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MORNING REPORT

Friday, October 27st, 2017


PROGRAM PENDIDIKAN
ILMU KESEHATAN ANAK
VISI
MENJADI PUSAT PENDIDIKAN DOKTER SPESIALIS ANAK PILIHAN DI
TINGKAT NASIONAL YANG MENGHASILKAN DOKTER SPESIALIS ANAK
YANG KOMPETEN DAN BERKUALITAS INTERNASIONAL TAHUN 2020
MISI
1. MENYELENGGARAKAN PENDIDIKAN KEDOKTERAN BERBASIS
KOMPETENSI BERSTANDAR NASIONAL, MUTAKHIR, PROFESIONAL,
DAN BERLANDASKAN KEILMUAN BERBASIS BUKTI
2. MENYELENGGARAKAN PENELITIAN KEDOKTERAN DAN KESEHATAN
YANG INOVATIF, UNGGUL, KOMPETITIF DAN BERORIENTASI PADA
PENGEMBANGAN ILMU DAN BERMANFAAT BAGI MASYARAKAT
3. MENYELENGGARAKAN PELAYANAN KESEHATAN ANAK YANG
HOLISTIK DAN KOMPREHENSIF
4. BERPERAN AKTIF DALAM PENGEMBANGAN PENDIDIKAN,
PENELITIAN KEDOKTERAN, PELAYANAN KESEHATAN ANAK DAN
PENGABDIAN MASYARAKAT
DOCTORS ON DUTY
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Junior On Duty Madya On Duty


dr. Fitriani Lastari dr. Avyandita Meirizkia
dr. Firman Syahbana dr. Herka P Putra

Madya II On Duty Emergency on duty:


dr. Yuyun Romaria dr. Yessi Seftriani
dr. Erika Astridevi

Onsite Supervisor Supervisor On Duty

dr. Rismarini, Sp.A(K) dr. Hertanti Indah Lestari, Sp.A


(K)
CO-ASSISTANT ON DUTY
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IKA – B IKA – C
Dwina, S.Ked Charita U, S.Ked
Rikka W, S.Ked George F, S.Ked

ER Neonatal Ward
M. Hadi, S.Ked Dwi Indah, S.Ked
TOTAL NUMBER OF INPATIENTS
Box Patients New Discharge Patient with Deceased Total
Patients Patients Problems
5 Gastroenterologi 6 - - - - 6
Nutrition & metabolic 2 - - - - 2
disease
Endocrine - - - - - -
Iinfection 3 - - - - 3
Respirology 8 - - - - 8
Al- Immunology 2 - - - - 2
Neurology 14 1 - - - 15
Nephrology 5 - - - - 5
Cardiology 6 - - - - 6
Hematology 48 1 - - - 48
Neonatology 23 1 - - - 24
PICU 6 - - - - 6
NICU 14 - - - - 14
Surgery 3 - - - - 3
140 - - -
NEW PATIENTS BEFORE DUTY
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No Identity Diagnose Box


1 An. Balqish / girl / TOF + atresia of pumonary+ Cardiology
5 years old Hemiparase dextra due to
Abcess Cerebri
2 An. Rafif / boy / 2 Choletasis GEH
months old
3 An. Fitria binti Sari / Anemia + Trombocytopenia due to Hematooncology
girl / 17 years old Aplastic Anemia
4 An. Natania Quratu PNET Hematooncology
aini / girl / 8 years
old
5 An. Sandi / boy / 13 Post CTR due to craniofaringoma Neuropediatry
years old
6 An Farid ß Mayor Thallasemia Hematoocology
NEW PATIENTS ON DUTY
N
7 Identity Diagnose Severity Box
o Level
1. M. Ilham Suhargani / boy / Seizure without Febrile due to Hematooncology
14 years old suspected Electrolytes Imabalance
DD/ Metastasis + Anemia +
Osteosarcoma + Undernourished +
Thrombocytopenia
2. By. Ny. Oktapia / girl /17 FT AGA + meteorismus due to Neonatalogy
days old suspected Hirschprung Disease

