16 juli 2012 english oke

DUTY REPORT July 16th 2012

TEAM ON DUTYTEAM ON DUTY

Chief : dr. Julinar ER Chief : dr. Risma

Ward Madya : dr. Ikhsan M dr. Riri D s dr. Ronaldinoor

Perinatology Madya : dr. Eni andriani dr. Febbianne

Junior : dr. Tilmiza

dr. betty H dr. Ranti A dr. M Robi dr. Dina

No Sub bagian Lama Baru Pulang Pindah † Jml

1 Infeksi 5 - - - - 5

2 Respirologi 1 - - - - 1

3 Gastrologi - 1 - - - 1

4 Hepatologi `- - - - - -

5 Neurologi 7 - - - - 7

6 Gizi & met. - - - - - -

7 Allergi Imm. -- - - - - -

8 Endokrin 1 - - - - 1

9 Hemato 19 - - - - 19

10 Nefrologi 1 - - - - 1

11 Kardiologi 3 1 - - - 4

12 Perinatologi 15 2 - - - 17

13 PGD 5 2 - - - 7

1415

NICUKlas I

26

-1

- - - 26

Jumlah 64 7 - - - 71

NEW PATIENTS

1. Ziyad ashif Zafran, 9/12 yr, boy, MR : 79 25 96

WD / acute diarrhea with moderate dehydration and undernorished

2. Afifa, 8/12 yr , girl, MR: 79 26 30.

WD/ suspect acute leukemia

3. Syifa nur fadila, 13/12 yr , girl , MR :79 25 29

WD/ congenital heart disease

4. Cerli rama putra, 32 days , boys, MR : 79 26 29

WD/ severe dehidration ect low intake

5. Salsabilla, 1 1/12 yr, girls, MR : 79 26 08 WD/ Acute diarrhoe with moderate dehidration, Complex febrile

seizure

Normositic normocrom anemia , Observation of febril ec susp UTI

6. Fajri , boy, class

thalasemia β

ZIYAD, 9/12 YEARS OLD, BOY, 79 25 96

* Chief complain: Watery stools since 2 days ago * Present Illness:

- Watery stools since 4 days ago, frequence 4-5 times/day, volume ¼ glass/times, there was no muccus and no blood.

- Vomiting since 3 days ago , frequence 2-3x/day, volume 3 spoon- ¼ glass /times, consist of food, not projectil,

- Fever since 1 day ago, not high, not continue, no

shivering, no seizure.

- No cought, no breathlessness- Nowadays, the child get breastfeeding and

porridge milk 3 times a day, volume ± 5-6 spoon/time

- Never get formula milk- Last mixturation 4 hours ago, dark coloured- The last Body weight unknown- Patient already got therapy from public

health center 3 days ago and got paracetamol syrp, ctm, cotrimoxsazol 2x 1 teaspoon, because the condition not recovery the child brought again to public health and got pulvis medicine 3 times a day,

- On ER M Djamil Hospital, the child has been got oralit oral, but couldn’t eaten up 250 cc from requirement (about 585 cc), vomite a time and watery diarhea a time.

* Past Illness:never had watery diarhea before

* Familly illness history :There was no family suffered diarhea

* Sosioeconomic history - Second child from 2 siblings, spontan delivery,mature, birth weight 3900 gram,

birth height 52 cm. - History of grow and development was normal - Basic imunization was not complete based on

age - Hygiene and sanitation was moderate

GENERAL EXAMINATIONGENERAL EXAMINATIONConciousness allertallert

HRHR 110606 x/mntx/mnt

TemperatureTemperature 336,86,8° ° CC

RRRR 3232 x/mntx/mnt

GA GA ModerateModerate

BBLL

BW BW 7373 cmcm

7.87.8 kgkg

Nutrition statusNutrition status UndernourishedUndernourished

BB/UBB/U :: 89,189,1 %%

TB/UTB/U : : 110000 %%

BB/TBBB/TB : 89,1: 89,1 %%

SianosisSianosis NoneNone

Edema Edema None None

AnemisAnemis None None

IkterusIkterus NoneNone

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

skin Warm, turgor was very slowly return

Lymph node not Palpable

Head Fontanella mayor was sunken. Round, simetric, head circumference : 43 cm( normal Standar Nellhaus)fontanel was sunken

