Urinary tract infection
WBC White Blood Cell
IX
CHAPTER ONE: INTRODUCTION
1.1 DESCRIPTION OF HOSPITAL PLACEMENT
As accredited by the Uganda National Council for Higher Education (NCHE), Mbarara University
of Science and Technology (MUST), commonly known as Mbarara University, is the second
public university in Uganda, after Makerere University. Mbarara University commenced student
intake and instruction in October 1989. It is one of the eight public universities and degree-
awarding institutions in the country. The Mbarara Campus is in the town of Mbarara, on the
Mbarara-Kabale Highway, approximately 266 kilometers (165 miles) southwest of Kampala
[Uganda’s capital and largest city]. MUST has contributed to the transformation of theoretical
knowledge into practical skills through programs like, community placement, Industrial training
and hospital training. The hospital training program was introduced in the academic year
2015/2016 to allow for pharmacy students to be equipped with the necessary knowledge, skills
and clinical guidelines required for competition globally. Irrespective of all the COVID-19
challenges, the 2020/2021 hospital placement was conducted for four weeks, from the month of
28th January, 2021 to 25th February, 2021.
1.2 DESCRIPTION OF PLACEMENT SITE
St. Francis Hospital Nsambya, commonly known as Nsambya Hospital, is a private not-for-profit
(PNFP) hospital on Nsambya Hill in Makindye Division in Kampala approximately 6 kilometers
(4 miles) southeast of Mulago National Referral Hospital. Nsambya hospital is a referral hospital
with a bed capacity of 361 beds. It is involved in patient care, research and teaching.
It offers specialist services in surgery, internal medicine, pediatrics, obstetrics and gynecology. In
addition, there are specialized services in urology. It has both general and private patient facilities.
Founded way back in 1903, Nsambya is a Catholic Mission Hospital owned by the Archdiocese
of Kampala and managed by the Little Sisters of St. Francis of Assisi.
The hospital has undergone major expansion since its inception and has recently built and
expanded the pharmacy and Out Patient Department (OPD) departments. Nsambya Hospital has
an average of 19,000 admissions every year and receives an average of 300 out-patients everyday
with 5500 deliveries annually.
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Mandate: Provision of quality affordable health care, backed by continuous training and research.
Vision: Satisfied customers pursuing healthy productive lives.
Mission: To provide sustainable quality Health Care, Training and Research without
compromising the efficiently disadvantaged.
Customer Value Proposition: Nsambya Hospital is committed to providing, prompt, quality and
affordable healthcare.
Core values
(i) Commitment to Catholic values

(ii) Integrity
(iii) Professionalism
(iv) Mutual staff respect
(v) Equitable treatment of external and internal clients
(vi) Hard work and provision of quality services
1.3 TRAINING OBJECTIVES
(i) To provide students with an insight of the future career opportunities.

(ii) To develop appropriate personality and understanding of work, individuals and teams
in the hospital work situations through hands-on-training experience, which may help
career choice.
(iii) To increase the students’ clinical knowledge and understanding, by developing his/her
intellectual skills in analyzing patient care challenge, proposing solutions to them and
working with the healthcare teams to improve the patients’ quality of life.
(iv) To improve students’ skills associated with scientific and technological operations in
the hospital, for example, drug dispensing, inventory management, and report writing.
1.4 TRAINING METHODS AND PROCEDURES USED
The following are some of the methods and procedures used in the training;
(i) Ward rounds: These were conducted every day from 9:00pm to 12:00pm. Doctors, nurses,
intern students, and the trainees participated in these sessions.
2
(ii) Discussions: These were done while on ward rounds, in the pharmacy store, dispensary,
and during break times.
(iii) Assignments: These were given by the hospital pharmacist, nurses, and also self-given
assignments.
(iv) Hands-on-training: This was through dispensing, reception of ordered items, issuing of
items and stock card filling.
(v) Asking Relevant Questions: During any activity in which students participated.
(vi) Presentations: The patient cases and assignments were presented to the responsible
supervisors.
3
CHAPTER TWO: STORES DEPARTMENT
The hospital store has various functions, that is, ordering for and procurement of supplies from
suppliers, receiving the items, storage of the items, issuing of the supplies, stock maintaining. This
is known as stock management/ inventory management.
2.1 ORDERING OF SUPPLIES
Before ordering / replenishment of supplies from the suppliers, the following are considered;
(1) Calculation of Average Monthly Consumption (AMC)

𝑇𝑜𝑡𝑎𝑙 𝑞𝑢𝑎𝑛𝑡𝑖𝑡𝑦 𝑖𝑠𝑠𝑢𝑒𝑑 𝑖𝑛 𝑡ℎ𝑒 𝑝𝑎𝑠𝑡 4 𝑚𝑜𝑛𝑡ℎ𝑠
𝐴𝑀𝐶 =
4
(2) Lead time: This is the lapse in time between when an order is placed to
replenish inventory and when the order is received. Lead time affects the amount
of stock the hospital needs to hold at any point in time because the hospital ought not to
run out of stock even during the lag time. At Nsambya hospital, the Lead time is 1 week.
(3) Buffer stock: Also known as safety stock inventory, is the level of extra stock that is
maintained to mitigate risk of run-out for supplies due to uncertainties in supply or demand.
Safety stock also depends on lead time. Whenever the stock reaches buffer stock, the ‘SAP
Business One’ system makes an alarm. At Nsambya, buffer stock is calculated from the
formula;
1
𝐵𝑢𝑓𝑓𝑒𝑟 𝑠𝑡𝑜𝑐𝑘 = 𝑥 𝐴𝑀𝐶
4
(4) Maximum stock: it is calculated from the formula;
𝑀𝑎𝑥𝑖𝑚𝑢𝑚 𝑠𝑡𝑜𝑐𝑘 = 𝐴𝑀𝐶 + 𝐵𝑢𝑓𝑓𝑒𝑟 𝑠𝑡𝑜𝑐𝑘
(5) Order quantity: This is the actual quantity to be ordered. It’s calculated from the formula;
𝑂𝑟𝑑𝑒𝑟 𝑞𝑢𝑎𝑛𝑡𝑖𝑡𝑦 = 𝐴𝑀𝐶 + 𝐵𝑢𝑓𝑓𝑒𝑟 − 𝑆𝑡𝑜𝑐𝑘 𝑜𝑛 ℎ𝑎𝑛𝑑
After all the above is considered, a purchase request is raised which goes to the head of department
for approval, then to head of stores. The procurement committee meeting is then conducted which
involves Heads of departments, accounting officer, head of finance.
4
2.2 PROCUREMENT PROCESS
(1) The request for quotation (RFQ) is sent to the supplier. This requests the supplier to quote
for the client (hospital) the available items, batch numbers, manufacturing dates, expiry
dates, and unit prices.
(2) The supplier replies with a proforma invoice, presenting what items the supplier has, their
batch numbers, manufacturing dates, expiry dates, stock availability, and the unit costs of
each item.
(3) The hospital raises a local purchase order (LPO) indicating what items they need, and the
quantities. The LPO expires within a week.
(4) Delivery: The delivered items come with an invoice and delivery note. There should be no
variations between the LPO, invoice and the delivery note. At Nsambya hospital, goods
are always bought on credit with an allowance of 45 days to pay.
(5) Receiving of items: The goods are checked for expiry dates, manufacturing dates, batch
numbers, and any damages. It’s always a good practice to receive the goods from outside
the store. The stores officer then signs on the invoice and a copy is kept. Only goods with
long expiry dates are ordered for. However, goods with near expiry dates (<6months) can
be allowed provided the supplier gives a commitment letter, which shows the supplier’s
commitment to either replace or pay for the items in case they expire in the store.
(6) A goods received note (GRN) is posted.
2.3 GOODS STORAGE PRACTICES
During storage of items, temperatures and relative humidity of the storage room must be well
controlled and monitored daily. There are three storage conditions as shown below;
Storage conditions Items

