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MORNING REPORT

Disusun oleh:
Noermawati Dewi

FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH SURAKARTA
2017
IDENTITY
• Name : An. F
• Date of birth : 06 December 2016
• Gender : girl
• Age : 8 months
• Address : Surakarta
• Religion : Islam
• Tribe : Java
• Date of hospitalization : 23-08-2017 (12.00)
• Date of examination : 23-08-2017 (18.30)
ANAMNESIS

Chieft Complaint

Fever
HISTORY OF ILLNESS
3 days before admission
• The mother said that on Sunday evening, the
patient got fever (+), and he had crying after
urination.
• The defecation was normal.
• There was no cough and runny nose.
HISTORY OF ILLNESS
2 days before admission

• The mother said patient still got fever (+),


cried when urinating (+), blocked nose.
• The defecation was normal

1 day before admission

Pasien still got same complaints.


HISTORY OF ILLNESS

The day on admission


• The mother said that the patient still got fever (+), crying after urination
(+).
• Mother took him to the hospital.
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 : Admitted (Amoxicillin)

Conclusion: there is no history of past illness that related to


current illness
HISTORY OF ILLNESS IN FAMILY

History of Similiar symptom : Denied


History of Seizure with fever : Denied
History of Asma : Denied
History of Hypertention : Denied
History of Diabetes Mellitus : Denied
History of Allergy : Admitted (Amoxicillin)

Conclusion: there is history of illness in family that not correlated with


patient’s disease
PEDIGREE

Ny. S 23 years old

Tn. M 26 years
old

An. F 8 months old

= Alergy of
Amoxicillin

Conclusion : there is hereditary illness


HISTORY OF PREGNANCY

Mother with P1A0 was pregnant at 22 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, infection, bleeding and
hypertension

Conclusion: history of pregnancy was good


HISTORY OF DELIVERY

The mother gave birth to her baby assisted by a obstetrician with a normal
delivery. 42 weeks pregnancy age, baby born with body weight 3000
grams and body lenght 49cm . 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 but 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, grandparents


and aunty-uncle. Ceramic-floored patient houses, walled walls, tile
roofs, adequate ventilation, bathrooms in the house, water source
from well water.
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

• According to her mother, the patient had not received


the vaccine.

Conclusion : history of vaccine was not good


HISTORY OF FEEDING
Age 0 – 6 months

• Exclusive Breastmilk

Age > 6-7 months

• Breastmilk + instant porridge a day 3 times a small dishes and always finished

Age 7-now

• Breastmilk + porridge of filter and vegetable teams smoothed 3 small dishes per day and always finished

Conclusion : history of feeding quality and quantity were good








• The answer “Yes” = 10 poin

Conclusion : Development history is according to age


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

 Vital Sign
Blood Pressure :-
Heart rate : 118x/ menit
Respiratory Rate : 26x/ menit
Temperature : 37,3º C
Nutrisional status

WEIGHT : 7,1 KG Height : 65,0 CM

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


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

Conclusion : The patient's nutritional status is good


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

• Conclusion : the examination of skin was normal

23
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  there was in normal limits


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

Conclusion : There was no abnormality


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 is good

Conclusion : the examination of extremity was normal limits

Genitalia
• OUE hiperemis (+)
• Fimosis (+)

Conclusion : the genitalia examination : there was hiperemis of OUE and


fimosis 26
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 (-), turgor kulit (< 2
detik)
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 no abnormality


LABORATORIUM EXAMINATION
Routine blood examination
PEMERIKSAAN HASIL SATUAN NORMAL
 Leukosit 24.50 H 10ˆ3/ul 4.5 – 12.50
 Eritrosit 4.31 jt/ul 3.8 – 5.20
 Hemoglobin 10.2 L g/dl 11.7 – 14.5
 Hematokrit 29.4 L % 35.0 – 47.0
 Trombosit 540 H 10ˆ3/ul 217 – 497
 Limfosit 47.9 H % 25 – 40
 Netrofil 44.9 L % 50 - 70
 Monosit 7.2 % 2–8
 MCV 68.4 L fl 74.0 – 102.0
 MCH 23.6 pg 22.0 – 34.0
 MCHC 34.6 H g/dl 30.0 – 34.0

Result : Routine blood examination’s result there were leukositosis, anemia,


trombositosis
RESUME
ANAMNESIS
Fever
Crying after urination

Physical examination
Blood Pressure : -
Heart rate : 118x/ menit
Respiratory Rate : 26 x/ menit
temperature : 37,3º C

Laboratorium
Leukositosis
Anemia
Trombositosis
ASSESMENT

1. Suspek infeksi
2. Common cold
Saluran Kemih
• DD : • DD:
• Dengue Fever • Rhinitis
• Morbili
• And others
infection
ACTION PLAN
• Observation of vital signs

DIAGNOSIS ENFORCEMENT PLAN

• Urin routine examination


Terapi

kebutuhan energi : Porridge rice, eggs, meat,


Kalori : 7.1x 98= 695.8 kkal fish, vegetables a day 3 times a small plate of
Protein : 7.1x 1.5 = 10.65 g food was always finished.
Cairan : 7.1x 125= 887.5 ml  rute oral
Kebutuhan energi : 695.8 kalori/hari dibagi
dalam 3 kali waktu makan

kebutuhan energi :
Nasi tim 100 gram: 120 kalori
Bayam rebus 100 gr : 23 kalori
1/2 butir telur rebus : 77 kalori
1 tahu rebus: 32 kalori
1 ati ayam: 105 kalori
Pepaya 100 gram: 46 kalori
` PLAN
THERAPY

• Paracetamol 10mg/kgBB x 7.1 kg = 71 mg/ kali pemberian


tiap 4 jam bila demam

• Ceftriaxone 75mg/kgBB x 7.1kg= 532.5 mg/hari


FOLLOW UP
TANGGAL SOA PLANNING
24-8- -S/on the morning, fever (-), still crying after urination Paracetamol = 71 mg/
2017 O/ kali pemberian
Jam - KU : Compos Mentis tiap 4 jam bila
- HR : 118x/menit demam
07.00
Ceftriaxone = 532.5
- RR : 24 x/menit
mg/hari
- S : 36.7
- Kepala: konjunctiva anemis (-/-), sklera ikterik (-/-)
- Tho: suara vesikuler(+/+)
- Abd : peristaltik (+)
- Genitalia : OUE hiperemis (+), fimosis (-)

A/suspek ISK
FOLLOW UP
TANGGAL SOA PLANNING
25-8- -S/on the morning, fever (-), crying after urination (-) Paracetamol = 71 mg/
2017 O/ kali pemberian
Jam - KU : Compos Mentis tiap 4 jam bila
- HR : 122x/menit demam
07.00
Ceftriaxone = 532.5
- RR : 26 x/menit
mg/hari
- S : 36
- Kepala: konjunctiva anemis (-/-), sklera ikterik (-/-)
- Tho: suara vesikuler(+/+)
- Abd : peristaltik (+)
- Genitalia : OUE hiperemis (+) <<, fimosis (-)
- Urine Routine : normal limit

A/suspek ISK
THANK YOU