Soap DM Thyroid

1
Patient Profile
58 170 . 68 .
CC:
HPl:
PMH:
MH:
Glucophage XR
tab BID pc
60 tab
Actosmet
1 tab OD pc
60 tab
Amaryl (2)
1 tab OD ac
60 tab
Amlodipine (5)
1 tab OD pc
60 tab
HCTZ (25)
tab OD pc
30 tab
Livalo (2)
1 tab OD hs
30 tab
(750)
ALL: NKDA
PE : DMT2 , HTN , DLP
Lab :-
Problem list : Diabetes type II DRP with Drug interaction

and improper drug selection
S:O:A:
(Causes of Diabetes)

4
1. 1 (type 1 diabetes mellitus,
T1DM)
T2DM)
3. (other specific
types)
4. (gestational diabetes
mellitus, GDM)
1.
2.
3.
4.
5.
6.
4
1.

200 ./.
2.
8 (FPG) > 126 ./.
3. (75 g Oral Glucose Tolerance

Test, OGTT) 2 > 200
./.
4. hemoglobin A1c (HbA1c)
6.5%

(NGSP certified and standardized to
DCCT assay)

1
1
*** HbA 1c
standardization quality
control HbA1c

HbA 1c 6.0-6.4% 2550%
2
1

1

2

***
sulfonylureas DM Type 1
DM Type 2

1.
2.
3.
4. 140/90 mmHg
5. HDL 35 % TG
250 .%
6.
4
7. HbA1c>5.7
IFG IGT
8.
9.
BMI = 68/1.7^2 = 23.52

cohort study2

1
(risk
score)
( 12 )
(
++)
*** 9
9
3
2
*** 9
12
20%
Assessment of therapy
1 2
*** 3
Metformin(Glucophage) , Pioglitazone(Amaryl) ,
Glimerpiride+Metformin (Astosmet)
IESAC Sulfonylurea
sulfonylurea
glimerpiride
Indication
Efficacy
Safety
Adherance
glipizide
Anti-diabetics
Bioavailability : 100%
Excretion : urine 60%
excretion : urine 63-90%
1-2mg PO qAM after
5mg PO qDay before
Protein bound : 99.5%
breakfast or with first
Protein bound : 99%
breakfast or with first meal
meal ; may increase dose
by 1-2mg every 1-2 weeks

; not to exceed 8mg/day
Cost
0.20
***
Glimerpiride(Amaryl)
glipizide
UC
IESAC Thiazolidinedione
Thiazolidinedione
pioglitazone
Indication
Efficacy
Safety
rosiglitazone
Anti-diabetics
Protein bound : >99%
Excretion : urine 15-30%
Adherance
15-30mg PO with meal
4 mg PO qDay or divided
qDay initial ; may increase
q12 hr
dose by 15mg with careful

monitoring to 45 mg qDay
maximum
Cost
2.2
64.80
*** Thiazolidinedione
rosiglitazone
hypertention
rosiglitazone
Ref :
1. http://dmsic.moph.go.th/dmsic/index.php?
p=1&type=3&s=3&id=middle_drug
2.
http://dmsic.moph.go.th/dmsic/admin/files/userfiles/files/essentia
l_book_56.pdf
3.
Plan (P)
Goal :
Short term goal :
HbA 1c 7.0-7.5
%
Long term goal : HbA1c 2-6

Treatment therapy:
Metformin(750) tab BID pc
glipizide 5mg
PO ac
Actosmet 1 tab OD pc
Therapeutic Monitoring : HbA 1c 7.0-7.5
%
ADRs/Toxic Monitoring :
Metformin : , , ,
Glipizid :
Pioglitazone :

Patient education:

Future plan: progress note

-

albuminuria (microalbuminuria)
urine albumin/creatinine ratio 1 12

1
2 (1 45 .
120 . 330 .)

