Name Age RN Admitted Date

: Shameera Nashreen Binti Mohammad Samar : 12 Years 5 Month : AM00203735 : 21 October 2013

Subjective Patient is 12 years old, Malay girls which refer for acute exacerbations of bronchial asthma (AEBA). She was diagnosed for bronchial asthma since 2 years old. Patient had multiple admissions previously in Serdang Hospital and Pantai Hospital due to her bronchial asthma. Currently, she is undergoing follow up under Serdang Hospital. The medications prescribed are Berodual PRN, Alvesco, Singulair and Loratidine. Patient also under ENT for chronic sinusitis. Currently, she is on Nasonex. She came to Emergency Department previously on 14 October 2013 for AEBA Secondary to Upper Respiratory Tract Infection, poorly controlled asthma. Patient denied admission at that time. She was discharged with T. EES (erythromycin ethylsuccinate) 400mg BD, T. Prednisolone 30mg OD and MDI Ventole. Patient had shortness of breath which is worsening in morning. Multiple nebs given at home but does not seem resolving. She also had cough past 2 weeks with yellowish sputum. Initially it was greenish, but improved after the day 6 with EES. Otherwise, she doesnt have failure symptoms, no chest pain, no palpitation and no other active complaints.

As for asthma control, the past 2 months, she was almost daily taking MDI and 2-3 times per week taking nebs. She had night symptoms but none of day symptoms. There is no exercise induce symptoms, no intubation and no ICU admission.

Objective Patient is alert, no tachypneic, speak in full sentences and no edema. Lungs: equal air entry and no ronchi Abdomen: soft, non-tender BP: 100/54 PR: 95 Spo2: 98% Temperature: 37 Degree Celsius FBC; HMB Haematocrit Platelet WBC 12.8g/dL 38.9% 348 k/uL 8.2 k/uL (12-18) (37-51) (140-440) (4-11)

Imaging; CXR: Hyper inflated lungs, clear lung field Clinically patient had improved.

Assessment Patient was diagnosed with acute exacerbations of bronchial asthma (AEBA) secondary to
partially treated pneumonia.

This due to past upper respiratory tract infections that not fully recovered. This condition contributes to acute exacerbations of bronchial asthma. The role of respiratory infections in asthma is well known; the micro-organisms most commonly involved are viruses and atypical bacteria. C. pneumoniae and M. pneumoniae represent an important cause of human respiratory tract diseases. These agents are involved in upper respiratory tract infections acute bronchitis and exacerbations of chronic bronchitis, and pneumonia. C.pneumoniae infection has been implicated in severe chronic asthma, whereas other groups demonstrated that C. pneumoniae and M. Pneumonia causes AEBA both in children and adult.

Plan For partially treated pneumonia, antibiotic upgraded to IV Augmentin 1.2g stat then tds combined antibiotic treatment given with T. Azithromycin 500mg, stat then od. Amoxicillin-clavulanate (Augmentin) is augmented penicillin that works against a wide spectrum of bacteria. An extended-release form has been approved for treating adults with community-acquired pneumonia caused by bacterial strains that have become resistant to penicillin. Azithromycin antibiotics are effective against atypical bacteria such as mycoplasma and chlamydia. Azithromycin is the first anti-pneumonia antibiotic that can be given in a single dose. It is effective against Gram-positive, Gram-negative, and atypical pathogens. For acute exacerbation of bronchial asthma, nebuliser Ventolin 4 hourly and IV Hydrocortisone given. Ventolin neb is the routine management of chronic bronchospasm unresponsive to conventional therapy and in the treatment of acute severe asthma. It provides short-acting (46 hrs) bronchodilation with fast onset (within 5 min) in reversible airway obstruction. It is particularly suitable for the relief and prevention of asthma symptoms. Ventolin should be used to relieve symptoms when they occur, and to prevent them in those circumstances, recognised by the patient to precipitate an asthma attack. Hydrocortisone is a corticosteroid used for its anti-inflammatory and immunosuppressive effects. MDI Alvesco restarted. It is prophylactic treatment of asthma.160-640 mcg/day should be given. In severe asthma, dose may be increased to 1280 mcg/day. Patient also prescribed with T.Prednisolone 20mg OD and loratidine 10mg ON. To prevent the exacerbation of asthma the allergens such as dust and cat fur.

The investigation should be further includes sputum and blood c&s test. This to clearly identify the suitable antibiotic treats for pneumonia. Assess progress by continued close monitoring of objective measures of improvement. Spirometry is the most reliable measure of response to treatment. Measurement of PEF may be used if a spirometer is not available. In adults with severe acute asthma, measurement of arterial blood gases after initiating treatment is indicated to assess CO2 retention as well as to enable management of hypoxaemia. Oxygen saturation on oximetry (SaO2) should be kept above 90%. eart rate, respiratory rate and pulsus paradoxus (abnormal decrease in systolic blood pressure during inspiration) are also useful measures of response. Reduction in wheezing is an unreliable indicator of improvement, as it may indicate deterioration. Intubation and ventilation are indicated for patients with acute respiratory failure that does not respond to treatment and for respiratory arrest or exhaustion suggesting impending respiratory arrest.

Pharmaceutical Care Issues There pharmaceutical care issues that indentified in this case include the use of the steroid. The steroid withdrawal should be using tapering method. This to prevent the withdrawal symptoms of steroid drugs. Next, the method of using of inhaler. The correct method of using inhaler should be explained to the patient to ensure the effectiveness of the therapy. Further investigations, includes sputum and blood c&s test should be done to ensure correct antibiotic regimens to treat the infection condition. The antibiotic should be changed if the current antibiotic is not effective to resolve the issue.