CASE CONFERENCE

TUESDAY NIGHT SHIFT,

FEBRUARY 25 TH, 2020

dr. Ibrahim/ dr Hendra / dr. Iriz / dr. Disa / dr.

Labiq
dr. Yanuar / dr. Fitri
dr. Wulan / dr. Prima

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PATIENT ADMISSION

Melati 2
Ward
• Child A/ 3 years old / 10 kilograms with acute
tonsilopharyngitis with low intake, well nourished.
• Child A / 3 years old / 10 kilograms, with acute
tonsilopharyngitis, with low intake, well nourished,
• Child A / 8 month old / 9,3 kilograms with acute diarrhea mild
dehydration, well nourished
• Child A / 6 month old / 8,2 kilograms with suspected hisprung
disease, suspected hipotyroid conginetal, micrositic
hipocromic due to Fe deffisiention dd infection proccesing,
well nourished
• Child F / 7 months old / 5,1 kilograms, with acute diarrhea
mild dehidration, acquired heart disease, AVSD,, TR mild,
Ross 1, well nourished 2

• Child E / 10 years old/ 26 kilograms with acquired heart

disease, suspected VSD, NYHA I1, acute bronchitis, under
PATIENT ADMISSION
Melati
-
3
ward
Child I / 4 years old / 18 kilograms with simple siezure, acute
tonsilopharyngitis with low intake, well nourished

HCU Pediatri
-
-

HCU Neonatus
Baby Mrs’s S/ 8 days old / 3000 grams with neonates infection,
suspected acquired heart disease, suspected AVSD, Ross 1,
down syndrome, hyperbilirubinemia, Neonate, Female, normal 3
birth weight, aterm, inappropriate for gestational age, born
cesarean section due to mother with olygrohidroamnion
PATIENT ADMISSION
Internal
parturition
/

• Baby Mrs’s Y / o days old / 2400 grams, with mild distress respiratoric
due to hipotermia, neonate infection, moderate asfiksia, neonates,
male, normal birth weight, aterm, appropriate for gestational age,
born cesarean section due to mother with gemelli

• Baby Mrs’s Y / 2 days old / 2400 grams with distress respiratoric due
to hypotermia, infection neonates, nonate, male, normal birth weight,
aterm, appropriate for gestational age, born cesarean section due to
mother with gemelli,

• Baby Mrs’s W / 0 days old / 3400 grams with moderate distress

respiratoric due to hidrothorac, moderate asfiksia, hidrop fetalis,
ascites, hidrocele, scalp oedem, normal birth weight, aterm,
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inappropriate for gestational age, born cesarean section due to
mother with polidroamnion
PATIENT ADMISSION

NICU
-

PICU
-

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PATIENT IDENTITY

 Name: Baby Mrs’s S

 Sex : Female
 Age : years old
 Body weight / height : 3000 / 150 cms
 Address : Pucangsawit, Jebres, Surakarta
 Medical Record : 01497625

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  Appearance
 Tone : normal
Irritability : normal, fully conscious
Consolability : normal, calm
Look : normal, focus
Speech : normal, active speech
Appearance; Work of Breathing :
Normal Normal
 Work of Breathing
Breath sound: vesikuler (-/-) PEDIATRIC
ASSESMENT
Positioning : normal TRIANGLE
Nasal flaring :-
Retraction :-

Circulation
 Circulation
Normal
Pallor :-
Cyanosis: -
Mottle :- 7
Bleeding : -
CHIEF COMPLAINT

Breathless

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CURRENT MEDICAL HISTORY

8 days before admission

 Baby was born in APGAR Score 8-9-10
 Caesarean section delivery due to
Oligohidromanion(+)
 Breatless (-)
 Cough (-)
 Cold (-)

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 CURRENT MEDICAL HISTORY

5 days before admission

 Baby got cefotaxime 100 mg/12 hours, Light therapy 3x20
 Total Billirubin 10, Direct Billirubin :10, indirect Billirubin :
 Breathless (+)
 Cough (-)
 Cold (-)
 Patient was reffered to moewardi hospital because of the
O2 saturation < 90

