MORNING REPORT

SATURDAY MORNING SHIFT

JANUARY 25 TH 2020

dr. Tere / dr. Ama/ dr. Rizky / dr. Dinar / dr. Susi
dr. Fatimah/ dr. Syahmi
dr. Ika / dr.Labiq

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 PATIENT ADMISSION

Ward:
•Child A /15 y.o/ 42 kgs with gum bleeding due to
thrombocytopenia, aplastic anemia, malnourished
•Child H/ 19 months old/5.2 kgs with vomiting with mild to moderate
dehydration due to acute rhinopharyngitis, Barter syndrome, general
symptomatic epilepsy, stage III CKD, marasmic type malnourished
•Child B/ 8 y.o/ 28 kgs with suspected leucemic arthritis, ALL L2 SR
suspected in relapse, malnourished

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 PATIENT ADMISSION

Inborn Delivery :

1. Baby Mrs. S/ 0 day old/ 3200 grams/with severe respiratory

distress due to congenital pneumonia, severe asphyxia, early onset
neonatal sepsis, hypovolemic shock due to intrapartum
hemorrhage, neonate, male, normal birth weight, aterm,
appropriate for gestational age, spontaneous delivery with 15
hours of PROM, with nuchal cord

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 PATIENT IDENTITY

• Name : Child A
• Sex : Female
• Age : 15 years old
• W/H : 42 kgs
• Address : Sukoharjo

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CHIEF COMPLAINT

Gum Bleeding

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 CURRENT MEDICAL HISTORY

7 days prior to admission

• + Gum bleeding, stopped spontaneously

• No history of trauma
• No fever
• No rashes
 CURRENT MEDICAL HISTORY

3 days prior to admission

• Gum bleeding again, stopped spontaneously

• Patient had joint pain on both legs, with difficulty in
walking
• No fever
• + petechial rashes on legs
• The pain continues until the day of admission
 CURRENT MEDICAL HISTORY

Day of admission

• Gum bleeding
• Patient was in her first day of menstruation, had 3
fully soaked pads in half day
• Still with joint pain
• + fatigue
• No fever
• More petekie on leg
• Patient then brought to Dr. Moewardi Hospital.
 CURRENT MEDICAL HISTORY

At Emergency room

• Fully alert
• Gum bleeding
• Pale, joint paint
• No fever
• No seizure
• Last urination were 3 hours prior to admission,
reddish urin -
 PAST MEDICAL HISTORY

 History of previous admission : + almost one to twice a

month due to aplastic anemia, affirmated by PBS and BMP results
 History of blood transfusion: the latest was 15/1/20, had PRC and
TC
 History of trauma :-
 History of anticoagulant meds :-

FAMILY MEDICAL HISTORY

• History of same symptoms in the family : -
• History of relatives with bleeding disorder : -
 HISTORY OF PREGNANCY AND DELIVERY

Pregnancy
She is the second child of her family. Gestational age of 39 weeks. The mother
consumed vitamins and pills routinely from her midwife. Routine check up to
the midwife 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 spontaneously at a private midwife. There were no
complications during procedure. The baby was delivered aterm, cried vigorously;
weighed 2900 grams and the mother forgot the length. history of cyanotic or
icteric before was denied.

Conclusion: pregnancy and delivery were normal 11

 GROWTH AND DEVELOPMENT HISTORY

Growth
Appropriate for age

Development
Patient is a junior high school student

Conclusion : growth and development within normal limit

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 VACCINATION HISTORY

0 month : hepatitis B
1 month : BCG, polio 1
2 month : DPT1, hepatitis B2, polio2
3 month : DPT2, hepatitis B3, polio3
4 month : DPT3, polio3
9 month : measles (+)
18 month : measles , DPT, Hepatitis B
7 years : DT
8 years : Td
11 years : Td

Conclusion : vaccination history was complete according to

Ministry of Health’s Vaccination Schedule 2006 13
 IX. NUTRITION HISTORY

Patient eats rice packs 3 times a day from served foods at

the house

Conclusion : quality and quantity are adequate

 PEDIGREE

II

III

A, 15 y.o, 42 kgs
 NUTRITIONAL STATUS

• Body weight ; 42 kgs

• Body height ; 158cm

• Weight for Age : -3 SD < WFA < -2 SD (underweight)

• Height for Age : -2 SD < HFA < 0 SD (normoheight)
• Weight for Height : -2 SD < WFH < -1 SD

Conclusion : normoweight, normoheight, malnourished

 PHYSICAL EXAMINATION

GA : moderate ill, fully alert E4V5M6

VS : Heart rate: 102 bpm Temp: 36.5oC BP 90/60 mmHg
Resp. rate :24 bpm SiO2 : 99%