- HCTZ
drug interaction
3
Calcium Chanel Blocker
Problem list 2 Hypertention DRP with Adverse drug reaction and

drug interaction
S:O:A:
Assessment(A)
(Etiology)
Hypertension
140/90 mmHg

pheochromocytoma
primary aldosteronism 2

, cocaine, amphetamine, steroids, non-steroidal anti

inflammatory drugs (NSAIDs), pseudoephedrine

1.
/
.
/
/
2.
()
. .
.
3.

.

4.
5.

6.

7.
8.

18
(Symptoms)

1
Treatment
***
Thiazide ACEI ARB CCB
guildline Amlodipine
+HCTZ HCTZ Hyperglycemia

HCTZ Antidiabetic agent

ARB
IESAC
Losartan
Indication
Efficacy
Bioavailability
Bioavailability
Bioavailability
: 25%
: 25%
: 15%
bound : 98%
bound : 94-
bound : >99%
4%
Excretion :
26%
Excretion :
Adherance
Candesartan
Anti-hypertension
Protein
Safety
Valsartan
50 mg
Protein
95%
13%
Protein
Excretion :
80-160 mg
16 mg
Cost
1.9
15.5
14.88
*** ARB
Losartan HCTZ
HCTZ interaction
anti-diabetics agent
Plan (P)
Goal :
Short term goal : SBP < 140
mmHg DBP < 90 mmHg
Long term goal : 1. SBP <
140 mmHg DBP < 90 mmHg
2.
Treatment therapy:
Losartan : 50 mg
Therapeutic Monitoring :
SBP 140 mmHg DBP 90 mmHg

2-4

Patient education:
1. 5-6 /

1 2,000 1
500 1
140 1
490 1 400

2.
3. 30 5-7 /
4.
(Body mass index) =
18.5-24.9 ./..
5.

6.
Future plan:
1. SBP <
140 mmHg DBP < 90 mmHg 1

2.
/

- ACEI ARB (
ACEI ARB )
-
betablocker, aldosterone antagonist

Problemlist 2 : Dyslipidemia with DRP needed

therapy
Subjective data(S) : Objective data(O) : -
Assessment(A)
Etiology

(Artherosclerosis)
(cardiovascular diseases)
(coronary heart disease)
(cerebrovascular disease)
(peripheral arterial disease)
Differential diagnosis
3
1. (primary dyslipidemia)

polygenic hypercholesterolemia, familial
hypercholesterolemia (FH) familial combined
hyperlipidemia
2. (seconary dyslipidemia)
/ lipoprotein

LDL-C
hypothyroidism, cholestasis, nephrotic syndrome,
thiazides, progestogens, cyclosporine

estrogen, beta-blockers, glucocorticoids, thiazides,
protease inhibitors
HDL-C
anabolic steroids,
testosterone, progestogen, beta-blockers
3. (dietary
dyslipidemia)
LDL-C
/

***
2.
(seconary dyslipidemia

severity
3
1 LDL-C
(>200 /)
non-HDL-C nonHDL-C total
cholesterol HDL-C ( 2)
-
- Ischemic stroke carotid
artery, transient ischemic attack
- Symptomatic peripheral arterial disease
- Abdominal aortic aneurysm
LDL-C
<100 / non-HDL-C <130 /
2

2
LDL-C
-
- ( >140/90 mmHg
)
- HDL-C (< 40 ./)
-

55 , 65
- 45 ,
55
LDL-C <130
/ non-HDL-C <160 /
3

0-1
2 LDLC <160 / non-HDL-C <190 /
2 3 HDL-C >60
/ 1
***

2
- ( >140/90 mmHg
)
- 45
***non-HDL-C = 177
non-HDL-C <160 /
ASCVD
Cause of problems and Risk factors
-
-
-

, ,
*
Treatment
***
2 40-75
Statin (high-intensity statin 10-y
ASCVD risk 7.5%
ref
http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx
***
2 40-75
Statin (high-intensity statin 10-y
ASCVD risk 7.5%
Rosuvastatin 20 mg
Rosuvastatin 40 mg
IESAC
Pitavastatin
Indication
Efficacy
Simvastatin
Anti-lipidemia
2 mg PO OD
10-20 mg PO
OD
Back pain
Diarrhea
UTI ,CPK
,Myopathy
s,
LN)
is
,UTI
,Transaminases
al pain
LN)
4 mg
Safety
Atorvastatin
,Joint pain
40 mg PO OD
,Nasopharyngiti elevation(>3xU
,Rhabdomyolys Arthralgia
,Flatulence
,Hyperglycemia ,Musculoskelet increased(>3xU

