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- 1. Morning Report Thursday, August8th 2024 On Call: Dr. dr. Anidar, SpA(K) Moderator: dr. Baitil Atiq, SpA Pediatric Residents Chief 1: dr. Amelia Wijaya Chief 2: dr. Rahmayanti Emergency Room: dr. Rachmi Darmia, dr. Villna Cinthya Pediatric Intensive Care Unit : dr. Mestika Neonatology Intensive Care Unit : dr. Syarifah Ranny and dr. Siti Chalizar Ward and POC: dr. Winda Fauti, dr. Kiki Tazkiyatun
- 2. Patient's Recap August 7th –August 8th 2024 No Division All DPJP Ward ARAFAH 1 ARAFAH 2 RAUDHAH 2 NICU PICU ER ZAM ZAM Thursina 1 Others Death case < 24 hour > 24 hour < 48 hour > 48 hour INFECTION 1 NEUROPED 5 1 2 GEH 4 2 3 3 IPT 1 4 RESPI 2 2 1 HOP 4 2 NEFRO 3 3 KARDIO 1 4 ALIM 0 5 ENDOKRIN 0 6 NPM 2 1 7 TKPS 0 NICU 11 ERIA 4 Other DPJP 1 Ward Damaged Room 3 5 0 0 Filled Room 23 9 4 8 Unfilled Room 2 3 0 16 Capacity 28 17 4 24
- 3. No. Identity DiagnoseDPJP 1 MA/ M/1 year 2 months/376686 • Acute Kidney Injury ec dd 1. Acute Glomerulonefritis 2. Nephrotic syndrome • Pneumonia Lobaris • Increase in the enzyme transeminase ec dd 1. Infection 2. Sepsis • Microcytic hypochromic anemia ec dd 1. Iron deficiency 2. Chronic disease • Incomplete Immunization Nephrology 2 TA/F/ 11 year 3 months/159265 • Bronchial asthma mild to moderate attacks of intermittent degree • Incomplete immunization Discharge with education Patient Admission August 7th – 8th 2024
- 4. Patient Admission withPV/SC August 7th – 8th 2024 No Identity Indication of PV/SC Diagnose Summary 1 By. Mrs. S G4P3A0, 40-41 Weeks Pregnant, Single Live Fetus in Oblique Presentation Aterm Neonates with Appropriate Gestational Age Post Sectio Caesarea APGAR SCORE 8/9 Downe score 0 BW 3100 grams BL 46 cm HC 34 cm CC 32 cm AC 30 cm AC 11 cm NBS: 37 GA: 38-40 weeks Perinatology
- 5. Patient Admission withPV/SC August 7th – 8th 2024 No Identity Indication of PV/SC Diagnose Summary 2 By. Mrs. MS G3P2A0, 38-39 Weeks Pregnant, Single Live Fetus in Head Presentation, Premature Rupture of Membranes (11 hours) Aterm Neonates with Appropriate Gestational Age Post Pervaginam APGAR SCORE 4/5/8 Downe score 0 BW 3500 grams BL 46 cm HC 36 cm CC 34 cm AC 32 cm AC 12 cm NBS: 37 GA: 38-40 weeks Perinatology
- 6. Patient Identity Name Age Date ofBirth Sex MR number Date of admission : AN : 1y 2m 20d : 18/05/2023 : Male : 1-37-66-86 : August 7th 2024 6.30 pm Fever Chief complaint
- 7. Pediatric Assessment Triangle Conclusion:Respiratory Distress N ABN N Appearance Tone : normal Interactiveness: normal Consolability : normal Look : normal Speech/Cry : normal Work of Breathing No abnormal breath sounds No abnormal positioning Retraction (+) Nasal flaring (+) Circulation No Pale No Mottling No Cyanosis
- 8. Primary Survey Airway Free airway,clear, patent Breathing Respiratory rate 40 times/minute, nasal flare (+), retraction (+), SpO2 99% room air Circulation Blood pressure 80/48 mmHg (TF 84-98/41-50), Pulse rate 175 beats/minute, regular, warm extremities, CRT < 2 seconds, strong palpable pulse Disability GCS E4M6V5= 15 Dehydration No sign of dehydration Exposure No Pale, No rash, no crust on the skin, GDS : 98 gr/dL
- 9. Primary Management Fever, palpebraedema, shortness of breath, pale, cough, coryza 6.30 pm GCS E4M6V5 = 15, Blood pressure 80/48 mmHg (TF 84-98/41-50), Pulse rate 175 beats/minute, Respiratory Rate 36 times/minutes, T 40 C, SpO2 99% room air, strong palpable pulse, warm extremities O2 Nasal canul 2 lpm Stopper Inj Metamizole 120 mg KP IV Inj Ceftriaxone 450 mg/12 hours IV Ambroxol 5mg/8 hours PO Check blood routine , SGOT/SGPT, Ur/Cr, Electrolyte + Calcium, PT/APTT, Albumin,HbsAg, MDT, Urine Dipstick 6.35 pm 6.40 pm
