FACULTY OF PHARMACY

CLINICAL PHARMACY IV WARD CLERKSHIP

CASE 10

Hematologic Disorders

“NSAIDS INDUCED GASTROPATHY

LEADS TO SEVERE IRON
DEFICIENCY ANEMIA”

NAME : Mehul Chitalia

WARD :

DATE : 27 May - 30 May 2020

PRECEPTOR : Madam Wati

A. PATIENT’S DETAILS
Name : Mr WC
Sex : Male Race : White Male Age : 67 years old
RN: Height : 185 cm Weight : 78 kg
Admission Date: Discharged Date:

B. CHIEF COMPLAINTS (CC)

 Belly pain and feel tired all the time

C. HISTORY OF PRESENTING ILLNESS (HPI)

 He started self-medicating with ibuprofen 200 mg four tablets four times a

day about 6 months ago for pain associated with “arthritis” in his right knee
and ankle
 Stomach pain has gotten progressively worse over the past few months
 This pain as a burning sensation that usually begins 30 minutes to 1 hour
after meals and may or may not be relieved by antacid administration.
 Use of over the counter ranitidine as needed has likewise not provided
much acute pain relief.
 Further questioning reveals a history of an ulcer approximately 5 years ago.

D. PAST MEDICAL HISTORY (PMH)

 Osteoarthritis of the knees and ankles
 Peptic Ulcer Disease 5 years ago
 GI bleeding 7 years ago
 COPD for 10 years
 Hypertension for 10 years

E. PAST MEDICATION HISTORY

Name of drugs Dose Freq Route Indication

Lisinopril 10mg Daily Oral To treat hypertension

Tiotropium 18 mcg Once Inhalation To treat COPD
daily
Formoterol 12 mcg Every 12 Inhalation To treat COPD
hours
Ibuprofen 200mg Three or Oral To treat osteoarthritis
four
tablets
three or
four
times a
day
Antacids When Oral To treat stomach
necessary discomfort
OTC Prilosec 20mg When Oral To treat peptic ulcer
necessary disease

F. FAMILY HISTORY (FH)

 Mother died in childbirth
 Father died of cancer at the age of 93

G. SOCIAL HISTORY (SH)

 Married
 Cigarette smoker two packs per day for 42 years
 Quit alcohol

H. ALLERGY
Codeine (upset stomach)
Aspirin (upset stomach)

I. PHYSICAL EXAMINATION (PE)

Gen
WM in acute distress who appears his stated age
VS
BP 118/51 mm Hg, P 121 bpm, RR 22, T 36.2°C, pulse oximetry 90% in room air;
Wt 78 kg, Ht 6′1″
Skin
Age- and sun-related lentigines and seborrheic keratoses noted
HEENT
PERRL; EOMI; conjunctivae are pale; mucous membranes pale and dry; normal
funduscopic examination
with no retinopathy noted; deviated nasal septum; no sinus tenderness; oropharynx
clear
Neck/Lymph Nodes
Neck supple without masses; trachea midline; no thyromegaly, no JVD
Thorax
Breath sounds decreased bilaterally, increased anterior–posterior diameter, (+)
rhonchi, pursed-lip
breathing
CV
Tachycardia with a soft systolic murmur; PMI at fifth ICS, MCL; (–) bruits
Abd
Soft, tender to palpation; no masses or organomegaly; (+) BS
Genit/Rect
Normal external male genitalia; rectal examination (+) stool guaiac
MS/Ext
Slight knee joint enlargement, with pain and tenderness noted, and limited ROM of
both knees and ankles,
 worse on right side; crepitation noted at the talus–tibia junction on dorsiflexion of
the right foot; changes
consistent with OA; strong pedal pulses bilaterally; no peripheral edema; pallor of
the nail beds
Neuro
A & O × 3; DTR 2+; normal gait
Other
Peripheral blood smear: hypochromic, microcytic red blood cells
J. DIAGNOSIS / IMPRESSION
 Severe IDA probably of GI origin, possibly secondary to NSAID-induced
gastropathy
 OA of both knees and ankles, worse on right side
 COPD
 HTN
 FULL CODE status but patient does not wish to be left on a machine if there
is no hope of recovery
K. MANAGEMENT PLAN


