DEMOGRAPHY

Name: Cahaya
Age: 4 years 4 months old
Gender: Girl
Race: Malay
Address: Batu Kurau
Date of admission: 17/4/2018
Date of clerking: 18/4/2018
Date of discharge: 19/4/2018
Informant: Mother

HISTORY PRESENTING ILLNESS

Fever for 4 days, cough and rapid breathing for 3 days.

HISTORY OF PRESENTING ILLNESS

Cahaya has underlying Bronchial Asthma, came to the Pediatrics Ward after being referred from the
Emergency department for having fever for 4 days, cough and rapid breathing for 3 days. The fever was of sudden
onset and continuous throughout the four days. It is relieved temporarily by Paracetamol given by the Klinik
Kesihatan 1Malaysia and not exacerbated by any measure. There was flu like symptoms reported by the mother,
which had clear discharge. Temperature of fever was 38.6ºC at the emergency department.
As for cough, it was chesty in nature and Cahaya is unable to expectorate the sputum. She was found to
cough throughout the day especially during the night to a point where the child could not sleep. On the other hand,
she was reported to have rapid breathing for 3 days which started in the morning and worsened in the evening. Her
mother noted that there was chest recession, however she denied of her child turning blue or cyanosed. It was
associated with noisy breathing. Cahaya was then brought to Klinik Kesihatan 1Malaysia and was discharged with
cough medication as well as syrup Paracetamol. Unfortunately, the rapid breathing and cough persist even after
medication was given. The next morning, she was rushed to the Emergency Department and nebulized in the asthma
bay. She was given the nebulizer twice within four hours and fever medication in between. Mother claimed that she
was quite agitated at that time as she was tired and can only speak in phrases. Later, she was referred to the Pediatrics
department since the rapid breathing still persist.
Furthermore, Cahaya was reported less active since the first day of illness and she had poor oral intake.
There was no history of sick contact at home, however mother is unsure of the condition in the kindergarten Cahaya
goes to.

SYSTEMIC REVIEW
CVS: No history of cyanosis
GIT: There was history of vomiting on two occasions both on different days. Other than that, there is no
other relevant history.
EENT: No history of frequent sneezing.

ASTHMA PROFILE
This is Cahaya’s second hospitalization. She was diagnosed with asthma after the first hospitalization in
January 2015 at two years of age, where she had similar symptoms of fever, cough and rapid breathing for a few
days. She was immediately rushed to the hospital and was nebulized in the ward for three consecutive days.
Antibiotics were given too and she responded well to the treatment given. A referral letter was given to visit the
Pediatrics Clinic one month after and she was diagnosed with Bronchial Asthma. At that time, mother claimed she
was given a pump of medication and there was relief noted.
At the end of the visit, she was provided with a blue inhaler (MDI Salbutamol) which has to be taken (one
pump) if Cahaya has persistent coughing or difficulty in breathing and a chocolate inhaler (MDI Budesonide) to be

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taken every day (one pump) either in the morning or at night before sleep. An aerochamber was given to facilitate
the administration of the drugs. Mother claimed that Cahaya responded well with the treatment.
However, there was history of nebulization in June 2017 and March 2018 where on both occasions, Cahaya
was found to be having upper respiratory tract infection but there was no subsequent hospitalization.
In the past 1 month, mother denied of her child having both daytime or nighttime symptoms, but in January
2017, Cahaya was found to have exercise-induced asthma after starting kindergarten. She had rapid breathing while
participating in light sports in school and sometimes mother noticed that she would get tired playing with her little
sister or when she runs around the house. Henceforth, during one of the appointments at the Pediatrics Clinic, she
was advised by the doctor to administer one pump of the blue inhaler (MDI Salbutamol) half an hour before joining
sports or playing and increased from one to pumps of the chocolate inhaler at one occasion (MDI Budesonide) daily
either in the morning or night to prevent the exercise-induced asthma. According to the mother, Cahaya was
responding very well with the course of medication given and there were no symptoms seen during exercise or
while playing. Upon asking to demonstrate the usage of drugs with the aerochamber, the technique was correctly
demonstrated.
Cahaya has allergic rhinitis from time to time after waking up from sleep, where she would sneeze multiple
times. However, it would subside after a few hours without the help of any medications. She has no eczema or
conjunctivitis. Other than that, currently Cahaya has no other known trigger to her asthma other than upper
respiratory tract infection. There is strong family history on the maternal side, where Cahaya’s mother was
diagnosed with Bronchial Asthma when she was 13 years old and currently, on medication and under follow-up
with Physician Clinic Hospital Taiping. There was history of intubation for one day in the ICU during postnatal
period. Currently, she claims that it is under good control.
Her mother is well-versed with the triggers of the house. Therefore, she cleans the house with vacuuming
daily and does damp wiping once in a week to prevent dust accumulation. She changes the bed lining once every
week. There are no carpets and pets at home. She denied of living in a area that has a factory nearby or living near
the roadside with frequent smoke emission from vehicles. Her father smokes at home but not in front of the child.
He does not regularly shower or change his clothing after he smokes.

