CLINICAL CONFRENCE

RESPIROLOGY DIVISION
(New Case)
August 27th , 2021

Hardiyanti / Presenter
Irfadah Dinar / Madya Division
Nurfajrin Utami Ansari / Senior Division
Ade Nur Prihadi Sutopo / Senior Division
Yusriwanti Kasri / Senior Division
Fitrayani Hamzah / Senior Division
Misjunalling Paluyukan / senior Division
 PATIENT IDENTITY

Name : FH
MR Number : 944260
Date of Birth : 10-5-2020
Admission Date : 24-8-2021
Medical Diagnosis
Community Acquired Pneumonia + Hypothyroid Congenital +
Iron Deficiency of Anemia Diffrential Diagnosis Chronic
Disease of Anemia + Imbalance Electrolyte + Suspected
Cytomegalovirus infection + Diaper Rash + Stunting +
Mikrocephal + Underimunization
Patient Picture
 HISTORY TAKING
History of Present Illness
A girl 10 month of age was admitted to the hospital with
complaints of a shortness of breath, noticed since 7 days
before admission to the hospital and get worse 1 days
Chief Complaint ago, not blue.
Shortness of breath There was intermittent cough, there was mucous.
There was fever since 1 days before admission to the
hospital. No seizures.
No vomiting
Urination: Normal, yellow.
Defecation: Yellow soft stool.
 No history of contact with tuberculosis patient or a
long cough
No history of fever >2 weeks
History of Past Illness No history of cough >2 weeks
No history of decreased body weight
There was history of difficult weight gain
There was history of control in Social and pediatrics
policlinic Wahidin’s hospital (20/8/2021) with diagnosis
mix developmental delay + Community Acquired
Pneumonia + hypothyroid subclinic + suspected
cytomegalovirus infectioan and get therapy ambroxol
suspension, cefixime suspension, vitamin C, Vitamin B
and Folic acid tablet.
5
 Pregnancy history: Third pregnancy at the age of 32 years, during pregnancy the mother
routinely check at the doctor and routinely get vitamins and blood boosters. There was no
history of hypertension, diabetes mellitus, heart disease, and fever during pregnancy.
 Birth history: Child born vaginally, at term, APGAR score unknown, birth weight 3.500
grams and birth length unknown.
 Breastfeeding history: the child has been breastfed from birth to 4 month of age and has
been drinking formula milk until now
 PHYSICAL EXAMINATION
Antropomethry
Vital Sign
Body weight : 5,7 kg
General condition: Moderate
ill/malnourished/GCS 15 Length : 65 cm
(E4M6V5) Head Circumference : 40 cm, mikrochepal (Normal: 42,5 – 47,8 cm)
Blood Pressure : 90/60 mmhg
Heart Rate : 128 times/min Weight for length : between -2SD and -3SD (Malnourished)
Temperature : 38,9 °C Length for age : between -2SD and -3SD (Short stature)
Respiration Rate : 44
times/min Weight for age : under -3SD (severly underweight)
SpO2 : 99% via nasal canul Mid Parental Height: 163 – 180 cm
Pain Scale : 1 FLACC

7
 PHYSICAL EXAMINATION
Weight For Height: Malnourished
 PHYSICAL EXAMINATION
Head Circumference : 48 cm
(normal : 42,5 – 47,8 cm)
 PHYSICAL EXAMINATION

Weight for age: Under -3SD (severly underweight) Length for age: between -2SD and -3SD (Short Stature)
 PHYSICAL EXAMINATION
History of Vaccine
Frequency
Vaccine
Not given 0 1 2 3 4

Hep B 10/5/2021
BCG v
DPT v
Hib v
OPV 10/5/2021
IPV v
MMR v
Rotavirus v
Influenza v
Japanese Encephalitis v
PCV v
Varicella v
Hepatitis A v
Tifoid v
 Observe the hand : forgot

History of Growth Grabbing object : 3 month

and Development Prone position by self : 4 month
One syllables : not yet
Pointing the object : not yet
First tooth : not yet

12
Dismorfik’s face
PHYSICAL EXAMINATION
Cardiovascular
No Low Seat Ear Pure regular I / II heart sound, no additional sound

No Hipertelorisme
No macroglossy Abdomen
Tonsils: T1-T1 not hyperemic Peristaltic sound : normal

