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Cese Asthma BAB II

ilmiah

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Shawn Dyer
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18 views8 pages

Cese Asthma BAB II

ilmiah

Uploaded by

Shawn Dyer
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CHAPTER II

CASE REPORT
Identity

 Name : Mrs. S
 Age : 35 years old
 Medical Record : 12.59.02
 Admission date : August 3th 2018

Chief Complaint
A 35 years old woman was admitted to PONEK of Prof. DR. M. Ali Hanafiah SM regional
public hospital of Batusangkar, August 3th 2018 at 06.45 am, with chief complaint feeling short
of breath, wheezing and can’t stop coughing. The patient was pregnant of her third child

Present Illness History


 Previously, the patient had felt short of breath since 1 day ago, difficult to breath, wheezing
and tightness of chest, no decress with rest and change the potition. The patient got cough
since 2 days ago and has worsened since 4 hours ago. the cough and shorth of breath come
after patient cleaning her house and inhaled the dust and being worsened 4 hours ago
because of could air. The patient has been known had uncontrolled asthma since she was
12 years old and consume salbutamol 2 mg every attact of asthma, but never consume
salbutamol again sice she know she was pregnant. This is the first time she got asthma attact
since this pregnance.
 Pelvic pain to the groin (-)
 Bloody show from the vagina was (-)
 Fluid leakage from the vagina was absent
 Massive bleeding from the vagina was absent
 Amenorrhea since 5 months ago.
 First date of last menstrual on 19 – 03 – 2018
 Estimation date of delivery on 26 –12 – 2018
 Fetal movement was felt since 1 months ago
 No complain of nausea, vomiting, and vaginal bleeding neither during early pregnancy nor
late pregnancy
 Prenatal care : prenatal care to midwife at 2th and 3th month of pregnancy.
 Menstruation history: menarche at 12 years old, regular cycle once for every 28 days, 2-3
times pad changes / day without menstrual pain

Previous Iilness history


The patient has been known had uncontrolled asthma since she was 12 years old and consume
salbutamol 2 mg every attact of asthma
The patient has an allergy of seafood, dust and cold
There wasnt previous history of heart, lung, liver, kidney, DM

Family Iilness history


father of the patient have an allergy of cold and dust

Obstetric History
 Marriage History : Once in 2008
 History of pregnancy/Abortus/Labour : 3/0/0
- 2009/female/3200gr/spontan/midwife/alive
- 2012/male/3500gr/spontan/midwife/alive
- present
 History of Contraception : (-)
 History of immunization : (-)
 History of education : Senior high school

Physical Examination
General record
GA Cons BP HR RR Temp.
Moderate CMC 110/70 105 x/mnt 30 x /mnt 36,9oC
 Head : Normocephaly
 Eyes : Conjunctiva wasn’t anaemic, sclera wasn’t icteric
 Neck : JVP 5 – 2 cmH2O, there is no enlargement in thyroid gland
 Thorax :
 Heart :
Inspection : ictus cordis was not
Palpation : ictus cordis was palpable 1 finger medil LMCS ICS V
Percussion : value of the heart in normal limited
Auscultation : Heart sound I-II regular, gallop (-), murmur (-)
 Lung:
Inspection : chest movement was symmetrical left and right, retraction (-)
Palpation : left fremitus = right fremitus
Percussion : sonor/sonor
Auscultation : Wheezing (+/+) ves (+/+) Rh(-/-)
 Abdomen : Obstetrical record
 Genitalia : Obstetrical record
 Extremity : oedema -/-, Physiological reflex +/+, Pathological reflex -/-

Obstetric Record
Abdomen
 Inspection : Enlarge accordance to preterm pregnancy,
Striae gravidarum (+), cicatrix (-)
 Palpation : Uterine fundal was palpable at 2 finger below umbilical, tenderness (-)
Uterine fundal height: 22 cm
Uterine contraction : (-)
 Percussion : Tympani
 Auscultation : Peristaltic sound was normal, FHR : 145-155 x/minutes

Genitalia
 Inspection : V/U normal, vaginal bleeding (-)
Laboratorium Examination
- Haemoglobin : 11,9 gr/dl
- Leukocyte : 15.900 / mm3
- Lym: 8,7% Mon: 1,3% Gra: 90,0%
- Haematocrit : 32, 8%
- Platelet : 331.000/mm3
- Blood glucose : 137 mg/dl

Diagnose
G3P2A0L2 20-21 weeks of pretterm pregnancy + asthma bronchial exacerbation acute
Fetal alive singleton intrauterine

Action
 Control general appearance, vital sign, uterine contraction, fetal heart rate.
 Informed consent
 IVFD RL 20 drops/minute
 O2 3-4 lpm
 Ventoline nebu
 Ambroxol syr 3x1C

