MORNING REPORT

TUESDAY (NIGHT SHIFT),

DECEMBER 20TH 2017

dr. Prima / dr. Tatag

dr. Chandra / dr. Pitra / dr. Winda
dr. Syahmi / dr. Rini
dr. Connie / dr. Rekno

1
 PATIENT ADMISSION

MELATI 2 WARD :
 Child Y, 1 y.o. 10 kgs with pneumonia, candidiasis, global delay
development, wellnourished
 Child S, 3 y.o. 10.7 kgs with obstructive ileus low position, acute
diarrhea with mild to moderate dehydration, microtia, wasted.
HCU NEONATUS :
 Baby S, 0 day, 3040 grs with suspected diaphragmatic hernia and mild
respiratory distress, infectious potential, aterm, normal birth weight,
appropriate for gestational age.

2
PICU :
 Child G, 17 y.o. 50 kgs with EDH on right temporobasal
region pro Emergency craniotomy, wellnourished.
HCU MELATI 2 :
 Child H, 1.5 months old, 2.4 kgs with left scrotal hernia,
acute diarhea without dehydration, wellnourished.
NICU : -

3
PATIENT IDENTITY

 Name :S
 Sex : Female
 Age : 3 years old
 Body weight / height : 10.7 kgs / 89 cm
 Adress : Karanganyar, Ngawi
 Medical Record : 014028xx

4
CHIEF COMPLAINT

abdominal enlargement

5
CURRENT MEDICAL HISTORY
•Patient got fever, along ,the day
improve with medication
•No cough, no runny nose
•No vomitting, no nausea
•Defecation & urination were
normal.
4 days before admitted
3 days before admitted
•Patient got diarrhea 3x a day,
blood (-), mucous (-), each ±
1/3 of glass size, feces (+)
•Her mother took her to
midwife and got 3 kinds of
medication. After took the
medication, her abdomen
started to enlarge
•She lost her appetite
6
CURRENT MEDICAL HISTORY

Previous day
• Abdomen was getting larger, she before admission
still 5x defecation brown colour,
without blood and mucous
• Her stomach getting larger, bloating also
• Started to vomit, 3x a day, can’t fart
contained undigested food • Watery diarrhea 5x, no blood no mucous
• She felt bloating, her appetite got • Vomitting 3 times, contained yellowish
worsened, not ate anything for 2 fluid.
days • Brought to local midwife, but no
improvement
2 days before • Then she was brought to Moewardi
admission hospital.

7
AT MOEWARDI’S EMERGENCY ROOM

 She looked irritable, and weak. Loose defecation 1

times, watery stool > dregs, blood (-), mucous (-).
Vomitting 1 time with yellowish contained. Fever(+),
cough and runny nose (-)

8
PAST MEDICAL HISTORY

 History of hospitalization (-)

 History of frequently playing around the raw ground (-)
 History of rarely defecation (+): 1x / week since 6 months
old

9
FAMILY MEDICAL HISTORY

 History of same complaint was denied

10
PREGNANCY AND DELIVERY HISTORY

• During pregnancy, his mother routinely checked her pregnancy to

midwife. She was given vitamin, and she didn’t consume any
medicine besides it. She hasn’t got hospitalized during pregnancy
and has no fever, no hypertension
• Baby girl was born in 38 weeks of pregnancy by spontaneous
delivery. Shortly after birth, she cried vigorously, cyanosis or
jaundice wasn’t found. Her birth weight was 3500 grams, 48
centimeters in length, meconeum had passed

Conclusion: Pregnancy and delivery history were normal

11
VACCINATION HISTORY

 BCG : 1 month
 Hepatitis B0 : 0, 2,3,4 months
 DPT-HB-HiB : 2,3,4 months
 Polio : 2,3,4 months
 measles : 9 months

Conclusion :
complete immunization,
appropriate with Ministry of Health schedule 2014
12
 NUTRITION HISTORY

Got breastfed until 3 months old, 3 to 6 months provided by formula

milk. 6 months till nowadays, milk intake (-), just consume rice
porriedge 2x / day
Conclusion: nutrition status is inadequate