Pharynx is not hyperemic Liver dan spleen its not pepable

No lymphadenopathy
Genitalia
Pulmo
There was papul eritema multiple and Skuama
Xhylophone ribs
There was subcostal, intercostal retraction
Vesicular breath sounds
Rales was in both lung fields
No wheezing
 LABORATORY FINDING
August 24th August 25th
August 19th 2021
Laboratory 2021 2021 Normal Value
(Wahidin)
(Wahidin) (Wahidin)
Hb 9,9 10,6 10,9 12.0 – 16.0 gr/dL
WBC 16.300 9.000 18.800 4.0 – 10.0/μL
PLT 336.000 364.000 360.000 150.000 – 400.000/mm3
HCT 29 % 31 % 33% 37.0 – 48.0 %
MCV 78 82 81 80 -100 μm3
MCH 27 28 27 27 - 32 Pg
NEUT 63,9 72,60 67,8 52 – 75 103/μL
LYMPH 21,9 23,4 20,7 20 – 40 103/μL
MONO 13,9 2,9 11,2 2 – 8 103/μL
RET - - 4,04 0,00 – 0,10 x 103/ul
Natrium 133 126 - 136 – 145 mmol/l
Pottasium 3,6 2,3 - 3,5 – 5,1 mmol/l
Clorida 94 80 - 97 – 111 mmol/l
GDS 70 83 - 140 mg/dl
CRP - - >1,00 <5 mg/l
Prokalsitonin - - 4,07 <0,05 ng/ml
 LABORATORY FINDING
August 19th 2021
Laboratory Normal Value
(Wahidin)
FT4 0,84 0,93 – 1,71 ng/dl
TSHs 12,77 0,27 – 4,20 mIU/ml
Anti TOXO IgG Non Reactive Non Reactive
Anti TOXO IgM Non Reactive Non reactive
Anti Rubella IgG Non Reactive Non reactive
Anti Rubella IgM Non Reactive Non reactive
Anti CMV IgG Reactive (titer = 28) Non reactive
Anti CMV IgM Non Reactive Non reactive
 LABORATORY FINDING
Peripheral Blood Smear ( August 25st 2021)

Eritrosit
Normocitic Normokrom, anisopoikulositosis, ovalosit (+), akantosit (+), Pencil cell
(+), Inklusion body (-), normoblast (-)

Leukosit
Normal count, PMN > Lymphocyte, toxic granulation, Normal morphology,
normoblast (-)

Trombosit
Normal count and morphology

Impression
Leukocytosis with infection sign
 RADIOLOGY FINDING

CHEST X-RAY WAHIDIN’S

HOSPITAL (25/8/2021)
IMPRESSION:
PNEUMONIA BILATERAL
CORDIS WITH NORMAL LIMIT
 - Community Acquired Pneumonia
- Hypothyroid Congenital
- Iron Deficiency of Anemia Diffrential
ASSESMEN Diagnosis Anemia of Chronic Disease
T - Imbalance Electrolyte
- Suspected Cytomegalovirus Infection
- Diaper Rash
- Stunting
- Mikrocephal
- Underimunization

18
 • Oxygen 2 Liter/minute via nasal canul
• Fluid Requirements 570 ml - 20% respiratory distress  456 ml/ 24 hours
• Asering 19 cc/ hours / Intravenous
• Stop Intake Oral (Nasogastric Tube Decompression)
• Paracetamol 60 mg / 8 hours/ intravenous (if the temperature is > 38.5 Celsius)
• Ceftriaxone 570 mg/ 24 hour/ intervenous
• Gentamicin 15 mg/ 12 hour/ intrervenous
• Correction of hyponatremia  Asering/ intravenous

TREATMENT • Corection of hypokalemia  Asering 547 cc + KCl 7,43% 11 cc/ intravenous  23 cc/ hour/
intravenous
• Myco Z salf
• Management of Nutritional Marasmus
• Day 1 Stabilization phase  postpone
• Vitamin C 50 mg/ 24 hour/oral  postpone
• Vitamin B Complex 1 tablet/ 24 hour/ oral  postpone
• Folic Acid 5 mg/ 24 hour/ oral (Day 1)  postpone

19
 ◦ Tracking of Anemia (Blood Smear peripheral, Ferritine,
Reticulocyte, TIBC)
◦ Tracking of Tuberculosis Pulmonal (Gastric lavage and Mountox’s

PLANNING Test)
◦ Consult to Nutrition and Metabolic Disease
◦ Consult to Endocrinology Division
◦ Consult to Infection and Tropical Disease Division

20
THANK YOU

21