MORNING REPORT

Disusun oleh:
Noermawati Dewi

FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH SURAKARTA
2017
 IDENTITY
• Name : An. N
• Date of birth : 07 October 2016
• Gender : Girl
• Age : 10 months
• Address : Karanganyar
• Tribe : Java
• Date of hospitalization : 28-08-2017 (13.30)
• Date of examination : 28-08-2017 (15.00)
ANAMNESIS

Chief Complaint

Vomit
 HISTORY OF ILLNESS
The day on admission
• The mother told that the patient got from the
bed at 3 a.m, then when she drank milk, she
got vomit (10x).
• There was no seizure, fever (+), cough (-),
runny nose (-).
• Urination was decreased (terakhir 6 a.m)
• Defecation  watery stool (2x) no blood
 HISTORY OF PAST ILLNESS

History of Seizure with fever : Denied

History of seizure without fever : Denied
History of dengue fever : Denied
History of typhoid fever : Denied
History of long cough : Denied
History of asma : Denied
History of allergy with food and drug : Denied

Conclusion: there is no history of past illness that related to

current illness
 HISTORY OF ILLNESS IN FAMILY

History of Similiar symptom : Denied

History of Seizure with fever : Denied
History of Asma : Denied
History of allergy with food and drug : Admitted (amoxicilin &
gentamicin)
History of Hypertention : Denied
History of Diabetes Mellitus : Denied

Conclusion: there is history of illness in family that not correlated with

patient’s disease
 PEDIGREE

Ny. M 29 years old Tn. S 30 years old

An. N 10 months old

= Alergy of amoxicilin and

gentamicin

Conclusion : there is no hereditary illness

 HISTORY OF PREGNANCY

Mother with P2A0 was pregnant at 27 years old. Mother began to

check pregnancy and routinely control to the obstetrician.
During pregnancy the mother does not feel nausea, vomiting
and dizziness that interfere with daily activities. During
pregnancy there was no history of trauma, bleeding, infection,
and hypertension.

Conclusion: history of pregnancy was good

 HISTORY OF DELIVERY

The mother gave birth to her baby assisted by a obstetrian with C-section
delivery. 41 weeks pregnancy age, baby born with body weight 3400
grams and body lenght 51cm . At the time of birth the baby didn’t cry
instantly because of respiratory distress, but there was no congenital
defect at birth.
Conclusion : history of delivery was good

HISTORY OF POST DELIVERY

The baby girl has active motion, red skin color, not blue and
yellow skin color, got milk on first day, urination and defecation
less than 24 hours
Conclusion : history of post delivery was good
 HISTORY OF ENVIRONMENT

The patient lives at home with both parents and old sister.
Ceramic-floored patient houses, walled walls, tile roofs, adequate
ventilation, bathrooms in the house, water source from well water.
A few days before the patient was treated in the hospital,
neighbors and the family have not experienced some complaints.

Conclusion : there is no a risk factors for transmitted disease

 HISTORY OF VACCINE

• At that time of examination, the mother did not bring

KMS.
• According to her mother, the patient had received the
basic vaccine (kemenkes) completely. Vaccinations
were obtained at the primary care (midwife).

Conclusion : history of vaccine was good based on

KEMENKES
 HISTORY OF FEEDING
Age 0 – 6 months

• Exclusive breastmilk

Age 6-8 months

• Breastmilk + Formula + porridge of gasol 3 times a small dishes per day

Age 8-10 months

• Breastmilk + Formula+ porridge of rice, eggs, meat, fish, vegetables a day 3 times small dishes of food is
always finished

Conclusion : history of feeding  quality and quantity was good



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• The answer “Yes” = 10 poin

Conclusion : Development history is according to age

 Physical Examination
 General appearance
General appearance : good
Awareness : Alert

 Vital Sign
Blood Pressure :-
Heart rate : 124x/ menit
Respiratory Rate : 36x/ menit
Temperature : 37,5º C
 Nutrisional status

WEIGHT : 8.6 KG Height : CM

-Weight // age : antara 0 sampai 2 line (gizi baik)

-Height // age : antara -2SD sampai 0 line (normal)
-Weight // Lenght : antara 0 sampai 1 line (normal)

Conclusion : The patient's nutritional status is good

 Physical examination
• Skin examination
Color : brown
Moisture: moist
Turgor : <2 second
Edema (-) does not exist

• Conclusion : the examination of skin was normal

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 PEMERIKSAAN KHUSUS
Neck : No enlargement of lymph node and no increase jugular venous
Chest : Simetris, retration (-), miss the motion (-).
• Heart
Inspeksi : The ictus cordis is not visible
Palpasi : Ictus cordis not strong lift
Perkusi : sound “redup”
Auskultasi : sound of cor I-II reguler, bising jantung (-)
• Lung
Inspeksi : Simetris, retraksi intercostal (-/-), retraksi
subcostal (-/-), retraksi substernal (-), retraksi
suprasternal (-)
Palpasi : Simetris kanan kiri, There is no missed breath
Perkusi : sonor
Auskultasi : Vesicular (+/+) normal, rhonki (-/-), wheezing (-/-)

