CASE REPORT

TETRALOGY OF FALLOT
Supervisor : dr. Muhammad Ali, Sp.A(K) Presentator: Citra Aryanti Marianto 080100050 080100112

PEDIATRICS DEPARTMENT MEDICAL FACULTY UNIVERSITY OF SUMATERA UTARA HAJI ADAM MALIK GENERAL HOSPITAL CENTER MEDAN 2013

CHAPTER

Introduction

CHAPTER 1

CHAPTER 2

CHAPTER 3

CHAPTER 4

CHAPTER 5

chapter

Literature Review

CHAPTER 1

CHAPTER 2

CHAPTER 3

CHAPTER 4

CHAPTER 5

Management of TOF
Newborn: PGE1 0.01-0.20 g/kg/min infusion

Prophylaxis and comorbidity treatment

Shunting and surgery

Lifestyle and rehabilitation

Infant: oral propanolol 0.51.5 mg/kg/6 h

What surgery?

Single stage

or

Double stage

Types of shunting

Hypoxic spells

Managemet of hypoxic spells

Phenylephrine Ketamine Fluid and acidosis correction Propranolol 25 g/kg020 g/kg IV slow push

Morphine 0,1-0,2 Oxygen mg/kg i.m. or s.c 100% Knee chest position

Complications
Cerebral abscess Bacterial endocarditis Arrythmia, heart block Iron deficiency anemia

Stroke

Heart block

Heart failure

Prognosis

CHAPTER

Case Report

CHAPTER 1

CHAPTER 2

CHAPTER 3

CHAPTER 4

CHAPTER 5

Personal Identity
Name Age Sex MR Address Date of Admission : : : : : : Muhammad Zuhri 6 years Male 54.21.61 Dusun I Desa Sartono Tebing Tinggi December, 25th 2012

History Taking
MZ, a 6 years old boy, weight 3.1 kg, height 98 cm, presented to Pediatrics Department at Haji Adam Malik General Hospital Center on December 25th 2012 at 16.00 with the main complaint history of bluish skin. Bluish skin was first experienced by the patient when he was 5 months. Bluish skin was found initially on the finger nail and spreaded slowly to the lips, head, and entire body. Shortness of breath was experienced by the patient all the time, especially when the patient was crying. Shortness of breath was not associated with the weather but strong associated with exertion. The child may play for only a short time before sitting or lying down. Once able to walk, the child often assumes a squatting position to catch his breath and then resumes physical activity within a few minutes.

The patient also encounter an easy of fatiguability. The child usually tires easily and begins panting with any form of exertion. The patient found it comfortable to curl at sleep and rest. History of frequently discontinued breast feeding was found. The patient often experienced rapid worsening shortness of breath along with dizziness and muscle rigidity while sometimes ended with syncope. Frequency 2-3 times a day and each attack lasted 5-20 minutes. Since 5 years old, the attack was decreasing in frequency (1-2 times in a week). Patient used squatting position to relieve his breath. This complaint mostly appeared when the patient was crying, feeding, dan waking up in the morning. The parents also felt that the patient was shorter than his peers. Urination and defecation were within normal limit. Cough and fever was not found. History of family experienced the same complaint was not found.

History of Previous illness: the patient was previously admitted to a general hospital at Tebing Tinggi with the same complaint five years ago. The patient was diagnosed with the heart disease by the general physician. Diagnosis was made by history and physical examination. Physicians there referred the patient to Haji Adam Malik Hospital but the patient refused to came by.
History of Previous medication: unknown herbs.

History of Pregnancy: the patients mother pregnant at age 28. Patient was the third child in his family. Antenatal care was never done by his mother. His mother felt very easily tired and weak when the pregnancy but never consult physicians for the complaint. No history of fever, infection, drugs, herbs and alcohol consumption was found. The mother was exposed to cigarette smoke when the pregnancy since his father was a smoker. History of stillbirth was not found.

History of Birth: the patient was born at the familys house and assisted by a nurse. Gestational age was 37 weeks. Patient was delivered on spontaneous labor and cried immediately. No icteric and cyanosis. Birth weight was 3,100 grams, birth length was not measured, and history of cyanosis was not found during the birth.
Feeding History Birth-6 months 6-9 months 9 months-2 years 2 years-until now

: Breast milk, formula milk, and rice porridge : Breast milk, formula milk, rice porridge, and soft rice : Breast milk, formula milk, rice porridge, and soft rice : Formula milk and family food

History of Growth and Development Sitting : 12 months Crawling : 18 months Standing : 24 months Talking : 24 months Walking : 60 months Reading : hasnt been sent to school yet
Developmental screening test on this patient: The patient can recognize colors well The patient cant hopping on one foot several times The patient cant write, draw, and read well The patient hardly able to maintain balance when standing on one foot The patient also hardly to answer some questions well It concluced that the patient has development delay. History of Immunization: BCG, DPT (1x), measles, polio (1x)

Physical Examination
PRESENCE STATUS Sensorium : compos mentis BP : 100/60 mmHg HR : 110 bpm RR : 30 x/min Temperature : 37oC. Anemic (-), dyspnea (+), cyanotic (+), edema (-), icteric (-). ANTROPOMETRIC STATUS Body weight (BW): 14 kg Body length (BL): 98 cm. CDC: BW/Age: 67%, BL/Age: 84%, BW/BL: 93%.

