Complaint Of Right Sided Chest Pain Biology Essay

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Patient admitted to the hospital with the complaint of right-sided chest pain and the severe onset is at 10pm (24/1/2011). The pain score is 7-8/10. The pain had been radiated to the arms and neck. But patient did not experience shortness of breath, sweating, nausea, vomiting and palpitation.

3. Related medical history:

Family history: Married and has 5 children. Work as a religious teacher at JAIS.

Social history: Patient is a smoker for 40 years , he smokes 15 cigarettes per day but he is not an alcoholic drinker.

Allergies & intolerance : Nil

Past medical history : HPT

Past medication history Nil

4. Medical Adherence Evaluation

- The patient has good adherence level.

5. On admission physical examination and lab investigations.

Physical examination:

BP: 70 / 32 mmHg

PR: 56 bpm

Temp: 37.0 °C

CVS: S1S2 murmur, apex beat not displaced and no pedal edema

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Lung: Clear

SpO2: 98%

Medication given : - Aspirin 300mg stat

- S/C GTN 0.5mcg stat

- IV morphine 3mg stat

6. Diagnosis or differential diagnosis

- Acute inferior myocardial infarction with postero-lateral extension ( Killip II )

- severe 3 vessels disease ( VSD ) with left main stem ( LMS ) involvement

- The Killip classification is a system used in individuals with an acute myocardial infarction (heart attack), in order to risk stratify them. Individuals with a low Killip class are less likely to die within the first 30 days after their myocardial infarction than individuals with a high Killip class. Killip class II includes individuals with rales or crackles in the lungs, an S3, and elevated jugular venous pressure.

7. Laboratory investigation and impression

Parameter/Date

7/2

8/2

9/2

10/2

11/2

12/2

13/2

14/2

15/2

16/2

BP (mmHg)

98/63

101/64

112/79

117/66

112/64

128/74

134/80

108/88

119/74

126/73

HR (b/min)

131

80

68

90

84

86

80

60

97

RR (c/min)

12

20

23

26

28

22

Temp (°C)

38

37.3

36.8

36

36.8

36.8

37

37.1

37.4

Blood pressure of patient is within the normal range. Patient does not experience hypotension. If hypotension occur, there is possibility bleeding occur at site of surgery. Heart rate of patient after the surgery was increased and it indicate patient was developed tachycardia which was complication of post-surgery. But the heart rate slowly returned to the normal range after few days. Patient was developed fever after surgery due to the high body temperature which may caused by infection.

- Endocrine

Parameter/Date

7/2

8/2

9/2

10/2

11/2

12/2

13/2

14/2

15/2

RBS (<11.1 mmol/L)

9.7

9.4

8.1

6.8

6.2

9.7

5.6

5.7

5.4

Blood glucose of patient is well controlled. Blood glucose must be monitor to detect if patient experience hyperglycemia. Hyperglycemia may increase rate of infections and poor wound healing. Hyperglycemia is associated with impaired leukocyte function, including decreased phagocytosis, impaired bacterial killing and chemotaxis.

- Full Blood Count

Parameter/Date

7/2

8/2

9/2

10/2

11/2

12/2

13/2

14/2

15/2

16/2

WBC (4-11x109/L)

21.9

12.0

15.7

12.0

9.7

8.1

10.6

11.5

11.4

11.5

RBC (3.8-4.8x1012/L)

4.14

3.09

3.49

3.54

3.61

3.61

3.88

4.26

4.25

4.31

Hb (12.3-15.3 g/dL)

14.2

10.8

10.4

10.6

12.6

11.0

11.8

12.7

17.6

12.8

Hct (37-47%)

37.4

28.2

31.6

32.5

32.7

32.7

35.2

39.2

38.8

38.8

Platelet (150-400x109/L)

236

304

270

215

255

244

272

341

359

415

MCH (28-33 pg)

29.9

30.2

30.0

30.0

29.9

30.4

30.3

29.9

29.6

29.6

MCHC (15-45 g/dL)

33.1

33.1

33.4

32.7

33.0

33.6

33.5

32.5

32.4

32.8

MCV (76-95 fL)

90.4

91.3

89.8

91.7

90.7

90.4

90.7

92.2

91.5

90.2

Neutrophil (40 - 75%)

