Kepaniteraan I.K.

Anak
Universitas Kristen Indonesia

MORNING REPORT

Data subjective
Name
: By.Ny.Fitri
Age
: newborn
Sex
: male
Weight
: - kg
Address
: kramat jati
MR
:
date of arrival
: Thursday, June
18th 2013

Anamnesis
Chief Complaint : loss of
consciousness
Additional complaint : -

Anamnesis
History of illness:

Patient came to UKI ER delivered by a midwive and his

father with loss of consciousness. Patient is a newborn
baby. He had been born about 40 minutes before
admittance. The midwive said that patient was not directly
cry after birth, appear bluish, a little movement, weak
breath and pulse rate about 60 times/minutes. He looks
breathable about 3 minutes after birth and the APGAR
score is 6/7. During the process of birth, the color of
amniotic fluid looks cloudy. According to the patients
father, 2 days before the patients birth mother was out of
brown spots and no other complaints. During pregnancy,
mother do the antenatal care regularly. And there was
never a problem during pregnancy. This is the second
pregnancy for the patients mother. At first pregnancy, the
fetus has died in the womb without a known cause.

Past illness
Any complaints that similar with present complaint is
denied
Familiy History
denied
.

Objective data
Appearance
: severly ill
Level of conciousness : Coma (eye opening (-), verbal responses (-),
motor response (-))
Respiration rate
: 2 times/minute (inadequate)
Pulse rate
: 120 times/minute (powerfull, regular)
temperature
: 35,7C (axilla)
head
eye
Ear-nose-throat

: normochepali, caput succidaneum (+)

: Icteric -/-, anemic -/-, pupil isochor 5mm/5mm
: ear : wide/wide, sekret -/nose : nasal cavity wide/wide, sekret -/lips : dry mucose

Pulmo :
Insp : non static and dynamic symmetric
Pal : stemfremitus
Perc : sonor / sonor
Ausc : Basic Breath Sound Vesicular, Rh +/+, Wheezing -, cardiac sound I and II
regular, murmur (-), Gallop (-)
ABDOMEN
Insp : flat,
Ausc : Bowel sound (+)
Pal : Liver Spleen impalpable ; distended abdomen (-), palpation pain (-)
Perc : EXTREMITIES
Edema (-) ; cold (+), capillary refill more than 2 seconds.

Genitalia
: male, undensensus
Skin : sianotic, icteric (-)
Rooting reflex : (-)
Sucking reflex : (-)
Grasping reflex : (-)

Assessment
SEVERE ASFIKSIA

Tatalaksana
RESUSITATION
Bag to mouth
02 10lpm
Intubation
endotracheal tube

IVFD : dextrose 5%
Mm: adrenalin 3 x 0,1mg

Kepaniteraan I.K. Anak

Universitas Kristen Indonesia

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