MORNING REPORT

THURSDAY NIGHT SHIFT,

NOVEMBER16TH 2017

dr. Fitri/ dr. Prima / dr.Tatag/ dr. Anin/ dr. Adam

dr. Labiq / dr. Rekno
dr. Dhimas/ dr. Lubna

1
 PATIENT ADMISSION

 MELATI 2 WARD
 H, male, 2 months old, 2.8 kgs, with pneumonia, Etiological
diagnosis: acyanotic congenital heart disease, anatomical
diagnosis: AVSD PMO, TR, PS mild; microcephal, due to TORCH
infection DD malnutrition; umbilical hernia, suspected
congenital hypothyroid, wasted.
 B, male, 1 years 9 months old, 11 kgs with vomitus due to acute
tonsilopharyngitis, acute tonsilopharyngitis, well-nourished
 A, 5 years old, 25 kgs, with petechie due to thrombocytopenia,
neutropenia, ALL SR induction phase 3rd weeks, well-nourished
 PICU -
 NEONATAL HCU: -
 MELATI 2 HCU : -
 NICU : - 2
PATIENT IDENTITY

 Name :M
 Sex : male
 Age : 2 months old
 Body weight / height : 2.8 kgs / 48 cm
 Adress : Bolak Rejo, Wonogiri
 Medical Record : 01394604

3
CHIEF COMPLAINT

Shortness of breath
(referred from private hopsital)

4
 CURRENT MEDICAL HISTORY

14 days before At ER
admission • Patient admitted in • Patient was fully
• Cough (+), ICU for 13 days, use alert, shortness of
productive cough, oxygen via nasal breath (+)
fever (+), got canule, perform chest • No fever, no
shortness of X-ray examination: cyanotic, no vomit
breath and Pneumonia • The last urination
looked cyanotic • Patient perform was in ER yellowish
around his face laboratory in colour
• No vomit ,no examination: Hb 10.1
diarrhea, no g/dl, WBC 27.7 x
seizure, no 103/uL, platelet count
complaint about 394 thousand/uL
urination and no improvement 
defecation reffered to Moewardi
• Patient admitted hospital
to private
hospital in
Wonogiri
5
PAST MEDICAL HISTORY

 Patient routinely checked up in cardiology outpatient clinic

Moewardi Hospital for VSD PMO, ASD, TR mild, PS mild, and
routinely consume furosemid 5 mg/12 hours p.o,
spironolactone 3.1 mg/12 hours p.o
 History of hospitalization (+) in private hospital in Wonogiri
after birth for 18 days due to pulmonal infection

6
FAMILY MEDICAL HISTORY

 History of congenital heart disease (-)

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PREGNANCY AND DELIVERY HISTORY

• During pregnancy, his mother routinely checked up her pregnancy

to midwife. The mother was given vitamin, and she didn’t consume
any medicine beside it. She hasn’t got hospitalized during pregnancy
and has no fever during labor, no hypertension, and no vaginal
bleeding.
• Baby boy was born in 39 weeks of pregnancy by spontaneous
delivery. He cried vigorously, no cyanosis or jaundice. His birth
weight was 2700 grams, 48 centimeters in length. The baby got
cyanotic after he drank milk for the first time.

Conclusion: Pregnancy and delivery history were normal

8
 VACCINATION HISTORY

0 month : Hepatitis B0
1 month : BCG, polio 1
2 months : DPT1, hepatitis B1, Hib1, polio2

Conclusion :
appropriate with Ministry of Health immunization
schedule 2004

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 NUTRITION HISTORY

Patient never got breastfeeding by his mother. He was getting formula

milk standard until now. He drink approximately 30 ml every 2 hours
Conclusion: quantity and quality were inadequate

GROWTH AND DEVELOPMENT

He is 2 months old now, 2800 in weight, his eyes can follow the object to the
midline
Conclusion: inappropriate for his age

