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CHAPTER III
CASE REPORT
3.1 ObjectiveThe objective of this paper is to report a case of a 11 month old boy with a
diagnosis of bronkopneumonia.
3.2 Case
AS, a 11 month old boy, with 6, kg of !" and 66 cm of !#, came to #aji Adam
$alik %eneral #ospital $edan on 1& th 'ovember at &&.(). #is chief complaint
was dyspnea.
History of disease:
AS, a 11 month old boy, with 6, kg of !" and 66 cm of !#, came to #aji Adam
$alik %eneral #ospital $edan on 1& th 'ovember at &&.() with dyspnea as chief
complaint. The patients have been e*perienced this about 1 week before admitted
to hospital. +yspnea was not directed with weather and activity. yanosis - /,
patient also e*perienced cough since & weeks ago followed by sputum. #istory of
contact with adult cough - /. 0ever has been e*perienced by patient since & weeks
and the body temperature rises and drop. Shivering was not found. omiting - /
and nausea - /. +efecation and urination is normal. #istory of weight loose is not
found .
History of medicatio :
2 &, 3 0+ ringer lactate, nebule ventolin, inj meropenem, triamsinolon,
bromhe*ine an salbutamol
History of fami!y:
There is no famiy history of similar disease found.
History of "are t#s medicatio 4
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'ot found
History of "re$ a cy:
5atient s mother was (1 years old during pregnancy. She regularly goes for
control. 'o history of complication neonate and maternal problem. onsumtion of
herbal medication - /
History of birt%:
5atient was first child. %estational age was preterm -&7 weeks/. !ody weight was
1&)) gram, body length was not measured. !irth was assisted by traditional
midwife. !aby was born normally and cried spontaneously. !lusih was not found.
History of imm& i'atio :
'ot complete
History of $ro(t% a d deve!o"me t:
5atient s mother e*plained that he grew normally. #e was able to crawl and sit
appropriately based on his age.
P%ysica! E)ami atio :
Prese t stat&s:
Sensorium 4 $, body temperature4 (8,69 , #:4 1(7 bpm, ::4 ; *<i, !"4 6,
kg, !#4 66 cm, !"<A4 = score > ( , !?<A4 = score > (, !"<!?4 = score > (,
anemic - /, icteric - /, dyspnea -@/, cyanosis - /, edema - /.
*oca!i'ed stat&s:• #ead 4 0ace4 within normal range
yes4 light refle* @<@, isochoric pupil, pale inferior
palpebral conjunctiva < , superior and inferior palpebra
edema <
ars4 within normal range
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'ose4 nasal flaring
$outh 4 within normal range
• 'eck 4 lymph node enlargement - /• Thora*4 Symmetrical fusiform, retraction intercostal and epigastric
-@/#:4 1(7 bpm, regular, murmur - /
::4 ;*<i, regular, ronchi -@<@/, wheeBing - < /
• Abdomen4 Symmetric, supple, normal peristaltic, liver and spleen4
normal•
*tremities 4 pulse 1(7 bpm regular, adeCuate p<v, felt warm, :T> (D
+or,i $ dia$ osis 4 ++ bronkopneumonia
bronchiolitis
*aboratory fi di $
omplete blood analysis -1& th 'ovember &)1 < &(.)(/
Test :esult Enit :eferences
#emoglobin F.&) gG 11.( 1;.1
rythrocyte (. 1 1) 6<mm( ;.;) ;.;7
?eucocyte 1F.8; 1) ( <mm( 6.) 18.
Thrombocyte &6( 1) ( <mm( &18 ;F8
#ematocrite &7.8) G (8 ;1
osinophil ). ) G 1 6
!asophil ). )) G ) 1
'eutrophil 1.)) G (8 7)
?ymphocyte (F.F) G &) ;)
$onocyte 7.1) G & 7
'eutrophil absolute 1).)7 1) ( <H? 1.F .;
?ymphocyte 8.77 1)(
<H? (.8 1).8
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absolute
$onocyte absolute 1. F 1)(
<H? ).( ).7osinophil absolute ).)F 1) ( <H? ).&) ). )
!asophil absolute ).1) 1) ( <H? ) ).1
$ 71.7) 0l 71 F
$ # &6.&) 5g & &F
$ # (&.1) gG &F (1
linical chemistry -1& 'ovember &)1 < &(.)(/
Test :esult Enit :eferences
!lood %lucose 81.8) mg<d? ;) 6)
Ereum 1;.8) mg<d? > )
reatinine ).&( mg<d? ).18 ).;1
'atrium 1(6 m C<? 1( 1
5otassium .( m C<? (.6 .
hloride 1)) m C<? F6I1)6
5rocalcitonin ).;& ng<m? >).)
