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CASE CONFERENCE
Thursday, March 1 2018

st
dr. Anto/ dr.Susi/ dr.Debby/ dr.Dilla/ dr.Heru
dr. Dhimas/ dr. Lucky
dr. Mono
PATIENT ADMISSION
• Melati 2 : (-)
• NICU : (-)
• HCU Neonates : (-)
• HCU Melati 2 : (-)
• PICU : (-)
• Outpatient patient
H, 2 y.o, 12 kg, Acute Rhinofaringitis, well nourished
• Death on Emergency Room (DOE)
R, 3.5 y.o, 10 kg, Septic shock, sepsis, rhabdomiosarcoma
on chemotheraphy 7th weeks, undernourished
2
PATIENT IDENTITY
Name : R
Age : 3 years 6 months
Gender : Male
W/ L : 10 kg/85 cm
Address : Sukoharjo
MR : 01353703
3
Chief Complaint :
Severe breathlesness
4
• Patient got weak
• Patient ate little
• No fever
2 weeks before
• No cough or runny nose
admission
• Patient suddenly got severe breathlesness

• No nausea or vomit
• No fever
3 hours before • No cough or runny nose
admission • Patient was brought to dr.Moewardi hospital
5
• Patient was delirium
• No fever
• No cough, runny, nausea or
At vomit
emergency • Still got severe breathlesness
room • Last urination 6 hours before
admission
6
Past Medical History
History of illness : (+) Rhabdomyosarcoma, chemotheraphy 7th

week
7
Family Medical History
• History of hospitalized : (-)
8
Pregnancy and Delivery History
• During pregnancy, mother routinely checked her

pregnancy to midwife. She was given vitamin, and she
didn’t consume any other of medicine. No history of
hospitalization during pregnancy
• Baby boy was born in full term pregnancy, normal
delivery, cried vigorously, no cyanosis or icteric was
found and his birth weight was 2950 grams
Conclusion: normal birth history and normal pregnancy
9
Vaccination History
Hep B : 0 month
Polio : 1, 2, 3, month
BCG : 1 month
DPT, Hib,HepB : 2,3,4 month
Measles : 9 months
Conclusion : complete immunization, according to Ministry of

Health’s schedule 2014 .
10
Nutrition History
Patient eat 3 times a day, a little portion
Conclusion : quality and quantity of nutrition are
inadequate
Growth and Development

He is now 3 year 6 months old, he can walk, and can say
his name.
His weight is 10 kg with body height 85 cm.
Conclusion: growth and development is normal
11
Nutritional Status
• Weight for Age : (BB/U < -3 SD) severely underweight
• Height for Age: ( TB/U < -3 SD) severely stunted
• Weight for height: (-1 SD <BB/U < -2SD SD) under nourished
Conclusion: under nourished, severely underweight, severely

stunted 12
Pedigree
I
II
III
13
R, 3 year, 6 months old
Physical Examination (01.50 am) on ER
General appearance: Delirium, E3V3M4
Vital Signs:
Heart rate: 138 bpm
Body temperature : 37.10C
Respiration rate: 41x/min
Oxygen Saturation: 88%
14
• Head : mesocephal
• Eyes : pale conjunctiva (-/-), icteric conjunctiva (-/-),
light reflex (+/+), isochoric pupil 2 mm/2mm
• Nose : nasal flare (-/-), discharge (-/-)
• Mouth : cyanosis (-), hyperemis pharynx (-),
T1-T1 hyperemis (-/-)
• Neck : lymph nodes enlargement (-)
15
LUNG:
• I: normal, symmetric, no retraction, floating rib (-/-)
• P: right fremitus = left fremitus
• P: sonor in both lung
• A: vesicular breath sound (+/+), additional breath sound (-/-)
CARDIAC:
• I : ictus cordis not visible
• P: ictus cordis not palpable
• P: there is no cardiac enlargement
• A: 1st 2nd Heart sound normal intensity, regular, murmur (-) 16
ABDOMINAL:
I: abdominal wall = thorax wall
A: peristaltic sound (+)
P: shifting dullness (-), undulations (-)
P: palpable pain (-), there are no enlargement of the spleen
and liver
EXTREMITIES:
CRT > 2 seconds,
Dorsalis Pedis artery weakly palpable
Cold extremities
RBG : 541mg/dL 17
Problem List
R, 3.5 years old, male, weight 10 kgs with
1. Severe breathlesness
2. Last urination 6 hours before admision
3. History of illness: Rhabdomiosarcoma on chemotheraphy
7th weeks
4. Delirium, E3V3M4
5. CRT > 2 seconds,
6. Dorsalis Pedis artery weakly palpable
7. Cold extremities
18
Differential Diagnosis
1. Septic shock dd hypovolemic shock
2. Sepsis
3. Rhabdomiosarcoma on chemotheraphy 7th weeks
19
Working Diagnosis
1. Septic shock
2. Sepsis
4. Undernourished, severely underweight, severely stunted
20
Plan
Therapy
1. O2 NRM 5 lpm
2. Get intravenous line  Asering Loading (20mg/kg) =
200ml / 15 minutes
21
Plan
Blood exam :
DL2, RBG, SGOT, SGPT, Ureum, Creatinine, electrolyte
Monitoring
• General appearance /Vital signs/ SiO2/ 15 minutes
22
Evaluation (02.00 am) on ER
S: got intravenous line access
O: General appearance: Delirium, E3V3M4

