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clinical pharmacist in community pharmacy and GP pharmacy setting.

Introduction
Ali – clinical pharmacist in community pharmacy and GP pharmacy setting.
Patient details;
Mrs. KM
Female
Aged 27
Presenting Complaint;
Wheeze and intermittent shortness of breath
Coughing – more frequent at night
History of Presenting Complaint;
Wheeze present over last few months, relieved by use of salbutamol inhaler, however frequency of occurrence increasing over past 3 weeks.
Cough worsened over previous 2 weeks, particularly worse at night. Occasional relief by taking robitussin dry cough syrup (pholcodine is the active ingredient)
Wheeze not predictable as present at random intervals throughout the day, often 2 puffs of salbutamol provide temporary relief but do not control. This has been ongoing for much of the current year – Mrs KM has wanted to speak to the GP or her asthma nurse but has been unable to do so due to no face to face appointments initially available as a result of COVID.
Last asthma review with nurse was July 2019.
Has NOT been using clenil inhaler regularly – often forgets and leaves inhaler either at home or at work – works at heathrow airport alternating between day and night shifts as security staff member.
Has not felt need for hospitalisation but symptoms interfering with sleep and day to day activities in an increasingly progressive matter – patient is also aware of the risk uncontrolled asthma poses and doesn’t want it to be too late.
Past Medical History;
Asthma – diagnosed at age 14
Social History;
non-smoker
occasional alcoholic beverage – less than 10 units a week on average
no recreational drugs
no pets, no children
lives with partner who doesn’t smoke and works from home in IT
Medical History;
Ventolin 100mcg Inhaler 1-2 puffs four times daily when required
Clenil Modulite 100mcg inhaler 2 puffs twice daily
Desogestrel 75mcg tabs – 1 tablet daily (contraceptive)
No known drug allergies
Assessment and observations;
temperature = 36.4 (no fever) blood pressure = 127/72 hear rate = 78bpm
respiratory rate = 14 no tremor, no signs of cyanosis not obese – 51kg, 162cm
lung auscultation using stethoscope – wheeze upon exhale (rear facing due to covid)
no crackles, no stridor, no difficulty taking deep breaths
lymph node palpitation – no noticeable swelling of the neck no sputum upon coughing
Differential Diagnosis;
Bronchiectasis – no sputum, no fever, glands not swollen, no signs of infection
COPD – unlikely due to age, non smoker, social history doesn’t suggest regular exposure to smoke elements, wheeze often relieved by use of salbutamol (SABA) inhaler
COVID-19 – no signs of infection, no changes in sensory smell/taste, confirmed negative PCR test as compulsory by employer
Diagnosis – uncontrolled asthma
– previous diagnosis of asthma
– clear wheeze present during expiration upon auscultation assessment
– non-productive cough
– symptoms relieve by SABA
– SABA used more than 3 times a week with daytime symptoms, disruption of sleep, and disruption at work
– lack of concordance with clenil inhaler – not being used regularly as prescribed
Prescribing Action;
Fostair 100/6 Nexthaler – 1 puff twice daily, up to 8 puffs daily if needed in presence of wheeze x 2 inhalers (1 for work 1 for home)
– review after 8 weeks
Non-Pharmacological action/advice;
– inhaler technique shown and confirmed by asking patient to demonstrate
– new medicine service signposted to community pharmacy
– keep log/diary of when wheeze occurs/worsens and identify possible triggers
– avoid use of NSAIDS over the counter
– re-emphasise importance for fostair inhaler to be used twice daily regardless if symptoms absent
– if finding that needing to use more than 6 puffs of fostair daily and symptoms not improving – ask for earlier review with gp surgery.

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