CASE BASED DISCUSSION

Anemia, Acute Bronchitis And

Adequate Nutrition
Mohammad Fajar Sodiqi
30101507494

Pembimbing: Dr. dr. Sri Priyantini, Sp. A

Patient’s Indentity

Name : By. TSN

Date of birth (Age) : 25/09/2019 (1 month 24 days)
Gender : Female
Address : Rusunawa Kudu
Date of hospital admission : 18 November 2019 (21.00)
Parents’ Identities
Father’s Name : Mr. R
Date of birth (Age) : 60 years old
Occupation : Laborer
Religion : Moslem
Address : Rusunawa Kudu

Mother’s Name : Mrs. E

Date of birth (Age) : 44 years old
Occupation : Laborer
Religion : Moslem
Address : Rusunawa Kudu
 Anamnesis

Alloanamnesis was done on Monday 25th of November 2019 at 16.00 WIB in Peristi RSI
SA supported by medical record.
 Anamnesis
Main Problem
01
The child got fever for 3 days
 Anamnesis
Present Medical History
02
Patient went to Sultan Agung Islamic Hospital at 21.00 on 18th November
2019 with 3 days of fever. Her parents said that the temperature reached
39,4oC. Her parents haven’t given any medication to patient. She was just
compressed with wet towel by her parents to relieve her fever. Other than
that, her parents said that she also had cough.
Anamnesis
Past Medical History

03 The child has never got same problem before

Faringitis : denied Convulsion : denied

Tonsilitis : denied Enteritis : denied
Bronkiolitis : denied Basiler Dysentry : denied
Pnemonia : denied Amoeba Dysentry : denied
Morbili : denied Thyphoid fever : denied
Pertusis : denied Worms infection : denied
Varisela : denied Surgery : denied
Difteri : denied Trauma : denied
Malaria : denied Allergy : denied
Polio : denied Tuberculosis : denied
Anemia : denied
Anamnesis

Socio Economic History

The father and the mother are
Family Medical History working as laborers. The patient
and her parents are living
04 No family member complained
of the same problem or other
05 together. The medical expenses
diseases. are using BPJS.
Socio Economic impression:
moderate
Anamnesis
Perinatal History
A girl was born from a G2P1A1 mother with gestational age 35 weeks. The mother
regularly doing antenatal care in Sultan Agung Islamic Hospital but didn’t consume
06 the drugs. The mother didn’t get any disease during pregnancy. The girl was born
caesarean because of breech in Sultan Agung Islamic Hospital and she cried at
birth with birth weight 1300 gr and birth length 40 cm.
The girl was stayed in hospital right after she was born because of the prematurity.
The doctor said she should stay in hospital until her weight reach 2 kg but the
family enforce to go home after 3 weeks hospitalized, when the girl’s weight at 1600
gr.
Perinatal impression: Preterm

Feeding History
07 The girl didn’t get any breastmilk at all because it wouldn’t come out. The mother
gave her formula milk until now but the girl hasn’t got any weaning food.
 Anamnesis
Primary Vaccine History
08
No. Vaccine Freq Recommended
1. BCG 0 1st month
2. Polio 0 0th, 2nd, 4th, 6th month
3. Hepatitis B 0 0th, 2nd, 6th month
4. DPT 0 2nd, 4th, 6th month
5. Measles 0 9th month

Impression: incomplete
 Anamnesis
Growth and Development History
09
Smilling :-
Sleeping on his/her side :-
Sleeping on his/her stomach :-
Sitting without hold on to something : -
Crawling :-
Standing with hold on to something : -

Impression: according to age

 Anamnesis
Contraception History
10
The mother used contraceptive injection for every 3 month.
Physical Examination
Nutritional Status
 
A 1-month girl
• Weight = 3200 gr
• Height = 52 cm

 WAZ =
 HAZ =

 WHZ =

Impression: Adequate Nutrition

Physical Examination
It was done on Monday 25th November 2019, at
16.00 WIB at Peristi RSISA

