DEPARTMENT OF PEDIATRICS

18th childrens hospital

Case history report

Patient Data

Name: Lenin Bogdan

Date of Birth: 22/06/2004
Date of admission: 23/10/2010
Method of admission: by ambulance
Home Address: zhukovskova 71,
Patient was admitted with suspected diagnosis of Right sided focal Pneumonia

Complaints

Frequent unproductive cough, temp is normal, decreased appetite. Malaise, fatigue

and difficulty in breathing, most especially at Nights and very loud breathing.

Anamnesis Morbi
1

DEPARTMENT OF PEDIATRICS
18th childrens hospital
Case history report
The child was ill, one week ago. He took augumentin and expectorant at home but
no improvement and then he was brought to the hospital.

Anamnesis Vitae
The child has a mother is 34years old, father, and a 10years old brother who are
healthy. Mothers pregnancy was normal and child was born with out complications
and normal weight of 2.3kg.
Neonate period was normal and Agar score 9.0. The child was breast feed until 1
year. The child was ill with frequent bronchitis and pneumonia 4times when he was
6month.
Development was normal.

Physical examination

Temperature 37.5oc, pulse rate 110Bpm, respiratory rate 28/mins, BP: 90/50mmHg,
weight 22kg, Height 120cm, heart rate 108pm.
General appearance
Child is norm asthenic. The patient appear ill
Degree of prostration: - Normal consciousness, No abnormalities, gait is normal,
facial expression is good.
Skin
Color of skin is normal, hair distribution is normal, no nodules, no dilated vessel, and
direction of blood flow is normal, no edema, and no eruption
Lymph nodes
Palpable in the right inguinal region, liver is palpable and normal and the spleen is
not palpable.
Head
The size, shape circumference is normal, and also symmetrical
Face
Symmetrical, distance between nose and mouth is normal, no paralysis, depth of
nasolabial folds and bridge of nose is normal.
Eyes
Visual acuity is normal, no exophthalmos or enophthalmos pupil size, shape and
reaction to light and accommodation is normal.
Nose
Shape is normal, no discharge and no bleeding
Throat
No inflammation of tonsils, absence of hypertrophic lymphoid tissues, voice is
normal
Ear
No inflammation and discharge, the hearing ability is normal
Neck
The neck position is normal, no swelling, thyroid, lymph nodes, vein, position of
trachea, sternocleidomastoid muscle are normal.
Thorax
Shape is normal, absence of pigeon breast, the thorax is symmetrical, pulsation and
length of the sternum is normal, thorax participation in respiration is observed.
Extremities
2

DEPARTMENT OF PEDIATRICS
18th childrens hospital
Case history report
(a) General: absence of deformities, no paralysis and edema. Posture and gait is
normal
(b) Joints: the joints are normal, no swelling, no redness and pain. Absence of
rheumatic nodules
(c) Hands and feet: Normal
(d) Peripheral vessels: absence.
Spine and back
Normal
Lungs
Abdominal breathing, dyspnea present, unproductive cough, dullness to percussion
is heard on the lower lobe of the right lungs. Shortness of resonance, diminish
breathing, crepitation is present, no rales, absence of wheezing.

Cardiovascular system
Auscultation: on the lower lobe of the right lungs, diminishing breathing was heard
on the left lungs (half or superficial breathing.)
Abdomen:
Size and shape is normal, umbilicus is in the midline, absence of palpable masses.
Vein is not distended and direction of flow is normal.
Liver:
The size of the liver is normal, liver is palpable and normal
Spleen:
The spleen is not palpable
Urogenital system
Urination is normal, painless, absence of abdominal development.
Rectum and Anus:
Absence of irritation fissure and Artesia
Nervous system:
Behavior is normal, level of consciousness and intelligence was excellent, ability to
understand, to communicate and write was also good.
Provisional diagnosis: Right sided focal pneumonia.
Plan

of clinical and laboratory Examination:

Determining the presence of pneumonia
Assessing disease severity at the time of presentation
Identifying causative agent

Laboratory analysis and findings

Stool: normal
X-ray examination: Enrichment of lungs picture and infiltration in the lower lobe of
right lung.
Blood test:
Hemoglobin: 120g/l
RBC: 3.5x1012/l
Color index:1
3

DEPARTMENT OF PEDIATRICS
18th childrens hospital
Case history report
Leukocyte 12 x109/L
Neutrophil;
Stab:6%
Segmented: 64%
Eosinophil: 2%
Lymphocyte: 20%
Monocyte:8%
ESR: 26mm/h

Urinalysis
Vol: 75.0
Color: slight yellow, clear urine
Sugar and protein: negative
Concentration of urine: 1020
Leukocyte: 1-2 in field of visual
Erythrocyte: absent
Mucosal: is a little slightly

Differential diagnosis

Acute respiratory viral infection, bronchiolitis, bronchiestasis, chronic bronchitis. In

lingering course of pneumonia; primary tuberculosis, cystic fibrosis, COPD.