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 CURRENT MEDICAL HISTORY

ER admission

 Cry strong (+)

 Active motion (+)
 Breathless (-)
 Fever (-)

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PETIENT’S MEDICAL HISTORY

History of same illness : denied

History of alergic : denied

FAMILY MEDICAL HISTORY

 History of same illness : denied

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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. She hasn’t been hopitalized during the
pregnancy
• He was born in aterm pregnancy, 38 weeks, delivered
by caesarean section at the hospital, crying vigorously,
no cyanosis or icteric was found and his birth weight
was 2100 grams

Conclusion: normal pregnancy and delivery

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VACCINATION HISTORY

0 month : Hepatitis B0
1 month : BCG, polio 1
2 months : DPT1, hepatitis B1, Hib1, polio2
3 months : DPT2, hepatitis B2, Hib2, polio3
4 months : DPT3, hepatitis B3, Hib3, polio4
9 moths :-
18 months -
24 months -

Conclusion :
complete immunization according ministry of
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health 2004
 FAMILY TREE
I

II

II
I

Baby Mrs’s, 8
15
days old, 3
kilograms
 NUTRITION HISTORY

Patient eat rice , vegetable and meat every days. Usually drink
mineral water
Conclusion: adequate quantity and quality

GROWTH
GROWTH AND
AND DEVELOPMENT
DEVELOPMENT

She is 16 years old now, 6.5 kgs in body weight, 68 cms in

body length
Birth weight : 2100 grams, birth length : 45 cms.
He can sit down and crawling

Conclusion: normal growth and development 16

NUTRITIONAL STATUS

• Weight for Age: W/A < + 3 SD

severe underweight
• Height for Age : -3SD < H/A < -2SD
stunted
• Weight for Length: W/H = + 1 SD
under nourished
Conclusion (WHO) :
Well nourished, underweight, stunted 17
PHYSICAL EXAMINATIONS

 Moderate illness, compos mentis

 Heart Rate = 122 bpm
 Respiratory rate = 42 times/ minute
 Temperature = 36,3o C per axillar
 O2 saturation = 97%

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 Head : mesocephaly (+), old man face (-)
 Eyes : pale conjunctiva (-/-), icteric sclera (-/-), tears (+/+)
cornea reflex (+/+)
Nose : nasal flaring (-), discharge (-/-)
 Mouth : wet lips (+), tonsil T1-T1 hyperemis (-/-), hiperemic
pharying (-/-), pale(-) ,cyanosis (-)
 Ear : discharge (-/-)
 Neck : enlargement of lymph node (-) mobile, tenderness (-),
the same color as the skin
 Thorax : symmetric (+), retraction (-)

LUNG:
 I: normal, symmetric, retraction (-)
 P: fremitus same in both side
 P: sonor in both lungs
 A: normal vesicular breathing sound, additional breathing sound 19
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 normal limit
P: tympani (+), shifting dullness (-), undulations (-)
P: supple, liver and spleen not palpable, epigastric pain (+), mcburney (-),
obturatory sign (-), psoas sign (-)

EXTREMITIES:
Warm, capillary refill time < 2 sec, and pedicle dorsalis artery was strongly
palpable. 20
LABORATORY RESULTS FEBRUARI 15TH 2020

  Value Reference Units

Hemoglobin 11.2 11.1-14.1 g/dl
Hematocrit 35 35-43 %
Leucocyte 29.8 5.0-19.5 103/ul
Platelet 178 150-450 103/ul
Eritrocyte 2.81 3.60-5.20 106/ul
MCV 125.4 80.0-96.0 /um
MCH 40.0 28.0-33.0 pg
MCHC 31.9 33.0-36.0 g/dl
PDW 19.9 11.6-14.6 %

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 LABORATORY RESULTS FEBRUARI 15TH 2020

