Name: Barindirize Getrude

Sex: Female

Age: 70 years

Tribe: Miyankole

Religion: Catholic

Address: Kasali( Mbarara)

DOA: 23/04/2010

DOD: 25/05/2010

Presenting complaint

Difficulty in breathing for 6 hours

History of presenting complaint

Getrude is patient who was treated as an asthmatic patient for years. She was relatively
well until 6 hours prior to her admission to KIUTH when she noticed sudden difficulty in
breathing. It was rainy cold evening around 6pm.

The difficulty in breathing was associated with parasternal chest tightness, dry cough,
inability to complete sentence, and musical sound coming out from her chest. She also
reported that her heart was beating very fast and she sweated a lot however she denied
history of fever, hemoptysis or weight loss. She didn’t report any history of fever,
orthopnea, paroxysmal nocturnal dyspnea or edema.

She couldn’t deliberate anything that could have triggered her symptoms except the
evening was very cold. She doesn’t remember any environmental factor such as dust,
exercise, animal dander that exacerbates her problem.

She has been on Salbutamol inhaler for the last 3 years and used to employ whenever she
has an attack to relieve her. This episode was not exception, but unfortunately she had not
had any relieve even after she used above 20 puffs of it. This is what prompts her to come to
hospital.

Review of other systems

Gastroinstestinal system:

No history of abdominal pain, diarrhea, constipation, loss of appetite or weight loss.

Nervous system:

She reports history of headache. However there was no history of dizziness, vertigo, sudden
loss of consciousness, deafness, and problem in sensation or weakness in the limbs.

Muskuloskeletal system:

No history of joint pain, stiffness, or swelling.

Past medical History

She has been diagnosed to have Peptic Ulcer Disease 2 years ago at Ishaka Adventist
Hospital, and was given treatment for several occasions as an outpatient from different
clinics. She couldn’t remember the medications she was given and currently she is not on
any treatment. She has never been hospitalized for any other ailment. Her serostatus for
HIV is not known.

She has no food or drug allergy.

Past surgical History

Had no history of surgical operation, trauma, or blood transfusion

Family history

She is the 1st born of a family of five siblings (2sisters and 3 brothers). One of her sisters is
asthmatic and one of her brothers is diabetic. Both her parents have died. She thinks her
mother died for the same problem.

Social History

Getrude lives in Kasari with her husband and her 4 of her children who are alive.

She has smoked tobacco (3 pieces per day) for over 20 years, but didn’t smoke for the last
30 years. No history of alcohol. Her husband is a smoker as well.

Summary

Getrude is a 70 year old lady who presented with an acute shortness of breath which
associated with chest tightness, dry cough, inability to complete sentence, wheezes, and
over 20 years history of smoking. She has been on Salbutamol for that last 3 years, but this
episode didn’t respond to it despite she has used it more than 20 puffs.

Examination

General Examination
She was sick-looking elderly women, conscious, and mildly dehydrated. She was in obvious
respiratory distress and wheezes could be heard.

She wasn’t cyanosed, pale, had no finger clubbing, lymph node enlargement, or edema.

Respiratory Examination

She was in respiratory distress (RR- 40/min, use of accessory muscles, nasal flaring, and
intercostal recession). Had barrel chest, which was moving symmetrically with respiration.
Trachea was centrally placed. Apex beat was not palpable. The percussion note was hyper –
resonant in all lung fields. Tactile vocal fremitus was decreased. On auscultation both
inspiratory and expiratory rhonchi were heard. Inspiratory crackles were also heard.

Cardiovascular Exam

The pulse was 120bpm (Tachycardia), but was regular. The BP was 140/100 (high). The JVP
was not raised. The apex beat couldn’t be palpated. Heart sounds 1 and 2 were heard. No
murmurs or gallop.

Abdominal Exam

The abdomen was scaphoid, and was symmetrically moving with respiration. No visible
scars or therapeutic marks. The umbilicus was inverted. No tenderness or masses noted. No
organ enlargement noted. The percussion note was tympanic throughout the abdomen.
Shifting dullness or fluid thrill wasn’t present. The bowel sounds were heard and were of
normal intensity.

Nervous system

She was conscious. Had no signs of meningeal irritation or focal neurological deficit. No
cranial Nerve abnormality noted. Sensation, motor functions, reflexes, coordination, and
gait were all intact.

List of Problems

 Acute shortness of breath

 Inability to complete sentence
 Chest tightness, dry coughs, and wheezes.
 No fever
 Use of salbutamol inhaler without improvement.
 History of smoking
 1st degree relative- asthmatic.
 Signs of respiratory distress
 Hyperinflated chest
  Decreased vocal fremitus
 Rhonchi/crackles
 Tachycardia and high BP.

