MORNING

REPORT
Sunday, September 17th 2023
IDENTITY

● Name : Mrs Kusmiati’s Baby

● Age : 7 days old
● Gender : Female
● Address : Batu
● Consultation date : September 17th, 2023
● Patient Type : Non Trauma
 ANAMNESIS
● Main complaint: greenish vomiting since 1 day ago
● Present History:
The baby is a referral patient who has experienced greenish vomiting since 1 day ago.
The baby also hasn't defecated since birth. The baby was born by SC with indications of
PROM accompanied by high myopia. Fever (-), defecation (-), urination (+)
● Disease history: APGAR score 7-9
● Imunization: hep B (+)
● Medication:
Therapies in RS Permata Bunda:
OGT installation, Inf Kaen IB 300cc/24 jam, Inj Cefotaxime 2x175mg, Inj Metronidazole
2x5mg, Inj Ranitidine 2x5 mg, Lacto B 2x5 mg
● Social and habit: -
● Family history: Mom had a high myopia and PROM
● Allergy history: -
 PHYSICAL
EXAMINATION
Generalist Status

GCS : 456 – alert

BP : - mmHg
HR : 98x/menit
RR : 28x/menit
SPO2: 95% on RA
T : 36.6° C
BB : 3300gr
PB : 49 cm
N : 140x/min
 PHYSICAL EXAMINATION
THORAX :
HEAD/NECK:
Cor:
Inspection: ictus cordis invisible
Head: a/i/c/d : -/-/-/-
Palpation: ictus cordis palpable at ICS 5
Eyes: isochoria pupil 3mm|3mm, Light
MCL S
reflex direct and indirect +/+
Percussion: Cardiac border D at ICS 4 PSL
Ear: ottorhea (-/-) serumen (not
D, cardiac border S at ICS 5 MCL S
evaluated)
Auscultation: S1 S2 single, regular, murmur
Nose: deformity (-), bloody rhinorhhea (-)
(-), gallop (-)
Mouth: installed OGT (greenish vomiting),
Pulmo:
cyanosis (-)
Inspection: normal chest wall shape
Neck:
Palpation: symmetrical D/S chest wall
Inspection : tracheal deviation (-);
movement
laceration(-)
Percussion: sonorous
Palpation : palpable carotid artery
Auscultation: Ves + + Wh - - Rh - -
pulsation, lymph node enlargement (-)
+ + - - - -
Auscultation: bruit (-)
+ + - - - -
 PHYSICAL EXAMINATION

ABDOMEN:
Inspection : distended, scar (-), anus (+)
Auscultation : bowel sound 29x/min
Palpation : superficial & deep tenderness:

Percussion : tympanic
RT: using small suction (no squrting
defecation)

EXTREMITY:
Dry warm red acral, CRT <2 s, oedema (-/-)
 PROBLEM LIST & PLANNING
Problem list
PROBLEM LIST & Initial Diagnosis Planning
Diagnosis
Anamnesis : PLANNING
• The baby experienced greenish vomiting since 1 day after labor.
- Obstructive ileus CBC
BOF/ baby
• The baby hasn't defecated since birth gram
• Fever (-), defecation (-), urination (+)
• Disease history: was born by SC with indications of PROM and
high myopia, APGAR score 7-9, hep B imunization
• Therapies on previous hospital: OGT installation, Inf Kaen IB
300cc/24 jam, Inj Cefotaxime 2x175mg, Inj Metronidazole
2x5mg, Inj Ranitidine 2x5 mg, Lacto B 2x5 mg
Physical examination
GCS : 456 – alert
HR : 98x/menit
RR : 28x/menit
SPO2: 95% on RA
T : 36.6° C
BB : 3300gr
PB : 49 cm
N : 140x/min
 PROBLEM LIST & PLANNING
Problem list
PROBLEM LIST &
Initial Diagnosis Planning Diagnosis
Mouth: installed OGT (greenish vomiting), - Obstructive ileus CBC
cyanosis (-) PLANNING BOF/ baby gram
Abdomen:
Inspection : distended, scar (-), anus (+)
Auscultation : bowel sound 29x/min
Palpation : superficial & deep tenderness:

Percussion : tympanic
RT: using small suction (no squrting defecation)
 Laboratorium
CBC (15/9/2023) CBC (17/9/2023)
Urinalysis
HB 15.7 HB 15.0
(14/9/2023) SGPT 3.4
HCT 48.6 H HCT 42.2
Makroskopis Sedimen
SGOT 34.9
MCV 106.5 H MCV kuning
Warna 93.8 muda Silinder
Ureum 60.8- H
MCH 34.4 MCH 33.3
keruh Leukosut
Creatinin 28-30sel/LPB
0.84
MCHC 32.3 PHMCHC
6.0 35.5 H Ertirosit
GDS 80 3-5 H sel/LPB
WBC 16.500 H BJWBC
1.0206.3600 Epitel ep skuamosa 2-3sel/LPK
Na 140.1
PLT 164.000 PLT 255.000
Albumin, reduksi, Kristal
K 2.93 -L
LED 15 LED 10bilirubin (-)
urobilin, Cl 107.9
GDS 118 Leukosit +3
Nitrit - Imunology
Blood +1 Hs-CRP 2.3
Keton -
Baby Gram
(17/9/2023)
 PROBLEM LIST & PLANNING
Problem List
PROBLEM LIST & Definitive
Diagnosis
Planning
Diagnosis
Planning Therapy &
Monitoring
Anamnesis :
PLANNING
• The baby experienced greenish vomiting
- Hiscprung
disease dd
-SpA (BNO)
-Colon in loop
• Decompression with
OGT and urine
since 1 day after labor. Necrotizing hischprung catheter
• The baby hasn't defecated since birth enterocolitis SpA
• Fever (-), defecation (-), urination (+) • O2 NC 0.5 lpm
• Disease history: was born by SC with • Inf D5% 225cc/24 jam
indications of PROM and high myopia, • Inf Asam Amino10%
APGAR score 7-9, hep B imunization 60% cc/24 jam
• Therapies on previous hospital: OGT • Inf Lipid 20%
installation, Inf Kaen IB 300cc/24 jam, Inj 15cc/24jam
Cefotaxime 2x175mg, Inj Metronidazole • Fasting
2x5mg, Inj Ranitidine 2x5 mg, Lacto B • Install OGT with the
2x5 mg bigger size
• Check the atresia with
suction  a few
meconial
 PROBLEM LIST & PLANNING
Problem list Definitive Planning Planning Therapy

Physical examination
PROBLEM LIST &
- Hiscprung
Diagnosis Diagnosis
-SpA • Decompression
GCS : 456 – alert
HR : 98x/menit
PLANNING disease dd
Necrotizing
(BNO)
-Colon in
with OGT and
urine catheter
RR : 28x/menit enterocolitis loop SpA
SPO2: 95% on RA hischprung • O2 NC 0.5 lpm
T : 36.6° C • Inf D5%
BB : 3300gr 225cc/24 jam
PB : 49 cm • Inf Asam
N : 140x/m Amino10% 60%
Mouth: installed OGT (greenish vomiting), cyanosis (-) cc/24 jam
Abdomen: • Inf Lipid 20%
Inspection: distended, scar (-), anus (+) 15cc/24jam
Auscultation : bowel sound 29x/min • Fasting
Palpation : superficial & deep tenderness: • Install OGT with
the bigger size
Percussion : tympanic • Check the
RT: using small suction (no squrting defecation) atresia with
suction  a few
meconial
THANK YOU