CASE PRESENTATION

Presented by:
Ceyka Maduma
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IDENTIFICATION
Name
: Ana Elvira
Age / Date of Birth : 2 months 3 weeks / 3 January
2014
Gender
: Female
Fathers Name: Julis
Mothers Name : Erni
Nationality
: Indonesia
Religion
: Islam
Address
: Pampangan, OKI
Transfered By : RSUD Kayu Agung
Date of admission: Tuesday (18-03-2014)

HISTORY OF ILLNESS
Chief Complain
: dyspnea
Additional Complain : fever and cough
History of Present Illness :

3 days before admission, the child got a high

fever. Shiver (-). She also has cough. Sputum (-).
1 day before admission, she had dyspnea at the
night. Dyspnea doesnt depend on weather. There
are intercostal retraction and epigastric
retraction. Seizure (-). Common cold (-). Diarrhea
(-). She was brought to the Kayu Agung Hospital
and transferred to RSMH.

HISTORY OF ILLNESS

Since newborn, there is snoring sound. She always

choke and vomit when get milk too much.
History of hospital admission
In February, 2014 treated in Charitas Hospital
because of cows milk allergic.
Family history: tuberculosis contact (-), prolong
cough (-).

Pregnancy and Labor :

Pregancy : Aterm
Labor
: Spontaneous
Helped by : Midwife
Date of birth : 3 January 2014
Birth Weight: 3.8 kg
Birth Height : 48 cm

Immunization
BCG : yes, scar (+)
DPT : yes
Polio : yes
Hepatitis B: yes
Rubella : not sure
Conclusion : basic immunization was completed
Child Development :
Roll Over (Tengkurap): Crawl (Merangkak) : Sit : Stand : Walk: Conclusion : cant identify

PHYSICAL EXAMINATION ON
ADMISSION
General
General Condition : compos mentis, moderate sickness
Temp.
: 37C
Respiration Rate : 63x/minute, thoracal
Blood Pressure
:Pulse Rate : 130 BPM
Weight : 3.7 kg
Height : 53 cm
Nutritional Status
Weight : 3.7 kg
Height : 53 cm
Weight/Age: between -2 and -3 SD wasting
Height/age : -2 SD mild stunting
Weight/Height : between -1 and -2 SD mild malnutrition

PHYSICAL EXAMINATION
Head
Shape
Hair
Eye
Nose
Ear
Mouth
Throat
Neck

: normal, symmetrrical
: black, not fragile
: CA (-), SI (-) in normal limit
: nasal flare (+), secret (-)
: secret (-), pain (-)
: normal
: Faring Hyperemis (-)
: Lymph Node (-)
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PHYSICAL EXAMINATION
Pulmo
Inspection : symmetric, intercostal retraction (+), epigastric
retraction (+), pectus excavatum (+)
Palpation : stem fremitus ()
Percussion
: dullness
Auscultation : vesiculer (), rales (+), wheezing (-)
Cor
Inspection : ictus cordis at 5th ICS
Palpation : thrill (-)
Percussion
: heart within normal limits
Auscultation : reguler, murmur (-), gallop (-), BJ I/II normal
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PHYSICAL EXAMINATION
Abdomen
Inspection : convex, vein enlargement/venektasi (-)
Palpation :
Hepatomegali (-), Spleenomegali (-)
Percussion
: thympani
Auscultation : bowel sound (+) 5x/minute, normal
Extremities
Oedem (-), pale (-)
Neurology Examination
normal
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LABORATORY FINDINGS
Hematology
Hb
Ht

: 11 g/dl
: 32 vol%

Leukosit

: 12.500 /mm3

Trombosit

: 371.000/mm3

Diff count

: 0/1/1*/37*/49*/12*

Retikulosit

: 2,9 %

MCH

: 28

MCV
MCHC
LED

: 79,4
: 35
: 15 mm/jam

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Kimia Klinik

DIFFERENTIAL DIAGNOSE DIAGNOSE

Differential Diagnose:
Bronchopneumonia e.c bacterial infection
Bronchopneumonia e.c viral infection
Diagnose :
Bronchopneumonia e.c bacterial infection

