Morning Report

Tuesday, 20
th
Mei 2014
Identity
MR number : 77-29-05-00
Date of admission : Monday, 19th Mei 2014
Name : Darrel
Sex : Male
Age :
Address : Cipinang muara no. 16

Chief complaint: Fever
Additional complaints: vomit, nausea, stomachache.
The patient comes in with complaints of fever since 3
days before entering the hospital. Fever appears
suddenly and are constantly but the temperature has
not been resized. already given febrifuge, fever was
down, then up again. Since 2 days before entering
the hospital, the patient complained of abdominal
pain accompanied by pain in the eyes and
nosebleeds. to stop a nosebleed, the patient wears a
tissue. diarrhoea patients today 3 times with the
consistency of liquid, the Lees (+), blood (+), mucus
(-). Nausea (-), vomiting (-), gums bleeding (-). Good
appetite there is no interference. a history of cough
is undeniable. Cold 2 days before entering the
hospital. greenish color of secretions.
Past Medical History
Ever hospitalization because of a virus singapore
three months ago
Family medical history
Denied
Personal Habits
The acts of immunization complete and according to
age
Travelling history is denied

Physical Examination
Weight: 10 kg
IMT : 12 kg
General state: mild-sickness (no cyanosis found, can
communicate well, active)
Awareness: compos mentis (contact +, response +)
Respiratory rate : 27x/m (regular)
Heart rate: 128x/mnts (strong palpable, well content,
regular)
Blood pressure: 120/80 mmHg
Temperature: 38,4C (axilla)
Physical Examination
Head: normocephali, prevalent hair growth, not
easily removed
Eyes: anemic conjunctivitis -/-, jaundice sclera -/-
Nose: nasal flaring -/-, no hyperemia, no mucus
Mouth: not hyperremic pharing
Throat: tonsil T1-T1, no mucosal hyperemia
Ears: normotia, wide ear canal, no cerrument, no
secret

Physical Examination
Thorax:
a. Inspection: symmetric movements of the chest wall
b. Palpation: symmetric movements of vocal fremitus
c. Percussion: both sonor
d. Auscultation: basic breath sounds vesicular, ronkhi -,
wheezing -, heart sounds normal, gallop -, murmur -
Abdomen
a. Inspection: flat stomach
b. Auscultation: bowel sounds +, 5x/mnts
c. Percussion: tympani
d. Palpation: tenderness on epigastric (+), hepa and lien
not palpable

Physical Examination
Extremity: no cyanosis, movement in all directions,
warm
Integument: Rumple Leed test:-
Laboratory Report
Type Result Type Result
LED 40 mm/hour MCH/HER
MCHC
30,5 pg (L)
35,8 %
Hemoglobin 11,6 g/dl Basofil 0 %
Eritrosit 4,40 juta/ml Eosinofil 0 %
Leukosit 9,6 ribu/uL Neutrofil Batang 3 %
Trombosit 213 ribu/uL Neutrofil Segmen 84%
Hematokrit 33 % Limfosit 11%
Monosit 2 %
Diagnose
Working diagnose: Dengue fever
Differential diagnose: DHF, Thypoid fever, ISPA
Management
Diet: a diet of soft not stimulate
IVFD: Ringer lactate 16 drops/mnts (macro)
Mm: Sanmol syr 3x11/2 cth (PO)
terpacef 2x750mg
nymico 3x1cc
isprinol 3x cth
Morning Report
Second Case Thursday, 20
th
June 2013
Identity
MR number : 92-56-05-00
Date of admission : Thursday, 13th april 2014
Name : diantama r. tobing
Sex : Female
Age : 14 years old

Chief complaint: Fever
Additional complaints: nausea, not deffecate three
days
Current Illness
Patient came with current fever since six days ago.
Sudden fever and intermitten percieved. Percieved
fever usually appear at night and began to fall late
morning or afternoon. The patient was taking
medication, complaints had disappeared but
reappeared. 3 days ago patient admitted to
defecating bit and not defecate. In addition to the
above patient also complained of no coughing,
feeling dizzy and nauseous, but vomiting denied.
Allergic: denied
Past Medical History
Appendectomy (2005)
DHF (2006, 2010)
IMMUNISATION
Complete
Physical Examination
Weight: 44 kg
Height: -
General state: mild-sickness (no cyanosis found, can
communicate well, active)
Awareness: compos mentis (contact +, response +)
Respiratory rate: 24x/min
Heart rate: 80x/mnts (regular)
Blood pressure: 110/80 mmHg
Temperature: 36C (axilla)
Physical Examination
Eyes: anemic conjunctivitis -/-, jaundice sclera -/-
Nose: nasal flaring -/-, no hyperemia, no mucus
Mouth: dry lips mucosal
Throat: tonsil T1-T1 , no mucosal hyperemia
Ears: normotia, wide ear canal, no cerrument, no
secret
Neck : limfadenopati (-)

