Case 1 & 2awd

CASE 1

Patient Database:

Demographic Data

Name: WLO Weight: - kg

Age: 69 years old Height: - cm

Gender: Female Date of admission: 18/4/2014

Race: Chinese MRN: 1915303

Ward/Bed: W24/B15

Chief Complaint

Having bilateral leg swelling, periorbital swelling and mild shortness of breath (SOB).

History of Present illness

Bilateral leg swelling

Periorbital swelling

Past Medical History

Diabetes Mellitus (DM)

Hypertension (HTN)

Ischaemic Heart Disease (IHD)

Chronic Kidney Disease (CKD)

Family history / Social history

NA.

Past Medication history

Simvastatin 40 mg, Aspirin 300 mg,

Furosemide 40 mg, Felodipine 10 mg,

Metoprolol 100 mg, Minoxidil 5 mg,

Ferrous Fumarate 200 mg, Neurobion 1 tablet,

SC Actrapid, SC Insulatard.

Allergy

No known drug allergy (NKDA).

Review of system

BP: 135/50 mmHg RR: 21 b/min

PR: 67 p/min T: 37 C

Patient denies chest pain, nausea or vomiting, abdominal pain, fever and UTI symptoms.

Compliance evaluation

NA.

Physical examination

General: alert, oriented, speak in full sentence.

Head: bilateral periorbital oedema.

Lung: decreased breath sounds bibasally.

Abdomen: soft and not tender.

Diagnosis / Surgical procedure

Decompensated CCF (Congestive Cardiac Failure) 2o to non-compliance to restriction of fluid

(ROF).

Admission medication chart

Drug Dosage regimen Date start Date stop

T. Simvastatin 40 mg ON 19/4/14 Ongoing

T. Aspirin 75 mg OD 19/4/14 Ongoing

T. Ferrous Fumarate 200 mg OD 19/4/14 Ongoing

T. Furosemide 40 mg OD 19/4/14 Ongoing

IV Furosemide 20 mg in between transfusion 20/4/14 20/4/14

SC Actrapid 6 units TDS 19/4/14 Ongoing

SC Insulatard 8 units ON 19/4/14 Ongoing

T. Neurobion (Vitamin B1, B6, B12) 1 tablet OD 20/4/14 Ongoing

Significant laboratory data

(a) Full blood count

Day, Date

& Time

N. Range

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

18/4

22:30

19/4

03:10

19/4

08:00

19/4

15:00

19/4

21:45

20/4

03:30

20/4

08:30

20/4

15:55

20/4

22:00

21/4

03:00

21/4

08:00

TWBC 411 x10/L 4.4

Hb 12-15

g/100mL

*8.3

RBC 3.8-4.8x1012/L *2.94

HCT 0.4/0.36-

0.52/0.46

*0.25

Platelet 150-400x109/L *127

(b) Renal profile

Urea 1.7-8.3 mmol/L *25.2

Na 135-145 mmol/L 141

K 3.5-5.0 mmol/L 3.5

Cl 96-106 mmol/L 106

Ca 2.1-2.6 mmol/L

Mg 0.7-1.3 mmol/L

PO4- 0.8-1.45 mmol/L

SCr 64-122 umol/L 316

ClCr 105-150 Ml/min

(c) Liver profile

Albumin 35 50 g/L 38

T.Bilirubin

(f) Vital signs

BP 135/50 128/54 119/51 140/58 134/61 118/60 128/58 150/73 134/61 119/74 132/62

TEMP 37 37 37 37 37 37 37 37 37 37 37

RR 12 18 b/min 21 18 20 20 20 19 20 20 21 19 19

PR 60 100

p/min

67 64 68 79 67 62 60 65 60 71 66

(g) Lipid

Date

T. Chol < 5.7 mmol/L

C-TG < 1.7 mmol/L

C-HDL > 1.7 mmol/L

C-LDL < 3.9 mmol/L

(h) I/O chart

Date 19/4 20/4

Input 800 688

Output 700 3100

Balance +100 -2412

Blood transfusion on 20/4/14 (due to anemia)

Blood product: 16 packed cell (IV Furosemide 20 mg in between transfusion)

Time start: 8.25 pm

Time complete: 2.25 am

Allergic reactions: No

Vital sign during transfusion:

Schedule Time Pulse (p/min) Blood pressure (mmHg) Temperature (oC)

Baseline 8.25 pm 63 127/53 37

15 minutes 8.40 pm 64 131/50 37

30 minutes 9.10 pm 73 120/56 37

Hourly 10.10 pm 69 111/74 37

11.10 pm 63 101/75 37

12.10 am 60 121/70 37

1.10 am 64 118/84 37

2.10 am 61 105/63 37

Drug-related problems / Pharmaceutical care issues

DRP 1: Appropriateness of addition of ACE-I / ARBs in the management of hypertension with diabetes and chronic kidney disease.

