MORNING REPORT

Saturday Night, June 5th 2021

 PROGRAM PENDIDIKAN
ILMU KESEHATAN ANAK
VISI
MENJADI PUSAT PENDIDIKAN DOKTER SPESIALIS ANAK YANG MAMPU BERSAING
TINGKAT NASIONAL YANG MAUPUN ASIA TENGGARA DI BIDANG PENDIDIKAN,
PENELITIAN DAN PENGABDIAN MASYARAKAY TAHUN 2025
MISI
1. MENYELENGGARAKAN PENDIDIKAN KEDOKTERAN BERBASIS KOMPETENSI
BERSTANDAR NASIONAL, MUTAKHIR, PROFESIONAL, DAN BERLANDASKAN
KEILMUAN BERBASIS BUKTI DAN KEARIFAN LOKAL
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
5. MENYELENGGARAKAN PENGELOLAAN BAGIAN KESEHATAN ANAK YANG
TRANSARAN DAN AKUNTABEL YANG MENJAMIN PENINGKATAN KUALITAS
BERKELANJUTAN
 DOCTORS ON DUTY
3

Junior On Duty Madya On Duty

dr. Alessandri Perdana Putra dr. Michael Septian Sihombing dr.

dr. Isnalisa Fatimatuzzahra

Madya II On Duty Emergency on duty:

dr. Rezky Endah Puteri dr. Nurmega Kurnia S

dr. Arif Budiman

Onsite Supervisor afternoon: Inward Supervisor

dr. Desti Handayani, Sp.A(K)
dr. Hertanti Indah Lestari, Sp.A(K)
Onsite Supervisor night :
dr. Hasri Salwan, Sp.A(K)
 CO-ASSISTANT ON DUTY
4

IKA – B IKA – C
, SKed , Sked

ER Neonatal Ward
, SKed ,SKed
 TOTAL NUMBER OF INPATIENTS
Box Patients New Patients New Patients During Discharge Patient with Deceased Total Note
Before On Duty On Duty Patients Problems
Gastroenterologi 3 0 0 0 0 0 3
Nutrition & metabolic disease 1 0 0 0 0 0 1
Endocrine 2 0 0 0 0 0 2
5 Infection 1 0 0 0 0 0 1
Respirology 1 0 0 0 0 0 1
Al- Immunology 6 0 0 0 0 0 6
Neurology 12 0 0 0 0 0 12
Nephrology 10 0 0 0 0 0 10
Cardiology 6 0 0 0 0 0 6
Hemato-Oncology 15 0 0 0 0 0 15
Neonatology 8 0 0 0 0 0 8
NICU 9 0 0 0 0 0 9
Rooming-in 1 0 1 0 0 0 2
PICU 3 0 0 0 0 0 3
PICU-HDU 1 0 1 0 0 0 2
PICU-Borang 5 0 0 0 0 0 5
Ogan/ Rawas/Musi 9/2/0 0/0/0 0/0/0 0/0/0 0/0/0 0/0/0 9/2/0
Triase Sekunder P2-ISO IGD 2 0 0 0 0 0 2
Total 122 0 2 0 0 0 124
 NEW PATIENTS BEFORE ON
DUTY
No. Identity Diagnose/ Severity Division
Differential Diagnose Level
 NEW PATIENTS DURING ON
DUTY
No. Identity Diagnose/ Severity Division
Differential Diagnose Level
1 K/ F /9 years old Dangue Shock Syndrome + Obesity 1 ERIA
2. By.Ny.S / F / 0 days old FT-AGA 4 PERINATOLOGI
(Rawat Gabung)
 PATIENTS STILL ON ER
8

No. Identity Diagnose/ Severity Division Time Admission

Differential Diagnose Level
1. R/ M / 2 Years Old ALL HR + Trombocytopenia + 1 PIE Collaboration 4th June 2021
Febrile with Neutropenia + Hematooncology (ISO ER) (09.00 AM)
Heordeolum palpebra superior et
inferior Dextra + Covid -19
Infection
2. Z/ M / 4 Months Old Acute Diarhea with Mild-Moderate 2 PIE Collaboration 5th June 2021
Dehydration + Pneumonia + Respirology (12.30 AM)
Suspected Covid-19 Infection ( Secondary TRIAGE ER)
 PROBLEM DURING ON DUTY
9

