DUTY REPORT

WED, 10TH JANUARY

2011
 TEAM ON DUTY

Team on duty:
Ward chief : dr. Hernofialdi
ER chief : dr. Rahmi Lestari
Madya B: dr. Asviandri, dr.Aslinar
Madya A: dr.Devi Gusmayanto, dr. Eni Andriani
Junior: dr.Fitria R, dr. Roza, dr. Rita A, dr. Dian, dr.
Laura
No Sub bagian Lama Baru Pulang Pindah Jml

1 Infeksi 2 - - - - 2
2 Respirologi 2 1 - - - 4
3 Gastrologi - - - 1
4 Hepatologi 1 - - - - 1
5 Neurologi 3 1 - - - 4
6 Gizi & met. - - - - - -
7 Allergi Imm. 1 - - - - 1
8 Endokrin - - - - - 2
9 Hemato 6 1 - - - 4
10 Nefrologi 3 1 - - - 4
11 Kardiologi - - - - - 1
12 Perinatologi 21 2 - - 1 21
13 PGD 3 2 - 1 5
14 NICU 2 - - - - 2
15 Klas I 5 6
48 8 - 2 56
New patient
1.Nadhira, female, 1 year,
bronkiolitis, tonsilopharingitis akut
2. Tessa, Female 1 2/12 y
asthma moderate attack partial respon, rare episode
TFA
3. Fajar, male 5/12 y
susp .Meningitis purulenta
anemia micrositik hypocrom ec. Susp Fe def
undernourished
4. Reski Aditia,male,5/12
Susp. Encephalitis
DD/seizure ec electrolit inbalance
Seizure ec metabolic disturbance
1. Reski Raditya, , 5/12, 733009
Chief complain :
breathless since 4 days ago
Present Illness History:
- Fever since 3 days ago, not high, intermeittent, not continueous, no
shivering and sweating. Fever has appeared after getting shot of DPT
3.
- Cough and cold since 2 days ago. Expectorated.
- Nausea and Vomit not present
- There is no history contact of death poultry
- Urinate and defecation are normal
Past ilness history
Patient has been treated before when he was one month with
Pneumonia Aspiration for 8 days in M. Djamil Hospital
Family Illness history
His father has sneezing history while getting cold
Social history :
Second child of two siblings, Sectio cesaria due to CPD, body
weigth 3000 gram, body heigth 51cm
Imunization was complete
Growth and development was normal
Higene and sanitation is enough
General examination

- General appearance : severe ill

- Consiousness : GCS E1M1V1
- Blood pressure : 70/30
- HR : 120
- Temp : 36,5C
- RR : apneu
- Nutritional status : Under nourish
- BW : 6 kg
- BH : 69 cm
- BW/A :%
- BH/A :%
- BW/BH :%
- Cyanosis :- Icteric : -
- Edema :- Anemic : -

Cold palpable, turgor turnback fast

Lymph node: not palpable

Skin: round, symetrics, large fontanel closed

Head sircumference 44cm, normal std.Nellhaus

Eyes: Conjunctiva not anemic, sklera not icteric, pupil

isokor d:4mm/4mm, light reflex -/-

Nose : in normal limit

ETN In normal limit

Thorax pulmo: vesicular, no ronchi and no wheezing

cor regular rythme, no murmur

Abdomen Distention (-), hepar palpable: -1/3, sharp margin, flat superficial,
chewy,lien not palpable, turgor turnback fast
Genitalia no abnormality found ( puberty state: A1,P1, G1

Anus rectal toucher not performed

Extremity warm acral, good refilling capiller, fisiologis reflex +/+

patologis reflex babinsky +/+, scaefer, chaddoc, gordon,oppenheim -/-
Motoric
TRM kernig sign (-), Brudzinsky I (-), BrudzinskyII (-)
Klonus +/+
Laboratorium
Blood :
Hb : 7 gr/d
Leuco : 22.100/mm3
Tc : 14.000
LED : 50 mm/jam
Diff. count: 0/0/1/67/24/8

Urine :
Colour : yellow
Protein :-
Reduksi :-
Billirubin :-
Urobilinogen :+
Cediment : Leucocyte : -
Eritrocyte : -
flat epitel : -
square epitel -
Diagnosis
Susp. Encephalitis
dd/ seizure e.c electrolit imbalance
Seizure e.c metabolic disturbance
Therapy
VTP 30-40x/mnt
IVFD RL 20cc/kgBB/30mnt : 120 cc/30mnt
: 60 gtt/I macro
Ceftriaxon 1 x 300 mg i.v
Luminal 2 x 15 mg p.o
Perform ETT
Perform Folley catheter
Decompresi NGT
Plan
Electrolit (Na, K, Ca)
Random blood glucose
Consult to eye departement
Laboratory result
Randomized blood 119 mg/dl Normal
Glucose
Na
K
Ca
2. Nadhira Salsabila,female, 1year,
733023
Chief complain :
breathlessness since 1 day ago