EYE

NOSE EARS MOUTH NECK

: light reflex (+/+), isochoric pupil 3 mm, inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-). : nasal flaring (+) : within normal limits : lips cyanosis (+), cyanotic tongue (+), oral candidiasis (-), atrophy papilla (-) : Lymph node enlargement (-)

Inspection
Palpation

Anterior Symmetrical fusiform Ictus cordis unvisible Lungs : Tactile fremitus right=left, normal impression Heart : Iktus kordis (+) Lungs : Resonant in both lungs

Posterior Symmetrical fusiform Lungs: right=left, normal impression Lungs: Resonant in both lungs

Percussion

Heart : Superior : ICR III sinistra border Right : LSD Left : 1 cm medial LMCS Auscultation Lungs : respiratory sounds vesicular, respiratory sounds no additional sound vesicular, no additional Heart : single S2 heart sound, sound murmur (+), systolic ejection murmur grade III/VI

ABDOMEN Inspection Palpation Perkusi Auskultasi

: : : :

symmetrical soepel, no palpation pain, H/L/R: not palpable tympanic normoperistaltic

EKSTREMITY Superior : sianosis (+/+), clubbing finger (+/+) Inferior : sianosis (+/+), clubbing finger (+/+), pretibial edema(-/-), pulsasi arteri (+/+), regular, pressure/volume adequate, CRT <2 seconds Acral : warm GENITALIA
Male, within normal limit.

BLOOD LABORATORY ANALYSIS

Complete Blood Count Hb Result 22.2 Unit gr% Referral 11.3 14.1

WBC RBC Hematocrite PLT

MCV MCH MCHC RDW

16.39 9.61 71 105

73.9 23.1 31.3 25.4

x 103/mm x 106/mm % x 10/mm

fL Pg g% %

4.5 13.5 4.40 4.48 37 41 150 450

81 95 25 29 29 31 11.6 14.8

Neutrophil
Lymphocyte Monocyte Eosinophil Basophil

83.1
12.8 3.8 0.1 0.2

%
% % % %

37 80
20 40 28 16 01

Blood Gas Analysis pH pCO2 pO2 Bicarbonat Total CO2 BaseExcess O2 Saturation

Result 7.189 22.2 79.0 8.3 9.0 -17.9 90.9

Unit

Referral 7.35-7.45

mmHg mmHg mmol/L mmol/L mmol/L %

38-42 85-100 22-26 19-25 (-2) - (+2) 95 100

Conclusion:severe acidocis metabolic with partial compensation, normoxemia Electrolyte Result Unit Referral Sodium 142 mEq/L 135-155 Kalium 4.1 mEq/L 3.5-5.5 Chloride 113 mEq/L 96-106

CHEST X-RAY
Asymmetrical photo, heart enlarged with upward apex, aorta arch elongated, decreased pulmonary vascularity was found, both hillus was blurred, hillus position was in the center, diaphragm and costophrenicus sinus angle was sharp. Bones was intact and normal. Conclusion: Congenital heart disease with increased vascularity

Electrocardiography
Sinus rhythm, QRS rate 135 bpm, QRS axis: left axis deviation, P pulmonale (+), PR interval 0,16 s, QRS pathologist on lead I and aVL, ST-T changes (+), T tall (+) on V3 and V5, LVH (-).

DIAGNOSIS
Differential Diagnosis: Cyanotic Congenital Heart Disease ec. dd/ 1. Tetralogy of fallot 2. Transposition of great artery 3. Pulmonary atresia + failure to thrive Temporary Diagnosis: Cyanotic congenital heart disease ec. tetralogy of fallot + failure to thrive

TREATMENT

Bed rest, knee chest position Regular meals 1500 kcal with 28 gram protein Urine catheter O2 1-2 L/i nasal cannule IVFD D5% NaCl 0,45% 100 gtt/i micro Lactulac syr 2 x Cth II (if necessary) Work up: balance every 6 hours, urine disptick Plan: Echocardiography, consultation to pediatric cardiology module

