MORNING REPORT

Sunday Night, July 1st, 2018

 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
3

Junior On Duty Madya On Duty

dr. Rahman Setiawan dr. Dwi Gustiarini
dr. Septian Tri Muhari dr. Fitriani Lastari

Madya II On Duty Emergency on duty:

dr. Fandi Agriansya dr. Febrialita
dr. Evi Dewiyanti

Onsite Supervisor Supervisor On Duty

dr. Afifa Ramadanti, SpA(K) dr.
dr. Indrayady,
Atika Akbari,
Sp.A(K)
Sp.A
CO-ASSISTANT ON DUTY

Jaga IKA - B Jaga IKA - C

Eka, S.Ked Nindy, S.Ked
M. Rizki, S.Ked Ainindia, S.Ked

Jaga IRD Jaga Neonatus

Intania, S.Ked M. Ridho, S.Ked
Hilda, S.Ked
 TOTAL NUMBER OF INPATIENTS
Box Patients New Discharge Patient with Deceased Total
Patients Patients Problems
5 Gastroenterologi 10 - - - - 10
Nutrition & 1 - - - - 1
metabolic disease
Endocrine - - - - - -
Infection 2 - - - - 2
Respirology 10 - - - - 10
Al- Immunology 3 - - - - 3
Neurology 14 - - - - 14
Nephrology 8 - - - - 8
Cardiology 4 1 - - - 5
Hematology 22 - - - - 22
Neonatology 36 - - - - 36
PICU 6 - - - - 6
NICU 15 - - - - 15
Total 132 1 - - - 133
 NEW PATIENTS ON DUTY

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No Identity Diagnose / Differential Level of Box
Diagnostic Severity
1. An. Decomp Cordis ec Large PDA + 3 (Still in ER)
M.Farzan/boy/1,5 Failure to Thrive + suspect Cardiology
mo tracheomalacia
 PAT

Appearance Breathing
normal Abnormal

Circulation
normal

Respiratory & Breathing :

Appearance: NCH (+), retraction (+) subcostal
T: alert (-)
I: interaction (+)
C: consability (-)
L: look or gaze (-) Circulation:
S: speech or cry (-) Pale (-), sianosis (-)
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Identity : By. M. FZ/ Boy / 1,5 month

Time of Admission in Emergency : 01.00 PM Time of admission in ward :

ANAMNESA
Chief Complaint : Shortness of Breath
Additional complaint : Cough
Present Illness History
Since 1 day before admission, Patient have shortness of breath. Sound of breathing likely “Grok-
Grok”, Cough (+), Fever (-), Vomite (-), Choking (-) No complaint of micturition and defecation 
ER RSMH

History of Past Ilness

- Previously been treated in Cardiology Paediatric Division at RSMH with Decomp Cordis e.c
Large PDA + Bronchopneumonia + Failure To Thrive discharge on 30th June 2018.
- Therapy IVFD D5 ¼ NS 13 cc/Hour, Ampicilin 3x220 mg (8 days) iv, Gentamisin 1x20 mg
(8 days) iv, Captopril 2x2 mg PO, Furosemid 2x3 mg iv, O2 nasal 1 LPM, Diet ASI every 2
hour alternately with sufor F75 6x70 cc
- Echo date 21/6/18
- assesment : Large PDA, Stretch PFO/small secundum ASD, Mild Tricuspid regurgitation
History of Family Disease
- No History of Congenital Heart Disease in the family

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Physical Examination
General Condition : Nutrition Status
Pulse : 132 x/m Body weight : 3200 gr Anemic (-)
Temp : 36.5’C Body height : 51 cm Cyanotic (-)
RR : 58 x/m WAZ : -3 < Z < -2 SD Dyspnea (+)
SpO2 : 98% (underweight) Ikterik (-)
HAZ : < - 3SD (stunted)
WHZ : -1 s/d -2 SD (wellnourished)
FTT
Specific Condition
Head : Nasal Flare (+), Icteric Slera (-), Anemic conjungtiva (-), icteric sclera (-/-), fontanel
(flat)
Chest : symmetrical, retraction (+) Subcostal
Pulmo : Vesicular (+) normal, rales (-), wheezing (-)
Heart : Ist and 2nd Heart Sound Normal, murmur (+) Systolic ICS II LPS sinistra, gallop (-)
Stomach : flat, supple, bowel sound (+) normal, hepar 4x1 cm, lien not palpable.
Extremity : warm extremity (+), CRT < 3”
Genitalia : boy

9
 0

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 PROBLEMS ASSESSMENT
1. Shortness of breath Decomp Cordis ec Large PDA +
2. Cough Failure to Thrive + suspect
3. Large PDA Stretch PFO/small traceomalasia
secundum ASD, Mild
Tricuspid regurgitation
4. Failure to Thrive

DIFFERENTIAL DIAGNOSIS WORKING DIAGNOSIS

Decomp Cordis ec Large PDA + Decomp Cordis ec Large PDA +
Failure to Thrive + suspect Failure to Thrive + suspect
traceomalasia traceomalasia

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PLAN EXAMINATION THERAPY
- Blood routine • O2 nasal 1 L/m
• IVFD D5 ¼ NS 13 cc/hour
• Furosemide 2x3 mg PO
• Captopril 2x2 mg PO
• ASI 8x70 cc Via NGT

MONITORING DIET
• Vital Sign Formula milk 6x70 cc via NGT
• Balance and diuresis

ADMISSION
12
Cardiology
 Laboratory Finding (2 july 2018) in RSMH
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1/07/2018 Result Normal Value Unit

Haematology :
Haemoglobin 13,6 10,7-17,1 g/dL
RBC 4,25 3,75-4,95 106/mm3
WBC 9,3 6.0-17.5 103/mm3
PLT 720 217-497 103/µL
Ht 39 47-57 %
RDW-CV 19,80 11-15 %
Diff count 0/7/42/37/14 0-1/1-6/50-70/20-40/2-8 %
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THANK
YOU