Morning Report

January 25 2019

A Boy Aged 10 Years 4 Months with LFG

decreasedd CKD stad I, comorbid UTI
compleks, Anemia Micrositic Hypocromic,
proteinuria, Very Short stature, severe
malnutrition
 A GIRL AGED 13 YEARS 9 MONTHS WITH LUPUS NEPHRITIS
PRO FIRST CPA, OBSERVATION INFERIOR EXTREMITY
EDEMA DD/ RENAL, MODERATE CHRONIC
MALNUTRITION

MORNING REPORT
JAN 25TH 2019

Your Date Your Footer Here 2

RESIDEN JAGA JUMAT 25 JAN 2019
TIM JAGA JUMLAH PASIEN
• Jaga I : dr. Nelly
• C1LD : 16
• Jaga PICU : dr. Emir
• C1L1 : 39
• Jaga NICU : dr. Jati
• Jaga RSND : dr. Philip
• Parkit : 2
• Jaga PBRT I : dr. Imam • Elang : 1
• Jaga PBRT II : dr. Andrew • PBRT : 20
• Jaga IGD :dr. Adel • NICU : 4
• Jaga HCU : dr. Ian
• PICU : 7
• Jaga IV+A : dr. Tina
• HCU : 5
• Jaga IV+B : dr. Rara
• Jaga IV- : dr. Affri
• Jaga V+ : dr. Ratna • Pasien baru : 5
• Jaga IGD Junior : dr. Syifa • Meninggal : -
• Jaga V-A : dr. Friska • APS : -
• Jaga V-B : dr. Irma
IDENTITAS PASIEN

Name : An. MR
Age : 10 years 4 months
Date of birth : September 17th 2008
Sex : Male
Address : Wadung, Demak

👦
Religion : Islam
No. CM : C643xxx
Date of admission : January 25th 2019
ANAMNESIS : HISTORY OF DISEASE

chief complaint: Malaise

• Less than 1 month before entering the hospital, the child has a fever. The fever
improved with paracetamol but after a while a fever returned.
• Approximately 2 weeks before entering the hospital, the child is weak. Complaints are
felt more and more  unconscious. The patient was taken to the Kartini Hospital and
a blood examination was carried out. The results of blood tests showed 6.5 Hb results
so that patients were given 2 bags of blood transfusion. After being given a
transfusion, the patient's complaints gradually improved.
• The child also complains of cloudy bladder 2 weeks before being
hospitalized. Patients urinate twice a day, the amount every time urinary is
approximately ¼ glass. Pain (+), red (-), nausea (-), vomiting (-). Swollen complaints on
both hands and feet (-), history of sore throat (-), history of cavities (-). Patients were
diagnosed with kidney problems and referred to RSDK for further examination and
treatment
ANAMNESIS
Past Medical History Family History

Children diagnosed with Anorectal Family history of kidney disease is

Malformation by making colostomy in 2008 at denied
Kudus Teak Hospital, making anus in 2008 at
RSDK, and closing Colostomy in 2010 at RSDK

Sosio economic History

The child is the third child of 3 siblings. Father and mother

work as private employees. Financing using BPJS
Kesehatan
Socio-economic impression: lacking
Perinatal History
• she had >4x routine antenatal care to midwife during pregnancy
• TT(+) imunitation history, cons.of folic acid (+)
Prenatal • history of illness during pregnancy (-), DM(-), HT(-)
• history of taking medicine or herbal (-)

• Born from G3P2A0, 34 years, aterm, spontaneus, vigourus baby,history of

respiratory problem (-) cyanotic (-), ichteric (-)
Natal • birth weight 3.500 grams, birth lenght 50 cm
• Ateresia anii

• Jaundice history is denied

Postnatal • Cyanotic history is denied
• operation of making colostomy (3 days)
History of Immunization

• Hepatitis B : 4x (0,2,4,6 month)

• Polio : 4x (0,2,4,6 month )
• BCG :-
• DPT :-
• HiB :-
• Campak :-

Impression : incomplete recommended routine

immunization, booster (-)
 History of food
– 0-6 months :
FOOD RECALL
Breast Milk
Pagi Siang Sore
– 6-12 months :
1 serving of rice 1 serving of rice 1 serving of rice
BM + Cerelac porridge ½ set 3 x 1 + 23/01/2019 Nugget Spinach Fried chicken
bananas ½ + Formula milk ½ of milk ½ of milk
– 12-24 bulans : 1 serving of rice 1 serving of rice
1 serving of rice
24/01/2019 Fried fish Tofu
Team rice w/ spinach and chicken + fruit soup
½ of milk ½ of milk
+ formula milk + BM
1 serving of rice 1 serving of Fried
1 serving of rice
– 24 months-now : 25/01/2019
Opor chicken
Soup rice
½ of milk ½ of milk
Fam. food
Impression : quality and quantity are enough

Exclusive breastfeeding
RIWAYAT PERTUMBUHAN & PERKEMBANGAN

Z-Score
• Present weight = 16,5 • very short stature
kg
• present height= 112,1 • WAZ = NA
cm • HAZ = -4,23 SD
• WHZ = -2,74 SD
during
Impression
inspection

