MORNING REPORT

FRIDAY, AUG 11 T H 2018

dr.Anto / dr.Susi / dr.Winda / dr.Mitha / dr.Cempaka

dr.Rahmi / dr.Nunki
dr.Kiki / dr.Tatag

1
 PATIENT ADMISSION

• MELATI 2 :-
• HCU NEONATUS : -
• NICU :-
• HCU MELATI 2 :-
• PICU :-
• VIP:
1. M, 15yo, 76kgs, ED: susp acquired heart dissease, susp rheumatic heart
dissease, AD: susp MR, FD: NYHA I, hypertension stage 2 due to essential
dd secondary, overweight
2. D, 8 yo, 25kgs, acute diarrhea with mild moderate dehidration due to
ETEC dd EIEC, acute tonsilopharyngitis, well nourished

2
 PATIENT IDENTITY

• Name :M
• Sex : Male
• Age : 15 years old
• W/H : 76 kgs / 157 cm
• Address : Wonokarto
• Medical Record : 01156096

3
CHIEF COMPLAINT

Chest pain

4
 PRESENT MEDIAL HISTORY

1 day before admission

• Headace, around the patient like spinning
• Tinitus, pain on ear (-)
• Patient lose conciousness  rest  fully alert
• Vomit, 3-4 times, yellowish colour, ±1 tsp every vomit
• Go to Wonogiri General Hospital

5
 PRESENT MEDIAL HISTORY

• On Wonogiri Hospital ER :
• fully alert
• cold sweat
• headache
• vomit 4 times: yellowish, @ 1 tsp
• Chest pain, like got heavy goods in chest
• Tingling, move from hand, abdominal until leg  CT Scan : normal;
Lab result: Hb 14.1 mg/dl, Ht 43.3%, Leucocyte 14.400/ul, trombocyte
401.000/ul; ECG: RBBB ; chest x ray : enlargement of heart
• Got asering, Amoxicilin inj, Norages inj, Ranitidine inj, Ondancentrone
inj
• Lack of facilities  Reffered to Dr.Moewardi Hospital
6
 PRESENT MEDIAL HISTORY

On Dr.Moewardi Hospital ER :
• Fully alert
• Chest pain (-)
• Breathlessness (-)
• Headache (-)
• Vomit (-)
• Blurred vision (-)
• Tingling (+) right leg
• Urination and defecation within normal limit
7
 PAST MEDICAL HISTORY

• History of fever : (+) 0-3 years old

• History of sinusitis : (+) maxillaris since 1 year ago, got Avamys
• History of hospitalized : (+) fever from 0-3 yo
(+) chest pain 3 days ago when got physical
exercise, but gone itself

8
 FAMILY MEDICAL HISTORY

• History of heart dissease : denied

• History of hypertension : (+) uncle

9
 HISTORY OF PREGNANCY AND DELIVERY

Pregnancy

• This is the first pregnancy of his mother(G1P0A2). Gestational age was 39

weeks. The mother never consumed “jamu” or drug, only consumed vitamins
and pills that routinely given by obstetrician. She routinely check up to
obstetrician. There was history of vaginal bleeding and viral infection during
pregnancy. The mother got antiviral drug until 7 months of pregnancy.
Delivery
• The baby boy was born by caesarian section delivery due to prolonged
delivery and cord loop. No premature rupture of membrane. When he was
born, baby was cried loudly. The baby weight is 3000grams, lenght= 50 cm,
HC= 32 cm, with APGAR score 8-9-10

Conclusion: pregnancy and delivery history was abnormal

 VACCINATION HISTORY

• BCG : 1 month
• Hepatitis B : at birth
• DPT-HB-HiB : 2, 3, 4, 18 months
• Polio : 1, 2, 3, 4 month
• Measles : 9, 18 months
• MR : 15 years

• Conclusion : complete immunization, according to Ministry

of Health’s schedule 1999
11
 NUTRITION HISTORY

Patient eats rice and side dish, but little vegetable 2-3 times a day in 1 portion. Patient
usually eat “gorengan” and “jeroan” from 1 year ago

Conclusion : quality and quantity of nutrition are adequate

Growth and Development

Patient started to walk and speak when he is 2 yo. He is now 15 years old and
able to do activities like his friend, he can follow studies well.
Her weight is 76 kg and her height is 157 cm
Conclusion: growth and development is abnormal

