Kumpulan Pengetahuan

CASE IV

A. Patient Description

Name : MYPM
Age : 59 years
Reg. No : 552069
Gender : Male
Admission : 13/10/06
Weight : 104 kg (IBW=66.1)
Race : Malay
Heights : 170 cm

B. Chief Complaint (CC)

Chest pain: +severe, typical, Left arm numbness for 1 day

+ Sweating

+ Nausea

C. History of present illness (HPI)

ŸKnown history of IHD (3 vessel disease with occluded SVE)

ŸPlanned for PCI in December 2006

ŸOn 16/2/06, NYHA I-II, TIMI score 4/7

ŸCABGs were done on 1986 & 1995

D. Family & Social History

n Father and mother has history of Ischemic heart disease and Diabetes Mellitus.

n Staying with family member.

n None smoker or alcoholic user

n Pensioner from Penang Hospital as attendant.

E. Medical History Interview

HEART PROBLEMS:		URINARY/REPRODUCTIVE:
Chest pain (angina)	ü	Urinary or bladder infection
Past heart attack	ü	Prostate problems
Heart failure		Hysterectomy
Irregular heartbeat		Chronic yeast infections
Heart by-pass surgery	ü	Kidney disease
Rheumatic fever		Dialysis
Other:		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	ü	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. Aspirin 150mg		OD	Antiplatelet		Con’t
T. Metoprolol 100mg		BD	Hypertention/IHD		Con’t
T. Isorsobide Dinitrate 10mg		TDS	IHD		Con’t
T. Vastarel 20mg		TDS	IHD		Con’t
T. Valsartan 80mg		OD	Hypertension/IHD		Con’t
T. Simvastatin 10mg		OD	Dyslipidaemia		Con’t
T. Metformin 1g		BD	Diabetes mellitus		Con’t
T. Gliclazide 80mg		OD	Diabetes mellitus		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?

Claimed tolerate well by patient.

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

H. Social History

Smoking : Ex-smoker

Alcohol : Non alcoholic user

Other drug use : -

Caffeine intake : 3 cups (≈100ml) per week

Diet	Routine Exercise/Recreation	Daily Activities/Timing
Low salt – moderate compliance	Daily brisk walking	Routine exercise, mild to moderate daily activities.
Low fat diet
Diabetic diet – compliance

J. Physical examination / laboratory for initial and follow-up.

Date	13/10/06	Date	13/10/06
Height(cm)	170 cm	Na⁺ (mmol/L)	137
Weight(kg)	104 kg	K⁺ (mmol/L)	4.1
Temp(C°)	37.0	BUN (mmol/L)	6.4
BP(mmHg)	147/86	Creatinine (umol/L)	105
Pulse(bpm)	82	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)	8.7 (17/10/06)
HCO	-	BMI	36
LDL (mmol/L)	1.8 (19/9/06)	LDH (U/L)	164
HDL (mmol/L)	0.9 (19/9/06)	CK (U/L)	87
TG (mmol/L)	2.1 (19/9/06)	INR	1.1
T.Chol (mmol/L)	3.7 (19/9/06)	PT/aPTT	12.8/25.4
WBC (x10³/uL)	8.3	TT/FDP
Hgb (g/dL)	13.9	Total Bili (umol/L)	12
Platelet (x10³/uL)	234	Hct	41.9
		ALT/AST (U/L)	ALT:73 ; AST:49
		Alk Phos (g/L)	61
X-ray		Total Protein (g/L) Albumin (g/L)	71 40
Echocardio	EF 33% (15/10/06)	TSH	-
ECG	Lead I, II Q wave	HbA1c (6.8-8.6)-Fair control >8.6%- Poor control	8.6% (17/10/06)

Pharmalogic review of system:

General: Alert, conscious, chest pain, left arm numbness, +sweating

Vital Signs: BP 147/86 mmHg ; PR 82bpm ; T 37.0 °C ;

