Monday, May 25, 2015

STUDI KASUS C



CASE III
A.                      Patient Description
  • Name      : VA 
  •  Age        : 71 years 
  • Reg. No  : 550429 
  •  Gender   : Male 
  • Admission   : 3/10/06
  • Weight : 60 kg 
  • Heights            : 165 cm

B.            Chief Complaint (CC)
               Shortness of Breath and tiredness x 1/52
               Difficult in passing urine x 1/7
              
C.           History of present illness (HPI)
Ÿ Recent MI (13 September), just discharged from Seberang Jaya Hospital 1 day ago (2 October).
Ÿ Upon discharge, he is still complaining SOB, fatigue and unable to lie flat. Sleep with 2 pillows.
Ÿ Poor oral intake for the past 1 week. Normal bowel habits.
Ÿ Still having difficulty in passing urine.

D.           Family & Social History  
n  All patient siblings have IHD, some passed away due to heart attack. Mother has history of Diabetes Mellitus.
n  Live alone. Children married.
n  None smoker or alcoholic.                                 



E.           Medical History Interview


HEART PROBLEMS:

URINARY/REPRODUCTIVE:

Chest pain (angina)
ü
Urinary or bladder infection

Past heart attack
ü
Prostate problems
ü
Heart failure
ü
Hysterectomy

Irregular heartbeat
ü
Chronic yeast infections

Heart by-pass surgery

Kidney disease

Rheumatic fever

Dialysis

Other:

Other:

EYES, EARS, NOSE & THROAT

MUSCLES AND BONES

Poor vision
ü
Arthritis

Poor hearing

Gout

Glaucoma

Back pain

Sinus problem

Amputation

Bladder disorder
ü
Joint replacement

Other:

Other:

GASTROINTESTINAL

NEUROLOGICAL

Heartburn

Headache

Ulcer

Seizures or epilepsy

Constipation

Parkinson’s disease

Diverticulitis

Dizziness

Liver disease

Past stroke

Gallbladder problems

Fainting

Pancreatitis

Depression

Other:

Anxiety



Other:

DO YOU HAVE:

LUNG PROBLEMS

High blood pressure

Asthma

Low blood pressure

Emphysema

High cholesterol

Bronchitis

Diabetes
ü
Other:

Cancer



Anaemia



Bleeding disorder

DO YOU HAVE OR USE…?

Hay fever

Glasses

Sleeping problems

Hearing aid

Other:

Other:

DO YOU HAVE A FAMILY HISTORY OF:
High blood pressure



Heart disease
ü
Other:Stroke

Diabetes
ü




F.S.1

Current Prescription Medication Regimen
Name/Dose/Strength/Route
Schedule/
Frequency of Use
Indication
Start Date (and stop date if applicable)
Prescriber
Indication issues, effectiveness, safety, compliance and cost
T. Hytrin 5mg
OD
BPH
Con’t


T. Glibenclamide 2.5mg
OD
NIDDM
Con’t


T. Lovastatin 20mg
ON
Hyperlipidaemia
Con’t


T. Spironolactone 25mg
OD
Heart Failure
Con’t


T. Perindopril 2mg
OD
Anti-hypertension/IHD/HF
Con’t


T. Aspirin 75mg
OD
Antiplatelet
Con’t


T. Cefuroxime 250mg
BD
? Pneumonia
Con’t


T. Amiodarone 400mg
OD
Ventricular tacchyarrhymia
Con’t


T. Carvedilol 6.25mg
BD
Heart Failure
Con’t


T. B Complex 1/1
OD
Vitamin Deficiency
Con’t








F.S.2
Current Nonprescription Medication Regimen (OTC, herbal, homeopathic, nutritional, etc)
Name/Dose/Strength/Route
Schedule/
Frequency of Use
Indication
Start Date (and stop date if applicable)
Prescriber
Indication issues, effectiveness, safety, compliance and cost
Nil

















F. Allergies:
History of allergies:     Yes [  ]                No known allergies [ü]
Are you allergic to any prescription drugs, over-the-counter medication, herbals or food supplements?

  If yes, please list the medications and type of allergic reaction experienced:_______________


Are there any medications that you are not allergic but cannot tolerate?

[  ]Yes    [ü] No    If yes, please list the medications and the reaction experienced:
                                                                                   
 



What environmental allergies do you have?           Nil

 


G.  Medication Compliance assessment
Base questions on history obtained to this point.
Your medication regimen sounds complex and must be hard to follow;

How often would you estimate that you miss a dose?
Seldom

Everyone has problems with following a medication regimen exactly as written.
What are the problems you are having with your regimen?
Blood pressure will drop when take the hytrin 5mg, so he altered to 1.25mg and agreed by priscriber from IJN.

