Internal médecine pathology kk ASTHMA.pptx

Inetral

1. Asthma in pregnancy Nader Ahmed M.D candidate

2. A 23-year-old African American G3P2002 at 220/7 weeks by LMP consistent with a first-trimester ultrasound presents as a new patient because she has recently moved to the area. Her medical history is significant for asthma since the age of 7. Her asthma has always been well controlled rarely requiring the use of her albuterol inhaler. One month before conception, however, she had “several” mild exacerbation relieved easily with the use of her inhaler. Last month she had four asthma exacerbations which required a visit to the emergency room for nebulizer treatment.

3. Last month she had four asthma exacerbations which required a visit to the emergency room for nebulizer treatment. It was recommended that she start a “new inhaler” but she did not fill the prescription prior to relocating. She is currently using her albuterol inhaler daily for symptoms and has exacerbations 2 to 3 times per week . She also reports chest tightness, wheezing, and waking up 1 to 2 times per week at night . In addition, she has congestion with yellow nasal discharge and sinus tenderness f or 1 month not relieved with over-the-counter decongestants.

4. She denies allergies, fever, or sick contacts. She denies prior intubations, use of steroids, and has never measured a baseline peak flow. Her obstetrical history is significant for two prior vaginal deliveries without asthma complications. With her last delivery she had postpartum hemorrhage requiring blood transfusion due to a “floppy” immediately after delivery. She is otherwise healthy and denies other medical problems. Prenatal labs are unremarkable.

5. Personal history: 23 years old African American, she has been [married/ for …8 years/), she is ( gravida …3..para 2 with2…. living offsprings 1….males and …1..females and the youngest is 3 …..years old. She is (housewife and she, has no special habits of medical importance no smoking

6. Complain She is pregnant in her 5 month & coming for antenatal care as she is known to have asthma  

7. Past history: - Past history of asthma since the age of 7. -no Past history of surgical operation( General & gynecological ) - no Past history of  Trauma , radiotherapy   -. Contraception. Iuds used for 2 years with no complication - histry of blood transfusion after vaginal delivary for post partum hge . - Immunisation patient has not been immunised against influenza and pneumococcus

8. Medication  no Drug allergy _ Antibiotics. antibiotics that may be needed for the treatment of infective exacerbations , no hormonal therapy   _ Inhalers. the patient Is already being prescribed albuterol NO aspirin and other NSAIDs Steroids. She denies use of steroids No history of Alcohol, smoking and recreational drugs

9. MENSTRUAL HISTORY Menarche 13YEARS OLD The patient used to have regular menses for 5 days cycling every 30 days average in amount (2 padsl day) with spasmodic dysmenorrhea. No inter-menstrual pain,bleeding , discharge The first day of the last menstrual period (LMP) was on 7/2/2020.  

10. Obstetric history: G3P2002 . Her (1 st ) pregnancy was (6Y ago)with (no remarkable antenatal events). It was terminated (at full-term by (VD with no complications/ 2nd in hospital . The outcome is (living [male and puerperium was (free /complicated by [puerperal sepsis /PPH] and the baby is (breast fed for 2y with NO breast complications.

11. Her (2nd) pregnancy was (3Y ago)with (no remarkable antenatal events). It was terminated (at full-term by (VD with no complications in hospital . The outcome is (living [FEMALE and puerperium was complicated by PPH] and the baby is (breast fed for 2y with NO breast complications Her last labour was 3 y ago while her last abortion was … y ago. And (her blood group is.O / She is Rh POSITIVE

12. Family history -no Family history of  D.M , hypertension no family history of asthma and other atopic conditions no Malignancy e.g. breast cancer , twins. - no Consanguinity or hereditary diseases

13. HISTORY OF PRESENT ILLNESS The patient is known to suffer from asthma since the age of 7 years First the patient noticed missed period so she made a pregnancy test in urine and it was + ve (She passed through a normal 1st trimester apart from mild nausea, vomiting ….which disappeared spontaneously by the end of 1st trimester She perceived fetal movements for the first time at 16 w