Follow up 26th December 2012 (Day 2) S : Blusih skin (+), shortness of breath (+) O : sens=compos mentis BP=100/60 mmHg, HR=92 x/i, RR=28 x/i, T=36,8C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm, inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-) Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2 cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border. Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable Extremities : pulse 92 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+). A : Cyanotic congenital heart disease ec. dd/ 1. TOF + failure to thrive 2. TGA 3. Pulmonary atresia P : - Bed rest, knee chest position - Regular meals 1500 kcal with 28 gram protein - O2 2 L/i nasal cannule - IVFD D5% NaCl 0,45% 100 gtt/i micro - Lactulac syr 2 x Cth I (if necessary)

Blood laboratory analysis Test Result Unit Complete blood count Hb 21.4 gr% WBC 8.96 x 103/mm RBC 6.96 x 106/mm Hematocrite 65.5 % PLT 114 x 10/mm MCV 73.1 fL MCH 23.9 pg MCHC 32.7 g% RDW 25 % Neutrophil 54.8 % Lymphocyte 34.7 % Monocyte 7.9 % Eosinophil 1.9 % Basophil 0.7 %

Referral 11.3 14.1 4.5 13.5 4.40 4.48 37 41 150 450 81 95 25 29 29 31 11.6 14.8 37 80 20 40 28 16 01

Fluid balance (06.00) Input= IVFD + Diet = 450 cc + 100 cc = 450 cc Output= IWL + UOP = 70 cc + 250 cc = 320 cc Balance= Input Output = 450 cc 320 cc = 130 cc Fluid requirement for the next 6 hours = 300 cc 130 cc = 170 cc (12.00) Input= IVFD + Diet = 350 cc + 150 cc = 500 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input Output = 500 cc 170 cc = 330 cc Fluid requirement for the next 6 hours = 300 cc 330 cc = -30 cc (18.00) Input= IVFD + Diet = 350 cc + 200 cc = 550 cc Output= IWL + UOP = 70 cc + 125 cc = 195 cc Balance= Input Output = 550 cc 195 cc = 335 cc Fluid requirement for the next 6 hours = 300 cc 335 cc = -35 cc Urine disptick (18.00) leu (-), nit (-), uro 0,2, pro , pH 5, blo (-), SG 1,02, ket (-), bil (-), glu (-)

Follow up 27th December 2012 (Day 3) S : Blusih skin (+), shortness of breath (+) O : sens=compos mentis BP=100/70 mmHg, HR=108 x/i, RR=28 x/i, T=36,5C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm, inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-) Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2 cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border. Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable Extremities : pulse 108 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+). A : Cyanotic congenital heart disease ec. dd/ 1. TOF + failure to thrive 2. TGA 3. Pulmonary atresia P : - Bed rest, knee chest position - Regular meals 1500 kcal with 28 gram protein - O2 2 L/i nasal cannule - IVFD D5% NaCl 0,45% 100 gtt/i micro - Propranolol 4 x10 mg - Lactulac syr 2 x Cth II (if necessary) Plan: echocardiography, phlebomtomy

Fluid balance (00.00) Input= IVFD + Diet = 100 cc + 200 cc = 300 cc Output= IWL + UOP = 70 cc + 250 cc = 320 cc Balance= Input - Output = 300 cc - 320 cc = -20 cc (06.00) Input= IVFD + Diet = 100 cc + 100 cc = 200 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input Output = 200 cc 170 cc = 30 cc Fluid requirement for the next 6 hours = 300 cc - 30 cc = 270 cc (12.00) Input= IVFD + Diet = 100 cc + 100 cc = 200 cc Output= IWL + UOP = 70 cc + 50 cc = 120 cc Balance= Input Output = 200 cc 120 cc = 80 cc Fluid requirement for the next 6 hours = 300 cc - 80 cc = 220 cc (18.00) Input= IVFD + Diet = 200 cc + 150 cc = 350 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 350 cc - 170 cc = 180 cc Fluid requirement for the next 6 hours = 300 cc - 180 cc = 120 cc Urine dipstick (00.00) leu (-), nit (-), uro 0,2, pro , pH 5, blo (-), SG 1,005, ket (-), bil (-), glu (-) (12.00) leu (-), nit (-), uro 0,2, pro +, pH 6, blo (-), SG 1,015, ket (-), bil (-), glu (-) (18.00) leu (-), nit (-), uro 0,2, pro +, pH 6, blo (-), SG 1,025, ket (-), bil (-), glu (-)

Follow up 28th December 2012 (Day 4) S : Blusih skin (+), shortness of breath (+) O : sens=compos mentis BP=90/60 mmHg, HR=110 x/i, RR=24 x/i, T=36,7C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm, inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-) Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2 cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border. Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable Extremities : pulse 110 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+). A : Cyanotic congenital heart disease ec. dd/ 1. TOF + failure to thrive 2. TGA 3. Pulmonary atresia P : - Bed rest - Regular meals 1500 kcal with 28 gram protein - O2 2 L/i nasal cannule - IVFD D5% NaCl 0,45% 50 gtt/i micro - Propranolol 4 x10 mg - Lactulac syr 2 x Cth II (if necessary)

