bronkopneumonia(theodora and anusha)
DESCRIPTION
bpTRANSCRIPT
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Case Report
BRONCHOPNEUMONIA
SUPERVISOR : dr. Rina A. C. Saragih, M. Ked (Ped), Sp. A
PRESENTATOR : Theodora Purba 110100267
Anusha Chandra Sikaran 110100414
DEPARTMENT OF CHILD HEALTH
MEDICAL FACULTY NORTH SUMATRA UNIVERSITY
H. ADAM MALIK GENERAL HOSPITAL
MEDAN
2015
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ACKNOWLEDGMENTS
We are greatly indebted to the Almighty One for giving us blessing to finish this case
report,“Bronchopneumonia”. This case report is a requirement to complete the clinical
assistance program in Department of Child Health in H. Adam Malik General Hospital,
Medical Faculty of North Sumatra University.
We are also indebted to our supervisor and adviser, dr. Rina Amelia, Sp.A (K) for
much spent time to give us guidances, comments, and suggestions. We are grateful because
without him this case report wouldn’t have taken its present shape.
This case report has gone through series of developments and corrections. There were
critical but constructive comments and relevants suggestions from the reviewers. Hopefully
the content will be useful for everyone in the future.
Medan, th November 2015
Presentator
3
TABLE OF CONTENTS
COVER ........................................................................................................... . i
ACKNOWLEDGMENT………………………………………………………ii
TABLE OF CONTENT ............................................................................... ..3
CHAPTER I INTRODUCTION ................................................................... .4
CHAPTER II LITERATURE REVIEW ...................................................... 6
2.1. Definition ....................................................................................6
2.2. Classification ............................................................................. 6
2.3. Etiology ....................................................................................... 7
2.4. Pathogenesis and Pathophysiology ……………………………. 9
2.5. Clinical Manifestation .................................................................13
2.6. Diagnosis ……….............................................................................13
2.7. Treatment and Management ……………………………………...14
2.8. Complications ................................................................................ 15
CHAPTER III CASE REPORT .................................................................... .16
3.1 Objective ......................................................................................... 16
3.2 Case ..................................................................................................16
3.3 Follow Up ...................................................................................... . .22
CHAPTER IV DISCUSSION ....................................................................... ...30
CHAPTER V SUMMARY ............................................................................ .. 31
REFERENCES ............................................................................................32
4
CHAPTER 1
1.1. Introduction
Each year, pneumonia kills more than 4 million people and causes illness
in millions more around the world. In developed countries, pneumonia primarily
affects elderly persons. However, half of pneumonia-related deaths worldwide
actually occur among children under age five – most of whom live in developing
countries. For every child that dies from pneumonia in developed countries, more
than 2,000 children die from pneumonia in developing countries.9
Data from the World Health Organization confirm that acute respiratory
illness remains a leading cause of childhood mortality, causing an estimated 1.6–
2.2 million deaths globally in children < 5 years.14,15 In North America the annual
incidence in children younger than 5 years of age is 34–40 cases per 1000.11
In the UK, from 750 children assessed in hospital, incidence of CAP was
14·4/10 000 children per year and 33·8 for <5-year-olds; with an incidence for
admission to hospital of 12·2 and 28·7 respectively. Risk of severe CAP was
significantly increased for those aged <5 years and with prematurity.4
In Indonesia, Pneumonia is the 2nd most common cause of death in
children after diarrhea (15,5%). A 2007 study conducted by the Indonesia
Ministry of Health shows that 30.470 children died from pneumonia that year,
which is equal to 83 children in a day.10 Pneumonia is also listed as the third cause
to cause the fatality among children besides the cardiovascular diseases and
tuberculosis.
About 27.6% of death among babies and 22.8% in children is observed in
Indonesia due to respiratory disease, especially pneumonia. In RSUD Dr.
Soetomo located in Surabaya, pneumonia is listed at fourth among the ten most
treated diseases in a year. Mortality rate in children those who are admitted in the
hospital are estimated around 20-35%.8,10
5
According to the WHO publication, the research done in different
countries shows that S.pneumoniae and H.influenza are the most common bacteria
found in the developing countries which is 73% found from pulmonary aspiration
and 69.1% are from blood specimen.6
1.2 Objective
This paper is one of the requirements to fulfill the senior clinical assistance
programs in the Pediatric Department of Haji Adam Malik General Hospital,
University of Sumatera Utara. This paper was written to report a case of a 5
months old girl with the diagnosis of Bronchopneumonia.
