Antibiotics- Tan Swee Vien

1.       89/Male/Malay with UL COAD X 1 year, chronic smoker
P/W progressively worsening shortness of breath X 3/7 and productive cough with purulent sputum X 3/7

PE: Afebrile. Signs of COAD with no crepitations.

Invx: Blood investigations within normal limits, Chest x-ray showed reticulonodular shadowing with air bronchogram on right lower zone.

Provisional Diagnosis: Acute exacerbation of COAD secondary to Community Acquired Pneumonia

Mx: treated with T. Augmentin 1.2g TDS and T. EES 800mg BD.

2.       83/Male/Malay with UL CVA X 5 years ago

P/W acute confused state which fluctuates X 1/52, no oral intake X2/7, low grade fever X1/52 and lumbar back painX 2/7

PE: Very agitated, afebrile

Invx: Urine FEME: urinary tract infection +ve

Provisional Diagnosis: Acute delirium with sepsis secondary to Urinary tract Infection

Mx: treated with IV Cefuroxime 750mg TDS and ·IV Ciprofloxacin 200mg BD

Note: Urinary tract infections occurring in men should not be regarded as uncomplicated. Administer antimicrobial therapy, initially given intravenously, such as a third-generation cephalosporin, a fluoroquinolone, or an aminoglycoside. In patients with risk factors associated with an unfavorable prognosis, such as old age, debility, renal calculi, recent hospitalization or instrumentation, diabetes, sickle cell anemia, underlying carcinoma, or intercurrent cancer chemotherapy, the antimicrobial coverage should be broadened and an antipseudomonal agent should be added.

They should receive a 10- to 14-day course of antibiotics.

3.       75/Male/Malay, NKMI

P/W progressively worsening shortness of breath X3/7 and non-productive cough X3/7, heart failure symptoms

PE: BP on admission: 196/109

Invx: ECG: T depression in avL, V6, LVH. CXR: Cardiomegaly,

Provisional Diagnosis:? See Mx below

Mx: treated for decompensated congestive cardiac failure with community acquired pneumonia on the 1^st day, IV Augmentin 1.2g TDS and T. EES 800mg BD given. However, on the 2^nd day of admission, another doctor noted that there were no pneumonic changes in chest x-ray, as well as blood investigations normal, therefore, AB was taken off. Patient was treated for decompensated congestive cardiac failure alone.

4.       71/Male/Indian UL COAD, HPT, ex-chronic smoker

P/W progressively worsening shortness of breath X2/7 and productive cough with purulent sputum X2/7. No fever. A/W orthopnea. Hx of admission to ICU and intubation X3 years ago.

PE: Respi rate: 26, SP02: 100% under Venti-mask, Signs of COAD, crepitations on left lower zone of lung

Invx: ABG: Respiratory acidosis with type 1 failure. WBC slightly raised. ECG: SR, poor R wave progression, tall P wave

Provisional Diagnosis: Acute exacerbation of COAD secondary to community acquired pneumonia with Cor pulmonale

Mx: treated with IV Augmentin 1.2g TDS and T. Azithromycin 50mg OD

Note: *Compared with erythromycin, azithromycin offer improved tolerability, however both are clinically effective for treatment of respiratory infections. Azithromycin retains the activity of erythromycin against gram-positive organisms but offers increased gram-negative coverage over erythromycin and clarithromycin.

5.       51/Female/Malay UL Hyperthyroidism x 10 years

P/W progressively worsening diarrhea X 6/7, >10times/day and high grade fever X 3/7. A/W generalised colicky abdominal pain and palpitations. History of taking outside food with husband but he is well

PE: Febrile, PR: 75beats, irregularly irregular. Abdo: soft, tender at lower abdomen, bowel hyperactivity.

Invx: WBC slightly raised. Stool C&S, ova and cyst results pending.

