Department of Pharmacy, Faculty of Medicine, University of Malaya

Clinical Clerkship Form

Student Name : Nurul Hananibt Ab Aziz (MEH150047) Preceptor Name : Miss Lee Hong Gee
: Low Wei Kent (MEH150034)

Date of admission 12/10/2018 Review of system

Name SZ Weight 24.1
(Code) (kg) Physical Assessment
RN 33935730 Height -
(m)
DOB/age 4 years old Sex Female 1. Mental Status Alert
6 months
Ward 8PA 2. Visual System Normal
Spectacles: No
Chief Complaints
3. Auditory System Normal
● Developed fever when return from hospital at Hearing aids: No
10pm
● Temperature 38-38.5C with chills and rigor not 4. Cardiovascular BP : 116/62 mmHg
resolved with paracetamol.
System Pulse : 132 / min
● Noted tachycardic after insertion of chemo
port. Volume : Good
● Pain at surgery site. Rhythm : Regular
● Reduced oral intake but tolerating bottle Chest pain : No
feeding every 4hr Capillary refill : Less than 2 secs

5. Respiratory SPO2 : 100 %

System Regular
History of Presenting Illness
6. Integumentary Body Temperature : 37.6oC
● New chemoport inserted on 10/10 System Peripheral : Warm
● Previously discharged from Ward 8PA on Specify site : Axillary
11/10
● Fever with chills and rigor not resolved with -- Skin Normal
paracetamol.
-- Skin Integrity Normal/Intact
Skin Turgor : Good
Past Medical History
-- Mouth/Oral Moist
Very severe aplastic anemia.
- 2 weekly packed cell transfusion dependent Mucosa Dentures : No
- Weekly platelet transfusion dependent
-- Hair Normal
Past Surgical History
7. Muscular Skeletal Normal
History of cracked chemoport and migrated System
chemoport catheter into the right atrium.
8. Gastrointestinal Bowel movement : 1 /day(s)
- Port and catheter removal done on 28/9 by
IR surgery System No assistance needed

9. Genito-Urinary Normal urinary pattern : 4-5

System times/day
No assistance needed
Diagnosis and Problem List
-- Perineum No Discharge
Neutropenic sepsis due to surgical site infection
Past Medication History
Drug Dose Duration
Itraconazole suspension 50mg BD 4 weeks
Tranexamic acid capsule 250mg TDS 4 weeks
Relevant Non-drug Treatment & Comments Trimethoprim - 60mg BD On Mon,
sulfamethoxazole suspension Wed, Fri for 4
● (Day 1) IV bolus NS 240ml/hr for 1 hour weeks
Phenoxymethylpenicillin 125mg BD 4 weeks
● (Day 1-Day 8) IV drip HSD5% 65ml/hr to (Penicillin V) tablet
maintain good I/O and prevent renal impairment Acyclovir tablet 200mg TDS 4 weeks

● Packed Cell and Platelet transfusion - palliative

treatment Drug Allergies
- (Day 1) -1 pooled platelet 240ml Piperacillin and Tazobactam
- (Day 2) -1 pooled platelet 240ml and 1
packed cell 360mg (15ml/kg)
- (Day 7) -1 pooled platelet 240ml Social History
- (Day 12) -1 packed cell 240ml and 1 Smoking :No
pooled platelet 240ml Alcohol :No
Drug abuse: No

Family History
Patient is dependent on parents. Patient live with parents in lift
apartment. Primary caregiver is family members and relatives.
 Ward Medication
Drug Dose Date Started Date stopped Indication
Antibiotic Medication
IV Vancomycin 720mg stat 12/10/2018 12/10/2018 Empirical antibiotic
treatment Gram positive
IV Cefepime 1.2g stat 12/10/2018 12/10/2018 Empirical antibiotic
therapy for broad spectrum
IV Vancomycin 360mg TDS 12/10/2018 17/10/2018 Empirical antibiotic
treatment Gram positive
IV Cefepime 1.2g TDS 12/10/2018 15/10/2018 Empirical antibiotic
treatment broad spectrum
IV Meropenem 965mgTDS 15/10/2018 22/10/2018 Antibiotic treatment broad
spectrum
IV Vancomycin 360mg QID 17/10/2018 22/10/2018 Antibiotic treatment Gram
positive
IV Lock Vancomycin 3mg/1.5ml 3mg Single Dose 19/10/2018 19/10/2108 Sterilize the catheter
STAT
IV Lock Vancomycin 3mg/1.5ml 3mg Single Dose 20/10/2018 20/10/2108 Sterilize the catheter
STAT
IV Clindamycin 240mg TDS 22/10/2018 - Antibiotic treatment as it
has better perfusion
LA Clindamycin 1% Gel OD 23/10/2018 - Topical treatment around
chemoport wound
Prophylaxis Medication
PO Itraconazole Suspension 50mg BD 12/10/2018 - Prophylaxis for fungal
infection
PO Tranexamic acid Capsule 250mg TDS 12/10/2018 - Prophylaxis for bleeding
tendencies
PO Trimethoprim-sulfamethoxazole 60mg BD MWF 12/10/2018 - Prophylaxis for bacterial
Suspension infection
PO Acyclovir 200mg TDS 12/10/2018 - Prophylaxis for viral
infection
Management of fever and pain
PO Paracetamol Suspension 350mg (PRN) 12/10/2018 12/10/2108 Treatment of fever
Maximum 4
doses in 24 hours
PO Paracetamol Suspension 350mg QID 13/10/2018 21/10/2018 Treatment of fever and
pain

PO Paracetamol Suspension 350mg PRN 21/10/2018 - Treat fever and pain

Other Medication
IV Promethazine 5mg PRN IV 12/10/2018 19/10/2018 Given with Platelet
bolus Transfusion to prevent
allergic reaction
IV Furosemide 10mg STAT 13/10/2018 13/10/2018 Given with Packed Cell
 bolus Transfusion to prevent
volume overload
LA Aqeous Cream BD 19/10/2018 - Treat the rashes at the back
IV Furosemide 10mg STAT 23/10/2018 23/10/2018 Given with Packed Cell
bolus Transfusion to prevent
volume overload
IV Promethazine 5mg Single Dose 23/10/2018 23/10/2018 Given with Platelet
STAT Transfusion to prevent
allergic reaction

