INTERNA MEDICINE CASE REPORT

PROF. DR. W. Z. JOHANNES HOSPITAL AUGUST 2019

MEDICAL FACULTY
NUSA CENDANA UNIVERSITY

by :

Aditya Josua Elvon, S.Ked

1508010024

Consultant :
dr. Nikson Eduard Faot, Sp.P
Pulmonologist

1
 INTRODUCTION

• Chronic Airway Inflamation

Asthma • Reversible episode of
bronchoconstriction due to inflammation
process

ASTHMA in • Morbidity • MONITORING

PREGNANCY • Mortality • ASTHMA
TREATMENT

2
 Patient Identity
Name : Mrs. JMN
Sex : Female
Date of Birth : 01 - January - 1976
Age : 43 tahun
Religion : Christian
Adress : Oebobo
Work : Housewife
Last Education : Elementary School
Ethnicity : Rote
Marital Status : Married
Come to the ER : 17th July 2019 (19.43 WITA)
Room : Cempaka
No. MR : 371366
Payment Method : BPJS 3
GINA 2015, Box 3-2
 History Taking

History Taking did on 18th July 2019, at Cempaka Room, Prof. DR.W. Z.
Johannes Hospital, 05.30 WITA. Autoanamnesis with the patient.

Main Complaint
Shortness of breath since 1 days before
in the hospital

4
GINA 2015, Box 3-2
 History Taking
The patient came at Emergency Room Prof. Dr. W. Z. Johannes with
complaints shortness of breath since one day before in the hospital.
Patients had come to Emergency Room in the morning with same
complaints and got nebulisation therapy 2x and sent home. In the
afternoon, the patient perceives shortness of breath again and
become heavy, the patient coming back to Emergency Room.
Shortness of breath that perceived caused patient cannot do daily
activities. The shortness of breath often appear while the night and
when after do severe physical acitivity, lightened by the use of
reliever therapy. Patients said that complaints appear at least 2x per
month. Patients also complained about cold and coughing since one
day before in the hospital, with white mucus. Patient 6 months
pregnant. Fever (-), Nausea (-), Vomiting (-). Good appetite. Urination
and defecation no complaints. 5
GINA 2015, Box 3-2
 History Taking
PAST MEDICAL HISTORY
The patient had a history of asthma since age 17 years old and
control in oebobo community health centre.

FAMILY MEDICAL HISTORY

A family member patients who suffer from asthma is the patient
mother.

MEDICATION HISTORY
Patients obtain seretide disk 50/250mcg, last 3 day of patients not
consuming the medication. Patients often to emergency room to get
nebulization therapy when get asthma attack.
6
GINA 2015, Box 3-2
 History Taking
HABIT HISTORY
Patients consumption food regularly, 3 times in a day and consumed
enough mineral water. Smoking (-) , drinking alcohol (-), consume
betel (-).

SOSIOECONOMIC HISTORY
The patient lives with her husband and children. The patient's house
has a wall with a zinc roof, there are several windows that are often
opened, there is ventilation, there is a ceiling and tile floors.

7
GINA 2015, Box 3-2
 Physical Examination
General state : Moderate ill
GCS : Compos Mentis (E4V5M6)
Vital Sign
• Blood Pressure : 120/80 mmHg
• Pulse : 100x/min
• Temperature : 36.20C
• Respiratory Rate : 24 x/min
• SpO2 : 97% with O2 nasal canul 3lpm
• VAS :0
Antropometri
Weight : 75 kg
Height : 165 cm
BMI : 27,05 kg/m2
Status : Obese I 8
GINA 2015, Box 3-2
 Physical Examination

 Skin : pale (-), cyanotic (-) , jaundice (-)

 Hair : black hair, spread evenly, not easily uprooted
 Eyes : Anemic conjunctiva (-/-), jaundice sklera (-/-),
round pupils 3mm/3mm isochor, direct light reflex
(+/+)
 Nose : rhinorea (-/-), epistaksis (-/-), septum deviation (-)
 Ear : otorea (-/-), tragus tenderness (-/-)
 Mouth : dry lip mucosa, moist tongue mucosa, tonsil
T1/T1, hyperemia (-)
 Neck : lymph nodes enlargement (-), tiroid enlargement
(-), JVP 5cm+0
9
GINA 2015, Box 3-2
 Physical Examination
Pulmo Anterior
• Inspection : symmetrical chest development, mass (-)
• Palpation : tenderness (-), vocal fremitus D=S, symmetrical chest development
• Percussion : sonor in both lung
• Auscultation :
Vesikuler Ronkhi Wheezing
+ + - - + +
+ + - - + +
+ + - - + +