Compliance rate: Compliant [ü ]    Moderate/partial compliant [  ]    Noncompliant [  ]



H. Social History
            Smoking                      : Non smoker
            Alcohol                       : Non alcoholic user
            Other drug use            : -
            Caffeine intake           : Seldom, only on occasionally basic.

Diet
Routine Exercise/Recreation
Daily Activities/Timing
Low salt – moderate compliance
Seldom exercise
Because long term in the hospital, so temporally bed-ridden. Previously having mild activity.
Low fat diet


Diabetic diet – compliance




J. Physical examination / laboratory for initial and follow-up.
Date
3/10/06
Date
3/10/06
Height(cm)
165 cm
Na+ (mmol/L)
134
Weight(kg)
60 kg
K+ (mmol/L)
4.0
Temp(C°)
37.2
BUN (mmol/L)
11.9
BP(mmHg)
102/79
Creatinine (umol/L)
136
Pulse(bpm)
90
Urine output
-
RR/VENT
20
I/O
-
Peak Flow
-
Uric acid/Mg (mmol/L)
Mg: 0.84 (4/10/06)
pH
-
Ca2+ (mmol/L)
2.0
SPO2
-
PO4 (mmol/L)
1.24
PCO2
-
RBS (mmol/L)
6.8
HCO
-
BMI
22.04
LDL (mmol/L)
2.2 (5/10/06)
LDH (U/L)
345
HDL (mmol/L)
0.6 (5/10/06)
CK (U/L)
88
TG (mmol/L)
0.8 (5/10/06)
INR
1.7
T.Chol (mmol/L)
3.2 (5/10/06)
PT/aPTT
20.9/ 25.1
WBC (x103/uL)
12.1
TT/FDP
-
Hgb (g/dL)
11.8
Total Bili (umol/L)
32
Platelet (x103/uL)
182
Hct
39.0%


ALT/AST (U/L)
ALT:307 ; AST:143


Alk Phos (g/L)
94
X-ray
No obvious pneumonia changes; Gross cardiomegaly & congestion.
Total Protein (g/L)
Albumin (g/L)
65
30
Echocardio
-
TSH
-
ECG
No acute ischemic changes; broad QRS complex.



Pharmalogic review of system:
General: Alert, conscious, able to speak in sentences
Vital Signs: BP 102/79mmHg ; PR 90bpm ; T 37.2 °C ;
KUT: -
HEPATIC: No hepatomegaly
CVS: DRNM (Pacemaker insitu)
CHEST: Lungs fine crepitation on bilateral midzone and lower zone.
BLOOD: Mild anemic
ABDO: Soft, non tender, no organomegaly
SKIN/MUSCLE: -
NEURO/MENTAL: -
HEENT: -
K. Physical Examination/ Daily Progress (D1-D4)

3/10/06
4/10/06
5/10/06
6/10/06
General
No chest pain, dizziness/headache, palpitation, afebrile, +SOB, + urine problem, poor oral intake.
No chest pain, alert & conscious, dyspnea at rest
Still SOB at rest,
Complaint coughing throughout the night, no pedal edema, tongue + grossitis
Vital Sign




BP (mmHg)
102/79
90/67
100/72
90/60
Pulse (bpm)
90
98
100
90
Temp (oC)
37.2
37.0
37.0
37.0
CVS
DRNM (pacemaker insitu)
No gallop
No gallop
DRNM (pacemaker insitu)
Lungs
+ fine crepitation
Clear
Clear
Not much rhonchi/crepitation
ECG
No acute ischemic changes, broad QRS complex
Complete PQRS, no dynamic changes
-
-
Physician Plan
1.       Off Cefuroxime
2.       Withold Carvedilol
3.       start IV fortum 1g TDS
4.       IV Frusemide 40mg TDS
5.       T.Glibenclamide 2.5mg OD
6.       T.Hytrin 1.25mg OD
7.       T.Lovastatin 20mg ON
8.       T.Perindopril 2mg OD
9.       T.Spironolactone 25mg OD
10.    T.Aspirin 75mg OD
11.    T.Amiodarone 400mg OD
12.    Restrict fluid to 1L/day, strict I/O chart
13.    NP O2 2L/min
1.       Withold all antiHTN till BP stable (terazosin, perindopril, spironolactone, frusemide) & amiodarone.
2.       Continue Aspirin, Glibenclamide, lovastatin.
3.       O2 10L/min adjust to ABG
1.       Start T. Digoxin 0.25mg OD
2.       continue others.
1.       Start T.EES 800mg BD
2.       T. Augmentin 375mg TDS
3.       ↓ T. Digoxin 0.125mg OD
4.       Off IV Fortum
5.       Witholh oral antiHTN
6.       Withhold Frusemide
7.       ↓Nasal Prong O2 2L/min
8.       Cont others

