MORNING REPORT

Disusun oleh:
Ratna Ayu Wulandari

FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH SURAKARTA
2017
 IDENTITY
• Name : An. A
• Date of birth : 13 Februari 2001
• Gender : Girl
• Age : 16 years 8 months old
• Address : Surakarta
• Religion : Islam
• Tribe : Java
• Date of hospitalization : 27-10-2017 (13.15)
• Date of examination : 27-10-2017 (13.25)
 ANAMNESIS

Chief Complaint

Abdominal Pain
 HISTORY OF ILLNESS
4 days before admission
• the patient got Abdominal pain in the epigastric region and the
hypogastric region
• fever (+) 38 C
• abdominal pain in the epigastric region and the hypogastric region
• Headache
• Hot pee
 HISTORY OF ILLNESS
2 days before admission
• The patient got Abdominal pain in the epigastric region and the hypogastric
region
• fever (+) 38 C
• Headache
• Cough (+) sputum (+)
• Hot pee
• Shivering
• Vomitus
• The mother went to the doctor, the doctor gives chloramfenicol 250mg 3x1
after eating, antasid done 3x1 before eating, CTM 3x1
• Patient chek up laboratorium examination
 LABORATORIUM EXAMINATION
Routine blood examination
PEMERIKSAAN HASIL SATUAN NORMAL
 Leukosit 5.0 10ˆ3/ul 4.5 – 12.50
 Eritrosit 4.77 jt/ul 3.8 – 5.20
 Hemoglobin 10.9 L g/dl 11.7 – 14.5
 Hematokrit 38.8 % 35.0 – 47.0
 Trombosit 158 H 10ˆ3/ul 217 – 497
 Granulosit 43.2 % 43.0 – 76.0
 MCV 81.4 fl 74.0 – 102.0
 MCH 22.8 pg 21.0 – 34.0
 MCHC 28.0 g/dl 26.0 – 34.0

Result : Routine blood examination was anemia, trombositopenia

 LABORATORIUM EXAMINATION
Immunoserology examination
Widal Slide Test
PEMERIKSAAN HASIL NORMAL
 S. Typhi O (TO) 1/80 negatif
 S. Paratyphi A (AO) negatif negatif
 S. Paratyphi B (BO) negatif negatif
 S. Paratyphi C (CO) negatif negatif
 S. Typhi H (TH) 1/60 negatif
 S. Paratyphi A (AH) negatif negatif
 S. Paratyphi B (BH) negatif negatif
 S. Paratyphi C (CH) negatif negatif

Result : immunoserology examination was normal

 HISTORY OF ILLNESS
The day on admission
• The patient got Abdominal pain in the epigastric region and
the hypogastric region
• fever (+) 38 C
• Headache
• Cough (+) sputum (+)
• Hot pee
• Shivering
• Vomitus (-)
 LABORATORIUM EXAMINATION
Routine blood examination
PEMERIKSAAN HASIL SATUAN NORMAL
 Leukosit 7.67 10ˆ3/ul 4.5 – 12.50
 Eritrosit 5.55 H jt/ul 3.8 – 5.20
 Hemoglobin 13.7 g/dl 11.7 – 14.5
 Hematokrit 40.6 % 35.0 – 47.0
 Trombosit 260 10ˆ3/ul 217 – 497
 Netrofil 56.8 % 50 - 70
 Limfosit 34.4 % 25 – 40
 Monosit 7.4 % 2–8
 Eosinofil 1.3 L % 2-4
 Basofil 0.1 % 0-1
 MCV 76.4L fl 74.0 – 102.0
 MCH 26.2 pg 21.0 – 34.0
 MCHC 34.3 g/dl 26.0 – 34.0
 MPV 9.1 fL 9.0-13.0
Result : Routine blood examination was eosinofilia, mikrositik.
 LABORATORIUM EXAMINATION
Complete urine examination
PEMERIKSAAN HASIL NORMAL
 Warna kuning kuning
 Kekeruhan agak keruh jernih
 Glukosa negatif negatif
 Bilirubin +1 negatif
 Keton +3 negatif
 Berat Jenis >=1.030 1.003-1.030
 Darah negatif negatif
 PH urin 6.0 4.8– 7.8
 Protein negatif negatif
 Urobilinogen 3.2 <16.9
 Nitrit negatif negatif

