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MORNING REPORT

Disusun oleh:
Noermawati Dewi

FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH SURAKARTA
2017
IDENTITY
• Name : An. E
• Date of birth : 03 July 2015
• Gender : Boy
• Age : 25 months (2 years 1 months old)
• Address : Surakarta
• Religion : Islam
• Tribe : Java
• Date of hospitalization : 26-08-2017 (23.00)
• Date of examination : 27-08-2017 (07.00)
ANAMNESIS

Chieft Complaint

Seizure
HISTORY OF ILLNESS
The day on admission
• The mother said that the patient got fever (+)
on 19.00, then he got seizure. The seizure <15
minute, and it was the third time in a day. He
was still conscious when seizure happened.
There was no vomit (-), cough (-), runny nose
(-).
• The defecation was normal. But when the
patient urinated, he got bulging on the end of
penis.
HISTORY OF PAST ILLNESS

History of Seizure with fever : Admitted (1 th, 1,5th)


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

Conclusion: there is history of past illness that related to current


illness
HISTORY OF ILLNESS IN FAMILY

History of Seizure with fever : Admitted (uncle)


History of Seizure without fever : Denied
History of Asma : Denied
History of Hypertention : Denied
History of Diabetes Mellitus : Denied

Conclusion: there is history of illness in family that correlated with


patient’s disease
PEDIGREE

Ny. T 27 years old


Ny. S 26 years old

An. E 25 months old

= seizure with fever

Conclusion : there is hereditary illness


HISTORY OF PREGNANCY

Mother with P1A0 was pregnant at 24 years old. Mother began to


check pregnancy and routinely control to the midwife. During
pregnancy the mother does not feel nausea, vomiting and
dizziness that interfere with daily activities. During pregnancy
there was no history of trauma, bleeding, infection, and
hypertension.

Conclusion: history of pregnancy was good


HISTORY OF DELIVERY

The mother gave birth to her baby assisted by a midwife with normal
delivery. 40 weeks pregnancy age, baby born with body weight 3300
grams and body lenght 54 cm . At the time of birth the baby cries instantly,
there was no congenital defect at birth.

Conclusion : history of delivery was good

HISTORY OF POST DELIVERY

The baby boy was born crying, active motion, red skin color, not
blue and yellow skin color, got milk on first day, urination and
defecation 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,
neighbors and the family have not experienced some complaints.

Conclusion : there is no a risk factors for transmitted disease


HISTORY OF VACCINE

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


KMS.
• According to her mother, the patient had received the
basic vaccine (kemenkes) completely. Vaccinations
were obtained at the primary care (PUSKESMAS).

Conclusion : history of vaccine was good based on


KEMENKES
HISTORY OF FEEDING
Age 0 – 6 months
• Exclusive breastmilk

Age 6-9 months


• Breastmilk + instant porridge 2 times a small dishes per day

Age 9-12 months

• Breastmilk + porridge of filter and vegetables teams smoothed a day 2-3 times small dishes of food is always
finished

Age 12-18 months

• Breastmilk + soft rice, eggs, meat, fish, vegetables a day 2-3 times small dishes of food is always finished

Age 18-24 months

• Formula + rice, eggs, meat, fish, vegetables a day 2-3 times small dishes of food is always finished

Conclusion : history of feeding  quality and quantity was good










• The answer “Yes” = 9 poin

Conclusion : Development history is not according to age


Physical Examination
 General appearance
General appearance : good
Awareness : Alert

 Vital Sign
Blood Pressure :-
Heart rate : 108x/ menit
Respiratory Rate : 24x/ menit
Temperature : 37,2º C
Nutrisional status

WEIGHT : 11,5 KG Height : 84,5 CM

-Weight // age : antara -2SD sampai 0 line (gizi baik)


-Height // age : antara -2SD sampai 0 line (normal)
-Weight // Lenght : median line (normal)

Conclusion : The patient's nutritional status is good


Physical examination
• Skin examination
Color : brown
Moisture: moist
Edema (-) does not exist

• Conclusion : the examination of skin was normal

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PEMERIKSAAN KHUSUS
Neck : No enlargement of lymph node and no increase jugular venous
Chest : Simetris, retration (-), 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 kanan kiri, There is no missed breath
Perkusi : sonor
Auskultasi : Vesicular (+/+) normal, rhonki (-/-), wheezing (-/-)

Conclusion : Neck, Chest, Heart, Lung  were normal limits


Stomach : Inspeksi : Distended (-), sikatrik (-), purpura (-)
Auskultasi : Peristaltik (+)
Perkusi : Timpani (+)
Palpasi : Massa abnormal (-), nyeri tekan (-),
turgor kulit baik.
Liver : normal
Spleen : normal

