1

CASE CONFERENCE
July 25th 2017

dr. Susi/ dr. Fitri/ dr. Indra/ dr. Patra/ dr. Devi
dr. Debby/dr. Anggra
dr. Pitra/ dr. Heru
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Patients Admission
Melati 2 Ward
1. J, girl, 1 years old, 5.7 kgs, with acyanotic congenital heart
disease, ASD, TR mild, secondary hyperthyroid, prolonged fever
due to suspected urinary tract infection dd TB dd TORCH infection,
Vomitting without dehidration, under-nourished, severe
underweight, severe stunted.
2. M, 5 years old, 20 kgs, with ALL L1 HR in 6th cycle of
chemotherapy, general symptomatic epilepsy, well-nourished.
Neonatal HCU (-)
Baby Mrs Y, 5 days old, 3.5 kgs, with early onset sepsis, multiple
congenital anomaly, neonate, boy, normal birth weight, aterm,
apropriate for gestasional age, delivered by C-section, outside
delivery.
NICU: ( - )
Melati 2 HCU (-)
PICU (-)
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Patient Identity
Name : baby mrs Y
Sex : male
Age : 5 days old
Address : Grobogan
Med. record : 01386596
Weight/Height : 3150 g/53 cm
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Chief Complain

Multiple congenital anomaly

Chief Complaint: newborn infant

There were
multiple
congenital
anomaly
Mother had such as:
routinel having
y supernum
checked erary
Four days before up her fingers or
admission pregnan toes,
a baby boy cy to defect
midwife characteri
was born zed by
from 16 y.o sac-like
mother, C- protrusion
section, A/S when the
s of the
Birth baby brain and
born
Chief Complaint: newborn infant

At
Patient got emerg
D10%, ency
Vicilin, room;
dexamet non
2 days before ashone vigoro
admis Norages, usly
sion, Ranitidin baby,
baby ,Sibital norma
was and l
seizur aminofus respir
e for in atory
30 effort,
minut muscl
Because of e tone
es,
limitation was
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Pregnancy and Delivery

During pregnancy,History
the mother routinely checked up her
pregnancy to midwife. She was given vitamin, and she
didnt consume any of medicine beside it.
Baby boy was born in full term pregnancy (37 weeks),
delivered by sectio caesarean delivery due to
cephalopelvic disproportion, cried vigorously, no
cyanosis or icteric was found and his birth weight was
3500 grams. There were multiple congenital
abnormality when he was born.

Conclusion: pregnancy history was normal and delivery

history was abnormal
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Vaccination History
Vaccination history
Hepatitis B1 :-

Conclusion : incomplete immunization, based on

Ministry of Healths schedule 2017
 PEDIGREE

II

III
Baby Mrs Y, male, 5 days old, 3500
grams
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Physical Examination
General appearance: moderately ill, fully alert, wellnourished
Vital Signs :
Heart rate : 138 bpm
Body temperature : 37.3 0C
Respiration rate : 38 bpm
Saturation : 93 %
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Head : mesocephal, mass (+), soft, cystic,

mobile, 1 cm in diameter
Face : dysmorphic (+)
Eyes : pale conjunctiva (-/-), icteric
conjunctiva(-/-), light reflex (+/+), isochoric
pupil 2 mm/2mm
Nose : nasal flare (-/-),discharge (-/-)
Mouth : wet lips, lips and tongue not cyanotic,
abnormal tongue.
Neck : no enlargement of lymph node
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LUNG:
I: normal, symmetric, no retraction
P: right fremitus = left fremitus
P: sonor in both lung
A: normal 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, no murmur
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ABDOMINAL:
I: abdominal wall // thorax wall
A: peristaltic in normal limit
P: tympani(+), shifting dullness (-), undulations(-)
P: splenomagaly (-), enlargement of liver (-)

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec,
and dorsalis pedis artery was strongly palpable.
Polydactyl (+) both in fingers and toes
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Laboratory Findings (July 25th 2017)

Hb : 17.9 g/dl Blood sugar : 61 mg/dl
HCT : 54 % albumine : 3.2 g/dl
AL : 9.7 thousand/ul Potasium : 5.6 mmol/L
AT : 168 thousand/ ul Sodium : 139 mmol/L
AE : 5.40 mil/ul
Calsium : 1.07 mmol/L
MCV : 100.7 /um
HbsAg Rapid : (-)
MCH : 33.1 pg
MCHC : 32.9 g/dl
Netrophyl: 77.60 %
Lymphocyte : 15.90%

