MORNING REPORT

Rabu

Duty 1st on Ward

: DM Yaya

Duty 2nd

: dr. Chandra J

Supervisor

: dr. Isa, Sp.P

| 15 Juli 2015

Pulmonary Department
of Ulin Hospital

Identity of patient
Name
Age
Adreess
Occupation

Wednesday | January
11, 2012

:
:
:
:

Mr. M
50 yo
Jl. Teluk Tiram
Miner

ANAMNESA
Main complain: Shortness of Breath
History of Present Illness: Shortness of Breath
since 5 days. Cough since 3 days ago with
purulen sputum yellowish, fever (+) since 2 day
ago. Patient has to ventolin inhaller to
relievier, but shortness was increase.
There is no loss of appetite and no loss of body
weight, nausea (+), vomiting (-), chest pain (-)
History of past illness:
- DM(-), HT (-), asthma (-), Bloody cough (-) ,
Anti Tb Drug (-)
History of asthma bronchiale since 20 years
ago and the last exaserbation was July 2015.
SOB came at the patient hyeractivity and cold
wheather

Phsical Examination
Status Present: weakness , GCS : 456
Vital sign
: BP :120/80 mmHg, P : 100 x/m, RR : 28 x/m, T : 38,7 oC
Head/Neck
: anemia (-), icteric (-), cyanosis (-), dyspneu (+),
Lymph node Colli (-), JVP (-), neck edema (-/-)
Thorax :
Cor : S1-2 single, murmur (-), gallop (-), es (-)
Pulmo :
Inspection : symetric
Palpation :

Abd: distended (-), H / L : not palpable

Ext: warm, edema - / -

LABORATORY
BLOOD
Hb

16,1

WBC

16,6

4,86

Ht

50

Trom

261

CXR

1. Shortness Of Breathing
2. Respiration tract infection
3.

Asthma bronkhiale
exaserbation

acut

no

Problem

P Diagnosis

P Therapy

P Monitor

1.

SOB

02 nasal 4 lpm

C/Vs

2.

Respiratory Tract
Infection

Check sputum
gram
k/s sputum aerob

Azitomisin 1X 500 mg

DL 3 day post
Ab

3.

Asthma
bronkhiale
eksasebasi
akut

Spiometri
Test

Ventolin nebule 1
Spirometr
amp/6 h
i
Inj Kotikosteroid 3 x BGA
62,5 mg
Azitromisin 1 x 500 mg
Inf Aminofilin 20
mg/KgBB/24h

PEMBAHASAN
Asthma is a heterogeneous disease,
usually accompanied by chronic
inflammation of the respiratory tract
Asthma is marked by the presence of
symptoms such as wheezing, shortness
of breath, heaving and cough which
varies during the course of the day
and its intensity also accompanied by
limited airway which is reversible in
nature (Gina,2015)

Patofisiologi Asma
Hipertrofi
kelenjar sub mukosa
& sel goblet

Sumbatan
oleh mukus

Deskuamasi
sel-sel epitel
Penebalan
sub membrana basalis
Deposisi kolagen

Hipertrofi
Sel-sel otot polos
bronkus
Vasodilatasi dan
leakage

Infiltrasi
eosinofil, sel mast,
netrofil, sel T
Edema mukosa
dan submukosa

bronchus at asthma patient

Diagnosis of Asthma
1. Patient history and symptom pattern
2. Lung function testing
Spirometry
Peak expiratory flow / PEF
3. Airway responsiveness testing
4. Allergic status testing for identification
of risk factors
5. Additional steps which may be required for
asthma diagnosis in less than 5 years old
children and in the

Factors Which Cause

Asthma Exacerbation
1. Allergens
2. Respiratory tract infection
3. Activity and
hyperventilation
4. Changes in weather
5. Sulphur dioxide
6. Food, additives, drugs

Asthma Management and

Prevention Program
Asthma may be effectively controlled in
most patient through intervention which
intended to suppress and decrease
inflammation also treating
bronchoconstriction and symptoms
Early intervention aimed to stop
exposure of risk factor to the
sensitive respiratory tract may help to
improve asthma control and decrease the
need for medication.

Treating Asthma
Treatment options must be based
on:
1. Asthma control level
2. Current treatment
3. Pharmacological properties
and availability of various
asthma medication formulations
4. Economical considerations

Treatment Options
Relieving Medications /
Reliever
1. Inhaled short acting 2-agonists
Short-acting (SABA) and
Long-acting (LABA) with quick
onset of
acition
2. Systemic glucocorticosteroids
3. Anticholinergics
4. Theophylline
5. Oral short-acting 2-agonists

Treatment Options
Controlling Medications /
Controller

1. Inhaled glucocorticosteroids (ICS)

2. Leukotriene modifiers
3. Long-acting inhaled 2-agonists (LABA)
combination with inhaled
glucocorticosteroids (ICS) LABA + ICS =
LABACs
4. Systemic glucocorticosteroids
5. Theophylline
6. Cromones
7. Anti-IgE

Asthma Clinical Control

1. Assess the early asthma control stage or
level to decide the type of medications to
be used (assess the patients asthma
control level)
2. Maintain the asthma control after
initiation of therapy (assess the
patients asthma risk)

Asthma Control Level

Control the Symptoms

Asthma Symptoms Control Level

During the past 4 weeks, did

the patient experience:

Fully controlled
Partially
controlled
Not controlled

1. Daily asthma symptoms

more than two
times within one week
2. Awakened at night due to
asthma
3. Use of reliever
medications to alleviate
symptoms more than two times
in 1 week
4. Limitation of activity
due to asthma

Not even
Found 1 - 2 criteria
Found 3 - 4 criteria
one criteria
found

KESIMPULAN
Komponen kunci terapi asma
Edukasi penderita & keluarganya
Pengendalian lingkungan (hindari
alergen pencetus asma)
Terapi farmakologis
Evaluasi obyektif faal paru (menilai &
memonitor perjalanan penyakit)

Pulmonary Department
of Ulin Hospital