MORNING

REPORT
Friday, 6th March 2020
 PROGRAM PENDIDIKAN
ILMU KESEHATAN ANAK
VISI
MENJADI PUSAT PENDIDIKAN DOKTER SPESIALIS ANAK
PILIHAN DI TINGKAT NASIONAL YANG MENGHASILKAN
DOKTER SPESIALIS ANAK YANG KOMPETEN DAN
BERKUALITAS INTERNASIONAL TAHUN 2020
MISI
1. MENYELENGGARAKAN PENDIDIKAN KEDOKTERAN
BERBASIS KOMPETENSI BERSTANDAR NASIONAL,
MUTAKHIR, PROFESIONAL, DAN BERLANDASKAN
KEILMUAN BERBASIS BUKTI
2. MENYELENGGARAKAN PENELITIAN KEDOKTERAN DAN
KESEHATAN YANG INOVATIF, UNGGUL, KOMPETITIF DAN
BERORIENTASI PADA PENGEMBANGAN ILMU DAN
BERMANFAAT BAGI MASYARAKAT
3. MENYELENGGARAKAN PELAYANAN KESEHATAN ANAK
YANG HOLISTIK DAN KOMPREHENSIF
4. BERPERAN AKTIF DALAM PENGEMBANGAN PENDIDIKAN,
PENELITIAN KEDOKTERAN, PELAYANAN KESEHATAN
ANAK DAN PENGABDIAN MASYARAKAT
 DOCTORS ON DUTY
3

Junior On Duty Madya On Duty

dr. Nila sari B dr. Tessa Rulianty
dr. Sahala Iriawan dr. Rezky Indah P

Madya II On Duty Emergency on duty:

dr. Shinta Nareswari dr. Herka Pratama Putra
dr. Esti Febriyanti

Onsite Supervisor Supervisor On Duty

dr. Hasri Salwan, Sp.A(K) dr. Azwar Aruf, Sp.A,M.Sc
 CO-ASSISTANT ON DUTY
4

IKA – B IKA – C
Oktaviani, S.Ked Arisda, S.Ked
Ima, S.Ked Fatya, S.Ked
Ridho, S.Ked

ER Neonatal Ward
Nur Azizah, S.Ked Pramadita, S.Ked
Clarisya, S.Ked Jason, S.Ked
 TOTAL NUMBER OF INPATIENTS
Box Patients New Discharge Patient with Deceased Total
Patients Patients Problems
Gastroenterologi 5 - - - - 6
5
Nutrition & metabolic disease 2 - - - - 2

Endocrine 0 - - - - 0
Infection 3 1 - - - 3
Respirology 10 - - - - 10
Al- Immunology 5 - - - - 6
Neurology 9 - - - - 9
Nephrology 4 - - - - 5
Cardiology 9 - - - - 9
Hemato-Oncology 35 - - - - 36
Neonatology 16 1 - - - 19
PICU 4 1 - - - 4
NICU 11 1 - - - 11
Total 123 4 - - - 131
 NEW PATIENTS DURING ON
No Identity DUTY
Diagnose/ Severit Division
. Differential Diagnose y Level
1. By.E/M/4 D.O PT-AGA + RD ec susp HMD dd BP 2 NICU
2. By.M/F/2 D.O FT-AGA + RD e.c TTN dd BP 3 Neonatologi
3. An.I/F/ 4 M.O Respiratory distress e.c Severe Decomp 3 PICU
cordis e.c Hypertrophy Obstructive
Cardiomiopathy
4 An. Y.P/M/ 12 Y.O DHF Gr I 2 Infection
 1

