Asthma

CASE REPORT

By:
NURFI PRATIWI
NIM. 1508434430

Pembimbing : dr. Riza Iriani Nasution, Sp.A

Kepaniteraan klinik bagian Ilmu Kesehatan Anak

Fakults kedokteran Universitas Riau
RSUD Arifin Achmad
Pekanbaru
2016
Definition
Asthma is a chronic airway inflammation, characterized
by recurrent attacks of breathlessness and wheezing,
which vary in severity and frequency from person to
person and often starts in childhood.

Epidemiology
The prevalence of asthma in
children aged 5-14 years old in
Indonesia is 16,78%.
Etiology
Intrinsic
Genetic
Sex
obesity
Enviromental
Alergen
Infections : virus, bacteria,
fungi, parasite
Tobacco smoke
Pollution (indoor & outdoor)
pathogenesis
Severity of asthma

Mild-moderate Severe attack Life threatening

attack Inappropriate word Sleepy
Inappropriate Sitting with an lethargy
statements appropriate arm No audible
prefer to sit than (crouching) breathing sounds
lying agitated
not agitated Increased
Increased respiratory rate
respiratory rate Increased pulse
Increased pulse frequency
frequency Deeper retraction
Mild retraction SpO2 <90%
SpO2 90-95%
Stage diagnosis of asthma

Initial
Current condition Level of control
classification
Intermitten Without uncontrolled
mild persitent simptoms Partly
moderate simptoms controlled
persistent Mild moderate Well controlled
severe attack
persistent Severe attack
Life
threatening
Diagnosis
Indicator of level of
History control
Daytime symptoms
Physical Night waking due to
asthma
examination
Reliever needed for
Supported symptoms
Any limitation of activity
examination Risk factor for severity
Management of asthma attack

Mild or moderate Life-threatening or

exacerbations severe acute asthma
SABA inhaler or nebulized combination
nebulizer ipratropium bromide
recommended to give and SABA
3 times in 1 hour systemic
The combination of corticosteroids
SABA and ,oxygen and
ipatropium intravenous fluid
bromide on the 3rd
nebulizer
 CASE REPORT

Identity

Name : SC
Sex : Female
Age : 4 years old
Address : Jl. Kenari, Pekanbaru
Date of admission : June 9th 2016
No.MR : 898628
ANAMNESIS
Alloanamnesis with patients mother
Chief complaint : breathlessness one day before
admission
2 days before admission
Unproductive cough, cough leading to
breathlessness. Fever (+) temp. Down with
paracetamol

1 day before admission

Patient feels breathlessness after eating
chocolate breathlessness for 30 min.
wheezing (+)
 Past iIlnes History Family Illness History
The patient had asthma history since 2 The uncle had asthma history
months old Father had allergic history

Parental history Pregnancy history

Father : Construction worker Aterm, SC, weight of birth 3500 gr
Mother: Housewife No complaint when preganant

Feed history Vaccination history

Breast feeding: 0-7 months BCG (+) / Polio (+) / DPT (+) / Hib (+) /
Milk formula: 7 months 1 year Measles (-)
Food : 1 year - now Based on age

Growth history Developmental history

Birth of weight 3000 gr Appropriate
Weight 25 kg
Hright of birth (-) Height 136 cm

House and living history

Permanent house
Sanitary water from well
Drinking water from gallon
Physical Examination
GA : moderate illness
Height : 100 cm
Conscience : composmentis
Weight : 14 kg
HR : 122 x/i
Arm length : 14 cm
RR : 40 x/i
Head circumference : 49 cm
T : 36,9 0 C

Head : Normocephali, black Ears : Within normal limit

hair, uneasy to grab Nose : Within normal limit
Eyes : pale conjungtiva (-), Mouth : Dry lips, stomatitis(-)
icteric sclera (-)
Neck :Lymph node
round pupil isokor, 2 enlargement (-)
mm/2 mm
Neck stifness : (-)
light reflexes (+/+)
Thorax Exam

Inspection : Symmetrical shape and chestwall movement,

suprasternal retraction (+),subcostal retraction (+) ictus cordis unseen
Palpation : Symmetrical vocal fremitus, unpalpable ictus cordis
Percussion : Sonor on both lungs. Normal heart limit.
Auscultation : Vesiculer (+/+), wheezing (+/+, ronkhi (-/-) Heartsounds I
dan II regular, gallop and murmur not found

