MORNING REPORT

Disusun oleh:
Noermawati Dewi

FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH SURAKARTA
2017
 IDENTITY
• Name : An. A
• Date of birth : 06 February 2016
• Gender : girl
• Age : 18 months
• Address : Surakarta
• Religion : Islam
• Tribe : Java
• Date of hospitalization : 23-08-2017 (12.00)
• Date of examination : 23-08-2017 (19.00)
ANAMNESIS

Chieft Complaint

Diarrhea
 HISTORY OF ILLNESS
3 days before admission
• The mother said that on Sunday evening, the
patient got vomit 2x after she drink or eat.
Fever (+). Cough (+), runny nose (+).
• The defecation and urination was normal.
 HISTORY OF ILLNESS
2 days before admission

• The patient still got vomit 4x. Fever (+), runny

nose (+), cough (+).
• The appetite had decreased
• The defecation and urination was normal
• The mother took her to the general
practicioner.
 HISTORY OF ILLNESS
1 day before admission
• The mother said that on Tuesday, the patient got vomit 2x,
there was no fever, and frequency of cough was decreased but
runny nose (+).
• The defecation was washy (4x), there was no blood or mucus.
And urination was decreased.
• The patient always ask to drink.
 HISTORY OF ILLNESS

The day on admission

• The mother said that the patient still got diarrhea 3x, vomit (+), runny
nose (+), recovery cough, fever (-).
• The urination was decreased.
• Mother took her to the hospital.
 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 Hypertention : Denied
History of Diabetes Mellitus : Denied

Conclusion: there is no history of illness in family that not correlated with

patient’s disease
 PEDIGREE

Ny. M 27 years old

Tn. S 29 years old

An. A 18 months old

Conclusion : there is no hereditary illness

 HISTORY OF PREGNANCY

Mother with P1A0 was pregnant at 25 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 trauma, infection, and
hypertension but the mother got bleeding (ngeflek) at the
gestational age 7 months because of plasenta previa.

Conclusion: history of pregnancy was good

 HISTORY OF DELIVERY

The mother gave birth to her baby assisted by a obstetrician with a C-

section delivery. 38 weeks pregnancy age, baby born with body weight
2600 grams and body lenght 47cm . 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 but 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 uncle. Ceramic-floored patient houses, walled walls, tile roofs,
adequate ventilation, bathrooms in the house, water source from
PDAM.
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 – 3 months
• Breastmilk

Age 3-4 months

• Formula + breastmilk

Age 5-6months
• Formula ± 6 bottles /day

Age 6 -9 months
• Formula + porridge of filter and vegetable teams smoothed 2-3 small dishes per day

Age 9 -12 months

• Formula + soft rice, eggs, meat, fish, vegetables a day 2-3 times small dishes of food is always finished

Age >12 months

• Formula + rice, eggs, meat, fish, vegetables a day 2-3 times small dishes of food is always finished

Conclusion : history of feeding  quality was not good and quantity was
good
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• The answer “Yes” = 10 poin

Conclusion : Development history is according to age

 Physical Examination
 General appearance
General appearance : Fussy
Awareness : Alert

 Vital Sign
Blood Pressure :-
Heart rate : 120x/ menit
Respiratory Rate : 26x/ menit
Temperature : 37,2º C
 Nutrisional status

WEIGHT : 9,0 KG Height : 82,0 CM

-Weight // age : antara -2SD sampai 0 line (gizi baik)

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

24
 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  there was rhonki in the

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

Conclusion : There was no abnormality

 Ekstermitas

•Warm of acral
•Perfusion of tissue is good

•Cyanosis is not found in the 4 extremities

•No udem is found in the extremities

CRT <2 sec
Turgor is good

Conclusion : the examination of extremity was normal limits

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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: Faring hiperemis

