Thursday, April 4, 2019

Case Study: Patient With Asthma

Case Study Patient With asthmaPatient RR is a 58 years old female with a weight of 55kg. Patient was admitted to hospital on 9th April 2009. Her presenting complaints were cough with sputum, pain when inhaling transmit at chest, breathless and unable to speak in full sentence. Her past medical histories were hypercholesterolemia, bronchial bronchial asthma and she has no known drug allergy. For her social write up, she works as a security guard and is bread and butter with her husband. She is a non smoker as well as non alcoholic and she has no known family history.Patients drug history include timeed dose inhaler (MDI) salbutamol 200mcg as required, MDI budesonide 400mcg twice twenty-four hour periodtime-by- daytime, theophylline SR launch area 250mg once daily and lovastatin tablet 20mg once daily.InvestigationsBlood Test9th April12th AprilWBC10.9109/L12.9109/L juicy (4-10.0)RBC4.821012/L4.91012/LHigh (3.8-4.8)MCV78.7 fl/ stall78.6 fl/cell baseborn (83-101)MCH26.5 pg/cell2 5.3 pg/cellLow (27-32)ESR24 mm/hrHigh (0-20)Blood HbA1c7.2%Good oblige 8.0%Renal indite9th April11th AprilPlasma K+2.8 mmol/L2.5 mmol/LLow (3.5-5.1)Creatinine100 mol/L79 mol/L(58-96)Blood test indicated that the level of white declination cell and erythrocyte bank deposit rate is higher than conventionality which suggests the diligent of had an infection. The blood HbA1c showed adequate control of blood glucose. On the opposite hand, the renal test showed that the patient had low plasma kelvin and the plasma creatinine level is normal.Clinical march onOn examination, the patient was alert with no pedal oedema. Her pulse rate was 120 beats per present moment, blood pressure was 130/62 mmHg, and respiratory rate was 22 breaths per min. She was diagnosed with penetrative exacerbation bronchial asthma secondary to upper respiratory tract infection. The plan was to give intravenous (IV) hydrocortisone 200mg immediately past 100mg three times daily, IV Augmentin 1.2g three ti mes daily, nebulizer atrovent ventolin normal saline (AVN) 212 every two hours and to continue SPO2 monitoring.On day 1, the patient was given MDI Budesonide 400mcg, nebulizer AVN, IV hydrocortisone 100mg three times daily, bromhexine tablet 8mg three times daily, erythromycin tablet 400mg twice daily, prednisolone tablet 40mg once daily, oxygen 3L/min and lovastatin tablet 20mg once daily. theophylline were stopped.On day 3, patients blood pressure was 120/70 mmHg, respiratory rate was 26 breaths per minute and the SPO2 was 98%. She has cough with yellow sputum and the sputum culture showed that there are no pathogen isolated. The patient was to start on long acting beta agonist (LABA). Other medications that were given include potassium tablet 1.2g twice daily, Neb Combivent 4 hourly, IV Augmentin 1.2g three times daily, MIST expectorant 15mL three times daily. Hydrocortisone and bisolvon were stopped.On day 4, the patient had fever, cough with yellow sputum and difficultness in breathing. No new action was taken.On day 6, patient had no more fever but still had cough with yellow sputum. Her blood pressure was 122/80 mmHg and respiratory rate was 20 breaths per minute. The plan was to give MDI formoterol 9mcg once daily and augmentin tablet 625mg. Oxygen and prednisolone were stopped.On day 8, patient still had cough but the sputum turned white. Patient was given theophylline SR tablet 250mg twice daily and was ready to be discharged the next day.Medication Summary medicineDoseFrequencyIndicationT.Bisolvon8mgtds(stop at day 3)CoughMist Expectorant15 mLtds (day3-day 6)CoughT.Erythromycin400mgbd (stop on day 6)InfectionKCl solution20mLtds (stop on day 7)HypokalaemiaT.Prednisolone40mgod (stop on day 6)Acute asthmaT.Augmentin625mgtdsInfectionT.Lovastatin20mgodHyperlipidaemiaT.Nuelin SR500mgbdAsthmaOXIS inhaler (formoterol)9mcgodAsthmaMDI Budesonide400mcgbdAsthmaSalbutamol200mcgwhen requiredAsthmaPharmaceutical Care PlanCare PlanRecommendation desired Outcom e1. Monitor K+ level-high dose salbutamol and theophylline causes hypokalaemiaK+ level should be monitored. K+ supplement should be given if K+ level is low.Maintain stable potassium level.2. On day 4, patient had fever but not treated.Paracetamol should be given.To lower down patients temperature.3. Concurrent use of vocal prednisolone and IV hydrocortisone for acute treatment-If patient can tolerate orally, oral prednisolone should be adequate.