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7/23/2019 Case Presentation BP
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Case Presentation
Bronchopneumonia Preceptor: dr. Ulynar Marpaung, Sp.A
Presenter: Julianti Mulya Utami - 11020101!
DEPARTMENT OF PEDIATRIC
RADEN SAID SUKANTO POLICE CENTER HOSPITAL
FACULTY OF MEDICINE YARSI UNIERSITY
PERIOD DECEMBER !"#hMARCH $ MEY %&r' %(!)
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∗ Name : FAH
∗ Birth Date : October 10th 2014
∗ Age : 6 months∗ Gender : Male∗ Address : eta!ang"M#n$#l∗ Nationalit% : &ndonesia
∗ 'eligion : &slam∗ Date o( admission : A!ril 4th 201)∗ Date o( e*amination: A!ril +th 201)
Patient Identity
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,arents &dentit% Father Mother
Name Mr- . Mrs- M
Age 2+ %ears old 2) %ears old
Job /ntre!rene#r Ho#sei(e
Nationality aanese aanese
Religion &slam &slam
Education High 3chool grad#ated5s High 3chool grad#ated5s
Earning/month A!!ro*imatel% '!-2-000-000"
Address eta!ang"M#n$#l-
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∗ Alloanamnesis (rom !atient7s mother on thedate o( admission" A!ril 4th 201)-
History Taking
Chief complain:• 8o#gh since ) da%s be(ore admission to the hos!ital-
Additional complains: • F e 2 e r 4 9 5 " s h o r t n e s s o ( b r e a t h " 2 o m i t -
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3 day before hospitaladmission, the
patient’s mother saidthat the child still
fever even she got
febrifuge.
5 days beforehospital admission,the child got fever
and cough.
n the !dmissionHospital "ay, the
child #as still feverishand there are
shortness of breath.
History of Present Illness
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haryngitis/!onsil
itis
" #acillary
$ysentry
"
Bronchitis Amoeba D%sentr%
,ne#monia Diarrhea
Morbilli .h%!oid
,ert#ssis ;orms
<aricella 3#rger%
Di!hteria Brain 8onc#ssion
Malaria Fract#re
,olio Dr#g 'eaction
/nteritis
History f Past Illness
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∗!ntenatal care
!ntenatal check ups performed at the doctor
in the hospital. There #as no problemsduring pregnancy.
∗ $o maternal illness during pregnancy
∗"rugs consumption%
&itamins every antenatal care
,renatal Histor%
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∗ 'abor % Hospital
∗ (irth attendants % doctor
∗ )ode of delivery % pervaginam
∗ *estation % 3+ #eeks
∗ Infant state % healthy
∗ (irth #eight % 3-- grams
∗ (ody length % 5- cm
∗ !ccording to the mother, the baby started to cry and the
babys skin is red, no congenital defects #ere reported
Birth Histor%
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∗/0amination by mid#ife
∗The state of the infant%
healthy
,ost Natal Histor%
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∗ First dentition: 6 months
∗ ,s%chomotor deelo!ment∗ Head =! : 1 month old
∗ 3mile : 1 month old
∗ >a#ghing : 1 2 month old
∗
3lant : 2") months old∗ 3!eech &nitiation : 4 months old
∗ ,rone ,osition : 4 months old
∗ Food 3el( : ) ? 6 months old
∗ 3itting : 6 months old
∗ Mental 3tat#s: Normal
∗ 8oncl#sion: Groth and deelo!ment stat#s is still inthe normal limits and as a!!ro!riate according to the
!atient7s age
Development History
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#reast Mil% E&clusi'ely ( month))
Form#la mil@ 1
Bab% bisc#itsBisc#its milna
Fr#it and egetables Banana" 8arrots
History of /ating
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*mmuni+ation Fre,uency !ime
#C- 1 time 1 month old
.epatitis # times 0" 1" 6 months old
$! times 2" 4" 6 months old
olio 4 times 0" 2" 4" 6 months
old.ib times 2" 4" 6 months old
Immuni2ation History
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∗ ,atient7s both !arents ere married hen the% ere26 %ears old and 24 %ears old" and this is their rstmarriage-
∗ .here are not an% signicant illnesses or chronicillnesses in the (amil% declared-
amily History
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Histor% o( her brothers
Childbirth -ender Age
Age $ied umption
$ied
pontan
per'aginam0
gestationaterm
-irl
1 years
2
monthsold
" "
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∗There is no one living around their homekno#n for having the same condition as
the patient.
History of the disease people around the patient
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∗ The patient lived at the house #ith si2e 4-m 0 - m together #ith
father and mother.
∗ There are door at the front side, toilet near the kitchen and 3
rooms, in #hich room is the bedroom of three of them and
room is for guest. There are #indo#s inside the house. The
#indo#s are ocassionaly opened during the day.
