1

PHM 491
1 22 23
2560
. 5600214

____________________________________________________________________
______________________________________
Patient Profile
Demographic Data

53 64 154
BMI 26.99 kg/m2
Admit date 31/5/60
Discharge Date 5/6/60
Admission note
CC: 21.00 .
HPI: 1 .
PMH: COPD
SH:
ALL: NKDA
Physical examination:
Vital sign: Temp.= 37.5 C, BP = 110/70 mmHg, PR = 86
bpm, RR = 20/min,
O2 Sat = 100 %
GEN:
Skin:
HEENT:
CVS:
RS:
Abdomen:
Neu: E4V5M6, pupil 3 mm BRTL
Diagnosis: Acute pyelonephritis with Acute kidney injury
Vital sign
Date 31/05/60 1/06/60
2 6 10 14 18 22 2 6 10 14 18 22

1


 SBP - - - - 110 120 100 110 120 110 - -
(mmHg)
DBP - - - - 70 70 60 80 60 70 - -
(mmHg)
RR - - - - 20 20 20 20 20 20 - -
(bpm)
PR - - - - 86 110 70 84 70 74 - -
(bpm)
Temp - - - - 37.5 38.5 36.5 37.2 36.5 36.7 - -
(oC)

Laboratory Data:
Hematology
Parameter Reference 31/05/60
range
3
WBC (10 /L) 4.0 11.0 13.4
RBC count 4.00 6.00 6.25
6
(10 /L)
Hb (gm%) 13.5 17.5 12.0
HCT (%) 40 52 35.5
MCV (fl) 80 95 56.8
MCH (pg) 27 34 19.2
MCHC (%) 33 35 33.9
RDW (%) 11.5 13.5 16.2
Platelet count 140 440 154
3
(10 /L)
Platelet smear Adequate
Neutrophil (%) 45.0 70.0 67.30
Lymphocyte (%) 25.0 40.0 15.20
Monocyte (%) 2.0 12.0 11.30
Eosinophil (%) 1.0 8.0 5.40
Basophil (%) 0 1.0 0.8
Neu# (103/L) 2.5 7.5 9.0
Normochromia - No
Normocytosis - No
Anisocytosis - Few
2


 Microcytosis - 1+
Macrocytosis - Few
Hypochromia - +1
Ovalocyte - Few

Chemistry
Parameter Reference 31/05/60
range
BUN (mg/dl) 7 18 15.99
Creatinine (mg/dl) 0.6 1.3 0.93
Na (mmol/L) 136 145 137
K (mmol/L) 3.5 5.1 3.4
Cl (mmol/L) 98 107 104
Bicarbonate 21 32 25.9
(mmol/L)
Vital sign
Date 31/05/60 1/06/60
2 6 10 14 18 22 2 6 10 14 18 22
SBP - - - 130 140 100 100 120 - - - -
(mmHg)
DBP - - - 80 70 60 60 60 - - - -
(mmHg)
RR - - - 24 24 20 20 20 22 22 - -
(bpm)
PR - - - 116 100 98 94 96 85 83 - -
(bpm)
Temp - - - 37.3 37.0 37.0 36.6 36.9 36.7 36.6 - -
(oC)

3


Current drug therapy:
Drugs 31/05/ 1/06/6
60 0
Order for one day
1. 0.9% NaCl 1000 mlx2 IV 80 ml/h /
2. Ventolin (Salbutamol) 1 NB q 4 h / /
3. Berodual (Fenoterol/Ipratropium) /
1 NB q 4 h
4. Dexamethasone 4 mg/ml IV q 6 h /
5. Dexamethasone 4 mg/ml IV q 8 h /
6. O2 Canular 3 LPM / /
Order for continues
1. Ceftriazone 2 g IV q 24 h /
2. Azithromycin 250 mg 2x1 ac / /
3. Paracetamol 500 mg 1 tab po prn / /
4. Glyceryl guaiacolate 100 mg 1x3 / /
pc
5. Acetylcysteine 200 mg 1x3 pc / /

Home Medication:
Drugs
1. Amoxycillin 825 mg + Clavulanic acid 125 mg 1x2 pc
#14
2. Azithromycin 250 mg 2x1 ac #6
3. Salbutamol MDI 100 mcg/dose 1 puff prn q 4 h #1
4. Seretide evohaler 25/125 mcg/dose 1 puff bid #1
5. Glyceryl guaiacolate 100 mg 1x3 pc #20

Problem lists:
1. COPD with Acute exacerbation with Pneumonia with
DRPs (Unnecessary drug therapy of Salbutamol and
Glyceryl guaiacolate with Dosage too low of
Dexamethasone)

4


 SOAP analysis

Problem list: COPD with Acute exacerbation with Pneumonia

with DRPs (Unnecessary drug therapy of Salbutamol and
Glyceryl guaiacolate with Dosage too low of Dexamethasone)

