Morning Report

Night Shift, January 30th – 31st 2021

Resident on Duty :
Chief Wandering : Andreas
Emergency Ward : Mawan
Isolation Ward (Mawar) : Tyas
Pediatric Ward (Tulip) : Galih/Emil
Supervisor on Duty :
dr. Arief Budiarto, 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 2021

2
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 generally.
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
3
educational programs.
 New patient : 3 patients
Emergency Ward : 2 Patients

Neonatology Ward : 1 Patient

Isolation Ward : - Patient

Pediatric Ward : - Patient

Total : 3 Patients
4
 List New Patient
Emergency Ward
Suspect Bronchopneumonia + Suspect Laryngomalacia +
Global Developmental Delay + Hernia Scrotalis Dextra
M. Zaini/Male/ 10 Isolation
1 months old Reponible + Severe malnutrition Marasmic type
Stabilization phase, Severely Underweight + Microchepaly ward 2B
+ Incomplete immunization + Suspect Covid 19
ALL type L1 + Neoplasma Related pain + Vomiting e.c
2 Siti Az-Zahra/F/17 yo Chemotherapy Induced + Thrombocytopenia + Aster
Normocytic Normochromic Anemia

Isolation Ward

- - - -

Neonatology Ward1
Extremely Pre Term + Extremely Low Birth weight + AGA +
1 Baby Mrs.Aulia/F/6 do Respiratory Distress e.c HMD DD/ Early Onset Neonatal NICU
Sepsis (EONS) + EONS + Stress Hyperglicemia

5
 Identity
Name : M.Z
Age : 10 months old
Gender : Male
No. RM : 1-46-87-22
Day of : January 31st 2021
Admission
Address : Banjarmasin

Chief complaint :

• Fever since 2 days prior admission (p.a)

16
 Pediatric Assessment Triangle
• Appearance (TICLS)
– Tonus : adequate
– Interactiveness : adequate N
↑
– Consolability : consolable
– Look or gaze : eye contact (+)
– Speech : adequate
N
• Breathing
– Tachypnea (-) nasal flare (+) subcostal retraction (-)
– Stridor (+) gurgling (-) snoring (-) wheezing (-) tripod position (-) head bobbing
(-)

• Circulation
– Pale (-) mottled (-) cyanosis (-)

Conclusion: Respiratory Distress 17

 Primary survey
• Airway
– Patent, no snoring, gurgling (-)
• Breathing
– RR 50 times/min, regular breathing rhythm, SpO2 90-92% room air,
SPO2 98% NC 1 LPM
– Nasal flare (+), subcostal retraction (-)
• Circulation
– Pulse 120 bpm, regular, adequate
– CRT < 2 seconds, pale (-) mottled (-) cyanosis (-)
• Disability
– E4M5V6 = 15, light reflex (+) symmetrical, lateralization (-)
• Environment
– Body temperature 39.1ᴼC

Conclusion : Respiratory distress 18

 History of Present Illness

2 days p.a Hospital

• Fever (+) since 2 days p.a,  didn’t get any medication  just apply cold compress on
forehead but didn’t relieve  no shivering, highest temperature not measured.
• He got productive cough (+), sputum (+), whitish color, no blood on sputum, shortness of
breath, (+), runny nose (+) since 2 days p.a, no specific precipitating/aggravating factor.
• Patient had additional breathing sound (+) such as “grok-grok” or “ngik-ngik” , sometimes
relieved by changing position since 2 days p.a. Relieved by lying on one side, and increase
by supine position.
• He got seizure 2 days p.a, 1 time, duration for 1 minute, frequency 1x/day. Accompanied
by fever. General tonic seizure type, patient conscious before seizure, unconscious during
seizure, after seizure patient crying  didn’t get any medication.
• No history of recent chocking (-). But mother said that he was easily choking when
drinking.
• Patient was brought to Pediatrician  Diagnosed with : Febris e.c DD/ DHF + Motoric
delay + history of febrile seizure  referred to Ulin Hospital for further therapy and
management
• No nausea, no vomiting
• No bluish lip
• No hoarse voice
• No ear discharge
• Normal urination and defecation 19
 History of Present Illness
Ulin Hospital

