Case report

PNEUMONIA

Eggy Khosasi
Elfiah Luthfianty
Laila Fitria Djaimi
Zusmitha Desy Putri
Syifa Farhani
Dini Astari

 
Supervisor:
dr. Riza Yefri, Sp.A
PEDIATRIC DEPARTMENT
FACULTY MEDICINE OF RIAU UNIVERSITY
ARIFIN ACHMAD REGIONAL GENERAL HOSPITAL
2021
 TEAM

Dini Astari Eggy Khosasi Zusmitha Desy Putri Laila Fitria Djaimi Elfiah Luthfianty Syifa Farhani
 01
INTRODUCTION
 PNEUMONIA
An acute infection of the lung parenchyma

Kemenkes RI, 2017 :

Causes : WHO, 2017 : the incidence of pneumonia
Bacteria the leading Infectious ranks 9 out of 10 diseases that
Viruses cause of death in often occur in Indonesia,
amounting to 2,157 cases
Fungi children worldwide (9.91%)

Riau Province, 2019 :

found pneumonia in
children as many as
4,272 cases (24.2%)
 02
Literatur Review
Definition

Pneumonia is inflammation of the

parenchyma of the lungs

WHO: The definition of pneumonia is based

on clinical symptoms from inspection and
respiratory rate

Sandora TJ dan Sectish TC. Community acquired pneumonia. In: Kliegman RM, Stanton BF, Geme JW, Schor NF, Behrman RE. Nelson
textbook of pediatrics. Elsevier health sciences. 19 th edition. 2011:1474-8

Ikatan Dokter Anak Indonesia. Pedoman pelayanan medis ikatan dokter anak indonesia. Jakarta: Ikatan Dokter Anak Indonesia 2011. p.250-255
Epidemiologi
158 million cases of pneumonia per Coverage of finding pneumonia in children under five in
year in the world with 154 million Indonesia in 2009-2019
cases occur in developing countries.
01 The death rate from pneumonia is
around 3 million cases or an estimated
29% of the total deaths in children
under five years old

Provinces of West Papua and DKI

02 Jakarta occupy the highest position in
the coverage of pneumonia case
detection

Riau (2019): 24.2% or 4,272 cases, with

details of 4,122 cases of pneumonia
03
and 150 cases of severe pneumonia.
There were no cases of death
• Sandora TJ dan Sectish TC. Community acquired pneumonia. In: Kliegman RM, Stanton BF, Geme JW, Schor NF, Behrman RE. Nelson textbook of pediatrics.
Elsevier health sciences. 19th edition. 2011:1474-8
• Kementrian Kesehatan RI. Profil kesehatan Indonesia tahun 2019. Katalog KEMENKES RI. 2020:161-2
• Ikatan Dokter Anak Indonesia. Pedoman pelayanan medis ikatan dokter anak indonesia. Jakarta: Ikatan Dokter Anak Indonesia 2011. p.250-255
Etiology

Sandora TJ dan Sectish TC. Community acquired pneumonia. In: Kliegman RM, Stanton BF, Geme JW, Schor NF, Behrman RE. Nelson
textbook of pediatrics. Elsevier health sciences. 19 th edition. 2011:1474-8
Etiology

Sandora TJ dan Sectish TC. Community acquired pneumonia. In: Kliegman RM, Stanton BF, Geme JW, Schor NF, Behrman RE. Nelson
textbook of pediatrics. Elsevier health sciences. 19 th edition. 2011:1474-8
Classification
Based on clinical and epidemiology

Community Acquired Pneumonia Hospital Acquired Pneumonia

is pneumonia in the community, which occurs

Pneumonia that occurs after 48 hours of hospitalization
through inhalation or aspiration of
Ventilator associated pneumonia (VAP) is pneumonia
pathogenic microbes into the lungs (lung
that occurs after 48 hours of endotracheal intubation
lobes)

Health Care Associasted Pneumonia Pneumonia aspiration

Pneumonia occurring in members of the

Pneumonia that occurs due to the entry of
public (who are not hospitalized), who are in
foreign objects into the respiratory tract
extensive contact with health care

