MORNING REPORT

Disusun oleh:
NIA AMALIA ULFAH

FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH SURAKARTA
2018
 IDENTITY
• Name : An. F
• Date of birth : 13 Januari 2018
• Gender : Boy
• Age : 10 month
• Address : Surakarta
• Date of hospitalization : 03-11-2018 (17.30)
• Date of examination : 03-11-2018 (17.40)
ANAMNESIS

Chieft Complaint

vomiting
 HISTORY OF PRESENT ILLNESS

2 days before admission

• Vomitting 3 times while he eat, contain food and mucous, no blood
• Fever
• No seizure, no loss of consciousness
• nausea
• Irritable
• No Cough, no dispneu
• Decreased feeding
• excessive thirst
• Urination rarely ,defecate is normal
 HISTORY OF PRESENT ILLNESS

1 days before admission

• Vomitting 3 times while he eat, contain food and mucous, no blood
• fever 38,6
• seizure, no loss of consciousness
• nausea
• Weak
• Irritable
• No Cough, no dispneu
• Decreased feeding
• Urination just 2 times/day, the colour is yellow to brown
• Can’t defecate
• The mother give sanmol 1x 0,6ml
 HISTORY OF PRESENT ILLNESS

the days before admission

• Vomitting 3 times while he eat, contain food and mucous, no blood
• Fever 38.6°C
• No seizure, no loss of consciousness
• nausea
• Weak and Irritable
• Cough, no dispneu
• Decreased feeding but excessive thirst
• Urination just 1 times since last night, the colour is yellow to brown
• The mother brought her to the emergency department
 HISTORY OF PAST ILLNESS

History of Seizure with fever : Denied

History of Seizure without fever : Denied
History of dengue fever : Denied
History of typhoid fever : Denied
History of long cough : Denied
History of asma : Denied
History of allergy with food and drug : Denied
History of hospitalized : approved, diarrhea 5
month ago

Conclusion: there is history of hospitalized because of diarrhea

 HISTORY OF ILLNESS IN FAMILY

History of Seizure with fever : Denied

History of Seizure without fever : Denied
History of Anemia : Denied
History of asma : Denied
History of atopi : Denied
History of hypertention : Denied
History of Diabetes Mellitus : Denied

Conclusion: there is no history of illness in family that correlated with

patient’s disease
 PEDIGREE

Tn. T 26 years old Ny. Ok 27 years old

An. F 10 month old

Conclusion : there is no illness is inherited

 HISTORY OF PREGNANCY

Mother with P1A0 is pregnant at 26 years old. Mother began to

check pregnancy and routinely control to the obstetriciant.
During pregnancy the mother does feel nausea, vomiting and
dizziness that interfere with daily activities. During pregnancy
there was no history of bleeding, hypertention, and infection.

Conclusion: the history of pregnancy was good.

 HISTORY OF DELIVERY
The mother gave birth to her baby assisted by a doctor with a sectio
caesaria. 39 weeks pregnancy age, baby born with body weight 2800
grams with body length 49 cm. At the time of birth the baby cries
instantly, there is no congenital defect at birth.

Conclusion : history of delivery was not good (sectio caesaria)

HISTORY OF POST DELIVERY

The baby was born crying, active motion, red skin color, not blue
and not yellow skin color, got milk on first day, urination and
defecated less than 24 hours

Conclusion : history of post delivery was good

 HISTORY OF ENVIRONMENT

The patient lives at home with both parents. Ceramic-floored

patient houses, walled walls, tile roofs, adequate ventilation,
bathrooms in the house, water source from PDAM.
A few days before the patient was treated in the hospital, his
grandmother experienced similar complain before patient’s
admission.

Conclusion : there is a risk factors for transmitted disease

 HISTORY OF VACCINE

• At that time of examination, the mother did not bring

KMS.
• According to the mother's confession, the patient have
complete recieve vaccine.

