MORNING REPORT

Monday, July 23rd, 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 FAKULTAS KEDOKTERAN TERKEMUKA DI
BIDANG KEDOKTERAN DAN KESEHATAN BERPERINGKAT
100 BESAR DI ASIA PADA TAHUN 2020
1.MELAKSANAKAN DAN MENINGKATKAN KEGIATAN
PENDIDIKAN KEDOKTERANDAN KESEHATAN BERKELAS
DUNIA SERTA BERBASIS KEARIFAN LOKAL
2.MENINGKATKAN AKTIVITAS PENELITIAN BERDAYA
SAING DAN BERKUALITAS INTERNASIONAL
3.MENINGKATKAN KUALITAS DAN KUANTITAS
KEGIATAN PENGABDIAN DAN PELAYANAN KEPADA
MASYARAKAT
4.MENINGKATKAN MUTU SISTEM MANAJEMEN DAN TATA
KELOLA FAKULTAS
 DOCTORS ON DUTY
4

Junior On Duty Madya On Duty

dr. Nurmega Kurnia Saputri dr. Diah Anggraini
dr. Enggrajati dr. Lilik Fitriana

Madya II On Duty Emergency on duty:

dr. Yuyun Romaria S. dr. Febrialita
dr. Fandi Agriansyah

Onsite Supervisor Supervisor On Duty

dr. Yulia Iriani Sp.A(K) dr. Hertanti Indah Lestari,
Sp.A (K)
 CO-ASSISTANT ON DUTY
5

IKA – B
Ezi, S.Ked IKA – C
Amalia, S.Ked Annisa, S.Ked
Imam, S.Ked Stellanisa, S.ked

ER Neonatal Ward
Dena, S.Ked Essy, S.Ked
Brillia, S.Ked
 TOTAL NUMBER OF INPATIENTS
6
 NEW PATIENTS DURING ON
No. Identity DUTY
Diagnose/Differential Diagnose Severity Level Division

1 Radit Dwi TDBD grade II + anemia ec blood 3 Infection

Ramadhon/boy/8 loss
y.o.
2 Lukki Khali Al Profuse vomiting with mild- 2 Outpatient
Kasah/boy/7 m.o. moderate dehydration + obs.
Febris ec dehydration dd/ viral
infection

3 Kanaya Obs febris ec susp. Urinary Tract 3 Gastroenterol

Gitarianti/girl/11 Infection dd/ viral infection + ogy
m.o. meteorismus ec gastroenteritis
dd/ partial obstruction dd/
electrolyte imbalance +
hypothyroid + marasmus +
moderate ASD
4 By. Ny. Rien Preterm AGA + Respiratory 3 NICU
Ariska/boy/0 day distress
 NEW PATIENTS DURING ON
DUTY
No. Identity Diagnose/Differential Diagnose Severity Level Division

5 Muhammad 3 PICU
Loss of consciousness ec
Rizki/boy/16 y.o.
Intracranial haemorrhage regio
temporal dextra + anemia ec
blood loss
6 M. Abdullah/boy/2 Mild Capitis trauma (GCS 15) + 3 Still in ER
y.o. vomitus
DECEASED PATIENT
No. Identity Diagnose Box
An.RDR/boy/8 years old PAT

Appearance
Breathing Normal
Normal

Circulation
Abnormal

Respiratory & Breathing :

Appearace: Nasal flare (-), retraction (-)
T: alert (+)
I: interaction (+)
C: consability (+)
L: look or gaze (+) Circulation:
S: speech or cry (+) Pallor (+), CRT < 3”
10
 2

11
Identity : An.RDR/boy/8 years old

Time of Admission in IGD : 17.15 PM , Time admission in pediatric ward : 21.00 PM

