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i Case Report BRONCHOPNEUMONIA SUPERVISOR : dr. Rina A. C. Saragih, M. Ked (Ped), Sp. A PRESENTATOR : Theodora Purba 110100267 Anusha Chandra Sikaran 110100414

Bronkopneumonia(Theodora and Anusha)

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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

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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

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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

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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.

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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

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- 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

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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

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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

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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

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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

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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

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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.

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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.

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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

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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)

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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)

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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

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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

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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

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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

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- 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 (-/-)

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- 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 (-)

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- 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

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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

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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

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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.

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