∗ Hygiene%
∗ The patient changes his clothes everyday #ith clean clothes.
∗ (ed sheets changed every t#o #eeks.
6osial and /conomic History
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∗ Date :April 1th 3452
∗ -eneral tatus
∗ General condition: mild ill∗ Aareness : 8om!os Mentis∗ ,#lse : 12 *Cmin" reg#lar" (#ll" strong-∗ Breathing rate : 6*Cmin∗ .em!erat#re : +"+o8 !er a*illa5
Physical /0amination
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Antropometry tatus
∗ ;eight : " @ilogram∗ Height : 0 cm
Physical /0amination 7cont’d8
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N#tritional 3tat#s basedN8H3 National 8enter (orHealth 3tatistics5 %ear
2000:;FA Weight for Age5:"C") * 100 E E good n#trition5HFA Height (or Age5:0C6+ * 100 E 102 E
good n#trition5;FH ;eight (or Height5:")C * 100 E +) Enormal5
Conclusion: The patient
has good nutritionalstatus.
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• Head $ormocephaly, hair 7black, normal distributon, not easily removed 8 sign oftrauma 718, large fontanelle closed.
• /yes Icteric sclera -/-, pale con9unctiva 1:1, hyperaemia con9unctiva 1:1 , lacrimation1:1, sunken eyes 1:1, pupils 3mm:3mm isokor, "irect and indirect lightresponse ;;:;;
• /ars $ormal shape, no #ound, no bleeding ,secretion or serumen
• )outh 'ips%Teeth%)ucous%Tongue%
Tonsils% Pharyn0%
dryno cariesmoist $ot dirty
T:T, $o hyperemiahyperemia
• $eck 'ymph node enlargement 718, scrofuloderma 718
6ystematic Physical /0amination
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!hora& *nspection:
ymmetric 6hen breathing 0 no retraction0 ictuscordis is not 'isible
,al!ation: mass 5" tactile (remit#s 9C9
,erc#ssion: sonor on a l#ng
A#sc#ltation8or :,#lmo:
reg#lar 3132" m#rm#r 5" gallo! 5esic#lar 9C9" ;heeing C " 'honch% 9C9
Abdomen :&ns!ection : 8one*" e!igastric retraction 5" there is no a idening o(
the eins" no s!ider nei-
,al!ation : s#!!le" lier and s!leen not !al!able" I#id ae 5"
abdominal mass 5
,erc#ssion: .he entire eld o( t%m!anic abdomen" shi(ting d#llness 5
A#sc#ltation: normal boel so#nd" br#it 5
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An#s Hole intact" no mass seeno#t o( the an#s
/*tremities arm" ca!illar% rell timeJ 2 second" edema5
3@in Good t#rgor
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.ematology Results Normal 7alue
.aemoglobin 10 gCd> 116 gCd>
8eu%ocytes 11-)00CK> )"000 ?
10"000CK>
.ematocrits 0 E 40 ? 4+ E
!rombocytes 6)-000C K> 1)0"000 ?
400"000CK>
Erythrocytes 4"0
millionCK>
4 ? ) millionCK>
Laboratory InvestigationHematology (April 4th 2015
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∗ A 6 months old child came to ,olri Hos!ital
ith a chie( com!lain o( co#gh since ) da%sbe(ore admission-
∗ Feer 95" shortness breath" omit-
'/3=M/
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∗ Hematolog% April 4th 2015
'es#me--
.ematology Results Normal 7alue
.aemoglobin 10 gCd> 116 gCd>
8eu%ocytes 11-)00CK> )"000 ? 10"000CK>
.ematocrits 0 E 40 ? 4+ E
!rombocytes 6)-000C K> 1)0"000 ?
400"000CK>
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∗ (ronchopneumonia
∗ "": (ronkiolitis
!"#$I%& DIA&%"'I'
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∗O2 1>Cm∗ &<FD '> )0cc C 24 Ho#rs-∗ &n$- 8e(ota*ime 2*)0 mg &<∗ &n$- De*amethasone * 1 mg &<∗
,8. s%r#! *0"6 cc∗ &nhalation :
∗ Bisolon dro!s tice a da%∗ Na8l 1 cc
A%A&))%*
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∗ <uo ad vitam % dubia ad bonam
∗ <uo ad functionam % dubia ad bonam
∗ <uo ad sanactionam% dubia ad bonam
+#"&%"'I'
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∗ !pril 4-5 = !pril + 4-5.
Follo =!
April 2th 3452 econd day of hospitali+ation )th day of
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Fe'er 9;
hlegm 9;$efecation 9"; < times
= General condition: 8om!os mentis-
Heart rate 110 *Cmin
'es!irator% rate 24*Cmin
.em!erat#re L8
8ardio : 31C32" reg#ler" no m#rm#r" no gallo!
