1

CASE CONFERENCE
Friday, November 4th 2017

dr. Fitri/ dr. Debby/ dr. Nunki/ dr. Lucky/ dr. Febry
dr. Leksmana
dr. Winda/ dr. Ahimsa
 Patients Admission 2

Melati 2 Ward
1. E, male, 1 years old, 8.5 kgs, with complex febrile seizure,
pneumonia dd bronchiolitis and well nourished, normoweight,
normoheight.
Neonatal HCU (-)
NICU (-)
Melati 2 HCUm (-)

PICU (-)
 3

Patient Identity
Name :E
Sex : male
Age : 1 years old
Address : Jebres
Medical record : 01384770
Weight/Height : 8.5 kgs/ 72 cm
 4

Chief Complain

Seizure
 Present Medical Hystory 5

14 hour’s before
admission
High fever (+)
continuously, respon to
4 day’s before admission anti pyretic drug, 2-3
Common cold (+), cough (+), hours the temperature
productive cough, still active, no increased again,
productive cough (+),
complain about urination, no dyspneu
defecation, and nutrition intake
 Present Medical Hystory 6

At the ER
Patient got recurrence stiffness
on hands for 1 minute, the eyes
rolls upward, given stesolid
2 hour’s before admission supposituria and the seizure
stopped, patient cried vigorously
Fever (+), stiffness on hands (+) for 1 after that.
minute, stopped by it self, patient
cried shortly after that, patient than During examination patient fully
reffered to the ER alert, cried vigorously, still got
fever, the last urination and
defecation at ER
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Past Medical History

History of febrile seizure (-)
History of Epilepsy (-)
History of hospitalization (-)
 8

Family Medical History

• History of Epilepsy : (-)

• History of Febrile seizure : (-)
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Pregnancy and Delivery History

• During pregnancy, the mother routinely checked up
her pregnancy to midwife and obstetrician. She was
given vitamin, and she didn’t take any of medicine
beside it.
• Baby boy was born in full term pregnancy, delivered
by spontaneous delivery at the primary health care,
cry vigorously, no cyanosis or icteric and his birth
weight was 3000 grams

Conclusion: pregnancy and delivery history was normal

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VII. Vaccination History

Vaccination history
BCG : 3 month
Hepatitis B1 : 1 month
DPT-HB-Hib : 2, 4, 6 months
Polio : 0, 2, 4, 6 months
Measles :-
MR : 9 month

Conclusion : incomplete immunization, based on

Ministry of Health’s schedule 2016
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Nutrition History
Patient drink breast milk on demand for the diet, patient
eat porridge also three times/ day, 1/3 portion of adult.
Conclusion : quality and quantity of nutrition were
enough

Growth and Development

He is 1 years old now, he could stand without support
and practicing to walks, he could kick the ball and
could say 1 words
His weight is 8.5 kgs with body height 72 cm.
Conclusion: growth and development are apropriate for
his age
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Nutritional Status
• Weight for Age : 8.5/9.4 x 100% = 90.4 %
(-2 SD< WAZ < 0 SD) normoweight
• Height for Age: 72/74 x 100% = 97%
(-2 SD< HAZ < 0 SD) normoheight
• Weight for height 8.5 / 8.7 x 100% =97 %
(-1 SD< WHZ < 0 SD) well-nourished

Conclusion: well-nourished, normoweight, normoheight

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FAMILY TREE

II

III

E, 1 years old
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Physical Examination

General appearance: Fully alert, E4V5M6

Vital Signs:
Heart rate: 160 bpm
Body temperature : 39.80C
Respiration rate: 30 bpm
Oxygen Saturation: 99%
 15