Provisional Diagnosis: Infective Acute Gastroenteritis

Mx: Treated with IV. Ceftriaxone 1g OD. Discharged with T. Ciprofloxacin 250mg BD X1/7

6.      90/Female/Malay UL Childhood Bronchial Asthma

P/W progressively worsening of breath X1/7 and productive cough with purulent sputum 3/7

PE:not done

Provisional Diagnosis: newly diagnosed COAD with cor pulmonale, community- acquired pneumonia

Mx: Initially treated with IV Augmentin 1.2g TDS and T.EES 800mg on Day 1. But was changed to IV Moxifloxacin 400mg OD, and  subsequently on Day 2 –added T. Azithromycin 500mg OD

7.       /Male/Malay UL gouty arthritis diagnosed few months ago

P/W progressively worsening pain and swelling on bilateral lower limbs, more severe on the joints and high grade fever.

PE: not done

Invx: WBC count raised.

Mx: Initially treated as acute exacerbation of gouty arthritis, but after joint aspiration was done, septic arthritis was noted. Treated with IV Cloxacillin 1g QID.

Note: Staphylococcus aureus is the most common pathogen in all age groups and should be treated with antimicrobial regimens similar to those recommended for osteomyelitis, although generally a 2 - 3-week treatment regimen is sufficient. However, depending on the patient’s age, other pathogens may need consideration.

8.       62/Male/Malay UL COAD X 3 years

P/W Progressively worsening shortness of breath X 2/7 and productive cough with purulent sputum x4/7.

PE: Respi rate: 20, febrile. Signs of COAD with right basal crepitations.

Invx: WBC raised. CXR: Opacities over right lower zone with air bronchogram

Provisional diagnosis: Acute exacerbation of COAD secondary to community-acquired pneumonia

Mx: was treated with T. Ciprofloxacin 500mg BD

9.       80/Male/Malay UL DM, HPT

P/W: Swelling of the right lower limb up to shin level. Hyperpigmentation

PE: not done

Ivx: Blood C&S done on multiple occasions

Provisional Diagnosis: Right leg cellulitis

Mx: IV Cefepime 2g BD

Note:The most common etiology of cellulitis with purulent drainage is S. aureus, although Group A streptococci and other streptococcal species can also present in this manner.

The appropriate antibiotics:

Mild:	Moderate/Severe
Augmentin 875 mg PO BID OR Ciprofloxacin 500 mg PO BID] PLUS Clindamycin 300 mg PO TID	Piperacillin/tazobactam 3.375 g IV q6h OR Meropenem 500 mg IV q8h. If concern for MRSA, add vancomycin -Severe PCN allergy: Ciprofloxacin + Clindamycin OR Aztreonam + Clindamycin. If concern for MRSA, use vancomycin instead of clindamycin and add anaerobic coverage with metronidazole.

10. 36/Female/Malay UL SLE with lupus nephritis, CVA right hemiparesis, DM, HPT
P/W non-productive cough X1/7 and shortness of breath on exertion, low grade fever X2/7, no heart failure symptoms.
Recently discharged on 19/3/2014 from Hosp Muar for SLE with anemia and recurrent ascites. Peritoneal tapping was done but no growth was found.
PE: Respi: bronchial breathing, course crepitations over bilateral lungs
Inx: WBC slightly raised, ESR and CRP raised, CXR: cardiomegaly with bilateral lung haziness up to mid-zone, Blood C&S showed no growth
Provisional Diagnosis: Healthcare associated pneumonia
Mx: Aside fr treating patient's SLE condition, she was treated with IV Cefepime 2g TDS.(initially started on Augmentin and EES but was then off and changed).
Note: *what is healthcare associated pneumonia?

• Residence in a nursing home or other long-term care facility
• Hospitalization in an acute care hospital for two or more days within the prior 90 days
• Attendance at a hospital or hemodialysis clinic within the prior 30 days
• Intravenous therapy, wound care, or intravenous chemotherapy within the prior 30 days

Since patient has no known multi-drug resistance risk factors, therefore it is appropriate to give this antibiotics as it can cover gram-neg bacilli resistant.

Questions

1. Why are different types of antibiotics prescribed for community-acquired pneumonia and COAD?

Bacterial infections appear to trigger one-third to one-half of COAD exacerbations. Nontypeable Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae are the bacteria most frequently isolated bronchoscopically from patients having an exacerbation of COAD. Pseudomonas aeruginosa and Enterobacteriaceae are also commonly isolated, particularly from patients with severe COPD.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline, recommends antibiotic therapy for patients who have the following features: a severe exacerbation requiring mechanical ventilation (noninvasive or invasive) or an exacerbation with increased sputum purulence plus either increased dyspnea or increased sputum volume

Historically favored (ie, first-line) antibiotics based upon randomized trials include doxycycline, trimethoprim-sulfamethoxazole, and amoxicillin. However, amoxicillin is no longer considered a first-line agent because it is inactive against most nontypeable H. influenzae and M. catarrhalis.

