Case Conference

Tuesday, FEBRUARY 13th, 2018

dr. Dinar/ dr. Eddy/ dr. Sekar/ dr. Ahimsa/ dr. Anin/ dr. Dayat
dr. Disa/ dr. Anggra
dr. Connie/ dr. Ida

1
 PATIENT ADMISSION

• NICU: -
• HCU Neonatus:
• Melati:
• R, 13 y.o, 37 kg, with Steroid resistance Nephrotic Syndrome, Hypertension
stage 2, Acute pharyngitis, well-nourished
• J, 1.5 y.o, 10,3 kg,with paraplegia due to ATM DD GBS DD SCI , well-
nourished
• NICU: -
• HCU Melati 2:
• PICU: -
• ER:
2
 IDENTITY

Name :J
Sex : Female
Age/Wt/L : 1 years 5 months/ 10,3 kg / 79
cm
Sex : Female
Address : Banjarsari, Surakarta
Medical : 01409088
Record 3
 CHIEF COMPLAINT
Lower limb weakness

4
 THE CURRENT MEDICAL HISTORY

• Patient got lower limb One week before

weakness since 20 hours admission
before admission, started
in the morning, after she
woke up. Her upper • Patient got diarrhea,
extremities move 4-5 times a day,
normally. waterry diarrhea. Her
• She fell everytime she mother gave her Lacto
tried to get up B
• There were no vomittes, • Diarrhea got improved
no nausea., no pain, no in 3 days.
cough, no fever. • No vomit, urinate was
• No seizure, urinary and like before
defecate within normal
limit
1 days before
admission
5
 AT ER

Patient looked fussy, no fever,no vomit, no diarrhea.

She couldn’t stand with both of her legs.
Her last urinate was 3 hours before and last defecate was 1
day before.

THE PAST MEDICAL HISTORY

• History of same illness : (-)

• History of trauma : (-)
• History of diarreha : (+) a week ago
6
 THE FAMILY MEDICAL HISTORY

• History of limb weakness : (-)

7
 HISTORY OF PREGNANCY AND DELIVERY
Pregnancy
The patient is the 3rd child of her family. She was born from a 32 years
old mother, G3P2A0, at 39th weeks of gestational age. Her mother
consumed vitamins from a doctor. According to the mother, she had
routinely check up to the doctor and midwife. There was no history of
hospital admission during pregnancy.

Delivery
The patient was delivered spontaneously with midwife assistance. There
was no complication during procedure. The baby was crying vigourously,
weighed 3200 grams and 50 cms in length, the amniotic fluid was clear.

Conclusion : the pregnancy and delivery history was normal

8
 VACCINATION HISTORY

BCG : 1 month
Hepatitis Bo : 0 month
DPT-HB-HiB : 2,3,4 months
Polio I-IV : 1,2,3,4 months
Measles : 9 months

Conclusion : Complete Immunization, appropriate with

Ministry Of Health 2013

9
 PEDIGREE

II

III

J, 1yo 5 mo , 10,3 kgs 10

 NUTRITIONAL HISTORY

Patient eats 2-3 times a day, with porridge, eat snack, and also milk 3-
4 times a day.
Conclusion: nutrition status is adequate

GrowthGROWTH
and Development History
AND DEVELOPMENT
She is now 1 year 5 mo. She can walk, run, grab something around
her, and say 2 words before she got sick. Her weight is 10,3 kg with
body height 79 cm.
Conclusion: appropriate for her age

11
 NUTRITIONAL STATUS

W/A : 0 SD < W/A < +2 SD Normoweight

H/A : -2 SD < H/A < 0 SD Normoheight
W/H : 0 SD < W/H < +1 SD Wellnourished

Conclusion :
Wellnourished, normoweight, normoheight (WHO)