KUT: -

HEPATIC: No hepatomegaly

CVS: DRNM

CHEST: Lungs clear

BLOOD: WNL

ABDO: Soft, non tender, no organomegaly

SKIN/MUSCLE: -

NEURO/MENTAL: -

HEENT: -

K. Physical Examination/ Daily Progress (D1-D4)
	13/10/06	14/10/06	15/10/06	16/10/06
General	Alert, conscious, complaint of chest pain (severe, typical), left arm numbness, +sweating, +Nausea	Still complaint of chest pain, left sided, no shortness of breath	Alert, conscious, no more chest pain	Comfortable，afebrile
Vital Sign
BP (mmHg)	147/86	126/80	137/87	157/71
Pulse (bpm)	82	61	68	65
Temp (^oC)	37.0	37.0	37.0	37.0
CVS	DRNM	DRNM	DRNM	S1S2
Lungs	Clear	Clear	Clear	Clear
ECG	Q wave at lead I, II	No ischemic changes	-	--
Physician Plan	1. T. Plavix 300mg stat, then 75mg OD 2. S/L T. GTN 1/1 stat 3. IV Morphine 2.5mg stat 4. IV Metoclopromide 10mg stat 5. SC Clexane (Enoxaparin) 80mg stat & BD x 3/7 Patient refuse sc Clexane 6. Change to IV Heparin bolus 5000 U, then 1000U infusion/hour 7. NP O2 3L/min	1. ↑IV Heparin to 1200U/hour and review APTT 2. ↑T. Gliclazide 160mg BD 3. ↑IV Heparin to 1300U/hour (11.55pm) 4. Start IV Isoket 1mg/hour & inform if BP<100/60 (11.55pm)	1. Off IV Isoket 2. Off Nasal Prong 3. Continue Hepatin & keep INR 1.5-2.5 (should be APTT not INR, written by houseman)	1. ↑ IV Heparin to 1600U/hour 2. ↑ T. Isosorbide dinitrate 20mg TDS 3. Add Gemfibrozil 300mg BD 4. Plan PCI (LAD) in December

	K. Physical Examination/ Daily Progress (D5-D6)
	17/10/06	18/10/06
General	Afebrile, comfortable	+ chest pain, afebrile
Vital Sign
BP (mmHg)	132/68	113/68
Pulse (bpm)	62	83
Temp (^oC)	37.0	37.0
CVS	S1S2, DRNM	S1S2
Lungs	Clear	Clear
ECG	-	-
Physician Plan	1. ↑ IV Heparin to 1800U/hour 2. Continue others 3. Check APTT on 12 noon	1. ↑ IV Heparin to 2000U/hour 2. Off Heparin 3. PCI on 11/12/06 4. Discharge patient today

L. Laboratory findings and follow up:

		13/10/06 15:53	13/10/06 21:56	14/10/06 10:49	14/10/06 19:39	15/10/06 08:40	15/10/06 22:11	16/10/06 17:31	17/10/06 08:55	17/10/06 14:57
PT	11.5-13.5 sec	12.8	13.4	13.4	12.7	12.7	13.7	13.0	13.0	12.9
INR	0.8-1.2	1.1	1.1	1.1	1.1	1.1	1.1	1.1	1.1	1.1
APTT	24.0-35.0 sec	25.4	34.8	25.3	30.7	28.0	31.0	43.8	61.6	41.2
Action		Baseline	Start IV Heparin		↑ IV Heparin to 1300U/hour	↑ IV Heparin to 1400U/hour		↑ IV Heparin to 1600U/hour	↑ IV Heparin to 1800U/hour

