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ALL CASES

KLATEN
Friday and Sunday,7 & 9 April 2018
ALL CASES, 7 April 2018 16.00-07.00
No Identity Chief complaint Assesment Ward DPJP

1 ADS, male, 2 years Dyspneu Intermittent Asthma Inpatient – Menur dr. Arif, Sp. A
8 months old, 9 kg Severe Asthma Attack

2 AN, male, 2 years Dyspneu Mild Persistent Asthma Inpatient – Menur dr. Arif, Sp. A
1 months old, Mild-Moderate Asthma Attack
12,5 kg with Partial Respon

3 AF, female, 11 Cough & Dyspneu Community Acquired Inpatient – Kenanga dr. Arif, Sp. A
months old, 6,5 kg Pneumonia

4 HI, female, 3 Seizure & Febrile Complex Febrile Seizure Inpatient – Kenanga dr. Arif, Sp. A
years, 13 kg
5 RW, male, 3 Cough & Dyspneu Community Acquired Inpatient - Kenanga dr. Arif, Sp. A
months old, 6,6 kg Pneumonia

6 AM, male, 3 Outpatient dr. Samad, Sp. A (K)


months old, 6,6 kg
ALL CASES, 30 March 2018 16.00-07.00
No Identity Chief complaint Assesment Ward DPJP

7 AK, male, 2 years 5 Watery Stool Acute Watery Diarrhea Outpatient dr. Samad,
months old, 14 kg Without Dehydration Sp. A (K)

8 By. Ny. F, male, 3 Tail Mass Myocele Lumbosacral Inpatient – Bakung dr. Arif, Sp. A
days old, 3 kg Icteric Neonatorum
BBLC, CB, SMK, Normal Delivery
9 AP, female, 1 years Fever days 5 Susp. Dengue Fever Inpatient – Kenanga dr. Arif, Sp. A
8 months old, 10 kg

10 By. Ny. E, female, 0 - BBLC, CB, SMK, Normal Delivery Inpatient – Anggrek dr. Arif, Sp. A
hours, 2700 g with Gestational Hypertension
Mother
11 KB, male, 3 years 10 Disuria & Susp. Urinary Tract Infections Inpatient - Kenanga dr. Hendra,
months old, 14 kg Abdominal Pain Sp. A
with Fever
ALL CASES, Sunday, 8 April 2018 07.00-19.00
No Identity Chief complaint Assesment Ward DPJP

1 By.NY.RA, male, 0 newborn BBLC, CB, SMK, Spontan Rawat gabung dr. Nov, Sp. A
day, 2.5 kg
2 By.Ny.A, female, o Newborn - BBLC, CB, SMK, Spontan Rawat gabung dr. Nov, Sp. A
day, 3 kg - Riw. Fetal distress, riw.
Vakum ekstrasi

3 DA, male, 2 years Dyspneu CAP Kenanga dr. Nov, Sp. A


11 months, 12 kg
4 NTR, female, 9 cyanosis - Periodic apnea ec epilepsy dr. Arif, Sp. A
months, 4kg dd cardiac problem
- Hirscprung disease
- Russel-silver syndrome
ALL CASES, Sunday, 9 April 2018 19.00-07.00
No Identity Chief complaint Assesment Ward DPJP

1 FAA ,Male, 1 years Cough Susp pertussis Kenanga dr. Nov, Sp. A
10 months old, 7,3
kg

2 KA,Female,5 years Diarrhea Acute watery diarhea with non Menur dr. Nov, Sp.A
9 months old, 19 kg severe dehydration

4. SKS,Female,3 Diarrhea Acute watery diarhea with no Outpatient dr. Nov, Sp. A
years 5 months, 14 dehydration
kg
EMERGENCY CASE
NO IDENTITY AND DIAGNOSIS DPJP AND WARD
1 ADS, male, 2 years 8 months old, 9 kg Inpatient – Menur
dr. Arif, Sp. A
Chief complaint:
Dyspneu

Diagnosis:
Intermittent Asthma
Severe Asthma Attack
12 HSMRS HMRS

 Cough & Coryza (+)


• ER RSUD Cawas, • Cough & Coryza (+)
 Dyspneu (+)
nebulizer 1x • Dyspneu (+)
 Fever (-)
• Syr. Tremenza, & Pulv for • Fever (-)
dyspnea

• History inpatient in RSST 1 month ago with Asthma


• Seretide (+), run out for 1 month ago
Physical Examination in the ER

General condition CM, Dyspneu


Vital Sign HR 165 bpm, RR 50-65 x/min, t: 37°C
SpO2 98% O2 room air, BB 9 kg
Neck Lymph nodes not palpable
HENT CA-/-, SI -/-, Nose thrill (-)
Thorax Symmetrical, retraction subcostal (+)
Heart & Lung S1 single, S2 split not constant, murmur (-)
vesicular +/+, wheezing +/+, rhonki +/+
Abdomen Flat (+), Supple (+), Suprapubic Tenderness (-)
BU(+) 10x/minutes, hepatomegaly (-), splenomegaly (-), rapid turgor
Extremities Warm, pulse palpable & strong, Cyanotic (-)
Pulmo Dextra Pulmo Sinistra
Pre-Nebu Ventolin Wheezing (+) Wheezing (+)
Ventolin 1st Wheezing (+) Wheezing (+)
Combivent 1st Wheezing (+) Wheezing (+)
Combivent 2nd Wheezing (+), Ronkhi (+) Wheezing (+), Ronkhi (+)
RR : 52 x/menit
Blood test
Parameter Result Normal Range
Hemoglobin (g/dL) 12,7 11.3-14.1
Eritrosit (10 ̂6/uL) 4,83 3.90 – 5.90
Trombosit (10 ̂3/uL) 357 150 – 450
Hct (%) 38 31 – 43
MCV (fL) 78,6 (L) 80 – 99
MCH (fL) 26,3 (L) 27 – 31
MCHC (fL) 33,4 33 – 37
RDW 16.5 (H) 10.0 - 15.0
Leukosit (10 ̂3/uL) 14,7 4.5 – 10.4
Diff. Count Neutrofil (%) 78,61 (H) 0.4-1
Limfosit (%) 10,42 (L) 32 – 52
Eosinofil (%) 0,24 (L) 1–3
Basofil (%) 0,51 38 – 60
Monosit (%) 10,22 (H) 4–9
MPV 8,5
Assesment Plan

