History and examination findings

Personal Details

Name: Suba A/P RamasamyRegistration no.: SB323827Age: 31Sex: FemaleRace: IndianReligion: HinduOccupation: HousewifeMarital status: Married with one childAddress: Rawang

Chief Complain

Breathlessness for two days

History of Presenting Illness

Ms Suba was brought to Accident and Emergency Department of Hospital Sungai Buloh on the 3rd October 2012 with the complaint of intermittent breathlessness for two days, where the latest episode of breathlessness before the admission was lasted for two hours. The breathlessness was sudden and each episode normally lasts for about 10 minutes. Normally she has the breathlessness around 2-3 am, which will disrupt her sleep and she uses two pillows every night while sleeping. According to her, expiration was harder compared to inspiration during breathlessness. Running around, climbing the stairs, heavy work, cold weather, cold drinks and dust aggravate the breathlessness. During the time, Ms Suba always uses Ventolin inhaler to relieve the symptoms and tried to sit down upright. Out of a scale of 1-10, where 1 is the least severe and 10 is the most severe, Ms Suba ranked 8 for the severity of her breathlessness. Together with the breathlessness, she also had productive cough with scanty thick yellow sputum without blood, throat pain, running nose and wheezing. The cough was frequent during cold weather and night time.

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Past Medical History

Ms Suba was having childhood asthma since born, which was resolved at the age gap of 10-20 years old. But then she got it back after that. Normally she used to go to the clinic and take medication if she felt breathlessness. She also consumed some traditional medication at the age of 10. Since the past 4 years she had stopped consuming tablet and started to use inhalers which are ventolin (salbutamol) whenever she feels breathlessness and beclometasone pressurised inhalation (100µg/dose) once in the morning and once at night. Sometimes during breathlessness she will take oral prednisolone (5mg) but it did not get better these two days.

Surgical History

In 1995, Ms Suba had undergone two orthopaedic surgeries due to her right distal tibia fracture.

History of Allergies

Ms Suba is allergic to dust especially if any dusty carpets are around, which will cause her to have breathlessness, running nose and sore throat.

Family History

Ms Suba’s mother died due to diabetes mellitus. All her other family members are fine. No history of asthma in the family.

Social History

Ms Suba felt comfortable and clean to stay at her house. Her housing area is clean with a clean and good supply of water and electricity. Currently she is staying with her husband, son, mother-in-law, father-in-law and two nephews. From June to December 2011 (6 months), Ms Suba worked at a rice company called Beras Jati as a person who does the packing work. The company was located at Rawang. Since the dust there aggravated her breathlessness frequently, she had stopped working there. She has no history of recent travelling, contact with animals, alcohol consuming or smoking. Her husband is actually a chronic smoker but he does not smoke in the house or smoke in front of Ms Suba.

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Review of Systems

Cardiovascular system – Chest pain and palpitation together with breathlessness, fatigue, no sweating.

Hematopoietic system – Slight fever on the first day of breathlessness (37.5 °C), no rashes.

Respiratory system – Productive cough with scanty yellow sputum, wheezing, running nose, sore throat, no hemoptysis.

Gastrointestinal system – No vomiting, normal bowel movements, normal appetite, heartburn after eating, no history of gastric pain.

Urinary system – Normal urine flow, no hematuria, no hesitancy, no urgency, no pain during urination.

Reproductive system – Menarche in November 1995. Normal menstruation cycle for every 27th day. Each cycle will lasts for 5 days. In the first 2 days, she will use 4-5 pads. Out of the 4-5 pads, 3 pads will be full while the other 2 will be half full. In the last 3 days, she will use 3 pads which will be half full. Since menarche, she has menstruation pain on the first day of menstruation. Gave birth to her son on 27th February 2009 by vaginal delivery.

Musculoskeletal system – No muscle, bone or joint pain.

Nervous system – Headache, no blurring of vision, no history of seizure.

Endocrine and metabolism system – No history of thyroid diseases or diabetes mellitus, gained 4kg of weight this year.

General Examination

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General inspection: On examination, Ms Suba was alert, conscious, well nourished and hydrated, pink, average height and build, not very comfortable but responding and communicating well..........................................................................................................

