History and examination findings Personal Details Name: Suba A/P Ramasamy Registration no.: SB323827 Age: 31 Sex: Female Race: Indian Religion: Hindu Occupation: Housewife Marital status: Married with one child Address: Rawang Chief Complain Breathlessness for two days History of Presenting Illness Ms Suba was brought to Accident and Emergency Department of Hospital Sungai Buloh on the 3 rd October 2012 with the complaint of intermittent breathlessness for two days, where the latest episode of breathlessness before the admission was lasted for two hours. The breathlessness was sudden and each episode normally lasts for about 10 minutes. Normally she has the breathlessness around 2-3 am, which will disrupt her sleep and she uses two pillows every night while sleeping. According to her, expiration was harder compared to inspiration during breathlessness. Running around, climbing the stairs, heavy work, cold weather, cold drinks and dust aggravate the breathlessness. During the time, Ms Suba always uses Ventolin inhaler to relieve the symptoms and tried to sit down upright. Out of a scale of 1-10, where 1 is the least severe and 10 is the most severe, Ms Suba ranked 8 for the severity of her breathlessness. Together with the breathlessness, she also had productive cough with scanty thick yellow sputum without blood, throat pain, running nose and wheezing. The cough was frequent during cold weather and night time. 1
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History and examination findings
Personal Details
Name: Suba A/P RamasamyRegistration no.: SB323827Age: 31Sex: FemaleRace: IndianReligion: HinduOccupation: HousewifeMarital status: Married with one childAddress: Rawang
Chief Complain
Breathlessness for two days
History of Presenting Illness
Ms Suba was brought to Accident and Emergency Department of Hospital Sungai Buloh on the 3rd October 2012 with the complaint of intermittent breathlessness for two days, where the latest episode of breathlessness before the admission was lasted for two hours. The breathlessness was sudden and each episode normally lasts for about 10 minutes. Normally she has the breathlessness around 2-3 am, which will disrupt her sleep and she uses two pillows every night while sleeping. According to her, expiration was harder compared to inspiration during breathlessness. Running around, climbing the stairs, heavy work, cold weather, cold drinks and dust aggravate the breathlessness. During the time, Ms Suba always uses Ventolin inhaler to relieve the symptoms and tried to sit down upright. Out of a scale of 1-10, where 1 is the least severe and 10 is the most severe, Ms Suba ranked 8 for the severity of her breathlessness. Together with the breathlessness, she also had productive cough with scanty thick yellow sputum without blood, throat pain, running nose and wheezing. The cough was frequent during cold weather and night time.
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Past Medical History
Ms Suba was having childhood asthma since born, which was resolved at the age gap of 10-20 years old. But then she got it back after that. Normally she used to go to the clinic and take medication if she felt breathlessness. She also consumed some traditional medication at the age of 10. Since the past 4 years she had stopped consuming tablet and started to use inhalers which are ventolin (salbutamol) whenever she feels breathlessness and beclometasone pressurised inhalation (100µg/dose) once in the morning and once at night. Sometimes during breathlessness she will take oral prednisolone (5mg) but it did not get better these two days.
Surgical History
In 1995, Ms Suba had undergone two orthopaedic surgeries due to her right distal tibia fracture.
History of Allergies
Ms Suba is allergic to dust especially if any dusty carpets are around, which will cause her to have breathlessness, running nose and sore throat.
Family History
Ms Suba’s mother died due to diabetes mellitus. All her other family members are fine. No history of asthma in the family.
Social History
Ms Suba felt comfortable and clean to stay at her house. Her housing area is clean with a clean and good supply of water and electricity. Currently she is staying with her husband, son, mother-in-law, father-in-law and two nephews. From June to December 2011 (6 months), Ms Suba worked at a rice company called Beras Jati as a person who does the packing work. The company was located at Rawang. Since the dust there aggravated her breathlessness frequently, she had stopped working there. She has no history of recent travelling, contact with animals, alcohol consuming or smoking. Her husband is actually a chronic smoker but he does not smoke in the house or smoke in front of Ms Suba.
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Review of Systems
Cardiovascular system – Chest pain and palpitation together with breathlessness, fatigue, no sweating.
Hematopoietic system – Slight fever on the first day of breathlessness (37.5 °C), no rashes.
Respiratory system – Productive cough with scanty yellow sputum, wheezing, running nose, sore throat, no hemoptysis.
