Morning Report

July 23rd – 24th 2024

Resident on Duty:
Chief Frontward : Jeffry
Chief Backward : Galih
Emergency Ward : Evan
PICU/NICU : Arvin
Pediatric + Isolation Ward : Fikry, Bethari, Rifqi, Ersa

Supervisor on Duty :
Prof Dr. dr. Edi Hartoyo, Sp. A (K)
 Visi Departemen Ilmu Kesehatan Anak Fakultas Kedokteran ULM

Menjadi Program Studi Pendidikan Dokter Spesialis Anak

yang unggul, terkemuka, dan berdaya saing khususnya di
lingkungan lahan basah

2
 Misi Departemen Ilmu Kesehatan Anak
Fakultas Kedokteran ULM
1. Menyelenggarakan pendidikan dokter dokter spesialis anak yang
menghasilkan sumber daya manusia yang berkualitas, professional, dan
berakhlak mulia
2. Menyelenggarakan penelitian yang menghasilkan IPTEK Ilmu Kesehatan
Anak yang berwawasan lingkungan lahan basah
3. Menyelenggarakan pengabdian dan pelayanan kepada masyarakat
terutama di bidang kesehatan berwawasan lingkungan lahan basah
4. Melakukan kerjasama dengan pemerintah daerah, perguruan tinggi
dalam dan luar negeri serta para pihak lainnya untuk peningkatkan
pelaksanaan Tridharma Perguruan Tinggi
5. Meningkatkan mutu Program Studi Pendidikan Dokter Spesialis Anak
melalui peningkatan kualitas sarana dan prasarana Pendidikan
6. Meningkatkan transparansi dan akuntabilitas dalam pengelolaan Program
Studi Pendidikan Dokter Spesialis Anak
3
 New patient : 4 patients
Emergency Ward : - Patients
Neonatology Ward : 1 Patient
PICU : - Patient
Isolation Ward : - Patient
Pediatric Ward : 3 Patient

Death Patient : - Patient

Remnant Patient : - Patient
Total New patient : 4 Patients
4
 List New Patient
Pediatric ward
Brain Ischemic a/r cortical subcortical left temporoparietal lobe
and left basal ganglia + Hemiparese dextra related to brain
ischemic + Motor Aphasia related to brain ischemic + Suspected
asianotic congenital heart disease + Hypochromic microcytic 23/07/24
1 Shiren Nayla / F / 5 y 3 m.o anemia ec susp iron deficiency anemia DD Anemia of chronic Tulip 2A
07.30
disease + Underweight + Short Stature + Moderate Malnutrition +
ncomplete immunization

Vomitus ec susp. Ileus obstructive ec susp adhesion + 23/7/24

2 Nadzifah / M / 10 y.o Tulip 2A
Abdominal pain ec post drainage external biopsy 14.52
23/7/24
3. Bilqy / M / 9 y.o Thalasemia 17.40 Tulip 4A

Emergency Ward

1.

2.

5
 PICU ward
1

Neonatology ward
1
Baby, Mrs. Sophia / F / 26 Respiratory Failure ec Pneumonia Neonatal + Susp PJB 23/7/24
d.o asianotic 17.30

List Remnant Patient

Emergency ward

List Death Patient

6
 Identity
• Name : SN
• Age : 5 years 3 months old
• Gender : Female
• No. RM : 01-56-66-37
• Day of admission : July, 23rd 2024
• Address : Buntok

Chief complaint :

• Weakness on right extremities since 1 month p.a

7
 Pediatric Assessment Triangle
• Appearance (TICLS)
– Tonus : adequate
N
– Interactiveness : adequate
– Consolability : consolable
– Look or gaze : eye contact (+)
– Speech or cry : adequate
N
• Breathing
– Tachypnea (-), kussmaul type (-), nasal flare (-), retraction (-),
stridor (-), gargling (-) snoring (-) wheezing (-) tripod position (-)
head bobbing (-)

