Download Case cont…..

Done by : Mohannad AL.shibani
clinical pharmacist intern
Supervised by: Dr. Muna Fliflan
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FILE NO. :248758
CASE
ROOM NO. :451 D
86 years Saudi male,70 KG, presented to ER. On (16/10/2008) C/O
fever, productive cough, and not eating well since 2 day back.
Patient was discharged from medical department 1 month back
(13/9/2008) on case of “”drug induced hypoglycemia”” and all
his medication was stopped .then he was well until 7 day back
when he started to have fever 39°C . He was seen in polyclinic and
discharge on antibiotic and cough syrup but was not given to
patient . 2 days back patient was lethargic with fever ,decrease in
appetite and weakness. he is not eating well according to his son
and he took him to private polyclinic and found to be febrile and
dehydrated with blood glucose 420 mg/dl. They gave him IVF
,insulin and they told him to take patient to big hospital.
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Case cont…..
Past medical history:
I.
II.
III.
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Type 2 DM from
HTN
Old CVA
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Case cont…..
Past medication:
I.
II.
III.
IV.
V.
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ASA 81 mg po OD
Omeprazole 20 mg po OD
Glibenclamide
D/C on 13/9
Metformin
HCTZ
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Case cont…..
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Diagnosis: chest infection and dehydration
Vital signs: Temp. 38.5°C
Bp.
161/83 mm/Hg
pulse 70/min
RR.
22 /min
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Case cont…..
Physical examination:
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16/10/2008
Skin & extremities: not pale or jaundice, sleepy , difficult
in hearing
Eyes , ears & neck: normal
Chest wall & lungs: clean with equal air entry bilaterally,
spontaneous breathing & yellowish sputum
Cardiovascular: S1 + S2 + 0
Abdomen : soft , no organomegally
Bone & joints : skin pealing & dry bed sores
Mental status : conscious
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Progress note:
Date:16/10
Plan:
1) Urine analysis
3) 4 points BS monitoring
4) low salt & DM diet
6) ½ NS 60cc /hr IV.
8) klaccid 250 mg BID PO
10) omeprazole 20mg OD PO
12) capoten 12.5mg BID PO
2) blood c/s, urine c/s & sputum c/s
5) sliding scale for DM
7) PLASIL 10 mg IV. (immediately)
9) ROCEPHINE 1g IV. BID
11) ASA 81mg OD PO
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Date:18/10
Temp. :37.5
Bp. :163/74 RR. :20/min
pulse=60
Subjective: patient seeing fine , conscious , but complain of dry bed ulcer
and BS. was 258 mg/dl
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Progress note:
Labs :
OSMO.= 265
Alb.= 2.4g/dl
ESR.= 45 mm/hr
PTT=27.5 (control=31.6)
k =2.8 mmol/l
Na= 132mmol/
INR= 0.9
PT=10.8 (control=12.5)
Urine analysis: urine is light , yellowish & turbid appearance
PH=6.5
WBC= 60-70
Hematology analysis: Neut.=9.46
RBC= 3.77
Hct= 31.6%
plan:
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1)
2)
3)
4)
Glucose: +ve
leucocytes :+ve
Bacteria: +++ve
WBC=11.56
Hgb=11.00 g/dl
Dermatology counseling
Add lantus 10 U am.
Add fucidin ointment locally BID
Add flamazine
ointment locally BID
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Progress note:
Date:19/10 :
Temp. :37.5
Bp. :140/70
RR. :20/min
pulse=65
BS.=256 mg/dl ac.
CBC:
Plan:
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BUN=25.3
Glu=288
RBC=3.8
Na=130
WBC=11.9
Hgb=11.1
1) lantus 10 U pm.
