CASE REPORT

BRONCHOPNEUMONIA
B Y:
Lilis Ariska, MD

SEPERVISOR:
M Diana Rahim, MD
Ina Berliana, MD
PATIENT IDENTITY

Name : Sabki
Gender : Male
Age : 8 month
Date of birth : 29 June 2019
Address : Kp. Panyingkirang 03/03 Ds. Sukaergi, Cisurupan, Garut
Medrec : 0-15-04-48
 COURSE OF DISEASE

22/02/2020 23/02/2020 24/02/2020 25/02/2020 27/02/2020

Fever Fever Fever Visited Pediatrician Control to Pediatrician
Cough Cough Were given No sign of improvement
Cold Cold antipyretic, cough ↓
medicines, and
Shortness of breath Referred to
antibiotics
Emergency Department
Unit with CC: shortness
of breath
 PATHOPHYSIOLOGY
Aspiration of bacteria from upper airway

Bacteria enter the lung Red Hepatization

Inflammation Gray to brown Hepatization

Fever Cough Shortness of breath Patchy

appearance in Resolution
thorax x-ray
CLINICAL PATHWAY
HISTORY TAKING
CC : Shortness of breath
The patient came to the emergency department unit with chief complaint shortness of breath since 4 days
before being admitted to the hospital, and the symptom became progressive over time. Complaints of
shortness of breath are not accompanied by wheezing or snoring or cyanosis on the tips of the finger or
around the mouth. The complaints are preceded by sudden high body temperature, and high fever is
sustained occurring whole day. Patient also complaint cough since 6 days before admitted to the hospital.
The complaints are not accompanied by vomiting, convulsions or loss of consciousness. There are no
defecation and urination complaints.
Previously, patients visited a pediatrician, and were given antipyretic, cough medicine and antibiotics.
Because there was no change in the patient’s condition, the pediatrician who previously treated the patient
referred the patient to Guntur Garut Hospital. This is the first time the patient has this disease.
There is no previous history of choking,contact with an adult who has had a cough for more than two weeks
or bloody cough, And history of fever and cough for more than 2 weeks is absent. Immunization history of
the patients is incomplete. The patient’s home is permanent, with cement floor. The ventilation of the
patient’shouse are considered sufficient, only a little sunlight enters the house, and the patient’s bedroom is
damp.
CLINICAL PATHWAY
PHYSICAL EXAMINATION
General condition: Moderately ill RR : 78 x/minutes
Level of conciousness: Compos mentis
PR : 148 x/minutes
BW : 8 kg
T : 38,0 C
Oxygen Saturation : 93% with room temperature
Head : Conjunctiva not anemic, sclera not icteric
Nasal flaring (+), POC (-)
Neck : Suprasternal retraction (-), no enlargement of the lymph node
Thorax Shape and movement are simetric, intercostal retraction (-)
P/ Sonor and VBS in the both lung, crackles (+), wheezing (-)
C/ Heart sound S1 S2 regular, additional sound (-)
Abdomen Epigastric retraction(-), flat, soft, liver and spleen are not palpable, peristaltic normal,
epigastric tenderness (-)
Ekstrimity : No oedema, CRT <2’’
CLINICAL PATHWAY
ADDITIONAL EXAMINATION
 Complete blood count examination

Hemoglobin : 8,7 gr %
Leukocyte : 11.900 /mm2
Trombocyte : 245.000 /mm3
Hematocrite : 31,5 %
CLINICAL PATHWAY
ADDITIONAL EXAMINATION
 PA Projection Chest X-Ray
DIAGNOSIS

Dx : Bronchopneumonia
MANAGEMENT

• Oxygen 2-3 Lpm

• IVFD : Asering 10 drops per minutes
• Sanmol drops 3 x 0,8 ml PO
• Mucos drops 3 x 0,4 ml PO
• Cefotaxime 2 x 400 mg injection IV
THANK YOU