Case Study: Patient With Shortness Of Breath

Case Study unhurried With Shortness Of BreathPatient IdentityThe enduring role role is a 54 year old female, Mrs SK who is a ho engrosswife with a BMI of 25.7kg/m2.Presenting ComplaintsShe was brought in to the chance and Emergency (AE) department, complaining of shortness of breath ( bull) and a productive cough. archives of Presenting ComplaintsThe longanimous was experiencing SOB for the past 2-3 twenty- quaternity hourss, and was progressively worsening on the twenty-four hours on admission. It was non associated with chest tightness and she was capable to sleep the nighttime beforehand. She was too having persistent productive cough with snow-clad sputum since she was support discharged 12 days past.Past Medical narrationShe was diagnosed with diabetes mellitus and high stock pressure 8 years ago and has history of gastritis for the past 5 years. She was fresh diagnosed with bronchial bronchial asthma attack in her croak admission two weeks ago. complaisant narrationThe long-suffering is a widow since 6 years ago and is a ho wasting diseasewife with 3 children. She stays in a manufacturing plant atomic number 18a and has a cat at home. She is a non-smoker and a non-alcoholic.Family HistoryHer mother and father provoke no knget medical illness, save she has a cousin who suffers from bronchial asthma and is frequently admitted to the wards.Drug HistoryThe patient was on Salbutamol and Budesonide inhalers, 200mcg when necessary and 200mcg erstwhile at night respectively for her bronchial asthma. For her hypertension, she was on 40mg Telmisartan tablets at a time at night. She was likewise taking Gliclazide tablets, 80mg doubly daily and Metformin tablets, 500mg troika time a day for her diabetes mellitus. For her hypercholestrolaemia, the patient was taking lovastatin tablets 20mg once at night. Based on the Morisky Scale, she was manipulable with her medication and she had no known drug aloneergy.Examination DetailsOn exam ination, the patient was alert and conscious. She was pink and appe bed to be f cinchly hydrated. She was also able to speak in full sentences, and was not tachypnoeic. A pectus roentgen ray showed that in that location was a pneumonic consolidation at the right dismount lobe of her lungs. Her line of work pressure (BP) was 152/82mmHg, pulse rate (PR) was 109 beats per minute (bpm) and was afebrile. Her atomic number 8 loudness (SpO2) was 96% to a lower place 3 litres of oxygen and her blood glucose was mensural to be 4.7mmol/L.InvestigationsUpon admission, standard laboratory investigations were carried away and were obtained. From the renal function test, it was seen that the patient had a low potassium take aim of 2.8mmol/l and her calculated creatinine headway was 60.0ml/min which indicated that she had modest-mannered renal impairment. The liver function test showed that she had frequent liver function. The following shows the results that were out of the referenc e values for her haematological tests.C-Reactive Protein (CRP)31.1 erythrocyte Sedimentation Rate (ESR) (0 15 mm/hr)110 Haemoglobin (Hb)(13.5-18 g/dl)10.3 Haematocrit(0.36-0.46 L/l)0.303 Red Blood Count (RBC)(3.8-4.8 x 1012 /l)3.45 neat Cell Count (WCC)(4-11 x 109 /l)15.1 Neutrophil (Neutro)(2 7.5 x 109 /l)10.57 Diagnosis/ touch sensationPatient was initially diagnosed with Acute provocation of bronchial Asthma (AEBA) alternative to an upper respiratory infection (URTI) to rule out pneumonia. However, later in the day when the chest X-ray came back, she was diagnosed with pneumonia with right parapneumonic effusion.Management PlanThe patients sure medication was continued and was devoted 3 litres of oxygen via a bony prong (NP). She was commenced on prednisolone tablets, 30mg once a day and was given nebulised Combivent (Ipratropium 20mcg/salbutamol 100mcg), any 4 hours. Her peak expiratory flow rate (PEFR) and SpO2 was to be monitored. Antibiotics were unbroken in view to be started if necessary after the total white blood count results came back.clinical ProgressUpon admission, the patient was afebrile, was tolerating orally well, did not have any sorethroat but was having a non productive cough. An echocardiogram (ECG) was do and it showed that she had fistula rhythm with no ischaemic changes. As her chest x-ray showed a right lower zone consolidation, she was diagnosed with pneumonia. She was immediately commenced on 2g ceftazidime intravenously, and past continued on 1g three multiplication a day. She was also under nebulised combivent every 6 hours. Her metformin and gliclazide was stopped and she was started on subcutaneous 10 units of