Echocardiography today

Fluid balance (00.00) Input= IVFD + Diet = 100 cc + 150 cc = 350 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 350 cc - 170 cc = 180 cc Fluid requirement for the next 6 hours = 300 cc - 180 cc = 120 cc (06.00) Input= IVFD + Diet = 50 cc + - = 50 cc Output= IWL + UOP = 70 cc + - = 70 cccc Balance= Input - Output = 50 cc - 70 cc = -20 cc Fluid requirement for the next 6 hours = 300 cc + 20 cc = 320 cc (12.00) Input= IVFD + Diet = 100 cc + 100 cc = 200 cc Output= IWL + UOP = 70 cc + 250 cc = 320 cc Balance= Input - Output = 200 cc - 320 cc = -120 cc Fluid requirement for the next 6 hours = 300 cc + 120 cc = 420 cc (18.00) Input= IVFD + Diet = 200 cc + 100 cc = 300 cc Output= IWL + UOP = 70 cc + 250 cc = 320 cc Balance= Input - Output = 300 cc - 320 cc = -20 cc Fluid requirement for the next 6 hours = 300 cc + 20 cc = 320 cc Urine dipstick (00.00) leu (-), nit (-), uro 0,2, pro , pH 5, blo (-), SG 1,005, ket (-), bil (-), glu (-) (12.00) leu (-), nit (-), uro 0,2, pro +, pH 6, blo (-), SG 1,015, ket (-), bil (-), glu (-) (18.00) leu (-), nit (-), uro 0,2, pro +, pH 6, blo (-), SG 1,025, ket (-), bil (-), glu (-)

Results of echocardiography The echocardiogram revelead severe infundibular pulmonary stenosis with a large but mild alignment ventricular septal defect and a large aortic override (>50%). There was no patent ductus arteriosus, no pericardial effusion, and no collateral image. Conclusion: tetralogy of fallot.

Follow up 29th December 2012 (Day 5) S : Blusih skin (+), shortness of breath (+) O : sens=compos mentis BP=100/70 mmHg, HR=100 x/i, RR=22 x/i, T=36C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm, inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-) Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2 cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border. Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable Extremities : pulse 100 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+). A : Tetralogy of fallot + failure to thrive P : - Bed rest, knee chest position - Regular meals 1500 kcal with 28 gram protein - O2 2 L/i nasal cannule - IVFD D5% NaCl 0,45% 50 gtt/i microaff - Propranolol 4 x10 mg - Lactulac syr 2 x Cth II (if necessary) Plan: cardiac catheterization, phlebotomy

Fluid balance (00.00) Input= IVFD + Diet = 100 cc + 100 cc = 200 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input Output = 200 cc 170 cc = 30 cc Fluid requirement for the next 6 hours = 300 cc - 30 cc = 270 cc (06.00) Input= IVFD + Diet = 100 cc + 0 cc = 100 cc Output= IWL + UOP = 70 cc + 50 cc = 120 cc Balance= Input - Output = 100 cc - 120 cc = -20 cc Fluid requirement for the next 6 hours = 300 cc + 20 cc = 320 cc (12.00) Input= IVFD + Diet = 50 cc + 120 cc = 170 cc Output= IWL + UOP = 70 cc + 50 cc = 120 cc Balance= Input - Output = 170 cc - 120 cc = 50 cc Fluid requirement for the next 6 hours = 300 cc - 50 cc = 250 cc (08.00) Input= IVFD + Diet = 100 cc + 100 cc = 200 cc Output= IWL + UOP = 70 cc + 50 cc = 120 cc Balance= Input - Output = 200 cc - 120 cc = 80 cc Fluid requirement for the next 6 hours = 300 cc - 80 cc = 220 cc Urine dipstick (06.00) leu (-), nit (-), uro 0,2, pro , pH 5, blo (-), SG 1,020, ket (-), bil (-), glu (-)

Follow up 30th December 2012 (Day 6) S : Blusih skin (+), shortness of breath (+) O : sens=compos mentis BP=100/70 mmHg, HR=98 x/i, RR=22 x/i, T=36,3C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm, inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-) Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2 cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border. Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable Extremities : pulse 98 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+). A : Tetralogy of fallot + failure to thrive P : - Bed rest - Regular meals 1500 kcal with 28 gram protein - IVFD D5% NaCl 0,45% 50 gtt/i microaff - O2 2 L/i nasal cannule (if necessary) - Propranolol 4 x 10 mg - Lactulac syr 2 x Cth II (if necessary) Plan: cardiac catheterization, phlebotomy

