Internal medicine Case 3 (Asthma)

Mohammad Foqahaa 11840178

1) Finding

Name: YA Age: 30years BP: 96/60 mm

Gender: Male Blood group: A+ HR: 90 bpm
Height: 175cm Weight: 90kg SpO2: 91%
Adress: Tulkarm Tel:05999999 Tem:37
Immunization: Full immunized Food/drug allergy: NKFDA BSA: 2.09 m2
 Family history: Father suffers from COPD.

 Social history: Married, smoker, denies drink alcohol.

 PMH: For two years, the patient has been complaining of cough, shortness of breath, and
bilateral chest wheezing, which affects daily activities and worsens in winter. Last month,
symptoms worsened and he was hospitalized with severe shortness of breath.

 Current medications:
salbutamol respiratory solution 5mg/ml when needed.
Azithromycin 250mg PO once daily.

 Chef compliance: the patient come to the emergency department complaining of productive
cough with worsening shortness of breath & wheeze chest.

 Sings & symptoms:

Productive cough and shortness of breath daily with bilateral chest wheeze for 2years limits the
daily activity (some limitation).

Chest X-ray: free. Spectrum culture: negative

 Final diagnosis: Acute asthma exacerbation.

2) Assessment

 Short term gals:

- For acute severe asthma, the primary goal is prevention of life-threatening asthma by early
recognition of signs of deterioration and early intervention.

 Long term gals:

-Achieve good control of symptoms and maintain normal activity levels.
-Minimize future risk of exacerbations, fixed airflow limitation, and side effects.
 DRP: wrong medication, need drug therapy.
3)Resolution

 Non-pharmacological
-The patient should receive annual influenza vaccine.
-Patient education is mandatory to improve medication adherence, self-management skills, and
use of healthcare services.
-Avoidance of known allergenic triggers can improve symptoms, reduce medication use, and
decrease BHR. Environmental triggers (eg, animals) should be avoided in sensitive patients, and
smokers should be encouraged to quit.
-In acute asthma exacerbations, initiate oxygen therapy to achieve an arterial oxygen saturation
of 93%–95% in adolescents and adults and 94%–98% in school-aged children and pregnant
women or those with cardiac disease.
-Correct dehydration if present.

 Pharmacological
Stop Azithromycin (no indication, wrong use of antibiotics)
 For exacerbation attack:
Give short course oral prednisolone 20mg twice daily for 7 days.
Continue salbutamol respiratory solution 5mg/ml when needed.
Give ipratropium 500mcg/2ml nebulized solution 500mcg q20min for 3 doses, then PRN
Give moderate dose budesonide/formoterol (80/4.5) tow buff twice daily +PRN
 For chronic management of moderate persistent asthma (step 3):
Low dose budesonide/formoterol (80/4.5) one buff twice daily + when needed.

4) Monitoring

For the effectiveness of medications & disease control:

-REVIEW RESPONSE and optimize control about every 3 months. Step-down of controller
treatment may be considered if symptoms have been well controlled and lung function has been
stable for 3 months or longer.

For the safety of medications:

Prednisone: mostly the patient will not have toxic symptoms with this short course and don’t
need tapering for the dose.

Salbutamol: monitor heart rate (may induce tachycardia, tremor and palpitation).

Ipratropium: may cause dry mouth and urinary retention.

Budesonide/formoterol inhaler: Systemic side effects are rarely with local use. Local adverse
effects include dose-dependent oropharyngeal candidiasis and dysphonia, which can be reduced
by using a spacer device.

We should counsel the patient to rinse his mouth with water and spit the water out after each
dose to avoid local side effects.

We should counsel the patient about the proper use of inhaler.