Morning Report

Pediatric Department
Oleh:
DM Denaner

Mentor:
dr. Gebyar Tri Baskoro, Sp.A

Pediatric Department
dr. SOEBANDI REGIONAL HOSPITAL JEMBER
2019
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 PATIENT’S IDENTITY

Name : An. A
Age : 4 y.o
Sex : Female
Address : Jember
Ethnic : Madura
Religion : Moslem
Admission : September 24th 2016
Examination : 1st day of admission
Medical Record : 2*****

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 PARENTS’ IDENTITY

Father Mother

Name Mr. F Mrs. N

Age 25 y.o 21 y.o

Address Jember Jember

Ethnic Maduranese Maduranese

Religion Moslem Moslem

Education S1 S1

Job Teacher Housewife

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 ANAMNESIS

Heteroanamnesis was conducted with patient’s mother (1st day of

admission) in the Room A., RS D.S. Jember.

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 HISTORY OF PRESENT ILLNESS

CHIEF COMPLAINT
Fever , Dhiarrhea

HISTORY OF PRESENT ILLNESS:

4 years old girl was taken to the IGD RS D.S. because the patient complained of fever since 6
months ago, the heat went up and down. the patient said that if the febrile patient was only given
paracetamol to relieve the fever. Patients say that there is bleeding gums too.The patient also complained
of diarrhea since this morning, the consistency of liquid, no mucus, no blood, no nausea, vomiting, no
abdominal pain and flu.

HISTORY OF MEDICATION
Paracetamol

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 HISTORY OF PAST ILLNESS
HISTORY OF PAST
No history of trauma, diarrhea, no asthma, and no allergic reaction to drug or food

HISTORY OF FAMILY DISEASE

Allergy (-) hemofillia (-), thallasemia (-)

HISTORY OF ENVIROMENTAL DISEASE

No people around him have same sign

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 FAMILY TREE

62 60 56
60 y.o
y.o y.o y.o

25 y.o 21 y.o

4 yo
Keterangan:
: Perempuan
: perempuan
: pasien

Kesan :there’s no inherited disease

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 PATIENT’S HISTORY

HISTORY OF GESTASIONAL
The patient was born from a mother G1P0000Ab000. The pregnancy was up to 9 months and the mother checked up
her pregnancy routinely at SpOG. During pregnancy the patient's mother does not experience high blood pressure, no
seizures, no excessive vomiting, no fever, no congestion, no bleeding through the birth canal. The quantity and
quality of food consumed is good, eat 3-4 times a day, a portion of rice, vegetables and side dishes. The mother did
consume any alcohol or jamu during pregnancy.

HISTORY OF LABORY
This patient was born to mother G1P0000Ab000, spontaneously, helped by midwives, first head born, clear
amniotic water, baby crying, birth weight 3000 grams, birth length 48 cm. There was no trauma at birth, no
disability, no finger abnormalities and umbilical cord care was carried out by midwives.
Conclusion: History of gestational and labory were good

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 PATIENT’S HISTORY

HISTORY AFTER LABORY

The cord is maintained, the fifth day breaks, there is no bleeding in the umbilical cord, the baby does not appear
yellow and the baby can drink well, the mother's milk is smooth.

Conclusion: History after labory was good

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 Social Economy and Environmental
History

Social economy history:

The father is a theacher, monthly income ±2.000.000 to support his wife and 1 children.
Environmental history:
The patient live with her parents at house with size 10m x 12m x 8m, 2 bed room with size 3m x
3m. Source of water from PDAM. This house has 1 bath room and 1 kitchen. This house is far
away from waste disposal and factories. The family member didn’t perform right handwash
in their home. They drink mineral water.

