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Acute infective exacerbation of asthma

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History was obtained from aunty (mother’s sister)

PRESENTING COMPLAINTS
Cough    - 2 days
Fever    - 2 days
Wheezing - 1 day

HISTORY OF PRESENTING COMPLAINTS
She is a known child with childhood Asthma since the age of 9th
month. This is 5th attack of wheezing.
The previous 4 attacks had hospital admissions, but no ETU
admissions. The last attack was on 10th of April 2008, that time she
was on inhalers.
According to aunt, baby was well prior to the admission. Two days
before child has got fever. It was mild to moderate and intermittent
type, not associated with chills or rigors, and responded well to
Paracetamol syrup (5ml/ 6hourly), but on the same day she had
developed cough. Initially it was mild cough but became worse on early
morning. It was productive with whitish sputum. But child had no cold,
watery nasal discharge (rhinitis) or obstruction of nostrils (nasal
congestion).
Second day of the illness, child was taken to General practitioner &
treated with 3 types of syrups.
Theophyline syrup – 1 tsp bd
Salbutamol syrup - 1 tsp tds
Cephalexine syrup - 1 tsp tds

Then cough & fever was responded. But on that night she has
developed mild wheezing, which did not disturb her sleep or speech.
But next day early morning, she ended up with severe cough which
disturbed her sleep & speech. Then only, inhaler used (blue colour
inhaler, aunt doesn’t know about the dosage). But there was no
improvement.
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So parent were became panic & took the baby to hospital by a three-
wheeler around 5o’clock & got admitted to the ward around 5.30am.
At the time of admission child was nebulized & frequent nebulization
was continued. There after she has improved much and fever
disappeared
She has no history of atopy, like allergic conjunctivitis, eczema or
rhinitis

SYSTEMIC REVIEW
No history of photophobia, irritability, excessive crying, or
drowsiness.
No history of vomiting, abdominal distention, no changes in bowel
habit (bowel opening once per day)
Her urine output is adequate, no haematuria or not crying during
micturition (dysuria).
There is no contact history of fever, cough or Tuberculosis.

PAST MEDICAL HISTORY
Child was apparently well up to the age of 9 months (September
2006). She was admitted to the ward [1st attack] with cough, cold and
noisy breathing then diagnosed as acute attack of Asthma with right
sided chest infection. At that time child was treated with intravenous
drugs, intravenous fluid with frequent nebulization. Followed she was
discharged with oral medications (pink & white colour tablets)
probably salbutamol & prednisolone for few days.
2 months later (November 2006), again she has got cough, cold, fever
& wheezing, was admitted to ward. That time she was diagnosed as
acute severe attack of asthma with silent chest & treated with
intravenous drugs, intravenous fluid & frequent nebulization, then
discharged with two types of inhalers (blue & brown colour).
One month later (December 2006), child had 3rd attack of wheezing
because of wrong technique of using inhalers, and then mother was
educated about the correct inhaler technique.
In between the episodes child has had cough and common cold once a
month and treated with oral medication by General practitioner. But
there was no nebulization or hospital admission.
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Four months later (April 2007), child had 4th attack &admitted to the
ward & treated with syrup (probably salbutamol) & white tablets
(probably prednisolone).
There after she was in the phase of good control with the regular
prophylactic treatment and corrected good technique till the last
month. Unfortunately she missed her regular prophylaxis, because of
mother delivered another child during that period.
No past history of Fit, Renal disease, or Hematological problems



BIRTH AND ANTENATAL HISTORY
She is the product of non consanguineous parent. It was a planned
pregnancy. Mother had not developed complications like pregnancy
induced hypertension, gestational diabetes mellitus or any febrile
illness during pregnancy. She is a full term baby delivered by normal
vaginal delivery, weight was 2.460 kg. Baby cried at birth and breast
feeding was established within half an hour. No intrapartum
complications like birth asphyxia or post partum complication like
post partum hemorrhage. No history of NICU or PBU care. Both baby
and mother were discharged on the next day. Mother has vaccinated
against Rubella.




FAMILY HISTORY
She is the second child in the family of non-consanguineous parents.
Her brother has bronchial asthma, but not on regular treatment.
No family history of childhood asthma among others (parent or grand
parent), no history of atopy, chronic cough, Tuberculosis or other
significant illness
              34y            38y
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            6y         2 1/2y    4days



IMMUNIZATION HISTORY
Immunization is up to date according to the EPI schedule.
At birth              - BCG
 nd  th  th
2 , 4 , 6 months – OPV, DPT, Hep B
9th month            – Measles
  th
18 month              – DPT, OPV 4th dose
JE was not given yet.

