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Difficulty of breathing,
Noisy and Rapid breathing
4
20 days PTA (+) Recurrent asthma attacks
characterized as difficulty of
breathing, shortness of breath,
HISTORY OF and rapid breathing
PRESENT (+) During morning, evening,
after school activities and
ILLNESS exposure to newly painted
school gym
(+) Relieved by Salbutamol neb
during morning, evening, and as
necessary for asthma attacks
Cyanosis spontaneously
resolved upon awakening
No medications 4
taken and no
consult was done
Six hours prior to
(+) Persistence of
admission
productive cough
(+) DOB
(+) SOB
(+) Rapid breathing
(+) Nasal congestion
(+) Dysphagia with
solid foods
(+) Poor appetite
(-) Vomiting
(-) Fever
Slightly relieved with one
dose of Salbutamol
nebulization
4
Four hours prior to
admission Persistence of symptoms
GENERAL: (-) febrile episodes, (+) weakness, (+) poor oral intake, (-)
lethargy
SKIN: (-) rashes, (+)cyanosis
HEENT: (+) Allergic Rhinitis, (+) Progression of snoring (soft to loud,
intermittent to persistent), (+) OSA, (+) frequent mouth breathing, (+)
voice change
RESPIRATORY: (+) productive cough, (+) DOB, (-) post tussive vomiting, (-)
hemoptysis
CARDIAC: (-) edema (+) severe pulmonary hypertension
REVIEW OF SYSTEMS
GASTROINTESTINAL: (+) poor oral intake, (-) Abdominal pain, (-)
vomiting, (-) changes in bowel movement
GENITOURINARY: (-) dysuria, (-)incontinence, (-)frequency
MUSCULOSKELETAL: (-) swelling, (-) trauma
HEMATOLOGIC: (-) anemia, (-)bleeding, (-)bruising
NERVOUS: (-) seizures, (-) tremors
FEEDING HISTORY
MEALS BEFORE ILLNESS CALORIC INTAKE SUBTOTAL BEFORE ILLNESS CALORIC INTAKE SUBTOTAL
SPECIFIC INTAKE (Percentage) SPECIFIC INTAKE (Percentage)
Before Dietary Restriction On Dietary Restriction
Breakfast 1 1/2 cup rice 339 kcal 699 kcal 1/2 cup rice 113 kcal 223 kcal
2 slice meat 360 kcal 1 serving 110 kcal
vegetables
Snack 2 piece apple 80 kcalx2 160 kcal None None
Lunch 1 cup rice 226 kcal 696 kcal 1/2 cup rice 113 kcal 293 kcal
1 serving veg 110 kcal 2 stick barbecue 180 kcal
4 stick 360 kcal
barbecue
Snacks 1 piece wheat 90 kcal 90 kcal 1 piece wheat 90 kcal 90 kcal
bread w/ tuna bread w/ tuna
Dinner 1 cup rice 226 kcal 336 kcal 1/2 cup rice 113 kcal 223kcal
1 serving veg 110 kcal 1 serving vegetables 110 kcal
EDUCATION: Grade 3
Elementary student with
good grades
ACTIVITY: He is fond of watching
TV while playing Rubrics, Clash of
Clans and Mobile Legends on his
tablet
DRUGS: No known 4
history of illicit
drug use
Growth and
Development SEXUAL: Has a girl crush at school
4
Given as Penta vaccine in a private clinic
IMMUNIZATION ** Vaccination which were advised to the patient but
was refused by the mother
Vaccine 1st dose 2nd dose 3rd dose Booster Place Reaction
BCG Given BeGH Scar
DPT Given* Given* Given* None
OPV Given* Given* Given* None
HiB General
Given* Given* Skin
Given* HEENT None
Maternal
Paternal
(+) ADHD
(+) Bronchial
(+) Arthritis
Asthma
(+) HPN
(-) OSA
(-) OSA
(-) Obesity
(-) Obesity
(-) DM
(-) Ca
(-) CA
(-) DM
SOCIAL AND ENVIRONMENTAL HISTORY
Weight 46 kg 3 Obese
HEENT
Non sunken eyeballs, anicteric sclera, pink palpebral conjunctiva, (+) alar flaring,
(+) nasal discharges, (+) congested nasal turbinates, dry lips, moist buccal
mucosa,
(+) circumoral cyanosis while asleep, (+) Kissing, congested tonsils
Chest and Lungs