Medication Day of admission

1 2 3 4 5 6 7 8 9 10 11 12 13 14
Antibiotic Regimen
IV Vancomycin 360mg TDS
IV Vancomycin 360mg QID
IV Cefepime 1.2g TDS
IV Meropenem 965mg TDS
IV Lock Vancomycin 3mg/1.5ml STAT
IV Clindamycin
LA Clindamycin 1% Gel
Oral Prophylaxis
PO Itraconazole Suspension 50mg BD
PO Tranexamic acid Capsule 250mg TDS
PO Trimethoprim-sulfamethoxazole Suspension
60mg BD MWF
PO Acyclovir 200mg TDS
Fever and Pain Management
PO Paracetamol Suspension 350mg QID PRN
Other Medication
IV Promethazine
IV Furosemide
LA Aqeous Cream BD
 Therapeutic Drug Monitoring
Drug / Dosage Last dose given Sample taken Plasma Comments
(date/time) (date/time) Concentration
(units)
IV Vancomycin 14/10/2018 Pre dose (15/10, 0800) ---------------- ● Pre-dose could not interpret
0000hr Post Dose (15/10,1300) 15.54 mg/dL because sample expired.
● Post Dose was below targeted
range.
● Suggest to maintain
vancomycin 380mg TDS.

IV Vancomycin 16/10/2018 Pre Dose (17/10,0800) 4.24 mg/dL ● Pre Dose and Post dose were
0000hr Post dose (17/10,1200) 13.07 mg/dL both below targeted range.
● Actual post level could be high
due to delayed sampling time.
● Suggest to change vancomycin
dose to 360mg QID starting
today (17/10) at 2400hr.

IV Vancomycin 18/10/2018, Pre Dose (18/10,1330) ----------- ● Pre Dose sample was
1000hr Post Dose (18/10,1600) 12.85mg/dL insufficient.
● Post Vancomycin level was
below target range.
● Suggest to maintain the current
vancomycin dose at 360mg
QID.
IV Vancomycin Pre Dose (22/10,0400) 8.05mg/dL ● Both Pre and Post Vancomycin
Post Dose (22/10,0930) 12.46mg/dL levels were below the targeted
ranges.
● Post Vancomycin level was
expected to be higher in view of
delayed sampling time.
● No recommendation is required
as vancomycin has been
discontinued.
 Factors that may affect disposition of drugs
Absorption In pediatrics, there is reduced intestinal transit, decrease in gastric pH and reduction bile
acid secretion. Reduced gastric pH may reduce absorption of weak bases such as
Itraconazole. Reduced intestinal transit may increase time to reach therapeutic
concentration while reduced bile acid secretion may affect absorption of lipophilic drugs.
Drugs applied topically such as Clindamycin may have higher absorption as stratum
corneum is thin.

Distribution In pediatrics, volume of extracellular water is higher. This may require dose reduction for
lipophilic drugs as the concentration increase due to low volume of distribution (Vd) and
higher dose for hydrophilic drugs. Itraconazole has high Vd and it may have different Vd
in pediatrics due to this factor. Pediatric also have lower albumin protein concentration
and thus highly protein bound drugs such as Itraconazole may have higher concentration.

Metabolism In pediatrics, the liver enzymes have very irregular pattern and this may affect drugs
metabolized by specific pathways such as sulfamethoxazole. Larger relative size of liver
also leads to increased hepatic clearance of drugs extensively metabolized in liver.

Excretion In pediatric, the larger relative size of kidney causes increased renal clearance of
medication excreted unchanged or mainly cleared in urine such as acyclovir,
trimethoprim, tranexamic acid and acetaminophen.
 Culture and Sensitivity

Date Source /sample M/organism Sensitivity Resistant

sampling
12/10 Blood culture (paediatric No growth - -
aerobic)
12/10 Blood culture (anaerobic) No growth - -
14/10 Peripheral (paediatric No growth - -
aerobic)
14/10 Peripheral (anaerobic) No growth - -
16/10 Urine No growth - -
16/10 Chemoport (paediatric Gram positive bacilli vancomycin -
aerobic) (propionibacterium
acnes)
16/10 Chemoport (anaerobic) No growth - -
17/10 stool No - -
shigella/salmonella
18/10 Chemoport (paediatric No growth - -
aerobic)
18/10 Chemoport (anaerobic) No growth - -
22/10 Chemoport (paediatric Gram positive cocci - -
aerobic) seen
22/10 Chemo port (anaerobic) Gram positive Cocci - -
seen
22/10 Chemo port (swab) Result in progress - -
25/10 Blood culture (peadriatric Result in progress - -
aerobic)
25/10 Blood culture (anaerobic) Result in progress - -

Other relevant diagnostic tests or assessments:

Date Test Result

23/10/2018 Chest Ultrasound There is ill-defined hypoechoic superficial collection seen

predominantly at lateral and superior lateral site of chemoport. The
largest collection measuring 0.9x0.8 cm. No demonstrable extension
of collection into intrathoracic region. Surrounding skin is thickened
and edematous.
Impression: Left chest wall superficial collections.
 Laboratory Results
12/10 13/10 14/10 15/10 17/10 18/10 21/10 22/10 24/10 25/10

Complete Blood Count

9
WBC 5-15 x10 /L 1.1 1 1 1.1 0.9 1.2 0.9 1.1 1.3
RBC 4.0-5.2x1012/L 4.42 3.74 4.7 4.28 4.4 3.31 3.3 5.34 3.63
Hb 110-140g/L 114 97 125 113 116 88 87 135 92
Hct 0.34-0.40 L/L 0.31 0.27 0.34 0.31 0.31 0.23 0.24 0.37 0.25
Platelets 200-450x109/L 18 46 Fibrin 31 5 Fibrin 13 19 59
clot clot
seen seen
MCV 75-87 fl 71 71 72 72 71 70 72 69 70
MCH 24-30 pg 25.8 25.9 26.2 26.4 26.4 26.6 26.4 25.3 25.3
MCHC 310-370g/L 365 365 368 369 373 381 369 367 364
RDW 11.6-14% 12.4 12.3 12.3 12 11.3 10.7 10.7 11.7 11.5
Differential Blood Count
Neutrophil % 9 4 2 10 WBC 4 6 12
too
low
for
DC
# Neutrophil 1.50-8.00x109/L 0.1 0.04 0.02 0.13 0.05 0.07 0.16
Lymphocyte % 85.6 92 96 84 86 92 82
# Lymphocyte 6.00-9.00x109/L 0.94 0.92 0.96 1.09 1.03 1.01 1.07
Monocyte % 5.4 4 2 6 4 2 6
# Monocyte 0.20-1.00x109/L 0.06 0.04 0.02 0.08 0.05 0.02 0.08
Renal Profile
Na+ 136-145mmol/L 134 136 137
K+ 3.6-5.2mmol/L 3.9 3.4 3.2
Urea 3.2-8.2mmol/L 3.6 3.2 2.8
CO2 20-31mmol/L 28 27 30
Cl- 99-109mmol/L 99 100 97
Anion Gap 10-20mmol/L 11 13 12
Scr 44-71µmol/L 19 23 19
CrCL ml/min Not available for patient under 18 years old.
Liver Profile
AST <34 IU/L 36
Tot Bilirubin <17µmol/L 17
AlkPhosph 54-369 U/L 166
Alanine 10-49 U/L 50
aminitransferase
GGT <38 IU/L 21
Albumin 32-48g/L 30
 Coagulation Profile
PT patient 9.4-12.0s 16.3
aPPT 25.6-38.4s 34.1
INR 1.5
OtherLaboratory Result
C reactive <0.3mg/dL 10 19.2 16.2 14.9
Protein (serum)

