TETRALOGY OF FALLOT LAPKAS

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 (-).


Head Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebrainferior (-/-).





RR: 52 x/i, regular.Additional sound: (+). Crackles (+/+) at both lung

fields.



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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inferior (-/-).Ear/Mouth: within normal limit





fields..




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 (-).



inferior (-/-).Ear/Mouth: within normal limit





fields..




DD.Bronchopneumonia/ bronchiolitis

Management:


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March 10th

, 2013

Dyspnea (+), fever (-)Sens: CM, Temp: 36,7oC. Anemic (-), Icteric (-),Cyanosis (-).



inferior (-/-).






fields..

Abdomen Soepel. Peristaltic (+) normal. Liver/Spleen/Renal: undeterminate.Extremities Pulse 100 x/i, regular, adequate p/v, warmacral, CRT < 3.



Management:


March 11t

, 2013

Dyspnea (+), fever (-)




inferior (-/-).


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Thorax Simetris fusiformis. Retraction (+)epigastrial, intercostal . HR: 120 bpm,reguler. Murmur (-).


fields..





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 (-)




inferior (-/-).






fields..




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


Sens: CM, Temp: 37oC. Anemic (-), Icteric (-),Cyanosis (-).

Body weight: 5 kg, Body length: 56 cm. BW/BL: -2 < Z score < + 2 (normal)


inferior (-/-).




reguler. Murmur (-).RR: 54 x/i, regular.Additional sound: (+). Stridor(+/+).


Extremities Pulse 56x/i, regular, adequate p/v, warmacral, CRT < 3.


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


Sens: CM, Temp: 36,9oC. Anemic (-), Icteric (-).

Body weight: 5 kg, Body length: 56 cm. BW/BL: -2 < Z score < + 2 (normal)


inferior (-/-).





RR: 54 x/i, regular.Stridor (+/+) .


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,


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/4/7/379


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11.Everard, M.L. Respiratory Syncytial Virus Associated Lower RespiratoryTract Disease in Pediatric Respiratory Medicine 2nd Edition. Mosby Inc.

2008:491-499,

12.Watts,K.D and Goodman,D.M. Wheezing in infants : Bronchiolitis inNelson Textbook of Pediatrics 18th Edition. Elsevier Inc. 2007 : 1773-

1778.

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TETRALOGY OF FALLOT LAPKAS