PART 2: PATIENT HISTORY

Chief Complaint:

 Short of breath × 1/7 days

Current Medical/Surgical History Illness:

 Patient complain of short of breathes since today

 Coughing with yellowish sputum since today
 No fever
 No flu
 No vomiting
 No diarrhoea
 No takipnea

 in casualty
 6.35am
- Patient still alert but breath fast and still claiming short
of breath but the saturation still 99 % under room
temperature
- Found that there are rhonchi sound occur on both lung
occur during auscultation

Past Medical/Surgical History Illness (including allergy to medicines):

 Patient never been admitted to the ward since she was diagnosed as
bronchial asthma since she was young
 She was on inhaler salbutamol 2 puff tds/prn

Family History:

 no diabetes mellitus
 no hypertension
 no other bronchial asthma found occur among her other siblings

Social History:

 patient not smoking

 patient not drink alcohol

O&G History:
 patient married
 patient has four children
 patient menstrual cycle is normal
PART 3: PHYSICAL EXAMINATION

General Examination:

 pink
 alert
 conscious
 walk in
 good on speech

Vital Sign:

BI OBSERVATION RESULTS
L
01 Pain score 3/10
02 Temperature 36.8 ˚C
03 Respiration rate 20/minutes
04 Blood pressure 120/74mmHg
05 Pulse rate 95 bpm
06 Pulse rhythm Normal
07 Pulse volume Good
08 Body weight 65kg
09 GCS 15/15

Head & Sensory Organ Examination:

 Head
 Inspection
- No swelling or active bleeding
- No discoloration noted

 Palpation
- No swelling

 Eyes
 Inspection
- Up rolling eyeballs
- No discharged found from both of the eyes
- No discoloration noted

 Palpation
- No per orbital tenderness or swelling noted
 Ears
 Inspection
- No active bleeding or swelling
- Both ears remain in same size
- No discharged at both ears noted
- No abnormalities of hearing noted

 Palpation
- No tenderness
- No mass palpated

 Nose
 Inspection
- No bleeding and swelling
- In normal shape of nose
- No discharged from the nose
- No nasal polyps seen
- No nasal obstruction noted

 Palpation
- No tenderness
- No mass found

 Throat
 Inspection
- Cough and sore throat for 1/7 day
- Yellowish sputum occur
- No tonsil enlargement

 Mouth
 Inspection
- Normal in shape
- Dry lips

 Neck
 Inspection
- No abnormality in shape
- No complaint of dysphagia
- No swelling
- Able to swallowed

 Palpation
- No tenderness
- No mass palpable
- No lymph node swelling
- No increasing pressure of Jugular Venous Pressure(JVP)
Chest:

 Heart
 Inspection
- No previous cardiac operation scars on the chest wall.
- No abnormalities seen.

 Palpation
- No chest wall pain or tenderness.
- No presence of abnormal thrill.
- Apex beat at 5th intercostal space midclavicular line.

 Percussion
- Normal cardiac dullness on the fifth intercostal space of
the left heart border.

 Auscultation
- Sound 1 and sound 2 heard clearly.
- Dual rhythm no murmur.
- Heart beat- Normal

 Lungs
 Inspection

- Shape and symmetry of chest- Normal.

- Chest wall movement anteriorly and posteriorly-
Normal and no abnormalities
- Has coughing.
- Breathlessness
- Tightness

 Palpation
- Chest expansion- Normal
- Apex beat- Normal
- No vocal (tactile) fremitus.
- Ribs- no pain localised.

 Percussion
- Cardiac dullness- Normal.
- Normal resonance at both lungs.

 Auscultation
- Breathe sound- Has rhonchi, no crepitation
- No added (adventitious) sounds.
- Air entry equal bilateral
Abdomen:
 Inspection
- No previous surgical scar seen.
- No wound.

 Palpation
- No pain during palpitation on the abdomen
- No pain
- No tender

 Percussion
- No fluid thrill.

