Morning Report

Tuesday, August 8th 2018

AWA / RAN
No Name Gender/Age Working Diagnosis
1 JMH Boy, 3 years 2 DD/ -Probable Tonsillar diphteria
. months 18 days Streptococcal tonsilitis
A new patienton on ward, JMH, infection unit, boy, 3 years 2 months, address at
Tahan Rahayu, Weight: 24kgs, Height: 103 cms, IBW: 17 kgs
W/A : Z score >+3 H/A : 0< Z score <2
W/H : Z score >+3

Chief complaint : White patch on the throath

History of present illness:
-It was realized by his parents since 1 day prior to admission, the white patch is
covering the right and left tonsil and seemed widening
-Fever was found since 5 days ago, high grade fever, continuously, and didn’t
getting better with anti piretic. Shivering (-) , seizure (-)
-Cough (-), history of cough (-), shortness of breath (-)
-Neck swelling (-), hoarseness (-)
-Vaccination status was complete (BCG 1 time, DPT 4 times, Hep B 4 times,
Polio 4 times)
History of previous illness:
The patient was referred by a pediatrician from Columbia Hospital due to
Probable Diphtheria

History of previous medication:

• Azithromycin for 3 days, Norages, Vomitas
Physical Examination
General status:
Alertness: CM Temperature: 38,5oC
dyspnoe (+), cyanosis (-), edema (-), icteric (-), anemis (-)

Localized status:
Head :Eye: Light reflexes (+/+), symmetric pupil Ø 3mm/3mm, pink palpebral
conjunctiva inferior (+/+)
Ear/nose: within normal limit/within normal limit
Mouth: (+) pseudomembran with white greyish membrane and bleeding with
attempt of removal.
T2-T2 hiperemis (+)
Neck : lymph node enlargement (-)
Thorax : Symmetrical chest expansion, retraction (-)
Heart rate : 140 beats/minute, regular, murmur (-)
Respiratory rate : 24 breaths/minute, regular, no rales,and
wheezing, stridor (-/-)

Abdomen: firm, normal peristaltic sound, liver and spleen were not palpable

Extremities: pulse 140 bpm, full and equal pulse, regular, warm extremities,
capillary refill time (CRT) < 2 seconds, blood pressure: 110/60 mmHg
Laboratory Result
• Complete Blood Count:
MCV/MCH/MCHC:
Hb: 11,6 gr/dL
79 fL / 27,0 pg / 34,2 g/dL
Ht: 34%
Neu/Lim/Mon/Eos/Bas:
Eri: 4,30 million/micL
52,1/ 37,3/ 0,3 /0,1 / 0,2
Leu: 8.570/micL
Plt:283.000 /micL

•Procalcitonin: 0,17 ng/mL

Differential diagnosis:
Probable Tonsillar diphteria
Streptococcal tonsilitis

Working Diagnosis:
Probable tonsillar diphtheria

Therapies:
•IVFD D5% NaCl 0,45% 30 gtt/i micro
•Anti Diphtheria Serum 40.000 IU/IV
•Penicillin Procaine 600.000 IU/12 hours/IM
•Paracetamol injection 300 mg/4 hours/IV
•Regular food 1500 ccals with 40 grams protein
Plans:
• Culture from throat and nose swab
• Consult to infection of pediatric division
Time Sensorium HR RR Temp Notes
(bpm) (tpm)

23.00 CM 98 24 38,5 Giving Paracetamol injection 300

mg / IV

00.00 CM 100 24 37,9 Giving ADS injection 40.000

IU/IV
Lab practitioner taking blood
sample
01.00 CM 98 20 37,5

02.00 CM 98 20 37,5
Time Sensorium HR RR Temp Notes
(bpm) (tpm)

03.00 CM 98 24 37,6 Giving PP 600.000 IU/IM

04.00 CM 100 24 37,5

05.00 CM 98 20 37,5

06.00 CM 98 20 37,5