Case 1-Compliance with oral medications

Mrs NYC a Chinese lady age 73.8 years old with estimated weight of 70 kg was
admitted to the hospital on 1st April 2017. She was admitted to hospital due to loss of
consciousness. Prior to admission, her son claimed that his mother had loss her appetite and
had been lethargic for 1 week. She was bedbound through that period. She was also having
diarrhea on and off. Before losing her consciousness, she was less responsive.

She was previously ADL semi-dependent, had poor hygiene and poor hydration. Her
family has history of DM. She had no known drugs allergy. From her records, she had
underlying Diabetes Mellitus, Hypertension and Dyslipidemia for 35 years. Other than that,
she had history of stroke during the age of 40 years old.

Her son informed that Mrs NYC managed her medication by herself and had
defaulted her medication for two weeks due to taking a traditional medicine which was
recommended by her son. He states that the Chinese health traditional practitioner (Tabib),
asked her to stop taking the hospital medication. Her non-compliance was the reason of her
uncontrolled DM and hyperglycaemic hyperosmolar state.

Upon admission, her blood pressure was very low which is 64/44mmHg. Her
heartrate was high, 121 beat/min and she was febrile (38.7°C). Her random blood sugar was
really high, 56mmol/L and the serum osmolality measured was 384.3 mOsm/kg. She was also
in acidotic state where her pCO2 was 26.1 mmHg and HCO3-was 14.4 mmol/L.

Mrs NYC was diagnosed with Hyperglycemic and Hyperosmolar state secondary to
noncompliance to medication, Acute Kidney Injury secondary to severe Metabolic Acidosis,
Upper Gastrointestinal Bleeding secondary to stress ulcer, Atrial Fibrillation and Community
Acquired Pneumonia. She was discharged with the following medications:

SC Insulatard 8 iu ON
Tab Metformin 1g BD
Tab Gliclazide 160 mg BD
Tab. Telmisartan 80 mg OD
Tab. Hydrochlorothiazide 12.5 mg ON
Tab. Aspirin100 mg OD
Tab. Simvastatin 40 mg ON

Questions
Indication of each medication
Counsel on patient compliance
Counsel on non-pharmacological treatments

1
2
 Case 2-Home Care Pharmacy
Patients’ profile
Name MD Age 53
Date of home 29/04/2017 Gender Male
visit
Race Java
Height 165cm Weight 70kg
Calculated Body Mass Index (BMI) 25.71 pre obese
Past Medical history x (years)
- Diabetes Mellitus (14 years)
Hypertension (1 year)
Chief complaints

Shortness of breath x 1/7 while lying on bed

-sudden onset
-chest discomfort, nausea and epigastric pain
-patient claim hiccup x 5/7
-legs and hand numbness since discharge from hospital and unable to ambulate due to bilateral
Lower limbs weakness
Constipation x 1/52

No vomiting,no palpitation, no loose stool, no fever, no cough runny nose

Prescribed Medication
S/C Actrapid10 iu TDS
S/C Insulatard 10 iu ON
T. Perindopril 8 mg OD
T. Amlodipine 10mg ON
T. Hydrochlorothiazide 25mg ON
T. Pantoprazole 40mg OD
T. Aspirin (acetylsalicylic acid)150mg OD
T. Simvastatin40mg ON
T. Neurobion 1/1 OD

State the indication of each drug.

