561551IntroductiontoPharmaceuticalCareClerkship

. 4750332

90 Admissiondate:2/1/52

7/1/52

CC:.14
HPI:2 .
pneumonia ceftriaxone+PGS refer .
PMH:COPD
All: Nodrugandfoodallergy
FH:
SH:
PE:

V/S :T38.3CBP148/94mmHgPR106/minRR28/min
G/A :Athaimale,normalconscious

HEENT:notpale,nojx

Heart:normals1s2,nomurmur

Lung :crepitationwithExpiratorywheezingbothlung

ABD :soft,nottender,noguarding,activebowelsound

Ext :bothhandedema,pittingedemabothlegs

LaboratoryData:
Labs
normal
Na(mEq/L)
136144
K(mEq/L)
3.55.1
Cl(mEq/L)
98106
CO2(mEq/L)
2229
BUN(mg/dl)
718
Cr(mg/dl)
0.81.3
Hb(g/dl)
1318
Hct(%)
4052
3
Plt(x10 /UL)
140400
3
WBC(x10 /UL)
510
Neutrophil(%)
4075
L/M/E
2050/210/16
T.prot
6.48.2
Albumin(g/dl)
3.45
AST(U/L)
<35IU/L
ALT(U/L)
<35IU/L
ALP(U/L)
51136
T.bili(mg/dl)
0.11.2
D.bili(mg/dl)
00.3

2/1/52
132L
3.3L
93
28
12
0.9
9.8L
30L
249
5.2
H80.2
7.1/6.3/6.2
6.4
2.5L
30
23
76
0.27
0.1

6/1/52
132L
4.9

27
0.9

. 4750332

561551IntroductiontoPharmaceuticalCareClerkship

Micro:
U/A(2/1/52):
Color
:yellow

Sp.gr
:1.020
PH
:5.0

Leucocyte :negative
Nitrite
:negative

protein
:trace
Sugae
:negative

ketone
:negative
Urobilinogen :negative

blood
:negative

RBC
:

WBC
:23/HP

SqEpi.
:01cell/HP
Bacteria
:01cell/HP
Hyacast
:01cell/HP
Urine(MSU,void)[report3/1/52]
Aerobicculture
Nogrowthafterday2
Sputum()[report3/1/52]
Gramstain
o Leukocyte
:few
o Epicell
:moderate
o Grampositivecocci(cluster) :moderate
o Grampositivecocci(chain) :few
o Grampositivecocci(inpaiar) :few
o Gramnegativebacilli
:few
o Yeastwithbudding&pseudohyphae:few
Aerobicculture
1. Moderateyeast
2. Moderatecoagulasenegativestaphylococci
3. ModerateStreptococcusgr.D(notenterococcus)

Vitalsign:
Vitalsign
Tmax
BP
HR
RR

2/1/52
38.3
127/57
106
28

3/1/52
38
116/74

4/1/52
37.3
118/67

5/1/52
38.6
119/72

6/1/52
37.3
108/74

7/1/52
36.8
166/93

561551IntroductiontoPharmaceuticalCareClerkship

. 4750332

Medicationdata:
Drug/dose/route
2/1/52 3/1/52 4/1/52 5/1/52 6/1/52 7/1/52
Ventolin(1:3)NBq4h
x
x
x

3
Furosemide(40)mgstat
x
x

KCl30mlq4hxII
x

3
3
3
Therodur(200)1x2pc

3
3
3
3
3
3
Paracet1tabprnq4h
3
3
Bromhexine1x3pc
off

Sulperazone2gIVq12h
D1
D2
D3

3
BD(1.2:1)200mlX4feed

3
3
3
3
3
BD(1.2:1)300mlX5feed

Cefotaxime1gIVq4h

D1
D2
D3
D4
PGs2mUq6h

D1
D2
D3
D4
3
3
3
3
Roxithromycin1tabBID

3
3
3
3
Bisolvon1x2

3
3
3
3
Ventolin1x2q6h

3
Dexamethasone(5)IVq12

0ff

3
3
3
Prednisolone(5)2x3pc

3
3
3
Buradual(1:3)NBq4h

3
Aminophylline1tabTFq12h

0ff

3
3
Aminophylline1tabTFq8h

Problemlists:
1. CommunityAcquiredPneumonia(CAP)[3/1/52]
2. R/OCongestiveHeartFailure
3. COPD

. 4750332

561551IntroductiontoPharmaceuticalCareClerkship

SOAP NOTE: Community Acquired Pneumonia (CAP) [3/1/52]

Subjective data: . 14
2 . pneumonia
ceftriaxone + PGS refer .

