CASE SUMMARY

Patients particulars
Name : Mrs. NH Registration No. : 020880 - 09
IC No : 600520-06-5270 Date of admission : 26 August 2009
Age : 49 years old Date of discharge : 29 August 2009
Race : Malay Date of clerking : 27 August 2009
Gender : Female Source of information : Patient
History
Chief complaint
Sudden onset of severe shortness of breath for 1 hour prior to admission.
History of Presenting Complaint
Mrs. NH was relatively well until 5 days ago when she developed shortness of breath in
the car on the way to her sister’s house in Temerloh. Her brother drove her to the sister’s house
from Jerantut. The shortness of breath started at 4pm on the day of admission when her brother
lower down the air-conditioner temperature. Initially the attack was mild but gradually become
severe that she could not speak a full sentence in 1 breath and was gasping for air. She claimed
that she could not even stand or walk when they reached the house, so the brother immediately
bring her to the Emergency Department of HOSHAS. However, she did not lose her
consciousness. The shortness of breath was continuous, aggravated by cold temperature in the
car, could not relieved by resting or sitting position and bronchodilator like she usually did when
she had the attack before as she did not bring it with her during the current attack. The shortness
of breath was preceded by cough and runny nose for 1 week prior to admission. The cough was
non-productive and she was on medication for the symptoms, so the symptoms have subsided.
The attack was associated with wheezing and chest tightness all over the chest.
Mrs. NH started to get asthmatic attack in 2002, which is 7 years ago and she noticed
that it became severe since 1 year ago. Initially she had the attack once or twice in a month, yet
since a year ago the shortness of breath occurred about 2 to three times. She claimed to have
shortness of breath on exertion for example after doing heavy house chores, walking for a long
distance, and climbing up stairs. She even had an episode of syncope 4 months ago while
cleaning her house thoroughly. The onset of the attacks was usually sudden, precipitated by cold
or hot weather and is usually relieved by bronchodilator and in resting or sitting position.
She had orthopnoea since almost 7 years ago as she always sleeps with 3 pillows every
night and claimed to get shortness of breath if lies flat. Sometimes, she had paroxysmal
nocturnal dyspnoea as she claimed she was awakened suddenly by the dyspnoea with wheezing
in the middle of her sleep. The shortness of breath is then relieved by back massage with
traditional medicine and also by inhaling the bronchodilator.
Prior to the current attack, Mrs. NH has no fever, sore throat or night sweats. She also
had no pleuritic chest pain, palpitation, or headache.

Systemic Review
Cardiovascular System – She had dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea.
However, there were no palpitation, chest pain or ankle swelling.
Respiratory System – She had shortness of breath, cough and runny nose but no sore throat,
sputum, heamoptysis, fever or night sweats.
Gastrointestinal System – She had no abdominal pain, nausea, vomiting and diarrhoea. She did
not experience loss of appetite or loss of weight. Her bowel habits are normal.
Genitourinary System – the frequency and color of urine were as usual. There was no dysuria,
polyuria, haematuria, urgency, or urinary incontinence.
Musculoskeletal System – There was no complained of myalgia, muscle weakness, arthralgia
and backpain.
Central Nervous System – She had no headache and no history of stroke. She had previous
history of seizures in her childhood but claimed no more seizures attack after she finishes her
primary school. No other remarkable sign of neurological disorders.

Past Medical History

Mrs. NH was a known case of Diabetes Mellitus since 10 years ago. She took medication
for her diabetes irregularly, only when she remember to take it. She described the drug as white
tablet and should be taken 3 times a day.
She was also a known case of asthma since 7 years ago in 2002 at the age of 42 years
old. She is on her medication for asthma, which she described 2 tablets per day; a white and a
pink tablet. She also claimed being incompliance due to forgetfulness. Her asthmatic attack was
once to 3 times in a month. The last attack was 2 weeks prior to the current attack. The attacks
were relieved by bronchodilator, usually around 20- 30 minutes after puffing the inhaler twice.
She was warded several times for her acute exacerbation of asthma since 7 years ago.
Besides, Mrs. NH claimed previously she had hypertension only during her pregnancy.
But on admission, she is newly diagnosed as hypertensive and was on medication given by the
doctors in the ward.
Past Surgical History
Nil

Drugs History
No other significant drugs other than mentioned above.