Adherance
PO
PO
PO
Cost
27.7
21.5
**** IESAC Pitavastatin

Simvastatin Pitavastatin
UC
Pitavastatin
simvastatin
simvastatin
pitavastatin
Plan (P)
Goals :
Long term goal :
Drug Treatment :
- Simvastatin 40mg/day 1
ref(http://www.nephrothai.org/nephrothai_boffice/images
_upload/news/441/files/final_
%E0%B8%84%E0%B8%B9%E0%B9%88%E0%B8%
A1%E0%B8%B7%E0%B8%AD_ckd_2015.pdf)
Therapeutic mornitoring :
LDL
100
mg/dl
Total Cholesterol <200 mg/dl

HDL
60
mg/dl
Triglyceride < 150
mg/dl
High-intensity
statin LDL
50
baseline
Safety mornitoring :
-
UTI ,
-
CPK elevation(>3xULN) ,Flatulence
,Transaminases increased(>3xULN)
Patient education :
-

-
Future plan :
2
Patient Profile
28 162 . 55 .
CC: HPl: PMH: MH:
1.
Euthyrox (100)
tab OD pc
Levothyroxine
2.
Prednisolone (5)
30
tab
1 tab pc AM, tab pc PM
30
tab
3.
Caltrate-D (1500)
1 tab OD pc
calcium
1
bottle
carbonate/vitamin
D3
4.
Fluoxetine (20)
1 tab OD pc
3
strip
5.
Nexium
tab OD hs
(40)Esomeprazole
6.
Zigacal Ultra
2
strip
1-2 tab prn
(1000)ca carbonate
20
tab
ALL: NKDA
PE : hypothyroidism (secondary), adrenal insuff. (secondary)
Lab :-
problem list
1.Hypothyroidism DRP with unnecessary drug
with drug interaction (levo-calcium
S :O : hypothyroidism (secondary), adrenal insuff. (secondary)
A :
Etiology
Hypothyroidism ()

0.3% overt
hypothyroidism 4.3% subclinical hypothyroidism
the United States National Health and Nutrition
Examination Survey (NHANE III)
1. Primary hypothyroidism
2. Secondary hypothyroidism
hypothalamus
Symptoms
(hypothyroidism)
:
o
(Lack of energy)
()
(muscle cramps & stiffness)
1. Hyperthyroidism

2. Hypothyroidism

2
1.
/ (Primary
hypothyroidism)
2.
/
(Secondary hypothyroidism)
IESAC
Levothyroxine
Indication
Efficacy
hypothyroidism
Bioavailability :
Bioavailability :
80%
95%
2-3
T3
T3
T3
24
Angina pectoris ,
Tachycardia ,
Congenstive heart
Hypotension,
Half life : 9 day

Safety
Liothyronin
Half life : 1

T3
failure ,Flushing ,
Myocardia
Myocardial
infraction,
infraction
Cardiopulmonary
arrest
Adherance
Cost
0.56
2-3
levothyroxine
sodium
total
body scan
IESAC
Ref: http://www.chatlert.worldmedic.com/docfile/hypothyroidism.doc
***** IESAC
Levothyroxine

T3 T3

Liothyronin
T3
24 T3

Plan (P)
Goal :
Short term goal :
1. thyroid hormones
Long term goal :
1. thyroid hormones
2.

