The Respi Clinic

65 years old chinese gentleman turned up at the Respi clinic as he developed generalised itchy maculopapular rashes on D8 of the treatment. He was then admitted for reintroduction of anti TB following the onset of adverse reactions on Akurit 4 + pyrodixine.
TB clinic check list:
1) Explore and address the pt's general complaints
2) Explore and address pt's complaints specific to his condition
3) Explore pt's ICE
4) Explore pt's drug compliance
5) Explore any drug side effects
     -minor side effects: reassure, provide symptomatic relieve and encourage pt to continue treatment
                                  if still not relieved, withraw the tx
     - Rifampicin (R)
        Isoniazid (H)
       Pyrazinamide (Z)
       Ethambutol (E)
       Streptomycin (S)       
     -major side effects: ask specifically about drug toxicity
     -double check on drug interactions:
       Rifampicin: Liver Enzyme Inducer - drug plasma level decrease secondary to increase drug metabolism
                                                             OHA, OCP, Oral anticoagulat (warfarin), Cyclsporin,    
                                                             Corticosteroids, Cimitedine, PI, Phenytoin, digitalis glycosides,
                                                            theophylline (Oral, Cs, Ps)
       Isoniazide: Liver Enzyme Inhibitor - drug plasma level increased secondary to decrease drug metabolism
                                                              Phenytoin, CBZ
6) Reinforce pt's knowledge on TB and TB Tx
     -dietry
     -excercise
     - herbal medicine
7) Safety Netting

59 years old obese lady referred to respi clinic TRO OHS (Obesity hypoventilation syndrome) with overlapping OSA. She has the following problems:
1) DM/ HPT
2) Decompensated CCF
3) TRO OHS with overlapping OSA
4) TRO COAD/ adult onset BA: previously working in a painting factory dealing with chemicals for many years and was involved in spraying chemical compounds. She developed sx of SOB with wheezing after stopped working 5 years ago which has become more frequent since the past 2 years. No positive FHx of BA, and there was no obvious PEFR reversibilty seen in the ward.

Investigations done:
HRCT: no evidence of intistial fibrosis
Lung function test: severe restriction
ECHO: poor window dt very obese pt, Mild MR and Mild TR, EF: 56%
ECG: poor R wave progression
ABG: Respiratory acidosis with Type 2 RF (ph 7.318  pco2 59  po2  47  hco3  25.4

Medications:
MDI combivent 2 puffs TDS
MDI seretide 2 puffs BD
montelukast 10mg ON
perindopril 4mg OD
metformin 1g BD
frusemide 40mg OD
aspirin 150mg OD
SR neulin 250mg OD
atorvastatin 40mg OD
Bromohexine 8mg TDS
SC actrapid 16u TDS
SC insulatard 26u ON

Chest clinic checklist:
1) Explore and address the pt's general complaints
2) Explore pt's ICE
3) Explore and address pt's complaints specific to his condition
    ESS
    Mallampati score
4) Explore pt's drug compliance
5) Explore any drug side effects
6) Reinforce pt's knowledge on her condition and current treatment
     -dietry
     -excercise
     - herbal medicine
7) Safety Netting