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 her parents 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, no exact time of feverish condition, her parents complained theres an increased temperature during the evening and lower temperature during the afternoon. 7/24/12

The complaint accompanied by coughing since 3 days ago, with a lot of clear mucus and infrequent, sometimes containing food (vomiting). The patients parents also complained about headache and epigastrial tenderness. The weight of the child is said to have dropped 1 kg during sickness with a decreased appetite. Any history of blood cough, vomiting, diarrhea and difficulty of breathing were denied. Any history of 7/24/12 epistaxis and gum bleeding were denied

Mictie : the color is yellow; there is no blood, normal in frequency and volume, with no pain. Defecate : difficulty in defecating since 1 day before, mushy in consistency, normal colour, frequency and volume in last defecation. Habits : her parents denied any bad habits of giving foods to the patient recklessly and stated that the higienity of the foods in home was always 7/24/12 maintained

Record of family health: her parents complained about coughing since 3 days with no fever. Medical effort : One day after the fever occurred, the patient was brought to a health centre and was given 2 kinds of drugs (antibiotic was claimed to be one of them-the patients parents forgot the brands). 2 days later, the patient then brought to a GP and was given 3 kinds of drugs (the patients parents 7/24/12 the forgot brands) but after no significant

Birth History The patient is the 1st child from 1 child. No stillbirth and no abortion. Birth: aterm, spontaneous, directly cry and helped by an obstetrician. Birth weight: 2900 grams. Birth length: 47 cm

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Immunizations
Booster Vaccination Vaccine BCG Polio DPT Hep B Measles + + + Basic Vaccination + (scar + ) + + + + + + + Recommended Vaccination HiB MMR Hep A Varicella : : : : none none none none : none

Typhim/typha

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:70x110x/minute) Respiration : 30 times per minute (N: <40x/ minute) Temperature : 36,3 oC, axillar (N: 36-37,2oC)
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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 examinations Skin : icteric - , pale -, cyanosis Head Hair : black, disseminated, not easy to yanked out Eyes : conjunctiva anemic -/-, sclera icteric -/-, subconjunctival bleeding -/ Nose : nasal flare -/-, secretes -/epistaksis -/ Ears : symetric, left was equal to right, no discharge Lips : dry -, anemic -, cyanosis -, 7/24/12

Neck Nuchal rigidity : Lymph node : not palpable Thorax Lungs Inspection : symmetrical shape, right = left, retractions (-) Palpation : vocal fremitus right = left, symmetrical movement Percussion : dullness (-) Auscultation : VBS +/+, coarse 7/24/12 crackles +/+ in most part of the

Abdomen: Inspections : flat Auscultations : bowel sound (+) normal Percussions : tympanic, Traubes space: tympanic Palpations : soepel, tenderness (-) Liver palpable 1,5 cm BAC & 1 cm BPX 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 -/7/24/12

4/6/2012 Hb : 14.5 g/dl Ht : 43% Leucocyte: 6300/mm3 Trombocyte: 156000/mm3 MCV: 80.1 fl MCH: 27.3 pg/dl MCHC: 34,0 g/dl Diff. count:

Laboratory Finding (Biotest)

Widal slide test S. typhi O: 40 * S. typhi H: nonreactive S. paratyphi AO: non-reactive S. paratyphi AH: non-reactive S. paratyphi BO: non-reactive S. paratyphi BH: 7/24/12 non-reactive

Radiology Finding
5/6/2012

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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 minimal soft 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 10 kg & height 82 cm, normal nutritional status, moderate sickness and compos mentis, came to Immanuel Hospital with fever as a chief complaint. Fever (+) since 6 days ago, with an increased temperature in the evening, and would only be relieved when given antipiretics. Coughing (+) since 3 days ago, lots of clear mucus, no blood, sometimes contains food (vomiting). 7/24/12 Headache (+), epigastrial tenderness

Mictie : normal. Defecate : difficulty in defecating since 1 day, before mushy consistency for 5 days. No habits as reckless eating (-), homemade food (+). Past & family medical history: Typhoid fever (patient), coughing (parents). Medical effort : First day of fever health centre, 2 days after GP, but theres no significant improvement, dr. Tisna, SpA hospitalized in Immanuel Hospital. Physical examination: Vital signs, pulse120x/min, regular, equal, strong; 7/24/12 Respiration 30x/min, Temperature 36,3 C,