Vital Signs: Pulse rate: 84 bpm, regular rhythm, bounding pulseRespiratory rate: 20/minBlood pressure: 126/74 mmHgTemperature: 37.0 °C

Hands: Warm and dry, pink, no clubbing, no tar-stained finger, no splinter haemorrhage, no peripheral cyanosis, left hand had a scar from an accident.

Eyes: No conjunctival pallor, no yellow discolouration of the sclera.

Mouth: No mouth ulcer or central cyanosis.

Systemic Examination

Respiratory system ................................................................................................................... .Neck: Carotid pulse can be felt and jugular venous pressure is not raised.

Chest:Inspection: Chest wall looks symmetrical and surgical scars was absent.Palpation: - Trachea is centrally located................................................................................ - No masses or lumps can be felt over the chest area....................................... - Apex beat can be felt at the 5th intercostal space of mid-clavicular line. - Chest expansion was equal on both sides, anteriorly and posteriorly. - Vocal fremitus can be felt equally all over the lungs, anteriorly and posteriorly.Percussion: The lung areas were resonant except for the cardiac dullness.Auscultation: - Fine crackles can be heard on upper lobes of both lungs, anteriorly and posteriorly............................................................................................... - Vocal resonance was equally heard all over the lungs, anteriorly and posteriorly.

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Legs: Rough and dry, pedal edema was absent, surgical marks on the right leg due to the accident.

Summary

Ms Suba, 31 years old, Indian, Hindu, married housewife, who is currently staying at Rawang. She was admitted to Hospital Sungai Buloh with the chief complaint of intermittent dyspnoea for two days, which was severe for two hours. It was associated with productive cough with scanty yellow sputum, wheezing, throat pain, and running nose. She also has paroxysmal nocturnal dyspnoea and orthopnoea. So she uses two pillows under the head during sleeping. The dyspnoea usually aggravated by running around, climbing the stairs, heavy work, cold weather, cold drinks and dust while relieved by inhaling ventolin. Ms Suba is having childhood asthma since born and taking medication for it which is ventolin, beclometasone pressurised inhalation and oral prednisolone. She is allergic to dust and very easily gets flu. There is no history of asthma or any diseases in the family except that her mother died of diabetes mellitus. No history of smoking, alcohol consumption, recent travelling or contact with animals. She also had chest pain, palpitation, fatigue and headache during dyspnoea and heartburn during sore throat.

Provisional diagnosis

Bronchial asthma

Differential diagnosis

Pericarditis Acute bronchitis Acute pneumonia

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Investigations and results

Chest x-ray Full blood count

Chest x-ray

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Full blood count

[L] - Low [H] - High

(Renal Profiles)- Urea03/10/2012 02:56 5.6 mmol/L(Renal Profiles)- Sodium03/10/2012 02:56 137 mmol/L(Renal Profiles)- Potassium03/10/2012 02:56 3.30 mmol/L [L](Renal Profiles)- Chloride03/10/2012 02:56 101.0 mmol/L(Renal Profiles)- Creatinine03/10/2012 02:56 62.9 umol/L(Venous Blood Gases)- Partial Carbon Dioxide03/10/2012 02:56 43.8 mmHg(Venous Blood Gases)- Partial Oxygen03/10/2012 02:56 40.4 mmHg [L](Venous Blood Gases)- HCT03/10/2012 02:56 34.9 %(Venous Blood Gases)- HCO3 act03/10/2012 02:56 28.2 mmol/L(Venous Blood Gases)- HCO3 std03/10/2012 02:56 27.3 mmol/L(Venous Blood Gases)- pH03/10/2012 02:56 7.425(Venous Blood Gases)- BE(ecf)03/10/2012 02:56 4.1 mmol/L(Venous Blood Gases)- Base Excess03/10/2012 02:56 3.9 mmol/L [H](Venous Blood Gases)- ctCO203/10/2012 02:56 25.8 mmol/L(Venous Blood Gases)- Oxygen Saturation03/10/2012 02:56 70.9 % [L](Venous Blood Gases)- O2 CT03/10/2012 02:56 11.2 mL/dL(Liver Function Tests (LFT))- Protein, Total03/10/2012 02:56 69.0 g/L(Liver Function Tests (LFT))- Globulin03/10/2012 02:56 38 g/L [H](Liver Function Tests (LFT))- Albumin/Globulin Ratio

