Morning Report

th
June, 04 2018
Onsite :
Dr. dr. Herlina Dimiati, Sp. A (K)

Resident:
dr. Deska, dr. T. Ade, dr. Hirsa
dr. Fira, dr. Sannita, dr. Diana

Bagian/SMF Ilmu Kesehatan Anak FK UNSYIAH/RSUD Dr. Zainoel Abidin Banda Aceh
2018
IDENTITY

• Name : Hafizzuddin
• Sex : Male
• Date of Birth : March, 03th 2002
• Age : 16 years 3 months 1 day
• Address : Manggeng, Blangpidie, Aceh Barat Daya
• MR No. : 1.17.42.99
• Date of Admission : June, 4th 2018 at 20. 05 WIB
Appearance Work of Breathing
- Tone : couldn’t sit and just lie - No Flaring Nostril
down - No retraction
- Interactiveness: stupor - No Dyspneu
- Consolability : unstabil
- Look : not good in eye contact
- Speech : can’t speak

PAT
Circulation
- Not Pale
- Not sianosis
- Capillary refill time: 2 seconds
- Warm extremities
ANAMNESIS
• Chief Complaint:
loss of conciousness
• Additional Complaint:
History of seizure, fever and History of vomit
• Present History:
• Patient was referred from Teungku Peukan Hospital, Blangpidie, Aceh Barat Daya with
diagnosed Infection of central nervous system ec. DD: 1. Encephalitis 2.
Meningoencephalitis + DHF grade II with encephalopaty. He has been hospitalized for 2
days at Teungku Peukan Hospital, Blangpidie, Aceh Barat Daya.
• Patient complained by his family about loss of conciousness since 2 days before
admission. Loss of conciousness happen slowly. Loss of conciousness begins with seizure.
After seizure happened, he cannot speak and getting weak until he cannot wake up
anymore.
• Patient had a history of seizure since 3 days before admission. Seizure happened with
rigid of the whole body and wide eyes. This complain happen for 5 minutes and
recurrent by 5 minutes, all of the day, however patient not complaint seizure anymore
for today.
• Fever suffered since 6 days before admission. Fever sudden high
temperature, fever may come down with antipyretic and then up to
high fever again
• Patients had a history of vomiting 6 days ago followed by fever.
Vomiting contains what is eaten and drink, volume ± 200cc for a day,
bursts of vomit. 1 day after that, vomit with red brownish blood
spots,blood vomit just happened 2 times. This complaint not suffered
anymore until now.
• Patient Defecation and urinary are normal?last urine ....?
Refferal Letter
ANAMNESIS
• History of illness:
• Patient ever been diagnosed with Morbili at 2 weeks ago.

• History of Family Illness

• Patient’s family never been in the same condition like he has now.
• No family member suffers cought for more than 2 weeks or suffers Tb pulmonal

• History of drug use

• O2 nasal canul
• IVFD RL 30 gtt/i ( makro)
• Inj. Meropenem 1 gr/12 hours
• Inj. Diazepam 10 mg/8 hours
• Inj. Ranitidine 1 amp/ 12 hours
• Inj. Dexamethason 1 amp/8 hours
• Paracetamol 3 x 500 mg 7
ANAMNESIS
• Pre Natal, Natal and Post Natal Care
• Patients of 2th child of 2 siblings, borned via vaginal delivery, helped by
midwife at clinics, at 38 weeks of gestation, BBW 4000 grams, immediately
crying, and no sianosis.
• During pregnancy his mother controls the pregnancy regularly in the midwife.
No complaints during her pregnancy. History of hypertension, DM is denied.
History of falls and vaginal discharge during pregnancy does not exist

• Immunizations:
His mother do not remember about his immunization.

• Growth and development History:

Patient is student at Junior High School. Patient has much friend, and has good
achievement for 10th big rank at his class.
ANAMNESIS
• Feeding History
0 – 6 bulan : Exclusive beastfeeding
6 – 12 bulan : breastfeeding with MPASI
12 bulan – 2 years : breastfeeding + family menu
2 tahun until now : family menu

Before ill patient eat 3 times a day, eat regularly family menu and like to eat snack
by the roadside.

9
 Time table
Admitted to IGD
RSUZA with
6 days before 3 days before 2 days before
2 weeks ago 04/06/2018
admitted to admitted to admitted to -
20.05 WIB
RSUZA RSUZA RSUZAt

- Loss of
- Fever - Loss of conciousness
- Seizure
Morbili - Blood conciousness - Fever
- Fever
vomitus - Fever

Hospitalized at
RS Teungku
Peukan,
Blangpidie, Aceh
Barat Daya for 2
days 10
ANTHROPOMETRY
• Actual Body Weight : 47 kg
• Ideal Body Weight : 55 kg
• Length : 168 cm
• Weight/ Age : 76 %
• Length/ Age : 96%
• Weight/Lenght : 85%
• HA : 14year 9 month
• Head of Circumferrence : 54 cm
• Nutritional Status : Underweight

