Morning Report

Monday, July 29th 2019 – Wednesday, July 31st 2019

KEPANITERAAN KLINIK ILMU KESEHATAN ANAK

FAKULTAS KEDOKTERAN
UNIVERSITAS LAMPUNG
2019
1 Monday, July 29th 2019
CO-ASSISTANT ON DUTY

ER Alamanda, 2nd floor

Mira Kurnia, S.Ked Agtara Liza A., S.Ked
Dita Mauliana P., S.Ked Danang Hafizfadillah, S.Ked
Frigandra Syahputri, S.Ked

Alamanda, 3rd floor Perina

Denny Habiburrohman, S.Ked Adelia Meutia P., S.Ked
Neli Salsabila, S.Ked Astrid Ananda, S.Ked
Nidia Putri M., S.Ked
 NEW PATIENTS ON DUTY

No Identity Diagnosis/Differential Level of Division

Diagnosis Severity
1 Risky Leukimia 3 Hematology
Kurniawan/
boy/ 11 yo

2 Kevin Encephalitis 3 Neurology

Athariz /
boy/ 6mo

3 Andhika Granulomasis TB with Pleura Effusion on 3 Respirology

Pratama/bo WSD
y/10yo

4 Reyhan Obs. Fever + Febrile Confulsion 3 Neurology

Anggara/bo
y/6yo
 NEW PATIEN IN PERINATAL
5 ROOM
No Identity Diagnosis/Differential Level of Division
Diagnosis Severity
1 By. Ny. NKB + Hipotermi 1 Neonatology
Nurbaya/ 1 do

2 By. Ny. Okta NCB + SMK 1 Neonatology

Malia/1 do
Reyhan A./boy/6yo
Cardio-Pulmonary Failure

Appearance Breathing
Weak Shorten of breath

Circulation
Cyanosis

Respiratory & Breathing :

Appearance: Nasal flare (-), retraction (-), Abnormal
T: alert (+) position (+)
I: interaction (+)
C: consability (+)
L: look (+) Circulation:
S: speech (+) Cyanosis extremity (+)
 ANAMNESIS NEW PATIENT
Identity: Reyhan A./boy/6yo
Time of Admission in ER : 8.06 PM
Main Complaint : Fever since 5 days before admission
Additional Complaint : Seizure, short of breath, headache, nausea, stomachache

Present Illness History

Parent’s said patient had fever since 5 days before admission. Fever went ups and downs
sometimes, fever accompanied by cold sweat and shivering is denied. For the first time
patient had a seizure for about 10-15 minutes. During seizure, patient’s eyes glared up, the
head looked to the left, and both hand were stiff. Patient had shorten of breath and felt easier
to breath when sit down rather than lie down. Patient felt headache and had back eye pain.
Neither nosebleed nor bleeding gums were approved. Urination within normal, while
defecate (liquid) for 6 times a day start this morning. And every defecate as much as a half
glass (±100 ml). Defecate colored normal, neither black nor bleed, mucuse is denied. Patient
also felt nausea and stomachache started this morning. Patient had diagnosed ToF before and
had been done catheterization.

7
History of Past Ilness
• ToF

Medication History
• Cateterization

Family & Environment History

• None
History of past food
• ASI (+)

History of pregnancy
• G1P1A0
• Sickness during pregnancy (-)
• ANC (+)

History of nativity
• Patient born with aterm with SC procedure

8
 0

9
 Physical Examination
General Condition Body Weight : 14 kg
Sens : E4M6V5 Length : 110 cm
Pulse : 95x /m Arm diameter : 15 cm
Temp : 36C Head Diameter : 52 cm
RR : 60x/m Anemic (+)
SpO2 : 98% with O2 Nasal Cannul 2 lpm Cyanosis (+)
Dypsnea (+)

Spesific Condition
Head : Nasal flaring (-), Anemic Conjunctiva (+), Icteric sclera (-), Light reflex (+),
cyanosis in lips, palpebra edema (-)
Neck : Enlargement of lymph (-)
Thorak : Symmetrical expansion , retraction (-)
Lungs : Vesicular breathe sound, rhales (-/-), wheezing (-/-)
Heart : Murmur sistolic (+), gallop (+)
Abdomen: flat, normal bowel sound, unpalpable hepar/lien, palpation pain (-), Ascites(-)
Flank : lession (-), edema (-), pain of CVA (-)
Extremities : cold extremities, edema (-) ,cyanosis (+), clubbing finger (+)
10
Body Weight : 14 Kg
Body Height : 110
cm

