CASE PRESENTATION

“PRESISTENT MODERATE BRONCHIAL

ASTHMA “
Presented by:
Nadien 1102013200

Supervisor:
dr. Ulynar Marpaung, Sp.A

Department of Pediatrics Bhayangkara

Tk. I R. Said Sukanto Hospital
 Patient’s Identity

Name : Child IR
Gender : Male
Age : 14 years and 1 month
Religion : Islam
Nationality : Indonesia
Address : Kramat Jati, East Jakarta
Parent’s
Identity Father Mother

Name Mr. AS Mrs. M

Age 46 years old 43 years old

Job Traders Private employee

Nationality Indonesian Indonesian

Religion Islam Islam

Education Senior High School Senior High school

Address Kramat Jati, East Jakarta

 The anamnesis was taken on August,2th, 2018 using autoanamnesis
method. It was taken at room Flamboyan
Bhayangkara Tk.I R. Said Sukanto Hospital, Jakarta
Chief complain : shortness of breath

Additional complains : Coughs, The throat feels

itchy, pain when swallowing
 History of Present Illness

Since nine hour before the shortness of breath

often recurs when eating chocolate, chiki and ice cream
patient came to the hospital with wheezing

Shortness of breath is felt

more than once a week and
less than once a day and disrupt activity cough with a little colorless sputum, and difficult to remove,
patient also complain that the throat feels itchy,
accompanied by pain when swallowing.
 Birth History
Mother’s Pregnancy History
• Antenatal Care :
Mother checkups her pregnancy to midwife
monthly
• Pregnancy Illness :
No history of problems and diseases during
pregnancy
• Drug Consumed :
Mother get vitamins every antenatal care
 • Labor : Hospital
• Birth attendants : midwife
• Mode of delivery : Pervaginam
• Gestation : 39 weeks
Child’s
• Infant state : Healthy
Birth
• Birth weight : 3100 grams
History • Body length : 50 cm
According to the mother, the baby cried, had normal of breathing.
Development
History
motoric development
There no delayed development Smile : 1 months old
(normal development) Slant : 2,5 months old
Prone Position : 5 months old
Sitting : 6 months old
Standing : 1 years old
Walking : 1 year 4 months
speaking : 1 year 11 months
 Immunization History
According to the mother, there was a complete
history of immunization.

History of Eating

Breast milk : Exclusively 2 years

Formula milk : SGM
Fruit and vegetables : Banana and papaya
 Family Ilness History
 Patient’s both parents were married when they were 26 years old and 24 years old, and
this is their first marriage.
 There are not any significant illnesses or chronic illnesses in the family declared.
 The mother had history of asthma
 The patient is the first child of the family.
 The patient has two siblings
 Born died : ( - )
 Child dies : ( - )
 Miscarriage : ( - )
 PHYSICAL EXAMINATION

General Status
• General condition : Mildly ill
• Consciousness : Compos Mentis
• Pulse : 134x/min, regular
• Breathing rate : 48x/min
• Temperature : 37C
Anthropometry Status
• Weight : 50kg
• Height : 150kg
Conclution : The patient has a normal noutritional status.

PHYSICAL EXAMINATION

• WFA (Weight for Age): 50/50 x 100 % = 100%

• LFA (Length for Age) : 150/164 x 100 % = 91%
• WFS (Weigh for Stature): 50/40 x 100% = 125%

