Case report

KEPANITERAAN KLINIK ILMU KESEHATAN ANAK

PERIOD 1 OKTOBER 2018 – 8 DESEMBER 2018

Gea Anugrah Adinda
MEDICAL FACULTY – CHRISTIAN UNIVERSITY OF INDONESIA 1361050170

JAKARTA Dokter Pembimbing : dr. Alfred ,

Sp.A.
2018
CHAPTER I Introduction
INTRODUCTION

Bronchopneumonia is pneumonia in the lobular part which is

characterized by patches of infiltrates caused by infectious agents
such as bacteria, viruses, fungi and foreign objects, which are
characterized by symptoms of high fever, restlessness, dyspnoea,
rapid and shallow breathing (sounds of rhonchi) , vomiting, diarrhea,
dry and productive cough.

Sumber : Saputri ND. Evaluasi penggunaan antibiotik pada pasien pneumonia pediatrik di instalansi rawat inap RSUP Dr. Soeradji Tritonegoro

Klaten tahun 2011: Jakarta: 2018.

Bronchopneumonia is a major cause of morbidity and
mortality in children under 5 years of age

The incidence of pneumonia in developing countries is 30-

45% per 1000 children under the age of 5, 16-22% per
1000 children at the age of 5-9 years and 7-16% per
1000 children in the older.
 OBJECTIVE
The purpose of making this case is to remind how to treat
bronchopneumonia in children.
CHAPTER II Subjective Data
PATIENT IDENTITY
Identity Patient
No. MR : 00.34.91.69
Name : An. S
Age : 2 years 11 months
Type sex : Male
Religion : Kristen
Address : Menteng
 HISTORY CARE THE IGD
Chief Complaint:
 Cough with phlegm
Additiional Complaint:
 Fever , dyspneu
Current medical history:
 Patient come with phlegm coughing since 4 days ago, sputum is difficult to remove, fever ,
dyspneu, nausea, vomiting, appetite decreases
History Disease from the past
-
Family History Disease
 Not there is in family that suffer disease as patient,
ANAMNESIS
The patient came to the emergency room at the UKI General Hospital with complaints
of phlegm coughing since 4 days ago, sputum is difficult to remove, accompanied by
fever measured 39.2 C continuously throughout the day, the more days higher, not
accompanied by sweat at night, to the nearest health center given paracetamol and
ambroxol drugs but did not improve, the patient's mother said 6 hours smrs, the child
was seen short of breath with breathing which was panting, restless and moaning,
every time it was tight for 2-3 minutes. Other additional complaints are nausea,
vomiting (+) containing food mixed with mucus. Appetite decreases, the frequency of
breastfeeding decreases, usually 5 bottles per day, since it hurts only 3-4 bottles per
day. History of drug allergy and food is denied, history of asthma is denied, fever
accompanied by indisputable seizures, history of long-standing coughs denied
Patients have not defecated since 2 days, urination no complaints.
 PHYSICAL EXAMINATION
General appearence : appear sick moderate
Cinssciouness : composmentis
Blood Pulse : 130 times/minute
Respiratory rate : 60 times / minute
Body Temperature : 39,2 °C (axilla)
 GENERAL EXAMINATION
Head : Normocephali ( head Circumference = 45 Cm)
Hair : Color Black, Distribution Equally, Not Easy Repealed
Eyes : Conjunctiva Anemia (-), Sclera ikterik (-), Allergic Shiner(-),
Not There Darkening Periorbital
Ear : Normotia, Burrow Ear Roomy/Roomy,
Nose : Cavum nasi Roomy, Secretions - / -, Breathing Lobe Nose (-), Allergic Salute (-)
Tonsils : T1-T1, No sign of Hyperemia
Neck : Lymph gland is not palpable
 GENERAL EXAMINATION
Thoracic
 Inspection : Movement Wall Chest Left And Right Symmetrical, Ribs space Retraction (+)
 Palpation : Vowel Fremitus Left And Right Same
 Percussion : Percussion Comparison Left And Right Same Sonor
 Auscultation : Basic respiratory sound Bronkhial (-), Ronki (+ / +), Wheezing (- / -), Sound Heart I And II Normal,
Murmur (-), Gallops (-)

Abdomen
 Inspection : Stomach Appear Flat
 Auscultation : Noisy Gut Audible 15 Second Once
 Palpation : Sipel, Painful Pressure (+) Regio Epigastrium, Undulations (-), Not Found Enlargement Hepatic
 Percussion : Timpani, Painful Knock (-)

Genitalia : Not There Is Abnormality

Skin : Not There Is Abnormality
Extremity : extremity skin feel warm ,Cyanosis (-), Capillary Refill time< 2 Second, Edema (-)
X-RAY

