LONG CASE

PNEUMONIA
WITH
ATELEKTASIS LUNG DEXTRA

Mentor :
dr. Ulynar Marpaung, Sp. A

Written by :
Rhandy Septianto
1112103000051

Faculty of Medicine Islamic State University

Pediatric Department

Bhayangkara Tk. I R. Said Sukanto Hospital

January 2nd 2017 March 12th 2017

 CHAPTER I
CASE REPORT

IDENTITY
Patient
Name : Child R
Birth Date : November 12th, 2016
Age : 2,5 months
Gender : Female
Address : Tanah Merdeka AMD XII Street Num. 10, Rt. 09/02, Ciracas
Nationality : Indonesian
Religion : Islam
MR No. : 858487
Date of admission : January 20th, 2017
Date of examination : January 25th, 2017

Parents
Father Mother

Name Mr. NR Mrs. F

Age 28 years old 27 years old

Job Employee Employee

Nationality Indonesian Indonesian

Religion Islam Islam

Education SHS SHS

Address Tanah Merdeka AMD XII Street Num. 10, Rt. 09/02,
Ciracas

ANAMNESIS

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The anamnesis was taken on January 25th, 2016 using alloanamnesis and
autoanamnesis method. It was taken at room No. 5 Anggrek 2, Bhayangkara Tk.I R.
Said Sukanto Hospital, Jakarta.
Chief complaint : cough since 4 days before admission to the hospital.
Additional Complaint :
Fever, breatheless, vomitus, nausea decreased appetite.
History of Present Illness :
A child aged 2.5 months to come to the hospital with complaints of cough, cough
experienced by patients already 4 days before admission. cough with sputum, and
yellowish sputum, phlegm experienced throughout the day and subside when the
cough medicine, but soon reappear. Patients also felt his fever, the fever felt since 4
days before admission, the fever is felt throughout the day, and not down, no chills,
and fever is not accompanied by seizures. and patients also complain of nausea, and
vomiting, vomiting that comes up is the food just issued. since 2 days before
admission, the patient complained of shortness increasingly become heavy, the
tightness is felt throughout the day, did not subside with rest and not to increase the
activity. defecate and urinate normally.
History of Past Illness
History of Past Illness
Pharyngitis/Tonsilitis -
Bronchitis -
Pneumonia -
Morbilli -
Varicella -
Diphteria -
Enteritis -
Bacillary Dysentry -
Amoeba Dysentry -
Diarrhea -
Thypoid -
Worms -

3
 Surgery -
Brain Concussion -
Fracture -
Drug Reaction -
Febril seizure -

Allergic History
The patient have no allergy to medicine and food.

Birth History
Mothers Pregnancy History
The mother routinely checked her pregnancy at local clinic with a midwife
since she knew she got pregnant and every months until she gave birth. She
also said that she consumed vitamins, iron supplement, and folic acid during
pregnancy. Birth weight 3000 gram, body length 51 cm.

Childs Birth History

- Labor : Local clinic
- Birth attendants : Midwife
- Mode of delivery : Pervaginam
- Gestation : 39 weeks
- Infant state : Healthy
- Birth weight : 3000 grams
- Body length : 51 cm
- According to the mother, the baby started to cry, the babys skin is red, and
no congenital defects were reported.

Development History
- First dentition :-
- Psychomotor development
Smile :-
Slant :-
Speech initiation :-
Prone position :-
Sitting :-
Crawling :-
Standing :-
Walking :-

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 Jumping :-
- Conclution : growth and developmental is still in the normal limits and was
appropriate according to the patients age.

History of Eating
- Breast milk : Still Exclusively.
- Patient like to eat rice, vegetables and fruits.

History Immunization
Immunization Frequency Time

BCG 1 time 1 month old

Hepatitis B 2 times 0, 1 months old

DPT 1 times 2 months old

Polio 2 times 0, 2 months old

Measles 0 times -

Family History : None

History of Sibling
- The patient is the first child of the family
- The patient has no sibling
- Born died : (-)
- Child dies : (-)
- Miscarriage : (-)

Neighbour History : There is no person with the same symptom like patient.
Environment history : There is no puddles and flooding around patients house.

PHYSICAL EXAMINATION (January 25st, 2016)

General Status
- General condition : Mildly ill
- Consciousness : Compos Mentis
- Pulse : 110 x/min, regular
- Breathing rate : 30 x/min
- Temperature : 38 C per axilla
Anthropometry Status
- Weight : 5 kg

5
 - Height : 56 cm
Nutritional Status based on NCHS (National Center for Health Statistics) year
2000 :
- WFA (Weight for Age) : 5/5.2 x 100 % = 96 % (good nutrition)
- HFA (Height for Age) : 56/58 x 100 % = 103 % (good noutrition)
- WFH (Weight for Height) :5/4.8 x 100 % = 104 % (good noutrition)

Conclution : The patient has good noutritional status.

