Morning Report

Ilmu Kesehatan Anak

Patient’s Identity
• Name : An. M
• Age : 25 days
• Sex : Female
• Adress : Patrang, Jember
• Ethnic : Javanese
• Religion : Islam
• Hospitalized : December 12th 2018
• Examination date : December 12th 2018
• Medical record number : 237503

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Parents’s Identity
Father Mother
Name Mr. S Mrs. M

Age 44 years old 35 years old

Address Patrang, Jember Patrang, Jember

Ethnic Javanese Javanese

Religion Islam Islam

Education SHS SHS

Job Wiraswasta IRT

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Anamnesis
Heteroanamnesis is carried out to
mother at Room A RSDS on the
first day of hospitalized.

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History of Present Illness:
Chief complain:
cold
History of Present Illness:
H1MRS:
The patient was taken to the RSDS IGD (12/12/2018) with complaints
of cold and snoring. The patient experiences cold since 3 days ago
with fever. According to the patient's parents, the patient does not
complain of pain or discharge of fluid in the ear, vomiting (-), BAB (+)
with diarrhea and BAK (+).

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 symptom H1SMRS H2MRS
• seizure - -
• Cough - -
• cold + +
• Fever + +
• Loss of - -
consciousness
• BAB + +
• BAK + +

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Past Illness:
There isn’t past illness

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History of Medication:
 Pulveres from doctor

History of Family Disease:

● Father has allergic rhinitis

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 Family tree

72 th 65 th 60 th 61 th

44 th
44 35 th

Keterangan:

: laki-laki
1
12 th month : perempuan

Conclusion: there is an : pasien

allergic disease

9 : allergic
History of Gestational:
The patient was born to mother G4P1001A200. At present, the mother is 35 years
old and at the time of pregnancy the mother is 35 years old. Pregnancy up to 9
months. Mothers of patients routinely check their pregnancies at the posyandu,
midwives and health centers from the age of 3 months. During pregnancy the
patient's mother does not experience high blood pressure, no seizures, no excessive
vomiting, no fever, no congestion, no bleeding through the birth canal. The quantity
and quality of food consumed is good, eat 3-4 times a day, a portion of rice,
vegetables and side dishes.

Conclusion: History of gestational and nutrition is good

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History of Labory
Children born to mothers G4P1001A200 spontaneously helped by Midwives in the
hospital. 9 months gestational age, first head born, clear amniotic water, baby crying,
birth weight 3510 grams, birth length 52 cm. There was no trauma at birth, no
disability, no finger abnormalities and umbilical cord care was carried out by
midwives.

History after Labory:

The cord is maintained, the third day breaks, there is no bleeding in
the umbilical cord, the baby does not appear yellow and the baby
can drink well, the patient drink ASI + formula (SGM) when the
produce of ASI is low.
Conclusion : history of labory and post labory is good
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History of Imunitation:

Conclusion : the history of imunitation is complete

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 History of nutrition :
Age Food

0-1 months Breast milk every 3-4 hours or when the child feels thirsty +
formula when mother doesn’t produce milk

Conclusion : history of nutrition is good

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 History of
growth

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 Nutritional Status
 Born weight : 3510gram Nutritional Status According to the CDC :
 BBS / BBI x 100% =
 Current weight : 4,1 kg 4,1 / 4,5 x 100% = 91,1%
 Ideal weight CDC : 4,5 kg
 Born high : 52cm
 Current high : 58 cm

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Developmental history :
Passive Communication
Look around : 1 months

Conclusion: developmental history according to age 16

Social Economy and Environmental
History :
Social Economy: Father works as a private worker and the mother does not work with an
income of Rp. 1,500,000.00 to 2,000,000.00 / month, to support 1 wife and 2 child.

Environmental : The patient lives with her parents and grandparents. The patient sleeps
with the patient’s parents. The patient lives in a 9m x 8m x 3m house, consisting of 2
bedrooms measuring 3m x 3m. Adequate ventilation and lighting, sources of drinking
water from well-cooked well water, have 1 bathroom, 1 kitchen, and have a toilet.
Home away from waste disposal and factories.The father of the patient is smoker.

Conclusion : socio-economic and environmental history is not good

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 Anamnesis System:

 Cerebrospinal System : febris (+), seizzure (-), loss of

consciousness(-)
 Respiratory system : cough (-), cold (+).
 Gastrointestinal system : poop (+) diarrhea
 Urogenital system : pee (+) normal
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Physical Examination
General condition Awareness
Qualitative : Compos Mentis
Special condition Quantitative : E:4 V:5 M: 6

 Vital signs
Heart rate : 144x/minutes, regular, lift
strength
Respiratory rate : 60 x/minute, regular, rhonchi -/+
Temperature : 37,40C
CRT : < 2 seconds

