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CASE CONFERENCE
July 25th 2017

dr. Susi/ dr. Fitri/ dr. Indra/ dr. Patra/ dr. Devi
dr. Debby/dr. Anggra
dr. Pitra/ dr. Heru
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Patients Admission
Melati 2 Ward
1. J, girl, 1 years old, 5.7 kgs, with acyanotic congenital heart disease,
ASD, TR mild, secondary hyperthyroid, prolonged fever due to
suspected urinary tract infection dd TB dd TORCH infection,
Vomitting without dehidration, under-nourished, severe
underweight, severe stunted.
2. M, 5 years old, 20 kgs, with ALL L1 HR in 6th cycle of chemotherapy,
general symptomatic epilepsy, well-nourished.
Neonatal HCU (-)
Baby Mrs Y, 5 days old, 3.5 kgs, with early onset sepsis, multiple
congenital anomaly, neonate, boy, normal birth weight, aterm,
apropriate for gestasional age, delivered by C-section, outside
delivery.
NICU: ( - )
Melati 2 HCU (-)
PICU (-)
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Patient Identity
Name : baby mrs Y
Sex : male
Age : 5 days old
Address : Grobogan
Med. record : 01386596
Weight/Height : 3150 g/53 cm
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Chief Complain

Multiple congenital anomaly

 Chief Complaint: newborn infant

There were
multiple
congenital
Mother had anomaly such as:
having
routinely supernumerary
checked up her fingers or toes,
pregnancy to defect
Four days before midwife characterized by
admission a baby sac-like protrusions
boy was born from of the brain and
16 y.o mother, C- A/S when the the membranes
section, Birth baby born was that cover it, and
5/7/8, lessions tongue.
weight : 3500 gram
Chief Complaint: newborn infant

At
Patient got emergency
D10%, Vicilin, room;
dexametashone non
Norages, vigorously
Ranitidin ,Sibital baby, normal
2 days before
and aminofusin respiratory
admission,
effort, muscle
baby was
tone was
seizure for 30 Because of abnormal, no
minutes, limitation facility, fever, no
seizure was patient was seizure
stopped after reffered to
having Moewardi
medicine hospital
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Pregnancy and Delivery History

During pregnancy, the mother routinely checked up her
pregnancy to midwife. She was given vitamin, and she
didnt consume any of medicine beside it.
Baby boy was born in full term pregnancy (37 weeks),
delivered by sectio caesarean delivery due to
cephalopelvic disproportion, cried vigorously, no cyanosis
or icteric was found and his birth weight was 3500 grams.
There were multiple congenital abnormality when he was
born.

Conclusion: pregnancy history was normal and delivery

history was abnormal
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Vaccination History

Vaccination history
Hepatitis B1 :-

Conclusion : incomplete immunization, based on

Ministry of Healths schedule 2017
 PEDIGREE

II

III
Baby Mrs Y, male, 5 days old, 3500 grams
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Physical Examination
General appearance: moderately ill, fully alert, wellnourished
Vital Signs :
Heart rate : 138 bpm
Body temperature : 37.3 0C
Respiration rate : 38 bpm
Saturation : 93 %
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Head : mesocephal, mass (+), soft, cystic,

mobile, 1 cm in diameter
Face : dysmorphic (+)
Eyes : pale conjunctiva (-/-), icteric
conjunctiva(-/-), light reflex (+/+), isochoric pupil
2 mm/2mm
Nose : nasal flare (-/-),discharge (-/-)
Mouth : wet lips, lips and tongue not cyanotic,
abnormal tongue.
Neck : no enlargement of lymph node
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LUNG:
I: normal, symmetric, no retraction
P: right fremitus = left fremitus
P: sonor in both lung
A: normal vesicular breath sound, additional breath sound
(-),
CARDIAC:
I : ictus cordis not visible
P: ictus cordis not palpable
P: there is no cardiac enlargement
A: 1st 2nd Heart sound normal intensity, regular, no
murmur
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ABDOMINAL:
I: abdominal wall // thorax wall
A: peristaltic in normal limit
P: tympani(+), shifting dullness (-), undulations(-)
P: splenomagaly (-), enlargement of liver (-)

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec,
and dorsalis pedis artery was strongly palpable.
Polydactyl (+) both in fingers and toes
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Laboratory Findings (July 25th 2017)