-if cant, give IV hydrocortisone 100mg every 6 hour until conversion to oral is possible.4. confederacy inhaler can be given to patientSymbicort inhaler (1-2 puffs bd) can be given sort of of OXIS and budesonide inhaler. Besides that, Symbicort can be also given as relief to replace Combivent.Less surprise and increases compliance.5. Technique to use inhaler-Counsel patient on proper technique-advice on oral hygiene to bar oral candidiasis.6. Prophylaxis of asthmaCounsel patient to avoid allergen that may trigger attack and avoid NSAID s.Lowers risk of asthma attack7. Compliance issueAdvice patient on the importance to take control medication accordingly even if patient feels well.Lowers risk of asthma attackDisease Overview and Pharmacological dry land of Drug TherapyAsthma affects heap of all ages, but it normally starts at childhood1. Asthma affects 5-8% of the population virtually the world2. A study done by World Health Organization (WHO) shows that there are 15 million disability-adjusted life years lost yearly because of asthma, displaying 1% of total disease burden worldwide3. The yearly worldwide mortality ca utilise by asthma is estimated to be 250,000. In Scotland, the incidence of clinical asthma is about 18.4% of the population3.Asthma is an inflammatory disease where there is frequent reversible airway obstruction1. The narrowing of the airway happens when people with asthma react strongly to certain substance they breathe in. These irritant stimuli are too vulnerable to affect normal individual s1. The narrowing of airway is also caused by other factors which include mucosal pretentiousness or inflammation caused by inflammatory mediators released by mast cell and basophil degranulation as well as mucus or phlegm production2.The causes of asthma include genetic factor, environmental factor and history of etopic disorder5. The almost common symptoms of asthma are wheezing, shortness of breath, chest tightness and sometimes cough, especially at iniquity in younger people1, 4. The probability of asthma increased if symptoms worsen at night and early first light or in response to exercise, allergen and cold air5. Acute severe asthma may cause hypoxaemia and is not easily reversed. Therefore, the patient needs prompt treatment and hospitalization1.Patients with asthma have continuous and excessive T-helper cell type 2 (Th2)-dominated immune response and the Th1 which is responsible for structural and defensive status of the tissue is reduced4. The mad T-cells produce cytok ines in the bronchial mucosa and this attract other inflammatory granulocytes especially eosinophils which produce cysteinyl leukotrienes on with granule protein to damage epithelium. The cytokines released also promotes immunoglobulin E synthesis in some asthmatic patients which cause expression of IgE receptors on mast cell and eosinophils1, 4. The important mediators associated with asthma are leukotriene B4, cysteinyl leukotrienes (C4 and D4), interleukins IL-4, IL-5, IL-13 and tissure-damaging eosinophil proteins1. In atopic asthmatic patients, inhaled allergen caused cross-linking of IgE molecules on mast cells hence activating degranulation with histamine and leukotriene B4 release. These substances are powerful bronchoconstrictors thus causing acute exacerbation of asthma1.For diagnosis of asthma, spirometry is the preferable initial test5. It is a device to measure the functional lung volumes. Through the patients full force expiration into the device, the agonistic expi ratory volume in 1 second (FEV1) and force vital capacity (FVC) are measured. termination continues until there is no more breath to be exhaled. The FEV1/FVC ratio shows the severity of airflow obstruction and the normal ratio is 75-80%2. The ratio is less than 75% in asthma which indicates obstructive defect. There is normally more than 15% improvement in FEV1 after administration of B2 agonist or steroid trial in asthma patients2. Peak expiratory flow (PEF) is also another test for asthma though FEV1 uses lesser effort2. It is measured by the maximum forced expiratory through a peak flow meter and acts as an estimate of airway calibre. PEF is measured frequently to check response to treatment and disease control. PEF is used to test acute and chronic asthma with PEF decreases along with severity2.Moderate acute asthmaSevere acute asthmaLife-threateningAble to talk, Respiratory rate (RR)50-75%Incomplete sentence, RR25/min, SPO2110/min, PEF 33-50%Silent chest, cyanosis, exhaustion, confusion, feeble respiratory effort, SPO2

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