CLINICAL CONFERENCE

NEONATOLOGY DIVISION
OCTOBER 7th 2021

Rizna Ariani Said/ Presenter

Clara Parannuan
Andi Ayu Hafsari M
Sy. Raehana Mardiah
Andi Utari Dwi Rahayu
Erni Murdaningsih
 PATIENT IDENTITY
By. Mrs. F, 0 day (Male)
MR Number 949160
Date of Birth October 6th 2021
Admission Date October 6th 2021

MEDICAL DIAGNOSIS
Respiratory Distress of the Newborn due to Transient Tachypneu of the Newborn
Low Birth Weight
Aterm Baby / Appropriate for Gestational Age
Hypoglycemia
 HISTORY TAKING
Chief Complain
Shortness of breath

History of Present Illness

A baby girl was born through C-section at 38 weeks of gestational age due to
placenta previa + suspected accreta, cried immediately, normal muscle tone.
APGAR score was 7/9. There was shortness of breath. No fever. No seizure.
No vomiting.
 HISTORY TAKING
History of Pregnancy:

This is the 3rd pregnancy. The mother was 21 years old when she was
pregnant. There was no history of high blood pressure nor diabetes. There
was no history of vaginal discharge, no fever and no painful urination.
There was no history of consuming traditional herbs. She routinely went
to the obstetrician and got vitamins and iron supplements.
 PHYSICAL EXAMINATION

Vital Sign
Body weight : 2410 gr
General Status: Passive
Body length : 46 cm
Heart Rate : 132 bpm
Head circumference : 32 cm
Temperature : 36,6 °C
Respiration Rate : 70 times per
minute
BW : 2410 GR
BL : 46 CM
HC : 32 CM
 PHYSICAL EXAMINATION
History of Vaccine
Frequency
Vaccine Not given 0 1 2 3 4

Hep B v
BCG v
DPT v
Hib v
OPV v
IPV v
MMR v
Rotavirus v
Influenza v
Japanese v
Encephalitis
PCV v
Varicella v
Hepatitis A v
Tifoid v
 Observe the hand : not yet
Grabbing object : not yet
History of Growth
and Development Prone position by self : not yet
One syllables : not yet
Pointing the object : not yet
First tooth : not yet

8
 PHYSICAL EXAMINATION

Head And Neck Cardiovascular Hematology

Normocephaly I / II heart sound, Regular rhythm No paleness, no bleeding
No lymphadenopathy No murmur
Blood glucose : 28 mg/dl
Chest and pulmo Gastrointestinal
Retraction (+) subcostal Peristaltic sound normal
Breath sounds brochovesicular Liver and spleen were not palpable
There was no rales
There was no wheezing Metabolic
Downe Score : 5 No oedem, no jaundice
(Retraction 1, Respiratory Rate I, Grunting I,
Urination: yellow
Air Entry 1, Cyanosis 1)
 RSUP. DR. WAHIDIN SUDIROHUSODO
INSTALASI RADIOLOGI
JL. PERINTIS KEMERDEKAAN KM. 11 MAKASSAR
TELP. (0411)584677, 583333 FAX. (0411)581666
RADIOLOGY FINDING
Tanggal : 07-10-2021 06:24:53 Nomor RM : 949160
Nama : BY NY FELI
Tgl Lahir/J. Kelamin : 6-10-2021 / Perempuan
Alamat : JL DANAU TIGI
Klinis : RDN (SC, 2410 gr, CB) + PJB Sianotik e.c TGA dd/ TOF
Jenis Pemeriksaan : Foto Thoraks PA/AP

Yth TS,

[ Copy ]
Foto Thorax AP :

- Posisi asimetris, kondisi film baik, inspirasi cukup

- Tampak bercak retikulogranular pada kedua paru
- Tidak tampak pemadatan hilus
- Tampak pelebaran mediastinum superior (thymus)
- Cor dan aorta: sulit dievaluasi (posisi asimetris)
- Kedua sinus dan diafragma baik
- Tulang-tulang intak
- Jaringan lunak sekitar kesan baik
Kesan : Transient tachypnea of the newborn

Usul : Echocardiography

Konsulen BTK, SS

dr. Rosdianah, Sp.Rad.M.Kes. dr. Dewi Damayanti

Hal : 1
 ASSESMENT
Respiratory Distress of the Newborn due to Transient Tachypneu
of the Newborn
Low Birth Weight
Aterm Baby / Appropriate for Gestational Age
Hypoglycemia
 TREATMENT
- Oxygen support via T-Piece resuscitator
- Prepare for CPAP, Oxygen Flow 8, PEEP 7, FiO2 40%
- Treat the baby in incubator
- Fluid requirement 80 cc/kgbw + 20% (incubator) – 20% (respiratory distress)
- Enteral : stop oral intake, OGT decompression
- Parenteral: Dextrose 10% 2cc/kgbw/intravenous, maintainance with Dextrose 10% 6 cc/hour
- Ampicillin / intravenous
- Gentamicin / intravenous
THANK YOU