CASE PRESENTATION

BRONCHIAL ASTHMA
FIORENZO RUIZ JAIRIN
BPP2020-0200
PATIENT PARTICULARS
REGISTRATION NUMBER: 12-5116

SEX: FEMALE

RACE: KADAZAN

OCCUPATION: CLERK

AGE: 27

HOSPITAL/CLINIC: PENAMPANG CLINIC

DATE: 30/09/2021
PATIENT’S HISTORY
CHIEF COMPLAINT
● SHORTNESS OF BREATH X 1/7
HISTORY OF PRESENT ILLNESS
● PATIENT COUGHING WITH
YELLOWISH SPUTUM
● NO FEVER
● NO VOMITING
● NO DIARRHEA
● NO TACHYPNEA
PAST MEDICAL HISTORY
● PATIENT NEVER ADMITTED TO
HOSPITAL SINCE DIAGNOSED WITH
BRONCHIAL ASTHMA WHEN SHE AS
7 YEARS OLD
● PATIENT WAS ON INHALER
SALBUTAMOL 2 PUFF TDS/PRN
FAMILY HISTORY
● NO FAMILY HISTORY OF DIABETES
MELLITUS
● NO HISTORY OF HYPERTENSION
● PARENTS AND OTHER SIBLINGS
NOT HAVE BRONCHIAL ASTHMA
SOCIAL HISTORY O&G
● NON-SMOKER ● NOT RELATED
● NON-ALCOHOLIC
● PATIENT IS SINGLE
REVIEW OF SYSTEMS
CVS
● NO CHEST PAIN
● NO PALPITATION

RESPIRATORY
● CHEST SYMMETRY
● TIGHTNESS
● BREATHLESSNESS
● COUGHING
● NORMAL CHEST EXPANSION
ENDOCRINE CIRCULATORY
● NORMAL ● NO PALE
● NO TREMOR ● NO DIZZINESS
● NO ENLARGEMENT OF LYMPH
NODES

MUSCULOSKELETAL NERVOUS
● NO INJURY
● NO DEFORMITY
● NO SWELLING
● HAND AND LEG MOVEMENT
● NO OEDEMA
NORMAL
PHYSICAL EXAMINATION
GENERAL EXAMINATION: VITAL SIGNS:
SKIN TONE PINK, CONSCIOUS, ACTIVE 1. PAIN SCORE: 4/10
SPEECH, ALERT 2. BODY TEMPERATURE: 36.4 CELCIUS
3. PULSE: 90 BPM
4. WEIGHT: 65KG
5. RESPIRATION: 21/MIN
6. RHYTHM: NORMAL
7. BP: 120/75mm/Hg
8. VOLUME: GOOD
EXAMINATION OF HEAD AND SPECIAL SENSES:

INSPECTION PALPATION
● NO SWELLING ● NO PAIN
● NO DISCHARGE ● NO TENDERNESS
● NO DISCOLORATION ● NO JUGULAR VENOUS PRESSURE
● SYMMETRY EAR,EYE AND NOSE (JVP) RISE
● DRY LIPS
● ABLE TO SWALLOW
CHEST (HEART)
INSPECTION PERCUSSION
● NO SCAR ● NORMAL CARDIAC DULLNESS AT
● NO DEFORMITY AT CHEST REGION 5TH INTERCOSTAL SPACE

PALPATION AUSCULTATION
● NO TENDERNESS ● DUAL RHYTHM
● NO PAIN ● NO MURMUR
● NORMAL APEX BEAT AT 5TH ● NORMAL HEARTBEAT
INTERCOSTAL SPACE
CHEST(LUNGS)
INSPECTION PERCUSSION
● SYMMETRY ● NORMAL CARDIAC DULLNESS
● NORMAL CHEST RISE ● NORMAL RESONANCE AT BOTH
● TIGHTNESS LUNGS
● BREATHLESSNESS
● NO SCAR AUSCULTATION
PALPATION ● HAS RONCHI
● BILATERAL AIR ENTRY
● NO TENDERNESS
● NORMAL CHEST EXPANSION
ABDOMEN
INSPECTION PERCUSSION
● NO SCAR ● NO FLUID THRILL
● NO WOUND
● NO SPIDER NAEVI

