done by : mohannad al.shibani clinical pharmacist intern supervised by: dr. muna fliflan 111

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Done by : Mohannad AL.shibani clinical pharmacist intern Supervised by: Dr. Muna Fliflan 1 1 1 1 1

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Page 1: Done by : Mohannad AL.shibani clinical pharmacist intern Supervised by: Dr. Muna Fliflan 111

Done by : Mohannad AL.shibani clinical pharmacist intern

Supervised by: Dr. Muna Fliflan

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Page 2: Done by : Mohannad AL.shibani clinical pharmacist intern Supervised by: Dr. Muna Fliflan 111

CASECASE

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.

FILE NO. :248758FILE NO. :248758 ROOM NO. :451 ROOM NO. :451 DD

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Page 3: Done by : Mohannad AL.shibani clinical pharmacist intern Supervised by: Dr. Muna Fliflan 111

Case contCase cont..…..…

Past medical history:Past medical history:I.I. Type 2 DM fromType 2 DM from

II.II. HTNHTN

III.III. Old CVAOld CVA

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Page 4: Done by : Mohannad AL.shibani clinical pharmacist intern Supervised by: Dr. Muna Fliflan 111

Case contCase cont..…..…

Past medication:Past medication:I.I. ASA 81 mg po ODASA 81 mg po OD

II.II. Omeprazole 20 mg po ODOmeprazole 20 mg po OD

III.III. GlibenclamideGlibenclamide

IV.IV. Metformin Metformin

V.V. HCTZHCTZ

D/C on 13/9

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Page 5: Done by : Mohannad AL.shibani clinical pharmacist intern Supervised by: Dr. Muna Fliflan 111

Case contCase cont..…..…

DiagnosisDiagnosis: : chest infection and chest infection and dehydrationdehydration

Vital signsVital signs: Temp. 38.5°C: Temp. 38.5°C

Bp. 161/83 mm/Hg Bp. 161/83 mm/Hg

pulse 70/minpulse 70/min

RR. 22 /minRR. 22 /min

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Page 6: Done by : Mohannad AL.shibani clinical pharmacist intern Supervised by: Dr. Muna Fliflan 111

Case contCase cont..…..…

Physical examinationPhysical examination: : 16/10/200816/10/2008 Skin & extremitiesSkin & extremities: : not pale or jaundice, sleepy , not pale or jaundice, sleepy ,

difficult in hearing difficult in hearing Eyes , ears & neckEyes , ears & neck: : normalnormal Chest wall & lungsChest wall & lungs: : clean with equal air entry bilaterally, clean with equal air entry bilaterally,

spontaneous breathing & spontaneous breathing & yellowish sputumyellowish sputum CardiovascularCardiovascular: : S1 + S2 + 0S1 + S2 + 0 AbdomenAbdomen : : soft , no organomegally soft , no organomegally Bone & joints Bone & joints : : skin pealing & dry bed soresskin pealing & dry bed sores Mental status Mental status : : consciousconscious

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Page 7: Done by : Mohannad AL.shibani clinical pharmacist intern Supervised by: Dr. Muna Fliflan 111

Progress note:

Date:16/10

Plan: 1) Urine analysis 2) blood c/s, urine c/s & sputum c/s 3) 4 points BS monitoring 4) low salt & DM diet 5) sliding scale for DM 6) ½ NS 60cc /hr IV. 7) PLASIL 10 mg IV. (immediately) 8) klaccid 250 mg BID PO 9) ROCEPHINE 1g IV. BID 10) omeprazole 20mg OD PO 11) ASA 81mg OD PO 12) capoten 12.5mg BID PO

____________________________________________________________________

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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Page 8: Done by : Mohannad AL.shibani clinical pharmacist intern Supervised by: Dr. Muna Fliflan 111

Progress note:

Labs :

Urine analysis:

Hematology analysis:

plan:

OSMO.= 265 k =2.8 mmol/l Alb.= 2.4g/dl Na= 132mmol/ ESR.= 45 mm/hr INR= 0.9 PTT=27.5 (control=31.6) PT=10.8 (control=12.5)

urine is light , yellowish & turbid appearancePH=6.5 Glucose: +ve leucocytes :+veWBC= 60-70 Bacteria: +++ve

Neut.=9.46 WBC=11.56RBC= 3.77 Hgb=11.00 g/dlHct= 31.6%

1) Dermatology counseling 2) Add lantus 10 U am.3) Add fucidin ointment locally BID4) Add flamazine ointment locally BID

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Page 9: Done by : Mohannad AL.shibani clinical pharmacist intern Supervised by: Dr. Muna Fliflan 111

Progress note:

Date:19/10 : Temp. :37.5 Bp. :140/70 RR. :20/min pulse=65 BS.=256 mg/dl ac.

