CASE PRESENTATION

Aguilar, Joan F.
arry
Canillas, Emmanuel L

DATE OF INTERVIEW: sept 2, 2016

TIME OF INTERVIEW: 9 AM
SOURCE OF INFORMATON: Patient
SOURCE OF REFERRAL: None
RELIABILITY: 95 %

IDENTIFYING DATA

MPP
44 years old
Female
Married
Roman Catholic
Filipino
Housewife
East rembo, Makati city

CHIEF COMPLAINTS

dyspnea

HISTORY OF PRESENT ILLNESS

Productive cough & colds, yellowish phlegm, 7 days ptc

Dyspnea
associated low-grade on-and-off fever, 3 days
Known case of asthma
Paracetamol 500 mg/tab for the fever
Azithromycin 500 mg/tab, 1 tab od x 3 days
salbutamol+carbocyesteine cap, 1 cap bid x 5 days
Provided relief, however, cough persisted

Maintenance Medications.
(1) Salmeterol + Fluticasone 125/5.25 mg/mL, 2 puffs twice a day;
(2) Avamys - only taken again last week d/t diificulty breathing
through the nose;
(3) Levocetirizine unrecalled dose; and
(4) Isoptin unrecalled dose

_ *Allergies: Allergic Rhinitis

_ Tobacco: Non smoker

_ Alcohol/drugs: Beer on rare occasions. No illicit drugs.

PAST MEDICAL HISTORY

MEDICAL: Asthma; Community Acquired Pneumonia (2014);

Steatocystoma (20150
OB/GYNE: G4P4 (T3- P1- A0 L4)
SURGICAL: none
PSYCHIATRIC: NONE

FAMILY HISTORY
(+) asthma daughter
No family history of diabetes, tuberculosis, heart or kidney disease,
cancer, anemia, epilepsy, or mental illness

PSYCHOSOCIAL HISTORY

Housewife
Lives with husband and 4 children
Recently acquired pet dog
Lives in urban area
Does not engage in socio-civic activities
No problems pertaining to home
Gets little exercise

REVIEW OF SYSTEMS
General: No noted weight loss since the onset symptoms, no
weakness, afebrile
Skin: dry skin, no rashes, no sores, no itching, no changes on hair
and nails, no lumps
Head: no headache, no dizziness, no lightheadedness, no head injury
Eyes: Patient is wearing glasses, last examination was 2 years ago,
NO pain, redness, excessive tearing, double vision, blurring of vision,
spots, specks, flashing lights, glaucoma, cataracts.

Ears: no ear ache, no discharges, no tinnitus, no vertigo

Nose & Sinuses: Frequent colds, nasal stuffiness,
discharge of yellowish fluid, NO itching, epistaxis, sinus
trouble
Mouth & Throat: NO bleeding gums, dentures, last
dental examination was in 2015, NO sore tongue, dry
mouth, frequent sore throats, hoarseness.
Neck: no swollen glands, no lumps, no pain, no
stiffness, no neck rigidity
Breasts: no pain, no lumps, no nipple discharge, no skin
changes

Respiratory: (+) productive cough of yellowish sputum of

about approximately 1 tbsp/expectoration, (+) dyspnea, no
hemoptysis
Cardiovascular: no high blood pressure, chest pain, no
palpitations, no orthopnea, no paroxysmal nocturnal
dyspnea
Gastrointestinal: NO trouble swallowing, heartburn, loss of
appetite, nausea and vomiting, hemorrhoids, constipation,
diarrhea, change in bowel habits; bowel movement once
daily. NO abdominal pain, excessive belching or passing of
gas.
Urinary: urinates 5-8x a day to a yellow-colored urine
amounting to 240 ml per urination, no polyuria, no burning
pain, no hematuria, no dysuria, no urinary incontinence

Genital: no pain, no discharge, no itching, no sores, no

redness
Peripheral Vascular: no intermittent claudication, no
varicosities, no leg cramps, no swelling, no redness, no
tenderness, no lesions, no stiffness
Musculoskeletal: no muscle weakness, no pain, no
stiffness, no backache, no redness, no tenderness, no
limitation of motion, no joint pains, no numbness, no
history of trauma

