Siska

I4061152014
Consultant : dr. Hilmi K Riskawa, Sp. A, M. Kes
 M,a 4 months 20 days, female toddlers,
medical record number 127745,
hospitalized in Dahlia room of Kartika
Husada for four days from Nov 7th 2017 –
Nov 10th 2017.
 Chief complaint: Dyspnoea
± 3 days before admission: dyspnoea
appeared slowly and get worsening
everyday.
 ± 7 days before admission: in the first two
days, patient got dry cough and cough
become productive in days 3 and get
worsening everyday.
 ± 5 days before admission: Fever got high
gradually and in full one day fever can go
down until normal temperature.
 ± 3 hours before admission: inability to
breast feed and drink milk.
± 7 days before admission: Rhinorrhea got
worsening everyday and sometimes patient
felt difficult to breathe from nose, and
started to breathe from mouth.
 ± 4 days before admission: left eye became
red and patient commonly rubbing her
eyes. When patient wake up in the morning,
patient eyes always difficult to open
because of the mucopurulent discharge. The
next day the right eye also got red.
 Patient never had dyspnoea before.
 Patient had never been hospitalized until now.
 History of taking antipiretic and mucolitic drugs
but patient wasn’t improved.
 Patient’s mom has same complaint such as cough,
rhinorrhea and red eye ± 3 days before patient
got sick.
 History of growth and development are
appropriate to her age, vaccination appropriate
to government vaccination schedule, and breast
feeding mixed with feeding milk.
General Condition :
 General appearance : Moderate sick, irritable
 Consciousness : Compos mentis
Anthropometric
 Weight : 6,6 kg
 Height : 64 cm
Nutrition Status based on (WCGS, 2007) :
 Weight for age : +1 > z > 0
 Length for age : 0 > z > -1
 Weight for length : +1 > z > 0
Vital Sign :
 Heart rate : 138 bpm, strong in palpable
 Respiratory rate : 52 bpm
 Temperature : 37,2oC
 Pulse Oximetry : 98% without O2
 Head : Normocephaly
 Eyes : Anemic conjunctiva (-/-), Icteric sclera (-/-),
sunken eyes (-/-), discharge (+/+), conjunctiva
injection (+/+), conjunctival bleeding (+/+)
 Ear : discharge (-/-), hyperemic auricula (-/-)
 Nose : discharge (+/+), hyperemic nasal mucosa
(-/-)
 Mouth : dry mucosa (-)
 Throat : Hyperemic pharynx (-/-), tonsil T2/T2,
crypta (-), detritus (-)
 Neck : Lymph node enlargement (-)
 Thorax : simetric (+), subcostal and substernal
retraction (+)
 Anterior lung :
- Inspection : chest wall shape and expansions
simmetryc
- Palpation : vocal fremitus right = left
- Percussion : Sonor right = left
- Auscultation : Breath sound bronchovesicular, rhoncii
(+/+) at all region, wheezing (+/+) at all region
 Posterior lung :
- Inspection : chest wall shape and expansions
simmetryc
- Palpation : vocal fremitus right = left
- Percussion : Sonor right = left
- Auscultation : Breath sound bronchovesicular, rhoncii
(+/+) at all region, wheezing (+/+) at all region
 Cor : regular heart sound, murmur (-), gallop (-)
 Abdomen :
- Inspection : Looks flat, Supple, there is no mass
- Auscultation : bowel sounds (+) normal
- Percussion : Tymphani
- Palpation : Liver and spleen are not palpable,
tenderness (-), shifting dullness (-), decrease of
skin turgor (-)
 Extremity : warm (+/+), capillary refill time < 2
seconds, cyanosis (-), edema (-)
 Pulmonal Score : 4 (RR: 52 bpm, substernal and
subcostal retraction (+), wheezing (+) during
expiration)
Date: November 7th 2017
 Leukocytes : 7.900 /mm3 (Normal : 6.000-15.000 /mm3)
 Hemoglobines : 11,9 g/dl (Normal : 10,5-14,0 g/dl)
 Hematocrit : 37,1 % (Normal : 33-42%)
 Trombocytes : 352.000 /mm3(Normal : 150.000-400.000/mm3 )
 Limphocytes (%) : 61,3% (Normal : 15-50%)
 Granulocytes (%) : 30,8% (Normal : 35-80%)
Differential diagnosis
 Bronchopneumonia
 Bronchiolitis
 Pertussis

