MORNING REPORT

Tuesday, March 07th 2023

 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. Salahuddin Alvayuby dr. Marlinawaty
dr. Farissa Utami dr. Krypton Rakehalu Karnadjaja

Madya II On Duty Emergency on duty:

dr. Rieska Yunika Machyar dr. Septian Tri Muhari
dr. Riyantono Putra

Onsite Supervisor Inward Supervisor

dr. Denny Salvera Yosy, dr. Moretta Damayanti,
Sp.A(K), M.Kes Sp.A(K), M.Kes
 CO-ASSISTANT ON DUTY
4

IKA – B IKA – C
-
-

IGD
PICU -
-
 TOTAL NUMBER OF INPATIENTS
5

Box Patients New Disharge Patients Patient with Deceased Total

Patients Problems
Gastroenterologi 7 0 0 0 0 7
Nutrition & metabolic disease 6 0 0 0 0 6
Endocrine 3 0 0 0 0 3
Infection 3 0 0 0 0 3
Respirology 13 0 0 0 0 13
Al- Immunology 9 0 0 0 0 9
Neurology 23 0 0 0 0 23
Nephrology 7 0 0 0 0 7
Cardiology 5 1 0 0 0 6
Hemato-Oncology 32 0 0 0 0 32
Neonatology 15 1 0 0 0 16
NICU 15 0 0 0 0 15
PICU-MUSI—LAIS- HDU 5-7-1-1 1-0-0-1 0 0 0-0-0-0 16
OGAN-RAWAS 0-0 0 0 0 0 0
MUSI COVID 0 0 0 0 0 0
STILL ER-Out Patient 0-0 0-0 0 0 0 2

Total 161 4 0 0 0 165

 NEW PATIENTS BEFORE ON
No. Identity
DUTY
Diagnose/ Severity Division
Differential Diagnose Level
1. MR/M/13 y.o Vomite without dehydration + CML + 3 Hemato-
anemia + thrombocytopenia oncology
 NEW PATIENTS DURING ON
DUTY
Identity Diagnose/ Severity Division
Differential Diagnose Level
1. AA/F/ 3 y.o Decomp. Cordis ross score 3 ec 3 Cardiology
large PDA + small ASD + Mild
TR + mild pulmonary
hypertension + Diarrhea without
dehydration
2. DA/F/ 8 y.o Woundehiscence grade 3 + susp 3 Pediatric Surgery
fistula enterokutan post laparatomi ERIA
eksplorasi + appendektomi
(6/2/2023) + hiponatremia +
hipokalemia
3. MPF/F/ 20 d.o FT-AGA + clinically sepsis + 3 Neuro surgery
ruptur meningocele Neonatology
4. ASA/M/ 16 y.o DSS + decomp. cordis ec 2 ERIA
perimyocarditis dd/PJR + Acute
Limb ischemic stage 1 ec
thrombosis in situ dd/ embolism
 PATIENT STILL ON ER
Identity Diagnose/ Severity Division Time
Differential Diagnose Level Admission
 PROBLEM DURING ON DUTY
9

No Identity Diagnoses/ Division

Problem
 DECEASED PATIENT
10

No Identity Diagnoses/ Division

Cause Of Death
 Patient Identification
11

Name : MPF
Date of birth : February, 19th 2023
Age : 20 days old
Sex : Female
Date of admission : March, 07th 2023
Address : Curup
Referral : RSUD Curup
 98 mg/dL

36,8 C

Normal

CRT 2”

Within normal

Adequate

12
ANAMNESIS
Identity: MPF/female/20 days old
Time of Admission in ER : 01.00 AM, Time of Admission in Ward : 04.00 AM
Main Complain : rupture of lump on lower back
Additional Complain : hypoactive
Present Illness History
A female baby was born spontaneous delivery helped by midwife from G1P0A0 mother of aterm gestational
age. The baby was crying immediately after birth, APGAR score (?), BBW 3100 gr, BBL 48 cm. History of
premature rupture of membrane (-), foul smelling amniotic fluid (-), maternal fever (-). Vitamin K injection
(+).
After the baby born, the midwife noted there was a mass on the back of the baby and was suspected with
spina bifida, the lump size likely orange fruit. The baby was planned to control to hospital. But since 7 hours
before hospital admission in curup, the lump was ruptured, and clear liquid comes out. The baby looked
crying in pain. There was no weakness of suckling. There was no fever. There was no dyspneu. Three days
in curup hospital patient give intravena fluid and antibiotic ceftazidime. The patient then referal to RSMH
for further management. Patient had CT scan without contrast, M Yunus Bengkulu Hospital, 23/2/2023
Impression: Defect in the vertebrae Th-9 Sacrum that extends to the subcutis in the thoracolumbal area (at
the level of the vertebrae Th9-L3) accompanied by herniated structures in it with a component of the
hypodense lesion ec spina bifida with suspected meningocele

History of maternal pregnancy:

Mother routinely controlled once a month to midwife. Mother doesnt have history hypertension, and DM.
She was given multivitamin. No history of consuming other certain medication during pregnancy. No
history of vaginal bleeding during pregnancy. No history of seizure before.
13
Physical Examination
Activity : hypoactive Weight : 2,5 kg Anemic (-)
Sucking reflex : moderate Length : 49 cm Cyanosis (-)
Cry : moderate Head circumference : 34 cm Dyspnea (-)
HR: 120 x/min
(normocephaly) Icterus (-)
RR: 40 x/min
Temp: 36.6℃ Blood Sugar 98 mg/dL
room air SpO2 98-99%

Specific
Condition
HEENT : Nasal flaring (-), anemic conjunctiva (-), icteric sclera (-), normocephaly
atraumatic), PERRLA,(pupil equal round reactive to light accomodation),
dismorphic face (-), flat fontanella.
Thorax : simetric, retraction (-).
Lung : vesiculer normal, rales (-), wheezing (-), grunting (-)
Cor : Regular rhythm, murmur (-), gallop (-)
Abdomen : flat, bowel sound (+) normal, liver and spleen not palpable
Back : mass in the back diameter 5x4cm, with colour same with around, firm,
immobile, rupture from the center, produce yellowish liquid.
Extremities : warm, CRT <3”, eutoni
Genitalia/ : female genitalia, anus (+), faeces (+) fistule (-)
15
16
PROBLEMS ASSESSMENT
1. Rupture of lump on the back FT-AGA + clinically sepsis + Rupture
2. Clinically sepsis susp meningocele

DIAGNOSIS/ DIFFERENTIAL WORKING DIAGNOSIS

DIAGNOSIS FT-AGA + clinically sepsis + Rupture
Fullterm Appropriate Gestational Age meningocele
+ Rupture susp meningocele dd/
myelomeningocele

17
PLAN EXAMINATION THERAPY
•Hb, Ht, WBC, PLT, Diff Count, ESR, Fluid needed : 150 mL/KgBW/day
Quantitative CRP, It Ratio, Blood IVFD D10⅕NS rate 13 mL/hour
sugar Aminosteril 6% rate 3.3 ml/hour
•Blood culture Inj Cefotaxime 125 mg every 8 hours (iv)
•Consult cardiology division for Consult to neurosurgery division  pro repair
echocardiography

MONITORING DIET
Vital sign Breast milk on demand every 3 hours
Oxygen saturation and signs of
respiratory distress
Seizure

ADMISSION Neonatology

18
 Laboratory Finding in RSMH (March 07th, 2023)
19 Result Normal

18.2
Haemoglobin 12.4 – 18,6 g/dL
4.18
WBC 6 – 17.5 103/mm3
323
PLT 217 - 497 103/µL
51
Ht 35 - 45 %
2
LED 0-20 mm/hours
Not finished yet
DC 0-1/1-3/50-70/25-40/2-8 %
Not finished yet
IT ratio <0.2
216.4
CRP <5 gr/dl
127
Na 135-145
5.1
K 3.5-4.5
89
GDS <200
 Ro thorax
20
 Patient Photo
21
22

THANK
YOU
 Meningomyelocoele is the most severe type of SPINA
BIFIDA.
 Spina Bifida means "split spine”
 4 types of Spina Bifida are:
◦ Spina bifida occulta,
◦ Meningocele
◦ Spina bifida cystica (Myelomeningocele) and
◦ Lipomeningocele
 Meningomyelocoele
◦ occurs due to Failure of closure of the neural tube
during the third week of gestation
◦ abnormal differentiation of the embryonic neural
tube
 In Meningomyelocoele
A cystic swelling occurs over the site of the spinal
defect which contains meninges, nerve roots, and the
spinal cord itself which has left the vertebral canal
 Spina bifida is caused by the failure of the neural tube
to close during the first month of embryonic
development (often before the mother knows she is
pregnant).

 Under normal circumstances, the closure of the

neural tube occurs around the 23rd (rostral closure)
and 27th (caudal closure) day after fertilization.
 Due to risk factor

Failure of NTD to close during 1st month of embryonic

development

Increase central nervous system

pressure Fails to close properly

NTD occur
 Ultrasound during the second trimester
 The diagnosis of meningocele/ myelomeningocele is

certain when 3 classic central findings are present in

ultrasonography
◦ concavity of the frontal bones,
◦ ventriculomegaly, and
◦ Chiari II malformation.
 Positive screening for maternal serum alpha-

fetoprotein (AFP)
 Screening of the amniotic fluid for AFP, as well as for

the presence of acetylcholinesterase

 Intrauterine surgery
 Post-natal surgery:- Closure of the

Myelomeningocele is performed immediately after

birth if external CSF leakage is present and typically
within the first 24-48 hours in the absence of CSF
leakage
 Multidisciplinary interventions needed to prevent

progressive deterioration of multiple body systems

 Treatment team consists of pediatric specialists in

◦ Physical medicine and rehabilitation

◦ Neurosurgery
◦ Urology
 Dietary supplementation with folic acid has been
shown to be helpful in reducing the incidence of
spina bifida. Sources of folic acid include whole
grains, fortified breakfast cereals, dried beans, leaf
vegetables and fruits.
 It is recommended that any woman considering

becoming pregnant take 0.4 mg of folic acid a day.

Pregnant women need 1 mg per day.
32

THANK
YOU