A CASE STUDY ON

ASTHMA
ASTHMA
 Asthma is a major non-communicable disease
characterized by recurrent attacks of
breathlessness and wheezing, which vary in
severity and frequency from person to person.
Symptoms may occur several times in a day or
week in affected individuals, and for some
people become worse during physical activity
or at night (WHO)
ASTHMA
 According to the latest WHO estimates,
released in December 2016, there were 383,
000 deaths due to asthma in 2015. The
strongest risk factors for developing asthma
are inhaled substances and particles that may
provoke allergic reactions or irritate the
airways (WHO)
ANATOMY, PHYSIOLOGY, AND
PATHOPHYSIOLOGY
ANATOMY, PHYSIOLOGY, AND
PATHOPHYSIOLOGY
ANATOMY, PHYSIOLOGY, AND
PATHOPHYSIOLOGY
ANATOMY, PHYSIOLOGY, AND
PATHOPHYSIOLOGY
ANATOMY, PHYSIOLOGY, AND
PATHOPHYSIOLOGY
ANATOMY, PHYSIOLOGY, AND PATHOPHYSIOLOGY
PARAMETERS
 Pulmonary function tests
 Spirometry (FEV1 and FVC)
 Peak expiratory flow rate (PEFR)
 Blood analysis
 Arterial blood gas measurements

Comprehensive Pharmacy Review for NAPLEX Eighth Edition

EPIDEMIOLOGY
 The Philippines rank number 9 in asthma mortality,
with up to 7.9% of approximately 315 million
suffering from the ailment globally. The prevalence
of asthma in the Philippines alone was reported at
26.7% back in 2002, according to the data from the
National Asthma Epidemiology Survey.
Philippine Daily Inquirer 2018
RISK FACTORS
Precipitating factors of an acute asthma exacerbation may include the
following:
1. Allergens (e.g., pollen, house dust mite, animal dander, mold,
cockroaches, food)
2. Occupational exposures (e.g., chemical irritants, flour, wood, textile
dusts)
3. Viral respiratory tract infections
4. Exercise
5. Emotions (e.g., anxiety, stress, hard laughter, crying)

Comprehensive Pharmacy Review for NAPLEX Eighth Edition

RISK FACTORS
6. Exposure to irritants (e.g., strong odors, chemicals,
fumes)
7. Environmental exposures (e.g., weather changes, cold air,
sulfur dioxide, cigarette smoke)
8. Drugs (e.g., aspirin, medications (or foods) that contain
tartrazine

Comprehensive Pharmacy Review for NAPLEX Eighth Edition

RISK FACTORS (other)
 Family history
 Gender
 Smoking
 Obesity
CASE PROPER
Demographics
Name: R.L.
Age: 43 yrs old
Sex: Female
Weight: 65kg
Height: 5’
Chief Complaint
Patient experienced the following symptoms:
Cough that worsens at night
Wheezing
Difficulty in breathing

Patient also complain about:

Painful urination/Dysuria
Sore throat
Foul vaginal discharge
History of Present Illness
 Non Diabetic
 Asthmatic; no other co-morbidities
Past Medical History
 (-) HTN
 (-) DM
 (-) Kidney Disease
 (+) Asthma
 (+) Allergieswith nuts and
acetaminophen
 (+) CS-twice
 PE/PA History
Social
Smoking Occasional Works as a
(18 pack alcoholic call
year beverage center
smoking) drinker agent
Family History

Father Siblings Mother

(+) Pulmonary (+) Bronchial (+) DM
Tuberculosis Asthma
 Medication History
Medication History
 OC (ethinyl estradiol + levonorgestrel) OD
 Salbutamol inhaler as needed
 Prednisone 2mg tablet as needed
Review of System
(+)high pitched wheezes =Narrowing of the bronchial
tubes
FEV1 of less than 40% =Severe obstruction

PEF variability of > 30% =Red or danger zone. Less

than 50%.
(+) cervical gram stain =Bacterial infection
LAB AND
Lab and DIAGNOSTICS
Diagnostics
Lab test Result Normal value Interpretation

WBC 5.2x109L 4.5 – 11.0x109L Normal

Acute allergic
EOs Increase 0-5
reaction

Curcshmann’s Bronchial
+ asthma
spirals
150 - 400 x
Platelet 201 x 109/L Normal
109/L
LAB AND
Lab and DIAGNOSTICS
Diagnostics
Diagnostic test Result Normal value Interpretation

Normal
Blunting of the R costophrenic angle
Possible Lung
Chest X-ray & L costophrenic measures
hyperexpansion
angles approximately 30
degrees.
 Patient Problem
Patient ProblemList List

