II.

Brief Discussion of the Disease

Bronchial Asthma in Acute exacerbation

Asthma is a chronic inflammatory respiratory disorder that causes recurrentepisodes of wheezin

g, breathlessness, chest tightness and cough, especially at night or in the early morning. These
asthma episodes are associated with air flow limitation or obstruction that is reversible either
spontaneously or with treatment. Asthma usually begins in childhood or adolescence, but it also
may first appear during adult years. While the symptoms may be similar, certain important
aspects of asthma are different in children and adults.
Bronchial asthma is the more correct name for the common form of asthma. The term 'bronchial'
is used to differentiate it from 'cardiac' asthma, which is a separate condition that is caused by
heart failure. Although the two types of asthma
havesimilar symptoms, including wheezing (a whistling sound in the chest) andshortness of
breath, they have quite different causes.
Bronchial asthma is usually intrinsic (no cause can be demonstrated), but is occasionally
caused by a specific allergy (such as allergy to mold, dander, dust)

a Etiology and Incidence

Allergy is the strongest predisposing factor for asthma. Chronic exposure to airway
irritants or allergens can be seasonal such as grass, tree and weed pollens or
perennial under this are the molds, dustand roaches. Common triggers of
asthma symptoms and exacerbations include air way irritants like air pollutant, cold,
heat, weather changes, strong odors and perfumes. Other contributing factor
wouldinclude exercise, stress or emotional upset, sinusitis with post nasal drip,
medications and viral respiratory tract infections. Most people who have asthma
are sensitive to a variety of triggers. A persons asthma changesdepending on the
environment activities, management practices and other factor.

b Pathophysiology

c ClinicalSymptomatology
The symptoms can range from mild to severe during an exacerbation. They may
include
Shortness of breath
Chest tightness or pain
Trouble sleeping caused by shortness of breath, coughing or wheezing
A whistling or wheezing sound when exhaling (wheezing is a common sign of
asthma in children)
Coughing or wheezing attacks that are worsened by a respiratory virus, such as a cold
or the flu
 a Laboratory Findings

Laboratory testing is used to help rule out conditions that cause symptoms similar to
asthma, to identify allergies, and to help identify and evaluate complications that arise. During
severe asthma attacks, testing may be ordered to evaluate and monitor organ function, oxygen
levels, and the bodys acid-base balance. Tests include:

Blood testing for allergic sensitivity blood tests that are specific for the allergen(s)
suspected to be causing symptoms, such as dust mites, mold, pet dander, and pollens;
may be ordered to help determine asthma triggers.
Blood gases an arterial blood sample is collected to evaluate blood pH, oxygen, and
carbon dioxide; may be ordered when a person is having an asthma attack.
CBC (complete blood count) to evaluate blood cells and provide information on infection
and inflammation
CMP (comprehensive metabolic panel) to evaluate organ function
Theophylline therapeutic drug monitoring if an individual with asthma is taking this
medication

A healthcare practitioner will consider the results of the general tests, medical history, family
history, and risk factors for certain diseases as well as the results of a physical examination.
Based on these findings, some additional laboratory tests could be done. Other tests that may
be occasionally ordered include:

Tests to rule out cystic fibrosis, such as a sweat test or trypsin/chymotrypsin

Sputum culture to diagnose lung infections caused by bacteria
AFB testing to diagnose tuberculosis and nontuberculous mycobacteria (NTM)
Lung biopsy to evaluate lung tissue for damage and for cancer
Sputum cytology occasionally ordered to evaluate cells found in the
lungs; eosinophils and neutrophils, two types of white blood cells, can be increased with
inflammation in some people with asthma.

b Prognosis
Asthma is a disorder that affects individuals of essentially any age group. While it is
particularly common in children, it may persist for decades. In general, once an
asthmatic, long-term an asthmatic. That doesn't mean that the asthma will always be as
severe as it might be initially. And it is also true that asthma, while it waxes and wanes,
may be more severe at certainly times of the year or in certain years than others. There
are certain things that exacerbate asthma such as viral infections and those may also
predispose to a more severe asthma episode.The prognosis of asthma is generally quite
 good. The therapies that are available are excellent and control of asthma is generally
quite easily achieved. It may take more work for some than others and it does take
perseverance in using the treatments that are prescribed. But in general, asthma is not
associated with long-term severe respiratory consequences.

c Complications and Sequela

In rare cases, asthma can lead to a number of serious respiratory complications,
including:

pneumonia (infection of the lungs)

a collapse of part or all of the lung

respiratory failure, where the levels of oxygen in the blood become dangerously low,
or the levels of carbon dioxide become dangerously high

status asthmaticus (severe asthma attacks that do not respond to treatment).