90.4

88.2

83.7

87.6

81.3

73.2

73.6

76.6

73.9

77.1

Lymphocytes (20-45%)

7.1

6.1

10.8

7.9

11.7

16.0

16.0

14.7

17.0

16.4

Monocytes (2-10%)

2.2

5.6

4.8

4.2

4.5

5.6

5.6

4.2

5.1

4.3

Eosinophil (1-4%)

0.3

0.0

0.0

0.1

2.2

4.9

4.6

4.1

3.8

2.0

Basophil (0-1%)

0.0

0.1

0.7

0.2

0.3

0.3

0.2

0.4

0.2

0.2

After the surgery 7/2/2011, the WBC and neutrophils percentage was exceed the normal range. Lymphocytes percentage was lower than normal range. Patient got infection. Since postoperative antibiotic is given to the patient, WBC and neutrophils value drop back within normal range. However, the lymphocytes percentage is still lower than normal range. On the 15-16/2, WBC and neutrophil level of patient were slightly increased. According to the lab result, the RBC and hemoglobin levels of patient were lower than normal range at the beginning of post-surgery due to the loss of blood during surgery and production of RBC took 120 days. But, the value of RBC and hemoglobin slowly become normal.

-Liver Function Test

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Parameter/Date

9/2

10/2

11/2

12/2

13/2

14/2

ALT (0-31u/L)

31

40

32

24

28

20

ALP (35-104 u/L)

50

64

63

75

82

96

T. Bili (0-17 umol/L)

11

9

8

9

9

9

Albumin (35-50 g/L)

23

21

21

21

22

26

T. Protein (66-87 g/L)

49

46

48

50

54

58

Patient has normal value of ALT, ALP and bilirubin. Albumin and total protein value showed lower than normal range. It might be due to low appetite which leads to inadequate nutrition. Although patient can tolerate orally, patient seem not have energy to do other things and also talk. Poor nutritional status may delay the wound healing process.

-Renal Profile and BUSE

Parameter/Date

7/2

8/2

9/2

10/2

11/2

12/2

13/2

14/2

15/2

16/2

SrCr (62-100 umol/L)

89

146

134

118

88

88

84

93

84

105

CLCr (ml/min)

67

44.6

64.3

56.9

Na+ (135-150 mmol/L)

133

139

145

134

143

127

132

133

133

130

K+ (3.5-5.0 mmol/L)

4.0

4.5

4.3

4.2

4.5

3.7

4.7

5.5

4.4

4.7

Urea (2.5-6.4mmol/L)

7.0

10.0

10.0

9.4

9.0

7.7

6.1

4.6

3.7

4.5

Patient creatinine level is higher than normal range after the surgery. It means that kidney function is altered by the surgery. However, the value fell to normal range back in previous day. Patient has develop hyponatremia in which may be due to the use of diuretic (Lasix). The potassium level is within the normal range except on the 14/2. Patient develops hyperkalemia. Patient may experience symptoms like irregular heartbeat, fatigue, weakness and difficulty in breathing. Urea level was high after the surgery but stabilize back to normal range 2 days ago because patient took adequate amount of fluid to eliminate the urea in body.

-Culture and sensitivity

9/2/2011 Tracheal Aspirate C&S Pseudomonas aeruginosa Beta Lactamase Gp.1

Sensitivity ciprofloxacin S

amikacin S

cefepime S

11/2/2011 Blood C&S Gram +ve cocci

Microbiology

8/2/2011 Procalcitonin 7.85 ng/mL

9/2/2011 Procalcitonin 4.32 ng/mL

(PCT >2 and <10 ng/mL indicate severe systemic inflammatory response/sepsis)

I/O Chart

Date

8/2

11/2

13/2

14/2

15/2

16/2

Input

2813

3434

3120

2561

500

400

Output

1310

3740

3520

3640

700

600

Balance

+1350

-305

-400

-1079

-200

-200

Patient had developed dehydration due to the loss of fluid during the surgery.

8. List of Current Medication

No.

Medication Name &Regimen

Date

7/2

8/2

9/2

10/2

11/2

12/2

13/2

1.

IV Bisolvon 8mg tds

2.

IV Nexium 40mg od

3.

