Professional Documents
Culture Documents
night shift
Monday, November 25th 2019
dr. Mega / dr. Etika /dr. Kiki / dr. Disa/ dr. Winda
dr. Tria/dr. Efan
dr. Zilmi/ dr. Nunki
1
PATIENT ADMISSION
2
• Melati 2 ward :
- A, 4 y.o, 16.5 kgs with Guillain Barre syndrome dd
ATM, wellnourished
• Melati 3 Ward
- Af, 3 y.o, 14 kgs with Acute Gastroenteritis with
moderate dehydration, hydrocephalus post VP shunt,
wellnourished
- L, 11 y.o, 21 kgs with Dengue Fever dd unspecified
viral infection, ED: Acyanotic CHD, AD: Tricuspid atresia,
VSD, PMO, L to R shunt post BCPS surgery,
malnourished
3
IDENTITY PASIEN
Name : A
Age : 4 years 2 months
Gender : Female
W/ L : 16.5 kgs/101 cms
Address : Ngemplak, Boyolali
MR : 01485407
Chief Complaint :
Paralyzed
4
Appearance
Tone : normal, active movement
Irritability : normal, fully conscious
Consolability : normal, calm
Look : normal, focus
Speech : normal, active speech
Circulation
Pale :-
Cyanosis :- Circulation:
Mottle :- Normal
Bleeding :-
Primary Survey
• Airway:
– Within normal limit
• Breathing:
– Work of breathing : within normal limit
• Circulation:
– Within normal limit
6
THE CURRENT MEDICAL HISTORY
1 weeks before
admission •Fever(+)
•Cough and cold (+)
7
THE CURRENT MEDICAL HISTORY
3 days before
admission •Fever(-)
•Weakness in the feet and legs
8
THE CURRENT MEDICAL HISTORY
1 days before
admission •Fever(-)
•Weakness in the lower body, moving forward
9
THE CURRENT MEDICAL HISTORY
• Fully alert At ER
• Dyspnea (-)
• Fever (-)
• Urinating (+)
10
11 PAST MEDICAL HISTORY
Pregnancy
The patient is 1st child of her family. She was born from 35 years old mother,
G1P0A0 at 38th week of gestational age. Her mother checked her pregnancy
to midwife, consumed vitamins routinely, and never hospitalized.
Delivery
The baby was delivered spontaneous from mother with premature
rupture of membrane 7 hours . She was born aterm, Birth weight
2600 gram.
Conclusion :
The pregnancy dan delivery was normal
14
ANAMNESIS
Growth
Development
Growth
This patient’s age is 4 years old with the weight 16.5 kgs and the
height 101 cm.
Development
• Speak clearly using more complex sentences
• Peddle a bicycle
• Draw a person with a body
• Understand and obeys rules
Vaccination History
VACCINE MONTH
Hepatitis B1 (+) Polio 1 0 month
BCG(+), Hepatitis B2 1 month
DTP1 (+),Polio 2(+) 2 month
DTP2 (+), polio 3 (+) 4 month
DTP3 (+), polio 3 (+), Hepatitis B3 (+) 6 month
Measles (+) 9 month
DTP4 (+), polio 4 (+) 18 month
Measles (+) 24 month
Conclusion :
Complete basic immunization
according to Ministry of Health schedule 2014
FAMILY TREE
II
III
16
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Head : Normocephalic
Eyes : Anemic conjungtiva -/-, icteric sclera -/-, isochoric
pupils 2mm/2mm
Nose : Nostrils flares(-), discharge (-)
Mouth : Wetness (+), cyanosis (-), pharynx and tonsil difficult to
evaluated
Ears : Ear discharge -/-
Neck : Node enlargement (-)
Chest : Symmetrical in shape and movement, retraction (-)
19
Interpretation :
• Thrombocytosis
• limfopheni
23 Problem List
A, female, 4 yo , 16.5 kg with :
1. Hystory of Fever
2. Hystory of cough and cold
3. Weakness in the lower body, moving forward
24 DIFFERENTIAL DIAGNOSIS
1. Lumbar puncture
2. EMG
3. Spinal MRI
MONITORING
General Appearance/Vital Signs/Blood
pressure/8hour
Monitoring respiratory distress
FOLLOW UP 26/11/2019
28
29
PHYSICAL EXAMINATION
GA : moderate illness, compos mentis
VS : Heart rate: 102x/min Temp. : 36,8oC
Resp. rate : 24x/min SiO2 : 98%
Head : Normocephalic
Eyes : Anemic conjungtiva -/-, icteric sclera -/-, isochoric
pupils 2mm/2mm
Nose : Nostrils flares(-), discharge (-)
Mouth : Wetness (+), cyanosis (-), pharynx and tonsil difficult to
evaluated
Ears : Ear discharge -/-
Neck : Node enlargement (-)
Chest : Symmetrical in shape and movement, retraction (-)
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1. Lumbar puncture
2. EMG
3. Spinal MRI
MONITORING
General Appearance/Vital Signs/Blood
pressure/8hour
Monitoring respiratory distress
THANK YOU
35
Clinical question
• Which is better plasma exchange or IVIG for
GBS in the pediatrics population?
• CRITICAL APPRAISAL
VALIDITY
WAS THERE A CLEAR QUESTION FOR THE STUDY
TO ADDRESS?
YES
valid
2A
applicable important