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Morning Report: Disusun Oleh: Devy Puspo Wardoyo
Morning Report: Disusun Oleh: Devy Puspo Wardoyo
Morning Report: Disusun Oleh: Devy Puspo Wardoyo
Disusun oleh:
Devy puspo wardoyo
FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH SURAKARTA
2017
IDENTITY
• Name : An. N
• Date of birth : 13 Februari 2015
• Gender : Girl
• Age : 2 years 6 month
• Address : Surakarta
• Religion : Islam
• Tribe : Java
• Date of hospitalization : 18-10-2017 (23.00) pm
• Date of examination : 18-10-2017 (23.10) pm
ANAMNESIS
Chief Complaint
Fever
HISTORY OF ILLNESS
5 days before admission
• The mother said that on Saturday night the patient got fever
(+) , fever up and down. Already given paracetamol but still
fever with a cough and runny nose. watery stool (-), vomit -
• The defecation and urination was normal.
2 day on admission
• The mother said that on tuesday morning then vomit (-),
fever (+) , fever up and down with a cough and runny nose ,
watery stool-
• The defecation and urination was normal.
HISTORY OF ILLNESS
The day on admission
• fever (+)
• runny nose and cough (+)
• the defecation and urination was normal
HISTORY OF PAST ILLNESS
26 yo 30 yo
2 y 6mo
The mother gave birth to her baby assisted by a midwife with a c-section
delivery. 40 weeks pregnancy age, baby born with body weight 2800
grams and body lenght 50 cm . At the time of birth the baby cries instantly,
there was no congenital defect at birth.
The baby boy was born crying, active motion, red skin color, not
blue and yellow skin color, got milk on first day, urination and
defecation less than 24 hours
Age 5 – 12 months
• Breastmilk + porridge of rice, vegetables , fish, egg, fruits 2-3 times a small dishes per day
• Rice, vegetables , fish, egg, fruits 2-3 times a small dishes per day
Conclusion : history of feeding quality was not good and quantity was
good
• The answer “Yes” = 10 poin
Vital Sign
Blood Pressure :-
Heart rate : x/ menit
Respiratory Rate : x/ menit
Temperature : 38,4º C
Nutrisional status
WEIGHT : KG Height : 0 CM
22
PEMERIKSAAN KUSUS
Neck : No enlargement of lymph node and no increase jugular venous
Chest : Simetris, retration (-), miss the motion (-).
• Heart
Inspeksi : The ictus cordis is not visible
Palpasi : Ictus cordis not strong lift
Perkusi : sound “redup”
Auskultasi : sound of cor I-II reguler, bising jantung (-)
• Lung
Inspeksi : Simetris, retraksi intercostal (-/-), retraksi
subcostal (-/-), retraksi substernal (-), retraksi
suprasternal (-)
Palpasi : There is no missed breath
Perkusi : Sonor
Auskultasi : Vesicular (+/+) normal, Rhonki (-/-), wheezing (-/-)
•Warm of acral
•Perfusion of tissue is good
25
PHYSICAL EXAMINATION
Physical examination
Heart Rate, Respiratory rate and temperature were normal.
Laboratorium
-
ASSESMENT
1. Vomitus profuse
DD causa
Gastroenteritis
ISK
ACTION PLAN
• Observasi tanda dehidrasi
kebutuhan energi :
Nasi putih 100 gram: 176kalori
Bayam rebus 100 gr : 23 kalori
1 butir telur rebus : 154 kalori
1 tempe goreng : 82 kalori
1 ayam sayap: 295 kalori
Pepaya 100 gram : 46 kalori
` PLAN
THERAPY
• Maintenance : RL : 100cc x10kg = 1000cc/24jam = 10 tpm
A/ vomitus profuse
THANK YOU