Case Presentation BP

7/23/2019 Case Presentation BP

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Case Presentation

Bronchopneumonia Preceptor: dr. Ulynar Marpaung, Sp.A

Presenter: Julianti Mulya Utami - 11020101!

DEPARTMENT OF PEDIATRIC

RADEN SAID SUKANTO POLICE CENTER HOSPITAL

FACULTY OF MEDICINE YARSI UNIERSITY

PERIOD DECEMBER !"#hMARCH $ MEY %&r' %(!)



∗ Name : FAH

∗ Birth Date : October 10th 2014

∗ Age : 6 months∗ Gender : Male∗ Address : eta!ang"M#n$#l∗ Nationalit% : &ndonesia

∗ 'eligion : &slam∗ Date o( admission : A!ril 4th 201)∗ Date o( e*amination: A!ril +th 201)

Patient Identity



,arents &dentit% Father Mother

Name Mr- . Mrs- M

Age 2+ %ears old 2) %ears old

Job /ntre!rene#r Ho#sei(e

Nationality aanese aanese

Religion &slam &slam

Education High 3chool grad#ated5s High 3chool grad#ated5s

Earning/month A!!ro*imatel% '!-2-000-000"

Address eta!ang"M#n$#l-



∗ Alloanamnesis (rom !atient7s mother on thedate o( admission" A!ril 4th 201)-

History Taking

Chief complain:• 8o#gh since ) da%s be(ore admission to the hos!ital-

Additional complains: • F e 2 e r 4 9 5 " s h o r t n e s s o ( b r e a t h " 2 o m i t -



3 day before hospitaladmission, the

patient’s mother saidthat the child still

fever even she got

febrifuge.

5 days beforehospital admission,the child got fever

and cough.

n the !dmissionHospital "ay, the

child #as still feverishand there are

shortness of breath.

History of Present Illness



haryngitis/!onsil

itis

" #acillary

$ysentry

"

Bronchitis Amoeba D%sentr%

,ne#monia Diarrhea

Morbilli .h%!oid

,ert#ssis ;orms

<aricella 3#rger%

Di!hteria Brain 8onc#ssion

Malaria Fract#re

,olio Dr#g 'eaction

/nteritis

History f Past Illness



∗!ntenatal care

!ntenatal check ups performed at the doctor

in the hospital. There #as no problemsduring pregnancy.

∗ $o maternal illness during pregnancy

∗"rugs consumption%

&itamins every antenatal care

,renatal Histor%



∗ 'abor % Hospital

∗ (irth attendants % doctor

∗ )ode of delivery % pervaginam

∗ *estation % 3+ #eeks

∗ Infant state % healthy

∗ (irth #eight % 3-- grams

∗ (ody length % 5- cm

∗ !ccording to the mother, the baby started to cry and the

babys skin is red, no congenital defects #ere reported

Birth Histor%



∗/0amination by mid#ife

∗The state of the infant%

healthy

,ost Natal Histor%



∗ First dentition: 6 months

∗ ,s%chomotor deelo!ment∗ Head =! : 1 month old

∗ 3mile : 1 month old

∗ >a#ghing : 1 2 month old

∗

3lant : 2") months old∗ 3!eech &nitiation : 4 months old

∗ ,rone ,osition : 4 months old

∗ Food 3el( : ) ? 6 months old

∗ 3itting : 6 months old

∗ Mental 3tat#s: Normal

∗ 8oncl#sion: Groth and deelo!ment stat#s is still inthe normal limits and as a!!ro!riate according to the

!atient7s age

Development History



#reast Mil% E&clusi'ely ( month))

Form#la mil@ 1

Bab% bisc#itsBisc#its milna

Fr#it and egetables Banana" 8arrots

History of /ating



*mmuni+ation Fre,uency !ime

#C- 1 time 1 month old

.epatitis # times 0" 1" 6 months old

$! times 2" 4" 6 months old

olio 4 times 0" 2" 4" 6 months

old.ib times 2" 4" 6 months old

Immuni2ation History



∗ ,atient7s both !arents ere married hen the% ere26 %ears old and 24 %ears old" and this is their rstmarriage-

∗ .here are not an% signicant illnesses or chronicillnesses in the (amil% declared-

amily History



Histor% o( her brothers

Childbirth -ender Age

Age $ied umption

$ied

pontan

per'aginam0

gestationaterm

-irl

1 years

2

monthsold

" "



∗There is no one living around their homekno#n for having the same condition as

the patient.

