A

Pharmacology
Oriented Case
Study

Radika Wheeler
The case study of Mr. Cough C. Lot, a 32
year old male living with cystic fibrosis,
admitted to the hospital with abdominal
pain.

Francis Tuttle
Technology Center
Respiratory Care
Pharmacology
Spring 2010
 Radika Wheeler2

Study Summary

Respiratory Diseases:
#1 Cystic Fibrosis
#2 Pseudomonas aeruginosa infection

Non-Respiratory Disease:
#3 Diabetes (type II)
#4 Distal Intestinal Obstruction Syndrome

Complications:
Respiratory – Pneumothorax
Non-respiratory – Nausea and vomiting

Drugs:
Disease #1 Cystic Fibrosis
• Pulmozyme
• Albuterol sulfate

Disease #2 Pseudomonas aeruginosa infection

• Azithromycin

Disease #3 Diabetes
• Insulin

Disease #4 Distal Intestinal Obstruction Syndrome

• GoLytely

Complications
• Versed during chest tube placement
• Promethazine
 Radika Wheeler3

Mr. Cough C. Lot

Presenting History and Physical:

Mr. Lot presented to the emergency room complaining of extreme

abdominal pain, nausea, and constipation. He also complains of
chills, decreased appetite and abdominal enlargement.

Mr. Lot has a history of cystic fibrosis which he treats at home with
aerosolized Pulmozyme BID, Hypertonic saline, and CPT.

Physical exam shows the following findings:

Subjective: A slightly emaciated middle aged male that appears to be

experiencing abdominal pain with respiratory distress and use of
accessory muscles.

Objective: 5’11’’ male Weight 140 HR 122, RR 28 with bilateral

coarse crackles and diminished basilar breath sounds also RUL fine
crackles. Gastric sounds are present but diminished in right lower
quadrant. Temp 102.5 orally. Heart arrhythmias are tachycardia.
Abdominal palpations find a firm regular mass in the right lower
quadrant that is sensitive to pressure. Pulse oximetery shows
saturation of 84%.

Laboratory:

CBC with Diff Value Normal

WBC 16,000 µL 4,5000 –11,000 µL
RBC 6.5 x 106 µL 3.8 – 5.7 x 106 µL
H/Hb 20 g/dL 13.5 – 17.0 g/dL
Neutro 86% 35-73%
Lymphocytes 44% 15-52%
 Radika Wheeler4

ABG Value Normal

pH 7.47 7.35 – 7.45
PCO2 45 35 - 45
PO2 58 80 - 100
HCO3 31 22-26
Sat 84% > 90%

Triglyceride Panel
LDL 150 <130
HDL 70 >60
Total Cholest. 220 <200
Triglycerides 220 <150 mg/dL

Chest X-ray: Bilateral interstitial infiltration and RUL consolidation

Sputum Culture Gram negative rod shaped bacterium

positive for Pseudomonas aeruginosa

Glucose 230mg/dL 82 - 110 mg/dL

 Radika Wheeler5

Assessment:
Patient is in respiratory distress with a moderate hypoxemia. Chest x-
ray demonstrates a possible lobar pneumonia with infiltration caused
by cystic fibrosis .Increased WBC indicated possible infection. Patient
may have appendicitis. Patient is presenting hyperglycemia due to
possible unmanaged diabetes.

Plan:
Admit to hospital on 25% venturi mask with continuous pulse
oximetry. Begin Azithromycin until sputum specimen can be obtained
and identified. Give 2.5 mg Pulmozyme BID. Give 5.0 mg Albuterol
sulfate and CPT Q4.Give two units of insulin to correct hyperglycemia
and start IV fluids. Perform abdominal ultrasound to rule out
appendicitis STAT.

Abdominal ultrasound: Appendicitis has been ruled out but

there appears to be a large intestinal
blockage seen in the ascending colon.

Assessment: Distal Intestinal Obstructive Syndrome.

Plan: Treat DIOS with Golytely.

Progress Note Day 2:

Subjective:
Patient’s abdomen is less tender and palpations do not detect a
large mass. Patient says his abdomen feeling better after having
numerous bowel movements last night. Patient complains of
nausea and vomiting.

