An Early Arrival

Rohani, 30, 2 past pregnancies in the past, currently 3rd pregnancy

Occupation=work in paddy field, strenous, under hot sun.

Cone biopsy in the past because of cervical carcinoma in situ. Increased frequency, T=38C

Urinalysis=positive for blood and UTI.

Membrane intact, 2cm dilated. 30th week of pregnancy.

Ddx=Pre-term labour, UTI?

Diagnosis=Pre-term labour.

Causes of preterm labour?
=multiple pregnancies, infection, drugs, stress, low SES(malnutrition etc), cone biopsy.




Definition, Causes, Epid :Kaarthik

Signs and Symptoms : Pik Yin

Normal physiology of labour : Huey Ting, Jun Beng


Causes of pre-term labour :Fuad



Management of pre-term labour, pre-term neonatal care(APGAR Score, normal scores for heart rate, Oxygen saturation, RR, Pa02) : Kee Hao, Mona

Prognosis of baby delivered 30/40
complications of baby(10 weeks early:respiratory, cranial haemorrhage, T regulation and mother
Breastfeeding complications, Respiratory Distress Syndrome : Prish, Shakir, Ewe Jin


Psychosocial and cultural issues
involving mother and preterm baby, family support : Rui Wan

PCL 10 - Waterworks

Symptoms:
Nocturia
Urgency
Dribbling

Diff Dx:
Benign Prostatic Hyperplasia (most likely la ha.)
Prostate Cancer
Bladder Cancer

Learning Issues:
Definition for BPH, Prevalence, Incidence, Types (How common are these symptoms in the population) -Mona

Signs and Symptoms (IPSS - Internation prostate symptom score) - Prish

Anatomy of the Prostate, Pathophysio (What is BPH compared to prostate cancer?) - Fuad, Huey Ting

Causes - Ewe jin

Diagnosis and investigation (What are you likely to find through DRE?; Diagnostic accruacy of DRE ; Characteristics that indicate BPH or malignancy; What happens if the test is positive, negative, or inconclusive? ; investigation for BPH and prostate cancer; reliability of available tests; PSA; Biopsy complications) - Alex, Karthik, Jun Beng

Management (consider risk and benefits.) - Pik Yin

Prognosis and complications - Shakir

Psychosocial and cultural issues (Why was Marzuki embarrassed to admit his problem?) - Kee Hao

Waterworks

Been trying to have baby for 2 years but fail.

Night manager at tesco and primary school teacher, not stress
examination done before, breast examination, uterus, sperm, no ED or premature ejaculation ( 15ml of testicles-normal size and texture )

37 years old (W)
40 years old (H)
sex 2-3 times a week
Takes folic acid (W)
BMI 23
uterus ovaries not enlarges
pap smear not done for 3 years

smoke 15-20 ciggs/day, half a bottle of wine/day (W) (H)

Diet - good, healthy (W) (H)
Renal system - ok (H)
Menstrual hx - not heavy, regular, not painful, menarche 14 yrs old, frequency? features? STD?

Married in past for 10 years and failed to get children and ex-wife have 2 children (H)

on OCP sometime ago but stop 2 years ago, also had pregnancy 10 years ago with former husband but termination at 10 weeks (suction)(W)

catholic (W) think being punished for her past.

Differentials: Infertility

Tasks:

Definition for infertility(primarysecondary,)fecundability, Prevalance, Incidence - Shaq

Normal ovarian cycle and what happens when pregnancy occurs - Kaarthik

Key factors on history and examination - Alex

Causes for male and female - Jun Beng & Huey Ting

Diagnosis and investigation for male and female - Fuad & Mona

Management and cost where applicable - Kee Hao

Prognosis and complications - Piggy

Psychosocial and cultural issues - Prish & Ewe Jin

PCL 8: IT'S A BOY....NOT!!!

DDx:
1. Congenital Adrenal Hyperplasia (CAH)

Learning issues
1. definitions, incidence, prevalence (Why might there have been some doubt at the assignation of Kamal sex at the time of birth?) - Prish
2.signs and symptoms (Why might Kamal be losing salt?, What other things might go wrong other than losing sodium?) -Huey Ting
3. pathophysiology (If Kamal has been exposed to excess androgen in fetal life and has a deficiency in the production of mineralocorticoids, how could have these come about?, Why is a genitalia ambiguous? What causes this?, What do you think Kamal's internal reproductive organs may have been like?, Why both of glucocorticoid and mineralocorticoid are necessary?) -Alex, Kee Hao

5. commonest causes and provoking factors - Karthik

7. investigations, genetics (Can prenatal diagnosis be achieved?) - Shakir
8. treatment, management and prevention -Mona
9. Psychosocial randoms (What are the parental issues? What sources of information they could identify with?Comment on the quality of those sources of information, What are the arguments for and against raising Kamal as a girl?, What do you think of the decision to raise the baby as a girl or boy?)- JB
What were the specific instructions that Lisa and Omar receive regarding the medications for Nabila(Kamal as a girl) when she became sick and what was the rational behind that advice?, Doctor-patient interaction regarding this condition,
If the parents present to Dr. Yasmin with a large quantity of information, how should the doctor respond and how should the parents act upon it?,- FUAD
How would you as a doctor to help the parents make this difficult decision? What sort of question would you put to them and how would you help work through it? Would or should you give advice or recommendation?, - TJ KOH
What sort of impact might be raised on Nabila on her mental health and social functioning? What ethical issues can you identify regarding Nabila's decision to have a surgery? - py
-Ewe Jin, Fuad, Pik Yin, JB


www.rch.org/cah_book

The Wedding

Differentials:

1. Hyperthyroidism
2. HIV
3. Infections: Parasitic ( no fever, acute onset)

Learning Issues:

1. definitions, incidence, prevalence (fuad)
2.signs and symptoms(shakir)
3. pathophysiology(pik yin)
4. what is thyroid and its function(jun beng)
5. commonest causes and provoking factors(huey ting)
6. what distinguishes grave's and other forms of hyperthyroidism(ewe jin)
7. investigations and why (alex, prish)
8. management , esp grave's disease (mona, kaarthik)
9. psychological stress affects immune function such as grave's (keehao)

Websites:
www.mja.com.au/public/issues/180_04_160204/top10414_fm.html

www.betterhealth.vic.gov.au/bhcv2/bhcpdf.nsf/ByPDF/Thyroid_disorders_hyperthyroidism/$File/Thyroid_disorders_hyperthyroidism.pdf#search='hyperthyroidism'

www.acadmed.org.my/cpg/thyroid_consensus2000



3.

Cushing Syndrome Week 6

Siti 43
Have hypertension
Depressed
Growing moustache (Hirsutism)
Took steroids, immunosuppresants?