6
CHAPTER 2
LITERATURE REVIEW
2.1. Definition
Pneumonia defines where it is an infection that inflames the air sacs in one or both
lungs. The air sacs filled with fluid or pus, causing cough with phlegm, fever,
chills and difficulty in breathing. Clinically, pneumonia is defined as an inflamed
lung which caused by microorganisms (bacteria, virus, fungal and parasite),
prolonged exposure to chemicals and radiations, aspiration, drugs and others.1
Bronchopneumonia is the inflammation at the respiratory tract which starts from
bronchus until the alveoli. The tract is blocked by mucopurulent exudates that
forms patch consolidation at the nearest lobules. This condition is always
secondary which always joins the upper respiratory tract infection, followed by
fever caused by infection, diseases that causes immunosuppression.5
Anatomically, pneumonia are divided into three categories:
1. Lobar pneumonia
2. Interstitial pneumonia (bronchiolitis)
3. Lobular pneumonia (bronchopneumonia)
2.2. Classification
WHO provide guidelines on classification of pneumonia according to the age
which as follows:8,16
1. Age < 2 months
a. Severe pneumonia
- Chest indrawing (subcostal retraction)
- Tachypnea (> 60x/minutes)
b. Very Severe Pneumonia
- Poorly fed
- Seizures
- Loss of conscious
7
- Hyperthermia/ hypothermia
- Bradypnea
2. Age 2 months – 5 years
a. Mild pneumonia
- Tachypnea (> 60x/minutes)
b. Severe pneumonia
- Chest indrawing (subcostal retraction)
- Tachypnea
>50x/minute for children age from 2 months – 1 year
>40x/minute for children age from >1-5 years
c. Very Severe Pneumonia
- Poorly fed
- Seizures
- Loss of conscious
- Malnutrition
2.3 ETIOLOGY
The etiology of pneumonia differs between children and adults. Because of
this, age plays a very important role in determining the cause of pneumonia in
children.17
Table 1.The etiology of pneumonia based on Age17
Age Common Etiology Less common Etiology
Born- 20 days Bacteria
E. Coli
Group B Streptococcus
Listeria monocytogenes
Bacteria
Anaerobic bacteria
Haemophilus influenza
Streptococcus pneumonia
Virus
CMV
Herpes Simpleks Virus
8
3 weeks-3 months Bacteria
Chlamydia trachomatis
Streptococcus pneumonia
Virus
Respiratory Synctial
Virus
Adeno Virus
Influenza Virus
Bacteria
Bordetella pertussis
Haemophillus influenza
type B
Staphylococcus aureus
Virus
CMV
4 months- 5 years Bacteria
Chlamydia pneumonia
Mycoplasma pneumonia
Streptococcus pneumonia
Virus
Adeno Virus
Influenza Virus
RinoVirus
Parainfluenza Virus
Respiratory Synctial
Virus
Bacteria
Haemophillus influenza
type B
Staphylococcus aureus
Neisseria meningitidis
Virus
Varicella-Zoster virus
6 years-teenagers Bacteria
Chlamydia pneumonia
Mycoplasma pneumonia
Streptococcus pneumonia
Bacteria
Haemophillus influenza
Staphylococcus aureus
Virus
Adeno Virus
Influenza Virus
RinoVirus
Parainfluenza Virus
Respiratory Synctial
Virus
Varicella-zoster Virus
9
There are several known risk factors for CAP to consider in addition to
immunization status, exposure to other children, especially preschoolers, asthma,
history of wheezing episodes, tobacco smoke exposure, malnutrition,
immunological deficits, mucocilliary dysfunction (cystic fibrosis, cilliary
dyskinesia), congenital malformation of airways, impaired swallowing. 2 Tobacco
smoke exposure has been found to increase risk of hospitalization for pneumonia
in children < 5. Conditions predisposing to severe pneumonia include age <5 and
prematurity.12
2.4. Pathogenesis and pathophysiology3
An inhaled infectious organism must bypass the host's normal nonimmune
and immune defense mechanisms in order to cause pneumonia. The nonimmune
mechanisms include aerodynamic filtering of inhaled particles based on size,
shape, and electrostatic charges; the cough reflex; mucociliary clearance; and
several secreted substances (eg,lysozymes, complement, defensins). Macrophages,
neutrophils, lymphocytes, and eosinophils carry out the immune-mediated host
defense.
