Case presentation

A 29 YEARS-OLD PREGNANT WOMAN

G3P2A0 CAME WITH SHORTNESS OF
BREATH SINCE 6 HOUR BEFORE
ADMISSION

By:
Iqbal Habibie, S.Ked
Ramitha Yulisman, S.Ked

Advisor:
Prof. dr. Eddy Mart Salim, SpPD, K-AI, FINASIM

Introduction
Asthma

Asthma is a chronic inflammatory airway disorders

People with asthma are more responsive to certain factors than people
without asthma
Excessive narrowing of airway, consequent reduced airflow and
symptomatic wheezing and dyspnea
Several risk factors that can predispose to asthma are genetic
predisposition and atopy
Asthma can be triggered with environmental factors such as allergens,
respiratory tract infections, cold air, exercise and stress

Introduction

In Indonesia, the prevalence of asthma ranges

1012%
of
adults
and 15%
ofthe
TheApproximately
prevalence has risen
in affluent
countries
over
from
57%
last 30 years
children affected
by the disease

Respiratory symptoms
such a wheeze,
shortness of breath,
chest tightness and
cough
Expiratory volume
limitations.

Keeping airways
dilated with
bronchodilator so air
circulation goes
smoothly
Reduce the
inflammation of the
airway

Principle of Treatment

Defning Features

Introduction

Patient Identifcations

Name
: Mrs. SA
Birthdate
: July 5th 1972 (44yo)
Sex
: Female
Occupation
: Housewife
Status
: Married
Address
: Jl. Orde Baru Lorong Badak No. 2168, Sekip
Ujung Palembang
Date of admission : September 24th 2016
Medical record : 894756

Chief complaint
shortness of breath since about six hour before admission.

Course of present illness

She experienced
another severe
shortness of breath
with wheezing, but
the shortness of
breath was not
relieved by
salbutamol tablet so
she came to RSMH.
Six hours before admission

She felt a severe

shortness of breath,
there was wheezing,
and cough with
colorless phlegm, no
fever, no nauseous,
no vomit. She
immediately took
salbutamol and she
felt better.
Two days before admission

Three days before admission

She got a cough,

with colorless
plegm, no fever. She
felt shortness of
breath that was not
affected by activity,
there wa no
wheezing. There
were no
medications.

Past medical history

The patient has a frst history of asthma attack when she was about 10 years old and
there were no medications
The patient claimed that the asthma attack come if she is exposed to cold weather,
dusts, eating prawn, and eating pineapple
The patient said that her asthma attacks come not more than 3 times in a month
She drinks a cup of coffee every morning until now, drinks tea about once or twice
in a month. She does not smoke, consume alcohol and traditional medicine

Past medical history

Other medical
conditions

Family disease history

Hypertension (+) from mother

Hypertension (-)
Diabetes (-)

Diabetes (-)
Asthma (+) from grandmother
Allergy (-)

Physical examinations

General status
General appearance : Looked moderately sick
Consciousness
: Compos mentis
Blood Pressure
: 130/80 mmHg
Pulse Rate
: 104x/minute
Respiratory rate : 34x/minute
Body Temperature : 36,4oC
Body Weight
: 52 Kg
Body Height
: 154 cm

Physical Examinations
Specific examinations
Head : normocephaly, symmetrical face shape, no deformities
Eyes : pale conjunctiva palpebral (-/-), icteric sclera (-/-), pupils are
round and isocor, light reflex (+), no restricted movement
Nose : septum deviations (-), no discharge
Mouth
: cyanotic (-), papil atrophy (-), symmetric pharyngeal
arch, uvula in the middle, no tonsil enlargement
Ears : shape is normal, no discharge
Neck : no lymph node enlargement, no thyroid gland enlargement,
JVP (5-2) cm H2O

Physical Examinations
Thorax (Pulmo)
o Inspection : static was symmetrical, and dynamic was symmetrical, no
retractions of intercostal space
o Palpation : tactile fremitus of both lungs was symmetric
o Percussion: both lungs are sonor, border of lung and liver in ICS V, with 1 ICS
shifting in inspiration
o Auscultation : vesicular (+), wheezing (+) expiration, rales (-)