12
 PHYSICAL EXAMINATION
GA : moderately ill, compos mentis, E4V5M6
VS : Heart rate: 130 bpm Temp: 36.5oC
Resp. rate : 28 bpm BP: 90/60 mmHg
SiO2 : 99%
Head : normocephal , HC= 49 cm (0 SD< HC<+2SD)
Eyes : pale conjunctiva -/-, icteric sclera -/-, isocoric
pupil (2mm/2mm), light reflexes (+/+)
Nose : nasal flares (-), nasal discharge (-)
Mouth : cyanosis (-), hyperemic pharynx (-)
Ears : Ear discharge -/-
Neck : Lymph node enlargement (-)
Chest : Symmetrical in shape and movement, chest indrawing (-)
13
Cor : I : Ictus cordis did not appear
P : Ictus cordis was not palpable
P : no sign of heart border enlargement
A : heart sounds I-II normal intensity, regular, murmur(-),
Pulmo: I : symmetrical movement (+)
P: fremitus sounds hard to evaluate
P: sonor / sonor
A: vesicular breath sounds +/+ , additional breath sound (-/-)
Abd : I : abdominal wall equals to chest wall
A : peristaltic sound (+) normal
P : tympanic sound
P : supel, liver and spleen no enlargement, empty bladder
Extremity : Cold extremities: -/-
-/-
Strong palpable of dorsal pedis artery
CRT < 2”

14
 NEUROLOGICAL EXAMINATION

Physiologic Reflex Pathological Reflex Meningeal Reflex

Biceps +2/+2 Babinsky -/- Nuchal rigidity -
Triceps +2/+2 Chaddock -/- Kernig -
Patella +1/+1 Gordon -/- Brudzinsky I/II -/-
Achilles +1/+1 Oppenheim -/-
Schaffer -/-

Clonic Spastic Laterali- motor sensory

zation
- - - - 5555 5555 + +
(-)
- - - - 1111 1111 + +
 NEUROLOGICAL EXAMINATION

Olfactory Nerve (I) : cannot be evaluated yet.

Opticus Nerve (II) : isochoric pupil, Light reflex -/+, funduscopy
not performed
Occulomotorius Nerve (III), N. Trochlear (IV), N. Abduscens (VI):
Eye movement cannot be evaluated, pupils at center, no strabismus -
Trigeminus Nerve (V) : corneal reflex (+/+)
Facialis (VII) : symmetric face
Accustikus (VIII) : hearing and balance test not performed
Glossopharyngeus (IX) : hard to evaluate
Vagus nerve : voice (+)
Accsesorius (XI) : no shoulder paralyzed found
Hypoglossus : hard to evaluate

16
February 14th 2018 LABORATORY FINDING
Value Reference Units
Hemoglobin 11.3 12.3-15.3 g/dl
Hematocrit 34 33-45 %
Leucocyte 5.7 4.5-14.5 x103/ul
Thrombocyte 379 150-450 x103/ul
Erythrocyte 5.00 3.8-5.8 x106/ul
MCV 67.8 80.0-96.0 /um
MCH 22.6 28.0-33.0 pg
MCHC 33.3 33.0-36.0 g/dl
RDW 16.9 11.6-14.6 %
MPV 8.3 7.2-11.1 fl
PDW 16 25-65 %
Eosinophil 0.7 0.00-4.00 %
Basophil 0.2 0.00-1.00 %
Neutrophil 40.9 29.00-72.00 %
Lymphocyte 50.10 33.00-48.00 %
Monocyte 6.1 0.00-7.00 %
17
February 14th 2018 LABORATORY FINDING
Value Reference Units
RBG 74 60-100 mg/dl
Sodium 138 132-145 mmol/L
Potassium 4.3 3.1-5.1 mmol/L
Chloride 105 98-106 mmol/L
Calcium 1.31 1.17-1.29 mmol/L
Creatinine 0.3 0.5-1.0 mg/dl
Ureum 19 <48 mg/dl

Microcytic hypochromic anemia

18
 RESUME
A girl, 1 years old 5 mo, 8.3 kgs with:
1. Limb weakness
2. History of diarrhea
3. No history of trauma
4. No fever
5. No seizure
6. Motor strength decrease
7. No sensory involvement in lower extremities
8. Physiologic reflexes examination decrease
9. Microcytic hypochromic anemia

19
 DIFFERENTIAL DIAGNOSIS

1. Acute Flacid Paralysis due to suspected Acute

Transverse Myelitis (G37.3) DD Guillain Barre
Syndrome (G61.0) DD Acute Flaccid Myelitis (G81.00)
DD Spinal Cord Injury (S14.109A) DD Poliomyelitis
(Z86.12)
2. Microcytic hypochromic anemia due to iron deficiency
(D50.9) DD infection process (D63.8)