• Intermittent Asthma • Nebulizer Combivent / 2 hours


• Severe Asthma Attack • Inj. 3 mg / 8 hours
• Inj. Ampicillin 50 mg/BW / 6 hours
• Common Cold dd – 150 mg / 6 hours
Community Acquired • Inj. Gentamisin 7,5 mg / BW / 24 hours
Pneumonia – 70 mg / 24 hours
EMERGENCY CASE
NO IDENTITY AND DIAGNOSIS DPJP AND WARD
2 AN, male, 2 years 1 months old, 12,5 kg Inpatient – Menur
dr. Arif, Sp. A
Chief complaint:
Dyspneu

Diagnosis:
Mild Persistent Asthma
Mild-Moderate Asthma Attack with Partial Respon
20 Hours
SMRS

 Cough (+) & Coryza


 Dyspneu every
(+) month
 Dyspneu (+)  Nebulizer relieve
symptoms
 Fever (+) 37c
 Drug history (-)

 History : inpatient with Pneumonia (+) 3 month ago


Physical Examination in the ER

General condition CM, iritable


Vital Sign HR 130 bpm, RR 64 x/min, t: 36,9°C, SpO2 96% O2 room air,
98% NC 1 L/m, BB 12,5 kg, TB : 89 cm, LK : 49 cm
Neck Lymph nodes not palpable
HENT CA-/-, SI -/-, sunken eyes (-), nasal flare (+)
Thorax Symmetrical, retraction subconstal & suprasternal (+)
Heart & Lung S1 singular, S2 split not constant, murmur (-)
vesicular +/+, wheezing minimal, rhonki +/+, Krepitasi (-/-)
Abdomen Flat, Supple, BU(+) N, rapid turgor

Extremities Warm, pulse palpable & strong, CRT<2”, cyanotic (-)


Pulmo Dextra Pulmo Sinistra
Pre-Nebu Ventolin Wheezing (+) Wheezing (+)
Ventolin 1x Wheezing (+) Wheezing (+)
Ventolin 2x Wheezing (+) Wheezing (+)
Combivent Wheezing (+) Wheezing (+)

• BB/U : Z = 0
• TB/U : 0 < Z < +2
• BB/TB : Z = 0
Blood test
Parameter Result Normal Range
Hemoglobin (g/dL) 11,9 11.3-14.1
Eritrosit (10 ̂6/uL) 4,85 3.90 – 5.90
Trombosit (10 ̂3/uL) 646 (H) 150 – 450
Hct (%) 35,2 31 – 43
MCV (fL) 78,8 (L) 80 – 99
MCH (fL) 26,7 (L) 27 – 31
MCHC (fL) 33,9 33 – 37
RDW 15,7 (H) 10.0 - 15.0
Leukosit (10 ̂3/uL) 16,8 4.5 – 10.4
Diff. Count Neutrofil (%) 72,8 (H) 0.4-1
Limfosit (%) 19,59 (L) 32 – 52
Eosinofil (%) 0,6 (L) 1–3
Basofil (%) 0,12 (L) 38 – 60
Monosit (%) 6,89 4–9
MPV 7,1
Assesment Plan

• Mild Persistent Asthma  Nasal Canule O2 1 L/m


• Mild-Moderate Asthma Attack  Nebulizer Combivent / 4-6 hours
with Partial Respon  Inj. MP 0,5 – 1 mg/BW/hours
 4mg/ 8 hours
 Syr. Paracetamol 5 cc / 4-6 hours if needed
EMERGENCY CASE
NO IDENTITY AND DIAGNOSIS DPJP AND WARD
3 AF, female, 11 months old, 6,5 kg Inpatient – Kenanga
dr. Arif, Sp. A
Chief complaint:
Cough & Dyspneu

Diagnosis:
Community Acquired Pneumonia
5 Days SMRS

 Cough (+) & Coryza  Drug history :  HMRS


(+) amox syrup, Ear
 yellowish discharge
 Dyspneu (+)
drop
from ear
 Continous Fever (+)

 Risk of Pneumonia :
 Cooking with firewood
 Smoke (+)
 Family Smoking (-)
Physical Examination in the ER

General condition CM, iritable


Vital Sign HR 112 bpm, RR 55 x/min, t: 38,1°C, SpO2 97% O2 room air,
BB 6,5 kg, PB 70 cm
Neck Lymph nodes not palpable, not pain
HENT CA-/-, SI -/-,
Thorax Symmetrical, retraction (-)
Heart & Lung S1 singular, S2 split not constant, murmur (-)
vesicular +/+, wheezing -/-, rhonki +/+
Abdomen Supple, BU(+) N, hepatomegaly (-), Splenomegali (-)tenderness (-)
rapid turgor
Extremities Warm, pulse palpable & strong, CRT<2”
Blood test
Parameter Result Normal Range
Hemoglobin (g/dL) 11 (L) 11.4-14.5
Eritrosit (10 ̂6/uL) 4,54 3.90 – 5.90
Trombosit (10 ̂3/uL) 275 150 – 450
Hct (%) 33 (L) 31 – 43
MCV (fL) 72,7 (L) 80 – 99
MCH (fL) 24,1 (L) 27 – 31
MCHC (fL) 33,2 33 – 37
RDW 16.6 (H) 10.0 - 15.0
Leukosit (10 ̂3/uL) 6,7 4.5 – 10.4
Diff. Count Neutrofil (%) 26,75 (L) 50 – 65
Limfosit (%) 61,34 (H) 38 – 60
Eosinofil (%) 0,28 (L) 1–3
Basofil (%) 0,94 (L) 0,4 – 1
Monosit (%) 10,69 (H) 4–9
MPV 10,2
Parameter Result Normal Range
Natrium 138,7 129 – 143
Kalium 4,35 3,6 – 5,8
Chlorida 109,7 93 – 112

