35

CHAPTER 3
CASE REPORT
History taking
:
Chief complaint
: Shortness of breath
A male newborn, named DNM, was admitted to the neonatal unit at General Hospital
Haji Adam Malik Medan (RSUP HAM) on June 9, 2015 with shortness of breath as
the chief complaint. The neonate was born on the same day, about one hour before
admission to the hospital with gestational age = 30-32 weeks. This complaint had
been experienced since delivery with no history of bluishness. When admitted, the
newborn had weak cry, less of activity, and weak suckle. Urinate (+) normal.
Meconium hadnt been yet excreted.
History of pregnancy : the neonate is the first baby born to the 20-year-old mother.
History of diabetes (-), gestational diabetes (-), hypertension (-), fever during
pregnancy (-), PROM (-). History of mother with fever (-), herb & medication use
(-).
History of delivery

: the neonate was born spontaneously outside RSUP HAM,

helped by a midwife and immediately crying. Birth weight (BW) = 1860 gr, birth
length (BL) = 37 cm, birth head circumference = 29 cm. APGAR score was unclear.
Vitamin K injection was unclear.
Physical examination
:
Sensorium
: compos mentis
Temperature : 36.5C
present BW : 1860 gr
present BL
: 37 cm
Anemia (-)
Jaundice (-) Cyanosis (-) Dyspnea (+) Edema (-)
Downe Score = 6
CNS system
: stable
Head : anterior fontanelle is still palpable. Head circumference = 29 cm.
Eye : light reflex (+) normal, isochoric pupils 3mm/3mm
Ear
: within normal limit
Nose : nasal flare (+) found
Mouth : oral gastric tube (+) attached
Primitive reflex (+)
Respiratory system : unstable
CPAP (+) attached with FiO2 = 25%, PEEP = 6,
flow = 8L/ min, Sp. O2 = 93-95%
Respiratory rate = 72 times/ min, regular, rales (-)
Cardiovascular system: unstable

36

Heart rate = 180 times/ min, regular, murmur (-)

Pulse rate = 180 times/ min, regular, P/V adequate
Periphery : warm extremities (+), edema (-), CRT <3 secs.
Metabolic system
: stable
Blood glucose = 54 gr/ dL
Abdomen : tender, peristaltic movement (+) normal,
liver/ spleen = impalpable
Hematologic system : unstable
Pale (-), bleeding (-)
Laboratory findings : Hb/ Ht/ PLT = 14.4/ 43.8/ 234000
Infection system
: stable
New Ballard Score : 30- 32 weeks
Lubchenco Curve
: appropriate for gestational age (AGA)
Laboratory Findings :
Hematology (June 9th, 2015)
Test
CBC

Result

Unit

Referral

Hemoglobin
Erythrocyte
Leucocyte
Thrombocyte
Hematocrite
MCV

14.4
4.18
10.85
234
43.80
104.80

g%
106/mm3
103/mm3
103/mm3
%
fL

13.4-19.8
4.71-5.14
9.3-30.
150-450
51-65
85-95

MCH

34.40

pg

28-32

MCHC

32.90

gr%

33-35

RDW

14.30

11.6-14.8

MPV

9.50

fL

7.0-10.2

PCT

0.22

PDW

10.2

fL

0.60
0.400
50.90
40.30
7.80
5.53
4.37
0.85
0.06
0.04

%
%
%
%
%
103/L
103/L
103/L
103/L
103/L

Differential
Eosinophil
Basophil
Neutrophil
Lymphocyte
Monocyte
Neutrophil absolute
Lymphocyte absolute
Monocyte absolute
Eosinophyl absolute
Basophyl absolute

1-6
0-1
37-80
20-40
2-8
5.5-18.3
2.8-9.3
0.5-1.7
0.02-0.70
0.1-0.2

37

ABG Analysis, Blood Glucose (June 9th, 2015)

