MORNING REPORT

Disusun oleH
DEVY PUSPO WARDOYO

FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH SURAKARTA
2017
 IDENTITY
• Name : An. A
• Date of birth : 15 November 2017
• Gender : Girl
• Age : 23 months
• Address : Surakarta
• Religion : Islam
• Tribe : Java
• Date of hospitalization : 12-10-2017 (08.00)am
• Date of examination : 12-10-2017 (08.10)am
 ANAMNESIS

Chief Complaint

fever
 HISTORY OF ILLNESS
5 days before admission
• The mother said that on Monday morning, the
patient got fever (+) , fever up and down then
weighs at night, vomit (+)2x
• The defecation and urination was normal.

2 days before admission

• The complaints were still persist.
• The patient got cough (+), runny nose (+)
• The defecation and urination was normal.
 HISTORY OF ILLNESS
The day on admission
• The complaints were still persist.
• The patient got cough (+), runny nose (+)
• The defecation and urination was normal.
• The mother took her to the hospital
 HISTORY OF PAST ILLNESS

History of Seizure with fever : Denied

History of seizure without fever : Denied
History of dengue fever : Denied
History of typhoid fever : Denied
History of asma : Denied
History of allergy with food and drug : Denied
History of hospitalization : Denied

Conclusion: there is no history of past illness that related to

current illness
 HISTORY OF ILLNESS IN FAMILY

History of Similiar symptom : Denied

History of Seizure with fever : Denied
History of Asma : Denied
History of Allergy : Denied
History of Hypertention : Denied
History of Diabetes Mellitus : Denied

Conclusion: there is no history of illness in family that correlated with

patient’s disease
 PEDIGREE

NY.E 37yo BP.H 40yo

An.B 10 1yo
23 mo

Conclusion : there is hereditary illness

 HISTORY OF PREGNANCY

Mother with P2A0 was pregnant at 36years old. Mother began to

check pregnancy and routinely control to the obstetrician.
During pregnancy the mother does feel nausea, vomiting and
dizziness that interfere with daily activity. During pregnancy
there was no history of trauma, bleeding, infection, and
hypertensi.

Conclusion: history of pregnancy was good

 HISTORY OF DELIVERY

The mother gave birth to her baby assisted by a midwife with a sectio
caesaria indication oligohidromnion. 40 weeks pregnancy age, baby born
with body weight 3100 grams and body lenght 49cm . At the time of birth
the baby cry.

Conclusion : history of delivery was not good

HISTORY OF POST DELIVERY

The baby girl cry and no blue skin color. She got milk on first day,
urination and defecation less than 24 hours

Conclusion : history of post delivery was good

 HISTORY OF ENVIRONMENT

The patient lives at home with both parents and

grandparents. Ceramic-floored patient houses, walled walls, tile
roofs, adequate ventilation, bathrooms in the house, water source
from well water.
A few days before the patient was treated in the hospital,
neighbors and the family have not experienced same complaints.

Conclusion : there is no a risk factors for transmitted disease

 HISTORY OF VACCINE

• At that time of examination, the mother did not bring

KMS.
• According to her mother, the patient had received the
basic vaccine (kemenkes) completely. Vaccinations
were obtained at the primary care (puskesmas).

Conclusion : history of vaccine was good based on

KEMENKES
 HISTORY OF FEEDING
Age 0 – 6 months
• Exclusive Breastmilk

Age 6-10 months

• Breastmilk + porridge of rice 1-2x small dishes per day but not finished

Age 10-11 months

• Breastmilk + rice, vegetables, fish, egg, 1-2x small dishes per day but not finished

Conclusion : history of feeding  quality and quantity was not good



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• The answer “Yes” = 10 poin

Conclusion : Development history is according to age

 Physical Examination
 General appearance
General appearance : Fussy
Awareness : Alert

 Vital Sign
Blood Pressure :-
Heart rate : 132x/ menit
Respiratory Rate : 24x/ menit
Temperature : 38,3º C
 Nutrisional status

WEIGHT : 10.0 kg Height :83 .0 cm Hc :47 .0 cm

-Weight // age : < 0 SD (normo weight)

-Height // age : <-2SD SD (stunted)
-Weight // Lenght : > 0 SD (gizi baik)

Conclusion : The patient's nutritional status is not good

d
 Physical examination
• Skin examination
Color : brown
Skin turgor: <2 sec (good)
Moisture: moist
Edema (-) does not exist

• Conclusion : the examination of skin was normal

22
 PEMERIKSAAN KUSUS
Neck : No enlargement of lymph node and no increase jugular venous
Chest : Symetrical, retraction (-), miss the motion (-).
• Heart
Inspeksi : The ictus cordis is not visible
Palpasi : Ictus cordis not strong lift
Perkusi : sound “redup”
Auskultasi : sound of cor I-II reguler, murmur (-)
• Lung
Inspeksi : Symetricasl, retraction (-)
Palpasi : Symetrical on both sides
Perkusi : Sonor
Auskultasi : Vesicular (+/+) normal, rhonchi (-/-), wheezing (-/-)