12
 NUTRITIONAL STATUS

• Weight for Age : 76 / 56 x 100% = 135.7%

p90 < W/A < p95
• Heigth for Age : 157 / 170 x 100% = 92.3%
p5 < H/A < p10
• Weight for Length : 76 / 56 x 100% = 135.7%

Conclusion: overweight, normoheight 13

 FAMILY TREE

II

II
I

M, 15 yo, 76 kgs

14
 PHYSICAL EXAMINATION

• General appearance : moderate illness, fully alert

• Vital sign :
• Heart Rate = 82 bpm S D
• Respiration rate = 24 bpm p95 132 86
• Temperature = 36.6 0C p99+5 140 94
• O2 saturation = 99 % HC ≥180 ≥120

• BP = 140/90mmHg

15
Head : mesocephal
Eyes : pale conjunctiva (-/-), icteric conjunctiva(-/-)
light reflexes (+/+), isochoric pupil 3 mm/3mm
Nose : nasal flare (-/-),discharge (-/-)
Mouth : lips and tongue cyanotic, moist lips mucosa (+),
tonsil T0-T0 hyperemic (-)
Neck : no enlargement of lymph node

16
 LUNG:
• I : normal, symmetric
• P : fremitus right = left
• P : sonor in both lung
• A : vesicular breath sound(+/+) additional breath sound (-),
coarse -/- crackles -/- wheezing -/-

CARDIAC:
• I : ictus cordis not visible
• P : ictus cordis palpable at SIC IV
• P : cardiac enlargement to right lateral
• A : 1st 2nd Heart sound normal intensity, regular, wide split
2nd Heart sound, murmur (+) holosistolic, MP on SIC II-III
LPSS, grade II/VI, gallop (-)
17
ABDOMINAL:
I : abdominal wall // thorax wall
A : peristaltic sound (+) normal
P : tympani
P : tenderness (-), no enlargement of the liver and spleen

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis pedis
artery was strong
clubbing finger -/- cyanotic -/- edema -/-
-/- -/- -/-

18
 Laboratory Findings (July 22th 2018)
Value Reference Units
Hemoglobin 14.3 12,3-15.3 g/dl
Hematocrit 43 33-45 %
Leucocyte 8.8 4.5-14.5 x103/ul
Thrombocyte 379 150-450 x103/ul
Erythrocyte 4.57 3.8-5.8 x106/ul
RBG 98 60-100 mg//dL
Ureum 1 0.5-1 mg/dl
Creatinine 17 < 48 mg/dl
Sodium 130 129-147 mmol/L
Kalium 3.2 3.1-5.1 mmol/L
Chloride 103 98-106 mmol/L

Conclusion :
Within normal limit
19
 ECG

Conclusion :
1. RVH, T inverted in V1, III  ischemic miocard on right precordial 20
2. Incomplete RBBB
 PROBLEM LISTS
M, 15 years old, 76 kgs with:
Medical history
• Headace, around the patient like spinning
• cold sweat
• vomit 4 times: yellowish, @ 1 tsp
• Chest pain, like got heavy goods in chest
• Tingling, move from hand, abdominal until leg  CT Scan : normal; Lab result: Hb 14.1
mg/dl, Hct 43.3%, Leucocyte 14.400/ul, thrombocyte 401.000/ul; ECG: RBBB ; chest x ray :
enlargement of heart
• Tingling (+) right leg
• History of sinusitis : (+) maxillaris since 1 year ago, got Avamys
• History of hospitalized : (+) fever from 0-3 yo
(+) chest pain 3 days ago when got physical
exercise, but gone itself
• History of hypertension : (+) uncle 21
 PROBLEM LISTS
M, 15 years old, 76 kgs with:
Physical exam
• History of hypertension : (+) uncle
• Cardiac exam: cardiac enlargement to right lateral; 1st 2nd Heart sound normal intensity,
regular, wide split 2nd Heart sound, murmur (+) holosistolic, MP on SIC II-III LPSS, grade
II/VI, gallop (-)

Other exam:
• ECG: 1. RVH, T inverted in V1, III  ischemic miocard on right precordial
2. Incomplete RBBB

