Case Report

By : Winda Sofvina Nim. 0508111054 Supervisor: dr. Riza Yefri Sp.A

Senior clerkship-Departement of Pediatric FK UR- RSUD AA 2012

background
Pneumonia is an infection of one or both lungs which

is usually caused by bacteria, viruses, or fungi Pneumonia is the leading cause of death in children worldwide Pneumonia is the single largest cause of death in children worldwide. Every year, it kills an estimated 1.4 million children under the age of five years

definition
Pneumonia is a form of acute respiratory infection that

affects the lungs. When an individual has pneumonia, the alveoli are filled with pus and fluid, which makes breathing painful and limits oxygen intake

Etiology
Pneumonia is caused by a number of infectious agents,

including viruses, bacteria and fungi.

The most common are:

Streptococcus pneumoniae the most common cause

of bacterial pneumonia in children; Haemophilus influenzae type b (Hib) the second most common cause of bacterial pneumonia; respiratory syncytial virus is the most common viral cause of pneumonia;

pathophysiology
Pneumonia develops when foreign matter such as viruses,

bacteria, parasites, or fungus enters the lungs and causes inflammation. There are also chemicals that can enter the lungs and cause pneumonia. Additionally, an injury to the lungs may cause pneumonia, but it is much less common. Once this foreign matter enters the body, it provokes a response of the immune system. After that, the person's oxygen levels begin to deplete and he or she begins to breathe faster.

Clinical Manifestation

Cough, Grunting, Chest pain, Tachypnea Retractions, Signs of consolidation, Crackles Wheezing , Cyanosis, Abdominal pain

How to diagnose pneumonia

If pneumonia is suspected on the basis of a patient's

symptoms and findings from physical examination, further investigations are needed to confirm the diagnosis. A chest X-ray is usually ordered to confirm the diagnosis of pneumonia A blood test that measures white blood cell count (WBC) may be performed. An individual's white blood cell count can often give a hint as to the severity of the pneumonia and whether it is caused by bacteria or a virus.
An increased number of neutrophils, one type of WBC, is

seen in most bacterial infections,

Differential diagnosis
Chronic obstructive pulmonary disease(COPD) or

asthma similar to that of pneumonia congestive heart failure, bronkhiolitis, lung abscess, emphysema

Risk factor
children whose immune systems are compromised are at higher

risk of developing pneumonia. A child's immune system may be weakened by malnutrition or undernourishment, especially in infants who are not exclusively breastfed. Pre-existing illnesses, such as symptomatic HIV infections and measles, also increase a child's risk of contracting pneumonia. The following environmental factors also increase a child's susceptibility to pneumonia:
indoor air pollution caused by cooking and heating with biomass

fuels (such as wood or dung) living in crowded homes parental smoking.

Treatment
Pneumonia can be treated with antibiotics.
These are usually prescribed at a health centre or

hospital, but the vast majority of cases of childhood pneumonia can be administered effectively within the home. Hospitalization is recommended in infants aged two months and younger, and also in very severe cases.

Complication
Pleuritis
Empyema Pneumothorax

Lung abscess
pericarditis

Name Age Father/mother Address

: S, female : 4 years 3 months : Mr. H dan Mrs. M : Pekanbaru

Chief complaint : Shortness of breath since 1 days before admitted

History
Since 9 day before admission, the patient had a fever

that appear suddenly, high fever, shortness of breath (),seizures (-), nausea (-), vomiting (), abdominal pain (-), cough (-), cold (-), pain on swallowing (-), spots on skin (-), the patient felt pain in the joints, there was no defecation and mixturition complaints, the appetite was decreased, and the patient was taken to general practitioner and given medicine for fever, but after 4 days of taking the drug, patient did not recover.

 5 day before admission, patient had a shortness of

breath, cyanotic lips (-), cyanotic extremities (-), there was no wheezing, chest pain (-), the shortness of breath was not reduced when the patient sit. The fever was still continue and patient returned to general practitioner and are asked to do routine blood examination. Patient went to Santa Maria Hospital to check the blood, and from the result, patient are recommended to be hospitalized. patient were hopitalized for 2 days. The family did not know what drugs was given during hospitalization.

 1 day before admission, the shortness of breath was

worsening, the fever continues, there was joint pain, then the patient admitted to the AA General Hospital emergency room and hospitalized in pediatric ward. In the ward, patient was nebulized 3 times in one day. After 3 days of hospitalization, the shortness of breath gets worse, patient felt difficult to eat and drink, so that the patient had a nasal feeding tube installed, then moved to Pediatric Intensive Care Unit.

 patient hospitalized in PICU for 2 days, the condition

was improved, the shortness of breath was decreased, and patient returned to pediatric ward.

Past illness history

6 months ago,the patient had a typhoid fever, and

was given chloramphenicol, then the patient had a skin exfoliation, the general practitioner said that the patient had chloramphenicol allergy. There was no history of cough.

Family illness history

There was no similar complaints History Parents Patient's father worked as an enterpreneur and the patient's mother was a housewife.

Pegnancy and birth history

There was no serious illnesson pregnancy and mother never take drugs, jamu, and there was no smoke and alcohol history.
The gestational age was 9 month, the labour was assisted by midwife. Birth weight 3300 grams. The mother control her pregnancy every month (on midwife).

Food And Drink History

patient are breastfed since birth untill 2 years.
patient often loss appetide.

 Immunization history : no immunization

History Of Physical Growth : according to the age History Of Mental Growth : according to the age

 General appearance: moderate illness Awareness: composmentis

BP T pulse RR weight height Nutritional state

: 100/70 mmHg : 36,6 oC : 120 x/i : 60 x/i : 14 kg : 100cm : 87,7% mild malnutrition

 Head

and eye lid Skin : cyanosis(-), jaundice (-), petechie (-) Hair : normal Eyes : palpebra edema(+/+), anemic conjunctiva (-/-), sclera jaundice (-/-), pupil isochor +/+, light reflex + / + Ears : normal Nose : Nostril breath (+), discharge (-), deformity(-)

: simmetric, normocefal, edema in face

 Lip

: cyanosis (-), wet (+) Mucus membrane: wet (+) Palate : whole, pharyngeal hiperemis (-) Tongue : normal Teeth : normal Lymph nodes : enlarged (-) Stiff neck :-

 THORAX : Lungs: Inspection symmetrical chest movements left and right, retraction (+)intercostal, supraclavicular Palpation :Right = Left fremitus percussion at both lung fields : dull Auscultation: fine crackles wet + / +, wheezing - / Kardiovaskuler:

Inspection : ictus cordis(-) palpation palpable ictus Cordis RIC V, 1 finger medial LMCS Percussion Limits the right heart: RIC V LSD Limit of the left heart: RIC VI LMCS medial fingers Auscultation : normal heart sounds heart , murmur (-), gallop (-) : normally

ABDOMEN

 GENITALIA

female, normally
EXTREMITY

Symmetric, pale (-), warm acral, CRT<2 Oedem foot and arms (+)

Laboratory examination
Urin makroskopis: Warna : kuning Kejernihan : agak keruh
Mikroskopis urin: Eritrosit : -/LPB Leukosit : -/LPB Epitel : 2-4/LPB Kristal : Silinder : Bakteri : 0/LPK Jamur :0

Routine blood
Hb: 8,2 gr/dl
Ht : 23,5% Leukosit : 25.700 Neutrofil 85,5%, Lymfosit 10,5%, Monosit 2,6%, Eosinofil 1,1 %, Basofil 0 %

Shift to the left

Trombosit : 477.000

 Cor : normally Lung : pneumonia

IMPORTANT THINGS OF ANAMNESIS

Fever 9 days since before admitted, cough (-

), spots on skin (-)

5 days before admission, patient had a shortness of breath,

cyanotic lips (-),cyanotic extremities (-), and chest pain (-)

after 3 days of hospitalization at the pediatric ward, the

shortness of breath get worse, continuous fever, the patient felt difficult on eating and drinking, so that the patient had a nasal feeding tube installed.

IMPORTANT THINGS OF PHYSICAL EXAMINATION

Nostrils breathing, intercostal and supraclavicular

retractions
smooth wet crackles + / + dull sound on both lung

 Important thing of laboratory finding : leukocytosis :

shift to the left

Ro thorax : pneumonia

Working Diagnosis
pneumonia

MANAGEMENT
- Medikamentosa IVFD D5NS 12 tpm Paracetamol 3x 1 cth Ceftriakson 2x750mg Kalmetason 20mg /8 jam O2 3l/menit
Diit 1260 kkal

 15 Maret 2012 S : short of breath (+), fever (+) O : Nostrils breathing, intercostal and

supraclavicular retractions

BP : 100/70 mmHg Pulse : 126 x/menit Temperature : 38,6C RR : 62x/menit

A P

: Pneumonia : IVFD D5NS 12 tpm, Paracetamol 3x cth, Injeksi Ceftriakson 2x750mg, Injeksi Kalmetason 20mg /8 jam, O2 3l/menit