Round plethoric face
oily skin with acne
abdominal obesity with striae
new bruises
infected tear in the skin
Hirsutism

Differential
Cushing syndrome
PCOS
Hypothyroidism
Metabolic syndrome

Learning issues for CUSHING SYNDROME

Definition, Prevalance Incidence, Differential diagnosis - Alex

Pathophysiology - 4 different thyroid hormones testosterone oestrogen glucocorticoids. names, site of production and site of release, main target organs and means of transport and feedback loop. Rship between blood pressure and cushing syndrome - Pik Yin and Kee Hao and Fuad

Causes and Risk Factors - Mona

Sign and Symptoms : explain S&S why facial hair oily skin how bruising happens, striae, potential for easy tear, reasons of weight gain - Jun Beng


Examination and Investigation - 24 hour urinary free cortisol - Kaarthik

Treatment and Management - (lifestyle, medical, firstline, CAM, surgical), ACTH and adrenal, dexamethasone, microsurgical and why headache after surgery, why HRT necessary after surgery and complications of surgery - Shakir and Huey Ting

Complications, Prognosis - Ewe Jin

Psychosocial, How does it affect? - Prish

Anatomy Pract Abdomen V

Q 1, 2, 3 - Prish, Ewe jin, Jun Beng
Q 4, 5 - Alex, Mona, Fuad
Q 6, 7, 8 - Kaarthik, Pikky, HT

PCL Week 5

Pek Har's Reflux

Pek Har, 50, presented with chest pain (burning sensation)
Past 2-3 months, usually after big meals, lying down, and being anxious.
Duration of pain: couple of hours.
Medication to alleviate: Quik-eze and Gaviscon
Similar episode 30 years ago while pregnant

Medications: CCBs and NSAIDs
Smoking: 20/d Alcohol: 1-2 glasses of wine every night
BP: 135/80 Pulse rate: 80 BMI: 32

DDx:
GERD
Dyspepsia

Fun fact:
20% of adults experience heartburn once a week

Learning issues for GERD

Definition, Stats, Differences between GERD and Dyspepsia. (What is reflux? Stats.) - Huey Ting

Pathophysiology - Jun Beng

Causes and Risk Factors - Shakir

S&S (Typical, Atypical, Alert), What is PEG feed? (www.gesa.org.au/consumer/publications/peg/PEG.pdf) - Pik Yin

Examination and Investigation - When and how investigate. Advantages and disadvantages of endoscopy. Is the finding of hiatal hernia significant? Alternatives for endoscopy for GERD. Should you look for H. pylori? Is H. pylori the culprit? - Fuad, Ewe Jin

Treatment and Management - Management of GERD (lifestyle, medical, firstline, CAM, surgical) - Alexandra Kang, Kaarthikeshen

Complications, Prognosis (Barrett's oesophagus, dysphagia and causes for dysphagia) - Mona

Articles + oesophageal cancer, types of oesophageal cancer including risks - Prisheila, Lai Kee Hao

A Lot Of Fuss

DD
1.Crohns Disease
2. Irritable Bowel Syndrome-ulcerative colitis,
3.Celiac Disease
4.Gastric Cancer
5.Malabsorption
6.

Symptoms

abdoinal; pain, flatuence. anemia, bloating, fatigue

Learning Issues for Coeliac Disease

• Definition, Incidence and Prevalence, DD-why are ppl with celiac disease misdiagnosed with IBS -Pik Yin
  

• Causes(diet-gluten &gluten free diet,other causes of anemia, risk factors,prevention-Kee hao
  

• Signs and symptoms (nutritional deficiency among ppl with coeliac disease)-u jin
  

• Histology(funct of villi and microvilli), pathophysiology- jb, prisheila
  

• complication and prognosis,reason for bone deficiency test-mona
• investigations-blood test,antibody test.-alex
• treatments and management-other treatments besides gluten free diet-shakir
• phychososcial-impact of gluten free diet on personal lifestyle, challenges if a child is diagnosed with celiac disease,naturopath and dieticianm, role of dietician in management of celiac disease-huey ting, fuad
  
• health promotion-hw to increase the rates of diagnosis in the community, list of gluten free diets available in the market-kaarthik

Anatomy Practical

Q 1 and 2 - Prish, Jun Beng, Mona

Q 3 and 4 and 5 - Fuad, Alex , Pik yin

Q 6 and 7 and 8 - Ewe Jin, Kh, HT

Whoever not coming for practical speak now or forever hold your Peace!!

male, mid aged teacher,
passing small bowl motions, with fresh bloody crap
receding hair line and over weight
father had cancer at 60
little bro had it too
constipation

large solid mass upon rectal exam
occasional drinker
had colonoscopy 10 yrs ago

going for CAT scan and colonosocypy

wat wud u like to know????? biopsy, blood tests,

DD:
-colon cancer
-rectal cancer
-colorectal cancer
-internal hemorrhoids
-inflammation of rectum
-tchulangaishlonghe

-def. (incidence, prevalence),differential diagnosis, minor ---kee hai---
-pathophysio, pathology ---mona---
-risk factors, causes, signs and symptoms (how does the bleeding occur?) ---fuad---
-investigations,cancer markers ---shakir, prish---
-treatment, other treatment, and management, follow up, palliative care, what aspects of care might a palliative care team deal with? ---ujin, waiting---
-prevention, advice of dr to pts to reduce risks ---jun beng---
-complications, prognosis (staging of cancer, dukes criteria, TNM) ---alex--
-What factors influence outcome of surgery ---piggy---
-psychosocial, implications on family, can they influence incidence of cancer? religion? is it protective or causative? what sorta pain will he feel in the end of his life? ---tick---

DD
Gastritis
Dyspepsia
Gastric ulcer
Duodenal ulcer
cron's disease
Acute cholecystitis
Lactose intolerance

Cholangitis
Choledocholithiasis - gallstone in the CVD' accumilates near papillae
Cholecystitis - stone in cystic duct from gallbladder

Learning issues

1. Definition, prevalence, incidence, Anatomy (biliary tree, site of obstruction)- (JB)
2. pathophysiology (cholesterol and bile pigment gallstone eg calcium binerubinate) ( Shakir)
3. Signs and symptoms - which disease causes which symptoms (all three!!) (Pik Yin)
4. causes and risk factors (Mona)
5. examination and investigations (blood test, liver function test, imaging techniques) and types of gallstones (Prish and HT)
6. treatment- pain relief, antibiotics, hydration and surgery. cholecystectomy (lapro and open)- ERCP, Spinchterotomy and stone collection, choledocholithomy
, bile duct clearance (Alex, kaarthik and KH)
7. complications (gallstone induced pancreatitis, surgical problems regarding choledocholithomy and mortality and morbidity) and prognosis (Fuad And EJ)

Learning Issues


1. Read the 2003 clinical practice guidelines www.acadmed.org.my/cpg/CPG-Obesity.pdf
www.nhmrc.gov.au/publications/pdf/n33.pdf (Ewe jin, Kaarthik)

2. visit www.ifnotdieting.com, read the 3 articles printed under Australian Family Physicians under Tips for long term weight management (Fuad)

3. using the internet or other sources, find out what each of the diet involves and what are the proposed mechanisms by which it is aimed to produce weight loss.
what is the scientific support for the diets being effective and what are the possible risks and disadvantages in following these diets (Atkins-Prisheila, Ornish and Pritikin-Mona, Sears-Kee Hao, The Zone-Huey Ting and The South Beach Diet-Alex, weight watchers-Pik Yin)


4. Search the internet beginning with the key words "unilever + atkins diet" to find example to explore the questions as to what potential impact a popular diet such as the Atkins diet mught have on:-

(a) the low fat diet industry
(b) the food industry in general. (Shakir)

The Atkins diet is apparently inconsistent with main stream healthy diet recommendations. What impact do these have on mainstream public health nutrition campaigns and how should these issues be addressed. (Jun Beng)

Week 13...tonight's gonna be a good night!!!

