CASE REPORT

MILD PERSISTENT SEVERE ASTHMA

(J45.31)
+
MILD AND MODERATE MALNUTRITION
Pediatric (E44)
Consultant:
dr. Hilmi Kurniawan Riskawa,
Sp.A, M.Kes
Presented by:

Iqnasia Windy Novitasari

I11111059
KARTIKA HUSADA HOSPITAL
KUBU RAYA
2016

IDENTITY
Name
:S
Sex
: Female
Age
: 9 years and 3 months old
Date of Admission : August, 25th 2016

CHIEF COMPLAINT
Shortness of breath

HISTORY OF RECENT
ILLNESS
A 9-years-old girl was admitted to ED
complaining shortness of breath (SOB). SOB
started 2 days ago and getting worse. Patient
descibe the SOB as difficulty breathing with
wheeze sound. During the acute episode, she
cant even sleeping nor talking. Lying down and
physical exercise will provoke SOB. SOB was
accompanied by cough and fever. The SOB was
persisted for every month in last 2 years.

PAST MEDICAL
HISTORY
Patient had been evaluated for pulmonary
tuberculosis (TB) by pediatrician recently, but
PPD test and Chest X-ray were negative for
TB.
For the last 3 months, she used seretide
inhaler and consumed salbutamol tablet twice
daily.
Patient was hospitalized 3 times in the last 2
years for the same condition.

FAMILY HISTORY
Family genogram revealed that patients
mother and grandmother had asthma.
No known drug allergies.
No history of contact with TB.

SOCIAL HISTORY
Patient lived with her parents, her father was
an active smoker for 10 years. They had a
cat.

PHYSICAL
EXAMINATION
General condition : look moderately ill
Counsiousness

: compos mentis

GCS

: 15 (E4V5M6)

ANTHROPOMETRIC
MEASUREMENTS
Weight

: 20 kg (BB Ideal:

Height

: 120 cm

BMI

: 13,8

Arm circumference

: 15 cm

W/A

: between -2 and -3 SD

H/A

: between -2 and -3 SD

BMI/A

: between -2 and -3 SD

Nutritional Status : Mild and moderate

malnutrition

VITAL SIGNS
Blood pressure

: 110/80 mmHg

Pulse Rate
regular

: 148 beat per minute,

Respiratory Rate : 38 breaths per minute,

thoracoabdominal
pattern
Temperature

: 37,6 oC

SpO2

: 92 %

PHYSICAL
EXAMINATION
Head
hair, thick,

: normocephal, black
not easily uprooted

Eye
(-/-)

: anemic (-/-), icteric

Oral cavity
mucous
bleeding, no
cyanosis, oral

: moist tongue and

membrane, no gum
ulcers, no central
hygiene was good

Ear, nose, and throat : there was no

nasal nor ear
discharge, the
pharynx was
good, tonsil T1/T1

PHYSICAL
EXAMINATION
Neck
node

: there was no palpable lymph

Chest

: suprasternal retraction (+)

Lungs

Inspection
Palpation
for both
Percussion
Auscultation
wheezing

Heart

: shape and move simetrical

: tactile vocal fremitus same
hemithorax
: sonor on both hemithorax
: vesicular breath sound (+/+),
(+/+), ronkhi (-/-)

: S1/S2 regular, murmur (-),

PHYSICAL
EXAMINATION
Abdominal
no palpable
were not
sound 8

: flat, soef, no tenderness,

masses, liver and spleen
palpable, timpanic, bowel
tpm

Genitalia

: normal

Extremities
no cyanotic

: warm, CRT < 2s, there was

nor edema nor petechie

Skin
was good, no
nor baggy

: skin turgor and elasticity

cracked skin nor scally skin
pants

DIAGNOSTIC FINDING
Further diagnostic studies
was done in this patient:
CBC revealed
leucocytosis (18.500
cells/mm3)
Chest X-ray was normal

DIFFERENTIAL
DIAGNOSIS
Mild persistent severe asthma + mild and
moderate malnutrition
Acute bronchitis

WORKING DIAGNOSIS
Mild persistent severe asthma + mild and
moderate malnutrition

TREATMENT
IVFD RL 15 dpm macro set
3.5 litre/minute O2 administration via nasal
canule
Paracetamol infusion 3 x 250 mg i.v
Ceftriaxone injection 2 x 800 mg i.v
Dexamethasone injection 3 x 0.4 cc i.v
Ranitidin injection 2 x 20 mg i.v
Aminofilin injection: loading dose 120 mg in
20 cc D5% for 1/2 h then maintenance dose
10 mg/h in 20 cc D5% with syringe pump

TREATMENT
Combivent 1 respul + 2 cc NS nebulation
every 8h
Ventolin turbohaler 3 x puff 2
Cough pill 3 x 1 pulv

ADVICE
Use of a regimen that minimizes
exacerbations
Avoiding allergen, avoidance of exposure to
tobacco smoke
Preventing excessive activities, but
encourage the patient to engage in regular
physical activity because of its general
health benefits
Keep a good hygine practice

SUGGESTED
DIAGNOSTIC
STUDIES
Lung function test
Skin-prick test for known allergen

PROGNOSIS
Ad Vitam

: dubia ad Bonam

Ad Functionam

: dubia ad Bonam

Ad Sanactionam : dubia ad Bonam

DISCUSSION
Patient had diagnose for asthma based on
history taking and physical examination. This
patient had classic presentation of asthma
including provokable SOB, wheezing, and
cough. Physical exam reveal wheezing and
suprasternal retraction. Suprasternal
retraction is a sign of respiratory distress, also
shown from pulmonal score was 7.

DISCUSSION
Based on PNAA (2004), this patient was
classified frequent episodic where the
frequency is more than 1 time/mo, duration of
attack is less more than 1 week, theres
symptom between two consecutive attack,
sleep and activity are disturbed, and needed
for inhaler steroid.
Based on PNAA (2015), this patient was
classified for mild persistant asthma where
symptom is more that 1 time/mo but less
than 1 time/week, the preceding attack
disturb sleep and activity, and have a
nocturnal more than 2 times/mo.

DISCUSSION
Based on severity of asthma exacerbation,
this patient was classified severe asthma
exacerbation where the symptoms such as
breathless while at rest, talks in words,
alertness agitated and the signs such as
respiratory rate > 30 x/m, use of accessory
muscles (suprasternal retraction), wheeze
loud throughout inhalation and exhalation,
pulse >120x/m.

DISCUSSION
Patient had severe athma attack because the
initial presentation in ED is severe.
Diagnostic studies done in this patient shown
leucocytosis, which indicate the probability of
infection.
Patient was treated with RL, broad-spectrum
antibiotik, antipiretic, H-2 blocker, cough pil,
nebulation, inhaler, and aminofilin.

DISCUSS
ION

DISCUSSION
The patients prognosis was good.
Patient symptom resolved in 3 days after
extensive therapy.

THANK YOU