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CASE CONFERENCE
SUNDAY NIGHT SHIFT,
ST
1 OCTOBER 2017

dr. Rara / dr. Guntur / dr. Winda / dr. Delfia / dr. David
dr. Aya / dr. Prabu
dr. Hamid / dr. Ahimsa
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PATIENT ADMISSION
NICU: -
HCU Neonatus: -
Melati 3: -
Melati 2: -
HCU Melati 2: -
PICU: -
ER: An. D/6y.o./20kgs with Abdominal Pain due
to suspected Appendicitis, well nourished.
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IDENTITY

Name :D
Age/Wt/L : 6 y 11mo/ 23 kgs / 117 cms
Sex : Boy
Address : Sukoharjo, Central Java
Medical : 01393957
Record
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CHIEF COMPLAINT
Abdominal Pain
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THE CURRENT MEDICAL HISTORY

Had abdominal pain, intermittent, especially in the

epigastric area
No nausea, no vomitted
Had fever, not too high
Dyspneu
Parents brought him to private clinic, gave him
nebulize therapy and medicine dyspneu resolved
but the abdominal pain persist
Parents brought him to Moewardi hospital ER, got
medicine, and sent home

1 day before
admission
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THE CURRENT MEDICAL HISTORY

Got abdominal pain, in the epigastrium regio, radiating

to umbilical and lower right quadran
Got nausea and vomitted, 2 times, contained water
and digested food
Got fever intermittent
Parents brought him to Moewardi Hospital

Admission
Day
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THE CURRENT MEDICAL HISTORY

Got abdominal pain, especially in the lower right

quadran
No vomitted, still had nausea

At ER
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THE PAST MEDICAL HISTORY

History of same illness : (-)

History of trauma : (-)
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THE FAMILY MEDICAL HISTORY

History of same illness : (-)

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HISTORY OF PREGNANCY AND DELIVERY

Pregnancy
The patient is the 4th child of her family. She was born from a 40 years
old mother, G4P3A0, at 40th weeks of gestational age. His mother
consumed vitamins from a doctor. According to the mother, she had
routinely check up to the doctor and midwife. There was no history of
hospital admission during pregnancy.

Delivery
The patient was delivered spontaneously with midwife assistance. There
was no complication during procedure. The baby was crying vigourously,
weighed 3500 grams and 51 cms in length, the amniotic fluid was clear.

Conclusion : the pregnancy history was abnormal and delivery

history was normal
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VACCINATION HISTORY

BCG : 1 month
Hepatitis B : 0,1,6 month
DPT-HB I-III : 2,3,4 months
Polio : 1,2,3,4 months
Measles : 9 months
Conclusion : Complete Immunization, appropriate with
Ministry Of Health 2004
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PEDIGREE

II

III

D, 6 yo, 23 kgs
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NUTRITIONAL HISTORY

Patient eats 2-3 times a day, rice with tofu, tempe, sometimes
fish and egg. the portion of meal was just 1/2 portion. Patient
had feeding difficulty. He likes to drink milk.
Conclusion: nutrition status is adequate

Growth and Development

GROWTH History
AND DEVELOPMENT
She is now 6 years old, can communicate and interact well with
her family and friends.
Her weight is 23 kg with body height 117 cm.
Conclusion: appropriate for her age
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Nutritional status
Weight for Age
W/A = 23/23 x 100% = 100% (normoweight)
Height for Age
H/A = 117/121 x 100% = 96.6% (normoheight)
Weight for Height
W/H = 23/22 x 100% = 104.5% (wellnourished)

Conclusion:
Wellnourished
( CDC 2000)
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PHYSICAL EXAMINATION
GA : moderately ill, compos mentis
VS : Heart rate: 110 bpm Temp: 37oC
Resp. rate : 28 bpm SiO2 : 99%

Head : mesocephal,
Eyes : pale conjunctiva -/-, icteric sclera -/-, isochoric
pupil (2mm/2mm), light reflex (+/+),
Nose : nasal flares (-), nasal discharge (+)
Mouth : cyanosis (-), hyperemic pharynx (-)
Ears : Ear discharge -/-
Neck : Lymph node enlargement (-)
Chest : Symmetrical in shape and movement, retraction (-)
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Cor : I : Ictus cordis did not appear

P : Ictus cordis was not palpable
P : no sign of heart border enlargement
A : heart sounds I-II normal intensity, regular, murmur(-),
Pulmo: I : symmetrical movement (+)
P: fremitus sounds equals
P: sonor / sonor
A: vesicular breath sounds +/+ , additional breath sound (-/-)
Abd : I : abdominal wall equals to chest wall
A : peristaltic sound (+) normal
P : tympani (+),
P : supel, pain in the lower right quadran (+), McBurney sign (+)
Extremity : Edema : +/+ Cold extremities: -/-
+/+ -/-
Strong palpable of dorsal pedis artery
CRT < 2
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October 1st 2017 LABORATORY FINDING
Value Reference Units
Hemoglobin 13.3 12.3-15.3 g/dl
Hematocrit 39 33-45 %
Leucocyte 14.2 4.5-14.5 x103/ul
Thrombocyte 263 150-450 x103/ul
Eritrocyte 5.05 3.8-5.8 x106/ul
MCV 77.5 80.0-96.0 /um
MCH 26.3 28.0-33.0 pg
MCHC 34 33.0-36.0 g/dl
RDW 12 11.6-14.6 %
MPV 6.9 7.2-11.1 fl
PDW 16 25-65 %
Eosinophil 0.2 0.00-4.00 %
Basophil 0.2 0.00-1.00 %
Neutrophil 82.7 29.00-72.00 %
Lymphocyte 9.4 33.00-48.00 %
Monocyte 7.5 0.00-6.00 %
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LABORATORY FINDING
October 1st 2017