ANAMNESIS
Main Complaint : nose bleeding
Additional complain : fever, cough

Present Illness History

4 days before admission, patient had suffered from low grade fever (not measured),
cough (+) with phlegm, cold (-), nausea (-), vomit (-), stomache (-), nose bleed (-),
red-spot in skin (-). Urine with blood (-), black stool (-). Patient was given with
Bodrex ½ tab when fever.
12 hours before admission, patient had nose bleed (+), low grade fever (+),
stomache (+), nausea (+), vomit (+), frequent 2x, consist of food and drink eaten, @
¼ glass. Projectile vomitus (-), Red-spot in skin (+), Urine with blood (-), black stool
(-), cough (+) with phlegm. Patient then brought to Internist. Patient was given
drugs for gastritis and fever. Lab result: Hb 9,1 ; Leukocyte 11,5 ; Ht 27 ;
Thrombocyte 17
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Present Illness History
 History of prolonged fever was denied
 History of illness with the same complaint was denied
 History of pale before was denied
 History of Dengue Haemorrhagic Fever in the neighbourhood (+)

Family Illness History

 History of illness with the same complaint was denied
Physical Examination
Weight : 19 kgs height 114 cm
Weight for age : < percentile 5
Height for age : < percentile 5
Weight for height : 95%
Nutritional Status : FTT

General Condition :
Sense : E4M6V5
BP : 100/60 mmHg
HR : 84 times/minute
Pulse : 84 x/m (content and tense was good)
RR : 24 time/minute (reguler)
Temp : 37,1’C
SpO2 : 97%

Specific Condition
Head : Nasal flare (-), conjungtiva anemis (+/+), blood clot cavum nasi sinistra (+),
rhagaden (+)
Chest : Symmetrical, retraction (-)
Heart : Normal 1st and 2nd heart sound, murmur (-) Gallop (-)
Lung : Vesicular breath sound (+) normal, ronkhi (-/-), wheezing (-/-)
Stomach : flat, supple, hepar slightly palpable, non palpable spleen, epigastric pain (-),
normal bowel sound (+) normal
Extremity : warm extremity (+), CRT < 3”, spontaneous ptechie (+)
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 PROBLEMS ASSESMENT
1.Nose bleeding Susp. Dengue Haemorrhagic Fever
2.Fever
3.Stomache Anemia ec blood loss + FTT
4.Anemia
5.Thrombocytopenia
6.FTT

DIAGNOSIS/DIFFERENTIAL WORKING DIAGNOSIS

DIAGNOSIS Susp. Dengue Haemorrhagic Fever
Dengue Haemorrhagic Fever dd/ Dengue + Anemia ec blood loss + FTT
Fever dd/ Immune Thrombocytopenia
Purpura + viral infection +
Anemia ec blood loss dd/ defisiensi Fe
dd/ micronutrient deficiency dd/ chronic
disease + FTT

15
PLAN EXAMINATION THERAPY
•Complete blood count, blood •IVFD RL gtt 10 x/min macro (40cc/hr)
smear, reticulocyte, •Paracetamol 3 x 250 mg PO if T ≥ 38,5oC
•NS1, IgM dengue, IgG
dengue

DIET MONITORING
oral • Vital sign
• Bleeding
• Temperature/6 hours
• Balance diuresis/6 hours

ADMISSION Infection
 Laboratory Finding (24/07/2018) RSMH
14/07/2018 Result Normal Value Unit

Haematology :
Haemoglobin 8,7 11.3 – 14.1 g/dL
RBC 3,68 4.40 – 4.48 106/mm3
WBC 10,8 4.5 – 13.5 103/mm3
Ht 26 37-41
PLT 12 217 – 497x 103 /µL
Diff count 0/0/48/38/14 0-1/1-6/50-70/20-40/2-8 %
MCV 70,1 81 – 95
MCH 24 25 – 29
MCHC 34 29 – 31

17
 Laboratory Finding (14/07/2018) RSMH
14/07/2018 Result Normal Value Unit

IgM dengue Negative

IgG dengue Negative

NS1 Ag Negative

SGOT 1129 0 – 38

SGPT 294 0 – 41

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THANK
YOU