This document presents a case study of a 60-year-old male patient admitted to the hospital with abdominal discomfort for 10 days and a history of bronchial asthma and GERD. Examination findings and investigation reports are provided. The patient is assessed and diagnosed with bronchial asthma and GERD. A drug chart outlines the treatment plan and discharge summary is presented advising the patient to continue medications and make lifestyle modifications. The case study concludes with a discussion of monitoring parameters, pharmacist interventions, and patient counseling on drug therapy and disease and lifestyle management.

1. PHARMACOTHERAPEUTICS-III
CASE PRESENTATION
NANDHA COLLEGE OF PHARMACY
RAJNANDINI SINGHA
IV Pharm D

2. CASE STUDY
ON
GERD

3. SUBJECTIVE
A 60 year old Male patient was
admitted in Perundarai medical
college hospital on 25/1/2018
with the complaints of
abdominal discomfort for 10 days.

4. HISTORY OF PRESENT ILLNESS
H/O Abdominal discomfort
H/O Difficulty in breathing
H/O skin allergy
H/O cough with expectoration

5. PAST HISTORY
K/C bronchial asthma before 3
days

6. PERSONAL HISTORY
Diet: Mixed.

7. GENERAL EXAMINATION
 Patient conscious,
oriented
 BP :160/70 mmHg
 PR :79 bpm

8. SYSTEMIC EXAMINATION
 CVS – S1S2 Heard
 RS - B/L AE+,B/L WHEEZ+
 CNS – NFND
 P/A - Soft

9. OBJECTIVE
INVESTIGATION CHART
NAME OF
INVESTIGATION
OBSERVED VALUE NORMAL VALUE
WBC 14.0x109/L 4.5-10.5×109/L
RBC 4.26x1012/L 3.8-5.9×1012/L
HAEMOGLOBIN 10.5g/dl 12-14g/dl
PLATELETS 173.0109/L 130-400109/L
L/M/G 2.5/1.5/11.0109/L
MCV 92.9 FL 80-100FL
HCT 40.2% 35-50%
MCH 27.6pg 27- 34pg

10. MCHC 29.7g/dl 32-36g/dl
ESR 32mm/hr 0-20mm/hr
BIOCHEMISTRY
RBS 67 mg/dl Up to 140 mg/dl
BLOOD UREA 30 mg/dl 10-40 mg/dl
SERUM CREATININE 1.0mg/dl 0.6-1.3 mg/dl
SERUM PHOSPHATE 3.5 mg/dl 2.5-4.5 mg/dl
URINE ANALYSIS
COLOUR PALE YELLOW
REACTION Acidic
ALBUMIN NIL

11. PROGRESS CHART

DATE TEMP (°F) B.P P.R R.R
25/1/18 98.4 110/80 80 20
26/1/18 98.4 110/80 75 22
27/1/18 98.8 100/80 84 20
28/1/18 98.6 140/60 82 20
29/1/18 98.4 110/80 78 22
30/1/18 99 140/80 82 20
31/1/18 98.5 120/80 80 20
1/1/18 98.7 140/80 85 22
2/1/18 98.4 120/80 82 22

12. OTHER INVESTIGATION
X-RAY –Increased BVM
(bronchovascular marking)

14. ASSESMENT
FINAL DIAGNOSIS:
 Bronchial Asthma
 GERD( Gastroesophageal reflux
disease)

15. DRUG CHART
DRUG GENERIC NAME DOSE ROUTE FREQ 3 4 5 6 7
Inj.genta Gentamycin 1mg IV 1-0-1 √ √ √ √ √
INJ .RANTAC Ranitidine 2ml IM 1-0-0 √ √ √ √ √
T.CPM Chlorphenaramin
e
10mg PO 1-0-1 √ √ √ √ √
T. Dolo Paracetamol 650mg PO 1-1-1 √ √ √ √ √
Inj. Deri Theophylline+Eto
phylline
2ml IV 1-0-1 √ √ √ √ √
T.celin Vitamin C 40mg PO 1-0-0 √ √ √ √ √
SYRUP.
Rantac
ranitidine 15mg PO 1-0-1 √ √ √ √ √
Liquid paraffin Liquid paraffin 10ml topical 0-0-1 √ √ √ √ √

16. DRUG GENERIC NAME DOSE ROUTE FREQ 3 4 5 6 7
BVM
OINTMENT
Betamethasone
valarate
0.1% 1-1-1 topical √ √ √ √ √
SYRUP.
REXCOF
Dextromethophan
and
chlorpheniramine
maleate
100ml 1-0-1 PO √ √
SALBUTAMOL
NEB
SUBUTAMOL 1-1-1 NASAL √ √ √ √ √

17. DISCHARGE SUMMARY
The patient was discharged on 7/02/18
DISCHARGE ADVICE
T.PARACETAMOL(1-1-1) 650mg
T.CPM(1-0-1)10mg
SYRUP.RANTAC(1-1-1)10ml
T.CELIN(VITAMIN C) (1-0-0)500mg
Liquid paraffin(1-0-1)
BVM OINTMENT(1-0-1)

18. PLAN

19. PATIENT COUNSELLING:
DRUG RELATED DISEASE RELATED LIFE STYLE
MODIFICATION
•Take SYRUP Rantac
before 30mins of food
•LIQUIID PARAFFIN and
BVM OINTMENT should
be apply on dry skin.
• Advice the patient not
to skip meals.
•Avoid stress and NSAIDS
• Elevate the head on the
bed.
COPD:
On coughing mouth
should be closed.
Avoid dust, allergen,
alcohol, smoking.
•Avoid choclate, coffee,
soda, alcoholic drinks.
• Avoid Citrus fruits and
juices of tomato.
•Advice the patient to eat
boil food for 2-3 weeks.
•Green vegetables should
be taken to regenerate
the lining of stomach.

20. S.N
O
ASSESMENT PLAN
1. Chlorpheniramine + food
Alcohol can increase the CNS Side
effect such as drowsiness, dizziness
..
MANAGEMENT: To avoid
consumption of alcohol , hazardous
activities require complete
alterness
,mental alertness.
Syrup Ranitidine should administered
30mins before food.
3. T.CPM AND SYRUP .Rexcof
Side effect - sleepiness
Do not prescribe in the morning

21. MONITORING PARAMTER:
 pH Monitoring for GERD
Increased acid exposure time.

22. PHARMACIST INTERVENTION:
 Antacid should be recommended in the prescription.
 Suggesting to Reduce the adminstration of PARACETAMOL to
reduce toxicity.
 Proton pump inhibitor is recommended to be add in the
prescription.

23. THANK YOU