lapkas anak febi c3-4

8/10/2019 Lapkas Anak Febi c3-4

1/17

16

CHAPTER 3

CASE REPORT

Name : Baby BC

Age : 2 months

Sex : Female

Date of Admission : March, 6th2013

Chief Complaint : Dyspnea

History :This has been happening to the patient since ten days ago,

shortness of breath not related to the activities (nursing) or weather.

Cough (+) has been experienced since five days ago, phlegm (+).

Fever (-), history of fever (+), high fever, fever decreased with fever medicines,

chills (-), seizures (-).

History of choking (+) has been experienced two weeks ago before cough and

dyspnoe, milk came out from nose.

History of vomiting (-).

History of contact with an infected person coughs long was denied.

History of pregnancy; the mother was thirty years old when pregnant, history of

recurrent fever(-), hypertension (-), diabetes mellitus (-), maternal age G4P3A1,

taking drugs (-), taking herbs (-),control routine of ANC (+).

History of birth; spontaneous, helped by midwife, crying soon after born (+),

bluish (-), infant birth weight not clear,injection of vit.K (+).

History of feeding : 0-2 months of breastfeeding.

Immunization : BCG (+),Polio I(+)

History of previous illness: patientwas referral from RSU Pakpak Barat ,Dx:

pertusiss + Leukositosis

History of previous medications: Eritromicyn 4x 8 mg, Injection cefotaxim 250

mg/iv, IVFD 4:1 gtt /i


2/17

17

Physical Examination

General ized status

Body weight: 4,6kg, Body length: 56 cm, Head circumtance 37 cm.

BW/BL: -2 < Z score < + 2 (normal)

BW/age:-2 < Z score < + 2 (normal)

BL/age : -2 < Z score < + 2 (normal)

Head circumtance : -2 < Z score < + 2 (normal)

Presens status

Sens.Compos Mentis, Body temperature: 37oC,Score down 3

Anemic (-). Icteric (-). Cyanosis (-). Edema (-). Dyspnea (++).

Locali zed status

Head :

Bulging Fontanella open flat,paleness inferior palpebra conjunctiva (-/-). Icteric

sclera (-). Light reflex (+/+). Isochoric pupil. Ear/Mouth: within normal limit.

Nose:Nostril breathing (+).

Neck: Lymph node enlargement (-).

Thorax: Symmetrical fusiformis. Chest retraction (+)epigastrial, intercostal. HR:

118 bpm, reguler, murmur (-). RR: 80x/i, reguler.Crackles (+/+) .

Abdomen:

Soepel.Peristaltic (+) normal.Liver/Spleen/Renal undeterminate.


3/17

18

Extremities:

Upper extremities: Pulse 110x/i, regular, adequate pressure and volume,

warmacral, CRT < 2.

Lower extremities: oedem (-/-)

Urogenital:

Female, in normal range.

Differential Diagnosis

- Bronchopneumonia

- Pertussis

Working Diagnosis:

- Bronchiolitis

Management:

- Bedrest

-

O2 nasal canul1 L/i

- IVFD D5% NaCl 0,225% 10 gtt/i micro

- Inj. Ampicilin 250 mg / 8 hours/intravenous

-

Inj. Gentamycin 25 mg /24 hours/ intravenous

- Diet breastfeeding 60cc/ 3 hours/ NGT


4/17

19

Laboratory Results 6th

March 2013

Parameters Value Normal Value

Complete Blood Count

Hemoglobin 9,60 % 10,717,1 gr%

Hematocrite 29,00% 3852%

Erithrocyte 3,30 x 10 /mm 3,754,95 x 10 /mm

Leucocyte 42,53 x 10 /mm 6,017,5 x 10 /mm

Platelet 812.000 /mm 217.000497.000 /mm

MCV 96,00 fl 93115 fl

MCH 29,10 pg 2935 pg

MCHC 32,10 gr% 2834 gr%

RDW 16,00 % 14,918,7 %

Diftel

Neutrofil 47,10 % 37-80

Limfosit 41,80 % 20-40

Monosit 10,70 % 2-8

Eosinofil 0,30 % 1-6

Basofil 0,100 % 0-1

Neutrofil Absolut 20,04 x 10 / L 1,9- 5,4

Limfosit Absolut 17,78 x 10 / L 3,7-10,7

Monosit Absolut 4,54 x 10 / L 0,3-0,8

Eosinofil Absolut 0,11 x 10 / L 0,20-0,50

Basofil Absolut 0,06 x 10 / L 0-0,1

Glucose Metabolism

Blood Glucose ( sewaktu) 105,00 mg/dl < 200 mg/dl

Blood Gas Analysis Test

PH 7,391 7,35-7,45

pCO2 38,9 mgHg 38-42 mgHg

pO2 126,6 mmHg 85-100 mmHg

Bicarbonate (HCO3) 23 mmol/L 22-26 mmol/L


5/17

20

Total CO2 24,2 mmol/L 19-25 mmol/L

BE -1,7mmol/L (-2)(+2) g/dL

Saturation O2 98,9 % 95-100%

Anemia: Normositik Normokrom + Leukositosis

WHO Growth Chart Base on Weight for age Girls Birth to 5 years

Baby BC 2 months 4,9kg 56 cm

BW/age: -2 < Z score < + 2 (normal)


6/17

21

Chest Radiograph Baby BC from PakPak Barat Hospital

From this AP chest radiograph figure infiltrate in both of lung field.


7/17

22

FOLLOW UP

March7t

, 2013

Dyspnea(+), fever (-)

Sens: CM, Temp: 37oC. Anemic (-), Icteric (-), Dyspoe (+), Edema (-), Cyanosis (-).

Body weight: 4,9 kg, Body length: 56 cm. BW/BL: -2 < Z score < + 2 (normal)

Head Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra

inferior (-/-).

Ear/Mouth: within normal limit

Nose: nasal flare (+)

Thorax Simetris fusiformis. Retraction (+)epigastrial, intercostal . HR: 120 bpm,

reguler. Murmur (-).

RR: 80 x/i, regular. Additional sound: (+). Crackles (+/+) at both lungfields..

Abdomen Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.

Extremities Pulse 120 x/i, regular, adequate p/v, warmacral, CRT < 2.

Genital Female, in normal range.

Suspect Bronchopneumonia + Sepsis

Management:

- O2 nasal canul1 L/i


-

Inj. Ampicilin 250 mg / 8 hours/intravenous

- Inj. Gentamycin 25 mg /24 hours/ intravenous

-

Diet breastfeeding 60cc/ 3 hours/ NGT

March8th

, 2013

Dyspnea(+), fever (-)

Sens: CM, Temp: 37,2 oC. Anemic (-), Icteric (-), Dyspoe (+), Edema (-), Cyanosis (-).


Head Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebrainferior (-/-).





RR: 52 x/i, regular.Additional sound: (+). Crackles (+/+) at both lung

fields.



Genital Female, in normal range,

Suspect Bronchopneumonia + Sepsis


8/17

23

Management:

-

O2 nasal canul1 L/i

-

IVFD D5% NaCl 0,225% 10 gtt/i micro

- Inj. Ampicilin250 mg per 8 hours/intravenous (D2)

-

Inj. Gentamycin 25 mg per 24 hours/ intravenous (D2)


- Nebule Nacl 0,9 % 2,5 cc / 8 hours

Plan :

- Consult Pediatric Sub-Division of respirology

-

Physiotherapy- Septic Workup ( CRP, Blood culture,procalcitonin)

Laboratorium Results (8th

March 2013)

PARAMETER Value Normal range

Imunoserologi

Autoimmune

CRP Kualititatif

negative

Other Test

Procalcitonin

0,17 ng/ml >0,05

>0,5 ng/ml low risk of septic shock


9/17

24



Thorax Simetris fusiformis. Retraction (+)epigastrial, intercostal . HR: 104 bpm,reguler. Murmur (-).


fields..




Modul of Respirology : DD.Bronchopneumonia/ bronchiolitis

Management:


-


- Injection Dexa 0,8 mg/8 hours/iv

- Nebule Nacl 0,9 % 2,5 cc + ventolin 1 resp/8 hours

-

Inj. Ampicilin250 mg per 8 hours/intravenous (D3)

- Inj. Gentamycin 25 mg per 24 hours/ intravenous (D3)


Plan:

-

Consult Pediatric Sub-Division of respirology-

Physiotherapy

March 10t

, 2013

Dyspnea (+), fever (-) (+), fever (-)

Sens: CM, Temp: 36,7oC. Anemic (-), Icteric (-),Cyanosis (-).



inferior (-/-).



Thorax Simetris fusiformis. Retraction (+)epigastrial, intercostal . HR: 100 bpm,reguler. Murmur (-).


fields..




DD.Bronchopneumonia/ bronchiolitis

Management:


-



10/17

25






March 10t

, 2013

Dyspnea (+), fever (-)



Head Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebrainferior (-/-).






fields..




DD.Bronchopneumonia/ bronchiolitisManagement:






-

Inj. Gentamycin 25 mg per 24 hours/ intravenous (D4)

-


March 11th

, 2013





inferior (-/-).




11/17

26



RR: 54 x/i, regular.Additional sound: (+). Crackles (+/+) at both lungfields..




DD.Bronchopneumonia/ bronchiolitis

Management:

- O2 nasal canul 1-2 L/i

-



-

Nebule Nacl 0,9 % 3 cc + ventolin 1 resp/8 hours



-


Chest Physiotherapy has been done.

March 12nd

, 2013


Sens: CM, Temp: 36,8oC. Anemic (-), Icteric (-),Cyanosis (-).Body weight: 4,9 kg, Body length: 56 cm. BW/BL: -2 < Z score < + 2 (normal)


inferior (-/-).






fields..




Dd.Bronchopneumonia/ bronchiolitis


12/17

27

Management:

-

O2 nasal canul -1 L/i

-



-

Nebule Nacl 0,9 % 3 cc + ventolin resp/8 hours



-


March 13t , 2013


Sens: CM, Temp: 37oC. Anemic (-), Icteric (-),Cyanosis (-).

Body weight: 5 kg, Body length: 56 cm. BW/BL: -2 < Z score < + 2 (normal)


inferior (-/-).




reguler. Murmur (-).RR: 54 x/i, regular.Additional sound: (+). Stridor(+/+).


Extremities Pulse 56x/i, regular, adequate p/v, warmacral, CRT < 3.


Bronchiolitis

Management:

- O2 nasal canul -1 L/i


-





Plan :

- Consult Pediatric Sub-Division of Cardiology ( screening), Hematology, Infection

(Suspect Pertussis)

- Azithromicyn 2 x 40 mg


13/17

28

Laboratory Results 13th

March 2013

Parameters Value Normal ValueComplete Blood Count

Hemoglobin 10,70 % 10,717,1 gr%

Hematocrite 34,00 % 3852%

Erithrocyte 3,70 x 10 /mm 3,754,95 x 10 /mm

Leucocyte 30,59 x 10 /mm 6,017,5 x 10 /mm

Platelet 208.000 /mm 217.000497.000 /mm

MCV 91,60 fl 93115 flMCH 28,80 pg 2935 pg

MCHC 31,50 gr% 2834 gr%

RDW 19,00 % 14,918,7 %

Diftel

Neutrofil 50,90 % 37-80

Limfosit 45,40 % 20-40

Monosit 2,80 % 2-8Eosinofil 0,80 % 1-6

Basofil 0,100 % 0-1

Neutrofil Absolut 15,57 x 103/ L 1,9- 5,4

Limfosit Absolut 13,88 x 103/ L 3,7-10,7

Monosit Absolut 0,85 10 / L 0,3-0,8

Eosinofil Absolut 0,24 x 10 / L 0,20-0,50

Basofil Absolut 0,04 x 10 / L 0-0,1-

March 14t

, 2013


Sens: CM, Temp: 36,9oC. Anemic (-), Icteric (-).