20
 WORKING DIAGNOSIS

1. Acute Flacid Paralysis due to suspected for Acute

Transverse Myelitis (G37.3)
2. Microcytic hypochromic anemia due to suspected for
iron deficiency anemia (D50.9)
3. Well-nourished (Z71.3)

21
 THERAPY
1. Admitted to neurological ward
2. Diet rice 1000 kcal/day
3. IVFD D51/4NS 40 ml/hour
4. High dose methylprednisolone (30 mg/kgBW/day) =
300 mg/day (for 3 days) intravenously

22
 PLAN
1. Urinalysis and stool analysis (routine and polio stool test)
2. Lumbar puncture
3. Contrasted spinal cord MRI
4. Electromyography and nerve conduction study
5. Iron status examination and peripheral blood smear

MONITORING
 General Appearance/Vital Signs/SiO2/BP/8 hour
 Observation of ascending motor plegia and sensory
involvement 23
 FOLLOW UP FEBRUARY 14TH 2018
Subjective: no fever, lower limb weakness (+), upper limb
movement (+)
GA : moderately ill, compos mentis, E4V5M6
VS : Heart rate: 130 bpm Temp: 36.5oC
Resp. rate : 28 bpm BP: 90/60 mmHg
SiO2 : 99%
Head : normocephal , HC= 49 cm (0 SD< HC<+2SD)
Eyes : pale conjunctiva -/-, icteric sclera -/-, isocoric
pupil (2mm/2mm), light reflexes (+/+)
Nose : nasal flares (-), nasal discharge (-)
Mouth : cyanosis (-), hyperemic pharynx (-)
Ears : Ear discharge -/-
Neck : Lymph node enlargement (-)
Chest : Symmetrical in shape and movement, chest indrawing (-
)
24
Cor : I : Ictus cordis did not appear
P : Ictus cordis was not palpable
P : no sign of heart border enlargement
A : heart sounds I-II normal intensity, regular, murmur(-),
Pulmo: I : symmetrical movement (+)
P: fremitus sounds hard to evaluate
P: sonor / sonor
A: vesicular breath sounds +/+ , additional breath sound (-/-)
Abd : I : abdominal wall equals to chest wall
A : peristaltic sound (+) normal
P : tympanic sound
P : supel, liver and spleen no enlargement, empty bladder
Extremity : Cold extremities: -/-
-/-
Strong palpable of dorsal pedis artery
CRT < 2”

25
 NEUROLOGICAL EXAMINATION

Physiologic Reflex Pathological Reflex Meningeal Reflex

Biceps +2/+2 Babinsky -/- Nuchal rigidity -
Triceps +2/+2 Chaddock -/- Kernig -
Patella +1/+1 Gordon -/- Brudzinsky I/II -/-
Achilles +1/+1 Oppenheim -/-
Schaffer -/-

Clonic Spastic Laterali- motor sensory

tation
- - - - 5555 5555 + +
(-)
- - - - 1111 1111 + +
 NEUROLOGICAL EXAMINATION

Olfactory Nerve (I) : cannot be evaluated yet.

Opticus Nerve (II) : isochoric pupil, Light reflex -/+, funduscopy
not performed
Occulomotorius Nerve (III), N. Trochlear (IV), N. Abduscens (VI):
Eye movement cannot be evaluated, pupils at
center, no strabismus -
Trigeminus Nerve (V) : corneal reflex (+/+)
Facialis (VII) : symmetric face
Accustikus (VIII) : hearing and balance test not performed
Glossopharyngeus (IX) : hard to evaluate
Vagus nerve : voice (+)
Accsesorius (XI) : no shoulder paralyzed found
Hypoglossus : hard to evaluate

27
 WORKING DIAGNOSIS

1. Acute Flacid Paralysis due to suspected for Acute

Transverse Myelitis (G37.3)
2. Microcytic hypochromic anemia due to suspected for
iron deficiency anemia (D50.9)
3. Well-nourished (Z71.3)

28
 THERAPY
1. Diet rice 1000 kcal/day
2. IVFD D51/4NS 40 ml/hour
3. High dose methylprednisolone (30 mg/kgBW/day) =
300 mg/day intravenously

29
 PLAN
1. Urinalysis and stool analysis (routine and polio stool test)
2. Lumbar puncture
3. Contrasted spinal cord MRI
4. Electromyography and nerve conduction study
5. Iron status examination and peripheral blood smear

