PLENO SCENARIO 1

GROUP 2
MEMBER OF GROUP 2
◦Dita Eka Octavia 6130018011

◦Qhilyatul Musyarofah 6130018012

◦Diana Wulan Ndari 6130018013

◦Jihan Winda Rahmah 6130018014

◦Davin Rachma Azizah 6130018015

◦M.Setio Widodo 6130018016

◦Fitria Istifarin6130018017

◦Ninda Lucida Alzalia 6130018018

◦Mimhadah Zahrotul Ulya 6130018019

 SCENARIO 1
“a 5 month old baby girl was brought by her mother to the igd because of shortness of breath since 1 day
ago".
 STEP 1
◦ Difficult word :
1. IGD (emergency installation): ◦ Keyword :
Is a section in a hospital that provides initial care for 1. Baby girl 5 months
the patient is suffering from illness and injury, which 2. Shortness of breath 1 day ago
can threaten his survival.
2. Tightness:
- Can't get enough air
- The air doesn't get in perfectly
- Full feeling in the chest
- Chest feels heavy, narrow
- Choking feeling
- Shortness of breath
- Heavy breathing
 DD
1. Bronkopneumonia
2. Pneumonia
3. Asma bronkial
4. Tuberculosis
 STEP 2
◦ History taking
◦ Physical examination : ◦ Hypothesis:

- general circumstances - Bronchial asthma

- head and neck - Bronkopneumonia

- thorax
◦ Supporting investigation :
- General check up
- X-rays
- CT Scan
- Urine culture
 STEP 3 (ADDITIONAL INFORMATION)
◦ History ◦ Supporting government
- Shortness of one day ago, the sound of expiration is heard - General cekup: hb 13.2 g / dl, LED 25 mm / hour, Leu:
9300, tro: 605000
- Fever with cough and cold since 1 week ago
- Chest X-ray: looks ete bloodinfiltrates across lung fields
- Cough colds continuously without phlegm
- GDS: 94 ml / dl
- High heat above 38
- Never been given medication
◦ DD : Bronkopneumonie
◦ Physical Development
- Babies moan
- Pulse 160x / minute
- Respiration 60x / minute
- 92% oxygen saturation
- Nostril exhalation
- Intercostal and substernal retraction
- Rhonki
- Wheezing
 STEP IV
(TPL & PPL)
 DX:
1. Microbiological culture
ID: female 5 months 2. Blood serology
Dipsneu
KU: Shortness of TX:
breath 1. Penicillin G IV
Bronkopneumon
RPS: since 1 day, antibiotics (25,000 u / kg /
ie
there was shortness 4 hours)
of breath in the mlm
Wheezing (+) Cloramfenicol 15
day. Fever, cough,

POMR runny nose since 1

week RPD (-)
RPK (-)
Thorax x ray
infiltrate Bronko
mlg / kg / 6
hours IV

all pnrumonie Septriaxone 50mlg / kg /

RPE (-) 12 hours
lung fields
Physical
examination: Oxygen 2-4L / minute
Tachycardia
Pulse 160x / min
RR 60x / min MX :
Thrombocytosis Observation of vital sign
Axila temperature
38C Patient complaints
LED
Head neck:
increase
Nasal lobe (+) Ed:
1 Adequate nutrition
 Symmetrical chest
movements,
intercostal (+) 2. Immediately check
andretraction if any symptoms recur
subternal (+).breath 3. Immunization
sounds 4. Providing exclusive
Additional, ronkhi (+), breastfeeding
Wheezing (+), 5. Prevent babies from

POMR
saturation 92% oxygen
sufferers of ARI
Investigations: Whole 6. Isolate the patient
Blood: 7. Maintain PHBS
Leukocytes 9300 / uL premises
Platelets 605,000 / uL Live
Hb 13.2 g / dL 8. Prevent babies from
LED 25 / hour exposure to cigarette
GDA 94
smoke and pollution
Thorax x ray infiltrate
whole lung field
 STEP V (Learning Objectif)
1. anatomy of respiratory system
◦ The respiratory system consists of the nose, pharynx, larynx, trachea, bronchi, bronchioles, alveoli,
lungs, ribs, intercostal muscles, and diaphragm.

◦ Upper airway: nose, pharynx, larynx, trachea.

◦ Lower airways: bronchi, bronchioles, terminal bronchioles, respiratory bronchioles, alveolar ducts and
sacs, alveoli.
◦ alveoli divided by 3:

◦ Type I alveolar cells: epithelial cells that form the walls of the alveoli.

◦ Type II alveolar cells: cells that are metabolically active and secrete surfactants.

