CASE CONFERENCE

night shift
Monday, November 25th 2019

dr. Mega / dr. Etika /dr. Kiki / dr. Disa/ dr. Winda
dr. Tria/dr. Efan
dr. Zilmi/ dr. Nunki

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 PATIENT ADMISSION
2

• Melati 2 ward :
- A, 4 y.o, 16.5 kgs with Guillain Barre syndrome dd
ATM, wellnourished
• Melati 3 Ward
- Af, 3 y.o, 14 kgs with Acute Gastroenteritis with
moderate dehydration, hydrocephalus post VP shunt,
wellnourished
- L, 11 y.o, 21 kgs with Dengue Fever dd unspecified
viral infection, ED: Acyanotic CHD, AD: Tricuspid atresia,
VSD, PMO, L to R shunt post BCPS surgery,
malnourished
 3
IDENTITY PASIEN

Name : A
Age : 4 years 2 months
Gender : Female
W/ L : 16.5 kgs/101 cms
Address : Ngemplak, Boyolali
MR : 01485407
Chief Complaint :
Paralyzed

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Appearance
Tone : normal, active movement
Irritability : normal, fully conscious
Consolability : normal, calm
Look : normal, focus
Speech : normal, active speech

Work of Breathing Appearance: Work of Breathing:

Breath sound : normal Normal normal
Positioning : normal
Nasal flaring : normal PEDIATRIC
ASSESMENT
Retraction :- TRIANGLE

Circulation
Pale :-
Cyanosis :- Circulation:
Mottle :- Normal
Bleeding :-
 Primary Survey
• Airway:
– Within normal limit
• Breathing:
– Work of breathing : within normal limit
• Circulation:
– Within normal limit

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 THE CURRENT MEDICAL HISTORY

1 weeks before
admission •Fever(+)
•Cough and cold (+)

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 THE CURRENT MEDICAL HISTORY

3 days before
admission •Fever(-)
•Weakness in the feet and legs

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 THE CURRENT MEDICAL HISTORY

1 days before
admission •Fever(-)
•Weakness in the lower body, moving forward

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 THE CURRENT MEDICAL HISTORY

• Fully alert At ER
• Dyspnea (-)
• Fever (-)
• Urinating (+)

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 11 PAST MEDICAL HISTORY

• History of physical injury : (+) 1 month ago with

injured left hip
 12 FAMILY MEDICAL HISTORY

• The family didn’t have any history of same

symptoms
 13
ANAMNESIS
PREGNANCY AND
DELIVERY

Pregnancy
The patient is 1st child of her family. She was born from 35 years old mother,
G1P0A0 at 38th week of gestational age. Her mother checked her pregnancy
to midwife, consumed vitamins routinely, and never hospitalized.

Delivery
The baby was delivered spontaneous from mother with premature
rupture of membrane 7 hours . She was born aterm, Birth weight
2600 gram.

Conclusion :
The pregnancy dan delivery was normal
 14
ANAMNESIS
Growth
Development

Growth
This patient’s age is 4 years old with the weight 16.5 kgs and the
height 101 cm.

Development
• Speak clearly using more complex sentences
• Peddle a bicycle
• Draw a person with a body
• Understand and obeys rules

Conclusion: normal growth and normal development

15

Vaccination History
VACCINE MONTH
Hepatitis B1 (+) Polio 1 0 month
BCG(+), Hepatitis B2 1 month
DTP1 (+),Polio 2(+) 2 month
DTP2 (+), polio 3 (+) 4 month
DTP3 (+), polio 3 (+), Hepatitis B3 (+) 6 month
Measles (+) 9 month
DTP4 (+), polio 4 (+) 18 month
Measles (+) 24 month

Conclusion :
Complete basic immunization
according to Ministry of Health schedule 2014
 FAMILY TREE

II

III

A, 4 y.o, 16.5 kgs

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17

• Weight for Age :

0 SD < W/A < 2 SD (normoweight)
• Height for Age :
-2 SD < H/A < 0 SD (normoheight)

• Weight for height :

0 SD< W/H < +1 SD (wellnourished)

Conclusion (WHO 2005) : normoweight, normoheight,

wellnourished
 18
PHYSICAL EXAMINATION
GA : moderate illness, compos mentis
VS : Heart rate: 110x/min Temp. : 37,1oC
Resp. rate : 22x/min SiO2 : 97%

Head : Normocephalic
Eyes : Anemic conjungtiva -/-, icteric sclera -/-, isochoric
pupils 2mm/2mm
Nose : Nostrils flares(-), discharge (-)
Mouth : Wetness (+), cyanosis (-), pharynx and tonsil difficult to
evaluated
Ears : Ear discharge -/-
Neck : Node enlargement (-)
Chest : Symmetrical in shape and movement, retraction (-)
 19

Cor : I : Ictus cordis not appeared

P : Ictus cordis was palpable SIC V LMCS
P : Heart enlargement (-)
A : Heart sounds I-II normal intensity, regular, murmur (-)
Pulmo: I : left hemithorax = right hemithorax
P: Fremitus right = left
P: Sonor / sonor
A: Vesicular breath sounds +/+ , additional sounds -/-
Abdomen : I : abdominal wall = chest wall
A : peristaltic sound (+) normal
P : hypertympani (+)
P : distended, tenderness (-),
liver were not palpable enlarged, spleen were not
palpable enlarged, skin turgor within normal limit
 20
Extremity :
Cyanosis : -/- Cold extremity : -/-
-/- -/-
Clubbing finger (-)
arteri dorsalis pedis strong palpable
capillary refill time< 2 seconds
Neurological state:
Motoric: Phisiological Reflex : Pathological Reflex :
3333 3333 Biseps +1/+1 Openheim -/-
3333 3333 Triceps +1/+1 Gordon -/-
Patella +1/+1 Babinsky -/-
Achiles +1/+1 Schuffner-/-

