PERSONAL DETAILS

Patients name Ward Age Sex Address Occupation Marital status Race Religion Date of Admission Date of Clerking Hartini bt. Harun 9C 39 years old Female Taman Desa Pinggiran Housewife Married Malay Muslim 5/2/2013 7/2/2013

PRESENTING COMPLAINT(S) Mrs. Hartini bt Harun, a 39 years old Malay, Muslim woman presented to the Emergency Department of Hospital Selayang on 5th February 2013 with tachypnea and shortness of breath associated with audible wheezing and chest tightness. HISTORY OF PRESENTING COMPLAINT (S) Two weeks before admission, the patient started to have cough. There was no chest tightness or shortness of breath at that time. In two weeks duration, the cough continue and becomes progressive. The cough was productive and produce sputum in white colour. There was no blood in the sputum. The cough became worse in the morning, or in cold environment and surroundings, or after the patient do housework. The cough was relieved in the afternoon and when the patient rest or stop doing the housework. Patient did not seek any medical treatment in that time. On the day of admission, in the morning at 9 am when the patient is mopping the floor, she experienced heavy cough, associated with dyspnea, tachypnea, nausea, and chest tightness chest pain. The chest pain is located at the center of chest and is valued by the patient of scale 3/10. She also produced audible wheezing. Patient has taken her prescribed medications of Budesonide and Ventolin at home with no relief of symptoms prior to coming to the ER. In the emergency room, she was given Hydrocortisone (IV) and was put on oxygen

mask. After the condition had stabilized, the patients was admitted to the ward 9C. Patient has asthma since she was 12 years old. She had experienced acute asthma exacerbation for every 2 months since she was 12 years old. The exacerbation started with continuous productive cough. For every episode, she experienced chest tightness at the chest center, with scale of 4-5/10. The chest tightness lasted in 5-10 minutes. The aggravating factor for every episodes are cold and dusty environment and houseworks. For every episode of attack, she also experienced rapid breathing and shortness of breath with audible wheezing. It were relieved when the patient used the inhaler (Ventolin/Budesonide), but the patient is a non-compliant user. It disturb the patients daily activity on the day of the episode. Her last attack was on 12th January 2013. PAST MEDICAL AND SURGICAL HISTORY Other than asthma, the patient has no other long term illness such as hypertension or diabetes mellitus. Patient was never been admitted into hospital due to diseases. She never undergone any surgery before. DRUG HISTORY Patient is prescribed with inhaler for her asthma episodes Budesonide and Ventolin (non-compliant). Patient did not take any other medication. ALLERGIES Patient had allergic rhinitis. She is allergic towards dust. Patient has no known allergy towards any food or medication. FAMILY HISTORY The mother is healthy and the father has cardiovascular disease. Both parents are still alive. Her spouse is healthy. One out of her four children has asthma. Her siblings are all medically fit. SOCIAL HISTORY Patient is a 39 years old housewife. She lives in Taman Desa Pinggiran. She is married for twelve years and has four children. She has good family

relationship. Patient has stable social and financial status. She denies any past or present smoking, alcohol consumption, or illicit drug use.

SYSTEMIC REVIEW
SYSTEM General Health POSITIVE SYMPTOMS Slightly fatigue NEGATIVE SYMPTOMS No loss of appetite No loss of weight No fever No sore throat No night sweat No haemotypsis No vomiting No constipation No diarrhea No hematemesis No rectal bleeding No hematuria No dysuria No nocturia No polyuria No loin pain No seizure No dizziness No double vision No neck stiffness No back pain No muscle pain No joint pain No restriction movement No polydipsia No polyphagia No heat intolerance No cold intolerance No nose bleeding No gum bleeding No bruises

Respiratory

Gastrointestinal

Shortness of breath Difficulty in breathing Productive cough Chest tightness wheezing Nausea

Genitourinary

Central Nervous

Musculoskeletal

of

Endocrine

Haematology

PHYSICAL EXAMINATION Mrs. Hartini bt Harun was sitting comfortably on the bed. She was conscious and alert to time, place and person. She looks slightly fatigue. She was not in pain and not in respiratory distress. His hydrational and nutritional status was adequate. She is afebrile. Interpretation : Patient is slightly fatigue but she is not in respiratory distress Vital signs: a) Blood pressure : 122/87 mmHg b) Pulse rate : 78 beats/min with regular rhythm and normal volume c) Respiratory rate : 16 breaths/min d) Temperature : 37 C Interpretation: Respiratory rate is slightly decreased Jaundice : Negative. No yellow discoloration of skin or sclera Anemia : Negative. No pale appearance of conjunctiva or skin Clubbing : Positive. There is moderate generalized clubbing at the angles of the nails. Cyanosis : Negative. There is no bluish discoloration of lips (central) or nails (peripheral) Oedema : Negative. No pitting edema on both legs. Lymphoedenopathy : Negative. No swelling or palpable lymph nodes noted No palmar erythema, no flapping tremor, good hydrational status.

