CASE CONFERENCE

September 22 2018
nd

Night shift

dr.Anto / dr.Eddy / dr.Pitra / dr.Delfia

dr.Connie / dr.Syahmi
dr.Rekno
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PATIENT ADMISSION
• MELATI 2
1. MB, 2 mo, 3.4 kg with aspiration penumonia with respiratory failure
type II, intrahepatic dd extrahepatic cholestasis, (clinical) Down
syndrome, Suspected congenital hypothyroid, ED : suspected
acyanotic heart disease AD : Suspected ASD dd PDA FD : Ross II,
fracture costae 6-7 due to vit D deficiency dd trauma,
wellnourished, underweight, normoheight.
• NICU :-
• HCU MELATI 2 :-
• PICU :-
• Neonatal HCU :-
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PATIENT ADMISSION
• Delivery :
1. Baby Mrs.R, 2600 grams, with neonates, boy,
aterm, apropriate for gestational age, spontaneous
delivery with anemic mother (Rooming in)
2. Baby Mrs.N, 0 do, 1900 grams, with moderate
respiratory distress due to HMD dd congenital
pneumonia dd moderate hypotermia, neonatal
infection, caput succadeneum dd cephal hematom,
neonates, boy, preterm, small for gestational age,
spontaneous delivery with PPROM, pansitopenia,
pre eclamsi, partial HELLP syndrome
(Reffered due to lack of facility)
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Patient Identity

Name : MB
Age : 2 Months old
Gender : Male
W/ L : 3400 grams, 52 cm
Address : Mojosongo, Jebres
MR : 01433385
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Chief Complaint :
Breathlessness
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2 weeks before admission

• Patient’s belly was distended
• No vomiting was reported
• Defecation (+) 2-3x/day, yellow-brown
• The parents did not realize whether their child
was icteric
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7 days before admission

• The parent said that the patient looks breathless and
wasn’t affected by weather
• Patient’s breath sounds coarse
• The symptom first appeared after patient vomited
• Patient vomit contains milk, and happens 2-3x after
given milk (> 60ml)
• Fever was present but wasn’t high and resolve with
antipyretic drug
• Patient was then taken to Puskesmas and was referred to
Surakarta Hospital
• Patient was examined, given IV line, and got lab checked
• Urine (+) and Stool (+)
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At the ER
• At the ER patient looks breathless and yellow on
the body and eyes
• Patient can move actively
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PAST MEDICAL HISTORY

• History of past illness :
▫ Patient was born prematurely at 34+5 weeks
▫ Patient was admitted to Surakarta hospital due to
distended abdomen 2 weeks prior
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Family & environmental History

• History of respiratory illness : -
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Pregnancy and Delivery History

• The mother never expected the pregnancy. She also never

checked the pregnancy to doctor or midwife before. Her age
was 41 years old
• Patient was born spontaneously at 34+5 weeks after mother
felt contraction and water coming out. Patient was born with
the help of midwife. Patient cried loudly, not cyanotic or
yellow. Meconium has passed.
• Patient’s birth weight and length was 2400 grams and 47 cm

Conclusion: Abnormal pregnancy and delivery history

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Vaccination History
Basic
• Hep B0 :-
• Polio : 1st month, 2nd month
• BCG : 1st month
• DPT-HB-Hib : 2nd month
• MR :-

Conclusion : Incomplete basic immunization according to Ministry of

Health’s schedule
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Nutrition Growth and

History Development
• Patient was given formula • The patient’s weight is
milk 60-90 ml every 2-3 3400 gr and the height is
hours. 52 cm

Conclusion: quality and Conclusion: normal growth

quantity of nutrition are and abnormal development
adequate
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Nutritional Status
WHO
• Weight for Age: -2SD < WFA < 0 SD underweight
• Length for Age: -2SD < HFA < 0 SD normoheight
• Weight for length: -2SD < WFL < 0 SD well-nourished

Conclusion: wellnourished, normoheight, normoweight

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Pedigree
I

II

III

M, 2 months old
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Physical Examination
General appearance:
Looks breathlessness, Icteric, fully alert

Vital Signs:
• Heart rate: 138 bpm
• Body temperature : 36,50C
• Respiration rate: 64x/min
• Oxygen Saturation: 92-96%
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Physical Examination
• Head : Mesocephal, HC 34cm (-2 SD < HC < 0 SD,
Fenton), dysmorphic face (+)
• Eyes : Isochoric pupils (2mm/2mm), light reflex
(+/+), anemic conjunctivae (-/-), icteric (+/+)
• Nose : Nasal flare (+)
• Mouth : Dry mucosa (-), cyanosis (-)
• Ear : Discharge (-/-)
• Neck : Lymph nodes enlargement (-/-)
• Chest : Symmetric, retraction (+) subcostal,
intercostal, suprasternal

