Bronkopneumonia (Theodora and Anusha)

i
Case Report
BRONCHOPNEUMONIA
SUPERVISOR
: dr. Rina A. C. Saragih, M. Ked (Ped), Sp. A
PRESENTATOR
: Theodora Purba
Anusha Chandra Sikaran
110100267
110100414
DEPARTMENT OF CHILD HEALTH

MEDICAL FACULTY NORTH SUMATRA UNIVERSITY
H. ADAM MALIK GENERAL HOSPITAL
MEDAN
2015
ii
ACKNOWLEDGMENTS
We are greatly indebted to the Almighty One for giving us blessing to finish this case
report,Bronchopneumonia. This case report is a requirement to complete the clinical
assistance program in Department of Child Health in H. Adam Malik General Hospital,
Medical Faculty of North Sumatra University.
We are also indebted to our supervisor and adviser, dr. Rina Amelia, Sp.A (K) for
much spent time to give us guidances, comments, and suggestions. We are grateful because
without him this case report wouldnt have taken its present shape.
This case report has gone through series of developments and corrections. There were
critical but constructive comments and relevants suggestions from the reviewers. Hopefully
the content will be useful for everyone in the future.
Medan, th November 2015
Presentator
TABLE OF CONTENTS
COVER ........................................................................................................... . i
ACKNOWLEDGMENTii
TABLE OF CONTENT ............................................................................... ..3
CHAPTER I INTRODUCTION ....................................................................4
CHAPTER II LITERATURE REVIEW ...................................................... 6
2.1. Definition
....................................................................................6
2.2. Classification
2.3. Etiology
............................................................................. 6
....................................................................................... 7
2.4. Pathogenesis and Pathophysiology

2.5. Clinical Manifestation
2.6. Diagnosis
. 9
.................................................................13
.............................................................................13
2.7. Treatment and Management

2.8. Complications
...14
................................................................................ 15
CHAPTER III CASE REPORT .....................................................................16

3.1 Objective
3.2 Case
......................................................................................... 16
..................................................................................................16
3.3 Follow Up
....................................................................................... .22
CHAPTER IV DISCUSSION ..........................................................................30

CHAPTER V SUMMARY .............................................................................. 31
REFERENCES .......................................................................
.....................32
CHAPTER 1
1.1. Introduction
Each year, pneumonia kills more than 4 million people and causes illness
in millions more around the world. In developed countries, pneumonia primarily
affects elderly persons. However, half of pneumonia-related deaths worldwide
actually occur among children under age five most of whom live in developing
countries. For every child that dies from pneumonia in developed countries, more
than 2,000 children die from pneumonia in developing countries.9
Data from the World Health Organization confirm that acute respiratory
illness remains a leading cause of childhood mortality, causing an estimated 1.6
2.2 million deaths globally in children < 5 years. 14,15 In North America the annual
incidence in children younger than 5 years of age is 3440 cases per 1000.11
In the UK, from 750 children assessed in hospital, incidence of CAP was
144/10 000 children per year and 338 for <5-year-olds; with an incidence for
admission to hospital of 122 and 287 respectively. Risk of severe CAP was
significantly increased for those aged <5 years and with prematurity.4
In Indonesia, Pneumonia is the 2nd most common cause of death in
children after diarrhea (15,5%). A 2007 study conducted by the Indonesia
Ministry of Health shows that 30.470 children died from pneumonia that year,
which is equal to 83 children in a day.10 Pneumonia is also listed as the third cause
to cause the fatality among children besides the cardiovascular diseases and
tuberculosis.
About 27.6% of death among babies and 22.8% in children is observed in
Indonesia due to respiratory disease, especially pneumonia. In RSUD Dr.
Soetomo located in Surabaya, pneumonia is listed at fourth among the ten most
treated diseases in a year. Mortality rate in children those who are admitted in the
hospital are estimated around 20-35%.8,10
According to the WHO publication, the research done in different

