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CASE REPORT
BRONCHOPNEUMONIA

DENGUE
HEMORRHAGIC
FEVER
Compiled By
Nia Stefani Tambunan Supervisor
(120100093) dr.Hj. Tiangsa br Sembiring,
M.Ked (Ped), Sp. A (K)
Verra Anindya S.R
(120100022) 1
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INTRODUCTION
2
 Caused by
INTRODUCTION a variety
of etiology
such as
The main bacteria,
cause of
Broncho
viruses,
death, fungi, and
especially in foreign
children
under five pneumo bodies
years.
nia

3
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LITERATURE REVIEW
4
WHAT IS
BRONCHOPNEUMONIA
Pneumonia is
an The infection
inflammation causes
of the lungs inflammation
Bronchopneumon caused by a in the alveoli
ia is a type of variety of in the lungs,
pneumonia etiology such causing the
as bacteria, alveoli to fill
viruses, fungi, with pus or
and foreign fluid
bodies

5
EPIDEMIOLOGY

Pneumonia is the number 1 killer

among the leading infection
disease Source: UNICEF,
6
EPIDEMIOLOGY

Percentage of deaths among children under-five attributable to pneumoniain 2015

Source: UNICEF,
7
EPIDEMIOLOGY
64.73 65.09 64.81

35.27 34.91 35.19

Infant (<1 year) Children (1-4 years)

Prevalence pneumonia in Indonesia between 2007-2009

Source: Buletin Pneumonia
8 Depkes
WHAT CAUSES
BRONCHOPNEUMONIA?
Age Etiologic agents 3 months 5 RSV, PIV, Influenza,
0- 3 weeks Group B streptococcus
years Human meta
Gram-negative enteric bacili
pneumovirus, adenovirus,
Cytomegalovirus
rhinovirus
Listeria monocytogenes
Streptococcus pneumonia
Herpes simplex virus
Haemophilus aureus
Treponema pallidum
Staphylococcus aureus
3 weeks 3 Chlamydia trachomatis
Mycoplasma pneumonia
months Respiratory syncytial virus
Mycobacterium
(RSV)
tuberculossis
Parainfluenza viruses (PIV), 5 years 15 Mycoplasma pneumonia
especially type 3 years Chlamydophila pneumonia
Streptococcus pneumonia
Bordetella pertussis
9
WHAT CAUSES
BRONCHOPNEUMONIA?
Age Etiologic agents Age Etiologic agents
0- 3 weeks 1. Group B streptococcus 3 months 5 1. RSV, PIV, Influenza, Human
2. Gram-negative enteric years meta pneumovirus,
bacili adenovirus, rhinovirus
3. Cytomegalovirus 2. Streptococcus pneumonia
4. Listeria monocytogenes 3. Haemophilus aureus
5. Herpes simplex virus 4. Staphylococcus aureus
6. Treponema pallidum 5. Mycoplasma pneumonia
6. Mycobacterium
tuberculossis
3 weeks 3 1. Chlamydia trachomatis 5 years 15 1. Mycoplasma pneumonia
months 2. Respiratory syncytial virus years 2. Chlamydophila pneumonia
(RSV)
3. Parainfluenza viruses (PIV)
10
WHO IS AT
RISK?

Pollution Malnutrition, poor

Young age breast feeding
practices

Cold weather or Lack of immunization Low birth weight

chilling
WHO IS AT
RISK?

Crowding Vitamin A deficiency High prevalence of

nasopharyngeal
carriage of
pathogenic bacteria
 PATHOGEN
ESIS
Stages:

Red Hepatization Stadium:

alveoli consist of
leucocyte,
fibrine,erythrocyte, bacteria

Grey Hepatization Stadium:

fibrine deposition,
phagocytosis

Resolution Stadium:
neutrophil degeneration,
loose of fibrine, bacterial
CLASSIFICATION
Clinical and Pathog Morphology
Epidemiology ens
Community- Typical Lobaris
acquired peumonia
Hospital-acquired Atypical Bronchopneu
pneumonia/ monia
nosocomial
pnuemonia
Aspiration Interstitial
pneumonia
Immmunocompromi
sed pneumonia

