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 Initials : MH
 Age : 6 years and 8 months old
 Ethnicity : Malay
 Gender : Male
 DOA :23/12/2010
 DOD : 25/12/2010
 Informant : Grandmother

 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

 His mother gave him syrup PCM but fever didn't subside.  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. .  The vomitus contain some clear mucus and also the medication.  There is no chills or rigor.  He vomit once after taking the medication.  The amount is about one table spoon  Not blood-stained or bile-stained.HISTORY OF PRESENTING COMPLAIN  He was previously well until 1 day prior to admission when he started to develop fever.

He was then brought by his grandparents to HSB. mother noticed that he was snoring during sleeping.  The fever also associated with productive cough  Sputum was light yellow in colour with some clear mucus.m.  It occurred mostly during night.  Patient did not take any medication for this problem.  Then around 12a. . he suddenly awaken from sleep. cont..  At night. He starts to cough continuously and develop the shortness of breath together with rapid breathing.  Amount was about one tea spoon.

 Came to Sg.  His father just recovered from fever 1 week prior to MH admission  No other family members have the same symptom like him ..  Both his and his aunt housing area are not a dengue prone area. cont. Buloh to visit aunt since 2 days prior to admission.

. no episode of fainting or fit attack.  MSK : No muscle pain or join pain. normal bowel habit.  ENT : No sore throat. no diarrhea.  Urinary System: No dysuria or hematuria.  GIT : No constipation.  Skin : No rashes or itchiness. no runny nose.SYSTEMIC REVIEW  CVS : No excessive night sweating.  CNS : No headache/dizziness. no orthopnea.

 The last attack was on October  Took nebulizer at GP/hospital in Ipoh if attack occur but no hospitalization required. . cold weather or do vigorous exercise  He also has the intervals symptoms of cough and wheezing.  No hx of eczema.  The pattern of the attack is once in 2 months  It occur mostly when px took cold drinks. PAST MEDICAL/SURGICAL Hx  He has been diagnosed to have asthma since he was 4 years old.

. 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 .

meat and rice . 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.

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 √ .

 Gross motor : Can walks heel to toe. knows ABC and numbers.  Fine motor : Can imitate or copies pictures like steps with 10 cubes . . knows age. DEVELOPMENTAL Hx  Up to his chronological age. climbs and throwing.  Social :Can dresses and undresses alone. Can kick. He is currently at preschool and his performance is good. can ride tricycle. can write his name  Speech and language : Can speak fluently.

 Grandmother in paternal side also have asthma.FAMILY Hx  2nd child out of 3 siblings  Both father and mother have asthma and currently on medication. Both of them are well  No history of consanguinity .  Elder sister is 3 years old and younger sister is 13 months old.

 Mother is a housewife  Live in their own terrace house with adequate basic amenities. Perak  Father is a policeman  Father is a smoker but did not smoke inside the house or near the patient. .SOCIAL & ENVIRONMENTAL Hx  Live with parents and 2 siblings at Ipoh.  The total income is about RM 2000  Don’t have any cats or carpet in house.

a lot of time and money have been spent. the disease didn’t give much effects in his school activities. he had to go to GP several times in order to get the treatment if the asthma attack occur.  Father have to take leave from works for a few more days.  The asthma also affecting MH lifestyle since this condition had restricted him from doing certain activities or eat certain food. .  Regarding the asthma. Thus.EFFECT OF ILLNESS  They have to delay their plan to return back to Ipoh since patient was admitted.  However.


His hydration and nutritional status were good. He is not in pain. MH was sitting on the bed comfortably. He was conscious and cooperative and orientated to time and place. He was in respiratory distress as there was suprasternal and subcostal recession. No gross deformities and abnormal movement seen. . His grandmother was sitting next to him. There was a brannula attached to the dorsum of his left hand.

. 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.

(10th centile) Impression:  His growth is within 10th centile. Height : 110cm. (10th centile)  BMI : 14.05kg/m2. . (10th centile)  Weight : 17kg.

