Professional Documents
Culture Documents
Morning Report
Thursday, 4TH July 2017
dr. Raisa / dr. Connie/ dr. Syahmi/ dr. Pridania/ dr. Ifa/ dr.
Cempaka
dr. Disa / dr. Laras
dr. Ratna / dr. Patra
2
PATIENT ADMISSION
• MELATI 2 WARD
• Wing Mawar
▫ Child L, male, 5 y.o, 15 kgs, Round cell Pneumonia dd
pulmonal abses dd mass in thorax cavity, anemia due to
infection dd iron deficiency, thrombocytosis reactive.
wellnourished.
• HCU NEONATUS: -
• PICU : -
• HCU MELATI 2 : -
• NICU : -
3
PATIENT IDENTITY
• Name :L
• Sex : Male
• Age : 5 y.o
• Adress : Surakarta
• Medical Record : 01424177
4
Chief complaint
FEVER
5
At Emergency Room
Moewardi Hospital
• Fever(+)
• Cough (-), runny nose(-), breathlessness
(-)
• Vomit (-)
• Cephalgia (-)
• Lose of appettite
• Defecation and urination within normal
limit
7
Pregnancy
He is the second child of his family. Gestational age of 39 weeks. The
mother consumed vitamins and pills routinely from her doctor . Routine
check up to the hospital monthly within first and second trimester,
weekly on third trimester. There were no history of illness and admission
to the hospital during the course of pregnancy.
Delivery
The baby was delivered per vaginam by a doctor. There were no
complication during procedure. The baby delivered well, active, cried
loudly. The baby weighed at 2800 grams and 49 cm in length.
VACCINATION HISTORY
Hep B : 0 months
Polio : 1, 2, 3, months
BCG : 1 months
DPT, hib,HepB : 2,4,6 months
Measles : 9 months
MR : 4 years
Conclusion : vaccination history was complete according to
Ministry of Health’s Vaccination Schedule 2013.
NUTRITIONAL HISTORY
Patient family meal three times a day each meal 1
adult portion. Sometimes drank milk 1-2 times a
day. Fruit one time a day
Growth
Her weight is 15 kg with body height 103 cm
Development
He is now 5 years old. he plays with friends and communicates well with
her parents and her peers.
• BB/U : BB/U = P3
• TB/U : 103/109 x 100 % = 94.4% (TB/U =P10)
• BB/TB : 15/16.5 x 100 % = 90.9% (P10 < BB/TB < P25)
• IMT :
Conclusion : Wellnourished
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Family tree
II
II
I
child. L, 2 m. o
15
PHYSICAL EXAMINATION
• Head : mesocephal,
• Eyes : pale conjunctiva (-/-), icteric conjunctiva (-/-), light reflex
(+/+), isochoric pupil 3 mm/3mm,
• Nose : nasal flare -, discharge (-/-)
• Mouth : wet lips (+), lips and tongue not cyanotic
• Neck : enlargement of lymph node (+) submandubula and
cervical, multiple, d 2 cm, soft in concisstency, skin colour still
the same.
