sample of morning presentation

1. Morning case presentation
By Derso bewket (Idno_6083/07)
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8/27/2019

2. Outline
2
• Socio-Demographic Data
• Clinical History
• Physical examination
• Investigation data
• Medication
• Pharmaceutical care plan
• Disease background
8/27/2019

3. IDENTIFICATION 3
 Name M.Z
Age 18 years old
Sex M
Card no. 832824
 Bed no. 13
 Address Dabat
 Admitted to the Internal medicine ward-D on 10/11/11
Patient stay 27 days
Ethnic origin ƒAmhara
Religion ƒorthodox
Occupation farmer 8/27/2019

4. Clinical History 4
Previous Admissions
November , 2011E.C, private clinic diagnosis pulmonary
tuberculosis and kalazar at shedy hospital
Chief complaints:- (general body swelling )GBS of 1
month duration
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5. HISTORY OF PRESENT ILLNESS 5
• This is 18 years old known TB patient for the last 2 month and 10 days
on anti TB medication
• Currently presented with GBS of 1 month duration the GBS started
from bilateral legs and gradually presented to abdomen. it associated
with easy fatigability during the normal activates.
• The patient also have SOB, orthopenea of of 02-03 pillows in the last
01 month
• The patient was having cough for the past 04 month productive blood
tingled sputum, night sweating , loss of appetite significant but un
quantified weight loss for which he was treated with anti TB
medication pas 04 month 8/27/2019

6. Cont… 6
• He has no Hx of contact with chronic cougher or Known TB patient
• He has no Hx of self /family Hx of HTN,DM
Past medical histories:- he has Hx of TB, kalazar& malaria epidemic area
Past medication histories :-
He has hx of kalazar treatment novmber 2011 at shedy hospital
Has hx of anti TB treatment 04 month back
Family histories:-there is no family Hx of TB, HTN,DM
Social histories:- he has alcohol drinker
Allargic histories :- there is no drug and food allergies
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7. Physical Diagnosis At admission 7
 G/A=ASL
V/S BP=110/70mmHg PR=100 RR=28 SO2= 100%
HEENT=pink conjunctive
LGS=no lephadnopathy
Respiratory =there is BBS heard over the right middle third of lung field
= decrease air entry over the left posterior 1/3of lung field
CVS= S1&S2are well heard
=JVP raise
Abd= full Abd move with respiration
 GUS= NO CVAT
 MSS= GII peating edema
IGI = no rash and pallor
CNS=conscious &oriented 8/27/2019

8. • Assessment NYHA class IV stage c 2o to DCMP with sever LV systolic
dysfunction(EF 15%)+ SCAP
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8

9. v/s
BP PR RR Tem so2
At admission 110/70 100 28 100%
16/11/11 100/70 92 22 36 95
18/11/11 110/80 87 21 36.5 94who
2211/11 100/60 96 23 36 95
24/11/11 100/60 92 24 36 94
25/11/11 >> 94 23 >> -
26/11/11 100/70 92 22 36.5 -
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10. Investigation
• 10/11/11
RBS 79mg/dl
U/A PH 6 5-8
Spg 1.030
Blood +3
Others NEG
 11/11/11
 Cr 0.75 0.6-1.1
Na 147 136-145mmol/l
K 5.34 3.5-5.1mmol/l
Chest X-ray cardiomegally with pulmonary arterial hypertension
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11. • 14/11/11
• Urea 93.73 16-48mg/dl
• Cr 1.48 0.6-1.1mg/dl
• SGOT 176.66 up to 32u/l
• SGPT 29.45 up to 31u/l
• BIIL T 5.82 up to 1mg/dl
• BILL D 4.45 up to 0.25mg/dl
• Serum protein 5.32 6.4-8.3g/dl
• Na 141 136-145mmol/l
• K 4.7 3.5-5.5mmol/l
• Cl 110 101-110mmol/l
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12. CBC
14/11/11
normal range level
• WBC 14.8 3.5-10x103/mm3 High
• RBC 6.12 3.8-5.8x106/mm3 High
• Hgb 12.2 11-18g/dl
• Hct 43 35-50%
• Plt 277 150-400
• Pct 0.176 0.1-0.5
• MCV 70 80-97fl low
• MCH 19.9 26.5-33.5 low
• MCHC 28.4 31.5-35g/dl low
• RDW 18.5 10-15 high
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13. Cont…
• %Lym 17.7% 17-49%
• %Mon3.5% 4-10% low
• %Gra 78.8% 43-76% high
16/11/11
Na 142 136-145mmol/l
K 2.7 3.5-5.1 low
SGOT 82 0-37u/l high
SGPT 54 0-47u/l high
Cr 0.72 0.6-1.1mg/dl
Cl 102 98-108
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14. 20/11/11 22/11/11
• SGOT 74 high K 4.46
• SGPT 59 high Na 143.9
• BILLD 1.29(1.5 Cl 106.9
• BILLT ica 1.46(1.1-1.4) H
• TP 5.7 Tca 2.86(2.2-2.9)
Ph 8(5-8)
SGOT 49 H
SGPT 39
BILLD 1.52mg/dl
TP 6.2G/dl
alb 0.87g/dl
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15. Other diagnosis
15/11/11
• HCV NEG
• HbsAG NEG
9/11/11
Echo ST-Segment elevation on V1-V2
-T wave inversion on V2-V3
13/11/11
PICT NR
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16. Treatment
At admission
Vancomycin 1g iv bid
Ceftraxon 1g iv bid
Doxycline 100mg po bid
Dopamine20ug/kg
Omeprazole 20mg po bid
Hold anti TB
Digoxin 0.25mg iv loading then 0.125mg po/day
Lasix 20mg iv stat
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8/27/2019

