Date and Time of Interview: April 19,2017; 9:30 am

PATIENT HEALTH HISTORY

IDENTIFYING DATA
This is a case of FA, a 73 year old Filipino, male, househusband, lives in San Julian
Norte, Vigan City, Ilocos Sur. He is a Roman Catholic, married, with 6 children. He was
admitted for the 4th time in Gabriela Silang General Hospital last March 18, 2017at around
4oclock in the afternoon.

Source of History: Patient and his wife

Percent Reliability: 92%
CHIEF COMPLAINT: difficulty of breathing (dyspnea)

HISTORY OF PRESENT ILLNESS:

16 months PTA, patient experienced sudden difficulty of breathing upon exertional
activities that last for about 5 minutes per episode happened at late afternoon. This
was associated with sudden, dry, non productive cough, and chest tightness that was
characterized by the patient as discomfort sensation between upper abdomen and the
neck. They went to the nearest barangay health station and was given with salbutamol
nebulization. Patient experienced relief, but as they went home, symptoms recurred
thus they decided to go to Garbriela Silang General Hospital, admitted for 3days and
consequently discharged with recalled home medications of salbutamol neb via
inhalation, administered 3 times a day and to be given as needed for asthma attack
as verbalized by the wife. After 1 week of proper compliance with the treatment
regimen, he becomes symptoms free for almost one month interval.

15 months PTA, he experienced recurrence of symptoms with same character,

intensity and frequency. The said dyspnea was associated with chest tightness . It was
precipitated by extreme cold environment during night time when the symptoms
episode happened. Since they dont have nebulizer and the center was closed during
that night, they rushed directly to Gabriela Silang General Hospital and immediately
managed at the ER with nebulization of unrecalled name of bronchodilator. He was
relieved but he decided to be admitted for further monitoring and evaluation. He was
admitted for 2 days and sent home with recalled home medications of salbutamol +
ipatropium nebulization to be administered three times a day for 4 days and to be
given as needed for asthma attack.

He then experienced symptom free for more than 9 months.

5mos PTA, at around late afternoon he had sudden mild dyspneic episode associated
with chest tightness characterized as mild discomfort due to feeling of fullness of the
chest. It was triggered by exposure to cold environment and strenuous activity. This
was relieved by rest and salbutamol nebulization.

He became symptom free for 3 months.

2 months PTA, he experienced sudden recurrence of difficulty of breathing

precipitated by strenuous activities and extreme cold and hot environment. Dyspnea
was associated with unproductive cough and undocumented fever observed at noon
and night time. He verbalized that dyspneic episodes lasted not more than 5 minutes.
He was temporarily relieved by rest, paracetamol tablet and nebulization of
salbutamol that was given at the health center. Fever persisted, thus he decided to be
admitted in the same hospital for the 3rd time. After 6 days of confinement, he was
discharged with recalled home medications of salbutamol +ipatropium nebulization
with unrecalled name of antibiotic. He cant recall the exact diagnosis of his last
admission. Patient was noted to be non compliant with the prescribed antibiotics due
to financial constraint. However, he becomes well and symptoms free after a week of
treatment. His symptoms free episode lasted for 2 months.

5 days PTA, he experienced recurrence of a sudden difficulty of breathing with non

productive cough and chest tightness described as feeling of fullness and discomfort
 between upper abdomen and neck that worsens during activity of daily living and
precipitated by exposure to extreme hot environment during noon time and extreme
cold environment at night time. This was associated with colds with less than 1
teaspoon greenish nasal discharge. It was also associated with sudden easy fatigability
described as not able to successfully perform daily activities. He was unable to
successfully walk a distance of approximately 3-4 meters. He even complained of
sleep disturbance due to bouts of dyspneic episode and he needed to use pillows at
night to ease breathing. No fever, nausea and vomiting episode associations. He was
relieved by rest, on sitting upright position and salbutamol nebulization.

2 hrs PTA, patients symptoms persisted with the same character, intensity and
frequency associated with sudden mild dizziness characterized as feeling of spinning
environment aggravated by ambulation like walking a long distance and exposure to
extreme hot environment. There was no association of nausea and vomiting. He was
partially relieved by rest and sitting upright position. No medical interventions done at
home but due to the persistence of symptoms , it prompted the patient to seek
admission at Gabriela Silang General Hospital.

Allergies: No known allergies to medications. However, he claimed to have allergy to

chicken

Tobacco/Alcohol/drug: He claimed to smoked 1 pack per day (20 pack years) and drinks
gin for about 150ml/day started at 20 y/o and stopped at age of 40; No illicit
drugs

MEDICATIONS DOSAGE ADVERSE COMPLIANCE

EFFECTS
Salbutamol + ipatropium 1 nebule 3x/ day via none Noted to be compliant
nebule nebuliztion with the treatment
regimen of 1st
hospitalization ;
administered only
during episode of
dyspnea
Salbutamol nebule 1 nebule as needed for Non- compliant;
asthma attacks none administered only
 administered via during episode of
nebulization dyspnea
Antibiotics unrecalled none Non-compliant, was not
able to comply in taking
the prescribed
antibiotics due to
financial constraint
Non-compliant; only
Metoprolol ( Neobloc) 50mg/tab, once a day none taken when he feels
tablet dizzy; Last intake dated
on March 15, 2017; Last
BP monitoring done last
March 29, 2017
Paracetamol (Biogesic) 500mg/tab, taken as none Taken only when he
tablet needed for fever feels warm and when
he experienced flu-like
symptoms

PAST HISTORY
A. Childhood Illnesses:
(+) measles, chickenpox (with unrecalled dates).
(- )mumps, rubella, whooping cough, rheumatic fever, scarlet fever, and polio.
B. Adult Illnesses
Medical:
In December 2015- admitted due to difficulty of breathing , non-productive cough
and chest tightness at Gabriela Silang General Hospital , with diagnosis of bronchial
asthma
In January 2016- admitted due to difficulty of breathing and non-productive cough
in same institution with diagnosis of bronchial asthma
February 2017- admitted due to fever, non productive cough and difficulty of
breathing at Gabriela Silang General Hospital with unrecalled diagnosis
In 2016, he was diagnosed of hypertension by the RHU doctor and given Metoprolol
(Neobloc) 50mg once daily as a maintenance medication.
Surgical:
- No history of surgery and blood transfusion
Psychiatric:
 No history of psychiatric illness.
Health Maintenance:
Immunizations: Childhood immunizations were unrecalled
Screening Tests & Results:
Chest X-ray (December 2015, January 2016, February 2017)
Findings: Unrecalled