◦ Type III alveolar cells: are macrophages which are photosic cells and work as a defense mechanism.
 2. Physiology of respiratory system

◦ The breathing process consists of 3 parts, namely:

1. Ventilation is the entry and exit of atmospheric air from outside to the lungs or vice versa. Factors affecting
ventilation:
◦ - Atmospheric air pressure
◦ - Clean airway
◦ - Adequate lung development
2. Diffusion is the exchange of gases between the alveoli and capillaries of the lungs. Factors affecting diffusion:
◦ - Lung surface area
◦ -Thickness of respiration membrane
◦ -The amount of blood
◦ -The state / number of blood capillaries
◦ -Affinity
◦ -When there is air in the alveoli
3. Transport is the transport of oxygen through the blood in the lungs to the body's tissue cells and
vice versa carbon dioxide from the body tissues to the capillaries. Factors affecting the rate of
transportation:
-Cardiac output (CO)
-The number of red blood cells
-Blood hematocrit
-Exercise (exercise)
 3. Hystology of Respiratory System

◦ NOSE
In the nose the respiratory epithelium turns into the olfactory epithelium which contains cells support near the
epithelial surface.
◦ Lung
The bronchi are lined with semi-cylindrical stratified epithelium and goblet secretions. Its walls consist of a thin
lamina propria, a thin layer of smooth muscle, submucoa with bronchial glands, plates of hyalin and adventisia .
 Bronchioles, the lumen is lined with ciliated cylindrical pseudo-stratified epithelium and sometimes goblet cells
are found.
◦ Alveoli are the evaginations / outer sacs of the respiratory bronchioles, alveolar ducts, and alveolar sacs. So that the
alveoli are covered by epithelial cells, a layer of alveolar cell typia.
◦ Alveoli also contain alveolar macrophages / dust cells.
4. Anatomical Pathology of Bronchopneumonia

Gross :
• lung surface is slightly raised, dry and granular with a diameter
of 3-4 cm. These nodules are red, gray or yellow in color
•The incision shows an area of ​lung consolidation (lobular
pneumonia) due to inflammation in the form of the lung
parenchyma area if it is caused by pyegeneous bacteria and
can be advanced when the lesions join until they affect the
entire lobe
Mikroskopi :
• The alveolar lumen is completely filled with suppurative
exudate consisting of inflammatory cells
• Bronchial lumen containing suppurative exudate (PNN
inflammatory cells and cellular debris).
• Damaged bronchial epithelial cells.
• Alveolar walls, some are intact and some are damaged. PMN
and celluler debris
5. Definition and clinical manifestations of bronchopneumonia

Definitions:
Bronchhopneumonia is inflammation of the lungs, usually starting in the bronchioles
terminalis. The terminal bronchioles become clogged with mucopurulent exudate to form patches
of consolidation in the adjacent lobules.
This disease is often secondary in nature, following infection of the upper respiratory tract,
fever in specific infections and diseases that weaken the body's defense system.
Clinical manifestations :
a. The presence of epigastric, intercostal, suprasternal retractions
b. The existence of rapid breathing and nostril breathing
c. Usually preceded by infection of the upper respiratory tract for several days
d. Fever, dyspnea, sometimes accompanied by vomiting and diarrhea
e. Cough is usually not at the onset of the disease, there may be a cough, a few days at first dry then becomes
productive
f. On auscultation, ronkhi was found soft and hard wet
g. On the peripheral blood examination, there was leukocytosis with PMN predominance
h. On chest X-rays, there was an interstitial infiltrates and alveolar infiltrates and a picture of bronchopneumonia.
6. Etiology and Epidemiology of bronchopneumonia

Etiology :
The cause of bronchopneumonia is :
◦ Bacteria such as diplococus pneumonia, pneumococcus, stretococcus, hemolyticus
aureus, haemophilus influenza, bacillus friendlander (klebsial pneumoni),
mycobacterium tuberculosis.
◦ Caused by viruses such as respiratory syntical virus, influenza virus and cytomegaly
virus, and caused by fungi such as citoplasma capsulatum, criptococcus nepromas,
blastomices dermatides, aspergillus Sp, candinda albicans, mycoplasma pneumonia
and foreign body aspiration
Epidemiology :
In developed countries there are 4 million cases each year, so the total incidence of
pneumonia worldwide is 156 million cases of pneumonia in children under five every
year.
There are 15 countries with the highest incidence of pneumonia in children under five,
covering 74% (115.3 million) of 156 million cases worldwide. More than half of them are
found in 6 countries, covering 44% of the world's population of children under five
The number of children under five with pneumonia in Indonesia is 600,720 children,
consisting of 155 children who died under 1 year of age and 49 children who died at the
age of 1-4 years.
7. Pathophysiology Broncopneumonie

Causes of Bronchopneumonia enter the respiratory tract.

Inflammation of Broncus and Alveoli characterized by a

build-up of secretions.