Eye Sunken eyes, tears drop (+), Conjunctiva was not anemic, sklera was not icteric, pupil isocor diameter 2mm, light reflex +/+ normal

ear In normal limit

nose In normal limit

throat Tonsil T1-T1 not hiperemic, faring not hiperemic

Teeth and mouth lips and mouth mucose was dryNo oral trush

neck JVP was difficult to examine

lung I : normochest, simetrisP : fremitus left+ rightP : sonorA : bronchovesikuler, rough rales -/-, no wheezing

heart I : ictus was not seenP : ictus palpable on LMCS RIC VP : difficult to examinedA : sinus rhytme, no murmur

Abdomen Ins : no distentionPal : Supel, liver was palpable 1/4-1/4, flat, sharp, elastic and spleen was not palpablePer : timpaniAus : peristaltic sounds (+) normal

back No abnormalities found

Genetalia In normal limit

puberty state: A1P1G1

Anus rectal toucher not performedEritema natum (+)

Extremity warm acral, good refilling capiller, Fisiologis reflex +/+ normalPatologis reflex: -/-

LABORATORIUMLABORATORIUM

BloodHb 11,9 g/dl

Leucocyte 10800/mm3

Diff count 0/2/2/44/50/2

Platelete 505.000/mm3

Ht 38%

URINEProtein -

Reduksi -

Leukosit -

Eritrosit -

BilirubinUrobilinogen

-+

FESESMacroscopis Yellow, soft, mucous +

Mikcoscopis Eritrosit 0-1 , leukosit 1-2

Diagnosis Acute diarrhoe with moderate dehidration,

Under nourished

Therapy IGFD Oralit 75 cc/kgBW/ 3hours = 48 gtt /mnt (makro)

Oralit 80 cc/kgBW/ watery diarhea

Breast feeding OD

Cefixim 2x20 mg po

Zink 1 x 20 mg

Plan electrolyte, feses cultur

Stool analisys, rehidration evaluate on 10 pm

FOLLOW UPFOLLOW UP 23 0023 00S/:Watery stool (+), 1xFever (-), breathlessness –No vomite, micturation + normal

PE/:HR: 104/i RR: 30x/i T: 37WB: 8.25 kgEye : no sunken, tears drop (+) konj not anemic, not ictericThorax: cor and pulmo in normal limit Abdomen: distensi (-), intestines sounds (+) . Turgor was goodExtremitas: warm acral, good perfution ,

Im/ rehidration

Th/

IGFD Oralit 75 cc/kgBW/ 3hours = 48 gtt /mnt (makro)

Oralit 80 cc/kgBW/ watery diarhea

Breast feeding OD

Cefixim 2x20 mg po

Zink 1 x 20 mg

MORNING MORNING FOLLOW UPFOLLOW UP S/:No feverWatery stool (+ 1times),No vomitusNo breathlessnessMixturation was normaly

PE/:HR: 102/i RR: 32x/i T: 36,8C BW : 8,1kgEye : no sunken, tears drop (+) konj not anemic, not ictericThorax: cor and pulmo in normal limit Abdomen: distension (-), intestines sounds (+) .Extremity : warm acral, good perfution ,

Im/ acute diarrhea wihout dehidration

Th/IGFD Oralit 80cc/kgBW/ 3hours = 48 gtt /mnt (makro)

Oralit 80 cc/kgBW/ watery stool

Breast feeding OD

Zink 1 x 20 mg

Cefixims 2x20mgPO

AFIFA, GIRL, 8/12 TH,

Chief complain: look pale since 7 days ago

Present Illness:- look pale since 7 days ago, become worse since 3 days ago- swelling found at left and right neck since 6 days ago, become

bigger, and no redness appearance- fever since 1 day ago, no continous, no chills, no sweating, no

seizure- waterry stool since 1 day ago,5 times,volume 1-2 spoon/ times,

no mucous and no bleeding- no vomiting - no cough and cold, no breathlessness- no bleeding from nose, gums, skin, gastrointestinal and the

other organs- no history of tranfusion- no history of radiasion- no history icterik at eyes and skin

