HOSPITAL TRAINING-CASE DATA SHEET
حسين جاسم لفتة:PATIENT NAME AGE: 69 SEX: MALE
DATE OF ADMISSION: 26\4\2019 WEIGHT: 83kg HEIGHT:175cm BMI=27.1
Chief complaint (CC):
Shortness of breath for 2 days
History of present illness:
A know case of heart failure presented with acute onset of severe shortness of breath developed in 2 days the SOB
exacerbated while lying flat, and partially relieved by sitting, the condition also associated with cough with white
sputum, he noticed a bluish discoloration around his mouth, he stated that he had fever few days, he has no chest
pain or palpitation he has episodes of SOB that awakens him from sleep and he has leg swelling in the past few
months
PAST MEDICDAL HISTORY:
Acute MI: 3 years ago, Heart failure: 2 years ago, Hypertension: 12 years ago, not diabetic
PAST SURGICAL HISTORY:
Nothing significant
MEDICATION HISTORY:
medication indication dose Frequency of dosing Day started
atrovastatin Post MI
prevention
captopril Hypertension+
heart failure
aspirin Post MI
prevention
carvidalol Heart failure
spironolactone Heart failure
DRUG ALLERGY
No labeled allergy for any drug
SOCIAL HISTORY
Ex-smoker for 30 years 1 pack per day quit 3 years ago, non-alcoholic
:REVEW OF SYSTEMS
- CNS: -ve
- CVS: orthopnea, PND, leg swelling
- GIT: nausea without vomiting
- RS: dyspnea, cough
- GUT: dysurea, frequency, urgency, turbid urine
1
VITAL SIGNS:
date BP HR PR RR TEMP
On admisson 60\110 120 120 31 38.9
Day 1 80\140 86 86 22 38.5
Day 2 85\140 80 80 19 37.9
Day 3 80\140 78 78 18 36.6
INVESTIGATION
LAB DATA VALUE REFERENCE RANGE DATE
WBC x 103 14.6 x 103 10.2 – 3.6 On admission
HBG 14.2 g/dl 16.6 – 12.5 On admission
RBS 87 mg/dl 160 – 79 On admission
B. urea 51 15 – 45 mg/dl On admission
S. creatinine 1.1 0.4 – 1.2 mg/dl On admission
PaO2 71 80 – 100 mmHg On admission
PaCO2 37 35 – 45 mmHg On admission
pH 7.38 7.35 – 7.45 On admission
HCO3 23 22 – 26 meq/l On admission
SaO2% 85% 95 – 100% On admission
S. sodium 143 136 – 145 mmol/l On admission
S. potassium 5.1 3.5 – 5.5 mmol/l On admission
WBC 14.3 x 103 x 103 10.2 – 3.6 Day 1
S. sodium 139 136 – 145 mmol/l Day 1
S. potassium 4.1 3.5 – 5.5 mmol/l Day 1
WBC 15.6 x 103 3.6 – 10.2 x 103 Day 2
S. sodium 145 136 – 145 mmol/l Day 2
S. potassium 4.42 3.5 – 5.5 mmol/l Day 2
WBC 11.2 x 103 3.6 – 1x 103 0.2 Day 3
S. sodium 139 136 – 145 mmol/l Day 3
S. potassium 4.1 3.5 – 5.5 mmol/l Day 3
B. urea 41 15 – 45 mg/dl Day 3
S. creatinine 0.9 0.4 – 1.2 mg/dl Day 3
2
Others (U\S , ECG):
On admission:
CXR: diffuse lung infiltration signs of pulmonary edema
ECG: sinus tachycardia, old MI, left axis deviation
Day 1:
Urinalysis: turbid, pus cells=++++, RBC=6, pH= acidic, epithelial cells: +
Echocardiography: EF=45%, LV dilation
Urine culture and sensitivity
Day 3:
CXR: decrease infiltration
DIAGNOSIS:
Acute pulmonary edema (decompensated heart failure) probably exacerbated by UTI
TREAMENT .
Medication Dose Frequency of dosing Day started Day stopped
Oxygen On addmision Day 2
Lasix On addmision
Glyceryle trinitrate On addmission Day 1
captopril Day 1
spirolonactone Day 1
advostatin Day 1
aspirin Day 1
Ciprofloxacin 100mg 2*1 Day 1
meropenem 500 i N/S 3*1 Day 1
Paracetamol vial Day 1
metronidazole Day 2
metoclopramide 10mg 2*1 Day 3 Day 4
3
Clinical progress
date Morning tour Night tour
On admission Consious Conscious
Agitated Oriented
Very tachypnic Tachypnic
Febrile Febrile
Bilateral diffuse fine crackles Bilateral diffuse fine crackles
Bilateral pitting edema Bilateral pitting edema
SpO2 87%
Day 1 Conscious Conscious
Oriented Oriented
tired Tachypnic
Tachypnic Febrile
Febrile Bilateral basal fine crackles
Bilateral basal fine crackles Bilateral pitting edema
Bilateral pitting edema
SpO2 93%
Day 2 Conscious Conscious
Oriented Oriented
Febrile Febrile
Decrease in crackles Basal fine crackles
Decrease in leg edema
SpO2 95%
Day 3 Conscious Conscious
Oriented Oriented
Afebrile afebrile
Nausea Decrease in crackles
Decrease in crackles Decrease in leg edema
Decrease in leg edema
SpO2 96%
4
Pharmaceutical care plans
day Care issue action
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