MORNING REPORT

SUNDAY MORNING SHIFT

NOVEMBER 3 TH 2019

dr. Fatimah / dr. Ama / dr. Connie / dr. Disa / dr. Hamid
dr.Ibrahim/ dr. Dhimas
dr.Wulan / dr. Ifa

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 PATIENT ADMISSION

Melati 2 :
• Child I / 2 years 10 months/ 15 kilograms with Initial Nephrotic
Syndrome, Acute tonsilopharyngitis, Well nourished.
Outpatient :
- -
Inborn Delivery :
• Baby Mrs. S I, 0 day old, 2800 grams with mild respiratory distress
due to suspected congenital pneumonia; infection of neonates, caput
succadeneum, bilateral CTEV, male neonates , normal birth weight,
aterm, appropriate for gestational age, spontaneous delivery with
vacuum extraction from mother with history of caesarean section
delivery 2
 PATIENT IDENTITY

• Name : Baby Mrs. S

• Sex : Male
• Age : 0 day old
• W/H : 2800 gr / 47 cm
• Address : Ngemplak, Boyolali
• Medical Record : 01482237

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CHIEF COMPLAINT

Breathlessness
Newborn

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 PRESENT MEDIC AL HISTORY

At the delivery room

• Birth weight : 2800 grams
• Body length : 47 cms
• Head circumference : 34 cms
• Chest circumference : 33 cms
• Mid-upper arm cirumference : 11 cms
• Abdominal circumference : 30 cms
• Apgar score : 4-6-7
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HISTORY OF PREGNANCY AND DELIVERY

Pregnancy

• The mother was pregnant at 32 years old. This is her second

pregnancy. The gestational age was 37 weeks. The mother had
routine check up with an Obstetrician and consumed vitamins and
pills as prescribed.

Delivery

• The baby was born by spontaneous delivery with vacuum extraction.

The baby weight is 2800 grams.

Conclusion:
Normal pregnancy, abnormal delivery
 NUTRITIONAL STATUS

• Weight for age : 0 SD > W/A > -2 SD (normorweight)

• Height for age : 0 SD > H/A > -2 SD (normoheight)
• Weight for height : -1 SD > H/A > -2SD (wellnourished)

Conclusion: well-nourished, normoweight, normoheight

(WHO, 2006) 8
 FAMILY TREE

II

III

Baby Mrs. S 0 day old, 2800 grams

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PHYSIC AL EXAMINATION

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 HCU NEONATUS
Issues Mild respiratory distress
Pregnancy Last menstrual period : 17-02-2019
status Pregnancy due date : 24-11-2019
Gestational age : 37 weeks
Mother’s age : 32 years old
Assesment : aterm
Mother status History of hypertension : denied
History of diabetes : denied
History of asthma : denied
History of heart disease : denied
HbsAg : (-)
Assessment : within normal limits
Mother’s Hb : 9.2 g/dL
laboratory Hct : 27 %
result Leucocyte count : 14.9x 103/uL
Trombocyte count : 37x 103/uL
Eritrocyte count : 3.09x 104/uL
PT/APTT : 16.8/ 37.8 second
INR : 1.390 11

Assessment : within normal limits

Issues Breathlessness
CNS Cried vigorously (+↓), Active in motion (+↓), Spontaneous eyes
opening(+↓)
Assessment: S3
Cardiovascular Heart rate : 167x/minutes, SiO2 : 93% (without O2)
System Murmur (-), capillary refill time <3 seconds, dorsalis artery strong palpable,
warm extremities
Assessment: within normal limits
Respiratory Respiratory rate : 50x/minute, air entry (+), nasal flaring (-/-), grunting (-) ,
System retraction (+) subcostae. DS : 1
Assessment : mild respiratory distress
GIT Hepatal Meconium (+), defecation (-), icteric (-)
System Assessment : within normal limits
Genitourinaria Urination (+)
System Assessment: within normal limits
Infection Thermoregulation System 36.60C
System Assessment : within normal limits
Other Caput (+)
Anus (+)
Bilateral CTEV (+)
Assessment : Abnormal 12
13 PROBLEM LIST
Baby Mrs S, 0 day old, 2800 grams with :

1. Difficulty of breathing
2. Respiratory system : Respiratory rate : 50x/minute, air entry (+),
nasal flaring (-/-), grunting (-) , retraction (+) subcostae.
Assessment : mild respiratory distress.
3. Caput (+) post vacuum extraction
4. Bilateral CTEV
 14 DIFFERENTIAL DIAGNOSIS

1. Mild respiratory distress due to suspected Congenital

pneumonia DD MAS
2. Moderate Asphyxia
3. Infection of neonate
4. Caput succedaneum
5. Bilateral CTEV
6. Neonate, male, normal birth weight, aterm, appropriate for
gestational age, spontaneous delivery with vacuum extraction
from mother with history of caesarean section delivery
 15 WORKING DIAGNOSIS

1. Mild respiratory distress due to suspected Congenital

pneumonia
2. Infection of neonate
3. Caput succedaneum
4. Bilateral CTEV
5. Neonate, male, normal birth weight, aterm, appropriate for
gestational age, spontaneous delivery with vacuum extraction
from mother with history of caesarean section delivery
 THERAPY

1. Admitted to HCU Neonatus

2. Oxygen 0.5 lpm
3. Keep the baby warm
4. ASI on demand
5. IVFD D10% (60ml/kg/days)= 7ml/jam iv
6. Ampicilin (50mg/KgBB/12hours)= 140mg/12 jam iv
7. Umbilical cord care
8. Neo K 1 mg intramuscular
9. Gentamicin eye ointment ODS
10. Hepatitis B vaccination