History of the disease people around the patient



∗ The patient lived at the house #ith si2e 4-m 0 - m together #ith

father and mother.

∗ There are door at the front side, toilet near the kitchen and 3

rooms, in #hich room is the bedroom of three of them and

room is for guest. There are #indo#s inside the house. The

#indo#s are ocassionaly opened during the day.

∗ Hygiene%

∗ The patient changes his clothes everyday #ith clean clothes.

∗ (ed sheets changed every t#o #eeks.

6osial and /conomic History



∗ Date :April 1th 3452

∗ -eneral tatus

∗ General condition: mild ill∗ Aareness : 8om!os Mentis∗ ,#lse : 12 *Cmin" reg#lar" (#ll" strong-∗ Breathing rate : 6*Cmin∗ .em!erat#re : +"+o8 !er a*illa5

Physical /0amination



Antropometry tatus

∗ ;eight : " @ilogram∗ Height : 0 cm

Physical /0amination 7cont’d8



N#tritional 3tat#s basedN8H3 National 8enter (orHealth 3tatistics5 %ear

2000:;FA Weight for Age5:"C") * 100 E E good n#trition5HFA Height (or Age5:0C6+ * 100 E 102 E

good n#trition5;FH ;eight (or Height5:")C * 100 E +) Enormal5

Conclusion: The patient

has good nutritionalstatus.



• Head $ormocephaly, hair 7black, normal distributon, not easily removed 8 sign oftrauma 718, large fontanelle closed.

• /yes Icteric sclera -/-, pale con9unctiva 1:1, hyperaemia con9unctiva 1:1 , lacrimation1:1, sunken eyes 1:1, pupils 3mm:3mm isokor, "irect and indirect lightresponse ;;:;;

• /ars $ormal shape, no #ound, no bleeding ,secretion or serumen

• )outh 'ips%Teeth%)ucous%Tongue%

Tonsils% Pharyn0%

dryno cariesmoist $ot dirty

T:T, $o hyperemiahyperemia

• $eck 'ymph node enlargement 718, scrofuloderma 718

6ystematic Physical /0amination



!hora& *nspection:

ymmetric 6hen breathing 0 no retraction0 ictuscordis is not 'isible

,al!ation: mass 5" tactile (remit#s 9C9

,erc#ssion: sonor on a l#ng

A#sc#ltation8or :,#lmo:

reg#lar 3132" m#rm#r 5" gallo! 5esic#lar 9C9" ;heeing C " 'honch% 9C9

Abdomen :&ns!ection : 8one*" e!igastric retraction 5" there is no a idening o(

the eins" no s!ider nei-

,al!ation : s#!!le" lier and s!leen not !al!able" I#id ae 5"

abdominal mass 5

,erc#ssion: .he entire eld o( t%m!anic abdomen" shi(ting d#llness 5

A#sc#ltation: normal boel so#nd" br#it 5



An#s Hole intact" no mass seeno#t o( the an#s

/*tremities arm" ca!illar% rell timeJ 2 second" edema5

3@in Good t#rgor



.ematology Results Normal 7alue

.aemoglobin 10 gCd> 116 gCd>

8eu%ocytes 11-)00CK> )"000 ?

10"000CK>

.ematocrits 0 E 40 ? 4+ E

!rombocytes 6)-000C K> 1)0"000 ?

400"000CK>

Erythrocytes 4"0

millionCK>

4 ? ) millionCK>

Laboratory InvestigationHematology (April 4th 2015



∗ A 6 months old child came to ,olri Hos!ital

ith a chie( com!lain o( co#gh since ) da%sbe(ore admission-

∗ Feer 95" shortness breath" omit-

'/3=M/



∗ Hematolog% April 4th 2015

'es#me--



8eu%ocytes 11-)00CK> )"000 ? 10"000CK>


!rombocytes 6)-000C K> 1)0"000 ?

