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CASE CONFERENCE
TUESDAY NIGHT SHIFT,
TH
NOVEMBER 21 2017

dr. Rara / dr. Debby / dr. Prima / dr. Cempaka / dr. Devy
dr. Dhimas / dr. Lubna
dr. Winda / dr. Kandar
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PATIENT ADMISSION
• NICU:
• A, girl, 21 days old, 2200 grams with neonatal sepsis,
ED: cyanotic congenital heart disease, AD: DORV,
PFO, TR mild, FD: Ross II-III, neonate girl, low birth
weight, preterm, appropriate for gestational age,
spontaneous delivery, twin 2nd born, outside delivery
• Neonatal HCU: -
• Melati 2 ward:
•-
• Melati 2 HCU:
•-
• PICU: -
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IDENTITY

Name :A
Age/Wt/L : 21 days old/ 2200 grams /
48 cms
Sex : Girl
Address : Sragen, Central Java
Medical : 01398766
Record
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CHIEF COMPLAINT
Bluish in the mouth and extremities
(referred from private hospital)
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THE CURRENT MEDICAL HISTORY

•Patient hospitalized since birth in private hospital’s

Neonatal High Care Unit
•At that time, she had shortness of breath, no bluish
color in her mouth or extremities; she used CPAP in
neonatal HCU, got better and moved to the ward at
the 5th day of admission
•At the 9th days of hospitalization in the ward, she
looked bluish, got chest X-Ray with conclusion 
normal heart and lungs with sign of dextrocardia
•Because of limited facilities, patient referred to
Moewardi hospital, but because no room available,
she moved to another private hospital
22 days before
admission
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THE CURRENT MEDICAL HISTORY

•Patient hospitalized in another private hospital’s High

Care Unit with diagnosis: cyanotic congenital heart
disease, DORV, suspected pulmonal atresia, with
neonatal sepsis.
•Patient got oxygen therapy head box 3lpm+ canul nasal
1lpm, infusion D51/4NS 8ml/h, cefotaxime 100mg/12h IV,
gentamycin 10mg/24h, cendophenicol 3x1gtt.
•Patient didn’t had neither fever nor shortness of breath
•Got bluish color in the mouth and extremities
•Patient can drink from mouth approximately 20-30ml
every 2 hours
•Because of limited facilities, patient transferred to
Moewardi hospital

7 day before
admission
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THE CURRENT MEDICAL HISTORY

• Bluish color in patient’s mouth and extremities

• No fever
• No shortness of breath
• Urination and defecation within normal limit

At ER
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THE PAST MEDICAL HISTORY

• -
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THE FAMILY MEDICAL HISTORY

• History of asthma : denied

• History of congenital heart disease : denied
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HISTORY OF PREGNANCY AND DELIVERY

Pregnancy
The patient was born from a 22 years old mother, G1P0A0, at 35th weeks
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 spontaneously. She is the second born twin.
There was no complication during procedure. The baby was crying not
vigourously, weighted 2100 grams, body length unknown, less active.
The amniotic fluid was clear.

Conclusion : the pregnancy history was but delivery history was

abnormal
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VACCINATION HISTORY

BCG :-
Hepatitis B :-
DPT-HB :-
Polio I-IV :-
Measles :-
DT :-

Conclusion : not complete Immunization, inappropriate

with Ministry Of Health’s Schedule 2009
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PEDIGREE

II

III

A, 22 days old , 2.2 kgs

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NUTRITIONAL HISTORY

Patient drinks breast milk and formula milk in every 2-3 hours,
approximately 20 ml.

Conclusion: nutrition quantity and quality status is

inadequate

Growth and Development

GROWTH History
AND DEVELOPMENT
She is now 22 days old.
Her weight is 2.2 kg with body height 48 cm.
Conclusion: inappropriate for his age
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Fenton Chart
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PHYSICAL EXAMINATION
GA : moderately ill, compos mentis
VS : Heart rate: 128 bpm Temp: 36.5oC
Resp. rate : 36 bpm SiO2 : 32 39
44 79
Head : mesocephal, normocephal HC:33 cm
(p10< HC < p50, Fenton chart)
Eyes : anemic conjunctiva -/-, icteric sclera -/-, isochoric
pupil (2mm/2mm), light reflex (+/+), tears +/+
Nose : nasal flares (-), nasal discharge (-)
Mouth : perioral 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 seen at ICS IV-V LPSS

P : Ictus cordis palpable at ICS IV-V
P : difficult to evaluate
A : Heart sounds I-II normal intensity, regular, systolic murmur (+)
Pulmo: I : symmetrical movement (+)
P: fremitus sounds equals
P: sonor / sonor
A: vesicular breath sounds +/+ , additional breath sound (-/-),
Abd : I : abdominal wall // chest wall
A : peristaltic sound (+) normal
P : tympani (+),
P : supel, hepar and spleen not palpable
Extremity : cyanosis +/+ Cold extremities: -/- clubbing finger +/+
+/+ -/- +/+
Strong palpable of dorsal pedis artery
CRT < 2”
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LABORATORY FINDING
November 22th 2017