Pulmo Posterior
• Inspection : symmetrical chest development, mass (-)
• Palpation : tenderness (-), vocal fremitus D=S, symmetrical chest development
• Percussion : sonor in both lung
• Auscultation :
Vesikuler Ronkhi Wheezing
+ + - - + +
+ + - - + +
+ + 10
- - + +
GINA 2015, Box 3-2
 Physical Examination
Cor
• Inspection : ictus cordis not visible
• Palpation : ictus cordis not palpable
• Percussion :
• Right : ICS 4 linea parasternalis dextra
• Left : ICS 5 linea midclavicularis sinistra
• Auscultation : S1 S2 regular tunggal, murmur (-), gallop (-)

Abdomen
• Inspection : convex, mass (-), scar (-)
5 5
• Auscultatiion : bowel sounds (+)10x/menit
5 5
• Palpation : tenderness (-), hepar and lien not palpable
• Percussion : tympani

Extremity
CRT < 2 s, warm extremity, edema (-)
Motoric strength: 5 5
5 5

11
GINA 2015, Box 3-2
 Laboratory Findings (17 July 2019)
Pemeriksaan Hasil Satuan Rujukan Nilai
Jumlah
HEMATOLOGI 17 Juli 2019 1.52 103/uL 1.00-3.70 N
Limfosit
Hemoglobin 11.5 g/dL 13,0-18,0 L
Jumlah
Eritrosit 3.96 106/uL 4,50-6,20 L 0.83 103/uL 0.00-0.70 H
Monosit
Hematokrit 33.4 % 40,0-54,0 L
Jumlah
MCV 84.3 fL 81,0-96,0 N 199 103/ul 150-400 N
Trombosit
MCH 29.0 Pg 27,0-36,0 N
MPV 10.1 fL 9,0-13,0 N
MCHC 34.4 g/L 31,0-37,0 N
PDW 10.8 fL 9,0-17,0 N
RDW-CV 12.6 % 11,0-16,0 N
P-LCR 24.0 % 13,0-43,0 N
RDW-SD 38.3 fL 37-54 N
PCT 0.20 % 0.17-0.35 N
Jumlah
15.23 103/ul 4,0-10,0 H GDS 109 mg/dl 70-150 N
leukosit
BUN 6.0 mg/dl <48 N
HITUNG JENIS
Cr. Darah 0.58 mg/dl 0.7-1.3 L
Eosinofil 1.3 % 1.0-5.0 N
ELEKTROLIT
Basofil 0.3 % 0-1 N
Natrium
Neutrophil 83.0 % 50-70 H 139 mmol/L 132-147 N
Darah
Limfosit 10.0 % 20-40 L
Kalium Darah 3.1 mmol/L 3.5-4.5 L
Monosit 5.4 % 2-8 N
Klorida Darah 99 mmol/L 96-111 N
Jumlah
0.20 103/uL 0.00-0.40 N 1.120-
Eosinofil Kalsium Ion 1.020 mmol/L L
1.320
Jumlah
0.04 103/uL 0.00-0.10 N Total kalsium 2.1 mmol/L 2,2-2,55 L
Basofil
Jumlah
12.64 103/uL 1.50-7.00 H 12
Neutrophil
GINA 2015, Box 3-2
 Laboratory Findings (19 July 2019)
URIN ANALISA
MAKROSKOPIS
Pemeriksaan Hasil Satuan Rujukan
Warna Kuning Kuning
Kejernihan Jernih Jernih
Berat Jenis 1.025 1.000-1.030
Ph 7.0 4.5-8.0
Lekosit esterase Negatif Leu/uL Negatif
Nitrit Negatif Negatif
Protein Negatif mg/dL Negatif
Glukosa Negatif mg/dL Negatif
Keton Negatif mg/dL Negatif
Bilirubin Negatif mg/dL Negatif
Darah Negatif mg/dL Negatif
SEDIMEN
Eritrosit 0-2 /lpb Negatif
Leukosit 1-2 /lpb 0-5
Silinder Negatif /lpk Negatif
Sel Epitel 5-7 /lpk 0-2
13
Bakteri
GINA 2015, Box 3-2 Negatif 131313
 Laboratory Findings (21 July 2019)

