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 ward.

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 3rd 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.

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 rashes, 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 of

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 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 able to read and do simple calculations. She likes to play netball at 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 reaction.
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 pedal 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 trachea deviation, trachea tug or
narrowed cricosternal distance.

Palpation: Reduced chest expansion. Apex beat is in the left 5th intercostals space at midclavicular 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.

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