Vital Signs:
Heart rate: 138 bpm
23
24
LUNG:
CARDIAC:
ABDOMINAL:
and liver
EXTREMITIES:
CRT > 2 seconds,
Cold extremities
26
Working Diagnosis
1. Septic shock
2. Sepsis
27
Plan
Therapy
1. O2 NRM 5 lpm
2. Asering Loading (20mg/kg) = 200ml / 15 minutes ( I )
28
Plan
Blood exam :
DL2, RBG, SGOT, SGPT, Ureum, Creatinine, electrolyte
Monitoring
29
S: Eveluation after loading Asering

Vital Signs:
Heart rate: 128 bpm
Tension : 70/50 mmHg
30
31
LUNG:
CARDIAC:
ABDOMINAL:
and liver
EXTREMITIES:
CRT > 2 seconds,
Cold extremities
33
Working Diagnosis
1. Septic shock
2. Sepsis
34
Plan
Therapy
1. O2 NRM 5 lpm
2. Asering Loading (20mg/kg) = 200ml / 15 minutes ( II )
35
Plan
Wait for Blood exam results
Monitoring
36
S: Gasping

Vital Signs:
Heart rate: 98 bpm
37
38
LUNG:
CARDIAC:
ABDOMINAL:
and liver
EXTREMITIES:
CRT > 2 seconds,
Cold extremities
40
Working Diagnosis
1. Fluid refractory septic shock
41
Plan
Therapy
1. O2 NRM 5 lpm
2. Dobutamin (5mcg/kg/minute) 144mg+NS until 24ml ~
1ml/hours
3. Prepared for Intubation
42
Plan
Monitoring
43
S: Got intubated

