CASE PRESENTATION

DEPARTMENT OF PEDIATRICS

P R E C E P T O R : D R . U L Y N A R M A R P A U N G , S P. A C O M P I L E D B Y: D O N AT U S A P R I A N TO ( 0 7 1 2 0 0 8 0 0 3 1 )

FACULTY OF MEDICINE UNIVERSITAS PELITA HARAPAN DEPARTMENT OF PEDIATRICS - CLINICAL CLERKSHIP BHAYANGKARA TK.I R.SAID SUKANTO HOSPITAL - EAST JAKARTA

IDENTITY
Name Gender Age : Child F : Boy : 5 years 2 months

Address
Weight Height

: Jln. Lembur RT 014/006 MAKASAR

: 17 kg : 109 cm

Date of admission : 17 November 2013

Date of exam

: 18 November 2013

ANAMNESIS
Done by autoanamnesis and alloanamnesis to the patient himself, his mother, and his father on first and second day of medical care. Chief Complaint Fever since 3 days before admitted to the hospital Other Complaints Rash on whole body since 1 day before admitted to the hospital Shortness of breath since 2 days after admission

HISTORY OF PRESENT ILLNESS

Three days before admitted to the hospital, patient complained of fever. His body temperature was about 39C. Fever stayed high all day and was not affected by night time or at any other time. Patient already went to pediatrician 3 days before admitted and the pediatrician said its only bacterial infection and given antibiotics and antipyretic, the patient didnt know the name of the drugs. The antibiotics and the antipyretic did not recover the patients symptoms Two days before hospital admission, patient had cough and cold. Cough was nonproductive, with no mucus. He complained of pain on swallowing, so that he didnt want to eat nor drink. His eyes were red without discharge Other complains 1 days before admission his parents noticed rash that started on the face, then spread to the rest of the body. Rash wasnt itchy. Patient also complain shortness of breath since 2 days after admission to the hospital, there are no position that can recover the shortness of breath. Patient didnt complain any symptom of nosebleed, gum bleed nor diarhea

TIMELINE
3 days BHA All day long, 39C, stayed Fever. high all day. Already went to pediatrician but didnt recover 2 days BHA Non productive cough & cold Pain on swallowing Eyes were red but no discharge Emergency Department R. Said Sukanto Polri Hospital

1 day BHA Rash Started on the face, then spread to the rest of the body

PAST MEDICAL HISTORY

Pharyngitis/tonsillitis : (+) Bronchitis Pneumonia Morbili Pertussis Varicela Diphteriae Malaria : (-) : (-) : (-) : (-) : (-) : (-) : (-) Basilar dysentriae : (-) Amoeba dysentria : (-) Typhoid Abdomen : (-) Parasite Operation Brain injury Fracture : (-) : (-) : (-) : (-)

Medicine reaction : (-)

Polio
Enteritis

: (-)
: (-)

Others

: (-)

FAMILIAL & MARITAL HISTORY

Married Marital age : once : 10 years

Year

Gestational Age Method of Delivery

Sex Birthweight Breastmilk

2008 9 months 2012 9 months

Normal Delivery Normal Delivery

Boy 3300 gram Boy 3200 gram

1 year old 6 months

Past Obstetric State

Prenatal care:
Antenatal Care is done regularly at Community Health Center By Midwife Both father and mother of this child is in good healths

Pregnancy History
Gestational age: Normal for gestational age (37-38 weeks) Born in Community Health Center Helped by a Midwife Born on Normal Delivery for, cry directly after delivery Weight : 3300 gr (Normal:2500- 4000 gr) Height : 57 cm

GROWTH AND DEVELOPMENTAL STATE

Vaccination BCG Varicella DPT Polio Hepatitis B Measles Other vaccinations

: 1x : 0x : 3x : 4x : 3x : 1x :-

Patients been given fundamental vaccination in according to the governments law

Food intake
Breastfeeding since born until the age of 1 year old. Stopped because the breast milk doesnt come out anymore Started given formula milk since the age of 1 years. Milk given by the mom is Dancow. Fruits have been given since the age of 6 months (banana, apple, melon, and papaya) Vegetables been given since the age of 1 year old (spinach and carrot) Condensed food been given since the age of 1 year old (rice, beef meat, chicken meat, and fish).

