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    Case Conference Monday Morning Shift, October 8 2018

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    latifah
    The document describes a case conference discussion of a 9 month old boy presenting with shortness of breath. Key details include findings of tachycardia, tachypnea, fever, retractions and heart murmur. Working diagnoses include pneumonia, suspected congenital heart disease, dehydration and malnutrition. Therapy includes antibiotics, oxygen and monitoring. Follow up notes continued shortness of breath and fever.

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    Case Conference Monday Morning Shift, October 8 2018

    Uploaded by

    latifah
    31 views34 pages
    The document describes a case conference discussion of a 9 month old boy presenting with shortness of breath. Key details include findings of tachycardia, tachypnea, fever, retractions and heart murmur. Working diagnoses include pneumonia, suspected congenital heart disease, dehydration and malnutrition. Therapy includes antibiotics, oxygen and monitoring. Follow up notes continued shortness of breath and fever.

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    laporan pagi pneumonia

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    CC Pagi Pneumonia

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    The document describes a case conference discussion of a 9 month old boy presenting with shortness of breath. Key details include findings of tachycardia, tachypnea, fever, retractions and heart murmur. Working diagnoses include pneumonia, suspected congenital heart disease, dehydration and malnutrition. Therapy includes antibiotics, oxygen and monitoring. Follow up notes continued shortness of breath and fever.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    31 views34 pages

    Case Conference Monday Morning Shift, October 8 2018

    Uploaded by

    latifah
    The document describes a case conference discussion of a 9 month old boy presenting with shortness of breath. Key details include findings of tachycardia, tachypnea, fever, retractions and heart murmur. Working diagnoses include pneumonia, suspected congenital heart disease, dehydration and malnutrition. Therapy includes antibiotics, oxygen and monitoring. Follow up notes continued shortness of breath and fever.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 34

    1

    CASE CONFERENCE
    MONDAY MORNING SHIFT,
    OCTOBER 8TH 2018
    2

    IDENTITY

    Name :A
    Age/Wt/L : 9 mo/ 4.8 kgs / 66 cms
    Sex : Boy
    Address : Sragen, Central Java
    Medical : 01399293
    Record
    3

    CHIEF COMPLAINT
    Shortness of breath
    (referred from private hospital)
    4

    THE CURRENT MEDICAL HISTORY

    3 days before
    admission •Got coughed rarely, no
    shortness of breath, no
    cyanosis
    •No fever
    •Still wanted to drink
    •No watery stool
    •No rash
    5

    THE CURRENT MEDICAL HISTORY

    1 day before admission

    •Got fever, the temperature was not too high


    •Became fussy
    •No seizure
    •No vomit
    •No flatulence
    •Got shortness of breath
    •Still wanted to drink
    •Parents didn’t give her any medicine
    6

    THE CURRENT MEDICAL HISTORY

    •
    •
    Got shortness of breath
    Fully alert
    At ER
    • No pale
    • No cyanosis
    • Still had fever
    • Urination and defecation within normal limit
    7

    THE PAST MEDICAL HISTORY

    • History of previous dyspnea : denied


    • History of hospitalization : denied
    • History of insufficient weight gain (+)
    8

    THE FAMILY MEDICAL HISTORY

    • History of tuberculosis : denied


    • History of asthma : denied
    • History of congenital heart disease: denied
    9

    HISTORY OF PREGNANCY AND DELIVERY


    Pregnancy
    The patient is the 2nd child of his family. he was born from a 25 years
    old mother, G2P1A0, at 41st 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 postdate
    pregnancy. There was no complication during procedure. The baby was
    crying vigourously, weighted 2700 grams, body length 41 cm. The
    amniotic fluid was clear.

    Conclusion : the pregnancy and delivery history were abnormal


    10

    VACCINATION HISTORY

    BCG : 1 month
    Hepatitis B : at birth
    DPT-HB : -
    Polio I-IV : 1,2 months
    Measles :-
    DT :-

    Conclusion : Complete Immunization, appropriate with


    Ministry Of Health’s Schedule 2017
    11

    PEDIGREE

    II

    III

    A, 9 mo, 4.8 kgs


    12

    NUTRITIONAL HISTORY

    Patient drinks breast milk and formula milk in every 4-6 hours,
    approximately 20 ml in 20 minutes each meal, she couldn’t suck strongly

    Conclusion: nutrition quantity and quality status is inadequate

    Growth and Development


    GROWTH History
    AND DEVELOPMENT
    She is now 2 months old, already can rolling to belly.
    Her weight is 3 kg with length 53 cm.
    Conclusion: inappropriate for his age
    13

