<format type="yaml">{report_id: string, report_date: date, patient_details: {patient_id: string, age_at_reaction: number optional, gender: string, relevant_history: list[string]}, suspected_drugs: list[{drug_name: string, drug_class: string optional, dosage: string, route_of_administration: string, start_date: date, end_date: date optional, indication_for_use: string}], adverse_reactions: list[{symptom_name: string, onset_date: date, severity: string, outcome: string, intervention_required: boolean, intervention_details: string optional}], causality_assessment: {naranjo_score: number optional, assessment_conclusion: string, dechallenge_rechallenge: string}, reporting_facility: string, reporter_type: string, notes: string optional}</format> <data>PHARMACOVIGILANCE CASE REPORT - CONFIDENTIAL
Report Identifier: ADR-2025-925
Date of Submission: 2025-06-11

This report was submitted by a Patient from Johnston-Nelson Medical Center concerning patient ANON-PX-9273. The subject is a 61-year-old other with a significant medical history including anxiety, asthma, migraines, atrial fibrillation. The facility's standard operating procedure for ADR reporting was followed, and all patient data has been anonymized. The patient chart was reviewed for comorbidities. 

Current medication review revealed the following suspected agent(s): Levothyroxine (Thyroid hormone) administered via the Intramuscular route at a dosage of 175mg, initiated on 2025-04-04 for Hypothyroidism with the course ongoing; Sertraline administered via the Intramuscular route at a dosage of 86mg, initiated on 2025-04-04 for Major depressive disorder with the course ongoing.

On approximately 2025-05-29, the patient began to manifest an adverse event. The primary symptoms noted in the clinical log were Nausea, Pruritus, Maculopapular Rash. The Nausea was classified as Moderate in severity. No specific therapeutic intervention was required. The current patient status regarding this symptom is 'Recovering'. The Pruritus was classified as Moderate in severity. This necessitated clinical intervention. The documented action was: Prescribed loss and advised data. The current patient status regarding this symptom is 'Not Recovered'. The Maculopapular Rash was classified as Moderate in severity. This necessitated clinical intervention. The current patient status regarding this symptom is 'Recovering'. 

CAUSALITY ASSESSMENT:
An evaluation of causality was performed. The assessment concluded the relationship was 'Probable'. Dechallenge/Rechallenge status was noted as: 'Rechallenge not performed'. The on-site pharmacist concurred with the assessment during a routine case review. 

</data>
report_id: ADR-2025-925
report_date: '2025-06-11'
patient_details:
  patient_id: ANON-PX-9273
  gender: Other
  relevant_history:
  - anxiety
  - asthma
  - migraines
  - atrial fibrillation
  age_at_reaction: 61
suspected_drugs:
- drug_name: Levothyroxine
  dosage: 175mg
  route_of_administration: Intramuscular
  start_date: '2025-04-04'
  indication_for_use: Hypothyroidism
  drug_class: Thyroid hormone
- drug_name: Sertraline
  dosage: 86mg
  route_of_administration: Intramuscular
  start_date: '2025-04-04'
  indication_for_use: Major depressive disorder
adverse_reactions:
- symptom_name: Nausea
  onset_date: '2025-05-29'
  severity: Moderate
  outcome: Recovering
  intervention_required: false
- symptom_name: Pruritus
  onset_date: '2025-05-29'
  severity: Moderate
  outcome: Not Recovered
  intervention_required: true
  intervention_details: Prescribed loss and advised data.
- symptom_name: Maculopapular Rash
  onset_date: '2025-05-29'
  severity: Moderate
  outcome: Recovering
  intervention_required: true
causality_assessment:
  assessment_conclusion: Probable
  dechallenge_rechallenge: Rechallenge not performed
reporting_facility: Johnston-Nelson Medical Center
reporter_type: Patient
