CASE CONFERENCE

th
January 29 2018

A N TO, M D / L A B I Q , M D / H A M I D, M D / D I L L A , M D / G A L I H , M D
I Z N I , M D / M O N O, M D
SUSI, MD / DELFIA, MD

1
New Patients

Melati 2 Ward :
F, 5yo, 17 kg, cephalgia,
HCU Neonatus: (-)
NICU: ( - )
HCU Melati 2: (-)
PICU / ROI : (-)

2
 Patient Identity

Name :N
Sex : Male
Age : 13 years old
Weight/Height : 40 kg / 160cm
Address : Solo
Med. Record : 01304329

3
 Chief Complaint

Decrease of conciousness

4
 Present Medical History
2 HOURS BEFORE ADMISSION AT THE EMERGENCY ROOM
• Patient felt fatique, while playing • Still unconscious
with friends. • Vomitted 2 times, contained of food
• At home, he became unconscious. that had been consumed, projectile.
• Parents brought him to Moewardi • Seizure (-)
hospital  had seizure one time, • Fever (-)
less than 1 minute, all of the body, • Defecation and urination within
stopped by itself normal limit
• Vomitted (+), 1 x, contained of
food that had been consumed,
blood (-), projectile
• Breathing difficulty (-)
• Urination and defecation within
normal limit

5
Past Medical History
History of similar symptoms (+)
◦ At 2015 patient was diagnosed with ruptured AVM, and then
the doctors did Digital Subtraction Angiography to him  got
valproic acid (10 mg/kgBW/day)
History of trauma (+)
◦ At September 2017, patient had traffic accident  had maxilla
fracture  undergone plastic surgery.

Family Medical History

• History of the same illness : (-)
• History of coagulation disorder : (-)

6
 Pregnancy and Birth History
• During pregnancy, mother routinely checked her
pregnancy to midwife. She was given vitamin, and
she didn’t consume any other of medicine. No history
of hospitalization during pregnancy
• Baby boy was born in full term pregnancy, normal
delivery, cried vigorously, no cyanosis or icteric was
found and his birth weight was 2900 grams

Conclusion: normal birth history and normal pregnancy

7
 Immunization Status
BCG : (+) 1 months
Hepatitis B : (+) 0 months
DPT : (+) 2, 3, 4 months
Polio : (+) 2, 3, 4 months
Measles : (+) 9 months
DT,measles : elementary school first grade
TT : elementary school second and thirth
grade

Conclusion : complete immunization, according to

Ministry of Health’s schedule 2004

8
Nutrition History
Patient eat 3 times a day, and also drink milk, and some snack with usual
portion,
Conclusion : quality and quantity of nutrition are normal

Growth and Development

He is now 13 years old, a junior school student.
His weight is 40 kg with body height 160 cm.
Conclusion: growth and development is normal

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 Nutritional Status
• Weight for Age : 40/45 x 100% = 88% (p10 < BB/U < p50)

• Length for Age : 160/156 x 100% = 102% (p25 < TB/U < p75)

• Weight for Length : 40/48 x 100% = 183% (p50 < BB/TB < p75)

Conclusion: normoweight, normoheight, wellnourished

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 Pedigree
I

II

III

N, 13 years old

11
 Physical Examination
General appearance: compos mentis (E1V1M4)
VS :
Heart rate: 76 x/menit body temp : 37,10C
Respiration rate: 20 x/menit saturation : 99 %
Blood press: 112/73 mmHg
Head : mesocephal
Eyes : pale conjunctiva (-/-), icteric conjunctiva(-/-)
light reflex (+/+), isochoric pupil 2 mm/2mm, edema palpebra (-/-)
Nose : nasal flare (-/-),discharge (-/-)
Mouth : lips and tongue cyanotic, moist lips mucosa (+)
Neck : no enlargement of lymph node

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LUNG:
I : normal, symmetric, retraction (-)
P : hard to evaluate
P : sonor in both lung
A : vesicular breath sound(+/+) additional breath sound (-),
coarse -/- crackles -/- wheezing -/-