2-8oC Cold chain items like;
Injections (Neurorubine, insulin, some liquid antibiotics, oxytocin)
Vaccines (Anti Rabies Vaccine, Tetanus vaccine)
Anticancers (carboprost)
<25oC (50%RH) Most tablets
25-30oC Mannitol, dry powders
5
2.4 INVENTORY MANAGEMENT
Inventory management, also known as stock management, involves all the policies, procedures,
and techniques used to maintain the optimum amount of each item in stock. It involves ordering,
receiving, storing, issuing, and reordering items. The basic elements of the stock control system
include: Manual systems (stock cards), and Electronic systems (equivalent to a stock book in
government hospitals).
2.4.1 Documentation/record keeping
Stock management enables one to track an item’s consumption history to quantify future needs. It
is therefore necessary to keep correct records of an item. The tools used to keep stock records are
the stock cards and the stock books (the electronic system). From these, one can calculate the
average monthly consumption (AMC), minimum stock, maximum stock, what to order and when
to order.
Benefits of keeping good records
(i) Good records allow for easy estimation of the cost of medical supplies for the year so that
a budget can be prepared.
(ii) Record keeping ensures that the staff does what they are supposed to do correctly.
(iii) Good records protect the staff against accusations of misuse or theft of medicines and
health supplies.
(iv) When the arrival of medicines and health supplies is always tracked, the stuff is protected
against cases of disputed delivery.
(v) Good records prevent under stocking and stock-outs because stock balances are known at
all times and items can be ordered in time to ensure availability
(vi) Prevents overstocking and wastage because large quantities of stock can be redistributed
before it expires.
(vii) Good records save time because:
• The time when to order which medicines can be established.
6
• The store can easily be handed over to a colleague; if one is not at work, others can
understand the quantities of medicines and supplies available at the health facility by
looking at the stock cards.
• The expected quantity in stock is known before doing a physical count.
• Patterns of use at your health facility can be determined and any unusual changes
detected.
2.4.2 Stock cards
The stock card is a record of all transactions related to items received or issued out of the store.
Each item should have a stock card. Stock cards track the movement of medicines and health
supplies in the stores and one card is kept for each item in the store. Each time a transaction takes
place, it is recorded on the stock card; for example, receipt of new stock, issuing of item, or
physical count. There is a separate stock card for similar items if they have: -
• Different pack sizes (e.g., paracetamol 500 mg pack of 100 tablets and paracetamol 500
mg pack of 1000 tablets).
• Different strengths or weights or volumes (e.g., co-trimoxazole 400/80 mg tablets and
cotrimoxazole 800/160 mg tablets, metformin 1000mg tablets and metformin 500mg
tablets, prednisolone 5mg tablets and prednisolone 8mg tablets).
• Different formulations (e.g., flucamox syrup and flucamox capsules).
• Different drug release rates of the same formulations (e.g., metformin SR 1000mg and
metformin 1000mg).
Preferably, the stock card is kept with the item on the shelf or on top of the refrigerator for items
stored in the refrigerator.
2.4.2.1 Parts of a stock card

(1) Header information: includes health unit name and level of care and the Health Unit Code
provided by the Ministry of Health (MOH)
(2) Item description: comprises name of item, dosage form and strength
(3) Pack size: e.g., metformin 1000mg tablets box of 60’s.
(4) Code no.: the official number of the item as given by the medical store (e.g., NMS)
7
(5) Special storage conditions: e.g., refrigeration (2-8oC)
(6) Unit of issue: the smallest unit of the item issued from the store (e.g., 1,000 tablets for co-
trimoxazole)
(7) AMC: the quantity of items consumed per month called average monthly consumption; it
should be calculated periodically because the consumption rate may vary; AMC is useful
in determining the maximum and minimum stock.
(8) Maximum stock level: the largest amount of stock that should be held by the facility.
(9) Minimum stock level: the lowest amount of stock that should be held by the facility.
(10) Date: the date when the transaction (receipt or issue) is made; each transaction should be
recorded on a separate row.
(11) To or from: the location where the product is coming from or is being sent to is entered
here.
(12) Voucher number: any transaction (except a loss or adjustment) should always be
accompanied by a voucher.
(13) Quantity in: the number of packs of the item received is entered here (e.g., 50 packets of
Aspirin 75mg tablets).
(14) Quantity out: the pack units of the amount of an item being given out.
(15) Losses/adjustments: refers to any issue out of the store for reasons other than consumption
within the facility
• Changes in your stock due to removal of expired items, damaged items, theft, or
adjustments to stock numbers during stock-taking (i.e., if the actual physical count
does not add up with the numbers on the stock card)
• Redistribution to other facilities should be recorded as a loss (inserting the negative
sign [−] before the figure)
• Gains in stock quantities by means other than normal procurement channels (e.g.,
borrowing from a neighboring facility) should be recorded as an adjustment
(inserting the positive sign [+] before the figure)
(16) Balance on hand: the balance remaining after adding quantities received or subtracting
quantities issued or making adjustments for losses from the previous stock balance
(17) Expiry date: the expiry date for each new item received should be written in the given
space
8
(18) Batch no.: record the batch or lot number indicated on the manufacturer’s packaging on
every new item received.
(19) Remarks: record any necessary comments, notes, or explanations (for example; physical
count).
(20) Initials: the person updating the stock card should fill in his or her initials.
Note: The used stock cards are kept for at least six years in a file or in a clearly labelled envelop
for auditing purposes.
Figure 1: The major features in a stock card
9
2.4.3 ABC analysis
This is a tool of stock management where the inventory is classified in three classes; A, B and C
depending on the value, and quantity.
Class Description
Value Quantity Control Importance
Class A Highest Least Strict & Constant (stock taking Highly
done periodically) important
Class B Moderate Moderate Need based control Moderately
important
Class C Least Highest Little control Least
important
2.4.4 The physical count
This refers to counting the amount of actual stock on the shelf and recording the balance on the
stock card. Physical count is done every quarter in the store, and for items with stock cards in the
main pharmacy (dispensary), it’s is done after every shift.
The purpose of a physical count is to; -

• Verify the stock level of medicines and health supplies
• Verify the accuracy of stock-keeping records
• Detect losses of medicines and health supplies in the store
• Ensure all stock in the store is usable (not damaged or expired)
• Determine whether the stock will be used up before the expiry date or if you need to take
action to redistribute.
Physical count is done by the store keeper and another member from the facility management. If
the actual number (quantities) available does not equal the amount or the balance stated on the
stock card, you should record the actual amount (physical count) and then investigate the
discrepancy. This is done by; -
(i) Checking the entries and arithmetic since the last physical count
(ii) Checking with other staff members and ensuring all entries have been made
(iii) Checking quantities dispensed in the bin cards against the entries on the stock card
10
(iv) Notifying your supervisors (e.g., data entrants, pharmacist, pharmacy technician)
(v) Involving the police if necessary
2.4.5 What to do with expired stock
(1) They are removed from the shelves and then recorded in the stock card as a negative
adjustment so that the correct balance on hand is calculated.
(2) The expired stock is collected in a salvage area.
(3) All expired items are recorded in the register along with the prices.
(4) For items without commitment letters from the suppliers, they are taken to NMS for destruction
under the hospitals’ expense.
(5) However, for items with commitment letters, they are taken back to the supplier for either
replacement or payment.
11
CHAPTER THREE: PHARMACY
3.1 ISSUING OF ITEMS FROM THE STORE
An order (inventory request form) is posted from the main pharmacy, the pharmacist/Managing
director approves the order, then it’s forwarded to the store’s manager for issuing. The store’s
manager issues the items together with the inventory transfer form. The issued items are cross-
checked as per the inventory transfer form, then distributed between the night pharmacy and day
pharmacy. Currently, both the night pharmacy and day pharmacy are considered as one warehouse
in the electronic system. Only items in the pharmacy warehouse [not in the store] can be billed to
inpatients and out patients and issued to the Wards.
3.2 DISPENSING OF DRUGS
This is the process of preparing and giving correct medicine to a named person on the basis of a
prescription. Dispensing ensures that the patient receives;
• The correct medicine.
• The correct amount of the medicine.
• The correct information about the medicine and how to use the medicine.
3.2.1 Steps involved in dispensing
Step 1 Check the prescription (and the payment receipt)
 Check for the patient’s particulars (name, gender, age, weight), the diagnosis, treatment as
well as the name and signature of the prescriber.
 Check that the treatment prescribed is as per the Uganda Clinical guidelines
 Check that the medicines, dosages and strength prescribed are appropriate for the patient
age and weight.
 Check that the payment receipt, unless otherwise explained by the patient, fits the
prescription drug list in dosage and duration.
12
Step2 Prepare the medicines
 Collect the container/packets of the medicines; check the name, strength and expiry date
of the medicine. Pack and label the right amount of the medicine and record the transaction
on the bin card/stock card, where necessary.
Step 3 Double check information and counting
 The packed medicines are checked to ensure that the right medicine and right quantities
have been packed as per both the prescription and the payment receipt.
Step 4 Dispense the medicines
 A dispensing envelop is labeled with the medicine name, strength, dosage form, direction
of use, quantity dispensed, and any precautions necessary (like No alcohol for
metronidazole, no dietary products for fluoroquinolones, drink plenty of fluids for
cotrimoxazole)
Step 5 Provide appropriate information
 Teach the patient or their care taker how to use the medicine.
 Tell the patient the name of the medicine, its form (tablet, suppository, syrup etc.), and why
and how they should use the medicine; for example, when to take the medicine (e.g.,
morning for diuretics), how much of the medicine to take (e.g., 2 tablets, ½ a tablet, 1 tablet
etc.), how long to take the medicine (e.g., for two days, for 7 days), how to take the
medicine (with food, after food, or before food)
 Show the patient how to measure the right dose by breaking the tablet or using the
measuring cup/spoon and in which conditions to store the medicines e.g., in a fridge for
reconstituted syrups or away from direct light.
 Patients should be advised to complete the dose even if they feel better before completion,
especially for antibiotics, they should not share their medicines with others and they should
note that medicines are poisons when not well used.
13
CHAPTER FOUR: WARDS AND CASE WRITEUPS
4.1 CASE STUDY 1: SEVERE MALARIA AND BILARTERAL ACUTE OTITIS MEDIA
4.1.1 Introduction
4.1.1.1 Malaria
Malaria is an acute febrile illness caused by infection with plasmodium parasites and is transmitted
from person to person by an infected female anopheles mosquito.
Causes of malaria
There are five Plasmodium species of malaria parasites which infect humans, namely: P.
falciparum, P. vivax, P. ovale, P. malariae and P. knowlesi. P. falciparum is the most virulent and
also the most common malaria parasite in Uganda.
4.1.1.2 Otitis media
Otitis media is an acute or chronic infection of the middle ear occurring mostly in children <2years.
Causes of otitis media
Bacterial infection, e.g., Streptococcus pneumoniae, Haemophilus influenzae.
Commonly follows an acute infection of the upper respiratory tract.
4.1.2 Patient demographics
Name Initials: MJ Age: 2years Gender: Male