Hypothyroidism
Treatment therapy:
1. TSH
2. T3
1. Levothyroxine
Calcium carbonate calcium
carbonate levothyroxine
2. Levothyroxine adrenal insufficiency
ref : drug inform 20th edition p.956

3. Angina pectoris
, Congenstive heart failure ,Flushing , Myocardial infraction
Patient education:
1.

2.
3. amiodarone
4.

hypothyroidism
Future plan : pharmacist note
Fluoxetine
levothyroxine calcium carbonate

4

problem list
2. Adrenal insuff with DRP

Subjective (S) : Objective (O) : hypothyroidism (secondary), adrenal insuff.
(secondary)
Assessment(A)
(Etiology)
Adrenal insufficiency

adrenal crisis
adrenal insufficiency
primary secondary adrenal insufficiency
1. Primary adrenal insufficiency ( Addisons disease )
Autoimmune adrenalitis
( idiopathic)
70-80

primary AI (isolated)
( polyglandular autoimmune syndrome )
2. Secondary adrenal insufficiency

hypopituitarism

(Sheehans
syndrome)

craniopharyngioma
lymphocytic hypophysitis, sarcoidosis,
histiocytosis X
3. Tertiary adrenal insufficiency

AI
corticotropin
releasing hormone (CRH) ACTH
cortisol

Ref : http://www.chatlert.worldmedic.com/docfile/ai.doc
(Symptoms)
secondary AI
hyperpigmentation plasma ACTH pale skin
Cushings syndrome
1. Primary adrenal insufficiency ( Addisons disease )

Autoimmune adrenalitis
( idiopathic)
70-80

primary AI (isolated)
( polyglandular autoimmune syndrome )
2. Secondary adrenal insufficiency

hypopituitarism

(Sheehans
syndrome)

craniopharyngioma
lymphocytic hypophysitis, sarcoidosis,
histiocytosis X
3. Tertiary adrenal insufficiency

AI
corticotropin
releasing hormone (CRH) ACTH
cortisol

Ref : http://www.chatlert.worldmedic.com/docfile/ai.doc
**** Secondary

1. glucocorticoid
2. sepsis
3. surgical stress
4. anticoagulation
5. adrenal hemorrhage meningococcemia,
pseudomonas a. (Waterhouse-Friderichsen syndrome)
secondary tertiary AI
glucocorticoid prednisolone ( 5mg. )
5-7.5 mg. 1
3 dexamethasone 0.5
mg.
IESAC
Prednisolone
dexamethason
e
Indication
Efficacy
Secondary adrenal insufficiency

duration 18-36 hr
Half life : 1.8 -3.5
91%
Metabolism : liver
protein binding 65Metabolism primary

hepatic
Half-life 3.6 hr
hr
excretion prmary
urine
Safety
Acne , Adrenal
Acne , Adrenal
suppression DM, GI
suppression, Cardiac
ulcer ,Hypokalemic
perforation , Peptic
,Osteoporosis ,
Osteoporosis, weigh
perforation , Peptic
alkalosis
weigh gain ,
arrest ,DM,GI
ulcer ,Moon face,

gain , Pituitary
Pituitary adrenal axis adrenal axis

suppression
suppression
Adherance
PO
PO
Cost
0.3
0.12
IESAC
**** IESAC Prednisolone

Dexamethasone Prednisolone
Ref : http://dmsic.moph.go.th/dmsic/index.php?
&p=1&type=3&t=3&id=26&sch=3
Plan (P)
Goal :
Short term goal : ACTH
Long term goal :

Treatment therapy:
prednisolone ( 5mg. )
5-7.5 mg. 1
3
1.
2.

3.

4. hyponatremia, hyperkalemia
hypoglycemia & acidosis
- Adrenal suppression DM, GI perforation ,

Peptic ulcer ,Hypokalemic alkalosis ,Osteoporosis , weigh
gain , Pituitary adrenal axis suppression
Patient education:
1. steroid
2. orthostatic
hypotension
3.

4.

5.

