DUTY REPORT

20 Januari 2015
 Team of duty
Chief of Emergency : dr. Febbiane eldrian
Chief of Ward : dr. Eni Andriani
Madya of Perinatolology : dr. Trisna Resti yanti
dr. Mila Agustia
Madya of Emergency : dr. Ranti Adriani
Madya of Ward : dr. Anggia perdana
dr. Fitriyana
dr. M. Robi
Junior : dr. Irhamna Yusra
dr. M.Hafiz
dr. Devi Novriyanti
dr. Handre Putra
dr. Shinta Ayudhia
 LIST OF NEW PATIENTS
NO NAME DIAGNOSIS
1. Khairi lutfi, boy, 7 years. 882925 Nefrotic syndrome dependat steroid
Hipotention stage 1
2 Rizky habib Mulya , boy, 9 years Suspected Epilepsy
5 month
894129

3 Fina Jantika Putri, Pr, 13 tahun, MR DHF grade III (shock has been resolved)
896100 Overweight

4 Genta Saputra, boy, 11 4/12 years Observation of Long Febrile due to Suspected Typhoid Fever, DD/
old Lung Tuberculosis, Urinary Trcatus Infection
89 61 14 Moderate dehydration due to tough intake

Zhafran Gustindo P, Boy, 5 month, Susp. Renal tubular asidosis

881364 Bronkopneumonia in treatment
Post colostomy a/I atresia ani
Failure to thrive
Susp. sepsis
Khairi lutfi, boy, 7 years.
882925
 Anamnesis
(Alloanamnesis from mother)

Chief complain :

Increasing of Oedem
since 2 weeks ago
 Present illness History
Oedem since 2 weeks ago and got swollen
since a week ago. First, oedem looked at
palpebra,then oedem wide to whole body

Patient known has nefrotic syndrome

since august 2014 and treated at regional
hospital in Solok Selatan for 14 days

He got prednison for 1 month . Proteinuria

(-) but when the dose changed into
intermitten, proteinuria (+) in 3rd week

Treatment was contanue untill november

2014
 Present illness History
29 desember 2014 he came to
take reguler treatment at
RSUP DR. M. Djamil
He got MMF 1x 375 mg,
Captopril 3x6,25 mg, prednison
1x 5 tab intermitten
Parent stop the medicine and
then take the alternative

No fever
 Present illness History

No cough, no cold, no
breathless

No nausea and vomit

He got appropriate diet menu

(low salt)

No abdominal pain
 Present illness History

No history of bloody defecation

Murky color urination, usual

amount

He got appropriate diet menu

(low salt)

Usual Color and consistency of

defecation
 Past illness

Child has been known History of birth

with nefrotic syndrome
since august 2014

Family He is the first from 2

history child ,spontan labour,
weight of birth 2900
gr,length of birth 49 cm
There is no aterm,cried directly
family having
disease before
 History of basic immunization was
complete
Growth and development was normal
Higiene and sanitation was good
General examination
General appearance
Insert Text Here
consciousness Alert
Blood presure 130/80
HR 100 x/minutes
Temperature 37,5C
RR 20 x/minutes
Height 115 cm
Weight 28 kg
Upper Middle Arm 108,5 mm
Nutritional status Well nourished
w/a : 121,727 %
h/a : 94,26%
w/Th : 133,33 %

Cyanotic Not present

Edema present
Anemic Not present
skin Insert Text Here
Warm palpable
Lymph node Lymnode was not palpable
Head Round, symmetric
Hair Black, hard to be pulled
Eye Palpebra oedema +/+
Conjunctiva was not anemic , sclera not icteric
pupil isochors, diameter 2mm, light reflect +/+ normal
Ear In normal limit
nose In normal limit
neck JVP 5-2 cmH2O
throat Tonsil T1-T1, not hiperemis
Faring was not hiperemis
Teeth and mouth Lips and mouth mucous were wet
Lung Ins : normochest, simetris, no retaction
Pal : Fremitus right=left
Per : sonor
Aus :vesiculer, Rhales -/-, wheezing -/-

cor I ; ictus was not seen

P : ictus was palpable on1 finger medial line intercostal space
V
P : heart border,upper : RIC II, right : LSD, left: 1 finger medial
LMCS RIC V
A : reguler rythym, no murmur
Abdomen Ins : distention
Pal : supel, liver and lien was not palpable, undulation
(+),shifting dullness (+) abdominal circumference 69,5 cm
Per :timpani, shifting dullness
Aus : Intestinal sound normal
back In normal limit
Genitalia A1M1P1
Pubertal status oedem in genital

