Case Conference

Saturday Morning Shift,

June 9th 2018
dr. Dini / dr. Eddy / dr. Pridania / dr. Guntur / dr. Kandar / dr. Rini
dr. Rizki / dr. Hamid
dr. Kiki / dr. Galih
 PATIENT ADMISSION
Melati 2
1. Child A, male, 2 years old, 13 kgs, with acute tonsillopharyngitis with difficult intake,, ALL
L2 SR maintenance phase 64th week, under-nourished
2. Child N, female, 3 years, 15 kgs, with acute tonsillopharyngitis with difficult intake,
vomitus due to acute tonsillopharingytis without dehydration, erythroderma due to
Chronic Bullous Disease of Childhood (CBDC), well-nourished
3. Child E, 15 years, 35 kgs, with epidemic parotitis DD/ supurative parotitis, right
mandibular abcess, multiple caries dentis, acute tonsillopharyngitis, completed
chemotherapy NHL, under-nourished
HCU Neonatus
1. Baby Mrs D, female, 13 days old, 2250 grams, with Late onset sepsis, mild
respiratory distress due to Pneumonia DD/ RDS, sepsis; mild hypothermia;
neonate, female, low birth weight, aterm, small for gestational age, SC
delivery due to cross position, premature rupture of membrane 21 hours,
outside partus
NICU -
HCU Melati 2 -
PICU -
 IDENTITY

Name :Baby Mrs. D

Age/W/L : 13 days/ 2250 grams/ 48 cms
Sex/Gender : Female
Address : Serengan, Surakarta
Medical : 01421725
Record
 CHIEF COMPLAINT
Breathlessness
(Referred from a Private Hospital in Surakarta)
 THE CURRENT MEDICAL HISTORY
Before admission

Patient was referred from Private Hospital At the ER

with neonatal sepsis, neonate, low birth
weight, aterm, small for gestational age, Patient was moderately ill,
treated at HCU neo for 12 days. During
treatment received Cefotaxime antibiotic shortness of breath (+), active
(7 days), Meropenem, transfusion of TC movement, urination and
35ml/ day for 5 days, transfusion of defecation within normal limit.
albumin 25% 25 ml 2 times.
The last lab test results were Hb 10.8
gr/dl, platelets 7000 /ul, leukocyte
46300 /ul, albumin 2.3 g/dl, hs-CRP 96,
Na 131 mmol /l, K 5.4 mmol /l, Ca 1.2
mmol /l.
 HISTORY OF PREGNANCY AND DELIVERY

Pregnancy
The baby is the fourth child of her family. Gestational age is 38 weeks. The
mother consumed vitamins and pills routinely from a doctor. According to the
mother, she took routine check up to the doctor monthly. She got ‘binding of
uterus’ procedure at 10th week of pregnancy with bleeding history. Premature
rupture of membrane history (+) 21 hours.

Delivery
The baby was delivered with sectio caesarea procedure due to cross position in
G4P3A0 mother. There were no complication during procedure. When she was
born the baby looked less active, cried less vigorously, and looked reddish
colour on her skin. The baby weighed at 2250 grams and 48 cm in length.

Conclusion : pregnancy was abnormal and delivery history was abnormal

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 VACCINATION HISTORY

• Hepatitis B :+

Conclusion :
The vaccination is appropriate with Ministry of Health’s
program 2015

7
 PEDIGREE (FAMILY TREE)

II
32th 28th

III

Baby Mrs D, 13 days old

 NUTRITIONAL STATUS

Fenton Chart
BW/A : 2,25/2 x 100% = 112,5% (P100<BW/A<P120)
Normoweight

H/A : 48/44 x 100 % = 109 % (P100<H/A<P120)

Normoheight

Head Circumference : 28/30 x 100% = 93% (HC=P10)

Conclusion : normoweight, normoheight

 PHYSICAL EXAMINATION

General appearance : fully alert, GCS E4M6V5

Vital sign :
Heart Rate = 138 bpm
Respiration rate = 68 bpm
Temperature = 36.7 0 C peraxilar
O2 saturation = 99%
Downe Score = 3
 PHYSICAL EXAMINATION

Head : mesocephal, head circumference = 28 cm (head circumference )

Eyes : pale conjunctiva (-/-), light reflex (+/+), isochoric pupil 3 mm/3mm
Nose : nasal flare (-/-), discharge (-/-), nosebleed(-/-)
Mouth : wet lips (+), lips and tongue not cyanotic, gum bleeding(-/-),
stomatitis(-)
Throat : hyperemic pharing (-), Tonsil T1-T1 hyperemic (-), detritus (-)
Neck : Enlargement of lymph node (-)
Thorax: symmetric (+), retraction (+) suprasternal, intercostal

LUNG:
I: normal, symmetric, retraction (+)
P: fremitus difficult to evaluate
P: difficult to evaluate
A: normal vesicular breath sound, additional breath sound (+/+), crackles (+/+)
 PHYSICAL EXAMINATION
CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: no cardiac enlargement
A: 1st 2nd Heart sound normal intensity, regular, murmur (-)

