SHAZLIN BT. SABAAH
SALWA HANIM BT. MOHD. SAIFUDDIN
KAMARULZAMAN B. MUZAINI
Initials : MH
Age : 6 years and 8 months old
Ethnicity : Malay
Gender : Male
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 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.
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.
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
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.
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.
No known allergies
Born at Hospital Kota Baru
Weight : 2.5kg
Antenatal, intrapartum and postpartum hx was uneventful
Admitted to NICU for 15 days due to neonatal jaundice diagnosed to have G6PD
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
Up to his age
Didn’t have any complications after taking the injections
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.
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.
1. GENERAL CONDITION
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
His vital signs are normal.
2. VITAL SIGNS
Height : 110cm. (10thcentile)
Weight : 17kg. (10thcentile)
BMI : 14.05kg/m2. (10thcentile)
His growth is within 10thcentile.
Appearance: No dysmorphic features.
Face: No cyanosis, no pallor, no pursed lips.
Moist tongue and mucous membrane
No gum bleeding
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.
4. Examination face, head, neck & limbs
Neck: No cervical lymph nodes enlargement.
Skin: Normal skin tone,no eczema, no rashes and no petechiae.
No cyanosis at the nail bed
No clubbing of fingers
Capillary refilling time was less than two seconds
No peripheral oedema
Impression: No abnormal findings.
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.
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.
Normal air entry bilaterally.
Vesicular breath sound with prolong expiratory.
Ronchi during expiration on the upper zone bilaterally.
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.
2. Cardiovascular Examination
There were no visible pulsations, surgical scars, cardiac bulging or superficial dilated veins at precordial area.
Apex beat was palpable at the 5th intercostals space lateral to midclavicular line. There was no thrill or heave.
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
3. Abdominal examination
The abdomen was not distended and moved with respiration. The umbilicus was centrally located and inverted. There were no surgical scars
The abdomen was soft and non-tender. There was no hepatosplenomegaly. Both kidneys were not ballotable.
The abdomen was tympanic. There was negative shifting dullness and no fluid thrills.
Normal bowel sound present.
Impression: No abnormal findings.
4. Lymphatic System
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.
4. Central Nervous System
Mental status: She was alert and well oriented to time, place and person.
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.
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.
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
1) Full Blood Count and automated differentials
2) Venous Blood Gas
3) Chest X-Ray
Salbutamol Nebulizer –cont 1hour
Blood investigation: FBC, VBG, electrolyte
If not, IV salbutamoloraminophyline
If the symptoms persist, intubation.
Monitoring: vital signs, SpO2, VBG
Syrup prednisolone 17mg OD 5/7
mdifluticasone 125mcg BD
mdisalbutamol 200mg 4 hourly
DISCUSSION OF ASTHMA
KAMARULZAMAN BIN MUZAINI
Chronic inflammatory disorder of airways that causes recurrent episodes of wheezing, breathlessness, chest tightness and coughing.
Smoke (passive smoker)
Exercise and hyperventilation
Emotional upset or excitement
Food, additives, drugs
Pathogenesis of asthma
Bronchial hyperactivity + trigger factors
Oedema , bronchononstriction, & increase mucous production
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.
History and patterns of symptoms
Measurements of lung function
Measurements of allergic status to identify risk factors
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
-(tachypnic, wheezing, drowsiness, central cyanosis, hyperinflated chest, head bobbing, peripheral cyanosis, using accessory muscle when breathing, SCR ,ICR & suprasternal recession)
- Decrease symetrically chest wall expansion
-(reduced breath sound, rhonci, vesicular breath sound with prolong expiration time)
INVESTIGATION1)LUNG FUNCTION TEST
This can be done by using Peak Expiratory Flow Rate(PEFR).
2)Blood and sputum test.3)Chest X-ray.
Asthmatic patient may have increase number of neutrophils in pheripheral blood
Helpful in excluding a pneumothorax / pneumonia.
Criteria for admission
failure to respond to standard home treatment
Failure of those with mild or moderate acute asthma to respond to nebulised B2-agonist.
Relapse within 4 hours of nebulised B2-agonist.
Severe acute asthma
* This patient was admitted to ward because failed respond towards the nebulisersalbutamol 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.
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
PEFR <50% from normal
Silent chest and cyanosis.
Exhaustion,confusion or coma.
PEFR <33% of prediction.
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
-Is an acute exacerbation of asthma attack which do not respond adequately to therapeutic measures and required hospitalization