14
WHAT ARE THE SYMPTOMS?
Fever
Cough
Shortness of breath
Chest pain
Rapid breathing
sweating
Shaking chills
Malaise
fatique Age Breaths per
Confusion or delirium minute
<2 months age >60 breaths per
minute
15
2-12 months age >50 breaths per
TEST AND DIAGNOSIS
Clinical symptoms
Physical exam : fever, lung sound, percussion,
crackles, retraction, dullness, etc
Laboratorium: complete blood count (CBC)
number of WBC elevated bacterial infection
Chest x ray
Sputum test
16
TREATMENT OPTIONS
Viral bronchopneumonia:
normally doesnt require
medical treatment and
improves on its own in one
to two weeks
Bacterial
bronchopneumonia:
antibiotic
17
Recommendation 1
Children with fast breathing pneumonia with no chest
indrawing or general danger sign should be treated with oral
amoxicillin: at least 40 mg/kg/dose twice daily (80 mg/kg/day)
for 5 days. In areas with low HIV prevalence, give amoxicillin
for three days.

Children with fast breathing pneumonia who fail on first line

treatment with amoxicillin should have the option or referral
to a facility where there is appropriate second line treatment

18
Recommendation 2
Children age 2-59 months with chest indrawing pneumonia
should be treated with oral amoxicillin: at least 40
mg/kg/dose twice daily for five days

19
Recommendation 3
Children aged 259 months with severe pneumonia should be
treated with parenteral ampicillin (or penicillin) and
gentamicin as a first-line treatment.
Ampicillin: 50 mg/kg, or benzyl penicillin: 50 000 units per
kg IM/IV every 6 hours for at least five days
Gentamicin: 7.5 mg/kg IM/IV once a day for at least five
days
Ceftriaxone should be used as a second-line treatment in
children with severe pneumonia having failed on the first-line
treatment.

20
Recommendation 4
Ampicillin (or penicillin when ampicillin is not
available) plus gentamicin or ceftriaxone are
recommended as a first-line antibiotic regimen for
HIV-infected and -exposed infants and for children
under 5 years of age with chest indrawing
pneumonia or severe pneumonia.
For HIV-infected and -exposed infants and for
children with chest indrawing pneumonia or severe
pneumonia, who do not respond to treatment with
ampicillin or penicillin plus gentamicin, ceftriaxone
alone is recommended for use as second-line
treatment.
21
Recommendation 5
Empiric cotrimoxazole treatment for suspected
Pneumocystis jirovecii (previously Pneumocystis
carinii) pneumonia (PCP) is recommended as an
additional treatment for HIV-infected and -exposed
infants aged from 2 months up to 1 year with chest
indrawing or severe pneumonia.
Empirical cotrimoxazole treatment for Pneumocystis
jirovecii pneumonia (PCP) is not recommended for
HIV-infected and -exposed children over 1 year of
age with chest indrawing or severe pneumonia.

22
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CASE REPORT
23
 CASE REPORT
AKZ, a 1years 17 days old girl
BW: 6 kg BH: 59 cm
Main complain :
Shortness of breath since 7 days ago . Not
associated with activity or weather, occurs
after coughing. Restlessness due to short of
breathing at night (+). Grunting (+). History of
shortness of breath (-). Wheezing (-). History
of choking (-). Cyanosis (-). 24
 CASE REPORT
Cough, 2 days ago. Sputum (-). Hemoptysis
(-). History of exposure with people who have
lung disease (+)
Fever, 7 days ago. Characteristic of fever is
high (>38o C), responded to antipyretic drug
but it increase again after 2 hours. Convulsion
(-). Shivering (-)
Flu (-)
Vommiting (-), nausea (-) 25
CASE REPORT
History of medication : azithromycin,
paracetamol, ibuprofen, L-Bio, Lasal*
(salbutamol), Univir* (acyclovir), valproate acid
(since 8 months)
History of previous disease: ventricular septal
defect (VSD) (since 1 month old), epilepsy (since
8 months old)
History of family : none
26
History of pregnancy: during pregnancy mother is 25
y.o. Hypertension (-). DM (-). Fever (-). Medicine
consumption (-). Ante natal care during pregnancy (+)
History of birth :Birth was assisted by a doctor.
Cesarean section with indication post-term pregnancy
and cried immediately after birth. Cyanosis (-). BW:
3500 gram. Body length 40 cm. head circumference (?)
History of feeding :
1. 0 6 months : formula milk freq: 4-6 x/day
2. 6 7 months : strained porridge + formula milk,
freq: 2- 4 x/day
3. 7 months now : smooth porridge + formula milk,
27
History of growth and development: the patient
can not stand, sit, and talk until now
History of immunization: according to patients
mother, immunization was complete except measles
vaccine