Conclution : The patient has a

obesse noutritional status.
• Head
normocephal, hair (black, normal distribution, not
easily removed), no sign of trauma
• Eyes • Neck
Scleral icterus -/-, pale conjunctiva -/-, lacrimation +/+, Lymph node enlargement (-), scrofuloderma (-)
pupil 3mm/3mm, isocor, direct light response +/+,
indirect light response +/+, • Thorax
• Ears Inspection : Symmetric when breathing,
Normal shape, no wound, no bleeding, no secretion, retraction (+), ictus cordis is not visible
no cerumen. Palpation : Fremitus tactile +/+ symmetric,
• Nose mass (-)
Normal shape, midline septum, secretion -/-. Percussion : Sonor on both lungs
• Mouth Auscultation :
Lips : dry Cor : S1S2 Reguler, murmur (-), gallop (-)
Teeth : no teeth Pulmo : vesicular +/+, rhonchi -/-,
Mucous : dry wheezing +/+
Tongue : no dirty
Pharinx : no hyperemia
• Abdomen
Inspection : Relax, spider nevi (-)
Palpation : Abdominal mass (-),
hepatomegaly (-) and splenomegaly (-) Neurogical Examination
Percussion : tympanic, shifting dullness (-) Meningeal Sign
Auscultation : Increased bowel sound, bruit
(-)
Nuchal rigidity (-)
• Vertebra
There is no scoliosis, kyphosis, lordosis, and Kernig sign (-)
any mass along the vertebral line. Lasegue sign (-)
• Extremity Brudzinski I (-)
Warm, capillary refill time <2 second, edema Brudzinski II (-)
-/-
• Skin
Skin pinch goes back slowly
 Power
- Hand 5555/5555
- Feet 5555/5555
Tonus
- Hand Normotonus/ Normotonus
- Feet Normotonus / Normotonus
Trophy
- Hand Normotrophy / Normotrophy
- Feet Normotrophy / Normotrophy
Physiologic Reflex
Upper extremities
Motoric Examination - Biceps +2 / +2
- Triceps +2 / +2
Lower extremities
- Patella +2 / +2
- Achilles +2 / +2
Pathologic Reflex
Upper extremities
- Hoffman -/-
- Trommer -/-
Lower extremities
- Babinsky -/-
- Chaddock -/-
- Oppenheim -/-
- Gordon -/-
- Schaeffer -/-
Clonus
- Patella -/-
- Achilles -/-
 Autonom Examination

• Defecation • Normal

• Urination • Normal

• Sweating • Normal
 Laboratory Investigation
• Hematology

results Normal Range

Haemoglobin 14,9 12-14 g/dl
Leucocyte 11.600 5000-10.000 u/l
Hematocrite 43 37-43%
trombocyte 328.000 150.000-400.000 /ul
Working Diagnosis

• PRESISTENT MODERATE
BRONCHIAL ASTHMA
Management

- IVFD RL 20 TPM
- Inhalation combivent + pulmicort + Nacl 0,9% 2cc
- Injection Dexamethasone 2x5mg
- Salbutamol 3 x 1 Tab
- Ambroxol 3 x 1 Tab
 Follow Up
August 3 th 2018, second day
of hospitalization
S : shortness of breath , cough (+),throat feels itchy, accompanied by pain when swallowing (+) P : IVFD RL 20 TPM - Inhalation combivent +
pulmicort + Nacl 0,9% 2cc
Injection Dexamethasone 2x 5mg
Ambroxol 3 x 1 Tab
Salbutamol 3 x 1 Tab
O : General appearance: look moderate ill
Vital sign: HR: 80 bpm , RR: 22 x/minute, S: 36.6 C
Eye: pale -, icteric -, sunken –
Mulut : coated tongue -, dry mucousa –
ENT: hyperaemic pharynx (+), T1-T1
Thorax: Intercostal retraction –
Lungs: vesicular +/+, rhonki -/-, wheezing +/+
Heart: S1S2 murmur -, gallop –
Abdomen: Inspection: even
Auscultation: Normal bowel sound
Palpation: suprapubic tenderness -, hepar and lien not palpable, epigastric pain -.,
Percussion: tympani CVA -/-, Ballotment -/Extremity: warm, CRT < 2 s, oedema –

A : PRESISTENT MODERATE BRONCHIAL ASTHMA

 August 4st 2017, third of
hospitalization,

S : shortness of breath , cough (+) ,throat feels itchy, accompanied by pain when swallowing (+) P : IVFD RL 20 TPM - Inhalation combivent +
pulmicort + Nacl 0,9% 2cc
Injection Dexamethasone 2x 5mg
Ambroxol 3 x 1 Tab
Salbutamol 3 x 1 Tab
O : General appearance: look moderate ill
Vital sign: HR: 80 bpm , RR: 22 x/minute, S: 36.6 C
Eye: pale -, icteric -, sunken –
Mulut : coated tongue -, dry mucousa –
ENT: hyperaemic pharynx (+), T1-T1
Thorax: Intercostal retraction –
Lungs: vesicular +/+, rhonki -/-, wheezing -/-
Heart: S1S2 murmur -, gallop –
Abdomen: Inspection: even
Auscultation: Normal bowel sound
Palpation: suprapubic tenderness -, hepar and lien not palpable, epigastric pain -.,
Percussion: tympani CVA -/-, Ballotment -/Extremity: warm, CRT < 2 s, oedema –

A : PRESISTENT MODERATE BRONCHIAL ASTHMA

August 5nd 2017, four of
hospitalization

S : shortness of breath , cough (-),throat feels itchy, accompanied by pain when swallowing (-) P : IVFD RL 20 TPM - Inhalation combivent +
pulmicort + Nacl 0,9% 2cc
Injection Dexamethasone 2x 5mg
Ambroxol 3 x 1 Tab
Salbutamol 3 x 1 Tab
O : General appearance: look moderate ill
Vital sign: HR: 80 bpm , RR: 22 x/minute, S: 36.6 C
Eye: pale -, icteric -, sunken –
Mulut : coated tongue -, dry mucousa –
ENT: hyperaemic pharynx (+), T1-T1
Thorax: Intercostal retraction –
Lungs: vesicular +/+, rhonki -/-, wheezing -/-
Heart: S1S2 murmur -, gallop –
Abdomen: Inspection: even
Auscultation: Normal bowel sound
Palpation: suprapubic tenderness -, hepar and lien not palpable, epigastric pain -.,
Percussion: tympani CVA -/-, Ballotment -/Extremity: warm, CRT < 2 s, oedema –

A : PRESISTENT MODERATE BRONCHIAL ASTHMA

PROGNOSIS

• Quo ad vitam : Bonam

• Quo ad functionam : Bonam
• Quo ad sanationam : Bonam
Literature Review and Discussion
ASTHMA BRONKIALE
DEFINITION

GINA defines asthma as a chronic inflammatory

disorder of the respiratory tract with many cells,
especially mast cells, eosinophils, and T lymphocytes.
In people who are susceptible to inflammation, it
causes recurrent wheezing episodes, shortness of
breath, depressed chest feeling, and coughing,
especially at night or early day.
 epidemiology
Prevalence in
children
suffering from
asthma
increases 8-10
times in
developing
countries
compared to
developed
countries. The
prevalence
varies greatly.
ETIOLOGY

• Allergen
• Infection
• Genetic
• Weather
• Sport activity
• Food
• Polusion
• Ispa
• drug
PHATOPHYSIOLOGY
 Asthma Clasification GINA

Symptoms during day Symptoms during Lung

night fuction
Degree 1 Intermittent <1 time per week <2 times a month >80%
Asymptomatic and normal <20%
PEF value between attacks
Degree 2 Persistent > 1 time a week but <1 time >2 times a month >80%
mild per day Attack can disrupt 20-30%
activities
Degree 3 Persistent Once a day Attack disrupt > 1 time a week 60-80%
moderate activity >30%
Degree 4 Persistent Continously all day Limited Often <60%
severe physical activity >30%
Asthma Classification PNAA
 CLINICAL MANIFESTATION

Child's breath sounds

like a whistle or
wheezing

coughing with phlegm, • Beginning with an individual trigger

shortness of breath, factor.
feeling of heaviness in
the chest

Symptoms arise /
worsen especially at
night / early morning
 DIAGNOSIS
PHYSICAL SUPPORTING
ANAMNESIS
EXAMINATION EXAMINATION
• Symptoms of
• Diagnosis is asthma vary
• Eosinophil
sufficiently throughout the day blood test
established so that mild and and
moderate asthma is
with clinical not found physically tuberculin tes
symptoms of outside the attack • Uji faal baru
anamnesis • Rotgen
and physical thorax
examination
 PHYSICAL EXAMINATION

Retraction (+)
Inspection : breathing is quick expiration extends
and difficult supraklavikular, suprasternal,
wheezing
epigastrium dan intercostal

Percussion : sounds
hipersonor throughout the Auscultation: wheezing
thorax
 Differential Diagnosis

Rhinosinusitis
gastroesofageal reflucks
bronkiolitis
Displasia bronkopulmoner
Tuberkulosis
Corpus allenum
 TREATMENT
Education of patients and families

Evaluate the classification / severity of asthma

Avoid exposure to risk factors

 TREATMENT

Asma Episodik Sering:low-dose

Episodic asthma is rarely enough to
be treated with medications such
as β2-agonists and theophylline
steroids (budesonide (50-100 ug /
day of fluticasone) for children
less than 12 years old, and 200-
400 ug / day of budesonide (100-
200 ug / day of fluticasone) for
children over 12 years.
 In persistent asthma management there are two
alternatives, namely using steroids in a medium dose of
giving budenoside 200-400 ug / day of budesonide (100-
200 ug / day of fluticasone) for children less than 12 years
old, 400-600 ug / day budesonide (200 -300 ug / day of
fluticasone) for children over 12 years. In addition,
alternative alternatives can be used by using low-dose
sniffing steroids plus LABA (Long Acting β-2 Agonist) or
adding Theophylline Slow Release (TSR) or adding Anti-
Leukotriane Receptor (ALTR.)
 PROGNOSIS

• The prognosis of patients in this case is quite improved, this is based

on the development revealed by the patient from day to day in the
form of wheezing and shortness of complaints.
Thank you