History (asthma) SOB when gardening, started noon same day

A few months – SOB on exertion – usually goes to clinic for a pump

Started a month ago to get more frequent/worse – sometimes spontaneous but rare (e.g. after a shower,
in the morning, after a URTI)
Clueless of what triggers SOB
Ask about CCF/cardiac symptoms including PND, orthopnea, ET, chest pain and SOB/AMI ss
Ask open ended qs – enquire about character of SOB + associated respiratory symptoms and their
frequencies
Asthma – enquire about time of day, severity of wheeze, exacervation, abiity to speak in
sentences/trouble in breathing/ cyanosis
Enqure about cough/hemoptysis
Cardiac – palpitation, pedal oedema
Enquire about need for inhalers and compliance
Enquire about effectiveness of inhalers + HOW SHE USED THEM
Enquire aout their side effects such as palpitations
Enquire abou reason for change in inhalers/why she was prescribed brown inhaler
Enquire about asthma diary
Enquire about hospitalisations
Other illnesses related to asthma syndomre
Physical examination
Differentials
Investigations
Management of patients Intrinsic vs extrinsic asthma
Must include family hx in asthma – includes skin rash, allergic rhinitis, allergic oncjunctivitis
History (COPD) 1. PC: SOB
2. 60 yo female COAD since 2012, actve smoker with 5 d of cough and SOB
3. SOB – progression, ET (unable to walk up stairs) – enquire about closely related cardiac SS –
PND.orthopnea
4. No trigger for cough and SOB
5. No aggravating factor which would suggest asthma
6. No features of asthma
7. Chest pain – nil – pleuritic chest pain, AMI/ costochondritis
8. Cough – non purulent
9. No infectious features like fever, chills, rigors
10. No malignancy features – TRO lung ca
11. PMH – several admission
12. No surgeries so far
13. On Ventolin 2 pf tds and prn
14. Brodual and fulmicort 1pf bd
15. Lives in crowded place,15 sticks for 20 years
16. no sig occupational hazard
17. no hx of Catopy in family or features of COPD sugg of antitrypsin deficiency
18. points to also include – a clear description of ET + establish PREMORBID condition –
ENCOURAGE TO DRAW A GRAPH of SOB against TIME in years/months
19. explore nature of admissions = were they increasing in freq, length of stay
20. any hx of INFECTIONS
21. to add:
a) physical limitations
b) social history and living conditions – why did patient manage stairs?
c) Impact of COPD on daily life
d) Exposure to passive smoking
e) >20years of smoking required to have COPD
f) Systemic review MUST INCLUDE – because need to exclude systemic signs of ILD
(especially if clubbing, lady, bilateral fine crackles and <20years smoking at a young age)
g) Patient is already on 2 SABA – hence fine tremors even before nebulizer
h) Pulmicort – inhaled CS – MUST KNOW DOSE because need to know how mucj to step
up – take the value BEFORE exacerbation
i) Interesting note, yellow sptum in asthma may be due to eosinophils not neutrophils hence
not necc to give ABX
Physical examination Vitals – BP 170/90, 88% BEFORE NEBULIZER, RR 25 , AFEBRILE , PULSE 120
After neb = sat 1—with venture 60% oxygen 15L/min, pulse 100
At presentation = SOB at rest, clubbing, fine tremors (anxiety, beta 2 agonist, hyperthyroidism) vs
 (coarse tremors – CO2 retention) – must try to relate to use of nebulizer to justify fine tremor existence,
pink peripheries, hyper inflated chest and generalized rhonchi, pedal oedema
Chronic suppurative condition = clubbing likely; non suppurative COPD = rare to have clubbing
On examination, SPO2 93% under RA, afebrile (IMPORTANT TO MENTION FOR COPD)
On examination – alert, pink, good pulse volume, warm peripheries, bibsasal crepitations, pedal oedema
– crepitations over posterior lobes with pedal oedema (symmetrical, up to midshin, pitting) – a pitting
oedema is suggestive of vs non pitting oedema

MUST INCLUDE FALPPING TREMORS

Note: ABG is only required if after neb, still less than 92%

IF SUSPECT RIGH SIDED HEART FAIL, PLEASE DO HEPATOMEGALY

If see bilateral ankle oedema – must TRO DVT + detect displaced apex + mention JVP
Differentials 1. infective exacerbation of COPD
2. asthma – inquire if reversal vs irreversible; or is there a clear deterioration in lung function ;
baseline lung practical function
3. pneumonia
4. bronchiectasis
5. CCF
Investigations 1. ABG – normal pH, P02 hypoxic at 60%, normal CO2 (TYPE 1 RESP F), bicarb normal –
compensated respiratory acidosis
2. Cultures – blood and sputum + smear
3. CXR
4. Continuous CT – bullae and emphysema – more accurate depiction than CXR; continuous CT
is better ;high resolution CT is usually for ILD to get a clear picture – but a continuous CT is
good enough for COPD
5. BNP
6. TROPONIN –to detect silent MI leading to CCF hence a rise in troponin (though not as high as
in MI)
7. ECHO
8. ECG –TRO ischemic, rhythyic
9. SPIROMETRY
10. Baseline FBC (raised WCC – 25 – INFECTION/SEPTIC), RP,LFT ( mild liver congestion)
11. Raised lactate – 2.1 mmol/L
12. RP – normal
Hence, need to suspect sepsis – raised HR, LACTATE, WCC
13. PEFR pre ned 150 – post neb 170 (height 160cm) – hence, WAY LOWER than expected for a
woman of her height and age – IN PERCENTAGE (400-150/400) = 65% reduction iei only at
35% of normal – hence SEVRE COPD based on GOLD
14. PEFR is not a very accurate predictor of severity – but based on GOLD grades, PEFR is used
– hence based on GOLD, she is moderately severe – this is important to determinte what initial
treatment of COPD to use or when to upgrade tx
15. Spirometry/lung function test SHOULD NOT BE DONE DURING AECOPD – only basic PEFR.
This is bc it will be less accurate.
16. To assess severity of COPD in patient using pulmonary test/spiro – give MAXIMUM OPTIMAL
TREATMENT FIRST UNTIL STABLE, THEN ONLY MEASURE – hence at this point in time,
just do PEFR only
Management of patients 1. PROLONGED EXPIRATORY PHASE ON OBSTRUCTIVE DISEASE (seen in athma, COPD)
– if consolidation such as TB/pnm then expiratory phase is SHORT
2. BODE INDEX
3. GOLD CLASS
4. Working diagnosis = infective exacerbation of COPD with septic picture
5. Acute mgmt.:
a) Nebulized bronchodilator – 1st line inhaled SABA +/- SAMA (or if inadeq add theiphyll)
b) Oral pred or IV hydrocort
c) Oral/IV abx – target pseudomonas, HIB and PCC
d) O2 therapy aim SpO2 88-92%
e) Nebulized saline to allow expectoration
f) Chest physiotx
g) +/- non invasive ventilation [arterial pH<7.35 and/or Pco2 > 6.5KpA)
h) +/- INTUBATION AND MECHANICAL VENTILATION IF APPROPRIATE
6. This patient was given ben salbut twice, combinet once, IV hydrocot 200 stat s/c bricanyl
(terbutaline) stat, oxygen thx via venture mask 40% and IV ceftriaxone 2g (initially started on
tazocin) stat
7. Then maintenance mgmt. by IPR:
a) IV ceftria 2g stat and QID
b) IV aminophylline 250tds
c) Nebulized combinet 4 hourly
d) PCV one shot (but if younger than 60, PCV every 5 years)