14. one month ago The patient had 4 attacks of wheeze, shortness of breath, chest tightness and cough. asthma are often worse at night ,the inability to talk in full sentences and severe breathlessness which required a visit to the emergency room for nebulizer treatment. It was recommended that she start a “new inhaler” but she did not fill the prescription prior to relocating. She is currently using her albuterol inhaler daily for symptoms and has exacerbations 2 to 3 times per week . She also reports chest tightness, wheezing, and waking up 1 to 2 times per week at night . In addition, she has congestion with yellow nasal discharge and sinus tenderness f or 1 month not relieved with over-the-counter decongestants She has not been on regular follow-up to monitor response to treatment

15. Examination General examination - General appearance (conscious , weight 80kg , height 160 cm gait ) - Vital signs (pulse 80 beate / min , bl. Pressure 120/70 mm /hg, temp. 37 , respiratory rate 17 ) - Complexion . (no pallor , jaundice , cynosis ) - Head & Neck . examination . sinus tenderness bilaterally , erythematous nasal mucosa bilaterally, purulent nasal discharge No L.N (submandibular, preauricular,postauricular and occipital L.Ns) tenderness bilaterally, erythematous nasal mucosa bilaterally, purulent nasal discharge tenderness bilaterally, erythematous nasal mucosa bilaterally, purulent nasal discharge

16. - Chest examination. 1-Thoracic cage 2- - _ Lungs. No wheeze, although this will not always be present, as the clinical signs of asthma can be variable. In very severe asthma or emphysema, there may be no wheeze and air entry will be reduced (‘silent chest’). Basal crackles suggest heart failure, whereas focal crackles may indicate chest infection. _ 3-Heart. Check for any signs of heart failure, such as cardiomegaly or a fourth heart sound tenderness bilaterally, erythematous nasal mucosa bilaterally, purulent nasal discharge tenderness bilaterally, erythematous nasal mucosa bilaterally, purulent nasal discharge

17.   6-Breast examination a-Signs of pregnancy : Enlargement , fullness , increase vascularity , pigmentation of the primary aerola & montogomery sign 7-Back examination   8-Upper & lower limbs   2- Abdominal examination: Inspection of the abdomen: (size, contour, scars, hernia)---- Palpation of the abdomen: (superficial ---for tenderness &rigidity) ( deep ----to examine the abd . Organs in clockwise manner ) Palpation of liver, spleen, kidneys----normally not feltfudal level below umbilicus Auscultation of featal heart sound    

18. Diagnosis 23 years old, G3P2002 at 22 weeks, not in labor. asthmatic

19. ➤ What is your next step? ➤ How would you classify this patient’s asthma? ➤ What are the potential maternal complications associated with asthma in pregnancy? ➤ What are the potential fetal complications.

20. Summary : This is a 23-year-old woman G3P2002 at 220/7 weeks gestation with a history of asthma that has worsened during this pregnancy. ➤ Next step: Evaluate patient with peak expiratory flow rate (PEFR). ➤ Classify this patient’s asthma: This patient has moderate persistent asthma because she has daily symptoms with exacerbations > 2 times/ wk and nocturnal symptoms > 1 time/wk. Patients with moderate persistent asthma also have pulmonary function test 60% to 80% of predicted and may experience some interference with normal activities.

21. Potential maternal complications associated with asthma in pregnancy: Patients with moderate or severe asthma may have increased number of exacerbations, hospitalizations, and unscheduled visits. The risk of cesarean delivery may also be increased in these women. Women with severe asthma may have an increased risk of preeclampsia and gestational diabetes mellitus (GDM). Women with mild or well-controlled asthma tend do well in pregnancy with outcomes similar to nonasthmatics . Although rare, potential life-threatening complications of untreated severe asthma include pneumothorax, pneumomediastinum, acute cor pulmonale, and respiratory arrest.

22. ➤ Potential fetal complications: Preterm birth (< 37 wk ) and small- forgestational - age infants (SGA) may complicate pregnancies in those with severe asthma or those who require the use of oral corticosteroids .