MONITORING
 General Appearance/Vital Signs/SiO2/BP/8 hour
 Observation of ascending motor plegia and sensory
involvement 30
 FOLLOW UP FEBRUARY 15TH 2018
Subjective: no fever, lower limb weakness (+), upper limb
weakness (+), no voice
GA : moderately ill, compos mentis, E4V5M6
VS : Heart rate: 112 bpm Temp: 36.5oC
Resp. rate : 30 bpm BP: 90/60 mmHg
SiO2 : 99%
Head : normocephal , HC= 49 cm (0 SD< HC<+2SD)
Eyes : pale conjunctiva -/-, icteric sclera -/-, isocoric
pupil (2mm/2mm), light reflexes (+/+)
Nose : nasal flares (+), nasal discharge (-)
Mouth : cyanosis (-), hyperemic pharynx (-)
Ears : Ear discharge -/-
Neck : Lymph node enlargement (-)
Chest : Symmetrical in shape and movement, chest indrawing (-
)
31
Cor : I : Ictus cordis did not appear
P : Ictus cordis was not palpable
P : no sign of heart border enlargement
A : heart sounds I-II normal intensity, regular, murmur(-),
Pulmo: I : symmetrical movement (+)
P: fremitus sounds hard to evaluate
P: sonor / sonor
A: vesicular breath sounds +/+ , additional breath sound (-/-)
Abd : I : abdominal wall equals to chest wall
A : peristaltic sound (+) normal
P : tympanic sound
P : supel, liver and spleen no enlargement, bladder (+) palpated
Extremity : Cold extremities: -/-
-/-
Strong palpable of dorsal pedis artery
CRT < 2”

32
 NEUROLOGICAL EXAMINATION

Physiologic Reflex Pathological Reflex Meningeal Reflex

Biceps 0/0 Babinsky -/- Nuchal rigidity -
Triceps 0/0 Chaddock -/- Kernig -
Patella 0/0 Gordon -/- Brudzinsky I/II -/-
Achilles 0/0 Oppenheim -/-
Schaffer -/-

Clonic Spastic Laterali- motor sensory

zation
- - - - 1111 1111 - -
(-)
- - - - 1111 1111 - -
 NEUROLOGICAL EXAMINATION

Olfactory Nerve (I) : cannot be evaluated yet.

Opticus Nerve (II) : isochoric pupil, Light reflex -/+, funduscopy
not performed
Occulomotorius Nerve (III), N. Trochlear (IV), N. Abduscens (VI):
Eye movement cannot be evaluated, pupils at
center, no strabismus -
Trigeminus Nerve (V) : corneal reflex (+/+)
Facialis (VII) : symmetric face
Accustikus (VIII) : hearing and balance test not performed
Glossopharyngeus (IX) : hard to evaluate
Vagus nerve : voice (-)
Accsesorius (XI) : no shoulder paralyzed found
Hypoglossus : hard to evaluate

34
 WORKING DIAGNOSIS

1. Acute Flacid Paralysis due to suspected for Guillain

Barre Syndrome (G61.0)
2. Microcytic hypochromic anemia due to suspected for
iron deficiency anemia (D50.9)
3. Well-nourished (Z71.3)

35
 THERAPY
1. Oxygen 2 lpm via nasal canule
2. Diet rice 1000 kcal/day
3. IVFD D51/4NS 40 ml/hour
4. High dose methylprednisolone (30 mg/kgBW/day) =
300 mg/day intravenously
5. Proposed for IVIG (400 mg/kgBW/day) for 5 days

36
 PLAN
1. Urinalysis and stool analysis (routine and polio stool test)
2. Lumbar puncture
3. Contrasted spinal cord MRI
4. Electromyography and nerve conduction study
5. Iron status examination and peripheral blood smear

MONITORING
 General Appearance/Vital Signs/SiO2/BP/8 hour
 Observation of ascending motor plegia and sensory
involvement 37
 Clinical question
Can ATM be concurrent with GBS in lower limb
weakness as a chief complaint?

• P : children with lower limb weakness

• I : ATM happens concurrently with GBS
• C :-
• O : Incidence

• We had tried to find a journal, but we could not

find a proper study related to our question
7 cases have been reported as ATM and GBS that happen
concurrently
• LOE 4B
THANK YOU