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TETRALOGY OF FALLOT Supervisor : dr. Muhammad Ali, Sp.A(K) Presentator: Citra Aryanti 080100050 Marianto 080100112 CASE REPORT PEDIATRICS DEPARTMENT MEDICAL FACULTY UNIVERSITY OF SUMATERA UTARA HAJI ADAM MALIK GENERAL HOSPITAL CENTER MEDAN 2013

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Page 1: Presentasi Lapkas Tof

TETRALOGY OF FALLOTSupervisor : dr. Muhammad Ali,

Sp.A(K)

Presentator:

Citra Aryanti 080100050Marianto 080100112

CASE REPORT

PEDIATRICS DEPARTMENTMEDICAL FACULTY

UNIVERSITY OF SUMATERA UTARAHAJI ADAM MALIK GENERAL HOSPITAL CENTER

MEDAN 2013

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CHAPTER 1 CHAPTER 2 CHAPTER 3 CHAPTER 4

S

E

W

N

CHAPTER 1Introduction

CHAPTER 5

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CHAPTER 1 CHAPTER 3 CHAPTER 4CHAPTER 2

S

EW

N

chapter 2Literature Review

CHAPTER 5

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Management of TOF

Shunting and

surgery

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or

What surgery?

Single stage Double stage

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Types of shunting

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When to do surgery?

3 to 11 months

1-29 years

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Hypoxic spells

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Knee chest position

Oxygen 100%

Morphine 0,1-0,2 mg/kg i.m. or s.c

Fluid and acidosis correction

Propranolol  2-5 μg/kg0-20 μg/kg IV slow push

PhenylephrineKetamine

Managemet of hypoxic spells

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Complications

Cerebral

abscess

Bacterial

endocarditis

Stroke

Arrythmia, heart block

Heart block

Iron deficiency

anemia

Heart failur

e

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Prognosis

With corrective surgery

Cumulative survival was 94.4%

Without corrective surgery

30-35% die in the first year, 50% by

the third year

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CHAPTER 1 CHAPTER 2 CHAPTER 3 CHAPTER 4

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E

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CHAPTER 3Case Report

CHAPTER 5

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Personal Identity

Name : Muhammad ZuhriAge : 6 yearsSex : MaleMR : 54.21.61Address : Dusun I Desa Sartono Tebing TinggiDate of Admission : December, 25th 2012

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History TakingMZ, a 6 years old boy, weight 3.1 kg, height 98 cm, presented to Pediatrics Department at Haji Adam Malik General Hospital Center on December 25th 2012 at 16.00 with the main complaint history of bluish skin. Bluish skin was first experienced by the patient when he was 5 months. Bluish skin was found initially on the finger nail and spreaded slowly to the lips, head, and entire body.Shortness of breath was experienced by the patient all the time, especially when the patient was crying. Shortness of breath was not associated with the weather but strong associated with exertion. The child may play for only a short time before sitting or lying down. Once able to walk, the child often assumes a squatting position to catch his breath and then resumes physical activity within a few minutes.

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The patient also encounter an easy of fatiguability. The child usually tires easily and begins panting with any form of exertion. The patient found it comfortable to curl at sleep and rest. History of frequently discontinued breast feeding was found. The patient often experienced rapid worsening shortness of breath along with dizziness and muscle rigidity while sometimes ended with syncope. Frequency 2-3 times a day and each attack lasted 5-20 minutes. Since 5 years old, the attack was decreasing in frequency (1-2 times in a week). Patient used squatting position to relieve his breath. This complaint mostly appeared when the patient was crying, feeding, dan waking up in the morning.The parents also felt that the patient was shorter than his peers. Urination and defecation were within normal limit. Cough and fever was not found. History of family experienced the same complaint was not found.

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History of Previous illness: the patient was previously admitted to a general hospital at Tebing Tinggi with the same complaint five years ago. The patient was diagnosed with the heart disease by the general physician. Diagnosis was made by history and physical examination. Physicians there referred the patient to Haji Adam Malik Hospital but the patient refused to came by. History of Previous medication: unknown herbs.

History of Pregnancy: the patient’s mother pregnant at age 28. Patient was the third child in his family. Antenatal care was never done by his mother. His mother felt very easily tired and weak when the pregnancy but never consult physicians for the complaint. No history of fever, infection, drugs, herbs and alcohol consumption was found. The mother was exposed to cigarette smoke when the pregnancy since his father was a smoker. History of stillbirth was not found.

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History of Birth: the patient was born at the family’s house and assisted by a nurse. Gestational age was 37 weeks. Patient was delivered on spontaneous labor and cried immediately. No icteric and cyanosis. Birth weight was 3,100 grams, birth length was not measured, and history of cyanosis was not found during the birth.

Feeding HistoryBirth-6 months : Breast milk, formula milk, and rice

porridge6-9 months : Breast milk, formula milk, rice

porridge, and soft rice9 months-2 years : Breast milk, formula milk, rice

porridge, and soft rice2 years-until now : Formula milk and family food

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History of Growth and DevelopmentSitting : 12 monthsCrawling : 18 monthsStanding : 24 monthsTalking : 24 months Walking : 60 monthsReading : hasn’t been sent to school yet

Developmental screening test on this patient:• The patient can recognize colors well• The patient can’t hopping on one foot several times• The patient can’t write, draw, and read well• The patient hardly able to maintain balance when standing on one

foot• The patient also hardly to answer some questions wellIt concluced that the patient has development delay.

History of Immunization: BCG, DPT (1x), measles, polio (1x)

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Physical Examination

PRESENCE STATUSSensorium : compos mentisBP : 100/60 mmHgHR : 110 bpmRR : 30 x/minTemperature : 37oC. Anemic (-), dyspnea (+), cyanotic (+), edema (-), icteric (-).

ANTROPOMETRIC STATUSBody weight (BW): 14 kgBody length (BL): 98 cm.CDC: BW/Age: 67%, BL/Age: 84%, BW/BL: 93%.

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EYE : light reflex (+/+), isochoric pupil 3 mm, inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-). NOSE: nasal flaring (+)

EARS : within normal limitsMOUTH : lips cyanosis (+), cyanotic tongue (+), oral candidiasis (-), atrophy papilla (-)NECK : Lymph node enlargement (-)

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Anterior PosteriorInspection Symmetrical fusiform

Ictus cordis unvisibleSymmetrical fusiform

Palpation Lungs : Tactile fremitus right=left, normal impression

Lungs: right=left, normal impression

Heart : Iktus kordis (+)

Percussion Lungs : Resonant in both lungs Lungs: Resonant in both lungs

Heart border

: Superior : ICR III sinistraRight : LSDLeft : 1 cm medial

LMCSAuscultation Lungs : respiratory sounds vesicular,

no additional soundrespiratory sounds vesicular, no additional soundHeart : single S2 heart sound,

murmur (+), systolic ejection murmur grade III/VI

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ABDOMENInspection : symmetricalPalpation : soepel, no palpation pain, H/L/R: not palpable

Perkusi : tympanicAuskultasi : normoperistaltic

EKSTREMITYSuperior : sianosis (+/+), clubbing finger (+/+)Inferior : sianosis (+/+), clubbing finger (+/+), pretibial

edema(-/-), pulsasi arteri (+/+), regular, pressure/volume adequate, CRT <2 seconds

Acral : warm

GENITALIAMale, within normal limit.

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BLOOD LABORATORY ANALYSISComplete Blood Count Result Unit Referral

Hb 22.2 gr% 11.3 – 14.1WBC 16.39 x 103/mm³ 4.5 – 13.5RBC 9.61 x 106/mm³ 4.40 – 4.48Hematocrite 71 % 37 – 41 PLT 105 x 10³/mm³ 150 – 450 MCV 73.9 fL 81 – 95 MCH 23.1 Pg 25 – 29 MCHC 31.3 g% 29 – 31 RDW 25.4 % 11.6 – 14.8 Neutrophil 83.1 % 37 – 80 Lymphocyte 12.8 % 20 – 40 Monocyte 3.8 % 2 – 8 Eosinophil 0.1 % 1 – 6 Basophil 0.2 % 0 – 1

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Blood Gas Analysis Result Unit Referral

pH 7.189 7.35-7.45

pCO2 22.2 mmHg 38-42

pO2 79.0 mmHg 85-100

Bicarbonat 8.3 mmol/L 22-26

Total CO2 9.0 mmol/L 19-25

BaseExcess -17.9 mmol/L (-2) - (+2)

O2 Saturation 90.9 % 95 – 100

Conclusion:severe acidocis metabolic with partial compensation, normoxemiaElectrolyte Result Unit ReferralSodium 142 mEq/L 135-155Kalium 4.1 mEq/L 3.5-5.5Chloride 113 mEq/L 96-106

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CHEST X-RAYAsymmetrical photo, heart enlarged with upward apex, aorta arch elongated, decreased pulmonary vascularity was found, both hillus was blurred, hillus position was in the center, diaphragm and costophrenicus sinus angle was sharp. Bones was intact and normal.Conclusion: Congenital heart disease with increased vascularity

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Electrocardiography

Sinus rhythm, QRS rate 135 bpm, QRS axis: left axis deviation, P pulmonale (+), PR interval 0,16 s, QRS pathologist on lead I and aVL, ST-T changes (+), T tall (+) on V3 and V5, LVH (-).

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DIAGNOSIS

Differential Diagnosis: Cyanotic Congenital Heart Disease ec. dd/ 1. Tetralogy of fallot 2. Transposition of great artery 3. Pulmonary atresia + failure to thrive Temporary Diagnosis: Cyanotic congenital heart disease ec. tetralogy of fallot + failure to thrive

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TREATMENT• Bed rest, knee chest position• Regular meals 1500 kcal with 28 gram protein• Urine catheter• O2 1-2 L/i nasal cannule• IVFD D5% NaCl 0,45% 100 gtt/i micro• Lactulac syr 2 x Cth II (if necessary)• Work up: balance every 6 hours, urine disptick• Plan: Echocardiography, consultation to pediatric cardiology

module

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Follow up 26th December 2012 (Day 2) S : Blusih skin (+), shortness of breath (+) O : sens=compos mentis BP=100/60 mmHg, HR=92 x/i, RR=28 x/i, T=36,8°C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm,

inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-)

Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral

candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2

cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus

left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border.

Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable

Extremities : pulse 92 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+).

A : Cyanotic congenital heart disease ec. dd/ 1. TOF + failure to thrive 2. TGA 3. Pulmonary atresia

P : - - - - -

Bed rest, knee chest position Regular meals 1500 kcal with 28 gram protein O2 2 L/i nasal cannule IVFD D5% NaCl 0,45% 100 gtt/i micro Lactulac syr 2 x Cth I (if necessary)

Blood laboratory analysis Test Result Unit Referral Complete blood count Hb 21.4 gr% 11.3 – 14.1 WBC 8.96 x 103/mm³ 4.5 – 13.5 RBC 6.96 x 106/mm³ 4.40 – 4.48 Hematocrite 65.5 % 37 – 41 PLT 114 x 10³/mm³ 150 – 450 MCV 73.1 fL 81 – 95 MCH 23.9 pg 25 – 29 MCHC 32.7 g% 29 – 31 RDW 25 % 11.6 – 14.8 Neutrophil 54.8 % 37 – 80 Lymphocyte 34.7 % 20 – 40 Monocyte 7.9 % 2 – 8 Eosinophil 1.9 % 1 – 6 Basophil 0.7 % 0 – 1

Fluid balance (06.00) Input= IVFD + Diet = 450 cc + 100 cc = 450 cc Output= IWL + UOP = 70 cc + 250 cc = 320 cc Balance= Input – Output = 450 cc – 320 cc = 130 cc Fluid requirement for the next 6 hours = 300 cc – 130 cc = 170 cc (12.00) Input= IVFD + Diet = 350 cc + 150 cc = 500 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input – Output = 500 cc – 170 cc = 330 cc Fluid requirement for the next 6 hours = 300 cc – 330 cc = -30 cc (18.00) Input= IVFD + Diet = 350 cc + 200 cc = 550 cc Output= IWL + UOP = 70 cc + 125 cc = 195 cc Balance= Input – Output = 550 cc – 195 cc = 335 cc Fluid requirement for the next 6 hours = 300 cc – 335 cc = -35 cc Urine disptick (18.00) leu (-), nit (-), uro 0,2, pro ±, pH 5, blo (-), SG 1,02, ket (-), bil (-), glu (-)

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Follow up 27th December 2012 (Day 3) S : Blusih skin (+), shortness of breath (+) O : sens=compos mentis BP=100/70 mmHg, HR=108 x/i, RR=28 x/i, T=36,5°C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm,

inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-)

Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral

candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2

cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus

left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border.

Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable

Extremities : pulse 108 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+).

A : Cyanotic congenital heart disease ec. dd/ 1. TOF + failure to thrive 2. TGA 3. Pulmonary atresia

P : - - - - - -

Bed rest, knee chest position Regular meals 1500 kcal with 28 gram protein O2 2 L/i nasal cannule IVFD D5% NaCl 0,45% 100 gtt/i micro Propranolol 4 x10 mg Lactulac syr 2 x Cth II (if necessary)

Plan: echocardiography, phlebomtomy

Fluid balance (00.00) Input= IVFD + Diet = 100 cc + 200 cc = 300 cc Output= IWL + UOP = 70 cc + 250 cc = 320 cc Balance= Input - Output = 300 cc - 320 cc = -20 cc (06.00) Input= IVFD + Diet = 100 cc + 100 cc = 200 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input – Output = 200 cc – 170 cc = 30 cc Fluid requirement for the next 6 hours = 300 cc - 30 cc = 270 cc (12.00) Input= IVFD + Diet = 100 cc + 100 cc = 200 cc Output= IWL + UOP = 70 cc + 50 cc = 120 cc Balance= Input – Output = 200 cc – 120 cc = 80 cc Fluid requirement for the next 6 hours = 300 cc - 80 cc = 220 cc (18.00) Input= IVFD + Diet = 200 cc + 150 cc = 350 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 350 cc - 170 cc = 180 cc Fluid requirement for the next 6 hours = 300 cc - 180 cc = 120 cc Urine dipstick (00.00) leu (-), nit (-), uro 0,2, pro ±, pH 5, blo (-), SG 1,005, ket (-), bil (-), glu (-) (12.00) leu (-), nit (-), uro 0,2, pro +, pH 6, blo (-), SG 1,015, ket (-), bil (-), glu (-) (18.00) leu (-), nit (-), uro 0,2, pro +, pH 6, blo (-), SG 1,025, ket (-), bil (-), glu (-)

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Follow up 28th December 2012 (Day 4) S : Blusih skin (+), shortness of breath (+) O : sens=compos mentis BP=90/60 mmHg, HR=110 x/i, RR=24 x/i, T=36,7°C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm,

inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-)

Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral

candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2

cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus

left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border.

Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable

Extremities : pulse 110 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+).

