BRONKOPNEUMONIA 2

7/21/2019 BRONKOPNEUMONIA 2

http://slidepdf.com/reader/full/bronkopneumonia-2 1/14

1

CHAPTER III

CASE REPORT

3.1 ObjectiveThe objective of this paper is to report a case of a 11 month old boy with a

diagnosis of bronkopneumonia.

3.2 Case

AS, a 11 month old boy, with 6, kg of !" and 66 cm of !#, came to #aji Adam

$alik %eneral #ospital $edan on 1& th 'ovember at &&.(). #is chief complaint

was dyspnea.

History of disease:


$alik %eneral #ospital $edan on 1& th 'ovember at &&.() with dyspnea as chief

complaint. The patients have been e*perienced this about 1 week before admitted

to hospital. +yspnea was not directed with weather and activity. yanosis - /,

patient also e*perienced cough since & weeks ago followed by sputum. #istory of

contact with adult cough - /. 0ever has been e*perienced by patient since & weeks

and the body temperature rises and drop. Shivering was not found. omiting - /

and nausea - /. +efecation and urination is normal. #istory of weight loose is not

found .

History of medicatio :

2 &, 3 0+ ringer lactate, nebule ventolin, inj meropenem, triamsinolon,

bromhe*ine an salbutamol

History of fami!y:

There is no famiy history of similar disease found.

History of "are t#s medicatio 4



2

'ot found

History of "re$ a cy:

5atient s mother was (1 years old during pregnancy. She regularly goes for

control. 'o history of complication neonate and maternal problem. onsumtion of

herbal medication - /

History of birt%:

5atient was first child. %estational age was preterm -&7 weeks/. !ody weight was

1&)) gram, body length was not measured. !irth was assisted by traditional

midwife. !aby was born normally and cried spontaneously. !lusih was not found.

History of imm& i'atio :

'ot complete

History of $ro(t% a d deve!o"me t:

5atient s mother e*plained that he grew normally. #e was able to crawl and sit

appropriately based on his age.

P%ysica! E)ami atio :

Prese t stat&s:

Sensorium 4 $, body temperature4 (8,69 , #:4 1(7 bpm, ::4 ; *<i, !"4 6,

kg, !#4 66 cm, !"<A4 = score > ( , !?<A4 = score > (, !"<!?4 = score > (,

anemic - /, icteric - /, dyspnea -@/, cyanosis - /, edema - /.

*oca!i'ed stat&s:• #ead 4 0ace4 within normal range

yes4 light refle* @<@, isochoric pupil, pale inferior

palpebral conjunctiva < , superior and inferior palpebra

edema <

ars4 within normal range



3

'ose4 nasal flaring

$outh 4 within normal range

• 'eck 4 lymph node enlargement - /• Thora*4 Symmetrical fusiform, retraction intercostal and epigastric

-@/#:4 1(7 bpm, regular, murmur - /

::4 ;*<i, regular, ronchi -@<@/, wheeBing - < /

• Abdomen4 Symmetric, supple, normal peristaltic, liver and spleen4

normal•

*tremities 4 pulse 1(7 bpm regular, adeCuate p<v, felt warm, :T> (D

+or,i $ dia$ osis 4 ++ bronkopneumonia

bronchiolitis

*aboratory fi di $

omplete blood analysis -1& th 'ovember &)1 < &(.)(/

Test :esult Enit :eferences

#emoglobin F.&) gG 11.( 1;.1

rythrocyte (. 1 1) 6<mm( ;.;) ;.;7

?eucocyte 1F.8; 1) ( <mm( 6.) 18.

Thrombocyte &6( 1) ( <mm( &18 ;F8

#ematocrite &7.8) G (8 ;1

osinophil ). ) G 1 6

!asophil ). )) G ) 1

'eutrophil 1.)) G (8 7)

?ymphocyte (F.F) G &) ;)

$onocyte 7.1) G & 7

'eutrophil absolute 1).)7 1) ( <H? 1.F .;

?ymphocyte 8.77 1)(

<H? (.8 1).8



4

absolute

$onocyte absolute 1. F 1)(

<H? ).( ).7osinophil absolute ).)F 1) ( <H? ).&) ). )

!asophil absolute ).1) 1) ( <H? ) ).1

$ 71.7) 0l 71 F

$ # &6.&) 5g & &F

$ # (&.1) gG &F (1

linical chemistry -1& 'ovember &)1 < &(.)(/

Test :esult Enit :eferences

!lood %lucose 81.8) mg<d? ;) 6)

Ereum 1;.8) mg<d? > )

reatinine ).&( mg<d? ).18 ).;1

'atrium 1(6 m C<? 1( 1

5otassium .( m C<? (.6 .

hloride 1)) m C<? F6I1)6

5rocalcitonin ).;& ng<m? >).)

