Presentation Rota
Transcript of 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