Case Presentation in SOAP Format

He I present a case of Type 1 Diabetes mellitus with Pneumonia in standard SOAP format.

1. CASE PRESENTATION IN SOAP FORMAT Abel C. Mathew 5th year PharmD Al Shifa College of Pharmacy 1

2. 2 A CASE ON TYPE 1 DM WITH PNEUMONIA

3. NAME : XYZ AGE : 35 years SEX : Male MRD NO : 3093218 DOA :08/09/2018 DOD :14/09/2018 Dept: Pulmonology, General Medicine I 3 PATIENT DEMOGRAPHICS DETAILS

4. REASON FOR ADMISSION Fever, cough with expectoration since 4 days. One episode of cough with mild blood stain on coughing today. Breathlessness, no chest pain 4

5. 5 MEDICAL HISTORY Type 1 DM since past 20 years MEDICATION HISTORY Inj. Human Mixtard 20 U- 0- 20 U FAMILY HISTORY No relevant family history SOCIAL HISTORY Not relevant

6. ON EXAMINATION Conscious , Oriented, Afebrile , PR -92/ mt , B.P- 130/90 mm Hg, PR- 88 / mt Chest – NVBS, crepts from infrascapular area CVS- S1S2+ 6

7. PROVISIONAL DIAGNOSIS Type 1 DM, Pneumonia? (right lower lobe) 7

8. LAB ADVICES LFT SPUTUM CULTURE BLOOD CULTURE AFB STRAIN X-RAY HBA1C FBS RFT URE 8

9. 9 LAB REPORTS TEST VALUE NORMAL HBA1C 9.1 % Non diabetics -4.2-6.3% Diabetics with good control- 6.3-7.1 % Poor control >7.1% FBS 205.5 mg/dl 80-110 RBS 374 mg/dl 80 - 140 S .CREATININE 0.6 mg/dl 0.6-1.2 S. UREA 17.3 mg/dl 12-40 URINE ROUTINE EXAMINATION APPEARENCE Clear PROTEIN Nil SUGARS Nil EPITHELIAL CELLS 1-2 / hpf PUS CELLS 1-3/ hpf

10. 10 ALBUMIN 3.7 g/L 3.5-5.5 GLOBULIN 2.8g /L 2.3-3.5 A/G RATIO 1.3:1 TOTAL PROTEIN 6.5 g/L 6.4-8.3 ALT 15.8 U/I 5-35 AST 12.2 U/I 8-40 ALKALINE PHOSPHATASE 73 U/I 30-130 BILIRUBIN TOTAL 0.67 mg/dl 0.29-1.2 DIRECT BILIRUBIN 0.24 mg/dl 15-45 INDIRECT BILIRUBIN 0.43 mg/dl 70-150 Casts Nil Crystals Nil LIVER FUNCTION TESTS

11. TEST PATIENT VALUE NORMAL RANGE RBC 5.37 x 10 6 cells/microliter 4.5-5.9 WBC 8.3 x 1000 cells /mm3 4-11 NEUTROPHILS 80% 45-75 LYMPHOCYTES 15% 20-45 BASOPHILS 0% 0-1 EOSINOPHILS 1% 0-6 MONOCYTES 4% 0-7 PLATELETS 458x10 ^3 cells/ µL 150-450 MCV 68 fl / cell 66-96 MCH 22.4 pg / cell 27-32 MCHC 32.9% 32-36 RDW 13.1% 11-16 ESR 90 mm/hr 0-20 11

12. 12 SERUM SODIUM 140.7 mEq /L 135-145 SERUM POTASSIUM 3.73 mEq /L 3.5-5.5

13. OTHERS X-Ray: Right lower lobe consolidation of lungs Sputum culture : Normal flora of upper RT grown in culture. Smear for gram stain in sputum: Occasional gram negative bacilli and few gram positive cocci seen. Blood Culture : No growth seen. Smear for AFB staining : No AFB seen 13

