Clinical Conference September 30, 2022: Tropic Infection Division (New Case)
Clinical Conference September 30, 2022: Tropic Infection Division (New Case)
There was History of watery diet 2 weeks ago for 4 days, frequency > 5 times, dregs, mucus, no blood
No history of contact with patients with the same complaint at this time.
There was history of being treated at the Haji Hospital for 1 week and receiving ampicillin /intravenous for 6 days.
Gentamycine/intravenous for 1 days, Paracetamol/intravenously, zinc/oral.
History of Vaccine
PHYSICAL EXAMINATION
Frequency
Vaccine Not yet given 0 1 2 3 4
Hep B √ √ √ √ √
BCG √
DPT √ √ √ √
Hib √ √ √ √
POLIO √ √ √ √
MMR √
Rotavirus √
Influenza √
Japanese Encephalitis √
PCV √
Varicella √
Hepatitis A √
Tifoid √
PHYSICAL EXAMINATION
Vital Sign Antropomethry
General condition: Moderate illness/Good
Body weight : 17 kg
Nourished/GCS 15 (E4M6V5)
Length : 104 cm
Blood Pressure: 90/60 mmHg
Head Circumference : 50 cm (Normal: 48-53 cm) normocephal
Heart Rate : 110 times/min
Weight/Height : 17/18 x 100 % = 94% (Good nourished)
Temperature : 38.4 °C
Height/Age : 104/108 x 100 % = 96% (normal stature)
Respiration Rate : 32 times/min
Weight/Age : 17/17 x 100 % = 100 % (normal bodyweight)
SpO2 : 98%
Urinalysis
Color Yellow
pH 5,5
BJ 1020
Protein +2
Glucose Negative
Bilirubin Negative
Urobilinogen Normal
Keton Negative
Nitrit Negative
Blood Negative
Leukocyte Negative
Leukocyte Sediment 5
Erythrocyte Sediment 1
Thorac Sediment 4
Epithel cell 118
Peripheral Blood Smear RSWS (September 28th 2022)
Erythrocytes: Normocytic normochrome, anisocytosis, ovalocyte (+), inclusion body (-), normoblast (-)
Leukocytes: Adequate number, PMN > lymphocytes, toxic granulation (+), young cells (-)
Platelets: Decreased number, large platelets (+)
Impression: Normochromic normocytic anemia with leukocytes with signs of infection
Chest X-Ray RADIOLOGY FINDING
(Wahidin Hospital 27/09/2022)
• Simetric position, good photo
condition, less inspiration
• There was consolidation at medial lung
dextra and infiltrat at upper lung
sinistra
• Cor : normal
• Both of diaphragma sinus are normal
• Bones intact
• Surrounding Soft tissues are normal
• Impression :
Bilateral pneumonia
ASSESMENT
• Typhoid fever
• Network Anoxia
• Community Acquired Pneumonia
• anemia of chronic disease
• Thrombocytopenia
• Hypoalbuminemia
• hyponatremia
TREATMENT
- Oxygen via nasal cannula Paracetamol/intravenous (if temperature > 38.5°C or pain
- Total bed rest scale > 3NRS)
- Fluid requirement : Holiday fresh - 20% : 1350cc - 20% = Albuforce/oral
1,080 cc/ 24 hours watch for signs of tissue anoxia
- Enteral : 6x100 cc/oral Food diet
- Parenteral : Ringer Lactate Infusion 20
cc/hour/intravenous
- The sodium deficit is fulfilled by giving Ringer's Lactate
20 cc/hour
1) Cefriaxone / intravenous
2) Gentamicin / intravenous
PLANNING
- Consult to hematoncology division
- Consult to Respirology division
THANK YOU