Clin-pharm-report.pdf

1:30-4:30 TUES A403

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Cough Wheezing Mild difficulty breathing during normal activities Difficulty sleeping Hiccups Peak expiratory flow rate (PEFR) is 70 to 90% of personal best

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Severe cough Moderate wheezing Shortness of breath Chest tightness that usually worsens with exercise Inability to sleep Nasal congestion PEFR is 50 to 70% of personal best

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Severe wheezing Severe difficulty breathing Inability to speak in complete sentences Inability to lie down Signs of severe difficulty breathing Use of accessory muscles: neck muscles are prominent during each breath Sharp, chest pain when taking a breath, coughing PEFR is <50% of personal best Confusion Rapid pulse Fatigue Rapid breathing rate 6

◉ Ideally, asthma severity is determined before initiating therapy. The EPR-3 guideline classification divides asthma severity into four groups:

 Intermittent  Persistent-mild  Persistent-moderate  Persistent-severe *Note: “Mild-intermittent,” a classification in previous reports, has been eliminated. This term really only applies to mild disease, and not to patients with periods of moderate or severe exacerbation.

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Classification of a patient's disease also depends on current impairment and future risk.

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Impairment is determined by patient symptoms and objective measurement of lung function.

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The guideline recommends that, at a minimum, assessments of the patient's symptoms include:

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daytime symptoms nighttime awakenings frequency of short-acting beta agonist use for symptom relief, and inability to do (or difficulty with) normal activities because of symptoms

***Spirometry is recommended as a component of the determination of current impairment. In addition, future risk is categorized by the frequency of oral 8 systemic corticosteroid use.

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Terri Collins is an 8-yo AfricanAmerican girl who presents to the ED with a 2-day history of fevers, malaise, and nonproductive cough. The mother gave acetaminophen and ibuprofen to help control the fever. The mother stated that “a lot of other kids in her class have been sick this fall, too”. Terri started having trouble breathing the morning of admission, and the mother gave her albuterol, 2.5 mg via nebulization twice within an hour.

African-American more severe asthma, higher IgE levels, higher degree of steroid dependency ED Emergency Department APAP & Ibuprofen Combination of Antipyretic Albuterol Management of Asthma 10

Terri still sounded wheezy to the mother after the albuterol, and Terri stated it was “hard to breath”. Terri was previously well controlled regarding asthma symptoms. Previous clinic notes reported symptoms during the day only with active play at school or at home and rare nighttime symptoms. She use PRN albuterol to help with symptoms after playing. Her assessment in the ED revealed Terri to have labored breathing, such that she could only complete four to five-word sentences.

Wheezing High pitch whistling sound.

Labored Breathing Abnormal breathing Increased effort to breath

She had subcostal retractions, tracheal tugging with tachypnea at 54 breaths/min. Her other vital signs were a heart rate of 160 bpm, BP of 115/59, temperature of 38.8°C, and a weight of 22.7 kg. The initial oxygen saturation was 88%, and she was started on oxygen at 1 L/min via nasal cannula. Subcostal Retractions Indrawing of abdomen Tracheal Tugging Downward pull of trachea Tachypnea Abnormal rapid breathing

Vital Signs of the Pt HR 160 bpm BP 115/59 T 38.8 °C Wt 22.7 kg O2 sat. 88%

Normal 70-110 bpm 95-110 / 60-73 mmHg 36.5-37.5 °C

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Bilateral expiratory and inspiratory wheezes were noted on examination. A chest x-ray revealed a right lower lobe consolidation consistent with pneumonia and possible effusion. After receiving three albuterol/ipratropium nebulizations, her breath sounds and oxygenation did not improve. 1

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Albuterol

Oxygen

Methylprednisolone

Continuous nebulization at 10 mg/h

Titrated to 3 L/min

Pediatric Intensive Care Unit (PICU)

25 mg IV

Magnesium Sufate 600 mg IV

Further treatment and monitoring

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Asthma, last hospitalization 4 years ago, and last course of oral corticosteroids over a year ago

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Asthma on father’s side of the family

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Lives with mother, father, and two siblings, both of whom have asthma. There are two cats and a dog in the home. Father is a smoker, but states that he tries to smoke outside and not around the kids. She is in the second grade and is very active on the playground.

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Lives with mother, father, and two siblings, both of whom have asthma. There are two cats and a dog in the home. Father is a smoker, but states that he tries to smoke outside and not around the kids. She is in the second grade and is very active on the playground.

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Lives with mother, father, and two siblings, both of whom have asthma. There are two cats and a dog in the home. Father is a smoker, but states that he tries to smoke outside and not around the kids. She is in the second grade and is very active on the playground.

