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CASE CONFERENCE
TUESDAY NIGHT SHIFT,
JANUARY 7, 2019

dr. Ama/ dr. Chandra/ dr. Rara/ dr. Ida/ dr. Nunki
dr. Dini/ dr. Lubna
dr. Iriz/ dr. Prima
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PATIENT ADMISSION
• NICU: -
• Neonatal HCU: -
• Wing Mawar 2:
• Melati 2 HCU:
• PICU:
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• Melati 2:
• Child MN, 7 yo, 37 kg, with vomitus dehydration mild
moderate due to gastritis dd duodenitis, obese.
• Melati 3:
• Child L, 10 yo, 44 kg, with menometrorrhagia, abdominal
pain due to urinary tract infection dd adnexitis, wel
nourished
• Child D, 2 yo, 9 kg, with severely wasted stabilization
phase type day 1, suspected HIV infection, reactive
thrombocytosis dd essential
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PATIENT IDENTITY

Name :D
Age/Wt/L : 2 yo/ 9 kgs / 95 cms
Sex : Male
Address : Karanganyar, Central Java
Medical : 01396428
Record
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CHIEF COMPLAINT
Patient did not want to eat
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THE CURRENT MEDICAL HISTORY

A week before
admission
• Diarrhea (+), blood (-) mucous (-) Fever (-), given
medicine  diarrhea was stopped and patient had appetite
to eat
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THE CURRENT MEDICAL HISTORY

Day of
admission
• Patient did not want to eat at all, loss a lot of body weight,
the patient was brought to private hospital. There patient
vomited 2x about one and a half glass contain of milk.
• Patient was diagnosed with severe under nourished and
suspected HIV and then patient was referred to Moewardi
hospital.
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THE CURRENT MEDICAL HISTORY

At the ER
• Fully alert, no fever, no vomit, no diarrhea
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THE PAST MEDICAL HISTORY

Patient was being treated in Moewardi hospital in

December with diagnosed of GEA and severe under
nourished
History of repeated diarrhea and stomatitis
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HISTORY OF PREGNANCY AND DELIVERY

Pregnancy
The patient is the 1st child of his family. She was born from a 25 years
old mother, G1P0A0, at 40th 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 normal labor. There was no complication
during procedure. The baby cried vigourously, weighted 2200 grams,
body length 41 cm. The amniotic fluid was clear.

Conclusion : the pregnancy were normal and the delivery were

normal
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VACCINATION HISTORY

0 month : Hepatitis B0
1 month : BCG, polio 1
2 months : DPT1, hepatitis B1, polio2
3 months : DPT2, hepatitis B2, polio3
4 months : DPT3, hepatitis B3, polio4
9 months : Measles
18 months : DPT4, polio 5

Conclusion :
complete immunization,
appropriate with Ministry of Health schedule
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PEDIGREE

II

III

D, 2 yo, 9 kgs
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NUTRITIONAL HISTORY

Patient eats rice 3 times a day with rice packs with vegetables, soya
cake, ‘tempe’, sometimes egg, chicken, and beef rarely. Sometimes
he drinks formula milk 2 times a day ± 150 ml
Conclusion: nutrition quantity and quality status is
adequate

Growth and Development

GROWTH History
AND DEVELOPMENT
He is 2 years old now, 9 kgs in body weight. The growth
and developments are normal. Patient could socialize with
her schoolmate well.
Conclusion: appropriate for his age
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Nutritional status
• Body Weight/Age
Z score < -3SD (severely underweight)
• Body Height/Age
-2 SD < Z score < 0 SD (normoheight)
• Body Weight/Body Height
Z score < -3 SD (severe wasted)

Conclusion : severely underweight, normoheight,

severely wasted
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PHYSICAL EXAMINATION
GA : moderate ill, fully alert, E4V5M6
VS : Heart rate: 124 bpm
Resp. rate : 24 x/ minutes
SiO2 : 99%
Temp: 36.7 oC