• Circulation
– Pale (-), mottled (-), cyanosis (-)

Conclusion: No Emegency
8
 Primary survey
• Airway
– Patent, no snoring, no gurgling
• Breathing
– RR 24 times/min, regular breathing rythm, SpO2 98% room air.
• Circulation
– Blood pressure: 90/60 mmHg (P50-P90), Pulse 134 bpm, regular,
adequate
– CRT < 2 seconds, pale (-) mottled (-) cyanosis (-)
• Disability
– E4V5 M6 = 15, Light reflex (+/+), lateralization (+), motoric weakness
(+)
• Environment
– Body temperature 37.1ᴼC
Conclusion: Stable 9
 Emergency Management
23/7/2023
07.30 WITA

Patient referred from Jaraga Sasameh Hospital, Buntok with diagnosis Suspect Myastenia Gravis +
Tetraparese + Susp CHF ec Rheumatic Heart Disease. Patient came to ER with chief complain
Weakness on right extremities since 1 months prior to admission (p.a). Patient’s general condition was
moderatly ill, GCS E4V5M6, BP: 90/60 mmHg (P90-95) Temp : 37,1˚C, HR: 134 bpm, RR: 24x/min, CRT < 2
sec, SpO2: 99% without oxygen supplementation, warm extremities
Recheck patency iv access
Perform laboratories examination
Perform Electrocardiogram
Monitoring vital signs and observation
Consult to supervisor in charge
23/7/2023
14.30 WITA

During observation, patient was stable, general condition was moderately ill, GCS
E4V5M6,BP 100/70 mmHg HR 109 bpm, regular and adequate, respiration rate 24
times/minute, temperature 36.8 oC, SpO2 99 % room air, CRT < 2 seconds, warm
extremities.

Patient was stable and admitted to Pediatric Ward

10
 Secondary Survey
History of present illness
3 months p.a 40 days p.a

• Tenderness at the left leg, appeared

• Spontaneous weakness at right extremities
especially at the thigh, pain until couldn’t
when patient woke up in the morning.
walk, pain improve with massage oil, and
Patient can only stand by holding on
after resting,
things. Patient couldn’t speak, but still
• No redness understood the conversation by the
• No trauma parents.
• No headache • Then patient was brought to Jaraga
• No migrating pain Sasameh Hospital, Buntok and refered to
• No shortness of breath Neurosurgery Polyclinic at Ulin General
• No headache Hospital, Banjarmasin to further treatment
• No fever • CT Scan Examination result was clogged in
• No decrease of consciousness her brain and suggested to MRI for further
• No weight loss examination and got treatment paracetamol
• No lump at neck, armpit, and groin and multivitamin.
• No nausea and vomiting. • Left leg pain improved
• • No accending weakness
No Abdominal pain
• No watery stool
• No shortness of breath
• No projectile vomiting
• Normal defecation • No excessive salivation
• Normal urination • No history of trauma
• No headache

11
 Secondary Survey
History of present illness
1 week p.a Ulin General Hospital

• Stiffness right hand, spontaneous appeared after

woke up. Right hand bends can’t be returned to its
previous position and tenderness
• Pale, first noticed by her family, at face and lips • Stiffness right hand not improved
region, with no spontaneous bleeding like nose • Weakness at right extremities not
bleeding, gum bleeding, black tarry stool.
• Then patient was brought again by her parents to improved
Jaraga Sasameh Hospital. Patient was hospitalized • No trauma
since 22nd July for 1 day and got treatments: • No headache
- O2 2 lpm • No migrating pain
- IV Ampicillin 250 mg / 6 hours (H1) • No shortness of breath
- IV Ranitidine 10 mg / 12 hours
• No headache
- PO. Prednisone 3x1 pulv
- PO. Digoxin 2x165 mcg • No fever
• No trauma • No decrease of conseusness
• No headache • No weight loss
• No shortness of breath • No lump at neck, armpit, and groin
• No headache • No nausea and vomiting.
• No fever
• No Abdominal pain
• No decrease of consciousness
• No weight loss • No shortness of breath
• No nausea and vomiting. • Normal defecation and normal urination
• No Abdominal pain
• No shortness of breath
• Normal defecation and urination