Anus Rectal toucher not performed

Extremities Warm, good refilling capillary
Physiologic Reflex +/+ normal
Pathologic Reflex -/-
 Insert Text Here
Blood examination (LYSIS) URINE
Hb : 13,9 gr/dl Albumin +++
Leukocyte : 13.500/mm Reduction -
DC : 0/1/2/79//5 Sedimen -
Platelet :593.000/mm3
Leucocyte 15-30/ LPB
LED : 20
Eritocyte 1-2/LPB
:
Diagnosis Nefrotic syndrome depend at steroid
Insert Text Here
Hipotention stage 1
UTI

Therapy MB nefrotic 1500 kkal

Salt 1 gram/day
Protein 40 gr/day
Captopril 3x6,25 mg
Ceftriaxone 1 x 1,5 gram
Plan Urin cultur
Electrolit, albumin, ureum, creatinin
colesterol
Total protein 3,9 Hipoalbuminemia No need corection
Albumin 1,2
Globulin 2,7
Na : 125 Hiponatremia No need corection
K : 3,4 In normal limit
Ca : 5,6 Hipocalsemia With albumin corection :
7,8
A/ calnic syrp 2 x cth 1
1/2
Ur : 38 In normal limit
Cr 0,9
 Morning Follow Up
Subjective Objectives therapy
no fever moderate ill , alert, HR: 90x/mnt, RR MB nefrotic 1500 kkal
Oedem still present Salt 1 gram/day
No cought :24x/mnt, Protein 40 gr/day
No seizure Eyes :conjunctiva was not anemic, sclera Captopril 3x6,25 mg
No vomit Ceftriaxone 1 x 1,5 gram
No abdominal pain not icteric, oedem palpepra Prednison 1 x 5 tab
Mixturition in normal +/+ Lasix 2 x 20 mg
limit MMF 1 x 500 mg
Thorax : retraction (-)
Cor: ritmic, no thirill Fluid balance : - 60 cc
Diuresis : 1 cc/kgbw/hour
Pumo: vesiculer, Rh -/-, Wh-/-
Abd : distension(-), Intestinal sound(+) N,
Ekstr : warm, perfusion is good

Interpretation: anasarka oedem due to

hipoalbumin
Rizky habib Mulya , boy, 9 years 5 month
894129
 Anamnesis
(Alloanamnesis from mother)

Chief complaint :

Repeated seizure 4
Hours ago
 History of present illness

4 hours ago
Repeated seizure, frequency 4x, duration 1-3 minutes/ time,
interval between seizure 15 minutes- 1 hour, seizure all of body,
eyes look upper, alert after seizure
 History of present illness

no fever , no cough, no cold

Patient still want to eat and drink. No nausea, vomiting
No breathlessness
No history of head trauma
Mixturition was normal
Defecation was normal
 Past illness

Patient has been

hospitalized in m History of birth
djamil hospital 18
days ago with
epilepsy and Family The 3th child from 3
history of history siblings, spontaneus,
birth body weight 3500
epileptical status.
grams, birth body lenght
Patient was No family was forgotton, cried
discharge as suffered seizure directly
before
family request
ang get luminal 2
x 60 mg( oral),
latest , Child get
luminal in
emergency ward.
 history of basic immunization was
completed
Growth and development was normal
Higiene and sanitation was good enough
General examination
General appearance Moderate ill
consciousness Alert
HR 98 x/minutes
Temperature 37 C
RR 20x/minutes
Height 130 cm
Weight 29 kg
Nutritional status well nourish
w/a : 96,67 %
h/a : 96, 29 %
w/Th : 107,41 %

