PHMM4124

Clinical Case
Grand Seminar
BY SITI AISYAH BINTI BURHAN
(1619342)
Patient History
Taking
 Patient Profile
MR ZAK, 75 years old, W: 86 kg, DOA : 19/2/2020, DOD: -

Chief Complaint
• Referral from Klinik Putramedik for fluid overload
• Bilateral lower limb swelling, painful

History Of Presenting Illness

• Bilateral lower limb swelling 1/52
• Associated with red discoloration
• Claims painful
• No vomit, diarrhea, abd pain, chest pain
• Worsening reduce effort tolerance for 5 days
• Orthopnea/ Paroxysmal nocturnal dyspnea (PND)
-sleeping on 2 pillows at home
• Patient walk using elderly walker
• Patient lack on mobilization
 Past Medical History
Underlying DM, HPT, CKD, HPL, Complete Heart Block
Under Cardiology Unit HTAA
-follow up next TCA March 2020
-done permanent pacemaker implantation on 19/2/2019

Past Medication History • T. Cardiprin 100 mg OD

• T. Perindopril 4 mg OD • T. Spirinolactone 12.5 mg
• T. Felodipine 5 mg OD OD
• T. Gliclazide MR 30 mg OD • T. Lasix 40 mg OD
• T. Simvastatin 40 mg OD • T. Mecobolamin 50 mg OD

Social/Family History
• Pensioner (Previously teacher)
• No smoking history

Compliance Assessment
• Not compliance to medication if without reminder from
guardian
• Patient currently under the care of KPJ Wellness Centre
(monitored by the staff)
Review of System
Blood Pressure Cardiovascular System
114/97 mmHg (Normal : 1. Bedside ECHO : good
<130/80 in patient with cardiac contractility, EF 40%
HFrEF) eye balling
Respiration Rate 2. CVS DRNM (Dual
20 bpm Rhythm Non-Murmur)

Pulse Rate
Pulmonary System
62 bpm
1. Lungs fine crepitation
over bilateral LZ
Temperature
36°C Musculoskeletal System
General Appearance • Bilateral LL swelling
1. Alert conscious • Pitting edema up to knee
2. Not tachypneic • Warm on touch edematous ,
• Skin: Erythematous
3. Warm peripheries
4. Good pulse volume
5. Hydration fair
6. No fever, abd pain, chest pain,
profuse sweating, hx of insect bite
Provisional diagnosis/ Impression/ Current diagnosis
• Decompensated CCF secondary to non-compliance to ROF
(HFrEF with underlying complete HB -on Pacemaker : EF : 48%)
• AKI with electrolyte imbalance (secondary) hyponatremia
• Lower Limb Cellulitis • Anemia
• Stable CCF • HAP

19-Feb 20-Feb to 25-Feb

• HAP
• AKI on CKD secondary to • Bilateral lower limb cellulitis
hypotension/overdiueresis. Hypotension
• Claims feel better
• Hypocalcemia

1-Mar to 4-Mar 29-Feb 26-Feb to 28-Feb

Lab
Investigations
 Place Your Picture Here and send to back

Parameter Normal Date

range 19/2 20/2 21/2 22/2 23/2 24/2 25/2 26/2 27/2 28/2 29/2 1/3 2/3

BP 120/80 118/57 127/52 117/56 110/61 134/57 126/60 123/55 130/52 120/54 111/61 87/67 145/59 130/61
mmHg
TEMP 37.2ºC 37 36.5 37 37 37 36.5 37 37 37 37 36 37 37

V I TA L S I G N
RR 12-18 22 17 20 20 20 20 20 19 20 19 18 20 20
b/min
PR 60- 59 60 59 60 61 60 60 90 61 60 60 62 61
100p/mi
n
SPO2   92 96 97 100 100 99 98 99 100 96 98 98 96
Glucose 4.4 – 7.8 6.8 4.3 5.2 5.8 4.8 5.4 7 5.2 5.1 5.5 7.7 12pm
mmol/L 6.2 6.3 5.8 6.8 7.8 5.0 6.2 5.2 4.7 5.4 7 9.2
6.20
5.8 7.3 6.2 8.2 5.7 7.7 4.5 6.8 7.7 6.5
am
7.3 7.5 8.0 6.7
8.4
(6pm)
4.8
5.4
 Full Blood Count
WBC RBC HB CRP