PAST MEDICAL AND SURGICAL HISTORY

Significant medical history as written above. Other than that, Cahaya has no other comorbidities and there is no
significant surgical history.

DRUG OR ALLERGIC HISTORY

There is no known allergic to drug or food.

PAEDIATRIC HISTORY

Prenatal History
Cahaya’s mother was 22 years old when she was pregnant of her. She attended all the antenatal check-up
along the period of pregnancy. According to her, she was healthy and there were no complications like
pregnancy-induced hypertension, gestational diabetes mellitus or preeclampsia along the period of pregnancy. She
did not smoke or consume alcohol during the pregnancy.

Birth History
Cahaya is the first child born at term through spontaneous vaginal delivery in Hospital Taiping without any
complications with the birth weight of 3.2kgs. Mother is unsure of the APGAR score.

Neonatal History
Cahaya was reported to have neonatal jaundice for a few days but was not hospitalized because of it as it
resolved spontaneously.

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Feeding & Nutritional History
Cahaya was not breastfed when she was younger, as her mother was admitted to the ICU for a day after
having exacerbation asthma subsequently after giving birth to her. She was given bottled formula milk up till
now. She weaned normally at six months. She is currently practising adult diet and is not a picky eater. She is
drinking Dumex formula milk everyday twice of 3 scoops in 320mls of hot water.

Immunisation History
Immunizations are all up to date and there were no reported side-effects after administration.

Developmental Milestones
Gross Motor : can jump and climb up the stairs
Vision & Fine Motor : write alphabets and colouring within the lines
Hearing, Speech & Language : point objects and naming them
Personal Social : smiles and laugh, showers on her own and able to wave her hand
Conclusion: His developmental milestone is up to age

FAMILY HISTORY
Cahaya is the eldest and she has a sister who is 2 years old. Her sister is healthy and has no history of
hospitalization so far. There is no consanguinity among the parents. Mother has asthma that was diagnosed at the
age of fifteen years old and currently under follow up with Physician Clinic Hospital Taiping. She is currently on
red inhaler (MDI Flixotide) and claims that it is well-controlled.

SOCIAL HISTORY
Cahaya is taken care by both her parents. Her father works as machine operator in the village and her
mother is a housewife. They are both financially stable. Cahaya’s social life is not affected by her ailment, she is
still playful and loves to make friends. There is no restriction of activity.

PHYSICAL EXAMINATION

On general inspection, Cahaya has a small body built, lying down supine on the bed playing with a phone. She is
alert, conscious and seem to be tachypnoeic. She has a nasal prong attached to 2L of Oxygen and a yellow branula
attached on the dorsum of her left hand. She looks like she in respiratory distress.

Anthropometric measurement:
Height : 99 cm (on the 50th centile)
Weight : 12.5 kg (between 10th to 25th centile)
Head circumference : 49 cm (between 25th to 50th centile)
Conclusion: Cahaya is growing up to the requirement needed for her age.

Vital Signs:
Temperature : 36.5°C
Pulse Rate : 156 beats/ minute, regular rhythm, normal volume
Respiratory Rate : 40 breaths/ minute
Blood pressure : 102/65mmHg
Oxygen saturation : 98% under room temperature
Comment: She is not having hyperthermia, hypertension or hypoxia. However, she is tachypnoeic and
tachycardic.

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Hand
The nail bed was pink. There was no clubbing, cyanosis, palmar erythema, leukonychia or koilonychias.
Radial pulse was regular rhythm and normal volume. Capillary refill time was less than 2 seconds. There are no
presence of dry skin or erythema seen over the antecubital fossa or the wrists. BCG scar was present.