GROWTH AND DEVELOPMENT

She is now 3 years old
Her weight is 10.7 kgs with body height 89 cm.
Birth weight : 3500 gram
She can play and interact with others child
Conclusion: appropriate for his age
13
NUTRITIONAL STATUS

• Weight for Age: 10.7/14.8 x 100% = 72% (-2 SD < Z score

<-3 SD) underweight
• Height for Age : 89/98.4 x 100% = 90% (-2 SD < Z score < -
3 SD) stunted
• Weight for Height : 10.7/12.4 x 100% = 86% (-1 SD < Z
score < -2SD) well nourished

Conclusion:
Well nourished, underweight, stunted

14
 FAMILY TREE

II

III

S, 3 years old 10kgs

15
 PHYSICAL EXAMINATION

 General appearance : looked severely ill, fully alert, GCS

E4M6V5
 Vital sign :
 Heart Rate = 128 bpm
 Respiratory rate = 16 x per minute
 Temperature = 36 0 C peraxilar
 O2 saturation = 96%

16
 Head : mesocephal, HC = 38cm (<2 SD <0 nelhaus), right microtia +
 Eyes : pale conjunctiva (-/-), icteric sclera (-/-), light reflex (+/+),
isochoric pupil 3 mm/3mm, sunken eyes (+/+), tears (+/+) ↓
 Nose : nasal flare (-/-), discharge (-/-),
 Mouth : dry lips (+), lips and tongue not cyanotic,
 Throat : hyperemic pharing (-),Tonsil T1-T1 hyperemic (-), detritus (-)
 Neck : Enlargement of lymph node (-)
 Thorax : symmetric (+), retraction (-)

LUNG:
 I: normal, symmetric, retraction (-)
 P: fremitus difficult to evaluation
 P: sonor in both lung
 A: normal vesicular breath sound, additional breath sound (-/-)

17
CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, no murmur
ABDOMINAL:
I: distended (+), AC = 56cm
A: peristaltic sounds was decreased
P: hipertympani(+), shifting dullness (-), undulations(-),
P: liver and spleen was hard to examine, slow skin turgor
EXTREMITIES:
The extremities were warm, capillary refill time < 2 sec, and dorsalis pedis artery was
strongly palpable, icteric -/-/ swelling -/-
-/- -/-
GENITALIA : female, no abnormality
18
19
20
 LABORATORY FINDINGS ( 20 DEC
2017) 4.57 AM
• Hb :11.6 g/dl
• HCT : 35 %
• Leuco : 13.9 thousand/ul
• PLT : 557 thousand/ ul
• Erytro : 4.47 mil/ul
• MCV : 77.1 /um
• MCH : 26.0 pg
• MCHC : 33.6 g/dl
• RDW : 10.9 %
• Eosinophyl : 0.20 %
• Basophil : 0.80 %
• Netrophyl : 53.4 %
• Limphocyte : 33.20 %
• Monocyte: 12.4 %
• PT : 18“
• APTT : 31.4 “
• RBG : 34 mg/dl  96 mg/dl (08.41 AM)
• Creatinine : 0.2
• Ureum : 61
• HbsAg : non reactive
• Sodium : 130 mmol/l
• Potassium : 3.1 mmol/l
• Chloride : 94 mmol/l
• Calsium ion : 0.83 mmol/l
• Hypoglicemia, hypocalcemia,
thrombocytosis
21
ECG

22
 QOTC

 QTV Interval / √ RR =
 20 / 2.8 = 7.1 x40 = 284 msec

23
06:30

 S: hypoglycemia
 O: manual glucose level check: low detected
 A: hypoglycemia
 P: bolus D10% (2ml/kgbw)= 20ml,
 Change to inf D10% (GIR 6)
 repeat glucose check in 1 hour

24
 S: glucose evaluation
 O: glucose level: 76

25
 LISTS OF PROBLEM

 Eyes : sunkes eyes, tear drop↓

A female child, 3.5 y.o, 10.7 kgs  Right microtia

with :  Distended abdomen, AC = 56 cm

 Fever since 4 days before  peristaltic sounds was decreased,

admitted hipertympani
 Hypoglicemia, hypocalcemia,
 Watery diarhea, 5times a day, thrombocytosis
yellowish faeces
 Well nourished, underweight,
 Vomitting 3 times stunted

