Morning Report

Sunday Morning, March 8th 2020

SYT/SLR/STH/SWI
No Name M/F AGE DIAGNOSE ETC

1 WK M 11 years 7 Susp. Cerebral tumor + RB4

months hidrosefalus obstructive

2. SA F 16 years Lymphoma Hodgkin RB4

3months +mediatinal mass +
varicella zooster
1
New patient in ward at 08:00 p.m, WK, female, 11 years 7 months
address:
BW : 32 kg, BL : 137 cm
W/A : 88,8% H/A : 95,8% W/H : 106%
Chief complain : Headache
History of disease :
- It suffered since 1 month ago. It is like stabbing pain with intermitten pain
- history of seizure 3 hour before come to ward, spasm are whole body for 5
minutes. Frequency one times. After seizure, he suffered decrease of
conciousness
- History of vomit 1 day ago. it contained of food that he was e
- History of Fever was not found.
- History of trauma was not found
- history of diarrhea was not found
Past Medical History:
The patient has previously been treated in Madani hospital with the diagnose
thypoid fever.

History of medication:
- -
Physical Examination
General status :
Alertness : GCS VII (E1M3V3) Temperature : 37,6C
dyspnea (-), cyanosis (-), edema (-), icteric (-), pallor (-)

Localized status:
Head : Eye : Light reflexes (-/-), pupil MØ 3mm/3mm,
pale inferior palpebral conjunctiva (-/-)
Ear : within normal limit
Nose : within normal limit, O2 canule nasal 5 lpm
Mouth: within normal limit
Thorax : Symmetrical fusiform, No retraction
Heart rate : 98 beats/minute, regular, murmur (-)
Respiratory rate : 24 times/minute, regular, Wheezing (-/-) Ronkhi (-/-)
Abdomen : Soepel, normal peristaltic sound, Liver and spleen was not palpable. The
smell of umbilical cord was abnormal.
Extremities : Pulse rate 98 beats/minute, regular, warm extremities, CRT < 3
second, SaO2 96%-98%
 Laboratory result from Adam Malik Hospital
March 08 th 2020

Hemoglobin : 12,4 g/dL BUN :6

Hematocrit : 36 % Ureum : 13
Leukocytes : 8.900 /µL Creatinine : 0,55
Platelets : 293.000 /µL
MCV : 75 fl
MCH : 25,8 pg Ca : 9,5
MCHC : 34,4 g/dl Na : 133
Blood glucose ad random : 102 K :4
mg/dl Cl : 99
CT Scan
Working diagnosis :

Respiratory failure ec cerebral tumor + Hidrosefalus obstructive

Therapy:
O2 nasal canule 0,5 lpm
• IVFD D5% NaCL 0,9% 20 gtt/minute
• Inj phenytoin LD 300 mg in 20 cc Nacl 0,9% and next Inj phenytoin MD 80 mg/12h
in 20 cc NS 0,9% for 20 minutes
• Inj dexamethasone 5 mg/8h
• Acetazolamide 3x200 mg
• Paracetamol pulv 4x480 mg

