Morning Report

Tuesday, June 13th 2023

Oncall: Dr. dr Bakhtiar Sp.A

Moderator : dr. T.M Thaib Sp. A (K)
Pediatric Residents
Chief: dr. Farish Faza
Emergency room: dr. Sari Novita, dr Cut Shelfi, dr Nurul Laxmi
Pediatric Intensive Care Unit: dr Aris Gunawan
Neonatology Intensive Care Unit: dr. Alivia, dr Susi Safinah, dr Hirli Septiana
Ward : dr. Zuhaira, dr RR Rima, dr Dewi Hestina, dr Ahmad Mukhlis
POC : dr. Mestika Kuine

Department of Pediatric Medical Faculty Syiah Kuala University

Zainoel Abidin Hospital Banda Aceh
2023 1
 PATIENT DIVISION
June 12th - June 13th 2023

Jumlah RUANGAN    
No Divisi
DPJP IGD MENINGGAL

ARAFAH ARAFAH RAUDAH ZAMZA

NICU PICU <24 > 24 DLL < 48 > 48
INFEKSI   1 2 2 M
JAM JAM JAM JAM

1 NEUROPED 8 6 2
2 GEH 5 2 3
3 IPT 4 3 1
4 RESPI 2 2

NON INFEKSI
5 HOM 8 3 1 4
6 NEFRO 12 4 3 4 1
7 KARDIO 1 1
8 ALIM 0

9 ENDOKRIN 1 1
10 NPM 1 1
11 TKPS 0 0
12 NICU 10 10
13 ERIA 4 4 2
 PATIENT ADMISSION June 12th - June 13th 2023

No NAME SEX / AGE DIAGNOSE DIVISION

1. Rafka Shaquille Male, 4 years 7 Probable Difteri Tonsil Pharing Tropic
Zafran, months Immunization not complete Infection
Disease

2. Mikail Altaf Arkana Male, 8 years 3 Dengue Viral Infection Discharge

months Immunization not complete with
permission

3. M. Naufal Riyadi, Male, 23 days Sepsis Neonatorum Neonatology

Necrotizing Enterocolitis
Aterm neonates with appropiate
gestational age post sectio caesaria
 PATIENT ADMISSION June 12th - June 13th 2023

No NAME SEX / AGE DIAGNOSE DIVISION

4. Sige Iwan Doa Male, 12 years 2 -Severe Anemia HOP
months -Pansitopenia ec. Aplastic anemia
-Epistaxis posterior
-Viral Hepatitis
-Immunization not completed
5. Muhammad Tunisi Male, 2 years 8 Moderate Tetanus Tropic Infection
months 2 Immunization not complete Disease
 Patient Admission With PV/SC
June 12th - June 13th 2023
NO. NAME Indication of SC/PV DIAGNOSE Summary
1 By. Ny. Rizatul • G3 Gravide 38-39weeks, live • Aterm neonates with big BBW 3900 grams
Husna singleton head presentation, gestational age post sectio LBW 50 cm
active phase 1st caesaria A/S 8/9
Observation in
perinatolgy

2 By. Ny. Efariyani • G1 Gravide 39-40 weeks, live • Caput succedaneum BBW 3300 grams
binti Ibrahim singleton head presentation, • Aterm neonates with LBW 48 cm
distosia active phase 1st and appropriate gestational age post A/S 8/9
Observation in
CPD sectio caesaria perinatolgy
 Case of Death June 12th - June 13th 2023
NO. NAME Sex DIAGNOSE Date of Death
1 By. Mrs. Badratul Male, 12 days old Multi Organ System Failure 9th June 2023 at
Septic Syok 08.30 pm
Nafis Sepsis Neonatorum
Respiratory Distress Syndrome
div. Neonatology
Patent Ductus Arteriosus
Patent Foramen Ovale
Neonatal Seizure
Very low Birth weight Baby
Gemeli 1
Small preterm neonates during pregnancy post sectio caesaria
2 By. Mrs. Betti Male, 5 days old -Multi Organ System Failure 11th June 2023 at
yumarlina, - Respiratory distress syndrom 10.05 am
- Neonatal sepsis
- Ikterus Neonatorum
- Asidosis respiratorik div. Neonatology
- Asfiksia neonatorum
- Very low Birth weight Baby
- Hipoalbuminemia
- Hipocalsemia
- Hiponatremia
- AKI stadium injury
-Small preterm neonates during pregnancy post sectio caesaria
 Case of Death
June 12th - June 13th 2023

