CASE CONFERENCE

Sunday , February 5th 2017

(Night Shift)
dr. Devi/dr. Prabu
dr. Tatag/ dr. Anggra/ dr. Lubna
dr. Hamid /dr. Bayu
dr. Debby/ dr. Dewi
 PATIENT ADMISSION
 Melati 2
1. An. NMP/ Boy/2 months 12 days/ 5,5 kg with Dx : suspected Aspiration
Pneumonia + Respiratory Distress Syndrome + Septic Shock dd
Cardiogenic Shock+ Asianotic Congenital Heart Disease ec. PDA dd VSD,
Ross III + susp. Rubella Congenital + Congenital Cataract Oculo Dextra
et Sinistra
 HCU Neonatus
1. By. Mrs. SM/ Girl/ 0days/ 2450 grams with Dx : Severe Asfixia ec General
Anaesthetic + Potential Infection + Mild hypothermia + Low Birth weight +
Neo, Girl, LBW, Aterm, Small Gestational Age, SC ai eclampsia , General
Anaesthetic, muddy amnion fluid
 NICU
-
 PICU
-
 HCU Melati2
-
 IDENTITAS PASIEN

Name : An. NMP

Age : 2 months 12 days
Gender : Boy
W/ L : 5,5 kg/54 cm
Address : Karanganyar, Central Java
MR : 01362053
Chief Complaint : Shortness of breath

On Emergency
room, he looked
troublesome,
dyspneau, no fever,
His mother brought no seizure. His last
him to the nearest urine flow was
midwife to check gotten out when he
him up. The midwife had been going to
suggested to get him hospital.
straight to the
hospital because of
his emergency
condition. By his
Suddenly look dyspneau
family, he was
after vomitting since this
brought to the
evening at 18.00, no
Emergency room at
history of choking, cough
Moewardi hospital.
(-), fever (-). Patient
vomitted twice, as much
as a tea cup, filled of
milk, squirtly.
 PAST MEDICAL HISTORY

 Hospital admission history when he just

delivered for 10 days because of icterus
neonatorum.
 Routinely controlled to ophtalmologist
because of cataract congenital
 History of : seizure (-), dyspneau (-),
sianotic spell(-)
 FAMILY MEDICAL HISTORY

• Congenital heart disease (-)

• His first sister was death on 1 weeks
old because of the same illness with
this patient ( cataract congenital +)

6
 ANAMNESIS
PREGNANCY AND
LABOURED

Pregnancy
The mother controlled her pregnancy to the midwife routinely. She never
checked for ultrasonography. History of leukorrhea (+). When pregnant, she
never hospitalised. No history of drug or “jamu” consumption during
pregnancy.
Laboured
The baby was delivered by obstetrician with Caesarian sectio because
failure of induction. He was born aterm, but didn’t cry directly. He
was hospitalised for 10 days because of icterus neonatorum. Birth
weight 3200 gram, birth length 47 cm.
Conclusion :
The pregnancy was not normal, the laboured was not normal

7
 ANAMNESIS
Growth
Development

Growth
This patient’s age 2 months, 12 days with the weight 5,5 kg and the
body length 54 cm, head circumference 41 cm.

Development
• This patient hasn’t had eye contact with the surrounding
• Sucking reflex of this patient was good

Conclusion: Growth was normal but development was not

normal

8
BCG : 1 month
Hep B : 0 month 2 month
DPT : 2 month
Polio : 0 month 2 month
Measles : -

Conclusion : Imunization schedule as the

health ministry time table 2016

Vaccination History
 FAMILY TREE

II
32 y.o 28 y.o

III
An NMP , 2 months 12 days

1 weeks 5 y.o
 PHYSICAL EXAMINATION

At 21.45
Airway : grunting head tilt, chin lift
Breathing : O2 face mask non-rebreathing 5 lpm
Circulation : acral cold, CRT >2 sec  iv line +
laboratory test
Drug : -
 PHYSICAL EXAMINATION
At 22.00
GA : severe illness, sopor, well nourished
VS : Heart rate: 88x/min Temp. : 38,2oC
Resp. rate : 12x/min SiO2 : 70%

