Case Conference

Sunday, september 5th, 2017

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DR. PITRA/DR. HAMID/ DR. PRIMA/ DR. WINDA/ DR. PATRA/ DR.KANDAR

DR. IZNI/DR. PRABU

DR. AYA/DR. DEVI

 PATIENT ADMISSION
2
Melati 2

HCU Neonatus
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NICU
-
HCU Melati 2
-
PICU
-
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IDENTITY

Name :MW
Age/Wt/L : 2 yo/ 10 kgs / 97 cms
Sex : Boy
Address : Wonogiri
Medical : 01391288
Record
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CHIEF COMPLAINT
Fever
 THE CURRENT MEDICAL HISTORY
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5 days before
Patient had fever, fever with
discharge came out from her
admission
ears, no symptom of chough, no
seizure Patient had fever, look pale,
Patient look pale, defecate Defecate and urinate with normal
blackish colour,
Eat and drink regularly
No nausea or vomit
No vomiting blood
Patient check the laborathory
result haemoglobin is 4,5 gr/dl
Patient check the laborathory
result haemoglobin is 8,4 gr/dl

9 days before
admision
THE CURRENT MEDICAL HISTORY
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fever
Patient checked into pediatrican the
patient is referred ro moewardi hospital
Defecate and urinate with normal
No nausea or vomit
Patient look pale

Admission
day
 THE PAST MEDICAL HISTORY
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Never been Hospitalised

No history of anemia
 THE FAMILY MEDICAL HISTORY
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No other family with tuberculosis

No other family with same symtoms
 HISTORY OF PREGNANCY AND DELIVERY
Pregnancy
The patient is the only child of his family. He was born from a 35 years
old mother with G2P1A0, at 38th weeks of gestational age. His mother
consumed vitamins from a doctor. According to the mother, she had
routinely check up to the doctor and midwife. There was no history of
hospital admission during pregnancy.

Delivery
The patient was delivered with Caesarean section due to stuck labour.
There were no complication during procedure. The baby was crying
vigourously, weighed 3400 grams and 49 cms in length, the amniotic
fluid was clear.
Conclusion : pregnancy and delivery history were normal

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 VACCINATION HISTORY

BCG : 1 month
Hepatitis B0 : 0 month
DPT : 2,3,4 month
Polio : 1,2,3,4 month
Measles : 9 month
MR booster : 2 year

Conclusion : completed according to Ministry of Health

schedule

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 PEDIGREE

II

III

MW 2 yo 3 month
 NUTRITIONAL HISTORY
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Patient eats 2-3 times a day, consist of rice, egg, and vegetables. She
was just trained to eat solid food by her mother. Patient has
difficulty in feeding due to her condition. HShe not like drinks millk
Conclusion: nutrition status : quality is not adequate,
quantity is adequate

Growth and Development

GROWTH History
AND DEVELOPMENT
She is now 2 years 3 months old, She can walk by him self only.
Play with hermates , She can understand the daily conversation
Her weight is 10 kg
Conclusion: growth development is appropriate for his
age
 NUTRITIONAL STATUS

Wt/A : 10 /12 x100 = 83,3 -2 SD < BB/U < 0 SD (Normoweight)

Ht/A : :97/89 x100 = 108 2 SD < TB/U < 3 SD (Normoheight)
Wt/Ht: 10/14 x 100 = 71,4 -2 SD < BB/TB < -3 SD
(undernourished)

Conclusion : undernourished normoweight,

normoheight
(WHO, 2006)

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 PHYSICAL EXAMINATION
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GA: moderate ill, fully alert, GCS E4V5M6

VS : Heart rate: 100 bpm Temp: 39,6oC
Resp. rate : 36 bpm SiO2 : 98%
Head : mesocephal circumference 46 cm (2 sd nellhouse)
Eyes : anemic conjunctiva +/+, icteric sclera -/-, isocoric
pupil (2mm/2mm), light reflex (+/+)
Nose : Nostrils Flares (-) nasal discharge (+)
Mouth: cyanosis (-), hyperemic pharynx (-), Tonsil T2-T2
hyperemic (-)
Ears : Ear discharge -/-
Neck : Lymph node enlargement (-)
LUNG: 16
I : normal, symmetric, no retraction
P : hard to evaluate
P : sonor in both lung
A : normal vesicular breath sound, additional breath sound
(-/-)

CARDIAC:
I : ictus cordis not visible
P : ictus cordis palpable at SIC I V LMCS
P : there is no cardiac enlargement
A : 1st 2nd Heart sound normal intensity, regular, no murmur
ABDOMINAL:
I : abdominal wall // thorax wall
A : peristaltic in normal limit
P : shifting dullness (-), undulations(-)
P : there is enlargement of the liver 1 cm, splenomegali shuffner 1

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis
pedis artery was palpably strong.