Conclusion : socio-economic and environmental history are not good

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 SYSTEMIC ANAMNESIS

Systemic Anamnesis
Cerebrospinal system fever (+) seizure (-)
Cardiovascular system Chest pain (-)
Respiration system cough (-), flu (+)
Gastrointestinal system nausea (-), vomitting (+), constipation (+)
Urogenitalia system urination (+) normal
Integumentum system Normal, rash (-)
Muskuloskeletal system normal

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Physical Examination

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 General Examination

General condition : Limp Skin : Pale (-), hematom (-),

Awareness : Compos Mentis ptekie (-) purpura (-)
Vital Sign : Lymph nodes : Enlarge lymph nodes (-)
Heart Rate : 86x/minute Bone : Deformitas (-), pain (-), dan
Respiration rate : 28x/minute inflamatory sign (-)
Axilla temperature : 37,20C Joints : Deformitas (-), pain (-), dan
CRT : < 2 second inflamatory sign (-)
Muskular : Spastik (-) Atrofi (-)

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 NUTRITIONAL STATUS

Born weight 3000 gram

Born lenght 48 cm
Weight 12 kg
Ideal weight 15 kg (WHO)
Gizi status 67%

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 SPECIFIC EXAMINATION

Head and Neck Chest

Size : Normocephal Normal form, simetric (+/+), retraction (-/-).
Hair : Straight, black, not easily revoked
Face : Normal mimmick, hematom (-), ptekie (-)
Heart
Inspection : Ictus cordis can not be seen
Eyes : Anemic +/+, conjungtiva -/-, sklera icteric -/-, Palpation : Ictus cordis can be feel
reflex to light +/+, shunken eyes (+) Perkution : Redup
Nose : Sekret -/- hemorhage -/-, not hiperemis mucous, Upper right border : ICS II parasternal line dextra
Lower right border : ICS IV parasternal line dextra
nostrils breathing (-)
Upper left border : ICS II parasternal line sinistra
Ears : Secret -/-, hemorhage -/- Lower left border : ICS IV midclavicula line sinistra
Mouth : Syanosis (+), Hiperemi (-), gingival bleeding (-) Auscultation :
S1S2 single, reguler, ekstrasistol (-), gallop (-),murmur (-)
Faring : Hiperemi (-)
Tonsil : Hiperemi (-), no enlargment
Neck : Simetric (+), lymph enlargment (-)

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 SPESIFIC EXAMINATION
Lung
Stomach
Dekstra Sinistra
Inspection : round, hematom (-), ptekie (-)
Insp : Simetris Insp : Simetris Auscultation : Bowel sound (+) normal 14x/minute

Palp: fremitus tactil Palp : fremitus tactil Percution : Timpani

Front Palpation : soepel, tenderness (-), hepatomegali

normal normal
(-), splenomegali (-) tenderness in
Perk : sonor Perk : sonor
lower right abdomen
Ausk : Ves (+), Rho Ausk : Ves (+), Rho
Limb
(-), Whe (-) (-), Whe (-)
Upper : Warm akral +/+, edema -/-, sianosis (+)
Insp : Simetris Insp : Simetris
atrophy (-), pale (+)
Palp: fremitus tactil Palp: fremitus tactil Lower : Warm akral -/-, edema -/-, sianosis (+)
normal normal atrophy (-) hematom (-), pale (+)
Back
Perk : sonor Perk : sonor Skin turgor normal
Anus and genital
Ausk : Ves (+), Rho Ausk : Ves (+), Rho
Anus : Normal
(-), Whe (-) (-), Whe (-) genital : Normal

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 Differential
Anamnesis Diagnosis Planning Therapy
Diagnosis
Chief complaint : Pale Dengue Fever Influenza Infusion:
History of present illness : Dhirrea acute Chikungunya Inf Asering 1100
4 years old girl was taken to the IGD RS D.S. because the patient complained cc/hr
of fever since 6 months ago, the heat went up and down. the patient said that if Santagesk 4x120mg
the febrile patient was only given paracetamol to relieve the fever. Patients say Ondamcentron inj
that there is bleeding gums too.The patient also complained of diarrhea since jika muntah
this morning, the consistency of liquid, no mucus, no blood, no nausea, Planning Psiidi syr 3x 1 cth
vomiting, no abdominal pain and flu. Diagnosis
Physical Examination Blood smear
General condition : Limp Blood Observe awareness,
Awareness : Compos Mentis examination vital sign, sign
Vital Sign : HR 128, RR 28, Tax 37,2 dehydration
Head & Neck : anemis (-), pale (-), shunken eyes (+), dry mouth (-)
Chest : normal
Stomach : normal, hepatomegali (-) tenderness on lower right abdomen
Limb : oedem(-), hematom (-), ptekie (-)

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