Result : complete urine examination ketonuria

 LABORATORIUM EXAMINATION
Complete urine examination
Sedimen

PEMERIKSAAN HASIL NORMAL

Leukosit 1-2 1-4
Eritrosit 1-2 H 0-1
Epitel Squamous 5-10 5-15
Bakteri positif (++)/banyak
Kristal negatif
silinder negatif
Lain - lain negatif

Sero imunologi
Urobilinogen 3.2 <16.9
Nitrit negatif negatif

Result : complete urine examination bekteri (++) banyak

 HISTORY OF PAST ILLNESS

History of Seizure with fever : Denied

History of seizure without fever : Denied
History of dengue fever : Denied
History of typhoid fever : Denied
History of asma : Denied
History of allergy with food and drug : Denied

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 : Admitted (Brother)
History of Allergy Food : Denied
History of Hypertention : Denied
History of Diabetes Mellitus : Denied

Conclusion: there is history of illness in family that not correlated with

patient’s disease
 PEDIGREE

29 yo 30 yo

16 years 8
Asthma
months old

Conclusion : there is hereditary illness

 HISTORY OF PREGNANCY

• Mother with P3A0 was pregnant at 34 years old. Mother began

to check pregnancy and routinely control to the midwife and
obstitrician. During pregnancy the mother does not feel
nausea, vomiting and dizziness that interfere with daily
activities. During pregnancy there was no history of trauma,
bleeding, infection, and hypertension.

Conclusion: history of pregnancy was good

 HISTORY OF DELIVERY

The mother gave birth to her baby assisted by a obstetrian with a normal
delivery. 37 weeks pregnancy age, baby born with body weight 3000
grams and body lenght 47 cm . At the time of birth the baby cries instantly,
there was 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 yellow skin color, got milk on first day, urination and
defecation less than 24 hours

Conclusion : history of post delivery was good

 HISTORY OF ENVIRONMENT

The patient lives at home with both parents. 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 and the family have not experienced same complaints.

Conclusion : there is no a risk factors for transmitted disease

 HISTORY OF VACCINE

JENIS JM USIA
Hepatitis B 4 kali 0, 2, 3,4 bulan
BCG 1 kali 1 bulan
DPT 4 kali 2, 3, 4,18 bulan
Hib 3 kali 2, 3 , 4 bulan
Polio 4 kali 1, 2, 3, 4 bulan
Campak 3 kali 9, 24 bulan, SD kelas 1
dT 3 kali SD kelas 1, 2 , 3
 HISTORY OF FEEDING
Umur 0 - 6 bulan
• Exclusive breastmilk

Umur 6 - 8 bulan
• Formula + instan food 1 day 3 small bowls and always spent

Umur 8 - 10 bulan
• Formula + porridge of filter and vegetable teams smoothed 1 day 3 small dishes and always spent

Umur 10 - 12 bulan
• Rice porridge, vegetables and fruits are mashed 1 day 3 small dishes and always spent

Umur 1- 2 tahun
• White rice, eggs, meat, fish, vegetables a day 3 times a large plate of food is always exhausted.

Umur 2 - 4 tahun
• White rice, eggs, meat, fish, vegetables a day 3 times a large plate of food is always exhausted.

Umur 4 - 6 tahun
• White rice, eggs, meat, fish, vegetables a day 3 times a large plate of food is always exhausted.

Umur 6 - 16 tahun
• White rice, eggs, meat, fish, vegetables a day 3 times a large plate of food is always exhausted.