Ref :
http://www.thaihp.org/index.php?
option=other_detail&lang=th&id=42&sub=26
http://portal.nurse.cmu.ac.th/ELearning/Lists/List/Attachments/21/endocrine2.ppt
Future plan
15
prednosolone 7.5 mg
3
Patient Profile
68 175 . 73 .
CC:
HPl:
PMH:
MH:
Rx
1.
Janumet
( sitagliptin/metfor
min HCl)
1 tab BID pc
56
tab
2.
Diamicron MR
1 tab OD pc
(Gliclazide )
3.
Utmos
tab
1 tab OD pc
(pioglitazone )
4.
Lantus Solostar
Exforge HCT
28
tab
30 unit OD
(glargine)
5.
28
28
tab
1 tab OD pc
(amlodipine,
28
tab
hydrochlorothiazid
e, and valsartan)
6.
Neurontin(Gabapen 1 cap OD hs
28
tin)
tab
ALL:Bactrim ()
PE : DMT2 w/ DN & neuropathy, HTN
Lab :-
Problem list DMT2 DRP with Sub-optimal drug

Subjective (S) -
Objective (O) : DMT2 w/ DN & neuropathy, HTN

Assessment(A)
(Etiology)

1. 1 (Type 1 Diabetes)

(beta cells)
1

2. 2 (Type 2 Diabetes)

Ref : http://www.roche.co.th/home/disease/diabetes.html
(Symptoms)
2
40
-
-
-
-
-
-
() 70-99 ./. 2
140 ./.
Ref : http://www.diabetescareth.com/diabetes_detail.php?
diabetesid=10

4
1.

200 ./.
2.
8 (FPG) > 126 ./.
Test, OGTT) 2 > 200
./.
6.5%

DCCT assay)

3
*** HbA 1c
control HbA1c
HbA 1c 6.0-6.4% 2550%

2
1

1

2

***** 2
2

2
-
/
-
-
-
- (HDL) 35
/ (Triglycerides)
250 /
-
*** Combination injectable

therapy 3 sitagliptin/metformin
(Janumet ) , Gliclazide (Diamicron MR ) , Pioglitazone
(Utmos
) Glagine ( Lantus Solostar)
IESAC glucosidase inhibitor

acarbose
Indication
Efficacy
voglibose
Anti-diabetics
Bioavailability :
<2%
Excretion : urine
34%
Safety
Adherance
25 mg
0.3 mg
Cost
6.05

*** Bactrim(Cotrimazole)
sulfonamide Diamicron MR
(Gliclazide)
sulfonamide glucosidase inhibitor acarbose

IESAC Thiazolidinedione
Thiazolidinedione
pioglitazone
rosiglitazone
Indication
Anti-diabetics
Efficacy
30%
Safety
Excretion : urine 15-
Adherance
15-30mg PO with meal 4 mg PO qDay or

qDay initial ; may
increase dose by 15mg

with careful monitoring
to 45 mg qDay
maximum
divided q12 hr
Cost
2.2
64.80
*** Thiazolidinedione
rosiglitazone
hypertention
rosiglitazone
IESAC DPP-4 inhibitor
sitagliptin
Indication
Efficacy
vildagliptin
Anti-diabetics
Bioavailability :
Bioavailability :
87%
87%
38%
9.3%
87%
85%
Protein bound :
Excretion : urine
Safety
Protein bound :
Excretion : urine
Adherance
100 mg once daily
100 mg once daily
Cost
45.52 /
21.78 /
vil >>
http://www.ema.europa.eu/docs/en_GB/document_library/EPAR__Product_Information/human/000771/WC500020327.pdf
sita >> drug information 1927
*** IESAC Vidagliptin

Galvumet
(Vidagliptin + metformin)
Plan (P)
Goal :
Short term goal :
HbA 1c 7.0-7.5
%

Treatment therapy:
acarbose (25) 1X3 pc

pioglitazone 1 tab OD pc
Galvumet (50/1000) 1 tab BID pc
Lantus Solostar 30 unit OD
Therapeutic Monitoring : HbA 1c 7.0-7.5

%
acarbose :
pioglitazone :
Galvumet :
Lantus Solostar : Hypoglycemia
Patient education:
-
-
5
-
- hypoglycemia
3 , 180 . , 180
. , 3 , 1 , 240 . ,
2 , , 1

15-20
- insulin
- Abdominal , arm , hip , thigh
- insulin
- (2-8 oC)
-

1
Future plan: pharmacist note
-


1
2 (1 45 .
120 . 330 .)