CBC:

Plan:

BUN=25.3 Na=130 Glu=288 WBC=11.9 RBC=3.8 Hgb=11.1

1) lantus 10 U pm. 2)add RI. 8 U SC. TID premeal3)D/C sliding scale 4)add clexane 40 mg SC. OD5) dermatolodist seen pt. then change dreesing daily 6) continuous other treatment

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Page 10: Done by : Mohannad AL.shibani clinical pharmacist intern Supervised by: Dr. Muna Fliflan 111

Progress note:

Date:20/10: Bp. :139/88 BS.=200 mg/dl pc

Subjective:

plan:

1)bilateral hand swelling in Rt. Hand2) febrile vital stable

1) increase lantus to 14 U Pm. 2)incourage oral intake3) D/C IVF. 4) Continuous the treatment 5) C.S.T 6) Repeat chemistry

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Page 11: Done by : Mohannad AL.shibani clinical pharmacist intern Supervised by: Dr. Muna Fliflan 111

Progress note:

Date:23/10 Bp. :125/72 BS.=141 mg/dl ac.

Subjective:

Lab test:

Plan:

1)sacral ulcer not improve 2)cough developed during take pre meal3)lab showed no growth factor on blood after 5 days

1) BUN=25.9 2) Na= 131

1)insert NGT but his son refused2) Continuous the treatment3)C.S.T again

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Page 12: Done by : Mohannad AL.shibani clinical pharmacist intern Supervised by: Dr. Muna Fliflan 111

Progress note:

Date:27/10 Bp. :130/91 BS.=205 mg/dl ac

Subjective:

C.S.T:

Biochemistry:

Hematology:

Plan:

1)sacral ulcer still not improve2)pt. fine, febrile vital stable

1)Urine culture showed Enterococcus spp.

1) BUN=28mg/dl 2)ALB=2.5g/dl

1)RBC=3.85 2)Hgb=11.13)Hct=33.2

1)increase lantus to 18 U Pm. 2)repeat CBC chemistry 12121111

Page 13: Done by : Mohannad AL.shibani clinical pharmacist intern Supervised by: Dr. Muna Fliflan 111

Progress note:

Date:28/10: Bp. :161/89 BS.=88 mg/dl ac

Subjective:

Plan:

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Subjective: Pt. fine, febrile vital stable

Plan: 1) increase RI. To 6 U SC. TID premeal 2) increase lantus to 20 U SC. Pm.

Pt. fine, febrile vital stable

Decrease RI. to 4 U SC. TID

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Page 14: Done by : Mohannad AL.shibani clinical pharmacist intern Supervised by: Dr. Muna Fliflan 111

Diabetic follow upDiabetic follow upDATE6 am. 11 am.6 pm.11 pm.

16/10275 pc181 pc168 pc

17/10190 ac168 ac144 pc120 pc

18/10131 ac258 ac270 pc219 pc

19/10256 ac118 ac195 ac260 pc

20/10200 pc321 pc287 pc

21/10121 ac180 pc134 ac141 pc

22/10125 ac107 ac205 ac183 ac

23/10141 ac158 ac253 pc

24/10168 ac144 ac260 pc220 pc

25/10107 ac326 pc242 pc

26/10222 ac185 pc231 ac240 pc

27/10205 ac188 pc222 ac247 pc

28/1088 ac98 pc157 ac151 pc

29/10120 ac123 ac174 ac158pc

30/10178 ac144 pc177 ac210 pc

31/10170 ac206 pc222 pc228 pc 14141111

Page 15: Done by : Mohannad AL.shibani clinical pharmacist intern Supervised by: Dr. Muna Fliflan 111

DiscussionDiscussion

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Why?Why?

Factor associated with switching to Factor associated with switching to insulininsulin::II..younger at diagnosisyounger at diagnosis

II.II.Suffer from more health proplem Suffer from more health proplem espicially cardiovascular diseaseespicially cardiovascular disease

III.III.Have worse metabolic controlHave worse metabolic control

IVIV..HbA1c > 8%HbA1c > 8%

Page 16: Done by : Mohannad AL.shibani clinical pharmacist intern Supervised by: Dr. Muna Fliflan 111

Discussion contDiscussion cont....

1)1) Single dose of bedtime(long acting) insulin Single dose of bedtime(long acting) insulin plus daytime sulfonylureaplus daytime sulfonylurea

2)2) Two injections of intermediate acting insulinTwo injections of intermediate acting insulin

3)3) Multiple daily injection, combination of short Multiple daily injection, combination of short acting and intermediate actingacting and intermediate acting

4)4) Single dose of bedtime(long acting) insulin plus Single dose of bedtime(long acting) insulin plus three times rapid acting insulin before mealsthree times rapid acting insulin before meals

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Protocol used when switch to insulinProtocol used when switch to insulin::

Page 17: Done by : Mohannad AL.shibani clinical pharmacist intern Supervised by: Dr. Muna Fliflan 111

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Page 18: Done by : Mohannad AL.shibani clinical pharmacist intern Supervised by: Dr. Muna Fliflan 111

referencereference

http://grande.nal.usda.gov/ibids/index.php?mode2=detail&origin=ibids_references&therow=485719

Wayne A.Kradjan.Handbook of Wayne A.Kradjan.Handbook of applied therapeuetic.Lippincott applied therapeuetic.Lippincott Williams and Wilkins.8Williams and Wilkins.8thth ED,2007;Chapter 49,page:650-69ED,2007;Chapter 49,page:650-69

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