LUNG:
• I: normal, symmetric,
floating rib (-/-)
• P: hard to evaluate
• P: sonor
• A: vesicular breath sound
(+/+), additional
breath sound (+/+),
Rales (+/+), wheezing
(-/-)
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HEART:
• I : ictus cordis not visible
• P: ictus cordis not
palpable
• P: cardiac
enlargement (+)
• A: 1st 2nd Heart sound
normal intensity, regular,
systolic murmur (+)
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ABDOMEN
• I: abdominal wall > thoracic wall, enlarged
veins, umbilical herniation (+)
• A: peristaltic sound (+)
• P: tympanic (+)
• P: distended (+), tenderness (-) hepatomegaly
4cm under right arc costae, spleenomegaly (-)
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EXTREMITIES:
• CRT < 2 seconds,
• Dorsalis Pedis artery strongly palpable
• Warm extremities
• Hypotonia
• Edema
- -
- -
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Surakarta Hospital Laboratory Findings (22/08/2018)

Value Reference Units
Hemoglobin 9,7 9,2-13.6 g/dl
Hematocrit 30 45-67 %
Leucocyte 11,69 4.5-14.5 x103/ul
Thrombocyte 304 150-450 x103/ul
Erythrocyte 3,07 3.8-5.8 x106/ul
MCV 97,1 80.0-96 /um

MCH 31,6 28.0-33.0 Pg

MCHC 32,6 33.0-36.0 g/dl

Eosinophil 3 0.00-4.00 %

Basophil 0 0.00-1.00 %

Neutrophil segment 21 18.00-45,00 %

Neutrophil rods 2 2-6 %

Lymphocyte 61 20.00-40.00 %

Monocyte 13 0.00-6.00 %
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Value Reference Units

Total bilirubin 5,48 4-8 Mg/dl
Direct bilirubin 3,49 0,0-1,2 Mg/dl
Indirect bilirubin 1,99 0,7-0,7 Mg/dl
Random blood 83 70-140 Mg/dl
glucose

Conclusion : elevated direct bilirubin

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RSDM Laboratory Findings (22/09/2018)

Value Reference Units

Albumin 3,4 3.8-5.4 g/dL
Blood type A
SGOT 113 < 35 u/L
SGPT 115 < 45 u/L
Na 136 138-146 mg/dL
K 5,8 3,6 – 6,1 mmol/L
Cl 112 98-106 mmol/L
Ca 1,11 1,17-1,29 mmol/L

Conclusion : Elevated liver enzymes

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Blood Gas Analysis

PH 7,270 7.350 – 7.450
BE -2,7 -2 - +3 mmol/L
PCO2 52,7 27.0-41.0 mmHg
PO2 106,2 83.0 – 108.0 mmHg
Hct 34 37-50 %
HCO3 24,4 21.0 – 28.0 mmol/L
Total CO2 26,0 19.0 -24.0 mmol/L
O2 Saturation 96,9 40-90 %
Arterial Lactate 4,30 0.36-0.75 mmol/L

Conclusion : Respiratory failure type II

24
Uncompensated respiratory acidosis
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Baby Gram (22/09/18)

1. Cardiomegaly (CTR 70%)
2. Hepatomegaly
3. 6th and 7th right anterior
costal space widening
suggests rosary rachitis (?)
4. Meteorismus
5. Gastric tube installed with
tip inside the stomach
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Problem List
M, 2 weeks old, male, 3,4 kg with :
1. Breathlessness
2. History of vomit after drink milk
3. History of fever
4. History of premature delivery from 41 years old mother
5. Abdominal distention
6. Jaundice
7. Normal defecation and urination
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Problem List
Physical exam
1. Dysmorphic face
2. Nasal flare
3. Chest retraction, rhales
4. Cardiac enlargement and systolic murmur
5. Distended abdominal wall with enlarged veins and
umbilical herniation, hepatomegaly
6. Hypotonia

Other findings
1. Lab: cholestasis
2. BGA: Respiratory failure type II, Uncompensated respiratory
acidosis
3. Baby gram: cardiomegaly, hepatomegaly
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Differential Diagnosis
1. Aspiration pneumonia dd community acquired
pneumonia with respiratory failure type II
2. Intrahepatic dd extrahepatic cholestasis
3. Down syndrome (clinical)
4. Suspected congenital hypothyroid
5. ED : suspected acyanotic heart disease
AD : Suspected ASD dd PDA
FD : Ross II
6. Fracture costae 6-7 due to susp deficiency vitamin D
dd trauma
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Working Diagnosis
1. Aspiration pneumonia with respiratory failure type II
(J69.0)
2. Intrahepatic dd extrahepatic cholestasis (K71.0)
3. (Clinical) Down syndrome (Q90)
4. Suspected congenital hypothyroid (E03.1)
5. ED : suspected acyanotic heart disease (Q24.9)
AD : Suspected ASD dd PDA
FD : Ross II
6. Fracture costae 6-7 due to susp deficiency vitamin D
dd trauma (M84.4)
7. Well nourished, underweight, normoheight
 30

Plan : Therapy
1. Admitted to neonatal PICU with NIV  Family
declined  admitted to pediatric respiratory ward
2. O2 nasal canule 1 lpm
3. Temporary fasting  install NGT (open flow) 
evaluate product then start intake if RR < 60x/min
4. D5 ¼ NS inf. 14 ml/h IV
5. Ampicillin inj. (50 mg/kg/6h)  175mg/6h IV
6. Gentamycin inj. (7,5 mg/kg/24h)  30 mg/24h IV
7. Paracetamol (10mg/kg/dose)  35 mg orally if needed
8. Vitamin A 6000 IU/24h PO
9. Vitamin D 0,25 mcg/24h PO
10. Vitamin E 100 IU/24h PO
11. Vitamin K 2,5 mg/24h PO
 31

Plan
PLAN
• Echocardiography
• Abdominal USG (2 phase)
• TSH, FT4

MONITORING
• General appearance/Vital signs/Saturation/2hour
• Fluid balance/Diuresis/8 hours
FOLLOW UP
23/09/2018
 33

S: breathlessness (+), still fasting, vomit (-)

O:
General appearance:
Looks breathless, Icteric, fully alert

Vital Signs:
1. Heart rate: 132 bpm
2. Body temperature : 36,70C
3. Respiration rate: 64x/min
4. Oxygen Saturation: 96-98%
5. RBG : 140mg/dL
 34

Physical Examination
• Head : Mesocephal, HC 34cm (-2 SD < HC < 0 SD,
Fenton), dysmorphic face (+)
• Eyes : Isochoric pupils (2mm/2mm), light reflex
(+/+), anemic conjunctivae (-/-), icteric (+/+)
• Nose : Nasal flare (+), NGT installed (+)
• Mouth : Dry mucosa (-), cyanosis (-)
• Ear : Discharge (-/-)
• Neck : Lymph nodes enlargement (-/-)
• Chest : Symmetric, retraction (+) subcostal,
intercostal, suprasternal

LUNG:
• I: normal, symmetric,
floating rib (-/-)
• P: hard to evaluate
• P: sonor
• A: vesicular breath sound
(+/+), additional
breath sound (+/+),
Rales (+/+), wheezing
(-/-)
35
HEART:
• I : ictus cordis not visible
• P: ictus cordis not
palpable
• P: cardiac
enlargement (+)
• A: 1st 2nd Heart sound
normal intensity, regular,
systolic murmur (+)
 36

ABDOMEN
• I: abdominal wall > thoracic wall, enlarged
veins, umbilical herniation (+)
• A: peristaltic sound (+)
• P: tympanic (+)
• P: distended (-), tenderness (-) hepatomegaly
(+), spleenomegaly (-)
 37

EXTREMITIES:
• CRT < 2 seconds,
• Dorsalis Pedis artery strongly palpable
• Warm extremities
• Hypotonia
• Edema
- -
- -
 38

Working Diagnosis
1. Aspiration pneumonia with respiratory failure type II
(J69.0)
2. Intrahepatic dd extrahepatic cholestasis (K71.0)
3. (Clinical) Down syndrome (Q90)
4. Suspected congenital hypothyroid (E03.1)
5. ED : suspected acyanotic heart disease (Q24.9)
AD : Suspected ASD dd PDA
FD : Ross II
6. Fracture costae 6-7 due to susp deficiency vitamin D
dd trauma (M84.4)
7. Well nourished, underweight, normoheight
 39

Plan : Therapy
1. Admitted to neonatal PICU with NIV  Family
declined  admitted to pediatric respiratory ward
2. O2 nasal canule 1 lpm
3. Temporary fasting  install NGT (open flow) 
evaluate product then start intake if RR < 60x/min
4. D5 ¼ NS inf. 14 ml/h IV
5. Ampicillin inj. (50 mg/kg/6h)  175mg/6h IV
6. Gentamycin inj. (7,5 mg/kg/24h)  30 mg/24h IV
7. Paracetamol (10mg/kg/dose)  35 mg orally if needed
8. Vitamin A 6000 IU/24h PO
9. Vitamin D 0,25 mcg/24h PO
10. Vitamin E 100 IU/24h PO
11. Vitamin K 2,5 mg/24h PO
 40

