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Anak Broncho

Anak Broncho

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Case report BRONCHOPNEUMONIA Presenters Day/Date Supervisor : Kiki Anggrita Sari Mutiara Hutagalung : Thursday/December 23rd

2010 : dr. Lily Irsa, Sp.A (K) CHAPTER 1 1.1. INTRODUCTION Pneumonia can be generally defined as inflammation of the lung parenchyma, pneumonia is characterized by consolidation of the affected part and a filling of the alveolar air spaces with exudate, inflammatory cells, and fibrin. Most cases of pneumonia are due to infection by bacteria or viruses, although they may also be due to the inhalation of chemicals, trauma to the chest wall, or other infectious agents such as rickettsiae, fungi, and yeasts. 1 Bronchopneumonia is one of two types of bacterial pneumonia as classified by gross anatomic distribution of consolidation (solidification), the other being lobar pneumonia. Bronchopneumonia is an acute inflammation of the walls of smaller bronchial tubes, with varying amount of pulmonary consolidation due to spread of the inflammation into peribronchiolar alveoli and the alveolar ducts.2.3 Although most cases of pneumonia are caused by microorganisms. Pneumonia is an acute infection of one or both lungs that can be caused by a bacterium, usually Streptococcus pneumoniae (also called pneumococcus; see streptococcus streptococcus, any of a group of gram-positive bacteria, genus Streptococcus, some of which cause disease, or by a virus, fungus, or other organism. The causal organisms reach the lungs through the respiratory passages. Usually an upper respiratory infection precedes the disease. Alcoholism, extreme

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youth or age, debility, immunosuppressive disorders and therapy, and compromised consciousness are predisposing factors. 1.4 When one or more entire lobes of the lung are involved, the infection is considered a lobar pneumonia. When the disease is confined to the air spaces adjacent to the bronchi, it is known as bronchopneumonia. Aspiration pneumonia is the pathological consequence of the abnormal entry of fluids, particulate matter, or secretions in the lower airways. Noninfectious causes include aspiration of food or gastric acid, foreign bodies, hydrocarbons, and lipoid substances, hypersensitivity reactions and drug or radiation induced pneumonitis.4 1.2. DEFINITION Bronchopneumonia is a type of pneumonia that is characterized by an inflammation of the lung generally associated with, and following about with bronchiolitis. Bronchopneumonia or bronchial pneumonia or bronchogenic pneumonia is an acute inflammation of the walls of the bronchioles. It is a type of pneumonia characterized by multiple foci of isolated, acute consolidation, affecting one or more pulmonary lobules. It is one of two types of bacterial pneumonia as classified by gross anatomic distribution of consolidation (solidification), the other being lobar pneumonia.2.3 1.3. ETIOLOGY Pneumonia is most often caused by a bacterial infection (bacterial pneumonia) or a viral infection (viral pneumonia). However, pneumonia can also be caused by a fungal infection, yeast infection, trauma, or from inflammation of the lungs due to exposure to toxic substances, such as poisonous gases. Pathogens implicated in pneumonia vary with the age of the child, the underlying patient-specific risk factors, immunization status, and seasonality.8 In the neonate, pathogens that may infect the infant via the maternal genital tract include group B streptococci, Escherichia coli and other fecal coliforms, and C trachomatis. Group B streptococci most often is transmitted to the fetus in utero, usually as a result of colonization of the mother's vagina and cervix by the organism. Affected infants commonly present within the first few

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Infection with Staphylococcus aureus may be complicated by lung abscess. In the young infant. However. but only a 9. Mycoplasma accounts for 1435% of pneumonia hospitalizations in this age group. continued concern about perinatally acquired pathogens mentioned above as well as the unusual Listeria monocytogenes remains. C pneumoniae can cause pneumonia in this age group. and signs of respiratory distress. The usual presenting symptoms include tachypnea.hours after birth.1% reduction in children older than 2 years. and the chest radiograph may demonstrate a ground-glass appearance and air bronchograms. particularly against pertussis. 3|Page . Physical examination may reveal diffuse fine crackles. and empyema. Streptococcus pneumoniae is by far the most common bacterial pathogen in this age group.2% reduction in the first year of life and a 23. aged 1-3 months. parapneumonic effusions. and lack of immunization.4% reduction between 1-2 years. The usual culprits are those previously discussed.Children in this age group are also at risk for infection by M pneumoniae. M. the presentation may be delayed. viruses are a common cause of pneumonia among toddlers and preschoolers. Tsolia et al identified a viral infection among 65% of hospitalized children with community-acquired pneumonia. 6 Young children. Among hospitalized children. Black et al showed a 32. most pneumonia in this age group is community acquired and involves Streptococcus pneumoniae.6 Older children and adolescents. hypoxemia. Streptococcus pneumoniae accounts for 21-44% of disease. but if infection is acquired during the delivery. In a recent study to evaluate the effectiveness of heptavalent pneumococcal conjugate vaccine in prevention of pneumonia in children younger than 5 years. and non-typeable Haemophilus influenzae. Staphylococcus aureus. Streptococcus pneumoniae is by far the most common bacterial cause of pneumonia. Risk factors for infection include older siblings. pneumoniae is a frequent cause of pneumonia among older children and adolescents. group daycare.6 Newborns may be affected by the bacteria and viruses that cause infections in older infants and children.

