Hospital Inpatient Chart
Sandip Patel: Script 7
Sandip Patel
Was diagnosed with COPD in 2005.
EX -smoker
Prescription number : 7
Today's date : 17th March
You are carrying out your ward round and come across Mr. Patel. He was admitted to hospital 5 days ago, this is the first time you have seen his chart.
Questions
What is wrong with the patient?
What are the issues on the prescription?
What will be the effect on the patient if this isn't corrected?
How will you remedy the situation?
Brief Hospital Notes
Spirometry chest. FEV1 reading 62
X-ray showed COPD
Started on Salbutamol prn & Clenil bd inhaler
Jan 2010
Admitted to hospital ward via with chronic chest infection. nebulised/ oxygen therapy in A&E. Query penicillin allergy patient unsure, Rx erythromycin and oral prednisolone 5 days.
Rx on discharge Tiotropium (spiriva respimat), clenil & Salbutamol inhaler.
13th March 2019
Admitted by walk in center, with chest infection, persistent exacarbation/wheeziness/breathlessness
Feb 2012
Chest clinic appointment
FEV1 deteriation airways, reading 48
Patient difficult with inhaler technique
Rx replace clenil and salbutamol inhaler with combined Seretide 100 accuhaler
13th March 2019
Admitted to A&E via GP referral with persistent exacerbation/breathlessness & chest infection. SpO2 levels = 90%
X -ray taken confirmed infections lungs, query pneumonia ?
ECG clear.
Microbiological sample sent off
FBC, urea, electrolytes samples sent off.
baseline C-reactive protein concentration 120mg/l
see drug treatment chart.