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CASE CONFERENCE

th
February 15 2018
Morning Shift

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New Patients

Melati 2 Ward :
S, 21mo, 9kg, prolonged fever due to suspect UTI dd
typhoid fever dd lung TB, well nourished
A, 5mo, 8.8 kgs, diarrhea without dehydration due to
cow’s milk alergy dd rotavirus dd EIEC, Bronchitis,
Alergic Contact Dermatitis, well nourished
HCU Neonatus: (-)
NICU: ( - )
HCU Melati 2: (-)
PICU / ROI : (-)

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Patient Identity

Name :A
Sex : Male
Age : 5 months old
Weight/Height : 8.8 kg / 70 cm
Address : Wonogiri
Med. Record : 01409300

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Chief Complaint

Diarrhea

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Present Medical History
9 DAYS BEFORE ADMISSION 8 DAYS BEFORE ADMISSION
• Patient got cough with mucous. • Still got cough with mucous
• Cough everyday, not depend on • Vomit (+) decreased
weather • Patient didn’t get fever
• Vomit 10x/day @1/4 glass contain • Chest x-ray showed that patient got
water and mucous bronchopneumonia
• Patient got mild fever, didn’t get • Lab result: Hb 11.6, Hct 35.3,
fever when drink medicine Leucocyte 11.6, tombocyte 520.000
• Defecation 1x, soft, yellowish, • Urination and defecation within
mucous(-), blood (-) normal limit
• Urination within normal limit
• Patient went to Private hospital
and got hospitalization

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Present Medical History
ON ADMISSION DAYS ON EMERGENCY ROOM
• When patient got discharged from
private hospital, patient got vomit • Patient fully alert
> 10 times, ±1/4 glass, contained • No fever
water and mucous. • Diarhhea, 1 times, watery, yellowish,
• Patient got diarrhea 10-12 times, no blood or mucous.
waterry, mucous (+), blood (+) • Nausea (-), vomit (-)
• Patient still can drank • No cough or flu
• Urination within normal limit • Urination within normal limit
• Patient reffered to Dr.Moewardi
Hospital

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Past Medical History
◦ Patient got hopitalization on Jauary 31th on private hospital
due to fever and vomit

Family Medical History


• History of the same illness : (-)
• History of asthma : (+) mother

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Pregnancy and Birth History
• During pregnancy, mother routinely checked her
pregnancy to midwife. She was given vitamin, and
she didn’t consume any other of medicine. No history
of hospitalization during pregnancy
• Baby boy was born in full term pregnancy, normal
delivery, cried vigorously, no cyanosis or icteric was
found and his birth weight was 2950 grams

Conclusion: normal birth history and normal pregnancy

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Immunization Status
Hep B : 0 month
Polio : 1, 2, 3, month
BCG : 1 month
DPT, Hib, HepB : 2,4 month
Measles : - months

Conclusion : incomplete immunization, according to


Ministry of Health’s schedule 2017

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Nutrition History

Patient drank cow’s milk 2 months before got symptoms vomit and cough.
Patient drank milk 8-10times/day
Conclusion : quality and quantity of nutrition are normal

Growth and Development


He is now 5 months old,. He can sits with trunk support, respond to name,
reaches midline and enjoys looking arround
His weight is 8.8 kg with body height 70 cm.
Conclusion: growth and development is normal

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Nutritional Status
• Weight for Age : 0 SD < BB/U < 2 SD

• Length for Age : TB/U = 2 SD

• Weight for Length : 0 SD < BB/TB >1 SD

Conclusion: wellnourished, normoweight, normoheight


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Pedigree
I

II

III

A, 5 months old

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Physical Examination (February 15th 2018 at ER)
General appearance: Fully alert (E4V5M6)
VS :
Heart rate: 134 x/menit body temp : 36,50C
Respiration rate: 32 x/menit saturation : 98%

Head : mesocephal
Eyes : pale conjunctiva (-/-), icteric conjunctiva(-/-)
light reflexes (+/+), isochoric pupil 2 mm/2mm, sunken eyes (-/-)
Nose : nasal flare (-/-),discharge (-/-)
Mouth : lips and tongue cyanotic, moist lips mucosa (+)
Neck : no enlargement of lymph node