Present ilness history:

Cough since 2 days ago, productive, with out cold
Fever since 1 days ago, no whistle, not depent on, food, weather and
activity.
Vomiting since 1 days ago, frequence 2x, volume 2 spoonfull, contain
food and drink, not projectile
No history of atopy
No contact history with patient suffering prolonged cough
No history of chocking
No history of bluish skin before
- No history of of reccuring stop breastfeeding
- Mixturation and defecation in normal limit

Patien have been hospitalized for 1 day at GH Yarsi

BukitTinggi,with thorax X ray:Cor in normal limit,Pulmo
calcification infiltrat perihiler ,Sinus + diaphragma in normal
limit,I/ Active Specific procees. Because of no improvement
patient asked to be reffered to CGH.M.Djamil Padang
Past illness history
Never suffer this kind of disease before
Family illness history
Mother suffering asthma bronchial since 8 years ago
with once exacerbation in 2 months
Social history :
The only child , Sectio cesaria due to fetal distress,
body weigth 2400 gram, body heigth 48cm, directly
cry
Imunization was complete
Growth and development was normal
Higene and sanitation is good
General examination

- General appearance : severe illness

- Consiousness : alert
- Blood pressure : 90/60mmHg
- HR : 120x/mnt
- Temp : 39,1C
- RR : 53
- Nutritional status : well
- BW : 7,4 kg
- BH : 66 cm
- BW/A :77,89 %
- BH/A : 89,2%
- BW/BH :100 %
- Cyanosis :- Icteric : -
- Edema :- Anemic : -

skin Warm palpable

Lymph node: No enlargement of lymphnode

Head: round, symetrics, large fontanel not closed yet

Head sircumference 45cm, normal std.Nellhaus

Eyes: Conjunctiva not anemic, sklera not icteric, pupil

isokor d:4mm/4mm, light reflex -/-

Nose : Nasal flare +

ETN Tonsil T1 T1 hiperemic, no enlargement of cripti, no detritus, Pharing
hiperemic

Thorax pulmo: Retraction epigastrium, intercostal, supraclavicula

bronchovesicular, rales and no wheezing, prolong experium

cor regular rythme, no murmur

Abdomen Distention (-), hepar palpable: 1/4-1/4, sharp margin, flat superficial,
chewy,lien not palpable, turgor turnback fast
Genitalia no abnormality found ( puberty state: A1,M1P1

Anus rectal toucher not performed

Extremity warm acral, good refilling capiller, fisiologis reflex +/+ N

patologis reflex
Laboratorium
Blood :
Hb :11,1 gr/d
Leuco 12.400/mm3
Diff. count: 0/0/1/32/62/4

Urine and feses : in normal limit

Diagnosis
Bronchiolitis
Tonsilopharingitis acute
Therapy :
- O2 2ltr/mnt
- IVFD KaEN IB 105cc/kgBB/Day : 8gtt/mnt (macro)
- Temporary fasting
- Amoxicillin 3 x 200
- Chloramfenicol 4 x 150
- Dexamethasone 4mg i.v
- Dexamethasone 3x 1mg iv
- Paracetamol 75mg
Plan
Electrolit (Na, K, Ca)
Blood Gasses analyzes
Blood culture
Na : 136
K : 3,7
i/ normal limit
Blood Gas analyzes
pH: 7,27
pCO2:51
pO2: 20
HCO3-: 23,5
SO2: 22%
i: hipoksemia
Acidosis respiratoric (maybe mixed with vein blood)
3. Fajar,Male, 5/12, 733013
Chief complain :Fontanel bulging 2 days ago
Present ilness history:
- Fever since 12 days ago, high, continous, no shivering, no sweating, no
convultion
- Patient fussy and cried since 2 days ago, cannot persuade, cried not followed by
high pitched cry
- Fontanel bulging 2 day ago
- Cough and flu not present, dyspnoe not present
- Vomitus not present
- Child got breastfeeding
- No history of trauma capitis
- Mixturation and defecation in normal limit
- Patient had bought at GH.Lubuk Sikaping Pasaman, hospitalized for 2 days, got
therapy ampicillin 6 x 300mg i.v, Gentamicin 2x20mg/iv, dexamethasone3x1mg
iv, IVFD KaEN IB 12 gtt/mnt, because no improvemnet patient reffered to
CGH.Dr,M.Djamil Padang with d/ susp.Meningitis Purulenta
Past illness history
Patient used to fall from cradle at the age of 3 month, from 0,5m
height
Family illness history
None of family member suffer this kind of illness
Social history :
The only child , Sectio cesaria due to fetal distress,
body weigth 2400 gram, body heigth 48cm, directly
cry
Imunization was complete
Growth and development was normal
Higene and sanitation is good
Socioeconomic history
Second child from 2 siblings, spontanous
delivery, mature, helped by midwife, birth
weight 2800grams, body height mother
forgot, directly cried
Growth and development in normal limit
History of immunization never got any at all
Hygiene and sanitation less
General examination

