DUTY REPORT July 16th 2012

TEAM ON DUTY
Chief ER Chief Ward Madya : dr. Julinar : dr. Risma : dr. Ikhsan M dr. Riri D s dr. Ronaldinoor : dr. Eni andriani dr. Febbianne

Perinatology Madya Junior

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

No
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Sub bagian
Infeksi Respirologi Gastrologi Hepatologi Neurologi Gizi & met. Allergi Imm. Endokrin Hemato Nefrologi Kardiologi Perinatologi PGD NICU Klas I Jumlah

Lama
5 1 `7 -1 19 1 3 15 5 2 6 64

Baru
1 1 2 2 1 7

Pulang
-

Pindah
-

Jml
5 1 1 7 1 19 1 4 17 7 2 6 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

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 glass/times, there was no muccus and no blood. - Vomiting since 3 days ago , frequence 2-3x/day, volume 3 spoon- 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 couldnt 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 EXAMINATION
Conciousness HR Temperature RR GA allert 106 x/mnt 36,8 C 32 x/mnt Moderate

BL BW
Nutrition status

73 cm 7.8 kg
Undernourished BB/U : 89,1 % TB/U : 100 % BB/TB : 89,1 % None None None

Sianosis Edema Anemis

Ikterus

None

PHYSICAL EXAMINATION
skin Warm, turgor was very slowly return

Lymph node
Head

not Palpable
Fontanella mayor was sunken. Round, simetric, head circumference : 43 cm ( normal Standar Nellhaus) fontanel was sunken Sunken eyes, tears drop (+), Conjunctiva was not anemic, sklera was not icteric, pupil isocor diameter 2mm, light reflex +/+ normal In normal limit In normal limit

Eye

ear nose

throat
Teeth and mouth neck

Tonsil T1-T1 not hiperemic, faring not hiperemic

lips and mouth mucose was dry No oral trush

JVP was difficult to examine

lung

I P P A I P P A

: normochest, simetris : fremitus left+ right : sonor : bronchovesikuler, rough rales -/-, no wheezing : ictus was not seen : ictus palpable on LMCS RIC V : difficult to examined : sinus rhytme, no murmur

heart

Abdomen

Ins : no distention Pal : Supel, liver was palpable 1/4-1/4, flat, sharp, elastic and spleen was not palpable Per : timpani Aus : peristaltic sounds (+) normal No abnormalities found

back

Genetalia

In normal limit puberty state: A1P1G1

Anus Extremity

rectal toucher not performed Eritema natum (+) warm acral, good refilling capiller, Fisiologis reflex +/+ normal Patologis reflex: -/-

LABORATORIUM
Blood
Protein
Hb Leucocyte Diff count Platelete Ht 11,9 g/dl 10800/mm3 0/2/2/44/50/2 505.000/mm3 38%

URINE
Reduksi Leukosit Eritrosit

Bilirubin Urobilinogen

FESES
Macroscopis Mikcoscopis Yellow, soft, mucous + Eritrosit 0-1 , leukosit 1-2

Diagnosis

Acute diarrhoe with moderate dehidration, Under nourished 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

Therapy

Plan

electrolyte, feses cultur Stool analisys, rehidration evaluate on 10 pm

FOLLOW UP 23 00
S/: Watery stool (+), 1x Fever (-), breathlessness No vomite, micturation + normal PE/: HR: 104/i RR: 30x/i T: 37 WB: 8.25 kg Eye : no sunken, tears drop (+) konj not anemic, not icteric Thorax: cor and pulmo in normal limit Abdomen: distensi (-), intestines sounds (+) . Turgor was good Extremitas: 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
S/: No fever Watery stool (+ 1times), No vomitus No breathlessness Mixturation was normaly

FOLLOW UP
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

PE/: HR: 102/i RR: 32x/i T: 36,8C BW : 8,1kg Eye : no sunken, tears drop (+) konj not anemic, not icteric Thorax: cor and pulmo in normal limit Abdomen: distension (-), intestines sounds (+) . Extremity : warm acral, good perfution , Im/ acute diarrhea wihout dehidration

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 dont 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 EXAMINATION
Conciousness
Blood Pressure HR Temperature RR GA BL BW Nutrition status 148 x/mnt 38,1 C 44 x/mnt Severe 65 cm 7,8 kg normal W/A H/A W/H None None anemic : 96 % : 95 % : 108 %

allert

Sianosis Edema Anemis

Ikterus

None

PHYSICAL EXAMINATION
skin Lymph node Look pale Palpable node at right submandibullaleft and right,single, size 1x1x1cm, mobile Palpable node at right and left coli, size 1x1x1cm, mobile, Round, simetric,head sircumfrence 42cm( N standart nellhauss) conjunctiva anemic, sclera not icteric, pupil diameter 2mm, light reflex +/+ N In normal limit