Other (ie, second-line) antibiotics are also logical choices for outpatients based upon in vitro activity and trials showing efficacy that is comparable, but usually not superior, to doxycycline and trimethoprim-sulfamethoxazole. Antibiotics in this category include amoxicillin-clavulanate, azithromycin, cefpodoxime, cefprozil, cefuroxime, loracarbef, and the fluoroquinolones. In patients with complicated COPD and risk factors for Pseudomonas who do not have indications for hospitalization, ciprofloxacin is a good choice.

Risk for developing Pseudomonas includes

- Frequent administration of antibiotics (4 or more courses over the past year)

  - Recent hospitalization (2 or more days' duration in the past 90 days)

  - Isolation of Pseudomonas during a previous hospitalization

  - Severe underlying COPD (FEV1 <50 percent predicted)

In-Patients with risk factors should be given IV/PO Levofloxacin 750mg OD OR IV Cefipime/Ceftazidime OR IV Unasyn 4.5g

In-Patients without risk factors should be treated with IV/PO Levofloxacin 750mg OD OR IV/PO Moxifloxacin.

2. Ciprofloxacin vs Moxifloxacin in treating CAP?

Compared with other quinolones, moxifloxacin and gatifloxacin have been shown to have superior in vitro activity against pneumococci. Although this activity may make moxifloxacin or gatifloxacin an attractive choice for pneumococcal infections, these agents should probably be reserved for treatment of infections with atypical pathogens or for life-threatening pneumonias.

The activity of newer generation fluoroquinolones against gram-negative microorganisms is preserved, but they are less active against gram-negative bacteria than is ciprofloxacin. Specifically, these agents are not as active against Pseudomonas aeruginosa as is ciprofloxacin. For other respiratory pathogens, including Moraxella catarrhalis, Haemophilus influenzae, and Legionella pneumophila, both older and newer fluoroquinolones demonstrate excellent activity. For Chlamydia pneumoniae and Mycoplasma pneumoniae, gatifloxacin, gemifloxacin, and moxifloxacin appear to be comparable to one another and superior to ciprofloxacin.

3. Should patients having diarrhea X6/7 be started on antibiotics?

The management of patients with acute diarrhea begins with general measures such as hydration and alteration of diet. Antibiotic therapy is not required in most cases since the illness is usually self-limited. Nevertheless, empiric and specific antibiotic therapy can be considered in certain situations.

Patients with fever or bloody diarrhea, patients with >8stools/day, dehydration, symptoms>1/52, immunocompromised should be considered empiric antibiotics while awaiting culture results.

Empiric therapy with an oral fluoroquinolone (ciprofloxacin 500 mg twice daily, norfloxacin 400 mg twice daily, or levofloxacin 500 mg once daily) for three to five days in the absence of suspected EHEC or fluoroquinolone-resistant campylobacter infection. Azithromycin (500 mg PO once daily for three days) or erythromycin (500 mg PO twice daily for five days) are alternative agents, particularly if fluoroquinolone resistance is suspected. 

Antibiotic Prescriptions in the Ward- Sarah Low

MRA, 57 year old gentleman was admitted to the ward due to suspected lobar pneumonia, where he presented with fever for the past 1 week with cough and productive yellowish sputum. He is a non-smoker. Prior to his admission, he went to a clinic and was prescribed antibiotics but unsure what was it. And upon physical examination, there was crepitations heard over bilateral lungs more over the right middle zone. Chest X-Ray showed consolidation over the right lower lobe. He was prescribed IV Augmentin (Amoxicillin/Clavulanate) 1.2 g stat and tds with Azithromycin 500 mg OD for the next 3 days. When amoxicillin (susceptible to penicillases) combined with clavulanate (inhibitors of penicillase), their anti-bacterial activities are enhanced. It has a wider spectrum on infections, resulting from enterococci, Listeria monocytogenes, E. Coli, Proteus mirabilis, H. Influenzae, and Moraxella catarrhalis, although resistant strain occurs. Azithromycin, a macrolide antibiotic has a more active role against H influenza, Morazella catarrhalis, Neisseria. Because of its long half life, a single dose is effective in the treatment of urogenital infections caused by C. trachomatis, and a 4 day course of treatment has been effective in community acquired pneumonia.

