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Asthma
August 2, 2013 Talanquines, Daryl Talplacido, April Cherisse Tan, Joseph Tan, Katherine
Scenario
CD, 52 yo, female Chief Complaint: severe wheezing, shortness of breath and coughing HPI: serious motor vehicle accident 10 weeks ago; frequent asthma attacks for the past 2 months; post traumatic seizure 2 weeks after the accident
Past Medical History: - Periodic asthma attacks since early 20s - Mild CHF (3 years) Family History: -Mother (deceased at age 62) CHF -Father (deceased at age 59) kidney failure secondary to hypertension
Social History: - Caffeine use: 4 cups of coffee and 4 diet colas per day Medication History: - Theophylline SR capsules, 300mg PO BID - Albuterol inhaler, 2 puffs PRN - Phenytoin SR capsules - Hydrochlorothiazide tablets, 50mg PO BID - Enalapril tablets, 5mg PO BID
Allergies: NKDA Physical Examination: GEN: pale, well-developed, anxious-appearing woman VS: ED admission: BP 171/94, RR 31, HR 122, T 38.5C, Wt 61kg, Ht 161cm Current: BP 142/79, HR 80, RR 18, T 38.3C HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation; no nystagmus noted; positive for AV nicking
COR: no murmurs, normal S1 and S2 CHEST: bilateral expiratory wheezing ABD: nontender, non distended, no masses GU: unremarkable EXT: 1+ ankle edema on right, no bruising, normal pulses NEURO: Ox3; CN intact
Laboratory result
Theophylline: 62 ug/mL Phenytoin: 17 ug/mL Pulmonary Function Tests: FEV1 1.8; FVC 3.0; FEV1/FVC: 60% Initial Peak Flow: 75/min 2nd reading (1hr after treatment): 102/min ECG: Voltage changes consistent with LVH Chest X-ray: blunting of the right and left costophrenic angles
Problem List
1) 2) 3) 4) Asthma Theophylline toxicity Congestive Heart Failure Seizure disorder
Asthma
Problem 1
Talplacido, April Cherisse A.
Problem 1: Asthma
Objectives: 1) To be able to define Asthma and review its pathogenesis and its pathophysiology 2) To be able to enumerate its clinical manifestations and establish the basis for the disease 3) To be able to come up with a treatment objective and give the nonpharmacological and pharmacological approach 4) To be able to prescribe a drug suitable to the patients profile
What is Asthma?
Chronic inflammatory disorder of the airways. trachea to the terminal bronchioles Many cells are involved: - T-lymphocytes, eosinophils, mast cells, macrophages, and neutrophils
Major etiologic factors: predisposition to type I hypersensitivity acute and chronic airway inflammation bronchial hyper responsiveness
Types of Asthma
1. 2. 3. 4. Atopic Asthma Non-Atopic Asthma Drug-induced Asthma Occupational Asthma
Clinical Manifestations
Recurrent episodes of: Wheezing Dyspnea Chest tightness Cough
Diagnosing Asthma
History and PE Measurements of lung function Spirometry measures airflow limitation and its reversibility An increase in FEV1 of 12% and 200 ml after administration of a bronchodilator indicates reversible airflow limitation consistent with asthma. Peak Expiratory Flow (PEF) measurements An improvement of 60 L/min (or 20% of pre-bronchodilator PEF) after inhalation of a bronchodilator.
Therapeutic Goals
prevent chronic asthma symptoms and asthma exacerbations maintain normal activity levels normal or near normal lung function experience no or minimal side effects patient satisfaction with asthma care.
