Case Report

ASMA
PEMBIMBING :
dr. Alfred Siahaan, SpA

Di susun oleh :
Bella Alfianty
1261050095

KEPANITERAAN KLINIK ILMU KESEHATAN ANAK

FAKULTAS KEDOKTERAN UNIVERSITAS KRISTEN INDONESIA
Periode 26 februari – 5 mei 2018
 KASUS

Patient’s Identity
• An. Z, Female, 4 yo 2 mo
• Come in: March, 6th 2018
• Hospitalize : 2 days

Chief complain

• Dyspnea since 9 hours hospitalizing

 PRESENT ILLNESS

• Dyspnea since 9 hours hospitalizing

• With a wheezing sound
• shortness of breath often recur when cold weather, a lot of dust and air
musty
• Cough up phlegm since 1 week ago
• Sputum is difficult to remove and does not bleed
• throat feels itchy
• pain during swallowing
• Cold 1 day ago
 PAST ILLNESS
In January 2016, the patient had experienced
shortness of breath and was once disembodied
HISTORY OF FAMILY MEMBER’DISEASE

• Family history of asthma is denied

History of Pregnancy and Labor

• Single child
• History of normal pregnancy, no morbidity
• Born spontaneously, enough month, assisted by
midwife
• BL 3250 g, PL 49 cm, instantly crying, tightness (-),
blue (-), yellow (-)
PEDIGREE
Immunization history
• Basic immunization is complete, according
to age.

Nutrition history

• Good in quality and quantity

History of Growth

• Complete according to age and oncourse.

 Patients at the Emergency
(Tuesday, 6 March2018)

Physical examination:
CM, GCS E4 M6 V5,
• Blood pressure : 90 / 60 mmHg
• HT : 96 times / min, regular, strong lift, enough content
• RR: 36 times / min, abdominal breathing, regular
• T emperature : 36,7°C
 Physical Examination
• Head : Normocephali, hair growth evenly, hair
is not easily revoked, black hair
• Eye : Conjunctival anemis (- / -), sclera ikterik
(- / -), sunken eyes (- / -)
• Ear : Liang ear field, intact tympanic
membrane (+ / +), serumen (- / -)
• Nose : No form of abnormality, no septum
deviation, visible clear secret (+ / +), nasal lobe
breathing (- / -)
Mouth
• Lips: Dry lips mucosa (-), hyperemic (-), cyanosis (-)
• Teeth : Tooth perforated (-), caries (-)
• Tongue : Normal shape and size, not dirty
• Faring: Hyperemic (+) Tonsil: T1-T1, hyperemic (- / -)

Lung
• Inspection: Movement of right and left symmetric
thoracic wall, Rearrangement of ribs (-)
• Palpation: Fremitive vowel is not hardened,
symmetricalRight and left
• Percussion: Sonor - Sonor
• Auscultation: vesicular BND (+ / +), wheezing (+ / +)
Ronkhi (-/-)
Heart
Inspection : The curt pulse is not visible
Palpation : The palpable cordis pulsation is palpable
on the ICS 5 linea midclavicula sinistra
Percussion : The right heart margin lies on the ICS IV
linea parasternalis dextra. The left heart border lies on
the ICS V linea midclavicula sinistra
Auscultation: The heart sounds I and II regular, murmur
(-) gallop (-)

Abdomen
Inspection : Abdomen looks flat
Auscultation: Bowel sound (+), 4 times/minute
Percussion : Timpani, tap pain (-)
Palpation : Supel, tenderness (-), pain relief (-)
Ekstremitas
Laboratory Findings
BASED ON RESULTS NORMAL LIMITS