- baby this time still get brest milk, fruit and biscuit and don’t realy want to eat since

illness, Body weight 7,6kg at 2 weeks ago

- now baby all ready crawl- urination normal- baby allready take to RSUD sei. Dareh and take

blood examination, trombocite 20.000/mm3

Past Illness:

never get illnes like this before

Familly illness history :

There was no family, neighbourhood get suffer from this desease

Sosioeconomic history- The 4th child from 4 sibling, twin, SC, mature, birth

weight 2700 gram, birth height 47 cm, directly cry - History of grow and development was normal- History of basic imunization was complete- Hygiene and sanitation was good

GENERAL EXAMINATIONGENERAL EXAMINATION

Conciousness allert

Blood Pressure

HR 148 x/mnt

Temperature 38,1 C

RR 44 x/mnt

GA Severe

BL

BW

65 cm 7,8 kg

Nutrition status normalW/A : 96 %H/A : 95 %W/H : 108 %

Sianosis None

Edema None

Anemis anemic

Ikterus None


skin Look pale

Lymph node Palpable node at right submandibullaleft and right,single, size 1x1x1cm, mobilePalpable node at right and left coli, size 1x1x1cm, mobile,

Head Round, simetric,head sircumfrence 42cm( N standart nellhauss)

Eye conjunctiva anemic, sclera not icteric, pupil diameter 2mm, light reflex +/+ N

ear In normal limit



neck JVP 5-2 cmH2O

lung I : normochest, simetricP : fremitus right = leftP : sonorA : vesikuler, no rhonchi, no wheezing

heart I : ictus not seenP : dificult to examinedP :in normal lineA : sinus rhytme, sistolik noise grade 3/6 at all ostium

Abdomen Ins : no distentionPal : Supel, liver and spleen was not palpablePer : timpanyAus : peristaltic sounds (+) normal

back No abnormality


puberty state: A1M1P1

Anus rectal toucher was not performed

Extremity warm acral, good refilling capillerFisiologis reflex +/+ normalPatologis reflex: -/-


BloodHb 4,3 g/dl

Leucocyte 11.800

Diff count 0/0/0/0/92/0

Platelete 9.000/mm3

Ht 13%

blast 8%

URINEProtein -

Reduksi -

Leukosit -

Eritrosit -


-+

FESESMacroscopis yellow

Mikcoscopis Eritrocyte (-), Leucocyte (-)

Diagnosis susp,. Acute Leukimia

Therapy O2 2l/i

IVFD KaEN 1B4drop/i (makro)

Cefotaxime 2x200mg

Paracetamol 80 mg (t > 38,5 C)

Soft meal 3x

Fruit and biscuit 2x

Plan Blood culture

Cross match

X ray thorax

BMP

Faal hepar

Faal renal

Uric acid

Morning Follow Up

Subjetif Objectis

Fever (+)

No breathlessnes

No vomit

No bleeding

Mixturation normal

severe illness, conciousHR 134 x/mnt, RR 40 x/mnt, BP 90/60 T= 36,6 C

eye : Konjungtiva anemis, sklera not ikterik Thorax : Retraction (-)

Cor : regular rhytm, no murmurregular rhytm, no murmur

Pulmo : vesikuler, Rhales -/-, WH -/-Rhales -/-, WH -/-

Abd : distension(-), Intestinal sound(+) N,

Ekstr : warm, perfusion is good,warm, perfusion is good, ptechie positifptechie positif

Impresion ; febrisImpresion ; febris

O2 2l/i

IVFD KaEN 1B4drop/i (makro)

Cefotaxime 2x200mg

Paracetamol 80 mg (t > 38,5 C)

Soft meal 3x

Fruit and biscuit 2xBlood trunfution PRC and TC

BY CHERLI RAMA PUTRA, BOYS, 32DAYS, 792625

Chief ComplainDoesn’t want to take breast milkHistory of present illness- Baby doesn’t want to take breast milk since 2days old- Look ikteric since 2days old, start from face, and than to all of body- Fever since 3days old, not too high, not continue, no chills- Ovten vomite since 3days old, frec 2-3 times a day, volume 2-3 small

spoon/times,consist with milk and some times the color green- Now baby get formula milk, NanHA, becouse brest milk not enough- History mom had fever since pregnance negatif, white mucous from

vagina, bad smell and icth negatif- History of dysurria negatif- Vitamine K unknown- No ikteric history- Rhesus mom and daddy unknown- The last phie 6 hours ago, color normal- The last Stool 1day ago, yellow, konsistency normal, - Patient all ready admision in RSUD M. Thalib about 23days, allready get O2,

and infus. The patient allready ask to rever to Hospital 2 days ago, but his parent denay, than patient rever by specialist as septic and susp. Down sindrom