12
History of Past illness

• No history of hypertension
• No history hospitalization before
• No history of blood transfusion
Conclusion: No remarkable data

Family history

• Mother had history of urticaria

• Grandmother had hypertension
• No similar complaints of illness in the family
• No history of autoimmune disorder in the family
Conclusion : No remarkable data

Birth and Delivery

• The patient was born aterm, spontaneous vaginal delivery assisted by doctor, birth
weight was 2600, birth length was 51 and head circumference mother was forget.
Patient immediately crying, no history of active resuscitation, no bluish, no pale, no
bloating.
Conclusion : No remarkable data 13
Immunization
• BCG (1), Polio (3), DPT(3), Hep B (4), MR (1), HiB (0) PCV(0)
• Conclusion: Incomplete immunization (Indonesia Pediatric Association)

Nutrition
• Exclusive breastfeeding since birth until 4 month old @10-12 times
• Complementary food since 6 months old.
• Regular family meal since 12 months old, 3 times a day, 10-15 spoonful each meal.
• Currently patient eat regular meal 1-2 times per day, 1-2 full portion with rice, few
chicken thigh or fish with vegetables (810 kcal) (75,8 % RDA).
• Conclusion: Inadequate nutritional intake

Development
• Patient can lift head at 2 months old
• Patient can turn over the body at 4 months old
• Patient can sit at 6 months old
• Patient can stand at 10 months old
• Patient can walk at 13 months old
• Patient can talk properly 1 year until now
• Now patient at playgroup, no difficulties at studying and socialize with her peer.
• Conclusion: No remarkable data
14
Social Environment
• Patient is the third child in the family.
• Patient lived in a house
• Patient lived with his parent, and two older brother.
• The father is a mechanic
• mother is a housewife
• Father was an active smoker
• Income 2.000.000 – 3.000.000 per month
• No history of usage of Mosquito burning coil
• There is no pet in patient house.
• They use gas for cooking
• Patient use a water from well for daily needs, and for shower
and laundry
• Conclusion: low socioeconomic status

15
 Pedigree

F 5 y 3 mo
M, 10 y.o M, 7 y.o

Patient
Conclusion :
Patient was the 3rd child this family
Grandmother history of hypertention
Mother history of urticaria
No history of malignancy in family
No history of consanguinity marriage.
16
 Physical Examination
(23/7/2024 07.30, at Ulin Hospital)
General condition

• Moderately-ill
• Alert
• pGCS: E4V5M6

Vital sign

• BP : 90/60 mmHg (P50-P90)

• Pulse : 134 x/min, regular
• RR : 24 x/min, regular P 5 : 84/48 mmHg
P 50 : 95/59 mmHg
• Temp : 37,1 0C P 90 : 105/67 mmHg
• SpO2 : 98% Room Air P95 : 108/70 mmHg
• CRT : < 2 secs P95 +12 : 120/82 mmHg
P99 + 30: 150 / 112 mmHg

