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Transcript of Anak Broncho
Case report
BRONCHOPNEUMONIA
Presenters : Kiki Anggrita
Sari Mutiara Hutagalung
Day/Date : Thursday/December 23rd 2010
Supervisor : dr. Lily Irsa, Sp.A (K)
CHAPTER 1
1.1. INTRODUCTION
Pneumonia can be generally defined as inflammation of the lung
parenchyma, pneumonia is characterized by consolidation of the affected part and
a filling of the alveolar air spaces with exudate, inflammatory cells, and fibrin.
Most cases of pneumonia are due to infection by bacteria or viruses, although they
may also be due to the inhalation of chemicals, trauma to the chest wall, or other
infectious agents such as rickettsiae, fungi, and yeasts. 1
Bronchopneumonia is one of two types of bacterial pneumonia as
classified by gross anatomic distribution of consolidation (solidification), the
other being lobar pneumonia. Bronchopneumonia is an acute inflammation of the
walls of smaller bronchial tubes, with varying amount of pulmonary consolidation
due to spread of the inflammation into peribronchiolar alveoli and the alveolar
ducts.2.3
Although most cases of pneumonia are caused by microorganisms.
Pneumonia is an acute infection of one or both lungs that can be caused by a
bacterium, usually Streptococcus pneumoniae (also called pneumococcus; see
streptococcus streptococcus, any of a group of gram-positive bacteria, genus
Streptococcus, some of which cause disease, or by a virus, fungus, or other
organism. The causal organisms reach the lungs through the respiratory passages.
Usually an upper respiratory infection precedes the disease. Alcoholism, extreme
1 | P a g e
youth or age, debility, immunosuppressive disorders and therapy, and
compromised consciousness are predisposing factors. 1.4
When one or more entire lobes of the lung are involved, the infection is
considered a lobar pneumonia. When the disease is confined to the air spaces
adjacent to the bronchi, it is known as bronchopneumonia. Aspiration pneumonia
is the pathological consequence of the abnormal entry of fluids, particulate matter,
or secretions in the lower airways. Noninfectious causes include aspiration of
food or gastric acid, foreign bodies, hydrocarbons, and lipoid substances,
hypersensitivity reactions and drug or radiation induced pneumonitis.4
1.2. DEFINITION
Bronchopneumonia is a type of pneumonia that is characterized by an
inflammation of the lung generally associated with, and following about with
bronchiolitis. Bronchopneumonia or bronchial pneumonia or bronchogenic
pneumonia is an acute inflammation of the walls of the bronchioles. It is a type of
pneumonia characterized by multiple foci of isolated, acute consolidation,
affecting one or more pulmonary lobules. It is one of two types of bacterial
pneumonia as classified by gross anatomic distribution of consolidation
(solidification), the other being lobar pneumonia.2.3
1.3. ETIOLOGY
Pneumonia is most often caused by a bacterial infection (bacterial
pneumonia) or a viral infection (viral pneumonia). However, pneumonia can also
be caused by a fungal infection, yeast infection, trauma, or from inflammation of
the lungs due to exposure to toxic substances, such as poisonous gases.
Pathogens implicated in pneumonia vary with the age of the child, the
underlying patient-specific risk factors, immunization status, and seasonality.8
In the neonate, pathogens that may infect the infant via the maternal
genital tract include group B streptococci, Escherichia coli and other fecal
coliforms, and C trachomatis. Group B streptococci most often is transmitted to
the fetus in utero, usually as a result of colonization of the mother's vagina and
cervix by the organism. Affected infants commonly present within the first few
hours after birth, but if infection is acquired during the delivery, the presentation
2 | P a g e
may be delayed. The usual presenting symptoms include tachypnea, hypoxemia,
and signs of respiratory distress. Physical examination may reveal diffuse fine
crackles, and the chest radiograph may demonstrate a ground-glass appearance
and air bronchograms.6
Newborns may be affected by the bacteria and viruses that cause
infections in older infants and children. Risk factors for infection include older
siblings, group daycare, and lack of immunization, particularly against pertussis.
In the young infant, aged 1-3 months, continued concern about perinatally
acquired pathogens mentioned above as well as the unusual Listeria
monocytogenes remains. However, most pneumonia in this age group is
community acquired and involves Streptococcus pneumoniae, Staphylococcus
aureus, and non-typeable Haemophilus influenzae. Streptococcus pneumoniae is
by far the most common bacterial pathogen in this age group. Infection with
Staphylococcus aureus may be complicated by lung abscess, parapneumonic
effusions, and empyema. 6
Young children, viruses are a common cause of pneumonia among
toddlers and preschoolers. The usual culprits are those previously discussed.
