1

CASE REPORT
Name

: Jihan Talita Ulfa Siregar

Age

: 11 months 16 days

Sex

: Female

Date of Admission

: December, 21th 2014

Chief Complaint

: Shortness of Breath

History: These was realized by the Os parents one month ago. Restlessness and shortness of
breath was seen during activities such as when Os is crying and consuming milk. These complain
was encountered by os since birth but it got worst in this few months. In the past two months, Os
has a history of interrupted consumption of milk and heavy sweating during consumption of
milk. Fever (-), diarrhea (-), cough (+) flam (-), vomiting (-) and sweating (+) in the last one
month. Os have defecation problem (constipation) in the last two weeks. Os has no urination
problem.
Pregnant History
Patient was conceived at second pregnancy at the age 28, first child (2 yrs old): normal delivery
and healthy. There was no history of fever, hypertension, diabetic mellitus, and consumption of
drugs and herbal medicine as well jaundice during pregnancy period.
Birth History
Spontaneous; attended by midwives; BW 3800 gram; BL 50 cm, cyanotic (-)
Immunization History
BCG I (no scar), DPT II, Polio III, Measles I, Hepatitis III
Feeding History
From birth to 4 months

: Breast milk only

From 4 months up to date

: Breast milk, biscuit porridge (SUN) and Formulated Milk

History of Growth and Development

Sitting

- months

Crawling

- months

Standing

- months

Walking

- months

History of previous illness

The patient has been suffering from growth stunt where the growth doesnt match the age and
was experiencing shortness of breath when crying and ingesting milk for almost more than a
month. Patient was then brought by the parents to Tapsel District General Hospital and was
diagnosed as noncynotic CHF. Later the patient was then referred to Dr. Pringadi District
General Hospital where was diagnosed as CHF ec acynotic CHD. Finally the patient was
referred to Haji Adam Malik General Hospital on the 21th of Dec 2014.
History of previous medications

: none

History of Family Disease

: unclear

Pysical Examination
Generalized status
Body weight: 5kg, Body length: 62 cm
Body weight in 50th percentile according to age: 8.5 kg
Body length in 50th percentile according to age: 73 cm
Body weight in 50th percentile according to body length: 6.5 kg
BW/BL: 5/6.5 x 100% = 77 % (Moderate Malnutrition)
BW/age: 5/8.5 x 100% = 59 % (Severe Malnutition)
BL/age : 62/73 x 100% = 85% (Mild malnutrition)
Weight for lenght: -3 < Z scores < -1 (underweight)
Presens status
Consciousness: Compos mentis , Body temperature: 36,7 oC. HR 140x/i, RR 50x/i, BP 90/70
mmHg,

Anemic (-); Icteric (-); Cyanosis (-); Edema (-). Dyspnea (+).

Localized status
Head :
Large crown closed. 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 (-). TVJ R+2 cmH20
Thorax:
Symmetrical fusiformis. Chest retraction (+) epigastrial, intercostals, suprasternal. HR: 140 bpm,
regular, murmur (+) pansistolik grade III/6 LMCS ICR III-IV.
RR: 50x/i, ireguler, rales -/Abdomen:
Soepel, Normoperistaltic. Liver, spleen and renal unpalpable..
Extremities:
Pulse 136x/i, regular, adequate p/v, warm acral , CRT < 3.
Urogenital:
Female; within normal limit.

Laboratory Findings (December, 21st 2014):

Parameters
Complete Blood Count
Hemoglobin
Hematocrite
Erithrocyte
Leucocyte
Platelet
MCV
MCH
MCHC
RDW
MPV
PCT
PDW
Hitung Jenis
Neutrofil

Value

Normal Value

10.30 gr%
31.60 %
4.06 x 106 /mm3
12.06 x 103 /mm3
385.000 /mm3
77.80 fl
25.40 pg
32.60 gr%
18.80 %
7.80 fl
0.30%
7.2%

12,0 14,4 gr%

37 41%
4,40 4,48 x 106 /mm3
4,5 13.5x 103 /mm3
150.000 450.000 /mm3
81 95 fl
25 29pg
29 31 gr%
11.6 14.8 %
7,0 10,2 fl

24,30

37-80

Limfosit

70,00

20-40

Monosit

5,20

2-8

Eosinofil

0,20

1-6

Basofil

0,300

0-1

Neutrofil absolute

2.92

1,9-5,4

Limfosit absolute

8,44

3,7-10,7

Monosit absolute

0.63

0,3-0,8

Eosinofil absolute

0.03

0,2-0,5

Basofil absolute

0,04

0-0,1

Laboratory Findings (December, 21st 2014):

Parameters
Carbohydrate Metabolism
Blood Glucose ad random
AGDA
pH
pCO2

Value

Normal Value

91,00 mg/dL

< 200

7,437
21,7 mmHg

7,35 7,45
38 42

pO2
Bicarbonate (HCO3)
Total CO2
Base Excessive (BE)
O2 Saturation
Cardiac Marker
Troponin T

137,7 mmHg
14,3 mmol/L
15,0 mmol/L
-8.6 mmol/L
99.1%

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

Negative (g/L)

0 0,1

Radiologic Imaging

Figure 8:The chest x-ray of the patient

Chest x-ray interpretation:
J P G , 9 year 4 month, Mr, August 27th 2014.
KV weak. Less Inspiration, no trachea deviation found(middle trachea), both costophrenicus
angel were sharp, smooth diaphragm, not seen infiltrates in both lung fields, Heart has a boots
shaped. Cardio Thoracic Ratio is enlarged to the left lateral with, Cardio thoracic Ratio is more

than 50 %, apex embedded (apex downward), bones and soft tissues in good condition, waist
of heart not prominent.
Result : Tetralogy of Fallot with lung edema.
EKG

Interpretasi:
Sinus tachycardia, reguler, HR :111x/i, Right Axis Deviation, P Pulmonal Lead II, interval PR
0,14 s, Q patologis (-), QRS interval 0,08s, T inverted (V1 V4), ST elevation (-), ST depresion
(-) RAD (+) RVH (+) LVH (+), iscemic anteroseptal, S persisten V5,V6.