From the results of chest x-ray

examination, it was found:
- bilateral diffuse with increased
bronchovascular / blotchy spots
small and fine infiltrates that are
spread on the edge of the lung
field.
 Working Differential
diagnosa diagnosa
bronkopneumonia Bronkiolitis

Inpatient
Diet: soft
IVFD: Ringer Lactate 16 drops per minute (macro)
MM:
Nasal O2 cannula 2 lpm
Paracetamol 4 x 1 pulv (PO)
Ambroxol 3 x 5mg pulv (PO)
Vicilin injection 3 x 250 mg in Nacl 0.5% 100cc in 2 hours
Gentamicin injection 2 x 20 mg in Nacl 100cc in 2 hours
Ad vitam : Dubia ad bonam
Ad functionam : Dubia ad bonam
Ad sanationam : Dubia ad bonam
FOLLOW UP DAY 1
Fever , cough phlegm, dyspnea (-), decrease appetite . General Conditions:
Moderate Pain / Compos Mentis N: 130 x, RR: 37x, S: 37.4 oC. Thoracic : Retraction
Interrupt Ribs In Intercostal (+), Noisy Breath Basic vesikuler (-), Ronki (+ / +)
Therapy : IVFD: Ringer Lactate 16 drops per minute (macro)
MM:
Inhalasi ventolin + NaCl 3 cc
Paracetamol 4 x 1 pulv (PO)
Ambroxol 3 x 5mg pulv (PO)
Vicilin injection 3 x 250 mg in Nacl 0.5% 100cc in 2 hours
Gentamicin injection 2 x 20 mg in Nacl 100cc in 2 hours
FOLLOW UP DAY 2
Fever , cough phlegm, dyspnea (-) . General Conditions: Moderate Pain / Compos
Mentis N: 122 x, RR: 33x, S: 38 oC. Thoracic : Retraction Interrupt Ribs In Intercostal
(-), Noisy Breath Basic vesikuler (-), Ronki (+ / +)
Therapy : IVFD: Ringer Lactate 16 drops per minute (macro)
MM:
Inhalasi ventolin + NaCl 3 cc ( 2 times a day )
Paracetamol 4 x 1 pulv (PO)
Ambroxol 3 x 5mg pulv (PO)
Vicilin injection 3 x 250 mg in Nacl 0.5% 100cc in 2 hours
Gentamicin injection 2 x 20 mg in Nacl 100cc in 2 hours
FOLLOW UP DAY 3
Fever (-) , cough phlegm (-), dyspnea (-), . General Conditions: Moderate Pain /
Compos Mentis N: 68 x, RR: 23x, S: 37.1 oC. Thoracic : Retraction Interrupt Ribs In
Intercostal (-), Noisy Breath Basic vesikuler (-), Ronki (- / -)
Therapy : IVFD: Ringer Lactate 16 drops per minute (macro)
MM:
Inhalasi ventolin + NaCl 3 cc ( 2 times a day)
Paracetamol 4 x 1 pulv (PO)
Ambroxol 3 x 5mg pulv (PO)
Vicilin injection 3 x 250 mg in Nacl 0.5% 100cc in 2 hours
Gentamicin injection 2 x 20 mg in Nacl 100cc in 2 hours
CHAPTER III Base theory
DEFINITION

Pneumonia in the lobules is characterized by patches

of infiltrates caused by infectious agents such as
bacteria, viruses, fungi and foreign matter
 Etiology

Streptococcus Rhinovirus
pneumoniae
Respiratory
syncytial virus
(RSV)
Haemophillus
Influenzae
Clinical manifestation

Cough with phlegm

Dyspnea

decreased appetite
Fever

Fatigue

Vomit
PATOGENESIS
Microorganisms Histamine and
Release of
Endurance
enter the airway Infect the alveoli inflammatory prostaglandin 
decreases mediators weakens the
alveoli vascular muscle

Increases capillary Inter capillary Exudate and fibrin The surface of the Phagocytosis of
permeability edema >>, leukocytes >>, pleura is gloomy, bacteria
erythrocytes >> covered in fibrin

Tissue reabsorption Fibrin and lysis Abrosorption by The tissue back to

(gray) exudate macrophages normal
DIAGNOSIS
History Physical examination
It is very important to note on history: a. Axillary body temperature ≥ 37.5
°C
a. Complaints: fever, coughing with rapid breathing
b. Nostril breathing
b. Decreased appetite
c. rib retraction
c. There is a history of ARI
d. Ronki was found on auscultation
d. Children are restless and fussy
e. Bronchial base breath sounds
f. chest drawning
LABORATORY AND RADIOLOGICAL EXAMINATION
Laboratory examination
Examination of leukocyte count and leukocyte
count helps determine antibiotic therapy
Examination of sputum culture and staining (for
severe pneumonia)
Blood cultures are recommended for severe
conditions in each child suspected of bacterial
pneumonia
Pleural fluid puncture if there is pleural
effusion
Tuberculin test in children with a history of
contact with adult TB patients.
Radiological examination
Not recommended in children with mild,
uncomplicated acute lower respiratory tract
infections
Chest photos are recommended for patients who
are hospitalized or if clinical signs and symptoms
are found to be confusing
Folllow up of chest photos is only done if there is
lobe collapse or suspected complications or
persistent symptoms that worsen or not respond to
antibiotics
THERAPY
Oxigen 1
lpm Mukolitik

