pneumonia

Dian Handayani
Hanifah Aldi Puteri
Lia Pertiwi
Ulfa Mariyanti

SUPERVISOR
dr. Riza Iriani Nasution, Sp. A

PEDIATRIC DEPARTMENT OF
MEDICAL FACULTY OF RIAU UNIVERSITY
 Identity
– Name : By. SN
– No MR : 01006346
– Date of admission : 21th January 2019
– Date of examination : 21th January 201
– Date of discharge : 14th February 2019
– Patient status : Alive
– Day of treatment : 25 days

Chief Complaint
Shortness of breath since 2 weeks before entering
the hospital
 History of Present Illness

2 weeks Breathless, fever

Dry cough -> Cough with phlegm, 2 times

3 weeks
seizure (1st : for 10 miutes, 2nd : for 5
minutes) -> without fever

Because the shortness of breath is getting worse -> clinic (febrifuge and cough medicine) ->
complaints do not decrease -> the patient was referred to the Puri Husada Hospital and treated for
2 weeks with a diagnosis of plmonary infection and observation of seizure with a dd of epilepsi ->
periodic apnue -> refer to RSUD AA
 Past Medical History FH Family History
• Seizure (2 years old) No family with the same complaint
• Repeated history of shortness of
PMH
breath is denied

PH
Pregnancy History
Parents History
• Mother : 22 years old, High
HP • P1, aterm, spontan in widwife,
weight 3.300 gram.
• 4 times ANC in midwife.
School, housewife • Untreated vaginal discharge (+)
• Father : 25 years old, Junior
High School, enterpriser

Dietary Vaccination
0-now ASI Never vaccines
Growth :
- Birth weight : 3,3 kg => 3,6 kg
- Birth length : 43 cm => 45 cm
Development :
- Rough motoric : can turn around
- Fine motor : trying to reach
- Speak up : turned towards the sound
- Social : trying to reach for food

History of housing and residence :

- Home : permanent and sufficient ventilation
- Total bedroom : 1 and total of residents is 5 people
- Father : smoker
 - General appearance : moderate illness
- Awareness : Composmentis
- Vital signs : Pulse (84x/i), RR (52x/i), T

Head to neck : within normal (38,2ºC)

limits

Torax
- Inspection : retraction of intercostae and subcostae (+)
- Auscultation : fine wet cracks (+/+)

Nasal lobe breath (+)

Abdomen and Extremities : within normal limits

Lab Work up Chest X-Ray AP
Routine Blood Tests (21/01/2019)
Hb : 14,3 g/dl
Hematokrit : 51,1%
Leukosit :11.070 /ul
Eritrosit : 4,88 x 106/ul
Trombosit : 163.000 /ul
MCV : 105,5 fl
MCH : 29,3 pg
MCHC : 27,8 g/Dl

Diff Count :
Neutrofil : 42,2
Limfosit : 43,8
Monosit : 11,7
Eosinofil : 0,3
Basofil : 2,0

Cor : Configuration looks great

Pulmo : Pneumonia dextra
Working Diagnosis

Pneumonia + Epilepsi
Medikamentosa : - Tuberculin test
- IVFD 2A ¼ 8cc/jam - Culture and gram coloring
- O2 NRM 5 l/menithh sputum
- Inj. Ampisilin sulbactam 150 mg/8 jam - CRP and LED
- Drip PCT 3 x 0,4 cc - Gen expert sputum
Gizi : - Kultur darah
RDA X BBI = 100 x 6,9 = 690 kkal - Pulse oxymetri

PROGNOSIS
Quo ad vitam : Bonam
Quo ad functionam : Bonam
Week Subjektif Objektif
Week 1 Shortness of breath, cough, CM, frequency of breath, pulse
seizure 1 time at night for 5 and T are stable, breath nostrils,
minutes. retraction intercostae and
subcostae, fine wet rhonki
Week 2 Shortness of breath, CM, frequency of breath, pulse
coughing, seizure 3 times for and T are stable, breath nostrils,
3 minutes. retraction intercostae and
subcostae, fine wet rhonki
Week 3 Shortness of breath, cough, CM, frequency of breath, pulse
seizure (-). and T are stable, breath nostrils,
retraction intercostae and
subcostae, fine wet rhonki, gene
expert (MTB not detected)
Week 4 Shortness of breath (-), cough CM, frequency of breath, pulse
(-), seizure (-). and T are stable, pigeon chest
appears
Assesment Treathment
Pneumonia + Epilepsi IVFD 2A ¼ 8cc/jam, O2 Nasal canul 2 l/menit, Inj.
Ampisilin sulbactam 150 mg/8 jam, PCT drip 0,4 cc/3 jam
(kp), Kepra 2 x 75 mg PO, ASI 12-20 cc/15 menit
Pneumonia + Epilepsi IVFD 2A ¼ 8cc/jam, O2 NRM 5 l/menit, Inj. Meropenem
125 mg/8 jam, Inj. Dexamethason 1 mg/12 jam, Inj.
Omeprazole 4cc/12 jam, Inj. Gentamisin 7,5 gr/12 jam, PCT
drip 0,4 cc/3 jam (kp), Kepra 2x100 mg, Nebu ventolin 1
amp 3x1, ASI 12-20 cc/15 menit, Chest terapy, Hasil kultur
sputum : Klebsiella pneumonia
IVFD D5 ¼ NS 8cc/jam, O2 NRM 5 l/menit, Inj. Meropenem 125
Pneumonia + Epilepsi
mg/8 jam (hari 10), Inj. Amikasin 10 mg/12 jam (hari 8), Nebu
ventolin 1 amp 3x1, PCT drop 0,4 cc/3 jam (kp), Kepra 2x100 mg,
ASI / Neocate 25-40 cc, Apyalis 1x0,4 ml
Pneumonia + Epilepsi Iv plug, Cefixim 2x10 mg (hari 1), Kepra 2x100 mg,
Apyalis 1x0,4 ml, Pct drop 4 x 0,4 (k/p), Diet 8 x 40-45 cc,
BLPL
 DISCUSSION

Patient of age 5 months Incomplete immunization

Theory Theory
Children aged 0-24 years are more at risk of DPT and measles immunization can
pneumonia because Immune system in children is reducehe incidence of pneumonia as a complicatin
not of measles and Pertussis
perfect and the anatomy of the respiratory tract is Case
relatively narrow the patient has not received measles immunization
Case because he is only 5 months old and the has never
Patient age of 5 months received DPT immunization.
The result of sputum culture is
Father of a smoker Seizures Klebiella pneumoniae

Theory Theory
Theory The most etiology in children aged
the content of cigarettes can cause
Seizures are one of the symptoms of 3 -12 months is S. pneumoniae,
epithelial damage, interfere with the
very severe pneumonia that occurs in H. influenzae type b, C.Trachomatis
phagocytic ability of alveolar
patients aged 2 months to 5 years Mycoplasma pneumoniae, group A
macrophages and the mechanism of
Case streptococci
mucociliary causing disruption of the
Seizures in these patients occur Case
lung defense system
repeatedly and are a criterion for The results of sputum culture were
Case
epileptic seizures obtained by Klebsiella pneumoniae
the patient's father is a smoker
TERIMAKASIH