S Patient is having bilateral leg swelling, periorbital swelling and mild shortness of breath (SOB).

O Past Medical History: Diabetes Mellitus, Hypertension, Ischaemic Heart Disease, Chronic Kidney Disease.

Diagnosis: Decompensated Congestive Cardiac Failure 2o to non-compliance to restriction of fluid (ROF).

Admission medication chart:


T. Furosemide 40 mg OD 19/4/14 Ongoing

IV Furosemide 20 mg in between transfusion 20/4/14 20/4/14


T. Aspirin 75 mg OD 19/4/14 Ongoing

18/4

22:30

19/4

03:10

19/4

08:00

19/4

15:00

19/4

21:45

20/4

03:30

20/4

08:30

20/4

15:55

20/4

22:00

21/4

03:00

21/4

08:00

BP 135/50 128/54 119/51 140/58 134/61 118/60 128/58 150/73 134/61 119/74 132/62

Serum creatinine on 19/4: 316 mol/L a

A Congestive cardiac failure is the most common discharge diagnosis in patient > 65 years old.1

The treatment goals for management of heart failure are:2,3

1. To relieve or reduce symptoms of heart failure.

2. To prevent or minimize hospitalizations for exacerbations of heart failure.

3. To prolong the survival of patient and reduce morbidity rates within the population of patients with heart failure.

4. To improve patients quality of life.

Factors contributing to decompensated CCF: excessive fluid and salt intake, anemia, non-compliance to medications,

uncontrolled blood pressure, IHD, and development of renal failure.1,2

Higher BP will increased the risk of worsening kidney function, while diabetic patients with microalbuminemia are at

increased risk of both CVD and progressive kidney disease.4

KDIGO CPG suggested that those hypertensive patients with DM and non-dialysis CKD with urine albumin excretion

30-300 mg/day whose office BP is > 130/80 mmHg should be treated with and angiotensin-converting enzyme

inhibitors (ACE-I) or angiotensin II receptor blockers (ARBs) to maintain a BP 130/80 mmHg.4

ACE-I are the first-line therapy in hypertension with DM and CKD, as well as CCF since ACE-I have been shown to

improve symptoms and survival, slow the progression of heart failure.1,3,5 A low initiating dose should be given to

elderly patient, and slowly titrated up to the target dose as shown below:1,2

Whereas for those patients who unable to tolerate with ACE-I, ARBs will be the alternative therapy.1,3,5

Diuretics are indicated for fluid retention, combination with ACE-I are preferably for treating patient with heart failure

with preserved left ventricular systolic function to relieve dyspnoea and oedema.2

Hoyt RE et al. mentioned that the trend in treating mild-moderate heart failure is to maximize the usage of ACE-I and

minimize/possibly stop the usage of loop diuretics because over-diuresis will activate both the sympathetic nervous

system and the renin-aldosterone systems, which will in turn aggravate heart failure.1

According Malaysia CPG on management of heart failure, in patients with cardiac disease but do not as yet have

evidence of myocardial dysfunction should be treated appropriately with antiplatelet agents, -blockers, ACE-I and

statins.2 Therefore, T. simvastatin 40mg ON and T. aspirin 75mg OD are given for this patient.

P Suggest to add T. Ramipril 1.25 mg OD.

Monitor blood urea, creatinine and serum potassium at 7-14 days after the initiation of ramipril. Stop the medication

if SCr level is > 20 % compared to baseline.

Monitor side effects of ACE-I (cough, hypotension, renal insufficiency, hyperkalaemia, angioedema).

DRP 2: Dosage adjustment of insulin in the management for uncontrolled diabetes mellitus.

