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)
+ SOB on exertion for past 4 months
Atrial fibrillation on warfarin
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 |