SEROLOGI 21 Juli 2019

HbsAg Rapid Non Non
Test Reaktif Reaktif
IMUNOLOGI
Non Non
HIV FOCUS
Reaktif Reaktif

14
GINA 2015, Box 3-2
 Diagnose

Asthma Bronchial + Gravida 24 week

Treatment
• IVFD NaCl 0,9% 14 tpm
• Inj. Methylprednisolone 2 x 62,5 mg
• Nebu combivent/8jam
• NAC 3 x 200 mg

15
GINA 2015, Box 3-2
 19/7/2019
S: Cough (+) white
mucous, flu (+), 21/7/2019
shortness of breath (+) S: Cough (+) white mucous
reduced. reduced, flu (+) reduced,
shortness of breath (+)
O: Wh +++/+++ greatly reduced.
BP: 120/80 mmHg O: Wh +++/+++
HR: 100x/min BP: 110/70 mmHg
T: 35,8 °C HR: 86x/min
RR: 24 x/min T: 36 °C
SpO2: 98% nasal kanul 2 RR: 22 x/min
lpm SpO2: 96%

20/7/2019 22/7/2019
S: Cough (+) white mucous S: Cough (+) white mucous
reduced, flu (+), shortness reduced, flu (-), shortness of
of breath (+) reduced. breath (-)
O: Wh +++/+++
O: Wh +++/+++
BP: 120/80 mmHg
BP: 110/70 mmHg
HR: 88x/min
HR: 92x/min
T: 36,1 °C
T: 36 °C
RR: 24 x/min
SpO2: 95% RR: 22 x/min
SpO2: 96%
16
Patient can out fron hospital
Clue and Cue Problem List DD Diagnosis Theraphy Planning Monitoring Education
Planning Planning Planning
History Taking 1. Asthma Spirometry • IVFD NaCl 0,9% • Main • Educate
• Shorthnes s of breath Exacerbation 14 tpm complaint about the
since 1 day before come in Pregnancy • Inj. • Vital Sign disease
to ER Methylpredniso (Mainly • Educate
• Often appear while the lone 2 x 62,5 Oxygen about the
night and when after do mg Saturation) complicati
severe physical acitivity, • Nebu • Spirometry ons
lightened by the use of combivent/8ja • Educate
reliever therapy. m about
• 2x/in a month • NAC 3 x 200 mg medicatio
• Cough (+), Flu(+) n
• Pregnant on 24 weeks adherenc
• History of asthma since e
17 years old • Educate
• History using Seretide to control
disk to the
• Mother has asthma doctor
Physical Examination
BP: 120/80 mmHg
HR: 100x/min
T: 35,8 °C
RR: 24 x/min
SpO2: 97% nasal kanul 3 lpm
Wheezing: Wheezing

+ +
+ +
17
+ +
 Definition
Asthma is a heterogeneous disease, usually characterized by chronic
airway inflammation.

It is defined by the history of respiratory symptoms such as wheeze,

shortness of breath, chest tightness and cough that vary over
time and in intensity, together with variable expiratory airflow limitation.

Asthma is a chronic inflammation of the airways,

causes an increase in airway hyper-responsiveness which
causes
• Recurrent episodic symptoms such as wheezing, shortness
of breath, chest tightness and coughing especially at night
and / or early morning.
18
 Epidemiology
WHO (2018),
asthma prevalence The
in the world :
339 million prevalence of
people asthma in
pregnancy
Indonesian,
asthma
ranges
prevalence between
4,5% from the
population 3,7%-4%
Prevalence by age:
• 25-34 (5,7%)
< • 15-24 (5,6%)
• 35-44 (5,6%) 19
 Risk Factors

