MORNING REPORT

Disusun oleh:
RIA MAULINDASARI

FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH SURAKARTA
2019
 IDENTITY
• Name : An. N
• Date of birth : 10 July 2007
• Gender : Girl
• Age : 11 years 8 Month
• Address : Banjarsari, Solo
• Religion : Islam
• Tribe : Java
• Date of hospitalization : 25-03-2019 (03.00)
• Date of examination : 25-03-2019 (07.30)
ANAMNESIS

Chieft Complaint

Fever
 HISTORY OF ILLNESS

5 days before admission

• He had fever in afternoon, but didn’t know the body temperature

• Nausea and vomitus
• Cough and rhinorrhea
• Headache
• Normal feeding
• Normal urination and defecate
• Stomatitis
 HISTORY OF ILLNESS

4 days before admission

• fever still remains, but his mother didn’t know the body temperature
• Cough and rhinorrhea
• He complaint muscle pain to walk
• Stomatitis
• Normal feeding
• No seizure, no loss of conciousness
• Normal defecation and urination
• Patient check a doctor
 HISTORY OF ILLNESS

The day of admission

• Fever
• Cough and rhinorrhea
• Headache
• No abdominal pain
• Normal feeding
• Vomiting (+), nausea (+)
• Stomatitis
• Normal urination and defecate
 HISTORY OF PAST ILLNESS

History of anemia : Denied

History of Seizure with fever :+
History of dengue fever : Denied
History of typhoid fever : Denied
History of long cough :+
History of asma : Denied
History of allergy :+
History of hospitalized :+

Conclusion: there is history of seizure with fever, history of long

cough, history of allergy, history of hospitalized
 HISTORY OF ILLNESS IN FAMILY

History of Anemia : Denied

History of asma : Denied
History of atopi : Denied
History of hypertention : Denied
History of Diabetes Mellitus : Denied

Conclusion: there is no history of illness in family

 PEDIGREE

51 42 36

Tn. A 47 years old Ny. T 39 years old

15 3
An. N 12 years

Conclusion : there is no illness inherited

 HISTORY OF PREGNANCY

Mother with P4A1 is pregnant at 26 years old. Mother began to

check pregnancy and routinely control to the midwife. During
pregnancy the mother does feel nausea, vomiting and dizziness
that interfere with daily activities. During pregnancy there is no
history of trauma, bleeding, infection, and hypertension during
pregnancy.

Conclusion: history of pregnancy was good

 HISTORY OF DELIVERY

The mother gave birth to her baby assisted by a doctor with a cesarean
delivery. 38 weeks pregnancy age, baby born with body weight 2800
grams with body length 46 cm. At the time of birth the baby cries
instantly, there is no congenital defect at birth.

Conclusion : history of delivery was good

HISTORY OF POST DELIVERY

The baby boy was born crying, active motion, red skin color, not
blue and not yellow skin color, got milk on first day, urination
and defecated less than 24 hours

Conclusion : history of post delivery was good

 HISTORY OF ENVIRONMENT

KOMPONEN
RUMAH YG KRITERIA NILAI BOBOT
DINILAI
KOMPONEN
RUMAH 31

1 Langit-langit a. Tidak ada 0

b. Ada, kotor, sulit dibersihkan, dan rawan kecelakaan 1
c. Ada, bersih dan tidak rawan kecelakaan 2 62
2 Dinding a. Bukan tembok (terbuat dari anyaman bambu/ilalang) 1
b. Semi permanen/setengah tembok/pasangan bata atau 2
batu yang tidak diplester/papan yang tidak kedap air.
c. Permanen (Tembok/pasangan batu bata yang
diplester) 3 93
Conclusion papan
: there is no
kedap air.
a risk factors for transmitted disease
3 Lantai a. Tanah 0
b. Papan/anyaman bambu dekat dengan tanah/plesteran 1
yang retak dan berdebu.
c. Diplester/ubin/keramik/papan (rumah panggung). 2 62
 HISTORY OF ENVIRONMENT
4 Jendela kamar tidur a. Tidak ada 0
b. Ada 1 31
5 Jendela ruang keluarga a. Tidak ada 0
b. Ada 1 31
6 Ventilasi a. Tidak ada 0

b. Ada, lubang ventilasi dapur < 10% dari luas lantai 1

c. Ada, lubang ventilasi > 10% dari luas lantai 2 62
7 Lubang asap dapur a. Tidak ada 0
b. Ada, lubang ventilasi dapur < 10% dari luas lantai
dapur 1 31
b. Ada, lubang ventilasi dapur > 10% dari luas lantai
dapur 2

(asap keluar dengan sempurna) atau ada exhaust fan

atau ada peralatan lain yang sejenis.

