Case BP Dr Tisna

7/31/2019 Case BP Dr Tisna

1/41

Click to edit Master subtitle style7/24/12

Bed Side teaching

BRONCHOPNEUMONIA

Presented by :Yudi Agustinus (0710195)

Counselor :

H. Tisna Sukarna., dr., SpA., MBA, M.Kom


2/41

7/24/12

Patient Identification

Name : L

Age : 1 year 10 months

Sex : Female

Consignment from : ER

Date of hospitalized : June, 4th 2012

Date of examination : June, 5th 2012


3/41

7/24/12

Anamnesis

Heteroanamnesis was given by herparents on June, 5th 2012

Chief complaint : fever

History of present illness :Since 6 days before hospitalization,

patient developed fever, it occurred

slowly and no sudden onset of ever, noexact time of feverish condition, herparents complained theres an increasedtemperature during the evening and

lower temperature during the afternoon.


4/41

7/24/12

The complaint accompanied by coughingsince 3 days ago, with a lot of clearmucus and infrequent, sometimes

containing food (vomiting). The patientsparents also complained aboutheadache and epigastrial tenderness.

The weight of the child is said to have

dropped 1 kg during sickness with adecreased appetite. Any history of bloodcough, vomiting, diarrhea and difficultyof breathing were denied. Any history ofepistaxis and gum bleeding were denied


5/41

7/24/12

Mictie : the color is yellow; there is noblood, normal in frequency and volume,with no pain.

Defecate : difficulty in defecating since1 day before, mushy in consistency,normal colour, frequency and volume inlast defecation.

Habits : her parents denied any badhabits of giving foods to the patientrecklessly and stated that the higienity of

the foods in home was alwaysmaintained


6/41

7/24/12

Record of family health: her parentscomplained about coughing since 3 dayswith no fever.

Medical effort : One day after the feveroccurred, the patient was brought to ahealth centre and was given 2 kinds ofdrugs (antibiotic was claimed to be one

of them-the patients parents forgot thebrands). 2 days later, the patient thenbrought to a GP and was given 3 kinds of

drugs (the patients parents forgot thebrands but after no si nificant


7/41

7/24/12

Birth History

The patient is the 1st child from 1 child.No stillbirth and no abortion.

Birth: aterm, spontaneous, directly cryand helped by an obstetrician.

Birth weight: 2900 grams. Birth length:

47 cm


8/41

7/24/12

Immunizations

Vaccine Basic Vaccination

Booster VaccinationRecommended

Vaccination

BCG + (scar + ) - - - HiB : none

Polio + + + - - - MMR : none

DPT + + + - - - Hep A : none

Hep B + + + - - - Varicella : none

Measles + - - - Typhim/typha : none

Influenzae : none


9/41

7/24/12

Nutrition and Feeding


10/41

7/24/12

Physical Examination

(June, 5th 2012)

General appearance

Condition : Moderate sickness

Consciousness : compos mentis

Activity and position : no force position

General condition : weak


11/41

7/24/12

Vital signs

Pulse : 120 times per minute,regular, equal, strong (N:70x-

110x/minute) Respiration : 30 times per minute (N:


12/41

7/24/12

Measuring

Age : 1 year 10 months old

Weight : 10 kg

Height : 82 cm

Nutrition status :

- Weight for age (z score) : below -1 :Normal

- Height for age (z score) : Normal- Weight for height (z score) : Normal


13/41

7/24/12

Systematic examinationsSkin : icteric - , pale -, cyanosis -

Head Hair : black, disseminated, not easy

to yanked out

Eyes : conjunctiva anemic -/-,sclera icteric -/-, subconjunctivalbleeding -/-

Nose : nasal flare -/-, secretes -/-

epistaksis -/- Ears : symetric, left was equal to

right, no discharge

Lips : dry -, anemic -, cyanosis -,-


14/41

7/24/12

NeckNuchal rigidity :

Lymph node : not palpableThorax

Lungs

Inspection : symmetrical shape, right= left, retractions (-)

Palpation : vocal fremitus right =

left, symmetrical movement Percussion : dullness (-)

Auscultation : VBS +/+, coarse

crackles +/+ in most part of the


15/41

7/24/12

Abdomen:

