FOLLOW UP

November 14th 2014
S Diarrhea (+)
O Sens: Allert, Pale (+) Jaundice (-) Edema (-) Cyanosis (-) Dyspnoe (-) Body Temperature:
38,60C. Body weight: 12 kg, Body length: 102 cm.
Head
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra
conjunctiva pale (+/+), icteric sclera (-/-).
Nose, Mouth and Ear were within normal limit
Neck

TVJ difficult in value, Lymph node enlargement (-).

Thorax

Symmetrical fusiformis, Chest retraction (-), HR : 96 bpm, reguler, murmur (-),
RR: 22 x/i, regular, rales (-/-).

Abdomen

Rapid turgor. Normoperistaltic. Liver palpable with 2cm, spleen and renal
unpalpable.

Extremities Pulse 96 bpm, regular, adequate pressure and volume, warm acral,CRT < 3”
Genital

Female, within normal limit

A Susp. TB milier + susp. HIV and Malnutrition
P

-

Diet F 75 130cc/2hr/with Mineral Mix 2,6cc

-

Rifampisin 1×150mg

-

INH 1×100mg

-

Pirazinamid 1×150mg

-

Prednisolon 1×15mg

-

Vitamin A 1×200mg

-

Asam Folat 1×50mg

-

Multivitamin without Fe 1×1 cth
Diagnostic Planning :

-

Consul division of respiratory and pulmonulogy

-

Consul division of nutrition and metabolic disease

-

Consul division of social pediatric

-

Consul division of allergy and immunology

HIV and Malnutrition P - Diet F 75 130cc/2hr/with Mineral Mix 2. murmur (-). within normal limit A Susp. Pale (+) Jaundice (-) Edema (-) Cyanosis (-) Dyspnoe (-) Body Temperature: 38. adequate pressure and volume. light reflex (+/+). Pale (+) Jaundice (-) Edema (-) Cyanosis (-) Dyspnoe (-) Body Temperature: 38. regular. Nose. regular. Fever (-) O Sens: Allert. Fever (-) O Sens: Allert.CRT < 3” Genital Female. Body length: 102 cm. rales (-/-). Liver palpable with 2cm.60C.60C. reguler. TB milier + susp. Normoperistaltic.6cc - Rifampisin 1×150mg - INH 1×100mg - Pirazinamid 1×150mg - Prednisolon 1×15mg - Vitamin A 1×200mg - Asam Folat 1×50mg - Multivitamin without Fe 1×1 cth Diagnostic Planning: - Consul division of nutrition and metabolic disease November 16th 2014 S Diarrhea (+). warm acral. Head Eye: Isochoric pupil (3mm/3mm). Chest retraction (-). . Thorax Symmetrical fusiformis. icteric sclera (-/-). RR: 22 x/i. spleen and renal unpalpable. Extremities Pulse 96 bpm. inferior palpebra conjunctiva pale (+/+). inferior palpebra conjunctiva pale (+/+). HR : 96 bpm. Mouth and Ear were within normal limit Neck TVJ difficult in value. Body length: 102 cm.November 15th 2014 S Diarrhea (+). Abdomen Rapid turgor. Lymph node enlargement (-). Head Eye: Isochoric pupil (3mm/3mm). Body weight: 12 kg. Body weight: 12 kg. light reflex (+/+). icteric sclera (-/-).

adequate pressure and volume. Abdomen Rapid turgor. murmur (-). Cough (+) O Sens: Allert. Thorax Symmetrical fusiformis. Lymph node enlargement (-). Fever (-). rales (-/-). icteric sclera (-/-). reguler. TB milier + susp. HR : 96 bpm. Liver palpable with 2cm. Pale (+) Jaundice (-) Edema (-) Cyanosis (-) Dyspnoe (-) Body Temperature: 38.60C. within normal limit A Susp. regular. Lymph node enlargement (-). Normoperistaltic. Mouth and Ear were within normal limit Neck TVJ difficult in value. inferior palpebra conjunctiva pale (+/+).6cc - Cotrimoxazole 1×240mg - Rifampisin 1×150mg - INH 1×100mg - Pirazinamid 1×150mg - Prednisolon 1×15mg - Vitamin A 1×200mg - Asam Folat 1×50mg - Multivitamin without Fe 1×1 cth November 17th 2014 S Diarrhea (-). murmur (-). Thorax Symmetrical fusiformis. Chest retraction (-). Nose. HR : 96 bpm. rales (-/-). spleen and renal unpalpable. reguler. Mouth and Ear were within normal limit Neck TVJ difficult in value. Body weight: 12 kg. Abdomen Rapid turgor. Chest retraction (-). warm acral. Head Eye: Isochoric pupil (3mm/3mm). Liver palpable with 2cm. Extremities Pulse 96 bpm. regular. Body length: 102 cm. spleen and renal . light reflex (+/+). RR: 22 x/i. RR: 22 x/i. HIV and Malnutrition P - Diet F 75 130cc/2hr/with Mineral Mix 2.Nose. Normoperistaltic. regular.CRT < 3” Genital Female.