Tsolia et al identified a viral infection among 65% of hospitalized children with
community-acquired pneumonia. Streptococcus pneumoniae is by far the most
common bacterial cause of pneumonia. Among hospitalized children,
Streptococcus pneumoniae accounts for 21-44% of disease. In a recent study to
evaluate the effectiveness of heptavalent pneumococcal conjugate vaccine in
prevention of pneumonia in children younger than 5 years, Black et al showed a
32.2% reduction in the first year of life and a 23.4% reduction between 1-2 years,
but only a 9.1% reduction in children older than 2 years.Children in this age group
are also at risk for infection by M pneumoniae.6
Older children and adolescents, M. pneumoniae is a frequent cause of
pneumonia among older children and adolescents. Mycoplasma accounts for 14-
35% of pneumonia hospitalizations in this age group. C pneumoniae can cause
pneumonia in this age group.
3 | P a g e
Streptococcus pneumoniae (pneumococcus) and Mycoplasma pneumoniae
both are the common bacterium which causes bronchopneumonia in the adults
and children.1.6
1.4. EPIDEMIOLOGY
The WHO Child Health Epidemiology Reference Group estimated the
median global incidence of clinical pneumonia to be 0.28 episodes per child-
year.1 This equates to an annual incidence of 150.7 million new cases, of which
11-20 million (7-13%) are severe enough to require hospital admission. Ninety-
five percent of all episodes of clinical pneumonia in young children worldwide
occur in developing countries.7
The insiden of pneumonia is 10 times higher in developing than in
developed countries, with as many as 5 million deaths occurring yearly in children
younger than 5 years. Such variable as nutritional status, age, and the presence of
an underlying condition influence morbidity and mortality rafes due to community
acquired pneumonia.8
In the United State, In a randomized double-blind trial, the heptavalent
pneumococcal vaccine reduced the incidence of clinically diagnosed and
radiographically diagnosed pneumonia among children younger than 5 years by
4% and 20%, respectively.7
1.5. PATHOPHYSIOLOGY
Pneumonia results from inflammation of the alveolar space and may
compromise air exchange. While often complicating other lower respiratory
infections such as bronchiolitis or laryngotracheobronchitis, pneumonia may also
occur via hematogenous spread or aspiration. Most commonly, this inflammation
is the result of invasion by bacteria, viruses, or fungi, but it can occur as a result of
chemical injury or may follow direct lung injury.7
Four stages of lobar pneumonia have been described. In the first stage,
occurring within 24 hours of infection, the lung is characterized microscopically
by vascular congestion and alveolar edema. Many bacteria and few neutrophils
are present. The stage of red hepatization (2-3 d), so called because of its
similarity to the consistency of liver, is characterized by the presence of many
4 | P a g e
erythrocytes, neutrophils, desquamated epithelial cells, and fibrin within the
alveoli. In the stage of gray hepatization (2-3 d), the lung is gray-brown to yellow
because of fibrin purulent exudates, disintegration of red cells, and hemosiderin.
The final stage of resolution is characterized by resorption and restoration of the
pulmonary architecture. Fibrinous inflammation may extend into the pleural
space, causing a rub heard by auscultation, and it may lead to resolution or to
organization and pleural adhesions.7
Bronchopneumonia, a patchy consolidation involving one or more lobes,
usually involves the dependent lung zones, a pattern attributable to aspiration of
oropharyngeal contents. The neutrophilic exudates are centered in bronchi and
bronchioles, with centrifugal spread to the adjacent alveoli. 7 In a person suffering
from bronchopneumonia, bacteria invade the lungs, which results to an
inflammatory immune response. This reaction of the lungs leads to the filling of
the alveolar sacs with exudates. As a result, consolidation takes place a condition
where in the air space in the lungs is replaced with fluids.
In pathology, we can found macroscopically multiple foci of consolidation
are present in the basal lobes of the human lung, often bilateral. These lesions are
2-4 cm in diameter, grey-yellow, dry, often centered on a bronchiole, are poorly
delimited and have the tendency to confluence, especially in children,
microscopically, A focus of inflammatory condensation is centered on a
bronchiole with acute bronchiolitis (suppurative exudates - pus - in the lumen and
parietal inflammation). Alveolar lumens surrounding the bronchiole are filled with
neutrophils ("leukocytic alveolitis"). Massive congestion is present. Inflammatory
foci are separated by normal, aerated parenchyma.1
1.6. CLINICAL FEATURES ( Signs & Symptoms )
Fever and difficulty in breathing are commonest presenting symtoms,
usually preceded by an upper respiratory tract infection. Other symptoms include
cough, lethargy, poor feeding, an “unwell child”. Localized chest, abdominal, or
neck pain is feature of pleuralirritationand suggest bacterial infection.10 The signs
and symptoms of pneumonia are often nonspecific and widely vary based on the
patient’s age and the infectious organisms involved.