28
Physical Examination
Present Status:
Sensoriu : CM (GCS 14 = E4V4M6) BW : 6,1 Kg
m
HR : 140 x/i reguler, murmur BL : 59 cm
(+) systolic grade III/6
Linea Mid Claviculari
ICS III-IV
Temp : 38,5oC BW/A : - 3 SD < Z score < -2
SD
RR : 52 x/i BH/A : Z score < 3 SD
BW/BH : - 2 SD < Z score < -1
SD
Anemic (-), icteric (-), dyspnea (+), cyanosis (-), oedema (-/-)

29
Localized Status:
Head : Eye: Light reflex (+/+), isochoric pupil (R:3mm ,L: 3 mm),
pale inferior conjungtival palpebra(-/-), palpebra edema (-/-)
Ear: Both ear lobe in normal morphologic
Nose : Septum deviation (-), normal morphologic.
Mouth: Cleft palate (+), Cyanosis (-)
Neck : Lymph node enlargement (-).
Thorax : Symmetrical fusiform, epigastric retraction (+),
- HR: 110 bpm, regular, murmur (+) systolic grade III/6 linea
midclavicula sinistra (LMCS) ICS III-IV
- RR: 52 bpm, regular, ronchi (+/+), bronchial, wheezing
(-/-).

30
Localized Status:

Abdome : Symmetrical, Soepel, normal peristaltic, shifting dulless (-)

n Liver ad spleen: unpalpable, Umbilical hernia (+)
Extremit : BP: cant be measured, Pulse 110 x/i, regular, adequate p/v,
ies felt warm, CRT 3, cyanosis (-), clubbing finger (-), oedema
(-/-), clubbing
Anogeni : Normal (female)
tal

31
Laboratory Finding :
Complete Blood Analysis (28-12-2016 )
Count B loodCell (CBC) AGDA
Haemoglobin : 10,5 g/dl PH : 7,38
Hematocryte : 32,5 % PCO2 : 48 mmHg
Leukocyte : 17,150 PO2 : 44,2 mmHg
103/uL
Thrombocyte : 226 103/uL HCO3 : 27,3 mmol/L
Eosinophil : 4,3 % Total CO2 : 24
Basophil : 0,9 % BF : 2,5 mmol/L
Limphocyte : 19 % SaO2 : 86,6 %
Monocyte : 10,9 %
Neutrophil : 64,9 %
Electrolite Methabolism
Natrium : 132 mmol/L Blood glucose : 118 mg/dL
Kalium : 4,4 mmol/L
Chloride : 101 mmol/L 32
33
 Differensial Diagnosis:
1. Bronchopneumonia + VSD + Palatoschisis + epilepsy
+ umbilical hernia
2. Tuberculosis + Atrial septal defect (ASD) +
Palatoschisis + epilepsy+ umbilical hernia
3. Fungal lung + Patent Ductus Arteriosus (PDA) +
Palatoschisis + epilepsy+ umbilical hernia

Working Diagnosis :
Bronchopneumonia + Ventricular Septal defect (VSD) +
Palatoschisis + Epilepsy + Umbilical Hernia 34
 Therapy :
IVFD D5% NaCL 0,225% 25 gtt/I
Inj. Ampicillin 300 mg/6h/IV
Inj. Gentamicin 40 mg/24h/IV
Paracetamol drop 3 x 60 mg (0,6 cc)
Diet F75 100 cc/3 hour + 2 cc mineral mix/oral/NGT
Valproat acid syr 2 x 1 cc
Inj. Furosemide 6 mg/12h/IV
Spironolactone 2 x 6.25 mg
Folat acid 1 x 1 mg
Vit. B complex 1 x 1 tab
Vit. C 1 x 50 mg