Fluid balance (00.00) Input= IVFD + Diet = - + 200 cc = 200 cc Output= IWL + UOP = 70 cc + 50 cc = 120 cc Balance= Input - Output = 200 cc - 120 cc = 80 cc Fluid requirement for the next 6 hours = 300 cc - 80 cc = 220 cc (06.00) Input= IVFD + Diet = - + 200 cc = 200 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 200 cc - 170 cc = 30 cc Fluid requirement for the next 6 hours = 300 cc - 30 cc = 270 cc (12.00) Input= IVFD + Diet = - + 120 cc = 120 cc Output= IWL + UOP = 70 cc + 50 cc = 120 cc Balance= Input - Output = 120 cc - 120 cc = 0 cc Fluid requirement for the next 6 hours = 300 cc - 0 cc = 300 cc (18.00) Input= IVFD + Diet = - + 250 cc = 250 cc Output= IWL + UOP = 70 cc + 300 cc = 370 cc Balance= Input - Output = 250 cc - 370 cc = -120 cc Fluid requirement for the next 6 hours = 300 cc + 120 cc = 420 cc Urine dipstick (06.00) leu (-), nit (-), uro 0,2, pro , pH 5, blo (-), SG 1,020, ket (-), bil (-), glu (-)

Follow up 31st December 2012 (Day 7) S : Blusih skin (+), shortness of breath (+) O : sens=compos mentis BP=100/70 mmHg, HR=104 x/i, RR=28 x/i, T=36,3C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm, inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-) Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2 cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border. Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable Extremities : pulse 104 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+). A : Tetralogy of fallot + failure to thrive P : - Bed rest, knee chest position - Regular meals 1500 kcal with 28 gram protein - O2 2 L/i nasal cannule (if necessary) - Propranolol 4 x 10 mg - Lactulac syr 2 x Cth II (if necessary) Plan: cardiac catheterization, phlebotomy

Fluid balance (00.00) Input= IVFD + Diet = - + 100 cc = 100 cc Output= IWL + UOP = 70 cc + 300 cc = 370 cc Balance= Input - Output = 100 cc - 370 cc = -270 cc Fluid requirement for the next 6 hours = 300 cc + 270 cc = 570 cc (06.00) Input= IVFD + Diet = - + 175 cc = 200 cc Output= IWL + UOP = 70 cc + 25 cc = 95 cc Balance= Input - Output = 200 cc - 95 cc = 105 cc Fluid requirement for the next 6 hours = 300 cc - 105 cc = 195 cc (12.00) Input= IVFD + Diet = - + 300 cc = 300 cc Output= IWL + UOP = 70 cc + 150 cc = 220 cc Balance= Input - Output = 300 cc - 220 cc = 80 cc Fluid requirement for the next 6 hours = 300 cc - 80 cc = 220 cc (18.00) Input= IVFD + Diet = - + 200 cc = 200 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 200 cc - 170 cc = 30 cc Fluid requirement for the next 6 hours = 200 cc - 30 cc = 170 cc Urine dipstick (06.00) leu (-), nit (-), uro 0,2, pro , pH 5, blo (-), SG 1,010, ket (-), bil (-), glu (-)

Follow up 1st January 2013 (Day 8) S : Blusih skin (+), shortness of breath (+) O : sens=compos mentis BP=100/70 mmHg, HR=100 x/i, RR=26 x/i, T=36,5C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm, inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-) Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2 cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border. Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable Extremities : pulse 100 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+). A : Tetralogy of fallot + failure to thrive P : - Bed rest - Regular meals 1500 kcal with 28 gram protein - O2 2 L/i nasal cannule (if necessary) - Propranolol 4 x 10 mg - Lactulac syr 2 x Cth II (if necessary) Plan: cardiac catheterization, phlebotomy

Fluid balance (00.00) Input= IVFD + Diet = - + 200 cc = 200 cc Output= IWL + UOP = 70 cc + 150 cc = 220 cc Balance= Input - Output = 200 cc - 220 cc = -20 cc Fluid requirement for the next 6 hours = 300 cc + 20 cc = 320 cc (06.00) Input= IVFD + Diet = - + 100 cc = 100 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 100 cc - 170 cc = 270 cc Fluid requirement for the next 6 hours = 100 cc - 270 cc = -170 cc (12.00) Input= IVFD + Diet = - + 200 cc = 200 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 200 cc - 170 cc = 30 cc Fluid requirement for the next 6 hours = 300 cc - 30 cc = 270 cc (18.00) Input= IVFD + Diet = - + 200 cc = 200 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 200 cc - 170 cc = 30 cc Fluid requirement for the next 6 hours = 200 cc - 30 cc = 170 cc Urine dipstick (06.00) leu (-), nit (-), uro 0,2, pro , pH 6, blo (-), SG 1,015, ket (-), bil (-), glu (-)