18
•Patient have underlying kidney
16
disease Reduced EPO
production Reduce RBC, Hb
14
level Anemia
12
•High WBC, CRP : Sign of
10 infection

0
19-Feb 20-Feb 21-Feb 25-Feb 28-Feb 1-Mar 2-Mar
 Place Your Picture Here and send to back
Parameter Normal Day/Date
range 19/2 21/2 28/2 1/3 2/3
• Hyponatremia
Urea 2.8-7.2
probably due
11.1 11.2 13 16.5 17.4
mmol/L to overdiuresis

RENAL PROFILE
Serum 135-146 130 132 136 136 138
sodium mmol/L
• Patient had
AKI with
Serum 3.5-5.1 4.2 4.3 3.4 3.2 4.2 underlying
potassium mmol/L CKD
Serum 95-108 98 101 92 95 97
chloride mmol/L • AKI Stage 2
Serum 2.20-2.65  - - - 1.85 1.87 Increase >
Calcium two- to
Serum 0.73-1.06 threefold from
 -  -  - 0.87 0.89
Magnesium mmol/L baseline

Serum 0.81-1.45  - - - 1.41 1.52 • High

Phosphate mmol/L phosphate
level due to
Creatinine 44-133 111 105 180 288 340 failure of
mmol/L excretion by
eGFR >90 56 60 31  - 14 kidney thus
ml/min/1.73 leading to
m2 hypocalcemia
Creatinine 97–137 62 65 38 24 20
Clearance mL/min
Parameter Day/Date

20/2 21/2 22/2 23/2 24/2 25/2 26/2 27/2 28/2 29/2 1/3

IO CHART & WEIGHT

 
Total input (ml) 900 210 470 330 325 775 950 945 475 627.2 457
 
 
Total output (ml) 3050 3300 3300 2600 3900 3100 850 900 750 200 1279
 
 
Balance (ml) -2150 -3090 -2830 -2270 -3575 -2335 +100 +45 -275 +427.2 -822

• Fluid retention : Warm and wet CHF

DAILY WEIGHT
Date 20/2 21/2 22/2 23/2 24/2 25/2 26/2 27/2 28/2 29/2 1/3 2/3 3/3 4/3
 Weight 98.7 94.2 91.3 91.1 86.8 82.2 88 87.1 86.8 85.9 85.2 85 87.8 86.2
(kg)

• Decrease in weight shows that fluid retention was improving

Medication In
Ward
 Medication In Ward
 Medication Indication 19/2 20/2 21/2 22/2 23/2 24/2 25/2 26/2 27/2 28/2 29/2 1/3 2/3 3/3
IV Unasyn 1.5 g                            
TDS IV infuse for
1 week Lower Limb Cellulitis
Potassium
Permanganate
0.1% : TDS
IV Tazosin 4.5 g Hospital Acquired                            
QID iv infuse for Pneumonia
1 week
IV Frusemide 40                            
mg STAT
IV Frusemide 40                            
mg BD for 1
week
  Acute Kidney Injury,
Heart Failure
Tab Frusemide (Fluid Retention)                          
40 mg BD for 1
week

IV Frusemide 40                            
mg TDS IV Bolus
for 2 days
  Medication Indication 19/2 20/2 21/2 22/2 23/2 24/2 25/2 26/2 27/2 28/2 29/2 1/3 2/3 3/3

Spironolactone 12.5 mg                            
OD oral for 1 week
Spironolactone 25 mg                          
OD oral for 1 week
Heart Failure,
Tab.Valsartan 80 mg BD Hypertension                            
for 1 week
Sacubitril/Valsaratan 50                            
mg (Entresto) (Drug
Sample) tablet : 50 mg
BD oral for 1 week

Noradrenaline 4mg/4ml Hypotension                        

Inj IV Infuse 41.15 mcg  
over 1 hr for 1 day  
 

Cardiprin 100 mg OD for Prophylaxis                            

1 week after meals from thrombo
  embolism
 
  Medication Indication 19/2 20/2 21/2 22/2 23/2 24/2 25/2 26/2 27/2 28/2 29/2 1/3 2/3 3/3