Result :P pulmonal, Biventricular hipertrophy (+), iscemic anteroseptal

Ecocardiography

Right Ventricular hipertrofi, VSD Pulmonary stenosis seen. RPA 8,9 mm. LPA 10,9 mm
overriding aorta 50% Ejection Fraction 12%, FS 5%
Result : Pulmonary stenosis and Overriding aorta
Differential Diagnosis:

VSD
ASD
PDA

Working Diagnosis:
CHF ec acynotic CHD

Management:

Bed rest
O2 Nasal kanul L/i
Furosemide 2x5mg
Spironolactone 2x6,25mg
Sildenafil 3x1.5mg
IV Dobutamin 5mcg/kgbw/minute (75mg in 50cc Nacl 0.9%) in 1cc perhour

Diagnostic Planning:
-

Consul cardiologist

Urinalysis
Echocardiography

FOLLOW UP
December , 21 -22 th 2014
S Dyspnoe +

O Sens: Compos mentis, Temp: 36,7 oC. Anemic (-). Icteric (-). Edema (-). Cyanosis (-)
Dyspnoe (+)
Body weight: 5 kg, Body length: 62 cm
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 (-).

Neck
Thorax

Icteric sclera (-). Light reflex (+)..

Lymph node enlargement (-)
Simetris fusiformis. Retraction (+) epigastrial; intercostals, suprasternal.
HR: 150 bpm, reguler; murmur (+) pansistolik grade III/6 LMCS III-IV.

Abdomen
Extremitie

A
P

RR: 50 x/i, regular, rales (-/-)

Soepel. normoperistaltic. Liver, spleen and renal unpalpable.
Pulse 140 x/i, iregular, adequate p/v, warm, CRT < 3.

s
Genital
Female; within normal limit.
CHF ec acynotic CHD ec dd/ VSD
ASD
PDA
Management:
-

Bed rest
O2 Nasal kanul L/i
Furosemide 2x5mg
Spironolactone 2x6,25mg
Sildenafil 3x1.5mg
IV Dobutamin 5mcg/kgbw/minute (75mg in 50cc Nacl 0.9%) in 1cc perhour

Diagnostic Planning:
-

Echokardiografi
Urinalisis
Consul kardiologist

December , 23 -24 th 2014

S Dyspnoe +
O Sens: Compos mentis, Temp: 36,7 oC. Anemic (-). Icteric (-). Edema (-). Cyanosis (-)
Dyspnoe (+)
Body weight: 5 kg, Body length: 62 cm
Head

Right Eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-).
Icteric sclera (-). Light reflex (+).

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Left eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (-).
Neck
Thorax

Icteric sclera (-). Light reflex (+)..

Lymph node enlargement (-)
Simetris fusiformis. Retraction (+) epigastrial; intercostals, suprasternal.
HR: 150 bpm, reguler; murmur (+) pansistolik grade III/6 LMCS III-IV.

Abdomen
Extremitie

A
P

RR: 50 x/i, regular, rales (-/-)

Soepel. normoperistaltic. Liver, spleen and renal unpalpable.
Pulse 140 x/i, iregular, adequate p/v, warm, CRT < 3.

s
Genital
Female; within normal limit.
CHF ec acynotic CHD ec dd/ VSD
ASD
PDA
Management:
-

Bed rest
O2 Nasal kanul L/i
Furosemide 2x5mg
Spironolactone 2x6,25mg
Sildenafil 3x1.5mg
IV Dobutamin 5mcg/kgbw/minute (75mg in 50cc Nacl 0.9%) in 1cc perhour

Diagnostic Planning:
-

Echokardiografi

December , 25 -26 th 2014

S Dyspnoe +
O Sens: Compos mentis, Temp: 36,7 oC. Anemic (-). Icteric (-). Edema (-). Cyanosis (-)
Dyspnoe (+)
Body weight: 5 kg, Body length: 62 cm
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 (-).

Neck
Thorax

Icteric sclera (-). Light reflex (+)..

Lymph node enlargement (-)
Simetris fusiformis. Retraction (+) epigastrial; intercostals, suprasternal.
HR: 180 bpm, reguler; murmur (+) pansistolik grade III/6 LMCS III-IV.

Abdomen

RR: 70 x/i, regular, rales (-/-)

Soepel. normoperistaltic. Liver, spleen and renal unpalpable.

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Extremitie

A
P

Pulse 140 x/i, iregular, adequate p/v, warm, CRT < 3.

s
Genital
Female; within normal limit.
CHF ec acynotic CHD ec dd/ VSD
ASD
PDA
Management:
-

Bed rest
O2 Nasal kanul L/i
Furosemide 2x5mg
Spironolactone 2x6,25mg
Sildenafil 3x1.5mg
IV Dobutamin 5mcg/kgbw/minute (75mg in 50cc Nacl 0.9%) in 1cc perhour

Diagnostic Planning:
-

Echokardiografi

26th December 2014

Patient exitus after sudden drop in blood pressure and worsening dyspneo. Resuscitation failed.
Cause of death is suspected aspiration of fluid into lungs.