1

1 15
30 2553

Quatiapine

risperidone

ascites

Amlodipine 10 mg

2.5
mg
3

ascites

Metoclopamide 10
mg
Clcr 10-40 ml/min
50 %
normal dose
4.

mg/

Amlodipine 20

10 mg/
5

Aspirin Aspirin
CVD event

AF

Ischemic stroke
Warfarin

hs 3 mg

3 mg

INR 0.9

5 mg * 1

*1 hs 2
1*1 hs 5

INR
7

HIV/TB

..

48010710130

: (General Medicine I)
: 15 30 2553
: 1 2553

56 55 170
(.2)
20 2553

CC: 3 day PTA

HPI:

Known case TVD S/P PCI 5 , CABG 6

MRI CABG , EF 30 %, CABG

3 Day PTA

1 Day PTA

PMH: TVD, Diabetes mellitus, Hypertension ~ 5 yr PTA

FH:

SH:

~ 30 ,
~ 5

ALL: Sulfonamide ,

Med PTA :

Furosemide (40) 2*1 pc

Aspirin (81) 1*1 O pc

Isosorbide mononitrate (20) 1*2 O ac

Spironolactone (25) 1*1 O pc
Carvedilol (6.25) *2 O pc
Enalapril (5) 1 *2 O pc

Amlodipine (10) *2 O pc

Gemfibrozil (300) 2*2 O pc

Air-X (80) 1*3 O pc
FBC 1*3 O pc

Simvastatin (20) 1*1 O pc

Lorazepam (0.5) 1*1 O hs

Esomeprazole (20) 1*1 O ac

Warfarin (3) 1
Physical Examination
V/S:

T 37.2 c

BP 94/61 mmHg

PR 86 bpm RR 20 bpm

Gen : A man, good conscious.

HEENT: not pale, no jaundice
Heart: Regular, no murmur
EKG: No AF

Lung: Fine crepitation both lung

Extremities: Pitting edema 2+
Abdomen: Soft not tender

CXR: Cardiomegaly, Pulmonaly edema.

Data/Lab

Normal

20

21

22

23

24

25

135-148

121

129

128

4.31

3.91

3.57

92

97

97.5

21

24

26

37

26

Electrolyte
Na

mEq/L
3.5-5.5

mEq/L
95-106

Cl

mEq/L
22-30

CO2

mEq/L
1.8-2.6

Mg

mg/dL
8.6-

Ca
Phos

1.9
8

10.3mEq/d
L

2.84.9
mEq/dL

Renal Relate
BUN
SCr

FBG
HbA1c

7-18 mg/dL

40

0.6-1.2

2.27

70110

208

mg/dL

mg/dL
9.6

233

1.7

1.5

139

143 346

1.47

9.6

Hematology
4.4-

11.310 /
WBC

3.37

8.7

8.4

27

26.3

g/dL
36.0-45.0

Hct

MCV

80-96 fL

80.2

27.5-33.2

25.9

33.4-35.5

32.3

11.6-16.5

24

150-400

138

Neu

40-65 %

69

Lym

20-40 %

24

Data/Lab

Normal

20

Mono

210 %

Eos

0-9 %

Baso

0-1 %

MCH
MCHC
RDW

3.2

10 /L
12.3-15.3

Hb

10.3

L
4.5-5.9

RBC

9.1

pg
%

MPV
Plt

10 /L

21

22

23

24

25

Poikilocyto
sis

Ovalocyte
Hypochrom
asia

Anisocytosi
s

Macrocytos
is

Microcytosi
s

Target cell
Reticulocyt

0.5-2.5%

ec
Feritin

10-300
ng/ml

Serum iron

61-165
ugm%

UIBC

170-230
ugm%

TIBC

228-428
ugm%

% iron sat.

30-50 ugm
%

Coagulation
PT

10.2-14.1

68.1

>120

5.4

2.6

PT ratio
INR

1.1

23.1-32.3

58.3

103.

PTT

33.8

Protein
3.4-4.8

2.8

1.5

2.8

2.7-3.5

3.9

2.8

3.8

SGOT

10-37

40

54

SGPT

10-37

14

20

ALK

34-104

511

T.bil

0-1

3.5

2.8

D.bi

0-0.3

2.1

1.5

0-171

244

Alb

g/dL

Glo

g/dL

LFT

Other
CPK
CKMB

2.99

3.1

0.14

0.1

Tro-p

Patient Data Record Form

Date
Day

Admissi

after

on
Systolic

BP

Diastolic

Respirations

20

21

22

23

24

25

90-

90-

80-

100-

110-

100-

94

107

110

119

119

120

56-

51-

46-

60-

60-

62-

61

62

64

84

80

82

20

20

20

20

20

10

20
Temperature(max)
Pulse

37.2

37.2

37.1

37.4

37.3

37.0

86

80-

76-

82-

84-

84-89

86

86

84

88

600

Intake

560

555

1,385

Output

320

100

1,700 1,900

Medications

Order for One Day

Drug/Dosage regimen

Administrati
on

20 21 22 23 24

Furosemide 40 mg

Iv stat

Dobutamine (2:1)

5 ud/min

3 LPM

SC

O2 canular
HR

25

IF 201-250 = 4 U

251-300= 6 U
301-350= 8 U

Vitamin K 2 mg
FFP 2 unit
Furosemide 20 mg

IV

Drip in 1 hr

IV

Order for Continue

Drug/Dosage regimen
Pantoprazole 40 mg

administratio

20

21

22

23

IV OD

Of

24

25

10

11

Warfarin 3 mg

* 1 O hs

of

1*1 O hs
Air-x

1*3 O pc

Simvastatin 20 mg

1*1 O pc

Lorazepam 0.5 mg

1*1 O hs

prn
ASA 81 mg

1*1 O pc

Spironolactone 25 mg

1*1 O pc

of

administratio

20

21

22

23

24

25

Drug/Dosage regimen

n
Ferrous fumarate

1*3 O pc

Isodil 5 mg

1 tab SL prn

Rupect

1*3 O pc

Of

Clarithromicin 500 mg

1*2 O pc

of

Furosemide 40 mg

1*2 O pc

Enalapril 5 mg

of

*1 O pc

Pantoprazole 40 mg

1*1 O ac

NAC 600 mg

1*2 O pc

of

Vitamin C 500 mg

6*2 O pc

of

Furosemide 40 mg

1*1 O pc

Problem lists
1. CHF with TVD s/p PCI and CABG
2. Bleeding per- gum

11

12

3. R/O Cardiac cirrhosis

4. Acute renal injury
5. Anemia

6. Diabetes mellitus
7. Hypertension

Hospital course
21/3/2553
Case 56
CC : 3
PI :