with as many as 5 million deaths occurring yearly in children younger than 5 years. or fungi. so called because of its similarity to the consistency of liver. Ninetyfive percent of all episodes of clinical pneumonia in young children worldwide occur in developing countries. occurring within 24 hours of infection. but it can occur as a result of chemical injury or may follow direct lung injury. In the first stage.1. Most commonly.7 The insiden of pneumonia is 10 times higher in developing than in developed countries. age. Such variable as nutritional status.28 episodes per childyear. Many bacteria and few neutrophils are present.Streptococcus pneumoniae (pneumococcus) and Mycoplasma pneumoniae both are the common bacterium which causes bronchopneumonia in the adults and children.7 Four stages of lobar pneumonia have been described. EPIDEMIOLOGY The WHO Child Health Epidemiology Reference Group estimated the median global incidence of clinical pneumonia to be 0. the lung is characterized microscopically by vascular congestion and alveolar edema.7 million new cases.8 In the United State.1 This equates to an annual incidence of 150. The stage of red hepatization (2-3 d). the heptavalent pneumococcal vaccine reduced the incidence of clinically diagnosed and radiographically diagnosed pneumonia among children younger than 5 years by 4% and 20%. this inflammation is the result of invasion by bacteria.7 1. respectively. While often complicating other lower respiratory infections such as bronchiolitis or laryngotracheobronchitis. is characterized by the presence of many 4|Page .5.6 1. In a randomized double-blind trial. PATHOPHYSIOLOGY Pneumonia results from inflammation of the alveolar space and may compromise air exchange.4. and the presence of an underlying condition influence morbidity and mortality rafes due to community acquired pneumonia. of which 11-20 million (7-13%) are severe enough to require hospital admission. viruses. pneumonia may also occur via hematogenous spread or aspiration.

neutrophils. often centered on a bronchiole. microscopically. This reaction of the lungs leads to the filling of the alveolar sacs with exudates. aerated parenchyma. disintegration of red cells. or neck pain is feature of pleuralirritationand suggest bacterial infection. we can found macroscopically multiple foci of consolidation are present in the basal lobes of the human lung. 10 The signs and symptoms of pneumonia are often nonspecific and widely vary based on the patient’s age and the infectious organisms involved. Massive congestion is present. and hemosiderin. desquamated epithelial cells. A focus of inflammatory condensation is centered on a bronchiole with acute bronchiolitis (suppurative exudates .pus .7 Bronchopneumonia. Other symptoms include cough. grey-yellow. usually involves the dependent lung zones. and it may lead to resolution or to organization and pleural adhesions. especially in children. abdominal. usually preceded by an upper respiratory tract infection. bacteria invade the lungs. consolidation takes place a condition where in the air space in the lungs is replaced with fluids.in the lumen and parietal inflammation). are poorly delimited and have the tendency to confluence. These lesions are 2-4 cm in diameter. a pattern attributable to aspiration of oropharyngeal contents. and fibrin within the alveoli. an “unwell child”. Localized chest.erythrocytes. In the stage of gray hepatization (2-3 d). 7 In a person suffering from bronchopneumonia.1 1. Fibrinous inflammation may extend into the pleural space. the lung is gray-brown to yellow because of fibrin purulent exudates. CLINICAL FEATURES ( Signs & Symptoms ) Fever and difficulty in breathing are commonest presenting symtoms. often bilateral. which results to an inflammatory immune response. poor feeding. a patchy consolidation involving one or more lobes. dry. As a result. with centrifugal spread to the adjacent alveoli. In pathology. Inflammatory foci are separated by normal.6. Alveolar lumens surrounding the bronchiole are filled with neutrophils ("leukocytic alveolitis"). causing a rub heard by auscultation. lethargy. The final stage of resolution is characterized by resorption and restoration of the pulmonary architecture. The neutrophilic exudates are centered in bronchi and bronchioles. 5|Page .