Meningeal Sign : Spastic -/-, clonus (-)

Nuchal rigidity (-) -/-
Brudzinky I/II (-)/(-) Cranial Nerves:II normal IV normal
Kernig Sign (-) III normal VII Symetrical
 21
LABORATORY FINDING
November, 24th 2019
Value Reference Units
Hemoglobin 13.6 11.5-13.5 g/dl
Hematocrit 39.2 34-40 %
Leukocyte 7.91 5.5-17.0 x103/ul
Thrombocyte 526 150-450 x103/ul
Eritrocyte 5.21 3.90-5.30 x106/ul
MCV 75.2 80.0-96.0 /um
MCH 26.1 28.0-33.0 pg
MCHC 34.7 33.0-36.0 g/dl
Eosinophil 1.4 0.00-4.00 %
Basophil 0.3 0.00-1.00 %
Neutrophil 52.1 29.00-72.00 %
Lymphocyte 42.0 60.00-66.00 %
Monocyte 4.2 0.00-11.00 %
 22 LABORATORY FINDING
November 24th 2019

Value Reference Units

Sodium 134.9 129-147 mmol/L
Kalium 4.54 3.6-6.1 mmol/L
Chlorida 97.3 98-106 mmol/L

Interpretation :
• Thrombocytosis
• limfopheni
 23 Problem List
A, female, 4 yo , 16.5 kg with :
1. Hystory of Fever
2. Hystory of cough and cold
3. Weakness in the lower body, moving forward
 24 DIFFERENTIAL DIAGNOSIS

1. Guillain Barre syndrome dd ATM

2. Wellnourished
 25 WORKING DIAGNOSIS

1. Guillain Barre syndrome dd ATM (G61)

2. Wellnourished
 26 THERAPY

1. Admitted to Neurology ward

2. Rice pack diet 1200kkal
3. IVFD D5 ¼ NS 54 cc/hour
4. Paracetamol (15 mg/kg/8 hr) = 240 mg/8
hours IV
 27
PLAN

1. Lumbar puncture
2. EMG
3. Spinal MRI

MONITORING
 General Appearance/Vital Signs/Blood
pressure/8hour
 Monitoring respiratory distress
FOLLOW UP 26/11/2019

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PHYSICAL EXAMINATION
GA : moderate illness, compos mentis
VS : Heart rate: 102x/min Temp. : 36,8oC
Resp. rate : 24x/min SiO2 : 98%

Head : Normocephalic
Eyes : Anemic conjungtiva -/-, icteric sclera -/-, isochoric
pupils 2mm/2mm
Nose : Nostrils flares(-), discharge (-)
Mouth : Wetness (+), cyanosis (-), pharynx and tonsil difficult to
evaluated
Ears : Ear discharge -/-
Neck : Node enlargement (-)
Chest : Symmetrical in shape and movement, retraction (-)
 30

Cor : I : Ictus cordis not appeared

P : Ictus cordis was palpable SIC V LMCS
P : Heart enlargement (-)
A : Heart sounds I-II normal intensity, regular, murmur (-)
Pulmo: I : left hemithorax = right hemithorax
P: Fremitus right = left
P: Sonor / sonor
A: Vesicular breath sounds +/+ , additional sounds -/-
Abdomen : I : abdominal wall = chest wall
A : peristaltic sound (+) normal
P : hypertympani (+)
P : distended, tenderness (-),
liver were not palpable enlarged, spleen were not
palpable enlarged, skin turgor within normal limit
 31
Extremity :
Cyanosis : -/- Cold extremity : -/-
-/- -/-
Clubbing finger (-)
arteri dorsalis pedis strong palpable
capillary refill time< 2 seconds
Neurological state:
Motoric: Phisiological Reflex : Pathological Reflex :
3333 3333 Biseps +1/+1 Openheim -/-
3333 3333 Triceps +1/+1 Gordon -/-
Patella +1/+1 Babinsky -/-
Achiles +1/+1 Schuffner-/-

Meningeal Sign : Spastic -/-, clonus (-)

Nuchal rigidity (-) -/-
Brudzinky I/II (-)/(-) Cranial Nerves:II normal IV normal
Kernig Sign (-) III normal VII Symetrical
 32 WORKING DIAGNOSIS

1. Guillain Barre syndrome dd ATM (G61)

2. Wellnourished
 33 THERAPY

1. Rice pack diet 1200kkal

2. IVFD D5 ¼ NS 54 cc/hour
3. Paracetamol (15 mg/kg/8 hr) = 240 mg/8
hours IV
 34
PLAN

1. Lumbar puncture
2. EMG
3. Spinal MRI

MONITORING
 General Appearance/Vital Signs/Blood
pressure/8hour
 Monitoring respiratory distress
THANK YOU

35
 Clinical question
• Which is better plasma exchange or IVIG for
GBS in the pediatrics population?
• CRITICAL APPRAISAL
 VALIDITY
WAS THERE A CLEAR QUESTION FOR THE STUDY
TO ADDRESS?
YES

WAS THE DIAGNOSTIC TEST EVALUATED IN

REPRESENTATIVE SPECTRUM PATIENTS?
YES
• WHAT ABOUT THE
RESULT?
• WAS THE COMPARISSON WITH APPROPRIATE
REFFERENCE STANDART?
 applicability
9. Are The findings of the study feasible in my
setting?
yes
10. Can the result apply to my setting?
yes
 LOE

valid

2A

applicable important