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DUTY REPORT
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DUTY REPORT
SATURDAY MORNING,April 20th2013
Alissa D.,MD./ Windi I.,MD./ Listya D,MD.Rozalina Loebis, MD.Ophthalmologist
Pre op : - 1stclass : 7 patients
Post op : - 2ndclass : 7 patientsconsult : 1 3rdclass : 21 patients
TOTAL : 35 patients
BOR : 89.74 %
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Consult from Pediatric department
Menghadapkan pasien An. M. Fian/ laki-laki/ 2
tahun 8 bulan/ 7 kg yang kami rawat dengan
Bisitopenia e.c CMV infection.
Mohon konsul evaluasi adakah kelainan di bidang
teman sejawat sehubungan dengan infeksi CMV
tersebut?Atas perhatian dan kerjasamanya, banyak terima
kasih.
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Subjective
Heteroanamnesis:
Main Complaint: Bloody stool
Bloody stool since 2 weeks before hospitalized. He
often suffers bloody stool since 2 months old. Novomitting.
He also suffers cough since the last 2 months.
No complains related to visual function, patient able
to play with small toys.
There is growth and developmental delay
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During Pregnancy:
Pre Natal: mother suffers from illness, no history of
drinking herbal drink,TORCH (not examined)
Natal:delivered by an obstetrician, sectio caesaria, 9
months, birth weight: 2100 gram
Post Natal:jaundice (phototherapy)
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Objective
General Status:
HR: 118 x/minute
RR: 30 x/minute
Temp: 36.5 C
Visual Acuity: Right eye : Fix and Follow (+)
Left eye : Fix and Follow (+)
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Anterior Segment
Right eye Left eye
Eyelid Edema Spasm - Edema Spasm -
Conjunctiva Hyperemia - Hyperemia -
Cornea Clear + Clear +
Anterior Chamber Deep + Deep +
Iris Radier + Radier +
Pupil Round + 3mm LR +RAPD-
Round + 3mm LR +RAPD-
Lens Clear Clear
Intra Ocular Pressure Normal Palpation Normal Palpation
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Posterior SegmentRight eye Left eye
Fundal Reflex +Optic Disc:sharp margin, normal color
Retina:hemorrhages - exudate
Macular Reflex +
Fundal Reflex +Optic Disc:sharp margin, normal color
Retina:intra retinal hemorrhages +
(along vascular arcades)exudate+
Pigmented area+Macular Reflex +
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Picture of the patient
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Schematic Picture
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Laboratory Results
(April 19th2013)
Hb : 9.81
RBC : 4.10 x 106
WBC : 9.59 x 103
Plt : 153 x 103
(March 30th2013)
SGOT : 50
SGPT : 25
Alb : 4.0
BUN : 13 Creatinin Serum : 0.2
K : 4.5
Na : 135
Cl : 100
(March 19th2013)
Parasitology examination:
Faeces:
Entamoeba hystolitica + Bacteria +
Candida
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CMV IgM : 0.730
CMV IgG : > 500 ( positive)
Avidity:
CMV IgG: H 1.00 (high avidity)
Determine HIV : non Reactive
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Other Examination
Chest X-ray : Pneumonia
Skull Photo : within normal limit
Echocardiography : within normal limit
Abdominal USG : Hepatomegali
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Consultation
Ear Nose Throat Department:
Serumen Obsturan
Dermatology Department:
Atopic Dermatitis
Cardiology Pediatri:
Pro Echocardiography
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Temporary Problem List Bloody stool Entamoeba hystolitica
Hb 9.81 Rubella IgG + Rubella IgM + CMV IgG H 1.00 (high avidity) Chest x-ray: pneumonia
Hepatomegali Atopic dermatitis Developmental delay
Retina: hemorrhages + exudate + on the left eye
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Permanent Problem List
CMV Infection
Pneumonia
Hepatomegali
Atopic dermatitis
Developmental delay
Amoebiasis
CMV Retinitis on left eye
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Therapy from pediatric department:
Tranexamic acid 3x100 mg iv
Pro biotic 2x1 sach
Zinc 1x20 mg Physiogel
Hydrocortisone Cream for skin
Myconazole
Na Fusidate
Bubur 3 x daily
Pro consult to Tropic-Infection division forGancyclovir therapy
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Konsul dijawab:
Saat ini dibidang mata secara optalmoskopis direk
kami dapatkan CMV retinitis.
Saran:
Apabila pasien poliklinis, dapat dikonsulkan ke Poli
Mata divisi pediatri-ophthalmology.
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Thank You