Case

Presentation

PNEUMONIA

Elia Megasari
1408465699
Supervisor :
dr. Dedi Satriya Putra, Sp.A (K)

KEPANITERAAN KLINIK SENIOR BAGIAN ANAK

FAKULTAS KEDOKTERAN UNIVERSITAS RIAU
RSUD ARIFIN ACHMAD PEKANBARU
2016

INTRODUCTION
Background

Pneumonia is an acute infection lung

parenchyma includes alveolar and interstitial
tissue

Pneumonia most common in children aged

<5 years the main cause of death of more
than 2 million children each year that occur in
developing
countries.
155
million
new
incidence of pneumonia in children, 7-13%
severe pneumonia can be life-threatening.

Pneumonia
diarrhea.

second cause of death after

LITERATURE REVIEW

Virus

RSV (<3years)

Bacteria

S. pneumoniae (<3month)
Haemophylus influenzae
Streptococcus haemolyticus
Mycoplasma pneumoniae
Chlamydia pneumoniae
Staphylococcus aureus

MICROORGANISMS THAT CAUSE PNEUMONIA

ACCORDING TO AGE
Born-20
days

3 weeks 3
months

4 months
5 years

5 years adolescen
t

WHO CLASSIFICATION

Infant < 2 month:

Severe Pneumonia : tachypnea / severe
retraction
Very Severe Pneumonia : unable to feed or
drink, convulsions, lethargy,
fever/hypothermia, bradipnea/ irregular breath

Child 2 months - 5 years

Mild Pneumonia : tachypnea
Severe Pneumonia : retraction
Very Severe Pneumonia : unable to drink or
eat, convulsions, lethargy, malnutrition

EPIDEMIOL
OGY
Riskesdas, increased in 2007 by
2.1% to 2.7% in 2013

Demographic and Health Survey,

7.6% in 2002 to 11.2% in 2007
WHO, developing countries 151.8
million pneumonia cases / year,
8.7% (13, 1 million) of whom are
severe pneumonia and need
hospitalization

RISK FACTOR
Intrinsic

Age
Gender
Nutritional status
Low birth weight
Immunization status

Extrinsic

Density habitation
Air pollution
Type of house
Ventilation
Humidity
Cigarette smoke
Family income
Maternal factors

CLINICAL MANIFESTATIONS
Non spesific
fever, anxiety,
gastrointestinal
disorders such as
vomiting, bloating,
diarrhea or
abdominal pain.
Pleural
(Streptococcus
pneumoniae and
Staphylococcus
aureus) chest
pain

Pulmonary
symptoms cough
and colds, nostril
breath, tachypnea
dyspnea and apnea,
retraction.
Extrapulmonary
(Streptococcus
pneumoniae or
Haemophillus
influenza) Otitis
media,
conjunctivitis,
sinusitis

Diagnosis
Fever, cough,
increased
respiratory rate
and an increase
in respiratory
effort

Anamnesi
s

Physical
examinati
on

Respiratory
nostril
Intercostal
retractions,
substernal,
epigastric
Wet rhonchi
auscultation

Laboratory
(leukocytosis)
Radiological
Chest X-Ray
(infiltrates)

Supportin
g
examinati
on

Hospitalization Criteria
Infant
O2 saturation

92%, cyanosis
Respiratory
rate> 60x /
minute
Respiratory
distress, apnea
intermittent
Do not want to
drink /
breastfeed
The family
could not care

Child
O2 saturation
<92%, cyanosis
Frequency of
breath> 50x /
minute
Grunting
Respiratory
distress
There are signs
of dehydration
The family could
not care for at

MANAGEMENT
Mild
Pneumonia

Outpatient care
Antibiotic
therapy

Severe
Pneumonia

Hospitalized
Antibiotic
therapy

Oxygen therapy

CASE ILLUSTRATION
Patient identity
Name / Medical Record

By.HS / 916738

Age

4 months

Gender

female

Father/Mother

S/D

Date of admission

February 24th , 2016

Address

Minas

ANAMNESIS
Alloanamnesis (Patients parents)
Chief complaint : Shortness of breath that
become heavy since one day before the
hospitalization

Fever, cough and

colds,
coughadmitted
with sputum,
persistent cough and
3 days
before
to hospital
reduced at rest. Patients go for treatment to the Puskesmas and
were given fever medicine and cough medicine, fever recovered but
the cough has not diminished

2 days before admitted to hospital

Patient appears shortness of breath, shortness felt every cough,
vomiting (+), 1 time a day, mucus (+). Defecation 1 times a day,
liquid consistency, yellow color, aqua-cup amount. Urination normal.

1 days before admitted to hospital

Shortness of increasingly become heavy, felt shortness at any time,
not reduced during sleep, nose seemed to expand and deflated,
patient is often silent.

PIH
Never felt
same
complaint
Travel
related
history (-)

FIH
Patients
Grandfather
being
treated for
tuberculosis,
with a
history of
chronic
cough
No family
felt same
complaint

Parental H.
Father :
farmer
Mother :
Housewife

Pregnancy H.

Feed H.

Enough
months
pregnancy
Regular ANC
to midwife,
Complaint
during
pregnancy or
delivery (-)
Normal labor
Assisted by
doctor
BBW 2700
gr, forget
birth weight
2rd child of 2
children

Gross motor
skills: face
down since
the age of 3
months
Fine motor
skills:
holding toys
Communicati
on: laughing
and
screaming,
turned to
sound if
called since
age of 4
months

Vaccination H.
Complete
basic
vaccination
Based on age

Growth H.
Growth age
appropriate

Developmental
H.
Appropriate

House and
Livings H.

Staying in oil
palm
plantations
Boards house,
sufficient
lighting
Sources of
drinking water
: gallon water
Source of MCK
: dug wells

Physical Examination
GA : moderate illness
Conscience: respon to verbal
HR : 140 x/i (regular, weak palpated)
RR : 65 x/i
T : 37,5C

Head
: Normocephali, black hair, uneasy
to grab
Eyes
: Conjunctiva anemis (-), sclera
icteric (-)
round pupil isokor, 2 mm/2 mm
light reflexes (+/+)
Ears
: Within normal limit
Nose : Nostril breath (+)
Mouth
: Dry lips mucosal, bloody gum (-),
tonsil and pharynx non hyperemia

Thorax

Inspection :
Symmetrical chest wall movement, subcostal
retraction (+), intercostal retractions (+)
Palpation :
Vocal Fremitus normal (when the child cry), IC
palpable
Percussion
:
sonor the whole lung fields
Auscultation :
Wet rhonchi the whole lung fields (+/+),
wheezing(-/-)
Regular heart sounds, murmur (-), gallop (-)

Abdomen :
I : flat shape, venectation (-), scar (-)

P : bowel sounds normal, frequency 8x/minute

P : Tympani (+)
A : Normal peristaltic sound

Extremity :
Warm acral, capillary refill time < 2 sec, edema
(-), clubbing finger (-), cyanosis (-)

Laboratory Findings

Routine blood (February 24th,

2016)
WBC : 20,2x103/ul
MCV : 76,5
Hb : 9,5 g/dl
MCH : 26,4
HT : 27,5 %
MCHC : 34,4
PLT : 572 x 103 /ul

Electrolyte (February 24th,

2016)
Na+ : 131,9 mmol/L
K : 3,59 mmol/L
Cl : 103,9 mmol/L

Blood chemistry (February

24th, 2016)
Glu : 102 mg/dL
Ure : 24 mg/L
Cre : 0.24 mg/dL
SGOT: 69 U/L
SGPT : 31 U/L
Alb : 4.36 g/dL

CHEST X-RAY (FEBRUARY 24TH , 2016)

Cor: normal size and
shape
Pulmo: corakan
bronkovaskuler
increased
Looks small
infiltrates in almost
all lung fields
Impression:
Bronchopneumonia

Diagnosis
Working diagnosis :
Severe Pneumonia
Anemia
Nutritional
diagnosis :
Normal

Treatment
Pharmacology
O2 1-2 L
IVFD D5 NS +
KCl 5 meq 8
drops/minute
micro
Kalpicilin IV 150
mg/6hour
Kemicetin IV 125
mg/6hour

Prognosis
Quo ad vitam :
dubia
Quo ad
functionam : dubia

DAY/DATE

25/2/
2016
PICU

SUBJECTIVE

Patients mom
complain of
shortness
reduced, fever
(-), cough with
sputum (+),
diarrhea (-)

OBJECTIVE

Consciousness: apathetic
General appearance: severe
illness
BP: 97/44 mmHg HR : 130
x/minute RR : 53x/minute
T : 36,50c
weight : 5200gr
Eye : CA (-/-), SI (-/-)
Nose : nostril breath (+)
Neck : normal
Thoraks
:
subcostae
retraction (+), wet rhonchi
the whole lung fields (+/+)
Abdomen : flat
Extremities : warm acral,
CRT < 2

Immunoserology:
CRP: Reactive 128 mg/dL
Blood gas analysis:
Ph : 7.40, pCO2 : 38 mmHg,
pO2
:
97
mmHg,
HCO3:23.5mmHg,
TCO2: 24.7mmHg, BE :-1.1,
SO2c : 98%
Electrolyte:
Na+:135mmol/L
K: 3,7 mmol/L

ASSESMENT

Severe
pneumonia
anemia

THERAPY

+
-

IVFD RL 10
dpm
Ceftriaxon
2x250mg
Ranitidine
2x5mg
Dexametaso
n 3x1mg
Nebulizer
ventolin / 16
hour

DAY/DATE

SUBJECTIVE

26/2/2016
PICU

Patients mom
complain of
shortness
reduced, fever
(-), cough with
sputum (+),
diarrhea (-)

OBJECTIVE

ASSESMENT

Consciousness: alert
Severe
General
appearance: pneumonia
moderate illness
+ anemia
BP: 101/68 mmHg
HR : 91 x/minute
RR : 27x/minute
T : 36,50c
weight : 5200gr
Eye : CA (-/-), SI (-/-)
Nose : nostril breath (+)
Neck : normal
Thoraks
:
subcostae
retraction
(+),
wet
rhonchi the whole lung
fields (+/+)
Abdomen : flat
Extremities : warm acral,
CRT < 2

THERAPY

IVFD RL 10 dpm
Ceftriaxon
2x250mg
Ranitidine 2x5mg
Dexametason
3x1mg
Nebulizer
ventolin / 16 hour

DAY/DATE

SUBJECTIVE

27/2/2016
PICU

Patients mom
complain of
shortness
reduced, fever
(-), cough with
sputum (+),
diarrhea (-)

OBJECTIVE

ASSESMENT

Consciousness: alert
Pneumonia
General
appearance:
moderate illness
BP: 100/69 mmHg
HR : 120 x/minute
RR : 30 x/minute
T : 360C
SPO2 : 100%
Eye : CA (-/-), SI (-/-)
Nose : nostril breath (+)
Neck : normal
Thoraks
:
subcostae
retraction
(+),
wet
rhonchi the whole lung
fields (+/+)
Abdomen : flat
Extremities : warm acral,
CRT < 2
Blood Culture :
Strepcocus B Hemoliticus

THERAPY

IVFD RL 10 dpm
Ceftriaxon
2x250mg
Ranitidine 2x5mg
Dexametason
3x1mg
Nebulizer
ventolin / 16 hour

DAY/DATE

SUBJECTIVE

28/2/2016
PICU

Shortness of
breath (+)
fever (-), cough
(+), diarrhea
(-)

OBJECTIVE

ASSESMENT

Consciousness: alert
Pneumonia
General
appearance:
moderate illness
BP: 91/67 mmHg
HR : 132 x/minute
RR : 22 x/minute
T : 36,50C
SPO2 : 100%
Eye : CA (-/-), SI (-/-)
Nose : nostril breath (+)
Neck : normal
Thoraks
:
subcostae
retraction (+), rhonchi
(-/-)
Abdomen : flat
Extremities : warm acral,
CRT < 2

THERAPY

IVFD RL 15 dpm
Ceftriaxon
2x250mg
Ranitidine 2x5mg
Dexametason
3x1mg
Nebulizer
ventolin / 16 hour

DAY/DATE

SUBJECTIVE

29/2/2016
PICU

Shortness of
breath (+)
fever (-), cough
(+), diarrhea
(-)

OBJECTIVE

ASSESMENT

Consciousness: alert
Pneumonia
General
appearance:
moderate illness
BP: 100/83 mmHg
HR : 101 x/minute
RR : 26 x/minute
T : 36,80C
SPO2 : 95%
Eye : CA (-/-), SI (-/-)
Nose : nostril breath (-)
Neck : normal
Thoraks
:
subcostae
retraction (+), rhonchi
(-/-)
Abdomen : flat
Extremities : warm acral,
CRT < 2

THERAPY

IVFD RL 10 dpm
Ceftriaxon
2x250mg
Ranitidine 2x5mg
Dexametason
3x1mg
Nebulizer
ventolin / 16 hour
Breastmilk directly
and moved into a
regular room

DAY/DATE

SUBJECTIVE

1/3/2016
Flamboyan

Shortness of
breath (-) fever
(-), cough (-),
diarrhea (-),
nausea (-),
vomiting (-),
strong suckle.

OBJECTIVE

ASSESMENT

Consciousness: alert
Pneumonia
General
appearance:
mild illness
HR : 126 x/minute
RR : 26 x/minute
T : 36,50C
Eye : CA (-/-), SI (-/-)
Nose : nostril breath (-)
Neck : normal
Thoraks:
subcostae
retraction (-), rhonchi
(-/-)
Abdomen : flat
Extremities : warm acral,
CRT < 2

THERAPY

IVFD RL 10 dpm
Ceftriaxon
2x250mg
Ranitidine 2x5mg
Dexametason
3x1mg
Nebulizer
ventolin / 16 hour
Breastmilk

DAY/DATE

SUBJECTIVE

2/3/2016
Flamboyan

Shortness of
breath (-) fever
(-), cough (-),
diarrhea (-),
nausea (-),
vomiting (-),
strong suckle.

OBJECTIVE

ASSESMENT

Consciousness: alert
Pneumonia
General
appearance:
mild illness
HR : 126 x/minute
RR : 26 x/minute
T : 36,50C
Eye : CA (-/-), SI (-/-)
Nose : nostril breath (-)
Neck : normal
Thoraks:
subcostae
retraction (-), rhonchi
(-/-)
Abdomen : flat
Extremities : warm acral,
CRT < 2

THERAPY

IVFD RL 15 dpm
Ceftriaxon
2x250mg
Ranitidine 2x5mg
Dexametason
3x1mg
Nebulizer
ventolin / 16 hour
Breastmilk
Plan
returning
home

Medication :
Multivitamin
Cefixime 150mg

Discussion

Therapy
Ceftriaxon
Ranitidine
Dexameta
son
Nebulizer

Prognosis
Quo ad
vitam :
dubia
Quo ad
fungsiona
m: dubia

THANK YOU