S -

O Past Medical History: Diabetes Mellitus


SC Actrapid 6 units TDS 19/4/14 Ongoing

SC Insulatard 8 units ON 19/4/14 Ongoing

Blood glucose profile

Date 7 a.m. (Pre-breakfast) 11 a.m. (Pre-lunch) 5 p.m. (Pre-dinner) 10 p.m. (Pre-bed)

19/4/14 (mmol/L) 12.2 16.4 11.6 15.9

20/4/14 (mmol/L) 6.2 11.2 11.7 9.4

21/4/14 (mmol/L) 10.7

A The goals of monitoring the blood sugar profile is to adjust the insulin regimens in order to reach the blood glucose

target range.6

Glycaemic Control Levels

Fasting 4.4-6.1 mmol/L

Non-fasting 4.4-8.0 mmol/L

HbA1c < 6.5 %

Dosage adjustment should not be made based on a single raised of blood glucose. However, the blood glucose need

to monitor closely at least for 48 hours to determine the effect of the insulin dose before making any dosage

adjustment.7

Blood glucose target range and dose adjustment should be individualized.7

Insulin dose adjustment for basal bolus regimen with 4 injections per day is shown as below:7,8

Blood Testing

Times

Blood Glucose < 4 mmol/l or

Hypo

Blood Glucose 4-6 mmol/l Blood Glucose > 6 mmol/l

Pre-breakfast Reduce bedtime intermediate

insulin by 2 units

Maintain current dose Increase bedtime intermediate

insulin by 2 units

Pre-lunch Reduce morning short acting

insulin by 2 units

Maintain current dose Increase morning short acting

insulin by 2 units

Pre-dinner Reduce lunchtime short

acting insulin by 2 units

Maintain current dose Increase lunchtime short


Pre-bed Reduce dinner meal short


Maintain current dose Increase dinner meal short


Each component of the insulin regimen affects only one blood glucose value. For example, if patient has elevated pre-

lunch blood sugar to > 6 mmol/l for 3 consecutive readings, then the dose of morning actrapid should be increased by

2 units.7,8

Based on the pre-breakfast, pre-lunch, pre-dinner and pre-bed glucose level and comparing to the insulin dose

adjustment table, intermediate insulin (Insulatard) should be increased by 2 units, while morning, lunchtime and dinner

meal short acting insulin (Actrapid) should be increased by 2 units respectively.7,8

Drug Dosage regimen (HKL) Dosage regimen (calculated)

SC Actrapid 6/6/6 8/8/8

SC Insulatard 8 units ON 10 units ON

Optimal dose for basal-bolus insulin:8

Prandial insulin: 0.5 units/kg/dose

Basal: 0.4-0.5 units/kgh

Hypoglycaemia has become progressively more frequent with advanced duration of T2DM and the use of intensive

insulin therapy. Thus, it is important to recognize sign and symptoms, and treatment of hypoglycaemia as is has a

negative impact on physical and psychological well-being such as cardiovascular death, MI, cardiac arrhythmias,

cardiac ischaemic, progressive neuroglycopenia and autonomous nervous system abnormalities.8

Sign and symptoms of hypoglycaemia:8

P Adjust the SC Actrapid to 8/8/8 instead of 6/6/6, and SC Insulatard 10 units ON instead of 8 units ON.

Counsel the patient the importance of self blood glucose monitoring (SBGM) with correct method and timing: premeal

(breakfast, lunch, dinner) and pre-bed glucose levels (weekly fortnightly).

Educate patient the prevention and treatment of hypoglycaemia (e.g., hard candy).

HbA1c should be monitored every 3-6 months.

DRP 3: Management of anemia.

S Patient is having mild shortness of breath (SOB).

O 19/4/14 Lab data: Hb (*8.3 g/100mL), RBC (*2.941012/L), HCT (*0.25), Platelets (*127109/L), Proteinuria: 1+

Blood transfusion on 20/4/14 (due to anemia)

Blood product: 16 packed cell (IV Furosemide 20 mg in between transfusion)

Time: 8.25 pm - 2.25 am (No allergic reactions noted)

Vital sign during transfusion:

Schedule Time Pulse (p/min) Blood pressure (mmHg) Temperature (oC)

Baseline 8.25 pm 63 127/53 37

15 minutes 8.40 pm 64 131/50 37

30 minutes 9.10 pm 73 120/56 37

Hourly 10.10 pm 69 111/74 37

11.10 pm 63 101/75 37

12.10 am 60 121/70 37

1.10 am 64 118/84 37

2.10 am 61 105/63 37

Admission medication: T. Ferrous Fumarate 200 mg OD, T. Neurobion (Vitamin B1, B6, B12) 1 tablet OD

A The normal full blood count for adult females:

Haemoglobin level is 12-15 g/100mL.

