MORNING

REPORT

KEPANITERAAN KLINIK ILMU KESEHATAN ANAK

FAKULTAS KEDOKTERAN
UNIVERSITAS LAMPUNG
2021
April 23rd 2021
2 pm – 9 pm

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 CO-ASSISTANT ON DUTY

Alamanda Perina

Firinda Soniya (2nd floor) Mutiara Khalish

Angwen Rial Huga (3rd floor) Maharani A

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 NEW PATIENT ON DUTY

Level of
No Identity Diagnosis Division
Competition

An. Zaaef Alli Jaber Ascites ec Susp.

1. - Non-infection
Rizal/Boy/2 months old Nephrotic Syndrome

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An. Zaaef Alli Jaber Rizal/Boy/2
months old

Stable

Appearance Breathing
Normal Normal

Circulation
Normal

Appearance: Respiratory & Breathing:

T: alert (+) Nasal flare (-), retraction (-)
I: interaction (+)
C: consability (+) Circulation:
L: look (+) Pale extremity inferior (+),
S: speech (+) CRT inferior > 2 sec

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 The History
Identity: An. Zaaef Alli Jaber Rizal / Boy / 2 months old

Time of Admission in Alamanda 2nd floor: 4:30 p.m.

Main Complaint : Enlarged stomach
Additional Complaint : Swollen scrotal (enlarged testicles)
Present History:
The patient was reffered to the Emergency Department of Abdul Moeloek Hospital from Ahmad Yani Hospital Metro
at 16.40 PM April 21st 2021 with history of enlarged stomach and bilateral scrotal swelling (enlarged testicles), which
had slowly grown since half a month ago. The patient’s mama said that the enlargement was also followed by puffy on
his face especially his cheeks (chubby). Then, the patient’s parents took him to a pediatrician in Metro and was
performed laboratory examination in Unyai Clinic Metro. The patient was then treated at Ahmad Yani Hospital Metro
for 12 days before entering Abdul Moeloek Hospital. On the third day of hospitalization, the patient has seizure less
than 1 minute, without a fever, just once and then stopped. On the fourth day of treatment, the seizures continued more
than 10 times a day. The seizures is twitching last for 5-10 seconds and not following with a fever. The patient was
given medication and then a CT scan of the head was performed. The patient arrived at Alamanda 2 nd floor with
oxygen nasal canulla and looks pale. The patient's mother said that the patient had never difficulty breastfeeding and
the patient could breastfeed up to 480 cc per day, with diaper changes up to 7 times a day. The patient had no fever, no
shortness of breath, no vomiting, and no bleeding.

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History of Past Illness
• The mother said that her baby had never any illness before

History of Family Illness

The History
• The mother said that no one had experienced like this before, the illness like ascites, anemia, DM,
hypertension, genital disesase, heart disesase, lungs disesase, and etc be denied

History of Pregnancy
• Maternal health condition: the amniotic fluid was low (around 28 weeks), the mother has never
experienced pain during pregnancy, has never had spots or bleeding, has never had a history of miscarriage,
has never taken certain drugs
• Mother’s habit: always took vitamins, works a lot and often tired
• ANC: with obstetricians, routinely
• TT imunitation: (+)
• Birth spacing: interval between 1st child and 2nd child  2 years
• Number of births: 2
• When the mother’s gestational age was 28 weeks, the mother carries out control to the obstetrician and the
result is that mother’s amniotic fluid was low so that it needs to be treated at hospital for 3 days. After that
the mother was sent home for a total bed rest for 7 days, therefore that a caesarean section can be done
afterwards. However, in less 7 days the mother experiences contraction and it was necessary to take action
(caesarean section) immediately

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History of Nativity
• P2A0
• Date of birth: Feb 14th 2021
• Weight at birth: 2200 gr, and Height at birth: 49 cm History
The
• Preterm (but the mother said her baby had no history of incubation)
• Caesarean section (because of mother’s amniotic fluid was low)
• Crying after birth (+)

History of Immunitation
• BCG (+)

History of Past Food

• 0 - 1 month 27 days : ASI Exclusive (+)
• 1 month 28 days – 2 months 9 days : ASI Exclusive (+) and baby formula (since being sick, the mother gave her
baby formula milk Bebelac)

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 Physical Examination
General Condition Vital Signs:
• Impression: moderate illness The History • HR: 123 x/minutes
• Sens: E4M6V5 • RR: 50 x/minutes
• Sex: Boy • T: 37,2 ºC
• Weight: 5600 gr with ascites and edema on cheeks, genital and • SpO2: 87% with nasal cannula
inferior extremities (Anasarca oedem)
• Weight with correction: 5,6 kg – (30% x 5,6 kg) = 3,92 kg (3920
gr)
• Length: 50 cm
• Upper arm Circumference : 12 cm
• Head Circumference : 37 cm

