BY:

SHAZLIN BT. SABAAH

SALWA HANIM BT. MOHD. SAIFUDDIN
KAMARULZAMAN B. MUZAINI
DEMOGRAPHIC DETAIL
Initials : MH
Age : 6 years and 8 months old
Ethnicity : Malay
Gender : Male
DOA :23/12/2010
DOD : 25/12/2010
Informant : Grandmother
 PRESENTING COMPLAIN
MH, a 6 years and 8 months old Malay boy, a known case
of G6PD and asthma was admitted to HSB due to fever,
cough and 1 episode of vomiting since one day prior to
admission and S.O.B and rapid breathing 4 hours prior to
admission.
HISTORY OF PRESENTING COMPLAIN
He was previously well until 1 day prior to admission when he
started to develop fever.
The fever was sudden onset and low grade as he was warm to
touch
Grandmother claimed that the fever might be due to playing
actively during the evening.
There is no chills or rigor.
His mother gave him syrup PCM but fever didn't subside.
He vomit once after taking the medication.
The vomitus contain some clear mucus and also the medication.
The amount is about one table spoon
Not blood-stained or bile-stained.
 cont..

The fever also associated with productive cough

Sputum was light yellow in colour with some clear mucus.
Amount was about one tea spoon.
It occurred mostly during night.
Patient did not take any medication for this problem.
At night, mother noticed that he was snoring during sleeping.
Then around 12a.m, he suddenly awaken from sleep. He starts
to cough continuously and develop the shortness of breath
together with rapid breathing. He was then brought by his
grandparents to HSB.
 cont..
Came to Sg. Buloh to visit aunt since 2 days prior to
admission.
Both his and his aunt housing area are not a dengue prone
area.
His father just recovered from fever 1 week prior to MH
admission
No other family members have the same symptom like him
SYSTEMIC REVIEW
CVS : No excessive night sweating, no orthopnea.
CNS : No headache/dizziness, no episode of fainting or fit
attack.
GIT : No constipation, no diarrhea, normal bowel habit.
MSK : No muscle pain or join pain.
Urinary System: No dysuria or hematuria.
Skin : No rashes or itchiness.
ENT : No sore throat, no runny nose.
 PAST MEDICAL/SURGICAL Hx
He has been diagnosed to have asthma since he was 4 years old.
The pattern of the attack is once in 2 months
It occur mostly when px took cold drinks, cold weather or do
vigorous exercise
He also has the intervals symptoms of cough and wheezing.
The last attack was on October
Took nebulizer at GP/hospital in Ipoh if attack occur but no
hospitalization required.
No hx of eczema.
 DRUGS Hx
He is not on any medication
Doctor advice him to take MDI but mother insist as she claimed
that px did not know how to handle the medication.
 ALLERGIES

No known allergies
 BIRTH Hx
Born at Hospital Kota Baru
FTSVD
Weight : 2.5kg
Antenatal, intrapartum and postpartum hx was uneventful
Admitted to NICU for 15 days due to neonatal jaundice
diagnosed to have G6PD
 FEEDING Hx
Grandmother did not recall how long he had exclusive
breastfeeding
Currently he is on family diet with balance and adequate amount
of fish, meat and rice
 IMMUNISATION Hx
Up to his age
Didnt have any complications after taking the injections
BCG HepB DTaP IPV Hib MMR
After birth