Host External
Factors Factors

20
Immunology

21
 Pathophysiology
Trigger Factor

Antigen and Antibody Reaction

Release Vasoactive Substance

Airway Muscle Constriction Capillary Permeability Hipersecretion of Mucous

Bronchohonstriction Mucosa Edema, Muscle Mucous

contraction

Narrowing
Breathing
Passages

Hipoventilasi, Hi poxemia,
Hiperkapnia 22
 Classification of Asthma
Classification Symptom Nights Symptoms Lung Function
Intermitten Monthly APE≥80%
 Symptom<1x/week ≤ 2 x/month  VEP1 ≥ 80% predicted,
 Asymptomatic between Variabiliti APE <20%
exacerbations
 Brief exacerbations
Mild Persistent Weekly APE>80%
 Symptom>1x/month but <1x/day >2x/month  VEP1≥80% predicted
 Exacerbations affect activity  Variabiliti APE 20-30%

Moderate Persistent Daily APE 60-80%

 Daily symptoms >1x/week  VEP1 60-80%
 Exacerbations affect activity predicted
 Need bronchodilator every day  Variabiliti APE >30%

Severe Persistent Continue APE ≤60%

 Daily symprtoms Frequently  VEP1 ≤60% predicted
 Limited physical activity  Variabiliti APE >30%
 Frequent severe exacerbation 23
 Clinical Symptoms

Shortness
Wheezing
of breath

Chest
Cough
Thightness
24
 Diagnosis

Support
Examination
History Physical • Pulmo function
Taking Examination • Reversibility test
• Bronkus
Provocation Test
• Skin prick test
• Thorax Rontgen

25
 Managing Asthma Exacerbations
INITIAL ASSESSMENT Are any of the following present?
A: airway B: breathing C: circulation Drowsiness, Confusion, Silent chest

NO
YES

Further TRIAGE BY CLINICAL STATUS Consult ICU, start SABA and O2,
according to worst feature and prepare patient for intubation

MILD or MODERATE SEVERE

Talks in phrases Talks in words
Prefers sitting to lying Sits hunched forwards
Not agitated Agitated
Respiratory rate increased Respiratory rate >30/min
Accessory muscles not used Accessory muscles being used
Pulse rate 100–120 bpm Pulse rate >120 bpm
O2 saturation (on air) 90–95% O2 saturation (on air) < 90%
PEF >50% predicted or best PEF ≤50% predicted or best

26
© Global Initiative for Asthma
 MILD or MODERATE
Talks in phrases
Prefers sitting to lying
Not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100–120 bpm
O2 saturation (on air) 90–95%
PEF >50% predicted or best
Short-acting beta2-agonists
Consider ipratropium bromide
Controlled O2 to maintain
saturation 93–95% (children 94-98%)
Oral corticosteroids
GINA 2015, Box 4-4 (3/4)
SEVERE
Talks in words
Sits hunched forwards
Agitated
Respiratory rate >30/min
Accessory muscles being used
Pulse rate >120 bpm
O2 saturation (on air) < 90%
PEF ≤50% predicted or best
Short-acting beta2-agonists
Ipratropium bromide
Controlled O2 to maintain
saturation 93–95% (children 94-98%)
Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS
27
Short-acting beta2-agonists Short-acting beta2-agonists
Consider ipratropium bromide Ipratropium bromide
Controlled O2 to maintain Controlled O2 to maintain
saturation 93–95% (children 94-98%) saturation 93–95% (children 94-98%)
Oral corticosteroids Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS

If continuing deterioration, treat as

severe and re-assess for ICU

ASSESS CLINICAL PROGRESS FREQUENTLY

MEASURE LUNG FUNCTION
in all patients one hour after initial treatment

FEV1 or PEF <60% of predicted or

FEV1 or PEF 60-80% of predicted or
personal best,or lack of clinical response
personal best and symptoms improved
SEVERE
MODERATE
Continue treatment as above
Consider for discharge planning
and reassess frequently

28
© Global Initiative for Asthma
 GINA Asthma Treatment Strategy
Diagnosis
Symptom control & risk factors
(including lung function)
Comorbidities
Inhaler technique & adherence
Patient goals
Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function

Treatment of modifiable risk

factors & comorbidities
Non-pharmacological strategies
Education & skills training
Asthma medications 29
GINA 2015, Box 3-2
 GINA Asthma Treatment Strategy

STEP 5

STEP 4

PREFERRED
STEP 3 High dose
STEP 1 STEP 2
CONTROLLER ICS-LABA
CHOICE
As-needed Med dose
low dose Refer for
ICS-LABA
ICS-
Low dose phenotypic
Daily low dose inhaled corticosteroid ICS-LABA asessment
formoterol*
(ICS)
Other Low dose ICS Medium dose ICS, or High dose ICS, Add low
controller taken whenever Leukotriene receptor antagonists (LTRA), or Low dose ICS taken Low dose ICS+LTRA add on tiotropium, dose OCS, but
options SABA is taken whenever SABA taken or add on LTRA consider side
effects