Indicator:
Lower than normal

Higher than normal

Interpretation of laboratory /diagnostic test results or assessments:

Abnormal parameters Possible Clinical explanation

Complete Blood Count The main reason for the low level of WBC, RBC, Hb and platelet is because
● Low WBC the patient has underlying aplastic anemia. The body stop producing enough
● Low RBC new blood cell and this will cause high risk of infection, bleeding tendency
● Low Hb and feel fatigue easily due to insufficient blood cell in the body.
● Low Platelet

Differential Blood Count This is also due to the aplastic anemia.

● Low neutrophil
● Low lymphocyte
● Low monocyte

Renal Profile Basically, the renal function of the patient is normal, the low serum
● Low serum creatinine creatinine might be due to the malnutrition of the patient.

Liver Profile The liver function of the patient is normal

Coagulation Profile This is due to the low platelet count that causing the blood coagulate slower
● High prothrombin time than a normal person.

High C-Reactive Protein High C-reactive protein level act as a marker of inflammation. This might be
caused by the infection.
 Systolic Blood Pressure
140 125 127
111 115 112 110 111 111
Systolic blood pressure (mmHg)

120 105 104 109

101 99
100 89

80
60
40
20
0
day 1 day 2 day 3 day 4 day 5 day 6 day 7 day 8 day 9 day 10 day 11 day 12 day 13 day 14

Day of Admission
Systolic Blood Pressure (mmHg)

Figure 1: Systolic blood pressure

Patient’s blood pressure almost maintained within the normal range throughout the whole
admission to the hospital.

Heart Rate
132 128 127 128
140 124 122 121 123
117 117
120 105 109
97 95
Hear Rate (bpm)

100
80
60
40
20
0
day 1 day 2 day 3 day 4 day 5 day 6 day 7 day 8 day 9 day 10 day 11 day 12 day 13 day 14

Day of Admission
Heart Rate

Figure 2: Heart Rate

The patient’s heart rate is high during the first 12 days of admission. This is because the patient
is having sepsis due to the surgical site infection that cause tachycardia. On day 13 and day 14
the heart rate drops to the normal range which indicates the patient condition is getting better and
the infection is almost resolved.
 Body Temperature
41 39.9
39.7
Body Temperature (°C)

40 38.9 38.9
38.7 38.5 38.5 38.8 38.6
39 38.3 38.1 38.4
38 37.1 37.2
37
36
35
day 1 day 2 day 3 day 4 day 5 day 6 day 7 day 8 day 9 day 10 day 11 day 12 day 13 day 14

Day of Admission
Body Temperature

Figure 3: Body Temperature

Normal body temperature for a person is at the range of 36.5 °C to 37.5 °C. The patient is having
high temperature for the first 12 days of admission to the hospital. This indicate the presence of
infection in the patient. After the source of infection has been removed, the body temperature
returned to normal.

Respiratory Rate
28 27
Respiratory Rate (bpm)

27 26 26 26
26 25 25 25 25
25 24 24 24 24
24 23 23
23
22
21
day 1 day 2 day 3 day 4 day 5 day 6 day 7 day 8 day 9 day 10 day 11 day 12 day 13 day 14

Day of Admission
Respiratory Rate

Figure 4: Respiratory Rate

A normal person has a respiratory rate of 12-25 breath per minutes. Patient has a normal
respiratory rate throughout the hospital admission except 4 days where the respiratory rate
slightly exceeds the normal range which is 26 and 27 breath per minute which is not a very
significant abnormality.
 Input / Output Balance
1500 1101
975 939 901
1000 650
470 436
500 162 257
15 -10 85
-151
0

-500 -705

-1000
day 1 day 2 day 3 day 4 day 5 day 6 day 7 day 8 day 9 day 10 day 11 day 12 day 13 day 14

Day of Admission
Figure 5: Input / Output Balance

Basically, the input output balance for the patient is well controlled except for day 4 which has a
value of -705 and day 13 which has a value of -151. Otherwise all is normal.

SpO2
120
100
80
60
%

40
20
0
day 1 day 2 day 3 day 4 day 5 day 6 day 7 day 8 day 9 day 10 day 11 day 12 day 13 day 14

Day of Admission
SpO2

Figure 6: SpO2

The patient’s SpO2 value is maintained at 100% throughout the hospital admission.
 Summary of clinical progress

Date/Day of Subjective (S) Objective (O) Assessment (A) Plan(P)

admission

12/10/2018 ● Fever with chills and rigors
(Day 1) ● Pain over chemoport
insertion site
● no cough / URTI
● no vomiting
● no diarrhea
● no abdominal pain
● no new rashes / bruises
● old bruise over the right UL
● reduce oral intake since
yesterday
● reduce taking solid but taking
bottle feeding and fluids
regularly
● taking 8Oz : every 4 hrs
● and taking other fluid in
between
Vital Sign (1219) Diagnosis: Neutropenic ● Admit 8PA, isolation room
● SpO2: 100% Sepsis due to surgical site ● Bolus NS 10ml/kg over 1 hour
● BP:123/55 mmHg infection with underlying ● IV cefepime 1.2 gm stat
● HR: 113 bpm very severe aplastic anemia. (50mg/kg/dose)
● Temperature: 37.8C Discussion with surgeon: ● IV Vancomycin 720mg stat
chemoport has never been (30mg/kg/dose)
Post NS bolus: used, highly unlikely will be ● IVD HSD5% full maintenance
● BP:111/72 mmHg line related sepsis. 65ml/hr
● HR: 113 bpm ● Serve stat dose Syrup Paracetamol
350mg (15mg/kg/dose)
Vital Sign (1655) ● Monitor i/o
● BP:113/63 mmHg ● Monitor vital sign every hour
● HR: 103 bpm ● Trace blood investigation taken
from ED
Complete Blood Count ● Prefer not to use chemoport until 1-
● Low MCV 2 weeks.
● Low WBC ● Transfuse 1unit pooled platelet with
● Low Platelet IV promethazine 5mg before
treatment
● Continue with IV cefepime 1.2gm
TDS (50mg/kg/dose) and
vancomycin 360mg TDS
(15mg/kg/dose).