26
DIFFERENTIAL DIAGNOSIS

 Suspected of obstructive ileus dd congenital megacolon

 Acute diarrhea with mild to moderate dehydration
 History of hypoglycemia, hypocalcemia
 Right microtia
 Well nourished, underweight, stunted

27
WORKING DIAGNOSIS

 Obstructive ileus short segmental (K56.6) dd congenital

megacolon (Q43.1)
 Acute diarhea (A09.0) with mild to moderate dehydration
 History of hypoglycemia, hypocalcemia
 Well nourished, underweight, stunted

28
 THERAPY

 Admitted to pediatric gastroenterologi subdivision ward

 Apply nasogastrial tube, NPO
 Temporary fasting
 IVFD Asering (200ml/kgbw/day)  2000ml/day = 83ml/hr until rehydrated
 continue with maintanance solution D ½ NS 10 drops per minute
 Ampicillin Sulbactam (25mg/kgbw/6 hrs) 250mg/ 6 hrs IV

29
 PLANNING

1. - Abdominal X-ray 3 position

2. - Electrolyte evaluation after rehydrated
3. - Urine and Fecal analysis
4. - Consult to surgery division

MONITORING

• General appearance / vital sign / HS every hour

until rehydrated
• Diuresis and fluid balance every 8 hours 30
ABDOMINAL XRAY

31
ABDOMEN LLD

32
 FOLLOW UP (DEC 20TH 2017)
 S: dark colour of NGT
 General appearance : looked severely ill, fully alert, GCS
E4M6V5
 Vital sign :
 Heart Rate = 128 bpm
 Respiratory rate = 16 times per minute
 Temperature = 36 0 C peraxilar
 O2 saturation = 97%
33
 Head : mesocephal, HC = 38cm (<2 SD <0 nelhaus), right microtia +
 Eyes : pale conjunctiva (-/-), icteric sclera (-/-), light reflex (+/+),
isochoric pupil 3 mm/3mm, sunken eyes (-/-), tears (+/+)
 Nose : nasal flare (-/-), discharge (-/-),
 Mouth : dry lips (+), lips and tongue not cyanotic,
 Throat : hyperemic pharing (-),Tonsil T1-T1 hyperemic (-), detritus (-)
 Neck : Enlargement of lymph node (-)
 Thorax : symmetric (+), retraction (-)

LUNG:
 I: normal, symmetric, retraction (-)
 P: fremitus difficult to evaluation
 P: sonor in both lung
 A: normal vesicular breath sound, additional breath sound (-/-)

34
CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, no murmur
ABDOMINAL:
I: distended (+), AC = 56cm
A: peristaltic sounds was decreased
P: hipertympani(+), shifting dullness (-), undulations(-),
P: liver and spleen was hard to examine, good skin turgor
Rectum : applied rectal tube, product (+) faeces, brownish, no mucus
EXTREMITIES:
The extremities were warm, capillary refill time < 2 sec, and dorsalis pedis artery was
strongly palpable, icteric -/-/ swelling -/-
-/- -/-
GENITALIA : female, no abnormality
35
WORKING DIAGNOSIS

 Obstructive ileus short segmental (K56.6) dd congenital

megacolon (Q43.1)
 Acute diarhea (A09.0) with mild to moderate dehydration
 Gastrointestinal bleeding
 Right microtia
 Well nourished, underweight, stunted

36
 THERAPY

 Temporary fasting
 Inj. Ampicillin Sulbactam (25mg/kgbw/6 hrs) 250mg/ 6 hrs IV
 Ranitidin inj (1mg/kgbw/12h)= 10mg/12h IV
 Sucralfat spooling 5ml+NaCl/8hr
 Total parenteral nutrition
 Dextrose 8.5% + Potassium chloride 10ml + Calcium
gluconas 10ml  73 ml/h
 Aminofuhsin paed 5% (1gram/kg/day)  8.9 ml/h 37