Four interrelated components of therapy are required to achieve and maintain control of asthma: Develop patient/doctor partnership Identify and reduce exposure to risk factors Assess, treat and monitor asthma Manage asthma exacerbations
Non-pharmacologic Approach
In the hospital Evaluate symptoms and, as much as possible, peak flow. Assess oxygen saturation; do ABG Initiate supportive care
Non-pharmacologic Approach
On follow up Develop patient-doctor partnership for the patient to learn to: Identify risk factors/triggers Understand the difference between controller and reliever medications Take medications correctly Monitor their status using symptoms and, if relevant, PEF Recognize signs and to take action when asthma is worsening Seek medical advice as appropriate Reduce exposure to risk factors
Pharmacologic Approach
Relievers - Reverse airflow obstruction - Quickly relieve accompanying symptoms
Reliever
Short-acting beta-2 agonist Anti-cholinergics Short-acting theophylline
Efficacy
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Suitability
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Safety
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Cost
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Controller
Budesonide Budesonide + Formoterol Fluticasone propionate
Efficacy
++
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Suitability
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Safety
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Cost
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P drug: Budesonide
THEOPHYLLINE TOXICITIES
Katherine Mae Tan
THEOPHYLLINE toxicities
Salient Features: 4 cups of coffee and diet colas per day Anxious appearing woman HR 122; RR 31 ; T= 38.5 (ED)
THEOPHYLLINE toxicities
K+ (3.5-5.0mEq/L) 4.9 mEq/L normal
normal
normal
decrease
normal
OBJECTIVE
1. Relieve the patient symptoms related to Theophylline toxicity
OBJECTIVE
1. Relieve the patient symptoms related to Theophylline toxicity 2. Monitor serum concentration level and reduce or eliminated the toxicity level of Theophylline
OBJECTIVE
1. Relieve the patient symptoms related to Theophylline toxicity 2. Monitor serum concentration level and reduce or eliminated the toxicity level of Theophylline 3. To educated patient on proper use of asthma medication to prevent further complications
OBJECTIVEs
1. Relieve the patient symptoms related to Theophylline toxicity 2. Monitor serum concentration level and reduce or eliminated the toxicity level of Theophylline 3. To educated patient on proper use of asthma medication to prevent further complications 4. Reduce morbidity and mortality
Theophylline
One of the methylxanthine drugs (includes caffeine, theobromide)
Theophylline
One of the methyxanthine drugs (includes caffeine, theobromide) White ,odorless, crystalline powder with bitter taste Bronchodilator relieves airflow obstruction MOA : inhibit the cyclic nucleotide PDE high concentration of cAMP (smooth muscle relaxation)
Theophylline
One of the methyxanthine drugs (includes caffeine, theobromide) White ,odorless, crystalline powder with bitter taste MOA : inhibit the cyclic nucleotide PDE high concentration of Intracellular cAMP PKA activated (bronchodilation) : inhibition of cell surface receptors for non specific adenosine
Theophylline
Adenosine blockade reduces histamine release and indirectly reverse bronchospasm. ANTI INFLAMMATORY Inhibit the synthesis and secretion of inflammatory mediators from mast cells and basophils
Theophylline
Adenosine blockade reduces histamine release and indirectly reverse bronchospasm ANTI INFLAMMATORY Inhibit the synthesis and secretion of inflammatory mediators from mast cells and basophils Increases the IL-10
Theophylline
ANTI INFLAMMATORY Inhibit the synthesis and secretion of inflammatory mediators from mast cells and basophils Increases the IL-10 Promote apoptosis in Eosinophils and neutrophils perpuate chronic inflammation in asthma and COPD
Theophylline
ANTI INFLAMMATORY Inhibit the synthesis and secretion of inflammatory mediators from mast cells and basophils Increases the IL-10 Promote apoptosis in Eosinophils and neutrophils perpuate chronic inflammation in asthma and COPD Activates histone deacetylase Smokers,increase oxidative stress
Theophylline
Therapeutic serum levels :10-20 mcg/ml Toxic dose >20mcg/ml
THEOPHYLLINE
INDICATIONS COPD ASTHMA INFANT APNEA - Additional drug for uncontrolled asthma Nebulizer Antibiotic (if with bacterial infections) Steroids
THEOPHYLLINE
Precautions of administration of theophylline : RISK FACTOR Elderly CHF Liver Disease hypoalbuminemia Dose MUST be decreased and MONITOR CLOSELY!
THEOPHYLLINE
PHARMACODYNAMICS: CNS :
1.mild cortical arousal with increase alertness and deferral of fatigue 2. insomnia 3. HIGH DOSES: medullary stimulation and convulsions 4. Primary SE: nervousness and tremor
THEOPHYLLINE
PHARMACODYNAMICS: CVS :
1.Positive INOTROPIC and CHRONOTROPIC effects 2. ARRHYTHMIAS 3. Slight tachycardias and INCREASE CO 4. Rises PVR an BP
THEOPHYLLINE
PHARMACODYNAMICS: Lungs:
1. Increase the force of contraction of diaphragmatic muscle enhancement of calcium uptake through adenosine-mediated channel (increase RR) 2. Bronchodilation (5 to 20mcg)
THEOPHYLLINE
PHARMACODYNAMICS: GIT : stimulate gastric secretion and digestive enzymes KIDNEYS : Weak diuretics SKELETAL MUSCLES : improve contractility SMOOTH MUSCLES : inhibit the antigen-induced release of histamine from lung tissue
THEOPHYLLINE
PHARMACOKINETICS:
orally and parental administration distributed into all body compartments cross the placenta and pass into BM,CSF Bioavailabity 100% metabolized by liver (CYP1A2; CYP3A4) Unchanged in urine (5-15%) 40% -50% protein bound Usual dose: 3-4 mg/kg q 6 hrs
THEOPHYLLINE
T1/2 : 3.5 hrs children;
8 to 9 hrs adult 4 to 5 hrs smoker 12 hours CHF class III,elderly 24 hours CHF class IIIIV, hepatic impairment
THEOPHYLLINE
INCREASE HALF-LIFE (decrease clearance) Elderly .3rd trimester pregnancy Erythromycin, cimetidine, fluoroquinolones hypothyroidism Cirrhosis CHF Acute Pulmonary edema, pneumonia,influenza infections COPD Obesity High CHO, low protein High levels of methylxanthines (caffeine) DOSE DUMPING
THEOPHYLLINE
Decrease half life (increase CLEARANCE) PHENYTOIN, PHENOBARBITAL, rifampin barbiturates OC Smoking; marijauna Low CHO ; high CHON diet Hyperthyroidism Parenteral nutriotion Charcoal-broiled beef
Theophylline toxicity
Acute overdose >10mg/kg Chronic overdose (repeated doses that are excessive) Generalized seizure Life threatening cardiac arrhythmias Death Seizures, hypotension and dysryhtmias occurs ~ 80 mcg/ml
6. 7. 8. 9. 10.
