Clin Pharm Case Study

PROJECT

PROJECT

IN

CLINICAL PHARMACY

Case Study

Submitted by:

Alduheza, Shynne B.

Villoria, Christy Grace

Submitted to:

Mae Quenie A. Tiro, RPh.

January 2015

ISCHAEMIC HEART DISEASE

Rationale

Ischemic Heart Disease (IHD) belongs to a group of cardiovascular diseases known as Coronary Artery Disease. CAD remains to be a major health problem in western countries and the rest of the world despite the advances in medicine. The reasons for this are multifactorial and are due to the advancing age of the population.

Background

Ischemic Heart Disease is characterized by reduced blood supply to the heart.Ischaemia means a "reduced blood supply".The coronary arteries supply blood to the heart muscle and no alternative blood supply exists, so a blockage in the coronary arteries reduces the supply of blood to heart muscle. Most ischaemic heart disease is caused by atherosclerosis, usually present even when the artery lumens appear normal by angiography.Initially there is sudden severe narrowing or closure of either the large coronary arteries and/or of coronary artery end branches by debris showering downstream in the flowing blood. It is usually felt as angina, especially if a large area is affected. The narrowing or closure is predominantly caused by the covering of atheromatous plaques within the wall of the artery rupturing, in turn leading to a heart attack (Heart attacks caused by just artery narrowing are rare). A heart attack causes damage to heart muscle by cutting off its blood supply.

Ischemic heart disease (IHD) is the generic designation for a group of closely related syndromes resulting from myocardial ischemiaan imbalance between the supply (perfusion) and demand of the heart for oxygenated blood. It comprises not only insufficiency of oxygen, but also reduced availability of nutrient substrates and inadequate removal of metabolites. Isolated hypoxemia (i.e., diminished transport of oxygen by the blood) induced by cyanotic congenital heart disease, severe anemia, or advanced lung disease is less deleterious than ischemia because perfusion (including metabolic substrate delivery and waste removal) is maintained.

Clinical Manifestations:

A. Myocardial infarction (MI), the most important form of IHD, in which the duration and severity of ischemia is sufficient to cause death of heart muscle.

B. Angina pectoris, in which the ischemia is less severe and does not cause death of cardiac muscle. Of the three variantsstable angina, Prinzmetal angina, and unstable anginathe latter is the most threatening as a frequent harbinger of MI.

C. Chronic IHD with heart failure.

D. Sudden cardiac death.

Etiology of IHD

- coronary atherosclerosis

- non-atheromatous coronary artery diseases

Risk Factors

Modifiable

- Hyperlipidemia

- Cigarette smoking

- Hypertension

- Diabetes mellitus

- Low physical activity

- Postmenopausal state

- High lp(a) level (homology with plasminogen)

- Hyperhomocysteinemia (it may inhibit fibrinolisis)

- Hyperlipidemia

- Stress

- Alcohol consumption

Non-Modifiable

- age

- gender

- genetic predisposition

- personality factors

- family history

Prevention of IHD

- proper dietary manipulation

- avoid smoking

- exercise regularly

- correct hyperlipidemia

- regular medical check-up

CEFUROXIME

I. Drug

Generic Name: Cefuroxime

Chemical/ IUPAC Name:

(6R,7R)-3-{[(aminocarbonyl)oxy]methyl}-7-{[(2Z)-2-(2-furyl)-2-(methoxyimino) acetyl]amino}-8-oxo-5-thia-1-azabicyclo[4.2.0]oct-2-ene-2-carboxylic acid; C16H16N4O8SBrand Name:

a. Oral- Zinnat (GSK), Axet (Microlabs), Zoltax, Cimex, Panaxim

b. Parenteral- Zinacef (GSK), Kefox, Profurex, Ecocef

II. Chemistry and Stability

Pharmacology

- second generation cephalosporin

- antibacterial agent

- broad spectrum

- bactericidal

- good stability against bacterial beta-lactamase

III. Mechanism of Action

- a well-characterised and effective antibacterial agent which has bactericidal activity against a wide range of common pathogens

- has good stability against bacterial beta-lactamase and active against many ampicillin-resistant or amoxicillin-resistant strains

- inhibit bacterial cell wall synthesis

Spectrum

- aerobe gram-negative, aerobe gram-positive, anaerobe

- Clostridium difficile, Psedomonas, Camphylobacter, Listeria monocytogenes, MRSA, Legionella, Enterococcus, Proteus vulgaris, Enterobacter, etc.

IV. Pharmacokinetics

Absorption

- slowly absorbed from the gastrointestinal tract

- rapidly hydrolysed in the intestinal mucosa and blood to release cefuroxime into the circulation

- optimum absorption: after meals

- bioavailability: 37% (empty stomach), 52% (with food)

B. Distribution

- 33-50% bound to proteins

- distributed throughout the extracellular fluid

C. Elimination/Excretion

- not metabolised

- half-life: 80 minutes

- excreted by glomerular filtration and tubular secretion

- excreted unchanged in urine 66-100% approximately 50% of the administered dose is recovered in the urine within 12 hoursV. Uses

- upper respiratory tract infections: ENT infections, otitis media, tonsilitis, pharyngitits, sinusitis

