MR ASMA 14-15 desember.pptx onf indnoensa

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1. Morni n g Report December 14 th – 15 th 2022 Resident on D uty : ER + PICU/NICU Chief Resident: Tyas Isolation + Pediatric Ward Chief Resident: Rahmah Emergency Ward: Andrew PICU/NICU : Dhini , Galih Pediatric + Isolation Ward : Albert, Pepita , Evan, Fely Supervisor on D uty : dr. Arief Budiarto , Sp.A

2. Misi Departemen Ilmu Kesehatan Anak Fakultas Kedokteran ULM Menyelenggarakan pendidikan dokter dokter spesialis anak yang menghasilkan sumber daya manusia yang berkualitas , professional, dan berakhlak mulia Menyelenggarakan penelitian yang menghasilkan IPTEK Ilmu Kesehatan Anak yang berwawasan lingkungan lahan basah Menyelenggarakan pengabdian dan pelayanan kepada masyarakat terutama di bidang kesehatan berwawasan lingkungan lahan basah Melakukan kerjasama dengan pemerintah daerah , perguruan tinggi dalam dan luar negeri serta para pihak lainnya untuk peningkatkan pelaksanaan Tridharma Perguruan Tinggi Meningkatkan mutu Program Studi Pendidikan Dokter Spesialis Anak melalui peningkatan kualitas sarana dan prasarana Pendidikan Meningkatkan transparansi dan akuntabilitas dalam pengelolaan Program Studi Pendidikan Dokter Spesialis Anak 2

3. Visi Departemen Ilmu Kesehatan Anak Fakultas Kedokteran ULM Menjadi Program Studi Pendidikan Dokter Spesialis Anak yang unggul , terkemuka , dan berdaya saing khususnya di lingkungan lahan basah 3

4. New P atient s : 6 patient s 4

5. List New Patients 5 Pediatric Ward 1. M Fikri /M/ 11 y.o Heart failure NYHA III IV due to DCM 14 th Dec 22 17.00 Tulip 2A 2. Raina/F/1y.o Obs fever days 8 + diarrhea without dehydration + susp UTI 14 th Dec 22 18.00 Tulip 2A Emergency Ward 1. Ahmad Nabih /M/ 11 yr 7 m.o Moderate persistent Asthma + chronic sinusitis + moderate malnutrition 14 th Dec 22 14.00 Tulip 2A 2. Nuramda Safitri /F/1 y.o CAP + moderate malnutrition + low intake 14 th Dec 22 21.00 Tulip 2A 3. Dila Ristia /F/17 y.o Embryonal rhabdomyosarcoma + vaginal bleeding + anemia ec blood loss + obesity 14 th Dec 22 23.55 Tulip 3A 4. Muhammad zulkarnaen /M/14 y.o 14 th Dec 22 Neonatology Ward

6. List Remnant Patient 6 List Death Patient Emergency Ward 1. M. Rafif Fritzi Triathayya /M/ 9 yr 3 m.o Mild to Moderate Asthma Exacerbation ER 2. Raudaotul Jannah/F/8 y.o Acute Diarrhea with Mild to Moderate Dehydration ER 3. M. Rozqt Aditya/M/12 y.o Anmei + Susp Hemophillia A ER PICU

7. Identit y Nam e : AN Age : 11 years 7 months old Gender : Male No. RM : 01-51-75-09 Day of a dmission : December 14 th 2022 Address : Martapura 7

8. Pediatric Assessment Triangle Appearance (TICLS) Tonus : adequate Interactiveness : ade quate Consolability : consolable Look or gaze : eye contact ( + ) Speech : adequate Breathing Tachypnea (+), nasal flare (+), retraction (+) , cyanosis (-) Stridor (-) gargling (-) snoring (-) wheezing (+) tripod position (-) head bobbing (-) Circulation Pale ( - ) mottled ( - ) cyanosis ( - ) Conclusion: Respiratory Distress 8 N N ↑

9. Primary Survey Airway Patent, no snoring, gurgling (-) Breathing RR 32 times/min , regular breathing rhythm, SpO 2 95% without oxygen supplementation Nasal flare (+), retraction (+), wheezing (+) Circulation BP 110/80 mmHg, pulse 117 bpm, regular, adequate CRT < 2 seconds, pale (-), mottled (-) cyanosis (-) Disability E 4 M 5 V 6 = 15, light reflex (+) symmetrical, lateralization (-) Environment Body temperature 36,7ᴼC Conclusion : Respiratory Distress 9