• Head : normocephal with head circumference 45

cm (-2 SD <HC< 0SD, nellhaus),
• Eyes : pale conjunctiva (-/-), icteric conjunctiva
(-/-), light reflex (+/+), isochoric pupil
2 mm/2mm
• Nose : nasal flare (-/-), discharge (+)
• Mouth : cyanosis (-), tonsil T1-T1, hyperemic (-)
• Neck : no enlargement of lymph node
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LUNG:
• I: normal, symmetric, no retraction
• P: right fremitus = left fremitus
• P: sonor in both lung
• A: normal vesicular breath sound, additional breath sound (+/+),
Ronchi (+/+)

CARDIAC:
• I : ictus cordis not visible
• P: ictus cordis not palpable
• P: there is no cardiac enlargement
• A: 1st 2nd Heart sound normal intensity, regular, no murmur
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ABDOMINAL:
I: abdominal wall // thorax wall
A: peristaltic sound is within normal limit
P: shifting dullness (-), undulations(-)
P: there are no enlargement of the spleen and liver

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec,
and dorsalis pedis artery was strongly palpable.
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Neurological Examination
Physiological reflexes
Meningeal sign
- Biceps +2/+2
- Triceps +2/+2 • Nuchal rigidity -
- Patella +2/+2 • Kernig’s sign –
- Achilles +2/+2
• Brudzinsky sign –
Pathology reflexes
- Chaddock -/-
- Oppenheim -/- Lateralization (-)
- Schaeffer -/-
- Gordon -/-
- Babinski -/-
Cranial Nerves Examination

• NI : cant evaluate
• N II : cant evaluate
• N III, IV, VI : light reflex within normal limit
• NV : kornea’s reflex within normal limit
• N VII : symmetrical face, no abnormal face’s move
• N VIII : cant evaluate
• N IX : no uvula deviation
• NX : vomitus reflex (+)
• N XI : symmetrical shoulder
• N XII : no atropy of tongue
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Laboratory Findings (November 4th 2017)
• Hb : 11.2 g/dl • Blood sugar : 106 mg/dl
• HCT : 35% • Sodium : 133 mmol/L
• AL : 16,700 /ul • Potassium : 4.2 mmol/L
• AT : 425,000/ ul • Calcium : 1.27 mmol/L
• AE : 4.71 mil/ul
• Chloroda : 102 mmol/L
• MCV : 73.2 /um
• MCH : 23.8 pg
• MCHC : 32.5 g/dl
• Netrophyl: 63.00%
• Lymphocyte : 23.20%
• Mono, Eos, bas : 14.0/0.00/0.00
%

Conclusion: lymphopenia
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Chest radiography

Conclusion: Pneumonia
Problem List 22

1 Year old, male, weight 8.5 kgs with

Hystory taking
1. Seizure with stiffness on hands for 1 minute
2. Continuous high fever
3. Productive cough
Physical examination
1. Fully alert E4V5M6
2. Temperature 39.8 o C
Laboratory result and radiologic finding
Lymphopenia, radiologic finding: pneumonia
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Differential Diagnosis
1. Complex febrile seizure
2. Pneumonia dd bronchiolitis
3. Well-nourished, normoweight, normoheight
 24

Working Diagnosis
1. Complex febrile seizure
2. Pneumonia dd bronchiolitis
3. Well-nourished, normoweight, normoheight
 Plan 25
• Therapy
1. Admitted to Pediatric neurology ward
2. Poridge diet 1000 kcals/day
3. Oxygen 2 lpm via nasal canule
4. IVFD D5 ¼ NS 35 ml/ hour
5. Ampicilin (25 mg/Kgbw/6 hours) 250 mg/6 hours IV
6. Paracetamol (15 mg/kgBw/6 hours) 130 mg/ 6hours I.V
7. Diazepam (0.2 mg/ KgBw) 2 mg p.o. If temperature > 38 oC
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Planning
• Urinalysis
• Routine stool examination

Monitoring
• General appearance /Vital signs/ oxygen
saturation/ 4 hours
• Fluid balance and diuresis / 8 hours
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Follow up, November 5th 2017

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Subjective: fever, no seizure, no dyspneu

