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
 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
 Didn’t 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
 Don’t 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 didn’t 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/µL 4.5-13.5
Red Blood Cell 4.17X106/µL 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 Width 14.5% 30.0-100.0
Platelet 396x103/µL 150-400
Neutrophil % 82.8% 40-75
Neutrophil # 8.71x103/µL 2.9-7.9

Lymphocyte % 11.5% 20.0-50.0

Lymphocyte # 1.20x103/µL 1.8- 4.0
Monocyte % 2.4% 0-8
Monocyte # 0.25x103/µL 0.0- 1.6
Eosinophil % 1.9% 0-5
Eosinophil # 0.20x103/µL 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, ch
est 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