(+) Brassy cough, Symmetrical Chest Wall Expansion, (+) subcostal retractions,
(+) Use of accessory Muscles for respiration, Tachypneic, (+) Inspiratory Stridor,
(+) Tight air entry (+) Decreased breath sound (-) Wheeze (-) Crackles
PHYSICAL EXAMINATION
Heart
PMI @5th ICS LMCL, (-) thrills, (-) heaves, tachycardic, regular rhythm, (-)murmurs
Abdomen
Extremities
(-) gross deformities, (-) clubbing of fingernails, (+) cold extremities,
Capillary refill of <2secs
Neurologic Examination
Problem Oriented Medical Record
1. Difficulty of breathing, noisy breathing,
tachypnea, brassy cough
2. OSA
3. Obesity
4. ADHD
5. Financial difficulty
Problem #1: Difficulty of breathing, noisy
breathing, tachypnea, brassy cough
Subjective Objective
8 y/o, male G/S: awake, ambulatory, conscious, talks in
(+) difficulty of breathing phrases, in O2 inhalation @ 3-4 LPM/NC
(+) fast breathing HEENT: Congested nasal turbinate, nasal discharges,
(+) Recurrent cough & colds mouth breather, pink palpebral conjunctiva
(+) nasal congestion C/L: Brassy cough, SCWE, (+) subcostal retractions,
(-) fever (+) use of accessory muscles (+), (+)tachypneic, (+)
(+) Bronchial Asthma inspiratory stridor, (+) tight air entry, (+)decreased
(+) Family history of Asthma breath sounds, (-) wheeze, (-) crackles
(+) Allergic Rhinitis Heart: tachycardic, normal rhythm, (-) murmurs
(+) Salbutamol nebulization at home: Extremities: cold, with capillary refill <2 seconds
no relief of symptoms
BRONCHIAL ASTHMA IN ACUTE
EXACERBATION
t/c Acute Laryngotracheobronchitis
r/o Vocal Cord Dysfunction
4
PATIENTS SIGNS & BAIAE ALTB VOCAL CORD
SYMPTOMS DYSFUNCTION
(+) difficulty of breathing + + +
(+) cough + + +
(-) fever -
+ -
(+) Bronchial Asthma +
(+) No relief with Salbutamol +/- - +/-
nebulization +
(+) tachypneic + + +
(+) inspiratory stridor - + +
(+) tight air entry, (+)decreased +/- - +/-
breath sounds
+/-
(-) wheeze +/- -
PLAN
Admit patient to ward
Diagnostics:
CBC
CXRAY AP, including the neck
Lateral xray of the neck
PLAN
Therapeutics:
D5NM 1L x 28-29 gtts/min (M%)
Salbutamol neb, 1 nebulization Q20 minutes x 3 doses then
RA
Prednisolone 20mg/5ml, 4ml TID
Montelukast 10mg OD HS
Continue O2 inhalation and titrate to maintain O2
saturation of > 94 98%
Problem #2: Apneic episodes, very loud
snore, Kissing congested tonsils
Subjective Objective
8 y/o, male
G/S: awake, ambulatory, conscious, talks in phrases, in
(+) sleeps in a sitting position, with noted very loud snore
and an episode of apnea which lasted less than a minute
O2 inhalation @ 3-4 LPM/NC
(+) facial cyanosis during apneic episodes VS: SpO2: 96 % at 3-4 lpm per NC - AWAKE
(+) difficult to awaken 80% - <90% at 3-4 lpm per NC ASLEEP
(+) cyanosis spontaneously resolved upon awakening BMI: 26.80 kg/m2 (Obese)
(+) Difficulty maintaining sleep, prefers sitting position with
head extended HEENT: mouth breather, (+) circumoral cyanosis/facial
(+) Stridor cyanosis noted while sleeping, Kissing, congested tonsils
(+) Daytime Somnolence and frequent napping in school C/L: (+) use of accessory muscles, (+) inspiratory stridor
(+) Diagnosed with OSA Heart: tachycardic, normal rhythm, (-) murmurs
>Scheduled for Adenoidectomy Extremities: cold, with capillary refill <2 seconds
> Deferred for surgery due to recurrent URTI and was lost
to follow-up
8 year old male, Obese Noted interrupted sleep, with very loud snore, prefers
