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Morning Report
Thursday, 4TH July 2017

dr. Raisa / dr. Connie/ dr. Syahmi/ dr. Pridania/ dr. Ifa/ dr.
Cempaka
dr. Disa / dr. Laras
dr. Ratna / dr. Patra
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PATIENT ADMISSION
• MELATI 2 WARD

• Wing Mawar
▫ Child L, male, 5 y.o, 15 kgs, Round cell Pneumonia dd
pulmonal abses dd mass in thorax cavity, anemia due to
infection dd iron deficiency, thrombocytosis reactive.
wellnourished.
• HCU NEONATUS: -
• PICU : -
• HCU MELATI 2 : -
• NICU : -
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PATIENT IDENTITY
• Name :L
• Sex : Male
• Age : 5 y.o
• Adress : Surakarta
• Medical Record : 01424177
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Chief complaint

FEVER
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2 months before 1 week before


admission admission

• Patient had fever • Still got fever


• Pale (+) • Cough (-), runny nose(-),
• Cough (-), runny nose(-), breathlessness (-)
breathlessness (-) • Patient brought to private
• Decrease of body weight 2,5 kg in 2 hospital  hospitalization for 8
months days
• Patient brought to private hospital • Had laboratory examination,
 hospitalization 2 times  went Result: Anemia  got
home before complete therapy due transfusion
to financial issue. • Had CT scan and biopsy 
didn’t find malignancy
• Because minimal of facility,
patient reffered to Moewardi
hospital
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At Emergency Room
Moewardi Hospital
• Fever(+)
• Cough (-), runny nose(-), breathlessness
(-)
• Vomit (-)
• Cephalgia (-)
• Lose of appettite
• Defecation and urination within normal
limit
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PAST MEDICAL HISTORY


• History of hospitalization before: 3 times with the same
chief complain
• History of transfusion PRC: 2 times
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FAMILY MEDICAL HISTORY


• History of same illness in family was denied
• History of allergy was denied
• History of tuberculosis in family was denied
• History of cardiac disease in family was denied
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HISTORY OF PREGNANCY AND DELIVERY

Pregnancy
He is the second child of his family. Gestational age of 39 weeks. The
mother consumed vitamins and pills routinely from her doctor . Routine
check up to the hospital monthly within first and second trimester,
weekly on third trimester. There were no history of illness and admission
to the hospital during the course of pregnancy.

Delivery
The baby was delivered per vaginam by a doctor. There were no
complication during procedure. The baby delivered well, active, cried
loudly. The baby weighed at 2800 grams and 49 cm in length.

Conclusion : pregnancy and delivery history was within


normal limit
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VACCINATION HISTORY

Hep B : 0 months
Polio : 1, 2, 3, months
BCG : 1 months
DPT, hib,HepB : 2,4,6 months
Measles : 9 months
MR : 4 years
Conclusion : vaccination history was complete according to
Ministry of Health’s Vaccination Schedule 2013.
NUTRITIONAL HISTORY
Patient family meal three times a day each meal 1
adult portion. Sometimes drank milk 1-2 times a
day. Fruit one time a day

conclusion : Good quality good quantity.


GROWTH AND DEVELOPMENT HISTORY

Growth
Her weight is 15 kg with body height 103 cm

Development
He is now 5 years old. he plays with friends and communicates well with
her parents and her peers.

Conclusion : growth and development history are abnormal


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NUTRITIONAL STATUS

• BB/U : BB/U = P3
• TB/U : 103/109 x 100 % = 94.4% (TB/U =P10)
• BB/TB : 15/16.5 x 100 % = 90.9% (P10 < BB/TB < P25)
• IMT :

Conclusion : Wellnourished
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Family tree

II

II
I

child. L, 2 m. o
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PHYSICAL EXAMINATION

• General appearance : moderate ill, fully alert, no


breathlessness and irritable
• Vital sign :
▫ Heart Rate = 120 bpm
▫ Respiration rate = 28 tpm
▫ Temperature = 37.9 0 C peraxilar
▫ O2 saturation = 98%
▫ BP 100/60 mmHg
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• Head : mesocephal,
• Eyes : pale conjunctiva (-/-), icteric conjunctiva (-/-), light reflex
(+/+), isochoric pupil 3 mm/3mm,
• Nose : nasal flare -, discharge (-/-)
• Mouth : wet lips (+), lips and tongue not cyanotic
• Neck : enlargement of lymph node (+) submandubula and
cervical, multiple, d 2 cm, soft in concisstency, skin colour still
the same.
• Thorax :symmetric (+), retraction (-)
LUNG:
• I: normal, symmetric, retraction (-)
• P: fremitus right = left
• P: dim in hemithorax dextra as high as SIC 4-5
• A: normal vesicular breath sound (+/+) decrease in SIC 4-5
additional breath sound (+/+), crackles (+/+), wheezing (-/-)
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CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was not palpable
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, murmur (-)

ABDOMINAL:
I: abdominal wall same with chest wall
A: peristaltic sounds in normal limit
P: tympani(+), shifting dullness (-), undulations(-),
P: liver and spleen was not palpable, good skin turgor

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis
pedis artery was strongly palpable

GENITALIA : ♂, no abnormality, phimosis (-)