History of past illness:Never suffer from similar disease before.History of family illness:There was no family, neighbourhood get sufferfrom this desease

Social Economic historyThe last child of 4siblings, spontaneus

delivery, assisted by midwife, BW 2300 gr, not Cried directly, cried after 30 minutes


skin Look iktericuntil extremity, turgor very slowly

Lymph node No Palpable node

Head Round, simetric,head sircumfrence 31cm,

Eye conjunctiva not anemic, sclera not icteric, pupil diameter 2mm, light reflex +/+ N

ear In normal limit



neck In normal limit

lung I : normochest, simetricP : fremitus right = leftP : sonorA : broncovesikuler, no rhonchi, no wheezing

heart I : ictus not seenP : dificult to examinedP :in normal lineA : sinus rhytme,

Abdomen Ins : no distentionPal : Supel, liver palpable ¼-1/4 Per : timpanyAus : peristaltic sounds (+) normal

back No abnormality

BackBack scolyosiscolyosis s (+)(+)

GenitaliaGenitalia

Pubertal Pubertal statusstatus

No abnormalities foundedNo abnormalities founded

AnusAnus Rectal toucher was not doneRectal toucher was not done

extremitiesextremities Warm acral, good capillary refillWarm acral, good capillary refill

Blood

Hb 13,7 g/dl

Leukocyte 21.000/mm3

DC 0/0/0/85/15/0

reticulocit 21%

hematocrit 41%

trombocit 123.000/mm3

bilirubinTotal : 22,47mg/dlBil I: 415Bil II: 1828

Laboratorium Findings

Laboratorium result:- Na : 126mmol/L (Hiponatremia)- K : 3,7 mmol/L (normal)- GDR : 99mg/dl (normal )

Lumbal pungtion result :- LCS liquid drop slowly- Color xantocrom- None (-)- Pandi (-)- PMN cell : (-)- MN cell : (-)

- Still fever

- No breathlessness

- No nausea and vomitting

- No cought and flu, no breathlesness

- Micturition and defecation was normal

FOLLOW UP MORNING

OBJEKTIF

General Appearence severe illness

Consciusness Alert, not active

Blood Pressure

Pulse Rate 140 x/mnt

Respiratory Rate 40x/mnt

Temperature 37,5 oC

Eyes Conjunctive was not anemic, sclera was not icteric

Thorax Heart and lung didn’t find any abnormalities

Abdomen No Distention, bowel sound (+)

Ekstremities Warm acral, good perfussion

SYIFA NUR FADILLAH, GIRL, 1 2/12 TH, 79 25 29

Chief ComplainThe child look sianotic since 1 year agoHistory of present illness- The child look sianotic since 1 year ago, sianotic become worse when child

crying- Extremity look swelling and look sianotic- History often get fever since 7month 2-4 times amonth- Child doesn.t like to eat since 7 month ago, child only eat 2-3 spoon/times- BW no increase since 7 mounth ago- Cough and cold since 4 days ago- Fever since 3 days ago, not high,intermiten, no chill - No vomite- Urination normaly- Defecation normaly- The patient already treat by Sp.A in muaro tebo since 7 years old with

diagnose congenital heart disease and get medicine once a day. Than patient revered to M. Djamil Hospital.

History of past illness- Never suffer from similar disease before.History of family illness- There is no family suffer the same disease

Social Economic history- Spontaneus delivery, assisted by

midwife, BW 3500 gr, BL 50 cm, Cried directly.

- Basical immunization was completed.- Growth and development was not

disturbed.- Good hygiene and environment

sanitation.

Mouth Mouth Wet buccal and lip mucoseWet buccal and lip mucose

NeckNeck JVP5-2 cmH2O,neck rigidity was not present.JVP5-2 cmH2O,neck rigidity was not present.