recombinant human insulin three times a day and 12 units of recombinant human insulin N once at night. On Day 2 of her stay, her blood results came back and as she has low potassium levels, she was given 15mls of veil KCl three times daily and two Slow K tablets once daily. She was fluent complaining of co ugh without sputum and was given 15mls of Benadryl (diphenhydramine) syrup three times a day. The patient did not have any study complaints on the third day and was tolerating orally well. at that place was no SOB seen and she had good inhaler technique. She was then taken off the nebulizer combivent and the oxygen. By day 4, the patient was comfortable, and her cough and sputum had decreased. Examination on her lungs showed that she had prolonged expiratory phase. She was stopped on the Benadryl as well as Mist KCl and Slow K. After reinforcement on the inhaler technique by the pharmacist, the patient was discharged on day 5 as she was afebrile and had minimal cough. On discharge, she was then switched back to her oral hypoglycaemics and her intravenous antibiotic drug was switched to oral Cefuroxime 500mg twice daily for the next 10 days. She was also given Neulin SR 250mg once at night. Table 1 shows the live signs chart for Mrs SK throughout her infirmary stay.Table 1 Vit al Signs mapDayTimeBP (mmHg)PR (bpm)SpO2Blood Glucose (mmol/l)113.00178/102109100%6.914.00152/8210998% NP15.404.718.40133/7311497% RA21.156.223.05151/82119203.15143/8110606.006.308.30119/6794100%10.354.811.24100/6110797%15.20112/8210016.30128/701006.222.003.623.50118/596698%3L O2304.10124/64104100%3L O206.158.209.40100/609611.508.515.30108/679417.207.420.00121/7586404.00110/566206.007.908.00110/70634.216.00105/759196%17.009.722.00138/671146.1505.009.607.1511.1Pharmaceutical C atomic number 18 IssuesThe archetypical c ar riposte is to review the oversight of AEBA found on the British Guideline on the Management of Asthma. The dose of prednisolone should be increased to 50mg once a day for at least(prenominal) 5 days or until recuperation. Since the patient is convinced(p) with theophylline on discharge, she should be counseled on the signs and symptoms of theophylline perniciousness such as confusion, dizziness, diarrhoea, nausea, fatigue and headache.The second riposte is regarding the choice of antibiotics for the discussion of community acquired pneumonia in this patient. A sputum full examination microscopic examination (FEME) should be requested to identify the causative microorganisms of the lung infection. If empirical discourse is to be started the preferred drugs of choice would be amoxicillin 500mg three times a day plus every erythromycin 500mg four times a day or clarithromycin 500mg twice daily. Alternative choices would be levofloxacin 500mg once daily or moxifloxacin 400mg once a day, should the patient be illiberal of the preferred regimen. Thirdly, in that respect is no clear indication of the prescription of the diphenhydramine in the first place, as it would only if suppress the patients cough, which is inappropriate. Hence it should be stopped immediately.Next, the patients updated blood cholesterol levels should be taken and the appropriate use of statins should be reviewed. As she is on long-term statin use, her liver en zymes should be monitored regularly and if is raised by three-fold, she should stop taking the Lovastatin. She should also be counseled on the symptoms of rhabdomyolysis which is related to the long term use of statins, such as unexplained muscle pain, stiffness, weakness and the darkening of urine colour.The following issue is regarding the patients diabetes steering. A HbA1c test should be done to determine her glycated haemoglobin level to see how well her self-management has been. She should also be advised on victuals and lifestyle to keep her diabetes under catch. Lastly, as she has low red blood count, haemoglobin and haematocrit levels, it is suspected that she has anaemia. progress tests should be done to avow this, and if it is diagnosed, she should be given ferrous supplements such as ferrous sulphate tablets 200mg twice daily.DISEASE OVERVIEW AND PHARMACOLOGICAL BASIS OF do drugs THERAPYAcute Exacerbation of Bronchial Asthma An OverviewAsthma is a chronic inflamma tory inconvenience oneself of the airline businesss where many cells and cellular elements play a role. This leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, in particular at night or in the morning. These inflammatory symptoms be commonly associated with extensive but variable airflow block within the lung as well as airway hyperresponsiveness and this is reversible either on its own or with manipulation. 