Conclusion: Netrophylia, lymphocytopenia,

 LIST OF PROBLEMS

Male, neonate, 5 days old, 3150 grams, with :

Neonates with multiple congenital anomaly

history of Seizure
Mass in head, 1 cm in diameter, softly palpable, cys
tic
Dysmorfic face
tongue lessions
Polydactyl in both fingers and toes
Netrophylia, lymphocytopenia
1. Well-nourished normoweight normoheight
 DIFFERENTIAL DIAGNOSIS

1. Early onset sepsis

2. Multiple congenital anomaly
3. Neonate, boy, normal birth weight, aterm, a
propriate for gestasional age, delivered by
sectio caesarean due to cephalopelvic dyspr
oportion, outside delivery
 WORKING DIAGNOSIS

1. Early onset sepsis

2. Multiple congenital anomaly
3. Neonate, boy, normal birth weight, aterm, apropr
iate for gestasional age, delivered by sectio cae
sarean due to cephalopelvic dysproportion, outsi
de delivery
 THERAPIES

1. Admitted to Neonatal HCU

2. Formula milk on cue
3. IVFD D5 NS 13.8 ml/ hour
4. Ampicilin-sulbactam (100 mg/kg/day) 175 mg
/ 12 hours I.V
 PLANNING

1. Baby gram and extremities x-ray

2. Echocardiography examination
3. TSH and FT4 test examination
4. Blood culture examination
5. chest x-ray examination

MONITORING
General appearance/vital sign/sio2/3 hours
Fluid balance / 8 hours
FOLLOW UP
July, 26th 2017
Issues Multiple congenital anomaly

CNS not cry vigorously, not active in motion, spontaneously open

eyes (+)
Assessment: S3
I
Cardiovascular Heart rate : 140 x/minute
System Murmur (-) Capillary refill time < 2 seconds, dorsalis artery pulse
(+) strong palpable
Assessment: within normal limit
Respiratory Respiratory rate : 40 x/minute Si02 : 98%
System Retraction (-), Air entry (+), grunting (-), sianosis (-)
Downe score (0)
Assessment : within normal limit
GIT Hepatal Distended (-), defecation(-), peristaltic sound (+), vomit (-),
System icteric (-)
II
Assessment : within normal limit
Genitourinaria39th Urination (+) 34th
System Assessment: within normal limit
Infection Thermoregulation System Gastrointestinal Assessment: within
III
System 36.80C (-) System (-) normal limit
Central nervous
8 system Hematology System
(-) t (-)
3hari
Cardiovascular System
h (-) /3800gram
Hemodynamic
Respiratory System n(-) System(-)
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Localis status

1. Polydactyl in both fingers and toes

2. Mass in occipital region suspect meningocel
e
3. Dysmorphic face
4. Abnormal tongue
 WORKING DIAGNOSIS

1. Early onset sepsis

2. Polydactyl
3. Meningocele
4. Tongue fibroma
5. Neonate, boy, normal birth weight, aterm, apropr
iate for gestasional age, delivered by sectio cae
sarean due to cephalopelvic dysproportion, outsi
de delivery
 THERAPIES

1. Formula milk/ breast milk 15-20 ml/ 3 hour

s
2. IVFD D 12% = D5 NS 123 ml + D40% 20 ml +
KCL 1 meq + Ca Gluconas 2 ml + soluvit @ ml
= 149 ml/day= 6.2 ml/hour
3. Aminofusin 6% 52.5 ml/day = 2.2 ml/hour I.V
.
4. Lipofundin 20% 15.8 ml/day = 0.6 ml/hour I.
V
5. Ampicilin-sulbactam (100 mg/kg/day) 160 mg/
12 hours I.V
 PLANNING

1. Echocardiography examination
2. TSH and FT4 test examination
3. Blood culture examination
4. Head CT-scan examination

MONITORING
General appearance/vital sign/sio2/3 hours
Fluid balance / 8 hours
FOLLOW UP
July, 26th 2017
Issues Multiple congenital anomaly