RELIEVER As-needed low dose ICS-formoterol*

As-needed low dose ICS-formoterol*
Other reliever
options As-needed short-acting beta2-agonist (SABA)

*data only with budesonide-formoterol

30
GINA 2015, Box 3-5, Step 1 (4/8)
 Low, Medium and High dose ICS
Adults and Adolescents (≥12 years)

Inhaled corticosteroid Total daily dose (mcg)

Low Medium High

Beclometasone dipropionate (CFC) 200–500 >500–1000 >1000

Beclometasone dipropionate (HFA) 100–200 >200–400 >400
Budesonide (DPI) 200–400 >400–800 >800
Ciclesonide (HFA) 80–160 >160–320 >320
Fluticasone propionate (DPI or HFA) 100–250 >250–500 >500
Mometasone furoate 110–220 >220–440 >440
Triamcinolone acetonide 400–1000 >1000–2000 >2000
DPI: dry powder inhaler, HFA: hydrofluoroalkane propellant, CFC: chlorofluorocarbon propellant

31
GINA 2015, Box 3-2
 Reviewing Response & Adjusting
Treatment
• How often should asthma be reviewed?
– 1-3 months after treatment started, then every 3-12 months
– During pregnancy, every 4-6 weeks
– After an exacerbation, within 1 week
• Stepping up asthma treatment
– Sustained step-up (for at least 2-3 months): if symptoms and/or exacerbations persist despite 2-3
months of controller treatment
• Important: first assess the folowing common issue before considering step up
– Incorrect inhaler technique
– Poor adherence
– Modifiable risk factors, e.g. smoking
– Are symptoms due to comorbid conditions, e.g. allergic rhinitis
– Short-term step-up, for 1-2 weeks, e.g. with viral infection or allergen exposure
• Stepping down asthma treatment
– Consider step-down after good control maintained for 3 months
– Find each patient’s minimum effective dose, that controls both symptoms and exacerbations
– Choose an appropiate time for step-down (no respiratory infection, patient not travelling, not
pregnant)

32
GINA 2015, Box 3-2
 GINA assessment of symptom control

A. Symptom control
Well- Partly Uncontrolled
In the past 4 weeks, has the patient had:
controlled controlled
• Daytime asthma symptoms more
than twice a week? Yes No
• Any night waking due to asthma? Yes No
None of 1-2 of 3-4 of
• Reliever needed for symptoms* these these these
more than twice a week? Yes No
• Any activity limitation due to asthma? Yes No

*Excludes reliever taken before exercise, because many people take this routinely

33
GINA 2015, Box 3-2
Asthma in Pregnancy

34
 Pregnancy Effect in Asthma
Anatomic Changes Increased Use of Oxygen
Physiologic Changes
Hormonal Changes:
• Estrogen hormones enhancement: Nasal capillary congestion
• Progesteron hormones enhancement: Increased Respiratory Rate

Pregnancy Effect Unpredictable

Turner et al (1980), 1054 pregnant woman with asthma, found
that 49% stay same as before pregnancy, and 22% case
become severe.

35
Asthma in Pregnancy

Low Birth
Weight

Prematur
Asthma
Preeclampsia
(Hypertension
in Pregnancy)

Fetal Death

36
 Asthma in Pregnancy
Low Birth Weight Premature Preeclampsia Fetal Death

• Sobande (2002) • A cohort study • Stenius-Aarniala et • In 1970, Gordon et

found that the conducted by al. (1996) found al conducted a
group of pregnant Perlow et al. (1992) that mild study of 277
women with in 81 pregnant preeclampsia was pregnant women
asthma would give women who used found 3x higher in with asthma, 16 of
birth to babies with oral steroids, found pregnant women whom had severe
lower birth weight 54% of them gave with asthma who asthma. Six out of
than the group of birth prematurely. had been treated in 16 pregnant
pregnant women • Schatz et al (2004) hospital women who
without asthma get the same • Case-control study experience
• Jana et al. (1995) ± results that the use by Martel et al exacerbations
50% of babies born of oral steroids is (2005) found that experience
to pregnant women associated with there was no miscarriage and
with asthma who preterm birth relationship fetal death. This
have had between study long before
exacerbations are exacerbations inhaled
babies with low during pregnancy corticosteroid
birth weight and the risk of therapy was
preeclampsia. introduced as
asthma therapy

