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CASE CONFERENCE
SATURDAY MORNING SHIFT,
TH
OCTOBER 27 2018

dr. Ismi/ dr. Connie/ dr. Dhimas/ dr. Prima/ dr. Delfia
dr. Anin
dr. Kiki/ dr. Pitra
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PATIENT ADMISSION
• NICU: -
• Neonatal HCU: -
• Melati 2:
• A,16 y.o, 72 with pancytopenia due to ALL dd AML, neutropenic febrile,
undernourised.
• A,7 y.o, 20 with acute diarrhea without dehydration, vomit without
dehydration, post reconstruction due to neuromuscular scoliosis, ED:
acquired heart disease, AD: MR severe, TR moderate, FD:NYHA I,
rehabilitation phase of marasmic tipe of severe malnourished.
• H,7y.o, 25kgs with DHF grade I, acute tonsilitis, wellnourished
• PICU: -
• Melati 2 HCU:-
• VIP ward:
1. M, 7 y.o, 23 with DHF 4-5th day, wellnourised.
2. M, 16 y.o, 59 with DF dd DHF, wellnourised.
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PATIENT IDENTITY

Name :M
Age/Wt/L : 7 yo/ 23 kgs / 120 cms
Sex : Male
Address : Blora, Central Java
Medical : 01437269
Record
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CHIEF COMPLAINT
Fever
(referred from Cepu with DHF)
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CURRENT MEDICAL HISTORY

5 days before • Fever (+), improved with paracetamol

admission
• Cough (-)
• Runnynose (-)
• Swallowing pain (-)
• Loss of appetite (-)
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CURRENT MEDICAL HISTORY

2 days before • High Fever (+), continously

admission • Cough (-)
• Runnynose (-)
• Swallowing pain (-)
• Loss of appetite (-)
• Vomit (-)
• Patient took to private clinic  blood check 
thrombocyte 122,000  patient refered to private hospital
in Cepu.
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CURRENT MEDICAL HISTORY

2 days before • Patient hospitalized for 2 days (in private hospital in

admission Cepu)
• Lab 25th oct 2018: Hb: 13,8, Hct: 40,4, Leucocyte: 3,5,
Thrombocyte: 118,000
• Lab 26th oct 2018: Hb: 12,8, Hct: 36, Thrombocyte:
112,000
• Lab 27th oct 2018: Hb: 12,9, Hct: 38,5, Thrombocyte:
69,000
• Drugs: Asering, ceftriaxone, paracetamol
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CURRENT MEDICAL HISTORY

day before • High Fever (+), continously

admission • Patient look somnolen, vital sign: HR: 120 bpm RR: 28,
temp: 38.3  diagnosed as DHF
• Got Asering loading 500 cc for 2 hours  HR 118bpm
• Patient reffered to RSDM
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THE CURRENT MEDICAL HISTORY

• Fully alert (+)

At ER
• Fever (+)
• Vomit (-)
• Dypsneu (-)
• Urine yellow colour
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THE PAST MEDICAL HISTORY

• History of hospitalization : (-)

• History of fever : (-)
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THE FAMILY MEDICAL HISTORY

• History of hospitalization : denied

• History of fever : denied
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HISTORY OF PREGNANCY AND DELIVERY

Pregnancy
The patient is the 1st child of his family. He was born from a 27 years old
mother, at 40th week of gestational age. His mother consumed vitamins
from a doctor, not consumed any traditional herbal drink. According to
the mother, she had routine check her pregnancy to the doctor and
midwife.

Delivery
The patient was delivered by normal labour. There was no complication
during procedure. The baby was crying vigorously, weighted 2700
grams, body length 41 cm. The amniotic fluid was clear.

Conclusion : the pregnancy and delivery history were normal

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VACCINATION HISTORY

0 month : Hepatitis B0
1 month : BCG, polio 1
2 months : DPT1, hepatitis B1, polio2
3 months : DPT2, hepatitis B2, polio3
4 months : DPT3, hepatitis B3, polio4
9 months : measles
18 months : DPT4, hepatitis B4
20 months : measles and rubella

Conclusion :
Complete immunization,
appropriate with Ministry of Health schedule 2010
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PEDIGREE

II

III

M, 7 yo, 23 kgs
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NUTRITIONAL HISTORY

Patient eats rice 3 times a day with ½ bowl portion with vegetables,
soya cake, ‘tempe’, sometimes egg, chicken, and beef rarely. He
drinks formula milk 3 times a day ± 150 m
Conclusion: nutrition quantity and quality status is
adequate

Growth and Development

GROWTH History
AND DEVELOPMENT
He is 7 years old now, 23 kgs in body weight. He studied in
first grade of elementary school now. He can communicate
well with his friends.

Conclusion: appropriate for his age

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Nutritional status
• Body Weight/Age
23/23x 100% = 100 % (normoweight)
• Body Height/Age
120/122 x 100% = 98 % (normoheight)
• Body Weight/Body Height
23/22 x 100% = 104 % (wellnourised)

Conclusion (CDC 2000) :

wellnourised, normoweight, normoheight
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PHYSICAL EXAMINATION

GA : moderate ill, fully alert

VS : Heart rate: 94 bpm Temp: 38.4 oC
Respiratory rate : 24 bpm Blood pressure: 100/60 mmHg
SiO2 : 99%

Head : mesocephal
Eyes : anemic conjunctiva -/-, icteric sclera -/-, isochoric
pupil (2mm/2mm), light reflex (+/+)
Nose : nasal flares (-), nasal discharge (-)
Mouth : cyanosis (-), pharynx and tonsil T1-T1 hyperemis (-)
Ears : Ear discharge -/-,
Neck : Lymph node enlargement (-)
Chest : Symmetrical in shape and movement, retraction (-)
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Cor I : ictus cordis was not visible
P: ictus cordis was not palpable
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, no murmur
Pulmo: I : symmetrical movement (+)
P: fremitus sounds +/+
P: sonor +/ sonor +
A: vesicular breath sounds +/+, additional breath sound (-/-)
Abd : I : abdominal wall = chest wall
A : peristaltic sound (+) normal
P : tympani (+), normal skin turgor
P : tender, liver palpable in 3 cms under right arcus costae and spleen
not unpalpable
Extremity : Edema : -/- Cold extremities: -/- Pale -/-
-/- -/- -/-
Strong palpable of dorsal pedis artery, CRT < 2”
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LABORATORY FINDING
October 27th 2018

Value Reference Units

Hemoglobin 14.6 11.5-15.5 g/dl
Hematocrit 45 35-45 %
Leucocyte 2.4 4.5-14.5 x103/ul
Thrombocyte 57 150-450 x103/ul
Erythrocyte 5.46 4.00-5.20 x106/ul
MCV 81.9 80.0-96.0 /um
MCH 26.7 28.0-33.0 pg
MCHC 32.7 33.0-36.0 g/dl
Neutrophil 48.0 29.00-72.00 %
Lymphocyte 42.0 30.00-48.00 %
Monocyte 10.0 0.00-5.00 %
Eosinophil 0.0 0.00-4.00 %
Basophil 0.0 0.00-1.00 %

CONCLUTION:
Leucocytopenia, thrombocytopenia
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PROBLEMS

A boy, 7 years old, 23 kgs with:

1. Fever (+) since 5 days, continously
2. Productive cough (-)
3. Runny nose (-)
4. Swallowing pain (-)
5. Loss of appetite (-)
6. Vomit (-)
7. Leucocytopenia
8. Thrombocytopenia
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DIFFERENTIAL DIAGNOSIS

1. DHF1st grade (4-5th day)

2. Wellnourised, normoweight, normoheight.
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WORKING DIAGNOSIS

1. DHF 4-5th day 1st grade

2. Wellnourised, normoweight, normoheight.
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THERAPIES

1. Rice pack diet 1500 kcal/day

2. IVFD Asering (5ml/kg/hour) = 115 ml/hour
3. Paracetamol (15mg/kg/8h)  250 mg/8h po
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PLAN

1. Complete blood count / 8 hours

2. Ig M-Ig G dengue

MONITORING
 General Appearance/Vital Signs/ 8 hours
 Diuresis/Fluid balance/8 hours
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FOLLOW UP 28TH OCTOBER 2018

GA : moderate ill, fully alert

VS : Heart rate: 94 bpm Temp: 38.5 oC
Respiratory rate : 24 bpm Blood pressure: 100/60 mmHg
SiO2 : 99% fluid balance +20ml, diuresis 1,4ml/kgbw/h

Head : mesocephal
Eyes : anemic conjunctiva -/-, icteric sclera -/-, isocoric
pupil (2mm/2mm), light reflex (+/+)
Nose : nasal flares (-), nasal discharge (-)
Mouth : cyanosis (-), pharynx and tonsil T1-T1 hyperemis (-)
Ears : Ear discharge -/-,
Neck : Lymph node enlargement (-)
Chest : Symmetrical in shape and movement, retraction (-)
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Cor I : ictus cordis was not visible
P: ictus cordis was not palpable
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, no murmur
Pulmo: I : symmetrical movement (+)
P: fremitus sounds +/+
P: sonor +/ sonor +
A: vesicular breath sounds +/+, additional breath sound (-/-)
Abd : I : abdominal wall = chest wall
A : peristaltic sound (+) normal
P : tympani (+), normal skin turgor
P : tender, liver palpable in 3 cms under right arcuscostae and spleen
not palpable
Extremity : Edema : -/- Cold extremities: -/- Pale -/-
-/- -/- -/-
Strong palpable of dorsal pedis artery, CRT < 2”
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LABORATORY FINDING
October 28th 2018

Value Reference Units

Hemoglobin 12.7 11.5-15.5 g/dl
Hematocrit 40 35-45 %
Leucocyte 2.2 4.5-14.5 x103/ul
Thrombocyte 52 150-450 x103/ul
Erythrocyte 4.73 4.00-5.20 x106/ul
MCV 83.9 80.0-96.0 /um
MCH 26.8 28.0-33.0 pg
MCHC 32.0 33.0-36.0 g/dl
Neutrophil 30.0 29.00-72.00 %
Lymphocyte 59.0 30.00-48.00 %
Monocyte 10.0 0.00-5.00 %
Eosinophil 1.0 0.00-4.00 %
Basophil 0.0 0.00-1.00 %

CONCLUTION:
Leucocytopenia, thrombocytopenia
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WORKING DIAGNOSIS

1. DHF 4-5th day

2. Wellnourised, normoweight, normoheight.
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THERAPIES

1. Diet rice 2000 kcal/day

2. IVFD Asering (5ml/kg/hour) = 115 ml/hour
3. Paracetamol (15mg/kg/8h)  250 mg/8h po
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PLAN

1. Complete blood count/ 24 hours

2. Ig M Ig G dengue

MONITORING
 General Appearance/Vital Signs/ 8 hours
 Diuresis/ Fluid balance/8 hours
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FOLLOW UP 29TH OCTOBER 2018
S: fever still persist, frequency was improved
GA : moderate ill, fully alert
VS : Heart rate: 94 bpm Temp: 36.9 - 38.0 oC
Respiratory rate : 24 bpm Blood pressure: 100/60 mmHg
SiO2 : 99% fluid balance +30ml, diuresis 1,2ml/kgbw/h

Head : mesocephal
Eyes : anemic conjunctiva -/-, icteric sclera -/-, isocoric
pupil (2mm/2mm), light reflex (+/+)
Nose : nasal flares (-), nasal discharge (-)
Mouth : cyanosis (-), pharynx and tonsil T1-T1 hyperemis (-)
Ears : Ear discharge -/-,
Neck : Lymph node enlargement (-)
Chest : Symmetrical in shape and movement, retraction (-)
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Cor I : ictus cordis was not visible
P: ictus cordis was not palpable
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, no murmur
Pulmo: I : symmetrical movement (+)
P: fremitus sounds +/+
P: sonor +/ sonor +
A: vesicular breath sounds +/+, additional breath sound (-/-)
Abd : I : abdominal wall = chest wall
A : peristaltic sound (+) normal
P : tympani (+), normal skin turgor
P : tender, liver palpable in 3 cms under right arcuscostae and spleen
not palpable
Extremity : Edema : -/- Cold extremities: -/- Pale -/-
-/- -/- -/-
Strong palpable of dorsal pedis artery, CRT < 2”
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LABORATORY FINDING
October 29th 2018

Value Reference Units

Hemoglobin 14.2 11.5-15.5 g/dl
Hematocrit 42 35-45 %
Leucocyte 3.5 4.5-14.5 x103/ul
Thrombocyte 50 150-450 x103/ul
Erythrocyte 4.83 4.00-5.20 x106/ul

IgG Dengue Negative

IgM Dengue Negative

CONCLUTION:
Leucocytopenia, thrombocytopenia
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WORKING DIAGNOSIS

1. DHF 1st grade (day 5-6th )

2. Wellnourised, normoweight, normoheight.
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THERAPIES

1. Diet rice 1500 kcal/day

2. IVFD Asering (3ml/kgs/hours) = 80 ml/hours
3. Paracetamol (15mg/kg/8hours)  250 mg/8h po
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PLAN

1. Complete blood count/ 24 hours

2. Ig M Ig G dengue

MONITORING
 General Appearance/Vital Signs/ 8 hours
 Fluid balance/8 hours
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FOLLOW UP 30TH OCTOBER 2018
S: fever still persist, frequency was improved
GA : moderate ill, fully alert
VS : Heart rate: 94 bpm Temp: 36.9 - 38.0 oC
Respiratory rate : 24 bpm Blood pressure: 100/60 mmHg
SiO2 : 99% fluid balance +40ml, diuresis 1,3ml/kgbw/h

Head : mesocephal
Eyes : anemic conjunctiva -/-, icteric sclera -/-, isocoric
pupil (2mm/2mm), light reflex (+/+)
Nose : nasal flares (-), nasal discharge (-)
Mouth : cyanosis (-), pharynx and tonsil T1-T1 hyperemis (-)
Ears : Ear discharge -/-,
Neck : Lymph node enlargement (-)
Chest : Symmetrical in shape and movement, retraction (-)
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Cor I : ictus cordis was not visible
P: ictus cordis was not palpable
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, no murmur
Pulmo: I : symmetrical movement (+)
P: fremitus sounds +/+
P: sonor +/ sonor +
A: vesicular breath sounds +/+, additional breath sound (-/-)
Abd : I : abdominal wall = chest wall
A : peristaltic sound (+) normal
P : tympani (+), normal skin turgor
P : tender, liver palpable in 3 cms under right arcuscostae and spleen
not palpable
Extremity : Edema : -/- Cold extremities: -/- Pale -/-
-/- -/- -/-
Strong palpable of dorsal pedis artery, CRT < 2”
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WORKING DIAGNOSIS

1. DHF 1st grade (day 5-6th )

2. Wellnourised, normoweight, normoheight
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THERAPIES

1. Diet rice 1500 kcal/day

2. IVFD Asering (3ml/kg/hours) = 80 ml/hour
3. Paracetamol (15mg/kg/8hours)  250 mg/8h po
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PLAN

1. Complete blood count/ 24 hour

MONITORING
 General Appearance/Vital Signs/ 8 hours
 Fluid balance/8 hours
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Is there any new parameters that help predict the severity of dengue infection?

P Children whom infected dengue virus

I New parameter

C Standard parameter

O Severity, outcome
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VALIDITY
• Was there a clear question for the study to address?
YES, the population, how the test is done, the
monitoring were approppiate for this study

• Was there a comparison with an appropriate

reference standard?
YES

• Did all patients get the diagnostic test the reference

standard?
YES, all patients were checked serology
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IMPORTANCY
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APPLICABILITY
• Can the results be applied to your patients / the
population of interest?
YES

• Can the test be applied to your patient or population

of interest?
YES
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IMPORTANT

LoE
VALID
2B
APPLICABLE
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•v
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