A : Cyanotic congenital heart disease ec. dd/ 1. TOF + failure to thrive 2. TGA 3. Pulmonary atresia

P : - - - - - -

Bed rest Regular meals 1500 kcal with 28 gram protein O2 2 L/i nasal cannule IVFD D5% NaCl 0,45% 50 gtt/i micro Propranolol 4 x10 mg Lactulac syr 2 x Cth II (if necessary)

Fluid balance (00.00) Input= IVFD + Diet = 100 cc + 150 cc = 350 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 350 cc - 170 cc = 180 cc Fluid requirement for the next 6 hours = 300 cc - 180 cc = 120 cc (06.00) Input= IVFD + Diet = 50 cc + - = 50 cc Output= IWL + UOP = 70 cc + - = 70 cccc Balance= Input - Output = 50 cc - 70 cc = -20 cc Fluid requirement for the next 6 hours = 300 cc + 20 cc = 320 cc (12.00) Input= IVFD + Diet = 100 cc + 100 cc = 200 cc Output= IWL + UOP = 70 cc + 250 cc = 320 cc Balance= Input - Output = 200 cc - 320 cc = -120 cc Fluid requirement for the next 6 hours = 300 cc + 120 cc = 420 cc (18.00) Input= IVFD + Diet = 200 cc + 100 cc = 300 cc Output= IWL + UOP = 70 cc + 250 cc = 320 cc Balance= Input - Output = 300 cc - 320 cc = -20 cc Fluid requirement for the next 6 hours = 300 cc + 20 cc = 320 cc Urine dipstick (00.00) leu (-), nit (-), uro 0,2, pro ±, pH 5, blo (-), SG 1,005, ket (-), bil (-), glu (-) (12.00) leu (-), nit (-), uro 0,2, pro +, pH 6, blo (-), SG 1,015, ket (-), bil (-), glu (-) (18.00) leu (-), nit (-), uro 0,2, pro +, pH 6, blo (-), SG 1,025, ket (-), bil (-), glu (-)

Echocardiography today

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Results of echocardiographyThe echocardiogram revelead severe infundibular pulmonary stenosis with a large but mild alignment ventricular septal defect and a large aortic override (>50%). There was no patent ductus arteriosus, no pericardial effusion, and no collateral image.Conclusion: tetralogy of fallot.

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Follow up 29th December 2012 (Day 5) S : Blusih skin (+), shortness of breath (+)↓ O : sens=compos mentis BP=100/70 mmHg, HR=100 x/i, RR=22 x/i, T=36°C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm,

inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-)

Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral

candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2

cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus

left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border.

Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable

Extremities : pulse 100 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+).

A : Tetralogy of fallot + failure to thrive P : -

- - - - -

Bed rest, knee chest position Regular meals 1500 kcal with 28 gram protein O2 2 L/i nasal cannule IVFD D5% NaCl 0,45% 50 gtt/i microaff Propranolol 4 x10 mg Lactulac syr 2 x Cth II (if necessary)

Plan: cardiac catheterization, phlebotomy

Fluid balance (00.00) Input= IVFD + Diet = 100 cc + 100 cc = 200 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input – Output = 200 cc – 170 cc = 30 cc Fluid requirement for the next 6 hours = 300 cc - 30 cc = 270 cc (06.00) Input= IVFD + Diet = 100 cc + 0 cc = 100 cc Output= IWL + UOP = 70 cc + 50 cc = 120 cc Balance= Input - Output = 100 cc - 120 cc = -20 cc Fluid requirement for the next 6 hours = 300 cc + 20 cc = 320 cc (12.00) Input= IVFD + Diet = 50 cc + 120 cc = 170 cc Output= IWL + UOP = 70 cc + 50 cc = 120 cc Balance= Input - Output = 170 cc - 120 cc = 50 cc Fluid requirement for the next 6 hours = 300 cc - 50 cc = 250 cc (08.00) Input= IVFD + Diet = 100 cc + 100 cc = 200 cc Output= IWL + UOP = 70 cc + 50 cc = 120 cc Balance= Input - Output = 200 cc - 120 cc = 80 cc Fluid requirement for the next 6 hours = 300 cc - 80 cc = 220 cc Urine dipstick (06.00) leu (-), nit (-), uro 0,2, pro ±, pH 5, blo (-), SG 1,020, ket (-), bil (-), glu (-)

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Follow up 30th December 2012 (Day 6) S : Blusih skin (+), shortness of breath (+)↓ O : sens=compos mentis BP=100/70 mmHg, HR=98 x/i, RR=22 x/i, T=36,3°C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm,

inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-)

Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral

candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2

cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus

left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border.

Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable

Extremities : pulse 98 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+).

