Direct by : Cindy Berlian Sulaeman

Advicer : dr. Irman, Sp.A / dr. Tatan Sp.A

 Name : M
 Age : 1 y.o
 Sex : Female
 Address : Babakan
Main Complain : demam sudah 2 hari (fever two days)
 Pasien datang ke IGD RSUD Waled dengan keluhan demam
sudah 2 hari di sertai menggigil. Mual, muntah dan kejang
disangkalnya (Patient come in the Waled hospital emergency
room with a complaint of fever two days with shiver. Nausea,
vomiting and seizures denied)
 Pasien sebelumnya tidak pernah mengalami keluhan seperti ini
(Patients had never experienced a complaint)
 Keluarga tidak ada yang mengalami keluhan yang sama (Family
not having the same complaints)
 A history of suffering from the same disease previously
does not exist. There wasn’t a history of the same
disease in the family and neighbors. History of contact
with patient with long coughing or taking drugs for a
long time does not exist. Immunization history was
complete. Age-appropriate developmental
history.aku bingung mksud kamu apa disini
 Treatment history: patient had been brought to the
midwife and doctor's clinic and was given medications.
Fever decreased when taking the drug, but re-
appeared when the drug is up.
General examination
 General appereance : Alert
 Pulse : 112x/minute, regual, equal
 Respiration : 28 x/minute
 Temperature : 38,0C
 Body Weight : 8 kg
 Body Height : 115 cm
 Nutrition Status
BMI/Age : < pesentil -3
Height/Age : < pesentil -3
 Body surface : 0.56
Spesifik examination
 Head : Sclera icteric (-) Conjungtiva Anemis
(-)
 Nasal : Pernapasan Cuping Hidung (-)
 Mouth : Per Oral Cianosis (-)
 Neck : Lymphadenopathy (-)
 Thorax : Symmetric with good expansion intercostal retractions (-)
- Lung : Breath sound vesicular right=left, rales (-),
wheezing (-), rhonchi (+)
- Heart : S1,S2 regular rhythm.
 Abdomen : Soft, Liver and spleen is not palpable, Bowel sound (+)
28 x/minute
 Extremities : Warm, Acrocyanosis (-) CRT <3”
 broncopneumonia
 pneumonia
 bronkhiektasis
 Complete Blood Count
Hemoglobin : 11,2
Leukosit : 15,8
Eritrosit : 4,4
Hematokrit : 34
Trombosit : 269
Basofil :0
Eosinofil :0
Neutrofil Batang :0
Neutrofil Segmen : 67
Limfosit : 26
Monosit :7
 bronchopnemonia
 IVFD RL 30 tpm (micro)
 Sanmol drops 4x0,8 cc
 Goforan 2x400g iv
 Nebu combiven / 12 jam