Case 8: I M

Silver Group
Key Features
History (Chief Complaint & History of Present illness)
● 32/M

● Intermittent shortness of breath

HPI
● 10+ years PTC, Symptoms of intermittent shortness of breath

● 5 years PTC, patient used inhaler which reported to have helped

● 6 months PTC, patient reports that his symptoms have been worsening. He now has
intermittent periods of shortness of breath on most days, and he wakes up approximately 2
nights a week with a cough and shortness of breath
Key Features

History (excluding Chief Complaint & History of Present illness)

● Never had regular medical care or been able to afford to fill the prescriptions for inhalers
that he has received previously
● Has insurance through his job and is interested in treatment for his shortness of breath

● No chest pain, edema, heartburn, diarrhea, arthralgia, or neurologic, hematologic, or

psychiatric symptoms
● Medical history is significant for eczema and frequent "bronchitis" as a child
Key Features

History ( excluding Chief Complaint & History of Present illness)

● Smokes since 16, 5 pack/year, had history with cocaine

● Works in a hamburger restaurant

● Family history for asthma

● No current medication
Key Features
Review of systems
● General
○ Weight loss (volitional)

● Eyes
o Occasional itching
● Skin
o Eczema
● Abdomen
○ Pain
Key Features
Physical Exam
●Patient under respiratory distress

●Temp 36.4’C

●RR 14

●O2 Sat 95%

●BP 136/78
Key Features
HEENT Within normal limits, supple neck

Occasional wheezes; no crackles; no accessory muscle use;

Lungs
prolonged expiratory phase; good air movement

Heart Regular rate and rhythm

Abdomen Soft, nontender; bowel sounds present

Extremities No edema or joint swelling

Skin Small patch of eczema behind right knee

Neurologic Grossly normal

Test Results
Hct 44%, WBC 7.5 K/mcL,
CBC
eosinophils 0.9%
IgE 900 IU/mL

IgE for dog dander Class 5 (high reaction)

Prealbuterol: FVC 3.4 L, FEV1 2.0 L

Spirometry
(68% predicted); FEV1/FVC ratio 59%

Postalbuterol: FVC 3.8 L, FEV1 2.5 L

Problem Presentation

A 32-year-old man with multiple Respiratory disease risk factors is experiencing Allergy
induced Asthma, Patient is also Eczematous and hypertensive
Framework-Anatomic

Cardiovascular
Congestive heart failure
Anemia
Arrhythmia
Anaphylaxis
Framework-Anatomic

Respiratory
Asthma Allergic reaction
Bronchitis Anaphylaxis
Pneumonia Subglottic stenosis
Pneumothorax Interstitial lung disease
Lung cancer Tuberculosis
Pulmonary embolism Epiglottitis
Emphysema
COPD
Framework-Anatomic

Neurologic

Anxiety
Guillain-Barré syndrome
Framework-Anatomic

GI

Anaphylaxis
Primary Diagnosis
Asthma Secondary to
allergy
 Applying key features and tabulation
Features Allergy inmduced Bronchitis COPD
Asthma

Shortness of breath + + +

Hypertension + + +

Smoking history + + +

Ige increased due to + +/- -

exposure to allergens

Decreased O2 Sat + + +
 Applying key features and tabulation

Features Allergy inmduced Bronchitis COPD

Asthma

Eczema/atopic + - -
disorder history
Widespread wheeze + + +
on auscultation

Low forced expiratory +/- + -

volume in the first
second (FEV1)
 Applying key features and tabulation
Features Allergy inmduced Bronchitis COPD
Asthma

Eosinophilia - + -
peripheral blood
reversibility of airflow + + +
obstruction via
albuterol “E.g”

Serum + + +
Immunoglobulin E
>100 IU
Working diagnosis
Allergy Induced Asthma
Diagnostics
● Spirometry +/-
● Blood and Sputum Eosinophils
Diagnostics
● Spirometry +/-
● Blood and Sputum Eosinophil
● Serum Immunoglobulin E
Diagnostics
● Spirometry +/-
● Blood and Sputum Eosinophil
● Serum Immunoglobulin E
● Pulse Oximetry Assessment
Diagnostics
● Arterial Blood Gas
Diagnostics
● Arterial Blood Gas
● Chest CT Scanning
● Chest Radiography
● Allergy Skin Testing
Diagnostics
● Arterial Blood Gas
● Chest CT Scanning
● Chest Radiography
● Allergy Skin Testing
Treatment
Treatment
Inhaled corticosteroids (ICS)
Management
● Long-acting beta agonist (LABA)
● Avoidance of allergen triggers
● Nasal steroid spray or leukotriene
● Use indoor cleaning device such as
high-efficiency particulate air and
electrostatic precipitating filters to
reduce allergens
● Subcutaneous allergen
immunotherapy