EVALUATION CHECKLIST CASE 7: Cough and Bronchial asthma (100 pts) Residents Name: ______________________________ CASE ESSENTIAL ASPECTS

OF HISTORY & PHYSICAL EXAM: 5/M with chief complaint of cough and difficulty of breathing History: 1-mo cough & breathlessness 3x/week, night symptoms <3x/month, relieved by salbutamol Past Medical HIstory: 3-year recurrent cough with difficulty of breathing, triggered by colds, exposure to dust and strong odors, admitted a year ago and given budesonide MDI 400mcg/day for 3 mos with resolution of symptoms Birth and Maternal History: Unremarkable. PE: Awake, prefers sitting position, talks in phrases, irritable. HR 116, RR 42, Temp 38.3C, SaO2 92%. (+) Alar flaring, (+) suprasternal and intercostals retractions, (+) wheezing over both lung fields, regular cardiac rhythm, no murmur soft nontender abdomen and full pulses. Year Level: ____

CONTENT 1. What additional information in the history would you ask for and why? Other manifestations and associations:wheeze, chest tightness, breathlessness, gurgly chest/halak possible asthma Association with exercise, nocturnal/episodic/seasonal occurrence personal or family history of atopy * The patients father has asthma other recognizable triggers no smokers in the family but to save on LPG, they sometimes use firewood for cooking Association with feeding gastroesophageal reflux, swallowing dysfunction Cardiac signs and symptoms (easy fatigability, orthopnea, respiratory distress, tachycardia, rales, palpitations, murmur, etc.) congestive heart failure Response to medications: immediate relief with beta-2 agonists (approx 5 min with inhaled and 30 min with oral salbutamol) asthma

YES NO RED COMMENTS FLAG

Yes Yes

2. What specific physical findings would you look for and why? Blood Pressure Yes

100/70 Weight/nutritional status, Height The patients weight is 16 kg; height is 108 cm Thoracic cavity shape/deformities None Duration of expiration Prolonged expiratory phase in intrathoracic obstruction (asthma) Breath sounds - decreased (rule out atelectasis, consolidation, effusion, mass) Auscultatory findings which may point to other respiratory diseases - crackles, grunting, stridor Wheezing Signs of atopy (allergic rhinitis, allergic conjunctivitis, atopic dermatitis) Puffy bluish eyelids Other signs of impending respiratory failure: paradoxical thoracoabdominal movement None Other signs of impending respiratory failure: pulsus paradoxus (decrease of systolic BP >10mm Hg during inspiration correlate with the degree of airway obstruction in asthma) none Clubbing none 3. What is your primary impression? Enumerate and justify common differential diagnoses based on the history and physical examination. Primary impression: exacerbation Mild persistent asthma in moderate Yes

Differential diagnosis for chronic cough: PND GERD TB, CHF, Bronchiectasis, Recurrent Aspiration, Foreign body Psychogenic cough Differential diagnoses for recurrent wheezing: Chronic rhino-sinusitis Gastroesophageal reflux Recurrent viral lower respiratory tract infections Cystic fibrosis Bronchopulmonary dysplasia Tuberculosis Congenital malformation causing narrowing of the intrathoracic airways Foreign body aspiration Primary ciliary dyskinesia syndrome Immune deficiency Congenital heart disease

Differential diagnoses of asthma: a. Aspiration syndromes Gastroesophageal reflux disease - may mimic or trigger asthma by recurrent aspiration or through vagally mediated reflex bronchoconstriction Swallowing dysfunction of whatever cause - results to recurrent aspiration which can mimic or trigger an acute asthma attack b. Congestive heart failure - Cardiac conditions that result in pulmonary artery dilatation and/or left atrial enlargement can compress large airways and cause wheezing. Left ventricular failure or pulmonary venous outflow obstruction can result in distention of the pulmonary vascular bed, bronchiolar edema and increase airway resistance and wheezing, thus mimicking asthma. c. Airway obstruction due to intraluminal (foreign body aspiration, tumors) or extraluminal (compression from adjacent tumor or enlarged lymph node) can clinically manifest as wheezing and simulate asthma d. Allergic rhinitis - 70-90% of asthmatics have concomitant rhinitis and 40-50% of patients with allergic rhinitis have concomitant asthma. e. Interstitial lung disease, bronchiectasis and bronchopulmonary dysplasia can mimic asthma because of increased reactivity of the airways f. Persistent bronchitis - persistent, wet cough present for >1 month that resolves with appropriate antibiotic treatment. Diagnosis can be made by doing bronchoscopy and clinical assessment of its response to antibiotic therapy 4. Identify and interpret pertinent laboratory work-up necessary to come up with the final diagnosis. a. Peak Expiratory Flow Rate (PEFR) Measurement If PEFR is below normal, give inhaled short-acting B2 agonist. A 20% increase in PEFR after giving B2 agonist supports the diagnosis of asthma. If theres a <20% increase after B2 agonist administration or if the baseline PEFR is normal, may perform an exercise challenge test, measure peak flow variability, or do a 5-day therapeutic trial with oral corticosteroid and bronchodilator. The patients baseline PEFR readings are 165, 160, 155, 160. What is his predicted PEFR? Is his PEFR normal? Predicted PEFR for males = (Height in cm -100) x 5 + 175 = (108-100) x 5 + 175 = 215 Get the highest of the patients PEFR readings: 165 (76.7% of predicted PEFR). This is below the normal 80% predicted PEFR. The patients PEFR increased by 15% after administering Yes

inhaled beta-2 agonist. Does this support your diagnosis? What is the next step? b. Peak Flow Variability Correlates well with airway hyperresponsiveness. This is computed from the twice daily PEFR monitoring done for 2-3 weeks. Peak flow variability = [(Highest reading - Lowest reading) / Highest reading] x 100. Variability 20% supports a diagnosis of asthma.

c.Exercise Challenge Test

During the challenge, the child is asked to run on a flat surface, on

a treadmill or exercise with a stationary bicycle for 6 minutes. The degree of physical exertion should produce a heart rate of about 180/min. Baseline pulmonary function measurements are obtained before and after exercise, FEV1 and/or PEFR are measured serially every 5 minutes for 20 minutes. A positive response is demonstrated with a fall of at least 15% in FEV1 or 20% in PEFR. Such fall is readily reversible with inhalation or nebulization of beta2 agonist. Ancillary: pulse oximetry 5. What is your final diagnosis based on the history, physical examination, and laboratory parameters?

d.

Mild persistent asthma in moderate exacerbation [based on

Phil Asthma Consensus 2002 classifying asthma according to severity] Uncontrolled asthma [based on GINA Consensus 2008 classifying asthma according to control] 6. Discuss the pathophysiology of the disease. Key words: Inflammation Airway Obstruction

Airway Hyperresponsiveness

Clinical Symptoms Asthma is a chronic inflammatory disorder of the airways in which many cells (e.g., mast cells and eosinophils) play a role. In susceptible individuals, this inflammation causes symptoms that are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment, and causes associated increase in airway hyperresponsiveness to a variety of stimuli. Clinically, asthma is characterized by airway hyperresponsiveness presenting as widespread narrowing of the airway which results from a variety of stimuli like allergens, exercise, physical factors and irritant gases. It is also characterized by intermittent episodes

of a constellation of symptoms in-between asymptomatic intervals. The primary physiologic manifestation of this process is spontaneous variable airway obstruction, which can be increased by many stimuli (environmental, behavioral, chemical and pharmacologic) and alleviated by bronchodilators and/or antiinflammatory agents. 7. Discuss the key points in the management of the disease. a. Asthma education to establish a patient-parents-physician partnership in asthma care b. Environmental control c. Treatment of associated medical conditions known to trigger exacerbations d. Drug therapy for acute exacerbation FOR MODERATE ASTHMA EXACERBATION: Inhaled short-acting B2 agonist (SABA) every 20 min up to 3 doses Oxygen to achieve O2sat 95% Correct dehydration Assess response If good response (presenting symptoms reversed; PEFR 80% predicted or personal best, and response to B2 agonist sustained for 4 hours): continue inhaled SABA every 4 hours for 24-48 hours; continue maintenance medications; give follow-up instructions to parents If poor response (presenting symptoms persist or progress; PEFR <80% predicted or personal best, or response to B2 agonist not sustained for 4 hours): inhaled SABA every 20 min or continuously; IV corticosteroids; oxygen to achieve O2sat 95%; correct dehydration; refer to specialist; admit to hospital If there is impending or actual respiratory failure: in addition to above, assist ventilation and admit to ICU. Yes

Yes

Yes

Yes

e. Drug therapy for long-term management of asthma

Key points:
1) For treatment-nave patients, classify asthma according to

severity and initiate pharmacologic therapy corresponding to the severity category. For this patient, initiate drug therapy corresponding to his mild persistent asthma classification: Reliever: As needed rapid-acting B2 agonist Controller: Preferred: Low-dose inhaled corticosteroids 100-200 mcg/day Alternative: Leukotriene modifier such as montelukast An option but not recommended for routine use as initial controller: Sustained release theophylline (less desirable because of its safety profile and the need to adjust dose

Yes Yes

Yes

based on diet, drug interactions & variable metabolism with age) In 2-4 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly based on level of control. **In the Phil Asthma Consensus 2002, drugs for mild persistent asthma included: as needed inhaled SABA; inhaled corticosteroids at 200-400 mcg/day for maintenance; long-acting B2-agonist (LABA) or sustained-release theophylline for night-time symptom control; and LABA or anti-leukotrienes or sustained-release theophylline as addon medications.
2) Once treatment is established (on follow-up), the emphasis is

on assessing asthma control to determine if the goals for therapy have been met and if adjustments in therapy (step up or step down) would be appropriate. Controlled asthma: maintain & find lowest controlling step. Partly controlled asthma: consider an increase in treatment to gain control. Uncontrolled asthma: step up treatment until controlled. Treat exacerbations accordingly.
3) Consider the following before stepping up therapy:

Yes

Patient compliance Review inhaler technique Environmental control Presence of comorbid conditions

4) If control has been maintained for at least 3 months, a

gradual reduction in treatment is recommended to establish the lowest step and dose of treatment that maintains control f. Monitoring of disease status Closely observe the symptomatology and physical manifestations; ability to enjoy normal activities including exercise; adverse reactions to drugs being given; need for medications and medical attention; measurements of pulmonary function (serial spirometry or PEFR monitoring) 8. What advise would you give the patient and family? Control of triggers Compliance to medications Side effects of medications - steroids Monitoring

OVERALL EASE and CONFIDENCE in taking the oral examination 1- No self-confidence whatsoever

2- Showed very little self-confidence 3- Showed little self-confidence 4- Generally at ease and confident 5- Impressive confidence

Examiners Name and Signature: __________________________