Pneumonia is characterized by inflammation of the alveoli and terminal
airspaces in response to invasion by an infectious agent introduced into the lungs
through hematogenous spread or inhalation. The inflammatory cascade triggers
the leakage of plasma and the loss of surfactant, resulting in air loss and
consolidation.
The activated inflammatory response often results in targeted migration of
phagocytes, with the release of toxic substances from granules and other
microbicidal packages and the initiation of poorly regulated cascades (eg,
complement, coagulation, cytokines). These cascades may directly injure host
tissues and adversely alter endothelial and epithelial integrity, vasomotor tone,
intravascular hemostasis, and the activation state of fixed and migratory
phagocytes at the inflammatory focus. The role of apoptosis (noninflammatory
programmed cell death) in pneumonia is poorly understood.
Pulmonary injuries are caused directly and/or indirectly by invading
microorganisms or foreign material and by poorly targeted or inappropriate
10
responses by the host defense system that may damage healthy host tissues as
badly or worse than the invading agent. Direct injury by the invading agent
usually results from synthesis and secretion of microbial enzymes, proteins, toxic
lipids, and toxins that disrupt host cell membranes, metabolic machinery, and the
extracellular matrix that usually inhibits microbial migration.
Indirect injury is mediated by structural or secreted molecules, such as
endotoxin, leukocidin, and toxic shock syndrome toxin-1 (TSST-1), which may
alter local vasomotor tone and integrity, change the characteristics of the tissue
perfusate, and generally interfere with the delivery of oxygen and nutrients and
removal of waste products from local tissues.
On a macroscopic level, the invading agents and the host defenses both
tend to increase airway smooth muscle tone and resistance, mucus secretion, and
the presence of inflammatory cells and debris in these secretions. These materials
may further increase airway resistance and obstruct the airways, partially or
totally, causing airtrapping, atelectasis, and ventilatory dead space. In addition,
disruption of endothelial and alveolar epithelial integrity may allow surfactant to
be inactivated by proteinaceous exudate, a process that may be exacerbated
further by the direct effects of meconium or pathogenic microorganisms.
In the end, conducting airways offer much more resistance and may
become obstructed, alveoli may be atelectatic or hyperexpanded, alveolar
perfusion may be markedly altered, and multiple tissues and cell populations in
the lung and elsewhere sustain injury that increases the basal requirements for
oxygen uptake and excretory gas removal at a time when the lungs are less able to
accomplish these tasks.
The stages of pneumonia consists of 4 which as follows:13
Pneumonia has four stages, namely consolidation, red hepatization, grey
hepatization and resolution.
Consolidation
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o Occurs in the first 24 hours
o Cellular exudates containing neutrophils, lymphocytes and fibrin replaces the
alveolar air
o Capillaries in the surrounding alveolar walls become congested
o The infections spreads to the hilum and pleura fairly rapidly
o Pleurisy occurs
o Marked by coughing and deep breathing
Red Hepatization
o Occurs in the 2-3 days after consolidation
o At this point the consistency of the lungs resembles that of the liver
o The lungs become hyperemic
o Alveolar capillaries are engorged with blood
o Fibrinous exudates fill the alveoli
o This stage is characterized by the presence of many erythrocytes, neutrophils,
desquamated epithelial cells, and fibrin within the alveoli
Grey Hepatization
o Occurs in the 2-3 days after Red Hepatization
o This is an avascular stage
o The lung appears gray-brown to yellow because of fibrinopurulent exudates,
disintegration of red cells, and hemosiderin
o The pressure of the exudates in the alveoli causes compression of the capillaries
o Leukocytes migrate into the congested alveoli
12
Resolution
o This stage is characterized by the resorption and restoration of the pulmonary
architecture
o A large number of macrophages enter the alveolar spaces
o Phagocytosis of the bacteria-laden leucocytes occurs
o Consolidation tissue re-aerates and the fluid infiltrate causes sputum
o Fibrinous inflammation may extend to and across the pleural space, causing a rub
heard by auscultation, and it may lead to resolution or to organization and pleural
adhesions
2.5. Clinical Manifestation
Signs and symptoms can vary depending on causing pathogen, patients’ age and
immunologic status and the severity of the disease.1,8
Prodromal symptoms:
1. High fever followed by shivering
2. Headache
3. Uncomfortable
Gastrointestinal disturbances:
1. Vomiting
2. Bloating
3. Diarrhea
4. Stomachache
Pulmonary Symptoms:
1. Nasal Flaring
2. Tachypnea
3. Dyspnea
4. Apnea
5. Usage of respiratory accessory muscles (Intercostal and Abdominal)
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6. Cough
7. Retraction of subcostal during inspiration followed by tachypnea
8. Dull Percussion
9. Fremitus Sound Weakens
10. Rales
Respiratory rate is the most sensitive index to measure the severity of the disease.