Social History
Mrs. NH is a single mother, living with 2 sons aged 9 and 12 years old in a low cost
housing area in Kg. Sri Pedah, Jerantut. Her eldest daughter aged 13 years old was sent to an
orphanage in Temerloh, near her sister’s house due to family financial problem since her
husband died 3 years ago. Previously, she worked as a cook in a restaurant but because of her
illness, she stopped and currently is unemployed for 2 month. However, she takes orders for
traditional kuih from the neighbourhood.
No history of smoking and drinking alcohol. She is a passive smoker since 10 years
before her husband died.
Family History
Her husband died at the age of 50, 3 years ago due to ischemic heart disease. Her father
died because of animal attack and her mother died of ischemic heart disease. She has a strong
background of atopic asthma on her father’s side. No family history of hypertension on both
side and was unsure of any history of diabetes mellitus. No history of malignancy in the family.
Allergy
She is allergic to seafood and a type of drug which she mentioned as a capsule; blue
colored at one side and yellow colored on the other side. She claimed the drug is most probably
antibiotics but was unsure of it.

Physical Examination
General appearance
Patient was conscious, alert, responsive to people and environment and lying on the bed
comfortably in a propped up position of 45 degree. She appeared pink, well, stable and did not
show any painful expression and was not in respiratory distress. Her vitals signs were:

Blood pressure : 140/ 83mmHg

Pulse rate : 88 beats/minute; regular rhythm, good volume and symmetry
Respiratory rate : 20/minute
Temperature : 37.0 oC
SPO2 : 95% on room air
Peripheral examination
Hands - No finger clubbing, peripheral cyanosis, palmar erythema, flapping tremor and wasting
of small muscle of hand. Her palm was warm. Capillary filling time was normal (less than 2
seconds)

Face - Her conjunctiva was not pale and there was no jaundice. She had no central cyanosis.

Leg - She had multiple dermopathy at both of her lower legs. Minimal pitting edema was
present up to the middle of both legs.

Respiratory system

On inspection, chest wall was symmetrical with no chest deformity. There was no surgical scar
or dilated veins present. She was not using her accessory muscle for breathing. Chest wall
moves synchronously with respiration and no audible sound heard. On palpation, trachea was
centrally located, cricosternal distance was not reduced. There was no masses in the neck and no
lymphadenopathy. Chest expansion was reduced equally on both side. Vocal fremitus was also
reduced at the lower zone of both side of the lungs. On percussion, lung was resonance
throughout the whole chest. On auscultation, air entry was reduced equally on both side with
prolonged expiratory phase. Vocal resonance reduced bilaterally at the lower lobes, anteriorly
and posteriorly. No rhonchi was heard.

Cardiovascular System

Jugular Venous Pressure was not raised. On general inspection of precordium, there was no scar
and no visible abnormal pulsation at the chest. Apex beat was regular and not displaced (located
at 5th intercostal space at mid-clavicular line). There was no thrills or parasternal heaves felt. On
auscultation, dual rhythm (S1, S2) heart sounds were heard. No murmur.

Gastrointestinal System

Abdomen was symmetry with no deformity, and the wall moves synchronously with respiration.
Abdomen was not distended. No surgical scars, pulsation or dilated veins was seen. A few striae
present at the lower part of her abdomen. Abdomen was soft, non tender on palpation and no
palpable mass. No evidence of organomegaly. Kidneys were not ballotable. Normal bowel
sound is heard on auscultation and no renal or liver bruit present.
Central nervous system

The patient was alert, conscious and well orientated to people and surroundings. She can follow
command very well. CNS was generally intact. All reflexes in the upper and lower limbs were
present. Tone and power were normal. There was no cerebellar effect signs detected.

Summary

My patient, Mrs. NH, a 49 year-old Malay housewife, who has a known case of asthma
for 7 years and Diabetes Mellitus for 10 years presented with cough for 1 week and sudden
onset severe shortness of breath for 1 hour prior to admission. She also had dyspnoea on
exertion, orthopnoea and paroxysmal nocturnal dyspnoea. On physical examination chest
expansion and air entry were reduced symmetrically throughout the whole chest. Vocal fremitus
and vocal resonance were also reduced bilaterally at the lower zones of the lungs. No rhonchi
was heard on examination. All her vitals signs were normal with no other significant respiratory
and systemic findings.

Provisional Diagnosis
Acute Exacerbation of Bronchial Asthma secondary to Upper Respiratory Tract Infection
Differential Diagnoses

