CASE VI
A.
Patient
Description
- Name : QSC
- Age : 63 years
- Reg. No : 556286
- Gender : Male
- Admission : 11/11/06
- Weight : 63 kg
- Race : Chinese
- Heights : 173 cm
B. Chief Complaint
(CC)
High
grade fever, chills, ◦
rigor x 2/7
+ Vomit x 1/7
+ Diarrhea 6-7 times/day, no
abdominal pain for 2 days
Yellow discoloration for both
eyes, + tea colour urine
C. History of
present illness (HPI)
Ÿ
+ SOB on exertion for past 4 months
Ÿ
Atrial fibrillation on warfarin
Ÿ
Severe Mitral valve regurgitation (newly
diagnose in August 06, patient refuse to go for surgery)
D. Family & Social
History
n
Sister has hypertension
n
Patient was ex-teacher, has 5 childrens, live
with family members.
n
Non smoker
n
Non alcoholic user
E. Medical History
Interview
HEART PROBLEMS:
|
URINARY/REPRODUCTIVE:
|
||
Chest pain (angina)
|
Urinary or bladder
infection
|
||
Past heart attack
|
Prostate problems
|
||
Heart failure
|
Hysterectomy
|
||
Irregular heartbeat
|
ü
|
Chronic yeast infections
|
|
Heart by-pass surgery
|
Kidney disease
|
||
Rheumatic fever
|
Dialysis
|
||
Other:
severe Mitral valve
regurgitation
|
ü
|
Other:
|
|
EYES, EARS, NOSE &
THROAT
|
MUSCLES AND BONES
|
||
Poor vision
|
Arthritis
|
||
Poor hearing
|
Gout
|
||
Glaucoma
|
Back pain
|
||
Sinus problem
|
Amputation
|
||
Bladder disorder
|
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
|
ü
|
Asthma
|
|
Low blood pressure
|
Emphysema
|
||
High cholesterol
|
Bronchitis
|
||
Diabetes
|
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
|
ü
|
||
Heart disease
|
Other:
|
||
Diabetes
|
|||
F.S.1
|
Current Prescription Medication Regimen |
|||||||
Name/Dose/Strength/Route
|
Schedule/
Frequency of Use
|
Indication
|
Start Date (and stop date if applicable)
|
|||||
T. Digoxin 0.125 mg
|
OD
|
Atrial fibrillation
|
April 2006 and
continue
|
|||||
T. Frusemide 40mg
|
OD
|
Hypertension
|
Continue
|
|||||
T. Metoprolol 50mg
|
BD
|
Hypertension
|
Continue
|
|||||
T. Slow K 1/1
|
OD
|
Potassium supplement
|
Continue
|
|||||
T. Perindopril 2mg
|
OD
|
Hypertension
|
Continue
|
|||||
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
|
|||
T. Multivitamin 1/1
|
OM
|
For vitamin
supplement
|
Continue
|
-
|
-
|
|||
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;
* Still okay to be
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?
Claimed
tolerate well by patient.
Compliance
rate: Compliant [ü ] Moderate/partial
compliant [ ] Noncompliant [ ]
H. Social History
Smoking : Non smoker
Alcohol : Non alcoholic user
Other drug
use : -
Caffeine
intake : Previously 5 cups
coffee per day,
after having MVR, reduce to 1-2 cup a day.
Diet
|
Routine Exercise/Recreation
|
Daily Activities/Timing
|
Low salt –compliance
|
Daily brisk walking and regular
exercise for 1 hour
|
Routine exercise, moderate daily
activities
|
Low fat diet-compliance
|
J. Physical examination / laboratory for initial and
follow-up.
