MORNING REPORT

Disusun oleh:
Noermawati Dewi

FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH SURAKARTA
2017
 IDENTITY
• Name : An. E
• Date of birth : 14 December 2008
• Gender : Boy
• Age : 9 years old
• Address : Surakarta
• Religion : Islam
• Tribe : Java
• Date of hospitalization : 27-08-2017 (14.00)
• Date of examination : 27-08-2017 (16.00)
ANAMNESIS

Chief Complaint

Fever
 HISTORY OF ILLNESS
3 days before admission
• The mother said that on Thursday evening,
the patient got fever (+) and vomit (+) 3x.
• There was no diarrhea, cough (-), runny nose
(-).
• The defecation and urination was normal.
 HISTORY OF ILLNESS
2 days before admission

• The patient still got vomit 2x. Fever (+), watery

stool (+) 1x no blood  about ½ of glass.
• The appetite had decreased
• The urination was normal
 HISTORY OF ILLNESS
1 days before admission
• The patient still got fever (+), watery stool (+)1x about ¾ of
glass.

The day on admission

• The patient still got fever (+), defecation (-), urination was
normal.
 HISTORY OF PAST ILLNESS

History of Seizure with fever : Denied

History of seizure without fever : Denied
History of dengue fever : Denied
History of typhoid fever : Denied
History of long cough : Denied
History of asma : Denied
History of allergy with food and drug : Denied

Conclusion: there is no history of past illness that related to

current illness
 HISTORY OF ILLNESS IN FAMILY

History of Similiar symptom : Denied

History of Seizure with fever : Denied
History of Asma : Denied
History of Alergy : Admitted (grandfather)
History of Hypertention : Denied
History of Diabetes Mellitus : Denied

Conclusion: there is history of illness in family that not correlated with

patient’s disease
 PEDIGREE

Ny. S 33 years old

Tn. T 35 years old

An. E 9 yearsold
= Urticaria

Conclusion : there is hereditary illness

 HISTORY OF PREGNANCY

Mother with P1A0 was pregnant at 24 years old. Mother began to

check pregnancy and routinely control to the obstetrician.
During pregnancy the mother does not feel nausea, vomiting
and dizziness that interfere with daily activities. During
pregnancy there was no history of infection, and hypertension
but the mother got bleeding at the gestational age 5 months
because of fallen

Conclusion: history of pregnancy was not good

 HISTORY OF DELIVERY

The mother gave birth to her baby assisted by a midwife with a normal
delivery. 40 weeks pregnancy age, baby born with body weight 3100
grams and body lenght 51cm . At the time of birth the baby cries instantly,
there was no congenital defect at birth.

Conclusion : history of delivery was good

HISTORY OF POST DELIVERY

The baby boy was born crying, active motion, red skin color, not
blue and yellow skin color, got milk on first day, urination and
defecation less than 24 hours

Conclusion : history of post delivery was good

 HISTORY OF ENVIRONMENT

The patient lives at home with both parents, grandparents

and aunty. Ceramic-floored patient houses, walled walls, tile roofs,
adequate ventilation, bathrooms in the house, water source from
well water.
A few days before the patient was treated in the hospital,
neighbors and the family have not experienced same complaints.

Conclusion : there is no a risk factors for transmitted disease

 HISTORY OF VACCINE

• At that time of examination, the mother did not bring

KMS.
• According to her mother, the patient had received the
basic vaccine (kemenkes) completely. Vaccinations
were obtained at the primary care (midwife).

Conclusion : history of vaccine was good based on

KEMENKES
 HISTORY OF FEEDING
Age 0 – 6 months
• Exclusive breastmilk

Age 6-12 months

• Breastmilk + instant porridge 3 times small dishes per day

Age 12-18 months

• Breastmilk + porridge of filter and vegetable teams smoothed 3 small dishes per day

Age 18 months - now

• Rice, eggs, meat, fish, vegetables a day 3 times small dishes of food is always finished

Conclusion : history of feeding  quality and quantity were good

 History of Development
• Patient in 3 grade of elementary school
• Patient can follow the lesson in the class
• Patient play with his friends and he has a lot
of friends
 Physical Examination
 General appearance
General appearance : Good
Awareness : Alert

 Vital Sign
Blood Pressure :-
Heart rate : 102x/ menit
Respiratory Rate : 23x/ menit
Temperature : 38,1º C
 Nutrisional status

WEIGHT : 25,0 KG Height : 120,0 CM

-Weight // age : antara -1SD sampai 0 line (gizi baik)

-Height // age : -2SD line (normal)
-Weight // Lenght : antara 0 sampai 1SD (normal)

Conclusion : The patient's nutritional status is good

 Physical examination
• Skin examination
Color : brown
Skin turgor: <2 sec (good)
Moisture: moist
Edema (-) does not exist