Pneumonia in immunocompromised patients

Pneumonia that occurs in patients with poor immune
conditions
• Rahajoe NN, Supriyatno B, Setyanto DB. Buku ajar respirologi anak edisi I. Jakarta:
Ikatan Dokter Anak Indonesia. 2018
• Warganegara E. Pneumonia nosokomial (hospital-acquired, ventilatorassociated, dan
health care-associated penumonia) Fakultas Kedokteran, Universitas Lampung.
Jurnal Kedokteran Unila.2017;1(3)
Classification
Based on anatomy
WHO

Pneumonia lobaris Not Pneumonia Warning signs

Fever and cough without fast
Pneumonia lobularis (bronkopneumonia) breathing and chest indrawing
Pneumonia interstitial (bronkiolitis) Pneumonia
With fast breathing and/or chest
indrawing
Not able to drink
Persistent vomiting
Convulsions
Lethargic or unconscious
Stridor in a calm child
Severe malnutrition.

Severe Pneumonia

Pneumonia with any danger sign

• Perhimpunan Dokter Paru Indonesia. Pneumonia komunitas: pedoman diagnosis & penatalaksanaan di Indonesia. Jakarta:
Badan Penerbit FKUI; 2003.
• Revised WHO classification and treatment of childhood pneumonia at health facilities. WHO. 2014.
 Risk Factors

1 Not getting adequate breast milk 4 Low birth weight

2 Malnutrition
5 Incomplete immunization

3 Cigarette exposure and air

pollution
• Wahidah LK, Wahyuni NT, Putri DM. Evaluasi penggunaan antibiotik penumonia dengan metode ATC/DDD pada pasien pediatri di instalansi rawat inap RSUD DR. A. Dadi Tjokrodipo Bandar Lampung
tahun 2019. 2020;9(2):99-108.
• Sutriana VN, Sitaresmi MN, Wahab A. Risk factors for childhood pneumonia: a case-control study in a high prevalence area in Indonesia. Clin Exp Pediatr. 2021: 1-8
• Kulsum U, Astuti D, Wigati A. Kejadian pneumonia pada balita dan riwayat pemberian asi di Upt Puskesmas Jepang Kudus. Jurnal Ilmu Keperawatan dan Kebidanan. 2019;10(1):130-5
• Efni Y, Machmud R, Pertiwi D. Faktor risiko yang berhubungan dengan kejadian pneumonia pada balita di Kelurahan Air Tawar Barat Padang. JKA. 2016;5(2):365-70
• Artawan A, Purniti PS, Sidiartha IGL. Hubungan antara status nutrisi dengan derajat keparahan pneumonia pada pasien anak di RSUP Sanglah. Sari Pediatri. 2016;17(6):418-22
• Setyoningrum RA, Mustiko H. Faktor risiko kejadian pneumonia sangat berarat pada anak. J Respir Indo.2020; 40(4): 243-50
• Rigustia R, Zeffira L, Vani AT. Faktor Risiko yang berhubungan dengan kejadian pneumonia pada balita di Puskesmas Ikur Koto Kota Padang. Health & Medical Journal. 2019;1(1):22–97.
 Pathogenesis
2. Red hepatization (next 48 hours): Occurs in the
1. Congestion (24 hours first): This is the first second stage, which ends after a few days. There was an
stage, protein-rich exudate enters the alveoli accumulation that was still in the alveolar space,
through dilated and leaky blood vessels, together with lymphocytes and macrophages. Many red
accompanied by venous congestion. The lungs blood cells are also removed from the stretched
become heavy, edematous and red. capillaries. The pleura covering the pleura is covered
with fibrinous exudate, the lungs appear reddish in color,
solid without containing air, with a consistency similar to
that of a fresh, granular liver (hepatization = liver-like).

3. Gray hepatization (3-8 days): In the third

stage shows continued accumulation of fibrin 4. Resolution (8-11 days): In this fourth stage,
with destruction of white blood cells and red the exudate is lysed and reabsorbed by
blood cells. The lungs appear gray-brown and macrophages and inflammatory waste digestion,
congested because leukocytes and fibrin are maintaining the architecture of the underlying
consolidating in the affected alveoli. alveolar wall, so that the tissue returns to its
original structure.

