Case Presentation: Part 1
Sep. 4th, 2013 11:12 am![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
pharming_in_korea• CC:
– Burning sensation during urination.
– Feverish.
• History of Present Illness (HPI):
– Ms. K is a 40 year old female presented with painful urination on 2013/08/22.
– Ms. K states that she began to experience painful urination 5 days prior to the hospital visit.
– 3 days prior to admission she had a fever of 38.7C. Patient self-administered Tylenol 325mg 1 tab and fever subsided.
• Past Medical History (PMH):
– Systemic lupus erythematosus (SLE) – diagnosed in 1989
– Lupus nephritis – diagnosed in 1990
- s/p Cytoxan pulse
- s/p methylprednisolone
- s/p Bredinin
– DM on med
• Family History (FH)/Social History (SH):
– Family history: None
– Social history
- Alcohol: No
- Smoking: No
• Allergies and Adverse Drug Reactions:
– N/A
• Compliance History:
– Practical impediment: None
– Attitudinal barrier: None
– Knowledge deficit: None. Knows her medications very well.
• Medication Profile (at the time of admission):
– Solondo (prednisolone) 10mg 1 tab PO daily
– Alkyloxan (cyclophosphamide) 50mg 1.5 tab PO daily
– Glupa (metformin) 500mg 1 tab PO daily
– Januvia (sitagliptin) 100mg 1 tab PO daily
– Trental SR (pentoxifylline) 400mg 1 tab PO Q12h
– Mevalotin (pravastatin) 40mg 1 tab po daily
– Cicibon (CaCO3) 500mg 2 tab PO Q12h
– Feburic (Febuxostat) 80mg 0.5 tab PO daily
• Physical Examination:
– Height 160 cm
– Weight 63.7 kg
– Gen Looks healthy, alert, and oriented
– VS BP 119/70 PR 97 RR 18 BT 38.7
– Skin warm & dry
– HEENT L/R(++/++), isocoric, prompt
Not anemic, anicteric, dehydrated tongue(-),
LNE(-), PI(-), PTH(-/-), neck stiffness(-)
– Lungs/Thorax Sym exp s retraction, CBS s crackle, wheezing, RHB s murmur
– Cor or CV RRR, Normal S1/S2, No murmur
– Abd soft & flat
– Genit/Rect normal rectal exam, prostate benign, stool heme(-)
– MS/Ext CVAT (-/-), P/C/C (-/-/-)
– Neuro A&Ox3, CN II-XII intact , normal DTRs bilaterally
• Review of Systems (ROS):
– G/W(-) E/F(-) HA/DZ (-/-) Wt loss(-)
– F/C(+/-) C/S/R(-/-/-) C/D/P(-/-/-) Abd pain(-) A/N/V/D/C(-/-/-/-/-)
– H/M/H(-/-/-) Urinary Sx(+) CVAT(+/-)
• Labs: (현재)
Na 141 mEq/L K 4.0 mEq/L Cl 106 mEq/L
Ca 9.1 mg/dL P 4.3 mg/dL Alb 3.4 mg/dL
BUN 33 mg/dL Scr 2.14 mg/dL TCO2 26 mmol/L
Uric acid 5.7 mg/dL WBC 5.01 x103/㎕ RBC 3.04 x백만/㎕
Hgb 9.8 g/dL Hct 29 % Platelet 191 x103/㎕
Chol 110 mg/dL hs-CRP 3.57 mg/dL T 36.8 C
Urine WBC 3+ (pyuria) Urine pH 6.5 Urine alb 3+
C3/C4 145/38 P/Cr 5.27 u-Protein 379 mg/dL
HbA1C 6.9% Glc 174 mg/dL
[Micro Lab: Gram Stain]
- Moderate(5~10) WBC, No EP, No Bacteria
- 3 X 104 G(-) rods
• Identification of Real or Potential Drug Therapy Problems:
To be continued...
-Jason
– Burning sensation during urination.
– Feverish.
• History of Present Illness (HPI):
– Ms. K is a 40 year old female presented with painful urination on 2013/08/22.
– Ms. K states that she began to experience painful urination 5 days prior to the hospital visit.
– 3 days prior to admission she had a fever of 38.7C. Patient self-administered Tylenol 325mg 1 tab and fever subsided.