• Fever still persisted, slightly relieved by using

paracetamol
• Productive cough (+), sputum (+), whitish colour, no
blood on sputum, runny nose (+).
• Additional breathing sound was relieved by changing
position.
• No seizure
• No ear discharged
• No hoarse voice
• No bluish lip
• Normal urination and defecation
20
 History of Past Illness
• Patient often got shortness of breath and noisy breath since he
was 3 months old  untreated.
• Patient had history of previous febrile seizure, general tonic clonic
seizure accompanied by fever since 6 months old, with duration
less than 3 minutes. Patient was conscious before seizure,
unconscious during seizure, after seizure patient crying  no
specific treatment.
• Patient got right scrotal enlargement since he was 4 months old,
especially when he was crying, relieved by itself and did not get
any treatment.
• He had brought to Pediatrician with chief complaints : recurrent
shortness of breath, noisy breath, febrile seizure, and scrotal
enlargement  got therapy and suggested to reffer to Pediatric
surgeon but parents patient refused
Conclusion: History of recurrent shortness of breath,
noisy breath, seizure and enlargement of scrotalis
dextra reponible.
21
 Family History

• Conclusion: No remarkable data

Birth and Delivery

• History of pregnancy : Poor ANC, seldom took vitamin in early age of gestational,
USG at 32 weeks of GA  baby weight is under normal gestational baby weigh,
mother had history of IUGR in the pregnancy, flour albous (+), untreated UTI (+),
excess of nausea and vomiting  low intake during pregnancy
• Patient is the second child, aterm, spontaneous vaginal delivery assisted by
midwife, BW 2200 gr, BL mother forgot, head circumference mother didn’t know,
history of active resuscitation (+), not immediately cry, no history of prolong
oxygenation usage, no history of jaundice
Conclusion: History of pregnancy with Poor ANC, IUGR, Non infection
factor (1) , infection factor (2 and history of delivery low birth weight,
got active resuscitation , not immediately crying.
22
 Immunization
• Conclusion : Incomplete immunization (Indonesian Ministry of Health)

Nutrition
•Conclusion: Inadequate nutritional intake

Development
•Patient unable to raise his head, unable to sit, and unable to babbling
•Conclusion: global developmental delay

Social and Environment

• Father is an active smoker
• Conclusion: High risk of respiratory infection, low social economy, and
low risk of covid 19 23
 Physical Examination
General Vital sign

• BP : 85/40 mmHg (P90)

• Pulse : 120 times/minute,
• Moderately ill
regular, adequate
• Compos Mentis • RR : 50 times/minute,
• GCS E4V5M6 regular
• CRT : <2 seconds
• Temp : 39.1oC
• SpO2 : SpO2 90-92% room
air, SPO2 98% with oxygen
supplementation via NK 1 LPM

24
Organ Descriptions
Head Microcephaly, facial edema (-), old face (+), open fontanell 2-3 cm, flat (+)
Pale conjunctiva (-), icteric sclera (-), isochor pupil 3 mm/3 mm, normal pupillary reflex,
Eyes normal eye movements, sunken eyes (-)
Neck Lymph nodes enlargement (-), nuchal rigidity (-), tracheal tug (+)
Nasal flare (+), nasal discharge (-/-) whitish, pharynx hyperemia (-/-), tonsils (T1/T1),
ENT
detritus (-), pseudomembranous (-), No discharge from both ear
Mouth Dirty and whitish tongue (-), oral thrush (-), sub gingival bleeding (-), gum swelling (-), wet
mucous (+), macroglossia (-)
Heart Heart sound I-II normal, murmur(-), gallop (-)
Inspection : wasted ribs (+) subcostal retraction (-),
Palpation : symmetrical of vocal fremitus, No axilla lymph nodes enlargement
Thorax Percussion : sonor at both lungs
Auscultation : no decreased of breath sounds, wheezing(-), prolonged expiration (-), stridor
(+), rhonchi (-), coarse rhonki (+) in both lower lobes
Inspection : Distended (-), scar (-), protruding umbilical (-)
Auscultation : normal abdominal sound, 4-5x/minute, Palpation : soft, no organomegaly (-),
Abdomen
shifting dullness (-), ascites (-), palpable mass (-), inguinal lymph nodes enlargement (-),
normal skin turgor
Anogenital Hernia scrotalis D Reponible (+), pain (-), Erythema natum (-), baggy pants (-)
Warm, CRT < 2 seconds, edema (-), parese (-), subcutaneous fat (-) muscle atrophy (-)
Extremities inguinal & axillary lympadenopathy (-) crazy pavement dermatosis (-)
Body Weight : 5.5 kg, Body Length : 71 cm, Head circumference : 42 cm (Microcephaly), arm
Anthropometric
Status circumeference 9 cm
conclusion : Severely Underweight, normal stature, severe malnutrition Marasmic type.