    Nutritional status
    • Weight for Age:
    - 3 SD < W/A < -2 SD (underweight)
    • length for Age:
    - 3 SD < H/A < -2 SD (stunted)
    • Weight for length:
    W/H < -3 SD (severely wasted)

    Conclusion (WHO 2005):


    underweight, stunted, severely wasted
    14

    PHYSICAL EXAMINATION
    GA: moderately ill, compos mentis
    VS : Heart rate: 189 bpm Temp: 38.4oC
    Resp. rate : 71 bpm SiO2 : 96%

    Head : mesocephal
    Eyes : anemic conjunctiva -/-, icteric sclera -/-, isochoric
    pupil (2mm/2mm), light reflex (+/+), tears +/+
    Nose : nasal flares (-), nasal discharge (-)
    Mouth : cyanosis (-), hyperemic pharynx (-)
    Ears : Ear discharge -/-,
    Neck : Lymph node enlargement (-)
    Chest : Symmetrical in shape and movement, retraction (+)
    intercostal and epigastrium, wasted (-)
    15

    Cor : I : Ictus cordis seen at ICS IV LPSS


    P : Ictus cordis palpable at ICS IV-V LMCS
    P : cannot be evaluated
    A : Heart sounds I-II normal intensity, regular, pansistolic murmur (+)
    grade III/VI PM LPSS SIC IV
    Pulmo: I : symmetrical movement (+)
    P: fremitus sounds equals
    P: sonor / sonor
    A: vesicular breath sounds +/+ , additional breath sound (+/+),
    crackles (+/+), rales (+/+)
    Abd : I : abdominal wall < chest wall, umbilical hernia (+)
    A : peristaltic sound (+) normal
    P : tympani (+), normal skin turgor
    P : tender, hepar and spleen not palpable
    Extremity : Edema : +/+ Cold extremities: -/- Pale +/+
    +/+ -/- +/+
    Strong palpable of dorsal pedis artery
    CRT < 2”, wasted in all extremities
    MUAC : 9 cms
    16
    LABORATORY FINDING
    October 8th 2018
      Value Reference Units
    Hemoglobin 11.9 9.4-13.0 g/dl
    Hematocrit 41 28-42 %
    Leucocyte 11.9 5.0-19.5 x103/ul
    Thrombocyte 527 150-450 x103/ul
    Erythrocyte 4.37 4.00-5.20 x106/ul
    MCV 94.7 80.0-96.0 /um
    MCH 27.2 28.0-33.0 pg
    MCHC 28.7 33.0-36.0 g/dl
    RDW 12.7 11.6-14.6 %
    MPV 8.1 7.2-11.1 fl
    Neutrophil 16 18.00-74.00 %
    Lymphocyte 1.5 60.00-66.00 %
    Mono, Eos, Bas 0.9 0.00-11.00 %
    RBG 100 50-80 mg/dl
    17

    PROBLEMS
    A boy, 9 months old, 4.8 kgs with:
    1. Had fever, shortness of breath
    2. Tachycardia, tachypnea, fever
    3. Retraction (+) intercostal and epigastrium
    4. Heart enlargement (+), heart sounds I-II normal intensity,
    regular, pansistolic murmur (+) grade III/VI
    5. Severely wasted with wasted extremities
    18

    DIFFERENTIAL DIAGNOSIS

    1. Pneumonia
    2. ED : suspected acyanotic congenital heart disease
    AD : moderate DCSA, VSD, TR mild
    FD : ROSS II
    3. Vomitus mild-moderate dehydration due to suspected
    UTI dd pneumonia
    4. underweight, stunted, severely wasted
    19

    WORKING DIAGNOSIS

    1. Pneumonia
    2. ED : suspected acyanotic congenital heart disease
    AD : moderate DCSA, VSD, TR mild
    FD : ROSS II
    3. Vomitus mild-moderate dehydration due to suspected
    UTI dd pneumonia
    4. underweight, stunted, severely wasted
    20

    THERAPY
    1. Admitted to Melati 2 ward
    2. O2 nasal canule 1 lpm
    3. Inf. RL 40 ml/h
    4. Inj. Ampicillin (50 mg/kg/6h)  150mg/6h iv
    5. Inj. Gentamicin (7.5 mg/kg/24h)  25 mg/24h iv
    6. Inj.Paracetamol (10 mg/kg/8h)  30 mg/8h iv
    7. Furosemid 4mg/12 hours po
    8. Sildenafil 1 pulv/12 hours po
    9. Donor 5 mg/12 hours po
    10. KCl 10 mg/24 hours po
    11. Bisoprolol 0.2 mg/12 hours po
    21

