Morning Report

Sunday, September 30th 2018

VIR/LII
No Name Gender/Age Working Diagnosis
1. EMS Girl, 1 year 7 acute gastroenteritis without
months dehydration
1
New Patient of emergency room at 08.20 pm, EMS, girl, 1 year 7 months,
address: Jln. Jamin Ginting, Medan
BW : 8,8 kg BL : 77 cm HC: 45 cm (-2<SD<2)
W/A : -2SD<Z<0SD H/A: -2SD<Z<0SD W/H: -2SD<Z<2SD

Chief complain : diarrhea

History of disease:
-It experienced since 2 days ago, ± 4 times/day, pulp>water, no blood, no
mucus. Stool colour was yellow and smell like acid with volume ±1/4-1/2
cup/diarrhea
-Nausea (+), vomit (+) since 2 days ago, ± 2 times/day, projectile vomit (-)
-Fever (+) since 1 day ago, mild grade, intermittently and step down with
medicine
History of disease:
-Convulsion (-), shivering (-)
-Thristy (-)
- Urinary volume was normal
- Her auntie was suffering with the same illness

History of previous medication:

• Paracetamol

History of growth and development :

• Peer as age. She can speak a short sentence and run

History of immunization :
• Immunization was complete
History of diet :
0-4 months : Breastfeeding ad libitum
4-6 months : Formula milk
6-12 months : Porridge 3 times/day + formula milk
12 months-now : Regular food 3 times/day + formula milk
Physical Examination
General status :
Alertness : composmentis Temperature : 38,7ºC
dyspnoe (-), cyanosis (-), edema (-), icteric (-), anemic (-)

Localized status:
Head : Eye : Light reflexes (+/+), isochoric pupil Ø3mm/3mm,
Sunken eyelids (-/-), tears (+/+)
Ear : No secret and cerumen
Nose : No secret
Mouth : Dry lips mucosa (-), Tonsil T1-T1, pharynx: no hyperemic mucosa
Neck : lymph node enlargement (-)
Thorax : Symmetrical fusiform, no retraction
Heart rate : 120 beat/minute, regular, murmur (-)
(N: 90-150 times/minute)
Respiratory rate : 28 breath/minute, regular, no rales, stridor,
and wheezing (N: 20-30 times/minute)

Abdomen : Soft, peristaltic sound (↑), no palpable liver and spleen, turgor return
quickly

Extremities : Pulse 120 bpm, regular, warm extremities, capillary refill time (CRT) <
2 second
Diferential diagnosis :
Acute gastroenteritis without dehydration due to DD/ - viral infection
- bacterial infection

Working diagnosis :
Acute gastroenteritis without dehydration due to viral infection

Therapy :
•Oralit 50-100 ml/diarrhea or vomit
•Zinc 1 x 20 mg
•Paracetamol 3 x 80 mg
•Outpatient