A 62 years old Man Came In With Severe Shortness of Breath Since 2 Day

Before Admission
Yulia Rahmi Z.J*, Elisha Jethro Solaiman*, Eddy M. Salim**
ABSTRACT
INTRODUCTION
It was reported a case with shortness of
breath at RSMH. A 62 years-old man was admitted
with a chief complain of shortness of breath since 2
days before admission. One week before admitted,
patient started to feel shortness of breath which was
affected by cold weather and not reliefed by rest,
Wheezing (+), nauseous (-), vomit (-), cough (+)
with a clear colored phlegm (+), fever (-), shivering
(-), and common cold (+) sore throat (+). The
patient took salbutamol and navacyn and the
complaint decreased a little. One day before
admitted, the patient started to feel shortness of
breath which was affected by cold weather and not
relief by rest. Wheezing (+), nauseous (-), vomit
(-), cough (+) phlegm (-), fever (-), shiver (-). The
patient went to a public health center, then the
patient got salbutamol and the compliant little
decreased. Two hours before admitted, the patient
complained great shortness of breath, wheezing (+),
affected by cold weather (+), it was not decreased
after consuming salbutamol 3x1, the patient then
was referred to RSMH.
The patient has a history of asthma since
10 year old and there was not medication. The
patient was also a smoker, since the age of 15 years
old smoking 1 pack daily. History of drinking a cup
of coffee every morning until now. History of
drinking a cup of tea 4-5x daily. History of drinking
alcohol when hes still young. Family history of
hypertension and heart disease from mother,
asthma from grandmother. Based on physical
examination, quick respiratory rate 32xm, the
patient was wheezing (+) with prolonged
expiration.
From the laboratory findings Hb: 12,7
mg/dl,
erythrocyte:
4.58x106,
leucocyte:
3
10.500/mm , hematocrite: 38 %, LED: 226, DC :
0/0/93/6, ureum: 31 mg/dL, creatinine: 0,95 mg/dL,

Asthma is a heterogeneous disease,

usually characterized by chronic airway
inflammation. It is defined by the history of
respiratory symptoms such as wheeze, shortness of
breath, chest tightness and coughing that vary over
time and in intensity, together with variable
expiratory airflow limitation1.
The prevalence of asthma in younger
adults varies widely as it does in children. Overall,
4,3 % of respondents to WHOs World Health
Survey aged 18-45 in 2002-2003 reported a
doctors diagnosis of asthma, 4.5 % had reported
that they had experienced attacks of wheezing or
whistling breath (symptoms of asthma) in the
preceding 12 month. The highest prevalence was
observed in Australia, Norhern and Western Europe
and Brazil. The prevalence administered to
1777,496 person aged 18-45 years living in 70
countries2.

Keywords : Asthma
* Medical Student of Sriwijaya University, Clerkship Program
Moh.Hoesin General Hospital
** Staff of Allergy-Immunology Division of Internal Medicine
Department of Dr. Moh. Hoesin General Hospital

Factors that may trigger or worsen asthma

symptoms include viral infection, domestic or
occuputional allergens (e.g. house dust mite,
pollens, cockroach), tobacco smoke, exercise and
stress. These responses are more likely to occur
when asthma is uncontrolled. Some drug can
induced or trigger asthma, e.g. beta-blockers and
(in some patient) aspirin or other NSAIDs3.
Asthma causes symptoms such as
wheezing, shortness of breath, chest tighness and
cough that vary over time in their
occurence.frequency and intensity. The symptoms
are associated with variable expiratory air flow, i.e.
Difficulty breathing air out of the lungs due to
bronchoconstriction (airway narrowing), airway
wall tichkning, and increased mucus. Some
variation in airflow can also occur in people
without asthma, but it is greater in asthma.
Because asthma symptoms can vary, the
physical examination of the respiratory system may
be normal. The most usual abnormal physical
finding is wheezing on auscultation, a finding that
confirms the presence of airflow limitation.
However, in some people with asthma, wheezing
may be absent or only detected when the person
exhales forcibly, even in the presence of significant
airflow limitation. Occasionally, in severe asthma
exacerbations, wheezing may be absent owing to
severely reduced airflow and ventilation. However,
patients in this state usually have other physical
signs reflecting the exacerbation and its severity,
such as cyanosis, drowsiness difficulty speaking,
tachycardia, hyperinflated chest, use of accessory
muscles, and intercostal recession. Other clinical
signs are only likely to be present if patients are
examined during symptomatic periods. Features of
hyperinflation result from patients breathing at a
higher lung volume in order to increase outward
retraction of the airways and maintain the patency
of smaller airways (which are narrowed by a
combination of airway smooth muscle contraction,
edema, and mucus hypersecretion). The
combination of hyperinflation and airflow
limitation in an asthma exacerbation markedly
increases the worof breathing1.
Spirometry is the recommended method of
measuring airflow limitation and reversibility to
establish a diagnosis ofasthma. Measurements of
FEV1 and FVC are undertaken during a forced
expiratory maneuver using a spirometer.
Recommendations for the standardization of
spirometry have been published 13-15. The degree
of reversibility in FEV1 which indicates a
diagnosis of asthma is generally accepted as 12%
(or 200 ml) from the pre-bronchodilator value 13.
However most asthma patients will not exhibit
reversibility at each assessment, particularly those

on treatment, and the test therefore lacks sensitivity.