  Value Reference Units

Eosinophil 0.00 1.00-2.00 %
Basophil 0.00 0.00-1.00 %
Netrophil 57.00 29.00-72.00 %
Lymphocyte 25.00 60.00-66.00 %
Monocyte 12.00 0.00-6.00 %
albumin 3.5 60-100 Mg/dl

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Conclusion : Normal
PROBLEM LIST

 Birthless (+)
 O2 saturation < 90
 Hiperbilirubinemia
 Well nourished, underweight, stunted

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DIFFERENTIAL DIAGNOSIS

 Neonates infection,
 DE : suspected acquired heart disease,
 DA : suspected AVSD,
 DF : Ross 1,
 down syndrome,
 hyperbilirubinemia,
 Neonate, Female, normal birth weight, aterm,
inappropriate for gestational age, born cesarean
section due to mother with olygrohidroamnion 24
WORKING DIAGNOSTIC

 Neonates infection,
 DE : suspected acquired heart disease,
 DA : suspected AVSD,
 DF : Ross 1,
 down syndrome,
 hyperbilirubinemia,
 Neonate, Female, normal birth weight, aterm,
inappropriate for gestational age, born cesarean 25

section due to mother with olygrohidroamnion

THERAPY

1. Diet ASI / formula milk 12 x 30 – 35 ml

2. Infus D51/2 NS 6 ml/hour iv
3. Ampicillin (50mg/ body weight/12 hours) 150
mg/12 hours iv

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PLAN

1. Complete Blood Count

2. Albumin
3. GDT IT-Ratio

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FOLLOW UP (26/02/2020)

 Moderate illness, compos mentis

 Heart Rate = 88 bpm
 Respiratory rate = 25 times/ minute
 Temperature = 36,8o C per axillar
 O2 saturation = 97%

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 FOLLOW UP May 2nd 2017
Issues New baby born
CNS cry vigorously(+), HC = 34 centimeters
Active movements (+)
Spontaneously opened her eyes (+)
Assessment: S5
CV system Heart rate : 150 bpm
Murmur (-), capillary refill time < 2’ , DPA strong palpable
Assessment: normal
Respiratio Respiration rate: 40 bpm
Chest retraction (-) Cyanotic (-)
n system Air entry (+) Grunting (-)
Assessment : mild respiratory distress

GIT Meconium (-) bowel sound (-), feces (-)vomitus (-), icterus (-)
Assessment :normal
system
Genitourinary Urine output not yet evaluated
system Assessment: cannpt evaluated yet
State of Thermoregulation status GIT system : no Assessment: new baby
infection (36,50C ) abnormalities found born
CNS (+) S5
CV system (-)
Respiration system : no
respiratory distress

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PROBLEM LIST

 Birthless (+)
 O2 saturation < 90
 Hiperbilirubinemia
 Well nourished, underweight, stunted

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DIFFERENTIAL DIAGNOSIS

 Neonates infection,
 DE : suspected acquired heart disease,
 DA : suspected AVSD,
 DF : Ross 1,
 down syndrome,
 hyperbilirubinemia,
 Neonate, Female, normal birth weight, aterm,
inappropriate for gestational age, born cesarean
section due to mother with olygrohidroamnion 31
WORKING DIAGNOSTIC

 Neonates infection,
 DE : suspected acquired heart disease,
 DA : suspected AVSD,
 DF : Ross 1,
 down syndrome,
 hyperbilirubinemia,
 Neonate, Female, normal birth weight, aterm,
inappropriate for gestational age, born cesarean 32

section due to mother with olygrohidroamnion

THERAPY

1. Diet ASI / formula milk 12 x 30 – 35 ml

2. Infus D51/2 NS 6 ml/hour iv
3. Ampicillin (50mg/ body weight/12 hours) 150
mg/12 hours iv

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PLAN

1. Complete Blood Count

2. Albumin
3. GDT IT-Ratio

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JOURNAL
 …THANK YOU
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