• Conclusion : the examination of skin was normal

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 PEMERIKSAAN KUSUS
Neck : No enlargement of lymph node and no increase jugular venous
Chest : Simetris, retration (-), miss the motion (-).
• Heart
Inspeksi : The ictus cordis is not visible
Palpasi : Ictus cordis not strong lift
Perkusi : sound “redup”
Auskultasi : sound of cor I-II reguler, bising jantung (-)
• Lung
Inspeksi : Simetris, retraksi intercostal (-/-), retraksi
subcostal (-/-), retraksi substernal (-), retraksi
suprasternal (-)
Palpasi : Simetris kanan kiri, There is no missed breath
Perkusi : sonor
Auskultasi : Vesicular (+/+) normal, rhonki (-/-), wheezing (-/-)

Conclusion : Neck, Chest, Heart, Lung  within normal limits

Stomach : Inspeksi : Distended (-), sikatrik (-), purpura (-)
Auskultasi : Peristaltik (+) meningkat
Perkusi : Hipertimpani (+)
Palpasi : Supel, massa abnormal (-), nyeri tekan (-),
turgor kulit menurun (-)
Liver : normal
Spleen : normal

Conclusion : There were hipertimpani (+) and increased of peristaltik (+)

 Ekstermitas

•Warm of acral
•Perfusion of tissue is good

•Cyanosis is not found in the 4 extremities

• petekie (+) in the 4 extremities

•No udem is found in the extremities

CRT <2 sec
Turgor is good

Conclusion : the examination of extremity  there was petekie

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 PHYSICAL EXAMINATION

Head : Normochephal
Eyes : CA (-/-), SI (-/-), edema palpebra (-/-) , sunken eyes(-/-)
Nose : Sekret (-), epistaksis (-), nafas cuping hidung (-/-)
Ears : Sekret (-)
Mouth : Stomatitis (-), perdarahan gusi (-), sianosis (-), faring hiperemis(-)
Skin : Warna sawo matang, Pucat (-), Ikterik (-), Sianosis (-), turgor kulit (< 2
detik)
Lymph nodes : Tidak didapatkan pembesaran limfonodi
Muscle : Tidak didapatkan kelemahan, atrofi, maupun nyeri otot
Bone : Tidak didapatkan deformitas tulang
Joints : Gerakan bebas
Extremities : CRT < 2 Second, sianosis (-/-), edema (-/-), akral hangat(+/+), petekie
(+/+)

Conclusion: there was petekie (+)

 LABORATORIUM EXAMINATION
Routine blood examination
PEMERIKSAAN HASIL SATUAN NORMAL
 Leukosit 2.61L 10ˆ3/ul 4.5 – 12.50
 Eritrosit 5.26 jt/ul 3.8 – 5.20
 Hemoglobin 12.8 g/dl 11.7 – 14.5
 Hematokrit 37.6 % 35.0 – 47.0
 Trombosit 97 L 10ˆ3/ul 217 – 497
 Limfosit 22.6 L % 25 – 40
 Netrofil 72.8 H % 50 - 70
 Monosit 4.2 % 2–8
 MCV 71.5 fl 69.0 – 93.0
 MCH 24.3 pg 22.0 – 34.0
 MCHC 34.0 g/dl 30.0 – 34.0

Result : Routine blood examination was leukopenia and trombositopenia

 RESUME
ANAMNESIS
Fever (4 days)
Vomit
Watery stool

Physical examination
Blood Pressure : -
Heart rate : 102x/ menit
Respiratory Rate : 23 x/ menit
Temperature : 38,1º C
Abdomen : increased of peristaltik and hipertimpani (+)

Laboratorium
Lekopenia
Trombositopenia
 ASSESMENT

1. Dengue
Fever
•DD : DHF,
Campak, ITP,
 ACTION PLAN
• Observation of vital signs
• Observasi tanda perdarahan

DIAGNOSIS ENFORCEMENT PLAN

Pemeriksaan trombosit dan hematokrit ulang

 Terapi

kebutuhan energi : White rice, eggs, meat, fish,

Kalori : 25x 70= 1750kkal vegetables a day 3 times a large plate of food
Protein : 25x 1.0 = 2.5g was always finished.
Cairan : 25 x 70 = 1750ml  rute oral
Kebutuhan energi : 1750 kalori/hari dibagi
dalam 3 kali waktu makan

kebutuhan energi :
Nasi putih 100 gram: 178 kalori
Tumis bayam 100 gr : 193 kalori
1 butir telur rebus : 154 kalori
1 tempe goreng : 82 kalori
1 ayam sayap: 295 kalori
Pisang 100 gram: 99 kalori
 ` PLAN
THERAPY

• Cairan : RL 5 ml/kgBB/jam x 25 = 125 ml/jam

• Paracetamol : 10mg/kg x 25 = 250 mg/ kali pemberian bila

demam
 FOLLOW UP
TANGGAL SOA PLANNING
28-8- -S/on the morning, vomit (-), watery stool (-) P/ -RL : 125 cc/jam
2017 O/ - Paracetamol 250mg/
Jam - KU : Compos Mentis kali bila demam
07.00 - HR : 84x/menit
- RR : 22 x/menit
- S : 37.2
- Kepala: konjunctiva anemis (-/-), sklera ikterik (-/-)
- Tho: suara vesikuler(+/+), wheezing (-/-), Rhonki (-/-)
- Abd : tampak normal, peristaltik (+), supel (+), timpani
(+)
- Extremities : ptekie (+)

A/Dengue Fever
THANK YOU