MORNING REPORT

Disusun oleh:
DEVY PUSPO WARDOYO

FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH SURAKARTA
2017
 IDENTITY
• Name : An. A
• Date of birth : 14 May 2012
• Gender : Boy
• Age : 5 years 6 months
• Address : Surakarta
• Religion : Islam
• Tribe : Java
• Date of hospitalization : 15-11-2017 (02.30) am
• Date of examination : 15-11-2017 (02.40) am
ANAMNESIS

Chief Complaint

watery stool
 HISTORY OF ILLNESS
1 day before admission

• The father said on tuesday afternoon , the

patient got watery stool 8x with mucus and no
blood, vomit 4x. patients also have fever and
runny nose.
• patients appear lethargic
• excessive thirst
• concave eyes
• The urination was normal.
 HISTORY OF ILLNESS

The day on admission

• The father said that he took the patient to PKU because the fever and
lethargic .
• the urination was normal
 HISTORY OF PAST ILLNESS

History of Seizure with fever : admitted

History of seizure without 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

Conclusion: there is history of past illness that related to current

illness
 HISTORY OF ILLNESS IN FAMILY

History of Similiar symptom : Denied

History of Seizure with fever : Denied
History of Asma : Denied
History of Hypertention : Denied
History of Diabetes Mellitus : Denied

Conclusion: there is no history of illness in family that not correlated with

patient’s disease
 PEDIGREE

Ny. M 29 years old Tn. S 30 years old

An. A 5 years 6
month

Conclusion : there is no hereditary illness

 HISTORY OF PREGNANCY

Mother with P1A0 was pregnant at 23 years old. Mother began to

check pregnancy and routinely control to the midwife. During
pregnancy the mother does not feel nausea, vomiting and
dizziness that interfere with daily activities. During pregnancy
there was no history of trauma, bleeding, infection, and
hypertension.

Conclusion: history of pregnancy was good

 HISTORY OF DELIVERY

The mother gave birth to her baby assisted by a midwife with a normal
delivery. 39 weeks pregnancy age, baby born with body weight 3500
grams and body lenght 48 cm. At the time of birth the baby cries instantly,
there was no congenital defect at birth.

Conclusion : history of delivery was good

HISTORY OF POST DELIVERY

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

Conclusion : history of post delivery was good

 HISTORY OF ENVIRONMENT

The patient lives at home with both parents, sister and

brother. Ceramic-floored patient houses, walled walls, tile roofs,
adequate ventilation, bathrooms in the house, water source from
well water.
A few days before the patient was treated in the hospital,
neighbors and the family have not experienced some complaints.

Conclusion : there is no a risk factors for transmitted disease

 HISTORY OF VACCINE

JENIS JM USIA
Hepatitis B 4 kali 0, 2, 3,4 bulan
BCG 1 kali 1 bulan
DPT 4 kali 2, 3, 4,18 bulan
Hib 3 kali 2, 3 , 4 bulan
Polio 4 kali 1, 2, 3, 4 bulan
Campak 2 kali 9 bulan dan 18 bulan
 HISTORY OF FEEDING
Age 0 – 1,5 months
• Breastmilk

Age > 1,5-6 months

• Formula + breastmilk

Age >6-12 months

• Formula + porridge rice and vegetables teams smoothed 1 day 2 small dishes and always finished

Age ≥ 12 months
• Rice + vegetables + egg+ fish 1 day 2 small dishes and always finished

Conclusion : history of feeding quality and quantity were not good

 HISTORY OF GROSS MOTOR

Kemampuan Umur pencapaian Range normal

miring 3 bulan 0-3 bulan
Duduk 7 bulan 6 – 7,5 bulan
Berdiri 11 bulan 11 - 14 bulan
Berjalan 12 bulan 11-15 bulan
berlari 18 bulan 13,5-20 bulan
melompat 2 tahun 22-30 bulan
Lompat jauh 3 tahun 2,5-3 tahun

Conclusion :Development history of Gross motor according

to age
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 HISTORY OF FINE MOTOR

Kemampuan Umur pencapaian Range normal

Meraih 5 bulan 4,5 – 5,5 bulan
Mencoret coret 12 bulan 12 – 17 bulan
Membuat menara 1,5tahun 13-21 bulan
Mencontoh 4 tahun 3-4 tahun

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Conclusion :Development
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 HISTORY OF LANGUAGE
Kemampuan Umur pencapaian Range normal
Bersuara 3 bulan 1 – 3 bulan
Menoleh ke arah suara 5 bulan 3,5 – 7 bulan
Meniru bunyi kata-kata 6 bulan 3,5 – 9 bulan
Berbicara beberapa kata 2 tahun 17-39 bulan
Bicara semua dimengerti 2,5 tahun 1,5-3 tahun
Menyebut 4 warna 4 tahun 3-4 tahun

Conclusion :Development history of language according to

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 HISTORY OF SOCIAL
Kemampuan Umur Range normal
pencapaian
Tersenyum spontan 2 bulan 0-2 bulan
Makan sendiri 6bulan 4,5 – 6,5 bulan
Menyatakan keinginan 12 bulan 7,5- 13 bulan
Minum dengan cangkir 15 bulan 9-18 bulan
Membuka pakaian 18 bulan 14bulan – 2 tahun
Memakai baju 2,5 tahun 24 bulan- 2,5 tahun

Conclusion :Development history of social according to age

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 Physical Examination
 General appearance
General appearance : Tampak baik
Awareness : Alert

 Vital Sign
Blood Pressure : 110/70 mmHg
Heart rate : 100x/ menit
Respiratory Rate : 22x/ menit
temperature : 37,6º C
 Nutrisional status