DEVELOPMENT HISTORY
Gross motor - She started to sit at 7th month and stand with
support around 1 year, and now she can run safely, climb upstairs &
downstairs alone.
Fine motor- She started to hold the things and transfer to other
hand by around six months, her pincer grasp was around 1 year, now
she can put shoes alone.
Speech & hearing - She started to talk single word around 11 months,
now she can talk well in complete sentences.
Social & Emotional- She has day time bladder control & play with
other children.
According to this child’s development is age appropriate.



DIETARY HISTORY
Exclusively breast fed up to 6 months. Then weaning food started.
Now she eats normal diet from common family pot.

ALLERGY HISTORY
Not known to allergic to food, drug or plaster

SOCIAL HISTORY
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Father is 38 years old business man and educated up to A/L.
 He is the only breadwinner. Monthly income is 10,000/-
 He is a non smoker and non alcoholic.
Mother is 34 years old house wife and also educated up to A/L.
They bought the baby haler, but the aunt doesn’t know about the
cost, and they spend about 200Rs per month for medication.
She has an elder brother who is schooling in grade 1 and has a
younger sister who is just 4 days old. So mother stays at home to look
after the new born. There fore Aunt is staying with this child in the
hospital. Hopefully the Awareness of the disease is good among the
parent and aunty.

Environment
House is situated in a flat area. It has 2 rooms with windows for
adequate ventilation.
Kitchen is inside, has window. They use gas cooker.
Floor & wall are cemented.
The house is roofed by tiles with under ceiling. Sweep the house 2-3
times per day.
They change the bed linen & pillow cases once in two days, they use
net for mosquito, and they Sambrani once a week. No pets at home,
Child plays with soft toys oftenly.
Toilet is inside, which is commod.
Water supply is from pipe line, they drink boiled &cool water.
They come to THK by three wheeler & spent 200/- per hire.
The bus fee is 7/- from Kaluwelle to Galle & 16/- from Galle to
Karapitiya.

EXAMINATION

GENERAL EXAMINATION
OFC -43cm
Height -85 cm (between 25th and 10th centile),
Weight - 10kg (below 3rd centile)

According to Gomez classification;
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Weight/weight for age Χ 100 = 10/13.5 Χ 100 =74.07%= PEM –ІІ

According to Waterlow classification
Height/Height for age Χ 100 = 85/89 Χ100 =95.5% = Normal
Weight for height =10/12.5Χ100 = 80.0%. = Low normal


                         Height/Height for age Χ 100
                           >90%                    <90%


                 >80% normal                 chronic malnutrition
        Weight
        For
        Height          acute malnutrition    acute on chronic
                 <80%                         malnutrition




Well looking child.
Afebrile.
Not dyspnic at rest.
Not using accessory muscle
Not pale, not plethoric, no cyanosis
No flaring alae of nose, no nasal discharge
No lymph node enlargement, no clubbing
Throat not inflamed, Ear normal
BCG scar is there.




RESPIRATORY SYSTEM

Inspection
Respiratory rate -30 cycles per minute
No sub costal or intercostal recession
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No chest deformity, no Harrison's sulcus
Chest movement is symmetrical.

Palpation
Trachea lies in the midline
Chest expansion is equal in both sides
Vocal fremitus couldn’t check

Percussion
Resonance on both sides

Auscultation
Vesicular breathing with equal breath sounds
There are bilateral rhonchi with bilateral crepitations throughout the
lung field.

CARDIOVASCULAR SYSTEM
Pulse rate is 96 bpm, regular rhythm with normal volume
Apex beat at 5th intercostal space, in the midclavicular line
No parasternal heaving,
First and second heart sounds are heard in normal intensity.
No murmur.

ABDOMEN
Moves with respiration,
Not distended
Soft, non tender.
No hepatosplenomegaly
Hernial orifices & genitalia normal.




CENTRAL NERVOUS SYSTEM
Child was conscious,
Eye movements are normal,
Fundi normal
Muscle tone, reflexes are normal.
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SUMMARY

Baby Fathima Sheema, 2 years & 6 months old child from Kaluwelle is
a known patient with childhood asthma since 9months of age, had four
hospital admissions for wheezing and on prophylactic treatment but
not on regular in recent past, came with mild fever and cough which is
productive and worsening in early morning for 2 days duration &
wheezing for one day duration. She has a positive family history.
There are some precipitating factors.
On Examination child was afebrile, not dyspnic with respiratory rate
of 30 cycles per minute, no subcostal or intercostal recessions,
bilateral rhonchi and coarse crepitations heard all over the lung fields
with equal breath sounds. And her pulse rate is 96 bpm and other
examination findings revealed normal .Growth assessment of child
showed PEM 11 according to Gomez classification. But according to
Waterlow classification, her nutritional level is low normal.