Objective data:
PE:
V/S
: T 38.3 C BP 148/94 mmHg PR 106/min RR 28/min
Lung : crepitation with Expiratory wheezing both lung
Laboratory Data :
Labs
Hb
Hct
Plt
WBC
Neutrophil
L/M/E

(g/dl)
(%)
3
(x10 /UL)
(x103/UL)
(%)

normal
13-18
40-52
140-400
5-10
40-75
20-50/2-10/1-6

2/1/52
9.8
30
249
5.2
H 80.2
7.1/6.3/6.2

Micro:
Sputum() [report 3/1/52]
Gram stain
o Leukocyte
: few
o Epi cell
: moderate
o Gram positive cocci(cluster)
: moderate
o Gram positive cocci(chain)
: few
o Gram positive cocci(inpaiar)
: few
o Gram negative bacilli
: few
o Yeast with budding & pseudohyphae : few
Aerobic culture
4. Moderate yeast
5. Moderate coagulase negative staphylococci
6. Moderate Streptococcus gr.D (not enterococcus)
Vital sign :
Vital sign
2/1/52
3/1/52
4/1/52
5/1/52
37.3
Tmax
38.3
38
38.6
127/57
116/74
118/67
119/72
BP
HR
106
RR
28

6/1/52

6/1/52
37.3
108/74

7/1/52
36.8
166/93

561551IntroductiontoPharmaceuticalCareClerkship

. 4750332

Assessment:
Etiology:
Community Acquired Pneumonia (CAP)
14
3
pluritic chest pain
crepitation consolidation
CXR
Streptococcus Pneumoniae.(15-50%), Haemophillus Influenzae., virus,
M.chartarrhalis.,Mycoplasma Pneumoniae.,Legionella spp., Enterobacteriaceae spp., Staphylococcus aureus.
nasopharynx


antibiotic
crepitation CXR
2 1
antiobiotics CAP
COPD gram negative (H. Influenzae) DRSP
coagulase negative staphylococci Streptococcus gr.D (not
enterococcus) antiotics Streptococcus
Pneumoniae,DRSP, Haemophillus Influenzae, M.chartarrhalis.,Mycoplasma Pneumoniae
Assessment if therpy is indicated:
Community Acquired Pneumonia (CAP)

CAP susceptibility
coagulase negative staphylococci Streptococcus gr.D (not enterococcus)
ICU
Primary regimen :
Ceftriaxone 1 g IV q 24 h + Azithromycin 500 mg IV q 24 h
Ertapenem 1 g IV q 24 h+ Azithromycin 500 mg IV q 24 h
Secondary regimen : Levofloxacin 750 mg IV q 24 h Moxifloxacin 400 mg IV q 24 h
Assessment of current therapy:
ceftrixone 14 PGs 5
Sulperazone (cefoperazone+sulbactam) 2 g IV q 12 h Sulperazone
atypical pathogen
(3/1/52) Cefotaxime 1 g IV q 4 h ,PGs 2mU q 6 h
Roxithromycin 1 tab BID cefotaxime roxithromycin
cefotaxime S.pneumoniae. S.aureus roxithromycin atypical pathogen
2 spectrum
PGS

561551IntroductiontoPharmaceuticalCareClerkship

. 4750332

Ventolin(1:3) NB q 4 h

Plan:
Therapeutics Plan:
Cefotaxime 1 g IV q 4 h
Roxithromycin 1 tab BID
Ventolin 1x2 TID
Drug to be avoid: Goal:
1.
2. (<37.8 C) WBC

3. reversible or irreversible disease,drug-induced organ toxicity, sepsis, lung

abscess, emphyema
Therpeutics monitoring parameters:
1. Vital sign (Body temp., RR, HR)
2.
Toxicity mornitoring parameters:
Cefotaxime
:
Ventolin
: hypokalemia
Patient education:
1.

2.

Future plan:

o 2-4
o Neutrophil 4
o
o CXR 4
7-10
o 2 8
o
o
o
Hemoculture
o positive
o negative septic work up

561551IntroductiontoPharmaceuticalCareClerkship

. 4750332

References
1. . . . . ..
;2547.
2. GloverML.,ReedMD. Lowerrespiratorytractinfection. In:DiPiroJT,TalbertRL,YeeGC,MatzkeGR,
WellsBG,PoseyLM.Phamacotherapy:apathophysiologicapproach.6thed.NewYork:MCGRAWHILL
MedicalPublishingDivision;2005.p.194360.
3. SanfordJP.Sanfordguidetoantimicrobialtherapy2008.38thed.VT:Antimicrobialtherapy;2007.