1

CASE CONFERENCE
Friday, November 4th 2017

dr. Fitri/ dr. Debby/ dr. Nunki/ dr. Lucky/ dr. Febry
dr. Leksmana
dr. Winda/ dr. Ahimsa
 Patients Admission 2

Melati 2 Ward
1. E, male, 1 years old, 8.5 kgs, with complex febrile seizure,
pneumonia dd bronchiolitis and well nourished, normoweight,
normoheight.

Neonatal HCU (-)

NICU (-)

Melati 2 HCUm (-)

PICU (-)
 3

Patient Identity
Name :E
Sex : male
Age : 1 years old
Address : Jebres
Medical record : 01384770
Weight/Height : 8.5 kgs/ 72 cm
 4

Chief Complain

Seizure
 Present Medical Hystory 5

14 hours before
admission
Suddenly got
continuous High fever,
4 days before admission but responed to
Common cold (+), cough (+), antipyretic drug,
productive cough, still active, no although 2-3 hours the
temperature increased
complain about urination, again, productive cough
defecation, and nutrition intake (+), no dyspneu
 Present Medical Hystory 6

At the ER
Patient got seizure on hands and
feet for 1 minute, the eyes rolls
upward, given stesolid
2 hours before admission supposituria by the triage doctor
and the seizure stopped, patient
Fever (+), seizure on hands (+) and cried vigorously after that.
feet, no eye contact for 1 minute,
stopped by it self, patient cried shortly During examination patient fully
after the seizure, patient than reffered alert, cried vigorously, still got
fever, the last urination and
to the ER defecation at ER
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Past Medical History

History of febrile seizure (+) at age 7 month old
History of Epilepsy (-)
History of hospitalization (-)
 8

Family Medical History

History of Epilepsy : (-)

History of Febrile seizure : (-)
 9

Pregnancy and Delivery History

During pregnancy, the mother routinely checked up
her pregnancy to midwife and obstetrician. She was
given vitamin, and she didnt take any of medicine
beside it.
Baby boy was born in full term pregnancy, delivered
by spontaneous delivery at the primary health care,
cry vigorously, no cyanosis or icteric and his birth
weight was 3000 grams

Conclusion: pregnancy and delivery history was normal

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VII. Vaccination History

Vaccination history
BCG : 3 month
Hepatitis B1 : 1 month
DPT-HB-Hib : 2, 4, 6 months
Polio : 0, 2, 4, 6 months
Measles :-
MR : 9 month

Conclusion : incomplete immunization, based on

Ministry of Healths schedule 2016
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Nutrition History
Patient drink breast milk on demand for the diet, patient
eat porridge also three times/ day, 1/3 portion of adult.
Conclusion : quality and quantity of nutrition were
enough

Growth and Development

He is 1 years old now, he could stand without support
and practicing to walks, he could kick the ball and
could say 1 words
His weight is 8.5 kgs with body height 72 cm.
Conclusion: growth and development are apropriate for
his age
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Nutritional Status
Weight for Age : 8.5/9.4 x 100% = 90.4 %
(-2 SD< WAZ < 0 SD) normoweight
Height for Age: 72/74 x 100% = 97%
(-2 SD< HAZ < 0 SD) normoheight
Weight for height 8.5 / 8.7 x 100% =97 %
(-1 SD< WHZ < 0 SD) well-nourished

Conclusion: well-nourished, normoweight, normoheight

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FAMILY TREE

II

III

E, 1 years old
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Physical Examination

General appearance: Fully alert, E4V5M6

Vital Signs:
Heart rate: 150 bpm
Body temperature : 39.80C
Respiration rate: 30 bpm
Oxygen Saturation: 99%
 15

Head : normocephal with head circumference 45

cm (-2 SD <HC< 0SD, nellhaus),
Eyes : pale conjunctiva (-/-), icteric conjunctiva
(-/-), light reflex (+/+), isochoric pupil
2 mm/2mm
Nose : nasal flare (+) minimal, discharge (+)
Mouth : cyanosis (-), tonsil T1-T1, hyperemic (-)
Neck : no enlargement of lymph node
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LUNG:
I: normal, symmetric, no retraction
P: vocal fremitus couldnt be evaluated
P: sonor in both lung
A: normal vesicular breath sound, additional breath sound (+/+),
fine rales (+/+) wheezing (+/+) decreased

CARDIAC:
I : ictus cordis not visible
P: ictus cordis palpabled but not forceful
P: there is no cardiac enlargement
A: 1st 2nd Heart sound normal intensity, regular, no murmur
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ABDOMINAL:
I: abdominal wall // thorax wall
A: peristaltic sound is within normal limit
P: shifting dullness (-), undulations(-)
P: there are no enlargement of the spleen and liver

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec,
and dorsalis pedis artery was strongly palpable.
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Neurological Examination
Physiological reflexes
Meningeal sign
- Biceps +2/+2
- Triceps +2/+2 Nuchal rigidity -
- Patella +2/+2 Kernigs sign
- Achilles +2/+2
Brudzinsky sign
Pathology reflexes
- Chaddock -/-
- Oppenheim -/- Lateralization (-)
- -
- Schaeffer -/- Spastic
- Gordon -/- - -