Head : mesocephal, head circumference 48.5 cm (-2SD < HD <0SD)

Eyes : anemic conjunctiva -/-, icteric sclera -/-, isocoric
pupil (2mm/2mm), light reflex (+/+), old man face (+)
Nose : nasal flares (-), nasal discharge (-)
Mouth : cyanosis (-), stomatitis (+)
Ears : Ear discharge -/-,
Neck : Lymph node enlargement (-),
Chest : Symmetrical in shape and movement, retraction (-) , floating
ribs (+)
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Cor I : ictus cordis was not visible

P: ictus cordis was palpable in SIC VI LPSS
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, no murmur
Pulmo: I : symmetrical movement (+)
P: fremitus sounds +/+
P: sonor +/ sonor +
A: vesicular breath sounds +/+, additional breath sound (-/-)
Abd : I : abdominal wall = chest wall
A : peristaltic sound (+) normal
P : tympani (+), normal skin turgor
P : tender, hepar and spleen not palpable,
Extremity : Edema : -/- Cold extremities: -/- wasting +/+
-/- -/- +/+
Strong palpable of dorsal pedis artery
CRT < 3”
baggy pants -, scar of BCG +
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LABORATORY FINDING
January 7, 2019

Value Reference Units

Hemoglobin 7.0 11.5-15.5 g/dl
Hematocrit 26 35-45 %
Leucocyte 17.7 4.5-14.5 x103/ul
Thrombocyte 1210 150-450 x103/ul
Erythrocyte 3.64 4.00-5.20 x106/ul
MCV 7.26 80.0-96.0 /um
MCH 19.2 28.0-33.0 pg
MCHC 26.5 33.0-36.0 g/dl
Neutrophil 17,0 29.00-72.00 %
Lymphocyte 15 30.00-48.00 %
Monocyte 5.60 0.00-5.00 %
Eosinophil 0.40 1.00-4.00 %
Basophil 0.10 0.00-1.00 %
Random blood
sugar 84 60 -100 Mg/dl
albumine 3.2 38 – 5.4 g/dl
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LABORATORY FINDING
October 17th 2018

Value Reference Units

Sodium 136 132-145 mmol/L

Potassium 4.4 3.1-5.1 mmol/L
Calcium 1.11 1.17-1.29 mmol/L
Chloride 109 98-106 mmol/L

CONCLUTION:
Anemia, thrombocytosis, hypoalbuminemia
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CHEST X RAY (9/01/19)

Concluson : Pneumonia
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PROBLEMS

A boy, 2 years old, 9 kgs with:

1. Vomit (+)
2. Fever (-)
3. Diarrhea (+), blood (-) mucous (-)
4. Hard intake, loss a lot of body weight
5. Stomatitis (+)
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DIFFERENTIAL DIAGNOSIS

1. Severely wasted stabilization phase day 1

2. Suspected of HIV
3. Reactive thrombocytosis dd essential
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WORKING DIAGNOSIS