Planning :
Consult to Neuro surgery division  CITO !!
Chest x-ray
Time Sens HR RR Temp SaO2 Additional
(bpm) (tpm)
14:20 GCS V 60 20 38,6 84% VTP and education to his parents about
the patient’s condition
14:30 GCS 50 10 37 45% VTP + Resusitation (RJPO)
IV
14:35 GCS 20 5 36,4 18% Eye : light reflexes (-), pupil dilatation (+)
III VTP + RJPO
Inj. Ephinefrine 0,1mg/kgBB
14:40 GCS Asistole Apnoe 36,3 9% Eye : light reflexes (-), maximum
III mydriasis pupils
VTP+ RJPO
Inj. Ephinefrine 0,1 mg/kgBB
14:45 GCS II - - - - Eye : light reflexes (-), maximum
mydriasis pupils
VTP+ RJPO
Inj. Ephinefrine 0,1 mg/kgBB
No Respon EXITUS
2
New patient in ward at 16:00 p.m, by. SA, female, 16 years 3 months 8 days
address: Sei Putih Tengah
BW : 46 kg, BH : 151 cm
W/A : 85,1% H/A : 92,9% W/H : 109,5%
Chief complain : Shortness of breath
History of disease :
• It was experienced suddenly since 5 days ago. Shortness of breath is not affected by the
activity and weather. Shortnesss of breath decreases when the patient faces left and
right.
• Rash all over the body was found. The rashes appear since 4 days ago, first rash on the
stomach and then face dan all over body. Rashes likes vesicles, sized vesicles 1
cm,vesicles swarming
• Itchy rash, rashes appear after fever, pain in the rash was not found.
• Nausea and vomiting were not found
• Fever was found 3 days ago, intermitten, and decreased with antipyretic drug.
• Urination and defecation within normal limit
• Pain in the joints was not found.
History of previous illness :
• The patient has previously been treated in the Adam Malik hospital with the
diagnose Non Hodgkin Lymphoma and have received chemotherapy 43 times.
The patient was reffered from Royal Prima Medan hospital with diagnose
Mediastinal mass + lymphoma+ susp. Varicella.

History of medication:
-
Physical Examination
General status :
Alertness : Compos mentis Temperature : 37.6C
dyspnea (-), cyanosis (-), edema (-), icteric (-), pallor (-)

Localized status:
Head : Eye : Light reflexes (+/+), equal pupil Ø 3mm/3mm,
pale inferior palpebral conjunctiva (-/-)
Ear : within normal limit
Nose : within normal limit, O2 canule nasal 5 lpm
Mouth : within normal limit
Thorax : Symetrical fusiform, no retraction, vesicles were found
Heart rate : 120 beats/minute, regular, no murmur systolic
Respiratory rate : 26 times/minute, regular, no rales and wheezing
Abdomen : Soepel, normal peristaltic sound, hepar and lien was not palpable
Extremities: Pulse 120 beats/minute, regular, peripheral pulse = central pulse, warm
extremities, CRT < 2 second, vesicles in palmar and plantar were found.
Blood pressure : 130/90 mmHg
SpO2 : 98-99 %
 Laboratory result from Adam Malik Hospital
March 08th 2020

Hemoglobin : 9,4 g/dL Ca/Na/K/Cl : 7,2/ 127/2,9/101

Hematocrit: 29 % BUN : 3
Leukocytes : 4450 /µL Ureum : 6 mg/dl
Platelets : 26.000 /µL Creatinine: 0,46 mg/dl
MCV : 75 fL pH : 7,480
MCH : 24,2 pg pCO2 :18
MCHC : 32,1 gr/dl pO2 : 189
RDW : 24,3 % HCO3 : 13,4
Tot CO2 : 14
BE : -9,1
Sat O2 : 100
Chest X-Ray from Adam Malik Hospital
08th March 2020
Differential diagnosis:
- Lymphoma Hodgkin + mediastinal mass + Varicella Zooster
- Lymphoma Hodgkin + pulmonary mass + Varicella Zooster

Working Diagnosis:
Lymphoma Hodgkin + mediastinal mass + varicella zooster
Therapy :
• Oxygen reabreathing mask 5 liter per minute
• Acyclovir 4 x 400 mg
• Paracetamol 4 x 500mg
• Hypocalemia Correction : 23 cc KCL + 69 cc NS for 3 h
• Hypocalcemia correction : 23 cc Ca Gluconas + 23 cc NS for 30 minutes
• Hyponatremia correction with D5% NaCl 0,9% 60 cc/h for 24 h

Planning:
• Consult to Infection and tropical medician division
• CT Scan thorax with contras
Time Sens HR RR Sat.O2 Temp

16:00 CM 130 22 99% 37.8

17:00 CM 120 26 99% 36.8

18:00 CM 130 28 99% 38.6

19:00 CM 128 30 98% 37

20:00 CM 120 26 98% 36,8