CASE

PRESENTATION
SUBJECTIVE DATA
ID : ACW/Female/1 month old
CM : 01.55.37.49
Chief complaint (Heteroanamnesis) :
- Vomitting and lazy to drink

PRESENT HISTORY
- Lazy to drink since 1 day PTA.
- Vomiting (+) one time per day, glasses, with
the ammount of liquid. Blood (-). Slym (-).
- Urination normal.
- Passing stool normal.
- Fever (-).
- Reduced activity and cry (+) since 1 day PTA
- The body weight is difficult to increase since
born. Born with 3000 gram of body weight. Now
still in the same body weight.
- Dyspnoe (-).


PREVIOUS MEDICAL HISTORY
Patent Ductus Arteriosus (+)
Echocardiography (+)
Known since 25 days old
Imunization History : complete for the age
Labour History : Normal , helped by doctor,
3000 gram, no other abnormalities found.
Nutrition History : Susu Formula since born
until now.
Growth and development history : normal for
her age.
Family medical history : the first child of this
family was died at the age of 5 months old
caused by cholestasis.

PHYSICAL EXAMINATION
APP : moderately ill
Tax : 36.7
0
C
PR : 146 x/mnt, reguler
RR : 48 x/mnt
Oxygen Saturation : 98%

HEAD : Normal
EYE : an (-), ict (-), Oedema (-). Sunken (-)

ENT : Normal

PHYSICAL EXAMINATION
THORAX : Simetric
Cor : S1S2 Normal , Regular, Continous machinary
murmur at upper left sternal border ICS II, radiate
to sternal border
Po : Bves +/+, Ronchi -/-. Wh -/-
ABD : normal
EXTREMITY : Warm (+). Oedema (-)
ANTROPOMETRI
Born Weight : 3000 gram
Current weight : 3000 gram
Ideal Weight : 3750 gram
Height : 54 cm
Head Circumference : 35 cm
Upper Arm Circumference : 6 cm

Weight/Age (P) : < p5
Height/Age (P) : p5-10
Weight/Height (P) : p10-25

Nutritional status : Gizi kurang (80%)

FOOD RECALL
Milk (Susu Formula) :
Anmum 12 x 60 cc 1 week
Pregistimil (difficult to get) 1 week
Nutrillon hypoallergenic 8 x 60 cc 2 week until
now 384 kalori
ASSESMENT
Moderate-Large PDA + Failure To Thrive +
Undernutrition (Gizi Kurang)
THERAPY
Furosemide/Spironolactone/Digoxin : 3 mg/3
mg/10 mg pulv BID continue
Liquid demand : 300 cc/day


NUTRITIONAL THERAPY
Total calorie needed : 120 kal x 3.75 kg : 450 kal
Protein : 2.5 x 3.75 : 9.375 kal prot
Liquid : 375 cc : 8 @ 60 cc
Density : 1.2

PRENAN 60 cc 8 times per day

THANK YOU