Morning Report

List of the patient : 1 patient

No. Identity Diagnose Date of arrived on
the hospital
1. DOS/ 7years 4 Months/ Bisitopenia e.c. Acute Leukemia 10 Jan 2021
Girl
 Patient Identity
Name
Age
Gender
No. RM
Address
Admission
date

Chief Complaint: Pale

 Pediatric Assessment Triangle
• Behaviour
– Tonus : within normal limit
– Interactivene : within normal limit
ss : within normal limit
– Consolability : within normal limit
– Look or gaze : within normal limit
– Speech and
cry
• Breathing : reguler
• Body Color : pale was found

Conclusion:
 Primary survey
Airway Exposure
Clear, spontaneously -Allergy : none
Breathing -Medication : IVFD RL
RR 20, SpO2 99%, no chest retraction. -Past history : RS Royal Prima
Circulation -last meal : none
HR 80 beat per minute, regular, strong pulses, warm
extremities. CRT < 3sec.
-Events : none
Disability
Compos mentis GCS 15(E4 M6 V5).

Impression: within normal limit

 Secondary Survey
History of present illness

Onthedayadmission

• pale experienced this 1 month. getting worse this week.

• No history of spontaneous bleeding was found.
• No history of trauma was found.
• No fever, no bruising.
• There was no family history of exposure to chemicals.
• cough is not found, shortness of breath is not found.Defecation and micturition within normal limit
• RPT the patient was admitted to the Royal Prima Hospital with a diagnosis of typhoid + bilateral pneumonia.
CXR ( 09th 03 2022)
 Laboratory result
Result Result
Hb 6.8 Gambaran darah
Ht 20.4 Tepi
Leucocyte 22.630 Leukosit Blast, immature cel
Platelet 29.000 Normal, jumlah
MCV 88 Trombosit berkurang
MCH 29.5 Normokrom
MCHC 33.6 Eritrosit normositer, jumlah
berkurang
E/B/N/L/M 0.4/1.2/15.8/24.8/
57.8
Past Medical History

• Patient was admitted at Royal Prima Hospital with diagnose suspect

leukemia. The patient has had a 4 bag prc transfusion at the Royal
Prima Hospital, then he was referred to the RSUPHAM
• In January 2022 patient was admitted to RS Eshmun with DX typhoid
fever.

Family History

No similar history was found in the family.

Growth and development History

• Within normal limit

Birth history

• Patient was born by section caesaria, aterm, BW

3600g, Strong cry, no retraction
• Patient is the second child from 2 siblings

Immunization history

complete

Nutrition history

Adequate food intake

Anthropometric Measurements
• Weight = 20,5 kg
• Height = 120 cm
• W/A = 83%
• H/A = 96%
• W/H = 90%
• LLA =

Impression : good nutrition status

 Physical Exam
General Condition
• No pale, GCS 15 (E4M6V5)

Vital signs
• Blood Pressure : 100/70 mmHg, P50-90 (93-108/56-70)
• HR : 80 bpm
• RR : 20 cpm
• Temp : 36,9 oC
• O2 Saturation : 98%

14
Head : Normocephaly, no deformity
Eye : Conjunctive palpebral inferior was not pale, isochoric pupil, light reflexes (+/+), no icteric

Nose : no nose flare

Mouth : Lips mucous wasn’t pale, no gum bleeding

Neck : no enlargement of cervical lymph nodes

Chest : fusiform symmetrically, without retraction
HR : 76 times per minute, regular, murmur (-)
RR : 18 times per minute,regular, rhonki (-/-)

Abd : soepel, peristaltic (+), palpable liver 3 cm BAC, spleen : palpable schufnner 4
Extremity: pale, warm extremities with CRT < 3 secs, pulse 76x/min, BP : 100/60 mmHg ( N 93-108 / 56-70 )
 Differential Diagnoses
• Bisitopenia e.c. Acute Leukemia
 Working diagnose
• Bisitopenia e.c. Acute Leukemia
 Primary intervention
Oxygenation/ventilation :-
Fluid : IVFD 4:1 20 gtt/i
Hyperglycemia therapy :-
Treat acidosis metabolic :-
Antibiotic treatment :-
Diagnostic Evaluation : CBC, peripheral blood morphology
Monitoring : Vital signs
Report to ER supervisor :
• Agree with diagnosis and plan
• For admission
• Consult to Hematology Oncology division
 Monitoring
Sensorium HR (bpm) RR (bpm) BP (mmHg) temp detail

19.30 CM 80 20 100/70 36.9

20.30 CM 88 18 100/60 36.6
21.30 CM 86 20 100/70 36.7 Send to the
ward
Thank you