1. Definition, incidence, prevalence, what is thrombo-embolism and DVT?( Kaarthik) screw you Fuad!!!

2. Causes, risk factors (DVT)(Shakir)

3. Pathophysiology, Virchow's triad (Jun Beng, Kee Hao)

4. What underlying medical conditions can cause thrombosis and how they are managed? (Fuad)

5. Sign,symptoms, summary of clinical findings and why it occurs?( HT)

6. Investigations. What investigations are required and what they show? ( EJ, Mona)

7. Treatment and management of Anne's DVT. ( Pikky)

8. Complication and prognosis of DVT considering Anne's situation? Would there be any restrictions to Anne's lifestyle after diagnosis of DVT.? What is her prognosis and what are the possible complications and prevention of DVT? ( 1 page)( Alex, Prish)

PCL 12

www.donateblood.com.au
www.who.int

Learning Objectives & Tasks
- Definition & Prevalence MONA
- Pathophysiology & causes PIK YIN & PRISHIELA
- Risk factors & Internet as a source of information- pros and cons EWE JIN
- Signs & symptoms
- Examination & Investigation ALEX & JUN BENG
- interpretation of FBC and Blood Film
- Role and procedures of bone marrow biopsy
- Treatment & Management- SHAKIR & HUEY TING & KEE HAO
(oral iron- slow or poorly tolerated, IM injections- painful, risk of skin staining, blood transfusions-issues on blood transfusions Jehovah Witnesses, hospitalization, severe reactions, quick and long lasting, cost, blood borne disease risk- HIV, how much iron you get from blood)
- Complications & Prognosis FUAD

- Normal red blood cell development KARTHIK
- Definition of Poikilocytosis, Anisocytosis, Spherocytes, hypochromia


Suggested areas
- Review of oxygen transport
- How oxygen is converted in muscles
- What does a baby haemoglobin remains oxygenated in the uterus
- Review the role of vitamin B12 & folic acid in blood formation (absorption, storage and transport)
- Would you transfuse Lily? Justify your decisions in physiological terms.
- How much blood is donated in Red Cross
- What are the beliefs of jehovah witness on blood transfusion?
- What are the patients rights & what are YOUR duties as a doctor in relation to previous questions.
- What are the religious beliefs that impact the patients choice on blood transfusion? like animal products eg. bovine for hindus and pigs for muslims
- what is vegan?
How is FBC taken?

Wk 9 Complications - Nephrotic Syndrome

TO DO LIST
- Incidence and Prevalence and Definition - WHAT IS GFR? (SHAQ)
- Causes & Risk factors – WHAT IS RSHIP WITH DIABETES (PIGGY)
- Pathophysiology - FIND RSHIP FOR PLASMA CREATININE LEVELS & GFR (HUEY TING & EWE JIN)
- Sign and symptoms – SUMMARY OF CLINICAL FINDINGS AND WHY OCCURS (JB)
- Investigations and Examination – TEST TO MEASURE AND MONITOR RENAL FUNCTION, WHAT IS CREATININE CLEARENCE, WHAT IS EGFR AND ITS LIMITATIONS (ALEX & PRISH)
- Treatment Management – WHAT CAN BE DONE TO SLOW DOWN HOA’s KIDNEY DISEASE (FUAD & KAARTHIK)
- Complication and Prognosis – RETINOPATHY, NEUROPATHY, ARTHEROSCLEROSIS WHY OCCUR AND HOW TO PREVENT (KEE HAO & MONA)

Pathophysiology of COPD

 The most consistent pathological finding is hypertrophy and increase in number of the mucus secreting goblet cells of the bronchial tree, evenly distributed throughout the lungs but mainly seen in the larger bronchi.
 In more advanced cases, bronchi themselves are inflamed ; there will be infiltration of the walls of the bronchi and bronchiole with acute and chronic inflammatory cells and lymphoid follicles.
 The epithelial layer may become ulcerated and when ulcers heal, squamous epithelium may replace the columnar cells – squamous metaplasia
 Inflammation is then followed by scarring and a remodeling process that thickens the walls and leads to widespread narrowing in the small airways.
 If the airway narrowing is combined with emphysema, then the resulting airflow is even more severe.


 The small airways are particularly affected in the initial stage of the disease, initially without the development of any significant breathlessness.
 The initial inflammation of the small airways are reversible ; there will be improvement if smoking stops early. In later stages, the inflammation continues even if smoking is stopped.


 Emphysema leads to expiratory airflow limitation and air trapping. The loss of lung elastics recoil increases total lung capacity while the loss of alveoli with emphysema results in decreased gas transfer.
 V/Q mismatch occurs because of damage and mucus plugging of smaller airways from chronic inflammation and partly because of the rapid closure of the smaller airways owing to loss of elastic recoil from emphysema.
 This leads to a fall in PO2 and an increase in the work of respiration.
 However, many patients will show low normal PCO2 values – pink puffers – seek to maintain their blood gases by increasing their respiratory effort.
 Other patients who fail to maintain their respiratory effort will have a high level of CO2.
 In the short term, the rise in CO2 level will stimulate the increase in respiration rate but in the long term, these patients become insensitive to CO2 and come to depend on hypoxemia to drive the ventilation.- adaptation of central chemoreceptors due to kidney compensation
 These patients appear less breathless, and because they run on low PO2 level, production of RBCs and retention of fluid will be stimulated and hence, polycythaemia.
 In consequence, they will become bloated, plethoric and cyanosed.
 Attempts to abolish hypoxemia may make the situation much worse by decreasing respiratory drive in patients who rely on hypoxia to drive their ventilation.
 In summary, 3 mechanisms are suggested for the limitation of airflow :
 Loss of elasticity and alveolar attachments of air airways due to emphysema.
 Inflammation and scarring – narrowing of airways
 Mucus secretion which blocks the airways
Pathophysiology of asthma
Airways of asthma patients are hypersensitive  type 1 hypersensitivity  bronchi spasm  inflammation
Parasympathetic of afferent nerve endings in the lining of the bronchus is stimulated and impulse travels to brain then efferent nerve endings releasing Ach and causing formation of inositol 1,4,5-triphosphate (IP3) in bronchial smooth muscles  shortening bronchoconstriction.
Bronchial inflammation
Allergens gets ingested by antigen-presenting cells and present the allergen to immune cells TH0 and gets ignored, but in asthma, TH0 transform into TH2.
Activates humoral immune system  antibodies against the inhaled allergen  Inflammation  wall of airway thicken, remodeling due to scaring of the airway, mucus producing cells grow larger and produce more and thicker.
The "hygiene hypothesis" postulates that an imbalance in the regulation of these TH cell types in early life leads to a long-term domination of the cells involved in allergic responses over those involved in fighting infection. The suggestion is that for a child being exposed to microbes early in life, taking fewer antibiotics, living in a large family, and growing up in the country stimulate the TH1 response and reduce the odds of developing asthma
Pathophysiology of Emphysema
 Panacinar (or panlobular) emphysema: The entire respiratory acinus, from respiratory bronchiole to alveoli, is expanded. Occurs more commonly in the lower lobes, especially basal segments, and anterior margins of the lungs.[2]
 Centroacinar (or centrilobular) emphysema: The respiratory bronchiole (proximal and cen-tral part of the acinus) is expanded. The distal acinus or alveoli are unchanged. Occurs more commonly in the upper lobes.[2]

