1. Therapeutics I III Sessional practicals Minor practical Acute asthmatic exacerbation Presented to : Mr. Zia Inamdar sir Presented by : Manoj Kumar

2. Patient Demographics Patient name: mallappa I.P No : 77440
Unit : Unit VI
Age : 60yrs
Dept : Medicine
Sex : Male
DOA : 10/02/2013
DOD : 14/02/2013
Present complaints :C/O, pain in chest since 1 week, breathlessness since a fortnight.
History of present illness :- patient was apparently normal 1 month back since he developed breathlessness, persistant since 3 days back & gradually progressive in nature & c/o, cough since 3 days back. Patient also c/o pinpoint pain pearcing type in the shoulders particularly in the right shoulder during the cough .

3. Past medical history :- k/c/o, Bronchial asthma last 1 year
Past medication history :-nothing significant
Personal history :- smoking from last 6 years
Diet – veg
sleep –adequate
Apeptite : Good
Bladder and Bowel: Normal

4. Laboratory Investigations:
RBC : 5.39
WBC : 21,600
HB : 13.0
PLATELET COUNT : 3.85
ESR : 20
POLYMORPHS : 93
LYMPOCYTES : 04
BASOPHILS :00
MONOCYTES :00
ESINOPHILS :01
PCV : 43.4
MCV :80.5
MCH :24.5
MCHC :30.1

5. Electrolytes :- NA+ 13.9 K+ 3.7 Renal function test :-
Sr. creatinine
0.8
Urine examination :-
Albumin :- trace
pus cells :-2-3
sugar :- absent
epithelial cells :-1-2

6. SOAP NOTE:- SUBJECT: C/O, Breathlessness since 3days C/O, cough since 4 days OBJECTIVE: BP chart & other investigations
DATE
10/3
11/3
12/3
13/3
14/3 BP
180/100
130/90
140/88
PULSE
100 86 80 90
TEMP 37
37.2
37.1
RESP.RATE 22 20
WBC : 21,600
ESR : 20
POLYMORPHS : 93

7. LYMPOCYTES : 04
MCH :24.5
MCHC :30.1
Sr. creatinine :- 0.8
ASSESSMENT :
Problem list :-
Cough
Breathlessness
1)Cough :-Protective reflex against infections by activating of mechano & chemoreceptors

8. 2) Breathlessness :- mucous gland hypertropy due to inflammation excessive mucous production & airway plugging leads to breathlessness . PLAN : 1)Inj. Kephazone-S – cefoperazone-1gm all the days Moa :-Acts on cephalosporin protein binding cells. 2) Inj . Pan –pantoprazole-40mg all days Moa :-It’s a proton pump inhibitor ,it reduces gastric acid secreation.

9. 3) Inj Deriphylline-etophylline+theophylline-1-1-1-all days
Moa :-1. Combines with the adenosine receptor (PI) and acts as antagonist of adenosine thus prevents it to cause contraction of the bronchial smooth muscle.
2. Combines and inactivates phospho-diesterase enzyme and degradation of the cyclic-AMP stops. C-AMP accumulates in the bronchial smooth muscle and causes bronchodilatation. C-AMP has negative effect on the release of the calcium from the endoplasmic reticulum.
4) Inj effcorlin –hydrocortisone – 1amp st 2 days & last 2 days
Moa :- Hydrocortisone is a corticosteroid used for its anti-inflammatory and immunosuppressive effects. The anti-inflammatory actions of corticosteroids are thought to involve lipocortins, phospholipase A2 inhibitory proteins which, through inhibition arachidonic acid, control the biosynthesis of prostaglandins and leukotrienes.
  Phospholipase A2 blocker
 Acts by inhibiting the PG secretion, no leukotriens secretion
  Decrease permeability to capillaries—↓ exudation and transudation

10. 5)Duoline neubulization –salbutamol + ipratropium Br 1-1-1-1- all the days
Moa :-1. Salbutamol → Stimulates β2 receptors of the bronchial smooth muscle → Stimulation of the Adenylate Cyclase enzyme → Increased intracellular cyclic-AMP (also reduction of the intracellular calcium) → Smooth muscle relaxation → Bronchodilatation occurs.
2. Salbutamol → Acts on the β2 receptor of the mast cell → ↑ c-AMP production → Stabilization of the mast cell membrane → No Histamine release → No bronchoconstriction
6) Inj lasix-furosemide-stat-1st dat only
Moa :-Furosemide, a loop diuretic, inhibits water reabsorption in the nephron by blocking the sodium-potassium-chloride cotransporter (NKCC2) in the thick ascending limb of the loop of Henle thus preventing the transport of sodium from the lumen of the loop of Henle into the basolateral interstitium
7)Budecort neubulization :-budesonide st day only
Moa:-anti-inflammatory corticosteroid ,  inhibitory activities against multiple cell types (e.g., mast cells, eosinophils, neutrophils, macrophages, and lymphocytes) and mediators (e.g., histamine, eicosanoids, leukotrienes, and cytokines) involved in allergic- and non-allergic-mediated inflammation

11. 8) Inj dexona –dexamethasone-2cc 1-1-1- 2,3,4day only
Moa:-It is a corticosteroid used for its anti-inflammatory . 1.Phospholipase A2 blocker
  2. Acts by inhibiting the PG secretion, no leukotriens secretion
9)Triohale rotacaps –titropium Br 9mcq+ formetrol nd day only
Moa :-  β2-agonists, causing bronchodilation by relaxing the smooth muscle in the airway so as to treat the exacerbation of asthma

12. 10)Maxiflo rotacaps - formetrol fummarate + flucicarane propionate last 3 days Moa :- β2-agonists, causing bronchodilation by relaxing the smooth muscle in the airway 11) Tab pan-pantoprazole-40mg last 2 days Moa:- It’s a proton pump inhibitor ,it reduces gastric acid secreation

13. Follow up & discharge drugs :-
1)Tab deriphylline -150mg days
2)Tab desatax XL days
3)Tab pan –40mg days
4)Duoline neubulization days
CLINICAL PHARAMACIST INTERVENTIONS & SERVICES PROVIDED :
DDI’s :
1)Theophylline + pantoprazole – moderate –PPI’s increase rate of theophylline absorption

14. 2) Theophylline + Budesonide – moderate - Hypokalemia & increased theophylline levels 3) Theophylline + dexamethasone – moderate –Hypokalemia & increased theophylline levels PATIENT COUNSELLING :- 1)Exercise regularly 2)Stop smoking 3)Maintain healthy lifestyle