5 | P a g e
Newborns, newborns with pneumonia rarely cough; they more commonly
present with tachypnea, retractions, grunting, and hypoxemia. Grunting in a
newborn is due to vocal cord approximation as they try to provide increased
positive end-expiratory pressure (PEEP) and keep their lower airways open.
Grunting suggests a lower respiratory tract disease. Retractions result from the
effort to increase intrathoracic pressure to compensate for decreased compliance.
Older infants, grunting may be less common; however, tachypnea,
retractions, and hypoxemia are common and may be accompanied by a persistent
cough, congestion, fever, irritability, and decreased feeding.
Toddlers and preschoolers, these children most often present with fever,
cough (productive or nonproductive), tachypnea, and congestion. They may have
some posttussive emesis.
Older children and adolescents, this group may also present with fever,
cough (productive or nonproductive), congestion, chest pain, dehydration, and
lethargy.
Extra pulmonary signs and symptoms include (1) abdominal pain or an
ileuses accompanied by emesis in patients with lower lobe pneumonia, (2) nuchal
rigidity in patients with right upper lobe pneumonia, or (3) a rub caused by
pericardial effusion in patients with lower lobe pneumonia due to Haemophilus
influenzae infection.
All children, many children present with nasal flaring, which increases
airflow to respiratory surfaces.7
Auscultation of the lung fields may yield rales, wheezing, diminished
breath sounds, tubular breath sounds, or pleural friction rub. The affected lung
field may be dull to percussion. Decreased tactile and vocal fremitus, as well as
egophony, may be appreciated over the area of pneumonia.10
1.7. LABORATORY STUDY
Identifying the causative infectious agent is the most valuable step in
managing a complicated case of pneumonia. Unfortunately, an etiologic agent can
be difficult to identify. Therefore, in most patients with community-acquired
pneumonia who are treated on an outpatient basis, treatment is empiric and based
primarily on patient age and clinical presentation.
6 | P a g e
a. CBC count
Testing should include a CBC count with differential and evaluation of
acute-phase reactants (ESR, CRP, or both) and sedimentation rate. The total WBC
and differential may aid in determining if an infection is bacterial or viral, and,
together with clinical symptoms chest radiography and ESR can be useful in
monitoring the course of pneumonia. In viral pneumonia, the WBC count may be
normal or elevated . Bacterial pneumonia is often associated with an elevated
WBC count in the range of 15,000–40,000/mm3 and a predominance of
granulocytes.1.3
b. Sputum culture
Sputum is rarely produced in children younger than 10 years, and samples
are always contaminated by oral flora. An adequate sputum culture should contain
more than 25 polymorphonuclear (PMN) cells per field and fewer than 10
squamous cells per field.
The common agents that cause pneumonia may be normal oral flora. For
these reasons, sputum cultures are not useful in most children with pneumonia,
although a Gram stain may help. An example of a positive Gram stain for S
pneumoniae is shown in the image below.3.8
(A) Gram stain demonstrating gram-positive cocci in pairs and chains and
(B) culture positive for Streptococcus pneumoniae.
c. Blood culture
Although blood cultures are technically easy to obtain and relatively
noninvasive and non traumatic, the results are rarely positive in the presence of
pneumonia and even less so in cases of pretreated pneumonia.
7 | P a g e
In a study of 168 patients with known pneumonia, Wubbel et al found only
sterile blood cultures. In general, blood culture results are positive in 10-15% of
patients with streptococcal pneumonia. The numbers are even less in patients with
Staphylococcus infection. A blood culture is still recommended in complicated
cases of pneumonia.3
d. Skin tests
Tuberculosis should always be considered as possible diagnose, especially
in endemic areas.8
These tests are used in diagnosing TB. Mantoux skin test (intradermal
inoculation of 5 TU of purified protein derivative) results should be read 48-72
hours after placement. In children older than 4 years without any risk factors, test
results are positive if the indurations (not the area of erythematic, which may be
larger) is 15 mm or larger. Among children younger than 4 years, those who have
an increased environmental exposure to TB or other medical risk factors (eg,
lymphoma, diabetes mellitus, malnutrition, renal failure), results are positive if the
indurations is 10 mm or larger. In immunosuppressed children or those in close
contact with others who have known or suspected cases of TB, test results are
positive if the indurations is 5 mm or larger.