Problemlist 2 : Hypertention with DRP drug

interaction
Subjective (S) Objective (O) : DMT2 w/ DN & neuropathy, HTN
Assessment(A)
(Etiology)
Hypertension
140/90 mmHg

pheochromocytoma


9.
/
.
/
/
10.
()
. .
.
11.
12.
13.

14.
15.
16.
18
(Symptoms)

1
Treatment
*** Exforge HCT combination

3 1. Amlodipine ( CCB) 2.
HCTZ( Thiazide) 3. valsartan ( ARB)
HCTZ( Thiazide)

pioglitazone (Utmos)
Exforge HCT
HCTZ valsartan ( ARB)

Amlodipine
Plan (P)
Goal :
mmHg DBP < 90 mmHg
2.
Treatment therapy:
Valsartan : 80-160 mg
Amlodipine : 5 mg
SBP 140 mmHg DBP 90 mmHg
2-4
Valsartan :

Amlodipine :
Patient education:
1. 5-6 /

1 2,000 1
500 1
140 1
490 1 400

2.
3. 30 5-7 /
4.
(Body mass index) =
18.5-24.9 ./..
5.

6.
Future plan:
1. SBP <

2.
/

- ACEI ARB (
ACEI ARB )
-

4
- 65
PMH:
Degenerative joint disease (x 15 )

Hyperthyroidism (x 10 )
DM type2 (x 8 )
HTN (x 5 )
Dyslipidemia (x 5 )
MH:
Prednisolone (5) 3 tab OD

Nurofen (400) 1 tab QID prn pain
Tapazole (5) 1 tab OD
Eltroxin (100) tab OD
Humulin (70/30) 50-0-24 ac -
Galvusmet (50/1000) 1 tab OD
Crestor (20) 1 tab OD
Plendil (10) 1 tab OD
Blopress plus (8/12.5) 1 tab OD
Aspent-M (81) 1 tab OD
All:
Dicloxacillin erythema multiforme
PE:
GEN- obese, cushingoid-appearing, mild swelling and
tenderness in both knees.
VS- BP 158/96 , HR 93 regular, T 37.1, Wt 73, Ht

168, waist 97
HEENT- thin, fine hair w/ male-pattern baldness;
bilateral proptosis R>L, (+) lid lag, normal size thyroid
gland
CHEST- WNL
ABD- central obese, soft, no mass, (+) striae
GU- mild enlarged prostate gland
RECT- guaiac-negative
EXT- thin, wasted extremities, several ecchymoses;
knees warm and tender to pressure
NEURO- decreased pin prick and vibratory sensation in
lower extremities
Lab:
Na 138
108
K 3.9
HCO3 19
Cl
BUN 6.4
Scr 1.1
Hct 42%
ALT 28
Phos 68
Hgb 14
AST 25
Alk
FBS 148
TC 223
HbA1c 7.2%
HDL-C 46
TG 270
Free T4 9 pg/mL
Free T3 4.5 pg/mL
TSH 1.8 mIU/L
ClCR= 66.56 ml/min
Problemlist 1 : Diabetes mellitus with DRP noncompliance

Subjective (S) Objective (O) :
Na 138
K 3.9
HCO3 19
BUN 6.4
Hct 42%
ALT 28
Cl 108
Scr 1.1
Hgb 14
AST 25
Alk Phos
68
FBS 148
TC 223
HDL-C 46
HbA1c 7.2%
TG 270
Free T4 9 pg/mL
Free T3 4.5 pg/mL
Assessment(A)
TSH 1.8 mIU/L
(Etiology)
(Causes of Diabetes)

4
T1DM)
T2DM)
3. (other specific
types)
4. (gestational diabetes
mellitus, GDM)
Symptoms
7.
8.
9.
10.
11.
12.
4
1.

200 ./.
2.
8 (FPG) > 126 ./.
Test, OGTT) 2 > 200
./.
6.5%

DCCT assay)