TM, a 64 year old female known case of childhood bronchial asthma, presented to the ward with acute onset of shortness of breath on day of admission. She also had productive cough for the past 1 week prior to admission. Upon examination, there was occasional rhonci with prolonged expiration. Sputum FEME showed G+ cocci, G- bacilli and pus 5-10 HPF. She was given IV augmentin 1.2 g stat and tds with tablet erythromycin ethylsuccinate (EES) 800 mg BD. Erythromycin has activity against many species caused by M pneumonia, Corynebacterium, Campylobacter jejuni, gram positive cocci, and some gram-negative organisms. Azithromycin has a similar spectrum of activity but greater efficacy than erythromycin in therapeutic option for treatment of community acquired classic and atypical pneumonia

MJHN, a 64 year old gentleman known case of diabetes and hypertension for 10 years, was admitted to the ward after being noted in the Klinik Kesihatan for high urea and creatinine of 35.9 and 1027 respectively. He also had typical features of chronic renal failure such as generalised body weakness, with reduced oral intake and itchiness for past 2 weeks. He also had fever with cough and productive whitish sputum for the past 2 weeks, and was diagnosed of having community acquired pneumonia. His admission to the ward showed high spiking temperature, and he is currently on peritoneal dialysis. It is noted one of the top mortality cause in a dialysis patient is septicaemia, thus it is important to treat extensively with broad spectrum antibiotics which is IV Ceftriaxone for 3 days. Upon discharge, he was prescribed with oral tablet Augmentin 625 mg OD for the next 5 days. Ceftriaxone a third generation cephalosporin has increased activity against gram negative organisms resistant to other beta-lactam drugs and ability to penetrate the blood-brain barrier. It is active against producing strains of H influenza and Neisseria, and they are most active against penicillin-resistant pneumococci (PRSP strains). In populations of known/suspected pneumococcal resistance, a single dose of Ceftriaxone appears to be as effective as a 10 day course of Augmentin.

90 year old Malay gentleman presented with productive cough with whitish sputum. He was treated for community acquired pneumonia. IV Augmentin 1.2 g tds and EES 500 mg BD was prescribed in the beginning before changing it to IV Moxifloxacin (Avelox) 400 mg OD and Azithromycin 500 mg OD. Upon discharge, he was given tablet Moxifloxacin 400 mg OD. Based on the management above, the commonly preferred treatment for community acquired pneumonia is beta-lactamase inhibitors such as augmentin, however this patient was treated with  Moxifloxacin, which is a fourth generation fluoroquinolone. It is one of the broadest spectrum fluoroquinolones to date, with enhanced activity against gram positive and gram-negative organisms, atypical pneumonia agents, and some anaerobes. The conservative use of quinolone is recommended to minimise resistant pathogen. It is commonly used when failed first-line regimen or allergic to alternative.

AMY, a 61 year old gentleman presented with bilateral knee pain with consistently high spiking fever. Joint aspiration was done and noted there was 15-20 high. He was treated with IV Cloxacillin 1 g QID in view of septic arthritis and prevention of osteomyelitis. It is shown that cloxacillin is effective against organisms such as staphylococcal organisms, an etiological organism for septic arthritis. An inadequate dosage regimen (a single daily dose) prevented spread of bacteria but did not control abscesses. Delay in commencing treatment permitted persistence and spread of abscesses with destruction of the secondary (epiphyseal) ossification center and even transphyseal spread into metaphyseal bone. Repair by fibroblasts was mainly seen in articular and epiphyseal cartilage but was not seen in the epiphyseal ossification center (up to 18 days). Synovial fluid sampling with measurement of leukocyte and bacterial concentrations appears to be a useful guide to the effectiveness of treatment, because the numbers of cells correlate with the pathological process.