Red blood count is 3.8-4.8 1012/L.

Haematocrit is 0.36-0.46.

Platelet count is 150-400 109/L.

Patient is having anemia with symptoms (SOB) and laboratory investigations (low Hb, low RBC, low HCT).

Anemia is especially common in female, diabetic, CKD, and heart disease patients. It is estimated that 1/5 patients

with diabetes and stage 3 CKD have anemia, and its severity worsens with more advanced stages of CKD and in those

with proteinuria.9,10,11

Anemia developed in CKD patients due to iron deficiency, diminished erythropoietin (EPO) secretion from kidney

failure and hyporesponsiveness to the actions of EPO. Proper attention to iron and folic acid stores is important as

deficiencies in these nutrients will secondarily complicate the anemia of kidney failure.9,10,11

Blood transfusion is needed in patients with anemia who have CKD and do not require dialysis. The transfusion events

are more likely to occur at Hb levels < 10 g/dL.12

During blood transfusion, vital signs (e.g., temperature, pulse rate and blood pressure) of patient should be recorded

before, periodically and after the completion of transfusion.13

Goal of treatment is to correct anemia and to replenish body iron stores.

Ferrous fumarate is indicated for iron deficiency anaemia, 150 200 mg/day to correct iron deficiency and to replenish

iron stores.14,15 Vitamin C may enhances iron absorption.15

Folic acid 5 mg/day is indicated for folate deficiency while Vitamin B1, B6, B12 (Neurobion) is indicated for B12

deficiency; both are required for DNA synthesis.14

P Suggest to continue T. Ferrous Fumarate 200 mg OD and T. Neurobion 1 tablet OD, but add on folic acid 5 mg OD

and Vitamin C 1000 mg OD.

Continue monitoring of haemoglobin, haematocrit and RBC count every 1 3 weeks until stabilised, then every 3

months for 1 year, then every year after.14

CASE 2

Patient Database:

Demographic Data

Name: CKL Weight: - kg

Age: 7 years old Height: - cm

Gender: Female Date of admission: 20/4/2014

Race: Chinese MRN: 1915636

Chief Complaint

Referred from Changi General Hospital, Singapore for the treatment of NSTEMI and urosepsis

complicated acute kidney disease.

History of Present illness

Dysuria and fever for 2 days

Vomiting past 1 day

Past Medical History

No known underlying disease.

Family history

NA.

Social history

She is a widow, has 3 children and 6 grandchildren. She currently stay at Setapak with her

daughter. She smokes under stress.

Past Medication history

SC Fondaparinux sodium 2.5 mg STAT + OD Sublingual GTN PRN

T. Ciprofloxacin 500 mg BD T. Paracetamol 1 g PRN

T. Omeprazole 40 mg OD T. Atorvastatin 40 mg ON

T. Aspirin 100 mg OM T. Clopidrogel 75 mg OM

Allergy

No Known Drug Allergies (NKDA).

Review of system

BP: 103/43 mmHg RR: 16 b/min

PR: 85 p/min T: 36.5 C

Compliance evaluation

NA.

Physical examination

General: alert, pink, warm peripheral, good pulse volume, no tachycardia.

Lung: No crepitation.

CVS: DRNM.

Abdomen: soft, non-tender.

Diagnosis / Surgical procedure

Urinary Tract Infection (UTI) and NSTEMI.