Tribe: Muganda Address: Makindye-Kampala Religion: Catholic
Next of kin: Father/Mother Ward: Pediatric, St. Theresa Bed No.: 20
DOA: 13th/2/2021
4.1.3 Subjective information
MJ, a 2-year-old male presented with high grade fever associated with chills. No sweating, no
convulsions. This is the first day of admission (1DOA), 14th/02/2021. Father reports that he was
previously managed for severe malaria 10 days ago with IV artesunate (3 doses) but without oral
Artemisinin-based combination therapy (ACTs), then a week later he was managed for otitis media
14
with flucamox syrup, diclofenac suppositories, and paracetamol syrup and montelukast tablets
with noted improvement.
4.1.4 Past medical history (subjective)
No known drug allergies
Diagnosis Medication Date started Date ended

(Name/Strength/dosage)
Severe malaria Artesunate 42mg IV at 0 hours, 1th/2/2021 2/2/2021
12hours and 24hours
No oral ACTs were used
Bilateral acute Otitis Syrup Flucamox ([125/125mg]/5mls) 8th /2/2021 13th/2/2021
media 5mls tds po for 5days
Diclofenac suppositories 100mg 8th/2/2021 8th/2/2021
rectally stat.
Paracetamol syrup (250mg/5ml); 5ml 8th/2/2021 ………..
po tds prn for 3 days
4.1.5 Objective information
4.1.5.1 Vitals
Date SPO2 (%) Temp (oC) BP (mmHg) PR (bpm) Weight
Reference ranges 95-100 36.1-37.2 <120/80 80-120 12.5kg
15th/02/2021 (2DOA) 99 (room air) 38.3 123/77 93 14kg
16th/02/2021 (3DOA) 98 (room air) 37.7 126/80 86 14kg
17th/02/2021 (4DOA) 100 (room air) 35.2 120/84 88 13.9kg
4.1.5.2 Hemo parasites tests

8th/2/2021 13th/2/2021 (DOA) 15th/2/2021 (2DOA) 16th/2/2021 (3DOA)
Malaria No Malaria 15 MPs /HPF 5 MPs/HPF No MPs
Microscopy Parasites (MPs)
15
4.1.5.3 Urinalysis
Appearance 8th/2/21 14th/2/21 (1DOA)
Appearance Pale yellow, clear Yellow, clear
Specific gravity (1.005-1.010) 1.010 1.020**
Glucose and Urobilinogen Normal Normal
Blood/Hb, bilirubin, ketone, Negative Negative
Leucocyte esterase, nitrite,
protein
pH (6.5-7.0) 8** 6**
4.1.5.4 Haeme studies (only derangements are indicated)

Test Reference ranges 8th/2/2021 13th/02/2021 15th/02/2021
(DOA) (2DOA)
RBC (x106/µL) 3.10-5.70 2.91
Hematocrit (%) 35.0-44.0 29.6 25.4 20.4
Hemoglobin (g/dL) 9.5-13.5 7.9 7.1
Mean Cell Volume (fL) 76.0-92.0 71.8 73.1 69.9
MCHC (g/dL) 28.0-33.0 34.2 34.8
MCH (pg) 23.0-31.0 22.7
RDW (%) 11.0-16.0 19.7 18.9 21.4
Platelets (x103/µL) 150-400 125 124
Neutrophils (%) 35.0-47.0 51.3 25.5
Lymphocytes (%) 40.0-45.0 61.0
Monocytes (%) 3.0-11.0 18.2 11.8
Eosinophils (%) 1.0-5.0 0.1 0.5
Basophils (%) 0.0-0.1 0.7 0.8 1.2
16
4.1.6 Current medication plan
Date Diagnosis Medication Date started Date Ended

(name/Strength/Dosage)
Severe malaria and Ceftriaxone 700mg IV 13/02/2021 17/2/2021
bilateral acute otitis od x 5/7
13th/02/2021 media Paracetamol 210mg IV 13/02/2021 16/2/2021
(DOA) tds x 4/7
Quinine 140mg in 140ml 13/02/2021 16/2/2021
of D5% IV tds until BS
is negative and able to
take oral ACTs
4.1.7 Current Pharmaceutical care plan
Date Disease related Medication Action taken Result of action

problem related problem
14th/02/2021 Persistent Dosage too low Increase paracetamol Fevers reduced
(1DOA) fevers dosage from 210 mg IV tds
to 210mg IV qid prn
15th/02/2021 Resolving Continue Quinine 140mg in Reduced the
(2DOA) malaria 140ml of D5% IV tds until MPs to none
able to use oral ACTs, and
BS is negative
Resolving Continue Ceftriaxone Treated the
acute otitis 700mg IV od x 3/7 bacterial
media infection
16th/02/2021 Resolving Inappropriate Stop paracetamol IV managed fevers
(3DOA) fevers drug therapy Start Syrup paracetamol less
(250mg/5mls); 5ml po tds aggressively
prn
17
17th/02/2021 Developing Additional drug Start: Syrup Treated the
(4DOA) wet cough and therapy amoxicillin/clavulanic acid cough, and
resolving (200/28.5mg/5ml); 5ml po resolving otitis
Acute otitis tds x 5/7 media
media
17th/2/2021 Mild anemia Additional drug Start Treated the
(4DOA) therapy Folic acid tablets 5mg po od anemia
x 1/12
Resolving Unnecessary Stop IV Quinine Correctly
severe malaria drug therapy Start managed the
(repeat BS was Additional drug Dihydroartemisinin/piperaq malaria as per
negative) therapy uine (40/320) tablets the guidelines
Take 1 tablet po od x 3/7
Resolving mild Continue paracetamol syrup Managed
fevers (250mg/5ml); 5ml po tds fevers
prn
Patient counselling points and discharge plan (18/2/2021)
(1) Comply with malaria control methods like sleeping under a treated mosquito net, wearing long
sleaved clothes during the evening hours, closing windows and doors as early as 3:00pm,
clearing bushes and stagnant water around the compound.
(2) Increase fluid intake (Total fluid intake, TFI of 1.2L/day)
(3) Ensure compliance to medication, especially the oral medicines.
(4) Stop IV ceftriaxone.
(5) Discharge drugs are;
• Paracetamol syrup (250mg/5mls) drink 5ml orally every 8 hours when required
• Folic acid 5mg tablets take 1 tablet po once daily for 30 days
• Dihydroartemisinin/piperaquine (40/320mg) tablets; 1 tablet po once daily for 3 days
• Syrup amoxicillin/clavulanic acid (200/28.5mg/5ml); drink 5ml po every 8hours for 5 days
18
4.1.8 Pharmacology of the drugs used in case study 1
Drug and class Mechanism of action Pharmacokinetics Side effects &

Drug interactions
Ceftriaxone Bactericidal; Inhibits Administered Side effects:
(beta-lactam, 3rd bacterial cell wall parenterally (IV, or Leukopenia,
generation mucopeptide IM); eosinophilia, seizures,
cephalosporin) synthesis Metabolism; CYP450 anaphylaxis,
𝑡1⁄ 5.8-8.7h; nephrolithiasis.
2
Excretion: urine Drug Interactions: Risk
unchanged (33-67%), of Kidney and lung Ca-
bile/feces ceftriaxone ppt with

