Morning Report

Tuesday,
September 05th, 2019
Onsite:
Dr. dr. Herlina Dimiati, Sp.A(K)

Pediatric Residents
Chief: dr. Pretyca YP
PICU: dr. Tommy
NICU: dr. Muslim, dr. Lilis
Ward: dr. Nurul, dr. Rizky
ER: dr. Finda, dr. Eva
Department of Pediatric Medical Faculty Syiah Kuala University/
Zainoel Abidin Hospital Banda Aceh
2019
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Appearance Work of Breathing
- Tone: active - No flaring nostril
- Interactive: good - No retraction
- Consolability : stabil - No dyspneu
- Look: good in eye
contact
- Speech: speak well
PAT

Circulation
- Not pale
- Not sianosis
- Capillary refill time 2
seconds
- Warm extremities 2
 Patient Identity
• Name : Nura Usrati
• Sex : Female
• Birth of date : September 4th, 2002
• Age : 17 years
• RMN : 1.21.98.40
• Address : Padang Tiji
• Patient admission : September 4th, 2019

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 Anamnesis
Chief Complaint:
Abdominal pain
Additional Complaint:
Chest Pain, nausea
Present illness history
• patients came to the hospital by her parents for complaining of
abdominal pain. This complaint has been felt since 5 hours ago.
The pain is felt suddenly. Abdominal pain is felt through the chest
to the back
• The patient also complained of nausea that occurred along with
the emergence of abdominal pain
• Complaints of vomiting and fever do not exist
• Patients are currently in the 2nd day of menarche
 Time table

5 hours 04/09/2019
before adm

Patient admission
Abdominal pain, - RSUZA
chest pain, nausea - Abdominal pain
- Chest pian
- Nausea

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• History of Disease
Patient had never suffered a serious illness before.

• Family History of Disease

no family suffers from the same illness as patients.

• History of Drugs Use

Sucralfat syrup

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• Prenatal, Antenatal, and Postnatal History

• Her Mother got antenatal care at midwife clinic,

she has no compliance during pregnancy.

• She is the 4th child of six brotherhood, she was born

by normal delivery helped by a midwife, BBW
3000 grams. Immediately crying.

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• Immunization

HB0 and Polio

2 months BCG
Polio 2 - DPT-HB1-hib 1
4 months Polio 3 - DPT-HB2-hib2
6 months Polio 4- DPT-HB3-hib3
9 months Measles

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• Feeding Hystory
The last 3 months she comsume family menu 3 times a day,
she like eat instant noodle

Growth and developmental history :

- Patient is in 3rd grade of senior high school, has much
friends, and she can get along well with his friends
- Patient get a first menarche at 12 years of age with 28 days
of a cycle, and menstrual period is 7 days

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KAKEK NENEK KAKEK NENEK

AYah PEDIGREE Ibu

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Vital sign

Conciousness : Compos mentis

Blood Pressure : 110/ 80 mmHg
Heart Rate : 88 beats/min
Respiratory Rate : 24 breaths/min
Temperature : 37.2 C
Task Force
Systole : 109-122 mmHg
Dyastole : 65-79 mmHg

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 Antropometry
• Actual Body Weight : 38 kg
• Ideal Body Weight : 44 kg
• Height/Length : 155 cm
• HoC : 53 cm
• upper left arm circumference : 14 cm
• Weight for Age : 69% (severe underweight)
• Height/Length for age : 95% (median)
• Weight for height/length : 86% (wasted)
• HA: 13 years

• Nutritional status : chronic malnutrition

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BB/TB

TB/U

BB/U

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 Physical Examination

• Head : normocephaly, HoC= 53 cm, black hair, difficult to pull

• Face : simetris
• Eyes : conj.palp. Inferior not pale, sclera unicteric,
pupil isokor (3mm/3mm)
• Nose : no nostril breath , no secretions
• Mouth : Tonsil T1/T1
• Ears : normotia, no secretions

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• Thorax
Anterior:
Inspection : Symmetrical, no retractions
Auscultation: Vesiculer without crackles and wheezing

Posterior:
Inspection : Symmetrical, no retractions
Auscultation : Vesiculer without crackles and wheezing

