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CASE DISCUSSION

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  1. CASE DISCUSSION RIVERA, JOANNA GRACE ASMPH BATCH 2013

  2. OBJECTIVES • At the end of this case presentation, we should be able to do the following: • Discuss the case of bronchial asthma • Understand the pathophysiology of bronchial asthma • Know the basic management and prevention of bronchial asthma

  3. GENERAL INFORMATION EPYN Female 3 years old Filipino Roman Catholic Mandaluyong City Informant: Father Reliability: 80%

  4. CHIEF COMPLAINT Difficulty of Breathing (two days duration)

  5. HISTORY OF PRESENT ILLNESS Two days PTA • Nonproductive cough • Difficulty of breathing • (-) colds and fever • Nebulized with salbutamol with improvement of DOB

  6. HISTORY OF PRESENT ILLNESS • Worsening of cough and DOB • Unrelieved by salbutamol nebulization • No other associated symptoms Few hours PTA DAY OF ADMISSION

  7. REVIEW OF SYSTEMS • General: (-) changes in weight, (-) sweats, (-) weakness, (-) fatigue • Skin: (-) itchiness, (-) color changes, (-) pigmentation, (-) rashes, (-) photosensitivity, changes in hairs and nails • Eye: (-) blurring of vision, (-) redness, (-) itchiness, (-) pain, (-) increased lacrimation

  8. REVIEW OF SYSTEMS • Ear: (-) deafness, tinnitus, discharge • Nose: (-) epistaxis, (-) nasal discharge, obstruction, (-) postnasal drip • Mouth and throat: (-) bleeding gums, sores, fissures, tongue abnormalities, dental caries, • (-)sore throat, lump sensation • Pulmonary: (-) hemoptysis

  9. Review of Systems • Cardiac: (-) easy fatigability, orthopnea, nocturnal dyspnea, syncope, edema • GI: (-) retching, hematemesis, melena, hematochezia, dysphagia, belching, indigestion, food intolerance, flatulence, • (-)abdominal pain, (-) diarrhea, (-) vomiting, constipation, anal lesion

  10. Review of Systems • GU: (-) urinary frequency, urgency, hesitancy, nocturia • Musculoskeletal: (-) joint stiffness, pain, swelling, cramps, muscle pain, weakness, wasting • Endocrine: (-) heat-cold intolerance, polyuria, polydipsia

  11. Review of Systems • Hematopoietic:(-) abnormal bleeding, (-) bruising • Neurologic: (-) headache, seizure, mental status changes, head trauma

  12. PAST MEDICAL HISTORY • Asthma – Nov 2010 • Reliever medications: Salbutamol and Prednisone • Last attack: January 2012 • Denies nocturnal awakenings • (+) occasional shortness of breath after heavy exercises or activities • Allergic to Peanuts • No known allergies to medications

  13. BIRTH AND MATERNAL HISTORY Born full term via CS to a 38 year old G2P2 in Makati Medical Center attended by an Ob-Gyne BW: 3 kg Cord-coil

  14. IMMUNIZATION HISTORY • BCG (1 dose) • DPT/IPV (3 doses) • Hepa B (3 doses) • Measles (1) • Rotavirus (2)

  15. NUTRITIONAL HISTORY • Breastfed until 2 months • Formula fed with Nestogen (3 ounces/bottle) • Weaning age: 6 months (Cerelac); 9 months (rice)

  16. NUTRITIONAL HISTORY • 24 hour food recall • Breakfast: ½ cup of rice + tocino/hotdog/sausage/bacon/egg • Lunch: ½ cup of rice + sausage/fried chicken • Snacks: 1 pack of biscuit • Dinner: ½ cup of rice + tocino/sausage/chicken • Loves eating chocolates, candies and junk foods

  17. Developmental History GROSS MOTOR 6 months: sits with support 10 months: stands with support 1o months: walks with support 15 months: walks well alone 2 years: runs well, can climb up and down stairs, jumps 3 : throws balls, downstairs on one foot per step, hops on one foot FINE MOTOR 9 months: holds bottle 1 year and 3 months: can drink from cup 2 years old: can imitate a circle; 3 years old: imitates cross LANGUAGE 9 months: can speak mama and papa 1 and ½ year: can indicate needs; can speak three-word sentences 2 years old: can point to parts of the body and can follow directions; names on pictures 3 years old: tells little stories about experiences, gives full name and sex; recognizes 3 or more colors, counts to ten SOCIAL 2 years: can remove garment; toilet trained; uses spoon 3 years: dry by night; play interactive games; dresses with supervision; tells tail tales

  18. FAMILY HISTORY • Asthma (Maternal grandmother and cousins) • Hypertension and Diabetes (paternal) • (-) Allergies

  19. GENOGRAM Casino dealer Call center agent 41 40 3 18

  20. PERSONAL-SOCIAL HISTORY Lives in a two bedroom condominium with 6 household members With good ventilation Water source: Mineral water Garbage collected twice a week House is not near factories or highway No pets at home Parents and sibling are smokers

