MORNING REPORT

Disusun oleh:
Ria Maulindasari

FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH SURAKARTA
2018
 IDENTITY
• Name : An. M
• Date of birth : 23 February 2019
• Gender : Boy
• Age : 1 month 2 day old
• Address : Surakarta
• Date of hospitalization : 25-03-2019 (13.00)
• Date of examination : 26-03-2019 (07.00)
ANAMNESIS

Chief Complaint

Cough
 HISTORY OF ILLNESS

9 days before admission

• Cough “grok-grok”
• Rhinore (+)
• No Fever
• Dipsneu
• Normal feeding and defecation
 HISTORY OF ILLNESS

5 days before admission

• Cough “grok-grok”
• Rhinore (+)
• No fever
• Dipsneu
• Normal feeding and defecation
• His mother brought him to the puskesmas
 HISTORY OF ILLNESS

The day of admission

• Cough “grok-grok” still remains and didn’t improve

• Rhinore (+)
• No Fever
• Dipsneu (+)
• Normal feeding and defecation
• His mother brought him to PKU Solo
 HISTORY OF PAST ILLNESS

History of Seizure with fever : Denied

History of dengue fever : Denied
History of typhoid fever : Denied
History of bronkhopneumonia : Denied
History of asma : Denied
History of allergy with food and drug: Denied
History of hospitalized : Denied
History of malnutrition : Denied

• Conclusion: there is no HISTORY OF PAST ILLNESS

 HISTORY OF ILLNESS IN FAMILY

History of Anemia : Denied

History of asma : Denied
History of atopi : Denied
History of hypertention : Denied
History of Diabetes Mellitus : Denied

Conclusion: there is no HISTORY OF ILLNESS IN FAMILY

 PEDIGREE

Tn. A 47 years old Ny. N 22 years old

An. M 1 months 2 day old

Conclusion : there is no illness is inherited

 HISTORY OF PREGNANCY

Mother with P1A0 is pregnant at 21 years old. Mother began to

check pregnancy and routinely control to the doctor. During
pregnancy the mother does feel nausea, vomiting and dizziness
that interfere with daily activities. During pregnancy there is no
history of trauma, bleeding, infection, and hypertension.

Conclusion: the history of pregnancy was good

 HISTORY OF DELIVERY

The mother gave birth to her baby assisted by a obstetrician with a

cesarean delivery. 38 weeks pregnancy age, baby born with body weight
2500 grams with body length 47 cm. At the time of birth the baby cries
instantly, there is no congenital defect at birth.

Conclusion : history of delivery was good

HISTORY OF POST DELIVERY

The baby was born crying, active motion, red skin color, not blue
and not yellow skin color, got milk on first day, urination and
defecated less than 24 hours

Conclusion : history of post delivery was good

 HISTORY OF ENVIRONMENT

The patient lives at home with both parents. Ceramic-floored

patient houses, walled walls, tile roofs, adequate ventilation,
bathrooms in the house, water source from well water.

Conclusion : there is a risk factors for transmitted disease

 HISTORY OF VACCINE

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

KMS.
• Patient get the BCG, Hepatitis and Polio Vaccine

Conclusion : the history of vaccine is not complete

acording to KEMENKES
 HISTORY OF FEEDING

Age 0 - now months

• Breastmilk + formula milk

Conclusion : history of feeding from quality and quantity was not good
 HISTORY OF GROSS MOTOR

Kemampuan Umur pencapaian Range normal

Head up 90 degress Can’t 3-4 month
Sit no support Can’t 6 – 7 month
Stand holding on Can’t 6,5 – 8,5 month
Stand 2 second Can’t 9,5 – 11,5 month
Stand alone Can’t 10,5 – 13,5 month

Conclusion :Development history of Gross motor according

to age
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 HISTORY OF FINE MOTOR

Kemampuan Umur pencapaian Range normal

Reaches Can’t 4,5 – 5,5 month
Thumb – finger grasp Can’t 8,5 - 10,5 month
Scribbles Can’t 12 – 17month

4/22/2019
Conclusion :Development
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 HISTORY OF LANGUAGE
Kemampuan Umur pencapaian Range normal
Vocalizes ooo/aah 1 month 1 – 3 month
Turn to voice Can’t 3,5 – 5,5 month
Imitate speech sounds Can’t 3,5 – 9 month

Conclusion :Development history of language according to

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 HISTORY OF PERSONAL SOCIAL
Kemampuan Umur Range normal
pencapaian
Smile spontaneously 1 month 0-2month
Feed self Can’t 5 – 6,5 month
Indicate wants Can’t 7,5- 13 month
Wave bye-bye Can’t 7 – 14 month
Drink for cup Can’t 9 – 17,5 month

Conclusion :Development history of social according to age

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 History of DEVELOPMENT and
INTELLEGENT

• Conclusion: History of development and

intellegent was good
 Physical Examination
 General appearance
General appearance : alert

 Vital Sign
Blood Pressure :-
Heart rate : 124 x/ menit
Respiratory Rate : 28 x/ menit
temperature : 36,8° C
 Nutrisional status