22
 DIFFERENTIAL DIAGNOSIS

1. ED: susp acquired heart dissease, susp rheumatic heart dissease

AD: susp MR
FD: NYHA I
2. Hypertension stage 2 due to essential dd secondary

23
 WORKING DIAGNOSIS

1. ED: susp acquired heart dissease, susp rheumatic heart dissease

AD: susp MR
FD: NYHA I
2. Hypertension stage 2 due to essential dd secondary
3. Overweight

24
 THERAPY

1. Admitted to VIP Cendana

2. O2 nasal canul 1 lpm
3. Diet heart II 2000kcal/day, low salt 1gr/day
4. IVFD D5½NS 20dpm macro (maintenance)
5. Furosemide inj 20mg/12 hr iv
6. Captopril 12.5mg/12hr po

25
 PLAN

• ECG morning evaluation

• Echocardiography (13/08/2018)

MONITORING

• General appearance/Vital signs/Blood Pressure/Saturation/8 hours

• Fluid balance & diuresis/8hr
• ECG / day
26
FOLLOW UP

27
 SATURDAY, AUG 11 T H 2018

S : chest pain (-), Tingling (+) right leg

O:
• General appearance : moderate illness, fully alert
• Vital sign :
• Heart Rate = 84 bpm
S D
• Respiration rate = 22 bpm
p95 132 86
• Temperature = 36.7 C0
p99+5 140 94
• O2 saturation = 99 % HC ≥180 ≥120
• BP = 140/90mmHg

28
Head : mesocephal
Eyes : pale conjunctiva (-/-), icteric conjunctiva(-/-)
light reflexes (+/+), isochoric pupil 3 mm/3mm
Nose : nasal flare (-/-),discharge (-/-)
Mouth : lips and tongue cyanotic, moist lips mucosa (+),
tonsil T0-T0 hyperemic (-)
Neck : no enlargement of lymph node

29
 LUNG:
• I : normal, symmetric
• P : fremitus right = left
• P : sonor in both lung
• A : vesicular breath sound(+/+) additional breath sound (-),
coarse -/- crackles -/- wheezing -/-

CARDIAC:
• I : ictus cordis not visible
• P : ictus cordis palpable at SIC IV
• P : cardiac enlargement to right lateral
• A : 1st 2nd Heart sound normal intensity, regular, wide split
2nd Heart sound, murmur (+) holosistolic, MP on SIC II-III
LPSS, grade II/VI, gallop (-)
30
ABDOMINAL:
I : abdominal wall // thorax wall
A : peristaltic sound (+) normal
P : tympani
P : tenderness (-), no enlargement of the liver and spleen

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis pedis
artery was strong
clubbing finger -/- cyanotic -/- edema -/-
-/- -/- -/-

31
ECG EVALUATION on AUG 11TH 2018

32
 WORKING DIAGNOSIS

1. ED: susp acquired heart dissease, susp rheumatic heart dissease

AD: susp MR
FD: NYHA I
2. Hypertension stage 2 due to essential dd secondary
3. Overweight

33
 THERAPY

1. O2 nasal canul 1 lpm

2. Diet heart II 2000kcal/day, low salt 1gr/day
3. IVFD D5½NS 20dpm macro (maintenance)
4. Furosemide inj 20mg/12 hr iv
5. Captopril 12.5mg/12hr po

34
 PLAN

• ECG morning evaluation

• Echocardiography (13/08/2018)

MONITORING

• General appearance/Vital signs/Blood Pressure/Saturation/8 hours

• Fluid balance & diuresis/8hr
• ECG / day
35
 SUNDAY, AUG 12 T H 2018

S : chest pain (-), tingling (+) right leg

O:
• General appearance : moderate illness, fully alert
• Vital sign :
• Heart Rate = 84 bpm
S D
• Respiration rate = 22 bpm
p95 132 86
• Temperature = 36.7 C
0
p99+5 140 94
• O2 saturation = 99 % HC ≥180 ≥120
• BP = 140/90mmHg

36
Head : mesocephal
Eyes : pale conjunctiva (-/-), icteric conjunctiva(-/-)
light reflexes (+/+), isochoric pupil 3 mm/3mm
Nose : nasal flare (-/-),discharge (-/-)
Mouth : lips and tongue cyanotic, moist lips mucosa (+),
tonsil T0-T0 hyperemic (-)
Neck : no enlargement of lymph node

