Case
A 38-year-old male patient, Mr. S A, visits the pharmacy with complaints of Shortness of breath (SOB)
for the past 3 days. He mentions that he recently recovered from a cold and had been taking over-thecounter (OTC) medication for the past month. He has a history of hypertension. His blood pressure was
recorded at 145/90 mmHg during his visit.
He reports no significant lifestyle changes but admits to Smoking.
ASSESSMENT OF THE PATIENT
A 35-YEAR-OLD MAN WITH 3-days HISTORY OF Shortness of breath
- Is the shortness of breath acute or chronic? Chronic:
-Does the shortness of breath worsen with physical activity or at rest? During activity
-Is the SOB associated with chest pain? No
-Are there any accompanying symptoms? Cough Wheezing:
-How many cigarette packs per day for how many years? 2 pack per day for 3-4 years
DO YOU DRINK ALCOHOLIC BEVERAGES? No
- Have you been exposed to allergens or irritants? No
-Do you have palpitation? No
-Do you experience swelling in your legs or abdomen? No
-Do you feel worse when lying flat? yes
-Have you noticed fatigue, pale skin, or dizziness? No.
ANY CHANGES IN BOWEL HABITS, SUCH AS DIARRHEA OR CONSTIPATION? NO.
DOES THE SOB WAKE YOU UP AT NIGHT? No.
IS THE SOB WORSE WHEN YOU LIE DOWN? Yes.
WHAT PRESCRIPTION MEDICATIONS DO YOU TAKE? I Don’t know, I don’t take it
regularly
WHAT NONPRESCRIPTION MEDICATIONS DO YOU TAKE REGULARLY? NONE
DO YOU TAKE Acetaminophen OR IBUPROFEN PRODUCTS OFTEN? Rarely, for headache.
His Vital sign are as follows:
Respiratory rate 23
Pulse rate 86 bpm
Blood pressure 145/90 mmhg
Temperature 37 degree
Spo2 97%
Assessment: After assessing the patient we diagnosed that his SOB symptom is most likely
caused by COPD ,mostly due to smoking
Patient care plan
Monitoring plan:
Not-Pharmacological treatment
-Smoking Cessation
-Air Quality management ex: wearing masks for outside
-Breathing exercise
-Physical activity
-Healthy diet
-Educate patient about symptoms
-Educate patient to taking medications properly
-management of stress
Pharmacological treatment
-Mucolytic syrup for cough (Guanifensin)
-We recommend the patient to go to physician ASAP, For taking medications
Such as : Broncho-dilators (SABA) Salbutamol
(LAMA) Formetrol
Also, as guidelines said we can recommend Broncho-dilator drug such as Theophylline for treating SOB
and make easier to breath with patient.
1. Clinical Analysis: Based on Mr. Ahmed’s symptoms and lab results, what is the most likely diagnosis?
2. Drug Interactions: Could the OTC medication or his current prescriptions be contributing to his
symptoms? Why or why not?
3. Liver Function: How do his elevated ALT, AST, and bilirubin levels correlate with his symptoms? What
could be causing this?
4. Lifestyle Factors: How might his alcohol consumption and chemical exposure contribute to his
condition?
5. Management Plan: What immediate actions would you recommend to address his symptoms and
prevent further complications?
6. Patient Education: What advice would you provide regarding his lifestyle, including alcohol
consumption, chemical exposure, and medication use?