10
NUTRITIONAL STATUS

• Weight for Age: Weight/Age < - 3 SD

• Severe underweight
• Height for Age: Height/Age < -3 SD
• Severe stunted
• Weight for Height : -3 SD< Weight/ Height < -2 SD
Wasted
Conclusion:
Severe Underweight, Severe stunted, Wasted
(WHO growth chart standard 2006)
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 FAMILY TREE

II

III

12
H, 2 months old, 2.8kgs
 PHYSICAL EXAMINATION

 General appearance :fully alert, GCS E4M6V5, shortness

of breath (+), no cyanotic
 Vital sign :
 Heart Rate = 140 bpm
 Respiration rate = 68 bpm
 Temperature = 37.3 0 C peraxilar
 O2 saturation = 97%

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 Head : mesocephal, head circumference = 34 cm (HC < -2 SD) microcephal
 Eyes : pale conjunctiva (-/-), icteric conjunctiva (-/-), light reflex (+/+),
isochoric pupil 2 mm/2mm, sunken eyes (-/-), tears (+/+)
 Nose : nasal flare (-/-), discharge (-/-), nosebleed(-/-)
 Mouth : wet lips (+), lips and tongue not cyanotic
 Neck : Enlargement of lymph node (-)
 Thorax : symmetric (+), retraction (+)

LUNG:
 I: normal, symmetric, retraction (+)
 P: fremitus difficult to evaluate
 P: sonor in both lung
 A: normal vesicular breath sound, additional breath sound (+/+) ronkhi (+/+)

14
CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, murmur (+)
ABDOMINAL:
I: abdominal wall equal to chest wall, umbilical hernia (+)
A: peristaltic sounds normal limit
P: tympani(+), shifting dullness (-), undulations(-)
P: liver and spleen was not palpable, good skin turgor
EXTREMITIES:
The extremities were warm, capillary refill time < 2 sec, and dorsalis pedis artery
was strongly palpable
GENITALIA : ♂, phimosis (-) 15
 Hypotiroid score:
Feeding problem : 0
Constipation :0
Lethargy :1
Hypotonia :1
Coarse facies :0
Macroglosia :0
Open posterior fontanel: 0
Dry skin :0
Mottling of skin :0
Umbilical hernia : 1
Total : 3

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LABORATORY FINDINGS NOVEMBER 16TH 2017

• Sodium : 134 mmol/L

• Hb : 9.9 g/dl
• Potasium : 4.2 mmol/L
• HCT : 29%
• AL : 25.2 thousand/ul • Chloride : 97 mmol/L
• AT : 539 thousand/ ul • Calcium : 1.34 mmol/L
• AE : 3.20 mil/ul
• MCV : 90.8 /um Conclusion :
• MCH : 30.9 pg - Leucocytosis
• MCHC 34.0%
• RDW: 12.4%
• Netrophyl :56.50 %
• Lymphocyte : 31.80 %
• Blood glucose : 86 mg/dl

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CHEST X RAY (NOVEMBER, 10TH 2017)

 Conclusion: pneumonia

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 LISTS OF PROBLEM

H, 2 months old, 2.8 kgs with :

 Shortness of breath
 Fever since 2 weeks ago
 Productive cough
 Microcephal
 Tachipnea
 Murmur (+)
 Ronkhi on both lung
 Umbilical hernia
 Laboratory result: leucocytosis
 Chest x ray : pneumonia
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 Echocardiography: VSD PMO, PS mild, ASD, TR mild (october, 6th 2017)
DIFFERENTIAL DIAGNOSIS

1. Pneumonia
2. DE : congenital heart disease
DA :VSD PMO, ASD, PS mild, TR mild
DF : Ross II
3. Microcephal due to suspected congenital CMV
4. Reponible umbilical hernia
5. Suspected congenital hipothyroid
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6. Wasted
WORKING DIAGNOSIS

1. Pneumonia
2. DE : congenital heart disease
DA :VSD PMO, ASD, PS mild, TR mild
DF : Ross II
3. Microcephal due to suspected congenital CMV
4. Reponible umbilical hernia
5. Suspected congenital hipothyroid
6. Wasted 21
 THERAPIES