Diagnosis

Bronchial Asthma

Differential Diagnosis

Chronic Obstructive Airway Disease (COPD)

Bronchopneumonia.

INVESTIGATIONS:

1. Lung function test- the diurnal variation in Peak expiratory flow rate [PEFR] is a good measure
of asthma activity and is of help in the long term assessment of the patient’s disease and it’s
response to treatment.
Also Spirometry is useful, especially in assessing reversibility. Asthma can be diagnosed by
demonstrating a greater than 15% improvement of Forced expiratory volume1 or PERF
following the inhalation of bronchodilators.
2. Blood and sputum tests- patients with asthma may have an increase in the number of
eosinophils in peripheral blood [>0.4 x 109\L ]. The presence large numbers of eosinophils in the
sputum is more a useful diagnostic tool. This was not done.
3. Chest X-ray- there are no diagnostic features of asthma in chest x-ray but in acute episode or
chronic severe disease you get overinflation. Also may be helpful in excluding pneumothorax.
4. Skin tests- skin prick tests [SPT] should be performed in all cases of asthma to help identify
allergic causes.
5. Others: like full blood counts in case of acute respiratory infection will show neutrophilia.

Note: All the above investigations were not done, patient was treated clinically.

Plan and Treatment

A patient with acute severe asthma should be commenced with

- 5mg of nebulised salbutamol or 10mg terbutalin or ipratropium can also be helpful.

-Hydrocortison sodium succinate 200mg i.v.

-Oxygen 40-60%

-Then reassessed if no improvement, start with intravenous infusions of Beta2-adrenocepter agonist

[salbutmol or terbutalin 250 microgram over 10 minutes] and or [magnesium sulphate 1.2-2g over
20 minutes. Hydrocortisone 200mg i.v. should be given 4 hourly for 24 hours, and 60mg of
predinsolone should be given orally daily. If the patient does not respond to this regimen, ventilation
is often required.

-Oxygen saturation should be monitored and predinsolone to be reduced to 30mg once after
improvement

Non pharmacological treatment:

-Educate the patient and the family about asthma and its management

-Educate on factors which can stimulate attack like cold weather, pets, moulds, food stuff and drugs
like aspirin or other NSAIDS and its importance to avoid them.

For Getrude, on admission received:

- I.V. aminophyline 250mg slowly over 10 minutes stat, then tab 100mg bd …..which was
changed to salbutamol 4mg tds x4\7.
- Beclomethasone inhaler 2puffs bd….
- IV hydrocortisone 120mg
- Oxygen 5L per minute

Follow Up

25/05/2010

Noted above, a 70years old female who is a known asthmatic patient admitted with severe acute
asthma but now reports improvements. She can speak full sentences.

ON EXAMINATION: status quo, no pallor, jaundice, cyanosis, oedema, dehydration or

lymphadenopathy. Not in respiratory distress.

Respiratory system: respiratory rate 25 cycle per minute. She has scattered expiratory ronchi but no
crackles.

PLAN

-Discharge home through medical outpatient clinic after 2\52 on:

- salbutamol inhaler 2 puffs PRN

- Beclamethasone inhaler 2 puffs bd x 2\52

- Patient was advised to stop smoking.

Discussion

Getrude is a known asthmatic and she presented with an acute shortness of breath,
accompanied by chest tightness, and inability to talk, and audible wheezes which are all
features of a bronchial asthma. This further supported by the salbutamol inhaler which used
to relieve her attacks in the past. Her sister is also an asthmatic. The long history of smoking
however may suggest co-morbidity, or an alternative diagnosis of COPD. Absence of fever
may speak against the diagnosis of pneumonia. The examination findings were important,
but no very helpful in differentiating asthma from COPD. For example presence of
respiratory distress, hyper inflated lung, tachycardia and increased blood pressure are
common findings in both of the conditions. Wheezes are very common in asthmatic
patients, but COPD patients can also have it. Crackles are usually for COPD. This further
complicates the diagnosis. I think co-morbidity is most probable and just diagnosis here.

Oxygen saturation determination is important and dictates whether to give oxygen.

Spirometry is important to narrow down your diagnosis. Chest X-ray is indicated to confirm
hyperinflation, and to rule out pneumonia.

Beta2 agonist is the treatment of choice in both asthma and COPD. Addition of anti
cholinergic agent reduced the admission. Corticosteroids are given to both patients with
asthma and COPD. Cessation of smoking should be emphasized before discharging such a
patient, and follow them up.

References

1. Davidson’s Principles and Practice of Medicine, 20th edition.

2. www.emedicine.medscape.com