bronkopneumoni

Dr. irman permana Sp.A

Akroman

Name : An. Faza

Age : 5 mount
Gender : boy
Religion : islamic
Address : bekasi

 Main complain :dispnea

History of present illnes:
Patient has been hospitaled in room
anyelir with complain dispnea, from
mother explanation patient has been
feel dispnea from 5 days ago. Dispnea
occour suddenly, and then Get worse.

Dispnea accompanied with high body temperature

and cough with phlegm. This complain appear 5
days ago with the dispnea. Patient feel weak and lost
appetite.
Past medical history
Patient never have same complain before
Family medical history
No same complain in the family

 Treatment History
Patient never have a treatment
growth and development history
in age 5 month patient can do prone
position
immunization history
Hepatitis, BCG, polio

 Gestation history
- mother do a routine ANG
examination
- mother don't have a abnormality or
disease when in gestation perioid
Childbirth history
Baby born with sectio caesar surgery
Baby born with Weight 3100 gram

 Food and drink History

ASI
Social and economy history
Solid House environment

physical examination
Common Condition : look moderate pain
awareness composmentis
Vital sign
Heart rate : 120 x/minute
Respiration : 40 x/minute
Temperature : 35,8 C
Weight : 10 kg
Height :

 Head : normocephal
Hair : black, straight, smooth
distribution,
hard to pull
Ear: simetris, otorrhea (-)
Nose : rinorrhea
Mouth : stomatitis (-)
Lips : sianosis (-)

 Thorax :
cor
Inspection: lectus cordis
Palpation : normality
Percution: normality
Auscultation: heart sound 1= 2 regular
pulmo
Inspection: breathing movement simetric
Palpation : simetrical breathing
Percution: sonor
Auscultation: vascular, creackles +/+, slem -/-, wh -/-

 Abdomen
Auscultation: intestine sound (+)
Inspection: flat stomatch, massa(-)
Palpation :
Percution: timpani

 Extremity
No odema
No abnormality

differential Diagnose
Bronkopneumoni
Bronkiolitis

supporter inspection
Laboratory: routine blood
Rontgen : photo thorax

treatment

Infusion
Cefotaxim 50mg/kgBB/hari I.V
Paracetamol 10mg/kgBB/x
Nebu combiv