Neurologic: no changes in orientation, no change in

memory, insight or judgment, no motor and sensory loss,
no fainting, no blackouts, no seizures, no numbness, no
tingling sensation, no tremors, no vertigo
Hematologic: no easy bruising, no bleeding, no history of
transfusion
Endocrine: no heat and cold intolerance, no diaphoresis,
no polyuria, no polydipsia, no polyphagia
Psychiatric: no history of depression or treatment of
psychiatric conditions, no history of suicidal attempts, no
nervousness, no tension, no depression, no memory
change

PHYSICAL EXAMINATION

GENERAL SURVEY
Patient was examined Conscious, coherent, oriented to time, place
and person, afebrile, mesomorph, not in cardio-respiratory distress
With the ff vital signs:
BP: 120/80 mmHg
RR: 21 cpm
PR: 84 bpm
Temp: 36.5 C axilla

Integument
Skin: brown in complexion, warm, dry, no edema,
no petechiae, no ecchymoses, no jaundice, no
rashes
Nails: with good capillary refill, smooth, no
cyanosis, no breaks
HEAD
Skull: normocephalic, symmetric, smooth skull
contours, no nodules or masses
Scalp: no active lesions, no nodules, no nits, no
tenderness
Hair: short, straight, evenly distributed, no lice

EYES
Eyebrows: symmetrical, no scar, no active lesions
Eyelashes: fine and black, no ectropion, no
entropion
Eyelids: no lid lag, no ptosis, no edema, no
tenderness
Conjunctiva: pale, no ulcerations, no redness
Sclera: no hemorrhage, anicteric, no redness
Cornea: with opacity on the left eye, no ulceration
Pupil: symmetrical, reactive to direct and
consensual light stimulation, with 3mm in diameter
EOM: full movement

EARS: symmetrical, with cerumen, no discharge, no

tenderness, difficulty hearing whispered voice
NOSE & SINUSES: (+) clear whitish discharge, no septal
deviation, pinkish nasal mucosa, no flaring of ala nasi, no
tenderness of nasal tip, MOUTH AND THROAT
Lips: dry, pinkish, smooth, no lumps, no ulcers
Oral Mucosa: pinkish, moist, no sores, no bleeding, no
nodules
gums: pink, no swelling or ulcerations on gums margins,
no bleeding
teeth: with dental carries, no dentures
Tongue: symmetric protrusion, pinkish, smooth, no
ulcerations and sores
Throat: uvula at the midline

NECK: trachea at midline, thyroid gland not enlarged

and moves with deglutition, no visible pulsations,
no palpable lymph nodes, no lumps
BREAST: not done

CHEST AND LUNGS

Inspection: truncal in shape, no lagging, no
subscapular and intercostals retraction on
respiration
Palpation: confirmed symmetrical chest expansion,
unimpaired tactile fremitus, no masses
Percussion: resonant on right and left lungs
Auscultation: (+) wheezing on right upper lobe of
lung, no crackles, no rales, no wheezing, no pleural
friction rub

HEART
Inspection: no precordial bulging, no visible pulsations
Palpation: no heaves, no thrills
Auscultation: normal rate, irregular rhythm and
nonsynchronous with pulse, no murmur, no pericardial
friction rub

ABDOMEN
Inspection: abdomen flat, inverted umbilicus, no
engorged vein, no scars
Auscultation: no peritoneal friction rub, hypoactive
bowel sounds
Percussion: liver 8cm at midclavicular line and 5 cm
at the midsternal line, no shifting dullness, no
costo-vertebral tenderness
Palpation: no mass, liver not enlarged, spleen not
palpable, kidney not palpable

EXTREMITIES
Inspection: no edema, equal in length and size, no
rashes, no cyanosis, no swelling of joints
Palpation: no limitation of range of motion,
peripheral pulses +2
BACK AND SPINE
Inspection: no abnormal deviation, no bulging
Palpation: no paravertebral tenderness or mass

GENITAL: not done

RECTAL EXAM: Not done

SALIENT FEATURES

45 years old
Female
Productive cough and colds, yellowish sputum, 7 days
Low-grade, on-and-off fever, 3 days
Dyspnea
(+) wheezes on Right upper lobe of lung
Childhood history of Asthma
On maintenance meds due to recurrence of asthma (2014)
Trigger: fur of animal (dog)

DIFFERENTIAL DIAGNOSIS

Chronic obstructive pulmonary disease

RULE IN

RULE OUT

Cough
with
phlegm Cough of 7 days
production
Smoker (>/= 2 years)
Exertional dyspnea
Barrel chest
Expiratory wheezes
Cachexia

DIFFERENTIAL DIAGNOSIS

ACUTE BRONCHITIS

RULE IN

Cough
Dyspnea
(+) wheeze
Low-grade fever
colds

RULE OUT

deep barking cough

Chest pain
Muscle aches
Sore throat
Extreme fatigue
(+)stridor

DIFFERENTIAL DIAGNOSIS

FOREIGN BODY ASPIRATION

RULE IN

Cough
Fever
Dyspnea
(+) wheezes

RULE OUT

NO history of impaired
swallowing, impaired
coughing, traumatic loss of
consciousness, intoxication or
oropharyngeal surgery
Old age, no signs of poor
dentition
NO history of alcohol or
sedative use

IMPRESSION:
BRONCHIAL
ASTHMA IN ACUTE
EXACERBATION

Plan:
Salmeterol + fluticasone 250/, 1 puff twice a
day
Medrol 16mg 1 tab twice daily
Ipratropium bromide neb q 8 hrs
Montelukast + levocetirizine once daily for 7
days

DISCUSSION

Description of asthma:
a heterogeneous disease, usually characterized
by chronic airway inflammation.
defined by the history of respiratory symptoms
such as wheeze, shortness of breath, chest
tightness and cough that vary over time and in
intensity, together with variable expiratory
airflow limitation.
airway hyperresponsiveness and airflow
inflammation
reversibility and variability

PATHOGENESIS

Diagnosis
LFTs
Airway

responsiveness
Hematologic tests
Imaging
Skin tests

PHARMACOLOGIC THERAPY FOR ASTHMA

Bronchodilator therapies at primarily on

airway smooth muscle to reverse the
bronchoconstriction of asthma

B2 agonists
activate 2-adrenergic receptors, which are
widely expressed in the airways.
relaxes smooth-muscle cells and inhibits
certain inflammatory cells.

relax airway smooth-muscle cells of all

airways
functional antagonists
reversing

and preventing contraction of airway

smooth-muscle cells by all known
bronchoconstrictors.

inhibition of mast cell mediator release,

reduction in plasma exudation, and inhibition
of sensory nerve activation

Clinical use:
inhalation
SABA albuterol; terbutaline (duration of 3-6
hrs)
Rapid

onset of bronchodilation and are needed for

symptom relief

LABA salmeterol and formoterol

12h

duration of action; given 2x daily by inhalation

Should not be given in the absence of ICS do not
control the underlying inflammation
Improve asthma control and reduce exacerbations
when added to ICS

Side effects: muscle tremor and palpitations

more common in elderly patients

Anticholinergics:
muscarinic receptor antagonists
Examples: ipratropium bromide
MOA: prevent cholinergic nerve-induced
bronchoconstriction and mucus secretion;
slower onset of bronchodilataiton
Side effects: dry mouth; urinary retention
and glaucoma (in elderly patients)

Theophylline:
Inhibits phosphodiesterases in airway
smooth-muscle, which increases AMP.
Activates the key nuclear enzyme histone
deacetylase-2 (HDAC2)
a

critical mechanism for switching off activated

inflammatory genes
reduce corticosteroid insensitivity in severe
asthma.

Clinical use:
additional

bronchodilator in patients with severe

asthma when plasma concentrations of 1020
mg/L are required.