H/A =
Below 5th percentile

Nutritional status :
Underweight
Body Weight : 14 Kg
Body Height : 110
cm

BW/A =
Between 10th
percentile and 25th
percentile

Nutritional status :
Normal
Body Weight : 14Kg
Body Height : 110
cm
BMI =11,5

BMI/A=
Under 5th percentile

Nutritional status :
Wasted
14
 Head Circumference
Currently : 52 cm

Normocephal

15
Nelhaus : Head circumference graphic
 PROBLEMS ASSESMENT
1. Fever 5th day ER:
2. Seizure (1 times) Obs. Febris + Febrile Convulsion
3. Shortness of breath
4. Retroorbital pain Discussion
5. Cyanosis Acute Febris ec. Viral Infections Susp.
6. Clubbing Finger Dengue Fever + Febrile Convulsion + ToF
7. Headache
8. Diarrhea
9. Nausea
10. Stomachace

DIAGNOSIS/DIFFERENTIAL WORKING DIAGNOSIS

DIAGNOSIS Dengue Fever +Febrile Convulsion + ToF
Dengue Fever
Typhoid Fever
Febrile Confulsion
Acute Diarrhea ec Rotavirus
ToF

16
 PLAN EXAMINATION
• Complete blood count
• Pheriperal blood smear
• Imunology Dengue
• Imunology Typhoid
DIET
• High Calorie and High Protein
ADMISSION
• Refer to Pediatric Specialist
17
THERAPY
• O2 nasal canule 2 lpm
• Paracetamol 10-15mg/kgBB/6 hours
(250mg /6 hours)
• IVFD RL 5cc/kgBB/hour
MONITORING
• General condition
• Vital sign (HR, RR, SpO2, T)
• Bleeding existance
 Laboratory Finding (29/07/2019)
Result Normal Value Unit
Haematology :
Haemoglobin 21,2 14 – 18 g/dL
RBC 7,2 4.7 – 6.1 106/mm3
WBC 9.600 4.8 – 10.8 103/mm3
HT 65 42-52 %
PLT 95.000 150 – 450x 103 103/µL
Malaria Not found Not found
Diff Counr B=0 0-5 %
E=0 3-6 %
N.rod =0 3-6 %
N.Segmen : 76 25-60 %
L= 18 25-50 %
M=6 1-6 %
Laboratory Finding (29/07/2019) RSMH
Result Normal Value
Imunology & Serology :
Typhi H Antigen 1/160
Typhi O Antigen 1/160
Parayphi AO 1/80
Antigen
Parathypi BO 1/160
Antigen
Dengue Fever Negatif Negatif
IgM
Dengue Fever IgG Positif Negatif
 PROBLEMS ER:
1. Fever Obs. Febris + ToF + Febrile Convulsion
2. Seizure
3. Shortness of breath Discussion
4. Tachypnea Acute Febris ec. Viral Infections Susp.
5. Cyanosis Dengue Fever + Febrile Convulsion + ToF
6. Headache
7. Diarrhea Re - ASSESMENT
8. Increasing Segment Neutrophil Typhoid Fever + Febrile Convulsion + ToF
9. Widal Test (increased)

Working Diagnosis Theraphy

O2 nasal canule 2 lpm

Typhoid Fever + Febrile Convulsion + •• Kloramfenikol 50-100mg/kg/day
ToF devided in 4 doses or Amoksisilin 150-
200mg/kg/day
• Diazepam if seizure occurs 0,2 – 0,5 mg
/ KgBB

20
2 Tuesday, July 30th 2019
CO-ASSISTANT ON DUTY

Emergency room Alamanda 2nd floor

Tasya Khalis Ilmiani, S.Ked
Hasril Mulya Budiman, S.Ked Celine Grace Sita, S.Ked
Farhandika Muhammad, Ghazlina Winanda Putri
S.Ked Edwin, S.Ked

Alamanda 3rd floor Perinatology Room

Dwirani Sukma,S.Ked Alfia Nikmah, S.Ked
Amalia Widya L,S.Ked Nadia Eva, S.Ked
Zihan Zetira, S.Ked
 NEW PATIENTS ON DUTY

