Medical clinical case study

1. NOSOCOMIAL PNEUMONIA
CASE STUDY
KAVITHA SATHASIVAN
19/07/2012

2. • 64 yr old, male was readmitted to 4A on 10/07/12 due to unresponsiveness (poor GCS-
E3V2M2) possible 2^ to CAP with poor oral intake.
• He was discharged previously on 08/07/12 where he was treated as
1)recent CVA with left hemiparesis (CT Brain done on 5/7/12 & found left sided old
infarction)
2) Acute renal impairment secondary to dehydration
3) Hyponatratemia due to poor oral intake
4) Macrocytic anaemia
5) Community Acquired Pneumonia (CXR formal reporting on 5-7-2012 & imp: Patchy
opacities of both lung fields likely to be pneumonia. PTB has to be considered.)
• Meds on discharge: • T Dipyridamole 75mg tds
• T Augmentin 625mg bd (for 1/52) • T Simvastatin 10mg on
• T Cardipirin 100mg od • T Ferrous Fumarate 1/1 od
• T Amlodipine 10mg od • T Folic Acid 1/1 od
• T Metoprolol 50mg bd • T Vit B Co 1/1 od
• T Baclofen 5mg tds • T Vit C 1/1 od

3. • Name : JN
• Age : 64 yo
• Gender : Male
• Race : Malay
• Daughter brought pt to ED due to
unresponsiveness to call

4. Hx taken from daughter:
• noted by daughter, patient less responsive since discharge from ward yesterday
• not responding to call, occasionally opening eyes, not taking orally
• appears lethargic
• claims pt slept through most of the day
• no fever, nausea, vomiting
• no SOB, chest pain
• still coughing and producing whitish sputum but reducing as compared to
previous recent admission
Further hx from wife:
• Patient has difficulty swallowing medications
• Less responsive and less limb movement at home
• feverish yesterday
• No GI loss at home

5. •1) CVA with right hemiplegia with expressive aphasia
-ADL dependent
- March 2009 at Hospital Serdang
- multifocal infarct
- power right side 0/5
2) LVH with paroxysmal AF
-since 2006
- history of CCU admission in 2006
3) Chronic CO2 retention, possibly OSA
4) Type II Diabetes mellitus
5) Hypertension
6) Left above knee amputee secondary to MVA 2002

6. •T Augmentin 625mg bd (for 1/52) T Dabigatran 1 tab BD
•T Cardipirin 100mg od
•T Amlodipine 10mg od
•T Metoprolol 50mg bd
•T Baclofen 5mg tds
•T Dipyridamole 75mg tds
•T Simvastatin 10mg on
•T Ferrous Fumarate 1/1 od
•T Folic Acid 1/1 od
•T Vit B Co 1/1 od
•T Vit C 1/1 od
•T Metformin 1.5G BD
DRUG ALLERGIES & COMPLIANCE
•Not known to any drug or food allergy

7. Social Hx
• lives with daughter in Puchong
• blessed with 2 children
• non smoker
• non alcohol intake
• worked in Majlis Perbandaran previously
Family Hx
• Father had IHD
• Mother had HTN
• no family hx of DM/Lung disease/ Cancer

8. • BP : 144/90 mmHg
• PR : 75 p/min
• RR : 20 b/min
• Temp : 36.9°C
• GM : 5.9mmol/L
• Lungs : Crepts Bibasal
•Glasgow Coma Scale: E3V2M2
•Pupils 3mm equal and reactive bilaterally
•Gag reflex weak

9. DIAGNOSIS / IMPRESSION
• Nosocomial pneumonia
• Poor GCS possible secondary to CAP with poor oral intake
• AKI secondary to poor oral intake
• Macrocytic anemia

16. CXR
• CXR:
• rotated film
• air bronchogram and consolidation worsening over left
side
•
• imp: nosocomial pneumonia

17. CT BRAIN
• CT BRAIN PLAIN DONE ON 10.07.2012
• COMPARISION MADE WITH CT DONE ON 05.07.2012
•
• No intraparenchymal bleed seen.
• Old infarct at left basal ganglia extending to corona
radiata.
• No new focal lesions.
• No significant interval change from previous CT brain
plain.

20. PHARMACUETICAL CARE ISSUES
1) Improper Antibiotic Emperical Therapy in CAP
2) Polypharmacy of anticoagulant
3) Renal dosing of Ertapenem

21. Improper Antibiotic Emperical Therapy in CAP
• On 10/07/12, pt was treated with antibiotic IV Augmentin 1.2G TDS & IV
Ceftriaxone 2G OD as an emperical therapy for his suspected nosocomial
infection and there wasn’t any respond to antibiotic in patient.
Suggestion:
• Change to IV Tazocin 4.5G TDS
• Repeat Chest X-RAY
Outcome:
• IV Tazocin 4.5G TDS was changed on the 11/07/12
• Pt is still having bibasal crepts in lungs.

22. Improper Antibiotic Emperical Therapy in CAP

23. Improper Antibiotic Emperical Therapy in CAP
• On 10/07/12, patient’s treatment was switched from IV Augmentin 1.2G
TDS & IV Ceftriaxone 2G OD to IV Tazocin 4.5G TDS as an emperical
therapy for his suspected nosocomial infection and there wasn’t any
respond to antibiotic in patient.
Suggestion:
• Change to IV Ertapenem 500mg OD
• Repeat Chest X-RAY
Outcome:
• Pt is still having bibasal crepts in lungs.

24. Polypharmacy of anticoagulant
• On 13/07/12, Pt was treated with T.Cardiprin 100mg OD, T dipyridamole
75mg TDS and T. Dabigatran 1 tab BD simultaneously for his AF in ward and
patient was suspected to have internal bleeding GI bleeding in view of low hb
count.
Suggestion:
• Withold T.Cardiprin 100mg OD, T dipyridamole 75mg TDS and T. Dabigatran 1
tab BD
• Monitor the level of patient
Outcome:
•

25. RENAL DOSING OF ERTAPENEM
• On 16/07/12, Dr ordered IV Ertapenem 1G OD for this patient as an emperical
therapy. However, patients kidney profile shows that the CLcr was 18ml/min
with the creatinine was 263
Suggestion:
• Start renal dosing of IV Ertapenem 500mg OD
Outcome:
• Patient’s condition deteriorating .

26. • Patient’s condition was deteriorating and patient passed away
on the 17th july 2012
• Cause of death: sepsis secondary to pneumonia
• Family members understood & accepted the loss.
Final diagnosis
Subarachnoid bleed