Subjective Data

2 COPD

Objective Data
Physical examination:
31 2560
Vital sign: BP = 146/84 mmHg, O2 Sat = 95 %
GEN:
Chest: wheezing both lungs, crepitation both lungs
Diagnosis: COPD with Acute exacerbation,
Tracheobronchitis
:
1. Dexamethasone 4 mg IV
2. Berodual 1 NB q 15 min
3. Ceftriazone 2 g IV
4. Azithromycin 250 mg 2x1 po ac

Physical examination:
31 2560 13.30 .
Vital sign: PR = 116 bpm, RR = 24/min, O2 Sat = 92 %
GEN:
Chest: wheezing both lungs, crepitation both lungs
Diagnosis: COPD with Acute exacerbation, Pneumonia

5


 Vital sign
Date 31/05/60 1/06/60
2 6 10 14 18 22 2 6 10 14 18 22
SBP - - - 130 140 100 100 120 - - - -
(mmHg)
DBP - - - 80 70 60 60 60 - - - -
(mmHg)
RR - - - 24 24 20 20 20 22 22 - -
(bpm)
PR - - - 116 100 98 94 96 85 83 - -
(bpm)
Temp - - - 37.3 37.0 37.0 36.6 36.9 36.7 36.6 - -
(oC)

Laboratory Data:
Hematology
Parameter Reference range 31/05/60
WBC (103/L) 4.0 11.0 13.4
Lymphocyte (%) 25.0 40.0 15.20
3
Neu# (10 /L) 2.5 7.5 9.0

Current drug therapy:

Drugs 31/05/ 1/06/6
60 0
Order for one day
1. 0.9% NaCl 1000 mlx2 IV 80 ml/h /
2. Ventolin (Salbutamol) 1 NB q 4 h / /
3. Berodual (Fenoterol/Ipratropium) /
1 NB q 4 h
4. Dexamethasone 4 mg/ml IV q 6 h /
5. Dexamethasone 4 mg/ml IV q 8 h /
6. O2 Canular 3 LPM / /
Order for continues
1. Ceftriazone 2 g IV q 24 h /
2. Azithromycin 250 mg 2x1 ac / /
3. Paracetamol 500 mg 1 tab po prn / /
6


 4. Glyceryl guaiacolate 100 mg 1x3 / /
pc
5. Acetylcysteine 200 mg 1x3 pc / /
Home Medication:
Drugs
1. Amoxycillin 825 mg + Clavulanic acid 125 mg 1x2 pc
#14
2. Azithromycin 250 mg 2x1 ac #6
3. Salbutamol MDI 100 mcg/dose 1 puff prn q 4 h #1
4. Seretide evohaler 25/125 mcg/dose 1 puff bid #1
5. Glyceryl guaiacolate 100 mg 1x3 pc #20

Assessment
Etiology:
(Chronic Obstructive Pulmonary
Disease)


(not fully reversible)
(progressive)

(extrapulmonary effects)
90%

1 (Force expiratory volume in one
second: FEV1)
COPD



(pulmonary vasculature)
neutrophils, macrophage T-
lymphocyte (CD8) mediator
leukotriene B4, interleukin 8 tumor necrosis factor

alveolar attachment


7





( )
(purulent sputum)[1]
(Pneumonia)


3 1.
2.
3.( )

(alveolar macrophage function,
mucociliary clearance)

(Community-acquired pneumonia)

(community organism)
(new
pulmonary infiltration)

2

Risk factors:
1.
2.
3.
4.

Severity:
8


 GOLD 2017 Global Strategy for the Diagnosis,
Management and Prevention of COPD[2]

1 The refined ABCD assessment tool [2]

1. Spirometrically confirmed diagnosis

Spirometer

FVC, FEV1 FEV1/FVC


FEV1/FVC
70% FVC
Spirometer
FVC, FEV1 FEV1/FVC
2. Assess of airflow limitation

FEV1
FEV1 80% : GOLD 1 : Mild
FEV1 5079% : GOLD 2 :
Moderate
FEV1 3049% : GOLD 3 :
Severe
FEV1 30% : GOLD 4 : Very
Severe
FEV1

9


 3. Assess of symptoms/risk of exacerbations



2
(Modified
Medical Research Council Dyspnea Score; mMRC)
(COPD Assessment
Test, CAT)
1 (mMRC)[1]
(mMRC)


0

1
2

100 3

4


1

2 Assess of symptoms/risk of exacerbations[2]

2
1

C D

Infectious Diseases Society of America/American

Thoracic Society Consensus Guidelines on the Management of
1

0
Community-Acquired Pneumonia in Adults[3]

CURB-65 criteria

3 CURB-65 criteria[]

- Confusion = E 4V 5M 6 0

(E4 = , V5 = , M6 =

)
- Blood Urea Nitrogen : BUN = 15.99 mg/dL
0
- Respiratory rate = 24/min 0

- Blood pressure = 130/80 mmHg

0
- Age = 53
0
CURB-65 criteria 0
30 0.7 %

Assessment if therapy is indicated:







GOLD 2017 Global
Strategy for the Diagnosis, Management and Prevention of
COPD[2]

1

1

C LAMA


LABA
LABA+ICS D
LAMA+LABA
ICS
LABA+ICS

(1. 2.