14. FINAL DIAGNOSIS Right lower lobe Pneumonia ,Type 1 DM 14

15. PHARMACOTHERAPY 15

16.       DRUG       D1     D2     D3   D4     D5     D6     D7     BRAND NAME   GENERIC NAME WITH DOSE, ROUTE AND FREQUENCY T.AZITHRAL   INJ.AUGMENTIN   CAP.FLUVIR   INJ.PANTODAC   T.MONTEK LC   T. BROCLEAR   T.GLYMI   OTRIVIN NASAL SPRAY   T.ULTRACET    SYP.SUCRAMAL O   Azithromycin (500mg) P/O 1-0-0   Amoxicillin (1000mg) + Clavulanic acid( 200 mg) IV 8th hourly Oseltamivir (75 mg) P/O 1-0-1 Pantoprazole (40mg) IV OD   Monteleukast(10mg) + Levocetrizine (5 mg)P/O HS   Acebrophylline (100 mg)+ Acetyl cysteine(600 mg) P/O BD Glymepiride (2mg) P/O BD   Xylometazoline ( 0.1%) 2 puffs inhalation TID   Tramadol(37.5mg)+ Paracetamol(325mg) P/O BD   Sucralfate (1000mg) + Oxetacaine (20mg) 2tsp P/O TID +   + +      +   +     +   +   +   +   +   +     +   +             +   +   +   +   +     +   +   +             +   +   +   +   +     +   +   +           +   +   +   +   +     +   +   +           +   +   +   +   +     +   +       +   +   +   +   +   +   +     +           +   + 16

17. DISCHARGE MEDICATIONS: T.FORENZA ( Cefpodoxime 200mg+ Clavulanic Acid 125 mg) 1-0-1 T.PANTOCID DSR ( Pantoprazole 40 mg + Domperidone 10 mg) 1-0-0 SYP.SUCRAMAL O ( Sucralfate 1000 mg + Oxetacaine 20 mg) 2tsp-2tsp-2tsp T.BROCLEAR ( Acebrophylline 100 mg + Acetyl cysteine 600 mg) 1-0-1 T.MONDESLOR ( Monteleukast 10 mg + Desloratadine 5 mg) 0-0-1 EZICAS NASAL SPRAY (Fluticasone Propionate 0.05 %) 1 puff - 0- 1 puff 17 7 DAYS

18. PROGRESS CHART 18   DAY     INVESTIGATIONS 8/9   9/9   10/9   11/9   12/9   13/9     14/9   All vitals stable :( BP -120/70,Temp -98.6º F, PR -72 /min ,RR – 20/min)     Vitals stable. Sputum taken for culture . BP- 120/70,Temp – 98.6 ,PR-80/min, RR-20 /min   Vitals stable. AFB smear done.BP-110/70, Temp-98.6, PR -70 /min, RR-18/ min   Vitals stable BP-110/70, Temp-98.6, PR -74 /min, RR-20/ min     Vitals stable BP-110/80, Temp-98.6, PR -70 /min, RR-18/ min     Vitals stable and patient experienced right side pain and gastric discomfort BP-80/60, Temp-98.6, PR -76 /min, RR-18/ min     Vitals stable BP-100/70, Temp-98.6, PR -72/min, RR-20/ min    

19. FOLLOW UP/ REVIEW   Review after 1week in OPD with chest X- ray reports. 19

20. INSTRUCTIONS/ADVICES Drink plenty of fluids to help loosen secretions and bring up phlegm. Get lots of rest. Do not take cough medicines without first talking to your doctor. If you smoke, stop. Follow diabetic diet, exercise as advised 20

21. SOAP ANALYSIS 21

22. SUBJECTIVE EVIDENCE A 35 year old male was admitted in general medicine department with fever, cough with expectoration since 4 days, One episode of cough with mild blood stain on coughing today, Breathlessness, no chest pain and was a known case of type I diabetic. 22

23. OBJECTIVE EVIDENCE 23 . 1. Elevated HbA1C[9.1%] 2. Elevated fasting blood sugar [ 205.5 mg/dl] 3. X ray showed right lower lobe consolidation of lung. 4. Smear for gram stain in sputum identified occasional gram negative bacilli and few gram positive cocci .

24. ASSESSMENT Etiology: Known case of type I diabetes. Community acquired pneumonia 24

25. Assessment of current therapy- Rationality of each drug: 25 Azithromycin- In an open-label, prospective study ( Sanchef F. et,al 2005) Combination treatment with a beta-lactam plus a macrolide may improve the outcome for elderly patients with community-acquired pneumonia (CAP). Comparison of CAP patients who receive ceftriaxone combined with a 3-day course of azithromycin or a 10-day course of clarithromycin were compared in an. Of 896 assessable patients, 220 received clarithromycin and 383 received azithromycin. However , for patients treated with azithromycin, the length of hospital stay was shorter (mean+/-SD, 7.4+/-5 vs. 9.4+/-7 days; P<.01) and the mortality rate was lower (3.6% vs. 7.2%; P<.05), compared with those treated with clarithromycin. Paracetamol / Tramadol - A multicenter, randomized, double-blind, parallel-group, 10-day treatment study ( Perrot et.al 2006) efficacy and tolerability of paracetamol /tramadol (325 mg/37.5 mg) combination treatment compared with tramadol (50 mg) monotherapy in patients with subacute low back pain: by. A total of 119 patients were enrolled (PIT, n = 59; T, n = 60). The reduction in pain intensity was significant in both treatment groups (P < 0.001).