Inspections : flat

Auscultations : bowel sound (+) normal

Percussions : tympanic, Traubes space:tympanic

Palpations : soepel, tenderness (-)

Liver palpable 1,5 cm BAC & 1 cmBPX

Spleen impalpable

Kidney impalpable


16/41

7/24/12

Genital : Female, normal

Anus & Rectal : (+), normal

Extremities : no disparity

Upper : left: active, right: active

Lower: left: active, right: active

Joint : no disparity Muscle : normal tonus

Reflex : physiological +/+,

pathological -/-


17/41

7/24/12

a ora ory n ng(Biotest)

4/6/2012

Hb : 14.5 g/dl

Ht : 43%

Leucocyte:

6300/mm3Trombocyte:

156000/mm3

MCV: 80.1 fl MCH: 27.3 pg/dl

MCHC: 34,0 g/dl

Diff. count:

Widal slide test

S. typhi O: 40 *

S. typhi H: non-reactive

S. paratyphi AO:non-reactive

S. paratyphi AH:

non-reactive S. paratyphi BO:

non-reactive

S. paratyphi BH:

non-reactive


18/41

7/24/12

Radiology Finding5/6/2012


19/41

7/24/12

Expertise :

Normal air column inside trachea.Normal aorta. No cardiac enlargement.

Normal sinuses and diaphragms. Pulmo: rugged hili. An increased

bronchovascular marking, with minimalsoft spot in right pericardial.

Normal clavicular costae dan soft tissue.

Impression: Right bronchopneumonia.


20/41

7/24/12

Resume

One year 10 months old girl, weight 10kg & height 82 cm, normal nutritionalstatus, moderate sickness and compos

mentis, came to Immanuel Hospital withfever as a chief complaint.

Fever (+) since 6 days ago, with anincreased temperature in the evening,

and would only be relieved when givenantipiretics. Coughing (+) since 3 daysago, lots of clear mucus, no blood,sometimes contains food (vomiting).Headache + , e i astrial tenderness


21/41

7/24/12

Mictie : normal. Defecate : difficulty indefecating since 1 day, before mushyconsistency for 5 days. No habits asreckless eating (-), homemade food (+).

Past & family medical history: Typhoidfever (patient), coughing (parents).Medical effort : First day of fever healthcentre, 2 days after GP, but theres nosignificant improvement, dr. Tisna, SpA

hospitalized in Immanuel Hospital.Physical examination: Vital signs,

pulse120x/min, regular, equal, strong;Res iration 30x min Tem erature 36 3 C


22/41

7/24/12

Physical examination

Skin icteric -, pale -, cyanosis -; Head:Nose: nasal flare -/-, secrets -/-, Lip:cyanotic (-), Tongue: wet, Oropharynx

normal. Thorax: no retractions, Lungs: VBS+/+, coarse crackles +/+ in most part ofthe thorax, slem +/+, no wheezing.Abdomen: Flat, bowel sound (+) normal,

soepel, tympanic, tenderness (-), liverpalpable and spleen not palpable, Traubesspace tympanic. Extremities: Normal;Neurological Examination : normal. In

Chest Radiography: Impression: Right


23/41

7/24/12

Diagnosis

Differential Diagnosis

Bronchopneumonia caused bybacterial infection

Bronchitis

Typhoid fever

Working diagnosis

Bronchopneumonia caused bybacterial infection


24/41

7/24/12

Suggested Further Studies

Blood: complete blood count (Hb, Ht, L,Tc)

Blood culture + sensitivity test

Blood isolate (virus) Widal test repeat

PPD test


25/41

7/24/12

Planning Therapy

Non Medicamentous

Bed Rest

Fluid : KaEN IB 1000cc for 24 hours

Diet : porridge

Medicamentous

Ambroxol syrup 15mg/5ml 3x1 teaspoon

Paracetamol syrup120mg/5ml,3x1teaspoon, prn (To >38.5oC)

Cefotaxime vial 0.5g 2x500mg IV


26/41

7/24/12

Prognosis

Quo ad vitam : ad bonam

Quo ad functionam : ad bonam


27/41

7/24/12

Discussion

The diagnosis of bronchopneumonia basedon :

Anamnesis :

Infrequent coughing with clear mucus Indetermined fever

Decreased appetite


28/41

7/24/12

Physical Verification :

Condition : moderate sickness

Thorax : coarse crackles +/+ in mostpart of the thorax, slem +/+

Radiology Findings (5/6/2012) Normal air column inside trachea.