3
*** HbA 1c
control HbA1c
HbA 1c 6.0-6.4% 2550%
HbA 1c 7.2%
2
1

1

2

*** 2

1.
2.
3.
4. 140/90 mmHg
5. HDL 35 % TG 250
.%
7.
4
8.HbA1c>5.7
IFG IGT
9.
10.
***

140/90 mmHg , HbA1c>5.7 ,
BMI = 73/1.68^2 = 25.86
Severity

cohort study2

1
(risk
score)
( 12 )
(
++)
*** 11
9

*** 11
12
20%
*** 2
Metformin + Vidagliptin (Galvusmet)
premix insulin ( isophane+regular )
HbA1C 7.2%( <7.0%)

FBS 148 (<126) HbA1C compliance

Plan (P)
Goal :
Short term goal :
HbA 1c < 7%

Treatment therapy:
Therapeutic Monitoring : HbA 1c < 7%
Patient education:
1. 5-6 /

1 2,000 1
500 1
140 1
490 1 400

2.
3. 30 5-7 /
4.
(Body mass index) =
18.5-24.9 ./..
5.

6.
7.
Future plan: progress note
-


1
2 (1 45 .
120 . 330 .)

insulin rapid acting
Problemlist 2 : Dyslipidemia with

DRP needed therapy
Assessment(A)
Pathology

(Artherosclerosis) (cardiovascular
diseases) (coronary heart
disease) (cerebrovascular disease)
(peripheral arterial disease)

Differential diagnosis
3

1. (primary dyslipidemia)

polygenic hypercholesterolemia, familial hypercholesterolemia
(FH) familial combined hyperlipidemia
2. (seconary dyslipidemia)
/
lipoprotein LDL-C
hypothyroidism, cholestasis, nephrotic syndrome,
thiazides, progestogens, cyclosporine

estrogen, beta-blockers, glucocorticoids,
thiazides, protease inhibitors HDL-C
anabolic steroids, testosterone,

progestogen, beta-blockers
3. (dietary dyslipidemia)
LDL-C
/

***

2. (seconary
dyslipidemia

severity
3 1

LDL-C
(>200
/) non-HDL-C nonHDL-C total
cholesterol HDL-C ( 2)
1

-
- Ischemic stroke carotid artery,
transient ischemic attack
- Symptomatic peripheral arterial disease
- Abdominal aortic aneurysm

LDL-C <100 / non-
HDL-C <130 /
2

2
LDL-C

-
- ( >140/90 mmHg
)
- HDL-C (< 40 ./)
- 55 ,
65
- 45 , 55
LDL-C <130 / nonHDL-C <160 /

3

2
0-1

LDL-C <160 / non-HDL-C <190 /
2 3 HDL-C >60 /
1
***

2

- ( >140/90 mmHg
)
- 45
***
non-HDL-C = 177 non
HDL-C <160 /

ASCVD
Cause of problems and Risk factors
-
-
-
,
,
*
Treatment
***

2
40-75 Statin (high-intensity statin
10-y ASCVD risk 7.5%
ref http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx
***

2
40-75 Statin (high-intensity statin
10-y ASCVD risk 7.5%

Rosuvastatin
20 mg
Rosuvastatin 40
mg
Plan (P)
Goals :
Long term goal :

Drug Treatment :
- Rosuvastatin 40mg/day() 1
ref(http://www.nephrothai.org/nephrothai_boffice/images_upl
oad/news/441/files/final_
%E0%B8%84%E0%B8%B9%E0%B9%88%E0%B8%A1%E0%B8
%B7%E0%B8%AD_ckd_2015.pdf)
Therapeutic mornitoring :
LDL 100 mg/dl
Total Cholesterol <200 mg/dl
HDL 60 mg/dl
Triglyceride < 150

mg/dl
High-intensity statin

LDL 50 baseline
Safety mornitoring :

Patient education :
-

-

Future plan :
Problemlist 3 : Hypertension with

DRP
S:O:PE:
GEN- obese, cushingoid-appearing, mild swelling and
tenderness in both knees.