1Asthma is a worldwide problem as it is estimated that about 4.5% of the worlds population is affected, which amounts to 300million individuals approximately. The global prevalence of asthma varies from 1-18% of populations in countries all over the world.Asthma has three distinguishing characteristics which be airflow limitation, airway hyperresponsiveness, and bronchial inflammation. Airflow limitation is usually resolved by itself with or without sermon but for individuals with chronic asthma, inflammation may result in permanent airflow limitation. Stimuli such as irritants or allergens may pose as triggers in airway hyperresponsiveness and bronchial inflammation is associated with eosinophils, T-lymphocytes and mast cells which cause plasma exudation, legato muscle hypertrophy, mucous plugging and epithelial changes. It is shown that inflammation of the airways play a major role in the pathology of asthma and this starts when allergens or irritant trigger the activating of cells such as epithelial cells, macrophages, lymphocytes and mast cells. This leads to cytokine or mediator wrench and smooth muscle contr movement resulting in cellular infiltration of eosinophils and neutrophils causing airway inflammation including oedema, epithelial permeability or injury, mucous secretion and vascular permeability which eventually leads to airway obstruction and hyperresponsiveness.The diagnosis of asthma is based on a collection of signs and symptoms without a reasonable explanation for them and spirometry i s an archean test which is easy to assess if there is any airflow obstruction present tense and its extent. For diagnosed patients with asthma, exquisite exacerbations may occur and because patients with strong asthma are at increased risk of death following exacerbations, assessments of exacerbations are crucial. Clinical features of penetrating asthma exacerbations include severe breathlessness, tachypnoea, tachycardia, silent chest, cyanosis, or syncope. teetotum Expiratory Flow (PEF) or Forced Expiratory Volume in one second (FEV1) is also used to measure the lung capacity. Oxygen saturation (SpO2) is measured using a pulse oximetry and this aids oxygen therapy as oxygen therapy is given in order to keep SpO2 levels at 94-98%. Measurements of arterial blood gases (ABG) are usually not necessary unless patients present with features of dangerous asthma or have SpO2 of less than 92% as there may be a risk of hypercapnea if SpO2 is lower than 92%. Chest X-rays are also no t recommended unless patients are suspected of pneumonia or lung consolidations, damage from life-threatening asthma, having un comforting response to discussion or if they require ventilation.pharmacological Intervention in the management of AEBA2OxygenOxygen therapy is requisiteed nearly of the time as patients who are having lancinate asthma usually present with hypoxia as well. Hence, all patients with hypoxia who are woeful from acute severe asthma should be given oxygen and their SpO2 levels should be kept at 94-98%.2 champion bronchodilatorsAs first line therapy, high dose inhaled 2 friend bronchodilators are used as soon as achievable as rapid removers of bronchospasm. For patients who are unable to use inhaled therapy, intravenous 2-agonists are used instead. 2 agonist bronchodilators work by stimulating the 2 adrenoceptors in the lungs, thus causing relaxation of the airways. Examples of short acting 2-agonist are salbutamol and terbutaline, and a long acting 2-a gonist is salmeterol.GlucocorticosteroidsSteroids should always be given in all berths of acute asthma. Examples of these are prednisone, prednisolone, dexamethasone, and hydrocortisone. They exert an anti-inflammatory effect by inhibiting transcription of the genes for the cytokines implicated in asthmatic inflammation and hence curtail airway hyper-responsiveness.Anti-cholinergic agentsIpratropium bromide is one of the anti-cholinergic agents that is used widely in preaching of acute exacerbations of asthma. Nebulised ipratropium bromide is used in combination with a 2-agonist bronchodilator as treatment for patients with severe acute or life-threatening asthma. Anti-cholinergic agents work by inhibit muscarinic sensory receptors M1 and M3 which then reduces cGMP formation and decreases smooth muscle contractility in the lungs. This eventually results in bronchodilation and reduces mucus secretion. otherwise therapiesOther therapies include the use of milligram sulphate. A si ngle bolus dose of intravenous milligram sulphate is administered to patients with acute severe asthma with previous unsatisfactory response to