13/10/2018 ● Febrile
(Day 2) ● No vomiting, diarrhea
● No body rash
● No loose stool
● Wound over chemoport:
- Not erythematous
- Left upper chest wall
wound tender
- No swelling over
chemoport site and left
upper neck wound
● PCM 360mg QID for regular pain
control.
● Oral prophylaxis:
● PO Bactrim 60mg BD (Mon, Wed,
Fri)
● PO itraconazole 50mg BD
● PO Acyclovir 200mg TDS
● PO Tranexamic acid 250mg TDS
● PO Penicillin V
125mg BD
● Examine Renal Profile
● Examine complete blood count
● For TDM vancomycin tomorrow.
Vital Sign (0800) Diagnosis: Neutropenic ● On IV drip HSD5% at 65ml/hr
● SpO2: 100% Sepsis due to surgical site ● Transfuse 1 Pooled Platelet and
● BP: 109/54 mmHg infection with underlying Packed Cell 360mg (15ml/kg)
● HR: 114 bpm very severe aplastic anaemia. ● IV Promethazine 5mg before
● Temp: 38.0 C transfusion
Vital Sign (1000) ● IV furosemide 10mg stat in between
● Pain Scale : 0 transfusion.
● SpO2: 100% ● Repeat CBC
● RR: 26 rpm ● Trace blood culture today
● BP: 117/51 mmHg ● Not use chemoport yet
● HR: 105 bpm ● Continue use peripheral line
● Temperature: 37.1 ● Continue antibiotic
Complete blood count ● Removed IV line at right hand and
● Hb decrease inserted new line at left leg due to

14/10/2018 ● No swelling or redness seen
(Day 3) ● Inspection over wound :
- Swollen
- No discharge, no pus
● Still have temperature spike.
15/10/2018 ● Still spiking fever, last at
(Day 4) 12pm today 39.9'C
● Eating, no vomiting
● No bleeding tendency
● Complains of pain but
refused to be inspected.
● IV line at left lower limb
dislodges when patient
fretful.
● PLT increase poor flow of blood transfusion.
Vital Sign (0900) Diagnosis: Neutropenic ● IV HSD5% at 65ml/hr
● Pain Scale : 0 Sepsis due to surgical site ● Oral medication served.
● SpO2: 100% infection with underlying ● Blood culture on 12/10 show no
● RR: 19 rpm very severe aplastic anaemia. growth.
● BP: 111/60 mmHg ● Repeat blood culture.
● HR: 92 bpm ● Stop Cefepime and change to IV
● Temperature: 37.7 meropenem 965mg TDS
Vital Sign (1700) (40mg/kg/dose)
● SpO2: 100% ● Continue vancomycin.
● RR: 27 rpm ● Trace FBC today.
● BP: 111/61 mmHg ● Check renal profile and vancomycin
● HR: 96 bpm TDM tomorrow.
● Temperature: 36.5 ● Oral medication served.
Vital Sign (0645) Diagnosis: Neutropenic ● Cont IV drip 20ml/hr and increase
● SpO2: 100% Sepsis due to surgical site to 40ml/hr at 2045.
● RR: 25 rpm infection with underlying ● Cont IV Meropenem and
● BP: 118/62 mmHg very severe aplastic anaemia. vancomycin
● HR: 110 bpm ● Examine liver function test.
● Temperature: 38.8C ● Renal profile and Full blood count
Vital Sign (1955) taken and TDM vancomycin done.
● SpO2: 100% ● Watch out bleeding tendency and
● RR: 20rpm sign of sepsis
● BP: 123/79 mmHg ● Chemoport accessed this evening -
● HR: 90 bpm blood culture and fungal culture

16/10/2018 ● Child have been spiking
(Day 5) temperature since admission
5 days ago.
● Temperature trend seems
better past 11hour - no more
spike above 38C (last spike
at 11pm)
● Chemoport was accessed
yesterday without
complication
● So far, no chills and rigors
with antibiotic administration
through chemoport
● Still refusing to move her
neck but swelling and
redness around chemoport is
better.
● Oral intake still poor - still on
⅔ maintenance drip
● Alert, good pulse volume,
CRT<2sec, warm peripheries
● Temperature: 36.8C sent.
● Stool virology and culture
● CBC: WBC low ● Allowed to access chemoport with
● DC (manual): all aseptic technique.
parameters low ● Continue oral medication.
● C-Reactive Protein
High
Vital Sign (0501) Diagnosis: Neutropenic ● Continue IV vancomycin and PO
● SpO2: 100% Sepsis due to surgical site prophylaxis
● RR: 26rpm infection with underlying ● Continue IV drip HSD5 ⅔
● BP:105/79 very severe aplastic anaemia. maintenance 40ml/hr
● HR:91bpm ● Trace level vancomycin in system
● Temp: 37.8C ● Suggested to maintain vancomycin
380mg TDS (8hr)
● CBC : Hb 9 low
● WBC 0.9 low
● PLT 31 low
● I/O (-705), u/o:
3.8cc/kg/hr
● Chemoport culture:
Gram positive Bacilli
seen
● TDM Vancomycin:
Pre dose (15/10,
0800) could not
interpret because
sample expired while
Post Dose
 ● Lungs clear, a/e equal BL
● CVS DRNM
● Pa soft non-distended
● Liver palpable 2cm. Spleen
difficult to palpate today-
fretful
17/10/2018 ● Noted afebrile since 5am,
(Day 6) temperature reaching 36++
● Noted blood C&S from
chemoport grew Gram+ve
bacilli
● Noted after starting
antibiotics via chemoport
temperature trend improved
and CRP start to come down
● Appetite slowly improving
today-eat rice
● Sleeping, non-tender left
chest wall
● Pulse volume is good
● CRT <2 seconds
● Lungs, good air enter
bilaterally
● CVS; S1 S2 no murmur
(15/10,1300) was
below targeted range.
Vital Sign (0518) Diagnosis: ● Continue IV meropenem 4hr
● SpO2: 100% Gram+ve Bacilli Neutropenic infusion
● RR: 23rpm Sepsis (Provisional) due to ● IV vancomycin reduce to 2hr
● BP:112/62 mmHg surgical site infection with infusion
● HR:122bpm underlying very severe ● Trace culture urgently tomorrow
● Temperature: 37.7C aplastic anaemia. ● Repeat C&S from chemoport today
Vital Sign (0800) ● Reduce IV drip to 30ml/hr
● SpO2: 100% ● Monitor temperature trend
● RR: 22rpm ● If persistent fever, KIV lock
● BP:121/71 mmHg chemoport and use peripheral line
● HR:92bpm ● Suggest to change vancomycin dose
● Temperature: 36.2C to 360mg QID (Q6hr) starting today
Vital Sign (1228) (17/10) at 2400hr
● SpO2: 100%
● RR: 23rpm
● BP:117/58 mmHg
● HR:108bpm
● Temperature: 37.0C
● CRP high
● I/O balance -92.5
● Urine output good
● Rotavirus not