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LUNG:
I : normal, symmetric, retraction (-)
P : hard to evaluate
P : sonor in both lung
A : vesicular breath sound(+/+) additional breath sound (+),
coarse +/+ crackles -/- wheezing -/-

CARDIAC:
I : ictus cordis not visible
P : ictus cordis palpable at SIC IV LMCS
P : there is no cardiac enlargement
A : 1st 2nd Heart sound normal intensity, regular, no murmur

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ABDOMINAL:
I : abdominal wall // thorax wall
A : peristaltic within normal limit
P : tympani
P : no enlargement of the spleen and liver, skin turgor good

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis pedis
artery was strong , no cyanotic

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LABORATORY FINDINGS
February 15th 2018
Value Reference Units
Hemoglobin 11.5 14-17.5 g/dl
Hematocrit 35 33-45 %
Leucocyte 13.2 4.5-14.5 x103/ul
Thrombocyte 410 150-450 x103/ul
Eritrocyte 4.48 3.8-5.8 x106/ul
MCV 78.3 80.0-96.0 /um
MCH 25.9 28.0-33.0 pg
MCHC 33.0 33.0-36.0 g/dl
RDW 14.1 11.6-14.6 %
Eosinophil 3.60 0.00-4.00 %
Basophil 0.20 0.00-1.00 %
Neutrophil 17.60 29.00-72.00 %
Lymphocyte 68.20 33.00-48.00 %
Monocyte 4.90 0.00-6.00 %

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LABORATORY FINDINGS
February 15th 2018

Value Reference Units


RBG 90 80-100 mg/dl
Sodium 137 132-145 mmol/L
Potassium 3.7 3.1-5.1 mmol/L
Chloride 107 98-106 mmol/L
Calcium 1.33 1.17-1.29 mmol/L

Interpretation :

• within normal limit

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Problem List 18

1. diarrhea 10-12 times, waterry, mucous (-), blood (-), on


admision days
2. Vomit > 10 times, ±1/4 glass, contained water and
mucous
3. Sunken eyes (-)
4. moist lips mucosa (+)
5. additional breath sound (+), coarse +/+
6. Wellnourished, normoweight, normoheight

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Differential Diagnose
1. Acute Diarrhea without moderate dehydration e.c cow’s milk alergy
dd rotavirus dd EIEC
2. Mild-moderate cow’s milk alergy
3. Bronchitis
4. Alergy contact dermatitis
5. Well nourished

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Working Diagnosis
1. Acute Diarrhea without moderate dehydration e.c cow’s milk alergy
2. Mild-moderate cow’s milk alergy
3. Bronchitis
4. Alergy contact dermatitis
5. Well nourished

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THERAPY
1. Admitted to Gastroenterology Ward
2. Diet breast milk 8 x100 ml
3. IVFD D51/4NS 36.6 ml/ hour
4. Oralit 10ml/kgBW/diarrhea = 90ml/diarrhea
5 ml/kgBW/diarrhea = 45ml/diarrhea
5. Zinc 10mg/24 hours p.o
6. Probiotic 1 sach / 12 hours
7. Nebulize NaCl 0.9% 2 ml/8hours

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PLAN

•Chest x-ray
•Urinalysis
•Routine feces

Monitoring
General appearance / vital signs / saturation /4 hour
Fluid balance and diuresis / 8 hours

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Chest X-Ray

Conlusion:
1. Pneumonia
2. Persistant Thymus

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FOLLOW UP 16th JANUARY 2018 06.00
S: no fever, no vomit, waterry diarrhea 4 times, grout > water, blood (-), mucous (-)
General appearance: Fully alert (E4V5M6)
VS :
Heart rate: 133 x/menit body temp : 36.4 (36.2-36.4) 0C
Respiration rate: 26 x/menit Fluid Balance : +226 cc
Diuresis : 2.84 cc/kg/hour
Head : mesocephal
Eyes : pale conjunctiva (-/-), icteric conjunctiva(-/-)
light reflexes (+/+), isochoric pupil 2 mm/2mm, sunken eyes (-/-)
Nose : nasal flare (-/-),discharge (-/-)
Mouth : lips and tongue cyanotic, moist lips mucosa (+)
Neck : no enlargement of lymph node

