CLINICAL CONFERENCE

RESPIROLOGY DIVISION
(New Case)
July 4th , 2023
IKA KURNIA FAIZIN, AYU JAURY, TRI WIRA/ JUNIOR
RIMA KHAIRUNNISA, CAHYA KAMILA BAUSAT, SITI SOPIA / MADYA
MUHAMMAD MUSTAQIBLAT, DIAN JABAL RACHMAN BEY, IRFADAH DINAR / SENIOR
PATIENT IDENTITY
FF, 1-Year-and-15-day-old, male
MR Number 01029276
Date of Birth May 01th , 2022
Admission Date June 19th , 2023
MEDICAL DIAGNOSIS
COMMUNITY-ACQUIRED PNEUMONIA
ACUTE TONSILLOPHARYNGITIS
ANEMIA OF CHRONIC DISEASE DIFFERENTIAL DIAGNOSE WITH
IRON DEFICIENCY ANEMIA
LEUCOCYTOSIS
ELEVATED TRANSAMINASE ENZYME
REACTIVE THROMBOCYTOSIS
STUNTING
PATIENT PICTURE
 HISTORY TAKING
Chief complaint:
Shortness of breath

History of Present Illness

• A 1-Year-old boy was referred from pediatrician with diagnosis of anemia pro evaluation with
leucocytosis.There was shortness of breath experienced since 3 days prior admission and got worsening 1
day before admission. There was productive cough since 1 week before admitted to the hospital. No fever,
there was history of fever since 1 week before admitted to the hospital, not continuous, reduce with
antypiretic drugs. No seizure (1 seizure history, duration <5 minutes, the patien crying when the seizure
stop).
• No vomiting.
• Oral intake normal.
• Urination and defecation within normal limit
HISTORY TAKING
There was no history of fever > 2 weeks.
There was history of cough > 3 weeks
No history of contact with TB-confirmed patient or with chronic cough
No family history of smoking
There was history of seizure on June 2023
There was history of hospitalization at B hospital on June 2023, diagnosed with febrile seizure
and acute pharyngitis
There was history of previous treatment with a pediatrician and got therapy: Isprinol 2,5 ml / 8
hour / oral and Amoxicilin clavulanat 5 ml / 8hour / oral
There was history of Mantoux test with negative result
History of Vaccination MONTH YEARS
Vaccine
0 1 2 3 4 6 7 8 9 12 15 18 24 3 5 6 7 8

Hep B V

BCG

DPT

Hib

OPV V

IPV

MR/MMR

PCV

Rotavirus

Japanese
Encephal
itis

Influenza

Varicella

Hepatitis
A

Tifoid

Covid-19
 PHYSICAL EXAMINATION
Vital Sign Anthropomethry
General condition: Severely ill/severely Body weight : 7,5 kg
wasted/GCS 15 (E4M6V5) Body Height: 67 cm
Blood pressure: Head Circumference : 45 cm (44-49 cm)
Heart Rate 112 times/min
Nutritional status
Temperature: 36,9 C
Weight for age: in between -3 SD and -2 SD
Respiration Rate: 25 times/min
(underweight)
SpO2: 99% via canula nasal
Height for age: -3 SD (Short stature)
Pain scale: 1 FLACC
Weight for height: in between -1 SD and median
(normal)
HEAD
CIRCUMFERENCE
NORMOCEPHAL
45 cm (44 cm – 49 cm)
Weight for age: in between -3 SD
and -2 SD (underweight)

Height: 67 cm
Weight: 7,5kg
 Height for age: -3 SD (Short
stature)

Height: 67 cm
Weight: 7,5kg
Weight for Length:
in between -1 SD and median
(normal)

Height: 67 cm
Weight: 7,5kg
PHYSICAL EXAMINATION
Pale, no jaundice Abdomen:
No Lymphadenopathy Inspection: not distended
Hyperemic Pharynx Auscultation: Peristalsis sound was normal
Tonsil T2-T2 hyperemic Percussion: Tympanic
Palpation: Hepar and Lien were not palpable
Pulmo:
Inspection: Symmetrical left and right Extremities:
movement Warm acral, capillary refill time <3 seconds, no edema
Palpation: vocal fremitus was symmetric
Percussion: sonor on both of lung fields
Auscultation: vesicular breath sounds,
ronchi on both lungs no wheezing

