case presentation box b anak
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CaseTRANSCRIPT
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CASE PRESENTATION
Presented by:
Ceyka Maduma
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IDENTIFICATION
Name : Ana Elvira
Age / Date of Birth : 2 months 3 weeks / 3 January
2014
Gender : FemaleFather’s Name: Julis
Mother’s Name : Erni
Nationality : Indonesia
Religion : Islam
Address : Pampangan, OKI
Transfered By: RSUD Kayu Agung
Date of admission: Tuesday (18-03-2014)2
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HISTORY OF ILLNESS
Chief Complain : dyspnea
Additional Complain : fever and cough
History of Present Illness :
± 3 days before admission, the child got a highfever. Shiver (-). She also has cough. Sputum (-).
± 1 day before admission, she had dyspnea at the
night. Dyspnea doesn’t depend on weather. There
are intercostal retraction and epigastric
retraction. Seizure (-). Common cold (-). Diarrhea(-). She was brought to the Kayu Agung Hospital
and transferred to RSMH.3
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HISTORY OF ILLNESS
Since newborn, there is snoring sound. She alwayschoke and vomit when get milk too much.
History of hospital admission
In February, 2014 treated in Charitas Hospitalbecause of cow’s milk allergic.
Family history: tuberculosis contact (-), prolong
cough (-).
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Pregnancy and Labor :
Pregancy : Aterm
Labor : Spontaneous
Helped by: MidwifeDate of birth : 3 January 2014
Birth Weight: 3.8 kg
Birth Height : 48 cm
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Immunization
BCG: yes, scar (+)
DPT: yes
Polio: yes
Hepatitis B: yes
Rubella: not sureConclusion: basic immunization was completed
Child Development :
Roll Over (Tengkurap): -
Crawl (Merangkak): -
Sit : -
Stand : -
Walk: -
Conclusion: can’t identify
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PHYSICALEXAMINATIONON
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PHYSICAL EXAMINATION ON ADMISSION
General
General Condition : compos mentis, moderate sicknessTemp. : 37°C
Respiration Rate: 63x/minute, thoracal
Blood Pressure : -
Pulse Rate: 130 BPM
Weight : 3.7 kg
Height: 53 cm
Nutritional Status
Weight : 3.7 kgHeight: 53 cm
Weight/Age: between -2 and -3 SD wasting
Height/age: -2 SD mild stunting
Weight/Height: between -1 and -2 SD mild malnutrition7
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PHYSICAL EXAMINATION
Head
Shape : normal, symmetrrical
Hair : black, not fragile
Eye : CA (-), SI (-)
in normal limitNose : nasal flare (+), secret (-)
Ear : secret (-), pain (-)
Mouth : normal
Throat: Faring Hyperemis (-)
Neck : Lymph Node (-)
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Pulmo
Inspection: symmetric, intercostal retraction (+), epigastric
retraction (+), pectus excavatum (+)
Palpation: stem fremitus (↓)
Percussion : dullness Auscultation: vesiculer (↑), rales (+), wheezing (-)
Cor
Inspection: ictus cordis at 5th ICS
Palpation: thrill (-)Percussion : heart within normal limits
Auscultation: reguler, murmur (-), gallop (-), BJ I/II normal
PHYSICAL EXAMINATION
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Abdomen
Inspection: convex, vein enlargement/venektasi (-)
Palpation:
Hepatomegali (-), Spleenomegali (-)
Percussion : thympani
Auscultation: bowel sound (+) 5x/minute, normal
Extremities
Oedem (-), pale (-)
Neurology Examinationnormal
PHYSICAL EXAMINATION
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Hematology
Hb : 11 g/dlHt : 32 vol%
Leukosit : 12.500 /mm3
Trombosit : 371.000/mm3
Diff count : 0/1/1*/37*/49*/12*
Retikulosit : 2,9 %
MCH : 28
MCV : 79,4
MCHC : 35
LED : 15 mm/jam
Kimia Klinik
LABORATORY FINDINGS
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DIFFERENTIAL DIAGNOSE -
DIAGNOSE
Differential Diagnose:
Bronchopneumonia e.c bacterial infection
Bronchopneumonia e.c viral infection
Diagnose :
Bronchopneumonia e.c bacterial infection
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MANAGEMENT
IVFD D-5
Ampicillin 150 mg 3x/day