Known case TVD s/p PCI 5

CABG : 6

12

13

MRI CABG EF= 30 %

CABG

3 PTA

GA : Good conscious ,not pale

Lung : Fine crepitation both lung

Ext : pitting edema 2+
Tro-p : 0.18

EKG : No AF
CXR: Cardiomegaly, pulmonary edema
Plan :

of enalapril/aldactone Cr rising
enoxaparin OD
V/S

Liver : Liver sign

Cr
Plan start ARB ( pt. ACEI )

23/3/2553

LVEF = 26 %

MR +/_ (19/2/53)
1) CHF : pitting edema 1+
No Crepitation

Heart normal s1s2 , No murmur,No gallop , I/O = 1,385/1,700

Plan : continue diuretic

2) PT > 120 ,PTT 91.2

Vit K 2 mg IV , FFP 2 unit PT =31.2 ,INR 2.6 ,

PTT =48.8

13

14

F/U

PT = 12.3 , INR = 1.1 , PTT =

30.3
23/3/2553

Echo W/U poor LVEF poor LVEF

Consult Plan medication

Revascularization by PCI
set CAG

Medication

Re-challeng warfarin D/C

24/ 3/ /2553

TVD S/P CABG 5 MO . LVEF 26 % on warfarin & ASA

Admit CHF Precipitate ????
1) CHF with TVD S/P CABG

precipitate neg I/O

Plan : balance I/U , Challenge ACEI - Aldactone

2) Bleeding per-gum & Hemolysis (non massive with coagulopathy)
INR prolong on warfarin & Clarithromicin
Bleeding correct with vit K & FFP INR 1.1

Plan : If clinical : no bleeding plan start warfarin

3) R/O Cardiac Cirrhosis

No Hx Alcohol/Herb

IF no stigmata , Ascite +
LFT : reverse A/G ratio & billirubin ^
Plan : V/S upper abdomen

14

15

4) AKI
Cr ^ -> prerenal azotemia CHF -> low CO CHF
improve BUN/Cr (1.5)

Problem 1: CHF with TVD s/p PCI and CABG : DRP warfarin
drug interaction with simvastatin aspirin enalapril furosemide
S : Subjective data
3 day PTA

O: Objective data

PMH: TVD, Diabetes mellitus, Hypertension ~ 5 yr PTA

Med PTA :

Furosemide (40) 2*1 pc

Aspirin (81) 1*1 O pc

Isosorbide mononitrate (20) 1*2 O ac

15

16

Spironolactone (25) 1*1 O pc

Carvediol (6.25) *2 O p
Enalapril (5) 1 *2 O pc

Amlodipine (10) *2 O pc

Gemfibrozil (300) 2*2 O pc

Simvastatin (20) 1*1 O pc

Esomeprasole (20) 1*1 O ac

Warfarin (3) s1

Physical Examination

V/S: BP 94/61 mmHg

Lung: Fine crepitation both lung

Extremities: Pitting edema 2+

CXR: Cardiomegaly, Pulmonaly edema.

Na

121

Alb

2.8

Cl

92

Glo

3.9

BUN

40

Cr

2.27

CPK

244

CKMB

2.99

Tro-p

0.14

Intake

56
0

Medications

Output

32
0

16

17

Order for One Day

Drug/Dosage regimen

Administrati
on

20 21 22 23 24

Furosemide 40 mg

iv stat

Dobutamine (2:1)

5 ud/min

3 LPM

SC

O2 canular
HR

25

IF 201-250 = 4 U

251-300= 6 U
301-350= 8 U

Furosemide 20 mg

IV

Order for Continue

Drug/Dosage regimen

Administratio 20

21

22

23
of

24

25

n
Pantoprazole 40 mg

IV OD

Warfarin 3 mg

* 1 O hs

of

1*1 O hs
Simvastatin 20 mg

1*1 O pc

ASA 81 mg

1*1 O pc

Spironolactone 25 mg

1*1 O pc

of

Isodil 5 mg

1 tab SL prn

Furosemide 40 mg

1*2 O pc

of

Enalapril 5 mg

*1 O pc

Pantoprazole 40 mg

1*1 O ac

Furosemide 40 mg

1*1 O pc

17

18

A: Assessment

Etiology : Congestive heart failure (CHF)

edema

fluid overload pulmonary congestion peripheral

peripheral
edema
(TVD) (MR)

CHF Tripple vessel disease (TVD)

coronary artery

Indication for therapy :

TVD

18

19

Assessment

of

therapy : stage

CHF ACC/AHA Practice Guidelines

stage
B-C Structural heart disease
cardiomegaly X-ray

peripheral edema HTN TVD

New York Heart Associated (NYHA)

classification Class III

ACC/AHA Practice Guidelines

Stage C Diuretics, ACEI, ARBs,

Aldosterone antagonist, Beta-blockers, Hydralazine/nitrates

Catecholamine Dopamine dobutamine

Medications

Order for One Day

Drug/Dosage regimen

Administrati
on

20 21 22 23 24

Furosemide 40 mg

Iv stat

Dobutamine (2:1)

5 ud/min

3 LPM

O2 canular
Furosemide 20 mg

IV

25

19

20

Order for Continue

Drug/Dosage regimen

Administratio 20

21

Spironolactone 25 mg

1*1 O pc

of

Furosemide 40 mg

1*2 O pc

Enalapril 5 mg

*1 O pc

Furosemide 40 mg

1*1 O pc

22

23

24

25

Of

1) Lasix 20-80
mg/dose 20-40 mg 6-8
20-40 mg
1-2

2) Dobutamine beta-receptor

cardiac output
2-3
IV drip 2-5 mcg/kg/min
3 mcg/kg/min (7)

3) Enalapril 2.5 mg 1-2 target dose

10-20 mg 2

Cr
Raising

4) Spironolactone 12.5-25 mg/day maximum dose 50

mg/day

20

21

TVD

ACC/AHA

- 130/80 mmHg

- 130 mg/dL HbA1C

7 %

- LDL-C 100 mg/dL

- HDL-C 60 mg/dL

- BMI = 18.5-24.9 kg/m

- 30-60 3-4

Antiplatelet agent ,Antiischemic agent , Statin secondary prophylaxis

Order for Continue

Drug/Dosage regimen

Administratio 20

21

22

23
Of

24

25

n
Pantoprazole 40 mg

IV OD

Warfarin 3 mg

* 1 O hs

of

1*1 O hs
Simvastatin 20 mg

1*1 O pc

ASA 81 mg

1*1 O pc

21

22

Isodil 5 mg

1 tab SL prn

1) ASA (81) 1*1 O pc Antiplatelet agent

Aspirin 75325 mg

2) Isosorbide dinitrate (5)

3) Simvastatin (20) 1 *hs secondary prevention

plaque rupture 20-40 mg/day

(max dose 80 mg/day)

4) Pantoprazole 40 mg IV
Aspirin

peripheral edema serum creatinine

acute renal failure SCr Bblocker ACEI

MR warfarin

INR prolong,
warfarin 1-2 dose
bleeding INR

warfarin

P :

Therapeutic plan :

22

23

Drug/Dosage regimen

administratio
n

Furosemide 40 mg

iv stat

Dobutamine (2:1)

5 ud/min

O2 canular
Drug/Dosage regimen

3 LPM
administratio
n

Pantoprazole 40 mg

IV OD

Simvastatin 20 mg

1*1 O pc

ASA 81 mg

1*1 O pc

Spironolactone 25 mg

1*1 O pc

Isordil 5 mg

1 tab SL prn

Enalapril 5 mg

*1 O pc

Pantoprazole 40 mg

1*1 O ac

Furosemide 40 mg

1*1 O pc

AKI

Goal :

23

24

Therapeutic monitoring :
-

-
- Balance Intake / output
- BP

ADRs

monitoring :

Furosemide

Electrolyte

Simvastatin

BUN Cr

Isosorbide dinitrate
Enalapril

BP

BP ,

ASA

CBC ,Bleeding

Dobutamine

HR , BP ,PR

Patient education :

-
HTN, DM CAD

- < 130/80 mmHg

- < 130 mg%

Future plan :

24

25

- Beta-blockers

carvidilol, metoprolol

Problem 2 : Bleeding per-gum & Hemolysis (non massive with

coagulopathy) : DRP : Over dose of warfarin , Subtherapeutic
S : Subjective data
-

O: Objective data
RBC

3.37

Hb

8.7

Hct

27

MCH

25.9

MCHC

32.3

RDW
Plt

24
138

25

26

Neu

69

PT

68.1

INR

5.4

PTT

58.3

A: Assessment
Etiology: Bleeding INR prolong

warfarin 5 Tipple vessel

disease (TVD) +/- Mitral valve regurgitation (MR)

Myocardial infarction
22
INR prolong Bleeding

warfarin 1. 2.

warfarin 3.
metabolite 4. factor

7. 8.

simvastatin aspirin enalapril

furosemide clahrithromycin
Warfarin acute kidney
injury , cardiac cirrhosis , congestive heart failure, Hypertension,

Diabetes mellitus
Bleeding

Indication for therapy :Bleeding

26

27

Assessment of therapy : Bleeding

ACCP guideline 2008

Dose alteration for goal INR

2.0-3.0

INR < 2

INR 3-3.5

INT 3.6-4

INR > 4

Increase weekly

Decrease weekly

Withhold no

Withhold no

dose by

dose by 5-15

dose to one dose

dose to one dose

27

28

Decrease weekly
dose by 10-15

Decrease weekly
dose by 10-20

15 mg/wk INR admit =

5.4 1- 2 dose 10-20 %

12- 13.5 mg/wk

13.5 mg/wk

INR prolong
22 (

non massive) ACCP guideline 2008

vitamin K 10 mg Fresh fasting plasma 150 300 ml

(1 unit = 300 ml) 2 unit

P :

Goal :
1. bleeding
2. INR

3.

4.
Therapeutic plan :

1. vitamin k 10 mg slow IV infusion

2. FFP 1 unit drip in 1 hr.

28

29

3. bleeding INR warfarin

* 1 O pc

Therapeutic monitoring :
1. INR 2-3 (monitor bleeding )
2. HF (SOB, DOE, nocturia, edema)
3. CBC

4. PT, PTT
ADRs monitoring :

1. warfarin : bleeding (INR PT PTT)

2. vitamin k : INR PT PTT

3. FFP : Hypersensitivity ( CBC)

Education plan

1.

warfarin

2.

Future plan : F/U 7 PT, INR

Problem 3: Cardiac cirrhosis without DRP

29

30

S: Subjective data
-

O: Objective data
SGOT

40

ALK

511

T.bil

3.5

D.bi

2.1

A: Assessment
Etiology: Cardiac cirrhosis fibrosis

portal fibrosis
AST, ALT, LDH Total billirubin

Indication for therapy :

Assessment of therapy :

P :

Therapeutic plan :

Goal :

1.
2. BUN = 7-18 mg/dL

3. SCr = 0.6 1.2 mg/dl

4. BUN/SCr = 10-15 : 1

Therapeutic monitoring :

30

31

1. BUN/Cr
ADRs

monitoring :

Patient education :

1.

2.

