FOLLOW UP

November 14th 2014

S Diarrhea (+)
O Sens: Allert, Pale (+) Jaundice (-) Edema (-) Cyanosis (-) Dyspnoe (-) Body Temperature:
38,60C. Body weight: 12 kg, Body length: 102 cm.
Head
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra
conjunctiva pale (+/+), icteric sclera (-/-).
Nose, Mouth and Ear were within normal limit
Neck

TVJ difficult in value, Lymph node enlargement (-).

Thorax

Symmetrical fusiformis, Chest retraction (-), HR : 96 bpm, reguler, murmur (-),

RR: 22 x/i, regular, rales (-/-).

Abdomen

Rapid turgor. Normoperistaltic. Liver palpable with 2cm, spleen and renal
unpalpable.

Extremities Pulse 96 bpm, regular, adequate pressure and volume, warm acral,CRT < 3
Genital

Female, within normal limit

A Susp. TB milier + susp. HIV and Malnutrition

P

Diet F 75 130cc/2hr/with Mineral Mix 2,6cc

Rifampisin 1150mg

INH 1100mg

Pirazinamid 1150mg

Prednisolon 115mg

Vitamin A 1200mg

Asam Folat 150mg

Multivitamin without Fe 11 cth

Diagnostic Planning :

Consul division of respiratory and pulmonulogy

Consul division of nutrition and metabolic disease

Consul division of social pediatric

Consul division of allergy and immunology

November 15th 2014

S Diarrhea (+), Fever (-)
O Sens: Allert, Pale (+) Jaundice (-) Edema (-) Cyanosis (-) Dyspnoe (-) Body Temperature:
38,60C. Body weight: 12 kg, Body length: 102 cm.
Head
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra
conjunctiva pale (+/+), icteric sclera (-/-).
Nose, Mouth and Ear were within normal limit
Neck

TVJ difficult in value, Lymph node enlargement (-).

Thorax

Symmetrical fusiformis, Chest retraction (-), HR : 96 bpm, reguler, murmur (-),

RR: 22 x/i, regular, rales (-/-).

Abdomen

Rapid turgor. Normoperistaltic. Liver palpable with 2cm, spleen and renal
unpalpable.

Extremities Pulse 96 bpm, regular, adequate pressure and volume, warm acral,CRT < 3
Genital

Female, within normal limit

A Susp. TB milier + susp. HIV and Malnutrition

P

Diet F 75 130cc/2hr/with Mineral Mix 2,6cc

Rifampisin 1150mg

INH 1100mg

Pirazinamid 1150mg

Prednisolon 115mg

Vitamin A 1200mg

Asam Folat 150mg

Multivitamin without Fe 11 cth

Diagnostic Planning:
-

Consul division of nutrition and metabolic disease

November 16th 2014

S Diarrhea (+), Fever (-)
O Sens: Allert, Pale (+) Jaundice (-) Edema (-) Cyanosis (-) Dyspnoe (-) Body Temperature:
38,60C. Body weight: 12 kg, Body length: 102 cm.
Head
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra
conjunctiva pale (+/+), icteric sclera (-/-).

Nose, Mouth and Ear were within normal limit

Neck

TVJ difficult in value, Lymph node enlargement (-).

Thorax

Symmetrical fusiformis, Chest retraction (-), HR : 96 bpm, reguler, murmur (-),

RR: 22 x/i, regular, rales (-/-).

Abdomen

Rapid turgor. Normoperistaltic. Liver palpable with 2cm, spleen and renal
unpalpable.

Extremities Pulse 96 bpm, regular, adequate pressure and volume, warm acral,CRT < 3
Genital

Female, within normal limit

A Susp. TB milier + susp. HIV and Malnutrition

P

Diet F 75 130cc/2hr/with Mineral Mix 2,6cc

Cotrimoxazole 1240mg

Rifampisin 1150mg

INH 1100mg

Pirazinamid 1150mg

Prednisolon 115mg

Vitamin A 1200mg

Asam Folat 150mg

Multivitamin without Fe 11 cth

November 17th 2014

S Diarrhea (-), Fever (-), Cough (+)
O Sens: Allert, Pale (+) Jaundice (-) Edema (-) Cyanosis (-) Dyspnoe (-) Body Temperature:
38,60C. Body weight: 12 kg, Body length: 102 cm.
Head
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra
conjunctiva pale (+/+), icteric sclera (-/-).
Nose, Mouth and Ear were within normal limit
Neck

TVJ difficult in value, Lymph node enlargement (-).

