MODULE 4 ASYNCHRONOUS ACTIVITY MCNP ROSITO, AMBER JOY C.

ADVERSE DRUG REACTION REPORTING FORM

REPORT ON SUSPECTED DRUG REACTION

CASE 1:

1. PARTICULARS OF THE PATIENT

Name of Patient: Analiza De Jesus

Age: 30 Weight: 60 Kg

Sex: ☐ MALE ☒ FEMALE

Pregnant: ☐ Yes ☒ No ☐ not applicable

2. ADVERSE REACTION

Date of onset of reaction: 9/28/2021

Time of onset of reaction: 13:10 a9/p9

Description of reaction: Severe hypoglycemia

3. MEDICINES

Trade Name Daily Dose Date Started Date Stopped Reason for use
Glyburide 2.5 mg 9/28/2021 9/28/2021 Type 2Diabetes
Mellitus
Gliclazide 160 mg 9/28/2021 9/28/2021 Type 2 Diabetes
Mellitus

4. TREATMENT OF REACTION

 Discontinuation of drug.
 Reduce the dose of the drug.
 Have close observation of the patient’s glucose.
 Diet monitoring.

5. REPORTING PHARMACIST/PHYSICIAN/NURSE:

Signature:

Name: Amber Rosito

Date: 9/28/2021

PHARMACOVIGILANCE | ADVERSE DRUG REACTION

MODULE 4 ASYNCHRONOUS ACTIVITY MCNP ROSITO, AMBER JOY C.

CASE 2:

1. PARTICULARS OF THE PATIENT

Name of Patient: Jacob Ford

Age: 75 Weight: 50 Kg

Sex: ☒ MALE ☐ FEMALE

Pregnant: ☐ Yes ☐ No ☒ not applicable

2. ADVERSE REACTION

Date of onset of reaction: 9/28/2021

Time of onset of reaction: 13:10 a9/p9

Description of reaction: Bradycardia

3. MEDICINES

Trade Name Daily Dose Date Started Date Stopped Reason for use
Bisoprolol 5 mg 9/28/2021 9/28/2021 Atrial Fibrillation

4. TREATMENT OF REACTION

 Discontinuation of drug.
 Blood Pressure Monitoring.

5. REPORTING PHARMACIST/PHYSICIAN/NURSE:

Signature:

Name: Amber Rosito

Date: 9/28/2021

PHARMACOVIGILANCE | ADVERSE DRUG REACTION

MODULE 4 ASYNCHRONOUS ACTIVITY MCNP ROSITO, AMBER JOY C.

CASE 3:

1. PARTICULARS OF THE PATIENT

Name of Patient: Dave Santos

Age: 20 Weight: 55 Kg

Sex: ☒ MALE ☐ FEMALE

Pregnant: ☐ Yes ☐ No ☒ not applicable

2. ADVERSE REACTION

Date of onset of reaction: 9/28/2021

Time of onset of reaction: 13:10 a9/p9

Description of reaction: Respiratory distress

Laryngeal Edema

Bronchial Spasm

Swelling of lip, throat & eyeball

3. MEDICINES

Trade Name Daily Dose Date Started Date Stopped Reason for use
Ibuprofen 500 mg 9/28/2021 9/28/2021 Minor Injury

4. TREATMENT OF REACTION

 Complete cessation of ibuprofen

 Administration of alternative drugs for asthma
 Strict patient monitoring
 Administration of total parenteral nutrition.

5. REPORTING PHARMACIST/PHYSICIAN/NURSE:

Signature:

Name: Amber Rosito

Date: 9/28/2021

PHARMACOVIGILANCE | ADVERSE DRUG REACTION

MODULE 4 ASYNCHRONOUS ACTIVITY MCNP ROSITO, AMBER JOY C.