%as blood analysis -1& 'ovember &)1 < &(.)(/

p# 8.1 8.( 8.;

p 2& (7.8 mm#g (7 ;&

p2& 188. mm#g 7 1))

!icarbonate -# 2(/ 1(.; mmol<? & &6

Total 2& 1;. mmol<? 1F &

!ase *cess -! / 1;. mmol<? - &/ I -@&/

2& Saturation F7.7 G F 1))



5

T%era"y 4 2&1 & ?< min via nasal cannula

3 0+ + G 'a l ),&& G & gtt<menit -micro/

3nj eftria*one ()) mg< 1& hours <iv

5aracetamol (* cth 1<&

0luid challenge 1) cc<kg!! -6 cc/

-o!!o( "

1( th /ovemember 201S +yspnea-@/O Sensorium4 $, Temp4 (8,&9 , !"4 6, kg, !#4 66 cm

#ead 4 0ontanella $ajor was closed

ye 4 ?ight refle* -@<@/, isochoric pupil, pale inferior conjunctiva

palpebra - < /, sclera icteric - < /

ar 4 within normal range'ose 4 nasal flaring$outh 4 within normal range

'eck 4 lymph node enlargement - /

Thora* 4 symmetrical fusiform, retraction -@/ intercostal, epigastric

#:4 1;) bpm, regular, murmur - /:: 4 &*<i, regular, ronchi -@<@/, wheeBing- < /Abdomen 4 supple, peristaltic -@/', ?iver and Spleen4 no palpable

*tremities 4 pulse 1;) bpm, regular, adeCuate p<v , felt warm,

:T > (D



6

A ++<!roncopneumonia

!ronchiolitisP 2 & 1 ?<min nasal canule

3 0+ + G 'a l ),&& G & gtt<i -micro/

5aracetamol (* 8 mg

3nj Ampicilin 16) mg<6h

3nj %entamycin ;) mg<&;h

'ebule entolin 1 respul@ 'a l ,F G <6h

$eylon &7 m C, J dosis 34 1; m C meylon in 1))cc + G in ; hours

+iet Su 6 ) kkal and 1( gr proteinAt &&.()S dyspnea KK, fever -@/O Sensorium4 % S 1( - ;, (, $6/ , TL (7,7 9

Thora*4 Simetris 0usiformis, retraksi -@/ epigastrial

#:4 16 *<i, reg, murmur - /

::4 6 *<i, reg, stridor -@/, ronchi -@/P 'ebule entolin 1 respul@ 'a l ),FG < 7hR heck blood gas analysis, heck electrolite post correctionAdvise from dr. "isman +alimunthe, SpA

$ucolitic 4% ( * J tab -pulv/Analgetic 5aracetamol4 ; * 1) mg -pulv/

%as blood analysis -1( 'ovember &)1 < &). F/

p# 8.;&8 8.( 8.;

p 2& &8.F mm#g (7 ;&

p2& 16 .) mm#g 7 1))

!icarbonate -# 2(/ 17.) mmol<? & &6

Total 2& 17.F mmol<? 1F &

!ase *cess -! / . mmol<? - &/ I -@&/

2& Saturation FF.; G F 1))



7

Carbo%ydrate etabo!ism

!lood %lucose ad

random

1)7.( mg<d? ;) 6)

lectrolyte

alsium 7.) mg<d? 7.; 1).;

'atrium 1( m C<? 1( 1

5otassium ;.7 m C<? (.6 .

hloride 1)& m C<? F6I1)6

linical hemistry

?iver 0unction Test

0osfatase Alkalase -A?5/ 1;7 E<? >;,6&

AST<S%2T ;6 E<? >(7

A?T<S%5T && E<? >;1

:enal 0unction Test

Ereum 11,6 mg<d? > )reatinin ),&& mg<d? ).18 ),;&

3mmunoserology

Autoimmune - :5 Muantitatif/ ,6 mg<d?

2ther Test -5rocalcitonin/ ).18 ng<m? >),)



8

1; th /ovemember 201S dyspnea -@/O Sensorium4 $, Temp4 (89 , !"4 6, kg, !#4 66 cm

#ead 4 0ontanella $ajor was closedye 4 ?ight refle* -@<@/, isochoric pupil, pale inferior conjunctiva

palpebra - < /, sclera icteric - < /ar 4 within normal range

'ose 4 nasal flaring$outh 4 within normal range

'eck 4 lymph node enlargement


#:4 1;) bpm, regular, murmur - /

:: 4 )*<i, regular, ronchi -@<@/, wheeBing- < /Abdomen 4 supple, peristaltic -@/', ?iver and Spleen4 no palpable

