Case Report

Bronchopneumonia
in pediatric
Direct by : Cindy Berlian Sulaeman

Advicer : dr. Irman, Sp.A / dr. Tatan Sp.A

Identity

 Name : M
 Age : 1 y.o
 Sex : Female
 Address : Babakan
 History taking
main complain : breathlessness
history of present illness: breathlessness preceded by a high
body heat suddenly, continuous, and coughs and colds (flu) since
two days. breathlessness isn't accompanied by vomiting,
convulsions, loss of consciousness, defecation and urination dont
complaints. anorexia patient began to decrease since 1 month, so
the body looks thin.
 Riwayat Penyakit Dahulu: penderita
baru pertama kali sakit seperti ini. Riwayat tersedak
sebelumnya disangkal. Riwayat batuk, pilek lama dan
berulang disangkal.
Riwayat Penyakit Keluarga: riwayat
kontak dengan penderita dewasa dengan batuk lama dan
berdarah disangkal. Terdapat kontak erat dengan keluarga
penderita yang merokok, yaitu ayah penderita.
Riwayat Lingkungan: padat
penduduk, ventilasi cukup, sekitar rumah tidak ada yang
menderita penyakit yang serupa. Pasien memakai sumber air
dari PAM
Riwayat imunisasi: imunisasi BCG
sudah dilakukan sejak anak usia 2 minggu.
 past medical history: first ill patients like
this. a history of choking previously denied. history of cough, flu old
and repeatedly denied.
A fami medical history: history of contact
with adult patients with chronic coughing and bloody denied. There
is close contact with the families of patients who smoke, the father
of the patient.
environmental history: Population density,
sufficient ventilation, around the house there is a similar disease.
Patients wear a water source of Municipal Water Corporation.
immunization history: BCG immunization
has been made since children aged 2 weeks.
 Physical Examination

General examination
General appereance : Alert
 Pulse : 112x/minute, regual
 Respiration : 28 x/minute
 Temperature : 38,0C
 Body Weight : 8 kg
 Body Height : 73 cm
 Nutrition Status
Weight/Age : < persentil -1
Height/Age : < persentil -1
 Physical Examination
Spesifik examination

 Head : Normochephaly

 Eye :Sclera icteric (-)

Conjungtiva Anemis (-)

 Nasal : Nostril Breathing (+) Secret (-)

 Mouth : Per Oral Cianosis (-)

 Neck : Lymphadenopathy (-)

retraction
SS (+)
 Physical Examination
 Thorax : Symmetric with good expansion
intercostal retractions (+)
- Lung : Breath sound vesicular right=left, rales (-),
wheezing (-), rhonchi (+)

- Heart : S1,S2 regular rhythm.

 Abdomen : Soft, Liver and spleen is not palpable,

Bowel sound (+) 28 x/minute

 Extremities : Warm, Acrocyanosis (-) CRT <2”

Differential Diagnosis

 broncopneumonia
 bronkhiolithis
 Further Examination
 Complete Blood Count
Hemoglobin : 11,2

Leukosit : 15,8

Eritrosit : 4,4

Hematokrit : 34

Trombosit : 269

Basofil :0

Eosinofil :0

Neutrofil Batang :0

Neutrofil Segmen : 67

Limfosit : 26

Monosit :7
Resume
Penderita datang ke IGD RSUD
Waled dengan keluhan sesak. Sesak didahului oleh
panas badan yang mendadak tinggi terus menerus,
siang sama dengan malam dan batuk pilek sejak 2
hari. Keluhan sesak tidak disertai dengan muntah,
kejang ataupun penurunan kesadaran, BAB dan Bak
tidak ada keluhan. Nafsu makan penderita mulai
berkurang sejak 1 bulan, sehingga badan tampak
kurus
Dari pemeriksaan fisik didapatkan
pasien gizi normal, febris (38,0oC), Nostril Breathing (+)
, sianosis (-), suara napas bronkovesikuler, ronkhi
(+/+), wheezing (-/-), retraksi ic sc (+), lainnya
dalam batas normal. Pada pemeriksaan laboratorium
didapatkan anemia dan leukositosis.
Resume
Patients come to the waled
hospital emergency room with breathlessness.
breathlessness preceded by a high body heat
suddenly, continuous, siang sama dengan malam and
coughs and colds (flu) since two days. breathlessness
isn't accompanied by vomiting, convulsions, loss of
consciousness, defecation and urination dont
complaints. anorexia patient began to decrease since
1 month, so the body looks thin.
physical examination of patients
obtained normal nutrition, febrile (38°C), Nostril
Breathing (+), cyanosis (-), breath sounds
bronchovesicular, rhonchi (+/+), wheezing (-/-),
retractions ic sc (+), within normal limits. laboratory
tests obtained anemia and Leukocytosis.
Working Diagnosis

 Bronchopnemonia
Treatment
O2 Nasal 1 liter/menit
IVFD KAEN IB 30cc/jam
PCT 3x80mg iv
Ampisilin 4X400mg iv
Gentamisin 2x40mg iv
Prognosis
 Ad Vitam : dubia ad
bonam
 Ad Functionam : dubia
ad bonam
 Ad Sanationam : dubia
ad bonam
Thank you