Cyanotic None
Edema None
Anemic None
Icterus None
skin Warm palpable
Lymph node No Palpable
Head Round, symmetric, head circumference 51 cm ( normal std
Nellhaus),
Hair Black, hard to withdraw
Eye Conjunctiva was not anemic, sclera not icteric
pupil isochors, diameter 2mm, light reflect +/+ normal
Ear In normal limit
nose In normal limit
neck JVP 5-2 cmH2O
No nuchal rigidity
throat Tonsil : T1-T1 , not hiperemic, no detritus,
Faring not hiperemic
Teeth and mouth lips and mouth mucous was wet
Lung Ins : no retraction
Pal : fremitus is simetric
Per : sonor
Aus : vesiculer, no rales, no wheezing

cor I ; ictus was not seen

P : ictus was palpable on midclavicularis line intercostal space V
P: hard to examine
A : regular rhythm, no murmur
Abdomen Ins : no distention
Pal : supel, liver was and spleen was not palpable
Per : timpani
Aus : Intestinal sound (+) normal
back In normal limit
Genitalia No abnormality
State puberty A1P1G1
Anus Rectal toucher not performed
Extremities Warm, good refilling capillary
Physiologic Reflex +/+ normal
Pathologic Reflex -/- : babinsky reflek -/-, openheim -/-
.chadock -/-, gordon -/-, schaefer -/-
Meningeal sign : brudzinky I -, Brudzinky II -, kernig sign -
Diagnosis Suspected Epilepsy
Insert Text Here
Therapy Regular meal 1000 kcal
Luminal 2 x 70 mg PO

Plan SGOT, SGPT

EEG
 03.00 Follow Up
Subjective Objectives therapy
Seizure, freq 3 times, moderate ill , alert, HR: 90 x/mnt, RR 21 Regular meal 2000 kcal
periode 30 second 1 Luminal 2x70 mg (po)
minute, focal seizure on x/mnt,
right face, self stopped Eyes : conjunctiva was not anemic, sclera
No fever
No nausea was not icteric, pupil isocor
No vomiting Cor: regular rhythm, no murmur
Pulmo : vesiculer,no rales, no wheezing
Abd : distension(-), Intestinal sound(+) N,
Ekstr : warm, perfusion is good
Interpretation: focal seizure do to
epilepsy
 06.00 Follow Up
Subjective Objectives therapy
Seizure, freq 2 times, moderate ill , alert, HR: 93 x/mnt, RR 22 Regular meal 2000 kcal
periode 20 second, focal Luminal 2x70 mg (po)
seizure on right face, x/mnt,
self stopped Eyes : conjunctiva was not anemic, sclera
No fever
No nausea was not icteric, pupil isocor, 2 mm
No vomiting Cor: regular rhythm, no murmur
No cought, no cold
Mixturation in normal Pulmo : vesiculer,no rales, no wheezing
limit Abd : distension(-), Intestinal sound(+) N,
Defecation in normal
limit Ekstr : warm, perfusion is good
Interpretation: focal seizure do to
epilepsy
Fina Jantika Putri, Girl, 13 yo, 89
61 00
 Anamnesis
(Alloanamnesis from mother)

Chief complaint :

Cold hands and foot

since 5 hours ago
 History of present illness
Fever since 4 days ago, high, continuous, no shivering,
no sweating, no seizure

