Exp no:1

Cardiogenic Pulmonary Edema.

Dt:

Name: M.kalayan Age: 88yrs

Sex: Male IP No:1603183
DOA:29-09-2020 DOD:05-10-2020

Chief Complaints:
 Overwhelming of pulmonary edema is difficulty breathing,
 Coughing up blood,
 Excessive sweating,
 Anxiety, and
 Pale skin.

History Of Present Illness:

A 88yr male patient was prepared with complaints of wheezing , shortness of
breath and altered sensorium since 20days. He had history of fever with
thrombopenia one month back, followed with altered behaviour. He is non
alcoholic, non smoker and takes mixed diet. From 3 days his urine output was
decreased and constipation was observed.
Patient was conscious. He is pallor and pedal edema was obeseved up to Knees.
 On physical examinations his vital signs were
 BP:130/50mmHg,
 PR:100beats/min,
 RR: 20cycles/min,
 CVS: S1S2+
 RS: Creps,Rhonchi
 CNS: Consicous,coherent and occasionally talks irrelevantly.
  Abdomen: Distension and Suprapublic dullness.
 CT brain scan showed age related diffuse cerebral atrophy.
 2D echo cardiography showed maildly dilated RA and RV, mild TR with
PAH.
 Ultrasonography reported moderate hydrouretero nephrosis.

Problem list:
 Cardiogenic Pulmonary edema

CURRENT MEDICATIONS:
 DRUG DOSE FREQUENCY ROUTE START DATE STOP DATE

Inj.Optineuron 2amp OD Ⅳ 29-09-2020 04-10-2020

Inj.Bactrimfort 3gm BD Ⅳ 30-09-2020 04-10-2020

e
Inj.Pantop 1amp BD Ⅳ 30-09-2020 01-10-2020

Neb.Asthalin 2nd hourly 30-09-2020 01-10-2020

Neb. Duolin 6th hourly 30-09-2020 01-10-2020

Budecort
Tab.Azitral 500mg BD PO 01-10-2020 04-10-2020

Tab.Synasma 400mg BD PO 30-09-2020 03-10-2020

Tab.Amifru OD PO 01-10-2020 03-10-2020

Tab.Dytor 10mg OD PO 02-10-2020 04-10-2020

Tab.Benformat 1 tablet OD PO 03-10-2020 O4-10-2020

plus
Tab.Pantop 40mg OD PO 02-10-2020 04-10-2020

SUBJECTIVE AND OBJECTIVE EVIDENCE:

 Patient was presented with complaints of wheezing, shortness
of breath.
 Decreased urine output and constipation.

Current medications:
 Inj.Bactrim forte 3gm/BD/Ⅳ
 Neb.Asthalin 2nd hourly
 Neb.Duolin Budecort 6th hourly
 Tab.Azitral 500mg/BD/PO
 Tab.Synasma 400mg/BD/PO
  Tab.Dytor 10mg/OD/PO

ASSESSMENT:
Etiology: Congestive heart failure.
Risk factors:
 Left ventricular failure.
 History of lung disease, such as tuberculosis, chronic obstructive
pulmonary disorder. (COPD).
 Kidney failure.
 Vascular disorders.

EVALUATE NEED FOR THERAPY

(EVALUATE CURRENT OR NEW THERAPY)
Cardiogenic Pulmonary edema:
Yes patient needs therapy to reduce symptoms and prevent possible
complications like pulmonary hypertension, acute heart attack, cardiogenic
shock, arrhythmias, electrolyte disturbances, respiratory arrest.

PLANNING
RECOMMEND DRUG TREATMENT (DRUGS TO BE AVOIDED;
FURTHER TESTES)
 The effective dose of Amifru (Furosemide) is 40mg 1tablet daily.
But it was not given in the prescription.
 When Asthalin or the Duolin given with diuretics like Furosemide
and Torsemide causes hypokalemia. So Ipratropium bromide
500mcg 1 unit dose vial can be administered 3 to 4 times a day.

Goals of therapy:
 Reduce symptoms.
 Reduce the fluid in the lungs.
 Improve gaseous exchange and heart function.
 PATIENT EDUCATION
Azithral(Azithromycin):
Take the tablet once daily in the morning.
Take low-sodium or low-salt diet, potassium supplements, and
potassium-rich foods like bananans, raisins, and orange juice in your diet.

Duolin with Budecort:

Twist open the top of one unit dose vial and squeeze the contents in
the nebulizer reservoir.
Connect the nebulizer reservoir to the mouthpiece.
Connect the nebulizer to the compressor.
Sit in a comfortable, upright position; place the mouthpiece in your
mouth and turn on the compressor.
Follow the instructions provided to add the solution to the nebulizer
and inhale the aerosol using the nebulizer.
You should use your nebulizer continually for as long as your doctor
recommends.

Pantoprazole:
Take the medicine at same time each day.
Swallow this medicine as a whole, do not crush or chew the tablet .
Take it 30min before meal, if it upsets your stomach then take it with
food.
DRUG THERAPY PROBLEM WORK SHEET:

Type of problem Possible Cause Comment

Needs different drug More effective drug Ipratropium bromide 500mcg 1 unit
product available. dose vial can be administered 3 to 4
times a day.

Adverse drug reaction Unsafe drug for patient Azithromycin reacts with the pyridoxine
and decreases the level or affect of
pyridoxine by altering the intestinal
flora, so dosing space is required.

PHARMACEUTICAL CARE PLAN

1.Medical problem list: Drug Interaction
Current drug regimen: Azithromycin reacts with pyridoxine.
Drug therapy problem: Decreases the level or affect of pyridoxine by
altering the intestinal flora.

Therapy recommendations: Dosing space is required for 2hrs.

2.Drug therapy problem: Wrong Dose
Current drug regimen: Azithromycin 500mg BD
Therapy goals/ Therapy end points: To reduce the infection.
Therapy recommendations: Azithromycin 500mg orally as a single
dose on the first day followed by 250mg upto 2 or 5 days.
3.Drug therapy problem: wrong dose
Current drug regimen: Bactrim forte 3gm iv
Therapy goals/ therapy end points: To reduce the infection.
Therapy Recommendations: Bactrim forte of 8 to 10 mg/kg given in 2
or 4 equally divided doses through for every 8 or 12 hours for upto 14 days.

REFERENCES:
1. www.webmd.com/.../mono-3223azithromycin+250%2F500+MG+..
2. www.medindia.net/doctors/drug_information/doxofylline.htm
3. www.healthkartplus.com/details/drugs/58409/amifru-40mg
4. www.healthkartplus.com/details/drugs/64284/dytor-plus-10mg
5. www.drugs.com/pantoprazole.html
6. www.mayoclinic.org/disease.../pulmonary-edema/basics/.../con-200224
7. www.nlm.nih.gov/medlineplus/ency/article/000140.htm
8. Reference.medscape.com/drug-interaction checker
9. http://www.inhousepharmacy.biz/p-630-duolin-inhalation.aspx
10. https://www.nhlbi.nih.gov/guidelines/asthma/