Spesific Condition
• Head: normocephal, the fontanel isnt closed yet, black hair, spread evenly, not easy to remove and moon face
(+)
• Eye: icteric sclera (-/-), anemic conjungtiva (+/+), oedem palpebra (-/-), light reflex (+/+)
• Mouth: pale lips (+), dry lips (-)
• Neck: normal, enlargement of lymph (-)
• Skin: normal colour

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Spesific Condition (Thorax)

Lungs:
Anterior
• Inspection : lesions (-/-), retractions (-/-)
• Palpation : pain (-/-), chest wall expansion (same)
• Percussion: not rated
• Auscultation: vesiculer (+/+)
Posterior
• Inspection : not rated
• Palpation : not rated
• Percussion: not rated
• Auscultation: not rated
Heart:
• Inspection : ictus cordis is not visible
• Palpation : ictus cordis palpable
• Percussion: not rated
• Auscultation:normal heart sound (I & II), regular

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Spesific Condition (Abdomen)
• Inspection : bloated (+), dilatation of vein, spider nevus (+)
• Auscultation: bowel sound 10x/minutes
• Percussion: ascites (+)
• Palpation : pain (-)

Hepar: liver is hard to be rated

Spleen: spleen is hard to be rated

Extremity:
• Superior: warm extremities, CRT <2 seconds
• Inferior: cold extremities, CRT >2 seconds, pitting edema (+/+)

Genital: swollen scrotal (enlarged testicles), transilumination (-), anus (+)

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 Physical Examination (Nervous System)
Primitive Reflex
• Rooting reflex : (+)
• Plantar grasp reflex : (+)
• Palmar grasp reflex : (+)
• Moro reflex : not rated
• Tonik neck reflex : not rated

• The activity of baby : the baby was asleep and calm, sometimes crying
• Consciousness level : conscious
• Movement: spontant
• Opening eyes: spontant

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Nutritional Status: Fenton Chart

Body Weight : 3,92 kg

Body length : 50 cm
Age : 2 months 9 days old (9 weeks)
Gestational age: 28 weeks
Correction Age: 28 + 9 = 37 weeks

Interpretation:
Body Weight > 90th percentile (Large for
Gestational Age)
Body Height 10th – 90th percentile
(Appropriate for Gestational Age)

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 Nutritional Status: Lubchenco Chart

Body Weight : 3,92 kg

Body length : 50 cm
Age : 2 months 9 days old (9 weeks)
Gestational age: 28 weeks
Correction Age: 28 + 9 = 37 weeks

Interpretation:
Body Weight > 90th percentile (Large for Gestational
Age)
Body Height 10th – 90th percentile (Appropriate for
Gestational Age)

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 Nutritional Status: Lubchenco Chart

Body Weight : 3,92 kg

Body length : 50 cm
Age : 2 months 9 days old (9 weeks)
Gestational age: 28 weeks
Correction Age: 28 + 9 = 37 weeks

Interpretation:
Body Weight > 90th percentile (Large for Gestational
Age)
Body Height 10th – 90th percentile (Appropriate for
Gestational Age)

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 ADDITIONAL DIAGNOTIC TEST
April 22nd 2021

Parameter Result Reference Value Unit

Hematology Test
Hemoglobin 7,2 9.2 - 13.6 g/dL
Hematocrit 22 30 - 46 %
Platelets 368.000 217.000 – 497.000 /µL
Leukocytes 12.450 5.500 – 18.000 /µL
Eritrhocytes 2.5 2.8 – 4.8 106/µL
MCH 29 24 - 36 fL
MCV 89 81 - 121 pg
MCHC 32 26 - 34 g/dL

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 ADDITIONAL DIAGNOTIC TEST
April 22nd 2021

Parameter Result Reference Value Unit

Diff Count
Basofil 0 0-1 %
Eosinofil 1 0-1 %
Batang 0 0-8 %
Segmen 24 17 - 60 %
Limfosit 63 20 -70 %
Monosit 12 1 - 11 %

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 ADDITIONAL DIAGNOTIC TEST
April 22nd 2021
Parameter Result Reference Value Unit
Chemical
SGOT 41 <77 U/L
SGPT 18 <56 U/L
Albumin 1 3,5 – 5,2 g/dL
Ureum 7 11 - 36 mg/dL
Creatinine 0,15 <0,42 mg/dL
Natrium 129 132 - 140 mmol/L
Kalium 4,9 3,5 – 5,6 mmol/L
Kalsium 4 9 - 11 mg/dL
Klorida 105 97 - 108 mmol/L

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 Additional Diagnostic Lab: Ro Thorax