General appearance: Fully alert, E4V5M6

Vital Signs:
Heart rate: 120 bpm
Body temperature : 39.10C
Respiration rate: 30 bpm
Oxygen Saturation: 99%
 29

• Head : normocephal with head circumference 45

cm (-2 SD <HC< 0SD, nellhaus),
• Eyes : pale conjunctiva (-/-), icteric conjunctiva
(-/-), light reflex (+/+), isochoric pupil
2 mm/2mm
• Nose : nasal flare (-/-),discharge (+)
• Mouth : cyanosis (-), tonsil T1-T1, hyperemic (-)
• Neck : no enlargement of lymph node
 30
LUNG:
• I: normal, symmetric, no retraction
• P: right fremitus = left fremitus
• P: sonor in both lung
• A: normal vesicular breath sound, additional breath sound (+/+),
Ronchi (+/+)

CARDIAC:
• I : ictus cordis not visible
• P: ictus cordis not palpable
• P: there is no cardiac enlargement
• A: 1st 2nd Heart sound normal intensity, regular, no murmur
 31
ABDOMINAL:
I: abdominal wall // thorax wall
A: peristaltic sound is within normal limit
P: shifting dullness (-), undulations(-)
P: there are no enlargement of the spleen and liver

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec,
and dorsalis pedis artery was strongly palpable.
 32

Neurological Examination
Physiological reflexes
Meningeal sign
- Biceps +2/+2
- Triceps +2/+2 • Nuchal rigidity -
- Patella +2/+2 • Kernig’s sign –
- Achilles +2/+2
• Brudzinsky sign –
Pathology reflexes
- Chaddock -/-
- Oppenheim -/- Lateralization (-)
- Schaeffer -/-
- Gordon -/-
- Babinski -/-
Cranial Nerves Examination

• NI : cant evaluate
• N II : cant evaluate
• N III, IV, VI : light reflex within normal limit
• NV : kornea’s reflex within normal limit
• N VII : symmetrical face, no abnormal face’s move
• N VIII : cant evaluate
• N IX : no uvula deviation
• NX : vomitus reflex (+)
• N XI : symmetrical shoulder
• N XII : no atropy of tongue
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Diagnosis
1. Complex febrile seizure
2. Pneumonia dd bronchiolitis
3. Well-nourished, normoweight, normoheight
 Plan 35
• Therapy
1. Poridge diet 1000 kcals/day
2. Oxygen 2 lpm via nasal canule
3. IVFD D5 ¼ NS 35 ml/ hour
4. Ampicilin (25 mg/Kgbw/6 hours) 250 mg/6 hours IV
5. Paracetamol (15 mg/kgBw/6 hours) 130 mg/ 6hours I.V
6. Diazepam (0.2 mg/ KgBw) 2 mg p.o. If temperature > 38 oC
 36

Planning
• Urinalysis
• Routine stool examination

Monitoring
• General appearance /Vital signs/ oxygen
saturation/ 4 hours
• Fluid balance and diuresis / 8 hours
 Clinical questions: were antibiotics
improved or worsened clinical
outcomes
• Childreninunder
children with of age with
two years
P bronchiolitis?
bronchiolitis

• Antibiotics
I

• Placebo or other interventions

C

• Clinical outcomes
O
 validity
• Was the assignments of patients to treatment
randomized? Yes
• Is the patient observations made sufficiently long
and complete? Yes, since the diagnostic is made
until the problem resolved.
• Aside from the experimental treatment, were the
groups treated equally? Yes
• Were the group similar at the start of the trial? Yes
the group is children under two years of age.
Importance
IMPORTANCE

• Are the Result important? yes

• CI interval in most symptom
observed in most study are
narrow
APPLICABILITY

1. Were the study patients is

similar to your own? YES
2. Will this evidence make a
clinically important impact on
your conclusions about what
to give to your patient? YES
conclusions

• VALID, IMPORTANT and

APPLICABLE
• Level of Evidence : 1A
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THANK YOU