Case Presentation Box B Anak

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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 : FemaleFather’s Name: Julis

Mother’s Name : Erni

Nationality : Indonesia

Religion : Islam

 Address : Pampangan, OKI

Transfered By: RSUD Kayu Agung

Date of admission: Tuesday (18-03-2014)2

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HISTORY OF ILLNESS

Chief Complain : dyspnea

 Additional Complain : fever and cough

History of Present Illness :

± 3 days before admission, the child got a highfever. Shiver (-). She also has cough. Sputum (-).

± 1 day before admission, she had dyspnea at the

night. Dyspnea doesn’t 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.3

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HISTORY OF ILLNESS

Since newborn, there is snoring sound. She alwayschoke and vomit when get milk too much.

History of hospital admission

In February, 2014 treated in Charitas Hospitalbecause of cow’s milk allergic.

Family history: tuberculosis contact (-), prolong

cough (-).

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Pregnancy and Labor :

Pregancy : Aterm

Labor : Spontaneous

Helped by: MidwifeDate of birth : 3 January 2014

Birth Weight: 3.8 kg

Birth Height : 48 cm

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Immunization

BCG: yes, scar (+)

DPT: yes

Polio: yes

Hepatitis B: yes

Rubella: not sureConclusion: basic immunization was completed

Child Development :

Roll Over (Tengkurap): -

Crawl (Merangkak): -

Sit : -

Stand : -

Walk: -

Conclusion: can’t identify

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PHYSICALEXAMINATIONON

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PHYSICAL EXAMINATION ON ADMISSION

General

General Condition : compos mentis, moderate sicknessTemp. : 37°C

Respiration Rate: 63x/minute, thoracal

Blood Pressure : -

Pulse Rate: 130 BPM

Weight : 3.7 kg

Height: 53 cm

Nutritional Status

Weight : 3.7 kgHeight: 53 cm

Weight/Age: between -2 and -3 SD  wasting

Height/age: -2 SD mild stunting

Weight/Height: between -1 and -2 SD mild malnutrition7

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PHYSICAL EXAMINATION

Head

Shape : normal, symmetrrical

Hair : black, not fragile

Eye : CA (-), SI (-)

 in normal limitNose : nasal flare (+), secret (-)

Ear : secret (-), pain (-)

Mouth : normal

Throat: Faring Hyperemis (-)

Neck : Lymph Node (-)

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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

PHYSICAL EXAMINATION

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 Abdomen

Inspection: convex, vein enlargement/venektasi (-)

Palpation:

Hepatomegali (-), Spleenomegali (-)

Percussion : thympani

 Auscultation: bowel sound (+) 5x/minute, normal

Extremities

Oedem (-), pale (-)

Neurology Examinationnormal

PHYSICAL EXAMINATION

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Hematology

Hb : 11 g/dlHt : 32 vol%

Leukosit : 12.500 /mm3

Trombosit : 371.000/mm3 

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

Retikulosit : 2,9 %

MCH : 28

MCV : 79,4

MCHC : 35

LED : 15 mm/jam

Kimia Klinik

LABORATORY FINDINGS

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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/mPASI 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/mTemp. = 35.8°C

Pulmo

Inspection: symmetric, intercostal retraction (+),

epigastric retraction (+), pectus excavatum (+)Palpation : stem fremitus (↓)

Percussion: dullness

 Auscultation : vesiculer (↑), rales (+), wheezing (-)14

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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

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 Age Most Rare

Bacterial infection Bacterial infection

E. colli Anaerob bancterial

Streptococcus group B Streptococcus group D

Newborn-20 days

age

Listeria monocytogenes Haemopillus influenzae

Streptococcus

pneumoniae

Ureaplasma urealyticum

 Viral infection

Sitomegalo virus

Herpes simplex virus

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 Age Most Rare

Bacterial infection Bacterial infection

Chlamydia trachomatis Bordetella pertusis

Streptococcus

pneumoniae

Haemophillus influenzae

tipe B

3 weeks-3 months

age

 Viral infection Moraxella catharalis

 Adeno virus Staphylococcus aureus

Influenza virus Ureaplasma urealyticum

Parainfluenza 1,2,3 virus Viral infection

RSV Sitomegalo virus

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 Age Most Rare

Bacterial infection Bacterial infection

Chlamydia pneumoniae Haemophillus influenzae

tipe B

Mycoplasma pneumoniae Moraxella catharalis

4 months-5 years

age

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 Most Rare

Bacterial infection Bacterial infection

Chlamydia pneumoniae Haemophillus influenzae

Mycoplasma pneumoniae Legionella sp

5 years age-

teenager

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

Infection symptomRespiratory symptomInfection symptom

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DIAGNOSIS

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 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

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 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: 37°C- Puse: !3" #$%inute

- &&: '3#$er %inute

- ntercosta &etraction and

*igastric &etraction- Percussion: duness

- Auscutation: raes (+)

- C,&: infitrates of ung tissue

- Sudden onset of fever- Shortness of breath 

- Productive cough

- Tachynea

- Signs of resiratory distress(retractions faring grunting)

- ncreased fre%itus

- .uness

- &aes- C,&: infitrates of ung tissue

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 THANKYOU