Counsel on appropriate use of Insulin technique

3
Subjek Objek Assesment Planning KIE dan
Monitoring
Laki-laki usia 53 Tinggi 165 cm
tahun, BB 70 kg
Riwayat BMI 25,71
penyakit Pengobatan
Diabetes
Mellitus (14 S/C Actrapid 10 iu Insulin fast Obat dilanjutkan Digunakan 30
years) TDS acting, interaksi menit sebelum
dengan ACEI dan makan
Hypertension (1 salisilat , dapat
year) menurunkan
Keluhan : absorbs insulin
Shortness of
breath x 1/7 S/C Insulatard 10 iu Insulin long Obat dilanjutkan Diinjeksikn pada
while lying on ON acting, interaksi malam hari
bed dengan ACEI dan
-sudden onset salisilat , dapat
-chest discomfort, menurunkan
nausea and absorbs insulin
epigastric pain
-patient claim T. Perindopril 8 mg Terdapat DRP Sebaiknya obat Monitoring
hiccup x 5/7 OD interaksi obat diganti dengan tekanan darah,
-legs and hand dengan aspirin golongan ARB serum creatinin
numbness since yang dapat seperti valsartan dan elektrolit.
discharge from menurunkan dengan dosis 80- Diminum dengan
hospital and kadar obat 160mg / hari atau tanpa
unable to perindoprildan makanan
ambulate due to interaksi dengan
bilateral Lower insulin
limbs weakness
Constipation x Terdapat DRP Obat dilanjutkan Dapat digunakan
1/52 T. Amlodipine interaksi obat dengan atau tanpa
dengan makanan
No vomiting,no 10mg ON
simvastatin dapat Monitoring
palpitation, no meningkatkan tekanan darah,
loose stool, no resiko myopati t dan heart rate
fever, no cough ermasuk
runny nose rhabdomiolisis

Menurukan efek Obat dilanjutkan Makanan dapat

T. antidiabetes menurunkan
Hydrochlorothiazide bioavailabilitas
25mg ON Monitoring
kehilanngan
cairan, tekanan
darah, serum
elektrolit dan
kreatinin dan
BUN

T. Pantoprazole Untuk peptic Obat dilanjutkan Dapat digunakan

40mg OD ulcer dengan atau tanpa
makanan.
Monitoring kadar

4
 Mg

T. Aspirin Mencegah infark Obat dilanjutkan

(acetylsalicylic miokard
acid)150mg OD

T. Simvastatin40mg Obat tanpa Obat dihentikan

ON indikasi

T. Neurobion 1/1 Tidak ada DRP Obat dilanjutkan

OD
Untuk
penanganan
konstipasi
sebaiknya dengan
terapi non
farmakologi
dengan
mengkonsumsi
banyak serat dan
air putih

Jadwal minum obat

Nama obat pagi siang sore Malam
S/C Actrapid10 iu TDS √ √ √
S/C Insulatard 10 iu ON √
Valsartan 80 mg √
T. Amlodipine 10mg ON √
T. Hydrochlorothiazide √
25mg ON
T. Pantoprazole 40mg √
OD
T. Aspirin (acetylsalicylic √
acid)150mg OD
T. Neurobion 1/1 OD √

5
Case 3. Management of hypoglycemia
Patients’ profile
Name Mr Y.M.P
Reg. No XXXXXX Gender Male
Address Kuala Krau
Telephone - Race Malay Age 72 years old
DoA 07/02/2017 DoD 09/02/2017
Height 170cm Weight 90kg
2
Calculated Body Mass Index (BMI) kg/m
Chief complaints
- Referred from Health Clinic Kuala Krau for symptomatic hypoglycemia.
- DXT at KK: 1.7 mmol/L
History of presenting illness
- Generalized body weakness x 3/7
- Poor oral intake x 3/7
- ADL dependant x 1 year
Past medical history
Disease x (years) Other medical history (procedure/surgical)
- Diabetes Mellitus more than 10 years - nil
- Hypertension more than 10 years
- Spondolytic and spondylolisthesis at L4
and L5.
Past medication history
- T. Amlodipine 100 mg BD
- T. Calcium Carbonate 500 mg BD
- T. Metoprolol Tartarate 100 mg BD
- T. Gliclazide 300 mg MR
Any Drugs/ antibiotics allergy: - NKDA
Hx of ADR: - nil

Review of system (during admission) Social/Family history

BP (mmHg) : 174/61 Smoking : No
PR (bpm): 105 Alcohol : No
T (ºC): 37˚ Drug abuse: No
SpO2 (%): 99% Pregnant : No
Pain score: 2 Occupation: nil
Lung: Clear Family: nil
DXT: 5.6 mmol/L
General appearance: alert, mild pale, warm peripheries.

6
 Provisional diagnosis/ Impression/ Current diagnosis

- Hypoglycemia secondary to poor oral intake/ OHA

- Non-oliguric AKI on CKD secondary to dehydration/ traditional medication use.