D5 ¼ NS

Antibiotic
Antipiretic
CHAPTER IV Case Analysis
 Case References

- Complaints: fever, coughing with rapid breathing

- Coughing up phlegm since 4 days ago
- Decreased appetite
- Fever with a temperature of 39.2 C throughout the
day - There is a history of ARI
- Shortness of breath and a history of drug allergy - Children are restless and fussy
and food are denied, history of asthma is denied,
fever accompanied by seizures is denied. - GIT disorders

- Nausea, vomiting containing food mixed with mucus

- Decreased appetite

History of drug allergy and food is denied, history of asthma is denied, fever accompanied by seizures is
denied, never experienced the same complaint before.
EXAMINATION PHYSICAL
Circumstances : appear sick moderate
Awareness : composmentis
Frequency blood : 130 times/minute
Frecuency breathing : 60 times / minute
Temperature body : 39,2 °C (axilla)
Nose : Cavity Rice Roomy, Secretions - / -, Breathing Lobe Nose (+), Allergic Salute (-
)
Thorax :
Inspection : movement wall chest left and right symmetrical, retraction interrupt ribs in intercostal (+)
Palpation : vowel fremitus left and right simetris
Percussion : percussion comparison left and right same (sonor-sonor)
Auskultasi : noisy breath basic bronchial, ronkhi +/+, wheezing -/-
 CASE ANALYSIS.
Laboratatorium examination Laboratatorium examination

- From the results of the lab An increase in the number of

examination, no significant shift was leukocytes
found in the peripheral blood count.

- Found the presence of leukocytosis,

leukocytosis can be found in diseases
due to viral infection.
 Case
Inpatient
Diet: soft
IVFD: Ringer Lactate 16 drops per
minute (macro)
MM:
* Nasal o2 cannula 2 lpm
* Paracetamol 4 x 1 pulv (PO)
* Ambroxol 3 x 5mg pulv (PO)
* Vicilin injection 4 x 250 mg in Nacl
0.5% 100cc in 2 hours
* Gentamicin injection 2 x 20 mg in
Nacl 100cc in 2 hours
Theory
Inpatient
Diet: soft
IVFD: D5 ¼ NS 16 drops per minute (macro)
Mm /:
* Cannula nasal O2 1 lpm
* Paracetamol 3 x 0.5 cc or 3 x ½ cth (PO)
* Ambroxol 3 x 7.5 mg (PO)
* Ampicillin 100 mg / kg / 6 hours (10 x 100 mg =
1000 mg) => 4 x 250 mg in 0.5% NaCl 100CC in 2
hours (IV)
* Gentamicin 2 mg / kg / 8 hours (10 x 2 = 20 mg)
=> 3 x 20 mg in 0.5% NaCl 100 cc in 2 hours (IV)
CHAPTER V Conclution
 Conclution

 In this case report An. S 2 years old (male) comes with a complaint of phlegm
cough that is difficult to remove accompanied by fever with a temperature of
39.2 C, 6 hours smears patients with shortness of breath with breathing
gasping, anxiety and whimpering, each time the duration of duration is 3- 5
minutes, nausea accompanied by vomiting and decreased appetite.
 In patients already can be seen the presence of clinical signs in general,
namely the presence of fever, restlessness, decreased appetite and
gastrointestinal disorders in the form of nausea accompanied by vomiting
and clinical signs of respirology, namely coughing up phlegm, shortness of
breath with panting breathing and whimpering.
CONCLUTION
From the physical examination in this case the temperature increases with the
size of the axilla, 39.2 C, breathing 60x / minute breathing fast and deep,
the pulse frequency 130x / minute content is sufficient, regular and lifting
strength, nasal lobe breathing, visible thoracic examination seen interrupted
retraction ribs in both lung fields, heard using a stethoscope of bronchial
breath and an additional sound, rhonki in both lung fields.
CONCLUTION
On laboratory examination, leukocytosis was found and no significant shift was
found in peripheral blood counts. Examination of the chest radiograph was
found to be diffuse bilaterlal with an increase in bronchovascular / spotting
and small and fine infiltrates scattered on the lung periphery.

Treatment in these patients is in accordance with the gold standard, namely by

giving 2 antibiotics and symptomatic therapy to relieve symptoms.
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