Cardiovascular
Inspection: Ictus cordis was not seen
Palpation: Thrill not palpable
Percussion: Normal heart border
Auscultation: Heart sounds I/II normal,
regular rhythm, no murmur
 CENTOR SCORE
Fever 1
No Cough 0
Lymphadenopathy 0
Tonsil Swelling 1
3-14 year of age 0
Score 2
 TB SCORE
Contact 0
Fever 0
Cough 1
Lymphadenopathy 0
Joint Swelling 0
Thorax Xray not performed
Nutritional Status 0
Mantoux not performed
Score 1 (without Thorax Xray and Mantoux test)
Laboratory Finding
Laboratory July, 04th 2023 (RSWS) Normal Value

WBC 26.200 4.0 – 10.0/μL

Hb 7,8 12.0 – 16.0 gr/dL
MCV 58 80 -97 μm3
MCH 17 26.5 - 33.5 Pg
PLT 797.000 150.000 – 400.000/mm3

% Neut 18.9 52,0-75,0

% Lymph 65.7 20,0-40,0

% Mono 12.7 2,00-8,00
GDS 84 <200 mg/dl
Ureum 14 10 - 50 mg/dl
Creatinin 0.42 L < 1.3, P <1.1
SGOT 53 < 38 u/l
SGPT 20 < 41 u/l
Albumin 4.3 3,5 -5,0 gr/dl
Sodium 139 135-145
Potassium 4.0 3,5-5,1
Chloride 106 97-111

Ferritine 39.38 13.00-400.00

CRP 10.5 <5

Laboratory Finding
4/7/2023
Urinalysis Normal value
(WS Hospital)
Color Yellow Yellow
pH 4.5 4.5-8.0
Bj 1.00 1.005-1.035
Protein Negative Negative
Glucose Negative Negative
Bilirubine Negative Negative
Urobilinogen Normal Normal
Ketone Negative Negative
Nitrite Negative Negative
Blood Negative Negative
Lekosit Negative Negative
Leukocyte Sediment 2 <5
Erythrocytes Sediment 0 <5
Torak Sediment 0
Crystal Sediment 0
Epithelial Cells Sediment 0
Others Sediment Bac = 3
Assesment
● Community-acquired pneumonia
● Acute tonsillopharyngitis
● Short Stature
● Delayed imunization
● Anemia
● Leucocytosis
● Elevated transaminase enzyme
● Reactive thrombocytosis
 Working diagnosis
● Community-acquired pneumonia
● Acute tonsillopharyngitis
● Stunting
● Delayed imunization
● Iron deficiency anemia differential diagnosed with anemia of chronic
disease
● Leucocytosis
● Elevated transaminase enzyme
● Reactive thrombocytosis
 Treatment
• oxygenation via nasal cannula 1-2 liter /min • 1) Ceftriaxone 750 mg/24 hours/intravenous
• Fluid requirement • 1) Gentamycin 20 mg/12 hours/intravenous
Holiday segar – 20% respiratory distress • Paracetamol 100 mg/8 hours/intravena ( temperature
>38 C)
600 ml/24 hours
• Nebulisation with NaCl 0,9% / 8 hours / inhalation
Enteral: 5x100 = 500cc
• N-acetylcysteine 40 mg / hours/ oral
Parenteral: Infusion of dextrose 5% 5cc/hours/iv.
Planning
 Thorax Xray
 Tuberculosis tracking (Mantoux test and gastric lavage examination)
 Sepsis workup (CRP, Procalsitonin, peripheral blood semar, Rasio IT, Culture of
Blood, Urine)
 Consult to nutrition and metabolic disease division
 Consult to Hematology Oncology division
THANK YOU