CASE REPORT

Zainul - James
 LAPORAN KASUS 1

 IDENTITAS PASIEN
Nama : An. D
Usia : 3 bulan
Jenis Kelamin : laki-laki
Alamat : Bojonegoro
 PEDIATRIC ASSESSMENT TRIANGLE

•Appearance
Tonus: Baik
Interactiveness: baik
Consolability: gelisah
Look/Gaze: kontak mata adekuat
Speech/cry: menangis kuat
•Breathing
Bebas
RR: 58 x/menit, reguler, kedalaman cukup
NCH (-) dan retraksi otot bantu nafas (-)
Vesikuler, ronki (+), wheezing (+)
•Circulation
N: 122 x/menit, reguler, cukup
S : 36,8°C
Akral hangat, CRT < 2”

•Kesan : terdapat kegawat daruratan di bidang breathing

 Sesak sejak tadi malam jam 18.30 (19-3-2017)
Sesak terus-menerus awalnya sesak ringan malam jam
2.00 sesak memberat disertai rewel. Sebelum sesak
didahului batuk berdahak (+) sejak 3 hari yll. Dahak
warna kuning batuk ngekel sampai tidak bisa tidur
Semakin hari batuk semakin memberat. Mulut membiru (-
). Panas sejak hari jumat malam, sumer-sumer
Bab cair ± 6-8 kali sejak hari jumat sore cair
campur ampas ± ¼ gelas aqua tiap berak, ada serat
merah Lendir 1x saat hari jumat saja Bau anyir (-) kuning,
Bak biasa, lancar kuning Ma/min asi berkurang
• RPD
Belum pernah sakit seperti ini sebelumnya
• RPK
Nenek riwayat punya penyakit sesak nafas
• RPO
Sabtu dibawa ke dokter umum diberi puyer dan
parcetamol (keluhan tidak membaik). Senin pagi
dibawa ke di bawa ke klinik senori diberi obat 3 macam
keluhan tidak membaik, kemudian di bawa ke PKM
senori dan dirujuk
 PEMERIKSAAN FISIK

[O] Keadaan Umum: sedang Kesadaran: Alert

• RR : 58 x/menit GCS : E4 V5 M6
• Nadi : 122 x/menit
• Suhu : 36,3 oC

• Kepala/Leher: anemis/icterus/cyanosis/dispneu , Pch -/-/-/-/-

Faring hiperemi (-) Pembesaran KGB (-)

• Thoraks: Cor : A : S1 dan S2 normal , m (-) g (-)

• Pulmo : I: retraksi intercosta (-), gerak dada simetris

A : Vesikuler +/+, Rhonki+/+, Wheezing +/+
 PEMERIKSAAN FISIK

•Abdomen :
Inspeksi : Distended (-)
Auskultasi : bising usus (+) >
Perkusi : timpani, meteorismus (-)
Palpasi : soepel, hepatosplenomegali (-)
splenomegali (-) nyeri tekan (-)
•Ekstremitas :
Akral HKM
CRT < 2 detik
Edema (-)
 ASSESSMENT
• Pneumonia
• Diare akut
 TERAPI
• O2 nasal 4 lpm
• Inf KAEN 3B 900cc/24jam
• Inj ceftriaxon 2x150mg
• Inhalasi fentolin 1amp dalam 8cc PZ 3x1

• Planning diagnosis
• DL, Foto Thoraks PA ,lateral
 Hasil Satuan Nilai Rujukan
Darah Lengkap
Hemoglobin 10,2 g/dL 11.0-15.0
Leukosit 10,7 10^3/μL 5.0-12.5
Eritrosit 4,02 10^6/μL 4.10-5.50
Hematokrit 29,4 % 34.0-45.0
MCV 74,1 fL 73.0-91.0
MCH 25,4 pg 24.0-30.0
MCHC 34,2 g/dL 32.0-37.0
RDW-CV 12,9 % 11.5-14.5
RDW-SD 34 fL 35-47
Trombosit 504 10^3/μL 150-400
PDW 9,7 fL 9.0-13.0
MPV 8,7 fL 7.2-11.1
P-LCR 15,8 % 15.0-25.0
PCT 0.440 % 0.150-0.400
 Hasil Satuan Nilai Rujukan
Hitung Jenis
Eosinofil 0,3 % 0-3
Basofil 0.4 % 0-1

