MORNING REPORT

Friday , March 3rd 2017

dr. Heru/ dr. Sandi

dr. Ida/ dr. Ahimsa/dr Patra
dr. Winda /dr. Bayu
dr. Guntur/ dr. Andhika
 PATIENT ADMISSION

Melati 2
-

HCU Neonatus
Baby Mrs. E, 2 days old, 2200 grams, with anorectal malformation, anal fistula, neonate, babygirl,
normal birth weight, fullterm, appropriate to the gestational age, spontaneous delivery
Baby Mrs. R, 3 days old, 2200 grams, with suspected for acyanotic congenital heart disease dd
TOF, PS, Ross I, neonate, babygirl, normal birth weight, fullterm, small for gestational age,
SC due to breech presentation

NICU
-
PICU
-
HCU Melati2
- Child A, Girl, 5 months old, 6,8 kgs, with Pneumonia, Well Nourished, normalweight,
normalheight
 IDENTITAS PASIEN

Name : A
Age : 5 months old
Gender : Girl
W/ L : 6.8 kgs / 64 cms
Address : Grobogan, Central Java
MR : 01371127
 Chief Complaint

Breathless
(Patient was referred from Purwodadi
General Hospital with apnea history and
bronchopneumonia)
 CURRENT MEDICAL HISTORY

A week before admission, patient had high

fever, cough, and flu. Then she was
admitted to the private doctor, received
some oral medicines, and she could be in
outpatient condition.
Three days later, all those complaints were
getting worse then she was hospitalized in
Purwodadi General Hospital. Then she was
examined by Xray on her chest, and she
was claimed suffering from pneumonia.
 CURRENT MEDICAL HISTORY

During Hospitalization for 3 days, patient came to

Purwodadi general hospital with cough,
breathlessness, and cyanosis complaints. Cyanosis
happened when the patient was coughing. Her
mother said that those complaints occurred
approximately a week ago.
During hospitalization, the patient had ever
suffered from apnea. During this period, the
patient had cough period as long as a recent
month. During the cough, patient had phlegm and
the phlegm was difficult to be discharged.
 From that hospital, Patient had
treated by Infusion, Vicillin and
Gentamycin intravenously, and
Paracetamol orally.
 PAST MEDICAL HISTORY

Cyanosis during breast fed :

Dyspnea during breast fed :
 FAMILY MEDICAL HISTORY

Her older brother suffered from cough

and flu

9
 ANAMNESIS
PREGNANCY AND
LABOUR HISTORY

The mother had routinely checked up her pregnancy to

midwife. Gestational age was 39 weeks. The mother consumed
vitamins and pills routinely from her midwife. Routine check up
to the midwife every month monthly within first and second
trimester, weekly on third trimester and go to doctor every 3
month There were no history of illness and admission to the
hospital during the course of pregnancy.
Labor
The baby was delivered by midwife. She was born fullterm,
with normal birth weight. Birth weight was 2800 grams, birth
length was 49 cms.
Conclusion :
The pregnancy was normal, labor was normal.

10
 GROWTH AND DEVELOPMENT HISTORY

Growth
According to her mother. She always gained weight and
increased height when she was taken to the nearest health
center.

Development
She reacted to the noise surrounding her, She always had a
look to any dolls or toys in front of he eyes, She had been able
to give an attention to clap hand sound

Conclusion : growth and development history are

within normal 11
 VACCINATION HISTORY

Hep B : 0 month
Polio : 1, 2, 3, 4 month
BCG : 1 month
DPT-HB-HiB : 2,3, 4 month
Measles : -

Conclusion : vaccination complete according to

Ministry of Healths Vaccination Schedule 2016.

12
 Pedigree

II

III
Child A/ 6,8 kg
 NUTRITIONAL STATUS

BB/U : 6.8/6.8x 100% =100% (-2 SD<z score<2SD

Normoweight
TB/U : 64/64 x 100 % =100% (-2SD<z score<2SD)
Normoheight
BB/TB: 6.8/6.8 x 100 % = 100 % (-1SD<z score<1SD)
Well nourished

Conclusion : well nourished, normalweight,

normalheight
 PHYSICAL EXAMINATION

GA: moderate ill, fully alert, GCS E4V5M6

VS : Heart rate: 130x/min Temp: 37.8oC
Resp. rate :55x/min SiO2 : 94%
Head : normocephal, head circumference 40cm
Eyes : anemic conjunctiva -/-, icteric sclera -/-, pupil isocor
(2mm/2mm), light reflect (+/+)
Ear : secret (-/-)
Nose : Nostrils Flares (-) nasal discharge (+)
Mouth : cyanosis (-), tonsil T1-T1 hyperemic (-), redness of the
pharynx (-)
Ears : Ear discharge -/-
Neck : Node enlargement (-)
Chest : Symmetrical in shape and movement, chest indrawing (+)
Cor : I : Ictus cordis not appeared
P : Ictus cordis was palpable
P : heart border enlargement (-)
A : heart sounds I-II normal intensity, regular, murmur(-)
Pulmo: I : symetris
P: fremitus sounds equals
P: sonor / sonor
A: vesicular breath sounds +/+ , additional breath sounds (+/+)
crackles +/+
Abd : I : abdominal wall equals to chest wall
A : peristaltic sound (+) within normal
P : tympani (+)
P : distended, pain (-), no palpable liver or spleen
Extremitas : Edema : -/- Cold extremities:
-/-
-/- -/-
Strongly palpable ADP CRT < 2
 LABORATORY FINDING
March 1st 2017 in Previous Hospital