2
7

7
ANAMNESIS
Identity : an. BPR /Male/4 Mo
Time of Admission in ER : 6th March 2020 22.30 PM

Chief complain : Severe Respiratory Distress

Present Illness History
Since 8 days before admission the patient start to cough, mucus (+) and the patient also
had a runny nose, the patient also looks breathless, breathless not affected by the
weather nor position, and the patient also had a fever, the fever not high but did not
measure by the parents, there was no vomit nor nausea than the patient was brought to
Pediatrician and the patient suggested to admitted, and the patient was admitted to
Private hospital. The patient was admitted to private hospital for 9 days, and was
diagnosed with decomp cordis and pneumonia, while admitted the patient got
Ceftazidime3x200mg and propranolol2x2mg, Furosemide 2x4mg, on 9th day of
admitted there were no improvement of the patient condition, and the patient look even
more breathless and irritable, and then the patient suggested to reffered to RSMH for
further treatment.
The patient was diagnosed with hypertrophy obstructive cardiomyopathy with severe
mitral regurgitation and severe tricuspid regurgitation since 21 January 2020 and was
admitted in cardiology division for 2 weeks and the patient was discharged in 9
february 2020
Physical Examination
Sens: E3M6v4 (Iritabel) BW: 4,9 kg length: 55 cm Anemic (-)
BP: 100/60 mmHg WAZ: 0Sd<Z<2Sd Cyanosis (-)
HR:170 x/min HAZ: 0Sd<Z<2Sd Dypsnea (+)
RR: 65 x/min WHZ: 1SD Icterus (-)
Temp:37,3 ’C Good nutritional Status BSS 91mg/dl
SpO2 without O2 80% Ross Score modifikasi : 9
SpO2 with NRM 8LPM 88-
92%
Specific
Condition
HEENT : Nasal flaring (+), anemic conjunctiva (-), icteric sclera (-),
Normocephaly,Pupil isocor 3mm-3mm and reacted with light
Thorax : simetric, Retraction (+) intercostal and epigastrium

Lung : vesiculer normal, rales (+), wheezing (+)

Cor Regular regularly rhythm, murmur (+) Sistolik ICS II-III LPS Sinistra, gallop (-)
Abdomen Round, shifting dullness (-), normal bowel sound, liver Palpable 2cm Bac 1cm Bpx and spleen
not palpable
Extremities : warm, CRT <3’

Genitalia/ : Normal
Anus
 PROBLEMS ASSESMENT
1.Respiratory Distress Respiratory Distress e.c Severe Decomp
2.Decrease of consciousness (Iritabel) Cordis e.c Hypertrophy Obstructive
3.Fever Cardiomyopathy + Pneumonia
4.Cough
5.Diagnose with Hypertrophy
Obstructive Cardiomyopathy

DIAGNOSIS/DIFFERENTIAL WORKING DIAGNOSIS

DIAGNOSIS
Respiratory Distress e.c Severe
Decomp Cordis e.c Hypertrophy
Obstructive Cardiomyopathy +
Pneumonia dd pulmonary edema
Respiratory Distress e.c Severe Decomp
Cordis e.c Hypertrophy Obstructive
Cardiomyopathy + Pneumonia

10
PLAN EXAMINATION THERAPY
• CBC, ESR, CRP, Blood Gas • IFVD D5 ¼ NS kec 15cc/hrs (3/4
analysis retriction)
•Blood culture • Ampicillin 3x350 mg intravena
• Ceftazidime 3x200md intravena
• Propanolol 2x2mg
• Furosemide 2x4mg
• NIV

DIET MONITORING
NPO Vital sign
Degree of consciousness
Breathing and oxygention

ADMISSION PICU
 Laboratory Finding RSMH (22/02/20)
Result Normal

Haemoglobin 12.4 12,0-14,4 g/dL

12 RBC 4.95 4.75-4.85 106/mm3

WBC 7.97 4.5 – 13.5 103/mm3

PLT 423 217 – 497 103/µL

Ht 37 37-41 %

Diff count 0/0/32/52/16 0-1/1-6/50-70/20-40/2-8 %

SGOT 233 0-38

SGPT 185 0-41

Ureum 32 16.6-48.5
Kreatinin 0.41 0.57-0.87

MCV 75.4 75-87 fL

MCH 25 25-31 pg

MCHC 33 33-35 g/dL

Alb 4.0 3,8-5,4 g/dl

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Result Normal

Ca 9.6 9.2-11

BSS 93 <200

Na 136 135-155

K 5.5 3.5-5.5

Cl 103 96-106
CRP <5 <5
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YOU