Case Presentation

Asthma in Pediatric
Preceptor:

dr. Ulynar Marpaung, Sp.A

Presenter:

Mainurtika
(1102011151)
Pediatric Department
Raden Said Soekanto Hospital
Yarsi Medical University
Periode December 21rd February 28th 2016

IDENTITY
PATIENT
Name
: C.A
Birth date
: July 27th 2009
Age
: 7 years old
Gender
: female
Adresss
: Jalan kerja bakti RT 01/04 makassar
Nationality
: Indonesia
Religion
: Islam
Date of admission
: January 5th 2016
Date of examination : January 7th 2016

ANAMNESIS
The Anamnesis Was Taken On January 5rd 2016, By Alloanamnesis (Fro
m Patients Mother And Grandmother).

Chief complain

Shortness Of Breath
Additional
complain
Non
Productive
Cough,

HISTORY OF PRESENT ILLNESS

A 7 years old child came to raden said sukanto police cen
ter hospital emergency room suffering from hard to breath sin
ce 3 hours before admission the hospital, right after soft drink
s consumption and playing with friends. Patients mother also
complaining cough continuously. Mother said that her child g
ot this disease when she was 1 years old.

HISTORY OF PRESENT ILLNESS (2)

Her mother
said that her
child got
asthma when
she was 1
years old.

suffering
from hard to
breath,
cough
continuously

Suffering from
hard to breath,
cough
continuously.

HISTORY OF PAST ILLNESS

Pharyngitis
Bronchitis
Pneumonia
Morbili
Pertussis
Varicella
Diphteria
Malaria
Polio
Enteritis

+
-

Bacillary dysentry
Amoeba dysentry
Diarrhea
Thyphoid
Worms
Surgery
Brain concussion
Fracture
Drug reaction

ALLERGIC HISTORY
The patient have asthma history when she is 1 year
s old.
The patient didnt have allergy to medicine.
The patient have allergy to dust, and cold weather.

BIRTH HISTORY
MOTHERS PREGNANCY HISTORY
The mother routinely checked her pregnancy to the hospital. She den
ied any problem noted during pregnancy.
CHILDS BIRTH HISTORY
Labor : hospital
Birth attendants: doctor
Mode of delivery : pervaginam
Gestation
: 9 months
: healthy
Infant state
: 2900 grams
Birth weight
: 46 cm
Body lenght

Development History
Psycomotor development
Head up
: 1 month old
Smile
: 1 month
Laughing
: 1-2 month old
Mental status : Normal
Slant
: 2,5 months old
Conclusion: Growth
Speech initiation : 5 month old
Prone podition
: 5 month old factor and development
Sitting
: 6 month old
status is still in
Crawling
: 8 months old

the normal limits and was

appropriate according to
the
patients age

Immunization
HISTORY OF EATING
History
Frequency
Breast milk: exclusively 1 years.Immunizati
on
Formula milk: bebelac
Hepatitis B
3 times
Fruit and vegetables: carrots, brocolli,
papaya
Polio
6 times

BCG

1 time

DPT

5 times

Hib

4 times

Measles

1 time

Time
0,1,6 months
old
0, 2, 4, 6
months old,
2, 5 years old
1 month old
2, 4, 6
months old, 2
, 5 years old
2, 4, 6, 12
months old
9 months
old

FAMILY HISTORY
Father have food allergic.

HISTORY OF DISEASE IN OTHER FAMILY MEMBER

There is no one living around their home known for having same conditio
n as the patient.

SOCIAL AND ECONOMIC HISTORY

Patient lived at house with size 20 m x 8 m together with pare
nts.
There 1 door at the front side,1 toilet near the kitchen and 3 b
edrooms, there are 6 windows.
Hygiene
The patients mother changes his clothes everyday with cle
an clothes.
Bed sheets changed every one weeks.

PHYSICAL EXAMINATION
( JANUARY 5TH 2016)

GENERAL STATUS
General condition : compos mentis
Awareness : compos mentis
Pulse
: 109 x/min, regular, full, strong
Breathing rate : 45 x/min
Temperature
: 36,4 0C (per axila)

Antropometry Status
5-01-2016 7 years

15 kg

18 kg

Weight : 15kg
Height :110 cm
Nutritional status based NCHS
2000
(National Center for Health
Statistic)
year 2000
WFA (Weight for Age)
15 / 18 x 100% = 83 %
HFA (Height for Age)
110/115 x100% = 95 %
WFH (Weight for Age)
15 /17 x 100% = 88 %

HEAD TOE EXAMINATION

HEAD
Normocephaly, hair (black, normal distribution, not easily remove
d) sign of trauma (-) large fontanelle opened, petechiae EYES
Icteric sclera -/-, pale conjuctiva -/-, lacrimation -/-, sunken eyes -/
-, pupils 3mm/3mm isokor, direct and indirect light response ++/++.
EARS
Normal shape, no wound, no bleeding, secretion or serumen -/NOSE
Normal shape, midline septum, secretion -/-

Head Toe Examination (2)

MOUTH
Lips : moist
Mucous : moist
Tongue: no dirty
Tonsils : T1/T1, no hyperemia
Pharynx : hyperemia

NECK

Lymph node enlargement (-), scrofuloderma (-).