Vomit since 4 day ago, frequency 1x, amount 1/4

glass/time, contains what he had been eaten and
drunk

Less drinking water since 3 days

Stomachache since 3 days ago, particularly in

epigastric area

Cold hands and foot since 5 hours ago

 History of present illness
There were no gum and nose bleeding
There were no cold and cough
Today, she is first menstrual period. Changing menstrual
pads 1 x, amount nearly the same within normal.
Urinate was less, concentrated in color, latest urinate about
6 hours ago
Defecation was within normal limit
Child has been came by General practitioner and undergone
Rumple Leed (+), last laboratory finding were Hb: 17,5 gr/dl,
Ht : 53%, thrombocyte : 55.000/mm3, leucocyte : 5000/mm3,
and referred to Dr. M. Djamil hospital
At ER of M. Djamil Hospital, child got shock, the finding was
pulse around 120x/minute, not strong lifted pulse, blood
pressure 110/90 mmHg, CRT > 2 seconds, and treated by giving
RL 20 cc/kg BW/20 minutes, shock was resolved after giving
cristaloid 20cc/Kg BW/20 minutes (Blood pressure 120/80
mmHg, HR 106x/minute, strong lifted pulse)
 Past illness

There was no History of birth

history of
suffering Dengue
Family Third child from 4
Fever before
history siblings, spontaneous,
helped by doctor, aterm,
birth body weight was
There are no 3500 grams, birth body
history of lenght was 50 cm, cried
blood related directly
and
neighbour
suffering DHF
 History of basic immunization was
complete
Growth and development was normal
Higiene and sanitation were good enough
General examination
General appearance
InsertSevere
Text ill
Here
consciousness alert
Blood Pressure 110/80 mmHg
HR 110 x/minute
Temperature 38,1 C
RR 28 x/minutes
Height 150 cm
Weight 54 kg
Nutritional status Overweight
W/A : 117 %
H/A : 95 %
W/A : 131 %

Cyanotic None
Swelling None
Anemic None
Icteric None
 Insert Text Here
skin Warm palpable, Rumple Leed (+) at right antebrachial
Lymph node Not Palpable
Head Round, symmetric
Hair Black, hard to withdraw
Eye Conjunctiva not anemic, sclera not icteric
pupil isochors, diameter 2mm, light reflect +/+ normal
Ear within normal limit
Nose Within normal limit
Neck JVP 5-2 cmH2O
Throat Tonsil : T1-T1 , not hyperemic
Pharynx : not hyperemic
Teeth and mouth lips and mouth mucous were wet
Lung Ins : normal chest, retraction (+) in epigastric area
Pal : left fremitus = right fremitus
Per : sonor
Aus : vesicular ,no rales, wheezing -/-

Cardiac I : ictus was not seen

P : ictus was palpable on 1 finger medial midclavicular line
intercostal space V
P : heart border, upper: RIC II, right: LSD, left: 1 finger medial
midclavicular line ICS V
A : regular rhythm, no murmur
Abdomen Ins : not distended
Pal : supple, liver and spleen werent palpable. No
tenderness
Per :tympani
Aus : Intestinal sound normal
back within normal limit
Genitalia Not found abnormality
State puberty A1M2P2
Anus Rectal touche was not performed
Extremities Warm, good refilling capillary, CRT <2 seconds
Physiologic Reflex +/+ normal
Pathologic Reflex -/-
 Insert Text Here
Blood
Stool
Hemoglobin 17,5 g/dl Macroscopic Brown, tender
Leukocyte 5700/mm3
Microscopic Leukocyte (-)
DC 0/0/5/36/55/4 Erythrocyte (-)
Thrombocyte 50.000/mm3 Worm eggs (-)
Hematocrit 53 %
Erythrocyte 4 x 106 /mm3
Diagnosis DHF grade III (shock has been resolved)
Insert Text Here
Overweight

blood

Hb 8.9 g/dl
Therapy IVFD RL 10cc/kgBW/hours 120 drops/I macro -> 60
drops/I (two lines)
Leukocyte 7100/mm
ML 3
2000 Kkal
More drinking water
DC Paracetamol
0/0/0/52/47/13x500mg (T>38,5 C)

MCH 28,7
Plan
MCV Serial
87,09 Hb, Ht, Tc
MCHC IgG and IgM anti dengue
32,9%
interpretation Normositic
Vital sign
normocrom
Fluid balanceanemia
 Hb, Ht serial

Hb:15 gr/dl
Ht : 45 %
Platelet: 10.000/mm3

Interpretation : Decreasing of platelet than

before, decreasing of hematocrit than before
 Hb, Ht serial

Hb: 14,7 gr/dl

Ht : 43 %
Platelet: 10.000/mm3

Interpretation : Decreasing of hematocrit

than before
Action : IVFD RL 65 cc/kgbw/hour 36
drops /minute
 Follow Up 06.00
Subjective Objectives therapy
fever was present, not severely ill , alert, HR: 102 x/mnt, RR : 28 IVFD RL 65 cc/kgbw/hour
high 36 drops /minute
No vomit x/mnt, T : 37,9 C ML 2000 Kkal
Menstrual bleeding was Skin : warm palpable More drinking water
not much Paracetamol 3x500mg
Abdominal pain, Eyes : conjunctiva was not anemic, sclera (T>38,5 C)
intermitten not icteric
No seizure Fluid balance : + 1860cc
No breathelessness Cor and Pulmo : in normal limit Diuresis : 2,6
Mixturation and Abd : distension(-), Intestinal sound(+) N, cc/kgwb/hour
defecation in normal limit
Ekstr : warm, perfusion is good

Interpretation: Febris D5-6

Genta Saputra, boy, 11 4/12 years old
89 61 14
 Anamnesis
(Alloanamnesis from mother)

Chief complaint :

Fever since 20 days ago

 History of present illness

20 days ago
Fever, high, intermittent, shivering, no sweating, high
fever, particularly at night and less in the morning

10 days ago
Patient appears thinner. History of body weight
before unknown
Abdominal pain, intermittent, particularly felt at
epigastric area

7 days ago
Cough, not expectorant, not followed with cold and
breathless
Felt weak, so that child lied down only in bedroom
The Patient doesnt want to eat since he got ill. Patient only eats twice per day,
eating only 2-3 tablespoons/time
No nausea and vomit
Defecation wasnt smooth since he got ill, defecation was only one time over three
days and the latest a week ago, color and consistency were normal
The latest urinate was 10 hours ago, dense yellow in color, amount less than before
No history contact with patient that has long coughing
No History of ear discharge
No history of urinal pain
The patient isnt a student anymore. Patient was only received education till 2nd
grade of elementary school. Then he stopped schooling due to not getting higher
level. And he could only read by spelling the words. He couldnt count the number
fluently.
The patient couldnt speak fluently and often spattered
He had never been visited General Practitioner and only treated by herbal
medicines. Because of weaknesses, the patient has been brought to ER M Djamil
hospital
 Past illness
Family
There was no history History of birth
history of suffering
illness like this No family history
before The third child of 3
has been suffering
illness like this and siblings, spontaneous
had history of delivery helped by
chronic cough midwife, aterm, forgot
of birth body weight,
forgot of birth body
length, cried directly
 Basic immunization was not complete
Growth and development was within
normal limit
Hygiene and sanitation were enough
General examination
General appearance Moderate Illness
consciousness Alert
HR 108 x/minutes
Temperature 39,0 C
RR 28x/minutes
Height 134 cm
Weight 20 kgs, rehydration body weight: 21,2 kgs
Nutritional status undernourished
w/a :57,29 %
h/a : 92,09%
w/Th : 75,7%

Cyanotic None
Edema None
Anemic None
Icteric None
Skin Warm palpable, thin subcutaneous layer, late return turgor
Lymph node Palpable lymph node at right and left neck, multiple, mobile,
size 0,5x0,5x0,5 cm, elastic, and no tenderness
Head Round, symmetric
Head circumference 50,5 cm ( normal in accordance with
Nellhaus standart)
Hair Black, hard to withdraw
Eye Sunken, eyes tear (+)
Conjunctiva were anemic, sclera was not icteric
pupil isochors, diameter 3mm/3mm, light reflect +/+ normal
Ear Not found abnormality
Nose No Nasal flare
Neck JVP 5-2cm H20
Throat Tonsil : T1-T1 , not hyperemic
Pharynx : not hyperemic
Teeth and mouth lips and mouth mucous were dry
Dirty tongue, edge of tongue were hyperemic, tremor (-)
Lung Ins : normochest, simmetrical, retraction (-)
Pal : fremitus left = right
Per : sonor
Aus :bronchovesicular, no rales, no wheezing

