1

212 511010046 .

Infectious Disease
511010045 511010062 23 2554 511010071

47

Patient Medical Profile

50 kg.

162 cm. (BMI

30

19 kg/m2) 2554

(Chief complaint)

(History of present illness) 3 1 I131, I131 induced

(Past medical illness) Thyroid toxicosis (Grave s disease) ( . . 43) hypothyroidism ( . .52), Thyroid cancer (Inoperable)

(Social History): (Family History) Rocil (Clindamycin) : Generalized erythematous MP Naranjo s score=7; probable rash (physical examination) Vital sign: T 37 c RR 20 /min O2sat 95% PR 80 /min BP 107/73 mmHg General appearance: A middle age woman with normal consciousness HEENT: mild pale, no icteric sclera, exopthalmos neck mass with tracheostomy Heart: regular, no murmur

(Medical History) Codeine Phosphate 15 mg + Paracetamol 300 mg 1x3 Ondansetron 8 mg 1x3 Acetylcysteine 200 mg 1x3 Tramadol 50 mg 1x4

Lung: Inspiratory stridor both lungs, secretion sound Abdomen: Soft, not tender, jejunostomy exist (no redness, pus) Extremity: no edema Neurologic: normal consciousness, stiff neck negative Skin: no rash Vital signs and Input/Output

(c) 37.3 37.3 38.1 37.9 38.1 37.6 38.1 39.0 38.1 38.3 39.4 37.9 37.6 37.5

(mmHg)

30/10 1/11 2/11 3/11 4/11 5/11 6/11 7/11 8/11 9/11 10/11 11/11 12/11 13/11

107/73 132/88 90/60 132/86 160/11 120/90 140/110 145/196 160/90 119/67 140/90 141/86 110/70 100/70 93/60 100/70 100/70 112/58

Respiratory rate ( / )

20-24 20-24 20-28 20-24 20-24 20-24 20 20 20-24 20-24 19-24 18-23 20-24 20-22

Pulse Rate ( /

Input (ml.)

Output (ml.)

Pain score

96

3400 3300 1700 2800 2400 3450 2650 2200 2500 3250 4000 3350 3300

1300 1050 800 200+

10 10 5 0 0 8 10 5 10 5 5 10 0

72 114 126 102 108 109 130 134 92 124 80 94 112

3100 1950 1900 2200 1650 2100 2300

Hematology
Hb (10-15) Hct (40-50) WBC (500010000)

30/10 12.0 36.1 10900 89.0 0.3 0.1 4.8 5.8 770000 84.3 28.0 33.2

3/11 11.5 36.3 10800 80.7 0.9 0.7 7.3 7.7 886000 84.3 -

7/11 12.1 37.2 14400 93.1 0 0.1 2.1 4.7 772000 85.2 28.0 32.9

9/11 12.3 17840 91.2 0.5 0.1 1.5 6.0 767000 81.7 26.9 32.9

Neu (40-75%) Eos (1-3%) Baso (0-1%) Lym (25-35%) Mono (3-6%) Plt (100-400K) MCV (82-98) MCH (28-32) MCHC (32-28) Blood chemistry 30/ 10 Glu (70124
110) BUN (7-24) sCr (0.61.6) CrCl Na (137150) K (3.5-5.3) Cl (98-111) TotCO2 (19-29) Total Ca (7-11)

3/11 88 12 0.7 78.5 147 3.3 102 36 11.9 13.1 4.4

4/11 163 12 0.8 68.6 144 3.5 102 30 10.6 11.9 4.2

5/11 17 0.7 78.5 144 3.1 98 35 11.1 12.5 2.7

6/11 3.9 11.7 -

7/11 21 0.7 78.5 148 3.3 109 35 10.4 11.7 3.2

8/11 22 0.9 61.0 157 3.9 110 40 11.6 12.0 -

9/11 204 27 0.8 68.6 152 3.7 107 35 12.0 3.4

11/1 1 28 1.1 49.9 155 2.8 117 39 12.2 2.9

20 0.8 68.6 137 3.6 94 31 -

Corrected Ca Inor P

(2.5-4.5)
Mg (1.52.2) Tot prot (68.5) Alb (3.2-5)

1.94 2.5

1.94 6.5 2.4

1.74 2.2

2.4

1.99 6.1 3.5

2.06 -

2.0 -

Sputum gram stain 30/10/54 (Many PMNs , Low squaremous epithelial cell) Gram negative bacilli Positive bacilli Positive cocci Positive cocci bacilli Grade Moderate few few few