Calcium chloride and
Calcium gluconate
Paracetamol (anilide Unknown; Administered orally, Side effects:
Non-steroidal Anti- antipyretic effect via IV, rectally; Hypersensitivity
inflammatory Drug, direct action on Metabolism: liver reaction,
NSAID) hypothalamic heat- CYP1A2, CYP2E1; Anaphylaxis,
regulating center toxic metabolites; hepatotoxicity.
Excretion: urine Drug Interactions:
unchanged (5-10%); Methemoglobinemia
𝑡1⁄ 2-4hours with topical benzocaine
2
and lidocaine
Quinine (antimalarial) Binds to hemazoin in Administered by oral, Side effects:
parasitized IV routes; Cinchonism; QT
erythrocytes Metabolism: hepatic by prolongation; deafness;
CYP3A4 to active urticaria; tinnitus.
metabolites; Drug interactions:
Excretion: urine (20% Quinine levels increased
unchanged), 𝑡1⁄ 9.7- with fluconazole,
2
Posaconazole;
19
12.5. acidic urine Increased risk of
doubles excretion rate. ototoxicity with
amikacin
Folic acid (vitamins) Participates in DNA Administered oral, IV, Side effects: Nausea,
synthesis and IM, or SC routes; altered sleep patterns,
erythropoiesis Metabolism: liver to abdominal pain, rash
active metabolite. Drug interactions:
Excretion: urine; Cholestyramine and
storage in the liver colestipol decrease folic
acid absorption/efficacy
Amoxicillin/clavulanate Amoxicillin inhibits Administered by oral, Side effects: C. difficile
(Bata-lactam penicillin, cell wall IV food. -associated diarrhea,
plus a beta-lactamase mucopeptide Metabolism: liver rash, urticaria,
inhibitor) synthesis; (10% amoxicillin & candidiasis, elevated
Clavulanate causes 50% clavulanate) LFTs.
suicide inhibition of Excretion: urine Drug interactions:
beta-lactamases; primarily (60-75%) increases methotrexate
unchanged 𝑡1⁄ 1h, 12h levels.
2
(severe renal disease) Synergistic effect with

amikacin.
Dihydroartemisinin / Dihydroartemisinin: Administered by oral Side effects: Nausea,
piperaquine undergoes cleavage route. anorexia, abdominal
(Artemisinin-based of endoperoxidase Metabolism: liver pain, diarrhea,
combination bridge by iron, Elimination: bile dizziness, itching
antimalarial, ACT) producing free
radicals
Piperaquine:
interferes with the
detoxification of
heme to hemozoin
20
4.2 CASE STUDY 2: SEVERE BRONCHOPNEUMONIA
4.2.1 Introduction
Pneumonia refers to acute infection and inflammation of the alveoli. There are two major types of
pneumonia i.e.
 Bronchopneumonia: involves both the lung parenchyma and the bronchi. Common in
children and the elderly
 Lobar pneumonia: involves one or more lobes of the lung. Common in young people
4.2.1.1 Causes of pneumonia

Pneumonia can be caused by viruses, bacteria, or parasites. Pathogens vary according to age,
patient’s condition and whether infection was acquired in the community or hospital (recall: Gram
negatives are more common in hospital).
 Neonates: group B streptococcus, Klebsiella, E. coli, Chlamydia and S. aureus
 Children <5 years: Pneumococcus, Haemophilus influenzae, less frequently: S. aureus, M.
catarrhalis, M. Pneumoniae,
 Viruses (Respiratory Syncytial virus, influenza, measles)
 Adults and children >5 years: most commonly S.pneumoniae, followed by atypical
bacteria, e.g. Mycloplasma pneumoniae, viruses
 Immunosuppressed: Pneumocystis (in HIV infected)
4.2.1.2 Predisposing factors

• Malnutrition
• Old age
• Immunosuppression (HIV, cancer, alcohol dependence)
• Measles, pertussis
• Pre-existing lung or heart diseases, diabetes
4.2.1.3 Pneumonia in a Child of 2 months-5 years

Clinical features
Fever, may be high, low grade or absent (in severe illness)
21
Pneumonia
• Cough
• Fast breathing (2-12 months: ≥50 bpm, 1-5 years: ≥ 40 bpm)
• Mild chest wall in-drawing
Severe pneumonia
As above plus at least one of the following:
• Central cyanosis (blue lips, oral mucosa, finger nails or oxygen saturation < 90% using a
pulse oximeter)
• Inability to feed, vomiting everything
• Convulsions, lethargy, decreased level of consciousness
• Severe respiratory distress (severe chest indrawing, grunting, nasal flaring)
• Extrapulmonary features, e.g., confusion or disorientation, may predominate and may be
the only signs of pneumonia in malnourished or immunosuppressed children
Initials: KE Age: 1 year and 1⁄12 Gender: Female
Tribe: Musoga Address: Gaba-Makindye- Religion: Pentecost

Kampala
Next of kin: Mother Ward: Children’s ward Bed No: Room 3 Cot 4
DOA: 8th/2/2021
4.2.4 Subjective Information
KE, a 13 months-old female was admitted one day ago (DOA is 8th/2/2021) with wet cough x 5/7,
flue and fever x 5/7, and Difficulty in breathing (DIB) x 1/7. Patient has same complaints even
now (9th/02/2021, 1DOA). 6 days ago, she had wet cough, flue, and fever and was managed at
Nsambya with amoxiclav syrup, ascoril syrup, apidone syrup, rectal paracetamol but was no great
improvement (only fevers reduced but recurred again, this time associated with DIB). No family
history of DM, HTN, SCD, Asthma.
22
4.2.5 Past medication history(subjective)
No known drug allergies

(Name/Strength/Dosage)
Respiratory tract Syrup amoxiclav (unable to
infection (RTI) recall strength and dosage)
(wet cough, flue, Ascoril syrup 5ml po tds x 5/7
3th/2/2021 8th/2/2021
fevers) Apidone syrup 5ml po bd x 5/7
Paracetamol suppositories
250mg rectally tds prn
Weight: 10kg
4.2.6.1 Vitals
SPO2 (%)
Date Temp. (oC) PR (bpm) BP (mmHg) RR (bpm)
On RA On O2 therapy
Reference
95-100 36.1-37.2 80-120 <120/80 24-40
ranges
8/02/2021
85 98 38.1 130/77 41
(DOA)
9/2/2021 87 96 35.6 128/80 44
100 48
10/02/2021 93 99 35.3 127/84 40
11/2/2021 95 37.0 120 24
12/2/2021 97 36.4 52
13/2/2021 97 36.6 150 50
14/2/2021 96 36.2 102
23
4.2.6.2 Full Blood Count (only derangements indicated)
Test Reference ranges 6th/2/2021 9th/2/2021
(1DOA)
RBC (x106/µL) 3.10-5.70 5.73
WBC (x103/µl) 5.5-17.0 5.4
Hematocrit (%) 35.0-44.0 33.0
Mean Cell Volume, MCV (fL) 76.0-92.0 61.6 61.2
Mean Corpuscular Hemoglobin Concentration,
28.0-33.0 33.2 33.4
MCHC (g/dL)
Mean Corpuscular Hemoglobin, MCH (pg) 23.0-31.0 20.5 20.4
Red Blood Cell Distribution Width, RDW (%) 11.0-16.0 20.0 20.2
Platelets (x103/µL) 150-400 4.38
Neutrophils (%) 35.0-47.0 19.8 10.1
Lymphocytes (%) 40.0-45.0 61.7 72.3
Monocytes (%) 3.0-11.0 15.7 14.9
Eosinophils (%) 1.0-5.0 0.1
Basophils (%) 0.0-0.1 1.6 2.6
4.2.6.3 Other tests

Reference ranges 6/2/2021 9th/2/2021(1DOA)
Malaria Microscopy No MPs seen No MPs seen
C-Reactive protein (CRP) (mg/dl) 0.0-50 0.1
24
4.2.7 Current Medication plan
Date Diagnosis Medication Date Date

