Intensive Care Unit ( ICU ) Case Studies Detailed Initial Assessment A.

Patient Description
Age Name Reg. No. Race Admission. : Lim Khim Chuar :SP 00064098 :Chinese : 24/07/2011( 18.08) : 53 Gender : Male Weight : None Height : None BMI : None
Note: BMI <18.5 18.5 24.9 25 29.9 > 30 Status Underweight Normal Overweight Obese

Chief Complaint Organophosphate Poisoning Around 11.00am 11.45am today ( 24/07/2011 ).Started to has vomiting and drooling of saliva. Still able to talk to his wife at home apparently. History of Present Illness Patient went out at from home at 11.0.00am and come back around 11.45a.m and told his wife that he took poison that use in the farm. Patient was misunderstood for having affair with another girl and was bitted by a group of gangster ( 5 people ) yesterday for that. They asked him to meet them today at 1.30p.m again, thus, he drank the poison. Upon arrival to casualty ( GCS E4V1M2 ( 7/15 )), patient noted with hypersalivation with drooling of saliva Pupils: Pin Point Lungs : transmitted sound Abdomen: soft Muscle Fasciculation seen Thus, was intubated by casualty Medical Officer and intubated with ETT 7.5, anchored at 21 CL 4, laryngeal edema noted. Refer patient for ventilator support

Upon receiving patient in ICU 2, patient intubated, sedated, restless, connected to SIMV mode PEEP:8, rate: 12, Ti: 1.4, PS: 12, PC: 15, FiO2: 0.5 Pupils : Bilaterally Pin Point BP: 140/87 mmHg

HR: 90bpm SPO2 : 100% Lungs: Clear CVS: DRNM Per Abdomen ( p/a): soft, bowel sound( bs ) present Right Radial Arterial Line Inserted Right External Jugular Triple Lumen Inserted Under Aseptic Technique. Intubation: Yes Ventilated: Yes

Past Medical History No Known Medical Illness. Family History None Social History None

Vital Signs Monitoring

Date 24/7/2011 Time 06.08pm BP (mmHg) 140/87 PR (/min) 90 Temp (oC) DXT Fluid I/O -

25/07/2011

07.45am

124/76

100

6.3

26/07/2011

9.24am

169/76

95

7.0

27/07/2011

10.29am

169/103

83

28/07/2011

10.20am

126/76

93

8.3

29/07/2011

08.26am

114/85

102

7.7

Physical Examination/ Daily Progress Review Of System (ROS): ( 25/07/2011 7.45am )

CVS Lungs/Respiratory SpO2 PA bal u/o

: DRNM ( Dual Rhythm No Murmur ) : Lung Reduce a/e right lower zone : 100% : soft and bowel sound : 1119 : 40-70

CVP ( Central Venous Pressure ) : 6 GCS ( Glasgow Coma Scale ) : 2T/15 Pupils : 4mm reactive ( 26/07/2011 9.24am )

CVS : S1S2 ( First and Second Heart Sound ) Lungs/Respiratory : clear SpO2 : 100% PA : soft bal : 1663.8 u/o : 50-100 CVP ( Central Venous Pressure ) : 13 GCS ( Glasgow Coma Scale ) : 15/15

( 27/07/2011 10.29am )

General

: Alert, Consciousness No sedation CVS : DRNM ( Dual Rhythm No Murmur ) Lungs/Respiratory : clear SpO2 : 100% PA : soft with bowel sound GCS ( Glasgow Coma Scale ) : E1M4V1

( 28/07/2011 10.20am )

General : Alert, Consciousness CVS : S1S2 ( First and Second Heart Sound ) Lungs/Respiratory : clear SpO2 : 100% PA : soft bal : 158 u/o : 100 -150 CVP ( Central Venous Pressure ) : 10 GCS ( Glasgow Coma Scale ) : 15/15

( 29/07/2011 08.26am )

General CVS Lungs/Respiratory SpO2 PA

: Alert, Consciousness : S1S2 ( First and Second Heart Sound ) : transmitted sound : 100% : soft with bowel sound

bal : 386.8 u/o : 100 cc GCS ( Glasgow Coma Scale )

: 12

Clinical Progress Date 24/7/2011 ( 06.08pm) Progress Investigation Plan - Knbm - IV drip 5pint / day ( 3ds, 2Ns ) - IV midazolam + morphine 5mg/hour - Mechanical dvt thromboprophlaxis - Prop up patient - IV pantaprazole 40mg bd - Dxt 3 hourly, keep dxt 6mmol/L 10mmol/L - Start Insulin sliding scale if dxt more than 10mmol/L - Repeat ECG and CXT - No need septic work up and antibiotic yet TDS tip and abg - IV atropine 1mg/hour infusion ( to adjust according to clinical response ) -vIV pralidoxime 2gm in 500cc ns over 1 hour, then, follow by -IV pralidoxime 500mg in 500cc ns over 1 hour for the next 47 hours -Regular Suction -Refer chest and limb physio 25/07/2011 ( 7.45am ) -In ICU2 ( Day 2 ). -Currently still intubated and sedated -GCS 2T/15 -Pupils 4mm reactive - Secretion minimal 26/07/2011 ( 9.24am ) -In ICU2( Day 3 ) -Still intubated GCS-15/15 For extubation today Continue IVD 5 pint ( 2pint NS / 3 pint Ds with 3gm KCL correction ) To change to CPAP once patient have spontaneous IV lasix 20mg bolus Off sedation

