General data

42 y/o
Female Single Filipino Catholic Self-employed Residing in caloocan city

Chief complaint:
Difficulty of Breathing

History of present illness

3 DAYS PTA 2 DAYS PTA 1 DAY PTA
Fever of 38-39C relieved by paracetamol 500mg Productive cough with yellowish mucoid phlegm No consult done

Fever of 38C not relieved by paracetamol 500mg Productive cough with greenish mucoid phlegm, took carboceistein affording no relief No consult done Persistence of above symptoms Shortness of breath temporarily relieved by salbutamol nebulization Shortness of breath Air hunger upon taking few steps Nebulized with salbutamol affording no relief
Consult at E.R.

FEW HOURS PTA

ADMISSION

Past medical history

(+) asthmatic Managed by salbutamol, celestamine (-)hypertension
(-)DM (-)CVD (-)allergy to food and drugs (+) hyperthyroidism ; patient taking methimazole

Family history
(+)HPN- paternal
(+)DM- paternal (+) asthma- maternal

Personal/social history
Self-employed
Non-smoker Non-alcoholic beverage drinker

Review of systems
General:(+) fatigue, (-) fever, (-) weight loss. Skin:(-) rashes, eczema, itching, color changes, lumps,

nightsweats, excessive dryness or moistness, nail changes, mole changes Head: (-)headache, (-) dizziness, (-) hairloss Eyes: (-) eye pain, tearing, dryness, diplopia, glaucoma, cataracts, blurring of vision, itching, redness, discharge. Ears: (-) earache, (-)discharge. Nose/sinuses: (-) cough and colds, (-) bleeding, (-) stuffiness, (-) facial/sinus pain. Throat/mouth: (-) sore throat, (-)pain, (-) dysphagia, (-) hoarseness, dental cavities, taste problems

Review of systems
Neck: (-) lumps, (-) goiter, pain, stiffness. (-) swollen

lymph nodes. Respiratory: (+)dyspnea (-) cough, (-)hemoptysis, , orthopnea. Cardiovascular: (+) palpitations, (-) chest pain, (-) cyanosis GI: good appetite, once a day bowel movement , (-) nausea, vomiting, bowel movement regular once a day, no recent change in bowel movement pattern, color, consistency. No jaundice, no post meal abdominal pain, (-) rectal bleeding.

Review of systems
Urinary: (-) hesitancy, urgency, dribbling, residual urine. (-)

increase force of urinary stream. (-) oliguria, (-) dysuria, (-) nocturia. Female Repro: (-)discharges, or sores, (-) abnormal bleeding Musculoskeletal: (-)generalized weakness, (-) pain, (-) backache, difficulty in moving extremities. Neurologic: No numbness, no paralysis, (-) seizures, convulsions, loss of balance, speech problems, loss of memory (+) tremors Hematologic: (-) pallor, no easy bruising. Endocrine: (-) heat / cold intolerance, (-) polyuria, (-) polydipsia. Psychiatric: (-) unusual prolonged sadness, (-) mood swings, anxiety, nervousness, phobias, insomnia.

Physical examination
General: The patient is seen as weak looking,

obtundent, medium height with small built, cyanotic, fairly well kempt and groom with poor hygiene, with unsustained eye contact, sitting on bed lying forward, restless. The patient is in cardiorespiratory distress Vital signs:
BP: 120/70 PR: 153 RR: 45 Temp: 36.9C

Physical examination
Skin: cold and clammy, with good skin turgor. Nails with cyanosis. No macuopapular changes. No suspicious nevi. No lesion, no open wounds HEENT Head Hair is black colored and distributed diffusely, without focal area of hair loss. Scalp is intact without obvious lesion
Eyes Sclera were anicteric and conjunctiva were pale, no ptosis, (+)

exophthalmos, lesions, deformities, or asymmetry. No visual field defect on all quadrants, intact extraocular movements, both pupils equally round and reactive to both light and accommodation. tympanic membrane with good cone of light of nasal bone.

Ears AD: intact tympanic membrane with good cone of light, AS: intact

Nose nasal mucosa is pink, septum is midline. No obvious lesion. No fracture

Physical examination
Neck:

Supple and midline and symmetric. The thyroid isthmus is located between the apex of the thyroid cartilage and substernal notch. The thyroid gland lobes are enlarged. JVP 2cms, normal. normal pink and moist mucosa. No active ulcerations were found. Tonsils are not enlarged. Midline uvula. Symmetric soft palate.

Mouth/Throat: Oral mucosa to the posterior pharynx presents with

Thorax and lungs: No abnormal lesion or open wounds, with chest

retractions, subcostal and supraclavicular. Thorax is symmetric and expands bilaterally equal on both posterior and anterior chest. AP diameter is 2:1. Tactile fremitus is not increased on posterior and anterior chest. Lung area is mostly hyperreresonant except in the area of cardiac dullness. Both lobes of the lungs are wheezes, especially on the upper lobe,

Physical examination
Cardiovascular: Dynamic precordium. Point of maximal

impulse is tapping, 7cm lateral to midsternal line in 5th ICS. There was a tachypneic with irregular rhythm. The carotid pulses were normal and 3+ bilaterally without bruits. Peripheral pulses were 3+ and symmetric. is flat. Normoactive bowel sound (12/min) is noted. No direct tenderness. (-) obturator sign (-) heel jarring test, (-) psoas sign, (-) rovsing sign. Entire abdomen is tymphanitic except for the area of liver dullness. Liver span measures 6cm midclavicular. Liver edge and spleen is not palpable. No costovertebral angle tenderness.

Abdomen: No abnormal lesions, no visible mass. Abdomen

Physical examination
Genitalia: Not examined
Extremities: No cyanosis, clubbing or edema. Both legs

are equal in length and size, and without abnormal lesions. The upper extremities have equal length and size. No restricted mobility on all extremities.

Salient features
Subjective Difficulty of breathing Fatigue Palpitations Tremors Objective Fever Productive cough Known asthmatic Known hyperthyroidism Tachypnea Tachycardia Wheezes Chest retractions Unresponsiveness to bronchodilators

Initial diagnosis
Acute respiratory distress 2 to status asthmaticus
Community acquired pneumonia, moderate risk

Differential diagnosis
Bronchial Asthma
COPD Pneumonia Congestive heart failure

Allergen (exposure) / exercise / stress

Infection

Irritation of airways

Activation of Alveolar macrophage

Phagocytosis IgE Production Ag-Ab reaction

IgE antibodies binds to mast cells in airway mucosa

Release of mediators

FEVER

Histamine tryptase

Prostaglandins D2 Leukotrienes C4 Platelet activating factor

Cytokines IL4, IL 5 GM-CSF TNF

Released in airway mucosa Attract and activate Airway smooth muscle contraction eosinophils Vascular Leakage ECP MBP Proteases PAF neutrophils

bronchoconstriction

DIFFICULTY OF BREATHING

Definition
Chronic inflammatory obstruction of the airway
Airway hyperresponsiveness Wheezing, breathlessness, chest tightness, coughing

Prevalence
300 million affected
10-12% in adults; 15% in children Developed countries > developing countries

Factors influencing asthma

Host factors Genetics Obesity Sex Environmental factors Allergens Infections Occupational sensitizers Tobacco smoke Air pollution diet

Mechanism of asthma
Allergen
Mast cells Airway structural cells Release inflammatory mediators

eosinophils
T -lymphocytes

Inflammation of airways

Airway narrowing

Airway smooth muscle contraction Airway edema Airway thickening Mucus hypersecretion

Clinical diagnosis
Any attacks or recurrent attacks on wheezing?
Troublesome cough at night? Wheezing or coughing after exercise? Symptoms after exposure to allergens or irritants?

Colds go to the chest or last 10 days to clear up?

Symptoms relieved by appropriate asthma treatment?

Physical examination
Wheezing
Hyperinflation

Tests for diagnosis and monitoring

lung function Airway hyperresponsiveness Allergic status

Measurements of lung function

Spirometry FEV1/FVC ratio (> 0.75-0.80) = normal (< 0.75-0.80) = airflow limitation Peak expiratory flow 60L/ml improvement after bronchodilator treatment (>20%) pre-bronchodilator PEF

 Measurement for hyperresponsiveness Direct (methacholine and histamine) Indirect (Mannitol60 and exercise induction) Measurement of allergic status Skin testing

Classification of asthma
Levels of asthma control Characteristic Daytime Symptoms Limitation of activities Nocturnal symptoms Need for relievers Lung function(PEF or FEV1) Controlled none( twice or less/week) none none none( twice or less/week) normal Partly controlled More than twice/week any any More than twice/week <80% Uncontrolled Three or more features of partly controlled asthma

Treatment and management

Medical management Relievers

Bronchodilators Short acting b2 agonist (e.g. salbutamol) Anitcholinergics (e.g. ipratropium bromide)

Controllers Long acting b2 agonist (e.g. salmeterol, formeterol) Glucocorticoids (e.g. hydrocortisone) Leukotriene antagonist (e.g. montelukast, zafirlukast) Mast cell stabilizers (e.g. cromolyn sodium)

Non-medical management Avoidance to triggers

references
GINA report May 4, 2011
Harrisons Principles of Internal Medicine 17th edition

Final diagnosis
Bronchial Asthma, uncontrolled
Community acquired pneumonia- moderate risk