LocationLocation: E.R
C.C: Severe shortness of breath
Vitals:
Pulse: 130/min,Temp: 99° F, B.P: 120/70 with pulsus paradoxus, R.R: 34/min
HPI:
A 36-year-old asthmatic man is brought to the ED by his co-workers with
complaints of severe shortness of breath, cough, wheezing, chest tightness, and
diaphoresis. He is unable to speak in phrases and his speech is restricted to
single syllables between breaths. He was doing his routine work when he
developed breathless and wheezing. He used his prescribed as needed inhalers
twice, but his condition deteriorated. The patient has never been intubated or
mechanically ventilated for asthma. Other components of history couldn’t be
obtained. He denies any chest pain, fever, chills, and hemoptysis. His other ROS
are unremarkable.
ROS:
Skin: No rashes, sore, itchy patches, or nail changes
HEENT: Denies head trauma, vision changes, hearing loss, tinnitus, swollen or
stiff neck, sore throat or hoarseness.
Musculoskeletal: Denies weakness, joint stiffness, or pain.
Cardiac: Denies palpitations and chest pain.
Respiratory: Positive shortness of breath, wheezes, and cough. Denies sputum
production or hemoptysis.
Genitourinary: No dysuria, penile discharge or hematuria.
Neuro psychiatric: No complaints.
PMH:
Bronchial asthma
FH:
Mother has H/O bronchial asthma
Father is healthy
Social History:
Married for 12 years. No children. Smokes 10 cigarettes for the last 10 years
and drinks alcohol occasionally.
Allergies:
Pollen and dust
Medications:
Albuterol 2 puffs Q 4 hrs prn
Vaccinations: Up to date
How would you approach this patient?
Dyspnea alone doesn’t signify pulmonary disease; it may be present in
cardiovascular and pulmonary diseases. This patient has severe dyspnea. The
management in such patients depends upon identifying the cause of dyspnea. The
patient is a known asthmatic. Start with a broad differential diagnosis.
Dyspnea in a patient with known asthma may be due to:
Asthma exacerbation
Status asthmaticus
Pneumonia
Pneumothorax

And few causes in the context of any case of acute dyspnea;
Pulmonary Embolism
Cardiogenic pulmonary Edema
Cardiac tamponade
Upper airway obstruction (foreign body aspiration, anaphylaxis)

On the basis of history and vitals, we cannot rule out the possibilities of
pneumothorax, or pulmonary embolism; however most likely cause of acute dyspnea
in this patient is Asthma exacerbation. Now proceed to physical examination.
Order:
Stat pulse oxymetry, and continuous
Head elevation
IV access
Order examination:
HEENT
Physical examination of Chest/Lung
Heart
Abdomen
Extremities
Results of Physical Examination:
Pulse oxy showed 89% O2 saturations on room air
HEENT: WNL, no JVD
LUNG/CHEST: Patient is agitated and unable to recline. He is gasping for breath
and using his accessory muscles. Respiratory rate is 34/min. Percussion note
is resonant in all lung fields. On auscultation of lungs, air entry is
bilaterally equal. Loud inspiratory and expiratory wheezing is audible in all
lung fields.
CVS: Decrease in systolic B.P. on inspiration is 20 mmHg (pulsus paradoxus).
There is no pedal edema.
Abdomen: Benign
Extremitas: NO calf tenderness, edema
How do you approach now?
Pneumothorax is unlikely in the presence of breath sounds in all lung fields.
Cor pulmonale refers to acute right heart failure due to pulmonary disease.
Pulmonary embolism is mostly responsible for the acute decompensation of right
heart. Pulmonary embolism is unlikely in the absence of chest pain, any
predisposing factor such as orthopedic surgery. Wheezing may be present in such
patients due to reflex bronchospasm.
Pulsus paradoxus again is non-specific for pericardial tamponade. It may be
present in asthma and severe COPD.
Pneumonia is unlikely in the absence of fever and productive cough. Respiratory
examination didn’t reveal any crackles or bronchial breath sounds.
Order review:
Stat Oxygen via facemask or nasal cannula
Arterial Blood Gas (ABG)
Peak expiratory flow rate (PEFR)
EKG 12 lead, stat
CXR PA view (to determine infectious exacerbation of asthma and rule out other
causes)
Albuterol nebulization, stat and repeat for every 20 minutes
IV methyl prednisolone, stat and Q 6-8 hours
CBC with diff, stat ((to determine infectious exacerbation of asthma)
Basic metabolic panel, stat
Results:
ABG shows
pH 7.35
pO2 60 mmHg
pCO2 40 mm Hg

PEFR 40% of the documented personal best
CXR shows hyperinflation, no infiltrate, no pneumothorax or effusions
EKG is unremarkable for new changes ex


admit to icu......
continue treatment
regular diet
asthamaa eductaion
abg
d/c iv steroid
continue oral steroids
neb teratment prn
when stabel send to floor
asthamaa eductaion
no smoking
limit alcohol
seat belt
no asp
solemetrol
avoid allergen
medication adherence
peekflow check at home

diag acute asthamaa
oral steroids