CASE REPORT

Name :Mardani
Age : 12 years 10 month
Sex : Male
Date of Admission : July, 20
th
2014

Chief Complaint : Involuntary movement

History :-Hal ini dialami OS sejak 2 minggu ini, sebelumnya os tiba-tiba tidak
dapat berjalan, dan os tidak dapat berbicara sejak 1 hari sebelum
masuk rumah sakit.
-Demam (-), RW Demam (+) 2 minggu yang lalu, demam tidak tinggi
dan turun dengan obat penurun panas.
-Kejang(-), RW kejang (-), riwayat truma (-), Riwayat sakit
tenggorokan(-), batuk (-), pilek (-).
-keluar cairan dari telinga kanan sejak 1 minggu yang lalu, warna
jernih, bau (-)
-Sebelumnya OS telah dibawa berobat ke Rumah Sakit Vita Insani dan
dilakukan pemeriksaan CT-Scan dan keluarga OS mengatakan tidak di
ada kelainan (hasil tidak dibawa) dan terdapat pembesaran jantung
pada hasil foto thoraks (hasil tidak dibawa).
RPT : Os merupakan rujukan rumah sakit tarutung dengan diagnosa
Chorea Synden Ham + demam rematik akut.
RPO : Eritromicin, haloperidol, depakene, PCT





Pregnant History
There is no history of fever, hypertension, diabetic mellitus, and consumed herbal
medicine.

Birth History
Spontaneous; attended by midwives; BW 3200 gram; BL 50 cm, cyanotic (-).

Immunization History
Polio.

Feeding History
From birth to 3 months : Breast milk only
From 3 months to 1 year 3 months : Breast milk only and rice porridge

History of Growth and Development
Sitting : 4 months
Crawling : 7 months
Standing : 12 months
Walking : 12 months

History of previous illness : Sebelumnya OS dibawa keluarga ke rumah
sakit vita insani di tarutung dan OS melakukan Pemeriksaan CT scan dan foto
thoraks, keluarga OS mengatakan hasil CT scannya tidak ada kelainan, dan foto
thoraks terdapat pembesaran jantung, tetapi keluarga OS tidak membawa hasilnya.
History of previous medications : Eritromicin, haloperidol, depakene, PCT

History of Family Disease
-



Pysical Examination
Generalized status
Body weight: 20 kg, Body length: 127 cm
Body weight in 50th percentile according to age: 28 kg
Body length in 50th percentile according to age: 133 cm
Body weight in 50th percentile according to body length: 25 kg

BW/BL: 20/25 x 100% = 80 %
BW/age: 20/28 x 100% = 71,42 %
BL/age : 127/133 x 100% = 93,49 %

Weight for lenght: 0< Z scores < 1 (within normal range)

Presens status
Consciousness: Apatis , Body temperature: 37,0
o
C.
Anemic (-); Icteric (-); Cyanosis (-); Edema (-). Dyspnea (-).

Localized status
Head :
Large crown closed. Head circumference: cm. Black hair, normal.
Right Eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-). Icteric sclera
(-). Light reflex (+).
Left eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-). Icteric sclera
(-). Light reflex (+).
Ear, nose and mouth were within normal limit.




Neck :
Lymph node enlargement (-).

Thorax:
Symmetrical fusiformis. Chest retraction (-) epigastrial, intercostals, suprasternal.
HR: 90 bpm, regular, murmur (+) sistolik grade III/6 LMCS ICR III-IV.
RR: 22x/i, reguler, rales (-).
Abdomen:
Rapid turgor. Normoperistaltic. Liver, spleen and renal unpalpable..
Extremities:
Pulse 90x/i, regular, adequate p/v, warm acral , CRT < 3. BP: 100/80 mmHg.
Urogenital:
Male; within normal limit.

Laboratory Findings (July 20
th
2014):
Parameters Value Normal Value
Complete Blood Count
Hemoglobin 12,00 gr% 11,1 14,4 gr%
Hematocrite 35,70 % 35 41%
Erithrocyte 4,62 x 10
6
/mm
3
3.71 4,25 x 10
6
/mm
3

Leucocyte 3,20 x 10
3
/mm
3
6.0 17.5x 103 /mm
3

Platelet 341.000 /mm
3
217.000 497.000 /mm
3

MCV 77,30 fl 82 100 fl
MCH 26,0pg 24 30 pg
MCHC 33,6 gr% 28 32 gr%
RDW 14,80 % 14.9 18.7 %


MPV 9,40 fl 7,0 10,2 fl
PCT 0,32%
PDW 10,3%
Hitung Jenis
Neutrofil 40,40 37-80
Limfosit 34,00 20-40
Monosit 19,20 2-8
Eosinofil 6,20 1-6
Basofil 0,200 0-1
Neutrofil absolute 2,10 1,9-5,4
Limfosit absolute 1,77 3,7-10,7
Monosit absolute 1,00 0,3-0,8
Eosinofil absolute 0,32 0,2-0,5
Basofil absolute 0,01 0-0,1