FAMILY HISTORY
AGE and HEALTH AGE and CAUSE OF
FAMILY HISTORY
STATUS DEATH
FATHER 75y.o.; old age
MOTHER 78y.o; Asthma attack
SIBLINGS
4 brothers and 6 sisters
= 11 siblings
5th sibling( PATIENT) 73 y/o- Asthma and
Hypertension
6th sibling 54 y/o; Asthma attack
WIFE 58 y/o- Generally healthy
CHILDREN:
1st 38 y/o
2nd 34 y/o
3rd 33 y/o- history of fracture
4th 24 y/o
5th 22 y/o
6th 19 y/o
PERSONAL AND SOCIAL HISTORY
He was born and raised in San Julian Norte, Vigan City, Ilocos Sur. He attended until
Grade 4 of his elementary years. He worked as construction worker for almost 30 yrs,
starting at the age of 25 and stopped working at age 60. He got married at age of 40.
He has six children with three sons at the age of 38, 34 and 24 and three daughters
aging 33, 22 and 19. Four of his children are already married and his two daughters are
still single. He is a member of senior citizen organization of their barangay.
Now, he lives with her two daughters and his wife in a bungalow type house. They
live within the community which has live stocks (e.g. cow and chicken) near the house
and they have dog and cat at home as their pet. Moreover, their house is located in a
nearby street that is exposed to a dusty environment.
 Both of his wife and children have no known medical conditions and claimed to be
physically well.Their source of water is deep well, and has pit latrine type of toilet.
They just dispose their garbage in a compost pit in their backyard.
He typically sleeps at 10: 00 PM and wakes up at 5: 30 AM. He used to help his wife
in doing housechores like cooking and cleaning the house during the day. He is no
longer into strenuous and heavy workload activities since first hospitalization and his
wife is the one taking care of their livestocks such as the cow and chicken. He started
smoking cigarette and drinking alcohol at the age of 18 and stop at age of 40. He used
to smoke for about 1 pack per day (20 pack years) and drinks gin for about 150ml/day.
He has no history of using prohibited drugs. He does not do any form of exercise. He
eats regularly for about three times a day with snack at the afternoon. He drinks water
for about 8-10 glasses/day and a cup of coffee amounting 200ml per day. He prefers to
eat high protein and high fat foods such as meat than vegetables.
He considers his family as his primary support both financial and social aspect. He
has close family ties.
REVIEW OF SYSTEMS
General: (-) recent weight change, (-) clothing that fits more loosely than before, (-)
clothing that fits more tightly than before, (-) weakness, (+) fatigue (see HPI)
Skin: (-) Rashes, (-) Dryness, (-) Soreness, (-) Itching, (-) Lumps, (-) Changes in
color, (-) changes in hairs or nails, (-) changes in size or color of moles
Head, Eyes, Ears, Nose, Throat (HEENT)
Head: (-) Headache, (-) head injury, (+) dizziness (see HPI)`, (-)
lightheadedness
Eyes: (-) glasses or contact lenses, (-) pain, (-) redness, (-) excessive tearing,
(-) double or blurred vision, (-) spots, (-) specks, (-) glaucoma, (-) cataracts
Ears: (-) tinnitus, (-) vertigo, (-) earaches, (-) discharge, (-) hearing aids
Nose and Sinuses: (+) Colds ( see HPI), (-) Nasal stuffiness, (-) itching, (-) hay
fever, (-) nosebleeds, (-) sinus trouble
Throat (or mouth and pharynx): (-) Bleeding gums, (-) dentures, (-) Sore
tongue, (-) Dry mouth, (-) Hoarseness, (-) Sore throat
Neck: (-) Lumps, (-) Swelling, (-) Stiffness (-) pain
Breasts: (-) lumps, (-) pain, (-) discomfort, (-) nipple discharge
Respiratory: (+) Cough( see HPI), (-) sputum, (+)dyspnea ( see HPI), (-) wheezing, (-)
pleuritic pain, Paroxysmal nocturnal dyspnea (-), Last chest x-ray February
2017.
Cardiovascular: (+) high blood pressure sudden onset, associated by mild dizziness,
precipitated by strenuous activities and stress, relieved by taking
antihypertensive medication , (-) rheumatic fever, (-) heart murmurs, (+)
chest pain or discomfort ( see HPI)t, (-) palpitations, (+) dyspnea ( see HPI),
(+) orthopnea ( see HPI), (-) edema
Gastrointestinal: (-) dysphagia, (-) heartburn, (-) loss of appetite, (-) nausea, (-) excessive
belching, (-) liver trouble,(-) changes in bowel habits, (-) rectal bleeding or
black stools,(-)constipation, (-) diarrhea, (-) jaundice, (-) gallbladder
trouble, (-) pain with defecation, (-) hemorrhoids, (-) abdominal pain, (-)
food intolerance, (-) hepatitis
Peripheral vascular: (-) claudication, (-) leg cramps, (-) varicose veins, (-) past clots in the
veins, (-) edema of calves, legs or feet, (-) cyanosis during cold weathers,(-)
swelling in redness or tenderness
Genitourinary: (-) bleeding between periods or after intercourse, (-) dysmenorrhea,
(-) premenstrual tension, (-) itching, (-) sores, (-) lumps, (-) postmenopausal
bleeding, (-) sexually transmitted infections, (-) dyspareunia
Psychiatric: (-)nervousness,(-)tension,(-)depression,(-)suicidal ideation,(-)past
counseling, (-) psychotherapy,(-) psychiatric admissions
Neurologic: (-) headache, (+) dizziness( see HPI), (-) vertigo, (-) tingling or pin
sensation,(-) fainting, (-) blackouts, (-) seizures,(-) paralysis, (-) tremors, (-)
numbness or loss of sensation
Hematologic: (-) anemia, (-) easy bruising, (-) past transfusions, (-) easy bleeding
Endocrine: (-) thyroid trouble, (-) heat intolerance, (-) cold intolerance, (-) excessive
sweating, (-) excessive thirst, (-) excessive hunger, (-) polyuria
PHYSICAL EXAMINATION
General Survey

Mr. FA is a 73 year old male, thin and appears acutely ill but is alert and responsive. He has
signs of respiratory distress with difficulty of breathing. He has a good skin color. He has
sustained his eye contact towards the examiner and was cooperative but prefers sitting
position during the examination. Physical appearance is clean and appropriate for her age.
Dress, grooming and personal hygiene is appropriate for the temperature and setting.

Height: 152.4 cm

Weight: 50 kg

BMI: 21.52kg/m2(optimum)

Waist Circumference: 28 in

Vital signs

Blood pressure: 160/100(supine, right arm); 150/90 (sitting, right arm)

Heart rate: 82bpm regular, right radial artery

Respiratory rate: 16 cpm, regular, silent

Temperature: 36.2 0C

Skin, Hair and Nails

Inspection Skin Color is good. Skin warm and dry. No rash, petechiae or
ecchymoses. No suspicious nevi. Skin mobility lifts up
easily and skin turgor returns quickly. With cracked heels
on both feet.
Hair Hair is generally black and white, fine and smooth, and
evenly distributed. No patches of alopecia.

Nails Nails are pink without clubbing or cyanosis. Capillary refill

time is less than 2 seconds
Palpation Skin Skin is warm to touch. No marked sweating or dryness.
Skin lifts up easily with slow skin turgor
Hair No hair for hair pull and hair tug test, soft hair with some
dandruff
Head, Eyes, Ears, Nose and Throat (HEENT)

Inspection Head The patients hair color is grayish white, has average texture.
The scalp is absent of scaliness, lumps, lesions, and lice. The
cranium is normocephalic with no deformities, depressions,
lumps and tenderness.
Eyes The patient is able to read a 20 sized font at 1 meter and has
no visual field defects. There is normal alignment of the eyes.
The eyebrows are black in color, thick and well distributed.
Eyelids has no lesions, and edema noted. Sclera is white,
conjunctiva is pink and Iris is round and black in color with
corneal arcus. Pupils are round and symmetrical. There is
normal accommodation reflex and is reactive to both direct
and consensual light.
Ears There are no deformities, lumps and lesions noted on the ears.
The patient is negative for Tug Test and the ear canal is
negative for foreign bodies and swelling and redness. No
discharges noted. Acuity is good to whispered voice.
Tympanic membranes are normal with good cone of light.
Weber midline. AC > BC.
Nose Nose is symmetrical. There is no flaring of alanasi. Vestibule is
patent. Nasal septum is straight at the midline and has no
perforation.
Mouth & Lips and buccal mucosa are pinkish in color and moist. There
Pharynx are no lesions and swelling noted. Tongue is in the midline. It
can move without difficulty upon protrusion and retraction.
There is no hypertrophy, atrophy and lesions observed.

The patient has incomplete teeth. Gingivas are pinkish and

have no bleeding and hypertrophy. Palate is pinkish and has
no lesion. Uvula is in midline. Palate wall has symmetrical
elevation. Tonsils are small and pink. Posterior pharyngeal
wall is pinkish and has no lesion, swelling and exudates.

Palpation Eyes No excessive tearing, no fluid regurgitation on nasolacrimal

duct
Nose No frontal and maxillary sinuses tenderness
Throat Trachea midline. Neck supple; thyroid lobes palpable but not
enlarge. No lymphadenopathy.
THORAX AND LUNGS

Inspection Patient is eupnic,cyanosis or palloris not presentbut contraction of

intercostal muscles on inspiration is visible. Thorax is symmetric. The
ratio of AP diameter to the lateral chest diameter is 0.8.

Palpation Tenderness, crepitus is not present with good expansion of the chest,
and symmetric tactile fremitus.

Auscultation Intensity of breath sounds in the left is decreased compared to the

right heard mid to lower portion of the chest wall. Silent gap, wheezes,
crackles, ronchi are not present. Audible whistling during inspiration
over the neck and lungs (stridor) is not heard. Egophony,
bronchophony and whispered pectoriloquy are also not present.
Percussion Lungs are resonant. Diaphragm descends 4.5 cm bilaterally

CARDIOVASCULAR

Inspection The JVP is 1 cm above the sternal angle with the head of bed elevated
to 30o.

Palpation Carotid upstroke is brisk without bruit. No heaves, lifts and thrills. The
PMI is tapping, 1.5 cm lateral to the midclavicular line in the 5th
intercostals space.
Auscultation At the base, S2 is louder than S1. At the apex, S1 is louder than S2. No
murmurs.

BREAST AND AXILLA

Inspection Breast symmetric and smooth without nodules or masses

Palpation Pectoral, subscapular and lateral nodes not palpable.

ABDOMEN

Inspection The abdomen is flat and symmetric. No dilated veins, rashes, scars and
striae. No peristalsis and pulsations. No visible masses.
Auscultation Active bowel sounds. No abdominal bruits.
Percussion Liver span is 4.5 cm in the midsternal angle and 6.5 in the
midclavicular angle. Splenic percussion sign is negative.
Palpation It is soft and nontender; no palpable masses. Nonpalpable liver edge,
spleen and kidney. No costovertebral angle (CVA) tenderness.

PERIPHERAL VASCULAR SYSTEM

Inspection Extremities are symmetric with no discoloration of skin and nail beds,
ulcerations, rashes, scars, edema and varicosities or stasis changes.
Palpation Radial Brachial Popliteal Doralis Posterior
Pedis tibialis
RT 2+ 2+ 1+ 2+ 1+
LT 2+ 2+ 1+ 2+ 2+
Femoral pulse and inguinal lymph nodes not palpated

Auscultation Femoral and abdominal bruits are absent

MUSCULOSKELETAL SYSTEM
Temporomandibular Inspection- Face is symmetrical. Swelling and redness are absent.
Joint
There is bilateral smooth range of motion as to protrusion, retraction
and lateral motion of the mandible

Palpation- No signs of swelling and tenderness.

Shoulder Inspection- No signs of swelling, deformity, muscle atrophy or
fasciculation or abnormal positioning.

There is bilateral full range of motion on both shoulder joints as to

flexion, extension, adduction, abduction, internal and external rotation,
and circumference. Negative for Apley scratch test.

Palpation- No signs of swelling and tenderness

Arm Inspection- Muscle mass is symmetrical on both upper arms.
Palpation- Muscle deformity, swelling and tenderness are absent.

Elbow Inspection- Swelling or nodules are absent over the ulna and olecranon
process.
There is full range of motion on both sides as to flexion and extension.
Palpation- Synovium and olecranon bursae are not palpable.
Hands Inspection- Nail beds are pinkish in color. Nail plate abnormalities,
clubbing, swelling of nail folds and nodes are absent.

There is full range of motion on both right and left as to flexion,

extension, adduction and abduction of the fingers, and apposition of
 thumb
Palpation- No swelling is noted on the interphalangeal and
metacarpophalangeal joints.
Wrist Palpation- Swelling, tenderness and bogginess are absent.Signs of
tenderness or anything that can suggest scaphoid fracture in the
anatomical snuffbox are absent.

There is bilateral full range of motion as to flexion, extension,

adduction and abduction of the wrist.
There is bilateral full range of motion as to flexion, extension,
adduction and opposition of the thumb.
Weakness in strength is absent for hand grip strength test.
Pain or tingling sensation is absent upon performing Phalenssigns.
Spine/neck Inspection- There is normal prominence of the C7 spinal vertebrae.
Curvature of the spine is good.
There is full range of motion of cervical spine as to flexion, extension,
rotation, and lateral bending.

Palpation- Muscle deformity, swelling, tenderness, and crepitus of

spinous process and paravertebral muscle are absent.

Hip Inspection- lack of knee flexion is absent. The patient can maintain
balance. Length of legs is symmetric
There is bilateral full range of motion as to flexion, extension,
adduction, abduction,and internal and external rotation.

Palpation- Iliac crest, iliac tubercle and greater trochanter are palpable.
Deformities, swelling and tenderness on hip joint are absent.

Patricks test, straight leg raising and Trendelenbergs test show

negative results.
Knee Inspection- no signs of swelling in the knee joint and suprapatellar
pouch.

There is bilateral full range of motion as to flexion, extension, internal

rotation and external rotation.

Palpation- Medial and lateral epicondyles are palpable. Deformities,

swelling, tenderness, cysts on anterior and posterior of knee joint, and
crepitus are absent.

Negative for bulge sign and balloon sign test.

Ankle/Foot Inspection- deformities, nodules, swelling, calluses or corns are absent.

There is full range of motion on both ankle joints as to eversion,
 inversion, dorsiflexion &plantar flexion.
Both feet can perform full range of motion as to flexion and extension.
Palpation- Calcaneus, and lateral and medial malleolus are palpable.
Muscle deformities, swelling and tenderness are
absent.Metatarsophalangeal joint, and proximal and distal
interphalangeal joints are palpable. Muscle deformities, swelling and
tenderness of both pedal and big toes are also absent.

NEUROLOGIC SYSTEM

Mental Status Patient is conscious, coherent and oriented to person, time and
Examination place. He is in a pleasant mood, answers in phrases when asked but
no slurring of speech observed. He has sustained his eye contact
towards the examiner and was pleasant and cooperative during the
examination.

Cranial Nerves CN I Olfactory

- Patient was able to inhale and exhale through open nostril
without obstruction. He was able to correctly identify the
odor of alcohol at approximately 10cm with eyes closed.
CN II Optic
Visual acuity
- Patient was able to read the letters in font size 20 at a
distance of 1 meter with 100% accuracy.
Visual fields by confrontation
- Patient was able to identify the both wiggling fingers
towards him at the same time (2 ft. apart lateral to the
patients ear).
CN III Oculomotor, CN IV Trochlear and CN VI Abducens
- Patients eyelids are symmetrical and do not obscure the
pupils. His pupils are round, equal in size (4mm) and
appropriate to room light. Direct and consensual reactions
are normal his pupils are dilated with distant gaze and
constricted with near effort.
- Eye movements are symmetrical and no jerky movements
with lateral and upward gaze. His eyes can follow the
examiners finger towards the bridge of his nose within 6-8
cm.
CN V Trigeminal
Motor:
- Strength of muscle contraction and relaxation are
symmetrical on both sides of the face (temporal and
masseter muscle) when patient was asked to clench and
relax his jaw.
 Sensory:
- Patient was able to identify sharp and dull sensation on
scattered areas of the face. He was able to identify light touch
with wisp of cotton on scattered areas and was able to
compare it on both sides of the face.
CN VII Facial
- No facial asymmetry, tics or involuntary movements
observed. He was able to do all face maneuvers easily and
symmetrically.

CN VIII Acoustic
Whisper test
- Patient was able to hear clearly the spoken numbers and
letters by the examiner and was able to repeat it correctly.
Weber test
- Sound was heard equally on both ears.
Rinne test
- Patient was able to hear the sound longer through air than
bone.

CN IX Glossopharyngeal and CN X Vagus

- Soft palate rise promptly and symmetrically and the uvula
remained at midline. Without difficulty on swallowing and
no regurgitation noted.

CN XI Spinal Accessory
- Patient was able to shrug his shoulders upward against the
examiners hands.
- He was able to turn his head each side against examiners
hand.

CN XII Hypoglossal
- Tongue is in the midline, symmetrical when protruded. No
fasciculation, deviation or atrophy observed.

MOTOR System - No involuntary movements at rest and during movements.

No atrophy and no resistance to passive stretch .Patients
both arms and legs move easily and smoothly.
- Muscle strength is stronger in the dominant right side than
that of the other side. Scale of 5 on both upper and lower
extremities.
- Rapid alternating movement of the right hand is better
coordinated.
- He was able to tap the distal joint of his thumb with the tip of
 his index finger smoothly.
- No clumsiness and overshooting observed during the point-
to-point movement test.
- Patients gait is relaxed and balanced with easy alternating
arm swings.
DEEP TENDON Biceps, triceps, brachioradialist, knee and ankle refex are all normal
REFLEX with a grade of 2+.

SENSORY SYSTEM Pain sensation

- Patient was able to distinguish sharp and dull to scattered
areas of the body (proximal and distal) and was able to
compare equal levels of sensation.
Light touch sensation
- Patient was able to feel the wisp of cotton on the scattered
areas of the body and was able to compare equal levels of
sensation.
Vibratory sensation
- Patient was able to feel the vibration of the vibratory fork in
the distal interphalangeal joint of the finger and he was able
to identify when the sensation stops.
Position sense
- Patient was able to identify direction of motion with eyes
closed.
Graphistisia
- Patient was able to identify the number drawn in his palm
with eyes closed.
Two point discrimination
- He was able to identify if he was given one or two-point ends
of an open paper clip with a minimum distance of less than 5
mm.
Point localization
- Patient was able to point the place of the body that has been
touched by the examiner during his eyes closed.
Extinction
- He was able to feel the sensation in both areas of the body
PERTINENT DATA

PERTINENT POSITIVE PERTINENT NEGATIVE

Age- 73 y/o Hypertension diagnosed
since 2016
Gender- Male
History of smoking
Environmental Factor
- presence of pet (e.g. dogs and cats) at home
- presence of livestocks (e.g. cow and chicken) near the house
- house is situated in a dusty environment
Family history of Bronchial Asthma

HPI:
16 mos.PTA- difficulty of breathing upon exertional activities
associated with dry, non productive cough, with chest tightness;
partially relieved by salbutamol nebulization

With symptoms free episode for almost one month

15 mos. PTA- recurrence of dyspneic episode associated with non

productive cough and chest tightness. Precipitated by extreme cold
environment during night time

With symptom free period for about 9 months

5mos PTA- sudden mild dyspneic episode associated with chest

tightness happened at late afternoon; Triggered by exposure to cold
environment and strenuous activity and relieved by rest and
salbutamol nebulization.

With symptom free period for 3 about months

2 mos. PTA- sudden recurrence of difficulty of breathing precipitated

by strenuous activities and extreme cold and hot environment;
Associated with unproductive cough and undocumented fever
observed at noon and night time; Temporarily relieved by rest ,
paracetamol tablet and nebulization of salbutamol

Symptoms free episode lasted for 2 months

5 days PTA- recurrence of sudden difficulty of breathing with non

productive cough and chest tightness that worsens during strenuous
activity and precipitated by exposure to extreme hot environment
during noon time and extreme cold environment at night time;
Associated with colds with less than 1 teaspoon greenish nasal
discharge, sudden easy fatigability and sleep disturbance due to bouts
of dyspneic episode and he needed to use pillows at night to ease
breathing ( Orthopnea); relieved by rest, sitting on an upright
position and salbutamol nebulization

2 hrs PTA- Persistence of recurrent symptoms with the same

character, intensity and frequency associated with dizziness
aggravated by ambulation such as walking long distance and extreme
hot environment; partially relieved by rest and sitting on upright
position

PE FINDINGS:
(+) Contraction of intercostal muscles on inspiration
(+) Intensity of breath sounds in the left is decreased compared to
the right heard mid to lower portion of the chest wall

APPROACHES TO A PATIENT WITH DYSPNEA

Shortness of breath, or Dyspnea- is the sensation of uncomfortable breathing.

This feeling of discomfort may reflect an increased awareness of breathing or the
perception that breathing is difficult or inadequate. Dyspnea usually indicates pulmonary
or cardiac disease, but can also be the presenting symptom of metabolic derangements,
hematologic disorders, toxic ingestions, psychiatric conditions, or simple deconditioning.

Dyspnea can be classified based on the primary physiologic derangement:

Pulmonary
Cardiac
Hematologic (eg, anemia)
Chest wall or neuromuscular disease
Metabolic (eg, acidosis)
Functional (eg, panic disorders)
Deconditioning

ETIOLOGY
The purpose of breathing is to meet the metabolic demands of the body. Thus, any
condition that increases the work of breathing (eg, airway obstruction, changes in lung
compliance, or respiratory muscle weakness) or increases respiratory drive (eg, hypoxia or
acidosis) may result in dyspnea. In addition, dyspnea may result from or be exacerbated by
primary psychological conditions (eg, anxiety disorders).
The differential diagnosis of dyspnea depends on the duration of the symptom and the
clinical setting. Conditions associated with acute dyspnea (developing over hours to a few
days) are outlined under alarm conditions.
Conditions associated with insidious development of dyspnea are outlined below. In an
analysis of patients referred to a pulmonary clinic for evaluation of chronic, unexplained
dyspnea, 67% suffered from asthma, chronic obstructive pulmonary disease (COPD),
interstitial lung disease, or myocardial dysfunction.
REFERENCE:THE PATIENT HISTORY-An Evidenced Based Approach to Differential Diagnosis
2nd edition, pp248
Author: Mark C. Henderson, Lawrence M. Tierney Jr, Gerald W. Smetana
REFERENCE:
THE PATIENT HISTORY-An Evidenced Based Approach to Differential Diagnosis
2nd edition
Author: Mark C. Henderson, Lawrence M. Tierney Jr, Gerald W. Smetana
I.MOST PROBABLE DIAGNOSIS
Bronchial Asthma

Definition
Asthma is a chronic inflammation of the airways which contributes to airway hyper
responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest
tightness, and coughing particularly at night or in the early morning. These episodes are
usually with airflow obstruction within the lung that is often reversible either
spontaneously or with treatment.

Prevalence
Prevalence of asthma is increasing by 4% each year. In the United States, the
prevalence of asthma cases was noted to be increasing since the early 1980s for all ages,
sex, and racial groups. The prevalence is higher among children than adults and higher
among blacks than whites. In the general population, the prevalence of asthma is higher
among females, however, in children, the prevalence is higher among males. Furthermore,
the prevalence among impoverished inner city children has been much higher.

Incidence in the Philippines

Three thousand two hundred and seven children in Metro Manila aged 13-14 years
participated in the International Study of Asthma and Allergies in Children (ISAAC).
Participants accomplished a 12-month prevalence of self-reported asthma symptoms from
written questionnaires and from video questionnaires. The results showed that
approximately 12% and 8% prevalence based on responses to the written questionnaire
and to the video questionnaire respectively. In a subsequent study, 12.3% of the same
population reported wheezing.

A local study estimating the prevalence of asthma and allergies in adults was
completed in Malolos, Bulacan in 1998. One thousand five (1,005) adults (ages 18-44 years)
were interviewed using a pre-tested questionnaire adapted from the European Community
Health Survey (ECHRS) and the ISAAC. The study showed a prevalence of 17.2% for asthma
and 49.9% for allergy among adults. Another study conducted at the Lung Center of the
Philippines reported a prevalence of 22% in adults.
Risk Factors and Triggers

Pathophysiology

Pathophysiology of asthma
Asthma is associated with a specific chronic inflammation of the mucosa of the lower
airways. One of the main aim of treatment is to reduce this inflammation.

Pathology
The pathology of asthma has been revealed through examining the lungs of the
patients who have died of asthma and from bronchial biopsies. The airway mucosa is
infiltrated with activated eosinophils and T lymphocytes, and there is activation of mucosal
mast cells. The degree of inflammation is poorly related to disease severity and may even
be found in atopic patients without asthma symptoms. This inflammation is usually
reduces by treatment with ICS. There are also structural changes in the airways (described
as remodeling). A characteristic finding is thickening of the basement membrane due to
subepithelial collagen deposition. This feature is also found in patients with eosinophilic
bronchitis presenting as cough who do not have asthma and is, therefore, likely to be a
marker of eosinophilic inflammation in the airways as eosinophils release fibrogenic
mediator. The epithelium is often shed or friable, with reduced attachments to the airway
wall and increased numbers of epithelial cells in the lumen. The airway itself may be
thickened and edematous, particularly in fatal asthma. Another common finding in fatal
asthma is occlusion of the airway lumen by a mucous plug, which I comprised of mucus
glycoproteins secreted from goblet cells and plasma proteins from leaky bronchial vessels.
There I also vasodilation and increased numbers of blood vessels (angiogenesis). Direct
observation by bronchoscopy indicates that the airways may be narrowed, erythematous,
and edematous.

EFFECTS OF INFLAMMATION
The chronic inflammatory response has several effects on the target cells of the
airways, resulting in the characteristic pathophysiologic and remodeling changes
associated with asthma. Asthma may be regarded as a disease with continuous
inflammation and repair proceeding simultaneously, although the relationship between
chronic inflammatory processes and asthma symptoms is often obscure.

Airway epithelium
Airway epithelial shedding may be important in contributing to AHR and may
explain how several mechanisms, such as ozone exposure, virus infections, chemical
sensitizers, and allergens (usually proteases), can lead to its development, as all of these
stimuli may lead to epithelial disruption. Epithelial damage may contribute to AHR in a
number of ways, including loss of its barrier function to allow penetration of allergens; loss
of enzymes (such as neutral endo peptidase) that degrade certain peptide inflammatory
mediators; loss of a relaxant factor (so called epithelial-derived relaxant factor); and
exposure of sensory nerves, which may lead to reflex neural effects on the airway.
Fibrosis
In all asthmatic patients, the basement membrane is apparently thickened due to
subepithelial fibrosis with deposition of types III and V collagen below the true basement
membrane and is associated with eosinophil infiltration, presumably through the release
of profibrotic mediators such as transforming growth factor-. Mechanical manipulations
can alter the phenotype of airway epithelial cells in a profibrotic fashion. In more severe
patients, there is also fibrosis within the airway wall which may contribute to
irreversible narrowing of the airways.

Airway smooth muscle

In vitro airway smooth muscle from asthmatic patients usually shows no increased
responsiveness to constrictors. Reduced responsiveness to -agonists has also been
reported in postmortem or surgically removed bronchi from asthmatics, although the
number of -receptors is not reduced, suggesting that -receptors hav been uncoupled.
These abnormalities of airway smooth muscle may be secondary to the chronic
inflammatory process. Inflammatory mediators may modulate the ion channels that serve
to regulate the resting membrane potential of airway smooth-muscle cells, thus altering the
level of excitability of these cells. In asthmatic airways there is also a characteristic
hypertrophy and hyperplasia of airway smooth muscle, which is presumably the result of
stimulation of airway smooth-muscle cells by various growth factors such as platelet-
derived growth factor (PDGF) or endothelin - 1 released from inflammatory or epithelial
cells.

Vascular responses
There is increased airway mucosal blood flow in asthma, which may contribute to
airway narrowing. There is an increase in the number ofblood vessels in asthmatic airways
as a result of angiogenesis in response to growth factors, particularly vascular endothelial
growth factor. Microvascular leakage from postcapillar venules in response to
inflammatory mediators is observed in asthma, resulting in airway edema and plasma
exudation into the airway lumen.

MUCUS hypersecretlon
Increased mucus secretion contributes to the viscid mucous plugs that occlude
asthmatic airways, particularly in fatal asthma. There is hyperplasia of submucosal glands
that are confined to large airways and of increased numbers of epithelial goblet cells. IL- 13
induces mucus hypersecretion in experimental models of asthma.

Neural regulation
Various defects in autonomic neural control may contribute to AHR in asthma, but
these are likely to be secondary to the disease, rather than primary defects. Cholinergic
pathways, through the release of acetylcholine acting on muscarinic receptors, cause
bronchoconstriction and may be activated reflexly in asthma.
Pertinent data associated with the patient
Clinical Onset Precipitating Quality Relieving Timing Patient
manifestatio or aggravating factors
ns of asthma factors
dyspnea episodic Incidental use of worsen (+)
allergen anti- at night
exposure, non- asthma
specific medicatio
irritants, ns
exercise,
worsen at night
Cough Episodic Incidental Non use of worsen (+)
allergen productive anti- at night
exposure, non- asthma
specific medicatio
irritants, ns
exercise,
worsen at night
Chest episodic Incidental use of worsen (+)
tightness allergen anti- at night
exposure, non- asthma
specific medicatio
irritants, ns
exercise,
worsen at night
colds Mucus (+)
production
that is
difficult to
expectorate

Physical examination Expected finding for Patients physical

asthma examination finding
Inspection Cyanosis (-)
Hyperinflated chest (-)
Use of accessory muscle (+)
(Intercostals retractions)
Palpation
Percussion Resonant to diffusely (+) resonant
hyperresonant
Auscultation Wheezing (-)
Rhonchi throughout the (-)
chest
Clinical Diagnosis
To make a diagnosis of asthma, the following should be sought in the patients history:
1. on and off cough that gets worse at night or in the early morning
2. wheezing
3. episodic breathlessness
4. chest tightness
5. symptoms are triggered by exercise, allergen or irritant exposure, change in
weather, or viral respiratory infections
6. a history of asthma and atopic disease in the family, and
7. improvement of condition with the use of anti-asthma medications

Diagnostic Tests
The following are two acceptable methods use in the diagnosis of asthma as they provide
objective measures:
Spirometry
Peak Expiratory Flow (PEF)

Treatment
Classify all patients with asthma attacks (exacerbations) according to severity to help
determine need for therapy.
Severity Recommended Treatment
Daily controller Alternative controller Reliever
medications
Intermittent None needed SABA as needed
asthma attack
(exacerbations)
Mild to moderate ICS + LABA ICS high dose or ICS SABA as needed
asthma attacks combination as regular dose + any of the
(exacerbations) single inhaler following:
SR Theophylline
Antileukotriene
Oral SR B2 agonist
Severe asthma Oral steroids + ICS SABA as needed
attacks + LABA
(exacerbations) combination as
single inhaler + any
of the following;
SR Theophylline
Antileukotriene
Oral SR B2 agonist
The following medications may be administered to patients with asthmatic attacks:
inhaled B2 agonist
Systemic or oral steroids
Inhaled ipratropium bromide + inhaled B2-agonists

The recommended step-care approach in the management of asthma is as follow:

Step Medication
1 Consider low dose inhaled corticosteroid (ICS)
2 Low dose ICS
Low dose ICS or montelukast
3 Low dose ICS/LABA
Low dose ICS or
Moderate or high dose ICS
4 Moderate or high dose ICS/LABA or
Medium dose ICS or
High dose ICS + 2nd controller
5 High dose ICS/ LABA + OCS or
High dose ICS/LABA + other add-on agents

Criteria for Hospitalization

Inadequate response to therapy within 1-2 hours
Persistent PEF <50% after 1 hour of treatment
Presence of risk factors
Prolong symptoms prior to ER consult
Inadequate access to medical care and medications
Difficult home condition
Difficulty in obtaining transport to hospital in event of further deterioration

Asthma Exacerbations and Hospitalization

Despite appropriate therapy ~10 to 25% of ER patients with acute asthma will
require hospitalization
The response to initial treatment in the ER is a better predictor of the need for
hospitalization than is severity on presentation FEV1 or PEF appears to be more
useful in adults for categorizing severity of exacerbation and response to treatment
Management of Acute Exacerbations: Hospital Setting

(Continuation)
Criteria for ICU Admission
Lack of response to initial therapy in ER
Presence of confusion, drowsiness, other signs of impending arrest or loss of
consciousness

Impending respiratory arrest:

PaO2 < 60 mmHg on supplemental oxygen
PaCO2 > 45 mmHg

Management of Asthma Exacerbations:

Home Treatment

Referrences
Harrisons Principles of Internal Medicine, 19th Edition
Philippine Concensus Report on Asthma Diagnosis and Management 2009 by PCCP
Council on Bronchial Asthma
Philippine Concensus Report on Asthma Diagnosis and Management 2004

II. ALTERNATIVE DIAGNOSIS

 CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
Definition:

Disease state characterized by aoirflow limitation that is not fully reversible.

Inflammation is the key component of COPD.
COPD is the third leading causes of deth and affects >10 million persons in the
United States.
COPD includes:
CHRONIC BRONCHITIS
- clinically defined condition with chronic cough & phlegm
- For at least months in each 2 consecutive years associated with airflow

EMPHYSEMA
- Anatomically defined condition characterized by destruction & enlargement of the
lung alveoli.

Symptoms of COPD include:

Dyspnea
Chronic cough
Chronic sputum production

RISK FACTORS
o Cigarette smoking
o Airway responsiveness and COPD
o Respiratory infections
o The association of both adult and childhood respiratory infections to the
development and progression of COPD remains to be proven.
o Tuberculosis most recent studies which causes risk factors to COPD
o Occcupational exposures
o Ambient exposures
o Prolonged exposure to smoke produced by biomass combustion a common
mode of cooking in some countries.

o Passive, or secon-hand, smoking exposure

o Genetic considerations
o Severe 1 antitrypsin (Alpha-1AT)
o Also known as alpha-1 proteinase inhibitor which protects tissues from
enzymes of inflammatory cells, especially neutrophil elastase, freely break
down elastin, which contributes to the elasticity of the lungs.
PATHOLOGY
Large Airways
-Goblet cell hyperplasia
-Bronchi undergoes Squamous metaplasia
-Smooth muscle hypertrophy
Small Airways
-Goblet cell metaplasia
-replacement of surfactant-secreting Clara cells with mucus secreting cells
-Infiltration of inflammatory cells
-Smooth muscle hypertrophy
Lung Parenchyma
-Emphysema destruction of gas exchanging airspaces

PATHOGENESIS

cell release damage the

Chronic inflammatory
elastolytic extracellular
exposure cell recruitment
proteinase matrix

alveolar ineffective
apoptosis of loss of matrix-
dilatation repair of elastin
structural cell cell attachment
(increase RV) (fibrosis)

airspace airflow
enlargement limitation

PATHOPHYSIOLOGY
Airflow Obstruction
-Also known as airflow obstruction
-Patients with airflow obstruction related to COPD have a chronically reduced ration
of FEV1/FVC
Hyperinflation
-There is air trapping
-The lungs is full -> thus inflate -> pushes diaphragm which flattens it
-increase residual volume which results to reduce ventilation perfusion mismatch
Nonuniform ventilation

Key indicators of disease

 Above 40 years old
With a history of exposure to risk factors which can be any of the following:
o Tobacco smoke
o Smoke from home cooking/ heating fuels
o Occupational dust/chemicals
And has any of the following clinical features:
o Dyspnea that is persistent and usually progressive
o Chronic cough that maybe productive or unproductive
o Chronic sputum production
o Family history of COPD

History Onset Precipitatin Quality Relieving Timin Patients

g factors factors g manifestations

Chronic Cough Intermittent Maybe (-)

unproductive
or chronic
sputum
production

Dyspnea Progressive exercise Worsens over (+)

time

Smoking (+)

Family history (-)

Age >40 (+)

Physical Expected findings Patients findings

Examination

Inspection Clubbing on the digits (-)

Barrel chest (-)

Peripheral cyanosis (-)

Use of accessory muscles (+)

Percussion Hyperresonance (-)

Palpation

Auscultation Wheezing (-)

Diffusely decreased breath sounds (+)

REFERENCES:

o PCCP: Council on COPD and Pulmonary Rehabilitation Guide for the diagnosis and
management of Stable COPD 2014
o Harrisons Principles of Internal Medicine 19th edition
o Emedicine.medscape.com
III. MUST NOT MISSED DIAGNOSIS

LEFT SIDED HEART FAILURE

Definition

Heart Failure- HF as a complex clinical syndrome that results from structural or functional
impairment of ventricular filling or ejection of blood, which in turn leads to the cardinal
clinical symptoms of dyspnea and fatigue and signs of HF, namely edema and rales.

Left-sided heart failure (left ventricular failure)

- failure of the left ventricle to maintain a normal output of blood; it does not empty
completely and thus cannot accept all the blood returning from the lungs via
the pulmonary veins, whichbecome engorged. Fluid seeps out of the veins through the pul
monary capillaries and collects in the interstitial tissue ofthe lung, causing pulmonary ede
ma that eventually leads to right ventricular heart failure as well.

Epidemiology

HF is a burgeoning problem worldwidewith more than 20 million people affected.

The overall prevalence of HF in the adult population in developed countries is 2%. HF
prevalence follows an exponential pattern rising with age and affects 6-10% of people
over age 65. Although the relative incidence of HF is lower in women than in men women
constitute at least one-half the cases of HF because of their longer life expectancy. In North
America and Europe, lifetime risk of developing HF is one in five for a 40-year old. The
overall prevalence of HF is thought to be increasing,in part because current therapies for
cardiac disorders such as myocardial infarction (MI)valvular heart disease and
arrhythmias are allowing patients to survive longer. Very little is known about the
prevalence or risk of developing HF in emerging nations because of the lack of population -
based studies in those countries. HF was once thought to arise primarily in the setting of a
depressed left ventricular (LV ) ejection fraction (EF); however epidemiologic studies
have shown that approximately one-half of patients who develop HF have a normal or
preserved EF (EF50%). Accordingly HF patients are now broadly categorized into HF
with a reduced EF (HFrEF; formerly systolic failure) or HF with a preserved EF (HRpEF;
formerly diastolic failure).

In sharp contrast to the wealth of epidemiologic data on HF in Western populations,

reliable population-based data on the incidence, prevalence and secular trends of clinical
(Stage C) HF are scarce in Southeast Asia. In the Philippines, Cardiovascular diseases is still
the leading cause of death that accounts for 8 per cent of cases in the medical and pediatric
services combined, 13.8 per cent of the medical cases. It appears, further, that the cases are
steadily increasing year after year.

Pathophysiology

Systolic dysfunction leading to left-sided heart failure

Impaired ventricular contractility Myocardial infarction, or transient
myocardial ischemia
Chronic volume overload (mitral or aortic
regurgitation)
Dilated cardiomyopathy (see
cardiomyopathy chapter for etiology of
dilated cardiomyopathy)
Increased afterload Uncontrolled systemic hypertension
Aortic stenosis
Diastolic dysfunction leading to left-sided heart failure
Impaired ventricular relaxation Ventricular hypertrophy
Cardiomyopathy (hypertrophic or
restrictive)
Transient myocardial ischemia
Impaired ventricular filling Mitral stenosis
Pericardial constriction or tamponade
Clinical Onset Precipitati Quality/ Relieving Associate Timing Clinic
manifestations of ng factors quantity / d Signs al
Left-sided HF radiating and manif
factors symptom estati
s on of
the
patien
t
Dyspnea Sympt Exertion Rapid, Often May progress +
oms of early shallow relieved slowly or
heart stage breathing by rest suddenly
failure Less and
can be strenuous sitting
ongoi activity upright
ng and even though
(chron at rest- symptom
ic) or later stage s may
it may persist
Fatigue start Exertion/ Feeling of Relieved +
sudde physical heaviness of by rest
nly activities limbs and
(acute cessation
) of
physical
activities
Orthopnea Lying Difficulty of Sitting Nocturna Night +
down breathing in upright l cough
recumbent or
position sleeping
with
addition
al
pillows
Paroxysmal May be Severe May Night -
nocturnal dyspnea precipitat shortness of require
ed by breath and 30 mins
coughing coughing that or longer
at night awakens the sitting
patient from period in
sleep or upright
feeling of position
severe
anxiety,
 breathlessne
ss, and
suffocation

Cheyne- strokes Periodic Coughing -

respiration respiration or
or transient wheezing
cessation of
breathing
Cough May or +
may not
be
productiv
e
Acute pulmonary The patient appears extremely ill, poorly perfused, restless, sweaty, -
edema tachypneic, tachycardic, hypoxic, and coughing, with an increased work of
breathing and using respiratory accessory muscles and with frothy sputum
that on occasion is blood tinged.
Chest pain/ Could be -
pressure/ precipitat
palpitations ed by
coughing
Other symptoms: _
Gastrointestinal symptoms such as anorexia, nausea, and early satiety with abdominal pain (due
to congestion of liver and stretching of its capsule) and fullness are common complaints and may
be related to edema of the bowel wall.
Oliguria and nocturia (may contribute to insomnia)
In elderly patients with advance heart failure they may manifest: Confusion, Memory
impairment, Anxiety, Headaches, Insomnia, nightmares
 Physical Examination Expected Finding for Left- Patients Physical
Sided Heart Failure Examination Findings
Palpation Pulsus Alternans -

Pulmonary Crackles -

Cardiac Asthma -
Auscultation (coarse ronchi and wheezes)
Mitral regurgitation murmur -

Accentuated P2 -

References:

McMaster Pathophysilogy Review (http://www.pathophys.org/heartfailure/)

Harrisons