PREPARED BY:  NUR FADHILAH ARSHAD  NUR HAIDAR AKBAR  NABILAH JAMALUDIN  CHUA SUE HOON  CHAI YEE YIEN  TAN SIN YEIN  NIK NUR NASEELA FATHIN NIK MOHD SABRI

DATE SECTION WARD BED NO REG.NO

: 19/10/10 : NEUROLOGY : C7 : 26 : 805145

GROUP B

 Name: OO  Age: 46 years old  Gender: Male  Race: Malay  Date of admission: 7 th October 2010

x x x x x x

Had:-

 Fever (3 days)  Chills  Tremors

Do not had:-

Cough Runny nose Chest pain Vomit Shortness of breath diarrhea

 Diabetes mellitus  Hypertention

Name/Dose/Strength/Route Schedule Indication

T. Amlodipine 10mg OD Antihypertension T. Vitamin B complex/Folate/ Ferrous fumarate 1/1 T. CaCO 3 500mg OD BD Supplement Treatment hyperphosphatemia T. Lovastatin 20mg ON Antihyperlipidemic

 DM and HTN  No renal disease, heart disease, and hematology disorder.

 Allergic: No  Social History:   Smoking: stopped 1 year ago Alcohol: No



Upon admission:

 

Temp: 37.5⁰C BP :75/56

Date/Time 4am(⁰C) 13/10 14/10 15/10 16/10 17/10 18/10 19/10 37 8am(⁰C) 37 12pm(⁰C) 4pm(⁰C) 37 37.5

37 36.9

37.5

37 37.5

37.1

37 37.1

36.7

37 36.7

37 37 37 8pm(⁰C) 12am(⁰C) 37 37 37.8

37.9

37

1.30am

6.00am

8.00am

12.30pm

1.30pm

3.10pm

6.00pm

129/71 100/60 104/64 84/50 145/78 139/70 130/82

12.30am 3.00am

6.00am

12.15pm

3.10pm

4.25pm

5.30pm

11.00pm

156/79 126/70 109/67 170/82 102/76 111/64 122/78 138/77

5.30am

8.00am

12.00pm

3.16pm

8.00pm

11.10pm

130/75 135/81 134/84 119/58 120/64 138/67

5.00am

8.20am

11.00am

3.10pm

8.00pm

128/70 133/82 146/86 132/86 151/88

12.10am

8.15am

12.45pm

3.40pm

6.05pm

7.30pm

158/65 143/79 149/89 150/90 159/95 156/91

12.10am

4.30am

8.30am

1.55pm

2.15pm

3.10pm

3.15pm

4.00pm

166/78 143/72 155/93 115/60 139/75 210/117 204/110 153/68

12.30am

8.20am

12.50pm

4.00pm

132/80 142/92 150/84 159/78

13/10 14/10 15/10 16/10 17/10 18/10 19/10 Input 750 500 600 500 1100 750 Output Total 750 50 500 550 0 Dialysis 500 750

Date

Urea (mmol/L) Creatinine (µmol/L) WBC (10 3 /µL)

14/10

12.9

526 5.4

16/10

12.1

574 7.7

17/10

13.6

612 7.5

CULTURE TEST – MRSA (POSITIVE)

RESISTANCE

Cloxacillin

SENSITIVITY

Fucidic acid Cotrimoxazole Rifampicin Erythromcin Vancomycin Gentamycin

Drug Administration Sampling time K + level (mmol/L) Na + level (mmol/L) BUN (mmol/L) Creatinine (µmol/L) Albumin (g/L) Therapeutic Range (µg/mL) Measured level (µg/mL) Comments: IV Vancomycin 1g stat 13/10/10 (6.40pm) 14/10/10 (8.30am) 4.1

130 14.4

550 17 15-20 18.55

IV Vancomycin 1g stat 14/10/10 (11.00pm) 15/10/10 (11.50am) 3.7

131 12.9

526 19 15-20 37.16

IV Vancomycin 1g stat 17/10/10 (4.35am) 18/10/10 (9.30am) 3.9

132 12.5

585 17 15-20 26.24

Level within range, can give 1g today (14/10) Above toxic range, give 1g on 16/10, 11pm (tomorrow) Still high, give 1g on 19/10

 End stage renal failure  Grade IV bedsore

End Stage Renal Failure

Stage of Chronic Kidney Disease eGFR ml/min/1.73 m

Stage 1: the GFR shows normal kidney function but the patient are already known to have some kidney damage or disease. For example, the patient may have some protein or blood in his/her urine, an abnormality of the patient kidney, kidney inflammation, etc.

