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MORNING REPORT

Friday , January 25th 2019


Visi Misi FK UNSRI
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 VISI FK UNSRI
 Menjadi Fakultas Kedokteran Terkemuka di Asia Tenggara yang Berbasis
Pendidikan, Penelitian dan Pelayanan di Bidang Ilmu Kedokteran dan
Kesehatan pada Tahun 2025
Visi Misi FK UNSRI
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 MISI FK UNSRI
 Menyelenggarakan dan mengembangkan pendidikan di bidang Ilmu
Kedokteran dan Kesehatan sesuai dengan standar internasional berbasis
kearifan lokal
 Menyelenggarakan dan mengembangkan penelitian di bidang Ilmu
Kedokteran dan Kesehatan yang berkualitas sehingga dapat dikenali dan
diaplikasikan dalam pengembangan ilmu di tingkat nasional dan
internasional
 Menyelenggarakan dan mengembangkan pengabdian dan pelayanan
kepada masyarakat sebagai pusat rujukan di bidang Ilmu Kedokteran dan
Kesehatan
 Menyelenggarakan dan mengembangkan mutu sistem manajemen dan tata
kelola yang efisien dan berkualitas
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. M. Riefky dr. Yusardi
Dr. Tessa R dr. Rahman

Madya II On Duty Emergency on duty:


dr. Avyandita M dr. Dewi Rahmawati S
dr. Msy Mutiara

Onsite Supervisor Supervisor On Duty


Dr.Afifa Ramadanti, Sp.A(K) dr. Azwar Aruf, Sp.A, M.Sc
CO-ASSISTANT ON DUTY

Jaga IKA – B Jaga IKA – C


Rini Astika, S.Ked Putri Arini, S.Ked

Jaga IGD Jaga Neonatus


Ade Indah P.S, S.Ked Marini RG, S.Ked
NEW PATIENTS DURING ON DUTY
No. Identity Diagnose/ Severity Division
Differential Diagnose Level
1. Jaky F/12 do/boy FT AGA + Respiratory distress 3 Neonatology
ec Bronkopneumonia + CHD
asianotik ec susp. PDA dd/ VSD
+ multiple anomali congenital +
dehydration mild-moderate+
hypoglycemia
2. By. Ny. Siti PT AGA + low birth weight + 3 Neonatology
Fatimah/4 do/boy opthalmia gonorrhea
neonatorum
NORMAL

NORMAL

NORMAL

CRT<3

NORMAL

NORMAL

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ANAMNESIS
Identity : By. Mrs. SF/ boy / 4 days old
Weight : 2100 gr
Height : 43 cm
Time of Admission in IGD: 11.30 PM in ward : PM
Main Complaint : Eye discharge
Additional Complaint : red and swellen eyes
Present Illness History
Eye discharge since day 1 before admission (after born). Initially from the right eye
and spread to the other eye. The discharges are yellow, purulent, and more all the
time. The eyes are very red and the lid swelling. The baby can’t open his eyes.
There are no fever, no shortness of breath, no cough and cold, no arthritis. The baby
suckle and cry strongly.
His mother always clean the discharges with cotton bud/wet tissue/warm water and
the discharge will appear again after 3 hours. The discharge is more when the baby
is crying. His parents bring the baby to the doctor and have recommend taken to ER
RSMH.

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History of labor:
Patient was born spontaneously from 24 years old mother G2P1A0,
crying spontaneously, apgar score (?), birth weigh 2200gr, birth length
(?), head circumference (?), history of premature rupture membrane (-),
foul smelling liqour (-), maternal fever (-). History of vitamin K injection
(+). History of eye cream (-)

History of pregnant:
Preterm-appropriate gestational age 9 (34 weeks). History of infection
during pregnancy (-), hypertension (-), diabetes mellitus (-), thyroid
disease (-), history of taking drugs and herbs (-), history radiation (-).

History of past medication:


-
History of the parents
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 Father  have pain when he pee, and there was


pus. History of change partners sex (+)
 Mother  have vaginal discharge before pregnant
and have more at 6 months of pregnant. The
discharge was white like milk, fishy odor and itchy.
History of immunization

Basic Immunization
Hepatitis B 0 -
BCG -
DPT 1 - DPT 2 - DPT 3 -
Hepatitis B 1 - Hepatitis B 2 - Hepatitis B 3 -
Hib 1 - Hib 2 - Hib 3 -
Polio 1 - Polio 2 - Polio 3 -
Measles - Polio 4 -

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Physical Examination
General Condition :

Height : 43 cm Activity : active Anemic : (-)


Weight : 2,1 kg Sucking Reflex : normal Cyanotic : (-)
HR : 142 x/m Cry : normal Dyspnea : (-)
Temp : 36.8’C Tonus. : normal Icteric : (-)
RR : 50 x/m
SpO2 : 99%
Specific Condition
Head : nasal flare (-), icteric sclera (-), anemic conjunctiva (-), discharge (+) purulent
bilateral, edema lid bilateral (+), hyperemis conjungtiva (+)
Chest : symmetrical, retraction (-).
Heart : normal 1st and 2nd heart sound, murmur (-), gallop (-).
Lung : vesicular inceased, crackles (-/-), wheezing (-/-).
Stomach : flat, supple, liver and spleen unpalpable, bowel sound (+) normal.
Extremity : warm extremity (+), CRT <3’’.

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PROBLEMS ASSESSMENT
1. Eye discharge Preterm-Appropriate gestational age +
2. Red and swollen eye low birth weight + opthalmia gonorrhea
3. No imunization neonatorum
4. Preterm

DIAGNOSIS / DIFFERENTIAL DIAGNOSIS WORKING DIAGNOSIS


Preterm-Appropriate gestational age + low Preterm-Appropriate gestational age +
birth weight + low birth weight + opthalmia gonorrhea
neonatorum

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PLAN EXAMINATION THERAPY
Routine blood count, ESR, IVFD D10% 1/5 NS 7cc/hour
CRP, I/T Ratio Aminofusin 5% 4.6 cc/hour IV
Blood glucose Ampisilin 3x70mg iv
BNO 2 position Ceftazidime 3x140 mg iv
Surgery assestment Metronidazole 2 x20mg iv
NGT decompression

MONITORING DIET
Observation of vital sign NPO

ADMISSION Neonatology

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Laboratory Finding (08/12/2018)
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Result Normal Result unit


Haematology :
Haemoglobin 11.3 – 14.1 g/dL
WBC 6.0 – 17.5 103/mm3
RBC 4.40 – 4.48 106/m3
PLT 217-497 103/µL
Ht 37 – 41 %
Diff Count 0-1/1-6/50- %
70/20-40/2-8
ESR <20 mm/h

IT ratio

CRP <5 mg/dl