MORNING REPORT

Disusun oleh:
Noermawati Dewi

FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH SURAKARTA
2017
 IDENTITY
• Name : An. A
• Date of birth : 17 October 2015
• Gender : Girl
• Age : 22 months
• Address : Surakarta
• Religion : Islam
• Tribe : Java
• Date of hospitalization : 11-08-2017 (19.00)
• Date of examination : 12-08-2017 (20.00)
ANAMNESIS

Chieft Complaint

Vomit
 HISTORY OF ILLNESS
1 day before to the Hospital
• Her mother said on Thursday, the patient got vomitus >10x. It
happened especially when the patient drink and cough. Cough
happened when midnight. There was no fever.
• The appetite had decreased.
• And the defecation was soft and yellow color, 1 times / day.
• Urination was normall as usual .
• Patient was thirsty because she always ask to drink.
 HISTORY OF ILLNESS

The day on admission

• On Friday, the patient got vomitus >10x. Eventhough she didn’t
got cough.
• The mother took the patient to the PKU.
• Patient looked weak and rewel. Then at 12.00pm, she got fever.
• The appetite had decreased.
• The defecation was soft (1x). And urination was normall
• The history of the patient was she got a medication for CMV
infection since 6 July 2017
 HISTORY OF PAST ILLNESS

History of the similiar simpstoms : Denied

History of Seizure with fever : Admitted (9th months)
History of dengue fever : Denied
History of typhoid fever : Denied
History of long cough : Denied
History of asma : Denied
History of allergy : Admitted (cold)

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

current illness
 HISTORY OF ILLNESS IN FAMILY

History of Seizure with fever : Denied

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

Conclusion: there is no history of illness in family that correlated with

patient’s disease
 PEDIGREE

Ny. M 34 years old Tn. E 40years old

An. E 15 years old An. A 22 months

An. M 11 years old

Conclusion : there is no hereditary illness

 HISTORY OF PREGNANCY

Mother with P3A0 was pregnant at 32 years old. Mother began to

check pregnancy and routinely control to the midewife in the
Puskesmas. During pregnancy the mother does feel nausea,
vomiting and dizziness but not interfere the daily activities.
During pregnancy, the mother got hemorrhage (5 months
pregnancy age) but there is no trauma and hypertension.

Conclusion: history of pregnancy was good

 HISTORY OF DELIVERY

The mother gave birth to her baby assisted by a midwife with a normal
delivery. 36 weeks pregnancy age, baby born with body weight 3100
grams with body length 50 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 girl 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

The patient lives at home with both parents and old brother.
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 have not experienced similar complaints. Her brother also
don’t get any similar 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 completely. Vaccinations are obtained at
the primary care (posyandu, puskesmas).

Conclusion : history of vaccine was good

 HISTORY OF FEEDING
Age 0 - 3 months
• Breastmilk

Age 4 - 8 months
• Breastmilk + instan food 1 day 2-3 small bowls and always eat away

Age 9 - 12 months

• Formula + porridge of filter and vegetable teams smoothed 1 day 3 small dishes and always eat away

Age ≥12 months

• Rice, egg, fish, vegetables and fruits 1 day 3 small dishes and not eat away

Conclusion : history of feeding from quality and quantity was not good
 HISTORY OF GROSS MOTOR

Kemampuan Umur pencapaian Range normal

miring 3 bulan 0-3 bulan
Duduk 7 bulan 6 – 7,5 bulan
Berdiri Belum berdiri sendiri 11 - 14 bulan
Berjalan Belum berjalan 11-15 bulan

Conclusion :Development history of Gross motor not

according to age
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 HISTORY OF FINE MOTOR

Kemampuan Umur pencapaian Range normal

Meraih 5 bulan 4,5 – 5,5 bulan
Mencoret coret 17 bulan 12 – 17 bulan
Membuat menara 18 bulan 13-21 bulan

Conclusion :Development
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 HISTORY OF LANGUAGE
Kemampuan Umur pencapaian Range normal
Bersuara 3 bulan 1 – 3 bulan
Menoleh ke arah suara 6 bulan 3,5 – 7 bulan
Meniru bunyi kata-kata 8 bulan 3,5 – 9 bulan
Papa mama 13 bulan 7 – 13 bulan
Berbicara sebagian 19 bulan 17-39 bulan
dimengerti

Conclusion :Development history of language according to

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 HISTORY OF SOCIAL
Kemampuan Umur Range normal
pencapaian
Tersenyum spontan 2 bulan 0-2 bulan
Makan sendiri 6bulan 4,5 – 6,5 bulan
Menyatakan keinginan 12 bulan 7,5- 13 bulan
Minum dengan cangkir 18 bulan 9-18 bulan
Membuka pakaian 18 bulan 14bulan – 2 tahun

Conclusion :Development history of social according to age

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

 Vital Sign
Blood Pressure :-
Heart rate : 104x/ menit
Respiratory Rate : 32 x/ menit
temperature : 38,0º C
 Nutrisional status

WEIGHT : 10.3 KG Height : 87.0 CM

-Weight // age : < median line

-Lenght // age : > median line
-Weight // Lenght : >-1 SD line

Conclusion : The patient's nutritional status is good

Weight : 10.3 kg
Age : 22months
Height : 87.0 cm
Age : 22 months
 Physical examination
• Skin examination
Color : brown
Skin turgor: <2 sec (good)
Moisture: moist
Edema (-) does not exist