Follow up 2nd January 2013 (Day 8) S : Blusih skin (+), shortness of breath (+) O : sens=compos mentis BP=100/70 mmHg, HR=98 x/i, RR=28 x/i, T=36,5C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm, inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-) Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2 cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border. Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable Extremities : pulse 98 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+). A : Tetralogy of fallot + failure to thrive P : - Bed rest, knee chest position - Regular meals 1500 kcal with 28 gram protein - O2 2 L/i nasal cannule (if necessary) - Propranolol 4 x 10 mg - Lactulac syr 2 x Cth II (if necessary) Plan: cardiac catheterization, phlebotomy

Fluid balance (00.00) Input= IVFD + Diet = - + 100 cc = 100 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 100 cc - 170 cc = -70 cc Fluid requirement for the next 6 hours = 300 cc + 70 cc = 370 cc (06.00) Input= IVFD + Diet = - + 100 cc = 100 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 100 cc - 170 cc = 270 cc Fluid requirement for the next 6 hours = 100 cc - 270 cc = -170 cc (12.00) Input= IVFD + Diet = - + 300 cc = 300 cc Output= IWL + UOP = 70 cc + 200 cc = 270 cc Balance= Input - Output = 300 cc - 270 cc = 30 cc Fluid requirement for the next 6 hours = 300 cc - 30 cc = 270 cc (18.00) Input= IVFD + Diet = - + 250 cc = 200 cc Output= IWL + UOP = 70 cc + 150 cc = 220 cc Balance= Input - Output = 200 cc - 220 cc = 20 cc Fluid requirement for the next 6 hours = 200 cc + 20 cc = 220 cc Urine dipstick (06.00) leu (-), nit (-), uro 0,2, pro , pH 6, blo (-), SG 1,020, ket (-), bil (-), glu (-)

Follow up 3rd January 2013 (Day 8) Blusih skin (+), shortness of breath (+) sens=compos mentis BP=100/70 mmHg, HR=98 x/i, RR=24 x/i, T=36,1C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm, inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-) Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2 cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border. Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable Extremities : pulse 98 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+). Tetralogy of fallot + failure to thrive - Bed rest - Regular meals 1500 kcal with 28 gram protein - O2 2 L/i nasal cannule (if necessary) - Propranolol 4 x 10 mg - Lactulac syr 2 x Cth II (if necessary) Plan: cardiac catheterization, phlebotomy

Fluid balance (00.00) Input= IVFD + Diet = - + 100 cc = 100 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 100 cc - 170 cc = -70 cc Fluid requirement for the next 6 hours = 300 cc + 70 cc = 370 cc (06.00) Input= IVFD + Diet = - + 200 cc = 200 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 200 cc - 170 cc = 30 cc Fluid requirement for the next 6 hours = 300 cc - 30 cc = 270 cc (12.00) Input= IVFD + Diet = - + 250 cc = 250 cc Output= IWL + UOP = 70 cc + 300 cc = 370 cc Balance= Input - Output = 250 cc - 370 cc = -120 cc Fluid requirement for the next 6 hours = 300 cc + 120 cc = 420 cc (18.00) Input= IVFD + Diet = - + 300 cc = 300 cc Output= IWL + UOP = 70 cc + 250 cc = 320 cc Balance= Input - Output = 300 cc - 320 cc = -20 cc Fluid requirement for the next 6 hours = 300 cc + 20 cc = 320 cc Urine dipstick (06.00) leu (-), nit (-), uro 0,2, pro , pH 6, blo (-), SG 1,020, ket (-), bil (-), glu (-)

Follow up 4th January 2013 (Day 9) S : Blusih skin (+), shortness of breath (+), fever (+) O : sens=compos mentis BP=100/70 mmHg, HR=92 x/i, RR=24 x/i, T=37,9C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm, inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-) Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2 cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border. Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable Extremities : pulse 92 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+). A : Tetralogy of fallot + failure to thrive P : - Bed rest, knee chest position - Regular meals 1500 kcal with 28 gram protein - O2 2 L/i nasal cannule (if necessary) - Propranolol 4 x 10 mg - Paracetamol 3 x 150 mg - Lactulac syr 2 x Cth II (if necessary) Plan: cardiac catheterization and phlebotomy on 7th January 2013

