CASE CONFERENCE

SATURDAY NIGHT SHIFT,

MAY 4TH , 2019

DR. ETIK/ DR. CONNIE/ DR. NICKYTA/ DR. SEKAR/ DR. FEBRY
DR. EDDY/ DR. INDRA
DR. IKA / DR. HAMID

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PATIENT ADMISSION

INPATIENT
• N / 5.5 yo/ 19 kgs with DHF grade I, wellnourished.
Patient VIP Dr. Husnia, Sp.A, MKes.
• A / 10 mo / 6.7 kgs with pneumonia with respiratory
failure , encephalitis dd / meningitis, fluid refractory
shock, gastrointestinal bleeding due to hypoxic dd stress
ulcer, wellnourished.

Outpatient

• . G / 8 yo / 22 kgs with unspecified viral infection, 2

wasted.
HCU Neonatus

• Baby. Mrs. W, 0 days / 2800

grams with Neonates, boy,
normal body weight, appropriate
for gestational age, caesaria
section delivery with breech
presentation, mother with severe
preeclampsia 3
PATIENT IDENTITY

 Name :A
 Sex : Female
 Age : 10 months old
 Body weight / height : 6.7 kgs
 Address : Surakarta
 Medical Record : 01461352

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 Appearance
Tone :<
Interactiveness :-
Consolability :-
Look :-
Speech :-
Appearance Work of Breathing
 Work of Breathing

Breath sound :- PEDIATRIC

ASSESMENT
Positioning :- TRIANGLE
Nasal flaring :+
Retraction :+

 Circulation Circulation
Pallor :-
Cyanosis : -
Mottle :+
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CHIEF COMPLAINT

unconsciousness

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 CURRENT MEDICAL HISTORY

2 days before
admission • Sudden fever
• Cough (+) 5 days before admission, runny nose (+)
• Breathlesness
Urination and defecation : normal limit

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 CURRENT MEDICAL HISTORY

4 hours before admission

• Fever (+)
• seizure, whole body got spasm, the duration is 30 minutes
•Reffered to hospital got 2 times of diazepam by rectal

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 THE CURRENT MEDICAL HISTORY

At the ER

unconsciousness

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 THE PAST MEDICAL HISTORY

• History of previous complain : denied

• History of hospitalization : denied

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 THE FAMILY MEDICAL HISTORY

• History of allergy : denied

• History of asthma : denied

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 HISTORY OF PREGNANCY AND DELIVERY
Pregnancy
The patient is the 1st child of her family. she was born from a 19 years old
mother, G1P0A0, at 39st week of gestational age. Her 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 secaria section delivery. There was no
complication during procedure. The baby was crying vigourously, weighted
2300 grams, body length 46 cm. The amniotic fluid was clear.

Conclusion : The pregnancy normal and delivery abnormal 12

 VACCINATION HISTORY
0 month : Hepatitis B1, Polio 0
1 month : BCG, Hepatitis B2
2 months : DPT1, polio 1
4 months : DPT2, Hepatitis B3, polio 2
6 months : DPT3, polio 3
9 months : (-)

Conclusion :
Incomplete immunization
according to Ministry of Health schedule 2017 13
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FAMILY TREE

II

III

A, 10 month, 6.7 kgs

 NUTRITIONAL HISTORY

Patient eats poridge 3 times a day with with rice, vegetables, egg, or chicken.
She drinks formula milk 1 times a day ± 200 ml
Conclusion: nutrition quantity and quality status is adequate

GROWTH AND DEVELOPMENT

She is 10 months old now, 6.7 kgs in body weight, 67 cms in
body height. She could prone since 3,5 months old. She couldnt
sit since 6 months old. She could stand up since 9 months old.
Conclusion: appropriate for her age

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NUTRITIONAL STATUS

• Weight for Age :

0 <W/A < -1 Normoweight

• Height for Age :

0<H/A<-2, Normoheight
• Weight for height:
0 <W/H < 0, (wellnourished)

Conclusion (WHO) : normoweight, normoheight,

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wellnourished.
 PHYSICAL EXAMINATION

GA : Severely ill, E2V1M4

VS : Heart rate: 189 bpm Temp: 39.4oC
Resp. rate : 36 bpm SiO2 : 68%
Blood Pressure: 70/palpation
Head : mesocephal ,
Eyes : anemic conjunctiva -/-, icteric sclera -/-
Nose : nasal flares (+) epistaxis (-) NGT produk (+) blood
Mouth : wet (+), cyanosis (-), gum bleeding (-)
Ears : Ear discharge -/-,
Neck : Lymph node enlargement (-)
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Chest : Symmetrical in shape and movement, retraction (-)

