A 59-year-old male presented with cough, expectoration, fever for 2 days, and shortness of breath on exertion for 3 days. He has a history of anemia, congestive heart failure, and chronic liver disease with ascites. On examination, he had a temperature of 101F, oxygen saturation of 90%, and bilateral wheezing. Laboratory tests showed elevated white blood cell count and liver enzymes. He was diagnosed with lower respiratory tract infection and pneumonia. He was treated with antibiotics, nebulizers, steroids, and other medications. The pharmacist intervened due to some drug interactions and provided counseling to the patient.

1. Case Presentation on
Lower Respiratory Tract Infection
Name : Syeda Khadija Tazeen
Roll No. : 18111T0004
Pharm.D : 5th year

2. PATIENT DEMOGRAPHIC PROFILE:-
 Age : 59
 Gender : Male
 IP no. : 996663
 Dept. : Pulmonology
 Unit : II

3.  Reasons For Admission :
• Cough with expectoration
• Fever ∵2days low grade more during night time
• SOB at exertion ∵3days
• Swelling in both lower limbs
Medical History
• Anemia
• Congestive heart failure , Chronic liver disease with ascites.

4. DAY 1 • B.P - 160/100 mmHg
• P.R - 79 bpm
• Temp - 101F
• Spo2 - 90%
• C/O - fever, SOB
• ADV - CBP ,LFT

5. Brand name Generic name Dose Frequency Route
Augmentin Amoxicillin 1.2g BD IV
Tab. lasilactone Spirinolactone+
Furosemide
20mg BD SC
Inj. pan Pantaprazole 40mg OD IV
Inj. zofer Ondansetron 4mg TID IV
Inj. hydrocort Hydrocotisone 300mg TID IN
Neb. duolin
budecort
Budesonide
suspension
8TH HRLY Oral
Syp. Ascoril Levosalbutamol+
ambroxol+
guanaifenesin
6ml TID Oral
Tab. montek Levocetrizine +
montelukast
100ml OD Oral
Tab. orofer Ferrous ascorbate OD Oral
Tab. sporolac Lactic acid bacillus 500mg TID Oral
DAY 1

6. DAY 2 • B.P - 150/60 mmHg
• P.R – 115 bpm
• Temp - afebrile
• SpO2 - 92%
• C/O - SOB
• MEDICATION - C.S.T (DAY 1)

7. T.WBC 9800
Neutrophile 68%
lymphocyte 28%
esinophiles 2%
basophliles 3%
monocytes 2%
ESR 20mm/h
Hb 8.7
ALT (0-35) 49
AST(0-35) 47
ALP(30-
120)
106
bilirubin T
(0.1-
1mg/dl)
1.8
bilirubin D
(0-0.2
0.8
albumin
:globulin
3:1
HEMATOLOGY LIVER FUNCTION TEST

8. DAY - 3
• B.P -140/80mmhg
• P.R - 103bpm
• Temperature - Afebrile
• Spo2 - 96%
• MEDICATION : C.S.T as DAY-1
DAY - 4
• B.P - 140/80mmhg
• P.R- 103bpm
• Temperature- Afebrile
• Spo2- 96%
• MEDICATION:- C.S.T as DAY-1

9. DAY - 5
• B.P - 130/60mmhg
• P.R - 86bpm
• Temperature - Afebrile
• Spo2 - 96%
• C/O - Throat pain while swallowing
• MEDICATION - C.S.T as DAY-1
DAY - 6
• B.P - 130/80 mmhg
• P.R - 90bpm
• Temperature- Afebrile
• Spo2 - 95%
• MEDICATION - C.S.T as DAY1+
TAB. AZITHROMYCIN

10. DICHARGE MEDICATION
Brand name Generic name Dose Frequency Route
Augumentin Amoxicillin 1.2g BD IV
Tab lasilactone Spirinolactone+
furosemide
20mg BD SC
Inj pan Pantaprazole 40mg OD IV
Inj Hydrocort Hydrocotisone 300mg TID IN
Neb Duolin
Budecort
Budesonide
suspension
8TH HRLY ORAL
Aap Ascort Levosalbutamol+a
mbroxol+
guanaifenesin
6ml TID ORAL
Tab.Azithromycin Azithromycin 500mg OD ORAL
Tab orofer OD ORAL

11. SOAP FORMAT
 SUBJECTIVE DATA:-
• A male patient aged 59yrs was admitted to hospital with the Complaints of fever since 2 days low
grade; fever is increasing more during night time
• SOB at exertion , cough with expectoration ; white colour sputum
• Medical history :- CHF ,anemia, CLD with ascites
• Medication history:- Patient forgot to bring the medications and do not remember the name of
medications
 OBJECTIVE DATA:-
• B.P - 150/100mmhg CNS - NAD
• P.R - 82bpm P/S - Soft, Hepatomegaly
• Spo2 - 95% R/S - BAE+
• CVS - S1S2 + B/L - Crepts +
• Temperature - Afebrile B/L - wheeze +

12. LABORATORY DATA
HEMATOLOGY LIVER FUNCTION TEST
T.WBC 9800
Neutrophile 68%
lymphocyte 28%
esinophiles 2%
basophliles 3%
monocytes 2%
ESR 20mm/h
Hb 8.7
ALT (0-35) 49
AST(0-35) 47
ALP(30-120) 106
bilirubin T
(0.1-1mg/dl)
1.8
bilirubin D
(0-0.2
0.8
albumin :globulin 3:1

13.  OTHER TESTS :
• ECHO Cardio graphic and colour Doppler test EF -60%
• U/S scanning
 ASSESSTMENT:
 Based on the signs & symptoms, laboratory data , patient history, and other
investigations the patient was assessed to have “LOWER RESPIRATORY TRACT
INFECTION - PNEUMONIA ’’

