Presentation Rota

8/8/2019 Presentation Rota

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No Sub bagian Lama Baru Pulang Pindah Jml

1 Infeksi 2 - - - - 2

2 Respirologi 2 - - - - 2

3 Gastrologi 2 - - - - 2

4 Hepatologi 1 - - - - 1

5 Neurologi 3 - - - - 2

6 Gizi & met. - - - - - -7 Allergi Imm. - - - - - -

8 Endokrin - - - - - -

9 Hemato 6 - - - - 6

10 Nefrologi 5 - - - - 5

11 Kardiologi 1 - - - - 1

12 Perinatologi 9 2 - - - 11

13 PGD - 2 - - - 2

14 NICU - - - - - -

Jumlah - - - - -


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No Ruangan Lama Baru Pulang Pindah Jml

1 Infeksi 9 - - - - 9

2 Non Infeksi 12 - - - - 12

3 Kelas I 4 - - - - 4

4 PGD 2 1 - - 3

5 Perinatologi - - - - - -

6 NICU 2 - - - 1 1

Jumlah


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DUTY REPORT

Fajar, 7/12 years old,

SubjectiveChief Complaint

Recurrent seizure since 1 day ago

Present Illness History;

oRecurrent seizure since 1 day ago, 5-6 x, duration 5-15minutes/seizure, distance between seizure was 5-30 minutes,all of body, concius after 1st seizure, and unconcius after the

2nd seizure. This was the 2nd seizureoFever since 1 day ago, not high, not continously, nosweating, no shiffering.oCough since 1 day ago, no sputum.oNo breathless


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No vomite

No history of head trauma

The patient feed breast milk 5-6 x/day, milk porridge

3x1 day Urinary was normal

Defecation was normal


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Past Ilness History

Patient had been hospitalized in Pediatrics

dept of M. Djamil Hospital for 10 days (oct16th-25th 2010), with diagnosis Recurrent

seizure ec Meningitis Purulenta and then

went home by themselves.

Family history ilness

No his family get sickness like this


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Sosioeconomic history

- The patient is the 3rd child of 3 siblings,

spontaneus delivery, aterm, Birth weight3400 gr, Birth Height 50 cm,

Basic immunization was not complete

Growth and development history in normallimit

Higiene and sanitation: enough


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Objective

Moderate illness GCS E3M4V1=8HR 150 x/I, RR 64 x/I

T: 36,7C BW: 7,6 kg

BH: 67 cm BW/A: 90,5%BH/A:98,1% BW/BH:96,2%

Nutrition state: good

nutrition


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Head: circle, symmetric. Head circumference: 45cm (normal Nelhauss std). Fontanel was flat

Eyes : anemic, wasnt icteric. Isochor pupile, 2mm, light reflex +/+ normal

Neck: no neck stiffness

Thorax : no retraction.

Cor : regular rhytme, no murmur

Pulmo: broncovesikuler, wheezing -/-, rales -/-


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Abdomen: no distended, hepar - , lien S0,peristaltic sound (+)

Umbilical cord fresh, no smell, no hiperemic

Extremities : warm, well perfusionPhysiologic Rf: +/+ norma;

Patological Rf: Meningeal Excitatory sign

Babinsky : +/- Brudzinsky I : -

Oppenheim: -/- Brudzinsky II: -Gordon : -/- Kernig : -

Schaeffer : -/-

Chaddock : -/-


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Laboratory Findings:Hb : 9,4 g/dl Hematokrit : 30%

Leu: 14.000/mm3 Erytrosite : 3,7 million

DC 0/0/3/75/16/6 Retikulocyte : 22

Trombosit 37.000/mm3 MCH : 25,4 pq

MCV : 81,1 fl MCHC : 31,33%

Diagnosis:-Suspect meningitis bacterialis

dd/ encephalitis

-Mikrositik hipokrom anemia ec susp. deff. Fe


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Therapy:

O2 2l/IIVFD KaEN IB 105 cc/kgBW/day 32 drops/I

Luminal 50 mg im

Luminal 2x30 mg po

Ceftriaxon 2x375 mg

Dexamethason 3,5 mg iv

dexamethason 3x1mg IV

Temporary fasting

Plannings:Blood Gas Analyze, electrolite

Ca, RBG

Blood Culture

Consult to Ophtalmologist

Lumbal Puncture


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Blood Gas Analizes:

pH : 7,32

pCO2 : 39pO2 : 92

HCO3 : 20,1

BE : - 5,6

SO2 : 96%

Concl : asidosis metabolik,

Natrium 141 mmol/L

Concl: in normal limit Kalium 5,0 mmol/L

Concl: hyperkalemia


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Ophtalmologist Consultation:

There was no signals of increasing of IntraCranial Pressure

Random Blood Glucose

96 mg/dl

Conclusion: normoglikemia

Calcium 9,7 mg/dl


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Follow up

S/ Patient alert and cried

No fever, no seizure

No breathlessness

O/ severily ill, GCS E4M6V5HR 116x/i RR 40x/i

Conjunctiva anemic, sclera not icteric

Cor and pulmo was normal

Abdomen no distension, peristaltic sound wasnormal

warm acral and well perfusion

I/ improvement of consciousness


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Th/ - breastmilk 8x10ml/NGT

- continue other therapy


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2. M Kevin, 4/12 years old,

Subjective

Chief ComplaintRecurrent seizure since 12 hours ago

Present Illness History;oCold since 2 weeks ago, no cough

o Fever since 1 week ago, not high, not continously, no sweating,

no shiffering

oRecurrent seizure 4 days ago for 2 days, the frequency 2-4x/day, duration 5 minutes, distance between seizure was 2-4

hours, all of body and eyes view to the right side, and unconcius

after seizure


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No vomite

No breathless

No history of head trauma

Urinary was normal Defecation was normal

Patient had been hospitalized in Solok Hospital12hours ago, and got therapy: O2 3l/I, IVFD D10%:NaCl