It is used to support the diagnosis and monitor the management. Respiratory rate
is measured while the child is calm or asleep.
WHO has provide the criteria to measure tachypnea according to age which a
follows:8
< 2 months : ≥ 60x/minute
2 months – 1 year : ≥ 50x/minute
1-5 years : ≥ 40x/minute
2.6. Diagnosis
1. AnamnesisThe symptoms can occur suddenly but also can be started by the upper respiratory
tract infection. The other symptoms are cough, high continuous fever, and
dyspnea, bluish around the lips, shivering, seizures and chest pain. Normally
children tend to lie down on the pain side.15,17
2. Physical Diagnostics
Tachypnea, chest retraction, grunting, and cyanosis often found on neonate. At the
older babies, grunting is seldom discovered. The symptoms that often discovered
are tachypnea, retraction, cyanosis, cough, fever and irritability.
In preschool children, fever, productive or non-productive cough, tachypnea, and
dyspnea often found on them.17
Typical findings on physical examinations include:
- dullness on percussion of the chest
- decreased breath sounds
- additional breath sounds such as ronchi and wheeze
14
3. Laboratory Diagnostics
Blood studies on pneumonia often shows that leukocytosis (>15 000/mm3).9,13
4. Supporting Investigation:
a. Radiology
Chest x-ray is the main supporting diagnostics to define the diagnosis. On babies,
infiltrate often found on their chest x-ray. In bronchopneumonia, patchy infiltrates
are discovered in one or few lobules. If it is a diffuse then it is often caused by
Staphylococcus pneumonia.17
b. C-Reactive protein
c. Serologic test
d. Microbiology test
Diagnostics Criteria
Pneumonia can be confirmed if there are 3 of out 5 symptoms found, which as
follows:
a. dyspnea followed by nasal flaring dan retraction of chest wall during breathing
b. high fever
c. crackles caused by rales
d. chest x-ray that shows diffuse infiltrate
e. leukocytosis
2.7. Treatment & Management
The treatment of pneumonia in children consists of appropriate antibiotics
for the offending organisms, supportive treatment such as oxygen, iv fluid and
the correction of acid base disorder17.
a. Outpatient settings
The first line antibiotic for outpatient settings is Amoxicillin 20 mg/kg
or Cotrimoxazole (4mg/kg of Trimetoprim and 20 mg/kg of
Sulfamethoxazole)
b. Inpatient settings
15
The first line antibiotics for inpatient settings is Beta Lactamase group
or Chloramphenicol.
Antibiotic is administered for 7-10 days. Antibiotic must be given as
soon as possible in neonates. Broad spectrum antibiotics such as the
Beta Lactamase group or third generation of cephalosporine are
recommended. Upon stabilization, iv antibiotics can be switched to
oral antibiotics and patients can be treated in the outpatient settings.
2.8. Complications
Complication often happen when there are dispersion of bacteria in thoracic
region which cause such as pleural effusion, empyema, pericarditis.
16
CHAPTER III
CASE REPORT
3.1 ObjectiveThe objective of this paper is to report a case of a 11 month old boy with a
diagnosis of bronchopneumonia.
3.2 CaseAS, a 11 month old boy, with 6,5 kg of BW and 66 cm of BH, came to Haji Adam
Malik General Hospital Medan on 12th November at 22.30. His chief complaint
was shortness of breath.
History of disease:
AS, a 11 month old boy, with 6,5 kg of BW and 66 cm of BH, came to Haji Adam
Malik General Hospital Medan on 12th November at 22.30 with shortness of
breath as chief complaint. The patients have been experienced this about 1 week
before admitted to hospital. Dyspnea was not directed with weather and activity.
