MORNING REPORT

Disusun oleh:
Noermawati Dewi

FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH SURAKARTA
2017
 IDENTITY
• Name : An. I
• Date of birth : 2 Juny 2013
• Gender : Boy
• Age : 4 years 2 months
• Address : Surakarta
• Religion : Islam
• Tribe : Java
• Date of hospitalization : 19-08-2017 (00.00)
• Date of examination : 19-08-2017 (06.30)
ANAMNESIS

Chieft Complaint

Fever
 HISTORY OF ILLNESS
4 day before admission

• The mother said on Tuesday 07.00, the patient

got dizziness. Then at 18.00 he got fever. Fever
happened especially at night.
• There were nausea (-), vomit (-), diarrhea (-)
• The defecation and urination was normal.
 HISTORY OF ILLNESS

The day on admission

• The mother said that she took the patient to PKU because the fever was
hilang-timbul.
 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 long cough : 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 Similiar symptom : Denied

History of Seizure with fever : Admitted (older brother)
History of Asma : 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

Ny. M 35 years old Tn. S 38 years old

An. I 4 years old

= Kejang Demam

Conclusion : there is hereditary illness

 HISTORY OF PREGNANCY

Mother with P3A0 was pregnant at 31 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 not good

 HISTORY OF DELIVERY

The mother gave birth to her baby assisted by a midwife with a normal
delivery. 39 weeks pregnancy age, baby born with body weight 3500
grams and body lenght 48 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 not 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, sister and

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 and the family have not experienced some 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 (kemenkes) completely. Vaccinations
were obtained at the primary care (puskesmas).

Conclusion : history of vaccine was good based on

KEMENKES
 HISTORY OF FEEDING
Age 0 – 1,5 months
• Breastmilk

Age > 1,5-6 months

• Formula + breastmilk

Age >6-12 months

• Formula + porridge rice and vegetables teams smoothed 1 day 2 small dishes and always finished

Age ≥ 12 months
• Rice + vegetables + egg+ fish 1 day 2 small dishes and always finished

Conclusion : history of feeding quality and quantity were 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 11 bulan 11 - 14 bulan
Berjalan 12 bulan 11-15 bulan
berlari 18 bulan 13,5-20 bulan
melompat 2 tahun 22-30 bulan
Lompat jauh 3 tahun 2,5-3 tahun

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
Mencontoh 4 tahun 3-4 tahun

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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
Berbicara beberapa kata 2 tahun 17-39 bulan
Bicara semua dimengerti 2,5 tahun 1,5-3 tahun
Menyebut 4 warna 4 tahun 3-4 tahun

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 15 bulan 9-18 bulan
Membuka pakaian 18 bulan 14bulan – 2 tahun
Memakai baju 2,5 tahun 24 bulan- 2,5 tahun

Conclusion :Development history of social according to age

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 Physical Examination
 General appearance
General appearance : Tampak baik
Awareness : Alert

 Vital Sign
Blood Pressure : 120/60 mmHg
Heart rate : 70x/ menit
Respiratory Rate : 22x/ menit
temperature : 36,8º C
 Nutrisional status

WEIGHT : 18 KG Height : 119 CM BMI : 12,7

-Weight // age : -2SD line (gizi kurang)

-Lenght // age : antara -1SD sampai 0 (normal)
-Weight // Lenght : antara -3SD sampai -2SD (kurus)

Conclusion : The patient's nutritional status is good

 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 : Perut tampak membesar (+), sikatrik (-), purpura (-)
Auskultasi : Peristaltik (+)
Perkusi : Timpani (+)
Palpasi : Supel, massa abnormal (-), nyeri tekan (-),
turgor kulit menurun (-)
Liver : Hepatomegali (+)
Spleen : Splenomegali (+) Schuffner 3

Conclusion : There was hepatosplenomegali

 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

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 PHYSICAL EXAMINATION

Head : Normochephal, Facies Cooley (+)

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 was Facies Cooley

 LABORATORIUM EXAMINATION
Routine blood examination
PEMERIKSAAN HASIL SATUAN NORMAL
 Leukosit 8.16 10ˆ3/ul 4.5 – 12.50
 Eritrosit 3.56 L jt/ul 3.8 – 5.20
 Hemoglobin 7.4 L g/dl 11.7 – 14.5
 Hematokrit 22.2 L % 35.0 – 47.0
 Trombosit 439 10ˆ3/ul 217 – 497
 MCV 62.4 L fl 74.0 – 102.0
 MCH 20.8 L pg 22.0 – 34.0
 MCHC 33.3 g/dl 28.0 – 34.5
 MPV 8.2 L fl 9.0 – 13.0

Result : Routine blood examination there is anemia

 Elektroforesis Hemoglobin

• Analisa Hb (HPLC)
- HbA2 : >13 % (2.3-3.5)%
- HbF : 32,4 % (<1) %
- Fraksi lain: -
 RESUME
ANAMNESIS
Pale

Physical examination
Blood Pressure : 120/60 mmHg
Heart rate : 70x/ menit
Respiratory Rate : 22 x/ menit
temperature : 36,8º C

Laboratorium
Anemia
 ASSESMENT

1. Anemia et causa Thalasemia

Differential Diagnosis
Anemia Hemolitik Autoimun
Sickle Cell
Malaria
 ACTION PLAN
• Observation of vital signs

DIAGNOSIS ENFORCEMENT PLAN

• Elektroforesis Hb
 Terapi

kebutuhan energi : White rice, eggs, meat, fish,

vegetables a day 3 times a large plate of food was
Kalori : 18 x 70= 1280kkal
always finished.
Protein : 18x 1.0 = 18g
 rute oral
Cairan : 18x 70= 1280ml
 ` PLAN
THERAPY
• Transfusi PRC: (14 – 7,4) x4x 18 = 475,2 cc/ 12 jam  500cc/ 12
jam

• As. Folat : 2 x 1mg

• Vit C: 18 x 3mg/kgBB/hari = 54 mg/hari --> 50 mg/hari

• Vit E: 2 x 200IU
 FOLLOW UP
TANGGAL SOA PLANNING
17-8- -S/on the morning, the patient felt better P/
2017 O/ -Asam folat: 2 x 1mg
Jam - KU : Compos Mentis -Vit C: 50mg/hari
07.00 - HR : 78x/menit -Vit E : 2x200 IU
- RR : 22 x/menit
- Kepala: konjunctiva anemis (-/-), sklera ikterik (-/-)
- Tho: suara vesikuler(+/+)
- Abd : peristaltik (+)
- Hb: 13,5 g/dl
- Feritin : 478,86

A/ Anemia et causa Thalasemia

THANK YOU