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03/10/2012 02:56 0.81(Liver Function Tests (LFT))- Bilirubin, Total03/10/2012 02:56 4.9 umol/L(Liver Function Tests (LFT))- Alanine Transaminase (SGPT)03/10/2012 02:56 26 U/L(Liver Function Tests (LFT))- Albumin03/10/2012 02:56 31 g/L [L](Liver Function Tests (LFT))- Alkaline Phosphatase03/10/2012 02:56 109 U/LHaematology(Full Blood Count (FBC))- White Blood Cell03/10/2012 02:56 9.80 x10^9/L(Full Blood Count (FBC))- Red Blood Cell03/10/2012 02:56 5.00 x10^12/L [H](Full Blood Count (FBC))- Haemoglobin03/10/2012 02:56 11.2 g/dL [L](Full Blood Count (FBC))- Haematocrit03/10/2012 02:56 36.5 % [L](Full Blood Count (FBC))- Mean Cell Volume03/10/2012 02:56 73.0 fl [L](Full Blood Count (FBC))- Mean Cell Haemoglobin03/10/2012 02:56 22.4 pg [L](Full Blood Count (FBC))- Mean Cell Haemoglobin Concentration03/10/2012 02:56 30.7 g/dL [L](Full Blood Count (FBC))- Red Cell Distribution Width03/10/2012 02:56 18.0 % [H](Full Blood Count (FBC))- Platelet03/10/2012 02:56 276 x10^9/L(Full Blood Count (FBC))- Percentage Of Neutrophil03/10/2012 02:56 84.4 % [H](Full Blood Count (FBC))- Percentage of Lymphocyte03/10/2012 02:56 9.2 % [L](Full Blood Count (FBC))- Percentage Of Monocyte03/10/2012 02:56 6.3 %(Full Blood Count (FBC))- Percentage Of Eosinophil03/10/2012 02:56 0.0 % [L](Full Blood Count (FBC))- Percentage of Basophil03/10/2012 02:56 0.1 %(Full Blood Count (FBC))- Absolute Neutrophil03/10/2012 02:56 8.27 x10^9/L [H](Full Blood Count (FBC))- Absolute Lymphocyte03/10/2012 02:56 0.90 x10^9/L

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(Full Blood Count (FBC))- Absolute Monocyte03/10/2012 02:56 0.62 x10^9/L(Full Blood Count (FBC))- Absolute Eosinophil03/10/2012 02:56 0.00 x10^9/L(Full Blood Count (FBC))- Absolute Basophil03/10/2012 02:56 0.01 x10^9/L(Full Blood Count (FBC))- Mean Platelet Volume03/10/2012 02:56 10 fL(Urea & Electrolytes)- Urea01/10/2012 22:48 5.6 mmol/L(Urea & Electrolytes)- Sodium01/10/2012 22:48 137 mmol/L(Urea & Electrolytes)- Potassium01/10/2012 22:48 3.50 mmol/L(Urea & Electrolytes)- Chloride01/10/2012 22:48 104.0 mmol/L

The management, progress and follow-up plan

IV Hydrocortisone 100mg TDS IV Augmentin 1.2g TDS Budesonide 2 puffs BD Tab. Acitno 500mg OD

Assessments of other health professionals

Ms Suba was visited by a Pharmacist to teach her on how to use an inhaler.

Information and education provided to patients and their relatives

The patient was educated about the technique of the inhaler and was told about the aero chamber to use with the inhaler but the patient refused to buy it.

Correspondence about the patient

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Lot 82, Jalan Country Home,Sungai Bakau,48000 Rawang,Selangor.

012 – 219 5021

Advance directives or ‘living will’

Ms Suba was not against with any procedures and given her full cooperation.

Contact details about next of kin (model)

Gunalan Ganesan (Husband)012 – 354 7341Working as a technician at Subang

Theoretical discussion

Bronchial asthma

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Asthma is a condition in which your airways narrow and swell and produce

extra mucus. This can make breathing difficult and trigger coughing,

wheezing and shortness of breath.

For some people, asthma is a minor nuisance. For others, it can be a

major problem that interferes with daily activities and may lead to a life-

threatening asthma attack.

Asthma can't be cured, but its symptoms can be controlled. Because

asthma often changes over time, it's important that you work with your

doctor to track your signs and symptoms and adjust treatment as needed.

Symptoms

Asthma symptoms range from minor to severe and vary from person to

person. You may have infrequent asthma attacks, have symptoms only at

certain times — such as when exercising — or have symptoms all the

time.

Asthma signs and symptoms include:

Shortness of breath

Chest tightness or pain

Trouble sleeping caused by shortness of breath, coughing or wheezing

A whistling or wheezing sound when exhaling (wheezing is a common sign

of asthma in children)

Coughing or wheezing attacks that are worsened by a respiratory virus,

such as a cold or the flu

Signs that your asthma is probably worsening include:

Asthma signs and symptoms that are more frequent and bothersome

Increasing difficulty breathing (measurable with a peak flow meter, a

device used to check how well your lungs are working)

The need to use a quick-relief inhaler more often

For some people, asthma symptoms flare up in certain situations:

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Exercise-induced asthma, which may be worse when the air is cold and

dry

Occupational asthma, triggered by workplace irritants such as chemical

fumes, gases or dust

Allergy-induced asthma, triggered by particular allergens, such as pet

dander, cockroaches or pollen

Causes

It isn't clear why some people get asthma and others don't, but it's

probably due to a combination of environmental and genetic (inherited)

factors.

Asthma

trigger

s....................................................................................................................

.....

Exposure to various substances that trigger allergies (allergens) and

irritants can trigger signs and symptoms of asthma. Asthma triggers are

different from person to person and can include:

Airborne allergens, such as pollen, animal dander, mold, cockroaches and

dust mites

Allergic reactions to some foods, such as peanuts or shellfish

Respiratory infections, such as the common cold

Physical activity (exercise-induced asthma)

Cold air

Air pollutants and irritants, such as smoke

Certain medications, including beta blockers, aspirin, ibuprofen (Advil,

Motrin, others) and naproxen (Aleve)

Strong emotions and stress

Sulfites and preservatives added to some types of foods and beverages

Gastroesophageal reflux disease (GERD), a condition in which stomach

acids back up into your throat

Menstrual cycle in some women

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Risk factors

..................................................................................................................

A number of factors are thought to increase your chances of developing

asthma. These include:

Having a blood relative (such as a parent or sibling) with asthma

Having another allergic condition, such as atopic dermatitis or allergic

rhinitis (hay fever)

Being overweight

Being a smoker

Exposure to secondhand smoke

Having a mother who smoked while pregnant

Exposure to exhaust fumes or other types of pollution

Exposure to occupational triggers, such as chemicals used in farming,

hairdressing and manufacturing

Low birth weight

Exposure to allergens, exposure to certain germs or parasites, and having

some types of bacterial or viral infections also may be risk factors.

However, more research is needed to determine what role they may play

in developing asthma.

Complications

Asthma complications include:

Symptoms that interfere with sleep, work or recreational activities

Sick days from work or school during asthma flare-ups

Permanent narrowing of the bronchial tubes (airway remodeling) that

affects how well you can breathe

Emergency room visits and hospitalizations for severe asthma attacks

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Side effects from long-term use of some medications used to stabilize

severe asthma

Proper treatment makes a big difference in preventing both short-term

and long-term complications caused by asthma.

Treatment

Prevention and long-term control are key in stopping asthma attacks

before they start. Treatment usually involves learning to recognize your

triggers and taking steps to avoid them, and tracking your breathing to

make sure your daily asthma medications are keeping symptoms under

control. In case of an asthma flare-up, you may need to use a quick-relief

inhaler, such as albuterol.

Medications

The right medications for you depend on a number of things, including

your age, your symptoms, your asthma triggers and what seems to work

best to keep your asthma under control. Preventive, long-term control

medications reduce the inflammation in your airways that leads to

symptoms. Quick-relief inhalers (bronchodilators) quickly open swollen

airways that are limiting breathing. In some cases, allergy medications are

necessary.