1 month

2 months

3 months

5 months

6 months

12 months

18 months

6 years
 DEVELOPMENTAL Hx

Up to his chronological age. He is currently at preschool and his

performance is good.
Gross motor : Can walks heel to toe, Can kick, climbs
and throwing, can ride tricycle.
Fine motor : Can imitate or copies pictures like steps
with 10 cubes , can write his name
Speech and language : Can speak fluently, knows age, knows
ABC and numbers.
Social :Can dresses and undresses alone.
FAMILY Hx
2nd child out of 3 siblings
Both father and mother have asthma and currently on
medication.
Grandmother in paternal side also have asthma.
Elder sister is 3 years old and younger sister is 13 months
old. Both of them are well
No history of consanguinity
SOCIAL & ENVIRONMENTAL Hx
Live with parents and 2 siblings at Ipoh, Perak
Father is a policeman
Father is a smoker but did not smoke inside the house or near
the patient.
Mother is a housewife
Live in their own terrace house with adequate basic
amenities.
The total income is about RM 2000
Dont have any cats or carpet in house.
EFFECT OF ILLNESS
They have to delay their plan to return back to Ipoh since
patient was admitted.
Father have to take leave from works for a few more days.
Regarding the asthma, he had to go to GP several times in
order to get the treatment if the asthma attack occur. Thus, a
lot of time and money have been spent.
The asthma also affecting MH lifestyle since this condition
had restricted him from doing certain activities or eat certain
food.
However, the disease didnt give much effects in his school
activities.
 MH was sitting on the bed comfortably. His grandmother was

sitting next to him. He was conscious and cooperative and

orientated to time and place. He is not in pain. He was in
respiratory distress as there was suprasternal and subcostal
recession. His hydration and nutritional status were good.
There was a brannula attached to the dorsum of his left hand.
No gross deformities and abnormal movement seen.
 Temperature : 38.50C

Blood pressure : 115/66 mmHg, regular rhythm and normal

volume

Pulse rate : 110 beat per minute

Respiratory rate: 32 breaths per minute

Impression:

His vital signs are normal.

 Height : 110cm. (10th centile)

Weight : 17kg. (10th centile)

BMI : 14.05kg/m2. (10th centile)

Impression:

His growth is within 10th centile.

4. EXAMINATION FACE, HEAD, NECK & LIMBS
Appearance: No dysmorphic features.

Face: No cyanosis, no pallor, no pursed lips.

Oral cavity:

Moist tongue and mucous membrane

No gum bleeding

No ulcers

No central cyanosis

Oral hygiene was good

Eyes: No yellow discoloration, pink conjunctivae

Ear, nose and throat: There was no nasal discharge, no ear

discharge and the throat was mildly injected.

 Neck: No cervical lymph nodes enlargement.

Skin: Normal skin tone,no eczema, no rashes and no petechiae.

Extremities:

Warm peripheries

No cyanosis at the nail bed

No clubbing of fingers

No palmar erythema

Capillary refilling time was less than two seconds

No peripheral oedema

No koilonychias.

Impression: No abnormal findings.

1.RESPIRATORY SYSTEM
Inspection:

The chest was barrel shape. There was no scar on the chest wall and no
dilated veins. There were suprasternal and subcostal recession. The chest
moved symmetrically with respiration.

Palpation:
The trachea was centrally located. The chest expansion was symmetrical
bilaterally. The apex beat was palpable at 5th intercostals within
midclavicular line. Vocal fremitus was equal bilaterally.
 Percussion:

Resonance bilaterally.

Auscultation:

Normal air entry bilaterally.

Vesicular breath sound with prolong expiratory.

Ronchi during expiration on the upper zone bilaterally.

Impression:

MH was having respiratory disorders evidenced by suprasternal and

subcostal recession and presence of added breath sound, ronchi during
expiration on the upper zone of his chest.
 Inspection:
There were no visible pulsations, surgical scars, cardiac bulging or
superficial dilated veins at precordial area.

Palpation:
Apex beat was palpable at the 5th intercostals space lateral to midclavicular
line. There was no thrill or heave.

Auscultation:
The first and second heart sounds were heard with normal intensity and
frequency. There was no additional heart murmur detected.

Impression: There were no abnormal findings

 Inspection:
The abdomen was not distended and moved with respiration. The umbilicus was
centrally located and inverted. There were no surgical scars

Palpation:
The abdomen was soft and non-tender. There was no hepatosplenomegaly. Both kidneys
were not ballotable.

Percussion:
The abdomen was tympanic. There was negative shifting dullness and no fluid thrills.

Auscultation:
Normal bowel sound present.

Impression: No abnormal findings.

 Cervical / Supraclavicular Nodes Right submandibular lymph node
enlargement

Axillary Node- not palpable

Inguinal Nodes not palpable

Other groups of Lymphnodes (specify) not palpable

Impression: Infection causing enlarged lymph node.

 Mental status: She was alert and well oriented to time, place and
person.

