PNEUMONIA

By :
Febriyanti Farida, S.Ked
NIM. I1A007019

Preceptor :
Dr. dr. Moh. Isa, Sp.P

SMF/Pulmonology Departement
Medical Faculty UNLAM/RSUD Ulin
Banjarmasin
May, 2014


Case Report
INTRODUCTION
Pneumonia: One Of Acute Lower Respiratory Tract
Infections Are Common Clincher (In Primary Or Secondary
Phase Manifestation of Other Lower Respiratory Tract
Infection)


Number 6 Cause of Death in Indonesia (SEAMIC Health
Statistics 2001)


Sometimes The Cause is Difficult to Found and Needed
Time For Getting a result, While Pneumonia Can Cause
Death if Not Treated Immediately.
REFERENCE
DEFINITION :
Regarding the pulmonary parenchyma inflammation
clincher, Distal Part of the terminal bronchioles and
respiratory bronchioles clincher Includes alveoli, And
Potential Consolidation Lung Networks and Local Gas
Exchange Disorders
PATOGENESIS
Infection Lung Epithelial Damage By MO. By the
way:
1. Direct Inoculation
2. Spread Through Blood Vessels
3. Inhalation Aerosol Composition
4. Colonization of Mucosal Surfaces On
PATOLOGY
Basil Entered With Secretions Into The Alveoli
Cause an Inflammatory Reaction In The Form of
The Entire Alveolar Edema Followed By Infiltration
of Polymorphonuclear Cells and Diapedesis of
Erythrocytes Resulting In The Beginning of
Phagocytosis
PATOLOGY
In Time of War Occur Between Host and Bacterial
Will There are 4 Zones In Parasitic Regions are:
1. Outer Zone: The Unfilled Germs alveoli and
edema fluid
2. Starters Consolidation Zone: Consists of PMN
cells and exudation Some Red Cells
PATOLOGI
3. Extensive Consolidation zone: The area where
Phagocytosis That Happened On The Number
PMN
4. Zone Resolution: Resolution Happens Regions
Where many Dead bacteria, leukocytes and
Alveolar Macrophages
CLASSIFICATION
According Clinical dan Epydemiologys :
Community Acquired Pnemonia
Hospital Acquired Pnemonia
Aspiration Pnemonia
Pnemonia on Immuno compromised.

CLASSIFICATION
According to The Etiology :
Bacterial/Typhycal Pneumonia
Atyphycal Pneumonia
Viral Pneumonia
Fungal Pneumonia

According of Infection Predilection :
Lobaris Pneumonia
Bronkopnemonia
Intersitiel Pneumonia

DIAGNOSIS
According :
Complete History of Disease
Careful Physical Examination
Advance Examination
HISTORY OF DISEASE
Fever
Shiver
Increased body temperature can exceed 40 C
Cough with sputum mucoid or purulent sometimes
accompanied by blood
Shortness of breath and chest pain
Factors predisposing patients
The patient's age and the onset to determine the
possibility of germs
PHYSIC EXAMINATION FINDING
Depending on the extent of the lesion in the lung
Late Movement of Thorax Sick Side
Fremitus can be hardened
Percussion dim
Bronkovesikuler until bronchial breath sounds
which may be accompanied by fine wet rales, which
later became wet coarse crackles on the stage of
resolution
Clinical presentation varies depending on the
etiology, age and clinical state of the patient
ADVANCE EXAMINATION FINDING
RADIOLOGICAL
Radiological infiltrates can be up to the consolidation of
the Air broncogram

LABORATORY
Leukocytosis> 10.000/ul sometimes reaching 30.000/ul
Shift To The Left
Improved ESR
Required to Determine Etiology Diagnosis From Sputum
Examination, Blood Culture and Serology.
Blood gas analysis showed hypoxemia and hipokarbia, at
an advanced stage respiratory acidosis can occur.
TREATMENT
It should be noted that the clinical state of the
patient can be assessed by disease severity index
American Thoracic Society (ATS) criteria for severe
pneumonia when encountered 'one or more' criteria below:
Minor criteria as follows:
Respiratory rate> 30/menit
Pa02/FiO2kurang of 250 mmHg
Chest X-ray showed lung abnormalities bilateral
CXR lung involves> 2 lobes
Systolic pressure <90 mmHg
Diastolic pressure <60 mmHg

