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MORNING REPORT
TUESDAY, 3RD MAY 2017

dr. Rini/dr. Pipit

dr. Debby/dr. Guntur/dr. Lucky/dr. Ahimsa
dr. Rara/ dr. Irfan
dr. Fitri/ dr. Dian
 PATIENT ADMISSION
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 MELATI 2 WARD
1. G/3m.o./5.7kgs, with meningitis dd/ encephalitis, history of
status epilepticus, well nourished.
 HCU MELATI 2
1. M/2y.o./5.6kgs, female, with pneumonia; suspected for

laryngomalacia; spastic type CP; microcephaly due to

suspected for TORCH dd malnutrition, marasmic type
malnutrition in transitition phase
 PICU : -
 HCU NEONATUS : -
 NICU : -
 PATIENT IDENTITY
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 Name :M
 Sex : Female
 Age : 2 y.o
 Body weight : 5.6 kgs
 Adress : Polokarto, Sukoharjo,
Central Java
 Medical Record : 01377852
 CHIEF COMPLAINT
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Breathlessness
 Current Medical History
2 weeks before Day of admission ER RSDM
admission

• High fever • Patient looked • Patient looked

• The temperature breathlessness, breathlessness,
decreased after took irritable, runny nouse, irritable, fully alert
paracetamol and cough. • Lost the appetite
• Cough (+), runny nose • The fever was • Urinating and
(+), breathlessness (+) decreased because defecation within
• Seizure (+), spastic he had took normal limit
(+), + lasts 15 paracetamol before
minutes, unconcious it.
while having seizure. • Lost the appetite
• Admitted to hospital,
increasing work of
breathing, spastic
occurs more frequent,
moved to PICU for 8
days with Pneumonia
5
aspiration.
 Past Medical History
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 Since she was born, snoring breathing sounds, and dissapeared

with change in position. There were no bluish colour. Difficult in
gain weight, often choked while she was drinking. There were
no history of vomit.
 First seizure occurred when she was 1 y.o. accompanied with

fever, last 15 minutes, spastic, unconcious while having seizure,

fully awake after the seizure stops.
 Due to parent, the patients was having delayed development,
such as couldn’t raise her head or even sit upright. She was
brought to the doctor, given physiotherapy. She hasn’t had any
Head CT Scan.
 Family Medical History
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 History of same illness in family was denied

 History of hospitalized when she was born due to premature
and low birth weight
 Pregnancy and Delivery History
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 During pregnancy, her mother routinely checked her pregnancy to

doctor. She was given vitamin, and she didn’t consume any medicine
besides it. She had several vaginal bleeding during her pregnancy.
 Baby boy was born in 32 weeks of pregnancy, spontaneous, crying
vigorously, cyanosis or icteric wasn’t found. Her birth weight was 2200
grams, his mother forgot his birth length. She was hospitalized for 4
days due to underweight.
 Vaccination History
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 BCG : 1 month
 Hepatitis B0 : 0 month
 DPT-HB : 2,3,4 months
 Polio : 1, 2,3,4 months
 Measles : 9 months
 Nutrition History
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Patient eats 2-3 times a day, rice with tahu, tempe, seldom with meat,
fish, vegetables. the portion of meal is 2/3-3/4 portion. Patient has
difficulty in feeding due to her condition. She sometimes drinks milk 1-2
glasses a day.
Conclusion: nutrition status is not adequate

Growth and Development History

She is now 2 years old, can’t communicate with family and his friends.
Can’t tilt her head, sit upright.
Her weight is 5.6 kg with body height 72 cm.
Conclusion: inappropriate for his age
 Nutritional Status
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• Weight for Age: 5.6/13.5 x 100% = 41.5%, severe

underweight
• Height for Age: 72/93.5 x 100% = 77%, severe
stunted
• Weight for Height : 5.6/8.7 x 100% = 64%,
Malnutrition
 Family Tree
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II

III

Child M, 2 y.o., 5.6kgs

 Physical examination
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 General appearance : moderate illness, fully alert,

GCS E4M6V5, looked breathlessness and irritable
 Vital sign :
 Heart Rate = 140 bpm
 Respiration rate = 44 bpm

 Temperature = 37.6 0 C peraxilar

 O2 saturation = 98%
  Head : mesocephal, head circumference =m44 cm (-2SD < head
circumference < 0, Nelhaus)
 Eyes : pale conjunctiva (-/-), icteric conjunctiva (-/-), light reflex
(+/+), isochoric pupil 3 mm/3mm, sunken eyes (-/-), tears (+/+)
 Nose : nasal flare (+), discharge (-/-)
 Mouth : wet lips (+), lips and tongue not cyanotic
 Neck : enlargement of lymph node (+) regio colli dextra et sinistra ±
3 cm
 Thorax : symmetric (+), retraction (+) subcostal and suprasternal