Pulmo Pulmo

Ins : Normochest, Ins : Normochest,

Pal : Pal : Left Left fremitus = fremitus = right fremitusright fremitus

Per : sonorPer : sonor

Aul: Aul: broncovbroncovesikuler, esikuler, No RalesNo Rales, , No No wheezingwheezing

Cor Cor

Ins : Ictus Cordis Ins : Ictus Cordis was not visiblewas not visible

Pal : Ictus CordisPal : Ictus Cordis palpable at 1 finger at medial of palpable at 1 finger at medial of SSMCMCLL IC ICSS V V

Per : CorPer : Cor border, upper ICS II, Rght DSL, Left 1 border, upper ICS II, Rght DSL, Left 1 finger at medial of SMCL ICS V.finger at medial of SMCL ICS V.

Aul: Aul: Regular Rhytm, No MurmurRegular Rhytm, No Murmur

AbdomeAbdomenn

Ins : Ins : No DistentionNo Distention

Pal : Supel, Pal : Supel, liverliver and spleen wasand spleen was not not papable papable

Per : Per : Tympani Tympani

Aus : Aus : Intestinal sound (Intestinal sound ( + +)) normal normal

BackBack scolyosiscolyosis s (+)(+)

GenitaliaGenitalia

Pubertal Pubertal statusstatus

No abnormalities foundedNo abnormalities founded

A1PA1P11G1 G1

AnusAnus Rectal toucher was not doneRectal toucher was not done

Blood

Hb 12,3 g/dl

Leukocyte 13.400/mm3

DC0/3/1/54/41/1

Laboratorium Findings

Na 138mmol/l in normal limit)

K5,5 mmol (normal)

Kalsium (9,3mg)

OBJEKTIF

General Appearence Moderate ill

Consciusness Alert

Blood Pressure

Pulse Rate 98 x/mnt

Respiratory Rate 22 x/mnt

Temperature 37 oC

Eyes Conjunctive was not anemic, sclera was not icteric

Thorax Heart and lung didnt find any abnormalities

Abdomen No Distention, bowel sound (+)

Ekstremities Warm acral, good perfussion

SALSABILA, 1 1/12 YEARS OLD, GIRLS, 79 26 08

Chief complain: Fever since 9 days ago Present Illness:

- Fever since 9 days ago, high, not continue, no shivering, no seizure.

- Vomiting since 9 days ago , frequence 2-3x/day, volume 2-5 spoon/times, consist of food, not projectil,

- Watery stools since 7 days ago, frequence 5-6 times/day, volume 2-3 spoons/times, there was no muccus and no blood.

- When defecation 12 hours ago, there found one white worm

- Stomached looked dintention since 5 days ago- Last body weight 10 kg, measured 2 weeks

ago- The child still want drink- Nowadays, the child get porridge , got formula

milk- Never change formula milk- Last mixturation 3 hours ago, dark coloured,

little volume- Patiant already got therapy frompediatrician

2 days ago, have been got pulvis drug for fever 4x1, antibiotic pulvis 3x1, KCl pulvis 3x1, and colistin pulvis 3x1 and got advised to consultation again. Because still fever, the child brought to M Djamil Hospital and on ER the child was seizure all of the body, 2 times, for 1-2 minutes, stopped after got diazepam.

* Past Illness:never had seizure with or without fever

* Familly illness history :There was no family seizure with or without fever

* Sosioeconomic history - fifth child from 5 siblings, SC delivery et causa varices vaginal history, ,mature, birth weight

3100 gram, birth height 49 cm. - History of grow and development was normal - Basic imunization was not complete based on

age - Hygiene and sanitation was poor

GENERAL EXAMINATIONGENERAL EXAMINATIONConciousness allertallert

HRHR 112112 x/mntx/mnt

TemperatureTemperature 37,337,3° ° CC

RRRR 30 30 x/mntx/mnt

GA GA severesevere

BBLL

BW BW 7474 cmcm

99 kg rehidration body weight: 9.4 kgkg rehidration body weight: 9.4 kg

Nutrition statusNutrition status Good nutritionGood nutrition

BB/UBB/U :: 95,995,9 %%

TB/UTB/U : 98,6 %: 98,6 %

BB/TBBB/TB : 99,4 %: 99,4 %

SianosisSianosis NoneNone

Edema Edema None None

AnemisAnemis None None

IkterusIkterus NoneNone

PHYSICAL EXAMINATIONPHYSICAL EXAMINATIONskin Warm, turgor was slowly return

Lymph node not Palpable

Head Fontanella mayor was sunken. Round, simetric, head circumference : 48 cm( normal Standar Nellhaus)