Long-term asthma control medications, generally taken daily, are the

cornerstone of asthma treatment. These medications keep asthma under

control on a day-to-day basis and make it less likely you'll have an asthma

attack. Types of long-term control medications include:

Inhaled corticosteroids. These medications include fluticasone (Flovent

Diskus, Flonase), budesonide (Pulmicort, Rhinocort), mometasone

(Nasonex, Asmanex Twisthaler), ciclesonide (Alvesco, Omnaris),

flunisolide (Aerobid, Aerospan HFA), beclomethasone (Qvar, Qnasl) and

others. You may need to use these medications for several days to weeks

before they reach their maximum benefit. Unlike oral corticosteroids,

these corticosteroid medications have a relatively low risk of side effects

and are generally safe for long-term use.

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Leukotriene modifiers. These oral medications — including montelukast

(Singulair), zafirlukast (Accolate) and zileuton (Zyflo) — help relieve

asthma symptoms for up to 24 hours. In rare cases, these medications

have been linked to psychological reactions, such as agitation, aggression,

hallucinations, depression and suicidal thinking. Seek medical advice right

away for any unusual reaction.

Long-acting beta agonists. These inhaled medications, which include

salmeterol (Serevent) and formoterol (Foradil, Perforomist), open the

airways and reduce inflammation. Some research shows that they may

increase the risk of a severe asthma attack, so take them only in

combination with an inhaled corticosteroid. And because these drugs can

mask asthma deterioration, don't use them for an acute asthma attack.

Combination inhalers. These medications — such as fluticasone-salmeterol

(Advair Diskus), budesonide-formoterol (Symbicort) and mometasone-

formoterol (Dulera) — contain a long-acting beta agonist along with a

corticosteroid. Because these combination inhalers contain long-acting

beta agonists, they may increase your risk of having a severe asthma

attack.

Theophylline. Theophylline (Theo-24, Elixophyllin, others) is a daily pill

that helps keep the airways open (bronchodilator) by relaxing the muscles

around the airways. It's not used as often now as in past years.

Quick-relief (rescue) medications are used as needed for rapid, short-term

symptom relief during an asthma attack — or before exercise if your

doctor recommends it. Types of quick-relief medications include:

Short-acting beta agonists. These inhaled, quick-relief bronchodilators act

within minutes to rapidly ease symptoms during an asthma attack. They

include albuterol (ProAir HFA, Ventolin HFA, others), levalbuterol (Xopenex

HFA) and pirbuterol (Maxair). Short-acting beta agonists can be taken

using a portable, hand-held inhaler or a nebulizer — a machine that

converts asthma medications to a fine mist, so they can be inhaled

through a face mask or a mouthpiece.

Ipratropium (Atrovent). Like other bronchodilators, ipratropium acts

quickly to immediately relax your airways, making it easier to breathe.

Ipratropium is mostly used for emphysema and chronic bronchitis, but it's

sometimes used to treat asthma attacks.

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Oral and intravenous corticosteroids. These medications — which include

prednisone and methylprednisolone — relieve airway inflammation caused

by severe asthma. They can cause serious side effects when used long

term, so they're used only on a short-term basis to treat severe asthma

symptoms.

If you have an asthma flare-up, a quick-relief inhaler can ease your

symptoms right away. But if your long-term control medications are

working properly, you shouldn't need to use your quick-relief inhaler very

often. Keep a record of how many puffs you use each week. If you need to

use your quick-relief inhaler more often than your doctor recommends,

see your doctor. You probably need to adjust your long-term control

medication.

Allergy medications may help if your asthma is triggered or worsened by

allergies. These include:

Allergy shots (immunotherapy). Over time, allergy shots gradually reduce

your immune system reaction to specific allergens. You generally receive

shots once a week for a few months, then once a month for a period of

three to five years.

Omalizumab (Xolair). This medication, given as an injection every two to

four weeks, is specifically for people who have allergies and severe

asthma. It acts by altering the immune system.

Allergy medications. These include oral and nasal spray antihistamines

and decongestants as well as corticosteroid and cromolyn nasal sprays.

Bronchial thermoplasty

This treatment — which isn't widely available nor right for everyone — is

used for severe asthma that doesn't improve with inhaled corticosteroids

or other long-term asthma medications. Generally, over the span of three

outpatient visits, bronchial thermoplasty heats the insides of the airways

in the lungs with an electrode, reducing the smooth muscle inside the

airways. This limits the ability of the airways to tighten, making breathing

easier and possibly reducing asthma attacks.