Head : mesocephal
Eyes : anemic conjunctiva +/+, icteric sclera -/-, isocoric
pupil (2mm/2mm), light reflex (+/+)
Nose : Nasal flaring (-) discharge (-)
Mouth : cyanosis (-), moist mucous (+) Tonsil T1-T1
hyperemic (-), hyperemic pharynx(-), gum bleeding +
Ears : Ear discharge -/-
Neck : Lymph node enlargement (-)
Chest : Symmetrical in shape and movement, chest
indrawing (-)
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Cor : I : Ictus cordis not visible
P : Ictus cordis was palpable
P : heart border enlargement (-)
A : heart sounds I-II normal intensity, regular, murmur(-)
Pulmo: I : symmetrical movement (+)
P: fremitus sounds equal on both lung fields
P: sonor / sonor
A: vesicular breath sounds +/+ , additional breath sounds (-/-)
Abd : I : flat
A : bowel sound (+) within normal limit
P : tympani (+),
P : not distended, pain (-), no enlargement of liver and spleen, good skin
turgor

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Extremity : Edema : -/- Cold extremities: -/-
-/- -/-
Strong palpable of dorsal pedis artery
CRT < 2”, petechie +/+
Neurological examination
Patology reflex Meningeal reflex
Physiologic reflex
Babinsky -/- Nuchal rigidity -
Biceps +2/+2
Triceps +2/+2 Chaddock -/- Kernig sign -

Patella +2/+2 Gordon -/- Brudzinsky I/II -/-

Achilles +2/+2 Oppenheim -/-

Schaffer -/-

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January 25th, 2020 LABORATORY FINDING
• Hemoglobin : 8.5 g/dl
• Hematocrite: 25 %
• WBC :4,800/ul
• Platelet count :3 x 103 /ul • Basofile :0 %
• RBC : 3.21 million/ul • Monocyte : 6.7 %
• MCV : 77.6/ um
• MCH: 27.1/ um
• MCHC : 34.9/ um Conclusion : microcytic
• Neutrophils :59 % hypochromic anemia,
thrombocytopenia,
• Lymphocyte : 34.3%
• Eosinophile : 0 %
 Problem Lists

Child A, 15 years old, 42 kgs, with :

1. History of aplastic anemia

2. Current episode of bleeding
3. Joint pain
4. Fatigue
5. Lab: mycrocytic hypocromic anemia and thrombocytopenia
 DIFFERENTIAL DIAGNOSIS

1. Gum bleeding due to thrombocytopenia

2. Aplastic anemia
3. Malnourished
 WORKING DIAGNOSIS

1. Gum bleeding due to thrombocytopenia

2. Aplastic anemia
3. Malnourished
 THERAPY
1. Admitted to hematooncology ward
2. Room air
3. Rice pack diet 2000 kkal/day
4. IVFD D5 ½ NS 85 ml/hour
5. Paracetamol (10mg/kg/dose) = 500 mg IV as needed
6. 12 units of TC tranfusion
7. 1 bag of PRC tranfusion
 PLANNING

• CBC for evaluation after transfussion

• Peripheral blood smear
 Monitoring

 General survey / vital signs/SiO2/ BP

 Fluid balance and diuresis/8 hours
 Monitoring for bleeding
FOLLOW UP

MONDAY 27/1/20
 PHYSICAL EXAMINATION

S : fever -, gum bleeding -, patient changes the pads while menstruation >
9 times / day
GA : moderate ill, compos mentis E4V5M6
VS : Heart rate: 100 bpm Temp: 36.8oC BP 90/60 mmHg
Resp. rate : 22 bpm SiO2 : 99%

Head : mesocephal
Eyes : anemic conjunctiva +/+, icteric sclera -/-, isocoric
pupil (2mm/2mm), light reflex (+/+)
Nose : Nasal flaring (-) discharge (-)
Mouth : cyanosis (-), moist mucous (+) Tonsil T1-T1
hyperemic (-), hyperemic pharynx(-), gum bleeding -
Ears : Ear discharge -/-
Neck : Lymph node enlargement (-)
Chest : Symmetrical in shape and movement, chest
indrawing (-)
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Cor : I : Ictus cordis not visible
P : Ictus cordis was palpable
P : heart border enlargement (-)
A : heart sounds I-II normal intensity, regular, murmur(-)
Pulmo: I : symmetrical movement (+)
P: fremitus sounds equal on both lung fields
P: sonor / sonor
A: vesicular breath sounds +/+ , additional breath sounds (-/-)
Abd : I : flat
A : bowel sound (+) within normal limit
P : tympani (+),
P : not distended, pain (-), no enlargement of liver and spleen, good skin
turgor

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Extremity : Edema : -/- Cold extremities: -/-
-/- -/-
Strong palpable of dorsal pedis artery
CRT < 2”, petechie +/+
Neurological examination
Patology reflex Meningeal reflex
Physiologic reflex
Babinsky -/- Nuchal rigidity -
Biceps +2/+2
Triceps +2/+2 Chaddock -/- Kernig sign -