IV Cloxacillin 1g qid

4.

IV Rocephin 1g od

5.

T. Ultracet tds (1 tab)

6.

T. PCM 1g qid

7.

T. Aspirin 150mg od

8.

T. Plavix 75mg od

9.

T. Lasix 40mg bd

10.

T. Slow K od (2 tab)

11.

T. Bisolvon 8mg tds

12.

T. Nexium 40mg od

13.

T. Lasix 40mg od

14.

Cap. Tramal 50mg tds

15.

T. Lovastatin 40mg on

16.

Neb. Combivent % 6 hourly

17.

Neb. Saline 6 hourly

18.

Ravine enema x 2 stat

No.

Medications

Indication/Mechanism of action

Side effects

1.

Bisolvon

-mucolytic agent

-Acute and chronic bronchopulmonary diseases associated with abnormal mucous secretion and impaired mucous transport

rash, nausea, vomiting

2.

Nexium

-proton pump inhibitor

-Prevention of NSAID-induced gastric ulcers

Headache, Pain, bronchitis

3.

Tramal

-Analgesic, opiod.

-Relief pain. It bind to µ-opiate receptors in CNS, altering the perception of and response to pain.

GI disturbances, dizziness, sweating, dry mouth, fatigue, headache, tachycardia

4.

Cloxacillin

endocarditis treatment

Hypotension, Confusion, fever, rash, abdominal pain

5.

IV Rocephin 1g od

used in surgical prophylaxis

rash, diarrhea, lukopenia

6.

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T. Ultracet tds

Treatment of acute pain

dizziness, constipation, vomitinf, dry mouth

7.

T. PCM 1g qid

treatment of pain and fever

rash, nausea, vomiting

8.

T. Aspirin 150mg od

CABG:Oral: 75-100 mg once daily (usual dose: 81 mg) initiated 6 hours following surgery; if bleeding prevents administration at 6 hours after CABG, initiate as soon as possible

bleeding, cerebral edema. rash, hyperkalemia, epigastric discomfort

9.

T. Plavix 75mg od

prevention of coronary artery bypass graft closure (saphenous vein)

rash, bleeding, bruising

10.

T. Lasix 40mg bd

edema

acute hypotension, dizziness, hypokalemia, hyperuricemia

11.

T. Slow K od

hypokalemia

rash, hyperkalemia, abdominal discomfort

12.

T. Lovastatin 40mg on

Act as lipid-lowering agent. competitively inhibiting HMG-CoA reductase, the enzyme that catalyzes the rate-limiting step in cholesterol biosynthesis.

abdominal pain, constipation, flatulence, headache, vomiting, anemia, rash, muscle cramps

13.

Neb. Combivent % 6 hourly

Treatment of COPD in those patients who are currently on a regular bronchodilator who continue to have bronchospasms and require a second bronchodilator

Bronchitis, upper respiratory tract infection, chest pain, headache

9. Surgical Operation Report

Name : Maslam b. Nasib

MRN : N333420

I/C : 520811-01-5863

Age : 59 years old

Sex : Male

DIAGNOSIS : Triple Vessel Coronary Artery Disease, LMS severe disease

Cardiogenic shock x2/52

EF 44%

OPERATION : Off Pump Coronary Artery Bypass Grafts x3

Open SVG harvesting technique

DATE : 7 February 2011

Surgeon : AP Dr Zamrin

Assistant 1 : Mr Isham

Assistant 2 : Dr. Rushidi / Dr. Farina

Anaesthetist : Dr. Navin / Dr. Azmin

Scrub Nurse : SN Nor Akmar

Conduit : Site Conduit Size

LAD LIMA 1.75mm

OM1 SVG 1.75mm

PDA SVG 1.75mm

Findings : Sizable all distal targets. Slightly calcified and diseased PDA.

