MORNING REPORT

Disusun oleh:
Noermawati Dewi

FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH SURAKARTA
2017
 IDENTITY
• Name : An. R
• Date of birth : 03 March 2017
• Gender : Boy
• Age : 6 months
• Address : Surakarta
• Religion : Islam
• Tribe : Java
• Date of hospitalization : 04-09-2017 (14.45)
• Date of examination : 04-09-2017 (16.00)
 ANAMNESIS

Chief Complaint

Barky Cough
 HISTORY OF ILLNESS
3 days before admission
• The mother said that on Friday night, the patient got
cough (+), runny nose (+), Shortness of breath (+).
• There was fever (+) and vomit (+) 1x with mucus.
• The defecation and urination was normal.

The day on admission

• The fever was still persist.
• The patient got barky cough (+), runny nose (+),
shortness of breath (+), and napas cepat (+)
• The defecation and urination was normal.
 HISTORY OF PAST ILLNESS

History of Seizure with fever : Denied

History of seizure without fever : Denied
History of dengue fever : Denied
History of typhoid fever : Denied
History of asma : Denied
History of allergy with food and drug : Admitted (cold)
History of hospitalization : Admitted 2x
(pneumonia &bronkitis)

Conclusion: there is history of past illness that related to current

illness
 HISTORY OF ILLNESS IN FAMILY

History of Similiar symptom : Denied

History of Seizure with fever : Denied
History of Asma : Denied
History of Allergy : Admitted (father)
History of Hypertention : Admitted (grandmother)
History of Diabetes Mellitus : Admitted (grandmother)

Conclusion: there is history of illness in family that not correlated with

patient’s disease
 PEDIGREE

Ny. M 37 yo Tn. T 37 yo

10 yo 7 yo 3 yo
= Allergy (cold)
An. R 6 mo
= Hypertention

= Diabetes melitus

Conclusion : there is hereditary illness

 HISTORY OF PREGNANCY

Mother with P2A0 was pregnant at 35 years old. Mother began to

check pregnancy and routinely control to the obstetrician.
During pregnancy the mother does not feel nausea, vomiting
and dizziness that interfere with daily activities. During
pregnancy there was no history of trauma, bleeding, infection,
but the mother got PEB at the gestational age 36 weeks.

Conclusion: history of pregnancy was not good

 HISTORY OF DELIVERY

The mother gave birth to her baby assisted by a midwife with a C-section
delivery. 36 weeks pregnancy age, baby born with body weight 2300
grams and body lenght 48cm . At the time of birth the baby cries instantly,
there was no congenital defect at birth.

Conclusion : history of delivery was not good

HISTORY OF POST DELIVERY

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

Conclusion : history of post delivery was good

 HISTORY OF ENVIRONMENT

The patient lives at home with both parents and old brother.
Ceramic-floored patient houses, walled walls, tile roofs, adequate
ventilation, bathrooms in the house, water source from well water.
A few days before the patient was treated in the hospital,
neighbors and the family have not experienced same complaints.

Conclusion : there is no a risk factors for transmitted disease

 HISTORY OF VACCINE

• At that time of examination, the mother did not bring

KMS.
• According to her mother, the patient had received the
basic vaccine (kemenkes) completely. Vaccinations
were obtained at the primary care (midwife).

Conclusion : history of vaccine was good based on

KEMENKES
 HISTORY OF FEEDING

Age 0 – 6months

• Exclusive Breastmilk

Conclusion : history of feeding  quality and quantity was good










• The answer “Yes” = 10 poin

Conclusion : Development history is according to age

 Physical Examination
 General appearance
General appearance : Good
Awareness : Alert

 Vital Sign
Blood Pressure :-
Heart rate : 142x/ menit
Respiratory Rate : 28x/ menit
Temperature : 37,0º C
 Nutrisional status

WEIGHT : 6,9 KG Height : 63,0 CM

-Weight // age : < 0 SD (normo weigh)

-Height // age : <-2SD SD (stunted)
-Weight // Lenght : > 0 SD (gizi baik)

Conclusion : The patient's nutritional status is not good

 Physical examination
• Skin examination
Color : brown
Skin turgor: <2 sec (good)
Moisture: moist
Edema (-) does not exist

• Conclusion : the examination of skin was normal

21
 PEMERIKSAAN KUSUS
Neck : No enlargement of lymph node and no increase jugular venous
Chest : Simetris, retraction (+), miss the motion (-).
• Heart
Inspeksi : The ictus cordis is not visible
Palpasi : Ictus cordis not strong lift
Perkusi : sound “redup” batas jantung .....
Auskultasi : sound of cor I-II reguler, murmur (-)
• Lung
Inspeksi : Simetris,subcostal retraction (+)
Palpasi : Symetrical on both sides
Perkusi : Sonor
Auskultasi : Vesicular (+/+) normal, Stridor (+/+), wheezing (+/+)

Conclusion : there was Stridor and wheezing in the lungs

Stomach : Inspeksi : Distended (-), sikatrik (-), purpura (-)
Auskultasi : Peristaltik (+)
Perkusi : Timpani (+)
Palpasi : Soft, abnormal mass (-), tenderness (-),
skin turgor good
Liver : normal
Spleen : normal