LUNG:
 I: normal, symmetric, retraction (+) subcostal, suprasternal
 P: fremitus equal on both sides of hemithorax
 P: sonor in both lung
 A: normal vesicular breath sound, additional breath sound (+/+), crackles (+/+),
wheezing (+/+), inspiratory stridor (+)
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 CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, no murmur

ABDOMINAL:
I: abdominal wall same with chest wall
A: peristaltic sounds in normal limit
P: tympani(+), shifting dullness (-), undulations(-),
P: liver and spleen was not palpable, good skin turgor

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis pedis artery
was strongly palpable, mid upper arm circumference : 11.5 cms

GENITALIA : female, no abnormality

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Phisiology reflex Pathology reflex Meningeal sign

Biceps (2+/2+) Babinsky (-/-) Stiff neck(-)
Triceps (2+/2+) Chaddock (-/-) Kernig (-)
Patella (2+/2+) Gordon (-/-) Brudzinsky I/II (-/-)
Achilles (2+/2+) Oppenheim (-/-)

Craniales nerves
I nerve : can’t be evaluated IX nerve : centre uvula
II nerve : can’t be evaluated X nerve : can’t be evaluated
III, IV, VI nerves : light reflex (+/+) XI nerve : can’t be evaluated
V nerve : can’t be evaluated XII nerve : can’t be evaluated
VII nerve : can’t be evaluated
 Laboratory Findings
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• Hb : 6.5 g/dl • Albumin : 2.8 g/dL

• HCT : 21% • Ureum : 12 mg/dL
• AL : 26.3 thousand/ul • Creatinine : 0.2 mg/dL
• AT : 994 thousand/ ul • Blood sugar : 118 mg/dl
• AE : 4.61 mil/ul • Sodium : 131 mmol/L
• MCV : 81.2/um • Potassium : 3.9 mmol/L
• MCH : 25.7 pg • Calcium : 1.19 mmol/L
• MCHC : 31.7 g/dl • Chloride : 94 mmol/L
• RDW : 11.9
• PDW : 15%
• Netrophyl : 73.10 % Conclusion :
• Limphocyte : 19.60 % Anemia, leucocytosis,
• Monocyte : 6.80 % thrombocytosis, hypoalbuminemia,
hyponatremia, hypochloremia
• Blood type : A
 RO Thorax AP/Lat
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 Conclusion
Pneumonia
 List of Problem
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M, female, 2 y.o with:  Respiration rate 44 bpm

 Temperature = 37.60 C
 High fever
 Nasal flare
 Cough  Enlargement of colli node
 Runny nose
dextra et sinistra 3cm/3cm
 Retraction subcostal and
 Breathlessness supratracheal
 Seizure, spastic, lasts 15  Additional breath sound,
minutes, unconcious while crackles, wheezing,
inspiratory stridor
having seizure  Anemia, leucocytosis,
 Lost the appetite thrombocytosis,
hypoalbuminemia,
 Malnutrition hyponatremia, hypochloremia
 Differential diagnosis
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 Pneumonia dd acute bronchitis

 Suspected for laryngomalacia
 Spastic type CP
 Microcephaly due to suspected TORCH infection, malnutrition
 Malnutrition, marasmic type, transititional phase day-1
 Thrombocytosis reactive dd essential
 Working diagnosis
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 Pneumonia
 Suspected for laryngomalcsia
 Spastic type CP
 Microcephaly due to malnutrition
 Malnutrition, marasmic type, transititional phase day-1
 Thromobytosis reactive due to infection
 Therapy
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 Admitted to HCU pediatric

 O2 RM 8 litre/minute
 10 therapy of malnutrition
1. Prevent and treat hypoglicemia : Blood glucose 123 mg/dL

2. Prevent and treat hypothermia : T 37,20C

3. Prevent and treat dehydration (-)

4. Treat electrolyte imbalance

5. Treat infection : Ceftriaxone injection (50 mg/kgBW/12hours)

250mg/12 hours IV
 Therapy
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 Treat micronutrition deficiency :

1. Vitamin A 200.000 IU/x (single dose) orally
2. Vitamin B complex 1 tab/24 hours orally
3. Vitamin C 50mg/24 hours orally
4. Vitamin E 100 IU/24 hours orally
5. Zinc tab 20mg/24 hours orally
6. Folic acid 5 mg on day 1 orally
Food intake stabilization and transition phase : F100 6 x 90-100ml
(based on need of water : 560 cc/day)
Food intake for growth acceleration
Give stimulus for growth and development
Preparing for further care at home
 Plan
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1. Blood gas analysis

2. Blood culture
3. Consult to neurology department
4. Consult to ENT department

Monitoring
• General appearance/vital sign/SiO2/3 hours
• Diuresis and fluid balance/8 hours
 FOLLOW UP HCU, Wednesday 3rd May 2017
Subject Fever (-), breathless (+), stridor (+), cough (+)

