MORNING REPORT

FRIDAY NIGHT SHIFT

NOVEMBER 8 th , 2019

dr. Fatimah / dr. Etika / dr. Ata / dr. Connie / dr. Hamid
dr.Agus/ dr. Efan
dr. Rizki / dr. Raisa

1
 PATIENT ADMISSION

Melati 2 :
• Child N / 4 years 10 months/ 25 kgs with prolonged fever due to typhoid
fever dd urinary tract infection, anemia microcytic hypochromic due to
iron deficiency DD chronic illness, obese.
• Child AH / 2 yo / 10 kgs with pneumonia, hydrocephalus post VP shunt,
intracranial mass DD suspected meduloblastoma, undernourished.
• Child A/ 4 years / 15 kgs with acyanotic congenital heart disease,
ventricular septal defect, TR mild, MR mild, heart failure, suspected
pulmonal hypertension, NYHA II, undernourished
• Child R/ 14 years/ 50 kgs with Epidural hematoma temporoparietal region,
wellnourished,
2
 PATIENT ADMISSION

Outpatient :
- Child C/ 1.5 years/ 9 kgs with acute pharyngitis, acyanotic congenital
heart disease, atrial septal defect, NYHA I, undernourished.
Inborn Delivery :
• Baby Mrs. M, 0 day old, 1400 grams, female neonate , with very low
birth weight, preterm, inappropriate for gestational age, caesarean
section delivery due to severe preeclampsia of mother.
• Baby Mrs S, 0 day, 2900 grams with female neonate, fullterm,
appropriate for gestational age, spontaneous delivery

3
 PATIENT IDENTITY

• Name : Child N
• Sex : Female
• Age : 4 years 10 months old
• W/H : 25 kg / 110 cm
• Address : Pasar Kliwon,Surakarta
• Medical Record : 01394488

4
CHIEF COMPLAINT

Fever that lasts 14 days

5
 Work of breathing:
Appearance:
Position: N
Tone: N
Voice: N
Irritability: N
Nostrils breath: -
Consolability: N
Retraaction: -
Look: N
Cry: N

Circulation:
Pale: -
Cyanosis: -
Mottled: -
 CURRENT MEDICAL HISTORY

2 weeks before admission

• Fever.
• The fever sometimes gone, but
sometimes got arise especially in the
evening.
• No queasy and vomit.
• Then parents brought patient to primary
health care then got Paracetamol 7
 CURRENT MEDICAL HISTORY

7 days before admission

• Fever.
• Vomited 2 times and didn’t want to eat.
• She also complained stomachache and
queasy.
• Then parents brought patient to primary
health care then patient got Paracetamol
and Amoxicilin. 8
 CURRENT MEDICAL HISTORY

3 days before admission

• Fever
• Stomachache and queasy.
• Parents brought patient to midwife, and got Paracetamol
and pulves.
• The midwife suggested the patient to underwent
laboratory test if the condition didn’t get better.
The day of admission
• Patient still got fever, queasy and stomachache especially in
left upper stomach. She didn’t want to eat. 9
 CURRENT MEDICAL HISTORY

At the ER
• Fully alert.
• No breathlessness.
• Stomachace and queasy.
• Didn’t want to eat, just consumed
milk.
• The last defecation was 4 days ago.
10
 PAST MEDICAL HISTORY

• History of the same illness : -

Family Medical History

• History of the same illnes : -

1
1
HISTORY OF PREGNANCY AND DELIVERY

Pregnancy

• During pregnancy, his mother routinely checked up her pregnancy to

the midwife. She was given vitamin, and she didn’t consume any
medicine beside it. She never got hospitalized during pregnancy and
has no fever during labor, no hypertension, and no vaginal bleeding.

