MORNING REPORT

SUNDAY, SEPTEMBER 9TH 2018

(MORNING SHIFT)

dr. Raisa / dr. Anto / dr. Susi / dr. Guntur / dr.

Anggra
dr. Rekno
dr. Rahmi / dr. Dilla

1
 PATIENT ADMISSION

 MELATI 2 WARD
 Z, female, 3 years old, 14 kgs with Idiopatic general epilepsy, wellnourished

 MELATI 3 WARD

A, female, 15 years old, 58 kgs with

Prolonged Fever due to Typhoid Fever dd
Urinary track infection, Acute Tonsilofaringitis ,
Well nourished
 PICU -
NEONATAL HCU: -
MELATI 2 HCU : -
2
NICU : -
PATIENT IDENTITY

 Name :A
 Sex : Female
 Age : 15 years old
 Body weight / height : 58 kgs / 165 cms
 Adress : Blora
 Medical Record : 01431822

3
CHIEF COMPLAINT

Fever

4
CURRETNT MEDICAL HISTORY

10 days before 7 days before

admission admission
• Patient got high • Fever got better
fever • Runny nose (-),
• Runny nose (-), snezzing (-)
• No cough
snezzing (-), no • urination and
cough defecation within
• No vomite, no normal limit
diarrhea,
• No pain when 5
urinate,
• No discharge
CURRETNT MEDICAL HISTORY

4 days before admission

• Patient got high fever again
• Runny nose (-), snezzing (-),
• Cough (+) sore throat (-)
• No vomite, no diarrhea,
• No discharge from both ear
• Went to Private Hospital, got blood
examination
• Because lack of facilities  reffered to
Moewardi Hospital 6
AT DR. MOEWARDI HOSPITAL’S ER

 Patient fully awake

 Fever
 Cough
 No vomit
 Urination normal
 Last defecation 3 days ago

7
PAST MEDICAL HISTORY

 History of prolonged fever before (-)

 Contact TB (-)

8
FAMILY MEDICAL HISTORY

 History of prolonged fever before (-)

 Contact TB (-)

9
 PREGNANCY AND DELIVERY HISTORY

• During pregnancy, his mother routinely checked up her

pregnancy to doctor. She was given vitamin, and she
didn’t consume any medicine beside it. She never got
hospitalized during pregnancy and has no fever during
labor, no hypertension, and no vaginal bleeding.
• Baby boy was born in 40 weeks of pregnancy by
spontaneous delivery. He cried vigorously, no cyanosis
or jaundice. His birth weight was 3600 grams, 49
centimeters in length, no meconeum was found

Conclusion: Pregnancy and delivery history 10

were normal
VACCINATION HISTORY

 BCG : 1 month
 Hepatitis B : 0,2,3,4 months
 DPT-HiB : 2,3,4 months
 Polio : 1,2,3,4 months
 Measles : 9 months

Conclusion :
basic immunization complete,
appropriate with Ministry of Health schedule
1999
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 NUTRITION HISTORY

Patient eat rice, chicken, beef, fish, fruit and some of

vegetables. Her portion usually same with adult portion.
She also drink milk sometimes
Conclusion: nutrition status is adequate

GROWTH AND DEVELOPMENT

She is now 15 years old.
Her weight is 58 kgs with body height 165 cm.
Birth weight : 3600 gram
She can play with his friends, communicate well. She study at
3rd grade of junior high school, never retained
Conclusion: appropriate for his age 12
 13

NUTRITIONAL STATUS

• Weight for Age: P 50 < Weight/Age < P 75

58/60 x 100% = 96 %
• Height for Age: P 25 < Height/Age < P 50
165/170 X 100% = 97%
• Weight for Height : P 25 < Weight/ Height < P
50
58/54 X 100% = 107%
Conclusion:
Wellnourished, normoweight, normoheight
 FAMILY TREE
I

II

II
I

A, 15 years old, 58 14
kgs
 PHYSICAL EXAMINATION
General appearance : fully alert
GCS E4M6V5
Vital sign :
 Heart Rate = 103 bpm
 Respiration rate = 22 bpm
 Temperature = 39.3 0
C peraxilar
 T: 110/70
 O2 saturation = 99%
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 Head : mesocephal
 Eyes : pale conjunctiva (-/-), icteric conjunctiva (-/-), light
reflex (+/+),
isochoric pupil 2 mm/2mm, sunken eyes (-/-), tears (+/
+),
 Nose : nasal flare (-/-), discharge (-/-)
 Mouth : wet lips (+), typhoid tongue (+)
 Throat : hyperemic pharing (+), Tonsil T3-T1 hyperemic
(+), detritus (+)
 Neck : Enlargement of lymph node (-)
 Thorax : symmetric (+), retraction (-)

LUNG:
 I: normal, symmetric, retraction (-)
 P: fremitus normal in both lung
 P: sonor in both lung
 A: normal vesicular breath sound, additional breath sound (-/-)