Tachycardia Severe restlessness Agitation Fatal arrhyhtmias FOCAL AND GENERALIZED SEIZURES 11. sudden DEATH
THEOPHYLLINE
Electrolytes Hypokalemia Hyperglycemia Hypercalcemia Hypophosphatemia HYPOMAGNESEMIA
NON-PHARMACOLOGIC
STOP or WITHDRAW treatment Endotracheal intubation Hemoperfusion most effective Gastric lavage WBI Polyethylene glycol ECG monitoring ACTIVATED CHARCOAL mainstay treatment of theophylline toxicities ; block the absorption
0.5 g/kg up to 20 g
2 to 4 hours later
Pharmacologic
Medications for nausea and vomiting: Ondansetron (Zofran) Metoclopramide (Reglan) Prochlorperazine (Compazine)
Pharmacologic
Medications to control seizures: Diazepam (Valium) Lorazepam (Ativan) Midazolam (Versed) Phenobarbital (Barbita, Luminal) Medication to support abnormally low blood pressure: Phenylephrine (Neo-Synephrine) Norepinephrine (Levophed) Hemoperfusion or hemodialysis: Filtering the blood, in order to remove theophylline form the bloodstream
Cardiac Arrhytmias
Abnormal automaticity and abnormal conduction Not a normal sinus rhythm Tachycardia >100bpm Bradycardia <60 bpm
Non-pharmacological
Remove precipitating factors Fever Anxiety Theophylline Monitor ECG closely.
++(14-16) ++ (14-16)
Magnesium Oxide
cause hypotension depression myocardial conductivity bradyarrythmias. suppress the neuromuscular transmission diarrhea and nausea. Eliminated: renally and focally Duration 4 to 6 hours PO 140 mg (caps) 3 to 4 times/day or 400mg to 840 mg/day ) tabs
Katherine Mae A. Tan , M.D. Room 808, Right WING, MEDICAL ARTS BLDG CHINESE GENERAL HOSPITAL Tel no. 808-8888 Name : _____________________ AGE : ___________________ DATE:_____________ Address: _______________________________ Sex : _______
Sig . Take one tablet three times daily for 14 days Return after 14 days for check up.
Acetaminophen Efficacy Safety Suitability Cost ++ +++ +++ +++ (Tylenol 6.00)
P-drug Acetaminophen
Anti-pyretic and analgesic Weak COX1 and COX2 inhibitor Well absorbed Peak blood concentration: 30 to 60 mins Metabolized : hepatic microsomal enzyme Excretion unchanged <5% T1/2 : 2-3 hours Adverse Effects: hepatic toxicity Treatment for OD : N-acetylcysteine Dosage : 325- 500 mg tid
Katherine Mae A. Tan , M.D. Room 808, Right WING, MEDICAL ARTS BLDG CHINESE GENERAL HOSPITAL Tel no. 808-8888 Name : _____________________ AGE : ___________________ DATE:_____________ Address: _______________________________ Sex : _______
Paracetamol (500mg)
Basis
PMH Family/ Social history - Diagnosed mild CHF 3 yrs ago -father died of kidney failure - Na restricted secondary to diet hypertension - Hydrochlorthiazi -mother died of de CHF - Enalapril
Physical exam
General survey: Pale VS on admission BP: 171/94 RR: 31 HR: 122 Extremity 1+ ankle edema on right
ECG - Voltage changes consistent with LVH CXR - Blunting of the right and left costophrenic angles
HEART FAILURE
Inability of the heart to pump an adequate amount of blood to the bodys needs CONGESTIVE HEART FAILURE refers to the state in which abnormal circulatory congestion exists a result of heart failure
A disorder in which the heart loses its ability to pump blood efficiently throughout the body Affects Cardiac Output SV X HR
Intrinsic Pump Failure 1. 2. 3. 4. 5. Myocarditis Ischemic Heart Disease Cardiomyopathies Metabolic disorders Arrhythmia
Etiology
Increased workload on the heart Increased pressure load a) Hypertension b) Chronic lung disease a) b) c) d) Increased volume load Valvular insufficiency Severe anaemia Thyrotoxicosis Arteriovenus shunts
Compensatory Mechanisms
May lead to
TREATMENT OBJECTIVES
Increased Cardiac Contractility Alleviate Fluid Retention Prevent Disease Progression
NON-PHARMACOLOGIC TREATMENT
Light exercise Avoid heavy labor or exhaustive sports Monitor weight Na restriction
#30 tab
Sig. Take 1 tab once a day
Joseph Ivan B. Tan, MD Lic. No.: 123456 PTR No.: 9876
NOTE
Monitor Urine Output . Monitor for Fluid and Electrolytes Imbalances .
