Medical Diagnosis: Bronchial Asthma in Acute Exacerbation

Chief complaint: “I’m short of breath, I can’t stop coughing.”

Sixty- two year old Mr.PJ male Canadian nationality married who works as auto mechanic in a
private company presents in Gleneagles hospital emergency room @ 1300 hours of March 15,
2020 with progressive shortness of breath for the several days. His problem began four days ago
when he got cold consisted of a sore throat, rhinorrhea and myalgia.. His job forces him to work
in the cold and damp air. At first he just felt tired but later he developed a cough* and shortness of
breath. Initially, the cough was dry but within 24 hours of onset, it produced abundant yellow-
green sputum. He states, "I cough up a cup of this stuff every day." He didn't think much of the
cough because he continually coughs during the winter of each year. His wife states that he "hacks
and spits up" every morning when he gets up from bed.

The shortness of breath has worsened so that he can hardly speak now. He also has pain in the left
side of his chest when he coughs. He becomes very tired after walking up a flight of stairs or during
a coughing spell. He denies hemoptysis, night sweats, chills, and paroxysmal nocturnal dyspnea.
However, he does complain of swelling of his ankles: "I've had this for more than a year."

Mr. PJ has been treated for high blood pressure, pneumonias and infections of his hands. He has
been treated for similar episodes of coughing and shortness of breath during the past two years.
Once he was hospitalized because "I was drinking too much and my pancreas acted up." A previous
doctor gave him nitroglycerin. He smokes 1-2 packs of cigarettes per day and has done so for the
past 35 years. Had surgical history of appendectomy because of appendicitis when he was 20 years
old.

PHYSICAL EXAMINATION: The patient appears much older than he stated age of 62 years. He
is a stocky man who appears haggard, tired and anxious. He speaks with difficulty, quickly
becoming breathless. There is cyanosis which intensifies during coughing spells. Blood pressure
is 146/82 mmHg. Apical heart rate is 96/minute and regular. Respiratory rate is 28/minute.
Temperature is 97.7 F.

Examination of the head and neck reveals the use of accessory muscles during respiration. Jugular
veins are dilated to 5 cm. with a prominent "a" wave.

Examination of the chest reveals use of accessory respiratory muscles. The anterior-posterior
diameter of the chest is increased. Respiration rate is increased; respiration is regular and longer
in expiration. Fremitus is decreased and the lung fields are hyperresonant (diffusely) with
percussion. Percussion also reveals decreased excursion of the diaphragm (bilateral). Breath
sounds are diminished bilaterally. Coarse crackles, rhonchi and expiratory wheezes are heard
bilaterally. Most of these sounds clear with coughing.

Examination of the cardiovascular system reveals soft heart sounds: S2 is split and louder than S1.
The P2 component seems louder than A2 and is heard best at the base of the heart. An S4 is heard
best along the left lower sternal border. A murmur is not detected.
The abdomen is round but soft. Bowel sounds are not heard. The liver edge is round, slightly tender
and palpable 2 cm. beneath the right costar margin in the mid-clavicular line. The prostate is
enlarged and nodular on rectal exam.

Both feet show hallux valgus. There is pitting edema of the ankles.
Height is 166 cm, weight is 65 kgs.

Doctor’s Order

March 15, 2020 Admit to ward 4A

1300 hours Diet as tolerated , NPO when dyspneic
Carry out laboratory tests: CBC, Blood Chemistry, ABG
To start IVF of Plain NSS 1 liter at 20 drops per minute, to follow same
IVF at same rate
Medications:
1. Salbutamol 2.5mg via nebulization now, to repeat after 20
minutes then every 6 hours
2. Solu-cortef 100 mg IVTT stat dose then every 8 hours
Continue maintenance medication for Hypertension as ordered.
Refer prn
Dr. Steph Edwards

LABORATORY TESTS RESULTS

CBC:
Hemoglobin – 19.8 g/dl
Hematocrit – 60%
Leukocyte count is 12,500/mm3
Neutrophils – 58%
lymphocytes- 28% 6%
Monocytes- 6%
Eosinophils- 1%
Platelet count = 320,000/mm3.

Chemistry:
Glucose 112 mg/dL (non-fasting)
BUN 16mg/dL,
Creatinine 1 mg/dL;
Cholesterol 240 mg/Dl
Aspartate aminotransferase (AST) 18 U/L,
Alanine aminotransferase (ALT) 32 U/L,
Creatine kinase 72 U/L
Sodium 130 mEq/L,
Potassium 4.8 mEq/L
Chloride 90 mEq/L
Bicarbonate 33 mEq/L.

Arterial Blood Gases:

pH 7.38, Pa O2 44 mmHg, Pa CO2 58 mmHg, HCO3 31 mEq/L.