Conclusion : the history of vaccine is complete acording

to KEMENKES
 Physical examination
• Skin examination
Color : brown
Skin turgor: <2 sec
Moisture: moist
Edema (-) does not exist

• Conclusion : Skin examination was good

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 HISTORY OF FEEDING

Age 0 - 6 months

• Formula milk

Age 6 – 10 months

• Formula milk + instan food 1 day 3 small bowls

Conclusion : history of feeding from quality and quantity not good

 HISTORY OF GROSS MOTOR

Kemampuan Umur pencapaian Range normal

Head up 90 degress 3 month 3-4 month
Sit no support 6,5 month 6 – 7 month

Conclusion :Development history of Gross motor according

to age
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 HISTORY OF FINE MOTOR

Kemampuan Umur pencapaian Range normal

Reaches 5 month 4,5 – 5,5 month

Conclusion :Development
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 HISTORY OF LANGUAGE
Kemampuan Umur pencapaian Range normal
Vocalizes ooo/aah 1,5 month 1 – 3 month
Turn to voice 5 month 3,5 – 5,5 month
Imitate speech sounds 6,5 month 3,5 – 9 month

Conclusion :Development history of language according to

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 HISTORY OF PERSONAL SOCIAL
Kemampuan Umur Range normal
pencapaian
Smile spontaneously 1 month 0-2month
Feed self 7 month 5 – 6,5 month

Conclusion :Development history of social according to age

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 History of DEVELOPMENT and
INTELLEGENT

• Conclusion: History of development and

intellegent was good
 Physical Examination
 General appearance
General appearance : look pale, allert

 Vital Sign
Blood Pressure :-
Heart rate : 110 x/ menit
Respiratory Rate : 23 x/ menit
temperature : 37,7° C
 Nutrisional status

10 month old WEIGHT : 9.1 KG Length : 71 CM

-Weight // age : in the 0 SD normal

-length // age : < 0 SD normal
-Weight // length : in the 1 SD normal

Conclusion : nutritional status is normal

 PHYSICAL EXAMINATION
Neck : No enlargement of lymph node and no increase jugular venous
Chest : Simetris, retraction (-), miss the motion (-).
• Heart
Inspeksi : The ictus cordis is not visible
Palpasi : Ictus cordis not strong lift
Perkusi : sound “redup”
Auskultasi : sound of cor I-II reguler, bising jantung (-)
• Lung
Inspeksi : Simetris, retraksi intercostal (-/-), retraksi subcostal (-/-),
retraksi substernal (-), retraksi suprasternal (-)
Palpasi : Simetris dextra and sinistra, There is no missed breath
Perkusi : sonor
Auskultasi : Vesicular (+/+) normal, rhonki (-/-), wheezing (-/-)

Conclusion : neck, heart and lung examination was good

Stomach :
Inspeksi : Distensi (-), sikatrik (-), purpura (-), darm contour (-),
darm steifung (-)
Auskultasi : Peristaltik (+) normal, metalic sound (-)
Perkusi : hipertimpani (+)
Palpasi : supel (+), acites (-), abdominal mass (-), tenderness (-)
Liver : Hepatomegali (-)
Spleen : Splenomegali (-)

Conclusion : in stomach examination hipertimpani

 Ekstermitas

•Warm of acral
•Perfusion of tissue is good

•Cyanosis is not found in the 4 extremities

•No udem is found in the extremities

CRT <2 sec
Turgor < 2 second

Conclusion : ekstremitas examination within normal limits

28
 PHYSICAL EXAMINATION

Head : Normochephal
Eyes : CA (-/-), SI (-/-), edema palpebra (-/-), light reflek (+/+)
isokor (+/+), sunken eyes (+/+),
Nose : Secret (-), epistaksis (-), breath nostrills (-/-)
Ears : Secret (-), membrane hiperemis (-)
Mouth : Stomatitis (-), gingivitis (-), sianosis (-), pharynx hiperemis (+), exudate
(-), mucousa lips and mouth dry (+),
Skin : colour was white, pale (-), Ikterik (-), Sianosis (-)
Lymph nodes : enlargement limfadenopathy (-)
Muscle : pharese(-), atrofi (-), myalgia (-)
Bone : deformity (-)
Joints : free movement
Extremities : CRT < 2 Second, sianosis (-/-), edema (-/-), warm akral (+/+), petekie (-
/-)