Normal aorta. No cardiac enlargement.Normal sinuses and diaphragms.

Pulmo: rugged hili. An increasedbronchovascular marking, with minimalsoft spot in right pericardial.

Normal clavicular costae dan soft tissue.


29/41

7/24/12

REFERENCES


30/41

7/24/12

Bronchopneumonia

Introduction

Pneumonia is an inflammation of theparenchyma of the lungs

Most cases microorganisms, othercauses aspiration of food or gastricacid, foreign bodies, hydrocarbons, andlipoid substances, hypersensitivityreactions


31/41

7/24/12

Epidemiology

Pneumonia is a substantial cause ofmorbidity and mortality in childhood(particularly among children


32/41

7/24/12

Etiology

Using state-of-the-art diagnostictesting, a bacterial or viral cause ofpneumonia can be identified in 4080%

of children with community-acquiredpneumonia

Streptococcus pneumoniae(pneumococcus) is the most common

bacterial pathogen, followed byChlamydia pneumoniae and Mycoplasma

pneumoniae.


33/41

7/24/12

Pathophysiology

The lower respiratory tract sterile defense mechanisms (mucociliaryclearance, secretory IgA & coughing)

Immunologic defense mechanisms macrophages (alveoli and bronchioles),secretory IgA, and otherimmunoglobulins.

Viral pneumonia spread of infectionalong the airways + direct injury of therespiratory epithelium airway

obstruction (swelling, abnormal


34/41

7/24/12

Viral infection predispose tosecondary bacterial infection disturbing normal host defense , alteringsecretions & modifying the bacterial

flora Bacterial infection process :

- M. pneumoniae attaches torespiratory epithelium, inhibits ciliaryaction & leads to cellular destruction andan inflammatory response in thesubmucosa airway obstruction

- S. pneumoniae local edema


35/41

7/24/12

Clinical Features

Viral and bacterial pneumonias rhinitisand cough

Viral pneumonia fever (lower than

bacterial pneumonia), tachypnea,intercostal-subcostal-suprasternalretractions, nasal flaring, and use ofaccessory muscles

Auscultation crackles & wheezing(difficult to localize in very youngchildren)

Bacterial pneumonia shaking chill


36/41

7/24/12

consolidation or complications dullness on percussion & breath sounds(-)

Infants abrupt onset of fever,restlessness, apprehension, andrespiratory distress (grunting; nasalflaring; retractions of the

supraclavicular, intercostal, andsubcostal areas; tachypnea; tachycardia;air hunger and often cyanosis)

Some infants with bacterial pneumonia


37/41

7/24/12

Diagnosis

The chest radiograph confirms thediagnosis of pneumonia and mayindicate a complication such as a pleural

effusion or empyema Viral pneumonia hyperinflation with

bilateral interstitial infiltrates andperibronchial cuffing

Confluent lobar consolidation is typicallyseen with pneumococcal pneumonia


38/41

7/24/12

Hospitalization of Childrenwith Pneumonia

Age


39/41

7/24/12

Treatment

Mildly ill children amoxicillin

Communities with a high percentage of penicillin-resistant pneumococci high doses of amoxicillin(8090 mg/kg/24 hr)

Therapeutic alternatives cefuroxime axetil or

amoxicillin/clavulanate School-aged children & with infection M.

pneumoniae or C. pneumoniae azithromycin

Adolescents respiratory fluoroquinolone

(levofloxacin, gatifloxacin, moxifloxacin,gemifloxacin)

Parenteral cefuroxime (150 mg/kg/24 hr),cefotaxime, or ceftriaxone bacterial pneumonia

Clinical features suggest staphylococcal pneumoniatherapy include vancomycin or clindamycin


40/41

7/24/12

Prognostic

Depend on presence of complication,and also effectiveness of antibiotics


41/41

Click to edit Master subtitle style7/24/12

Documents

Case BP Dr Tisna