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1. 09408103
26-3-14

2.  Subjective:
 Patient has breathlessness and cough for 10 days.
 K/C/O COPD for the past 6 years. The symptoms aggravated
in the last 10 days. Ther is no fever. Sputum is mucoid in
nature.
 PAST MEDICATION HISTORY
 T.ASTHALIN 4mg-BD
 T.DERIPHYLLINE RETARD- BD
 TIOVA MDI- 2 PUFFS OD
 FORMETEROL & BUDESONIDE MDI- 2 PUFFS BD
 PERSONAL HISTORY:
 Stopped smoking 6 years ago

3.  Objective:
 RS : B/L Wheeze +; BS ↓
 GU& GI : Soft, liver just palpable BS +
 Old chest X-ray shows the presence of bullae.
 WBC-13250 cells/cumm (↑)
 PCV: 47.7% (↑)
 Assessment:
 The patient is diagnosed to have Acute Exacerbation of
COPD.

4.  Plan:
 T.UNICONTIN (Theophylline): It is an anti asthmatic drug
given for relieving shortness of breath. One tablet has to be
taken at night daily after food. It can cause headache, tremor,
abdominal pain and hypotension.
 T.RANTAC (Ranitidine): It is given to reduce gastric
irritation. One tablet is to be taken in the morning and one
tablet at night 15 minutes after food. Side effects include
diarrhoea, dizziness, pruritis..
 T.LASILACTONE (Furosemide & Spironolactone): It is
given to treat pulmonary edema and hypertension. One tablet
is to be taken in the morning. Side effects are rashes, fluid
electrolyte imbalance, headache and hypotension.

5.  DUOLIN NEB Ipratropium+Salbutamol): It is used to
relieve shortness of breath. Nebulise as directed by physician
and should be done by only a qualified personnel. It can cause
Palpitations, dry mouth, rashes, headache and hypersensitivity
reactions.
 BUDECORT NEB (Budesonide): It is used to relieve
shortness of breath and also reduce inflammation in the
airways. Nebulise as directed by physician and should be done
by only a qualified personnel. Side effects include dryness,
irritation, oral candidiasis.