Friday, April 7th 2017

dr. David /dr. Iqbal

dr. Izni/ dr. Nunki/ dr. Galih /dr. Tatag / dr. Heru
dr. Sekar/dr. Delfia
dr.Eddy /dr. Putri
 Name : H
Sex : Female
Age : 16 y.o.
Address : Klaten
Medical record : 01375409
Weight/Height : 60 kg/150 cm
Lethargic
 Unconscious, severe illness
Vomited (-), fever (-)
Patient got on portable ventilator, SIMV
mode
Intravenous line with dobutamine and
epinephrine (syringe pump)
Urine (-) with DC
Conclusion: history of pregnancy and delivery were
normal
Growth
The patient is 16 years old, 60 kg. Shes well
nourished and normal puberty status.

Development
The patient age is sixteen. Studying in senior
high school. She can adapt well and can
communicate with younger or older people.

CONSLUSION: growth and development

were normal
 BCG : 0 month
Hep B : 0,2,4,6 month
DPT : 1 month
Polio : 2,4,6 month
Measles : 9 month

Conclusion: vaccination history was

appropriate according to Ministry of
Healths Vaccination Schedule 1999
H, 16 y.o
 Weight / age : 60/61 x 100% = 98,36%
(P25<weight/age<P50) normoweight
Height / age : 157/174 x100 % = 90,22%
(height/age < P3)
Severe stunted
Weight / Height : 60/45 x100 % = 133%
(P75<weight/height<P90)
BMI: 60/1,572 = 14,3 (+1SD<z-score<+2SD)
overweight
Conclusion: overweight, normoweight,
severe stunted
General appearance : severe illness, GCS: E4VxM5, on portable
ventilator
VS :
HR 128 x/min RR 30 x/min on ventilator, SiMV mode
Temperature: 36,6C (axilar) SiO2 98%
BP 97/60 mmHg MAP 72.3 mmHg
Head : mesocephal,
Face : moonface (+)
Eyes : anemic conjungtiva -/-, icteric sclera-/-, isochoric pupil,
diameter 2mm/2mm, light reflexs (+/+)
Nose : nasal flares (-), nasal discharge (-)
Mouth : ET tube 7.5Fr
Ears : ear discharge -/-
Neck : lymph node enlargement(-), buffalo hump (-)
Chest :symmetrical in shape and movement, retraction (+)
suprasternal
Cor : I : Ictus cordis not appeared
P : Ictus cordis was palpable
P : heart enlargement (-)
A : heart sounds I-II normal intensity,
regular, murmur(-)

Pulmo:I : right hemithorax = left hemithorax

P: fremitus sounds right = left
P: sonor / sonor
A: bronchial breath sounds +/+ ,
crackles (+/+)
 Abd: I: abdominal wall=chest wall
A: peristaltic sound (+) within normal
P: tympani (+), ascites (+)
P: distended, palpable pain (-), liver and spleen cant
been evaluated, normal skin turgor

Extremity: Edema -/- Cold extremity -/-

-/- +/+
Arteri dorsalis pedis not palpable
Capillary refill time > 2 seconds

Locality status= ulcus (+) in gluteal region, pus (-)

Passive leg raise (PLR) negative
 pH : 7.517
BE : -7.6 mmol/L
PCO2 : 18.9 mmHg
PO2 : 107.5 mmHg
Ht : 32 %
HCO3 : 15,5
Total CO2 : 16,1
O2 Saturation : 98,6 %
Lactac artery : 2,70 mmol/L

Interpretation: alcalosis respiratoric, partial

compensation
Hb 11.9 g/dl
Ht 34%
Erithrocyte 4.0 million/ul
MCV 85.5/um
MCH 29.7 pg
MCHC 34.7 g/dl Conclusion:
Thrombocyte 62 x 10/ul Thrombocytopenia
Leucocyte 5.5 x10/ul Neutrophilia
RDW 15.0 %
Hypoalbuminemia
Hyponatremia
Neutrophyl 83,00% Hypchloremia
Lymphocyte 11.00%
Mono,Eos,Bas 6.00%