Tab. Simvastatin 40 Heart Failure                            

mg OD at night oral
for 1 week

Metformin 500 mg                            
BD after meals oral Type 2
for 1 week Diabetes
Mellitus
Empagliflozin Tab 25                            
mg OD oral for 1
week
Disease
Management
 MANAGEMENT IN WARD
19/2/2020 until 25/2/2020
Lower Limb Cellulitis • IV Unasyn 1.5 g TDS IV infuse for 1 weeks
• Potassium Permanganate 0.1% solution : TDS topical

GOAL OF THERAPY EBM MANAGEMENT

• Eradicate the bacteria. 1. To cover gram-negative bacteria and anaerobes, one of
• Prevent the development of osteomyelitis and the need for the following agents would be preferred (dosed for renal
amputation. dysfunction when indicated):
• Preserve as much normal limb function as possible.
✓ Piperacillin/tazobactam 2.25 g IV Q 6 h;
• Prevent infectious complications
✓ Ampicillin/sulbactam 3 g IV Q 8 h;
SUBJECTIVE ✓ Ertapenem 500 mg IV Q 24 h;
• Red discoloration of lower limbs
2. Non Drug Therapy
• Claims painful, no fever, Bed rest, minimal weight-bearing, leg elevation, and
• Ambulating using walking frame control of edema
• History of admission to KPJ 1 week ago for LL cellulitis, was given Reference : NAG 2019, Pharmacotherapy Casebook : A
IV antibiotic, claimed that condition improved Patient-Focused Approach (Access Pharmacy)
OBJECTIVE
Bilateral lower limb swelling and redness, erythematous, edematous, warm on touch, CRP:3 (21/2/2020)
CNS : SFNG (25/2/2020) Anaerobic Blood Culture (Source : Blood)

REMARKS
• Patient claims feeling better on 25/2/2020 (5 days abx) but CRP and WBC still higher than normal.
• Class III CREST Severe Cellulitis. LL Cellulitis improved but there was still sign and symptom of infection..
• This tells that the antibiotic given were not effective.Insufficient dose of Unasyn.
 MANAGEMENT IN WARD
Decompensated CCF Secondary To Infection 1) IV Frusemide 40 mg STAT (19/2/2020)
(LLC), Non-compliance To ROF 2) IV Frusemide 40 mg BD (21/2-22/2/2020)
3) Tab. Frusemide 40 mg BD (23/2/2020-24/2/2020)
4) IV Frusemide 40 mg BD (24/2-26/2/2020)
GOAL OF THERAPY 5) IV Frusemide 40 mg TDS (27/2-28/2/2020)
• Provide symptomatic relief while optimizing volume status 6) Spironolactone 12.5 mg OD (20/2/2020)
and CO so that a patient can be discharged in a stable 7) Spironolactone 25 mg OD (21/2/2020 – 28/2/2020)
compensated state on oral drug therapy. 8) Valsartan 80 mg BD (20/2/2020 – 26/2/2020)
9) Sacubitril/Valsartan 50 mg (Entrestol) (Drug Sample) tablet : 50
SUBJECTIVE mg BD oral (27/2/2020 – 29/2/2020)
• Exercise intolerance in 5 days EBM MANAGEMENT
• Orthopnea For patient HFrEF (LVEF < 40%);
• Paroxysmal nocturnal dyspnea (sleeping with 2 pillows) In stepwise manner, initiate:
• Diuretics if volume overload/congestion is present
OBJECTIVE (including MRA)
Peripheral edema (Fluid overload) • ACE-I (or ARB if ACE-I intolerant) or ARNI
• β-blockers if no signs of volume overload/congestion
• MRA
REMARKS
• Patient has adequate perfusion (based on BP readings and SPO2) but with fluid retention : classified as Warm and Wet
• Patient have complete heart block (depend on pacemaker). Absolute contraindication for Beta-Blocker.
• Patient were considered not hemodynamically stable (based on inconsistent BP readings), but still initiated with antihypertensive.
 MANAGEMENT IN WARD
AKI with electrolyte imbalance • IV Frusemide 40 mg BD for 1 week
(hyponatremia) secondary to CCF • Stop Frusemide on 20/2/2020, decrease IV Frusemide to 40 mg BD
(21/2/2020) and increase ROF to 800 cc/day
• Patient was on CBD
GOAL OF THERAPY
• Minimise the degree of insult to kidney, reduce extrarenal EBM MANAGEMENT
complication, expediting recovery of renal function.
• Therapy should focus on maintaining organ functions while • Maintenance of adequate cardiac output, blood pressure to
sustaining mean arterial pressure. The ultimate goal is to have optimise tissue perfusion.
the patient’s renal function restored to pre-AKI baseline. 
• Discontinue medication related to diminished renal function.
SUBJECTIVE • Initiate fluid and electrolyte management.
Oliguria (catheter bag drainage upon admission) • If plasma sodium level is >120 mmol/L, aggressive treatment
is generally not required. Gradual correction can be achieved
OBJECTIVE by water restriction or administration of normal saline or oral
salt.
28/2/2020 - 2/3/2020
• Urea : 13 -> 16.5 -> 17.4 • Reference : Sarawak Handbook Medical Emergencies, Dipiro
• Creatinine : 180 -> 288 -> 340