LABORATORY INVESTIGATION
Vital signs
BP T HR RR SPO2 Pain
Date Time
135/75 37°C 60-100 12-18 (%) score
mmHg bpm bpm
7/2 4.33 am 174/61 37 105 24 99 2
5.20 166/140 37 114 21 95
7.07 am 173/72 37 106 24 99
7.35 am 168/72 37 114 20 95
8 am 156/81 37 104 20 99
9.51 am 170/75 37 104 20
4.48 pm 162/70 37 100 21 96
10 pm 152/78 37 71 20 98
6 pm 150.71 37 110 20 96
8/2 4 am 157/67 37 88 20 97
9 am 124/60 37 67 20 95
9.21 am 152/78 37 88 20 97
12.01 pm 157/67 37 67 96
4 pm 132/62 37 104 20 95
7.24 pm 124/60 37 104 20 95
8 pm 132/62 37 100 20 91
11 pm 168/84 37 116 20 96
9/2 3 am 130/70 37 90 20 97
7.39 am 130/70 37 113 21 97
8.30 am 147/78 37 98 20 97
9.24 am 147/78 37 113
12 pm 136/74 37 98 20 98
4 pm 157/70 37 100 20 95

Arterial Blood Gas (ABG)

Parameter Normal range Date/ Day
8/2
pH 7.35-7.45 7.215
pCO2 35-45 mmHg 34
pO2 80-100 mmHg 22
T. Hgb 7.4- 10.9 g/dL 8.1
Hct 37-52% 25
SO2 93-100% 22
Lactate 0.5- 1.6 mmol/L 1.2
HCO3 22-26 mmol/L 13.1
T. CO2 23-27 mmol/L 29

7
Base Excess 1.5- 3.0 mmol/L -13.2
H+ Concentration 35.5- 44.7 mmol/L 60.9

Full blood count (FBC)

Parameter Normal range Date/ Day
6/2
Hgb 12.0 – 17.0g/dL 8.7
TWBC 4.5- 10.0 x 109 L 12.8
Plt 150 – 450x109L 440

BUSE/ Renal Profile

Parameter Normal range Date/ day
7/2 8/2 9/2
Urea 1.7-8.3 mmol/L 50.1 49.9 6.3
Serum sodium 135-145 mmol/L 127 127 137
Serum potassium 3.5-5.0 mmol/L 5.1 5.1 5.0
Serum chloride 95-108 mmol/L 90 106
Phosphate 0.8-1.45 mmol/L 2.86
Creatinine 44-133 mmol/L 643 591 155
Creatinine Clearance 105-150 ml/min 11.69 12.71 48.48

Liver Profile
Parameter Normal range Date/ day
7/2
ALP 53- 141 u/L 106
ALT <45 u/L 36
Albumin 35- 50 g/L 37
T. Bilirubin 5- 21 µmol/L 5.0
T. Protein 66- 83 g/L 32

Cardiac Enzyme
Parameter Normal range Date/ day
7/2
CK 24- 171 u/l 502
LDH 240- 460 g/l 68

Blood Glucose Level ( mmol/L)

Day/ Prebreakfast (PB) Prelunch (PL) Predinner (PD) Bed Time (BT)
Time
7/2 5.3 5.9 6.2

Input/Output chart
Parameter Day/Date
D1 D2
7/2 8/2
Total input (ml) 1960 1290

8
 Total output (ml) 900 200
Balance (ml) +1060 -710

Medication in Ward
Medication Date
7/2 8/2 9/2
Tab. Amlodipine Besylate 10 mg STAT 9.21 am
T. Amlodipine Besylate 10 mg OD 8 am
T. Calcium Carbonate 500 mg BD 8 am
Rectal, Glycerin 25% &NaCl 15% Enema, 1 8 am
Enema OD
Lactulose 3.35 g/5ml liquid. 15 ml STAT 9.18 am

Lactulose 3.35 g/5ml liquid. 15 ml TDS 4 pm 8am

IV Pantoprazole 40 mg inj STAT 9.22 am

IV Pantoprazole 40 mg OD 8 am

Please discuss on the followings:

1. Comments on all lab parameters
2. Provide indication on the drugs given
3. Identify any pharmaceutical care issues
4. Discuss on the management of hypoglycemia
5. Discuss on the other relevant conditions such as hypertension in diabetes patient
considering the acute renal failure and chronic kidney disease