Value Reference Units

Hemoglobin 13.6 13.4-19.8 g/dl
Hematocrit 47 50-82 %
Leucocyte 14.5 5.0-19.5 x103/ul
Thrombocyte 147 150-450 x103/ul
Erythrocyte 4.30 3.90-5.90 x106/ul
MCV 108.4 80.0-96.0 /um
MCH 31.6 28.0-33.0 pg
MCHC 29.2 33.0-36.0 g/dl
RDW 14.5 11.6-14.6 %
MPV 9.6 7.2-11.1 fl
Eosinophil 3.80 0.00-4.00 %
Basophil 0.30 0.00-1.00 %
Neutrophil 35.20 18.00-74.00 %
Lymphocyte 48.30 60.00-66.00 %
Monocyte 12.40 0.00-6.00 %
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LABORATORY FINDING
November 22th 2017

RBG 84 50-80 mg/dl

Sodium 134 129-147 mmol/L
Potassium 5.1 3.6-6.1 mmol/L
Calcium 1.22 1.17-1.29 mmol/L
Chloride 108 98-106 mmol/L
SGOT 33 <31 u/l
SGPT 11 <34 u/l
Albumin 3.6 3.8-5.4 g/dl
Creatinine 0.4 0.2-0.4 mg/dl
Ureum 11 <42 mg/dl

Conclusion:
• Within normal limit
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PROBLEMS
A girl, 22 days old, 2.2 kgs with:
1. Born spontaneous delivery with twin 2nd born,
2. Gestational age was 35 weeks, bodyweight was
2000 gram at birth
3. History of hospitalized since birth with CPAP usage,
then nasal oxygen
4. Bluish color in the mouth and extremities
5. Four extremities saturation

6. Perioral cyanosis
7. Systolic murmur
8. Cyanosis and clubbing finger in the extremities
9. Laboratory examination: within normal limit
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DIFFERENTIAL DIAGNOSIS

1. Neonatal Sepsis
2. ED : cyanotic congenital heart disease
AD : DORV with suspected pulmonal atresia, PFO,
mild TR
FD : Ross I-II
3. Neonate, girl, low birth weight, preterm, appropriate for
gestational age, delivered spontaneously, 2nd gemelli,
outside delivery
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WORKING DIAGNOSIS

1. Neonatal sepsis
2. ED : cyanotic congenital heart disease
AD : DORV with suspected pulmonal atresia, PFO,
mild TR
FD : Ross I-II
3. Neonate, girl, low birth weight, preterm, appropriate for
gestational age, delivered spontaneously, 2nd gemelli,
outside delivery
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THERAPY
1. Admitted to NICU
2. Diet breastmilk/ formula milk 8x 20-30ml
3. O2 nasal canule 1 lpm
4. Inf. D51/4NS 4 ml/h
5. Inj. Cefotaxime (50 mg/kg/12h)  100mg/12h iv
6. Inj. Gentamicin (4 mg/kg/24h)  10 mg/24h iv
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PLAN
1. Consult to cardiology subdivision
2. Echocardiography
3. Babygram X-Ray

MONITORING
 General Appearance/Vital Signs/SiO2/hour
 Fluid balance/8 hours
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FOLLOW UP
TH
NOVEMBER 22 2017
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Issues Cyanotic congenital heart disease

CNS Cried vigorously (-) Active in motion (+) , eyes open spontaneously
(+), normocephal HC 33 cm (p10< HC < p50, Fenton)
Assessment: S5
Cardiovascular Heart rate : 162 x/minute, systolic murmur (+), capillary refill time <
System 2 seconds, dorsalis pedis arteria pulse (+), warm extremities (+)
Assessment: cyanotic congenital heart disease
Respiratory Respiratory rate : 42 x/minute, head bobbing (-) Si02 : 99%
System Retraction (+) minimum, nasal flare (- ) Air entry (-) grunting (-),
cyanotic (+), Downe score (2)
Assessment : mild respiratory distress
GIT Hepatal Distended (-), peristaltic sound (+), vomit (-), jaundice (-)
System Assessment : within normal limit
Genitourinaria Urination (-)
System Assessment: cannot evaluated yet
Infection Thermoregulation Gastrointestinal Assessment:
System System 37.60C (+) System (-) Cyanotic
Central nervous system Hematology System congenital heart
(S5) (-) disease, neonatal
Cardiovascular System (- Hemodynamic sepsis
) System(-)
Respiratory System (-)
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Babygram X-Ray

 Conclusion:
 Cardiomegaly with
configuration of Right Atrial
Hypertrophy, Left Atrial
Hypertrophy, and Left
Ventricular Hypertrophy
 Pneumonia
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ECHOCARDIOGRAPHY