• BB/U : -3 < Z < -2


• TB/U : -2 < Z < 0
• BB/TB : -3 < Z < -2
Assesment Plan

• Community Acquired  O2 1 L/m


Pneumonia  Inj. Ampicillin 50 mg/BW/ 6 hours
 325 gram / 6 hours
 Inj. Gentamisin 7,5/BW / 24 hours
 50 mg/ 24 hours
 Nebulizer Ventolin 1 resp + 2 cc NaCl
0,9% / 6 hours
EMERGENCY CASE
NO IDENTITY AND DIAGNOSIS DPJP AND WARD
4 HI, female, 3 years, 13 kg Inpatient – Kenanga
dr. Arif, Sp. A
Chief complaint:
Seizure & Febrile

Diagnosis:
Complex Febrile Seizure
4 Days SMRS 2 Days SMRS HSMRS

 Vomitus (+) @ every  Fever (+)


 Last Diuresis 2
intake hours ago
 Watery Stool 2  Seizure (+)
times general tonic
 Already on clonic, eyes open
treatment (?) to front
 After seizure, OS
compos mentis
Physical Examination in the ER

General condition CM, calm


Vital Sign HR 126 bpm, RR 26 x/min, t: 39°C, SpO2 97% O2 room air
BB : 13 kg
Neck Lymph nodes not palpable
HENT CA-/-, SI -/-
Thorax Symmetrical, retraction (-)
Heart & Lung S1 singular, S2 split not constant, murmur (-)
vesicular +/+, wheezing -/-, rhonki -/-, krepitasi (-)
Abdomen Supple, BU(+) N, tenderness (-), rapid turgor

Extremities Warm, pulse palpable & strong, CRT<2”, cyanosis (-)


Pemeriksaan Ekstremitas
Akral Hangat Gerakan
Nadi Kuat B B
Edema (-) B B
Tonus Refleks Patologis
N N - -
N N - -

Trofi Refleks Fisiologis


E E +2 +2
E E +2 +2

Klonus (-) Sensibilitas (tdp)


Meningeal sign (-),
Blood test
Parameter Result Normal Range
Hemoglobin (g/dL) 13 11.4-14.5
Eritrosit (10 ̂6/uL) 4,73 3.90 – 5.90
Trombosit (10 ̂3/uL) 340 150 – 450
Hct (%) 39,1 31 – 43
MCV (fL) 82,7 80 – 99
MCH (fL) 27,4 27 – 31
MCHC (fL) 33,1 33 – 37
RDW 15 10.0 - 15.0
Leukosit (10 ̂3/uL) 9,1 4.5 – 10.4
Diff. Count Neutrofil (%) 53,42 50 – 65
Limfosit (%) 35,88 38 – 60
Eosinofil (%) 0,39 (L) 1–3
Basofil (%) 0,12(L) 0,4 – 1
Monosit (%) 10,19 (H) 4–9
MPV 7,6
Parameter Result Normal Range
Natrium 133,8 129 – 143
Kalium 5,06 3,6 – 5,8
Chlorida 103,5 93 – 112
GDS 72,11 70 – 140
Urine test
Parameter Result Normal Range Parameter Result Normal Range
Sedimen Keton 10 neg
Epitel Positif 1+ Bilirubin Neg neg
Eritrosit 0 0-4 pH 6 5-8
Leukosit ++30-50 0-5 Nitrite Neg neg
Silinder 0 0-1 Berat jenis 1.010 1.003 – 1.029
Kristal 0 0-1 Urobilinogen Norm 0-1
Lain Bakteri Blood Neg neg
Warna Kuning Agak Leukosit 75 0–5
Keruh
Protein Neg Neg Asam Arkobat neg 0-1
Glucose Neg Neg
Assesment Plan

• Complex Febrile Seizure  KC : 1100 cc + 110 cc


• Obs. Vomitus without dehydration  IUFD KAEN 3A -> 9 tpm
• Susp. Urinary Tract Infection  Syr. Paracetamol 10 – 15 mg/BW/4-6
hours
 180 mg/4-6 hours if needed
 Diazepam 0,3 mg/BW/8 hours
 3,6 mg / 8 hours for 48 hours
EMERGENCY CASE
NO IDENTITY AND DIAGNOSIS DPJP AND WARD
5 RW, male, 3 months old, 6,6 kg Inpatient - Menur

Chief complaint:
Cough & Dyspneu

Diagnosis:
Community Acquired Pneumonia
2 days SMRS HSMRS

 Cough (+), Coryza  Cough (+) with


(+) persistent sputum
 Fever (+)  Coryza (+)
 Syr. PCT, Syrup for  Fever (+)
cough and pulv (?)
Physical Examination in the ER

General condition CM, look dyspneu


Vital Sign HR 168 bpm, RR 80-90 x/min, t: 37,4°C, SpO2 98% O2 room air
BB 6,6 kg
Neck Lymph nodes not palpable
HENT CA-/-, SI -/-
Thorax Symmetrica, retraksi subcostal & suprasternal (+)
Heart & Lung S1 singular, S2 split not constant, murmur (-);
vesicular +/+ wheezing -/-, rhonki minimal / minimal,
Abdomen Supple, BU(+) 10x/menit, hepatomegaly (-), tenderness (-), rapid turgor

Extremities Warm, pulse palpable & strong, CRT<2”