Delivery

• Baby girl was born in 38 weeks of pregnancy by spontaneous delivery,

she cried vigorously, no cyanosis or jaundice. Her birth weight was
2600 grams

Conclusion:
Pregnancy and delivery history were normal
 VACCINATION HISTORY

0 month : Hepatitis B0
1 month : BCG, polio 1
2 months : DPT1, hepatitis B1, Hib1, polio2
3 months : DPT2, hepatitis B2, Hib2, polio3
4 months : DPT3, hepatitis B3, Hib3, polio4
9 months : measles and rubella
18 months : measles and rubella (booster)
: DPT, hepatitis B, Hib, Polio (booster)

Conclusion: complete immunization,

appropriate with Ministry of Health schedule 2017

13
 NUTRITION HISTORY

Patient eats rice 3-4 times a day since adult portion, with vegetables, ‘tahu’,
‘tempe’, egg, chicken, and beef. Patient also consumes one or two glass of milk
per day.
Conclusion:Adequate in quantity and quality

GROWTH AND DEVELOPMENT

She is 4 years 10 month old now, 25 kgs in body weight, 110 cm in height.
Birth weight : 2600 grams. she always gained weight and increased height when
she was taken to posyandu until 3 y.o. She studied in kindergarten, she can
communicate well with his friends.
Conclusion: appropriate for his age

14
 NUTRITIONAL STATUS

• Weight for age : 2 SD < W/A < 3 SD (overweight)

• Height for age : 0 SD < H/A < 2 SD (normoheight)
• Weight for height : 2 SD < W/H < 3 SD (overweight)
• BMI for age : BMI/A > 95th Percentile (obese)

Conclusion: Overweight, Normoheight, Overweight, Obese 1

(WHO, 2006) 5
 FAMILY TREE

II

III

Child N, female, 4 years 0 month old, 25 kg

16
 PHYSICAL EXAMINATION

• General appearance :fully alert, GCS E4M6V5

• Vital sign :
• Heart Rate = 101 bpm
• Respiration rate = 24 bpm
• Temperature = 37,8 0 C peraxilar
• O2 saturation = 98%

1
7
• Head : mesocephal
• Eyes : anemic conjunctiva (-/-), icteric conjunctiva (-/-), light reflex(+/+),
isochoric pupil 2 mm/2mm, sunken eyes (-/-)
• Nose : nasal flare (-/-), discharge (-/-)
• Mouth : wet lips (+), lips and tongue not cyanotic, stomatitis (+)
coated tongue (+)
• Throat :Tonsil T1-T1 and pharyng difficult to examine
• Neck : Enlargement of lymph node (-)
• Ears : discharge (-/-)
• Thorax : symmetric (+), retraction (-), visible ribs (-)
LUNG:
• I: normal, symmetric, retraction (-)
• P: fremitus simetrical
• P: sonor in both lung
• A: normal vesicular breath sound, additional breath sound (-/-)
18
CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, no murmur

ABDOMINAL:
I: abdominal wall equal to chest wall
A: peristaltic sounds normal limit
P: tympani(+), shifting dullness (-), undulations(-)
P: unpalpable liver and spleen, good skin turgor, left upper abdominal pain (+),
obturator sign (-), psoas sign (-)

EXTREMITIES:
The extremities were warm, capillary refill time < 2 sec, and pedicle dorsalis artery was
strongly palpable
19
 LABORATORY RESULTS 8 TH 2019
Value Reference Units
Hemoglobin 9.4 10.8-12.8 g/dl
Hematocrit 29 35-43 %
Leucocyte 12.4 5.5-17.0 x103/ul
Thrombocyte 387 150-450 x103/ul
Eritrocyte 4.49 3.9-5.3 x106/ul
MCV 65.0 80.0-96.0 /um
MCH 20.9 28.0-33.0 pg
MCHC 32.2 33.0-36.0 g/dl
RDW 15.4 11.6-14.6 %
MPV 8.8 7.2-11.1 fl
PDW 16 25-65 %
Eosinophil 1.00 0.00-4.00 %
Basophil 0.20 0.00-1.00 %
Neutrophil 71.00 29.00-72.00 %
Lymphocyte 21.40 36.00-52.00 % 20

Monocyte 6.40 0.00-5.00 %

 CONCLUSSION

Anemia microcytic hypochromic

21
22 PROBLEM LIST
Girl, 4 years 10 months old, 25 kgs:

1. Fever last for 14 days

2. Queasy
3. Vomit
4. Lost of appetite
5. Stomachache especially left upper stomach
6. Temperature : 37,8 0 C peraxilar
7. Mouth : wet lips (+), lips and tongue not cyanotic, stomatitis (+)
coated tongue (+)
8. Abdominal : left upper abdominal pain (+)
9. Laboratory: anemia microcytic hypochromic
 23 WORKING DIAGNOSIS

1. Prolonged fever due to typhoid fever DD urinary tract

infection
2. Anemia microcytic hypochromic due to iron deficiency DD
chronic illness
3. Obese
 THERAPY