Hb : 17.9 g/dl Blood sugar : 61 mg/dl
HCT : 54 % albumine : 3.2 g/dl
AL : 9.7 thousand/ul Potasium : 5.6 mmol/L
AT : 168 thousand/ ul
Sodium : 139 mmol/L
AE : 5.40 mil/ul
Calsium : 1.07 mmol/L
MCV : 100.7 /um
HbsAg Rapid : (-)
MCH : 33.1 pg
MCHC : 32.9 g/dl
Netrophyl: 77.60 %
Lymphocyte : 15.90%

Conclusion: Netrophylia, lymphocytopenia,

 LIST OF PROBLEMS

Male, neonate, 5 days old, 3150 grams, with :

1. Neonates with multiple congenital anomaly

2. history of Seizure
3. Mass in head, 1 cm in diameter, softly palpable, cystic
4. Dysmorfic face
5. tongue lessions
6. Polydactyl in both fingers and toes
7. Netrophylia, lymphocytopenia
8. Well-nourished normoweight normoheight
 DIFFERENTIAL DIAGNOSIS

1. Early onset sepsis

2. Multiple congenital anomaly
3. Neonate, boy, normal birth weight, aterm,
apropriate for gestasional age, delivered by
sectio caesarean due to cephalopelvic
dysproportion, outside delivery
 WORKING DIAGNOSIS

1. Early onset sepsis

2. Multiple congenital anomaly
3. Neonate, boy, normal birth weight, aterm,
apropriate for gestasional age, delivered by
sectio caesarean due to cephalopelvic
dysproportion, outside delivery
 THERAPIES

1. Admitted to Neonatal HCU

2. Formula milk on cue
3. IVFD D5 NS 13.8 ml/ hour
4. Ampicilin-sulbactam (100 mg/kg/day) 175
mg/12 hours I.V
 PLANNING

1. Baby gram and extremities x-ray

2. Echocardiography examination
3. TSH and FT4 test examination
4. Blood culture examination
5. chest x-ray examination

MONITORING
General appearance/vital sign/sio2/3 hours
Fluid balance / 8 hours
FOLLOW UP
July, 26th 2017
Issues Multiple congenital anomaly

CNS not cry vigorously, not active in motion, spontaneously open

eyes (+)
Assessment: S3
I
Cardiovascular Heart rate : 140 x/minute
System Murmur (-) Capillary refill time < 2 seconds, dorsalis artery pulse
(+) strong palpable
Assessment: within normal limit
Respiratory Respiratory rate : 40 x/minute Si02 : 98%
System Retraction (-), Air entry (+), grunting (-), sianosis (-)
Downe score (0)
Assessment : within normal limit
GIT Hepatal Distended (-), defecation(-), peristaltic sound (+), vomit (-),
System icteric (-)
II Assessment : within normal limit
Genitourinaria39th Urination (+) 34th
System Assessment: within normal limit
Infection Thermoregulation Gastrointestinal Assessment: within
IIISystem System 36.8 C (-)
0 System (-) normal limit
Central nervous system Hematology System
8 thn
(-) (-)
Cardiovascular System Hemodynamic
3hari /3800gram
(-) System(-)
Respiratory System (-)
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Localis status

1. Polydactyl in both fingers and toes

2. Mass in occipital region suspect
meningocele
3. Dysmorphic face
4. Abnormal tongue
 WORKING DIAGNOSIS

1. Early onset sepsis

2. Polydactyl
3. Meningocele
4. Tongue fibroma
5. Neonate, boy, normal birth weight, aterm,
apropriate for gestasional age, delivered by
sectio caesarean due to cephalopelvic
dysproportion, outside delivery
 THERAPIES

1. Formula milk/ breast milk 15-20 ml/ 3 hours

2. IVFD D 12% = D5 NS 123 ml + D40% 20 ml +
KCL 1 meq + Ca Gluconas 2 ml + soluvit @
ml = 149 ml/day= 6.2 ml/hour
3. Aminofusin 6% 52.5 ml/day = 2.2 ml/hour I.V.
4. Lipofundin 20% 15.8 ml/day = 0.6 ml/hour I.V
5. Ampicilin-sulbactam (100 mg/kg/day) 160
mg/12 hours I.V
 PLANNING

1. Echocardiography examination
2. TSH and FT4 test examination
3. Blood culture examination
4. Head CT-scan examination

MONITORING
General appearance/vital sign/sio2/3 hours
Fluid balance / 8 hours
FOLLOW UP
July, 26th 2017
Issues Multiple congenital anomaly