 Face: No cyanosis. no pallor. no pursed lips. EXAMINATION FACE. no ear discharge and the throat was mildly injected. . NECK & LIMBS  Appearance: No dysmorphic features.4. pink conjunctivae  Ear. HEAD.  Oral cavity:  Moist tongue and mucous membrane  No gum bleeding  No ulcers  No central cyanosis  Oral hygiene was good  Eyes: No yellow discoloration. nose and throat: There was no nasal discharge.

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 eczema. .  Neck: No cervical lymph nodes enlargement.  Skin: Normal skin tone.  Impression: No abnormal findings.

There was no scar on the chest wall and no dilated veins. The chest expansion was symmetrical bilaterally.1.RESPIRATORY SYSTEM  Inspection: The chest was barrel shape. • Palpation: The trachea was centrally located. . The chest moved symmetrically with respiration. Vocal fremitus was equal bilaterally. The apex beat was palpable at 5th intercostals within midclavicular line. There were suprasternal and subcostal recession.

 Vesicular breath sound with prolong expiratory. ronchi during expiration on the upper zone of his chest.  Auscultation:  Normal air entry bilaterally.• Percussion: Resonance bilaterally.  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. .

cardiac bulging or superficial dilated veins at precordial area.• Inspection: There were no visible pulsations. • Palpation: Apex beat was palpable at the 5th intercostals space lateral to midclavicular line. Impression: There were no abnormal findings . There was no thrill or heave. surgical scars. • Auscultation: The first and second heart sounds were heard with normal intensity and frequency. There was no additional heart murmur detected.

. Inspection: The abdomen was not distended and moved with respiration. There was negative shifting dullness and no fluid thrills. Impression: No abnormal findings. There were no surgical scars  Palpation: The abdomen was soft and non-tender. There was no hepatosplenomegaly. The umbilicus was centrally located and inverted. Both kidneys were not ballotable.  Percussion: The abdomen was tympanic.  Auscultation: Normal bowel sound present.

.not palpable • Inguinal Nodes –not palpable • Other groups of Lymphnodes (specify) – not palpable Impression: Infection causing enlarged lymph node. Cervical / Supraclavicular Nodes – Right submandibular lymph node enlargement • Axillary Node.

 Cranial nerves: Intact. The muscle bulk was equal bilaterally and not wasted. Mental status: She was alert and well oriented to time. The skin was normal and there was no surgical scar or fasciculation seen.  Motor system Inspection: The upper and lower limbs were symmetrical. or gross deformity. abnormal movement or posture. There was no muscle wasting. . Muscle tone: The muscle tone of the upper and lower limbs was normal. place and person.

Reflexes: The reflexes of upper and lower limbs were present with normal intensity. Impression: No abnormal findings. . Gait: Normal. Coordination: The coordination of the upper and lower limbs was normal. Babinski reflex was negative. Muscle power: The power of all muscles tested in the upper and lower limbs was normal. with grade 5/5.

 On physical examination. the chest was barrel shaped. MH. 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. vesicular breath sound with prolong expiration and ronchi on upper zone bilaterally during expiration was noted. suprasternal and subcostal recession. . 6years old Malay boy.

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 .

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 . normal •Lethargy vesicular breath sound are heard.Differential Diagnosis Points to support Points to against BRONCHOPNEUMONIA •Fever •On percussion lung is •Difficulty in breathing resonance bilaterally •Tachypnoea • on auscultation.


25x103/µL 0.17X106/µL 4.0 Monocyte % 2.5-13.0 MCH 27.2% 37. 1) Full Blood Count and automated differentials Components Result Normal White blood count 10.0 MCV 82.0-50.0-45.9-7.8% 40-75 Neutrophil # 8.9% 0-5 Eosinophil # 0.0 Lymphocyte # 1.4.3pg 24.0fL 76.0 Red Distribution 14.6 Eosinophil % 1.4 Hemoglobin 11.9 Lymphocyte % 11.2.5% 30.4% 0-8 Monocyte # 0.20x103/µL 1.4g/dL 11.8.1 .1.5 Red Blood Cell 4.0-92.5 Hematocrit 34.0-30.51x103/µL 4.0.20x103/µL 0.5% 20.5-14.0-5.0-100.0 Width Platelet 396x103/µL 150-400 Neutrophil % 82.71x103/µL 2.4.

