Download - Asma Ppt in English 2
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Case Report
Asthma
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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% '
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(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)%
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• (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
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*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
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• (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
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#urther examination
• ?lood ount :
leu)osit: -6%-•
#aal lung test 1#8, *#R
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*hoto rontgen
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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"
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prognosis
• Kuo ad "itam: ad bonam• Kuo ad sanationam: dubia ad bonam•
Kuo ada futionam: ad malam
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duation
7i"ing eduation to patient and patient$sfamily
• Inreasing the understanding about
asthma generally and the pattern of it• Inreasing s)ill 1the ability about hoe to
handle asthma
• Inreasing self onLdent• Inreasing the obidiene and handling
alone
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• Than) you
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Identity
• Name: T• age: = years old•
sex: female• #ather$s name: mr% I• Address: irebon•
Date in entry: >40>H04>-6• Date of examination: >30>H04>-6
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(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
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• *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
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• 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%
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*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
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• (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
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#urther examination
• ?lood ount:
Feu)osit -6%6
• Fung funtion test 1#8 dan *#R• photo rontgen
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*hoto rontgen
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• 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
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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%
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prognosis
• Kuo ad "itam: ad bonam• Kuo ad funtionam: dubia ad bonam•
Kuo ad sanationam: ad malam
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• 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
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• Than) you