Morning Report

Ilmu Kesehatan Anak

Senior : Ain
Junior : Wahyu dan Nurul

Pembimbing:
dr. H. Ahmad Nuri, Sp.A
dr. Gebyar Tri Baskoro, Sp.A
dr. Lukman Oktadianto, Sp.A
dr. M. Ali Shodikin, M.Kes, Sp.A

SMF ILMU KESEHATAN ANAK

RSUD DR. SOEBANDI
2018
Patient’s Identity
• Name : An. S
• Age : 9 months old
• Sex : Female
• Adress : Lumajang
• Ethnic : Javanese
• Religion : Islam
• Hospitalized : February 2nd 2018
• Examination date : February 3th 2018
• Medical record number : 23xxxx

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Parents’s Identity
Father Mother
Name Mr. S Mrs. M

Age 29 years old 26 years old

Address Lumajang Lumajang

Ethnic Javanese Javanese

Religion Islam Islam

Education SHS JHS

Job Wiraswasta IRT

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Anamnesis
Heteroanamnesis is carried out to
mother at Room A RSDS on the
second day of hospitalized.

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History of Present Illness:
Chief complain:
Seizure
History of Present Illness:
H1MRS:
The patient was taken to the RSDS IGD (02/02/2018) with complaints
of seizures. The patient experiences seizures at 12.30 when at home
for ± 5-10 minutes as much as 1x. Seizures are preceded by fever, but
the family does not know the body temperature before seizures.
Seizures throughout the body with stiffness throughout the body and
the patient immediately closes his eyes. When the seizure the patient
cannot be awakened. After the seizure the patient is aware but the
patient still has a fever. According to the patient's parents, the patient
is having a fever, cough and cold since 2 day ago, does not complain
of pain or discharge of fluid in the ear, normal BAB (+) and BAK (+),
diarrhea (-).
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The patient had vomited 2 times while on the emergency room,
containing rice. When in room A, the patient also had to vomit once,
browned and filled with food

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 symptom HSMRS H1MRS
• seizure - +
• Cough + +
• cold + +
• Fever + +
• Loss of - -
consciousness
• BAB + +
• BAK + +

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Past Illness:
The patient had experienced the first seizure which was preceded by a fever
when the patient was 5 months old. Seizures , for ± 5 minutes, spasm of the
whole body with stiffness throughout the body. After the patient's seizures
are conscious. Then he was taken to the U Clinic, had the MRS and was given
medication. After feeling healed, then the patient goes home.

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History of Medication:
 Febrifuge

History of Family Disease:

● There is not family disease

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 Family tree
65 62 60 57

38 35 29 26

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Male

9m Female
Conclusion: there is no
hereditary disease Patient
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History of Gestational:
The patient was born to mother G1P0A0. At present, the mother is 26 years old and
at the time of pregnancy the mother is 23 years old. Pregnancy up to 9 months.
Mothers of patients routinely check their pregnancies at the posyandu, midwives and
health centers from the age of 3 months. During pregnancy the patient's mother does
not experience high blood pressure, no seizures, no excessive vomiting, no fever, no
congestion, no bleeding through the birth canal. The quantity and quality of food
consumed is good, eat 3-4 times a day, a portion of rice, vegetables and side dishes.

Conclusion: History of gestational and nutrition is good

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History of Labory
Children born to mothers G1P0A0 spontaneously helped by Midwives. 9 months
gestational age, first head born, clear amniotic water, baby crying, birth weight 2000
grams, birth length 45 cm. There was no trauma at birth, no disability, no finger
abnormalities and umbilical cord care was carried out by midwives.

History after Labory:

The cord is maintained, the third day breaks, there is no bleeding in
the umbilical cord, the baby does not appear yellow and the baby
can drink well, the mother's milk is smooth.

Conclusion : history of labory and post labory is good

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History of Imunitation:

Conclusion : the history of imunitation is complet

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 History of nutrition :
Usia Makan dan Minum yang diberikan

0 - 6 months Breast milk every 3-4 hours or when the child feels thirsty

6 - 9 months MPASI in the form of instant refined porridge and crushed

bananas. Patients eat 3 times a day and a small bowl is
spent and drunk well.

Conclusion : history of nutrition is good

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 History of
growth

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 Developmental history :
Passive Communication Fine Motorbike
Look around : 1 months Unlocking toys : 6 months
Moves to state intent : 9 months
Intelligence
Active Communication Giving objects at oral request: 9 months
Issued 3 different votes : 5 months
Say 2 different words : 9 months Social Behavior
Smile to people : 1 month
Rough motoric
Upholding head : 2 months
Take small objects : 4 months

Conclusion: developmental history according to age 16

Social Economy and Environmental
History :
Social Economy: Father works as a private worker and the mother does not work with an
income of Rp. 1,000,000.00 to 1,500,000.00 / month, to support 1 wife and 1 child.

Environmental : The patient lives with her parents. The patient sleeps with the patient's
mother. The patient lives in a 9m x 8m x 3m house, consisting of 2 bedrooms
measuring 3m x 3m. Adequate ventilation and lighting, sources of drinking water from
well-cooked well water, have 1 bathroom, 1 kitchen, and have a toilet. Home away
from waste disposal and factories.The father of the patient not smoker.