Admission medication chart


T. Ciprofloxacin 500 mg BD 20/4/14 (D3) Ongoing

SC Fondaparinux 2.5 mg STAT + OD 20/4/14 Ongoing

S/L GTN PRN 20/4/14 Ongoing

T. Aspirin 100 mg OM 20/4/14 Ongoing

T. Clopidrogel 75 mg OM 20/4/14 Ongoing

T. Paracetamol 1 g PRN 20/4/14 Ongoing

T. Omeprazole 40 mg OD 20/4/14 21/4/14

IV Ranitidine 150 mg BD 21/4/14 Ongoing

T. Atorvastatin 40 mg ON 20/4/14 21/4/14


Significant laboratory data

(a) Full blood count

Day & Date

N. Range

1 2 3 4 5 6 7 8

19/4 20/4 21/4 22/4

TWBC 411 x10/L 12.1

Hb 11.5-16.5

g/100mL

12.2

RBC 4.5-6.3x106

HCT 37-48%

Platelet 150-400x10/L 176

(b) Renal profile

Urea 1.7-8.3 mmol/L 7.4

Na 135-145 mmol/L 134

K 3.5-5.0 mmol/L 3.9

Cl 96-106 mmol/L 101

Ca 2.1-2.6 mmol/L

Mg 0.7-1.3 mmol/L

PO4- 0.8-1.45 mmol/L

SCr 64-122 umol/L 105

ClCr 105-150 Ml/min

(c) Cardiac enzyme

CK 24 195 u/l 811

LDH 0 248 u/l

AAT

(d) Others

RBS 8.9

Troponin T 0-29 ng/L 217

CKMB < 5 ng/mL 8.06

(e) Vital signs

BP 103/43 127/75 128/50 120/87

TEMP 36.5 37 37

RR 20 25 b/min 16 20 20 19

PR 90 100 p/min 85 53 51 76

(f) Lipid

Date 19/4

T. Chol < 5.7 mmol/L 4.7

C-TG < 1.7 mmol/L 0.77

C-HDL > 1.7 mmol/L 1.18

C-LDL < 3.9 mmol/L 3.17

Drug-related problems / Pharmaceutical care issues

DRP 1: Inappropriate drug selection of antibiotic for urosepsis.

S Patient complains of fever, chill and cannot urinate or control urination for the past 2 days

before admitted to Changi General Hospital, Singapore.

O She is diagnosed with NSTEMI and urosepsis complicated acute kidney disease.

She is prescribed with T. Ciprofloxacin 500 mg BD.

A Urosepsis is a condition that the urinary tract infection (UTI) progress further and

the microorganisms enter the blood stream, which can be a life-thretening illness and

affect other organ in the body.16

Elderly, diabetic, immunosuppressed patient and those with acquired

immunodeficiency syndrome are more likely to develop urosepsis.16

E.coli, Kebsiella, Proteus, Enterococcus, Pseudomonas and Methicillin-resistant

Staphylococcus aureus (MRSA) are the most susceptible organisms.17

According to National Antibiotic Guideline 2008, IV cefepime 1g every BD or IV

imipenem/Cilastatin 500mg TDS is preferred for urosepsis.17

Cefepime is the 4th generation cephalosporin which has extended spectrum of

antibacterial activity that includes both aerobic gram negative bacteria

(Enterobacter, Escheichia coli, Klebsiella pneumonia, Proteus mirabilis, Neissria

meningitidis and pseudomonas aeruginosa) and gram positive bacteria

[Staphylococcus aureus (methicillin-susceptible strains only), Streptococcus

pneumonia and Streptococcus pyogenes (Lancefields Group A streptococci)].18

Imipenem/Cilastatin is carbapenem that cover gram-positive bacteria (methicillin-

sensitive S.aureus and Streptococcus spp), resistant gram-negative bacilli (extended

spectrum beta-lactamase-producing Escherichia coli and Klebsiella spp,

Enterobacter spp, and Pseudomonas aeruginosa) and anaerobes.19

However in this case, Ciprofloxacin have been used and it cover gram-positive

microorganisms [methicillin-susceptible staphylococcus aureus (MSSA),

streptococcus pneumonia], gram-negative microorganisms (enterobacteriaceae,

H.influenzae, haemophilus spp, N. gonorrhoeae, N. meningitides, M. catarrhalis, P.

aeruginosa, S. maltophilia], and atypical legionella pneumophilia.20

Culture and sensitivity test should be done to find out what kind of bacteria is causing

the infection and to see what antibiotic should be choosed.17 However, there are no

culture and sensitivity test done on this patient before and after starting the

medication.

P Culture and sensitivity test is recommended.

Suggest start with IV cefepime 1g BD instead of T. Ciprofloxacin 500mg BD.