17
Organ Descriptions
Head Normocephaly, facial edema (-), alopecia (-), dysmorphic face (-), malar rash (-)

Eyes Pale conjunctiva (+), icteric sclera (-), isochor pupil 3 mm/3 mm, light reflexes (+/+) , normal
eye movements, sunken eyes (-/-) allergy shinner (-), swelling (-), redness (-), discharge (-).
Neck Lymph nodes enlargement (-), no tenderness, no erythema, nuchal rigidity (-)
Ear discharge (-) Nasal discharge (-/-), Nasal flare (-)-Livid nasal mucosa (+), allergy crease (-),
ENT satellite lesion (-), hyperemic pharynx (-), tonsils hyperemic (-), detritus (-), pseudomembrane
(-)
Mouth Dirty and whitish tongue (-), stomatitis (-), oral trush (-), sub gingival bleeding (-) wet lips (+),
geographic tongue (-), tooth cavity (-)
Inspection: wasted ribs (-), subcostal retraction (-), pectus carinatum (-), pectus excavatum (-)
Palpation : Symmetrical vocal fremitus, no axilla lymph nodes enlargement
Percussion : sonor +/+
Thorax Auscultation: vesicular (+), rales (---/---), wheezing (-), prolonged expiration (-), stridor
inspiration (-), S1S2 regular, murmur 3/6 systolic left parasternal ICS III – IV , radiating (+)
apex , gallop (-)
Flat, distended (-), no tenderness, non-migrating, normal abdominal sound (+) liver not
Abdomen palpable, spleen not palpable, shifting dullness (-) undulation (-), normal skin turgor
Warm, CRT < 2 seconds, edema (-), pitting edema (-), petechiae (-), clubbing finger (-) axillary
Extremities lymph nodes enlargement (-), axilla and inguinal lymph nodes enlargement (-), cyanotic (-),
BCG scar (+)
Skin Pale (-), cyanotic (-), rash (-), hematoma (-), icteric (-), mottled (-), itchy (-)

18
Organ Descriptions
Meningeal sign (-), Brudzinski I (-), Brudzinski II (-), Kernig (-)
Motoric strength 4444 | 5555 Physiological reflex (N |N)
4444 | 5555 (N| N)
Pathologic reflex Babinski (-/-), Flaccid (+) right lower extremity, Spastic (+) right hand,
clonus (-) Muscle tone (-) Atrophy on extremities muscle (-), Limitation of Range Of
Motion
Sensoric : in normal range

Nervus Craniales
N. I hard to evaluated
N. II normal, strabismus (-)

Neurological N III, IV, VI normal

N V. hard to evaluate
N VII Symmetrical face (-), lower nasiolabial fold (-)
N VIII. Normal. Romberg test cannot be evaluate

N IX/ X Uvula deviation (-)

N. XI hard to evaluate

N. XII tongue deviation (-), no fasciculation

19
 Anthropometric Status
• Body Weight : 11,9 Kg
• Body Height : 102 cm
• Ideal Body Weight : 16,5 kg
• Height Age : 4 Years 3 months old
• Arm circumference : 16,5 cm
• Head circumference : 47 cm (Normocephaly)
CDC Growth Chart
• Weight/Age : < P3
• Height/Age : P5-10
• Weight/Height : 72 %

Underweight, Normal Height, Moderate

Malnutrition
20
 Clinical Features

Babinski (-/-) Spastic right hand

21
 Head CT Scan
without Contrast
at Ulin Hospital
(06/07/2024)

22
 Head CT Scan without Contrast
at Ulin Hospital (06/07/2024)

MSCT scan of the head 64 slices without contrast axial cut. Reconstruction performedsagittal and
coronal sections:
• A relatively well-demarcated hypodense lesion in the left cortical subcortical lobe temporo
parietalis and left basal ganglia
• The left lateral ventricle is dilated. The rest of the ventricular system is normal, no abnormal
dilation/narrowing
• No midline deviation of structures Sulci and other gyri, right fissure sylvii normal, cisterna open
• Pons, midbrain, cerebellum normal
• Air cell mastoid, nasopharyng, other paranasal sinuses within normal limits
• Bulbus oculi, retrobulber space, N opticus within normal limits
• Skeletal and soft tissue normal
• White matter and gray matter boundaries are clear
• Size of sella tursica is normal
Conclusion
1. Subacute ischemic lesions in the subcortical, cortical of left temporo parietal lobe and left basal
ganglia
2. Currently no hemorrhage /SOL/calvaria fracture seen

