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8/13/2019 TETRALOGY OF FALLOT LAPKAS
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CHAPTER 3
CASE REPORT
Name : Baby BC
Age : 2 months
Sex : Female
Date of Admission : March, 6th2013
Chief Complaint : Dyspnea
History :This has been happening to the patient since ten days ago,
shortness of breath not related to the activities (nursing) or weather.
Cough (+) has been experienced since five days ago, phlegm (+).
Fever (-), history of fever (+), high fever, fever decreased with fever medicines,
chills (-), seizures (-).
History of choking (+) has been experienced two weeks ago before cough and
dyspnoe, milk came out from nose.
History of vomiting (-).
History of contact with an infected person coughs long was denied.
History of pregnancy; the mother was thirty years old when pregnant, history of
recurrent fever(-), hypertension (-), diabetes mellitus (-), maternal age G4P3A1,
taking drugs (-), taking herbs (-),control routine of ANC (+).
History of birth; spontaneous, helped by midwife, crying soon after born (+),
bluish (-), infant birth weight not clear,injection of vit.K (+).
History of feeding :0-2 months of breastfeeding.
Immunization : BCG (+),Polio I(+)
History of previous illness: patientwas referral from RSU Pakpak Barat ,Dx:
pertusiss + Leukositosis
History of previous medications : Eritromicyn 4x 8 mg, Injection cefotaxim
250 mg/iv, IVFD 4:1 gtt /i
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Physical Examination
General ized status
Body weight: 4,6kg, Body length: 56 cm, Head circumtance 37 cm.
BW/BL: -2 < Z score < + 2 (normal)
BW/age:-2 < Z score < + 2 (normal)
BL/age : -2 < Z score < + 2 (normal)
Head circumtance : -2 < Z score < + 2 (normal)
Presens status
Sens.Compos Mentis, Body temperature: 37oC,Score down 3
Anemic (-). Icteric (-). Cyanosis (-). Edema (-). Dyspnea (++).
Locali zed status
Head :
Bulging Fontanella open flat,paleness inferior palpebra conjunctiva (-/-). Icteric
sclera (-). Light reflex (+/+). Isochoric pupil. Ear/Mouth: within normal limit.
Nose:Nostril breathing (+).
Neck: Lymph node enlargement (-).
Thorax: Symmetrical fusiformis. Chest retraction (+)epigastrial, intercostal. HR:
118 bpm, reguler, murmur (-). RR: 80x/i, reguler.Crackles (+/+) .
Abdomen:
Soepel.Peristaltic (+) normal.Liver/Spleen/Renalundeterminate.
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Extremities:
Upper extremities: Pulse 110x/i, regular, adequate pressure and volume,
warmacral, CRT < 2.
Lower extremities: oedem (-/-)
Urogenital:
Female, in normal range.
Differential Diagnosis
-Bronchopneumonia
- Bronchiolitis
Working Diagnosis:
- Bronchiolitis
Management:
- Bedrest- O2 nasal canul1 L/i- IVFD D5% NaCl 0,225% 10 gtt/i micro- Inj. Ampicilin250 mg / 8 hours/intravenous- Inj. Gentamycin 25 mg /24 hours/ intravenous- Diet breastfeeding 60cc/ 3 hours/ NGT
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Laboratory Results 6th
March 2013
Parameters Value Normal Value
Complete Blood Count
Hemoglobin 9,60 % 10,717,1 gr%
Hematocrite 29,00% 3852%
Erithrocyte 3,30 x 10 /mm 3,754,95 x 10 /mm
Leucocyte 42,53 x 10 /mm 6,017,5 x 10 /mm
Platelet 812.000 /mm 217.000497.000 /mm
MCV 96,00 fl 93115 fl
MCH 29,10 pg 2935 pg
MCHC 32,10 gr% 2834 gr%
RDW 16,00 % 14,918,7 %
Diftel
Neutrofil 47,10 % 37-80
Limfosit 41,80 % 20-40
Monosit 10,70 % 2-8
Eosinofil 0,30 % 1-6
Basofil 0,100 % 0-1
Glucose Metabolism
Blood Glucose ( sewaktu) 105,00 mg/dl < 200 mg/dl
Blood Gas Analysis Test
PH 7,391 7,35-7,45
pCo2 38,9mgHg 38-42 mgHg
pO2 126,6 mmHg 85-100 mmHg
Bicarbonate (HCO3) 23mmol/L 22-26 mmol/L
Total CO2 24,2mmol/L 19-25 mmol/L
BE -1,7mmol/L (-2)(+2) g/dL
Saturation O2 98,9 % 95-100%
Anemia: Normositik Normokrom + Leukositosis
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WHO Growth Chart Base on Weight for age Girls Birth to 5 years
Baby BC 2 months 4,9kg 56 cm
BW/age:-2 < Z score < + 2 ( normal )
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FOLLOW UP
March7t
, 2013
Dyspnea(+), fever (-)
Sens: CM, Temp: 37oC. Anemic (-), Icteric (-), Dyspoe (+), Edema (-), Cyanosis (-).