Future plan :

Problem 4 : Acute renal injury without DRP

S: Subjective data
-

O: Objective data

Extremities: Pitting edema 2+

Na

121

Cl

92

BUN

40

SCr

2.27

Alb

2.8

Glo

3.9

Intake

56

Output

32

0
0

31

32

Medications
Order for One Day
Drug/Dosage regimen

Administrati

20 21 22 23 24

25

on
Furosemide 40 mg

iv stat

Furosemide 20 mg

IV

/
/

Order for Continue

Drug/Dosage regimen

administratio

20

21

22

23

24

of

25

n
Furosemide 40 mg

1*2 O pc

NAC 600 mg

1*2 O pc

of

Vitamin C 500 mg

6*2 O pc

of

Furosemide 40 mg

1*1 O pc

A: Assessment

Etiology: Acute kidney injury (AKI)

( ) Glomerular filtration rate

BUN/Cr

400
ml/day stage 1 SCr 1.5-2
Baseline Oliguria
400 ml 24

32

33

Prerenal pre-renal
hypovolemia efective circulatory hypovolemia

efective circulatory

hypotension, heart failure

renal blood
flow Enalapril ACEI

Indication for therapy:

Assessment of therapy :

Dialysis
BUN/Cr

Enalapril

mannital 20% 12.5-25

g IV mannital AKI

33

34

Loop diuretic furosemide initial IV loading dose 40-80 mg

continuous infusion 10- 20 mg/hr.
1-3 g/day

Furosemide IV stat 40 mg
Furisemide (40) 1*2 O pc

N-acytylcystein (NAC) Vitamin c

1 600 mg q 12 hr 1
antioxidant

Nitric oxide
P :

Therapeutic plan :

Goal :

Furosemide IV stat 40 mg then

Furisemide (40) 1 * 2 O pc

1. s
2. BUN = 7-18 mg/dL

3. SCr = 0.6 1.2 mg/dl

4. BUN/SCr = 10-15 : 1

Therapeutic monitoring :
2. body weightss
3. input/output
4. Potassium
5. BUN/Cr
ADRs

monitoring :

Furisemide : Orthostatic hypotension (BP),

hyperglycemia (FBS), hypokalemia,

34

35

hyponatremia(electrolyte)
Patient education :

1.

2.

Phosphate
Future plan :

Problem 5 : Anemia without DRP

S: Subjective data
3 day PTA
O: Objective data
Med PTA :

FBC 1*3 O pc

RBC

3.37

Hb

8.7

Hct

27

MCH

25.9

MCHC

32.3

RDW
Plt

24
138

35

36

Medications
ferrous fumarate 1* 3 o pc
A: Assessment

Etiology : anemia Hemoglobin

12

bleeding

Indication for therapy :

Assessment of therapy :

200 mg/day 2-3 ferrous fumarate 1* 3

o pc
P :

Therapeutic plan :

Goal :

ferrous fumarate 1* 3 o pc

1. Hb > 13

2. HCT > 33

ADRs

Therapeutic monitoring :
monitoring :

CBC

ferrous fumarate :

Patient education :

36

37

Future plan :-

1. Wells BG, DiPiro JT, Schinghmmer TL and Hamilton CW.

th

Pharmacotherapy Handbook. 6 ed. Mc Graw Hill ; 2006.

2. . . 7.
. ; 2548.

3. Tatro DS. Drug interaction facts 2007. Wolters Kluwer; 2007.

4. David NG, Robert CM, George ME, et al. The Sanford
th

guideline to antimicrobial therapy 2009. 39 ed. Sperryville:

antimicrobial therapy; 2006.

5. Kasper DL, Fauci AS, Longo DL, Braunwald E, Hauser SL, and
th

Jameson JL. Harisons Principles of Internal Medicine. 16 ed.

Mc Graw Hill; 2005

6. Lacy CF, Armstrong LL, Goldman MP, Lance LL. Drug

th

Information Handbook. 17 ed. Lexi-Comp; 2009.

7. The Seventh Report of the Joint National Committee on

Prevention, Detection, Evaluation, and Treatment of High Blood

Pressure. JAMA 2003;289:256071.

2
:

..

48010710130

37

38

: (General Medicine I)
: 15 30 2553
: 29 2553

46 106 160
(.3) 19
2553

CC: 1 day PTA

HPI:

6 Day PTA

2 Day PTA

1 Day PTA

PMH: Diabetes mellitus, Hypertension , Chronic kidney disease R/O

ACD
FH:

SH:

ALL: NKDA
Med PTA :

Mixtard insulin 10-0-6

Clindamycin (300) 2*3 O pc
Cefspan (100) 1*3 O pc

Ferrous fumarate 1*3 O pc

Folic acid 1*1 O pc

38

39

Senokot 2* 1O hs
Prenolol (50) 1*1 O pc

CaCO3 (1.25 g) 1*1 O pc

Hydralazine (25) 1 Q 6 hr
Sodamint 2*3 O pc

Zimmex (20) 1* 1O hs
Physical Examination
V/S:

T 39.5 c

BP 180/90 mmHg

PR 86 bpm RR

40 bpm

Gen : A woman, good conscious.

HEENT: not pale, no jaundice, Marked obesity, Pharynx inject
Heart: Regular, no murmur
Lung: Clear

Extremities: pitting edema 1+, no cellulitis

Old scar (Hyperpigment) Lt leg
Dry wound at both foot
Abdomen: Soft not tender

Data/Lab

Normal

19

20

21

22

23

24

25

26

135-148

125

134

132

135

136

139

3.5-5.5

3.17 3.06 3.30

3.5

3.12

3.4

102

106

107.2

Electrolyte
Na
K
Cl

mEq/L
mEq/L

95-106
mEq/L

90

99.7

97.5

39

40

22-30
CO2

20

25

23

20

22

37

32

34

0.6-1.2

5.71 5.46 5.32 5.1

4.36

4.75

70110

444

mEq/L
1.8-2.6

Mg

2.1

mg/dL
8.6-

Ca
Phos

24

9.1

10.3mEq/d
L

2.84.9

5.2

mEq/dL

Renal Relate
BUN
SCr

FBG

7-18 mg/dL
mg/dL

44

40

393

mg/dL

40

402

294 240 219 216

199

HbA1c
Hematology
4.4-

18.4 10.8
3

WBC
RBC
Hb
Hct

11.310 /
L

4.5-5.9

3.69 3.41

12.3-15.3

9.8

36.0-45.0

29.5 27.6

10 /L
g/dL
%

9.2

40

41

150-400

227

234

Plt

10 /L
40-65 %

Neu

89.6 78.1

Lym

20-40 %

5.1

13.2

Mono

210 %

4.7

7.7

Eos

0-9 %

0.3

0.7

3.4-4.8

3.4

Protein
Alb

g/dL

Data/Lab

Normal

19

2.7-3.5

4.6

SGOT

10-37

17

SGPT

10-37

17

ALK

34-104

84

T.bil

0-1

0.5

D.bi

0-0.3

0.1

Glo

g/dL

20

21

22

23

24

25

26

LFT

Patient Data Record Form

Date
Day

Admiss

after

ion

BP

Systoli

19

20

21

22

23

24

25

26

180

170

160

160

160

90

90

90

90

90

170 180

170

c
Diastol

80

90

90

41

42

ic
20

20

20

39.5

37.5

37.1

Pulse

98

84

94

Intake

1500

3800

Output

2900

2200

Respirations
Temperature(m
ax)

