

Assignment
Applied medicine


Assignment
Submitted To: Dr. Asad Naqvi
Submitted By: Dr. Khadija Bakhtawar
Sap Id: 70059756
Semester: MID 5th
Course title: applied medicine


No.  Contents

1. CASE 1

2. COPD
 Definition
 Symptoms
 Causes
 Stages
 Etiology
 Pathogenesis
 Risk factors
 Diagnosis(investigations)
 Differential diagnosis
 treatment
3. CASE 2

4. ASTHMA
 Definition
 Symptoms
 Stages
 Causes
 Etiology
 Pathogenesis
 Risk factors
 complication
 Diagnosis(investigations)
 Differential diagnosis
 treatment
CASE 1

PATIENT HISTORY:
 A 38 year old female amateur astronomer, all the while knowing better, has smoked since
she was 18 years old. She has been having trouble for years with the smoke and the light
of the cigarette impairing her ability to see the more distant galaxies through her
telescope, but she has not been willing to quit yet.
 Additionally, she has noticed a mild, occasionally productive cough for the past 3-4
months. The cough is worse whenever she spends the night out in the country taking
astrophotos where she is exposed to the smoke of the nearby wild fires.
 She finally decides to visit her family physician who, after making appropriate patient-
centered inquiries as to how her astrophotography hobby is going, finds that she has been
smoking about one pack per day for the past 20 years.
 The cough has been present for almost a year. She has had no fever or chills. She does
admit to more shortness of breath when she exercises over the past six months.
 Her only other past medical history includes hypertension for which she is using
lisinopril, metoprolol, and hydrochlorothiazide.
INVESTIGATIONS:
 Chest radiograph (CXR)
 Computed axial tomography (CT) of the chest
 Complete blood count (CBC) and thyroid stimulating hormone (TSH) level
 Spirometry
 Perform a physical exam and obtain a CXR in the office; the findings are normal.
 SPIROMETRY:
o FEV1: 85% of predicted
o FEV1/FVC: 65%
DIAGNOSIS
 Mild COPD
TREATMENT:
 Counseling for tobacco cessation along with initiation of a pharmacologic agent to assist
in quitting has shown proven benefit.
 Her symptoms are mild, and while use of an inhaled beta agonist would not be
unreasonable, it would not slow progression.
 Bronchodilators are medicines that make breathing easier by relaxing and widening
your airways.
 SABAs, salbutamol (albuterol) is the most commonly used agent and can be delivered via
a metered dose inhaler or a nebulizer