Blood glucose 125 mg/dl

Albumin 2.0 g/dl

Sodium 113 mmol/L

Potassium 4.4 mmol/L

Chloride 84 mmol/L
Girl, H, 16 yo, 60 kg with:
1.Nausea
2.Vomited, every time she got meal and drin
3.Runny stool with no mucus no blood
4.Loose her appetite and refused
5.Unconsciuos
6.Lethargic
7.In previous hospital got asering 1000ml
infusion
8.Administered dobutamin and epinephrine iv
8. Severe SLE on therapy 15 month
9. Routine drugs: Cyclophosphamide,
Methylprednisolone, Cloroquine, Captopril
10. Severe illness, GCS E4VxM5, on portable
ventilator
11. Tachycardia
12. Insertion ET tube 7.5Fr
13. Chest retraction (+) suprasternal
14. Pulmo: bronchial bearth sound with crackles in
both lungs
15. Ulcus decubitus in the back
16. Cold extremities, CRT > 2 second, PLR negative
17. Thrombocytopenia
18. Neutrophilia
19. Hypoalbuminemia
20. Hyponatremia
21. Hypochloremia
22. Respiratory alcalosis partial compensated
 Respiratory Failure due to pneumonia
Fluid refractory shock
Severe SLE
Vomitting due to adverse effect of SLE
drugs
Decubitus ulcer grade 1
Hyponatremia
Hypoalbuminemia
Hypochloremia
Overweight
 Respiratory Failure due to pneumonia
Fluid refractory shock
Severe SLE
Vomitting due to adverse effect of SLE
drugs
Decubitus ulcer grade 1
Hyponatremia
Hypoalbuminemia
Hypochloremia
Overweight
 Oxygen on Jackson-reis with ET
IVFD D51/2NS 88ml/hours iv
Dobutamin (5mcg/kg/min ) = 430
mg+NaCL until 24ml 1 ml/hour iv
increased 2mL/hour iv ~
(10mcg/kgBW/minute)
Educated patient family about her
condition
 S : patient can response question with head
movements
O : GCS E4VxM5

HR: 120x/min T: 37C

RR: 40 on jackson-reiss TD: 95/57mmHg
Ext: dorsalis pedis artery: pulse strengthened
warm extremity
Capillary refill time < 2 sec
A : Fluid refractory shock (improved)
P : Dobutamin (10mcg/kg/min ) = 430
mg+NaCL until 24ml 2mL/hour iv
 Respiratory Failure due to pneumonia
Fluid refractory shock
Severe SLE
Vomitting due to adverse effect of SLE
drugs
Decubitus ulcer grade 1
Hyponatremia
Hypoalbuminemia
Hypochloremia
Overweight
 1. Admitted to PICU with ventilator mode SIMV
PEEP 6 cmH20, FiO2: 40%, RR 25x/min
2. IVFD D51/2NS 88ml/hours iv
3. Cefotaxime (50mg/kgBW) = 1 g/8 hour iv
4. Dobutamin (10mcg/kg/min ) = 430 mg+NaCL
until 24ml 2 ml/hour iv
5. Methylprednisolon tab 16mg, 1.5 tab-1 tab-1/2
tab via NGT
6. Captopril 12.5 mg/12 hours via NGT
 S: unconsious, vomited (-)
O: severe illness, somnolen

HR; 138x/min Temperature: 36.5 C

BP:70/40 mmHg MAP 50 mmHg
SiO2 94%
Cold extremities (+), CRT > 2 second
USCOM :
Circulation :
- CI : 2.1(1.9-5.6)
Preload :
- SVI : 20 (49-71)
- FTc : 318 (353-408)

Contractility :
- SMII : 0.57 (1.56- 2.6)

- Vpk: 0.8 (1.3-2.0)

Afterload :
- SVRI : 1952( 1078-1850)

- PKR : 43 (15-28)
A:Respiratory failure
Fluid refractory shock
P: oxygen ventilator SIMV, PEEP 4, FiO2 50%,
RR 15 x/min
Dobutamin increased (15mg/kgBb/min)=850 mg
+ NS until 24 ml 1 ml/hour
Loadig Nacl 0.9% 10cc/ kgbb 500 ml /
secepatnya