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ZD, a 51 year old Malay female presented with diarrhoea that has been ongoing for the past 5 days.  On the day of admission, she had high fever of 38.2 ⁰ C. She is a known case of hyperthyroidism, and has been compliant to her anti-thyroid medication, Carbimazole.  They were treating her for infective diarrhoea, thus tablet Ciprofloxacin was given. The most common approach in treatment of infectious diarrhoea would include supportive therapy- fluid and electrolyte replacement. There is a large body of evidence to show that antimicrobial agents can reduce the severity and duration of some intestinal infections, especially in those bacteria and infections that produce acute watery diarrhoea. As ZD has been having diarrhoea for past 5 days, antimicrobial agent was prescribed. Ciprofloxacin, second- generation fluoroquinolone have greater activity against gram-negative bacteria, especially enterotoxigenic E coli. Quinolone antibiotics are now the treatment of choice; standard doses for 3–5 days can reduce the severity and duration of illness by at least 50%

Diabetic Ketoacidosis in a type 1 DM patient

Mr. Abu is a 16 year old Malay gentlemen with no known medical illness who was referred from KK in view of high fasting glucose level (26mmol/L). He presented with fatigue for the past 1 week, polydipsia and nocturia for the past 3 weeks. The urine was always clear. He also presents with nausea and occasional vomiting for the past 3 days and has loss of appetite since 3 weeks ago. There was loss of weight within the past 1 month but he was unsure of the actual weight loss. He denies fever, cough, abdominal pain, headache, shortness of breath and numbness/tingling sensation. He has no significant family history of diabetes or hypertension. He is a non-smoker and non-alcoholic.

On admission, he was conscious and communicative but showed fatigue. His vitals were: BP-120/76, PR-88, RR-18, T-afebrile. His glucometer reading was 23mmol/L (He was infused with 1pint NS Stat at the KK before being referred)
Patient was noted to be obese, with acanthosis nigricans at neck and multiple lesions over bilateral lower limb.

CVS: DRNM
Respi: Air entry equal, no added sounds
Abdo: Soft, non-tender

Invx done on admission,
ABG noted to be metabolic acidosis(pH: 7.115, hCO3: 7.1) with respiratory alkalosis compensation(pCO2: 22.1)
Urine ketones: 150mg/dL( severe ketonuria)

Provisional Diagnosis: Diabetic Ketoacidosis in an undiagnosed Type 1 Diabetes Mellitus

Management at ED,
1. Run 2L NS bolus
2. Strict I/O Charting via CVL.
3. IV Actrapid 8U STAT
4. Start IV Actrapid infusion 8U/hr

Management in Ward
Other investigations: FBC, UFEME, FLP, HbA1C, LFT/RP, Ca/PO4/MG, daily ketones

1. IVD 2pints NS/2H with 1g KCL each pint
    IVD 2pints NS/4H with 1g KCL each pint
    IVD 2pints NS/8H with 1g KCL each pint
    IVD 2pints NS/16H with 1g KCL each pint
2. Trace RP Urgently --> Urea: 4.2, Na: 136, K: 3.5, Creat: 137
3. Monitor vitals every hourly
4. GCS Charting- to watch out for complications such as cerebral edema
5. Strict I/O charting via CBD
6. Allow orally
7. GM every hour
8. IVI Insulin 6U/hr, to target at 6-14mmol/L
9. Once GM<14, to change to IVD Dextrose Saline
10. IV Ranitidine 50mg STAT and TDS- to prevent complications such as stress ulcers
11. S/C Heparin 7500U BD- to prevent thomboembolic events

GM monitoring:
17/3- 3pm: 15.4
         4pm: 18.0
         5pm: 18.0
         7pm: 20.5- IVI Insulin increase to 8U/hr
         8pm: 16.6- IVI Insulin decrease to 6U/hr

18/3-5am:13.9
        6am:12.2
        8am: 12.2
19/3-2pm:18.7
         3pm:18.8
         8pm: 15.1
20/3- 10.30pm: 13.3
21/3- 4am: 8.7