Even if the child has received the Bacillus Calmette-Guérin (BCG)
vaccine, Mantoux test results should be interpreted using the criteria outlined
above.3
e. Bronchoscopy
Flexible fiberoptic bronchoscopy is occasionally useful to obtain lower
airway secretions for culture or cytology. This procedure is most useful in
immunocompromised patients who are believed to be infected with unusual
organisms (Pneumocystis, other fungi) or in patients who are severely ill.3
1.8. IMAGING STUDY
Radiography, this is the primary imaging study used to confirm the
diagnosis of pneumonia. Radiography is often performed when diagnosing
pneumonia, however, it is not always necessary or useful in determining the
etiology of the infection.3 In general, chest radiographs are standart practice with
8 | P a g e
hospitalized children whom a diagnose pneumonia being considered. The
sensitivity of the test to diagnose is approximately 75%.8
Viral pneumonias are associated with a patchy perihilar infiltrate,
hyperinflation, and atelectasis on chest radiography.In patients with bacterial
pneumonia, typical findings include a lobar consolidation with air bronchograms
occasionally accompanied by a pleural effusion (see the images below).Photo
thorax there bronkopeumoni patches infiltrates in one or several lobes, if the
pneumonia lobaris seen a consolidation in one or several lobes. Pneumatoceles
and abscesses are less commonly found but may indicate an S aureus, gram-
negative, or complicated pneumococcal pneumonia.3
A small propotion of pneumonias are associated with a parapneumonic
effusion, where they may be blunting of the costophrenic angle on the chest X-
ray. Some of this effusion develop into empyema.8
1.9. MANAGEMENT AND TREATMENT
Infant and children with mild and moderste low respiratory tract infection
can be safely cared for at home. In this situation, the child usually should be
reexamined within 48 hours of beginning treatment. According to the British
Thoracic Society guideline, an SaO2 of 92% or less, cyanosis, respiratory rate
greater than 70 breaths per minute, difficulty of breathing, intermittent apnea,
grunting, inability to feed, and family incapable of providing appropriate
observation or supervision are indicators for hospital admission among infant.8
General supportive care should include antipyretics, oxygen to keep
saturation > 92. Fluids should be given if necessary, ensuring that an excessive
volume is not given because of potensial inappropiate ADH secretion.10
Treatment decisions in children with pneumonia are dictated based on the
likely etiology of the infectious organism and the age and clinical status of the
patient. Antibiotic administration must be targeted to the likely organism, bearing
in mind the age of the patient, the history of exposure, the possibility of resistance
(which may vary, depending on local resistance patterns), and other pertinent
history. The initial outpatient treatment of children with pneumonia depends upon
the clinical findings and the patient's age.3
9 | P a g e
A position paper by the U.S Center for Disease and Control and
Prevention was recently published supporting the findings that intermediate
susceptible strain of pneumococcus respond well to high doses of beta-lactam.
High doses of penicillin, ampicillin, and amoxicillin have been
recommended whenever intermediate susceptible strain are considered. Some
expert suggest an option with third generation cephalosporins such as ceftriaxon
or cefotaxime.8
Children in whom pneumococcal disease is suspected initially should be
treated with amoxicillin or penicillin. A macrolide antibiotic alone, or in
combination with sulfisoxazole or an oral cephalosporin is an alternative.7
The choice antibiotic is determinaned by child’s age, newborn require
broad-spectrum intrvenous antibiotics. Most older infant can be manage with oral
amoxicillin, with broader spectrum antibiotics. For children >5 years of age either
amoxicillin or an oral macrolide such as erytrhomycin is the treatment of choice.10
1.10. COMPLICATION
Fortunately, most children with pneumonia recover without complications.
Persistent effusions and empyemas are the most common serious complications of
bacterial pneumonia, others include the following:7
Pulmonary abscess
Respiratory distress
Sepsis
1.11. PROGNOSIS
Patients who were placed on a protocol-driven pneumonia clinical
pathway are more likely to have favorable outcomes. The prognosis for most
forms of pneumonia is excellent. Most cases of viral pneumonia resolve without
treatment, common bacterial pathogens and atypical organisms respond to
antimicrobial therapy.7
The prognosis for varicella pneumonia is somewhat more guarded.
Staphylococcal pneumonia, although rare, can be very serious despite treatment.
Immunocompromised children, those with underlying lung disease, and neonates
10 | P a g e
are at high risk for severe sequelae. Some forms of viral pneumonia, particularly
adenoviral disease, may cause necrotizing bronchiolitis or bronchiolitis
obliterans.7
CHAPTER 2
2.1. OBJECTIVE
The aim of doing this paper is to report a case of bronchopneumonia of an
1-year-old girl that was admitted at the Infection Unit of Haji Adam Malik
General Hospital.
2.2. CASE
N, a 2-year-old girl, 9.5 kg, 82 cm, was admitted to the Infection Unit of
Haji Adam Malik General Hospital on September 16th, 2010 at 21.00 pm with
chief complaint was shortness of breath. The shortness of breath occurred since 2
days ago and getting worst in 1 day before she admitted to the hospital. The
shortness of breath was not related to activity and weather. Cyanosis was not
found. Productive cough occurred since 3 day ago. History of contact with TB
patient was not found.