K. Physical Examination/ Daily Progress (D5-D10)

7/10/06
8/10/06
9/10/06
10/10/06
11/10/06
12/10/06
General
Alert & consious
Alert, conscious, still having cough.
Alert, conscious, less SOB, no chest pain
+SOB on & off, no chest pain, alert, conscious, tachypnoic, coughing yellowish/green sputum
Tachypnoeic, no pedal edema, SOB reduced, ↑JVP
↓SOB,chesty cough, productive cough with yellowish with sériate of red, no chest pain, alert,conscious.
Vital Sign






BP (mmHg)
94/67
104/74
112/76
126/78
106/75
117/87
Pulse (bpm)
75
112
99
87
99
102
Temp (oC)
37.0
37.0
37.0
37.2
37.0
37.0
CVS
S1S2
-
DRNM
DRNM
S1S2 no murmur
DRNM
Lungs
Clear
Clear
Bibasal creps, with occasional rhonchi on left lung.
Creps up to midzone, occasional rhonchi on R lung.
Rales
Bilateral gross creps up to midzone, +rhonchi
ECG

-
-
-
-
-
Physician Plan
1.       Remain the same
2.       O2 3L/min
1. Cont same medication
1.       Stop T. Augmentin
2.       T. EES D4
3.       Start T Unasyn 750mg BD x 4/7 (to cover L thrombophlebitis)
4.       T.Lasix 40mg OD
5.       T.Slow K ii/ii OD
6.       Off Lovastatin
7.       Continue others
1.       T. EES D5
2.       Change T. Unasyn to IV Unasyn 1.5g stat & TDS
3.       Change T. Lasix to IV 40mg TDS
4.       IVD 2 pin N/S over 24hr.
1.       Off IV Drip
2.       Off IV Unasyn
3.       Start IV Cefoperazone 2g stat & 1g BD
4.       SC Heparin 5000unit BD (due to D-dimer >0.2)
1.       Start T.Amiodarone 400mg OD x 2/52, then 200mg OD
2.       IV Ceftriaxone 2g OD (in view of recurrent hospitalization & possibility of nosocomial infection)
3.       Continue the rest.

K. Physical Examination/ Daily Progress (D11-D17)

13/10/06
14/10/06
15/10/06
16/10/06
17/10/06
18/10/06
19/10/06
General
No SOB, chesty cough with productive sputum.
Patient alert, conscious, stable
Alert, conscious
Same
Afebrile, comfortable
Alert, conscious, weak
Comfortable
Vital Sign







BP (mmHg)
94/65
99/72
90/60
100/60
98/70
94/71
82/60 (patient take 5mg Terazosin)
Pulse (bpm)
99
78
146↑
69
68
85
100
Temp (oC)
37.2
37.0
37.0
37.0
37.0
37.0
37.0
CVS
Had 1 episode of VT at 1pm
-
Increase heart rate
S1S2
S1S2
DRNM
DRNM
Lungs
Rhonchi with R lower zone
-
-
Clear
Clear
Clear
Clear
ECG
-
-
-
-
-
-
-
Physician Plan
1.       IV Ceftriaxone D2
2.       Resume T Lovastatin 20mg ON
3.       Continue Amiodarone
4.       Still on Aspirin, EES, Slow K, Digoxin 0.125mg, SC Hepatin 5000units BD, IV Lasix
Continue the same
1. Start IV Amiodarone 600mg in 1pin D5% over 24hr
1.       IV Rocephine D5
2.       T. EES D11
3.       Start T. Amiodarone 400mg TDS x1/52, then 400mg BD x1/52
4.       T. Frusemide 40mg OD
5.       SC Heparin 5000units BD
6.       Start T.Terazosin 0.5mg OD
1. KIV to discharge tomorrow after complete IV Ceftriaxone.
1.       Cont same medication
1. ↑T. Digoxin 0.25mg OD




L. Laboratory findings and follow up:
Test
Normal Range
3/10/06
4/10/06
5/10/06
7/10/06
10/10/06
12/10/06
WBC
5.2-12.4 x 10^3/uL
12.1
-
-
-
14.5 H
-
RBC
4.2-5.4 x 10^6/uL
4.1 L
-
-
-
4.0 L
-
HGB
12 -16  g/dL
11.8 L
-
-
-
11.3 L
-
HCT
37 – 47  %
39.0
-
-
-
39.1
-
MCV
81 – 99  fL
95.4
-
-
-
97.8
-
MCHC
33 – 37  g/dL
30.3 L
-
-
-
28.9 L
-
PLT
130 – 400  10^3/uL
182
-
-
-
259
-