Plan
 konservative
 Consult Pulmonologist
August 3th 2018 At 08.00 am
Pulmo dept:
A/ Acute asthma exacerbation on G3P2A0H2 20-21 weeks of pregnancy
P/ drip aminophylin 1,5 amp in 500cc D5% 12 hours/kolf
Ventoline nebu/8 hours
Inj Metylprednisolon 2x125 mg
Inj Ceftriaxone 2x1 gr
Ambroxol syr 3 x 1C
Follow Up August 4th 2018 At 09.00 am
S/ Out of breath was decrease, wheezing was decrease, cough (+) phlegm, pelvic pain to the
groin (-), bloody show from the vagina was (-). Fetal movement (+)
O/
GA Cons BP HR RR Temp.
Moderate CMC 110/70 90 x/mnt 26 x /mnt 36,9oC
 Thorax :
 Heart :
Inspection : ictus cordis was not
Palpation : ictus cordis was palpable 1 finger medil LMCS ICS V
Percussion : value of the heart in normal limited
Auscultation : Heart sound I-II regular, gallop (-), murmur (-)
 Lung:
Inspection : chest movement was symmetrical left and right, retraction (-)
Palpation : left fremitus = right fremitus
Percussion : sonor/sonor
Auscultation : Wheezing (+/+) was decrease ves (+/+) Rh(-/-)
 Abdomen : Obstetrical record FHR: 148-158 bpm
 Genitalia : Obstetrical record
 Extremity : oedema -/-, Physiological reflex +/+, Pathological reflex -/-

A/ G3P2A0L2 20-21 weeks of pretterm pregnancy + asthma bronchial exacerbation acute


(improvement) D-1
Fetal alive singleton intrauterine
P/ Control general appearance, vital sign, uterine contraction, fetal heart rate.
O2 2-3 lpm
drip aminophylin 1,5 amp in 500cc D5% 12 hours/kolf
Ventoline nebu/8 hours
Inj Metylprednisolon 2x125 mg
Inj Ceftriaxone 2x1 gr (H2)
Ambroxol syr 3 x 1C
Follow Up August 5th 2018 At 09.00 am
S/ Out of breath was decrease, wheezing (-), cough (+) phlegm, pelvic pain to the groin (-),
bloody show from the vagina was (-). Fetal movement (+)
O/
GA Cons BP HR RR Temp.
Moderate CMC 100/70 84 x/mnt 22 x /mnt 36,9oC
 Thorax :
 Heart :
Inspection : ictus cordis was not
Palpation : ictus cordis was palpable 1 finger medil LMCS ICS V
Percussion : value of the heart in normal limited
Auscultation : Heart sound I-II regular, gallop (-), murmur (-)
 Lung:
Inspection : chest movement was symmetrical left and right, retraction (-)
Palpation : left fremitus = right fremitus
Percussion : sonor/sonor
Auscultation : Wheezing (-/-) ves (+/+) Rh(-/-)
 Abdomen : Obstetrical record FHR: 155-165 bpm
 Genitalia : Obstetrical record
 Extremity : oedema -/-, Physiological reflex +/+, Pathological reflex -/-
A/ G3P2A0L2 20-21 weeks of pretterm pregnancy + asthma bronchial (improvement) D-2
Fetal alive singleton intrauterine
P/ Control general appearance, vital sign, uterine contraction, fetal heart rate.
O2 2-3lpm  aff
drip aminophylin 1,5 amp in 500cc D5% 12 hours/kolf  aff
IVFD RL 28 tpm
Ventoline nebu/if need
Inj Metylprednisolon 2x125 mg
Inj Ceftriaxone 2x1 gr (H3)
Ambroxol syr 3 x 1C
Follow Up August 6th 2018 At 09.00 am
S/ Out of breath (-), wheezing(-), cough (+) phlegm, pelvic pain to the groin (-), bloody show
from the vagina was (-). Fetal movement (+)
O/
GA Cons BP HR RR Temp.
Moderate CMC 110/70 88 x/mnt 20 x /mnt 36,6oC
 Thorax :
 Heart :
Inspection : ictus cordis was not
Palpation : ictus cordis was palpable 1 finger medil LMCS ICS V
Percussion : value of the heart in normal limited
Auscultation : Heart sound I-II regular, gallop (-), murmur (-)
 Lung:
Inspection : chest movement was symmetrical left and right, retraction (-)
Palpation : left fremitus = right fremitus
Percussion : sonor/sonor
Auscultation : Wheezing (-/-) ves (+/+) Rh(-/-)
 Abdomen : Obstetrical record FHR: 153-163 bpm
 Genitalia : Obstetrical record
 Extremity : oedema -/-, Physiological reflex +/+, Pathological reflex -/-

A/ G3P2A0L2 20-21 weeks of pretterm pregnancy + asthma bronchial (improvement) D-3


Fetal alive singleton intrauterine
P/
Cefixime 2x200 mg
Ambroxol syr 3 x 1C
Vit C 3x50 mg
R/ Outpatien

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