18/10/2018 ● Last fever 5 am this morning- Vital Sign (0930)
(Day 7) 38.5C
● Fever frequency has reduced,
maximum temperature has
also reduced
● Complains of left hand pain
at times, especially during
periods of fever
● Sleeping / lying down
● Pink
● Warm peripheries
● Chemoport site dressed,
surrounding area does not
appear swollen
detected in stool
● TDM Vancomycin:
Pre Dose
(17/10,0800) and Post
dose (17/10,1200)
were both below
targeted range,
however, Actual post
level could be high
due to delayed
sampling time.
Diagnosis: ● Continue current antibiotics -
● SpO2: 100% Gram+ve Bacilli Neutropenic vancomycin and meropenem. Aim
● RR: 23rpm Sepsis (Provisional) due to total duration 7 days from last
● BP:110/62 mmHg surgical site infection with negative culture
● HR:114bpm underlying very severe ● If clinical condition deteriorates, to
● Temperature: 36.8C aplastic anaemia. stop using chemoport and lock with
Vital Sign (1600) IV vancomycin
● SpO2: 100% ● Trace organism identification and
● RR: 26rpm sensitivity.
● BP: 111/71 mm Hg ● Transfuse Pooled Platelet 240mls
● HR: 117bpm 1hr
● Temperature: 37.2 C ● IV Promethazine 5mg before
● Pain Score (At Rest): transfusion
0
● Pain Score (On
Movement): 2

19/10/2018 ● Still febrile. Temperature
(Day 8) 38.3C at 11pm 18/10 and
temperature spike at 1400.
● Clinically well perfused, not
septic.
● Noted +ve balance over past
2 days. IV antibiotics alone is
already 1000 ml.Taking
around 500 ml of intake
already.
● Blood from chemoport (1st
access after insertion) has G+
bacilli (awaiting
identification).
● Peripheral blood cultures
shows negative on this
admission.
● Complaint of intermittent
pain over chemoport area and
arm. No external obvious
reason.
● Area around chemoport
Vital Sign (1735)
● Temperature: 38.1C
● CBC: WBC and PLT
super low
● DC (Manual) : WBC
count too low for DC
Vital Sign (0242) Diagnosis: ● Encourage orally
● SpO2: 100% Gram+ve Bacilli Neutropenic ● Monitor temperature trend
● RR: 25rpm Sepsis (Provisional) due to ● To take FBC next blood taking
● Pain scale: 4 surgical site infection with ● Off IVD in view of total IV
Vital Sign (0545) underlying very severe antibiotic (998cc) + oral intake
● SpO2: 100% aplastic anaemia. (560cc) achieve her daily full
● RR: 23rpm maintenance requirement
● Pain Score (At rest):6 ● To give LA aqueous cream for the
● Pain Score (On back area.
movement) : 8 ● For Vancomycin lock starting today,
● BP: 101/47 to re-access 24H later post
● HR:99bpm administration
● Temperature: 37.4C ● Vancomycin lock for twice, today
and tomorrow
● Blood C+S from ● NOT FOR CHEMOPORT USE
Chemoport : until after Vancomycin lock x2
Preliminary report ● Vancomycin lock done on 1745h.
Propionibacterium On Vancomycin lock 24hr. Iv line
acnes inserted at left hand in-situ
● Sensitive to ● Trace formal result of blood culture
Vancomycin - sensitivity panel to review
● TDM Vancomycin; tomorrow.
 palpated - no swelling, no Pre Dose ● Trace Vancomycin TDM level
bogginess/ fluctuant areas -> (18/10,1330), Post
patient did not cry or stop me Dose (18/10,1600).
from examining her, appears Pre Dose sample was
non tender. No redness. insufficient while
● Area around neck more Post Vancomycin
visible today as child able to level was below
move her neck - noted clean target range. Suggest
wound. to maintain the
● Back of the body -> noted current vancomycin
widespread rash - dry skin, dose at 360mg QID
non-erythematous pigmented (8hr).
skin
● No papular lesions or
vesicular
lesions.Moodirritated when
approached. New swollen
appear on left nipple and
complain of pain.
● Patient unable to sleep at
night due to throbbing, give
PCM

20/10/2018 ● Child had a spike of Vital Sign (0452) Diagnosis: ● Encourage orally
(Day 9) temperature this morning- ● SpO2: 100% Propionibacterium ● Monitor temperature trend
38.5 ● RR: 25rpm Neutropenic sepsis due to ● To take FBC next blood taking on
● Had total of 3 spike of ● BP:109/58 mmHg surgical site infection with Mon when repeating TDM
temperature since last night ● HR:104bpm underlying very severe vancomycin.
● however child is still active ● Temperature: 38.5 C aplastic anaemia. ● Trace formal result of blood culture
 and afebrile ● Pain Score (At rest): - sensitivity panel to review
● still having poor oral intake 0 tomorrow
● refuses solid food, only ● Pain Score (On ● For vancomycin lock today at 1730
taking plain water and milk Movement): 0 ● Vancomycin change to QID infuse
Vital Sign (0800) over 2hours
● SpO2: 100%
● RR: 25rpm
● BP: 104/47mmHg
● HR:93bpm
● Temperature: 36.8C

● I/O 1392/1230 //+162

● U/O :2.1cc/kg/hr
● Blood C+S from
Chemoport :
Preliminary report
Propionibacterium
acnes
● S : Vancomycin