sitting position
DOB, Stridor Diagnosed case of Obstructive Sleep Apnea
Obesity
Collapse of the
pharyngeal
airway during Soft tissue Hypertrophy
sleep
Craniofacial Characteristics
PLAN
Dx: Polysomnogram
Tx: Medical: CPAP
Surgical: Adenoidectomy
COURSE IN THE
WARD:
UPON ADMISSION:
Initial treatment-
supplemental
oxygen D5NM 1L x 28-29 gtts/min (M%)
inhaled b agonist -Hooked to CPAP
therapy every 20 min Neb with 2.5mL (1
for 1 hour and if amp Epi + 9cc NSS) q
necessary, 20 x 3 doses
systemic
corticosteroids VS: 120/80 mmHg, 135
given either orally bpm, 44 cpm, T: 36.6
or intravenously. 4
LABS: CBC, CXR
CEFUROXIME 750 mg IV Q8
5 Hours After Admission
(+) persistence of cough and
stridor, labored breathing
Serum Electrolytes:
Na, K, Cl, Mg
Na: 139
K: 5.23 (high)
Cl: 99.1 VS:
Mg: 0.81 BP: 110/80
CR: 132
RR: 30
Midazolam Drip: 50 cc
x 8-33 cc/hr via
4 T: 36.6
SpO2: 100%
infusion pump
ABGs after 16 Hrs
METABOLIC ACIDOSIS
1st Hospital
Day
VS: Asleep most of the time, w/ occasional
BP: 110-140/70-90 cough, no febrile episode
CR: 75-115
RR: 27-32
T: 36.4-36.7 Asleep(irritable when
SpO2: 94-97% on awake), on 4 point
MV restraint, with
intact ET tube SCWE, no retractions, no
wheezing, (+) bibasal rales
more on the right
FIO2 was at 70% then 4
decreased by 10% Q2 to NGT was inserted
reach 30%
VS:
BP: 110-140/70-90,
2nd Hospital
CR: 75-115,
RR: 27-32,
Day
T: 36.4-36.7,
SpO2: 94-97% via
MV (+) occasional cough, no DOB, no
vomiting, no febrile episodes
Awake, irritable, with intact
ET tube, and NGT
no pallor, no cyanosis
With Grade 3 Tonsils, non-
exudative SCWE, no retractions, VS:
BP:120-140/80-90
(+) diffuse wheezing, (+) CR: 57-117
4 bibasal rales RR: 22-35
T: 36.5-36.8
(+) Extubation SpO2: 96-100% at
1 LPM
3nd Hospital
Day
Respiratory Symptoms
Ely, J.W. Osheroff J. A., et. Al. Evidence Based Clinical Medicine: Approach to
Leg Edema of Unclear EtiologyJ Am Board Fam Med 2006;19:14860
ETIOLOGY
Environmental
Exposure Biological
Allergens and Genetic
Infections Risk
Pollutants
Stress
Common Asthma Triggers:
Viral Infections
Allergens
Progressive
Progressive
decrease in
increase in
lung
symptoms
function
Asthma is an inflammatory disease of the lower respiratory
tract, manifesting as intermittent constriction of the bronchial
airways. Obstructive sleep apnea (OSA), on the other hand, is a
state-dependent condition that is characterized by intermittent
obstruction of the upper airway during sleep leading to
hypoxemia and sleep fragmentation [8].
The pathophysiology of these two conditions seems to overlap
significantly, as airway obstruction, inflammation, obesity, and
several other factors are implicated in the development of both
diseases
Moreover, OSA is generally linked to worse asthma outcomes.
The effects of the direct pathophysiologic consequences of OSA
(e.g., chronic intermittent hypoxemia, circadian alteration
of autonomic functions, and increased intrathoracic pressure
swings related to the occluded upper airway) on the clinical
severity of asthma are poorly understood [1]. Moreover, the
National Asthma Education and Prevention Program Expert
Panel Report recommends evaluating for OSA as a potential
contributor to poor asthma control [10]. Thus, clarifying the
nature of the relationship between OSAS and asthma is a
critical area with important therapeutic implications.