A : Tetralogy of fallot + failure to thrive P : -

- - - - -

Bed rest Regular meals 1500 kcal with 28 gram protein IVFD D5% NaCl 0,45% 50 gtt/i microaff O2 2 L/i nasal cannule (if necessary) Propranolol 4 x 10 mg Lactulac syr 2 x Cth II (if necessary)

Plan: cardiac catheterization, phlebotomy

Fluid balance (00.00) Input= IVFD + Diet = - + 200 cc = 200 cc Output= IWL + UOP = 70 cc + 50 cc = 120 cc Balance= Input - Output = 200 cc - 120 cc = 80 cc Fluid requirement for the next 6 hours = 300 cc - 80 cc = 220 cc (06.00) Input= IVFD + Diet = - + 200 cc = 200 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 200 cc - 170 cc = 30 cc Fluid requirement for the next 6 hours = 300 cc - 30 cc = 270 cc (12.00) Input= IVFD + Diet = - + 120 cc = 120 cc Output= IWL + UOP = 70 cc + 50 cc = 120 cc Balance= Input - Output = 120 cc - 120 cc = 0 cc Fluid requirement for the next 6 hours = 300 cc - 0 cc = 300 cc (18.00) Input= IVFD + Diet = - + 250 cc = 250 cc Output= IWL + UOP = 70 cc + 300 cc = 370 cc Balance= Input - Output = 250 cc - 370 cc = -120 cc Fluid requirement for the next 6 hours = 300 cc + 120 cc = 420 cc Urine dipstick (06.00) leu (-), nit (-), uro 0,2, pro ±, pH 5, blo (-), SG 1,020, ket (-), bil (-), glu (-)

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Follow up 31st December 2012 (Day 7) S : Blusih skin (+), shortness of breath (+)↓ O : sens=compos mentis BP=100/70 mmHg, HR=104 x/i, RR=28 x/i, T=36,3°C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm,

inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-)

Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral

candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2

cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus

left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border.

Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable

Extremities : pulse 104 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+).

A : Tetralogy of fallot + failure to thrive P : -

- - - -

Bed rest, knee chest position Regular meals 1500 kcal with 28 gram protein O2 2 L/i nasal cannule (if necessary) Propranolol 4 x 10 mg Lactulac syr 2 x Cth II (if necessary)

Plan: cardiac catheterization, phlebotomy

Fluid balance (00.00) Input= IVFD + Diet = - + 100 cc = 100 cc Output= IWL + UOP = 70 cc + 300 cc = 370 cc Balance= Input - Output = 100 cc - 370 cc = -270 cc Fluid requirement for the next 6 hours = 300 cc + 270 cc = 570 cc (06.00) Input= IVFD + Diet = - + 175 cc = 200 cc Output= IWL + UOP = 70 cc + 25 cc = 95 cc Balance= Input - Output = 200 cc - 95 cc = 105 cc Fluid requirement for the next 6 hours = 300 cc - 105 cc = 195 cc (12.00) Input= IVFD + Diet = - + 300 cc = 300 cc Output= IWL + UOP = 70 cc + 150 cc = 220 cc Balance= Input - Output = 300 cc - 220 cc = 80 cc Fluid requirement for the next 6 hours = 300 cc - 80 cc = 220 cc (18.00) Input= IVFD + Diet = - + 200 cc = 200 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 200 cc - 170 cc = 30 cc Fluid requirement for the next 6 hours = 200 cc - 30 cc = 170 cc Urine dipstick (06.00) leu (-), nit (-), uro 0,2, pro ±, pH 5, blo (-), SG 1,010, ket (-), bil (-), glu (-)

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Follow up 1st January 2013 (Day 8) S : Blusih skin (+), shortness of breath (+)↓ O : sens=compos mentis BP=100/70 mmHg, HR=100 x/i, RR=26 x/i, T=36,5°C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm,

inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-)

Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral

candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2

cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus

left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border.

Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable

Extremities : pulse 100 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+).

A : Tetralogy of fallot + failure to thrive P : -

- - - -

Bed rest Regular meals 1500 kcal with 28 gram protein O2 2 L/i nasal cannule (if necessary) Propranolol 4 x 10 mg Lactulac syr 2 x Cth II (if necessary)

Plan: cardiac catheterization, phlebotomy

Fluid balance (00.00) Input= IVFD + Diet = - + 200 cc = 200 cc Output= IWL + UOP = 70 cc + 150 cc = 220 cc Balance= Input - Output = 200 cc - 220 cc = -20 cc Fluid requirement for the next 6 hours = 300 cc + 20 cc = 320 cc (06.00) Input= IVFD + Diet = - + 100 cc = 100 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 100 cc - 170 cc = 270 cc Fluid requirement for the next 6 hours = 100 cc - 270 cc = -170 cc (12.00) Input= IVFD + Diet = - + 200 cc = 200 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 200 cc - 170 cc = 30 cc Fluid requirement for the next 6 hours = 300 cc - 30 cc = 270 cc (18.00) Input= IVFD + Diet = - + 200 cc = 200 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 200 cc - 170 cc = 30 cc Fluid requirement for the next 6 hours = 200 cc - 30 cc = 170 cc Urine dipstick (06.00) leu (-), nit (-), uro 0,2, pro ±, pH 6, blo (-), SG 1,015, ket (-), bil (-), glu (-)

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Follow up 2nd January 2013 (Day 8) S : Blusih skin (+), shortness of breath (+)↓ O : sens=compos mentis BP=100/70 mmHg, HR=98 x/i, RR=28 x/i, T=36,5°C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm,

inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-)

Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral

candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2

cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus

left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border.

Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable

Extremities : pulse 98 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+).

