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Morning report

No Kamar Nama Usia Diagnosis Presentant

1. III-3 An. FS 9 years DHF Ria

2. III-9 An. A 1 years 9 month DF Ria


3. III-11 An. MF 9 month Bronchopneumonia Ria
4. III-9 An. F 5 month Watery Acute Diarrhea with Ria
somedehidration
MORNING CASE

Disusun oleh:
RIA MAULINDASARI

FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH SURAKARTA
2019
IDENTITY
• Name : An. FS
• Date of birth : 24 February 2010
• Gender : Boy
• Age : 9 years
• Address : Sumbermayu
• Religion : Islam
• Tribe : Java
• Date of hospitalization : 29-3-2019 (21.00)
• Date of examination : 30-3-2019 (07.00)
ANAMNESIS

Chieft Complaint

Fever
HISTORY OF ILLNESS

3 days before admission

• He had high fever in afternoon, but temperature 40 degress celcius


• No nausea and vomitus
• No cough and rhinorrhea
• Normal feeding
• Normal urination and defecate
• His mother gave him paracetamol forte 5 ml, and fever was overcome
HISTORY OF ILLNESS

The day of admission


• Fever
• Abdomial pain
• Nausea
• No cough and rhinorrhea
• Not normal feeding
• Normal urination and defecate
• His parents brought him to PKU Muhammadiyah Surakarta
HISTORY OF PAST ILLNESS

History of Seizure with fever : Denied


History of dengue fever : Denied
History of typhoid fever : Denied
History of long cough : Denied
History of asma : Danied
History of allergy : Denied
History of hospital : Danied

Conclusion: there is no history of past illness


HISTORY OF ILLNESS IN FAMILY

History of Seizure with fever : Denied


History of Seizure withou 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
History of treated in the hospital : Denied
History of Hypertension : Denied
History of Diabetes Mellitus : Denied

Conclusion: there is no history of illness in family


PEDIGREE

40 38 33 30 26

Tn. A 45 years old


Ny. S 39 years old

11
An. FS 9 years

Conclusion : there is no illness inherited


HISTORY OF PREGNANCY

Mother with P2A0 is pregnant at 28 years old. Mother began to


check pregnancy when 1 month of pregnancy and then routinely
control to midwife initially 2 months and then once a month and
at 7 months of pregnancy, mothers routinely to midwife 2
weeks. When the mother control gets the vitamin that is always
spent. During pregnancy the mother does not feel nausea,
vomiting and dizziness that interfere with daily activities. During
pregnancy there is no history of trauma, bleeding or infection
during pregnancy and no hypertension during pregnancy.
Maternal weight weighed otherwise normal.

Conclusion: history of pregnancy was good


HISTORY OF DELIVERY

The mother gave birth to her son assisted by a doctor with a


normal delivery. 9 months pregnancy age, baby born with body
weight 2350 gram with body length 48 cm. At the time of birth
the baby cries instantly, there is no congenital defect at birth.

HISTORY OF POST DELIVERY

The baby girl was born crying, active motion, red skin color, not
blue and not yellow, got milk on first day, urination and
defecated less than 24 hours.

Result: history of delivery and post delivery was not good


HISTORY OF ENVIRONMENT

KOMPONEN
RUMAH YG KRITERIA NILAI BOBOT
DINILAI
KOMPONEN
RUMAH 31

1 Langit-langit a. Tidak ada 0


b. Ada, kotor, sulit dibersihkan, dan rawan kecelakaan 1
c. Ada, bersih dan tidak rawan kecelakaan 2 62
2 Dinding a. Bukan tembok (terbuat dari anyaman bambu/ilalang) 1
b. Semi permanen/setengah tembok/pasangan bata atau 2
batu yang tidak diplester/papan yang tidak kedap air.
c. Permanen (Tembok/pasangan batu bata yang
diplester) 3 93
Conclusion papan
: there is no
kedap air.
a risk factors for transmitted disease
3 Lantai a. Tanah 0
b. Papan/anyaman bambu dekat dengan tanah/plesteran 1
yang retak dan berdebu.
c. Diplester/ubin/keramik/papan (rumah panggung). 2 62
HISTORY OF ENVIRONMENT
4 Jendela kamar tidur a. Tidak ada 0
b. Ada 1 31
5 Jendela ruang keluarga a. Tidak ada 0
b. Ada 1 31
6 Ventilasi a. Tidak ada 0

b. Ada, lubang ventilasi dapur < 10% dari luas lantai 1


c. Ada, lubang ventilasi > 10% dari luas lantai 2 62
7 Lubang asap dapur a. Tidak ada 0
b. Ada, lubang ventilasi dapur < 10% dari luas lantai
dapur 1 31
b. Ada, lubang ventilasi dapur > 10% dari luas lantai
dapur 2

(asap keluar dengan sempurna) atau ada exhaust fan


atau ada peralatan lain yang sejenis.