23
 Laboratory Findings
at Jaraga Sasameh Hospital (22/07/2024)

Referenced value
Hb (g/dL) 7.8 11.5 - 14.5
Hematocrit (%) 25.8 34 - 40
RBC (milion/ul) - 3.9-5.3
Leukocyte (/µL) 14.500 5.000 – 14.500
Thrombocyt (/uL) 212.000 150.000 – 450.000
MCV (fl) 67.7 76.0 - 90.0
MCH (pg) 20.5 25.0 – 30.0
MCHC (g/dl) 30.3 32- 36 • Hypochromic
Neutr % 72 11.5 - 14.5 microcytic anemia
Lymph % 21 34 - 40
RBG 128 < 200
ESR mm/h 100 <25mm/h

24
 ECG at Jaraga Sasameh Hospital (22/07/2024)

Conclusion
Sinus tachycardi

25
 Chest X-Ray
at Jaraga Sasameh Hospital (22/07/2024)
AP Supine Position

• Cor: Cardiomegaly, CTR 58 %,

Heart waist dissapear
• Bone intact
• Trachea in the middle
• No Opacity with air
bronchogram Sharp
costophrenic angle D/S
• Hemidiaphragm D/S normal

Conclusion:
Cardiomegaly

26
 Differential Diagnosis
I. Brain Ischemic a/r cortical subcortical left temporoparietal lobe and left basal ganglia I67.82
II. Hemiparese dextra related to ischemic left basal ganglia G81
III. Motor Aphasia related to left temporoparietal lobe ischemic R47
IV. Suspected acynaotic congenital heart due to susp
1. Ventricullar septal defect Q21
2. Atrial septal Defect Q21.1
3. Atrio-Ventricullar septal defect Q21.23
V. Suspect Rheumatic Heart Disease I.00
VI. Microcytic hypochromic anemia due to susp
1. Hypochromic microcytic anemia due to susp iron deficiency anemia D64.9
2. Anemia of chronic disease D63.8
VII. Underweight R63.6
VIII. Short Stature R62.0
IX. Moderate Malnutrition E44
X. Incomplete immunization Z28

27
 Initial Managements
Fluid IVFD D5 1/2 NS 500 cc/ 24 jam (Half maintenance)
Antibiotics IV Ampicillin 4 x 600 mg (100 mg/kgBW/day)
Antipyretic IV Paracetamol 120 mg (10 mg/kgBW/dose) (if needed)
Planning Diagnostic CBC, Serum Electrolyte, ECG, MDT, CRP, ASTO, LED,
Echocardiography, Head MRI
Planning Monitoring Vital signs, GCS, seizure, sign of increased intracranial
pressure, balance diuresis, diuresis, antibiotic response
Family Education Educate the family about diagnosis, planning, treatment and
prognosis
Consult to Supervisor in Charge
Consult to Neurology Division
Consult to Cardiology Division
Plan to Hospitalized at Neurology Ward
Plan to catch up immunization

28
 Laboratory Findings
at Ulin Hospital (23/07/2024)
23/07/24 Referenced value 23/07/24 Reference value
Hb (g/dL) 8.4 11.5 - 14.5 Albumin (g/dl) - 3.8-5.4
Hematocrit (%) 28.8 34 - 40 AST(U/L) 25 5-34
RBC (milion/ul) 4.08 3.9-5.3 ALT(U/L) 11 0-55
Leukocyte (/µL) 15.600 5.000 – 14.500 Ureum (mg/dL) 24 5-25
Thrombocyt (/uL) 267.000 150.000 – 450.000 Creatinine (mg/dL) 0.33 0.57 – 1.11
Sodium (mEq/L) 138 136-145
MCV (fl) 70.6 76.0 - 90.0
Potassium (mEq/L) 4.4 3.5-5.5
MCH (pg) 20.6 25.0 – 30.0
Chloride (mEq/L) 112 95-105
MCHC (g/dl) 29.2 32- 36
Calsium 10.2 8.4-10.0
Neut % 61.5 37-71
Lymph % 30.5 17 - 67 AstoIU/ml <200 <200
RBG (mg/dL) 124 <200.0 CRPmg/l 79 <= 5