    PLAN
    1. Echocardiography
    2. Ro thorax AP/Lat

    MONITORING
     General Appearance/Vital Signs/BP/3 hours
     Fluid balance/8 hours
    22

    FOLLOW UP
    OCTOBER 9 2018
    TH

    Shortness of breath (+), fever (+)


    23

    PHYSICAL EXAMINATION
    GA: moderately ill, compos mentis
    VS : Heart rate: 145 bpm Temp: 37.4oC
    Resp. rate : 45 bpm SiO2 : 98%

    Head : mesocephal
    Eyes : anemic conjunctiva -/-, icteric sclera -/-, isochoric
    pupil (2mm/2mm), light reflex (+/+), tears +/+
    Nose : nasal flares (-), nasal discharge (-)
    Mouth : cyanosis (-), hyperemic pharynx (-)
    Ears : Ear discharge -/-,
    Neck : Lymph node enlargement (-)
    Chest : Symmetrical in shape and movement, retraction (+)
    intercostal and epigastrium, wasted (-)
    24

    Cor : I : Ictus cordis seen at ICS IV LPSS


    P : Ictus cordis palpable at ICS IV-V LMCS
    P : cannot be evaluated
    A : Heart sounds I-II normal intensity, regular, pansistolic murmur (+)
    grade III/VI PM LPSS SIC IV
    Pulmo: I : symmetrical movement (+)
    P: fremitus sounds equals
    P: sonor / sonor
    A: vesicular breath sounds +/+ , additional breath sound (+/+),
    crackles (+/+), rales (+/+)
    Abd : I : abdominal wall < chest wall, umbilical hernia (+)
    A : peristaltic sound (+) normal
    P : tympani (+), normal skin turgor
    P : tender, hepar and spleen not palpable
    Extremity : Edema : +/+ Cold extremities: -/- Pale +/+
    +/+ -/- +/+
    Strong palpable of dorsal pedis artery
    CRT < 2”, wasted in all extremities
    MUAC : 9 cms
    25

    WORKING DIAGNOSIS

    1. Pneumonia
    2. ED : suspected acyanotic congenital heart disease
    AD : moderate DCSA, VSD, TR mild
    FD : ROSS II
    3. Vomitus mild-moderate dehydration due to suspected
    UTI dd pneumonia
    4. underweight, stunted, severely wasted
    26

    THERAPY
    1. Admitted to Melati 2 ward
    2. O2 nasal canule 1 lpm
    3. Inf. RL 40 ml/h
    4. Inj. Ampicillin (50 mg/kg/6h)  150mg/6h iv
    5. Inj. Gentamicin (7.5 mg/kg/24h)  25 mg/24h iv
    6. Inj.Paracetamol (10 mg/kg/8h)  30 mg/8h iv
    7. Furosemid 4mg/12 hours po
    8. Sildenafil 1 pulv/12 hours po
    9. Donor 5 mg/12 hours po
    10. KCl 10 mg/24 hours po
    11. Bisoprolol 0.2 mg/12 hours po
    27

    PLAN
    1. Echocardiography
    2. Ro thorax AP/Lat

    MONITORING
     General Appearance/Vital Signs/BP/3 hours
     Fluid balance/8 hours
    28

    What is the risk factor for hospitalized patient


    suffer from community acquired pneumonia
    become severe pneumonia?

    • Children with community


    P acquired pneumonia

    • Medical chart and chest


    I radiograph reviews

    C • -

    • Risk factor for severe


    O community acquired pneumonia
    30

    Validity

    Was there a representative and well-defined sample of


    patients at a similar point in the course of the disease?
    • Yes. This study was involved 28.043 children with CAP

    Was follow-up sufficiently long and complete?


    • Yes. The patients were defined CAP for 30 days

    Were objective and unbiased outcome criteria used?


    • No. Not mention clearly
    31

    Importance
    32

    Applicability

    Were the study patients similar to my own?


    • Yes. The study was similar to my own patient
    Are the results useful for reassuring or
    counselling patients?
    • Yes
    33

    Level of Evidence

    Valid
    Importance
    Importance

    Applicable
    Applicable

    Level of evidence 3A
    34

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