Hemoglobin : 11.9 g/dl

Hematocrit :-
Leukocyte : 16.120/ul
Platelet count : 533x 103 /ul
Erythrocyte : 4.7 million/ul
MCV : - / um
MCH :-/ um
MCHC : -/ um
Netrofil :-%
Limfosit : -%
 LABORATORY FINDING
March 3rd 2017

Hemoglobin : 11.5 g/dl

Hematocrit : 36%
Leukocyte : 18.800/ul
Platelet count :364x 103 /ul
Erythrocyte : 4.34 million/ul
MCV :83.8/ um
MCH :26.5/ um
MCHC : 31.6/ um
Netrofil :19%
Limfosit : 70.8%
Eosinofil : 1.40%
Basofil : 0.7%
Monosit :8,1%
Chest Xray

Supported for pneumonia

appearence
 Problems List
A girl, 5 months of age, 6.8 kgs
1. Breathless
2. Phlegm cough and flu
3. History of cyanosis
4. History of apnea
5. Lymphocytosis
6. CXR : Pneumonia
 DIFFERENTIAL DIAGNOSIS

1. Pneumonia
2. Well Nourished, normalweight, normalheight
 WORKING DIAGNOSIS

1. Pneumonia,
2. Well Nourished, normalweight, normalheight
 THERAPY
1. Admitted to Pediatric HCU
2. Oxygen via nasal cannula 2 lpm
3. IVFD D5%1/2NS 28.3 cc/hour
4. Ampicilin (50 mg/kgBW/8 hours) : 350 mg/8 hours
(III)
5. Gentamycin (6 mg/kgBW/24 hours) : 40 mg/ 24
hours (III)
6. Paracetamol (10 mg/kgBW/8 hours) : 3 mL/8 hours
7. Nebulization by NS 5 cc/8 hours
 Monitoring
General survey / vital signs/ oxygen
saturation/ 3 hours
Fluid balance and diuresis / 8 hours
 4th march 2017
Issues Reduced breathlessness
St. CNS GA: moderate ill, fully alert, GCS
1. Chest Xray E4V5M6
Light reflex +/+
2. Echocardiography
St. CV
Isochoric pupils 2mm/2mm
HR : 140 bpm Strongly palpable ADP
3.
St.
Consult to Pediatric
Murmur -
Cardiology
CRT< 2
RR : 52 x/menit
I : symetris
Subdivision
Respirati SiO2: 95% P: fremitus sounds equals
on O2= On nasal P: sonor / sonor
Nostrile flares -
A: vesicular breath sounds +/+ ,
Chest indrawing + reduced
additional breath sounds (+/+) crackles
+/+
St GIT Vomit + No abnormality
Hepatic Stool +
St Random blood glucose: 122
Metabolik
St. GU Cant be evaluated yet
St. Fever (+) MONITORING
LC: 18.800 AB: inj Ampicillin (IV)
Infection t: 37.6 inj gentamicin (IV)
St. Cant be evaluated yet
Nutrition
 WORKING DIAGNOSIS

1. Pneumonia,
2. Well Nourished, normalweight, normalheight
 THERAPY
1. Oxygen via nasal cannula 2 lpm
2. IVFD D5%1/2NS 28.3 cc/hour
3. Ampicilin (50 mg/kgBW/8 hours) : 350 mg/8 hours
(IV)
4. Gentamycin (6 mg/kgBW/24 hours) : 40 mg/ 24
hours (IV)
5. Paracetamol (10 mg/kgBW/8 hours) : 3 mL/8 hours
6. Nebulization by NS 5 cc/8 hours
 Plan
Blood culture
 Clinical question: how is the prognosis
of pneumonia among infants with
congenital heart disease

P: CHILDREN WITH PNEUMONIA AND CHD

I:
C:
O: MORTALITY AND MORBIDITY
 ABSTRACT Introduction: The REGAL (RSV Evidencea Geographical Archive of the Literature) series provide a
comprehensive review of the published evidence in the field of respiratory syncytial virus (RSV) in Western
countries over the last 20 years. This fourth publication covers the risk and burden of RSV infection in infants
with congenital heart disease (CHD).
Methods: A systematic review was undertaken for articles published between January 1, 1995 and December
31, 2015 across PubMed, Embase, The Cochrane Library, and Clinicaltrials.gov. Studies reporting data for
hospital visits/admissions for RSV infection among children with CHD as well as studies reporting RSV-
associated morbidity, mortality, and healthcare costs were included. The focus was on children not receiving
RSV prophylaxis. Study quality and strength of evidence (SOE) were graded using recognized criteria.
Results: A total of 1325 studies were identified of which 38 were included. CHD, in particular hemodynamically
significant CHD, is an independent predictor for RSV hospitalization (RSVH) (high SOE). RSVH rates were
generally high in young children (\4 years) with CHD (various classifications), varying between 14 and 357/1000
(high SOE). Children (\6 years) with RSV infection spent 4.414 days in hospital, with up to 53% requiring
intensive care (high SOE). Infants (\2 years) with CHD had a more severe course of RSVH than those without
CHD (high SOE). Case fatality rates of up to 3% were associated with RSV infection in children with CHD (high
SOE). RSV infection in the perioperative period of corrective surgery and nosocomial RSV infection in intensive
care units also represent important causes of morbidity (moderate SOE).
Conclusion: CHD poses a significant risk for RSVH and subsequent morbidity and mortality. RSV infection often
complicates corrective heart surgery. To reduce the burden and improve outcomes, further research and specific
studies are needed to determine the longer-term effects of severe RSV infection in young children with CHD.
Keywords: Burden; Congenital heart disease; Hemodynamically significant; High risk; Hospitalization; Morbidity;
Mortality; Non-hemodynamically significant; Respiratory syncytial virus