JABATAN PEDIATRIK Tel : 03-26155555/26981044

HOSPITAL KUALA LUMPUR Samb : 5643/5643

JALAN PAHANG Fax : 03-26948187
50586 KUALA LUMPUR Website : www.pead.gov.my

Pediatrician
Pediatric Clinic,
Hospital Sultanah Aminah
Johor Bharu. 31st May 2016

Dear colleague,

Re:
Name :
MyKid :
RN :
Diagnosis :
1) Severe Exacerbation of Bronchial Asthma secondary to Pneumonia\
2) Uncontrolled Brochial Asthma

Thank you for following-up the above 2 years old boy. He was admitted to Institute Pediatric
Hospital Kuala Lumpur on 27th May 2016 for rapid breathing. Child was presented with cough and
runny nose for 1 day and subsequently had rapid breathing admitted after brief treatment in
Emergency Department, HKL. He has history of monthly nebulization and multiple admissions in
HSAJB due to Exacerbation of Bronchial Asthma since 1 year 2 month old. He responded well to
nebulisation Salbutamol.

2. His vital sign - pulse rate 190/min, respiratory rate 62/min, saturation 100%. He was lethargic,
and had respiratory distress with deep recession, reduced breath sound and generalized crepitations
and scattered rhonchi on arrival. He responded briefly with nebulisation Salbutamol but he remains
unwell, and in distress. He was transferred to PICU for non-invasive ventilation support, BiPAP for
remaining in respiratory distress needing high flow mask oxygen. He was on Vision BiPAP IPAP
12 and EPAP 6 FiO2 50%, and rate of 30/min for 1 day, which subsequently able to wean to
Onemask oxygen. He was in PICU for 2 days and transferred out back to ward on day 3 admission.

3. Investigations
Chest X-Ray showed hyperinflated chest, slight roated film with no cardiomegally. It
showed peribronchial cuffling, and bilateral perihilar haziness.
TWC xxxx 103/uL Hb xxxg/dL Platelet xxx 103/uL
Renal Profile – Sodium xxxmmol/L Potassium xxx mmol/L Urea xxx mmol/L Creatinine
xxx umol/L

4. He was on C-Penicillin for 5 days before changed to Syrup Pencillin V 150mg QID on discharge
to complete 1week. Nebulisation salbutamol was given regularly 4 hourly and changed to MDI
salbutamol 4 puff 6 hourly upon discharged. He was completed steroid – prednisolone 10mg OD
for 5 days. He was started with MDI Fluticasone 125mcg BD.

5. They came to Kuala Lumpur visiting grandparents. Father work as engineer in Singapore, while
mother is a house wife. Child having no nocturnal cough or day cough, but having exercise induce
cough and URTI induced cough with wheeze. Father had child hood asthma.

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