CASE PRESENTATION

ASTHMA

LARDEL KENT D. CARAY- MEDICAL CLERK

PATIENT INFORMATION

Name: s.s.
Age: 43 Y.O.
Sex: MALE
Address: putik, z.c
Civil Status: Married
Occupation: carpenter
Religion: ISLAM
Nationality: FILIPINO
PATIENT INFORMATION

CHIEF COMPLAINT:

difficulty of breathing
 HISTORY OF PRESENT ILLNESS
Patient is a known case of bronchial asthma
• was diagnosed when he was 20 years old

• was advised on home mediations, Prednisone

and Salbutamol but was non-compliant.
HISTORY OF PRESENT ILLNESS
1 DAY PTA
• Sudden onset of difficulty of
breathing, and shortness of
breath

• initially nebulized and given

Guafenesin, however there was
no relief of symptoms.
HISTORY OF PRESENT ILLNESS
Hours PTA
• Worsening of symptoms which
prompted consult at the ER-IM
 PAST MEDICAL HISTORY

• Known • No other • No known

asthmatic diagnosed allergies to
• Non- diaseases food or
compliant such as medication
to home hypertensi
medication on, DM, or
s CA
 Review of
systems
• Weight loss
• Difficulty of breathing
• Shortness of breath
• (-) cough
• (-) night sweats
 General
awake and conscious, in respiratory distress.
Survey

T: 36.7 ° C BP: 180/ 70 mmHg

Vital Signs HR: 116 bpm RR: 35breaths/min
Oxygen Saturation: 69 % at room air 

Skin No jaundice, rashes and hematoma.

PHYSICAL EXAMINATION
 HEENT: Head: Atraumatic head, no scars or lesions
Eyes: Anicteric sclera, pale palpebral conjunctivae,
Pupils are equal and reactive to light and accommodation.
Ears: No lesions, no discharges, nontender
Nose: No discharges, nontender
Throat and Mouth: Moist lips and oral mucosa

HEENT

No lymphadenopathies, No jugular vein distention

Neck

PHYSICAL EXAMINATION
 No scars or lesions, Equal chest expansion, (+) wheezing on bilateral lung
fields, (+) tachypneic
Chest/Respiratory

Adynamic precordium, tachycardic, regular rhythm, no heaves or thrills, no

Cardiovascular murmur, PMI at the 5th ICS midclavicular line

No scars or lesions, normoactive bowel sounds, tympanitic, nontender

Abdomen abdomen

Extremities Good peripheral pulses, no edema, CRT <2 seconds

PHYSICAL EXAMINATION
 Case discussion

Primary diagnosis: : Respiratory

Failure sec to Bronchial Asthma in
Acute Exacerbation

Secondary diagnosis: Chronic

Obstructive Pulmonary Disease in
Acute Exacerbation
 basis
RF secondary to
BA in acute COPD in AE
exacerbation
• Known asthma • Difficulty of
case breathing
• Difficulty of • Shortness of
breathing breath
• Shortness of
breath
• Wheezes on
bilateral lung
fields
 Case discussion:
ASTHMA
Asthma is a heterogeneous
disease with interplay between
genetic and environmental
factors. Several risk factors that
predispose to asthma have been
identified such as genetic
predisposition, atopy,
environmental allergens, and
 Case discussion:
ASTHMA
Asthma is associated with a specific chronic
inflammation of the mucosa of the lower airways.
One of the main aims of treatment is to reduce
this inflammation.
 Case discussion:
ASTHMA
• The characteristic symptoms of asthma are wheezing, dyspnea, and coughing,
which are variable, both spontaneously and with therapy.
• Symptoms may be worse at night and patients typically awake in the early
morning hours. Patients may report difficulty in filling their lungs with air. There
is increased mucus production in some patients, with typically tenacious mucus
that is difficult to expectorate.
• There may be increased ventilation and use of accessory muscles of ventilation.
Prodromal symptoms may precede an attack, with itching under the chin,
discomfort between the scapulae, or inexplicable fear (impending doom). Typical
physical signs are inspiratory, and to a greater extent expiratory, rhonchi
throughout the chest, and there may be hyperinflation.
• In our case since the patient is non-compliant to his medications, we see the
worsening of his dyspnea as well as evidence of respiratory failure.
 Case discussion: copd
• defined as a disease state characterized by persistent respiratory
symptoms and airflow limitation that is not fully reversible
(http://www.goldcopd.com/).

• COPD includes emphysema, an anatomically defined condition

characterized by destruction of the lung alveoli with air space
enlargement; chronic bronchitis, a clinically defined condition with
chronic cough and phlegm; and small airway disease, a condition
in which small bronchioles are narrowed and reduced in number.
 paraclinical diagnostic
procedure
  Certainty Treatment modality
1. BA in AE 60% Bronchidilators and anticholinergics
1. COPD in AE 40% Brochodilators

  Benefit Risk Cost Availability

1. Lung Function Quantify the decrease in expiratory No risk ?? available
test (e.g. PEF airflow during exacerbations
or FEV1)
1. Chest x ray Check for infiltrates or hyperinflation Radiation 150 available
of lungs risk

Both of these paraclinicals are available in ZCMC and since Lunf unction test is very
vital to the assessment and management of both, then we can order this. For
bronchial asthma, if Pre-treatment PEF or FEV1 is < 25% of predicted or personal
best then we can admit the patient; Or if Post treatment PEF or FEV1 is 40-60% then
we can continue treatment and reassess frequently.
 treatment
After the all that we have done, we are now committing our clinical diagnosis as
Bronchial Asthma in Acute Exacerbation (severe), so that we may be able to
accurately address the problem with on point treatment also. For this case , the
appropriate treatment should include:

• Admission to ward or ICU

• Give inhaled SABA and ipratropium bromide
• O2 support, maintain saturation at 93-95%
• Systemic corticosteroids
• Consider high dose ICS
• And consider referral to specialists
 Prevention and health
promotion

In order to prevent future recurrence, patient should be

advised on:

• Compliance to medications
• Proper use of inhalers
• Smoking cessation
• Balanced diet
 references

• Global Initiative for Asthma, 201. Rai CSP, et al, MJAFI 2007
• GOLD 201 COPD guidelines. www.goldcopd.org
• Harrison’s Principle of Internal Medicine. 20th Edition