(Name/Strength/Dosage) started ended
9/2/2021 Bronchopneumonia Ceftriaxone 800mg IV od x 6/7 8th/2/2021 14th/2/2021
(1DOA) Managed as Oxygen therapy 2l/minute (DOA) 13th/2/2021
COVID-19 patient; Ascorbic acid 50mg po od x 1/52 Till
planned to COVID Zinc sulfate 20mg po od x 2/52 discharge
swab today. TFI, 125ml po every 3 hours
Date Disease related Medication Action taken Result of action

problem related problem
9th/2/2021 Wet cough, flue, Continue; To treat the
(1DOA) nasal congestion, Ceftriaxone 800mg IV od cough, flue, and
DIB x 6/7 DIB
Ascorbic acid 50mg po od
prn
Zinc sulfate 20mg po od x
prn
Oxygen therapy 2l/minute
TFI 125ml po every 3h
10th/2/2021 Wet cough, flue, Additional drug Start; Managed the wet
(2DOA) DIB therapy Syrup Brozedex 2.5ml po cough
tds
11th/2/2021 DIB, and Additional drug Nebulize with Salbutamol To cause
(3DOA) bronchospasms therapy 1.25mg in 3ml of NS 8 bronchodilation
hourly prn
Flue Dosage too low Increase the Ascorbic acid To reduce the
dosage from 50mg po od duration of the
to 100mg po od prn flue /cold
25
12th/2/2021 Nasal congestion Additional drug Instill into the nostril’s To reduce nasal
(4DOA) therapy saline nasal drops (0.9%); congestion
2 drops in each nostril
every 4 hours
13th/2/2021 Better breathing Unnecessary Wean off oxygen therapy To make the
(5DOA) drug therapy while monitoring the patient able to
SPO2 levels. breathe room air.
14th/2/2021 No Unnecessary Stop Salbutamol To prepare for
(6DOA) bronchospasms drug therapy nebulization discharge
15th/2/2021 Discharge patient on: Discharge
(Discharge Ascorbic acid 100mg po
date) od x 4/7
Zinc sulfate 20mg po od x
7/7
Review on 23/2/21
Drug and class Mechanism of Pharmacokinetics Side effects &

action Drug interactions
Ascorbic acid Participates on Administered orally. Side effects: flushing, oxalate
(vitamins) physiologic Metabolism: liver nephropathy, nephrolithiasis,
processes, Excretion: urine hemolysis.
acidifies urine 𝑡1⁄ 6-10h Drug interactions: Decrease
2
Body stores approx. doxycycline, erythromycin,
1.5g of ascorbic acid kanamycin efficacy; increase

methotrexate levels
Zinc sulfate Essential Orally administered; Side effects: anemia, neutropenia,
(Minerals) component and Metabolism: leukopenia, abdominal cramps,
cofactor in DNA, CYP450 GI ulcer, gastritis
RNA, and protein
26
synthesis; blocks Excretion: feces Drug interactions: decreases
intestinal copper 90%, urine, sweat absorption and levels/efficacy of
absorption raltegravir, phosphate, baloxavir
marboxil, ciprofloxacin,
doxycycline
Salbutamol (Beta-2 𝛽2 agonist, Administered by Side effects: paradoxical
Agonists) causing oral, Inhalation bronchospasm, hyperglycemia,
bronchodilation route; tachycardia, insomnia
Metabolism: GI tract Drug interactions:
Excretion: urine 80- acetazolamide, betamethasone,
100%, feces <20%, dexamethasone increase risk of
half-life 2.7-6h hypokalemia; celecoxib increase
risk of HTN (additive effects)
Bro-zedex syrup Bronchodilation Well absorbed by Side effects: Stomach pain, skin
by 𝛽2 agonism enteral route rash, headache and dizziness
(terbutaline);
expectorant
(guaifenesin);
mucolytic
(bromhexine)
27
4.3 CASE STUDY 3: ISCHEMIC STROKE [CEREBROVASCULAR ACCIDENT (CVA)]
AND RESOLVING COVID-19 PNEUMONIA
4.3.1 Introduction
Stroke refers to a cerebral neurological dysfunction due to a problem in blood circulation: a clot
(ischemic stroke) or bleeding (hemorrhagic stroke).
4.3.1.1 Causes of stroke

 Clot (a thrombus in a brain vessel or an embolus from a clot somewhere else) – most
common.
 Hemorrhage (from trauma or spontaneous).
4.3.1.2 Clinical features of stroke

 Focal neurological deficits as one-sided weakness (face, arm, leg. Eyes are not affected) –
hemiparesis or hemiplegia
 Difficulty in speaking/swallowing
 Severe headache (especially in hemorrhage)
 Alteration of consciousness
 Convulsions
4.3.1.3 Investigations done

 Brain CT scan
Name Initials: TE Age: 85 years Gender: Female

Tribe: Munyankole Address: Zana, Wakiso Religion: Protestant
Next of kin: Son Ward: St. Gonzaga, Medical Bed No: 4 (SRA)
I P Number: 00410308
28
4.3.3 Subjective data
TE, an 85year-old-female is a known HTN, Type 2 DM with heart failure (HF) ambulating on
spironolactone, bisoprolol, diltiazem, irbesartan, glimepiride, kombyglyze (saxagliptin/metformin
SR) was admitted 4 days ago (DOA, 11th/2/2021) with on/off fever and chills & vomiting 2 weeks
ago; dry cough & runny nose for 2 weeks; DIB and GBW for 1 day; syncope. He was managed
for COVID-19 pneumonia. This is the 4th DOA (15th/2/2021) and the patient has negative COVID-
19 PCR and Antigen tests, with hyperglycemia, ischemic stroke, and resolving pneumonia.
4.3.4 Past medical history
Allergy history: allergic to dust and cold weather (allergic rhinitis)

HTN, DM, HF Spironolactone 25mg po od Patient can’t Currently still
Bisoprolol 10mg po od trace back on these
Diltiazem 90mg po bd medications
Irbesartan 300mg po od
Glimepiride 4mg po bd
Kombiglyze (saxagliptin
2.5mg/Metformin ER 1g) po od
29
4.3.5.1 vitals
Date SPO2 (%) Temp.(oC) BP (mmHg) PR (bpm) RBS
(mmol/L)
Reference ranges 95-100 36.1-37.2 <140/90 60-100 7.8
15th/2/2021 99 (room air) 180/80 71
36.7 11.7
(4DOA) 98 (room air) 160/80 80
16th/2/2021 140/100
97 (room air) 72 16.1
(5DOA) 160/80
17th/2/2021
97 (room air) 140/80 73 7.2
(6DOA)
18th/2/2021
130/90 19.0
(7DOA)
20th/2/2021
140/80 25.3
(9DOA)
4.3.5.2 HRCT-chest report (12th/2/2021)
• Features are suspicious for COVID-19 pneumonia (CO-RADS 4) in absorption stage;

• Diagnosis: Allergic Pneumonitis, constrictive bronchiolitis
4.3.5.3 Brain CT scan report (11th/2/2021)
• Features of severe brain atrophy with left peripheral ischemic infarct & periventricular
white matter ischemic lesions-features of leukoaraiosis
4.3.5.4 Liver Function Tests (LFTs)

Reference ranges 11th/2/2021
ALP (µ/L) 35-105 163**
ALT (µ/L) 0-33 13
AST (µ/L) 0-35 14
Albumin (g/L) 35.00-52.00 42.90
30
4.3.5.5 Renal Function Tests (RFTs)
Reference ranges 11th/2/2021 17th/2/2021
Urea (mg/dL) 16.6-48.5 80.4** 112.6**
Creatinine (mg/dL) 0.50-0.90 1.67** 1.28**
Sodium (mmol/L) 136.00-145.00 139.00 131.00**
Potassium (mmol/L) 3.50-5.10 5.92** 4.98
Chloride (mmol/L) 98.0-107.0 105.4 94.0**
4.3.5.6 Complete Blood Count

Test Reference ranges 11th/2/2021
RBC (x106/µL) 3.80-5.80 4.91
WBC (x103/µl) 4.0-11.0 9.9
Hematocrit (%) 37.0-47.0 38.9
Hemoglobin (g/dL) 11.5-16.5 12.2
Mean Cell Volume, MCV (fL) 76.0-96.0 79.2
31.0-35.0 31.2
MCHC (g/dL)
Mean Corpuscular Hemoglobin, MCH (pg) 27.0-32.0 24.7**
Red Blood Cell Distribution Width, RDW (%) 11.0-16.0 15.3
Platelets (x103/µL) 150-400 325
Neutrophils (%) 45.0-70.0 84.9**
Lymphocytes (%) 20.0-40.0 8.3**
Monocytes (%) 3.0-10.0 5.2
Eosinophils (%) 1.0-5.0 1.4
Basophils (%) 0.0-0.5 0.2
Neutrophils # (x 103/µL) 2.00-7.50 8.4**
Lymphocytes# (x 103/µL) 1.50-4.00 0.80**
Monocytes# (x 103/µL) 0.20-0.80 0.50
Eosinophils# (x 103/µL) 0.04-0.40 0.10
Basophils# (x 103/µL) 0.02-0.10 0.00**
31
4.3.5.7 Other tests
D-Dimers (µg/ml) 0.00-0.05 7.74**
CRP (mg/dL) 0.0-5.0 7.3**
Malaria Microscopy No MPs seen
Date Diagnosis Medication Date Date