- lower respiratory tract infections: pneumonia, acute bronchitis

- genito-urinary tract infections: pyelonephritis, cystitis, urethritis

- skin ans soft tissue infections: impetigo, furunculosis, pyoderma

- gonorrhea, acute uncomplicated gonococcal urethritis, cerviciti

- Lyme disease

VI. Caution

Adverse Drug Events

- Gastrointestinal Disorders: diarrhea, nausea, abdominal pain, vomitting

- Nervous System: headache, dizziness

- Hepatobiliary Disorders: transient increase of liver enzymes (SGPT,SGOT,LDH)

- Infections: Overgrowth of Candida

- Blood and Lymphatic Disorders: eosinophilia, positive coombs test, increased erythrocyte sedimentation rate

- Others: skin rashes, urticaria, pruritus, erythema multiforme, jaundice, hepatitis

Contraindications

- hypersensitivity to cephalosporins

Warnings and Precautions

- may cause dizziness: caution among those who would drive and operate machinery

- if there is no improvement within 72 hours, parenteral administration of treatment must be continued

Pediatric

- tablets should not be crushed and unsutiable for children

- oral suspension may be used

- no experience of using in children under 3 years of age

Pregnancy

- pregnancy category B

- no experimental evidence of embryopathic or teratogenic effect

- administered with caution during early months of pregnancy

- excreted in human milk: discontinue in nursing mothers

- reproduction studies have been performed in mice at doses up to 3,200 mg/kg/day (14 times the recommended maximum human dose based on mg/m2) and in rats at doses up to 1,000 mg/kg/day (9 times the recommended maximum human dose based on mg/m2)

- no evidence of impaired fertility or harm to the fetus due to cefuroxime- should be used when needed

Chronic Toxicity

- low toxicity

Acute Toxicity

- low toxicity

Drug Interactions

- drugs that reduce gastric acidity: lower bioavailability of Cefuroxime

- oral contraceptives: lower estrogen absorption and reduce efficacy of oral contraceptives

- aminoglycosides and diuretics: renal toxicity

- anticoagulants: risk of increased side effects by cefuroxime

- ferricyanide test: false negative result

VII.

A. Pharmaceutical Dosage Form

- tablet, powder for suspension, parenteral

B. Dosage

- 7-day treatment

- with food

C. Missed Dose

- If you miss a dose of cefuroxime, use it as soon as possible. If it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not use 2 doses at once.

- Skipping doses or not completing the full course of therapy may decrease the effectiveness of the immediate treatment and increase the likelihood that bacteria will develop resistance and will not be treatable.

D. Administration

- oral, IV, IM

E. Preparation

- 250 mg and 500 mg tablet

- 125/5 and 250/5 powder for suspension

- 250 mg and 750 mg vial

F. Storage Conditions

- Tablet: not exceeding 30C and protect from light

- Suspension: not exceeding 30C (unreconstituted), refrigerated immediately from 2-8C kept up to 10 days (reconstituted)

- Parenteral: 24 hours

G. Others

(reconstitution of suspensions)

- Shake the bottle to loosen the granules. Remove the cap and the heat-seal membrane. If the latter is damage or not present the product should be returned to the pharmacist.

- Add the total amount of water to the bottle as stated on its label. Replace the cap.

- Invert the bottle and rock vigorously for at least 15 seconds.

- Turn the bottle into an upright position and shake vigorously.

- Refigerate immediately at between 2 and 8C.

- If using a dosing syringe, allow the reconstituted suspension to stand for at least one hour before taking the first dose.

VII. Clinical Studies Done

Title:

Phase: I

Methodology:

Rationale:

Results:

PATIENT PROFILE

Patients Name: Perfecto Pandacan Balili

Hospital Number: 919684

Age: 60 years oldSex: Male

Address: Barangay 76-A, Sabrosa Village, Ecoland, Davao CityCivil Status: marriedReligion: Roman CatholicCitizenship: Filipino

Birthday: July 9, 1946Birthplace: Tagum CityName of Spouse: Lydia BaliliAge: 57 years old

Name of Father: Julio Balili (Deceased)

Name of Mother: Vicenta Pandacan (Deceased)Area: Coronary Care UnitBed: 1Attending Physician: Dr. Voltaire EgnoraMedical Diagnosis: Coronary Artery Disease, Acute Myocardial Infarction Killips II, Left

Ventricular Hypertrophy, Left Ventricular Dilatation, FC IIIChief Complaint: DyspneaDate and Time Admitted: November 12, 2006, 12:01 P.M.

HEALTH STATUS

Personal Data

Patients Name: Perfecto Pandacan Balili

Age: 60 years oldSex: Male

Address: Barangay 76-A, Sabrosa Village, Ecoland, Davao City

Chief Complaint: DyspneaMedical Diagnosis: Coronary Artery Disease, Acute Myocardial Infarction Killips II,

Left Ventricular Hypertrophy, Left Ventricular Dilatation, FC IIIFamily Background

The family has been living in Ecoland ever since Perfecto and Lydia got married, except for some years in between when the family went to Manila but apparently they also came back here in Davao. The couple has eleven children with 6 girls and 5 boys. Aside from that within the 6 girls there is a twin and the same applies with the 5 boys, apparently their third set of twins died due to miscarriage.

Among the eleven children only two of them were able to finish college and the rest were only able to study until their high school years for varied reasons. In addition, currently the couples children are in Manila, one is in Japan and three stayed here in Davao. All of their children are currently married except for the youngest three.