CHRONIC OBSTRUCTIVE PULMONARY DISORDER

DEFINITION
 Chronic obstructive pulmonary disease (COPD) Chronic obstructive pulmonary disease
(COPD) is a chronic inflammatory lung disease
that causes obstructed airflow from the lungs.
Symptoms include breathing difficulty, cough,
mucus (sputum) production and wheezing. It's
typically caused by long-term exposure to
irritating gases or particulate matter, most often
from cigarette smoke. People with COPD are at
increased risk of developing heart disease, lung
cancer and a variety of other conditions.
 Emphysema and chronic bronchitis are the two
most common conditions that contribute to COPD. These two conditions usually occur
together and can vary in severity
among individuals with COPD.
 Chronic bronchitis is inflammation of
the lining of the bronchial tubes,
which carry air to and from the air
sacs (alveoli) of the lungs. It's
characterized by daily cough and
mucus (sputum) production.
 Emphysema is a condition in which
the alveoli at the end of the smallest
air passages (bronchioles) of the
lungs are destroyed as a result of
damaging exposure to cigarette
smoke and other irritating gases and
particulate matter.
 Although COPD is a progressive
disease that gets worse over time,
COPD is treatable. With proper
management, most people with
COPD can achieve good symptom control and quality of life, as well as reduced risk of
other associated conditions.
Differential diagnosis
 Asthma
 Congestive heart failure
 Bronchiectasis
 Tuberculosis
 obliterative bronchiolitis.
Symptoms
  COPD symptoms often don't appear until significant lung damage has occurred, and they
usually worsen over time, particularly if smoking exposure continues.
 Signs and symptoms of COPD may include:
 Shortness of breath, especially during physical
activities
 Wheezing
 Chest tightness
 A chronic cough that may produce mucus
(sputum) that may be clear, white, yellow or
greenish
 Frequent respiratory infections
 Lack of energy
 Unintended weight loss (in later stages)
 Swelling in ankles, feet or legs
 People with COPD are also likely to experience episodes called exacerbations, during
which their symptoms become worse than the usual day-to-day variation and persist for
at least several days.
Causes
 The main cause of COPD in developed countries is tobacco smoking. In the developing
world, COPD often occurs in people exposed to fumes from burning fuel for cooking and
heating in poorly ventilated homes.
 Only some chronic smokers develop clinically apparent COPD, although many smokers
with long smoking histories may develop reduced lung function. Some smokers develop
less common lung conditions. They may be misdiagnosed as having COPD until a more
thorough evaluation is performed. Other irritants can cause COPD, including cigar
smoke, secondhand smoke, pipe smoke, air pollution, and workplace exposure to dust,
smoke or fumes.
Causes of airway obstruction
Causes of airway obstruction include:
 Emphysema. This lung disease causes
destruction of the fragile walls and elastic
fibers of the alveoli. Small airways
collapse when exhale, impairing airflow
out of your lungs.
 Chronic bronchitis. In this condition,
bronchial tubes become inflamed and
narrowed and lungs produce more mucus,
which can further block the narrowed
tubes. Patient develop a chronic cough
trying to clear airways.
Pathogenesis:
  Air travels down your windpipe (trachea) and into your lungs through two large tubes
(bronchi). Inside your lungs, these tubes divide many times — like the branches of a tree
— into many smaller tubes
(bronchioles) that end in clusters
of tiny air sacs (alveoli).
 The air sacs have very thin walls
full of tiny blood vessels
(capillaries). The oxygen in the air
you inhale passes into these blood
vessels and enters your
bloodstream. At the same time,
carbon dioxide — a gas that is a
waste product of metabolism — is
exhaled.
 Lungs rely on the natural elasticity of the bronchial tubes and air sacs to force air out of
your body. COPD causes them to lose their elasticity and over-expand, which leaves
some air trapped in your lungs when you exhale.
 In about 1% of people with COPD, the disease results from a genetic disorder that causes
low levels of a protein called alpha-1-antitrypsin (AAt). AAt is made in the liver and
secreted into the bloodstream to help protect the lungs. Alpha-1-antitrypsin deficiency
can cause liver disease, lung disease or both.
 For adults with COPD related to AAt deficiency, treatment options include those used for
people with more-common types of COPD. In addition, some people can be treated by
replacing the missing AAt protein, which may prevent further damage to the lungs.
Risk factors for COPD include:
 Exposure to tobacco smoke. The most significant risk factor for COPD is long-term
cigarette smoking. The more years you smoke and the more packs you smoke, the greater
your risk. Pipe smokers, cigar smokers and marijuana smokers also may be at risk, as
well as people exposed to large amounts of secondhand smoke.
 People with asthma. Asthma, a chronic inflammatory airway disease, may be a risk factor
for developing COPD. The combination of asthma and smoking increases the risk of
COPD even more.
 Occupational exposure to dusts and chemicals. Long-term exposure to chemical fumes,
vapors and dusts in the workplace can irritate and inflame your lungs.
 Exposure to fumes from burning fuel. In the developing world, people exposed to fumes
from burning fuel for cooking and heating in poorly ventilated homes are at higher risk of
developing COPD.
 Genetics. The uncommon genetic disorder alpha-1-antitrypsin deficiency is the cause of
some cases of COPD. Other genetic factors likely make certain smokers more susceptible
to the disease.
Complications
COPD can cause many complications, including:

 Respiratory infections. People with COPD are more likely to catch colds, the flu and
pneumonia. Any respiratory infection can make it much more difficult to breathe and could
cause further damage to lung tissue.
 Heart problems. For reasons that aren't fully understood, COPD can increase your risk of
heart disease, including heart attack
 Lung cancer. People with COPD have a higher risk of developing lung cancer.
 High blood pressure in lung arteries. COPD may cause high blood pressure in the arteries
that bring blood to your lungs (pulmonary hypertension).
 Depression. Difficulty breathing can keep you from doing activities that you enjoy. And
dealing with serious illness can contribute to the development of depression.
INVESTIGATIONS
 Lung (pulmonary) function tests. These tests
measure the amount of air can inhale and exhale, and
whether lungs deliver enough oxygen to blood.
During the most common test, called spirometry,
blow into a large tube connected to a small machine to
measure how much air lungs can hold and how fast
can blow the air out of lungs. Other tests include
measurement of lung volumes and diffusing capacity,
six-minute walk test, and pulse oximetry.
 Chest X-ray. A chest X-ray can show emphysema,
one of the main causes of COPD. An X-ray can also rule out other
lung problems or heart failure.
 CT scan. A CT scan of lungs can help detect emphysema and help
determine if might benefit from surgery for COPD. CT scans can
also be used to screen for lung cancer.
 Arterial blood gas analysis. This blood test measures how well
lungs are bringing oxygen into blood and removing carbon dioxide.
 Laboratory tests. Lab tests aren't used to diagnose COPD, but
they may be used to determine the cause of symptoms or rule out other conditions. For
example, lab tests may be used to determine if have the genetic disorder alpha-1-
antitrypsin deficiency, which may be the cause of COPD in some people. This test may
be done if have a family history of COPD and develop COPD at a young age
Treatment
 Many people with COPD have mild
forms of the disease for which little
therapy is needed other than smoking
cessation. Even for more advanced
stages of disease, effective therapy is
 available that can control symptoms, slow progression, reduce your risk of complications and
exacerbations, and improve your ability to lead an active life.
Quitting smoking
 The most essential step in any treatment plan for COPD is to quit all smoking. Stopping
smoking can keep COPD from getting worse and
reducing your ability to breathe. But quitting
smoking isn't easy. And this task may seem
particularly daunting if you've tried to quit and
have been unsuccessful.
Medications
 Several kinds of medications are used to treat the
symptoms and complications of COPD.

Bronchodilators are medications that usually come in inhalers — they relax

the muscles around airways. This can help relieve coughing and shortness of
breath and make breathing easier.)Examples of short-acting bronchodilators
include:
Bronchodilators
Albuterol ,Ipratropium
Examples of long-acting bronchodilators include:
Salmeterol
Inhaled corticosteroid medications can reduce airway inflammation
and help prevent exacerbations. Side effects may include bruising,
oral infections and hoarseness. These medications are useful for
Inhaled people with frequent exacerbations of COPD. Examples of inhaled
steroids steroids include:
Fluticasone (Flovent HFA)
Budesonide (Pulmicort Flexhaler)

Some medications combine bronchodilators and inhaled steroids.

Combination Examples of these combination inhalers include:-Fluticasone and
inhalers vilanterol (Breo Ellipta)-Fluticasone, umeclidinium and vilanterol
(Trelegy Ellipta)-Formoterol and budesonide (Symbicort)-Salmeterol
and fluticasone (Advair HFA, AirDuo Digihaler, others)
Oral steroids: For people who experience periods when their COPD becomes more severe,
called moderate or severe acute exacerbation, short courses (for example, five days) of oral
 corticosteroids may prevent further worsening of COPD

Phosphodiesterase-4 inhibitors
A medication approved for people with severe COPD and symptoms of chronic bronchitis is
roflumilast (Daliresp), a phosphodiesterase-4 inhibitor. This drug decreases airway
inflammation and relaxes the airways. Common side effects include diarrhea and weight loss.

Theophylline
When other treatment has been ineffective or if cost is a factor, theophylline (Elixophyllin,
Theo-24, Theochron), a less expensive medication, may help improve breathing and prevent
episodes of worsening COPD. Side effects are dose related and may include nausea,
headache, fast heartbeat and tremor, so tests are used to monitor blood levels of the
medication.

Antibiotics
Respiratory infections, such as acute bronchitis, pneumonia and influenza, can
aggravate COPD symptoms. Antibiotics help treat episodes of worsening COPD, but they
aren't generally recommended for prevention. Some studies show that certain antibiotics,
such as azithromycin (Zithromax), prevent episodes of worsening COPD, but side effects and
antibiotic resistance may limit their use

Lung therapies
Doctors often use these additional therapies for people with moderate or severe COPD:

Oxygen
rehabilitatio These programs generally combine
therapy.  If there isn't enough oxygen in your
blood, you may need supplemental
oxygen. There are several devices that
deliver oxygen to your lungs, including
lightweight, portable units that you can
take with you to run errands and get
around town.
Pulmonary
n program.education, exercise training,
nutrition advice and counseling.
You'll work with a variety of
specialists, who can tailor your
rehabilitation program to meet
your needs.

Some people with COPD use oxygen Pulmonary rehabilitation after

only during activities or while sleeping.
Others use oxygen all the time. Oxygen
therapy can improve quality of life and
is the only COPD therapy proved to
extend life. Talk to your doctor about
your needs and options.
episodes of worsening COPD may
reduce readmission to the hospital,
increase your ability to participate
in everyday activities and improve
your quality of life.
 Case 2
History

 A 44 year old woman, currently working in a

bakery, presents with a 1 year history of asthma and
allergic rhinitis symptoms, including episodic
cough, wheeze, shortness of breath and chest
tightness with itchy red watery eyes and a stuffy,
runny, itchy nose. These symptoms become worse
within 1-2 hours of starting work each day, and
worsen throughout the work week. She especially
finds red bran to worsen her symptoms almost
immediately on exposure. She notices an improvement within 1-2 hours outside of being at
her workplace. She has been working in the bakery for 13 years, and for the last 10 years has
been a "pre-scaler", weighing components, while wearing a paper mask. The line that she has
worked on for the last 2 years is dustier than other areas.

 Her past medical history is significant for seasonal allergic rhinitis in the summer months
since childhood. She is a lifelong non-smoker.
 Her family history is significant for asthma in her mother and brother.  
 She currently uses an inhaled steroid-long acting bronchodilator (ICS-LABA) daily, and
inhaled short-acting bronchodilator (SABA) as needed, generally up to 4 times a day at work
with relief.

Physical Exam
 Her physical examination is normal.
Lab
 Her chest x-ray is also normal.  Spirometry testing shows FEV1/FVC 0.62 (within 24
hours of work), FEV1 1.9L (60% predicted), and post-bronchodilator, the FEV1
increases to 2.2L (300cc, 16%).
 One year earlier, after 2 months off work, her FEV1 was 2.3L. Skin prick testing was
positive to grass (3+), a slurry of workplace flour (3+), wheat germ (3+), and red bran
(2+). Her home peak expiratory flow readings ranged between 270 and 340, with lower
readings on workdays.
Diagnosis
 A diagnosis of occupational asthma from wheat (including wheat germ and bran)
Management
  She was transferred to a muffin packing area where flour exposure was minimal, if any,
and was followed with further peak flow monitoring and spirometry
 She has since remained well with no symptoms and requiring no medications.

ASTHMA

Definition
 Asthma is a condition in which your airways
narrow and swell and may produce extra mucus.
This can make breathing difficult and trigger
coughing, a whistling sound (wheezing) when
you breathe out and shortness of breath.
 For some people, asthma is a minor nuisance.
For others, it can be a major problem that
interferes with daily activities and may lead to a
life-threatening asthma attack.
 Asthma can't be cured, but its symptoms can be
controlled. Because asthma often changes over
time.
Symptoms
 Asthma symptoms vary from person to person.
Asthma signs and symptoms include:
 Shortness of breath
 Chest tightness or pain
 Wheezing when exhaling, which is a common sign of asthma in children
 Trouble sleeping caused by shortness of
breath, coughing or wheezing
 Coughing or wheezing attacks that are
worsened by a respiratory virus, such as a
cold or the flu
Signs that your asthma is probably worsening
include:
 Asthma signs and symptoms that are more
frequent and bothersome
 Increasing difficulty breathing, as measured
with a device used to check how well your
lungs are working (peak flow meter)
 The need to use a quick-relief inhaler more
often
For some people, asthma signs and symptoms flare up in certain situations:
 Exercise-induced asthma, which may be worse when the air is cold and dry
  Occupational asthma, triggered by workplace irritants such as chemical fumes, gases or
dust
 Allergy-induced asthma, triggered by airborne substances, such as pollen, mold spores,
cockroach waste, or particles of skin and dried saliva shed by pets (pet dander)
Causes
 It isn't clear why some people get asthma and others don't, but it's probably due to a
combination of environmental and inherited (genetic) factors.
Asthma triggers:
 Airborne allergens, such as pollen, dust mites, mold spores, pet dander or particles of
cockroach waste
 Respiratory infections, such as the common cold
 Physical activity
 Cold air
 Air pollutants and irritants, such as smoke
 Certain medications, including beta blockers, aspirin,
and nonsteroidal anti-inflammatory drugs, such as
ibuprofen (Advil, Motrin IB, others) and naproxen
sodium (Aleve)
 Strong emotions and stress
 Sulfites and preservatives added to some types of
foods and beverages, including shrimp, dried fruit,
processed potatoes, beer and wine
 Gastroesophageal reflux disease (GERD), a condition in which stomach acids back up
into your throat
 Etiology
Pathogenesis
 IgE is the antibody responsible for activation of allergic reactions and is important to the
pathogenesis of allergic diseases and the development and persistence of inflammation.
IgE attaches to cell surfaces via a specific high-affinity receptor.
 The mast cell has large numbers of IgE receptors; these, when activated by interaction
with antigen, release a wide variety of mediators to initiate acute bronchospasm and also
 to release pro-inflammatory cytokines to perpetuate underlying airway inflammation.

Risk factors
 A number of factors are thought to increase your chances
of developing asthma. They include:
 Having a blood relative with asthma, such as a parent or
sibling
 Having another allergic condition, such as atopic
dermatitis — which causes red, itchy skin — or hay fever
— which causes a runny nose, congestion and itchy eyes
 Being overweight
 Being a smoker
 Exposure to secondhand smoke
 Exposure to exhaust fumes or other types of pollution
 Exposure to occupational triggers, such as chemicals used
in farming, hairdressing and manufacturing
Complications
Asthma complications include:
 Signs and symptoms that interfere with sleep,
work and other activities
 A permanent narrowing of the tubes that carry air
to and from lungs
 Emergency room visits and hospitalizations for
severe asthma attacks
  Side effects from long-term use of some medications used to stabilize severe asthma
Differential diagnosis

Investigations:
 Spirometry: Usually normal in-between exacerbations, although there may be an
obstructive pattern if poorly controlled (FEV1: FVC <70%). If an obstructive pattern
exists, a reversal to normal after bronchodilators is highly suggestive of asthma.
Other
 Peak expiratory flow rate (PEFR) is a crude measure of respiratory function
 Bronchial provocation tests (histamine or metacholine) can be used in uncertain
diagnoses, although they are not easy to interpret and require specialist input. Children
with mild asthma (where diagnosis may be in doubt) will give negative results in 50% of
cases.
 Exercise testing is useful to assess whether there is exercise-induced symptoms
 Skin prick testing or serum-specific IgE assays to allergens can be useful, but have
limited role in diagnosis or management of asthma. Negative tests rules out an allergic
sensitisation of airways to the allergen tested, although a positive result indicates only
sensitivity and not necessary allergy.
 Exhaled nitric oxide (ENO) testing may be performed. NO is produced in bronchial
epithelial cells and its production is increased in those with Th2-driven eosinophilic
inflammation. Those with asthma have raised ENO and it can be used to measure control.
It is also raised in allergic rhinitis (hay fever).
 Chest X-ray: in most children attending outpatient appointment a chest X-ray may be
requested as it is useful to have a baseline CXR
Classification

Asthma classification Signs and symptoms

 Mild intermittent Mild symptoms up to two days a week and up to two nights a month

Mild persistent Symptoms more than twice a week, but no more than once in a single day

Moderate persistent Symptoms once a day and more than one night a week

Severe persistent Symptoms throughout the day on most days and frequently at night

Treatment:

 Step 1 – as required short-acting beta-2 agonist (salbutamol).

 Step 2 – regular preventer therapy with inhaled corticosteroids.
 Step 3 – initial add on therapy:
 In combination with inhaled corticosteroid add a long-acting beta-2 agonist
(LABA) e.g. salmeterol/formeteroI
 If there is improvement but still not adequate symptom control increase dose of
inhaled corticosteroid
 If no response with LABA stop and add different medication – leukotriene
receptor atagonist (montelukast)
 Step 4 – persistent poor
control: Increase dose of
inhaled corticosteroids
 Step 5 – Regular oral
steroids – referral to
respiratory paediatrician
Asthma exacerbation
 An asthma attack has the
potential to be life-
threatening.

Immediate management
 Oxygen: SaO2 <94% should receive high flow oxygen to maintain saturations between
94-98%.
 Bronchodilators: Inhaled SABA (salbutamol) – via nebuliser if severe. Inhaler and spacer
device is as effective as nebuliser in children with mild/moderate asthma attack.
 Ipatropium bromide (anti-muscuranic) added in if no or poor response to inhaled SABA
  Corticosteroids: A short course (3 days) or steroids should be commenced. Oral
prednisolone is first-line however if the child vomits or is too unwell to take oral
medication intravenous hydrocortisone should be used.
Second-line management
 Intravenous salbautamol can be considered with specialist input if there is no response to
inhaled bronchodilators. It is essential to monitor for salbutamol toxicity.
 Magnesium sulphate can be considered, as it has an effect as a bronchodilator.