NURUL AIN BINTI ZAINAL ABIDIN 111303043/ G2

PATIENT PROFILE:
Name: Fathia Iman Bt Kamarul

Occupation: Student

Age: 7 years old

Date of clerking: 21th April 2016

Address: Bukit Baru

CHIEF COMPLAINT:
Shortness of breath for 6 days
HISTORY OF PRESENTING ILLNESS:
Patient is a known case of bronchial asthma since 4 years old. She was
apparently well until 6 days ago when she developed shortness of breath. It was
sudden in onset, 4-5 times/day and sometimes associated with wheezing. It
relieved when she leans forward and not relieved by metered dose inhaler. It
were not associated with fever, palpitation, chest pain, excessive sweating,
complained of she could not lie down flat ad need to sit up for breathing and
sudden breathlessness waking her from sleep
For systemic review:
GIT no abdominal pain, vomiting, diarrhoea and blood in stool
GU no dysuria, hematuria, dribbling, straining, low stream
Musculoskeletal no swelling of joint, no stiffness
Endocrine no cold or hot intolerance
Hematology no petechial haemorrhage, gum bleeding
CNS no fits, blurring of vision, numbness, loss of conscious
Patient had bronchial asthma since 4 years old. She was on MDI
salbutamol and budesonide. She used salbutamol 3-4 times/week and oxygen
nebulisation 2-3 times/year. She was hospitalized twice for asthma in 2013 and
2014. The triggering factor are dust, smoke and extreme cold temperature.
PAST HISTORY:
Sinusitis and allergic rhinitis 2 years ago
BIRTH HISTORY:
Antenatal- unplanned pregnancy, confirmed by dating ultrasound at 12
weeks, mother had no fever & rash or other complication during pregnancy,
nohistory of exposure to radiation, she consume folic acid and vitamin
supplement, she received 2 dose of TT injection and anomalies scan was done
during 2nd trimester.
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Natal Baby was born term (38 weeks) birth weight 2.8 kg, SVD, cried
immediately after bith, no forceps or vacuum used to assist the labour, breast
feeding is initiated 1 hour after birth and baby passed meconium after 1 day
Perinatal Baby had neonatal jaundice for 1 week and was admitted to
hospital for phototherapy, weaning was started at 6 months of age and breast
feeding was stopped at age of 1.5 years old.
DEVELOPMENTAL HISTORY:
Appropriate to age. Currently she was standard 1 student at SK Bukit Baru.
She is an intelligent student, has a good interaction with her peers and teachers
and always gets good grades. She never skipped school because of asthma
problem and able to join outdoor activities and sport but she must use 1 puff of
salbutamol before playing.
DIET HISTORY:
She consumed 3 times meal per day and usually includes rice,
chicken/fish/meat and vegetable. She ate fruits and drinks milk twice a day.
IMMUNIZATION HISTORY:
Up to date. BCG scar present at left arm.
DRUG HISTORY:
Patient used MDI salbutamol to relieve breathlessness at home at no
changes occur. No evidence of drug interaction. Patient did not have any drug
allergy.
FAMILY HISTORY:

Patients mother had asthma. No family history of hypertension, diabetes,

malignancy or pulmonary tuberculosis.
SOCIAL HISTORY:
She is currently standard 1 student. She lived with her parents who both
worked as teacher. Her family income is adequate. The house is near factory and
the main road. She had no pets at home. The inhaler was correctly use.
SUMMARY:
7 years old female child presented with shortness of breath for 6 days. She
is known case of bronchial asthma since 4 years old and currently on salbutamol
and budesonide inhaler. Her mother also had asthma. Past history and birth
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history are not significant with normal development and growth, immunization is
up to date.
GENERAL EXAMINATION
Patient is alert and cooperative. She is moderately built and nourished,
sitting comfortably on chair. Body mass index is 21.3 kg/m 2 and there is no
abnormality over the skin.
There is no pallor over the nail and capillary refill time is less than 2
seconds. The pulse rate is 70 beats/ minutes, regular rhythm, normal volume, no
collapsing pulse and no thickening of blood vessel. The respiratory rate is 22
breaths/minutes. The blood pressure is 124/78 mmHg and temperature is 37 oC.
There is no pallor, jaundice, puffiness of eyelids or ptrygium. There is no
central cyanosis, sublingual icterus or tongue coating. Trachea is centrally
placed, no neck swelling and dilated vein. Jugular venous pressure is not raise
and there are no palpable cervical and axillary lymph nodes. There was no spine
deformity nor tenderness over the back. No spider naevi over the chest and
back, no gynaecomastia, no pedal edema and peripheral pulses were palpable.
SYSTEMIC EXAMINATION

DIFFERENTIAL DIAGNOSIS:
1. Acute exacerbation bronchial asthma
2. Pneumonia
3. Foreign body
PROVISIONAL DIAGNOSIS:
Acute exacerbation bronchial asthma

DISCUSSION
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Asthma is a chronic inflammatory disease of the airways characterised by

reversible airways obstruction and bronchospasm. Exacerbations in children are
often precipitated by viral infection. In children less than 12 months of age
presenting with wheeze, consider the diagnosis of bronchiolitis. Wheeze in
preschoolers may not only be caused by reversible bronchospasm - this age
group may not respond well to bronchodilators and steroids may be less
effective. Steroids should only be given in this age group for admitted patients or
those with previous ICU admission - this should be discussed with a senior doctor.
For history, inquire specifically about the duration and nature of
symptoms, treatments used (relievers, preventers), trigger factors (including
upper respiratory tract infection, allergy, passive smoking), pattern and course of
previous acute episodes (eg. admission or ICU admissions), parental
understanding of the treatment of acute episodes, and the presence of interval
symptoms.
On examination, the most important parameters in the assessment of the
severity of acute childhood asthma are general appearance/mental state and
work of breathing (accessory muscle use, recession), as indicated in the table.
Initial SaO2 in air, heart rate and ability to talk are helpful but less reliable
additional features. Wheeze intensity, pulsus paradoxus, and peak expiratory
flow rate are not reliable. Asymmetry on auscultation is often found due to
mucous plugging, but warrants consideration of foreign body.

Diagnosis of asthma is based on a good history and physical examination.

Investigations are not usually necessary. Response to bronchodilator therapy,
that is, symptomatic improvement in the younger child or improvement in the
PEFR of >20% or FEV1 of >12% is usually supportive of the diagnosis of asthma.
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PEFR may show significant diurnal variability. Raised exhaled nitric oxide and
positive skin prick tests to aeroallergens are all supportive features of asthma.

REFERENCES:
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1. Clinical Practice Guidelines for the management of childhood asthma

2. Michael J Morris, 2016, Asthma, Medscape retrieved from
http://emedicine.medscape.com/article/296301-overview