Conclusion : There was no abnormality


Ekstremitas
•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 is good

Conclusion : the examination of extremity was normal limits

Genital
•Fimosis (+)

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PHYSICAL EXAMINATION

Head : Normochephal
Eyes : CA (-/-), SI (-/-), edema palpebra (-/-) , sunken eyes(-/-)
Nose : Sekret (-), epistaksis (-), nafas cuping hidung (-/-)
Ears : Sekret (-)
Mouth : Stomatitis (-), perdarahan gusi (-), sianosis (-), faring sulit dievaluasi
Skin : Warna sawo matang, Pucat (-), Ikterik (-), Sianosis (-)
Lymph nodes : Tidak didapatkan pembesaran limfonodi
Muscle : Tidak didapatkan kelemahan, atrofi, maupun nyeri otot
Bone : Tidak didapatkan deformitas tulang
Joints : Gerakan bebas
Extremities : CRT < 2 Second, sianosis (-/-), edema (-/-), akral hangat(+/+), petekie (-
/-)

Conclusion: there was abnormality


LABORATORIUM EXAMINATION
Routine blood examination
PEMERIKSAAN HASIL SATUAN NORMAL
 Leukosit 19.06 H 10ˆ3/ul 4.5 – 12.50
 Eritrosit 4.87 jt/ul 3.8 – 5.20
 Hemoglobin 12.2 g/dl 11.7 – 14.5
 Hematokrit 35.8 % 35.0 – 47.0
 Trombosit 358 10ˆ3/ul 217 – 497
 Limfosit 7.9 L % 25 – 40
 Netrofil 81.0 L % 50 - 70
 Monosit 10.8 H % 2–8
 MCV 73.5 fl 73.0 – 102.0
 MCH 25.1 pg 22.0 – 34.0
 MCHC 34.1H g/dl 30.0 – 34.0

Result : Routine blood examination there was Leukositosis with netrofilia


RESUME
ANAMNESIS
Seizure with fever. Seizure <15 mnt. 3x /day

Physical examination
Blood Pressure : -
Heart rate : 108x/ menit
Respiratory Rate : 24 x/ menit
Temperature : 37,2º C
Genital : fimosis (+)

Laboratorium
Bacterial infection
ASSESMENT

1. Kejang
2. Fimosis
Demam Komplek
• DD : • DD:
• Kejang konversi
ACTION PLAN
• Observation of vital signs

DIAGNOSIS ENFORCEMENT PLAN


Terapi

kebutuhan energi : White rice, eggs, meat, fish,


Kalori : 11.5 x 102= 1173kkal vegetables a day 3 times a large plate of food
Protein : 11.5x 1.23 = 14.15g was always finished.
Cairan : 11.5x 115= 1322.5ml  rute oral
Kebutuhan energi : 1173 kalori/hari dibagi
dalam 3 kali waktu makan

kebutuhan energi :
Nasi putih 100 gram: 178 kalori
Tumis bayam 100 gr : 193 kalori
1 butir telur rebus : 154 kalori
1 tempe goreng : 82 kalori
1 ayam sayap: 295 kalori
1 potong pepaya 100gr: 46 kalori
` PLAN
THERAPY

• Paracetamol = 10mg/kgBB x 11,5 = 115 mg/kali pemberian

• Diazepam = 0.1 mg/kgBBx 11.5 = 1.15 mg/ kali

• Rumatan : Fenobarbital = 3mg/kgBB x 11.5 = 34.5 mg/hari


FOLLOW UP
TANGGAL SOA PLANNING
24-8- -S/on the morning, vomit (-), diare (-), recovery cough, P/ -RL : 19 tetes
2017 recovery runny nose, urination was normal. But on the makro
Jam afternoon diarrhea 2x. • -Zink 20mg/hari
O/ • L-bio 2x1 sachet
07.00
- KU : Compos Mentis • Ondancentron
- HR : 114x/menit 1mg/ 12jam
- RR : 24 x/menit
- S : 37.2 • Ambroxol : 4,5 mg
• Salbutamol : 0.9
- Kepala: konjunctiva anemis (-/-), sklera ikterik (-/-)
mg
- Faring sulit dievaluasi. • Pseudoefedrin: 9
- Tho: suara vesikuler(+/+), wheezing (-/-), Rhonki (-/-) mg
- Abd : peristaltik (+), timpani (+)
- Extremities : normal

A/Diare cair akut


Rhinofaringitis
THANK YOU