MORNING REPORT

SUNDAY MORNING SHIFT

AUGUST 9TH, 2015

dr. Yanuar / dr. Finni

dr. Indra/ dr. Febry/ dr.Irfan
dr. Delfia/ dr. Catur
dr. Tatag/ dr. Miza
1. Ward
1. F. 8 years old/25kgs with susp meningitis dd
Enchepalitis and Well Nourished
normoweight,normoheight
2. B, 8 years old, 25 kgs with Nephrotic syndrom
and well nourished, underweight, stunted
3. M, 6 months/5.9 kgs with Acute Faringitis,
Teratoma and well nourish, normoweight,
normoheight
2. HCU Neo ( - )
3. HCU Ped ( - )
4. NICU ( - )
5. PICU
1. R. 14 years old/31 kgs with Cardiomyopati
dilatated, susp myocarditis and Well Nourished
 ASSESTMENT

1. Meningitis dd Enchepalitis
2. Well nourished, normoweight,normoheight
 THERAPY
 Enrolled to PICU
 Diet sonde 2000 kcal/day after NGT was clear
 Nasal O2 2 lpm
 IVFD D1/2 60 cc/h
 NGT line with live bait
 Diuretic cateter
 Ceftriaxone inj( 50 mg/kgBW/12 hours)
= 19 mg/12 hours
 Dexamethasone (0.6mg/kgBW/day)  3.5mg/6h
I.V
 Paracetamol inj. (10mg/kgBW/x) 250 mg/8h
PLANNING
 Urinalysis
 Stool Analysis

 Lumbal Punction

Monitoring
 General Condition and Vital Sign / hours
 Fluids balance / 8h
 ASSESTMENT

1. Meningitis dd Enchepalitis
2. Well nourished, normoweight,normoheight
 THERAPY
 Enrolled to PICU
 Diet sonde 2000 kcal/day after NGT was clear
 Nasal O2 2 lpm
 IVFD D1/2 60 cc/h
 NGT line with live bait
 Diuretic cateter
 Ceftriaxone inj( 50 mg/kgBW/12 hours)
= 19 mg/12 hours
 Dexamethasone (0.6mg/kgBW/day)  3.5mg/6h
I.V
 Paracetamol inj. (10mg/kgBW/x) 250 mg/8h
PLANNING
 Urinalysis
 Stool Analysis

 Lumbal Punction

Monitoring
 General Condition and Vital Sign / hours
 Fluids balance / 8h
 PATIENT IDENTITY

Name :F
Gender : Male
Age : 8 years old
Address : Wonorejo
Med Record : 01309920
Weight/Height : 25 kg/132 cm
 CHIEF
COMPLAINT

Lost of conscious
 HISTORY OF
PRESENT ILLNES

 Six days before admission ,patient complained fever,

no seizure,cough, cold, but its can stop. Three days
before admission patient complain headache after
wake up in the morning, the patient was awake, she
didn’t feel nausea,vomit and nor fever. Her parent
gived paracetamol syrup and after that she was
sleept while watched TV. After wake up patient
shivered,she can’t talk and communicate clearly.
Patient’s family brought the patient to the Javar’
clinic and the vital sign were BP : 85/60, Hr: 150x/m,
RR : 24x/m, and t: 37,8 0C. She got treatment nasal
O2 3 lpm, IVFD RL loading 1 flash and Stesolid supp
1 tube.The patient was referred to the Moewardi
general hospital couse limited medical equipment
with diagnose unconsciousness, suspect sepsis,dd
syok hipovolemik.
 HISTORY OF
PRESENT ILLNES

 In the ER of Moewardi General Hospital patient was

unconscious. The headache complaint in this patient
can’t be evaluated. Pupil myosis, not looking
lateralitation. There are no nausea, no vomite, fever,
no cold,no cough. The last urination was 2 hours ago
and defecation were normal.
 PAST MED.
HISTORY

History hospitalized with same complaint

(–)
History of fever,cough and cold (+)
History of trauma (-)
History of allergy (-)
History of seizure (-)
History of diarhea (-)
 FAMILY
HISTORY
 History of seizure complaint (–)
 PRENATAL AND BIRTH
HISTORY