 Conclusion:
 Transposition Great Artery with Patent Foramen Ovale
and Patent Ductus Arteriosus
 Small Ventricular Septal Defect
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WORKING DIAGNOSIS

1. Neonatal sepsis
2. ED : cyanotic congenital heart disease
AD : TGA with PFO and PDA, small VSD
FD : Ross I-II
3. Neonate, girl, low birth weight, preterm, appropriate for
gestational age, delivered spontaneously, 2nd gemelli,
outside delivery
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THERAPY
1. Diet breastmilk/ formula milk 8x 20-30ml
2. O2 nasal canule 1 lpm
3. Inf. D51/4NS 8 ml/h
4. Inj. Cefotaxime (50 mg/kg/12h)  100mg/12h iv
5. Inj. Gentamicin (4 mg/kg/24h)  10 mg/24h iv
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PLAN
1. Consult to cardiology department: plan for BAS (Nov 23th
2017)
2. Blood culture

MONITORING
 General Appearance/Vital Signs/SiO2/hour
 Fluid balance/8 hours
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FOLLOW UP
TH
NOVEMBER 23 2017
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Issues Cyanotic congenital heart disease

CNS Cried vigorously (-) Active in motion (+) , eyes open spontaneously
(+), normocephal HC 33 cm (p10< HC < p50, Fenton)
Assessment: S5
Cardiovascular Heart rate : 152 x/minute, systolic murmur (+), capillary refill time <
System 2 seconds, dorsalis pedis arteria pulse (+), warm extremities (+)
Assessment: cyanotic congenital heart disease
Respiratory Respiratory rate : 46 x/minute, head bobbing (-) Si02 : 99%
System Retraction (+) minimum, nasal flare (- ) Air entry (-) grunting (-),
cyanotic (+), Downes score (2)
Assessment : mild respiratory distress
GIT Hepatal Distended (-), peristaltic sound (+), vomit (-), jaundice (-)
System Assessment : within normal limit
Genitourinaria Urination (+)
System Assessment: within normal limit
Infection Thermoregulation Gastrointestinal Assessment:
System System 36.60C (+) System (-) Cyanotic
Central nervous system Hematology System congenital heart
(S5) (-) disease, sepsis
Cardiovascular System (- Hemodynamic neonatorum
) System(-)
Respiratory System (-)
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WORKING DIAGNOSIS

1. Neonatal sepsis
2. ED : cyanotic congenital heart disease
AD : TGA with PFO and PDA, small VSD
FD : Ross I-II
3. Neonate, girl, low birth weight, preterm, appropriate for
gestational age, delivered spontaneously, 2nd gemelli,
outside delivery
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THERAPY
1. Diet breastmilk/ formula milk 8x 20-30ml
2. O2 nasal canule 1 lpm
3. Inf. D51/4NS 8 ml/h
4. Inj. Cefotaxime (50 mg/kg/12h)  100mg/12h iv
5. Inj. Gentamicin (4 mg/kg/24h)  10 mg/24h iv
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PLAN
1. BAS

MONITORING
 General Appearance/Vital Signs/SiO2/hour
 Fluid balance/8 hours
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Clinical Question
1. How to manage oxygen supplementation in neonatal cyanotic
congenital heart disease? What is our oxygen saturation
target?
2. What age of the neonates with congenital heart defect should
we reffered?
3. How we differentiate cyanotic congenital heart defect
between TOF, DORV,and TGA before echocardiography? Is
there any special clinical feature in brief?
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What factors assosiated with delayed

diagnosis the congenital heart defects?
• Neonates with congenital
P heart defects

I • -

C • -

O • Delayed diagnosis
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Validity
1. Was the research question clear?
Yes, researcher want to examine trends in timing of diagnosis of critical congenital
heart defects (CCHDs) and factors associated with delayed diagnosis (diagnosis after
discharge home following delivery).
2. What was the design of the study?
The population-based retrospective cohort of CCHD cases among live births identified
through the Massachusetts Birth Defects Monitoring Program
3. How is the sample representative of the population?
researcher identified a cohort of CCHD cases among live births between January 1,
2004 and December 31, 2009
4. Describe the variables of interest. If a comparison study, on what variable(s) are
the groups being compared? How were the groups similar?
Demographic and perinatal information included the following maternal
and infant characteristics: age, race/ ethnicity, education, residence in or outside of
Boston, prenatal care insurance type, prenatal care initiation month, delivery hospital
level, gestational age, plurality, birth weight, and date and cause of any infant death
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Importancy
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Applicability
1. What relevance do the findings have to practice?
delayed diagnosis still occurs in over 10% of CCHD cases.

2. Discuss how the findings can be applied to practice.

Understanding the risk factors for delayed diagnosis of CCHD may help to
reduce delayed detection rates, to better target prenatal and postnatal CCHD
screening programs, and to allow for evaluation of screening program
effectiveness.
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