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Case Confrence
Case Confrence
June 2 2018
nd
Morning shift
PATIENT ADMISSION
MELATI 2 WARD:
AZ, 6 y.o, 37 kgs, neutropenia fever, acute
rhinopharingitis, osteosarcoma on chemotheraphy,
overnourished
HCU NEONATUS :
N, 1 days, 3800 grams. consulted by surgery with Atresia ani with
enterocutan fistel, neonatal sepsis, breathlessness due to
pneumonia, neonate, boy, normal birth weight, full term,
appropriate to gestational age, spontaneous outside delivery
PICU : (-)
HCU MELATI 2 : (-)
NICU : (-)
2
3
PATIENT IDENTITY
Name : AZ
Age : 6 years old
Gender : Female
W/ L : 38 kg, 116 cm
Address : Sungai Liat, Bangka
MR : 01419642
4
Chief Complaint :
Fever
5
Admission day
• Patient still had Fever (+), Cold (+), cough (-),
nausea (-), vomiting (-)
• Patient was given paracetamol at 12pm
9
AT THE ER
• Patient was fully alert, Fever (+), Cold (+), cough
(-), nausea (-), vomiting (-)
• Intake (+)
• Defecation & urination are normal
• Epistaxis (-), bleeding gum (-), bruises (-)
10
Vaccination History
Basic
• Hep B : 0 month
• Polio : 1,2,3,4 month
• BCG : 1 month
• DPT, Hib, HepB : 2,3,4 month
• Measles : 9 month
Booster :
• 18 months : Measles, DPT, HB, Hib
Conclusion: normal
Conclusion : quality and
quantity of nutrition are growth and
development
adequate
15
Nutritional Status
CDC
• Weight for Age : 25%< WFA < 50% normoweight
• Length for Age: 25% < HFA < 50% normoheight
• Weight for length: 38/21x100% = 180% over
nourished
Pedigree
I
II
III
Physical Examination
General appearance:
Moderately ill, fully alert
Vital Signs:
1. Heart rate: 140 bpm
2. Body temperature : 37,80C
3. Respiration rate: 24 x/min
4. Oxygen Saturation: 99%
18
Physical Examination
• Head : Mecocephalic
• Eyes : Isochoric pupils (2mm/2mm), light reflex
(+/+), anemic (+/+), icteric (-/-)
• Nose : Discharge (+), nasal flare (+)
• Mouth : wet mucosa (+), T3-T3, hyperemia (-)
• Ear : discharge (-/-)
• Neck : lymph nodes enlargement (-)
• Chest : symmetric, no retraction
19
LUNG: CARDIAC:
• I: normal, symmetric, no • I : ictus cordis not visible
retraction, floating rib (- • P: ictus cordis not
/-) palpable
• P: left =right • P: there is no cardiac
• P: sonor in both lung enlargement
• A: vesicular breath sound • A: 1st 2nd Heart sound
(+/+), additional breath intensity is normal,
sound (-/-), Ronchi (-/-), regular, murmur (-)
wheezing (-/-)
20
ABDOMEN EXTREMITIES:
• I: abdominal wall = • CRT < 2 seconds,
thorax wall • Dorsalis Pedis artery
• A: peristaltic sound (+) strongly palpable
normal • Warm extremities
• P: tympanic (+) • Palpable mass on
upper left arm
• P: hepatosplenomegaly
(-), soft, tenderness (-)
21
ANC : 1464
Result : Osteosarcoma
25
Problem List
AZ, female, 6 years old, 38 kgs with :
• Patient was discharged from Moewardi after chemo (1st
cycle)
• When discharged : fever (-), nausea (-), intake (+),
Normal urination & defecation
• Patient had cold 4 days later
• Fever (+) 38,1 oC and was given paracetamol, cough (-)
• At the ER patient was fully alert, Fever (+), Cold (+),
cough (-), nausea (-), vomiting (-)
• Epistaxis (-), bleeding gum (-), bruises (-)
26
Problem List
Physical exam
1. Anemic (+/+) conjunctivae
2. T3-T3 tonsils
3. Tumor on upper left arm
Lab findings
1. Microcytic hypochromic anemia
2. Neutropenia
3. Lymphocytosis
4. Monocytosis
5. PA : Atypical cells, osteosarcoma
27
Differential Diagnosis
1. Febrile observation due to suspected neutropenia
fever dd UTI
2. rhinopharingitis
3. Osteosarcoma in first cycle chemotherapy
28
Working Diagnosis
1. Neutropenia fever
2. Rhinopharyngitis
3. Osteosarcoma in first cycle chemotherapy
4. Overnourished
29
Therapy
1. Admitted to pediatric hemato-oncology
2. Rice and side dish diet 1800 kkal/day
3. IVFD D5 ½ NS 63 ml/hr IV
4. Paracetamol (15mg/kg/8h) ~ 500mg/8h
5. Cetirizine 5mg/24h
