MORNING REPORT

Tuesday, April 3rd, 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
 DOCTORS ON DUTY
3

Junior On Duty Madya On Duty

dr. Lilik Fitriana dr. Anies Mediressia
dr. M. Taufik Perwira dr. Firman Syahbana
W.
Madya II On Duty Emergency on duty:
dr. Muhammad Aulia dr. Erika Agustina
dr. Yuyun Romaria

Onsite Supervisor Supervisor On Duty

dr. RM Indra, Sp.A(K) dr. Msy Rita Dewi,

Sp.A (K), MARS
 CO-ASSISTANT ON DUTY
4

IKA – B IKA – C
Femmy, S.Ked
Andini, S.Ked Hawari, S.Ked
Atikah, S.Ked Annisa, S.Ked

ER Neonatal Ward

Sarah, S.Ked Mareta, S.Ked

Kms Afif S.Ked Esti Yolanda,
S.Ked
 TOTAL NUMBER OF INPATIENTS
5
 NEW PATIENTS BEFORE ON DUTY
6
No Identity Diagnose Box
.
1 Difha Cahya Neutropenia Fever + anemia Hemato onkologi
Putra/LK/11 + NHL + hipokalemia
tahun
2 M Ziham / boy / 11 Steroid Resisten on Neprhotic Syndrome Nephrologi
tahun + sindrome dyspepsia syndrome +
respiratory distress due to susp acidosis
dd/ pneumonia

3 Muhammad Evans syndrome Hemato onkologi

Febriansyah/Bo
y/6 yo

4 Sindi Roda / boy / 4 yo Paraparese inferior due to susp SGB Neuropediatric

5 M. Ulinnuha / boy / 7 Dyspepsia oro Endoscopy Gastroenterohepat

yo ology

6 Fikri Fadli Fahm / boy Chronic Osteomielitis regio cruris dextra

7 yo
 NEW PATIENTS BEFORE ON DUTY
7

No Identity Diagnose Severit Division

. y
1 Diego Acute nephritic syndrome + 3 Still et ER
Anemia + Impetigo crustose (nephrology)
Januarto / boy /
5 yo
2 Ananda Zahra Gum bleeding ec 3 Still et ER transit
N/Girl/9 years trombositopenia (Hematooncology)
Pansitopenia ec aplastic anemia
Acute rhinitis
 Normal

Appearance Breathing
normal normal

Circulation
normal

Breathing :
Appearance:
NCH (-), retraction (-)
T: conscious (+)
I: interaction (+)
C: consability (+)
L: look or gaze (+) Circulation:
S: cry (-) Pale (-)
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Identity : An. DJ/boy/ 5 years old
Weight : 19 kg, Length : 107 cm
Weight for age : 19/17 : 110%
Height for age : 107/110 : 97%
Weight for height : 19/17 : 110%
Nutritional Status : wellnourished
Time of Admission in ER : 05.00 PM
ANAMNESIS
Main Complaint : Swelling whole body
Aditional complain : small volume of mixturition
Present Illness History
Since 5 days before admission, patient had swelling of whole body,
abdomen and both of eyes in the morning and decreased in the
afternoon, small volume of urine, frecuency same as usual,
urine’color was dark brown, pain when mixturition (-), He also had
no defecation (-), and had low grade fever (+), not measured yet,
not given by medicine, headache (-), blurr vision (-), vomit (-),
cough (-), cold (-), shortness of breath (-), still want eat and drink
as usual. He brought to RS Muba Bayung Lincir and got some
examination, was diagnosed as nephritic syndrome and suggested
9
to refer to advanced hospital.
Past Illness History
•Lab examination (01/04/2018): Hb 9,4; leukocytes 12.800;
platelets 269.000; cholesterol 246.
•Urine: cloudy; BJ 1,005; ph 6; protein (+); erythrocytes 4-5;
leukocytes 7-8; epithelium 1-2.
•History of swollen body before was denied.
•History of reccurent upper respiratory tract infection (+)
•History of body weight decreasing was denied.
•History of rash in skin was denied.
•There was an ulcer on the right foot, approximately since 3 weeks
ago, recurent (+), pus (+).

History of family illness

•History of same complaint was denied

Food recall
•Rice 3x1 portion, consist of meat, fish, green vegetable, and also
milk 2x1

10
 Laboratory Finding (1/4/2018)
Result Normal
11
Haematology :
Haemoglobin 9.4 11.3 – 14.1 g/dL
WBC 12.8 4.5 – 13.5 103/mm3
PLT 269 217 – 497 103/µL
Ht 29 37-41 %
RBC 3.55

MCV 81.6
MCH 26.4
MCHC 32.2
Cholesterol 246
 Laboratory Finding (1/4/2018)

12 Parameter Result Parameter Result

Urinalysis
Color Cloudy yellow Nitrit negative
Bilirubin/urob Negative Lekosit negative
ilinogen esterase
BJ 1.005 Epitel 1-2
PH 6.0 Lekosit 7-8

