Bedside Teaching

Prepared by mel,
Y3B5

Table of Content
Long Case
CASE 1: AEBA
1.0 Chief Complaint (c/o)
2.0 History of Presenting Illness (HoPI)
3.0 Systemic Review (SysR)
4.0 Past History (PHx)
5.0 Family History (FHx)
6.0 Social History (SHx)
7.0 Summary of History
8.0 Physical Examination (RS)
8.1 Anterior Chest
8.2 Posterior Chest
9.0 Provisional Diagnosis (PDx)
10.0 Differential Diagnosis (DDx)
11.0 Complication of PDx
12.0 Investigations
13.0 Managements
14.0 Prognosis
15.0 References

L ong Case

CASE 1: AEBA
Patient Background
Name: Mudzilah Marina bt Mohamed
Age: 49
Gender: Female
Race: Malay
Occupation: None
Ward: 25
Bed number: Z4
R/N: 19835
Date of admission: 9/10/2024 morning

1.0 Chief Complaint (c/o)

Asthma

2.0 History of Presenting Illness (HoPI)

SOCRATES
Site: Pain at shoulder blade and chest
Onset: DAY, DATE, TIME
Character: Chest tightness
Radiation: None
Associated symptoms: Shortness of breath (SOB), productive cough
(green), palpitation
Time: Pain lasted for 30 minutes
Exacerbation factors: Worsen with heavy activies and lying down
Relieving factors: When sitting down
Severity: PAIN SCALE

Productive Cough
● Green sputum
● Started from 14/10/2024, Monday

SOB
● Unable to sleep at night
● Need 3 pillows in bed
3.0 Systemic Review (SysR)
Cardiovascular System
● Palpitation

Respiratory System
● Orthopnea

4.0 Past History (PHx)

Past illness
1. Asthma
● Since 6 years old

Previous admission to hospital

● Reason for admission is presence of bacteria in lungs
● Date of admission is 1981
● Length of stay is …
● No surgery that was done

5.0 Family History (FHx)

Father
● Died in 2010
● Deceased due to …

Mother
● Still alive
● History of asthma, hypertension (HTN), and diabetes mellitus (DM)
Grandmother from mother’s side
● Still alive
● History of asthma, hypertension (HTN), hyperlipidemia (HLD), and
gout

6.0 Social History (SHx)

Living area
● There are 3 people in house including patient
○ Mother
○ Aunty
● Live at Sibu Jaya

Job
● Unemployed but helps in aunty’s Nasi Lemak business
● Routine during work is sitting while selling Nasi Lemak
● Previous job …

Hobby
● Exercise …

Habit
● No smoking
● No alcohol
 ● But have exposure to smoke in house by family members

Travelling
● Complete vaccine
● Does not travel anywhere

Medication
● Prescribed by doctor
○ Blue inhaler - Salbutamol
○ Purple inhaler - Fluticasone propionate and Salmeterol

7.0 Summary of History

Differential diagnosis
● Bronchial asthma

System that is most likely to be involved

● Respiratory system

8.0 Physical Examination (RS)

❖ PATIENT IS SITTING AT 45 DEGREE ANGLE
❖ Expose patient’s CHEST AND LOWER LIMBS
❖ Ask if there’s any PAIN

8.1 Anterior Chest

Inspection
(A) End of the bed
 (a) Respiratory rate (normal: 12-20/min) - 19/min

(b) Breathing
(i) Shortness of breath (SOB) - None
(ii) Cough - Present
(iii) Wheeze - None
(iv) Stridor - None

(c) Disability - None

(d) Alertness - Conscious, comfortable

(e) Built - Normal

(f) Color
(i) Cyanosis - None
(ii) Pallor - None

(g) Drugs - None

(h) Equipment - IV drip

(B) Hands
(a) Color - Mild pallor

(b) Tar staining - None

(c) Muscle wasting - None

(d) Joint swelling - None

 (e) Capillary refill time (CRT) - Normal

(f) Tremor
(i) Fine - Present
(ii) Flapping - None

(g) Finger clubbing - None

(h) Temperature - Normal

(C) Arms
(a) Radial pulse (normal: 60-100/min)
(i) Rate
(ii) Rhythm

(b) Muscle wasting - None

(D) Face
(a) Plethoric congestion - None

(b) Eye
(i) Conjunctival pallor - Present
(ii) Ptosis, Miosis, Anhydrosis - None
 (c) Mouth
(i) Central cyanosis - None
(ii) Oral candidiasis - None