General impression : adequate

Consciousness : composmentis
Vital sign:
• HR : 96x/min, adequate filling and
tension
• RR : 30 x/min
• Temp : 36,7° C (In ER 38,5oC)
• BP :-
Internal Status
Head : Mesocephale, mayor fontanela hasn’t closed, intracranial hemorrhage sign
(-)
Hair : Black, easily pulled (-), dry (+)
Skin : Petechie (-), cyanosis (-), turgor returns slowly (-), pale (+)
Eyes : Sunken eyes (-), oedem palpebra (-/-), anemic conjungtiva (-/-)

Nose : Discharge (-/-), epistaksis (-/-), nasal flaring (-/-)

Ears : Discharge (-/-), tulang rawan
Lips : Stomatitis angularis (-), dry lips (-), cyanotic lips (-)
Mouth : Bleeding gum (-), stomatitis angularis (-), bula hemorargik (-)
Tongue : Tongue papil atrophy (-), glositis (-), slippery tongue (-)
Neck : Symmetrical, enlarged lymph nodes (-)
Throat : Hiperemic pharynx (-), white spots (-) Tonsil T1/T1
 Internal Status
Thorax
• Inspection : Normal shape, symmetrical, retraction (-)
• Palpation : Symetrical sterm fremitus dextra et sinistra simetris, palpation pain (-)
• Percussion : Sonor on all regio
• Auscultation : Vesicular sound (+), ronkhi (-/-), wheezing (-/-), amforik (-/-)

Cor
• Inspection : Unseen ictus cordis
• Percussion :-
• Palpation : Palpable ictus cordis, weak lifted
• Auscultation :
Rhythm : Reguler
Heart sound : S1 and S2 normal reguler
Murmur : (-)
 Internal Status

Abdomen :
• Inspection : Convex, hyperemic (-), lesion (-), bloated (+)
• Auscultation : Bowel sound (+) normal
• Percussion : Tympanic on all regio, intraabdomen hemorrhagic sign (-)
• Palpation : Palpation pain (-), defense muscular (-), palpable liver and spleen (-)
Internal Status
Extremities

  Superior Inferior
Cold acral -/- -/-
Cyanotic acral -/- -/-
Pathological reflexes -/- -/-
Oedem -/- -/-
Capillary refill time <2 s/<2 s <2 s/<2 s
Spoon nail -/- -/-
Red spots -/- -/-

Genital: Female, within normal limits

Anorectal: Normal
Workup
Laboratory Studies
Blood Test 18-11-2019

Examination Result Normal Unit

Hemoglobin 6,3 (L) 9,0 – 16,6 g/dL
Hematokrit 18,5 (L) 30 – 54 %
Leukosit 9,21 5,0 – 19,5 Ribu/uL
Trombosit 199 (L) 229 – 553 Ribu/uL
Blood Type/Rh O/Positif
Laboratory Studies
Blood Test 19-11-2019
Examination Result Normal Unit
Hemoglobin 9,3 9,0 – 16,6 g/dL
Hematokrit 28,1 (L) 30 – 54 %
Leukosit 9,97 5,0 – 19,5 Ribu/uL
Trombosit 162 (L) 229 – 553 Ribu/uL
Random glucose 96 (H) 50 – 80 Mg/dL
Natrium 138,7 135 – 147 Mmol/L
Kalium 5,19 (H) 3,5 – 5 Mmol/L
Chloride 110,0 (H) 95 – 105 Mmol/L
Laboratory Studies
Blood Test 21-11-2019