Fever was found since 1 week ago with a characteristic of high fever
which relieved with fever relieving medication. Shivers and seizures were not
found. History of diarrhea was found since 5 days ago with frequency 5 times a
day and the volume was 20cc/diarrhea. Currently the patient is having watery
stool. Micturition is in normal range. History of birth, the patient was delivered
11 | P a g e
through caesarian operation and cried instantly. She had a history of complete
immunizations.
History of previous illness: This patient was referred from pediatrician
History of drugs usage : -
PHYSICAL EXAMINATION
Generalized Status:
Body weight (BW) : 9.5 kg Body length (BL) : 82 cm
BW/ BL : 84% (mild malnutrition)
Sensorium : Compos Mentis Body Temperature : 40.5 ۫CAnemic (-), icteric (-), cyanosis (-), edema (-), dyspnea (+)
Localized Status:
Head : Eye: light reflexes (+/+), isochoric pupil (right=left), pale inferior
conjunctival palpebra (-/-), palpebra edema (-/-)
Mouth/Ears: Within normal limit, Nose: Nasal Flaring (+)
Neck : Lymph node enlargement (-), JVP: R-2cmH₂O
Chest : Symmetrical fusiformic, retraction (+)
HR: 180 bpm, regular, murmur (-)
RR: 20 rpm, regular, ronchi (+)
Abdominal : Soepel, peristaltic (+) normal, Liver/Spleen: within normal limits
Extremities : Pulse: 180 bpm, regular, pressure/volume = sufficient
BP: 90/60 mmHg, warm extremity
Urogenital : Female, within normal limit
Laboratory Findings (September 16th 2010) from Private Lab
Test Result Normal Value
Complete Blood Count
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Hemoglobin (HGB)
Erythrocytes (RBC)
Leucocytes (WBC)
Hematocrit
Thrombocytes (PLT)
MCV
MCH
MCHC
RDW
10,40 g%
4,15 x 106/mm3
10,79 x 103/ mm3
31,50 %
225 x 103/ mm3
75,9 fL
25,1 pg
33 g%
13,8 %
11,3-14,1
4,40-4,48
6,0-17,5
37-41
217-497
81-95
25-29
29-31
11,6-14,8
Cell Count
Neutrophil
Lymphocyte
Monocyte
Eosinophil
Basophil
75,40 %
13,60 %
10,90 %
0%
0,10 %
37-80
20-40
2-8
1-6
0-1
Arterial Blood Gases
pH
pCO2
pO2
Bicarbonate (HCO3)
Total CO2
BE
O2 Saturation
7,515
23,9 mmHg
135,2 mmHg
18,9 mmol/L
19,6 mmol/L
-3,0 mmol/L
99,2 %
7,35-7,45
38-42
85-100
22-26
19-25
(-2) – (+2)
95-100
Serum Electrolyte
Natrium
Kalium
Chloride
130 mEq/dL
3,0 mEq/dL
99 mEq/dL
135- 155
3.6- 5.5
96- 106
Chest X-Ray (September 16th 2010)
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Chest X-Ray showed infiltrated on right lower lung ( right pericardial), specific
process, with differential diagnosis Bronchopneumonia.
Differential diagnosis : 1. Bronchopneumonia + GE without Dehydration
2. Bronkiolitis
3. Pulmonary Tuberculosis
Working diagnosis : Bronchopneumonia + GE without Dehydration
Management :
O2 1 L/i Nasal Canal
Nebule NaCl 0,9% 2,5cc/8 hours
IVFD D5% NaCl 0,225% 40 gtt/i
Injection Ampicillin 250mg/6 hours/iv skin test
Injection Gentamycin 80mg/24 hours/iv skin test
Paracetamol 3x100mg, if needed
Fasting as the temporary diet
14 | P a g e
Investigation Plan: - Chest X-Ray (AP)
- Mantoux Test
Follow Up
Follow Up November 17th 2010 6:00 am
S Shortness of breath (+), Cough (+), Fever (-), Diarrhea (+)
O Sens: Compos Mentis T: 37.4 ۫C BW: 9.5 kg BL: 82 cm
BW/BL: 84% (mild malnutrition)
Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior
palpebral conjunctiva (-/-), Nose: Nasal Flaring (+)
Mouth/Ears: Within normal limits
Neck : Lymph nodes enlargement (-), JVP: R-2cmH₂O
Chest : Symmetrical fusiformic, retraction (+),
HR : 132 bpm, regular, murmur (-)
RR : 48 rpm, regular, ronchi (+)
Abdomen : Soepel, normal peristaltic,
Liver/Spleen: Within normal limits
15 | P a g e
Extremities : Pols 132 bpm, regular, Pressure/Volume: sufficient,
