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16

DISCUSSION

Pneumonia is an acute inflammatory disease of the lung parenchyma involving the distal
terminal bronchioles, respiratory bronchioles, alveoli ducts, alveoli sacs, and alveoli.
2,13

Conventional diagnosis of pneumonia consists of two stages: first, determining the syndrome by
history, clinical examination, and chest radiology; and second, determining the etiology by
microbiological, serological, and molecular tests.
2-3

Common symptoms of pneumonia in children and infants include rapid or difficult
breathing, cough, fever, chills, headaches, loss of appetite and wheezing.
2,5
Chest radiograph
supports the diagnosis of pneumonia; At one end is the typical appearance of severe lobar
consolidation, which is known to be strongly associated with bacterial pneumonia. Viral
pneumonia is usually characterized by hyperinflation with bilateral interstitial infiltrates and
peribronchial cuffing
16
. The peripheral white blood cell (WBC) count can be useful in
differentiating viral from bacterial pneumonia. In viral pneumonia, the WBC count can be
normal or elevated but is usually not higher than 20 000/mm
3
, with a lymphocyte predominance.
Bacterial pneumonia is often associated with an elevated WBC count, in the range of 15 000-40
000/mm
3
, and a predominance of granulocytes. The definitive diagnosis of a viral infection rests
on the isolation of a virus or detection of the viral genome or antigen in respiratory tract
secretions. The definitive diagnosis of a bacterial infection requires isolation of an organism
from the blood, pleural fluid, or lung.
2,15

In this case, patient was admitted to Haji Adam Malik Hospital on 1
st
Cotober 2013. This
patient was diagnosed with a bronchopneumonia. Diagnosis Bronchopneumonia is based on
history taking, clinical and symptoms of the patients, chest radiograph, and laboratorium
examination. Main complaint of this patient is shortness of breath. It has been occurred since 1
month ago and is not related to weather. This patient also complained about productive cough
since 2 months. On chest radiograph, Infiltrate in the supra hilar and perihilar bilateral was
found. In the laboratorium findings, there is increased of leukocyte with the number 21 380/
mm
3
.
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The effective management of cases of pneumonia relies on appropriate antibiotic therapy and
supportive care. From sensitivity testing of several antibiotics, especially those available in
Primary Health Centers, the recommended pattern of treatment for pneumonia in children,
according to the bacteria isolate is: amoxicillin + clavulanic acid, erythromycin, and
cephalosporin.
The patient is treated with Ampicilin 180 mg/6 hours/IV , Gentamycin 20 mg/24 hours
/IV and Paracetamol 50 mg, usual diet with Sonde Feeding level 400 kkal with 80 gr of protein,
nebulizer with NaCl 0,9 % and Salbutamol / 8 hours.
Cleft lip or palate (CL/P) is a common human congenital defect promptly recognized at
birth.
7
CLP is etiologically heterogeneous and this has critical implications for understanding the
biology of facial development, how environmental risks interact with genetic factors and how we
can incorporate known etiologic variables to improve clinical care.
7

Increased risks from exposure to maternal smoking during the peri-conceptual period
raises the possibility that genes in certain metabolic pathways may play a role in the
development of CLP. And exposure to maternal alcohol consumption has also been suggested as
a risk factor, but the evidence has been more inconsistent.
7-8
18

Individuals with CLP may experience problems with feeding, speaking, hearing and
social integration that can be corrected to varying degrees by surgery, dental treatment, speech
therapy and psychosocial intervention.
7
And plastic surgery for lip repair is ideally performed
around three months of age and represents the first among many surgical interventions to which
the individual with cleft lip and palate is submitted for full rehabilitation. This surgical procedure
reconstructs the skin, muscle, lip and oral mucosa, as well as the nasal columella.
15
In this patient was found labiognatopalatoschizis. Based on history of his mother, risk
factor of the labiognatopalaschizis was not found.
Hydrocephalus is a disorder that occurs as a result of obstruction to flow of cerebrospinal
fluid (CSF), leading to dilatation of the cerebral ventricles. It may be congenital in origin, often
as a result of a primary cerebral malformation, or it may be acquired postnatally, secondary to
diverse etiologies including tumor, infection, and hemorrhage. The obstruction in hydrocephalus
may be within the ventricular system or aqueduct (non-communicating or obstructive
hydrocephalus), or at the arachnoid villi, the site of absorption of CSF (communicating
hydrocephalus). Children with untreated hydrocephalus usually present with signs and symptoms
of increased intracranial pressure.

The signs and symptoms of hydrocephalus vary with the age of
the child and the degree of pressure. In infants and young children, the symptoms may be
insidious, with failure to thrive, vomiting, irritability, or somnolence.
10

Headache is a prominent symptom in older patients, in the other hand, an accelerated rate
of enlargement of the head is the most prominent sign in infants. The forehead is broad, and eyes
may deviate downward because of impingement of the dilated suprapineal recess on tectum,
producing the setting-sun sign.
11
Examination may demonstrate a tense or large anterior
fontanelle, distended scalp veins, a divergent strabismus, or spasticity in the lower extremities.
10

As their skull sutures have not fused, the head circumference may be disproportionately large or
show an excessive rate of growth. The skull sutures separate, the anterior fontanelle bulges and
the scalp veins become distended.
12
In the newborn or infant with an open anterior fontanelle, ultrasound is a useful tool both
for initial evaluation and as a method to follow ventricular size serially. Computed tomography
(CT), magnetic resonance imaging, or both are necessary to delineate the anatomy. The
advantage of CT is that it is quick and easy to perform and is available in many centers on an
emergency basis. Magnetic resonance imaging is superior in defining the anatomy, especially in
19

cases of obstructive hydrocephalus. Transillumination of the skull is an all-but-forgotten
technique that can be performed in young children to provide a clue to the presence of
hydrocephalus.
9

Treatment is required for symptomatic relief of raised intracranial pressure and to
minimise the risk of neurological damage. The mainstay is the insertion of a ventricular shunt ,
but endoscopic treatment and ventriculostomy can now be performed. Shunts can malfunction
due to blockage or infection (usually with coagulase-negative staphylococci). They then need
replacing or revising. Overdrainage of fluid can cause low-pressure headaches but the insertion
of regulatory valves can help avoid this.
12
Medical management, including the use of
acetazolamide and furosemide, can provide temporary relief by reducing the rate of CSF
production, but long-term results have been disappointing. Medical management of
hydrocephalus using diuretics and hyperosmolar agents to control CSF production or increase
excertion has been advocated by some, but a recent collaborative study in premature infants
found no benefits and possibly some negative effects.
10

In this patient, head enlargement was found, with head circumference 47 cm.
Symptom of vomitus was found, forehead is broad, Sunset-eye phenomenon, opened fontanella
buldge was found, and the trans luminence test is positive. Now, Condition of the patient is
stable and he has been taken over by the Neuro Surgery.













20

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