35
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FOLLOW UP
36
29thof December 2016
S : Dyspnea (+), cough (+), fever (+)
O : Sens : Compos mentis GCS 14 (E3M6V5), Temperature : 38C BB: 6,1 Kg
Head
Eye : Light reflex (+/+), isochoric pupil (R:3mm ,L: 3 mm), pale inferior
palpebral conj. (-/-)
Ears : Both ear lobe in normal morphologic.
Nose : Septum deviation (-), normal morphologic.
Mouth : Cleft palate/Palatoschisis (+), Cyanosis (-)
Neck : Lymph node enlargement (-).
Thorax : Symmetrical fusiform, epigastricretraction (+), HR: 120 x/i, regular,
murmur (+) systolic grade III/6 LMCS ICS III-IV RR: 60x/i, regular,
ronchi (+/+), bronchial (+/+), wheezing (-/-). Stridor (-/-)
Abdomen : Symmetrical, Soepel, peristaltic (+) normal, hepar, lien :
unpalpable, Umbilical hernia (+)
Extremities: BP: cant be measured, Pulse 120 x/i, regular,adequate p/v,felt
warm, CRT 3, cyanosis (-), clubbing finger (-), oedema (-/-).
A : Bronchopneumonia + Ventricular septal defect (VSD) + palatoschisis +
umbilical hernia + epilepsy
P :
IVFD D 5 % NaCL 0,225 % 25gtt/I
Inj. Ampicillin 300 mg/6h/IV
Inj. Gentamicin 40 mg/24h/IV
Paracetamol drop 3 x 60 mg (o,6 cc)
Diet F100 100 cc/3 hour + 2 cc mineral mix/oral/NGT
Valproat acid 2 x 1 cc
30-31thof December 2016
S : Dyspnea (+), cough (+), fever (+)
O : Sens : CM Temp : 37,8oC BW: 5,9 Kg
Head : old man face (-), prominent cheekbones (-), Head Circumference : 40 cm
(microcephaly),
Eye : Light reflex (+/+), isochoric pupil (R:3mm ,L: 3 mm), pale inferior palpebral
conj. (-/-).
Nose : Normal
Ear : Normal
Mouth : Palatoschisis
Thorax : Symmetrical fusiform, epigastricretraction (+), HR: 120 x/i, regular,
murmur (+) systolic grade III/6 line midclaviculasinistra ICS III-IV RR: 50x/i,
regular, ronchi (+/+), bronchial (+/+), wheezing (-/-). Stridor (-/-)
Abdomen : Symmetrical, Soepel, peristaltic (+) normal, hepar, lien : unpalpable,
Umbilical hernia (+)
A : Bronchopeumonia + Small VSD + Palatoschisis + microcephaly
+ Epilepsy
P :
IVFD D 5 % NaCL 0,225 % 25gtt/I
Inj. Ampicillin 300 mg/6h/IV
Inj. Gentamicin 40 mg/24h/IV
Paracetamol drop 3 x 60 mg (o,6 cc)
Diet F100 100 cc/3 hour + 2 cc mineral mix/oral/NGT
Valproat acid 2 x 1 cc
Vitamin B-Complex 1 x 1 tab
Vitamin C 1 x 100 mg
Inj. Furosemide 6 mg/12h/IV
Spironolactone 2 x 6,25 mg
Planning:
Blood culture and sensitivity
Consultation to the departement of nutrition about diet high
calory with fluid retriction
Table 2. Laboratorium Test Result (31-12-2016) AGDA Electrolite
PH 7,38 7,37-7,45 mmHg
pCO2 49,0 33-44 mmHg
pO2 43,20 71-104 mmHg
HCO3 28,4 22-29 mmol/L
BE 2,7 (-2)-3 mmol/L
O2 sat 71,2 94-98 %
Na/K/CL/C 134/4,81/98/0,5 135-155/3,1-5,1/96-106
a

Table 3. Laboratorium Test Result (31-12-2016)