Conclusion : There was no abnormality

 Ekstermitas

•Warm of acral
•Perfusion of tissue is good

•Cyanosis is not found in the 4 extremities

•No udem is found in the extremities

CRT <2 sec
Turgor is good

Conclusion : the examination of extremity was normal limits

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 PHYSICAL EXAMINATION

Head : Normochephal
Eyes : CA (-/-), SI (-/-), edema palpebra (-/-) , sunken eyes(-/-)
Nose : Sekret (-), epistaksis (-), nafas cuping hidung (-/-)
Ears : Sekret (-)
Mouth : Stomatitis (-), perdarahan gusi (-), sianosis (-), faring sulit dievaluasi
Skin : Warna sawo matang, Pucat (-), Ikterik (-), Sianosis (-), turgor kulit (< 2
detik)
Lymph nodes : Tidak didapatkan pembesaran limfonodi
Muscle : Tidak didapatkan kelemahan, atrofi, maupun nyeri otot
Bone : Tidak didapatkan deformitas tulang
Joints : Gerakan bebas
Extremities : CRT < 2 Second, sianosis (-/-), edema (-/-), akral hangat(+/+), petekie (-
/-)

Conclusion: there was no abnormality

 LABORATORIUM EXAMINATION
Routine blood examination
PEMERIKSAAN HASIL SATUAN NORMAL
 Leukosit 9.83 10ˆ3/ul 4.5 – 12.50
 Eritrosit 5.16 jt/ul 3.8 – 5.20
 Hemoglobin 9.2 L g/dl 11.7 – 14.5
 Hematokrit 29.3 L % 35.0 – 47.0
 Trombosit 556 H 10ˆ3/ul 217 – 497
 Netrofil 34.3 L % 50 - 70
 Limfosit 52.2 H % 25 – 40
 Monosit 11.8 H % 2–8
 MCV 66.7 L fl 74.0 – 102.0
 MCH 21.0 pg 21.0 – 34.0
 MCHC 31.4 g/dl 30.0 – 32.8

Result : Routine blood examination were micrositic and normocromic anemia,

trombositosis, shift to the left differential count of leucocyte
 RESUME
ANAMNESIS
Barky cough (+)
Runny nose (+)
Shortness of breath (+)
Fever (+)
Vomit 1x with mucus (+)

Physical examination
Heart Rate, Respiratory rate and temperature were normal.
Thorax Lung: subcostal retraction (+/+), stridor (+/+), wheezing (+/+)

Laboratorium
Anemia and trombositosis
 ASSESMENT

1. Laringotrakeobronkitis 2. Anemia mikrositik

(croup) normocromik
DD : DD causa :
Bronkiolitis Defisiensi Fe
Airway Foreign Body Chronic infection
Thalasemia

3. Stunting
 ACTION PLAN
• Observasi tanda sesak, respiratory rate, O2 saturation

DIAGNOSIS ENFORCEMENT PLAN

• Peripheral blood smear

• Status besi
 Terapi

kebutuhan energi : soft rice, eggs, meat, fish,

Kalori : 6.9 x 98= 676.2 kkal vegetables a day 3 times a large plate of food
Protein : 6.9x 1.5 = 10.35 g was always finished.
Cairan : 6.9x 125= 931.5 ml  rute oral
Kebutuhan energi : 676.2 kalori/hari dibagi
dalam 3 kali waktu makan

kebutuhan energi :
Nasi putih 100 gram: 176kalori
Bayam rebus 100 gr : 23 kalori
1 butir telur rebus : 154 kalori
1 ayam sayap: 295 kalori
Pepaya 100 gram : 46 kalori
 ` PLAN
THERAPY
• Oxygen therapy : 0,5 L/mnt

• Nebu : 4 ml adrenalin 1:1000 ditambahkan kedalam 2-3 ml garam

normal nebulizer 20 menit

• Dexamethasone : 0.6mg/kgBB per day devided in 4 times = 4.14

mg/ hari
= 0.15mg/kgBB per times
 FOLLOW UP
TANGGAL SOA PLANNING
05-9- -S/on the morning, fever (-), cough (+)still persist, runny • P/ Dexamethasone
2017 nose (+), shortness of breath (-) : 0.6mg/kgBB x 6.9
Jam O/ kg = 4.14 mg/ hari
07.00 - KU : Compos Mentis
- RR : 32 x/menit
- S : 36.4
- Kepala: konjunctiva anemis (-/-), sklera ikterik (-/-)
- Tho: retraksi (-), stridor(+/+) berkurang, wheezing (-/-)
- Abd : peristaltik (+), timpani (+)

A/ Croup
Anemia mikrositik
 FOLLOW UP
TANGGAL SOA PLANNING
06-9- -S/on the morning, fever (-), recovery cough and runny P/Dexamethasone :
2017 nose, shortness of breath (-) 0.6mg/kgBB x 6.9 kg =
Jam O/ 4.14 mg/ hari
07.00 - KU : Compos Mentis
- RR : 24 x/menit
- S : 36.6
- Kepala: konjunctiva anemis (-/-), sklera ikterik (-/-)
- Tho: retraksi (-), stridor(-/-), wheezing (-/-)
- Abd : peristaltik (+), timpani (+)

A/ Croup
Anemia Mikrositik
THANK YOU