in most patients with community-acquired 6|Page . tachypnea. as well as egophony. Toddlers and preschoolers. All children.Newborns. Retractions result from the effort to increase intrathoracic pressure to compensate for decreased compliance. Therefore. or pleural friction rub. (2) nuchal rigidity in patients with right upper lobe pneumonia. grunting. Extra pulmonary signs and symptoms include (1) abdominal pain or an ileuses accompanied by emesis in patients with lower lobe pneumonia. wheezing. Grunting in a newborn is due to vocal cord approximation as they try to provide increased positive end-expiratory pressure (PEEP) and keep their lower airways open. fever. tachypnea. Older children and adolescents. these children most often present with fever.7 Auscultation of the lung fields may yield rales. however. congestion. grunting may be less common. may be appreciated over the area of pneumonia. diminished breath sounds. they more commonly present with tachypnea. dehydration. and congestion. and decreased feeding. cough (productive or nonproductive). this group may also present with fever. The affected lung field may be dull to percussion. chest pain. Older infants. LABORATORY STUDY Identifying the causative infectious agent is the most valuable step in managing a complicated case of pneumonia. retractions. tubular breath sounds. and hypoxemia.7. Decreased tactile and vocal fremitus. Unfortunately. an etiologic agent can be difficult to identify. or (3) a rub caused by pericardial effusion in patients with lower lobe pneumonia due to Haemophilus influenzae infection. newborns with pneumonia rarely cough. retractions. which increases airflow to respiratory surfaces.10 1. congestion. cough (productive or nonproductive). Grunting suggests a lower respiratory tract disease. and lethargy. many children present with nasal flaring. and hypoxemia are common and may be accompanied by a persistent cough. They may have some posttussive emesis. irritability.

sputum cultures are not useful in most children with pneumonia. a. CRP. Bacterial pneumonia is often associated with an elevated WBC count in the range of 15. although a Gram stain may help. and samples are always contaminated by oral flora. Sputum culture Sputum is rarely produced in children younger than 10 years. For these reasons. The total WBC and differential may aid in determining if an infection is bacterial or viral. An adequate sputum culture should contain more than 25 polymorphonuclear (PMN) cells per field and fewer than 10 squamous cells per field.000/mm3 and a predominance of granulocytes. In viral pneumonia. The common agents that cause pneumonia may be normal oral flora.8 (A) Gram stain demonstrating gram-positive cocci in pairs and chains and (B) culture positive for Streptococcus pneumoniae.3 b.000–40. together with clinical symptoms chest radiography and ESR can be useful in monitoring the course of pneumonia. or both) and sedimentation rate. CBC count Testing should include a CBC count with differential and evaluation of acute-phase reactants (ESR. treatment is empiric and based primarily on patient age and clinical presentation. An example of a positive Gram stain for S pneumoniae is shown in the image below.1. and. the WBC count may be normal or elevated . 7|Page .3.pneumonia who are treated on an outpatient basis.

renal failure). especially in endemic areas. Bronchoscopy Flexible fiberoptic bronchoscopy is occasionally useful to obtain lower airway secretions for culture or cytology. blood culture results are positive in 10-15% of patients with streptococcal pneumonia. test results are positive if the indurations is 5 mm or larger.3 8|Page . In general. results are positive if the indurations is 10 mm or larger. Among children younger than 4 years. Even if the child has received the Bacillus Calmette-Guérin (BCG) vaccine. Mantoux test results should be interpreted using the criteria outlined above. In immunosuppressed children or those in close contact with others who have known or suspected cases of TB.3 e. diabetes mellitus.3 d. A blood culture is still recommended in complicated cases of pneumonia. malnutrition. Blood culture Although blood cultures are technically easy to obtain and relatively noninvasive and non traumatic. other fungi) or in patients who are severely ill. those who have an increased environmental exposure to TB or other medical risk factors (eg. Wubbel et al found only sterile blood cultures. test results are positive if the indurations (not the area of erythematic. The numbers are even less in patients with Staphylococcus infection. which may be larger) is 15 mm or larger. lymphoma.8 These tests are used in diagnosing TB. Mantoux skin test (intradermal inoculation of 5 TU of purified protein derivative) results should be read 48-72 hours after placement.c. Skin tests Tuberculosis should always be considered as possible diagnose. In children older than 4 years without any risk factors. the results are rarely positive in the presence of pneumonia and even less so in cases of pretreated pneumonia. In a study of 168 patients with known pneumonia. This procedure is most useful in immunocompromised patients who are believed to be infected with unusual organisms (Pneumocystis.

ensuring that an excessive volume is not given because of potensial inappropiate ADH secretion.8. and family incapable of providing appropriate observation or supervision are indicators for hospital admission among infant. inability to feed. if the pneumonia lobaris seen a consolidation in one or several lobes. grunting. The sensitivity of the test to diagnose is approximately 75%. In this situation. however. difficulty of breathing. it is not always necessary or useful in determining the etiology of the infection.8 Viral pneumonias are associated with a patchy perihilar infiltrate.Photo thorax there bronkopeumoni patches infiltrates in one or several lobes.3 A small propotion of pneumonias are associated with a parapneumonic effusion.3 In general. intermittent apnea. Radiography is often performed when diagnosing pneumonia.1. Fluids should be given if necessary. the child usually should be reexamined within 48 hours of beginning treatment. gramnegative. Some of this effusion develop into empyema. According to the British Thoracic Society guideline.8 1. respiratory rate greater than 70 breaths per minute. MANAGEMENT AND TREATMENT Infant and children with mild and moderste low respiratory tract infection can be safely cared for at home. where they may be blunting of the costophrenic angle on the chest Xray. hyperinflation. or complicated pneumococcal pneumonia. this is the primary imaging study used to confirm the diagnosis of pneumonia. and atelectasis on chest radiography.8 General supportive care should include antipyretics.In patients with bacterial pneumonia. cyanosis.9. IMAGING STUDY Radiography. typical findings include a lobar consolidation with air bronchograms occasionally accompanied by a pleural effusion (see the images below). chest radiographs are standart practice with hospitalized children whom a diagnose pneumonia being considered. Pneumatoceles and abscesses are less commonly found but may indicate an S aureus. an SaO2 of 92% or less.10 Treatment decisions in children with pneumonia are dictated based on the likely etiology of the infectious organism and the age and clinical status of the 9|Page . oxygen to keep saturation > 92.