(Name/Strength/Dosage) started ended
11th/2/2021 COVID-19 Dexamethasone 8mg IV tds 11th/2/2021 16th/2/2021
pneumonia Thiamine 200mg IV od (1DOA) (6DOA)
Omeprazole 40mg IV od
Ulinastatin 200,000IU IV stat, then
100,000IU IV bd x 5/7
Ivermectin 12mg po od x 5/7
Remdesivir 200mg IV stat then 100mg IV
bd x 5/7
Cefepime 2g IV bd x 5/7
Paracetamol 1g IV prn (not exceed 3g
daily)
Ondansetron 8mg IV prn (not exceed
16mg/day)
Azithromycin 500mg po od x 5/7
Zinc sulfate 40mg po od
Sackets Vitamin C 1000mg po bd
Melatonin 16mg po od
Atorvastatin 80mg po od x 1/52
Enoxaparin 80mg SC od
SC Lantus
RL 500ml IV tds
32
4.3.7 Current pharmaceutical care plan
Date Disease related Medication Action taken Result of
problems related problem action
15th/2/2021 High BP Drug-disease Stop dexamethasone IV Lowering of
(4DOA) (180/80mmHg) interaction Continue with actrapid and glucose & BP
Hyperglycemia glargine levels to
(11.7mmol/L) Monitor RBS & BP normal
High risk to Complete remdesivir dose Complete
covid-19 100mg IV bd x 5/7, prophylaxis
Ivermectin 12mg po od, against
Zinc sulfate 40mg po od, covid-19
Vit. C 1g po bd, cefepime
2g IV od, melatonin 16mg
po noct., Enoxaparin 80mg
SC od,
15th/2/2021 High blood Additional drug Start furosemide 40mg IV Reduce BP to
(4DOA) pressure therapy od, Bisoprolol 10mg po below
(180/80mmHg) od, Amlodipine 10mg po 140/90mmHg
od
Probable Additional drug Continue Prophylaxis
Hyperlipidemia- therapy Atorvastatin 80mg po noct. against
induced x 1/52 dyslipidemia-
ischemic stroke induced
stroke
16th/2/2021 Constipation Additional drug Start Syrup Lactulose 20ml Relieve
(5DOA) therapy po tds constipation
High blood Additional drug Start Hydralazine 50mg po Reduce BP to
pressure therapy bd below
140/90mmHg
17th/2/2021 Normalized BP Unnecessary Stop Bisoprolol, and IV Maintained
(6DOA) drug therapy furosemide BP <140/80
33
Continue; Amlodipine
10mg po od,
Spironolactone 25mg po
bd.
17th/2/2021 Risk of neuron Additional drug Start: Somazina 1g po od x Increased
damage, due to therapy 1/12 neuron
stroke healing
18th/2/2021 Left knee Additional drug Start frost gel; apply to Reduced pain
(7DOA) tenderness therapy affected part tds prn of left knee
Relieved Unnecessary Stop lactulose syrup Stopped
constipation drug therapy lactulose
syrup
20th/2/2021 Patient counseling points: Discharge patient on;
(Discharge Do home physiotherapy Somazina 1g po od x 1/12
date) Continue antihypertensive and DM Hydralazine 50mg po bd x 2/52
medication Atorvastatin 80mg po noct. x 1/12
Reduce salt and sugar intake Insulin norvorapid
Monitor RBS Spironolactone 25mg po od x 2/52
Review to be on 8th/3/2021 Valsartan 160mg po bd x 2/52
34
Drug and class Mechanism of Pharmacokinetics Side effects &

action Drug interactions
Dexamethasone Phospholipase A2 Administered by oral, IV Side effects: diabetes
(corticosteroid) inhibitor: inhibits routes. mellitus, infection, PUD,
production of pro- Metabolism: liver immunosuppression,
inflammatory (CYP3A4) cushingoid appearance
prostaglandins and Excretion: urine primarily Drug interactions: risk of
cytokines; produces 𝑡1⁄ 4h (plasma), 36-54h disseminated infection &
2
multiple (biological) reduced immunologic
glucocorticoid and response to some vaccines
mineralocorticoid
effects
Remdesivir Inhibits RNA- IV administered; Side effects: acute kidney
(antiviral) dependent RNA Metabolism: CYP3A4, injury, nausea, elevated ALT
polymerase, prodrug converted to active & AST, hypersensitivity
preventing viral metabolite Drug interactions:
replication Excretion: urine 49%, phenytoin, rifampin,
𝑡1⁄ 1h (parent drug), >27h secobarbital reduces
2
(active metabolite) remdesivir levels/efficacy,
Insulin Stimulates Administered IV, SC Side effects: hypoglycemia,

(anti diabetic) peripheral glucose Metabolism: liver, kidney, hypokalemia, rash, weight
uptake, inhibits fat gain, injection site
hepatic glucose Excretion: urine 30-80% lipodystrophy
production, inhibits 𝑡1⁄ 17-52 min (IV route), Drug interactions:
2
lipolysis 86-141min (SC route) hypoglycemia with
betablockers (bisoprolol,
atenolol, timolol), increased
insulin requirement with
steroids
35
Enoxaparin Binds to Administered SC route Side effects: hemorrhage
(anticoagulants) antithrombin III Metabolism: liver (major), anemia,
and accelerates Excretion: urine 40%; thrombocytopenia, fever,
activity, inhibiting 𝑡1⁄ 4.5-7h hematuria.
2
thrombin and factor Drug interactions: prolonged
Xa vaginal bleeding with
misoprostol, alteplase,
aspirin, celecoxib.
Atorvastatin Inhibits HMG-CoA Orally administered Side effects: rhabdomyolysis,
(HMG-CoA reductase, Metabolism: CYP3A4; to pancreatitis, diabetes
reductase inhibiting the rate- active metabolite mellitus, photosensitivity.
inhibitors, limiting step of Excretion: bile primarily, Drug interactions: ritonavir,
Statins) cholesterol urine <2%; 𝑡1⁄ 14h (parent clarithromycin, increases
2
synthesis drug), 20-30h (metabolites) atorvastatin levels & side
effects
Hydralazine Directly dilates Administered orally, IM, IV Side effects: headache,
(vasodilators, peripheral vessels Metabolism: liver tachycardia, angina,
Nitrates) Excretion: urine 52-90%, palpitations, neutropenia
feces 10%, 𝑡1⁄ 3-7h Drug interactions: increases
2
thioridazine, tramadol,
methadone levels/side effects
Furosemide (loop Inhibits the Administered IV, orally Side effects: hypokalemia,
diuretic) Na+/K+/2Cl- Metabolism: liver severe electrolyte imbalance,
transporter in the minimally hypovolemia, ototoxicity,
ascending Loop of Excretion: urine 88%, urinary urgency, rash
Henle, preventing bile/feces 12%, 𝑡1⁄ 30- Drug interactions: increased
2
Na+, K+, Cl- 60min amikacin levels, mannitol
reabsorption, and levels (risk of renal
hence water. impairment), antagonistic
effects with prednisolone.
36
Spironolactone Antagonizes Orally active Side effects: gynecomastia,
(potassium- aldosterone-specific Metabolism: liver, active hyperkalemia, electrolyte
sparing diuretic) mineralocorticoid metabolite abnormalities,
receptors in the Excretion: urine primarily thrombocytopenia
distal convoluted (<10% unchanged), bile; Drug interactions: high risk
tubule, decreasing 𝑡1⁄ 1.3-2h (parent drug), of hyperkalemia with
2
Na and water 13.8-16.5h (active amiloride, eplerenone,
reabsorption and metabolites) KHCO3, triamterene;
increasing K Increases amikacin levels &
retention side effects
Somazina It protects the nerve Administered orally, IM, Side effects: decreased blood
(nootropics, cells in the brain IV; pressure, stomach pain,
psychostimulants) from damage and Crosses blood brain barrier; diarrhea, irregular heart beat
also helps to repair Total body clearance is 80- Drug interactions: no known
the damaged nerve 90ml/min. excretion route drug interactions
cells mainly urine (80-100%)
Amlodipine inhibits calcium ion Metabolism: liver CYP3A4 Side effects: fatigue, angina
(calcium channel influx into vascular Excretion: urine 59-62% (5- exacerbation, MI,
blocker, CCB) smooth muscle and 10% unchanged), bile/feces hypotension, palpitations,
myocardium 20-25%, 𝑡1⁄ 30-50h, & 56h Drug interactions: diltiazem
2
(in hepatic impairment) increases amlodipine levels,

