Case Scenario #2

Bronchial Asthma

A.R. a 10 y.o. boy was brought by his mother to UFC for consultation at around 9 a.m. due
to a sudden onset of difficulty in breathing, non-productive cough, and wheezing sounds as he
breathes. No prior history of this as stated by the mother. Positive family history of asthma on
the maternal side. No known allergies to drugs and food. Upon auscultation by the
physician, audible inspiratory and expiratory wheezes are heard. Use of accessory muscles was
also noted. The patient looks pale and weak. Complete immunization as stated by the mother.
The following medications were prescribed. Salbutamol Nebule for inhalation 1 nebule stat and
every 20 mins. after x 3 dose. To be assessed by the physician after each nebulization.
Salbutamol nebule, 1 nebule q6hrs x 5days. Montelukast 5 mg/sachet, 1 sachet OD HS for 7
days.

Vital Signs:

Temp. 37.1C

Pulse: 132 bpm

Respiration: 30cpm

O2 Sat.: 88% at room air

B/P: 110/80

Ht.:125 cm.

Wt.: 24 kg.

After nebulization, the child’s breathing improves and vital signs were back to normal with O2
sat of 98%. The mother was advised to seek consultation with a pulmonologist for further
evaluation and care.

Diagnosis: Bronchial Asthma