 Auscultation
- Bowel sound present- Normal

Nervous System:
 No swelling
 No oedema
 No bleeding
 No injury

Lower Extremities:
 Right and left leg movement - Normal
 No active bleeding seen
 No deformity / abnormality noted
 No pitting oedema
 Able to move right leg without restriction.
 Capillary refill- Normal

Upper Extremities:

 Right and left hand movement - Normal

 No active bleeding present
 No deformity / abnormality seen

Others (Genitalia, Rectum and etc):

 No physical examination done

PART 4: THE SUMMARIES OF IMPORTANT AND RELEVANT
FINDINGS

Cough and sore throat

with yellowish sputum
1/7 day

Breath sound : has

rhonchi, no crepitation
PART 5: DIAGNOSIS

 Provisional diagnosis
 Asthma

 Differential diagnosis
 Bronchial asthma
 Bronchopneumonia
 bronchitis
 COAD

 Final diagnosis
 Bronchial asthma
PART 6: RELEVANT AND IMPORTANT INVESTIGATON AND
RESULT

BI INVESTIGATION RESULT
L
01 HB 13
02 TW 19.5
03 pH 266
04 Na 13.9
05 K 4.34
06 Ur 5.9
07 Cr 80
08 RbS 5.5
09 Ca 256
10 Mg 0.76
11 P/S 0.92

The investigation which can be done for Asthma patients are:

 Auscultation to detect the breath sound

 Peak flow meter

 Angiography cerebral

 Lumbar puncture

 CT Scan
 To detect the lesion in brain

 MRI
 To detect the lesion in brain

 BUSE (done)

 FBC (done)
 To detect if any infection occur

 chest X-ray
PART 7: MANAGEMENT

 General management
 Inform the family about the illness
 Health education
 Important of treatment
 Safety precaution during illness attack

 Emergency treatment during illness attack

 Bring patient far from danger area
 Make sure the airways open and put patient in semi-prone
position
 Give patient nebulizer V:A:N (1:2:3)

 At emergency and trauma department

 Continue give patient V:A:N (1:2:3) stat
 Let patient rest in bed completely
 Monitor the vital sign
 Give oxygen when needed

 Doctor plan
 Continue NEB V:A:N (1:2:3)
 Iv Hydrocortisone Sodium 250mg STAT
 MDI Salbutamol 2 puff tds/prn
 Tab Prednisolone 30mg od
 Syrup Dephendhydramine HCl 15ml tds
 Tab Bromhexine HCl 8mg tds
 Tab Paracetamol 1gm tds/prn
 TCA prn
 Allowed discharge when the condition good
PART 9: RELEVANT ADVICES TO PATIENT AND FAMILY

 Explain to the patient and her family about the illness she was
facing so that the family can help the patient when she was short of
breath.

 Explain to the patient and family about the important of taking a

medication at the right time and dosage.

 Explain the side effect of the medication if not taken with

the correct direction

 Also explain the important of the continues treatment

 Make sure patient has done the blood test and also TDM
especially if patient take medication such as sodium
valproate

 Make sure patient use “medical alert” so that it can be identified

during seizures attack

 Avoid high risk activity

 Avoid other development factor such as bright light

REFLECTIVE REPORT
(Give comments about studies and implication of the management of these case that can be
found from this clerking case)

 Case management

 Good √
 Satisfied
 Week

 The reflection of the studies that can be found from these clerking
case:

 I study about the case of Bronchial Asthma in Asthma Bay,

Emergency And Trauma Department
 Bronchial Asthma is occurring when a patient has a chronic
inflammatory disease of the airways that causes periodic
attacks of coughing, wheezing, shortness of breath and
chest tightness.
 This due to some condition where a person has some
allergen to a certain thing such us animal fur or food.
 The patient was a woman, 40 years, with an history of
multiple breakthrough of asthma
 The day she was admitted to the A&E, she already had
short of breath, cough and a little tightness on her chest.
 She was given NEB V:A:N (1:2:3) STAT at A&E
 Doctor in charge planned:-
 Continue NEB V:A:N (1:2:3)
 Iv Hydrocortisone Sodium 250mg STAT
 MDI Salbutamol 2 puff tds/prn
 Tab Prednisolone 30mg od
 Syrup Dephendhydramine HCl 15ml tds
 Tab Bromhexine HCl 8mg tds
 Tab Paracetamol 1gm tds/prn
 TCA prn
 Allowed discharge when the condition good