MORNING REPORT

SATURDAY, 10 T H MARCH 2018

dr. Anto/dr. Nickyta/ dr. Aya/ dr. Rekno/ dr. Kandar

dr. Dhimas / dr. Delfia
dr. Eddy / dr. Rara

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 PATIENT ADMISSION

MELATI 2 WARD
Child Y, 14 y.o, 37 kg, with intradyalitic hypotention, CKD Stage V on HD, acute diarrhea without
dehydration, undernourished
HCU NEONATUS
Baby Y, male, 6 days old, 1000 gram with pneumonia, sepsis naonatorum, hyperbilirubinemia
high risk zone, neonate, very low birthweight, preterm, appropriate for gestational age, C-section
due to PROM, outside delivery.
Baby Mrs.S, male, 0 days old, 3000 gram with caput secadenium, neonatal infection, neonate, normal
birthweight, aterm, appropriate for gestational age, spontaneous delivery.
NICU : (-)
HCU MELATI 2 : (-)
PICU : (-)
Outpatient
1. Child D, 9 y.o, 26kg, muscle contusio, wellnourished
2. Baby M, 19 d.o, 3000 gram, history of post PSARP due to atresia ani 2
 PATIENT IDENTITY

• Name : Baby Mrs Y

• Sex : male
• Age : 6 day old
• W/H : 1000 gr / 36 cm
• Address : Surakarta
• Medical Record : 01411689

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CHIEF COMPLAINT

Premature
(low birth weight)

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 PRESENT MEDIAL HISTORY

• Patient has been delivered by mother 6 days ago in private hospital

• Gestational age : 29 weeks
• Birth weight:1300 grams
• Birth length 36cm
• APGAR score didn’t know
Delivery

• Patient cried
• Deep retraction
• Sometimes stop breathing
• Patient got CPAP for 5 days
• Infuse D5 175cc + NaCl 3% 8cc + KCl 5 cc + Ca gluconas 12.5 cc  4cc/hour IV
• Aminosterile 30mg/24 hours IV
After • Cefotaxim Inj 75mg/12 hours IV
delivery • Aminophyline Inj 4mg/12 hours IV
• Babygram  bronchopneumonia
• Reffered to Dr.Moewardi Hospital

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 • Patient got breathlesness
• Yellowish, Kramer IV
• No fever
• Got umbilical catheter IV line
At Emergency • Last Defecation didn’t know
room • Last urination on diaper

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 PAST MEDICAL HISTORY

• History of hospitalized:
(+) since birth on private hospital
• History of tranfusion:
(+) FFP I (has done at 10 march 2018 on 04.00am)

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 HISTORY OF PREGNANCY AND DELIVERY

Pregnancy
• This is the first pregnancy of his mother (G1P0A0). Gestational age was 29 weeks. The mother
consumed vitamins and pills routinely from a midwife. she routinely check up to the midwife every
month. There was no history of hospital admission, vaginal bleeding, hypertension, swollen in
the body, and urinary tract infection during pregnancy.

Delivery
• The baby was born by C section due to PPROM. When he was born, he cried
some times stop breathing, looked weak, acyanotic, chest retraction (+). Apgar
score was unknown. The baby weight is 1300 gram and 36 cm in length.

Conclusion: pregnancy and delivery history was abnormal

 FAMILY MEDICAL HISTORY

• History of premature babies (-)

• History of babies with congenital heart disease (-)

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 VACCINATION HISTORY

• Hepatitis B immunization : Hep B0 vaccine has not given yet

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 NUTRITIONAL
STATUS

Weight = 1300 gram

Length = 36 cm
HC = 24 cm

BW/A: P10 < BW/A < P50

L/A: P3 < L/A < P10
BW/L: P50 < BW/A < P90
HC/A < P3

Conclusions:
Well nourished, normoweight,
normoheight
Microcephal

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 FAMILY TREE

II

II
I

Baby Y, 6 day old

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 PHYSICAL EXAMINATION

• General appearance : moderate illness, looked weak, S3

• Vital sign :
• Heart Rate = 120 bpm
• Respiration rate = 62 bpm
• Temperature = 36.1 0C
• O2 saturation = 90%

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 • Head : buldging fontanell (-) head circumference 27 cm
• Eyes: pale conjunctiva (-/-), icteric conjunctiva (-/-)
• Nose : nasal flare (+), discharge (-/-)
• Mouth : wet lips (+), lips and tongue acyanotic
• Thorax : symmetric (+), severe retraction (+)
LUNG:
• I: normal, symmetric, retraction (+)
• P: fremitus can not be evaluated
• P: sonor in both lung
• A: normal vesicular breath sound, additional breath sound (-/-)
CARDIAC:
• I : ictus cordis not visible
• P: ictus cordis palpable on ICS 4 parasternal lines
• P: there is no cardiac enlargement
• A: 1st 2nd Heart sound normal intensity, regular, no murmur

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ABDOMINAL:
I : abdominal wall // thorax wall, abdominal distended (-)
A: peristaltic sounds (+)
P : within normal limit
P: enlargement of liver and spleen (-)

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis pedic
artery was palpable strongly, cyanotic (-), anomalies (-)