Kliegman, R. M., Behrman, R. E., Jenson, H. B., & Stanton, B. M. Nelson textbook of pediatrics e-book. Elsevier Health Sciences. 2011. p. 1474-1479
 Diagnose
The diagnosis of pneumonia is based on history, physical examination, laboratory
evaluation

General infection symptoms Symptoms of respiratory distress

Fever, headache, irritable, Coughing, shortness of breath,

restlessness, malaise, decreased chest retractions, tachypnea,
appetite, gastrointestinal nostrils, nasal flaring and cyanosis
complaints such as nausea,
vomiting or diarrhea, sometimes
extrapulmonary infection
symptoms are found

Kliegman, R. M., Behrman, R. E., Jenson, H. B., & Stanton, B. M. Nelson textbook of pediatrics e-book. Elsevier Health Sciences. 2011. p. 1474-1479
 Physical Examination

1 Tachypnea 4 Rhonchi/ decreased

breath sounds

Lower chest in-drawing:

2 Retractions, nasal flaring 5 Acute abdomen

3 Fever Increase in respiratory rate based on

age by WHO:
AGE Respiration rate/minute
<2 month >60 x/minute
2 – 12 month >50 x/minute
1-5 month >40 x/minute

Ikatan Dokter Anak Indonesia. Pedoman pelayanan medis ikatan dokter anak indonesia. Jakarta: Ikatan Dokter Anak Indonesia 2011. p.250-255
Kliegman, R. M., Behrman, R. E., Jenson, H. B., & Stanton, B. M. Nelson textbook of pediatrics e-book. Elsevier Health Sciences. 2011. p. 1474-1479
 Laboratory evaluation

1 Saturation oxygen

Laboratory evalution: C-
2 Reaktif Protein (CRP)

Rontgen Thorax: Infiltrat

3 interstitial, infiltrat alveolar,
bronchopneumonia

Ikatan Dokter Anak Indonesia. Pedoman pelayanan medis ikatan dokter anak indonesia. Jakarta: Ikatan Dokter Anak Indonesia 2011. p.250-255
Kliegman, R. M., Behrman, R. E., Jenson, H. B., & Stanton, B. M. Nelson textbook of pediatrics e-book. Elsevier Health Sciences. 2011. p. 1474-1479
Differential Diagnose

In infants and young children:

Congenital cardiopulmonary anatomic
-Object aspiration
abnormalities:
-Bronchiolitis
-Tracheoesophageal fistula
-Heart failure
-Congenital heart disease
-Sepsis
-Sepsis
-Metabolic acidosis

Dahlan Z, Setiati SI, Alwi I, Sudoyo AW, Simadibrata M, Setyohadi, et al. Pneumonia: Buku Ajar Ilmu Penyakit Dalam. 6th ed. Jakarta: Pusat Penerbitan Ilmu Penyakit Dalam FKUI;2014.
p1608-19
Management

Revised WHO classification and treatment of childhood pneumonia at health facilities. WHO. 2014.
 Several things indicate hospitalization for
people with pneumonia:
Supportive therapy that can be given to
Baby:
pneumonia are as follows:
- Oxygen saturation <92%
1. If there are thick secretions in the airways,
- Cyanosis
clean the secretions with suction.
- Respiratory rate >60 x/minute
2. Give paracetamol if you have a fever
- Respiratory distress, intermittent apnea, or
3. If there is wheezing, give a fast-acting
grunting
bronchodilator
- Don't want to drink/breastfeed
Provide adequate fluids and nutrition and avoid
- Requires intravenous antibiotics/nutritional
excessive dehydration.
support
- Families can't take care at home

-Sandora TJ dan Sectish TC. Community acquired pneumonia. In: Kliegman RM, Stanton BF, Geme JW, Schor NF, Behrman RE. Nelson textbook of pediatrics. Elsevier health sciences.
19th edition. 2011:1474-8

-Ikatan Dokter Anak Indonesia. Pedoman pelayanan medis ikatan dokter anak indonesia. Jakarta: Ikatan Dokter Anak Indonesia 2011. p.250-255

-Kliegman, R. M., Behrman, R. E., Jenson, H. B., & Stanton, B. M. Nelson textbook of pediatrics e-book. Elsevier Health Sciences. 2011. p. 1474-1479
 Indications for oxygen therapy in pneumonia
Criteria for discharge after the patient is
patients:
hospitalized:
-Cardiac-respiratory arrest
-Symptoms and signs of pneumonia disappear
-Hypoxemia (PaO2 <60 mmHg, SpO2 <90%)
- Adequate oral intake
Hypotension (systolic blood pressure <100
Antibiotics can be continued at home (orally)
mmHg)
-The family understands and agrees to provide
-Low cardiac output and metabolic acidosis
therapy and control plans
(bicarbonate <18 mmol/L)
-Home conditions allow for follow-up care at home
-Respiratory distress