Hb 10.8 712-16 g/dl

Ht 33,70 37-41%

Leu 19,36 6-17 103//uL

Tromb 276 150-440 103/uL

N/L/M/E/B 62/23/12,5/1,7/0,8 50-70/20-40/2-8/1-6/0-1

1stof January 2017
S : Dyspneu (+), cough (+), vomiting (+), Fever (+)
O : Sensorium : Compos mentis GCS 14 Temp : 38,4oC
Head : old man face (-), prominent cheekbones (-)
Eye : Light reflex (+/+), isochoric pupil (R:3mm ,L: 3 mm), pale inferior palpebral conj. (-/-)
Nose : Normal
Ear : Normal
Mouth : Palatoschisis
Thorax : Symmetrical fusiform, retraction (+), HR: 110 x/i, regular, murmur (+) systolic
grade III/6 line midclaviculasinistra ICS III-IV RR: 58x/i, regular, ronchi (+/+),
bronchial (+/+),wheezing (-/-), Stridor (-/-)
Abdomen : Symmetrical, Soepel, peristaltic (+) normal, hepar, lien : unpalpable, Umbilical
hernia (+)
Extremities :BP: cant be measured, Pulse 115 x/i, regular,adequate p/v,felt warm, CRT 3,
cyanosis (-), clubbing finger (-), oedema (-/-), hyphotrophy muscle (+), adipose
subcutaneous (<<)
A : Brochopeumonia + small VSD + palatoschisis + epilepsy
+ microcephaly + umbilical hernia
P :
IVFD D 5 % NaCL 0,225 % 25gtt/I
Inj. Ampicillin 300 mg/6h/IV
Inj. Gentamicin 40 mg/24h/IV
Paracetamol drop 3 x 60 mg (o,6 cc)
Valproat acid 2 x 1 cc
Vitamin B-Complex 1 x 1 tab
Vitamin C 1 x 100 mg
Inj. Furosemide 6 mg/12h/IV
Spironolactone 2 x 6,25 mg
Diet F100 100 cc/3 hour + 2 cc mineral mix/oral/NGT
Salbutamol 3 x 0,5 mg
Table 4. Laboratorium Test Result (01-01-2017) AGDA Electrolite

PH 7,42 7,37-7,45 mmHg

pCO2 45,5 33-44 mmHg
pO2 64,6 71-104 mmHg
HCO3 27,5 22-29 mmol/L
BE 4,4 (-2)-3 mmol/L
O2 sat 92 94-98 %
Na/K/CL 132/3.31/94 135-155/3,1-5,1/96-106

Table 5. Laboratorium Test Result (01-01-2017)

Hb 10.4 g/dl 12-16

Ht 32,00% 37-41
Leu 20,840 6.000-17.000
Tromb 254000 150.000-440.000
N/L/M/E/B 68,9/19,8/10,6/0,3/0,4 50-70/20-40/2-8/1-6/0-1
2ndof January 2017
S : Fever (+), cough (+), dyspnea (+), vomitting (-)
O : Sens : Compos mentis GCS 14, Temperature : 39C
Head : old man face (-), prominent cheekbones (-)
Eye : Light reflex (+/+), isochoric pupil (R:3mm ,L: 3 mm), pale inferior palpebral conj.
(-/-)
Nose : Normal
Ear : Normal
Mouth : Palatoschisis
Thorax : Symmetrical fusiform, retraction (+), HR: 110 x/i, regular, murmur (+) systolic
grade III/6 line midclaviculasinistra ICS III-IV RR: 50x/i, regular, ronchi (+/+),
bronchial (+/+),wheezing (-/-). Stridor (-/-)
Abdomen : Symmetrical, Soepel, peristaltic (+) normal, hepar, lien : unpalpable,
Umbilical hernia (+)
Extremities :BP: cant be measured, Pulse 110 x/i, regular,adequate p/v,felt warm,
A : Brochopeumonia + small VSD + palatoschisis +
epilepsy + microcephaly + umbilical hernia
P :
IVFD D 5 % NaCL 0,225 % 25gtt/I
Inj. Ampicillin 300 mg/6h/IV
Inj. Gentamicin 40 mg/24h/IV
Paracetamol drop 3 x 60 mg (o,6 cc)
Valproat acid 2 x 1 cc
Vitamin B-Complex 1 x 1 tab
Vitamin C 1 x 100 mg
Inj. Furosemide 6 mg/12h/IV
Spironolactone 2 x 6,25 mg
Salbutamol 3 x 0,5 mg
Diet F100 60 cc/3 hour + 2 cc mineral mix/oral/NGT
Folat acid 1 x 1 mg
3th of January 2017

S : Dyspneu (+), cough (+), fever (+)

O : Sensorium : Compos mentis GCS 14 Temp : 37,9oC BW: 5,9 Kg

Head : old man face (-), prominent cheekbones (-)

Eye : Light reflex (+/+), isochoric pupil (R:3mm ,L: 3 mm), pale inferior palpebral

conj. (-/-).