10. most children with pneumonia recover without complications. the possibility of resistance (which may vary. Antibiotic administration must be targeted to the likely organism. others include the following:7 • • • Pulmonary abscess Respiratory distress Sepsis PROGNOSIS Patients who were placed on a protocol-driven pneumonia clinical 1. Some expert suggest an option with third generation cephalosporins such as ceftriaxon or cefotaxime. bearing in mind the age of the patient.patient. A macrolide antibiotic alone. High doses of penicillin.8 Children in whom pneumococcal disease is suspected initially should be treated with amoxicillin or penicillin. The initial outpatient treatment of children with pneumonia depends upon the clinical findings and the patient's age.S Center for Disease and Control and Prevention was recently published supporting the findings that intermediate susceptible strain of pneumococcus respond well to high doses of beta-lactam. ampicillin. For children >5 years of age either amoxicillin or an oral macrolide such as erytrhomycin is the treatment of choice. and other pertinent history. Most older infant can be manage with oral amoxicillin. with broader spectrum antibiotics.3 A position paper by the U.10 1.11. Persistent effusions and empyemas are the most common serious complications of bacterial pneumonia. or in combination with sulfisoxazole or an oral cephalosporin is an alternative. The prognosis for most forms of pneumonia is excellent. depending on local resistance patterns).7 The choice antibiotic is determinaned by child’s age. and amoxicillin have been recommended whenever intermediate susceptible strain are considered. pathway are more likely to have favorable outcomes. the history of exposure. newborn require broad-spectrum intrvenous antibiotics. Most cases of viral pneumonia resolve without 10 | P a g e . COMPLICATION Fortunately.

7 CHAPTER 2 2.2.00 pm with chief complaint was shortness of breath. Staphylococcal pneumonia. CASE N. Immunocompromised children. common bacterial pathogens and atypical organisms respond to antimicrobial therapy. 2.5 kg. 2010 at 21. The shortness of breath was not related to activity and weather. The shortness of breath occurred since 2 days ago and getting worst in 1 day before she admitted to the hospital. and neonates are at high risk for severe sequelae. those with underlying lung disease. a 2-year-old girl.1. 9. Productive cough occurred since 3 day ago. History of contact with TB patient was not found. may cause necrotizing bronchiolitis or bronchiolitis obliterans. can be very serious despite treatment. OBJECTIVE The aim of doing this paper is to report a case of bronchopneumonia of an 1-year-old girl that was admitted at the Infection Unit of Haji Adam Malik General Hospital. Some forms of viral pneumonia. 82 cm. although rare. Cyanosis was not found. particularly adenoviral disease.7 The prognosis for varicella pneumonia is somewhat more guarded. was admitted to the Infection Unit of Haji Adam Malik General Hospital on September 16th. 11 | P a g e .treatment.

Fever was found since 1 week ago with a characteristic of high fever which relieved with fever relieving medication. warm extremity : Female. murmur (-) RR: 20 rpm.5 kg BW/ BL : 84% (mild malnutrition) Body Temperature : 40. the patient was delivered through caesarian operation and cried instantly. regular. Nose: Nasal Flaring (+) Neck Chest : Lymph node enlargement (-). pressure/volume = sufficient BP: 90/60 mmHg. isochoric pupil (right=left). Currently the patient is having watery stool. palpebra edema (-/-) Mouth/Ears: Within normal limit. regular.5 ۫C Sensorium : Compos Mentis Localized Status: Head : Eye: light reflexes (+/+). History of birth. History of previous illness: This patient was referred from pediatrician History of drugs usage :- PHYSICAL EXAMINATION Generalized Status: Body weight (BW) : 9. Micturition is in normal range. within normal limit Body length (BL) : 82 cm Anemic (-). retraction (+) HR: 180 bpm. History of diarrhea was found since 5 days ago with frequency 5 times a day and the volume was 20cc/diarrhea. She had a history of complete immunizations. icteric (-). cyanosis (-). pale inferior conjunctival palpebra (-/-). Shivers and seizures were not found. peristaltic (+) normal. regular. dyspnea (+) Laboratory Findings (September 16th 2010) from Private Lab Test Result Complete Blood Count Normal Value 12 | P a g e . JVP: R-2cmH₂O : Symmetrical fusiformic. edema (-). ronchi (+) Abdominal Extremities Urogenital : Soepel. Liver/Spleen: within normal limits : Pulse: 180 bpm.

