DUTY REPORT

DUTY REPORT SATURDAY MORNING, th April 20 2013

Alissa D.,MD./ Windi I.,MD./ Listya D,MD. Rozalina Loebis, MD.Ophthalmologist Pre op Post op consult :::1 1st class 2nd class 3rd class TOTAL BOR : 7 patients : 7 patients : 21 patients : 35 patients : 89.74 %

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.

Subjective
Heteroanamnesis: Main Complaint: Bloody stool Bloody stool since 2 weeks before hospitalized. He often suffers bloody stool since 2 months old. No vomitting. 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

 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)

Objective
General Status: HR: 118 x/minute RR: 30 x/minute Temp: 36.5 C Visual Acuity: Right eye Left eye

: Fix and Follow (+) : Fix and Follow (+)

Anterior Segment
Right eye Left eye

Eyelid
Conjunctiva Cornea Anterior Chamber Iris Pupil Lens Intra Ocular Pressure

Edema Spasm Hyperemia Clear + Deep + Radier + Round + 3mm LR + RAPDClear Normal Palpation

Edema Spasm Hyperemia Clear + Deep + Radier + Round + 3mm LR + RAPDClear Normal Palpation

Posterior Segment
Right eye Fundal Reflex + Optic Disc: sharp margin, normal color Retina: hemorrhages - exudate Macular Reflex + Left eye Fundal Reflex + Optic Disc: sharp margin, normal color Retina: intra retinal hemorrhages + (along vascular arcades) exudate+ Pigmented area+ Macular Reflex +

Picture of the patient

Schematic Picture

Laboratory Results
(April 19th 2013) Hb : 9.81 RBC : 4.10 x 106 WBC : 9.59 x 103 Plt : 153 x 103 (March 30th 2013) SGOT : 50 SGPT : 25 Alb : 4.0 BUN : 13 Creatinin Serum : 0.2 K : 4.5 Na : 135 Cl : 100
(March 19th 2013) Parasitology examination: Faeces: Entamoeba hystolitica +
Bacteria + Candida <<

(March 25th 2013) Toxoplasma IgG Toxoplasma IgM Rubella IgG

Rubella IgM

:5.0 :0.58 :+ 50.9 :+ 1.00

 CMV IgM CMV IgG Avidity:

: 0.730 : > 500 ( positive)

CMV IgG: H 1.00 (high avidity)

Determine HIV : non Reactive

Other Examination
Chest X-ray Skull Photo Echocardiography Abdominal USG : Pneumonia : within normal limit : within normal limit : Hepatomegali

Consultation
Ear Nose Throat Department: Serumen Obsturan Dermatology Department: Atopic Dermatitis Cardiology Pediatri: Pro Echocardiography

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

Permanent Problem List

CMV Infection Pneumonia Hepatomegali Atopic dermatitis Developmental delay Amoebiasis

CMV Retinitis on left eye

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 for Gancyclovir therapy

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.

Thank You