Patella +2/+2 Gordon -/- Brudzinsky I/II -/-

Achilles +2/+2 Oppenheim -/-

Schaffer -/-

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 WORKING DIAGNOSIS

1. Gum bleeding due to thrombocytopenia

2. Menorrhagia
3. Aplastic anemia
4. Malnourished
January 27th, 2020 LABORATORY FINDING
• Hemoglobin : 8.0 g/dl
• Hematocrite: 22 %
• WBC :2,600/ul
• Platelet count : 2 x 103 /ul • Basofile :0 %
• RBC : 2.69 million/ul • Monocyte : 4.7 %
• MCV : 82.4/ um
• MCH: 29.8/ um
• MCHC : 36.2/ um Conclusion : normocytic
• Neutrophils : 53.5 % normochromic anemia,
thrombocytopenia
• Lymphocyte : 41.3%
• Eosinophile : 0.5 %
 THERAPY
1. Room air
2. Rice packs diet 2000 kkal/day
3. IVFD D5 ½ NS 85 ml/hour
4. Paracetamol (10mg/kg/dose) = 500 mg IV as needed
5. 12 units of TC tranfusion
6. 1 bag of PRC tranfusion
 PLANNING

• CBC for evaluation tomorrow

FOLLOW UP

MONDAY 28/1/20
 PHYSICAL EXAMINATION

S:
GA : moderate ill, compos mentis E4V5M6
VS : Heart rate: 100 bpm Temp: 36.8oC BP 90/60 mmHg
Resp. rate : 22 bpm SiO2 : 99%

Head : mesocephal
Eyes : anemic conjunctiva +/+, icteric sclera -/-, isocoric
pupil (2mm/2mm), light reflex (+/+)
Nose : Nasal flaring (-) discharge (-)
Mouth : cyanosis (-), moist mucous (+) Tonsil T1-T1
hyperemic (-), hyperemic pharynx(-)
Ears : Ear discharge -/-
Neck : Lymph node enlargement (-)
Chest : Symmetrical in shape and movement, chest
indrawing (-)

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Cor : I : Ictus cordis not visible
P : Ictus cordis was palpable
P : heart border enlargement (-)
A : heart sounds I-II normal intensity, regular, murmur(-)
Pulmo: I : symmetrical movement (+)
P: fremitus sounds equal on both lung fields
P: sonor / sonor
A: vesicular breath sounds +/+ , additional breath sounds (-/-)
Abd : I : flat
A : bowel sound (+) within normal limit
P : tympani (+),
P : not distended, pain (-), no enlargement of liver and spleen, good skin
turgor

37
Extremity : Edema : -/- Cold extremities: -/-
-/- -/-
Strong palpable of dorsal pedis artery
CRT < 2”
Neurological examination
Patology reflex Meningeal reflex
Physiologic reflex
Babinsky -/- Nuchal rigidity -
Biceps +2/+2
Triceps +2/+2 Chaddock -/- Kernig sign -

Patella +2/+2 Gordon -/- Brudzinsky I/II -/-

Achilles +2/+2 Oppenheim -/-

Schaffer -/-

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 WORKING DIAGNOSIS

1. Gum bleeding due to thrombocytopenia

2. Menorrhagia
3. Aplastic anemia
4. Malnourished
 THERAPY
1. Room air
2. Rice packs diet 2000 kkal/day
3. IVFD D5 ½ NS 85 ml/hour
4. Paracetamol (10mg/kg/dose) = 500 mg IV as needed
 PLANNING

• CBC for evaluation

 CRITICAL
APPRAISAL

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 What can be given in recurrent aplastic anemia?

• Children hospitalized with aplastic

P anemia

• Immunosuppressive therapy
I

•-
C

• Outcome
O

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 VALIDITY

1. Was the assignment of patients to

treatments randomized?
• No
2. Was the randomized list concealed?
• No
3. Were patients and clinicians kept blind
to which treatment was being received?
• No

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 VALIDITY
4. Is the patient observations made
sufficiently long and complete?
• Yes
• Participants was followed up during
hopitalization until 2 months weeks after
5.discharge
Were all patients who entered the trial
accounted for? And were they analysed
in the groups to which they were
randomized?
• Yes, all patients who entered the trial
included in the analysis
• No, there weren’t any randomization
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 VALIDITY
6. Aside from the experimental
treatment, were the groups treated
equally?
• Yes
• Were
7. We canthe
seegroups
the study protocol
similar at the start of
the trial?
• yes

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 IMPORTANCE
• Number Needed to Harm (NNH) / Number Needed to
Treat (NNT) can not be calculated

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 APPLICABILITY
Were the study patients similar to our
own?
• Yes

Is the treatment feasible in my setting?

• Yes
Will the potential benefits of treatment
outweigh the potential harms of
treatment for patients?
• Yes

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 Importa
nt

LoE
Invali 2B Applicabl
d e

53
54
 LEVEL OF EVIDENCE
THERAPEUTIC STUDIES

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