MORNING REPORT

PEDIATRI
AUGUST 3
RD
2013
IDENTITY
Name : Miss N
Age : 8 y.o
Adress : Laren Lamongan
Date : 1
st
january 2014
Chief complaint :
fever
Present illness :
Patient came to the hospital with complaint of fever since
six day before hospitalized. High fever in the first day.
Patient drunk medicine but the didint change the
temperature. Nausea (+), vomit (+) about 1-2 times a day.
Myalgia (+), headache (+), dspneu (-), gum bleeding (+),
epistaksis (-), caugh (-) urination and defecation in normal
limit.
History illness :
3 days ago hospitalized at YPPI with DHF
Family illness history :
DF (-)
Social illness history :
DF (-)
Imunitation: complete
PHYSICAL EXAMINATION
General state: weakness
GCS : 456
BP : 106 / 66 mmHg
Pulse : 78 x/minutes
RR : 24 x / minutes
Temp : 37,2C
Weight : 35 kg
Head and neck :
anemic -/- , icteric -/- , cyanosis -/- , dyspneu -/-
Thorax :
Simetric +/+ , retraction -/-
Pulmo : ves/ves , rh -/- , wh -/-
Cor : S1S2 single, murmur (-), gallop (-)
Abdomen :
Soepel, ascites(-), tympani, bowel sound(normal),
met(-)
Hepar was not palpable, Spleen was not palpable.
Extremities :
Warm, dry, red
edema -/-
CLUE AND CUE
Female, 8 y.o
Fever 6 day
Nausea
Vomit
Myalgia
Headache
Gum bleeding



assesment
Probable dengue with warning sign gum
bleeding

PLANNING DIAGNOSIS
DL
LFT
IgG and IgM anti dengue

LABORATORY FINDINGS
Diff count :
1/0/59/26/14
Hct : 40,5
Hb : 14,1
Leucocyte : 8.800
Trombocyte : 32.000
SGOT 172
SGPT 69

anti dengue IgG
positif
Anti dengue Ig M
negatif
PLANNING THERAPY
IVFD Asering1500cc/24
jam
Inj. Rantidin 2x35mg
Drip cernevit 1x1/2 vial
Consult w/ internist



PLANNING MONITORING
Vital Sign
Patient complaint
PLANNING EDUCATION
Explain to the patien and his family about the
disease, cause, complication, intervention of
the therapy and prognosis.