increased simvastatin levels
Bisoprolol (Beta Selectively Orally active; Side effects: CHF, cough
Blockers) antagonizes Metabolism: liver bradycardia, heart block
𝛽1adrenergic Excretion: urine (50% headache, bronchospasm,
receptors unchanged), feces <2% Drug interactions: Risk of
𝑡1⁄ 9-12h hypotension, bradycardia,
2
AV block with verapamil
Valsartan Selectively Orally active; Side effects: rhabdomyolysis,
(Angiotensin antagonizes Metabolism: liver CYP2C9 hepatitis, angioedema,
37
Receptor Blocker, angiotensin II Excretion: feces 83%, urine hyperkalemia, back pain,
ARBs) (AT1) receptors 13% (10%unchanged) fatigue
𝑡1⁄ = 6ℎ Drug interactions: increases
2
amikacin levels/side effects,
risk of hypotension with
captopril
Cefepime (beta- Bactericidal; IV administered; Side effects: anaphylaxis,
lactam 4th inhibits cell wall Metabolism: minimal site seizures, rash, C. difficile-
generation mucopeptide unknown associated diarrhea, rash,
cephalosporin) synthesis Excretion: urine primarily injection site reaction,
(85% unchanged); 𝑡1⁄ 2h Drug interactions:
2
kanamycin-cefepime
combination increases levels
of both drugs
Lactulose Increases stool Orally administered Side effects: diarrhea,
(Osmotic water content, Metabolism: colon; electrolyte disorders,
laxative) softening it. minimal systemic flatulence, intestinal cramps,
absorption abdominal distension.
Excretion: feces (100% Drug interactions: lactulose
unchanged), urine <3% plus sodium phosphate in
𝑡1⁄ unknown bowel preparation increases
2
risk of dehydration,
electrolyte abnormalities
38
4.4 CASE STUDY 4: SHINGLES, URINARY TRACT INFECTION AND PEPTIC ULCER
DISEASE
4.4.1 Introduction
Herpes zoster, also known as Shingles, is an acute cutaneous infection involving primarily the
dorsal root ganglia, usually of a single dermatome. It is characterized by a vesicular eruption in
areas supplied by peripheral sensory nerves in the affected root ganglia.
4.4.1.1 Cause of Shingles

Varicella zoster virus, usually reactivated from the virus that entered the cutaneous nerves during
an earlier episode of chicken pox and remained in a latent form. This usually occurs during low
immunity.
4.4.1.2 Clinical features

 Pre-eruptive pain, itching or burning: generally localized to the dermatome, precedes the
eruption by 4-5 days.
 The above are followed by characteristic crops of very painful vesicles on the side supplied
by affected nerve.
 Mild chills, fever, malaise.
Name Initials: NY Age: 77 years Gender: Female

Tribe: Mukenge Address: Kampala Religion: Muslim
Next of kin: Daughter Ward: St. Gonzaga, Medical Bed No: 5
I P Number: 00275412
4.4.3 Subjective information
NY is a 77-year-old female; with HTN for 4 years, Rheumatic heart disease (RHD) for 3 years, on
ambulatory medication; amlozaar H, bisoprolol, clopidogrel, furosemide. Three days ago, she was
diagnosed with PUD, with a positive Urea Breath Test (UBT) and now on esofag kit, relcer syrup,
Panadol Advance, and Ginsomin capsules. She presented with history of post prandial nausea and
39
vomiting (>6 episodes/day), reduced appetite, on and off confusion for 3 hours, no convulsions.
Reports sharp on and off pain in upper right facial region and painful blisters for one day. The pain
worsens when chewing and is associated with itchy and watery right eye discharge.
4.4.4 Past medical history
Allergy history: No known drug / food allergies

HTN, RHD Bisoprolol 10mg po od 2017 Still on the
Clopidogrel 75mg po od medication
Furosemide 40 mg po od
Amlozaar-H 50/12.5/5mg po od
4.4.5.1 Vitals
Date SPO2 (%) Temp(oC) BP (mmHg) PR (bpm) RBS (mmol/L)
Reference ranges 95-100 36.1-37.2 <140/90 60-100 7.8
20th/2/2021 98 (room air) 180/100 4.6
36.4
(DOA) 98 (room air) 130/100 86 5.6
21st/2/2021
98 (room air) 110/60 86
(1DOA)
22nd/2/2021
98 (room air) 110/70 74
(2DOA)
23rd/2/2021
90/60
(3DOA)
40
4.4.5.2 Complete blood count (CBC)
Test Reference ranges 18th/2/2021
RBC (x106/µL) 3.80-5.80 4.84
WBC (x103/µl) 4.0-11.0 5.8
Hematocrit (%) 37.0-47.0 41.5
Hemoglobin (g/dL) 11.5-16.5 13.4
Mean Cell Volume, MCV (fL) 76.0-96.0 85.7
31.0-35.0 32.3
MCHC (g/dL)
Mean Corpuscular Hemoglobin, MCH (pg) 27.0-32.0 27.6
Red Blood Cell Distribution Width, RDW (%) 11.0-16.0 14.7
Platelets (x103/µL) 150-400 356
Neutrophils (%) 45.0-70.0 77.3**
Lymphocytes (%) 20.0-40.0 18.3**
Monocytes (%) 3.0-10.0 4.0
Eosinophils (%) 1.0-5.0 0.1**
Basophils (%) 0.0-0.5 0.3
Neutrophils # (x 103/µL) 2.00-7.50 4.50
Lymphocytes# (x 103/µL) 1.50-4.00 1.10**
Monocytes# (x 103/µL) 0.20-0.80 0.20
Eosinophils# (x 103/µL) 0.04-0.40 0.00**
Basophils# (x 103/µL) 0.02-0.10 0.00**
4.4.5.3 Renal Function Tests

Reference ranges 20th/2/2021 (DOA)
Sodium (mmol/L) 136.00-145.00 133.00**
Potassium (mmol/L) 3.50-5.10 3.66
Chloride (mmol/L) 98.0-107.0 96.0**
41
4.4.5.4 Urine parasites tests
Appearance Pale yellow and turbid
Bilirubin 0-0 Negative
Blood/Hb 10-50 Negative
Glucose 0-100 Normal
Ketone 0-5 15**
Leucocyte esterase 0-10 75**
Nitrite Negative
Protein 0.1-30 100
Specific gravity 1.005-1.010 1.015**
Urobilinogen 0.1-2 Normal
pH 6.5-7 8**
Microscopy Pus cells (>100)
comment Epithelial cells (+++)
seen/LPF
4.4.5.5 Other tests

18th/2/2021 23rd/2/2021 (3DOA)
Widal s. typhi O <1:80
Widal s. typhi H <1:80
Malaria Microscopy No Mps seen
Urea breath test (UBT) Positive
HIV (AG/AB) (COl) Non-reactive (negative)
42
Date Diagnosis Medication Date started Date ended

20st/2/2021 PUD, Ondansetron 8mg IV bd prn 21st/2/2021
(DOA) shingles, NS 500mls IV tds 22nd/2/2021
UTI Ciprofloxacin 400mg IV bd x 5/7 20th/2/2021 23rd/2/2021
Acyclovir 800mg po tds x 10/7 Until
Continuing ambulatory medications discharge
Nadofloxacin cream 1%; apply to
affected part bd
Date Disease related Medication Action taken Result of

problems related action
problem
20st/2/2021 Shingles Dosage too Increase Acyclovir dosage Shingles
(DOA) low frequency to 800mg po 5 managed
times a day x 7/7
Possible drug Hold esofag kit Esofag kit
interactions (esomeprazole, withheld
clarithromycin, amoxicillin)
Epigastric pain Additional Omeprazole 40 mg IV bd Inhibition of
drug therapy stomach acid
secretion
Facial Pain and Additional Calamine cream; apply to Relieve pain
itching drug therapy affected area bd and itching
21st/2/2021 UTI Continue Ciprofloxacin Manage the
(1DOA) 400mg IV bd for 5 days UTI
Right facial mild Additional Start Pregabalin 75mg po Stop nerve
pains drug therapy bd x 2/52 pains
43
22nd/2/2021 Conjunctival Additional Gutt. Tobradex; 1drop into Reduce eye
(2DOA) chemosis drug therapy right eye 3hourly x7/7 inflammation
(dragonized by Tetracycline eye oint.; & possible
the apply into right eye noct. x infection
ophthalmologist) 1/52
23rd/2/2021 Low BP Unnecessary Hold antihypertensives Allow for BP
(3DOA) (90/60mmHg) drug therapy to go back to
normal
Risk of kidney Additional Start Cital syrup UTI
stones with high drug therapy (1.37g/5ml);10ml po tds x managed
dose acyclovir 3/7 Kidney
stones not
formed
24th/2/2021 No complaints Discharge plan: Discharged
(discharge but; Stop Ciprofloxacin IV patient
date) Resolving Start. Cefixime 200mg po
shingles, PUD, bd for 5 days
UTI Continue:
Gutt. Tobradex; 1 drop into
right eye 3hrly X 7/7
Tetracycline eye oint. apply
noct. X 1/52
Acyclovir 800mg po 5
times a day for more 3 days
Cital syrup
(1.37g/5ml);10ml po tds
Nadofloxacin cream; apply
to affected part bd
Pregabalin 75mg po bd x
1/52
Esofagkit 3 tab. po bd x2/52
44
Drug and class Mechanism of action Pharmacokinetics Side effects &

