Done by : Mohannad AL.shibani clinical pharmacist intern Supervised by: Dr. Muna Fliflan 111

CASE 86 years Saudi male,70 KG, presented to ER. On (16/10/2008) C/O fever, productive cough, and not eating well since 2 day back. Patient was discharged from medical department 1 month back (13/9/2008) on case of “”drug induced hypoglycemia”” and all his medication was stopped.then he was well until 7 day back when he started to have fever 39°C. He was seen in polyclinic and discharge on antibiotic and cough syrup but was not given to patient. 2 days back patient was lethargic with fever,decrease in appetite and weakness. he is not eating well according to his son and he took him to private polyclinic and found to be febrile and dehydrated with blood glucose 420 mg/dl. They gave him IVF,insulin and they told him to take patient to big hospital. FILE NO. : ROOM NO. :451 D 211

Case cont….. Past medical history: I. Type 2 DM from II. HTN III. Old CVA 311

Case cont….. Past medication: I. A SA 81 mg po OD II. O meprazole 20 mg po OD III. G libenclamide IV. M etformin V. H CTZ D/C on 13/9 411

Case cont….. Diagnosis: chest infection and dehydration Diagnosis: chest infection and dehydration Vital signs: Temp. 38.5°C Vital signs: Temp. 38.5°C Bp. 161/83 mm/Hg Bp. 161/83 mm/Hg pulse 70/min pulse 70/min RR. 22 /min RR. 22 /min 511

Case cont….. Physical examination: 16/10/2008  Skin & extremities: not pale or jaundice, sleepy, difficult in hearing  Eyes, ears & neck: normal  Chest wall & lungs: clean with equal air entry bilaterally, spontaneous breathing & yellowish sputum  Cardiovascular: S1 + S2 + 0  Abdomen : soft, no organomegally  Bone & joints : skin pealing & dry bed sores  Mental status : conscious 611

Progress note: Date:16/10  Plan: 1) Urine analysis 2) blood c/s, urine c/s & sputum c/s 3) 4 points BS monitoring 4) low salt & DM diet 5) sliding scale for DM 6) ½ NS 60cc /hr IV. 7) PLASIL 10 mg IV. (immediately) 8) klaccid 250 mg BID PO 9) ROCEPHINE 1g IV. BID 10) omeprazole 20mg OD PO 11) ASA 81mg OD PO 12) capoten 12.5mg BID PO ____________________________________________________________________ Date:18/10 Temp. :37.5 Bp. :163/74 RR. :20/min pulse=60  Subjective: patient seeing fine, conscious, but complain of dry bed ulcer and BS. was 258 mg/dl 711

Progress note:  Labs :  Urine analysis:  Hematology analysis:  plan: OSMO.= 265 k =2.8 mmol/l Alb.= 2.4g/dl Na= 132mmol/ ESR.= 45 mm/hr INR= 0.9 PTT=27.5 (control=31.6) PT=10.8 (control=12.5) urine is light, yellowish & turbid appearance PH=6.5 Glucose: +ve leucocytes :+ve WBC= Bacteria: +++ve Neut.=9.46 WBC=11.56 RBC= 3.77 Hgb=11.00 g/dl Hct= 31.6% 1)Dermatology counseling 2) Add lantus 10 U am. 3) Add fucidin ointment locally BID 4) Add flamazine ointment locally BID 811

Progress note: Date:19/10 : Temp. :37.5 Bp. :140/70 RR. :20/min pulse=65 BS.=256 mg/dl ac.  CBC:  Plan: BUN=25.3 Na=130 Glu=288 WBC=11.9 RBC=3.8 Hgb=11.1 1) lantus 10 U pm. 2)add RI. 8 U SC. TID premeal 3)D/C sliding scale 4)add clexane 40 mg SC. OD 5) dermatolodist seen pt. then change dreesing daily 6) continuous other treatment 911

Progress note: Date:20/10: Bp. :139/88 BS.=200 mg/dl pc  Subjective:  plan: 1)bilateral hand swelling in Rt. Hand 2) febrile vital stable 1) increase lantus to 14 U Pm. 2)incourage oral intake 3) D/C IVF. 4) Continuous the treatment 5) C.S.T 6) Repeat chemistry 1011

Progress note: Date:23/10 Bp. :125/72 BS.=141 mg/dl ac.  Subjective:  Lab test:  Plan: 1)sacral ulcer not improve 2)cough developed during take pre meal 3)lab showed no growth factor on blood after 5 days 1) BUN=25.9 2) Na= 131 1)insert NGT but his son refused 2) Continuous the treatment 3)C.S.T again 1111

Progress note: Date:27/10 Bp. :130/91 BS.=205 mg/dl ac  Subjective:  C.S.T:  Biochemistry:  Hematology:  Plan: 1)sacral ulcer still not improve 2)pt. fine, febrile vital stable 1)Urine culture showed Enterococcus spp. 1) BUN=28mg/dl 2)ALB=2.5g/dl 1)RBC=3.85 2)Hgb=11.1 3)Hct=33.2 1)increase lantus to 18 U Pm. 2)repeat CBC chemistry 1211

Progress note: Date:28/10: Bp. :161/89 BS.=88 mg/dl ac  Subjective:  Plan:ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ Date:1/11: Bp. :132/74 BS.=157 mg/dl ac Subjective: Pt. fine, febrile vital stable  Plan: 1) increase RI. To 6 U SC. TID premeal 2) increase lantus to 20 U SC. Pm. Pt. fine, febrile vital stable Decrease RI. to 4 U SC. TID 1311

Diabetic follow up 11 pm.6 pm.11 am.6 am.DATE 168 pc181 pc275 pc16/ pc144 pc168 ac190 ac17/ pc270 pc258 ac131 ac18/ pc195 ac118 ac256 ac19/ pc321 pc200 pc20/ pc134 ac180 pc121 ac21/ ac205 ac107 ac125 ac22/ pc158 ac141 ac23/ pc260 pc144 ac168 ac24/ pc326 pc107 ac25/ pc231 ac185 pc222 ac26/ pc222 ac188 pc205 ac27/ pc157 ac98 pc88 ac28/10 158pc174 ac123 ac120 ac29/ pc177 ac144 pc178 ac30/ pc222 pc206 pc170 ac31/

Discussion 1115  Why?  Factor associated with switching to insulin: I.younger at diagnosis II. Suffer from more health proplem espicially cardiovascular disease III. Have worse metabolic control IV.HbA1c > 8%

Discussion cont.. 1) Single dose of bedtime(long acting) insulin plus daytime sulfonylurea 2) Two injections of intermediate acting insulin 3) Multiple daily injection, combination of short acting and intermediate acting 4) Single dose of bedtime(long acting) insulin plus three times rapid acting insulin before meals 1116 Protocol used when switch to insulin: Protocol used when switch to insulin:

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reference p?mode2=detail&origin=ibids_references& therow= p?mode2=detail&origin=ibids_references& therow= p?mode2=detail&origin=ibids_references& therow= p?mode2=detail&origin=ibids_references& therow= Wayne A.Kradjan.Handbook of applied therapeuetic.Lippincott Williams and Wilkins.8 th ED,2007;Chapter 49,page: Wayne A.Kradjan.Handbook of applied therapeuetic.Lippincott Williams and Wilkins.8 th ED,2007;Chapter 49,page: