PATIENT’S PROFILE

Initials : Mr Is
Gender : Male
Race : Malay
Age : 52 years old
Registration number : AM00114044
Address : Kampung Ampang Indah
Occupation : Clerk in Bank Simpanan Nasional
Date of admission : 17/06/2009
Date of discharge : 19/06/2009
Date of clerking : 18/06/2009
Source of information : Patient

HISTORY

Chief Complaint
- Sudden onset of severe shortness of breath in the early morning
- Associated with fever for two days, sore throat and minimal cough
History of Presenting Complaint
Mr Is is an asthmatic patient and he is a non-smoker. He presented at the casualty
department with severe shortness of breath that could not relieved by rest and sitting-up
position like usually he did before. He could not speak a full sentence in one breath,
gasping for air, and could not stand and walk. He did not lose his consciousness. The
shortness of breath started at 4 am which interfered and woke him up suddenly from
sleep. He cannot do his normal routine in the morning and had chest pain on coughing.
He was sent immediately to casualty by his wife. Apart from that, he had low grade fever
since past two days. This is the first time he had severe shortness of breath and fever
together. His fever associated with chills, rigors and sore throat. He had no headache. He
had minimal cough with yellowish sputum. He had orthopnea as he always sleeps with
two pillows every night for a long unspecified period due to shortness of breath and
claimed that it had become as his habit. His other associated complaint is that he always
had dyspnoea on exertion for example after distance walked and climbing stairs. He did
not have any inhaler as he refused to be independent on that instrument. He started to get
asthmatic attack on 2005 which is five years ago and become severe two years ago during
hajj due to dust. Since then, the shortness of breath occurred about once in three months.
He went to clinic to relieve the shortness of breath each time. A day prior to the
admission, in the evening, he also had a milder symptom of shortness of breath and went
to the nearby clinic. The shortness of breath was relieved as nebulizer given.
Systemic Review
Cardiovascular system- He had dypsnoea, orthopnea and chest pain on coughing.
However, there were no palpitation, paroxysmal nocturnal dypsnoea and ankle swelling.
Respiratory system- He had shortness of breath, sore throat, and minimal productive
cough with yellowish sputum. No haemoptysis.
Gastrointestinal system- He had no abdominal pain, vomiting and diarrhoea. He did not
experience loss of appetite or lost of weight. His bowel habits are normal.
Genitourinary system- The frequency and color of urine were as usual. There was no
dysuria, polyuria, hematuria, urgency, or urinary incontinence.
Musculoskeletal System- His fever associated with chills and rigor. No complained of
myalgia, muscle weakness, arthralgia and backpain.
Central Nervous System- He had no headache. There was no previous history of seizure
and stroke and no other remarkable sign of neurological disorders.
Past Medical History
He was diagnosed with asthma five years ago on 2005. He claimed that he used to be
active in sport and went jogging regularly five years ago when he stop suddenly, he got
asthma. He did not use inhaler as he refused to use it although was advised by the doctor.
He went for nebuliser at the clinics each time he gets shortness of breath in frequency
about once in three months for the past five years. He had never been admitted to the
ward before except on 1984 because of nose bleeding claimed to be due to the hot
weather. He also had an allergic rhinitis as he complaint of early morning sneezing.
Besides asthma, he has hypertension which is accidentally detected after screening test
before he go to hajj three years ago. He is not compliance to his antihypertensive
medication and does not control his diet and lifestyle. He never had gastritis.
Past Surgical History
He had no past surgical history.
Drug History
He is on antihypertensive medication but defaulted for the past one year. He never use
ventolin or salbutamol inhaler but depend on nebulizer to relieve his shortness of breath.
He also had no known drug allergies but have allergy to seafood. The dust can aggravate
his asthmatic condition.
Family History
His mother has asthma and died due to lung disease. His father did not have asthma or
other disease. He died due to ageing. His brother has hypertension and died due to heart
disease.
Social History
Patient never smoke and he is not an alcoholic. He was married and currently living with
his wife and two of his five children in a single storey house in Ampang. He worked as a
clerk in Bank Simpanan Nasional. He used to be active in sports and got asthma when he
stopped suddenly. He did not control his diet and lifestyle in spite of defaulting
antihypertensive medication for the past one year.

PHYSICAL EXAMINATION
General examination
Patient was alert, conscious, and response well. He was not restless, drowsy, or confused.
On general inspection, he looked well and was not in respiratory distress. He is on nasal
prong and I.V cannula was inserted at the dorsum of his left hand. There is a sputum pot
containing yellowish sputum but no inhaler was around. He could speak a full sentence in
one breath. He had loss half of his right ring finger due to childhood accident. There are
some scars on his both palm due to allergic. There was no clubbing, peripheral cyanosis,
palmar erythema, and wasting of the small muscles of hand. His palm was pink. His
conjunctiva was not pale and there was no jaundice. He had no central cyanosis. There
was no ankle swelling and pitting oedema. His vital signs were followed:
Temperature : 37◦C
Pulse rate : 96 bpm
Blood pressure : 135/80
Respiratory rate : 21 bpm
Respiratory examination
On general inspection, the chest wall was symmetrical and there was no chest deformity.
There was no scar present. He was not using his accessory muscle for breathing. There is
no increasing in anteroposterior diameter. The chest moved equally on respiration and
there was no audible noise during respiration. On palpation on his trachea, it was
centrally located. Cricosternal distance was not reduced. There was no presence of
masses in the neck and no lymphadenopathy. The chest expansion was reduced but vocal
fremitus were normal and equal for both lung. Percussion of the lungs was resonance in
all lung fields. On auscultation, generalized ronchi were heard. There was equal air entry.
The vocal resonance was equal on each side. On auscultation of his anterior part of chest,
minimal crepitation was heard on his left side of the lung.
Cardiovascular system examination
The Jugular Venous Pressure was not raised. On general inspection of praecordium, there
was no chest deformity and no scar present. The apex beat was palpable on the left 5 th
intercostal space in the mid-clavicular line. There was no sign of thrills or parasternal
heaves. On auscultation, the first and second heart sound was heard. There was no
murmur and additional heart sounds heard.
Gastrointestinal system examination
The abdomen moves with respiration, soft, no tenderness and no palpable mass. There
was no surgical scar, distended veins, and visible pulsations. The liver and spleen were
not palpable. The kidneys were not ballotable. There was no evidence of organomegaly
and ascites. On percussion, there were generalized resonant notes on her abdomen.
Normal bowel sounds were present. No liver and renal bruits were heard.
Central nervous system examination
The patient was orientated to place and time. All the cranial nerves were intact. All
reflexes in the upper and lower limbs were present. Tone and power was normal. There
were no cerebellar defect signs detected.
Summary
Mr Is, 52 year old Malay man with known history of asthma for 5 years and hypertension
for 3 years admitted to Ampang Hospital with chief complaints of severe shortness of
breath half an hour before admission and fever two days before admission associated
with chills, rigors, sore throat, and minimal cough with yellowish sputum. He also had
dyspnoea on exertion and orthopnea. Her signs were tachypnoea, reduced chest
expansion symmetrically, generalized ronchi , and minimal coarse crepitations on his left
side of lung at the end of expiration.
Differential diagnosis
i. Acute exacerbation asthma
ii. Acute pulmonary edema
iii. Left ventricular failure
iv. Acute exacerbation of chronic obstructive pulmonary disease
Provisional Diagnosis
Acute exacerbation asthma secondary to pneumonia

INVESTIGATIONS
Baseline examination
1) Full blood Count (This investigation was done on 18/6/2009) :
Hb: 12.8 g/dL ; Hct: 38.9 % ; Platelet: 156 x 109/ L ; WBC : 11.8 x 109/ L
Result : There was no significant change in full blood count except that there was an
increase level of white blood cells. This may occur due to fever (infection).
2) Renal profile (This investigation was done on 18/6/2009) :
Urea: 4.39 mmol/L ; Na+: 139 mmol/L ; K+: 2.8 mmol/L; Creatinine : 98 umol/L
Result : Everything is in normal range.
3) Cardiac enzymes – to rule out cardiac causes
4) Liver function test (LFTs)
5) Fasting blood sugar and other biochemical value
Specific examination
1) Arterial blood gases (ABG)
2) Chest X-ray - The chest X-ray was clear. There were no diagnostic features of
asthma (hyperinflated) on the chest x-ray. It may be helpful in excluding a
pneumothorax, which can occur as a complication, or in detecting the pulmonary
shadows associated with allergic bronchopulmonary aspergillosis.
 3) Sputum culture - To detect any suspected organism responsible for upper
respiratory tract infection which is Streptococcal group, the most common one.
4) Respiratory function test (PEF measurement) / Spirometry
5) Exercise test – diagnosis of asthma in children
6) Histamine bronchial provocation test – indicates the presence of airway
hyperresponsiveness.
7) ECG – to rule out cardiac causes

MANAGEMENT
For acute exacerbation asthma secondary to pneumonia for this patient include:
1) Drug therapy
• Nebulized salbutamol or terbutaline (or antimuscarinics eg: ipratropium bromide)
with oxygen as the driving gas
• Antibiotics orally if not severe and no vomiting (treatment of pneumonia)
-Amoxicillin 500mg-1.0g/8h or Erythromycin 500mg/ 6h
• Normal saline and KCl
2) Rehabilitation
• Educate on proper used of inhaler
• Advice patient to take haemophilus and pneumococcal vaccine
• Advice patient to avoid sedentary lifestyle and comply with antihypertensive
medication.
• Patient and family education about asthma.
Mr Is was on O2 3L/min via nasal prong on admission. He was prescribed with the
following medication by the doctor: IV drip 3 pints Normal Saline + 1 gm Kcl alt pint, IV
Augmentin 1.2gm, Nebulizer ventolin 6 hourly, and T.EES 400mg Bid
Discussion
i. Mr Is presented with symptoms of acute exacerbation of asthma. First, he came
to the hospital with sudden onset of severe breathlessness that could not relieved
by rest and sitting-up position like usually he did before. He could not speak a full
sentence in one breath, gasping for air, and could not stand and walk. Second, he
was diagnosed of asthma since he was 47 years old. Since he was diagnosed, he
 had persistent asthma with symptoms of wheezing, breathlessness, and cough
with whitish sputum between exacerbations. This pattern of asthma is commonly
seen in older patients with adult-onset asthma who are non-atopic. During this
admission, he had fever associated with chills, rigors, and sore throat which were
the symptoms of viral upper respiratory tract infection two day before he
developed acute severe breathlessness. Many viral and bacterial infections
produce a transient increase in airway responsiveness in asthmatic patients.
Therefore, for this asthmatic patient, lung infection might be the exacerbating
factor that led her to acute severe asthma. On general inspection, patient was
tachypnoic. The chest expansion was symmetrically reduced. On auscultation at
both of her anterior and posterior chest wall, generalized ronchi and minimal
crepitations on left side of the lung at the end of expiration were detected. These
findings were highly indicating asthma.
ii. Acute pulmonary oedema. Patient had sudden onset of severe shortness of breath
associated with cough and sputum. He also had dyspnoea and orthopnoea. These
were the clinical features of acute pulmonary edema. . The dyspnoea may first
occur at night in the form of paroxysmal nocturnal dyspnoea due to pulmonary
congestion. This occurs because of reabsorption of dependent edema when lying
flat, and the relative intensity of the respiratory centre at night allows pulmonary
congestion to develop. Crepitations and ronchi are heard throughout the chest
which is the signs of acute pulmonary edema. But in this case, patient did not
have paroxysmal nocturnal dyspnoea.
iii. Left ventricular failure. There were symptoms of orthopneoa, exertional dyspnoea
but absence of paroxysmal nocturnal dyspneoa. There was also no displacement
of apex beat in this patient
iv. Acute infective exacerbation of chronic obstructive pulmonary disease (COPD).
There were similar symptoms between asthma and COPD but this patient’s
condition was relieved by nebulizer and exacerbated by fever which resulted as
reduced in effort tolerance.