NO. NAME Sex DIAGNOSE Date of Death

3 Hafiza Yulisma Female, 12 years old Multi Organ System Failure 12th June 2023 at
Metabolic Acidosis 06.20 am
Ensefalopati uremikum
Nefritis lupus
div. ERIA
AKI stadium Failure
Suspect Sepsis
Suspect DIC
Parotitis Bilateral
hipoalbuminemia
hipocalsemia
hipocalemia
anemia hipokrom mikrositer
Mild Malnutrition
Immunization Not Carried Out
IDENTITY
• Name : SID
• Sex : Male
• Date of Birth : April 6th 2011
• Age : 12 years 2 months 7 days old
• Address : Mongal, Takengon
• MR No. : 1-24-59-49
• Date of Admission : June 12th 2023, 10.07 pm
 Appearance Work of Breathing
- Tone : normal - No Abnormal sounds
- Interactiveness: normal - No Abnormal position
- Consolability : normal - No gasping
- Look : normal - No Retraction
- Speech/cry : negatif
SAGA
Circulation
- Pale
- No mottling
- No cyanosis
Conclusion: Compensated Shock
ANAMNESIS
• Chief Complaint:
Epistaxis
• Additional Complaint:
Pale, weak, history of fever, history of nausea and vomiting, history of transfusions,
• Present History:
• The patient came with complaints of epistaxis since 1 days before admission. Nose bleeding occurs suddenly
on both sides of the nose with duration ± 12 hours.
• This complaint had been repeated in this last 1.5 years, and had lost weight in this one year.
• The patient look pale since 5 days ago, accompanied by weakness.
• Patien had intermitten fever for 3 days, but in last 2 days the patient had no fever. The parents never measured
the temperature before.
• The patient had history of nausea and vomiting since 5 days ago with frequency 1-2 more per day. Contains
food eaten. Patient’s last vomiting 1 day before.
• History of joint pain was denied, denied history of lumps.
• No history of bruises, bone pain.
• Defecation and urination were not complained, could drink 1000 mL per day
• Patient is not lived around hight electricity tower or had any chemical fertilizer.
ANAMNESIS
• History of previous illness
The patient had history of epistaxis for 1,5 years ago, accompanied by trombositopenia.
For 3 years with a history of repeated transfusions. ± 1 years the patient received PRC and
thrombocyte transfusions 6 times at Hospital in Takengon, with anemia and thrombocytopenia
indication.

• Family and Environmental History

There is no family member with the same complaint before.

• Drug History
Therapy in Datu Beru Hospital for 1 day
inj Kalnex 1 amp / 8 jam IV
Inj Ranitidin 50 mg/ 12 jam IV
Paracetamol 500 mg prn drip
Domperidon 10 mg / 8 jam po
 ANAMNESIS
• Pre Natal, Natal and Post Natal Care
The patient is the third child of fourth siblings, he was born by spontan delivery, aterm, birth weight was 3500
grams, crying immediately, no cyanotic history, no history of jaundice and history of being admitted to NICU
because choking on milk, and admitted for 3 days.
The mother had routine antenatal check-up at midwife, had received pregnancy vitamins, and was in healthy
condition during pregnancy. No history of hypertention, diabetes, seizure and fever or asthma.

• History of Nutritional
0-6 month : Breastmilk + Formula milk
6 month until 18 months : Formula Milk+ complementary food
19 month - Now : Family food

In this last 3 months, patient able to eat a half portion of food.

• Immunization History
The patient only had basic immunization, without any booster

• Growth and Development History

Growth : parents said that their child growth like another child at the sam age

Developmental : The patient able to follow lesson at the school and had a good interaction with other.
 TIME TABLE
5 days before 1 days before
3 years before 1,5 years before admission admission Now
Hospital Hospital

• Pale • Epistaksis • Nausea • Epistaksis

• History of • History of • Vomiting • Weak
transfusion transfusion • Pale • Pale Admission to
• Decrease of • fever RSUDZA
appetite
• Weight loss
Referral Letter
Vital Sign
• Consciousness : Compos mentis
• Blood pressure : 105/65 mmHg
Task force : systole 101-114 mmHg
diastole 62-75 mmHg
• Pulse : 94 beats/minute
• Respiratory rate : 22 times/minute
• Temperature : 36.8 0C
• SpO2 : 98 % in room air
ANTHROPOMETRY
• Actual Body Weight : 36 kg
• Ideal Body Weight : 35 kg
• Length : 142 cm
• Weight/ Age : 83,7 %
• Length/ Age : 94 %
• Weight/Lenght : 102 %
• HA : 11 years 8 months
• Head of Circumference : 55 cm
• Upper Arm Circumference : 26 cm
• Nutritional Status : Normoweight

17
BBI
Youth Pediatric Symptom Checklist-17

Score :
YPSC-17 – I =2
YPSC-17- A= 0
YPSC-17- E= 0
No Behavior Disorder
Tanner Stage
Physical Examination

• Head : Normocephali, HoC= 55 cm,black hair not easily pull out

• Eyes : Conj. Palpebra Inferior pale, Sclera icteric Negative
• Ears : Normotia
• Nose : tampons in both nose
• Mouth : Hiperemis at lips, no sianosis
• Neck : Lymp node enlargement not found
• Thorax
Anterior
Inspection : Symmetrical, no retraction
Auskultasi : Vesiculer, not found rhonchi and wheezing