-Ikatan Dokter Anak Indonesia. Pedoman pelayanan medis ikatan dokter anak indonesia. Jakarta: Ikatan Dokter Anak Indonesia 2011. p.250-255

-Kliegman, R. M., Behrman, R. E., Jenson, H. B., & Stanton, B. M. Nelson textbook of pediatrics e-book. Elsevier Health Sciences. 2011. p. 1474-1479
Complication
-Complications of pneumonia in children include thoracic empyema, purulent pericarditis, pneumothorax,
or extrapulmonary infections such as purulent meningitis.
-Complications of myocarditis (increased right ventricular systolic pressure, increased creatinine kinase,
and heart failure) are quite high in the pneumonia series of children aged 2-24 months

-Kliegman, R. M., Behrman, R. E., Jenson, H. B., & Stanton, B. M. Nelson textbook of pediatrics e-book. Elsevier Health Sciences. 2011. p. 1474-1479

-Revised WHO classification and treatment of childhood pneumonia at health facilities. WHO. 2014.
Prognosis
-In general, pneumonia in children recovers quickly although radiological abnormalities can persist for 6-
8 weeks before returning to normal conditions.
In some children, pneumonia can last more than 1 month or recur. In this case, the possibility of other
diseases should be investigated further.
-Children with tuberculosis are at high risk if the condition is not treated. Immunocompromised children
have the worst prognosis.

-Ilten F, Senocak F, Zorlu P, Tezic T. Cardiovascular changes in chuldrenn with pneumonia. Turk J Pediatric. 2003; 45:306-10
-Carter ER, Marshal SG. Sistem Respirasi. In: Marcdante KJ, Kliegman RM, Jenson HB, Behrman RE, editor. Nelson Ilmu Kesehatan Anak Esensial. 6th ed Update. Singapore: Elsevier; 2018. p.
529-36
 03
CASE REPORT
 Patient Identity

• Name : An. DAM

• Sex : Male
• Age : 3 years 1o days
• Medical Record : 0107xxxx
• Adress : Simpang Libo Kandis, Siak
• Admission date to RSUD : October, 15th 2021
• Examination Date : October, 18th 2021
 Chief Complaint
“Shortness of breath since 1 day before admission to the hospital”
 Present Illness History
4 months before 1 month before 1 month before 1 day before admission
admission to hospital admission to the hospital admission to the hospital to the hospital

• Cough getting worse • fever (+), with same

• Persistent cough
• Intermitten runny nose characteristics as before • Shortness of breath occurs
• Accompanied by
with nasal congestion • Vomiting (+), 3-5 times a suddenly, unaffected by
white sputum, half
• accompanied by yellow day, in small amounts, weather, food or activity, not
tea spoon, more
discharge with thick containing food and drink relieved by a change in
than 10 times a position
consistency • vomiting occurs every
day •
• fever for 5 days time the patient eats History of contacts withTB
• Difficult to expel
continuously with • watery stools,3 times a patients or people who have a
sputum long cough has been denied
temperature that always day, half glass, with a
• Not affected by
increases at night yellow-brown color. • Patient taken to the RSUD
weather and
• Fever is not accompanied AA
activity
by chills and sweat
• Fever cured without
treatment
 Past Illness History
• The patient never had complaints of shortness of breath before

Family Illness History

• The patient's cousin had been treated at Syafira Hospital with complaints of
fever and cough
• The patient's mother is coughing
• There is no family member suffering from pulmonary TB
 Parental History
• Father: 30 years old, working as a employee
• Mother: 29 years old, a housewife

History of Birth and Pregnancy

• The patient is an only child
• The mother took pregnancy control 5 times, with obstetrician.
• The patient's mother had blode vomited during pregnancy and was transfused 2 bags of blood
• The patient was born aterm, by spontaneous vaginal delivery. The birth weight 2.700 grams, and long 48 cm
 Immunization History