(E) Neck
(a) Jugular venous pressure (JVP) -> located medial end of clavicle
to ear lobe - Not raised

(b) Tracheal position - No deviation

(i) Deviates away from tension pneumothorax & large
pleural effusion
(ii) Deviates towards lobar collapse and pneumonectomy

(c) Cricosternal distance (normal: 3-4 fingers) - Normal

(F) Chest
(a) Scars - None
(i) Median sternotomy scar
(ii) Axillary thoracotomy scar
(iii) Posterolateral thoracotomy scar
(iv) Infraclavicular scar

(b) Chest wall deformity - None

(i) Asymmetry
(ii) Pectus excavatum
(iii) Pectus carinatum
(iv) Hyperexpansion
 (G) Lower limbs
(a) Pedal edema - None

(b) Muscle wasting - None

(c) Color - None

(d) Clubbing - None

Palpation
(A) Apex beat (normal: 5th ICS in midclavicular line) - Normal

(B) Tactile vocal fremitus (pt says ninety-nine)

(a) Increased vibration - None
(b) Decreased vibration - At left superior, middle, and lower lobes

(C) Lymph node - None

 (a) Submental
(b) Submandibular
(c) Pre-auricular
(d) Post-auricular
(e) Superficial cervical
(f) Deep cervical
(g) Posterior cervical
(h) Supraclavicular (Virchow’s node)

(D) Chest expansion (normal: more than 5cm) - Normal

(a) Reduced + Symmetrical)
(b) Reduced + Asymmetrical)

Percussion of Chest
There are 4 types of percussion notes, which are:
1. Resonant
2. Dullness
3. Stony dullness
4. Hyper-resonance

(A) Supraclavicular region

(B) Infraclavicular region
(C) Chest wall - Hyper-resonance
(D) Axilla

Auscultation of Chest
❖ Pt needs to BREATH IN & OUT
 (A) Quality of breath sound
(a) Vesicular
(b) Bronchial

(B) Volume of breath sound

(a) Normal
(b) Reduced

(C) Added sound

(a) Wheeze
(b) Stridor
(c) Coarse crackles
(d) Fine crackles

8.2 Posterior Chest

Inspection
(A) Spinal deformity - None
(B) Scar - None

Palpation
(A) Tactile vocal fremitus
(a) Decreased vibration - At left superior, middle, and lower lobes

Percussion
● Hyper-resonance at upper lobes
Auscultation
(A) Quality of breath sound
(a) Vesicular
(b) Bronchial
(B) Volume of breath sound
(a) Normal
(b) Reduced
(C) Added sound
(a) Wheeze
(b) Stridor
(c) Coarse crackles
(d) Fine crackles

Edema
(A) Sacral edema - None

Summary of Physical Examination

Patient is coughing during the examination. Hands reveal fine tremor and
pallor. Eyes reveal pallor. Chest examination revealed a centrally located
trachea with normal cricosternal distance. Tactile vocal fremitus reveals
decreased vibrations at left lung. Hyper-resonant chest percussion is
present with reduced breath sounds and expiratory wheezing. These
clinical findings support the diagnosis of bronchial asthma.

9.0 Provisional Diagnosis (PDx)

Acute exacerbation of bronchial asthma
DEFINITION Worsening episodes of asthma and reduced in lung function.

CAUSES 1. Viral infection (MC) -> Rhinovirus subtype A and C

2. Bacterial infection
3. Allergen exposure
4. Others
a. Tobaco smoke
b. Nitrogen dioxide
c. Sulfur dioxide
d. Diesel

RHINOVIRUS ● MC cause for common cold & asthma triggers

● Most cause asymptomatic or mild symptoms
● Rise in fall and spring

S&S -> mild

1. Nasal congestion
2. Fever
3. Mild body ache
4. Cough
5. Sneezing
6. Sore throat
7. Headache

S&S -> severe

1. Asthma
2. Bronchiolitis
3. Bronchitis
4. Pneumonia
5. Sinus infection
6. Middle ear infection

Justifications
1. Breathlessness
2. Coughing
3. Wheezing
4. Chest tightness
5. Increased respiratory rate
6. Increased pulse rate
7. Decreased lung function
a. forced expiratory volume
b. peak respiratory flow
c. partial pressure of oxygen
d. partial pressure of carbon dioxide
e. arterial oxygen saturation
10.0 Differential Diagnosis (DDx)
1. COPD
a. Productive cough
b. Dyspnea on exertion
c. Exposure to smoking

2. Bronchiectasis
a. Productive cough
b. Recurrent infections

3. Pulmonary embolism
a. Sudden onset of dyspnea
b. Chest pain

4. Pneumonia
a. Productive cough
b. Shortness of breath
c. Chest pain
d. Fatigue

5. Gastroesophageal reflux disease (GERD)

a. Productive cough
b. Chest pain
c. Shortness of breath

11.0 Complication of PDx

1. Exhaustion
a. Decreased oxygen level
 b. Extra energy for breathing to compensate the decreased
oxygen level
c. Disrupted sleep
d. Immune system fights off the exposure

2. Airway infection
a. Weakened immune system

3. Tussive syncope - blackout after violent series of cough

a. Decreased cardiac output
b. Decreased cerebral blood flow

4. Pneumothorax - collection of air outside the lung but within the

pleural cavity
a. Bronchospasm
b. Hyperinflation
c. Causing rupture to the thin-walled air sacs in lung tissues

5. Acute hypercapnic - high level of CO2 in blood

a. Alveolar hypoventilation -> poor gas-exchange
b. Muscle fatigue

6. Hypoxemic respiratory failure - low level of O2 in blood

a. Bronchospasm
b. High O2 demand
c. Alveolar hypoventilation -> poor gas-exchange
 12.0 Investigations

1. Lung function test

a. Spirometry - more reliable
i. Measures the amount of air you can breathe out in one
second and the total volume of air you can exhale in one
forced breath.
b. Peak expiratory flow (PEF) - maximum rate at which a person
can exhale air after a full breath in
i. FEV1 < 60% shows acute exacerbation

Peak Expiratory Flow (PEF) Maximum airflow speed during expiration

Forced Vital Capacity (FVC) Maximum amount of air during expiration

after maximum inspiration

Forced Expiratory Volume (FEV1) Volume of air during expiration in 1s

2. Bronchial provocation test

a. Assess airway hyper-responsiveness through multiple
challenges that induce histamine, methacholine, or mannitol,
and exercise
b. All of them will cause vasoconstriction and vasodilation
c. Negative test for pt that is not taking ICS
 d. Positive test in does not truly indicate asthma, need to confirm
with other clinical features

3. Allergy test
a. Presence of atopy can be identified by skin prick test or
measurement of specific IgE serum
b. Skin prick test is rapid and inexpensive
c. Specific IgE serum is more expensive but good for
uncooperative patient
d. Positive results in both tests does not indicate the atopy is
causing the symptoms

13.0 Managements
1. Pharmacological intervention
a. Controller medication
i. Reduce airway inflammation, control symptoms, and
decrease risk of exacerbations and lung function
ii. Use low-dose ICS-formoterol
iii. Daily or twice-daily
b. Reliever medication
i. Relieve worsen asthma or exacerbations
ii. Use low-dose ICS-formoterol and ICS-SABA, and SABA
 c. Vitamin D
i. Low serum of vitamin D is associated with impaired lung
functions, higher exacerbation risks, and reduced
corticosteroid function
ii. But more studies are needed to confirm this

2. Non-pharmacological intervention
a. Cessation exposure to smoke
b. Avoidance of environmental exposure to allergens
c. Breathing exercise
i. Buteyko method
1. Aims to correct hyperventilation by encouraging
slower, shallower breathing
ii. Papworth method
1. A series of diaphragmatic breathing and relaxation
exercises
14.0 Prognosis
If preventative measures are taken and the inhaled medication is
administered correctly, the vast majority of patients with chronic diseases
have good control over their condition. The proportion of people with
asthma who are not responsive to standard treatment is quite low.

15.0 References
1. https://bestpractice.bmj.com/topics/en-us/45
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5950727/
3. https://www.uptodate.com/contents/acute-exacerbations-of-asthma-
in-adults-home-and-office-management#:~:text=Acute%20asthma%20
exacerbations%20are%20episodes,other%20irritant%20exposure%2C
%20lack%20of
4. https://www.cdc.gov/rhinoviruses/about/index.html#:~:text=Most%20r
hinovirus%20infections%20are%20mild,the%20risk%20of%20their%20s
pread
5. https://www.aafp.org/pubs/afp/issues/2011/0701/p40.html
6. https://www.medicalnewstoday.com/articles/asthma-exacerbation#s
ummary
7. https://www.atsdr.cdc.gov/csem/asthma/differential_diagnosis_of_ast
hma.html