8 Pencahayaan a. Tidak terang, tidak dapat dipergunakan untuk membaca 0

b. Kurang terang, sehingga kurang jelas untuk membaca 1

dengan normal
c. Terang dan tidak silau sehingga dapat dipergunakan
Conclusion : there is no a risk factors for transmitted disease
untuk 2 62
membaca dengan normal.
 HISTORY OF ENVIRONMENT

II SARANA SANITASI 25

1Sarana Air Bersih a. Tidak ada 0

b. Ada, bukan milik sendiri dan tidak memenuhi syarat
(SGL/SPT/PP/KU/PAH). kesh. 1
c. Ada, milik sendiri dan tidak memenuhi syarat kesh. 2
e. Ada, milik sendiri dan memenuhi syarat kesh. 3
d. Ada, bukan milik sendiri dan memenuhi syarat kesh. 4 75

2Jamban (saran pembua- a. Tidak ada. 0

ngan kotoran). b. Ada, bukan leher angsa, tidak ada tutup, disalurkan ke 1
sungai / kolam
c. Ada, bukan leher angsa, ada tutup, disalurkan ke
sungai 2
atau kolam
d. Ada, bukan leher angsa, ada tutup, septic tank 3
e. Ada, leher angsa, septic tank. 4 100
 HISTORY OF ENVIRONMENT

a. Tidak ada, sehingga tergenang tidak teratur di

3 Sarana Pembuangan halaman 0
Air Limbah (SPAL) b. Ada, diresapkan tetapi mencemari sumber air (jarak 1
sumber air (jarak dengan sumber air < 10m).
c. Ada, dialirkan ke selokan terbuka 2
d. Ada, diresapkan dan tidak mencemari sumber air
(jarak 3 50
dengan sumber air > 10m).
e. Ada, dialirkan ke selokan tertutup (saluran kota)
untuk 4
diolah lebih lanjut.
4 Saran Pembuangan a. Tidak ada 0
Sampah/Tempat Sampah b. Ada, tetapi tidak kedap air dan tidak ada tutup 1
c. Ada, kedap air dan tidak bertutup 2
d. Ada, kedap air dan bertutup. 3 50
 HISTORY OF ENVIRONMENT
III PERILAKU PENGHUNI
44
1 Membuka Jendela a. Tidak pernah dibuka 0
Kamar Tidur b. Kadang-kadang 1
c. Setiap hari dibuka 2 88

2 Membuka jendela a. Tidak pernah dibuka 0

Ruang Keluarga b. Kadang-kadang 1
c. Setiap hari dibuka 2 88

3 Mebersihkan rumah a. Tidak pernah 0

dan halaman b. Kadang-kadang 1
c. Setiap hari 2 88

4 Membuang tinja bayi a. Dibuang ke sungai/kebun/kolam sembarangan 0

dan balita ke jamban b. Kadang-kadang ke jamban 1
c. Setiap hari dibuang ke jamban 2 88

5 Membuang sampah a. Dibuang ke sungai / kebun / kolam sembarangan 0

pada tempat sampah b. Kadang-kadang dibuang ke tempat sampah 1
c. Setiap hari dibuang ke tempat sampah. 2 88

TOTAL HASI PENILAIAN 1149

 HISTORY OF ENVIRONMENT

Kriteria :

1) Rumah Sehat = 1068 - 1200

2) Rumah Tidak Sehat = < 1068

Conclusion : there is no risk factors for transmitted disease

 HISTORY OF VACCINE

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

KMS.
• According to the mother's confession, the patient gets
complete vaccine.