%as blood analysis -1& 'ovember &)1 < &(.)(/
p# 8.1 8.( 8.;
p 2& (7.8 mm#g (7 ;&
p2& 188. mm#g 7 1))
!icarbonate -# 2(/ 1(.; mmol<? & &6
Total 2& 1;. mmol<? 1F &
!ase *cess -! / 1;. mmol<? - &/ I -@&/
2& Saturation F7.7 G F 1))
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T%era"y 4 2&1 & ?< min via nasal cannula
3 0+ + G 'a l ),&& G & gtt<menit -micro/
3nj eftria*one ()) mg< 1& hours <iv
5aracetamol (* cth 1<&
0luid challenge 1) cc<kg!! -6 cc/
-o!!o( "
1( th /ovemember 201S +yspnea-@/O Sensorium4 $, Temp4 (8,&9 , !"4 6, kg, !#4 66 cm
#ead 4 0ontanella $ajor was closed
ye 4 ?ight refle* -@<@/, isochoric pupil, pale inferior conjunctiva
palpebra - < /, sclera icteric - < /
ar 4 within normal range'ose 4 nasal flaring$outh 4 within normal range
'eck 4 lymph node enlargement - /
Thora* 4 symmetrical fusiform, retraction -@/ intercostal, epigastric
#:4 1;) bpm, regular, murmur - /:: 4 &*<i, regular, ronchi -@<@/, wheeBing- < /Abdomen 4 supple, peristaltic -@/', ?iver and Spleen4 no palpable
*tremities 4 pulse 1;) bpm, regular, adeCuate p<v , felt warm,
:T > (D
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A ++<!roncopneumonia
!ronchiolitisP 2 & 1 ?<min nasal canule
3 0+ + G 'a l ),&& G & gtt<i -micro/
5aracetamol (* 8 mg
3nj Ampicilin 16) mg<6h
3nj %entamycin ;) mg<&;h
'ebule entolin 1 respul@ 'a l ,F G <6h
$eylon &7 m C, J dosis 34 1; m C meylon in 1))cc + G in ; hours
+iet Su 6 ) kkal and 1( gr proteinAt &&.()S dyspnea KK, fever -@/O Sensorium4 % S 1( - ;, (, $6/ , TL (7,7 9
Thora*4 Simetris 0usiformis, retraksi -@/ epigastrial
#:4 16 *<i, reg, murmur - /
::4 6 *<i, reg, stridor -@/, ronchi -@/P 'ebule entolin 1 respul@ 'a l ),FG < 7hR heck blood gas analysis, heck electrolite post correctionAdvise from dr. "isman +alimunthe, SpA
$ucolitic 4% ( * J tab -pulv/Analgetic 5aracetamol4 ; * 1) mg -pulv/
%as blood analysis -1( 'ovember &)1 < &). F/
p# 8.;&8 8.( 8.;
p 2& &8.F mm#g (7 ;&
p2& 16 .) mm#g 7 1))
!icarbonate -# 2(/ 17.) mmol<? & &6
Total 2& 17.F mmol<? 1F &
!ase *cess -! / . mmol<? - &/ I -@&/
2& Saturation FF.; G F 1))
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Carbo%ydrate etabo!ism
!lood %lucose ad
random
1)7.( mg<d? ;) 6)
lectrolyte
alsium 7.) mg<d? 7.; 1).;
'atrium 1( m C<? 1( 1
5otassium ;.7 m C<? (.6 .
hloride 1)& m C<? F6I1)6
linical hemistry
?iver 0unction Test
0osfatase Alkalase -A?5/ 1;7 E<? >;,6&
AST<S%2T ;6 E<? >(7
A?T<S%5T && E<? >;1
:enal 0unction Test
Ereum 11,6 mg<d? > )reatinin ),&& mg<d? ).18 ),;&
3mmunoserology
Autoimmune - :5 Muantitatif/ ,6 mg<d?