No Identity Diagnoses/ Division

Problem
 DECEASED PATIENT
10

No Identity Diagnoses/ Division

Cause Of Death
 Consult PIE
11

No. Identity Diagnose Box

 Patient Identification
12

Name : KAR
Date of birth : 03/08/2011
Sex : female
Date of admission : 05/06/2021
Address : P city
Referral : With Refferal
 Pediatric Assessment Triangle
13

AABB
Appearance: Work Of Breathing :

LL
MAA
Respiratory Rate (44 tpm)

NNO
T: Look lethargic and sleepy

ORR
I: interactiveness (+) Nasal flaring (-)

ORR
NNO

M
retraction (-)

MAA
C: consolable (+)

AABB
L: eye contact (+) Abnormal airway sound (-)

LL
S: speech (+) Abnormal Breathing
position (-)
ABNORMAL
Abormal Abnorma
Abormal l
Circulation:
Pale (-) mottling (+), cyanosis (-) Intervention :
- 2 Line vein Acsess
Conclusion: - Nasal cannule 2 Lpm
Shock - Hook to monitor
•
AIRWAY
Identification
Primary Survey
• Patent and BREATHING
maintainable airway • Identification :
RR 44 x/min,
SpO2 96 % (room air)
Nasal flare (-) Circulation
• Intervention : Retraction (-)
Vesicular sound on left basal • Identification:
Maintenance of patency
airway with positioning . decreased • HR : 160 bpm (regular)
Pulse : unalpable in radialis, weak
Disability
palpable in brachialis
• Intervention : pale (+)
• Oxygen nasal cannule 2 Lpm Somnolen,
CRT 5 second
BP : 70/50 mmHg GCS E3M6V5 (14), Exposure
• Evaluation : Haemorrhage (+), petichie pupillary response,
• Evaluation : RR 34 x/min, equal (+)
SpO2 99 % Last urination was 4 hour before
Snoring (-) admission (+), volume and colour of Temp 35.4 C
Gurgling (-) Nasal flare (-)
Conclusion : Airway Clear Retraction (-) urine not clear.
• Intervention: Hematoma (-)
Vesicular sound on left basal Cold in fourth extrimites -Observasion of mental Exanthem (-)
decreased
• Intervention :
status petichie (+)
Conclusion : Breathing Clear
• Fluid Resucitation 20 mL /
• Intervention:
KgBW in 15-20 minutes
evaluate
temperature
• Evaluation :
• GCS E3M6V5 (14) changes

• Evaluation :
Afebrile
Time Identification Intervention Time Evaluation
21.00 Sense : Somnolen IVFD RL 20 - 21.15 1st line 21.30 :
HR : 160 bpm (regular) mL/KgBW access found : Sense : Somnolen
Pulse : unalpable in radialis, weak palpable in brachialis, (1000 mL ) 500 mL of RL HR : 125 bpm (regular)
pale (+), CRT 5 second, BP : 70/50 mmHg (21.15-21.30) Pulse : unalpable in radialis, weak palpable in brachialis,
Haemorrhage (-) mottling (+) pale (+), CRT 4 second, mottling (+)
Last urination was 4 hour before admission (+), volume BP : 90/70 mmHg
and colour of urine not clear. Cold in fourth extrimites (+)
Cold in fourth extrimites Urine Production (-)
Kesan : Shock Hipovolemik, susp. efusi pleura kanan Vesicular sound on left basal decreased

21.30 21.30 : Finishing IVFD RL 20 21. 30 : 21.40 :

Sense : Somnolen mL/KgBW 500 mL of RL Sense : Compos mentis
HR : 125 bpm (regular) (2) HR : 128 bpm (regular)
Pulse : unalpable in radialis, weak palpable in (21.30-21.40) Pulse : Palpable in radialis (content and volume was enough)
brachialis, pale (+), CRT 4 second CRT 3 second, mottling (-)
BP : 90/70 mmHg BP : 120/90 mmHg (p95)
Cold in fourth extrimites (+) Cold in fourth extrimites (+)
Urine Production (-) Urine Production (-)
Vesicular sound on left basal decreased Vesicular sound on left basal decreased
Kesan : Shock Hipovolemik belum teratasi, Respon
terhadap pemberian cairan, susp. efusi pleura kanan