ABDOMINAL:
I: abdominal wall equal to chest wall
A: peristaltic sounds within normal limit
P: tympani (+), shifting dullness (-), undulation(-)
P: liver and spleen was not palpable, good skin turgor

EXTREMITIES:
The extremities were warm, capillary refill time < 2 sec, and dorsalis pedis artery
was strongly palpable

GENITALIA : female, no abnormalities

 Lab Results (9/6/2018)

  Value Reference Units

Hemoglobin 7.6 15.0-24.6 g/dl
Hematocrit 22.0 47-75 %
Leucocyte 34.3 5.0-19.5 x103/ul
Thrombocyte 21 150-450 x103/ul
Erythrocyte 2.45 3.70-6.0 x106/ul
MCV 90.6 80.0-96.0 /um
MCH 31.0 28.0-33.0 pg
MCHC 34.2 33.0-36.0 g/dl
MPV 6.1 7.2-11.1 fl
PDW 19 25-65 %
Albumin 2.8 3.8-5.4 g/dl
Creatinine 0.4 0.2-0.4 mg/dl
Ureum 44 <42 mg/dl
Blood glucose 68 50-80 mg/dl
 Eosinophil 1.40 0-4 %
Basophil 0.20 0-1 %
Neutrophil 71.90 18-74 %
Lymphocite 16.90 60-66 %
Monocyte 9.60 0-6 %
SGOT 21 <31 u/l
SGPT 12 <34 u/l
Natrium 115 129-147 mmol/L
Calium 4.9 3.6-6.1 mmol/L
Chloride 109 98-106 mmol/l
Calcium 1.35 1.17-1.29 mmol/l
Blood type O
Total bilirubin 10.39 0.00-1.00 mg/dl
Conclusion:
- Normocytic normochromic anemia
- Leucocytosis
- Thrombocytopenia
- Hyperuremia
- Hyperchloremia
- Hypercalcemia
 PROBLEMS LIST

Baby Mrs. D, female, 13 days old, 2250 grams, with :

• Looks a little bit yellowish at the face
• Shortness of breath
• Gastrointestinal bleeding, brownish NGT product
• Thermoregulation System 35,30C
• Murmur (+) sistolic grade III-IV at 4thSIC of linea medio
clavicularis sinistra
- Normocytic normochromic anemia
- Leucocytosis
- Thrombocytopenia
- Hyperuremia
- Hyperchloremia
 DIFFERENTIAL DIAGNOSIS

1. Late onset sepsis

2. Mild respiratory distress due to Pneumonia DD/ RDS, sepsis
3. Mild hypothermia
4. Icteric neonatorum
5. Neonate, female, low birth weight, aterm, small for
gestational age, SC delivery due to cross position, premature
rupture of membrane 21 hours, outside partus
 WORKING DIAGNOSIS

1. Late onset sepsis (B36)

2. Mild breath disturbance due to Pneumonia DD/ RDS, sepsis
(R06.00)
3. Mild hypothermia (R68.0)
4. Icteric neonatorum (P59.9)
5. Neonate, female, low birth weight, aterm, small for
gestational age, SC delivery due to cross position, premature
rupture of membrane 21 hours, outside partus
 THERAPY

1. Admited to Neonatal HCU

2. O2 nasal canul 0.5 lpm
3. Breastmilk 12x10ml
4. IVFD D51/4NS 10 ml/hour
5. Ampcillin sulbactam (50 mg/kgBW/12 hours) – 110 mg/12 hours
IV
6. Gentamycin (4 mg//kgBW/24 hours) – 10 mg/24 hours IV
7. PRC transfusion 45 ml
 PLAN

1. GDT-IT ratio
2. Blood culture

MONITORING

 General Appearance/Vital Signs/oxygen saturation/3 hours

 Fluid balance and Diuresis/8 hours
 FOLLOW UP (June 10th, 2018)

Issues Gastrointestinal bleeding

CNS Cry loudly (+) Active in motion (+) ↓ eyes open spontaneously (+) ↓
Assesment: S4
Cardiovascular Heart rate : 15 x/minute
System Murmur (-), capillary refill time < 2 seconds, dorsalis artery pulse (+)
Assesment: no abnormality
Respiratory Respiratory rate : 64x/minute, head bobbing (-) Si02 :
System Retraction subcostal (+)
Air entry (+) grunting (-), sianosis (-) 99% 99%
Down score (2) 99% 99%
Assesement : distress respiration on CPAP
GIT Hepatal Distended (-), defecation(-), peristaltic sound (+), vomit (-), icteric (+)
System Kramer III
Assesement : icteric neonatorum
Genitourinaria Urination (+) 80ml
System BC 3.29 ml
D 4.35 ml/kg/hour
Assesement: not yet to be evaluated
Infection Thermoregulation System Gastrointestinal System Assesement: late onset
System 37,30C (+) of neonatal sepsis
Central nervous system (-) Hematology System (+)
Cardiovascular System (-) Hemodynamic System(-)
Respiratory System (+)
 WORKING DIAGNOSIS