Date
|
11/11/06
|
Date
|
11/11/06
|
Height(cm)
|
173
|
Na+ (mmol/L)
|
137
|
Weight(kg)
|
63
|
K+ (mmol/L)
|
2.9 L
|
Temp(C°)
|
38.0
|
BUN (mmol/L)
|
10.7
|
BP(mmHg)
|
103/63
|
Creatinine (umol/L)
|
132
|
Pulse(bpm)
|
102
|
Urine output
|
-
|
RR/VENT
|
20
|
I/O
|
-
|
Peak Flow
|
-
|
Uric acid/Mg (mmol/L)
|
-
|
pH
|
-
|
Ca2+ (mmol/L)
|
-
|
SPO2
|
-
|
PO4 (mmol/L)
|
-
|
PCO2
|
-
|
FBS (mmol/L)
|
-
|
HCO
|
-
|
BMI
|
21.05
|
LDL (mmol/L)
|
-
|
LDH (U/L)
|
|
HDL (mmol/L)
|
-
|
CK (U/L)
|
|
TG (mmol/L)
|
-
|
INR
|
2.1 H
|
T.Chol (mmol/L)
|
-
|
PT/aPTT
|
26.3H / 45.9H
|
WBC (x103/uL)
|
32.4 H
|
TT/FDP
|
-
|
Hgb (g/dL)
|
10.1 L
|
Total Bili (umol/L)
|
211 H
|
Platelet (x103/uL)
|
46 L
|
Hct
|
35.0 L
|
ALT/AST (U/L)
|
ALT:15
|
||
Alk Phos (g/L)
|
58
|
||
X-ray
|
Consolidation at basal
|
Total Protein (g/L)
Albumin (g/L)
|
70
41
|
Echocardio
|
-
|
TSH
|
-
|
ECG
|
-
|
HbA1c (6.8-8.6)-Fair
control
>8.6%- Poor control
|
-
|
Pharmalogic review of system:
General:
Alert, conscious, fever, jaundice, vomit and diarrhea
Vital
Signs: BP 103/63 mmHg ; PR 102bpm ; T 38.0 °C
; RR 20
KUT:
-
HEPATIC:
No hepatomegaly
CVS: irregularly irregular
CHEST: Lungs clear
BLOOD: ? hemolysis
ABDO: Soft, non tender, no organomegaly
SKIN/MUSCLE: -
NEURO/MENTAL: -
HEENT: -
K. Physical Examination/ Daily Progress (D1-D4)
|
||||
11/11/06
|
12/11/06
|
13/11/06
|
14/11/06
|
|
General
|
Fever,
diarrhea 6-7x/day, vomit,yellow discolouration of both eyes, tea colour urine
|
Fever, cough, productive, conscious, alert.
|
Uncomfortable, still cough, alert, conscious,
afebrile
|
Cough on and off,
improving, no hemotysis, afebrile, alert, conscious
|
Vital Sign
|
||||
BP (mmHg)
|
103/63
|
118/69
|
110/74
|
118/72
|
Pulse (bpm)
|
102
|
110
|
85
|
94
|
Temp (oC)
|
38.0
|
37.5
|
37.0
|
37.0
|
CVS
|
Irregularly
irregular
|
Irregularly irregular
|
PSM @ mitral arch
|
-
|
Lungs
|
Clear
|
Clear
|
Clear, Chest X-ray show some consolidation.
|
Creps at right base.
|
ECG
|
-
|
-
|
-
|
-
|
Physician Plan
|
1.
Cont patient
own medication.
2.
T. Digoxin
0.125mg OD
3.
T. Lasix 40mg
OD
4.
↑T. Slow K 11/11 BD
5.
T. Metoprolol
50mg BD
6.
T. Perindopril
2mg OD
7.
T. Warfarin 2.5
mg OD
|
1.
Start IV Ceftriaxone 2g stat then OD x 1/7
2.
T. Azithromycin 500mg x 3/7
3.
T. Hematinic 1/1 OD
4.
Sy Benadry 10ml TDS
5.
Cont the others.
|
1.
Cont
Ceftriaxone D2
2.
Azithromycin D2
3.
Cont the
others.
|
1.
Continue medication
|
K. Physical Examination/ Daily Progress
(D5-D8)
|
||||
15/11/06
|
16/11/06
|
17/11/06
|
18/11/06
|
|
General
|
Feeling
better, still cough at night.
|
Still some cough, no fever
|
Less cough, comfortable, alert, conscious
|
Comfortable
|
Vital Sign
|
||||
BP (mmHg)
|
109/68
|
100/80
|
96/58
|
106/76
|
Pulse (bpm)
|
86
|
68
|
71
|
75
|
Temp (oC)
|
37.0
|
37
|
37
|
37
|
CVS
|
-
|
-
|
-
|
-
|
Lungs
|
Clear
|
Clear
|
Clear
|
Clear
|
ECG
|
-
|
-
|
-
|
-
|
Physician Plan
|
1.
Continue the
same medication and observation.
2.
Continue T.
Azithromycin for another 4/7.
3.
to discharge
patient after completed IV antibiotic.
|
1.
T. Azithromycin D5
2.
IV Ceftriaxone D5
3.
Cont the others
|
1.
Off T.
Azithromycin after today dose
2.
Off IV
Rocephine after D7
3.
for discharge
the coming morning.
|
1.
Discharge
today.
2.
T. Digoxin
0.125mg OD
3.
T. Frusemide
40mg OD
4.
T.Slow K 11/11
OD
5.
T. Metoprolol
50mg BD
6.
T. Perindopril
2mg OD
7.