Major criteria is as follows:
Requires mechanical ventilation
infiltrates increased> 50%
Requires vasopressors> 4 hours (septic shock)
Serum creatinine> 2 mg / dl or an increase> 2 mg / dI, in
patients with a history of kidney disease or kidney failure that
requires dialysis.
PORT SCORE
PORT SCORE
MANAGEMENT
MANAGEMENT
MANAGEMENT
MANAGEMENT
CASE REPORT
THE PATIENT IDENTITY :

Name : Mrs. M
Age : 78 Years Old
Gender : Women
Work : HouseWife
Religion : Islam
Ethnic/Nation : Banjar/Indonesia
Status : Married
Pendidikan : Elementary School
Address : Pekapuran Raya
Hospitalized : February 9
th
2012
MR : 0-97-74-13

ANAMNESIS
HISTORY OF DISEASE :
Chief Complaint : Fever
HISTORY :
Fever 4 Days Before Admission
Cough With Sputum 1 Weeks Before Admission, White Yellow,
Smelling (-)
Short of Breath (+)
Pain (-)
Sweaty on the night (-)
Decreased of body weight (-)
Fainted (+)
Nausea/Vomiting 3 x Containing Food, Today
Eat/Drink (<) Since 1 Weeks Before Admission
Defecation/Miction was Normal
ANAMNESIS
HISTORY OF ILLNESS :
Hypertension (-)
Diabetes Mellitus (-)
Asthma (-)
History of TBC (-)
Cardiac Disease (-)
History of Treatment at PHC and Got Therapy
Dexamethason 3x1, Cefadroxyl 2x500 mg, Vitamin
1x1
Smoke (-)
Alcohol Consumption (-)
ANAMNESIS
Family Illness :
History of Similar DIsease (-)
Diabetes Mellitus (-)
Hypertension (-)
Asthma (-)
History of TBC (-)
PHYSIC EXAMINATION 9/2/2012
General Condition : Moderate Illness
Conciousness : Compos Mentis
Height : 165 cm
Weight : 50 Kg
BMI : 18,3 Kg/m
2

Vital Sign
BP : 110/70 mmHg
HR : 88 x/m
RR : 26 x/m
Temp : 38,5 C
Oxygen Saturation : 98%

PEMERIKSAAN FISIK
Head/Neck
I : Retraction (-), Scars (-), The Right Side was late when
breath
P : Increasing of Right Vocal Fremitus
P : Dullness/Sonor
A : Vesikular simetris, Rh (+/-), Wh (-/-)
See Localic Status
Thoraks
I : Datar, (-), Laseration (-)
A : Bowel Sound (+) Normal
P : Pressure Pain (-) H/L/M Not Palpable, Tenderness (-),

P : Thimpany In All Quadrant
Abdomen
Warm (+), Edema (-/-), Paresis (-/-)
Ekstremities
Eyes : Anemic Konj. (+/+), Icteric Sclera (-/-)
Mouth : Mucosa is Moist
Neck : JVP Within Normal Limit, Lymph Enlargement
(-)
PHYSIC EXAMINATION
Local Status of Thorax :

Late Movement (+)
Rhonchy (+)
Louder VF (+)
Dullness Percussion

CBC FEBRUARY 9
TH
2012
Jenis Pemeriksaan Hasil Nilai Normal Satuan
DARAH
RUTIN
Hb 10,00 12,00-16,00 g/dl
Leukosit 22,1 4,0-10,5 ribu/ul
Eritrosit 3,63 3,90-5,50 juta/ul
Ht 28,93 37,00-47,00 vol%
Trombosit 377 150-450 ribu/ul
RDW-CV 12,2 11,5-14,7 %
MCV 79,8 80,0-97,0 fl
MCH 29,8 27,0-32,0 pg
MCHC 34,5 32,0-38,0 %
HITUNG
JENIS
Gran% 82,5 50,0-70,0 %
Limfosit% 36,8 25,0-40,0 %
MID% 10,1 4,0-11,0 %
Gran# 6,8 2,50-7,00 ribu/ul
Limfosit# 3,1 1,25-4,0 ribu/ul
MID# 1,2 ribu/ul
KIMIA
DARAH
GDS 169 <200 mg/dl
SGOT 27 0-46 U/I
SGPT 23 0-45 U/I
Ureum 13 10-50 mg/dl
Creatinin 0,66 0,6-1,2 mg/dl
ELEKTROLIT Natrium 124 135-146 mmol/l
Kalium 4,2 3,4-5,4 mmol/l
Klorida 96,5 95-100 mmol/l
Albumin 2,8 3,4-4,3 g/dl
THORAX X-RAY FEBRUARY 9
TH
2012
Infiltrate on Right Upper
Field of Pulmo,
Consolidation (+)
Cardiomegaly with CTR
62%