VS- BP 158/96, HR 93 regular, T 37.1, Wt 73, Ht 168, waist
97
HEENT- thin, fine hair w/ male-pattern baldness; bilateral
proptosis R>L, (+) lid lag, normal size thyroid gland
CHEST- WNL
ABD- central obese, soft, no mass, (+) striae
GU- mild enlarged prostate gland

RECT- guaiac-negative
EXT- thin, wasted extremities, several ecchymoses; knees warm
and tender to pressure
NEURO- decreased pin prick and vibratory sensation in lower
extremities
A:
Assessment(A)
(Etiology)
Hypertension
140/90 mmHg

pheochromocytoma



1.
/
.
/
/
2.

.

3.
4.

5.

6.

18
(Symptoms)
Treatment
***
Thiazide ACEI ARB CCB
guildline
Felodipine(CCB) + candesartan cilexetil(ARB)/HCTZ

candesartan cilexetil 8 mg 16 mg
4 BP goal SBP < 140

mmHg DBP < 90 mmHg
Plan (P)
Goal :
mmHg DBP < 90 mmHg
2.
Treatment therapy:
- Plendil(felodipine)
10 mg PO OD 20 mg PO OD
- Blopress plus (8/12.5) 1 tab OD
1. SBP 140 mmHg DBP 90 mmHg
2-4
2.
3.
- ,
hypokalemia
- hypotension felodipine
Patient education:
1. 5-6 /

1 2,000 1
500 1
140 1
490 1 400

2.
3. 30 5-7 /
4.
(Body mass index) =
18.5-24.9 ./..
5.

6.
Future plan:
1. SBP <

2.
/

- ACEI ARB (
ACEI ARB )
-

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1

Problem list : Diabetes type II DRP with Drug interaction

3. (75 g Oral Glucose Tolerance

Excretion : urine 60%

excretion : urine 63-90%

1-2mg PO qAM after

5mg PO qDay before

Protein bound : 99.5%

breakfast or with first

Protein bound : 99%

breakfast or with first meal

meal ; may increase dose

by 1-2mg every 1-2 weeks

Protein bound : >99%

Excretion : urine 15-30%

Protein bound : >99%

Excretion : urine 64%

15-30mg PO with meal

qDay initial ; may increase

dose by 15mg with careful

Short term goal :

Future plan: progress note

Problem list 2 Hypertention DRP with Adverse drug reaction and

, cocaine, amphetamine, steroids, non-steroidal anti

HCTZ Antidiabetic agent

SBP 140 mmHg DBP 90 mmHg

Problemlist 2 : Dyslipidemia with DRP needed

<100 / non-HDL-C <130 /

,Hyperglycemia ,Musculoskelet increased(>3xU

**** IESAC Pitavastatin

Total Cholesterol <200 mg/dl

Triglyceride < 150

CPK elevation(>3xULN) ,Flatulence

1 tab pc AM, tab pc PM

1-2 tab prn

(muscle cramps & stiffness)

Half life : 9 day

ref : drug inform 20th edition p.956

levothyroxine calcium carbonate

2. Adrenal insuff with DRP

( polyglandular autoimmune syndrome )

2. Secondary adrenal insufficiency

3. Tertiary adrenal insufficiency

1. Primary adrenal insufficiency ( Addisons disease )

( polyglandular autoimmune syndrome )

2. Secondary adrenal insufficiency

Secondary adrenal insufficiency

Half life : 1.8 -3.5

protein binding 65Metabolism primary

ulcer ,Moon face,

Pituitary adrenal axis adrenal axis

Long term goal :

- Adrenal suppression DM, GI perforation ,

Problem list DMT2 DRP with Sub-optimal drug

Objective (O) : DMT2 w/ DN & neuropathy, HTN

HbA 1c 6.0-6.4% 2550%

*** Combination injectable

) Glagine ( Lantus Solostar)

IESAC glucosidase inhibitor

Protein bound : >99%

Excretion : urine 64%

Excretion : urine 15-

Protein bound : >99%

15-30mg PO with meal 4 mg PO qDay or