45 HCO3 22.35-7.Components Result Normal Unit pH 7.5 22-29 mmol/L Base excess -1.408 7.5 (-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




Chronic inflammatory disorder
of airways that causes recurrent
episodes of wheezing,
breathlessness, chest tightness
and coughing.

 Family size responsiveness  weather changes  Gender  Race/Ethnicity  Obesity .RISK FACTORS  Host Factors  Environmental Factors  Genetic  Indoor /allergens predisposition  Socioeconomic  Atopy factors  Airway hyper.

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 . & increase mucous production Airways narrowing Symptoms: -cough -wheezing -breathlessness -chest tightness . bronchononstriction.

CLINICAL FEATURES •Cough •Chest tightness •Wheezing sound of breath •Episodic shortness of breath •Worsen during night .

Various severities of asthma  Classification of asthma severity .Moderate persistent .Mild persistent . . it is mild intermittent.Mild intermittent .Severe persistent *In this patient.

.*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 .

 History of atopy? .since 4 years old.No significance  Prev hospital administration? . cold weather or do vigorous exercise  Have any prolong URTI sx? .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 . once in 2 months.No hospital administration before this. last attack was on October  Aggravating and relieving factors? -cold drinks.TAKING HISTORY  Since when it start & previous attack? .

Decrease symetrically chest wall expansion  PERCUSSION -resonance  AUSCULTATION -(reduced breath sound. peripheral cyanosis.PHYSICAL EXAMINATION  OBSERVATION -(tachypnic.ICR & suprasternal recession)  PALPATION . SCR . head bobbing. hyperinflated chest. wheezing. drowsiness. central cyanosis. using accessory muscle when breathing. vesicular breath sound with prolong expiration time) . rhonci.

INVESTIGATION 1)LUNG FUNCTION TEST This can be done by using Peak Expiratory Flow Rate(PEFR). .

2)Blood and sputum test. Helpful in excluding a pneumothorax / pneumonia. Asthmatic patient may have increase number of neutrophils in pheripheral blood 3)Chest X-ray. .

failure to respond to standard home treatment 2. 3. Relapse within 4 hours of nebulised B2-agonist. Severe acute asthma * This patient was admitted to ward because failed respond towards the nebuliser salbutamol given in the ED. Failure of those with mild or moderate acute asthma to respond to nebulised B2-agonist.Criteria for admission 1. 4. .

.Common management for AEBA  Gives neb oxygen  + neb salbutamol  + neb ipratopium bromide  + IV hydrocortisone  + hydration – IV normal saline  If symptoms not subside. do endotracheal intubation and gives mechanical ventilation. gives IV salbutamol  If symptoms still not subside.

MANAGEMENT  Give drug treatment to the patient by following the severity of the asthma. colour. PEFR. ◦ -how to recognized & treat worsening asthma ◦ -when to seek for medical attention ◦ -how to used MDI correctly . VBG and SPO2.  Hydration-give maintenance fluid  Monitor pulse. (4 hrly)  Antibiotic indicated only if bacterial infection suspected  Avoids sedatives and mucolytics  Health education involving the parents and their asthmatic child.

psychological and social well-being * Patient only had continuous night cough and sleeping disturbance during the attack. . disturbed sleep  Restriction in activity / exercise  Increased school absences (not able to pay attention in the class.Impact of asthma  Night cough. academic performance will drop)  Ongoing symptoms may have a detrimental effect on physical.

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.  PEFR <33% of prediction.confusion or coma.

teaching basic asthma facts . *in this case.PREVENTION  Education of the family members is a vital role : .explain role of medication given .teaching environmental control measures .improving parents skills in the use of spacer device MDI. 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 .