<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-2025-872
Date of Submission: 2025-07-29

This report was submitted by a Patient from Calderon, Lopez and Jackson Medical Center concerning patient ANON-PX-2576. The subject is an adult female with a significant medical history including chronic kidney disease, hypertension, asthma. 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): Gabapentin administered via the Topical route at a dosage of 102mg, initiated on 2025-06-22 for Neuropathic pain and discontinued on 2025-07-02; Sertraline (SSRI) administered via the Intramuscular route at a dosage of 469mg, initiated on 2025-06-22 for Major depressive disorder and discontinued on 2025-07-02.

On approximately 2025-06-29, the patient began to manifest an adverse event. The primary symptoms noted in the clinical log were Maculopapular Rash, Dizziness. The Maculopapular Rash was classified as Moderate in severity. This necessitated clinical intervention. The documented action was: Prescribed name and advised catch. The current patient status regarding this symptom is 'Fatal'. The Dizziness was classified as Moderate in severity. This necessitated clinical intervention. The current patient status regarding this symptom is 'Not Recovered'. 

CAUSALITY ASSESSMENT:
An evaluation of causality was performed. The assessment concluded the relationship was 'Probable'. Dechallenge/Rechallenge status was noted as: 'Positive rechallenge'. The on-site pharmacist concurred with the assessment during a routine case review. 

</data>
report_id: ADR-2025-872
report_date: '2025-07-29'
patient_details:
  patient_id: ANON-PX-2576
  gender: Female
  relevant_history:
  - chronic kidney disease
  - hypertension
  - asthma
suspected_drugs:
- drug_name: Gabapentin
  dosage: 102mg
  route_of_administration: Topical
  start_date: '2025-06-22'
  indication_for_use: Neuropathic pain
  end_date: '2025-07-02'
- drug_name: Sertraline
  dosage: 469mg
  route_of_administration: Intramuscular
  start_date: '2025-06-22'
  indication_for_use: Major depressive disorder
  drug_class: SSRI
  end_date: '2025-07-02'
adverse_reactions:
- symptom_name: Maculopapular Rash
  onset_date: '2025-06-29'
  severity: Moderate
  outcome: Fatal
  intervention_required: true
  intervention_details: Prescribed name and advised catch.
- symptom_name: Dizziness
  onset_date: '2025-06-29'
  severity: Moderate
  outcome: Not Recovered
  intervention_required: true
causality_assessment:
  assessment_conclusion: Probable
  dechallenge_rechallenge: Positive rechallenge
reporting_facility: Calderon, Lopez and Jackson Medical Center
reporter_type: Patient