BP : 90/60 mmHg, warm extremity
A Bronchopneumonia + GE without Dehydration
P O2 1 L/I Nasal Canal
Nebule NaCl 0,9% 2,5cc/8 hours
IVFD D5% NaCl 0,225% 40 gtt/i
Injection Ampicillin 250mg/6 hours/iv (D-2)
Injection Gentamycin 80mg/24 hours/iv (D-2)
Paracetamol 3x100 mg, if needed
Zinc Kid 1x20mg
Lacto B 2x1 sachet
Diet M II 900 kkal with 35 grams of protein
Investigation plan : -
Follow Up November 18th 2010 6:00 am
S Shortness of breath (+), Cough (+), Fever (-), Diarrhea (-)
O Sens: Compos Mentis T: 37.5 ۫C BW: 9.5 kg BL: 82 cm
BW/BL: 84% (mild malnutrition)
Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior
palpebral conjunctiva (-/-), Nose: Nasal Flaring (+)
Mouth/Ears: Within normal limits
Neck : Lymph nodes enlargement (-), JVP: R-2cmH₂O
Chest : Symmetrical fusiformic, retraction (+),
HR : 140 bpm, regular, murmur (-)
RR : 56 rpm, regular, ronchi (+)
Abdomen : Soepel, normal peristaltic,
Liver/Spleen: Within normal limits
Extremities : Pols 140 bpm, regular, Pressure/Volume: sufficient,
BP : 90/60 mmHg, warm extremity
16 | P a g e
A Bronchopneumonia + GE without Dehydration
P O2 1 L/I Nasal Canal
Nebule NaCl 0,9% 2,5cc/8 hours
IVFD D5% NaCl 0,225% 40 gtt/i
Injection Ampicillin 250mg/6 hours/iv (D-3)
Injection Gentamycin 80mg/24 hours/iv (D-3)
Paracetamol 3x100 mg, if needed
Zinc Kid 1x20mg
Lacto B 2x1 sachet
Diet M II 900 kkal with 35 grams of protein
Investigation plan : - Consultation to Respirology Department
Respirology Consult : Normal
Follow Up November 19th 2010 6:00 am
S Shortness of breath (+), Cough (+), Fever (-), Diarrhea (-)
O Sens: Compos Mentis T: 37.2 ۫C BW: 9.5 kg BL: 82 cm
BW/BL: 84% (mild malnutrition)
Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior
palpebral conjunctiva (-/-), Nose: Nasal Flaring (+)
Mouth/Ears: Within normal limits
Neck : Lymph nodes enlargement (-), JVP: R-2cmH₂O
Chest : Symmetrical fusiformic, retraction (-),
HR : 138 bpm, regular, murmur (-)
RR : 48 rpm, regular, ronchi (+)
Abdomen : Soepel, normal peristaltic,
Liver/Spleen: Within normal limits
Extremities : Pols 138 bpm, regular, Pressure/Volume: sufficient,
BP : 90/50 mmHg, warm extremity
A Bronchopneumonia + GE without Dehydration
17 | P a g e
P O2 1 L/I Nasal Canal
Nebule NaCl 0,9% 2,5cc/8 hours
IVFD D5% NaCl 0,225% 40 gtt/i
Injection Ampicillin 250mg/6 hours/iv (D-4)
Injection Gentamycin 80mg/24 hours/iv (D-4)
Ambroxol 5mg + Salbutamol 1mg : 3 x pulv I
Paracetamol 3x100 mg, if needed
Zinc Kid 1x20mg
Lacto B 2x1 sachet
Diet M II 900 kkal with 35 grams of protein
Investigation plan : - Mantoux Test
- Chest Physiotherapy (20/12/2010)
- Check for ABG and Electrolyte
Follow Up November 20th 2010 6:00 am
S Shortness of breath (+), Cough (+), Fever (+), Diarrhea (-)
O Sens: Compos Mentis T: 38.0 ۫C BW: 9.5 kg BL: 82 cm
BW/BL: 84% (mild malnutrition)
Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior
palpebral conjunctiva (-/-), Nose: Nasal Flaring (+)
Mouth/Ears: Within normal limits
Neck : Lymph nodes enlargement (-), JVP: R-2cmH₂O
Chest : Symmetrical fusiformic, retraction (-),
HR : 128 bpm, regular, murmur (-)
RR : 36 rpm, regular, ronchi (+)
Abdomen : Soepel, normal peristaltic,
Liver/Spleen: Within normal limits
Extremities : Pols 128 bpm, regular, Pressure/Volume: sufficient,
BP : 90/70 mmHg, warm extremity
A Bronchopneumonia
P O2 1 L/I Nasal Canal
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Nebule NaCl 0,9% 2,5cc/8 hours
IVFD D5% NaCl 0,225% 40 gtt/i
Injection Ampicillin 250mg/6 hours/iv (D-5)
Injection Gentamycin 80mg/24 hours/iv (D-5)
Ambroxol 5mg + Salbutamol 1mg : 3 x pulv I
Paracetamol 3x100 mg, if needed
Diet M II 900 kkal with 35 grams of protein
