CLINICAL CONFRENCE

ERIA DIVISION
(New Case)
june 28th, 2023

Dhody Setiamal,Ayi Suwarayi/ Junior

L.M.Isvan Davis, Nita Anugerawati N/Madya
Desi Nandiyarizky, Min Ayatina, Nurfajrin Utami, M. Rifani, Novian Sollina
Eoh/Senior
 PATIENT IDENTITY
MF, 9 years
MR Number 1028811
Date of Birth June 20th, 2014
Admission Date June 28th, 2023

MEDICAL DIAGNOSIS
Mild acute respiratory distress syndrome + Cardiomegaly + Acute Kidney Injury
KDIGO III + Acute nephritic syndrome + Hypertension grade 2 + Leucocytosis +
Hypoalbuminemia
 HISTORY TAKING
Chief Complaint
Shortness of breath 
History of Present Illness
A 9-year-old boy referred from yapika Hospital with a diagnosis of
encephalopathy + acute kidney injury + community acquired
pneumonia.
The patient was Intubated
There was shortness of breath since 1 week ago and getting worse since
12 hours ago, cough since 1 week ago, no mucus and blood
There was decrease of consciousness since 1 day prior admission.
There was swelling since 1 week ago, in the eyes, face, stomach and legs
No fever. History of fever 1 week before admitted to hospital, not
continuous fever and subsided with antipyretic. No seizures
Defecation and urination were normal
 HISTORY TAKING
• No history of bloody stool, reddish urine nor pain during urination.
• No history of seizures, hair loss, high blood pressure, frequent fever, frequent joint pain,
erythema with sunlight exposure, nosebleeds, bleeding gums, nor swelling.
• No history of previous steroid therapy, history of respiratory tract infections / skin infection.
• No family history of malignancy nor autoimmune disease.
• History of being hospitalized at Yapika Hospital for 6 days and got
meropenem/intravenous, norepinephrine/intravenous, furosemide/intravenous,
metylprednosolone/intravenous, paracetamol/intravenous, NaCl 0.9% /inhalation
 PHYSICAL EXAMINATION
Vital Sign Anthropometry
General condition: Severely ill/ Body weight : 24 kg
wasted / Fourscore (E2M4B3R1)
Height : 134 cm
BP: 120/80mmHg
Head Circumference : 52 cm (46 -52 cm)
p50 98/59
Weight for Height : 24/29x100%= 82 % (Wasted)
p90: 109/72
Height for Age : 134/133x100%=100%
p113/75 (normal stature)
Heart Rate : 116 times/min Weight for Age : 24/29x100%= 82%
(underweight)
Temperature : 37,1 °C
Respiration Rate : 32 times/min
SpO2 : 99 % via ventilator mekanik
Head Circumference : 52 cm
(46 -52 cm)
Weight for Height : 24/29x100%= 82 % (Wasted)
Height for Age : 134/133x100%=100% (normal
stature)
Weight for Age : 24/29x100%= 82% (underweight)
 History of vaccine
Month Years
Vaccine No 0 1 2 3 4 5 6 7 8 9 12 15 18 24 3 5 6 7 8
t
giv
en
Hep B v v v V v
BCG V
DPT v v v V
Hib V
OPV v v v V
IPV

Measles v
Ro- V
tavirus
In- V
fluenza
Japa- V
nese En-
cephali-
tis
PCV V
Varicella V
Hepatitis V
A
Typhoid V
PHYSICAL EXAMINATION
No pallor, no jaundice Cardiovascular
No lymphadenopathy Pure regular I / II heart sound,
No Hyperemic pharynx No murmur
T1-T1 tonsils,not Hyperemic Abdomen
Normal peristaltic sound
No xylophone Ribs Liver and Spleen was not palpable
Pulmonary
vesicular breath sounds Ekstremity
Rales both hemithoraks Edema
No wheezing CRT <3 second
 Meningeal stimulation
PHYSICAL EXAMINATION signs: negative

