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Case study

Case study. Done by : Mohannad AL.shibani clinical pharmacist intern Supervised by: Dr. Muna Fliflan. FILE NO. :248758. CASE. ROOM NO. :451 D. 86 years Saudi male,70 KG, presented to ER. On (16/10/2008) C/O fever, productive cough, and not eating well since 2 day back.

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Case study

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  1. Case study Done by :Mohannad AL.shibani clinical pharmacist intern Supervised by: Dr. Muna Fliflan 1

  2. FILE NO. :248758 CASE ROOM NO. :451 D 86 years Saudi male,70 KG, presented to ER. On (16/10/2008) C/O fever, productive cough, and not eating well since 2 day back. Patient was discharged from medical department 1 month back (13/9/2008) on case of “”drug induced hypoglycemia”” and all his medication was stopped .then he was well until 7 day back when he started to have fever 39°C . He was seen in polyclinic and discharge on antibiotic and cough syrup but was not given to patient . 2 days back patient was lethargic with fever ,decrease in appetite and weakness. he is not eating well according to his son and he took him to private polyclinic and found to be febrile and dehydrated with blood glucose 420 mg/dl. They gave him IVF ,insulin and they told him to take patient to big hospital. 1

  3. Case cont….. Past medical history: • Type 2 DM from • HTN • Old CVA 1

  4. Case cont….. Past medication: • ASA 81 mg po OD • Omeprazole 20 mg po OD • Glibenclamide • Metformin • HCTZ D/C on 13/9 1

  5. Case cont….. • Diagnosis: chest infection and dehydration • Vital signs: Temp. 38.5°C Bp. 161/83 mm/Hg pulse 70/min RR. 22 /min 1

  6. Case cont….. Physical examination: 16/10/2008 • Skin & extremities: not pale or jaundice, sleepy , difficult in hearing • Eyes , ears & neck: normal • Chest wall & lungs: clean with equal air entry bilaterally, spontaneous breathing & yellowish sputum • Cardiovascular: S1 + S2 + 0 • Abdomen : soft , no organomegally • Bone & joints : skin pealing & dry bed sores • Mental status : conscious 1

  7. 1

  8. OSMO.= 265 k =2.8 mmol/l Alb.= 2.4g/dl Na= 132mmol/ ESR.= 45 mm/hr INR= 0.9 PTT=27.5 (control=31.6) PT=10.8(control=12.5) urine is light , yellowish & turbid appearance PH=6.5 Glucose: +ve leucocytes :+ve WBC= 60-70 Bacteria: +++ve Neut.=9.46 WBC=11.56 RBC= 3.77 Hgb=11.00 g/dl Hct= 31.6% • Dermatology counseling • 2) Add lantus 10 U am. • 3) Add fucidin ointment locally BID • 4) Add flamazine ointment locally BID 1

  9. BUN=25.3 Na=130 Glu=288 WBC=11.9 RBC=3.8 Hgb=11.1 1) lantus 10 U pm. 2)add RI. 8 U SC. TID premeal 3)D/C sliding scale 4)add clexane 40 mg SC. OD 5) dermatolodist seen pt. then change dreesing daily 6) continuous other treatment 1

  10. 1)bilateral hand swelling in Rt. Hand 2) febrile vital stable 1) increase lantus to 14 U Pm. 2)incourage oral intake 3) D/C IVF. 4) Continuous the treatment 5) C.S.T 6) Repeat chemistry 1

  11. 1)sacral ulcer not improve 2)cough developed during take pre meal 3)lab showed no growth factor on blood after 5 days 1) BUN=25.9 2) Na= 131 1)insert NGT but his son refused 2) Continuous the treatment 3)C.S.T again 1

  12. 1)sacral ulcer still not improve 2)pt. fine, febrile vital stable 1)Urine culture showed Enterococcus spp. 1) BUN=28mg/dl 2)ALB=2.5g/dl 1)RBC=3.85 2)Hgb=11.1 3)Hct=33.2 1)increase lantus to 18 U Pm. 2)repeat CBC chemistry 1

  13. Pt. fine, febrile vital stable Decrease RI. to 4 U SC. TID 1

  14. Diabetic follow up 1

  15. Discussion • Why? • Factor associated with switching to insulin: I.younger at diagnosis II.Suffer from more health proplem espicially cardiovascular disease III.Have worse metabolic control IV.HbA1c > 8% 1

  16. Discussion cont.. • Protocol used when switch to insulin: • Single dose of bedtime(long acting) insulin plus daytime sulfonylurea • Two injections of intermediate acting insulin • Multiple daily injection, combination of short acting and intermediate acting • Single dose of bedtime(long acting) insulin plus three times rapid acting insulin before meals 1

  17. Thank you 1

  18. reference • http://grande.nal.usda.gov/ibids/index.php?mode2=detail&origin=ibids_references&therow=485719 • Wayne A.Kradjan.Handbook of applied therapeuetic.Lippincott Williams and Wilkins.8th ED,2007;Chapter 49,page:650-69 1

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