Investigation plan : -
Laboratory Findings:
ABG : pH/pCO2/pO2/HCO3 = 7.42/40.6/84.7/26.1
Total CO2/BE/SaO2 = 27.3/1.6/96.5%
Electrolyte : Na/K/Cl = 132/27/94
Follow Up November 21st 2010 6:00 am
S Shortness of breath (+), Cough (-), Fever (-)
O Sens: Compos Mentis T: 37.0 ۫C BW: 9.5 kg BL: 82 cm
BW/BL: 84% (mild malnutrition)
Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior
palpebral conjunctiva (-/-), Nose: Nasal Flaring (+)
Mouth/Ears: Within normal limits
Neck : Lymph nodes enlargement (-), JVP: R-2cmH₂O
Chest : Symmetrical fusiformic, retraction (-),
HR : 124 bpm, regular, murmur (-)
RR : 36 rpm, regular, ronchi (+)
Abdomen : Soepel, normal peristaltic,
Liver/Spleen: Within normal limits
Extremities : Pols 124 bpm, regular, Pressure/Volume: sufficient,
BP : 90/60 mmHg, warm extremity
A Bronchopneumonia
P O2 1 L/I Nasal Canal
Nebule NaCl 0,9% 2,5cc/8 hours
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IVFD D5% NaCl 0,225% 40 gtt/i
Injection Ampicillin 250mg/6 hours/iv (D-6)
Injection Gentamycin 80mg/24 hours/iv (D-6)
Ambroxol 5mg + Salbutamol 1mg : 3 x pulv I
Paracetamol 3x100 mg, if needed
Diet M II 900 kkal with 35 grams of protein
Investigation plan : -
Follow Up November 22nd 2010 6:00 am
S Shortness of breath (+) ↓, Cough (+) ↓, Fever (-)
O Sens: Compos Mentis T: 36.6 ۫C BW: 9.5 kg BL: 82 cm
BW/BL: 84% (mild malnutrition)
Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior
palpebral conjunctiva (-/-), Nose: Nasal Flaring (+)
Mouth/Ears: Within normal limits
Neck : Lymph nodes enlargement (-), JVP: R-2cmH₂O
Chest : Symmetrical fusiformic, retraction (-), stridor (+)
HR : 120 bpm, regular, murmur (-)
RR : 32 rpm, regular, ronchi (+), Prolonged expiration (+)
Abdomen : Soepel, normal peristaltic,
Liver/Spleen: Within normal limits
Extremities : Pols 120 bpm, regular, Pressure/Volume: sufficient,
BP : 90/60 mmHg, warm extremity
Bronchopneumonia
P O2 1 L/I Nasal Canal, if needed
Nebule Ventolin 2,5 cc + NaCl 0,9% 2,5cc/8 hours
IVFD D5% NaCl 0,225% 40 gtt/i
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Injection Ampicillin 250mg/6 hours/iv (D-7)
Injection Gentamycin 80mg/24 hours/iv (D-7)
Ambroxol 5mg + Salbutamol 1mg : 3 x pulv I
Paracetamol 3x100 mg, if needed
Diet M II 900 kkal with 35 grams of protein
Chest Physiotherapy
Investigation plan : -
Follow Up November 23rd 2010 6:00 am
S Shortness of breath (+)↓, Cough (+) ↓, Fever (-)
O Sens: Compos Mentis T: 36.7 ۫C BW: 9.5 kg BL: 82 cm
BW/BL: 84% (mild malnutrition)
Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior
palpebral conjunctiva (-/-), Nose: Nasal Flaring (+)
Mouth/Ears: Within normal limits
Neck : Lymph nodes enlargement (-), JVP: R-2cmH₂O
Chest : Symmetrical fusiformic, retraction (-), stridor (-)
HR : 110 bpm, regular, murmur (-)
RR : 36 rpm, regular, ronchi (+), prolonged expiration (+)
Abdomen : Soepel, normal peristaltic,
Liver/Spleen: Within normal limits
Extremities : Pols 110 bpm, regular, Pressure/Volume: sufficient,
BP : 100/60 mmHg, warm extremity
A Bronchopneumonia
P O2 1 L/I , if needed
Nebule Ventolin 2,5 cc + NaCl 0,9% 2,5cc/8 hours
IVFD D5% NaCl 0,225% 10 gtt/i
Injection Ampicillin 250mg/6 hours/iv (D-8)
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Injection Gentamycin 80mg/24 hours/iv (D-8)
Ambroxol 5mg + Salbutamol 1mg : 3 x pulv I
Paracetamol 3x100 mg, if needed
Diet M II 900 kkal with 35 grams of protein
Chest Physiotherapy
Investigation plan : - Discharge (24/12/2010)
CHAPTER 3
3.1. DISCUSSION
N, a 2-years-old girl, 9.5 kg, 82 cm, was admitted to the Infection Unit of
Haji Adam Malik General Hospital with chief complaint of shortness of breath.