• 0 month : Hepatitis B0, OPV

• 1st months : BCG
• 2nd months : Pentabio and OPV
• 3rd months : Pentabio and IPV
• 4th months : Pentabio and OPV
• 9th months : Measles
 Food and Drink History

• 0-3 months : Breast milk

• 3-6 months : Breast milk + Porridge meal (mashed rice mixed
with salt, 1 time/day)
• 6 month-2 y.o : Breast milk + Porridge meal (mashed rice mixed
with fish/soup/meatballs/other, 3 times/day)
• 2 y.o – now : Formula milk 150 ml, 3 times/day + family food
 24-hour diet recall
Time Type of food Amount Calories (kkal)
Morning Quarter plate of white rice 50 gram 87,5
Quarter bowl of spinach 25 gram 6
Formula milk 150 cc 105
Afternoon Quarter plate of white rice 50 gram 87,5
Half cut of fish 50 gram 45
Quarter bowl of spinach 25 gram 6
Formula milk 150 cc 105
Night Quarter plate of white rice 50 gram 87,5
Quarter bowl of spinach 25 gram 6
Half cut of fish 50 gram 45
Formula milk 150 cc 105
Total 685,5
 Daily Calorie Requirement
RDA X BBI = 100 x 13,8 = 1380 kkal

  𝑑𝑎𝑖𝑙𝑦 𝑐𝑎𝑙𝑜𝑟𝑖𝑒𝑠 685,5

food intake= ×100 %= × 100 %=49,67 %
𝑡𝑜𝑡𝑎𝑙 𝑐𝑎𝑙𝑜𝑟𝑖𝑒 𝑟𝑒𝑞𝑢𝑖𝑟𝑒𝑚𝑒𝑛𝑡 1380
 Growth and Development History

• Birth weight : 2700 grams

• Birth length : 48 cm
• Current weight : 10 kg
• Current height : 94 cm
• Upper arm circumference : 13 cm
• Since 2 y.o, the patient's weight has never been more than 10
kg.
Housing & Residence Conditions
• 0-30 months : lives in a factory area
• 31 months – now : lives with his grandmother in a private house with 2 other
family members
• Sanitation, ventilation, and lighting are good
 Physical Examinations

General Condition : Moderate illness

Consciousness : Composmentis cooperative
GCS : E4V5M6
Blood Pressure : 80/50 mmHg
Heart Rate : 106 beats / minute, regular, strong lifting
Respiration Rate : 55 breaths / minute, regular
Temperature : 38,8 C
 Physical Examinations
Weight : 10 kg
Height : 94 cm
Upper Arm Circumference : 13 cm
Ideal Body Weight : 13,8 kg

BB / U : -3 < SD <-2 (underweight)

TB / U : -2 < SD < 0 (normal tall)

BB / TB : SD < -3 (severly wasted)

 
• Status gizi : Kriteria Waterlow, WHO 2006: Gizi kurang
Weight : 10 kg
Height : 94 cm
Upper Arm Circumference : 13 cm
Ideal Body Weight : 13,8 kg
BB / U : -3 < SD <-2 (underweight)
Weight : 10 kg
Height : 94 cm
Upper Arm Circumference : 13 cm
Ideal Body Weight : 13,8 kg
TB / U : -2 < SD < 0 (normal tall)
Weight : 10 kg
Height : 94 cm
Upper Arm Circumference : 13 cm
Ideal Body Weight : 13,8 kg
BB / TB : SD < -3 (severly wasted)
 Physical Examinations

Head : Normocephal
Hair : Normal
Eye: Normal
Nose : Nostril breath (+)
Lip : Normal
Cor : Normal
Pulmo : Normochest, symmetrical movement, subcostal retraction (+), venectation (-), mass (-)
Vocal fremitus (+/+), tracheal deviation (-), Vesicular (-/-), rhonchi (+/+), wheezing (-/-)
 Physical Examinations