21.40 Sense : Somnolen IVFD RL 10 21. 45 : 21.55 :

HR : 116 bpm (regular) mL/KgBW 500 mL of RL Sense : Compos mentis
Pulse : pable in radialis (content and volume was (3) HR : 116 bpm (regular)
enough) CRT 3 second (21.45-21.55) Pulse : palpable in radialis (contente and volume was enough)
BP : 120/88 mmHg CRT < 2 second
Cold in fourth extrimites (+) BP : 120/80 mmHg (p95)
Urine Production (-) Cold in fourth extrimites (-)
Kesan : Shock Hipovolemik belum teratasi, Respon Urine Production (-)
terhadap pemberian cairan, susp. efusi pleura kanan Vesicular sound on left basal decreased
Time Identification Intervention Time Evaluation
21.55 Sense : Compos mentis IVFD RL 87 mL/Jam - 21. 55 22.30 :
HR : 116 bpm (regular) (maintenance) 500 mL of RL Sense : Compos mentis
Pulse : pable in radialis (contente and volume was (3)
enough) CRT < 3 second HR : 116 bpm (regular)
(21.55-22.30) Pulse : Palpable radialis
BP : 120/80 mmHg (p95)
Cold in fourth extrimites (-) ( volume and content was enough)
Urine Production (-) BP : 120/80 mmHg
Vesicular sound on left basal decreased Cold in fourth extrimites (-)
Kesan : Shock Hipovolemik teratasi, respon Urine Production (-)
pemberian cairan, susp. efusi pleura kanan
Vesicular sound on left basal decreased
22.30 2.30 : IVFD RL 87 mL/Jam 23.00 21.40 :
Sense : Compos mentis (maintenance) Sense : Compos mentis
HR : 116 bpm (regular) Rontgen Thorax HR : 114 bpm (regular)
Pulse : Palpable radialis Urine catheter insertion Pulse : Palpable radialis
( volume and content was enough) ( parents refuse the ( volume and content was enough)
BP : 120/77 mmHg plan) BP : 120/80 mmHg
Cold in fourth extrimites (-) Cold in fourth extrimites (-)
Urine Production (-) Urine Production (-)
Vesicular sound on left basal decreased Vesicular sound on left basal decreased
Kesan : Shock Hipovolemik teratasi, Respon Educate to insert Urine catheter
terhadap pemberian cairan , susp. efusi pleura kanan
Kesan : Hemodynamic status was stable 
Transportable to transfer to HDU Ward.
Evaluate sign of excessive rehydration
Vital sign on the first Vital sign after 20 Vital sign after 10
time coming mL /Kgbb resuscitation mL /Kgbb
resuscitation
ANAMNESIS
Time of Admission in ER : 21.00 AM Inward admission: 02.30 AM
Chief complain : Look sleepy
Additional complain : Cold extrimities
Present Illness History
Four days before admission (09.00 AM) , patient had high fever, didn’t measured. The
fever happened almost all day long, the temperature decreased after given antipyretic
drug. The temprature then increased again. There was no cough, no runny nose, and sore
throat. There was no complained of ottopain or tootache. There was no complained of
dysuria or hesitation when urinate on this patient. Volume and frequency of urine still
normal. Defecation was normal too. There was a complained of nausea and decreased of
appetite. There was no complained of loss of taste sensation or smells.
On the third day of sick, the fever still present, with the same pattern. The family then
bring the patient to the doctors and did laboratory examination. The result was : Hb 14.8
Leuco 6.100 Tro 185.000 Ht 42. Based on this laboratory result, the patient just educate
to take some rest at home and consume some vitamins.
19

10 Hours before admission the patient oftenly look sleepy. There was no more
fever present. There was petichie on her both upper arm. There was no other
bleeding manifestation happened like gum bleeding, nose bleeding or bloody stool
during this period of sick. There was a complained of nausea and followed with
vomit. Frequency was two times, with small amount. The patient not eager to
drink or eat. There was complained of cold on her fourth extrimities. Cold
Sweating all over her body. There was no complained of stomach ache. The patient
didn’t feel any shortness of breath, but the parent relized that her breath look
faster then before. The parents then went to pediatricians and assesst as DSS
Reffer to ER RSMH. Her last urination was 5 Hours before admission, with unclear
colour or amount.
Past Illness History :
• No history of travelling in this two weeks.
• No History of family member or neighborhood with Dangue Fever Infection.
• No History of Dangue Fever Before

Famillial History :
• No history of prolong cough
• No history of travelling in this two weeks.
• No history of confirmed COVID 19

Growth and development

• Normal Growth and development
Physical Examination TDS TDD

BP : 70/50 mmHg BW: 51 kg P5 94 53

HR: 160 x/min BH : 150 cm P50 106 64
RR: 44 x/min P90 117 73
Temp: 35.8℃ P95 121 75
SpO2 98% nasal cannule 2 Lpm
P99 127 79
Specific Condition
P99+5 132 84
HEENT : oedema palpebra superior et inferior (-/-), anemic
conjungtiva (-/-), icteric sclera (-/-), PERRLA,(pupil equal round reactive to light
accomodation), nasal flaring (-), discharge from OAE (-/-), tonsil T1-T1,
hyperemia (-)
Thorax : I : static- dynamic : symmetric, retraction (-), ictus cordis (-)
P: stemfremitus dekstra = sinistra, ictus cordis not palpable
P: dullness in basal hemithorax dextra , sonor in basal hemithorx sinistra
A: vesicular decreased on basal hemithoraks dextra, rales (-), wheezing (-/-)
Cor : regular regularly rhythm, murmur (-), gallop (-)
Abdomen : I : Convex
P: Supple, Liver palpable 2 cm under costae, and 1 cm under xiphoideus, Lien not
palpable, No tenderness.
P: shifting dullness (-), abdominal tenderness (-)
A : bowel sound (+) normal
Specific Condition
Extremities : Cold, CRT 5’, pitting type of oedema (-), mottling (+)

Genitalia/ : Normal
Anus
Puberty : P2M2
status
23

BB : 51 Kg TB : 150 cm Usia : 9 tahun

8 bulan JK : Perempuan
BB/U : 51/31 : > P95
TB/U : 150/137 : > P95
BB/TB : 51/ 40 x 100 % : 127,5%
Usia Tinggi : 12 tahun
BMI : 22.6  P90-95  Overweight
 Pediatric Early Warning Score (PEWS)
24

0
13
25
 PROBLEMS ASSESSMENT
• Sign of Shock / Circulatory Failure Dangue Shock Syndrome + Overweight
• ( Somnolen, cold extrimities, unpalpable
pulse on radialis, narrowing pulse pressure,
Last urination 4 Hours before Admission, )
• Fever Day -4
• Spontaneous Bleeding manifestation
( petichie)
• Mild Respiratory Distress
• Decreasing left basal vesicular sound
• Trombocytopenia
• Overweight

DIAGNOSIS/ DIFFERENTIAL DIAGNOSIS WORKING DIAGNOSIS

Dangue Shock Syndrome + Overweight Dangue Shock Syndrome + Overweight

26
 PLAN EXAMINATION THERAPY
Hb, leucocyte, Trombocyte,Ht, Albumin, A : Siffing Postion
Ureum, Creatinine, Electrolyte B : Nasal cannule 2 Lpm
Chest X-ray C : Fluid resucitation 20 mL/KgBw (RL)
D:
Pharmacology :
 Paracetamol 500 mh (po) if temp > 38,5 C

MONITORING DIET
Balance diuresis each hours Kebutuhan Kalori :
Vital sign each hours 47 x 51 : 2397 Kkal ( BB actual)
Sign of Fluid Overload : 47 x 40 : 1880 Kkal ( BB Ideal)
Edema palpebra, Acites, Efusi Pleura Rute : Oral
Sign of Hemmorage : Formula :
Abdominal Pain, Black stool, Nasi Biasa 3x1 porsi : 1500 Kkal
Full Cream : 2 x 250 mL : 335 Kkal
Snack : 2 x 100 Kkal : 200 Kkal
Total : 2035 Kkal
ADMISSION HDU

27
 Laboratory Finding (05/06/2021)

28

Result Normal
Haemoglobin 19,8 12,0 -14,4 g/dl
Leucocyte 4,21 4,5-13,5 103/mm3
Hematokrit 58 % 37-41 %
Trombosit 28 217-497 103/µl
Diff Count 0/0/56/37/7 0-1/1-6/50-70/20-40/2-8 %
MCV 83,0 81-95 fl
MCH 29 25-29 pg
MCHC 34 29-31 g/dL
RDW-CV 13,70 % 11-15 %
LED 4 < 20

Trombocytopenia
 Radiologic Finding (05/06/2021)
29
30

THANK
YOU