MORNING REPORT

Tuesday Morning, September 25, 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
 FAKULTAS KEDOKTERAN
UNIVERSITAS SRIWIJAYA
VISI
MENJADI PROGRAM STUDI KEDOKTERAN TERKEMUKA DI ASIA TENGGARA
YANG BERBASIS PENDIDIKAN, PENELITIAN DAN PELAYANAN DI BIDANG
KEDOKTERAN PADA TAHUN 2022
MISI
1. MENYELENGGARAKAN PENDIDIKAN KEDOKTERAN SESUAI DENGAN
STANDAR INTERNASIONAL BERBASIS KEARIFAN LOKAL
2. MENYELENGGARAKAN PENELITIAN DI BIDANG ILMU KEDOKTERAN
YANG BERKUALITAS YANG DAPAT DIPUBLIKASIKAN DITINGKAT
NASIONAL DALAM PENGEMBANGAN ILMU DAN KEPENTINGAN
MASYARAKAT
3. MENYELENGGARAKAN PENGABDIAN DAN PELAYANAN
KEDOKTERAN BERBASIS AKDEMIK YANG BERSTANDAR
INTERNASIONAL SEBAGAI PUSAT RUJUKAN DI TINGKAT REGIONAL
DAN NASIONAL
4. MELAKSANAKAN SISTEM MENAJEMEN DAN TATAKELOLA YANG
EFEKTIF, EFISIEN, DAN BERKUALITAS
 DOCTORS ON DUTY
4

Junior On Duty Madya On Duty

dr. Marselya Ulfa dr. MSY Mutiara
Dr. Rezky Endah Putri A Dr. Lilik Fitriana

Madya II On Duty Emergency on duty:

dr. Ading Rohadi dr. Teti Hendrayani
Dr. Annisa Permatasari

Onsite Supervisor Supervisor On Duty

dr. Fifi Sofiah, SpA (K) dr. Afifa Ramadanti, SpA(K)
 CO-ASSISTANT ON DUTY
5

IKA – B IKA – C
Rizky, S.Ked Rismitha, S.Ked
Puji, S.Ked Rasyid, S.Ked
Devi, S.Ked Eko, S.Ked

ER Neonatal Ward
Fahmi, S.Ked Fellani, S.Ked
Ria, S.Ked Indah, S.Ked
An. By. Ny. Sri Wahyuni/girl/ 26 days old

Appearance Breathing
Normal Abnormal

Appearance:
T: alert (-)
PAT Respiratory & Breathing
:
Nasal flare (+),
I: interaction (-) Circulation retraction (+), gasping
C: consability (-) Normal (-)
L: look or gaze (-)
S: speech or cry (-)

Circulation:
Pale (-),mottled skin (-), cyanotic (-)

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Identity : By. Ny. Sri Wahyuni/Girl/26 days old

Time of Admission in IGD : 01.50 AM

ANAMNESIS
Main Complaint : shortness of breath
Additional complain : cough
Present Illness History

Since + 4 days before admission, patient had suffered cough and flu, fever (-), vomit (-)
shortness of breath (-), cyanosis (-), pale (-), the baby still got breast feeding with the usual
amount milk, the mother didnt seek for any treatment. Since + 1 day before admission, patient
had suffered shortness of breath, not affected by weather, activity and position, cough (+), flu
(+), fever (-), vomit (-), cyanosis (-), pale (-), seizure (-) the baby still got breast-feeding but
decrease in amount, the baby didn’t got any formula milk. Urination and defecation as usual.
Her mother brought her into a midwife. The midwife gave her ambroxol syrup and gentamicin
syrup and told the mother to bring the baby into the hospital, the mother bring her to rs
muhammadiyah but being told that they were run out of room, and then the mother came to
RSMH without confirmation.

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Past Illness History
 The patient havent got any immunization
 The patient has exclusively breast-feeding

Family Illness History

 History of illness with the same complaint was denied
 History of contact with a person with the same complaint was denied
 History of congenital heart disease was denied
 Pastient was born from mother with G3P2A0, aterm gestational, spontaneous
delivered, helped by midwife, spontaneous crying, A/S ? Patient was born with birth
weight 2500 gram, body length 45cm, head circumference ? Injection of Vit K (+)
History of fever in pregnancy (-), history of premature rupture of membrane (-) thick
amniotic fluid (-) smell (-).
 Laboratory Finding (25/09/2018) RSMH
9
9

Result Normal Value Unit

Hemoglobin 15,2 13,4-19,8 g/dL

Eritrosit 4,78 4,32-4,98 106/m3

Leukosit 21,4 6,0-17,5 103/mm3
Hematokrit 44 37-41 %
Trombosit 482 217-497 103/uL
ESR 13 <20 mm/h
Diff Count Still waiting for
the result
IT Ratio Still waiting for
the result
BSS 85 50-90 Mg/dl
CRP kuantitatif 10 <5 mg/dL
 Body Weight : 3,1 kg
Length : 46 cm
Head circumference: 33 cm
WAZ : -2 < Z <0 (wellnourished)
HAZ : -3 < Z < -2 (stunted)
WHZ : 1< Z < 2 (wellnourished)

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 consentrated
urination
Physical Examination
General Condition : moderate activity
Heart rate : 148 times/minute
Temp : 36,5’C (aksilla)
RR : 62 times/minute
SpO2 : 93-95% with nasal canul

Specific Condition
Head : nasal flare (+) icteric sclera (-), anemic conjunctiva (-), isochoric pupil 4mm, light
reflex normal
Chest : simmetric, retraction (+) subcosta
Heart : normal 1st and 2nd heart sound, murmur (-), gallop (-)
Lung : vesiculer (+) meningkat, rales (-/-), wheezing (-/-)
Stomach : flat, supple, normal bowel sound (+) , liver and spleen lien was not palpable, full
blas (-)
Extremity : cold extremity (-), mottled skin (-) CRT 4’’, anemic (-)
Genithalia : urine catheter (-), consentrated urination
Skin : mottled skin (-), ptechie (-)

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 PROBLEMS ASSESMENT
1. Shortness of breath N: FT-AGA
2. Cough
3. Flu I: G3P2A0 aterm gestation
4. Downe Score 3 L: Spontaneous
A: Respiratory distress e.c susp
Bronchopneumonia

DIAGNOSIS/DIFFERENTIAL WORKING DIAGNOSIS

DIAGNOSIS FT-AGA + Respiratory distress e.c susp
FT-AGA + Respiratory distress e.c acute bronchopneumonia
susp acute bronchitis

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PLAN EXAMINATION THERAPY
• Rontgen Thoraks AP • O2 nasal canul 1lt/minutes
• Injection Ampicillin 3 x 80 mg IV
• Injectin Gentamicin 2 x 8 mg IV

DIET : Asi on demand MONITORING

• Vital sign

ADMISSION Neonatus
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THANK
YOU