MORNING REPORT

PEDIATRIC
January 20
th
2014
IDENTITY
Name : F
Age : 1 year 11 month
Adress : pagendingan RT 3 RW 2
kanugrahan Maduran
Date : 20
th
january 2014
Chief complaint :
dyspneu
Present illness :
Patient came to the hospital with complaint of dyspneu
since two day before hospitalized. Dsypneu continuosly
made the patient cant sleep. Dyspneu with productive
cough. The sputum cant out. Fever and seizure denial.
urination and defecation in normal limit. Patient often bite
her mouth. Everyday patient drink milk from NGT every
hour.
History illness :
a week ago hospitalized in RSML with
bronchopnemoni, cerebral palsy and epilepsy.
EEG a year ago CP
Family illness history :
epilepsy-
Social illness history : -
Imunitation: complete
History of pregnancy: normal
PHYSICAL EXAMINATION
General state: weakness
GCS : 425
Pulse : 151 x/minutes
RR : 54 x / minutes
Temp : 39,4C
Weight : 9 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 -/-, stiffness +/+
CLUE AND CUE
Male, 2 y.o
Dyspneu
Productive cough
Fever
Retraction +/+
Ronchi +/+
Wheezing +/+
Stiffness +/+


assesment
Bronchopnemoni
Cerebral palsy
Epilepsy

PLANNING DIAGNOSIS
Foto thorax
Kultur darah
Hs-CRP
IT ratio

LABORATORY FINDINGS
Diff count :
0/0/70/24/6
Hct : 36
Hb : 12
Leucocyte : 20.300
Trombocyte :
541.000
ANC: 14.210


PLANNING THERAPY
O2 nasal 2 lpm
IVFD kaen 1B 900cc/24
jam
Inj. Rantidin 2x10mg
Paracetamol 100 mg
Cefotaxim 3x225mg
Inj metamizole 10mg
Inj neurotam 3x150mg
As valproat 2x1



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.