Cyanosis (-), patient also experienced cough since 2 weeks ago followed by spu-
tum. History of contact with adult cough (-). Fever has been experienced by
patient since 2 weeks and the body temperature rises and drop. Shivering was not
found. Vomiting (-) and nausea (-). Defecation and urination is normal. History of
weight loose is not found.
History of medication:
O2, IVFD ringer lactate, nebule ventolin, inj meropenem, triamsinolon, bromhex-
ine an salbutamol
History of family:
There is no famiy history of similar disease found.
17
History of parent’s medication:
Not found
History of pregnancy:
Patient’s mother was 31 years old during pregnancy. She regularly goes for con-
trol. No history of complication neonate and maternal problem. Consumtion of
herbal medication (-)
History of birth:
Patient was first child. Gestational age was preterm (28 weeks). Body weight was
1200 gram, body length was not measured. Birth was assisted by traditional
midwife. Baby was born normally and cried spontaneously. Blusih was not found.
History of immunization:
Not complete
History of growth and development:
Patient’s mother explained that he grew normally. He was able to crawl and sit
appropriately based on his age.
Physical Examination:
Present status:
Sensorium : CM, body temperature: 37,6°C, HR: 138 bpm, RR: 54 x/i, BW: 6,5
kg, BH: 66 cm, BW/A: Z score < -3 , BL/A: Z score < -3, BW/BL: -1< Z score <
-2, anemic (-), icteric (-), dyspnea (+), cyanosis (-), edema (-).
Localized status:Head : Face: within normal range
Eyes: light reflex +/+, isochoric pupil, pale inferior palpebral conjuntiva -/-, superior and inferior palpebra edema-/-
Ears: within normal range
Nose: nasal flaring
18
Mouth : within normal range
Neck : Lymph node enlargement (-)
Thorax : Symmetrical fusiform, retraction intercostal and epigastric (+)
HR: 138 bpm, regular, murmur (-)
RR: 54x/i, regular, rales (+/+), wheezing (-/-)
Abdomen : Symmetric, supple, normal peristaltic, liver and spleen: normal
Extremities : Pulse 138 bpm regular, adequate p/v, felt warm, CRT < 3”
Working diagnosis : DD - bronchopneumonia
- bronchiolitis
Laboratory finding
Complete blood analysis (12th November 2015 / 23.03)Test Result Unit References
Hemoglobin 9.20 g% 11.3-14.1
Erythrocyte 3.51 106/mm3 4.40-4.48
Leucocyte 19.74 103/mm3 6.0-17.5
Thrombocyte 263 103/mm3 217-497
Hematocrite 28.70 % 37-41
Eosinophil 0.50 % 1-6
Basophil 0.500 % 0-1
Neutrophil 51.00 % 37-80
Lymphocyte 39.90 % 20-40
Monocyte 8.10 % 2-8
Neutrophil absolute 10.08 103/µL 1.9-5.4
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Lymphocyte
absolute
7.88 103/µL 3.7-10.7
Monocyte absolute 1.59 103/µL 0.3-0.8
Eosinophil absolute 0.09 103/µL 0.20-0.50
Basophil absolute 0.10 103/µL 0-0.1
MCV 81.80 Fl 81-95
MCH 26.20 Pg 25-29
MCHC 32.10 g% 29-31
Clinical chemistry (12 November 2015 / 23.03)
Test Result Unit References
Blood Glucose 71.70 mg/Dl 40-60
Ureum 14.70 mg/dL < 50
Creatinine 0.23 mg/dL 0.17-0.41
Natrium 136 mEq/L 135-155
Potassium 5.3 mEq/L 3.6-5.5
Chloride 100 mEq/L 96–106
Procalcitonin 0.42 ng/mL <0.05
Blood gas analysis (12 November 2015 / 23.03)
20
pH 7.155 7.35-7.45
pCO2 38.7 mmHg 38-42
pO2 177.5 mmHg 85-100
Bicarbonate (HCO3) 13.4 mmol/L 2-26
Total CO2 14.5 mmol/L 19-25
Base Excess (BE) -14.5 mmol/L (-2) – (+2)
O2 Saturation 98.8 % 95-100
Result of Radiology examination