• Conclusion : the examination of skin within normal

limits

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 PEMERIKSAAN KUSUS
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 within normal limits

Stomach : Inspeksi :Distensi (-), sikatrik (-), purpura (-)
Auskultasi :Peristaltik (+)
Perkusi :Timpani (+)
Palpasi :Supel, massa abnormal (-), nyeri tekan (-),
turgor kulit menurun (-), acites (-)
Liver : Hepatomegali (-)
Spleen : Splenomegali (-)

Conclusion : the examination is normal limits

 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

26
 PHYSICAL EXAMINATION

Head : Normochephal
Eyes : CA (-/-), SI (-/-), edema palpebra (-/-), sunken eyes(-/-)
Nose : Sekret (-), epistaksis (-), nafas cuping hidung (-/-)
Ears : Sekret (-)
Mouth : Stomatitis (-), perdarahan gusi (-), sianosis (-)
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(+/+), petekie (-
/-)

Conclusion: There is no abnormality

 LABORATORIUM EXAMINATION
Routine blood examination (11/8/17)
PEMERIKSAAN HASIL SATUAN NORMAL
 Leukosit 23.16 H 10ˆ3/ul 6 – 17
 Eritrosit 4.86 jt/ul 3.6 – 5.20
 Hemoglobin 11.7 g/dl 10.7 – 12.8
 Hematokrit 34.9 L % 35.0 – 43.0
 Trombosit 471 10ˆ3/ul 229 – 553
 Limfosit 32.3 % 25 – 40
 Netrofil 60.1 % 50 - 70
 Monosit 7.4 % 2–8
 Eosinofil 0.0 L % 2-4
 Basofil 0.2 % 0-1

Result : Routine blood examination there is leukositosis

 LABORATORIUM EXAMINATION
Routine blood examination (12/8/17)
PEMERIKSAAN HASIL SATUAN NORMAL
 Leukosit 13.43 10ˆ3/ul 6 – 17
 Eritrosit 4.55 jt/ul 3.6 – 5.20
 Hemoglobin 10.8 g/dl 10.7 – 12.8
 Hematokrit 32.9 L % 35.0 – 43.0
 Trombosit 354 10ˆ3/ul 229 – 553
 Limfosit 42.9 H % 25 – 40
 Netrofil 46.9 L % 50 - 70
 Monosit 10.0 H % 2–8
 Eosinofil 0.0 L % 2-4
 Basofil 0.2 % 0-1

Result : Routine blood examination is within normal limits

 LABORATORIUM EXAMINATION

Lab
• Ur : 34.0 (normal)
• Cr : 0.60 (normal)
 RESUME
ANAMNESIS
Vomitus
Fever
Weakness

Physical examination
Blood Pressure : -
Heart rate : 104x/ menit
Respiratory Rate : 32 x/ menit
temperature : 38,0º C

Laboratorium
Virus
 ASSESMENT

1. Gastroenteritis akut

Differential Diagnosis
Thypoid Fever
Dengue Fever
Urinary tract infection
 ACTION PLAN
• Observation of vital signs (pulse, temperature, frequency of
respiratory)

DIAGNOSIS ENFORCEMENT PLAN

Routine feces examination

 Terapi

Kalori : 10.3 x 102 = 1050.6 kkal

Protein : 10.3 x 1.23 = 12.669 g
Cairan : 10.3 x 125= 1287.5 ml
 ` PLAN
THERAPY

• Antipiretik : Paracetamol 10 mg x 10kg = 100mg / 4 jam

• Antiemetik :Ondancetron 0,1mgx10kg = 1mg/12jam

• Probiotik : L-bio 3x1 sachet

• Cairan : Oral sesuai yang dimuntahkan
IV  maintenance  10kg x 100cc= 1000cc
1000/24 = 41.6 tts mikro =10 tts
makro

• Zink : 20mg/day
 FOLLOW UP
TANGGAL SOA PLANNING
12-8 - -S/ On the morning, vomitus (+) after got cough P/
2017 Appetite (+) Drink (+) -Infus KAEN 3A= 10 kg
Jam Urination was normal = 1000 ml = 10 tpm
Defecation was soft macro
07.00
-Paracetamol 10-
O/ 15mg/kgBB
- KU : Compos Mentis 10 x 10 = 100 mg
- HR : 102 x/menit -L-Bio= 3x1 sachet
- Zink 20mg/hari
- RR : 26 x/menit
- S : 37,7°C
- Tho: SDV (+/+), Wh (-/-), Rh (-/-)
- Abd : BU (+)
- Turgor : good (<2s)
- Feces Routine (12/8/17) : within normal limits

A/ Gastroenteritis Akut
 FOLLOW UP
TANGGAL SOA PLANNING
14-8 - -S/ On the morning, vomitus (+), Drink (+), cough (+) P/
2017 mucus (+), eye secret (+) -Infus KAEN 3A= 10 kg
Jam = 1000 ml = 10 tpm
O/ macro
07.00
- KU : Compos Mentis -L-Bio= 3x1 sachet
- RR : 36 x/menit - Zink 20mg/hari
- S : 36,7°C -Ambroxol
0,5mg/kgBB 
- Eye : injeksi konjunctiva palpebrae (+)
5mg/kali
sekret purulen (+) -Salbutamol
- Tho: SDV (+/+) 0,1mg/kgBB 
- Abd : BU (+) 1mg/kali
- Turgor : good (<2s)

A/ Gastroenteritis Akut
Bronkhitis akut
THANK YOU