Hypertension

Hypertension is defined by a persistent elevation of arterial blood pressure (BP). It happens

when the force of the blood pumping through the arteries is too strong. Hypertension occurs
when the systolic blood pressure is higher than 120 mmHg and the diastolic blood pressure is
above 80 mmHg, averaged over time. Stages of high blood pressure in adults include:
Prehypertension (120-139/80-89), High blood pressure Stage 1 (140-159/90-99), and High
blood pressure Stage 2 (160 or higher/ 100 or higher). In most cases, a person will
be asymptomatic, having no noticeable symptoms.

a Etiology and Incidence

The true incidence of hypertension is not well known. In earlier studies, the incidence of
hypertensive crisis in the hypertensive population ranged between 1% and 7%. In a recent
study, the incidence was found to be 1 to 3 cases per 100, 000 per year in the general
population.

Several investigators have noted a declining incidence of hypertensive crisis, probably

owing to improvements in detection and therapy of patients with essential hypertension. This
impression was not collaborated in a recent study, in which no decline in the incidence of
hypertensive crisis was found an observation that the investigators hypothesized to be due to
racial factors.

Patients with hypertensive crisis are more commonly male, as is also the case in essential
hypertension. By contrast, the peak incidence of hypertensive emergencies is at age 40 to 50
years and differs from the incidence of uncomplicated essential hypertension, which increases
with age. Smokers appear to have a higher risk for the development of hypertensive crisis.

The factors that lead to severe and rapid elevation of blood pressure in patients with
hypertensive crisis are poorly understood. Many patients who experience hypertensive
emergencies had preexisting essential hypertension. In this respect, temporary discontinuation
of prescribed antihypertensive drugs is a frequent cause of a hypertensive crisis. In some
series, however, the incidence of underlying renal disease was found to be even higher than
50%. Other causes such as pheochromocytoma, oral contraceptives and several other drugs,
primary hyperaldosteronism, renal carcinoma and cholesterol embolism, are less common. With
the appearance of the drug called ecstacy, a new cause of hypertensive crisis has been
introduced.

b Pathophysiology

c Clinical Manifestation / Symptomatology

Patients with uncomplicated primary hypertension are usually asymptomatic initially. For
patients with secondary hypertension, they may complain of symptoms suggestive of the
underlying disorder. Patients with pheochromocytoma may have a history of paroxysmal
headaches, sweating, tachycardia, palpitations, and orthostatic hypotension. In primary
aldosteronism, hypokalemic hypertension secondary to Cushings syndrome may complain
 of weight gain, polyuria, edema, menstrual irregularities, recurrent acne, or muscular
weakness.

d Laboratory Findings

Laboratory testing is not diagnostic for hypertension, but tests are frequently ordered to detect
conditions that may be causing and/or exacerbating high blood pressure and to evaluate and
monitor organ function over time.

General tests that may be ordered include:

Urinalysis, urine protein to help assess kidney function

Urinary albumin (microalbumin), BUN (blood urea nitrogen) and/or creatinine to detect
and monitor kidney dysfunction or to monitor the effect of medications on the kidneys
Potassium as part of the electrolyte panel, which also includes sodium, chloride, and
carbon dioxide (CO2); to evaluate and monitor the balance of the body's
electrolytes. Cushing syndrome and Conn syndrome often cause low potassium, which can
be a clue to their presence. Some high blood pressure medications can upset the balance
by causing excessive loss of potassium or potassium retention.
Fasting glucose, A1c to help recognize diabetes and to monitor glucose control over
time in diabetic patients
Calcium to determine how much total calcium or ionized calcium is circulating in the
blood; increased activity of the parathyroid glands, which produces an increase in serum
calcium, is associated with hypertension.
TSH (thyroid stimulating hormone) and T4 to detect and monitor thyroid dysfunction
Lipid profile to evaluate levels of total cholesterol, HDL cholesterol, LDL cholesterol
and triglycerides and assess the risk of developing atherosclerosis
The basic metabolic panel (BMP) includes several of the tests listed above, so it may be
ordered instead of the individual tests.

