1. Casepresentation BY: SHAZLIN BT. SABAAH SALWA HANIM BT. MOHD. SAIFUDDIN KAMARULZAMAN B. MUZAINI

2. DEMOGRAPHIC DETAIL Initials : MH Age: 6 years and 8 months old Ethnicity: Malay Gender: Male DOA:23/12/2010 DOD: 25/12/2010 Informant: Grandmother 3. PRESENTING COMPLAIN 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. 4. 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. 5. cont.. 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. 6. cont.. 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 7. SYSTEMIC REVIEW 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. 8. PAST MEDICAL/SURGICAL Hx He has been diagnosed to have asthmasince 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 nebulizerat GP/hospital in Ipoh if attack occur but no hospitalization required. No hx of eczema. 9. DRUGS Hx 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. 10. ALLERGIES No known allergies 11. BIRTH Hx Born at Hospital Kota Baru FTSVD Weight : 2.5kg Antenatal, intrapartum and postpartum hx was uneventful Admitted to NICU for 15 days due to neonatal jaundice diagnosed to have G6PD 12. FEEDING Hx 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 13. IMMUNISATION Hx Up to his age Didnt have any complications after taking the injections 14. DEVELOPMENTAL Hx 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. 15. FAMILY Hx 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 16. 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 Dont have any cats or carpet in house. 17. EFFECT OF ILLNESSThey 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 conditionhad restricted him from doing certain activities or eat certain food. However, the disease didnt give much effects in his school activities. 18. PHYSICAL EXAMINATION 19. 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 20. 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 Impression:His vital signs are normal.2. VITAL SIGNS 21. Height: 110cm. (10thcentile) Weight: 17kg. (10thcentile) BMI: 14.05kg/m2. (10thcentile) Impression: His growth is within 10thcentile. 3.Anthropometric measurements 22. Appearance: No dysmorphic features. Face: No cyanosis, no pallor, no pursed lips. Oral cavity:Moist tongue and mucous membrane No gum bleeding No ulcers No central cyanosis Oral hygiene was good Eyes: No yellow discoloration, pink conjunctivaeEar, nose and throat: There was no nasal discharge, no ear discharge and the throat was mildly injected. 4. Examinationface, head, neck & limbs 23. Neck: No cervical lymph nodes enlargement. Skin: Normal skin tone,no eczema, no rashes and no petechiae. Extremities: Warm peripheriesNo cyanosis at the nail bedNo clubbing of fingers No palmarerythema Capillary refilling time was less than two seconds No peripheral oedema No koilonychias. Impression: No abnormal findings. 24. SYSTEMIC EXAMINATION 1.RESPIRATORY SYSTEM Inspection: 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. Palpation: 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. 25. Percussion: Resonance bilaterally. Auscultation: Normal air entry bilaterally.Vesicular breath sound with prolong expiratory.Ronchi during expiration on the upper zone bilaterally. Impression: 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. 26. 2. Cardiovascular Examination Inspection: There were no visible pulsations, surgical scars, cardiac bulging or superficial dilated veins at precordial area.Palpation: Apex beat was palpable at the 5th intercostals space lateral to midclavicular line. There was no thrill or heave. Auscultation: 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 27. 3.Abdominal examination Inspection:The abdomen was not distended and moved with respiration. The umbilicus was centrally located and inverted. There were no surgical scarsPalpation: The abdomen was soft and non-tender. There was no hepatosplenomegaly. Both kidneys were not ballotable. Percussion: The abdomen was tympanic. There was negative shifting dullness and no fluid thrills. Auscultation: Normal bowel sound present. Impression: No abnormal findings. 28. 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. 29. 4. Central Nervous System Mental status: She was alert and well oriented to time, place and person. Cranial nerves:Intact. Motor system Inspection: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. 30. 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. Gait: Normal. Impression:No abnormal findings. 31. SUMMARY 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. 32. PROVISIONAL DIAGNOSIS Bronchial asthma 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 expirationSuprasternal and subcostal recession Ronchi was heard on the upper zone during expiration bilaterally 33. DIFFERENTIAL DIAGNOSIS 34. INVESTIGATIONS 35. 1) Full Blood Count and automated differentials 36. 2) Venous Blood Gas Impression: Normal 37. Normal3) Chest X-Ray 38. MANAGEMENT 39. ED:Salbutamol Nebulizer cont 1hour Oxygen mask IV hydrocortisone Ipratropiumbromide: 4hourly IV fluid-maintainance 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 BDmdisalbutamol 200mg 4 hourlyAt home: Avoid allergens syrup prednisolone MDI Salbutamol 40. DISCUSSION OF ASTHMA KAMARULZAMAN BIN MUZAINI 2008402286 41. Chronic inflammatory disorder of airways that causes recurrent episodes of wheezing, breathlessness, chest tightness and coughing. DEFINITION 42. RISK FACTORS Host Factors Genetic predisposition Atopy Airway hyper-responsiveness Gender Race/Ethnicity Environmental Factors Indoor /allergens Socioeconomic factorsFamily size weather changesObesity 43. TRIGGERS FACTORS Allergens Smoke (passive smoker) Respiratory infections Exercise and hyperventilation Emotional upset or excitement Food, additives, drugs 44. Pathogenesis of asthma Enviromental factors Genetic factors Bronchial inflamation Bronchial hyperactivity+ trigger factors Oedema , bronchononstriction,& increase mucous production Airways narrowing Symptoms: -cough -wheezing -breathlessness -chest tightness 45. CLINICAL FEATURES Cough Chest tightness Wheezing sound of breath Episodic shortness ofbreath Worsen during night 46. Various severities of asthma Classification of asthma severity -Mild intermittent -Mild persistent -Moderate persistent -Severe persistent *In this patient, it is mild intermittent. 47. *Patient only developed asthma once in two month. 48. DIAGNOSIS History and patterns of symptoms Physical examination Measurements of lung function Measurements of allergic status to identify risk factors 49. TAKING HISTORY 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 administrationbefore 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 50. PHYSICAL EXAMINATION OBSERVATION-(tachypnic, wheezing, drowsiness, central cyanosis, hyperinflated chest,head bobbing, peripheral cyanosis, using accessory muscle when breathing, SCR ,ICR & suprasternal recession) PALPATION - Decrease symetrically chest wall expansion PERCUSSION -resonanceAUSCULTATION-(reduced breath sound, rhonci, vesicular breath sound withprolong expiration time) 51. INVESTIGATION1)LUNG FUNCTION TEST This can be done by using Peak Expiratory Flow Rate(PEFR). 52. 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. 53. Criteria for admissionfailure 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 patientwas admitted to ward because failed respond towards the nebulisersalbutamol given in the ED. 54. 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. 55. MANAGEMENT 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 56. 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. 57. Acute severe asthma Inability to complete a sentence in one breath. Respiratory rate >50/min Tachycardia >140/min PEFR