1. Late onset sepsis

2. Mild respiratory distress due to Pneumonia DD/ RDS, sepsis
3. Mild hypothermia
4. Icteric neonatorum
5. Neonate, female, low birth weight, aterm, small for gestational age, SC
delivery due to cross position, premature rupture of membrane 21 hours,
outside partus
 THERAPY

1. O2 nasal canul 0.5 lpm

2. Breastmilk 12x10-15 ml
3. IVFD D7% (GIR 7) = D1/4NS 181 ml + D40% 35 ml + KCl 3 ml + Ca
gluconas 3 ml + soluvit 3 ml = 225 ml/day = 9.4 ml//hour
4. Ampcillin sulbactam (50 mg/kgBW/12 hours) – 110 mg/12 hours
IV
5. Gentamycin (4 mg//kgBW/24 hours) – 10 mg/24 hours IV
6. Lipofundin 20% (2 gr/kg/day) = 23 ml + vitalipid 5 ml = 28 ml/day
= 1.2 ml/hour
7. Aminosteril 6% (3 gr/kg/day)= 115 ml/day = 4.8 ml//hour
 PLAN

1. GDT-IT ratio
2. Blood culture

MONITORING

 General Appearance/Vital Signs/oxygen saturation/hour

 Fluid balance and Diuresis/8 hours
 FOLLOW UP (June 11th, 2018)

Issues Gastrointestinal bleeding

CNS Cry loudly (+) Active in motion (+) ↓ eyes open spontaneously (+) ↓
Assesment: S4
Cardiovascular Heart rate : 15 x/minute
System Murmur (-), capillary refill time < 2 seconds, dorsalis artery pulse (+)
Assesment: no abnormality
Respiratory Respiratory rate : 64x/minute, head bobbing (-) Si02 :
System Retraction subcostal (+)
Air entry (+) grunting (-), sianosis (-) 99% 99%
Down score (2) 99% 99%
Assesement : distress respiration on CPAP
GIT Hepatal Distended (-), defecation(-), peristaltic sound (+), vomit (-), icteric (+)
System Kramer III
Assesement : icteric neonatorum
Genitourinaria Urination (+) 80ml
System BC 3.29 ml
D 4.35 ml/kg/hour
Assesement: not yet to be evaluated
Infection Thermoregulation System Gastrointestinal System Assesement: late onset
System 37,30C (+) of neonatal sepsis
Central nervous system (-) Hematology System (+)
Cardiovascular System (-) Hemodynamic System(-)
Respiratory System (+)
 WORKING DIAGNOSIS

1. Late onset sepsis

2. Mild respiratory distress due to Pneumonia DD/ RDS, sepsis
3. Mild hypothermia
4. Icteric neonatorum
5. Neonate, female, low birth weight, aterm, small for gestational age, SC
delivery due to cross position, premature rupture of membrane 21 hours,
outside partus
 THERAPY

1. O2 nasal canul 0.5 lpm

2. Breastmilk 12x10-15 ml
3. IVFD D7% (GIR 7) = D1/4NS 181 ml + D40% 35 ml + KCl 3 ml + Ca
gluconas 3 ml + soluvit 3 ml = 225 ml/day = 9.4 ml//hour
4. Ampcillin sulbactam (50 mg/kgBW/12 hours) – 110 mg/12 hours
IV
5. Gentamycin (4 mg//kgBW/24 hours) – 10 mg/24 hours IV
6. Lipofundin 20% (2 gr/kg/day) = 23 ml + vitalipid 5 ml = 28 ml/day
= 1.2 ml/hour
7. Aminosteril 6% (3 gr/kg/day)= 115 ml/day = 4.8 ml//hour
 PLAN

1. GDT-IT ratio
2. Blood culture

MONITORING

 General Appearance/Vital Signs/oxygen saturation/hour

 Fluid balance and Diuresis/8 hours
Is necessary to checked blood culture ?

P
• Baby with sepsis

I
• Checked blood culture

O
• Good diagnostic
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 Validity

Was the diagnostic test evaluated in a Representative spectrum of patients (like

those in whom it would be used in practice)?

• Yes

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Validity

Was the reference standard applied regardless of the index test result?

• Yes
• All patients using three clinical case vignettes, we explored risk
stratification, empiric antibiotics, initial investigations, intravenous–
oral switch, ambulatory management and antibiotic duration in
children with cancer and FN.

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Importan
ce

35
Applicabil
ity

Were the methods for performing the test described in sufficient

detail to permit replication?

• Yes
• The study patients similar to my own

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 Level of
Evidence

Important

Applicabl
Valid
e

LoE
2B
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