Blood laboratory test for cardiac catheterization preparation Test Result Unit Complete blood count Hb 22.1 gr% WBC 7.72 x 103/mm RBC 9.57 x 106/mm Hematocrite 70.4 % PLT 70 x 10/mm MCV 73.6 fL MCH 23.1 pg MCHC 31.4 g% RDW 26.2 % Neutrophil 61.4 % Lymphocyte 25.3 % Monocyte 9.1 % Eosinophil 3.4 % Basophil 0.8 % Liver function test Total bilirubin 0.71 mg/dL Direct bilirubin 0.46 mg/dL ALP 210 U/L AST/SGOT 83 U/L ALT/SGPT 10 U/L Renal function test Ureum 35 mg/dL Creatinin 0.33 mg/dL Uric Acid 9.5 mg/dL Immunoserologic HbsAg Negative Cut off index > 10 Anti-Hbs Negative Positive Anti HAV IgM Negative Negative < 1.0 Anti HCV Negative Cut off index > 10
Fluid balance (00.00) Input= IVFD + Diet = - + 100 cc = 100 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 100 cc - 170 cc = -70 cc Fluid requirement for the next 6 hours = 300 cc + 70 cc = 370 cc (06.00) Input= IVFD + Diet = - + 250 cc = 250 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 250 cc - 170 cc = 80 cc Fluid requirement for the next 6 hours = 300 cc - 80 cc = 220 cc (12.00) Input= IVFD + Diet = - + 300 cc = 300 cc Output= IWL + UOP = 70 cc + 300 cc = 370 cc Balance= Input - Output = 300 cc - 370 cc = -70 cc Fluid requirement for the next 6 hours = 300 cc + 70 cc = 370 cc (18.00) Input= IVFD + Diet = - + 200 cc = 200 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 200 cc - 170 cc = 30 cc Fluid requirement for the next 6 hours = 200 cc - 30 cc = 170 cc Urine dipstick (06.00) leu (-), nit (-), uro 0,2, pro , pH 6, blo (-), SG 1,020, ket (-), bil (-), glu (-)

Referral 11.3 14.1 4.5 13.5 4.40 4.48 37 41 150 450 81 95 25 29 29 31 11.6 14.8 37 80 20 40 28 16 01 <1 0-0.2 <269 <38 <41 <50 0.32-0.59 <7.0

Follow up 5th January 2013 (Day 10) S : Blusih skin (+), shortness of breath (+), fever (-) O : sens=compos mentis BP=100/70 mmHg, HR=88 x/i, RR=24 x/i, T=36C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm, inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-) Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2 cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border. Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable Extremities : pulse 88 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+). A : Tetralogy of fallot + failure to thrive P : - Bed rest - Regular meals 1500 kcal with 28 gram protein - O2 2 L/i nasal cannule (if necessary) - Propranolol 4 x 10 mg - Paracetamol 3 x 150 mg (if necessary) - Lactulac syr 2 x Cth II (if necessary) Plan: cardiac catheterization and phlebotomy on 7th January 2013

Fluid balance (00.00) Input= IVFD + Diet = - + 100 cc = 100 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 100 cc - 170 cc = -70 cc Fluid requirement for the next 6 hours = 300 cc + 70 cc = 370 cc (06.00) Input= IVFD + Diet = - + 200 cc = 200 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 200 cc - 170 cc = 30 cc Fluid requirement for the next 6 hours = 300 cc - 30 cc = 270 cc (12.00) Input= IVFD + Diet = - + 250 cc = 250 cc Output= IWL + UOP = 70 cc + 300 cc = 370 cc Balance= Input - Output = 250 cc - 370 cc = -120 cc Fluid requirement for the next 6 hours = 300 cc + 120 cc = 420 cc (18.00) Input= IVFD + Diet = - + 100 cc = 100 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 100 cc - 170 cc = 270 cc Fluid requirement for the next 6 hours = 300 cc - 270 cc = -170 cc Urine dipstick (06.00) leu (-), nit (-), uro 0,2, pro , pH 6, blo (-), SG 1,015, ket (-), bil (-), glu (-)

Follow up 6th January 2013 (Day 12) S : Blusih skin (+), shortness of breath (+), fever (-) O : sens=compos mentis BP=100/70 mmHg, HR=98 x/i, RR=26 x/i, T=36,8C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm, inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-) Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2 cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border. Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable Extremities : pulse 98 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+). A : Tetralogy of fallot + failure to thrive P : - Bed rest - Regular meals 1500 kcal with 28 gram protein - O2 2 L/i nasal cannule (if necessary) - Propranolol 4 x 10 mg - Lactulac syr 2 x Cth II (if necessary) Plan: cardiac catheterization and phlebotomy on 7 th January 2013