Repeated testing at different visits is advised1.
Asthma treatment for adults can be
administered in different ways inhaled, orally or
parenterally (by subcutaneous, intramuscular, or
intravenous injection). The major advantage of
inhaled therapy is that drugs are delivered directly
into the airways, producing higher local
concentrations with significantly less risk of
systemic side effects1.
CASE ILLUSTRATION
A 63 years old man who lives at Kenten
Laut, Talang Kelapa, Banyuasin, Palembang, was
admitted in Mohammad Hoesin General Hospital
on the 21th August 2016 with chief complaint of
shortness of breath since 2 days before admission.
One week before admitted, patient started to feel
shortness of breath which was affected by cold
weather and not relief by rest, Wheezing (+),
nauseous (-), vomit (-), cough (+) phlegm (-), fever
(-), shiver (-), and common cold (+) sore throat (+).
The patient got salbutamol and navacyn and the
compliant little decreased.
One day before admitted, patient started to
feel shortness of breath which affected by cold
weather and not relief by rest, Wheezing (+),
nauseous (-), vomit (-), cough (+) with colorless
phlegm (+), fever (-), shiver (-). The patient went to
public health center, then the patient got salbutamol
and the complaint decreased a little.
Two hours before admitted, the patient
complained great shortness of breath, wheezing (+),
affected by cold weather (+), it did not decreased
after consuming salbutamol 3x1, then patient was
referred to RSMH.
The patient has a history of asthma since
10 years old and there was not medication. The
patient denied any history of dermatitis, atopy, or
other allergies. Patient was also a smoker, since age
15, smoking 1 pack daily. History of drinking a cup
of coffee every morning until now. History of
drinking a cup of tea 4-5 x. History of drinking
alcohol when hes still young. The patient has a
family history of hypertension and heart disease
from mother, asthma from grandmother.
Based on the condition of the patient, he
was fully conscious, general appearance was
moderately sick with body weight 45 kg and height
160 cm, blood pressure 120/80 mmHg, pulse rate
112x/minute regular, respiration rate 32x/minute
regular and body temperature 36.5oC. Physical
examination of the head, mouth, ears, throat,

showed no abnormalities, eyes upon inspection

showed no swelling at his eyelid with pale
conjungtiva palpebra. Physical examination of the
neck showed no enlargement of lymph nodes and
jugular venous pressure (5-2) cm H 2O. The chest
was symmetric both in static and dynamic
breathing. Tactile fremitus was symmetric upon
both lungs, vesicular sound was normal, rales
absent and wheezing present upon both of lungs.
For heart examination, ictus cordis was neither
visible nor palpable, upon percussion shows normal
result. On auscultation, heart sound AI<AII,
PI<PII, MI>MII, TI>TII normal, no murmur and no
gallop heard. Inspection on the abdominal region
showed no abnormalities. In abdominal percussion
there was no shifting dullness. On the palpation
liver and lien showed no abnormalities and normal
bowel sound was detected during auscultation. On
the upper extremities showed no swelling and
lower extremities negative pretibial edema.
Based on physical examination, high
respiration rate 32xm, and the patient was
wheezing (+). The laboratory findings Hb: 12,7
mg/dl,
erythrocyte:
4.58x106,
leucocyte:
3
10.500/mm , hematocrite: 38 %,LED: 226
mm/hour, Diff count 0/0/93/6/1, ureum: 31 mg/dL,
creatinine: 0,95 mg/dL,
The patient and the family were informed
about from the aspect of non- pharmacology patient
was bed rest and avoidance of inducing factors. The
pharmacology treatment includes D5% gtt
xv/minute, nebulizer ventolin per 8 hours,
Dexametasone 3x5 mg IV, Salbutamol 3x2 mg, drip
Aminofilin 36 mg (1.5 ampule) in D5% 500 cc.
Differential diagnosis of asthma is COPD. The
patients prognosis is quo ad vitam dubia ad
bonam, quo ad fungtionam dubia ad bonam and
duo ad sanationam dubia ad malam.