warm acral. adequate pressure and volume. Extremities Pulse 96 bpm.unpalpable. rales (-/-). Thorax Symmetrical fusiformis. Extremities Pulse 96 bpm. within normal limit A Susp.CRT < 3” Genital Female. Chest retraction (-). regular. Lymph node enlargement (-). Liver palpable with 2cm. Cough (+) O Sens: Allert. HIV and Malnutrition P - Diet F 75 130cc/2hr/with Mineral Mix 2. Pale (+) Jaundice (-) Edema (-) Cyanosis (-) Dyspnoe (-) Body Temperature: 38. icteric sclera (-/-). adequate pressure and volume. Body length: 102 cm.60C. HR : 96 bpm. Fever (-). spleen and renal unpalpable. Body weight: 12 kg. murmur (-). light reflex (+/+). Mouth and Ear were within normal limit Neck TVJ difficult in value. regular. RR: 22 x/i. reguler. Normoperistaltic.CRT < 3” . regular. TB milier + Susp. Abdomen Rapid turgor.6cc - Cotrimoxazole 1×240mg - Rifampisin 1×150mg - INH 1×100mg - Pirazinamid 1×150mg - Prednisolon 1×15mg - Vitamin A 1×200mg - Asam Folat 1×50mg - Nystatin 4×1 cc - Multivitamin without Fe 1×1 cth November 18th 2014 – November 24th 2014 S Diarrhea (-). inferior palpebra conjunctiva pale (+/+). Head Eye: Isochoric pupil (3mm/3mm). Nose. warm acral.

Body length: 102 cm. RR: 22 x/i. Body weight: 12 kg. regular. TB milier + Susp. Abdomen Rapid turgor. Nose. Extremities Pulse 96 bpm. HIV and Malnutrition P - Diet MB 1500 calorie + F 100 /60cc/8 hours (Mineral Mix 3. warm acral. Cough (+) O Sens: Allert. Liver palpable with 2cm. inferior palpebra conjunctiva pale (+/+). adequate pressure and volume.2 cc) .2 cc) - Cotrimoxazole 1×240mg - Rifampisin 1×150mg - Etambutol 2×200 mg - Vitamin B6 2× 10mg - Vitamin A 1×200mg - Asam Folat 1×1 mg - Nystatin 4×1 cc - Dactarin Oral Gel - Lamivudin 150 mg - Stravudin 30mg - Multivitamin without Fe 1×1 cth November 25th 2014 – November29th 2014 S Diarrhea (-). Normoperistaltic.Genital Female.CRT < 3” Genital Female. rales (-/-). Mouth and Ear were within normal limit Neck TVJ difficult in value. within normal limit A Susp. TB milier + Susp.60C. Fever (-). murmur (-). within normal limit A Susp. HR : 96 bpm. spleen and renal unpalpable. HIV and Malnutrition P - Diet MB 1500 calorie + F 100 /60cc/8 hours (Mineral Mix 3. Thorax Symmetrical fusiformis. Pale (+) Jaundice (-) Edema (-) Cyanosis (-) Dyspnoe (-) Body Temperature: 38. Head Eye: Isochoric pupil (3mm/3mm). Chest retraction (-). Lymph node enlargement (-). reguler. regular. light reflex (+/+). icteric sclera (-/-).