2ther Test -5rocalcitonin/ ).18 ng<m? >),)
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1; th /ovemember 201S dyspnea -@/O Sensorium4 $, Temp4 (89 , !"4 6, kg, !#4 66 cm
#ead 4 0ontanella $ajor was closedye 4 ?ight refle* -@<@/, isochoric pupil, pale inferior conjunctiva
palpebra - < /, sclera icteric - < /ar 4 within normal range
'ose 4 nasal flaring$outh 4 within normal range
'eck 4 lymph node enlargement
Thora* 4 symmetrical fusiform, retraction -@/ intercostal, epigastric
#:4 1;) bpm, regular, murmur - /
:: 4 )*<i, regular, ronchi -@<@/, wheeBing- < /Abdomen 4 supple, peristaltic -@/', ?iver and Spleen4 no palpable
*tremities 4 pulse 1;) bpm, regular, adeCuate p<v , felt warm,
:T > (DA ++<!roncopneumonia
!ronchiolitisP 2 & 1 ?<min nasal canule
3 0+ + G 'a l ),&& G & gtt<i -micro/
5aracetamol (* 8 mg
3nj Ampicilin 16) mg<6 jam<iv
3nj %entamycin ;) mg<&; jam<iv
3nj +e*ametason &, mg<7 jam<iv
'ebule entolin 1 respul@ 'a l ,F G <7 jam
+iet Su 6 ) kkal dengan 1( gr protein:esult of :adiology e*amination
!oth of sinus costophrenicus are sharp. +iafragma is smooth
3nfiltrate on suprahilar, perihiler, dan parakardial paru bilateral
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'o cardiomegaly - T: ; G/Trachea in middle
!ones and soft tissue normalonclusion 4 !ronkopneumonia bilateral
1 t%/ovemember 201
S Shortness of breath -@/O Sensorium4 $, Temp4 (8,19 , !"4 6, kg, !#4 66 cm
#ead 4 0ontanella $ayor was closed
ye 4 ?ight refle* -@<@/, isochoric pupil, pale inferior conjunctiva
palpebra - < /, sclera icteric - < /ar 4 within normal range
'ose 4 nasal flaring$outh 4 within normal range
'eck 4 lymph node enlargement
Thora* 4 symmetrical fusiform, retraction -@/ intercostal, epigastric
#:4 1(7 bpm, regular, murmur - /:: 4 ;6*<i, regular, ronchi -@<@/, wheeBing- < /Abdomen 4 supple, peristaltic -@/', ?iver and Spleen4 no palpable
*tremities 4 pulse 1(7 bpm, regular, adeCuate p<v , felt warm,:T > (D
A ++<!roncopneumonia
!ronchiolitisP 2 & 1 ?<min nasal canule
3 0+ + G 'a l ),&& G & gtt<i -micro/
5aracetamol (* 8 mg
3nj Ampicilin 16) mg<6h
3nj %entamycin ;) mg<&;h
3nj +e*ametason &, mg<7h<iv
3nj Aminophylline $+ 1 cc<1& jam<iv diluted in cc 'a l ),F G bolus
slowly
'ebule entolin 1 respul@ 'a l ,F G <6h
1 t%/ovemember 201
S Shortness of breath -@/ NN
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O Sensorium4 $, Temp4 (89 , !"4 6, kg, !#4 66 cm
#ead 4 0ontanella mayor was closed
ye 4 ?ight refle* -@<@/, isochoric pupil, pale inferior conjunctiva
palpebra - < /, sclera icteric - < /ar 4 within normal range
'ose 4 nasal flaring$outh 4 within normal range
'eck 4 lymph node enlargement
Thora* 4 symmetrical fusiform, retraction -@/ intercostal, epigastric
#:4 1&) bpm, regular, murmur - /
:: 4 ;)*<i, regular, ronchi -@<@/, wheeBing- < /Abdomen 4 supple, peristaltic -@/', ?iver and Spleen4 no palpable*tremities 4 pulse 1(7 bpm, regular, adeCuate p<v , felt warm,
:T > (DA ++<!roncopneumonia
!ronchiolitisP 2 & 1 ?<min nasal canule
3 0+ + G 'a l ),&& G & gtt<i -micro/
3nj Ampicilin 16) mg<6h
3nj %entamycin ;) mg<&;h
3nj +e*ametason &, mg<7h<iv
3nj Aminophylline $+ 1 cc<1& jam<iv diluted in cc 'a l ),F G bolus
slowly
5aracetamol 8 mg -if needed/
% (* J tabAdvise from dr. "isman +alimunthe, SpA