Preparation for cardiac catheterization 1. Informed consent 2. Antibiotic prophylaxis cefotaxime 50 mg/kg (700 mg for this patient) - 1 hour before catheterization 3. Fasting min. 4 hours before catheterization Blood laboratory analysis Test Result Unit Referral Hemostatic test Bleeding time 430 minutes <5 PT + INR Protrombin time Control 13.3 seconds Patient 21.2 seconds INR 1.64 APTT Control 31.7 seconds Patient 35.5 seconds Trombin time Control 18.3 seconds Patient 16.8 seconds
Fluid balance (00.00) Input= IVFD + Diet = - + 100 cc = 100 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 100 cc - 170 cc = -70 cc Fluid requirement for the next 6 hours = 300 cc + 70 cc = 370 cc (06.00) Input= IVFD + Diet = - + 200 cc = 200 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 200 cc - 170 cc = 30 cc Fluid requirement for the next 6 hours = 300 cc - 30 cc = 270 cc (12.00) Input= IVFD + Diet = - + 250 cc = 250 cc Output= IWL + UOP = 70 cc + 300 cc = 370 cc Balance= Input - Output = 250 cc - 370 cc = -120 cc Fluid requirement for the next 6 hours = 300 cc + 120 cc = 420 cc (18.00) Input= IVFD + Diet = - + 100 cc = 100 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 100 cc - 170 cc = 270 cc Fluid requirement for the next 6 hours = 100 cc - 270 cc = -170 cc Urine dipstick (06.00) leu (-), nit (-), uro 0,2, pro , pH 6, blo (-), SG 1,010, ket (-), bil (-), glu (-)

Follow up 7th January 2013 (Day 13) S : Blusih skin (+), shortness of breath (+) O : sens=compos mentis BP=100/70 mmHg, HR=88 x/i, RR=24 x/i, T=36,5C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm, inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-) Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2 cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border. Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable Extremities : pulse 88 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+). A : Tetralogy of fallot + failure to thrive P : - Bed rest, knee chest position - Fasting for catheterization from 04.00 - O2 2 L/i nasal cannule (if necessary) - Three way - IVFD NaCl 0,9% 50 gtt/i (micro) - Inj. cefotaxime 700 mg/12 hours (day 1) (started 07.30) - Propranolol 4 x 10 mg - Lactulac syr 2 x Cth II (if necessary)

Cardiac catheterization and phlebotomy today

Cardiac catheterization report (08.48-09.27) Angiography: Hand injection at innominate vein: no persistent left subclavian vein Right ventricle: large VSD, aortic overriding, severe infundibular pulmonary stenosis, LPA 7,5 mm, RPA 8,5 mm Aortogram: good coronary artery postion, no collateral, no patent ductus arteriosus Conclusion : Tetralogy of fallot Nakata index 168, Mc Goon ratio 1,31 Note: During procedure, 150 cc blood has been taken (phlebotomy) Advice:Keep following until the patient fully awake

Watchout for bleeding at puncture site Continue cefotaxime i.v. for total 2 days

Follow up 8th January 2013 (Day 14) S : Post cardiac catheterization day 1, Blusih skin (+), shortness of breath (+) O : sens=compos mentis BP=90/70 mmHg, HR=128 x/i, RR=32 x/i, T=38C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm, inferior conjuctiva palpebra normal, icteric sclera (-/-) Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2 cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border. Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable Extremities : pulse 128 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+). A : Tetralogy of fallot + failure to thrive P : - Bed rest - Regular meals 1500 kcal with 28 gram protein - O2 1-2 L/i nasal cannule - Three way - IVFD NaCl 0,9% 20 gtt/i (micro) - Inj. cefotaxime 700 mg/12 hours (day 2) - Propranolol 4 x 10 mg - Paracetamol 3 x 150 mg - Lactulac syr 2 x Cth II (if necessary)

Follow up 9th January 2013 (Day 15) S : Post cardiac catheterization day 1, Blusih skin (+), shortness of breath (+), fever (-) O : sens=compos mentis BP=90/70 mmHg, HR=98 x/i, RR=26 x/i, T=36,5C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm, inferior conjuctiva palpebra normal, icteric sclera (-/-) Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2 cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border. Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable Extremities : pulse 98 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+). A : Tetralogy of fallot + failure to thrive P : - Bed rest, knee chest position - Regular meals 1500 kcal with 28 gram protein - O2 1-2 L/i nasal cannuleaff - Three wayaff - IVFD NaCl 0,9% 20 gtt/i (micro)aff - Inj. cefotaxime 700 mg/12 hoursaff - Propranolol 4 x 10 mg - Paracetamol 3 x 150 mg - Lactulac syr 2 x Cth II (if necessary)

Patient was discharged from hospital on 9th January 2013 because he was referred to Jakarta for surgical preparation and intervention.

CHAPTER 1

CHAPTER 2

CHAPTER 3

CHAPTER 4

CHAPTER 5

CASE REPORT

TETRALOGY OF FALLOT
Supervisor : dr. Muhammad Ali, Sp.A(K) Presentator: Citra Aryanti Marianto 080100050 080100112

PEDIATRICS DEPARTMENT MEDICAL FACULTY UNIVERSITY OF SUMATERA UTARA HAJI ADAM MALIK GENERAL HOSPITAL CENTER MEDAN 2013