( 11.25am ) -patient collapse but not asystole -attended stat on manual bagging -Labored breathing -Restless, thus intubated with ETT size 7.5, anchored at 20cm -PRE-MEDICATION: IV Fentanyl 100mcg IV Propofol 100mg IV scoline 100mg -post intubated: lungs equal air entry -connect to SIMV mode; rate 15, PEEP 8, FIO2: 0.5 GCS E1M4V1 SPO2 100% CXR Repeated ABG 1hour Continue Observation

27/07/2011 ( 10.29am)

-In ICU2 ( Day 4 ) -yesterday intubated in casuality -2 hours post extubation yesterday -Patient desaturated developed apnea but not asystole -thus, intubated with ETT size 7.5, anchored at 20cm -completed pyridoxine for 48 hours

GCS :E1M4V1

Change to HME Prop up patient Off IV pantaprazole Change to tablet Ranitidine 150mg BD Start feeding 1L jevity/day IV Drip 3pints Neb Combivent 2 Hourly, 4 Hourly pulmicort No need sedation For HME 24 hours Restart feeding KNBM at 12 mm KIV extubate CM

28/07/2011 ( 10.20am)

-In ICU 2 ( Day 5 ) - yesterday intubated in casuality -2 hours post extubation yesterday -Patient desaturated developed apnea but not asystole -thus, intubated with ETT size 7.5, anchored at 20cm -completed pyridoxine for 48 hours

GCS :E1M4V1

29/07/2011

- In ICU 2 ( Day 6 )

secretion ++

KNBM first

( 08.26am)

-failed extubation X 1 ( 28/07/2011) -just extubated this morning -appears tachypnoeic on HFMO2

IV Drip 4 pints Cont atropine Low threshold for reintubation PROGRESS NOTED : Patient appear tachypnoic secretion +++ RR: 20-22 abg: good

NEXT PLAN : Continue HFMO2 KNBM

09/08/2011

-In ICU (Day 17) -failed extubation X 3 -POD 5 ( 4/8/11) : tracheostomy -Closed fracture distal end right Radius post CMR -Fracture of the right body of mandible- given TCA 1/52 dental clinic -Intubated with ETT 7.5, anchored at 21 on 8/8/2011 -CL4 laryngeal edema noted -failed extubation X 2 ( 28/7/1129/7/11)

-Trachy C & S (3/8/2011): Klebsiella pneumonia sensitive to meropenem - Blood C & S on 6/08/2011 Gram negative rods seen -Secretion ++, difficulty in wearing off

Continue IV Meropenem (Day 4) Trace blood C&S 1pint NS per day with IV KCL 3g/day Continue trachy mask For trachy care and nursing care Continue feeding 1.5L Jevity/day BD RP Change to TAB Ranitidine 150mg BD KIV off IV Meropoenem after r/v culture result

Laboratory for Initial and Follow Up

Lab Normal Range Investigation Full Blood Count TWBC 4.1-10.9 x 109/L LYM 10-58.5%L Hb 12-18 g/100mL RBC 4.5-6.3 x 106m/L PCV 35-50% MCV 50-97fl MCH 26-32 pg MCHC 31-36 g/dL RDW 11.5-14.5% Platlet 140-440 k/uL Renal Profile Urea 3.0-9.2 mmol/L SCr 62-115 umol/L ClCr 105-150 mL/min Serum Electrolytes Na 136-145 mmol/L K 3.5-5.1 mmol/L Cl 98-107 mmol/L Ca 2.15-2.55 mmol/L Mg 0.66-1.07 mmol/L PO40.74-1.52 mmol/L Liver Function Profile Albumin 35-50 g/L T. Bilirubin <20 mmol/L T. Protein 64-83 g/L ALP 40-150 u/L ALT <32 u/L Coagulation Profile PT APTT INR Cardiac Enzyme CK LDH AAT Arterial Blood Gases pH pCO2 pO2 HCO2 O2 Saturation Lipid Profile T. Cholesterol C- TG C- HDL C- LDL Others RBS 11-16 sec 25.4-38.4 sec <1.5

