CHAPTER III

CASE REPORT
3.1 Objective
The objective of this paper is to report a case of a 14 years 2 months old boy with
a diagnosis of severe asthma exacerbation.
3.2 Case
DT, a 14 years 2 months old boy, with 41 kg of body weight and 146 cm of body
height, came to RSUP Haji Adam Malik Medan on 18th December 2015 at 00:30
AM. His main complaint was shortness of breath (dyspnea).
History of disease:
DT, a boy, 14 years 2 months old, with 41 kg of body weight and 146 cm of body
height, came to RSUP Haji Adam Malik Medan on 18th December 2015 at 00:30
AM with dyspnea as a chief complaint. It has been experienced by patient for one
week before being admitted to the HAM hospital. Dyspnea associated with the
changes in weather and worse especially at night.
Wheezing was found since 3 days before admitted to the hospital and usually
occured at night.
Cough was found since 1 day before admitted to the hospital. Cough was not
productive.
Fever was not found. Chest pain was not found.
History of allergy was declined.
Defecation and urination are normal.
History of medication

: Ventoline inhaler

History of family

: None

History of parents medication

: None

History of pregnancy

: The age of the patients mother was 29

during pregancy. The gestation age was 9
months.

History of birth

: Birth was assisted by doctor. The patient was

born pervaginam and cried immediately
after birth. Body weight at birth was 2700
gram, body length at birth was 46 cm and
head circumference was unclear. Cyanosis
(-), Jaundice (-).

History of feeding

: exclusive breast feeding, formula feeding (

since 6-10 months), porridge milk (since 10
-18 months), porridge rice (since 12-18
months), family food (since 18 months).

History of immunization

: complete

History of growth and development : Patients mother reported that patient

grew

normally.

developed

The

talking,

patient

had

crawling,

and

walking skills on time.

Physical Examination:
Present status:
Sensorium : Compos Mentis

Body temperature: 37.1C

HR: 110 bpm

RR: 42 bpm

BW: 41 kg

BH: 146 cm

BW/A: 80%

BL/A: 89%

BW/BL: 107%
anemic (-), icteric (-), dyspnea (+), cyanosis (-), edema (-).

Localized status:

Head
Face

:
: edema (-)

Eye

: light reflex (+/+), isochoric pupil, palpebral

conjunctiva inferior pale (-/-)

Ears

: normal

Nose : septum deviation (-), nasal canule (+)

Mouth : normal

Neck

:
Lymph node enlargement (-), neck stiffness (-)
Thorax
:
Symmetrical fusiform, epigastric retraction (+)
HR: 110 bpm, regular, murmur (-/-)
RR: 42 bpm, regular, wheezing (+/+), ronchi (+/+)

Abdomen
:
Soepel, normal peristaltic, liver and spleen unpalpable
Extremities :
Pulse 110 bpm, regular, adequate p/v, felt warm, CRT < 3,
pitting oedema (-/-)

Anogenital

: Male

Differential diagnosis

: Severe Asthma Exacerbation moderate episodic

Working diagnosis

: Severe Asthma Exacerbation moderate episodic

Laboratory finding:
Complete blood analysis (December 19th 2015 / 02:30)
Test
Hemoglobin
Erythrocyte
Leucocyte
Thrombocyte
Hematocrite
Eosinophil
Basophil
Neutrophil
Lymphocyte
Monocyte
Neutrophil absolute
Lymphocyte

Result
14,60
4.75
16.57
266
42.30
4.60
0.100
79.30
8.30
7.70
13.14
1.38

Unit
g%
106/mm3
103/mm3
103/mm3
%
%
%
%
%
%
103/L
103/L

References
12.0-14.4
4.20-4.87
4.5-11.0
150-450
43-49
1-5
0-1
37-80
20-40
2-8
2.7-6.5
1.5-3.7

absolute
Monocyte absolute
Eosinophil absolute
Basophil absolute
MCV
MCH
MCHC
Clinical Chemistry

1.27
0.76
0.02
89.10
30.70
34.50

103/L
103/L
103/L
fL
Pg
g%

0.2-0.4
0-0.10
0-0.1
85-95
28-32
33-35

Test

Result

Unit

References

Carbohydrate Metabolism
Blood Glucose

113.45

mg/dl

< 200

24.56
0.35

mg/dl
mg/dl

< 50
0.24-0.41

9.9
143
4.2
101

mEq/L
mEq/L
mEq/L
mEq/L

9.2-11.0
135-155
3.6-5.5
96106

Renal Function
Ureum
Creatinine
Electrolyte
Calcium (Ca)
Natrium
Potassium
Chloride
Therapy
:
-

O2 -1 L/i via nasal canule

Nebule Ventoline 1 respule
Inj. Aminofilin 10 mg/kgBB
IVFD D 5% NaCl 0.45% 20 gtt/minutes

Planning Assesment:
-

Complete Blood count

Blood glucose
AGDA
Electrolyte
Renal Function Test

FOLLOW UP
December 19th 2015
S

Dyspnea (+)

Sens: GCS: 15 (E5 V4 M6); temperature: 36.9o C BW: 41 kg, BH: 146 cm
BW/A: 80% ; BH/A: 89% ; BW/BH: 108%
Head :
Eye

: light reflex (+/+); isochoric pupil (+/+), conjungtiva palpebral

inferior pale(-/-)

Ear

: normal

Nose

: within normal range, O2 via nasal canule (+)

Mouth : normal
Neck

: limph node enlargement (-), neck stiffness (-)

Thorax : symmetric fusiform, epigastrial retraction (+)

HR : 100 bpm, reguler, murmur(-)
RR : 58 bpm, reguler, wheezing (+/+), ronchi (-/-)
Abdomen : soepel, peristaltic (+) normal, hepar/ lien
not palpable
Extremities : pulse : 100 bpm, regular, adequate p/v, warm extremities,
A
P

CRT < 3, BP : 100/60 mmHg, SaO2: 92%

Severe asthma exacerbation moderate episodic
O2 -1 L/minute via nasal canule
Aminofilin 500 mg in 1000 cc D5% must be finish within 24 hours

S
O

40 cc/hour
Nebule Ventoline 1 respule + Fluxotide 1 respule
Inj. Dexamethasone 1 amp/12 hours/IV
Diet MII 1800 kkal + 40 gr protein

R/ Nebule Combivent 1 respule/6 hours if patients symptoms worse

December 20th 2015
Dyspnea (+)
Sens: GCS: 15 (E5 V4 M6); temperature: 36.6o C BW: 41 kg, BH: 146 cm
BW/A: 80% ; BH/A: 89% ; BW/BH: 108%
Head :
Eye

: light reflex (+/+); isochoric pupil (+/+), conjungtiva palpebral

inferior pale(-/-)

Ear

: normal

Nose

: within normal range, O2 via nasal canule (+)

Mouth : normal
Neck

: limph node enlargement (-), neck stiffness (-)

Thorax : symmetric fusiform, epigastrial retraction (+)

HR : 108 bpm, reguler, murmur(-)
RR : 55 bpm, reguler, wheezing (+/+), ronchi (-/-)
Abdomen : soepel, peristaltic (+) normal, hepar/ lien
not palpable
Extremities : pulse : 108 bpm, regular, adequate p/v, warm extremities,
A
P

CRT < 3, BP : 100/70 mmHg, SaO2: 94%

Severe asthma exacerbation moderate episodic
O2 -1 L/minute via nasal canule
Aminofilin 500 mg in 1000 cc D5% must be finish within 24 hours

S
O

40 cc/hour
Nebule Combivent 1 respule/6 hours
Inj. Dexamethasone 1 amp/12 hours/IV
Diet MII 1800 kkal + 40 gr protein

R/ if patients symptoms worsen, Fulmicort 1 respule is added to nebule

December 21th 2015
Dyspnea (+)
Sens: GCS: 15 (E5 V4 M6); temperature: 36.8o C BW: 41 kg, BH: 146 cm
BW/A: 80% ; BH/A: 89% ; BW/BH: 108%
Head :
Eye

: light reflex (+/+); isochoric pupil (+/+), conjungtiva palpebral

inferior pale(-/-)

Ear

: normal

Nose

: within normal range, O2 via nasal canule (+)

Mouth : normal
Neck

: limph node enlargement (-), neck stiffness (-)

Thorax : symmetric fusiform, epigastrial retraction (+)

HR : 100 bpm, reguler, murmur(-)
RR : 30 bpm, reguler, wheezing (-/-), ronchi (-/-)
Abdomen : soepel, peristaltic (+) normal, hepar/ lien
not palpable

Extremities : pulse : 100 bpm, regular, adequate p/v, warm extremities,

A
P

CRT < 3, BP : 100/70 mmHg, SaO2: 98%

Severe asthma exacerbation moderate episodic
O2 -1 L/minute via nasal canule
Aminofilin 500 mg in 1000 cc D5% must be finish within 24 hours

40 cc/hour
Nebule Combivent 1 respule/6 hours
Inj. Dexamethasone 1 amp/12 hours/IV
Diet MII 1800 kkal + 40 gr protein

R/ if patients symptoms worsen, Fulmicort 1 respule is added to nebule