 16 Maret 2012 S : sesak (+), demam (+), batuk (-) O : nafas cuping hidung (+), retraksi intercosta (+),

ronkhi +/+ Tekanan darah : 100/70 mmHg Nadi : 126 x/menit Temperature : 38,6C Napas : 62x/menit A : Pneumonia P : IVFD D5NS 12 tpm, Paracetamol 3x cth, Injeksi Ceftriakson 2x750mg, Injeksi Kalmetason 20mg /8 jam, O2 3l/menit

 17 Maret 2012 S : sesak (+), demam (+), batuk (-) : nafas cuping hidung (+), retraksi intercosta (+), ronkhi +/+ BP : 100/70 mmHg Pulse : 126 x/menit Temperature : 38,6C RR : 64x/menit A : Pneumonia P : IVFD D5NS 12 tpm, Paracetamol 3x cth, Injeksi

Ceftriakson 2x750mg, Injeksi Kalmetason ampul /8 jam, O2 3l/menit

: Consul to the cardiology department to do echocardiography

 18 Maret 2012 S : short of breath (+), fever (+) O : Nostrils breathing, intercostal and supraclavicular

retractions

BP Pulse Temperature RR

: 100/70 mmHg : 126 x/menit : 38,6C : 62x/menit

: Pneumonia
Echocardiography : pericarditis

: IVFD D5NS 12 tpm, Paracetamol 3x cth, Injeksi Ceftriakson 2x750mg, Injeksi Kalmetason 20mg /8 jam, O2 3l/menit

19 Maret 2012 S : sesak (+) berkurang , demam (+), batuk (+) O : nafas cuping hidung (+), ronkhi +/+ Tekanan darah : 100/70 mmHg Nadi : 120 x/menit Temperature : 37,2C Napas : 54x/menit A : Perikarditis P : over to pediatric cardiology

Discussion
The diagnosis of pneumonia was based on history, physical

examination and investigation. From the anamnesis, the patient had a fever since 9 days before admission, shortness of breath since 5 days admission, there was no history of shortness of breath previously. There was no wheeze breathing sound, the appetite was decreased, in literature, this was symptoms of pneumonia . Symtomps of pneumonia was high fever, accompanied by shortness of breath, the literature stated that the patient suffering pneumonia, although this patient had no symptoms of cough

 From physical examination there was nostrils

breathing, RR was 60 times /minute. There was supraclavicular and intercostal retractions, dull sound at percussion and there was wet crackles sound on both lung. Nostrils the breathing, chest wall retraction, and fine crackles was a symptomp of pneumonia as stated in literature.

 Routine blood Exam. Shown that high level of

leucocyte and there was shift to the left. The WBC increased in neutrophil count and from xray imaging match with pneumonia. In theory, the leukocytosis, increased the number of leukocytes (morethan 10.000/mm3) sometimes reaching 30.000/mm3), which indicates the presence of infection or inflammation. Leukocyte counts "shift to the le ft". But in 20% of patient there was no leukocytosis. Thoracic PA X-Ray was the primary workup investigation for diagnosis.

 in this case, pneumonia occurred in children who did

not get any immunization. This was stated on the literature that the prevention strategies to reduce morbidity and mortality due to pneumonia was immunization.

 On literature, the pneumonia, supplemental

oxygenation should be administered. This can be given through nasal canule, In these patient are given 3 liters per minute with a pulse Oxymetry. This was appropriate with the literature, but the patient was not monitored with a pulse oxymetry because there was no oxymeter in the pediatric ward.

 Antibiotics are the primary treatment of

pneumonia. The selection of antibiotic and duration of treatment depends on the suspect organism. This patient was given ceftriaxone 750 mg / 12 hours. This was stated in the literature that the antibiotic of choice in pneumonia were 3rd generation sefalosforin (cefotaxim, ceftriakson, ceftazi dim, cefuroksim) given intravenously at a dose of 50100 mg / kg im / iv 1-2 times / day (ceftriakson).

 The management of these patient was intravenous

fluids D5NS 12 drops per minute (macro drop). As stated in literature that adequate fluids and calories (if necessary parenteral fluid). Appropriate amount of fluid weight gain, and hydration status. This patient had a regular diet.

 Altough

the patient had taken ceftriaxone the shortness of breath was not decreased. In this case, other possible causes shortness of breath including from heart. Then patient take echocardiography, and the result was found that patient had a pericarditis. This sign can occur in patient with pneumonia, because the complication of pneumo nia is pericarditis.

Thank You