Nur Rahwanie, 10 years old Malay girl admitted yesterday with chief complain of shortness of breath for 1 day. She was previously well until 3 days ago where she started to have cough. It was non-productive cough. It was intermittent in nature and there was increase in frequency of coughing especially in early morning and night. It was not associated with nasal discharge, and no post-tussive vomiting. There was no sore throat and no ear discharge. She has participated in sports day for long distance running prior to this episode. One day later, she developed shortness of breath at night around 8 pm. It was associated with noisy breathing. She then took inhaler (MDI salbutamol) 2 puffs and it was relieved. She also develop fever which was sudden in onset and continuous in nature. No documented temperature. No chills and rigor. Next morning around 5 am which is the day of admission, she developed another fast breathing episode and it was temporarily relieved by inhaler for about 1 hour and subsequently her condition worsen as her shortness of breath unable to resolve even after 3 puffs of MDI salbutamol. There was no bluish discolouration of lips and fingers. She only able speak in phrases. No altered consciousness but appears lethargic. She was then brought to ETD and nebulized about three times but her condition does not resolved and she then admitted to the war d. There was decreased in activity and reduced oral intake but no loss of weight. There was no night sweat, no chest pain and no palpitation. Bowel habit and urine was normal. There was no ill contact in the family.
Past medical history She was diagnosed with bronchial asthma since she was 8 years old. This is her 3 rd hospital admission for acute exacerbation of asthma. She had allergic rhinitis and cough in the early morning associated with cold weather for 3 times per month. There was no history of eczema. She had daytime symptom every day such as cough early morning and usually resolve by noon. She has nighttime symptom about once a week. She need reliever about 1-2 times per month. She had outpatient nebulization 3 times this year and her last nebulization was on September. Exacerbation did not affect much of her attendance in school. She was on 2 types of inhaler which are salbutamol and budesonide. However, she was not compliant with the medication given because she always forgot to take the medication. She default follow up at pediatrics clinic as she did not has transport. There was no carpet or pets in the house. Her father is a smoker but smoke outside the house. There was no construction or factory nearby the house.
Review of systems: Central Nervous system: No drowsiness, seizures or loss of consciousness. consciousness.
Cardiovascular system: No chest pain, ankle swelling or paroxysmal nocturnal dyspnoea. Genitourinary system: No dysuria, frequency or haematuria. Musculoskeletal system: No muscle or joint pain. Haematology system: No easy bruising.
Drug and allergies hx There was no over the counter medication. She has no known drug allergy but she had allergy to seafood which will causing her to have r ashes, eye puffiness and redness with clear watery discharges.
Antenatal history Her mother was 20 years old when she gave birth to her. This was her first pregnancy. Antenatal history was unremarkable.
Birth history She was born full tem via spontaneous vaginal delivery with birth weight o f
Neonatal history There was no history of neonatal jaundice and it was unremarkable.
Diet history She was exclusive breastfeeding until the age of ______. She started weaning at the age of 6 months old with porridge, vegetables and fish. She is a picky eater and she dislikes vegetables. Her daily meals not fixed ranged from 1x to 3x 3 x per day. Her meal usually rice, fish, and chicken.
Developmental history Her developemental milestone similar to her other siblings. She is now studying in Primary 4. She placed ___ out of ___ ___ in the class. She She able to read and do simple simple calculations. She likes likes to play netball at school. school. She has a lot of friends in school and has good relationships with her parents and siblings.
Immunization history She had completed all the immunization without any adverse re action.
Family history She is the eldest among 5 siblings. She has 3 younger sister who are 9, 7 and 6 years old. She has younger brother who now 1 year and 7 months old. Both her parents has no known medical illness. There was no family history of asthma and history of atopy.
Social history She lives in a single storey house with her parents in Kpg Semariang which equipped with basic amenities. Nearest clinic was about 10 minutes by motorcycle. Her father works as contract worker while her mother is a housewife. Their household income about RM700 per month.
Physical Examination General Examination:
Patient is thin build lying comfortably on the bed, alert, conscious and co-operative. Hydration status is good. There is a face mask prepared nearby the bed however she is not using it during the examination. She was on nasal prong 2L.
Vital Signs
Pulse Rate: 158 bpm. Good volume and regular rhythm.
Respiratory Rate: 28 breaths per min
Blood Pressure: 106/56 mmHg
Temperature: 37 oC
Capillary Refilling Time: < 2s
Hands: No finger clubbing, peripheral cyanosis or pallor of the palm. Face and neck: The conjunctiva is pink and no yellowish sclera. She has good oral hygiene and there is no central cyanosis. There is no visible scar, neck gland enlargement or palpable lymph node. No injected throat. Feet: There is no pe dal oedema at ankles on both feet. No clubbing of the toes is noted.
Anthropometric measurement
Height: ______cm
Weight: 17.2 kg
Systemic Examination Respiratory System:
Inspection: No chest deformities, no scar. There was subcostal recession and usage of accessory muscle. The chest moves symmetrically with respiration. There is no tr achea deviation, trachea tug or narrowed cricosternal distance. Palpation: Reduced chest expansion. Apex beat is in the left 5th intercostals space at midclavicular m idclavicular line. Equal tactile vocal fremitus. Percussion: Both lungs are normal on percussion. Ausculatation: air entry present on both lung. There is generalized rhonchi all over both lung fields. No crepitations or added sounds are heard on both lungs.
Abdomen: Inspection: The abdomen moved with respiration. It is not distended. The umbilicus is inverted and
situated at the centre. There are no surgical scars, dilated veins or scratch mark noted. Palpation:
Soft palpation: Abdominal is soft and non-tender. There is no guarding or rigidity. Deep palpation: There is no palpable mass. Liver and spleen are not palpable. Kidneys were not ballotable. Percussion: There is no shifting dullness. Auscultation: Bowel sounds were heard with normal frequency and intensity. No renal bruit heard.
Other systems: No significant findings.
Provisional dx Moderate acute exacerbation of bronchial asthma Hx of atopy, nocturnal cough, wheeze Differential dx Postnasal drip: doesn’t resolved Heart failure: dry nonproductive cough but no chest pain, no PND Pneumonia: cough, fever but no chest pain Tuberculosis: dry cough, underweight (FTT), fever but no l.o.w, no night sweats
Investigation Full blood count: neutrophillia, eosinophilia, anaemia BUSE: reduced oral intake, electrolyte imbalance Sputum culture and sensitivity Chest x-ray
Management Neb ventolin hourly and AVN 4 hourly Keep NPO2 2L/min, keep sPO2 >95% t.prednisolone 17.5mg OD cont MDI budesonide 200mg BD refer pharmacist come to assess MDI technique asthma action plan and compliance to treatment refer to dietician
