8/13/2019 Jaga 20042013 Edit-ica

1/19

DUTY REPORT

8/13/2019 Jaga 20042013 Edit-ica

2/19

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 %

8/13/2019 Jaga 20042013 Edit-ica

3/19

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.

8/13/2019 Jaga 20042013 Edit-ica

4/19

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

8/13/2019 Jaga 20042013 Edit-ica

5/19

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)

8/13/2019 Jaga 20042013 Edit-ica

6/19

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 (+)

8/13/2019 Jaga 20042013 Edit-ica

7/19

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

8/13/2019 Jaga 20042013 Edit-ica

8/19

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 +

8/13/2019 Jaga 20042013 Edit-ica

9/19

Picture of the patient

8/13/2019 Jaga 20042013 Edit-ica

10/19

Schematic Picture

8/13/2019 Jaga 20042013 Edit-ica

11/19

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

8/13/2019 Jaga 20042013 Edit-ica

12/19

CMV IgM : 0.730

CMV IgG : > 500 ( positive)

Avidity:

CMV IgG: H 1.00 (high avidity)

Determine HIV : non Reactive

8/13/2019 Jaga 20042013 Edit-ica

13/19

Other Examination

Chest X-ray : Pneumonia

Skull Photo : within normal limit

Echocardiography : within normal limit

Abdominal USG : Hepatomegali

8/13/2019 Jaga 20042013 Edit-ica

14/19

Consultation

Ear Nose Throat Department:

Serumen Obsturan

Dermatology Department:

Atopic Dermatitis

Cardiology Pediatri:

Pro Echocardiography

8/13/2019 Jaga 20042013 Edit-ica

15/19

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

8/13/2019 Jaga 20042013 Edit-ica

16/19

Permanent Problem List

CMV Infection

Pneumonia

Hepatomegali

Atopic dermatitis

Developmental delay

Amoebiasis

CMV Retinitis on left eye

8/13/2019 Jaga 20042013 Edit-ica

17/19

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

8/13/2019 Jaga 20042013 Edit-ica

18/19

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.

8/13/2019 Jaga 20042013 Edit-ica

19/19

Thank You