CASE PRESENTATION ON PNEMONIA AND COPD

1. CHIEF COMPLAINT: Mr. BRK is a 63 YOM, got admitted in the hospital on 09/03/2011 with breathlessness since 15 days.

2. SUBJECTIVE: y HPI: started present illness since 15 days as breathlessness and was in ICU and has been shifted to the room for further management. y y y PMH: HTN 5yrs PSH: No H/O previous surgeries SH: Smoking 15yrs

3. OBJECTIVE: y y ALLERGIES: No known drug allergy PHYSICAL EXAMINATION:

 GENERAL APPEARANCE: y y y  VITAL SIGNS: y y y y Pulse: 124 beats/min RR: 26breaths/min BP: 140/90mmHg Temp: Febrile Height: 5.6 Weight: 62kgs BMI: 22.0 kg/m2

 HEAD TO TOE EXAMINATION: y y y y y Skin: Normal Head: Normal EENT: Normal Neck: Normal Chest: Crackles in the mid zone and lower zone

y y y y y y y  CBC:

CVS: HTN Lungs: cough, sputum, SOB Abdomen: Soft Genitourinary: Normal Musculoskeletal/ neurological: Normal Endocrine: Normal

LABS:

TEST Hemoglobin Hematocrit RBC TLC Platelet count sodium Potassium Calcium 13.3 51 5.3 15000* 350 139 6.3* 2.23*

VALUES

NORMAL VALUE 13.0-18.0g/dl 39.0-54.0% 4.2-6.5 million/ml 4000-11000 cells/cumm 140-440103/mm3 135-145 mmol/L 3.5-5 mmol/L 4.36-5.20 mEq/L

 RENAL PACAKGE:
TEST Urea Creatinine Albumin Prealbumin VALUES 76* 2.9* 3.3* 32 NORMAL VALUE 15-38mg/dl 0.5-1.2mg/dl 3.5-5g/dl 18-45mg/dl

 URINE ANALYSIS :
TEST Sp. gravity pH VALUES 1.015* 5 NORMAL VALUE 1.016-1.026 4.6-8

y y y y y y y y y y y y

Color: Pale yellow Transparency: Clear Reaction: Acidic Glucose: negative Blood: negative Ketone: negative Bile pigments: negative Bile salts: negative Protein: 1+ Urobilinogen: Normal Nitrite: negative

 RADIOMETER ABL800 BASIC: Blood gas values:

TEST pH PCo2 PO2 VALUES 7.487* 22.2* 139* NORMAL VALUE 7.350-7.450 35.0-45.0 mmHg 83.0-108 mmHg

 CHEST X- RAY: showed bilateral basal crackles which suggested pneumonia. Diagnostic tests: CBC, renal package, urine analysis, radiometer, chest X ray Diagnosis: Pneumonia with acute exacerbation of asthma, COPD

y y

 CLINICAL PRESENTATION OF THE PATIENT: As soon as the patient was admitted the vitals were checked and started with the following medications.

DRUG

GENERIC NAME

DOSE

ROUTE

FREQUENCY INDICATION

Inj. AUGMENTIN

Amoxicillin and clavulanate potassium

1.2g

IV

OD

Antibiotic

Inj. Hydrocortisone HYDROCORTISONE acetate Inj. PANTODAC T. SYNASMA Pantoprazole Doxofylline Levosalbutamol and Ipratropium Bromide BUDECORT Inj. DERIPHYLLIN Inj. GLEVO Syr. AMBROXOL Budesonide Theophylline Levofloxacin Ambroxol hydrochloride T. MINIPRESS XL Prazosin hydrochloride T. DOLO Paracetamol

100mg

IV

BD

COPD

40mg 400mg (1/2 tab)

IV PO

OD OD

PPI Asthma

DUOLIN

2U

Nebulisation

Q 6hrly

Bronchospasm

1U 1 amp 500mg 2 tsp

Nebulisation IV IV PO

Q 8hrly TID OD TID

COPD Bronchospasm Antibiotic Mucolytic

2.5mg

PO

OD

Hypertension

650 mg

PO

TID

Antipyretic

On admission, the patient had elevated body temperature hence T. DOLO was given on 09/03/2011 and 10/03/2011. On 09/03/2011, the patient had severe SOB which was uncontrolled by the duolin and Budecort nebulisations, hence Inj. DERIPHYLLINE was started immediately and continued till 10/03/2011.

4. ASSESSMENT: y y Pneumonia: Inj. Augmentin and Inj. Glevo were given Severe COPD: Duloin and Budecort nebulisations were given along with Inj. Hydrocortisone. y Hypertensive from the past 5 years and was on T. MINIPRESS XL which was continued during his stay in the hospital. Goal BP<130/80 mmHg. y Fever: Paracetamol was given in order to reduce the elevated body temperature due to the infection. y Syr. AMBROXOL makes the sputum thinner and less viscous and therefore more easily removed by coughing.

5. PLAN: y y y y y y y Check for the improvement in respiratory status. Check for the ability to perform activities including exercise. Should be monitored for tachycardia, hypotension, changes in potassium and glucose. Monitor the BP levels. Goal BP < 130/80 mmHg Perform chest X ray and check for the status of pneumonia. Check TLC count, renal function tests and electrolytes. Assess the adherence to the therapy.

DISCHARGE MEDICATION AND COUNSELING: Patient had improvement in symptoms and was found to stable. Hence, was discharged on 16/03/2011 with the following medication and was asked to review after two weeks.

PRAZOSIN (T. Minipress XL) 2.5mg 1 tab, PO, OD for HTN. To be taken at bedtime after food. Seek the physician in case of weakness, light headedness, dizziness and palpitations.

LEVOSALBUTAMOL( Levolin inhaler)- 1 puff, TID at 6am, 12pm and 6pm. Seek medical advice in case of tachycardia, hypotension, and changes in either serum potassium or glucose. Patients receiving albuterol should be monitored for improvement in respiratory status. Treatment should be reviewed every 3 to 6 months and a stepwise reduction of therapy prescribed when possible.

TIOTROPIUM ( Tiova inhaler): 2 puffs, OD at 2pm. Consult the physician in case of corneal edema and blurred vision.

SALMETEROL AND FLUTICASONE (Seroflo inhaler): 2 puffs, BD at 8am and 8pm.Consult the doctor in case of repeated headaches, tremor and palpitations.

DOXOFYLLINE (T. Synasma): 400mg tab, PO, OD. Monitor the plasma doxofylline level. Consult the doctor in case of Nausea, vomiting, diarrhea, and headache. AMBROXOL (Syr. Ambroxol): 2tsp, PO, TID after food.

If a dose is missed: If you miss a dose or forget to use your medicine, use it as soon as you can. If it is almost time for your next dose, wait until then to use the medicine and skip the missed dose. Do not use extra medicine to make up for a missed dose.