- Both of sinus costophrenicus are sharp. Diafragma is smooth
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- Infiltrate on suprahilar, perihiler, dan parakardial paru bilateral- No cardiomegaly (CTR 45%)- Trachea in middle- Bones and soft tissue normal
Conclusion : Bronkopneumonia bilateral
Therapy:
O2 1-2 L/ min via nasal cannula
IVFD D5% NaCl 0,225% 25 gtt/menit (micro)
Fluid challenge 10 cc/kgBB (65 cc)
Inj Ceftriaxone 300 mg/ 12 hours /iv
Paracetamol syrup 3x cth 1/2
Follow Up
13th Novemember 2015
S Dyspnea(+)
O Sensorium: CM, Temp: 37,2°C, BW: 6,5 kg, BH: 66 cm
Head : Fontanella Major was closed
- Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-), sclera icteric (-/-)
- Ear : within normal range- Nose : nasal flaring- Mouth : within normal range
Neck : lymph node enlargement (-)
Thorax : symmetrical fusiform, retraction (+) intercostal, epigastric
- HR: 140 bpm, regular, murmur (-)- RR : 52x/i, regular, ronchi (+/+), wheezing(-/-)- Abdomen : supple, peristaltic (+)N, Liver and Spleen: no palpable- Extremities : pulse 140 bpm, regular, adequate p/v , felt warm,
CRT < 3”A DD/Bronchopneumonia
Bronchiolitis
P O2 1 L/min nasal canule
IVFD D5% NaCl 0,225 % 25gtt/i (micro)
22
Paracetamol 3x 75 mg
Inj Ampicilin 160 mg/6h
Inj Gentamycin 40 mg/24h
Nebule Ventolin 1 respul+ NaCl ,9 % /6h
Meylon 28 mEq, ½ dosis I: 14 mEq meylon in 100cc D5% in 4 hours
Diet Sv 650 kkal and 13 gr protein
At 22.30
S dyspnea ↑↑, fever (+)
O Sensorium: GCS 13 (E4, V3, M6) , T= 38,8 °C
Thorax: Simetris Fusiformis, retraksi (+) epigastrial
HR: 165x/i, reg, murmur (-)
RR: 65x/i, reg, stridor (+), ronchi (+)
P Nebule Ventolin 1 respul+ NaCl 0,9% / 8h
R Check blood gas analysis, Check electrolite post correction
Advise from dr. Wisman Dalimunthe, SpA
- Mucolitic :GE 3 x ½ tab (pulv)- Analgetic Paracetamol: 4 x 10 mg (pulv)
Blood gas analysis (13 November 2015 / 20.59)
pH 7.427 7.35-7.45
pCO2 27.9 mmHg 38-42
pO2 165.0 mmHg 85-100
Bicarbonate (HCO3) 18.0 mmol/L 2-26
Total CO2 18.9 mmol/L 19-25
Base Excess (BE) -5.5 mmol/L (-2) – (+2)
O2 Saturation 99.4 % 95-100
23
Carbohydrate Metabolism
Blood Glucose ad
random
108.3 mg/dL 40-60
Electrolyte
Calsium 8.0 mg/dL 8.4-10.4
Natrium 135 mEq/L 135-155
Potassium 4.8 mEq/L 3.6-5.5
Chloride 102 mEq/L 96–106
Clinical Chemistry
Liver Function Test
Fosfatase Alkalase (ALP) 148 U/L <4,62
AST/SGOT 46 U/L <38
ALT/SGPT 22 U/L <41
Renal Function Test
Ureum 11,6 mg/dL <50
Creatinin 0,22 mg/dL 0.17-0,42
24
Immunoserology
Autoimmune (CRP Kuantitatif) 5,6 mg/dL
Other Test (Procalcitonin) 0.17 ng/mL <0,05
14th Novemember 2015
S dyspnea (+)
O Sensorium: CM, Temp: 37°C, BW: 6,5 kg, BH: 66 cm
Head : Fontanella Major was closed
- Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-), sclera icteric (-/-)
- Ear : within normal range- Nose : nasal flaring- Mouth : within normal range
Neck : lymph node enlargement (-)
Thorax : symmetrical fusiform, retraction (+) intercostal, epigastric
- HR: 140 bpm, regular, murmur (-)- RR : 50x/i, regular, ronchi (+/+), wheezing(-/-)- Abdomen : supple, peristaltic (+)N, Liver and Spleen: no palpable- Extremities : pulse 140 bpm, regular, adequate p/v , felt warm,
CRT < 3”A DD/Bronchopneumonia
Bronchiolitis
P O2 1 L/min nasal canule
IVFD D5% NaCl 0,225 % 25gtt/i (micro)
Paracetamol 3x 75 mg
Inj Ampicilin 160 mg/6 jam/iv
Inj Gentamycin 40 mg/24 jam/iv
Inj Dexametason 2,5 mg/8 jam/iv