and a positive family history of asthma and atopic

disease are also helpful diagnostic guides. Asthma
associated with rhinitis may occur intermittently,
with the patient being entirely asymptomatic
between seasons or it may involve seasonal
worsening of asthma symptoms or a background of
persistent asthma. The patterns of these symptoms
that strongly suggest an asthma diagnosis are
variability; precipitation by non-specific irritants,
such as smoke, fumes, strong smells, or exercise;
worsening at night; and responding to appropriate
asthma therapy.
The lack of a clear definition for asthma
presents a significant problem in studying the role
of different risk factors in the development of this
complex disease, because the characteristics that
define asthma (e.g.,airway hyperresponsiveness,
atopy, and allergic sensitization) are themselves
products of complex gene-environment interactions
and are therefore both features of asthma and risk
factors for the development of the disease.
Asthma has a heritable component, but it
is not simple. Current data show that multiple
genes may becinvolved in the pathogenesis of
asthma and different genes may be involved in
different ethnic groups. The search for genes linked
to the development of asthma has focused on four
major areas: production of allergenspecific IgE
antibodies (atopy); expression of airway
hyperresponsiveness; generation of inflammatory
mediators, such as cytokines, chemokines, and
growth factors; and determination of the ratio
between Th1 and Th2 immune responses (as
relevant to the hygiene hypothesis of asthma)
Tobacco smoking is associated with
accelerated decline of lung function in people with
asthma, increases asthma severity, may render
patients less responsive to treatment with inhaled
and systemic glucocorticosteroids, and reduces the
likelihood of asthma being controlle. Smoking and
asthma. Tobacco smoking makes asthma more
difficult to control, results in more frequent
exacerbations and hospital admissions, and
produces a more rapid decline in lung function and
an increased risk of death. Asthma patients who
smoke may have a neutrophil-predominant
inflammation in their airways and are poorly
responsive to glucocorticosteroids.
The most usual abnormal physical finding
is wheezing on auscultation, a finding that confirms
the presence of airflow limitation. However, in
some people with asthma, wheezing may be absent
or only detected when the person exhales forcibly,

DISCUSSION
Asthma is a chronic inflammatory disorder
of the airways in which many cells and cellular
elements play a role. The chronic inflammation is
associated with airway hyperresponsiveness that
leads to recurrent episodes of wheezing,
breathlessness, chest tightness, and coughing,
particularly at night or in the early morning. These
episodes are usually associated with widespread,
but variable, airflow obstruction within the lung
that is often reversible either spontaneously or with
treatment1.
Episodic symptoms after an incidental
allergen exposure, seasonal variability of symptoms

even in the presence of significant airflow

limitation. Occasionally, in severe asthma
exacerbations, wheezing may be absent owing to
severely reduced airflow and ventilation. However,
patients in this state usually have other physical
signs reflecting the exacerbation and its severity,
such as cyanosis, drowsiness, difficulty speaking,
tachycardia, hyperinflated chest, use of accessory
muscles, and intercostal recession.
Spirometry is the recommended method of
measuring airflow limitation and reversibility to
establish a diagnosis of asthma. Measurements of
FEV1 and FVC are undertaken during a forced
expiratory maneuver using a spirometer.
Recommendations for the standardization of
spirometry have been published. The degree of
reversibility in FEV1 which indicates a diagnosis
of asthma is generally accepted as 12% (or 200
ml) from the pre-bronchodilator value.
The normal range of values is wider and
predicted values are less reliable in young people
(< age 20) and in the elderly (> age 70). Because
many lung diseases may result in reduced FEV1, a
useful assessment of airflow limitation is the ratio
of FEV1 to FVC. The FEV1/FVC ratio is normally
greater than 0.75 to 0.80, and possibly greater than
0.90 in children. Any values less than these suggest
airflow limitation.
In this case report, patient came with
shortness of breath, as known it is an abnormal
breathing or distress symptom. Dyspnea could
occur due to various conditions such as asthma,
COPD, pleura effusion, pulmonal edema, etc.
Based on the anamnesis, shortness of breath in this
patient was not influenced by activity. It was
triggered by the change in weather. In physical
findings there was no barrel chest, simetric stem
fremitus, vesicular sound were normal with the
presence of wheezing. Shortness of breath on this
patient was caused by asthma.
The laboratory findings of these patient
were normal. Differential diagnosis Asthma is
COPD. Prognosis quo ad vitam dubia ad bonam,
quo ad fungtionam dubia ad malam, quo ad
sanationam dubia ad malam. The management of
patient with asthma consists of non-pharmacology
and pharmacology. Non pharmacology is to explain
about patients illness to the family also including
the therapy and outcome, bed rest, and avoidance
of inducing factors. Pharmacology therapy for this
patient includes D5% gtt xv/minute, nebulizer
ventolin per 8 hours, Dexametasone 3x5 mg IV,
Salbutamol 3x2 mg, and aminofilin.

CONCLUSION
We have discussed a case of moderate
asthma attack in a 63 year old, male patient who
also had shortness as breath, affected by cold
weather and smoking, Family history was asthma
from grandmother, Wheezing (+) prolonged
expiration.
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