Conclusion : the history of vaccine is complete acording

to KEMENKES
 HISTORY OF FEEDING
0 – 6 month old
• Exclusive breastmilk

6 – 8 month old
• Breastmilk + Formula + instan food 1 day 3 small bowls

8 – 10 month old
• Breastmilk + Formula + porridge of filter and vegetable teams smoothed 1 day 3 small dishes

10 – 12 month old
• Formula + Rice porridge, vegetables and fruits are mashed 1 day 3 small dishes

1 – 2 years old
• Formula + White rice, eggs, meat, fish, vegetables a day 3 times a large plate of food

2 – 7 years old
• White rice, eggs, meat, fish, vegetables, fruits a day 3 times a large plate of food

Conclusion : history of feeding from quality and quantity was good

 HISTORY OF PERSONAL SOCIAL
Competence Age of achievment Normal age

Smile spontaneously 1 month 0-2month

Feed self 6 month 5 – 6,5 month
Indicate wants 12 month 7,5- 13 month
Drink from cup 15 month 9-17 month
Remove garment 22 month 14 month – 2 years
Wash and dry hands 2,5 years 19 month - 3 years
Put on t-shirt 3 years 2,5- 3,5 years
Play board/card games 4,5 years 2,8- 5 years
Brush teeth, no help 5.5 years 3 - 6 years

Conclusion :Development history of personal social

according to age
 HISTORY OF FINE MOTOR

Competence Age of achievment Normal age

Reaches 5 month 4,5 – 5,5 month
Scribbles 12 month 12 – 17 month
Tower of 2 cubes 16 month 13-21 month
Thumb wiggle 3,5 years 3-4 years
Pick longer line 5,5 years 4,5-6 years
Copy □ 6 years 4,8-6 years

Conclusion :Development
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 HISTORY OF LANGUAGE
Competence Age of achievment Normal age
Vocalizes ooo/aah 1,5 month 1 – 3 month
Turn to voice 5 month 3,5 – 5,5 month
Imitate speech sounds 7 month 3,5 – 9 month
Papa mama 10 month 7 – 13 month
Speech fluently 24 month 24-51 month
Name 4 pictures 2 years 2-3 years
Name 4 colors 3 years 3-4,8 years
Define 7 words 6 years 4 – 6 years

Conclusion :Development history of language according to

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 HISTORY OF LANGUAGE
Competence Age of achievment Normal age
Vocalizes ooo/aah 1,5 month 1 – 3 month
Turn to voice 5 month 3,5 – 5,5 month
Imitate speech sounds 7 month 3,5 – 9 month
Papa mama 10 month 7 – 13 month
Speech fluently 24 month 24-51 month
Name 4 pictures 2 years 2-3 years
Name 4 colors 3 years 3-4,8 years
Define 7 words 6 years 4 – 6 years

Conclusion :Development history of language according to

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(go to view menu and
choose header)
 History of DEVELOPMENT and
INTELLEGENT
• Patient ia a student in elementary school. The patient can
attend the lessons well

• Conclusion: History of development and

intellegent was good
 Nutrisional status

11 years 8 month WEIGHT : 37 KG Height : 145 CM BMI: 16.4

-Height // age : < 0 SD

-BMI // age : < 0 SD

Conclusion : the nutritional status is normal

 Physical Examination
 General appearance
General appearance : alert
 Vital Sign
Blood Pressure : 110/80 mmHg
Heart rate : 110 x/ menit
Respiratory Rate : 20 x/ menit
temperature : 38,5º C
 Physical examination
• Skin examination
Color : brown
Skin turgor: <2 sec (good)
Moisture: moist
Edema (-) does not exist

Conclusion : skin examination within normal limits

29
 PEMERIKSAAN FISIK
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 dextra and sinistra, There is no missed breath
Perkusi : sonor
Auskultasi : Vesicular (+/+) normal, rhonki (-/-), wheezing (-/-)

Conclusion : the examination is within normal limits

Stomach : Inspeksi : Distensi (-), sikatrik (-), purpura (-)
Auskultasi : Peristaltik (+) normal
Perkusi : Timpani (+)
Palpasi : massa abnormal (-), tenderness (+) Region
epigastrium and lumbar sinistra, turgor kulit normal,
acites (-)
Liver : Hepatomegali (-)
Spleen : Splenomegali (-)

Conclusion : the examination of stomach is tenderness in region epigastrium

and lumbar sinistra
 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 within normal limits