26. 26 5 . Montelukast / Levocetrizine –In a study( Kaur et al 2017) undertaken to compare the efficacy of leukotriene receptor antagonist and antihistamines in relieving nasal congestion/ obstruction symptom and itching /irritation in eyes. The study was conducted among 125 patients clinically diagnosed suffering from allergic rhinitis Patients were divided into 5 groups and were given oral treatment with oral antihistamines ( chlorpheniramine maleate, levocetrizine , fexofenadine, desloratadine ) and leukotriene receptor antagonist montelukast ) for a period of 6 weeks. For relieving nasal obstruction, levocetrizine group showed maximum improvement at 2 weeks. However, at the end of 6 weeks montelukast group showed maximum relief 6. Xylometazoline - A double-blind, placebo-controlled, parallel group study( Eccles et.al 2008) was performed. Patients with a common cold (n = 61) were treated with xylometazoline 0.1% (n = 29) or placebo (saline solution; n = 32; 1 spray three times a day for up to 10 days). The decongestant effect of xylometazoline was significantly greater than placebo, as shown by the nasal conductance at 1 hour (384.23 versus 226.42 cm3/s; p ≤ 0.0001) and peak subjective effect (VAS, 20.7 mm versus 31.5 mm; p = 0.0298).

27. RESPONSE TO THERAPY Patient responded well to the therapy , symptoms was reduced 27 ADR/DRUG INTERACTIONS No ADRs / drug interactions were identified PATIENT COMPLIANCE Patient was found to be compliant to the medications given.

28. ALTERNATE THERAPY IF ANY, CDC recommends use of a respiratory fluoroquinolone in non-ICU inpatients other than macrolide- penicillin combination. 28

29. PLAN Goals of therapy: 1. Curing the infection, 2. Preventing complications 3. Alleviating the symptoms 4. Returning the patient to normal activities 5. Preventing recurrence 29

30. GOALS ACHIEVED 1.Patient condition improved, symptoms improved, cough, breathlessness and fever decreased. 2. Complications prevented 3. Improved quality of life of patient. 30

31. MONITORING PARAMETERS 1. Amoxicillin/ Clavulanate • Hepatic Function 2. Azithromycin • Monitor hepatic function 2. Tramadol / Paracetamol • Respiratory depression • Hypotension • Worsening of GI conditions, sedation, respiratory depression 31

32. DRUGS/OTC TO BE AVOIDED Systemic steroid, birth control pills, isotretenoin use should be controlled in diabetic patients. . 32

33. CLINICAL PHARMACIST INTERVENTION The use of sulfonylureas in type 1 DM is irrational Usually azithromycin therapy in pneumonia patients can be limited within 5 days. Use of Oseltamivir should be 75 mg P/O twice daily for 5 days in case of Influenza treatment. 33

34. PATIENT CONSELLING CARRIED OUT: 34 A. On disease • Pneumonia is a infection that inflames air sacs in one or both lungs, which may fill with fluid. • A variety of organisms, including bacteria, viruses and fungi, can cause pneumonia. • Type 1 diabetes, once known as juvenile diabetes or insulin-dependent diabetes, is a chronic condition in which the pancreas produces little or no insulin. Insulin is a hormone needed to allow sugar (glucose) to enter cells to produce energy.

35. B. On diet • Avoid sugary drinks and fruit juices • Avoid soft drinks, packaged foods • Include more fiber in food. Avoid eating just before sleeping at night. • Increase fluid intake and take citrus fruits. • Avoid intake of cold foods C. On lifestyle modifications • Basic hygiene. Regular hand washing is recommended as a strategy for avoiding respiratory infections • Manage stress • Exercise 35

36. D. On drugs 1. Cefpodoxime / Clavulanic acid Report if any sort of serum sickness like reactions (rash, urticaria , arthralgia, fever, malaise) or severe diarrhea occur. Tablets should be taken with meals. 2. Montelukast / Desloratadine Patient should avoid activities which needs mental alertness and coordination 3. Fluticasone Propionate Take the nasal spray in proper technique Take medicine at the same time every day and not use it more than twice every 24 hours Patient should rinse mouth after use to avoid the risk of oral candidiasis if taken via inhalation When using nasal spray side effects like headache, sinusitis, mild nasal mucosal ulceration nasal mucosal erythema 36

37. FOLLOW UP DETAILS Review after 1 week in OPD with repeat chest X- ray reports 37

38. THANK YOU 38