Specific tests based on the individual's medical history, physical findings, and routine laboratory
test results may be ordered to help detect, diagnose, and monitor conditions causing secondary
hypertension. They include:

Aldosterone and renin to help detect the overproduction of aldosterone by the adrenal
glands (which may be due to a tumor) or renin by the kidneys (which may be due to kidney
damage or narrowing of the arteries bringing blood to the kidneys)
Cortisol to detect an overproduction of cortisol that may be due to Cushing syndrome
Catecholamines and metanephrines to measure epinephrine, norepinephrine, and
their metabolites, primarily to help detect the presence of a pheochromocytoma that can
cause episodes of severe hypertension
a. Prognosis
The prognosis in hypertensive crisis in the earlier days was grim: Almost all
patients died within 5 years, with less than a 20% 1 year survival rate. Most of these
patients died from the complications of uremia. The introduction of antihypertensive
agents and dialysis has greatly improved prognosis; Nowadays, the 5 year survival
rate is approximately 75%. Renal function at presentation still appears to be an
important prognostic factor. Also, differences in underlying factors may be related to
survival: Kawazoe and associates observed a better long term prognosis in patients with
underlying renal disease than in those with essential hypertension, although this
observation is not consistent with earlier finding.

b. Complication and Sequelae

The excessive pressure on your artery walls caused by high blood pressure can
damage your blood vessels, as well as organs in your body. The higher your blood
pressure and the longer it goes uncontrolled, the greater the damage.

Uncontrolled high blood pressure can lead to:

Heart attack or stroke. High blood pressure can cause hardening and thickening of the
arteries (atherosclerosis), which can lead to a heart attack, stroke or other complications.
Aneurysm. Increased blood pressure can cause your blood vessels to weaken and
bulge, forming an aneurysm. If an aneurysm ruptures, it can be life-threatening.
Heart failure. To pump blood against the higher pressure in your vessels, your heart
muscle thickens. Eventually, the thickened muscle may have a hard time pumping
enough blood to meet your body's needs, which can lead to heart failure.
Weakened and narrowed blood vessels in your kidneys. This can prevent these
organs from functioning normally.
Thickened, narrowed or torn blood vessels in the eyes. This can result in vision loss.
Metabolic syndrome. This syndrome is a cluster of disorders of your body's metabolism,
including increased waist circumference; high triglycerides; low high-density lipoprotein
(HDL) cholesterol, the "good" cholesterol; high blood pressure; and high insulin levels.
These conditions make you more likely to develop diabetes, heart disease and stroke.
Trouble with memory or understanding. Uncontrolled high blood pressure may also
affect your ability to think, remember and learn. Trouble with memory or understanding
concepts is more common in people with high blood pressure.

Seizure

A seizure is an abnormal, unregulated electrical discharge that occurs within the

brains cortical gray matter and transiently interrupts normal brain function, which leads
to changes in behavior, function, or attention. These manifestations can include visible
abnormal motor activity, loss of consciousness, and/or memory loss, as well as
abnormal sensory, psychic, or autonomic symptoms, altered awareness, abnormal
sensations, focal involuntary movements, or convulsions (widespread violent involuntary
contraction of voluntary muscles).
 a Etiology and Incidence
Seizures can be triggered by numerous temporary and potentially correctable
conditions such as high fever, head trauma, electrolyte disturbances, medications,
alcohol withdrawal, vascular malformations, tumor, infection, or stroke. These seizures
are considered to be provoked and will not recur once the offending cause is corrected.
If seizures occur repeatedly and chronically, and it is not provoked by an identifiable
cause, the condition is called epilepsy.

b Pathophysiology

c Clinical Symptomatology

Seizure signs and symptoms may include:

Temporary confusion
 A staring spell

Uncontrollable jerking movements of the arms and legs

Loss of consciousness or awareness

Psychic symptoms

d Laboratory Findings

An EEG (electroencephalogram) is the test to check the electrical activity in the

brain. People with epilepsy often have abnormal electrical activity seen on this test. In
some cases, the test shows the area in the brain where the seizures start. The brain
may appear normal after a seizure or between seizures

A complete physical examination on the patient, including a thorough

neurological examination must be performed. In addition to a careful history and
examination, selective laboratory screening along with other tests should be performed
to look for temporary or reversible causes of the seizure. Therefore, electrolytes,
glucose, calcium, magnesium, CBC, renal function, liver function, and toxicology
screenings should be determined.

e Prognosis
Seizures are eliminated in one third of patients with epileptic seizures and
frequency of seizures is reduced by greater than 50% in another third and about 60% of
patients whose seizures are well-controlled by drugs can eventually stop the drugs and
remain seizure-free.

f Complications and Sequelae