Morning Report

Night Shift, September 1st 2019

Resident on Duty : Andreas/Mawan/Dita

Supervisor in Charge (Ward) : Subdivisions Supervisors
Supervisor on Duty (Emergency Unit) :
dr. Meriah Sembiring , Sp.A
 Pediatric Department, ULM Medical
Faculty Vision
Making the Pediatric Education Program Institution,
ULM Medical Faculty, Banjarmasin as the center of
education, research, service and development in the
child health medical field especially in wetland disease
independently and superior in Kalimantan at 2020

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 Pediatric Department, ULM Medical
Faculty Mission
1. Perform the pediatric education that produces qualified, professional,
ethical and noble human resources to support the South Kalimantan's
health development programs particularly and Kalimantan generaly.
2. Conducting research that supporting the mastery of science and
technology based on wetlands disease.
3. Perform services to the community and disseminating the mastery of
science and technology in child health medical field to improve quality of
life, especially health issues on wetland diseases in South Kalimantan and
Kalimantan generally.
4. Strengthen cooperation with regional governments in the Kalimantan
region, domestic, foreign universities and other parties to improve the
implementation of the Three Pillars of Higher Education.
5. Improve facilities and infrastructure to improve the quality of pediatric
educational programs.
6. Increase transparency and accountability in the management of pediatric
educational programs.
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 Pediatric Ward 2nd Floor
• Total patients : 14 patients
• Inpatient : 14 patients
• New patients : - patients
• Transferred to other division : - patient
• Discharged : - patient
• Transferred to PICU : - patient
• Transferred from PICU : - patient
• Died : - patient

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 Pediatric Ward 3rd Floor
• Total patients : 27 patients
• Inpatient : 26 patients
• New patients : 1 patient
• Transferred to other division : - patient
• Discharged : - patient
• Transferred to PICU : - patient
• Transferred from PICU : - patient
• Died : - patient

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 New patient : 1 patients
No Identity Diagnosis
1 Kholifah/F/16 yo AIHA + Suspect UTI

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 Pediatric Ward 2nd Floor
Total Patient: 14 patients
No Identity Diagnosis
Neurology/Observation
1 Farisha/F/1 yo Cerebral Palsy + Pneumonia DD Bronchitis
Respirology/ Cardiology
1 M. Najib/M/1 yo Cyanotic Heart Disease Susp. TOF
2 Aqifa/ M/ 3 mo Secundum ASD + PDA
Bhroncopneumoniae dd/ Bronchiolitis + Normocytic
3 Teguh/M/16 yo
hypochromic anemia Susp. IDA dd/ Chronic infection
Infection
1 Nurul Hikmah/F/ yo Susp. Peritonitis ec Thypoid Fever
2 Marsya/ F/ 7 yo Suspect tifoid fever
3 A. Badali/ M/ 4 yo Suspect tifoid fever DD/ dengue fever
4 Arkaan/ M/ 10 mo Suspect viral infection

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 Pediatric Ward 2nd Floor
Total Patient: 14 patients
Nutrition and Metabolic
1 M. Irsyad/M/10 yo Anemia hypochromic microcytic ec DD Thalassemia B
2 Setiawan Zordi/M/16 yo MDS
3 Aqila/ F/ 3 yo Aplastic Anemia

Gastroenterology

Nephrology
1 Wulan/F/17 yo Nephritis Lupus + CKD stage V on HD
Isolation
Susp. Varicella + Hipoalbuminemia + Pansitopenia ec Susp.
1 Nadil/M/10 yo
ALL Relaps + Febrile neutropenia
2 Prasetya Y/ M/ 12 yo ALL + Varicella
 Pediatric Ward 3rd Floor
Total Patient: 27 patients

No Identity Diagnosis
Hematology I
1 M. Fadilah/ M/ 12 yo ALL
2 M. Syarif Aulia/ F/ 6 yo Bisitopenia DD/ Leukaemia
3 M. Syarif Hida/ M/ 13 yo Osteosarcoma
4 Nur Maulidan/ M/ 1 yo ALL
5 Kholifah/F/16 yo AIHA + Suspect UTI
Hematology II
1 Agung Fitriadi/ M/ 1 yo Abdominal Tumor

2 Erly Safitri/F/13yo Susp. ITP

3 Nor Fadila/M/4yo ALL

Hematology III
1 M. Aditya/ M/ 6 yo Thalassemia Beta

2 M. Nur Yudha/ M/ 6 yo Aplastic Anemia

3 Fahira/ F/ 17 yo ALL

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 Pediatric Ward 3rd Floor
Total Patient: 27 patients