1 4.6 mmol/L -3.0 mEq/dL 99 mEq/dL 11.48 6.106 Chest X-Ray (September 16th 2010) 13 | P a g e .0-17.9 mmol/L 19.40-4.79 x 103/ mm3 31.6.9 mmHg 135.15 x 106/mm3 10.10 % Arterial Blood Gases 7.90 % 0% 0.40 % 13.2 mmHg 18.45 38-42 85-100 22-26 19-25 (-2) – (+2) 95-100 135.40 g% 4.2 % Serum Electrolyte 130 mEq/dL 3.6-14.3-14.8 37-80 20-40 2-8 1-6 0-1 pH pCO2 pO2 Bicarbonate (HCO3) Total CO2 BE O2 Saturation Natrium Kalium Chloride 7.35-7.60 % 10.0 mmol/L 99.5.5 96.155 3.5 37-41 217-497 81-95 25-29 29-31 11.515 23.Hemoglobin (HGB) Erythrocytes (RBC) Leucocytes (WBC) Hematocrit Thrombocytes (PLT) MCV MCH MCHC RDW Neutrophil Lymphocyte Monocyte Eosinophil Basophil 10.8 % Cell Count 75.9 fL 25.1 pg 33 g% 13.50 % 225 x 103/ mm3 75.

specific process.9% 2. Bronkiolitis 3.5cc/8 hours IVFD D5% NaCl 0. with differential diagnosis Bronchopneumonia.Chest X-Ray showed infiltrated on right lower lung ( right pericardial). Differential diagnosis : 1. Pulmonary Tuberculosis Working diagnosis Management : • • • • • • O2 1 L/i Nasal Canal Nebule NaCl 0.225%  40 gtt/i Injection Ampicillin 250mg/6 hours/iv  skin test Injection Gentamycin 80mg/24 hours/iv  skin test Paracetamol 3x100mg. if needed : Bronchopneumonia + GE without Dehydration 14 | P a g e . Bronchopneumonia + GE without Dehydration 2.

4 ۫C BW: 9. normal peristaltic. pale inferior palpebral conjunctiva (-/-). retraction (+).• Fasting as the temporary diet Investigation Plan: .5 kg BL: 82 cm BW/BL: 84% (mild malnutrition) Head : Eyes: Light reflexes (+/+). Diarrhea (+) Sens: Compos Mentis T: 37. Cough (+). ronchi (+) Abdomen : Soepel. Fever (-). regular. Liver/Spleen: Within normal limits 15 | P a g e . Nose: Nasal Flaring (+) Mouth/Ears: Within normal limits Neck Chest : Lymph nodes enlargement (-). JVP: R-2cmH₂O : Symmetrical fusiformic. regular. isochoric pupil. HR : 132 bpm. murmur (-) RR : 48 rpm.Chest X-Ray (AP) Mantoux Test Follow Up S O Follow Up November 17th 2010 6:00 am Shortness of breath (+).

JVP: R-2cmH₂O : Symmetrical fusiformic.9% 2. Cough (+). normal peristaltic.5 kg BL: 82 cm BW/BL: 84% (mild malnutrition) Head : Eyes: Light reflexes (+/+). regular. murmur (-) RR : 56 rpm.Extremities : Pols 132 bpm. Liver/Spleen: Within normal limits Extremities : Pols 140 bpm. if needed Zinc Kid 1x20mg Lacto B 2x1 sachet Diet M II 900 kkal with 35 grams of protein Investigation plan : - S O Follow Up November 18th 2010 6:00 am Shortness of breath (+). pale inferior palpebral conjunctiva (-/-). regular.5 ۫C BW: 9. warm extremity Bronchopneumonia + GE without Dehydration • O2 1 L/I Nasal Canal • • • • • • • • Nebule NaCl 0.5cc/8 hours IVFD D5% NaCl 0. HR : 140 bpm. Pressure/Volume: sufficient. BP : 90/60 mmHg. ronchi (+) Abdomen : Soepel. Diarrhea (-) Sens: Compos Mentis T: 37. Pressure/Volume: sufficient. Nose: Nasal Flaring (+) Mouth/Ears: Within normal limits Neck Chest : Lymph nodes enlargement (-). isochoric pupil. A P BP : 90/60 mmHg. retraction (+).225%  40 gtt/i Injection Ampicillin 250mg/6 hours/iv (D-2) Injection Gentamycin 80mg/24 hours/iv (D-2) Paracetamol 3x100 mg. warm extremity Bronchopneumonia + GE without Dehydration A 16 | P a g e . regular. regular. Fever (-).