inhaled bronchodilator therapy or for patients who are suffering from life-threatening or near fatal asthma. It is believed that milligram sulphate works by reducing calcium uptake by the bronchial smooth muscle cells, causing bronchodilation and also inhibits mast cells degranulation, thus reducing the release of inflammatory mediators such as histamines, and leukotrienes.EVIDENCE FOR TREATMENT OF THE CONDITIONThe management of asthma can be divided into two parts acute treatment, and long term management.Management of acute asthmaIt has been shown that most patients suffering from acute severe asthma are hypoxaemic. therefore it is essential that supplementary oxygen therapy be given to them.3-6 This is administered via a face mask or nasal prong with the patients SpO2 kept between 94-98%.7 Where nebulisers are shooted in therapy, oxy gen-driven nebulisers are favoured instead of those that are air-driven due to oxygen desaturation when driven by air alone.8-10 However, the lack of provision of supplemental oxygen should not pose as a factor in omitting nebulised therapy from administration if deemed appropriate.11Referring to the case presented above, the patient was interact accordingly as she was immediately given supplemental oxygen and her SpO2 was well-kept well above 96% throughout hospital stay.As acute asthma is associated with symptoms of bronchospasms such as wheezing and tachypnoea, the main aim of treatment is to quickly resolve these symptoms and most often, high doses of inhaled 2 agonist bronchodilators are effective with minimum adverse set up.12-14 Salbutamol is usually the drug of choice although there is no significant differences in terms of efficacy as compared to Terbutaline. It is shown that there are no significant clinical benefits by using a non-selective 2 agonist such as epinephrine instead of selective 2 agonists.15 Based on a meta-analysis, it is seen that 2 agonists administered via inhalation are more(prenominal) than preferable and has similar efficacy with those administered intravenously in bragging(a) acute asthma.16 In ventilated patients or those in life-threatening conditions, parenteral 2 agonists may be added to inhaled 2 agonist treatment although there is little yard supporting this treatment. Although a single bolus nebulisation may relieve most acute asthma cases, it is shown that continuous nebulised treatment of 2 agonists is more effective in relieving acute asthma for those with unsatisfactory response to initial therapy.17, 18Steroid therapy is always given in acute exacerbations of asthma and it is proven that it has better result if given earlier. It not only reduces death rate but it also reduces relapses and the number of hospital admissions as well.19, 20 spoken steroids given are seen to be equally as effective as parenteral tr eatment hence there is no look at for the use of parenteral administration of steroids unless the patient is unable to tolerate orally.19 Prednisolone 40-50mg is given daily for at least five days or until recovery and this can be stopped abruptly after the patient has recovered.2 As long as the patient is on inhaled steroids, there is no need for the dose to be tapered floor slowly prior to discontinuation.21In the case presented, the patient was commenced on steroid therapy but was under-treated as she was only given prednisolone 30mg once daily for just one day. Hence, there is a need to increase the dose of prednisolone to 50mg and to continue is for at least another four days or until recovery before stopping this treatment.In hospital therapy, anticholinergic treatments are given to severe exacerbations of asthma and nebulised ipratropium bromide is always the drug of choice used in clinical settings. A combination of nebulised ipratropum bromide with a 2 agonist bronchodila tor is often given as treatment as it is proven that a combination of these two agents has a significant increase in bronchodilatation as compared to the use of a 2 agonist alone. Hence, there is faster recovery and will reduce the length of hospital stay. However, it is also seen that anticholinergic treatment is not particularly effective and favourable for cases of mild exacerbations of asthma as well as after the patient has been stabilized, thus is not necessary in these cases.22-24The patient in this case was seen to be having a mild exacerbation of acute asthma and hence nebulised ipratropium bromide treatment was not necessary. However, the use of nebulised Combivent, a combination of ipratropium bromide and salbutamol was justified since this patient was re-attending with a relapse and she was also suffering from