Procedures:

Routine stemotomy. LIMA and SVG harvested. Pericardiotomy performed. Full dose of heparin administered. LIMA to the LAD, SVG to the OM1 and PDA using 'Octopus' Medtronic Stabiliser and 1.5mm intra-coronary arterial shunts. The distal anastomosis were then performed using running 8'0 for the LAD and 7'0 Prolene for the PDA. " O2 blower" used to maintain bloodless field for the anastomosis. Proximal anastomosis of the OM1 done using site-biting clamp and performed using running 6'0' Prolene. The graft were then deaired. Proximal PDA SVG anastomosed to OM1 SVG ( as pi-graph- due to the fact that aortic root was small ). Heparin was reversed with half dose of Protamine. Haemostasis achieved. The chest was closed in routine fashion using sternal wires, draining both pleural spaces bilaterally and the mediastinum. The patient was then transferred to the Cardiac Intensive Care Unit with satisfactory haemodynamic stability.

Pre-operative prophylactic antibiotic given: No

Intra- operative prophylactic antibiotic given: No

Post- operative prophylactic antibiotic given: Yes

Post-op orders:

-Back to ward

-Keep IVD normal saline

-Keep NBM for today, KIV feed CM

-Continue antibiotic

-Keep ryle tube

Post operative nursing record and patient transfer out record.

Patient was conscious and breathing spontaneously. The circulation of extremities was pink. Operation site was dry.

Drug induction and maintenance:

- IV noradrenaline 4mg/50cc

- IV Adrenaline 3mg/50cc

- IV GTN 1mg/mL

- IV Morphine 1mg/mL

- IV KCL 2g/50cc

- IV Dopamine 200mg/ 50cc

- IV Midazolam

- IV Rocephin 1g od

- IV Cloxacillin 1g od

- IV Bisolvon 8mg tds

- IV Nexium 40mg od

10. Day by day progress notes (at least 5 days)

Date

Subjective

Objective

Assessment

Plan

25/1

-Alert

-Conscious

-Right sided chest pain

-BP:70/32 mmHg

-HR: 56 bpm

-Temp: 37°C

-SpO2: 98%

-Pain score: 6/10

- Chest pain might due to acute myocardial infarction.

Low BP may lead to hypotension.

-Suggest to do the ECG.

-Monitor the vital signs closely.

-Give dobutamine improve heart dunction and morphine to control the pain

27/1

-Mild chest discomfort

-Alert

-Conscious

-Swelling on left arm

-BP:127/60 mmHg

-HR: 97 bpm

-RR: 17 breaths/min

-Temp: 37°C

-SpO2:97%

-Patient has heart problem.

-Monitor the I/O chart for fluid retention problem.

-Monitor vital sign

28/1

-Alert

-Conscious

-Swelling on left arm

-BP:125/59 mmHg

-HR: 73 bpm

-Temp: 37.5°C

-Fluid retention or left forearm swelling may due to acute myocardial infarction and thrombophlebitis. -Fever may caused by hospital-acquired pneumonia.

-Monitor the vital signs such as temperature.

-Monitor I/O chart

6/2

-Before surgery:

No acute complaint of pain

Comfortable

-After surgery:

Clinically dehydration

-BP: 148/85 mmHg

-HR: 84bpm

-Temp: 37 °C

-5 hr post surgery:

Tachycardia

Dry mucous

-Tachycardia is one of the post operative complications.

-Continue IV drip 3 pint N/S and 2 pint D5%.

-Allows sips of clear fluid.

-Take care on stoma.

-Monitor the vital signs, I/O chart and full blood count.

7/2

-Currently comfortable.

- Complaint pain at operation site.

-No SOB

-Dressing minimal soaked.

-BP:98-124/63-74 mmHg

-HR:140bpm

-RR: 12 breaths/min

-Temp:37.3°C

-Neutrophil:90.4%

-Lymphocyte:7.1%

-Fever occurs and increased of neutrophils level indicate infection.

Tachycardia not resolved because heart rate is 140bpm.

-Continue IV drip 3 pint N/S and 2 pint D5%.

-Start IV antibiotic.

-Strict I/O chart

-Well tolerate with orally

-Allow sips of clear fluid.

-Monitor ECG

-Monitor vital signs

9/2

-Complaint pain at operation site.

-Alert

-Conscious

- Headache

- Lethargy

-BP:104/71 mmHg

-HR: 132 bpm

-RR: 20-22 breaths/min

-Temp: 37.3-38.0°C

-RBC: 3.49 X109/L

-Hb:10.4g/dL

-WCC:12 X109/L

-Urine output:240cc

-Overnight on and off hypotension

-Tachycardia persist

-The fever still unresolved.