countries shows that S.pneumoniae and H.influenza are the most common bacteria
found in the developing countries which is 73% found from pulmonary aspiration
and 69.1% are from blood specimen.6
1.2 Objective
This paper is one of the requirements to fulfill the senior clinical assistance
programs in the Pediatric Department of Haji Adam Malik General Hospital,
University of Sumatera Utara. This paper was written to report a case of a 5
months old girl with the diagnosis of Bronchopneumonia.
CHAPTER 2
LITERATURE REVIEW
2.1. Definition
Pneumonia defines where it is an infection that inflames the air sacs in one or both
lungs. The air sacs filled with fluid or pus, causing cough with phlegm, fever,
chills and difficulty in breathing. Clinically, pneumonia is defined as an inflamed
lung which caused by microorganisms (bacteria, virus, fungal and parasite),
prolonged exposure to chemicals and radiations, aspiration, drugs and others.1
Bronchopneumonia is the inflammation at the respiratory tract which starts from
bronchus until the alveoli. The tract is blocked by mucopurulent exudates that
forms patch consolidation at the nearest lobules. This condition is always
secondary which always joins the upper respiratory tract infection, followed by
fever caused by infection, diseases that causes immunosuppression.5
Anatomically, pneumonia are divided into three categories:
1. Lobar pneumonia
2. Interstitial pneumonia (bronchiolitis)
3. Lobular pneumonia (bronchopneumonia)
2.2. Classification
WHO provide guidelines on classification of pneumonia according to the age
which as follows:8,16
1. Age < 2 months
a. Severe pneumonia
- Chest indrawing (subcostal retraction)
- Tachypnea (> 60x/minutes)
b. Very Severe Pneumonia
- Poorly fed
- Seizures
- Loss of conscious
- Hyperthermia/ hypothermia
- Bradypnea
2. Age 2 months 5 years
a. Mild pneumonia
- Tachypnea (> 60x/minutes)
b. Severe pneumonia
- Chest indrawing (subcostal retraction)
- Tachypnea
>50x/minute for children age from 2 months 1 year
>40x/minute for children age from >1-5 years
c. Very Severe Pneumonia
- Poorly fed
- Seizures
- Loss of conscious
- Malnutrition
2.3 ETIOLOGY
The etiology of pneumonia differs between children and adults. Because of
this, age plays a very important role in determining the cause of pneumonia in
children.17
Table 1.The etiology of pneumonia based on Age17
Age
Born- 20 days
Common Etiology
Bacteria
Less common Etiology

Bacteria
E. Coli
Anaerobic bacteria
Group B Streptococcus
Haemophilus influenza
Listeria monocytogenes
Streptococcus pneumonia
Virus
CMV
3 weeks-3 months
Bacteria
Herpes Simpleks Virus

Bacteria
Chlamydia trachomatis
Bordetella pertussis
Haemophillus
Virus
type B
Respiratory
4 months- 5 years
Synctial
influenza
Staphylococcus aureus
Virus
Virus
Adeno Virus
CMV
Influenza Virus
Bacteria
Bacteria
Chlamydia pneumonia
Haemophillus
Mycoplasma pneumonia
type B
Virus
Neisseria meningitidis
Adeno Virus
Virus
Influenza Virus
Varicella-Zoster virus
influenza
RinoVirus
Parainfluenza Virus
Respiratory
6 years-teenagers
Synctial
Virus
Bacteria
Bacteria
Chlamydia pneumonia
Haemophillus
Mycoplasma pneumonia
Virus
influenza
Adeno Virus
Influenza Virus
RinoVirus
Parainfluenza Virus
Respiratory
Synctial
Virus
Varicella-zoster Virus
There are several known risk factors for CAP to consider in addition to
immunization status, exposure to other children, especially preschoolers, asthma,
history
of
wheezing
episodes,
tobacco
smoke
exposure,
malnutrition,
immunological deficits, mucocilliary dysfunction (cystic fibrosis, cilliary