Toxicants are breathed into the lungs, it is trapped in the alveoli  Localized inflammation
One of the inflammatory response, leucocyte elactase cause alveolar septum to disintegrate.(Septal rupture)  Deformed alveoli  Reduced surface area  Decrease gas exchange
Also decreased elastin, loss of support  alveoli tend to collapse  limiting air flow
With reduced surface area  Thoracic cage expansion (barrel chest), and diaphragm contraction (flat-tening)  CO2 exhalation impaired
As it continues to break down  hyperventilation unable to compensate for shrinking surface area  insufficient O2  vasoconstriction (hypoxic pulmonary vasoconstriction)  pulmonary hypertension  increased strain on right side of heart, right heart hypertrophy  jugular venous distension  blood start backing up (liver)
Alpha 1-antitrypsin (A1AT) breaks down elastase
Thus, increased risk in patients with alpha 1-antitrypsin deficiency for emphysema

However, more recent studies have brought into light the possibility that one of the many other numer-ous proteases, especially matrix metalloproteases might be equally or more relevant than neutrophil elastase in the development of non-hereditary emphysema.

Job distribution

HYPONATREMIA

Definition & types fuad

Normal physiology: alex, kee hao, prish
Major sources of input and output of fluid in body, sources of sodium input and output of body
What is dextrose and why 5%? Difference btwn osmolarity, osmolality & tonicity
How fluid is distributed ECF and ICF?
What happens to osmolarity on input and output of water?
How is total input and output balanced- mechanism?

Pathophysiology & causes mona

Signs & symptoms . pikkie

Investigation/clinical examination karthik, jb
How to assess low sodium- normal blood test reading.
How to measure plasma osmolarity and tonicity
How did Sara find out?

Treatment/management shakir, ej
How to give dosage of saline/fluids.
Why is maintaining sodium level important? What happens to plasma volume?

Complications & prognosis huey ting

Signs & Symptoms and Causes of Chronic bronchitis

Definition- Bronchitis

Bronchitis is a term that describes inflammation of the bronchial tubes (bronchi and the smaller branches termed bronchioles) that results in excessive secretions of mucus into the tubes, leading to tissue swelling that can narrow or close off bronchial tubes. Bronchial tubes extend from the trachea and terminate at the alveoli in the lungs; the bronchial system resembles an inverted tree and is sometimes termed the "bronchial tree." A few authors include the trachea and upper airway in the definition. There are two major types of bronchitis, acute and chronic.

Definition-chronic bronchitis

Chronic bronchitis is defined as a cough that occurs every day with sputum production that lasts for at least three months, two years in a row. This definition was developed to help select uniform patients for research purposes i.e. to study medication therapies for treatment of chronic bronchitis. Many of the bronchi develop chronic inflammation with swelling and excess mucus production in chronic bronchitis; the inflammation, swelling, and mucus frequently and significantly inhibit the airflow to and from the lung alveoli by narrowing and partially obstructing the bronchi and bronchioles. Many cells that line the airway lose the function of their cilia (hair-like appendages that are capable of beating rapidly), and eventually the ciliated cells are lost. Cilia perform the function of moving particles and fluid (usually mucus) over the epithelial surface in such structures as the trachea, bronchial tubes, and nasal cavities to keep these hollow structures clear of particles and fluids. Mucus-producing cells increase due to irritation. These cells produce a viscous fluid that facilitates cleansing of the airway. If the mucus becomes thick (less fluid or viscous, it may contribute to airway blockage.
With long standing inflammation, as can be seen in chronic bronchitis, scarring inside the bronchial tree may develop. These scarred areas do not clear particles and secretions very well, and can result in a fixed, non reversible narrowing of the airway and the condition, chronic obstructive pulmonary disease (COPD). Chronic coughing develops as the body attempts to open and clear the bronchial airways of particles and mucus or as an overreaction to ongoing inflammation. Chronic bronchitis can be a progressive disease; symptoms (listed below) increase over time.
COPD also includes the entities of emphysema, chronic bronchitis, and chronic asthma. These conditions are not always separable and patients often have components of each. In the case of chronic bronchitis, the fixed airway obstruction, airway inflammation and retained secretions can result in a mismatch of blood flow and airflow in the lungs. This can impair oxygenation of the blood as well as removal of the waste product, carbon dioxide.

Although people of any age can develop chronic bronchitis, the majority of people diagnosed with the disease are 45 years of age or older.

Causes

There can be many causes of chronic bronchitis, but the main cause is cigarette smoke. Statistics from the US Centers for Disease Control and Prevention (CDC) suggest that about 49% of smokers develop chronic bronchitis and 24% develop emphysema/COPD. Some researchers suggest that about 90% of cases of chronic bronchitis are directly or indirectly caused by exposure to tobacco smoke.

Many other inhaled irritants (for example, smog, industrial pollutants, and solvents) can also result in chronic bronchitis.

Viral and bacterial infections that result in acute bronchitis may lead to chronic bronchitis if people have repeated bouts with infectious agents.

Also, underlying disease processes (for example, asthma, cystic fibrosis, immunodeficiency, congestive heart failure, familial genetic predisposition to bronchitis, and congenital or acquired dilation of the bronchioles, known as bronchiectasis) may cause chronic bronchitis to develop, but these are infrequent causes as compared to cigarette smoking.


Signs & Symptoms

Cough and sputum production are the most common symptoms; they usually last for at least three months and occur daily. The intensity of coughing and the amount and frequency of sputum production vary from patient to patient. Sputum may be clear, yellowish, greenish, or occasionally, blood-tinged. Since cigarette smoke is the most common cause for chronic bronchitis, it should not be surprising that the most common presentation is so called smoker's cough. This is characterized by a cough that tends to be worse upon arising and is often productive of discolored mucus in the early part of the day. As the day progresses, less mucus is produced.

Dyspnea (shortness of breath) gradually increases with the severity of the disease. Mucus plugs up and makes it hard for them to bresthe. Usually, people with chronic bronchitis get short of breath with activity and begin coughing; dyspnea at rest usually signals that COPD or emphysema has developed.

Wheezing (a coarse whistling sound produced when airways are partially obstructed) often occurs.

In addition, symptoms of fatigue, sore throat, muscle aches, nasal congestion, and headaches can accompany the major symptoms. Severe coughing may cause chest pain; cyanosis (bluish/grayish skin coloration) may develop in people with advanced COPD. Fever may indicate a secondary viral or bacterial lung infection. When symptoms worsen or become more frequent, this is often referred to as an exacerbation of chronic bronchitis. These exacerbations often require antibiotics, and may need steroid medication and an increase in respiratory inhaled medications.

Diagnosis

Using a combination of a person's medical history, physical exam, and diagnostic tests. A history of a daily productive (sputum production) cough that lasts at least three months, especially if has occurred two years in a row, fits the criteria for a clinical diagnosis of chronic bronchitis. The physical examination often allows caregivers to hear wheezes, a sign of airflow obstruction.

A chest X-ray is often performed to help rule out other lung problems (for example, pneumonia, bronchial obstructions). Additional tests such as a complete blood count(CBC), arterial blood gas measurements, CT scan of the chest, and pulmonary function tests are often done to characterize the structure and function of the lungs and to exclude other conditions.