Head to Toe Examination

- Head
Normocephal, hair (black, normal distribution, not easily removed), no
sign of trauma.
- Eyes
Scleral icterus -/-, pale conjunctiva -/-, lacrimation -/-, pupil 3mm/3mm,
isocor, direct light response +/+, indirect light response +/+.

6
 - Ears
Normal shape, no wound, no bleeding, no secretion, no cerumen.
- Nose
Normal shape, midline septum, secretion -/-.
- Mouth
Lips : wet
Teeth : no caries
Mucous : moist
Tongue : No dirty
Tonsils : T2/T2, no hyperemia
Pharinx : no hyperemia
- Neck
Lymph node enlargement (-), scrofuloderma (-).
- Thorax
Inspection : Symmetric when breathing, retraction (-), ictus cordis is
not visible
Palpation : Fremitus tactile +/+ symmetric, mass (-), ictus cordis (+)
Percussion : Dim percussion on the lower both lung, and sonor on
upper and middle both lungs
Auscultation :
Cor : S1-S2 regular, murmur (-), gallop (-)
Pulmo : vesicular in upper lobe/normal, rhonchi +/+, wheezing
-/-
- Abdomen
Inspection : Distended, spider nevi (-)
Palpation :Abdominal mass (-), hepatomegaly (-), and splenomegaly
(-)
Percussion : tympanic, shifting dullness (-)
Auscultation : Normal bowel sound, bruit (-)
- Vertebra
There is no scoliosis, kyphosis, lordosis, and any mass along the vertebral
line.
- Extremity
Warm, capillary refill time <2 second, edema -/-

Neurogical Examination
Meningeal Sign
- Nuchal rigidity (-)
- Kernig sign (-)
- Lasegue sign (-)
- Brudzinski I (-)
- Brudzinski II (-)

Motoric Examination

7
 Power
- Hand 5555/5555
- Feet
5555/5555
Tonus
- Hand Normotonus/ Normotonus
- Feet
Normotonus / Normotonus
Trophy
- Hand Normotrophy / Normotrophy
- Feet
Normotrophy / Normotrophy
Physiologic Reflex
Upper extremities
- Biceps +2 / +2
- Triceps
+2 / +2
Lower extremities
- Patella
+2 / +2
- Achilles
+2 / +2
Pathologic Reflex
Upper extremities
- Hoffman -/-
- Trommer
-/-
Lower extremities
- Babinsky
-/-
- Chaddock
- Oppenheim -/-
- Gordon
-/-
- Schaeffer
-/-
-/-
Clonus
- Patella -/-
- Achilles
-/-

Autonomic Neurological Examination

Defecation Normal (frequency 1 times daily)
Urination Normal (3 times daily)
Sweating Normal

8
9
LABORATORY INVESTIGATION
Hematology (January, 21st 2017)

Results Normal Value

Hemoglobin 14 13 16 g/dl
White blood cells 22.700 5.000 10.000 u/l
Hematocrit 43 40 48 %

Platelet count 606.000 150.000 390.000 /ul

Na 134 135-145
K 5,2 3,5-5,0
Cl 99 99-108
pH 7,34 7,35-7,45
pco2 37 35-45
po2 64 85-95
o2 saturasi 91 85-95
HCO3 20 21-25
Base Excess -5 -2,5 2,5
SBC 20 22-26
Total CO2 21 21-27
sbe -5 -2,4 2,3

THORAX RONTGEN EXAMINATION

10
Conclusion : Atelectasis Upper Lung Dextra.

WORKING DIAGNOSIS
Pneumonia
Atelectasis upper lung dextra.
Hospitalization 5th days

MANAGEMENT
- IVFD RL 500/24jam
- Cefotaxime injection 2 x 250 gr (5th day)
- Paracetamol syr 4 x 1 ots
- Ambroxol 2 x 0,5 cth
- O2 3 lpm.
- Salbutamol inhalation 2x2,5 mg.

PROGNOSIS
- Quo ad vitam : Bonam
- Quo ad functionam : Bonam
- Quo ad sanationam : Bonam
-
FOLLOW UP

January 26th 2016, 6th day of hospitalization.