CARDIAC:
I : ictus cordis not visible
P : ictus cordis palpable at SIC IV LMCS
P : there is no cardiac enlargement
A : 1st 2nd Heart sound normal intensity, regular, no murmur

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ABDOMINAL:
I : abdominal wall // thorax wall
A : peristaltic within normal limit
P : tympani
P : no enlargement of the spleen and liver

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis pedis
artery was strong , no cyanotic, icteric (+/+)

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 Neurological Examination
Physiological reflexes Meningeal signs
-Biceps +2/+2 Nuchal rigidity (–)
-Triceps +2/+2 Kernig’s sign (–)
-Patella +2/+2
Brudzinsky sign (–)
-Achilles +2/+2

Pathology reflexes Lateralization (-)

-Chaddock -/- Motoric +5555 +5555
-Oppenheim -/-
+5555 +5555
-Schaeffer -/-
-Gordon -/-
-Babinski -/-

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 LABORATORY FINDING
January 29th 2017
Value Reference Units
Hemoglobin 13.3 14-17.5 g/dl
Hematocrit 44 33-45 %
Leucocyte 15.3 4.5-14.5 x103/ul
Thrombocyte 335 150-450 x103/ul
Eritrocyte 5.56 3.8-5.8 x106/ul
MCV 78.4 80.0-96.0 /um
MCH 23.9 28.0-33.0 pg
MCHC 30.5 33.0-36.0 g/dl
RDW 15.7 11.6-14.6 %
Eosinophil 6.8 0.00-4.00 %
Basophil 6.8 0.00-1.00 %
Neutrophil 54.40 29.00-72.00 %
Lymphocyte 38.8 33.00-48.00 %
Monocyte 6.8 0.00-6.00 %

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 LABORATORY FINDING
January 29th 2017

Value Reference Units

PT 13 10-15 Seconds
APTT 26.3 20-40 Seconds
RBG 157 80-100 mg/dl
Sodium 142 132-145 mmol/L
Potassium 3.6 3.1-5.1 mmol/L
Chloride 106 98-106 mmol/L
Calcium 1.19 1.17-1.29 mmol/L
Ureum 18 <48 mg/dl
Creatinin 0.6 0.5-1 mg/dl

Interpretation :
• Leucocytosis

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Head MSCT without contrast
(20-6-2015)
Interpretation :
 IVH third and lateral ventricle
sinistra
 IVH lateral ventricle dextra
 ICH corona radiate sinistra

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Head MSCT without contrast
(16-2-2017)
Interpretation :
 IVH left lateral ventricle
 ICH left corona radiate
 Brain edema

19
Head MSCT without contrast
(13-9-2017)
Interpretation :
 Fracture os nasal, right medial
maxillary sinus, left medial
maxillary sinus, os maxillary
dextra, os mandibular dextra with
hematosinus maxilla, bilateral
ethmoidalis, bilateral sphenoidalis,
bilateral frontalis
 No intracerebral hemorrhage

20
Angiography (20-6-2017)
Interpretation :
 Medium nidus AVM left
temporoparietal with the feeder
from artery choroidalis anterior
and posterior

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 22

Problem List
1. Generalized seizure < 1 minutes, tonic clonic,
stopped by itself
2. Decrease of consciousness immediately 2 hours
before admission, no trauma
3. History ruptured AVM on 2015
4. No lateralization, normal physiologic reflex, no
pathological reflex, no meningeal sign
5. Leucocytosis
6. Wellnourished, normoweight, normoheight

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Differential Diagnose
1. Decrease of conciousness e.c susp rupture AVM
2. Wellnourished , normoheight, normoweight

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Working Diagnosis
1. Decrease of conciousness e.c susp rupture AVM
2. Wellnourished , normoheight, normoweight

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THERAPY
1. Observation of decrease consciousness  if the
consciousness scale is still the same indicate of
craniotomy decompression
2. Admitted to High Care Unit Pediatric
3. Oxygen 1 lpm via nasal canul
4. IVFD D5 1/2 NS 80 ml/ hour (maintenance)
5. Inj Manitol 20 % (0.5 gr/kgBW/day) 200 mg
loading dose  100 mg / 8 hours iv
6. Inj Tranexamic acid 500 mg/8 hours iv