Mr. Perfecto Balili has an educational attainment of until second year high school and his wife Lydia got until second year College with a course of Accountancy. According to Mrs. Balili they got married when she was in third year high school because she already got pregnant with their first child. But even though this is the case she still continued her schooling until second year college with the financial support of her husband. In addition, she got pregnant with only a years difference on all of her children.

Perfecto has always been a taxi driver. He supported his familys daily needs, educational needs and others with only this kind of job. He worked as a taxi driver both here in Davao and even when they came to Manila he also worked as an FX driver. Back then when their children was young Mr. Perfecto is the only one that works because Lydia is the one that takes care of the children and until today she is still a plain house wife. But when Mr. Balili experienced his first heart attack in Manila, he temporarily stopped driving and took a rest. After a few months he then continued his work and did not totally stop driving until after his third attack and so their children are the ones that supported the family. Currently, they get their financial support in their daughter who is in Japan.

Some of his vices include drinking and smoking. He is a hard drinker and started drinking when he was only a teenager. He can consume half a box of cigarette in a day and this started during his twenties. He is also fond of eating meat compared to fish and vegetables.Furthermore, Perfectos father died due to cancer and his mother died due to asthma. Among his siblings, 3 of his siblings had pulmonary tuberculosis namely Emilio, Carlos and Lucia. One of his sisters had a renal failure and hypertension. Other than that they have no trace of any hereditary diseases. Perfectos son, Adrian, had PTB and 3 of his children had pneumonia. His daughter, Jackilyn, had Rheumatic Heart Disease and his son, Jeffrey, had asthma.History of Past Illness

Back in 1986, Perfecto was diagnosed of pulmonary tuberculosis and he sought medical help from the Barangay Health Center. He was then given the 6 months treatment for PTB, after the completion of the medication the patient failed to have a follow-up check-up after the treatment.

Perfecto had his first attack 7 years ago; he had his first and second heart attack in Manila. During his first attack he was admitted in Manila Hospital then was transferred to San Juan Hospital for five days and was then brought back to Manila Hospital. His third and fourth heart attack happened in Davao. He was admitted in Med-Main in DMC on his third attack and his fourth attack was in Med CP for he had COPD and was then transferred to CCU for he was diagnosed with Coronary Artery Disease basing on his result of Echocardiogram. His fourth attack happened only last July 2006.

History of Present Illness

One month PTA, the patient had his available oxygen via oxygen tank in his house as aid for his breathing, which they bought for P4,500. He also had an air conditioned room at his home just to aid his condition. Two weeks PTA, patient had bipedal edema, loss weight; decrease appetite and experienced paroxysmal nocturnal dyspnea. He had difficulty sleeping during the night. Three days PTA, patient has been having episodes of chest pain at the left anterior chest radiating to the arm, lasting for a minute. Five hours PTA, he had recurrence of chest pain of the same character. He then took isosorbide mononitrate SL but without relief. Persistence of symptoms prompted this admission, with a previously diagnosed coronary artery disease by 2D Echo result.

Effects and Expectation of Illness to Family

Mr. Perfecto already had five heart attacks and his condition got worse every time this happens. Although the family is very well aware of his degenerating condition they are still hoping that he will get better and that will live much longer. As observed the family is not really affluent and that they are having financial problems due to the recurrent attacks of the patient. Luckily, they are being assisted by his daughter, Jackilyn, who had a Japanese husband and currently resides in Japan. In addition, he also had a senior citizens identification card that becomes a big aid in their financial needs. Aside from the financial help the family is greatly affected by the patients condition and thus still tries their best to live a normal life.

PHYSICAL ASSESSMENT

I. General appearance & mental status

Mr. Perfecto Balili, a 60 year old male client, was admitted on November 12, 2006 in Davao Medical Center. Upon assessment the patient was lying on bed in moderate high back rest and is awake, conscious, coherent & responsive. He has an IVF of D5W 500cc @ 300cc level running at KVO infusing well @ right cephalic vein, with O2 inhalation @ 5Liters per minute via nasal cannula, is wearing a hospital gown and has diaper.

The client has a generalize weakness and needs assistance upon moving or position changes. He has difficulty of breathing and is constantly expectorating whitish phlegm into his bedside receptacle. He is 56 in height and weighs 59 kg.

II. Vital Signs:

BP- 110/80mmHg

CR- 43 bpm; irregular rate and rhythm

RR- 25 cpm; regular rhythm

Temp- 36.5 C

III. Skin

The color of the skin is brown with rough and dry texture. The patient has poor skin turgor and clammy to touch. Scars in lower extremities are observed; no wounds or lesions are noted.

IV. Head

He has a normocephalic configuration with head circumference of 22 cm. His facial movements are symmetric and he has a thin, evenly distributed, white in color hair. Scalp is dry but there is no presence of dandruff or lice upon inspection

V. Eyes

Eyes have symmetrical lids and normal periorbital area. Conjunctiva is pale and sclera is observed to be anicteric. Both left and right pupils are black in color with pupillary size of 3mm, briskly reactive to light. He has a slightly sunken periorbital region, eye bugs present with eyebrows and eyelashes evenly distributed. Client wears eyeglasses only upon reading.

