Procedure Logs

C3.2 R4(c): Clarify a medication order with a prescriber

ID: AB is a 1 y/o 2 mos. male (=8kg) with query bronchiolitis and/or first episode of reactive airway disease (RAD).

CC: Fever and shortness of breath

HPI: Shortness of breath since the evening prior to admission. Previously no issues with breathing. Fever for 2 days prior to admission. Two bouts of emesis prior to admission.

PMHx: Previously healthy, but had a viral illness (with fever) 1 week ago. Birth hx: born at term, breech and was delivered via C-section. Home with mom (no hospitalization)

Family Hx: No asthma, eczema, allergic rhinitis in family

  • During his emergency visit he was treated as an acute asthma exacerbation (given dexamethasone 4.8mg – 0.6mg/kg/dose) as well as ipratropium (3 puffs via MDI).
  • At admission to the ward, he was prescribed fluticasone 250 mcg BID as well as salbutamol 100 mcg 5 puffs as needed Q4H.
  • Upon discussion with the prescribing resident who admitted AB we brought up that the fluticasone was not indicated, as this was only his first RAD episode, and was in context of a viral illness. Moreover the dose of fluticasone is too high (should be 125mcg BID).
    • The resident was hesitant to discontinue the fluticasone but was willing to decrease the dose. Upon further questioning he was open for pharmacy to  discuss this further in rounds with the attending physician.
  • Upon discussion with the medical team during rounds we advocated that the fluticasone is not indicated (for the reasons above) and we were able to discontinue the fluticasone.

This was a wonderful opportunity to practice safe prescribing and ensure that our patient did not get inappropriately diagnosed and treated indefinitely with inhaled corticosteroids. This was a great way to advocate for my patient and their family, by ensuring they were not having to administer unnecessary medication, and that they were not exposed to unnecessary adverse events.

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