8 Pencahayaan a. Tidak terang, tidak dapat dipergunakan untuk membaca 0

b. Kurang terang, sehingga kurang jelas untuk membaca 1


dengan normal
c. Terang dan tidak silau sehingga dapat dipergunakan
Conclusion : there is no a risk factors for transmitted disease
untuk 2 62
membaca dengan normal.
HISTORY OF ENVIRONMENT

II SARANA SANITASI 25

1Sarana Air Bersih a. Tidak ada 0


b. Ada, bukan milik sendiri dan tidak memenuhi syarat
(SGL/SPT/PP/KU/PAH). kesh. 1
c. Ada, milik sendiri dan tidak memenuhi syarat kesh. 2
e. Ada, milik sendiri dan memenuhi syarat kesh. 3
d. Ada, bukan milik sendiri dan memenuhi syarat kesh. 4 75

2Jamban (saran pembua- a. Tidak ada. 0


ngan kotoran). b. Ada, bukan leher angsa, tidak ada tutup, disalurkan ke 1
sungai / kolam
c. Ada, bukan leher angsa, ada tutup, disalurkan ke
sungai 2
atau kolam
d. Ada, bukan leher angsa, ada tutup, septic tank 3
e. Ada, leher angsa, septic tank. 4 100
HISTORY OF ENVIRONMENT

a. Tidak ada, sehingga tergenang tidak teratur di


3 Sarana Pembuangan halaman 0
Air Limbah (SPAL) b. Ada, diresapkan tetapi mencemari sumber air (jarak 1
sumber air (jarak dengan sumber air < 10m).
c. Ada, dialirkan ke selokan terbuka 2
d. Ada, diresapkan dan tidak mencemari sumber air
(jarak 3 50
dengan sumber air > 10m).
e. Ada, dialirkan ke selokan tertutup (saluran kota)
untuk 4
diolah lebih lanjut.
4 Saran Pembuangan a. Tidak ada 0
Sampah/Tempat Sampah b. Ada, tetapi tidak kedap air dan tidak ada tutup 1
c. Ada, kedap air dan tidak bertutup 2
d. Ada, kedap air dan bertutup. 3 50
HISTORY OF ENVIRONMENT

a. Tidak ada, sehingga tergenang tidak teratur di


3 Sarana Pembuangan halaman 0
Air Limbah (SPAL) b. Ada, diresapkan tetapi mencemari sumber air (jarak 1
sumber air (jarak dengan sumber air < 10m).
c. Ada, dialirkan ke selokan terbuka 2
d. Ada, diresapkan dan tidak mencemari sumber air
(jarak 3 50
dengan sumber air > 10m).
e. Ada, dialirkan ke selokan tertutup (saluran kota)
untuk 4
diolah lebih lanjut.
4 Saran Pembuangan a. Tidak ada 0
Sampah/Tempat Sampah b. Ada, tetapi tidak kedap air dan tidak ada tutup 1
c. Ada, kedap air dan tidak bertutup 2
d. Ada, kedap air dan bertutup. 3 50
HISTORY OF ENVIRONMENT

Kriteria :

1) Rumah Sehat = 1068 - 1200

2) Rumah Tidak Sehat = < 1068

Conclusion : there is no risk factors for transmitted disease


HISTORY OF VACCINE

• According to the mother's confession, the patient gets


complete vaccine.

Conclusion : the history of vaccine is complete acording


to KEMENKES
HISTORY OF FEEDING
Age 0 - 6 month
• Breast milk + formula milk

Age 6 - 8 month
• Breast milk +Formula + instan food 1 day 3 small bowls

Age 8 - 10 month
• Formula + porridge of filter and vegetable teams smoothed 1 day 3 small dishes

Age 10 - 12 month
• Rice porridge, vegetables and fruits are mashed 1 day 3 small dishes

Age 12- 22 month


• White rice, eggs, meat, fish, vegetables a day 3 times a large plate of food

Age 22 month - now


• White rice, eggs, meat, fish, vegetables + fruits a day 3 times a large plate of food

Conclusion : history of feeding from quality wasn’t good and quantity was good
HISTORY OF PERSONAL SOCIAL
Competence Age of achievment Normal age