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Case 5_DKA with thigh abscess
Patients’ profile
Name Mrs M Age 67
Race Malay Gender Female
Height 155cm Weight 55kg
Calculated Body Mass Index (BMI) 22.89 kg/cm2
DoA 29/4/17 ToA 10.00am

Chief complaints
Body weakness

History of presenting illness

Left thigh swelling x 3/7
-painful, noticed because of pain over left inner thigh with pus discharge x 3/7
-swollen and ertyhematous
-semi dependent ADL since 3/7 ago
-on day 2, the skin over swelling started to turn black
-no history of trauma/insect bite
-did not apply any ointment/med on swelling
Fever x 3/7
-associated with chills and rigor
-no cough/runny nose
-no dysuria/increase frequency
Reduce oral intake x 3/7
-unable to tolerate
-vomit each time take orally, fluid particle
-become lethargy and weak

Past medical history

Disease (x years) Other medical history (procedure/surgical)
Hypertension x 10 years Done operation on left leg
Diabetes mellitus x 5 years

Past medication history

No Known Drug Allergy
Prescribed Medication
Medications Indication
Nil. Patient not come for follow up.

Compliance Assessment (A. Modified Morisky Scale/MMS)

Instructions: Ask the patient each question and circle the corresponding “yes” or “no” response. Circle the
answer to each question and sum the score for the motivation column and sum the score for the knowledge
column.
Question Answer
1. Do you sometimes forget to take your pills? Yes(0) No (1)

2. People sometimes miss taking medications for reasons other than Yes(0) No (1)
forgetting. Thinking over the past two weeks, were there any days when
you did not take your medicine?

3. Have you ever cut back or stopped taking your medication without Yes(0) No (1)
telling your doctor because you felt worse when you took it?

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 4. When you travel or leave home, do you sometimes forget to bring along Yes(0) No (1)
your medications?

5. Did you take your medicine yesterday? Yes(1) No (0)

6. When you feel like your disease is under control, do you sometimes Yes(0) No (1)
stop taking your medicine?

7. Taking medication every day is a real inconvenience for some people. Yes(0) No (1)
Do you ever get hassled about sticking to your treatment plan?
8. How often do you have difficulty remembering to take all your Never/ Rarely …. (1)
medication? Once in a while (0.75)
Sometimes ……. (0.5)
Usually ………… (0.25)
All the time ……. (0)
Please refer manual for scoring. Score :
(<6) Low-adherence
(6 to <8) Medium adherence LOW ADHERENCE 0.25
(8) High adherence

Review of system (during admission)

BP : 174/79 mmHg
RR : - breath/min
PR : 113 beats/min
T : 38.1 °C
SPo2 : 96 % under room air

Lung : Clear
CVS: S1S2 no murmur
Abd: Soft, not tender
General: Alert, concious, GSC 15/15, lethargic looking, good pulse volume
Social/Family history
Smoking : Nil
Alcohol : Nil
Drug abuse: Nil
Pregnant : Nil
Occupation: Housewife
Family: -

Provisional diagnosis/ Impression/ Current diagnosis

Mild diabetic ketoacidosis (DKA) secondary to left thigh abscess
Acute kidney injury (AKI) secondary to 1

Surgical
Date: 30/4/17
Time: 1149-1205
Diagnosis: Sepsis secondary to left thigh abscess
Operation: Wound debridement of left thigh

Vital signs
Vital signs
Date Time BP (normal HR (normal RR (normal SPO2 (normal range: Temperature Pain
range: range: 60-100 range: 12-18 ≥ (37.2˚C) Score