Abdomen : Flat, symmetric, mass (-), venectation (-), supple, tenderness (-) skin turgor returned
fast, Liver enlargement (-), spleen enlargement (-) ballottement (-), tenderness & knock pain
on CVA regio (-/-), bowel sounds (+) 12 time/minute
Genitourinary : normal
Extremities : Normal
 Laboratory Findings: Emergency Department
Laboratory Findings Result October, 15th 2021
Haemoglobin 11,6 g/dL
Leukocyte 5.830 /uL(L)
Thrombocyte 231.000/uL Laboratory Findings Result
Haematocrit 33%
MCV 79,0 fL Dengue
IgM anti dengue Non reactive
MCH 26,2 pg IgG anti dengue Non reactive
MCHC 33,1 g/dL
IgM anti Salmonela Reactive score 6
Basophil 0,2%
Eosinophil 0% (L)
Neutrophil 50,6%
Lymphocyte 35%
Monocyte 14,2% (H)
CRP 1,3mg/L
Blood Glucose 60 mg/dL
Rontgent Thorax October, 15 th
2021

• Clavicle, scapula and ribs intact

• Midline Trachea
• Soft Tissue <2 cm
• Pulmo: normal bronchovascular pattern, infiltrates in both
lung fields
• Sharp costophrenic sinus
• Slippery Diaphragm
• CTR <50%
• Heart waist: does not disappear
• Impression: Suspect Pneumonia
 Working Diagnose
Pneumonia

Nutrition Diagnose
Underweight, normal tall, severly wasted with poor nutritional status

Differential Diagnose
• Pulmonary tuberculosis
 Recommended for the Next
Examination
• Mantoux test
• GenXpert
• sputumculture
 Management: Inpatient room
Pharmacotherapy
• Inf KA-EN 1B 10 tpm
• Inj ceftriaxone 400 mg/12 hours
• Inj Omeprazol 10 mg/12 hours
• Inj dexametason 1,5 mg/12 hours
• Pct inf 100mg/6 hours k/p
• Nebulisasi ventolin /18 hours
• Ambroxol syr 3x1 cth
• Zinc 1x5 ml
 Prognosis

• Quo ad vitam : dubia ad bonam

• Quo ad fungsionam : dubia ad bonam
• Quo ad sanationam : dubia ad bonam
 Follow Up
Subjective: 10/15/2021
Fever(+), Shortness of breath(+), doesn't want to eat, Cough with sputum and
hard to come out

Objective:
General condition: Moderate illness
Consciousness : CM
Blood Pressure : 115/100 mmHg
HR : 135x/i
RR : 60 x/i
T : 36,8 C
SpO2 : 95% without O2
Face : dry mucous of lip (+)
Pulmo : retraction (+)
Extremities : Warm, CRT < 3 sec

Assessment :
Pneumonia

Management
• Move to HCU on Saturday, October 16, 2021 at 00.14 WIB
 Follow Up
Subjective: 10/16/2021
Fever(+), Shortness of breath(+), doesn't want to eat, Cough with sputum and
hard to come out

Objective:
General condition: Moderate illness Management
Consciousness : CM Formula milk 8 x 95 cc per NGT
Blood Pressure : 91/67 mmHg Infus Ringer Laktat 20 cc/hour
HR : 118 x/i Inj. Ceftriaxone 400 mg/12 hours
RR : 50 x/i Paracetamol infus 100 mg/6 hours
T : 37,1 C Injeksi Dexametason 1,5 mg/8 hours
SpO2 : 99% with O2, 1L Injeksi omeprazole 10 mg/12 hours
Face : dry mucous of lip (+)
Nebulisasi Ventolin ½ resp/8 hours
Pulmo : retraction (+)
Extremities : Warm, CRT < 3 sec Ambroxol syrup 3 x 1 cth

Assessment :
Pneumonia
 Follow Up
Subjective: 10/17/2021
Shortness of breath(↓), want to eat, Cough with sputum and hard to come out

Objective:
General condition: Moderate illness
Consciousness : CM
Management
Blood Pressure : 94/71 mmHg Formula milk 8 x 95 cc per NGT
HR : 100 x/i
Infus Ringer Laktat 20 cc/hour
RR : 47 x/i
T : 37, C
Inj. Ceftriaxone 400 mg/12 hours
SpO2 : 99% with O2, 1L Paracetamol infus 100 mg/6 hours
Pulmo : retraction (+), vesicular (+) Injeksi Dexametason 1,5 mg/8 hours
Extremities : Warm, CRT < 3 sec Injeksi omeprazole 10 mg/12 hours
Nebulisasi Ventolin ½ resp/8 hours
Assessment : Ambroxol syrup 3 x 1 cth
Pneumonia
 Follow Up
Subjective: 10/18/2021
want to eat, Cough with sputum and hard to come out