225%  40 gtt/i Injection Ampicillin 250mg/6 hours/iv (D-3) Injection Gentamycin 80mg/24 hours/iv (D-3) Paracetamol 3x100 mg. murmur (-) RR : 48 rpm. Diarrhea (-) Sens: Compos Mentis T: 37. retraction (-). pale inferior palpebral conjunctiva (-/-). isochoric pupil.P • • • • • • • • • O2 1 L/I Nasal Canal Nebule NaCl 0. Fever (-). if needed Zinc Kid 1x20mg Lacto B 2x1 sachet Diet M II 900 kkal with 35 grams of protein Investigation plan : . JVP: R-2cmH₂O : Symmetrical fusiformic.Consultation to Respirology Department Respirology Consult : Normal S O Follow Up November 19th 2010 6:00 am Shortness of breath (+). regular. Pressure/Volume: sufficient. ronchi (+) Abdomen : Soepel. HR : 138 bpm.5 kg BL: 82 cm BW/BL: 84% (mild malnutrition) Head : Eyes: Light reflexes (+/+).5cc/8 hours IVFD D5% NaCl 0. warm extremity Bronchopneumonia + GE without Dehydration • O2 1 L/I Nasal Canal A P 17 | P a g e . Liver/Spleen: Within normal limits Extremities : Pols 138 bpm. BP : 90/50 mmHg. regular. Cough (+).9% 2. Nose: Nasal Flaring (+) Mouth/Ears: Within normal limits Neck Chest : Lymph nodes enlargement (-). normal peristaltic. regular.2 ۫C BW: 9.

5 kg BL: 82 cm BW/BL: 84% (mild malnutrition) Head : Eyes: Light reflexes (+/+). JVP: R-2cmH₂O : Symmetrical fusiformic.9% 2. normal peristaltic. Fever (+).Chest Physiotherapy (20/12/2010) .• • • • • • • • • Nebule NaCl 0. Liver/Spleen: Within normal limits Extremities : Pols 128 bpm. if needed Zinc Kid 1x20mg Lacto B 2x1 sachet Diet M II 900 kkal with 35 grams of protein Investigation plan : . isochoric pupil. retraction (-).225%  40 gtt/i Injection Ampicillin 250mg/6 hours/iv (D-4) Injection Gentamycin 80mg/24 hours/iv (D-4) Ambroxol 5mg + Salbutamol 1mg : 3 x pulv I Paracetamol 3x100 mg. Cough (+).9% 2. regular.0 ۫C BW: 9. A P BP : 90/70 mmHg.5cc/8 hours IVFD D5% NaCl 0.5cc/8 hours S O 18 | P a g e . regular. ronchi (+) Abdomen : Soepel. HR : 128 bpm. murmur (-) RR : 36 rpm. Diarrhea (-) Sens: Compos Mentis T: 38. pale inferior palpebral conjunctiva (-/-). regular. Nose: Nasal Flaring (+) Mouth/Ears: Within normal limits Neck Chest : Lymph nodes enlargement (-).Mantoux Test . Pressure/Volume: sufficient. warm extremity Bronchopneumonia • O2 1 L/I Nasal Canal • Nebule NaCl 0.Check for ABG and Electrolyte Follow Up November 20th 2010 6:00 am Shortness of breath (+).

6/84. JVP: R-2cmH₂O : Symmetrical fusiformic.9% 2.1 Total CO2/BE/SaO2 = 27. retraction (-). ronchi (+) Abdomen : Soepel.5 kg BL: 82 cm BW/BL: 84% (mild malnutrition) Head : Eyes: Light reflexes (+/+).0 ۫C BW: 9. Fever (-) Sens: Compos Mentis T: 37. Pressure/Volume: sufficient.• • • • • • IVFD D5% NaCl 0. pale inferior palpebral conjunctiva (-/-).42/40. murmur (-) RR : 36 rpm. warm extremity Bronchopneumonia • O2 1 L/I Nasal Canal • • • Nebule NaCl 0. Nose: Nasal Flaring (+) Mouth/Ears: Within normal limits Neck Chest : Lymph nodes enlargement (-).225%  40 gtt/i Injection Ampicillin 250mg/6 hours/iv (D-6) 19 | P a g e S O . regular. A P BP : 90/60 mmHg.225%  40 gtt/i Injection Ampicillin 250mg/6 hours/iv (D-5) Injection Gentamycin 80mg/24 hours/iv (D-5) Ambroxol 5mg + Salbutamol 1mg : 3 x pulv I Paracetamol 3x100 mg.7/26. regular.5cc/8 hours IVFD D5% NaCl 0. HR : 124 bpm. regular. Cough (-). normal peristaltic. if needed Diet M II 900 kkal with 35 grams of protein Investigation plan : Laboratory Findings: ABG : pH/pCO2/pO2/HCO3 = 7.5% Electrolyte : Na/K/Cl = 132/27/94 Follow Up November 21st 2010 6:00 am Shortness of breath (+).3/1. Liver/Spleen: Within normal limits Extremities : Pols 124 bpm.6/96. isochoric pupil.