Stage 2: mildly reduced kidney function AND the patient already known to have some kidney damage or disease. People with an eGFR of 60-89 without any known kidney damage or disease are not considered to have CKD.

Stage 3: moderately reduced kidney function. (With or without a known kidney disease. For example, an elderly person with ageing kidneys may have reduced kidney function without a specific known kidney disease.) Stage 4: severely reduced kidney function. (With or without known kidney disease.) Stage 5: very severely reduced kidney function. This is sometimes called end-stage kidney failure or established renal failure.

90 or more 60 to 89 45 to 59 (3A) 30 to 44 (3B) 15 to 29 Less than 15

Causes of ESRF

Diabetes. Diabetic kidney disease is a common complication of diabetes. High blood pressure. Untreated or poorly treated high blood pressure is a major cause of CKD. However, CKD can also cause high blood pressure, as the kidney has a role in blood pressure regulation. About nine out of ten people with CKD stages 3-5 have high blood pressure.

Bedsore Alternative name : pressure ulcer An area of skin that breaks down when the patient stay in one position for too long without shifting your weight.

The constant pressure against the skin reduces the blood supply to that area, and the affected tissue dies

Pressure sores are categorized by severity, from Stage I (earliest signs) to Stage IV (worst): Stage I: A reddened area on the skin that, when pressed, is "nonblanchable" (does not turn white). This indicates that a pressure ulcer is starting to develop. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin breakdown now looks like a crater where there is damage to the tissue below the skin. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes tendons and joints.

Drug treatment in the ward Current Drug Therapy Oral

Drug Name

Calcium Carbonate

Dose/Strength

500mg TDS

Duration start

19/10/2010 Benadryl Lovastatin 15 mL TDS 20 mg ON 19/10/2010 10/10/2010

Indication

To remove excess phosphate in renal failure.

It is used as a phosphate binder in the management of renal failure where it works by removing excess phosphate from the body.

Antihistamine Relieve itches that caused by excessive phosphate.

It reduces the blood cholesterol level. This helps to prevent heart disease, stroke, and related diseases in people at increased risk.

Drug Name

T.vitamin B complex Folate

Dose/Strength

I/I OD Syrup Lactulose 15 mL BD

Duration start

14/10/2010 14/10/2010

Indication

It Vitamin B complex is used in vitamin B deficiency It may take a few days for the full effect of the medicine to develop and relieve the constipation.

Drug Name

IV Vancomycin

Dose/Strength

1 g Stat

Duration start

13/10/2010

Indication

The injection is used to treat certain severe infections that are resistant to other antibiotics.

Parenteral

Formula used in the calculation:

13/10/2010 Vancomycin therapy starts  1g stat given at 6.30pm

14/10/2010 Sampling is done at 8.30 am.

 Serum level = 18.55mcg/ml; within range ( Therepeutic range = 15-20mcg/ml ) Therefore, next dose given was on the same day.

15/10/2010 Blood sampling is done at 11.50am.

 Serum level = 37.16 mcg/ml; which is above toxic level.

 C min = C max e -keT

Time ( Hour )

Serum Level ( mcg/ml)

24

24.65

36

20.08

48

16.35

Recommendation:

 With held one dose.

 Give 1g on the following day.

 However, the next dose given was on 17/10/2010

17/10/2010

1g stat IV vancomycin is given at 4.35am

18/10/2010

Blood sampling is done at 9.30am

 serum level = 26.24mcg/ml ; above toxic level  The calculated concentration after 24 hours is 17.92mcg/ml Therefore, the pharmacist recommends the next dose should be given on 19/10/2010.