 Sore throat
 Painful urination
 Foul Vaginal discharge
 Cough that worsens at night
 Wheezing
 Difficulty in breathing
 Asthma
PHARMACIST’S CARE PLAN
 Pharmacist Care Plan
Health
Pharmacotherap Recommendations / Desired
Care Monitoring Parameters Frequency
eutic Goal Interventions Endpoint
Need
To achieve good S/O: FEV1 <40% Objective Therapeutic:
PEF variability >30% FEV1 80% or greater
control of symptoms   Daily
FVC 80% or greater> 70%
such as cough, chest
Needs additional drug therapy

A: Patient has poor asthma symptom

FEV1/FVC
tightness, wheezing control. She also has several additional risk
(-) SOB
of factors for future exacerbations Subjective Therapeutic:
and dyspnea and Daily
including low lung function, current SOB (-) DOB
reduce future risk of DOB
 
smoking, and poor medication adherence.
exacerbations and   Subjective Toxic  
decline in lung P: We respectfully suggest to initiate Watch out for SE : No occurrence of S.E.
function therapy with Budesonide/Formoterol Oropharyngeal candidiasis Daily
MDI 2 inhalations twice daily every
morning and evening for symptom control
and relief of asthma.
 
Discussion: For patient maintenance
treatment with as needed SABA, adding
LABA to ICS in a combination inhaler
provides additional improvements in
symptoms and lung function with a
reduced risk of exacerbations compared
with the same dose of ICS as per GINA
2018
Health
Pharmacotherap Recommendations / Desired
Care Monitoring Parameters Frequency
eutic Goal Interventions Endpoint
Need
To watch out for We respectfully suggest patient to Objective Therapeutic:
adverse drug reaction use spacer when using Oropharyngeal candidiasis (-) Oropharyngeal Daily
such as Oropharyngeal Budesonide/Formoterol MDI and
candidiasis candidiasis  
rinse the mouth in a “swish and
Subjective
spit” method with water following
use of the inhaler to decrease the Therapeutic:N/A
 
Adverse Drug Reaction

chances of these adverse events

as per GINA 2018 Subjective Toxic: N/A
Health
Pharmacotherap Recommendations / Frequenc
Care Monitoring Parameters Desired Endpoint
eutic Goal Interventions y
Need
To achieve good NON-PHARMACOLOGIC TREATMENT Objective Therapeutic:
We respectfully recommend patient to quit FEV1 80% or greater
control of symptoms smoking and avoid environmental smoke Daily
FVC 80% or greater> 70%
such as cough, chest exposure as it may increase risk of
exacerbations as per GINA 2018 FEV1/FVC
tightness, wheezing
Needs additional drug therapy

and dyspnea and Subjective Therapeutic: (-) SOB

We respectfully suggest patient to engage
reduce future risk of in regular physical activity for it’s general SOB (-) DOB Daily
exacerbations and health benefits as per GINA 2018 DOB  
decline in lung  
We respectfully suggest patient to avoid Subjective Toxic No occurrence of S.E.
function medications that may make asthma worse Watch out for SE : N/A Daily
such as drugs containing acetaminophen as
as well as NSAID’s and aspirin as per
GINA 2018

We respectfully suggest patient to consume

a diet high in fruit and vegetables for it’s
general health benefits

We respectfully suggest patient to avoid

food allergens such as nut containing
products to reduce asthma exacerbations as
per GINA 2018
Health
Pharmacotherap Recommendations / Desired
Care Monitoring Parameters Frequency
eutic Goal Interventions Endpoint
Need
To correct dosage We respectfully suggest to increase Objective Therapeutic:
strength and dose of Salbutamol INH to FEV1 80% or greater Daily
frequency to Salbutamol MDI 90 mcg/actuation: FVC 80% or greater> 70%  
provide desired 4-8 inhalations every 20 minutes for FEV1/FVC  
outcome and up to 4 hours, then every 1-4 hours Subjective Therapeutic:  
as needed for SOB for the SOB (-) SOB Daily
provide
Salbutamol Dose too Low

management of asthma as per DOB (-) DOB  

symptomatic relief Lexicomp  
Subjective Toxic
of asthma Watch out for SE :
Salbutamol: Skeletal Muscle No occurrence of S.E.
Tremor
Daily
Health
Pharmacotherap Recommendations / Frequenc
Care Monitoring Parameters Desired Endpoint
eutic Goal Interventions y
Need
To manage acute We respectfully suggest the Objective Therapeutic:
compliance of patient to Salbutamol FEV1 80% or greater Daily
asthma MDI 90 mcg/actuation: 4-8 FVC 80% or greater> 70%
symptoms such inhalations every 20 minutes for up FEV1/FVC
to 4 hours, then every 1-4 hours as Subjective Therapeutic:
as shortness of needed for SOB as per Lexicomp and (-) SOB Daily
SOB
breath and (-) DOB
Management of Asthma