  21. Physical Examination

  22. PHYSICAL EXAMINATION GENERAL APPEARANCE Alert, quiet, weak-looking, in respiratory distress VITAL SIGNS BP: 100/70 RR: 40 O2 Sat (room air): 89% HR: 110 Temp: 37º C ANTHROPOMETRICS: Height: 106 cm (2 to 3) Weight: 22.6kg (3) BMI: 20.11 (3)

  23. PHYSICAL EXAMINATION SKIN warm skin, good skin color and turgor HEENT no lesions or matting of the eyelids, no eye discharge, no swellling, anicteric sclerae, pink palpebral conjunctiva, No tragal tenderness, no ear discharge, intact TM

  24. PHYSICAL EXAMINATION HEENT No alar flaring, nasal septum midline, with minimal nasal discharge dry lips, moist tongue, no circumoral cyanosis, no buccal mucosal lesions, no TPC no masses in the neck, (-) CLAD, flat neck veins

  25. PHYSICAL EXAMINATION RESPIRATORY can talk in sentences, (+) subcostal retractions, symmetric chest expansion, wheezes on both lung fields, no crackles or rhonchi HEART adynamicprecordium, no thrills, heaves or lifts, PMI at 5th ICS, MCL, normal rate, regular rhythm, distinct S1 and S2 sounds, no murmurs

  26. PHYSICAL EXAMINATION ABDOMEN Flabby abdomen, normoactive bowel sounds, soft, no organomegaly, no tenderness EXTREMITIES full and equal pulses, no edema, no cyanosis, no atrophy/hypertrophy, no deformities NEUROLOGIC EXAMINATION Intact cranial nerves, no sensory and motor deficits, normoreflexive, (-) Babinski, (-) clonus

  27. SUBJECTIVE OBJECTIVE SALIENT FEATURES 3/F Asthmatic Difficulty of breathing Cough Audible wheeze Relieved by Salbutamol nebulization initially  unresponsive • Respiratory distress • Tachypnea • Desaturation (87%) • Retractions • Wheeze • Normal cardiac findings

  28. PRIMARY WORKING IMPRESSION BRONCHIAL ASTHMA IN ACUTE EXACERBATION

  29. Differential Diagnosis • Bronchiolitis • Pneumonia • Upper Respiratory Tract Infection

  30. Course in the wards

  31. Emergency Treatment • O2 supplementation via face mask at 6 LPM • Salbutamol 1 nebule x 3 doses 20 minute interval • On admission: • Salbutamol 1 nebule every 6 hours • Salbutamol + Ipatropium (Combivent) 1 nebule every 6 hours • Prednisone 20 mg/5 ml 3 ml every 12 hours

  32. Day 1

  33. Day 1

  34. Day 2

  35. Day 1

  36. DISCUSSION

  37. Bronchial Asthma Excessive Contraction of the smooth muscle Uncoupling Thickening of the airway wall Sensitized sensory nerves • Chronic inflammatory condition of the lung airways resulting in episodic airflow obstruction • Airway hyperresponsiveness

  38. INFLAMMATORY CELLS Mast cells Eosinophils T-lymphocytes Dendritic Cells Macrophages Neutrophils INFLAMMATORY MEDIATORS Chemokines CysteinylLeukotrienes Cytokines Histamine Nitric oxide Prostaglandin D2 INFLAMMATORY CELLS Airway epithelial cells Airway smooth muscle cells Endothelial cells Fibroblasts Myofibroblasts Airway nerves

  39. Smooth muscle contraction Edema Airway thickening Mucus hypersecretion

  40. SMOOTH MUSCLE INCREASE BLOOD VESSEL WALL PROLIFERATION MUCUS HYPERSECRETION

  41. Clinical Signs and Symptoms Wheezing Cough Breathlessness Nocturnal symptoms/awakenings

  42. Diagnostic Examinations • SPIROMETRY • Airflow Limitation • Low FEV1 (relative to percentage of predictive norms) • FEV1 /FVC ratio <0.80 • Bronchodilator response • Improvement in FEV1 ≥12% and ≥200 mL • Exercise challenge • W0rsening in FEV1 ≥15% • Peak Expiratory flow monitoring • Day to day and/or AM-to-PM variation ≥20%

  43. Diagnostic Examinations • Therapeutic Trial • Short-acting bronchodilators and inhaled glucocorticosteroids (at least 8-12 weeks) • Test for Atopy • Immediate hypersensitivity Skin testing • Antigen-specific IgE antibody • Chest Radiograph • Hyperinflation and peribronchial thickening

  44. Treatment and Management Regular Assessment and monitoring Patient Education Control of Factors Contributing to Asthma Severity Principles of Asthma Pharmacotherapy

  45. Component 1 Regular Assessment and Monitoring

  46. Levels of Asthma Control for Children

  47. Component 2 Patient Education

  48. Component 3 Control of Factors Contributing to Asthma Severity