cardiac I ; ictus cordis was not seen

P : ictus cordis was palpable at mid clavicularis line intercostal
space V
P: heart border, upper: RIC II, right: LSD, left: 1 finger medial
midclavicular line ICS V
A : regular rhythm, no murmur
Abdomen Ins : no distended
Pal : supple, liver and spleen were not palpable, epigastric
tenderness (+), late feedback of return turgor
Per : tympani
Aus : Intestinal sound (+) normal

back within normal limit

Genitalia Not found abnormality
State puberty A1 P1 G1

Anus Rectal toucher was not performed

Extremities Warm peripher, good refilling capillary, CRT < 2 second
Physiologic Reflex +/+ normal
Pathologic Reflex : -/-
 Laboratory finding
Blood URINE
Hb 9,4 gr/dl Protein -
Reduction -
Leukocyte 3100/mm3
DC 0/0/2/36/62/0 Leukocyte -
platelet 87.000/mm3 Erythrocyte -
LED 28 mm at First Hour
Bilirubin -
Malaria Slides There is not found
Urobilinogen +
Malaria Parasites of
blood smear
Diagnosis Insert Text Here
Observation of Long Febrile due to Suspected Typhoid Fever,
DD/ Lung Tuberculosis, Urinary Trcatus Infection
Moderate dehydration due to tough intake
Therapy IVFD 2A 135cc/KgBW/day 2700cc/day = 38 drops/I macro
Ceftriaxon 2x1 gram IV
Smooth Meal 1500 Kkal
Paracetamol 250 mg ( T> 38,5 C)
Plan Random Blood Glucose
Erythrocyte sedimentation rate
Mantoux Test
Follow up the rehydration for 24 hours (21 January 2015, 9 PM)
Blood Culture
IQ Test
Zhafran Gustindo P, Boy, 5
month, 881364
 Anamnesis
(Alloanamnesis from mother)

Chief complaint :

Appear cyanotic since

6 hours ago
 History of present illness
Fever since 17 days ago, along 5 days, not high, no
shivering, no sweating, not followed seizure

Cough since 10 days ago, expectorated, not followed by

cold, no shrinking sound, not induced by weather and
activities

The patient appeared cyanotic by parent since 6 hours

ago

No vomiting. Hiccoughing history was denied

The patient is still getting breast milk since he born,

frequencies 10-12x/day, period 5-10 minutes/time,
no history of interrupted breastfeed
 History of present illness
No history of contact with chronic cough person
No history contact with sudden death poultry
Micturition was in normal limit, last micturition 2
hours ago
Defecation was in normal limit, exit from stoma
Previously child was hospitalized at district hospital
M Zein Painan with pneumnia+anemia+post
colostomy. Had been performed Hb: 10,3 gr/dl,
Leucocyte : 11000/mm3, platelet : 86.000/mm3,
after administered PRC transfusion 2x25 cc and
PRC 2x40 cc and had got cefotaxim injection for 7
days and then adviced to be hospitalized at RSUP
dr M Djamil Padang with severe dehydration +
pneumonia+ susp anemia aplasia+ post colostomy
 Past illness

Child had been History of birth

known as atresia
ani patient and
Family The first child,
had been
history spontaneous, helped by
performed doctor, preterm, birth
colostomy body weight was 2000
operation at There are no grams, birth body lenght
September 2014 family was forgot, cried directly
member w
suffered
disease like
this
 History of basic immunization was not
given
Growth was normal and development was
disturb
Higiene and sanitation were good enough
General examination
General appearance
InsertSevere
Text ill
Here
consciousness alert
HR 130 x/minute
Temperature 37,5 C
RR 54 x/minutes
Height 49 cm
Weight 2,5 kg
Nutritional status Failure to thrive
W/A : 41,67 %
H/A : 80,32 %
W/A : 71,42 %