Sputum culture 7/11/54 Pseudomonas aeruginosa Susceptible Meropenem Colistin Resistance Piperacillin/tazobactam

Pleural fluid 8/11/54 Gram strain: no bacteria found Body fluid chemistry( Exudate) : Glucose: 34/163 LDH: 318/189 Protein: 3.7/6.5

Pleural fluid 9/11/54 Gram strain: no organism

Body fluid chemistry( Exudate) : Glucose: 126/204 LDH: 389/235 Protein: 3.3/6.0

Thyroid function test TSH (0.27-4.20 U/ml) FT4 (0.9-1.70 ng/ml) FT3 (0.18-0.46 ng/ml)

3/11/54 43.4 0.34 0.10

Problem list 1 : Pneumonia (HCAP) 30/10/54 DRP: Need for additional drug - Ciprofloxacin Subjective data: Objective data: CXR : Pulmonary infiltration

Sputum exam: moderate negative bacilli, few positive bacilli , few positive cocci, few positive cocci bacilli (Many PMNs , Low squamous epithelial cell) Vital sign : RR = 20-24 BUN: 20 mg/dl Scr: 0.8 mg/dl / PR = 96 / Temp = 37.3 c

CBC : WBC = 10,900 Neu = 89%

Assessment : Etiology: infiltrate

30 10900 cell/mm3

2554

Pneumonia CAP

10000 cell/mm3

22 - 30

2554

Jejunostomy tube Jejunum nodule (3 7 (Respiratory Obstruction) 30

Jejunostomy tube

) (Trachyostomy)

2554

60

HCAP

HCAP) 2 90

(healthcare-associated pneumonia,

Acinetobacter species Methicillin Resistant Staphylococcus aureus (MRSA) K. pneumonia moderate negative bacilli

P. aeruginosa, E. coli, K. pneumonia S. aureus Sputum exam

Resistant Staphylococcus aureus (MRSA) few positive cocci bacilli

Acinetobacter species , few positive cocci

Streptococcus pneumoniae

few positive bacilli Methicillin

P. aeruginosa

Indication for Therapy : Jejunum Assesment of Therapy : HCAP American Thoracic Society

Carbepenem

Fluoroquinolone Aminoglycoside Methicillin Resistant Staphylococcus aureus (MRSA) Vancomycin

Antipseudomonal Cephalosporin Antipseudomonal -lactam/ -lactamese inhibitor Antipseudomonal Linezolid

aeruginosa

sputum exam

P.

Antiobiogram

Piperacilln/Tazobactam Streptococcus spp., Enterococcus spp., Peptostreptococcus spp., Staphylococcus spp. (MRSA, MRSE) species Enterobacteriaceae Acinetobacter Piperacilln/Tazobactam Ciprofloxacin Aminoglycoside serious side effect (Neurotoxicity, Ototoxicity) Vancomycin intermittent infusion 60 Red

empirical therapy

man red neck syndrom ( maculopappular rash Sputum exam Vancomycin Methicillin Resistant Staphylococcus aureus (MRSA)

Ciprofloxacin 400 mg IV

Piperacillin 4 g Tazobactam 500 mg IV 8 empirical therapy , , ,

Cipro oxacin DNA (synergism) IV

) Piperacilln/Tazobactam Topoisomerase II

Plan : Goal:

Therapeutic plan: IV infusion

(burning, pain, ereythema ,swelling) Therapeutic monitoring:

60

Ciprofloxacin 400 mg IV 8 venous irritation 2 mg/ml

1. Vital sign (Body temp., RR, HR) 2. 3.

, WBC,neutrophill

di erential, PT, PTT; sign of bleeding ;monitor for sign anaphylaxis during first dose 4. Cipro oxacin CBC,

Piperacillin/Tazobactam

Creatinine,BUN,CBC with

CYP 1A2 inhibitor (strong) CYP3A4 inhibitor (weak) ,P-glycoprotein substrate drug interaction 5.

Toxic mornitoring: Piperacillin/ Tazobactam: , Meropenem:

, , Ciprofloxacin:

serious hypersensitivity, peripheral visceral disorder anemia Patient education: Future plan:

Problem list 2 : Pain management DRP : Need for additional drug therapy - Morphine Subjective data : Objective data :

10

31/ 10 10

Past medical history Codigesic (Codeine Phosphate 15 mg + Paracetamol 300 mg ) 1x3 Onsia (Ondansetron 8mg) 1x3 Tramadol 50mg 1tab q 8 hr Pain score (VAS) 01/ 02/ 03/ 04/ 05/ 06/ 07/ 08/ 09/ 10/ 11/ 12/ 13/ 14/ 11 11 11 11 11 11 11 11 11 11 11 11 11 11 10 5 0 0 8 10 5 10 5 (pain 5 10 0 5-10 0 ( 0 score)