- Babinski -/-
Cranial Nerves Examination

NI : cant evaluate
N II : cant evaluate
N III, IV, VI : light reflex within normal limit
NV : korneas reflex within normal limit
N VII : symmetrical face, no abnormal faces move
N VIII : cant evaluate
N IX : no uvula deviation
NX : vomitus reflex (+)
N XI : symmetrical shoulder
N XII : suck and swallow in normal limits
 20
Laboratory Findings (November 4th 2017)
Hb : 11.2 g/dl Blood sugar : 106 mg/dl
HCT : 35% Sodium : 133 mmol/L
AL : 16,700 /ul Potassium : 4.2 mmol/L
AT : 425,000/ ul Calcium : 1.27 mmol/L
AE : 4.71 mil/ul
Chloroda : 102 mmol/L
MCV : 73.2 /um
MCH : 23.8 pg
MCHC : 32.5 g/dl
Netrophyl: 63.00%
Lymphocyte : 23.20%
Mono, Eos, bas : 14.0/0.00/0.00
%

Conclusion: lymphopenia
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Chest radiography

Patchy infiltrate with hyperinflation

Problem List 22

1 Year old, male, weight 8.5 kgs with

Hystory taking
1. Got general Seizures while having high fever 2 time,
for 1 minute, conscious between seizures.
2. After seizure fully alert
3. Productive cough
Physical examination
1. Fully alert E4V5M6
2. Temperature 39.8 o C
3. No neurologic disturbance
Laboratory result and radiologic finding
Lymphopenia, radiologic finding: pneumonia
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Differential Diagnosis
1. Bronchiolitis dd Pneumonia
2. Complex febrile seizure
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Working Diagnosis
1. Bronchiolitis
2. Complex febrile seizure
3. Well-nourished
 Plan 25
Therapy
1. Admitted to Pediatric neurology ward
2. Poridge diet 1000 kcals/day
3. Oxygen 2 lpm via nasal canule
4. IVFD D5 NS 35 ml/ hour
5. Paracetamol (15 mg/kgBw/6 hours) 130 mg/ 6hours I.V
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Planning
Urinalysis
Routine stool examination

Monitoring
General appearance /Vital signs/ oxygen
saturation/ 4 hours
Fluid balance and diuresis / 8 hours
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Follow up, November 5th 2017

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Subjective: fever, no seizure, no dyspneu

General appearance: Fully alert, E4V5M6

Vital Signs:
Heart rate: 120 bpm
Body temperature : 38.10C
Respiration rate: 30 bpm
Oxygen Saturation: 99%
 29

Head : normocephal with head circumference 45

cm (-2 SD <HC< 0SD, nellhaus),
Eyes : pale conjunctiva (-/-), icteric conjunctiva
(-/-), light reflex (+/+), isochoric pupil
2 mm/2mm
Nose : nasal flare (-), discharge (+)
Mouth : cyanosis (-), tonsil T1-T1, hyperemic (-)
Neck : no enlargement of lymph node
 30
LUNG:
I: normal, symmetric, no retraction
P: vocal fremitus couldnt be evaluated
P: sonor in both lung
A: normal vesicular breath sound, additional breath sound (+/+),
fine rales (+/+) wheezing (+/+) decreased

CARDIAC:
I : ictus cordis not visible
P: ictus cordis palpabled but not forceful
P: there is no cardiac enlargement
A: 1st 2nd Heart sound normal intensity, regular, no murmur
 31
ABDOMINAL:
I: abdominal wall // thorax wall
A: peristaltic sound is within normal limit
P: shifting dullness (-), undulations(-)
P: there are no enlargement of the spleen and liver

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec,
and dorsalis pedis artery was strongly palpable.
 32

Neurological Examination
Physiological reflexes
Meningeal sign
- Biceps +2/+2
- Triceps +2/+2 Nuchal rigidity -
- Patella +2/+2 Kernigs sign
- Achilles +2/+2
Brudzinsky sign
Pathology reflexes
- Chaddock -/-
- Oppenheim -/- Lateralization (-)
- -
- Schaeffer -/- Spastic
- Gordon -/- - -

- Babinski -/-
Cranial Nerves Examination

NI : cant evaluate
N II : cant evaluate
N III, IV, VI : light reflex within normal limit
NV : korneas reflex within normal limit
N VII : symmetrical face, no abnormal faces move
N VIII : cant evaluate
N IX : no uvula deviation
NX : vomitus reflex (+)
N XI : symmetrical shoulder
N XII : suck and swallow in normal limits
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Diagnosis
1. Bronchiolitis
2. Complex febrile seizure
3. Well-nourished
 Plan 35
Therapy
1. Poridge diet 1000 kcals/day
2. Oxygen 2 lpm via nasal canule
3. IVFD D5 NS 35 ml/ hour
4. Paracetamol (15 mg/kgBw/6 hours) 130 mg/ 6hours I.V
 36

Planning
Urinalysis
Routine stool examination
Lumbar puncture

Monitoring
General appearance /Vital signs/ oxygen
saturation/ 4 hours
Fluid balance and diuresis / 8 hours
Clinical questions: were antibiotics
improved or worsened clinical
outcomes in children with
bronchiolitis?
Children under two years of age with bronchiolitis
P

Antibiotics
I

Placebo or other interventions

C

Clinical outcomes
O
 validity
Was the assignments of patients to treatment
randomized? Yes
Is the patient observations made sufficiently long
and complete? Yes, since the diagnostic is made
until the problem resolved.
Aside from the experimental treatment, were the
groups treated equally? Yes
Were the group similar at the start of the trial? Yes
the group is children under two years of age.
Importance
IMPORTANCE

Are the Result important? yes

CI interval in most symptom
observed in most study are
narrow.
APPLICABILITY

1. Were the study patients is similar to

your own? YES
2. Will this evidence make a clinically
important impact on your
conclusions about what to give to
your patient? YES. We can exclude
antibiotic from therapy for patients
with bronchiolitis.
conclusions

VALID, IMPORTANT and

APPLICABLE
Level of Evidence : 1A
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THANK YOU