CHAPTER 1

CASE REPORT

1. Identification of Patients

Name: Baby of Mrs. S

Female gender

Age / Date of Birth: 4 day / 23 October 2015

Address: Perbalan Semarang

Sign RSDK: 24 October 2015

No. CM: C556501

Ward: NICU

Mother's Name: Mrs. S

Age: 40th

Education: elementary school

Occupation: self-employed

Father's Name: Mr. P

Age: 42th

Education: elementary school

Occupation: self-employed

2. Basic Data

2.1 History

Alloanamnesis with the father and mother of the patient and medical record on

October 28th 2015, at 12.00 pm in room NICU

Main complaints: Referral newborns with severe asphyxia

History of present illness

On 23 October 2015 at 20.30 born baby girl from Mother P3A0, 38 weeks pregnant,

40 years, ANC (+) in Sp.OG, antenatal bleeding (-), Mother had a hystory of gestational

disease, Hipertension (+), DM (+), consumption outside of prescription drugs (-), a history of

herbal drink (-), a history of abortion (-), a baby girl born in SCTP in RS Tugu on

indications severe preeclampsia, fetal distress, and polyhidramnion, at birth the baby didn’t

immediately cry, APGAR Score 1-2-3, BBL 3500 gram, ASI (+), manual delivery of the

placenta 15 minutes after delivery, complete cotyledons, no infarct, no hematom. History

injection of vitamin K (+), the baby was referred to RSDK for reasons of infant severe

asphyxia. when the baby arrived in the ER RSDK, the baby experienced apnea, looked bluish,

and HR was 68x/minute then performed intubation and CPR, after CPR the baby breathe

spontaneously. and HR increased by more than 100x / min, the baby have experienced shock

2

given 0.9% NaCl bolus of 20 cc / kg and drip bobutamin 5 mcg / kg / min. Patients

programmed to do babygram, routine blood test, blood sugar when, urea, creatinine, sodium,

potassium, calcium and blood gas analysis. Attach the pipe orogastrik then flowed, then the

patient was transferred to the NICU, the patient is placed in an incubator and installed

monitors and ventilators with RR 25 mode, PEEP 5, PIP 15, FiO 2 of 60%. Patient's general

condition is still less active, looking limp and not crying. Ampicillin injection of 175 mg/12 h,

intravenous injection of gentamycin 20mg/24 jam , intravenous drip of dopamine 5 mcg / kg /

min.

2.2 Family History

- No family members or people in the neighborhood around the house sick like this

- No member of the family with a history of congenital heart disease, shortness of birth, blue

birth

- No member of the family with a history of birth defects

2.3. Socioeconomic history

Father and mother worked as a self-employed (the shop owner). Earnings per month

on average Rp 2.000.000,00. The cost of treatment by using non PBI BPJS.

Impression: lack of socioeconomic

3. Special Data

3.1 History of prenatal, natal, postnatal:

Prenatal: Mother G3P2A0 38 weeks pregnant, antenatal care regular 7 times in

doctor, immunization TT 2 times. A history of vaginal discharge during pregnancy denied, a

history of fever during pregnancy denied, denied a history of bleeding during pregnancy,

denied a history of trauma, history of herbal drink, drugs, and alcohol is undeniable.

Natal: Birth mothers 38 weeks pregnant P3A0, born SCTP helped SpOG on

indications severe preeclampsia, fetal distress, and polyhidramnion,500 grams birth weight,

body length 50 cm, birth indirect cry, jaundice (-).

Postnatal: After birth 1 day ago referred to RSDK because of severe asfixia

3.2 History of Eating and Drinking

Age 0 days giving breast milk diet was delayed due to severe asphyxia.

1 days given breast milk through a pipe orogastrik., dieting ASI 8 x 10-15 ml.

3.3 Basic immunization history and repeatedly

Hepatitis B : not done

Polio : not done

3

BCG : not done

Impression: basic immunization has not been done.

3.5 History of Family Planning parents

Mother patients not using birth control.

4. Physical Examination (October 27, 2015)

Held on 27 october 2015 at 14:00 pm

Baby girl aged 27 days, weight 3500 grams, length50 cm.

General state: apatis, less active,spontaneous breathe

Vital signs

Blood pressure: 68/34mmHg MAP(46)

Heart rate : 107 times per minute

Breathing: 40 times per minute

Temperature: 36,2oC(axillary)

SpO2= 90%

Status internus:

• Head: Normosefali, head circumference = 32 cm, the large fontanelle = not closed, not

tensed, not obtrusived, caput succedaneum (-), cephal hematoma (-), black hair

evenly distributed, are not easily removed, scalp no abnormalities.

• Eyes: Round pupils, isokor, light reflex direct and indirect (+ / +)

• Nose: Normal form, the nostril breath (+ / +), secretions (- / -), septal deviation (-).

• Ear: Normotia, secretions (- / -), back quickly after being folded.

• Mouth : ET is attached, Cyanosis (-), trismus (-), labiopalatognatoschizis (-)

• Thorax

Lung :

• Inspection: hemithoraks dextra and the left symmetrically on

a state of inspiration and expiration, epigastric retraction (-)

• Palpation: not examined

• Percussion: not examined

• Auscultation: vesicular breath sounds (+ / +), additional breath sounds (- / -)

Heart :

• Inspection: ictus cordis invisible pulsation

• Palpation: ictus cordis was not palpated

• Percussion: not examined

• Auscultation: heart sounds I - II regular pure, murmur (-), gallops (-)

Abdomen

• Inspection: flat

4

• Auscultation: bowel (+) 1 times per minute

• Palpation: sociable, liver and spleen not palpable enlarged

• Percussion: timpani in the entire quadrant of the abdomen

• Spine

There does not appear deformities, spina bifida (-), meningokel (-)

• Genitalia and anorectal

Female gender, partially covering the labia majora labia minora, anus (+) no

abnormalities.