Reference:
http://www.medicinenet.com/chronic_bronchitis/article.htm#what
http://familydoctor.org/online/famdocen/home/articles/280.printerview.html
http://www.nlm.nih.gov/medlineplus/bronchitis.html

Financial and social implications of asthma

The stress of living with a chronic disease reveals itself in many ways among the various family members.

Someone with asthma may be more likely to

• get involved in fights
• be less cooperative
• be stubborn
• depressed
• anxious
• Withdrawn
• Be timid

Parents of kids with asthma are more likely to suffer from

• Fatigue
• Headaches
• Insomnia
• Depression and
• Appetite loss

Siblings of kids with asthma may

• Feel guilty, thinking that somehow they have caused the illness.
• They also may be jealous or angry because of the additional attention their sibling receives
• or they may be afraid that they may get the asthma themselves
• Some may also feel embarrassed by the symptoms that their sibling displays

Financial Strain

Nebulizer - RM 15-20 each time, at clinic

Medication for the inhaler

• Nonsteroidal RM 20
• Steroidal RM 40

Drugs - for when needed RM 20

But………………….
These are not the only costs…………………

1. MEDICAL RELATED COSTS
Pharmaceutical
Medical Consultations
Hospital
Indirect Medical - Secondary illnesses
CM - such as acupuncture, homoeopathy, physiotherapy or chiropractice
Ambulance

2. INDIRECT COSTS .
Absenteeism
Lost Productivity At Work
Travel Cost and Time For Treatment
http://www.healthinsite.gov.au/expert/Asthma___Expert_View

Differences between patients suffering from emphysema (pink puffers) and chronic bronchitis (blue bloaters)

Clinical feature................Emphysema...............Chronic bronchitis
Dyspnoea.........................Sever........................Mild
Cough.......................After Dyspnoea starts.......Before Dyspnoea starts
Sputum.........................Scantly mucoid.................Purulent
Mucopurulent relapses...........Less frequent................More frequent
Cyanosis...........................Absent..............Present (Blue bloaters!!)
Hyperventilation...............Late and mild...............Early and severe

Smoking statistics & smoking cessation guidelines

Global statistics
•About 12x more British people have died from smoking than from WWII.
•One British survey found that nearly 99% of women did not know of the link between smoking and cervical cancer.
•Around 80,000 – 100,000 children worldwide start smoking every day – roughly half of whom live in Asia.
•In Asia, tobacco companies are among the top 10 advertisers in Cambodia, Indonesia, Malaysia, Myanmar and the Philippines.
•A survey in the UK found about half of smokers think that smoking “can’t really be all that dangerous, or the Government wouldn’t let cigarettes be advertised”.


WHO, 2002 (stats in Malaysia)
•About 50% Malaysian men smoke.
•About 30% of adolescent boys (aged 12 to 18) smoke.
•The numbers of female teens smoking rose from 4.8% to 8% from 1996 – 1999. Nearly one in five teens smokes.
•Smoking rates are highest in rural Kelantan and lowest in urban Penang and Sarawak.
•Malaysia has been dubbed the "indirect advertising capital" of the world.
•Some of the tobacco industry's most obvious efforts to target young people can be seen here.


Smoking Cessation Guidelines
http://www.ahrq.gov/clinic/tobacco/clinhlpsmksqt.htm

COPD - Financial & Social Burden, Kicking the Habit

Financial Burden

In 2008, the financial cost of COPD in Australia was $8.8 billion.

Of this:

¡ $6.8 billion was productivity lost due to lower employment, absenteeism and premature death of Australians with COPD

¡$0.9 billion was direct health system expenditure

¡- $1.2 billion including welfare payments and taxation foregone, and other indirect costs such as aids and home modifications

Additionally, the overall value of loss of wellbeing due to COPD is estimated at a further $89.4 billion

Health costs - in 2008, COPD will cost the economy an estimated $98 billion

In Europe, 2001:

¡Per patient Direct costs £819.42

¡Per patient Indirect costs £819.66

Social Burden

Depression and anxiety much higher (in COPD) than in the general community:

¡40% to 12.3% depression

¡ 36% anxiety to 9% depression

Feeling fatigued easily makes activities less enjoyable and frustrating. Sometimes even stressful. Increased stress leads to many psychological problems which increases social burden.

Kicking the Habit

Employers may introduce an incentive to smokers vs. non-smokers. Eg. Charge an extra RM150 to smokers for health insurance. Ask a loved one to help in quitting smoking. Join a support group.

Nicotine Replacement Therapy:

¡involves "replacing" cigarettes with other nicotine substitutes, such as nicotine gum, patch, nasal spray, inhaler, and lozenges.

¡Delivers “small and steady doses” of nicotine into the body to relieve some of the withdrawal symptoms without the tars and poisonous gases found in cigarettes.

Drug Therapy

¡Buproprion. Similar to varenicline, but less desirable safety profile. (eg. Causes fits)

¡In Malaysia, Pfizer markets varenicline.

Hypnosis

¡Places a suggestion in the subconscious in order to strengthen will against smoking.

Behavioural therapy

Motivational therapy

Investigations for Obstructive Sleep Apnea

Polysomnography

Basically a diagnostic sleep study. Measures sleep cycles of a person by recording information such as:
-Blood oxygen levels (Oximeter)
–Body position (Device placed on chest)
–Brain waves (EEG): Measurement of electrical signals from the brain to determine whether you are awake or asleep and what stage of sleep you are in.
–Breathing rate
–Eye movement (EOG) – to determine REM sleep. Some people have worse symptoms in REM sleep.
–Heart rate

AHI measures the number of atypical breathing incidents during 1 hour of sleep. An AHI of 5 or less is normal; 5 to 14 is mild obstructive sleep apnea; 15 to 29 is moderate obstructive sleep apnea; more than 30 is severe. RDI is AHI/hr. All oxygen desaturations <90% during sleep are considered medically significant.

Performed at a special sleep center. The test is often done during the night so that your normal sleep patterns can be studied. Electrodes will be placed on your chin, scalp, and the outer edge of your eyelids. These must remain in place while you sleep.

Signals from electrodes are recorded while you are awake (with your eyes closed) and during sleep. The time it takes you to fall asleep is measured, as well as the time it takes you to enter REM sleep.

Monitors to record your heart rate and breathing will be attached to your chest. These also must remain in place while you sleep. A specially trained health care provider will directly observe you while you sleep and note any changes in your breathing or heart rate. The number of times that you either stop breathing or almost stop breathing will be measured. In some sleep study centers, a video camera records your movements during sleep.


Multiple Sleep Latency Test: In some cases, a multiple sleep latency test is performed on the day after the overnight test to measure the speed of falling asleep. In this test, patients are given several opportunities to fall asleep during the course of a day when they normally would be awake.

At-Home Sleep Apnea Test: To diagnose sleep apnea, a portable test, which can be conducted at home can be used as an alternative to polysomnogram for diagnosing obstructive sleep apnea. The home tests are portable devices that are composed of a recording device, belts, sensors and other cables. The data gathered overnight has to be reviewed by sleep specialist and thereby diagnosis and treatment plan has to be developed.


Sleep studies can also determine whether you have a problem with your stages of sleep. Normally, NREM and REM alternate 4 to 5 times during a night's sleep. A change in this cycle may make it hard for you to sleep soundly. Non-REM sleep is in turn further divided into four different stages (1 through 4), with stages 3 and 4 often referred to as "deep sleep." Normal sleep patterns break down your time asleep as follows: stage one sleep for 5% of the time, stage two for 55% of the time, stage three and four at 20% of the time and REM sleep for 20%.