25
Organ Descriptions

Vertebrae Kyphosis (-) Scoliosis (-)

Meningeal sign (-), nuchal rigidity (-), Brudzinski I (-), Brudzinski II (-), Kernig (-)
Motoric strength 5555 | 5555 Sensoric (+)
5555 | 5555
Physiological reflex (biceps,brachioradialis, triceps, knee, ankle) +2/+2,
Pathologic reflex Babinski (+), Chaddock (-), Oppenheim
(-), Hoffman Tromner (-/-)
Spastic (-) clonus (-) Muscle tone (-) Atrophy on extremities muscle (-)

Nervus Craniales
N. I. Hard to evaluate
N. II Afferent pupil reflex (+/+)

Neurological N III, IV, VI Hard to evaluate

N V. Hard to evaluate
N VII Symmetrical face
N VIII. Hard to evaluate

N IX/ X Hard to evaluate

N. XI Hard to evaluate

N. XII Hard to evaluate

26
 Anthropometric Status
• Body Weight : 5.5 kg
• Body Length : 71 cm
• Ideal Body Weight : 9 kg
• Height Age: 9 months old
• Arm circumference : 9 cm (< P5)
• Head circumference : 42 cm (Microcephaly)
WHO
• Weight/Age : Z < -3 SD
• Height/Age : -2 < Z < 0 SD
• Weight/Height: Z < -3 SD

Severely Underweight, Normal Stature, Severe

Malnutrition Marasmic type.
27
Nellhauss

Microcephaly 28
 Clinical Feature

Hernia scrotalis D
Reponible, pain (-),
redness (-)

Wasted ribs (+)

30
 Laboratory Finding at Ulin Hospital
31/01/2021
31/1/2021 Reference value

Hb (g/dL) 11.3 12.0 - 16.0

Hematocrit (%) 36.3 5 37-47
Leukocyte (/µL) 6,100 4,000-10,500
Thrombo (/uL) 147,000 150,000 - 450,000
MCV (fl) 72.9 75.0 - 96.0
MCH (pg) 22.7 28 - 32
MCHC (g/dl) 31.1 33 - 37
Limf % 43.7 20 - 40
RBG (mg/dl) 79 <200
Sodium (Meq/L) 131 136 – 145 Thrombocytopenia
Potassium (Meq/L) 4.3 3.5 – 5.1 Mild lymphocytosis
IgG and IgM anti SARS Cov 2 Reactive
Chloride (Meq/L) 104 98 - 107
IgG anti Sars Cov-2 Reactive Non-Reactive

IgM anti Sars Cov-2 Reactive Non-Reactive

Chest X-Ray at Ulin hospital (31/1/2021)

- Infiltrat in left and right parahilar

- Bone intak
- CTR 55%
Impression: Bronchopneumonia 32
 Problem List
Anamnesis:
• Male patient, 10 months old.
• Fever (+) since 2 days p.a,  didn’t get any medication  just apply cold compress on forehead but
didn’t relieve  no shivering, highest temperature not measured.
• He got productive cough (+), sputum (+), whitish color, no blood on sputum, shortness of breath,
(+), runny nose (+) since 2 days p.a, no specific precipitating/aggravating factor.
• Patient had additional breathing sound (+) such as “grok-grok” or “ngik-ngik” , sometimes relieved
by changing position since 2 days p.a. Relieved by lying on one side, and increase by supine position.
• He got seizure 2 days p.a, 1 time, duration for 1 minute, frequency 1x/day. Accompanied by fever.
General tonic seizure type, patient conscious before seizure, unconscious during seizure, after
seizure patient crying  didn’t get any medication.
• No history of recent chocking (-). But mother said that he was easily choking when drinking.
• History of recurrent shortness of breath, noisy breath, seizure and enlargement of scrotalis dextra
reponible since 4 months old.
• History of pregnancy : Poor ANC, Non infection factor (1) , infection factor (2)
• History of delivery : low birth weight, got active resuscitation , not immediately crying
• History of Global developmental delay
• History of incomplete immunization
• History of inadequate nutrition
• History of social environment : High risk of respiratory infection
33
 Problem List
Physical examination
•Moderately ill, RR : 50 times/minute, Temp : 39.1oC, SpO2 90-92% room air, SPO2 98% with oxygen
supplementation via NC 1 LPM
•Head : Microchepaly
•ENT : Nasal flare (+)
•Neck : tracheal tug (+)
•Thorax : wasted ribs (+), stridor (+),coarse rhonki (+) in both lower lobes.
•Anogenital : hernia scrotalis dextra reponible
•Severely underweight, severe malnutrition Marasmic type

Laboratory
•Thrombocytopenia
•Mild lymphocytosis
•IgG and IgM anti SARS Cov 2 Reactive