• Thorax :symmetric (+), retraction (-)
LUNG:
• I: normal, symmetric, retraction (-)
• P: fremitus right = left
• P: dim in hemithorax dextra as high as SIC 4-5
• A: normal vesicular breath sound (+/+) decrease in SIC 4-5
additional breath sound (+/+), crackles (+/+), wheezing (-/-)
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CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was not palpable
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, murmur (-)
ABDOMINAL:
I: abdominal wall same with chest wall
A: peristaltic sounds in normal limit
P: tympani(+), shifting dullness (-), undulations(-),
P: liver and spleen was not palpable, good skin turgor
EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis
pedis artery was strongly palpable
Conclusion :
Anemia
Thrombocytosis
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• Conclusion
• tend to lung tumor right
20
21
22
• Conclusion:
• Hippodens lession
round shape in superior
and medius lobe,
attached to the minor
fissura and the
posterior thoracal wall
LIST of PROBLEM
A child, male, 5 years old / 15 kgs with :
1. Prolonged fever for 2 months
2. Pale
3. Blood transfusion
4. Loss of appetite
5. Decrease of body weight
6. Lymphadenopathy
7. Lungs examination : dim in hemithorax dextra as high as SIC 4-5,
decrease vesicular breath sound (+/+) in SIC 4-5 additional breath
sound (+/+), crackles (+/+), wheezing (-/-)
8. Anemia
9. Thrombocytosis
10. CXR : lung tumor dextra
11. Abdominal US : Meteorismus, structure of the abdomen organ
within normal limit
12. CT scan : Hippodens lession round shape in superior and medius
lobe, attached to the minor fissura and the posterior thoracal wall
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Differential diagnosis
1. Round cell pneumonia dd Pulmonal abses
dextra dd Pulmonal mass dextra (P24.81)
2.Anemia normositic normochromic due to
infection procces dd iron deficiency (D64.9)
3.Trombocytosis reactive (D21.4)
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WORKING diagnosis
1. Round cell pneumonia dd Pulmonal
abses dextra dd Pulmonal mass dextra
2.Anemia normocytic normochromic due
to infection procces dd iron deficiency
3.Trombocytosis reactive
29
therapy
• Admitted to pediatric ward
• Nutrition diet rice pack, 1500 kkal/day
• IVFD D1/4 NS 52 ml/hour
• Ampicillin (50mg/kgBW/6hour) = 750 mg/6hour iv
• Gentamycin (7,5 mg/kgbw/ 24 hour) 120 mg/ 24 hours iv
30
PLAN
1. Routine blood count, blood culture, sputum
culture, gen expert
2. Exision of the tumor
MONITORING
• General appearance / vital signs / 8 hours
• Fluid balance and diuresis / 8 hours
31
PHYSICAL EXAMINATION
• Head : mesocephal,
• Eyes : pale conjunctiva (-/-), icteric conjunctiva (-/-), light reflex
(+/+), isochoric pupil 3 mm/3mm,
• Nose : nasal flare -, discharge (-/-)
• Mouth : wet lips (+), lips and tongue not cyanotic
• Neck : enlargement of lymph node (+) submandubula and
cervical, multiple, d 2 cm, soft in concisstency, skin colour still
the same.
• Thorax :symmetric (+), retraction (-)
LUNG:
• I: normal, symmetric, retraction (-)
• P: fremitus right = left
• P: dim in hemithorax dextra as high as SIC 4-5
• A: normal vesicular breath sound (+/+) decrease in SIC 4-5
additional breath sound (+/+), crackles (+/+), wheezing (-/-)
34
CARDIAC:
I : ictus cordis was not visible
P: ictus cordis was not palpable
P: cardiac enlargement (-)
A: 1st 2nd Heart sound normal intensity, regular, murmur (-)
ABDOMINAL:
I: abdominal wall same with chest wall
A: peristaltic sounds in normal limit
P: tympani(+), shifting dullness (-), undulations(-),
P: liver and spleen was not palpable, good skin turgor
EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis
pedis artery was strongly palpable
Differential diagnosis
1. Round cell pneumonia dd Pulmonal
abses dextra dd Pulmonal mass dextra
(P24.81)
2.Anemia normocytic normochromic due
to infection procces dd iron deficiency
(D64.9)
3.Trombocytosis reactive (D21.4)
36
WORKING diagnosis
1. Round cell pneumonia dd Pulmonal
abses dextra dd Pulmonal mass dextra
2.Anemia normocytic normochromic due
to infection procces dd iron deficiency
3.Trombocytosis reactive
37
therapy
• Nutrition diet rice, 1500 kkal/day
• IVFD D1/4 NS 52 ml/hour
• Ampicillin (50mg/kgBW/6hour) = 750 mg/6hour iv
• Gentamycin (7,5 mg/kgbw/ 24 hour) 120 mg/ 24 hours iv
38
PLAN
1. Routine blood count, blood culture, sputum
culture, gen expert
2. Tumor exision
MONITORING
• General appearance / vital signs / 8 hours
• Fluid balance and diuresis / 8 hours
39