MORNING REPORT

Saturday, February 14th, 2019

 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. Stefani Gunawan dr. Rian Narulita
dr. Sahala Iriawan dr. Novalina S.

Madya II On Duty Emergency on duty:

dr. Rini Gitasari dr. Herka Pratama Putra
dr. Maria Lydwina

Onsite Supervisor morning Supervisor On Duty

dr. Dian P.S, SpA(K) dr.Eka Intan, Sp.A(K)
Onsite Supervisor Afternoon
Dr.Indrayady, Sp.A(K)
 CO-ASSISTANT ON DUTY
4

IKA – B IKA – C
Riswan, S.Ked Yuni, S.Ked
Angela, S.Ked Syauqi, S.Ked
Nada, S.Ked Yuana, S.Ked

ER Neonatal Ward
Rani, S.Ked Feisal, S.Ked
Leo, S.Ked Nauval, S.Ked
 TOTAL NUMBER OF INPATIENTS
Box Patients New Discharge Patient with Deceased Total
Patients Patients Problems
5 Gastroenterologi 9 - - - - 9
Nutrition & metabolic disease 2 - - - - 2

Endocrine 1 - - - - 1
Infection 3 1 - - - 3
Respirology 6 - - - - 7
Al- Immunology 4 - - - - 4
Neurology 9 1 - - - 10
Nephrology 5 1 - - - 5
Cardiology 5 2 - - - 5
Hemato-Oncology 23 - - - - 23
Neonatology 21 2 - - - 21
PICU 4 - - - - 4
NICU 13 - - - - 13
Total 105 7 - - - 112
 NEW PATIENTS DURING ON
No
DUTY
Identity Diagnose/ Severity Division
. Differential Diagnose Level

1 By. Ny. R /girl/ 4 H.O Respiratory Distress DS 4 ec HMD dd 3 Neonatology

BP
2 An. F.S/girl/3 yo Fever without seizure ec Susp 3 Neuropediatry
Epilepsy + CP spastic quadripleqic
3 An.J.S/Boy/15 Y.O PJR 3 Kardiologi

4 An.A.J/Boy/3Y.O Mild Decomp cordis e.c ASD 3 Kardiologi

Secundum + Pneumonia
5 By.T.A/Girl/4. D.O Respiratory Distress DS 2 ec BP dd 3 Neonatology
aspiration pneumonia +clinical sepsis
6 An.M.I/Boy/9 Y.O Herpes zoster + All SR 3 Hemato-Oncology

7. An. S/Girl/12 Y.O Edema e.c susp Nefritis lupus + SLE 3 Nephrology
+AIHA
 DECEASED PATIENT
7

No. Identity Diagnose Box

 Identity : FS/ 3 years old

Appearance
normal Breathing
abnormal

Normal Circulation

Appearance:
T: normal tone (+) Breathing :
I: interaction (+) NCH (-), retraction (-)
C: irritable (-), consolable (+)
L: look or gaze (+) Circulation:
S: cry (+) Pale (-) mottling (-)

CNS /metabolic
8 disturbances (-)
ANAMNESIS
Identity : FS/ 3 years old

Time of Admission in ER : 12.00 pm Time of Admission in ward: 15.00 pm

Chief complain : Seizure
Additional complain :

Present Illness History

Since 1 Hours before admission patients started experienced tonic clonic, on both
hands and feet. Frequency were 1 times, duration 30 minutes (the times between house
and hospital approximately 30 minutes) the patient while seizure was not given any
medication and was taken to hospital right away. In ER the patient still in seizure
conditions and was given diazepam rectal 5mg 2 times but the seizure did not stop, and
the patient got diazepam intravena but sthe seizure still did not stop then the patient we
loading with fenitoin and the seizure stop. The parents said there were no any fever, no
cogh or runny nose before the seizure start. The parents also said that before the seizure
start, the patient was still asleep so the patient had not taken the seizure medication for
morning.
The patient was already diagnosed with Cerebral palsy since 1 month old and start
developed seizure since 2 years old and already got routine seizure medication valproic
acid 2x3ml
Ilness History
the patient born from G1P0A) 40 weeks of pregnancy, spontaneous birth assisted by
midwives in hospital, after birth tha patient did not cry and looked bluish all over the
body, then hospitalized in Bari Hospital for 1 month.
Patient was diagnosed with Cerebral Palsy 1 month old.since the body was stiff.
The patient start to develops seizure since 2 Y.O
Medication History
Valproic Acid 2 x 3 ml
Physical Examination
Sens: Under influence of drug BW: 9 kg height: 85 cm Anemic (-)
HR:110 x/min W/A: <-3SD Cyanosis (-)
RR: 30 x/min H/A: <-3SD Dypsnea (-)
Temp:36,8 W/H: -3SD<z<-2SD Icterus (-)
SpO2 room air 99% Head Circumference:
44.4 cm(<-2SD):
microcephaly

Specific
Condition
HEENT : Nasal flaring (-), anemic conjunctiva (-), icteric sclera (-), petekie, subconjunctiva bleeding (-)
Micocephaly,Pupil pin point and not reacted with light

Thorax : simetric, Retraction (-)

Lung : vesiculer normal, rales (-), wheezing (-)

Cor Regular regularly rhythm, murmur (-), gallop (-)

Abdomen Round, shifting dullness (-), normal bowel sound, unpalpable lien and liver

Extremities : warm, CRT <3’

Genitalia/ : Normal
Anus
 Neurological State
12
RA LA RL LL
Movement Difficult to Difficult to Difficult to Difficult to
assest assest assest assest
Strength Difficult to Difficult to Difficult to Difficult to
assest assest assest assest
Tonus Hypertoni Hypertoni
Physiologic normal normal
Reflex

Pathologic No No
Reflex

Klonus yes yes

GRM -
 0

13
 PROBLEMS ASSESSMENT
Seizure
Fever Status Epilepticus ec Epilepsy +
Cerebral Palsy Cerebral Palsy spastic type
Failure to thrive quadriplegic + failure to thrive
History diagnosed with epilepsy

DIFFERENTIAL DIAGNOSIS WORKING DIAGNOSIS

Status epilepticus ec Epilepsy +

Cerebral Palsy spastic type
quadriplegic + failure to thrive

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 PLAN EXAMINATION THERAPY
 CBC, ESR, CRP quantitatif Phenitoin Loading 180 mg in D5% 30cc
 EEG Inj Phenitoin maintenance 2 x 30 mg iv
Valproic Acid 2 x 3.5 ml (40mg/Bw/day)

MONITORING DIET
Degree of consciousness Via NGT
Work of breathing 9 (110-120) : 990-1080Kkal
temperature MC 1,2 8x100cc

ADMISSION Neuropediatry

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 Laboratory Finding
22/08/2018 Result Normal Value Unit
Haemoglobin 12.1 12 – 14,4 g/dL

RBC 4.15 4,75-4,85 106/mm3

WBC 20.10 4,5-13,5 103/mm3
Ht 37 36-42 %
PLT 392 217 – 497x 103 /µL
MCV 81.9 75-87 fL
MCH 28 25-31 pg
MCHC 34 33-35 g/dL
ESR 45 <20 mm/h
Diff count 0/0/22/74/2 0-1/1-6/50-70/20-40/2-8 %

16
 Laboratory Finding (28/12/2018) RSMH
17 21/08/2018 Result Normal Value Unit
BSS 109 50-90 mg/dL

Ca 9.1 8.4-10.4 mg/dL

Na 146 138 mg/dL
K 3.9 3-7 mg/dL
Cl 110 96-106 mg/dL
Mg 2.20 1.6-2.6 mg/dL

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THANK
YOU