• Hypochromic microcytic anemia

• Mentzer index : 17,3
• Leukocytosis

29
 ECG at Ulin Hospital (23/07/2024)

Sinus rhythm with rate of 150 beats per minute. P wave Present before each QRS complex, PR Interval
within normal limits, QRS Complex narrow and upright, ST Segment Isoelectric, normal axis
Impression:
•Sinus tachycardia
30
 Problem List
Anamnesis
• Female, 5 years 3 months old
• Tenderness at the left leg 3 months p.a
• Spontaneous weakness at right extremities 40 days p.a
• Patient couldn’t speak, but still understood the conversation by the parents 40 days p.a
• Then patient brought by her parents to Jaraga Sasameh Hospital and refered to Neurosurgery
Polyclinic at Ulin General Hospital 40 days p.a
• Stiffnes right hand 1 week p.a
• Pale at lips and face region 1 week p.a
• Incomplete immunization
• Inadecuate nutrinitonal intake
• Low economic status

Physical Examination
• Murmur 3/6 systolic left parasternal ICS III – IV , radiating (+) apex
• Decrease Motoric Strength at right extremities
• Spastic (+) right hand
• Limitation of Range Of Motion
• Underweight, Normal Height, Moderate Malnutrition

31
 Problem List

Jaraga Sasameh Hospital Ulin Hospital

Laboratory Finding Head CT Scan without contrast
• Hypochromic microcytic anemia • Subacute ischemic lesions in the
subcortical, cortical of left temporo
parietal lobe and left basal ganglia
ECG
• Normal ECG
ECG
• Normal ECG
Chest X ray
• Cardiomegaly
Laboratory Findings
• Hypochromic microcytic anemia
• Mentzer index : 17,3 (>13)
• Leucocytosis

32
 Working Diagnosis
I. Brain Ischemic a/r cortical subcortical left temporoparietal lobe and left basal ganglia I67.82
II. Hemiparese dextra related to ischemic left basal ganglia G81
III. Motor Aphasia related to left temporoparietal lobe ischemic R47
IV. Suspected acynaotic congenital heart due to susp
1. Ventricullar septal defect Q21
2. Atrial septal Defect Q21.1
3. Atrio-Ventricullar septal defect Q21.23
V. Microcytic hypochromic anemia due to susp
1. Hypochromic microcytic anemia due to susp iron deficiency anemia D64.9
2. Anemia of chronic disease D63.8
VI. Underweight R63.6
VII. Short Stature R62.0
VIII. Moderate Malnutrition E44
IX. Incomplete immunization Z28

33
 Final Managements
Fluid IVFD D5 1/2 NS 500 cc/ 24 jam (Half maintenance)
Nutrition Recommended Daily Allowance:
Determination of calorie needs
Calories 90 x 16,5 = 1485 kcal/day
Protein 1 x 16,5 = 16,5 g/day
Fluid 90-110 x 11,7 = 1053 - 1287 mL/day
Route of feeding : Oral route, Fullfilled with :
Soft porridge 3 x 400 kcal = 1200 kcal
Snack 2x100 Kcal = 200 kcal
Total 1400 kcal, Fulfilled 94.2 % RDA, 11% PER

Antibiotics IV Ampisilin 4 x 600 mg (100 mg/kgbb/day)

