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MEDICATION HISTORY:
medication indication dose Frequency of dosing Day started
atrovastatin Post MI
prevention
captopril Hypertension+
heart failure
aspirin Post MI
prevention
carvidalol Heart failure
spironolactone Heart failure
DRUG ALLERGY
No labeled allergy for any drug
SOCIAL HISTORY
Ex-smoker for 30 years 1 pack per day quit 3 years ago, non-alcoholic
:REVEW OF SYSTEMS
- CNS: -ve
- CVS: orthopnea, PND, leg swelling
- GIT: nausea without vomiting
- RS: dyspnea, cough
- GUT: dysurea, frequency, urgency, turbid urine
1
VITAL SIGNS:
date BP HR PR RR TEMP
INVESTIGATION
2
Others (U\S , ECG):
On admission:
CXR: diffuse lung infiltration signs of pulmonary edema
ECG: sinus tachycardia, old MI, left axis deviation
Day 1:
Urinalysis: turbid, pus cells=++++, RBC=6, pH= acidic, epithelial cells: +
Echocardiography: EF=45%, LV dilation
Urine culture and sensitivity
Day 3:
CXR: decrease infiltration
DIAGNOSIS:
Acute pulmonary edema (decompensated heart failure) probably exacerbated by UTI
TREAMENT .
3
Clinical progress
4
Pharmaceutical care plans
5
6
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