dyskinesia), congenital malformation of airways, impaired swallowing. 2 Tobacco
smoke exposure has been found to increase risk of hospitalization for pneumonia
in children < 5. Conditions predisposing to severe pneumonia include age <5 and
prematurity.12
2.4. Pathogenesis and pathophysiology3
An inhaled infectious organism must bypass the host's normal nonimmune
and immune defense mechanisms in order to cause pneumonia. The nonimmune
mechanisms include aerodynamic filtering of inhaled particles based on size,
shape, and electrostatic charges; the cough reflex; mucociliary clearance; and
several secreted substances (eg,lysozymes, complement, defensins). Macrophages,
neutrophils, lymphocytes, and eosinophils carry out the immune-mediated host
defense.
Pneumonia is characterized by inflammation of the alveoli and terminal
airspaces in response to invasion by an infectious agent introduced into the lungs
through hematogenous spread or inhalation. The inflammatory cascade triggers
the leakage of plasma and the loss of surfactant, resulting in air loss and
consolidation.
The activated inflammatory response often results in targeted migration of
phagocytes, with the release of toxic substances from granules and other
microbicidal packages and the initiation of poorly regulated cascades (eg,
complement, coagulation, cytokines). These cascades may directly injure host
tissues and adversely alter endothelial and epithelial integrity, vasomotor tone,
intravascular hemostasis, and the activation state of fixed and migratory
phagocytes at the inflammatory focus. The role of apoptosis (noninflammatory
programmed cell death) in pneumonia is poorly understood.
Pulmonary injuries are caused directly and/or indirectly by invading
10
microorganisms or foreign material and by poorly targeted or inappropriate

responses by the host defense system that may damage healthy host tissues as
badly or worse than the invading agent. Direct injury by the invading agent
usually results from synthesis and secretion of microbial enzymes, proteins, toxic
lipids, and toxins that disrupt host cell membranes, metabolic machinery, and the
extracellular matrix that usually inhibits microbial migration.
Indirect injury is mediated by structural or secreted molecules, such as
endotoxin, leukocidin, and toxic shock syndrome toxin-1 (TSST-1), which may
alter local vasomotor tone and integrity, change the characteristics of the tissue
perfusate, and generally interfere with the delivery of oxygen and nutrients and
removal of waste products from local tissues.
On a macroscopic level, the invading agents and the host defenses both
tend to increase airway smooth muscle tone and resistance, mucus secretion, and
the presence of inflammatory cells and debris in these secretions. These materials
may further increase airway resistance and obstruct the airways, partially or
totally, causing airtrapping, atelectasis, and ventilatory dead space. In addition,
disruption of endothelial and alveolar epithelial integrity may allow surfactant to
be inactivated by proteinaceous exudate, a process that may be exacerbated
further by the direct effects of meconium or pathogenic microorganisms.
In the end, conducting airways offer much more resistance and may
become obstructed, alveoli may be atelectatic or hyperexpanded, alveolar
perfusion may be markedly altered, and multiple tissues and cell populations in
the lung and elsewhere sustain injury that increases the basal requirements for
oxygen uptake and excretory gas removal at a time when the lungs are less able to
accomplish these tasks.
The stages of pneumonia consists of 4 which as follows:13
Pneumonia has four stages, namely consolidation, red hepatization, grey
hepatization and resolution.
11
Consolidation
o Occurs in the first 24 hours
o Cellular exudates containing neutrophils, lymphocytes and fibrin replaces the
alveolar air
o Capillaries in the surrounding alveolar walls become congested
o The infections spreads to the hilum and pleura fairly rapidly
o Pleurisy occurs
o Marked by coughing and deep breathing
Red Hepatization
o Occurs in the 2-3 days after consolidation
o At this point the consistency of the lungs resembles that of the liver
o The lungs become hyperemic
o Alveolar capillaries are engorged with blood
o Fibrinous exudates fill the alveoli
o This stage is characterized by the presence of many erythrocytes, neutrophils,
desquamated epithelial cells, and fibrin within the alveoli