Body weight: 4,9 kg, Body length: 56 cm. BW/BL: -2 < Z score < + 2 (normal)
Head Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra
inferior (-/-).
Ear/Mouth: within normal limit
Nose: nostril breathing(+)
Thorax Simetris fusiformis. Retraction (+)epigastrial, intercostal . HR: 120 bpm,
reguler. Murmur (-).
RR: 80 x/i, regular.Additional sound: (+). Crackles (+/+) at both lungfields..
Abdomen Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Extremities Pulse 120 x/i, regular, adequate p/v, warmacral, CRT < 2.
Genital Female, in normal range.
Suspect Bronchopneumonia + Sepsis
Management:
- O2 nasal canul1 L/i- IVFD D5% NaCl 0,225% 10 gtt/i micro- Inj. Ampicilin250 mg / 8 hours/intravenous- Inj. Gentamycin 25 mg /24 hours/ intravenous- Diet breastfeeding 60cc/ 3 hours/ NGTMarch8
th, 2013
Dyspnea(+), fever (-)
Sens: CM, Temp: 37,2 oC. Anemic (-), Icteric (-), Dyspoe (+), Edema (-), Cyanosis (-).
Body weight: 4,9 kg, Body length: 56 cm. BW/BL: -2 < Z score < + 2 (normal)
Head Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebrainferior (-/-).
Ear/Mouth: within normal limit
Nose: nostril breathing(+)
Thorax Simetris fusiformis. Retraction (+)epigastrial, intercostal . HR: 120 bpm,
reguler. Murmur (-).
RR: 52 x/i, regular.Additional sound: (+). Crackles (+/+) at both lung
fields.
Abdomen Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Extremities Pulse 120 x/i, regular, adequate p/v, warmacral, CRT < 3.
Genital Female, in normal range,
Suspect Bronchopneumonia + Sepsis
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Management:
- O2 nasal canul1 L/i- IVFD D5% NaCl 0,225% 10 gtt/i micro- Inj. Ampicilin250 mg per 8 hours/intravenous (D2)- Inj. Gentamycin 25 mg per 24 hours/ intravenous (D2)- Diet breastfeeding 60cc/ 3 hours/ NGT- Nebule Nacl 0,9 % 2,5 cc / 8 hours
Plan :
- Consult Pediatric Sub-Division of respirology- Physiotherapy- Septic Workup ( CRP, Blood culture,procalcitonin)
Laboratorium Results (8th
March 2013)
PARAMETER Value Normal range
Imunoserologi
Autoimmune
CRP Kualititatif
negative
Other Test
Procalcitonin
0,17 ng/ml >0,05
>0,5 ng/ml low risk of septic shock
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Body weight: 4,9 kg, Body length: 56 cm. BW/BL: -2 < Z score < + 2 (normal)
Head Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra
inferior (-/-).Ear/Mouth: within normal limit
Nose: nostril breathing(+)
Thorax Simetris fusiformis. Retraction (+)epigastrial, intercostal . HR: 104 bpm,
reguler. Murmur (-).
RR: 50 x/i, regular.Additional sound: (+). Crackles (+/+) at both lung
fields..
Abdomen Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Extremities Pulse 124 x/i, regular, adequate p/v, warmacral, CRT < 3.
Genital Female, in normal range.
