210254 LOGO Ambulatory care 1 Ambulatory care 040154

21/02/54 LOGO Ambulatory care

กรณศกษาท 1 Ambulatory care

ประวตการรกษา 04/01/54 § Furrous 1 x 3 § Folic acid )5 (1 x 1 § Sodamint )300 ( 2 x 3 § Furosemide )500 ( 0. 5 x 1 § Cotrimoxazole )400( 2 x 1 § Fluconazole )200 ( 2 x 1 สปดาหละ 1 วน (วนพธ ( 18/2/54 § CPM )4 (1 x 3 § Furosemide inj 40 mg IM §Triamcinolone cream 0. 1% Ambulatory care

Time line + ขอมลสมภาษณเพมเตม 04/01/54 -Cotrimoxazole prophylaxis -Fluconazole prophylaxis 17/02/54 เรมคน และมผนท วตว 18/02/54 มา รพ. แพทยสง off ยา Pt. อาการดขน Ambulatory care

Cotrimoxazole § § Treatment and prophylaxis PCP SMX = 400 mg + TMP 80 mg Peak : 1 -4 hr. Half life : SMX = 9 hr. , TMP =6 -17 hr. )prolong in renal failure ( ขบออกทางไตในรป metabolites และ unchanged drug § Reduce dose in patients with renal insufficiency -Clcr 15 -30 ml/min ใหยาในขนาด 50% ของ standard regimen - Clcr < 15 ml/min ไมมขอแนะนำ Ambulatory care

ADR of cotrimoxazole § § § Cardiovascular Central nervous system Dermatologic Endocrine & metabolite Gastrointestinal § § § Hematologic Hepatic Neuromuscular & skeletal Renal Respiratory Common ADR of cotrimoxazole § Dermatologic: Rash, Urticaria § Gastrointestinal: Loss of appetite, Nausea, Vomiting [MICROMEDEX® 1. 0 , December 30 2010] Ambulatory care

)WHO guidelines on cotrimoxazole prophylaxis for HIV related infection , 2006(

Fluconazole § § § Treatment candidiasis ; crytococcal prophylaxis Peak : 1 -2 hr. )oral( Half life : normal functions ~30 hr. Excretion : urine )80% unchanged from( Dose adjustment/interval in renal impairment - no adjustment for vaginal candidiasis single-dose therapy - for multiple dose ; Clcr ≤ 50 ml/min)no dialysis ( ใหยาในขนาด 50% ของ standard regimen หรอ ใหยาทก 48 hr. Ambulatory care

ADR of fluconazole § § Cardiovascular CNS Dermatologic Endocrine & metabolic §Gastrointestinal §Hematologic §Hepatic §Respiratory Common ADR of fluconazole § Gastrointestinal: Nausea (2. 3% to 7% ), Vomiting § Hepatic: Increased liver enzymes § Neurologic: Headache [MICROMEDEX® 1. 0 , February 04 2011] Ambulatory care

กรณทไมสามารถทานยา ไดอก TMP-SMX Alternative -Dapsone 100 md/day or - Dapsone 50 mg/day+pyrimethamine 50 mg/wk+folinic acid 25 mg/wk or - Clindamycin 600 mg iv q 8 hr or oral 300 -450 mg q 6 hr + Primaquin 30 mg/day # 21 days Ambulatory care

LOGO