• Skin

There does not appear efloresensi meaningful, jaundice (-), pale (-), coloring

mekoneum (-)

• Extremities

Superior Inferior

Deformity - / - - / -

Akral Cold - / - - / -

Acral cyanosis - / - - / -

Jaundice - / - - / -

CRT <2 " <2"

Tonus Normotonus Normotonus

5. HEMATOLOGY (October 27th, 2015)Examination Result Unit Normal value Description Hematology PackageHemoglobin 17.9 g% 13.6 - 19.6Hematocrit 53.7 % 44 - 62Erythrocytes 5.98 million/mmk 3.9 – 5.9MCH 29.8 pg 24,0 – 34,0MCV 89.7 fL 83,0 – 110,0 MCHC 33.2 g/dL 29,0 – 36,0Leukocyte 11.3 thousand/mmk 9 - 30 Platelets 168 thousand/mmk 150,0 – 400,0Differential Counts

Eosinophyls 2% 2 – 4Basophyls 1% 0 – 4Staf 1% 2 – 5Segment 61% 45 – 75Lymphocytes 20% 20 – 40Monocytes 10% 3 - 12

Peripheral blood figureErythrocyte anisocytosis moderate (macrocytes, normosit,micrositik)),

light poikilositosis moderate (tear drop,fragmentosit,pear shapeovalosit, eliptosit), polikromasi (+), young eritrosit ++/pos 2

Trombocytes Estimates of the number of normal platelets, form a large, Giant platelets (+)

5

Leukocytes The estimated amount of normal leukocytes

Clinical ChemistryGDS 64 mg/dL 80 – 160 Ureum 15 mg/dL 15 – 39Kreatinin 0.9 mg/dL 0,6 – 1,3Calcium 2.1 mmol/L 2,12 – 2,52Sodium 127 mmol/L 136 – 145 LPottasium 3.2 mmol/L 3,5 – 5,1Chloride 98 mmol/L 98 – 107Total Bilirubin 8.03 mg/dL 0.0-1.0 HDirect Bilirubin 0.97 mg/dl 0.0-1.0Albumin 2.6 g/dl 3.4-5.0CRP Kualitatif 0.02 mg/L 0-0.30TSHs 12.52 uIU/mL 0.25-5Free T4 22.29 pmol/L 10.6-19.4 H

6. X PHOTOS BABYGRAM (24 October 2015, 00:40 pm)

CLINICAL: severe asphyxia, cardiogenic shock observation

Looks endotracheal tube attached to the distal end of the third thoracic vertebral body height

COR: CTR = 62% The shape and location of the normal heart

Pulmo: vascular markings appear to be increasing Looks patches on top of the left lung field

Looks opacity lobulated form on the right trachea vertebral body height thoraca 1-6 tend

thymus structure

Right hemidiaphragm as high as 8 posterior costa

Sinus costofrenikus left and right taper

ABDOMINAL

Looks attached umbilical catheter with cranial end looks superposition with thoracic

vertebra 11

Invisible dilated and distended intestines

Air is not visible on the pelvic cavity

Invisible free water

IMPRESSIONS

The distal end of the endotracheal tube thoracic vertebral body height 3

The shape and location of the normal heart

Overview of neonatal pneumonia

Abdomen within normal limits

6

7. X-Thorax AP photo (24 October 2015 06:50)

(compared with x-photo dated 24 October 2015, 00:40 pm)

CLINICAL: severe asphyxia, reintubation

Looks endotracheal tube attached to the distal end of the thoracic vertebral body height 3-4

Looks gastric tube attached to the distal end of the thoracic vertebral body height 9

COR: CTR = 60%

The shape and location of the normal heart

7

Pulmo: vascular markings appear to be normal

Looks spots on the field on the left lung is relatively the same compared to the previous photo

Linear opacities appear at the bottom right lung field DD / Vascular, thickening interseptal

Tubular opacity appear on the right hemkithorak vertebral body height 2-7 thoraca tend

thymus structure

Right hemidiaphragm as high as 8 posterior costa

Sinus right costofrenicus left taper superposition with costa

IMPRESSIONS:

The distal end of the endotracheal tube 3-4 thoracic vertebral body height (height carina)

Configuration is relatively the same heart

Pulmonary infiltrates relatively equal

8

9

8. Assesment

Severe Respiratory Distress on VM

Aterm neonates

Post severe asphyxia

neonatal infections

A history of recurrent hypoglycemia

Post-shock dd / cardiogenic shock

suspect cardiomegaly

9. Program O2 VM SIMV PEEP 5 PIP 15 RR 30 FiO 2 50%

Infusion of D 12.5% 288 ml / 24 hours ≈ 12 ml / h (7.1 GIR)

+ NaCl 3% (4 meq) 47 ml

Being a 500 ml D 12.5%

+ Kcl Otsu (2 mEq) 12 ml

Aminosteril 6% 86.4 ml / 24 hours ≈ 3.6 ml / hour (3gr / kg / day)

Ivelip 20% 12 ml / 4 hours ≈ 0.5 ml / h (1 g / kg / day)

Intravenous: ampicillin 175 mg / 12 h ()

Gentamicin 20 mg / 24 hours

Ca gluconas 1.5 ml / 12 hours 1v slowly

5 mcgram dobutamine / kg / min

Diet ASI 8x10 ml / pregistimil

Program: blood culture (26/10/2015)

10