-Low red blood cell count ( Anemia )

-Continue IV drip 3 pint N/S and 2 pint D5%.

-IV NA, adrenaline and dopamine are given

-Monitor I/O chart

-Cap Tramadol is given for pain

-Continue antibiotic

-Monitor vital sign, RBC count.

10/2

-Comfortable

-Mild pain at operation site during coughing

-Conscious

-BP:117/66 mmHg

-HR: 75 bpm

-RR: 23 breaths/min

-Temp: 36.8°C

-RBC: 3.54 X109/L

-WCC: 12 X 109/L

-Hb: 10.6 g/dL

-Albumin: 21 g/L

-The fever was resolved

-Low red blood cell and lead to anemia

-Low albumin level due to less intake of diet

-Allow soft diet and supplement to increase red blood cell

-Refer to chest physiotherapist.

-Monitor vital sign

11-12/2

-Alert

-Conscious

-Complaint pain

-BP:112/64-125/71 mmHg

-HR: 80-106 bpm

-RR: 20 breaths/min

-Temp: 37.0°C

-RBC:3.61X109/L

-Hb: 10.8 g/dL

-Urine C&S suggest gram positive cocci infection for last infection at 9/2/11

-I/O : -305

-Upper wound has old blood

-The fever was resolved and the neutrophils and WBC were returned to normal range.

-Anemia

-Polyuria

-Monitor the vital signs and I/O chart

-May start using IV morphine in low dose

-Do stoma charting.

-Off inotropic drugs

13-14/2

-Tolerated normal fluid and food

-Alert

-conscious

-Pain at operation site

-Cough persistent

-BP:134/80-108/88 mmHg

-HR: 60-86 bpm

-RR: 20 breaths/min

-Temp: 37.0°C

-Normal Hb and WBC level

-I/O: 2561/3640 (-1079)

-Anemia and fever were resolved

-Polyuria

-Decreased in hydration status and lead to dry mucosa

-Mild lethargy

-Cough may caused by pleural effusion

-Monitor the vital signs, electrolytes level and FBC.

-Monitor I/O chart

-Make sure patient get adequate fluid so that he was well-hydated but did not cause fluid accumulation.

-IV normal saline was given and Lasix tablet was not served.

-Do chest X-ray to confirm pleural effusion

15/2

-Feel better

-Fair appetite

-No chest pain

-BP:119/74mmHg

-HR:90bpm

-Temp: 37.1°C

-Dxt:5.4

-WCC: 11.4 X 109/L

-Hb: 12.6 g/dL

-Slightly increased in temperature and WCC level which indicate infection might occurred

-Continue to monitor vital sign and full blood count profile

16/2

-Patient feels comfortable

-Mild cough

-No chest pain and SOB

-BP:126/73mmHg

-HR:97bpm

-Temp: 37.4°C

-Fever may be developed due to infection

-Patient is prescribed with fusidic acid 200mg bd and tablet ciprobay 500mg bd to prevent any bacteria infection

11. Major Diagnosis

Pathogenesis of Acute Myocardial Infarction

Acute myocardial infarction (AMI), commonly known as a heart attack, is the interruption of blood supply to a part of the heart, causing heart cells to die. This is most commonly due to occlusion (blockage) of a coronary artery following the rupture of a vulnerable atherosclerotic plaque, which is an unstable collection of lipids (fatty acids) and white blood cells (especially macrophages) in the wall of an artery. The resulting ischemia (restriction in blood supply) and oxygen shortage, if left untreated for a sufficient period of time, can cause damage or death (infarction) of heart muscle tissue (myocardium). Classical symptoms of acute myocardial infarction include sudden chest pain (typically radiating to the left arm or left side of the neck). Risk factors for atherosclerosis are generally risk factors for myocardial infarction which include tobacco smoking, male , age and etc.

Treatment Goal

Treatment is designed to relieve distress, interrupt thrombosis, reverse ischemia, limit infarct size, reduce cardiac workload, and prevent and treat complications. Goal of treatment is improving quality of life by decreasing heart attack and other CHD symptoms and improving the pumping action of heart if it has been damaged by a heart attack as well as lowering the risk of a heart attack.