 Admitted to pediatric pulmonology ward consult to pediatric

cardiology division.
 Oxygen 2 lpm via nasal canul
 Nutrition  formula milk diet 40 ml every 3 hours
 IVFD D 1/4 NS 4 ml/hour
 Ampicilin-sulbactam (25 mg/kgBW/6 hours) 75 mg/6 hours I.V.
 Furosemid 5 mg/ 12 hours p.o
 Spironolacton 3.125 mg/ 12 hours p.o
 Paracetamol (10 mg/kgBw/8 hours) 30 mg/8 hours p.o (if
22
temperature > 380 C) p.o
 PLAN

Blood smear examination

TSH and FT4 examination

MONITORING

• General appearance / vital signs / oxygen

saturation every 4 hours
• Fluid balance and diuresis /8 hours
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 FOLLOW UP NOVEMBER 17TH 2017

 S : no fever, cough (+), dyspneu (+)

 O: General appearance :fully alert, GCS E4M6V5,

shortness of breath (+), no cyanotic
 Vital sign :
 Heart Rate = 143 bpm
 Respiration rate = 57 bpm
 Temperature = 36.7 0 C peraxilar
 O2 saturation = 97% 24
 Head : mesocephal, microcephal HC = 34 cm (HC < -2 SD)
 Eyes : pale conjunctiva (-/-), icteric conjunctiva (-/-), light reflex (+/+),
isochoric pupil 2 mm/2mm, sunken eyes (-/-), tears (+/+)
 Nose : nasal flare (-/-), discharge (-/-), nosebleed(-/-)
 Mouth : wet lips (+), lips and tongue not cyanotic
 Neck : Enlargement of lymph node (-)
 Thorax : symmetric (+), retraction (-)

LUNG:
 I: normal, symmetric, retraction (-)
 P: fremitus difficult to evaluate
 P: sonor in both lung
 A: normal vesicular breath sound, additional breath sound (+/+) ronkhi (+/+)

25
CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, murmur (+)
ABDOMINAL:
I: abdominal wall equal to chest wall, hernia umbilicalis (+)
A: peristaltic sounds normal limit
P: tympani(+), shifting dullness (-), undulations(-)
P: liver and spleen was not palpable, good skin turgor
EXTREMITIES:
The extremities were warm, capillary refill time < 2 sec, and dorsalis pedis artery
was strongly palpable
GENITALIA : ♂, phimosis (-) 26
DIAGNOSIS
1. Pneumonia
2. DE : congenital heart disease
DA :VSD PMO, ASD, PS mild, TR mild
DF : Ross II
3. Microcephal due to suspected congenital CMV
4. Reponible umbilical hernia
5. Suspected congenital hipothyroid
6. Wasted
27
 THERAPIES

 Oxygen 2 lpm via nasal canul

 Formula milk diet 40 ml every 3 hours
 IVFD D 1/4 NS 4 ml/hour
 Ampicilin-sulbactam (25 mg/kgBW/6 hours) 75 mg/6 hours I.V.
 Furosemid 5 mg/ 12 hours p.o
 Spironolacton 3.125 mg/ 12 hours p.o
 Paracetamol (10 mg/kgBw/8 hours) 30 mg/8 hours p.o (if
temperature > 380 C) p.o
28
 PLAN
Gram stain sputum
Sputum culture examination
Bloood culture
Waiting blood smear result
TSH and FT4 (on next blood check)
Consult to neurology departement

MONITORING
• General appearance / vital signs / oxygen
saturation every 4 hours
• Fluid balance and diuresis /8 hours
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 FOLLOW UP NOVEMBER 18TH 2017

 S : no fever, cough (+), dyspneu (+)

