Case Conference

Sunday Morning, January 29th,

2017
dr. Laras/dr. Dewi
dr. Guntur/dr. Nunki/dr. Delfia
dr. Nurdin/dr. Devi
dr. Lubna/dr. Trio
 PATIENT ADMISSION
Melati 2
1. An. D, 10 months, 8 kg, with acute diarrhea without dehydration,
morbili dd/ rubella, eksantema subitum, well nourished,
normoweight, normoheight

HCU Neonatus
-

NICU
-

HCU Melati 2
-

PICU
-
 IDENTITY

Name :Baby D
Age/W/L : 10 months/ 8 kg / 78 cm
Sex/Gende : Female
r
Address : Surakarta, Jawa Tengah
Medical : 01367491
Record
CHIEF COMPLAINT
Diarrhea
 CURRENT MEDICAL HISTORY

24
2 days IGD
hours
Since 3 days before admission, the mother
complained about her daughters high fever. It
developed gradually and become higher. According
to the mother, her child get cough and runny nose.
Then vomiting for three times a day, containing
undigested foods. There were no complain about
urination and defecation. Because of her signs and
symptoms, her mother and family brought her to
the nearest health center and received 3 types of
drug.
 CURRENT MEDICAL HISTORY

Two days before admission, the babys

temperature was still high. It became higher than
yesterday. Shes still got cough and runny nose.
According to the mother, her babys appetite was
decreased. She was still vomiting during that day.
There were red spots that appeared on her face. It
didnt itch. Her baby was not scratching her face.
There were no complain about urination and
defecation.
 CURRENT MEDICAL HISTORY

One day before admission, the mother said that

the red spots on her babys face spread to her
body. She still got high temperature, cough and
runny nose. She started to feel short of breath. Her
breathing became faster and shorter. She didnt
want to eat anything. She was still vomiting during
that day, three times a day, followed by diarrhea
three times a day, no mucus and no blood in stool.
There were no complain about urination and
defecation. Her mother and family brought her to
the general practitioner and received 2 types of
drug.
 CURRENT MEDICAL HISTORY

On the day before admission, the babys had

diarrhea more than seven times a day, no mucus
and no blood in stool. The baby also vomit seven
times a day, containing milk. She looked
exhausted. She didnt want to eat. Shes still got
high temperature, cough and runny nose. She
looks hard to breathe. The red spots expanded to
her arms. Because of her signs and symptoms, her
mother and family brought her to the Emergency
Unit of RS. Dr. Moewardi. During examination in the
Emergency Unit, she still got fever, cough, and red
spots all over her body.
 PAST MEDICAL HISTORY
(Family)
History of hospital admissions : denied
History of fever accompanied by red spots :
denied

PAST MEDICAL HISTORY

(Environment)

History of fever accompanied by red spots :

denied

9
 HISTORY OF PREGNANCY AND DELIVERY

Pregnancy
She is the second child of her family. Gestational age of 39
weeks. The mother consumed vitamins and pills routinely from
her doctor. Routine check up to the doctor monthly within first
and second trimester, weekly on third trimester. There were no
history of illness and admission to the hospital during the
course of pregnancy.
Delivery
The baby was delivered per vaginam by a doctor. There were
no complication during procedure. The baby delivered well,
active, cried loudly. The baby weighed at 3500 grams and 51
cm in length.

Conclusion : pregnancy and delivery history are

within normal 10
 GROWTH AND DEVELOPMENT HISTORY

Growth
According to her mother. She always gained weight and
increased height when she was taken to the nearest health
center.

Development
She could sit upright by herself. She could grabbed things. she
could stand with help but not for long.

Conclusion : growth and development history are

within normal 11
 VACCINATION HISTORY

Hep B : 0 months
Polio : 1, 2, 3, months
BCG : 1 months
DPT, hib,HepB : 2,3, months
Measles :-
Conclusion : vaccination history isnt complete
according to Ministry of Healths Vaccination
Schedule 2016.

12
 PEDIGREE (FAMILY TREE)

II

29 28
yr yr

III
2,5
yr Baby D, 10
mos, 8 kgs
 NUTRITIONAL STATUS

BB/U : 8/8.5 x 100% = 94.1 % (-2 SD<BB/U<0SD

Normoweight
TB/U : 78/71.5 x 100 % = 109 % (2SD<TB/U<3SD)
Normoheight
BB/TB: 8/9.7 x 100 % = 82.4 % (-2SD<BB/TB<-1SD)
Well nourished

