Morning Report

Thursday, March 17th 2021

IPS/IKH/TAM
A new patient was arrived to NICU at 05.00 AM, male, 16 days old,
with chief complaint: shortness of breath
- It was happened since he has born.
- Sucking reflex was not good enough since he was born
- The patient looked yellowish in this 5 days.
- Cyanosis was not found.
- Vomit and fever was not found
- Defecation and micturition in normal limit
• History of pregnancy: mother’s age while pregnant was 47 years old,
mother have diabetic mellitus, antenatal care was not routine
• History of delivery: patient is the fifth child, born 31 weeks pregnancy
by spontaneous vaginal delivery and assisted by midwife. He was not
crying immediately after birth, no cyanosis, with birth weight of 1500
grams. Vitamin K injection and immunization was given after birth.
• History of previous illness: Patient was refferred from
Bhayangkara Hospital in tebing tinggi and treated for 4 days,
and then refered again to Bina Kasih Hospital and hospitaized
for 14 days. The patient refered to Adam Malik hospital caused
of DORV + ASD + ASD Secundum + dextrocardia.
• History of previous medications: IVFD D5% NaCl 0,45%, Inj
Ceftriaxone, inj gentamicin, dexametason, spironolactone and
captopril. The patient have got CPAP ventilation for 6 days and
got light therapy also.
Physical Examination
General status:
Sensorium: Compos mentis Temperature : 36,40C
dyspnea (-), cyanosis (-), edema (-), icteric (-), anemic (-)
Nutritional status:
BW: 1300 kg, BL: 31 cm
NBS : 33 weeks
Localized status:
Head: Eye :Light reflexes (+/+), isochoric pupils, Ø 3mm/3mm, pale inferior
palpebral conjunctiva (-/-), icteric sclera (-/-)
Ear : within normal limit
Nose : O2 nasal was paired (-)
Mouth: OGT was paired (+)
Neck : lymph node enlargement (-)

Thorax : Symmetrical fusiform, no retraction

Heart rate : 136 bpm, regular, murmur (+)
Respiratory rate : 60 bpm, regular, no rales, stridor and wheezing

Abdomen : firm, normal peristaltic sound

liver and spleen was not palpable
Extremities: Pulse rate 136 bpm, regular, equal peripheral and central pulsation,
warm extremities, CRT<2 seconds, pale on palmar extremities. Blood pressure:
90/60 mmHg. Peripheral oxygen aturation: 99%, yellowish body (krammer 2)
 Laboratory Result from Adam Malik Hospital March 15th 2021
Parameter Value Normal Parameter Value Normal
Hemoglobin 14.5 g/dL 13,5-15,5 g/dL Eosinophyl 2.5 1-3 %
Hematokrit 43 % 30,5-45% Basophyl 0.2 0-1 %
WBC 20,870/mm3 5.000-11.000/mm3 Neutrophyl 79.80 50-70 %
Platelet 286.000/mm3 150.000-450.000/mm3 Lymfocyte 12.40 20-40 %
MCV 110 fl 75-95 fl Monocyte 7.50 2-8 %
MCH 37.2 pg 27-31pg  Antigen SARS Negatif  
Cov-2
MCHC 33.9 g/dl 32-34 g/dl
Echocardiograpy 20/2 (bina Kasih Hospital)
Echocardiograpy 20/2 (bina Kasih Hospital)
X ray thorax 4/3
Adam Malik Hospital
Workingl Diagnosis : Therapy :
1. DORV • Treat in incubator  temp: 36,5-
2. VSD Sub-aortic 37,5 C
3. ASD secundum • O2 via nasal cannula 0,5 Lpm
4. Small PDA • IVFD N5% 4 cc/h
5. Dextrocardia • Inj Cefotaxime 60 mg/8 h
6. Susp neonatal sepsis • Inj gentamicine 5 mg/24 h
7. Hypocalsemia • Spironolactone 1x 6,25 mg
8. Hyponatremia • Captopril 3 x 0,25 mg
9. Neonatal hiperbillirubinemia • Diet breast milk / formula milk 15
10.Preterm baby cc/ 2h
• Hyponatremia and hypocalsemia
correction
Planning :
- Check blood culture.
- Consult to cardiolology division  repeat echo
Time Sensorium HR RR Temp Additional
(bpm) (tpm) ◦C

05.30 GCS15 110 44 36,4

am
06.30 GCS15 130 40 36,5
am
08.00 GCS 15 110 43 36,5
am
Thank You