6. Amoxicillin clavulanate inj (15 mg/kg/8h) ~
600mg/8h IV
30
Plan Monitoring
• CBC • General appearance/Vital
• Urinalysis signs/Saturation/8 hours
• Routine feces
• Fluid balance &
diuresis/8hr
31
FOLLOW UP
32
O:
General appearance:
Moderately ill, fully alert
Vital Signs:
1. Heart rate: 140 bpm
2. Body temperature : 37,80C
3. Respiration rate: 24 x/min
4. Oxygen Saturation: 99%
33
Physical Examination
• Head : Mecocephalic
• Eyes : Isochoric pupils (2mm/2mm), light reflex
(+/+), anemic (+/+), icteric (-/-)
• Nose : Discharge (+), nasal flare (+)
• Mouth : wet mucosa (+), T3-T3, hyperemia (-)
• Ear : discharge (-/-)
• Neck : lymph nodes enlargement (-)
• Chest : symmetric, no retraction
34
LUNG: CARDIAC:
• I: normal, symmetric, no • I : ictus cordis not visible
retraction, floating rib (- • P: ictus cordis not
/-) palpable
• P: left =right • P: there is no cardiac
• P: sonor in both lung enlargement
• A: vesicular breath sound • A: 1st 2nd Heart sound
(+/+), additional breath intensity is normal,
sound (-/-), Ronchi (-/-), regular, murmur (-)
wheezing (-/-)
35
ABDOMEN EXTREMITIES:
• I: abdominal wall = • CRT < 2 seconds,
thorax wall • Dorsalis Pedis artery
• A: peristaltic sound (+) strongly palpable
normal • Warm extremities
• P: tympanic (+) • Palpable mass on
upper left arm
• P: hepatosplenomegaly
(-), soft, tenderness (-)
36
Differential Diagnosis
1. Febrile observation due to suspected neutropenia
fever dd UTI
2. rhinopharingitis
3. Osteosarcoma in first cycle chemotherapy
37
Working Diagnosis
1. Neutropenia fever
2. Rhinopharyngitis
3. Osteosarcoma in first cycle chemotherapy
4. Overnourished
38
Therapy
1. Admitted to pediatric hemato-oncology
2. Rice and side dish diet 1800 kkal/day
3. IVFD D5 ½ NS 63 ml/hr IV
4. Paracetamol (15mg/kg/8h) ~ 500mg/8h
5. Cetirizine 5mg/24h
6. Amoxicillin clavulanate inj (15 mg/kg/8h) ~
600mg/8h IV
39
Plan Monitoring
• CBC • General appearance/Vital
• Urinalysis signs/Saturation/8 hours
• Routine feces
• Fluid balance &
diuresis/8hr
40
O:
General appearance:
Moderately ill, fully alert
Vital Signs:
1. Heart rate: 120 bpm
2. Body temperature : 37,20C
3. Respiration rate: 24 x/min
4. Oxygen Saturation: 99%
41
Physical Examination
• Head : Mecocephalic
• Eyes : Isochoric pupils (2mm/2mm), light reflex
(+/+), anemic (+/+), icteric (-/-)
• Nose : Discharge (+), nasal flare (+)
• Mouth : wet mucosa (+), T3-T3, hyperemia (-)
• Ear : discharge (-/-)
• Neck : lymph nodes enlargement (-)
• Chest : symmetric, no retraction
42
LUNG: CARDIAC:
• I: normal, symmetric, no • I : ictus cordis not visible
retraction, floating rib (- • P: ictus cordis not
/-) palpable
• P: left =right • P: there is no cardiac
• P: sonor in both lung enlargement
• A: vesicular breath sound • A: 1st 2nd Heart sound
(+/+), additional breath intensity is normal,
sound (-/-), Ronchi (-/-), regular, murmur (-)
wheezing (-/-)
43
ABDOMEN EXTREMITIES:
• I: abdominal wall = • CRT < 2 seconds,
thorax wall • Dorsalis Pedis artery
• A: peristaltic sound (+) strongly palpable
normal • Warm extremities
• P: tympanic (+) • Palpable mass on
upper left arm
• P: hepatosplenomegaly
(-), soft, tenderness (-)
44
Differential Diagnosis
1. Febrile observation due to suspected neutropenia
fever dd UTI
2. rhinopharingitis
3. Osteosarcoma in first cycle chemotherapy
45
Working Diagnosis
1. Neutropenia fever
2. Rhinopharyngitis
3. Osteosarcoma in first cycle chemotherapy
4. Overnourished
46
Therapy
1. Admitted to pediatric hemato-oncology
2. Rice and side dish diet 1800 kkal/day
3. IVFD D5 ½ NS 63 ml/hr IV
4. Paracetamol (15mg/kg/8h) ~ 500mg/8h
5. Cetirizine 5mg/24h
6. Amoxicillin clavulanate inj (15 mg/kg/8h) ~
600mg/8h IV
47
Plan Monitoring
• CBC • General appearance/Vital
• Urinalysis signs/Saturation/8 hours
• Routine feces
• Fluid balance &
diuresis/8hr
48