1. Admitted pediatric infection and tropic ward

2. Porridge 1000 kilo calories per day + milk 3 x 100 ml
3. IVFD D5 ¼ NS 12,5 ml/hour
4. Paracetamol (10mg/kg/8 hours)= 250 mg/8 hours IV
5. Ampicilin (50mg/KgBB/6 hours)= 1gram/6 jam IV
6. Betadine gurgle 3x1

24
 PLAN

Blood smear
Urinalysis
IgM Salmonella
Blood culture

MONITORING

• General appearance / vital signs / 8 hours

• Fluid balance and diuresis / 8 hours

25
 FOLLOW UP
NOVEMBER 9 TH 2019

26
 PHYSICAL EXAMINATION

• General appearance :fully alert, GCS E4M6V5

• Vital sign :
• Heart Rate = 114 bpm
• Respiration rate = 20 bpm
• Temperature = 37,8 0 C peraxilar
• O2 saturation = 98%

2
7
• Head : mesocephal
• Eyes : anemic conjunctiva (-/-), icteric conjunctiva (-/-), light reflex(+/+),
isochoric pupil 2 mm/2mm, sunken eyes (-/-)
• Nose : nasal flare (-/-), discharge (-/-)
• Mouth : wet lips (+), lips and tongue not cyanotic, stomatitis (+)
dirty tongue (+)
• Throat :Tonsil T1-T1 and pharyng difficult to examine
• Neck : Enlargement of lymph node (-)
• Ears : discharge (-/-)
• Thorax : symmetric (+), retraction (-), visible ribs (-)
LUNG:
• I: normal, symmetric, retraction (-)
• P: fremitus simetrical
• P: sonor in both lung
• A: normal vesicular breath sound, additional breath sound (-/-)
28
CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, no murmur

ABDOMINAL:
I: abdominal wall equal to chest wall
A: peristaltic sounds normal limit
P: tympani(+), shifting dullness (-), undulations(-)
P: unpalpable liver and spleen, good skin turgor, left upper abdominal pain (+), obturator
sign (-), psoas sign (-)

EXTREMITIES:
The extremities were warm, capillary refill time < 2 sec, and pedicle dorsalis artery was
strongly palpable
29
 30 WORKING DIAGNOSIS

1. Prolonged fever due to typhoid fever DD urinary tract

infection
2. Anemia microcytic hypochromic due to iron deficiency DD
chronic illness
3. Obese
 THERAPY

1. Porridge 1000 kilo calories per day + milk 3 x 100 ml

2. IVFD D5 ¼ NS 12,5 ml/hour
3. Paracetamol (10mg/kg/8 hours)= 250 mg/8 hours IV
4. Ampicilin (50mg/KgBB/6 hours)= 1gram/6 jam IV
5. Betadine gurgle 3x1

31
 PLAN

Blood smear
Urinalysis
IgM Salmonella
Blood culture

MONITORING

• General appearance / vital signs / 8 hours

• Fluid balance and diuresis / 8 hours

32
 FOLLOW UP
NOVEMBER 10 TH 2019

33
 PHYSICAL EXAMINATION

• General appearance :fully alert, GCS E4M6V5

• Vital sign :
• Heart Rate = 114 bpm
• Respiration rate = 20 bpm
• Temperature = 37,8 0 C peraxilar
• O2 saturation = 98%

3
4
• Head : mesocephal
• Eyes : anemic conjunctiva (-/-), icteric conjunctiva (-/-), light reflex(+/+),
isochoric pupil 2 mm/2mm, sunken eyes (-/-)
• Nose : nasal flare (-/-), discharge (-/-)
• Mouth : wet lips (+), lips and tongue not cyanotic, stomatitis (+)
dirty tongue (+)
• Throat :Tonsil T1-T1 and pharyng difficult to examine
• Neck : Enlargement of lymph node (-)
• Ears : discharge (-/-)
• Thorax : symmetric (+), retraction (-), visible ribs (-)
LUNG:
• I: normal, symmetric, retraction (-)
• P: fremitus simetrical
• P: sonor in both lung
• A: normal vesicular breath sound, additional breath sound (-/-)
35
CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, no murmur