CNS not cry vigorously, not active in motion, spontaneously open

eyes (+)
Assessment: S3
I
Cardiovascular Heart rate : 140 x/minute
System Murmur (-) Capillary refill time < 2 seconds, dorsalis artery pulse
(+) strong palpable
Assessment: within normal limit
Respiratory Respiratory rate : 40 x/minute Si02 : 98%
System Retraction (-), Air entry (+), grunting (-), sianosis (-)
Downe score (0)
Assessment : within normal limit
GIT Hepatal Distended (-), defecation(-), peristaltic sound (+), vomit (-),
System icteric (-)
II
Assessment : within normal limit
Genitourinaria39th Urination (+) 34th
System Assessment: within normal limit
Infection Thermoregulation System Gastrointestinal Assessment: within
III
System 36.80C (-) System (-) normal limit
Central nervous
8 system Hematology System
(-) t (-)
3hari
Cardiovascular System
h (-) /3800gram
Hemodynamic
Respiratory System n(-) System(-)
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Localis status

1. Polydactyl in both fingers and toes

2. Mass in occipital region suspect meningocel
e
3. Dysmorphic face
4. Abnormal tongue
 WORKING DIAGNOSIS

1. Early onset sepsis

2. Polydactyl
3. Meningocele
4. Tongue fibroma
5. Neonate, boy, normal birth weight, aterm, apropr
iate for gestasional age, delivered by sectio cae
sarean due to cephalopelvic dysproportion, outsi
de delivery
 THERAPIES

1. Formula milk/ breast milk 15-20 ml/ 3 hour

s
2. IVFD D 12% = D5 NS 123 ml + D40% 20 ml +
KCL 1 meq + Ca Gluconas 2 ml + soluvit @ ml
= 149 ml/day= 6.2 ml/hour
3. Aminofusin 6% 52.5 ml/day = 2.2 ml/hour I.V
.
4. Lipofundin 20% 15.8 ml/day = 0.6 ml/hour I.
V
5. Ampicilin-sulbactam (100 mg/kg/day) 160 mg/
12 hours I.V
 PLANNING

1. Echocardiography examination
2. TSH and FT4 test examination
3. Blood culture examination
4. Head CT-scan examination

MONITORING
General appearance/vital sign/sio2/3 hours
Fluid balance / 8 hours
FOLLOW UP
July, 27th 2017
Issues Multiple congenital anomaly

CNS not cry vigorously, not active in motion, spontaneously open

eyes (+)
Assessment: S3
I
Cardiovascular Heart rate : 140 x/minute
System Murmur (-) Capillary refill time < 2 seconds, dorsalis artery pulse
(+) strong palpable
Assessment: within normal limit
Respiratory Respiratory rate : 40 x/minute Si02 : 98%
System Retraction (-), Air entry (+), grunting (-), sianosis (-)
Downe score (0)
Assessment : within normal limit
GIT Hepatal Distended (-), defecation(-), peristaltic sound (+), vomit (-),
System icteric (-)
II
Assessment : within normal limit
Genitourinaria39th Urination (+) 34th
System Assessment: within normal limit
Infection Thermoregulation System Gastrointestinal Assessment: within
III
System 36.80C (-) System (-) normal limit
Central nervous
8 system Hematology System
(-) t (-)
3hari
Cardiovascular System
h (-) /3800gram
Hemodynamic
Respiratory System n(-) System(-)
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Localis status

1. Polydactyl in both fingers and toes

2. Mass in occipital region suspect meningocel
e
3. Dysmorphic face
4. Abnormal tongue
laboratory finding

TSH 6.87
FT4 13.7
 WORKING DIAGNOSIS

1. Early onset sepsis

2. Polydactyl
3. Meningocele
4. Tongue fibroma
5. Neonate, boy, normal birth weight, aterm, apropr
iate for gestasional age, delivered by sectio cae
sarean due to cephalopelvic dysproportion, outsi
de delivery
 THERAPIES

1. Formula milk/ breast milk 15-20 ml/ 3 hour

s
2. IVFD D 12% = D5 NS 123 ml + D40% 20 ml +
KCL 1 meq + Ca Gluconas 2 ml + soluvit @ ml
= 149 ml/day= 6.2 ml/hour
3. Aminofusin 6% 52.5 ml/day = 2.2 ml/hour I.V
.
4. Lipofundin 20% 15.8 ml/day = 0.6 ml/hour I.
V
5. Ampicilin-sulbactam (100 mg/kg/day) 160 mg/
12 hours I.V
 PLANNING

1. Echocardiography examination
2. Blood culture examination
3. Head CT-scan examination

MONITORING
General appearance/vital sign/sio2/3 hours
Fluid balance / 8 hours
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