10. Emergency Management 10 Performed IV access Oxygen supplementation 2 lpm via nasal canula Nebulization ventolin 1 respule Perform laboratory examination and chest x-ray Consult to supervisor in charge Patient brought to Ulin Hospital by parents with chief complaint shortness of breath since 3 day prior admission ( p.a ) . Patient’s g eneral condition was moderately ill, GCS: E 4 M 6 V 5 = 15, BP 110/80 mmHg (P 50 -P 90 ), pulse: 117 bpm regular and adequate , RR: 32x /minute regular, Temp : 36.7˚C, CRT <2 secs, SpO 2 95% without oxygenation supplementation. Wheezing (+) December 14 th 2022 14.00 WITA At observation, patient was stable with GCS: E 4 M 6 V 5 = 15, BP 100/70 mmHg (P 50 -P 90 ), pulse: 112 bpm regular and adequate , RR: 30x /minute regular, Temp : 36.8˚C, CRT <2 secs, SpO 2 99% with O2 nasal canula 1 Lpm. Wheezing (+) minimal Patient was stable and admitted to Pediatric Ward December 14 th 2022 20.30 WITA

11. History of present illness 11 3 day p.a Shortness of breath since 1,5 months p.a worsen since 3 days p.a , no bluish. Not relieved by changing position. Shortness of breath increased after patient walking or doing simple activity, not getting better with a nebulizer Ventolin. Heavy at night make agitated and difficult to sleep. Cough since 2 days p.a , sputum hard to expelled, whitish sputum, no blood, present rare, no specific time of day. With additional breathing sound “ ngik ngik ” Decreased of appetite Dysphagia since 1.5 months p.a worsen since 3 days p.a , often burp and reflux No runny nose, sore throat or ear discharge No fever No nausea and vomiting No abdominal pain and abdominal enlargement No unexplained weight loss No night sweat Normal defecation and urination At Ulin Hospital Shortness of breath still persist Cough still persist Additional breathing “ ngik-ngik ” still persist Decreased of appetite still persist Dysphagia still persist No fever No runny nose, sore throat, or ear discharge No nausea and vomiting No abdominal pain and abdominal enlargement No unexplained weight loss No night sweat Normal defecation and urination

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15. Pedigree Conclusion : Patient is the 3 rd child from 3 children. There is history of mother and uncle with asthma bronchiale . There is history of grandmother with dermatitis atopy. Patient’s father died due to sudden death Patient

16. Physical Examination (14/12/2022 at Tulip Ward 23.30 WITA) 16 P5 94/54 mmHg P50 106/65 mmHg P90 117/75 mmHg P95 101/54 mmHg P95+12 113/66

17. Organ Descriptions Head Normocephaly , dysmorphic face (-) thinning and brittle hair (-), old man’s face (-), facial edema (-), head bobbing (-) Eyes Pale conjunctiva ( - ) , palpebra edema (-), i cteric sclera (-) , isochor pupil 3 mm/3 mm, light reflex (+/+), exophthalmos (-), sunken eyes (-) ENT Ear discharge (-), nasal discharge (-) nasal flare (+) tonsil T1-T1, hyperemic pharynx (-), detritus (-), depression of nasal bridge (-), oral ulcer (-), cyanotic lips (-) maxillary hypertrophy (-), wet buccal mucosa Neck Lymph nodes enlargement (-) , mobile (-), pain (-) tender (-) nuchal rigidity (-), increase of JVP (-), tracheal tug (+) Mouth Dirty and whitish tongue (-) , stomatitis (-), oral trush (-), sub gingival bleeding (-) wet lip (+), cyanotic lips (-) , caries dentis (-) ,dirty tongue (-) Thorax Inspection : wasted ribs (-), subcostal retraction (+) , pectus carinatum (-), pectus excavatum (-) Palpation : symmetrical of vocal fremitus, no axilla lymph nodes enlargement Percussion : sonor at both lungs Auscultation : rales (-), muffled heart sound (-), vesicular (+), wheezing (+) on both lung , prolonged expiration (-), stridor inspiration (-) , Abdomen S oft, normal abdominal sound (+), tenderness (-), murphy sign (-), hepatosplenomegaly (-) , no palpable mass, shifting dullness (-), undulation (-) Inguinal Lymph nodes enlargement (-) Extremities Pale (-), Warm, CRT < 2 seconds, edema (-) spoon nail (-) muscle atrophy (-) BCG scar (+), no erythema palmaris, no telangiectasis, no mottled, baggy pants (-) Tanner G1 P2 A1 17 Physical Examinatio n