Head Toe Examination (4)

THORAX
Inspection : symetric when breathing, retraction +, ictus
cordis is not visible.
Palpation : mass (-), tactile fremitus +/+
Percussion : sonor sound
Auscultation
Cor

: Regular S1-S2, murmur (-), gallop (-)

Pulmo : Vesicular +/+, wheezing +/+ ekspiration, rales -/-

Head Toe Examination (5)

ABDOMEN
Inspection : convex, epigastric retraction (-), there is no wid
ening of the veins, no spider nevi.
Palpation : supple, liver and spleen not palpable, fluid wave
(-), abdominal mass (-)
Percussion : the entire field of tympanic abdomen, shifting
dullness (-)
Auscultation : normal bowel sound, bruit (-)

Head Toe Examination (6)

VERTEBRA

There does not appear scoliosis, kyphosis, and lordosis, do not loo
k any mass along the line of the vertebral
EKSTREMITIES

Warm, petechiae (-),purpura (-),capillary refill time < 2 seconds, edema

(-)
SKIN
Normal turgor

NEUROLOGICAL EXAMINATION
MENINGEAL SIGN
Nuchal rigidity

Kernig sign

Lasegue sign

Brudzinski 1

Brudinski 2

MOTORIC EXAMINATION
Power

Hand

5 5 5 5/ 5 5 5 5

Feet

5 5 5 5/ 5 5 5 5

Tonus

Hand

Normotonus / Normotonus

Feet

Normotonus / Normotonus

Trophy

Hand

Normotrophy / Normotrophy

Feet

Normotrophy / Normotrophy

Motoric Examination (2)

Physiologic Reflex
Upper extrimities

Biceps

+/+

Triceps

+/+

Lower extrimities

Patella

+/+

Achilles

+/+

MOTORIC EXAMINATION (3)

Pathologic Reflex

Upper
extrimities

-/-

Hoffman

-/-

Trommer

Lower - / -

extrimities
Babinsky

-/-

Chaddock

-/-

Oppenheim

-/-

Gordon
Schaeffer

-/-

Clonus

Patella

-/-

Achilles

-/-

Autonom Examination
Defecation

Normal ( 1-2 times daily)

Urination

Normal ( 4-5 times daily )

Sweating

Normal

LABORATORY INVESTIGATION
Hematology

Results

Normal Value

Haemoglobin
Leukocytes
Hematocrytes
Trombocytes

13,5
17.600
40
356.000

13-16 g/dL
5,000 10,000/L
40 48 %
150,000

4,07

400,000/L
4 5 million/L

Erythrocytes

WORKING DIAGNOSIS

ASTHMA IN PEDIATRIC

MANAGEMENMANAGEMENT IN HOSPITAL
O2 1L/M
IVFD KAEN 3B.
INJ. CEFOTAXIME 2X600 MG IV
INJ. DEXAMETHASONE 3 X 1 MG IV
AMBROXOL 3X1 CTH
INHALATION : TWICE A DAY
VENTOLIN (1,25 MG)
BISOLVON 10 DROPS
NACL 2 CC

PROGNOSIS

QUO AD VITAM
: DUBIA AD BONAM
QUO AD FUNCTIONAM : DUBIA AD BONAM
QUO AD SANACTIONAM : DUBIA AD BONAM

A
P

FOLLOW UP (05-01-16)

Fever (-)
Phlegm (+)
Breathless (+)
Productive cough (+)
General condition: Compos mentis.
Heart rate
= 115 x/min
Respiratory rate = 35x/min
Temperature
= 36,4C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing +/+
Asthma Bronchiale
DD/ Bronchiolitis
- O2 1L/m
IVFD Kaen3B, , 750cc / 24 Hours.
Inj. Cefotaxime 2x600 mg IV
Inj. Dexa 3x1 mg IV
Ambroxol syr 3 x 1 cth
Inhalation fourth a day : Ventolin (1,25 mg) Bisolvon
10 drops NaCl 1 cc

A
P

FOLLOW UP (06-01-16)