3 An. Salwa / girl / 9 years Decrease of Consciousness due to Neuropediatry


old suspected Meningitis Bacterialis
DECEASED PATIENT
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No. Identity Diagnose Box


1. An. MI/ girl / 14 years old / Weight : 28kg Heigth :145cm /
undernourished
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 Chief Complaint : Seizure


 Additional Compalint : Headache, pale
 History of illness :
hours before hospital admission, patient had seizure suddenly, eyes glared upward, about
1-2 second, seizure stopped itself, patient was consciousness post ictal, fever (-), headache
(+), nausea (+), vomiting (-),Defecation and urination was normal. History of injury (-),
bleeding (-)  taken treatment to RSMH
Patient had diagnosed osteosarcoma since november 2016. Patient chemotherapy routinely
according to osteosarcoma protocol. The last chemotherapy on September, 30th 2017 . the
last MRI on June 2017  malignancy appeared
 Physical Examination : anemia (+) statis neurological is within normal
 Laboratory Finding : Hb 8.2 RBC 2.69 WBC 5.4 Ht 23 PLT 256 RDW-CV 20.50 DC
0/1/81/7/11 Ca 9.3 Mg 1.17 Na 137 K 2.7
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 Diagnosis :
Seizure without Febrile due to Electrolytes Imbalances DD/ Metatastasis +
Anemia + Osteosarcoma + thrombocytopenia
 Treatment :
 O2 1lpm
 IVFD D51/2 NS gtt 12/minute (IVFD KAEN 3 B gtt 12 x/minute)
 KSR 3 x 1 tab (po)
 Inj diazepam 8.5 mg iv if seizure
 Transfusion PRC 2 x 200 cc
 Check blood routine count, electrolyte, BSS
 Diet : Rice 3 x per day, FC 3 x 200 cc
2. By. Ny OK / girl / 18 day old/ Weight : 2,9 kg Length : 50.5 cm
 Chief Complaint : flatulence
11  Add complaint : diarrhea, vomiting, jaundice
 History of illness :
Baby, female, born in the clinic, SCon indication of section caesaria 2nd times, from
mother G3P1A0, full term pregnancy, birth weight 3100 gram, birth length ?. history
of mother fever (-), history of premature membranes rupture
At 2 weeks of age, bayi had diarrhea, freq10 times per day, liquid more then
dregs, vomitting (+), frequency 10 times per day, volume was 1 tablespoons 
wasn’t take treatment.
1 days before hospital admission, baby’s stomach looked bloated, diarrhea (+),
frequency about 4-5 times per day, the dregs more than liquid, vomitting (+)
frequency 2 times, containing of milk, fever  to muhammad husein hospital
 History of Past Illness
At 2 weeks of age, baby was jaundice on the eyes and whole body, hospitalized 2
days, irradiated, then baby home.
 History of breastfeeding (+)
 Medical History : medicine concoction (drugs because high bilirubin)
 Physical Examination : mild activity, , mild sucking reflex, loud
12 crying, pulse 160 bpm SpO2 99%, Abdomen : convex, supple, BU
(+) normal
 Laboratory Finding : Hb 14.4 RBC 4.10 WBC 10.8 Ht 38 PLT 296
RDW-CV 14.80 LED 28 BT 17.57 BD 0.66 BI 16.01 Ca 10.7 Mg
2.13 Na 129 K 2.8 Cl 89 BSS 85 CRP 6 LED 28

 Diagnosis :
FT AGA + Meteorismus due to Suspected Hirschprung Disease
 Treatment :
 IVFD D101/5NS + KCl 3 meq rate 6 cc / hour