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CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, no murmur
ABDOMINAL:
I: abdominal wall equal to chest wall, hernia umbilicalis (-)
A: peristaltic sounds normal limit
P: tympani (+), shifting dullness (-), undulations(-)
P: liver Palpable 1-1.5 cm under arcus costae
and spleen was not palpable, good skin turgor
EXTREMITIES:
The extremities were warm, capillary refill time < 2 sec, and
dorsalis pedis artery was strongly palpable,
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 LABORATORY RESULTS
  6/9 7/9 8/9 9/9 Reference Units
Hemoglobin 11.6 12.7 11.5 12-15 g/dl
Hematocrit 38.3 39.4 36.5 35-49 %
Leucocyte 4.4 5.9 4.7 5-10 x103/ul
Thrombocyte 122 113 139 150-450 x103/ul
Lymphocyte 20.1 36 28.1 20-40 %
SGOT 89.8
SGPT 148.6
IgG Dengue +
IgM Dengue -
IgG Typhoid -
IgM Typhoid -

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 CENTOR SCORE

 Fever > 38oC : +1

 Absence of cough :0
 Swollen, tender anterior cervical nodes :0
 Tonsillar swelling or exudate : +1
 Age : 15-44yo :0

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PROBLEM LIST

15 years old, female, weight 58 kg with

1. Prolonged Fever
2. Runny nose (-), snezzing (-),
3. Cough (+) sore throat (-)
4. No vomite, no diarrhea,
5. No discharge from both ear
6. Typhoid tongue
7. Hyperemic pharing and Tonsil T3-T1
8. Thrombocytopenia
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DIFFERENTIAL DIAGNOSIS

1. Prolonged Fever due to Typhoid Fever dd

Urinary track infection
2. Acute Tonsilopharingitis

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WORKING DIAGNOSIS

1. Prolonged Fever due to Typhoid Fever

2. Acute Tonsilopharingitis
3. Well nourished

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 THERAPIES

 Admitted to pediatric infection ward

 Nutrition  rice pack 2000 kkal/ day
 IVFD D 1/2 NS 103 ml/hour intravenously
 Ampicillin Sulbactam (50 mg/kgBW/6 hours) 1 g/6 hours
 Paracetamol (10 mg/kgBW/8 hours) 600 mg/8 hours iv
 Ranitidin (1 mg/kgBW/8 hours) 1 amp/8 hours iv

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 PLAN

1. Urinalysis, stool analysis

2. IgG, IgM Typhoid
3. Throat swab culture

MONITORING
• General appearance / vital signs/ 8
hours
• Fluid balance and diuresis /8 hours

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FOLLOW UP
10 / 09/ 2018

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 S: FEVER (+), COUGH (+)
General appearance : fully alert
GCS E4M6V5
Vital sign :
 Heart Rate = 102 bpm
 Respiration rate = 22 bpm
 Temperature = 38.3 0
C peraxilar
 T: 110/70
 O2 saturation = 99%
26
 Head : mesocephal
 Eyes : pale conjunctiva (-/-), icteric conjunctiva (-/-), light
reflex (+/+),
isochoric pupil 2 mm/2mm, sunken eyes (-/-), tears (+/
+),
 Nose : nasal flare (-/-), discharge (-/-)
 Mouth : wet lips (+), typhoid tongue (+)
 Throat : hyperemic pharing (+), Tonsil T3-T1 hyperemic
(+), detritus (+)
 Neck : Enlargement of lymph node (-)
 Thorax : symmetric (+), retraction (-)

LUNG:
 I: normal, symmetric, retraction (-)
 P: fremitus normal in both lung
 P: sonor in both lung
 A: normal vesicular breath sound, additional breath sound (-/-)

27
CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, no murmur
ABDOMINAL:
I: abdominal wall equal to chest wall, hernia umbilicalis (-)
A: peristaltic sounds normal limit
P: tympani (+), shifting dullness (-), undulations(-)
P: liver Palpable 1-1.5 cm under arcus costae
and spleen was not palpable, good skin turgor
EXTREMITIES:
The extremities were warm, capillary refill time < 2 sec, and
dorsalis pedis artery was strongly palpable,
28
WORKING DIAGNOSIS

1. Prolonged Fever due to Typhoid Fever

2. Acute Tonsilopharingitis
3. Well nourished

29
 THERAPIES

 Nutrition  rice pack 2000 kkal/ day

 IVFD D 1/2 NS 103 ml/hour intravenously
 Ampicillin Sulbactam (50 mg/kgBW/6 hours) 1 g/6 hours
 Paracetamol (10 mg/kgBW/8 hours) 600 mg/8 hours iv
 Ranitidin (1 mg/kgBW/8 hours) 1 amp/8 hours iv

30
 PLAN

1. Urinalysis, stool analysis

2. IgG, IgM Typhoid
3. Throat swab culture

MONITORING
• General appearance / vital signs/ 8
hours
• Fluid balance and diuresis /8 hours

31