Thorax

Symmetrical fusiformis, Chest retraction (-), HR : 96 bpm, reguler, murmur (-),

RR: 22 x/i, regular, rales (-/-).

Abdomen

Rapid turgor. Normoperistaltic. Liver palpable with 2cm, spleen and renal

unpalpable.
Extremities Pulse 96 bpm, regular, adequate pressure and volume, warm acral,CRT < 3
Genital

Female, within normal limit

A Susp. TB milier + Susp. HIV and Malnutrition

P

Diet F 75 130cc/2hr/with Mineral Mix 2,6cc

Cotrimoxazole 1240mg

Rifampisin 1150mg

INH 1100mg

Pirazinamid 1150mg

Prednisolon 115mg

Vitamin A 1200mg

Asam Folat 150mg

Nystatin 41 cc

Multivitamin without Fe 11 cth

November 18th 2014 November 24th 2014

S Diarrhea (-), Fever (-), Cough (+)
O Sens: Allert, Pale (+) Jaundice (-) Edema (-) Cyanosis (-) Dyspnoe (-) Body Temperature:
38,60C. Body weight: 12 kg, Body length: 102 cm.
Head
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra
conjunctiva pale (+/+), icteric sclera (-/-).
Nose, Mouth and Ear were within normal limit
Neck

TVJ difficult in value, Lymph node enlargement (-).

Thorax

Symmetrical fusiformis, Chest retraction (-), HR : 96 bpm, reguler, murmur (-),

RR: 22 x/i, regular, rales (-/-).

Abdomen

Rapid turgor. Normoperistaltic. Liver palpable with 2cm, spleen and renal
unpalpable.

Extremities Pulse 96 bpm, regular, adequate pressure and volume, warm acral,CRT < 3

Genital

Female, within normal limit

A Susp. TB milier + Susp. HIV and Malnutrition

P

Diet MB 1500 calorie + F 100 /60cc/8 hours (Mineral Mix 3,2 cc)

Cotrimoxazole 1240mg

Rifampisin 1150mg

Etambutol 2200 mg

Vitamin B6 2 10mg

Vitamin A 1200mg

Asam Folat 11 mg

Nystatin 41 cc

Dactarin Oral Gel

Lamivudin 150 mg

Stravudin 30mg

Multivitamin without Fe 11 cth

November 25th 2014 November29th 2014

S Diarrhea (-), Fever (-), Cough (+)
O Sens: Allert, Pale (+) Jaundice (-) Edema (-) Cyanosis (-) Dyspnoe (-) Body Temperature:
38,60C. Body weight: 12 kg, Body length: 102 cm.
Head
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra
conjunctiva pale (+/+), icteric sclera (-/-).
Nose, Mouth and Ear were within normal limit
Neck

TVJ difficult in value, Lymph node enlargement (-).

Thorax

Symmetrical fusiformis, Chest retraction (-), HR : 96 bpm, reguler, murmur (-),

RR: 22 x/i, regular, rales (-/-).

Abdomen

Rapid turgor. Normoperistaltic. Liver palpable with 2cm, spleen and renal
unpalpable.

Extremities Pulse 96 bpm, regular, adequate pressure and volume, warm acral,CRT < 3
Genital

Female, within normal limit

A Susp. TB milier + Susp. HIV and Malnutrition

P

Diet MB 1500 calorie + F 100 /60cc/8 hours (Mineral Mix 3,2 cc)

Cotrimoxazole 1240mg

Rifampisin 1150mg

Etambutol 2200 mg

Vitamin B6 2 10mg

Vitamin A 1200mg

Asam Folat 11 mg

Nystatin 41 cc

Dactarin Oral Gel

Lamivudin 150 mg

Stravudin 30mg
Multivitamin without Fe 11 cth

November30th 2014
Short of breathness is decreased (+), Diet is done,Vomiting (-),Diarrhea (-)
Sens: Allert, Pale (+). Jaundice (-). Edema (-). Cyanosis (-) Dyspnoe (-). Body Temperature
:36,80C. Body weight: 4,1 kg, Body length: 55 cm.
Head
Eye: Isochoric pupil (3mm/3mm),light reflex (+/+), inferior palpebra
conjunctiva pale (+/+), icteric sclera (-/-),old man face (+)
Nose, Mouth and Ear were within normal limit
Neck

TVJ R-2 cmH2O, Lymph node enlargement (-).