Treat by severity for better control: A stepwise approach

Your treatment should be flexible and based on changes in your

symptoms, which should be assessed thoroughly each time you see your

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doctor. Then, your doctor can adjust your treatment accordingly. For

example, if your asthma is well controlled, your doctor may prescribe less

medicine. If your asthma isn't well controlled or is getting worse, your

doctor may increase your medication and recommend more-frequent

visits.

Asthma action plan

Work with your doctor to create an asthma action plan that outlines in

writing when to take certain medications, or when to increase or decrease

the dose of your medications based on your symptoms. Also include a list

of your triggers and the steps you need to take to avoid them.

Diagnosis

Physical exam

To rule out other possible conditions — such as a respiratory infection or

chronic obstructive pulmonary disease (COPD) — your doctor will do a

physical exam and ask you questions about your signs and symptoms and

about any other health problems.

Tests to measure lung function

You may also be given lung (pulmonary) function tests to determine how

much air moves in and out as you breathe. These tests may include:

Spirometry. This test estimates the narrowing of your bronchial tubes by

checking how much air you can exhale after a deep breath and how fast

you can breathe out.

Peak flow. A peak flow meter is a simple device that measures how hard

you can breathe out. Lower than usual peak flow readings are a sign your

lungs may not be working as well and that your asthma may be getting

worse. Your doctor will give you instructions on how to track and deal with

low peak flow readings.

Lung function tests often are done before and after taking a

bronchodilator (brong-koh-DIE-lay-tur), such as albuterol, to open your

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airways. If your lung function improves with use of a bronchodilator, it's

likely you have asthma.

Additional tests

Other tests to diagnose asthma include:

Methacholine challenge. Methacholine is a known asthma trigger that,

when inhaled, will cause mild constriction of your airways. If you react to

the methacholine, you likely have asthma. This test may be used even if

your initial lung function test is normal.

Nitric oxide test. This test, though not widely available, measures the

amount of the gas, nitric oxide, that you have in your breath. When your

airways are inflamed — a sign of asthma — you may have higher than

normal nitric oxide levels.

Imaging tests. A chest X-ray and high-resolution computerized

tomography (CT) scan of your lungs and nose cavities (sinuses) can

identify any structural abnormalities or diseases (such as infection) that

can cause or aggravate breathing problems.

Sputum eosinophils. This test looks for certain white blood cells

(eosinophils) in the mixture of saliva and mucus (sputum) you discharge

during coughing. Eosinophils are present when symptoms develop and

become visible when stained with a rose-colored dye (eosin).

Provocative testing for exercise and cold-induced asthma. In these tests,

your doctor measures your airway obstruction before and after you

perform vigorous physical activity or take several breaths of cold air.

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Prevention

Working together, you and your doctor can design a step-by-step plan for

living with your condition and preventing asthma attacks.

Follow your asthma action plan. With your doctor and health care team,

write a detailed plan for taking medications and managing an asthma

attack. Then be sure to follow your plan. Asthma is an ongoing condition

that needs regular monitoring and treatment. Taking control of your

treatment can make you feel more in control of your life in general.

Get immunizations for influenza and pneumonia. Staying current with

immunizations can prevent flu and pneumonia from triggering asthma

flare-ups.

Identify and avoid asthma triggers. A number of outdoor allergens and

irritants — ranging from pollen and mold to cold air and air pollution —

can trigger asthma attacks. Find out what causes or worsens your asthma,

and take steps to avoid those triggers.

Monitor your breathing. You may learn to recognize warning signs of an

impending attack, such as slight coughing, wheezing or shortness of

breath. But because your lung function may decrease before you notice

any signs or symptoms, regularly measure and record your peak airflow

with a home peak flow meter.

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Identify and treat attacks early. If you act quickly, you're less likely to

have a severe attack. You also won't need as much medication to control

your symptoms. When your peak flow measurements decrease and alert

you to an oncoming attack, take your medication as instructed and

immediately stop any activity that may have triggered the attack. If your

symptoms don't improve, get medical help as directed in your action plan.

Take your medication as prescribed. Just because your asthma seems to

be improving, don't change anything without first talking to your doctor.

It's a good idea to bring your medications with you to each doctor visit, so

your doctor can double-check that you're using your medications correctly

and taking the right dose.