The shortness of breath occurred since 2 days ago and getting worst in 1 day
before she admitted to the hospital. The shortness of breath was not related to
activity and weather. Cyanosis was not found. Productive cough occurred since 3
day ago. Fever was found since 1 week ago with a characteristic of high fever
which relieved with fever relieving medication. Shivers and seizures were not
found. History of diarrhea was found since 5 days ago with frequency 5 times a
day and the volume was 20cc/diarrhea. Currently the patient is having watery
stool. This patient was referred to Haji Adam Malik Hospital by pediatrician with
bronchopneumonia and gastroenteritis without dehydration.
Bronchopneumonia is a type of pneumonia that is characterized by an
inflammation of the lung generally associated with, and following about with
bronchiolitis. Bronchopneumonia or bronchial pneumonia or bronchogenic
pneumonia is an acute inflammation of the walls of the bronchioles. Pneumonia is
most often caused by a bacterial infection (bacterial pneumonia) or a viral
infection (viral pneumonia). The insiden of pneumonia is 10 times higher in
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developing than in developed countries, with as many as 5 million deaths
occurring yearly in children younger than 5 years. In this case patient is a girl 2
years old.
In clinical feature, fever and difficulty in breathing are commonest
presenting symtoms, usually preceded by an upper respiratory tract infection. In
this case patient was admitted with chief complaint shortness of breath, fever was
found since 1 week ago and her temperature 40,50C, productive cough occurred
since 3 day ago.
Pneumonia results from inflammation of the alveolar space and may
compromise air exchange. While often complicating other lower respiratory
infections such as bronchiolitis or laryngotracheobronchitis, pneumonia may also
occur via hematogenous spread or aspiration. Most commonly, this inflammation
is the result of invasion by bacteria, viruses, or fungi, but it can occur as a result of
chemical injury or may follow direct lung injury. In the young infant, aged 1-3
months most pneumonia in this age group is community acquired and involves
Streptococcus pneumoniae, Staphylococcus aureus, and non-typeable
Haemophilus influenzae. Streptococcus pneumoniae is by far the most common
bacterial pathogen in this age group.
Usually preceded by upper respiratory tract infection. This disease usually
arises suddenly, the temperature increased 39-40 0C with chills, shortness of
breath and rapid, coughing productive "breath sounds" when percussion dim lung
examination, breath sounds during auscultation ronchi smooth wet and loud. The
laboratory found leukocytosis 15000-40000 / mm3. Photo thorax there
bronkopeumoni patches infiltrates in one or several lobes, if the pneumonia
lobaris seen a consolidation in one or several lobes.
Treatment decisions in children with pneumonia are dictated based on the
likely etiology of the infectious organism and the age and clinical status of the
patient. Antibiotic administration must be targeted to the likely organism, bearing
in mind the age of the patient, the history of exposure, the possibility of resistance
(which may vary, depending on local resistance patterns), and other pertinent
history. Children in whom pneumococcal disease is suspected initially should be
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treated with amoxicillin or penicillin. A macrolide antibiotic alone, or in
combination with sulfisoxazole or an oral cephalosporin is an alternative.
Fortunately, most children with pneumonia recover without complications.
Persistent effusions and empyemas are the most common serious complications of
bacterial pneumonia
Patients who were placed on a protocol-driven pneumonia clinical
pathway are more likely to have favorable outcomes. The prognosis for most
forms of pneumonia is excellent. Most cases of viral pneumonia resolve without
treatment, common bacterial pathogens and atypical organisms respond to
antimicrobial therapy.
This patient N, a 2-years-old girl had shortness of breath, productive
cough, high fever, and history of diarrhea was found. Physical examination found
nasal flaring, chest symmetrical fusiformic, retraction, ronchi on both left and
right lower lungs. From chest X-ray showed infiltrated on right lower lung
(pericardial). Thus, the patient was diagnosed as bronchopneumonia.
3.2. SUMMARY
It has been reported a case of a 2-years-old girl with Bronchopneumonia.
The diagnosis was established based on history taking, clinical manifestation, and
laboratory findings. Treatment for this patient was only supportive and
symptomatic. This patient was discharged after free from any complaint such as
shortness of breath, fever, and diarrhea.
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