T. Warfarin
2.5mg OD
|
Test
|
Normal Range
|
11/11/06
|
14/11/06
|
15/11/06
|
16/11/06
|
WBC
|
5.2-12.4 x 10^3/uL
|
32.4 H
|
8.7
|
8.8
|
11.1
|
RBC
|
4.2-5.4 x 10^6/uL
|
5.1
|
4.7
|
4.4
|
4.4
|
HGB
|
12
-16 g/dL
|
10.1 L
|
9.1 L
|
9.3 L
|
8.7 L
|
HCT
|
37
– 47 %
|
35.0 L
|
32.7 L
|
32.6 L
|
30.6 L
|
MCV
|
81
– 99 fL
|
68.9 L
|
70.3 L
|
73.4 L
|
70.0 L
|
MCHC
|
33
– 37 g/dL
|
28.9 L
|
27.8 L
|
28.5 L
|
28.4 L
|
PLT
|
130
– 400 10^3/uL
|
46 L
|
66 L
|
116 L
|
132
|
Na+
|
135-145 mmol/L
|
137
|
-
|
-
|
139
|
K+
|
3.5-5.0 mmol/L
|
2.9 L
|
-
|
-
|
3.9
|
Urea
|
1.7-8.3 mmol/L
|
10.7 H
|
-
|
-
|
3.8
|
Creat
|
57-130 umol/L
|
132 H
|
-
|
-
|
79
|
Cl-
|
86-108
|
98
|
-
|
-
|
104
|
CLcr
|
75-125ml/min
|
45.1
|
-
|
-
|
75.4
|
T Pro
|
66-87g/L
|
70
|
71
|
-
|
-
|
Alb
|
35-52
g/l
|
41
|
36
|
-
|
-
|
Glb
|
23-35
g/l
|
29
|
35
|
-
|
-
|
A/G
|
0.9-1.8
|
1.4
|
1.0
|
-
|
-
|
T Bili
|
0-24mmol/l
|
211 H
|
36 H
|
-
|
33
|
Direct Bili.
|
0-8
mmol/l
|
-
|
8
|
-
|
8
|
Indirect Bili.
|
0-16
mmol/l
|
-
|
28 H
|
-
|
25 H
|
ALT
|
0-42
U/l
|
15
|
-
|
-
|
-
|
ALP
|
34-104
g/l
|
58
|
48
|
-
|
-
|
AST
|
0-37
U/L
|
-
|
-
|
-
|
-
|
CK
|
24-195
U/L
|
-
|
-
|
-
|
-
|
LDH
|
135-225
U/L
|
-
|
227 H
|
-
|
-
|
T Chol
|
<5.2
mmol/L
|
-
|
-
|
-
|
-
|
TG
|
<1.8
mmol/L
|
-
|
-
|
-
|
-
|
LDL
|
<3.36
mmol/L
|
-
|
-
|
-
|
-
|
HDL
|
>1.29
mmol/L
|
-
|
-
|
-
|
-
|
%HDL-Chol
|
15-25
|
-
|
-
|
-
|
-
|
Reflomet
|
mmol/L
|
-
|
-
|
-
|
-
|
FBG
|
mmol/L
|
-
|
-
|
-
|
-
|
PT
|
11.5-13.5
sec
|
26.3 H
|
-
|
-
|
-
|
INR
|
0.8-1.2
|
2.1 H
|
-
|
-
|
-
|
APTT
|
24.0-35.0
sec
|
45.9 H
|
-
|
-
|
-
|
Culture and sensitivity
11/11/06 Blood C&S : No growth
12/11/06 Blood C&S : No growth
13/11/06 Blood C&S : No growth
13/11/06 Urine C&S : No growth
13/11/06 Sputum C&S : No growth
Urine FEME
SG
|
1.020
|
pH
|
6
|
Leu.
|
25/mL +
|
Nit.
|
Negative
|
Pro.
|
25mg/dL +
|
Glu.
|
Negative
|
Ket.
|
Negative
|
UBG
|
4mg/dL ++
|
Bil.
|
1mg/dL +
|
Ery.
|
25/mL
++
|
K
.Diagnoses/Provisional Dx / Acute / Chronic medical Problems
[1] Atypical pneumonia (?
Mycoplasma)
[2] Hypertension
[3] Atrial fibrillation
[4] Severe Mitral valve
regurgitation (patient refused to undergo operation)
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. Digoxin 0.125mg
|
OD
|
Continue
|
Continue
|
|
T. Frusemide 40mg
|
OD
|
Continue
|
Continue
|
|
T. Slow K 11/11
|
BD
|
11/11/06
|
17/11/06
|
|
T. Slow K 11/11
|
OD
|
17/11/06
|
Continue
|
|
T. Metoprolol 50mg
|
BD
|
Continue
|
Continue
|
|
T. Perindopril 2mg
|
OD
|
Continue
|
Continue
|
|
T. Warfarin 2.5mg
|
OD
|
Continue
|
Continue
|
|
IV Ceftriaxone 2g
|
Stat & OD
|
11/11/06
|
18/11/06
|
|
T. Azithromycin 500mg
|
OD
|
11/11/06
|
17/11/06
|
|
T. Hematinic 1/1
|
OD
|
11/11/06
|
17/11/06
|
|
Syr Benadryl 10ml
|
TDS
|
12/11/06
|
Continue
for prn after discharge for 1/52
|
|
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