Assesment Plan

• Community Acquired Pneumonia  Inpatient


 Nasal Cannule ½ L/m
 Nebulizer Ventolin 1 Resp / 6 hours
 Inj. Ampisillin 50 mg / BW / 6 hours
 350 mg / 6 hours
 Inj. Gentamisin 7,5 mg / 24 hours
 50 mg / 24 hours
EMERGENCY CASE
NO IDENTITY AND DIAGNOSIS DPJP AND WARD
6 AM, male, 4 years 6 months old, 13 kg Outpatient

Chief complaint:
Fever days 3

Diagnosis:
Acute Watery Diarrhea
3 HSMRS HMRS

 Fever (+) 38c


 More high in evening • Vomitus 2 times @ 50cc
and getting worse • Diarrhea 2 times @ 50cc
become continuous
• Last Diuresis : 3 hours
ago, volume decreases
 Drug history :
• In ER, Diuresis (+), 60 cc
 Syr PCT and Pulv
antibiotic already in 3
times
Physical Examination in the ER

General condition CM
Vital Sign HR 126 bpm, RR 26 x/min, t: 38°C
SpO2 96% O2 room air, BB 13 kg, PB 94 cm
Neck Lymph nodes not palpable
HENT CA-/-, SI -/-, sunken eyes (-)
Thorax Symmetrical, retraction (-)
Heart & Lung S1 single, S2 split not constant, murmur (-)
vesicular +/+, wheezing -/-, rhonki -/-
Abdomen Flat (+), Supple (+), abdominal Tenderness (-)
BU(+) 10x/minutes, hepatomegaly (-), splenomegaly (-), rapid turgor
Extremities Warm, pulse palpable & strong, cyanosis (-)
Blood test
Parameter Result Normal Range
Hemoglobin (g/dL) 11,2 (L) 11.4-14.5
Eritrosit (10 ̂6/uL) 4,25 3.90 – 5.90
Trombosit (10 ̂3/uL) 338 150 – 450
Hct (%) 33,1 31 – 43
MCV (fL) 77,8 (L) 80 – 99
MCH (fL) 26,3 (L) 27 – 31
MCHC (fL) 33,8 33 – 37
RDW 15,4 (H) 10.0 - 15.0
Leukosit (10 ̂3/uL) 6,5 4.5 – 10.4
Diff. Count Neutrofil (%) 68,24 (H) 50 – 65
Limfosit (%) 19,74 (L) 38 – 60
Eosinofil (%) 0,13 (L) 1–3
Basofil (%) 0,34 (L) 0,4 – 1
Monosit (%) 11,55 (H) 4–9
MPV 7,6
Parameter Result Normal Range
Natrium 127,7 (L) 129 – 143
Kalium 3,85 3,6 – 5,8
Chlorida 102,4 93 – 112
TUBEX TF 2

• BB/U : -3 < Z < -2


• TB/U : -3 < Z < -2
• BB/TB : -3 < Z < -2
Urine test
Parameter Result Normal Range Parameter Result Normal Range
Sedimen Keton 10 neg
Epitel Positif 1+ Bilirubin Neg neg
Eritrosit 0 0-4 pH 6 5-8
Leukosit 0 0-5 Nitrite Neg neg
Silinder 0 0-1 Berat jenis 1.020 1.003 – 1.029
Kristal 0 0-1 Urobilinogen Norm 0-1
Lain Bakteri (+) Blood Neg neg
Warna Kuning Agak Leukosit neg 0–5
Keruh
Protein Neg Neg Asam Arkobat 10 0-1
Glucose Neg Neg
Assesment Plan

• Acute Watery Diarrhea • Outpatient


• ( Catatan hilang )
EMERGENCY CASE
NO IDENTITY AND DIAGNOSIS DPJP AND WARD
7 AK, male, 2 years 5 months old, 14 kg Outpatient

Chief complaint:
Watery Stool

Diagnosis:
Acute Watery Diarrhea
3 days SMRS 2 days SMRS HMRS

 Fever (+)
• Watery Stool (+), 3 times • Food intake decreased
 Watery stool (-)
a day @ 50 cc, blood (-) • Fluid intake good
 Vomitus (-)
• Slimy stool (+) • Last diuresis 2 hours ago,
before last 3 hours ago,
volume normal
• Vomitus every take syr.
• History : Orange -> stop
• Eating 15 berry & sweet corn day before
Physical Examination in the ER

General condition CM, normal


Vital Sign HR 140 bpm, RR 22 x/min, t: 38°C
SpO2 98% O2 room air, BB 14 kg
Neck Lymph nodes not palpable
HENT CA-/-, SI -/-, Sunken eyes (-), tears (+)
Thorax Symmetrical, retraction (-)
Heart & Lung S1 single, S2 split not constant, murmur (-)
vesicular +/+, wheezing -/-, rhonki -/-
Abdomen Flat (+), Supple (+), Suprapubic Tenderness (-)
BU(+) Up, hepatomegaly (-), splenomegaly (-), rapid turgor
Extremities Warm, pulse palpable & strong, cyanosis (-)
Blood test
Parameter Result Normal Range
Hemoglobin (g/dL) 12,2 11.3-14.1
Eritrosit (10 ̂6/uL) 4,62 3.90 – 5.90
Trombosit (10 ̂3/uL) 310 150 – 450
Hct (%) 33,8 31 – 43
MCV (fL) 78,1 (L) 80 – 99
MCH (fL) 26,4 (L) 27 – 31
MCHC (fL) 33,4 33 – 37
RDW 13,3 10.0 - 15.0
Leukosit (10 ̂3/uL) 9,1 4.5 – 10.4
Diff. Count Neutrofil (%) 50,4 0.4-1
Limfosit (%) 45,4 32 – 52
Eosinofil (%) 1–3
Basofil (%) 38 – 60
Monosit (%) 4–9
MPV 6,9
Assesment Plan

• Acute Watery Diarrrhea • Outpatient


• Without Dehydration • Paracetamol 10-15 mg/BW / 4-6 hours
• 5-7,5 cc / 4 – 6 hours if needed
• Zinc 20 mg / 24 hours -> 10 days
• Lacto B 2x1
• Plan A Rehydration (oralit 100-200 cc
/diarrhea or vomit)
EMERGENCY CASE
NO IDENTITY AND DIAGNOSIS DPJP AND WARD
8 By. Ny. F, male, 3 days old, 3 kg Inpatient – Bakung
dr. Arif, Sp. A
Chief complaint:
Tail Mass

Diagnosis:
Myocele Lumbosacral
Icteric Neonatorum
BBLC, CB, SMK, Normal Delivery
HMRS

 3 days old Female, baby from P2 A0, Spontaneus Delivery, Loud Crying,
Mass in tail

GDS: 39 -> 70 - 74
Physical Examination in the ER

General condition CM, iritable


Vital Sign HR 132 bpm, RR 45 x/min, t: 37,6°C, SpO2 97% O2 room air,

Neck Lymph nodes not palpable


HENT CA-/-, SI -/-, sunken eyes (-)
Thorax Symmetrical, S1 singular, S2 split not constant, murmur (-)
Heart & Lung vesicular +/+, wheezing -/-, rhonki -/-, Krepitasi (-/-)

Abdomen Flat, Supple, BU(+) N, rapid turgor, Icteric (+), Kramer 4

Extremities Warm, pulse palpable & strong, CRT<2”, Cyanosis (-)


Blood test
Parameter Result Normal Range
Hemoglobin (g/dL) 11,9 11.3-14.1
Eritrosit (10 ̂6/uL) 4,85 3.90 – 5.90
Trombosit (10 ̂3/uL) 646 (H) 150 – 450
Hct (%) 35,2 31 – 43
MCV (fL) 80 – 99
MCH (fL) 27 – 31
MCHC (fL) 33 – 37
RDW 10.0 - 15.0
Leukosit (10 ̂3/uL) 16,8 4.5 – 10.4
Diff. Count Neutrofil (%) 72,8 (H) 0.4-1
Limfosit (%) 22,04 (L) 32 – 52
Eosinofil (%) 1–3
Basofil (%) 38 – 60
Monosit (%) 4–9
MPV 9,9
Assesment Plan

• Myocele Lumbosacral Inpatient – Bakung


• Icteric Neonatorum With Pediatric Surgery
• BBLC, CB, SMK, Normal Delivery
EMERGENCY CASE
NO IDENTITY AND DIAGNOSIS DPJP AND WARD
9 AP, female, 1 years 8 months old, 10 kg Inpatient – Kenanga
dr. Arif, Sp. A
Chief complaint:
Fever days 5

Diagnosis:
Susp. Dengue Fever
Physical Examination in the ER

General condition CM, look dyspneu


Vital Sign HR 123 bpm, RR 32 x/min, t: 38.3°C, SpO2 96% O2 with NC 1L/menit
BB : 10 kg
Neck Lymph nodes not palpable
HENT CA-/-, SI -/-, sunken eyes (-)
Thorax Symmetrical, retraction (-)
Heart & Lung S1 singular, S2 split not constant, murmur (-)
vesicular +/+, wheezing -/-, rhonki -/-, krepitasi (-)
Abdomen Supple, BU(+) N, tenderness (-), rapid turgor

Extremities Warm, pulse palpable & strong, CRT<2”, petechie (-)


Blood test
Parameter Result Normal Range
Hemoglobin (g/dL) 12,6 11.4-14.5
Eritrosit (10 ̂6/uL) 4,85 3.90 – 5.90
Trombosit (10 ̂3/uL) 152 150 – 450
Hct (%) 39,1 31 – 43
MCV (fL) 80,6 80 – 99
MCH (fL) 26 (L) 27 – 31
MCHC (fL) 32,2 (L) 33 – 37
RDW 14,4 10.0 - 15.0
Leukosit (10 ̂3/uL) 14,3 4.5 – 10.4
Diff. Count Neutrofil (%) 52 50 – 65
Limfosit (%) 45,2 38 – 60
Eosinofil (%) 1–3
Basofil (%) 0,4 – 1
Monosit (%) 4–9
MPV 6,5
Parameter Result Normal Range
Natrium 135,3 129 – 143
Kalium 4,49 3,6 – 5,8
Chlorida 109,3 93 – 112
Assesment Plan

• Susp. Dengue Fever  Inpatient – Kenanga


 Fluid : 1000cc/days -> 720 iv = 10 tpm
 Paracetamol 10-15 mg / BW / 4 – 6 hours
 120 mg / 4-6 hours if needed
EMERGENCY CASE
NO IDENTITY AND DIAGNOSIS DPJP AND WARD
10 By. Ny. E, female, 0 hours, 2700 g Inpatient – Anggrek
dr. Arif, Sp. A
Chief complaint:
-

Diagnosis:
BBLC, CB, SMK, Normal Delivery with Gestational
Hypertension Mother
Physical Examination in the ER

General condition CM, calm


Vital Sign HR 110 bpm, RR 21 x/min, t: 36,8°C, SpO2 97% O2 room air,
BB 2700 gram, LK 31 cm, PB 47 cm
Neck -
HENT CA-/-, SI -/-, icteric (-)
Thorax Symmetrical, retraction (-)
Heart & Lung S1 singular, S2 split not constant, murmur (-)
vesicular +/+, wheezing -/-, rhonki -/-
Abdomen Supple, BU(+) N, umbilical cord smelly (-), tenderness (-)
rapid turgor
Extremities Warm, pulse palpable & strong, CRT<2”, cyanosis (-)
EMERGENCY CASE
NO IDENTITY AND DIAGNOSIS DPJP AND WARD
11 KB, male, 3 years 10 months old, 14 kg Inpatient – Kenanga
dr. Hendra, Sp. A
Chief complaint:
Disuria & Abdominal Pain with Fever