- General appearance : moderate illness

- Consiousness : alert
- Blood pressure : 90/60mmHg
- HR : 118x/mnt
- Temp : 36,5C
- RR : 40
- Nutritional status : good
- BW : 6,5 kg
- BH : 62 cm
- BW/A : 89,04 %
- BH/A : 95,38%
- BW/BH : 100%
- Cyanosis :- Icteric : -
- Edema :- Anemic : +

skin Warm palpable

Lymph node: Not palpable

Head: round, symetrics, large fontanel swalle

Head sircumference 41,5cm, normal std.Nellhaus

Eyes: Conjunctiva anemic, sklera not icteric, pupil isokor

d:4mm/4mm, light reflex -/-

Nose : In normal limit

throat Difficult to examine

Thorax pulmo: vesicular, no ronchi and no wheezing

cor regular rythme, no murmur

Abdomen Distention (-), hepar palpable: 1/4-1/4, sharp margin, flat superficial,
chewy,lien not palpable, turgor turnback fast
Genitalia no abnormality found ( puberty state: A1,P1, G1

Anus rectal toucher not performed

Extremity warm acral, good refilling capiller, fisiologis reflex +/+ N

patologis reflex
Laboratorium
Blood :
Hb :6,8gr/d
Leuco 22.500/mm3
Diff. count: 0/0/12/65/21/2
Tc : 817.000

Urine :
Colour : yellow
Protein :-
Reduksi :-
Billirubin :-
Urobilinogen :+
Cediment : Leucocyte : -
Eritrocyte : -
flat epitel : -
square epitel -
Feses:
- Normal
Ro Thorax:
- Cor in normal limit
- Pulmo calcification infiltrat perihiler
- Sinus + diaphragma normal
I/ Active Specific procees
Therapy :

- IVFD KaEN IB 105cc/kgBB/Day : 4gtt/mnt

(macro)
- Breastmilk
- Ampicillin 6 x 300 iv
- Gentamicin 2x20mg iv
Diagnosis
Obs meningitis purulenta
Anemia mikrositik hipokrom ec susp. Deff Fe
Undernourish
Plan
Electrolit (Na, K, Ca)
Blood Gasses analyzes
Ro thorax
Na: 132 mmol/L
K : 4,6 mmol/L
Ca: 9,4 mmol/L
I: normal limit

PT: 11,5 (10,0-13,6)

APTT : 24,7(29,2-35)
Normal limit
Consult neurology Supervisor (dr.Iskandar
Sp.A(K))
- Give sepsis dose because patient consiouss
- Pending luminal
- Continue dexamethasone
- Prepare for lumbal punction
Consult eye department:
Cannot examine because patient alert so pupil
difficult to fixired
 Follow up this morning
S/
- No Fever
- No seizure
- No vomitus
- No prob lem in breast feeding
- Mixturation normal

GA: moderate illness , aware HR: 110x/I, RR: 36x/I

T: 36,5C
Eyes : conjunctive anemic and sclera no icteric, pupil isokor, light refleks +/+
Thorax : Cor : regular rhytme, no murmur
Pulmo : vesicular, no ronchi, no wheezing
Abdomen : no distention, bowel sound +
Extremity : warm acral, good perfusion