Vital Signs:
Heart rate: 90 bpm
Oxygen Saturation: not detected
44
45
LUNG:
CARDIAC:
ABDOMINAL:
and liver
EXTREMITIES:
CRT > 2 seconds,
Cold extremities
47
Working Diagnosis
1. Breathless
48
Plan
Therapy
1. O2 intubation 10 lpm
2. Epinephrine (0.1 mg/kg) ~ 1 mg IV
1ml/hours
49
Plan
Monitoring
50
S: evaluation
O:
Vital Signs:
Heart rate: 45 bpm
Respiration rate: - x/min
51
52
LUNG:
• I: can’t be evaluated
• P: can’t be evaluated
• A: inaudible breath sound
CARDIAC:
ABDOMINAL:
and liver
EXTREMITIES:
CRT > 2 seconds,
Cold extremities
54
Working Diagnosis
1. Bradycardia
2. Breathless
55
Plan
Therapy
1. Cardio-pulmonary resusitation + positive pressure
ventilation
1ml/hours
56
Plan
Monitoring
57
S: evaluation after CPR + PPV
O:
Vital Signs:
Heart rate: 70 bpm
58
59
LUNG:
CARDIAC:
ABDOMINAL:
and liver
EXTREMITIES:
CRT > 2 seconds,
Cold extremities
61
Working Diagnosis
1. Return of spontaneous circulation
2. Breathless
62
Plan
Therapy
1. O2 intubation 10lpm
1ml/hours
63
Plan
Monitoring
64
S: evaluation
O:
Vital Signs:
Heart rate: 40 bpm
65
66
LUNG:
CARDIAC:
ABDOMINAL:
and liver
EXTREMITIES:
CRT > 2 seconds,
Dorsalis Pedis artery not palpable
Cold extremities
68
Working Diagnosis
1. Bradycardia
2. Breathless
69
Plan
Therapy
ventilation
1ml/hours
70
Plan
Monitoring
71
O:
Vital Signs:
Heart rate: - bpm
Body temperature : 350C
72
73
LUNG:
CARDIAC:
• A: inaudible Heart sound 74
ABDOMINAL:
and liver
EXTREMITIES:
CRT > 2 seconds,
Cold extremities
75
Working Diagnosis
1. Cardiac arrest
2. Breathless
76
Plan
Therapy
ventilation
1ml/hours
77
Plan
Monitoring
78
O:
Vital Signs:
Heart rate: - bpm
Body temperature : 350C
79
• Eyes : pale conjunctiva (-/-), icteric conjunctiva (-/-)
80
LUNG:
CARDIAC:
ABDOMINAL:
A: peristaltic sound (-)
and liver
EXTREMITIES:
CRT > 2 seconds,
Cold extremities
82
Working Diagnosis
1. Cardiac arrest
2. Breathless
83
Plan
Therapy
ventilation
1ml/hours
84
Plan
Monitoring
85
O:
Vital Signs:
Heart rate: - bpm
86
• Eyes : pale conjunctiva (+/+), icteric conjunctiva (-/-),
light reflex (-/-), max midriatic pupil +/+
87
LUNG:
CARDIAC:
ABDOMINAL:
A: peristaltic sound (-)
and liver
EXTREMITIES:
CRT > 2 seconds,
Cold extremities
89
Patients declared dead in the presence of
doctors, nureses, and families
90
Laboratory Findings (March 1st 2018)
Value Reference Units
Hemoglobin 7.9 14-17.5 g/dl
Hematocrit 29 33-45 %
Leucocyte 22.0 4.5-14.5 x103/ul
Thrombocyte 394 150-450 x103/ul
Eritrocyte 3.11 3.8-5.8 x106/ul
MCV 92.4 80.0-96.0 /um
MCH 25.4 28.0-33.0 pg
MCHC 27.5 33.0-36.0 g/dl
RDW 19.8 11.6-14.6 %
Neutrophil 80.30 29.00-72.00 %
Lymphocyte 12.10 33.00-48.00 %
Monocyte
Eosynophyle 7.60 0.00-11.00 %
Basophyle
RBG 447 60-100 mg/dL 91
Laboratory Findings (March 1st 2018)
Value Reference Units

Ureum 32 <48 mg/dl
Creatinin 0.4 0.5-1 mg/dl
SGOT 124 <35 u/l
SGPT 35 <45 u/l
Sodium 128 132-145 mmol/L
Calium 6.2 3.1-5.1 mmol/L
Chloride 100 98-106 mmol/L
Calcium 1.17 1.17-1.29 mmol/L
92
Conclusion : anemia, hyperglycemia

THANK YOU
93

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CASE CONFERENCE

Thursday, March 1 2018

• Patient suddenly got severe breathlesness

History of illness : (+) Rhabdomyosarcoma, chemotheraphy 7th

• During pregnancy, mother routinely checked her

Conclusion: normal birth history and normal pregnancy

Conclusion : complete immunization, according to Ministry of

Growth and Development

Conclusion: under nourished, severely underweight, severely

S: got intravenous line access

O: General appearance: Delirium, E3V3M4

S: Eveluation after loading Asering

O: General appearance: Delirium, E3V3M4

O: General appearance: Delirium, E3V3M3

O: General appearance: Delirium, E3V3M3

S: evaluation after CPR + PPV

S: evaluation after CPR + PPV

S: evaluation after CPR + PPV

S: evaluation after CPR + PPV

Value Reference Units

Conclusion : anemia, hyperglycemia

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