Consciousness GCS 15 reflex was present Motor

E4V6M5
Nerve XII: tongue deviation Strength: 3333/2222
Cranialnerves: absent 
2222/3333
Nerve I: difficult to evaluate
Tonus: normal
Nerve II: pupil round isocor,
diameter 2.5/2.5 mm, Physiological reflexes:
positive light reflex normal
Nerves III, IV, VI: difficult to
evaluate
Pathological reflexes:
Babinsky negative
Nerve V: positive corneal
reflex Sensibility and
autonomic nervous
Nerve VII: negative facial system: difficult to
paresis
evaluate
Nerve VIII: difficult to
evaluate
Nerves IX, X, XI: swallowing
 LABORATORY FINDING
Yapika Wahidin
Laboratory Normal Value
26/06/23 28/06/23
Hb 14,4 14,3 12.0 – 16.0 gr/dL
WBC 32.500 32.900 4.0 – 10.0/μL
PLT 351.000 404.000 150.000 – 400.000/mm3
MCV 80,6 81 80 -100 μm3
MCH 25,8 26 27 - 32 Pg
%NEUT - 88,1 52 – 75 103/μL
%LYMPH 74,1 20 – 40 103/μL
%MONO 4,1 2 – 8 103/μL
Ret - 0,5 – 1 /μL
 Yapika
Laboratory Wahidin 28/06/23 Normal Value
26/06/23
Ureum 47 241 10 - 50 mg/dl
Creatinine 3,04 3,05 <1.3 mg/dl
SGOT 226 102 < 38 u/l
SGPT 39 65 < 41 u/l
3.5 – 5.0 mg/
Albumin 2,7 2,9
dl
136-145
Natrium - 144

Kalium - 6,6 3,5-5,1

Clorida - 115 97-111
CRP >130 <5
Prokalsitonin >200 <0,05
Urinalysa Yapika Hospital (24/06/2023) Blood gas 28/06/2023 Wahidin Hospital
Colour yellow
pH 6.0 PH 7.250
Bj 1.030 PO2 205.3 mmHg
Protein +4 PCO2 40.9 mmHg
Glukose Negatif
Bilirubine Negatif SO2 99.9 %
Urobilinogen normal HCO3 18.1 mmol/l
Keton Negatif BE -9.3 mmol/l
Nitrit Negatif
Blood 3+
Lekosit Negatif
Vit. C Negatif
Sedimen Lekosit 0
Sedimen Eritrosit 0
 Radiology finding

Thorax X-Ray Yapika hospital 27/06/2023

Impression:
- Bronchopneumonia bilateral
- Cardiomegali
Radiology finding
Foto Thorax AP 28/06/2023 Wahidin hospital

- Inserted ETT tip +/- 3.46 cm upper carina

- Inserted gastric tube
- Homogen consolidaton upper right lung
- Inhomogen consolidation and ilfiltrat upper mid-
dle left lung
- Cor:size CTR 0.61, aorta normal
- Both sinus dan diafragma normal
- bones intak
- Soft tissue normal

Impression:
- Atelektasis pulmo dextra
- Pneumonia bilateral
- Cardiomegaly
 ASSESMENT
• Shortness of breath
• Hypertension
• Edema
• Cardiomegaly
• Wasted
• Normocephal
• Normal stature
 WORKING DIAGNOSIS
• -Mild acute respiratory distress syndrome
• -Cardiomegaly
• -Acute Kidney Injury KDIGO III
• -Acute nephritic syndrome
• -Hypertension grade 2
• -Leucocytosis
• -Hypoalbuminemia
 TREATMENT
- Oxygenation via mechanical ventilator
PCV mode
Pinsp 15
Fio2 100%
PEEP 5
RR 25
- Fluid requirement : IWL+ UO = 377 cc/day
Enteral: stop intake oral
Parenteral : dextrose 5%/intravenous
- Furosemide 24 mg/12 hours/intravenous
- Fentanyl 1 mcg/intravenous
- Midazolam 1 mcg/intravenous
 Planning
 Consult to Respirology division
 Consult to Nutrition and metabolic disease division
 Consult to Gatroenterohepatology division

 
THANK YOU