This action might not be possible to undo. Are you sure you want to continue?
Female Single Filipino Catholic Self-employed Residing in caloocan city
Difficulty of Breathing
FEW HOURS PTA ADMISSION .R. took carboceistein affording no relief •No consult done •Persistence of above symptoms •Shortness of breath temporarily relieved by salbutamol nebulization •Shortness of breath •Air hunger upon taking few steps •Nebulized with salbutamol affording no relief Consult at E.History of present illness 3 DAYS PTA 2 DAYS PTA 1 DAY PTA •Fever of 38-39°C relieved by paracetamol 500mg •Productive cough with yellowish mucoid phlegm •No consult done •Fever of 38°C not relieved by paracetamol 500mg •Productive cough with greenish mucoid phlegm.
patient taking methimazole .Past medical history (+) asthmatic Managed by salbutamol. celestamine (-)hypertension (-)DM (-)CVD (-)allergy to food and drugs (+) hyperthyroidism .
paternal (+)DM.Family history (+)HPN.paternal (+) asthma.maternal .
Personal/social history Self-employed Non-smoker Non-alcoholic beverage drinker .
blurring of vision. (-) weight loss. lumps. (-) bleeding. Nose/sinuses: (-) cough and colds. discharge. (-) dizziness. tearing. eczema. itching. color changes. cataracts. (-) stuffiness. (-)discharge. Throat/mouth: (-) sore throat. redness. nightsweats. glaucoma. nail changes. dryness. (-)pain. itching. taste problems . mole changes Head: (-)headache. excessive dryness or moistness. diplopia. (-) dysphagia. (-) facial/sinus pain. Skin:(-) rashes.Review of systems General:(+) fatigue. (-) hoarseness. (-) hairloss Eyes: (-) eye pain. (-) fever. dental cavities. Ears: (-) earache.
no post meal abdominal pain. (-) chest pain. . orthopnea. vomiting. (-) goiter. Respiratory: (+)dyspnea (-) cough. bowel movement regular once a day. . consistency. no recent change in bowel movement pattern. (-) nausea. No jaundice. Cardiovascular: (+) palpitations. (-) rectal bleeding. (-) swollen lymph nodes. pain. color.Review of systems Neck: (-) lumps. once a day bowel movement . (-)hemoptysis. stiffness. (-) cyanosis GI: good appetite.
urgency. phobias. Psychiatric: (-) unusual prolonged sadness. (-) pain. (-) backache. (-) mood swings. (-) increase force of urinary stream. difficulty in moving extremities. or sores. insomnia. (-) abnormal bleeding Musculoskeletal: (-)generalized weakness. (-) polydipsia. (-) polyuria. (-) dysuria. dribbling. Endocrine: (-) heat / cold intolerance. (-) seizures. (-) nocturia. no paralysis. (-) oliguria. residual urine. convulsions. anxiety. loss of balance. loss of memory (+) tremors Hematologic: (-) pallor. speech problems. Female Repro: (-)discharges. no easy bruising. Neurologic: No numbness. . nervousness.Review of systems Urinary: (-) hesitancy.
sitting on bed lying forward. cyanotic. medium height with small built.Physical examination General: The patient is seen as weak looking. restless. fairly well kempt and groom with poor hygiene. obtundent. with unsustained eye contact.9°C . The patient is in cardiorespiratory distress Vital signs: BP: 120/70 PR: 153 RR: 45 Temp: 36.
intact extraocular movements. septum is midline.Physical examination Skin: cold and clammy. both pupils equally round and reactive to both light and accommodation. (+) exophthalmos. No suspicious nevi. No lesion. No visual field defect on all quadrants. tympanic membrane with good cone of light of nasal bone. No fracture . without focal area of hair loss. No obvious lesion. with good skin turgor. Nails with cyanosis. or asymmetry. Ears – AD: intact tympanic membrane with good cone of light. no open wounds HEENT Head – Hair is black colored and distributed diffusely. AS: intact Nose – nasal mucosa is pink. No macuopapular changes. deformities. no ptosis. Scalp is intact without obvious lesion Eyes –Sclera were anicteric and conjunctiva were pale. lesions.
Lung area is mostly hyperreresonant except in the area of cardiac dullness. The thyroid gland lobes are enlarged. No active ulcerations were found. JVP – 2cms. Symmetric soft palate. with chest retractions. Tactile fremitus is not increased on posterior and anterior chest.Physical examination Neck: Supple and midline and symmetric. The thyroid isthmus is located between the apex of the thyroid cartilage and substernal notch. normal. . normal pink and moist mucosa. Thorax is symmetric and expands bilaterally equal on both posterior and anterior chest. AP diameter is 2:1. Mouth/Throat: Oral mucosa to the posterior pharynx presents with Thorax and lungs: No abnormal lesion or open wounds. Midline uvula. Tonsils are not enlarged. especially on the upper lobe. Both lobes of the lungs are wheezes. subcostal and supraclavicular.