Grey Hepatization
o Occurs in the 2-3 days after Red Hepatization
o This is an avascular stage
o The lung appears gray-brown to yellow because of fibrinopurulent exudates,
disintegration of red cells, and hemosiderin

o The pressure of the exudates in the alveoli causes compression of the capillaries
o Leukocytes migrate into the congested alveoli
12
Resolution
o This stage is characterized by the resorption and restoration of the pulmonary
architecture
o A large number of macrophages enter the alveolar spaces
o Phagocytosis of the bacteria-laden leucocytes occurs
o Consolidation tissue re-aerates and the fluid infiltrate causes sputum
o Fibrinous inflammation may extend to and across the pleural space, causing a rub
heard by auscultation, and it may lead to resolution or to organization and pleural

adhesions
2.5. Clinical Manifestation

Signs and symptoms can vary depending on causing pathogen, patients age and
immunologic status and the severity of the disease.1,8
Prodromal symptoms:
1. High fever followed by shivering
2. Headache
3. Uncomfortable
Gastrointestinal disturbances:
1. Vomiting
2. Bloating
3. Diarrhea
4. Stomachache
Pulmonary Symptoms:
1. Nasal Flaring
2. Tachypnea
3. Dyspnea
13
4. Apnea
5. Usage of respiratory accessory muscles (Intercostal and Abdominal)
6. Cough
7. Retraction of subcostal during inspiration followed by tachypnea
8. Dull Percussion
9. Fremitus Sound Weakens
10. Rales
Respiratory rate is the most sensitive index to measure the severity of the disease.
It is used to support the diagnosis and monitor the management. Respiratory rate
is measured while the child is calm or asleep.
WHO has provide the criteria to measure tachypnea according to age which a
follows:8
< 2 months : 60x/minute
2 months 1 year : 50x/minute
1-5 years : 40x/minute
2.6. Diagnosis
1. Anamnesis
The symptoms can occur suddenly but also can be started by the upper respiratory
tract infection. The other symptoms are cough, high continuous fever, and
dyspnea, bluish around the lips, shivering, seizures and chest pain. Normally
children tend to lie down on the pain side.15,17
2. Physical Diagnostics
Tachypnea, chest retraction, grunting, and cyanosis often found on neonate. At the
older babies, grunting is seldom discovered. The symptoms that often discovered
are tachypnea, retraction, cyanosis, cough, fever and irritability.
In preschool children, fever, productive or non-productive cough, tachypnea, and
dyspnea often found on them.17
Typical findings on physical examinations include:
-
dullness on percussion of the chest
decreased breath sounds
14
additional breath sounds such as ronchi and wheeze
3. Laboratory Diagnostics
Blood studies on pneumonia often shows that leukocytosis (>15 000/mm3).9,13
4. Supporting Investigation:
a. Radiology
Chest x-ray is the main supporting diagnostics to define the diagnosis. On babies,
infiltrate often found on their chest x-ray. In bronchopneumonia, patchy infiltrates
are discovered in one or few lobules. If it is a diffuse then it is often caused by
Staphylococcus pneumonia.17
b. C-Reactive protein
c. Serologic test
d. Microbiology test
Diagnostics Criteria
Pneumonia can be confirmed if there are 3 of out 5 symptoms found, which as
follows:
a. dyspnea followed by nasal flaring dan retraction of chest wall during breathing
b. high fever
c. crackles caused by rales
d. chest x-ray that shows diffuse infiltrate
e. leukocytosis
2.7. Treatment & Management
The treatment of pneumonia in children consists of appropriate antibiotics
for the offending organisms, supportive treatment such as oxygen, iv fluid and
the correction of acid base disorder17.
a. Outpatient settings
The first line antibiotic for outpatient settings is Amoxicillin 20 mg/kg
or Cotrimoxazole (4mg/kg of Trimetoprim and 20 mg/kg of
Sulfamethoxazole)
15
b. Inpatient settings
The first line antibiotics for inpatient settings is Beta Lactamase group
or Chloramphenicol.
Antibiotic is administered for 7-10 days. Antibiotic must be given as
soon as possible in neonates. Broad spectrum antibiotics such as the
Beta Lactamase group or third generation of cephalosporine are
recommended. Upon stabilization, iv antibiotics can be switched to
oral antibiotics and patients can be treated in the outpatient settings.
2.8. Complications
Complication often happen when there are dispersion of bacteria in thoracic
region which cause such as pleural effusion, empyema, pericarditis.
16
CHAPTER III
CASE REPORT
3.1 Objective
The objective of this paper is to report a case of a 11 month old boy with a
diagnosis of bronchopneumonia.
3.2 Case
AS, a 11 month old boy, with 6,5 kg of BW and 66 cm of BH, came to Haji Adam
Malik General Hospital Medan on 12th November at 22.30. His chief complaint
was shortness of breath.
History of disease:
Malik General Hospital Medan on 12th November at 22.30 with shortness of
breath as chief complaint. The patients have been experienced this about 1 week
before admitted to hospital. Dyspnea was not directed with weather and activity.
Cyanosis (-), patient also experienced cough since 2 weeks ago followed by
sputum. History of contact with adult cough (-). Fever has been experienced by
patient since 2 weeks and the body temperature rises and drop. Shivering was not
found. Vomiting (-) and nausea (-). Defecation and urination is normal. History of
weight loose is not found.
History of medication:
O2, IVFD ringer lactate, nebule ventolin, inj meropenem, triamsinolon,
bromhexine an salbutamol
History of family:
There is no famiy history of similar disease found.
17
History of parents medication:

Not found
History of pregnancy:
Patients mother was 31 years old during pregnancy. She regularly goes for
control. No history of complication neonate and maternal problem. Consumtion of
herbal medication (-)
History of birth:
Patient was first child. Gestational age was preterm (28 weeks). Body weight was
1200 gram, body length was not measured. Birth was assisted by traditional
midwife. Baby was born normally and cried spontaneously. Blusih was not found.
History of immunization:
Not complete
History of growth and development:
Patients mother explained that he grew normally. He was able to crawl and sit
appropriately based on his age.
Physical Examination:
Present status:
Sensorium : CM, body temperature: 37,6C, HR: 138 bpm, RR: 54 x/i, BW: 6,5
kg, BH: 66 cm, BW/A: Z score < -3 , BL/A: Z score < -3, BW/BL: -1< Z score <
-2, anemic (-), icteric (-), dyspnea (+), cyanosis (-), edema (-).
Localized status:
Head
: Face: within normal range
Eyes: light reflex +/+, isochoric pupil, pale inferior palpebral
conjuntiva -/-, superior and inferior palpebra edema-/Ears: within normal range
18
Nose: nasal flaring

Mouth : within normal range
Neck
: Lymph node enlargement (-)
Thorax
: Symmetrical fusiform, retraction intercostal and epigastric (+)

HR: 138 bpm, regular, murmur (-)
RR: 54x/i, regular, rales (+/+), wheezing (-/-)
Abdomen
: Symmetric, supple, normal peristaltic, liver and spleen: normal
Extremities : Pulse 138 bpm regular, adequate p/v, felt warm, CRT < 3
Working diagnosis
: DD
bronchopneumonia
bronchiolitis
Laboratory finding
Complete blood analysis (12th November 2015 / 23.03)
Test
Result
Unit
References
Hemoglobin
9.20
g%
11.3-14.1
Erythrocyte
3.51
106/mm3
4.40-4.48
Leucocyte
19.74
103/mm3
6.0-17.5
Thrombocyte
263
103/mm3
217-497
Hematocrite
28.70
37-41
Eosinophil
0.50
1-6
Basophil
0.500
0-1
Neutrophil
51.00
37-80
Lymphocyte
39.90
20-40
Monocyte
8.10
2-8
Neutrophil absolute
10.08
103/L
1.9-5.4
Lymphocyte
7.88
103/L
3.7-10.7
1.59
103/L
0.3-0.8
absolute
Monocyte absolute
19
Eosinophil absolute
0.09
103/L
0.20-0.50
Basophil absolute
0.10
103/L
0-0.1
MCV
81.80
Fl
81-95
MCH
26.20
Pg
25-29
MCHC
32.10
g%
29-31
Clinical chemistry (12 November 2015 / 23.03)