11
 TB/U

BB/U

BBI

HA
Normocephali
Vital Sign

• Conciousness : E2M3V2
• Pulse : 82 beats/minutes
• RR : 17 times/minutes
• Temp : 37,80C (axilla)
• Blood Presure :110/800 mmhg ( TF: S: 114-128/D:64-79 mmhg)
Physical Examination
• Head: Normocephali, HoC= 50 cm,black hair
• Eyes : Conj. Palp. Inf Not pale, Sklera ikterik not found,
Pupil isokor. RCL(Positif/positif),
RCTL(Positif/Positif)
• Ears : normotia, no secrets
• Nose : Flaring nostril
• Mouth : Not Pale, no sianosis
• Lymp node enlargement not found,
• Thorax
Anterior
Inspection : Symmetrica,No Retraction
Perkution : Sonor/ Sonor
Auskultasi : Vesiculer, Rhonkhi and wheezing not found

Posterior
Inspection : Symmetrical,No retraction
Perkution : 2/3 superior pekak/ pekak, 1/3 inferior sonor/sonor
Auskultasi : Vesiculer, Rhonki and wheezing not found

• Heart
I : Ictus cordis not visibly
P : Ictus cordis palpable at ICS V midclavicula sinistra’s line
A : S I> S II, Reguler, no thrills or murmur

16
• Abdomen
Inspection : symmetrical, soepel, not distended
Palpation : soepel, No hepatomegaly
Percussion : timpany
Auscultation : Peristaltic 5 time/minute

• Ekstremity
-Superior : not edema not pale, warm,CRT 2 second
- Inferior : not edema,not pale, warm,CRT 2 second
 Status neurologis
• Consousieuness : E2 M3 V2
• Motorik :

• Sensorik :

• Reflek fisiologis:
- biseps (Positive/ Positive)
- trisep (Positive/ Positive)
- Patella (Positive/ Positive)
- Achilles (Positive/ Positive)

18
• Reflek patologis
- Babinski (Positive/ Positive)
- oppenheim (Positive/ Positive)
• Tanda rangsang meningeal
- kaku kuduk (Negative)
- Brudzinski I (Negative)
- Brudzinski II (Negative)
- Kernig (Negative)

19
Tanner Stage
 Types Result Normal Range
Hemoglobin 12,6 14.0 – 17,0 g/dl
Hematokrit 36 37 - 47 %
Eritrosit 4,6 4,2 – 5.4 x 106/mm3
Trombosit 147 150 – 450 x 106/mm3
Leukosit 15,0 4,5 – 10.5 x 103/mm3
Laboratoryum MCV 78 80 – 100 fL
(4/5/2018) MCH 28 27 – 31 pg
MCHC 35 32 – 36 %
RDW 12,0 11,5 – 14,5 fL
Eosinofil 0 0–6%
Basofil 0 0–2%
Netrofil Batang 1 2–6%
Netrofil Segmen 83 50 – 70 %
Limfosit 6 20 – 40 %
Monosit 10 2–8%
GDS 195 < 200 mg/dl
 Types Result Normal Range
Natrium (Na) 136 (132-146 mmol/l)
Laboratoryum Kalium (K) 4,2 (3,7-5,4 mmol/l)
Klorida (Cl) 106 (98-106 mmol/l)
(5/6/2018)
Ureum 27 13-43 mg/dl
Creatinin 0,42 0,51- 0,95 mg/dl
SGOT 592 < 31 U/L
SGPT 213 < 34 U/L
Albumin 3,56 3,5-5,2 g/dL
PT/ APTT 0.8/34,6 < 1,5/29,0-40,2
 Urine Dipstick Result
Leukosit Negative
Nitrit Negative
Uro 0,2(3,5)
Urine Dipstick Protein ++

(5/6/2018) PH 7,5
Blood +++
Sc 0,10
Keton Negative
Bil Negative
Glucosa Negative
Foto Thorax
4/6/2018
Head CT Scan
4/6/2018
Differential Diagnosis
• Enchephalitis
• Meningoencephalitis
• Meningitis
+ Underweight
Working Diagnosis

• Encephalitis
• Underweight
Fluid Requirement
Patient with actual body weight 47 kg
1500 + 20 ( 27 ) = 2440 cc / day
Restriksi 15 %  2074
Nutritional Requirement
• Patient with Ideal body weight 55 kg
Kalori : (38-47) x 55 = 2090 – 2585 kkal / day
Protein : 0,8 x 55 = 44 gram / day
Management
Supportif
• O2 2 L/i Nasal Kanul
• IVFD 2:1 1734 ml/ 24 hour  24 cc/hour
• Head up 30◦
• Diet Sonde by NGT 150 ml/ 3 Hour

Therapy
• Inj. Meropenem 1 gram / 8 Hour IV
• Inj. Ranitidin 50 mg / 12 Hour IV
• Inj. Dexamethasone 5 mg/ 8 Hour IV
• Inj. Metamizole Sodium 500 mg/ 12 Hour IV
PLANNING
• Division : ERIA
• Admitted at : PICU
• Consult to Optalmology Department
• Feces and Urine Routin
• Monitoring Balance cairan and vital sign