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 of the thorax, slem +/+, no wheezing. Abdomen: Flat, bowel sound (+) normal, soepel, tympanic, tenderness (-), liver palpable and spleen not palpable, Traubes space tympanic. Extremities: Normal; Neurological Examination : normal. In 7/24/12 Chest Radiography: Impression: Right

Diagnosis
Differential Diagnosis

Bronchopneumonia caused by bacterial infection Bronchitis Typhoid fever

Working diagnosis

Bronchopneumonia caused by bacterial 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 based on : Anamnesis : Infrequent coughing with clear mucus Indetermined fever Decreased appetite

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Physical Verification : Condition : moderate sickness Thorax : coarse crackles +/+ in most part 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 increased bronchovascular marking, with minimal soft spot in right pericardial. Normal clavicular costae dan 7/24/12 tissue. soft

REFERENCES

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Bronchopneumonia
Introduction Pneumonia is an inflammation of the parenchyma of the lungs Most cases microorganisms, other causes aspiration of food or gastric acid, foreign bodies, hydrocarbons, and lipoid substances, hypersensitivity reactions

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Epidemiology
Pneumonia is a substantial cause of morbidity and mortality in childhood (particularly among children <5 yr of age) throughout the world, rivaling diarrhea as a cause of death in developing countries With an estimated 146159 million new episodes per year in developing countries, pneumonia is estimated to cause approximately 4 million deaths among children worldwide. Currently, 7/24/12 the incidence of community-acquired

Etiology
Using state-of-the-art diagnostic testing, a bacterial or viral cause of pneumonia can be identified in 4080% of children with community-acquired pneumonia Streptococcus pneumoniae (pneumococcus) is the most common bacterial pathogen, followed by Chlamydia pneumoniae and Mycoplasma pneumoniae.

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Pathophysiology
The lower respiratory tract sterile defense mechanisms (mucociliary clearance, secretory IgA & coughing) Immunologic defense mechanisms macrophages (alveoli and bronchioles), secretory IgA, and other immunoglobulins. Viral pneumonia spread of infection along the airways + direct injury of the respiratory epithelium airway obstruction (swelling, abnormal 7/24/12

Viral infection predispose to secondary bacterial infection disturbing normal host defense , altering secretions & modifying the bacterial flora Bacterial infection process : - M. pneumoniae attaches to respiratory epithelium, inhibits ciliary action & leads to cellular destruction and an inflammatory response in the submucosa airway obstruction 7/24/12 - S. pneumoniae local edema

Clinical Features
Viral and bacterial pneumonias rhinitis and cough Viral pneumonia fever (lower than bacterial pneumonia), tachypnea, intercostal-subcostal-suprasternal retractions, nasal flaring, and use of accessory muscles Auscultation crackles & wheezing (difficult to localize in very young children) Bacterial pneumonia shaking chill 7/24/12

 consolidation or complications dullness on percussion & breath sounds (-) Infants abrupt onset of fever, restlessness, apprehension, and respiratory distress (grunting; nasal flaring; retractions of the supraclavicular, intercostal, and subcostal areas; tachypnea; tachycardia; air hunger and often cyanosis) Some infants with bacterial pneumonia 7/24/12

Diagnosis
The chest radiograph confirms the diagnosis of pneumonia and may indicate a complication such as a pleural effusion or empyema Viral pneumonia hyperinflation with bilateral interstitial infiltrates and peribronchial cuffing Confluent lobar consolidation is typically seen with pneumococcal pneumonia

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Factors Suggesting Need for Hospitalization of Children with Pneumonia

Age <6 mo Sickle cell anemia with acute chest syndrome Multiple lobe involvement Immunocompromised state Toxic appearance Severe respiratory distress Requirement for supplemental oxygen Dehydration 7/24/12 Vomiting

Treatment

Mildly ill children amoxicillin Communities with a high percentage of penicillinresistant 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 pneumonia 7/24/12 therapy include vancomycin or clindamycin

Prognostic

Depend on presence of complication, and also effectiveness of antibiotics

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