20

20

20

20

37.4

36.8

37.5

36.8

37.2

90

88

88

84

92

20

Medications
Order for One Day
Drug/Dosage regimen

Administratio 19 20 21 22 23 24 25 2
n

0.9% NSS 1000 ml

Iv 100 ml/hr /

RI At ER 10 Unit

SC

KCL elixer 50 ml

Q 4 hr ,2

dose
KCL elixer 50 ml

1 dose

0.9% NSS 1000 ml

Iv 80 ml/hr

0.9% NSS 1000 ml

Iv 60 ml/hr

Hs

Milk of magnesia 30 ml
Drug/Dosage regimen

Administratio 19 20 21 22 23 24 25 2
n

HN 6 unit

Stat

HR 8 unit

Stat

HN 4-0-10

SC

HN 6-0-12

SC

/
/
42

43

HN 10-0-14

SC

HN 14-0-14

SC

HN 14-0-12

SC

Mixtard 18 U

SC

/
/
/
/

Order for Continue

Drug/Dosage regimen
Ceftriazone 2 g

Administratio 19 20 21 22 23 24 25 26
n

Iv

of

1*hs

CaCO3 1.25 g

1*1 O pc

Folic acid

1*1 O pc

Apresoline 25 mg

1*3 Opc

of

Amlodipine 10 mg

1*1 O pc

of

Eprex 4000 UNIT

SC q 1 wk

of

Bromhexine

1*3Opc

Amlodipine 10 mg

1*2 Opc

Eprex 4000 UNIT

SC 2

Simvastatin 20 mg

/WK
Ommicef 100 mg

2*2Opc 2day

Apresoline 25 mg

2*3 Opc

43

44

Insulin
Sliding scale

201-250 HR 4 U
251-300 HR 6 U

301-350 HR 8 U

351-400 HR 10 U
//

Regular

Humulin

19/4/53

ER

444

20.00

241

06.00

141

11.00

393

10

15.00

358

20.00

350

06.00

290

20.00

402

10

06.00

249

11.00

257

15.00

236

20.00

294

20/4/53

21/4/53
22/4/53

insulin(u)

N(u)
4

4-0-10

6-0-12

44

45

23/4/53

24/453

25/4/53

26/4/53

06.00

208

11.00

240

15.00

223

20.00

192

06.00

152

11.00

147

15.00

219

20.00

204

06.00

140

11.00

216

15.00

212

20.00

214

06.00

199

10-0-14

14-0-14

14-0-12

Home medication

Mixtard insulin 20-0-12

Folic acid 1*1 O pcs
Senokot 2* 1O hs

CaCO3 (1.25 g) 1*1 O pc

Hydralazine (25) 1 Q 6 hr
Zimmex (20) 1* 1O hs

Amlodipine(10) 1*2O pc
Eprex 4000 U 2/week
Bromhexine 1*3 O pc
Problem lists

45

46

1. Acute febrile illness R/O Urinary tract infection

2. Diabetes mellitus with Dyslipidemia
3. Hypertension

4. Chronic kidney disease

5. Anemia of chronic kidney disease

Problem 1: Acute febrile illness R/O Urinary tract infection

Without DRP
S: CC:
HPI:

1 day PTA

6 Day PTA

2 Day PTA

O:
V/S:

1 Day PTA

T 39.5 c

Data/Lab

Normal

19

4.4-

20

18.4
3

WBC

11.310 /
L

46

47

Neu

40-65 %

89.6 78.1

Medications

Order for Continue

Drug/Dosage regimen

Administratio 19 20 21 22 23 24 25 26
n

Ceftriazone 2 g
Ommicef 100 mg

Iv

2*2Opc 2day

of
/

A:
Acute febrile illness (AFI)

6 Viral infection: Dengue fever Influenza ,

Rickettsiosis Leptospirosis , Malaria ,Typhoid fever ,Bacteremia

WBC ,neutrophil

Empiric Cefriaxone 2 g IV
5

Ceftriaxone

1-2 g /day
2 g / day
P :

Therapeutic plan : {Pharmacist plan}

47

48

- Ceftriaxone 2 g IV
- Cefdinir 300 mg 1*1 pc

Goal :

- WBC 4.4-11.310 /L
- Netrophile 40-65 %
Therapeutic monitoring :
- WBC

- Neutrophile

ADR

monitoring : -

- Ceftriaxone : Hemoglobin, Hematocrit , Transminase, Alkaline

phosphatase

- Cefdinir : rash

Patient education :

-
-

Problem 2 : Diabetes malletus DRP : Need to add drug

(Aspirin)

S:
O:

Old scar (Hyperpigment) Lt leg

Dry wound at both foot

48

49

Med PTA :
Mixtard insulin 10-0-6

Zimmex (20) 1* 1O hs

Data/Lab
FBG

Normal

19

70110

444

< 6.5

7.6

mg/dL

HbA1c

20

21

393 402

22

23

24

25

26

294

240

219

216

199

Medications
Order for One Day
Drug/Dosage regimen

Administratio 19 20 21 22 23 24 25 2
n

RI At ER 10 Unit

SC

HN 6 unit

Stat

HR 8 unit

Stat

HN 4-0-10

SC

HN 6-0-12

SC

HN 10-014

SC

HN 14-0-14

SC

HN 14-0-12

SC

Mixtard 18 U

SC

/
/
/
/
/
/

Insulin
//

19/4/53

ER

444

Regular

Humulin

insulin(u)

N(u)