21/10/2018 ● Patient stable. Vital sign Vital Sign (0547) Diagnosis: ● Chemoport assessment at 1730H
(Day 10) taken as recorded. Afebrile. ● SpO2: 100% Propionibacterium today, to chemoport culture together
● Propionibacterium ● RR: 22rpm Neutropenic sepsis due to ● Once after assessment, allow
Neutropenic sepsis ● BP: 110/55mmHg surgical site infection with chemoport use and continue
- preliminary report : sensitive to ● HR:110bpm underlying very severe flushing
vancomycin, however full ● Temperature:37.4 C aplastic anaemia. ● Encourage orally
sensitivity panel is still pending Vital Sign (1615) ● Monitor temperature trend, if temp
- vanco lock x1 on 19/10, x2 on ● SpO2: 100% spike, KIV for prolong vancomycin
20/10 at 1730H ● RR: 23rpm lock in future
 ● No fever overnight and ● BP: 106/57
afebrile for 24H (while on ● HR: 128bpm
2nd vancolock chemoport) ● Temperature: 38.8 C
● oral intake improving
● Temperature spike on 1415
● S/T MMB lab:
16/10: only done sensitivity for
vancomycin and penicillin, other
sensitivity not done yet
18/10: SFNG
● Temperature reduced to 37.0
Celsius. Blood culture from
chemoport taken Tried assess
the chemoport, seen redness
around the chemoport site
and to discuss can use for
flushing or not. IVI
vancomycin in progress at
left peripheral line. Iv
lineinsitu at left hand for IVI
antibiotic. Chemoport insitu,
spigot

22/10/2018 ● Patient had low grade fever
(Day 11) at 0210
● Propionibacterium acne,
Neutropenic sepsis
- Blood culture (chemoport on
16/10/18) report : sensitive to
Vital Signs (1256) Diagnosis: ● Off Ivi Meropenem. Continue IVI
● SpO2: 100% Propionibacterium vancomycin QID for 4 hours. Iv line
● RR: 24rpm Neutropenic sepsis due to pattern at left hand.
● BP: 102/48mmHg surgical site infection with ● For vanco level @ 0400. Encourage
● HR: 102bpm underlying very severe tepid sponging and fluid intake.
● Temperature: 37.3 C aplastic anaemia. ● Start IV clindamycin 240mg
vancomycin
- Blood culture chemoport
(18/10/18 and 22/10/18)
pending.
● Case referred to ID team
today for LA and IV
clindamycin (better tissue
penetration)
● noted chemoport site infected
- wound was gaping and has
serous discharge
-swab taken from infected
surgical site.
● site of chemoport also
appeared inflamed
● Temperature settling.
● Vitals stable.
● Alert, pink, lying
comfortably
● Good pulse volume, warm
peripheries.
● No bounding pulse
● Not in respiratory distress.
● No bleeding tendency.
● Lungs clear
● CVS: DRNM
● Abdomen soft.
● IVI Clindamycin on going
Vital Signs (1520) tds(10mg/kg/dose)
● SpO2: 100% ● Chemoport needle
● RR: 23rpm removed.Compression done over the
● BP: 111/61mmHg wound. Dressing done, clindamycin
● HR: 99bpm gel applied. LA clindamycin gel OD
● Temperature: 37.3C dressing at chemoport region
● Pain Score (At Rest): ● Off IV vancomycin.
0 ● Trace blood culture (chemoport) on
● Pain Score (On 18/10/18 and 22/10/18.
Movement); 4
● CRP 16.3 -->14.9 ● Transfusion:
● HGB and WBC low. ● IV promethazine 5mg before
● TDM Vancomycin: transfusion
Pre Dose ● For 1 unit pooled Plt transfusion on
(22/10,0400), Post 25/10/18 (weekly tx), or PRN if
Dose (22/10,0930) present of bleeding tendency
Both Pre and Post ● FBC and GSH on 25/10/18 or
Vancomycin levels during line setting.
were below the ● To transfuse leukodepleted PC if Hb
targeted ranges. Post is less than 8g/dL.
Vancomycin level ● Platelet 13, 1 unit leucodepleted
was expected to be pooled platelet transfused.
higher in view of ● During pass over, father complaint
delayed sampling of dressing at chemoport soaked
time. No with blood. Removed old dressing
recommendation is and applied new dressing (put
required as pressure dressing).
vancomycin has been
 via peripheral line at left
lower limb at right leg in situ
23/10/2018 ● Noted more pale today by
(Day 12) mother
● Clinically -> left arm pain
has resolved
● Appetite more improved -
eating more solids.
● CRP slightly reducing trend.
● No fever so far since 6 am
but still having temperature
spikes - yesterday 3 spikes /
day
● Blood C&S today grew
Gram +ve cocci - Culture on
the 22/10/18 after chemoport
was accessed post-Vanco
lock growing Gram
+vecocci.(day 2 growth) on
IVI Clindamycin Day 2
● Wound inspection today
- wound more gaping than
yesterday
- dry, no more bleeding.
- however, when palpated area
superior to chemoport -> firm
swelling extending around 5 cm
at 2 pm
discontinued.
Vital Sign (1000) Diagnosis: ● Cont IVI Clindamycin as planned
● SpO2: 100% Propionibacterium by ID team
● RR: 23rpm Neutropenic sepsis ● LA clindamycin gel OD dressing at
● BP:100/53 mmHg chemoport region
● HR: 107bpm Diagnosis: ● Trace blood culture (chemoport) on
● Temperature: 35.9 C infected chemoport with 18/10/18 and 22/10/18.
Vital Sign (1800) wound breakdown ● US of chemoport area to look for
● SpO2: 100% collection.
● RR: 23rpm Diagnosis: ● Cont IVI clindamycin
● BP:91/43 mmHg chemoport related sepsis ● To discuss with ID team regarding
● HR: 97bpm the new blood culture growth
● Temperature: 35.9 C ● KIV to repeat chemoport culture in
● C&S today grew 2-3 days time once wound heals.
Gram +ve cocci ● To transfuse packed cell 240 mls
● Chest Ultrasound : today. Serve IV lasix in between 5
Impression: Left mg in between transfusion.
chest wall superficial ● To transfuse 1 unit platelet with IV
collections. promethazine before transfusion.
● Take FBC CM
● To arrange for chemoport removal
Thursday 25/10.
● trace swab from chemoport
● to cont IVI Clindamycin (good skin
penetration and cover MSSA)
● if culture grow methicillin resistance
Staph/ CONS - to change IV
 ● USS was done urgently today Clindamycin to IV Vancomycin
- noted multiple collection at
superficial chest wall
● current issue: infected
chemoport and wound
breakdown
● Chemoport inserted on
10/11/18.
● 12/10/18 & 14/10/18: NG
● 16/10/18: Propionibacterium
acnes
● 18/10/18: NG
● 22/10/18: gram positive cocci
● persistent spikes of temp,
Chemoport site infection
propionibacterim and GPC
sepsis
● Discussion : ultrasound-
superficial collection,
worsening of wound gapping
therefore planned for
chemoport removal

