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Bed Side teaching
BRONCHOPNEUMONIA
Presented by :Yudi Agustinus (0710195)
Counselor :
H. Tisna Sukarna., dr., SpA., MBA, M.Kom
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Patient Identification
Name : L
Age : 1 year 10 months
Sex : Female
Consignment from : ER
Date of hospitalized : June, 4th 2012
Date of examination : June, 5th 2012
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Anamnesis
Heteroanamnesis was given by herparents on June, 5th 2012
Chief complaint : fever
History of present illness :Since 6 days before hospitalization,
patient developed fever, it occurred
slowly and no sudden onset of ever, noexact time of feverish condition, herparents complained theres an increasedtemperature during the evening and
lower temperature during the afternoon.
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The complaint accompanied by coughingsince 3 days ago, with a lot of clearmucus and infrequent, sometimes
containing food (vomiting). The patientsparents also complained aboutheadache and epigastrial tenderness.
The weight of the child is said to have
dropped 1 kg during sickness with adecreased appetite. Any history of bloodcough, vomiting, diarrhea and difficultyof breathing were denied. Any history ofepistaxis and gum bleeding were denied
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Mictie : the color is yellow; there is noblood, normal in frequency and volume,with no pain.
Defecate : difficulty in defecating since1 day before, mushy in consistency,normal colour, frequency and volume inlast defecation.
Habits : her parents denied any badhabits of giving foods to the patientrecklessly and stated that the higienity of
the foods in home was alwaysmaintained
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Record of family health: her parentscomplained about coughing since 3 dayswith no fever.
Medical effort : One day after the feveroccurred, the patient was brought to ahealth centre and was given 2 kinds ofdrugs (antibiotic was claimed to be one
of them-the patients parents forgot thebrands). 2 days later, the patient thenbrought to a GP and was given 3 kinds of
drugs (the patients parents forgot thebrands but after no si nificant
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Birth History
The patient is the 1st child from 1 child.No stillbirth and no abortion.
Birth: aterm, spontaneous, directly cryand helped by an obstetrician.
Birth weight: 2900 grams. Birth length:
47 cm
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Immunizations
Vaccine Basic Vaccination
Booster VaccinationRecommended
Vaccination
BCG + (scar + ) - - - HiB : none
Polio + + + - - - MMR : none
DPT + + + - - - Hep A : none
Hep B + + + - - - Varicella : none
Measles + - - - Typhim/typha : none
Influenzae : none
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Nutrition and Feeding
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Physical Examination
(June, 5th 2012)
General appearance
Condition : Moderate sickness
Consciousness : compos mentis
Activity and position : no force position
General condition : weak
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Vital signs
Pulse : 120 times per minute,regular, equal, strong (N:70x-
110x/minute) Respiration : 30 times per minute (N:
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Measuring
Age : 1 year 10 months old
Weight : 10 kg
Height : 82 cm
Nutrition status :
- Weight for age (z score) : below -1 :Normal
- Height for age (z score) : Normal- Weight for height (z score) : Normal
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Systematic examinationsSkin : icteric - , pale -, cyanosis -
Head Hair : black, disseminated, not easy
to yanked out
Eyes : conjunctiva anemic -/-,sclera icteric -/-, subconjunctivalbleeding -/-
Nose : nasal flare -/-, secretes -/-
epistaksis -/- Ears : symetric, left was equal to
right, no discharge
Lips : dry -, anemic -, cyanosis -,-
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NeckNuchal rigidity :
Lymph node : not palpableThorax
Lungs
Inspection : symmetrical shape, right= left, retractions (-)
Palpation : vocal fremitus right =
left, symmetrical movement Percussion : dullness (-)
Auscultation : VBS +/+, coarse
crackles +/+ in most part of the
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Abdomen:
Inspections : flat
Auscultations : bowel sound (+) normal
Percussions : tympanic, Traubes space:tympanic
Palpations : soepel, tenderness (-)
Liver palpable 1,5 cm BAC & 1 cmBPX
Spleen impalpable
Kidney impalpable
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Genital : Female, normal
Anus & Rectal : (+), normal
Extremities : no disparity
Upper : left: active, right: active
Lower: left: active, right: active
Joint : no disparity Muscle : normal tonus
Reflex : physiological +/+,
pathological -/-
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a ora ory n ng(Biotest)
4/6/2012
Hb : 14.5 g/dl
Ht : 43%
Leucocyte:
6300/mm3Trombocyte:
156000/mm3
MCV: 80.1 fl MCH: 27.3 pg/dl
MCHC: 34,0 g/dl
Diff. count:
Widal slide test
S. typhi O: 40 *
S. typhi H: non-reactive
S. paratyphi AO:non-reactive
S. paratyphi AH:
non-reactive S. paratyphi BO:
non-reactive
S. paratyphi BH:
non-reactive
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Radiology Finding5/6/2012
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Expertise :
Normal air column inside trachea.Normal aorta. No cardiac enlargement.
Normal sinuses and diaphragms. Pulmo: rugged hili. An increased
bronchovascular marking, with minimalsoft spot in right pericardial.
Normal clavicular costae dan soft tissue.
Impression: Right bronchopneumonia.
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Resume
One year 10 months old girl, weight 10kg & height 82 cm, normal nutritionalstatus, moderate sickness and compos
mentis, came to Immanuel Hospital withfever as a chief complaint.
Fever (+) since 6 days ago, with anincreased temperature in the evening,
and would only be relieved when givenantipiretics. Coughing (+) since 3 daysago, lots of clear mucus, no blood,sometimes contains food (vomiting).Headache + , e i astrial tenderness
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Mictie : normal. Defecate : difficulty indefecating since 1 day, before mushyconsistency for 5 days. No habits asreckless eating (-), homemade food (+).
