Morning Report

Night Shift, April 25 – 26 2019

Resident on duty: Jeshika/ Adel / Grit / Mawan

Supervisor on duty (ER): Prof. DR. Dr. Ruslan Muhyi, Sp. A, (K)
 New patients: patients
No. Identity Diagnosis
1.

2.

3.

4.

5.

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 Identity
Name : MH
Age : 3 months
Gender : Male
No. RM : 1-42-66-05
Day of Admission : April 25 2019
Address : Banjarmasin

Chief complaint :

• Getting cough since 2 months prior to admission

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 Pediatric Assessment Triangle
• Appearance (TICLS)
– Tonus : adequate
– Interactiveness : adequate
– Consolability : consolably
– Look or gaze : adequate eye contact
– Cry : adequate
• Breathing
– RR 60x/minutes, SpO2 90% room air, SpO2 97% with O2 2 lpm Nasal Canul
– Nasal flare (-), Retraction (+) subcostal, rhales (+), wheezing (-), stridor (-)
• Circulation
– Heart rate 98 x/min, good quality
– Warm extremities, capillary refill time 2 seconds, cyanosis (-), pale (-)

Conclusion: respiratory emergency (+)

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 Primary survey
• Airway
– Patent, no snoring, no gurgling
• Breathing
– RR 60 x/min, regular breathing rythm, SpO2 90 % without O2 , SpO2
97% with O2 2lpm Nasal Canul
– Retraction (+) subcostal
• Circulation
– pulse 120x/min, regular, adequate
– warm extremities, CRT <2 seconds
• Disability
– E4M5V6
• Environment
– Body temperature 36.8ᴼC
Conclusion: respiratory emergency (+)
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 History of present illness
2 months p.a RSUD Ulin

• Cough (+)
• Shortness of breath (+)
 Getting cough, with yellow sputum. • Work of breath (+)
 Shortness of breath Retraction (+) Subcostal
 Quick of breath occasionally • Febris (-)
 There is no fever • Diarrhea 4 times since
morning.
• Vomitting (-)

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 History
History of past illness

• Never felt the same complaint before

Family history

• The parents didn’t have history of asthma, his uncle has asthma.
• No history of TB diseases in family
• Father is active smoker

Birth and Delivery

• Aterm, no history of respiratory distress, BW 3600 gram, born at hospital

assisted by midwife.

Immunization

• Hep (1) BCG (1)

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Nutrition and Development

Nutrition

• Breast milk from birth until 2 mo then he was consume formula

milk from 2 mo until now

Development

• Development appropriate to the age

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Anthropometric Status (CDC)
• BW : 7,3 kg
• Height : 60 cm
• BW/A : 0<Z<2 SD
• H/A : -2<Z<0 SD
• BW/H : 2<Z<3 SD
• Head Circumference :
• UA Circumference : cm

Well nourish & normal stature

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 Physical Examination in
April 22 2019
General condition

• GCS E4M5V6

Vital sign

• HR : 120 x/min
• RR : 60 x/min
•T : 36,90C
• SpO2 90% without supplementation O2
• SpO2 97% with O2 2 lpm Nasal Canul
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Organ Descriptions
Deformity (-), normocephal (HC = cm), flat opened fontanel, no
Head hyperemia of pharyng / tonsil, tonsil enlargement (-), cyanosis of
the mouth (-).
Anemic (-), icteric (-), sunken eyes (-), oedema (-), isochor pupil,
Eyes
normal pupilary reflex, normal eye movements.

Neck Lymph nodes enlargement (-), nuchal rigidity (-),increased JVP (-)
Ears Normal auricles, inner ears hard to be evaluated, no secretion.
Chest Simetrical breath movement, subcostal retraction (+).
SI normal, single sound of SII, no audible murmur , gallop (-),
Heart
thrill (-), ictus cordis (-).
Lung Vesicular simetric, RH (+/+) , no wheezing
Flat, soft, normal abdominal sound, no hepatosplenomegaly,
Abdomen
abdominal pain (-), ascites (-), no palpable mass.
Warm, CRT <2 seconds, no ptechiae, no hematoma, no skin rashes,
Extremities oedema (-), cyanosis (-), normal physiologic reflexes, no patologic 14
reflexes, no paresis.
 Laboratory Findings (Ulin)
25/4/2019
Hb (g/dL) 10,7
Hematocrit (%) 35,4
Leukocyte (/µL) 14.400
MCV/MCH/MCHC 70,7/21,4/30,2 • Lymphocytosis
Thrombocyte (/ul) 340.000 • Anemia microcytic
hypochromic
Gran (%) 36,2
Lim (%) 59,6
Mid (%) 4,2

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Radiologi Thorax

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 Initial Diagnosis
Pneumonia
Acute Diarrhea without dehidration

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 Initial Managements
Fluid & Nutrition IVFD D5 ¼ NS 730 ml/24 hours 10 dpm macro
Energy 7,3 x 120 kkal/kg/day = 876 kkal
Protein 7,3 x 2,5 g/kg/day = 18,25 gram
Oxygenation Nasal Canul 2 lpm with SpO2 target 92-95%
Antipiretic Paracetamol drop 73mg (prn) febris
Antibiotic Ampicilin 300mg/12 hours (80mg/kgbw/day)
Gentamicin 50mg/24 hours (7mg/kgbw/day
Diarrhea Zink 1x10mg (10days)
Probiotics 1x1 shacet
Evaluation & monitoring Vital sign, Saturation
Laboratory evaluation CBC, Blood Culture

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 Consult to Supervisor in Charge

• Acc treatment

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 Final Diagnosis
Broncopneumonia (J18.0)
Acute Diarrhea without dehydration (R19.7)
Anemia microcytic hypochromic ec DD iron deficiency
(D50)

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 Initial Managements
Fluid & Nutrition IVFD D5 ¼ NS 730 ml/24 hours 10 dpm macro
Energy 7,3 x 120 kkal/kg/day = 876 kkal
Protein 7,3 x 2,5 g/kg/day = 18,25 gram
Oxygenation Nasal Canul 2 lpm with SpO2 target 92-95%
Antipiretic Paracetamol drop 73mg (prn) febris
Antibiotic Ampicilin 300mg/12 hours (80mg/kgbw/day)
Gentamicin 50mg/24 hours (7mg/kgbw/day
Diarrhea Zink 1x10mg (10days)
Probiotics 1x1 shacet
Evaluation & monitoring Vital sign, Saturation
Laboratory evaluation CBC, Blood Culture

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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