Test
Result
Unit
References
Blood Glucose
71.70
mg/Dl
40-60
Ureum
14.70
mg/dL
< 50
Creatinine
0.23
mg/dL
0.17-0.41
Natrium
136
mEq/L
135-155
Potassium
5.3
mEq/L
3.6-5.5
Chloride
100
mEq/L
96106
Procalcitonin
0.42
ng/mL
<0.05
Blood gas analysis (12 November 2015 / 23.03)

pH
7.155
7.35-7.45
pCO2
38.7
mmHg
38-42
pO2
177.5
mmHg
85-100
Bicarbonate (HCO3) 13.4
mmol/L
2-26
Total CO2
14.5
mmol/L
19-25
Base Excess (BE)
-14.5
mmol/L
(-2) (+2)
O2 Saturation
98.8
95-100
20
Result of Radiology examination

- Both of sinus costophrenicus are sharp. Diafragma is smooth
- Infiltrate on suprahilar, perihiler, dan parakardial paru bilateral
- No cardiomegaly (CTR 45%)
- Trachea in middle
- Bones and soft tissue normal
Conclusion : Bronkopneumonia bilateral
Therapy:
O2 1-2 L/ min via nasal cannula
IVFD D5% NaCl 0,225% 25 gtt/menit (micro)
Fluid challenge 10 cc/kgBB (65 cc)
Inj Ceftriaxone 300 mg/ 12 hours /iv
21
Paracetamol syrup 3x cth 1/2

Follow Up
13th Novemember 2015
Dyspnea(+)
S
O
Sensorium: CM, Temp: 37,2C, BW: 6,5 kg, BH: 66 cm
Head : Fontanella Major was closed
-
Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva

palpebra (-/-), sclera icteric (-/-)
- Ear : within normal range
- Nose : nasal flaring
- Mouth : within normal range
Neck : lymph node enlargement (-)
Thorax : symmetrical fusiform, retraction (+) intercostal, epigastric
-

RR : 52x/i, regular, ronchi (+/+), wheezing(-/-)
Abdomen : supple, peristaltic (+)N, Liver and Spleen: no palpable
Extremities : pulse 140 bpm, regular, adequate p/v , felt warm,
CRT < 3
DD/Bronchopneumonia
Bronchiolitis
O2 1 L/min nasal canule
IVFD D5% NaCl 0,225 % 25gtt/i (micro)
Paracetamol 3x 75 mg
Inj Ampicilin 160 mg/6h
Inj Gentamycin 40 mg/24h
Nebule Ventolin 1 respul+ NaCl ,9 % /6h
Meylon 28 mEq, dosis I: 14 mEq meylon in 100cc D5% in 4 hours
Diet Sv 650 kkal and 13 gr protein

At 22.30
S
dyspnea , fever (+)
O
Sensorium: GCS 13 (E4, V3, M6) , T= 38,8 C
Thorax: Simetris Fusiformis, retraksi (+) epigastrial
HR: 165x/i, reg, murmur (-)
P
RR: 65x/i, reg, stridor (+), ronchi (+)

Nebule Ventolin 1 respul+ NaCl 0,9% / 8h
22
R
Check blood gas analysis, Check electrolite post correction
Advise from dr. Wisman Dalimunthe, SpA
-
Mucolitic :GE 3 x tab (pulv)

Analgetic Paracetamol: 4 x 10 mg (pulv)
Blood gas analysis (13 November 2015 / 20.59)

pH
7.427
7.35-7.45
pCO2
27.9
mmHg
38-42
pO2
165.0
mmHg
85-100
Bicarbonate (HCO3) 18.0
mmol/L
2-26
Total CO2
18.9
mmol/L
19-25
Base Excess (BE)
-5.5
mmol/L
(-2) (+2)
O2 Saturation
99.4
95-100
mg/dL
40-60
Carbohydrate Metabolism
Blood Glucose ad 108.3
random
Electrolyte
Calsium
8.0
mg/dL
8.4-10.4
Natrium
135
mEq/L
135-155
Potassium
4.8
mEq/L
3.6-5.5
Chloride
102
mEq/L
96106
23
Clinical Chemistry
Liver Function Test
Fosfatase Alkalase (ALP)
148
U/L
<4,62
AST/SGOT
46
U/L
<38
ALT/SGPT
22
U/L
<41
Renal Function Test