Smile spontaneously 1 month 0-2month


Feed self 6 month 5 – 6,5 month
Indicate wants 12 month 7,5- 13 month
Drink from cup 15 month 9-17 month
Remove garment 22 month 14 month – 2 years
Wash and dry hands 2,5 years 19 month - 3 years
Put on t-shirt 3 years 2,5- 3,5 years
Play board/card games 4,5 years 2,8- 5 years
Brush teeth, no help 6 years-now 3 - 6 years

Conclusion :Development history of social according to age


HISTORY OF FINE MOTOR

Competence Age of achievment Normal age


Reaches 5 month 4,5 – 5,5 month
Scribbles 12 month 12 – 17 month
Tower of 2 cubes 16 month 13-21 month
Thumb wiggle 3,5 years 2,2-3,9 years
Pick longer line 5 years-now 3-5,3 years

Conclusion :Development
add footerhistory
here (go toof fine
view menumotor
and according to age
choose header)
HISTORY OF LANGUAGE
Competence Age of achievment Normal age
Vocalizes ooo/aah 1,5 month 1 – 3 month
Turn to voice 5 month 3,5 – 5,5 month
Imitate speech sounds 7 month 3,5 – 9 month
Papa mama 5 years - now 7 – 13 month

Conclusion :Development history of language not according


10/10/2019 to(goage
add footer here to view menu and
choose header)
22
HISTORY OF GROSS MOTOR

Competence Age of achievment Normal age


Head up 90 degress 3 month 3-4 month
Sit no support 6,5 month 6 – 7 month
Stand alone 11 month 11 - 13 month
Walk well 13 month 11-15 month
Runs 17 month 13-20 month
Jump up 24 month 21-26 month
Balance each foot 1 second 3 years 2,5-4 years
Balance each foot 4 second 4,5 years 3,5-5 years
Balance each foot 6 second 5,5 years-now 4-6 years

Conclusion :Development history of Gross motor according


to age
Physical Examination
 General appearance
General appearance : look weak
Consciousness : alert

 Vital Sign
Blood Pressure : 90/60
Heart rate : 110x/ menit
Respiratory Rate : 24 x/ menit
temperature : 38,2º C
Nutrisional status

9 years WEIGHT : 25 KG Height : 110 CM BMI : 20,6 kg/m2

- Weight // age : < 0 SD normal


- Height // age : < -2 SD stunted
- BMI // age : > 2 SD normal

Conclusion : the nutritional status is stunted


Physical examination
• Skin examination
Color : sawo matang
Skin turgor: kembali segera
Moisture: moist
Edema (-) does not exist

• Conclusion : skin examination was good

29
PEMERIKSAAN KUSUS
Leher : No enlargement of lymph node and no increase jugular venous
Thoraks : Simetris, retration (-), miss the motion (-).
• Cor
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 (-)
• Pulmo
Inspeksi : Simetris, retraksi intercostal (-/-), retraksi
subcostal (-/-), retraksi substernal (-), retraksi suprasternal (-)
Palpasi : Simetris kanan kiri, There is no missed breath
Perkusi : Redup
Auskultasi : Vesicular (+/+) dextra ↓, rhonki (-/-), whezzing (-/-)

Conclusion : perkusi pulmo redup, vesikuler (+/+) dextra ↓


Abdomen: Inspeksi : Distanded (+), Sikatrik (-), purpura (-)
Auskultas : Peristaltik (+) normal
Perkusi : shifting dullness (+)
Palpasi : Massa abnormal (-), nyeri tekan (+) regio epigastric
turgor kulit menurun (-), acites (+)
Hepar : Hepatomegali (+)
Lien : Splenomegali (+)

Conclusion : shifting dullness (+), distanded (+), acites (+)


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 kembali dengan segera
• Pulsasi nadi di keempat ekstremitas sama kuat

Conclusion : the examination of extremity within normal limits

32
PHYSICAL EXAMINATION

Kepala : Normochephal
Mata : CA (-/-), SI (-/-), edema palpebra (-/-), reflek cahaya (+/+)
isokor (+/+), mata cowong (-/-)
Hidung : Sekret (-), epistaksis (-), nafas cuping hidung (-/-)
Telinga : Sekret (-), hiperemis (-)
Mulut : Stomatitis (-), perdarahan gusi (-), sianosis (-), lidah kotor (-),
pharynx hiperemis (-).
Kulit : Warna sawo matang, Pucat (-), Ikterik (-), Sianosis (-), turgor kulit (< 2
detik), petekie (-)
Kelenjar limfa : Tidak didapatkan pembesaran limfonodi
Otot : Tidak didapatkan kelemahan, atrofi, maupun nyeri otot
Tulang : Tidak didapatkan deformitas tulang
Sendi : Gerakan bebas