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LUNG:
I : normal, symmetric, retraction (-)
P : hard to evaluate
P : sonor in both lung
A : vesicular breath sound(+/+) additional breath sound (+),
coarse +/+ crackles -/- wheezing -/-

CARDIAC:
I : ictus cordis not visible
P : ictus cordis palpable at SIC IV LMCS
P : there is no cardiac enlargement
A : 1st 2nd Heart sound normal intensity, regular, no murmur

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ABDOMINAL:
I : abdominal wall // thorax wall
A : peristaltic within normal limit
P : tympani
P : no enlargement of the spleen and liver, skin turgor good

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis pedis
artery was strong , no cyanotic

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Working Diagnosis
1. Acute Diarrhea without moderate dehydration e.c cow’s milk alergy
2. Mild-moderate cow’s milk alergy
3. Bronchitis
4. Alergy contact dermatitis
5. Well nourished

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THERAPY
1. Admitted to Gastroenterology Ward
2. Diet breast milk 8 x100 ml
3. IVFD D51/4NS 36.6 ml/ hour
4. Oralit 10ml/kgBW/diarrhea = 90ml/diarrhea
5 ml/kgBW/diarrhea = 45ml/diarrhea
5. Zinc 10mg/24 hours p.o
6. Probiotic 1 sach / 12 hours
7. Nebulize NaCl 0.9% 2 ml/8hours

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PLAN

•Urinalysis on February19th 2018


•Routine feces on February19th 2018

Monitoring
General appearance / vital signs / saturation /8 hour
Fluid balance and diuresis / 8 hours

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FOLLOW UP 17th JANUARY 2018 06.00

S: no fever, no vomit, waterry diarrhea 3 times, grout (+) water (+) little, blood (-), mucous (-)
General appearance: Fully alert (E4V5M6)
VS :
Heart rate: 126x/menit body temp : 36.6 (36.2-36.7) 0C
Respiration rate: 30 x/menit fluid balance: +144 cc
diuresis : 2.67 cc/kg/hours
Head : mesocephal
Eyes : pale conjunctiva (-/-), icteric conjunctiva(-/-)
light reflexes (+/+), isochoric pupil 2 mm/2mm, sunken eyes (-/-)
Nose : nasal flare (-/-),discharge (-/-)
Mouth : lips and tongue cyanotic, moist lips mucosa (+)
Neck : no enlargement of lymph node

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LUNG:
I : normal, symmetric, retraction (-)
P : hard to evaluate
P : sonor in both lung
A : vesicular breath sound(+/+) additional breath sound (+),
coarse +/+ crackles -/- wheezing -/-

CARDIAC:
I : ictus cordis not visible
P : ictus cordis palpable at SIC IV LMCS
P : there is no cardiac enlargement
A : 1st 2nd Heart sound normal intensity, regular, no murmur

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ABDOMINAL:
I : abdominal wall // thorax wall
A : peristaltic within normal limit
P : tympani
P : no enlargement of the spleen and liver, skin turgor good

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis pedis
artery was strong , no cyanotic

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Working Diagnosis
1. Acute Diarrhea without moderate dehydration e.c cow’s milk alergy
2. Mild-moderate cow’s milk alergy
3. Bronchitis
4. Alergy contact dermatitis
5. Well nourished

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THERAPY
1. Admitted to Gastroenterology Ward
2. Diet breast milk 8 x100 ml
3. IVFD D51/4NS 36.6 ml/ hour
4. Oralit 10ml/kgBW/diarrhea = 90ml/diarrhea
5 ml/kgBW/diarrhea = 45ml/diarrhea
5. Zinc 10mg/24 hours p.o
6. Probiotic 1 sach / 12 hours
7. Nebulize NaCl 0.9% 2 ml/8hours

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PLAN

•Urinalysis on February19th 2018


•Routine feces on February19th 2018

Monitoring
General appearance / vital signs / saturation /8 hour
Fluid balance and diuresis / 8 hours

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FOLLOW UP 18th JANUARY 2018 06.00
S:
General appearance: Fully alert (E4V5M6)
VS :
Heart rate: x/menit body temp : 0C
Respiration rate: x/menit fluid balance: cc
diuresis : cc/kg/hours
Head : mesocephal
Eyes : pale conjunctiva (-/-), icteric conjunctiva(-/-)
light reflexes (+/+), isochoric pupil 2 mm/2mm, sunken eyes (-/-)
Nose : nasal flare (-/-),discharge (-/-)
Mouth : lips and tongue cyanotic, moist lips mucosa (+)
Neck : no enlargement of lymph node

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LUNG:
I : normal, symmetric, retraction (-)
P : hard to evaluate
P : sonor in both lung
A : vesicular breath sound(+/+) additional breath sound (+),
coarse +/+ crackles -/- wheezing -/-

CARDIAC:
I : ictus cordis not visible
P : ictus cordis palpable at SIC IV LMCS
P : there is no cardiac enlargement
A : 1st 2nd Heart sound normal intensity, regular, no murmur

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ABDOMINAL:
I : abdominal wall // thorax wall
A : peristaltic within normal limit
P : tympani
P : no enlargement of the spleen and liver, skin turgor good

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis pedis
artery was strong , no cyanotic

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Working Diagnosis
1. Acute Diarrhea without moderate dehydration e.c cow’s milk alergy
2. Mild-moderate cow’s milk alergy
3. Bronchitis
4. Alergy contact dermatitis
5. Well nourished

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THERAPY
1. Admitted to Gastroenterology Ward
2. Diet breast milk 8 x100 ml
3. IVFD D51/4NS 36.6 ml/ hour
4. Oralit 10ml/kgBW/diarrhea = 90ml/diarrhea
5 ml/kgBW/diarrhea = 45ml/diarrhea
5. Zinc 10mg/24 hours p.o
6. Probiotic 1 sach / 12 hours
7. Nebulize NaCl 0.9% 2 ml/8hours

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PLAN

•Urinalysis on February19th 2018


•Routine feces on February19th 2018

Monitoring
General appearance / vital signs / saturation /8 hour
Fluid balance and diuresis / 8 hours

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FOLLOW UP 19th JANUARY 2018 06.00
S:
General appearance: Fully alert (E4V5M6)
VS :
Heart rate: x/menit body temp : 0C
Respiration rate: x/menit fluid balance: cc
diuresis : cc/kg/hours
Head : mesocephal
Eyes : pale conjunctiva (-/-), icteric conjunctiva(-/-)
light reflexes (+/+), isochoric pupil 2 mm/2mm, sunken eyes (-/-)
Nose : nasal flare (-/-),discharge (-/-)
Mouth : lips and tongue cyanotic, moist lips mucosa (+)
Neck : no enlargement of lymph node

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LUNG:
I : normal, symmetric, retraction (-)
P : hard to evaluate
P : sonor in both lung
A : vesicular breath sound(+/+) additional breath sound (+),
coarse +/+ crackles -/- wheezing -/-

CARDIAC:
I : ictus cordis not visible
P : ictus cordis palpable at SIC IV LMCS
P : there is no cardiac enlargement
A : 1st 2nd Heart sound normal intensity, regular, no murmur

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ABDOMINAL:
I : abdominal wall // thorax wall
A : peristaltic within normal limit
P : tympani
P : no enlargement of the spleen and liver, skin turgor good

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis pedis
artery was strong , no cyanotic

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Working Diagnosis
1. Acute Diarrhea without moderate dehydration e.c cow’s milk alergy
2. Mild-moderate cow’s milk alergy
3. Bronchitis
4. Alergy contact dermatitis
5. Well nourished

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THERAPY
1. Admitted to Gastroenterology Ward
2. Diet breast milk 8 x100 ml
3. IVFD D51/4NS 36.6 ml/ hour
4. Oralit 10ml/kgBW/diarrhea = 90ml/diarrhea
5 ml/kgBW/diarrhea = 45ml/diarrhea
5. Zinc 10mg/24 hours p.o
6. Probiotic 1 sach / 12 hours
7. Nebulize NaCl 0.9% 2 ml/8hours

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PLAN

•Urinalysis today
•Routine feces today

Monitoring
General appearance / vital signs / saturation /8 hour
Fluid balance and diuresis / 8 hours

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