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 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.

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 (100g/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 Subas 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.

Review of Systems
2

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

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..........................................................................................................
Vital Signs: Pulse rate: 84 bpm, regular rhythm, bounding pulse
Respiratory rate: 20/min
Blood pressure: 126/74 mmHg
Temperature: 37.0 C
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 5 th intercostal space of midclavicular
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.

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.

Provisional diagnosis
Bronchial asthma

Differential diagnosis

Pericarditis
Acute bronchitis
Acute pneumonia

Investigations and results

Chest x-ray
Full blood count

Chest x-ray

Full blood count

[L] - Low
[H] - High
(Renal Profiles)- Urea
03/10/2012 02:56 5.6 mmol/L
(Renal Profiles)- Sodium
03/10/2012 02:56 137 mmol/L
(Renal Profiles)- Potassium
03/10/2012 02:56 3.30 mmol/L [L]
(Renal Profiles)- Chloride
03/10/2012 02:56 101.0 mmol/L
(Renal Profiles)- Creatinine
03/10/2012 02:56 62.9 umol/L
(Venous Blood Gases)- Partial Carbon Dioxide
03/10/2012 02:56 43.8 mmHg
(Venous Blood Gases)- Partial Oxygen
03/10/2012 02:56 40.4 mmHg [L]
(Venous Blood Gases)- HCT
03/10/2012 02:56 34.9 %
(Venous Blood Gases)- HCO3 act
03/10/2012 02:56 28.2 mmol/L
(Venous Blood Gases)- HCO3 std
03/10/2012 02:56 27.3 mmol/L
(Venous Blood Gases)- pH
03/10/2012 02:56 7.425
(Venous Blood Gases)- BE(ecf)
03/10/2012 02:56 4.1 mmol/L
(Venous Blood Gases)- Base Excess
03/10/2012 02:56 3.9 mmol/L [H]
(Venous Blood Gases)- ctCO2
03/10/2012 02:56 25.8 mmol/L
(Venous Blood Gases)- Oxygen Saturation
03/10/2012 02:56 70.9 % [L]
(Venous Blood Gases)- O2 CT
03/10/2012 02:56 11.2 mL/dL
(Liver Function Tests (LFT))- Protein, Total
03/10/2012 02:56 69.0 g/L

(Liver Function Tests (LFT))- Globulin

03/10/2012 02:56 38 g/L [H]
(Liver Function Tests (LFT))- Albumin/Globulin Ratio
03/10/2012 02:56 0.81
(Liver Function Tests (LFT))- Bilirubin, Total
03/10/2012 02:56 4.9 umol/L
(Liver Function Tests (LFT))- Alanine Transaminase (SGPT)
03/10/2012 02:56 26 U/L
(Liver Function Tests (LFT))- Albumin
03/10/2012 02:56 31 g/L [L]
(Liver Function Tests (LFT))- Alkaline Phosphatase
03/10/2012 02:56 109 U/L
Haematology
(Full Blood Count (FBC))- White Blood Cell
03/10/2012 02:56 9.80 x10^9/L
(Full Blood Count (FBC))- Red Blood Cell
03/10/2012 02:56 5.00 x10^12/L [H]
(Full Blood Count (FBC))- Haemoglobin
03/10/2012 02:56 11.2 g/dL [L]
(Full Blood Count (FBC))- Haematocrit
03/10/2012 02:56 36.5 % [L]
(Full Blood Count (FBC))- Mean Cell Volume
03/10/2012 02:56 73.0 fl [L]
(Full Blood Count (FBC))- Mean Cell Haemoglobin
03/10/2012 02:56 22.4 pg [L]
(Full Blood Count (FBC))- Mean Cell Haemoglobin Concentration
03/10/2012 02:56 30.7 g/dL [L]
(Full Blood Count (FBC))- Red Cell Distribution Width
03/10/2012 02:56 18.0 % [H]
(Full Blood Count (FBC))- Platelet
03/10/2012 02:56 276 x10^9/L
(Full Blood Count (FBC))- Percentage Of Neutrophil
03/10/2012 02:56 84.4 % [H]
(Full Blood Count (FBC))- Percentage of Lymphocyte
03/10/2012 02:56 9.2 % [L]
(Full Blood Count (FBC))- Percentage Of Monocyte
03/10/2012 02:56 6.3 %
(Full Blood Count (FBC))- Percentage Of Eosinophil
03/10/2012 02:56 0.0 % [L]
(Full Blood Count (FBC))- Percentage of Basophil
03/10/2012 02:56 0.1 %