49

50

20/4/53

21/4/53
22/4/53

23/4/53

24/453

25/4/53

26/4/53

20.00

241

06.00

141

11.00

393

10

15.00

358

20.00

350

06.00

290

20.00

402

10

06.00

249

11.00

257

15.00

236

20.00

294

06.00

208

11.00

240

15.00

223

20.00

192

06.00

152

11.00

147

15.00

219

20.00

204

06.00

140

11.00

216

15.00

212

20.00

214

06.00

199

4-0-10

6-0-12

10-0-14

14-0-14

14-0-12

Order for Continue

50

51

Drug/Dosage regimen

Administratio 19 20 21 22 23 24 25 2
n

Simvastatin 20 mg

1*hs

6
/

A:
Etiology

Insulin

metabolism
Insulin

ADA

200 mg/dl ,

Fast plasma glucose 126 mg/dl Oral glucose

tolerance test 200 mg/dl
Indication for therapy

Assessment of therapy

ADA

metfomin 2 3

51

52

HbA1C
6.5
Sulfonylurea, Thiazolidinedione Insulin

Insulin

Insulin Slinding scale

Dyslipidemia

TG < 150 , HDL> 40 , HDL> 50

LDL < 100 ,

DM CVD

52

53

1. LDL<100
2. >40 y statin LDL 30-40%

3. <40 y CVD risk factor

LDL goal

DM CVD

1. statin LDL 30-40%

2. LDL goal<70 high dose statin
3. TG<150, HDL>40/50 (M/F)

1. ASA (75-162 mg/day) secondary prevention

DM+CVD

2. ASA (75-162 mg/day) primary prevention

Type2 or Type1DM > 40

CVD, HTN, smoking, dyslipidemia, or
albuminuria

40

Simvastatin 20 mg
Coronary event
20-40 mg 20 mg

Aspirin

75-162 mg/day
Aspirin(81mg) 1*1 O pc
P :

Therapeutic plan : {Pharmacist plan}

Mixtard insulin 20-0-12

Goal :

Simvastatin 20 mg 1*hs
Aspirin 81 mg 1*1 O pc

53

54

- FBS <126 mg%

- HbA1C < 6.5%

Therapeutic monitoring :

- FBS

- HbA1C
ADR

monitoring : -

Mixtard insulin : FBS

Simvastatin : Transminase , CPK 3

Aspirin : Bleegind

Patient education :

-



Future plan :

FBS, HbA1C

Lipid profile
Problem 3: Hypertention DRP: Over dosage of Amlodipine

S:

54

55

O:

Med PTA :
Prenolol (50) 1*1 O pc

Hydralazine (25) 1 Q 6 hr
Patient Data Record Form
Date
Day

after

19

20

21

22

23

24

25

26

Admiss

Systoli

180

170

160

160

160

Diastol

90

90

90

90

90

ion
c

BP

ic

170 180
80

170

90

90

Medications
Order for Continue
Drug/Dosage regimen

Administratio 19 20 21 22 23 24 25 2
n

Apresoline 25 mg

1*3 Opc

Amlodipine 10 mg

1*1 O pc

of

f
Amlodipine 10 mg

1*2 Opc

Apresoline 25 mg

2*3 Opc

A:

Etiology

55

56

Hypertension ()
140/90 .
JNC 7

2 Essential

hypertension

secondary hypertension

primary renal disease, oral contraceptive,

pheochromocytoma, primary hyperaldosteronism

Premature cardiovascular disease

, Left ventricular hypertrophy, stroke

End stage renal failure

Indication for therapy

56

57

Assessment of therapy

130/80 mmhg ACEI,ARB

Glucose metabolism Diabetic
nephropathy Renal vascular resistance perfusion

pressure Proteinuria Diuretic

beta blocker

Hypoglycemia
CCB

57

58

130/80 ACEI

Creatinine
loop diuretic Volume overload

dihydropyridine calcium channel blocker

10

> 160 /90 mmHg JNC 7 Hypertension

stage 2
Clcr 20.6 ml/min
ARB

CCB Amlodipine(10) 1*2

Opc Hydralazine (25) 1*3 O pc

1. Amlodipine(10) 1*1 O pc CCB

proteinuria 2.52

10 mg/day (max 10 mg/day) 20 mg

2. Hydralazine (25) 2*3 O pc Direct

smooth muscle
vasodilator

Artery Vein severe hypertension

25-100 mg (Max 300 mg) 2

P :

150 mg /day

Therapeutic plan :

{Pharmacist plan}

Hydralazine (25) 2*3 O pc

58

59

Amlodipine (10) 1*1 O pc

Goal :

- BP<130/80 mmHg
Therapeutic monitoring :

- BP
ADRs
titer

monitoring :

Hydralazine

Heart rate , blood pressure, ANA

Amlodipine

Heart rate , blood pressure ,

Peripheral edema
Patient education :

- 130/80 mmHg

- 30
3

-
Future plan :

- 130/80 mmHg

59

60

Problem 4 : Chronic renal failure DRP : Low dose of Sodium

bicarbonate
S:
-

O:
Med PTA :

CaCO3 (1.25 g) 1*1 O pc

Sodamint 2*3 O pc

Extremities: pitting edema 1+

Data/Lab

Normal

19

20

21

22

23

24

25

26

135-148

125

134

132

135

136

139

3.17 3.06 3.30

3.5

3.12

3.42

Electrolyte
Na

mEq/L
3.5-5.5

mEq/L
95-106

Cl

99.7

97.5

102

106

107.2

20

25

24

23

20

22

mEq/L
2.84.9

Phos

90

mEq/L
22-30

CO2

5.2

mEq/dL

Renal Relate

60

61

BUN

7-18 mg/dL

SCr

37

32

34

0.6-1.2

5.71 5.46 5.32 5.1

4.36

4.75

4.5-5.9

3.69 3.41

mg/dL

44

40

40

Hematology
6

RBC

10 /L
12.3-15.3

Hb

9.8

9.2

g/dL
36.0-45.0

Hct

29.5 27.6

Patient Data Record Form

Date

19

20

21

22

23

180

170

160

160

160

90

90

90

90

90

Intake

1500

3800

Output

2900

2200

Systoli

24

25

26

170 180

170

BP

Diastol

80

90

90

ic

Order for Continue

Drug/Dosage regimen
CaCO3 1.25 g

Administratio 19 20 21 22 23 24 25 2
n

1*1 O pc

A:

61

62

Chronic renal failure

,
BUN Cr proteinuria

Creatinin clearance CockcrofGault equation ClCr = 20.6 ml/min Stage 4

hyperphosphatemia

hyperphosphatemia

Ca correct = (4-Alb)*0.8+Ca= (4-3.4)*0.8+ 9.1

Ca*Phos

= 9.58*5.2

= 9.58 mEq/L

= 49.81

KDOQI guideline CaCO3

phosphate binder

0.5-1.5 g (Max 3 g ) tid with meal

phosphate

1.25 g/day

Metabolic acidosis Anion gap =

125 -( 90+20)= 10 mmol/L NaHCO3 HCO3

-

deficit = 0.5 x BW(kg) x ((HCO3 desired) - ( HCO3 measured))

= 0.5(106)(22-20)=106 mEq
-

CO2 22 mEq/L HCO3 106 mEq

-

53 mEq HCO3

300 mg HCO3 3.6 mEq

Sodamint 4x3 O pc bicarbonate
HCO2

62

63

P :

Therapeutic plan :
Sodamint 4x3 O pc
Caco3 1*1 Opc

Goal :

PO4 2.84.9 mEq/dL

CO2 22-30 mEq/L

Therapeutic monitoring :
- CO2

- PO4

-
2

ADRs

monitoring :

CaCO3

PO4, Calcium, Constipation, stomach cramps, nausea,

NaHCO3
vomiting,

HCO3 , metabolic alkalosis, pulmonary edema

Patient education :

-
-
1 g/day

- 8 /

63

64

30 3 /
Future plan :

- electrolyte (HCO3 )

1. Wells BG, DiPiro JT, Schinghmmer TL and Hamilton

th

CW. Pharmacotherapy Handbook. 6 ed. Mc Graw Hill ;

2006.

2. . . 7.
. ; 2548.

3. Tatro DS. Drug interaction facts 2007. Wolters Kluwer;

2007.

4. David NG, Robert CM, George ME, et al. The Sanford

th

guideline to antimicrobial therapy 2009. 39 ed.

Sperryville: antimicrobial therapy; 2006.

5. Kasper DL, Fauci AS, Longo DL, Braunwald E, Hauser

SL, and Jameson JL. Harisons Principles of Internal
th

Medicine. 16 ed. Mc Graw Hill; 2005

6. Lacy CF, Armstrong LL, Goldman MP, Lance LL. Drug

th

Information Handbook. 17 ed. Lexi-Comp; 2009.

7. The Seventh Report of the Joint National Committee on

Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure. JAMA 2003;289:256071.

64

65

65

66

Cost effectiveness of COX 2 selective inhibitors and

traditional NSAIDs alone or in combination with a
proton pump inhibitor for people with osteoarthritis.

Objective: cyclooxygenase-2 (COX 2)

selective inhibitors traditional non-steroidal anti-inflammatory

drugs (NSAIDs) proton pump inhibitor

osteoarthritis

Design : Markov model

Systematic review.

RCT 3
Observational

Western Ontario and McMaster

Universities (WOMAC) osteoarthritis index score ( meta- analysis)

osteoarthritis Subgroup analyses

Comparator : COX 2 selective inhibitors (celecoxib etoricoxib)

traditional NSAIDs (diclofenac, ibuprofen, and naproxen)

Paracetamol proton pump inhibitor (omeprazole)

66

67

Main outcome measures : cost - efectiveness quality adjusted

life years gained Quality adjusted life year scores
efficacy

major adverse events (dyspepsia; symptomatic ulcer;

complicated gastrointestinal perforation, ulcer, bleed; myocardial

infarction; stroke; and heart failure)

Results : proton pump inhibitor COX 2 selective

inhibitors traditional NSAIDs cost efective (incremental

cost efectiveness ratio 1000 (1175, $1650).

PPI

(incremental cost efectiveness ratio 10 000)

COX 2 selective inhibitor traditional NSAID

Conclusion: proton pump inhibitor Osteoartitis

traditional NSAID COX 2 selective inhibitor
Cost-efective

traditional NSAID COX 2 selective inhibitor

67

68

Introduction
osteoarthritis Traditional
non-steroidal anti-inflammatory drugs (NSAIDs)

cyclo-

oxygenase-2 (COX 2) selective inhibitors.

osteoarthritis United kingdom NSAID

COX 2 selective inhibitor.

2007 COX 2

selective agents traditional NSAIDs COX2 selective

Inhibitors celecoxib and etoricoxib
5.8% NSAIDs 20%
traditional

NSAIDs

COX 2 selective inhibitors

traditional NSAIDs

gastrointestinal side efects COX 2 selective Inhibitors

gastrointestinal side efects
cardiovascular safety

National Institute for Health and Clinical

Excellence clinical guidance for the management of osteoarthritis

cyclo-oxygenase-2 (COX 2) selective inhibitors

osteoarthritis rheumatoid arthritis
serious
NSAIDs

gastrointestinal adverse events traditional

guildeline

gastroprotactive cyclo-oxygenase-2 (COX 2) selective

inhibitors

National Institute for Health and

Clinical Excellence guidance

adverse events
gastroprotection

68

69

proton pump inhibitor

National Institute for Health

and Clinical Excellence clinical guidance

Traditional non-steroidal anti-inflammatory drugs
(NSAIDs)

cyclo-oxygenase-2 (COX 2) selective inhibitors

Gastroprotactive Osteoartitis
Methods

- National Institute for

Health and Clinical Excellence clinical guidance

quality adjusted life years

healthcare

payer NHS England Wales.