Actual & Recommended Treatment

Actual treatment :

Coronary Artery Bypass Grafting ( CABG ) at 7/2/2011

- Coronary artery bypass grafting (CABG) is a type of surgery that improves blood flow to the heart. It's used for people who have severe coronary heart disease (CHD), also called coronary artery disease. During CABG, a healthy artery or vein from the body is connected, or grafted, to the blocked coronary artery. The grafted artery or vein bypasses the blocked portion of the coronary artery. This creates a new passage, and oxygen-rich blood is routed around the blockage to the heart muscle.

Recommended treatment :

Medical care

Thrombolytic therapy - has been shown to improve survival rates in patients with acute myocardial infarction if administered in a timely fashion in the appropriate group of patients.

Aspirin and/or antiplatelet therapy - reduce the tendency of platelets in the blood to clump and clot. These medicines help to prevent the arteries from becoming blocked again. Clopidogrel is used as an alternative in cases of a resistance or allergy to aspirin.

Glycoprotein (GP) IIb/IIIa-receptor antagonist - Antagonists to glycoprotein IIb/IIIa receptors are potent inhibitors of platelet aggregation. The use of glycoprotein IIb/IIIa inhibitors during percutaneous coronary intervention (PCI) and in patients with MI and acute coronary syndromes has been shown to reduce the composite end point of death, reinfarction, and the need to revascularize the target lesion at follow-up.

Heparin ( anti-coagulant )

Nitrates - a vasodilator (blood vessel dilator), widens the blood vessel by relaxing the muscular wall of the blood vessel.

ACE inhibitors - type of vasodilator, improve the heart muscle healing process. They do this by blocking the production of a hormone (chemical signal carried in the blood) called angiotensin II.

Beta-blockers - reduce the rates of reinfarction and recurrent ischemia.

Surgical care

Percutaneous coronary intervention ( PCI ) - also called as angioplasty, is the preferred emergency procedure for opening the arteries for some types of heart attacks. It should preferably be performed within 90 minutes of arriving at the hospital and no later than 12 hours after a heart attack. Angioplasty is a procedure to open narrowed or blocked blood vessels that supply blood to the heart. A coronary artery stent is a small, metal mesh tube that opens up (expands) inside a coronary artery. A stent is often placed after angioplasty. It helps prevent the artery from closing up again. A drug eluting stent has medicine in it that helps prevent the artery from closing.

Coronary Artery Bypass Grafting - Coronary angiography may reveal severe coronary artery disease in many vessels, or a narrowing of the left main coronary artery (the vessel supplying most of the blood to the heart). The surgeon takes either a vein or artery from another location in your body and uses it to bypass the blocked coronary artery.

Monitoring Efficacy of Treatment

- Monitor parameters for efficacy of therapy include :

Relief of ischemic discomfort

Return of ECG changes to baseline

Absence or resolution of heart failure signs

- Monitor parameters for adverse effects are dependent upon the individual drugs used. In general, the most common adverse reactions are hypotension and bleeding, so we need to monitor red blood cell count and vital sign such as blood pressure of patient.

12. Pharmaceutical Care Issue

Pain Management

Inside the ward, patient was given Tramal capsule 50mg tds to manage the pain that caused by after surgery. Before start the pharmacology pain management, we need to do the pain assessment. We may use the verbal rating scale, visual analog scale and numeric rating scale to assess the pain intensity. Hospitals advocate continuous around-the-clock dosing through the use of a pump-type device that immediately delivers medication into the veins (intravenously, the most common method), under the skin (subcutaneously), or between the dura mater and the skull (epidurally).

To manage the pain, we can use the WHO analgesic Ladder. This approach consists of 3 steps to relief the pain. The first step which covers the mild pain involves the use of a nonopioid with or without adjuvant analgesic. The nonopioid includes NSAIDS, paracetamol while the adjuvants are tricyclic antidepressant, anticonvulsants or steroids. If the pain persists, we can move to the second step which covers the mild to moderate pain. Weak opioids such as codeine, dihydrocodeine with or without non-opioid (and adjuvants if needed) are involved in this step. If the pain still persisting and increasing, we can move to the step 3. In this step, the stronger opioid such as morphine, dimorphine and fentanyl are used to replace the weak opioids in step 2.