Plan
PLAN
• Echocardiography
• Abdominal USG (2 phase)
• TSH, FT4

MONITORING
• General appearance/Vital signs/Saturation/2hour
• Fluid balance/Diuresis/8 hours
FOLLOW UP
24/09/2018
 42

S: breathlessness (+), still fasting, vomit (-)

O:
General appearance:
Looks breathless, Icteric, fully alert

Vital Signs:
1. Heart rate: 140 bpm
2. Body temperature : 37 0C
3. Respiration rate: 64 x/min
4. Oxygen Saturation: 97-99%
 43

Physical Examination
• Head : Mesocephal, HC 34cm (-2 SD < HC < 0 SD,
Fenton), dysmorphic face (+)
• Eyes : Isochoric pupils (2mm/2mm), light reflex
(+/+), anemic conjunctivae (-/-), icteric (+/+)
• Nose : Nasal flare (+), NGT installed (+)
• Mouth : Dry mucosa (-), cyanosis (-)
• Ear : Discharge (-/-)
• Neck : Lymph nodes enlargement (-/-)
• Chest : Symmetric, retraction (+) subcostal,
intercostal, suprasternal

LUNG:
• I: normal, symmetric,
floating rib (-/-)
• P: hard to evaluate
• P: sonor/sonor
• A: vesicular breath sound
(+/+), additional
breath sound (+/+),
Rales (+/+), wheezing
(-/-)
44
HEART:
• I : ictus cordis not visible
• P: ictus cordis not
palpable
• P: cardiac
enlargement (+)
• A: 1st 2nd Heart sound
normal intensity, regular,
systolic murmur (+)
 45

ABDOMEN
• I: abdominal wall > thoracic wall, enlarged
veins, umbilical herniation (+)
• A: peristaltic sound (+)
• P: tympanic (+)
• P: Soft, tenderness (-) hepatomegaly (+),
spleenomegaly (-)
 46

EXTREMITIES:
• CRT < 2 seconds,
• Dorsalis Pedis artery strongly palpable
• Warm extremities
• Hypotonia
• Edema
- -
- -
 47

Working Diagnosis
1. Aspiration pneumonia with respiratory failure type II
(J69.0)
2. Intrahepatic dd extrahepatic cholestasis (K71.0)
3. (Clinical) Down syndrome (Q90)
4. Suspected congenital hypothyroid (E03.1)
5. ED : suspected acyanotic heart disease (Q24.9)
AD : Suspected ASD dd PDA
FD : Ross II
6. Fracture costae 6-7 due to susp deficiency vitamin D
dd trauma (M84.4)
7. Well nourished, underweight, normoheight
 48

Plan : Therapy
1. Admitted to neonatal PICU with NIV  Family
declined  admitted to pediatric respiratory ward
2. O2 nasal canule 1 lpm
3. Temporary fasting  install NGT (open flow) 
evaluate product then start intake if RR < 60x/min
4. D5 ¼ NS inf. 14 ml/h IV
5. Ampicillin inj. (50 mg/kg/6h)  175mg/6h IV
6. Gentamycin inj. (7,5 mg/kg/24h)  30 mg/24h IV
7. Paracetamol (10mg/kg/dose)  35 mg orally if needed
8. Vitamin A 6000 IU/24h PO
9. Vitamin D 0,25 mcg/24h PO
10. Vitamin E 100 IU/24h PO
11. Vitamin K 2,5 mg/24h PO
 49

Plan
PLAN
• Echocardiography
• Abdominal USG (2 phase)
• TSH, FT4

MONITORING
• General appearance/Vital signs/Saturation/2hour
• Fluid balance/Diuresis/8 hours
 50

Clinical question: How effective is

ampicillin sulbactam in treating
pneumonia in children?
P: Children with pneumonia

I: Ampicillin sulbactam

C:

O: Efficacy or effectivity
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52
53
 54

Validity
Was the assignment of patients to
treatments randomised?
• Yes. They were randomized

Were the groups similar at the start of the

trial?
• Yes, they were similar and selected based on inclusion
and exclusion criterias

Aside from the allocated treatment, were

groups treated equally?
• Yes, they were treated equally
 55

Validity
Were all patients who entered the trial accounted for? – and
were they analysed in the groups to which they were
randomised?
• Yes, they were analyzed on sub groups based on different treatment received

Were measures objective or were the patients and clinicians

kept “blind” to which treatment was being received?
• Not clearly stated in the journal.
 56

Important
How large was the treatment effect?
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 58

Applicability

Can the result be applied to the local population?

• Yes, it can be applied

Are the results useful for reassuring or counselling

patients?

• Yes, the information could be useful for

counselling patients
 59

important

LoE
2B
Valid applicable
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