Cor : I : Ictus cordis not visible
P : Ictus cordis not palpable
P : cannot be evaluated
A : Heart sounds I-II normal intensity, regular
Pulmo: I : symmetrical movement (+)
P: fremitus sound equal
P: sonor / sonor
A: vesicular breath sounds +/+ , additional breath sound (+/+), ronchi (+/+)
wheezing (-/-)
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: +/+
-/- +/+
weak palpable of dorsal pedis artery
CRT > 2”
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Phisiological Reflex Pathological Reflex
Biseps R. +3/+3 Openheim +/+
Triceps R +3/+3 Gordon -/-
Patella R. +3/+3 Babinsky +/+
AchilesR. +3/+3 Schufnner-/-
anbnormal dollseye movement
Meningeal Sign
Nuchal rigidity (-)
Brudzinky I,II,(-)
Kernig Sign (-)

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 LABORATORY FINDING
May 15th 2019

  Value Reference Units

Hemoglobin 8.1 14.0-17.5 g/dl
Hematocrit 25 33-45 %
Leucocyte 18.6 5.0-14.5 x103/ul
Thrombocyte 60 150-450 x103/ul
Eritrocyte 2.89 4.00-5.20 x106/ul
MCV 85.9 80.0-96.0 /um
MCH 28.0 28.0-33.0 pg
MCHC 32.7 33.0-36.0 g/dl
Eosinophil 12.9 0.00-4.00 %
Basophil 0.20 0.00-1.00 %
Neutrophil 34.20 18.00-74.00 %
Lymphocyte 60.50 30.00-48.00 %
Monocyte 4.4 0.00-11.00 %
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 LABORATORY FINDING
May 15th 2019

  Value Reference Units

Natrium 134 mmol/L 129-147
Calium 4.3 mmol/L 3.6-6.1
Chloride 108 mmol/L 98-106
Calsium 0.85 mmol/L 1.17-1.29
GDS 21 mG/dL

Conclusion : hypoglicemia, hypocalsemia

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LABORATORY FINDING
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May 15th 2019 : Dr Moewardi Hospital

Blood Gas Analysis Value Reference Normal

PH 7.040   7.350-7.450

BE -17.9 mmol/L -2 - +3

PCO2 42.0 mmHg 27.0-41.0

PO2 338.0 mmHg 83.00-108.00

Hematokrit 26 % 37-50

HCO3 11.0 mmol/L 21.0-28.0

Total CO2 12.2 mmol/L 19.00-24.0

O2 Saturation 99.0 % 94.0-98.0

Lactate Arteri 4.40 mmol/l 0.36-0.75

 DIFFERENTIAL DIAGNOSIS

1. Pneumonia with respiratory failurre

2. Unconsciousness due to encephalitis dd meningitis
3. Gastrointestinal bleeding due to gastric ulcer dd hypoxia
4. Hypoglikemia
5. Fluid refractory shock

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 WORKING DIAGNOSIS

1. Pneumonia with respiratory failurre (J18.0)

2. Unconsciousness due to encephalitis dd meningitis (R40.2)
3. Gastrointestinal bleeding due to gastric ulcer dd hypoxia
(K92.2)
4. Hypoglikemia (E16.2)
5. Fluid refractory shock (R57.9)

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 THERAPY

1. Admitted to PICU
2. O2 intubated endotracheal with jackson rees while waiting for ventilator mechanic
3. Diet: temporary fasting, NGT streamed
4. D51/4 NS 28ml/hour
5. Dobutamine (5mcg/kgBW/minute)= 160 mg+ NS up to 24 cc= 1 cc/h iv
6. Ca. Glukonas (1mg/kgBW) ~ 22mg +NS 0.9% 20 cc, give in 30 minutes iv
7. Ampicilin Sulbactam (25mg/kgBW/6hours) = 500 mg/6 hours iv
8. Gentamicin 50mg/24 hours iv
9. Paracetamol 100 mg/8 hours iv
10. Spooling sucralfat 55 ml/8hours 25

11. Omeprazole 5mg/12hours iv

 PLAN
1. Chest x ray on bed
2. Blood and sputum culture
3. Lumbal punction

MONITORING
 General Appearance/Vital Signs/BP/hours
 Fluid balance/diuresis/8 hours

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HOW IS THE PROGNOSIS OF ENDOTRACHEAL
INTUBATION IN THE PEDIATRIC EMERGENCY
DEPARTMENT ?

P
Children in PED

I
Endotracheal intubation

C
-

O
Several adverse effect

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