 Patients are spontaneus born at the

maternity clinic at the age of 9 months of
pregnancy and assisted by a midwife with BW
: 2800 grams
 During pregnancy routine checkups to the
midwife and get vitamin.There was no history
of illness and take the other medicine.
 At birth the patient started to cry, active
motion, not cyanotic, with clear amniotic
fluid.
 IMMUNIZATION
HISTORY

 Hep B : 0, 2, 4, 6 month
 Polio : 0 , 2, 4 , 6 month
 BCG : 2 month
 DPT : 2,4, 6 month
 Measles : (-)
 DT : Class 1 of elemantery school

 Impression: is not appropriate MoH

 NUTRITION
HISTORY

Since birth patients were breastfed until 6

months after that she get food and breasfed
until 1 years and get milk formula 1 year until 2
years.

Patienteat three times a day with vegetables

and eggs or meat

Impression: quantity and quality sufficient

 FAMILY TREE

II

III

F 8 y.o.
 PHYSICAL
EXAMINATION
GC : Somnolen, E2V5M3
VS : HR : 130x/mnt t : 38,50C BP: 100/60 mmHg
RR : 24 x/ mnt Si02: 98%
Head : mesocephal, LK 55cm (0SD<LK<+2SD)
Eye : CA -/- , SI -/-, RC+/+, Ø 1mm/1mm
myosis (+)
Ears : discharge -/-
Nose : Nasal flaring -, grunting -
Throat : Wet oral mucosa +, pharynx erythema
(-), cyanotic (-)
Neck : Lymph Nodes enlargement (-)
 ...PHYSICAL
EXAMINATION
Chest : retractions (-)
cor : I : IC not visible
P : IC not palpable
P : cardiac border is not widened
A : Heart sounds I-II (N) , reguler, murmur (-)
Pulmo :I : symmetry movement of both hemithorax
P: Symmetry of chest wall fremitus
P: sonor / sonor
A: Vesicular sounds +/+, adventitious sound -
Abd : I : abdominal wall parallel to the chest wall
A : Bowel sounds (+) normal
P : Tympani +, ascites -,
P : tenderness -, liver/spleen not palpable
Extremity :
Edema : -/- cyanotic : -/-
-/- -/-
DPA strong pulsation
CRT < 2”

Neurological state:
R. Biceps ++/++ R. Babinsky -/+ Kaku Kuduk +
R. Triceps ++/++ R. Chaddock -/- Brudzinski I/II +/-
R. Patella ++/++ R. Oppenheim -/- Motorik 5555 / 5555
R. Achilles ++/++ R. Gordon -/- 5555 / 5555

Sensorik (can’t be evaluated)

Cranial Nerves :
N. I, II: can’t be evaluated
N. III, IV VI can’t be evaluated
N. V: can’t be evaluated
N. VII: can’t be evaluated
N. VIII, IX, X, XI, XII can’t be evaluated
 NUTRITIONAL
ASSESSMENT

 BW / A : 25/25.5X 100% = 84.6% (P25<BW/U<P50)

 Normoweight
 L / A : 132/127.5x100 % = 100% ( P75<L/A<P50)
 Normoheight
 BW/L : 25/28x100 % = 84.6% (BW/L=P25)
 Conclusion: well nourished normoweight
normoheight
 LABORATORIUM

 Hb : 13.6 g/dl SGOT : 33 u/l

 Hct : 41 % SGPT : 16 u/l
 WBC : 16100/ul Albumin : 4.3 g/dl
 Platelet : 352.000/ ul Creatinin : 0.4 mg/dl
 RBC : 5.15 million/ul Ureum : 45 mg/dl
 MCV : 79.8 PH : 7.509
 MCH : 26.4 BE : - 3.9
 MCHC : 33.1 PCO2 : 21.4
 RDW : 11.3 PO2 : 143.3
 Net/ Limf : 89.60/7.1 Hematocrit : 44 %
 GDS : 134 HCO3 : 21.0 mmol/L
Total CO2 : 14.2 mmol/L
 Natrium : 136 O2 saturated : 99.2%
 Kalium : 3.9
 Calsium : 1.14
 Chlorida : 106

 Conclusion: leukositosis ,Alkalosis…..