17. Cont…
Revised order 14/11/11
• Vancomycin 1g iv every other day (48hr)
• Dopamin 15ug/kg
• The rest same the previous data
15/11/11
Hold dopamine
Hold lasix
Added KCL60meqin 500ml NS
17/11/11 Lasix 20mg po
D/c Doxyclin
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8/27/2019

18. Cont…
19/11/11 Revised order
• Vancomycin 1g iv bid
• Ceftraxon 1g iv bid
• Lasix 40mg iv bid
• Digoxin 0.125mg po/day
• Spirnolactone 25mg po/day
• Enalapril 2.5mg poBID
• KCL 60meqiv in500ml NS run over Q8hr 22dpm
20/11/11 Added order
• Added KCL 40meq iv in 500ml NS
23/11/11
D/c antibiotics
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19. Currently revised order
• Lasix 40mg iv bid
• Enalapril 5mg po bid
• Metoprolol succinate 25mg po/day
• Spironolacton 25mgpo/day
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20. Pharmaceutical care plan
Goal of therapy:
• To alleviate all symptoms(SOB, orthopenea , GBS) and improve quality
of life
• To Prevent further complications
• To decrease death and hospitalization
• To Improve survival
• Treat the precipitating cause
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21. Monitoring parameter
• Vital sign
• CBC
• Organ function test
 lever function test
 Renal function test
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22. Un necessary drug's
Doxycline not used fore SCAP
Addational drug therapy macrolid nessray
DTP
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23. 23
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24. Definition
• Heart Failure is an abnormality of cardiac structure or function leading to failure of the
cardiac output to meet the body's metabolic requirements despite normal filling pressures.
• Clinically it is a syndrome consisting of typical symptoms (shortness of breath, fatigue,
orthopnea, ankle swelling) and signs (raised JVP, pulmonary crackles, displaced apex beat,
edem
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25. Form(type) of heart failure
 Systolic(with out) vs Diastolic(with reserved EF
 Left vs Right
 High output Vs Low output
 Acute Vs Chronic
 Forward Vs Backward
 Congenital vs Aquired
 Refractory vs Non refractory
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26. • Systolic heart failure:- HF due to abnormalities in cardiac
contractility.
• HF with depressed EF (systolic HF) EF<40%
 Diastolic heart failure:- HF due to impaired cardiac relaxation or
abnormal ventricular filling.
 HF with preserved EF (Diastolic HF)EF>40-50%
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27. Etiology 27
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28. Etiology
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29. 29
NYHA heart failure classification
Class Patient Symptoms
I No limitation of physical activity. Ordinary physical activity does not cause undue
fatigue, palpitation, dyspnea (shortness of breath).
II Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity
results in fatigue, palpitation, dyspnea (shortness of breath).
III Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity
causes fatigue, palpitation, or dyspnea.
IV Unable to carry on any physical activity without discomfort. Symptoms of heart failure
at rest. If any physical activity is undertaken, discomfort increases.8/27/2019

30. • Stage A — High risk for HF, without structural heart disease or
symptoms
• Stage B — Heart disease with asymptomatic left ventricular
dysfunction
• Stage C — Prior or current symptoms of HF
• Stage D — Advanced heart disease and severely symptomatic or
refractory HF
30stages of HF
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31. Investigation
 CBC, UA, OFT(LFT, RFT and TFT),Electrolyte, Glucose, lipid
profile, BNP, cardiac markers
 CXR, ECG, ECHO
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32. H =Hypertension
E=Endocarditis
A=Anemia
R=Rheumatic fever
T=Thyrotoxicosis
F=Fever
A=Arrhythmia
I =Ischemia
L=Lung infection
S=Stress (emotional, physical, dietary…)
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Precipitant factor

33. Non pharmacologic
• Reduce salt intake, avoid salt intake of >6g/day
• Avoid “salt replacement” tablets due to their high potassium content.
• Encourage patients to weigh themselves
• Reduction of weight in overweight and obese individuals
• Refraining from excessive alcohol consumption
• Avoid smoking. Patients should be offered smoking cessation advice
and support.
• Encourage low intensity physical activity amongst patients with
stable Heart Failure - Bed rest in hospitalized patients.
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34. Pharmacology
Initial therapy of severe Heart Failure (NYHA CLASS IV)
 Furosemide, 40mg iv
Add KCl 600mg, 1-2 tabs, twice per day or Spironolactone 25-50mg,
BID, if there is no renal impairment or hyperkalemia
ACE inhibtors or ARBS
N.B. Do not start ACE inhibitors/Angiotensin Receptor
Blockers until the patient is haemodynamically stable. For
patients with Left ventricular systolic dysfunction. Start with
low dose and increase gradually.
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35. Cont…
Beta blockers –
N.B. Beta blockers – should not be started in the acute management of
decompensated Heart Failure . After patient stabilization, beta
blockers can be started during discharge or as an out patient
management. Start with low dose and escalate gradually.
Digoxin, 0.125 mg once, P.O, daily
Dopamine, I.V infusion 1-5 ug /kg/minute up to 50 ug /kg/minute;
increase by 1- 4mcg/kg/minute at 10-to 30-minute intervals until
optimal response is obtained
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36. Reference
• Patient chart and pt interview
• Ethiopian standard treatment guideline 2014
• Uptodate 21.6
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37. 37
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