According to this case, patient still complaining of pain after surgery so it indicate that analgesic effect of tramadol is not strong enough. Therefore, stronger opiods such as morphine, hydrocodone or oxycodone can be suggested to replace tramadol so that patient has better pain control. Or keep using tramadol while adjuvant analgesic such as gabapentin added into tramadol because tramadol causes significantly less respiratory depression than morphine. However, combination between tramadol with MAO inhibitors, SSRIs and tricyclic antidepressant may enhance CNS depression effect.

To monitor the efficacy of pain-killer, we may ask the patient about the pain relief and pain intensity after the pain management. Frequent reassessment of pain with the scales mentioned above or questionnaire can ensure that the current pain management is adequate to the patient. Pain score of patient is 3-4/8 after taking tramadol.

Tramadol has CNS depression effects such as drowsiness, dizziness, headache and confusion. Close monitoring of these effects is needed. Besides, this drug may cause constipation, so we need to monitor patient bowel output. In this case, ravin enema stat dose was given to the patient to solve the constipation.

Post surgery infection

After surgery patient was developing infection. Patient was having fever and there was an increased of neutrophils count and WBC. Temperature of patient was 38°C at 8/2/2011. WBC count and neutrophils count were higher than normal range from 7/2 till 10/2. Lymphocyte level was lower than normal range from 7/2 till 14/2. Blood culture and sensitivity test showed that there were presence of gram positive cocci and Pseudomonas aeroginosa. IV Cloxacillin 1g qid and IV Rocephin 1g od were given to the patient to eradicate the infection. According to the Surgical Infection Society Guidelines on Antimicrobial Therapy, cloxacillin and Rocephin ( ceftriaxone ) are suitable for treatment post surgery infection. Cloxacillin is a penicillin-related antibiotic prescribed to treat a variety of bacterial infections such as Gram positive cocci. Rocephin is in a group of drugs called cephalosporin antibiotics. It is a third-generation cephalosporin antibiotic. Like other third-generation cephalosporins, it has broad spectrum activity against Gram-positive and Gram-negative bacteria. Thus, it can be used to treat gram +ve cocci and Pseudomonas aeroginosa that arised after surgery. The preoperative administration of a single 1 gm dose of Rocephin may reduce the incidence of postoperative infections in patients undergoing surgical procedures classified as contaminated or potentially contaminated and in surgical patients for whom infection at the operative site would present serious risk (eg, during coronary artery bypass surgery). Patient also show sensitivity towards ciprofloxacin, amikacin and cefepime.

To monitor the efficacy of the antibiotic therapy, we may monitor the white cell count, neutrophiles count and body temperature. If the infection is resolved, these laboratoray investigation values will return to the normal level. Besides, the relief of symptoms such as fever may also indicate the therapy efficacy.

The common adverse effects of cloxacillin may include upset stomach, diarrhea, nausea, vomiting, anxiety, colitis, confusion, convulsions, dizziness and appetite loss. For rocephin, its side effects are ain, warmth or minor swelling at injection site, rash and diarrhea. In oder to monitor the therapy safety, it is necessary to monitor the side effects that caused by the cloxacillin and rocephin.

Anemia

On 8/2 till 12/2 , 1 day after the surgery, we can notice that RBC and hemoglobin level of the patient are quite low. Patient may developed anemia due to the blood loss during the surgery. However, there is no drug have been prescribed by doctor to treat this symptom. So, haematinic can be suggested to resolve the anemia. Haematinic is composed of ascorbic acid, vitamin B complex, ferrous fumarate 200 mg, folic acid 5 mg. Each drug was taken one tablet once daily. Basically, the causes of anemia for this patient may due to the iron deficiency, Vitamin B12 deficiency, folate deficiency or deficiency of two or all these element. To determine the type of deficiency anemia, we may carry out the laboratory evaluation such as complete blood count, peripheral blood smear and iron indices (transferrin saturation, ferritin). According to Pharmacotherpy Handbook, oral iron therapy with soluble ferrous iron salts is recommended at a daily dosage of 200 mg elemental iron in two/three divided doses for iron deficiency anemia. In Vitamin B12 deficiency anemia, oral cobalamine is initiated at 1 to 2 mg daily for 2 to 2 weeks, followed by 1 mg daily. For treatment of folate deficiency anemia, oral folate 1 mg daily for 4 months is usually sufficient. Haematinic may suggested for the anemia that caused by deficiency of iron, folate and Vitamin B12.

