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A Case Study of A 1-Year-Old Child Diagnosed With Bronchial Asthma in Acute Exacerbation

A 1-year-old male infant was admitted to the hospital with cough, colds, and asthma exacerbation. Upon examination, he had rapid breathing, wheezing, and chest retractions. Over a few days of treatment including antibiotics, nebulizers, and IV fluids, his symptoms improved with stable vital signs and decreased wheezing. He was discharged with medications and instructions to follow up in one week.

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Kyra Bianca R. Famacion
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457 views36 pages

A Case Study of A 1-Year-Old Child Diagnosed With Bronchial Asthma in Acute Exacerbation

A 1-year-old male infant was admitted to the hospital with cough, colds, and asthma exacerbation. Upon examination, he had rapid breathing, wheezing, and chest retractions. Over a few days of treatment including antibiotics, nebulizers, and IV fluids, his symptoms improved with stable vital signs and decreased wheezing. He was discharged with medications and instructions to follow up in one week.

Uploaded by

Kyra Bianca R. Famacion
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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2 NF PRESENTS

A Case Study of a 1-year-old Child Diagnosed with


Bronchial Asthma in Acute Exacerbation
Assessment
Patient X is a 1-year-and-3-month-old male infant from Indahag,
Cagayan de Oro City. On December 1, 2020, at 3:30 PM, Patient X
was admitted to Maria Reyna - Xavier University Hospital with a chief
complaint of cough and colds and an admitting diagnosis of pediatric
community-acquired pneumonia with asthma.
Upon physical examination, the patient was conscious and was not
lethargic nor drowsy. His vital signs upon admission were at
temperature of 36.6 degrees Celsius, respiratory rate of 44 breaths
per minute, heart rate of 188 beats per minute, and oxygen saturation
of 97%. Rales were heard in both lungs upon auscultation and
intercostal retraction was evident.
Upon assessment, he weighed 11.5 kilograms and was noted
to be formula-fed. He was delivered via normal spontaneous
delivery (NSD) without any complications at JRB Hospital,
Cagayan de Oro City. Immunizations received by Patient X
include BCG, DPT 3, OPV 3, and HIB 3. The mother is the
primary caregiver.
At 1 year old, the patient is able to walk alone and able to say
“mama” and “papa.” Patient X has a family history of bronchial
asthma from the maternal side. In the past two weeks, Patient X
presented with the following symptoms: vomiting, dry cough,
runny nose, and shortness of breath. His RT-PCR test result
came in negative for COVID-19 Infection.
One day prior to admission, Patient X had a sudden
onset of a non-productive cough, with clear nasal
discharge; but without fever, LBM, and vomiting. He
was given salbutamol syrup (self-medicated) 0.5mL x 3
doses.
Morning prior to admission, Patient X had a recurrence of
symptoms associated with fast breathing, with decreased
appetite and decreased milk formula intake (6oz from normal
intake of 180z), and post-tussive vomiting. On the day of
admission, he was seen by the attending physician, which
prompted admission.
On the second day of admission, December 2, 2020, upon assessment at 6:30
AM, Patient X was afebrile, had decreased tachypnea with a respiratory rate of
50-52 breaths per minute, and decreased intercostal retractions. Rales were still
heard upon auscultation. Heart rate was 150 beats per minute and oxygen
saturation was at 97%. Patient X was reported to be eating better. Diet for age
was allowed but with strict aspiration precaution and continuation of
medications was ordered.
At 3:00 PM, IVF rate was ordered to be
decreased to a rate of 50 cc/hr with an
additional order of IVF to follow D5IMB
(balanced multiple maintenance solution) at
50 cc/hr in cycles until further notice.
At 7:40 PM, Patient X remained afebrile with a respiratory rate
of 50 beats per minute. Heart rate was 120 beats per minute and
oxygen saturation was at 98%. Bilateral rales were still heard
upon auscultation and chest retraction was still present with an
occasional wheeze. Chest tapping after every nebulization was
then instructed along with the continuation of his treatment with
Ceftriaxone D1.
On December 3, 2020, Patient X was placed safely at the
center of the bed, with side rails raised. The mother was
instructed not to leave the patient unattended due to
medications given, kept watch for any unusualities.
At 9:40 AM, assessment of Patient X revealed that he was
afebrile and had a good appetite. His vital signs that time
were: heart rate - 110, respiratory rate - 20, SPO2 - 98% -
room air (RA), tolerated well. Bilateral rales were still
positive upon auscultation and audible wheeze was still
present, however, there were no observable retractions upon
examination.
He continued his course of antibiotic therapy (Ceftraixone
D1+1). Patient X’s oxygen was ordered to be discontinued
with the order to refer if with desaturation (<95% sat). His IV
fluid was ordered to be decreased to a rate of 45cc/hr with IV
fluid to follow (D5IMB at 45 cc/hr). Nebulization interval was
decreased to q4.
At 4:00 PM, Patient X’s follow-up assessment revealed
that the audible wheeze was still present, however, no
retractions were observed. His vital signs were: blood
pressure - 90/60 mm/Hg, heart rate - 114 bpm, respiratory
rate - 30 cpm, and SPO2 - 99% at room air.
On the last day of admission, December 4, 2020, at 9AM, no
wheezing was noted upon auscultation and retractions were not
evident. His vital signs were as follows: blood pressure - 90/60, heart
rate - 114 BPM, respiratory rate - 28-38 CPM, and oxygen
saturation - 98%. Patient was advised to do chest tapping every
after nebulization and was encouraged to increase oral fluid intake
(OFI).
At 11 AM, Patient X was afebrile, no wheezing and
retractions were noted, and oxygen saturation was at
97% at room air (RA). Patient was ordered to
consume the remaining ceftriaxone 600 mg and was
ordered to shift to co-amoxiclav (Natravox) 250
mg/62.5 mg every 5 mL, 2.5 mL TID.
The physician instructed not to reinsert IV line once
dislodged. IVF rate was decreased to 30cc/hour and
salbutamol + ipratropium was discontinued. Salbutamol
was increased to 1 nebule q4h and hydrocortisone was
continued.
At 11:30 AM, Patient X was
discharged with the final diagnosis of
bronchial asthma in acute
exacerbation.
The following were the take-home medications: salbutamol 1
nebule q6h for 5 days, co-amoxiclav 250 mg/62.5 mg,
prednisone 20mg/5mL, and phenylpropanolamine HCl +
Brompheniramine maleate (Nasatap) drops 1 mL OD.
Patient X was instructed to have a follow-up check-up on
December 14, 2020 in Maria Reyna Xavier University
Hospital clinic at 12 NN.
Pathophysiology
Thank you!

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