Body weight: 5 kg, Body length: 56 cm. BW/BL: -2 < Z score < + 2 (normal)


inferior (-/-).




14/17

29



RR: 54 x/i, regular.Stridor (+/+) .Abdomen Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.



Bronchiolitis

Management:

-

O2 nasal canul -1 L/i

- IVFD D5% NaCl 0,225% 4gtt/i micro

-

Injection Dexa 0,8 mg/8 hours/iv

-




- Inj.Ceftiaxone 250/12 hours/ivSkin test

- Azithromicyn 2 x 40 mg


Visite dr. Wisman Dalimunthe, Sp.A (K):

-

Inj. Dexa 0,5 mg/8 hours/ iv (tapp.off)

- Nebule Nacl 0,9 % 3 cc/ 8 hours

- Cek CBC, repeated AGDA

Answer Consult:

Consult Pediatric Sub-Division of infection :

Diagnose :

- Clinis : Cough ShrillredCyanosis, vomiting (+)

-

Lab : Leukositosis, ELISAserum Ig G,Ig M,Ig A- DD: Spasmodik CoughBronchiolitis , Pertusis Like cough

Th/ Appropriate with Pediatric Sub-Division of respirology

Suggestion: Imunisasi on schedule

Consult Pediatric Sub-Division of respirology :

Thorax : Simetris fusiformis. Retraction (+)epigastrial, intercostal . HR: 124 bpm,


RR: 60 x/i, regular.Stridor (+/+) .

Abdomen :Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.


15/17

30

Extremities :Pulse 124 x/i, regular, adequate p/v, warmacral, CRT < 3.

A: Bronchiolitis + Suspect Pertusis


16/17

31

CHAPTER 4

DISCUSSION AND SUMMARY

4.1.Discussion

Baby BC, a 2 months old girls, with body weight of 4,9 kg, and body height of

56cm, was admitted to the Pediatric Infection Unit of Haji Adam Malik General

Hospital on March 6th2013 ,with chief complain of havingshortness of breath/

dyspnea. The shortness of breath started since ten days ago. Shortness of breath

not related to activity (nursing) and weather. Cough (+) has been experienced

since five days ago, phlegm (+), fever (-). History of fever (+) has been

experienced, high fever (-), fever decreased with fever medicines. Physical

assessment: Chest retraction (+) epigastrical intercostal, nasal flare, crackles (+) in

early,stridor (+/+).This patients while diagnose of bronchiolitis.

Bronchiolitis is a viral lower respiratory tract infection (VlRI) in a child 90 %. Continuous monitoring is recommended if

supplemental oxygen is required. If supplemental oxygen is not needed, every 4

hour oxygen saturation monitoring may be used.Infants with bronchiolitis are

mildly dehydrated because of decreased fluid intake and increased fluid losses

from fever and tachypnea. Due to that situation, it is vital to maintain adequate

hydrationandthe fluid for this patient is IVFD D5% NaCl 0,225% 4 gtt/i micro,

and diet breastfeeding 60cc/ 3 hours/ NGT.


17/17

32

Nebule with three cc of NaCl 0,9% combine with cc ventolin to help the

mucus secretion each day every eight hours to clear the airway. Dexamethasone

with dosage of 0.8 mg intravenously each eight hours as an immunosuppresive to

reduce the secretion of IgE that has a role for the patophysiology bronchiolitis.

Ampicillin injection with a dosage of 250 mg per eight hours via intravenous,

Gentamycin injection 25 mg per 24 hours via intravenous, Inj.Ceftiaxone 250 per

twelve hours via intravenous, and Azithromicyn 40 mg twice is given to anticipate

the bronchiolitis infection that cause by other viruses or secondary infection by

bacteria .

4.2 Summary

A case was reported about a two months old girls with five kg of body weight

and 56 cm of body length. Who was admitted in peadiatrics infection ward in

RSUP Haji Adam Malik on 6thMarch 2013 with the diagnose of Broncholitis. The

patient was diagnosed based on history taking,physical examination The teraphy

that was given for her was based on empiric antibiotics and supportive treatments.

lapkas anak febi c3-4

Documents