 LABORATORIUM EXAMINATION
Routine blood examination
PEMERIKSAAN HASIL SATUAN NORMAL
 Leukosit 8.20 10ˆ3/ul 4.5 – 12.50
 Eritrosit 4.32 jt/ul 3.8 – 5.20
 Hemoglobin 11.1 g/dl 11.7 – 14.5
 Hematokrit 32.4 L % 35.0 – 47.0
 Trombosit 420 10ˆ3/ul 217 – 497
 Limfosit 36.5 % 25 – 40
 Netrofil 54.8 % 50 - 70
 Monosit 8.7 H % 2–8
 MCV 75.0 fl 74.0 – 102.0
 MCH 25.6 pg 22.0 – 34.0
 MCHC 34.2 H g/dl 30.0 – 34.0

Result : Routine blood examination was normal limit

 RESUME
ANAMNESIS
Watery stool 3-4xper days. Blood (-)
Vomit
Cough
Runny nose
Fever

Physical examination
Blood Pressure : -
Heart rate : 120x/ menit
Respiratory Rate : 26 x/ menit temperature : 37,2º C
Faring hiperemis (+)
Thorax Lung: crakcles (+)
Laboratorium
Normal limits
 ASSESMENT

1. Diare cair akut

dengan dehidrasi tak 2. Bronkitis
berat telah teratasi
• DD : • DD:
• Intoleransi laktosa • Bronkhiolitis
• Cholera
 ACTION PLAN
• Balance cairan
• Observation of vital signs

DIAGNOSIS ENFORCEMENT PLAN

• Feces Routine examination

 Terapi

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

Kalori : 9 x 102= 918kkal vegetables a day 3 times a large plate of food
Protein : 9x 1.23 = 11.07g was always finished.
Cairan : 9x 115= 1035ml  rute oral
Kebutuhan energi : 918 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
 ` PLAN
THERAPY

• Cairan : Karena anak muntah setiap minum  parenteral (iv)

• RL : 200ml/kgBB/hari  200x9 = 1800cc  18,75 tetes
makro 19 tetes makro

• Zink 20mg/hari
• L-bio 2x1 sachet
• Ondancentron 0,1mg/kgBB x 9kg = 0,9 1mg/ 12jam
 FOLLOW UP
TANGGAL SOA PLANNING
24-8- -S/on the morning, vomit (-), diare (-), recovery cough, P/ -RL : 19 tetes
2017 recovery runny nose, urination was normal. But on the makro
Jam afternoon diarrhea 2x. • -Zink 20mg/hari
O/ • L-bio 2x1 sachet
07.00
- KU : Compos Mentis • Ondancentron
- HR : 114x/menit 1mg/ 12jam
- RR : 24 x/menit
- S : 37.2 • Ambroxol : 4,5 mg
• Salbutamol : 0.9
- Kepala: konjunctiva anemis (-/-), sklera ikterik (-/-)
mg
- Faring sulit dievaluasi. • Pseudoefedrin: 9
- Tho: suara vesikuler(+/+), wheezing (-/-), Rhonki (-/-) mg
- Abd : peristaltik (+), timpani (+)
- Extremities : normal

A/Diare cair akut

Rhinofaringitis
 FOLLOW UP
TANGGAL SOA PLANNING
25-8- -S/on the morning, diarrhea (-), vomit (+) mucus after she P/ -RL : 19 tetes
2017 cough 2x, recovery runny nose, urination was normal. makro
Jam O/ • -Zink 20mg/hari
07.00 - KU : Compos Mentis • L-bio 2x1 sachet
- HR : 118x/menit • Ambroxol : 4,5 mg
- RR : 23 x/menit • Salbutamol : 0.9
- S : 35.5 mg
• Pseudoefedrin: 9
- Kepala: konjunctiva anemis (-/-), sklera ikterik (-/-)
mg
- Faring sulit dievaluasi.
- Tho: suara vesikuler(+/+), wheezing (-/-), Rhonki (-/-)
- Abd : peristaltik (+), timpani (+)
- Extremities : normal
- Feces routine : normal limits

A/Diare cair akut

Rhinofaringitis
THANK YOU