PART 2: PATIENT HISTORY

Chief Complaint:
Short of breath 1/7 days
Current Medical/Surgical History Illness:
Patient complain of short of breathes since today
Coughing with yellowish sputum since today
No fever
No flu
No vomiting
No diarrhoea
No takipnea
in casualty
6.35am
- Patient still alert but breath fast and still claiming short
of breath but the saturation still 99 % under room
temperature
- Found that there are rhonchi sound occur on both lung
occur during auscultation
Past Medical/Surgical History Illness (including allergy to medicines):
Patient never been admitted to the ward since she was diagnosed as
bronchial asthma since she was young
She was on inhaler salbutamol 2 puff tds/prn
Family History:
no diabetes mellitus
no hypertension
no other bronchial asthma found occur among her other siblings
Social History:
patient not smoking
patient not drink alcohol
O&G History:
patient married
patient has four children
patient menstrual cycle is normal

PART 3: PHYSICAL EXAMINATION

General Examination:

pink
alert
conscious
walk in
good on speech

Vital Sign:
BI
L
01
02
03
04
05
06
07
08
09

OBSERVATION

RESULTS

Pain score
Temperature
Respiration rate
Blood pressure
Pulse rate
Pulse rhythm
Pulse volume
Body weight
GCS

3/10
36.8 C
20/minutes
120/74mmHg
95 bpm
Normal
Good
65kg
15/15

Head & Sensory Organ Examination:

Head
Inspection
- No swelling or active bleeding
- No discoloration noted

Eyes

Palpation
- No swelling

Inspection
- Up rolling eyeballs
- No discharged found from both of the eyes
- No discoloration noted
Palpation
- No per orbital tenderness or swelling noted

 Ears

Inspection
- No active bleeding or swelling
- Both ears remain in same size
- No discharged at both ears noted
- No abnormalities of hearing noted
Palpation
- No tenderness
- No mass palpated

Nose
Inspection
- No bleeding and swelling
- In normal shape of nose
- No discharged from the nose
- No nasal polyps seen
- No nasal obstruction noted

Palpation
- No tenderness
- No mass found

Throat
Inspection
- Cough and sore throat for 1/7 day
- Yellowish sputum occur
- No tonsil enlargement
Mouth
Inspection
- Normal in shape
- Dry lips
Neck
Inspection
- No abnormality in shape
- No complaint of dysphagia
- No swelling
- Able to swallowed

Palpation
- No tenderness
- No mass palpable
- No lymph node swelling

No increasing pressure of Jugular Venous Pressure(JVP)

Chest:
Heart
Inspection
- No previous cardiac operation scars on the chest wall.
- No abnormalities seen.

Palpation
- No chest wall pain or tenderness.
- No presence of abnormal thrill.
- Apex beat at 5th intercostal space midclavicular line.

Percussion
- Normal cardiac dullness on the fifth intercostal space of
the left heart border.

Auscultation
- Sound 1 and sound 2 heard clearly.
- Dual rhythm no murmur.
- Heart beat- Normal

Lungs
Inspection
-

Shape and symmetry of chest- Normal.

Chest wall movement anteriorly and posteriorlyNormal and no abnormalities
Has coughing.
Breathlessness
Tightness

Palpation
- Chest expansion- Normal
- Apex beat- Normal
- No vocal (tactile) fremitus.
- Ribs- no pain localised.

Percussion
- Cardiac dullness- Normal.
- Normal resonance at both lungs.

Auscultation
- Breathe sound- Has rhonchi, no crepitation

No added (adventitious) sounds.

Air entry equal bilateral

Abdomen:

Nervous System:

Lower Extremities:

Inspection
- No previous surgical scar seen.
- No wound.

Palpation
- No pain during palpitation on the abdomen
- No pain
- No tender

Percussion
- No fluid thrill.

