Asthma Exacerbation

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of ‍wheezingshortness of breathcough

Symptoms include:

‍shortness of breath

‍wheezing

‍cough, ‍non-productiveproductive of ‍clearcolored phlegm

‍chest tightness

‍chest discomfort

‍tachypnea

‍difficulty speaking

‍fatigue

‍sleep disturbance

‍anxiety



Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective



Contributing factors:

‍smoking

‍occupational exposure to irritants

no history of: ‍asthma, ‍COPD, ‍GERD, ‍allergies

no use of: ‍beta-blockers





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Nose: ‍clear, discharge ‍clear, ‍

Throat: ‍normal, ‍erythema, ‍exudate, ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions





ASSESSMENT:

‍Asthma exacerbation ‍likelysuspectedpossible

DDx: asthma exacerbation, COPD exacerbation, viral URI, bronchitis, pneumonia, allergic rhinitis, sinusitis, GERD, vocal cord dysfunction, heart failure, pulmonary embolism, anaphylaxis, bronchiolitis, foreign body aspiration, medication noncompliance, environmental triggers, psychogenic dyspnea





PLAN:

Investigations:

- Chest X-ray

- Blood gaz

- Peak flow

- Pulmonary function tests

Treatments:

- Increase ‍Short-acting bronchodilators (SABAs)

- Increase ‍Inhaled corticosteroids (ICS)

- Increase ‍Combination inhalers with ICS

- ‍Antibiotics

- ‍Steroids

- Oxygen therapy if SpO2 < 92%

- Ensure proper inhalation technique and spacer use

- Smoking cessation counseling

Further care:

- Referral to pulmonologist

- Follow-up in ‍ ‍daysweeksmonths