Chest Examination Inspection: There was no chest wall deformity. Chest wall moves symmetrically with each respiration. There was no surgical scar, no evidence of chest drains, no dilated vein and no visible pulsation. However, there was usage of accessory muscle noted. Palpation: The chest expands normally. The apex beat is located at the 5th intercostals space. The vocal fremitus is normal and absent. Percussion: There are resonance sounds over the lung area. No liver or cardiac dullness detected. Auscultation: Reduced breath sounds and low-pitched wheezes over the smaller bronchi is heard. Interpretation: She is mildly tachypneic. CLINICAL SUMMARY Mrs. Hartini Harun, a 39 years old housewife was presented to the emergency department of Hospital Selayang on 5th February 2013 with tachypnea and shortness of breath associated with audible wheezing and chest tightness. It occurs when she is doing housework- mopping the floor. In the emergency room, she was put on oxygen mask and given Hydrocortisone (IV) and the symptoms resolved. She had started coughing since a month ago. The cough is progressive. She has asthma since she was 12 years old. She is a non-compliant user of inhaler (Budesonide and Ventolin). According to her, she had experienced an episode of asthma attack for every two months. The episodes were aggravated by cold and dusty environments and after doing housework. Usually the asthma will resolve after she used the inhaler. But prior to her admission, the usage of inhaler did not relieve any symptom. Although she had experienced an episode of asthma attack for every two months, she was never hospitalized due to any episode. Her last attack was on 12th January 2013.

DIFFERENTIAL DIAGNOSES 1) Acute Exacerbation of Bronchial Asthma 2) Bronchiectasis 3) Congestive cardiac failure INVESTIGATION 1) Full Blood Count
Investigation WBC RBC Normal range 4.0 - 11.0 x 109 /uL 3.80 4.80.0 x 1012 /uL 12.0-15.0 g/dl 37.0- 47.0 % 150-400 x 103 /uL Status Normal Normal

Haemoglobin Haematocrit Platelet

Normal Normal Normal

Impression : Normal level of all the value indicates that there is no anemia or infection 2) Chest X-ray No hyperinflated lung and no flattened of diaphragm

PROVISIONAL DIAGNOSIS Acute Exacerbation of Bronchial Asthma

DISCUSSION Mrs Hartini is diagnosed as having Acute Asthma Exacerbation. This is supported by the heavy prolonged and progressive cough that she had since 2 weeks prior to her admission. This diagnosis is also supported by productive cough, rapid breathing, shortness of breath, chest tightness, and the audible wheezing sound produced. Upon examination, she has decreased respiratory rate, and appear fatigue due to decreased in respiration. Clubbing detected at the nails angle is one of the sign of asthma. Chest examination shows hyperresonant on percussion and on auscultation, reduced breath sound is detected. Furthermore, the patient already has asthma since childhood, and according to her, she will experience an asthma attack in every two months. The last attack was on 12th January 2013. The duration between the date of the last attack and the exacerbation is almost two months. In addition, the aggravating factors of her asthma episodes are cold and dusty environment, and after doing housework. The symptoms appeared in the morning, when the patient is doing housework, and there is possibility that she is cleaning the dusty furniture and get shortness of breath due to the housework. The appearance of wheezing sound and productive cough will lead the diagnosis to bronchiectasis. This diagnosis is against by the persistent cough and no pathological abnormality detected on chest x-ray. This rule out bronchiectasis. The shortness of breath can be diagnosed as congestive cardiac failure. But in congestive cardiac failure, the patient should have orthopnea, paroxysmal nocturnal dyspnea, and ankle swelling. In this patient, all of the three features are not present in this patient. This rule out congestive cardiac failure. MANAGEMENT 1) Adequate oxygenation 2) IV Hydrocortisone 3) Nebulizer 4) Inhaler (Ventolin and Budesonide)