Morning Report

Sunday Morning, April 22nd 2018

MID/KRS/WWA
No Name Gender/Age Working Diagnosis
1 NFI Male, 4 years 8 DD/ - Suspected tonsillar diphtheria
. months 27 days - Streptococcal tonsillitis
1
A new patient, male, male, 4 years 8 months 27 days, address: Jl. Karya
Bersama Gg. Bersama, admitted to emergency room at 10.22 AM
Weight: 15 kg, Height: 103 cm,
W/A : -2< Z score < 0 H/A : -2 < Z score <0
W/H : -1 < Z score < 0 (well nourished)
Chief complaint : white patch on the throat
History of present illness:
- It was experienced since 1 day prior to admission, the white patch is covering
the right tonsil and seemed widening.
- Fever (-), history of low grade fever (+) since 3 days prior to admission,
shivering (-), seizure (-).
- Cough (-), History of cough (-).
- Hoarseness (-).
- Painful swallowing (+) since 1 day prior to admission.
- Neck swelling (-)
- History of contact with person who had similar symptoms (-)
- Vaccination status is complete (BCG 1 time, DPT 3 times, Hep B 4 times,
Polio 4 times, booster DPT 1 times at 18 months of age)
History of previous illness:
• The patient was referred by a pediatrician from Balai Pengobatan Marisya
due to Suspected Diphtheria

History of previous medication:

• Erythromycin, Ibuprofen, Maxprinol
Physical Examination
General status:
Alertness: CM Temperature: 36,9oC
dyspnoe (-), cyanosis (-), edema (-), icteric (-), anemis (-)

Localized status:
Head :Eye: Light reflexes (+/+), symmetric pupil Ø 3mm/3mm, pink palpebral
conjunctiva inferior (+/+)
Ear/nose: within normal limit/within normal limit
Mouth: Tonsils T2 / T2 hyperemic, white patch on the right tonsil, no
bleeding with attempt of removal
Neck : lymph node enlargement (-)
Thorax : Symmetrical chest expansion, retraction (-)
Heart rate : 100 beats/minute, regular, murmur (-) (N: 65 - 130
beats/minute)
Respiratory rate : 24 breaths/minute, regular, no rales, stridor, and
wheezing (N: 20 - 25 breath / minute)
Abdomen: firm, normal peristaltic sound, liver and spleen were not palpable
Extremities: pulse 100 bpm, full and equal pulse, regular, warm extremities,
capillary refill time (CRT) < 2 seconds
Differential diagnosis:
- Suspected tonsillar diphtheria
- Streptococcal tonsillitis

Working Diagnosis:
Suspected tonsillar diphtheria

Therapies:
• Erythromycin 4x150 mg
• Paracetamol 150 mg
• Diet MII 1550 Kcal with 30 g protein

Plans:
• Complete blood count, ECG, culture from throat and nose swab
Time Sensorium HR RR Temp Notes
(bpm) (tpm)

11.00 CM 100 24 36,9 Samples from throat and nose

were obtained

11.30 CM 103 24 36,8 Laboratory staff drew blood for

sample

12.00 CM 98 20 36,9 Patient was admitted to isolation

room