Laporan kasus

Oleh:
Ratna Mega Sary
NIM. 1408465676

Pembimbing :
dr. Riza Iriani Nasution, SpA

KEPANITERAAN KLINIK BAGIAN ILMU KESEHATAN ANAK

FAKULTAS KEDOKTERAN UNIVERSITAS RIAU
RSUD ARIFIN ACHMAD
PEKANBARU
2016
 inflammation
chronic inflammation
Episodic wheezing, cough and WHO 100-150 million asthma
shortness Not prevented reach 180,000 every
year

Asthma is a common chronic disease

in children and still remains a
problem for patients, families and
even clinicians
 Asthma is recurrent wheezing and persistent
cough with the following characteristics : arise
episodic, inclined at night / early morning,
seasonal, after physical activity, and there is a
history of asthma or other atopic patients or
their families.
Asthma can occur via two pathways
immunologically

autonomic nervous
 Originator of the asthma attacks can be caused by a
number of factors, such as allergens, viruses, and an
irritant that can induce an acute inflammatory
response.

Immunological pathways dominated by IgE

antibodies, a type I hypersensitivity reaction (allergic
type), consisting of fast phase and slow phase.
Allergic reactions occur in people with a tendency to
form abnormal amount of IgE antibodies in large
quantities, this group is called atopy
 In the autonomic nervous pathways, inhalation
of allergens to activate mast cells intraluminal,
alveolar macrophages, the vagus nerve and
possibly also airway epithelium.

In such circumstances the reaction occurs

through nerve reflection. Efferent vagal nerve
endings are stimulated mucosa cause the
release of sensory neuropeptid compound P,
neurokinin A and Calcitonin Gene-Related
Peptide (CGRP).
 Genetic Factors
a. Atopic / allergic

b. bronchial hyperreactivity

c. Gender
d. Race / ethnicity

e. obesity
 Environmental factors
a. Allergens in the home (house dust mites, mold
spores, cockroaches, animal dander such as
dogs, cats, etc.).
b. Outdoors allergens (pollen, and mold spores).
 Other factors
a. food allergens
b. Allergens drugs
c. Ingredients that irritate Example: perfumes,
household sprays, and others.
d. Excessive emotional expression / stress
e. Cigarette smoke for active and passive smokers
f. Air pollution from the outside and indoors
g. Exercise-induced asthma
h. Changes in the weather
i. economic status
Clinical parameters, needs Infrequent episodic asthma Frequent episodic asthma persistent asthma
medication and pulmonary
asthma

1. The frequency of attacks <1x / month > 1x / month Often

2. Long attack <1x/ week >1x / week Most of the year there was no
attack free period

3. The intensity of the attacks usually mild usually being usually weight

4. Among attack asymptomatic Often there are symptoms Symptoms day and night

5. Sleep and activities Not distrubed frequently interrupted very disturbed

6. Physical examination Normal found disorders Never normal

outside attacks

7. drug control (anti- No needed Need Need

inflammatory)

8. Lung function tests PEF and FEV1> 80% PEF and FEV1 <60-80% PEV or FEV 1 <60%
(outside attack)
9. Variability pulmonary Variability> 15% Variability> 30% Variability> 50%
function (if there is an attack)
From anamnesis
To reinforce the notion of asthma, history
should be done carefully in order to get proper
medical history of the symptoms of difficulty
breathing, wheezing or chest feels heavy
episodic and associated with the seasons. As
well as a history of asthma and atopic disease
in family members.
Physical Examination
Awareness

Body temperature

Shortness of breath, whether there is shortness

of breath
Signs of respiratory failure

Signs concomitant infections or complications

Assessment of the degree of asthma attacks:

mild / moderate / severe / life-threatening
Examination Support
Examination of lung function: peak flow meter,
spirometer
Blood gas analysis: in general seemed
hiperaerasi asthma, can be found complications
such as atelectasis, pneumothorax and
pneumomediastinum
 Oxygen
Fast-acting bronchodilators
Children given quick-acting bronchodilators in
one of three ways: nebulized sabutamol,
salbutamol by MDI with a spacer or a shot of
adrenaline / epinephrine subcutaneously.
Steroids
Aminofilin
Antibiotics
PATIENT IDENTITY