L. Laboratory findings and follow up:

Test	Normal Range	13/10/06	14/10/06	15/10/06	16/10/06	17/10/06	18/10/06
WBC	5.2-12.4 x 10^3/uL	8.3	-	-	-	-	-
RBC	4.2-5.4 x 10^6/uL	4.6	-	-	-	-	-
HGB	12 -16 g/dL	13.9	-	-	-	-	-
HCT	37 – 47 %	41.9	-	-	-	-	-
MCV	81 – 99 fL	91.9	-	-	-	-	-
MCHC	33 – 37 g/dL	33.2	-	-	-	-	-
PLT	130 – 400 10^3/uL	234	-	-	-	-	-
			-	-	-	-	-
Na⁺	135-145 mmol/L	137	-	-	-	-	-
K⁺	3.5-5.0 mmol/L	4.1	-	-	-	-	-
Urea	1.7-8.3 mmol/L	6.4	-	-	-	-	-
Creat	57-130 umol/L	105	-	-	-	-	-
Cl^-	86-108	101	-	-	-	-	-
CLcr	75-125ml/min	62.61	-	-	-	-	-
			-	-	-	-	-
T Pro	66-87g/L	71	-	-	-	-	-
Alb	35-52 g/l	40	-	-	-	-	-
Glb	23-35 g/l	31	-	-	-	-	-
A/G	0.9-1.8	1.3	-	-	-	-	-
T Bili	0-24mmol/l	12	-	-	-	-	-
ALT	0-42 U/l	73	-	-	-	-	-
ALP	34-104 g/l	61	-	-	-	-	-
			-	-	-	-	-
AST	0-37 U/L	38	49	46	-	-	-
CK	24-195 U/L	87	67	71	-	-	-
LDH	135-225 U/L	164	168	205	-	-	-
			-	-	-	-	-
T Chol	<5.2 mmol/L	3.7 (19/9)	-	-	-	-	-
TG	<1.8 mmol/L	2.1 (19/9)	-	-	-	-	-
LDL	<3.36 mmol/L	1.8 (19/9)	-	-	-	-	-
HDL	>1.29 mmol/L	0.9 (19/9)	-	-	-	-	-
%HDL-Chol	15-25	24 (19/9)	-	-	-	-	-
			-	-	-	-	-
Reflomet	mmol/L		-	-	8.2	8.9	9.4
FBG	mmol/L		-	-	-	8.7	-
HbA1c	6.8-8.6%-Fair control >8.6%-Poor control		-	-	-	8.6	-

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

[1] Unstable Angina

[2] Hypertension

[3] Type II Diabetes Mellitus

[4] Ischemic Heart Disease (COROS showed 3VD)

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. Aspirin 150mg	OD	cont	cont
T. Metoprolol 100mg	BD	cont	cont
T.Isorsobide Dinitrate 10mg	TDS	cont	16/10/06
T.Isorsobide Dinitrate 20mg	TDS	16/10/06	cont
SL GTN 1/1	STAT	13/10/06	13/10/06
IV Morphine 2.5mg	STAT	13/10/06	13/10/06
IV Metoclopromide 10mg	STAT	13/10/06	13/10/06
T. Vastarel 20mg	TDS	cont	cont
T. Valsartan 80mg	OD	cont	cont
T. Simvastatin 10mg	ON	cont	cont
T. Metformin 1g	BD	cont	cont
T. Gliclazide 80mg	OD	cont	14/10/06
T. Gliclazide 160mg	BD	14/10/06	cont
T. Plavix 300mg stat & 75mg	OD	13/10/06	cont
C. Gemfibrozil 300mg	BD	16/10/06	cont
IV Isoket 1mg/hr	Infusion	14/10/06	15/10/06
IV Heparin 5000U Bolus, then 1000U/hr	Infusion	13/10/06	14/10/06
IV Heparin 1200U/hr	Infusion	14/10/06	14/10/06
IV Heparin 1300U/hr	Infusion	14/10/06	16/10/06
IV Heparin 1600U/hr	Infusion	16/10/06	17/10/06
IV Heparin 1800U/hr	Infusion	17/10/06	18/10/06

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Kumpulan Pengetahuan.

STUDI KASUS D

DO YOU HAVE OR USE…?

Current Prescription Medication Regimen