Eye Sunken eyes, tears drop (+), Conjunctiva was not anemic, sklera was not icteric, pupil isocor diameter 2mm, light reflex +/+ normal

ear In normal limit



Teeth and mouth lips and mouth mucose was dryNo oral trush

neck JVP was difficult to examineNuchal rigidity (+)

lung I : normochest, simetrisP : difficult to examinedP : sonorA : bronchovesikuler, rough rales -/-, no wheezing

heart I : ictus was not seenP : ictus palpable on LMCS RIC VP : left side of cor: LMCS RIC VA : sinus rhytme, no murmur

Abdomen Ins : no distentionPal : Supel, liver was palpable 1/4-1/4, flat, sharp, elastic and spleen was not palpablePer : timpaniAus : peristaltic sounds (+) normal

back No abnormalities found


puberty state: A1M1P1

Anus rectal toucher not performedEritema natum (+)

Extremity warm acral, good refilling capiller, Fisiologis reflex +/+ normalPatologis reflex: Babinsky: -/-Chaddock : -/-Oppeinheim: -/-Schaeffer: -/-Gordon : -/-Meningeal provocated sign: kernig sign: -/- brudzynsky I : -/- brudzinsky II: -/-


BloodHb 10,8 g/dl

Leucocyte 8300/mm3

Diff count 0/0/1/60/37/2

Platelete 255.000/mm3

Ht 33.4 %

URINEProtein -

Reduksi -

Leukosit 0-1/

Eritrosit 1-2/


-+

Anemia normositic normocromMCV 78.6 fl

MCH 25.4 pq

MCHC 32 %

Diagnosis Acute diarrhoe with moderate dehidration,

Complex febrile seizure

Normositic normocrom anemia

Observation of febril ec susp UTI

Therapy IVFD 2A 200 cc/kgBW/ day = 18 gtt /mnt (makro)

Breast feeding OD

Luminal 75 mg IM continue luminal 2x40 mg

Paracetamol 4x100mg

Zink 1x20 mg

Albendazol 180 mg

Antibiotic pulvis 3x1

KCL pulvis 3x1

Kolistin pulvis 3x1

Plan electrolyte, glucose blood random

Stool analisys, evaluate rehidration on 1 am

Examination

Result Impression Plan

Natrium

Kalium

114 mmol/l

0

hiponatremi

hipokalemi

Natrium correction 113 mEq on 2A liquid

Evaluate again

Confirm ECG

K correction in 1 hour 9cc/hour

Temporary fasting

Recheck K

Kidney faal

GDR 162mg/ dl

Normal

ECG impressionST depresion (+)Twave (-)U wave (-)

Impresion ; suitable to hypocalemia

Konsult to supervisor : agree with thy

K post correction : lowStill hypocalemiaAct : correction in 1 hour 9 meq/h

Ureum : 12 mg/dlCreatine : 0.6 Immp : in normal limit

MORNING MORNING FOLLOW UPFOLLOW UP S/:No seizureNo breathlessNo feverNo vomitNo coughMixturation normalWatery stool (-)Na and K correction were doneInfusion 2A 500cc

PE/:HR: 110/i RR: 30x/i T: 38C Eye : sunken decreased, konj not anemic, not ictericThorax: cor and pulmo in normal limit Abdomen: distensi (-), intestines sounds (+) . Turgor was slowExtremitas: warm acral, good perfution ,

Im/ febris

Th/IVFD 2A 200 cc/kgBW/ day = 18 gtt /mnt (makro)

Luminal 2x40 mg

Paracetamol 4x100mg

Zink 1x20 mg

Antibiotic pulvis 3x1

KCL pulvis 3x1

Kolistin pulvis 3x1

Balance : 196ccDiuresis : 2.6cc/kg bw/h

K post correction : still low Recorrection in hourPlan : recheck K postcorrection

Na post correction : 138 (in normal limit)

16 juli 2012 english oke

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