 Inj ceftazidime 3 x 150mg iv

 Abdominal 3 positions x-ray

 Check blood routine test, electrolyte, ESR, CRP, I/T ratio

 Consult to surgeon
Identity : An. SW/girl/9years old
Weight : 33 kg, Height : 130 cm
WFA: P50 – P75 (normal) HFA : P10<P<P25 (normal)
WFH : 33/28 x 100% = 114% (normal)
Interpration : overweight
Puberty Status : P1M2
Status nutritional: underweight
Time of Admission in ER : 19.00 p.m/ Time of Admission in ward : 21.00 WIB
HISTORY
Chief Complaint : unsciousness
FeverAdditional Complaint : high fever (temperature was not measure), headache
Present Illness History
Approximately 1 weeks before hospital admission, patient had high fever, up and down, more
often at night, coughing (-), runny nose (-), defecation and urination was normal. Patient wasn’t
taken treatment yet.
Approximately 3 days before hospital admission, patient still had high fever continuously,
headache (+), coughing (+), runny nose (-), vomiting (-). Patient looked often sleepy, often sleep,
delirious, seizure (-), defecation and urination was normal. Patient was taken treatment to medical
doctor, given paracetamol and vitamin but no progress.
One days before hospital admission, patient looked more weak, more often sleep, fever (+) 
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pediatrician  hospitalized at hospital
History of Past Illness
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 History of Past Illness


History of febrile seizure at 1 year of age, frequency
two times, and be hospitalized, then go home and
control

 History of medicine :
paracetamol tablet and vitamin syrup

 History of family :
history of febrile seizure in family (+), patient’s brother
and cousin
Physical Examination
General Condition :
Sens : E2M3V3
Pulse : 112x/m (I/t cukup)
Temp : 39,7’C
RR : 26 x /m
BP : 100/70 mmHg
Specific Condition
Head : nasal flare (-) icteric sclera (-) anemic conjunctiva (+/+), pharynx
hyperemia (-), pupil ishocor (+/+) Ø 3mm/3 mm
Chest : symmetrical, retraction (-)
Heart : normal 1st and 2nd heart sound, murmur (-), gallop (-)
Lung : vesicular (+) normal, rales (-/-), wheezing (-/-)
Stomach : Flat, supple, liver and lien are unpalpable, normal bowel sound (+)
Extremity : warm extremity (+), CRT < 3’’
Lympadenopathy (-)

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Neurology status Upper extremites Lower extremity
Strenght Can’t be evaluate
Movement Can’t be evaluate
Tonus eutoni eutoni
Clonus (-)
Physiology reflek Normal Normal
Phatology reflek (-) (-)
GRM (+)
Brudzinski I sign (+)
Brudzinski II (+)
Kernig sign (+)
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Respiratory Failure

Appearance Breathing N

Circulation

Breathing :
Appearance: NCH (-), retraction (-)
T: decrease of consciousness
I: interaction (+)
C: consability
L: look or gaze Circulation:
S: cry Pale (-)
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1. Decrease of consciousness
2. Headache Altered of Consciousness due to
3. High Fever suspected Infection Intracranial
4. Meningeal sign due to Meningitis Bacterial +
5. Overweight overweight

DIFFERENTIAL DIAGNOSIS WORKING DIAGNOSIS

1. Altered of Consciousness due to Altered of Consciousness due to


suspected Infection Intracranial due suspected Infection Intracranial due to
to Meningitis Bacterial + Meningitis Bacterial + overweight
overweight
2. Altered of Consciousness due to
suspected Uremic Encephalophaty+
overweight

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PLAN EXAMINATION THERAPY
 Blood routine count - IVFD D5 ½ NS gtt 12 / minute
 Blood culture - Drip Ceftriaxone 100 mg/BW/time
 Urine culture  1 x 2 gr iv
 CRP - Inj vancomycin 15 mg/BW/time 
 Lumbar puncture 4 x 500 mg iv
 Consult to Nephrology - Paracetamol 350 mg if T > 38.5 C

MONITORING DIET
Observe vital sign 1600 Cal 
Rice 3 times perday
Observe Temperature every 6 Snack 1time perday
hours
Balance and Diuresis evey 6 hours
ADMISSION Neuropediatry

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Laboratory Finding (27/10/2017)
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13/10/17 Hasil Nilai Normal Satuan