Objective:
HR 98 RR 12 with bilateral coarse crackles diminished basilar
breath sounds and RUL fine crackles. Gastric sounds are present.
Heart sounds regular rate and rhythm. Temp is 99.3 orally. Pulse
oximetery shows a saturation of 94%.
 Radika Wheeler6

Laboratory:
ABG Value Normal
pH 7.39 7.35 – 7.45
PCO2 52 35 - 45
PO2 65 80 - 100
HCO3 31 22-26
Sat 94% > 90%

Glucose 105 mg/dL 82 - 110 mg/dL

Assessment:
Patient is experiencing some nausea. Blockage appears to be
resolving.

Plan:
Discontinue GoLytely. Treat nausea with promethazine. Continue
to follow abdominal mass for resolvement.

Progress Note Day 3:

Subjective:
Patient is complaining of breathlessness and a sharp pain by his
right upper lobe.

Objective:
Patient is exhibiting respiratory distress. HR 156 /RR 36
/Diminished breath sounds on the RUL. Patient’s trachea has
deviated to the left. Chest percussion reveals tympanic sound over
the right upper lobe.

Assessment:
Patient has a suspected pneumothorax.

Plan:
CXR STAT
Lab:
 Radika Wheeler7

Chest X-ray: Air present in right pleural cavity. Pneumonia appears

to be resolving.

ABG Value Normal

pH 7.25 7.35 – 7.45
PCO2 69 35 - 45
PO2 40 80 - 100
HCO3 31 22-26
Sat 75% > 90%

Treatment:
Chest tube with patient receiving versed during placement.

Progress Note Day 4:

Subjective:
Mr. Lot appears to be doing fine. His appetite has returned. His
abdomen is not tender. He is not short of breath.

Objective:
HR 88 RR 20 BP 120/80 Breath sounds: Faint bilateral course
crackles. Temp 98.6 F orally. Heart sounds regular rate and
rhythm. Chest tube placement is good. Abdominal palpations
appear normal.
 Radika Wheeler8

Assessment:
Patient’s collapsed lung is still being treated with the chest tube.
Patients DIOS appears to be corrected. Pneumonia appears to be
responding to antibiotics.

Plan:
Remove chest tube when pneumothorax has resolved.

Lab:
ABG Value Normal
pH 7.38 7.35 – 7.45
PCO2 52 35 - 45
PO2 68 80 - 100
HCO3 31 22-26
Sat 95% > 90%

Progress Note Day 5:

Subjective:
Patient is feeling better and wants to go home.

Objective:
HR 80 RR 16 BP 120/80 Breath sounds faint bilateral course
crackles to auscultation. Trachea is midline.

Assessment:
Pneumothorax has been treated.

Plan:
Remove chest tube and send patient home. Continue aerosolized
Pulmozyme and Albuterol at home.
 Radika Wheeler9

Disease Summaries:

Cystic Fibrosis
• Etiology

Cystic fibrosis is an autosomal recessive trait. Both parents

must carry at least one of the recessive forms of the gene to
pass it on, but in order for the child to express that form of the
mutation, they must inherit that particular gene from each
parent. The gene responsible is found on the long arm of the
seventh chromosome. This gene encodes a particular protein
responsible for transference of chloride across the cell
membrane, but due to a deletion of three bases, that protein is
never produced. This particular known cause of CF accounts
for 70% of all the CF cases (Cystic Fibrosis). The rest of the
cases of CF are caused by over 300 other mutations of this
gene.

• Pathophysiology

There are several debates about the pathophysiology of this

disease, but no absolute knowledge to how this disease affects
the biochemical functions of the human body as of yet.

• Clinical signs

The earliest sign which occurs at birth is meconium ileus, which

is a small bowel obstruction resulting from thick stool. Other
signs include a chronic cough, foul-smelling stools, frequent
diarrhea, and reoccurring upper respiratory infections.

• Diagnostic test

Patients in which CF is suspected undergo a sweat test. This is

when a clean patch of skin is covered with plastic, warmed up,
and the sweat is measured for the amount of salt present. A
chloride concentration > 60mEq/L is abnormally high and
usually results in a positive diagnosis of CF.
 Radika Wheeler10

• Treatment

Depending on each patient’s symptoms, treatment can include

oral enzyme replacements, mucolytics, insulin injections,
expectorants, antibiotics, steroids, and a recent study even
indicated ibuprofen therapy to reduce airway edema. There is
no cure for CF; the only thing possible right now is to treat the
symptoms.