400"000CK>



∗ (ronchopneumonia

∗ "": (ronkiolitis

!"#$I%& DIA&%"'I'



∗O2 1>Cm∗ &<FD '> )0cc C 24 Ho#rs-∗ &n$- 8e(ota*ime 2*)0 mg &<∗ &n$- De*amethasone * 1 mg &<∗

,8. s%r#! *0"6 cc∗ &nhalation :

∗ Bisolon dro!s tice a da%∗ Na8l 1 cc

A%A&))%*



∗ <uo ad vitam % dubia ad bonam

∗ <uo ad functionam % dubia ad bonam

∗ <uo ad sanactionam% dubia ad bonam

+#"&%"'I'



∗ !pril 4-5 = !pril + 4-5.

Follo =!

April 2th 3452 econd day of hospitali+ation )th day of



Fe'er 9;

hlegm 9;$efecation 9"; < times

= General condition: 8om!os mentis-

Heart rate 110 *Cmin

'es!irator% rate 24*Cmin

.em!erat#re L8

8ardio : 31C32" reg#ler" no m#rm#r" no gallo!

,#lmonar% : esic#ler 9C9" rhonchi C" heeing C

A Deng#e Haemoragic Feer

DDC .h%!oid Feer

− I&" >aen3(, micro drip, 44 dpm ?--cc : 4 Hours.

− In9. @efota0ime 40A-- mg I&

− P@T syrup 30 cth

− Imboost orce 30 cth

− !ntasida syrup 3 0 cth

−

@heck full blood test

April 2th 3452) econd day of hospitali+ation0 )th day ofillness

H t l A il +th 2015





8eu%ocytes -600CK> )"000 ? 10"000CK>


!rombocytes )+-000C K> 1)0"000 ? 400"000CK>

Hematology April +th 2015

April 5>th 3452 !hird day of hospitali+ation (th day of



Fe'er 9;

hlegm 9;

$efecation 9"; < times

= General condition: 8om!os MentisHeart rate 120 *Cmin'es!irator% rate 24*Cmin

.em!erat#re +-)L88ardio : 31C32" reg#ler" no m#rm#r" no gallo!

,#lmonar% : esic#ler 9C9" rhonchi C" heeing C 3@in: &ns!ection: ,etechiae 95 hands and legs



− In9. @efota0ime 40A-- mg I&

− Paracetamol syrup 30 cth



− @heck full blood test

April 5>th 3452) !hird day of hospitali+ation0 (th day ofillness





8eu%ocytes -600CK> )"000 ? 10"000CK>


!rombocytes 2-000C K> 1)0"000 ? 400"000CK>

Hematology !pril Bth 4-5



Fe'er 9;

hlegm 9;

= *eneral condition% @ompos mentis.Heart rate C - 0:min

Despiratory rate C 4?0:min

Temperature C 3AE@

@ardio % 6:64, reguler, no murmur, no gallop

Pulmonary % vesiculer ;:;, rhonchi 1:1, #hee2ing 1:1

6kin% Inspection% Petechiae 7;8 hands and legs



−In9. @efota0ime 40A-- mg I&

− Paracetamol syrup 30 cth



− @heck full blood test

April 34th 3452) Fourth of hospitali+ation0 th day of illness





8eu%ocytes -600CK> )"000 ? 10"000CK>


!rombocytes +6-000C K> 1)0"000 ? 400"000CK>


A!ril 35th 3452 Fifth days of hospitali+ation @th day of



Fe'er 9";0 ?ea%ness 9;

= General condition: com!os mentis

Heart rate 100 *Cmin'es!irator% rate 26*Cmin

.em!erat#re 6-2L88ardio : 31C32" reg#ler" no m#rm#r" no gallo!,#lmonar% : esic#ler 9C9" rhonchi C" heeing C

3@in: ,etechiae 95 hands and legs

A Deng#e Haemoragic Feer − Patient may go home

−

!ff I&" >aen3(, micro drip, 44 dpm ?--cc : 4 Hours.− Paracetamol syrup 30 cth



A!ril 35th 3452) Fifth days of hospitali+ation0 @th day ofillness





8eu%ocytes -600CK> )"000 ? 10"000CK>


!rombocytes 111-000C K> 1)0"000 ? 400"000CK>




'iterature Devie# and "iscussion



Denition



/tiology



,atho!h%siolog%



8linical Mani(estation



3tages o( He!atic /nce!halo!ath%



Diagnosis



>aborator% Findings

. t t



.reatment



,rognosis



Case Presentation BP

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