Ureum
Creatinin
11,6
0,22
mg/dL
mg/dL
<50
0.17-0,42
Immunoserology
Autoimmune (CRP Kuantitatif)
Other Test (Procalcitonin)
5,6
0.17
mg/dL
ng/mL
<0,05

S
dyspnea (+)
O
Sensorium: CM, Temp: 37C, BW: 6,5 kg, BH: 66 cm
Head : Fontanella Major was closed
-

Neck : lymph node enlargement (-)
-

CRT < 3
DD/Bronchopneumonia
24
Bronchiolitis
Inj Ampicilin 160 mg/6 jam/iv
Inj Gentamycin 40 mg/24 jam/iv
Inj Dexametason 2,5 mg/8 jam/iv
Nebule Ventolin 1 respul+ NaCl ,9 % /8 jam
Diet Sv 650 kkal dengan 13 gr protein

S
O
Shortness of breath (+)

Sensorium: CM, Temp: 37,1C, BW: 6,5 kg, BH: 66 cm
Head : Fontanella Mayor was closed
-

Neck : lymph node enlargement(-)
-

CRT < 3
DD/Bronchopneumonia
Bronchiolitis
Inj Dexametason 2,5 mg/8h/iv
25
Inj Aminophylline MD 1 cc/12 jam/iv diluted in 5 cc NaCl 0,9 % bolus

slowly
16thNovemember 2015
S
O

Head : Fontanella mayor was closed
-

-

CRT < 3
DD/Bronchopneumonia
Bronchiolitis
Inj Dexametason 2,5 mg/8h/iv
Inj Aminophylline MD 1 cc/12 jam/iv diluted in 5 cc NaCl 0,9 % bolus
slowly
Paracetamol 75 mg (if needed)
GE 3x tab
Advise from dr. Wisman Dalimunthe, SpA
-
Aff NGT
Consul for Cardiology Division (echocardiography)
Tappering off Inj dexamethasone
26

S
O

-

- Nose : within normal range
-

CRT < 3
DD/Bronchopneumonia
Bronchiolitis
O2 1 L/min nasal canule (intermitten)
Inj Ampicilin 160 mg/6h/iv
Inj Gentamycin 40 mg/24h/iv
Inj Dexametason 2mg/12h/iv (tapering off)
Inj Aminophylline (MD) 1 cc/12 jam/iv diluted in 5 cc NaCl 0,9 % bolus
pelan

S
O
Dyspnea (-)
-

27

Thorax : symmetrical fusiform, retraction (-)
-

CRT < 3
DD/Bronchopneumonia
Bronchiolitis
Inj Dexametason 2mg/12h/iv (tapering off)
Inj Aminophylline (MD) 1 cc/12h /iv diluted in 5 cc NaCl 0,9 % bolus
slowly

