CASE PRESENTATION

Pharmacotherapeutics-2

presented by
Harish.K

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LOWER RESPIRATORY TRACT
INFECTIONS

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 SUBJECTIVE EVIDENCE
PATIENT’S PROFILE:

NAME: XY D.O.A: 11/12/2019 at 3.00 am

AGE:78 years old IP.NO:F32899(4)
MARITAL STATUS: Married REG.NO: 565863
Weight: - Height: -

REASON FOR ADMISSION:, cold, fever, chillness, abdomen pain &

breathing difficulty.

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PAST MEDICAL HISTORY:
1)HTN- 20 years
2)T2DM- 20 years
3)CAD
PAST MEDICATION HISTORY:
1) Tab. Cilacar (CILNIDIPINE) taken 20mg OD for Hypertension.
PREVIOUS SURGERY:
PCI done on 7/3/2018.

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OBJECTIVE EVIDENCE
• On admission patient was conscious, oriented and febrile.
Vitals Observed value
Temperature 99.2℉
Respiratory rate 20 breaths/min
Blood pressure 160/90mmhg
SpO2 96%

Pulse rate 84 b/m

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Vitals on hospitalisation:
Date 11/12/2019 12/12/2019

Time 6AM 10AM 2PM 6PM 10PM 6AM 10AM 6PM 10PM

Temperature (℉) 98.4℉ 101℉ 98.6℉ 98.4℉ 98.6℉ 97.6℉ 100.2℉ 98.6℉ 99.0℉

Heart rate 102 112 111 112 116 112 112 96 98

(beats/min)

Blood pressure 100/60 160/90 180/90 130/80 150/80 140/70 150/70 150/90 130/80
(mmhg)

SpO2(%) 96% 93% 94% 94% 96% 98% 98% 97% 96%

Respiratory 20 20 20 20 20 20 20 20 20
rate(breaths/min)

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Contd…,,
Date 13/12/2019 14/12/2019
Time 6AM 10AM 2PM 5PM 10PM 6AM 10AM 6PM

Temperature (℉) 97.8℉ 98.4℉ 98.6℉ 98.4℉ 98.2℉ 97.8℉ 97.4℉ 97.8℉

Heart rate (beats/min) 124 112 112 106 102 98 96 96

Blood pressure 130/100 140/90 130/80 150/90 120/80 130/90 130/90 12070
(mmhg)

SpO2(%) 96% 93% 94% 94% 96% 98% 98% 97%

Respiratory 20 20 20 20 20 20 20 20
rate(breaths/min)

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Lab investigation tests:

Lab tests Observed value

Hb (mg/dl) 9.9
Total count(cells/cu.mm) 11000
P (%) 87
L (%) 12
DC E (%) 00
B (%) 00
M (%) 01
Total RBC(million cells/cu.m) 3.56
PCV (%) 35.4
MCV (%) 83.6
MCH(g/dL) 33.4
Platelet count (cells/cu) 164000

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 Lab tests Observed value

Date 11/12/19 12/12/19 13/12/19 14/12/19

urea 15 17
FBS 100
RBS 213
Sodium 135 135 139
Potassium 4.6 3.9 4.0 3.6
RDW 15.8
T4 1.2 1.7

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DIAGNOSTIC TEST:
Blood culture test (positive)
 Urine culture test (negative)
 chest X - ray taken
 ECG taken
 CT scan

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ASSESSMENT:
BLOOD CULTURE TEST:
The impression shows the presence of GRAM NEGATIVE
BACTERIA (i.e) E.Coli is present.
CT SCAN REPORT:
The impression shows that the EPIPLOIC APPENDIGITIS
that means inflammation in the stomach by the accumulation of fat.
DIAGNOSIS:
With the patient complaints & blood culture test and symptoms, the
patient was diagnosed to have LOWER RESPIRATORY TRACT
INFECTIONS.

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Goals of treatment:
• Reduce the symptoms.
• Improve quality of life
• Remove or reduce the risk factors.
• Reduce the stomach ache.
• Reduce the breathing difficulty.

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STAT:
DRUG DOSE TIME

Inj. Pantocid 40 mg 6.30 pm

Inj. Emeset 8mg 6.30 pm

Neb . levolin 1 resp 7.30 pm

Inj. Piptaz 0.1ml 10.30 pm

Inj. Piptaz 4.5gm 10.45 pm

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PLAN
Treatment chart:
Drug name Generic name Dose FREQ TIME 11/12 12/12 13/12 14/12

Tab. Elitroxin levothyroxine 12.5mg OD 6 AM    

Tab. Astor Atorvastatin 20mg H.S 9PM   DOSE CHANGES

TO 80 mg

Tab. Astor Atorvastatin 80mg H.S 9PM - -  

Tab. Cordarone Amiodarone 100mg od 9PM -   STOPPE

D

Tab. Esomac D Esomeprazole 20mg OD 6 AM - -  

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Contd….
Drug name Generic name Dose FREQ TIME 11/12 12/12 13/12 14/12

Tab. Silodol Silodosin 4mg HS 9PM   - -

Cap. pregaba Pregabalin 75mg HS 9PM - -  -

Tab. Prazopress prazosin 5mg HS 9PM -   

XR

Tab. Cilacar Cilnidipine 20mg OD 9AM -   

Inj. Human Insulin 15 units BD 8AM    

mixtard 8PM    

Tab. Dolo Acetaminophen 500mg SOS 8AM -  stopped

2PM  -
8PM - -
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Contd..,
Drug Generic name Dose FREQ TIME 11/12 12/12 13/12 14/12
name

Inj . Piptaz Piperacillin/ 2.25gm TID 6AM  Frequency changed

tazobactam 2PM 
10PM 

QID 6AM   
2PM   
6PM   
10PM   

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Pharmacist intervention:
 Hb level is low and RDW is high that indicates patients is in anemic
condition. Here no drug is prescribed for anemia.
 we can prescribe FOLIC ACID orally 1 mg once daily or
RIBOFLAVIN 5mg can be given in orally.

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PATIENT COUNSELLING:
BASED ON DRUG PROFILE
1. Levothyroxine drug should be
taken half an hour before a
breakfast.
2. Silodosin should taken only
with food.
BASED ON DISEASE
PROFILE
1.The seriousness of the disease.
2. In emergency condition
immediately contact the hospital.
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Based on lifestyle & Home remedies:
 Change the clothes if once used.
 Use the own utensils.
 Keep bathroom & surroundings clean
 Avoid contact with the sick person
 Avoid pollutants area such as chemical fumes or industry visits
 Quit smoking.

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THANK YOU
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