- 10. Secondary Survey AMPLE AMPLE • Allergy: None • Medication : Ceftriaxone, Paracetamol, Ambroxol, Salbutamol • Past Illness : None • Last Meal : One hours before admission • Event Lead : None
- 11. Secondary Survey 4 daysbefore admission RSUDZA 2 weeks before admission • The patient has been complaining of recurring fever for two weeks before admission to the hospital. The fever has been rising and falling. 7 days before admission • Cough and runny nose for 7 days before hospital admission. The cough produced mucus that was thick and yellowish. 4 days before admission • The patient with fever. The fever is very high starting from 4 days before admission. The fever is intermittent. The fever subsides with antipyretic medication. The fever was not measured with a thermometer by parents. • Swelling in the eyelids was present for 4 days before hospital admission. • The patient complained of pallor. • No weight loss was reported. RSUDZA • The child has a high fever. The child has had two large bowel movements. • The child's eyelids are swollen. • He’s still has a cough and runny nose. • The child still looks pale. • The last urination was yellow and clear.
- 12. • No historyof pale or blood transfusion. History of Previous Illness • No history of pale and blood transfusion in patient’s family. • Father with heavy smoker Family History • Patient was born aterm, by pervaginam. Patient is 2nd child from 2 siblings with birth weight 2500 grams. Patient has no history of NICU care. Pre Natal, Natal, and Post Natal Care
- 13. • According tothe Parents, Patient have no immunization yet History Of Immunization • 0 – 6 month: Exclusive Breastmilk • 6 month – 2 years: Breastmilk and complementary food for breast milk Nutrition History • Growth : Patient grows like his other peers • Development : Patient is 1 year 2 months old. The child can stand without holding onto anything. The child can call the parents “mom” and “dad”. The child can point to an object if they want it. History of Child Growth and Development
- 14. Anthrophometry • Body Weight: 8,5 kg • Body Height : 74 cm • Head Circumferrence: cm • Arm Circumferrence : 13,5 cm (normal) • BW/Age : -2SD s/d +2SD • BH/Age : -2SD s/d +2SD • BW/BH : -2SD s/d +2SD • AC/Age : -2SD s/d +2SD • Height age : 6 months • Weight age : 8 months • Ideal body weight : 19 kg Nutritional Status: Normal Nutrition, normal stature
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- 19. PHYSICAL EXAMINATION • GCS15 (E4M6V5) Consciousness Vital Sign 16 Blood pressure : 80/48 mmHg, (TF 84-98/41-50 mmHg) Pulse : 175 beats/minute, regular Respiratory rate : 40 times/minute Temperature : 400 C Saturation : 99 % room air PELOD SCORE : 0 PHOENIX : 0
- 20. • Head :Normocephaly, • Face : Symmetrical, udema palpebra • Eyes : Conj. palpebra inferior pale, sclera not icteric, • pupil isochor (3mm/3mm), light reflexes positive • Nose : nasal flare (+), secrets (+) yelowish green • Mouth : No cyanosis • Ears : normotia, no secrets • Neck : Enlarged lymph nodes found ar coli dextra 1x1cm, imobile PHYSICAL EXAMINATION
- 21. • Thorax • Anterior: Inspection: Symmetrical, retraction epigastrial (+) Auscultation : Vesicular ↓ upper right lobe, ronkhi positive and no wheezing • Posterior: Inspection : Symmetrical Auscultation: Vesicular, ronkhi positive and no wheezing PHYSICAL EXAMINATION
