Morning Report

Friday(night shift), March 31th 2018

RIA / MUU / WON

No Name Gender/Age Working Diagnosis
1. F M T Male, 6 year 4 month Suspect spontenous bacterial peritonitis +
Nephrotic syndrome + Gastroenteritis with
no dehydration
1
New Patient of emergency room admitted at 23.00, F M T, male, 6 year 4
month, address, Pardinggaran kec Bonatua Lunas
BW : 24 kg BH : 111 cm,
W/A : 114% IBW : 19 kg H/A: 95% W/H: 126% Arm circumference(AC) : 19.5
cm (P5-50th) (well nourished)

Chief complaint : Swelling

History of present illness :
- It appeared since 1 week ago. Swelling was seen on the eyelids at first, then
spread to face, stomach, genital and extremities.
- Fever was found during these 2 days. The highest temperature was at 39 C.
Fever declined with anti pyretic.
- Abdominal pain was found these 2 days and was felt on the whole area.
- Shortness of breath was not found. History of shortness of breath was found
1 days before. Symptom was alleviated on lying right side.
- Urination was found normal. History of red color urination, pain in urination,
difficulty in passing urine were denied.
• History of throat sore was denied
• Diarrhea was found today, frequency 6 times, volume about ½ glass of
water. Watery stool. Blood (-), Mucus(-)
• History of vomit was found 1 day ago. Frequency was about 5 times per
day. Volume was about ½ glass of water per vomit. Today, vomitting has
ceased.
History of previous illness :
• Patient was referred by pediatrician from RSUD Balige, was hospitalized
for 2 days with the diagnose was Pleural effuion and nephrotic syndrome.
The patient had been diagnosed nephrotic syndrome since October 2017
and had taken full dose of prednison for 2 months then tappering.
Proteinuria seems to be reccurent when the dose was being tappering.
History of previous medication:
• Inj Cefotaxime 1 gr/ 12 h, Inj Ampicillin 1 gr/ 6 h, Inj Furosemide 20 mg/ 12
h, Prednisone 2 x 1 tab
Physical Examination
General status :
Alertness : Compos Mentis Temperature :38°C
dyspnoe (-), cyanosis (-), edema (+), icteric (-), anemis (-)
BW : 24 kg BH : 111 cm,
W/A : 114% H/A: 95% W/H: 126% AC : 19.5 cm (well nourished)
BWI : kg RDA: kkal
Localized status:
Head : Eye : Light reflexes (+/+), equal pupil Ø 2mm/2mm, pale inferior
palpebral conjunctiva (-/-), edema palpebra superior (+/+)
Ear/nose/mouth : within normal limit / within normal limit/ within normal limit
Neck : Enlargement of lymph node (-)
Thorax : simetrical fusiformis, Retraction (-)
Heart rate : 110 beats/minute, regular, murmur (-) (N: 60-120 beats / minute)
Respiratory rate : 28 times/minute, regular, vesicular (+) weaken on left lung middle
to lower field, no rales, stridor, and wheezing, O2 saturation 99% (N: 16-20 times /
minute)
Abdomen : smiley umbilical (+), supple in palpation. Pain on palpation (+) through
whole abdomen. Rebound tenderness (-), Peristaltic sound (+) normal. Liver and
spleen were difficult to examined.
Extremities : Pulse 110 times/minute, regular, warm extremities, capillary refill time
(CRT) < 2 second, pitting edema on inferior extremities (+/+)
Blood pressure: 100/60 mmHg (P50-90: 92-108/55-71 mmHg)
Anogenital : Scrotal edema (+/+)
Laboratory Result from RSUD BALIGE
29/03/2018
• Hemoglobin : 12.7 g/dL
• Hematocrit : 36 %
• Leukocytes : 12.000 /mm3
• Platelets : 429.000/mm3
• BG : 114 mg/dl
Laboratory Result from 30th March RSUP
HAM
• Hb : 11.8 • BG : 62mg/dl
• Ht : 4.64 • Alb : 0.8 g/dl
• Leu : 18.250 • BUN/Ur/Cr :18/39/0.29
• Trom : 415.000 • GFR : 210 (N : 79.7 – 107.7)
• N : 87.5 • Na/K/Cl/Ca : 123/3.5/98/6.1
• L : 8.3 • Procalsitonin : soon updated
• M : 3.8
• E : 0.2
• B : 0.2
Chest X-ray on 29th March RSUD BALIGE
Chest X-ray on 30th March RSUP HAM
Differiantial Diagnosis
Susp. Spontaneous Bacterial peritonitis + Pleural effusion (R) +
Due to DD Steroid resistant - nephrotic syndrome
Relapsing – nephrotic syndrome
Working diagnosis :
Pleural effusion (R) + Steroid resistant - nephrotic syndrome
Therapy :
• IVFD D5% NaCl 0.45% 10 gtt/minute macro
• Inj Ceftriaxone 1 gr/ 12 h
• Urine dipstick ( Urine had not been obtained in ER )
• Laboratory : Complete blood count, Electrolyte, Random blood glucose, Renal
function, Albumin
• Chest Xray, Abdomen Xray (3positions)
Planning :
• Albumin substitution
• Fluid Balance / 6 h
• Consult to Pediatric Nephrology
Time Sens BP HR RR Sat.O2 Temp Additional
oriu (bpm) (tpm) (%)
m
23.00 Alert 100/60 110 26 99 36.9 Give disposable urine container
 for dipstic

24.00 Alert 100/60 102 22 99 37.0 Critical value of Albumin

Prescribe  Albumin 25% 130
cc
01.00 Alert 100/60 106 24 99 37.0 Patient was sent to ward
•Thank You