Aff '%Tonsul for ardiology +ivision -echocardiography/Tappering off 3nj de*amethasone
14 t%/ovemember 201
S Shortness of breath -@/ NNO Sensorium4 $, Temp4 (89 , !"4 6, kg, !#4 66 cm
#ead 4 0ontanella $ayor was closed
ye 4 ?ight refle* -@<@/, isochoric pupil, pale inferior conjunctiva
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palpebra - < /, sclera icteric - < /ar 4 within normal range
'ose 4 within normal range$outh 4 within normal range
'eck 4 lymph node enlargement
Thora* 4 symmetrical fusiform, retraction -@/ intercostal, epigastric
#:4 117 bpm, regular, murmur - /:: 4 ( *<i, regular, ronchi -@<@/, wheeBing- < /Abdomen 4 supple, peristaltic -@/', ?iver and Spleen4 no palpable
*tremities 4 pulse 117 bpm, regular, adeCuate p<v , felt warm,
:T > (D
A ++<!roncopneumonia !ronchiolitis
P 2 & 1 ?<min nasal canule -intermitten/
3 0+ + G 'a l ),&& G & gtt<i -micro/
3nj Ampicilin 16) mg<6h<iv
3nj %entamycin ;) mg<&;h<iv
3nj +e*ametason &mg<1&h<iv -tapering off/
3nj Aminophylline -$+/ 1 cc<1& jam<iv diluted in cc 'a l ),F G bolus
pelan
5aracetamol 8 mg -if needed/
'ebule entolin 1 respul@ 'a l ,F G <7h
15 t% /ovemember 201
S +yspnea - /O Sensorium4 $, Temp4 (89 , !"4 6, kg, !#4 66 cm
#ead 4 0ontanella $ayor was closed
ye 4 ?ight refle* -@<@/, isochoric pupil, pale inferior conjunctiva
palpebra - < /, sclera icteric - < /ar 4 within normal range
'ose 4 within normal range$outh 4 within normal range
'eck 4 lymph node enlargement
Thora* 4 symmetrical fusiform, retraction - /
#:4 117 bpm, regular, murmur - /
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:: 4 ( *<i, regular, ronchi -@<@/, wheeBing- < /Abdomen 4 supple, peristaltic -@/', ?iver and Spleen4 no palpable
*tremities 4 pulse 117 bpm, regular, adeCuate p<v , felt warm,:T > (D
A ++<!roncopneumonia
!ronchiolitisP 3 0+ + G 'a l ),&& G & gtt<i -micro/
3nj Ampicilin 16) mg<6h<iv
3nj %entamycin ;) mg<&;h<iv
3nj +e*ametason &mg<1&h<iv -tapering off/
3nj Aminophylline -$+/ 1 cc<1&h <iv diluted in cc 'a l ),F G bolus
slowly
5aracetamol 8 mg -if needed/
'ebule entolin 1 respul@ 'a l ,F G <7h
16 t% /ovemember 201
S dyspnea - /
O Sensorium4 $, Temp4 (89 , !"4 6, kg, !#4 66 cm#ead 4 0ontanella $ayor was closed
ye 4 ?ight refle* -@<@/, isochoric pupil, pale inferior conjunctiva
palpebra - < /, sclera icteric - < /ar 4 within normal range
'ose 4 within normal range$outh 4 within normal range
'eck 4 lymph node enlargement
Thora* 4 symmetrical fusiform, retraction - /
#:4 116 bpm, regular, murmur - /:: 4 &&*<i, regular, ronchi -@<@/, wheeBing- < /Abdomen 4 supple, peristaltic -@/', ?iver and Spleen4 no palpable
*tremities 4 pulse 11) bpm, regular, adeCuate p<v , felt warm,
:T > (D A !roncopneumonia
P 3 0+ + G 'a l ),&& G & gtt<i -micro/
3nj Ampicilin 16) mg<6h<iv
3nj %entamycin ;) mg<&;h<iv
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5aracetamol 8 mg -if needed/
'ebule entolin 1 respul@ 'a l ,F G <7h
CHAPTER 7
S AR8
AS, a 11 month old boy, with 6, kg of !" and 66 cm of !#, came to #aji Adam
$alik %eneral #ospital $edan on 1& th 'ovember at &&.(). #is chief complaint
was dyspnea.5atient was diagnosed as bronkopneumonia. 5atient was treated with
paracetamol, ampicilin, gentamycin, ventolin, meylon and aminophylline -$+/.
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