 Lipofundin 20% (1 gram/kg/day) 2.2 ml/h

 PLANNING

1. - Electrolyte evaluation after rehydrated

2. - Urine and Fecal analysis
3. - Confirm to surgery division (plan for procedure)

MONITORING

• General appearance / vital sign / 4 hours

• Diuresis and fluid balance every 8 hours
• Blood glucose/ day 38
 FOLLOW UP (DEC 21ST 2017)
 S: diarrhea, brown colour of feces
 General appearance : looked severely ill, fully alert, GCS
E4M6V5
 Vital sign :
 Heart Rate = 128 bpm
 Respiratory rate = 26 times per minute
 Temperature = 36 0 C peraxilar
 O2 saturation = 97%
39
 Glucose level
 Head : mesocephal, HC = 38cm (<2 SD <0 nelhaus), right microtia +
 Eyes : pale conjunctiva (-/-), icteric sclera (-/-), light reflex (+/+),
isochoric pupil 3 mm/3mm, sunken eyes (-/-), tears (+/+)
 Nose : nasal flare (-/-), discharge (-/-),
 Mouth : dry lips (+), lips and tongue not cyanotic,
 Throat : hyperemic pharing (-),Tonsil T1-T1 hyperemic (-), detritus (-)
 Neck : Enlargement of lymph node (-)
 Thorax : symmetric (+), retraction (-)

LUNG:
 I: normal, symmetric, retraction (-)
 P: fremitus difficult to evaluation
 P: sonor in both lung
 A: normal vesicular breath sound, additional breath sound (-/-)

40
CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, no murmur
ABDOMINAL:
I: distended (+), AC = 56cm
A: peristaltic sounds was decreased
P: hipertympani(+), shifting dullness (-), undulations(-),
P: liver and spleen was hard to examine, good skin turgor
Rectum : applied rectal tube, product (+) faeces, brownish, no mucus
EXTREMITIES:
The extremities were warm, capillary refill time < 2 sec, and dorsalis pedis artery was
strongly palpable, icteric -/-/ swelling -/-
-/- -/-
GENITALIA : female, no abnormality
41
WORKING DIAGNOSIS

 Obstructive ileus short segmental (K56.6) dd congenital

megacolon (Q43.1)
 Acute diarhea (A09.0) with mild to moderate dehydration
 Gastrointestinal bleeding
 Right microtia
 Well nourished, underweight, stunted

42
 THERAPY
 Temporary fasting
 Inj. Ampicillin Sulbactam (25mg/kgbw/6 hrs) 250mg/ 6 hrs IV
 Ranitidin inj (1mg/kgbw/12h)= 10mg/12h
 Sucralfat spooling 5ml+NaCl/8h
 Total parenteral nutrition
 Dextrose 8.5% + Potassium chloride 10ml + Calcium
gluconas 10ml  73 ml/h
 Aminofuhcin paed 5% (1gram/kg/day)  8.9 ml/h
 Lipofundin 20% (1 gram/kg/day) 2.2 ml/h 43
 PLANNING

1. - Confirm to surgery division (plan for

procedure)

MONITORING

• General appearance / vital sign / 4 hours

• Diuresis and fluid balance every 8 hours
• Blood glucose/ day 44
WHAT IS THE RISK FACTOR OF CHILDREN WITH
DIARRHEAL TO DEVELOP ILEUS?

P • CHILDREN WITH DIARRHEA

I • ILEUS

C • NOT ILEUS

O • RISK FACTOR
46
Was the defined representative sample of patients YES
assembled at a common (usually early) point in the course
of their disease)?
Was patient follow-up sufficiently long and complete? NOT
EXPLAINED
Were outcome criteria either objective or applied in a ‘blind’ YES
fashion?
If subgroups with different prognoses are identified, did adjustment YES
for important prognostic factors take place?
48
 General Validity Import Applicabil
Description ance ity

49
 General Importa Applicabil
Validity nce
Description ity

Can the results be applied to the local population? yes

Do the results of this study fit with other available yes
evidence?

50
LEVEL OF EVIDENCE

Valid

2
Applicable
B

51
52