PATIENT

IDENTITY
BRONKOPNEUMONI

COURSE OF By:
DIAGNOSE DISEASE dr. Tantsa Tamia

Supervisor:
dr. M. Diana Rahim

MANAGEMENT
LABORATORY PHYSICAL
EXAMINATION EXAMINATION
 PATIENT IDENTITY

An.J/1 years old/193367

January, 27 2023/08.24
GP : dr. Tendy
 COURSE OF DISEASE

The patient came to the emergency department unit with chief complaint shortness of breath since 2
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 4 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.

Patient did’nt come to pediatrician and 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 complete. In patient house there were
mother, father. Her father was active smoker and always smoke in house.
 2 Days Ago ER

Complaints of
shortness of breath,
fever, and cough
 PHYSICAL EXAMINATION

General Condition : moderately illness

Awareness : conscious
GCS : 15
BB : 9 kg
Tension : - mmHg
Pulse Rate : 162 x/minute
Respiratory Rate : 35 x/minute
Temperature : 36.1 C
Oxygen Saturation : 89% free air menjadi 97%
use NK 2 Lpm
Head
Eyes : anemic conjungtiva -/-, icteric sclera -/-
Nose : nostring breathing (-)
Mouth : cyanosis (-)
Neck : lymph node enlargment (-)

Thorax : symmetrical chest movements

Cor : S1 S2 regular, gallop (-), murmur (-)
Pulmo : vesicular breath sounds , crackles +/+,
wheezing -/-
 Abdomen : flat, soepel, bowel sound (+) normal, tenderness (-) a/r
epigastric
Liver : within normal limits
Spleen : within normal limits

Extremities :
warm, CRT <2 seconds, Edema (-)

7
 LABORATORY EXAMINATION
(29 NOV 2021)

Blood routine

- Hb : 12,9 gr/dL
- Leukocyte : 14.700/mm3
- Trombocyte : 341.000/mm3
- Ht : 41,2
- Erythrocyte : 5.30 millions/mm3
Thorax X-ray
DIAGNOSE

Bronkopneumoni
 MANAGEMENT

Emergency Room :
IVFD D5 ¼ NS 40 dpm micro
Inj Cefotaxim 2x450 mg IV
Inj Dexametason 2x0,2 cc
Paracetamol 3x90 mg iv prn
O2 : 2 lpm NK
Nebu Velutin ½ amp / 8 hours
Zinc drop 1x1 ml po
L-Bio sach 3x1 po
 MANAGEMENT
January, 28 2023

Subjective Shortnes breathness (-), cough (-), Fever (-)

Tension : - mmHg
PR : 100 x/m
RR : 20 x/m
Objective T : 36,4 C
SpO2 : 94%
Pulmo: vesicular breath sounds , crackles +/+, wheezing -/-

Bronkopneumoni

IVFD D5 ¼ NS 40 dpm micro

Diagnose and Inj Cefotaxim 2x450 mg IV
Inj Dexametason 3x0,2 cc IV
Planning Inj parasetamol 3x90 mg prn
Inj Amikacin 1x130 mg IV
Nebu Velutin ½ + Budesma ½ 2x
Zinc drop 1x1 cc po
 MANAGEMENT
January, 29 2023

Subjective Shortnes breathness (-), cough (-), Fever (-)

Tension : - mmHg
PR : 114 x/m
RR : 22 x/m
Objective T : 36,4 C
SpO2 : 98%
Pulmo: vesicular breath sounds , crackles -/-, wheezing -/-

Bronkopneumoni
Diagnose and
Planning Discharge
Afialys drop 1x1 ml
Thank You