Quantity and quality of the food intake, in overall is considered as sufficient

PHYSICAL EXAMINATION 18TH NOVEMBER 2013 FIRST DAY OF MEDICAL CARE

General condition : Patient looks moderately ill

Level of consciousness : Compos Mentis, GCS 15 (E4M6V5) Blood Pressure : 110/80 mmHg

Pulse Rate adequate

Respiratory Rate Axilla temperatur

: 90 x/minute, regular,
: 25x/minute : 39C

NUTRITIONAL STATUS
Weight Height Weight for Age Height for Age : 17 kg : 109 cm : 98.7% : 95.6% : 97.2% : normal

Weight for Height

Interpretation

PHYSICAL EXAMINATION
Head:
- Normocephaly - Deformity (-) - Rash maculopapular +

Eyes:
- Pale conjunctiva +/+ - icteric sclera -/ Secretions +/+, slightly watery discharge Pupil is rounded, isochore 3mm/3mm Direct light reflex +/+

Nasal:
Septum is in the middle Secretions +/+

Ear:
External acoustic meatus +/+ Timpany membrane is intact +/+ Cerumen +/+ Secretions -/-

Mouth

Dry lips Oral mucous is dry Tongue is wet (coated tongue -) Pharyx is hyperemic (+) Tonsil is T2/T2

Neck

Intact trachea in the middle Mass (-) Enlarged lymph nodes (-) Maculopapular rash +

Thorax
Pulmo Inspection: symmetrical breathing movements, maculopapular rash + Palpation: Stem fremitus on the right and the left is equivalent. Percussion: Sonor in both lungs field Ausculation: Vesicular breath sound +/+, wheezing -/-, rhonchi +/+

CardioVaskular Inspection Ictus cordis is unseen, maculopapular rash + Palpation : Ictus cordis is palpated at the 5th intercostal Rights midclavicular line Percussion : Cardiomegaly (-) Auscultation : S1 and S2, regular, gallop (-), murmur (-)

Abdomen Inspection: Flat abdomen, maculopapular rash + Auscultation: Bowel sound (+) 3-4x/minute Palpation: Tender, hepatomegaly (-), splenomegaly (-), pain on deep palpation (-) Percussion: Timpany on all abdominal region

Extremity : Warm Capillary refill time < 3 seconds Edema (-) Maculopapular rash +
Skin: Lesion (-), maculopapular rash +

LABORATORY EXAMINATION

Examination

Result

Unit Normal Value

Hematology I
Hemoglobin Hematocrit 12.7 36 g/dl % Boy : 13-18; Girl : 12-16 Boy : 40-58; Girl : 37-43

Leukocyte

3900

/L

5.000-10.000

Thrombocyte 231.000 / L 150.000-500.000

RESUME

Boy patient, aged 5 years old, came to the emergency department of Polri Hospital at 17th November 2013. Through anamnesis is done at first and second day of medical care, as written below: Fever since 3 days before hospital admission. Body temperature 39C. Stayed high all day, and no recovery after taking antipyretic and antibiotic Nonproductive cough and cold 2 days before hospital admission. Pain on swallowing +, anorexia +, conjunctivitis +/+. Rash that started on the face, then spread to the rest of the body 1 day before hospital admission. Nosebleed, gumbleed, bloody stool, diarrhea were denied

PHYSICAL EXAMINATION
General condition moderately ill Level of consciousness
GCS 15 (E4M6V5)

: Patient looks : Compos Mentis,

Blood Pressure Pulse Rate

adequate

: 110/80 mmHg : 90 x/minute, regular,

Respiratory Rate Axilla temperatur

: 35 x/minute : 39 C

Eyes : anemic conjunctiva +/+, conjunctivitis +/+ Nose secrete +/+ :