pneumonia as well. Hence, there was probably a need for a quicker rate of bronchodilation as well as faster recovery for her.The use of magnesium sulphate in hospi tal treatment of AEBA is not widely seen, just there have been about evidence showing the bronchodilating effects of magnesium sulphate when used in adults.25 There are also studies which report that nebulised magnesium sulphate unite with a 2 agonist shows positive outcomes and good clinical potentiality in hospital settings.26, 27 The use of an intravenous bolus administration of magnesium sulphate is believed to promote lung function in patients who have severe asthma without noisome side effects.28 Nevertheless, there have been no studies on the ingeminate administrations of magnesium sulphate, though it is presumed that repeated use may lead to hypermagnesaemia, causing muscle weakness and respiratory failure. As further extensive studies need to be done to determine the most suitable route and dosing of magnesium sulphate, this treatment is reserved only for patients with acute severe asthma without satisfactory response to inhaled bronchodilator therapy and patients wit h life-threatening of near fatal asthma.Monitoring should be carried out constantly throughout hospital stay and in acute asthma cases, monitor of PEF is crucial. PEF readings should be measured and recorded every 30 legal proceeding after treatment has been started. PEF should also be monitored pre- and post- nebulisation therapies as long as the patient is in hospital and until the asthma is well under control after discharge.It is seen that after hospital discharge, a relative amount of patients either experience relapse or are readmitted into the hospital with at least 15% within two weeks following discharge.29 Therefore it is essential that patient education such as proper inhaler technique, and well-documented PEF recordings with action plans depending on symptoms experienced should be instilled in order to reduce rate of relapses as well as minimize problems associated with exacerbations after discharge.30Monitoring of the patients PEF was done consistently throughout her h ospital stay and the patient was given sufficient focusing prior to discharge on her inhaler technique. However, there was no evidence that the patient was educated on self-documenting PEF recordings as well as action plans based on symptoms experienced following discharge and this should be done in this case to avoid another exacerbation of her condition.Long marge Management of AsthmaThe aim of management of asthma is to keep it well-controlled without the need of rescue medications, asymptomatic, no exacerbations, no hindrance to daily activities including exercise as well as normal lung function. A tintwise management nest is adopted for asthma patients and this is to acquire initial control and hold it by stepping up treatment to improve control if necessary or stepping down treatment if there is good control over the condition to maintain the lowest step that will control the patients condition.As the patient is currently on regular preventer therapy with inhaled steroid s, she is currently on step 2 of the management of asthma. There have been many studies being carried out to compare the polar inhaled steroids that are being used for asthma and it is shown that beclomethasone diproprionate and budesonide are both in addition clinically effective although there may be different devices for delivery. It has also been seen that fluticasone and mometasone being administered at half the dosage of beclomethasone and budesonide shows equivalent clinical effectiveness, however there is somewhat inadequate evidence that fluticasone possesses fewer side effects and further studies need to be carried out on establishing the safety visibility of mometasone.31 A new inhaled steroid has been introduced which is ciclesonide and clinical trials have shown evidence that it has more local activity than systemic and less oropharyngeal side effects as compared to the regular inhaled steroids.32-35 Although this seems promising, this clinical advantage is still cont roversial as its safety to efficacy ratio has yet to be established and compared with the conventional inhaled steroids. Inhaled steroids are recommended as preventer drug therapy for adults as they are most clinically effective in controlling asthma based on the treatment goals outlined.36-39 The frequency of dosing of inhaled steroids are generally twice daily and it is shown that there is supple clinical benefit obtained when taken twice a day than once daily, however a once daily dosing may suffice for those with