14. PLANNING: STANDARD TREATMENT PROTOCOL

16. TREATMENT GIVEN IN HOSPITAL
Brand Name Generic Name Dose Frequency Route
Augumentin Amoxicillin 1.2g Bd Iv
Tab Lasilactone Spirinolactone+
Furosemide
20mg Bd Sc
Inj Pan Pantaprazole 40mg Od Iv
Inj Zofer Ondansetron 4mg Tid Iv
Inj Hydrocort Hydrocotisone 300mg Tid In
Neb Duolin
Budecort
Budesonide
Suspension
8th Hrly Oral
Aap Ascort Levosalbutamol+
ambroxol+
Guanaifenesin
6ml Tid Oral
Tab Montek Levocetrizine+m
ontelukast
100ml Od Oral
Tab Orofer Od Oral
Tab Sporolac Lactic Acid
Bacillus
500mg Tid Oral

17.  PHARMACIST INTERVENTION:
• Drug-drug interaction was found with medication given
• Azithromycin +Ondensetron : Both increase QT interval. Avoid or use alternative drug
• ECG monitoring recommended with concomitant medication that prolong QT
interval etc
• Spironolactone +Hydrocortisone : Spironolactone will increase the level or effect of
hydrocortisone by Glycoprotein efflux transporter
• MINOR
• Hydrocortisone + Furosemide : Pharmacokinetic Synergism Risk Of Hypokalemia
• Hydrocortisone +Monletlukast : Hydrocortisone Decrease The effect of montelukast
• by affecting enzyme CYP3A4Metabolism

18. RATIONALITY OF PRESCRIBING :
There should be a thorough assessment and training of
knowledge of appropriate drugs or antibiotic therapy ; among
the healthcare workers including type of antibiotic dosage
and duration of treatment should be or to be recommended
by national guidelines

19. PATIENT COUNSELLING:
 ABOUT THE DISEASE : Pneumonia is an infection that inflames the air sacs in one or both lungs. The
air sacs may fill with fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and
difficulty breathing. A variety of organisms, including bacteria, viruses and fungi, can cause pneumonia.
ABOUT THE DRUGS :
•Inj. Augumentin dose 1.2 mg BD :
Mechanism of action - Augmentum binds to penicillin binding protein With in the bacterial cell and inhibit
bacterial cell wall synthesis
ADR- diarrhea nausea vomiting meiosis and hypersensitivity reaction
Monitoring parameters-monitor liver function test and renal function test cautiously use the drug
•Tab. Lasilactone dose 20 mgBD :
Mechanism of action- lasilactone contains a short acting diuretic and a long acting aldosterone antagonist
prevent the buildup of extra water in your body increase urine excretion
ADR –feeling confusion lack of energy headache
Monitoring parameters electrolyte monitoring renal function test monitoring

20.  Inj . Pan 40 mg OD
• MOA : it covalently bind to H+/K+ exchanging ATP ase in gastric parietal cells resulting in block age
of GASTRIC ACID secretion
• ADR- head ache, abdominal pain , dyspepsia
• Monitoring parameters : Mg levels
 Inj. Zofer dose 4mg TID
• MOA - Ondensetron block the action of 5HT receptor present on vagal nerve and certain areas of the
brain
• ADR – Headache, malaise, fatigue
• M.P - Monitor for decrease to bowel activity particularly inpatient with risk factor of GI obstruction
 Inj. Hydrocortisone
• MOA- It is a corticosteroid and acts as a corticosteroids receptor agonist; it decrease permeability to
capillaries and causes decrease in exudates
• Adr – glaucoma, hyperlipidemia, osteoporosis
• M.P : Lipid profile and Calcium levels

21.  Neb. Budecort 8th hourly
• MOA : it suppress the inflammatory responses and decreases airways hyperesponsivness ; they bind to
glucocorticoid on cytoplasm
• ADR : oropharyngeal cardidias and dyphome
 Tab . Azithromycin 500mg OD
• MOA : it binds to 50S ribosome of bacteria and inhibit translation of mrna thus interfere protein synthesis
of bacterial cell
• ADR : diarrhea nausea abdominal pain
 T. Sporolac TID
• MOA : sporolac is a combination of good bacteria and yeast it lowers the ph and produce lactic acid in
the intestine thus help in absorption of micronutrients and regulation of gastrointestinal tract
• ADR : flatulence abdominal bloating
 Syrup Ascoril dose TID
• It work by thinning and loosening mucus in the the airways clearing congestion and making breathing
easier
• ADR : Palpitation muscle cramp muscle cramp epigastric pain
• M.P : Monitor liver function test and renal function test

22. Inj. Duolin 8th hourly
• MOA : the combination of ipratropium bromide and levosalbutamol ipratropium bromide acts as
anticholinergic and antagonise the action of the acetylcholine. Salbutamol acts as beta 2 agonist
• ADR : tachycardia ,tremors, dizziness
• M.P : heart rate
 Tab. Orofer
• MOA : ferrous ascorbate work as a source of iron folic acid work by helping your body produce and
maintained new cells
• ADR : nausea, bitter taste. Diarrhea
• Avoid alcohol intake
 ABOUT LIFESTYLE MODIFICATION:
• Avoid smoking and excessive alcohol consumption
• Eat nutrient dense diet rich in unprocessed whole plant based food
• Exercise is though to activate immune cells, it helps to expel bacteria from the airways and reduce
stress
• Regular hand washing is recommended as a strategy for avoiding respiratory infection.