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PLAN

• Head CT-scan without contras

• Consult to neurosurgery subdivision

Monitoring
General appearance / vital signs / blood pressure / hour
Fluid balance and diuresis / 8 hours

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Head MSCT without contrast
(29-1-2018)
Interpretation :
 ICH left temporal lobe
 IVH lateral ventricle bilateral,
third ventricle, fourth ventricle
 Dilatation lateral ventricle cornu
anterior bilateral, cornu
temporalis bilateral

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 HCU, Jan 30th 2018
Subjective Patient agitated, no seizure, no vomite, no fever

CNS General appearance: severely ill, apatis

GCS:E3V4M5
Light reflex (+/+)
Isochoric pupil 2mm/2mm
Analgetic (-) Sedative drug (-)
CV system Heart rate :76 bpm. BP 110/70
Murmur (-), capillary refill time < 2”, DPA strong palpable
Respiration Respiration rate: 20 bpm, Sio2 = 98%
I : Chest retraction (-) , Cyanotic (-) nasal flare (-) Chest expansion right = left
System P: fremitus hard to evaluate
P: Sonor +/+
A: vesicular breath sound +/+
GIT system Feces (-), NGT product (-) , vomit (-)
I: abdominal wall // thorax wall
A: peristaltic in normal limit
P: tympani
P: supel (+), organomegaly (-)

Genitourinary Urine output

Fluid balance can not be evaluated yet
system Diuresis can not be evaluated yet

Infection Thermoregulation status Fever (-) (37.10C)

Leucocyte 15.300
status Neutrophyl 53.4
Lymphocyte 38.8
ANC 8170
ALC 5936
Ab: -
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Hematologic Bleeding (-)
status Hb 13.3
Hct 44%
Trombocyte 335 thousand
Erythrocyte 5.56 mil

GDS 157
Metabolic Na 142 mmol/l
status K 3,6 mmol/l
Cl 106 mmol/l
Ca 1.19 mmol/l
Nutritional status Fluid requirement 1900 ml/day
Calorie requirement 1567 Cal/day
Oral : (-)
Diet analysis : can not be evaluated yet

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Diagnosis
1. Decrease of conciousness e.c susp rupture AVM
2. Wellnourished , normoheight, normoweight

30
Therapy
1. Pro craniotomy decompresion cito
2. Oxygen 1 lpm via nasal canul
3. IVFD D5 1/2 NS 80 ml/ hour (maintenance)
4. Inj Manitol 20 % (0.5 gr/kgBW/day) ~ 100 mg / 8
hours iv
5. Inj Tranexamic acid 500 mg/8 hours iv

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PLAN

Pro craniotomy decompression

MONITORING
General appearance / vital signs / blood pressure / 4 hour
Fluid balance and diuresis / 8 hours

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Clinical question:
what is the best management of children with
AVM?
P : Children with AVM
I : Conventional
C : Gold Standard
O : Overall outcome/survival rate
 Validity

Did the review address a clearly focused

question?
• Yes, they aimed to review the current literature regarding the
natural history and clinical outcome after multimodality AVM
treatment in the pediatric population

Did the authors look for the right type of papers?

• Yes, the authors included studies about evaluating about the

safety and efficacy of stereotactic radiosurgery and
endovascular embolization for treatment of AVM in children
 Validity

Were the sources and resources used to

search for studies adequate?
• Yes, the sources and resources were adequate and
eligible

Were the criteria for appraising studies

appropriate?
• Yes, they used and compared different criteria from
all of the study included
 Important

What are the overall results of the

review?
• The overall results of the review is microsurgical
resection remains the gold standard for the
treatment of all pediatric AVMs

How precise are the results?

• Not clear, it was not stated in the paper

 Applicability
Can the results be applied to the local
population?
• Yes, it can be applied to our patients

Were all important outcomes considered?

• Not clear, the author didn’t stated in the paper

Are the benefits worth the harms and costs?

• Yes, it could give the best result for patient’s prognosis

Level of Evidence

Important

1A
Valid Applicable
THANK YOU

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