Thorax

Symmetrical fusiformis, intercostal space looks clearly (+),Chest retraction

intercostal (-), HR : 122 bpm, reguler, murmur (+)continous murmur grade 3/6
at ICR II-III linea parasternal dekstra, radiation (+) until left lower sternal
border, RR: 42tpm, regular,crackles (-/-),stridor (-/-)

Abdomen

Rapid turgor. Normoperistaltic. Liver, spleen and renal unpalpable.

Extremities Pulse 122 bpm, regular, adequate pressure and volume, warm acral,CRT < 3,
muscle hypotrophy,subcutaneous fat getting thinner, baggy pants (+)
Genital

Male, within normal limit

CHF due to moderate PDA + Marasmus+ failure to thrive

O21/2 l/i with nasal canule

IVFD D 5% NaCl 0,225% 4gtt/i (micro)

Furosemide 2 x 6 mg

Spironolakton 2 x6,25 mg

- Diet F100 70Cc/3hour solute in 90 cc water + mineral mix 1,44 cc

- Folic acid1x1 mg
- Cotrimoxazole 2x Cth I
- Multivitamin without Fe 1 x Cth
- Injection Ampisilin 50 mg/kgBB = 250 mg/6 hour/iv
- Injection Gentamisin 5mg/kgBB=25 mg/12 hour/iv
R/ PDA ligation

DISSCUSION
Theory

Discussion

Ross criteria of CHF:

Short of breathness was realized by his

parents since 2 months ago, then it become
heavier in 1weeks, shortness of breath is not
related to the the weather and activity.
Shortness of breath becomes heavier when
the patient inhale. Shortness of breath is
relieved when his parents put one or two
pillow below his head. The patient often
wake up in the middle of the night because of
his shortness of breath.

I. No limitation or symptoms
II. Mild tachypnea or diaphoresis with
feeding in infants, dyspnea on exertion in
older children, no growth failure
III. Marked tachypnea or diaphoresis with
feeds or exertion, prolonged feeding
times, growth failure from CHF
IV. Symptoms at rest with tachypnea,
retractions, grunting, or diaphoresis

Interrupted feeding history (+), history

forehead sweating while feeding (+) in these
2 months.
In Clinical Features of Heart failure find History of :
Feeding difficulties (and therefore growth

failure) are commonly recognized as Interrupted feeding history (+), history

presenting symptoms of congestive HF in forehead sweating while feeding (+) in these
infants and young toddlers (age 0-2 years). 2 months.
The characteristic findings range from
prolonged feeding time (> 20 minutes) with
decreased volume intake to frank intolerance
and vomiting after feeds. Irritability with
feeding, sweating, and even refusal of feeds
Left to right shunting of blood on the PDA, Echocardiography result at RS Mutiara:
VSD and ASD and other results in an
increase in pulmonary blood flow. PDA Moderate (3,8 mm-4,4mm,L-R shunt)
Pulmonary over circulation from a large leftto-right shunt results in CHF.
Cardiomegaly with increased pulmonary
blood flow (pulmonary plethora), prominent
main and branch pulmonary arteries, left
atrial enlargement etc. are signs of
significantly increased pulmonary blood flow
which could cause HF.

The physical examination findings vary as

much as the medical history. Patients with
tiny, incidentally discovered patent ductus
have no abnormal physical findings. The
hallmark physical finding is a continuous
murmur, located at the upper left sterna
border, often referred to as a machinery
murmur. The murmur often radiates down
the left side of the sternum and into the back,
and a thrill may be present.

Chest x-ray interpretation;

Costophrenicus

angle

is

sharp

the

diaphragm slippery, paracardial infiltrates in

the right and left, enlarged heart size, trachea
in the middle, CTR 58%.

From Physical Findings in Thorax:

Symmetrical fusiformis, Chest retraction
intercostal (+), HR : 165 bpm, reguler,
murmur (+)continuous murmur grade 3/6 at
ICR II-III linea parasternal dekstra, radiation
(+) until left lower sternal border,RR:40 tpm,
regular.