REMARKS
• Fluid overload was improving. Patient return to dry body weight starting from 27/2/2020.
• Frusemide stopped starting 29/2/2020 because goal achieved and prevent worsening of AKI.
• LD can effectively reduce fluid overload, but can worsen AKI. KDIGO guideline recommend limiting the use of LD for sole purpose of treatment of
AKI.
 MANAGEMENT IN WARD
Hospital Acquired Pneumonia • Piperacillin/tazobactam 4.5 g IV QID for 7 days
(Late Onset: 26/2/2020 diagnosed)
EBM MANAGEMENT
GOAL OF THERAPY  According to NAG (2019), this patient is considered
• To eradicate causative organism suffering from late onset HAP which is defined as 5
• To avoid unnecessary antibiotics usage days or more of admission.
 The preferred treatment for late onset HAP is
SUBJECTIVE piperacillin/tazobactam 4.5 g IV q6-8h for 7 days.
Patient is assymptomatic, no sob, no chest pain  However, for renal impaired patients with CrCl <20
ml/min, the dosage should be adjusted to 2.25 g IV
OBJECTIVE q6h for HAP (MIMS Malaysia, Medscape).

• Lungs crepitation on the left side till midzone  Meanwhile, the alternative treatment for late onset
• Bilateral pleural effusion HAP is imipenem/cilastatin 500 mg IV q6h for 7
days (NAG, 2019).

REMARKS
This patient received correct medication with correct indication but incorrect dosage. The doctors must consider the deteriorating
renal function of patient.
 MANAGEMENT IN WARD

Hypotension • Noradrenaline 4mg/4ml Inj IV Infuse 41.15 mcg over 1 hr

• Start on 2 pm 29/2/2020 and tapper down and stop on
2/3/2020
GOAL OF THERAPY
EBM MANAGEMENT
• To increase blood pressure to the normal baseline
• To relieve sign and symptom • Norepinephrine 1 mg/1 ml
• Initial: 8-12 mcg/minute intravenous (IV) infusion; titrate to
effect
SUBJECTIVE • Maintenance: 2-4 mcg/minute IV infusion
• the rate in mL/hour depends on the weight of the patient
• Feel giddy when standing (and the desired rate of infusion
• Nausea
REMARKS
OBJECTIVE
 Patient were considered not hemodynamically stable
• BP Standing : 80/40, Postural hypotension (on 28/2/2020) (based on inconsistent BP readings), but was given with
• BP lowish 80-84/40-53 (29/2/2020) additional antihypertensive
• BP stable on NA (29/2/2020)
• Patient asymptomatic comfortable, no active complaint
 MANAGEMENT IN WARD

Type 2 DM •
•
20/2/2020 – 27/2/2020
Metformin 500 mg BD after meals oral for 1 week
• Empagliflozin Tab 25 mg OD oral for 1 week
• Withold on 28/2/2020 when eGFR : 31 ml/min
GOAL OF THERAPY
• To achieve appropriate glycemic levels EBM MANAGEMENT
• To reduce risk of microvascular and macrovascular Pharmacotherapy Recommendations for Patients with Diabetes
complications. Mellitus and Cardiovascular or Chronic Kidney Disease
• To improve quality of life
 Several SGLT2i have also been shown to positively impact
cardiovascular outcomes. In patients with established ASCVD and
SUBJECTIVE T2DM, canagliflozin or empagliflozin offer cardiovascular benefit.
 