 PROBLEM LIST

 A child, 8 years old with:

 Unconsious
 History of fever (+), cought (+), cold (+)
 Headache complaint (+)
 Phisical examination :somnolen, E2V5M3
HR ; 130x/m RR: 24x/m t: 38,5 0C BP : 100/60 mmHg
Pupil : myosis 1 mm/1 mm
R. Babinsky -/+ Kaku Kuduk +
Brudzinski I/II +/-
 Laboratory :
 ASSESTMENT

1. Meningitis dd Enchepalitis
2. Well nourished, normoweight,normoheight
 THERAPY
 Enrolled to PICU
 Diet sonde 2000 kcal/day after NGT was clear
 Nasal O2 2 lpm
 IVFD D1/2 60 cc/h
 NGT line with live bait
 Diuretic cateter
 Ceftriaxone inj( 50 mg/kgBW/12 hours)
= 19 mg/12 hours
 Dexamethasone (0.6mg/kgBW/day)  3.5mg/6h
I.V
 Paracetamol inj. (10mg/kgBW/x) 250 mg/8h
PLANNING
 Urinalysis
 Stool Analysis

 Lumbal Punction

Monitoring
 General Condition and Vital Sign / hours
 Fluids balance / 8h
 FOLLOW-UP MONDAY AUGUST 10TH, 2015

GC : Somnolent E4V5M6
VS : HR : 80x/mnt t : 36.8’C
RR : 20 x/ mnt Si02: 98%
Head : mesocephal, LK55 cm (0SD<LK<+2SD)
Eye : CA -/- , SI -/-, RC +/+, Ø 1mm/1mm
myosis (+)
Ears : discharge -/-
Nose : Nasal flaring -, grunting -
Throat : Wet oral mucosa +, pharynx erythema(-),
cyanotic (-)
Neck : Lymph Nodes enlargment (-)
Chest : retractions (-)
cor : I : IC not visible
P : IC not palpable
P : cardiac border is not widened
A : Heart sounds I-II (N) , reguler, murmur (-)
Pulmo :I : symmetry movement of both hemithorax
P: Symmetry of chest wall fremitus
P: sonor / sonor
A: Vesicular sounds +/+, adventitious sound -
Abd : I : abdominal wall parallel to the chest wall
A : Bowel sounds (+) normal
P : Tympani +, ascites -,
P : tendernes -, liver/splen not palpable
Extremity :
Edema : -/- cyanotic : -/-
-/- -/-
DPA strong pulsation
CRT < 2”

Neurological state:
R. Biceps ++/++ R. Babinsky -/+ Kaku Kuduk +
R. Triceps ++/++ R. Chaddock -/- Brudzinski I/II +/-
R. Patella ++/++ R. Oppenheim -/- Motorik 5555 / 5555
R. Achilles ++/++ R. Gordon -/- 5555 / 5555

Sensorik (can’t be evaluated)

Cranial Nerves :
N. I, II: can’t be evaluated
N. III, IV VI can’t be evaluated
N. V: can’t be evaluated
N. VII: can’t be evaluated
N. VIII, IX, X, XI, XII can’t be evaluated
 ASSESTMENT

1. Meningitis dd Enchepalitis
2. Well nourished, normoweight,normoheight
 THERAPY
 Enrolled to PICU
 Diet sonde 2000 kcal/day after NGT was clear
 Nasal O2 2 lpm
 IVFD D1/2 60 cc/h
 NGT line with live bait
 Diuretic cateter
 Ceftriaxone inj( 50 mg/kgBW/12 hours)
= 19 mg/12 hours
 Dexamethasone (0.6mg/kgBW/day)  3.5mg/6h
I.V
 Paracetamol inj. (10mg/kgBW/x) 250 mg/8h
PLANNING
 Urinalysis
 Stool Analysis

 Lumbal Punction

Monitoring
 General Condition and Vital Sign / hours
 Fluids balance / 8h