PROBLEMS LIST
   Known childhood asthmatic patient came with 5th attack of
    wheezing associated with cough and fever while on prophylactic
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      inhaler therapy (but didn’t take regularly for last one month
      period), with the lung signs of bilateral rhonchi & coarse
      crepitations
     One of the siblings also has childhood asthma, not on regular
      treatment, during attacks treated by General practitioner.
     Has an environmental precipitating factor such as using
      sambrani & child plays with soft toys (teddy bear).
     Weight of the child is below 3rd centile, according to Gomaz
      classification, she is in PEM –ІІ, but according to water low
      classification she is in Low normal category.
      Mother can’t stay with the child, because she has 4days old
      baby.



  DIFFERENTIAL DIAGNOSIS

1-Acute infective exacerbation of asthma
        Diagnosed patient with childhood asthma came with wheezing
   associated with cough and fever, with lung signs of bilateral
   rhonchi and coarse crepitations.

2-Recurrent lower respiratory infection
    Child has fever & productive cough with bilateral crepitations.




DISCUSSION

Previously diagnosed child with infrequent wheezing with two severe
attacks, on prophylactic treatment, but not regularly for last one
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month, came with another episode of exacerbation following
respiratory tract infection.
So my final diagnosis is acute infective exacerbation of asthma.

The of management
 1- Treat the acute exacerbation.
 2- Plan for long term management.
 3- Improve the weight.




MANAGEMENT
Bed given in sub acute side
Quarter Hourly Temperature chart
Nebulize with Salbutamol 0.5 ml + 1.5 ml Normal saline 4 hourly
       Ipratropium bromide 0.5 ml + 1.5ml Normal saline 6 hourly

Paracetamol 150mg tds
Oral Salbutamol 1mg 8 hourly
Oral Deriphylline syrup 1 tsp bd
Oral Cephalexin syrup 1 tsp tds

INVESTIGATION
Chest X-ray - Lung fields are hyper inflated & no inflammatory
changes.
While on treatment
Lung signs reduced on next day and her general condition improved so
she was discharged on the next day with oral salbutamol 1mg 8 hourly,
prednisolone 10mg twice a day for 5 days.
Before discharging, planned for long term management
According to grading of asthma this child comes under mild
persistent asthma, so she needs low dose inhaled steroids, as given
before, but we have to find out the reason for poor control. It may
be due to
 1- Poor compliance
 2- Improper technique
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3- Inadequate dosage
4- Inappropriate pharmacological management
5- Poor environmental control
6- Wrong diagnosis

I have checked the dose, technique and found that child was not on
regular prophylaxis in the recent past, due to mother delivered a
baby recently so she is looked after by aunt, and also has
environmental precipitating factors according to the history.
I educated the aunt
-about the disease
-the importance of the prophylactic inhaler therapy
-the usage of medication
-washing mouth after the use of inhaler, and cleaning methods
-avoid the environmental risk factors to prevent recurrences,
-avoidance of allergic foods,
-good hygienic practices
-regular clinic follow up after two weeks time for good control
,monitor the response and growth assessment because chronic
respiratory infection can cause growth restriction, and this child is
PCM11 now.
So for the maintenance of proper weight and height nutritional
support and dietary modification are essential.

Ultimate goal of management is to give her a near normal life.




Some thing about Asthma

There is classification for acute asthma.



In mild attack: Patient can lie down,
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               Can talk in sentences
               Respiratory rate increased
               No use of accessory muscles of respiration
               End expiratory wheeze on auscultation
               Pulse rate is >100 bpm



In moderate attack:      Patient prefer sitting
                         Can talk in phrases
                         Respiratory rate >30 cycles per minute
                         Rhonchi throughout expiration
                         Pulse rate between 100-120 bpm.



In severe attack:    Breathless at rest
                    Sit up right
                    Talk in words
                    Respiratory rate >30 cycles per minute
                    Use of accessory muscles of respiration
                    Loud rhonchi heard throughout respiration
                    Pulse rate >120 bpm




There is another classification of asthma for further management.

 Mild intermittent asthma:
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     Symptoms < 2 times a week
     Night time symptoms >2 times a month
 Mild persistent asthma:
    Symptoms <2 times a week, < 1 time a day
    Night time symptoms >2 times a month
 Moderate persistent asthma
   Daily symptoms
   Exacerbations more than two times per week

 Severe persistent asthma
    Continuous symptoms
   Limited physical activity
   Frequent attacks
   Frequent nighttime symptoms



There is four steps management of chronic asthma

   Step 1   β2 agonist

   Step 2-β2 agonist + inhaled steroids

   Step 3 β2 agonist       + high dose inhaled steroids or low dose
    inhaled steroid +or – long acting bronchodilator

   Step 4 β2 agonist     + high dose inhaled steroid + long acting
    bronchodilator + or –
    Theophyllines or Ipratropium + or- alternate day prednisolone.

				
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