Modul of Respirology : DD.Bronchopneumonia/ bronchiolitis
Management:
- O2 nasal canul1 L/i- IVFD D5% NaCl 0,225% 10 gtt/i micro- Injection Dexa 0,8 mg/8 hours/iv- Nebule Nacl 0,9 % 2,5 cc + ventolin 1 resp/8 hours- Inj. Ampicilin250 mg per 8 hours/intravenous (D3)- Inj. Gentamycin 25 mg per 24 hours/ intravenous (D3)- Diet breastfeeding 60cc/ 3 hours/ NGT
Plan:
- Consult Pediatric Sub-Division of respirology- Physiotherapy
March 10th
, 2013
Dyspnea (+), fever (-) (+), fever (-)
Sens: CM, Temp: 36,7oC. Anemic (-), Icteric (-),Cyanosis (-).
Body weight: 4,9 kg, Body length: 56 cm. BW/BL: -2 < Z score < + 2 (normal)
Head Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra
inferior (-/-).Ear/Mouth: within normal limit
Nose: nostril breathing(+)
Thorax Simetris fusiformis. Retraction (+)epigastrial, intercostal . HR: 100 bpm,
reguler. Murmur (-).
RR: 60 x/i, regular.Additional sound: (+). Crackles (+/+) at both lung
fields..
Abdomen Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Extremities Pulse 100 x/i, regular, adequate p/v, warmacral, CRT < 3.
Genital Female, in normal range.
DD.Bronchopneumonia/ bronchiolitis
Management:
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- O2 nasal canul1 L/i- IVFD D5% NaCl 0,225% 10 gtt/i micro- Injection Dexa 0,8 mg/8 hours/iv- Nebule Nacl 0,9 % 2,5 cc + ventolin 1 resp/8 hours- Inj. Ampicilin250 mg per 8 hours/intravenous (D4)- Inj. Gentamycin 25 mg per 24 hours/ intravenous (D4)- Diet breastfeeding 60cc/ 3 hours/ NGT
March 10th
, 2013
Dyspnea (+), fever (-)Sens: CM, Temp: 36,7oC. Anemic (-), Icteric (-),Cyanosis (-).
Body weight: 4,9 kg, Body length: 56 cm. BW/BL: -2 < Z score < + 2 (normal)
Head Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra
inferior (-/-).
Ear/Mouth: within normal limit
Nose: nostril breathing(+)
Thorax Simetris fusiformis. Retraction (+)epigastrial, intercostal . HR: 100 bpm,
reguler. Murmur (-).
RR: 60 x/i, regular.Additional sound: (+). Crackles (+/+) at both lung
fields..
Abdomen Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.Extremities Pulse 100 x/i, regular, adequate p/v, warmacral, CRT < 3.
Genital Female, in normal range.
DD.Bronchopneumonia/ bronchiolitis
Management:
- O2 nasal canul1 L/i- IVFD D5% NaCl 0,225% 10 gtt/i micro- Injection Dexa 0,8 mg/8 hours/iv- Nebule Nacl 0,9 % 2,5 cc + ventolin 1 resp/8 hours- Inj. Ampicilin250 mg per 8 hours/intravenous (D4)- Inj. Gentamycin 25 mg per 24 hours/ intravenous (D4)- Diet breastfeeding 60cc/ 3 hours/ NGT
March 11t
, 2013
Dyspnea (+), fever (-)
Sens: CM, Temp: 36,7oC. Anemic (-), Icteric (-),Cyanosis (-).
Body weight: 4,9 kg, Body length: 56 cm. BW/BL: -2 < Z score < + 2 (normal)
Head Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra
inferior (-/-).
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Ear/Mouth: within normal limit
Nose: nostril breathing(+)
Thorax Simetris fusiformis. Retraction (+)epigastrial, intercostal . HR: 120 bpm,reguler. Murmur (-).
RR: 54 x/i, regular.Additional sound: (+). Crackles (+/+) at both lung
fields..
Abdomen Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Extremities Pulse 120 x/i, regular, adequate p/v, warmacral, CRT < 3.
Genital Female, in normal range.
DD.Bronchopneumonia/ bronchiolitis
Management:
- O2 nasal canul 1-2 L/i- IVFD D5% NaCl 0,225% 4 gtt/i micro- Injection Dexa 0,8 mg/8 hours/iv- Nebule Nacl 0,9 % 3 cc + ventolin 1 resp/8 hours- Inj. Ampicilin250 mg per 8 hours/intravenous (D5)- Inj. Gentamycin 25 mg per 24 hours/ intravenous (D5)- Diet breastfeeding 60cc/ 3 hours/ NGTChest Physiotherapy has been done.