Objective:
General condition: Moderate illness
Consciousness : CM
Management
Blood Pressure : 98/47 mmHg
Inj. Ceftriaxone 400 mg/12 hours
HR : 120 x/i
RR : 51 x/i Paracetamol infus 100 mg/6 hours
T : 36,8 C Injeksi Dexametason 1,5 mg/8 hours
SpO2 : 99% no divice Injeksi omeprazole 10 mg/12 hours
Pulmo : retraction (-), vesicular (+), ronkhi(-), Wheezing(-) Nebulisasi Ventolin/18 hours
Extremities : Warm, CRT < 3 sec Ambroxol syrup 3 x 1 cth
Zinc 1x 5
Assessment :
Pneumonia
 Follow Up
Subjective: 10/19/2021
Watery defecatin, 8 times/day, greenish yellow color, Cough with sputum (↓)
and hard to come out

Objective:
General condition: Moderate illness
Management
Consciousness : CM
HR : 101 x/i Inj. Ceftriaxone 400 mg/12 hours
RR : 45 x/i Paracetamol infus 100 mg/6 hours
T : 36,8 C Injeksi omeprazole 10 mg/12 hours
Pulmo : retraction (-), vesicular (+), ronkhi(-), Wheezing(-) Nebulisasi Ventolin/18 hours
Extremities : Warm, CRT < 3 sec Ambroxol syrup 3 x 1 cth
Zinc 1x 5
Assessment :
Pneumonia
 Follow Up
Subjective: 10/20/2021
Cough with sputum and hard to come out

Objective:
General condition: Moderate illness
Consciousness : CM
Management
HR : 121 x/i
RR : 42 x/i Inj. Ceftriaxone 400 mg/12 hours
T : 36,5 C Paracetamol infus 100 mg/6 hours
Pulmo : retraction (-), vesicular (+), ronkhi(-), Wheezing(-) Injeksi omeprazole 10 mg/12 hours
Extremities : Warm, CRT < 3 sec Nebulisasi Ventolin/18 hours
Ambroxol syrup 3 x 1 cth
Assessment : Zinc 1x 5
Pneumonia
 Follow Up
Subjective: 10/21/2021
Cough with sputum and hard to come out

Objective:
General condition: Moderate illness
Consciousness : CM
Management
HR : 110 x/i
RR : 36 x/i allowed to go home
T : 36,6 C
Pulmo : retraction (-), vesicular (+), ronkhi(-), Wheezing(-) Cefadroxil syrup 2 x 5 cc
Extremities : Warm, CRT < 3 sec Ambroxol syrup 3 x 2,5 cc
Sukralfat 3x1
Assessment :
Pneumonia
 04
DISCUSSION
 Discussion
• The patient is 3 years and 10 days, came with the chief complaint
of shortness of breath which had worsened since 1 day of SMRS.
CASE • The patient has a fever, malaise, does not want to eat, vomiting,
diarrhea, coughing, and shortness of breath

• Diagnosis of pneumonia based on WHO, which consists of at

THEORY
least a cough, rapid breathing, with or without chest indrawing
(TDDK).
• According to research the most common complaints in pneumonia were
fever (32.48%), cough (32.28%), and vomiting (13.77%)
 Discussion
• The patient obtained information that led to the suspicion of pneumonia,
namely shortness of breath, coughing up phlegm and fever
CASE

• Clinical manifestations of pneumonia are common infectious symptoms

THEORY
such as fever and decreased appetite and respiratory symptoms (cough
and shortness of breath).
• The most prominent complaints in pneumonia patients are cough and
fever
 Discussion
• Physical examination in the patient experienced tachypnea, namely
respiration rate 55x/minute, fever with a temperature of 38.8oC,
CASE subcostal retractions, and rhonchi in both lung fields

• According to WHO, the diagnosis of pneumonia can be made by rapid

THEORY breathing or by pulling in the lower chest wall (eg the lower chest wall
is pulled in when the child inhales)
• On physical examination, symptoms of respiratory distress were also
assessed, such as tachypnea, subcostal retractions, cough, crepitus and
decreased lung sounds
 Discussion
CASE
• In this case, the patient has diarrhea