Monitor renal function, and signs and symptoms of anaphylaxis during first dose of

cefepime. The side effects of included diarrhea, abdominal pain, nausea, dyspepsia,

flatulence and loose stools. 19

Measure total white blood cell and body temperature to observe the effect of the

medication.

DRP 2: Appropriateness of initiating beta blocker in NSTEMI.

S -

O Patient is diagnosed with NSTEMI.

Admission medication:


SC Fondaparinux 2.5 mg STAT + OD 20/4/14 Ongoing

S/L GTN PRN 20/4/14 Ongoing

T. Aspirin 100 mg OM 20/4/14 Ongoing

T. Clopidrogel 75 mg OM 20/4/14 Ongoing

T. Atorvastatin 40 mg ON 20/4/14 21/4/14


Lab test:

Laboratory test Normal level 19/4

CK 24-195u/l 811

Troponin T 0-29ng/l 217

CK-MB

A Medication therapy should be started in the management of NSTEMI for

intermediate/high risk patient. This patient is having elevated cardiac biomarkers, so

she is an intermediate/high patient.21,22

The initial medications include anti-thrombotics , beta-blockers, statins and nitrates,

while angiotensin converting enzyme inhibitors (ACE-I)/angiotensin receptor

blockers(ARBs), with or without calcium channel blockers (CCBs) is indicated for

certain condition.21,22

According to Malaysia CPG on UA/NSTEMI and Sarawak handbook,

intermediate/high risk patient should be initiated with aspirin, clopidogrel,

unfractionated heparin or low molecular weight heparin or fondaparinux, with or

without platelet GP IIb/IIIa receptor antagonist need to be administered.21,22

Soluble/chewable tablet of aspirin 300 mg should be given as the loading dose, while

soluble / enteric coated aspirin 75-150 mg daily is recommended as the maintenance

dose since > 300-325 mg/day associated with increased risk of minor bleeding

without greater efficacy.21,22

Whereas for clopidogrel, loading dose 300-600 mg follow by maintenance dose

75mg/day is recommended.21,22

Fondaparinux (factor Xa inhibitor) with 2.5mg SC daily is given for 8 days.21

Nitrate (GTN sublingual glyceryl trinitrate) 0.5mg is given to patient for

symptomatic relief. Use 1 tablet GTN every 5 minutes for 3 doses during attack.21,22

High dose statin should be initiated soon after admission in order to reduce major

adverse cardiac events.21,22

-blockers should be given if there are no contraindications like marked first degree

AV block, second or third degree AV block, history of bronchial asthma, severe

peripheral arterial disease, acute decompensate LV dysfunction or cardiogenic

shock.21,22,23

-blockers competitively block the effects of catecholamine on cell membrane beta

receptors, inhibition of catecholamine reduces myocardial contractility, sinus node

rate and AV node conduction velocity. Through these action, they can reduce

myocardial oxygen demand by inhibiting increase in heart rate and myocardial

contractility caused by adrenergic activity.22

ACE-I/ARB is also recommended for patient with LV dysfunction.21

If patient unable to tolerate with -blockers, continuing or recurring angina despite

adequate doses of nitrates and -blockers and during variant angina, CCB should be

given, but need to avoid short acting dihydropyridine CCB (nifedipine).21

P Supplement oxygen should be given when arterial saturation less than 90%, ECG

should be monitor continuously.

Add atenolol 25mg OD to this patient and titrate gradually to 100mg OD.

Monitor the systolic blood pressure and pulse rate when beta-blocker being

administered. Withhold the -blocker if systolic BP < 100 mmHg / pulse rate < 50

p/min.

Monitor side effects like persistent bradycardia, hypotension, chest pain, edema.

Monitor the risk of bleeding when using anti-thrombotic therapy.

Check liver function test and creatinine kinase if patient on statin. Withhold the statin

if the level is markedly increased.

References:

1. Hoyt RE, Bowling LS. Reducing readmissions for congestive heart failure. American

Family Physician. 2001 Apr; 63(8):1593-5.

2. Academy of Medicine Malaysia, National Heart Association of Malaysia. Clinical practice

guidelines: management of heart failure. Malaysia: Ministry of Health; 2007 Apr. p. 1, 3,

6-7, 20-1, 32.