GENITALIA Status : anus perforation (+)

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Issues Breathing difficulty
CNS Cry vigorously (+) ↓ Active in motion (+)↓ spontaneously open eyes (+)
Assessment: S3
Cardiovascular Heart rate : 120 x/minute
System Murmur (-) Capillary refill time < 2 seconds, dorsalis artery pulse (+)
strong palpable
Assessment: within normal limit
Respiratory Respiratory rate : 62 x/minute Si02 : 90% preductal
System Retraction (+), Air entry (+) ↓, grunting (+), cyanotic (-), crackles (-)
Downe score (6)
Assessment : severe respiratory distress
GIT Hepatal Peristaltic sound (+)
System Assessment : within normal limit
Genitourinaria Urination (-) ; Fluid balance can not be evaluated yet ; Diuresis: can not be
System evaluated yet
Assessment: can not be evaluated yet
Infection Thermoregulation System Gastrointestinal System Assessment:
System 36.10C (-) (-) Sepsis early onset
Central nervous system (+) Hematology System (-) Mild hypothermia
Cardiovascular System (-) Hemodynamic System
Respiratory System (+) (-)

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 LABORATORY RESULTS

  Value Reference Units

Hemoglobin 14-17.5 g/dl
Hematocrit 33-45 %
Leucocyte 4.5-14.5 x103/ul
Thrombocyte 150-450 x103/ul
Eritrocyte 3.8-5.8 x106/ul
MCV 80.0-96.0 /um
MCH 28.0-33.0 pg
MCHC 33.0-36.0 g/dl
RDW 11.6-14.6 %
Eosinophil 0.00-4.00 %
Basophil 0.00-1.00 %
Neutrophil 29.00-72.00 %
Lymphocyte 33.00-48.00 %
Monocyte 0.00-6.00 %
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 LABORATORY RESULTS

  Value Reference Units

Ureum <48 mg/dl
Creatinin 0.5-1 mg/dl
Albumin 3.2-4.5 g/dl
PT 10-15 Seconds
aPTT 20-40 seconds
INR

Conclusion : normochromic normocytic anemia, trombocytopenia

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 PROBLEM LISTS
Baby Y, 6 day old, 1000 gram with:

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DIFFERENTIAL DIAGNOSIS

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WORKING DIAGNOSIS

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THERAPY

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 PLAN

MONITORING

• General appearance / vital sign / SiO2 / hour

• GDS 24 hour
• Fluid balance and diuresis / 8 hour
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FOLLOW UP 11/03/2018

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Issues Breathing difficulty
CNS Cry vigorously (+) ↓ Active in motion (+)↓ spontaneously open eyes (+)
Assessment: S4
Cardiovascular Heart rate : 127 x/minute
System Murmur (-) Capillary refill time < 2 seconds, dorsalis artery pulse (+)
strong palpable
Assessment: within normal limit
Respiratory Respiratory rate : 54 x/minute Si02 : 95% preductal
System Retraction (-), Air entry (+), grunting (-), cyanotic (-), crackles (-)
Downe score (3)
Assessment : mild respiratory distress (on CPAP)
GIT Hepatal Peristaltic sound (+)
System Assessment : within normal limit
Genitourinaria Urination (+) ; Fluid balance : 50 ml/day ; Diuresis: 1,75 ml/kg/hour
System Assessment: within normal limit
Infection Thermoregulation System Gastrointestinal System Assessment:
System 36.90C (-) (-) sepsis early onset
Central nervous system (+) Hematology System (-)
Cardiovascular System (-) Hemodynamic System
Respiratory System (+) (-)

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WORKING DIAGNOSIS

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THERAPY

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 PLAN

MONITORING

• General appearance / vital sign / SiO2 / hour

• GDS 24 hour
• Fluid balance and diuresis / 8 hour
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FOLLOW UP 12/03/2018

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Issues Breathing difficulty
CNS Cry vigorously (+) ↓ Active in motion (+)↓ spontaneously open eyes (+)
Assessment: S4
Cardiovascular Heart rate : 127 x/minute
System Murmur (-) Capillary refill time < 2 seconds, dorsalis artery pulse (+)
strong palpable
Assessment: within normal limit
Respiratory Respiratory rate : 54 x/minute Si02 : 95% preductal
System Retraction (-), Air entry (+), grunting (-), cyanotic (-), crackles (-)
Downe score (3)
Assessment : mild respiratory distress (on CPAP)
GIT Hepatal Peristaltic sound (+)
System Assessment : within normal limit
Genitourinaria Urination (+) ; Fluid balance : 50 ml/day ; Diuresis: 1,75 ml/kg/hour
System Assessment: within normal limit
Infection Thermoregulation System Gastrointestinal System Assessment:
System 36.90C (-) (-) sepsis early onset
Central nervous system (+) Hematology System (-)
Cardiovascular System (-) Hemodynamic System
Respiratory System (+) (-)

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WORKING DIAGNOSIS

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THERAPY

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 PLAN

MONITORING

• General appearance / vital sign / SiO2 / hour

• GDS 24 hour
• Fluid balance and diuresis / 8 hour
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