Examination Result Normal Unit

Hemoglobin 8,9 (L) 9,0 – 16,6 g/dL
Hematokrit 27,2 (L) 30 – 54 %
Leukosit 6,30 5,0 – 19,5 Ribu/uL
Trombosit 158 (L) 229 – 553 Ribu/uL
 Laboratory Studies
Blood Test 23-11-2019
Examination Result Normal Unit Examination Result Normal Unit
Hemoglobin 11,0 9,0 – 16,6 g/dL Eosinofil 3,2 1–5 %
Hematokrit 32,3 30 – 54 % Basofil 0,4 0–1 %
Leukosit 5,69 5,0 – 19,5 Ribu/uL Neutrofil 56,3 17 – 60 %
Eritrosit 3,67 (L) 3,8 – 5,2 Juta/uL Limfosit 28,8 20 – 70 %
Trombosit 188 (L) 229 – 553 Ribu/uL Monosit 10,5 1 – 11 %
MCV 88 81 – 121 Fl IG 0,7 %
MCH 30 25 – 37 Pg Retikulosit 3,69 (H) 0,5 – 1,5 %
MCHC 34,1 26 – 34 g/dL Feritin 676,89 (H) 9,3 - 159 Ng/mL
Assesment

Anemia
Acute Bronchitis
Adequate Nutrition
 Anemia
DD:
• Anemia Hemolitic
• Thalasemia
• Anemia Chronic disease
• Anemia caused by infection
• Def G6PD

IP Dx:
S: Pale, Anemic Conjungtiva
O: Complete Blood Count, Ferritin, TIBC, SI

IP Tx:
• PRC leuko depleted transfusion 10ml/kgBB for 3-4 hours. If PRC is not avaible give fresh
whole blood (20 ml/kgBB) for 3–4 hours.
• Elemental Fe 3-5 mg/kgBB/day in 3 doses
 Anemia
IP Mx:
• General Impression
• Vital Sign
• Warning sign
• Transfusion Reaction

IP Ex:
• Explain about the disease
• Explain that the treatment needs time
• Explain that the patient needs blood transfusion
• Explain the family about transfusion reaction
 Acute Bronchitis
DD:
• Acute Bronkopneumonia
• Asthma

IP Dx:
S: Cough, sputum production, fever, wheezing
O: Complete blood count, chest radiography, spirometry, laryngoscopy

IP Tx:
• Cefotaxime
• 50 mg/kgBB/hari 2-4 kali pemberian (dosis neonatal)
• 100 – 150 mg/kgBB/hari 2-4 kali pemberian (anak≤12 thn)
• Ambroxol 1,2 – 1,6 mg/kgBB/hari
• Budesonide 0,5 – 1 mg 2x per hari
• Salbutamol inhalation 100 mcg – 200 mcg
 Acute Bronchitis
 • Fluid requirement
• Darrow’s Formula
BB: 3,2 kg
10 kg #1 = 3,2 kg x 100 cc = 320 cc
Suhu 38,5oC  kenaikan 1,5oC  1,5 x 12,5% = 18,75%
18,75% x 320 cc = 60 cc
Total = 320 cc + 60 cc = 380 cc
Tpm =

IP Mx:
• General Impression
• Vital Sign
• Warning sign
 Acute Bronchitis

IP Ex:
• Explain about the disease
• Explain that the treatment needs time
• Explain that disease is caused by viral
• Explain if the disease isn’t treated well, it will disturb patient’s growth and development
 Adequate Nutrition
DD: - Inadequate Nutrition
IP Dx:
S: -
O: Anthropometry, Z Score

IP Tx:
• 0 – 1 years old = 110 x ideal weight
• Ideal weight = (age in month + 9) / 2
(1 + 9) / 2
5 kg
• Calorie needed = 110 x 5 kg = 550 kcal
• Carbohydrate : 60% x 550 = 330 kcal
• Fat : 35% x 550 = 192,5 kcal
• Protein : 5% x 550 = 27,5 kcal
 Adequate Nutrition

IP Mx:
• General Impression
• Vital Sign
• Anthropometry

IP Ex:
• Explain to the family to eat regular and choose healthy food
Follow Up
 19-11-2019