Body length: 55 cm.Chest retraction intercostal (-). murmur (+)continous murmur grade 3/6 at ICR II-III linea parasternal dekstra. regular. warm acral. baggy pants (+) Genital Male. muscle hypotrophy. regular. Normoperistaltic.Diarrhea (-) Sens: Allert.- Cotrimoxazole 1×240mg - Rifampisin 1×150mg - Etambutol 2×200 mg - Vitamin B6 2× 10mg - Vitamin A 1×200mg - Asam Folat 1×1 mg - Nystatin 4×1 cc - Dactarin Oral Gel - Lamivudin 150 mg - Stravudin 30mg Multivitamin without Fe 1×1 cth November30th 2014 Short of breathness is decreased (+).subcutaneous fat getting thinner. icteric sclera (-/-). inferior palpebra conjunctiva pale (+/+). Extremities Pulse 122 bpm. adequate pressure and volume.Vomiting (-).80C.light reflex (+/+). HR : 122 bpm. Mouth and Ear were within normal limit Neck TVJ R-2 cmH2O. Edema (-). Jaundice (-). radiation (+) until left lower sternal border. Body Temperature :36.old man face (+) Nose. Thorax Symmetrical fusiformis. Liver. intercostal space looks clearly (+). Pale (+). spleen and renal unpalpable.stridor (-/-) Abdomen Rapid turgor.CRT < 3”. Head Eye: Isochoric pupil (3mm/3mm). reguler. within normal limit CHF due to moderate PDA + Marasmus+ failure to thrive .1 kg. Body weight: 4. Lymph node enlargement (-). Diet is done. RR: 42tpm. Cyanosis (-) Dyspnoe (-).crackles (-/-).

shortness of breath is not related to the the weather and activity.25 mg .Cotrimoxazole 2x Cth I .Injection Gentamisin 5mg/kgBB=25 mg/12 hour/iv R/ PDA ligation DISSCUSION Theory Discussion Ross criteria of CHF: Short of breathness was realized by his parents since 2 months ago. Marked tachypnea or diaphoresis with feeds or exertion.Diet F100 70Cc/3hour solute in 90 cc water + mineral mix 1. then it become heavier in 1weeks. Shortness of breath is relieved when his parents put one or two pillow below his head. The patient often wake up in the middle of the night because of his shortness of breath. growth failure from CHF IV.44 cc . Shortness of breath becomes heavier when the patient inhale. no growth failure III.225% 4gtt/i (micro) - Furosemide 2 x 6 mg - Spironolakton 2 x6.Folic acid1x1 mg . I. grunting. retractions. dyspnea on exertion in older children.- O21/2 l/i with nasal canule - IVFD D 5% NaCl 0. No limitation or symptoms II. history forehead sweating while feeding (+) in these 2 months. or diaphoresis Interrupted feeding history (+). Symptoms at rest with tachypnea.Multivitamin without Fe 1 x Cth ½ . In Clinical Features of Heart failure find History of : Feeding difficulties (and therefore growth . Mild tachypnea or diaphoresis with feeding in infants.Injection Ampisilin 50 mg/kgBB = 250 mg/6 hour/iv . prolonged feeding times.

From Physical Findings in Thorax: Symmetrical fusiformis. Echocardiography result at RS Mutiara: VSD and ASD and other results in an increase in pulmonary blood flow. Patients with tiny. The characteristic findings range from prolonged feeding time (> 20 minutes) with decreased volume intake to frank intolerance and vomiting after feeds.4mm. and a thrill may be present. paracardial infiltrates in the right and left. Irritability with feeding. Chest retraction intercostal (+). CTR 58%. The hallmark physical finding is a continuous murmur. sweating. 2 months.L-R shunt) Pulmonary over circulation from a large leftto-right shunt results in CHF. The murmur often radiates down the left side of the sternum and into the back. and even refusal of feeds Left to right shunting of blood on the PDA. history presenting symptoms of congestive HF in forehead sweating while feeding (+) in these infants and young toddlers (age 0-2 years). left atrial enlargement etc. incidentally discovered patent ductus have no abnormal physical findings. radiation (+) until left lower sternal border.failure) are commonly recognized as Interrupted feeding history (+). the diaphragm slippery.RR:40 tpm. prominent main and branch pulmonary arteries. reguler. Chest x-ray interpretation. HR : 165 bpm. PDA Moderate (3. murmur (+)continuous murmur grade 3/6 at ICR II-III linea parasternal dekstra. enlarged heart size. regular. The physical examination findings vary as much as the medical history. . located at the upper left sterna border. Costophrenicus angle is sharp . often referred to as a “machinery” murmur. are signs of significantly increased pulmonary blood flow which could cause HF.8 mm-4. Cardiomegaly with increased pulmonary blood flow (pulmonary plethora). trachea in the middle.