 O: General appearance :fully alert, GCS E4M6V5,

shortness of breath (+), no cyanotic
 Vital sign :
 Heart Rate = 143 bpm
 Respiration rate = 55 bpm
 Temperature = 36.7 0 C peraxilar
 O2 saturation = 97% 30
 Head : mesocephal, microcephal HC = 34 cm (HC < -2 SD)
 Eyes : pale conjunctiva (-/-), icteric conjunctiva (-/-), light reflex (+/+),
isochoric pupil 2 mm/2mm, sunken eyes (-/-), tears (+/+)
 Nose : nasal flare (-/-), discharge (-/-), nosebleed(-/-)
 Mouth : wet lips (+), lips and tongue not cyanotic
 Neck : Enlargement of lymph node (-)
 Thorax : symmetric (+), retraction (-)

LUNG:
 I: normal, symmetric, retraction (-)
 P: fremitus difficult to evaluate
 P: sonor in both lung
 A: normal vesicular breath sound, additional breath sound (+/+) ronkhi (+/+)

31
CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, murmur (+)
ABDOMINAL:
I: abdominal wall equal to chest wall, hernia umbilicalis (+)
A: peristaltic sounds normal limit
P: tympani(+), shifting dullness (-), undulations(-)
P: liver and spleen was not palpable, good skin turgor
EXTREMITIES:
The extremities were warm, capillary refill time < 2 sec, and dorsalis pedis artery
was strongly palpable
GENITALIA : ♂, phimosis (-) 32
DIAGNOSIS
1. Pneumonia
2. DE : congenital heart disease
DA :VSD PMO, ASD, PS mild, TR mild
DF : Ross II
3. Microcephal due to suspected congenital CMV
4. Reponible umbilical hernia
5. Suspected congenital hipothyroid
6. Wasted
33
 THERAPIES

 Oxygen 2 lpm via nasal canul

 Formula milk diet 40 ml every 3 hours
 IVFD D 1/4 NS 4 ml/hour
 Ampicilin-sulbactam (25 mg/kgBW/6 hours) 75 mg/6 hours I.V.
 Furosemid 5 mg/ 12 hours p.o
 Spironolacton 3.125 mg/ 12 hours p.o
 Paracetamol (10 mg/kgBw/8 hours) 30 mg/8 hours p.o (if
temperature > 380 C) p.o
34
 PLAN
Gram stain sputum (waiting result)
Sputum culture examination (waiting result)
Blood culture (waiting result)
Waiting blood smear result
TSH and FT4 (on next blood check)

MONITORING

• General appearance / vital signs / oxygen

saturation every 4 hours
• Fluid balance and diuresis /8 hours
35
 CLINICAL QUESTION:
WHAT IS ASSOCIATION BETWEEN PNEUMONIA
AND CONGENITAL HEART DISEASE?

 P: patient with congenital heart disease

 I: pneumonia
 C: no pneumonia
 O: association between pneumonia and congenital heart disease
VALIDITY

 Was the defined representative sample of patients assembled at a common (usually early) point
in the course of their disease)? Yes, All children admitted to Ankara University Medical School,
Department of Pediatric Infectious Diseases, between January 1997 and October 2002, with a
hospital discharge diagnosis of pneumonia were identified.
 Was patient follow-up sufficiently long and complete? Yes it was. Researcher follow the patient
sufficiently
 Were outcome criteria either objective or applied in a ‘blind’ fashion? No, there was no blind,
 If subgroups with different prognoses are identified, did adjustment for important prognostic
factors take place? Underlying diseases for pneumonia were bronchial asthma (32 per cent),
gastroesophageal reflux (15 per cent), immune disorders (10 per cent), congenital heart defects
(9 per cent), anomalies of the chest and lung (6 per cent), bronchopulmonary dysplasia (4 per
cent), cystic fibrosis (3 per cent), tuberculosis (3 per cent), and aspiration syndrome (3 per cent).
 IMPORTANCY
 What are the results?
 How likely are the outcomes over time?
 How precise are the prognostic estimates?

 We cannot calculate the confidence interval because no data of confidence interval

APPLICABILITY

 Is my patient so different to those in the study that the results cannot apply?
Yes, the study similar in our hospital
 Will this evidence make a clinically important impact on my conclusions about
what to offer to tell my patients: yes it give consideration for our clinical decision
 valid, not important, applicable
 Level of evidence: 3 A