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 PLAN

Septic work up

MONITORING

• General appearance / vital sign / SiO2 / 3 hours

• Fluid balance and diuresis / 8 hours

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 FOLLOW UP
NOVEMBER 4 TH 2019

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Issues Breathlessness
CNS Cried vigorously (+), Active in motion (+), Spontaneous eyes opening (+)
Assessment: S5
Cardiovascular Heart rate : 110x/minutes, SiO2 : 99% (with O2)
System Murmur (-), capillary refill time <3 seconds, dorsalis artery strong palpable,
warm extremities
Assessment: within normal limits
Respiratory Respiratory rate : 56x/minute, air entry (+), nasal flaring (-/-), grunting (-) ,
System retraction (0). DS : 0
Assessment : mild respiratory distress
GIT Hepatal Meconium (-), defecation (-), icteric (-)
System Assessment : within normal limits
Genitourinaria Urination (+)
System Assessment: within normal limits
Infection Thermoregulation System 36,50C
System Assessment : within normal limits
Other Caput (+)
Anus (+)
Bilateral CTEV (+)
Assessment : Abnormal 19
 LABORATORY RESULT

• Hb : 12.2 g/dL
• Hct : 34 %
• Leucocyte count : 7.8x 103/uL
• Trombocyte count : 137x 103/uL
• Eritrocyte count : 3.25x 104/uL
• Natrium : 131 mmol/L
• Kalium : 4.1 mmol/L
• Chloride : 97 mmol/L
• Calcium : 1.12

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 21 WORKING DIAGNOSIS

1. Mild respiratory distress due to suspected Congenital

pneumonia
2. Infection of neonate
3. Caput succedaneum
4. Bilateral CTEV
5. Neonate, male, normal birth weight, aterm, appropriate for
gestational age, spontaneous delivery with vacuum extraction
from mother with history of caesarean section delivery
 THERAPY

1. Admitted to HCU Neonatus

2. Oxygen 0.5 lpm
3. Keep the baby warm
4. ASI on demand
5. IVFD D10% (60ml/kg/days)= 7ml/jam iv
6. Ampicilin (50mg/KgBB/12hours)= 140mg/12 jam iv
7. Umbilical cord care

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 PLAN

Baby gram

MONITORING

• General appearance / vital sign / SiO2 / 3 hours

• Fluid balance and diuresis / 8 hours

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 FOLLOW UP
NOVEMBER 5 TH 2019

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Issues Breathlessness
CNS Cried vigorously (+), Active in motion (+), Spontaneous eyes opening (+)
Assessment: S5
Cardiovascular Heart rate : 143x/minutes, SiO2 : 99% (with O2)
System Murmur (-), capillary refill time <3 seconds, dorsalis artery strong palpable,
warm extremities
Assessment: within normal limits
Respiratory Respiratory rate : 62x/minute, air entry (+), nasal flaring (-/-), grunting (-) ,
System retraction (-). DS : 0
Assessment : mild respiratory distress
GIT Hepatal Meconium (-), defecation (-), icteric (-)
System Assessment : within normal limits
Genitourinaria Urination (+)
System Assessment: within normal limits
Infection Thermoregulation System 36,70C
System Assessment : within normal limits
Other Caput (+)
Anus (+)
Bilateral CTEV (+)
Assessment : Abnormal 25
 BABY GRAM

• Airbroncohogram (+) in
left suprahillar and
parahillar
• Conclusion : Pneumonia

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 27 WORKING DIAGNOSIS

1. Mild respiratory distress due to suspected Congenital

pneumonia
2. Infection of neonate
3. Caput succedaneum
4. Bilateral CTEV
5. Neonate, male, normal birth weight, aterm, appropriate for
gestational age, spontaneous delivery with vacuum extraction
from mother with history of caesarean section delivery
 THERAPY

1. Admitted to HCU Neonatus

2. Oxygen 0.5 lpm
3. Keep the baby warm
4. ASI on demand
5. IVFD D10% (60ml/kg/days)= 7ml/jam iv
6. Ampicilin (50mg/KgBB/12hours)= 140mg/12 jam iv
7. Umbilical cord care

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 PLAN

MONITORING

• General appearance / vital sign / SiO2 / 3 hours

• Fluid balance and diuresis / 8 hours

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 CLINIC AL QUESTION

• Is faster treatment of antibiotic give better

improvement in newborn with pneumonia?

•P : newborn baby with pneumonia

•I : antibiotic
•C : without antibiotic
•O : improvement
 VALIDITY

1. Was the assignment of patients to treatments

randomized?
• Not stated in the journal

2. Was the randomized list concealed?

• No

3. Were patients and clinicians kept blind to which

treatment was being received?
• No
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 VALIDITY

4. Is the patient observations made sufficiently long and

complete?
• Yes.

5. Were all patients who entered the trial accounted

for? And were they analysed in the groups to which
they were randomized?
• Yes
• No, the subjects were not randomized
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 VALIDITY

6. Aside from the experimental treatment, were the

groups treated equally?
• Not stated clearly

7. Were the groups similar at the start of the trial?

• Yes
• It can be seen in table 1.

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IMPORTANCE

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 APPLICABILITY

Were the study patients similar to our own?

• Yes

Is the treatment feasible in my setting?

• Yes

Will the potential benefits of treatment outweigh the

potential harms of treatment for patients?
• Yes

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 Important

LoE
2B
Valid Applicable

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THANK YOU
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