- 22. Cor • Inspection :Ictus cordis not seen • Palpation : Ictus cordis palpable on ics 5 linea midclavicula sinistra • Auscultation: S I > SII, Reguler, no murmur PHYSICAL EXAMINATION
- 23. Abdomen • Inspection :Symmetrical • Palpation : Soepel, ascites +, shifting dullnes +, enlarged hepar 3 cm BAC • Auscultation : Normal peristaltic Extremities • Superior : no cyanosis, warm, CRT < 2 seconds • Inferior : no cyanosis, warm, CRT < 2 seconds •Skoring TB 2 PHYSICAL EXAMINATION
- 24. Hematology RSUDZA (7/8/24)Normal Value Hemoglobin 8.0 12,5-14,5 gr/dl Hematokrit 25 45-55 % RBC 3.3 4.7-6.1x106 / mm3 WBC 10.99 4.5-10,5 103 /mm3 Platelets 159 150-450 /103 mm3 Eosinofil 0 0-6 % Basofil 0 0-2 % N. Bands forms 0 2-6 % N. Granulocytes 53 50-70 % Limfosit 39 20-40 % Monosit 8 2-8 % MCV 76 80-100 fl MCH 25 27-31 pg MCHC 32 32-36 % RDW 14.6 11,5-14,5 % LABORATORY
- 25. Hematology RS Cut Meutia RSUDZA(8/11/23) Normal Value SGOT 184 <35 U/L SGPT 67 <45 U/L albumin 2,95 3,5-5,2 g/dL Ureum 10 13-43 mg/dL Creatinin 0.89 0.67-1.17 mg/dL GFR 90 (↓52%) 102.5-150.5 Natrium 134 132-146 mmol/L Kalium 4.1 3.7-5.4 mmol/L Clorida 102 98-106 mmol/L Mentzer Index 23 HBsAg Negative Negative LABORATORY
- 26. Urine Dipstick Leukosit negatif Nitritnegatif Urobilinogen negatif Protein +1 pH 6,5 Blood negatif SG 1,010 Keton negatif Bilirubin negatif Glukosa negatif
- 27. Thorax X-Ray Suggest : Pulmo:Homogeneous consolidation is seen in the right suprahilary, with an air bronchogram + Cor: CTR 50%
- 28. Acute Kidney Injuryec dd/ 1.Glomerulonephritis ec infection 2.Nephrotic Syndrome Lobaris Pneumonia Micrositer Hypocrom Anemia ec dd/ 1. Fe Deficiency 2. Chronic Disease 3. Infection Elevated Liver Enzyme ec dd/ 3. Sepsis 4. Viral Infection Hypoalbuminemia Incomplete Immunization Differential Diagnose
- 29. 1. Acute KidneyInjury ec GNA N17.9 2. Lobaris Pneumonia J18.1 3. Iron Deficiency Anemia D50.9 4. Elevated Liver Enzyme ec Sup Sepsis R74.01 5. Hypoalbuminemia R77.0 6. Incomplete Immunization Z28 Working Diagnose
- 30. Diagnose Goals Intervention/Treatment Acute KidneyInjury Treat the infection maintain fluid balance • Fluid balance • Workup etiology: urinalisa, ASTO, usg trc urinarius Pneumonia Treat the infection • Ceftriaxone 450mg/12 jam • Oksigen 2 lpm/min Micrositer Hypocrom Anemia HB > 10 mg/dL • Workup anemia: SI TIBC Feritin Reticulosit Elevated Liver Enzyme ec Sup Sepsis Enzyme liver normal Treat infection • Curcuma 1x1 tab • Work up sepsis: Sputum culture, blood culture, Urinalisa, urin culture, CRP, Procalcitonin Hypoalbuminemia Albumin > 3.5 • Albumin 20% ~ 40 cc Mild Malnutrition Nutrional diet according to the patients age, weight and age • Fluids : 1230 cc/days • Calories : 1368 Kkal • Protein : 32,7 gr/days Incomplete Immunization Catch up immunization • Pentabio 4x, IPV 1x, OPV 4x, MR, PCV 2x Treatment
- 31. PLANNING • Main Division: Nefrologi Division • Admitted in Room • Sputum culture, blood culture, Urinalisa, urin culture, ASTO, CRP, Procalcitonin • Work up anemia: SI TiBC Feritin Retikulosit • Usg abdomen & tractus urinarius • Monitoring diuresis • Monitoring work of breathing and saturation • Catch up immunization • Consul Respirology • Consul GEH • Consul HOP
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- 34. Follow up thismorning S/ no vomiting, fever ever still goes up and down, and no seizure O/ conc : Compos Mentis BP : 90/55 mmHg (TF 93-105/50-62 mmHg) Pulse : 102 beats/ minutes RR : 35 times / minutes Temp. : 37,4 C SpO2. : 98% oksigen intermitten
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