Cranial nerves: Intact.

Motor system
Inspection:
The upper and lower limbs were symmetrical. There was no muscle
wasting, abnormal movement or posture, or gross deformity. The skin was
normal and there was no surgical scar or fasciculation seen. The muscle
bulk was equal bilaterally and not wasted.

Muscle tone: The muscle tone of the upper and lower limbs was normal.
 Muscle power: The power of all muscles tested in the upper and lower limbs
was normal, with grade 5/5.

Reflexes: The reflexes of upper and lower limbs were present with normal
intensity. Babinski reflex was negative.

Coordination: The coordination of the upper and lower limbs was normal.

Gait: Normal.

Impression: No abnormal findings.

 MH, 6years old Malay boy, a known case of asthma and G6PD deficiency

was admitted due to fever and cough one day prior to admission, shortness

of breath and rapid breathing 4hours prior to admission.

On physical examination, the chest was barrel shaped, suprasternal and

subcostal recession, vesicular breath sound with prolong expiration and

ronchi on upper zone bilaterally during expiration was noted.

 Bronchial asthma

Points to support:
Known case of asthma since 2years ago
MH developed shortness of breath and rapid breathing that was
exacerbated by cough
Vesicular breath sound with prolong expiration
Suprasternal and subcostal recession
Ronchi was heard on the upper zone during expiration bilaterally
Differential Diagnosis Points to support Points to against

BRONCHOPNEUMONIA Fever On percussion lung is

Difficulty in breathing resonance bilaterally
Tachypnoea on auscultation, normal
Lethargy vesicular breath sound
are heard.

BRONCHIOLITIS Low grade fever Usually in children less

Mild coryza than 2years
Cough and wheeze
Chest wall recession

VIRAL CROUP Low grade fever No barking cough

Cough and coryza Stridor on inspiration
 1) Full Blood Count and automated differentials
Components Result Normal
White blood count 10.51x103/L 4.5-13.5
Red Blood Cell 4.17X106/L 4.0-5.4
Hemoglobin 11.4g/dL 11.5-14.5
Hematocrit 34.2% 37.0-45.0
MCV 82.0fL 76.0-92.0
MCH 27.3pg 24.0-30.0
Red Distribution 14.5% 30.0-100.0
Width
Platelet 396x103/L 150-400
Neutrophil % 82.8% 40-75
Neutrophil # 8.71x103/L 2.9-7.9

Lymphocyte % 11.5% 20.0-50.0

Lymphocyte # 1.20x103/L 1.8- 4.0
Monocyte % 2.4% 0-8
Monocyte # 0.25x103/L 0.0- 1.6
Eosinophil % 1.9% 0-5
Eosinophil # 0.20x103/L 0.4- 2.1
Components Result Normal Unit
pH 7.408 7.35-7.45
HCO3 22.5 22-29 mmol/L
Base excess -1.5 (-3)-(+3) mmol/L

Impression: Normal
 Normal
 ED:
Salbutamol Nebulizer cont 1hour
Oxygen mask
IV hydrocortisone
Ipratropium bromide: 4hourly
IV fluid-maintainance
Blood investigation: FBC, VBG, electrolyte
If not, IV salbutamol or aminophyline
If the symptoms persist, intubation.

Monitoring: vital signs, SpO2, VBG

Syrup prednisolone 17mg OD 5/7

mdi fluticasone 125mcg BD

mdi salbutamol 200mg 4 hourly

At home:
Avoid allergens
syrup prednisolone
MDI Salbutamol
DISCUSSION OF ASTHMA

KAMARULZAMAN BIN MUZAINI

2008402286
DEFINITION

Chronic inflammatory disorder

of airways that causes recurrent
episodes of wheezing,
breathlessness, chest tightness
and coughing.
RISK FACTORS

Host Factors Environmental

Factors
Genetic Indoor /allergens
predisposition Socioeconomic
Atopy factors
Airway hyper- Family size
responsiveness
weather changes
Gender
Race/Ethnicity Obesity
TRIGGERS FACTORS
Allergens
Smoke (passive smoker)

Respiratory infections

Exercise and hyperventilation

Emotional upset or excitement

Food, additives, drugs

Pathogenesis of asthma
Enviromental factors Genetic factors

Bronchial inflamation

Bronchial hyperactivity + trigger factors

Oedema , bronchononstriction, & increase mucous production

Airways narrowing

Symptoms:
-cough
-wheezing
-breathlessness
-chest tightness
CLINICAL FEATURES

Cough
Chest tightness
Wheezing sound of breath
Episodic shortness of
breath
Worsen during night
Various severities of asthma
Classification of asthma severity
- Mild intermittent
- Mild persistent
- Moderate persistent
- Severe persistent

*In this patient, it is mild intermittent.