VI. Ears

Clients ears are symmetrical and are in line with the outer canthus of the eyes. His pinnae are normal, normoset and symmetric. No tenderness and lesions noted. Absence of discharges on the external canal is noted. No hearing problem noted.

VII. Nose

The clients nasolabial fold is normal, septum is medially located and no discharges are noted. There are no deformities or inflammation on the nose noted. No nasal flaring is noted and both nostrils are patent. He has an O2 inhalation via nasal cannula.

VIII. Mouth

The mucosa and gums of the client are pinkish and lips are dry. His tongue is medially located. Teeth were yellowish in color with loose teeth, he do not use dentures. He has no difficulty of swallowing and no halitosis and bleeding noted upon observation.

IX. Neck

There are no signs of abnormal growth or enlargement of the nodes of the neck of the client. There are no lesions noted.

X. Chest and Lungs

The client has rapid, regular breathing at the rate of 25 cpm. Wheezing is noted upon auscultation with symmetrical chest expansion. He has productive cough with whitish phlegm..

XI. Heart and Breast

The client has symmetrical, rounded shape breast with smooth surface. The areolas are bilaterally the same and are dark brown in color. There are no masses, lesions or tenderness noted on these areas. He has a capillary refill time of 4 seconds. His pericardial area is flat and heart sound is weak and irregular in rate and rhythm with a rate of 43 bpm. He is hooked to a cardiac monitor with Atrial Fibrillation in slow to moderate response with ST elevation pattern. An IVF of D5W 500cc @ KVO rate infusing well @ right cephalic vein @ 300cc level

XII. Abdomen

The skin in this area has uniform color and no lesions; with flat abdominal contour thus there is no evidence of an enlarged spleen or lived noted. He has normal bowel sound of one every 15 seconds.

XIII. Genito-Urinary

The client wears diaper but voids freely. There are no lesions or discharges noted. He can defecate without difficulty at least once a day.

XIV. Back and Extremities

Client needs assistance upon moving around and in doing activities of daily living. He can extend and flex both his upper and lower extremities with (-) bipedal edema or anasarca. Weakness upon movement is noted. He has dirty and untrimmed nails on all extremities.

DOCTORS ORDERS

Date/TimeDoctors OrderRationaleRemark

November

12,2006

12:10 pm

12:30 pm

Admit under white service

Low salt low fat diet

Temperature, pulse, respiratory every

hour and record

Venoclysis

D5W 500cc x KVO rate

Diagnostics:

Complete Blood Count

Platelet

Random Blood Sugar

Creatinine

Sodium, Potassium

Chest x-ray

Electrocardiogram

Troponin T qualitative

Therapeutics

Isosorbide Mononitrate (ISMN) 60mg/tab

tab OD

Isosorbide Dinirate (ISDN) 5mg/tab

1 tab now

Metoprolol 50mg/tab tab BID

Captopril 25mg/tab tab OD

Atorvastatin 80mg/tab 1 tab OD

Lactulose 30cc at HS

Moderate High Back Rest

Monitor intake and output

O2 at 4Lpm via nasal cannula

Hook to cardiac monitor

Refer accordingly

Retrieve previous 2Decho result c/o

watcher and attach to chart

Repeat ECG after 6 hours

Additional meds

ASA 80mg/tab OD

Clopidogrel 25mg/tab OD

Enoxaparin 6000 IV every 12 hours

Furosemide 40mg 1 tab OD

Digoxin 0.25 mg/tab ODPatient is admitted under the white service for close monitoring

LSLF is ordered for patients with cardiac conditions to decrease the salt and fats that further aggravates the pts current condition

Monitoring of TPR is done to detect any variation or changes from the normal range that would determine an abnormality in the patients condition

It is an isotonic solution that is needed by our body to help regulate the bodys nutrients; it doesnt swell or shrink the cell. Regulated only at the rate to maintain vein open for emergency and IVTT meds

Complete Blood Count offers necessary information about the kinds and numbers of cells in the blood. This analyzes the 3 major types of cells in the body which are the Red Blood Cell, White Blood Cell and Platelet

Blood test evaluates platelet production

Detects alterations in glucose metabolism

For evaluation of renal function

Evaluates fluid and electrolyte balance as well as renal or adrenal disorders

This identifies various abnormalities of the lungs and structures in the thorax Also used to identify localize fluid and air in the pleural cavity

Used to screen for and diagnose a variety of cardiac conditions as well as abnormal heart rhythms, conduction disturbance, hypertrophy and other disorders

Primarily ordered to determine if heart attack or other changes in the heart occurred

ISMN is the treatment for anginal attacks

ISDN is the treatment for anginal attacks

Treat hypertension, management of angina pectoris and prevention of MI

Treat hypertension and reduce risk of developing congestive heart failure following MI

Reduction of elevated total and LDL cholesterol and triglycerides

For chronic constipation

Lowers diaphragm, promoting chest expansion

Determine fluid and electrolyte balance and effectiveness of replacement

Help restore or improve breathing function and prevent damage to vital organs resulting from inadequate oxygen supply

Monitor the patients BP, CR and ECG reading

It is necessary to refer any unusualities to the physician prevent further complications

Have a basis of the patients current situation base on the result of the previous laboratory exam

For monitoring of any changes in the result

Treatment of mild to moderate pain and prophylaxis of MI

Reduction of atherosclerotic events in patients with atherosclerosis resulted from recent MI