(-) rovsing sign. Abdomen: No abnormal lesions. Peripheral pulses were 3+ and symmetric. Liver edge and spleen is not palpable.Physical examination Cardiovascular: Dynamic precordium. (-) psoas sign. Point of maximal impulse is tapping. No costovertebral angle tenderness. Normoactive bowel sound (12/min) is noted. no visible mass. No direct tenderness. Entire abdomen is tymphanitic except for the area of liver dullness. Liver span measures 6cm midclavicular. 7cm lateral to midsternal line in 5th ICS. is flat. There was a tachypneic with irregular rhythm. (-) obturator sign (-) heel jarring test. Abdomen . The carotid pulses were normal and 3+ bilaterally without bruits.
Both legs are equal in length and size. and without abnormal lesions. The upper extremities have equal length and size. clubbing or edema. No restricted mobility on all extremities.Physical examination Genitalia: Not examined Extremities: No cyanosis. .
Salient features Subjective Difficulty of breathing Fatigue Palpitations Tremors Objective Fever Productive cough Known asthmatic Known hyperthyroidism Tachypnea Tachycardia Wheezes Chest retractions Unresponsiveness to bronchodilators .
Initial diagnosis Acute respiratory distress 2° to status asthmaticus Community acquired pneumonia. moderate risk .
Differential diagnosis Bronchial Asthma COPD Pneumonia Congestive heart failure .
Allergen (exposure) / exercise / stress Infection Irritation of airways Activation of Alveolar macrophage Phagocytosis IgE Production Ag-Ab reaction IgE antibodies binds to mast cells in airway mucosa Release of mediators FEVER .
Histamine tryptase Prostaglandins D2 Leukotrienes C4 Platelet activating factor Cytokines IL4. IL 5 GM-CSF TNF Released in airway mucosa Attract and activate Airway smooth muscle contraction eosinophils Vascular Leakage ECP MBP Proteases PAF neutrophils bronchoconstriction DIFFICULTY OF BREATHING .
coughing . breathlessness.Definition Chronic inflammatory obstruction of the airway Airway hyperresponsiveness Wheezing. chest tightness.
15% in children Developed countries > developing countries .Prevalence 300 million affected 10-12% in adults.
Factors influencing asthma Host factors Genetics Obesity Sex Environmental factors Allergens Infections Occupational sensitizers Tobacco smoke Air pollution diet .
Mechanism of asthma Allergen Mast cells Airway structural cells Release inflammatory mediators ↑ eosinophils ↑ T -lymphocytes Inflammation of airways Airway narrowing •Airway smooth muscle contraction •Airway edema •Airway thickening •Mucus hypersecretion .
Clinical diagnosis Any attacks or recurrent attacks on wheezing? Troublesome cough at night? Wheezing or coughing after exercise? Symptoms after exposure to allergens or irritants? Colds “go to the chest” or last 10 days to clear up? Symptoms relieved by appropriate asthma treatment? .
Physical examination Wheezing Hyperinflation Tests for diagnosis and monitoring lung function Airway hyperresponsiveness Allergic status .
80) = normal (< 0.Measurements of lung function Spirometry FEV1/FVC ratio (> 0.80) = airflow limitation Peak expiratory flow 60L/ml improvement after bronchodilator treatment (>20%) pre-bronchodilator PEF .75-0.75-0.
Measurement for hyperresponsiveness Direct (methacholine and histamine) Indirect (Mannitol60 and exercise induction) Measurement of allergic status Skin testing .
Classification of asthma Levels of asthma control Characteristic Daytime Symptoms Limitation of activities Nocturnal symptoms Need for relievers Lung function(PEF or FEV1) Controlled none( twice or less/week) none none none( twice or less/week) normal Partly controlled More than twice/week any any More than twice/week <80% Uncontrolled Three or more features of partly controlled asthma .
g.g. montelukast.Treatment and management Medical management Relievers Bronchodilators Short acting b2 agonist (e. formeterol) Glucocorticoids (e.g. salmeterol. hydrocortisone) Leukotriene antagonist (e. cromolyn sodium) Non-medical management Avoidance to triggers .g. zafirlukast) Mast cell stabilizers (e. ipratropium bromide) Controllers Long acting b2 agonist (e. salbutamol) Anitcholinergics (e.g.g.
references GINA report May 4. 2011 Harrison’s Principle’s of Internal Medicine 17th edition .
uncontrolled Community acquired pneumonia.Final diagnosis Bronchial Asthma.moderate risk .