) Bone scan (15/10/54) : single bone metastasis at left proximal femur Assessment : Etiology: 3

78

19

migraine

thyroid cancer Indication of therapy : pain score =

anaplastic

5-10

Nociceptive pain

11

(Somatic (referred pain) (chonic

pain) pain)

prn Assessment of therapy : 2554 1 2554

(breakthrough

pain)

(pain score)

31

breakthrough weak opioids (codeine methadone 3 Morphine 20mg BID pc tramadol) strong opioids 2554 7 morphine, fentanyl

pain

Morphine syrup 3 ml prn q 6 hr 2554

12

morphine rescue dose

syrup opioids

morphine 20-25% breakthrough

sustained

release

pain

incident pain 5-11 2554 5-10 pain score

rescue dose Plan : Goal

Therapeutic plan : Rescue dose

20-25% Morphine 20mg BID = 40mg/day 20/100 x 40mg = 8 mg of Morphine 25/100 x 40mg = 10mg of Morphine Rescue dose Morphine 8-10

mg

Therapeutic monitoring : (Furrowed brow) Toxic monitoring : (Sedation) , , ( , RR ) education

(pain score 0-10) opioids (Delirium), Myoclonus, opioids :

Patient

Future

plan

13

Problem list 3: Hypercalcemia DRP: Need for additional drug 0.9% saline, bisphosphonate Objective data: Corrected Ca (3/11/2554): = 13.1 mg/dl

associated 20%

Bone scan (15/10/54): single bone metastasis at left proximal femur Assessment : Etiology: Hypercalcemia with malignancy 10-

osteolytic factor (PTH-rP) PTH 13

bone resorption,

humoral factor parathyroid hormone related peptide PTH PTH receptor

tumor necrotic factor, prostaglandin E

Bone scan

single bone metastasis at left proximal femur Indication of therapy : acute renal oliguric renal failure, coma, ventricular chronic renal insufficiency Assessment of therapy : calcification

insufficiency, obtundation arrhythmias

Hypercalcemia associated with malignancy (Hospital physician Hospitalist) 14 mg/dl ) 0.9%

moderate hypercalcemia (corrected Calcium = > 12 volume,

Internal medicine

saline

14

Bisphosphonates Bisphosphonates

proximal tubule

48

Plan : Goal : Therapeutic plan :

8.5

10.5 mg/dl

-normal saline IV infusion 200 300 ml/hr urine output = 150 ml/hr zolendronic acid 4 mg/dl IV infusion 15-30 urine output = 100 mL/hr acute reaction (eg. Arthralgia, fever, flu-like symptom, myalgia) acetaminophen Therapeutic monitoring : (corrected calcium) Toxic monitoring : CrCl, BUN, Scr

Problem list 4 :Hypokalemia DRP : without DRP Subjective data: Objective data: Serum potassium (3/11/2554): = 3.3 mEq/L (5/11/2554): = 3.1 mEq/L (7/11/2554): = 3.3 mEq/L (11/11/2554): = 2.8 mEq/L (12/11/2554): = 3.6 mEq/L

Assessment: Etiology: Hypokalemia

(K <3.5 mEq/L) 2 low K+ intake, increased K+ loss hyperaldosteronism, renal tubular acidosis, diuretics, alkalosis, poorly reabsorp anion vomiting, diarrhea, fistula, villous adenoma shift

15

alkalosis

(redistribution phenomenon) diuretics, 2-agonist insulin

drug-induced metabolic

Indication of therapy :

Assessment of therapy : hypokalemia mild moderate IV q total body deficit 200 mEq/L K = 60 mEq/L

serum potassium 4 serum K serum K KCl

KCl 30 ml (60 mEq) hr 1 mEq/L 0.3 mEq/L 30 ml (60 mEq)

serum potassium

Plan: Goal : Therapeutic plan :

(3.5-5.3 mmol/L) KCl 30 ml (60 mEq) IV infusion

Therapeutic monitoring : serum potassium hyperkalemia (K > 5.5 mEq/L) , glucose, CL, pH, Urine output , cardiac monitor Toxic monitoring : , , hyperkalemia

: 1. American Thoracic Society Documents. Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia. Am J Respir Crit Care Med.2005;171: 388-416.

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2.

; 2547 3. Jibrin IM, Lawrence GD and Miller CB. Hypercalcemia of Malignancy in Hospitalized Patients. Hospital Physician 2006 Nov:29-35.

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