Test
ABG

Result

Unit

Referral

pH

7.292

pCO2

38.9

mmHg

38-42

pO2

170.7

mmHg

85-100

HCO3-

18.4

mmol/L

22-26

Total CO2

19.6

mmol/L

19-25

Base excess

-7.6

mmol/L

(-2)- (+2)

Sp. O2
Blood Glucose

99.3
79.7

7.35-7.45

%
mg/dL

< 200

Diagnosis
:
Respiratory distress ec. DD/ - Hyaline Membrane Disease
-

Neonatal pneumonia

Suspect of neonatal sepsis

Low birth weight (LBW)
Preterm newborn- appropriate for gestational age (AGA)
Treatment

CPAP with FiO2 = 25%, PEEP = 6, O2 Flow = 8L/min, SpO2 = 93-95 %

Total fluid requisite = 80 cc/kgBW/day = 148.8 cc/day, consisting of:
o Parenteral = 80 cc/kgBW/day = 148.8 cc/day
IVFD D10% + Ca. Gluconas 10 cc 6 cc/ hour
o Enteral = diet is ceased for a while
- Vit. K injection 1 mg (IM)
- Cefotaxime injection 90mg/12 hrs (IV)
- Gentamycine injection 9mg/ 36 hrs (IV)
Planning
:
NaCl 0.9% loading 10cc/kgBW= 20cc (immediately), ABG analysis, BG test
Follow-up

38

June 10th 2015

S
O

Shortness of breath (+)

CNS system
: stable
Head : anterior fontanelle is still palpable, sensorium :CM
Eye : light reflex (+) normal, isochoric pupils 3mm/3mm
Ear
: within normal limit
Nose : nasal flare (+) found
Mouth : oral gastric tube (+) attached
Primitive reflex (+)
Respiratory system : unstable
CPAP (+) attached with FiO2 = 25%, PEEP = 6,
flow = 8L/ min, Sp. O2 = 90-98%
Respiratory rate = 68 times/ min, regular, rales (-)
Cardiovascular system: unstable
Heart rate = 128 times/ min, regular, murmur (-)
Pulse rate = 128 times/ min, regular, P/V adequate
Periphery : warm extremities (+), edema (-), CRT <3 secs.
Metabolic system
: stable
Abdomen : tender, peristaltic movement (+) normal,
liver/ spleen = impalpable
Hematologic system : unstable
Pale (-), bleeding (-)
Laboratory finding : Hb/ Ht/ PLT = 14.4/ 43.8/ 234000
Infection system

: unstable

Procalcitonin = 0.22
Respiratory distress ec. DD/ - Hyaline Membrane Disease
-

Neonatal pneumonia

Suspect of neonatal sepsis

Low birth weight (LBW)
Preterm newborn- appropriate for gestational age (AGA)
- CPAP with FiO2 = 25%, PEEP = 6, O2 Flow = 8L/min, SpO2 = 90-98 %
- Total fluid requisite = 100 cc/kgBW/day = 180 cc/day, consisting of:
o Parenteral = 100 cc/kgBW/day = 180 cc/day
IVFD D5% NaCl 0.225% (430 cc) + D40% (70 cc) + KCl 10 mEq + Ca.
Gluconas 10 cc 124 cc/ day 5 cc/ hour
o Enteral = trophic feeding 10 cc/ kg BW/ day 18.6 cc/ day
Breastfeeding 1.6 cc/ 2 hours
- Cefotaxime injection 90mg/12 hrs (IV)
- Gentamycine injection 9mg/ 36 hrs (IV)
Planning
:
Septic work-up, blood culture, chest x-ray

39

June 11th 2015

S
O

Shortness of breath (+)