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LABORATORY FINDINGS (4th July 2018)


 Hb = 8.8g/dl
 Hct = 28%
 Leucocyte count = 17.400/ul
 Trombocyte count = 1012.000/ul
 Erythrocytes = 3.70 million/ul

Conclusion :
Anemia
Thrombocytosis
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• Conclusion
• tend to lung tumor right
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21
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• May 18th 2018


• Conclusion:
• Meteorismus
• Structur of the
abdomen organ
within normal
limit
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• June 1st 2018

• Conclusion:
• Hippodens lession
round shape in superior
and medius lobe,
attached to the minor
fissura and the
posterior thoracal wall

• DD: Round pneumonia


• Inflamatory
myofibroblastic tumor
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Patology Anatomy 29th June 2018


• There’s no
malignant cell
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LIST of PROBLEM
A child, male, 5 years old / 15 kgs with :
1. Prolonged fever for 2 months
2. Pale
3. Blood transfusion
4. Loss of appetite
5. Decrease of body weight
6. Lymphadenopathy
7. Lungs examination : dim in hemithorax dextra as high as SIC 4-5,
decrease vesicular breath sound (+/+) in SIC 4-5 additional breath
sound (+/+), crackles (+/+), wheezing (-/-)
8. Anemia
9. Thrombocytosis
10. CXR : lung tumor dextra
11. Abdominal US : Meteorismus, structure of the abdomen organ
within normal limit
12. CT scan : Hippodens lession round shape in superior and medius
lobe, attached to the minor fissura and the posterior thoracal wall
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Differential diagnosis
1. Round cell pneumonia dd Pulmonal abses
dextra dd Pulmonal mass dextra (P24.81)
2.Anemia normositic normochromic due to
infection procces dd iron deficiency (D64.9)
3.Trombocytosis reactive (D21.4)
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WORKING diagnosis
1. Round cell pneumonia dd Pulmonal
abses dextra dd Pulmonal mass dextra
2.Anemia normocytic normochromic due
to infection procces dd iron deficiency
3.Trombocytosis reactive
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therapy
• Admitted to pediatric ward
• Nutrition  diet rice pack, 1500 kkal/day
• IVFD D1/4 NS 52 ml/hour
• Ampicillin (50mg/kgBW/6hour) = 750 mg/6hour iv
• Gentamycin (7,5 mg/kgbw/ 24 hour) 120 mg/ 24 hours iv
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PLAN
1. Routine blood count, blood culture, sputum
culture, gen expert
2. Exision of the tumor

MONITORING
• General appearance / vital signs / 8 hours
• Fluid balance and diuresis / 8 hours
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Follow up on 5th july 2018


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PHYSICAL EXAMINATION

• General appearance : moderate ill, fully alert, no


breathlessness and irritable
• Vital sign :
▫ Heart Rate = 110 bpm
▫ Respiration rate = 24 tpm
▫ Temperature = 37.8 0 C peraxilar
▫ O2 saturation = 98%
▫ BP 100/60 mmHg
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• Head : mesocephal,
• Eyes : pale conjunctiva (-/-), icteric conjunctiva (-/-), light reflex
(+/+), isochoric pupil 3 mm/3mm,
• Nose : nasal flare -, discharge (-/-)
• Mouth : wet lips (+), lips and tongue not cyanotic
• Neck : enlargement of lymph node (+) submandubula and
cervical, multiple, d 2 cm, soft in concisstency, skin colour still
the same.
• Thorax :symmetric (+), retraction (-)
LUNG:
• I: normal, symmetric, retraction (-)
• P: fremitus right = left
• P: dim in hemithorax dextra as high as SIC 4-5
• A: normal vesicular breath sound (+/+) decrease in SIC 4-5
additional breath sound (+/+), crackles (+/+), wheezing (-/-)
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CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was not palpable
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, murmur (-)

ABDOMINAL:
I: abdominal wall same with chest wall
A: peristaltic sounds in normal limit
P: tympani(+), shifting dullness (-), undulations(-),
P: liver and spleen was not palpable, good skin turgor

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis
pedis artery was strongly palpable

GENITALIA : ♂, no abnormality, phimosis (-)


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Differential diagnosis
1. Round cell pneumonia dd Pulmonal
abses dextra dd Pulmonal mass dextra
(P24.81)
2.Anemia normocytic normochromic due
to infection procces dd iron deficiency
(D64.9)
3.Trombocytosis reactive (D21.4)
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WORKING diagnosis
1. Round cell pneumonia dd Pulmonal
abses dextra dd Pulmonal mass dextra
2.Anemia normocytic normochromic due
to infection procces dd iron deficiency
3.Trombocytosis reactive
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therapy
• Nutrition  diet rice, 1500 kkal/day
• IVFD D1/4 NS 52 ml/hour
• Ampicillin (50mg/kgBW/6hour) = 750 mg/6hour iv
• Gentamycin (7,5 mg/kgbw/ 24 hour) 120 mg/ 24 hours iv
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PLAN
1. Routine blood count, blood culture, sputum
culture, gen expert
2. Tumor exision

MONITORING
• General appearance / vital signs / 8 hours
• Fluid balance and diuresis / 8 hours
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