MORNING REPORT

Disusun oleh:
Noermawati Dewi

FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH SURAKARTA
2017
 IDENTITY
• Name : An. M
• Date of birth : 19 November 2015
• Gender : Girl
• Age : 21 months
• Address : Surakarta
• Religion : Islam
• Tribe : Java
• Date of hospitalization : 08-08-2017 (14.00)
• Date of examination : 08-08-2017 (17.00)
ANAMNESIS

Chieft Complaint

Vomitus
 HISTORY OF ILLNESS

1 day before admission

• The mother said on Monday, patient got vomitus 8 times and washy
defecation 1 time
• When vomite, the patient excreted mucous and water
• The appetite had decreased (patient didn’t want to eat something
except breastmilk and plain water)
 HISTORY OF ILLNESS

The day on admission

• On tuesday, patient got vomitus 2 times and washy defecation 1 times,
the mother took the patient to the RS PKU Muhammadiyah.
• Patient looked weak and rewel.
• The appetite had decreased.
 HISTORY OF PAST ILLNESS

History of Seizure with fever : Recognized (13th

months)
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: the history of past illness is seizure with fever

 HISTORY OF ILLNESS IN FAMILY

History of Seizure with fever : Recognized (father)

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

An. M 21 months

Conclusion : there is no illness is inherited

 HISTORY OF PREGNANCY

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

check pregnancy and routinely control to the obstetrician.
During pregnancy the mother does feel nausea, vomiting and
dizziness that not interfere the 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 normal
delivery. 37 weeks pregnancy age, baby born with body weight 2700
grams. At the time of birth the baby cries instantly, there is no congenital
defect at birth. But when the baby born, the amniotic fluid was green
color .
Conclusion : history of delivery was good

HISTORY OF POST DELIVERY

The baby boy was born crying, active motion, red skin color, not
blue but at the 4th day baby got yellow skin color, and then the
baby got phototherapy. Patient got milk on first day, urination
and defecated less than 24 hours
Conclusion : history of post delivery was not good
 HISTORY OF ENVIRONMENT

The patient lives at home with both parents, old brother, and
grandparents. 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,
patient’s father had diarrhea.

Conclusion : there is 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.

Conclusion : history of vaccine was good

 HISTORY OF FEEDING
Age 0 - 6 months
• Exclusive breastmilk

Age 6 - 8 months
• Breastmilk + MP ASI (instant food)

Age ≥12 months

• Rice porridge, vegetables and fruits are mashed

Age 1- 2 years
• White rice, eggs, meat, fish, vegetables

Conclusion : history of feeding was good

 HISTORY OF GROSS MOTOR

Kemampuan Umur pencapaian Range normal

miring 3 bulan 0-3 bulan
Duduk 7 bulan 6 – 7,5 bulan
Berdiri 12 bulan 11 - 14 bulan
Berjalan 14 bulan 11-15 bulan
berlari 17 bulan 13,5-20 bulan

Conclusion :Development history of Gross motor 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 12 bulan 12 – 17 bulan
Membuat menara 1,5tahun 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 5 bulan 3,5 – 7 bulan
Meniru bunyi kata-kata 6 bulan 3,5 – 9 bulan
Papa mama 10 bulan 7 – 13 bulan
Berbicara sebagian 18 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 16 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 : Compos mentis
Awareness : weakness

 Vital Sign
Blood Pressure :-
Heart rate : 108x/ menit
Respiratory Rate : 30 x/ menit
temperature : 36,6º C
 Nutrisional status

WEIGHT : 7.4 KG Height : 75.0 CM

-Weight // age : -3 SD line

-Lenght // age : < -2 SD line
-Weight // Lenght : <-2 SD line

Conclusion : The patient's nutritional status is not good

Weight : 7,4 kg
Age : 21 months
Height :.0 cm
Age : 21 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 :BU (+) meningkat
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 (-/-), mata cekung (-/-), mukosa kering
(-/-)
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:
 LABORATORIUM EXAMINATION
Routine blood examination (8/8/17)
PEMERIKSAAN HASIL SATUAN NORMAL
 Leukosit 8.99 10ˆ3/ul 4.5 – 12.50
 Eritrosit 4.92 jt/ul 3.8 – 5.20
 Hemoglobin 12.8 g/dl 11.7 – 15.5
 Hematokrit 37.0 % 35.0 – 47.0
 Trombosit 427 10ˆ3/ul 217 – 497
 Limfosit 45.5 % 25 – 40
 Netrofil 39.6 % 25 - 40
 Monosit 13.1 % 2–8

Routine Feces Examination (9/8/17)

DBN
 RESUME
ANAMNESIS
Vomitus
Washy defecation
Decreased appetite
Weakness

Physical examination
Blood Pressure : -
Heart rate : 108x/ menit
Respiratory Rate : 30 x/ menit
temperature : 36,6º C

Laboratorium
Normal
 ASSESMENT

1. Gastroenteritis akut

Differential Diagnosis
Thypoid
Diare cair akut
 ACTION PLAN
• Observation of vital signs (pulse, temperature, frequency of
respiratory)

DIAGNOSIS ENFORCEMENT PLAN

• Feces examination
 Terapi

Kalori : 7.4 x 98= 725.2 kkal

Protein : 7.4 x 1.5 = 11.1 g
Cairan : 7.4x 125= 925 ml
 ` PLAN
THERAPY

• Antiemetik : ondancetron 0.2mg/kgBB/ 12 jam

 7.4x0.2 = 1.48  1.5 mg/12 jam
 FOLLOW UP
TANGGAL SOA PLANNING
8-6-2017 -S/ On the morning, vomitus (-). P/
Jam -Infus KAEN 3B= 7.4
07.00 O/ kg = 740 ml = 8 tpm
- KU : Compos Mentis macro
- HR : 110x/menit -ondancetron
0.2mg/kgBB/ 12
- RR : 32x/menit
jam 7.4x0.2 =
- S : 36,8°C 1.48  1.5 mg/12
jam
 A/ gastroenteritis akut dengan dehidrasi ringan
THANK YOU