ABDOMINAL:
I: abdominal wall equal to chest wall
A: peristaltic sounds normal limit
P: tympani(+), shifting dullness (-), undulations(-)
P: unpalpable liver and spleen, good skin turgor, left upper abdominal pain (+), obturator
sign (-), psoas sign (-)

EXTREMITIES:
The extremities were warm, capillary refill time < 2 sec, and pedicle dorsalis artery was
strongly palpable
36
 37 WORKING DIAGNOSIS

1. Prolonged fever due to typhoid fever DD urinary tract

infection
2. Anemia microcytic hypochromic due to iron deficiency DD
chronic illness
3. Obese
 THERAPY

1. Porridge 1000 kilo calories per day + milk 3 x 100 ml

2. IVFD D5 ¼ NS 12,5 ml/hour
3. Paracetamol (10mg/kg/8 hours)= 250 mg/8 hours IV
4. Ampicilin (50mg/KgBB/6 hours)= 1gram/6 jam IV
5. Betadine gurgle 3x1

38
 PLAN

Blood smear
Urinalysis
IgM Salmonella
Blood culture

MONITORING

• General appearance / vital signs / 8 hours

• Fluid balance and diuresis / 8 hours

39
 FOLLOW UP
NOVEMBER 11 TH 2019

40
 PHYSICAL EXAMINATION

• General appearance :fully alert, GCS E4M6V5

• Vital sign :
• Heart Rate = 114 bpm
• Respiration rate = 20 bpm
• Temperature = 37,8 0 C peraxilar
• O2 saturation = 98%

4
1
• Head : mesocephal
• Eyes : anemic conjunctiva (-/-), icteric conjunctiva (-/-), light reflex(+/+),
isochoric pupil 2 mm/2mm, sunken eyes (-/-)
• Nose : nasal flare (-/-), discharge (-/-)
• Mouth : wet lips (+), lips and tongue not cyanotic, stomatitis (+)
dirty tongue (+)
• Throat :Tonsil T1-T1 and pharyng difficult to examine
• Neck : Enlargement of lymph node (-)
• Ears : discharge (-/-)
• Thorax : symmetric (+), retraction (-), visible ribs (-)
LUNG:
• I: normal, symmetric, retraction (-)
• P: fremitus simetrical
• P: sonor in both lung
• A: normal vesicular breath sound, additional breath sound (-/-)
42
CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was palpable on ICS 4 parasternal lines
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, no murmur

ABDOMINAL:
I: abdominal wall equal to chest wall
A: peristaltic sounds normal limit
P: tympani(+), shifting dullness (-), undulations(-)
P: unpalpable liver and spleen, good skin turgor, left upper abdominal pain (+), obturator
sign (-), psoas sign (-)

EXTREMITIES:
The extremities were warm, capillary refill time < 2 sec, and pedicle dorsalis artery was
strongly palpable
43
 44 WORKING DIAGNOSIS

1. Prolonged fever due to typhoid fever DD urinary tract

infection
2. Anemia microcytic hypochromic due to iron deficiency DD
chronic illness
3. Obese
 THERAPY

1. Porridge 1000 kilo calories per day + milk 3 x 100 ml

2. IVFD D5 ¼ NS 12,5 ml/hour
3. Paracetamol (10mg/kg/8 hours)= 250 mg/8 hours IV
4. Ampicilin (50mg/KgBB/6 hours)= 1gram/6 jam IV
5. Betadine gurgle 3x1

45
 PLAN

Blood smear
Urinalysis
IgM Salmonella
Blood culture

MONITORING

• General appearance / vital signs / 8 hours

• Fluid balance and diuresis / 8 hours

46
THANK YOU
48
 DEFINISI

• Penyakit infeksi sistemik bersifat akut yang disebabkan oeh Salmonella

typhi
• Beberapa terminologi lain yang erat kaitannya adalah demam
paratifoid yang disebabkan oleh Paratyphi A, Paratyphi B, parathypi C
 Klinis

Gal
Widal Diagnosis kultur

Sampel
Minggu I dan II : darah
Minggu selanjutnya : urin dan feses Serologi
 PENATALAKSANAAN

• Tirah baring
• Pemenuhan kebutuhan cairan
• Nutrisi
• Antibiotik : oral atau injeksi
Kloramfenikol 100 mg/kgbb/hari dibagi 4
TMP-SMZ (10 mg/kgbb/hari dibagi 2)
Inj Ampicilin, inj Cefotaxime, inj Ceftriaxone