Name/MR : An. P/89 92 63

Sex : girls
Age : 10 years old
Parents initials : Mr. A/ Mrs. K
Address : pekanbaru city
Hospitalized : 1-12-2015
ALLOANAMNESIS

from her mother

CHIEF COMPLAIN

Blown recurent since 10 hours before admitted

to the hospital.
 Present Illness History

3 month ago 10 hours ago

a few hours earlier
shortness of breath repeated 4 had been taken to
shortness of times, wheezing sound, influenced
breath triggered by the cold weather, more heavily AA hospital in nebu
by the smoke of in the early morning, shortness of 3 timesm and
intermittent, sleep with a pillow, improvement and
the burning land, patients also complain of fever, not should go home.
went to the health too high, no chills, no sweating, until the patient's
puskesmas and fever was reduced by paracetamol ,
home back tightness
was diagnosed patients also complained of cough
with phlegm, greenish, viscous, no and was taken to AA
with asthma, blood, no foul smell, patients also hospital and treated
received the drug complain of cold, thick green color
salbutamol, and do not stink.
methylprednisolo
ne, and repair
PAST ILLNESS HISTORY

asthma since the age of 6 years old

a history of allergies, cause unknown

FAMILY HISTORY

The younger brother of seafood allergy

grandmother suffering of asthma

PARENTS HISTORY

Father : trader
Mother : trader
PREGNANCY HISTORY

Patient was borned spontaneously by a midwife,

birth weight (1600 gr)
ANC with a midwife
Hipertension (-), DM(-), Fluor albus (-), fever
Alcohol (-), smoking (-), Medication/ drugs(-)

FOOD AND DRINK HISTORY

Breast milk until 3 months

Formula milk since 4 month until 7 month
Eat porridge team 8 months 1,5 years old
Since 1,5 years old daily family food until now
IMMUNIZATION HISTORY

BCG 1 time
POLIO 5 time
CAMPAK 3 time

GROWTH HISTORY

Weight lifting age of 3 months

Crawling the age of 4 months
Sitting at 3 months
Standing age of 9 months
Walking at 12 months

Environment and House

Patients living in permanent house, good ventilation, drinking

water sources is water gallon, MCK is the source of wells.
 Physical Examination
General appearance: moderate sickness
Awareness: composmentis
Vital signs
BP : 130/100 mmHg
HR: 86 x / min
RR: 32 x / min
T : 36,8 C
 Height = 103 cm
Weight = 25 kg
BMI = 36 kg
Arm circumference = 18 cm
Head circumference = 51 cm
 Head : normochepal
Hair : black, not easy to be pulled
Eyes : anemic conjunctival (-/-), jaundice scleral (-
/-), pupil: isochor, light reflex (+/+)
Ears : normal
Nose : normal
Mouth : redness, moist, mocous membran wet,
palate intact, tongue clean, teeth normal
Neck : enlargement of lymph nodes (-), stiffness (-)
 Inspection : simetris, subcosta minimal
retraction
Palpation : VF simetris, increase
Percusion : hipersonor
Auscultation : Vesikuler (+/+), wheezing (-/-),
ronkhi (+/-), normal cardiac sound
 Inspection : flat stomach, scar (-)
Palpation : supple, tenderness (-)
Percussion : tympanic
Auscultation : bowel sound (+) normal
 Genitalia: Normal

Extremity:
Warm, CRT<2, edema (-), cyanosis (-)

Neurological State:
Physiologic (+), pathologic (-), convulsions (-)
1/12/2015
Routine Blood
Hb: 13,4 g/dl
Ht: 43,0%
Leukocytes: 18.300/mm3
Platelets: 503.000/mm3
Macroscopic : clear yellow color, sediment (-)
Chemical urine: protein (-), glucose (-), bilirubin (-
), urobilinogen 0-1, PH 7.0, BJ blood 1.00 (-),
ketones (-), nitrite (-)
Microscopic: 0-1 erythrocytes / LBP, leukocytes 0-
1 / LBP, 1-2 epithelial cell, crystal 0, cylinder 0,
0 bacteria, fungi 0.
 Shortness of breath since 10 hours SMRs, recurring
tightness
There was a wheezing
Shortness influenced the weather, smoke and cold air
Fever is not too high and given paracetamol fever is
reduced
Cough and cold
In the crowded nebulizer reduced
Asthma attacks last 3 months SMRs with the originator
of smoke
History of asthma since the age of 6 years
History alegi
History of atopy and asthma in the family
 Awareness composmentis
BP 130/100 mm Hg, pulse 86x / minute,
regular, T 36.8 C
Vocal fremitus increased
Pulmonary Percussion hipersonor
Vesicular hardened, dry crackles (+), wheezing
(+)
warm, CRT <2 seconds, edema (-), cyanosis (-)
 Leukositosis : 18.300/mm3
Working Diagnostic :
Bronchial asthma in acute exacerbation

Nutritional Diagnostic :
malnutrition

Differential Diagnostic :
Bronchiolitis
Pneumonia
Upper respiratory tract infection