Head
Eyes : No jaundice, pallor of conjunctivae or sunken eyes and there is no presence of conjunctivitis.
Nose : Rhinorrhoea with clear mucus, the turbinates were not hypertrophied.
Mouth : No central cyanosis or pallor. The tongue was moist.
Ear : No discharge noted.
Neck : There is no presences of eczema or dry skin over the neck, cervical lymph nodes were impalpable.
Legs : No clubbing, cyanosis and pitting ankle edema.

LOCAL EXAMINATION

Respiratory system
On inspection, there was subcostal and intercostal recession noted. The chest however moves symmetrically
with respiration and there was no other chest deformity noted both anteriorly and posteriorly. There were scars
seen over the chest.
Chest expansion and tactile vocal fremitus cannot be assessed as the Cahaya could not follow commands
properly. There was no displacement of trachea and apex beat was on the fifth intercostal space on the midclavicular
line.
On percussion, there was hyperresonance heard over both lungs anteriorly and posteriorly. Liver dullness
is displaced downwards on the fifth intercostal space. Cardiac dullness was also heard.
On auscultation, reduced air entry is heard on the right side compared to the left side. Generalized ronchi
is heard over both lungs on all lobes and there is basal crepitations heard over the lower lobe of right lung.

Abdominal examination
On inspection, the abdomen was flat and it move with respiration. There is no dilated vein, visible
peristalsis, scar and visible mass. The umbilicus was inverted and centrally located. The abdomen was soft, non-
tender, no palpable mass in light and deep palpation. The liver is two finger breadths palpable and the spleen is not
palpable. Kidneys were not ballotable and shifting dullness was not elicited. On auscultation, bowel sounds were
heard.

SUMMARY
In summary, Cahaya, a 4 years 4 months child who has underlying bronchial asthma diagnosed when she
was 2 years old, came to the Pediatrics ward due to fever for four days, cough and rapid breathing for three days.
She is currently on MDI Salbutamol (one pump during attacks) and MDI Budesonide (two pumps per day). She
has good control of bronchial asthma and reported to have a strong family history of bronchial asthma. Mother is
well-versed with the trigger prevention, however her father is a smoker.

PROVISIONAL DIAGNOSIS
ACUTE SEVERE EXACERBATION OF BRONCHIAL ASTHMA SECONDARY TO
BRONCHOPNEUMONIA
Points for:
1. Fever, cough and rapid breathing.
2. Diagnosed with Bronchial Asthma at two years old due to strong maternal history of Bronchial Asthma
3. Agitated
4. Rapid breathing with agitation and can only speak in phrases
5. Tachypneic of more 40 breaths per minute and tachycardic of 156 beats per minute
6. Usage of accessory muscle was present

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DIFFERENTIAL DIAGNOSIS
Multiple Trigger Wheezing
Points for:
1. There is active infection of the lungs
2. Age of only 4 years old
Points against:
1. There is an established diagnosis of Bronchial Asthma

Foreign Body Inhalation

Points for:
1. Presence of ronchi
Points against:
1. There is no history of choking
2. There was no monophasic ronchi to suggest lung collapse, instead it was generalized heard on both lungs.

Investigations
The following were investigations done in the ward:
1. Full blood count
Reason: to detect any sign of inflammation.
Hemoglobin (10.5-14.0 g/dl) 13.9
Packed cell volume (33-42%) 38
Mean corpuscular volume (70-74fL) 80.9
Mean corpuscular hemoglobin (25-31pg) 29
Neutrophil (30-50%) 72
Eosinophil (1-6%) 0
Basophil (0-1%) 0
Lymphocyte (20-45%) 28
Monocyte (0-1%) 0
Platelet (150,000- 400,000cmm³) 327000
Interpretation: The neutrophil count is increased suggesting a bacterial infection.

2. Blood urea and serum electrolytes (BUSE)

Reason: to detect any electrolyte imbalances which this can cause seizure.
Result:
Sodium (137- 146mmol/L) 139
Potassium (3.8-5.2mmol/L) 4.1
Chloride (97-107mmol/L) 105
Blood urea (1.7-8.3mmol/L) 3.3
Interpretation: There is no presence of hypokalemia. All other components are in normal range.