Value Reference Units

Blood type A
PT 15.9 10.0-15.0 Seconds
APTT 28.1 20.0-40.0 Seconds
INR 1.370
HBsAg Rapid Nonreactive Nonreactive
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Alvarado Score
Migratory pain 1
Nausea and vomiting 1
Anorexia 0
Tenderness in right iliac fossa 1
Rebound tenderness in right iliac fossa 1
Elevated temperature 1
Leucocytosis 0
Shift to the left of neutrophil 1
Score 7
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Ultrasonography FINDING
October 1st 2017

1. Non visualized appendix

2. Hepar, gallbladder, lien renal, within normal limit
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PROBLEMS
A boy, 6 years 11 months old, 23 kgs with:
1. Got abdominal pain, in the epigastrium regio, radiating to
umbilical and lower right quadran
2. Got nausea and vomitted
3. Got fever intermittent
4. Pain in the lower right quadran (+), McBurney sign (+)
5. Alvarado score 7 (probable)
6. Non visualized appendix
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DIFFERENTIAL DIAGNOSIS

1. Abdominal pain due to suspected acute appendicitis

2. Wellnourished
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WORKING DIAGNOSIS

1. Abdominal pain due to suspected acute appendicitis

2. Wellnourished
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THERAPY
1. Admitted to Melati 2 ward
2. O2 nasal 2 lpm
3. Diet rice packs 2000 kkal/d
4. IVFD D51/4NS 70 ml/hour
5. Paracetamol (10mg/kg/x) 250mg/8h
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PLAN
1. Consult to pediatric surgery department

MONITORING
General Appearance/Vital Signs/SiO2/8 hour
Fluid balance/ 8 hour
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Follow up 02-10-2017
GA : moderately ill, compos mentis
VS : Heart rate: 100 bpm Temp: 37oC
Resp. rate : 26 bpm SiO2 : 99%

Head : mesocephal,
Eyes : anemic conjunctiva -/-, icteric sclera -/-, isochoric
pupil (2mm/2mm), light reflex (+/+),
Nose : nasal flares (-), nasal discharge (+)
Mouth : cyanosis (-), hyperemic pharynx (-)
Ears : Ear discharge -/-
Neck : Lymph node enlargement (-)
Chest : Symmetrical in shape and movement, retraction (-)
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Cor : I : Ictus cordis did not appear

P : Ictus cordis was not palpable
P : no sign of heart border enlargement
A : heart sounds I-II normal intensity, regular, murmur(-),
Pulmo: I : symmetrical movement (+)
P: fremitus sounds equals
P: sonor / sonor
A: vesicular breath sounds +/+ , additional breath sound (-/-)
Abd : I : abdominal wall equals to chest wall
A : peristaltic sound (+) normal
P : tympani (+),
P : supel, pain in the lower right quadran (+), McBurney sign (+)
Extremity : Edema : +/+ Cold extremities: -/-
+/+ -/-
Strong palpable of dorsal pedis artery
CRT < 2
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WORKING DIAGNOSIS

1. Abdominal pain due to suspected acute appendicitis

2. Wellnourished
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THERAPY
1. Admitted to Melati 2 ward
2. O2 nasal 2 lpm
3. Diet rice packs 2000 kkal/d
4. IVFD D51/4NS 70 ml/hour
5. Paracetamol (10mg/kg/x) 250mg/8h
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PLAN
1. Consult to pediatric surgery department

MONITORING
General Appearance/Vital Signs/SiO2/8 hour
Fluid balance/ 8 hour
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 Validity

Was the assignment of patients to treatments Yes

randomized?
Were the group similar at the start of the trial? Yes
Aside from the allocated treatment were the group Yes
treated equally?
Were the patient who entered the trial accuounted Yes
for? Were they analysed in the groups to which they
were randomized?
Were measures objective or were the patients and Not blind
clinician keep blind to which treatment was being
received?
 Importancy

No complication
complication
Antibiotic group 22 2 24

Surgery group 26 0 26

48 2

How large was the

treatment effect?
RR>1
ARR= -2%
NNT= 50
Is my patient so different to those in the No
study?
Is the treatment feasible to my setting yes
Will the potential benefits of treatment outweight no
the potential harms of treatment for my
patients?
 valid
applicable

important

1B
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