Head : Mesocephal (HC=41cm, HC=2SD, Nellhaus), major

fontanella flat, dismorphic facies (+)
Eyes : Anemic conjungtiva -/-, icteric sclera -/-, pupil isocor
2mm/2mm,
Nose : Nostrils Flares Outwards (+) nasal discharge (-)
Mouth : Wetness (+), cyanosis (-), tonsil T1-T1 hyperemic (-),
redness of the pharyx (-)
Ears : Ear discharge -/-
Neck : Node enlargement (-),
Chest : Symmetrical in shape and movement, retraction (+)
suprasternal, intercostal, subcostal
Cor : I : Ictus cordis not appeared
P : Ictus cordis was palpable
P : heart enlargement (-)
A : heart sounds I-II normal intensity, regular,
murmur(+) sistolik grade IV/VI punctum maximum SIC III LPSS
Pulmo: I : right hemithorax = left hemithorax
P: fremitus sounds right = left
P: sonor / sonor
A: vesicular breath sounds +/+ , patologic sounds +/+
Coarse rales +/+
Abd : I : abdominal wall = chest wall
A : peristaltic sound (+) within normal
P : tympani (+)
P : distended, palpable pain (-),
liver and spleen were not palpable, turgor’s within normal
Extremity :
Edema : -/- Cold extremity : -/-
-/- -/-

arteri dorsalis pedis palpable

capillary refill time < 2 seconds
Nutritional
State

WHO Chart
BB/U : 5,5 / 5,5 x 100% = 100%(Z-SCORE = 0 SD)
Normoweight
TB/U : 54/58 x 100% = 93 % (Z-SCORE = -2 SD)
Stunted
BB/TB : 5,5/4,3 x 100% = 127% (Z-SCORE = +3SD)
Well nourished

Conclusion : well nourished, normoweight, stunted

 LABORATORIES
 Hb : 9,0 g/dl
 HCT : 32 %
 AL : 29 ribu/ul
 AT : 313 ribu/ ul
 AE : 2,95 Juta/ul
 MCV : 108,7/ um
 MCH : 30,5 pg
 MCHC : 28 g/dl
 RDW : 13,2
 MPV : 8,7
 PDW : 16
 Eos/ Bas/ Net/ Limf / Mono : 1,10/0,70/20,80/71,00/6,40
 GDS : 228 mg/dl
 PT/APTT : 23,1/ 67,3 second
 Natrium darah : 128 mmol/L
 Kalium darah : 6,4 mmol/L
 Kalsium ion :1,13 mmol/L
 Ureum / Creatinin : 0,4/31 mg/dl
Conclusion : Anemia normokromik normositik, Leukositosis,
Hiperglikemia, Hiponatremia, Hiperkalemia
 LABORATORIES
Blood Gas Analysis
• pH : 6.8
• BE : -24.2
• PCO2 : 31
• PO2 : 90
• Hct : 29 %
• HCO3 : 7.1
• O2 saturation : 92.4%
• Lactat artery : 11.5
Conclusion : Severe Asidosis Metabolic
 Problem List
A boy baby, 2 months, 5,5 kg, with :
1. Shortness of breath (dyspneau)
2. Dyspneau suddenly after vomitting twice, as much
as a tea cup, filled of milk
3. Fever (-), seizure (-), sianotic (-)
4. RR 12 x/mnt, HR 88 x/mnt, SiO2 70 %, temp 38,2
5. Nostril flare (+)
6. Retraction (+) suprasternal, intercostal, subcostal
7. Patologic breath sound +/+ coarse rales +/+
8. Anemia normochromic normocytic, leukositosis,
hiperglikemia, hiponatremia, hiperkalemia
9. Blood Gas Analysis : Severe Asidosis Metabolic
10.Well nourished, normoweight, stunted
ASSESS 1. Pneumonia aspiration
2. Septic dd Cardiogenic Shock
3. DE = PJB asianotik
DA = susp PDA dd VSD
DF = ross IV
4. Rubella Congenital
5. Cataract Congenital ODS
6. Well nourished, normoweight, stunted

TERAPI At 22.00
1. Intubation with endotracheal tube (non-
cuff)no 4.0 depth 12 cm
2. Bagging BVM 20 x/minute
3. Loading infusion Asering (20cc/kgBB) 110
cc
22.30 S : post resuscitation
O : HR= 92x/minute
RR = on bagging
SiO2 88%
temp : 37,6
ADP poor
A: Hipovolemic dd Septic Shock
P: Loading infusion Asering (20cc/kgBB) = 110cc

