Presentation 3 Ambulatory Clerkship Presentation.pptx - CASE PRESENTATION ON HTN RA Mild Bronchial Asthma Old Ischemic Stroke Ambulatory Clerkship 1 By

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CASE PRESENTATION ON HTN + RA + Mild Bronchial Asthma + Old Ischemic Stroke 1 Ambulatory Clerkship By: Melat, Mesfin, Mesele
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OUTLINE I. Case identification II. Subjective & Objective findings III. Clinical Assessment IV. Current Medications V. Background of the Disease VI. Pharmaceutical Care Plan and Follow up VII. Patient Counseling 2
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I . CASE IDENTIFICATION Initials: S.G Age: 56 years old Gender: Male Weight: 77Kg, Height: 1.72m MRN: 041551 Address: Mekelle 3
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II. SUBJECTIVE FINDINGS C/C - Follow up HPI - This is a 56yrs old male patient who is on antihypertensive and anti RA for the last 2 years. And he has been taking salbutamol puff PRN for his mild asthma for 2 years. Currently he came for follow up. PMH - He was admitted in ACSH due to stroke before 2 yrs. No surgical procedure. 4
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CONT’D…. PMxH - Methotrexate 15mg PO/Week (1yr) Chloroquine Phosphate 250mg PO/day (1yr) Predensolone 10mg PO/day (1yr) No OTC Medication No any Known allergy SHx - No Hx of taking tobacco and Khat FHx - Not known family Hx of chronic Medical illness. 5
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III. OBJECTIVE FINDINGS 1. Physical Examination GA: Well looking and Stable HEENT: Clear Conjunctiva and NIS CNS: COTPPT Chest: Clear and Resonant CVS: S 1 and S 2 well heard and no m and g ABD: Flat that moves with Respiration, No palpated organ and fluid accumulation. 6
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2. PERTINENT VITAL SIGNS Date BP (mmHg) PR ( b.p.m) RR (b.p.m) TEMP 6/10/08 140/70 72 26 36.5 2/12/08 150/90 76 24 36.5 22/02/09 140/100 66 22 36 24/04/09 150/90 68 22 ATT 7
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3. PERTINENT LAB AND INVESTIGATIONAL FINDINGS CBC Results Normal ranges Hbg 14.6 14 to 18 g/dL Hct 43 39% to 49% WBC 6.0 3.2 to 9.8 × 10 3 /mm 3 Plt 382 150 to 400 × 10 3 /mm 3 RBC 5.22 4.2 to 5.4 × 10 6 /mm 3 MCV 81 80-100FL ESR 8.7 0-20mm/Hr Basophils 1 1-4% of WBC 8
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BLOOD CHEMISTRY Test Name Results Normal ranges BUN 18 6–20 mg/dL SCr 0.8 0.6–1.3 mg/dL Cl - 100.6 95–105 mEq/L K + 7.05 3.5–5.2 meq/L Na + 136 135–147 mEq/L Ca ++ 9.6 8.5-10.5mEq/L 9
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LIPID PROFILE 10 Test Name Results Normal ranges Total Cholesterol 204 < 200 mg/dL HDL 44 > 60 mg/dL LDL 119 < 100 mg/L TG 197 < 150 mg/L OTHERS RF 12 < 20IU/mL RBS 89 70-110mg/dL
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URINALYSIS 11 Test Name Results Normal ranges Glucose Negative Negative Ketone Negative Negative Protein 11 Neg. to Trace P H 7.4 4.5-8.0 SpGr 1.01 1.005-1.025
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III.
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  • Fall '19
  • ischemic stroke, Salbutamol

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