Onkology I
1 Azril/ M/ 2 yo Hepatoblastoma

2 Nayla/ F/ 3 yo ALL

Onkology II
1 Nafish/ M/ 1 yo Hepatoblastoma

2 Rizki Adela/F/4 yo ALL

3 Yohanes/M/7 yo ALL
4 M. Ilham/ M/ 8 mo Leukaemia

5 Gusti Mujahid/M/12 yo NHL

Onkology III
1 Al Battar/M/ 3 mo Soft Tissue Giant

2 Alya Orensi/F/17 yo AML

3 Hilyatul/F/2 mo Hepatoblastoma
4 M. Hidayat/ M/ 16 yo ALL

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 Pediatric Ward 3rd Floor
Total Patient: 27 patient

Onkology IV

1 Kehza/ M/ ALL ALL

2 M. Nabil/M/4 yo ALL
3 A. Irfan/ M/ 3 yo Retinoblastoma
4 M. Fajar/ M/ 2 yo Retinoblastoma
5 Rafadayfa/ M/ 3 yo ALL

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 History of present illness
1 days ago

• Pale since 1 days prior to admission

• Easily fatigue (+)
• Fever (+)
• Vomiting (+)
• Shortness of breath (+)
• Epistaxis (+)
• No Gum Bleeding
• No Cough
• No runny nose
• No Edema
• No Waterry stool
• No Joint pain
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History of present illness
RSUD Ulin

• Pale still persist

• Easily fatigue (+)
• Dizziness (+)
• Shortness of breath (+)
• Bleeding (-)

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 History
History of past illness

• History of transfusion (+)

• History of hospitalization (+)

Family history

• No history of similar illness in the family

Birth and Delivery

• The patient was at term baby, normal delivery, immediately cry, no active
resuscitation, BW 2800 gr

Immunization

• Complete immunization (Depkes)

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Nutrition and Development

Nutrition

• Eat Regular meal 2-3 times a day 1 adult portion

Development

• Patient did not continue to school ( 3rd grade junior high school )

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 Problem List
• Pale
• Fever
• Epistaxis
• Anemia
• Shortness of breath
• Vomiting
• Hepatomegaly
• Splenomegaly
• Direct comb’s test (+)
 Initial Diagnosis
1. AIHA
2. Suspect Urinary Tract Infection
 Initial Managements
Nutrition and fluid IVFD D5 ¼ NS 1800 ml/d
Calorie = 70 x 41 = 2870 kcal/day
Protein = 0.9 x 41 = 36.9 g/day
Fullfilled with regular meal 3 times
Antibiotics Inj. Ampicillin-Sulbactam 3 x 1,5 gram
(100 mg/kgbw/day)
Inj. Metylprednisolon 1 x 90 mg ( 2 mg/kgbw)
Diagnostic Ferritin, Albumin, Total Billirubin, Direct Billirubin,
Indirect Billirubin, PT/APTT, Uric Acid, SGOT/SGPT,
Urinalysis, Ureum, Creatinin
Echocardiography, Rontgen Thorax
Monitoring Vital sign and signs of bleeding

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 Consult to Supervisor in Charge
• Agree with the diagnosis and management

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 Final Diagnosis
1. AIHA
2. Suspect Urinary Tract Infection
 Final Managements
Nutrition and fluid IVFD D5 ¼ NS 1800 ml/d
Calorie = 70 x 41 = 2870 kcal/day
Protein = 0.9 x 41 = 36.9 g/day
Fullfilled with regular meal 3 times
Antibiotics Inj. Ampicillin-Sulbactam 3 x 1,5 gram
(100 mg/kgbw/day)
Inj. Metylprednisolon 1 x 90 mg ( 2 mg/kgbw)
Diagnostic Ferritin, Albumin, Total Billirubin, Direct Billirubin,
Indirect Billirubin, PT/APTT, Uric Acid, SGOT/SGPT,
Urinalysis, Ureum, Creatinin
Echocardiography, Rontgen Thorax
Monitoring Vital sign and signs of bleeding

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 Follow Up
2/9/19, 06.00 AM
S: Fever (+) Pale (+) Bleeding (-)

0: GCS 456
HR : 86 x/m
RR : 24 x/m
Temp 37,8 0C
A:
AIHA
Susp. UTI
P:
Observation for vital sign and signs of bleeding

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Thank you