•Feeling very tired much of the time Reference : Related to: Chapter 74, Diabetes Mellitus in DiPiro
and Chapter 43, Diabetes Mellitus in Chisholm-Burns textbooks.
•Very dry skin
•Sores that are slow to heal It is recommended that metformin should be discontinued once
eGFR falls below 30 ml/min/1.73 m2 and to decrease the metformin
dose in mild to moderate renal impairment (eGFR 30–60 ml/min/1.73 
OBJECTIVE m2)
Reference : Journal of Diabetes Research
• Glucose level is well controlled
REMARKS
 Patient glucose level were under control.
 Both medication were withhold until eGFR improved.
 MANAGEMENT IN WARD

Anemia NCNC • Not treated

GOAL OF THERAPY EBM MANAGEMENT

• To restore substrate needed for RBC production  Erythropoiesis-stimulating agents (ESAs)

• Replace body stores o Epoetin alfa 50-100 units/kg three times per week
• Prevent long term complications o Darbepoetin alfa 0.45 ncg/kg once every 4 weeks
o Methoxy polyethylene glycol-epoetin (PEG) beta 0.6
SUBJECTIVE mcg/kg every 2 weeks, once Hb stabilizes, double
the dose and administer monthly
• No fever, not tachypneic, no syncopal presyncopal attack
 Regular iron supplementation to maintain hemoglobin
concentration and prevent the need for blood
OBJECTIVE transfusions. There is a higher risk of cardiovascular
• events when hemoglobin is targeted to a value of greater
Pbf (peripheral blood film) : consider anemia of chronic
disease than 11 g/dL (110 g/L; 6.83 mmol/L).
• Hb 8.0 -8.2 g/dL (Normal : 13.0-17.0 g/dL) since 19/2 until o Oral iron therapy of 150 to 200 mg elemental iron in
25/2, alert, comfortable, not tachypneic two/three divided dose
• Serum iron : 5 umol/L on 20/2 .
(Normal : 12.5-32.2 umol/L) REMARKS
CKD-induced anemia
 Hypocalcemia
MANAGEMENT IN WARD
GOAL OF THERAPY
• Not treated
• To prevent further complication such as tetany, worsened the
myocardial contractility

EBM MANAGEMENT
SUBJECTIVE  Calcium carbonate (40% elemental calcium ), 0.5 – 1 g
(elemental calcium) three times daily with meals.
• Patient is asymptomatic
 Calcium acetate (25% elemental calcium) 1334 mg three
tines daily with meals.
.
OBJECTIVE
Hypocalcemia from 1/3/2020 -2/3/2020 REMARKS
(Ca corrected : 2.03 on 1/3/2020)
CKD-Related Mineral Bone Disease
(Total serum Ca : 1.87, 1.85)
DRP / PCP
 Pharmaceutical Care Plan
Recommendation Monitoring and Follow Up
Actual DRP: Improper dose Insufficient treatment using IV Unasyn
- The recommended renal dose is IV Unasyn 3 g TDS for 5 to 10 • Monitor signs and symptoms of

01 IV Unasyn 1.5 g TDS IV infuse for 1 week days. 

IV Tazocin 4.5 g QID for 7 days
IV Tazocin
Suggest to consider the renal dose of patient. May reduce the
infection.
• Monitor WBC, platelet and
temperature of the patient.
dose first. Hence, the patient should be receiving IV Tazocin • Monitor C&S. Monitor side effects of
2.25 g QID. medication.