Fever (-), Nausea (-), Vomit (-), Malaise (+), Stomachache (-)
Cough (+) sputum (+), cold (-), minimum breatheless (+)
S Spontaneous bleeding (-)
Decreased appetite(+)
Defecation and miksi normal
Consciousness : Compos Mentis
General condition : Midly ill
Temperature : 37,2 C
Pulse :120 x/min
Respiratory rate : 28 x/min
Head : Normocephal
Eyes : Pale conjungtiva (-), icteric sklera (-)
Mouth : Dry lips, dry mucous, tonsils T1/T1,

11
 hyperemia pharynx (-)
Pulmonary : Retraction (-), Vesicular +/+ rhonchi +/+, wheezing
-/-
Cardio : S1/S2 normal regular, murmur (-), gallop (-)
Abdomen : Epigastric pain (+), Distention (-),
bowel sound (+) normal, shifting dullness (-)
Extremity : Warm, CRT <2 seconds

Laboratory Investigation
Results Normal Value
Hemoglobin 13,6 13 16 g/dl
White blood cells 8,100 5.000 10.000 u/l
Hematocrit 40 40 48 %

Platelet count 484.000 150.000 390.000 /ul

Pneumonia
A Atelectasis upper lung dextra
Hospitalization 6th day
IVFD RL 500cc/12jam
Inj. Cefotaxime 2 x 250 gr
Paracetamol syr 4x1 ots
Ambroxol 3x0,5 cth.
Salbutamol Inhalation 3 x 2,5 mg

January 27th 2017, 7th day of hospitalization.

S Fever (-), Nausea (-), Vomit (-), Malaise (+), Stomachache (-)

12
 Cough (+) sputum (+), cold (-), minimum breatheless (+)
Spontaneous bleeding (-)
Decreased appetite(+)
Defecation and miksi normal
Consciousness : Compos Mentis
General condition : Midly ill
Temperature : 37,2 C
Pulse :120 x/min
Respiratory rate : 28 x/min
Head : Normocephal
Eyes : Pale conjungtiva (-), icteric sklera (-)
O
Mouth : Dry lips, dry mucous, tonsils T1/T1,
hyperemia pharynx (-)
Pulmonary : Retraction (-), Vesicular +/+ rhonchi +/+, wheezing -/-
Cardio : S1/S2 normal regular, murmur (-), gallop (-)
Abdomen : Epigastric pain (+), Distention (-),
bowel sound (+) normal, shifting dullness (-)
Extremity : Warm, CRT <2 seconds
Pneumonia
A Atelectasis upper lung dextra
Hospitalization 7th day
IVFD RL 500cc/12jam
Inj. Cefotaxime 2 x 250 gr
P Paracetamol syr 4x1 ots
Ambroxol 3x0,5 cth.
Salbutamol Inhalation 3 x 2,5 mg

January 28th 2017, third day of hospitalization, 8th day of illness

Fever (-), Nausea (-), Vomit (-), Malaise (+), Stomachache (-)
Cough (-) sputum (-), cold (-), minimum breatheless (+)
S Spontaneous bleeding (-)
Decreased appetite(+)
Defecation and miksi normal
O Consciousness : Compos Mentis

13
 General condition : Midly ill
Temperature : 37,2 C
Pulse :120 x/min
Respiratory rate : 28 x/min
Head : Normocephal
Eyes : Pale conjungtiva (-), icteric sklera (-)
Mouth : Dry lips, dry mucous, tonsils T1/T1,
hyperemia pharynx (-)
Pulmonary : Retraction (-), Vesicular +/+ rhonchi +/+, wheezing -/-
Cardio : S1/S2 normal regular, murmur (-), gallop (-)
Abdomen : Epigastric pain (+), Distention (-),
bowel sound (+) normal, shifting dullness (-)
Extremity : Warm, CRT <2 seconds
Pneumonia
A Atelectasis upper lung dextra
Hospitalization 8th day
Cefixime 2 x 50 gr
P
Ambroxol 3x0,5 cth.

14
 CHAPTER 2
FOLLOW UP POST OPNAME

FOLLOW UP AT HOME
January 29th 2017
Fever (-), Nausea (-), Vomit (-), Malaise (+), Stomachache (-)
Cough (-) sputum (-), cold (-), minimum breatheless (-)
S Spontaneous bleeding (-)
Decreased appetite(+)
Defecation and miction normal
Consciousness : Compos Mentis
General condition : Midly ill
Temperature : 36.8 C
Pulse :124 x/min
Respiratory rate : 26 x/min
Head : Normocephal
Eyes : Pale conjungtiva (-), icteric sklera (-)
O
Mouth : Dry lips, dry mucous, tonsils T1/T1,
hyperemia pharynx (-)
Pulmonary : Retraction (-), Vesicular +/+ rhonchi +/+, wheezing -/-
Cardio : S1/S2 normal regular, murmur (-), gallop (-)
Abdomen : Epigastric pain (+), Distention (-),
bowel sound (+) normal, shifting dullness (-)
Extremity : Warm, CRT <2 seconds
A Pneumonia
Atelectasis upper lung dextra