*tremities 4 pulse 1;) bpm, regular, adeCuate p<v , felt warm,

:T > (DA ++<!roncopneumonia


3 0+ + G 'a l ),&& G & gtt<i -micro/

5aracetamol (* 8 mg

3nj Ampicilin 16) mg<6 jam<iv

3nj %entamycin ;) mg<&; jam<iv

3nj +e*ametason &, mg<7 jam<iv

'ebule entolin 1 respul@ 'a l ,F G <7 jam

+iet Su 6 ) kkal dengan 1( gr protein:esult of :adiology e*amination

!oth of sinus costophrenicus are sharp. +iafragma is smooth

3nfiltrate on suprahilar, perihiler, dan parakardial paru bilateral



9

'o cardiomegaly - T: ; G/Trachea in middle

!ones and soft tissue normalonclusion 4 !ronkopneumonia bilateral

1 t%/ovemember 201

S Shortness of breath -@/O Sensorium4 $, Temp4 (8,19 , !"4 6, kg, !#4 66 cm

#ead 4 0ontanella $ayor was closed






#:4 1(7 bpm, regular, murmur - /:: 4 ;6*<i, regular, ronchi -@<@/, wheeBing- < /Abdomen 4 supple, peristaltic -@/', ?iver and Spleen4 no palpable

*tremities 4 pulse 1(7 bpm, regular, adeCuate p<v , felt warm,:T > (D



3 0+ + G 'a l ),&& G & gtt<i -micro/

5aracetamol (* 8 mg



3nj +e*ametason &, mg<7h<iv

3nj Aminophylline $+ 1 cc<1& jam<iv diluted in cc 'a l ),F G bolus

slowly


1 t%/ovemember 201

S Shortness of breath -@/ NN



10

O Sensorium4 $, Temp4 (89 , !"4 6, kg, !#4 66 cm

#ead 4 0ontanella mayor was closed






#:4 1&) bpm, regular, murmur - /

:: 4 ;)*<i, regular, ronchi -@<@/, wheeBing- < /Abdomen 4 supple, peristaltic -@/', ?iver and Spleen4 no palpable*tremities 4 pulse 1(7 bpm, regular, adeCuate p<v , felt warm,

:T > (DA ++<!roncopneumonia


3 0+ + G 'a l ),&& G & gtt<i -micro/



3nj +e*ametason &, mg<7h<iv

3nj Aminophylline $+ 1 cc<1& jam<iv diluted in cc 'a l ),F G bolus

slowly

5aracetamol 8 mg -if needed/

% (* J tabAdvise from dr. "isman +alimunthe, SpA

Aff '%Tonsul for ardiology +ivision -echocardiography/Tappering off 3nj de*amethasone

14 t%/ovemember 201

S Shortness of breath -@/ NNO Sensorium4 $, Temp4 (89 , !"4 6, kg, !#4 66 cm





11


'ose 4 within normal range$outh 4 within normal range



#:4 117 bpm, regular, murmur - /:: 4 ( *<i, regular, ronchi -@<@/, wheeBing- < /Abdomen 4 supple, peristaltic -@/', ?iver and Spleen4 no palpable

*tremities 4 pulse 117 bpm, regular, adeCuate p<v , felt warm,

:T > (D

A ++<!roncopneumonia !ronchiolitis

P 2 & 1 ?<min nasal canule -intermitten/

3 0+ + G 'a l ),&& G & gtt<i -micro/

3nj Ampicilin 16) mg<6h<iv

3nj %entamycin ;) mg<&;h<iv

3nj +e*ametason &mg<1&h<iv -tapering off/

3nj Aminophylline -$+/ 1 cc<1& jam<iv diluted in cc 'a l ),F G bolus

pelan



15 t% /ovemember 201

S +yspnea - /O Sensorium4 $, Temp4 (89 , !"4 6, kg, !#4 66 cm






Thora* 4 symmetrical fusiform, retraction - /

#:4 117 bpm, regular, murmur - /



12

:: 4 ( *<i, regular, ronchi -@<@/, wheeBing- < /Abdomen 4 supple, peristaltic -@/', ?iver and Spleen4 no palpable

*tremities 4 pulse 117 bpm, regular, adeCuate p<v , felt warm,:T > (D


!ronchiolitisP 3 0+ + G 'a l ),&& G & gtt<i -micro/



3nj +e*ametason &mg<1&h<iv -tapering off/

3nj Aminophylline -$+/ 1 cc<1&h <iv diluted in cc 'a l ),F G bolus

slowly



16 t% /ovemember 201

S dyspnea - /

O Sensorium4 $, Temp4 (89 , !"4 6, kg, !#4 66 cm#ead 4 0ontanella $ayor was closed





Thora* 4 symmetrical fusiform, retraction - /

#:4 116 bpm, regular, murmur - /:: 4 &&*<i, regular, ronchi -@<@/, wheeBing- < /Abdomen 4 supple, peristaltic -@/', ?iver and Spleen4 no palpable

*tremities 4 pulse 11) bpm, regular, adeCuate p<v , felt warm,

:T > (D A !roncopneumonia

P 3 0+ + G 'a l ),&& G & gtt<i -micro/





13



CHAPTER 7

S AR8


$alik %eneral #ospital $edan on 1& th 'ovember at &&.(). #is chief complaint

was dyspnea.5atient was diagnosed as bronkopneumonia. 5atient was treated with

paracetamol, ampicilin, gentamycin, ventolin, meylon and aminophylline -$+/.



14

BRONKOPNEUMONIA 2

Documents