Cough (+) ↓. murmur (-) RR : 32 rpm. BP : 90/60 mmHg.225%  40 gtt/i Injection Ampicillin 250mg/6 hours/iv (D-7) Injection Gentamycin 80mg/24 hours/iv (D-7) Ambroxol 5mg + Salbutamol 1mg : 3 x pulv I 20 | P a g e P . retraction (-).5 kg BL: 82 cm BW/BL: 84% (mild malnutrition) Head : Eyes: Light reflexes (+/+). Nose: Nasal Flaring (+) Mouth/Ears: Within normal limits Neck Chest : Lymph nodes enlargement (-).5cc/8 hours IVFD D5% NaCl 0. isochoric pupil. Prolonged expiration (+) Abdomen : Soepel. Liver/Spleen: Within normal limits Extremities : Pols 120 bpm. JVP: R-2cmH₂O : Symmetrical fusiformic. stridor (+) HR : 120 bpm. pale inferior palpebral conjunctiva (-/-). normal peristaltic. Fever (-) Sens: Compos Mentis T: 36. warm extremity Bronchopneumonia • O2 1 L/I Nasal Canal.• • • • Injection Gentamycin 80mg/24 hours/iv (D-6) Ambroxol 5mg + Salbutamol 1mg : 3 x pulv I Paracetamol 3x100 mg. Pressure/Volume: sufficient. regular. regular.9% 2. regular.5 cc + NaCl 0. if needed • • • • • Nebule Ventolin 2. ronchi (+). if needed Diet M II 900 kkal with 35 grams of protein Investigation plan : - S O Follow Up November 22nd 2010 6:00 am Shortness of breath (+) ↓.6 ۫C BW: 9.

Cough (+) ↓. prolonged expiration (+) Abdomen : Soepel. Nose: Nasal Flaring (+) Mouth/Ears: Within normal limits Neck Chest : Lymph nodes enlargement (-). if needed A P 21 | P a g e . isochoric pupil. Pressure/Volume: sufficient. regular. normal peristaltic.225%  10 gtt/i Injection Ampicillin 250mg/6 hours/iv (D-8) Injection Gentamycin 80mg/24 hours/iv (D-8) Ambroxol 5mg + Salbutamol 1mg : 3 x pulv I Paracetamol 3x100 mg. regular. pale inferior palpebral conjunctiva (-/-).7 ۫C BW: 9.5 cc + NaCl 0. if needed Diet M II 900 kkal with 35 grams of protein Chest Physiotherapy Investigation plan : - S O Follow Up November 23rd 2010 6:00 am Shortness of breath (+)↓. regular. if needed • • • • • • Nebule Ventolin 2. JVP: R-2cmH₂O : Symmetrical fusiformic. Fever (-) Sens: Compos Mentis T: 36.5cc/8 hours IVFD D5% NaCl 0. warm extremity Bronchopneumonia • O2 1 L/I .5 kg BL: 82 cm BW/BL: 84% (mild malnutrition) Head : Eyes: Light reflexes (+/+).• • • Paracetamol 3x100 mg. murmur (-) RR : 36 rpm.9% 2. BP : 100/60 mmHg. Liver/Spleen: Within normal limits Extremities : Pols 110 bpm. ronchi (+). retraction (-). stridor (-) HR : 110 bpm.

Shivers and seizures were not found. The shortness of breath was not related to activity and weather. 22 | P a g e . DISCUSSION N. History of diarrhea was found since 5 days ago with frequency 5 times a day and the volume was 20cc/diarrhea. Fever was found since 1 week ago with a characteristic of high fever which relieved with fever relieving medication. The shortness of breath occurred since 2 days ago and getting worst in 1 day before she admitted to the hospital. Currently the patient is having watery stool. Bronchopneumonia is a type of pneumonia that is characterized by an inflammation of the lung generally associated with. and following about with bronchiolitis. This patient was referred to Haji Adam Malik Hospital by pediatrician with bronchopneumonia and gastroenteritis without dehydration.1. In this case patient is a girl 2 years old. Productive cough occurred since 3 day ago. Bronchopneumonia or bronchial pneumonia or bronchogenic pneumonia is an acute inflammation of the walls of the bronchioles.5 kg. 82 cm. Cyanosis was not found. The insiden of pneumonia is 10 times higher in developing than in developed countries.• • Diet M II 900 kkal with 35 grams of protein Chest Physiotherapy Investigation plan : . 9. a 2-years-old girl. was admitted to the Infection Unit of Haji Adam Malik General Hospital with chief complaint of shortness of breath. Pneumonia is most often caused by a bacterial infection (bacterial pneumonia) or a viral infection (viral pneumonia). with as many as 5 million deaths occurring yearly in children younger than 5 years.Discharge (24/12/2010) CHAPTER 3 3.

if the pneumonia lobaris seen a consolidation in one or several lobes. or in combination with sulfisoxazole or an oral cephalosporin is an alternative. A macrolide antibiotic alone. depending on local resistance patterns). fever and difficulty in breathing are commonest presenting symtoms. 23 | P a g e . fever was found since 1 week ago and her temperature 40. This disease usually arises suddenly. Children in whom pneumococcal disease is suspected initially should be treated with amoxicillin or penicillin. Photo thorax there bronkopeumoni patches infiltrates in one or several lobes. breath sounds during auscultation ronchi smooth wet and loud. bearing in mind the age of the patient. and non-typeable Haemophilus influenzae. Staphylococcus aureus. this inflammation is the result of invasion by bacteria. Antibiotic administration must be targeted to the likely organism. and other pertinent history. In the young infant. Usually preceded by upper respiratory tract infection. Most commonly. pneumonia may also occur via hematogenous spread or aspiration. In this case patient was admitted with chief complaint shortness of breath. aged 1-3 months most pneumonia in this age group is community acquired and involves Streptococcus pneumoniae.50C. or fungi. the temperature increased 39-40 0C with chills. shortness of breath and rapid. productive cough occurred since 3 day ago. viruses. but it can occur as a result of chemical injury or may follow direct lung injury.In clinical feature. Pneumonia results from inflammation of the alveolar space and may compromise air exchange. usually preceded by an upper respiratory tract infection. the possibility of resistance (which may vary. coughing productive "breath sounds" when percussion dim lung examination. The laboratory found leukocytosis 15000-40000 / mm3. While often complicating other lower respiratory infections such as bronchiolitis or laryngotracheobronchitis. Streptococcus pneumoniae is by far the most common bacterial pathogen in this age group. Treatment decisions in children with pneumonia are dictated based on the likely etiology of the infectious organism and the age and clinical status of the patient. the history of exposure.

retraction. a 2-years-old girl had shortness of breath. Most cases of viral pneumonia resolve without treatment. SUMMARY It has been reported a case of a 2-years-old girl with Bronchopneumonia. From chest X-ray showed infiltrated on right lower lung (pericardial). Treatment for this patient was only supportive and symptomatic. clinical manifestation. the patient was diagnosed as bronchopneumonia. Persistent effusions and empyemas are the most common serious complications of bacterial pneumonia Patients who were placed on a protocol-driven pneumonia clinical pathway are more likely to have favorable outcomes. ronchi on both left and right lower lungs.2. This patient N. high fever. and diarrhea. productive cough. fever. REFERENCES 24 | P a g e . Thus. The prognosis for most forms of pneumonia is excellent. and laboratory findings.Fortunately. The diagnosis was established based on history taking. This patient was discharged after free from any complaint such as shortness of breath. common bacterial pathogens and atypical organisms respond to antimicrobial therapy. chest symmetrical fusiformic. most children with pneumonia recover without complications. 3. and history of diarrhea was found. Physical examination found nasal flaring.

Available from: http://emedicine. Wardhani. Boat. Kliegman. N.com/ . Jakarta: Media Aesculapius. Supriyatno. Charles G.. 2009. B. [Accessed December 6th 2010] 5. Patofisiologi Konsep Klinis Proses-Proses Penyakit Volume 2 Edisi 6.com/ . Clayden. MD. Page: 804-810. 2006.1. Willmott. 2010. 2010. G. D. Page: 268-270. Kapita Selekta Kedokteran Edisi Ketiga Jilid Kedua. T. Bacterial Pneumonia. Available from: http://emedicine.. Wickham.medscape.. Robert M. Available from: http://ningrumwahyuni. Nelson Textbook of Pediatrics 17th ed. Emedicine. 9. W. Buku Ajar Respirologi Anak Edisi Pertama. Wilson. W. London: Mosby Elsevier. Supriohata. [Accessed December 6th 2010] 8.B. Pediatrics Pneumonia. In: Behrman. V. 11. 12. Pedoman Diagnosis dan Penatalaksanaan di Indonesia: Perhimpunan Dokter Paru Indonesia.. Page: 333-365. Emedicine... Page: 1433-1435. MD. Prober. 2004. Hal B. Perhimpunan Dokter Paru Indonesia.A. Chernick. Kendig’s Disorders of the Respiratory Tract in Children Seventh Edition.. Creative Commons..0/. Available from: http://emedicine. Page: 465-468.. Page: 15-19. N. 2003.com/ . Mansjoer. 4. Jenson. Price.. MB. Pneumonia. MPH. BCh\ 2010. Pneumonia.medscape... Bronkopneumonia. Jakarta: Badan Penerbit IDAI. USA: Saunders Elsevier. 2007. Setyanto. F. S.M. Medpaper.. Pathophysiology. Sectish. H.I. Available from: http://creativecommons. 2. T. Jakarta: EGC.wordpress.org/licenses/nc-sa/1. USA: Saunders.. Illustrated Textbook of Paediatrics Third Edition. 2006. Richard E. [Accessed December 6th 2010] 6. (eds). Nicholas John Bennett. 10. 2010. Emedicine. Mark I Neuman. Nader Kamangar. [Accessed December 7th 2010] 25 | P a g e . 3.com/2009/08/03/bronkopneumonia/ [Accessed December 7th 2010] 7. 2000. Lissauer. R.. A. Wahyuni. 2008. Page: 441-451.N. Theodore C. Rahajoe. L.medscape..

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