Conclusion : history of feeding from quality and quantity was good

 HISTORY OF ROUGH MOTORIC

Kemampuan Umur pencapaian Range normal

Duduk kepala tegak 4 bulan 2- 4,5 bulan
Membalik 6 bulan 3 - 6 bulan
Duduk tanpa pegangan 7 bulan 6 – 7,5 bulan
Berdiri sendiri 11 bulan 11 - 14 bulan
Berjalan dengan baik 12 bulan 11-15 bulan
berlari 15 bulan 13,5-20 bulan
Berdiri 1 kaki 4 tahun 4 tahun-6 tahun

Conclusion :Development history of rough motoric

according to age
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 HISTORY OF FINE MOTORIC

Kemampuan Umur pencapaian Range normal

Meraih 4.5 bulan 4,5 – 5,5 bulan
Memindahkan kubus 5 bulan 5 – 7 bulan
Mencoret coret 12 bulan 12 – 17 bulan
Membuat menara dari 2 kubus 1,5tahun 13-21 bulan
Menggoyangkan ibu jari 3,5 tahun 33-45 bulan
Memilih garis lebih panjang 4 tahun 3-5 tahun
Menggambar manusia (kepala, 4,5 tahun 3-5,5 tahun
tangan, kaki)

Conclusion :Development history of fine motoric according

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choose header)
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 HISTORY OF LANGUAGE
Kemampuan Umur pencapaian Range normal
Bersuara 2,5 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 spesifik 9 bulan 7 – 13 bulan
6 kata 18 bulan 14-23 bulan
Berbicara sebagian 2,4 bulan 17-39 bulan
dimengerti
Kegunaan benda 3,5 tahun 33-45 bulan

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
Tepuk tangan 11 bulan 7 – 11 bulan
Menyatakan keinginan 12 bulan 7,5- 13 bulan
Minum dengan cangkir 15 bulan 9-18 bulan
Membuka pakaian 18 bulan 14bulan – 2 tahun
Memakai baju 3 tahun 27 -42 bulan
Gosok gigi tanpa bantuan 4 tahun 30 bulan – 5 tahun

Conclusion :Development
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 History of Development
• Patient in Senior High School
• Patient can follow the lesson in the class
• Patient play with his friends and he has a lot
of friends
 Physical Examination
 General appearance
General appearance : Good
Awareness : Compos Mentis

 Vital Sign
Blood Pressure : 100/80 mmHg
Heart rate : 90x/ menit
Respiratory Rate : 20x/ menit
Temperature : 37.0º C
 Nutrisional status

WEIGHT : 42.0 KG Height : 145.0 CM

-IMT = 20 (Normal )

Conclusion : The patient's nutritional status is good

 Physical examination
• Skin examination
Color : Brown
Moisture: moist
Edema (-) does not exist

• Conclusion : the examination of skin was normal

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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 : There is no missed breath
Perkusi : Sonor
Auskultasi : Vesicular (+/+) normal, Rhonki (-/-), wheezing (-/-)

Conclusion : Neck, Chest, Heart, Lung  there was no abnormality

Stomach : Inspeksi : Distended (-), sikatrik (-), purpura (-)
Auskultasi : Peristaltik (+)
Perkusi : Timpani (+)
Palpasi : Soft, abnormal mass (-), tenderness (-),
skin < 2 seconds, abdominal pain in the epigastric
region and the hypogastric region
Liver : normal
Spleen : normal

Conclusion : Abdominal pain in the epigastric region and the hypogastric region
 Ekstermitas

•Warm of acral
•Perfusion of tissue is good

•Cyanosis is not found in the 4 extremities

•No udem is found in the extremities

Conclusion : the examination of extremity was normal limits

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 PHYSICAL EXAMINATION

Head : Normochephal
Eyes : CA (-/-), SI (-/-), edema palpebra (-/-)
Nose : Sekret (-), epistaksis (-), nafas cuping hidung (-/-)
Ears : Sekret (-)
Mouth : Stomatitis (-), sianosis (-).
Skin : 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 : sianosis (-/-), edema (-/-), akral hangat(+/+), petekie (-/-)