Head Eye

ear

nose
throat neck

In normal limit
Tonsil T1-T1 not hiperemic, faring not hiperemic JVP 5-2 cmH2O

lung

I P P A

: normochest, simetric : fremitus right = left : sonor : vesikuler, no rhonchi, no wheezing

heart

I : ictus not seen P : dificult to examined P :in normal line A : sinus rhytme, sistolik noise grade 3/6 at all ostium Ins : no distention Pal : Supel, liver and spleen was not palpable Per : timpany Aus : peristaltic sounds (+) normal No abnormality

Abdomen

back

Genetalia

In normal limit
puberty state: A1M1P1

Anus

rectal toucher was not performed

Extremity

warm acral, good refilling capiller Fisiologis reflex +/+ normal

Patologis reflex: -/-

LABORATORIUM
URINE

Blood
Hb 4,3 g/dl

Protein Reduksi Leukosit Eritrosit Bilirubin Urobilinogen

Leucocyte
Diff count

11.800
0/0/0/0/92/0

Platelete
Ht blast

9.000/mm3
13% 8%

FESES
Macroscopis Mikcoscopis yellow 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, HR 134 x/mnt, BP 90/60

concious RR 40 x/mnt, T= 36,6 C

eye : Konjungtiva anemis, sklera not ikterik Thorax : Retraction (-) Cor : regular rhytm, no murmur

O2 2l/i IVFD KaEN 1B4drop/i (makro) Cefotaxime 2x200mg Paracetamol 80 mg (t > 38,5 C) Soft meal 3x Fruit and biscuit 2x Blood trunfution PRC and TC

Pulmo : vesikuler, Rhales -/-, WH -/Abd : distension(-), Intestinal sound(+) N, Ekstr : warm, perfusion is good, ptechie positif Impresion ; febris

BY CHERLI RAMA PUTRA, BOYS, 32DAYS, 792625

Chief Complain
Doesnt want to take breast milk History of present illness - Baby doesnt 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 suffer from this desease

Social Economic history The last child of 4siblings, spontaneus delivery, assisted by midwife, BW 2300 gr, not Cried directly, cried after 30 minutes

Consciusness General Appearence Blood Pressure Pulse Rate Temperature Respiratory Rate Body Weight Body Height Cyanosis Edema Anemic Icteric

Alert, not active Severe 160x/minute 37,7oC 42x/mnt 46 Cm 1,9 kg Not Present Not present Not Present present

PHYSICAL EXAMINATION
skin Lymph node Head Eye Look iktericuntil extremity, turgor very slowly No Palpable node Round, simetric,head sircumfrence 31cm, conjunctiva not anemic, sclera not icteric, pupil diameter 2mm, light reflex +/+ N In normal limit In normal limit Tonsil T1-T1 not hiperemic, faring not hiperemic In normal limit

ear nose throat neck

lung

I P P A I P P A

: normochest, simetric : fremitus right = left : sonor : broncovesikuler, no rhonchi, no wheezing : ictus not seen : dificult to examined :in normal line : sinus rhytme,

heart

Abdomen

Ins : no distention Pal : Supel, liver palpable -1/4 Per : timpany Aus : peristaltic sounds (+) normal No abnormality

back

Back Genitalia Pubertal status Anus

scolyosis (+)

No abnormalities founded

Rectal toucher was not done

extremities

Warm acral, good capillary refill

Laboratorium Findings
Blood Hb Leukocyte DC 13,7 g/dl 21.000/mm3 0/0/0/85/15/0

reticulocit
hematocrit

21%
41%

trombocit bilirubin

123.000/mm3
Total : 22,47mg/dl Bil I: 415 Bil II: 1828

Diagnosis

Severe dehidration ec low intake Hiper bilirubunemia Conjungtivitis ODS Susp. Down sind Susp.hipothiroid congenital O2 1l/i nasal IVFD N4 20cc/hour Meropenem 3x75mg IV Urdofalk 3x20mgPO Breast milk 8x20cc Ofloxacine 6x1gtt ODS Chreatynin kinase Electromyography Electrocardiography Muscle Biopsy Rontgen vertebrae

Treatment

Planning

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 : (-)

FOLLOW UP MORNING
- Still fever - No breathlessness - No nausea and vomitting - No cought and flu, no breathlesness - Micturition and defecation was normal

OBJEKTIF

General Appearence
Consciusness Blood Pressure Pulse Rate Respiratory Rate Temperature Eyes Thorax Abdomen Ekstremities

severe illness
Alert, not active

140 x/mnt 40x/mnt 37,5 oC Conjunctive was not anemic, sclera was not icteric Heart and lung didnt find any abnormalities No Distention, bowel sound (+) Warm acral, good perfussion