ECG

Not a gold standard exam to diagnose OSA. Research has been done to diagnose OSA using ECG, with high success rate (80 to 95% accuracy). Use of algorithms. However, in a sleep study, ECG is used to detect irregularities in heart beat or rhythm. Complications of OSA is right ventricular hypertrophy, which may eventually lead to cor pulmonale. Also may be left ventricular hypertrophy. Can be detected by ECG – right or left axis deviation.

tasks for pcl week 6

Learning issues

· Definition, types of COPD, Prevalence & incidence of COPD in Australia & msia Kaarthik
· Pathophysiology – emphysema, chronic bronchitis, respiratory physiology & pathology hueyting, kee hao
· Patterns of respiratory function (diagram – norm, severe, restrictive, obstructive), difference between patients suffering from emphysema(pink puffers) & chronic bronchitis (blue bloaters)mona
· Causes of severe symptoms & aetiology of COPD, signs & symptoms of emphysema, chronic bronchitis, clinical findings, why it occurs?shakir, jun beng
· Investigation – definitive test for COPD, test for monitoring & potential complication prisheila
· Financial & social burden in health for COPD, Smoking cessation guidelines (TAK NAK campaign), smoking statistics, how to motivate patient to quit smoking? – NOT prochaska-diclemente (eg: nicotine patch) fuad, pikyin
· Management of COPD, benefits of seeing a regular doctor, Difference between asthma & COPD – irreversible? Etc…lung function test ewejin
· Complication & prognosis of COPD, Long term prognosis for Shamila as smoker & non smokeralex

Treatment for Sleep Apnea

Treatment and management
The goals of treating obstructive sleep apnea are to:
• Restore regular breathing during sleep
• Relieve symptoms such as loud snoring and daytime sleepiness
- Lifestyle changes is only for mild OSA
Lifestyle Changes
If you have mild sleep apnea, some changes in daily activities or habits may be all that you need.
• Avoid alcohol and medicines that make you sleepy. They make it harder for your throat to stay open while you sleep. (alcohol causes URT muscle to relax)
• Lose weight if you're overweight or obese. Even a little weight loss can improve your symptoms.
• Sleep on your side instead of your back to help keep your throat open. You can sleep with special pillows or shirts that prevent you from sleeping on your back.
• Keep your nasal passages open at night with nose sprays or allergy medicines, if needed. Talk to your doctor about whether these treatments might help you.
• Stop smoking.
• Gargle with salt water (without swallowing) to shrink your tonsils.
• Develop regular sleep habits, and make sure you get enough sleep at night.
• Use an air humidifier at night.
Mouthpiece/oral appliance
- Help with mild OSA or snoring
- Customize to fit different patients, plastic made.
- It adjust your lower jaw and your tongue to help keep your airways open while asleep.
- Make sure it is comfortable, adjustable.
-
Breathing Devices
CPAP – continuous positive airway pressure for moderate to severe sleep apnea in adults.
- It’s a mask that fits over mouth and nose and blows air into the throat.
- Air pressure adjusted to avoid airway being narrowed or blocked during sleep
- Sleep apnea returns if CPAP stops or not used correctly
- Machine set up by a technician with doctor’s orders
- May cause side effects, dry or stuffy nose, irritated skin on face, sore eyes, and headaches, stomach bloating and discomfort.
- Nasal spray and adding moisture to air is helped to relieve SE.
There is no drug that completely treats sleep apnea. Some of the drugs used in combination with CPAP include:
• Medroxyprogesterone -- side effects may include nausea, depression, excess hair growth, breast tenderness, and fluid retention.
• Protriptyline -- this medication is used rarely. Side effects may include dry mouth, constipation, frequent urination, impotence, and confusion (in the elderly).
• Modafinil -- sometimes prescribed in combination with CPAP to treat excessive daytime sleepiness.

Surgery
- To widen breathing passage, involves removing, shrinking or stiffening excess tissue in the mouth and throat or resetting the lower jaw.
- Shots to shrink tissue or plastic pieces inserted to stiffen loose tissue.
- Surgery to remove tonsils maybe helpful for children. Or wait for tissues to shrink by itself.
Uvulopalatopharyngoplasty (UPPP) -- The operation involves the removal of the uvula and back of the soft palate, often accompanied by tonsillectomy.
In UPPP, soft tissue on the back of the throat and soft palate (the uvula) is removed.
UPPP does not address apnea or snoring caused by obstructions at the base of tongue.
• First patient undergoes soft tissues surgeries, UPPP together with genioglossus advancement or hyoid suspension and usually fails
• Then a maxillomandibular advancement surgery to move the top jaw and bottom jaw forward. (pulling tongue forward)
• High rates of complication
Surgeons usually use either conventional scalpel techniques or newer laser methods (LAUP, or Laser-Assisted Uvulopalatoplasty). LAUP may have a higher rate of success than UPPP, but it also requires the expertise of a surgeon highly skilled in laser procedures.
LAUP Treatment Procedure
A laser beam to remove and tighten floppy soft palate tissue in the back of the mouth, thereby reducing the amount that these tissues contribute to snoring.
LAUP causes mild discomfort after surgery. Local anesthestic.
LAUP needs up to five treatments spaced four to eight weeks apart (although one to three are usual).

Tracheostomy -- to create an opening in the windpipe to bypass the blocked airway if there are anatomical problems (rarely done)
General anesthesia, exposure of the tracheal cartilage rings. The surgeon then creates an opening into the trachea and inserts a tracheostomy tube.
Complementary and Alternative Therapies
Useful in treating sleep apnea caused by allergies.
Homeopathy and nutrition are most likely to have a positive effect.
Nutrition and Supplements
• Diet: Try eliminating mucus-producing foods (such as bananas) for 2 weeks, then reintroducing them to see if you notice any difference in sleepiness or other symptoms.
• Essential fatty acids (EFAs) moderate inflammatory response and decrease allergic response. EFAs are low in obese people. Fish oil, evening primrose oil, flaxseed oil, and borage oil all contains essential fatty acids.
Acupuncture
Some evidence suggests that a type of acupuncture called auriculotherapy acupoint pressure may help treat sleep apnea.


http://www.umm.edu/altmed/articles/sleep-apnea-000156.htm
http://www.nhlbi.nih.gov/health/dci/Diseases/SleepApnea/SleepApnea_Treatments.html
http://www.nlm.nih.gov/medlineplus/ency/article/000811.htm
http://www.sleepdisordersguide.com/topics/laup.html
http://www.nlm.nih.gov/medlineplus/ency/article/002955.htm

Complications & Prognosis Of OSA

Common Problems
¢CVS Problems
¢Daytime Fatigue
¢Complications with Medicine & Surgery
¢Sleep-deprived partners
¢Nocturia
¢Impotence =P
¢GERD
¢ADHD

Daytime Fatigue
¢OSA make normal, restorative sleep impossible.
¢experience severe daytime drowsiness, fatigue and irritability.

Nocturia
¢Increased pressure=increased preload=increased CO
¢Heart works harder
¢Release of ‘atrial natriuretic peptide’(ANP) from atrial myocytes.
¢Function of ANP?