Conclusion: stomatitis (+), there was normal limits

 RESUME
ANAMNESIS
• Fever
• shivering
• abdominal pain in the epigastric region and the hypogastric region
• Headache
• Vomitus 1x
• Hot pee
Physical examination
• Physical Examination :
Vital sign : fever
Stomach : Abdominal pain in the epigastric region and the hypogastric region

Laboratorium
eosinofilia, mikrositik, anemis, trombositopenisa, ketonuria, bakteri ++ pada urin baynyak,
 USG Abdomen
• Gastritis
• Cystitis
 ASSESMENT

1. ISK
DD
Gastritis
 ACTION PLAN
• Observasi Fever

DIAGNOSIS ENFORCEMENT PLAN

 Terapi

kebutuhan energi : rice, eggs, meat, fish,

Kalori : 42 x 98= 4116 kkal vegetables a day 3 times a large plate of food
Protein : 42 x 1.5 = 63 g was always finished.
Cairan : = 1940ml  rute oral
Kebutuhan energi : 980 kalori/hari dibagi dalam
3 kali waktu makan

kebutuhan energi :
Nasi putih 100 gram: 176kalori
Bayam rebus 100 gr : 23 kalori
1 butir telur rebus : 154 kalori
1 tempe goreng : 82 kalori
1 ayam sayap: 295 kalori
Pepaya 100 gram : 46 kalori
 ` PLAN
THERAPY

• Paracetamol 10 – 15 mg/kgBB : 10 x 42 = 420 mg = 1 tab

Sediaan tab : 500mg
Ampisilin 15-25mg/kgbb= 15x42= 630 mg(sediaan 500mg)= 1 tab
 FOLLOW UP
TANGGAL SOA PLANNING
28-10- S/ nyeri perut (+) mual (-), muntah (-), demam (-), flatus (+), P/ ampisilin 1
2017 tab/6 jam
Batuk (+), BAK panas, nyeri kepala (+)
Jam
06.30
O/
- KU : Sedang, Compos Mentis
- TD: 100/80mmHg
- HR : 100 x/menit
- RR : 20 x/menit
- S : 37,0°C

Abdomen: Inspeksi : Distensi (-), sikatrik (-), purpura (-)

Auskultas : Peristaltik (+) normal
Perkusi : Timpani (+)
Palpasi : Supel, massa abnormal (-), nyeri tekan
(+) regio hipogastric dan epigastrium
A/ ISK
 FOLLOW UP
TANGGAL SOA PLANNING
29-10- S/ nyeri perut (+) mual (-), muntah (-), demam (-), flatus (+), P/ ampisilin 1
2017 tab/6 jam
Batuk (+), BAK panas, nyeri kepala (+)
Jam
06.30
O/
- KU : Sedang, Compos Mentis
- TD: 100/70mmHg
- HR : 104 x/menit
- RR : 20 x/menit
- S : 36,6°C

Abdomen: Inspeksi : Distensi (-), sikatrik (-), purpura (-)

Auskultas : Peristaltik (+) normal
Perkusi : Timpani (+)
Palpasi : Supel, massa abnormal (-), nyeri tekan
(+) regio hipogastric dan epigastrium
A/ ISK
 FOLLOW UP
TANGGAL SOA PLANNING
29-10- S/ nyeri perut (+) mual (-), muntah (-), demam (-), flatus (+), P/ ampisilin 1
2017 tab/6 jam
Batuk (+), BAK tidak nyeri
Jam
06.30
O/
- KU : Sedang, Compos Mentis
- TD: 100/70mmHg
- HR : 104 x/menit
- RR : 20 x/menit
- S : 36,6°C

Abdomen: Inspeksi : Distensi (-), sikatrik (-), purpura (-)

Auskultas : Peristaltik (+) normal
Perkusi : Timpani (+)
Palpasi : Supel, massa abnormal (-), nyeri tekan
(+) regio epigastrium
A/ ISK
THANK YOU