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September55h 2017 LABORATORY FINDING
Value Reference Units
Hemoglobin 4,6 12.3-15.3 g/dl
Hematocrit 16 33-45 %
Leucocyte 8,4 4.5-14.5 x103/ul
Thrombocyte 224 150-450 x103/ul
Eritrocyte 2.11 3.8-5.8 x106/ul
MCV 73.9 80.0-96.0 /um
MCH 21.8 28.0-33.0 pg
MCHC 29.5 33.0-36.0 g/dl
RDW 24.9 11.6-14.6 %
MPV 78,1 7.2-11.1 fl
PDW 16 25-65 %
Eosinophil 4 0.00-4.00 %
Basophil 0,4 0.00-1.00 %
Neutrophil 73,9 29.00-72.00 %
Lymphocyte 16,9 33.00-48.00 %
Monocyte 4,8 0.00-6.00 %
RBG 121 60-100 mg/dl

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 LABORATORY FINDING

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Conclusion
Micrositic hipokromic anemia
Neutrophilia
Lymphocytopenia
September 25h 2017 LABORATORY FINDING
Value Reference Units
Hemoglobin 4,8 12.3-15.3 g/dl
Hematocrit 17,2 33-45 %
Leucocyte 10,6 4.5-14.5 x103/ul
Thrombocyte 244 150-450 x103/ul
Eritrocyte 2.39 3.8-5.8 x106/ul
MCV 72.9 80.0-96.0 /um
MCH 20.1 28.0-33.0 pg
MCHC 27.9 33.0-36.0 g/dl
RDW 26,3 11.6-14.6 %
7.2-11.1 fl
25-65 %
Eosinophil 2 0.00-4.00 %
Basophil 0,7 0.00-1.00 %
Neutrophil 73,1 29.00-72.00 %
Lymphocyte 18,4 33.00-48.00 %
Monocyte 5,8 0.00-6.00 %
LED 96 0-10 mm/hour
HSCRP
61,3 0,8-0,9

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 LABORATORY FINDING

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Conclusion
Micrositic hipokromic anemia
Neutrophilia
Lymphocytopenia
Increase of HSCRP dan LED
 PROBLEMS
A girl, 2 years old, 10 kgs, with :
1. High fever (>390)
2. No dyspnea
3. History of melena
4. Ear discharge (+)
5. Microcitic hyprochomic anemia
6. Leucocytosis
7. Neutrophilia
8. Lymphocytopenia
9. Increase HSCRP and LED
10. undernourish

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 DIFFERENTIAL DIAGNOSIS

1. Prolonged fever dd/ UTI dd/ TB

2. Micrositic hipokromic anemia dd chronic
infection dd thallasemia
3. undernourished normoweight,
normoheight

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 WORKING DIAGNOSIS

1. Prolonged fever dd/ UTI dd/ TB

2. Micrositic hipokromic anemia dd chronic
infection dd thallasemia
3. undernourished normoweight,
normoheight

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 THERAPY
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1. Admitted to Infection Ward

2. Diet rice pack 1000 kkal/day
3. IVFD D51/4NS 40 mL/hour
4. Inj. Ampicillin sulbactam (25mg/kgBW/6h) 250
mg/6h i.v
5. Paracetamol (10mg/kgBW/8h) 120 mg/8h po
6. PRC tranfusion (1) 50 cc distance 12 hour
(2) 50 cc
(3) 120 cc distance 24 hour
 PLAN
1. urinalysis, feses analysis
2. Otolaryngologist and dental consult
3. Reticulosit count
4. Thorax rontgent
5. Blood culture
6. Ig M salmonella, Ig G salmonella

MONITORING

General Appearance/Vital Signs /8 hours

Fluid balance and Diuresis / 8 hours

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 Follow up 7-9-2017

S : fever still up and down with antipyretic

cough and rhinorrhea no improvement
O: General appearance moderate illness, fully alert
Heart rate : 114 bpm
Respiratory rate : 24 bpm
Axilla temperature : 37.6 C
Oxygen saturation :97%
Head : normocephal,
Eyes : anemic conjunctiva -/-, icteric sclera -/-, isocoric pupil
(2mm/2mm), light reflex (+/+)
Nose : Nasal Flares (-) nasal discharge (-)
Mouth : cyanosis (-), hyperemic pharynx, Tonsil T2-T2
hyperemic (+)
Ears : Ear discharge -/-
Neck : Lymph node enlargement (-)
Chest : Symmetrical in shape and movement, chest indrawing (-)
 Follow up 7-9-2017
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GA: moderate ill, fully alert, GCS E4V5M6

VS : Heart rate: 98 bpm Temp: 38,4oC
Resp. rate : 32 bpm SiO2 : 98%
Head : mesocephal circumference 46 cm (2 sd nellhouse)
Eyes : anemic conjunctiva +/+, icteric sclera -/-, isocoric
pupil (2mm/2mm), light reflex (+/+)
Nose : Nostrils Flares (-) nasal discharge (+)
Mouth: cyanosis (-), hyperemic pharynx (-), Tonsil T2-T2
hyperemic (-)
Ears : Ear discharge -/-
Neck : Lymph node enlargement (-)
LUNG: 29
I : normal, symmetric, no retraction
P : hard to evaluate
P : sonor in both lung
A : normal vesicular breath sound, additional breath sound
(-/-)

CARDIAC:
I : ictus cordis not visible
P : ictus cordis palpable at SIC I V LMCS
P : there is no cardiac enlargement
A : 1st 2nd Heart sound normal intensity, regular, no murmur
ABDOMINAL:
I : abdominal wall // thorax wall
A : peristaltic in normal limit
P : shifting dullness (-), undulations(-)
P : there is enlargement of the liver 1 cm, splenomegali shuffner 1

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis
pedis artery was palpably strong.

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 THERAPY
31

1. Diet rice pack 1000 kkal/day

2. IVFD D51/4NS 40 mL/hour
3. Inj. Ampicillin sulbactam (25mg/kgBW/6h) 250
mg/6h i.v
4. Paracetamol (10mg/kgBW/8h) 120 mg/8h po
5. PRC tranfusion (1) 50 cc already complete
(2) 50 cc
(3) 120 cc distance 24 hour
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