1 month WEIGHT : 3.9 KG Length : 55 CM

-Weight // age : < 0 SD

-Length // age : > 0 SD
-Weight // Length : < SD

Conclusion : nutritional status is good

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

• Conclusion : skin examination was good

24
 PHYSICAL EXAMINATION
Neck : No enlargement of lymph node and no increase jugular venous
Chest : Simetris, retration (-), 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, bising jantung (-)
• Lung
Inspeksi : Simetris, retraksi intercostal (-/-), retraksi subcostal (-/-),
retraksi substernal (+), retraksi suprasternal (-)
Palpasi : Simetris dextra and sinistra, There is no missed breath
Perkusi : sonor
Auskultasi : Vesicular (+/+) normal, rhonki (+/+), wheezing (-/-)

Conclusion : there was a ronkhi (+/+) in lung examination

Stomach :
Inspeksi : Distensi (-), sikatrik (-), purpura (-), darm contour (-),
darm steifung (-)
Auskultasi : hiper Peristaltik (+), metalic sound (-)
Perkusi : timpani (-)
Palpasi : supel (-), acites (-), abdominal mass (-)
Liver : Hepatomegali (-)
Spleen : Splenomegali (-)

Conclusion : stomach, liver and spleen examination was good

 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 within normal limits

27
 PHYSICAL EXAMINATION

Head : Normochephal
Eyes : CA (-/-), SI (-/-), edema palpebra (-/-), light reflek (+/+)
isokor (+/+), sunken eyes(-/-),
Nose : Secret (+) purulent mucous, epistaksis (-), breath nostrills (-/-)
Ears : Secret (-), membrane hiperemis (-)
Mouth : Stomatitis (-), gingivitis (-), sianosis (-), pharynx hiperemis (+), exudate
(-), mucousa lips and mouth dry (-),
Skin : colour was white, pale (-), Ikterik (-), Sianosis (-
Lymph nodes : enlargement limfadenopathy (-)
Muscle : pharese(-), atrofi (-), myalgia (-)
Bone : deformity (-)
Joints : free movement
Extremities : CRT < 2 Second, sianosis (-/-), edema (-/-), warm akral (+/+), petekie (-
/-)

Conclusion: there is secret mucous purulent in nose and pharynx hiperemis in

mouth examination
 PEMERIKSAAN PENUNJANG (25-03-2019)
INDIKATOR NILAI RUJUKAN
Leukosit 10.6 5.50 – 18.00
Eritrosit 3.40 3.20 – 4.60
Hemoglobin 10.9 10.3 – 17.9
Hematokrit 31.7 31.0 – 59.0
Trombosit 423 217 – 497
Netrofil 14.6 L 50 – 70
Limfosit 53.6 H 25 – 40
Monosit 26.1 H 2–8
Eosinofil 5.2 H 2–4
Basofil 0.5 0–1
MCV 93.2 82.0 – 126.0
MCH 32.1 26.0 – 38.0
MCHC 34.4 25.0 – 33.0
MPV 9.1 9.0 – 13.0

Conclusion : limfositosis, monositosis, eosinofilia, neutropenia

 PEMERIKSAAN Thorax AP 25-03-2019

Result : Bronchopneumonia
 RESUME
ANAMNESIS Physical examination
Cough “grok-grok” still remains and in the lung examination there is
didn’t improve substernal retraction, ronkhi (+/+),
Rhinore (+) wheezing (-/-); nose examination any
No Fever secret mucous purulent, in mouth
Dipsneu (+) examination any pharynx hiperemis
Normal feeding and defecation
His mother brought him to PKU Solo

Laboratory test : limfositosis,

monositosis, eosinofilia, neutropenia
 ASSESMENT

Diagnosis
Bronkhopneumonia
DD : bronkitis
bronkhiolitis
 ACTION PLAN
• Observation of vital signs (temperature, frequency of
respiratory)
• Observation the fever
• Observation work of breathing
• Observation the effect of mediaction

DIAGNOSIS ENFORCEMENT PLAN

• Blood examination
• Chest X-Ray
 ` PLAN
THERAPY

• Holliday segar, fluid maintenance

• BW = 3.9 kg
• 100 x 3.6 = 390
• = 390 ml/day  po 190 ml
• Iv 200 ml  3 tpm micro
 ` PLAN
THERAPY

• Antipiretics
• Paracetamol syrup 10 mg/kgbb/times(4hours)
• 10 x 3.9 = 39 mg/4 hours = 1.3 ml /times (1 spoon of peck
120 mg/5ml)  bila demam
• Antibiotics
• Ampicilin 100mg/kgbb/day  dosis max 4mg
• 100 x 3.9 = 390 mg/day = 100 mg/6 hours

• Nebu Ventolin/ 12 jam

 Follow up
26/3/2019
S/ patients fever (-), cough (+), rhinore (+)
O/ N : 114 x/minutes
RR : 28x/minutes
T : 36,8
Rhonki +/+

A/ Bronkopneumonia

P / inf. RL 3 tpm makro

Paracetamol 1.3 ml  bila demam
Ampicilin 100 mg / 6 hours
Nebu Ventolin / 12 jam
THANK YOU