Conclusion : Neck, Chest, Heart, Lung  were normal limits

Stomach : Inspeksi : Distended (-), sikatrik (-), purpura (-)
Auskultasi : Peristaltik (+)
Perkusi : Hipertimpani (+)
Palpasi : supel (+), massa abnormal (-), nyeri tekan (-),
turgor kulit baik.
Liver : normal
Spleen : normal

Conclusion : There was hipertimpani (+)

 Ekstermitas

•Warm of acral
•Perfusion of tissue is good

•Cyanosis is not found in the 4 extremities

•No udem is found in the extremities

CRT <2 sec
Turgor is good

Conclusion : the examination of extremity was normal limits

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 PHYSICAL EXAMINATION

Head : Normochephal
Eyes : CA (-/-), SI (-/-), edema palpebra (-/-) , sunken eyes(-/-)
Nose : Sekret (-), epistaksis (-), nafas cuping hidung (-/-)
Ears : Sekret (-)
Mouth : Stomatitis (-), perdarahan gusi (-), sianosis (-), faring sulit dievaluasi
Skin : Warna sawo matang, Pucat (-), Ikterik (-), Sianosis (-)
Lymph nodes : Tidak didapatkan pembesaran limfonodi
Muscle : Tidak didapatkan kelemahan, atrofi, maupun nyeri otot
Bone : Tidak didapatkan deformitas tulang
Joints : Gerakan bebas
Extremities : CRT < 2 Second, sianosis (-/-), edema (-/-), akral hangat(+/+), petekie (-
/-)

Conclusion: There was abnormality

 LABORATORIUM EXAMINATION
Routine blood examination
PEMERIKSAAN HASIL SATUAN NORMAL
 Leukosit 16.77 10ˆ3/ul 4.5 – 12.50
 Eritrosit 5.22 L jt/ul 3.8 – 5.20
 Hemoglobin 10.5 L g/dl 11.7 – 14.5
 Hematokrit 32.8 L % 35.0 – 47.0
 Trombosit 358 10ˆ3/ul 217 – 497
 Limfosit 39.6 % 25 – 40
 Netrofil 54.4 % 50 - 70
 Monosit 5.7 % 2–8
 MCV 62.8 L fl 74.0 – 102.0
 MCH 20.1L pg 22.0 – 34.0

Result : Routine blood examination there was anemia mikrositik hipokromik

 RESUME
ANAMNESIS
Vomitus 10x after she got fallen from the bed
Watery stool 2x
Urination was decreased

Physical examination
Heart rate Normal
Respiratory rate normal
Temperature normal
Abdomen : hipertimpani (+)

Laboratorium
Anemia mikrositik hipokromik
 ASSESMENT

1. Gastroenteritis 2. Anemia
akut defisiensi besi
• DD : • DD:
• Intelorensi • Anemia e.c
laktosa infeksi kronis
 ACTION PLAN
• Balance cairan

• Observation of GCS (awareness)

DIAGNOSIS ENFORCEMENT PLAN

• Pemeriksaan kadar Fe, transferin, TIBC

 Terapi

kebutuhan energi : White rice, eggs, meat, fish,

Kalori : 8.6x 98= 842.8kkal vegetables a day 3 times a large plate of food
Protein : 8.6x 1.5 = 12.9g was always finished.
Cairan : 8.6x 125= 1075ml  rute oral
Kebutuhan energi : 842 kalori/hari dibagi dalam
3 kali waktu makan

kebutuhan energi :
Nasi putih 100 gram: 178 kalori
Tumis bayam 100 gr : 193 kalori
1 butir telur rebus : 154 kalori
1 tempe goreng : 82 kalori
1 ayam sayap: 295 kalori
 ` PLAN
THERAPY

• Cairan : 75 ml/kg x 8.6kg = 645 cc  50 tetes makro dalam 3 jam

• Zink 20mg/hari

• Domperidon : 0.3 mg/kg x 8.6 = 2.58 mg/ 8 jam

 FOLLOW UP
TANGGAL SOA PLANNING
24-8- -S/on the morning, watery stool(+) 3x, vomitus 6x, fever P/ -RL : 10tetes makro
2017 (sumer-sumer), she always ask to drink • -Zink 20mg/hari
Jam • -paracetamol
- KU : Compos Mentis 95mg/kali
07.00
- HR : 124x/menit pemberian
- RR : 36 x/menit
- S : 36.9
- Kepala: konjunctiva anemis (-/-), sklera ikterik (-/-)
- Tho: suara vesikuler(+/+), wheezing (-/-), Rhonki (-/-)
- Abd : tampak membesar, peristaltik (+), distended (+),
hipertimpani (+)
- Extremities : normal

A/
 Feces routine
• Warna : hijau
• Konsistensi lunak: lunak
• Lendir : negatif
• Darah : negatif
• Lemak : negatif
• Leukosit : 1-2
• Eritrosit : 1-2
• Telur cacing : negatif
• Amoeba : negatif
• Catatan Lab : sel ragi  positif
Pseudohifa  positif
THANK YOU