37
 LUNG:
• I : normal, symmetric
• P : fremitus right = left
• P : sonor in both lung
• A : vesicular breath sound(+/+) additional breath sound (-),
coarse -/- crackles -/- wheezing -/-

CARDIAC:
• I : ictus cordis not visible
• P : ictus cordis palpable at SIC IV
• P : cardiac enlargement to right lateral
• A : 1st 2nd Heart sound normal intensity, regular, wide split
2nd Heart sound, murmur (+) holosistolic, MP on SIC II-III
LPSS, grade II/VI, gallop (-)
38
ABDOMINAL:
I : abdominal wall // thorax wall
A : peristaltic sound (+) normal
P : tympani
P : tenderness (-), no enlargement of the liver and spleen

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis pedis
artery was strong
clubbing finger -/- cyanotic -/- edema -/-
-/- -/- -/-

39
ECG EVALUATION on AUG 12TH 2018

40
 WORKING DIAGNOSIS

1. ED: susp acquired heart dissease, susp rheumatic heart dissease

AD: susp MR
FD: NYHA I
2. Hypertension stage 2 due to essential dd secondary
3. Overweight

41
 THERAPY

1. O2 nasal canul 1 lpm

2. Diet heart II 2000kcal/day, low salt 1gr/day
3. IVFD D5½NS 20dpm macro (maintenance)
4. Furosemide inj 20mg/12 hr iv
5. Captopril 12.5mg/12hr po

42
 PLAN

• ECG morning evaluation

• Echocardiography (13/08/2018)

MONITORING

• General appearance/Vital signs/Blood Pressure/Saturation/8 hours

• Fluid balance & diuresis/8hr
• ECG / day
43
 MONDAY, AUG 13 T H 2018

S:
O:
• General appearance : moderate illness, fully alert
• Vital sign :
• Heart Rate = 84 bpm
S D
• Respiration rate = 22 bpm
p95 132 86
• Temperature = 36.7 C
0
p99+5 140 94
• O2 saturation = 99 % HC ≥180 ≥120
• BP = 140/90mmHg

44
Head : mesocephal
Eyes : pale conjunctiva (-/-), icteric conjunctiva(-/-)
light reflexes (+/+), isochoric pupil 3 mm/3mm
Nose : nasal flare (-/-),discharge (-/-)
Mouth : lips and tongue cyanotic, moist lips mucosa (+),
tonsil T0-T0 hyperemic (-)
Neck : no enlargement of lymph node

45
 LUNG:
• I : normal, symmetric
• P : fremitus right = left
• P : sonor in both lung
• A : vesicular breath sound(+/+) additional breath sound (-),
coarse -/- crackles -/- wheezing -/-

CARDIAC:
• I : ictus cordis not visible
• P : ictus cordis palpable at SIC IV
• P : cardiac enlargement to right lateral
• A : 1st 2nd Heart sound normal intensity, regular, wide split
2nd Heart sound, murmur (+) holosistolic, MP on SIC II-III
LPSS, grade II/VI, gallop (-)
46
ABDOMINAL:
I : abdominal wall // thorax wall
A : peristaltic sound (+) normal
P : tympani
P : tenderness (-), no enlargement of the liver and spleen

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis pedis
artery was strong
clubbing finger -/- cyanotic -/- edema -/-
-/- -/- -/-

47
ECG EVALUATION on AUG 13TH 2018

48
 WORKING DIAGNOSIS

1. ED: susp acquired heart dissease, susp rheumatic heart dissease

AD: susp MR
FD: NYHA I
2. Hypertension stage 2 due to essential dd secondary
3. Overweight

49
 THERAPY

1. O2 nasal canul 1 lpm

2. Diet heart II 2000kcal/day, low salt 1gr/day
3. IVFD D5½NS 20dpm macro (maintenance)
4. Furosemide inj 20mg/12 hr iv
5. Captopril 12.5mg/12hr po

50
 PLAN

• ECG morning evaluation

• Echocardiography today (13/08/2018)

MONITORING

• General appearance/Vital signs/Blood Pressure/Saturation/8 hours

• Fluid balance & diuresis/8hr
• ECG / day
51