L. LABORATORY INVESTIGATIONS
Parameters Units Normal range 27/5/2020 28/5/2020
Renal profile
Urea mmol/L 1.7-8.3
SCr umol/L 64-122 70.72
CrCl ml/min 80-120
Electrolytes
Sodium mmol/L 135-145 138
Potassium mmol/L 3.5-5.0 3.7
Calcium mmol/L 2.14-2.58
Corrected mmol/L 2.14-2.58
calcium
Phosphate mmol/L 0.8-1.45
Magnesium mmol/L 0.7-1.3
Chloride mmol/L 96-106 104
Full Blood Count
WBC x109/L 4.0-11.0 10.7
Hb g/dL 11.5-15.5 7.2 12.6

RBC x109/L 4.2-5.4 3.77

Hct % 36.0-52.0 25 40.8
Plt x109/L 150-400
Coagulation Profile
PT seconds 10-13.5
APTT seconds 26-42
 INR <1.5
Liver Profile
Total Protein g/L 66-87 63
Albumin g/L 35-50 37
T. Bilirubin umol/L <20 26.52
ALT IU/L <32 23
AST IU/L 10
ALP IU/L 53-141
 Vital Signs
BP mm/Hg 118/51
Temperature ºC 36.2
HR Beats/min 121
Cardiac Profile
CK IU/L 24-195
Trop-T <0.1
LDH IU/L 0-248
Glucose test
Glucose mmol/L 3.9-6.1 5.0
Lipid profile
Total mmol/L <5.7
cholesterol
C-TG mmol/L <1.7
C-HDL mmol/L >1.7
C-LDL mmol/L <3.9

M. OTHER INVESTIGATIONS
 MCV: 66.2 micro meter cube
 Ferritin: 5ng/ml
 B12 : 680 pg/ml
 LDH: 85 IU/L

N. PROGRESSION REPORT
Date/Time Subjective Objective Assessment Plan
27/5/2020 No fever or chills BP: 118/51 mm Hg Severe IDA Admit to hospital for further
No heartburn Pulse: 121 beats per probably of evaluation
Burning pain in minute GI origin, Strict NPO
stomach after Temperature: 36.2 possibly Infuse 4 units PRBCs
meals ºC secondary to Begin D5% NS at 82 mL/hour
No significant Pulse oximetry 90% NSAID- continuous
weight changes in room air induced Begin esomeprazole 40 mg IV
over past 5 years. gastropathy daily
Experiences dry OA of both Morphine 2 mg IV Q 4 H as
mouth, fatigue, knees and needed for pain
dyspnea and ankles, worse Consult GI service for suspected
orthopnea, and on right side GI bleed
have bilateral joint COPD Sequential compression devices
pains in both knees HTN bilaterally for VTE prophylaxis
and ankle, worst on FULL CODE
right knee for 5 status but
years. patient does
Denies fainting, not wish to be
numbness, tremor, left on a
tinnitus or vertigo, machine if
denies nocturia, there is no
hematuria, dysuria hope of
or history of stones recovery
No significant
weight loss
Occasionally
headache.
Hay fever in
spring, have
cough, sputum
production and
wheezing but no
chest pain
Blood pressure chart

Date Time BP Pulse

27/5/2020 118/51 121

Diabetic chart

Date Time Glucose level (mmol/l) Insulin given

27/5/2020 5.0 -

I/O chart
Date
Input
Output
Balance
 O. CURRENT MEDICATION
Date Drug regimen Indication
Started Stopped Name, dose, frequency,
duration

*Note: Current Medication similar to Past Medication History

P. DISCHARGED MEDICATION
 Choline magnesium trisalicylate along with acetaminophen
 Zincofer
 Glucosamine
Q. PHARMACEUTICAL CARE ISSUES
Care issue Desired outcome Proposed action Monitoring Evidence
Patient is To avoid the sign Administer Monitor sign American
suffering from and symptoms of parenteral iron and symptoms Family
severe iron iron deficiency therapy such as of iron Physician on
anemia such as iron dextran 25- deficiency Evaluation and
deficiency anemia
pale skin, unusual 100 mg IV or anemia. Management
but no drug is craving. deep IM every of Iron
being prescribed day when Deficiency
necessary. Anemia.
Non-
Pharmacological
Treatment
Advice patient to
administer food
which is rich in
iron such as
quinoa, red meat,
broccoli.