Prevention of deep vein thrombosis and pulmonary embolism

Management of edema secondary to CHF and treatment of hypertension

Used to slow the ventricular rate in tachyarrhythmias such as AF and atrial flutterDone

Done

Done

Done

Done

Done

Done

Done

Done

Not Done

Done

Done

Done

Done

Done

Done

Done

Done

Done

Done

Done

Done

Done

Done

Done

Done

Done

Done

Done

Done

November

12, 2006

8:30 pmTo CCU

Start O2 5Lpm per nasal cannula

Furosemide 40 mg IVTT now

Spironolactone 100 mg 1 tab now

then OD

ReferPlace in a special area for close monitoring

Counteracts potassium loss induced by other diuretics, for edema and hypertension

Done

Done

Done

Done

Done

November

13, 2006

(+) chest pain

10:35 am

(+) Chest

tightness

O2 = 96

BP = 140/120

6:30 pm

7:30 pm

8:45 pm

(+) chest painContinue meds

Complete bed rest without bathroom privilege

Refer

Give Isordil 5mg SL

If not relieved by Isordil may give Tramadol 1 amp IVTT

Give Isordil 5g SL now

Start Isoket drip D5W 500cc + 1 amp Isoket to run out at 10cc/hr

Avoid valsalva maneuver

For Pro-time

Activated Partial

Thromboplastin Time

Refer

Isordil 5mg SL now

Increase Isoket drip to 15cc/hr

Morphine 2mg IVTT nowMedication needs to be continued for continuity of treatment

Minimize the workload of the heart and promote rest

Treatment of moderate to moderately severe pain

Treatment and prevention of angina pectoris attacks

Activities that require holding of breath and bearing down can result in bradycardia, temporarily reduced cardiac output and rebound tachycardia with elevated BP.

Screens for lack of coagulation factors necessary for blood clotting. Measures time required for a fibrin clot to form

Assess bleeding disorders or the effectiveness of heparin therapy by evaluating intrinsic coagulation factors necessary for blood clotting

Management of severe pain, pulmonary edema and pain associated with MIDone

Done

Done

Done

Done

Done

Done

Done

Done

Done

Done

Done

Done

Done

November

14, 2006

100/64Repeat ECG 12 leads with long lead II

Review of medicines

Spironolactone 25mg 1 tab OD

Digoxin 0.25 mg/tab OD

Carvedilol 6.25mg tab OD

Captopril 25mg/tab OD

Atorvastatin 80 mg tab OD

ASA 80 mg 1 tab OD

Clopidogrel 75mg/tab OD

Enoxaparin 0.6ml SQ every 12

Discontinue meds not in review of

medicines

ReferTreatment for essential hypertension and CHF

Done

Done

Done

Done

November

15, 2006

10:20 am

98/61

I = 1085

O = 800

(-) chest pain

(+) bowel

movementContinue meds

ReferDone

Done

November

16, 2006

2:50 am

(+) chest pain

7:15 am

still with

occasional

chest painGive Isordil 5mg 1 tab SL now then PRN for chest pain

Continue meds

ISDN 5mg/tab SL PRN for chest pain

Senna concentrate 2 tabs at HS

ReferTreatment for constipation Done

Done

Done

Done

Done

November

17, 2006

9:30 amDiagnostics: repeat ECG 12 leads now

Repeat Creatinine, Sodium, Potassium

Continue all meds

Refer accordinglyDone

Done

Done

Done

November

18, 2006

(+) chest pain

125/98

Diagnostics: repeat serum electrolyte

ISMN 60 mg tab

OD

Continue all other medsNot Done

Done

Done

November

19, 2006

8:30 amResume Isoket drip (D5W 90cc + 1 amp Isoket) to run at 10cc/hr

Continue other meds

Refer Done

Done

Done

November

20, 2006

7:20 am

102/68

9:00 am

(+) chills

(+) dyspnea

130/100

O2 sat 97

Hgt 72

130/90Continue all meds

Refer accordingly

Continue Isoket drip

Start Warfarin 5mg tab OD

For stat Complete blood count, Platelet count and Creatinine

Referred due to dyspnea

Diagnostics:

Hemogluco test now

Electrocardigram now

Arterial Blood Gas now

Creatinine, Sodium, Potassium

Give D5W 50cc 1 vial slow IVTT now

Refer once with result

Prophylaxis and treatment of venous thrombosis, pulmonary embolism, AF with embolization and management MI

Determine blood glucose level

Determine the acid-base balance and/or the respiratory or metabolic status

A hypertonic solution used for the treatment of hypoglycemic shockDone

Done

Done

Done

Done

Done

Done

Done

Done

Done

Done

Done

November

21, 2006

7:22 am

(-) chest painReview of medicines

Spironolactone 20 mg 1 tab OD

Digoxin 0.25 mg tab OD

Captopril 25 mg 1 tab OD

Atorvastatin 40 mg 1 tab OD

ASA 80 mg 1 tab OD

Clopidogrel 75 mg/tab OD

Senna concentrate 2 tabs OD

ISMN 60mg tab OD

Warfarin 5mg tab OD

Enoxaparin 0.6 ml SQ every 12 hours

ReferDone

Done

November 22, 2006Diagnostics:

Repeat Protime

Continue all meds

Refer

Ceftazidime 1gram IVTT q8 ANST (-)

Clindamycin 300mg 1cap q6 POThird generation cephalosporins used as treatment for infection

Anti-infective for infectionDone

Done

Done

Done

Done

November 23, 2006

7:05amFor repeat chest x-ray today

Continue antibiotics

Paracetamol 500mg 1tab q4

Refer

CXR was read

Bibasal pneumonia

Left sided cardiomegaly

Underlying minimal pleural effusion

Pericardial effusion not entirely ruled out

Not congested

Dr. DagumanFor mild to moderate pain and fever

Done

Done

Done

November 24, 2006

8:00am

(+) epigastric pain

(+) increase salivation

(-) chest pain

8:15 am

10:30am

1:00pm

4:15 pmOmeprazole 40mg IVTT every 12 hours

please retrieve chest x-ray place on bedside

hold aspirin, warfarin, enoxaparine temporarily

Refer

for STAT 12 lead ECG

Omeprazole 80mg IVTT now then 40mg IVTT q12

Rebamipide 100mg 1 tab 3x a day

Continue Omeprazole and Rebamipide

retrieve chest x-ray ASAP

Refer

Ranitidine 1 ampule IVTT OD

Vitamin K 1 ampule IVTT OD

Refer

Metoclopramide 1 ampule IVTT nowManagement for GERD and duodenal ulcer

Treatment of gastric mucosal lesions, acute gastritis and gastric ulcer

Short-term treatment for duodenal and gastric ulcer and GERD

Prevention and treatment of hypothrombinemia associated with excessive doses of anticoagulants

Treatment and prevention of nausea and vomitingDone

Done

Done

Done

Done

Done

Done

Done

Done

Done

Done

Done

Done

Done

November 25, 2006

Hold clindamycin

House Omeprazole IV to Pantoprazole 40mg 1 tab OD

Rebamipide 100mg 1 tab TID

Repeat CBC, platelet count

Continue meds

ReferTreatment of mild reflux Done

Done

Done

Done

Done

Done

November 26, 2006

5:45 amDiagnostics:

Follow up repeat CBC, platelet

Repeat protime, Sodium, Potassium

Continue medsDone

Done, protime Not Done

Done

November 27, 2006

10:15am

Continue all meds

Consume and discontinue ceftazidime, start levofloxacin 500mg/cap OD

Still for repeat protime

ReferTreatment of mild, moderate or severe infectionDone

Done

Not Done

Done

November 28, 2006

9:35 amResume Coumadin (Warfarin) 2.5mg tab OD

Resume Aspirin 80mg 1 tab OD

Continue Pantoprazole PO

Repeat chest x-ray todayDone

Done

Done

Done

November 29, 2006

10:30amPlease retrieve chest x-ray due 11/28/06

Continue meds

referNot Done

Done

Done

DIAGNOSTIC EXAMINATIONS

DateDiagnostic ProcedureRationaleNormal valuesResultImpression

November 12,

2006

November 21,

2006

Arterial Blood Gas(ABG)- Arterial blood gas analysis is a test in which blood is taken from an artery in your wrist to evaluate how effective your lungs in bringing oxygen to the blood and removing carbon dioxide from itBlood gases are used to determine the acid-base balance and/or the respiratory or metabolic status of the client.

The pH is the measurement of the free hydrogen ion concentration in the blood.

pCO2 represents the partial pressure carbon dioxide exerts in the arterial blood.

pO2 represents the partial pressure of oxygen in the blood, identifies how well the lungs are oxygenating the blood.

HCO3 is an alkaline substance that functions as an important buffer in the blood stream.

O2 sat is the amount of oxygen actually bound to the hemoglobin and available for transport throughout the body.pH

7.35-7.45 mmHg

pCO2

35-45 mmmHg

pO2

80-100mmHg

HCO3

22.0-27.0 mmol/L

BE(ecf)

(-2)-(+2) mmol/L

O2sat

80-100%

pH

7.35-7.45 mmHg

pCO2

35-45 mmmHg

pO2

80-100mmHg

HCO3

22.0-27.0 mmol/L

BE(ecf)

(-2)-(+2) mmol/L

O2sat

80-100%

pH

7.568mmHg

pCO2

16mmHg

pO2

137.3mmHg

HCO3

14.2mmol/L

BE(ecf)

-7.8

O2sat

99.1%

pH

7.439 mmHg

pCO2

22.9 mmmHg

pO2

124.2 mmHg

HCO3

15.2 mmol/L

BE(ecf)

-9.0 mmol/L

O2sat

98.6%

Increased pH

Decreased pCO2;

Increased pO2

Decreased HCO3

Decreased base excess; indicates non respi/meta disturbance or true base deficit

Normal

Partially Compensated Respiratory Alkalosis

Normal

Decreased pCO2

Increased pO2

Decreased HCO3

Decreased base excess

Normal

Fully Compensated Respiratory Alkalosis


November 12, 2006

November 17, 2006

November 21, 2006

November 26, 2006

Blood Chemistry

Analysis of the physical, chemical, and microbiological properties of blood, carried out to diagnose disease, monitor treatment, or detect the presence of specific substance.

RBS is used as a random screen for glucose level.

Creatinine is essential in the evaluation of renal function.