Result : There is a within normal limits


PEMERIKSAAN LABORATORIUM
Pemeriksaan Darah Rutin (30-03-2019)
PEMERIKSAAN HASIL SATUAN NORMAL
 Hematokrit 48 H % 33.0 – 45.0
 Trombosit 48 L 10ˆ3/ul 181 – 521

Result : Routine blood examination is trombositopenia, hematocrit meningkat


RESUME
ANAMNESIS
Fever 3 days
Abdominal pain
Nausea
Not normal feeding
Physical examination
• Fever : 38,2º C
• Perkusi pulmo : redup
• Perkusi abdomen : shifting dullness
• Distanded (+)
• Ascites (+)

Laboratorium
Hemoglobin meningkat
Trombosit meningkat
Trombositopenia
Neutropenia
Limfositosis
Monositosis
ASSESMENT

1. Dengue Hemmoraghic fever


Differential Diagnosis
- DSS
- Thypoid fever
2. Develompment delay
3. Stunted
ACTION PLAN
• Evaluation of general conditions, vital signs Blood pressure, pulse,
temperature and respiratory rate) / 4 hours
• Evaluation for signs of shock (rapid and weak pulse until not palpable,
narrowing of pulse pressure (≤20mmHg), hypotension to immeasurable, cold
feet and hands, moist skin, CRT kembali lambat and looking restless)

DIAGNOSIS ENFORCEMENT PLAN

• Cek trombosit dan hematocrit


• Cek anti dengue IgG dan IgM
• Foto Thorax AP
THERAPY PLAN
• Terapi awal (RL)
7ml/KgBB/jam = 7ml x 25/jam
= 175/3 = 58 tpm makro
Dinaikkan
10-15ml/kgBB/jam = 10ml x 25/jam
= 250/3 = 83 tpm
Diturukan
5ml/kgBB/jam = 5ml x 25/jam
= 125/3 = 41 tpm
Diturunkan
3ml/kgBB/jam = 3ml x 25/jam
= 75/3 = 25 tpm
• Antipiretik( dosis 10-15 mg/kgBB)
Paracetamol 250 kg x 10 mg = 250 mg/ 4 jam = 10 mL / 4 jam (paracetamol forte)
 jika demam 38°C
FOLLOW UP
TANGGAL SO
31 – 03 – 2019

S/ Demam (-), muntah (-), nyeri perut (-)


O/
- KU : Sedang, Compos Mentis, GCS E4V5M6
- TD : 110/80 mmHg
- HR : 94 x/menit
- RR : 24 x/menit
- S : 36.8°C

- KL : CA (-/-), SI (-/-), Mukosa Bibir berdarah (-), PKGB (-).

- TH : BJ I.II Reguler, SDV (+/+) dextra menurun, Ronkhi (-/-), Whezzing (-/-),

- AB : Supel (+), Peristaltik (+), Turgor Kulit Baik, Nyeri Tekan (-), hepatomegali (-), splenomegali (-),
acites (+), distanded (+), perkusi abdomen shifting dullness, perkusi pulmo redup

- EK : Ptekie (-), Hangat (+), oedem (-), CRT kembali dengan segera, flushig
PEMERIKSAAN LABORATORIUM
Pemeriksaan Darah Rutin (31-03-2019)
PEMERIKSAAN HASIL SATUAN NORMAL
 Hematokrit 43 % 33.0 – 45.0
 Trombosit 41 L 10ˆ3/ul 181 – 521

ANTI DENGUE
Anti Dengue IgG Positif Negatif
Anti dengue IgM Positif Negatif

Result : Routine blood examination is trombositopenia, hematocrit meningkat.


Anti dengue IgG dan Anti Dengue IgM Positif
PEMERIKSAAN Foto thorax

Result : efusi pleura dextra


PEMERIKSAAN Ekstremitas

Result : flushing
FOLLOW UP
AP

A/
1. Dengue Hemmoraghic fever
2. Efusi Pleura dextra
3. Develompment delay
4. Stunted

P/
Fluid Maintenance (RL)
3ml/kgBB/jam = 3ml x 25/jam
= 75/3 = 25 tpm
Antipiretik (dosis10-15mg/kgBB)
Paracetamol 250 kg x 10 mg = 250 mg/ 4 jam = 10 mL / 4 jam
(paracetamol forte)  jika demam 38 °C
Cek trombosit dan hematocrit
FOLLOW UP
TANGGAL SO
01 – 04 – 2019

S/ Demam (-), muntah (-), nyeri perut (-)


O/
- KU : Sedang, Compos Mentis
- TD : 110/80 mmHg
- HR : 90 x/menit
- RR : 24 x/menit
- S : 36.6°C

- KL : CA (-/-), SI (-/-), Mukosa Bibir berdarah (-), PKGB (-).