24/10/2018 ● Last spike of temperature
(Day 13) yesterday morning (24 hours
afebrile)
● According to mum more
active today, able to
mobilise- went don to buy
Vital Sign (0515) Diagnosis: ● Start octenesan bath before going
● SpO2: 100% infected chemoport with for op tomorrow
● RR: 24rpm wound breakdown ● Trace culture
● BP: 105/53 mmHg ● Cont. IV Clindamycin
● HR: 85 bpm ● To transfuse 1 unit of single donor
● Temperature: 36.7 C platelet 10mls /kg
 food, able to sit up and watch ● Pain Score (At Rest): ● If going for chemoport
videos. 0 removaltomorrow, for surgeons to
● No vomiting ● Pain Score (On take blood c&s from chemoport
● No diarrhea Movement): 0 ● Investigation:To repeat fbc,
Vital Sign (0800) gxmcm.To repeat blood c&s
● SpO2: 100% peripheral cm
● RR: 23rpm
● BP: 103/54 mmHg
● HR: 89 bpm
● Temperature: 37.0 C
● CRP trend:
● 16.2 ---> 16.3 --->
14.9

25/10/2018 last spike of temp 38.6 celcius on Vital Sign (0522) Diagnosis: ● to cont IVI Clindamycin (good skin
(Day 14) 23/10/18 0600H ● SpO2: 100% infected chemoport with penetration and cover MSSA)
afebrile for 48 hrs ● RR: 23rpm wound breakdown ● if culture grow methicillin resistance
child is more active ● BP: 103/59 Staph/ CONS - to change IV
● HR:86 bpm Clindamycin to IV Vancomycin
● Temperature: 36.2 C ● trace blood culture and its
Background: sensitivity
● sleeping, comfortable ● repeat CRP next blood taking
good pulse vol, CRT less
than 2s
 Pharmaceutical Care Plan (PCP)
Pharmaceutical Care Plan Management of infection
(PCP) for: - Systemic infection
(Types of - Localized infection (chemoport)
disease/condition)

Desired Outcome Proposed Action Follow-up/Monitoring Important Clinical Progress, Relevant Diagnostic Tests &
Parameters References
● Eradicate the ● For febrile neutropenia stable ● FBC ● Patient is given IV cefepime 1.2 gm stat (50mg/kg/dose) and
microorganism patients, piperacillin/tazobactam ● Liver function test IV Vancomycin 720mg stat (30mg/kg/dose) as loading dose.
● Restore neutrophil 100mg/kg IV q6-8h ● Renal function test ● Then continue with IV cefepime 1.2gm TDS
count ● For HSCT patients, cefepime ● C-reactive protein (50mg/kg/dose) and vancomycin 360mg TDS
● Prevent further organ 50mg/kg (max 2g) IV q8h. level (15mg/kg/dose).
damage or ● The alternative for stable patient is ● Heart rate ● At the same time, blood culture and urine culture is done
complication. meropenem 20mg/kg IV q8h ● Body temperature and send to the lab to analyze.
● Symptomatic relief. + ● Respiration rate ● FBC is done every day and other monitoring parameter is
Gentamicin 8mg/kg IV q24h for day ● Blood culture measured to monitor the progress of the antibiotic.
1, then 6mg/kg IV q24h. ● Vancomycin TDM is done from time to time.
● On 14/10, blood culture shows no growth.
● Cefepime is stopped and changed to meropenem 965mg
● For unstable patient, give TDS (40mg/kg/dose).
meropenem 40mg/kg IV q24h ● Chemoport culture is done.
+ ● On 16/10, chemoport culture shows gram positive bacilli
Vancomycin 15mg/kg (max 1gm) (propionibacterium acnes) which sensitivity to vancomycin
IV q8h. is presumption only.
● Continue with meropenem and vancomycin antibiotic.
● According to NICE guideline, do ● On 19/10, decision to do vancomycin lock in combination of
not offer empiric glycopeptide conventional vancomycin and meropenem antibiotic.
antibiotics to patients with ● On 20/10, second vancomycin lock is done.
neutropenic sepsis who have central ● On 22/10, chemoport culture shows gram positive cocci.
venous access devices unless there Hence meropenem and vancomycin is off and changed to
are patient-specific or local clindamycin 240mg TDS.
 microbiological indications. ● Chemoport needle is removed, dressing is done and
● Do not remove central venous clindamycin 1% gel is applied on the chemoport region
access devices as part of the initial topically.
empiric management of neutropenic ● Removal of chemoport is done.
sepsis.

Patient was managed correctly.

Reference: UMMC Antibiotic Guideline.
https://www.nice.org.uk/guidance/cg151/chapter/1-Guidance#managing-confirmed-neutropenic-sepsis-2

Pharmaceutical Care Issue (PCI)

Insufficient duration of the Vancomycin Lock
- Vancomycin lock only perform for 2 days and stopped after that.

Desired Outcome Proposed Action Follow-up/Monitoring Important Clinical Progress, Relevant Diagnostic Tests &
Parameters References
● Effectively resolve According to Malaysia national ● Respiratory rate ● Vancomycin lock was started on 2 days each 24 hours.
the underlying antibiotic guidelines, antibiotic lock ● Heart rate ● 19/10/2018 1745 - 21/10/2018 1730
infection. therapy should be used for catheter ● Body temperature ● KIV to prolong Vancomycin Lock in future if temperature
● Prevent further ● FBC spike but the wound at chemoport was infected, therefore
salvage in combination with
systemic removal of chemoport was done.
complication. conventional antibiotic therapy for 10-
14 days to effectively eradicate all the
microorganism and resolve the
infection.
Reference: Malaysia National Antibiotic Guideline, 2014, Ministry of Health.

Pharmaceutical Care Issue (PCI)

Potential Drug Interaction between Promethazine and Itraconazole
- Both Promethazine and Itraconazole increase the QT interval of heart and this may lead to arrythmia
Desired Outcome Proposed Action Follow-up/Monitoring Important Clinical Progress, Relevant Diagnostic Tests &
Parameters References
● Prevent any ● Maintain the normal regimen ● Heart rate ● Patient was tachycardic during admission and early
arrhythmic events. ● Closely monitor the heart rate ● Respiration Rate hospitalization due to the sepsis infection.
● Maintain normal during the IV promethazine giving ● Oxygen saturation ● Heart rate gradually reduces as patient recovers from
heart rate period. ● Blood Pressure sepsis infection.
● Ifresulting effect occur such as ● No sudden tachycardic events observed during infusion of
increase in heart rate, medication promethazine IV.
needs to be changed.

