Morning Report

Wednesday, September 11th, 2019

Onsite:
Dr. Mars Nasrah, Sp.A
Pediatric Residents
Chief: dr. Tita Menawati
Emergency room: dr. Syari,dr. fariyasni dr. Infra
Pediatric Intensive Care Unit: dr. Inayah
Neonatology Intensive Care Unit: dr. Sulasmi, dr. Sri
Ward : dr. Sulaiman, dr. Rizky

Department of Pediatric Medical Faculty Syiah Kuala University

Zainoel Abidin Hospital Banda Aceh
2019
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 IDENTITY
• Name : Habibur Rahman Al Fathir
• Sex : Male
• Date of Birth : 11-12-18
• Age : Month days
• Address : Jl. Unmuha Batoh
• MR No. : 1-22-06-18
• Date of Admission : September, 11th 2019
Appearance
- Tone : weak Work of Breathing
- Interactiveness: low - Nasal flare positive
- Consolability : gasping - Epigastrial,
- Look : not able to make eye intercostal,
contact suprasternal
- Speech/cry : weak cry retraction

PAT

Circulation
- Pale
- Icteric
- CRT 3 seconds
- Cold extremities
 ANAMNESIS
• Chief Complaint:
Asphyxiate and cough
• Additional Complaint:
Cough, out of breath. History of fever
• Present History:
• patient came with the family with complaints asphyxiate 2 days ago before
went to the hospital, and begin getting worse. Before went to the hospital, his
mother brought him to psychic and get some advice.
• He has cough since week ago, cough does not too active but productive. He
also had history out of breath since born. While drinking milk, he had out of
breath. He had formula milk since birth.
• Along this two months, he drinks SGM milk and get red blotches, swollen head,
and brought to pediatrician and diagnosed with an allergy and change the milk.
His breath was still sound, but his skin color was normal.
 ANAMNESIS
• History of illness:
Patient has not been like this condition before
• History of Family Illness
No family member suffers from the same illness as the patient
• History of drugs use
Antibiotic
Paracetamol
• History of allergy
Unknown

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 ANAMNESIS
Pre Natal, Natal and Post Natal Care
• 3rd child from 3 siblings. born cesarean with an umbilical cord. Birth weight
2800 gram, aterm baby, immediately crying, never admitted to Nicu.
History of immunisation:
• He had complete immunization
History of nutrition:
• 0-2 months  breast milk and formula milk BMT,
2 - 6 months old  formula milk / soya milk.
Above 6 months old: soya and rice
history of growth and development:
• He is already on his stomach and can turn around. He can not sit alone and
crawl yet.
 Time Table

2 days ago 1 day ago Now

Transferred
Dypsneu Dyspneu to RSUDZA
Fever Fever
Cough

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 Vital Sign
• Consciousness : E4 V5 M6 = (Compos Mentis)
• Pulse : 134 beats/minutes
• RR : 58 times/minutes
• Temp : 37,10C (axilla)
 ANTHROPOMETRY
• Actual Body Weight : 8,7 kg
• Height : 72 cm
• Weight/ Age : -2SD s/d +2SD
• Length/ Age : -2SD s/d +2SD
• Weight/Lenght : -2SD s/d +2SD
• HA : 9 Month
• Arm circumferrence : 15,5 cm
• Head of Circumferrence : 43 cm
• Nutritional Status : Normoweight

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 Physical Examination
• Head : Normocephaly, HoC= 36 cm, black hair, difficult to pull
• Face : Symmetrical
• Eyes : Conj. Palp inferior pale,
pupil isokor (3mm/3mm),
light reflexes positive
• Nose : Nasal flare
• Mouth : symmetric
• Neck : Symmetrical
• Ears : Normotia, no secretes

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• Thorax
Anterior:
Inspection : Retraction on suprasternal, intercostal, epigastrial
Auscultation : Vesiculer, Ronkhi on both lung, no wheezing

