Bronchial Asthma - A Long Case Study Approach

Chief Complaints: 

• Difficulty in breathing for … years
• Cough for … months
• Wheeze and tightness in the chest … months.

History Of Presenting Complaints: According to the statement of the patient, he has been suffering from difficulty in breathing for the last … years. Initially, for a few years, it was episodic, occurring mainly during the winter seasons, and he was asymptomatic in between the attacks. But for the last … years, it is persistent with occasional exacerbations. His breathlessness is worse at night and sometimes during the daytime. It is aggravated by cold, dust and activity. There is no history of orthopnea or paroxysmal nocturnal dyspnea.

The patient also complains of cough which is usually dry, with occasional scanty mucoid sputum

expectoration, but no history of hemoptysis. Cough is present throughout the day and night, more on

exposure to dust or cold. He also experiences wheeze and tightness of the chest during coughing.

For severe attack of breathlessness and cough, he was hospitalized twice within the last ... months.

On query, the patient agreed that he has occasional attack of running nose and sneezing, more

marked on exposure to dust. There is no history of chest pain, weight loss or fever. His bowel and

bladder habits are normal.

History of past illness: He is non-hypertensive, no history suggestive of cardiac illness or reflux

esophagitis.

Family history: His brother is suffering from bronchial asthma and food allergy.

Personal history: He is a school teacher, smokes 10 to 15 cigarettes daily for the last 10 years. There

is no history of exposure to cotton, coal, etc.

Drug history: He uses bronchodilator and steroid inhalers, and used to take tablets like aminophylline, ketotifen and montelukast.

General Examination: 

• The patient is dyspneic
• Decubitus is propped up
• No anemia, jaundice, cyanosis, edema, clubbing, koilonychia or leukonychia
• No lymphadenopathy or thyromegaly
• Neck vein: Not engorged
• Purse lip: Absent
• Nasal polyp: Present on both sides

Vital signs: 

• Pulse: 120/min
• BP: 120/70 mm Hg
• Respiratory rate: 24/min.

Systemic Examination: 

1. Respiratory examination: 

Inspection:

• Shape of the chest—Normal
• There is indrawing of intercostal spaces, suprasternal and supraclavicular excavation and prominent accessory muscles of respiration.

Palpation:

• Trachea: Central. Tracheal tug absent
• Apex beat: In the left 5th intercostal space in midclavicular line, 8 cm from midsternal line, normal in character
• Chest expansion: Reduced
• Vocal fremitus: Normal.

Percussion:

• Percussion note: hyperresonance in both sides
• Area of liver dullness: In 5th ICS in the right midclavicular line
• Area of cardiac dullness: Normal.

Auscultation:

• Breath sound: Vesicular with prolonged expiration
• Vocal resonance: Normal
• Added sounds: High pitched rhonchi are present in both sides of the chest, more marked on expiration.

FET (forced expiratory time): > 6 seconds (normally <6 seconds).

Examination of other systems reveals no abnormalities.

Provisional Diagnosis: Chronic bronchial asthma.

Differential Diagnosis: COPD (Chronic obstructive pulmanary disease).

Questions likely to be asked by the examiner: 

Characteristic Features Of Conditions Causing Diarrhea

For the case scenarios of patients presenting with diarrhea chose a diagnosis form the list below:

A. Gastroenteritis
B. Crohn's disease
C. Ulcerative colitis
D. Colorectal cancer
E. Laxative abuse
F. Constipation causing overflow
G. Lactose intolerance
H. Diverticulitis
I. Irritable bowel syndrome
J. Coeliac disease

1. A 24-year-old smoker presents with intermittent diarrhea for the past 6 months. She feels bloated, especially around her periods. Bloods tests are normal.

Answer: Irritable bowel syndrome

2. A 23-year-old student is admitted due to a two-week history of bloody diarrhoea. He is normally fit and well and has not been abroad recently. His CRP is raised at 56 on admission

Answer: Ulcerative colitis
(The duration of his symptoms make a diagnosis of gastroenteritis less likely. The presence of blood in the diarrhoea points to a diagnosis of ulcerative colitis rather than Crohn's.)