Prednisone 2mg tab as needed for DOB

prevent acute asthma attacks as per Subjective Toxic
Lexicomp Watch out for SE :
exacerbations  Salbutamol: Skeletal Muscle
Tremor No occurrence of S.E. Daily
Prednisone: Wound healing
impairment
Health
Pharmacotherap Recommendations / Frequenc
Care Monitoring Parameters Desired Endpoint
eutic Goal Interventions y
Need
NON-PHARMACOLOGIC Objective Therapeutic:
To manage acute TREATMENT 80% or greater Daily
FEV1
asthma We respectfully recommend patient to
FVC 80% or greater> 70%
quit smoking and avoid environmental
symptoms such smoke exposure as it may increase risk FEV1/FVC
Subjective Therapeutic:
as shortness of of exacerbations as per GINA 2018 (-) SOB Daily
SOB
breath and (-) DOB
Management of Asthma

We respectfully suggest patient to DOB

prevent engage in regular physical activity for Subjective Toxic
it’s general health benefits as per GINA Watch out for SE : N/A
exacerbations  2018
No occurrence of S.E. Daily
We respectfully suggest patient to
avoid medications that may make
asthma worse such as drugs containing
acetaminophen as as well as NSAID’s
and aspirin as per GINA 2018

We respectfully suggest patient to

consume a diet high in fruit and
vegetables for it’s general health
benefits

We respectfully suggest patient to

avoid food allergens such as nut
containing products to reduce asthma
exacerbations as per GINA 2018
Health
Pharmacotherap Recommendations / Frequenc
Care Monitoring Parameters Desired Endpoint
eutic Goal Interventions y
Need
To prevent occurrence We respectfully suggest patient to Objective Therapeutic:
of disulfiram-type avoid taking alcoholic beverages to Disulfiram-Type reaction (-) Disulfiram-Type Daily
reaction during avoid disulfiram-type reactions. reaction
Metronidazole Abstinence from alcohol use should Subjective Therapeutic:
therapy continue for 24 hours after Nausea (-) Nausea Daily
completion of metronidazole as per Vomiting (-) Vomiting
CDC 2015. Throbbing headache (-) Throbbing headache
Adverse Drug Reaction

Subjective Toxic: N/A

Health
Pharmacotherap Recommendations / Frequenc
Care Monitoring Parameters Desired Endpoint
eutic Goal Interventions y
Need
To provide treatment S/O: Foul Vaginal Discharge Objective Therapeutic:
for bacterial infection Dysuria/Painful urination WBC 4000-11,000/mm3 Once Weekly
suspected bacterial (+) Gram stain Subjective Therapeutic:
vaginosis A: Base from the symptoms Vaginal discharge (-) Vaginal discharge Daily
manifested, patient is suspected to (-) Dysuria
Needs additional drug therapy

Dysuria
have bacterial vaginosis which is Subjective Toxic
treated with antibiotics. Watch out for SE : No occurrence of S.E. Daily
Headache
P:We respectfully suggest to initiate
Nausea
therapy with Metronidazole 500mg
tablet twice daily for 7 days for the
treatment of suspected bacterial
vaginosis as per Lexicomp

Discussion:
As per Lexicomp bacterial vaginosis is
most often treated with Metronidazole
and Clindamycin. The rate of cure for a
seven-day course of metronidazole
(Flagyl) has been reported to be from 84
to 96 percent; for treatment with oral
clindamycin (Cleocin), the cure rate has
been reported to be 94 percent as per
AFP
Health
Pharmacotherap Recommendations / Frequenc
Care Monitoring Parameters Desired Endpoint
eutic Goal Interventions y
Need
To provide treatment Non- Pharmacologic Treatment Objective Therapeutic:
for bacterial infection We respectfully recommend patient to WBC 4000-11,000/mm3 Once Weekly
suspected bacterial refrain from sexual activity or use Subjective Therapeutic:
vaginosis condoms consistently and correctly Vaginal discharge (-) Vaginal discharge Daily
during the treatment regimen as per (-) Dysuria
Needs additional drug therapy

Dysuria
CDC Guideline 2015 Subjective Toxic
Watch out for SE : No occurrence of S.E. Daily
Headache
Nausea
Health
Pharmacotherap Recommendations / Frequenc
Care Monitoring Parameters Desired Endpoint
eutic Goal Interventions y
Need
To prevent unwanted We respectfully suggest the compliance Objective Therapeutic:
pregnacy of patient to Ethinyl estradiol + Pregnancy status Negative As needed
Levonorgestrel one pill once daily for
the prevention of pregnancy Subjective Therapeutic:
Breast tenderness (-) Breast tenderness Daily
Management of contraception

Weight gain (-) Weight gain

Subjective Toxic
Watch out for SE :
Headache No occurrence of S.E. Daily
Nausea