2)add RI. 8 U SC. TID premeal
3)D/C sliding scale
4)add clexane 40 mg SC. OD
5) dermatolodist seen pt. then change dreesing daily
6) continuous other treatment
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Progress note:
Date:20/10:
Bp. :139/88
BS.=200 mg/dl pc
Subjective: 1)bilateral hand swelling in Rt. Hand
2) febrile vital stable
 plan:
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1) increase lantus to 14 U Pm.
2)incourage oral intake
3) D/C IVF.
4) Continuous the treatment
5) C.S.T
6) Repeat chemistry
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Progress note:
Date:23/10
Bp. :125/72
BS.=141 mg/dl ac.
Subjective:
1)sacral ulcer not improve
2)cough developed during take pre meal
3)lab showed no growth factor on blood after 5 days
Lab test:
1) BUN=25.9
2) Na= 131
Plan:
1)insert NGT but his son refused
2) Continuous the treatment
3)C.S.T again
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Progress note:
Date:27/10
Subjective:
C.S.T:
Biochemistry:
Bp. :130/91
BS.=205 mg/dl ac
1)sacral ulcer still not improve
2)pt. fine, febrile vital stable
1)Urine culture showed Enterococcus spp.
1) BUN=28mg/dl
 Hematology:
1)RBC=3.85
2)Hgb=11.1
3)Hct=33.2
Plan:
1)increase lantus to 18 U Pm.
2)repeat CBC chemistry
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2)ALB=2.5g/dl
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‫‪Progress note:‬‬
‫‪Bp. :161/89‬‬
‫‪BS.=88 mg/dl ac‬‬
‫‪Date:28/10:‬‬
‫‪Pt. fine, febrile vital stable‬‬
‫‪Subjective:‬‬
‫‪Decrease RI. to 4 U SC. TID‬‬
‫‪Plan:‬‬
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‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
‫‪Date:1/11:‬‬
‫‪Bp. :132/74‬‬
‫‪BS.=157 mg/dl ac‬‬
‫‪Pt. fine, febrile vital stable‬‬
‫‪1) increase RI. To 6 U SC. TID premeal‬‬
‫‪2) increase lantus to 20 U SC. Pm.‬‬
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‫‪Subjective:‬‬
‫‪Plan:‬‬
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Diabetic follow up
DATE
6 am.
16/10
11 am.
6 pm.
11 pm.
275 pc
181 pc
168 pc
17/10
190 ac
168 ac
144 pc
120 pc
18/10
131 ac
258 ac
270 pc
219 pc
19/10
256 ac
118 ac
195 ac
260 pc
20/10
200 pc
321 pc
287 pc
21/10
121 ac
180 pc
134 ac
141 pc
22/10
125 ac
107 ac
205 ac
183 ac
23/10
141 ac
158 ac
253 pc
24/10
168 ac
144 ac
260 pc
25/10
107 ac
326 pc
26/10
222 ac
185 pc
231 ac
240 pc
27/10
205 ac
188 pc
222 ac
247 pc
28/10
88 ac
98 pc
157 ac
151 pc
29/10
120 ac
123 ac
174 ac
158pc
30/10
178 ac
144 pc
177 ac
210 pc
1
31/10
170 ac
206 pc 1
222 pc
228 pc
220 pc
242 pc
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Discussion
 Why?
 Factor associated with switching to insulin:
I.younger at diagnosis
II.Suffer
from more health proplem
espicially cardiovascular disease
III.Have worse metabolic control
IV.HbA1c
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> 8%
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Discussion cont..
Protocol
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used when switch to insulin:
Single dose of bedtime(long acting) insulin plus
daytime sulfonylurea
Two injections of intermediate acting insulin
Multiple daily injection, combination of short acting and
intermediate acting
Single dose of bedtime(long acting) insulin plus three
times rapid acting insulin before meals
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reference
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http://grande.nal.usda.gov/ibids/index.ph
p?mode2=detail&origin=ibids_references&
therow=485719
Wayne A.Kradjan.Handbook of applied
therapeuetic.Lippincott Williams and
Wilkins.8th ED,2007;Chapter 49,page:65069
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