Diagnosis:
Susp. Urinary Tract Infections
4 days SMRS 2 days SMRS HSMRS

 Fever (+), getting • Dysphagia (+)  Disuria (+)


worse until HMRS
• Cough (+), coryza (+)  Urgency (+)
 Minimal response to
white nasal discharge  Last Diuresis : 2
syr. PCT
• Antibiotic (+), 3 times hours, before the
last one 4 hours
already in
Physical Examination in the ER

General condition CM, calm


Vital Sign HR 136 bpm, RR 26 x/min, t: 38,1°C, SpO2 96% O2 room air
BB 14 kg, PB : 99 cm
Neck Lymph nodes not palpable
HENT CA-/-, SI -/-, sunken eyes (-), tears (+)
Thorax Symmetrica, retraksi (-)
Heart & Lung S1 singular, S2 split not constant, murmur (-);
vesicular +/+ wheezing -/-, rhonki -/-,
Abdomen Supple, BU(+) normal, splenomegaly (-), hepatomegaly (-), epigastric
tenderness (+), rapid turgor
Extremities Warm, pulse palpable & strong, CRT<2”, OUE Hiperemis
• BB/U : -2 < Z < 0
• TB/U : -2 < Z < 0
• BB/TB : -2 < Z < 0
Blood test
Parameter Result Normal Range
Hemoglobin (g/dL) 11,4 11.4-14.5
Eritrosit (10 ̂6/uL) 4,42 3.90 – 5.90
Trombosit (10 ̂3/uL) 180 150 – 450
Hct (%) 33,4 31 – 43
MCV (fL) 75,6 (L) 80 – 99
MCH (fL) 25,8 (L) 27 – 31
MCHC (fL) 33,1 33 – 37
RDW 10.0 - 15.0
Leukosit (10 ̂3/uL) 3,7 (L) 4.5 – 10.4
Diff. Count Neutrofil (%) 41,60 50 – 65
Limfosit (%) 56,9 38 – 60
Eosinofil (%) 1–3
Basofil (%) 0,4 – 1
Monosit (%) 4–9
MPV 7,1
Urine test
Parameter Result Normal Range Parameter Result Normal Range
Sedimen Keton 10 neg
Epitel Positif 1+ Bilirubin Neg neg
Eritrosit 0-2 0-4 pH 6 5-8
Leukosit 2-4 0-5 Nitrite Neg neg
Silinder 0 0-1 Berat jenis 1.015 1.003 – 1.029
Kristal 0 0-1 Urobilinogen Norm 0-1
Lain Bakteri Blood Neg neg
Warna Kuning Jernih Leukosit neg 0–5
Protein Neg Neg Asam Arkobat neg 0-1
Glucose Neg Neg
Assesment Plan

• Susp. Urinary Tract Infections  Inpatient


 Inj. Ampicillin 100 mg/BW/ day
 140 mg/hari -> 50 mg / 8 hours
 Inj. Paracetamol 10 -15 mg / BW / hari
 150 mg/ 4-6 hours if needed
EMERGENCY CASE
NO IDENTITY AND DIAGNOSIS DPJP AND WARD
1 By.Ny.RA, male, 0 months, 2.5 kg dr. Nov, Sp.A, rawat gabung

Chief complaint: newborn

Diagnosis:
BBLC, CB, SMK, Spontan
Admission day

25 March 2018

 Male, spontaneous delivered, active cry from mother G3P2A0 with


gestational age 39+3 weeks
 Resucitated until early step (suction)
 KPD (-)
 Amniotic fluid clear
 BBL : 2500 gram
 PB : 46 cm
 BAB (-)
 BAK (-)
Physical Examination at ER

General condition C5, letargis (-)


Vital Sign HR 146-150 bpm, RR 42-50 x/min, t: 36.6°C, SpO2 95% O2 room air, BW
2.5 kg
Head Pale conjunctiva (-), icteric sclera (-)
Antropometri BBl: 2500 g, pb: 46 cm, LK: 32 cm, LD: 31 cm, LP: 28 cm, Lila: 10 cm
Thorax Simetris, vesicular (+/+), ronchi (-/-), wheezing (-), murmur (-) gallop (-)
Heart & Lung
Abdomen Supple, umbilical cord normal
Extremities Warm, pulse palpable & strong
Apgar score
0 1 2
Heart rate per absent <100 >100
minute
Respiratory effort absent Slow, irregular Good, crying

Muscle tone limp Some flexion Active motion


Response to No response grimace Good response
stimulation
Color Blue or pale Pink body, blue Completely pink
extremities
• Apgar score : 8/9
Downe Score
Parameter 0 1 2
RR/ menit <60 60-80 >80
Sianosis Tidak ada Sianosis hilang Sianosis tetap
ketika diberik ada walaupun
O2 sudah diberi O2
Retraksi Tidak ada Mild Severe
Suara Napas Baik pada Penurunan Tidak terdengar
kedua paru suara napas
Merintih Tidak ada Dapat didengar Dapat didengar
dengan tanpa
stetoskop stetoskop
Downe score : 0
lubchenco
• SMK
Assesment Plan

• BBLC, CB, SMK, Spontan - Rawat Gabung


- Inj. Vit K1
- Eye ointment chloramphenicol
- Umbilical cord care
- ASI
EMERGENCY CASE
NO IDENTITY AND DIAGNOSIS DPJP AND WARD
2 By.Ny.A, female, 0 months, 3 kg dr. Nov, Sp.A, rawat gabung

Chief complaint: newborn

Diagnosis:
- BBLC, CB, SMK, Spontan
- Riw. Fetal distress, riw. Vakum ekstrasi
Admission day

25 March 2018

 Male, spontaneous delivered, active cry from mother G2P1A0 with


gestational age 39+1 weeks
 Resucitated until early step (suction)
 KPD (-)
 Amniotic fluid clear
 BBL : 3000 gram
 PB : 48 cm
 BAB (-)
 BAK (-)
Physical Examination at ER