Impotence
¢Many hypothesis….still not confirmed
1.Many men have erections during REM sleep. I don’t okay… Since patients have less sleep..therefore less REM erections.
2.Levels of testosterone drops in patients with sleep OSA. Less testosterone=less manhood=ED

GERD
¢phrenoesophageal ligament (PEL) connects the diaphragm to the lower esophageal sphincter (LES).
¢During OSA ,increased respiratory effort by the diaphragm.
¢PEL will open the LES due to increased activity of diaphragm when threshold is reached.
¢Gastric fluid enter esophagus.

CVS Problems
¢Blood oxygen levels drop.Furthermore, levels of NO drops. Increase in blood pressure leading to hypertension.
¢Severe hypoxia/hypoxemia leads to sudden death…

Attention Deficit Hyperactivity Disorder(ADHD)
¢Definition=co-existence of attentional problems and hyperactivity, with each behavior occurring frequently together.empirical evidence that there is overlap in the central nervous system centers that regulate sleep and those that regulate attention/arousal.

Prognosis
¢Untreated:
1.life-threatening.
2.Fall asleep at inappriopriate times.
Impt: no cure for sleep apnea!!

Are children predisposed to snoring if their parents are ‘snorers’?
¢Chest(April 2006)
¢Researchers from Cincinnati Children's Hospital studied 681 children, 45% girls, 80% white.
¢parents filled in questionnaires-to determine if there was a link.
¢20% of the mothers and 46% of the fathers were habitual snorers .

Result
¢Incidence of snoring among infants who had at least one parent who was a habitual snorer was 3 X>than infants whose parents did not snore.

Definition, Apopnea-Hypopnoea Index (AHI) , anatomy

Definition of OSA
- a sleep disorder
- Pauses in breathing during sleep due to airway obstruction
- 1 or more breaths are missed during each episode, occurring repetitively throughout sleep
- Breathing is interrupted by obstruction in airway despite the effort to breathe, preventing an adequate flow of air

Apopnoea-Hypopnoea Index
• To assess the severity of sleep apnoea
• Total number of complete cessation (apnoea) and partial obstructions (apopnoea) of breathing occurring per hour of sleep
• Pauses in breathing must last for 10s

Classification :
•Mild = 5-15
•Moderate = 15-30
•Severe = >30

Anatomy (the ones i think are relevant to Karim's case)
- Mouth
- tongue
- palate
- tonsils
- trachea

Diabetic Screening Test

TESTS
The best screening test for diabetes, the fasting plasma glucose (FPG), is also a component of diagnostic testing. The FPG test and the 75-g oral glucose tolerance test (OGTT) are both suitable tests for diabetes; however, the FPG test is preferred in clinical settings because it is easier and faster to perform, more convenient and acceptable to patients, and less expensive. An FPG ≥126 mg/dl (7.0 mmol/l) is an indication for retesting, which should be repeated on a different day to confirm a diagnosis. If the FPG is <126 mg/dl (7.0 mmol/l) and there is a high suspicion for diabetes, an OGTT should be performed. A 2-h postload value in the OGTT ≥200 mg/dl (11.1 mmol/l) is a positive test for diabetes and should be confirmed on an alternate day. Table 2 presents the diagnostic criteria for diabetes. Fasting is defined as no consumption of food or beverage other than water for at least 8 h before testing.
Nondiabetic individuals with an FPG ≥110 mg/dl (6.1 mmol/l) but <126 mg/dl (7.0 mmol/l) are considered to have IFG, and those with 2-h values in the OGTT ≥140 mg/dl (7.8 mmol/l) but <200 mg/dl (11.1 mmol/l) are defined as having IGT. Both IFG and IGT are risk factors for future diabetes. Normoglycemia is defined as plasma glucose levels <110 mg/dl (6.1 mmol/l) in the FPG test and a 2-h postload value <140 mg/dl (7.8 mmol/l) in the OGTT.

If necessary, plasma glucose testing may be performed on individuals who have taken food or drink shortly before testing. Such tests are referred to as casual plasma glucose measurements and are given without regard to time of last meal. A casual plasma glucose level ≥200 mg/dl (11.1 mmol/l) with symptoms of diabetes is considered diagnostic of diabetes. A confirmatory FPG test or OGTT should be completed on a different day if the clinical condition of the patient permits.
Laboratory measurement of plasma glucose concentration is performed on venous samples with enzymatic assay techniques, and the above-mentioned values are based on the use of such methods. The A1C test values remain a valuable tool for monitoring glycemia, but it is not currently recommended for the screening or diagnosis of diabetes. Pencil and paper tests, such as the American Diabetes Association’s risk test, may be useful for educational purposes but do not perform well as stand-alone tests. Capillary blood glucose testing using a reflectance blood glucose meter has also been used but because of the imprecision of this method, it is better used for self-monitoring rather than as a screening tool.

role of GP+fitness for driving+insurance

a health assessment is done before a driving permit is given

sleep problems
vision
dibetis
heart problems
epilepsy
blackouts and fainting
psychiatric disorders
age related decline


The Driver Licensing Authority always makes the final decision


Generally, only longer-term conditions will impact on your
licence status and will need to be reported to the
Driver Licensing Authority.
The relationship between you and your doctor is confidential,
therefore your doctor will not normally communicate directly
with the Driver Licensing Authority. He or she will provide
you with advice about your ability to drive as well as with
a letter or report to take to the authority.

In South Australia and the Northern Territory,
however, doctors are required by law to report
drivers who they believe to be medically unfit
to drive to the Driver Licensing Authority.

http://www.austroads.com.au/aftd/cvd.html



Apnea Index of:
0-10 - typically no additional life insurance cost
11-20 - 50% table rating increase over standard life insurance rates
21-30 - 100% table rating increase over standard life insurance rates
31-40 - 150% table rating increase over standard life insurance rates
Above 40 - decline.

http://www.lifeinsuranceadvisors.com/life-insurance-for-sleep-apnea.html

6 steps to management of asthma and yoga breathing exercises

To get back the natural and automatic diaphragmatic breathing, and not the thoracic type of breathing
To concentrate on exhalation especially at the commencement of an attack
Increasing the flexibility of the chest wall and to relax the accompanying muscles of the respiratory system and
To correct other problems commonly associated with chronic asthma


Since few of us are immune to the constant stresses and strains of modern life, most of us tend to take short shallow breaths, using only a half to two thirds of our lung capacity.
And asthmatics chronically over-breathe, often at a rate two to three times faster than normal which robs the cells of essential fuel versus providing more oxygen.

The more stress, pressure and emotion we experience, the more restricted the breath becomes, as the alarm bells of the sympathetic nervous system are constantly being rung.
This perpetuates the cycle of stress, anxiety and shallow breathing. This in turn deprives the body of oxygen

Benefits
Increased efficiency of each breath
Increased lung capacity
Increased flow of oxygen to all parts of the body
Increase concentration, creativity and cognitive brain functions
Increase relaxation and calmness by releasing tension
Improved mind and body control, helping control emotions and relieve tension.
Improved abdominal and diaphragm control and strength.

Step 1
If you recognise any of the following symptoms then you probably have moderate to severe
asthma:
• If you need asthma medication most weeks of the year.
• If you have needed urgent medical attention for asthma in the past year or so.
• If your peak flow measurement is consistently below expected, despite optimal
treatment.
Assess the severity of your asthma and have it checked by your doctor.