Sodium and Potassium evaluates fluid and electrolyte balance as well as renal or adrenal disorders

Chloride helps diagnose disorders of acid-base and water balance. Responsible for maintaining water balance and cellular integrity through its influence on osmotic pressure.Glucose RBS

3.90-6.10

Creatinine

53.0-115.0 mmol/L

Sodium

136.0-145.0 mmol/L

Potassium

3.5-5.5 mmol/L

Chloride

098.0-106.0 mmol/L

Creatinine

53.0-115.0 mmol/L

Sodium

136.0-145.0 mmol/L

Potassium

3.5-5.5 mmol/L

Creatinine

53.0-115.0 mmol/L

Sodium

136.0-145.0 mmol/L

Potassium

3.5-5.5 mmol/L

Sodium

136.0-145.0 mmol/L

Potassium

3.5-5.5 mmol/L6.52

146.53

140

5.1

107.0

123.61

144

4.0

127.80

140

4.4

141

4.0Increased; may indicate DM or stress

Increased; may indicate impaired renal function, essential hypertension, acute MI, severe CHF or urinary obstruction

Normal

Normal

Increased; may indicate dehydration, cardiac decompensation, or metabolic acidosis

Increased

Normal

Normal

Increased

Normal

Normal

Normal

Normal


November 12,

2006

November 21,

2006

November 25,

2006

Blood Hematology

Hemoglobin

Hematocrit

Erythrocyte

Leukocytes

Neutrophils

Lymphocyte

Monocyte

Eosinophils

Basophils

PlateletEvaluates blood loss, erythropoietic ability, anemia and response to therapy. It is an important component of red blood cell that carries oxygen and carbon dioxide to and from the tissues.

Evaluates blood loss, anemia, blood replacement therapy and fluid balance and screens red blood cell status. It is the measure of red blood cells within the volume and also evaluates dehydration and hypervolemia.

Evaluates anemia, polycythemia and calculates red blood cell indices. Oxygen transport to the cells throughout the body depends upon sufficient numbers of red blood cells with adequate amount of hemoglobin.

Evaluates a number of conditions and differentiates causes of alterations in the total WBC count including inflammation, infection, tissue necrosis and/or leukemic neoplasm.

Increase neutrophil count may indicate parasitic or bacterial infection, metabolic disorder including diabetic acidosis. Decrease in level may indicate infection and anemia.

Evaluate bacterial and viral infection, immune disease, leukemia and ulcerative colitis. Elevated levels may indicate active viral infection and depressed level may indicate exhausted immune system.

Evaluates function of phagocytic scavenger to remove foreigh materials.

Primary influenced by antigen-body responses.

Basophil function not understood as well as other white cell types; it is believed to be related to allergic and anaphylactic responses.

Evaluates platelet production. It notes the platelet size and shape. Low levels predispose bleeding while high levels may increase the risk of thrombocytosis.Hgb

135-175g/L

Hct

0.40-0.52

RBC

4.20-6.10x106/uL

WBC

5.0-10.0x103/uL

Neutrophil

55-75%

Lympocytes

20-35

Monocytes

2-10

Eosinophil

1-5

Basophil

0-1

Platelet

150-400x103/uL

Hgb

135-175g/L

Hct

0.40-0.52

RBC

4.20-6.10x106/uL

WBC

5.0-10.0x103/uL

Neutrophil

55-75%

Lympocytes

20-35

Monocytes

2-10

Eosinophil

1-5

Basophil

0-1

Platelet

150-400x103/uL

Hgb

135-175g/L

Hct

0.40-0.52

RBC

4.20-6.10x106/uL

WBC

5.0-10.0x103/uL

Neutrophil

55-75%

Lympocytes

20-35

Monocytes

2-10

Eosinophil

1-5

Basophil

0-1

Platelet

150-400x103/uL157

0.47

5.08

5.40

67

21

10

2

0

132

161

0.49

5.14

11.26

91

6

2

1

0

133

165

0.46

5.31

4.83

74

14

12

0

0

141Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Decreased; may be due to medication, blood clotting factor is decreased and so at high risk for spontaneous bleeding

Normal

Normal

Normal

Increased; may indicate infection, inflammation, tissue necrosis or stress

Increased; may indicate bacterial infection, tissue necrosis or MI

Decreased; may indicate defective lymphatic circulation, renal failure or advanced tuberculosis

Normal

Normal

Normal


Normal

Normal

Normal

Decreased; may indicate bone marrow failure, overwhelming infection, dietary deficiency or drug toxicity

Normal

Decreased; may indicate defective lymphatic circulation, renal failure or advanced tuberculosis

Increased; may indicate infection such as tuberculosis and subacute bacterial endocarditis

Decreased; may indicate stress response associated with trauma, shock or CHF

Normal


DateDiagnostic ProcedureRationaleNormal ValuesResultImpression

November

12, 2006

Urinalysis- is the testing of the physical characteristics and compositions of freshly voided urineScreens for abnormalities within the urinary system as well as for systemic problems that may manifest symptoms through the urinary tract. Color- Pale-star colored to amber color

Appearance- clear to slightly hazy

Reaction- 4.8-7.8

Specific gravity- 1.003-1.035

Albumin- Negative

Sugar- Negative

Normal RBC- 0- 2 hpf

Normal Pus cells- 0-2 hpf

Color- yellow

Appearance- slightly cloudy

Reaction- 6.0

Specific gravity- 1.025

Albumin- (+++)

Sugar-(-)

Result RBC - 25-30hpf

Result pus cells 3-4hpf

Normal

Hazy or cloudy urine may indicate the presence of RBC, WBC, bacteria, pus, phosphate, uric acid or spermatozoa

Normal

Normal

Positive albumin may indicate nephritic syndrome, UTI, fever, trauma, CHF, acute infection, or kidney disease

Normal

Increased; may indicate renal problem

Increased; may indicate presence of infection or tuberculosis

Date: May 15, 2006

Diagnostic procedure:

Echocardiogram (2D Echo report) test evaluates the size, shape & motion of various structures within the heart, it is a noninvasive test.