Sex:
Rx:
Losartan
#30 tab
Lic. No.:
123456 PTR No.:
9876
Digoxin
Inhibits Na/k ATPase increase of intracellular Na concentration increase Ca influx causing stronger systolic contraction
Date: July
Sex: female Age:
#14
Sig. Give 0.5ml every 6 hours per day for one week. Joseph Ivan B. Tan, MD Lic. No.: 123456 PTR No.: 9876
NOTE
Monitor Digoxin level and look for digitalis intoxication ( Anorexia, Nausea and Vomiting ) then give Digitoxin Ab (Fab fragments) for treatment Monitor Potassium Level
SEIZURES
By: Daryl O. Talanquines
Definition
A seizure (latin sacire, to take possession of)
CLASSIFICATION OF SEIZURES
This system is based on: CLIN. FEATURES EEG FINDINGS Other potentially distinctive features not included: ETIOLOGY CELLULAR SUBSTRATE
Atypical
LOSS OF POSTURAL CONTROL
ATONIC SEIZURES
SHORT SEIZURE AS Quick HEAD DROP or NODDING MOVEMENT Collapse
LONG SEIZURE AS
TONIC SEIZURES
Sudden but brief muscle contraction that may involve 1 or more body parts Associated with:
Myoclonic SEIZURES
Brief shock like jerks or contractions
Multiple EEG spikes
In COMPARISON....
FOCAL ORIGIN 1 Cerebral hemisphere (medial temporal) (Inferior frontal ) GENERALIZED 1 Cerebral hemisphere - but rapidly distributed across both cerebral hemisphere via neuronal network Brain Structure Abnormality plus.. cellular abn. biochem abn.
ASSOTIATED WITH
EEG
Non localizing EEG EEG depend on type Normal , but may show epileptiform spikes/sharp waves
EEG
FOCAL SEIZURE GENERALIZED
Unclassifiable Seizures
Example: Epileptic Spasm
Common in INFANTS
CAUSES
Persistently High fever Penetrating Head Trauma
Clinical syndrome with numeroues mendellian disorders in which seizures are 1 part of the PHENOTYPE.
DIAGNOSTICS
TREATMENT
If the sole cause of a seizure is a metabolic disturbance treat METABOLIC DISTURBANCE If the apparent cause of a seizure was a medication (e.g., theophylline) or illicit drug use (e.g., cocaine), then appropriate therapy is avoidance of the drug NO NEED FOR ANTI EPILEPTIC If confirmed with subsequent seizures occur in the absence of these precipitants... HISTORY, TYPE of Seizure, TREAT
TREATMENT
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++ ++ 39.00
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+ +++ 30.65
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LAMOTRIGINE
MOA: Indication: Toxicity: Focal Seizures Myoclonic Seizures dizziness diplopia nausea & vomiting 24 hours 100 300 mg adults
LAMOTRIGINE
LAMOTRIGINE ( Lamictal) ADULT dose PEDIA dose ORAL CHEWABLE 25, 150, 200 mg 2, 5, 25 mg 100 to300mg / day 75 to 100 mg/ day
Signa: to be taken twice a day (oral) Signa: to be taken 3x a day (chewable) Drug Interactions with Valproate causes increase by two fold
Daryl O. Talanquines MD Fatima medical center 930-29-55 ______________________________________________________ Patients name: JS Date: Aug 1, 2013 Address: Quezon city Age: 52 y/o
Rx
Sig: Take one tablet twice a day for 2 weeks. And return for follow up check
Refferences.......