3. Chest X-ray
Reason: to look for presence of consolidation suggesting pneumonia
Result: There was perihilar haziness on the middle zone of the right side of the lungs. No cardiomegaly
seen.
4. Arterial Blood Gas
Reason: to look for metabolic acidosis as patient is having acute severe asthma
Results: Unfortunately, I could not attain the ABG results.

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FINAL DIAGNOSIS

Acute Severe Exacerbation of Bronchial Asthma Secondary to Bronchopneumonia

TREATMENT
Acute Management
1. Initially, the severity of the acute asthma should be established. For Cahaya, in my opinion, her
condition falls under the severe category as evidenced by tachypnea, tachycardic, usage of
accessory muscles, agitation, audible wheezing and speaking in phrases due to difficulty in
breathing.
2. Monitor her pulse, colour, ABG results and Oxygen saturation every hour.
3. Give nebulizer Salbutamol and if her symptoms persist, she should be given Ipratopium Bromide
of 250mcg four to six hourly.
4. Provide Oxygen on face mask of 8L.
5. Intravenous Hydrocortisone should be given with the dosage of 4mg/kg/dose 6 hourly.
6. If her condition still persists, she should be given Intravenous Salbutamol continuous infusion of
1 to 5mg/kg/min over 10 minutes.
7. Infuse her with normal saline.
8. She should be given IV Penicillin for the pneumonia
9. Paracetamol Syrup should be given for the fever.
Long Term Management
1. We should educate the mother further on technique of administering the inhaler with an
aerochamber, the triggers as well as how to prevent them. Reemphasize the importance of
compliance to therapy.
2. Start an Asthma Action Plan for this patient in order to review her better in the future and prevent
attacks.
2. Continue follow-up with Pediatrics Clinic Hospital Taiping

DISCUSSION

Bronchial asthma is a very common condition affecting both children and adolescents worldwide. It is defined
as a chronic reversible airway inflammation that leads to a hyperresponsive reaction of the airway characterized by
wheezing, coughing, chest tightness and breathlessness which are overt early in the morning or at night. Cahaya is
four years old girl who has been officially diagnosed with bronchial asthma in January 2015, came into the ward
after having an episode of acute exacerbation of bronchial asthma. According to Ortiz-Alvarez and his colleagues
(2012), acute asthma exacerbations is one of the most common reason for presentation to the Emergency
Department (ED) and for hospitalization in the pediatric age. Asthma exacerbation is defined as an acute or subacute
deterioration of symptom control that causes distress or risks health to the extent that a visit to a health care provider
or treatment with systemic corticosteroids becomes necessary. Like in Cahaya’s case, a respiratory tract infection
was found to be the trigger for her condition, and a high number of cases of acute exacerbations are a result of
respiratory infection especially of a viral origin. It is of high importance for healthcare practitioners to grasp the
management of a child with acute exacerbation of asthma since it is very common.
One issue that I would like to address is the fact that Cahaya was diagnosed with Bronchial Asthma at a very
young age, which was when she was only 2 years old. The amount of history I was able to collect on this event
from her mother was quite limited as she could not remember what took place vividly. On first glance, it was quite
shocking for a diagnosis of asthma to be made for a 2 years old girl who came in with fever, cough and rapid
breathing, as she did not have an eventful peripartum or neonatal history that would suggest something congenital
in nature, neither was she able to do a successful peak expiratory flow meter assessment. However, it is possible to

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predict and diagnose asthma in children of less than 5 years old of age using the Asthmatic Predictive
Index. Children under 3 years of age who had four or more episodes of wheezing in the past year that lasted more
than 1 day and affected sleep are significantly likely to have persistent asthma after the age of 5 years if they also
have either one of the followings:
 parental history of asthma;
 a physician diagnosis of atopic dermatitis;
 evidence of sensitization to aeroallergens;

Or two of the following:

 evidence of sensitization to foods
 ≥4 percent peripheral blood eosinophilia
 wheezing apart from colds

Henceforth, in the case of Cahaya, she has had multiple episodes of wheezing before the diagnosis and the fact that
she has a very strong family history of asthma on her mother’s side have permitted such diagnosis. Her mother on
the other hand, was diagnosed with Bronchial Asthma when she was an adolescent. In my point of view, I think
Cahaya is currently under good control and does not need further step up in her management. Her current
management is good enough and only needed to be tweaked if there is an increased frequency of the daytime, night
time and exercise-induced symptoms.