March 12
nd
, 2013Dyspnea (+), fever (-)
Sens: CM, Temp: 36,8oC. Anemic (-), Icteric (-),Cyanosis (-).
Body weight: 4,9 kg, Body length: 56 cm. BW/BL: -2 < Z score < + 2 (normal)
Head Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra
inferior (-/-).
Ear/Mouth: within normal limit
Nose: nostril breathing(+)
Thorax Simetris fusiformis. Retraction (+)epigastrial, intercostal . HR: 98 bpm,
reguler. Murmur (-).
RR: 60 x/i, regular.Additional sound: (+). Crackles (+/+) at both lung
fields..
Abdomen Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Extremities Pulse 100 x/i, regular, adequate p/v, warmacral, CRT < 3.
Genital Female, in normal range.
Dd.Bronchopneumonia/ bronchiolitis
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Management:
- O2 nasal canul -1 L/i- IVFD D5% NaCl 0,225% 4 gtt/i micro- Injection Dexa 0,8 mg/8 hours/iv- Nebule Nacl 0,9 % 3 cc + ventolin resp/8 hours- Inj. Ampicilin250 mg per 8 hours/intravenous (D6)- Inj. Gentamycin 25 mg per 24 hours/ intravenous (D6)- Diet breastfeeding 60cc/ 3 hours/ NGT
March 13t , 2013
Dyspnea (+), fever (-)
Sens: CM, Temp: 37oC. Anemic (-), Icteric (-),Cyanosis (-).
Body weight: 5 kg, Body length: 56 cm. BW/BL: -2 < Z score < + 2 (normal)
Head Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra
inferior (-/-).
Ear/Mouth: within normal limit
Nose: nostril breathing(+)
Thorax Simetris fusiformis. Retraction (+)epigastrial, intercostal . HR: 96 bpm,
reguler. Murmur (-).RR: 54 x/i, regular.Additional sound: (+). Stridor(+/+).
Abdomen Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Extremities Pulse 56x/i, regular, adequate p/v, warmacral, CRT < 3.
Genital Female, in normal range.
Bronchiolitis
Management:
- O2 nasal canul -1 L/i- Injection Dexa 0,8 mg/8 hours/iv- Nebule Nacl 0,9 % 3 cc + ventolin resp/8 hours- Inj. Ampicilin250 mg per 8 hours/intravenous (D7)- Inj. Gentamycin 25 mg per 24 hours/ intravenous (D7)- Diet breastfeeding 60cc/ 3 hours/ NGT
Plan :
- Consult Pediatric Sub-Division of Cardiology ( screening), Hematology, Infection(Suspect Pertussis)
- Azithromicyn 2 x 40 mg
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March 14t
, 2013
Dyspnea (+), fever (-)
Sens: CM, Temp: 36,9oC. Anemic (-), Icteric (-).
Body weight: 5 kg, Body length: 56 cm. BW/BL: -2 < Z score < + 2 (normal)
Head Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra
inferior (-/-).
Ear/Mouth: within normal limit
Nose: nostril breathing(+)
Thorax Simetris fusiformis. Retraction (+)epigastrial, intercostal . HR: 100 bpm,
reguler. Murmur (-).
RR: 54 x/i, regular.Stridor (+/+) .
Abdomen Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Extremities Pulse 100 x/i, regular, adequate p/v, warmacral, CRT < 3.Genital Female, in normal range.
Bronchiolitis
Management:
- O2 nasal canul -1 L/i- IVFD D5% NaCl 0,225% 4gtt/i micro- Injection Dexa 0,8 mg/8 hours/iv- Nebule Nacl 0,9 % 3 cc + ventolin resp/8 hours- Inj. Ampicilin250 mg per 8 hours/intravenous (D8)- Inj. Gentamycin 25 mg per 24 hours/ intravenous (D8)- Inj.Ceftiaxone 250/12 hours/ivSkin test- Azithromicyn 2 x 40 mg- Diet breastfeeding 60cc/ 3 hours/ NGTVisite dr. Wisman Dalimunthe, Sp.A (K):
- Inj. Dexa 0,5 mg/8 hours/ iv (tapp.off)-
Nebule Nacl 0,9 % 3 cc/ 8 hours- Cek CBC, repeated AGDAAnswer Consult:
Consult Pediatric Sub-Division of infection :Diagnose :
- Clinis : Cough ShrillredCyanosis, vomiting (+)- Lab : Leukositosis, ELISAserum Ig G,Ig M,Ig A- DD: Spasmodik CoughBronchiolitis , Pertusis Like cough
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Th/ Appropriate with Pediatric Sub-Division of respirology
Suggestion: Imunisasi on schedule
Consult Pediatric Sub-Division of respirology :Thorax : Simetris fusiformis. Retraction (+)epigastrial, intercostal . HR: 124 bpm,
reguler. Murmur (-).