3. Parker RB, Rodgers JE, Cavallari L. Heart failure. In: Dipiro JT, Talbert RL, Yee GC,

Matzke GR, Wells BG, Posey LM. Pharmacotherapy: A pathophysiologic approach. 7th ed.

New York, NY: McGraw-Hill; 2008. p. 149, 184.

4. Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group.

KDIGO clinical practice guideline for the management of blood pressure in chronic kidney

disease. Kidney inter., Suppl. 2012; 2:366-7.

5. Malaysian Society of Hypertension, Academy of Medicine of Malaysia. Clinical practice

guidelines: management of hypertension. 4th edition. Malaysia: Ministry of Health; 2013.

p. 25.

6. Ministry of Health, Malaysian Endocrine and Metabolic Society, Academy of Medicine

Malaysia, Persatuan Diabetes Malaysia. Clinical practice guideline: management of type 2

diabetes mellitus. 4th edition. Malaysia: Ministry of Health; 2009. p. 10

7. Glasgow Diabetes Managed Clinical Network. Guidelines for insulin initiation and

adjustment in primary care in patient with type 2 diabetes: for the guidance of diabetes

specialist nurses. Greater Glasgow and Clyde: NHS; 2010 Jan. p. 11.

8. Practical guide to insulin therapy in type 2 diabetes mellitus. Malaysia: Ministry of Health;

2011. p. 29, 49, 51.

9. Mehdi U, Toto RD. Anemia, diabetes, and chronic kidney disease. Diabetes Care. 2009

July; 32(7):1320.

10. Anemia and chronic kidney disease: stages 1-4. New York: National Kidney Foundation;

2010. p. 3-6.

11. Wolfsthal S. NMS Medicine national medical series independent study. 7th ed. Lippincott

Williams & Wilkins; 2011. p. 119.

12. Lawler EV, Bradbury BD, Fonda JR, Gaziano JM, Gagnon DR. Transfusion burden among

patients with chronic kidney disease and anemia. Clin J Am Soc Nephrol. 2010 Apr;

5(4):667, 670.

13. National Blood Centre. Transfusion practice guidelines for clinical and laboratory

personnel. Malaysia: Ministry of Health; 2008. p. 25.

14. Youart A. Guidelines on the investigation and management of anaemia. National Health

Services, UK. [Online]. 2006 Feb 10 [cited 2014 April 24]; Available from: URL:

http://www.momentum.nhs.uk/pathology/Haematology/Guidelines%20on%20anaemia.ht

m

15. Ferrous fumarate (Rx, OTC). Medscape Reference. [Online]. 2014 [cited 2014 April 24];

Available from: URL: http://reference.medscape.com/drug/feostat-ferro-sequels-ferrous-

fumarate-342163#0

16. Gwagenlehner FME, Pilatz A, Naber KG, Weidner W. Therapeutic challenges of urosepsis.

Eur J Clin Investigation. 2008; 38(S2):45-9.

17. National Antibiotic Guidelines. Malaysia: Ministry of Health; 2008. p. 131.

18. Scates AC. Cefepime [Internet]. No date [cited 2014 April 26]. Available from:

http://legacy.uspharmacist.com/oldformat.asp?url=newlook/files/Drug/ACF2EF6.cfm&p

ub_id=8&article_id=36

19. Lexicomp. Drug Information Handbook with International Trade Names Index. 22nd ed.

USA: Wolters Kluwer Health; 2013. p. 179, 360-2.

20. Ciprofloxacin [Internet]. No date [cited 2014 April 26]. Available from:

www.antimicrobe.org/drugpopup/Ciprofloxacin.pdf

21. National Heart Association of Malaysia, Academy of Medicine Malaysia. Clinical practice

guidelines: UA/NSTEMI. Malaysia: Ministry of Health; 2011. p. 3-4, 23-32.

22. Soo HH, Lau LG, Chew PH, Hu M. Sarawak handbook of medical emergencies. 3rd ed.

Malaysia: C.E Publishing; 2011. p. 1.2-1.6.

23. ACCF/AHA. Focus update Incorporated into the ACCF/AHA 2007 guidelines for the

management of patient with unstable angina/non-ST-elevation myocardial infraction: A

report of the American College of Cardiology Formulation/American Heart Association

task force on practice guidelines. US: American Heart Association; 2013. p. 35-9.

Case 1 & 2awd

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