Conclusion : well nourished, normoweight,

normoheight
 PHYSICAL EXAMINATION

GA: moderate illness, compos mentis, well nourished

VS : Heart rate: 120x/min Temp. : 39oC
Resp. rate : 30x/min SiO2 : 99%
Head : Mesocephal
Eyes : Anemic conjungtiva +/+, icteric sclera -/-, pupil
isocor 2mm/2mm,
Nose : Nostrils Flares Outwards (-) nasal discharge (-)
Mouth : Wetness (+), cyanosis (-), tonsil T1-T1 hyperemic
(-), redness of the pharyx (-)
Ears : Ear discharge -/-
Neck : Node enlargement (-),
Chest : Symmetrical in shape and movement, retraction (-)
 PHYSICAL EXAMINATION
Cor : I : Ictus cordis not appeared
P : Ictus cordis was palpable
P : heart enlargement (-)
A : heart sounds I-II normal intensity, regular,
murmur(-)
Pulmo: I : right hemithorax = left hemithorax
P: fremitus sounds right = left
P: sonor / sonor
A: vesicular breath sounds +/+ , patologic sounds -/-
Abd : I : abdominal wall = chest wall
A : peristaltic sound (+) within normal
P : tympani (+)
P : distended, palpable pain (+) epigastrium,
liver and spleen were not palpable, turgors within
normal
 LABORATORY RESULTS (29/1/17)

Hb = 11.6g/dl
Hct= 37 %
Leucocyte count = 18600/ul
Trombocyte count= 283.000/ul
Erythrocytes = 4.60 million/ul
MCV = 81.0 /um
MCH = 25.2 pg
MCHC = 31.1 g/dL
RDW = 13.8 %
MPV = 9 FL
PDW = 16 %
Eos/Bas/Neut/Limf/Mono =
0.2%/1.30%/65.70%/27.50%/5.30%

Conclusion : within normal limit

 PROBLEMS

A female baby, 10 months, 8 kg, with :

1. Diarrhea since 2 days before admission, no blood
and mucus in stool.
2. Fever since three days before admission.
3. Cough and runny nose since two day before
admission
4. Vomited three to seven times a day since three day
before admission, containing undigested foods
5. Appetite was decreased
6. Red spots on her face that expands all over her
body that didnt itch
7. Looks exhausted
8. Shortness of breath
9. Well nourished, normoweight, normoheight
 DIFFERENTIAL DIAGNOSIS

1. Acute diarrhea with mild-moderate

dehydration
2. Morbili dd/ rubella dd exanthema subitum
3. Well nourished, normoweight,
normoheight
 WORKING DIAGNOSIS

1. Acute diarrhea with mild-moderate

dehydration
2. Morbili dd/ rubella, exanthema subitum
3. Well nourished, normoweight,
normoheight
 THERAPY

1. Admission to Gastroenterology Ward

(Isolation)
2. Diet rice porridge 800 kkal/days
3. IVFD Asering (200mL/kgBW/days) 66
mL/hours I.V. (29/1/17 13.30 WIB)
4. Paracetamol syr (15mg/kgBW/6 hours)
120mg/6hours P.O.
5. Vitamin A 100.000 IU single dose P.O.
6. Zinc tab 20mg/24 hours P.O.
7. Oralit sach (10mL/kgBW/x) 80 mL/x
diarrhea if already dehydrated
 PLAN

1. Urinalysis
2. Microbiology (Feces)

MONITORING

General Appearance/Vital Signs /

Hydration status/hours
Fluid balance and Diuresis / 8 hours
 FOLLOW UP (January 30th, 2017)

GA: moderate illness, compos mentis, well nourished

VS : Heart rate: 120x/min Temp. : 39oC
Resp. rate : 30x/min SiO2 : 99%
Head : Mesosefal
Eyes : Conjungtiva anemis +/+, sclera ikterik -/-,
pupil isokor 2mm/2mm,
Nose : Nasal breath (-) , sekret ( -/-)
Mouth : Wetness (+), cyanosis (-), tonsil T1-T1,
Hiperemis (-) pharynx hiperemis (-)
Ears : Secretion -/-
Neck : Node enlargement (-),
Chest/thorax : Symmetry in shape and movement, retraction (-)
 PHYSICAL EXAMINATION
Cor : I : Ictus cordis appeared
P : Ictus cordis was palpable
P : heart enlargement (-)
A : heart sounds I-II normal intensity, reguler,
murmur(-)
Pulmo: I : right hemithorax = left hemithorax
P: fremitus sounds right = left
P: sonor / sonor
A: vesicular breath sounds +/+ , patologic sounds -/-
Abd : I : abdominal wall = chest wall
A : peristaltic sound (+) within normal
P : tympani (+)
P : distended, palpable pain (+) epigastrium,
hepar dan lien were not palpable, turgors within
normal
 WORKING DIAGNOSIS

1. Acute diarrhea with mild-moderate

dehydration
2. Morbili dd/ rubella, exanthema subitum
3. Well nourished, normoweight,
normoheight
 THERAPY

1. Diet rice porridge 800 kkal/days

2. IVFD Asering (200mL/kgBW/days) 66
mL/hours I.V. (29/1/17 13.30 WIB)
3. Paracetamol syr (15mg/kgBW/6 hours)
120mg/6hours P.O.
4. Zinc tab 20mg/24 hours P.O.
5. Oralit sach (10mL/kgBW/x) 80 mL/x
diarrhea if already dehydrated
 PLAN

1. Urinalysis
2. Microbiology (Feces)

MONITORING

General Appearance/Vital Signs /

Hydration status/hours
Fluid balance and Diuresis / 8 hours
Clinical Question:

P :
I :
C :
O:
29