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

Chief Complain
The child look sianotic since 1 year ago History 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
Neck

Wet buccal and lip mucose

JVP5-2 cmH2O,neck rigidity was not present. Ins : Normochest, Pal : Left fremitus = right fremitus Per : sonor Aul: broncovesikuler, No Rales, No wheezing Ins : Ictus Cordis was not visible Pal : Ictus Cordis palpable at 1 finger at medial of SMCL ICS V Per : Cor border, upper ICS II, Rght DSL, Left 1 finger at medial of SMCL ICS V. Aul: Regular Rhytm, No Murmur

Pulmo

Cor

Ins : No Distention Pal : Supel, liver and spleen was not papable Abdomen Per : Tympani Aus : Intestinal sound ( +) normal

Back Genitalia Pubertal status

scolyosis (+) No abnormalities founded A1P1G1

Anus

Rectal toucher was not done

Laboratorium Findings
Blood Hb Leukocyte DC 12,3 g/dl 13.400/mm3 0/3/1/54/41/1

Diagnosis

Congenital heart disease ec susp TOF Failure to trive dextrocardi Regular Food 700 Breath milk

Treatment

Planning

Electromyography Electrocardiography Muscle Biopsy Rontgen vertebrae

Na 138mmol/l in normal limit) K5,5 mmol (normal) Kalsium (9,3mg)

OBJEKTIF

General Appearence
Consciusness Blood Pressure Pulse Rate Respiratory Rate Temperature Eyes Thorax Abdomen Ekstremities

Moderate ill
Alert

98 x/mnt 22 x/mnt 37 oC Conjunctive was not anemic, sclera was not icteric Heart and lung didnt find any abnormalities No Distention, bowel sound (+) 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 EXAMINATION
Conciousness HR Temperature RR GA allert 112 x/mnt 37,3 C 30 x/mnt severe

BL BW
Nutrition status

74 cm 9 kg rehidration body weight: 9.4 kg

Good nutrition BB/U : 95,9 % TB/U : 98,6 % BB/TB : 99,4 % None None None

Sianosis Edema Anemis

Ikterus

None

PHYSICAL EXAMINATION
skin Warm, turgor was slowly return

Lymph node
Head

not Palpable
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
In normal limit In normal limit Tonsil T1-T1 not hiperemic, faring not hiperemic

ear nose throat Teeth and mouth neck

lips and mouth mucose was dry No oral trush

JVP was difficult to examine Nuchal rigidity (+)

lung

I P P A I P P A

: normochest, simetris : difficult to examined : sonor : bronchovesikuler, rough rales -/-, no wheezing : ictus was not seen : ictus palpable on LMCS RIC V : left side of cor: LMCS RIC V : sinus rhytme, no murmur

heart

Abdomen

Ins : no distention Pal : Supel, liver was palpable 1/4-1/4, flat, sharp, elastic and spleen was not palpable Per : timpani Aus : peristaltic sounds (+) normal No abnormalities found

back

Genetalia

In normal limit puberty state: A1M1P1

Anus
Extremity

rectal toucher not performed Eritema natum (+)

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

LABORATORIUM
Blood
Protein
Hb Leucocyte Diff count Platelete Ht 10,8 g/dl 8300/mm3 0/0/1/60/37/2 255.000/mm3 33.4 %

URINE
0-1/ 1-2/ Reduksi Leukosit Eritrosit

Bilirubin Urobilinogen

Anemia normositic normocrom

MCV MCH MCHC 78.6 fl 25.4 pq 32 %

Diagnosis

Acute diarrhoe with moderate dehidration, Complex febrile seizure Normositic normocrom anemia Observation of febril ec susp UTI 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

Therapy

Plan

electrolyte, glucose blood random Stool analisys, evaluate rehidration on 1 am

Examinatio n Natrium

Result

Impression

Plan Natrium correction 113 mEq on 2A liquid Evaluate again

114 mmol/l hiponatremi

Kalium

hipokalemi Confirm ECG K correction in 1 hour 9cc/hour Temporary fasting Recheck K Kidney faal

GDR

162mg/ dl

Normal

ECG impression ST depresion (+) Twave (-) U wave (-)

Impresion ; suitable to hypocalemia

Konsult to supervisor : agree with thy

K post correction : low Still hypocalemia Act : correction in 1 hour 9 meq/h Ureum : 12 mg/dl Creatine : 0.6 Immp : in normal limit

MORNING
S/: No seizure No breathless No fever No vomit No cough Mixturation normal Watery stool (-) Na and K correction were done Infusion 2A 500cc

FOLLOW UP
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 : 196cc Diuresis : 2.6cc/kg bw/h

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

K post correction : still low Recorrection in hour Plan : recheck K postcorrection

Na post correction : 138 (in normal limit)