General condition C5, letargis (-)


Vital Sign HR 170-180 bpm, RR 50-600 x/min, t: 36.8°C, SpO2 95% O2 room air,
BW 3 kg
Head Pale conjunctiva (-), icteric sclera (-)
Antropometri BBl: 3000 g, pb: 48 cm, LK: 31 cm, LD: 29 cm, LP: 26 cm, Lila: 10 cm
Thorax Simetris, vesicular (+/+), ronchi (-/-), wheezing (-), murmur (-) gallop (-)
Heart & Lung
Abdomen Supple, umbilical cord normal
Extremities Warm, pulse palpable & strong
Apgar score
0 1 2
Heart rate per absent <100 >100
minute
Respiratory effort absent Slow, irregular Good, crying

Muscle tone limp Some flexion Active motion


Response to No response grimace Good response
stimulation
Color Blue or pale Pink body, blue Completely pink
extremities
• Apgar score : 7/9
Downe Score
Parameter 0 1 2
RR/ menit <60 60-80 >80
Sianosis Tidak ada Sianosis hilang Sianosis tetap
ketika diberik ada walaupun
O2 sudah diberi O2
Retraksi Tidak ada Mild Severe
Suara Napas Baik pada Penurunan Tidak terdengar
kedua paru suara napas
Merintih Tidak ada Dapat didengar Dapat didengar
dengan tanpa
stetoskop stetoskop
Downe score : 0
lubchenco
• SMK
Assesment Plan

• BBLC, CB, SMK, Spontan - Rawat Gabung


- Inj. Vit K1
• Riw. Fetal distress, riw. - Eye ointment chloramphenicol
Vakum ekstrasi - Umbilical cord care
- ASI
EMERGENCY CASE
NO IDENTITY AND DIAGNOSIS DPJP AND WARD
3 DA, 2 years 11 months, 12 kg Kenanga, dr. Nov Sp.A

Chief complaint : dyspnea

Diagnosis:
CAP
3 days before 2 days before 8 april2018

 Fever, continuous, temp: 38°C  Coryza (+)  Fever (+)


 Coryza (+)
 BAB (+) normal
 BAK (+) normal
 Vomitus (-)
Physical Examination at ER

General condition CM, active movement, loud cry


Vital Sign HR 133bpm, RR 50 x/min, T: 38.6°C, SpO2 95% room air
Head CA (-) SI (-), nasal flare (+)
Neck JVP increased (-), unpalpable limfnode
Thorax Simetris, ronchi (+/-), wheezing (-), subcostal whest indrawing (+),
Heart & Lung krepitasi (+/-)
murmur (-), gallop (-)
Abdomen Supel, bowel sound (+) , normal turgor, tendersness(-)

Extremities Warm, strong pulse


Blood test
Parameter Result
Hemoglobin (g/dL) 11.9
Eritrosit (10 ̂6/uL) 4.72
Leucocyte 9.4
Trombosit (10 ̂3/uL) 253
Hct (%) 35.7
MCV (fL) 75.9 (L)
MCH (fL) 25.1 (L)
MCHC (fL) 33.2
Diff. Count Neutrofil (%) 65.15 (H)
Limfosit (%) 26.9(L)
Monosit (%) 7.51
Basofil (%) 0.1 (L)
Eosinofil (%) 0.33 (L)
Assesment Plan

• CAP - Inpatient
- Ampicilin  200 mg/kg/day
~ 600 mg/6 hour

- Gentamicin  7.5 mg/kg/day


~ 90 mg/day
- Paracetamol  150 mg/ 4-6 hour IV
- If no intake, D5 ¼ NS Kaen 3A ~ 12 tpm
makro
EMERGENCY CASE
NO IDENTITY AND DIAGNOSIS DPJP AND WARD
4 NTR, female, 9 months, 4kg dr. Arif, Sp.A,

Chief complaint : cyanosis

Diagnosis:
- Periodic apnea ec epilepsy dd cardiac problem
- Hirscprung disease
- Russel-silver syndrome
1 days before 25 March 2018

 Cyanosis around lips  Cyanosis (+), 10x


 Fever (-)
 Coryza (-)
 Diagnosed russel-silver
syndrome, hirscprung disease
operated yet, hernia inguinal,
and pulmonary hypertention
echo from RSS
Physical Examination at ER

General condition CM, active movement


Vital Sign HR 132 bpm, RR 35 x/min, T: 36.8°C, SpO2 99% NK 1 lpm
Head CA (-) SI (-)
Neck JVP increased (-), unpalpable limfnode
Thorax Simetris, retraksi (-), ronchi (-), wheezing (-)
Heart & Lung murmur (-), gallop (-)
Abdomen Distended (+), bowel sound (+) , normal turgor, tendersness(-)

Extremities Warm, strong pulse


Assesment Plan

- Periodic apnea ec epilepsy - Inpatient


dd cardiac problem - Obs. Periodic apnea
- Oksigen 1 lpm
- Hirscprung disease
- Lactulac syrup  2 ml/kg/x
- Russel-silver syndrome ~ 8 ml/12 hour
- EEG tomorrow morning
- If still distended  dekompresi
EMERGENCY CASE
NO IDENTITY AND DIAGNOSIS DPJP AND WARD
1 FAA ,Male, 1 years 10 months old, 7,3 kg dr. Nov, Sp.A, Kenanga

Chief complaint: Cough

Diagnosis: Susp pertussis


2 weeks before
admission Day before admission Admission day

Patient got cough and runny Sudden stiff(+) 1 times Sudden stiff(+) 1
nose after coughing times after coughing
Medication(+) symptom didn’t approximately the approximately the
getting better duration is 1 minute duration is 1 minute
Cyanosis(+) Tired(+) Cyanosis(+) Tired(+)
Fever(-) Fever(-)
Physical Examination at ER

