1.

Antibiotics
Drug/Regimen

Start Date

Stop Date

Indication/Reason for Change

T. Azithromycin 500 mg
OD x 4/7
IV Augmentin 1.2g TDS
(amoxicillin/clavulanate)

30/11/15

3/12/15

29/11/15

4/12/15

IV Tazosin 3.375mg stat

& QID (CrCl:30)
(pipericillin/tazobactam)

4/12/15

Still cont.

For moderate and severe CAP. Given in

combination with amoxicillin/clavulanate.
For moderate and severe CAP. Given in
combination with azithromycin. Stop given because
already get the result of sputum culture
(pseudomonas aeruginosa), change to Tazosin
For moderate and severe CAP with pseudomonas
aeruginosa infection. The dose decreased from 4.5
mg to 3.375 mg because patient CrCl is 30 ml/min
(dose adjustment).

2. Other medications
Drug/Regimen
Start Date

IV Hydrocortisone
100mg TDS x 1/7
Neb. Combivent 3mL
Q4h
(albuterol/ipratropium)
Neb. Combivent 3mL
Q6h
(albuterol/ipratropium)

29/11/15
(4pm &
12am)
29/11/15
1/12/15
(12pm)

Stop Date

Indication/Reason for Change

30/11/15
(8am)

To improve lung function in CAP.

1/12/15 (8am)

As bronchodilator to increase oxygen saturation.

Stop to decrease the frequency by giving Q6h as
the SpO2 is normal.
As bronchodilator to increase oxygen saturation.
Stop because SpO2 already maintain and in normal
range even after stop this medication.

2/12/15

Reconciliation Note (Sstop, W- withhold, Dcontinue on discharge) +

Duration
Completed
Stop

Still continue

Reconciliation Note (Sstop, W- withhold, Dcontinue on discharge) +

Duration
Completed
Stop
Stop

T. Bisolvon 8mg TDS

(bromhexine HCl )

3/12/15

10/12/15

As mucolytic and expectorant agent to remove

mucous in bronchial tract, also reduce mucous
viscosity to ease respiration. Stop as patient already
stable.
As expectorant to remove mucous in bronchial tract
and to ease respiration. Stop as patient already
stable.

Stop

Syrup MES 15mls stat &

TDS (ammonium
bicarbonate, EFM squill,
Efm senega, liquid
extract of glycyrrhiza)
IV Parentrovite 1 pair x
3/7
(vit B & C)
T. Aspirin 150mg OD

3/12/15

10/12/15

1/12/15

3/12/15

To correct vitamin deficiency after the infection in

CAP.

Completed

30/11/15

7/12/15

Stop

T. Warfarin 5/3/3

3/12/15

5/12/15

T. Warfarin 3mg OD

7/12/15

Still cont.

T. Simvastatin 20mg ON
T. Metoprolol 50mg BD

29/11/15
29/11/15

Still cont.
30/11/15

T. Digoxin 0.125 mg OD
T. slow K ii/ii BD x 3/7
(potassium chloride)

30/11/15
29/11/15

Still cont.
1/12/15 (8am)

As thromboembolic prophylaxis in atrial

fibrillation. Given in combination with warfarin to
effectively prevent thromboembolism. Stop because
INR reading increases, from 1.24 to 1.40 (risk of
bleeding).
As thromboembolic prophylaxis in atrial
fibrillation. Given in combination with aspirin to
effectively prevent thromboembolism Given in
loading dose to increase INR.
As thromboembolic prophylaxis in atrial
fibrillation.
As prophylaxis of thromboembolism.
Withhold as the HR decrease gradually from 101 to
64 bpm. Change to digoxin to increase heart rate to
normal.
To increase heart rate in atrial fibrillation.
To treat and prevent hypokalemia. Stop to increase
frequency as the potassium level is decrease from

Stop

Completed

Still continue
Still continue
Withhold
Still continue
Stop

T. slow K ii/ii TDS

(potassium chloride)

1/12/15 (4pm)

3/12/15

T. slow K i/i OD
(potassium chloride)
IV Furosemide 40mg OD

4/12/15

7/12/15

30/11/15

Still cont.

S/C Actrapid 12u TDS

29/11/15

7/12/15

S/C Actrapid 12/12/10

7/12/15

8/12/15

S/C Actrapid 12/12/12

8/12/15

10/12/15

S/C Insulatard 14u ON

29/11/15

7/12/15

S/C Insulatard 16u ON

8/12/15

Still cont.

3.9 to 3.7 mmol/L.

To treat and prevent hypokalemia. Stop to decrease
dose and frequency as potassium level increased
and nearly reached upper boarder range
(4.9mmol/L).
To treat and prevent hypokalemia. Stop given
because potassium level is already in the range.
As diuretics in CKD and as prophylaxis to control
blood pressure.
To decrease blood glucose in DM. Stop to decrease
pre dinner dose to 10u as her blood glucose on
6/12/15 night was 3.8 mmol/L.
To decrease blood glucose in DM. Stop to increase
pre dinner dose to 12u as her blood glucose on
7/12/15 night was 14.7 mmol/L.
To decrease blood glucose in DM. Stop as doctor
plan to increase pre lunch dose to 14u as her blood
glucose on 9/12/15 was 13.5 mmol/L.
To decrease blood glucose in DM. Stop to increase
pre bed dose to 16u as her blood glucose on 8/12/15
morning was 11.6 mmol/L.
To decrease blood glucose in DM.

Reference:
1. National Antibiotic Guideline 2014
2. Clinical Practice Guideline Management of Type 2 Diabetes Mellitus 2015
3. Clinical Practice Guideline Management of Chronic Kidney Disease in Adults 2011
4. Clinical Practice Guideline Atrial Fibrillation 2012

Stop

Stop
Still continue
Stop
Stop
Stop
Stop
Still continue