– 2 months old : smile

– 4 months old : prone
– 6 months old : sit
– 8 months old : crawl
– 9 months old : stand up
– 10 months old : walk
At present the child is in grade 4 elementary school.
Children have never stayed in class and have excelled in
class. Since school, children have never participated in
physical exercise because they are often weak
Impression: Development according to age
PEDIGREE
PEMERIKSAAN FISIK

 General condition : alert, good

 Kesadaran : Composmentis
 Vital sign :
• HR : 117 x/menit
• Pulse : Reguler, isi/tegangan cukup
• RR : 22 x/menit
•T : 37,3 OC
• BP : 130/50 mmHg

 Head : Mesocephal
 Eye : Anemic (+/+), ichteric (-/-)
 Nose : Nafas cuping hidung (-), epistaksis (-), discharge (-)
 Ears : Discharge (-/-)
 Mouth : Cyanosis (-), pale (-), stomatitis (-), tonsil T1-T1, hyperemis (-)
 Neck : limphadenopathy(-/-)
 PEMERIKSAAN FISIK

THORAKS
Lung
Inspection : symmetrical chest expansion, chest indrawing (-)
Palpation : equal fremitus on both sides
Percussion : Sonor in all lung field
Auscultation: vesicular breath sound (+) normal;
adventitious sound: Rhonci (-/-), wheezes (-/-)

Heart
Inspection : Ictus cordis non visible
Palpation : Ictus cordis palpable on left midclavicular line SIC V,
no thrills or heaves palpated
Percussion : within normal
Auscultation : Heart sound I & II normal, murmur (-), gallop (-)
PEMERIKSAAN FISIK

ABDOMEN
Inspection : distended, striae (-)
Auscultation: normal bowel sound
Palpation : tenderness (-), guarding (-), flank pain (-)
hepar not palpable, lien schuffner 0
Perkusi : Tympanic, shifning (+), shifning dullness(-)
Extremity
Superior Inferior
warm +/+ + /+
Capillary refill <2”/ <2” <2”/ <2”
Edema -/- -/-
Cyanotis -/- -/-
Lboratory Exam (Jan 25/2019)

Hematology HASIL SATUAN Clinical

HASIL SATUAN
chemistry
Hemoglobin 10,7 g/dL
Albumin 4,0 mg/dL
Eritrosit 4,4 Juta/ml
Hematocrit 31,7 % Ureum 225 mg/dL
MCH 24,6 pg Creatinin 3,8 mg/dL
MCV 72,9 fl
MCHC 33,8 %
Leucocytes 10,4 10^3/Ul
Pletelets 435 10^3/uL
Urine Examination Result
Color Cloudy yellow
pH 6,3
Protein +/pos
Reduction -/neg
Sediment
Epithelium 1-3 LPK
Lecoyte > 100 LPB
Erythrocytes 8-10
Ca Oxalat -/neg
Uric Acid -/neg
Triple Phospate -/neg
Amorph -/neg
Hyaline cylinder -/neg
Coarse granule cylinder -/neg
Fine granules cylinder -/neg
Epithelial cylinder -/neg
Promblems
No Masalah Aktif Tanggal Masalah Pasif Tanggal
1. Limp 01/25/2019
2. History of fever 01/25/2019
3. Cloudy of miction 01/25/2019
4. Normochromic 01/25/2019
microsytic Anemia
5. Proteinuria 01/25/2019
6. Leukosituria 01/25/2019
7. Stage II Hypertention 01/25/2019
8. Azotemia (Ur 225, Cr 01/25/2019
3,8)
9. Very short stature 01/25/2019
nutrition
 DIAGNOSIS
 Main diagnosis : decrease in LFG dd/ CKD stg IV
 Comorbid diagnosis : Complex UTI, hypochromic micrositic anemia,
Proteinuria
 Diagnosis of complication: Hematuria, Proteinuria
 Growth diagnosis : Very short stature, underweight
 Developmental diagnosis: Development according to age
 Immunization diagnosis : basic immunization is incomplete
 Sosio-economic diagnosis: less
TATA LAKSANA

IpDx : S: -
O: urine culture
IpRx : D5 ½ NS infusion 120/5 ml/h
Bicnat 3 x 1 tab
CaCO3 3 x 1 tab a.c
Kalk 1 x 1 tab
Nifedipine 5 mg/8 h
Valsartan 40 mg/8 h
IpMx : general condition, TTV (blood pressure), urine production
IpEx :
• Explain to the patient's family about the patient's illness
• Explain to the patient's family about the next examination to be carried out
• Explain to the patient's family about the therapy to be given
• Explain to the patient's family about the side effects of treatment
 DIETETIK

fluid Calories Protein

Very short stature, underweight 24 hours
1325 cc 1920 kkal 32 gr
IpDx : S: - reguirement
O: - D5 ½ NS infusion 480 85 -
Requirement : w : 16,5 kg, ideal w : 22 kg
Pathway : Peroral, parenteral Low salt diet 300 1566 53,7
Monitoring: acceptability, weight increase,
Nefrisol (3 x 100 cc) 300 300 8,7
hemodynamic
Total 1080 1951 62,4
AKG % 81% 1951% 195%
PROGNOSIS

Quo ad vitam : dubia ad bonam

Quo ad functionam : dubia ad bonam
Quo ad sanationam : dubia ad bonam