Impression: Stable
LCS finding:
Slowly flow come out from a spinal needle, colour was red
(traumatic)
Nonne : +
Pandy : +
Cell count: 106
PMN 25%
MN 75%
Protein : cannot exemine because sample not enough
Glucose : 66
RBG: 150
I/ suitable to meningitis (mixed with peripheral blood?)
Consult with neurology supervisor : dr. Iskandar
Sp.A(K)
- General appearance is good, alert
- LCS finding cell account was increased
(description meningitis) but WBC LCS can be
came from peripheral leucosit
- Advice : continue therapy with septic dose
- Th/ ampicillin 4x 300mg i.v
- Gentamicin 2x16mg i.v
- Dexamethasone 3x1mg i.v
4. Tessa,Female, 1 2/12, 733042
Chief complain : Dyspnoe since 10 hours ago
Present ilness history:
- Cough since 1 day ago, productive, accompanied by flue
- Dyspnoe since 10 hours ago, whistle, not depend on weather or activity, but
influence by food like chocolate and preservative beverage
- Vomitus since 4 hours ago, frequency 3-4 times. Quantity 2 spoonfull/times,
contain what been eaten and drank, not projectile.
- Febris since 4 hours ago, not high, continous, no shivering, no seizure
- No history of atopic
- History contact with patient suffering prolong cough
- No history of bluish skin
- No history of of reccuring stop breastfeeding
- Mixturation and defecation in normal limit
- Patient had brought to midwife 6 hours ago, and given pulvis and vitamin syrup,
because the patient still dyspnoe, patient brougt to CGH.M.Djamil Padang, At
ER the child has nebulated ventolin 2 times and combiven 1 time, because the
symptom still present, the patient sugessted to be hospitalized
Past illness history
Since 5 months old patient often dyspnoe and cough almost every
month, last attack 1 month ago
Family illness history
Grandfather suffer asthma bronchiale
Social history :
Second child from 2 siblings, vaccuum delivery,
helped by doctor due to prolong labour, gravid
mature, Body birth weight 3200grams, Body birth
height 47cm, directly cry
Growth and development was normal
Basic imunization history complete
Higene and sanitation less
General examination

- General appearance : moderate illness

- Consiousness : alert
- Blood pressure : 90/60mmHg
- HR : 130x/mnt
- Temp : 38,2C
- RR : 48x/mnt
- Nutritional status : good
- BW : 9,5 kg
- BH : 75 cm
- BW/A : 90,47 %
- BH/A : 98,68%
- BW/BH : 96,93%
- Cyanosis :- Icteric : -
- Edema :- Anemic : -

skin Warm palpable

Lymph node: Not palpable

Head: round, symetrics, large fontanel still open

Head sircumference 45cm, normal std.Nellhaus

Eyes: Conjunctiva not anemic, sklera not icteric, pupil

isokor d:2mm/2mm, light reflex -/-

Nose : Nasal flare -

throat Tonsil T2-T2, hyperemic, detritus -, kripta normal, faring not hyperemic

Thorax pulmo: vesicular, no ronchi and no wheezing

cor regular rythme, no murmur

Abdomen Distention (-), hepar palpable: 1/4-1/4, sharp margin, flat superficial,
chewy,lien not palpable,
Genitalia no abnormality found ( puberty state: A1,M1, P1

Anus rectal toucher not performed

Extremity warm acral, good refilling capiller, fisiologis reflex +/+ N

patologis reflex -/-
Laboratorium
Blood :
Hb : 11,7gr/d
Leuco :17.100/mm3
Diff. count: 0/0/8/81/10/1
Tc: 390.000

Urine :
Colour : yellow
Protein :-
Reduksi :-
Billirubin :-
Urobilinogen :+
Cediment : Leucocyte : -
Eritrocyte : -
flat epitel : -
square epitel -
Feses:
- yellow, flabby
- Ery : -
- Leuco: -
- Worm egg: -
Therapy :
- O2 2ltr/mnt
- IVFD KaEN IB 4gtt/mnt (macro)
- MC 6 x 150cc/NGT
- Amoxicillin 3 x 150mg p.o
- Paracetamol 100mg
- Prednison 3x3 mg
- Ambroxol 3 x 5mg
- Salbutamol 3x1
- Nebulitation combiven 1/3 resp/2hours
Diagnosis
- Asthma Bronchiale moderate exacerbation rare
episode with partial respon
- Tonsilofaringitis acut
 Follow up this morning
S/
- No Fever
- Still pale since 2 days ago, more and more pale
- No vomite
- No cough and no cold, no breathlessness.
- No bleeeding from nose, gims, gastrointestinal ract and elsewhere.
- No bruising history
- No history of continous bleeding
- No history of using a drug, jamu, radiotherapy, and transfusion.
- Mixturation and bowel in normal limit.
0/
GA: moderate illness , aware BP:100/60mmHg HR: 110x/I,RR: 24x/I
T: 37C
Eyes : conjunctive was anemic and sclera was icteric
Thorax : Cor : regular rhytme, sytolic murmur in all ostium
Pulmo : vesicular, no ronchi, no wheezing
Abdomen : No distention, hepar palpable 2/3 sharp edge, flat, chewy , and spleen S 2-3
Extremity : warm acral, good perfusion

Impression: Stable