Drug interactions
Acyclovir Inhibits DNA Administered IV, Side effects: hallucinations,
(Antiviral, HSV) polymerase; orally, topically psychosis, headache,
incorporates into viral Metabolism: CYP450 neutropenia(neonates), confusion.
DNA Excretion: urine, Drug interactions: combination
𝑡1⁄ 2.5-3.3h with cidofovir, ganciclovir,
2
gentamicin increases levels of both
drugs, risk of myelosuppression,
nephrotoxicity
Cefixime (3rd Bactericidal; inhibits Orally active Side effects: anaphylaxis, C.
generation cell wall mucopeptide Elimination: urine difficile-associated diarrhea, super
cephalosporin) synthesis (50% unchanged), bile infection
>10%; 𝑡1⁄ 3-4h, & Drug interactions: prolonged
2
11.5h (CrCl 5-20) duration of action by probenecid,

decreased efficacy of BCG and
typhoid vaccine.
Omeprazole Inhibits the gastric Administered IV, Side effects: flatulence, Vitamin
(proton pump parietal cell H+-K+ orally. B12 deficiency (long term use),
inhibitors, PPIs) ATPase, reducing Metabolism: liver hepatic impairment, anaphylaxis
acid secretion extensively CYP2C19, Drug interactions: reduced
CYP3A4; prodrug absorption of rilpivirine, captopril,
converted to active cefpodoxime, iron, cefuroxime;
sulfenamide form. (these drugs need low pH for
`Excretion: urine 77%, absorption)
bile/feces; 𝑡1⁄ 0.5-1h,
2
3h (in hepatic disease)
45
Ciprofloxacin Bactericidal; inhibits Administered IV, Side effects: hypersensitivity,
(fluoroquinolones DNA gyrase and orally anaphylaxis, QT prolongation, toxic
) topoisomerase IV Metabolism: Liver; psychosis, myelosuppression,
strong CYP1A2 and restlessness
moderate CYP 3A4 Drug interactions: increased
inhibitor; active alfentanil, theophylline,
metabolites amiodarone levels; risk of QT
Excretion: urine (40- prolongation, cardiac arrhythmias
50% unchanged, feces with azithromycin.
(20-35%); 𝑡1⁄ 4h
2
Pregabalin Exact mechanism is Orally administered Side effects: hypersensitivity,

unknown; binds Excretion: urine (90% angioedema, rhabdomyolysis,
alpha2-delta subunit unchanged) 𝑡1⁄ 6.3h dizziness, respiratory depression
2
of calcium channels (adults), 3-6h Drug interactions: increased CNS
reducing (pediatrics) and respiratory depression with
neurotransmitter codeine, ethanol, fentanyl, tramadol
release; produces
antinociceptive and
antiseizure effects
Tobradex Tobramycin: Optically administered Side effects: Ocular pain, eyelid
(tobramycin/dexa bactericidal; binds to Minimal systemic edema, conjunctival hyperemia,
methasone 30S ribosomal absorption eyelid pruritus
ophthalmic) subunit, inhibiting Excretion: urine Drug interactions: delayed ocular
protein synthesis wound healing with diclofenac
Dexamethasone: ophthalmic & ketorolac ophthalmic
phospholipase A2
inhibitor, reducing
proinflammatory
cytokines
46
Cital syrup Oxidizes to Administered orally Side effects: seizures, metabolic
(urinary bicarbonate, raising Elimination: urine alkalosis, diarrhea, nausea,
alkalinizer) pH of urine vomiting
Drug interactions: increases
AL(OH)3 absorption/toxicity; milk-
alkali syndrome with other urinary
alkalinizes like Ca-acetate, CaCO3,
CaCl2, Ca-citrate, Ca- gluconate;
increases lithium, aspirin &
phenobarbital renal excretion;
47
CHAPTER FIVE: CONCLUSIONS AND RECOMENDATIONS
5.1 CONCLUSION
5.1.1 LEARNING EXPERIENCE THROUGH THE TRAINING
During the hospital training;
(i) The pharmacy practice skills, such as, dispensing have improved significantly.
(ii) The role of a pharmacist in patient care was greatly appreciated.
(iii) With the help of hospital staff and interns, the clinical skills have greatly been improved.
(iv) I have improved my interpersonal skills by interacting with different people.
5.2 CHALLENGES THE DURING TRAINING
(i) Patient monitoring was difficult due to limited time.

(ii) The cost of living was high during the training period.
(iii) The training started late because the University had not yet allocated some students to some
training centers in time.
(iv) Due to COVID-19 pandemic, our approval for participation in ward rounds was delayed
and as a result, we participated inward rounds for 2 weeks only, instead of the prescribed
four weeks.
(v) There was no pharmacist on ward to guide students about the pharmaceutical care plan.
5.3 RECOMMENDATIONS
5.3.1 To the Hospital

(i) The hospital should consider employing a pharmacist on wards in order to guide students
and interns about the pharmaceutical care plan.
(ii) The team involved in ward rounds should comprise of individuals from all sectors involved
in patient care, like, Nurses, doctors, pharmacists, social workers.
(iii) Patient therapy should be made affordable to all patients by prescribing affordable
medicines.
(iv) The prescribers should use clear, and readable handwritings, especially in patient books, to
avoid mistakes in interpretation of the prescriptions.
48
5.3.2 To the University
(i) The university should consider financial facilitation of students during hospital trainings
(ii) The university should also consider allocation of students to training centers before the
date of commencement. Otherwise, the four weeks are enough for the training if well
planned for.
49
REFFERENCES
(1) https://www.must.ac.ug/about-must/
(2) http://www.nsambyahospital.or.ug/about-us/
(3) Uganda Clinical guidelines 2016
(4) Management of Medicines and Health Supplies Manual 2012 (Uganda)
(5) Epocrates application software
50
APPENDICES
APPENDIX 1: PRESCRIPTION
51
APPENDIX 2: PAYMENT RECEIPT ATTACHED TO A PRESCRIPTION
52

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MBARARA UNIVERSITY OF SCIENCE AND TECHNOLOGY

Faculty of medicine, Department of pharmacy

STUDENT’S NAME: GOBERA BOAZ

A REPORT OF THE HOSPITAL TRAINING AT ST. FRANCIS HOSPITAL

HOSPITAL SUPERVISOR: Dr. ANN NABACWA

UNIVERSITY SUPERVISOR: Dr. NUWAGIRA PETER

PERIOD OF TRAINING: FOUR WEEKS, JAN/FEB 2021

HOSPITAL PHARMACIST, NSAMBYA

Dr. NUWAGIRA PETER

1.1 DESCRIPTION OF HOSPITAL PLACEMENT

1.2 DESCRIPTION OF PLACEMENT SITE

Vision: Satisfied customers pursuing healthy productive lives.

(i) Commitment to Catholic values

1.3 TRAINING OBJECTIVES

(i) To provide students with an insight of the future career opportunities.

1.4 TRAINING METHODS AND PROCEDURES USED

2.1 ORDERING OF SUPPLIES

(1) Calculation of Average Monthly Consumption (AMC)

2.3 GOODS STORAGE PRACTICES

Storage conditions Items

2.4.1 Documentation/record keeping

Benefits of keeping good records

• The expected quantity in stock is known before doing a physical count.

2.4.2 Stock cards

2.4.2.1 Parts of a stock card

(3) Pack size: e.g., metformin 1000mg tablets box of 60’s.

Figure 1: The major features in a stock card

2.4.4 The physical count

The purpose of a physical count is to; -

2.4.5 What to do with expired stock

3.1 ISSUING OF ITEMS FROM THE STORE

3.2 DISPENSING OF DRUGS

3.2.1 Steps involved in dispensing

Step 1 Check the prescription (and the payment receipt)

Step 3 Double check information and counting

Step 4 Dispense the medicines

Step 5 Provide appropriate information

4.1.1.2 Otitis media

4.1.2 Patient demographics

Name Initials: MJ Age: 2years Gender: Male

4.1.3 Subjective information

4.1.4 Past medical history (subjective)

No known drug allergies

Diagnosis Medication Date started Date ended

4.1.5 Objective information

4.1.5.2 Hemo parasites tests

4.1.5.4 Haeme studies (only derangements are indicated)

Date Diagnosis Medication Date started Date Ended

4.1.7 Current Pharmaceutical care plan

Date Disease related Medication Action taken Result of action

Patient counselling points and discharge plan (18/2/2021)

Drug and class Mechanism of action Pharmacokinetics Side effects &

Excretion: urine Drug Interactions: Risk

unchanged (33-67%), of Kidney and lung Ca-

bile/feces ceftriaxone ppt with

(severe renal disease) Synergistic effect with

4.2.1.1 Causes of pneumonia

4.2.1.2 Predisposing factors

4.2.1.3 Pneumonia in a Child of 2 months-5 years

4.2.3 Patient demographics

Initials: KE Age: 1 year and 1⁄12 Gender: Female

Tribe: Musoga Address: Gaba-Makindye- Religion: Pentecost