Conclution :
Pneumonia with Cardiomegaly
BLOOD CHEMISTRY FEBRUARY 11
TH
2012
Jenis Pemeriksaan Hasil Nilai Normal Satuan
ELEKTROLIT Natrium 137,5 135-146 mmol/l
Kalium 4,5 3,4-5,4 mmol/l
Klorida 95,4 95-100 mmol/l
Albumin 3,2 3,4-4,3 g/dl
CBC FEBRUARY 14
TH
2012
Jenis Pemeriksaan Hasil Nilai Normal Satuan
DARAH
RUTIN
Hb 11,00 12,00-16,00 g/dl
Leukosit 9,6 4,0-10,5 ribu/ul
Eritrosit 3,75 3,90-5,50 juta/ul
Ht 34,90 37,00-47,00 vol%
Trombosit 456 150-450 ribu/ul
RDW-CV 12,2 11,5-14,7 %
MCV 86.8 80,0-97,0 fl
MCH 28,6 27,0-32,0 pg
MCHC 35,4 32,0-38,0 %
HITUNG
JENIS
Gran% 54,5 50,0-70,0 %
Limfosit% 36,8 25,0-40,0 %
MID% 10,1 4,0-11,0 %
Gran# 6,8 2,50-7,00 ribu/ul
Limfosit# 3,1 1,25-4,0 ribu/ul
MID# 1,2 ribu/ul
KIMIA
DARAH
Albumin 3,7 3,4-4,3 g/dl
ELEKTROLIT Natrium 136,5 135-146 mmol/l
Kalium 4,3 3,4-5,4 mmol/l
Klorida 97,6 95-100 mmol/l
RESUME
Female, 78 Year Old
Fever 4 Days Before Admission
Cought with Sputum, White Yellow 1 Weeks Before
Admission
Short of Breathness (+)
Vomit/Nausea (+)
Anemic Conjunctiva (+/+)
Increasing of Right Vocal Fremitus
Dullness of The Right Side From Thorax Percussion
Rhonchy (+/-)
Leucositosis 22,1 thousand/ul
Thorax X-Ray : Pneumonia
DIAGNOSIS
Severe Pneumonia With Hypoalbumin and
Hyponatremia
THERAPY
Hospitalized
Oxygen 3 lpm Nasal kanul
IVFD NaCl 3% 14 tpm
Levofloxacin 1x1 Flash
Inj. Ondancentron 3x4 mg (IV)
Inj. Antrain amp 3 x 1 (IV)
Inj. Ranitidin amp 2 x 1 (IV)
VIP Albumin 3x1
HCHP Dyet