Step 2
When you are at your best you should ideally have:
• No symptoms.
• Best possible peak flow measurements and
• Your chest should sound normal when your doctor examines you. It may take a few
weeks of medication to achieve your best. Monitoring peak flow measurements at
home can help you to check your progress.
When you have reached your best you will probably feel much better.

Step 3
Find out what sets off your asthma and try to stay away from it. These triggers could be:
• House dust, pollens, pets, moulds.
• Tobacco smoke.
• Things around your workplace or school, like wood dust, flour dust, chemical fumes,
animals and many other things.
• Food preservatives, colourings and monosodium glutamate (MSG).
Air pollution and respiratory infections, such as colds or bronchitis, commonly trigger asthma
but are difficult to avoid.
Exercise is good for everyone including people with asthma. Although it can trigger asthma it is important not to avoid exercise. Exercise induced asthma (EIA) can usually be easily controlled through medication and an appropriate exercise regime. Talk to your doctor or local
Asthma Educator to learn how to control asthma during exercise.

Step 4
If you need medications these should be as simple, safe and effective as possible.
This is why inhaled medications are most often used for asthma.
There are four types of inhaled medication that your doctor might advise you to use.
• “Relievers” (such as Bricanyl, Ventolin, Asmol, Airomir and Epaq) are called
bronchodilators. These provide relief of asthma symptoms and are used in asthma first
aid.
• “Preventers” (such as Flixotide, Qvar, Pulmicort, Intal, Tilade, and Singulair) help to
keep your asthma under good control preventing asthma attacks. These will only work
if you use them regularly.
• “Symptom Controllers” (such as Oxis, Foradile, and Serevent)
• “Combination Medications” (such as Seretide and Symbicort) these combine a
Symptom Controller and a Preventer in one device.
Your doctor will prescribe the medications which are best for you.

Step 5
Together with your doctor you can work out a plan so that you can:
ﾕ Recognise when your asthma is getting worse.
ﾕ Know how to treat it quickly.
ﾕ Know how and where to get the right medical assistance.
Early attention to worsening asthma may prevent you from having a serious attack. Ask your
doctor for an Asthma Action Plan.

Step 6
Asthma can usually be kept under control. Follow your 6 point management plan and see
your doctor for regular check-ups, not just in emergencies. You should have your asthma
reviewed by your GP every 6 months.

Causes/Triggers of Asthma

The exact cause of asthma isn't known. Researchers think a combination of factors (family genes and certain environmental exposures) interact to cause asthma to develop, most often early in life. These factors include:

An inherited tendency to develop allergies, called atopy.
Parents who have asthma.
Certain respiratory infections during childhood.
Contact with some airborne allergens or exposure to some viral infections in infancy or in early childhood when the immune system is developing.

The factors(triggers) that can set off an asthma attack include:

inhaled allergens (such as dust mites, pollen, and cat and dog allergens).
tobacco smoke.
air pollution.
exercise.
strong emotional expressions (such as crying or laughing hard).
chemical irritants.
certain drugs (aspirin and beta-blockers).

pathophysiology

pathophysiology:

-airway inflammation
-intermittent airflow obstruction
-bronchial hyperresponsivness


http://emedicine.medscape.com/article/296301-overview


In allergic (extrinsic) asthma, the most common form, the respiratory
crisis is triggered by allergies in pollen, mold, animal dander, food,
dust mites, or cockroaches. Exposure causes release of histamine,
interleukins, and several other inflamatory chemicals, which
triggers intense airway inflammation.

Nonallergic
(intrinsic) asthma is not caused by allergens but can be triggered by
infections, drugs, air pollutants, cold dry air, exercise, or emotions.

Within minutes, bronchospasm occurs,along with wheezing, coughing and
possible fatal suffocation.

6-8 hours later, interleukins attract eosinophils to the bronachial
tissue. The eosinophils secrete protiens that paralyze the cilia,
damage the epithelium, and scar and cause long term damage to the
lungs. The bronchioles also oedematize and get plugged with thick
stucky mucus.

Saladin, unity of form

Definition, Types, Incidence and Prevalence of Asthma

Definition



Asthma is a chronic inflammation of the bronchial tubes (airways) that causes swelling and narrowing (constriction) of the airways. The result is difficulty breathing. The bronchial narrowing is usually either totally or at least partially reversible with treatments.

Types of Asthma

1. Allergies and Asthma

Allergies and asthma often go hand-in-hand. Allergic rhinitis (also called hay fever) is inflammation of the inside lining of the nose and is the single most common chronic allergic disease. In those with allergic rhinitis, increased sensitivity (allergy) to a substance causes your body’s immune cells to release histamines in response to contact with the allergens. Histamines along with other chemicals lead to allergy symptoms. The most common allergens enter the body through the airway.

With allergic rhinitis, you may feel a constant runny nose, ongoing sneezing, swollen nasal passages, excess mucus, weepy eyes, and a scratchy throat. A cough may result from the constant postnasal drip. Many times asthma symptoms are triggered by allergic rhinitis. Your doctor may prescribe medications to control the allergies and, in doing so, the cough and other asthma symptoms may subside.

2. Exercise-Induced Asthma

Exercise-induced asthma is a type of asthma triggered by exercise or physical exertion. Many people with asthma experience some degree of symptoms with exercise. However, there are many people without asthma, including Olympic athletes, who develop symptoms only during exercise.

With exercise-induced asthma, airway narrowing peaks five to 20 minutes after exercise begins, making it difficult to catch your breath. You may have symptoms of an asthma attack with wheezing and coughing. Your doctor can tell you if you need use an asthma inhaler (bronchodilator) before exercise to prevent these uncomfortable asthma symptoms.

Cough-Variant Asthma

In the type of asthma called cough-variant asthma, severe coughing with asthma is the predominant symptom. There can be other causes of cough such as postnasal drip, chronic rhinitis, sinusitis, or gastroesophageal reflux disease (GERD or heartburn). Coughing because of sinusitis with asthma is common.

Asthma is a serious cause of cough that is common today. Cough-variant asthma is vastly underdiagnosed and undertreated. Asthma triggers for cough-variant asthma are usually respiratory infections and exercise.

For any persistent cough, contact your doctor. Your doctor may order specific asthma tests, such as lung function tests, to show how well your lungs work. You might need to see a lung specialist for further tests before an asthma diagnosis is made.

Incidence and Prevalence

The prevalence of asthma in Australia is among the highest in the world: between 10% and 15% of children and between 10% and 12% of adults have asthma. Although it is not a major cause of death, asthma is one of the most common problems managed by doctors and is a frequent reason for the hospitalisation of children, especially boys.

In Malaysia, asthma is among the commonest conditions treated in the health
clinics. More than 73 % of outpatient attendances in the health clinics have been
managed for respiratory symptoms and asthma is one of the cases note to be
treated in health clinics.

Chan (1994) reported that 5 % of all outpatients in Ipoh General Hospital were
treated for asthma. Report was also shown that the hospital discharge due to
asthma was on the rise in the past five years (1990 - 1995). The mortality
statistics was also showed the similar trend.

http://www.healthinsite.gov.au/topics/Asthma

http://www.aihw.gov.au/publications/acm/aia08/aia08.pdf

http://www.medicinenet.com/asthma/page2.htm

http://www.webmd.com/asthma/guide/types-asthma