Thorax (Heart)
o
o
o
o

Inspection : ictus cordis was not visible

Palpation : ictus cordis was not palpable
Percussion: heart border showed no enlargement of the heart
Auscultation : first and second heart sound was normal (M1>M2, T1>T2,
A1<A2, P1<P2), murmur (-), gallop (-)

Physical Examinations
Abdomen
o
o
o
o

Inspection : flat
Auscultation : bowel sounds (+) normal
Palpation : supple, tenderness (-), liver and spleen was not palpable
Percussion: tympanitic

Extrimities
o Pale palmar (-), palmar erythema (-), swelling (-), clubbing finger (-),
deformities (-)

Discussion

Patients History
Physical
Examinations

Shortness of breath
Affected by cold weather and dust
First asthma attack: 10 years old
History of asthma from grandmother
High respiratory rate (34x/min)
Wheezing on both lungs

ASTHMA

Patients
Complaint

Classifcations of asthma
Severity of Asthma Exacerbations (GINA updated 2012)
Mild
Moderate
Parameter
Walking
Talking
Breathless
Can lie down
Prefer sitting
Talks in
Sentences
Phrases
May be agitated
Usually agitated
Alertness
Increased
Increased
Respiratory rate
Accessory muscles
Usually not
Usually
Moderate, often only
Wheeze
Loud
end expiratory
< 100
100-120
Pulse
May be present
Absent < 10 mmHg
Pulsus paradoxus
10-25 mmHg
Over 80%
60-80%
PEF
PaO2
Normal
> 60 mmHg
PaCO2
< 45 mmHg
< 45 mmHg

Severe
At rest
Hunched Forward
Words
Usually agitated
Often > 30/min
Usually
Usually loud
>120
Often present
> 25 mmHg
< 60%
< 60 mmHg
> 45 mmHg

Diagnosis
Working diagnosis
Moderate asthma attack

Differential diagnosis
COPD

Management
Non-Pharmacology

Pharmacology

Oxygen 3-4L/min
Rest
Avoid herself from exposure of
triggering factors
Control to the clinic

Farbivent nebulizer (2 cycles)

Dexamethasone 5mg IV
Salbutamol tablets 3x4mg
Methylprednisolone 3x4mg

Prognosis
quo ad vitam
is bonam
quo ad
quo ad
functionam is sanationam is
bonam
malam

Date

Time

Integrated Process Note

Saturday,
September 24th
2016

17.00

S: Shortness of breath since one hour before admission

O:
General Condition
Sens: CM, BP: 130/80 mmHg, HR: 104 x/min, RR: 34 x/m, T: 36,4
Head: Pale conjunctiva (-), icteric sclera (-)
Neck: JVP (5-2) cm H2O
Thoracal
Cor: HR 104x/min, murmur (-), gallop (-)
Pulmo: Vesicular (+), rales(-), wheezing (+)
Abdomen: flat, liver and spleen was not palpable, shifting dullness (-)
Extremity: Edema pretibia (-/-), pale palmar (-)
A: - Moderate Athma Attack
P:
Non Pharmacology

Bedrest, O2 3-4L/min

Pharmacology
Farbivent nebulizer (2 cycles)
Dexamethasone 5mg IV

THANK YOU

Questions
Rafenia: How can we eliminate DD of COPD?
Tiara: Why stop farbivent after two cycles?
Ivan: When is dexa inj given?
What is difference between reversible and irreversible in
asthma and COPD?

Questions
Rudi: Asthma attack at home, what is the
education?
Ramzie: What would be the best controller
treatment?
Ade: Prognosis, why malam in quo ad sanationam?

Questions
Dyaz: What additional examinations can be done?
George: Why methylprednisolone tablets was
given for this patient, why not just salbutamol?
Ami: When to use aminophiline in asthma?