Gentamicyn 20 mg 2x/day
Oxygen nasal 1L/mPASI 12 x 300 cc via NGT
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FOLLOW UP
25 March 2014
General condition = mild sickness
PR = 120 BPM
RR = 46 x/mTemp. = 35.8°C
Pulmo
Inspection: symmetric, intercostal retraction (+),
epigastric retraction (+), pectus excavatum (+)Palpation : stem fremitus (↓)
Percussion: dullness
Auscultation : vesiculer (↑), rales (+), wheezing (-)14
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Prognosis
Quo ad vitam : bonam
Quo ad functionam: bonam
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THEORY
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BRONCHOPNEUMONIA
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Definition
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ETIOLOGY
AGE-DEPENDENT
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Age Most Rare
Bacterial infection Bacterial infection
E. colli Anaerob bancterial
Streptococcus group B Streptococcus group D
Newborn-20 days
age
Listeria monocytogenes Haemopillus influenzae
Streptococcus
pneumoniae
Ureaplasma urealyticum
Viral infection
Sitomegalo virus
Herpes simplex virus
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Age Most Rare
Bacterial infection Bacterial infection
Chlamydia trachomatis Bordetella pertusis
Streptococcus
pneumoniae
Haemophillus influenzae
tipe B
3 weeks-3 months
age
Viral infection Moraxella catharalis
Adeno virus Staphylococcus aureus
Influenza virus Ureaplasma urealyticum
Parainfluenza 1,2,3 virus Viral infection
RSV Sitomegalo virus
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Age Most Rare
Bacterial infection Bacterial infection
Chlamydia pneumoniae Haemophillus influenzae
tipe B
Mycoplasma pneumoniae Moraxella catharalis
4 months-5 years
age
Streptococcus
pneumoniae
Neisseria meningitis
Viral infection Staphylococcus aureus
Adeno virus Viral infection
Influenza virus Varisela-Zoster virus
Parainfluenza virus
Rino virus
RSV
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Age Most Rare
Bacterial infection Bacterial infection
Chlamydia pneumoniae Haemophillus influenzae
Mycoplasma pneumoniae Legionella sp
5 years age-
teenager
Streptococcus
pneumoniae
Staphylococcus aureus
Viral infection
Adeno virus
Epstein-bar virus
Influenza virus
Parainfluenza virus
Rino virus
RSV
Varisella-zooster virus
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PATHOGENESIS
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LOCATION
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SIGN AND SYMPTOM
Infection symptomRespiratory symptomInfection symptom
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DIAGNOSIS
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Anamnesis
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CLASSIFICATION OF PENUMONIA
(FOR 2 MONTHS-5 YEARS OLD AGE)
Severe Pneumonia
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CLASSIFICATION OF PENUMONIA
(FOR INFANT < 2 MONTHS AGE)
Pneumonia
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TREATMENT
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Antibiotics for 10-15 days:
Ampicilin 100 mg/kgbb/day in 3-4 doses
Chloramphenicol:
< 6 months: 25-50 mg/kgbb/day
> 6 months: 50-75 mg/kgbb/day in 3 doses or Gentamicyn 3-5
mg/kgbb/day in 2 doses
Support treatment:
IVFD
Oxygen
Education:
Immunization,
Adequate ASI,
Nutrition,
Keep away children from cigarrete smoke and air pollution
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CASE ANALYSE
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PATIENT Bronchopneumonia
- Acute (3 days)- High fever
- Cough
- Shortness of breath
- T: 37°C- Puse: !3" #$%inute
- &&: '3#$er %inute
- ntercosta &etraction and
*igastric &etraction- Percussion: duness
- Auscutation: raes (+)
- C,&: infitrates of ung tissue
- Sudden onset of fever- Shortness of breath
- Productive cough
- Tachynea
- Signs of resiratory distress(retractions faring grunting)
- ncreased fre%itus
- .uness
- &aes- C,&: infitrates of ung tissue
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THANKYOU