Progress notes
Day 2-18/3/2014
Patient is comfortable and does not complain of shortness of breath, chest pain or abdominal pain. The polydipsia has decreased. His GCS is full. His BP was 138/63, PR:66, T: afebrile, SPO2: 98% RA. Input/Output levels were good.
Invx: UFEME revealed no presence of UTI, glucose was 56, ketone 15, protein 0.25.Another RP was done and the potassium level was noted to be 3.1. Hence, Tab. Slow K 1/1 BD was added to the regime.
The plan was to complete the current fluid regimen and once complete, to give patient 4pints of Dextrose Saline/24H.  The IVI Insulin 6U was to be continued until the ketosis resolves and thereafter changing it to basal bolus insulin.

Day 3-19/3/2014
Patient is comfortable and no complains of any sort. GCS full. His GM is control within 13-17mmol/L within 6H in the morning. The metabolic acidosis resolved fully (pH:7.36, HCO3:25.8, pCO2:45). Vital signs were good.
The plan was to convert to S/C Insulatard 30U STAT and ON(40U), S/C Actrapid 16U TDS, off IVI Insulin, Tab. Metformin 500mg BD. However, plan was withold as GM more than 15 in the evening. Slow K II/II BD and Mist KCL 15ml TDS  i/v/o K+:2.9. IVD 3pints NS +1.5g KCL in each pint was given.

Day 4-20/3/2014
Patient is comfortable. GM<15 for the whole day. Vital signs were good. The plan was to overlap with S/C Actrapid for 1H together with IVI Insulin and after that, to off IVI Insulin. Patient was started on S/C Actrapid 16U TDS, S/C Insulatard 40U ON, Mist KCL 15ml TDS + Slow K II/II TDS and was planned for fundoscopic examination. Patient was educated by the pharmacist regarding injection administration.

Day 5- 21/3/2014
Patient is comfortable. Vital signs were good. GM level <10 for more than 24H.  RP level: 0.9/135/3.2/47. K+ levels increasing after administration of Mist KCL and Slow K. Tab. Metformin 1g BD was added. Patient was allowed for discharge and was taught self-glucose monitoring. He was advised to buy a glucometer at home. He was asked to review at KK.

Case 3 - Cerebrovascular Accident with Right Sided Hemiparesis secondary to Hypertensive Emergency

Mr SJ, a 60 years old Malay male with a history of diabetes and hypertension for past 1 year presented with right sided hemiparesis that occurred upon awakening on day of admission. There was associated headache, dizziness and blurring of vision that came along with the presenting symptom. He also complained of having palpitations. However, he did not complain of any chest pain, sweating, or shortness of breath. He also has no slurring of speech or swallowing problems and is currently unable to walk due to right lower limb weakness.

Physical examination revealed on admission BP of 220/114 mm Hg. He was then given IV Labetalol 10 mg stat dose. Pulse was 79 bpm, with normal breath rate of 20 and was afebrile. GCS was full and he was alert, conscious and communicative. CNS examination revealed right sided normotonia, brisk reflexes and power 1/5 power over right upper limb, and power 2/5 over right lower lib. Cranial nerves and sensory were intact. CVS, respi, and abdomen examination were normal.

Investigation (FBS/FSL, RP, LFT, Ca, Mg, PO4 and coagulation profile was taken). A CT brain was taken and revealed no ischaemic changes.

A provisional diagnosis of: Cerebrovascular Accident with Right Sided Hemiparesis secondary to Hypertensive Emergency was made.

The management was to monitor vital signs 4 hourly and to allow orally since he did not have any swallowing impairment. He was given aspirin 300 mg stat and 150 mg OD, simvastatin 40 mg ON, subcutaneous actrapid 6 unit in view of blood glucose on admission was 17.6 mmol/L. He was also referred to a physiotherapist to regain functionality and muscle strength.

Day 2 of admission

Blood pressure was still high with 180/110 mm Hg. He was then started on tablet perindopril 4 mg OD. His muscle power has slightly been improved with 2/5 on right upper limb and 3/5 over right lower limb. There was still continued follow up with the physiotherapist.