Conclusion : there was neck,heart,lung is normal limits

Stomach : Inspeksi : Distended (-), sikatrik (-), purpura (-)
Auskultasi : Peristaltik (+)
Perkusi : Timpani (+)
Palpasi : Soft, abnormal mass (-), tenderness (-),
skin turgor good
Liver : normal
Spleen : normal

Conclusion : There was no abnormality

 Ekstermitas

•Warm of acral
•Perfusion of tissue is good

•Cyanosis is not found in the 4 extremities

•No udem is found in the extremities

CRT <2 sec
Turgor is good

Conclusion : the examination of extremity was normal limits

25
 PHYSICAL EXAMINATION

Head : Normochephal
Eyes : CA (-/-), SI (-/-), edema palpebra (-/-) ,
Nose : Sekret (-), epistaksis (-), nafas cuping hidung (-/-)
Ears : Sekret (-)
Mouth : Stomatitis (-), perdarahan gusi (-), sianosis (-), faring sulit dievaluasi
Skin : Warna sawo matang, Pucat (-), Ikterik (-), Sianosis (-), turgor kulit (< 2
detik)
Lymph nodes : Tidak didapatkan pembesaran limfonodi
Muscle : Tidak didapatkan kelemahan, atrofi, maupun nyeri otot
Bone : Tidak didapatkan deformitas tulang
Joints : Gerakan bebas
Extremities : CRT < 2 Second, sianosis (-/-), edema (-/-), akral hangat(+/+), petekie (-
/-)

Conclusion: normal limits

 LABORATORIUM EXAMINATION
Routine blood examination
PEMERIKSAAN HASIL SATUAN NORMAL
 Leukosit 3,30 10ˆ3/ul 4.5 – 12.50
 Eritrosit 5.37H jt/ul 3.8 – 5.20
 Hemoglobin 12.4 g/dl 11.7 – 14.5
 Hematokrit 35.9 % 35.0 – 47.0
 Trombosit 165 10ˆ3/ul 217 – 497
 Netrofil 26.8 L % 50 - 70
 Limfosit 52.9 H % 25 – 40
 Monosit 21.5 H % 2–8
 MCV 68.4 L fl 74.0 – 102.0
 MCH 22.3 pg 21.0 – 34.0
 MCHC 34.5 g/dl 30.0 – 32.8

Result : Routine blood examination there were leukopenia, trombositopeni,

neutropenia, limfositosis and monositosis
 RESUME
ANAMNESIS
Vomitus (+) 2x/day
Fever (+)
Cough (+)
Runny nose (+)

Physical examination
Heart Rate, Respiratory rate and temperature were normal.
Head : sunken eyes (+/+)
Thorax : neck, heart, Lung is normal limits

Laboratorium
Leukopenia, trombositopenia, neutropenia, Limfositosis and
monositosis
 ASSESMENT

Rinofaringitis akut
DD
morbili
ISK
DD
DHF
 ACTION PLAN
• Observasi vital sign

DIAGNOSIS ENFORCEMENT PLAN

• Routine blood examination

 Terapi

kebutuhan energi : soft rice, eggs, meat, fish,

Kalori : 10x 98= 980kkal vegetables a day 3 times a large plate of food
Protein : 10x 1.5 = 15 g was always finished.
Cairan : 10x 125= 1250ml  rute oral
Kebutuhan energi : 676.2 kalori/hari dibagi
dalam 3 kali waktu makan

kebutuhan energi :
Nasi putih 100 gram: 176kalori
Bayam rebus 100 gr : 23 kalori
1 butir telur rebus : 154 kalori
1 ayam sayap: 295 kalori
Pepaya 100 gram : 46 kalori
 ` PLAN
THERAPY

• Ondancentron : 0.1 mg/kgBB/kali x 10kg = 1 mg/8jam

• Paracetamol 15mgx10kg=150mg syrp/8j

 FOLLOW UP
TANGGAL SOA PLANNING
12-10- -S/on the morning, fever, cough (+)still persist, runny nose • P/ paracetamol
2017 (+), shortness of breath (-) 15mgx10kg=150
Jam O/ mg syrp/8j
08.00 - KU : Compos Mentis
- RR : 26 x/menit
- S : 38.4
- Kepala: konjunctiva anemis (-/-), sklera ikterik (-/-)
- Tho: retraksi (-), wheezing (-/-)
- Abd : peristaltik (+), timpani (+)

A/ rinofaringitis akut
DD
DD,DHF, ISK, Morbili
 FOLLOW UP
TANGGAL SOA PLANNING
12-10- -S/on the morning, fever (-), recovery cough and runny P/paracetamol 150mg
2017 nose, shortness of breath (-) syrp/8j
Jam O/
07.00 - KU : Compos Mentis
- RR : 24 x/menit
- S : 36.6
- Kepala: konjunctiva anemis (-/-), sklera ikterik (-/-)
- Tho: retraksi (-), stridor(-/-), wheezing (-/-)
- Abd : peristaltik (+), timpani (+)

A/ rinofaringitis akut
THANK YOU