1. Community- Acquired Pneumonia (CAP)

2. Left Ventricular Failure
3. Acute Pulmonary Oedema
Investigations
Baseline investigation
1) Full Blood Count and differential count of white blood cells – This test was done to
detect the presence of anemia, polycythemia or any infection.(secondary polycythemia
occurs with chronic hypoxia)
Hb: 12.8 g/dL ; Hct: 38.9% ; Platelet: 156 x 10^9/L ; WBC 11.8 x 10^9/L
Percentage Of Eosinophil - 4.4 % (N: 1-4%)
Percentage Of Monocyte - 6.1 % (N: 2-8%)
Percentage Of Neutrophil - 76.8 % (N: 50-70%)
Percentage of Basophil - 0.4 % (N: 0.4%)
Percentage of Lymphocyte-12.3 % (N: 20-40%)
 Impression: No significant change in full blood count except that there was an increase
in WBC level which may occur due to infection. Neutrophilia (suggestive of bacterial
infection) and eosinophilia (suggestive of underlying asthma)
2) Blood urea and serum electrolyte, plasma creatinine – Done to rule out any renal
impairment or electrolyte imbalance, and to check patient’s hydration status.
Urea: 4.39 mmol/L ; Na+ : 139 mmol/L ; K+ : 3.8 mmol/L ; Creatinine: 98umol/L
Impression : Normal result. Patients has good hydration status and no electrolyte
imbalance.
3) Random Blood Sugar
Result : 11.4 mmol/L (Referral range < 11.1)
Impression: Her Diabetes Mellitus was not well-controlled.
4) Liver Function Test – to detect any impairment of liver, due to possible cor pulmonale
5) Lipid Profile - to detect any predisposing factor for developing ischemic heart disease,
which can contributes to development of heart failure.
6) Cardiac Enzymes – to rule out cardiac causes
Specific Investigation
1) Arterial Blood Gas
pH: 7.42 (N: 7.35-7.45)
pCO2: 34.4 (N: 35-45mmHg)
pO2: 78.1 (N: 75-100mmHg)
HCO3: 21.6 (N: 24.1 meq/L)

2) Chest X-Ray – CXR was clear. However, was hyperinflation of the lung was detected on
the X-Ray.

3) Peak Expiratory Flow Rate (PEFR) – done pre and post nebuliser. PEFR post nebuliser
was improved.

4) Spirometry
5) Electrocardiogram (ECG) - to check whether there is any cardiac causes or cor
pulmonale due to underlying asthma.

6) Sputum culture – only done if she has productive cough

Management
Mrs. NH was on O2 3L/min via nasal prong on admission. She was prescribed with the
following by the doctors: IV drip 3 pints Normal Saline + 1gm KCl alt pint, IV Augmentin
1.2gm, Nebulizer 6 hourly, and T.EES 500mg BD.
1) Drugs Therapy
 IV hydrocortisone 100mg (during acute stage)
 Tablet prednisolone 30mg (once stabilized)
 Start metered dose inhaler (MDI) Salbutamol
 Start metered dose inhaler (MDI) Becotide
 Nebuliser AVN 1:2:1 two hourly then 4 hourly
 SPO2 monitoring : keep SPO2 95%, keep NPO2 3L/min
2) Rehabilitation
 Check and educate patient’s technique of using metered dose inhaler (MDI).
 Advice patient to take haemophilus and pneumococcal vaccine for infection prophylaxis.
 Advice to comply with antihypertensive and diabetic medication.
 Give patient and family education about asthma.

Discussion
1) Mrs. NH most probably was having an attack of acute exacerbation of asthma. The
reason for that is she came to the hospital with sudden onset severe breathlessness
associated with wheezing. Besides, she was diagnosed as having asthma since 42 years
old and had several times of the same attack previously. She had cough prior to the
attack, which is suggestive of presence of upper respiratory tract infection that can
precipitate asthmatic attack. She also complained of dyspnoea in cold weather, which is
also an aggravating factor for the attack. The current shortness of breath was so severe
that the patient was not able to complete a sentence in a single breath and was gasping
for air. She also had audible wheeze, diminished air entry and vocal resonance. The
findings on chest X-Ray also support the diagnosis.
2) Pneumonia is one of the differential diagnosis as it can exacerbate bronchial asthma.
However, the patient had no fever, cough with purulent sputum, sore throats or any chills
and rigors that suggests her to have pneumonia. There was also no consolidation of the
lung that suggests pneumonia.
3) Left Ventricular Failure can be another differential as Mrs. NH had symptoms of cardiac
failure like orthopnoea, paroxysmal nocturnal dyspnoea and also exertional dyspnoea. In
addition, physical examination found that she had very minimal ankle edema. However,
apex beat was not displaced and no significant findings of CVS was detected.
4) Acute Pulmonary Oedema (APO). Patient had sudden onset of shortness of breath
associated with cough that suggested an acute onset of the problem. She also had
orthopnoea and paroxysmal nocturnal dyspnoea which are the clinical features of
pulmonary oedema. These occur as a result of reabsorption of dependent oedema when
lying flat, and the relative insensitivity of the respiratory centre at night allows
pulmonary congestion to develop. Cough productive of frothy, blood-tinged sputum,
crepitations and Kerley B lines on chest x-Ray are some of the findings in patient with
pulmonary oedema, yet is not found in this patient .