Asma Ppt in English 2

8/16/2019 Asma Ppt in English 2

1/27

Case Report

Asthma


2/27

Identity of patient

• Name : R• Addres : Tanjung Anom, Cirebon•

age : 3 Tahun• Sex : male• etni : !a"a•

Religion : Islam• #ather$s name: mr% T• &other$s name: mrs% '


3/27

(istory ta)ing

• Chief omplaint: breathlessness• (istoryal illness of present:

*atient ame to emergeny room of +aled hospital ith omplaintbreathlessness sine - day ago% This breathlessness appearedafter the hild as playing in out of home here indy anddusty% This breathelessness as getting bad in the night untilldistrubing the sleeping% The breathlessness in not in.uened bypysial exerise, hanging of position and ithout painful hest,there is no yanosis on lips, in the tip toe and hands%

This breathlessness is aompanied produti"e ough, fe"er and

tightness hest% +hen ta)ing out the breath is hearing thehee/ing% The produti"e ought and fe"er appers together ithbreathlessness

There is no omplaint ith gastrointestinal tra)%


4/27

• (istorial illness of reent:

0 (istorial of asthma 12 sine 4 years old

0 The last relapsing of asthma sine - ee) ago

0 (istorial the long0term ough• (istorial illness of family:

0 There is not historial asthma in patient family

0 There is not historial tuberulosis5long0term ough

0 *atient$s mother has allergy to seafood• (istorial of "aination:

Aording to patient$s family, he has gotten 6 basi ofimmuni/ation, and the other "aines ha"e not

• (istorial of pregnant and birth:*atient as impregnated by his mother in just months,

hen he as born and helped by dotor in the hospitaland diretly ried


5/27

*hysial examination

• 7eneral state: seems breathlessness• 7eneral ondition: alert

8ital sign:

0Temperatur body: 39,;0pulse fre59> mmhg

Antropometry state:?ody eight: -4,3 )g

?ody hegith: 3 m


6/27

• (ead: CA 050, SI 050, nasal .aring 12,*@C 10

• Ne): limfe node 10• Thora): normothora) simetris%

*ulmo: +h 252, Rh 252

Cor: s- s4 reguler• Abdomen: distensi 10 bol sound 2,• )stremitas: CRT B4, arm


7/27

#urther examination

• ?lood ount :

leu)osit: -6%-•

#aal lung test 1#8, *#R


8/27

*hoto rontgen


9/27

0 DiEerential doagnosa

Asthma mild persistent exaerbation is often episodi

?ron)o*neumonia0 Diagnosi ati"ity

Asthma mild persistent exaerbation is often episodi12 bron)opnuemonia

- &anagement therapy@4 :4 Fiter 5 menit 5 nasal

Infus RF => T*& ma)ro

Ampisilin : =G H6> &g I8

Nebu ombi"ent per hoursAmbroxol 3 x J th

Dexametason 3 x -,6 gr i"


10/27

prognosis

• Kuo ad "itam: ad bonam• Kuo ad sanationam: dubia ad bonam•

Kuo ada futionam: ad malam


11/27

duation

7i"ing eduation to patient and patient$sfamily

• Inreasing the understanding about

asthma generally and the pattern of it• Inreasing s)ill 1the ability about hoe to

handle asthma

• Inreasing self onLdent• Inreasing the obidiene and handling

alone


12/27

• Than) you


13/27


14/27


15/27

Identity

• Name: T• age: = years old•

sex: female• #ather$s name: mr% I• Address: irebon•

Date in entry: >40>H04>-6• Date of examination: >30>H04>-6


16/27

(istory ta)ing

• Chief complaint: breathlessness

• *atient ame to the emergeny room aledhospital ith omplaning breathlessness sine -day ago% It seems disappear and suddenly appearespeially at the night% This breathlessnessappears hen the ondition is in old air% Thebreathlessness is aompanied tightness hest,ough and ha"e a old and subfebris

• This breathlessness is ithout aompaniedpainful hest, "omit, bluish on the tip toe andhands% &ition and defeataion no omplaint


17/27

• *ast history of illness

The history of thigh is assoiated to

hee/ing, is often happened by patienthen the air is old% (oe"er it an be healithout therapy% hee/ing happens tineIn a ee)% There is no ontat ith T?

patient or long term oughing, her father issmo)er%

• #amily history of illnes

There is no the member of the patient$sfamily ho has asthma% *atient$s motherhas allergen to egg, and patient$s fatherhas allergen to seafood


18/27

• Imuni/ation

(epatitis ?, polio, ?C7, D*T and (ibhas been done% *C8 did not• *regnany and birth

There as no history of any maternalillness during pregnany%

(e as a term spontaneus "aginal

deli"ery born by *3A> ith noompliation help by midi"es% (eas eight 49>>gr ith body length=6m%


19/27

*hysial examination

• 7eneral ondition: seeming tight• Aareness : alert• 8ital sign

tempearture: 39%6MC

Respiration: H> x5mntartery: -> x5mnt

?lood pressure: ->>59>mmhg• Antropometry:

eight: -3%6)gheight: Hm• eight5age: &DIAN• height5age: STNTD


20/27

• (ead : Conjungti"a Anemis 050, s)lera iterus 050,nasal .aring 12 *eri @ral Cyanosis 10

• ne): lymph enlargement 10, retrasion SS 12•

Thora)s: symmetry respiratory, retra)si IC 252pulmo: +( 252, R( 252

Cor: heart sound -04 regular

Abdomen: ?oel sound 12 normal

)stremity: a)rosianoti 10 % Capillary reLll timeB4


21/27

#urther examination

• ?lood ount:

Feu)osit -6%6

• Fung funtion test 1#8 dan *#R• photo rontgen


22/27

*hoto rontgen


23/27

• DiEeretial diagnosis

Asma bron)iale se"ere exaerbation1se"ere persistent

?ron)opneumonia

Fung Tuber)ulosis• +or)ing diagnosis

Asma bron)iale se"ere exaerbation

1se"ere persistent 2bron)opneumonia


24/27

Treatment

• The "alue of asthma se"ere

Nebulisation ombi"en, gi"ing @4 4F5mnt5nasal% Infus )aen 3b% Ta)e are in hospital%

after nebu 4x ith partial nebu response e"ery 4 hours% gi"ingdexamethason tablet 3x-tab

If in 0-4 hour the linial ondition is ell permit to go, if it isnot ell ontinue to stay in hospital and gi"ingdexamethason i" 3x=mg, nebu e"ery -04 hours% AminoLilin1initial >mg24>nal putting into4>03>mnt dgn syringepump, then mg -hour%

The impro"ementor not of obser"ation% If there is noimpro"ement in nebu in e"ery H0-4 hour, gi"ing steroid andaminoLlin hanged per oral% The linial ondition isonsistent in 4= hours, the patient permit to go home%


25/27

prognosis

• Kuo ad "itam: ad bonam• Kuo ad funtionam: dubia ad bonam•

Kuo ad sanationam: ad malam


26/27

• duation

7i"ing the understanding about asthmagenerally and the pattern of asthma

Inreasing the s)ill ho to handle asthma• *romoti"e

Inreasing obediene

Controlling asthma• *re"enti"e

+earing the thi) lothes in oldondition


27/27

• Than) you

Documents

Asma Ppt in English 2