32
 PHYSICAL EXAMINATION

Head : Normochephal
Eyes : CA (-/-), SI (-/-), edema palpebra (-/-), reflek cahaya (+/+)
isokor (+/+), sunken eyes(-/-)
Nose : Sekret (-), epistaksis (-), nafas cuping hidung (-/-)
Ears : Sekret (-), nyeri tekan (-)
Mouth : Stomatitis (-), perdarahan gusi (-), sianosis (-), pharynx hiperemis (+)
exudate (-)
Skin : Warna sawo matang, Pucat (-), Ikterik (-), Sianosis (-), turgor kulit (< 2
detik)
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(+/+)

Conclusion: there were pharynx hiperemis (+)

 LABORATORY TEST (25/3/2019)
INDICATOR VALUE REFERENCE

Leukosit 3.91 L 4.50 – 13.50

Eritrosit 5.52 H 3.80 – 5.20
Hemoglobin 14.2 11.8 – 15.0
Hematokrit 41.4 35.0 – 47.0
Trombosit 162 154 – 442
Netrofil 33.1 L 50 – 70
Limfosit 45.2 H 25 – 40

Monosit 17.5 H 2–8

Eosinofil 1.3 L 2–4
Basofil 2.9 H 0–1
MCV 75.0 L 80.0 – 10.0
MCH 25.7 L 26.0 – 34.0
MCHC 34.3 32.0 – 36.0

Conclusion : leukopenia, eritrosititosis, neutropenia, monositosis,

 LABORATORY TEST (25/3/2019)
INDICATOR VALUE REFERENCE

Warna Kuning Kuning

Kekeruhan Jernih Jernih
Glukosa Negatif Negatif
Bilirubin Negatif Negatif
Keton Negatif Negatif
Berat Jenis 1.010 1.003 – 1.030
–
Darah Negatif Negatif

PH Urin 6.5 4.8 – 7.8

Protein Negatif Negatif
Urobilinogen 3.2 < 16.9
Nitrit Negatif Negatif

Conclusion : normal
 LABORATORY TEST (25/3/2019)
INDICATOR VALUE REFERENCE

Lekosit 0–1 1–4

Eritrosit 0–1 0–1
Epitel squamous 0–1 5 – 15
Bakteri Positif (+) / sedikit Negatif
Kristal Negatif
Silinder Negatif
–
Lain-lain Negatif

Conclusion : bakteri (+)

 LABORATORY TEST (26/3/2019)
INDICATOR VALUE REFERENCE

Leukosit 6.30 4.50 – 13.50

Eritrosit 4.49 3.80 – 5.20
Hemoglobin 11.8 11.8 – 15.0
Hematokrit 35.2 35.0 – 47.0
Trombosit 129 L 154 – 442
Netrofil 62.6 50 – 70
Limfosit 22.7 L 25 – 40

Monosit 14.7 H 2–8

MCV 78.5 L 80.0 – 10.0
MCH 26.2 26.0 – 34.0
MCHC 33.5 32.0 – 36.0

IgG Positif Negatif

IgM Positif Negatif

Conclusion : trombositopenia, monositosis, IgG dan IgM (+)

 RESUME
ANAMNESIS Physical examination
Fever 5 days pharynx hiperemis (+)
Cough and rhinorrhea
Headache
No abdominal pain
Normal feeding
Vomiting (+), nausea (+)
Stomatitis Laboratory test : trombositopenia,
Normal urination and defecate monositosis, IgG dan IgM (+)
 ASSESMENT

Diagnosis
Dengue Fever

DD :
Rinofaringitis
Otitis Media akut
urinary tract infection
 ACTION PLAN
• Observation of vital signs (temperature, frequency of
respiratory)
• Observation the effect of mediaction

DIAGNOSIS ENFORCEMENT PLAN

• Check trombosit
 ` PLAN
THERAPY

• Fluid maintenance
Infus RL
100 x 10 = 1000
50 x 10 = 500
20 x 17 = 340
Total kebutuhan cairan = 1840/hari  26 tpm

• Paracetamol tab 500 mg

• Candestatin 500.000 iu/6jam
 Follow up
26/3/2019
S/ patients fever (-), cough (+), rhinore (+), nausea (+), vomitting (-),
stomatitis, headache, normal urinating and defecate, epistaxis (-)
O/ N : 94 x/Minutes
RR : 24 x / minute
S : 36,6 °C
Laboratory : IgG and IgM (+), trombositopenia

A/ DF

P / inf. RL 26 tpm
Paracetamol tab 500 mg jika demam
Candestatin 500.000 iu/6 jam
Cek trombosit
THANK YOU