37
 Pregnancy Effect in Asthma
Anatomic Changes Increased Use of Oxygen
Physiologic Changes
Hormonal Changes:
• Estrogen hormones enhancement: Nasal capillary congestion
• Progesteron hormones enhancement: Increased Respiratory Rate

Pregnancy Effect Unpredictable

Turner et al (1980), 1054 pregnant woman with asthma, found
that 49% stay same as before pregnancy, and 22% case
become severe.

38
Management Asthma in Pregnancy

Management of acute asthma in pregnancy

holds the same principles as ordinary asthma

Goals:
Maintaining adequate oxygenation of the fetus by
preventing hypoxic episodes of mother

39
 American College of Obstretricians and Gynecologists
(ACOG) 2008
Symptoms Theraphy
Intermiten No daily medications, SABA as needed
 Daily Symptom <2x/week
 Night symptom <2x/month
 Norma Daily Activity
 FEV1≥80%

Mild Persistent Preferred: Low dose inhaled corticosteroid

 Daily Symptom ≥2x/week
 Night symptom ≥2x/month Alternative: Cromolyn, Antileukotrien, atau teofilin (serum level 5-12
 Minor limitation activity mcg/mL)
 FEV1≥80%

Moderate Persistent
 Daily symptoms
 Night Symptoms ≥1x/week
 Medium limitation activity
 FEV1 60-80%
Severe Persistent
 Throughout the day
 Night symptoms ≥4x/minggu
 Extremely limited activity
 FEV1<60%
Preferred: Low dose inhaled corticosteroid and salmeterol or Medium dose
inhaled corticosteroid
Alternative: Low dose inhaled corticosteroid or Low dose inhaled
corticosteroid + leukotrien receptor antagonist or teofilin (serum level 5-12
mcg/mL)
Preferred: High dose inhaled corticosteroid, corticosteroid oral if needed
Alternative: High dose inhaled corticosteroid and teofilin (serum level 5-12
mcg/mL), corticosteroid oral if needed
40
 Controller Therapy by National Asthma Education and
Prevention Program (NAEPP)

41
GINA 2015, Box 3-2
 Discussion
CASE THEORY
Female, 43 years , • The prevalence of asthma in
gravida 24 weeks. women tends to be higher than
in men.
• The prevalence of asthma according to
age group, the highest was found in
the age group 25-34 years (5.7%), and
followed in the age group 15-24 (5.6%)
and 35-44 (5.6%).
• The prevalence of asthma in
pregnancy ranges between 3.7% -
4%.
• Asthma attacks in pregnancy
will usually occur from 24
weeks to 36 weeks, and will
decrease at the end of pregnancy.
 CASE
The patient came at Emergency
Room Prof. Dr. W. Z. Johannes
with complaints: THEORY
• Shortness of breath since Clinical Symptoms of Asthma
one day before in the • Shortness of Breath
hospital, often appear • Wheezing
while the night and when • Chest Tightness
after do severe physical • Cough
acitivity, lightened by the
use of reliever therapy.
• Cold and coughing since
one day before in the
hospital, with white
mucus.
• Asthma history since 17
years old
• Wheezing (+) in both of
lungs
 CASE
Treatment:
• IVFD NS 0,9 % 14 tpm
• O2 nasal kanul 3 lpm,
• inj. Methylprednisolone 2 x 62,5
mg
• Nebu combivent/8jam
• NAC 3 x 200 mg.
Theory
• Asthma exacerbation in a pregnant
patient, as in any adult, should be
managed with Oxygen (target
SpO2>95%), inhaled β-agonists,
inhaled anticholinergic drugs,
and systemic corticosteroids
 CONCLUSION

Based on history and physical examination and investigations, Patient Ms. JMN, 43 years was
diagnosed with Asthma Bronchial in Pregnancy 24 weeks and was administered:
• IVFD NaCl 0,9% 14 tpm
• Inj. Methylprednisolone 2 x 62,5 mg
• Nebu combivent/8jam
• NAC 3 x 200 mg

45
46