Nose : Normal

Ear : Normal

Mouth : Palatoschisis

Thorax : Symmetrical fusiform, retraction (+), HR: 132 x/i, regular, murmur (+)

systolic grade III/6 line mid clavicula sinistra ICS III-IV RR: 52x/i, regular,

ronchi (+/+), bronchial (+/+),wheezing (-/-), Stridor (-/-)

Abdomen : Symmetrical, Soepel, peristaltic (+) normal, hepar, lien :

unpalpable, Umbilical hernia (+)

Extremities : BP: cant be measured, Pulse 110 x/i, regular,adequate p/v,felt

A : Brochopeumonia + small VSD + palatoschisis +
epilepsy + microcephaly + umbilical hernia
P :
IVFD D 5 % NaCL 0,225 % 25gtt/I
Inj. Ampicillin 300 mg/6h/IV
Inj. Gentamicin 40 mg/24h/IV
Paracetamol drop 3 x 60 mg (o,6 cc)
Valproat acid 2 x 1 cc
Vitamin B-Complex 1 x 1 tab
Vitamin C 1 x 100 mg
Inj. Furosemide 6 mg/12h/IV
Spironolactone 2 x 6,25 mg
Salbutamol 3 x 0,5 mg tab
Diet F100 60 cc/3 hour + 2 cc mineral mix/oral/NGT
Nebule ventolin 1 resp + NaCl 0,9% 2,5 cc/8 hour
Folat acid 1 x 1 mg
Table 6. Laboratorium Test Result ( 03-01-2017)
Hb 10.4 g/dl 12-16
Ht 31,10% 37-41
Leu 19.720 6.000-17.000
Tromb 194000 150.000-440.000
N/L/M/E/B 64,9/26,9/6,8/0/1,4 50-70/20-40/2-8/1-6/0-1
4-7th of January 2017

S : Dyspneu (+), cough (+), fever (+)

O : Sensorium : Compos mentis GCS 14 Temp : 37,2oC BB: 5,9 Kg

Head : old man face (-), prominent cheekbones (-)

Eye : Light reflex (+/+), isochoric pupil (R:3mm ,L: 3 mm), pale inferior palpebral

conj. (-/-)

Nose : Normal

Ear : Normal

Mouth : Palatoschisis

Thorax : Symmetrical fusiform, retraction (-), HR: 124 x/i, regular, murmur (+)

systolic grade III/6 line midclaviculasinistra ICS III-IV RR: 40x/i, regular,

ronchi (+/+), bronchial (+/+),wheezing (-/-). Stridor (-/-)

Abdomen : Symmetrical, Soepel, peristaltic (+) normal, hepar, lien : unpalpable,

Umbilical hernia (+)

Extremities : BP: cant be measured, Pulse 110 x/i, regular,adequate p/v,felt

A : Brochopeumonia + small VSD + palatoschisis + epilepsy +
microcephaly + umbilical hernia
P:
IVFD D 5 % NaCL 0,225 % 25gtt/I
Inj. Ceftriaxone 300 mg/12h/IV
Paracetamol drop 3 x 60 mg (o,6 cc)
Valproat acid 2 x 1 cc
Vitamin B-Complex 1 x 1 tab
Vitamin C 1 x 100 mg
Inj. Furosemide 6 mg/12h/IV
Spironolactone 2 x 6,25 mg
Salbutamol 3 x 0,5 mg pulv
Nebuleventolin 1 resp + NaCl 0,9% 2,5 cc/8 hour
Folat acid 1 x 1 mg
Diet nutridrink 100 cc/3hour
Physiotherapy

Microbiology Result: Bacteria is not found

THORAX PA/LATERAL DEXTRA

Pneumonia DD Tuberculosis

8-9th of January 2017

S : Dyspneu (<<), cough (<<), fever (+) fluctuative

O : Sensorium : Compos mentis GCS 14 Temp : 37,3oC BB: 6,0 Kg

Head : old man face (-), prominent cheekbones (-)

Eye : Light reflex (+/+), isochoric pupil (R:3mm ,L: 3 mm), pale inferior palpebral

conj. (-/-).

Nose : Normal

Ear : Normal

Mouth : Palatoschisis

Thorax : Symmetrical fusiform, retraction (-), HR: 140 x/i, regular, murmur (+)

systolic grade III/6 line midclaviculasinistra ICS III-IV RR: 38x/i, regular,

ronchi (-/-), bronchial (+/+),wheezing (-/-). Stridor (-/-)

Abdomen : Symmetrical, Soepel, peristaltic (+) normal, hepar, lien :

unpalpable, Umbilical hernia (+)