Monitoring: evaluation resuscitation target 1hour

again
 S: unconsious, vomited (-)
O: severe illness, somnolen

HR; 138x/min Temperature: 36.5 C

BP:70/40 mmHg MAP 50 mmHg
SiO2 94%
Cold extremities (+), CRT > 2 second
A:Respiratory failure
Fluid refractory shock
P:loading Nacl 0.9% 10cc/kgbb 500
ml/fastly
ET with the distal tip in VTh 1
Pneumonia
S: unconscious, vomited
GA: severely ill, apatis
HR: 118x/min BP 102/70 mmHg
Temperature: 36,7 C (axilar)
SiO2 98%
Warm extremities (+), CRT < 2 second

A: fluid refractory shock (improved)

P: permanent
 pH : 7.517 Ganti mode ventlator :
BE : -7.6 mmol/L A/C PEEP : 5, Fio 40%
PCO2 : 18.9 mmHg i: E = 1:1.5
PO2 : 107.5 mmHg Inj miloz : 0.2 mg/kgbb/
Ht : 32 % jam 250mg kec 3.1
HCO3 : 15,5 cc/ jam
Total CO2 : 16,1
O2 Saturation : 98,6 %
Lactac artery : 2,70 mmol/L

Ass:
Alkalosis respiratorik mix
asidosis metabolik tidak
terkompensasi
 06.00 FOLLOW UP at PICU (8/4/2017) 06.00
Issues unconcious, on sedatives
St. CNS GA: severe illness, coma Sedation (+)midazolam
GCS: E1VxM4 Analgetic (-)
Light reflex (+/+)
Pupil isocoric 2mm/2mm
St. CV HR : 113x/menit ADP strongly palpable
TD: 90/38mmHg (MAP 51) CRT< 2
St. RR : 26 x/minute on venti I : right hemithorax = left hemithorax
Respirati SiO2:98% P: fremitus sounds right = left
on Nasal flares (-/-) P: sonor / sonor
Retraction (-) A: bronchial breath sounds +/+ , crackles
(+/+)
St GIT vomitting (-) I : abdominal wall = chest wall
Hepatic Gastric residual (+) bloody A : peristaltic sound (+) within normal
Defecation: cant be evaluated limit
P : tympani (+)
P : palpable pain (-) liver and spleen
were not palpable
St Blood glucose: 156 mg/dL
Metabolic Na= 113 mmol/L Cl = 84 mmol/L
K= 4.4 mmol/L
St. GU urinate (+)
BC: +1484 ml/6 hour
D: 3.63 ml/kg/hour
St. Infeksi t: 36,5C (axilar) Leucocyte : AB: + inj.cefotaxime
5.500/ul
St. Nutrisi Daily Fluid needs 1700 ml,
calories 1700 kkal/day
 Respiratory Failure due to pneumonia
Fluid refractory shock
Severe SLE
Vomitting due to adverse effect of SLE drugs
Decubitus ulcer grade 1
Hyponatremia
Hypoalbuminemia
Hypochloremia
Well nourished
1. O2 ventilator modus AC PEEP 5, RR : 20, Fio2 50
2. Temporarily fasting
3. D10%=D51/4NS 430+D40% 70ml/hours=
89cc/min
4. Cefotaxime (50mg/kgBW) = 1 g/8 hour iv
5. Dobutamin (15mcg/kgBW/min)=850
mg+NS until 24 ml 2 ml/hour iv
5. Midazolam (0.2mg/kgBW/hour)=124mg+NS
until 24 ml 3.1 ml/hour iv
6. Furosemide (0.5mg/kg/extra)=25mg iv
extra
 Bradicardia-desaturasi
GA: severe illness
HR68x/min SiO2 72%
A: breadicardia, desaturasi
P: educate the family

Family agree to DNR

The patient was declared dead
 P: SLE patient
I: clinical characteristics
C: -
O: outcome
Vomitus

Dehydrati Prolonged Disorder

on shock perfusion

Acidosis MODS
metabolic

tachypnea Death

Respiratory
PCo2
Alkalosis