ASTHMA

A. Descripton of Asthma

Asthma is a chronic disorder of the lungs that involves airway inflammation,

increased mucous production and over-reactive smooth muscles in which obstruction of
airflow within the small airways is partially or fully reversible. Common symptoms include
wheezing, coughing, chest tightness, and shortness of breath.

Asthma exacerbations result from an intense hyper-responsiveness of the small

airways to multiple triggers that include infection, irritants, allergens, changes in weather
conditions, emotions and exercise.

Sure name Saputra First Name Randa

DOB 05.07.90 Gender M F
Occupation security guard.

Marital Status Single

Next of Kin Brother,Andi
Contact no. 085287356776
Smoking Intake 15 cigarette a day
Alcohol Intake None
Reason for Asthma
admission
Medical history Asthma
Allergies Dust and cold air
GP Dr. Sonia

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B. Summary of patient’s admission
Randa Saputra was admitted that he is asthma. Mr. Randa was born in 1990. He is single
because he is not married and work as a security guard. His next of kin is his brother, Andi.
He is can be contacted on 085287356776. Mr. Randa Smokes 15 cigaratte a day he does not
drink alcohol. He is allergic dust and cold air. There is a family history of asthma on his
mother’s side.

C. The description of the pains of the patient

The patient feel crowded during breathing and chest pain. It began suddenly when he is
watching tv. The pain is worse when he strenuous activity and exposure to dust.

D. Symptoms and Signs

Symptoms : any subjective evidence of disease : a phenomenon that is experienced by the
individual affected by the disease.
E.g : shortness of breath, coughing, chest pain
Signs : any objective evidence of disease : a phenomenon that can be detecyed by
someone other than the individual..
E.g : retraction inter costa, wheezing, chest tightness, sputum contained

E. Symptom’s report
Two days ago, Mr. Randa was coughing and was not crowded, he was not taking medication.
Yesterday Mr. Randa was worsening cough and crowded and taken to doctor. Today the
patient immediately taken to the hospital because of crouded not recover.

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http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm