CASE CONFERENCE

WEDNESDAY NIGHT SHIFT,

OCTOBER 2ND, 2019

Dr. Hendra / dr. Dini / dr. Anto / dr. Aya / dr. Indra
Dr .Yanuar / dr Dhimas
Dr. Restu / dr. Ama

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PATIENT ADMISSION
PICU
• -

NICU
• -

Pediatric HCU
• - 2
Melati 2 Ward

• YG, 7 years old, 17 kgs with intractable

seizzure, spastic type CP, ginggivitis,
external hordeolum OD,
undernourished.
• MK, 9 years and 6 months old, 19 kgs,
with epistaxis e.c thrombocytopenia
due to chemotheraphy side effect, right
pelvis osteosacrcoma, grade I mucositis,
undernourished.
3
Rooming-in

• Baby Mrs N 1, 0 day old, 2.3 kgs with

neonate, twin boy, normal birth weight,
fullterm, appropriate for gestational age,
C-section due to severe pre eclampsia,
partially HELLP syndrome
• Baby Mrs N 1I, 0 day old, 2.7 kgs with
neonate, twin boy, normal birth weight,
fullterm, appropriate for gestational age,
C-section due to severe pre eclampsia,
partially HELLP syndrome
4
PATIENT IDENTITY

 Name :YG
 Sex : Male
 Age : 7 years old
 Body weight / height : 17 kgs
 Address : Surakarta
 Medical Record : 0116xxxx

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AT ER

Seizure 10 minutes, tonic seizure, no fever

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7
 Appearance
Tone : decreased
Irritability : decreased
Consolability : decreased
Look : (+) decreased
Speech : (-)

 Work of Breathing Work of Breathing

Breath sound : normal Appearance PEDIATRIC Normal
ASSESMENT
Positioning : normal TRIANGLE
Nasal flaring :-
Retraction :-

Circulation
 Circulation
Normal
Pallor :-
Cyanosis :-
Mottle :- 8
Bleeding :-
CHIEF COMPLAINT

Seizure

9
 CURRENT MEDICAL HISTORY

 Subfebris fever (+), highest temperature

was 37.8ºC
 Seizure (-)  reddish lump in patient’s right eyes
 Cough (-), runny nose (-), ear discharge (-  watery eyes (-), blurred vision (-)
)
 subfebris (+)
 Nausea (-), vomite (-)
 Seizure (-)
 painful urination (-), balloning of distal
penis while urinating, (-)  cough (-), runny nose (-)
 Diarrhea (-)  nausea,and vomite (-)
 fully awake  There was no changes in appetite
 Patient was taking Topamax 2 tablets / 12 10
hours and Bamgetol 250 mg / 12 hours
 CURRENT MEDICAL HISTORY

 There was toothache on the left

side.
 Patient’s parent said that his left jaw
was inflammed
 Subfebris (+)
 productive cough (+), runny nose (-)
 Seizure (-)
 nausea and vomiting (-)
 There was no changes in appetite
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 CURRENT MEDICAL HISTORY

 Seizure (+)
 Seizure was stop after administration of suppositoria stesolid
 Vomiting (-)
 Breathlessness (-)
 productive cough (+)

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PAST MEDICAL HISTORY

 Patient is routinely go to pediatric neurology clinic with

intractable epilepsy. Last control was on 12/9/2019 and was
prescribed with Topomax (6,2mg/kgBW/day) = 2 tablets / 12
hours po and Bamgetol (28mg/kgBW/day) = 250mg/12 hours po
 Last seizzure was in June 2019
 Head trauma history (-)
 Patient was admitted in Melati 2 ward in September 2019 with
acute tonsilopharyngitis
 Last EEG was in September 2017

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FAMILY MEDICAL HISTORY

 History of same illness : (-)

 History of allergy : (-)
 History of seizure : (-)

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PREGNANCY AND DELIVERY HISTORY

• During pregnancy, his mother routinely checked up her

pregnancy to doctor. She was given vitamin, and she didn’t
consume any medicine beside it. She never got hospitalized
during pregnancy and has no fever.
• Baby boy was born in 39 weeks of pregnancy by
spontaneous delivery. He cried vigorously, appear cyanosis.
Her birth weight was 3100 grams

Conclusion:
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Pregnancy and delivery history was normal
VACCINATION HISTORY

Conclusion :
Complete immunization based on Ministry of Health 2012 16
 NUTRITION HISTORY

Patient eats 3 times a day with family food (rice, dish, vegetables,
and sometimes fruits)
Conclusion: quantity and quality were adequate

GROWTH AND DEVELOPMENT

He is 7 years old now, 17 kg in body weight
Patient can’t speak, but can follow the instruction. He has routinely
phisiotherapy

Conclusion: growth and development were inadequate 17

NUTRITIONAL STATUS

• Weight for Age : -2 SD < W/A < 0 SD

• Height for Age : -2 SD < H/A < 0 SD
• Height for Weight : -2 SD < W/H < 0 SD

Conclusion:
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underweight, underheight, undernourished
 FAMILY TREE
I

II

III

YG, 7 years old, 17 kgs 19

PHYSICAL EXAMINATIONS

 Moderate illness, fully alert

• Heart Rate = 110 bpm
• Respiratory rate = 24 times/ minute
• Temperature = 37.1o C per axillar
• SiO2 = 98%

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 Head : mesocephal (HC : 53 cm). 0 SD < HC < 2 SD Nellhaus
 Eyes : isochoric pupil 2mm/2mm, light reflexes (+/+), hordeolum (+/-), secret (-
/-)
 Nose : nasal flaring (-/-), discharge (-/-)
 Mouth : multiple caries dentis (+), oedema ginggiva (+), cyanotic (-), gum
bleeding (-), stomatitis (-)
 Ear : discharge (+/-) at OAE dextra
 Neck : Enlargement of lymph node (-)
 Thorax : symmetric (+), retraction (-)

LUNG:
 I: normal, symmetric, retraction (-)
 P: fremitus same in both side
 P: sonor in both lungs
 A: vesicular breathing sound (+/+), additional breathing sound (-/-)

21
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
A: peristaltic sounds increased
P: tympani (+), shifting dullness (-), undulations (-)
P: supple, abdominal tenderness (-), liver and spleen does not palpable, turgor
return quickly

EXTREMITIES:
Warm, capillary refill time < 2 sec, and dorsalis pedis artery was strongly palpable
22
Physiological reflexes Pathological reflexes
R. Biceps +2/+2 R. Babinski -/-
R. Triceps +2/+2 R. Chaddok -/-
R. Patella +2/+2 R. Oppenheim -/-
R. Achilles +2/+2

Clonus (-)
Lateralization(-)
Spastic - -
+ +
Nuchal rigidity (-)
Brudzinski I/II (-)
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LABORATORY RESULTS OCTOBER 2ND 2019

Value Reference Units

Hemoglobin 10.5 11.5-15.5 g/dl
Hematocrit 32 35-45 %
Leucocyte 12.3 4.5-14.5 103/ul
Platelet 474 150-450 103/ul
Eritrocyte 3.76 4.00-5.20 106/ul
MCV 85.1 80.0-96.0 /um
MCH 27.9 28.0-33.0 pg
MCHC 32.8 33.0-36.0 g/dl
RDW 12.0 11.6-14.6 %
MPV 8.7 7.2-11.1 fl
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PDW 9 25-65 %
LABORATORY RESULTS OCTOBER 2ND 2019

Value Reference Units

Eosinophil 1.10 0.00-4.00 %
Basophil 0.50 0.00-1.00 %
Netrophil 45.10 29.00-72.00 %
Lymphocyte 49.70 30.00-48.00 %
Monocyte 3.60 0.00-5.00 %
Sodium 139 132-145 Mmol/L
Potassium 3.0 3.1-5.1 Mmol/L
Chloride 106 98-106 Mmol/L
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PROBLEM

Boys 7 years old, 17 kgs with:

1. General tonic seizure 10 minutes, stopped by diazepam supp
2. Subfebrile fever a week
3. Toothache (+)
4. reddish lump in patient’s right eyes
5. hordeolum (+/-),
6. multiple caries dentis (+), oedema ginggiva (+)
7. Spastic (+)
8. Normocytic hypochromic anemia
9. Mild hypokalemia

26
 DIFFERENTIAL DIAGNOSIS

1. Intractable epilepsy
2. Spastic CP
3. Ginggivitis
4. External hordeolum OD
5. Normocytic hypochromic anemia due to chronic infection dd/
iron deficiency
6. Mild hypokalemia

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 WORKING DIAGNOSIS

1. Intractable epilepsy
2. Spastic CP
3. Ginggivitis
4. External hordeolum OD
5. Normocytic hypochromic anemia due to chronic infection
6. Mild hypokalemia due to low intake
7. Undernourished

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 THERAPY

1. Admitted to neurology ward

2. O2 nasal canule, 2 lpm
3. Diet rice and dish 1800 kkal/day
4. IVFD D5 1/4 NS 56 ml/hour
5. Topomax (6,2mg/kgBW/day) = 2 tablets / 12 hours po
6. Carbamazepin (Bamgetol) (30 mg/kg/day) = 255mg / 12 hours po
7. KSR 75mg/kgBW/day = 400mg/8 hours po
8. If seizzure -> Diazepam (0,3mg/kgBW/IV) = 5 mg IV
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PLAN

 EEG
 Routine feces examination
 Consult dentistry depatment (in ward)
 Consult opthalmology department (in ward)

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MONITORING

• General appearance/ vital signs/ 8 hour

• Fluid balance and diuresis/ 8 hours

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FOLLOW UP ON OCTOBER 3RD 2019 (05.00)

S: seizure (-), fever (-)

O: Moderate illness, fully alert
• Heart Rate = 132 bpm
• Respiratory rate = 22 times/ minute
• Temperature = 36.8o C per axillar
• SiO2 = 99%

32
 Head : mesocephal (HC : 53 cm). 0 SD < HC < 2 SD Nellhaus
 Eyes : isochoric pupil 2mm/2mm, light reflexes (+/+), hordeolum (+/-), secret (-
/-)
 Nose : nasal flaring (-/-), discharge (-/-)
 Mouth : multiple caries dentis (+), oedema ginggiva (+), cyanotic (-), gum
bleeding (-), stomatitis (-)
 Ear : discharge (+/-) at OAE dextra
 Neck : Enlargement of lymph node (-)
 Thorax : symmetric (+), retraction (-)

LUNG:
 I: normal, symmetric, retraction (-)
 P: fremitus same in both side
 P: sonor in both lungs
 A: vesicular breathing sound (+/+), additional breathing sound (-/-)

33
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
A: peristaltic sounds increased
P: tympani (+), shifting dullness (-), undulations (-)
P: supple, abdominal tenderness (-), liver and spleen does not palpable, turgor
return quickly

EXTREMITIES:
Warm, capillary refill time < 2 sec, and dorsalis pedis artery was strongly palpable
34
Physiological reflexes Pathological reflexes
R. Biceps +2/+2 R. Babinski -/-
R. Triceps +2/+2 R. Chaddok -/-
R. Patella +2/+2 R. Oppenheim -/-
R. Achilles +2/+2

Clonus (-)
Lateralization(-)
Spastic - -
+ +
Nuchal rigidity (-)
Brudzinski I/II (-)
35
 WORKING DIAGNOSIS

1. Intractable epilepsy
2. Spastic CP
3. Ginggivitis
4. External hordeolum OD
5. Undernourished

36
 THERAPY

1. O2 nasal canule, 2 lpm

2. Diet rice and dish 1800 kkal/day
3. IVFD D5 1/4 NS 56 ml/hour
4. Topomax (6,2mg/kgBW/day) = 2 tablets / 12 hours po
5. Carbamazepin (Bamgetol) (30 mg/kg/day) = 255mg / 12 hours po
6. Look for recurrent seizzure -> Inj Diazepam (0,3mg/kgBW/IV) = 5 mg IV

37
PLAN

 EEG
 Routine feces examination
 Consult dentistry depatment (in ward)
 Consult opthalmology department (in ward)

38
MONITORING

• General appearance/ vital signs/ 8 hour Fluid balance and

diuresis/ 8 hours
• Look for recurrent seizure -> Inj Diazepam (0,3mg/kgBW/IV)
= 5 mg IV

39
 Is there any corelation between intractable
epilepsy and cerebral palsy?

• Journal wasn’t found

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What is the predictive factors patient with intractable epilepsy?

P Children with drug-resistant epilepsy

I -
C -
O predictive factors

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CRITICAL APPRAISAL

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 Validity

What question (PICO) did the systematic review address?

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 Validity

Is it unlikely that important, relevant studies were missed?

No

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 Validity

Were the criteria used to select articles for inclusion appropriate?

Yes

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 Validity

Were the included studies sufficiently valid for the type of question
asked?

Yes

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 Validity

Were the results similar from study to study?

Yes

48
Importance

49
Importance

50
 Applicability

Were our patient same?

• Yes

Were this helpful for patient?

• yes

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 Level of Evidence

Important

Valid Applicable

LoE
IA

52
Thank You

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