15
 Home Care 1st day
Cefixime 2 x 50 gr
P
Ambroxol 3x0,5 cth.

January 30th 2017

Fever (-), Nausea (-), Vomit (-), Malaise (+), Stomachache (-)
Cough (-) sputum (-), cold (-), minimum breatheless (-)
S Spontaneous bleeding (-)
Decreased appetite(-)
Defecation and miction normal
Consciousness : Compos Mentis
General condition : Midly ill
Temperature : 36.7 C
Pulse :118 x/min
Respiratory rate : 30 x/min
Head : Normocephal
Eyes : Pale conjungtiva (-), icteric sklera (-)
O
Mouth : Dry lips, dry mucous, tonsils T1/T1,
hyperemia pharynx (-)
Pulmonary : Retraction (-), Vesicular +/+ rhonchi +/+, wheezing -/-
Cardio : S1/S2 normal regular, murmur (-), gallop (-)
Abdomen : Epigastric pain (+), Distention (-),
bowel sound (+) normal, shifting dullness (-)
Extremity : Warm, CRT <2 seconds
Pneumonia
A Atelectasis upper lung dextra
Home Care 2nd day
Cefixime 2 x 50 gr
P
Ambroxol 3x0,5 cth.

January 30th 2017

S Fever (-), Nausea (-), Vomit (-), Malaise (+), Stomachache (-)
Cough (-) sputum (-), cold (-), minimum breatheless (-)
Spontaneous bleeding (-)
Decreased appetite(-)

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 Defecation and miction normal
Consciousness : Compos Mentis
General condition : Midly ill
Temperature : 36.5 C
Pulse :126 x/min
Respiratory rate : 28 x/min
Head : Normocephal
Eyes : Pale conjungtiva (-), icteric sklera (-)
O
Mouth : Dry lips, dry mucous, tonsils T1/T1,
hyperemia pharynx (-)
Pulmonary : Retraction (-), Vesicular +/+ rhonchi +/+, wheezing -/-
Cardio : S1/S2 normal regular, murmur (-), gallop (-)
Abdomen : Epigastric pain (+), Distention (-),
bowel sound (+) normal, shifting dullness (-)
Extremity : Warm, CRT <2 seconds
Pneumonia
A Atelectasis upper lung dextra
Home Care 3rd day
Cefixime 2 x 50 gr
P
Ambroxol 3x0,5 cth.

January 31th 2017

Fever (-), Nausea (-), Vomit (-), Malaise (+), Stomachache (-)
Cough (-) sputum (-), cold (-), minimum breatheless (-)
S Spontaneous bleeding (-)
Decreased appetite(-)
Defecation and miction normal
O Consciousness : Compos Mentis
General condition : Midly ill
Temperature : 36.7 C
Pulse :120 x/min
Respiratory rate : 228 x/min
Head : Normocephal
Eyes : Pale conjungtiva (-), icteric sklera (-)
Mouth : Dry lips, dry mucous, tonsils T1/T1,

17
 hyperemia pharynx (-)
Pulmonary : Retraction (-), Vesicular +/+ rhonchi +/+, wheezing -/-
Cardio : S1/S2 normal regular, murmur (-), gallop (-)
Abdomen : Epigastric pain (+), Distention (-),
bowel sound (+) normal, shifting dullness (-)
Extremity : Warm, CRT <2 seconds
Pneumonia
A Atelectasis upper lung dextra
Home Care 5th day
Cefixime 2 x 50 gr
P
Ambroxol 3x0,5 cth.

CONTROL AT PEDIATRIC POLICLINIC AT RS BHAYANGKARA Tk.1 R.

SAID SUKANTO
February 1st 2017
Fever (-), Nausea (-), Vomit (-), Malaise (+), Stomachache (-)
Cough (-) sputum (-), cold (-), minimum breatheless (-)
S Spontaneous bleeding (-)
Decreased appetite(-)
Defecation and miction normal
O Consciousness : Compos Mentis
General condition : Midly ill
Temperature : 36.8 C

18
 Pulse :128 x/min
Respiratory rate : 25 x/min
Head : Normocephal
Eyes : Pale conjungtiva (-), icteric sklera (-)
Mouth : Dry lips, dry mucous, tonsils T1/T1,
hyperemia pharynx (-)
Pulmonary : Retraction (-), Vesicular +/+ rhonchi +/+, wheezing -/-
Cardio : S1/S2 normal regular, murmur (-), gallop (-)
Abdomen : Epigastric pain (+), Distention (-),
bowel sound (+) normal, shifting dullness (-)
Extremity : Warm, CRT <2 seconds
A Post opname Pneumonia, and Atelectasis upper lung dextra
P Ambroxol 3x0,5 cth.

19