*Patient only developed asthma once in two month.
DIAGNOSIS
History and patterns of symptoms
Physical examination
Measurements of lung function
Measurements of allergic status to
identify risk factors
TAKING HISTORY
Since when it start & previous attack?
- since 4 years old, once in 2 months, last attack was on
October
Aggravating and relieving factors?
-cold drinks, cold weather or do vigorous exercise
Have any prolong URTI sx? - No significance
Prev hospital administration?
- No hospital administration before this.
History of atopy? - No eczema
Family history of asthma? -Strong family hx of asthma
Impact on lifestyle?
-Not impact patient lifestyle as he only developed mild
intermittent asthma
PHYSICAL EXAMINATION
OBSERVATION
-(tachypnic, wheezing, drowsiness, central cyanosis, hyperinflated
chest, head bobbing, peripheral cyanosis, using accessory muscle
when breathing, SCR ,ICR & suprasternal recession)

PALPATION
- Decrease symetrically chest wall expansion

PERCUSSION
-resonance

AUSCULTATION
-(reduced breath sound, rhonci, vesicular breath sound with
prolong expiration time)
INVESTIGATION

1)LUNG FUNCTION TEST

This can be done by using Peak Expiratory Flow Rate(PEFR).
2)Blood and sputum test.
Asthmatic patient may have increase
number of neutrophils in pheripheral
blood

3)Chest X-ray.
Helpful in excluding a pneumothorax /
pneumonia.
Criteria for admission
1. failure to respond to standard home
treatment
2. Failure of those with mild or moderate acute
asthma to respond to nebulised B2-agonist.
3. Relapse within 4 hours of nebulised B2-agonist.
4. Severe acute asthma

* This patient was admitted to ward because failed respond

towards the nebuliser salbutamol given in the ED.
Common management for AEBA
Gives neb oxygen
+ neb salbutamol
+ neb ipratopium bromide
+ IV hydrocortisone
+ hydration IV normal saline
If symptoms not subside, gives IV salbutamol
If symptoms still not subside, do
endotracheal intubation and gives mechanical
ventilation.
MANAGEMENT
Give drug treatment to the patient by following the
severity of the asthma.
Hydration-give maintenance fluid
Monitor pulse, colour, PEFR, VBG and SPO2. (4 hrly)
Antibiotic indicated only if bacterial infection
suspected
Avoids sedatives and mucolytics
Health education involving the parents and their
asthmatic child.
-how to recognized & treat worsening asthma
-when to seek for medical attention
-how to used MDI correctly
Impact of asthma
Night cough, disturbed sleep
Restriction in activity / exercise
Increased school absences (not able to pay
attention in the class, academic performance will drop)
Ongoing symptoms may have a detrimental effect
on physical, psychological and social well-being

* Patient only had continuous night cough and sleeping

disturbance during the attack.
Acute severe asthma
Inability to complete a sentence in one
breath.
Respiratory rate >50/min
Tachycardia >140/min
PEFR <50% from normal
LIFE-THREATENING ASTHMA
Silent chest and cyanosis.
Exhaustion,confusion or coma.
PEFR <33% of prediction.
PREVENTION
Education of the family members is a vital
role :
- teaching basic asthma facts
- explain role of medication given
- teaching environmental control measures
- improving parents skills in the use of spacer
device MDI.
*in this case, the parents of the patient did not
know how to use the device & his father is a
smoker
COMPLICATION

STATUS ASTHMATICUS
-Is an acute exacerbation of asthma attack
which do not respond adequately to
therapeutic measures and required
hospitalization
Thank you