Laboratory Findings (July 20
th
2014):
Parameters Value Normal Value
Carbohydrate Metabolism
Blood Glucose ad random 83,00 mg/dL < 200
Renal Function Test
Ureum 10 mg/dL < 50
Creatinine 0.14 mg/dL 0,17 0,42
Elektrolit
Kalsium 6,6 mg/dL 9,2 110 mg/dL
Natrium 136 mEq/L 135 155 meq/L
Kalium 4,1 mEq/L 3,6 5,5 mEq/L


Klorida 102 mEq/L 96 106 mEq/L
Imunoserologi
ASTO <200
CRP Kualitatif Positif
Procalcitonin 0,31 ng/mL <0,05


Differential Diagnosis:
-
Working Diagnosis:
- RHD

Management:
- Bed rest
- Nasal Canul 1L/i
- IVFD D5% NaCl 0,45%, 4 gtt/mikro
- Haloperidol 0,5 mg/8 jam/oral
- Depakene syr
- Diet MB 1600 kkal + 40 gr Protein

Diagnostic Planning:
- Urinalysis
- Liver function test
- Head CT-scan
- Nutrition consult
- Foto Thorax




FOLLOW UP

July , 21 th

2012
S Involuntary movement (+)
O Sens: Alert, Temp: 39,2
o
C. Anemic (-). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe
(+)
Body weight: 20 kg, Body length: 127
Head Right Eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-).
Icteric sclera (-). Light reflex (+).
Left eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-).
Icteric sclera (-). Light reflex (+)..
Neck Lymph node enlargement (-)
Thorax Simetris fusiformis. Retraction (-) epigastrial; intercostals, suprasternal.
HR: 92 bpm, reguler; murmur (+) sistolik grade III/6 LMCS III-IV.
RR: 24 x/i, regular, rales (-)
Abdomen Rapid turgor. normoperistaltic. Liver, spleen and renal unpalpable.
Extremities Pulse 92 x/i, regular, adequate p/v, warm, CRT < 3.
Genital Male; within normal limit.

A - Rheumatic Akut Fever
P Management:
- Bed Rest
- IVFD Dext 5% NaCl 0,45% 4gtt/i
- Nasal Kanul 1 L/i
- Inj. Benzatin penisilin 600.000 iv
- Haloperidol 8,5 mg/8 jam /oral
- Paracetamol 3x250 mg
- Diet MB 1600 kkal + 40 gr protein



Diagnostic Planning:
- Echokardiografi
July 22
th
2014
S Involuntary movement (+)
O Sens: Alert, Temp: 37
o
C. Anemic (-). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (+)
Body weight: 20 kg, Body length: 127
Head Right Eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-).
Icteric sclera (-). Light reflex (+).
Left eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-).
Icteric sclera (-). Light reflex (+)..
Neck Lymph node enlargement (-)
Thorax Simetris fusiformis. Retraction (-) epigastrial; intercostals, suprasternal.
HR: 96 bpm, reguler; murmur (+) sistolik grade III/6 LMCS III-IV.
RR: 22 x/i, regular, rales (-)
Abdomen Rapid turgor. normoperistaltic. Liver, spleen and renal unpalpable.
Extremities Pulse 92 x/i, regular, adequate p/v, warm, CRT < 3.
Genital Male; within normal limit.

A - Rheumatic Heart disease
P Management:
- Bed Rest
- Nasal Canul 1L/i
- IVFD Dext 5% NaCl 0,45% 4gtt/i
- Haloperidol 8,5 mg/8 jam /oral
- Depakene syr
- Diet MB 1600 kkal + 40 gr protein
Diagnostic Planning:
-
Hasil echocardiografi :


- Moderate MR
- Moderate AR
- Trivial TR
- Mild PR

July 28
th
2014
Involuntary movement (+)
Sens: Alert, Temp: 37
o
C. Anemic (-). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-)
Body weight: 20 kg, Body length: 127
Head Right Eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-).
Icteric sclera (-). Light reflex (+).
Left eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-).
Icteric sclera (-). Light reflex (+)..
Neck Lymph node enlargement (-)
Thorax Simetris fusiformis. Retraction (-) epigastrial; intercostals, suprasternal.
HR: 100 bpm, reguler; murmur (+) sistolik grade III/6 LMCS III-IV.
RR: 20 x/i, regular, rales (-)
Abdomen Rapid turgor. normoperistaltic. Liver, spleen and renal unpalpable.
Extremities Pulse 92 x/i, regular, adequate p/v, warm, CRT < 3.
Genital Male; within normal limit.

- Rheumatic Heart disease
Management:
- Bed Rest
- IVFD Dext 5% NaCl 0,45% 4gtt/i
- Haloperidol 8,5 mg/8 jam /oral
- Depakene syr
- Diet MB 1600 kkal + 40 gr protein
Diagnostic Planning: -