Asthma case study by abhishek pandey

Asthma case study

1. Case study ASTHMA By Abhishek Pandey College of Pharmacy

2. CASE A 48 yrs old female patient was admitted in the hospital with complaints breathlessness severe for the past one day Chest tightness Cough with expectoration

3. Demographic details Patient name :- Mrs. XYZ Age/sex :- 48/female weight:- 60 kgs . Date of admission :- 10/02/2021 Consultant doctor :- Dr. AB

4. Patient complaints breathlessness severe for the past one day Chest tightness Cough with expectoration

5. HISTORY OF PRESENT ILLNESS Breathlessness since 7days Cough with expectoration since 7days PAST MEDICAL HISTORY Nil

6. Physical examination Patient is conscious , oriented, Dyspenic O/E Temp-98.6F Pulse-120 beats/min BP-90/70mmHg RR-25 breaths/min SYSTEMIC EXAMINATION CVS-S1S2+ RS-Wheeze+ CNS-NFND+ P/A-Soft

7. Vital signs S.no 1 BLOOD PRESSURE 90/70 mmHg 2 TEMPERATURE 98.6F 3 PULSE 120 bpm 4 RESPIRATORY RATE 25 bpm

8. Laboratory tests:- SN Test Normal range 1 Heamoglobin 16.0 H 12-15.5g/dl 2 RBC 5.6x10^6/UL H 4.2-5.4x10^6/UL 3 ESR H 5-15mm/hr 4 Total WBC 15.00x10^9/L H 4.0-11.0x 10^9/L H 5 DC N 71 L 23 E 10 1-6% OTHER TESTS Spirometry I MPRESSION 62% of FEV1 was detected

9. Diagnosis Acute exacerbations of Asthma

10. DRUG CHART SN DRUG DOSE ROA Frequency Duration Generic name 1 Tab. Unicontine 1 tab PO BD 5 Days Theophylline 2 Inj . Augmentin 1.2gm IV BD 3days amoxicillin + clavulanicacid 3 Tab. Montak LC 4 +2.5mg PO BD 5days Monteleukast + levocetrizine 4 NEB. Ipravent 1 resp PN TDS 5days Ipratropium bromide 5 Tab. Lycolut 1 tab PO OD 5days M Vit , Ca, Fe and follic acid 6 Tab. Mahacef 200mg PO BD 2days Cefixime

11. Goal of treatment To relieve symptoms To prevent disease progression To improve exercise tolerance To improve overall health status To prevent and asthma To prevent and treat complications such as breathlessness

12. CRITICAL ANALYSIS OF PRESCRIPTION MEDICATION ERRORS No medication errors were found DRUG INTERACTIONS Theophylline -Food (Caffeine containing food)- It May increase the serum concentrations of theophylline

13. PHARMACIST INTERVENTION Patient was advised to avoid co-administration of theophylline with caffeine containing beverage like ; Coffee Tea

14. Patient counselling Good morning. Hello Mrs. xyz My name is Abhishek Pandey , a clinical pharmacist. I am here to guide you about your medication, disease and life style modification. Ok what do you know about your disease. You were admitted in emergency due to breathlessness severe for the past one day Chest tightness Cough with expectoration

15. From how long you are facing this problem? Can you tell me something about your symptoms? What did your doctor tell you about the medication. Ok, now I will be telling you everything in detail. REGARDING DISEASE ASTHMA - is a common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm Symptoms include wheezing, cough, chest tightness and shortness of breath.

16. REGARDING DRUGS Full course of antibiotics should be taken Don't miss any dose Avoid taking theophylline with caffeine Any seizures ,nausea ,coughing up of blood etc if seen are side effects of theophylline and if she experienced it should be stopped While inhaling ipratropium bromide, it should be prevented from going into eyes, since it can cause irritation and blurred vision . After inhalation the patient should clean her mouth to avoid throat irritation and dry mouth.

17. REGARDING LIFE STYLE MODIFICATION Avoid vigorous exercises and cool places since can cause asthma. Plenty of water should be taken since they keep body's cells functioning properly, and helps keep the mucus in the airways loose. Eight glasses of water a day is recommended. Healthy food choices include: adding more fruits and vegetables, avoid spicy and cold food, fried items as they can cause cough. When you feel out of breath, or become tired, stop what you're doing and sit down. Rest helps to keep your airways relaxed, and allows you to breathe easier. Exercises like morning walk and yoga should be done regularly as they can improve breathing Avoid getting in contact with substances like dust,flowers,animal , cigarette smoke, fog etc.

18. SOAP NOTES S A 48 year old female patient was admitted in hospital with complaints of breathlessness,cough,chest tightness O On examination patient was dyspenic and pulse rate, Hb , RBC, TWBC, Eosinophills were found to abnormal . Spirometry was done and found to have 62% FEV1 A Based on the above findings and spirometry test, the patient was assessed to have Acute exacerbations of asthma P Patient was treated with Bronchodilators antibiotics, leukotriene inhibitors and vitamin supplements.

19. Thank you