Auscultation
- Bowel sound present- Normal

No swelling
No oedema
No bleeding
No injury

Right and left leg movement - Normal

No active bleeding seen
No deformity / abnormality noted
No pitting oedema
Able to move right leg without restriction.
Capillary refill- Normal

Right and left hand movement - Normal

No active bleeding present
No deformity / abnormality seen

Upper Extremities:

Others (Genitalia, Rectum and etc):

No physical examination done

PART 4: THE SUMMARIES OF IMPORTANT AND RELEVANT

FINDINGS

Cough and sore

throat with yellowish
sputum 1/7 day

Breath sound : has

rhonchi, no
crepitation

PART 5: DIAGNOSIS
Provisional diagnosis
Asthma
Differential diagnosis
Bronchial asthma
Bronchopneumonia
bronchitis
COAD
Final diagnosis
Bronchial asthma

PART 6: RELEVANT AND IMPORTANT INVESTIGATON AND

RESULT
BI
L
01
02
03
04
05
06
07
08
09
10
11

INVESTIGATI
ON
HB
TW
pH
Na
K
Ur
Cr
RbS
Ca
Mg
P/S

RESUL
T
13
19.5
266
13.9
4.34
5.9
80
5.5
256
0.76
0.92

The investigation which can be done for Asthma patients are:

Auscultation to detect the breath sound
Peak flow meter
Angiography cerebral
Lumbar puncture
CT Scan
To detect the lesion in brain
MRI

To detect the lesion in brain

BUSE (done)
FBC (done)
To detect if any infection occur
chest X-ray

PART 7: MANAGEMENT
General management
Inform the family about the illness
Health education
Important of treatment
Safety precaution during illness attack
Emergency treatment during illness attack
Bring patient far from danger area
Make sure the airways open and put patient in semi-prone
position
Give patient nebulizer V:A:N (1:2:3)
At emergency and trauma department
Continue give patient V:A:N (1:2:3) stat
Let patient rest in bed completely
Monitor the vital sign
Give oxygen when needed
Doctor plan
Continue NEB V:A:N (1:2:3)
Iv Hydrocortisone Sodium 250mg STAT
MDI Salbutamol 2 puff tds/prn
Tab Prednisolone 30mg od
Syrup Dephendhydramine HCl 15ml tds
Tab Bromhexine HCl 8mg tds
Tab Paracetamol 1gm tds/prn
TCA prn
Allowed discharge when the condition good

PART 9: RELEVANT ADVICES TO PATIENT AND FAMILY

Explain to the patient and her family about the illness she was
facing so that the family can help the patient when she was short of
breath.
Explain to the patient and family about the important of taking a
medication at the right time and dosage.

Explain the side effect of the medication if not taken with

the correct direction

Also explain the important of the continues treatment

Make sure patient has done the blood test and also TDM
especially if patient take medication such as sodium
valproate

Make sure patient use medical alert so that it can be identified

during seizures attack
Avoid high risk activity
Avoid other development factor such as bright light

REFLECTIVE REPORT
(Give comments about studies and implication of the management of these case that can be
found from this clerking case)
Case management

Good
Satisfied
Week

The reflection of the studies that can be found from these clerking
case:

I study about the case of Bronchial Asthma in Asthma Bay,

Emergency And Trauma Department
Bronchial Asthma is occurring when a patient has a chronic
inflammatory disease of the airways that causes periodic
attacks of coughing, wheezing, shortness of breath and
chest tightness.
This due to some condition where a person has some
allergen to a certain thing such us animal fur or food.
The patient was a woman, 40 years, with an history of
multiple breakthrough of asthma
The day she was admitted to the A&E, she already had
short of breath, cough and a little tightness on her chest.
She was given NEB V:A:N (1:2:3) STAT at A&E
Doctor in charge planned: Continue NEB V:A:N (1:2:3)
Iv Hydrocortisone Sodium 250mg STAT
MDI Salbutamol 2 puff tds/prn
Tab Prednisolone 30mg od
Syrup Dephendhydramine HCl 15ml tds
Tab Bromhexine HCl 8mg tds
Tab Paracetamol 1gm tds/prn
TCA prn
Allowed discharge when the condition good