(Full Blood Count (FBC))- Absolute Neutrophil

03/10/2012 02:56 8.27 x10^9/L [H]
(Full Blood Count (FBC))- Absolute Lymphocyte
03/10/2012 02:56 0.90 x10^9/L
(Full Blood Count (FBC))- Absolute Monocyte
03/10/2012 02:56 0.62 x10^9/L
(Full Blood Count (FBC))- Absolute Eosinophil
03/10/2012 02:56 0.00 x10^9/L
(Full Blood Count (FBC))- Absolute Basophil
03/10/2012 02:56 0.01 x10^9/L
(Full Blood Count (FBC))- Mean Platelet Volume
03/10/2012 02:56 10 fL
(Urea & Electrolytes)- Urea
01/10/2012 22:48 5.6 mmol/L
(Urea & Electrolytes)- Sodium
01/10/2012 22:48 137 mmol/L
(Urea & Electrolytes)- Potassium
01/10/2012 22:48 3.50 mmol/L
(Urea & Electrolytes)- Chloride
01/10/2012 22:48 104.0 mmol/L

The management, progress and follow-up plan

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

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 7341
Working as a technician at Subang

10

Theoretical discussion
Bronchial asthma
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 lifethreatening 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)

11

The need to use a quick-relief inhaler more often

For some people, asthma symptoms flare up in certain situations:

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)
factors.
Asthma
triggers.........................................................................................................
................
Exposure to various substances that trigger allergies (allergens) and
irritants can trigger signs and symptoms of asthma. Asthma triggers are
different from person to person and can include:

Airborne

allergens,

such

as

pollen,

animal

dander,

mold,

cockroaches and dust mites

Allergic reactions to some foods, such as peanuts or shellfish

Respiratory infections, such as the common cold

Physical activity (exercise-induced asthma)

Cold air

Air pollutants and irritants, such as smoke

Certain medications, including beta blockers, aspirin, ibuprofen

(Advil, Motrin, others) and naproxen (Aleve)

Strong emotions and stress

Sulfites and preservatives added to some types of foods and

beverages

12

Gastroesophageal reflux disease (GERD), a condition in which

stomach acids back up into your throat

Menstrual cycle in some women

Risk
factors
..................................................................................................................
A number of factors are thought to increase your chances of developing
asthma. These include:

Having a blood relative (such as a parent or sibling) with asthma

Having another allergic condition, such as atopic dermatitis or

allergic rhinitis (hay fever)

Being overweight

Being a smoker

Exposure to secondhand smoke

Having a mother who smoked while pregnant

Exposure to exhaust fumes or other types of pollution

Exposure to occupational triggers, such as chemicals used in

farming, hairdressing and manufacturing

Low birth weight

Exposure to allergens, exposure to certain germs or parasites, and having
some types of bacterial or viral infections also may be risk factors.
However, more research is needed to determine what role they may play
in developing asthma.
Complications
Asthma complications include:

Symptoms that interfere with sleep, work or recreational activities

Sick days from work or school during asthma flare-ups

13

Permanent narrowing of the bronchial tubes (airway remodeling)

that affects how well you can breathe

Emergency room visits and hospitalizations for severe asthma

attacks

Side effects from long-term use of some medications used to

stabilize severe asthma
Proper treatment makes a big difference in preventing both short-term
and long-term complications caused by asthma.

Treatment
Prevention and long-term control are key in stopping asthma attacks
before they start. Treatment usually involves learning to recognize your
triggers and taking steps to avoid them, and tracking your breathing to
make sure your daily asthma medications are keeping symptoms under
control. In case of an asthma flare-up, you may need to use a quick-relief
inhaler, such as albuterol.
Medications
The right medications for you depend on a number of things, including
your age, your symptoms, your asthma triggers and what seems to work
best to keep your asthma under control. Preventive, long-term control
medications reduce the inflammation in your airways that leads to
symptoms. Quick-relief inhalers (bronchodilators) quickly open swollen
airways that are limiting breathing. In some cases, allergy medications are
necessary.
Long-term asthma control medications, generally taken daily, are the
cornerstone of asthma treatment. These medications keep asthma under
control on a day-to-day basis and make it less likely you'll have an asthma
attack. Types of long-term control medications include:

Inhaled

corticosteroids.

These medications

include

fluticasone

(Flovent Diskus, Flonase), budesonide (Pulmicort, Rhinocort), mometasone

(Nasonex, Asmanex Twisthaler), ciclesonide (Alvesco, Omnaris), flunisolide
(Aerobid, Aerospan HFA), beclomethasone (Qvar, Qnasl) and others. You
may need to use these medications for several days to weeks before they

14

reach their maximum benefit. Unlike oral corticosteroids, these

corticosteroid medications have a relatively low risk of side effects and are
generally safe for long-term use.

Leukotriene

modifiers.

These

oral

medications

including

montelukast (Singulair), zafirlukast (Accolate) and zileuton (Zyflo) help

relieve asthma symptoms for up to 24 hours. In rare cases, these
medications have been linked to psychological reactions, such as
agitation, aggression, hallucinations, depression and suicidal thinking.
Seek medical advice right away for any unusual reaction.

Long-acting beta agonists. These inhaled medications, which include

salmeterol (Serevent) and formoterol (Foradil, Perforomist), open the
airways and reduce inflammation. Some research shows that they may
increase the risk of a severe asthma attack, so take them only in
combination with an inhaled corticosteroid. And because these drugs can
mask asthma deterioration, don't use them for an acute asthma attack.

Combination inhalers. These medications such as fluticasonesalmeterol (Advair Diskus), budesonide-formoterol (Symbicort) and
mometasone-formoterol (Dulera) contain a long-acting beta agonist
along with a corticosteroid. Because these combination inhalers contain
long-acting beta agonists, they may increase your risk of having a severe
asthma attack.

Theophylline. Theophylline (Theo-24, Elixophyllin, others) is a daily

pill that helps keep the airways open (bronchodilator) by relaxing the
muscles around the airways. It's not used as often now as in past years.
Quick-relief (rescue) medications are used as needed for rapid, short-term
symptom relief during an asthma attack or before exercise if your
doctor recommends it. Types of quick-relief medications include:

Short-acting

beta

agonists.

These

inhaled,

quick-relief

bronchodilators act within minutes to rapidly ease symptoms during an

asthma attack. They include albuterol (ProAir HFA, Ventolin HFA, others),
levalbuterol (Xopenex HFA) and pirbuterol (Maxair). Short-acting beta
agonists can be taken using a portable, hand-held inhaler or a nebulizer
a machine that converts asthma medications to a fine mist, so they can
be inhaled through a face mask or a mouthpiece.

15

Ipratropium (Atrovent). Like other bronchodilators, ipratropium acts

quickly to immediately relax your airways, making it easier to breathe.
Ipratropium is mostly used for emphysema and chronic bronchitis, but it's
sometimes used to treat asthma attacks.

Oral and intravenous corticosteroids. These medications which

include prednisone and methylprednisolone relieve airway inflammation
caused by severe asthma. They can cause serious side effects when used
long term, so they're used only on a short-term basis to treat severe
asthma symptoms.
If you have an asthma flare-up, a quick-relief inhaler can ease your
symptoms right away. But if your long-term control medications are
working properly, you shouldn't need to use your quick-relief inhaler very
often. Keep a record of how many puffs you use each week. If you need to
use your quick-relief inhaler more often than your doctor recommends,
see your doctor. You probably need to adjust your long-term control
medication.
Allergy medications may help if your asthma is triggered or worsened by
allergies. These include:

Allergy shots (immunotherapy). Over time, allergy shots gradually

reduce your immune system reaction to specific allergens. You generally
receive shots once a week for a few months, then once a month for a
period of three to five years.

Omalizumab (Xolair). This medication, given as an injection every

two to four weeks, is specifically for people who have allergies and severe
asthma. It acts by altering the immune system.

Allergy

medications.

These

include

oral

and

nasal

spray

antihistamines and decongestants as well as corticosteroid and cromolyn

nasal sprays.
Bronchial
thermoplasty
This treatment which isn't widely available nor right for everyone is
used for severe asthma that doesn't improve with inhaled corticosteroids
or other long-term asthma medications. Generally, over the span of three
outpatient visits, bronchial thermoplasty heats the insides of the airways
in the lungs with an electrode, reducing the smooth muscle inside the

16

airways. This limits the ability of the airways to tighten, making breathing
easier and possibly reducing asthma attacks.
Treat by severity for better control: A stepwise approach
Your treatment should be flexible and based on changes in your
symptoms, which should be assessed thoroughly each time you see your
doctor. Then, your doctor can adjust your treatment accordingly. For
example, if your asthma is well controlled, your doctor may prescribe less
medicine. If your asthma isn't well controlled or is getting worse, your
doctor may increase your medication and recommend more-frequent
visits.
Asthma
action
plan
Work with your doctor to create an asthma action plan that outlines in
writing when to take certain medications, or when to increase or decrease
the dose of your medications based on your symptoms. Also include a list
of your triggers and the steps you need to take to avoid them.

Diagnosis
Physical
exam
To rule out other possible conditions such as a respiratory infection or
chronic obstructive pulmonary disease (COPD) your doctor will do a
physical exam and ask you questions about your signs and symptoms and
about any other health problems.
Tests
to
measure
lung
function
You may also be given lung (pulmonary) function tests to determine how
much air moves in and out as you breathe. These tests may include:

Spirometry. This test estimates the narrowing of your bronchial

tubes by checking how much air you can exhale after a deep breath and
how fast you can breathe out.

Peak flow. A peak flow meter is a simple device that measures how
hard you can breathe out. Lower than usual peak flow readings are a sign
your lungs may not be working as well and that your asthma may be

17

getting worse. Your doctor will give you instructions on how to track and
deal with low peak flow readings.
Lung function tests often are done before and after taking a
bronchodilator (brong-koh-DIE-lay-tur), such as albuterol, to open your
airways. If your lung function improves with use of a bronchodilator, it's
likely you have asthma.
Additional
Other tests to diagnose asthma include:

tests

Methacholine challenge. Methacholine is a known asthma trigger

that, when inhaled, will cause mild constriction of your airways. If you
react to the methacholine, you likely have asthma. This test may be used
even if your initial lung function test is normal.

Nitric oxide test. This test, though not widely available, measures
the amount of the gas, nitric oxide, that you have in your breath. When
your airways are inflamed a sign of asthma you may have higher
than normal nitric oxide levels.

Imaging tests. A chest X-ray and high-resolution computerized

tomography (CT) scan of your lungs and nose cavities (sinuses) can
identify any structural abnormalities or diseases (such as infection) that
can cause or aggravate breathing problems.

Sputum eosinophils. This test looks for certain white blood cells
(eosinophils) in the mixture of saliva and mucus (sputum) you discharge
during coughing. Eosinophils are present when symptoms develop and
become visible when stained with a rose-colored dye (eosin).

Provocative testing for exercise and cold-induced asthma. In these

tests, your doctor measures your airway obstruction before and after you
perform vigorous physical activity or take several breaths of cold air.

18

Prevention
Working together, you and your doctor can design a step-by-step plan for
living with your condition and preventing asthma attacks.

Follow your asthma action plan. With your doctor and health care
team, write a detailed plan for taking medications and managing an
asthma attack. Then be sure to follow your plan. Asthma is an ongoing
condition that needs regular monitoring and treatment. Taking control of
your treatment can make you feel more in control of your life in general.

Get immunizations for influenza and pneumonia. Staying current

with immunizations can prevent flu and pneumonia from triggering
asthma flare-ups.

Identify and avoid asthma triggers. A number of outdoor allergens

and irritants ranging from pollen and mold to cold air and air pollution
can trigger asthma attacks. Find out what causes or worsens your
asthma, and take steps to avoid those triggers.

19

Monitor your breathing. You may learn to recognize warning signs of

an impending attack, such as slight coughing, wheezing or shortness of
breath. But because your lung function may decrease before you notice
any signs or symptoms, regularly measure and record your peak airflow
with a home peak flow meter.

Identify and treat attacks early. If you act quickly, you're less likely
to have a severe attack. You also won't need as much medication to
control your symptoms. When your peak flow measurements decrease
and alert you to an oncoming attack, take your medication as instructed
and immediately stop any activity that may have triggered the attack. If
your symptoms don't improve, get medical help as directed in your action
plan.

Take your medication as prescribed. Just because your asthma

seems to be improving, don't change anything without first talking to your
doctor. It's a good idea to bring your medications with you to each doctor
visit, so your doctor can double-check that you're using your medications
correctly and taking the right dose.

Pay attention to increasing quick-relief inhaler use. If you find

yourself relying on your quick-relief inhaler, such as albuterol, your
asthma isn't under control. See your doctor about adjusting your
treatment.

Pericarditis
Pericarditis is a condition in which the sac-like covering around the heart
(pericardium) becomes inflamed.
Causes, incidence, and risk factors
The cause of pericarditis is often unknown or unproven, but is often the
result of an infection such as:

Viral infections that cause a chest cold or pneumonia, such as the

echovirus or coxsackie virus (which are common in children), as well
as influenza

Infections with bacteria (much less common)

20

Some fungal infections (even more rare)

In addition, pericarditis may be seen with diseases such as:

Cancer (including leukemia)

Disorders in which the immune system attacks healthy body tissue

by mistake

HIV infection and AIDS

Underactive thyroid gland

Kidney failure

Rheumatic fever

Tuberculosis(TB)

Other causes include:

Heart attack

Heart surgery or trauma to the chest, esophagus, or heart

Certain medications, such as procainamide, hydralazine, phenytoin,

isoniazid, and some drugs used to treat cancer or suppress the
immune system

Swelling or inflammation of the heart muscle

Radiation therapy to the chest

Often the cause of pericarditis is unknown. Pericarditis most often affects

men ages 20 - 50.

Symptoms
Chest pain is almost always present. The pain:

May be felt in the neck, shoulder, back, or abdomen

21

Often increases with deep breathing and lying flat, and may
increase with coughing and swallowing

Can be a sharp, stabbing pain

Is often relieved by sitting up and leaning or bending forward

You may have fever, chills, or sweating if the condition is caused by an

infection.
Other symptoms include:

Ankle, feet, and leg swelling (occasionally)

Anxiety

Breathing difficulty when lying down

Dry cough

Fatigue

Signs and tests

When listening to the heart with a stethoscope, the health care provider
can hear a sound called a pericardial rub. The heart sounds may be
muffled or distant. There may be other signs of fluid in the pericardium
(pericardial effusion).
If the disorder is severe, there may be:

Crackles in the lungs

Decreased breath sounds

Other signs of fluid in the space around the lungs (pleural effusion)

The following imaging tests may be done to check the heart and the
tissue layer around it (pericardium):

Chest MRI scan

Chest x-ray

Echocardiogram

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Electrocardiogram

Heart MRI or heart CT scan

Radionuclide scanning

To look for heart muscle damage, the health care provider may order a
troponin I test. Other laboratory tests may include:

Antinuclear antibody (ANA)

Blood culture

CBC

C-reactive protein

Erythrocyte sedimentation rate (ESR)

HIV test

Rheumatoid factor

Tuberculin skin test

Treatment
The cause of pericarditis must be identified, if possible.
High doses of nonsteroidal anti-inflammatory drugs (NSAIDs) such as
ibuprofen are often given. These medicines will decrease your pain and
reduce the swelling or inflammation in the sac around your heart.
A medicine called colchicine may be added, especially if pericarditis does
not go away after 1 to 2 weeks or it comes back weeks or months later.
If the cause of pericarditis is an infection:

Antibiotics will be used for bacterial infections

Antifungal medications will be used for fungal pericarditis

Other medicines that may be used are:

Corticosteroids such as prednisone (in some patients)

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"Water pills" (diuretics) to remove excess fluid

If the buildup of fluid makes the heart function poorly, treatment may
include:

Draining the fluid from the sac. This procedure, called

pericardiocentesis, may be done using an echocardiography-guided
needle.

Cutting a small hole (window) in the pericardium (subxiphoid

pericardiotomy) to allow the infected fluid to drain into the
abdominal cavity

If the pericarditis is chronic, recurrent, or causes scarring or tightening of

the tissue around the heart, cutting or removing part of the pericardium
may be needed. This surgery is called a pericardiectomy.
Expectations (prognosis)
Pericarditis can range from mild cases that get better on their own to lifethreatening cases. The condition can be complicated by fluid buildup
around the heart and poor heart function.
The outcome is good if the disorder is treated right away. Most people
recover in 2 weeks to 3 months. However, pericarditis may come back.
This is called recurrent, or chronic if symptoms or episodes continue.
Scarring and thickening of the sac-like covering and the heart muscle may
occur in severe cases. This is called constrictive pericarditis, and it can
cause long-term problems similar to those of heart failure.
Calling your health care provider
Call your health care provider if you have symptoms of pericarditis. This
disorder is usually not life threatening, but it can be if not treated.
Prevention
Many cases are not preventable.

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Acute Bronchitis
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

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Wheezing, in people with asthma

Even after acute bronchitis has cleared, you may have a dry, nagging
cough that lingers for 1 to 4 weeks.
At times, it may be hard to know whether you have pneumonia or only
bronchitis. If you have pneumonia, you are more likely to have a high
fever and chills, feel sicker, or feel short of breath.

Signs and tests

The health care provider will listen to your lungs with a stethoscope.
Abnormal, coarse breathing sounds may be heard.
Tests may include:

Chest x-ray, if the health care provider suspects pneumonia

Pulse oximetry to help determine the amount of oxygen in your

blood by using a device placed on the end of your finger

Treatment
Most people DO NOT need antibiotics for acute bronchitis. The infection
will almost always go away on its own within 1 week. Take the following
steps to get relief:

Drink plenty of fluids.

If you have asthma or another chronic lung condition, use your

inhaler (such as albuterol).

Rest.

Take aspirin or acetaminophen (Tylenol) if you have a fever. DO NOT

give aspirin to children

Use a humidifier or steam in the bathroom.

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Certain medicines that you can buy without a prescription can help break
up or loosen mucus. Look for the word "guafenesin" on the label.
If your symptoms do not improve, your doctor may prescribe an inhaler to
open your airways if you are wheezing.
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.

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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 hearts 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.

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