Fever (-)
Phlegm (-)
Breathlless (-)
Productive cough (+)
General condition: Compos Mentis
Heart rate
= 120 x/min
Respiratory rate = 30x/min
Temperature
= 38.5C
Cardio : S1/S2, reguler, no murmur, no
gallop
Pulmonary : retraction (+) vesiculer +/+,
rhonchi -/-, wheezing +/+
Astha Bronchiale
DD/ Bronchiolitis

O2 1L/m
IVFD Kaen3B,
Inj. Cefotaxime 2x600 mg IV
Inj. Dexa 3x1 mg IV
Ambroxol syr 3 x 1 cth

A
P

FOLLOW UP (07-01-16)

Fever (-)
Phlegm (-)
Productive cough (-)
Breathless (-)
General condition: Compos mentis.
Heart rate
= 110 x/min
Respiratory rate = 30x/min
Temperature
= 36C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing +/+
Asthma Bronchiale
DD/ Bronchiolitis

IVFD Ringer Laktat, , 750cc / 24 Hours.

Inj. Cefotaxime 2x600 mg IV
Inj. Dexa 3x1 mg IV
Ambroxol syr 3 x 1 cth
Inhalation twice a day Ventolin (1,25 mg) Bisolvon 10
drops NaCl 1 cc

ASTHMA IN PEDIATRIC

LITERATURE REVIEW

DEFINITION
Asthma is a chronic inflammatory disorder associat
ed with variable airflow obstruction and bronchial
hyperresponsiveness. It presents with recurrent epis
odes of wheeze, cough, shortness of breath, and c
hest tightness

CLASIFICATION :

PATHOPHYSIOLOGY

Immunological abnormalities
T-cell immunity.
Atopy
Structurefunction interactions
Airway remodeling.
Bronchial inflammation.
Nasal inflammation.
Role of epithelium.
Inflammatory cells and their recruitment.
Airway obstruction.
Airway hyperresponsiveness and neural control.

DIAGNOSIS

Diagnosing asthma in young children is difficult because childre

n often cough and wheeze with colds and chest infections but t
his is not necessarily asthma.
Bronchiolitis is another very common cause of wheeze in childre
n.
Physical examination
The physician will conduct a physical exam and may order som
e tests x ray, blood tests, allergy skin tests and pulmonary fun
ction tests (pfts).
History: the physician will take a detailed history of:
family allergy/ asthma with emphasis on parents
childs allergy history- e.G. Eczema
childs history of illness to date e.G. Frequency of colds
childs symptoms: severity, frequency and duration of sympto

DIFFERENT DIAGNOSIS

TREATMENT

TREATMENT
EDUCATION
Asthma education should not be regarded as a single event but
rather as a continuous process, repeated and supplemented at e
very subsequent consultation
TRIGGER AVOIDANCE
Asthma symptoms and exacerbations are triggered by a variety
of specific and nonspecific stimuli
PHARMACOTHERAPY
The goal of asthma treatment is control using the least possible
medications. Asthma pharmacotherapy is regarded as chronic tr
eatment and should be distinguished from treatment for acute e
xacerbations that is discussed separately.

Asthma
Stage

Clinical
manifes

Night
clinical
manifes

PEV

Treatment

Intermitten

<1x/Week

<2x/month PEV >80 %

s

SABA

Mild
Persistent

1x/week

>2x/month PEV 80
s
%

SABA, ICS
low dosage

Moderate
Persistent

Everyday
Need
reliever
everyday
Interupt
daily
activity

>1x/weeks

PEV 60
80 %

SABA, ICS
low
dosage,
LABA

Severe
Persistent

Everyday
Limited

Always

PEV <60%

SABA, ICS
high

TAKE HOME MESSAGES

Asthma management should be holistic including
all the elements necessary to achieve disease contr
ol
Patient and parent education
Identification and avoidance of triggers
Use of appropriate medication with a well-formed
plan, and regular monitoring.

Thank You

REFERENCES
ASTHMA SOCIETY OF CANADA. ASTHMA IN INFANTS AND YOUNG CHILDREN. 2007. AVAI
LABLE ON HTTP://WWW.ASTHMA.CA. ACCESSED: AUGUST 29TH
PAPADOPULOUS N.G, ARAKAWA H. CARLSEN K.H, ET AL. INTERNATIONAL CONSENSUS O
N (ICON) PEDIATRIC ASTHMA. EUROPEAN JOURNAL OF ALLERGY AND CLINICAL IMUNOL
OGY. P 976-997. 2012
MORRIS M.J. ASTHMA CLINICAL PRESENTATION. 2015. AVAILABLE ON
HTTP://WWW.MEDSCAPE.COM. ACCESSED: AUGUST 29TH. 2015