Past & family medical history: Typhoidfever (patient), coughing (parents).Medical effort : First day of fever healthcentre, 2 days after GP, but theres nosignificant improvement, dr. Tisna, SpA
hospitalized in Immanuel Hospital.Physical examination: Vital signs,
pulse120x/min, regular, equal, strong;Res iration 30x min Tem erature 36 3 C
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Physical examination
Skin icteric -, pale -, cyanosis -; Head:Nose: nasal flare -/-, secrets -/-, Lip:cyanotic (-), Tongue: wet, Oropharynx
normal. Thorax: no retractions, Lungs: VBS+/+, coarse crackles +/+ in most part ofthe thorax, slem +/+, no wheezing.Abdomen: Flat, bowel sound (+) normal,
soepel, tympanic, tenderness (-), liverpalpable and spleen not palpable, Traubesspace tympanic. Extremities: Normal;Neurological Examination : normal. In
Chest Radiography: Impression: Right
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Diagnosis
Differential Diagnosis
Bronchopneumonia caused bybacterial infection
Bronchitis
Typhoid fever
Working diagnosis
Bronchopneumonia caused bybacterial infection
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Suggested Further Studies
Blood: complete blood count (Hb, Ht, L,Tc)
Blood culture + sensitivity test
Blood isolate (virus) Widal test repeat
PPD test
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Planning Therapy
Non Medicamentous
Bed Rest
Fluid : KaEN IB 1000cc for 24 hours
Diet : porridge
Medicamentous
Ambroxol syrup 15mg/5ml 3x1 teaspoon
Paracetamol syrup120mg/5ml,3x1teaspoon, prn (To >38.5oC)
Cefotaxime vial 0.5g 2x500mg IV
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Prognosis
Quo ad vitam : ad bonam
Quo ad functionam : ad bonam
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Discussion
The diagnosis of bronchopneumonia basedon :
Anamnesis :
Infrequent coughing with clear mucus Indetermined fever
Decreased appetite
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Physical Verification :
Condition : moderate sickness
Thorax : coarse crackles +/+ in mostpart of the thorax, slem +/+
Radiology Findings (5/6/2012) Normal air column inside trachea.
Normal aorta. No cardiac enlargement.Normal sinuses and diaphragms.
Pulmo: rugged hili. An increasedbronchovascular marking, with minimalsoft spot in right pericardial.
Normal clavicular costae dan soft tissue.
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REFERENCES
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Bronchopneumonia
Introduction
Pneumonia is an inflammation of theparenchyma of the lungs
Most cases microorganisms, othercauses aspiration of food or gastricacid, foreign bodies, hydrocarbons, andlipoid substances, hypersensitivityreactions
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Epidemiology
Pneumonia is a substantial cause ofmorbidity and mortality in childhood(particularly among children
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Etiology
Using state-of-the-art diagnostictesting, a bacterial or viral cause ofpneumonia can be identified in 4080%
of children with community-acquiredpneumonia
Streptococcus pneumoniae(pneumococcus) is the most common
bacterial pathogen, followed byChlamydia pneumoniae and Mycoplasma
pneumoniae.
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Pathophysiology
The lower respiratory tract sterile defense mechanisms (mucociliaryclearance, secretory IgA & coughing)
Immunologic defense mechanisms macrophages (alveoli and bronchioles),secretory IgA, and otherimmunoglobulins.
Viral pneumonia spread of infectionalong the airways + direct injury of therespiratory epithelium airway
obstruction (swelling, abnormal
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Viral infection predispose tosecondary bacterial infection disturbing normal host defense , alteringsecretions & modifying the bacterial
flora Bacterial infection process :
- M. pneumoniae attaches torespiratory epithelium, inhibits ciliaryaction & leads to cellular destruction andan inflammatory response in thesubmucosa airway obstruction
- S. pneumoniae local edema
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Clinical Features
Viral and bacterial pneumonias rhinitisand cough
Viral pneumonia fever (lower than
bacterial pneumonia), tachypnea,intercostal-subcostal-suprasternalretractions, nasal flaring, and use ofaccessory muscles
Auscultation crackles & wheezing(difficult to localize in very youngchildren)
Bacterial pneumonia shaking chill
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consolidation or complications dullness on percussion & breath sounds(-)
Infants abrupt onset of fever,restlessness, apprehension, andrespiratory distress (grunting; nasalflaring; retractions of the
supraclavicular, intercostal, andsubcostal areas; tachypnea; tachycardia;air hunger and often cyanosis)
Some infants with bacterial pneumonia
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Diagnosis
The chest radiograph confirms thediagnosis of pneumonia and mayindicate a complication such as a pleural
effusion or empyema Viral pneumonia hyperinflation with
bilateral interstitial infiltrates andperibronchial cuffing
Confluent lobar consolidation is typicallyseen with pneumococcal pneumonia
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Hospitalization of Childrenwith Pneumonia
Age
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Treatment
Mildly ill children amoxicillin
Communities with a high percentage of penicillin-resistant pneumococci high doses of amoxicillin(8090 mg/kg/24 hr)
Therapeutic alternatives cefuroxime axetil or
amoxicillin/clavulanate School-aged children & with infection M.
pneumoniae or C. pneumoniae azithromycin
Adolescents respiratory fluoroquinolone
(levofloxacin, gatifloxacin, moxifloxacin,gemifloxacin)
Parenteral cefuroxime (150 mg/kg/24 hr),cefotaxime, or ceftriaxone bacterial pneumonia
Clinical features suggest staphylococcal pneumoniatherapy include vancomycin or clindamycin
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Prognostic
Depend on presence of complication,and also effectiveness of antibiotics
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Click to edit Master subtitle style7/24/12