 Bacterial conjunctivitis
 Viral conjunctivitis
 Allergy conjunctivitis

Working diagnosis
 Bronchopneumonia
 Bacterial conjunctivitis
 Intra Venous Fluid Drop Ringer Lactate 20
drops per minute micro
 Inj. Ampicillin 4 x 300 mg I.V (D1)
 Inj. Dexamethasone 3 x 0,2 cc I.V (D1)
 Inj. Paracetamol 3 x 60 mg I.V
 Nebuliser salbutamol 1 resp + 0,5 cc
bromhexin every 8 hours
 Dexamethasone 0,1%, Neomycin sulphate
3,5 mg, Polymyxin B sulphate 6000 IU/ml 3 x
1-2 gtt ODS (D1)
 8th November 2017, 07.00 A.M
S : Decrease of dyspnoea (+), breasfeeding (-), feeding formula milk (+),
Fever (-), free of fever for 12 hours ago. Decrease of cough with discharge
(+), occasionally coryza (+).
O : General condition : moderate illness
RR : 48 bpm, HR: 153 bpm, T : 36,6oC, Pulse oxymetry : 98% without
oxygen, Weight : 6,6 kg
General state:
Eye : decrease of conjunctival injection (+/+), conjungtival bleeding (+/+)
Nose : Discharge (+/+)
Thorax : Simetrical (+), substernal dan subcostal retraction (+)
Pulmo anterior et posterior : bronchovesicular breath sound (+/+),
rhonchii (+/+) at all right lung regio and left basal lung, wheezing (+/+) at
all regio
A: Bronchopneumonia and bacterial conjunctivitis
P : Nebuliser salbutamol 1 amp + 0,5 cc bromhexin every 8 hours ->
Nebuliser salbutamol 1 amp + 0,5 cc bromhexin combine with salbutamol
and ipratropium bromide 1 amp + 0,5 cc bromhexin every 6 hours
Other therapy continue
 9th November 2017, 07.00 A.M
S : Decrease of dyspnoea (+) from yesterday, breasfeeding (+),
feeding formula milk (+), Fever (-), free of fever for 7 hours ago.
Decrease of cough with discharge (+), coryza (-).
O : General condition : moderate illness
RR : 52 bpm, HR: 138 bpm, T : 36,8oC, Pulse oxymetry : 97% without
oxygen, Weight : 6,6 kg
General state:
Eye : decrease of conjunctival injection (-/-), conjungtival bleeding
(+/+)
Nose : Discharge (-/-)
Thorax : Simetrical (+), subcostal retraction (+)
Pulmo anterior et posterior : bronchovesicular breath sound (+/+),
rhonchii (+/+) at all basal lung, wheezing (-/-)
A: Bronchopneumonia and bacterial conjunctivitis
P : Continue therapy
 10th November 2017, 07.00 A.M
S : Dyspnoea (-), breasfeeding (+), feeding formula milk (+),
Fever (-), free of fever for 1 days 7 hours ago. Decrease of cough
with discharge (+), coryza (-).
O : General condition : mild illness
RR : 52 bpm, HR: 132 bpm, T : 36,9oC, Pulse oxymetry : 99% without
oxygen, Weight : 6,6 kg
General state:
Eye : conjunctival injection (-/-), conjungtival bleeding (-/-)
Nose : Discharge (-/-)
Thorax : Simetrical (+), retraction (-)
Pulmo anterior et posterior : bronchovesicular breath sound (+/+),
rhonchii (-/-), wheezing (-/-)
A: Bronchopneumonia and bacterial conjunctivitis
P : Allow to discharge, control at outpatient clinic next week
 P.O Amoxiclav syrup 3 x 2 ml
 P.O Eldorstein syr 2 x 2 ml
 Ad Vitam : Dubia ad bonam
 Ad Functionam : Dubia ad bonam
 Ad Sanactionam : Dubia ad bonam
 Bronchopneumonia
 Bacterial conjunctivitis
 Dyspnoea has so many differential
diagnosis in toddlers under 2 years.
 Pneumonia, bronchiolitis andpertussis
are the most common etiology of
dyspnoea in toddlers patient.
 Pneumonia is defined as a lower respiratory
tract infection (LRTI) typically associated
with fever, respiratory symptoms, and
evidence of parenchymal involvement by
either physical examination or the presence
of infiltrates in chest radiography
 Bronchiolitis signs and symptoms are
typically rhinitis, tachypnea, wheezing,
cough, crackles, use of accessory muscles,
and/or nasal flaring. Presence of
hyperinflation and occasionally air
entrapment in chest radiography.
 Pneumonia and bronchiolitis has many
similar symptoms and signs that
somehow difficult to differentiate.
 From the chest radiography, we found
some infiltrates in both of lung and
hyperinflation (-).
 Conclusion : Pneumonia
 Conjunctivitis is an inflamatory process that
involves the conjunctiva but not cornea.
Conjunctivitis characterized by dilation of
vessels, cellular infiltration, and exudation.
 Bacterial conjunctivitis in toddlers has many
symptoms and signs such as reddened eyes
caused by conjunctival injection and
conjunctival bleeding, production
mucopurulent to purulent discharge, lid
crust, and infection got bilateral eye.
 Causative therapy
 Pneumonia : From WHO guideline the first line
therapy for severe pneumonia is ampicillin 50
mg/kgBB each 6 hours and can be given
intamuscular or intravenous.
 Bacterial conjunctivitis : From AAP guidelines,
two of many antibiotics that can be use against
baterial conjunctivitis in toddlers and childrens
are neomycin sulphate 3,5 mg/mL and
polimyxcin B sulphate 6000 IU/mL . Patient also
got dexamethasone 0,1% for inhibit inflamatory
reponse from neomycin sulphate that can cause
chemical conjunctivitis.
Symptomatic therapy
 Fluid maintenance and IV line access
 Antipiretic drug (paracetamol/
acetaminophen)
 Nebuliser with salbutamol +bromhexin
and combine with salbutamol +
ipratropium bromide + bromhexin
 Corticosteroid (Dexamethasone)
Complications :
 Pneumonia : pleural effusion, empyema,
lung abscess, and pneumothorax
 Bacterial conjunctivitis : keratitis and
periorbital cellulitis
THANK YOU