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a. Before hospitalization

1. Albuterol

2. Fluticasone

Short-acting Inhaled B2-Agonist

Inhaled Corticoster oid

Asthma

Activate beta 2 adrenergic receptors

Tachycardia Hyperglycemia

Asthma

Inhibits inflammatory cells, secretion of histamines, cytokines and leukotrienes

Oral candidiasis Hoarseness

a. Before hospitalization DRUGS

3.Acetaminophen

4. Ibuprofen

USE

INDICATION

MECHANISM OF ACTION

ADVERSE EFFECTS

Rash Disorientation

Edema Dizziness

Anti-pyretic

Fever

Inhibits prostaglandin synthesis

NSAIDs

Pain

Inhibits COX 1 & COX 2

b. During hospitalization

1. Tiotropium

2. Methylprednisolo ne

3. IV Magnesium sulfate

Anticholinergic

Systemic corticosteroi d

Adjunct therapy

Upper Respiratory Tract Infection Dry mouth

Asthma

Inhibits M3 receptors at smooth muscle

Asthma

Binds and activates specific nuclear receptors

Adrenal suppression Erythema

Asthma

Inhibits calcium channels of airway smooth muscle

Hypotension Malaise

Consolidation

Result of replacement of air in the alveoli by transudate, pus, blood, cells or other substances

Pneumonia is by far the most common cause of consolidation

The disease usually starts

within the alveoli and spreads from one alveolus to another.

RIGHT LOWER LOBE CONSOLIDATION

(+) Fever

Cough increased work of breathing 23

Alert and oriented but in mild distress with difficulty breathing

generally alert and responsive to verbal and pain stimuli

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◉ BP 125/69 (Normal)

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Pulse 120 (Borderline Normal)

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◉ T 37.9ºC; (elevated) ◉ RR 40, (rapid)

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O2 sat 94% on 3 L/min nasal cannula

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◉ Skin Rashes

Bruises

Presence of skin rashes are examined since asthma and allergy can occur together. Yet, the patient doesn't experience any of those Presence of bruises are observed since the patient has fluticasone which is a inhalational corticosteroid that can cause thinning of skin and easy bruising. 27

Normocephalic (NC)

Pupil, Equal, Round, Reactive to Light and Accommodation

Atraumatic (AT)

(PERRLA)

Same size normal condition

Perfectly round

Reactive to light

without significant abnormalities

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◉ That means the neck is

Soft and Supple

Cervical lymphadenopathy

bendable and found no swelling, meaning the patient doesn't have enlarged lymph nodes that can be the cause of the patient’s , irregular breathing and wheezing .

Wheezes throughout all lung fields and still with subcostal retractions - Is the movement of muscles of the abdomen below the rib cage pull inward upon breathing. Subcostal Retractions

Usually seen in infants and children

aka. belly breathing

Inflammation and narrowing of the airway This is due to airway obstruction

- experiencing respiratory distress that can be manifested by tachypnea.

RRR; no m/r/g Meaning

translation

Heart exam - Regular rate and rhythm without murmurs, gallops, or rubs The heartbeat is of normal speed and consistent rhythm, without any extra sounds indicating abnormalities of the heart. 31

RRR; no m/r/g • RRR or regular rate and rhythm is noted when the heart is functioning completely normal.

• No m/r/g or murmurs, rubs, or gallops which denotes the absence of abnormalities in cardiac assessment.

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Soft, ntnd

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No Clubbing or Cyanosis ◉ ◉ ◉

Clubbing is an enlargement of the ends of the fingers and a downward sloping of the nails. It is not caused by COPD, but it can be a sign of coexisting lung cancer. Most cyanosis occurs because of a lack of oxygen in the blood. This can be caused by the problems with the lungs or blood clot in the arteries of the lungs (pulmonary embolism). In our case, Terri Collins has no clubbing or cyanosis. Therefore, our patient does not have other respiratory problems aside from asthma. 34

A & O, no focal deficits ◉ ◉

The patient is alert and oriented or A & O meaning she is conscious. Patient is oriented to self or person meaning the patient knows her own name and significant others. Absence of focal deficits or there are no signs of impairments of nerve, spinal cord, or brain function. Therefore, there are no specific manifestations in the some regions of the body, eg. Weakness in the left arm, the right leg, paresis or plegia.

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Potassium

3.1 mEq/L

3.5-5 mEq/L

• Albuterol -Sympathomimetic action

Lymphocytes

5%

20-40 %

• Redistribution of circulating lymphocytes • Cortisol 36

22-28 mEq/L

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Carbon dioxide (CO2)

29 mEq/L

Glucose

154 mg/dL

70-99 mg/dL

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Glucocorticoids

RBC

5.07 x 106/mm3

3.5-5.0 x 106/mm3

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Inflamed and narrowed airways, decrease air flow

WBC

34.2 x 103/mm3

4-11 103/mm3

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Glucocorticoid will increased polymorph nuclear leukocytes

Neutrophils

91%

40%-70%

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Corticosteroids -Neutrophilia -Inhibit neutrophils 37 to adhere to vessel walls

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Destroyed tissue in the lungs Deterioration of gas exchange