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MANAGEMENT
IVFD D-5
Ampicillin 150 mg 3x/day
Gentamicyn 20 mg 2x/day
Oxygen nasal 1L/m
PASI 12 x 300 cc via NGT

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FOLLOW UP
25 March 2014
General condition = mild sickness
PR = 120 BPM
RR = 46 x/m
Temp. = 35.8C
Pulmo
Inspection : symmetric, intercostal retraction (+),
epigastric retraction (+), pectus excavatum (+)
Palpation : stem fremitus ()
Percussion : dullness
Auscultation : vesiculer (), rales (+), wheezing (-)

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Prognosis
Quo ad vitam
: bonam
Quo ad functionam : bonam

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THEORY

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BRONCHOPNEUMONIA

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Definition

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ETIOLOGY
AGE-DEPENDENT
Age

Newborn-20 days

Most

Rare

Bacterial infection

Bacterial infection

E. colli

Anaerob bancterial

Streptococcus group B

Streptococcus group D

Listeria monocytogenes

Haemopillus influenzae

age
Streptococcus
pneumoniae
Ureaplasma urealyticum
Viral infection
Sitomegalo virus
Herpes simplex virus

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Age

3 weeks-3 months

Most

Rare

Bacterial infection

Bacterial infection

Chlamydia trachomatis

Bordetella pertusis

Streptococcus
pneumoniae

Haemophillus influenzae
tipe B

Viral infection

Moraxella catharalis

Adeno virus

Staphylococcus aureus

Influenza virus

Ureaplasma urealyticum

Parainfluenza 1,2,3 virus

Viral infection

RSV

Sitomegalo virus

age

20

Age

4 months-5 years
age

Most

Rare

Bacterial infection

Bacterial infection

Chlamydia pneumoniae

Haemophillus influenzae
tipe B

Mycoplasma pneumoniae

Moraxella catharalis

Streptococcus
pneumoniae

Neisseria meningitis

Viral infection

Staphylococcus aureus

Adeno virus

Viral infection

Influenza virus

Varisela-Zoster virus

Parainfluenza virus
Rino virus
RSV

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Age

5 years ageteenager

Most

Rare

Bacterial infection

Bacterial infection

Chlamydia pneumoniae

Haemophillus influenzae

Mycoplasma pneumoniae

Legionella sp

Streptococcus
pneumoniae

Staphylococcus aureus
Viral infection
Adeno virus
Epstein-bar virus
Influenza virus
Parainfluenza virus
Rino virus
RSV
Varisella-zooster virus

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PATHOGENESIS

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LOCATION

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SIGN AND SYMPTOM

Respiratory
Infection
symptom
symptom

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DIAGNOSIS
Anamnesis

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CLASSIFICATION OF PENUMONIA
(FOR 2 MONTHS-5 YEARS OLD AGE)
Severe Pneumonia

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CLASSIFICATION OF PENUMONIA
(FOR INFANT < 2 MONTHS AGE)
Pneumonia

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TREATMENT
Antibiotics for 10-15 days:
Ampicilin 100 mg/kgbb/day in 3-4 doses
Chloramphenicol:
< 6 months: 25-50 mg/kgbb/day
> 6 months: 50-75 mg/kgbb/day in 3 doses or Gentamicyn 3-5
mg/kgbb/day in 2 doses
Support treatment:
IVFD
Oxygen
Education:
Immunization,
Adequate ASI,
Nutrition,
Keep away children from cigarrete smoke and air pollution

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CASE ANALYSE

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PATIENT

Bronchopneumonia

Acute (3 days)
High fever
Cough
Shortness of breath
T: 37C
Pulse: 130 x/minute
RR: 63x/per minute
Intercostal Retraction and
Epigastric Retraction
- Percussion: dullness
- Auscultation: rales (+)
- CXR: infiltrates of lung tissue

Sudden onset of fever

Shortness of breath
Productive cough
Tachypnea
Signs of respiratory distress
(retractions, flaring, grunting)
Increased fremitus
Dullness
Rales
CXR: infiltrates of lung tissue
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THANKYOU
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