Cor
Inspection : ictus cordis not seen
Palpation: ictus cordis palpable on ics 5 linea midclavicula
sinistra
Auscultation : S I > SII, Reguler, no thrills or murmurs
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• Abdomen
Inspection : symmetrical, soepel, not distended
Palpation : soepel, Rovsing sign positif,
right lower abdominal pain
Percussion : timpany
Auscultation : Peristaltic 5 time/minute

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• Ekstremity
-Superior : not edema, not pale, warm CRT < 2 second
- Inferior : not edema, not pale, warm CRT < 2 second

• Genitalia : female

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Tanner Stage

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 Laboratory Examination
Hemotology RSUZA RSUZA Normal Value
(16/09/19) (16/09/19)
Blood Gas Normal
Hemoglobin 14,5 14,6 12-14,5 gr/dl Analysis Value
Hematokrit 42,6 41 37-47 %
RBC 5,56 5.2 4,2-5,4 106/
mm3 pH 7,430
WBC 6,64 6.1 4,5-10,5 pCO2 35,40
103/mm3
Platelets 278 277 150-450/103
pO2 38
mm3
HCO3 23,7
Eosinofil 5,7 6 0-6%
basofil 0,2 0 0-2%
Total CO2 24,6
N. Batang 0 2-6% BE 0,4
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N. Segmen 41 50-70% Saturasi O2 74,0
Limfosit 44,3 47 20-40%
Monosit 4,8 6 2-8%
MCV 78,6 76 80-100fl
MCH 26,6 28 27-31pg
MCHC 33,8 36 32-36%
RDW 37,3 12,5 11,5-14,5%
MPV 10,4 10,1 7,2-11,1fl

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 Kimia Klinik RSUZA Perta Nilai Urine dipstick
(16/09/19) medika Rujukan
Leucocyte: -
SGOT 26 <31 U/L
Nitrit : -
SGPT 13 <34 U/L
Ureum 21 18 13-43 mg/dl Urobilinogen: 1

Kreatinin 0,30 0,5 0,51-0,95 mg/dl Protein: -

Elektrolit pH: 7

Kalsium (Ca) 9,2 8,6-10,3 mg/dl Blood: +3

Natrium (Na) 144 132-146 SG: 10,2
Kalium (K) 4,0 3,7-5,4 Keton: 2
Klorida (Cl) 107 96-106 Bilirubin: -
KGDS 308 560 < 200 mg/dl Glucose: +3

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Laboratory

URINE RS Pertamedika Nilai

(16/09/2019) Rujukan

Warna Kuning Kuning

Kekeruhan Agak Keruh Jernih

Blood (+++) Negatif

Bilirubin Negatif Negatif
Bilirubinogen Normal Normal
Keton (+) Negatif
Glukosa (++) Negatif
Protein Negatif Negatif
Nitrit Negatif Negatif
Leukosit Negatif Negatif
pH 7.0 5.0-7.0
Berat Jenis 1.010 1.005-1.030
Eritrosit 20-25 0-5/LPB
Leukosit 0-3 0-5/LPB
Epytel 0-3 0-1/LPB
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USG: Normal

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Differential diagnose
- Hiperglikemia e.c DD:
- 1. DM Type I
- 2. DM Type II

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Working Diagnosis
Hiperglikemia e.c DM Tipe I

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Daily fluid maintenance

Daily fluid maintenance for patient with ABW 50 kg

= 1500+ 20(30) = 2100 cc/day
 Recommended Daily Allowance

• Calories for girl with HA 12 years (IBW 40 Kg)

= (39-49) x 40
= 1560– 1960 Kcal/day
• Proteins for girl with HA 12 years (IBW 40 Kg)
= 1 x 40 kg
= 40 gram/ day
treatment
Supportif
- IVFD 2:1 1800 cc/ day25 gtt/minute micro
- Diet 2500 kkal + 35 gram protein
- MB 3 times a day with 2 times snack a day

Medications

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Planning
• DPJP gastroenterohepatology
• Rooming in Arafah 1
• Consult to Nutrition and metabolic division
• Consult TKPS DIVISION  Catch up imunization

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• Consult to Pediatric Surgery Departement
• A/ Acute Appendicitis
• Suggest to laparotomy

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THANK YOU

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