IV aminophylline (a soluble
salt of theophylline) was used for the treatment of
severe asthma

largely replaced by high doses of inhaled SABA,

which are more effective and have fewer side effects

Side effects: nausea, vomiting, and

headaches
Due

to phosphodiesterase inhibition
Others: diuresis and palpitations, cardiac
arrhythmias, epileptic seizures

Due to adenosine A1-receptor antagonism

May

be elevated by drugs that block CYP450 (eg

erythromycin and allopurinol)

CONTROLLER THERAPIES

Inhaled corticosteroids
reducing inflammatory cell numbers and
their activation in the airways
reduce eosinophils in the airways and sputum
and the numbers of activated T lymphocytes
and surface mast cells in the airway mucosa

switch off the transcription of multiple

activated genes that encode inflammatory
proteins such as cytokines,
chemokines, adhesion molecules, and
inflammatory enzymes

inhibition of the transcription factor NF-B,

but an important mechanism is recruitment
of HDAC2 to the inflammatory gene complex,
reverses

the histone acetylation associated with

increased gene transcription

Activates anti-inflammatory genes

Mitogen-activated

protein (MAP) kinase

phosphatase-1
Increases the expression of beta 2 receptors

clinical use:
most effective controllers
beneficial in treating asthma of any severity
and age.
Usually given twice daily

Improves the symptoms of asthma, and lung

function improves over several days.
Effective in preventing asthma symptoms
such as EIA and nocturnal exacerbations, but
also prevent severe exacerbations.

Side effects: hoarseness and oral candidiasis

First-line therapy for patients with persistent
asthma, but if they dont control symptoms
at low doses, it is usual to add a LABA as the
next step.

Systemic corticosteroids
(hydrocortisone or methylprednisolone) for
the treatment of acute severe asthma,
although several studies now show that OCSs
are as effective and easier to administer
OCS (usually prednisone or prednisolone 30
45 mg once daily for 510 days) is used to
treat acute exacerbations of asthma; no
tapering of the dose is
needed

Systemic side effects:

truncal obesity, bruising, osteoporosis,

diabetes, hypertension, gastric ulceration,
proximal myopathy, depression, and cataracts,
may be a major problem, and steroid-sparing
therapies may be considered if side effects are
a significant problem

monitor bone density so that preventive

treatment with bisphosphonates or estrogen
in postmenopausal women may be initiated if
bone density is low.

Intramuscular triamcinolone acetonide depot preparation that is occasionally used in

noncompliant patients, but proximal
myopathy is a major problem with this
therapy.

Antileukotrienes
montelukast, block cys-LT1 -receptors and
provide modest clinical benefit in asthma.

given orally once or twice daily and are well

tolerated
have less effect on airway inflammation, but
are useful as an add on therapy in some
patients not controlled with low doses of ICS,
although less effective than LABA

Cromones
Cromolyn sodium and nedocromil sodium
inhibit mast cell and sensory nerve
activation
effective

in blocking trigger-induced asthma such

as EIA and allergen- and sulfur dioxideinduced
symptoms

little benefit in the long-term

control of asthma due to their short duration
of action (at least four times daily by
inhalation).

Steroid-sparing therapies
Methotrexate, cyclosporin A, azathioprine,
gold, and IV gamma globulin
used

as steroid-sparing therapies
No long-term benefit
associated with a relatively high risk of side
effects.

Anti-IgE
Omalizumab is a blocking antibody that
neutralizes circulating IgE without binding to
cell-bound IgE and, thus, inhibits IgEmediated reactions.
shown to reduce the number of
exacerbations in patients with severe asthma
and may improve asthma control

very expensive
given as a subcutaneous injection every 24
weeks and appears not to have significant
side effects
anaphylaxis is very occasionally seen

Acute severe asthma

prevent exacerbations
ICS + combination inhalers
Clinical features:
chest

tightness, wheezing, and dyspnea poorly

relieved by their usual reliever inhaler
patients may be so breathless may become
cyanotic
shows increased ventilation and tachycardia

 ABG:

hypoxemia, PCO2 is usually low due to

hyperventilation.

Treatment:
High

concentration of oxygen by face mask to

achieve oxygen saturation of >90%
High doses of SABA given either by nebulizer or
via metered-dose inhaler with a spacer.