Physical Examination
Thorax:
a. Inspection: symmetric movements of the chest wall
b. Palpation: symmetric movements of vocal fremitus
c. Percussion: both sonor
d. Auscultation: basic breath sounds broncovesiculer,
ronkhi -, wheezing -, heart sounds normal, gallop -,
murmur -
Abdomen
a. Inspection: flat stomach
b. Auscultation: bowel sounds +, 4x/mnts
c. Percussion: tympani
d. Palpation: defence muscular (-)

Physical Examination
Extremity: no cyanosis, movement in all directions,
warm
Laboratory Report
Type Result
Hemoglobin 13.6 g/dl (L)
Leukosit 3.700 /uL
Trombosit 121 ribu/uL (H)
Hematokrit 39.1 % (L)
Diagnose
Working diagnose:
Differential diagnose:
Management
Diet: absorbed food
IVFD: tridexplain 20 drops/m macro continue with RL
20 drops/m
mm/: Sanmol tab 3x1
isprinol 3x1
Morning Report
Third Case Thursday, 20
th
June 2014
Identity
MR number : 29-62-04-00
Date of admission : Tuesday, 17
th
May 2013,
3.30 PM
Name : M. Rachfatih Ariqin
Sex : Male
Age : 1 year 2 months
Address :

Chief complaint: Fever
Additional complaints: cough and narrow
Current Illness
Since 6 days ago patient got fever. Subfebris fever
among the body with the higher temperature in the
night. Patient was brought to general doctor and
given medicine for her fever and finally recovered. 5
days ago patient got fever again and her parents
counted the temperature 38 C.
Patient also had cough and shortness of breath
since 6 days ago. Cough with white secret all day
and getting worse. She had given medicine for her
cough but no improvement. Bloody cough denied.
Urinary and defecation have no problem.
Physical Examination
Weight: 11 kg
Height: 70 cm
General state: mild-sickness (no cyanosis found, can
communicate well, active)
Awareness: compos mentis (contact +, response +)
Respiratory rate:24x/mnts (strong palpable, well
content, regular)
Heart rate: 110x/mnts (regular)
Blood pressure: 100/70 mmHg
Temperature: 37,5C (axilla)
Past Medical History
Denied
Physical Examination
Head: normocephali, prevalent hair growth, not
easily removed
Eyes: anemic conjunctivitis -/-, jaundice sclera -/-
Nose: nasal flaring -/-, no hyperemia, no mucus
Mouth: dry lips mucosal
Throat: tonsil T1-T1 , no mucosal hyperemia
Ears: normotia, wide ear canal, no cerument, no
secret

Physical Examination
Thorax:
a. Inspection: symmetric movements of the chest wall
b. Palpation: symmetric movements of stem fremitus
c. Percussion: both sonor
d. Auscultation: basic breath sounds broncovesiculer,
ronkhi +, wheezing -, heart sounds normal, gallop -,
murmur -
Abdomen
a. Inspection: flat stomach
b. Auscultation: bowel sounds +, 5x/mnts
c. Percussion: tympani
d. Palpation: defence muscular (-)

Physical Examination
Extremity: no cyanosis, movement in all directions,
warm
Integument: Rumple Leede (+) petekie (-)
Laboratory Report
Type Result
Hemoglobin 11,1g/dl (L)
Eritrosit 4,32 juta/ml
Leukosit 12,700 /uL
Trombosit 114.000 ribu/uL (H)
Hematokrit 34,4 % (L)
Diagnose
Walking diagnose: dengue fever +
bronchopneumonia
Differential diagnose: thyphoid fever, TB
Management
Diet: breast milk and porridge
IVFD: RL 14 drips/ minute (macro) + O2 2 LPM
Mm: Sanmol syrup 3x10 cc (PO)
Ranitidine 2x15mg (IV)
Isprinol 3x3/4 cth (PO)
cough pulv 3x1 : ambroksol 5mg + salbutamol
0,5mg
+ceftrizime 1mg + prednison 1 mg
ventoin adn pulmicort inhalant 2x/day
ampicilin 4x200mg
kemicetin 4x250 mg