Posterior
Inspection : Symmetrical, No retraction
Auskultasi : Vesiculer, not found rhonchi and wheezing

• Heart
I : Ictus cordis not visibly
P : Ictus cordis palpable at ICS V midclavicula sinistra’s line
A : S I> S II, Reguler, no thrills or murmur

22
• Abdomen
Inspection : Symmetrical, not distended, striae positive
Palpation : soepel, hepar and lien are not palpable (no organomegali)
Percussion : tympani
Auscultation : normal peristaltic

• Extremities
-Superior : Pale, warm, CRT < 2 seconds, no edema/ sianosis
- Inferior : Pale, warm, CRT < 2 seconds, no edema/ sianosis

• Anogenitalia
Genetalia : Male
 RSU Datu Beru RSUDZA
Hematology Normal Value
12/6/2023 12/6/2023
LABORATORY Hemoglobin 7,71 6,9 12,0 - 14,0 gr/dl
Hematokrit 21,95 19 45-55 %
RBC 2,41 2,1 4.7 – 6.1 106/ mm3

WBC 3,76 3.17 4.5 - 10,5 103/mm3

Platelets 11 4 150-450/103 mm3

Eosinofil 0,03 0 0-6%
Basofil 4,83 0 0-2%
N. Bands forms (Bands) 0 2-6%

N. Granulocytes (segs) 55.15 51 50-70%

Limfosit 32,32 39 20-40%

Monosit 7,66 10 2-8%
MCV 91,05 91 80-100fl
MCH 31,98 34 27-31pg
MCHC 35,12 37 32-36%
RDW 13,48 14,8 11,5-14,5%
Ureum 46 13 – 43 mg/ dL
Kreatinin 0,70 0.67 – 1.0 mg/dL
GFR 111,57 96,5-136,9
 RSUDZA
Hematology Normal Value
12/6/2023
AST/ SGOT 261 < 35 U/L
ALT/SGPT 215 <45 U/L
Kalsium 8,0 8.6 – 10.3 mg/dl
Albumin 3,10 3,5 - 5,2 gr/dL
Natrium 127 132-146 mmol/liter
Kalium 4,4 3,7-5,4 mmol/liter
Clorida 106
Urine Dipstick
June 12th 2023

pH Urin :6
SG : 1,015
Protein : Negative
Leukocyte : Negative
Blood : Negative
Keton : Negative
Nitrit : Negative
Urobilinogen : Negative
Bilirubin : Negative
Glucosa : Negative
Differential Diagnosis
- Pancytopenia ec DD/
1. Aplastic anemia
2. Hematology malignancy
- Epistaxis posterior
- Elevated transaminase ec dd
1. viral hepatitis
2. Drug Induced
-immunization not completed
Working Diagnosis
- Severe Anemia (D64.9)
- Pansitopenia ec. Aplastic anemia (D 61.9)
- Epistaxis posterior ( R04.1)
- Viral Hepatitis (B19.9)
- Immunization not completed (Z28.1)
 Recommended Daily Allowance

• Daily fluid maintanance for patient with BW 36 kg

= 1.820 cc/day

• Calories for male with HA of 11 years 8 months (IBW 35 Kg)

= 50-70 kcal x 35 kg
= 1.750-2450 Kcal/day

• Proteins for male with HA of 11 years 8 months (IBW 35 Kg)

= 1,7 gr x 35 kg
= 59,5 grams/day
 Management
Supportive
• IVFD 2:1 ~ 820 cc/ 24 hours ~ 34 cc/hour
• Diet regularly food 3 times a day (3x500 kcal), entrakid 2x 100 cc
Total =1700 kcals (97% RDA)

Therapy
• Inj. Metamizole 400 mg PRN (IV)
• Curcuma 2x 1 tab po
• Transfusion of Trombocyte Concentrate 350 cc/day for 3 days
• Transfusion of PRC target 10 g/dl
H1 250 cc/day
H2 250 cc/day
Planning
• Division: Hemato Oncology Pediatric
• Admission to Arafah 1
• Check Peripheral blood morphology, Reticulocyte, Coombt test, Cross Match
• Check HbsAg, IgM anti HCV, total bilirubin, indirect bilirubin, direct bilirubin
• BMP
• Urinalysis
• Feces routine
• Catch Up Immunization (Td, MR/MMR, Hep B, polio)
• Consult to Gastroenterohepatology Division
• Monitoring of hemodynamic, urine output, vital sign and bleeding

31
Clinical Photo
 Follow up this morning (06 am)
• Consciousness : GCS E4M5V6 Compos Mentis
• Blood pressure : 106/63 mmHg
Task force : systole 101-114 mmHg
diastole 62-75 mmHg
• Pulse : 86 beats/minute
• Respiratory rate : 22 times/minute
• Temperature : 36,7 0C
• SpO2 : 98 %
• Diuresis : 2 cc/kg/hour