Diabetes
• Etiology

Type II diabetes has two known factors. One is impaired insulin

release following a meal especially if it was high in
carbohydrates. There is a very strong genetic factor in type II
diabetes. The second reason for type II diabetes is insulin
resistance, where the receptor sites of the cells become
defective. Insulin resistance can occur with obesity and/ or
pregnancy.

• Pathophysiology

Type II diabetes is an inherited trait that is commonly seen in

Native American, Hispanic-American, and Asian-American
populations. “The pathophysiology of type 2 diabetes mellitus is
characterized by peripheral insulin resistance, impaired
regulation of hepatic glucose production, and declining ß-cell
function, eventually leading to ß-cell failure” (Adler, 1999)

• Clinical signs

Clinical signs include: Increased thirst, frequent urination, dry

mouth, fatigue, headache, weight loss, blurred vision, and even
unconsciousness.

• Diagnostic tests
 Radika Wheeler11

Diabetes can be identified by any of these three tests: a fasting

blood plasma > 126 mg/dL, a casual glucose level >200 mg/dL,
or an oral glucose tolerance test >200 mg/dL after 2 hours.
There must be a second positive test on a different day to
confirm the diagnosis.

• Treatment

Type II diabetes can be non-insulin dependent with patients

who watch their diet and exercise.

Distal Intestinal Obstructive Syndrome

• Etiology

Distal intestinal obstructive syndrome, or DIOS for short, is to

children and adults as Meconium ileus is to newborns. The lack
of pancreatic enzymes in CF patient’s bowels cause food not to
breakdown and become thick and sticky in the gut.

• Pathophysiology

DIOS is often seen in patients with CF. Due to the thick, sticky
nature of their stools, it is easy to get an accumulation of stool
in the intestines resulting in a complete blockage.

• Clinical signs

Symptoms include nausea, vomiting, lack of appetite or feeling

of fullness, watery stools, stomach cramps, and pain around the
belly button.

• Diagnostic tests
 Radika Wheeler12

An abdominal ultrasound may be done to rule out appendicitis

which can have similar symptoms. An abdominal x-ray can also
detect DIOS.

• Treatment

Extreme cases of DIOS may require immediate surgery to

correct the problem. Otherwise, laxatives and stool softeners
may be used to treat the obstruction.

Pseudomonas a. Pneumonia

• Etiology

Pseudomonas is a gram negative rod bacterium.

• Pathophysiology

Pseudomonas is a water loving bacterium that is opportunistic

to people with CF, patients on ventilators attached to
humidifiers, and immune compromised patients. Pseudomonas
usually presents itself as an upper respiratory infection.
Normally, healthy people do not contract pseudomonas.

• Clinical signs

Symptoms include: fever, chills, severe dyspnea or dyspnea on

exertion, cyanosis, productive cough, confusion, increased
WBC count, hypoxemia, and fluffy white areas on x-ray.

• Diagnostic tests

CBC can show an infection by having an increased WBC count.

CXR will show if there is infiltrates in the lungs. Only a sputum
specimen that is sent for cytology can test that it is a
pseudomonas infection and not any other bacteria.
 Radika Wheeler13

• Treatment
Because of an increased frequency of antibiotic resistant
pseudomonas, normal antibiotics are usually not used. A more
powerful aminoglycoside is used to treat pseudomonas
infections.

Drug Summary

Pulmozyme:
• Classification
o mucolytic
• Mode of action
o Purulent secretions contain very high concentrations of
extracellular DNA. Pulmozyme is a genetically engineered
version of a naturally occurring human
enzyme which cleaves extracellular DNA, this causes the
“cut up” DNA to react with water and make the sputum
less viscous.
• Clinical Usage
o Management of cystic fibrosis (CF) patients to
improve pulmonary function.
• Dosage
o Pulmozyme contains 2.5 mg dornase alfa in 2.5 mL
solution
• Contraindications
o Pulmozyme should not be administered to patients with
known hypersensitivity to the active ingredient
or its additives.
• Hazards
o No known hazards
• Drug interactions
o Pulmozyme can be used safely in conjunction with
standard cystic fibrosis therapies

Albuterol Sulfate
• Classification
o Sympathomimetic, bronchodilator
 Radika Wheeler14