18. 18 Organ Descriptions Neurological Nuchal rigidity (-), Meningeal sign (-) , Brudzinski I (-), Brudzinski II (-), Kernig (-) M otoric strength 5555 | 5555 5555 | 5555 S ensoric hard to evaluated Patrick (-), contra Patrick (-), lass equ e (-) P hysiological reflex (biceps, triceps, knee, ankle) +2/+2 Pathologic reflex Babinski, Chaddock , Oppenheim, Hoffman Tromner ( - / - ) Spastic (-) clonus (-) Muscle tone (-) Atrophy on extremities muscle (-) Nervus Craniales N. I. Within normal limit N. II Afferent pupil reflex (+/+) N III, IV, VI Within Normal limit N V Within normal limit N VII Symmetrical face N VIII Within normal limit N IX/ X No hoarseness, dysphagia (-), no deviation of uvula N. XI Within normal limit N. XII Within normal limit

19. Anthropometric Status Body Weight : 35 kg Body Height : 150 cm Ideal Body Weight : 45 kg Height Age : 13 years Head circumference : 51 cm ( Normocephaly ) Arm circumference : 19 cm (P 10-25 ) CDC 2000 Growth Chart Weight/Age : P 25-50 Length/Age : P 50-75 Weight/Length : 78% 19 Normal weight, Normal stature, Moderate Malnutrition

20. Clinical Features 20 Nasal Flare (+) Subcostal Retraction (+)

21. 21 Clinical Features Tracheal Tug

22. TB Scoring 22 1 1 2 2

23. Rhinoscopy at Ulin Hospital (12/12/2022) Impression Normal patency of upper airway examination, no soft or hard tissue blockage in the airway, 23

24. Differential Diagnosis 24 Respiratory distress susp . R06.03 DD/ 1. Moderate persistent asthma J45.40 2. Sinobronchitis J42 3. Subglotic stenosis Q31.1 II. Susp . Chronic sinusitis J32.9 III. Moderate malnutrition E44.0

25. Working Diagnosis I. Moderate persistent asthma J45.40 II. Susp . Chronic sinusitis J32.9 III. Moderate malnutrition E44.0 25

26. Initial Management 26 Fluid & Nutrition IVFD D5 1/2 NS 1000 mL/24 hours Anti- inflamation IV Dexamethasone 3 x 5 mg Cough remedies PO (Salbutamol 2 mg + Ambroxol 15 mg) 3 x 1 Bronchodilator Nebu Combivent 1 resp /6 hours Nebu Pulmicort 3 resp /12 hours Planning Diagnostic CBC, CRP, ABG Planning Monitoring Vital sign, work of breathing Education Educate family about diagnosis, planning diagnosis, therapy and prognosis Consult to Respirology Division

27. 15/12/22 Referenced value Hb (g/dL) 15.3 11.5 - 15.5 Hematocrit (%) 37.5 35 - 45 RBC ( milion / ul ) 6.08 4.0-5.2 Leukocyte (/µL) 8.100 5.000 – 14.500 Thrombo cyte (/uL) 369.000 150.000 – 450.000 MCV ( fl ) 76.3 76.0 - 90.0 MCH ( pg ) 25.2 26.0 – 30.0 MCHC (g/dl) 33.0 32- 36 Neut % 76.4 33-76 Lymph % 16.6 15 - 61 Eosinofil % 2.1 1 - 3 AST (U/L) 39 20-60 ALT (U/L) 28 6- 50 Normal 27 Laboratory Findings at Ulin Hospital