Suggestive Examination :
Chest X-ray
Spirometry examination
 IVFD Ringer Lactate 20 gtt/minute (macro)
O2 3L/minute
Nebu Ventolin : Vulmicort 3 time distance 30
minute
Dexamethason 3x1 amp
Ceftriaxon 2x1 gr

Nutritional : 2520 kkal/day

 Quo ad vitam : bonam
Quo ad functionam : bonam
 Day/Date Subjective Objective Assesment Management

2-12-2015 reduced tightness, cough KU: looks ill being, Bronchial asthma in IVD RL 20 tpm macro
with phlegm (+), fever (- consciousness acute exacerbation Oxygen 3 L / m
composmentis, BP 100/80 Nebu ventolin 3x1 Ceftriaxon
), cold (+), nausea (-), mm Hg, pulse: 98x / i 2x1 amp Dexametason 2.5mg
vomiting (-), good (stuffing strong, regular), / 8 hour IV
breath 30x / i, a temperature ambroxol 3x4
appetite, BAB has not of 36.2 C, weight : 25.2 kg diet ML
existed since the first day Eyes: concave (- / -),
conjunctival anemic (- / -),
of admission, BAK no sclera jaundice (- / -), isokor
complaints) pupil, light reflex (+ / +)
Mouth: wet, cyanosis (-)
Nose: secretions (+) green,
nasal flaring (-) Thorax:
vocal fremitus increased,
vesicular hardened, crackles
(-), wheezing (+) abdomen
Inspection: looks flat,
supple, tenderness (-),
normal BU Extremities:
akral warm, CRT <2 ",
 Day/Date Subjective Objective Assesment Management

3-12-2015 reduced tightness, cough KU: looks ill being, Bronchial asthma in IVFD RL 20 tpm macro
with phlegm (+), fever (- consciousness acute exacerbation Oxygen 3 L / m
composmentis, BP 100/80 Nebu ventolin 3x1
), cold (+), nausea (-), mm Hg, pulse: 100x / i Dexametason 2.5 mg / 8 hour
vomiting (-), good (stuffing strong, regular), IV
breath 28x / i, a temperature Ceftriaxon 2x1 gr
appetite, BAB no of 36.6 C, weight : 25.3 kg ambroxol 3x4 diet ML
complaints, BAK no
Eyes: concave (- / -),
complaints conjunctival anemic (- / -),
sclera jaundice (- / -), isokor
pupil, light reflex (+ / +)
Mouth: wet, cyanosis (-)
Nose: secretions (+) green,
nasal flaring (-) Thorax:
vocal fremitus increased,
vesicular hardened, crackles
(-), wheezing (+) abdomen
Inspection: looks flat,
supple, tenderness (-),
normal BU Extremities:
akral warm, CRT <2 "
 Day/Date Subjective Objective Assesment Management

4-12-2015 shortness of (-), cough KU: looks ill being, Bronchial asthma in IVFD RL 20 tpm macro
with phlegm (+), fever (- consciousness acute exacerbation Nebu ventolin 3x1
composmentis, BP 100/80 Dexamethasone 2.5 mg / 8
), cold (+), nausea (-), mm Hg, pulse: 96x / i hour IV
vomiting (-), good (stuffing strong, regular), Ceftriaxon 2x1 gr
breath 28x / i, a temperature ambroxol 3x4
appetite, BAB no of 37.1 C, weight 25.6 kg diet ML
complaints, BAK no Eyes: concave (- / -),
conjunctival anemic (- / -), drug return
complaints sclera jaundice (- / -), ambroxol 3x4
isokhor pupil, light reflex (+ salbutamol 3x4
/ +) Mouth: wet, cyanosis (- Ceftriaxon 2 x 3
) Nose: secretions (+) green,
nasal flaring (-) Thorax:
vocal fremitus increased,
vesicular hardened, crackles
(-), wheezing (-) abdomen
Inspection: looks flat,
supple, tenderness (-),
normal BU Extremities:
akral warm, CRT <2

Clinical improvement of
patients return home
Pediatric patients 10 years old
with complaints of tightness
triggered by cold air, smoke, Based on the ennobled of
productive cough, runny these patients shortness
nose, fever is not too high, a since 10 hours SMRs and The risk factor is a history of
history of asthma since the repeated 4 times in 1 day, asthma in patients with a
age of 6 years, a history of attacks last 3 months SMRs history of allergies and
allergies, family history of triggered haze of smoke, asthma and atopy in the
atopy and asthma, breath beyond attack was not family, the trigger of
sounds wheezing, when the audible wheezing, do not shortness due to smoke and
attack is triggered by interfere with the activity dust, heavier early morning.
environmental factors such as and sleep, based on clinical A history of atopy
smoke. patient can be classified in
mild persistent asthma