X Ray Thorax :
•Impression : Bronchoneumonia
34
 Diagnosis
• Suspect Bronchopneumonia e.c Community Acquired Pneumonia J18.0
DD/ aspiration pneumonia J69.0
• Suspect Laryngomalacia e.c Primary Laryngomalacia Q31.5
DD/ secondary Laryngomalacia Q31.6
• Global Development Delay R62
• Hernia Scrotalis Dextra Reponible K40.90
• Severe malnutrition Marasmic type Stabilization phase E.42
• Severely Underweight R63.6
• Microchepaly Q02
• Incomplete immunization Z28.82
• Suspect Covid 19 Z20.822

35
 Managements
Hospitalized at Isolation ward
Oxygenation O2 1 lpm via nasal canule
Fluid & nutrition IV acess plug
NGT insertion
RDA requirement :
Calorie 110 x 9 = 990 kcal/day
Protein 2 x 9 = 18 g/day
Fluid = (125-145) x 5.5= 687.5 – 797.5 ml/day Fulfilled (~ 60 % RDA)
(PER 3%) via NGT with:
F75 8x75 ml = 600 kcal
Antibiotic IV Ceftriaxone 1x600 mg (100 mg/kgBW/dose)
Medicamentosa IV Omeprazole 2x5 mg (1 mg/KgBW/dose)
Multivitamin PO Vit A 100.000 IU
PO Vit C 1x 50 mg
PO Vit D 1x1 cth (400 IU)
PO Vit B 1x1 tab
PO Folic Acid 5 mg, continue 1x 1 mg
Antipyretic IV Paracetamol 3x60 mg (10 mg/KgBw/dose)
Planning Monitoring Vital signs, body weight, feeding tolerance, balance diuresis/24 hours, sign of fluid overload, sign
of dehydration, seizure, antibiotic response in 3 days of treatment, sign of incarcerated hernia, catch-up immunization
Planning Diagnostic Endoscopy, Rhinofaringolaryngoscope (RFL), liver function test, FT4, TSH, D-Dimer,
CRP, swab PCR anti SARS CoV 2, Head CT-Scan.
Education Educate family about disease, therapy and prognosis
Consult to Pediatric surgery, respirology, neurology, nutrition and metabolic, social pediatric division.

36
 Consult to Supervisor in Charge
dr. Arief Budiarto, Sp.A
• Agree to current therapy and management
• Hospitalized at Isolation ward

37
 Consult to Respirology Division
dr. Khairiyadi,M.Kes, Sp.A (K)
• Agree to current therapy and management
• IV ceftriaxone 1 x 600 mg
• Hospitalized at Isolation ward

38
 Follow Up
February 1st 2021 (07.00 AM)
S Fever ↓, shortness of breath ↓ , additional breath sound (+), Seizure (-), Pale (-),
O GCS E4V5M6
Pulse : 118 x/m, regular, adequate
RR : 32 x/m, regular
Temp : 36,90C
SpO2 98%-99% O2 1 LPM NK
Microchepali (+), tracheal tug (+), stridor (+),coarse rhonki (+) in both lower lobes, Wasted ribs
(+), enlargement testis dextra (+).
A Suspect Bronchopneumonia e.c Community Acquired Pneumonia J18.0
DD/ aspiration pneumonia J69.0
Suspect Laryngomalacia e.c Primary Laryngomalacia Q31.5
DD/ secondary Laryngomalacia Q31.6
Suspect Laryngomalacia Q31.5
Global Development Delay R62
Hernia Scrotalis Dextra Reponible K40.90
Severe malnutrition Marasmic type Stabilization phase E.42
Severely Underweight R63.6
Microchepaly Q02
Incomplete immunization Z28.82
Suspect Covid 19 Z20.822

39
February 1st 2020 (07.00 AM)
P Planning Monitoring Vital signs, body weight, feeding tolerance, balance diuresis/24
hours, sign of fluid overload, sign of dehydration, seizure, antibiotic response in 3 days of
treatment, sign of incarcerated hernia, catch-up immunization
Planning Diagnostic Chest X-ray, Endoscopy, Rhinofaringolaryngoscope (RFL), liver
function test, FT4, TSH, D-Dimer, CRP, swab PCR anti SARS CoV 2, Head CT-Scan
G Prevent refeeding syndrome
Prevent weight lost
Treat infection
Weight gain 50 mg/kgBW/week
Temperature 36.5 – 37.5
I IV acess plug
F75 8x75 ml via NGT
IV Ceftriaxone 1x600 mg (100 mg/kgBw/dose)
IV Paracetamol 3x60 mg (10 mg/KgBw/dose)
IV Omeprazole 2 x5 mg (1 mg/KgBW/dose)
PO Vit A 100.000 IU
PO Vit C 1x 50 mg
PO Vit D 1x1 cth (400 IU)
PO Vit B 1x1 tab
PO Folic Acid 5 mg, continue 1x 1 mg

40
Thank you