3. ) 2 3 Antibiotic
57
Amoxycillin + Clavulanic acid,
Macrolide Tetracycline



Infectious Diseases Society
of America/American Thoracic Society Consensus Guidelines
on the Management of Community-Acquired Pneumonia in
Adults[3]

1

2
 2 Recommended empirical antibiotics for community
acquired pneumonia[3]
Outpatient treatment
1. Previously healthy and - A macrolide (strong
no use of antimicrobials recommendation)
within the previous 3 - Doxycyline (weak
months recommendation)
2. Presence of - A respiratory
comorbidities such as fluoroquinolone
chronic heart, lung, liver (moxifloxacin,
or renal disease; gemifloxacin, or
diabetes mellitus; levofloxacin [750 mg])
alcoholism; (strong recommendation;
malignancies; asplenia; level I evidence)
immunosuppressing - A -lactam plus a
conditions or use of macrolide (strong
immunosuppressing recommendation; level I
drugs; or use of evidence)
antimicrobials within the
previous 3 months (in
which case an
alternative from a
different class should be
selected)
3. In regions with a high
rate (>25%) of infection
with high-level (MIC16
mg/mL) macrolide-
resistant Streptococcus
pneumoniae, consider
use of alternative
agents listed above in
(2) for patients without
comorbidities (moderate
recommendation)

1

3
Assessment of current therapy:
Order for one day
1. Berodual (Fenoterol/Ipratropium) 1 NB q 4 h

Short-
acting

SABASAMA SABA+SAMA
[2]
2. Ventolin (Salbutamol) 1 NB q 4 h

Berodual Fenoterol (SABA)

3. Dexamethasone 4 mg/ml IV


Corticosteroids Dexamethasone

5-10 mg IV q 6 h
7-14 2
[1]
4. O2 Canular 3 LPM oxygen
Oxygen
Saturation 90%[1]
Order for continues
1. Ceftriazone 2 g IV q 24 h Azithromycin 250 mg 2x1 ac

-
lactams Macrolides [3]

2. Paracetamol 500 mg 1 tab po prn

3. Glyceryl guaiacolate 100 mg 1x3 pc




4. Acetylcysteine 200 mg 1x3 pc


1

4
Home Medications
1. Amoxycillin 825 mg + Clavulanic acid 125 mg
1 2 -


-
lactams
[3]

2. Azithromycin 250 mg 2 1


-
lactams Macrolides Macrolides[3]

Morandini G.
Azithromycin

Roxithromycin[4]

3. Salbutamol MDI 100 mcg/dose 1 4


C D
Short-
acting [2]

4. Seretide evohaler (Salmeterol 25/Fluticasone propionate

125 mcg/dose) 1 2 -

LAMA,
LAMA+LABA, LABA+ICS
LAMA
LABA+ICS [2]

5. Glyceryl guaiacolate 100 mg 1 3

--




Plan
Therapeutic Goal:
1

5
 1.
2.
3.
4.
5.
6.
Therapeutic Plan:
1. Amoxycillin 825 mg + Clavulanic acid 125 mg 1x2 pc #14
2. Azithromycin 250 mg 2x1 ac #6
3. Salbutamol MDI 100 mcg/dose 1 puff prn q 4 h #1
4. Seretide evohaler 25/125 mcg/dose 1 puff bid #1
5. Glyceryl guaiacolate 100 mg 1x3 pc #20

Efficacy Monitoring:
Drug Efficacy Parameter
Amoxycillin/Clavulanic WBC
acid
Azithromycin
Salbutamol MDI SpO2, CO2,
Seretide evohaler FEV1
Glyceryl guaiacolate -

Safety Monitoring:
Drug ADR Parameter
Amoxycillin/Clavulanic Diarrhea, Loose stool, -
acid Nausea, Vomiting
Azithromycin Diarrhea, Nausea, -
Vomiting, Headache ALT, AST,
Increased ALT, AST, Bilirubin
Bilirubin
Salbutamol MDI Bronchitis, WBC
Seretide evohaler Nasopharyngitis,
Rhinitis, Sinusitis, -
Upper respiratory
infection
Cough
Glyceryl guaiacolate Nausea, Vomiting -
1

6
Patient Education:
1.

2.
3.
4.

5.
6.

Future Plan:
1.
2.

3.

1. .

.. 2553.
: (.); 2553.
2. Global Initiative for Chronic Obstructive Lung Disease
(GOLD). Global Strategy for the Diagnosis, Management
and Prevention of COPD 2017 Report. [cited 2017 June
3]. Available from: http://goldcopd.org.
3. Infectious Diseases Society of America/American Thoracic
Society Consensus. Guidelines on the Management of

1

7
 Community-Acquired Pneumonia in Adults. [cited 2017
June 4]. Available from: http://www.idsociety.org.
4. Morandini G, Perduca M, Zannini G, et al: Clinical efficacy
of azithromycin in lower respiratory tract infections. J
Chemother 1993; 5:32-36.

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8