New Case-Cap. Ma
New Case-Cap. Ma
New Case-Cap. Ma
RESPIROLOGY DIVISION
(New Case)
March 26th, 2022
MEDICAL DIAGNOSIS
Community Acquired Pneumonia + Bilateral Pneumonia +Acyanotic congenital heart
disease et causa VSD + ASD + Cytomegalovirus Infection + Rubella Infection + Down
Syndrome DD Congenital Hypotiroid+ Mycrochepal + Immunization Delay +Nutritional
Marasmus
HISTORY TAKING
Chief Complaint
Shortness Of Breath
History of Present Illness
A boy 8 month was admitted to the hospital with complaints of shortness of breath since 1 day
prior to hospital. There was cough since 2 days prior to hospital. No cyanosis.
There was fever since 3 days prior to hospital, decrease with fever medication. No seizures.
No vomiting.
Urination: yellow, smooth,
Defecation: normal, yellow
History of Past Illness HISTORY TAKING
There was no history of contact with adult pulmonary tuberculosis or patients with
chronic cough
No contact with covid 19 patient
No history of cough for more than 3 weeks
No history of fever for more than 2 weeks
No history of weight loss, there was history of difficulty gaining weight.
There was history of taking paracetamol.
History of treatment at the Wahidin Sudirohusodo Hospital at polyclinic (23/03/2022) with
a diagnosis of Cytomegalovirus Infection + Asianotic Congenital Heart Disease et Causa
Ventricular Septal Defect + Atrial Septal Defect + Down's Syndrome. Getting therapy with
Captopril/oral, Furosemide/oral and Valgancyclovir/oral
Pregnancy history; HISTORY TAKING
Pregnant mother with her 4 child, 40 years old. Regular check-ups with doctors and health
centers and regularly consume blood and vitamin supplements. There was no history of
fever, urinary tract infection and vaginal discharge during pregnancy. There was no history
of DM, hypertension and asthma during pregnancy.
Birth history:
Baby was born normal, cried immediately, full term, birth weight 2700 grams, forget the
birth length .
Breastfeeding history:
The child has been breastfeeding and formula milk since birth until now
History of Vaccine
Frequency
Vaccine Not given 0 1 2 3 4
Hep B √
BCG √
DPT √ √
Hib √
OPV √
IPV √
MMR √
Rotavirus √
Influenza √
Japanese Encephalitis √
PCV √
Varicella √
Hepatitis A √
Tifoid v
PHYSICAL EXAMINATION
Vital Sign Antropomethry
General condition: Severe Body weight : 5,2 kg
ill/Malnutrition/GCS 15 (E4M6V5) Height : 68 cm
Respiration Rate : 36 times/min Head circumference : 37 cm (42 – 47) microchepal
Heart Rate : 120 beats/min Weight for Height : Malnutrition
Temperature : 37,8 °C Weight for Age : Severely Underweight
Saturation : 99% via Nasal Canule Length for Age : Normal Stature
Head circumference :
37 cm ( 42- 47 cm)
Microcephal
Weight for age:
< -3 SD
Severely Underweight
Height for age:
Weight-2
Between forSD
Height : wasted
and Median
UnderStature
Normal -3 SD
Weight for height:
< -3 SD
Malnutrition
There was Dismorfic Face
PHYSICAL EXAMINATION
Abdomen
There was low set ear Peristaltic sound : normal
Pulmo
Tuberculosis Score
There was subcostal retraction
Contact : 0
Bronchovesicular breath sounds.
Mantoux : not yet
There was Rales minimal on both pulmo
Nutrition : 2
no wheezing.
Fever: 0
Cardiovascular
Cough : 0
Regular I / II heart sound, there was ejection systolic
Lymphadenopathy : 0
murmur
Joint swelling : 0
Chest X-ray: 0. Total: 2 not yet mantoux
LABORATORY FINDING
March 26th 2021
Laboratory Normal Value
(Wahidin)
150.000 –
PLT 559.000
400.000/mm3
MCH 25 27 - 32 Pg
Ureum 14 10 - 50 mg/dl
Impression :
• Bilateral Pneumonia
• Soft Tissue Mass Parahilar Dextra DD Thymus
• Bilateral Minimal Pleural Effusion
Echocardiography 17/12/2021
Impression :
- Perimembranous VSD L to R shunt
- ASD secondary L to R shunt
- Mild PR
- Mild TR
- Cor Triatriatum sinistra
- L V systolic function is good
- RV systolic function is good
ASSESMENT
• Community Acquired Pneumonia
• Bilateral Pneumonia
• Acyanotic congenital heart disease et causa VSD + ASD
• Cytomegalovirus Infection
• Rubella Infection
• Down Syndrome DD Congenital Hypotiroid
• Mycrochepal
• Immunization Delay
• Nutritional Marasmus
PLANNING
• Oxygenation 3 liter/minute via nasal canule
• Fluid requirement : 530 cc/24 hours – 20% respiratory distress = 424 cc/24 hours
• Stop Intake Oral
• NGT
• Parenteral : 424 cc/24 hours
• Infusion KAEN 3B/intravenous
• Paracetamol/intravenous (when temperature more than 38,5 0C)
• 1) Ampicilin/intravenous
• 1) Gentamicin/intravenous
• Captopril/Sonde
• Furosemid/Sonde
• Valgancyclovir/Oral (Pending)
PLANNING
• Consult for Infections and Tropical Diseases division
• Consult for Nutrion and metabolic disease division
• Consult for Endocrinology division
• Consult for Cardiology division
• Consult for Neurology division
THANK YOU