No Identity Diagnosis/Differential Diagnosis Level Division

23

1 By. Madam Yola Seizure fever 4a Neurology

Selvina/boy/ 1
month and 13
days old
2 Effendi/ boy/ 2 Simple Seizure Fever Post VP Shunt 4a Neurology
years and 6
month old
 DECEASED PATIENT
24

No Identity Diagnosis/Differential Diagnosis Level of Division

Severity

NONE
 By. Madam Yola
No Emergency Sign
Selvina/boy/ 1 month
and 13 days old

Appearance Breathing
Normal Normal

Circulation
Normal

Appearance: Respiratory & Breathing :

T: alert (+) Nasal flare (-), retraction (-)
I: interaction (+)
C: consability (+)
Circulation:
L: look (+)
Pale extremity (-), CRT < 3”
S: speech (+)
ANAMNESIS NEW PATIENT
Identity: By.Madam Yola Selvina/ boy / 1 month and 13 days old
Time of Admission in ER : 04.36 PM | 00.60.34.22
Main Complaint : Seizure
Additional Complaint : Cough
Present Illness History
Patient got first seizure on 1 week before comes to a hospital. The first seizure was preceded by fever.
Seizure was like both of hand and feet tense straight with both eyes pointing up. After the seizure
happen for around 10 minutes, patient’s family bring the patient to midwife around their house, but the
seizure was stop without doing anything and patient was awake and cry. The patient got cough too in
the same day.

One hour before comes to a hospital, afterwhile patient was going to Advent hospital for treat a cough
that doesn’t heal since 1 week ago. Patient got the second seizure same like before but without
preceded by fever. Seizure was like both of hand and feet tense straight with both eyes pointing up.
Seizure was happen for around 5 minutes while on the way home and patient’s family bring the patient
to emergency room of RSAM because of the closest distance of that time. When patient was arrived on
emergency room, the seizure was stop and the patient awake and cry without using drugs.

26
History of Family Ilness
• Fever seizure on his 2nd brother
History of past food
• ASI (+)

History of vaccine
• Hepatitis B

History of pregnancy
• G4P3A1
• Sickness during pregnancy (-)
• 5 times control of ANC

History of nativity
• Patient born with aterm with SC procedure because of small mother’s pelvis.

27
 0

28
Physical Examination
General Condition Birth Body Weight : 2700 g
Sens : E4M6V4 Body Weight Currently :4900 g
Pulse : 133x /m Birth Body Length : 46 cm
Temp : 36.8º C Body Length Currently : 54 cm
RR : 42x/m Head Circumference Currently : 37,6 cm
SpO2 : 98% without O2 Nasal canul Normocephal
Nutritional statue : WHZ= 1 < z < 2 Possible risk
of Overweight
HAZ= -2 < z < 0 Normal
WAZ = -2 < z < 0 Normal
Spesific Condition
Head : Bulge sinsiput (-) Anemic Conjunctiva (-) Icteric sclera (-) pupil isokor (+/+)
Light reflex (+) Nasal flaring (-)
Neck : Enlargement of lymph (-)
Thorax : Symmetric, Dyspnea (-) retraction (-)
Lung : Vesicular(+/+), Additional breathing sound (-/-)
Heart : Normal heart sound, murmur (-)
Abdomen : convex, normal bowel sound, unpalpable hepar/lien
Extremities : warm extremities, CRT <3 seconds
29
 Boy/1 month and 13
days o.

BW: 4900 g (4,9 kg)

BL: 54 cm

WHZ= 1 < z < 2

Nutritional Status
Possible risk of
Overweight

30
 Boy/1 month and 13
days o.

BL: 54 cm

WHZ= -2 < z < 0

Nutritional Status
Normal

31
 Boy/1 month and 13
days o.

BW: 4900 g (4,9 kg)

WHZ= -2 < z < 0

Nutritional Status
Normal

32
 Normal but possible risk of become
overweight
33
 Head Circumference
Currently : 37,6 cm

Normocephal

34
Nelhaus : Head circumference graphic
PROBLEMS ASSESMENT
1. Recurrent seizure
2. Cough Emergency room :
Fever Seizure

Discuss :
Recurrent seizure

DIFFERENTIAL DIAGNOSIS WORKING DIAGNOSIS

Recurrent seizure
Epilepsy

35
PLAN EXAMINATION THERAPY
• Complete blood count Emergency room :
• EEG (Electro Encephalogram) KAEN 3B 8 dpm
PCT 3 x ½ cth