- TH : BJ I.II Reguler, SDV (+/+) dextra menurun, Ronkhi (-/-), Whezzing (-/-),

- AB : Supel (+), Peristaltik (+), Turgor Kulit Baik, Nyeri Tekan (-), hepatomegali (-), splenomegali (-),
acites (-), distanded (-)

- EK : Ptekie (-), Hangat (+), oedem (-), CRT kembali dengan segera, flushig
PEMERIKSAAN LABORATORIUM
Pemeriksaan Darah Rutin (01-04-2019)
PEMERIKSAAN HASIL SATUAN NORMAL
 Hematokrit 37.5 % 33.0 – 45.0
 Trombosit 44 L 10ˆ3/ul 181 – 521

Result : Routine blood examination is trombositopenia


FOLLOW UP
AP

A/
1. Dengue Hemmoraghic fever
2. Efusi Pleura dextra
3. Develompment delay
4. Stunted

P/
Fluid Maintenance (RL)
3ml/kgBB/jam = 3ml x 25/jam
= 75/3 = 25 tpm
Antipiretik (dosis10-15mg/kgBB)
Paracetamol 250 kg x 10 mg = 250 mg/ 4 jam = 10 mL / 4 jam
(paracetamol forte)  jika demam 38 °C
Cek trombosit dan hematocrit
FOLLOW UP
TANGGAL SO
02 – 04 – 2019

S/ Demam (-), muntah (-), nyeri perut (-)


O/
- KU : Sedang, Compos Mentis
- TD : 110/80 mmHg
- HR : 94 x/menit
- RR : 24 x/menit
- S : 36.2°C

- KL : CA (-/-), SI (-/-), Mukosa Bibir berdarah (-), PKGB (-).

- TH : BJ I.II Reguler, SDV (+/+) dextra menurun, Ronkhi (-/-), Whezzing (-/-),

- AB : Supel (+), Peristaltik (+), Turgor Kulit Baik, Nyeri Tekan (-), hepatomegali (-), splenomegali (-),
acites (-), distanded (-)
- EK : Ptekie (-), Hangat (+), oedem (-), CRT kembali dengan segera, flushig
PEMERIKSAAN LABORATORIUM
Pemeriksaan Darah Rutin (02-04-2019)
PEMERIKSAAN HASIL SATUAN NORMAL
 Hematokrit 36.8 % 33.0 – 45.0
 Trombosit 67 L 10ˆ3/ul 181 – 521

Result : Routine blood examination is trombositopenia


FOLLOW UP
AP

A/
1. Dengue Hemmoraghic fever
2. Efusi Pleura dextra
3. Develompment delay
4. Stunted

P/
Fluid Maintenance (RL)
3ml/kgBB/jam = 3ml x 25/jam
= 75/3 = 25 tpm
Antipiretik (dosis10-15mg/kgBB)
Paracetamol 250 kg x 10 mg = 250 mg/ 4 jam = 10 mL / 4 jam
(paracetamol forte)  jika demam 38 °C
Cek trombosit dan hematocrit
FOLLOW UP
TANGGAL SO
03 – 04 – 2019

S/ Demam (-), muntah (-), nyeri perut (-)


O/
- KU : Sedang, Compos Mentis
- TD : 110/80 mmHg
- HR : 94 x/menit
- RR : 24 x/menit
- S : 36.2°C

- KL : CA (-/-), SI (-/-), Mukosa Bibir berdarah (-), PKGB (-).

- TH : BJ I.II Reguler, SDV (+/+) dextra menurun, Ronkhi (-/-), Whezzing (-/-),

- AB : Supel (+), Peristaltik (+), Turgor Kulit Baik, Nyeri Tekan (-), hepatomegali (-), splenomegali (-),
acites (-), distanded (-)
- EK : Ptekie (-), Hangat (+), oedem (-), CRTkembali dengan segera, flushig
PEMERIKSAAN LABORATORIUM
Pemeriksaan Darah Rutin (03-04-2019)
PEMERIKSAAN HASIL SATUAN NORMAL
 Hematokrit 36.5 % 33.0 – 45.0
 Trombosit 111 L 10ˆ3/ul 181 – 521

Result : Routine blood examination is trombositopenia


FOLLOW UP
AP

A/
1. Dengue Hemmoraghic fever
2. Efusi Pleura dextra
3. Develompment delay
4. Stunted

P/
BLPL