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 120/80mmHg) p/min) b/min) 95%)
29/4 2.45pm 153/74 117 22 95 0
3.15pm 159/72 111 20 97 under RA 38.4 0
7.30pm 156/76 114 20 95 under RA 37.5 0
10.45pm 171/88 104 20 98 under RA 38.7 0
30/4 6.00am 174/82 92 20 98 under RA 37.6 0
9.00am 168/82 94 20 98 under RA 38.0 0
10.50am 168/86 92 On OT call 0
1.20pm 151/85 100 20 98 under RA 37.8 0
3.30pm 155/84 102 20 96 under RA 37.5 0
7.20pm 171/87 111 20 96 under RA 39.0 0
11.00pm 161/90 99 20 98 under RA 37.4 0
1/5 4.20am 153/89 98 20 98 under RA 37.6 0
8.20am 147/64 100 20 97 under RA 38.0 0
11.15am 154/82 97 20 97 under RA 38.3 0
4.20pm 148/76 95 20 97 under RA 38.5 0
7.50pm 153/82 96 20 96 under RA 38.1 0
11.00pm 146/75 91 21 97 under RA 37.8 0
2/5 3.15am 155/96 88 21 97 under RA 37.6 0
8.00am 151/78 93 21 95 under RA 38.0 0
11.40am 145/74 89 22 97 under RA 37.1 0
4.00pm 101/69 79 21 98 under RA 37.5 0
7.30pm 138/66 80 20 99 under RA 37.3 0
11.00pm 109/64 78 20 98 under RA 37.0 0
3/5 4.30am 138/74 77 20 99 under RA 37.0 0
8.30am 134/89 78 20 95 under RA 37.0 0
1.40pm 167/87 78 20 100 under RA 37.0 0
4.00pm 145/79 79 20 99 under RA 37.0 0
8.00pm 138/70 80 20 99 under RA 37.0 0
10.45pm 127/74 90 20 99 under RA 37.0 0
4/5 3.30am 150/85 74 20 99 under RA 37.0 0
8.30am 148/74 86 21 100 under RA 37.0 0
12.25pm 142/78 80 21 100 under RA 37.0 0
4.00pm 152/79 76 21 100 under RA 37.0 0
7.30pm 146/68 76 21 99 under RA 37.0 0
10.50pm 116/75 71 20 98 under RA 37.0 0
5/5 4.00am 121/70 74 20 98 under RA 37.0 0
7.45am 183/88 73 22 99 under RA 37.0 0

LABORATORY INVESTIGATION

Full Blood Count (FBC)

Day/Date
Parameter Normal range
29/4 1/5
WBC 4.5 - 11.0 × 109/L 29.83 H 26.85 H
RBC 4-4.9 x1011/L 4.69 3.5 L
Hgb 12.0-15.0 g/dL 12.6 9.2 L
Plt 150-450 x 109/L 343 308
Neutrophil 2.0-7.0 g/dL 27.8 H 25.07 H
Eosinophil 0.02-0.5 g/dL 0L 0.12
Lymphocytes 1.0-3.0 g/dL 0.96 L 0.98 L
Monocytes 0.2-1.0 g/dL 0.99 0.57
Basophil 0.02-10.0 g/dL 0.08 0.11

BUSE / Renal Profile

Day/Date
Parameter Normal range
29/4 2/5 3/5

12
 Urea 3.0 – 9.2 mmol/L 5.7 2.5 L 2.4 L
Serum sodium 135–145 mmol/L 127 L 133 L 134 L
Serum potassium 3.5–5.1 mmol/L 5.7 H 3.0 L 3.3 L
Serum chloride 95–108 mmol/L 91 L 103 103
Serum calcium 2.2-2.65 mmol/L 2.32
Serum magnesium 0.73-1.06 mmol/L 0.84
Serum phosphate 0.87-1.45 mmol/L 1.28
Creatinine 44.0–133 mmol/L 121 H 57
Creatinine 34.63 73.51
105-150 mL/min
clearance

Liver Function Test (LFT)

Day/Date
Parameter Normal range
29/4
T. protein 66-87 g/L 76
Albumin 35-50 g/L 30 L
T. Bilirubin <20 μmol/L 13.4
ALP 53-141 u/L 152 H
ALT < 32 u/L 12
AST 5-34 u/L 32
Globulin 20-35 u/L 46 H

Venous Blood Gases (VBG )

Day/Date
Parameter Normal range
29/4 29/4 2/5
pH 7.32 – 7.43 7.32 H 7.424 7.411
PCO2 38 – 52 mmHg 30.4 L 31.5 L 35.3 L
PO2 28 – 48 mmHg 32 33.3 16.3 L
HCO3 22 – 24 mmol/L 16.3 L 20.2 L 21 L
O2 saturation 70-75% 57.7 L 66.3 L 23.7 L