• Mode of action
o Albuterol stimulates B2 receptors which increase cyclic
AMP and cause bronchial relaxation
• Clinical Usage
o To treat acute wheezing caused by bronchospasms
• Dosage
o Albuterol contains 2.5 mg of Albuterol sulfate in 3 mL
solution
• Contra-indications
o Prior hypersensitivity reaction to Albuterol and Cardiac
dysrhythmias associated with tachycardia
• Hazards
o Restlessness, apprehension, dizziness, palpitations,
increase in BP, dysrhythmia, vomiting
• Drug interactions
o Beta blocking drugs may inhibit Albuterol

Azithromycin
• Classification
o Antibiotic
• Mode of action
o By suppressing the RNA-dependent protein, inhibiting
bacterial growth
• Clinical Usage
o To treat patients with mild to moderate bacterial
infections
• Dosage
o 500 mg daily for three to five days
• Contra-indications
o in patients with known hypersensitivity a ketolide
antibiotic.
• Hazards
o Anaphylaxis, CDAD

• Drug interactions
o Co-administration of nelfinavir has shown an increase in
liver enzymes and possible hearing loss.
 Radika Wheeler15

Insulin
• Classification
o Anti diabetic agent
• Mode of action
o Attaches to cell call receptors and helps the cell take up
blood sugar to reduce the amount found in blood
• Clinical Usage
o To treat type 1 and type 2 diabetes mellitus
• Dosage
o As a general rule of thumb, 1 unit of insulin should
decrease blood glucose by 50 mg/dL
• Contra-indications
Hypoglycemia
• Hazards
o No known hazards
• Drug interactions
o Taking oral ant diabetes products, ACE inhibitors, MAO
inhibitors, and sulfonamide antibiotics may increase the
effect of insulin on the body, thereby causing the patient
to become hypoglycemic.

GoLytely
• Classification
o Laxative
• Mode of action
o The high sodium and ion concentration draws water out of
the body and into the digestive tract.
• Clinical Usage
o To treat bowel obstructions, and to prep patients for
invasive procedures such as colonoscopies
• Dosage
o Golytely contains 125 mEq/L sodium, 10 mEq/L
potassium, 20 mEq/L bicarbonate, 80 mEq/L sulfate, 35
mEq/L chloride and 18 mEq/L polyethylene glycol 3350
mixed with water to make 4 L of solution.
 Radika Wheeler16

• Contra-indications
o In patients with ileus, gastrointestinal obstruction, gastric
retention, bowel perforation, toxic colitis or toxic
megacolon.
• Hazards
o Allergic reaction, nausea, and vomiting.
• Drug interactions
o Drugs given orally within the first hour of administering
GoLytely may not be absorbed.

Versed
• Classification
o Sedative-hypnotic, benzodiazepine, CNS depressant
• Mode of action
o Increase the effects of gamma-aminobutyric acid, which
has a naturally calming effect
• Clinical Usage
o Used as a sedative, to treat anxiety, or anesthesia
medication used before or during surgeries, medical
procedures, or dental procedures
• Dosage
o Varies depending on age, weight, level of sedation
• Contra-indications
o Allergies to the medicine
• Hazards
o Apnea, hypotension, allergic reaction.
• Drug interactions
o Alcohol, antidepressants, antipsychotics, barbiturates,
narcotics, other benzodiazepines, seizure medication,
and sleep medication

Promethazine
• Classification
o Antihistamine
• Mode of action
o Decreases allergic response by blocking histamine
receptors
• Clinical Usage
 Radika Wheeler17

o Used to treat nausea, allergy symptoms, and used as a

sleep aid.
• Dosage
o 25 mg tablet
• Contra-indications
o If the patient is allergic to any ingredient in Phenergan,
CNS depression, coma, COPD, or sleep apnea, if the pt
is also taking astemizole, cisapride, terfenadine, or
tramadol
• Hazards
o Urinary retention, severe respiratory depression
• Drug interactions
o Prolong other CNS depressants, MAOI inhibitors
 Radika Wheeler18

Works Cited
Adler, R. J. (1999). Type 2 Diabetes Mellitus: Update on Diagnosis,
Pathophysiology, and Treatment . The Journal of Clinical Endocrinology
& Metabolism , 84 (4).

Cystic Fibrosis. (n.d.). Retrieved May 19, 2010, from

http://www.nku.edu/~rad350/cysticfibrosissc.html

Drug summaries were made with help from www.Drugs.com