02/08/11 13.5x109/L 10.6g/dl 3.49 x 1012 L

04/08/11 21.1x109/L 9.5g/dl 3.12 x 1012 L

07/08/11 16.7x109/L 8.9g/dl 2.97 x 1012 L

Date 10/08/11 16.9x109/L 9.0g/dl 2.88 x 1012 L

12/08/11 16.9x109/L 9.3g/dl 3.11 x 1012 L

14/08/11 10.4x109/L 8.2g/dl 2.73 x 1012 L

18/08/11 11.5x109/L 10.0g/dl 3.47 x 1012 L

30.4pg 34.8g/dL 328X 109 /L 4.5mmol/L 65umol/L

30.5pg 35.1g/dL 405 X 109 /L 4.4mmol/L 60umol/L

30.0pg 31.9g/dL 287 X 109 /L 3.5mmol/L 52umol/L

31.4pg 35.6g/dL 416X 109 /L 3.4mmol/L 50umol/L

29.9pg 30.9g/dL 484 X 109 /L 3.5mmol/L 50umol/L

30.2pg 34.4g/dL 237 X 109 /L 3.2mmol/L 49umol/L

28.8pg 30.7g/dL 214 X 109 /L 4.1mmol/L 47umol/L

139mmol/L 3.5mmol/L 105mmol/L 1.96mmol/L 0.94mmol/L 0.79mmol/L 24/07/11 33g/L 23umol/L 69g/L 83u/L

139mmol/L 3.6mmol/L 109mmol/L 1.96mmol/L 0.92mmol/L 0.64mmol/L 04/08/2011 21g/L 13umol/L 58g/L 75u/L

139mmol/L 3.6mmol/L 108mmol/L 1.95mmol/L 0.82mmol/L 0.67mmol/L 07/08/2011 18g/L 10umol/L 58g/L 74u/L

139mmol/L 3.3mmol/L 108mmol/L 1.94mmol/L 0.89mmol/L 0.39mmol/L 11/08/2011 20g/L 12umol/L 70g/L 115u/L

139mmol/L 3.5mmol/L 108mmol/L 2.00mmol/L 0.86mmol/L 0.60mmol/L 12/08/2011 19g/L 10umol/L 69g/L 110u/L

138mmol/L 3.6mmol/L 106mmol/L 2.10mmol/L 0.89mmol/L 0.65mmol/L 18/08/11 26g/L 9umol/L 79g/L 156u/L

132mmol/L 3.6mmol/L 106mmol/L 1.85mmol/L 0.72mmol/L 0.51mmol/L

24/07/11 10.9sec

25/07/11 25.3sec

31/07/11 25.3sec

02/08/11 24.6sec

07/08/11 No coagulation >2min

1.02 24/07/2011 262u/L 306u/L 10/08/2011 12/08/2011 14/08/2011 18/08/2011

24-195 u/l 0-248 u/l < 37 7.35-7.45 35-45 mmHg 80-90 mmHg 22-26 mmol/L 90-95% < 5.7 mmol/L < 1.7 mmol/L >1.7 mmol/L < 3.9 mmol/L 3.7-11 mmol/L

33mmHg 96.0mmHg 25mmol/L 98%

36.5mmHg 208.3mmHg 24.8mmol/L 99.8%

35.5mmHg 76.4mmHg 26.2mmol/L 96.4%

24.0mmHg 100.0mmHg 20.0mmol/L 98%

Current Drug Regimen in Ward

Drug/ Regim Antimicrobial Meropenam Cefuroxime Cloxacillin Sodium Cardiovascular

Schedule 1g inj 1500mg inj 250mg inj

Duration Start (Date) Stop (Date) 06/08/2011 09/08/2011 10/08/2011 16/08/2011 09/08/2011 17/08/2011

Appropriateness

Electrolyte Ferrous Fumarate Pottasium chloride Diabetic

200mg Tab -

06/08/2011 16/08/2011

16/08/2011 18/08/2011

Others Ascorbic Acid Atropine Sulphate Bromhexine Hcl Chlorhexidine Gluconate 0.2% Esomeprazole Folic Acid Pantoprazole Paracetamol Potassium Citrate & Citric Acid Mixture Pralidoxime Cl Ranitidine Sodium Chloride Gargle Vitamin B capsule Vitamin B complex Tablet

100mg tab 1mg/1ml inj 8mg tab 40mg tab 5mg tab 40mg inj 500mg tab 3g/10ml 0.5g/20ml inj 150mg tab -

06/08/2011 24/07/2011 10/08/2011 27/07/2011 05/08/2011 06/08/2011 25/07/2011 11/08/2011 10/08/2011 24/07/2011 27/07/2011 02/08/2011 10/08/2011 06/08/2011

16/08/2011 27/07/2011 24/08/2011 27/07/2011 10/08/2011 16/08/2011 09/08/2011 21/08/2011 15/08/2011 01/08/2011 16/08/2011 09/08/2011 16/08/2011 06/08/2011

Pharmaceutical Care Issue

I) Drug related issue Date Drug concerned Rationale of Drug Use Drug Related Issue Precaution

II) Drug related problem Date Drug concerned Problems Action Outcome

III) Non Drug Related issue Date Pharmaceutical Care issue Pharmacist Recommendation Outcome

J. Post Hospital Discharge

Date of discharge: Discharged Medications: