ADMISSION CONFERENCE

General DataName: L.D.Age & Gender: 68/Male

Chief Complaint: Difficulty of Breathing

History of Present Illness• Known case of Bronchial Asthma since

1964 (patient was 23 years old)• Was prescribed:– unrecalled inhaler PRN– Theophylline (Asmasolon) 1tab BID, not

compliant • Asthma attacks– occurred once every month– precipitated by hot weather and exposure

to smoke and dust – relieved with use of inhaler medications– no report of nocturnal awakenings

45 years PTA

History of Present Illness

• Asthma attacks – occurred 2-3x/week– precipitated by hot weather and

strenuous exercise– relieved with use of Salbutamol

rotacap– (+) nocturnal awakenings,

1-2x/month

20 years PTA

History of Present Illness• Acute exacerbation after exposure to a

significant amount of smoke• severe dyspnea and chest tightness• became unconscious & cyanotic after a

few minutes• Bought to Diosdado Macapagal Hospital • Assessment: Bronchial Asthma, in acute

exacerbation and Community Acquired Pneumonia

• Unrecalled laboratory examinations and medications given

• No immunization was offered

2 years PTA

History of Present Illness• Dyspnea even at rest, temporarily relieved by

Salbutamol inhaler • Productive cough of whitish sputum, (+) wheezing• Prefers to be in sitting position• No consult was done

• ↑severity of dyspnea, neither relieved by Salbutamol inhaler nor by nebulization

• (+) wheezing, cough, chest tightness, profuse sweating

• (-) fever & chills, orthopnea, PND, pleuritic chest pain

• His relatives also noticed that he was getting cyanotic on his extremities and lips

• Persistence of above symptoms consult

2 days PTA

7 hours PTA

ADMISSION

Review of Systems???(-) wt loss, (+)anorexia, (+)weakness, (-)fatigue, insomnia (-) itchiness, pigmentation, rash, active dermatoses(-) blurring of vision, redness, itchiness, Iacrimation(-) deafness, tinnitus, aural discharge(-) anosmia, epistaxis, sinusitis, nasal discharge(-) bleeding gums, oral sores, tonsillitis (-) neck mass, neck stiffness, limitation of motion(-) breast masses, discharge, trauma(+) dyspnea, (+) cough, (-) hemoptysis, (-) easy fatigability, chest pain, nocturnal dyspnea, palpitation, syncope, edema(-) phlebitis, varicosities, claudication(-) dyshpagia, nausea, (+)vomiting, retching, hematemesis, melena, hematochezia, belching, indigestion, diarrhea,

constipation(-) urinary frequency, urgency, hesitancy, dysuria, hematuria, nocturia, urethral (-) joint stiffness, joint pain, muscle pain, cramps(-) heat-cold intolerance, polydipsia, polyphagia, polyuria(-) headache, speech disturbance – change in voice, (-) seizures(-) anxiety, depression, IPR difficulties

Past Medical History

Previous Surgery– Anal Fistula, s/p Fistulectomy, February 2009

Major Adult Illnesses– Hypertension, Stage II, uncontrolled (1990)– Highest BP 190/110, Usual BP 180/90– Olmesartan 20mg/tab, non-compliant

Immunizations: unrecalledAllergies– Aspirin– Unrecalled antibiotics

Family History

(+) Hypertension : father(+) Heart disease : father, cause of death(+) DM type II : mother and sister(-) Asthma, PTB, Cancer, Thyroid disorder

Personal and Social History

• Mixed diet• Non smoker• Non alcohol beverage drinker• Denies illicit drug use

Physical Examination on AdmissionGeneral Survey: Conscious, coherent, ambulatory, in respiratory distress, in tripod position, speaks in phrasesVital Signs: BP 190/90mmHg PR 104bpm, regular RR 24cpm, regular T 38oC Height: 5ft Weight: 55kg BMI:Skin: Warm moist skin, no rashes, no jaundice, no active dermatosisHead: Normocephalic, pink palpebral conjunctiva, anicteric sclera, isochoric pupils, midline septum, no alar flaring, no nasoaural discharge, turbinates not congested, no oral ulcers, moist buccal mucosa, nonhyperemic pharyngeal wall, tonsils not enlarged, no aural pits or tags, no tragal tenderness, nonhyperemic EAC, intact TM, AU

Physical Examination on Admission

Neck: Supple neck, non prominent SCM, trachea at midlineno distended neck veins, no neck mass, no palpable cervical

lymph nodes, no carotid bruit, CAP: rapid upstroke, gradual downstroke, JVP: 4.5cm at 45o

Chest: Symmetrical chest expansion, no barrel chest, (+) supraclavicular retractions, ↓tactile and vocal fremiti at L hemithorax, dullness on R lung, T5-T7, (+) wheezes and (+) coarse crackles on both lung fields, (+) Egophony on both lung fields

Heart: Adynamic precordium, apex beat at 5th LICS, MCL, no lifts, no heaves, no thrills, S1 is louder at the apex, S2 louder at the base, (-) S3, (-) murmurs

Physical Examination on Admission

Abdomen: Globular, no scars, midline inverted umbilicus, normoactive bowel sounds (9/min), tympanitic all over, liver span = 8cm, Traube’s space not obliterated, (-) CVA tenderness, no direct or rebound tenderness, no massesExtremities: no deformities, no edema, no clubbing, no peripheral or central cyanosis, Pulses: ++ on all extremities

Physical Examination on AdmissionNeurologic ExaminationMental Status: Conscious, coherent, oriented to time, place and person, follows

commandsCranial nerves: Olfaction intact, bilateral pupils 2-3mm ERTL, no visual field cuts,

EOM’s full and equal, V1V2V3 intact, can raise eyebrows, smile, frown, puff cheeks, intact gross hearing, uvula midline on phonation, (+) gag reflex, can shrug shoulders, can turn head side to side against resistance, tongue midline on protrusion

Motor: no atrophy, no fasciculations, no spasticity or rigidity, MMT 5/5 on all extremities

Cerebellar: can do APST and FTNT with ease on both upper extremitiesSensory: no sensory deficit Reflexes: DTRs ++ on all extremities, (-) BabinskiMeningeal signs: (-) nuchal rigidty, (-) Brudzinski, (-) Kernig’s

Assessment

• Bronchial Asthma, moderate persistent?, in acute exacerbation

• Community Acquired Pneumonia, in patient, non-ICU• Hypertension, Stage 2, poorly controlled

PlansTherapeutic: • O2 supplementation (4lpm)• Salbutamol + Ipratropium Bromide

(Combivent) nebulization q6h• Hydrocortisone 100mg/IV q8h• Cefuroxime 500mg/tab 1tab BID• Azithromycin 500mg/tab 1 tab OD• Erdosteine 300mg/cap 1 cap BID• Simvastatin 20mg/tab 1tab ODHS• Losartan 50mg/tab 1tab OD• Amlodipine 5mg/tab 1tab OD• Clopidogrel 75mg/tab 1tab OD