Input Output Chart

Day/Date
Parameter 29/4 30/4 1/5 2/5 3/5 4/5
Total input (mL) 2775 2544 2411 2571 1468 1408
Total output (mL) 1700 1600 1200 1800 1150 1350
Balance (mL) 1075 944 1211 771 318 58

Coagulation profile
Day/Date
Parameter Normal range
29/4
PT 12-14.5 sec 15.4 H
aPTT 31-43 sec 52.5 H
INR < 1.5 1.2

Others
Day/Date
Parameter Normal range
2/5
C reactive protein <5 226 H 577.8 H 256.8 H

UFEME
Date:29/4/2017
pH 5
Specific gravity 1.02
Leucocyte Negative
Nitrite Negative

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Protein 75 mg/dL (2+)
Glucose 1000mg/dL (4+)
Ketone 150mg/dL (3+)
Urobilinogen Normal
Bilirubin Negative
Erythrocyte/blood 250 cells/Ul (4+)

Culture and sensitivity

Date Specimen Result
30/4 Blood So far no growth
Swab
Tissue

Random blood glucose level

Date Time Reading (mmol/L) Date Time Reading (mmol/L)
29/4 3.00pm 15.5 (IVI Insulin 1/5 10.30am 11.2
4ml/1hr)
4.00pm 13.4 11.45am 10.2
5.00pm 12.1 1.00pm 9.9
6.00pm 11.7 2.00pm 9.2
7.00pm 8.7 3.00pm 11.0
8.00pm 8.3 4.00pm 11.9
9.00pm 8.6 5.00pm 12.2
10.00pm 6.2 6.00pm 11.2
11.00pm 4.8 7.00pm 10.6
30/4 12.00am 5.0 8.00pm 9.7
1.00am 4.8 9.00pm 9.0
2.00am 5.0 10.00pm 9.7
3.00am 5.0 11.00pm 7.9
4.00am 4.9 2/5 1.00am 7.0
5.00am 4.8 2.00am 8.2
6.00am 5.0 3.00am 6.9
7.00am 6.4 (IVI Insulin 4.00am 7.2
2ml/1hr)
8.30am 8.0 5.00am 7.0
9.30am 8.5 6.00am 6.8
1.40pm 8.8 7.00am 8.8
3.00pm 9.3 (IVI Insulin 8.00am 7.7
1ml/1hr)
4.00pm 12.4 9.00am 8.6
5.00pm 12.4 10.00am 9.6
6.00pm 12.5 11.00am 8.4
7.00pm 15.8 12.00pm 8.9
8.00pm 13.0 5.00pm 14.2
9.00pm 16.0 11.00pm 13.6
10.00pm 15.9 3/5 7.00am 10.2
11.00pm 15.2 12.10pm 7.2
1/5 12.00am 12.3 5.30pm 8.8
1.00am 12.8 11.20pm 11.8
2.00am 13.1 4/5 7.15am 9.4
3.00am 12.7 12.00pm 8.6
4.30am 12.5 5.10pm 7.4
5.30am 11.9 11.15pm 8.6
6.40am 11.7 5/5 7.00am 5.7
8.20am 10.5
9.35am 10.9

14
 Medication Profile Emergency Department
Medication Regimen Date Started Date Stopped
IV Ampicillin+sulbactam 1.5 g STAT 29/4 29/4
IV insulin 4 u/hr 29/4 29/4
IV normal saline 1L/H 29/4 29/4

Medication Regimen Day/Date

29/4 30/4 1/5 2/5 3/5
IV Ampicillin+sulbactam 1.5 g TDS 8 pm
IV Ceftazidime 2 g STAT & BD 6 pm
2 g TDS
IV Pantoprazole 40 mg OD
IV Ranitidine 50 mg TDS
T. Perindopril 4 mg OD
IV Tramadol HCI 50 mg
STAT/PRN
50 mg
STAT/TDS
T. Paracetamol 1g QID
IM Pethidine 50 mg STAT OFF
S/C Enoxaparin 40 mg STAT OD
IVI insulin
S/C Actrapid 6 iu TDS
S/C Insulatard 6 iu ON
Hematinic 1/1 OD

15
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