Extremities : BP: cant be measured, Pulse 140 x/i, regular,adequate p/v,felt

A : Bronchopneumonia + small VSD + epilepsy + Palatoschisis +
microcephaly + umbilical hernia
P :
IVFD D 5 % NaCL 0,225 % 25gtt/I
Inj. Ceftriaxone 300 mg/12h/IV
Paracetamol drop 3 x 60 mg (o,6 cc)
Valproat acid 2 x 1 cc
Vitamin B-Complex 1 x 1 tab
Vitamin C 1 x 100 mg
Inj. Furosemide 6 mg/12h/IV
Spironolactone 2 x 6,25 mg
Salbutamol 3 x 0,5 mg pulv
Nebuleventolin 1 resp + NaCl 0,9% 2,5 cc/8 hour
Folat acid 1 x 1 mg
Diet nutri drink 100 cc/3hour
10th of January 2017 (OUT FROM HOSPITAL)
S : Dyspneu (<<), cough (<<), fever (+) fluctuative
O : Sensorium : Compos mentis GCS 14 Temp : 37,3oC BB: 5,8 Kg
Head : old man face (-), prominent cheekbones (-)
Eye : Light reflex (+/+), isochoric pupil (R:3mm ,L: 3 mm), pale inferior palpebral
conj. (-/-).
Nose : Normal
Ear : Normal
Mouth : Palatoschisis
Thorax : Symmetrical fusiform, retraction (-), HR: 110 x/i, regular, murmur (+)
systolic grade III/6 line midclaviculasinistra ICS III-IV RR: 50x/i, regular,
ronchi (-/-),wheezing (-/-). Stridor (-/-)
Abdomen : Symmetrical, Soepel, peristaltic (+) normal, hepar, lien : unpalpable,
Umbilical hernia (+)
Extremities : BP: cant be measured, Pulse 140 x/i, regular,adequate p/v,felt
warm, CRT 3, cyanosis (-), clubbing finger (-), oedema (-/-),
A : Bronchopneumonia + small VSD + epilepsy +Palatoschisis +
microcephaly + umbilical hernia
P :
IVFD D 5 % NaCL 0,225 % 25gtt/I
Inj. Ceftriaxone 300 mg/12h/IV
Paracetamol drop 3 x 60 mg (o,6 cc)
Valproat acid 2 x 1 cc
Vitamin B-Complex 1 x 1 tab
Vitamin C 1 x 100 mg
Inj. Furosemide 6 mg/12h/IV
Spironolactone 2 x 6,25 mg
Salbutamol 3 x 0,5 mg pulv
Nebule ventolin 1 resp + NaCl 0,9% 2,5 cc/8 hour
Folat acid 1 x 1 mg
Diet nutridrink 100 cc/3hour
Table 7. Laboratorium Test Result(10-01-2017)
Hb 10.2 g/dl 12-16
Ht 30,4% 37-41
Leu 10.710 6.000-17.000
Tromb 447000 150.000-440.000
N/L/M/E/B 44,6/42,5/8,2/1,5/3, 50-70/20-40/2-8/1-6/0-1
2
Click icon to add picture

DISCUSSION
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 DISCUSSION
Theory Cases
Definition: -
Pneumonia is an inflammation of the lungs
caused by a variety of etiology such as
bacteria, viruses, fungi, and foreign bodies.1
Pneumonia is a form of acute respiratory
infection that affects the lungs
Epidemiology: The patient was a girl, 1 year 17 days with
In Indonesia, pneumonia is the leading diagnose bronchopneumonia.
cause of death, especially in infants 1-4
years.3 Prevalence of pneumonia from 2007
until 2009 among children between 1-4
years is more common than infants (<1
years) and percentage of deaths among
children under-five in 2015 in Indonesia is
15-19%.

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DISCUSSION
Theory Cases
Risk factor: In this case, the patient is 1 years 17 days old. Infants from
- Young age birth to age two are at risk for pneumonia, as are indiviuals age
- Lack of 65 or older. Their immune system are weak rather than adult.
immunization
- Malnutrition Patient have a small ventricular septal defect (VSD) since 1
- Crowded months of age that predispose to bronchopneumonia. Most
- Pollution previous reports identified CHD as an underlying cause of
- Low birth weight recurrent pneumonia i.e. when there are two or more
- Vitamin A deficiency pneumonia episodes in a year.
Specific risk factors:
Lung disease
Anatomic problems
GERD
Some congenital
heart disease (CHD)
etc

