MORNING REPORT

Thursday,
September 8th
2017
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Identity An. NBD/Female/ 9 m.o./BW 6,5 kg/BH 63 cm / HC
43 cm
Bb/u : -2 <Z<0
Tb/u : -2 <Z<0
Bb/tb: 0 SD
Nutritional Status : good nutrition
Pubertal Status : P1M1
Time of admission in ER: 19.00 WIB
ANAMNESIS
Chief complain : watery stool
Additional complain : vomiting
Present illness history
Since 2 days before admission patient had watery stool, water more than dregs, frequency
7-8 x/day, @2-3 tsp, no muccus, no blood, no smelly odor, no vomit, but theres fever, its
insidious fever, the temperature was not measure by the mother. The mother gived sanmol
and the temperature got lower. Patient go to pediatrician and given drops precription but
the mane was unknown.
About 1 day before admission patients vomited, frequency 3-4x/day, theres no projectil
vomit, @ 1 tsp, the patient still want to eat and drink, the watery feces still exist, the body
temperature got lower. The patient go to general practitioner and given 3 kinds of drugs
(mother did not know the name) but no improvement,, theres still watery feces and vomit
(2x). The patient then brought to ER of RSMH.

In the childs skin theres vesicle, reddish vesicle in the entire body since 2 month ago,
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pruritus (+), the reddish vesicle itchy especially at night.
The pruritus ini the family skin (+) (mom and dad)
PHYSICAL EXAMINATION
General condition :
Sensorium : Compos Mentis
TD : -
Pulse : 124 x/min, reguler, enough Anemic (-)
RR : 30 x/min Icteric (-)
Temp : 36,8 C Cyanosis(-)
SpO2 : 99% Dyspneu (-)

Spesific condition
Head : normochepally, isocor pupil 3/3 mm, Light reflex (+/+), anemic
conjunctiva (-/-), icteric sclera (-), sunken eye (-), typhoid tongue (-), Hyperemic
Pharynx (-), nasal flare (-), sunken fontanelle (+), dry lips mucosa (+),
Thorax : dynamic static: symmetrical, retraction (-)
Cor : Normal I-II Heart Sound, murmur (-) Gallop (-)
Pulmo : Vesicular (+) Normal, rales (-) , wheeze (-)
Abdomen : Flat, supple, liver and lien are not palpable, normal bowel sounds,
epigastric tenderness (-)
Extremities : Warm extremity, CRT <3 '', edema (-)
Skin: multiple papul, the size is millier, eritematousa, theres pustul, erosion
and excoriation and krusta.

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PROBLEM : ASSESTMENT
1. Acute diarrhea Acute diarrhea mild to moderate dehydration ec
2. Mild to moderate dehydration rotavirus + Scabies
3. Vomiting
4. Skin lession
DIFFERENTIAL DIAGNOSIS WORKING DIAGNOSIS
1. Acute diarrhea mild to moderate Acute diarrhea mild to moderate dehydration +
dehydration ec rotavirus + Scabies Scabies
2. Acute diarrhea mild to moderate
dehydration ec shigela + Scabies
3. Acute diarrhea mild to moderate
dehydration ec amoeba + Scabies
PLANNING : TREATMENT
Oralit 75 ml/kgBB/4h -> 500 mL/4h-> start at 19.10
Zink 1 x20 mg
Consul to dermatologist department :
Assest : Scabies
Treatment : Scabimite cream, Fusidic acid cream,
cetitrizine.
DIET MONITORING
700 kkal Vital sign
Dehydration state
SUBDIVISION Out patient

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 THANK YOU