MORNING REPORT

Saturday Morning, July 14th, 2018

 FAKULTAS KEDOKTERAN
UNIVERSITAS SRIWIJAYA
VISI
MENJADI PROGRAM STUDI TERKEMUKA DI ASIA
TENGGARA BERBASIS PENDIDIKAN, PENELITIAN, DAN
PELAYANAN DI BIDANG ILMU KEDOKTERAN PADA
TAHUN 2022
1. MENYELENGGARAKAN PENDIDIKAN KEDOKTERAN
KESEHATAN BERSTANDAR INTERNASIONAL DAN
BERBASIS KEARIFAN LOKAL
2. MENYELENGGARAKAN PENELITIAN DI BIDANG
ILMU KEDOKTERAN YANG BERKUALITAS YANG
DAPAT DIPUBLIKASIKAN DI TINGKAT NASIONAL DAN
INTERNASIONAL, SERTA DAPAT DIAPLIKASIKAN
DALAM PENGEMBANGANGAN ILMU DAN
KEPENTINGAN MASYARAKAT
3. MENYELENGGARAKAN PENGABDIAN DAN
PELAYANAN KEDOKTERAN BERBASIS AKADEMIK
YANG BERSTANDAR INTERNASIONAL SEBAGAI
PUSAT RUJUKAN DI TINGKAT REGIONAL DAN
NASIONAL
4. MELAKSANAKAN SISTEM MANAJEMEN DAN
TATAKELOLA YANG EFEKTIF, EFISIEN, DAN
 CO-ASSISTANT ON DUTY
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IKA – B
Irma Pratiwi, S.Ked IKA – C
M. Afif Baskara, S.Ked Adi Putra Tandi,
Amanda Nathania, S.Ked
S.Ked Iqbal Fahmi, S.Ked

ER Neonatal Ward
M. Imam Mulia, S.Ked Nabilla Maharani Gumay,
Esty Risa Mubarani, S.Ked
S.Ked Jesslyn Juanti, S.Ked
An.R/girl/ 1 year old Respiratory Normal

Appearance
Breathing Normal
Abnormal

Circulation
Normal

Respiratory & Breathing :

Appearace: Nasal flare (-), retraction (-)
T: alert (+)
I: interaction (-)
C: consability (+)
L: look or gaze (-) Circulation:
S: speech or cry (+) Warm extremity (+), CRT < 3”
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Identity : An. Rafani/Girl/1 years old

Time of Admission in IGD : 02.30 PM , Time admission in pediatric ward : 05.50

p.m.
ANAMNESIS
Main Complaint : Continuous Fever
Additional complain : Vomitting

Present Illness History

Since 6 days ago, the patient began having fever, the temperature maintained
high continuously, decreased when given Paracetamol, since 2 days ago, the
fever was still high. coughing (-), runny nose (-), watery stool (-), the urination
is normal.
Since 2 days ago, vomiting (+), frequency 2x/day, urination and defecation are
normal, chilling (-), bleeding gum (-), red spots on the skin (-). The patient was
admitted to a midwife and given Paracetamol and mixed drugs but there was no
improvement. The patiet was finally admitted to RSMH.
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Present Illness History
 History of prolonged fever, DHF, fever with rash, diarrhea, febrile seizure, and trauma
were denied

History of Immunization
 History of basic immunization was completed

Family Illness History

 History of illness with the same complaint was denied

Birth History
 Baby girl was born from G4P3A0 aterm baby, spontaneous, helped by midwife,
directly crying, BW 2800 grams, Mother forgot HC
Physical Examination, July 16th 2018 at 03.30 p.m.
Weight : 9 kgs Length 77 cm
Weight for age : 0< Z < +2 SD
Height for age : 0 < Z < +2 SD
Weight for height : 0 < Z < -1 SD
Nutritional Status : Nourished
General Condition :
Sense : E4M6V5
BP : 90/60 mmHg
HR : 120 times/minute
Pulse : 120x/m (content and tense was good)
RR : 36 time/minute (reguler)
Temp : 38.3’C ( aksilla)
SpO2 : 97%

Specific Condition
Head : Nasal flare (-), conjungtiva anemis (-/-), sclera icteric (-/-), isocor pupils Ø3mm,
normal light reflex
Chest : Symmetrical, retraction (-)
Heart : Normal 1st and 2nd heart sound, murmur (-) Gallop (-)
Lung : Vesicular breath sound (+) normal, ronkhi (-/-), wheezing (-/-)
Stomach : flat, supple, non palpable liver and spleen, epigastric pain (-), normal bowel
sound (+) normal
Extremity
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: warm extremity (+), CRT < 3”, pitting edema (-), Rumple Leed (+)
 Laboratory Finding (16/07/2018) RSMH at 04.30 p.m

16/07/2018 Result Normal Value Unit

Haematology :
Haemoglobin 11.5 11.3-14.1 g/dL
RBC 4.55 4.75 – 4.85 106/mm3
WBC 11.5 4.5 – 13.5 103/mm3
Ht 34 37-41 %
PLT 19 217 – 497x 103 /µL
RDW-CV 14.20 11-15 %

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16/07/2018 Result Normal Value Unit

Haematology :
Haemoglobin 10.2 11.3-14.1 g/dL
Ht 31 37-41 %
PLT 18 217 – 497x 103 /µL
RDW-CV 14.20 11-15 %
 PROBLEMS ASSESMENT
1. Fever 6 days Suspected Dengue Hemorrhagic Fever
2. Frequent Vomiting Stage I
3. Trombocytopenia (19.000)
4. Rumple Leed Test (+)

DIAGNOSIS/DIFFERENTIAL WORKING DIAGNOSIS

DIAGNOSIS Suspected Dengue Hemorrhagic Fever
•Suspected Dengue Hemorrhagic Stage I
Fever Stage I
•Dengue Fever
•Viral infection

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PLAN EXAMINATION THERAPY
• Hb, Ht, Trombocytes serial • IVFD RL vel. 5 mL/KgBB/hour
• Electrolite • Paracetamol 10 mg/kgBB if fever occurs
• IgM and IgG Dengue

DIET MONITORING
NB 900 calories • BP, Heart Rate, RR, Temperature every 6
hours
• Balance Diuresis every 6 hours

ADMISSION Infection Division

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THANK
YOU
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