3. A 72-year-old woman presents with a two day history of diarrhoea and pain in the left iliac fossa. Her temperature is 37.8ºC. She has a past history of constipation.

Answer: Diverticulitis

Discussion:
Characteristic Features Of Conditions Causing Diarrhea:

Acute Conditions:

1. Gastroenteritis: May be accompanied by abdominal pain or nausea/vomiting

A 56 year old woman with known RA Suffers from Recurrent Hemoptysis

A 56-yr-old woman, who is known to suffer from RA, complains she has had recurrent
haemoptysis for over 5 yrs. She has never smoked and only takes NSAIDs. According to her, she
coughs up phlegm every day and at times this contains streaks of fresh blood. She has no known
respiratory disease, but tends to get frequent chest infections that are relieved by a course of
antibiotics. What is the most likely Dx?
A. Lung cancer
B. Bronchiectasis
C. TB
D. Pulmonary embolism
E. Atypical pneumonia

Answer:

Regarding a 34-year-old female presents to her GP due to a number of 'funny-dos'

A 34-year-old female presents to her GP due to a number of 'funny-dos'. She describes a sensation that her surroundings are unreal, 'like a dream'. Following this she has been told that she starts to smack her lips, although she has no recollection of doing this. What is the most likely diagnosis?

A. Myoclonic seizure
B. Simple partial seizure
C. Complex partial seizure
D. Partial seizure progressing to generalised seizure
E. Absence seizure

Answer: C. Complex partial seizure

Discussion: With simple partial seizures there is no disturbance of consciousness or awareness. Lip smacking is an example of an automatism - an automatic, repetitive act.

Basic Classification Of Epilepsy:

Heart Failure - Case Study

Case Scenario:
A 42-year-old white man is seen in the ER with a chief complaint of shortness of breath that has lasted for 1 week. He reports having had a viral syndrome approximately 3 weeks before admission. Subsequently, he noted the development of lower extremity edema, a 15-lb weight gain, dyspnea on
exertion, and orthopnea. Currently he complains of dyspnea at rest.
Physical examination reveals an irregularly irregular heart rate of 130 per minute. His blood pressure is 90/60 mm Hg, and his respiratory rate is 22 per minute.
Examination of the jugular venous pressure demonstrates a mean pressure of 12 to 14 cm of water with a prominent V wave.
Lung examination reveals bibasilar dullness with rales extending one fourth of the way up from the basal lung fields bilaterally.
Cardiac examination findings are significant for a diffuse point of maximal impulse, which is displaced to the anterior axillary line. The S1 and S2 are of variable intensity, and a prominent S3 gallop over the displaced cardiac apex is appreciated. There is a grade 2/6 holosystolic murmur that is heard best at the cardiac apex, with prominent radiation to the axilla and no change w ith respiration. On examination of the abdomen, an enlarged, tender liver is found.
The extremities are cool and exhibit 2+ pitting edema.
The ECG show s atrial fibrillation with nonspecific ST-T–w ave changes, a left bundle branch block (LBBB) and occasional ventricular premature beats.
Arterial blood gas measurements performed with the patient on 4 L of oxygen per minute by nasal cannula reveal a pH of 7.46, a PO2 of 52 mm Hg, a PCO2 of 32 mm Hg, and a bicarbonate (HCO3) concentration of 26 mmol/L.

Answer the following questions:
1. Does this patient have left, right, or biventricular failure?
2. An S3 is heard, but no S4. Why?
3. What chest radiographic findings would you expect to see in this patient?
4. What neurohormonal mechanisms are likely to be activated in this patient?
5. What diagnostic tests should be performed?
6. What treatment options would likely be beneficial in this patient?
7. Is it possible that the ventricular function w ill improve with medical therapy?

Answers:

Regarding A 30 Year Old man Feeling Symptoms Of Sweating And Shakiness Following an Accident

 A 30 year old man feels symptoms of sweating and shakiness after involved in an accident. Read the question below and chose the answer from the options given:

Answer With Discussion: