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Clinical Case Presentation

Monash University Professional Placement Program: The Northern Hospital

Group D: Palliative Care

Ayshah Shafeek, Hsuan-Ching Chen, Flower Lei,
James Collins, Li Bin Tan, Kum Chuan Leong, Bill Nguyen
Presented by: Casey Leong
Patient’s Details

Initial: G.M Social History:

Age: 74 years old. ● Non-Alcoholic

Gender: Female ● Non-smoker

● Independent and live with husband

Weight: 73kg (admission weight)
● Occasionally hire a home helper
Height: 156cm BMI: 30 (Obese)
● Exercise tolerance ~200m
Language spoken: English

Allergy: Nil known drug allergy

Past Medical History
▪ Heart Failure with preserved Ejection Fraction (HFpEF)
▪ Had angiogram on July 2017– NAD

▪ Had Echogram on September 2017 – NAD

▪ Biventricular fibrillation - with Permanent Pacemaker (PPM)

▪ Automated Implantable Cardiac Defibrillator for ventricular fibrillation

▪ Gastroesophageal Reflux Disease (GORD)

▪ Hypertension (HTN)
▪ Hypercholesterolaemia
▪ Myopericarditis
▪ Open cholecystectomy
Regular Medications
Medicine Strength Dose Form Frequency Indication

Aspirin 100mg Tablet 1 mane Prevention of MI

Atorvastatin 40mg Tablet 1 nocte Hypercholesterolaemia

Bisoprolol 2.5mg Tablet 1 mane VF, Rate control

Cholecalciferol 25microgram Tablet 1 mane Vitamin D deficiency

Esomeprazole 20mg Tablet 1 mane GORD

Frusemide 80mg (2x40mg) Tablet 1 BD HF, HTN

Glyceryl Trinitrate 400microgram Spray PRN Angina

Spironolactone 25mg Tablet 1 mane HF

History of Presenting
Lower Limb Pain and Oedema

▪ Patient comes in with lower limb pain and oedema

over the past 2 months, increases in leg pain causing
difficulty in walking and experiences shortness of

▪ She also complaints about LLQ abdominal pain and

had increased toilet visit.

▪ Physicians suspected she’d lower limb Deep Vein

Thrombosis (DVT).

▪ Patient then admitted to cardiology ward for

First impression:
 Non-pitting Lower Limbs Oedema

Urine and Electrolyte Test (U&E)

 Blood electrolytes are in range.
Interventions and  Urea - 14 mmol/L (3.0 – 10 mmol/L)
 Creatinine – 75 (45-90 micromol/L)
Examinations when  eGFR – 68 (>59mL/min/1.73m2)
patient first admitted  Calculated Creatinine Clearance - 45 mL/min

Full Blood Examination (FBE)

 Haemoglobin – 101 g/L (115-165 g/L)

Calculated CHAD-VASC Score: 4

Deep Vein Thrombosis (DVT)
Inflammation, hypercoagulation and endothelial tissue damages can results in the recruitment of the activated platelets
which leads to the commencement of the coagulation cascade by releasing microparticles that could secrete pro-
inflammatory mediator that binds to neutrophils, forming a prothrombin network. This network consist of histones that
stimulate platelet aggregation forming a plaque or thrombus which leads to DVT. Leg DVT is often precipitated by
placement of pacemaker, internal cardiac defibrillator and indwelling venous catheter and it is about 10 times more
common than upper extremity DVT. Clots may break and spread to another part of the blood vessels or veins causing
pulmonary embolism (PE).

**Obesity, smoking, chronic kidney disease, surgery, chronic obstructive pulmonary disease, trauma and so on are the
common pre-disposing factors for DVT.

Signs and Symptoms:

Ankles or calf swelling and leg itching.

Treatment options:
1 mg/kg Enoxaparin S/Cut BD for minimum 5 days and INR >2 on 2 consecutive days if would like to start on warfarin after. (INR 2-3)

Oral Rivaroxaban 15mg BD for 3 weeks then 20mg once daily

Day 1-2 Day 3-5 Day 6 Week 6-10 Week 11

Registrar Doctor Hospital Medical Officer Doctors All members All members

Diagnosis and
Further Investigations Patient’s Progression Analysing Data Final Report
Examination Plan

● Admission to Cardiology ● Lower Limbs DVT ● Patient developed

Ward. ● Ceased prophylactic generalised itch, ● Collect completed ● Finalise key
● FBE + LFT enoxaparin and cetirizine 10mg daily survey. changes made in
● Abdominal ultrasound commence on commenced. ● Evaluate feedback from final report.
● Daily weight therapeutic enoxaparin ● U&E – urea raised from mentor and ● Fine-tune details
● Clarify Regular 100mg daily 14 – 20.2, creatinine stakeholders. with members.
Medications. ● Ventilation/Perfusion raised to 100 and eGFR ● Implement changes to ● Practice for
● Start on perindopril Lung Scan - Clear, ruled dropped to 48. plan. presentation.
2.5mg out Pulmonary ● Frusemide withheld ● Continue discussion with
● Elevate legs and 1 L Embolism. ● Plan to start warfarin on relevant stakeholder.
fluid restriction. ● Thrombophilia tests. discharge and plan to ● Commence final report.
● VTE prophylaxis – ● Weights drops to 71kg discharge to HITH
Enoxaparin 40mg OD with fluid restriction. ● Restart frusemide once
renal function reclines.
Hospital in The Home

 Haemoglobin – ~101  Haemoglobin – 101 g/L

 Increase dose of frusemide g/L  Urea – 20.2 mmol/L
to 80mg once daily.  Urea ~12.1 mmol/L  Creatinine – 100
 Spironolactone and  Creatinine – 79  eGFR – 48
perindopril withheld.  eGFR – 64  CrCL: 34mL/min
 Discharge to home from
 Medication non-compliancy  INR: 2.1 HITH Continue monitoring
detected. – Forgetful  Warfarin: 2.5mg  GP review after 1 month
(from admission date)
and review
Day 32
Day 12

Day 8-11 Day 17

• Pharmacist faxed the scripts to local  Haemoglobin – 110 g/L
 Reviewed with G.P
 Haemoglobin – ~101 pharmacy and recommends websterpack  Urea - 13.5 mmol/L
g/L so the Mrs GM can take the medication on  Creatinine – 75
 Left leg venous doppler Ultrasound
 Urea ~12-14 mmol/L – No evidence of thrombus
next day.  eGFR – 68
 Creatinine – ~69-75 • Dose of frusemide increased back to  CrCL: 45mL/min
 eGFR – 68 80mg BD  INR: 2.1
 INR: 3.4, 3.2,3.1, 2.2  Warfarin dose: 2.5mg
 Warfarin dose: 8mg,
3mg, 2mg,2mg
 Obtain best possible medication history and medication

 Develop clear and informative medication management

plan to minimize medication misadventure while handling
Role of pharmacists over patients to another unit or ward.
throughout the
 Detect medication non-adherence and helped the patient
process for webster packaging arrangement in her local pharmacy.

 Medication use optimisation, education and counselling.

 Keep track of patients lab test, reconcile medication chart.

 Constructs Medilist for patients and their local GP.

 Dispense medication in a meticulous manner.

▪ https://www.heartfoun