• Research conducted by Saha et al found that 188 children had

diarrhea from 159 children who suffered from pneumonia
THEORY
• The results of blood cultures performed on children with
pneumonia and diarrhea showed that 85% were gram-negative
bacteria including Escherichia coli, Acinetobacter spp, and
Pseudomonas spp
 Discussion
• Routine blood laboratory examinations found a decrease in leukocytes,
eosinophils and an increase in monocytes
CASE • On a chest X-ray in this patient there is an infiltrate in both lung
fields with the impression of suspect pneumonia

• The laboratory examinations indicates that the patient has a

THEORY
bacterial or viral infection
• The chest X-ray of penumonia can show an infiltrate
 Discussion
• The differential diagnosis, in this case, is pulmonary tuberculosis. There
is a history of cough, fever, the weight that does not increase and the
CASE child is less active.
• In patients the fever does not persist, which only lasts for 5 days and
then heals on its own, and in patients, there is no contact with people
suffering from TB.

• Symptoms of TB are usually more typical, namely persisting for more

THEORY
than two weeks despite adequate therapy
• Supportive examinations are recommended to rule out the diagnosis of
TB in the form of the Mantoux test and GenXpert
 Discussion

• Another recommended investigation is sputum culture to determine the presence

CASE of bacteria causing pneumonia
• The patient did not perform a sputum culture because there are contraindications
for sputum induction

Contraindications to sputum induction, namely:

THEORY • oxygen saturation <92% even with oxygen administration
• respiratory distress
• severe bronchospasm
• seizures or in children with a history of seizures
• or other reasons as directed by a doctor
 Discussion
• The patient had respiratory distress in the form of subcostal
CASE retractions, so that in the ER the patient was given oxygen via a
nasal cannula 1 liter per minute

• If there are signs of use of the accessory respiratory muscles, such

as flaring of the nose and subcostal, intercostal, or suprasternal
retractions, oxygen therapy should be given
THEORY Indications for oxygen therapy are:
• Cardiac-respiratory arrest
• hypoxaemia (PaO2 <60 mmHg, SpO2 <90%)
• hypotension (systolic blood pressure <100 mmHg
• and low cardiac output and metabolic acidosis (bicarbonate <18
mmol/L)
• and the presence of respiratory distress
 Discussion
Case
• 55 breaths / minute, regular
• Respiratory distress retraction
• Warning sign of pneumonia  low intake, lethargic  needs to receive intravenous
therapy  Indications for hospitalization

Theory
Indications for hospitalization of pneumonia
• Oxygen saturation <92%
• Cyanosis
• Respiratory rate >50 breaths/minute
• Respiratory distress or grunting
• There are signs of dehydration
• Requires intravenous antibiotics or nutrition
 Discussion

Case
• Patients were given infusion therapy of KA-EN 1B, ceftriaxone, omeprazole,
dexamethasone, nebulized ventolin, ambroxol, and zinc.

Theory
• KA-EN 1B infusion fluid  helps replace electrolyte fluid
• Ceftriaxone  is a broad-spectrum cephalosporin given to pneumonia
patients
• Ambroxol  relieve cough symptoms
• Zinc  accelerates the recovery process of pneumonia patients
 Discussion

• Ventolin nebulization  to cause bronchodilation in the airways  to

help clear the airway
• Injection of dexamethasone (steroid)  an inflammatory inhibitor
that suppresses the expression of proinflammatory cytokines and has
the potential to prevent the inflammatory response
 Discussion

Case
• Home therapy  cefadroxil, ambroxol and sucralfate

Theory
• Ambroxol  as a mucolytic by breaking the mucopolysaccharide
fibers found in sputum  the viscosity of sputum is reduced 
sputum will be easily removed.
• Cefadroxil side effects  gastric irritation. So it is given sucralfate to
reduce gastric irritation
 Discussion

Case
• Malnutrition (72.46%)  waterlow criteria

Theory
• In children with less or malnutrition, the body's defense system
decreases so they are susceptible to infection
• Malnourished children have a 2.2 times greater risk of developing
more severe pneumonia
Revisi
• Status gizi  status pertumbuhan
• Halaman 30:
IgM anti dengue
IgG anti dengue
• Ada beberapa kertas yang tidak memiliki nomor halaman
• Halaman daftar isi salah
• Halaman 3 kosong
• Penulisan daftar pustaka belum sesuai kaidah
Thank You