Haematology :
Haemoglobin 11.8 12.3-15.3 g/dL
WBC 11.4 4500-13000 103/mm3
PLT 78 150 - 450 103/µL
Ht 39 35 - 47 %
Diff count 0/0/74/20/6 0-1/1-6/50- %
70/20-40/2-8
ESR 21 1-15 mm/jam
BSS 79 60 -100 Mg/dl
Hasil Nilai Normal Satuan

CRP <5 <5 g/dL

Function of Renal
Ureum 169 16.6 – 48.5 mg/dL
Creatinin 3.72 0.32 – 0.59 mg/dL

Electrolytes
Calsium 9.2 8.4 – 10.8 mg/dL
Natrium 137 135 – 155 mEq/L
Kalium 4.6 3–7 mEq/L
Chloride 114 96 - 106 Mmol/L
Magnesium 3.74 1.4 – 1.7 mEq/L
WORKING DIAGNOSIS

Altered of Consciousness due to suspected Infection Intracranial


due to Meningitis Bacterial + AKI stage Failure + uremia +
oliguria +overweight
Advice from SPV of Nephrology :

 Hydration RL 20 cc/BW/ 1 hour  RL maintenance 1.5 time maintenance


 Dose adjustment Inj vancomycin  1 gram every 24 hours
 The other therapies is same with neuropediatry

PLAN EXAMINATION
Check Function of renal and Blood Gas Analysis 12 hours after rehydration
Coomb Test, BT, BD, BI, Peripher blood count
Blood and urine culture

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Laboratory Finding (28/10/2017)
12 hours after rehydration
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13/10/17 Hasil Nilai Normal Satuan

Haematology :
Haemoglobin 8.4 12.3-15.3 g/dL
RBC 3.09 4.40-4.48 106/mm3
WBC 10.5 4500-13000 103/mm3
PLT 47 217-497 103/µL
Ht 28 35 - 47 %
Diff count 0/0/74/22/4 0-1/1-6/50- %
70/20-40/2-8
ESR 6 1-15 mm/jam
Ret 0.3 0.5 – 1.5 %
CRP <5 <5 mg/L
Hasil Nilai Normal Satuan
Function of liver
Bilirubin total 0.54 0.1 – 1.0 mg/dl
Bilirubin direct 0.24 0-0.2 mg/dl
Bilirubin indirect 0.30 <0.8 mg/dl
SGOT 329 0-32 U/l
SGPT 83 0-31 U/l
Alb 3.2 3.8-5.4 g/dl
Function of Renal
Ureum 190 16.6 – 48.5 mg/dL
Creatinin 6.40 0.32 – 0.59 mg/dL

Electrolytes
Calsium 8.4 8.4 – 10.8 mg/dL
Natrium 174 135 – 155 mEq/L
Kalium 4.5 3–7 mEq/L
Chloride 145 96 - 106 Mmol/L
Magnesium 2.93 1.4 – 1.7 mEq/L
Hasil Nilai Normal Satuan
Blood Gas Analysis
FiO2 21 %
Temperature 40.1 C
pH 7.259 7.35 – 7.45
pCO2 46.1 35 - 45
pO2 54.5 83 - 108 %
Lactat 1.9
HCO3 20.8 21 - 26 Mmol/L
Total CO2 22.3 Mmol/L
BUN 77 Mmol/L
PO2/FiO2 259.4 Mmol/L
Glucose 98
Hasil Nilai Normal Satuan
Urine Routine test
Color Yellow Yellow
Appearance Clear
pH 6.0 5.0 – 6.0
BJ 1.010 1.015 – 1.025
Glucose Negative Negative
Protein Positive++ Negative
Ascorbid Acid Negative Negative
Glucosa Negative Negative
Keton Negative Negative
Blood Positive++ Negative
leucocyte 10-12 0-5 /LPB
eritrosit 4-6 0-1 /LPB
Mucous Negative Negative
Silinder Silinder granular+++
Fungi Negative Negative
Bacteria Negative Negative
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THANK
YOU