S
O
dyspnea (-)
-

Thorax : symmetrical fusiform, retraction (-)
-

28
A
P

CRT < 3
Bronchopneumonia
29
CHAPTER IV
DISCUSSION
Case
Theory
Patient was admitted to the hospital Signs and symptoms can vary
with complaints such as :
depending on causing pathogen,
Dyspnea
patients age and immunologic status
Cough followed sputum
and the severity of the disease.
fever
Prodromal symptoms:
Diarrhea
1. High fever followed by shivering
Weight Lost
2. Headache
Nasal Flaring
3. Uncomfortable
Epigastric retraction
Gastrointestinal disturbances:
1. Vomiting
2. Bloating
3. Diarrhea
4. Stomachache
Pulmonary Symptoms:
1. Nasal Flaring
2. Epigastric retraction
Blood studies on pneumonia often In this case, patients complete blood
shows leukocytosis (>15 000/mm3).
study shows leukocytosis and the chest
Chest x-ray is the main supporting X-ray supports the diagnosis
diagnostics to define the diagnosis. On
babies, infiltrate often found on their
chest x-ray. In bronchopneumonia,
patchy infiltrates are discovered in one
or few lobules
The management of pneumonia The patient is treated with oxygen
patients includes supportive therapy supply, fluid and nutrition supply,
and etiologic therapy.
antibiotic (eg Beta Lactamase Group),
1. Oxygen supply 1-2L/minute.
and nebulizer to remove the mucus
2. Adequate supply of fluid and from the lungs.
nutrition.
3. Correction of electrolyte or
metabolic imbalance that occurs
4.
Antibiotics:Ampicilin
and
gentamycin
5. Inhalant therapy: Nebule Ventolin
30
CHAPTER V
SUMMARY
Malik General Hospital Medan on 12th November at 22.30. His chief complaint
was dyspnea. Patient was diagnosed as bronchopneumonia which confirmed with
clinical manifestasion (fever, shortness of breath, cough) and chest X-ray. Patient
was treated with paracetamol, ampicilin, gentamycin, ventolin, meylon and
aminophylline (MD). Patient is discharged from hospital on 19 November 20015
after patient condition was stable.
31
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Pulmonology, Pediatric Allergy and Clinnical Immunology, Poland: 2013.
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Bennett,
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Pediatric
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2015.
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(http://emedicine.medscape.com/article/967822-overview#a3
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Clark, J. e., Hammal, D., Hampton, F., Spencer, D., & Parker, L.
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pneumonia.
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: dr. Rina A. C. Saragih, M. Ked (Ped), Sp. A

DEPARTMENT OF CHILD HEALTH

Medan, th November 2015

2.4. Pathogenesis and Pathophysiology

2.7. Treatment and Management

CHAPTER III CASE REPORT .....................................................................16

CHAPTER IV DISCUSSION ..........................................................................30

According to the WHO publication, the research done in different

Less common Etiology

Herpes Simpleks Virus

immunological deficits, mucocilliary dysfunction (cystic fibrosis, cilliary

microorganisms or foreign material and by poorly targeted or inappropriate

desquamated epithelial cells, and fibrin within the alveoli

disintegration of red cells, and hemosiderin

heard by auscultation, and it may lead to resolution or to organization and pleural

2.5. Clinical Manifestation

< 2 months : 60x/minute

2 months 1 year : 50x/minute

1-5 years : 40x/minute

dullness on percussion of the chest

decreased breath sounds

additional breath sounds such as ronchi and wheeze

History of parents medication:

Nose: nasal flaring

: Lymph node enlargement (-)

: Symmetrical fusiform, retraction intercostal and epigastric (+)

: Symmetric, supple, normal peristaltic, liver and spleen: normal

Clinical chemistry (12 November 2015 / 23.03)

Blood gas analysis (12 November 2015 / 23.03)

Bicarbonate (HCO3) 13.4

Base Excess (BE)

Result of Radiology examination

Paracetamol syrup 3x cth 1/2

Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva

HR: 140 bpm, regular, murmur (-)

Diet Sv 650 kkal and 13 gr protein

RR: 65x/i, reg, stridor (+), ronchi (+)

Mucolitic :GE 3 x tab (pulv)

Blood gas analysis (13 November 2015 / 20.59)

Bicarbonate (HCO3) 18.0

Base Excess (BE)

Renal Function Test

14th Novemember 2015

Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva

HR: 140 bpm, regular, murmur (-)

15th Novemember 2015

Shortness of breath (+)

Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva

HR: 138 bpm, regular, murmur (-)

Inj Aminophylline MD 1 cc/12 jam/iv diluted in 5 cc NaCl 0,9 % bolus

Shortness of breath (+)

Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva

HR: 120 bpm, regular, murmur (-)

17th Novemember 2015

Shortness of breath (+)

Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva

HR: 118 bpm, regular, murmur (-)

18th Novemember 2015

Eye : Light reflex (+/+), isochoric pupil, pale inferior conjunctiva

- Ear : within normal range

HR: 118 bpm, regular, murmur (-)

19th Novemember 2015