Rationale:

This ultrasonic test diagnoses abnormalities in anatomy and valvular function within the heart. Sound waves are bounced off the heart using a transducer to image the heart in motion as well as its valves and vessels.

Normal findings:

Normal anatomical structure and position, normal and patent arteries and/or veins of the heart, normal valve structure, normal valve structure, normal blood flow within the heart, normal ventricular function, absence of thrombi or bacterial vegetations, absence of pericardial effusions

Result: Echo-Doppler findingsEccentric left ventricular hypertrophy with multisegmental wall motion abnormal with depressed systolic function

Left ventricular ejection fraction of 23%

Dilated left atrium

Normal right atrium, main pulmonary artery & aortic root dimension

Aortic sclerosis with aortic regurgitation of 2+

Mitral sclerosis with mild mitral regurgitation

Mild tricuspid regurgitation

Structurally normal tricuspid valve & pulmonic valve

No intra-cardiac thrombus or pericardial effusion noted

Normal pulmonary artery pressure by tricuspid regurgitation jet

Date: November 23, 2006


Chest x-ray is the most commonly performed diagnostic x-ray examination. A chest x-ray makes images of the lungs, airway, blood vessels and the bones of the spine and chest

Rationale:

Identify various abnormalities of the lungs and structures in the thorax, including the heart, great vessels, ribs or diaphragm. It may also be used as a general screening tool or for a specific diagnostic purpose, including identification of pulmonary diseases or orthopedic abnormalities. It is also used to evaluate the status of respiratory abnormalities or cardiac conditions.

Normal Findings:

Normal chest and surrounding structures, including bony thorax, soft tissues, mediastinum, lungs, pleura, heart, and great vessels

Result:

Study done in AP supine view. Haziness is noted in both lower lung fields. A thin band of opacity is noted in the right apex. The rest of the lungs are clear. Tracheal air column is at midline. The heart is enlarged with inferolateral displacement of the cardiac apex, fullness of the retro cardiac space and splaying of the carina. Both costophrenic sulci are blunted. The hemidiaphragms are obscured. The rest of the included structures are unremarkable.

Impression:Left sided cardiomegaly. Please correlate with ECG findings

Bibasal pneumonia with underlying minimal pleural effusion

Apico-pleural thickening, right


Electrocardiogram (ECG) most common test of hearts condition and is used to graphically record the electrical current generated by the beating heart

Rationale:

This electrophysiologic test is used primarily to screen for and diagnose a variety of cardiac conditions as well as to monitor the hearts response to therapy. It is used to diagnose abnormal heart rhythms, conduction disturbances, hypertrophy of cardiac chambers, myocardial infarction and ischemia and pericarditis.

Normal findings:

Normal sinus rhythm, normal conduction patterns, absence of areas of infarct or ischemia

First result:Second result:

AF in MVR

Old inferior wall infarct

Incomplete RBBB,

Anterolateral wall infarctCourse AF in slow VR

Infarction anterolateral wall

LAD, PVW R wave program

Incomplete RBBB

Date: November 12, 2006

Immunology:

Troponin T qualitative is reliable markers of myocardial injury and is found in human serum within 4-6 hours following MI

Rationale:

Primarily ordered for people who have chest pain to see if they have had a heart attack or other damage to the heart. It is done 2-3 times in 12-16 hours period.

Result: POSITIVE

Implication:

It indicates pulmonary embolism because of right ventricular dilatation and myocardial injury

Hematology:

PROTIME and APTT

Rationale (ProTime):

Screens for lack of coagulation factors necessary for blood clotting. Prothrombin time measures the time required for a fibrin clot to form in a citrated plasma sample after addition of calcium ions and tissue thromboplastin and compares this with fibrin clotting time in a control sample plasma.

Rationale (APTT):

Assess bleeding disorders or the effectiveness of heparin therapy by evaluating intrinsic coagulation factors necessary for blood clotting. The basis of the test is fibrin clot formation and it evaluates all the clotting factors of the intrinsic pathway except factors VII and VIII.

Normal Findings (ProTime): 11-14 seconds

Normal Findings (APTT): 27-34 seconds

November 16, 2006November 16, 2006November 22, 2006

Result: 19.5 seconds

Increased protime may indicate deficiency of clotting factors or circulating anticoagulant productsResult: 40 seconds

Increased Activated Partial Thromboplastin Time (APTT), may indicate vitamin k deficiency or presence of circulating anticoagulants Result: 16.3 seconds

Increased protime may indicate deficiency of clotting factors or circulating anticoagulant products

Clin Pharm Case Study

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