RR: 60 x/i, regular.Stridor (+/+) .
Abdomen :Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.
Extremities :Pulse 124 x/i, regular, adequate p/v, warmacral, CRT < 3.
A: Bronchiolitis + Suspect Pertusis
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CHAPTER 4
DISCUSSION AND SUMMARY
4.1.Discussion
There are a few involved in diagnosing TOF, among them are anamnesis,
Physical Diagnosis, Chest X-Ray, ECG and Echocardiography is the gold
standard in diagnosing TOF.
The growth and development of a child with TOF will be impaird
compared to normal children at the same age. Based on anamnesis, theres no
wight progress recorded form
4.2 Summary
A case was reported about a2 months old girls with 5 kg of body weight
and 56 cm of body length. Who was admitted in peadiatrics infection ward in
RSUP Adam Malik on 6th March 2013 with the diagnose of Broncholitis. The
patient was diagnosed based on history taking,physical examination The teraphythat was given for her was based on empiric antibiotics and supportive treatments.
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References
1. Quinn, T. The RCGP Journal for Associates in Training :Bronchiolitis.Available from http://ino.sagepub.com/content/4/7/379 accessed on 17
march 2013
2. Setiawati, L., Asih, R., Makmuri. Kapita Selekta Ilmu Kesehatan Anak IVHot Topics in Pediatrisc: Tata Laksana Bronkiolitis. FK Unair
Surabaya. 2005.
3. Scottish Intercollegiate Guidelines Network. Bronchiolitis in Children ANational Clinical Guidline. Available from:
http://www.sign.ac.uk/pdf/sign91.pdf.Accesed on March 10th 2013.
4. DeNicola, L.K. Bronchiolitis. Available from:http://emedicine.medscape.com/article.Accessed on March 10th 2013.
5. Antunes, H., Rodrigues, H., Silva, N., et al. Etiology of Bronchiolitis in AHospitalized Pediatric Population: Prospective Multicenter Study.
Elsevier: Journal of Clinical Virology 49. 2010
6.
Heidema, J., Kimpen, J.L., Bleek, G.M. Pathogenesis of respiratorysyncytial virus bronchiolitis, immunology and genetics. Horizon
Bioscience. 2005
7. Zorc, J.J and Hall, C.B. Bronchiolitis: Recent Evidence on Diagnosis andManagement. Available from:
http://pediatrics.aappublications.org/content/125/2/342.full.html. Accessed
on March 10th 2013
8. Archer, N.D. Guidelines for the management of bronchiolitis in children.United Bristol Healthcare. 2009.
9. Collin, P.T. and Graham, B.S. Viral and Host Factors in HumanRespiratory Syncytial Virus Pathogenesis. Journal Of Virology Vol 82 No
5. 2008
10.Ellen, M. Bronchiolitis in Kendigs Disorders of the Respiratory Tract inChildren 7thEdition. Elsevier Inc. 2006:423-429.
http://ino.sagepub.com/content/4/7/379http://ino.sagepub.com/content/4/7/379http://www.sign.ac.uk/pdf/sign91.pdfhttp://www.sign.ac.uk/pdf/sign91.pdfhttp://emedicine.medscape.com/articlehttp://emedicine.medscape.com/articlehttp://emedicine.medscape.com/articlehttp://emedicine.medscape.com/articlehttp://www.sign.ac.uk/pdf/sign91.pdfhttp://ino.sagepub.com/content/4/7/3798/13/2019 TETRALOGY OF FALLOT LAPKAS
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11.Everard, M.L. Respiratory Syncytial Virus Associated Lower RespiratoryTract Disease in Pediatric Respiratory Medicine 2nd Edition. Mosby Inc.
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12.Watts,K.D and Goodman,D.M. Wheezing in infants : Bronchiolitis inNelson Textbook of Pediatrics 18th Edition. Elsevier Inc. 2007 : 1773-
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