Morning Report

Saturday night, August 26th 2018

IRI/SSB/HOC
New patient of Non Infection ward at 00.15 AM,patient
FKHS, boy, 7 month, address Napa Batang Toru
BW : 6,8 kg BL : 68 cm
BW/A : -2<z<0 BL/A:-2< z<0 BL/BW: -2<z<-1

Chief complaint: Breathless

- This condition was found since 1 week before
admission, Breathless relates with activity.
- Fever (+) since 1 week before admission. Fever was
intermitten, and decreased with antipireutic drugs.
- Cough (+) since 1 week before admission.
- Pale (-), cyanotic (-).
- Micturition and defecation within normal limit
History of illness
This patient was referred from RS.Mitra Medika Sibolga
with acyanotic CHD + bronchopneumonia. Patient was
diagnosed with PDA + PFO when he was 4 years old

History of previous drugs

Ceftriaxone.inj 250 mg/12 hours, Furosemide inj 10 mg/12
hours

History of pregnancy
Patient was second child. Mother age when pregnancy 23
years old. History of previous disease such as DM (-),
hypertension (-). History of previous drugs (-)
History of delivery :
Patient was delivered via SC, aterm with GA (38-40
weeks), Birth weight: 3800 gr, unknown birth length,
baby was cyanotic and cry weakly, with unknown
APGAR score
Physical Examination
General status :
Alertness : Compos Mentis, Temperature : 36,80C
BW : 6,8 kg BL : 68 cm
BW/A : -2<z<0 BL/A:-2< z<0 BL/BW: -2<z<-1

Localized status:
Head:
Eye : Light reflexes (+/+), symmetric pupil, Ø 3mm/3mm,
pale inferior conjunctiva palpebral (-/-)
Ear/nose/mouth : within normal limit / within normal limit/
within normal limit
Thorax : Symmetrical fusiform, retraction (+) suprasternal
Heart rate : 124 beats/minute, regular, murmur (-)
(N : 110-170 bpm)
Respiratory rate : 36 breaths/minute, ronchi (-/-)
(N: 24-46 bpm)

Abdomen : Soepel, normal peristaltic movement, liver and

spleen unpalpable, normal turgor

Extremities: Pulse 124 beats/minute regular, pressure/volume

enough, warm, CRT< 2 seconds, pretibial
oedema (-), pitting oedema (-)
Echocardiography 19/6/2018
Working Diagnose
Patent Ductus Arteriosus + Persistent Foramen Ovale +
bronchopneumonia

Therapy
• O2 Nasal mask 2 lpm
• IVFD D5% NaCl 0,225% 4 cc/hours
• Furosemide 3x 7 mg
• Spironolacton 2 x 6,25 mg
Chest x-ray at Adam Malik Hospital
26/8/2018
Time Sens HR RR SaO2 Temp Additional
(bpm) (tpm) %

02.00 GCS 15 126 50 95 36.8

03.00 GCS 15 126 50 96 36.7

04.00 GCS 15 124 52 98 36.7

05.00 GCS 15 124 50 93 36.8

Thank You