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CASE REPORT

VSD

CASE REPORT Personal Identity • • • • • • • • • Name : An Naura Age : 2 month Gender : Female Religion : Islam Father’s name : Mr. Y Occupation : Housewife Age : 28 years old 2 . A Age : 28 years old Mother’s name: Mrs.

Patient did’t suffer from fever and night sweat.Main History Taking complaints: breathless History of present illness: Patient came to the hospital with parent’s and complaints of breathless. Patient mother’s said that the patient have a breathless since 2 day ago. Patient already received treatment from midwife in her place. wich now worsening. Patient mother said that patient’s weight did not increase since birth. Breathless occurs intermitten in the beginning but occur more after now. Patient also suffering from cought which occur since one week before admission. 3 .

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PHYSICAL EXAMINATION Generalized Status:  General state : Moderately illness  Stage : III Vital Sign  Respiration Rate : 77 tpm  Heart Rtae : 145 tpm  Body Temperature : 37.1 oC Antropometric Status  Body weight : 2200 gr  Body height : 44 cm Nutrition Status  BMI/Age (Z-score) : -1 (Thin/Wasted) .

Local Examination 7 .

Local Examination 8 .

Local Examination 9 .

Patient mother said that patient’s weight did not increase since birth. Vital sign: RR: 77 tpm. wich now worsening. since 2 day ago. within murmur. HR: 150tpm. Patient also suffering from cought which occur since one week before admission and febris with anoreksia. sleem (+/+). T: 37. creacles (+/+).II irregular rhytm.10 C And these are the findings from physical examination are retraction intercostale (+).RESUME Patient age 2 month complaint with dispneu. These are the findings from general appearance was moderately illness. and the level consciousness is stage IIII. the nutrition status is thin and wasted. Dispneu occurs intermitten in the beginning but occur more after now. 10 . and then ictus cordis heart sound I .

DIFFERENTIAL DIAGNOSE Bronkopneumonia with VSD Bronkhitis with VSD 11 .

85  Hematocrit 31 (L)  Routine Blood  Result Test  Basophil  Eosinophil  Lymphocyte 0 0 (L) 20 (L)  Platelet 321  Monocyte 7  MCH 27.5 6.8  Erythrocyte 3.3 (L)  RDW CV 15 (H)  RDW SD 41 12 .LABORATORY TESTING  Routine Blood Test  Haemoglobin  Leucocyte  Resul t 10.3  Segment 75  MCHC  MCV 34  Stab 0 (L) 80.

Rontgen .

WORKING DIAGNOSE Bronkopneumonia with VSD 14 .

THERAPY Surgery Simptomatic        for Bp: O2 2l/minute/nasal IVFD KAEN 1B 4cc/hour Ceftriaxone 2 x 125 mg (IV) Gentamicin 1 x 15 mg (IV) Dexamethason 3 x 0.21 mg (IV) Paracetamol 4 x 25 mg (IV) Chest Physiotherpy 15 .

Quo ad Vitam : depend with devect .Quo ad Sanationam : ad malam 16 .PROGNOSIS Prognosis : .Quo ad Functionam : dubia ad malam .

) For Attention .THANKSSss .