PCI : Ineffective antibiotic treatment but Recommendation Monitoring and Follow Up

no adjustment made After 2-3 days of antibiotic, if the person was not
 improving, the antibiotic used should be change to  Monitor sign and symptoms
From 19/2/2020 until 25/2/2020, patient
other alternative treatment for same indication. such as fever, malaise,
received IV Unasyn. The patient lower dyspnea, chest pain
Suggest to change to alternative treatment after 3
02 limb cellulitis improving (no calf
tenderness, reduced redness) but the level
days of ineffective Unasyn
 IV Tazocin 2.25 g QID for 5-10 days


Monitor WBC, CRP
Monitor renal function

of WBC and CRP was still high.

Also, after 7 days of IV Tazocin, the patient still have
high WBC, suggest to change antibiotic with IV
Meropenem 1 g TDS for 7 days
 Recommendation Monitoring and Folluw Up
PCI : Improper time of initiation

03
• The medication should be given once the patient was Monitor BP and kidney function
Sacubitril/Valsaratan 50 mg (Entrestol) hemodynamically stable.
(Drug Sample) tablet : 50 mg BD oral •
for 1 week

Recommendation
 Erythropoiesis-stimulating agents (ESAs) Monitoring and Follow Up
• Monitor the Hb and RBC of the
 Epoetin alfa 50-100 units/kg three times per week
patient.
Actual DRP : Untreated Condition  Darbepoetin alfa 0.45 ncg/kg once every 4 weeks
04 NCNC Anemia
 Methoxy polyethylene glycol-epoetin (PEG) beta 0.6
mcg/kg every 2 weeks, once Hb stabilizes, double the
•
•
Monitor the BP of the patient
Monitor electrolytes of the
patient such as potassium and
(CKD-induced anemia) dose and administer monthly Vitamin B12 levels, as well as
 Suggest to add on Ferrous Fumarate 200 mg TDS hematocrit and reticulocyte count

Recommendation Monitoring and Follow Up

 Suggest for oral calcium supplementation
- Calcium carbonate (40% elemental calcium ), 0.5 – 1 g
 Monitor calcium level
Actual DRP : Untreated Condition
05 Hypocalcemia
(elemental calcium) three times daily with meals.  Monitor ECG
- Calcium acetate (25% elemental calcium) 1334 mg three
 Monitor side effects
tines daily with meals.
Discharge
Summary
Proposed Discharge Medication
Tab. Frusemide 40 mg OD when necessary
This medication is for fluid overload. Take one tablet once daily after meals when
necessary.The side effects of the medication includes headache, hypertension,
muscle cramps, dry mouth, thirst and weakness
Tab. Sacubitril/Valsaratan 50 mg (Entresto) BD
This medication is for the treatment of heart failure with reduced ejection fraction. Take one tablet
two times daily with or without food. The side effect of the medication includes , dizziness,
headache, syncope, vertigo, orthostatic hypotension, cough, diarrhea, nausea, gastritis, renal
failure
Tab. Aspirin 100 mg glycine 45 mg (Cardiprin) 100 mg OD after meals
This medication is for prophylaxis against thromboembolism that can cause stroke and
heart attack. Patient have risk factor for thromboembolism which is complete heart block.
Take one tablet immediately after meals. Swallow tab whole with water. The side effects of
the medication includes dyspepsia.
4. Tab. Take one tablet once daily at night
Simvastatin with or without meals. The common DISCHARGED PLAN
40 mg OD side effect of this medication
includes abdominal pain,
constipation, headache, COUNSELLING
rhabdomyolysis.
POINTS
5. Fluid overload
-Reduce salty food intake
-Follow strictly fluid restriction
-High fluid intake negates the positive effects of
diuretics and induces hyponatraemia
-Avoid anything that can trigger cellulitis such as
injury due to insect bites, cut, fracture, burn that
allow the entrance of bacteria, eczema

6. Avoid or reduce intake meals with high calories,

cholesterols, sugar. Eat more fruits and fresh
vegetables, whole grains and fish.
7. Try to reduce your intake of saturated and trans
fats, and increase your intake of omega-3 fatty
acids.
8. Exercise at least 30 minutes a day
Thank You
May Allah bless us all