Nebule Ventolin 1 respul+ NaCl ,9 % /8 jam
Diet Sv 650 kkal dengan 13 gr protein
25
15th Novemember 2015
S Shortness of breath (+)
O Sensorium: CM, Temp: 37,1°C, BW: 6,5 kg, BH: 66 cm
Head : Fontanella Mayor was closed
- Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-), sclera icteric (-/-)
- Ear : within normal range- Nose : nasal flaring- Mouth : within normal range
Neck : lymph node enlargement(-)
Thorax : symmetrical fusiform, retraction (+) intercostal, epigastric
- HR: 138 bpm, regular, murmur (-)- RR : 46x/i, regular, ronchi (+/+), wheezing(-/-)- Abdomen : supple, peristaltic (+)N, Liver and Spleen: no palpable- Extremities : pulse 138 bpm, regular, adequate p/v , felt warm,
CRT < 3”A DD/Bronchopneumonia
Bronchiolitis
P O2 1 L/min nasal canule
IVFD D5% NaCl 0,225 % 25gtt/i (micro)
Paracetamol 3x 75 mg
Inj Ampicilin 160 mg/6h
Inj Gentamycin 40 mg/24h
Inj Dexametason 2,5 mg/8h/iv
Inj Aminophylline MD 1 cc/12 jam/iv diluted in 5 cc NaCl 0,9 % bolus
slowly
Nebule Ventolin 1 respul+ NaCl ,9 % /6h
16thNovemember 2015
S Shortness of breath (+) ↓↓
O Sensorium: CM, Temp: 37°C, BW: 6,5 kg, BH: 66 cm
Head : Fontanella mayor was closed
26
- Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-), sclera icteric (-/-)
- Ear : within normal range- Nose : nasal flaring- Mouth : within normal range
Neck : lymph node enlargement(-)
Thorax : symmetrical fusiform, retraction (+) intercostal, epigastric
- HR: 120 bpm, regular, murmur (-)- RR : 40x/i, regular, ronchi (+/+), wheezing(-/-)- Abdomen : supple, peristaltic (+)N, Liver and Spleen: no palpable- Extremities : pulse 138 bpm, regular, adequate p/v , felt warm,
CRT < 3”A DD/Bronchopneumonia
Bronchiolitis
P O2 1 L/min nasal canule
IVFD D5% NaCl 0,225 % 25gtt/i (micro)
Inj Ampicilin 160 mg/6h
Inj Gentamycin 40 mg/24h
Inj Dexametason 2,5 mg/8h/iv
Inj Aminophylline MD 1 cc/12 jam/iv diluted in 5 cc NaCl 0,9 % bolus
slowly
Paracetamol 75 mg (if needed)
GE 3x ½ tab
Advise from dr. Wisman Dalimunthe, SpA
- Aff NGT- Consul for Cardiology Division (echocardiography)- Tappering off Inj dexamethasone
17th Novemember 2015
S Shortness of breath (+) ↓↓
O Sensorium: CM, Temp: 37°C, BW: 6,5 kg, BH: 66 cm
Head : Fontanella Mayor was closed
- Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-), sclera icteric (-/-)
27
- Ear : within normal range- Nose : within normal range- Mouth : within normal range
Neck : lymph node enlargement(-)
Thorax : symmetrical fusiform, retraction (+) intercostal, epigastric
- HR: 118 bpm, regular, murmur (-)- RR : 35x/i, regular, ronchi (+/+), wheezing(-/-)- Abdomen : supple, peristaltic (+)N, Liver and Spleen: no palpable- Extremities : pulse 118 bpm, regular, adequate p/v , felt warm,
CRT < 3”A DD/Bronchopneumonia
Bronchiolitis
P O2 1 L/min nasal canule (intermitten)
IVFD D5% NaCl 0,225 % 25gtt/i (micro)
Inj Ampicilin 160 mg/6h/iv
Inj Gentamycin 40 mg/24h/iv
Inj Dexametason 2mg/12h/iv (tapering off)
Inj Aminophylline (MD) 1 cc/12 jam/iv diluted in 5 cc NaCl 0,9 % bolus
pelan
Paracetamol 75 mg (if needed)
Nebule Ventolin 1 respul+ NaCl ,9 % /8h
18th Novemember 2015
S Dyspnea (-)
O Sensorium: CM, Temp: 37°C, BW: 6,5 kg, BH: 66 cm
Head : Fontanella Mayor was closed
- Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-), sclera icteric (-/-)
- Ear : within normal range- Nose : within normal range- Mouth : within normal range