Antipyretic IV Paracetamol 120 mg (10-15 mg/kgBW/dose) (if needed)
Planning Diagnostic MDT, CRP, ASTO, LED, Echocardiography, Head MRI, SI, TIBC. Ferritin,
transferrin saturation, reticulocyte
Planning Monitoring Vital signs, GCS, seizure, sign of increased intracranial pressure, balance
diuresis, diuresis, antibiotic response
Family Education Educate the family about diagnosis, planning, treatment and prognosis
Consult to Supervisor in Charge
Consult to Neurology Division
Consult to Cardiology Division
Plan to Hospitalized at Neurology Ward
Plan to catch up immunization 34
 Pediatric Nutrition Care
1. Assessment
Underweight + Short Stature + Moderate Malnutrition + Hemiparese dextra + Ischemic a/r cortical
subcortical left temporoparietal lobe and left basal ganglia + Motor Aphasia + Suspected asianotic
congenital heart disease + Hypochromic microcytic anemia ec susp iron deficiency anemia + Incomplete
immunization

2. Recommended Daily Allowance:

Determination of calorie needs
• Calories 90 x 16,5 = 1485 kcal/day
• Protein 1 x 16,5 = 16,5 g/day
• Fluid 90-110 x 11,7 = 1053 - 1287 mL/day

3. Route of feeding : Oral route

4. Determining type of food

• Soft porridge 3 x 400 kcal = 1200 kcal
• Snack 2x100 Kcal = 200 kcal
Total 1400 kcal, Fulfilled 94.2 % RDA, 11% PER

5. Monitoring and evaluation

• Feeding tolerance, increase of body weight
35
Total score: 1  moderate risk
36
 Consult to Supervisor in Charge
dr. Astarini Hidayah, Sp.A

• Consult to Neurology Division

37
 Consult to Neurology Division
dr. Nurul Hidayah, M.Sc, Sp.A(K)

• Track the cause of brain ischemic

• Plan for lumbal puncture
• Consider consult to allergy and immunology
division whether there was immunology
involvement
• Join care with cardiology division

38
 Consult to Cardiology Division
dr. Hana C.E Sembiring, Sp.A

• Plan Echocardiography

39
 Follow up
July, 24th 2024, 07.00 WITA
S: Decrease of consciousness (-), seizure (-) fever (-), vomit (-), shortness of breath (-)
O: GCS E4V5M6
BP: 90/55 mmHg
Pulse : 122 bpm
RR: 24 times/minute Temp: 36.9oC
SpO2 : 98% room air CRT <2 seconds

Neurologic examination
Meningeal Sign (-) Sensory Hard to evaluate
Motor strength 4444/5555
4444/5555
Physiological reflex +3/+2 Pathological reflexes (-) spastic (+), clonus (-), flaccid (+)
+3/+2
A: I. Brain Ischemic a/r cortical subcortical left temporoparietal lobe and left basal ganglia I67.82
II. Hemiparese dextra related to ischemic left basal ganglia G81
III. Motor Aphasia related to left temporoparietal lobe ischemic R47
IV. Suspected acynaotic congenital heart due to susp
1. Ventricullar septal defect Q21
2. Atrial septal Defect Q21.1
3. Atrio-Ventricullar septal defect Q21.23
V. Microcytic hypochromic anemia due to susp
1. Hypochromic microcytic anemia due to susp iron deficiency anemia D64.9
2. Anemia of chronic disease D63.8
VI. Underweight R63.6
VII. Short Stature R62.0
VIII. Moderate Malnutrition E44
IX. Incomplete immunization Z28

40
 Follow up
July, 24th 2024, 07.00 WITA
P Planning Diagnostic MDT, CRP, Echocardiography, Head MRI, SI, TIBC. Ferritin,
transferrin saturation, reticulocyte
Planning Monitoring Vital signs, GCS, seizure, sign of increased intracranial
pressure, antibiotic response, shortness of breath
G No seizure
No increased intracranial pressure
No Shortness of Breath

I IVFD D5 1/2 NS 500 cc/ 24 jam (Half maintenance)

IV Ampisilin 4 x 600 mg (100 mg/kgbb/hari)
IV Paracetamol 120 mg (10-15 mg/kgBW/dose) (if needed)

41
Thank you