 

Day 3 of admission

Blood pressure still maintained at 174/94 mm Hg. However, his power over the right upper limb has improved to 3/5 and right lower limb still maintained at 3/5. His blood parameters were within normal range. His TG and LDL were elevated with 2.1 and 5.4 respectively. His potassium was low at 2.4 and after fast correct with 1.5 g KCl, his potassium level improved to 3.5.

 

He was then discharged with tablet aspirin 150 mg OD, perindopril 4 mg OD, metformin 500 mg BD, gliclazide 40 mg BD, and tablet simvastatin 40 mg ON. A memo was written  to Klinik Kesihatan to continue monitoring the blood pressure and to come again with a repeated renal profile and fasting serum lipid, in view of his dyslipidaemia and hyperkalaemia. He was also given slow K for the next 3 days.

Case 2- Stable Angina

Date of admission: 11/3/14, Date of clerking: 12/3/14
Mr. Muniyapan is a 51 year old Indian gentleman with a history of dyslipidemia presented with right sided chest pain for 30minutes prior to admission. On the day of admission, patient developed the chest pain while driving a lorry. It was sudden onset, crushing in nature and radiated to the left side of chest. It was not relieved by rest. Pain score was 6/10. There was no associated symptoms such as profuse sweating, shortness of breath, palpitations, nausea or vomiting, paroxysmal nocturnal dyspnea or orthopnea. This was his 1st episode. Patient claimed that he was diagnosed with dyslipidemia 3 years ago but defaulted follow up and non-compliant to medication since his supply finished. He does not have hypertension or diabetes mellitus.
His mother is a hypertensive and diabetic patient. Otherwise, there is no significant family history.
He is a non-smoker and a social drinker.

On examination
Patient was comfortable, no complains of chest pain. Patient was not tachypneic.
BP: 113/71
PR: 69
RR: 16
T: afebrile

CVS: apex beat not deviated, no thrills, S1, S2 heard, no murmurs
Respi: Lungs were clear, air entry equal, no added sounds such as crepitations.

Other systemic examinations were not remarkable.

Management on Admission:
Patient was treated with :
1. T Aspirin 150mg OD
2. T. Plavix 75mg OD
3. S/L GTN 1/1 PRN
4. Oxygen Supplementation 3L O2 on nasal prong

1. ECG upon admission was done and was noted to have ST elevation lead II(1 small box), III, aVF (2 small box) ST depression at lead 1, aVL.

1 hour later, another ECG was done and the ST elevation readings were noted to have resolved spontaneously.
2 hours later, a repeated ECG revealed the same findings, however there was a T wave inversion in lead II, III, aVF.
Cardiac Troponin was done: 0.77
Provisional Diagnosis: NSTEMI

Continued management:

1. T. Simvastatin 40mg ON
2. S/C Fondaparinux 2.5mg Stat and BD
3. T. ISMN 30mg ON
4. IV Ranitidine 50mg TDS
5. Complete rest in bed
6. Standby ECG if chest pain noted.

(Investigations incl FBC, RP, LFT, all were within normal parameters)

Progress Notes
Day 2-12/3/2014

Patient complained of central chest pain at 8.40am. A S/L GTN 1/1 Stat was given. The pain resolved after 20minutes. Otherwise, patient appeared comfortable and not in respiratory distress. He was tolerating orally. On examination, his vitals were normal and no other significant findings. He was started on T. Bisoprolol 1.25mg OD. The anti-coagulation medication was continued. The T. ISMN 30mg ON was changed to T. ISMN 30mg OD. He was planned for an ECHO and to continue complete rest in bed.

Day 3- 13/3/2014

Currently, patient appeared very comfortable and has not complain of chest pain for more than 24hours. On examination, vitals were normal and lungs were clear. He was seen by Dr. Tan and ECG on admission was noted to be non-significant. He was re-diagnosed as a stable angina and was allowed discharged to be followed-up at the KK in 1 month's time. A FSL and FBS was planned to be done after discharge.

*the revised diagnosed of stable angina was inappropriate.

Case 1- Acute Exacerbation of COAD secondary to Community Acquired Pneumonia

89 year old Malay male known case of chronic obstructive airway disease for the past 1 year, was given metered dose inhaler but was non-compliant. He presented with shortness of breath for the past 3 days, associated with productive cough that was whitish-greenish colour. He also complained of loss of appetite for the past 3 days. This is currently his first admisssion. He has no fever, palpitations, chest pain, paroxysmal nocturnal dyspnoea, orthopnoea, nausea or vomiting, bowel or bladder symptoms. He is an active smoker for more than 50 years (1 pack per day).

