Adam Md/Fatma MD

Eddy MD/Dian MD/Lucky MD

Cempaka MD/Sandi MD
Debby MD/Prabu MD
 PATIENT ADMISSION
Melati 2
-
HCU Neonatus
1. Baby Mrs S, a boy, 0 day, 3300 grams, with potentially infected,
moderate asphyxia ec hypotermia, caput succadaneum, a neonate,
boy, with normal birth weight and appropriate for gestational age,
born sectio secaria due to fetal hypoxia, premature rupture of
membrane for 24 hours

NICU
-
HCU Melati 2
-
PICU
-
 IDENTITY

Name : Baby Mrs. S

Age/W/L : 0 day/ 3300 grams / 49 cm
Sex/Gender : Boy
Address : Sukoharjo, Jawa Tengah
Medical : 01381025
Record
CHIEF COMPLAINT
Newborn
 THE CURRENT MEDICAL HISTORY

The patient was born from a 36 years old mother

G2P1A0 with 39 weeks of gestational age. The mother of the
patient came to hospital with chief complaint of premature
rupture of membrane for 24 hours. The mother of the
patient than get examined with result blood pressure 130/80
mmHg.
The baby was born with 3300 gram of birth weight, crying
mildly, looked reddish, greenish amniotic, didnt smell fishy.
Apgar score 5-7-9.
 THE PAST MEDICAL HISTORY

24 hours before labour, the mother had uterus

contraction and vaginal discharge, then she took
to nearby hospital. There were no fever, no pain in
urinating, and breaking of the mother's water.
 HISTORY OF PREGNANCY AND DELIVERY

Pregnancy
The baby was the second child of her family. Gestational age is 39 weeks.
The mother consumed vitamins and pills routinely from a midwife.
According to the mother, she took routine check up to the midwife
monthly. There were no history of admission to the hospital during the
course of pregnancy

Delivery
The baby was delivered by sectio secaria, due to fetal hypoxia, premature
rupture of membrane for 24 hours. There were no complication during
procedure. When he was born the baby cry mildly and looked reddish
colour on his skin. The baby weighed at 3300 grams and 49 cm in length.

Conclusion : pregnancy was normal, delivery history was

abnormal 7
 VACCINATION HISTORY

Hepatitis B :-

Conclusion : The baby hasnt got the vaccine yet

8
 PEDIGREE (FAMILY TREE)

II
37th 36th

III

0 day, 3300 grams

 NUTRITIONAL STATUS

BB/U : 3.3/3,3 x 100% = 100% % (Z score = 0 SD)

Normoweight
TB/U : 49/50 x 100% = 98% (-2 SD < Z score < 0 SD)
Normoheight
BB/TB : 3.3/3.2 x 100% = 100% (0 SD < Z score < 2 SD)

Conclusion : well nourished, normoweight, normoheight

 PHYSICAL EXAMINATION
Issues Potentially infected, moderate asphyxia ec hypothermia, caput
succadenum
CNSI Cry vigorously (+) Active in motion (+) spontaneously open eyes (+)
Diffuse edematous on scalp +, extend across the suture line +
Assessment: S5
Cardiovascular Heart rate : 132 x/minute
System Murmur (-), capillary refill time < 2 seconds, dorsalis artery pulse (+)
Assessment: no abnormality
Respiratory Respiratory rate : 40 x/minute, Si02 : 94%
System Retraction (-)
Air entry (+) grunting (-), sianosis (-)
II Downe score (0)
Assessment : no abnormality
GIT Hepatal 39thDistended (-), defecation(-), peristaltic sound
34th (+), vomit (-), icteric (-),
System Assessment : cannot be evaluated yet
Genitourinaria Urination (-)
III
System Assessment: cannot be evaluated yet
Infection 8 thnSystem
Thermoregulation Gastrointestinal Assessment: potential
System 36,20C System (-) infection
Central nervous system 3hari
(-) /3800gram
Hematologyy System
Cardiovascular System (-) (-)
Laboratorium
Hb 11.3 g/dl
Hct 35%
AL 14.9 ribu/ul
AT 167 ribu/ul
AE 4.64 juta/ul
Golongan darah AB
GDS 120 mg/dl
HBsAg nonreactive
 PROBLEMS

A boy infant, 0 day, 3300 grams, with :

1. Born Sectio Secaria with premature rupture of the membrane for 24 hours
2. Born with APGAR Score 5-7-9
3. Amniotic fluid was greenish, no fishy odor
4. edematous on scalp +, extend across the suture line +
5. Downe score (0)
6. Temperature 36.2C
 DIFFERENTIAL DIAGNOSIS

1. Potential infection
2. Moderate asphyxia ec hypotermia,
3. Caput succadaneum,
4. Neonate, boy, with normal birth weight and
appropriate for gestational age, born sectio secaria
due to fetal hypoxia, premature rupture of
membrane for 24 hours
 WORKING DIAGNOSIS

1. Potential infection
2. Moderate asphyxia ec hypotermia,
3. Caput succadaneum,
4. Neonate, boy, with normal birth weight and appropriate
for gestational age, born sectio secaria due to fetal
hypoxia, premature rupture of membrane for 24 hours
 THERAPY

1. Rooming In HCU Neonate

2. O2 nasal 2 lpm
3. Gentamicine eye cream
4. Vitamin K inj. 1 mg IM
5. Breast milk on cue
6. Hepatitis B vaccine
7. Keep the baby warm
 PLAN

1. Septic marker (DL2, Blood Smear, I/T Ratio,

Albumin, Electrolytes)
2. Infection Observation
3. Observe Caput and Hypothermia

MONITORING

General Appearance/Vital Signs / 3 hours

Fluid balance and Diuresis / 8 hours
 Follow up 3/6/2017
Issues Potentially infected, moderate asphyxia ec hypothermia, caput
succadenum
CNSI Cry vigorously (+) Active in motion (+) spontaneously open eyes (+)
Diffuse edematous on scalp +, extend across the suture line +
Assessment: S5
Cardiovascular Heart rate : 132 x/minute
System Murmur (-), capillary refill time < 2 seconds, dorsalis artery pulse (+)
Assessment: no abnormality
Respiratory Respiratory rate : 40 x/minute, Si02 : 94%
System Retraction (-)
Air entry (+) grunting (-), sianosis (-)
II Downe score (0)
Assessment : no abnormality
GIT Hepatal 39thDistended (-), defecation(-), peristaltic sound
34th (+), vomit (-), icteric (-),
System Assessment : cannot be evaluated yet
Genitourinaria Urination (-)
III
System Assessment: cannot be evaluated yet
Infection 8 thnSystem
Thermoregulation Gastrointestinal Assessment: potential
System 36,20C System (-) infection
Central nervous system 3hari
(-) /3800gram
Hematologyy System
Cardiovascular System (-) (-)
 WORKING DIAGNOSIS

1. Potential infection
2. Moderate asphyxia ec hypotermia,
3. Caput succadaneum,
4. Neonate, boy, with normal birth weight and appropriate
for gestational age, born sectio secaria due to fetal
hypoxia, premature rupture of membrane for 24 hours
 THERAPY

1. Breast milk on cue

2. O2 nasal 2 lpm
3. Hepatitis B vaccine
4. Keep the baby warm
 PLAN

1. Septic marker (DL2, Blood Smear, I/T Ratio,

Albumin, Electrolytes)
2. Infection Observation
3. Observe Caput and Hypothermia

MONITORING

General Appearance/Vital Signs / 3 hours

Fluid balance and Diuresis / 8 hours
22