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Physical Examination
General Condition  Head
Size : Normocephal
Crown : flat
Special condition hair : straigth, black
Face : Facial expression is normal
Eye : Conjungtiva anemis -/-, sklera ikterik -/-, edema palpebra
(-), reflek cahaya +/+, mata cowong (-)
Nose : secret-/-, blood -/-, mukosa hiperemic (-), PCH (-)
Ear : Sekret -/-, blood -/-
mouth : Cyanosis (-)
Faring : Hyperemic (-)
Tonsil : Hyperemic (-), no enlargement appears
Neck : Simmetric (-), enlarged lymph nodes(-)

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Physical Examination
General condition  Chest
normal, simetris, retraction (-)
 Jantung
Special condition Inspeksi : Iktus kordis tidak tampak
Palpasi : Iktus kordis teraba
Perkusi : Redup
Batas kanan atas : ICS II garis parasternal dextra
Batas kanan bawah : ICS IV garis parasternal dextra
Batas kiri atas : ICS II garis parasternal sinistra
Batas kiri bawah : ICS IV garis midklavikula sinistra
Auskultasi : S1S2 tunggal reguler, ekstrasistol (-), gallop (-), murmur
(-)

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Physical Examination
 Paru
Kanan Kiri
General condition
Frontal Insp : Simetris, Retraksi (-) Insp : Simetris, Retraksi (-)
Special condition Palp : fremitus raba sde Palp : fremitus raba sde
Perk : redup Perk : redup
Ausk : Ves (+), Rho (-), Ausk : Ves (+), Rho (+), Whe
Whe (-) (-)
Dorsal Insp : Simetris, Retraksi (+) Insp : Simetris, Retraksi (+)
Palp : fremitus raba sde Palp : fremitus raba sde
Perk : redup Perk : redup
Ausk : Ves (+), Rho (-), Ausk : Ves (+), Rho (+), Whe
Whe (-) (-)

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Physical Examination
 Abdomen
General condition
Inspeksi : flat
Auskultasi : Intestinal sound (+) Normal
Special condition Perkusi : timpani
Palpasi :soepel, hepatomegali (-), splenomegali (-), asites (-)

 Extremitas
upper : akral hangat +/+, edema -/-, sianosis (-), pengecilan jaringan otot
(-), atrofi (-)
Lower : akral hangat +/+, edema -/-, sianosis (-), pengecilan jaringan otot
(-), atrofi (-)

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Physical Examination
 Anus and genitalia
General condition
Anus : normal
Genital : female, normal
Special condition

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Physical Examination
 Neurologi
General condition GCS :4-5-6
Meningeal Sign: KK (-), K (-), L (-), B1 (-), B2(-)
Nervus Kranial:
Special condition  N. III : Pupil bulat isokor, 3mm/3mm, RC +/+
 N. VII : simetris/simetris
 N. XII : simetris/simetris
Motorik:
KO 555 555 TO n n RF B +2 +2 RP(-)
555 555 n n T +2 +2
K +2 +2
A +2 +2
Sensorik : dbn
Otonom : retensi urin (-), inkontinensia urin (+) saat kejang, retensi alvi (-),
inkontinensia alvi (-)
CV : dbn

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Supporting Examination
 Chest X-ray

Conclusion : left pneumonia

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Main Diagnosis
Pneumonia

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 Kumpulan Data Kumpulan Data Diagnosis dan Rencana Terapi
Rencana
Diagnosis

Anamnesis Pemeriksaan Fisik Pneumonia • Inf D5 ¼ NS cc/24 jam

Main complain: cold KU: lemah • Inj ampisx 3x150 mg
RPS : Kes : kompos mentis(4-5-6) • Inj. Gentamicin 2x10 mg
HMRS The patient was taken to the BP : Normotensi • Nebul suprasma 3x1 resp
RSDS IGD (12/12/2018) with complaints HR :normal • Inf Sanmol k/p
of cold and snoring. The patient RR : takipneu
experiences cold since 3 days ago with Tax : hipertermi
fever. According to the patient's Head/neck :
parents, the patient does not complain anemia (-), icteris (-), sianosis
of pain or discharge of fluid in the ear, (-), dypsnea (+)
vomiting (-), BAB (+) with diarrhea and cor/ pulmo: rhonchi on left
BAK (+). pulmo
RPD : Abd : BU (+) normal, timpani ,
There isn’t past illness soepel
RPO: pulveres from doctor Ext : AH (+), OE(-)
RPK :
Fathers has allergic rhinitis

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Planning
 Diagnostik
Chest x-ray

Monitoring
vital sign, therapy respon, side effect, complication

 Education
 Explain to the patient's family about the patient's illness, cause, treatment or therapy,
complications and prognosis
 Explain to the patient's family that the illness they suffer from must receive maintenance therapy
and require compliance so that the family must monitor the patient's progress

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Prognosis

 Quo ad vitam (hidup) : dubia

ad bonam
 Quo ad functionam (fungsi) : dubia
ad bonam
 Quo ad sanationam (sembuh) : dubia
ad bonam

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THANK YOU

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