23.00
S : post resuscitation
O : HR= 40x/minute
RR = on bagging
SiO2 86%
temp : 37,2
ADP not palpable, CRT > 2 second
A: Shock Cardiogenic dd Septic
23.00 P : Airway + Breathing : bagging BVM 20 x/minute
Circulation : RJP 100x/minute (5cycle)
Evaluation :
HR: 42x/minute SiO2 70%
RR : on bagging
RJP 100 x/minute + VTP 20x/minute (5cycle)
Evaluation :
HR : not palpable SiO2 –
RR on bagging
RJP 100x/minute + VTP 20x/minute (5 cycle)
Evaluation :
HR : 30x/minute temp 36,1
RR on bagging
Inj. Adrenalin (0,1mg/kgBB) 0,5 mg i.v
RJP 100 x/minute + VTP 20x/minute (5 cycle)
Evaluation :
HR 42x/minute
RR on bagging
Inj. Adrenalin ( 0,1mg/kgBB) 0,5mg i.v
23.00 RJP 100 x/minute + VTP 20 x/minute
Evaluation :
HR : 82 x/minute SiO2 93%
Temp : 36,5
RR on bagging
Plan :
1. Get intravenous line  Infuse maintenance D5 1/4NS
24 ml/hour
2. Inj. Dobutamin (10 mcg/kgBB/minute)  80mg+NaCL
0,9% 24 ml  1ml/hour

23.45

Evaluation : HR – SiO2 66%

RR on bagging
ADP poor, CRT >2 second
23.45
A : Shock Cardiogenic
Cardiac Arrest
Apneau
P : Airway Breathing : on bagging BVM 20x/minute
Circulation : RJP 100xminute + VTP 20x/minute
Evaluation :
HR : 40x/minute
RR : on bagging
RJP 100x/minute + VTP 20x/minute
Evaluation :
HR : 32x/minute
RR on bagging
RJP 100x/minute + VTP 20 x/minute
Inj. Adrenalin (0,1 mg/kgBB) 0,5 mg
Evaluation :
HR : 82x/minute
RR on bagging
ADP poor, CRT > 2 second
23.45

P: Education to patient’s family

Inj. Dobutamin ( 15 mcg/kgBB)  1,5 ml/hour
PRISM score >25
Maximal resuscitation in pediatric ward Melati 2
23.45

Therapy : Entered respirology ward

1. Fasting during dyspneau, NGT flow up
2. O2 BVM 10 lpm 20x/minute
3. Inf. D5 ¼ NS 23 ml/hour
4. Inj. Ampiccilin (100mg/KgBB/day) 125 mg/6hr i.v
5. Inj. Gentamycin loading (8mg/kgBB) 40mg 
maintenance (5mg/kgBB/24hr) 30 mg
6. Inj. Dobutamin (10 mg/kgBB/minute) 80 mg + NaCL
0,9 % 24 cc  1,5 ml/hr
7. Paracetamol (15 mg/kgBB/x) 75 mg  3 ml/8hr p.o.
via NGT
PLAN :
Education family
Monitoring : KU/VS/SiO2/hour
BCD/8hr
 FOLLOW UP Monday, 6 february 2016
01.30 S: Receiving patient from ER, dyspneau (+), acral cold
O: KU soporocomatous
HR : 90x/minute
RR : 12x/minute
SiO2 : 70 %
Nasal flare (+)
Thorax : retraction (+) suprasternal, intercostal
Pulmo : Coarse rales +/+, Fine rales +/+
Cor : heart sounds I-II normal intensity, regular,
murmur(+) sistolik grade IV/VI punctum
maximum SIC III LPSS
Extremity : CRT >2 second
A: Cardiogenic dd Septic Shock
P : Inj. Dobutamin (20 mcg/kgBB)  2ml/hour
03.00
S : gasping
O : KU severe illness, coma
HR not palpable
RR 8 x/minute (on jackson reese)
ADP not palpable, CRT > 2 seconds
A: Apneau
Septic Shock
P : RJP 100x/minute + VTP 20x/minute
Inj. Adrenalin (0,1mg/kgBB) 0,5mg i.v

03.15
S : Evaluation
O : HR not palpable
RR on bagging SiO2 –
A: Apneau
Septic shock
P : Inj. Adrenalin (0,1mg/kgBB) 0,5mg i.v
RJP 100x/minute + VTP 20x/minute
03.20
S : apneau
O : KU severe illness, coma
HR not palpable
RR not seen
ADP not palpable
SiO2 –
Pupil midriasis maximum
A: Apneau
Septic Shock
P : ECG  asystole
Patient was dying in front of his family