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CASE CONFERENCE
FRIDAY NIGHT SHIFT,
TH
OCTOBER 20 2017

dr. Rara / dr. Pitra / dr. Dian / dr. Indra / dr. Febri
dr. Izni / dr. Prabu
dr. Ida / dr. Kandar
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PATIENT ADMISSION
• NICU: -
• HCU Neonatus: -
• Melati 3: -
• Melati 2:
• L, girl, 22 yo, 52 kgs, with beta mayor thalassemia.
• R, boy, 6 yo, 18 kgs, with acute tonsillopharingitis and
intake difficulty
• F, girl, 6 yo, 17 kgs, with febrile neutropenia, astrocytoma
on chemotheraphy, faringitis.
• HCU Melati 2: -
• PICU: -
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IDENTITY

Name :R
Age/Wt/L : 6 yo/ 18 kgs / 115 cms
Sex : Male
Address : Jebres, Central Java
Medical : 01395985
Record
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CHIEF COMPLAINT
Fever
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THE CURRENT MEDICAL HISTORY

•Got fever with high temperature (390C)

•Cough and cold (+)
•No seizure
•Got nausea and vomit 2 times
•Sore throat and painful swallowing
•Decreased appetite
•No bleeding
•Urination and defecation within normal limit, no pain
while urinate
•Parents brought him to public health facility and got 3
kinds of medicine, still got intermittent fever

3 days before
admission
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THE CURRENT MEDICAL HISTORY

•Still got fever

•No seizure
•No nausea nor vomit
•Urination within normal limit, no pain while urinate

1 day before
admission
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THE CURRENT MEDICAL HISTORY

• Parents brought him again to public health

facility, got 2 kinds of medicine
• Because still got fever parents brought him
to Moewardi hospital

Admission
Day
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THE CURRENT MEDICAL HISTORY

• Fully alert
• Got fever
• No seizure
• No cough nor cold
• No nausea nor vomit
• Painful swallowing
• Decreased appetite
• Urination an defecation within normal limit

At ER
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THE PAST MEDICAL HISTORY

• History of hospitalization : (+)

• With febrile seizure and recurrent tonsillopharyngitis
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THE FAMILY MEDICAL HISTORY

• History of same illness : (-)

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HISTORY OF PREGNANCY AND DELIVERY

Pregnancy
The patient is the 3rd child of his family. He was born from a 33 years old
mother, G3P2A0, at 38th weeks of gestational age. His mother consumed
vitamins from a doctor. According to the mother, she had routine check
her pregnancy to the doctor and midwife. There was no history of
hospital admission during pregnancy.

Delivery
The patient was delivered spontaneously with midwife assistance. There
was no complication during procedure. The baby was crying vigourously,
weighted 3000 grams and 50 cms in length, the amniotic fluid was clear.

Conclusion : the pregnancy and delivery history were normal

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VACCINATION HISTORY

BCG : 1 months
Hepatitis B : 0 months
DPT-HB-Hib I-III : 2,3,4 months
Polio I-IV : 1,2,3,4 months
IPV : 4 months
Measles : 9 months

Conclusion : Complete Immunization, appropriate with

Ministry Of Health’s Schedule
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PEDIGREE

II

III

R, 6 yo, 18 kgs
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NUTRITIONAL HISTORY

Patient eats 2-3 times a day, rice with tofu, tempe, sometimes fish and
egg. the portion of meal was just 1/2 portion. He likes to drink milk.
But, after get ill, there is decrease of appetite

Conclusion: nutrition status is adequate

Growth and Development

GROWTH History
AND DEVELOPMENT
He is now 6 years old, can communicate and interact well with
her family and friends.
His weight is 18 kg with body height 115 cm.
Conclusion: appropriate for his age
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Nutritional status
• Weight for Age
W/A = 18/21 x 100% = 85.6% (normoweight)
• Height for Age
H/A = 115/118 x 100% = 97.4% (normoheight)
• Weight for Height
W/H = 18/20.5 x 100% = 87.8% (undernourished)

Conclusion:
normoweight, normoheight, undernourished
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PHYSICAL EXAMINATION
GA : moderately ill, compos mentis
VS : Heart rate: 147 bpm Temp: 38oC
Resp. rate : 24 bpm SiO2 : 98%

Head : mesocephal,
Eyes : anemic conjunctiva -/-, icteric sclera -/-, isochoric
pupil (2mm/2mm), light reflex (+/+), conjunctiva
hyperemic (-/-)
Nose : nasal flares (-), nasal discharge (+)
Mouth : cyanosis (-), hyperemic pharynx (+),
tonsil T2-T2 hyperemic (+)
Ears : Ear discharge -/-
Neck : Lymph node enlargement (-)
Chest : Symmetrical in shape and movement, retraction (-)
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Cor : I : Ictus cordis did not appear

P : Ictus cordis was not palpable
P : no sign of heart border enlargement
A : heart sounds I-II normal intensity, regular, murmur(-),
Pulmo: I : symmetrical movement (+)
P: fremitus sounds equals
P: sonor / sonor
A: vesicular breath sounds +/+ , additional breath sound (-/-)
Abd : I : abdominal wall equals to chest wall
A : peristaltic sound (+) normal
P : tympani (+),
P : supel, hepar/lien not palpable
Extremity : Edema : +/+ Cold extremities: -/-
+/+ -/-
Strong palpable of dorsal pedis artery
CRT < 2”
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Isacc Score
• Temperature >380 = 1
• Absence of cough = 1
• Swollen, tender anterior cervical nodes = 0
• Tonsillar swelling or exudate =1
• Age (<14 years) =1