Pay attention to increasing quick-relief inhaler use. If you find yourself

relying on your quick-relief inhaler, such as albuterol, your asthma isn't

under control. See your doctor about adjusting your treatment.

Pericarditis

Pericarditis is a condition in which the sac-like covering around the heart

(pericardium) becomes inflamed.

Causes, incidence, and risk factors

The cause of pericarditis is often unknown or unproven, but is often the

result of an infection such as:

Viral infections that cause a chest cold or pneumonia, such as the echovirus or coxsackie virus (which are common in children), as well as influenza

Infections with bacteria (much less common) Some fungal infections (even more rare)

In addition, pericarditis may be seen with diseases such as:

Cancer (including leukemia) Disorders in which the immune system attacks healthy body tissue

by mistake HIV infection and AIDS Underactive thyroid gland Kidney failure Rheumatic fever

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Tuberculosis(TB)

Other causes include:

Heart attack Heart surgery or trauma to the chest, esophagus, or heart Certain medications, such as procainamide, hydralazine, phenytoin,

isoniazid, and some drugs used to treat cancer or suppress the immune system

Swelling or inflammation of the heart muscle Radiation therapy to the chest

Often the cause of pericarditis is unknown. Pericarditis most often affects

men ages 20 - 50.

Symptoms

Chest pain is almost always present. The pain:

May be felt in the neck, shoulder, back, or abdomen Often increases with deep breathing and lying flat, and may

increase with coughing and swallowing Can be a sharp, stabbing pain Is often relieved by sitting up and leaning or bending forward

You may have fever, chills, or sweating if the condition is caused by an

infection.

Other symptoms include:

Ankle, feet, and leg swelling (occasionally) Anxiety Breathing difficulty when lying down Dry cough Fatigue

Signs and tests

When listening to the heart with a stethoscope, the health care provider

can hear a sound called a pericardial rub. The heart sounds may be

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muffled or distant. There may be other signs of fluid in the pericardium

(pericardial effusion).

If the disorder is severe, there may be:

Crackles in the lungs Decreased breath sounds Other signs of fluid in the space around the lungs (pleural effusion)

The following imaging tests may be done to check the heart and the

tissue layer around it (pericardium):

Chest MRI scan Chest x-ray Echocardiogram Electrocardiogram Heart MRI or heart CT scan Radionuclide scanning

To look for heart muscle damage, the health care provider may order a

troponin I test. Other laboratory tests may include:

Antinuclear antibody (ANA) Blood culture CBC C-reactive protein Erythrocyte sedimentation rate (ESR) HIV test Rheumatoid factor Tuberculin skin test

Treatment

The cause of pericarditis must be identified, if possible.

High doses of nonsteroidal anti-inflammatory drugs (NSAIDs) such as

ibuprofen are often given. These medicines will decrease your pain and

reduce the swelling or inflammation in the sac around your heart.

A medicine called colchicine may be added, especially if pericarditis does

not go away after 1 to 2 weeks or it comes back weeks or months later.

If the cause of pericarditis is an infection:

Antibiotics will be used for bacterial infections

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Antifungal medications will be used for fungal pericarditis

Other medicines that may be used are:

Corticosteroids such as prednisone (in some patients) "Water pills" (diuretics) to remove excess fluid

If the buildup of fluid makes the heart function poorly, treatment may

include:

Draining the fluid from the sac. This procedure, called pericardiocentesis, may be done using an echocardiography-guided needle.

Cutting a small hole (window) in the pericardium (subxiphoid pericardiotomy) to allow the infected fluid to drain into the abdominal cavity

If the pericarditis is chronic, recurrent, or causes scarring or tightening of

the tissue around the heart, cutting or removing part of the pericardium

may be needed. This surgery is called a pericardiectomy.

Expectations (prognosis)

Pericarditis can range from mild cases that get better on their own to life-

threatening cases. The condition can be complicated by fluid buildup

around the heart and poor heart function.

The outcome is good if the disorder is treated right away. Most people

recover in 2 weeks to 3 months. However, pericarditis may come back.

This is called recurrent, or chronic if symptoms or episodes continue.

Scarring and thickening of the sac-like covering and the heart muscle may

occur in severe cases. This is called constrictive pericarditis, and it can

cause long-term problems similar to those of heart failure.