28. Laboratory Findings at Ulin Hospital 28 15/12/2022 Referrence Value Blood Gas Analysis pH 7.385 7.35-7.45 pCO2 55.7 35-45 TCO2 33 22-29 pO2 163.0 80-100 HCO3 30.8 22-26 O2 Saturation 99 75-99 Base Excess 5.0 -2.0-3.0 Fully Compensated Acidosis Respiratory

29. Chest X-ray at Ulin Hospital (15/12/2022) AP/Lateral view No Infiltrate on right lung Cor: CTR 52%, normal size and shape Sharp costophrenic angle Normal diaphragm Bone intact Pulmo : normal bronchovascula patern Conclussion : Normal 29

30. Problem List Anamnesis Male, 11 years 7 months old Shortness of breath since 1.5 months p.a getting worsen in 3 day p.a. worsen when doing simple activity C ough since 2 day p.a. With additional breathing sound “ ngik-ngik ”. Dysphagia since 1.5 months p.a getting worsen in 3 days p.a , often burp and reflux History of hospitalization due to decrease of consciousness and use ventilators History mild to moderate persistent asthma decreased appetite since illness 30

31. Physical examination: Low oxygen saturation in room air Nasal flare (+) tracheal tug (+) s ubcostal retraction (+) Wheezing on auscultation (+) Normal weight, Normal stature, Moderate Malnutrition Laboratory Finding Normal Blood gas analysis  fully compensated respiratory acidosis Radiology Finding Normal x-ray 31 Problem List

32. Final Diagnosis I. Moderate persistent asthma J45.40 II. Susp . Chronic sinusitis J32.9 III. Moderate malnutrition E44.0 32

33. Final Management 33 Oxygenation Nasal 2 lpm Fluid & Nutrition IVFD D5 1/2 NS 1000 mL/24 hours RDA requirement : Calorie (60-70) x 45 kg = 2700 - 3150 kcal/day Protein 0.9 x 45 kg = 40.5 g/day Fluid = (70-85) x 35 = 2.450 – 2975 ml/day Fulfilled via Oral route with : Soft meal 3 x 600 kcal = 1800 kcal Snack 2 x 200 kcal = 400 kcal (81.48% RDA, PER 13.63 % ) Anti- inflamation IV Dexamethasone 3 x 5 mg Cough remedies PO (Salbutamol 2 mg + Ambroxol 15 mg) 3 x 1 Bronchodilator Nebu Combivent 1 resp /6 hours Nebu Pulmicort 3 resp /12 hours Planning Diagnostic Ig E total Planning Monitoring Vital sign, work of breathing Education Educate family about diagnosis, planning diagnosis, therapy and prognosis Consult to Respirology Division

34. Pediatric Nutrition Care 1. Assessment Normal weight, normal height, well nourished 2. Determination of calorie needs RDA requirement : Calorie (60-70) x 45 kg = 2700 - 3150 kcal/day Protein 0.9 x 45 kg = 40.5 g/day Fluid = (70-85) x 35 = 2.450 – 2975 ml/day 3. Fulfilled via Oral route 4. Determining type of food Soft meal 3 x 600 kcal = 1800 kcal Snack 2 x 200 kcal = 400 kcal (81.48% RDA, PER 13.63 % ) 5. Monitoring and evaluation Feeding tolerance, increase in body weight 34

35. 35 Total score: 1  Low Risk

36. Consult to Supervisor in Charge dr. Hana CE Sembiring , Sp.A Agree to current management and therapy Consult to Respirology Division 36

37. Follow Up December 15, 07.00 AM S : Fever (-) vomiting (-) , pain (-) , lesion (+), itchy (+) O : HR : 102 x/m (regular) RR : 24 x/m Temp : 37 C SpO2 98% with nasal canula 2 lpm Stridor (+) Retraction (+) Rales -/- Wh -/- A : I. Moderate persistent asthma J45.40 II. Susp . Chronic sinusitis J32.9 III. Moderate malnutrition E44.0 P : Planning Monitoring Vital sign, Planning Diagnostic : Ig E G : No respiratory distress Establish diagnosis I : IVFD D51/2 NS 1000 ml /day IV Dexamethasone 3 x 5 mg PO (Salbutamol 2 mg + Ambroxol 15 mg) 3 x 1 Nebu Combivent 1 resp /6 hours Nebu Pulmicort 3 resp /12 hours 37

38. 38 Thank You