▫ Bronchovesicular streak is normal

▫ Both costophrenic sinuses are taper
▫ Both diaphragms are smooth
▫ Cor, CTR <0.58
▫ Bone system is visualized intact
▫ Impression : pulmo and cor is normal

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 Additional Diagnostic Lab: CT-Scan

▫ Soft tissue extracalvaria: normal, no

hematoma/mass
▫ The boundaries of white matter and grey matter
accentuate
▫ There were no pathological hypo/hyperdense
lesions either intracerebral or intracerebellar
▫ The anterior cornu of the bilateral lateral
ventricles appears narrowed
▫ Midline is in the middle (not deviation)
▫ Impression: cerebral edema, no visible image of
mass/infarct/bleeding in the intracerebral and
intracerebellar

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 Additional Diagnostic Lab: USG
▫ Hepatobiliary: not enlarged, no visible mass, flat surface,
portal veins and hepatic veins are not dilated
▫ Gall bladder: large and normal shape, no visible
stones/masses, bile ducts are not dilated
▫ Spleen: not enlarged, no mass visible, normal parenchyma
▫ Pancreas: closed by intestinal air
▫ Kidney: not enlarged, no mass visible, normal parenchyma
▫ Ureter: undetectable
▫ VU: no enlargement, no visible stones/masses, no visible
ascites in the pelvic cavity
▫ Conclusion: hepar, gall bladder, spleen, kidney and VU is
normal
▫ There is a bilateral collection of fluid around the testicles

Impression: ascites, testicle hidrocele22

bilateral, no mass visible intraabdominal
Problem Assessment
• Seizures Emergency room:
• Anemia • Ascites ec Hypoalbuminemia
• Ascites • Anemia
• Swollen scrotal bilateral • Hidrocele
• Hypoalbuminemia • Electrolit Imbalance
• Electrolit imbalance (hypocalcemia and
hyponatremia)

Differential Diagnosis Working Diagnosis

Nephrotic Syndrome Ascites ec Susp Nephrotic Syndrome
Nephritic Syndrome
Hidrocele Communicating

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Therapy Monitoring
Emergency room: • Monitoring general condition
• Inf. D5 ¼ NS 15 tpm • Observation of vital sign
• Inf. Nacl 0,9% 30 cc/2 hours • Give comfort position
• Inj. Cefotaxim 200 mg/8 hours

Planning
• Inf. KAEN 3A 300 cc/24 hours
• Inj. Cefotaxim 200 mg/8 hours
• Inj. Lasix 4 mg/8 hours
• Transfusion PRC 30cc & 40 cc
• Albumin 25% 20 cc & Albumin 20 % 25 cc
• Metilprednisolon 400 mg/8 hours
• Ca Gluconas 3 cc/12 hours + aqua
• Lab test: urinalysis, profil lipid, hematology

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 ADDITIONAL DIAGNOTIC TEST
April 24th 2021
Parameter Result Reference Value Unit
Urinalysis
Colour Yellow Yellow
Clarity Clear Clear
Spesific Gravitiy 1,005 1,003 – 1,030
pH 6,0 4,6 – 8,5 g/dL
Leucocytes (-) (-) / 10 Leuco/ul
Nitrites (-) (-) mg/dL
Protein 500 (-) / < 30 mg/dl
Glucose (-) (-) / < 30 mg/dl
Ketones (-) (-) / < 50 mg/dL
Urobilinogen (-) (-) / < 1 mg/dl

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 ADDITIONAL DIAGNOTIC TEST
April 24th 2021
Parameter Result Reference Value Unit
Urinalysis
Bilirubin (-) (-) / < 2 mg/dl
Occult blood 50 (-) / < 10 ery/ul
Sediment
Leukocytes 0–4 1–4 /LP 400x/LPB
Erythrocytes 3 – 10 0–1 /LP 400x/LPB
Ephitelial cells 0–3 5 – 15 /LP 400x/LPB
Bacterial (-) (-)
Crystal (-) (-)
Silinder (-) (-)

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 ADDITIONAL DIAGNOTIC TEST
April 24th 2021
Parameter Result Reference Value Unit
Total Cholesterol 279 114 – 203 mg/dl

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 ADDITIONAL DIAGNOTIC TEST
April 24th 2021

Parameter Result Reference Value Unit

Hematology Test
Hemoglobin 10,2 9.2 - 13.6 g/dL
Hematocrit 31 30 - 46 %
Platelets 101.000 217.000 – 497.000 /µL
Leukocytes 20.500 5.500 – 18.000 /µL
Eritrhocytes 3,6 2.8 – 4.8 106/µL
MCH 28 24 - 36 fL
MCV 87 81 - 121 pg
MCHC 33 26 - 34 g/dL

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Attachment

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THANK YOU