1. Severely wasted stabilization phase day 1

2. Suspected of HIV
3. Reactive thrombocytosis dd essential
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THERAPY
1. Admitted to Nutrition and Metabolic Disease subdivision of
Pediatric
2. 10 treatment of severely wasted:
1. Management of hypoglycemia  RBS 103
2. Avoid hypothermia  t 37.2
3. Prevent dehydration  no dehydration
4. Management of imbalance electrolytes
5. Treatment of infection  cotrimoxazole (5 mg TMP/BW) 240 mg/ 12
h (I/V)
6. Manage the micronutrition:
1. Vit A 200000 IU single dose
2. Folic acid 5 mg
3. Elkana syrup 1 dd cth 1
4. Zinc 20 mg/ 24 h
5. Mineral mix cth 1
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THERAPY
7. Give intake :
Calorie needs : 80 -100 kcal/ kg/ day 720 -900 kcal/ day
Fluid needs : 130 ml/ kg/ day 1179 ml/ day
Protein : 1 -1.5 g/ kg/ day = 9 – 13.5 g/ day
Stabilization F75 12x 100 ml
8. Reach the growth spurt  rehabilitation phase
9. Give physical, sensory stimulation and emotional support
10. Prepare to the next care
11. Resomal (10 ml/kg/diarrhea) 90 ml/ diarrhea
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PLAN
1. CBC, blood sugar, electrolytes
2. HIV rapid test
3. Blood perifer analysis
4. Urinalysis
5. Stool analysis
6. Mantoux test, CXR
MONITORING
 General Appearance/Vital Signs/8 hours
 Balance fluid and diuresis/ 8 hours
 Up arm circumference / 3 days
 BW/ histogram/ day
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FOLLOW UP
JANUARY 8, 2019
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PHYSICAL EXAMINATION
GA : moderate ill, fully alert, E4V5M6
VS : Heart rate: 118 bpm
Resp. rate : 22 x/ minutes
SiO2 : 99%
Temp: 36.7 oC

Head : mesocephal, head circumference 48.5 cm (-2SD < HD <0SD)

Eyes : anemic conjunctiva -/-, icteric sclera -/-, isocoric
pupil (2mm/2mm), light reflex (+/+), old man face (+)
Nose : nasal flares (-), nasal discharge (-)
Mouth : cyanosis (-), stomatitis (+)
Ears : Ear discharge -/-,
Neck : Lymph node enlargement (-),
Chest : Symmetrical in shape and movement, retraction (-) , floating
ribs (+)
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Cor I : ictus cordis was not visible

P: ictus cordis was palpable in SIC VI LPSS
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, no murmur
Pulmo: I : symmetrical movement (+)
P: fremitus sounds +/+
P: sonor +/ sonor +
A: vesicular breath sounds +/+, additional breath sound (-/-)
Abd : I : abdominal wall = chest wall
A : peristaltic sound (+) normal
P : tympani (+), normal skin turgor
P : tender, hepar and spleen not palpable,
Extremity : Edema : -/- Cold extremities: -/- wasting +/+
-/- -/- +/+
Strong palpable of dorsal pedis artery
CRT < 3”
baggy pants -, scar of BCG +
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WORKING DIAGNOSIS

1. Severely wasted stabilization phase day 1

2. Suspected of HIV
3. Reactive thrombocytosis dd essential
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THERAPY
1. 10 treatment of severely wasted:
1. Management of hypoglycemia  RBS 103
2. Avoid hypothermia  t 37.2
3. Prevent dehydration  no dehydration
4. Management of imbalance electrolytes
5. Treatment of infection  cotrimoxazole (5 mg TMP/BW) 240 mg/ 12
h (I/V)
6. Manage the micronutrition:
1. Vit A 200000 IU single dose
2. Folic acid 5 mg
3. Elkana syrup 1 dd cth 1
4. Zinc 20 mg/ 24 h
5. Mineral mix cth 1
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THERAPY
7. Give intake :
Calorie needs : 80 -100 kcal/ kg/ day 720 -900 kcal/ day
Fluid needs : 130 ml/ kg/ day 1179 ml/ day
Protein : 1 -1.5 g/ kg/ day = 9 – 13.5 g/ day
Stabilization F75 12x 100 ml
8. Reach the growth spurt  rehabilitation phase
9. Give physical, sensory stimulation and emotional support
10. Prepare to the next care
11. Resomal (10 ml/kg/diarrhea) 90 ml/ diarrhea
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PLAN
1. CBC

MONITORING
 General Appearance/Vital Signs/8 hours
 Balance fluid and diuresis/ 8 hours
 Up arm circumference / 3 days
 BW/ histogram/ day
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Clinical Question
• What can cause hematological disorders in children
with malnutrition?

•P : children with malnutrition

•I : with hematological disorders
•C : without hematological disorders
•O : cause

The journal wasn’t found

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Important

LoE
4 Not
Valid Applicable