Reference: https://reference.medscape.com/drug-interactionchecker

Pharmaceutical Care Issue (PCI)

Query regarding usage of vancomycin as empirical antibiotic therapy
- Vancomycin is used as the first antibiotic to treat the infection without any information about presence of MRSA.

Desired Outcome Proposed Action Follow-up/Monitoring Important Clinical Progress, Relevant Diagnostic Tests &
Parameters References
● Prevent the ● Vancomycin should be used to treat ● Blood culture ● Vancomycin is used as the first antibiotic to treat the
development of serious infection caused by MRSA ● Urine culture infection without any information about presence of
antibiotic to prevent the development of ● Chemoport culture MRSA.
resistance. antibiotic resistance towards ● However, the patient is a frequently visiting UMMC. So,
● Proper handle of vancomycin. there is a possibility that the patient had MRSA infection
antibiotic regimen. in the past but it is not written in the most recently patient
clinical notes.

Reference: https://www.nice.org.uk/guidance/cg151/chapter/1-Guidance#managing-confirmed-neutropenic-sepsis-2
 Pharmaceutical Care Plan (PCP)
Pharmaceutical Care Plan (PCP) for: Management of Aplastic Anaemia
(Types of disease/condition)

Desired Outcome Proposed Action Follow-up/Monitoring Important Clinical Progress, Relevant Diagnostic Tests & References
Parameters
● Maintain safe and Based on the British ● FBC ● Patient previously taking cyclosporine and Horse/Rabbit ATG but poor
adequate levels of Journal of Hematology: ● DC response. Now only takes palliative treatment of 2 weekly Packed Cell
blood parameters ● First, Do ● LFT and weekly platelet.
in patient. (Hematopoietic Stem ● RFT ● 12/10/2018 : 1 unit pooled plaletet 200cc start at 1915hrs
● Improve symptoms Cell Transplant) HSCT ● Iron level ● 13/10/2018 : 1 unit platelet random200cc start at 1645hrs
of anaemia If no (Human ● Temperature ● 13/10/2018 : Packed Cell Leucodepleted 360mls over 4 Hours
● Maintain quality of Leukocyte Antigen) ● Heart rate ● 18/10/18 - Pooled platelet 233 mls start 1835 hr finished 1855 hr
life HLA-identical sibling ● 23/10/18 -1 unit (200cc) leucodepleted pooled platelet started at
available, perform 0030hour
unrelated donor search. ● 23/10/2018 - 240mls packed cell over 4hours ( started 1745hrs, finished
● Second, Immune at 2215hr)
Suppression Therapy ● 24/10/2018- 240mls -1 unit of single donor platelet ( started 1750h )
(IST) with (Anti-
Thymocyte Golbulin) ● From admission until now,
ATGAM /ciclosporin or ● all DC parameters is low
10/10 upfront (Matched ● WBC and platelet also low
Unrelated Donor) MUD
HSCT
● Third, Mismatched
unrelated donor HSCT
(9/10)
● Fourth, choose between
these options.
1. 2nd Course of IST
2. Androgens
3. Alemtuzumab
4. Eltrombopag
 5. Haploidentical or
unrelated donor
umbilical HSCT

Supportive therapy:
● Blood transfusions
should be given to
improve quality of life.
● Regular platelet
transfusion support may
be required for AA
patients.
● Aplastic anaemia
patients who are
severely neutropenic
should be given
prophylactic antibiotics
and antifungal therapy
according to local
policies.
Patient was managed
correctly.
Reference:Paediatric amendment to adult BSH Guidelines for Aplastic Anaemia, British Journal of Hematology, 2018
Discussions/Additional remarks:

Patient is a 4 years old 6 months girl admitted due to the complaint of fever and was diagnosed
with neutropenic sepsis with underlying aplastic anemia. Patient was admitted to Ward8PA, into
the isolation room. There are a few things need to be clarified about this case.

Patient was on chemoport even though not on chemotherapy. For this patient, the chemoport was
not for chemotherapy but for frequent blood and platelet infusion. Patient received supportive
care for management of aplastic anemiawhich entails Platelet infusion every week and Packed
Cell infusion every 2 weeks. As patient is platelet-deficient, inserting peripheral IV line every
week will result in frequent bleeding and open wound. In comparison, chemoport is a better
option as it reduces bleeding events and less wound for the patient.

The details regarding patient’s treatment for aplastic anaemia such as hematopoietic stem cell
and immunosuppressive therapy was not discussed during this clerkship, therefore the treatment
status on patient’s aplastic anaemia was not known. We only know that patient has frequent
hospitalization at UMMC due recurrent sepsis and patient acquires the aplastic anaemia for
unknown reasons 2 years ago when patient was only 2 years old. Patient was given horse and
rabbit ATG as treatment for aplastic anaemia but there is poor response to it and now only
supportive treatment which is platelet and packed cell infusion is given for this patient.

Conclusion:

Patient was admitted on 12/10/2018 due to the complaint of fever and tachycardia after insertion
of chemoport that day. This leads to the diagnosis of neutropenic sepsis. Patient was started on
several intravenous antibiotics including Vancomycin, Cefepime, Meropenem. However, the
infection is not systemic, therefore the infection is suspected to be a local infection and the most
possible cause is the chemoport which is proved by presence of Gram positive bacilli.
Vancomycin lock was initiated to sterilize the chemoport for 2 days. After that, only intravenous
Clindamycin was initiated for any possible systemic infection. The patient was gradually getting
better but the infection at chemoport site with gaping wound and serous discharge prevented the
use of chemoport again. It was then decided that the chemoport will be removed. Overall, patient
was managed well. We clerked the case until 25/10/2018 when the patient was about to undergo
chemoport removal on that day.
Self-reflection:

From this clerkship, we learned to apply clinical knowledge that we study previously by clerking
these cases. We learnt to discern which information is important and what should be emphasized
when using certain drugs such as side effects, drug interaction and its pharmacokinetic in
selected patients as this can seriously affect the clinical outcome of patients. We also realized
that different wards have completely different issues and we cannot expect to clerk the cases the
same way with other wards. We learnt to associate the lab parameters and clinical notes together
to understand the patient’s condition better. We must try our best to make the best clinical
decision for the patient’s health. These decisions must be supported by guidelines and based on
patient’s health condition and its risk and benefit. However, as we lack knowledge and
experience, we are lacking in making a good decision that require our judgement.