Mouth : dry mucosa, pharynx hyperemic +/+, T2/T2 Maculopapular rash on ears, face, neck, thorax, abdomen and extremities Thorax and abdomen examination are within normal limit when admitted at the first time There is ronchi (+/+) 2 days after admission

Further examination: - Laboratory result of blood examination are in normal range Suggested examination: - Rontgen thorax

DIAGNOSIS
Five years old boy, weighing 17 kg, and height is at 109 cm, with working diagnosis of: Morbilli, eruption stage Growth and development is appropriate with age Fundamental vaccination been completely given

TREATMENT AT EMERGENCY ROOM

IVFD Ringer Lactate maintenance 1350 cc/24jam Inj. Ranitidin 2 x amp Paracetamol syrup 3 x 150 mg

PROGNOSIS
Quo ad vitam Quo ad functionam Quo ad sanactionam : dubia ad bonam : dubia ad bonam : bonam

FOLLOW UP 18/11/2013 - FIRST DAY OF MEDICAL CARE

S:
Fever +, cough and cold +, watery eyes +, no shortness of breath, no appetite

O:
General condition Level of consciousness 15 (E4M6V5) Blood Pressure Pulse Rate Respiratory Rate Axilla temperature : Patient looks mildly ill : Compos Mentis, GCS : 110/80 mmHg : 85x/minute, regular, adequate : 30x/minute : 38C

PHYSICAL EXAMINATION
Eyes:
Anemic conjunctiva -/-, conjunctivitis +/+

Nose:
Secrete +/+

Mouth:
Dry mucosa, pharynx hyperemic +/+, T2/T2

Maculopapular rash on ears, face, neck, thorax, abdomen and extremities Thorax and abdomen examination are within normal limit

Examination Result

Normal

Examination

Result

Unit

Normal

Value
Urinalysis Color Clarity pH Weight Yellow Clear 7.0 1.025 5.5-8.5 1.0001.030 Protein Bilirubin Glucose Keton Blood/ Hb Nitric ++ Negative Negative Negative Negative Negative Negative Epithelial cells Cyclinder Crystal Others + / 40x FOV / 40x FOV / 40x FOV Urobilinogen Leukocyte Sediment Leukocyte Erithrocyte 2-3 0-1 / 40x FOV / 40x FOV 0,1 IU

Value
0,1-1,0 Negative

Negative Negative

Negative Negative Negative Negative

A: Morbilli, eruption stage

P: IVFD Ringer Lactate maintenance 1350 cc/24jam Paracetamol syrup 3x 150mg Ambroxol syrup 3x1 tablespoon Vitamin A 1x100.000 iu

19/11/2013 2ND DAY OF MEDICAL CARE

S :
Fever +, cough and cold +, watery eyes -, Shortness of breath (+), no appetite

O:
General condition Level of consciousness 15 (E4M6V5) Blood Pressure Pulse Rate Respiratory Rate Axilla temperatur : Patient looks moderately ill : Compos Mentis, GCS : 110/90 mmHg : 95x/minute, regular, adequate : 40x/minute : 36,5C

PHYSICAL EXAMINATION
Eyes: anemic conjunctiva +/+, conjunctivitis -/Nose: secrete -/Mouth: dry mucosa, pharynx hyperemic +/+, T2/T2

Maculopapular rash on ears, face, neck, thorax, abdomen and extremities

Lungs : I : Retraction of intercostal P : Breathing symmetrical on both lungs

P : Sonor
A : Vesicular +/+, Rhonki +/+, Wheezing -/-

Cardio in normal limits

A: Pneumonia et causa Morbilli, eruption stage P: Kaen 3 B + Aminofusin 250 mg 18 dpm makro Paracetamol syrup 3 x 150 mg Erdotin 3x 175 ml Vitamin A 1x 100.000 IU Isprinol 2 x 250 mg

20/11/2013 3TH DAY OF MEDICAL CARE S:

Fever +, cough and cold +, watery eyes -, Shortness of breath (+)

O:
General condition Level of consciousness (E4M6V5) Blood Pressure Pulse Rate adequate Respiratory Rate Axilla temperatur : Patient looksmoderately ill : Compos Mentis, GCS 15 : 110/80 mmHg : 111x/minute, regular, : 35x/minute : 36,9C

PHYSICAL EXAMINATION
Eyes: anemic conjunctiva +/+, conjunctivitis -/Nose: secrete -/Mouth: dry mucosa, pharynx hyperemic +/+, T1/T1

Maculopapular rash on ears, face, neck, thorax, abdomen and extremities

Lungs : I : Retraction of intercostal P : Breathing symmetrical on both lungs

P : Sonor
A : Vesicular +/+, Rhonki +/+, Wheezing -/-

Cardio in normal limits

A: Pneumonia et causa Morbilli, eruption stage P: Kaen 3 B + Aminofusin 250 mg 18 dpm makro Paracetamol syrup 3x2 tablespoon Erdotin 3x 175 ml Isprinol 2 x 250 mg

THORAX ROENTGEN ANTEROPOSTERIOR (20TH NOVEMBER 2013)

Sinus Diaphragm is good Cardio is normal Infiltrate around hilus and left paracardial Interpretation: Bronchopneumonia

21/11/2013 4TH DAY OF MEDICAL CARE

S: Fever +, cough and cold +, watery eyes -, no shortness of breath O: General condition : Patient looks moderately ill Level of consciousness: Compos Mentis, GCS 15 (E4M6V5) Blood Pressure : 110/80 mmHg Pulse Rate : 110x/minute, regular, adequate Respiratory Rate : 45x/minute Axilla temperatur : 38,5C

PHYSICAL EXAMINATION
Eyes: anemic conjunctiva +/+, conjunctivitis -/Nose: secrete -/Mouth: dry mucosa, pharynx hyperemic +/+, T1/T1

Maculopapular rash on ears, face, neck, thorax, abdomen and extremities

Lungs : I : Retraction of intercostal P : Breathing symmetrical on both lungs

P : Sonor
A : Vesicular +/+, Rhonchi +/+, Wheezing -/-

Cardio in normal limits

22/11/2013 5TH DAY OF MEDICAL CARE

S: Fever -, cough and cold -, watery eyes -, no shortness of breath O: General condition : Patient looks well Level of consciousness: Compos Mentis, GCS 15 (E4M6V5) Blood Pressure : 110/70 mmHg Pulse Rate : 95x/minute, regular, adequate Respiratory Rate : 25x/minute Axilla temperatur : 37,5C

PHYSICAL EXAMINATION
Eyes: anemic conjunctiva +/+, conjunctivitis -/Nose: secrete -/Mouth: wet mucosa, pharynx hyperemic -/-, T1/T1

Maculopapular rash on ears, face, neck, thorax, abdomen and extremities

Lungs : I : No Retraction of intercostal when breathing P : Breathing symmetrical on both lungs

P : Sonor
A : Vesicular +/+, Rhonki slightly +/+, Wheezing -/-

Cardio in normal limits

A: Pneumonia et causa Morbilli, eruption stage P: Kaen 3 B 18 dpm makro Paracetamol syrup 3x2 tablespoon Erdotin 3x 175 ml Actacef 3 x 500 mg

23/11/2013 6TH DAY OF MEDICAL CARE

S: Fever -, cough and cold -, watery eyes -, no shortness of breath O: General condition : Patient looks well Level of consciousness: Compos Mentis, GCS 15 (E4M6V5) Blood Pressure : 110/80 mmHg Pulse Rate : 90x/minute, regular, adequate Respiratory Rate : 20x/minute Axilla temperatur : 36,7C

PHYSICAL EXAMINATION
Eyes: anemic conjunctiva -/-, conjunctivitis -/Nose: secrete -/Mouth: wet mucosa, pharynx hyperemic +/+, T1/T1

Maculopapular rash on ears, face, neck, thorax, abdomen and extremities

Lungs : I : No Retraction of intercostal P : Breathing symmetrical on both lungs

P : Sonor
A : Vesicular +/+, Rhonki -/-, Wheezing -/-

Cardio in normal limits

A: Pneumonia et causa Morbilli, eruption stage P: Kaen 3 B 18 dpm makro Erdotin 3x 175 ml Actacef 3 x 500 mg

24/11/2013 7TH DAY OF MEDICAL CARE

S: Fever -, cough and cold -, watery eyes -, no shortness of breath O: General condition : Patient looks well Level of consciousness: Compos Mentis, GCS 15 (E4M6V5) Blood Pressure : 110/80 mmHg Pulse Rate : 90x/minute, regular, adequate Respiratory Rate : 19x/minute Axilla temperatur : 36,5C

PHYSICAL EXAMINATION
Eyes: anemic conjunctiva -/-, conjunctivitis -/Nose: secrete -/Mouth: wet mucosa, pharynx hyperemic -/-, T1/T1

Maculopapular rash on ears, face, neck, thorax, abdomen and extremities

Lungs : I :No Retraction of intercostal P : Breathing symmetrical on both lungs

P : Sonor
A : Vesicular +/+, Rhonki -/-, Wheezing -/-

Cardio in normal limits

A: Pneumonia et causa Morbilli, eruption stage P: Kaen 3 B 18 dpm makro Erdotin 3x 175 ml Actacef 3 x 500 mg Patient discharge

PNEUMONIA
Pneumonia is an inflammation of the parenchyma of the lung. - Most cases of pneumonia are caused by microorganism. - non infectious causes include aspiration of food or gastric acid foreign bodies hydrocarbons and lipoid. substances hypersensitivity reaction and drug or radiation induced pneumonitis.

PNEUMONIA
Classification . 1 : Anatomical classification.
A lobar pneumonia . The consolidalion involves all or part of lobe B Bronchopneumonia the consolidation involves scattered lobules C - Interstitial pneumonia . As in viral pneumonia where inflammatory Infiltrate involve mainly interstitial tissue between alveoli.

PNEUMONIA
2 : Etiological classfication. the cause of pneumonia in patient is often difficult to determine because direct culture of lung tissue invasive and rarely performed. - culture obtained from upper respiratory tract or sputum generally not accurate.

PNEUMONIA
Causes of infectious pneumonia. Bacterial. Common. - streptococcus pneumoniae Group B streptococci Group A streptococci . - Mycoplasma pneumoniae - chlamydia pneumoniae - chlamydia trachomatis

Adolescent. infant

PNEUMONIA
Uncommon.
Haemophilus influenza Unimmunized. Staphylococcus aureus Moraxella catarrhalis Neisseria meningitides Francisella tularensis Animal fly contact Nocardia species Immunosuppressed person. Chlamydia psittaci Bird contact Yersinia pestis Plague Legionella species Exposure to contaminated water.

PNEUMONIA
- Viral Common
Respiratory syncytial virus Parainflueza type 1 3 Influeza A . B Adenovirus Metapneumovirus
Un Common Rhinovirus Enterovirus Herpes simplex Cytomegalovirus Measles Varicella

Neonates Neonates Immunosuppressed person.

PNEUMONIA
-Fungal. Histoplasma capsulatum Cryptococcus neoformans Aspergillus species Mucomycosis Coccidioides immitis Blastomyces dermatitides
Bird, bat contact Bird contact. Immunosuppressed. Immunosuppressed

PNEUMONIA
Mycobacterial
Mycobacterium Tuberculosis Nycobacterium avium-inteacellulare Developed countries Immunosuppressed.

Parasitic
Pneumocystis Carini Eosinophilic Immunosuppressed. Steroid. Ascaris Lumbricoides

Non infectious causes

-Aspiration Of food. -Gastric acid. -foreign body. -Hydrocarbon -Lipoid substances - Aspiration of amniotic fluid.

Kerosen

PNEUMONIA
Age group
Neonate <1mo 1-3 mo febrile Pneumonia Afebrile Pneumonia

Frequent Pathogens
Group B straptococcus E coli streptococcus Pneumoniae H influeza. Rsv . Influenza viruses para fluenza viruses adenovirus S. pneumoniae . H . influenza Chlamydia trachomatis Mycoplasma hominis cytomegalovirus.

3 12 mo

Respiratory Syncytial Virus(RSV)

Influenza viruses para

fluenza viruses adenovirus S. pneumoniae H . Influenza Chlamydia trachomatis Mycoplasma pneumoniae Group A straptococcus

2 5 yr 5 18 yr > 18 yr

Influenza viruses para fluenza viruses adenovirus S. pneumoniae H . Influenza Mycoplasma pneumoniae Chlamydia pneumoniae Group A straptococcus S . Aureus. Mycoplasma pneumoniae S. pneumoniae Chlamydia pneumoniae H . Influenza Influenza viruses adenovirus Mycoplasma pneumoniae S. pneumoniae Chlamydia pneumoniae H . Influenza Influenza viruses adenovirus.

PNEUMONIA
Hospitalization of children with pneumonia
- Age < 6 month - Sickle cell anemia with acute chest syndrome. - Multiple lobe involvement. -Immunocompromised -Toxic appearance . - Severe respiratory distress -Requirement for supplemental oxygen. -Dehydration -Vomiting. -No response to oral antibiotic. - Non compliant parent.

PNEUMONIA
Recurrent pneumonia
-Hereditary disorder Cystic fibrosis -Disorders of immunity Aids Bruton agammaglobulemia Selective IgG subclass deficiencies Common variable immunodeficiency syndrom Sever combined immunodeficiency syndrom -Disorders of leukocytes Chronic granulomatous disease Hyperimmunoglobulin E syndrome Leukocyte adhesion defect

PNEUMONIA
- Disorders of cilia Immotile cilia syndrom Kartagener syndrom -Anatomic disorder Sequestration Lobar emphysema Esophageal reflux Foreign body Tracheo esophageal fistula Gastroesophageal reflux Bronchietasis Aspiration

PNEUMONIA
Pathogenesis
The lower respiratory tract is normally sterile by -Physiologic defense mechanisms including -Mucociliary clearance -Properties of normal secretion such as secretory immunoglobulin A IgA - Clearing of air way by coughing Immunologic defense mechanism of lung limit invasion by pathogenic organisms, includes macrophages are present in alveoli and bronchioles secretory IgA and others immunoglobulins

PNEUMONIA

PNEUMONIA
Viral pneumonia
usually result from spread of infection along the air way. Accompanied by direct injury of respiratory epithelium resulting in air way obstruction from swelling abnormal secretion and cellular debris small lobar of air way in young infant makes them particularly susceptible to severe infection. Viral infection predispose to secondary bacterial infection by disturbing normal host defense mechanism altering secretion and modifying bacterial flora.

PNEUMONIA
Bacterial infection In bacterial infection pathologic process varies according to the invading organism M . Pneumoniae attaches to the respiratory epithelium inhibit ciliary action and Lead to cellular destruction and an inflammatory response in the submucosa as the infection progresses sloughed cellular debris inflammatory cell and mucus Cause airway obstruction with spread of infection occuring along the bronchial Tree as in viral pneumoia.

- S . Pneumoniae Produce local edema that aids in the proliferation of organism and their spread Into adjacent portion of lung often resulting in the characteristic focal lobar Involvement

PNEUMONIA
-Group A . Streptococcus
pathology Includes necrosis of tracheobronchial mucosa formation of large amount of exudate edema and local hemorrhage with extension into the Interalveolar septa and involvement of lymphatic vessel and pleura.

-S. Aureus pneumonia

produces Toxin and enzymes as hemolysin coagulase and staphylo kinase It causes broncho pneumonia often unilateral characterized by presence of Hemorrhagic necrosis and irregular areas of cavitation of lung parenchyma Resulting in pneumatoceles empyema or broncho pulmonary fistula Pyopneumothorax.

PNEUMONIA
Following changes stages:
1- Congestion alveoli are filled with edema fluid and organism. 2- Red hepatization alveoli contain polymorph RBCs fibrin edema and organism. (found PMN, Fibrin, eritrocyte, fluid edema and bacteria in alveoli) 3-Grey hepatization deposition of fibrin over the pleural surface phagocytosis starts inside the alveoli which are now filled with polymorph and fibrin. 4-Resolution: neutrophil degenerate fibrin thread and remaining bacteria and digested and removed by phagocyte

CLINICAL MANIFESTATION
Viral & bacterial pneumonia are often preceded by several day of symptoms of URTI typically rhinitis and cough. In viral pneumonia: fever is usually present lower than in bacteria. Tachypnea increased work of breathing accompanied by intercostal, subcostal and suprasternal retraction nasal flaring and use of accessory muscle. Severe infection accompanied by cyanosis and respiratory fatigue in infant. Auscultation of chest wheezing and crackle

PNEUMONIA
In bacterial pneumonia: Sudden shaking chill followed high fever, cough, grunting, chest pain, drowsiness, rapid respiration, dry cough.

Physical finding:
Depends on the stage of pneumonia diminished breath sound scattered crackels and rhonchi over affected lung. Increasing consolidation or complication. Effusion empyema or pyopneumothorax dullness on percussion and breath Sound. Diminished abdominal distension because of gastric dilation from swallowed air or ileus. Abdominal pain in lower lobe pneumonia Liver may seem enlarged because downward of diaphragm secondary to hyper inflation of lung

DIAGNOSIS
Fever + Cyanosis and 1 of the symptoms : Tachypneu Napas Cuping hidung

Cough
Retraction Rhonci Weak breathing 2 Months 5 Years Old : Difficult to drink, seizure, stridor, decrease GCS < 2 months : Difficult to drink, Seizure, Stridor, wheezing, dan fever. Decrease GCS

Warning sign

PNEUMONIA
Diagnosis:
Chest X-ray diagnosis of pneumonia may indicate complication pleural effusion or empyema. Viral pneumonia X-ray hyper inflation with bilateral interstitial infiltrate pneumococcal pneumonia lobar consolidation repeat chest x-ray are not required for proof of cure for ratient with uncomplicated pneumonia. - WBC can differentiating viral from bacterial in virtual WBC normal or elevated but usually not higher than 20,000/mm3 with lymphocyte predominance Bacterial 15,000- 40,000 predominance granulocyte. -Pleural effusion lobar consolidation and high fever at onset of illness suggestive of bacterial. - Isolation of organism from blood-pleural fluid or lung culture of sputum blood culture.
positive PCR in viruses

TREATMENT

ANTIVIRAL

PNEUMONIA
Deterioration in clinical status antibiotic therapy should be initiated Slowly resolving pneumonia
1- complication as empyema. 2- bacterial resistance. 3- non bacterial etiology as viruses and aspiration of foreign bodies or food. 4- bronchial obstruction from endobronchial lesion foreign body or mucus plug. 5- pre-existing diseases such as immunodeficiencies- ciliary dyskinesia- cysticfibrosis pulmonary sequestration cystic adenomatoid malformation. 6- non infectious causes: - bronchoilitis obliterans. - hypersensitivity pneumonitis - eosinophils pneumonia - aspiration - wegener granulomatosis

PNEUMONIA
Complication:
Usually result of direct spread of bacterial infection within thoracic cavity. (pleural effusion, empyema, pericarditis) or bacteremia and hematologic spread meningitis suppurative arthritis osteomyelitis

X-RAYS

Viral pneumonia x-ray

X-RAYS

Lobar pneumonia x-ray (RUL)

X-RAYS

bronchopneumonia x-ray