General condition CM,


Vital Sign HR 120 bpm, RR 32 x/min, T: 36°C, SpO2 99% O2 room air, BW 7,3

Neck JVP (-) Palpable lymph node (-)

HENT Head nodding(-) CA (-/-) SI (-/-)

Thorax I : Flat, Symmetry, Retraction (-)


Heart & Lung Pa : Fr Symmetry
Pe : Sonor
Aus : Cor : Single S1, Split unconstant S2 , murmur (-)
Pulmo : Vesiculer , Wheezing -/-, rhonki -/-
Abdomen I : Flat, Supple
Aus : Bowel sound (+) Normal
Pe : Tymphani
Pa : Palpable hepar lien (-)
Extremities Warm, edema (-),
Blood test
Parameter Result Normal Range
Hemoglobin (g/dL) 13,1 11.3– 14,1
Eritrosit (10 ̂6/uL) 4.63 4.00 – 5.20
Leucocyte 15,1 6-17
Trombosit (10 ̂3/uL) 441 150 – 450
Hct (%) 39,2 37 – 52
MCV (fL) 84,7 80 – 99
MCH (fL) 28,3 27 – 31
MCHC (fL) 33.4 33 – 37
Diff. Count Neutrofil (%) 43,07L) 50 – 65
Limfosit (%) 48,94 38-60
Monosit(%) 7,07 4-9
Eosinofil(%) 0,89(L) 1-3
Basofil(%) 0,03(L) 0,4-1
RDW (%) 14,4 10.0 – 15.0
MPV 8,1
Assesment Plan

• Susp pertussis - Hospitalized


- Sputum B Pertussis examination
- Eritromisin 50 mg/kgbb/day
- Salbutamol syr 3x1mg
- O2 nk 1 L/menit
EMERGENCY CASE
NO IDENTITY AND DIAGNOSIS DPJP AND WARD
1 KA,Female,5 years 9 months old, 19 kg dr. Nov, Sp.A, Menur

Chief complaint: Diarrhea

Diagnosis: Acute watery diarhea with non severe


dehydration
Admission day

Patient is reffered from PKM with chief complaint diarrhea after


drinking goat milk. Diarrhea since morning 16x/day with volume
3 tablespoon/diarrhea . Dregs(+) mucus since evening (+),
blood(-). nausea(+) vomiting 5 times (+). Patient has history of
febrile convulsion. Last seizure is january 2017. Last urination 2
hours before admission . Food and drink intake decrease.
Fever(+) 38,4
Physical Examination at ER

General condition CM,


Vital Sign HR 143 bpm, RR 30 x/min, T: 38,4°C, SpO2 99% O2 room air, BW 19

Neck JVP (-) Palpable lymph node (-)

HENT Head nodding(-) CA (-/-) SI (-/-)

Thorax I : Flat, Symmetry


Heart & Lung Pa : Fr Symmetry
Pe : Sonor
Aus : Cor : Single S1, Split unconstant S2 , murmur (-)
Pulmo : Vesiculer , Wheezing -/-, rhonki -/-
Abdomen I : Flat, Supple
Aus : Bowel sound (+) Normal
Pe : Tymphani
Pa : Palpable hepar lien (-)
Extremities Warm, edema (-),
Urine test
Parameter Result Normal Range
Epitel + 1+
Erytrosit 0-1 0-4
Leucocyte 1-2 0-5
Silinder + 0-1
Kristal 0 0-1
Lain-lain Bakteri + 80 – 99
Makroskopis Kuning jernih
warna

Protein +- negatif
Glukosa - negatif
Keton positif negatif
Bilirubin negatif Negatif
pH 6 5-8
Nitrit - Negatif
Berat jenis 1,025 1,003-1,029
Urobilinogen +- 0-1+
Blood Negatif Negatif
Leukosit Negatif 0-5
Asam askorbat 0 0-1+
Assesment Plan

• Acute watery diarhea with non - Hospitalized low intake


severe dehydration - Inj Ondansetron 0,2mg/kgbb/8 hours
- Zinc 20 mg/24 hours
- Lact B 2x1sach
- Rehydration plan B for 3 hours, followed by
rehydration plan A (oralit 200cc/diarrhea and
vomit
EMERGENCY CASE
NO IDENTITY AND DIAGNOSIS DPJP AND WARD
1 SKS,Female,3 years 5 months, 14 kg dr. Nov, Sp.A, Outpatient

Chief complaint: Diarrhea

Diagnosis: Acute watery diarhea with mild-


moderate dehydration
Admission day

Patient with chief complaint diarrhea after drinking susu kotak.


Patient often drink it and never got problem. Diarrhea since 6
hours before admission 10x/day with volume 20 cc /diarrhea .
Dregs(+) mucus (+), blood(-). nausea(+) vomiting 10 times (+)
proyektil (-) Fever(-) Abdominal pain(-). Good water intake(+)
but lower food intake
Physical Examination at ER

General condition CM,


Vital Sign HR 145 bpm, RR 34 x/min, T: 36,8°C, SpO2 97% O2 room air,

Neck JVP (-) Palpable lymph node (-)

HENT sunken eyes(-) CA (-/-) SI (-/-)

Thorax I : Flat, Symmetry


Heart & Lung Pa : Fr Symmetry
Pe : Sonor
Aus : Cor : Single S1, Split unconstant S2 , murmur (-)
Pulmo : Vesiculer , Wheezing -/-, rhonki -/-
Abdomen I : Flat, Supple
Aus : Bowel sound (+) Normal
Pe : Tymphani
Pa : Palpable hepar lien (-)
Extremities Warm, edema (-),
Assesment Plan

• Acute watery diarhea with no - Outpatient with good intake


dehydration - Zinc 10 mg/24 hours (10 days)
- Lact B 2x1sach
- Rehydration plan A (oralit 200cc/diarrhea
and vomit
Thank you