When the spread of germs has reached the alveoli, the

complications that will occur are alveolar collapse, fibrosis,
emphysema and atelectasis.
 pneumonia that is a circumstances inflammation lungs Where all over alveoli filled with fluid and
cells blood. Disease this started with infection in alveoli, membrane lungs experience inflammation and
holes so that fluid and even cell blood red and cell blood white Exit from blood come in into the alveoli.
With thus, the alveoli infected in a manner progressive Becomes filled with fluid and cells, and infection
deployed by displacement bacteria from alveolus to alveolus.
8. Pathology and Pathogenesis

Stage II / Red
Stage I / Hyperemia Hepatissi

It is called It is called red

hyperemia hepatization because
it occurs when the
because of the
alveoli is filled with
initial red blood cells,
inflammatory exudate and fibrin
response that produced by the host
takes place in the as part of an
newly infected inflammatory
reaction.
area.
 Stage III / Gray Stage IV / Resolution
Hepatization
In stage IV /
Gray resolution that occurs
hepatization that during the immune
response and
occurs when
inflammationaBy
white blood cells subsiding, fibrin cell
colonize an remains and exudate
infected area of ​ lysis and are
the lung. absorbed by
macrophages so that
the tissue returns to
its original structure.
9. SUPPORTING INVESTIGATION

1. Laboratory examination
◦ In viral pneumonia and mycoplasma, the leukocytes are generally within normal limits. In bacterial
pneumonia, there is leukocytosis which ranges from 15,000 - 40,000 / mm 3 with PMN predominance.

2.C-Reactive Protein (CRP)

◦ Clinically CRP is used as a diagnostic tool to distinguish between infectious and non-infectious factors,
viral and bacterial infections, or superficial and deep bacterial infections .
3. Examination Microbiologist

◦ The diagnosis is definitive when germs are found from blood, pleural fluid, or pulmonary aspiration.

4. Serological examination

◦ Serologic tests to detect antigens and antibodies in bacterial infections have low sensitivity and
specificity.

5. Blood gas analysis (AGDA)

◦ Shows hypoxemia and hypercarbia. At an advanced stage metabolic acidosis may occur

6. Roentgenography examination

◦ X-ray of the posterior-anterior projection is the basis of the main diagnosis of pneumonia.
In general, the chest X-ray image consists of:

◦ Interstitial infiltrates, characterized by an increase in bronchovascular features,

peribronchial cuffing and overaeriation.

◦ Alveolar infiltrates, which are lung consolidation with air bronchogram.

◦ Bronchopneumoni is characterized by a uniform diffuse appearance in both lungs in the

form of patches of infiltrates that can extend to the peripheral areas of the lung
accompanied by an increase in peribronchial streaks..
10. MANAGEMENT

◦ Supportive: O2, enteral / parenteral nutrition

◦ Antibiotics empirically (germ culture and sensitivity tests)

- Age <3 months: ampicillin + gentamicin

- Age 3 months - 5 years: ampicillin + chloramphenicol, add macrolides if it does not

respond to ampicillin + chloramphenicol

- Age ≥ 5 years: macrolides, add beta lactam group if not responding to macrolides
Antibiotic Therapy

◦ Give it ampicillin / amoxicillin (25-50 mg / kg / times IV or IM every 6 hours), that is

should be monitored within 24 hours during the first 72 hours.

◦ When the child gives good response then given for 5 days.

◦ When things go clinical worsens before 48 hours, or there is a condition severe

(unable to suckle or drink / eat, or vomit completely, seizures, lethargy or
unconsciousness, cyanosis, respiratory distress

weight) then added chloramphenicol (25 mg / kg / times IM or IV each 8 hours).

◦ If the patient comes in a severe clinical condition, immediately give oxygen and
treatment ylylicin-chloramphenicol or ampicillin-gentamicin combination.
◦ As an alternative, give ceftriaxone (80-100 mg / kg IM or IV once a day).
◦ If the child does not improve within 48 hours, then if possible make a chest photo
Oxygen Therapy

◦ Give oxygen to all children with severe pneumonia

◦ When available pulse oximetry, use as a guide for therapy oxygen (give to child with oxygen
saturation <90%, if sufficient oxygen is available).

◦ Continue giving oxygen until signs of hypoxia (such as traction lower chest wall heavy inward or
breath> 70 / min) was not found again.
Supporting care
◦ If the child is accompanied by a fever (> 39º C) which seems to be causing distress, give paracetamol.
◦ If found wheeze, give a quick-acting bronchhodilator
◦ If there is thick discharge in the throat that cannot be removed by child, gently remove with suction.
◦ Make sure the child gets the need for maintenance fluids according to the child's age, be careful about excess
fluids / overhydration.
◦ Encourage breastfeeding or oral fluids.
◦ If the child is unable to drink, provide maintenance fluids via an intravenous line.
MM NYA BELOM
Conclusion
A 5 month old baby girl was brought by her mother to the ER because of shortness of breath
since 1 day ago and obtained from the results of the history, physical examination, and supporting
examinations, it can be concluded that the patient has bronchopneumonias. bronchopneumonia is
inflammation that affects the lung parenchyma, distal to the terminal bronchioles which includes the
respiratory bronchioles and alveoli, and causes consolidation of lung tissue and impaired local gas
exchange.