Cyanotic None
Swelling None
Anemic None
Icteric None
 Insert Text Here
skin Warm palpable
Lymph node Not Palpable
Head Round, symmetric, fontanella mayor was flat
Head circumference 32 cm ( <-2 SD standar nellhaus)
Hair Black, hard to withdraw
Eye Conjunctiva not anemic, sclera not icteric
pupil isochors, diameter 2mm, light reflect +/+ normal
Ear within normal limit
Nose Nasal flare (-)
Neck JVP 5-2 cmH2O
Throat Tonsil and pharynx was difficukt to be examined
Teeth and mouth lips and mouth mucous were wet
Oral trush (+)
Lung Ins : normal chest, retraction (+) in epigastric area
Pal : left fremitus = right fremitus
Per : sonor
Aus : bronchovesicular ,rales at both of lung, wheezing -/-

Cardiac I : ictus was not seen

P : ictus was palpable on medial midclavicular line intercostal
space V
P : heart border, upper: RIC II, right: LSD, left: medial
midclavicular line ICS V
A : regular rhythm, no murmur
Abdomen Ins : not distended, look stoma was red, pus (-), blood (-)
Pal : supple, liver -1/4, sharp edge, flat, rubbery and
spleen was not palpable
Per :tympani
Aus : Intestinal sound normal
back within normal limit
Genitalia Not found abnormality
State puberty A1P1G1
Anus Rectal touche was not performed
Extremities Warm, good refilling capillary, CRT <2 seconds
Physiologic Reflex +/+ normal
Pathologic Reflex -/-
 Insert Text Here
Blood

Hemoglobin 18,4 g/dl

Leukocyte 3900/mm3
Thrombocyte 18.000/mm3
Hematocrit 53 %
Erythrocyte 6,49x 106 /mm3
Diagnosis Susp. Renal tubular asidosis
Insert Text Here
Bronkopneumonia in treatment
Post colostomy a/I atresia ani
blood
Failure to thrive
Hb 8.9 g/dl
Susp. Sepsis
Candidiasis oral
Leukocyte
Therapy 7100/mm 3
O2 1l/I nasal
IVFD KaEN 1B 135 cc/kgBW/hours 14 gtt/I micro
DC 0/0/0/52/47/13x100 mg IV
Meropenem
Paracetamol 25mg (T>38,5 C)
MCH Enistin
28,7 drop 4 x 0,3 cc
MCV 87,09
MCHC 32,9%
interpretation
Plan Normositic
BGA, Na, K, GDR
normocrom anemia
 Laboratorium result

BGA : Interpretation : asidosis metabolic

pH: 7,28 Hipoxemia
PCO2: 38 Act : Incrase O2 3l/I nasal
PO2: 62
HCO3: 17,8
BE: -8,1
SO2: 87 %

Natrium : 145 mmol/l Interpretation : in normal limit

Kalium : 1,9 mmol/l Interpretation : Hipokalemia
Act : Kalium correction 6,2 meq in
maintenance fluid 24 hours
BGR : 66 mg/dl Interpretation : in normal limit
Anion gap 14,1 ( in normal limit )
 Follow Up
Subjective Objectives therapy
Fever was present this Severe ill , alert, HR: 130 x/mnt, RR :50 O2 3l/I nasal
morning, not high, no IVFD KaEN 1B 135
seizure, breathlessness x/mnt, T : 38,1 C cc/kgBW/hours 14 gtt/I +
(+) decrease than Eyes : conjunctiva was not anemic, sclera KCL 6,2 meqmicro
before, no vomitus, Meropenem 3x100 mg IV
intake per NGT, not icteric Paracetamol 25mg (T>38,5 C)
tolerantion was fine, Cor: regular rhythm, no murmur
Micturition was in normal
limit, defecation was in Pulmo : rales +/+, wheezing -/-
normal limit, exit from Abd : distension(-),Intestinal sound(+) N,
stoma
Ekstr : warm, perfusion is good

Interpretation: febris