Gastrointestinal system – No vomiting, normal bowel movements, normal appetite, heartburn after eating, no history of gastric pain.
Urinary system – Normal urine flow, no hematuria, no hesitancy, no urgency, no pain during urination.
Reproductive system – Menarche in November 1995. Normal menstruation cycle for every 27th day. Each cycle will lasts for 5 days. In the first 2 days, she will use 4-5 pads. Out of the 4-5 pads, 3 pads will be full while the other 2 will be half full. In the last 3 days, she will use 3 pads which will be half full. Since menarche, she has menstruation pain on the first day of menstruation. Gave birth to her son on 27th February 2009 by vaginal delivery.
Musculoskeletal system – No muscle, bone or joint pain.
Nervous system – Headache, no blurring of vision, no history of seizure.
Endocrine and metabolism system – No history of thyroid diseases or diabetes mellitus, gained 4kg of weight this year.
General Examination
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General inspection: On examination, Ms Suba was alert, conscious, well nourished and hydrated, pink, average height and build, not very comfortable but responding and communicating well..........................................................................................................
Hands: Warm and dry, pink, no clubbing, no tar-stained finger, no splinter haemorrhage, no peripheral cyanosis, left hand had a scar from an accident.
Eyes: No conjunctival pallor, no yellow discolouration of the sclera.
Mouth: No mouth ulcer or central cyanosis.
Systemic Examination
Respiratory system ................................................................................................................... .Neck: Carotid pulse can be felt and jugular venous pressure is not raised.
Chest:Inspection: Chest wall looks symmetrical and surgical scars was absent.Palpation: - Trachea is centrally located................................................................................ - No masses or lumps can be felt over the chest area....................................... - Apex beat can be felt at the 5th intercostal space of mid-clavicular line. - Chest expansion was equal on both sides, anteriorly and posteriorly. - Vocal fremitus can be felt equally all over the lungs, anteriorly and posteriorly.Percussion: The lung areas were resonant except for the cardiac dullness.Auscultation: - Fine crackles can be heard on upper lobes of both lungs, anteriorly and posteriorly............................................................................................... - Vocal resonance was equally heard all over the lungs, anteriorly and posteriorly.
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Legs: Rough and dry, pedal edema was absent, surgical marks on the right leg due to the accident.
Summary
Ms Suba, 31 years old, Indian, Hindu, married housewife, who is currently staying at Rawang. She was admitted to Hospital Sungai Buloh with the chief complaint of intermittent dyspnoea for two days, which was severe for two hours. It was associated with productive cough with scanty yellow sputum, wheezing, throat pain, and running nose. She also has paroxysmal nocturnal dyspnoea and orthopnoea. So she uses two pillows under the head during sleeping. The dyspnoea usually aggravated by running around, climbing the stairs, heavy work, cold weather, cold drinks and dust while relieved by inhaling ventolin. Ms Suba is having childhood asthma since born and taking medication for it which is ventolin, beclometasone pressurised inhalation and oral prednisolone. She is allergic to dust and very easily gets flu. There is no history of asthma or any diseases in the family except that her mother died of diabetes mellitus. No history of smoking, alcohol consumption, recent travelling or contact with animals. She also had chest pain, palpitation, fatigue and headache during dyspnoea and heartburn during sore throat.
IV Hydrocortisone 100mg TDS IV Augmentin 1.2g TDS Budesonide 2 puffs BD Tab. Acitno 500mg OD
Assessments of other health professionals
Ms Suba was visited by a Pharmacist to teach her on how to use an inhaler.
Information and education provided to patients and their relatives
The patient was educated about the technique of the inhaler and was told about the aero chamber to use with the inhaler but the patient refused to buy it.
Correspondence about the patient
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Lot 82, Jalan Country Home,Sungai Bakau,48000 Rawang,Selangor.
012 – 219 5021
Advance directives or ‘living will’
Ms Suba was not against with any procedures and given her full cooperation.
Contact details about next of kin (model)
Gunalan Ganesan (Husband)012 – 354 7341Working as a technician at Subang
Theoretical discussion
Bronchial asthma
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Asthma is a condition in which your airways narrow and swell and produce
extra mucus. This can make breathing difficult and trigger coughing,
wheezing and shortness of breath.