• Posterior:
Inspection : No retraction
Auscultation : Vesiculer, Ronkhi on both lung, no wheezing

• Cor
Inspection : Ictus cordis not seen
Palpation : Ictus cordis palpable on ICS 5 linea mid clavicularis sinistra
Auscultation : S I > SII, Reguler, no thrills or murmurs

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• Abdomen

Inspection : symmetrical, supple, not distended, hernia umbilical

Palpation : turgor normal

Percussion : Thimpany

Auscultation : Peristaltic normal

• Ekstremity

Superior : cold, CRT 5 second

Inferior : cold, CRT 5 second

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 Laboratory Examination

Hemotology 11-09-19 Normal Value

(RSUDZA)
Hemoglobin 9,1 9,0-14,0 gr/dl
Hematokrit 28 30-43 %
RBC 3,3 3,8-5,5 106/ mm3
WBC 14,7 6,0-17,5 103/mm3
Platelets 115 150-450/103 mm3
Eosinofil 0 0-6%
basofil 0 0-2%
N. Batang 0 2-6%
N. Segmen 73 50-70%
Limfosit 22 20-40%
Monosit 5 2-8%
MCV 84 80-100fl
MCH 27 27-31pg
MCHC 33 32-36%

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 Laboratory Examination
Hemotology 11-06-19 Normal Value BGA Result
(RSUDZA)
SGOT 447 <35 U/L pH 7,287
SGPT 160 <45 U/L pCO2 30,60
ALP <240 pO2 37
Bil. Total 0,3 - 1,2 mg/dl BE -10,1
Bil Indirect 0,3-1,9 mg/dl HCO3 14,7
Ureum 43 13-43 mg/dl TCO2 15,7
Creatinin 0,60 0,6-1,1 mg/dl SO2 64,2
Albumin 3,20 3-5 mg/dl
PT
APTT 26-37 detik
HBsAg Negatif
Natrium 137 129-143 mmol/L
GFR: ml/min/1,73 m2
Kalium 4,7 3,6-5,8 mmol/L ( N: 61-74 ml/ min/1,73 m2)
Calsium Ca 7,3 8,6-10,3 mmol/L

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Peripheral blood smear:
Erytrocyte : Normochrome, normositer

Leucocyte : Increased in amount, neutrophil segment dominant,

immature granulocyte positive (myelocyte), blast
negative, toxic granule positive, atypical lymphocyte
negative.

Trombocyte : Increased in amount, giant platelet positive.

Summery:
Leucocytosis, thrombocytosis, suspect leuchemoid reaction

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Thorak AP
 Recommended Daily Allowance

• Fluid Requirement for 1 month

= 150cc/kgBB/day = 720 cc/day
• Calories for boy with 1 month old (4,8 BW kg)
= (95-107) x kg
= 450 – 510 Kcal/day
• Proteins for boy with 1 month old (BW kg)
= 2,2 x 4,8 kg
= 10,56 grams/day
 Differential Diagnosis
• Respiratory failure threat ec DD/:
1. Severe Brochopneumonia
2. Bronchiolitis
• Severe Dehidration
• Proteinuria ec dd; Sindroma Nefrotik
• Anemia normositic normochrom

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 Working Diagnosis

• Respiratory failure threat ec Severe

Brochopneumonia (J96.00)
• Anemia normositic normochrom(D63.0)

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 Treatment

Supportive
- O2 5 lpm Simple mask
- IVFD NaCl 0,9% 10cc/ 1hour – 87cc/Hour
- Diet fasting temporary
Medications
- Inj. Cefotaxime 300 mg/8 hours IV
- Inj. Ampicilin 250 mg/6 hours IV
- Nebule NaCl 3% 2 cc/8 hours, suction post nebule

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 Planning

• Consult to growth and development division

• Diuresis monitoring every 6 hour
• Nasal Gastric Tube
• Suction Reguler
• DPJP Respirologi

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Clinical photo

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THANK YOU
THANK YOU