Neutrofil 62,4 % 32-52

Limfosit 30,4 % 30-60
Monosit 6,5 % 2-8
Elektrolit
Na 146 mEq/L 139-146
K 5.9 mEq/L 4.1-5.3
Cl 104 mEq/L 98-107
 PNEUMONIAE
• Pneumonia is an infection of the lower respiratory tract
that involves the airways and parenchyma with
consolidation of the alveolar spaces.
 PATOPHISIOLOGY
The lower respiratory tract is normally kept sterile
by physiologic defense mechanisms, including
mucociliary clearance, the properties of normal
secretions such as secretory immunoglobulin (Ig) A, and
clearing of the airway by coughing. Immunologic
defense mechanisms of the lung that limit invasion by
pathogenic organisms include macrophages that are
present in alveoli and bronchioles, secretory IgA, and
other immunoglobulins. Trauma, anesthesia, and
aspiration increase the risk of pulmonary infection.
 Viral pneumonia usually results from spread of
infection along the airways, accompanied by direct
injury of the respiratory epithelium, which results in airway
obstruction from swelling, abnormal secretions, and
cellular debris. The small caliber of airways in young
infants makes such patients particularly susceptible to
severe infection. Atelectasis, interstitial edema, and
ventilation–perfusion mismatch causing significant
hypoxemia often accompany airway obstruction. Viral
infection of the respiratory tract can also predispose to
secondary bacterial infection by disturbing normal host
defense mechanisms, altering secretions, and modifying
the bacterial flora.
 Bacterial pneumonia most often occurs when
respiratory tract organisms colonize the trachea and
subsequently gain access to the lungs, but pneumonia
may also result from direct seeding of lung tissue after
bacteremia. When bacterial infection is established in
the lung parenchyma, the pathologic process varies
according to the invading organism. M. pneumoniae
(see Chapter 223) attaches to the respiratory epithelium,
inhibits ciliary action, and leads to cellular destruction
and an inflammatory response in the submucosa. As the
infection progresses, sloughed cellular debris,
inflammatory cells, and mucus cause airway obstruction,
with spread of infection occurring along the bronchial
tree, as it does in viral pneumonia.
 S. pneumoniae produces local edema that aids in
the proliferation of organisms and their spread into
adjacent portions of lung, often resulting in the
characteristic focal lobar involvement.
Group A streptococcus infection of the lower
respiratory tract results in more diffuse infection with
interstitial pneumonia. The pathology includes necrosis of
tracheobronchial mucosa; formation of large amounts of
exudate, edema, and local hemorrhage, with extension
into the interalveolar septa; and involvement of
lymphatic vessels and the increased likelihood of pleural
involvement.
 S. aureus pneumonia manifests in confluent
bronchopneumonia, which is often unilateral and
characterized by the presence of extensive areas of
hemorrhagic necrosis and irregular areas of cavitation of
the lung parenchyma, resulting in pneumatoceles,
empyema, or, at times, bronchopulmonary fistulas.
 CLINICAL
MANIFESTATIONS
• Pneumonia is frequently preceded by several days of
symptoms of an upper respiratory tract infection,
typically rhinitis and cough
• In viral pneumonia, fever is usually present but
temperatures are generally lower than in bacterial
pneumonia.
• Tachypnea
• intercostal, subcostal, and suprasternal retractions,
nasal flaring, and use of accessory muscles is common
• Severe infection may be accompanied by cyanosis
and lethargy, especially in infants
• Auscultation of the chest may reveal crackles and
wheezing
• Bacterial pneumonia in typically begins suddenly with
high fever, cough, and chest pain
 DIAGNOSIS
• An infiltrate on chest radiograph (posteroanterior and lateral
views)
• Viral pneumonia is usually characterized by hyperinflation
with bilateral interstitial infiltrates and peribronchial cuffing
• Confluent lobar consolidation is typically seen with
pneumococcal pneumonia
• The radiographic appearance alone is not diagnostic, and
other clinical features must be considered.
• ultrasonography is highly
• sensitive and specific in diagnosing pneumonia in children by
determining lung consolidations and air bronchograms or
effusions
• 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/mm3,
with a lymphocyte predominance.
• Bacterial pneumonia is often associated with an
elevated WBC count, in the range of 15,000-
40,000/mm3, 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. Reliable DNA or
RNA tests for the rapid detection of many respiratory
pathogens, such as mycoplasma, pertussis, and viruses,
including RSV, parainfluenza, influenza, and
adenoviruses, are available and accurate
• The definitive diagnosis of a bacterial infection requires
isolation of an organism from the blood, pleural fluid, or
lung.
TREATMENT
 TREATMENT
• Treatment of suspected bacterial pneumonia Amoxicillin is
recommended.
• Therapeuticn alternatives include cefuroxime axetil and
amoxicillin/clavulanate
• infection with M. pneumoniae
• or C. pneumoniae is suggested, a macrolide antibiotic such
as azithromycin is an appropriate choice
• If viral pneumonia is suspected, it is reasonable to withhold
antibiotic therapy, especially for those patients who are
mildly ill, have clinical evidence suggesting viral infection,
and are in no respiratory distress. However, up to 30% of
patients with known viral infection, particularly influenza
viruses, may have coexisting bacterial pathogens