Neck : lymph node enlargement(-)
Thorax : symmetrical fusiform, retraction (-)
28
- HR: 118 bpm, regular, murmur (-)- RR : 35x/i, regular, ronchi (+/+), wheezing(-/-)- Abdomen : supple, peristaltic (+)N, Liver and Spleen: no palpable- Extremities : pulse 118 bpm, regular, adequate p/v , felt warm,
CRT < 3”A DD/Bronchopneumonia
Bronchiolitis
P IVFD D5% NaCl 0,225 % 25gtt/i (micro)
Inj Ampicilin 160 mg/6h/iv
Inj Gentamycin 40 mg/24h/iv
Inj Dexametason 2mg/12h/iv (tapering off)
Inj Aminophylline (MD) 1 cc/12h /iv diluted in 5 cc NaCl 0,9 % bolus
slowly
Paracetamol 75 mg (if needed)
Nebule Ventolin 1 respul+ NaCl ,9 % /8h
19th Novemember 2015
S dyspnea (-)
O Sensorium: CM, Temp: 37°C, BW: 6,5 kg, BH: 66 cm
Head : Fontanella Mayor was closed
- Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-), sclera icteric (-/-)
- Ear : within normal range- Nose : within normal range- Mouth : within normal range
Neck : lymph node enlargement(-)
Thorax : symmetrical fusiform, retraction (-)
- HR: 116 bpm, regular, murmur (-)- RR : 22x/i, regular, ronchi (+/+), wheezing(-/-)- Abdomen : supple, peristaltic (+)N, Liver and Spleen: no palpable- Extremities : pulse 110 bpm, regular, adequate p/v , felt warm,
CRT < 3”A Bronchopneumonia
29
P IVFD D5% NaCl 0,225 % 25gtt/i (micro)
Inj Ampicilin 160 mg/6h/iv
Inj Gentamycin 40 mg/24h/iv
Paracetamol 75 mg (if needed)
Nebule Ventolin 1 respul+ NaCl ,9 % /8h
CHAPTER IV
DISCUSSION
30
Case Theory
Patient was admitted to the hospital with complaints such as : Dyspnea Cough followed sputum fever Diarrhea Weight Lost Nasal Flaring Epigastric retraction
Signs and symptoms can vary depending on causing pathogen, patients’ age and immunologic status and the severity of the disease.Prodromal symptoms:1. High fever followed by shivering2. Headache3. Uncomfortable
Gastrointestinal disturbances:1. Vomiting2. Bloating3. Diarrhea4. Stomachache
Pulmonary Symptoms:1. Nasal Flaring2. Epigastric retraction
Blood studies on pneumonia often shows leukocytosis (>15 000/mm3).Chest x-ray is the main supporting diagnostics to define the diagnosis. On babies, infiltrate often found on their chest x-ray. In bronchopneumonia, patchy infiltrates are discovered in one or few lobules
In this case, patient’s complete blood study shows leukocytosis and the chest X-ray supports the diagnosis
The management of pneumonia patients includes supportive therapy and etiologic therapy.1. Oxygen supply 1-2L/minute. 2. Adequate supply of fluid and nutrition.3. Correction of electrolyte or metabolic imbalance that occurs4. Antibiotics:Ampicilin and gentamycin5. Inhalant therapy: Nebule Ventolin
The patient is treated with oxygen supply, fluid and nutrition supply, antibiotic (eg Beta Lactamase Group), and nebulizer to remove the mucus from the lungs.
CHAPTER V
SUMMARY
31
AS, a 11 month old boy, with 6,5 kg of BW and 66 cm of BH, came to Haji Adam
Malik General Hospital Medan on 12th November at 22.30. His chief complaint
was dyspnea. Patient was diagnosed as bronchopneumonia which confirmed with
clinical manifestasion (fever, shortness of breath, cough) and chest X-ray. Patient
was treated with paracetamol, ampicilin, gentamycin, ventolin, meylon and
aminophylline (MD). Patient is discharged from hospital on 19 November 20015
after patient condition was stable.
32
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