Final diagnosis.

Right sided focal pneumonia

Treatment

Augumentin 500g 2 times daily intramuscular

Lazolvan 30mm 3 times a day
Bufilat 1 tablet 2 times daily

Prognosis
With treatment, pneumonia can be cleared with 2-4 weeks. Generally prognosis is
good and so the outcome is favorable.

Pneumonia
An acute infectious inflammatory disease of various nature with involving of
respiratory organs into pathologic process and intra-alveolar inflammatory
exudation.

Classification
Groups of pneumonias: Primary and secondary
Primary pneumonia is a pathological process that first develop in lung t issue and is
considered as a basic disease

DEPARTMENT OF PEDIATRICS
18th childrens hospital
Case history report
Secondary pneumonia: pathologic process with complicated course of another
pulmonary disease or disease of other organ (same concern the chronic
pneumonia).
Forms of pneumonia
Focal (focal confluent)
Segmented (mono or poly segmented)
Croupous
Interstitial
Localization of process
Lungs, lobes, segment, one sided, double (two sided)
Course of pneumonia
Acute
Lingering (reverse development of pneumonia process earlier than 6 weeks
6 months after beginning of disease)
Recurrent (under exclusion of reinfection)
Variety of pneumonia
Out-of hospital (home)
Hospital (nosocomial)
Under perinatal infection aspirative one
In patients with immune deficiency
The type of infections agent is connected with variety of pneumonia.
In out-hospital pneumonia gram +ve cocci are predominant
In hospital pneumonia: staphylococci and gram ve micro flora
In new born-: Chlamydia, pneumocystas, urea plasma
In aspirative pneumonia: obligate anaerobes + Gram ve bacilli
In
case
of
prominent
immune
disorders:
pneumocysta,
fungi,
cytomegaloviruses
Pneumonia maybe complicated or not complicated
Complicated: pulmonary or extra-pulmonary
Pulmonary complications
Syn-pneumonial pleurisy
Meta-pneumonial pleurisy
Pulmonary destruction
Pneumothorax
Extra-pulmonary complications
Infections tissue shock
DIC- syndrome
Cardiovascular insufficiency
Respiratory distress syndrome of adult type
Criteria of pneumonia
I.
Anamnesis data
Connection with respiratory viral infections: common cold
II.
Clinical
5

DEPARTMENT OF PEDIATRICS
18th childrens hospital
Case history report
Syndrome of respiratory insufficiency: dyspnea, participation of axillary
muscles in breathing act, retraction of flexible parts of thorax, pallor of skin,
cyanosis of nasolabial triangle or spread cyanosis, increasing after physical
exertion
Syndrome of intoxication: worsening of feeling, sleep disturbances, motor
anxiety, hyperthermia, muffled heart sounds tarchycardia.

Infants of 1st 2 months of life marked signs of intoxication:

Are flaccidity, decreasing of appetite down to refusing of breast feeding, weight

loss, decreasing physiological reflexes, appearance of GIT disorders,
development of exicosis.

Focal signs in lungs:

They are prominent in segmented (poly-segmented) and affluent pneumonia,

less marked in focal pneumonia and minimal changes are supervised in
interstitial pneumonia.

III.

a. On percussion: shortening of resonance on the place of lesion

b. On auscultation: harsh bronchial or weakened bronchial breathing on
place of lesion.
c. Fine bubbling rales or crepitating rales above the infiltrative foci
X-ray: infiltrative changes of the lungs of focal or segmented type and
reaction of lungs hilus on the side of the lesion
Such a sign as emphysema and strengthening of hilus figure (perivascular
and peribronchial shadowing) may be separated either in bronchitis,
bronchiolitis of in pneumonia

IV.

Laboratory:
Blood cell count shows activity of bacterial inflammation leads to increase
ESR, Leucocytosis and neutrophils with slight to left infant of 1 st months of life
seen lymphocyte reaction, early developed anemisation (anemia)

Differential diagnosis
Acute respiratory viral infection, bronchiolitis
pneumonia: primary tuberculosis, cystic fibrosis.

in

lingering

course

of