Morning Report

Night Shift, July 7th – 8th 2019

Resident on duty: Anthony/ Adel/ Andreas/ Mawan

Supervisor on duty (ER): dr.Hasni Hasan Basri, Sp.A
 New patients: patients
No. Identity Diagnosis
1.

2.

3.

4.

5.

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 Identity
Name : By. NH
Age : 2 yo
Gender : Female
No. RM : 1-43-31-96
Day of Admission : July, 7th 2019
Address : Jambu Burung

Chief complaint :

• After drowning in the river

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 Pediatric Assessment Triangle
• Appearance (TICLS)
– Tonus : adequate
– Interactiveness : adequate
– Consolability : adequate
– Look or gaze : adequate with pain stimulated
– Speech and cry : not adequate
• Breathing
– Work of breathing (-)
• Circulation
– Pale (+), mottled (-), cyanosis (-)

Conclusion: respiratory emergency (-)

haematology emergency (-)

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 Primary survey
• Airway
– Patent (ETT in), no snoring, no gurgling
• Breathing
– RR 24 x/min, regular breathing rythm, SpO2 99 % without O2
– Retraction (-)
• Circulation
– pulse 110x/min, regular, adequate
– warm extremities, CRT <2 seconds
• Disability
– Compos mentis, E3M5V4 = 12, light reflex (+) symetric
• Environment
– Body temperature 37.3ᴼC
Conclusion: respiratory emergency (-)
haemodynamic emergency (-)
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Family History

• No history of same illness in family

Birth and Delivery

• Aterm, Spontan birth, no active

resuscitation, BW 2900 kg BL 50 cm,
history of cyanosis (-)

Immunization

• Complete immunization history (Depkes)

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Nutrition

• He was consume breast milk from birth until now

• Rice porridge and instant porridge drom 6 month until
1 year
• Family food from 1 years old, 3-4 times main meals
per day.

Development

•No developmental delay

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 Physical Examination
General condition

• Mildly Ill-appearing
• GCS E3V5M4

Vital sign

• Blood Pressure: 90/60 mmHg

• HR: 110 x/min, reguler, adequate
• RR: 24x/min, regular, nasal flaring (-)
• T: 37.30C
• SpO2 : 99% room air
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 Physical Examination
Organ Descriptions

Head Normocephal, deformity (-)

Eyes Anemic (-), icteric (-), isochor pupil 3 mm/3 mm, cyanotic (-)
Neck Lymph nodes enlargement (-), increased of JVP (-)
Chest Normal, lump (-), wasted ribs (-)

Heart SI-II single, murmur (-), gallop (-)

Lung Vesicular simetric, rales (-), wheezing (-)
Flat, soft, hepar enlargement (-) spleen enlargement (-)
Abdomen
abdominal pain (-), normal abdominal sound

Extremities Warm, CRT <2 seconds, edema (-), baggy pants (-)
 History of present illness
1 hour p.a. RSUD Ulin

• the patient falls into the

river less than 1 meter
deep for less than 15
minutes. • Looking sleepy (+)
• when patient was found, • Working of breath (-)
didn’t move. • Vomit (-)
• Was cry when the patient • Fever (-)
removed from water. • Seizure (-)
• Vomit (+)
• Water comes out from
nose (+)
• Seizure (-) Fever (-)

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Anthropometric Status (CDC)
• BW : 8.7 kg
• Height : 76.5 cm
• HC : 46.5cm
• BW/A : -3 < Z < -2 SD
• H/A : -3 < Z <-2 SD
• BW/H : -1 < Z <0 SD
• Height age : 14 months
• Ideal BW : 9.5 kg

Underweight & Stunted

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 Laboratory Finding
7-7-19
Hb (g/dL) 10.9 Glucose 185
Leucocyte 13,700 SGOT 139
Thrombocyte 208,000 SGPT 40
Hematocrite 33.1 Ureum 18
MCV (fL) 70.6 Creatinin 0.45
MCH (pg) 23,2 Na 137
MCHC (g/dL) 32,9 K 2.8
Gran# / Limf# 8.38/4.42 Cl 100

microcytic hypochromic
anemia
Leucocytosis
Hypokalemia
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 Laboratory Findings
BGA 7/7/2019
Temperature 37,3
pH 7.455
PCO2 26.2
TCO2 19.0
PO2 209.0
HCO3 18.4
02 Saturation 100
Base excees -5.0
%FiO2 33

Respiratory alcalosis, partially compensated

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 Problem List
• loss of consciousness
• microcytic hypochromic anemia
• Leucocytosis
• Hypokalemia
• Respiratory alcalosis, partially compensated

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 Initial Diagnosis
– Loss of consciousness e.c. moderate head injury
DD Prolonged hypoxia.
– microcytic hypochromic anemia e.c Iron Deficiency
– Hypokalemia
– Stunted
– Underweight

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 Initial Managements
Pro PICU
Oxygenation 2 lpm Nasal Canul
Nutrition and Fluid IVFD D51/4NS 35cc/h
Calorie = 9.5 x 100 = 950 kcal/day
Protein = 9.5 x 1,5 = 14.25 g/day
Correction hypokalemia Kalium 15 meq / 500 ml IVFD D51/4 NS
Evaluation & monitoring Vital sign
Laboratory evaluation BGA

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 Consult to Supervisor in Charge

• Acc treatment

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 Initial Managements
Pro PICU
Oxygenation 2 lpm Nasal Canul
Nutrition and Fluid IVFD D51/4NS 35cc/h
Calorie = 9.5 x 100 = 950 kcal/day
Protein = 9.5 x 1,5 = 14.25 g/day
Correction hypokalemia Kalium 15 meq / 500 ml IVFD D51/4 NS
Evaluation & monitoring Vital sign
Laboratory evaluation BGA

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 Patient update
Awareness HR RR BP ToC SpO2%
(06.00) (x/mnt) (x/mnt) (mmHg)
Compos
mentis

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Thank you