A : Tetralogy of fallot + failure to thrive P : -

- - - -

Bed rest, knee chest position Regular meals 1500 kcal with 28 gram protein O2 2 L/i nasal cannule (if necessary) Propranolol 4 x 10 mg Lactulac syr 2 x Cth II (if necessary)

Plan: cardiac catheterization, phlebotomy

Fluid balance (00.00) Input= IVFD + Diet = - + 100 cc = 100 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 100 cc - 170 cc = -70 cc Fluid requirement for the next 6 hours = 300 cc + 70 cc = 370 cc (06.00) Input= IVFD + Diet = - + 100 cc = 100 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 100 cc - 170 cc = 270 cc Fluid requirement for the next 6 hours = 100 cc - 270 cc = -170 cc (12.00) Input= IVFD + Diet = - + 300 cc = 300 cc Output= IWL + UOP = 70 cc + 200 cc = 270 cc Balance= Input - Output = 300 cc - 270 cc = 30 cc Fluid requirement for the next 6 hours = 300 cc - 30 cc = 270 cc (18.00) Input= IVFD + Diet = - + 250 cc = 200 cc Output= IWL + UOP = 70 cc + 150 cc = 220 cc Balance= Input - Output = 200 cc - 220 cc = 20 cc Fluid requirement for the next 6 hours = 200 cc + 20 cc = 220 cc Urine dipstick (06.00) leu (-), nit (-), uro 0,2, pro ±, pH 6, blo (-), SG 1,020, ket (-), bil (-), glu (-)

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Follow up 3rd January 2013 (Day 8) Blusih skin (+), shortness of breath (+)↓ sens=compos mentis BP=100/70 mmHg, HR=98 x/i, RR=24 x/i, T=36,1°C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm,

inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-)

Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral

candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2

cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus

left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border.

Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable

Extremities : pulse 98 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+).

Tetralogy of fallot + failure to thrive - - - - -

Bed rest Regular meals 1500 kcal with 28 gram protein O2 2 L/i nasal cannule (if necessary) Propranolol 4 x 10 mg Lactulac syr 2 x Cth II (if necessary)

Plan: cardiac catheterization, phlebotomy

Fluid balance (00.00) Input= IVFD + Diet = - + 100 cc = 100 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 100 cc - 170 cc = -70 cc Fluid requirement for the next 6 hours = 300 cc + 70 cc = 370 cc (06.00) Input= IVFD + Diet = - + 200 cc = 200 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 200 cc - 170 cc = 30 cc Fluid requirement for the next 6 hours = 300 cc - 30 cc = 270 cc (12.00) Input= IVFD + Diet = - + 250 cc = 250 cc Output= IWL + UOP = 70 cc + 300 cc = 370 cc Balance= Input - Output = 250 cc - 370 cc = -120 cc Fluid requirement for the next 6 hours = 300 cc + 120 cc = 420 cc (18.00) Input= IVFD + Diet = - + 300 cc = 300 cc Output= IWL + UOP = 70 cc + 250 cc = 320 cc Balance= Input - Output = 300 cc - 320 cc = -20 cc Fluid requirement for the next 6 hours = 300 cc + 20 cc = 320 cc Urine dipstick (06.00) leu (-), nit (-), uro 0,2, pro ±, pH 6, blo (-), SG 1,020, ket (-), bil (-), glu (-)

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Follow up 4th January 2013 (Day 9) S : Blusih skin (+), shortness of breath (+)↓, fever (+) O : sens=compos mentis BP=100/70 mmHg, HR=92 x/i, RR=24 x/i, T=37,9°C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm,

inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-)

Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral

candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2

cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus

left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border.

Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable

Extremities : pulse 92 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+).

A : Tetralogy of fallot + failure to thrive P : -

- - - - -

Bed rest, knee chest position Regular meals 1500 kcal with 28 gram protein O2 2 L/i nasal cannule (if necessary) Propranolol 4 x 10 mg Paracetamol 3 x 150 mg Lactulac syr 2 x Cth II (if necessary)

Plan: cardiac catheterization and phlebotomy on 7th January 2013

Fluid balance (00.00) Input= IVFD + Diet = - + 100 cc = 100 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 100 cc - 170 cc = -70 cc Fluid requirement for the next 6 hours = 300 cc + 70 cc = 370 cc (06.00) Input= IVFD + Diet = - + 250 cc = 250 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 250 cc - 170 cc = 80 cc Fluid requirement for the next 6 hours = 300 cc - 80 cc = 220 cc (12.00) Input= IVFD + Diet = - + 300 cc = 300 cc Output= IWL + UOP = 70 cc + 300 cc = 370 cc Balance= Input - Output = 300 cc - 370 cc = -70 cc Fluid requirement for the next 6 hours = 300 cc + 70 cc = 370 cc (18.00) Input= IVFD + Diet = - + 200 cc = 200 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 200 cc - 170 cc = 30 cc Fluid requirement for the next 6 hours = 200 cc - 30 cc = 170 cc Urine dipstick (06.00) leu (-), nit (-), uro 0,2, pro ±, pH 6, blo (-), SG 1,020, ket (-), bil (-), glu (-)

