1. A 35-year old male with type 1 diabetes was admitted with fever, cough, and breathlessness due to right lower lobe pneumonia. 2. Laboratory tests showed elevated HbA1c of 9.1% and fasting blood sugar of 205.5 mg/dl. Chest x-ray found right lower lobe lung consolidation. 3. He was treated with antibiotics, cough suppressants, diabetes medications, and inhalers. His symptoms improved and he was discharged on oral medications with instructions to follow up in one week.

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 106 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
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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. • Review after 1week in OPD with chest X- ray reports.
19

20. • 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. 21

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

25. Assessment of current therapy- Rationality of
each drug:
25
1. 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.
2. 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. Patient responded well to the therapy , symptoms was reduced
27
No ADRs / drug interactions were identified
Patient was found to be compliant to the medications given.

28. • CDC recommends use of a respiratory fluoroquinolone in non-ICU
inpatients other than macrolide- penicillin combination.
28

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

31. 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. • Systemic steroid, birth control pills, isotretenoin use should be
controlled in diabetic patients.
.
32

33. • 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. 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. Review after 1 week in OPD with repeat chest X- ray reports
37

38. 38