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CASE CONFERENCE
SUNDAY NIGHT SHIFT,
TH
OCTOBER 14 2018

dr. Ismi / dr. Disa/ dr. Ida/ dr. Ifa/ dr. Anggra
dr. Chandra/ dr. Dilla
dr. Nickyta/ dr. Rekno
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PATIENT ADMISSION
• NICU: -
• Neonatal HCU: -
• Melati 2: -
• Melati 2 HCU:-
• PICU: -
• ER:
• Child A, 6.5 m.o, 7.5 kgs with complex febrile seizure,
acute diarrhea due to Shigella dd rotavirus dd ETEC
with mild – moderate dehydration, wellnourished.
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PATIENT IDENTITY

Name :A
Age/Wt/L : 6.5 months old/ 7.5 kgs / 63
cms
Sex : Male
Address : Surakarta, Central Java
Medical : 01435824
Record
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CHIEF COMPLAINT
Seizure
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THE CURRENT MEDICAL HISTORY

2 days before
admission
• Fever (+) subfebril
• Vomit (+) > 3 times/ day, @ 50
ml content milk
• Diarrhea (-)
• Cough (-)
• Seizure (-)
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THE CURRENT MEDICAL HISTORY

1 day before
admission
• Fever (+) >>
• Vomit (+) > 10 times/ day, @ 50
ml content milk, blood (-)
• Diarrhea (+) 7 times/ day,
watery (+), mucous (+), blood (-),
yellowish (+).
• Tenesmus (+)
• Cough (-)
• Seizure (-)
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THE CURRENT MEDICAL HISTORY

1 hour before
admission
• Seizure (+) whole body +/- 2
minutes, patient cried after
seizure, repeated 2 times.
• Fever (+)
• Patient look thirsty (+), fussy (+)
• Because the condition
worsened, patient was took to
Moewardi hospital
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THE CURRENT MEDICAL HISTORY

ER

• Seizure (+) whole body +/- 30 seconds, patient cried

after seizure, repeated 2 times.
• Fever (+)
• Patient look thirsty (+), fussy (+)
• Diarrhea (-)
• Vomit (-)
• Last urinary at ER (+)
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THE PAST MEDICAL HISTORY

• History of diarrhea : (-)

• History of seizure : (+) 5 months old with fever
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THE FAMILY MEDICAL HISTORY

• History of seizure : denied

• History of diarrhea : 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 25 years old
mother, G1P0A0, at 38th 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 caesarean section due to twin pregnancy.
There was no complication during procedure. The baby was crying
vigourously, weighted 2300 grams, body length 47 cm. The amniotic fluid
was clear.

Conclusion : the pregnancy and delivery history were normal

limit
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VACCINATION HISTORY

0 month : Hepatitis B
1 month : BCG, polio 1
2 months : DPT1, hepatitis B1, Hib1, polio2
3 months : DPT2, hepatitis B2, Hib2, polio3
4 months : DPT3, hepatitis B3, Hib3, polio4
9 months :-
18 months :-
20 months :-

Conclusion :
incomplete immunization,
appropriate with Ministry of Health schedule 2017
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PEDIGREE

II

III

A, 6.5 m.o, 7.5 kgs

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NUTRITIONAL HISTORY

Patient drinks ASI on cue and milk porridge 3 times/day

Conclusion: nutrition quantity and quality status is
adequate

Growth and Development

GROWTH History
AND DEVELOPMENT
He is 6.5 months old now, 7.5 kgs in body weight, birth
weight 2300 gram, 47 cm in lenght. He can raise his head,
can speak ooo, aaaa and response the other with smile.

Conclusion: appropriate for his age

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Nutritional status

• Weight for Age :

-2 < Z-score < 0 SD (normoweight)
• Length for Age :
- 3 SD< Z-score < -2 SD (underheight)
• Weight for length:
+1 SD< W/H < +2 SD (wellnourished)

Conclusion (WHO 2005) : wellnourished,

normoweight, underheight.
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PHYSICAL EXAMINATION
GA : moderately ill, compos mentis
VS : Heart rate: 136 bpm Temp: 38.8oC
Resp. rate : 32 bpm
SiO2 : 96%

Head : mesocephal (HC= 42.5, HC = -2SD Nellhause), sunken big

fontanel (+)
Eyes : anemic conjunctiva -/-, icteric sclera -/-, isochoric
pupil (2mm/2mm), light reflex (+/+), sunken eyes
(+/+), tears (+/+) ↓↓
Nose : nasal flares (-), nasal discharge (-)
Mouth : mucosa dry (+), hyperemic pharynx (-), Tonsil T1/T1
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, 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 (+), skin turgor slow back (+)
P : tender, liver and spleen not palpable
Extremity : Edema : -/- Cold extremities: -/- Pale -/-
-/- -/- -/-
Strong palpable of dorsal pedis artery
CRT < 2”, wasted in all extremities
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PHYSICAL EXAMINATION

Physiological reflexes Meningeal sign

- Biceps +2/+2 - Nuchal rigidity -
- Triceps +2/+2
- Kernig’s sign -
- Patella +2/+2
- Achilles +2/+2 - Brudzinsky sign -

Pathology reflexes Lateralization (-)

- Chaddock -/- Clonus (-/-)
- Oppenheim -/_
- Schaeffer -/- Motoric
- Gordon -/-
5555 5555
- Babinski +/+

5555 5555
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LABORATORY FINDING
October14th 2018

Value Reference Units

Hemoglobin 10.8 11.1-14.1 g/dl
Hematocrit 38 35-43 %
Leucocyte 11.4 5.0-19.5 x103/ul
Thrombocyte 674 150-450 x103/ul
Erythrocyte 5.45 3.60-5.20 x106/ul
MCV 70.3 80.0-96.0 /um
MCH 19.8 28.0-33.0 pg
MCHC 28.2 33.0-36.0 g/dl
Neutrophil 58.2 18.00-74.00 %
Lymphocyte 28.5 60.00-66.00 %
Monocyte 13.00 0.00-6.00 %
Eosinophil 0.00 1.00-4.00 %
Basophil 0.30 0.00-1.00 %
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October 14th 2018

Value Reference Units

RBG 129 50-80 mg/dl
Sodium 143 129-145 mmol/L
Potassium 4.3 3.6-6.1 mmol/L
Calcium 1.34 1.17-1.29 mmol/L
Chloride 116 98-106 mmol/L
Ureum 63 <48 Mg/dl
Creatinine 0.4 0.2-0.4 Mg/dl

Conclusion:
Microcytic hypochromic anemia,
thrombocytosis, Lymphocytopenia
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PROBLEMS

A boy, 6.5 months old, 7.5 kgs with:

1. Seizure (+) whole body, @ 30 seconds, repeated, aware
between seizure
2. Diarrhea, mucous (+), tenesmus (+)
3. Fever (+)
4. Vomit (+)
5. Sunken big fontanel (+)
6. Sunken eyes (+/+), tears (+/+)↓
7. Dry mucosa (+)
8. Skin turgor slow back (+)
9. Neurological exam: babinsky (+/+)
10. Lab: microcytic hypochromic anemia, thrombocytosis,
lymphocytopenia
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DIFFERENTIAL DIAGNOSIS

1. Complex febrile seizure

2. Acute diarrhea due to Shigella dd rotavirus dd ETEC
with mild – moderate dehydration.
3. Wellnourished
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WORKING DIAGNOSIS

1. Complex febrile seizure (R56.01)

2. Acute diarrhea with mild – moderate dehydration
(R19.7)
3. Wellnourished
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THERAPY
1. Admitted to gastroenterology ward co neurology
2. Diet porridge 500 kkal + milk on demand
3. Asering (200ml/kg/day)  63 ml/h until dehydrated 
D51/4NS 27 ml/hour, IV
4. Paracetamol (15 mg/kg/8h)  100 mg/8h iv
5. Zinc 20 mg/24 h po
6. Oralit (10ml/kg/diarrhea)  70ml/ diarrhea
(5 ml/kg/vomit)  35 ml/vomit
7. Diazepam (0.3mg/kg)  2 mg iv (if seizure)
8. Diazepam (0.3mg/kg)  2 mg p.o (if t > 38oC)
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PLAN

1. Urinalisis and stool analysis

2. Stool culture
3. Lumbal punctie

MONITORING
 General Appearance/Vital Signs/Hydration
status/1hour
 Fluid balance/8 hours
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