Protein +1 Eritrosit 4-5

Glucosa Negative Crystal negative
Keton Negative
Blood +2
Past Illness History
General Condition :
Sense : E4M6V5
BP : 130/90 mmHg
HR : 85 x/m
Pulse : 85 x/m (content and tense was good)
Temp : 36,7°C
RR : 28x/minute
Specific Condition
Head : Conjunctiva Anemic (+), Sclera Icteric (-), edema palpebra (+),
sunken eye (-)
Chest : Simmetrical, retraction (-)
Heart : Normal 1st and 2nd heart sound, murmur (-) Gallop (-)
Lung : Vesicular (+) normal, rales (-/-), wheezing (-/-)
Stomach : Convex, suple, hepar and lien unpalpable, bowel
sound (+), shifting
dullness(+)
Extremity : Pale (+), minimal tibial edema (+/+)

Persentil sistole diastole

50 95 53
90 108 68
95 112 72
13
99 120 80
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14
 PROBLEMS ASSESMENT
1.Swelling Acute nephritic syndrome ec
2.Hypercholesterolemia GNAPS dd/nephrotic syndrome
3.Hypertension gr 2 + Anemia + Impetigo crustose
4.Proteinuria
5.Hematuria
6.Oliguria
7.Anemia
8.Impetigo crustose
DIFFERENTIAL DIAGNOSE WORKING DIAGNOSIS
Acute nephritic syndrome Acute nephritic syndrome +
ec GNAPS dd/nephrotic Anemia + Impetigo crustose
syndrome
+ Anemia ec dd/ iron deficiency
chronic disease
+ Impetigo crustose

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PLAN EXAMINATION THERAPY
•CBC, CRP, ASTO, C3-C4, •Stopper
renal function, •Bedrest
electrolyte, albumin, •Po. Amoxicillin 3x250mg
protein, liver function, •Inj. Furosemide 2x20mg
•Blood culture •Po. Captopril 2x6,25mg
•Urinalisis •Fluid balance : I = O +
•USG TUG IWL

DIET MONITORING
Calori = 90 x 19 =1710 Vital sign
ccal
rice 3x1 portion
Protein 10 gram/d

ADMISSION Nephrology
 Laboratory Finding in RSMH
(3/4/2018)
Result Normal
17
Haematology :
Haemoglobin 9.5 11.3 – 14.1 g/dL
WBC 13.6 4.5 – 13.5 103/mm3
PLT 301 217 – 497 103/µL
Ht 26 37-41 %
Diff count 0/1/68/23/8 0-1/1-6/50- %
70/20-40/2-8

CRP 20 <5
SGOT 18 0 - 38 ug/dL
SGPT 6 112 -136 ug/dL
Protein total 6.4 6.0-8.0 gr/dL
albumin 2.7 3.8 – 5.4 gr/dL
 Laboratory Finding (3/4/2018)
18 Result Normal

AU 16.2 <8.4 mg/dl

Ureum 178 16.6 – 48,5 mg/dL
Creatinin 7.00 0,24 – 0,41 Mg/dl
LFG 3.46
(decrease
96,4%)
Ca 7.0 8,4 – 10,4 mEq/L
Corrected Ca
7.64
Na 139 135-155 mEq/L
K 5.2 3.5-5.5 mEq/L
Cl 109 96-106 mEq/L
Total 196 < 200 Mg/dL
cholesterol
 Laboratory Finding (3/4/2018)
Result Normal
19
C3 complement 18.00 90-100 Mg/dL
C4 complement 7.20 10-40 Mg/dL
CRP 20 <5
ASTO Negative

Conclusion : anemia + increasing of CRP + hypocomplement +

AKI st.failure + hiperuricemia + hipocalsemia
Plan :
-Observation oxygenation disturbance
-Drip albumin 20% 100cc

Balance diuresis per 12h (06.00 pm – 06.00am)

I = 200
O = 50
IWL = 181.25
B = - 31.25
D = 0.2cc/kgBW/hour
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THANK
YOU
 AZN/Girl/9 years
SUBJECTIVE
Chief complaint
Gum bleeding
Additional complaint

Present Illness History

Since 1 day before admission, patient had gum bleeding, nose
bleeding (-), cough (-), cold (-), fever (-), then patient brought to RS
Hermina. The results of blood examination showed hb 8,3;
leukocytes 2.400; platelets 2.000. Patient referred to ER RSMH for
platelets transfusion.

History of the disease: aplastic anemia

Medical history: folic acid 1x1mg, lactulose 2x10cc
OBJECTIVE
General Condition
 Sense : Compos mentis
 anemic (-) cyanosis (-) icteric (-)
 Pulse : 120 bpm, (content and tense was good)
 Blood pressure : 110/80mmHg
 T : 38o C
 RR : 20 x/m (regular)
 Weight : 40 kg Height : 143 cm


Specific Condition
Head : Anemic conjunctiva (+), icteric sclera (-), gum bleeding (+),
nose bleeding (-), pharyngeal hyperemic (-)
Thorax : Symmetric, retraction (-)
Lungs : Normal vesicular breathe sound, rhales (-), wheezing (-)
Heart : Normal heart sound, murmur (-), gallop (-)
Abdomen : Flat, supple, liver and spleen not palpable, normal bowel sound
Extremities : Pale (+), hematoma (+), easy bruising (+) at right superior
extremity
ASSESMENT
 Gum bleeding ec trombositopenia
 Pansitopenia ec aplastic anemia
 Acute rhinitis

PLANNING
 Paracetamol 3x500mg po
 Cefadroxyl 3x500mg po
 Tranexamat acid 3x500mg po
 Lactulose 2x10cc po
 Folic acid 1x1 po