CNS system
: stable
Head : anterior fontanelle is still palpable, sensorium :CM
Eye : light reflex (+) normal, isochoric pupils 3mm/3mm
Ear
: within normal limit
Nose : nasal flare (+) found
Mouth : oral gastric tube (+) attached
Primitive reflex (+)
Respiratory system : unstable
CPAP (+) attached with FiO2 = 25%, PEEP = 6,
flow = 8L/ min, Sp. O2 = 85-95%
Respiratory rate = 65 times/ min, regular, rales (-)
Cardiovascular system: unstable
Heart rate = 125 times/ min, regular, murmur (-)
Pulse rate = 125 times/ min, regular, P/V adequate
Periphery : warm extremities (+), edema (-), CRT <3 secs.
Metabolic system
: stable
Abdomen : tender, peristaltic movement (+) normal,
liver/ spleen = impalpable
Hematologic system : unstable
Pale (-), bleeding (-)
Laboratory finding : Hb/ Ht/ PLT = 14.4/ 43.8/ 234000
Infection system
: unstable
Respiratory distress ec. DD/ - Hyaline Membrane Disease
-

Neonatal pneumonia

Suspect of neonatal sepsis

Low birth weight (LBW)

Preterm newborn- appropriate for gestational age (AGA)

- CPAP with FiO2 = 25%, PEEP = 6, O2 Flow = 8L/min, SpO2 = 85-95 %
- Total fluid requisite = 100 cc/kgBW/day = 180 cc/day, consisting of:
o Parenteral = 100 cc/kgBW/day = 180 cc/day
IVFD D5% NaCl 0.225% (430 cc) + D40% (70 cc) + KCl 10 mEq + Ca.
Gluconas 10 cc 124 cc/ day 5 cc/ hour
Aminosteril 6% 1 gr/kg BW/ day = 31 cc/ day 1.3 cc/ hour
o Enteral = trophic feeding 10 cc/ kg BW/ day 18.6 cc/ day
Breastfeeding 1.6 cc/ 2 hours
- Cefotaxime injection 90mg/12 hrs (IV)
- Gentamycine injection 9mg/ 36 hrs (IV)
June 11th 2015:

40

Chest x-ray finding

: ground glass appearance, air bronchogram, and mild

atelectasis

June 12th 2015

S
O

Shortness of breath (+)

CNS system
: stable
Head : anterior fontanelle is still palpable, sensorium :CM
Eye : light reflex (+) normal, isochoric pupils 3mm/3mm
Ear
: within normal limit
Nose : nasal flare (+) found
Mouth : oral gastric tube (+) attached
Primitive reflex (+)
Respiratory system : unstable
Respiratory rate = 43 times/ min, regular, rales (-), Sp. O2 = 90-100%
Chest retraction (+)
Cardiovascular system: unstable
Heart rate = 132 times/ min, regular, murmur (-)
Pulse rate = 132 times/ min, regular, P/V adequate
Periphery : warm extremities (+), edema (-), CRT <3 secs.
Metabolic system
: stable
Abdomen : tender, peristaltic movement (+) normal,
liver/ spleen = impalpable
Hematologic system : unstable
Pale (-), bleeding (-)
Laboratory finding : Hb/ Ht/ PLT = 14.4/ 43.8/ 234000
Infection system

: stable

Fever (-), temp = 36.6C

Respiratory distress ec. Hyaline Membrane Disease
Suspect of neonatal sepsis
Low birth weight (LBW)
Preterm newborn- appropriate for gestational age (AGA)
- Total fluid requisite = 130 cc/kgBW/day = 265 cc/day, consisting of:
o Parenteral = 90 cc/kgBW/day = 191 cc/day
IVFD D5% NaCl 0.225% (430 cc) + D40% (70 cc) + KCl 10 mEq + Ca.
Gluconas 10 cc 5.3 cc/ hour
Aminosteril 6% 2 gr/ kg BW/day3.72 gr=62 cc/ day2.6 cc/hour
o Enteral = 40 cc/ kg BW/ day 74 cc/ day
- Cefotaxime injection 90mg/12 hrs (IV)
- Gentamycine injection 9mg/ 36 hrs (IV)