CNS not cry vigorously, not active in motion, spontaneously open

eyes (+)
Assessment: S3
I
Cardiovascular Heart rate : 140 x/minute
System Murmur (-) Capillary refill time < 2 seconds, dorsalis artery pulse
(+) strong palpable
Assessment: within normal limit
Respiratory Respiratory rate : 40 x/minute Si02 : 98%
System Retraction (-), Air entry (+), grunting (-), sianosis (-)
Downe score (0)
Assessment : within normal limit
GIT Hepatal Distended (-), defecation(-), peristaltic sound (+), vomit (-),
System icteric (-)
II Assessment : within normal limit
Genitourinaria39th Urination (+) 34th
System Assessment: within normal limit
Infection Thermoregulation Gastrointestinal Assessment: within
IIISystem System 36.8 C (-)
0 System (-) normal limit
Central nervous system Hematology System
8 thn
(-) (-)
Cardiovascular System Hemodynamic
3hari /3800gram
(-) System(-)
Respiratory System (-)
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Localis status

1. Polydactyl in both fingers and toes

2. Mass in occipital region suspect
meningocele
3. Dysmorphic face
4. Abnormal tongue
 WORKING DIAGNOSIS

1. Early onset sepsis

2. Polydactyl
3. Meningocele
4. Tongue fibroma
5. Neonate, boy, normal birth weight, aterm,
apropriate for gestasional age, delivered by
sectio caesarean due to cephalopelvic
dysproportion, outside delivery
 THERAPIES

1. Formula milk/ breast milk 15-20 ml/ 3 hours

2. IVFD D 12% = D5 NS 123 ml + D40% 20 ml +
KCL 1 meq + Ca Gluconas 2 ml + soluvit @
ml = 149 ml/day= 6.2 ml/hour
3. Aminofusin 6% 52.5 ml/day = 2.2 ml/hour I.V.
4. Lipofundin 20% 15.8 ml/day = 0.6 ml/hour I.V
5. Ampicilin-sulbactam (100 mg/kg/day) 160
mg/12 hours I.V
 PLANNING

1. Echocardiography examination
2. TSH and FT4 test examination
3. Blood culture examination
4. Head CT-scan examination

MONITORING
General appearance/vital sign/sio2/3 hours
Fluid balance / 8 hours
FOLLOW UP
July, 27th 2017
Issues Multiple congenital anomaly

CNS not cry vigorously, not active in motion, spontaneously open

eyes (+)
Assessment: S3
I
Cardiovascular Heart rate : 140 x/minute
System Murmur (-) Capillary refill time < 2 seconds, dorsalis artery pulse
(+) strong palpable
Assessment: within normal limit
Respiratory Respiratory rate : 40 x/minute Si02 : 98%
System Retraction (-), Air entry (+), grunting (-), sianosis (-)
Downe score (0)
Assessment : within normal limit
GIT Hepatal Distended (-), defecation(-), peristaltic sound (+), vomit (-),
System icteric (-)
II Assessment : within normal limit
Genitourinaria39th Urination (+) 34th
System Assessment: within normal limit
Infection Thermoregulation Gastrointestinal Assessment: within
IIISystem System 36.8 C (-)
0 System (-) normal limit
Central nervous system Hematology System
8 thn
(-) (-)
Cardiovascular System Hemodynamic
3hari /3800gram
(-) System(-)
Respiratory System (-)
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Localis status

1. Polydactyl in both fingers and toes

2. Mass in occipital region suspect
meningocele
3. Dysmorphic face
4. Abnormal tongue
 12/19/2017

laboratory finding

TSH 6.87
FT4 13.7
 WORKING DIAGNOSIS

1. Early onset sepsis

2. Polydactyl
3. Meningocele
4. Tongue fibroma
5. Neonate, boy, normal birth weight, aterm,
apropriate for gestasional age, delivered by
sectio caesarean due to cephalopelvic
dysproportion, outside delivery
 THERAPIES

1. Formula milk/ breast milk 15-20 ml/ 3 hours

2. IVFD D 12% = D5 NS 123 ml + D40% 20 ml +
KCL 1 meq + Ca Gluconas 2 ml + soluvit @
ml = 149 ml/day= 6.2 ml/hour
3. Aminofusin 6% 52.5 ml/day = 2.2 ml/hour I.V.
4. Lipofundin 20% 15.8 ml/day = 0.6 ml/hour I.V
5. Ampicilin-sulbactam (100 mg/kg/day) 160
mg/12 hours I.V
 PLANNING

1. Echocardiography examination
2. Blood culture examination
3. Head CT-scan examination

MONITORING
General appearance/vital sign/sio2/3 hours
Fluid balance / 8 hours
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