Hemoglobin 13,5 g/dL 10.7 – 14.7 g/dl

Hematocrit 40% 37 - 43 %
Platelets 282 rb/uL 150.000 – 450.000 / ul

Leukocytes 14,1 rb /uL 5.000 – 10.000 / ul

Erythrocytes 4,67 juta/uL 4 – 4. 5 juta / ul
Calculate Type
Basophils 0% 0–1%
Eosinophils 0% 1–3%
Neutrophil Trunk 0% 2–6%
Neutrophil Segment 85 % 50 – 70 %
Lymphocytes 10 % 20 – 40 %
Monocyte 5% 2–8%
Working diagnose:
Mild Persistant Asthma

Treatment
• CIV RL 16 tpm (Makro)
• Oksigen nasal Canul 4 lpm
• Dexamethasone 2,5 mg
• Cefotaxime 50mg
Nutritional status

Anthropometri Status

BB Good Nutrition Status According to

WHO (Located between -1 SD & -2SD)

BB/U: 13.5 / 16 X 100 % = 84.37 %

 Normal Weight
TB/U: 102 / 101 X 100 % = 100.09 %
 Normal Heigh
BB/TB: 13.5 / 15.5 X 100 % = 87.09 %
 Good
FOLLOW UP
 Day-1 of care (Wednesday, 7 March 2018)
shortness decreases, Fever (-), cough (+), Cold (+), Vomiting (-) 1x liquid chapter with
S blackish yellow dregs, mucus (-), blood (-), BAK as usual clear color, intake of eating and
drinking well
General Condition: Moderate Sickness, Compositional awareness
O Blood pressure : 90 / 60 mmHg
HR : 116 x/menit, reguler, kuat angkat
RR : 31 x/menit
Temperature : 36.7 °C
Eye : CA -/-, SI -/-
Neck : KGB is not palpable enlarged
Thorax : found Wheezing + / +
Abdomen : Normal limits
Ekstremitas : Normal limits

A The Episodic Mild Degrees of Rare Dormity

The Soft Diet
P IVFD RL 16 tpm (Makro)
Ventolin inhaler 3xII/day
Dexamethasone 3X2,5 mg/day
Cefotaxime 2x50mg/day
Ambroxol puyer 3x 6mg Pulv
 Day-2 of care (Thursday, 8 March 2018)
dyspnea (-), fever (-), cough (+), cold (+), vomiting (-), defecate 2 times with normal
S stool, normal urinary as usual, food and drink in normal intake.

General Condition: Moderate Sickness, Compositional awareness

O Blood pressure : 90 / 60 mmHg
HR : 100 x/menit, reguler, kuat angkat
RR : 20 x/menit
Temperature : 36.5 °C
Eye : CA -/-, SI -/-
Neck : KGB is not palpable enlarged
Thorax : found Wheezing + / +
Abdomen : normal limits
Ekstremitas : normal limits
The Episodic Mild Degrees of Rare Dormity
A
The Soft Diet, IVFD RL 16 tpm (Makro)
P Ventolin inhaler 3xII/day
Dexamethasone 3X2,5 mg/day
Cefotaxime 2x50mg/day
Ambroxol puyer 3x 6mg Pulv
 LITERATURE REVIEW : Definition
According to respiratory IDAI of asthma is a
respiratory tract with a chronic inflammatory
basis that causes obstruction and
hyperreaktivity of the respiratory with varying
degress.
Clarification based on the description
of clinical manifestations
Aetiology and risk factors
The severity of asthma
• Test lung fuction with spirometry is one of the
recommended cheks on asthma attacks . If the
tool is available and the patient’s condition
allows before therapy is given
• If available cheks the oxygen saturation pulse
oximetry. Oxygen saturation < 92% is a sign of
a severe attack that requires aggressive
action.
Criteria of controlled asthma in children :

• No symptoms arise or minimal

• No asthma attack at night
• No limitations of activity
• No drug use or minimal daily
• Variation less than normal or near normal
values
Step of asthma handing in children
• Providing education to patients and their
families about asthma
• Assessment and monitoring of the degree of
avoidance of asthma
• Prevent of the triggering