Discuss :
• Diazepam while seizures.
0,2 – 0,5 mg / KgBB
Dissolve it on NaCl 0,9% / D5
2 cc Diazepam on 8 cc NaCl 0,9% : 10cc

For this patient :

DIET
Continuing breast milk until 6 month.
1mg / 30 sec-1 minute
max dose :10mg each day.
MONITORING
• General condition
• Vital sign, HR, RR, SpO2

36
ADMISSION Neurology Division
 Laboratory Finding (31/07/2019) RSAM
Result Normal Value (1-2 month) Unit
Haematology :
Haemoglobin 10 10.5 – 14 g/dL
RBC 3,1 3 – 5.4 106/mm3
WBC 5.100 5 – 19.5 103/mm3
Ht 29 32-42 %
PLT 661.000 150 – 450x 103 103/µL
Diff count 0/0/0/20/74/6 0-1/1-6/50-70/20-40/2-8 %

37
3 Wednesday, July 31st 2019
 DECEASED PATIENT
39

No Identity Diagnosis/Differential Diagnosis Level of Division

Severity
1 By. Ms. Yuliana / low weight of birth + premature + 1 Neonatology
male / 5 days gastroschizis + duodenal atresia
old

2 By. Ms. Siti

Khotijah/ 4 days low weight of birth + premature + respiratory 1 Neonatology
old distress syndrome
ANAMNESIS DECEASED PATIENT
Identity:
• Name : Male baby from Ms. Yuliani
• Date of Birth : 26/07/2019
• Age : 5 days
• Gestational Age: 28 weeks
• Gender : Male
• Birth Length : 33 cm
• Birth Weight : 1500 gram
Working Diagnosis : LBW (low birth weight) + Premature + Gastroschizis + Duodenal atresia
Labor History : Gestational weeks: 28 weeks G1P0A0
Intranatal History : Spontaneous vaginal delivery perfomed by midwife, spontaneous crying (+)
Postnatal History : -

Chronology
Tuesday, 30/07/2019
A male 4 days-newborn baby came to Abdul Moeloek hospital’s ER diagnosed with Low birth
weight, premature, gastroschizis, and duodenal atresia. The baby wos born by spontaenous
vaginal delivery at 28 weeks of gestasion to a 21-year-old gravida 1, para 0 mother. The
birth weight was 1500 grams. The baby was planned to have an emergency abdominal
surgery. Then the surgery was held on Wednesday July 31st 2019 at 15.30 WIB. After the
40 surgery, the baby was intubated and sent to NICU to be administered by ventilator. The baby
was observed hourly.
 17.15 17.20 17.22 17.30
SpO2: 88% SpO2: 85% Patient was not Death is stated
HR: 104x/mins HR: 49x/mins responding
T: 36,3ºC T: 36,0 ºC after
RR: 21x/mins RR: 18x/mins resusitation.

 Resusitation
is
performed 1
cycle
 Heart rate is
unmeasurab
le
 Pupil
midriasis

41
ANAMNESIS DECEASED PATIENT
Identity:
• Name : Male baby from Ms. Siti Khotijah
• Date of Birth : 27/07/2019
• Age : 4 days
• Gestational Age: 31 weeks
• Gender : Male
• Birth Length : 34cm
• Birth Weight : 2100 gram
Working Diagnosis : LBW (low birth weight) + Premature + Respiratory distress syndrome
Labor History : Gestational weeks: 31 weeks G3P3A0,
Intranatal History : Spontaneous vaginal delivery perfomed by midwife, spontaneous crying (+)
Postnatal History : A/S 8

Chronology


42
 14.00 15.00 16.00 17.00 18.00 18.15
Patient was SpO2: 96% SpO2: 88% SpO2: 60% SpO2: 61% The baby was
observed HR: 106x/mins HR: 90x/mins HR: 68x/mins HR: 52x/mins not respond-
with T: 36,3ºC T: 36,0 ºC T: 36,1 ºC T: 35,6 ºC ing
gasping RR: 40x/mins RR: 40x/mins RR: 40x/mins RR: 40x/mins
respira- HR was unmea-
tory and  Resusitatio surable
needed n was
ventila- performed Sianosis (+),
tor. 2 cycle mottled (+)
PEEP : 5
cmH20 Midriasis (+)
FiO2 : 55%
Flow : 8 lpm The death was
stated at 18.15

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44

THANK YOU