WEIGHT : 16,0 KG Height : 110,0 CM BMI : 13,2

-Weight // age : -2SD line (gizi kurang)

-Lenght // age : antara -1SD sampai 0 (normal)
-Weight // Lenght : antara -3SD sampai -2SD (kurus)

Conclusion : The patient's nutritional status is good

 Physical examination
• Skin examination
Color : brown
Skin turgor: <2 sec (good)
Moisture: moist
Edema (-) does not exist

• Conclusion : the examination of skin within normal

limits

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 PEMERIKSAAN KUSUS
Neck : No enlargement of lymph node and no increase jugular venous
Chest : Simetris, retration (-), miss the motion (-).
• Heart
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 (-)
• Lung
Inspeksi : Simetris, retraksi intercostal (-/-), retraksi
subcostal (-/-), retraksi substernal (-), retraksi
suprasternal (-)
Palpasi : Simetris kanan kiri, There is no missed breath
Perkusi : sonor
Auskultasi : Vesicular (+/+) normal, rhonki (-/-), wheezing (-/-)

Conclusion : Neck, Chest, Heart, Lung within normal limits

Stomach : Inspeksi :Perut tampak membesar (+), sikatrik (-), purpura (-)
Auskultasi :Peristaltik increases (+)
Perkusi :Timpani (+)
Palpasi :Supel, massa abnormal (-), nyeri tekan (-),
turgor kulit menurun (-)
Liver : Hepatomegali (-)
Spleen : Splenomegali (-)

Conclusion : There was normal limits

 Ekstermitas

•Warm of acral
•Perfusion of tissue is good

•Cyanosis is not found in the 4 extremities

•No udem is found in the abdomen

CRT <2 sec
Turgor is good

Conclusion : the examination of extremity within normal limits

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 PHYSICAL EXAMINATION

Head : Normochephal
Eyes : CA (-/-), SI (-/-), edema palpebra (-/-) , sunken eyes(-/-)
Nose : Sekret (-), epistaksis (-), nafas cuping hidung (-/-)
Ears : Sekret (-)
Mouth : Stomatitis (-), perdarahan gusi (-), sianosis (-),
Skin : Warna sawo matang, Pucat (-), Ikterik (-), Sianosis (-), turgor kulit (< 2
detik)
Lymph nodes : Tidak didapatkan pembesaran limfonodi
Muscle : Tidak didapatkan kelemahan, atrofi, maupun nyeri otot
Bone : Tidak didapatkan deformitas tulang
Joints : Gerakan bebas
Extremities : CRT < 2 Second, sianosis (-/-), edema (-/-), akral hangat(+/+), petekie (-
/-)

Conclusion: There was normal limits

 LABORATORIUM EXAMINATION
Routine blood examination
PEMERIKSAAN HASIL SATUAN NORMAL
 Leukosit 15.10 10ˆ3/ul 5.5 – 15.50
 Eritrosit 4.62 jt/ul 3.8 – 5.20
 Hemoglobin 11.2 g/dl 10.7 – 14.5
 Hematokrit 33.7 % 35.0 – 47.0
 Trombosit 415 10ˆ3/ul 217 – 497
 Limfosit 78.9 H % 25 – 40
 Netrofil 14.8 L % 50 - 70
 Monosit 6.6 % 2–8
 MCV 73.5 fl 73.0 – 102.0
 MCH 25.1 pg 22.0 – 34.0
 MCHC 33.1 g/dl 30.0 – 34.0

Result : Routine blood examination there limfositosis, neutropenia

 RESUME
ANAMNESIS
watery stool with mucus 8x
vomit 4x
excessive thirst
patients appear lethargic
Physical examination
Blood Pressure : 110/70 mmHg
Heart rate : 100x/ menit
Respiratory Rate : 22 x/ menit
temperature : 37,6º C

Laboratorium
Limfositosis, neutropenia
 ASSESMENT

• Diare cair akut dengan dehidrasi tak berat

• DD
• Intoleransi laktosa
 ACTION PLAN
• Balance cairan
• Observation of vital signs

DIAGNOSIS ENFORCEMENT PLAN

• Feces Routine examination

 Terapi

kebutuhan energi : White rice, eggs, meat, fish,

vegetables a day 3 times a large plate of food was
Kalori : 16 x 90= 1440kkal
always finished.
Protein : 16x 1.2 = 19.2g
 rute oral
Cairan : 16x 90= 1440ml
Kebutuhan energi : 918 kalori/hari dibagi dalam
3 kali waktu makan

kebutuhan energi :
Nasi putih 100 gram: 178 kalori
Tumis bayam 100 gr : 193 kalori
1 butir telur rebus : 154 kalori
1 tempe goreng : 82 kalori
1 ayam sayap: 295 kalori
 ` PLAN
THERAPY

• Paracetamol 10 mgx 16= 160mg/4 jam apabila suhu 38 derajat C

• Cairan : 75mL/kgBB x 16 = 1200 mL selama 3 jam

• Zink 20mg/hari
 FOLLOW UP
TANGGAL SOA PLANNING
15-11- -S/ watery stool (+) 4x, vomit (-) P/ Paracetamol 160
2017 O/ mg/4 jam
Jam - KU : Compos Mentis zink 20 mg
07.00 - HR : 78x/menit
- RR : 22 x/menit
- Kepala: konjunctiva anemis (-/-), sklera ikterik (-/-)
- Tho: suara vesikuler(+/+)
- Abd : peristaltik (

A/ Diare cair akut dengan dehidrasi tak berat

DD
Intoleransi laktosa
THANK YOU