To monitor the efficacy of haematinic, we need to observe the changes of the level of hemoglobin, hematocrit, RBC and iron indices. The hemoglobin and hematocrit level will rise about 1-2 weeks after start the therapy.

The common adverse effects of ferrous fumarate are constipation and black stool. We may advise patient to drink more water and eat more vegetables and fruits.

Dehydration

Patient experiences dehydration after surgery. From I/O chart, it showed that loss of 1049mL fluid from body on 12-13/2. Most of blood loss during surgery and minor factor due to exposure of large internal surfaces to the heat and light of the theatre lights as well as fluid loss from respiration while intubated. Depending on the type and length of the operation, it is common for patients to be several litres "dry" in the post-operative period. Patient experienced hyponatremia on 12/2 due to loss of fluid from body. The urea level also higher than normal range at the beginning of post surgery and it slowly returned to normal value after few days. Potassium level on 14/2 was higher than normal range.

For someone with a fluid deficit, that fluid is best replaced with saline rich solution which is either 0.9% NaCl solution (Normal Saline) or Hartmann's solution. Doctor should give adequate potassium replacement for patient in the first 24 hours post-operatively routinely (Slow K tablet) but in this case, patient had developed hyperkalemia and doctor should withdraw the Slow K tablet to prevent complications that might occurred. If low sodium level persist, doctor can consider to give sodium supplement to treat the condition.

To monitor efficacy of treatment, the fluid intake and also I/O chart can be monitored closely. Besides that, urea, sodium and potassium levels should be monitored too so that patient get enough electrolytes replacement after surgery.

Potential drug-drug interaction

Clopidogrel ( Plavix ) & Aspirin

Problem statement: Clopidogrel may enhance the adverse/toxic effect of high dose aspirin. Increased risk of bleeding may result. MOA is Clopidogrel may enhance the risk of bleeding associated with gastrointestinal ulcers such as can be caused by aspirin therapy.

Management: Patient should advise to observe the stool clour and black stool may indicate there is gastrointestinal bleeding. Nexium (esomeprazole) is prescribed to the patient to prevent formation of gastric ulcer in stomach.

Monitoring: Monitor for increased evidence of reduced platelet function (e.g., bleeding, bruising, etc.) during concomitant use of clopidpgrel and aspirin. RBC and hemoglobin level also should be monitored closely.

Esomeprazole & Lovastatin

Problem statement: Esomeprazole may increase the serum concentration Lovastatin. Inhibition of p-glycoprotein by omeprazole, leading to impaired lovastatin efflux to intestinal lumen and increased drug bioavailability.

Management: Patient should advise to notify physician if he experiences weakness or do not administer both drug at the same time.

Monitoring: Monitor for evidence of rhabdomyolysis, muscle pain, tenderness or weakness when concurrent use of both drugs.

Esomeprazole & Clopidogrel

Problem statement: Esomeprazole may diminish the therapeutic effect of Clopidogrel. This appears to be due to reduced formation of the active clopidogrel metabolite. Clopidogrel may increase the serum concentration of esomeprazole. 

Management: Patient should advise to inform physician if she experiences any uncomfortable and doctor may want to change proton pump inhibitor to a different medicine such as pantoprazole or refer the patient to gastroenterologist.

Monitoring: Monitor response to clopidogrel closely when using clopidogrel with a proton pump inhibitor. Patient's INR, PT, aPTT are closely observed.

13. Conclusion

Patient was diagnosed with acute myocardial infarction-3 vessels disease with LMS involvement and is managed with CABG surgery. Currently, patient's post surgical infection was resolved as the fever was relief and the neutrophils count was returned to normal range. Anemia that patient experienced also resolve automatically to improve patient's overall condition. Pain reassessment should be done regularly to ensure adequate pain management is given to the patient. Other supportive care to cover nausea/vomiting and gastric bleeding if needed for patient may provided to prevent and relieve suffering and to support the best possible quality of life for patients and their families.