Abdominal Exam

I : Look flat, scar (-)

P : Flexible, epigastrium tenderness (-), organomegali (-)
P : Tympani (+)
A : Normal peristaltic sound

Extremity

Warm extremity, CRT <2 Edema (-)

Neurological Status : - Patological reflexes (-), - Physiological reflexes (-)
Laboratory finding
Blood test : 9 June 2016
Hb : 13,1 gr/dl
Ht : 39,3%
Leucocyte : 17.070/UI
Platelet : 254.000/UI
 Diagnosis Treatment Prognosis

Working diagnosis : Quo ad vitam : dubia ad

acute exaserbation -O2 2 L/minute bonam
asthma --Dexametason injection
2,5mg/8 hours
Nutritional diagnosis : -First and second Quo ad functionam :
Mild malnutrition nebulizer : Vantolin dubia ad bonam
-Third nebulizer :
pulmicort
Follow up
Hari/tanggal subjektif objektif assesment therapy
10/6/2016 breathlessness (+), GA : moderate illness acute - IVFD KaEn IIIb 30
Conscience : composmentis
productive cough RR : 32 x/I
exaserbation cc/jam
(08.00 WIB) (+), of asthma
HR : 98 x/I - O2 2L/i
T: 36,9 C broncial
Eye : pale conjungtive (-/-), - Inj. Dexamethason
Thoraks 2,5 mg/8 hour
Inspection : simetrical,
suprasternal retraction (+), - Nebulize conbivent
subcostal retraction (+) + NaCl 0,9% 2 cc/
Intercostal retraction (+)
Auscultation : vesikuler (+/+), 8hour
wheezing (+/+), ronkhi (-/-)
Abdomen : within normal limit
Extremity : Warm limbs, CRT < 2
seconds, edema (-)
11/6/2016 breathlessness (-), GA : moderate illness acute - IVFD KaEn IIIb 30
Conscience : composmentis
productive cough RR : 26 x/I
exaserbation cc/jam
(08.00 WIB) (+), of asthma
HR : 86 x/I - O2 2L/i
T: 36,5 C broncial
Eye : pale conjungtive (-/-), - Inj. Dexamethason
Thoraks 2,5 mg/8 hour
Inspection : simetrical, subcostal
retraction (+) - Nebulize conbivent
Auscultation : vesikuler (+/+), + NaCl 0,9% 2 cc/
wheezing (+/+), ronkhi (-/-)
Abdomen : within normal limit 12 hour
Extremity : Warm limbs, CRT < 2
seconds, edema (-)
Day/date subjectif objectif assesment therapy
13/6/2016 breathlessness (-), GA : moderate illness acute exaserbation - IVFD KaEn IIIb 30
Conscience :
productive cough composmentis
of asthma broncial cc/jam
(08.00 WIB) (+), RR : 24 x/I - O2 2L/i
HR : 86 x/I
T: 36,5 C - Inj. Dexamethason
Eye : pale conjungtive 1,5 mg/8 hour
(-/-),
Thoraks - Nebulize ventolin +
Inspection : simetrical, NaCl 0,9% 2 cc/ 24
Auscultation :
vesikuler (+/+), hour
wheezing (-/-), ronkhi - Ambroxol 3 x 2,5 mg
(-/-)
Abdomen : within - Salbutamol 1 x 2,5
normal limit mg
Extremity : Warm
limbs, CRT < 2
seconds, edema (-)

After the fourth day of treatment, the patient allowed to go home

because there are clinical improvement in patients.
breathlessness and wheezing are disappear.
Patients allowed to go home and given drugs cefixime , salbutamol
and ambroxol
The patient should be given steroid sistemik for reliever
Discussion
Sign and simptom Diagnosis
Breathlessness Diagnosis in emergency unit
Productive cough Acute exaserbation of asthma
wheezing
Intermitent asthma on severe attack,
Appears twice in a week partly controlled
Inappropriate statements
prefer to sit than lying
On medication
Therapy in emergency unit
O2 nasal canul 3L/menit,
Oxygen therapy should be guided by pulse oximetry

Nebulizer of Ventolin 2x, nebulizer of pulmicort 1x

Salbutamol cause relaxation of airway smooth muscle.
Ipratropium bromide is an anticholinergic that stimulates the sympathetic
nerves and relax the muscles of the airways.
The combination b2 agonist and cholinergic nebulizer will effect better
bronchodilatation
Thankyou