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 25 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
IMPRESSION
62% of FEV1 was detected

9. DIAGNOSIS
Acute exacerbations of Asthma

10. DRUG CHART
SN DRUG DOSE ROA Frequenc
y
Duratio
n
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. CRITICALANALYSIS 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