=4:1, cefotaxim 2x150 mgiv, Gentamicin 2x12 mg iv,Dexamethason 3x0,6 mg iv, and then referred to M.djamil hospital with diagnosed Suspect Encephalitis


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Past Ilness History

Never got sickness like this before

Family history ilnessNo his family get seizure with fever or

without fever


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Sosioeconomic history

- The patient is only child, spontaneusdelivery, aterm, Birth weight 2400 gr, BirthHeight 50 cm,

Basic immunization was complete basecon his age

Growth and development history in normallimit

Higiene and sanitation: enough


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Objective

Moderate illness GCS E1M2V1=4HR 130 x/I, RR 44 x/I

T: 36,5C BW: 6,2 kg

BH: 59 cm BW/A: 91,1%BH/A:93,6% BW/BH:108%

Nutrition state: good

nutrition


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Head: circle, symmetric. Head circumference: 41cm (normal Nelhauss std). Fontanel was

concave

Eyes : anemic, wasnt icteric. Isochor pupile, 2mm, light reflex +/+ normal

Neck: no neck stiffness

Thorax : no retraction.

Cor : regular rhytme, no murmur

Pulmo: broncovesikuler, wheezing -/-, rales -/-


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Abdomen: no distended, hepar - , lien S0,peristaltic sound (+)

Extremities : warm, well perfusionPhysiologic Rf: +/+ normal

Patological Rf: Meningeal Excitatory sign:Babinsky : +/+ Brudzinsky I : -Oppenheim: -/- Brudzinsky II: -Gordon : -/- Kernig : -

Schaeffer : -/-Chaddock : -/-


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Laboratory Findings:Hb : 8,6 g/dl

Leu: 8900/mm3

DC 0/0/2/65/32/1

Diagnosis:

- susp. Encephalitisdd/ susp. HDN

susp. Meningitis bacterialis

- micrositic hipocrom anemia ec susp. Iron deff


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Therapy:

O2 2l/IIVFD G:Z=3:1 105 cc/kgBW/day 28 drops/I

Luminal 50 mg im

Luminal 2x30 mg po

Cefotaxim 2x300 mg

Gentamicin 2x24 mgDexamethason 3x1 mg

Fasting

Plannings:electrolite Ophthalmic consult SI/TIBCCa, RBG Brain CT Scan PT/APTT

Blood Culture Lumbal puncture


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Blood Gas Analizes:

pH : 7,32

pCO2 : 39pO2 : 92

HCO3 : 20,1

BE : - 5,6

SO2 : 96%

Concl : asidosis metabolik,

Natrium 132 mmol/L

Concl: in normal limit Kalium 4,5 mmol/L

Concl: hyperkalemia


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Ca: 8,2 mmol/L, normal

Random Blood Glucose 112 mg/dl

Conclusion: normoglikemia

PT 14',3''

APTT 51',2' Conclusion : 1,5 x

Ophthalmic consultation : no papil edema

Brain CT Scan : cannot be examined becausedisfunction of equipment


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Follow up

S/ No febrile, no seizure, no bleeding, still

not conscious

O/ severily ill, GCS E1M3V2, HR 120x/i, RR 40x/i, T 36,5Cconjunctiva not anemic, sclera not icteric

isokor pupil diameter 2mm, light reflex +/+

Cor and pulmo was normal

Abdomen not distended, peristaltic sound normal

Warm acral and well perfusion

I/ improvement of consciousness

Th/ continue the therapy


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3. By. Pipi Susanti, , 0 month,

Subjective

Chief Complaint

Newborn baby spontaneously deliver BW 3076 gr BH 48 cm

Present Illness History

- Newborn baby spontaneusly delivered BW 3076 gr BH 48 cm

-Mother was good condition, amnion was green, thicked and

smelled-APGAR Score: 6/7, Maturation prediction 39-40 weeks

-No fever, no breathless, no sianotic

--urinary not yet

--meconium not be excreted


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Moderate ill, active enough, HR 140 x/minute,

RR 50 x/minute, T: 36,7C

Eyes : wasnt icteric, wasnt anemic

Nose : no nostril breathing

Thorax : no retraction. Cor : regular rhytme, no murmur

Pulmo : bronkovesikuler, wheezing -/-, rales -/-

Abdomen : no distended, hepar - , lien S0,peristaltic sound (+)

Umbilical cord fresh, no smell, no hiperemic

Extremities : warm, well perfusion

Objective


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Laboratory findings Hb : 19,5 g/dl Leu: 26.500/mm3

DC 0/0/2/72/23/3 Trombosit 189.000/mm3

Assesment NNAWB BW 2700gr BH 49cm Spontaneous Delivery A/S 6/7

Mother was in good condition, amnion was green, thicked andsmelled Maturation prediction 40-41 weeks Delivery trauma was caput succadaneum No congenital abnormality Present Ilness: Risk of Infection


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Therapy :

- ASI OD

- Ampicillin Sulbactam 2x165mg

- Gentamicin 1x16mg

Planning

- Blood culture


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Follow up

S/ No febrile, no breathlessness, novomitus, not icteric, mixturation was

normalO/ active enough, HR 140x/i, RR 34x/i T

36,8CConjunctiva not anemic, sclera not icteric,

Cor and pulmo was normalAbdomen no distended, peristaltic sound normal

Warm acral and well perfusion

I/ stableTh/ ASI OD

Ampicillin Sulbactam 2x165mgiv

Gentamicin 1x16mg iv

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