• Past Medical History (PMH):
– Systemic lupus erythematosus (SLE) – diagnosed in 1989
– Lupus nephritis – diagnosed in 1990
- s/p Cytoxan pulse
- s/p methylprednisolone
- s/p Bredinin
– DM on med
• Family History (FH)/Social History (SH):
– Family history: None
– Social history
- Alcohol: No
- Smoking: No
• Allergies and Adverse Drug Reactions:
– N/A
• Compliance History:
– Practical impediment: None
– Attitudinal barrier: None
– Knowledge deficit: None. Knows her medications very well.
• Medication Profile (at the time of admission):
– Solondo (prednisolone) 10mg 1 tab PO daily
– Alkyloxan (cyclophosphamide) 50mg 1.5 tab PO daily
– Glupa (metformin) 500mg 1 tab PO daily
– Januvia (sitagliptin) 100mg 1 tab PO daily
– Trental SR (pentoxifylline) 400mg 1 tab PO Q12h
– Mevalotin (pravastatin) 40mg 1 tab po daily
– Cicibon (CaCO3) 500mg 2 tab PO Q12h
– Feburic (Febuxostat) 80mg 0.5 tab PO daily
• Physical Examination:
– Height 160 cm
– Weight 63.7 kg
– Gen Looks healthy, alert, and oriented
– VS BP 119/70 PR 97 RR 18 BT 38.7
– Skin warm & dry
– HEENT L/R(++/++), isocoric, prompt
Not anemic, anicteric, dehydrated tongue(-),
LNE(-), PI(-), PTH(-/-), neck stiffness(-)
– Lungs/Thorax Sym exp s retraction, CBS s crackle, wheezing, RHB s murmur
– Cor or CV RRR, Normal S1/S2, No murmur
– Abd soft & flat
– Genit/Rect normal rectal exam, prostate benign, stool heme(-)
– MS/Ext CVAT (-/-), P/C/C (-/-/-)
– Neuro A&Ox3, CN II-XII intact , normal DTRs bilaterally
• Review of Systems (ROS):
– G/W(-) E/F(-) HA/DZ (-/-) Wt loss(-)
– F/C(+/-) C/S/R(-/-/-) C/D/P(-/-/-) Abd pain(-) A/N/V/D/C(-/-/-/-/-)
– H/M/H(-/-/-) Urinary Sx(+) CVAT(+/-)
• Labs: (현재)
Na 141 mEq/L K 4.0 mEq/L Cl 106 mEq/L
Ca 9.1 mg/dL P 4.3 mg/dL Alb 3.4 mg/dL
BUN 33 mg/dL Scr 2.14 mg/dL TCO2 26 mmol/L
Uric acid 5.7 mg/dL WBC 5.01 x103/㎕ RBC 3.04 x백만/㎕
Hgb 9.8 g/dL Hct 29 % Platelet 191 x103/㎕
Chol 110 mg/dL hs-CRP 3.57 mg/dL T 36.8 C
Urine WBC 3+ (pyuria) Urine pH 6.5 Urine alb 3+
C3/C4 145/38 P/Cr 5.27 u-Protein 379 mg/dL
HbA1C 6.9% Glc 174 mg/dL
[Micro Lab: Gram Stain]
- Moderate(5~10) WBC, No EP, No Bacteria
- 3 X 104 G(-) rods
• Identification of Real or Potential Drug Therapy Problems:
| Medical problems | Current Medication | Drug-related Problem |
| Pyelonephritis (Upper UTI) | Not on medication | Indication for a drug but no drug prescribed |
| Lupus nephritis | Solondo (prednisolone) 5mg 1 tab PO daily Alkyloxan (cyclophosphamide) 50mg 1.5 tab PO daily | Alkyloxan held due to drug-disease interaction. Solondo dose increased from 5mg to 10mg. |
| Diabetes mellitus | Glupa (metformin) 500m g 1 tab PO daily Januvia (sitagliptin) 100mg 1 tab PO daily | Glupa has a contraindication. |
| Anemia | Not on medication | Indication for a drug but no drug prescribed |
| Proteinuria | Trental (Pentoxifylline) 400mg SR 1 tab PO Q12h | Maintain |
| Dyslipidemia | Mevalotin (pravastatin) 40mg 1 tab PO daily | Maintain |
| CKD-MBD | Cicibon (CaCO3) 500mg 2 tab PO Q12h | Maintain |
| Hyperuricemia | Feburic (Febuxostat) 80mg 0.5 tab PO daily | Maintain |
To be continued...
-Jason