Conclusion: there is sunken eyes, pharynx hyperemis and dry mucousa lips and
mouth
 PEMERIKSAAN LABORATORIUM
Pemeriksaan Darah Rutin
PEMERIKSAAN HASIL SATUAN NORMAL
 Leukosit 13\4.40 10ˆ3/ul 4.5 – 12.50
 Eritrosit 4.01 jt/ul 3.8 – 5.20
 Hemoglobin 11.2 g/dl 11.7 – 15.5
 Hematokrit 31.5 L % 35.0 – 47.0
 Trombosit 256 10ˆ3/ul 217 – 497
 Netrofil 55,5 % 50 - 70
 Limfosit 36,2 % 25 - 40
 Monosit 8.3 H % 2–8
 MCV 78.7 fl 74.0 – 102.0
 MCH 27.6 pg 22.0 – 34.0
 MCHC 35.2H g/dl 28.0 – 32.0
 MPV 7.9 L fl 9.0 – 13.0

Result : within normal limits

 RESUME
ANAMNESIS
Fever
Weak
Vomitting every drink
Irritable
Decreased feeding but excessive thirst
Urination just 1 times since last night, the colour is yellow to brown

Physical examination
Fever
Look thirsty
Sunken eyes, pharynx hyperemis and dry mucousa lips and mouth
 ASSESMENT

Diagnosis
1. Faringitis Viral

DD : Bacterial infection
Urinary track infection
typoid fever
dengue fever

2. Some dehydration
 ACTION PLAN
• Observation of vital signs (temperature, frequency of
respiratory)
• Observation the dehidration sign
• Observation the effect of mediaction

DIAGNOSIS ENFORCEMENT PLAN

• Urine examinatoin
 ` PLAN
THERAPY

• Rehidration plan B
Infus RL 75 ml/kgBW
75 x 9,1 = 683 ml/ 3 hours
683/3/3 = 76 dpm macro/ 3 hours
• Antipiretic
Paracetamol syrup 10 mg/ kgbw/4 hours
Paracetamol syrup 10 mg x 9,1 = 9.1 mg = 4 ml/4 hours (120/5ml)
 Terapi

Calori : 9.1 x 98 = 891.8 kkal

Protein : 9.1x 1.5 = 13.65 g
Fluid : 100 x 9.1 = 910

= 910 ml/day
p.o : 455 ml/day
i.v : 455/24/3=6 dpm
 Follow up
04/12/2018

S/ muntah 2 kali,belum bab dari hari minggu

O/ N : 110 x/minutes
RR : 23 x peer times
S : 36,3°C
eyes : sunken eyes (-/-)
mouth : dry lips (-), pharynx hiperemis (+), no exudate

A/ faringitis acute with some dehydration resolved

P/ infus RL 6 dpm macro

Paracetamol syrup 4 ml / 4 hours
 Follow up
05/12/2018
S/ muntah 1 kali,sudah bab
O/ N : 110 x/minutes
RR : 23 x peer times
S : 36,8°C
eyes : sunken eyes (-/-)
mouth : dry lips (-), pharynx hiperemis (+), no exudate
urin rutin; darah trace, eritrosit 2-3 menigkat, bakteri positif banyak

A/ faringitis acute with some dehydration resolved

urinary track infection
P/ infus RL 6 dpm macro
Paracetamol syrup 4 ml / 4 hours
amoxylin 25-40 mg/kgbb/times
9.1x 25= 227,5 mg/times(syrup 250/5ml)=4,5 ml
THANK YOU
TINJAUAN PUSTAKA