Na+
135-145 mmol/L
134 L
132 L
-
-
137
140
K+
3.5-5.0 mmol/L
4.0
3.7
-
-
3.9
3.9
Urea
1.7-8.3 mmol/L
11.9 H
12.1 H
-
-
5.5
9.0
Creat
57-130 umol/L
136 H
172 H
-
-
103
107
Cl-
86-108
102
97
-
-
101
97
CLcr
75-125ml/min
37.4
29.6
-
-
49.3
47.5








T Pro
66-87g/L
65 L
-
-
64 L
-
-
Alb
35-52 g/l
30 L
-
-
29 L
28 L
-
Glb
23-35 g/l
35
-
-
35
-
-
A/G
0.9-1.8
0.9
-
-
0.8
-
-
T Bili
0-24mmol/l
32 H
-
-
35 H
-
-
ALT
0-42 U/l
307 H
-
-
153 H
-
-
ALP
34-104 g/l
94
-
-
82
-
-








AST
0-37 U/L
143
-
-
-
-
46
CK
24-195 U/L
88
-
-
-
-
43
LDH
135-225 U/L
345
-
-
-
-
296








T Chol
<5.2 mmol/L
-
-
3.2
-
-
-
TG
<1.8 mmol/L
-
-
0.8
-
-
-
LDL
<3.36 mmol/L
-
-
2.2
-
-
-
HDL
>1.29 mmol/L
-
-
0.6 L
-
-
-
%HDL-Chol
15-25
-
-
19
-
-
-








PT
11.5-13.5 sec
20.9 H
19.0 H
-
-
16.9 H
17.5 H
INR
0.8-1.2
1.7 H
1.5 H
-
-
1.4 H
1.4 H
APTT
24.0-35.0 sec
25.1
23.1
-
-
26.2
24.3








D-Dimer
<0.20 mg/L
>0.20 (11/10/06)



K .Diagnoses/Provisional Dx / Acute / Chronic medical Problems

[1] Decompensate Cardiac Failure secondary to Pneumonia
[2] Recent Myocardiac Infarction
[3] Type II Diabetes Mellitus
[4] Benign Prostate Hyperplasia
[5] Ischemic Heart Disease
[6] Dyslipidaemia
[7] Ventricular tachycardia on automatic implantable cardioverter/defibrillator (AICD)
  
L. Drug treatment in the ward
Current Drug Therapy (Oral, Parenteral, Inhaler and others)
Drug Name/ Dose/ Strength /Route
Schedule
Duration
Indication


Start
Stop

T. Terazosin 1.25mg
OD
-
4/10

T. Terazosin 1.25mg
OD
16/10
Continue

T. Glibenclamide 2.5mg
OD
-
Continue

T. Lovastatin 20mg
ON
-
9/10

T. Lovastatin 20mg
ON
13/10
Continue

T. Spironolactone 25mg
OD
-
4/10

T. Perindopril 2mg
OD
-
4/10

T. Aspirin 75mg
OD
-
Continue

T. Carvedilol 6.25mg
BD
-
3/10

T. B complex 1/1
OD
-
Continue

T. Digoxin 0.25mg
OD
5/10
6/10

T. Digoxin 0.125mg
OD
6/10
18/10

T. Digoxin 0.25mg
OD
19/10
Continue

IV Frusemide 40mg
TDS
3/10
4/10

T. Frusemide 40mg
OD
9/10
10/10

IV Frusemide 40mg
TDS
10/10
15/10

T. Frusemide 40mg
OD
15/10
Continue

T. Slow K ii/ii
OD
9/10
Continue

IV Ceftazidime 1g
Stat & TDS
3/10
5/10

T. Augmentin 375mg
TDS
6/10
9/10

T. Unasyn 750mg
BD
9/10
10/10

IV Unasyn 1.5g
Stat & TDS
10/10
11/10

IV Cefoperazone 2g
Stat & 1g BD
11/10
11/10

IV Ceftriaxone 2g
OD
12/10
18/10

T. EES 800mg
BD
6/10
18/10

T. Amiodarone 400mg
OD
-
4/10

T. Amiodarone 400mg
400mg TDS for 1/52, then 400mg BD for another 1/52, then 400mg OD
16/10
Continue

SC Heparin 5000U
BD
11/10
18/10









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