Patient is being To avoid Increase the dose Monitor MIMS

prescribed with osteoarthritis from to 400 mg three to complete Malaysia
Ibuprofen (200 getting worse. four times a day. blood count
and renal
mg) for his
function test.
treatment of
osteoarthritis but
dosage is
incorrect

Drug-drug Avoid drug- drug Withold Monitor the Medscape

interaction interaction to ibuprofen for the sign and
between improve patient time being. symptoms of
quality of life. osteoarthritis.
ibuprofen and
Administer
Lisinopril. patient with
acetaminophen to
Co –
treat pain
administration symptoms of
may result in a osteoarthritis
significant
decrease in renal Morphine 2 mg
function. IV Q 4 H as
NSAIDS may needed for pain
diminish the
antihypertensive
effect of ACE
inhibitors.

Patient has smoke To improve the Non- Monitor Clinical

two packs per day quality of life of Pharmacological coughing Practice
for 42 years. patient as patient Treatment symptoms and Guidelines on
has COPD. Educate patient to Management
educate patient
undergo smoking of COPD 2nd
cessation on expulsion edition 2009.
program. of sputum.

Expulsion of
sputum can be
done through
deep coughing,
huff coughing
and postural
damage.

Patient is To find out which Perform Monitor sign Clinical

suffering from treatment is best FEV1/FVC ratio and symptoms Practice
COPD but for the patient test to identify of COPD Guidelines on
which group this Management
FEV1/FVC ratio
patient belongs of COPD 2nd
test is not being too. edition 2009.
conducted Non-
Pharmacological
Treatment:
Advice patient to
undergo
pulmonary
rehabilitation as it
improves
dyspnea, and
health status.
 Patient is To ensure patient is Educate patient Monitor the MIMS
discharged with aware of the side on side effects of sign and Malaysia
choline effects of the drug. both the drugs symptoms of
Choline
magnesium this drug.
magnesium
trisalicylate and trisalicylate: May
glucosamine cause fatigue, GI
disorder and
weakness.
Glucosamine:
May cause
hypercholesterole
mia, headache,
fatigue and
drowsiness.
Patient should
also be educated
that glucosamine
may cause
dizziness. If
affected do not
drive or operate
machinery
Patient is To ensure patient is Side effects of Monitor the MIMS
discharged with aware of the side zincofer: May sign and Malaysia
Zincofer effects of the drug. cause GI symptoms of
discomfort,
this drug.
anorexia, nausea
and vomiting as
well as darkening
of stool

Case summary
Mr WC is a 67 years old who suffers from Osteoarthritis of the knees and ankles, peptic ulcer
disease, GI bleeding, COPD and hypertension. He started self-medicating with ibuprofen 200
mg four tablets four times a day about 6 months ago for pain associated with “arthritis” in his
right knee and ankle. Stomach pain has gotten progressively worse over the past few months.
This pain as a burning sensation that usually begins 30 minutes to 1 hour after meals and may
or may not be relieved by antacid administration. Use of over the counter ranitidine as needed
has likewise not provided much acute pain relief. Patient is prescribed with Lisinopril 10 mg
daily, tiotropium 18 mcg once daily, formoterol 12 mcg every 12 hours, ibuprofen 200mg
three to four tablets three to four times a day, antacid when necessary and OTC Prilosec
20mg when necessary. The patient’s haemoglobin level was low on the first day. The patient
was discharged with Choline magnesium trisalicylate along with acetaminophen, Zincofer
and Glucosamine.