,#lmonar% : esic#ler 9C9" rhonchi C" heeing C
A Deng#e Haemoragic Feer
DDC .h%!oid Feer
− I&" >aen3(, micro drip, 44 dpm ?--cc : 4 Hours.
− In9. @efota0ime 40A-- mg I&
− P@T syrup 30 cth
− Imboost orce 30 cth
− !ntasida syrup 3 0 cth
−
@heck full blood test
April 2th 3452) econd day of hospitali+ation0 )th day ofillness
H t l A il +th 2015
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.ematology Results Normal 7alue
.aemoglobin 12 gCd> 116 gCd>
8eu%ocytes -600CK> )"000 ? 10"000CK>
.ematocrits 0 E 40 ? 4+ E
!rombocytes )+-000C K> 1)0"000 ? 400"000CK>
Hematology April +th 2015
April 5>th 3452 !hird day of hospitali+ation (th day of
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Fe'er 9;
hlegm 9;
$efecation 9"; < times
= General condition: 8om!os MentisHeart rate 120 *Cmin'es!irator% rate 24*Cmin
.em!erat#re +-)L88ardio : 31C32" reg#ler" no m#rm#r" no gallo!
,#lmonar% : esic#ler 9C9" rhonchi C" heeing C 3@in: &ns!ection: ,etechiae 95 hands and legs
A Deng#e Haemoragic Feer
− I&" >aen3(, micro drip, 44 dpm ?--cc : 4 Hours.
− In9. @efota0ime 40A-- mg I&
− Paracetamol syrup 30 cth
− Imboost orce 30 cth
− !ntasida syrup 3 0 cth
− @heck full blood test
April 5>th 3452) !hird day of hospitali+ation0 (th day ofillness
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.ematology Results Normal 7alue
.aemoglobin 12 gCd> 116 gCd>
8eu%ocytes -600CK> )"000 ? 10"000CK>
.ematocrits 0 E 40 ? 4+ E
!rombocytes 2-000C K> 1)0"000 ? 400"000CK>
Hematology !pril Bth 4-5
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Fe'er 9;
hlegm 9;
= *eneral condition% @ompos mentis.Heart rate C - 0:min
Despiratory rate C 4?0:min
Temperature C 3AE@
@ardio % 6:64, reguler, no murmur, no gallop
Pulmonary % vesiculer ;:;, rhonchi 1:1, #hee2ing 1:1
6kin% Inspection% Petechiae 7;8 hands and legs
A Deng#e Haemoragic Feer
− I&" >aen3(, micro drip, 44 dpm ?--cc : 4 Hours.
−In9. @efota0ime 40A-- mg I&
− Paracetamol syrup 30 cth
− Imboost orce 30 cth
− !ntasida syrup 3 0 cth
− @heck full blood test
April 34th 3452) Fourth of hospitali+ation0 th day of illness
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.ematology Results Normal 7alue
.aemoglobin 12 gCd> 116 gCd>
8eu%ocytes -600CK> )"000 ? 10"000CK>
.ematocrits 6 E 40 ? 4+ E
!rombocytes +6-000C K> 1)0"000 ? 400"000CK>
Hematology !pril Bth 4-5
A!ril 35th 3452 Fifth days of hospitali+ation @th day of
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Fe'er 9";0 ?ea%ness 9;
= General condition: com!os mentis
Heart rate 100 *Cmin'es!irator% rate 26*Cmin
.em!erat#re 6-2L88ardio : 31C32" reg#ler" no m#rm#r" no gallo!,#lmonar% : esic#ler 9C9" rhonchi C" heeing C
3@in: ,etechiae 95 hands and legs
A Deng#e Haemoragic Feer − Patient may go home
−
!ff I&" >aen3(, micro drip, 44 dpm ?--cc : 4 Hours.− Paracetamol syrup 30 cth
− Imboost orce 30 cth
− !ntasida syrup 3 0 cth
A!ril 35th 3452) Fifth days of hospitali+ation0 @th day ofillness
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.ematology Results Normal 7alue
.aemoglobin 12 gCd> 116 gCd>
8eu%ocytes -600CK> )"000 ? 10"000CK>
.ematocrits 4 E 40 ? 4+ E
!rombocytes 111-000C K> 1)0"000 ? 400"000CK>
Hematology !pril Bth 4-5
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'iterature Devie# and "iscussion
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Denition
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/tiology
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,atho!h%siolog%
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8linical Mani(estation
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3tages o( He!atic /nce!halo!ath%
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Diagnosis
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>aborator% Findings
. t t
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.reatment
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,rognosis
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