• Total = 4
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October 20th 2017 LABORATORY FINDING
Value Reference Units
Hemoglobin 13.2 11.5-15.5 g/dl
Hematocrit 39 35-45 %
Leucocyte 18.0 4.5-14.5 x103/ul
Thrombocyte 308 150-450 x103/ul
Eritrocyte 4.69 4.00-5.20 x106/ul
MCV 82.1 80.0-96.0 /um
MCH 28.1 28.0-33.0 pg
MCHC 34.3 33.0-36.0 g/dl
RDW 11.7 11.6-14.6 %
MPV 7.9 7.2-11.1 fl
PDW 16 25-65 %
Eosinophil 0.20 0.00-4.00 %
Basophil 0.10 0.00-1.00 %
Neutrophil 86.50 29.00-72.00 %
Lymphocyte 8.30 33.00-48.00 %
Monocyte 4.90 0.00-6.00 %
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LABORATORY FINDING
October 20th 2017

Value Reference Units

Sodium 136 132-145 mmol/L
Potassium 3.6 3.1-5.1 mmol/L
Calcium 1.26 1.17-1.29 mmol/L
Chloride 103 98-106 mmol/L

 Interpretation
 Leucocytosis with neutrophilia dominant
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PROBLEMS
A boy, 6 years old, 18 kgs with:
1. Got fever with high temperature (390C)
2. Cough and cold (+)
3. Got nausea and vomitted
4. Sore throat and painful swallowing
5. Decreased appetite
6. Hyperemic pharynx (+), tonsil T2-T2 hyperemic (+)
7. Pain in the epigastric regio (+)
8. McIsaac score = 4
9. Laboratorium finding  Leucocytosis with neutrophilia and
lymphopenia
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DIFFERENTIAL DIAGNOSIS

1. Febris due to acute tonsillopharingitis with intake

difficulty dd/ urinary tract infection
2. Undernourished
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WORKING DIAGNOSIS

1. Febris due to acute tonsillopharingitis with intake

difficulty dd/ urinary tract infection
2. Undernourished
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THERAPY
1. Admitted to Melati 2 ward, Infection subdivision
2. Diet rice pack 1600 kcal
3. Inf. D51/4NS 16 dpm
4. Inj. Ampicillin (25 mg/kgBW/6h)  450 mg/6h IV
5. Paracetamol (15mg/kg/8h)  270 mg/8h orally
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PLAN
1. Urinalysis and routine feces
2. Throat swab culture
3. Blood culture

MONITORING
 General Appearance/Vital Signs/8 hour
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FOLLOW UP
TH
OCTOBER 21 2017
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Subjective
• No fever
• No vomit
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PHYSICAL EXAMINATION
GA : moderately ill, compos mentis
VS : Heart rate: 130 bpm Temp: 37.1oC
Resp. rate : 22 bpm SiO2 : 98%

Head : mesocephal,
Eyes : anemic conjunctiva -/-, icteric sclera -/-, isochoric
pupil (2mm/2mm), light reflex (+/+), conjunctiva
hyperemic (-/-)
Nose : nasal flares (-), nasal discharge (+)
Mouth : cyanosis (-), hyperemic pharynx (+),
tonsil T2-T2 hyperemic (+)
Ears : Ear discharge -/-
Neck : Lymph node enlargement (-)
Chest : Symmetrical in shape and movement, retraction (-)
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Cor : I : Ictus cordis did not appear

P : Ictus cordis was not palpable
P : no sign of heart border enlargement
A : heart sounds I-II normal intensity, regular, murmur(-),
Pulmo: I : symmetrical movement (+)
P: fremitus sounds equals
P: sonor / sonor
A: vesicular breath sounds +/+ , additional breath sound (-/-)
Abd : I : abdominal wall equals to chest wall
A : peristaltic sound (+) normal
P : tympani (+),
P : supel, no tenderness
Extremity : Edema : +/+ Cold extremities: -/-
+/+ -/-
Strong palpable of dorsal pedis artery
CRT < 2”
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WORKING DIAGNOSIS

1. Febris due to acute tonsillopharingitis with intake

difficulty dd/ urinary tract infection
2. Undernourished
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THERAPY
1. Diet rice pack 1600 kcal
2. Inf. D51/4NS 16 dpm
3. Inj. Ampicillin (25 mg/kgBW/6h)  450 mg/6h IV
4. Paracetamol (15mg/kg/8h)  270 mg/8h orally
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PLAN
1. Urinalysis and routine feces
2. Throat swab culture
3. Blood culture

MONITORING
 General Appearance/Vital Signs/8 hour
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Clinical question :
what is the risk factor of recurrent tonsillopharyngitis in children ?

• P : children age between 2-10 y.o

• I : children with recurrent tonsillopharyngitis
• C :healthy children
• O :risk factor
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Validity
1. Was the defined representative sample of patients assembled
at a common (usually early) point in the course of their disease?
Yes, sample children with recurrent tonsillitis and
healthy children aging between 2 and 10 years were
enrolled in this study.
2. Was patient follow-up sufficiently long and complete?
Yes, Outpatient Clinic of General Pediatrics between April
2008 and April 2009.

3. Were outcome criteria either objective or applied in a ‘blind’

fashion?
Yes
4. If subgroups with different prognoses are identified, did
adjustment for important prognostic factors take place?
Yes.
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Result
• How likely are the outcomes over time?
• How precise are the prognostic estimates?
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IMPORTANCE
• Is my patient so different to those in the study that the
results cannot apply?
No, our patient same with the jurnal

• Will this evidence make a clinically important impact on

my conclusions about what to offer to tell my patients ?
Yes
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• Level of evidence : 3A
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