PROGNOSIS
Dubia ad Bonam
FOLLOW UP
9/2/2012 10/2/2012 11/2/2012 12/2/2012
IVFD NS 3% 14
tpm
Levofloxacin fls
1x1
Ondan 3x1 amp
Antrain 3x1 amp
Ranitidin 3x1
amp
(+) (+) (+) IVFD RL 20 tpm
(+) (+) (+) (+)
(+) (+) (+) (+)
(+) (+) (+) (+)
(+) (+) (+) (+)
Natrium Normal
140 120/70 110/70 120/70 110/70
120 26 x/m 24 x/m 22 x/m 22 x/m
100 38,0 C 39,0 C 39,0 C 38,5 C
80
60 HCHP Dyet HCHP Dyet HCHP Dyet HCHP Dyet
Cough (+) Cough (+) Cough (+) Cough (<)
Fever (+) Fever (+) Fever (+) Fever (+)
Short of Breath
(+)
Short of Breath (+) Short of Breath (<) Short of Breath (<)
Nausea/Vomit
(+/-)
Nausea/Vomit (+/-) Nausea/Vomit (+/-) Nausea/Vomit (+/-)
Eat/Drink (<) Eat/Drink (<) Eat/Drink (<) Eat/Drink (<)
Follow Up
FOLLOW UP
13/2/2012 14/2/2012 15/2/2012
IVFD RL 20 tpm
Levofloxacin fls
1x1
Ondan 3x1 amp
Antrain 3x1 amp
Ranitidin 3x1
amp
(+) (+) PO Levofloxacin 1x1
(+) (+) PO Lanso 2x1
(+) (+)
(+) (+)
(+) (+) Discharge By
Permission
Outpatient
140 110/70 110/70 110/70
120 21x/m 20x/m 18x/m
100 37,5 C 37,0 C 37,0 C
80
60 HCHP Dyet HCHP Dyet HCHP Dyet
Cough (<) Cough (<) Cough (<)
Fever (<) Fever (-) Fever (-)
Short of Breath (-
)
Short of Breath (-) Short of Breath (-)
Nausea/Vomit
(</-)
Nausea/Vomit (-/-) Nausea/Vomit (-/-)
Eat/Drink (<) Eat/Drink (+) N Eat/Drink (+) N
Follow Up
DISCUSSION
Female
78 YO (Geriatry)
High Fever, 39,0 C
Cough, Mukoid Sputum (+)
Short of Breath (+)
Ins : The Right Side of
Thorax was late when take
a breath
Pal : Increasing VF on
the`right side
Percussion : Dullness on
upper right thorax
Aus : Rhoncy (+/-)
Leucositosis 22,1 thousand
Thorax PA : Pneumonia
Baby or >65 YO
High Fever, 39,0 C
Cough, Mukoid Sputum
Short of Breath
Ins : The Sick Side of
Thorax was late when
take a breath
Pal : Increasing VF on
the`sick side
Percussion : Dullness on
sick side
Aus : Rhoncy
Leucositosis, Increasing
ESR
Thorax PA : Pneumonia
Sputum Culture
CASE
THEORY
CONCLUTION : PNEUMONIA
DISCUSSION
From Anamnesis, Physical Examination And Advance
Examination, The Diagnosis Is
Community Acquired Pneumonia :


From Radiologys With 2 Or More Sign : Cough, Characteristic
Change Drom Sputum/Purulent, Temp > 38
0
C (Axila)/History of
Fever, Physical Examination Consolidation Sign, Bronchyal dan
Rhoncy, With Leucocite > 10.000 or < 4500


From Clinical Appearance : Pneumonia Class IV With PORT
Score 100, NEEDED TO HOSPITALIZED
THE OTHER DIAGNOSIS
In this case, From Physical Examination Got Anemic
Conjunctiva (+/+) and From Laboratory Examination Got
Hyponatremia (124 mmol) and Hypoalbuminemia (2,8)


Correct The Condition :
Anemia (10,0 g/dl) -> HCHP Dyet
Hyponatremia -> IVFD NS 3% 14 tpm
Hypoalbuminemia -> HCHP Dyet + VIP Albumin 3x1
DISCUSSION
The Management is Appropriate With The Theory
Which The Patient Needed To Got Supportive dan
Symptomatic Therapy

Levofloxacin (Empiric Antibiotic From PDPI) With
Modification Factor is Cefalosporyn Gen. II, Gen. III
(IV) or Fluoroquinolone IV.

IV Antibiotic Was Stop at Hospitalized Day-6 After
Fever (-), Cough and Short of Breath was
decreased. And After That The IV Antibiotic was
Switch to Oral
DISCUSSION
Dubia ad Bonam -> With Early Diagnosis and
With Adequate Antibiotic Therapy
OCCLUTION
Have been reported cases of women 78 YO with a
diagnosis of severe pneumonia with hyponatremia
and hypoalbuminemia. Patients complained of high
fever since 4 days before admission and cough with
phlegm, shortness of breath. Of physical examination
found the right chest late movement, vocal fremitus
right side hardens, percussion dullness at right side
and the presence of rhonchy. Investigations found a
picture of pneumonia on chest X-Ray and
leukocytosis and hyponatremia and
hypoalbuminemia. Patients admitted to the
pulmonary ward for 6 days with positive responses
and the patient allowed to dischrage by permission
and being outpatient.
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