CNS Severe illness, compos mentis, GCS E4V5M6

Cardiovascular Heart rate : 120 x/minute

System Murmur (-), capillary refill time < 2 seconds, dorsalis artery pulse (+)
Assessment: no abnormality
Respiratory Respiratory rate : 34 x/minute, head bobbing (-) Si02 : 100%
System Retraction (+) suprasternal, epigastrium, subcostal
Air entry (-), grunting (-), sianosis (-), additional breath sounds (+/+) crackles (+/+),
inspiratory stridor (+)
Assessment : breathlessness
GIT Hepatal Distended (-), defecation (-), peristaltic sound (+), vomit (-), icteric (-),
System Assessment : no abnormality
Genitourinaria Urination (-)
System Assessment: no abnormality
Infection Thermoregulation System Gastrointestinal System Assessment: Pneumonia,
System 37.10C (-) (-) suspected
Central nervous system (-) Hematologyy System (-) laringomalasia, CP
Cardiovascular System (-) Hemodynamic System(-) spastic
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Respiratory System (+)
 Blood Gas Analysis Results
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 pH = 7.480
 BE = 20.7
 PCO2 = 59.1
 PO2 = 231.5
 Hematokrit = 21%
 HCO3 = 44.4
 Total CO2 = 46.2
 O2 saturation = 98.8 %
 Laktat = 0.90

Conclusion:
Metabolic alkalosis with partial respiratoric acidosis

Calculated fio2 target : 35%

 Working diagnosis
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 Pneumonia
 Suspected for laryngomalacia
 Spastic type CP
 Microcephaly due to malnutrition
 Malnutrition, marasmic type, transitition phase day-2
 Thrombocytosis reactive due to infection
 Therapy
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 O2 NRM 5 litre/minute
 F100 diet 6 x 90-100 ml
 Ceftriaxone injection (50 mg/kgBW/12hours) 250mg/12 hours IV (II)
 Paracetamol injection (10 mg/kgBW) 50 mg if got fever IV
 Vitamine B complex 1 tab/ 24 hours orally
 Vitamine C 50 mg/ 24 hours orally
 Vitamine E 100.000 IU/ 24 hours orally
 Folic acid 1 mg/24 hours orally
 Zinc 20 mg/ 24 hours orally
 Plan
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1. Packed red cell transfusion 60 ml

2. Blood culture

Monitoring
• General appearance/Vital Sign/SiO2/3 hours
• Diuresis and fluid balance/8 hours
 FOLLOW UP HCU, Wednesday 4th May 2017
Subject Fever (-), breathless (+), stridor (+), cough (+)

CNS Severe illness, compos mentis, GCS E4V5M6

Cardiovascular Heart rate : 120 x/minute

System Murmur (-), capillary refill time < 2 seconds, dorsalis artery pulse (+)
Assessment: no abnormality
Respiratory Respiratory rate : 34 x/minute, head bobbing (-) Si02 : 100%
System Retraction (+) suprasternal, epigastrium, subcostal
Air entry (-), grunting (-), sianosis (-), additional breath sounds (+/+) crackles (+/+),
inspiratory stridor (+)
Assessment : breathlessness
GIT Hepatal Distended (-), defecation (-), peristaltic sound (+), vomit (-), icteric (-),
System Assessment : no abnormality
Genitourinaria Urination (-)
System Assessment: no abnormality
Infection Thermoregulation System Gastrointestinal System Assessment: Pneumonia,
System 37.10C (-) (-) suspected
Central nervous system (-) Hematologyy System (-) laringomalasia, CP
Cardiovascular System (-) Hemodynamic System(-) spastic
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Respiratory System (+)
 Working diagnosis
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 Pneumonia
 Suspected for laryngomalacia
 Spastic type CP
 Microcephaly due to malnutrition
 Malnutrition, marasmic type, transitition phase day-2
 Thrombocytosis reactive due to infection
 Therapy
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 O2 NRM 5 litre/minute
 F100 diet 6 x 90-100 ml
 Ceftriaxone injection (50 mg/kgBW/12hours) 250mg/12 hours IV (II)
 Paracetamol injection (10 mg/kgBW) 50 mg if got fever IV
 Vitamine B complex 1 tab/ 24 hours orally
 Vitamine C 50 mg/ 24 hours orally
 Vitamine E 100.000 IU/ 24 hours orally
 Folic acid 1 mg/24 hours orally
 Zinc 20 mg/ 24 hours orally
 Plan
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1. Packed red cell transfusion 60 ml

2. Blood culture

Monitoring
• General appearance/Vital Sign/SiO2/3 hours
• Diuresis and fluid balance/8 hours
 CLINICAL QUESTION
Is there any variant type of laryngomalacia in older
children more than 2 years of age?
Do they need a specific therapy for better outcome?

 P : Children with laryngomalacia

 I : Supraglottoplasty
 C : -

 O : Late onset laryngomalacia with clinical

improvement
 Late-onset laryngomalacia: a variant of disease.
Arch Otolaryngol Head Neck Surg. 2008 Jan;134(1):75-80
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37 THANK YOU