For some people, asthma is a minor nuisance. For others, it can be a
major problem that interferes with daily activities and may lead to a life-
threatening asthma attack.
Asthma can't be cured, but its symptoms can be controlled. Because
asthma often changes over time, it's important that you work with your
doctor to track your signs and symptoms and adjust treatment as needed.
Symptoms
Asthma symptoms range from minor to severe and vary from person to
person. You may have infrequent asthma attacks, have symptoms only at
certain times — such as when exercising — or have symptoms all the
time.
Asthma signs and symptoms include:
Shortness of breath
Chest tightness or pain
Trouble sleeping caused by shortness of breath, coughing or wheezing
A whistling or wheezing sound when exhaling (wheezing is a common sign
of asthma in children)
Coughing or wheezing attacks that are worsened by a respiratory virus,
such as a cold or the flu
Signs that your asthma is probably worsening include:
Asthma signs and symptoms that are more frequent and bothersome
Increasing difficulty breathing (measurable with a peak flow meter, a
device used to check how well your lungs are working)
The need to use a quick-relief inhaler more often
For some people, asthma symptoms flare up in certain situations:
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Exercise-induced asthma, which may be worse when the air is cold and
dry
Occupational asthma, triggered by workplace irritants such as chemical
fumes, gases or dust
Allergy-induced asthma, triggered by particular allergens, such as pet
dander, cockroaches or pollen
Causes
It isn't clear why some people get asthma and others don't, but it's
probably due to a combination of environmental and genetic (inherited)
Acute bronchitis is swelling and inflammation of the main air passages to
the lungs. This swelling narrows the airways, making it harder to breathe
and causing other symptoms, such as a cough. Acute means the
symptoms have only been present for a short time.
Causes, incidence, and risk factors
Acute bronchitis almost always follows a cold or flu-like infection. The
infection is caused by a virus. At first, it affects your nose, sinuses, and
throat. Then it spreads to the airways leading to your lungs.
Sometimes, bacteria also infect the airways. This is called a secondary
infection.
Chronic bronchitis is a long-term condition. To be diagnosed with chronic
bronchitis, you must have a cough with mucus most days of the month for
at least 3 months.
Symptoms
The symptoms of acute bronchitis may include:
Chest discomfort Cough that produces mucus; it may be clear or yellow-green Fatigue Fever -- usually low-grade Shortness of breath that gets worse with activity
Sometimes, bacteria may also infect the airways along with the virus. If
your doctor thinks this has happened, you may be prescribed antibiotics.
Other tips include:
DO NOT smoke. Avoid secondhand smoke and air pollution. Wash your hands (and your children's hands) often to avoid
spreading viruses and other infections.
Expectations (prognosis)
Symptoms usually go away in 7 to 10 days if you do not have a lung
disorder. However, a dry, hacking cough can linger for a number of
months.
Calling your health care provider
Call your doctor if:
You have a cough on most days, or you have a cough that often returns
You are coughing up blood You have a high fever or shaking chills You have a low-grade fever for 3 or more days You have thick, greenish mucus, especially if it has a bad smell You feel short of breath or have chest pain You have a chronic illness, like heart or lung disease
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Acute Pneumonia
Pneumonia is a condition affecting the lungs and in this infection inflammation of lung tissue occurs. Acute pneumonia may be caused by the pneumococcus bacteria and these may be found within the bronchial secretions of the lung that is affected. Pneumonia most frequently affects the lower lobes or the base in the lungs and in many cases the right lung is affected by this condition.
This condition may affect a single or both the lungs in individuals. The basic symptoms associated with pneumonia include fever, disturbed respiration, chest pain and cough. Sputum in pneumonia may be brownish, yellowish or greenish in color. Physical examination of this condition can help physicians diagnose cases of acute pneumonia.
In acute pneumonia certain complications may be observed and these include pleurisy. In this the two pleura layers covering the lung and inner wall of chest are affected by accumulation of fluid in the space within these two layers. This complication is also referred to as pleuritis and causes sharp chest pain along with chest tenderness, shortness of breath and cough.
Another complication in acute pneumonia includes pericarditis which refers to inflammation of the tissue layers that surround the heart. Endocarditis may also be one of the possible complications and it causes inflammation of the heart’s inner lining and the valves. These complications can occur due to septic poisoning. One of the most serious complications in this condition includes meningitis and this causes a large number of fatalities.