Blood laboratory test for cardiac catheterization preparation Test Result Unit Referral Complete blood count Hb 22.1 gr% 11.3 – 14.1 WBC 7.72 x 103/mm³ 4.5 – 13.5 RBC 9.57 x 106/mm³ 4.40 – 4.48 Hematocrite 70.4 % 37 – 41 PLT 70 x 10³/mm³ 150 – 450 MCV 73.6 fL 81 – 95 MCH 23.1 pg 25 – 29 MCHC 31.4 g% 29 – 31 RDW 26.2 % 11.6 – 14.8 Neutrophil 61.4 % 37 – 80 Lymphocyte 25.3 % 20 – 40 Monocyte 9.1 % 2 – 8 Eosinophil 3.4 % 1 – 6 Basophil 0.8 % 0 – 1 Liver function test Total bilirubin 0.71 mg/dL < 1 Direct bilirubin 0.46 mg/dL 0-0.2 ALP 210 U/L <269 AST/SGOT 83 U/L <38 ALT/SGPT 10 U/L <41 Renal function test Ureum 35 mg/dL <50 Creatinin 0.33 mg/dL 0.32-0.59 Uric Acid 9.5 mg/dL <7.0 Immunoserologic HbsAg Negative Cut off index > 10 Anti-Hbs Negative Positive Anti HAV IgM Negative Negative < 1.0 Anti HCV Negative Cut off index > 10

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Follow up 5th January 2013 (Day 10) S : Blusih skin (+), shortness of breath (+)↓, fever (-) O : sens=compos mentis BP=100/70 mmHg, HR=88 x/i, RR=24 x/i, T=36°C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm,

inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-)

Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral

candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2

cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus

left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border.

Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable

Extremities : pulse 88 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+).

A : Tetralogy of fallot + failure to thrive P : -

- - - - -

Bed rest Regular meals 1500 kcal with 28 gram protein O2 2 L/i nasal cannule (if necessary) Propranolol 4 x 10 mg Paracetamol 3 x 150 mg (if necessary) Lactulac syr 2 x Cth II (if necessary)

Plan: cardiac catheterization and phlebotomy on 7th January 2013

Fluid balance (00.00) Input= IVFD + Diet = - + 100 cc = 100 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 100 cc - 170 cc = -70 cc Fluid requirement for the next 6 hours = 300 cc + 70 cc = 370 cc (06.00) Input= IVFD + Diet = - + 200 cc = 200 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 200 cc - 170 cc = 30 cc Fluid requirement for the next 6 hours = 300 cc - 30 cc = 270 cc (12.00) Input= IVFD + Diet = - + 250 cc = 250 cc Output= IWL + UOP = 70 cc + 300 cc = 370 cc Balance= Input - Output = 250 cc - 370 cc = -120 cc Fluid requirement for the next 6 hours = 300 cc + 120 cc = 420 cc (18.00) Input= IVFD + Diet = - + 100 cc = 100 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 100 cc - 170 cc = 270 cc Fluid requirement for the next 6 hours = 300 cc - 270 cc = -170 cc Urine dipstick (06.00) leu (-), nit (-), uro 0,2, pro ±, pH 6, blo (-), SG 1,015, ket (-), bil (-), glu (-)

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Follow up 6th January 2013 (Day 12) S : Blusih skin (+), shortness of breath (+)↓, fever (-) O : sens=compos mentis BP=100/70 mmHg, HR=98 x/i, RR=26 x/i, T=36,8°C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm,

inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-)

Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral

candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2

cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus

left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border.

Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable

Extremities : pulse 98 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+).

A : Tetralogy of fallot + failure to thrive P : -

- - - -

Bed rest Regular meals 1500 kcal with 28 gram protein O2 2 L/i nasal cannule (if necessary) Propranolol 4 x 10 mg Lactulac syr 2 x Cth II (if necessary)

Plan: cardiac catheterization and phlebotomy on 7th January 2013

Preparation for cardiac catheterization 1. Informed consent 2. Antibiotic prophylaxis cefotaxime 50 mg/kg (700 mg for this patient) ½ - 1

hour before catheterization 3. Fasting min. 4 hours before catheterization Blood laboratory analysis Test Result Unit Referral Hemostatic test Bleeding time 4’30’’ minutes <5 PT + INR Protrombin time

Control 13.3 seconds Patient 21.2 seconds

INR 1.64 APTT

Control 31.7 seconds Patient 35.5 seconds

Trombin time Control 18.3 seconds Patient 16.8 seconds

Fluid balance (00.00) Input= IVFD + Diet = - + 100 cc = 100 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 100 cc - 170 cc = -70 cc Fluid requirement for the next 6 hours = 300 cc + 70 cc = 370 cc (06.00) Input= IVFD + Diet = - + 200 cc = 200 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 200 cc - 170 cc = 30 cc Fluid requirement for the next 6 hours = 300 cc - 30 cc = 270 cc (12.00) Input= IVFD + Diet = - + 250 cc = 250 cc Output= IWL + UOP = 70 cc + 300 cc = 370 cc Balance= Input - Output = 250 cc - 370 cc = -120 cc Fluid requirement for the next 6 hours = 300 cc + 120 cc = 420 cc (18.00) Input= IVFD + Diet = - + 100 cc = 100 cc Output= IWL + UOP = 70 cc + 100 cc = 170 cc Balance= Input - Output = 100 cc - 170 cc = 270 cc Fluid requirement for the next 6 hours = 100 cc - 270 cc = -170 cc Urine dipstick (06.00) leu (-), nit (-), uro 0,2, pro ±, pH 6, blo (-), SG 1,010, ket (-), bil (-), glu (-)

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Follow up 7th January 2013 (Day 13) S : Blusih skin (+), shortness of breath (+)↓ O : sens=compos mentis BP=100/70 mmHg, HR=88 x/i, RR=24 x/i, T=36,5°C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm,

inferior conjuctiva palpebra hyperemia/hyperemia, icteric sclera (-/-)

Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral

candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2

cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus

left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border.

Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable

Extremities : pulse 88 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+).

A : Tetralogy of fallot + failure to thrive P : -

- - - - - - -

Bed rest, knee chest position Fasting for catheterization from 04.00 O2 2 L/i nasal cannule (if necessary) Three way IVFD NaCl 0,9% 50 gtt/i (micro) Inj. cefotaxime 700 mg/12 hours (day 1) (started 07.30) Propranolol 4 x 10 mg Lactulac syr 2 x Cth II (if necessary)

Cardiac catheterization and phlebotomy today

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Cardiac catheterization report (08.48-09.27) Angiography:Hand injection at innominate vein: no persistent left subclavian veinRight ventricle: large VSD, aortic overriding, severe infundibular pulmonary stenosis, LPA 7,5 mm, RPA 8,5 mmAortogram: good coronary artery postion, no collateral, no patent ductus arteriosus

Conclusion : Tetralogy of fallotNakata index 168, Mc Goon ratio 1,31

Note: During procedure, 150 cc blood has been taken (phlebotomy)

Advice:Keep following until the patient fully awake

Watchout for bleeding at puncture siteContinue cefotaxime i.v. for total 2 days

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Follow up 8th January 2013 (Day 14) S : Post cardiac catheterization day 1, Blusih skin (+), shortness of breath

(+)↓ O : sens=compos mentis BP=90/70 mmHg, HR=128 x/i, RR=32 x/i, T=38°C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm,

inferior conjuctiva palpebra normal, icteric sclera (-/-)

Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral

candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2

cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus

left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border.

Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable

Extremities : pulse 128 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+).

A : Tetralogy of fallot + failure to thrive P : -

- - - - - - - -

Bed rest Regular meals 1500 kcal with 28 gram protein O2 1-2 L/i nasal cannule Three way IVFD NaCl 0,9% 20 gtt/i (micro) Inj. cefotaxime 700 mg/12 hours (day 2) Propranolol 4 x 10 mg Paracetamol 3 x 150 mg Lactulac syr 2 x Cth II (if necessary)

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Follow up 9th January 2013 (Day 15) S : Post cardiac catheterization day 1, Blusih skin (+), shortness of breath

(+)↓, fever (-) O : sens=compos mentis BP=90/70 mmHg, HR=98 x/i, RR=26 x/i, T=36,5°C Head : Eyes : light reflex (+/+), isochoric pupil 3 mm,

inferior conjuctiva palpebra normal, icteric sclera (-/-)

Nose : nasal flaring (+), eutrophy concha Ears : within normal limits Mouth : lips cyanosis (+), cyanotic tongue (+), oral

candidiasis (-), atrophy papilla (-) Neck : lymph node enlargement, jugular venous pressure R+2

cmH2O Thorax : symmetric fusiform, retraction (-); tactile fremitus

left=right, normal impression; percussion resonant in both lungs; respiratory sound vesicular, no additional sound; ictus cordis unvisible; single S2 heart sound, murmur (+), systolic ejection murmur grade III/VI on upper left sternal border.

Abdomen : soepel, epigastric pain (-), normoperistaltic; liver, spleen, and renal are not palpable

Extremities : pulse 98 bpm, regular, adequate pressure/volume, warm axilla, capillary refill time <3, clubbing fingers (+) digiti manus and pedis, cyanosis (+).

A : Tetralogy of fallot + failure to thrive P : -

- - - - - - - -

Bed rest, knee chest position Regular meals 1500 kcal with 28 gram protein O2 1-2 L/i nasal cannuleaff Three wayaff IVFD NaCl 0,9% 20 gtt/i (micro)aff Inj. cefotaxime 700 mg/12 hoursaff Propranolol 4 x 10 mg Paracetamol 3 x 150 mg Lactulac syr 2 x Cth II (if necessary)

Patient was discharged from hospital on 9th January 2013 because he was referred to

Jakarta for surgical preparation and intervention.

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CHAPTER 1 CHAPTER 2 CHAPTER 3 CHAPTER 4

S

EW

N

CHAPTER 4Discussion

CHAPTER 5

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TETRALOGY OF FALLOTSupervisor : dr. Muhammad Ali,

Sp.A(K)

Presentator:

Citra Aryanti 080100050Marianto 080100112

CASE REPORT

PEDIATRICS DEPARTMENTMEDICAL FACULTY

UNIVERSITY OF SUMATERA UTARAHAJI ADAM MALIK GENERAL HOSPITAL CENTER

MEDAN 2013