Conclusion : socio-economic and environmental history is not good

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 Anamnesis System:

 Cerebrospinal System : febris (+), seizzure (+), loss of

consciousness(-)
 Respiratory system : cough (+), cold (+).
 Gastrointestinal system : poop (+) normal
 Urogenital system : pee (+) normal
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Physical Examination
General condition Awareness
Qualitative : Compos Mentis
Special condition Quantitative : E:4 V:5 M: 6

 Vital signs
Heart rate : 160 x/minutes, regular, lift
strength
Respiratory rate : 50 x/minute, regular, vesicular
Temperature : 38,8 0C
CRT : < 2 seconds

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 Nutritional Status
 Born weight : 3000 gram Nutritional Status According to the CDC :
 BBS / BBI x 100% =
 Current weight : 7,9 kg 7,9 / 8 x 100% = 99,8%
 Ideal weight CDC : 8 kg
 Born high : 51 cm
 Current high : 69 cm
 Ideal high : 70 cm

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Physical Examination
General Condition  Head
Size : Normocephal
Crown : flat
Special condition hair : straigth, black
Face : Facial expression is normal
Eye : Conjungtiva anemis -/-, sklera ikterik -/-, edema palpebra
(-), reflek cahaya +/+, mata cowong (-)
Nose : secret+/+, blood -/-, mukosa hiperemic (-), pernafasan
cuping hidung (-)
Ear : Sekret -/-, blood -/-
mouth : Cyanosis (-)
Faring : Hyperemic (-)
Tonsil : Hyperemic (-), no enlargement appears
Neck : Simmetric (-), enlarged lymph nodes(-)

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Physical Examination
General condition  Chest
normal, simetris, retraction (-)
 Jantung
Special condition Inspeksi : Iktus kordis tidak tampak
Palpasi : Iktus kordis teraba
Perkusi : Redup
Batas kanan atas : ICS II garis parasternal dextra
Batas kanan bawah : ICS IV garis parasternal dextra
Batas kiri atas : ICS II garis parasternal sinistra
Batas kiri bawah : ICS IV garis midklavikula sinistra
Auskultasi : S1S2 tunggal reguler, ekstrasistol (-), gallop (-), murmur
(-)

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Physical Examination
 Paru
Kanan Kiri
General condition
Frontal Insp : Simetris, Retraksi (-) Insp : Simetris, Retraksi (-)
Special condition Palp : fremitus raba sde Palp : fremitus raba sde
Perk : redup Perk : redup
Ausk : Ves (+), Rho (-), Ausk : Ves (+), Rho (-), Whe
Whe (-) (-)
Dorsal Insp : Simetris, Retraksi (-) Insp : Simetris, Retraksi (-)
Palp : fremitus raba sde Palp : fremitus raba sde
Perk : sonor Perk : sonir
Ausk : Ves (+), Rho (-), Ausk : Ves (+), Rho (-), Whe
Whe (-) (-)

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Physical Examination
 Abdomen
General condition
Inspeksi : flat
Auskultasi : Intestinal sound (+) Normal
Special condition Perkusi : timpani
Palpasi :soepel, hepatomegali (-), splenomegali (-), asites (-)

 Extremitas
upper : akral hangat +/+, edema -/-, sianosis (-), pengecilan jaringan otot
(-), atrofi (-)
Lower : akral hangat +/+, edema -/-, sianosis (-), pengecilan jaringan otot
(-), atrofi (-)

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Physical Examination
 Anus and genitalia
General condition
Anus : normal
Genital : female, normal
Special condition

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Physical Examination
 Neurologi
General condition GCS :4-5-6
Meningeal Sign: KK (-), K (-), L (-), B1 (-), B2(-)
Nervus Kranial:
Special condition  N. III : Pupil bulat isokor, 3mm/3mm, RC +/+
 N. VII : simetris/simetris
 N. XII : simetris/simetris
Motorik:
KO 555 555 TO n n RF B +2 +2 RP(-)
555 555 n n T +2 +2
K +2 +2
A +2 +2
Sensorik : dbn
Otonom : retensi urin (-), inkontinensia urin (+) saat kejang, retensi alvi (-),
inkontinensia alvi (-)
CV : dbn

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Main Diagnosis
Simple febrile seizure + Rhinitis

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 Kumpulan Data Kumpulan Data Diagnosis dan Rencana Terapi
Rencana
Diagnosis

Anamnesis Pemeriksaan Fisik Simple febrile • Inf D5 ¼ NS 800 cc/24 jam

Main complain: seizure KU: lemah • Inj. cefotaxim 3x300 mg
RPS : Kes: kompos mentis (4-5-6
seizure + • Inj santagesik 4x120 (k/p)
HMRS Patients of girls aged 9 months HR : 160 Rhinitis • Diazepam iv 2 mg bila
come to the RSDS with complaints of RR : 50 kejang
seizures at 12.30. Whole body spasms, ± Tax :38,8 • p/o tremenza 3x1/4 tab
5 minutes 1 time. Decreased Head/neck :
consciousness (-), Fever (+), Cold cough anemia (-), icteris (-), sianosis
(+), Normal BAB (+) BAK (+). (-), dypsnea (-)
RPD : cor/ pulmo: dbn
History of febrile seizures during the Abd : BU (+) normal, timpani ,
patient at 5 months old. soepel
RPO: paracetamol Ext : AH (+), OE(-)
RPK :
Cousin have seizure

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Planning
 Diagnostik
DL, UL, GDA, SE

Monitoring
Seizure, vital sign, therapy respon, side effect, complication

 Education
 Explain to the patient's family about the patient's illness, cause, treatment or therapy,
complications and prognosis
 Explain to the patient's family that the illness they suffer from must receive maintenance therapy
and require compliance so that the family must monitor the patient's progress

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Prognosis

 Quo ad vitam (hidup) : dubia

ad bonam
 Quo ad functionam (fungsi) : dubia
ad bonam
 Quo ad sanationam (sembuh) : dubia
ad bonam

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THANK YOU

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