On examination,
Vital signs:
BP:  124/72 mm Hg
PR: 88 bpm
T: 36.5
RR: 18
SpO2: 97% on nasal prong 3 L Oxygen

General Examination:
Patient looks comfortable, not in respiratory distress.
Noted there was finger clubbing and fine tremor
No pallor, cyanosis, edema

Lung examination:
No trachea deviation
Chest expansion reduced bilaterally
Vocal fremitus reduced
Percussion:
Auscultation: Air entry equal
Vesicular breath sound
Generalised expiratory rhonchi
Prolonged expiratory phase
No crepitations

Other systemic examination non- remarkable

Impression: Acute Exacerbation of COAD secondary to lower respiratory tract infection

Investigations:
Full Blood COunt:
Hb: 12
WBC: 6.5
Plt: 157

Differential:
Neut: 44.2
Lym: 42.4

Renal Profile
Urea: 7.5
Na: 135
K: 4.0
Creat: 72

Chest X-Ray:
hyperinflation at bilateral lung field, flattened diaphragm
reticulonodular shadowing at bibasal lung field.

Provisional Diagnosis: Acute exacerbation of COAD secondary to community acquired pneumonia

Plan:
1. Oxygen supplementation with face mask or nasal prong
2. IV fluids
3. Neb salbutamol with ipratropium bromide
4. IV hydrocorticotisone
5. Start augmentin and azithromycin for infection.
6. Monitor vital signs and SpO2 frequently

In-Ward Management

1.      2-hourly vital signs monitoring, then 4-hourly once stable

2.      Keep patient on nasal prong of 3L of oxygen.

3.      Nebulised Ipratropium bromide: salbutamol: normal saline at ratio of 2:1:1 4-hourly.

4.      Tab. Augmentin 1.2g STAT, then TDS

5.      Tab. Erythromycin 800mg STAT, then BD.

6.      Tab. Prednisolone 30mg OD.

7.      Tab Bisolven 8mg TDS.

8.      MDI Salbutamol 2 puffs PRN

9.      MDI Berodual 2 puffs TDS

To assess MDI technique.

Progress Notes:

Day 2- 3/3/2014

Currently patient’s shortness of breath symptoms has improved. However patient still had productive cough with yellowish sputum. Patient is able to tolerate orally. On examination, Mr. S was still on nasal prong 3L of O₂. Vital signs were good. Patient was mildly tachpneic but was able to speak in full sentences. On lung auscultation, there was good air entry. However, there was still prolonged expiratory phase and generalised expiratory rhonchi. Medication plan were continued. Patient’s technique of inhalation of MDI was assessed by the pharmacist and was noted to be poor. Mr. S was counselled on the indication, dose and frequency of MDI, technique and importance of compliance. Patient’s technique was reassessed once again and was still noted to be poor. Pharmacist suggest patient to buy an aerochamber.

Day 3- 4/3/2014

Mr. S did not complain of any shortness of breath anymore. He was able to breathe on his own without the aid of the nasal prong. Nasal prong was removed. SpO₂ was 98% under room air. The steroid medication was changed to Tab Prednisolone 30mg OD and the rest of the medications were continued. Patient was not allowed to be discharge due to lungs still having minimal generalised expiratory rhonchi and prolonged expiratory phase.

Day 4-5/3/2014

Currently, patient was comfortable and not tachypneic. Vital signs were good. There were minimal generalised expiratory rhonchi. Patient was able to buy the aerochamber and was taught by the pharmacist on the methods of using it. Patient was allowed for discharged and a memo was written to KK for follow-up and review of symptoms. He was also discharged with medications 

1.    MDI Berodual 2 puffs TDS

2.    MDI Salbutamol 2 puffs PRN

3.    Tab Prednisolone 40mg OD X 2/7

4.    Tab Bisolven 8mg TDS

5.    Tab Augmentin 625mg BD X 4/7

Tab Erythromycin 800mg BD X 2/7