Comparator

NSAIDs
RCT

RCT

the celecoxib long-term arthritis safety study (CLASS), the

therapeutic arthritis research andgastrointestinal event trial (TARGET)

multinational etoricoxib and diclofenac arthritis longterm

(MEDAL) study CLASS MEDAL rheumatoid

arthtitis

guideline

69

70

National Institute for Health and Clinical Excellence Osteoarthritis

Guideline

osteoarthritis rheumatoid arthritis

arthritis 1
CLASS, TARGET, MEDAL COX
2 selective inhibitors (celecoxib and etoricoxib)

traditional NSAIDs (diclofenac, ibuprofen, and naproxen)

80% ,

, paracetamol proton
pumpinhibitor (omeprazole) NSAIDs
NSAIDs

Model Design

70

71

economic model
Model Design parametors 2, 3, 4

model

gastrointestinal cardiovascular adverse

events Osteoarthritis

71

72

Clinical
dyspepsia; symptomatic ulcer; complicated
gastrointestinal perforation, ulcer, or bleed; myocardial infarction;
stroke; and heart failure

age specific
cardiovascular
gastrointestinal adverse events

Dyspepsia

COX 2 selective inhibitors traditional NSAIDs

PPI
paracetamol

cardiovascular gastrointestinal adverse events

Patient population

55 baseline risks of 21 and 42 per 10 000

person years serious gastrointestinal cardiovascular

72

73

events 65 (relative risks 2.96 and

1.94 for gastrointestinal and cardiovascular events, )
Adverse event

CLASS, TARGET

MEDAL study

traditional

NSAIDs ( )
COX 2 selective inhibitors

dose relate
OA

ADV RCT

ADV RCT

55 2
probabilistic sensitivity analysis

PPI Traditional NSaids Cox 2

Meta analysis trail

Traditional NSaids
Cox 2 ( 2)

73

74

Costs

NHS

( 2) ( 4) GI ADV
Healthcare Resource Group codes and average length

of stay Department of Health reference costs

Unit
cost CVD-ADV GI AVD
the Healthcare Resource Group and average length of
stay reference cost data, National Institute for Health and Clinical

Excellence clinical guideline for hypertension.

British National Formulary

3.5 %

the National Institute for Health and Clinical

Excellence
Quality of life weights

The Western

Ontario and McMaster Universities (WOMAC) osteoarthritis index

Meta-analysis total WOMAC scores

quality of life utility weights

Meta-analysis

traditional Nsaids Coxc2 inhibitor

traditional
Nsaids Coxc2 inhibitor

ADV ( 4 ) traditional Nsaids Coxc2

inhibitor Paracetamol

74

75

short-term (3 ) MI HF
Stroke

traditional Nsaids Coxc2 inhibitor

HF utility score

Health Survey for England

Sensitivity analysis

observational data sensitivity analyses

model. sensitivity analyses 5.

Results

75

76

76

77

1 quality adjusted life years costs

11 3

PPI traditional Nsaids Coxc2 inhibitor

quality adjusted life years cost
(

) PPI Cost 1000 (1175 ,

$1650 ) quality adjusted life years low

risk GI ADV
PPI

Incremental cost 20000 quality adjusted life years

Cost-efective

Cost-efectiveness 6
Celecoxib 200

77

78

mg PPI Incremental cost 1000 quality adjusted

life years low risk high risk

78

79

2 Celecoxib 200 mg PPI

Cost-efectiveness 50 % threshold of
30 000 per quality adjusted life year

Celecoxib 200 mg PPI ibuprofen 1200 mg plus a

proton pump inhibitor incremental cost efectiveness 30
400 21 000 quality adjusted life year gained
55 65

CVD-ADV

CLASS casts celecoxib

etoricoxib

stroke

celecoxib 200 mg 10/10000 MEDAL

study

etoricoxib 30 mg stroke

24/10000

MEDAL study stroke risk cox 2

etoricoxib PPI Cost-efectiveness

Traditional Nsaids
ADV ( 1 2 )
CVD , GI ADV (

65 ) Traditional Nsaids Cost- efective

paracetamol PPI

quality

79

80

adjusted life year

gained OA

Tradional Nsaids ADV ( 1)

Discussion

PPI traditional Nsaids Cox -2 inhibitor low

risk GI- ADV
PPI

Nsaids
cost- efective

PPI RR GI-ADV 0.98

threshold 20000 quality adjusted life year

PPI COX -2 Cost

efective Traditional Nsaids

GI ADV

COX 2

GI ADV
ADR

traditional Nsaid

cox 2 Cost efective

Cox 2

( 65 ) paracetamol

traditional nsaids PPI COX2

low risk traditional nsaids cox2
PPI paracetamol

traditional nsaids cox2

80

81

Cox2

traditional nsaids

GI,
CVD-ADV PPI

traditional nsaids cox2

PPI traditional nsaids

cox2 Cost efective

OA Low risk

CVD COX 2 PPI

OA

CVD COX 2
Cox 2 cox- 2
NSaids

traditional nsaids cost-efective COX 2

OA CVD

RCT

CVD, GI
ADV traditional nsaid cox 2 PPI

81

82

ADV

RCT

PPI hip

fracture

Conclusion

NSAIDs COX 2 OA PPI

Cost efective Cox 2 PPI

AVD

Founding : The National Institute for Health and Clinical Excellence

commissioned and funded this analysis

Competing interests: All authors were members of the National

Institute for Health and Clinical Excellence Osteoarthritis Guideline
Development Group

82

83

Ethical approval: Ethical approval was not required for this research

1.

Cost effectiveness of COX 2 selective

inhibitors and traditional NSAIDs alone o

in combination with a proton pump

inhibitor for people with osteoarthritis

2.

Nicholas Latimerg
health economics

Joanne Lord, health economics

Robert

Grant,

senior

technic

adviser,medical statistician

Rachel OMahony, research fellow

John Dickson, community physician

rheumatology
Philip

Conaghan,professor

musculoskeletal medicine

83

84

The National Institu

for

Health

and

Clinical

Excellenc

Osteoarthritis Guideline Development Grou

3.

British

Medical Journal

Impac
factor (2008) : 12.827
4.

cyclooxygenase-2 (COX 2) selective

inhibitors traditional non-steroidal anti

inflammatory drugs (NSAIDs)

proton pump inhibitor
osteoarthritis

Objectiv

5.

6.

1.

Review

65

55

84

85

2.

3.

4.

RCT

Systematic review

RCT

Review

5.

Cox 2 selective inhibito

Cox 2 selective

inhibitor PPI Cost-

85

86

efective
6. (
)

7.

8.

OA

RCT

CVD, GI ADV

traditional nsaid co

2 selective inhibitor PPI

RCT

86

87

7.

PPI Hip
fracture

8.

ve

9.

NSAIDs

subjecti

10.

PPI NSAIDs
Osteoartritis

11.

( 1- 10
)

87

88

1. Patient care round

08.00-12.00 .

88

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2. Medication conciliation

3.

4.

5.

6. Warfarin

7.

8. Academic in service
9. Journal club
10.

89

90

1.

2.

3.

90

91

91