CASE 4:

1. PARTICULARS OF THE PATIENT

Name of Patient: Ace Miller

Age: 37 Weight: 50 Kg

Sex: ☒ MALE ☐ FEMALE

Pregnant: ☐ Yes ☐ No ☒ not applicable

2. ADVERSE REACTION

Date of onset of reaction: 9/28/2021

Time of onset of reaction: 13:10 a9/p9

Description of reaction: Hyperpigmentation in forearms and genitals

3. MEDICINES

Trade Name Daily Dose Date Started Date Stopped Reason for use
Omeprazole 60 mg 9/28/2021 9/28/2021 Gastroesophageal
reflux disease

4. TREATMENT OF REACTION

 No treatment given

5. REPORTING PHARMACIST/PHYSICIAN/NURSE:

Signature:

Name: Amber Rosito

Date: 9/28/2021

PHARMACOVIGILANCE | ADVERSE DRUG REACTION

MODULE 4 ASYNCHRONOUS ACTIVITY MCNP ROSITO, AMBER JOY C.

CASE 5:

1. PARTICULARS OF THE PATIENT

Name of Patient: Jessie Smith

Age: 15 Weight: 35 Kg

Sex: ☐ MALE ☒ FEMALE

Pregnant: ☐ Yes ☒ No ☐ not applicable

2. ADVERSE REACTION

Date of onset of reaction: 9/28/2021

Time of onset of reaction: 13:10 a9/p9

Description of reaction: Abnormal pigmented patches over axilla, pubis, breast &
scalp

3. MEDICINES

Trade Name Daily Dose Date Started Date Stopped Reason for use
Omeprazole 60 mg 9/28/2021 9/28/2021 Gastroesophageal
reflux disease

4. TREATMENT OF REACTION

 No treatment given

5. REPORTING PHARMACIST/PHYSICIAN/NURSE:

Signature:

Name: Amber Rosito

Date: 9/28/2021

PHARMACOVIGILANCE | ADVERSE DRUG REACTION

MODULE 4 ASYNCHRONOUS ACTIVITY MCNP ROSITO, AMBER JOY C.

CASE 6:

1. PARTICULARS OF THE PATIENT

Name of Patient: John Smith

Age: 16 Weight: 40 Kg

Sex: ☐ MALE ☒ FEMALE

Pregnant: ☐ Yes ☒ No ☐ not applicable

2. ADVERSE REACTION

Date of onset of reaction: 9/28/2021

Time of onset of reaction: 13:10 a9/p9

Description of reaction: Hyperpigmentation in forearms and genitals

3. MEDICINES

Trade Name Daily Dose Date Started Date Stopped Reason for use
Clindamycin 30 mg/ml 9/28/2021 9/28/2021 Acne
suspension

4. TREATMENT OF REACTION

 Discontinuation of drug.

5. REPORTING PHARMACIST/PHYSICIAN/NURSE:

Signature:

Name: Amber Rosito

Date: 9/28/2021

PHARMACOVIGILANCE | ADVERSE DRUG REACTION

MODULE 4 ASYNCHRONOUS ACTIVITY MCNP ROSITO, AMBER JOY C.

CASE 7:

1. PARTICULARS OF THE PATIENT

Name of Patient: Johan Brown

Age: 48 Weight: 55 Kg

Sex: ☐ MALE ☒ FEMALE

Pregnant: ☐ Yes ☒ No ☐ not applicable

2. ADVERSE REACTION

Date of onset of reaction: 9/28/2021

Time of onset of reaction: 13:10 a9/p9

Description of reaction: bizarre, irregular heart rhythm, diarrhea, muscle cramps,

nausea, dizziness.

3. MEDICINES

Trade Name Daily Dose Date Started Date Stopped Reason for use
Cotrimoxazole 160 mg 9/28/2021 9/28/2021 Urinary tract
forte tablet Infection

4. TREATMENT OF REACTION

 Stop using the drug.

 Urinalysis.
 Give the proper medicine for her condition.

5. REPORTING PHARMACIST/PHYSICIAN/NURSE:

Signature:

Name: Amber Rosito

Date: 9/28/2021

PHARMACOVIGILANCE | ADVERSE DRUG REACTION