S O A P

Panas 3 hari HR 144x/mnt Febris, Anemia, • Inj Cefotaxime 2 x 150 mg

BAB cair 2x RR 49x/mnt Bronkitis akut • Inj Paracetamol 75 ml
BAK (+) SpO2 100% • PO Sanmol drop 0,3 ml k/p
T 39,4oC • PO Sambe plex drop 1 x 0,3 ml
Hb 6,3 • Infus 2A1/4 N 10 tpm micro
• Transfusi PRC 20 ml
• Puyer Ambroxol 2 x 1/20 tab
• Puyer Lacto-B 1 x ½ sachet
• Puyer Zinc 1 x 1/5 tab
• Nebulizer 2 x 1
 Pulmicort 1/3
 Ventolin 1/5
 NaCl 1 ml
• Headbox O2
• OGT
 20-11-2019

S O A P

BAB (+) HR 146x/mnt Febris, Anemia, • Inj Cefotaxime 2 x 150 mg

BAK (+) RR 48x/mnt Bronkitis akut • PO Sanmol drop 0,3 ml k/p
SpO2 100% • PO Sambe plex drop 1 x 0,3 ml
T 36,9oC • Infus D4:1 10 tpm micro
• Puyer Ambroxol 2 x 1/20 tab
• Puyer Lacto-B 1 x ½ sachet
• Puyer Zinc 1 x 1/5 tab
• Nebulizer 2 x 1
 Pulmicort 1/3
 Ventolin 1/5
 NaCl 1 ml
• Headbox O2
• OGT
 21-11-2019

S O A P

BAB (+) HR 146x/mnt Febris, Anemia, • Inj Cefotaxime 2 x 150 mg

BAK (+) RR 48x/mnt Bronkitis akut • PO Sanmol drop 0,3 ml k/p
SpO2 100% • PO Sambe plex drop 1 x 0,3 ml
T 36,9oC • Infus D4:1 10 tpm micro
Hb 8,9 • Transfusi PRC 20 ml
• Puyer Ambroxol 2 x 1/20 tab
• Puyer Zinc 1 x 1/5 tab
• Nebulizer 2 x 1
 Pulmicort 1/3
 Ventolin 1/5
 NaCl 1 ml
• Headbox O2
• OGT
 22-11-2019

S O A P

BAB (+) HR 140x/mnt Febris, Anemia, • Inj Cefotaxime 2 x 150 mg

BAK (+) RR 42x/mnt Bronkitis akut • PO Sanmol drop 0,3 ml k/p
SpO2 100% • PO Sambe plex drop 1 x 0,3 ml
T 36,7oC • Infus D4:1 10 tpm micro
• Transfusi PRC 20 ml
• Puyer Ambroxol 2 x 1/20 tab
• Puyer Zinc 1 x 1/5 tab
• OGT
 23-11-2019

S O A P

BAB (+) HR 140x/mnt Febris, Anemia, • Inj Cefotaxime 2 x 150 mg

BAK (+) RR 44x/mnt Bronkitis akut • PO Sanmol drop 0,3 ml k/p
SpO2 100% • PO Sambe plex drop 1 x 0,3 ml
T 36,9oC • Infus D4:1 10 tpm micro
• Transfusi PRC 20 ml
• Puyer Ambroxol 2 x 1/20 tab
• Puyer Zinc 1 x 1/5 tab
• OGT
 24-9-2019

S O A P

BAB (+) HR 140x/mnt Febris, Anemia, • Inj Cefotaxime 2 x 150 mg

BAK (+) RR 42x/mnt Bronkitis akut • PO Sanmol drop 0,3 ml k/p
SpO2 100% • PO Sambe plex drop 1 x 0,3 ml
T 36,6oC • Infus D4:1 10 tpm micro
Hb 11 • Transfusi PRC 20 ml
• Puyer Ambroxol 2 x 1/20 tab
Thank you