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DISCUSSION
Theory Cases
Etiology: multiple Routine laboratory test may be helpful for diagostic purpose,
microbes, predominantly A complete blood count (CBC) may show a high white blood
viruses and bacteria, cell count, indicating the presence of bacterial infection.
cause pneumonia in Leucopenia may suggest viral pneumonia. Blood culture are
infant and children ( 3 positive in 5-14% of cases.
months 5 years): In this patient we found that Leukocyte 17.150 (N:6.000-
RSV, PIV, Influenza, 17.000) (28-12-2016), and the leukocyte increase again
Human meta become 19.360 (31-12-2016) and 20.840 (1-1-2017), High
pneumovirus, white blood cell count may suggest bacterial infection. We
adenovirus, rhinovirus have do the culture test, but because of lack of blood, the
Streptococcus result is negative.
pneumonia
Haemophilus aureus
Staphylococcus aureus
Mycoplasma
pneumonia
Mycobacterium
tuberculossis
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DISCUSSION
Theory Cases
Diagnostic: In this patient, we found:
Symptoms: Fever : 38,5oC since 7 days ago, respons to antipyretic drug
Fever but increase again.
Cough Rapid breathing : 52 x/I (tachypnea: >40x/I for 12 months-5
Shortness of breath years)
Chest pain Cough with sputum (but patient can not cough up the
Rapid breathing sputum in her chest)
sweating
Shaking chills
Malaise
fatique
Confusion or delirium

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DISCUSSION
Theory Cases
General examination: In this patient, we found:
Fever HR: 140 x/I
Rapid breathing Murmur (+) systolic grade III/6 LMCS III-IV
Cyanosis RR: 42 x/I
Retraction Temp: 38,5oC
Chest indrawing Bronchial
grunting Crackles
Decrease breath Retraction
sounds Grunting
Crackles (rales)
Egophony on Umbilical hernia
auscultation
Pleural frictian rub
Dullness of the chest to
percussion
Altered mental stataus

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DISCUSSION
Theory Cases
Laboratory test and In this patient, we found:
radiology: Leukocytosis (17.150, 19.360, 20.840)
Leukocyte : normal or Saturation oxygen 86.6% (<90%) may indicated
decrease: viral respiratory distress and hypoxemia
pneumonia, increase: Infiltrate in the lungs with patchy appearance
bacterial pneumonia
Infiltrates. Lobar
pneumonia: an ill
defined area of
increase density,
bronchopneumonia:
infiltrate with patchy
appearance

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DISCUSSION
Theory
Treatment based on
classification:
severe pneumonia.
Bed rest
Medical form of antibiotic
inj. Ampicillin 300 mg /
6hr / iv and inj.Gentamicin
30 mg / 24hr / iv
Antipyretic use
paracetamol drop 3 x 60
mg (0.6 cc)
Anti-seizure use of valproic
acid syr 2 x 1 cc
Sup vit. B complex 1x1 tab
and vit.c 1x50 mg tab.
Cases
The treatment started from 29th December 2016 until 10th
January 2017. On the 29th December 2016 until 3th January
2017, we gave the patient with:
Inj. Ampicillin 300 mg/6hr/IV and Inj. Gentamicin 30
mg/24hr/IV for antibiotics while waiting for blood
cultures.
Paracetamol drop 3 x 60 mg
valproic acid syr 3 x 1 cc
and the supplements vitamin B and C. but the patient
did not respond to the drug. The symptoms such as
dyspneu, cough, and fever not improve.
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DISCUSSION
Theory
Ceftriaxone should be used as
a second-line treatment in
children with severe
pneumonia having failed on
the first-line treatment.
Cases
On the 4th January 2017, the blood culture result is
negative. But in routine clinical practice, a negative blood
result is almost inevitable for a large proportion of blood
cultures because of submission of an inadequate volume of
blood. The lab result for leukocytes is more than normal
(6.000-17.000), we assumed that the cause of pneumonia
in this patient is bacteria. We change the treatmet with
Inj. Ceftriaxone 300 mg.12hr/IV on 4th January 2017, and
the patient have improvement in symptoms.
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 SUMMARY
AKZ, a 1 year 17 days old girl, BW 6 kg BH 59 cm, came to
USU Hospital on December 28th at 02.45 PM. Her main complaint
was shortness of breath and diagnosed with Bronchopneumonia +
Ventricular Septal Defect (VSD) + Palatoschizis + Epilepsy +
Umbilical Hernia and got fluids IVFD D5% NaCl 0,225% and
medical form of antibiotic inj. Ampicillin 300 mg / 6hr / iv and
inj.Gentamicin 30 mg / 24hr / iv, antipyretic use paracetamol drop 3
x 60 mg (0.6 cc), anti-seizure use of valproic acid syr 2 x 1 cc, and
form of supplements vit. B complex 1x1 tab and vit.c 1x50 mg tab.

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THANK YOU!
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