PALPATION AUSCULTATION
● NORMAL BOWEL SOUND
● NO TENDERNESS
● NO PAIN
NERVOUS
● NO SWELLING
● NO INJURY
● NO OEDEMA
UPPER AND LOWER EXTRIMITIES
UPPER LOWER
● NORMAL BOTH HAND MOVEMENT ● NORMAL BOTH LEG MOVEMENT
● NO BLEEDING ● NO BLEEDING
● NO DEFORMITY ● NO DEFORMITY
● NO SCAR ● NO SCAR
● NO CLUBBING FINGER ● NO CLUBBING FINGER
● NORMAL CAPILLARY FINGER (<2 ● NORMAL CAPILLARY FINGER (<2
SECOND) SECOND)
SUMMARY OF IMPORTANT AND RELEVANT FINDINGS
DIAGNOSIS
PROVISIONAL DIAGNOSIS: DIFFERENTIAL DIAGNOSIS
● BRONCHIAL ASTHMA ● COPD
● COAD
● BRONCHITIS
● BRONCHOPNEUMONIA
INVESTIGATION
FULL BLOOD COUNT (FBC) RTK/PCR
● MEASURE HB, PLATLET COUNT, ● IDENTIFY FOR COVID-19
HEMATOCRIT, TOTAL WHITE BLOOD
COUNT

RENAL PROFILE
● IDENTIFY HEALTH OF KIDNEY
MANAGEMENT
● PATIENT WAS ADMITTED AT PENAMPANG CLINIC
● PATIENT WAS PLACED AT EMERGENCY ROOM
● PATIENT WAS RESTING IN BED AND TAKING PATIENT HISTORY TAKING
AS MAIN COMPLAINT
● PATIENT UNDERGO GENERAL AND PHYSICAL EXAMINATION
● VITAL SIGNS TAKEN SUCH AS BP, TEMPERATURE, PULSE RATE, PAIN
SCORE AND BREATHING RATE
● PATIENT GIVEN NEBULIZER ATROVENT:VENTOLIN:NORMAL SALINE
(1:2:3)
● PATIENT VITAL SIGN MONITORED EVERY 4 HOUR
MANAGEMENT
● LABORATORY INVESTIGATION:
BUSE - measure kidney function
FBC - detect infection
● RADIOLOGY INVESTIGATION:
CHEST X-RAY
● LET PATIENT REST
● DO RTK/PCR TEST BEFORE ADMISSION TO HOSPITAL
MANAGEMENT
● Doctor plan
a) Continue nebulizer A:V:N (1:2:3) stat
b) IV Hydrocortisone Sodium 250mg STAT
c) Salbutamol 2 puff tds/prn
d) Tab prednisolone 30mg OD
e) Syrup Dephenhydramine HCI 15ml tds
f) Tab Bromhexine HCI 8mg tds
g) Tab Paracetamol 1gm tds/prn
MANAGEMENT
● PATIENT ALLOWED TO DISCHARGE IF CONDITION GETTING STABLE
HEALTH EDUCATION AND ADVICE TO PATIENT
● EXPLAIN TO PATIENT AND HER FAMILY ABOUT THE DISEASE THAT
SHE HAVE AND HOW TO HELP WHEN PATIENT HAVING SHORTNESS OF
BREATH
● EMPHASIZE WHY IT IS IMPORTANT TO TAKE MEDICINE AT RIGHT
TIME AND DOSAGE TO PATIENT AND FAMILY AND CONSEQUENCES
WHAT WOULD HAPPEN WHEN SKIPPING DOSE
● AVOID HIGH RISK ACTIVITY
● TEACH PATIENT TO USE “MEDICAL ALERT” WHEN FACING SEIZURES
ATTACK
● RUSH TO EMERGENCY WHEN HAVING SHORTNESS OF BREATH TO GET
IMMEDIATE TREATMENT
REFLECTIVE REPORT
DURING MY CLINICAL AT PENAMPANG CLINICAL, I HAVE LEARN MANY
MEDICAL CASES AND I CHOOSE BRONCHIAL ASTHMA AS MY CLERKING
CASE. I HAVE INTERVIEWED AND OBSERVE THE PATIENT WHEN MY
CLINICAL AT THIS CLINIC. I LEARNED A LOT NEW KNOWLEDGE FROM THE
STAFF THERE ABOUT THE MEDICATION AND HOW TO HANDLE PATIENT
WITH THIS DISEASE BEFORE THE CONDITION GETTING WORSE. APART
FROM THAT, I ALSO HAVE LEARN ETIOLOGY AND PATHOPHYSIOLOGY OF
BRONCHIAL ASTHMA AND THE PREVENTION OF COMPLICATION OF THIS
DISEASE.