milder asthma. There is also limited evidence of advantage with increased frequency of greater than twice a day.37 In addition to that, starting at higher(prenominal) than recommended doses have no significant effectiveness in management of mild to moderate asthma.40 Hence the recommended dosage for inhaled steroids would be 200-800mcg daily. This would be an add-on therapy to the step 1 management of using inhaled short acting 2 agonist bronchodilator as required.Bas ed on the presented case, the patient was on budesonide 200mcg once at night prior to admission but this was immediately increased on admission and was in line with the recommended guidelines as she was continued on budesonide 400mcg twice a day together with salbutamol 200mcg as required following discharge.Other preventer therapies may be included for the patient despite inhaled steroids being the first choice of drugs for preventer therapy. These alternatives are less effective although they have shown some clinical benefit in patients who are on short acting 2 agonists only. Chromones which act as mast cell stabilizers such as atomic number 11 cromoglicate and nedocromil sodium have shown to be beneficial in adults.41, 42 Apart from that, leukotriene receptor antagonists montelukast and zafirlukast too have clinical benefits.37, 43, 44 Theophylline also have some evidence in showing benefits in adults.36, 45The patient in the case presented above was prescribed sustained-releas e theophylline on the last day of admission. Although it is another option that may be added to daily ascendancy medications for step 2 management, there is very little evidence on the clinical efficacy of it as a long term controller. There is no reason to justify the use of theophylline in this case as the patient is responsive and can be controlled on inhaled steroids. Further more, theophylline has a narrow therapeutic index and close monitoring of plasma theophylline levels is necessary because at concentrations above 25g/ml, there is high risk of tachycardia and seizures may occur if concentrations exceed 35g/ml.CONCLUSIONAfter reviewing the management of the patients condition throughout hospital stay, it can be concluded that SK was treated adequately based on the current guidelines and evidences attainable. She was given all necessary treatment at range of admission and there was no lacking of medications in all four days of her hospital admission. Apart from that, monito ring of her condition was carried out consistently and all data was updated, leaving no room for questioning and doubt. However, there were a few issues that came to attention which were the prescribing of several drugs that were unnecessary such as diphenhydramine and theophylline. There were little and no clear evidence that these drugs prescribed would be of benefit to the patient, and may also increase the risk of harmful effects to her as well.Alongside treatment of her acute condition, SKs controller medications were reviewed and attendant changes were made as appropriate. Besides that, her other co-morbidities were also managed well as treatments for her hypertension and diabetes mellitus were given accordingly.PATIENT MEDICATION PROFILEPATIENT elaborateNameS.K.ConsultantDr YKSGeneral PractitionerAddressGender womanlyWeight65kgHeight1.59mCommunity Pharmacist figure of Birth (Age)54 years oldKnown SensitivitiesNKDASocial HistoryWidow of 6 years, Housewife, Non-smoker, Does n ot drinkPATIENT HOSPITAL STAYPresenting complaint in primary care / reason for admissionAdmission date17/04/09Shortness of breath for the past two days, progressivelyDischarge Date Discharged to21/04/09 Homeworsening today and productive cough. applicable MEDICAL HISTORYRELEVANT DRUG HISTORYDate puzzle DescriptionDateMedicationComments2001Diabetes MellitusT. Diamicron80mg BD2001HypertensionT. Metformin500mg TDS2004GastritisT. Telmisartan40mg ON2009Bronchial AsthmaMDI Salbutamol200mcg PRNMDI Budesonide200mcg ONT. Lovastatin20mg ONRELEVANT NON DRUG TREATMENTPrescribed MedicationStartStopClinical/ testing ground TestsDate Result1T. Telmisartan 40mg OD18/0421/042T. Gliclazide 80mg BD17/0417/043T. Metformin 500mg TDS17/044T. Lovastatin 20mg ON17/0419/045MDI Salbutamol 200mcg 2 puffs PRN17/046MDI Budesonide 200mcg 2 puffs BD17/047T. Prednisolone 30mg OD17/0417/048Neb. Combivent 6-hourly17/0419/049IV Ceftazidime 2g STAT, then 1g TDS17/0421/0410S/C recombinant human insulin R 10units TDS17/ 0421/0411S/C Humulin N 12units ON17/0421/0412Syrup diphenhydramine 15mls TDS18/0420/0413T. Slow K 2tabs BD18/0420/0414Mist KCl 15mls TDS18/0420/0415T. Theophylline 250mg OD20/04CLINCIAL MANAGEMENTDiagn