Calling your health care provider

Call your health care provider if you have symptoms of pericarditis. This

disorder is usually not life threatening, but it can be if not treated.

Prevention

Many cases are not preventable.

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Acute Bronchitis

Acute bronchitis is swelling and inflammation of the main air passages to

the lungs. This swelling narrows the airways, making it harder to breathe

and causing other symptoms, such as a cough. Acute means the

symptoms have only been present for a short time.

Causes, incidence, and risk factors

Acute bronchitis almost always follows a cold or flu-like infection. The

infection is caused by a virus. At first, it affects your nose, sinuses, and

throat. Then it spreads to the airways leading to your lungs.

Sometimes, bacteria also infect the airways. This is called a secondary

infection.

Chronic bronchitis is a long-term condition. To be diagnosed with chronic

bronchitis, you must have a cough with mucus most days of the month for

at least 3 months.

Symptoms

The symptoms of acute bronchitis may include:

Chest discomfort Cough that produces mucus; it may be clear or yellow-green Fatigue Fever -- usually low-grade Shortness of breath that gets worse with activity

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Wheezing, in people with asthma

Even after acute bronchitis has cleared, you may have a dry, nagging

cough that lingers for 1 to 4 weeks.

At times, it may be hard to know whether you have pneumonia or only

bronchitis. If you have pneumonia, you are more likely to have a high

fever and chills, feel sicker, or feel short of breath.

Signs and tests

The health care provider will listen to your lungs with a stethoscope.

Abnormal, coarse breathing sounds may be heard.

Tests may include:

Chest x-ray, if the health care provider suspects pneumonia Pulse oximetry to help determine the amount of oxygen in your

blood by using a device placed on the end of your finger

Treatment

Most people DO NOT need antibiotics for acute bronchitis. The infection

will almost always go away on its own within 1 week. Take the following

steps to get relief:

Drink plenty of fluids. If you have asthma or another chronic lung condition, use your

inhaler (such as albuterol). Rest. Take aspirin or acetaminophen (Tylenol) if you have a fever. DO

NOT give aspirin to children Use a humidifier or steam in the bathroom.

Certain medicines that you can buy without a prescription can help break

up or loosen mucus. Look for the word "guafenesin" on the label.

If your symptoms do not improve, your doctor may prescribe an inhaler to

open your airways if you are wheezing.

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Sometimes, bacteria may also infect the airways along with the virus. If

your doctor thinks this has happened, you may be prescribed antibiotics.

Other tips include:

DO NOT smoke. Avoid secondhand smoke and air pollution. Wash your hands (and your children's hands) often to avoid

spreading viruses and other infections.

Expectations (prognosis)

Symptoms usually go away in 7 to 10 days if you do not have a lung

disorder. However, a dry, hacking cough can linger for a number of

months.

Calling your health care provider

Call your doctor if:

You have a cough on most days, or you have a cough that often returns

You are coughing up blood You have a high fever or shaking chills You have a low-grade fever for 3 or more days You have thick, greenish mucus, especially if it has a bad smell You feel short of breath or have chest pain You have a chronic illness, like heart or lung disease

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Acute Pneumonia

Pneumonia is a condition affecting the lungs and in this infection inflammation of lung tissue occurs. Acute pneumonia may be caused by the pneumococcus bacteria and these may be found within the bronchial secretions of the lung that is affected. Pneumonia most frequently affects the lower lobes or the base in the lungs and in many cases the right lung is affected by this condition.

This condition may affect a single or both the lungs in individuals. The basic symptoms associated with pneumonia include fever, disturbed respiration, chest pain and cough. Sputum in pneumonia may be brownish, yellowish or greenish in color. Physical examination of this condition can help physicians diagnose cases of acute pneumonia.

In acute pneumonia certain complications may be observed and these include pleurisy. In this the two pleura layers covering the lung and inner wall of chest are affected by accumulation of fluid in the space within these two layers. This complication is also referred to as pleuritis and causes sharp chest pain along with chest tenderness, shortness of breath and cough.

Another complication in acute pneumonia includes pericarditis which refers to inflammation of the tissue layers that surround the heart. Endocarditis may also be one of the possible complications and it causes inflammation of the heart’s inner lining and the valves. These complications can occur due to septic poisoning. One of the most serious complications in this condition includes meningitis and this causes a large number of fatalities.

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