MORNING REPORT

MONDAY, 30 AUGUST 2021

KEPANITERAAN KLINIK ILMU KESEHATAN ANAK

FAKULTAS KEDOKTERAN
UNIVERSITAS LAMPUNG
2021
 CO-ASSISTANT ON DUTY
GROUP 1
Alamanda 2nd Floor Perinatology
 Beni Wibowo (MODERATOR)  Helen Kusuma W
 Dzikrina Citra F  Melia Munasiah
 Riska Priyani
Alamanda 3rd Floor
 Clara Firhan Emergency Room
 Nurul Fitri Insani  Efrans Caesar
 Muhammad Bagus Nitei Ago
PRESENTER  Rifqi Fadhil M
Mrs.Sumarni’s baby/male/
3 days Pediatric Assessment

Appearance Breathing
Abormal Normal

Circulation
Normal

Appearance: Respiratory & Breathing :

T: Tone (+) Nasal flare (-), retraction(-)
I: interactiveness (+)
C: consobility (+)
L: look/gaze( ) Circulation:
S: speech/cry ( ) Pale extremity (-), CRT < 2”
THE HISTORY
Identity : Baby Mrs. Sumarni /Male/ 3 days
Birth date : August 23rd 2021
Time of Admission in Emergency Department : 07.30 PM local time
Gestational Age : 38 weeks
Corrected Age : 38 weeks + 3
Chronological Age: 3 days
Main Complaint : Hydrocephalus
Additional Complaint : Neonatal jaundice
Present History:
Patient was referred to the Emergency Department of Abdul Moeloek Regional General Hospital from Panti
Secanti Hospital at 07.30 PM on August 26th 2021 to get better care with better equipment with birth weight
3700g and birth length 51cm. Patient came with weak condition and hypoactive. The patient looks yellowish
tint of skin and head enlargement. The patient was with OGT with no product, no vomiting, no bloating, no
hypersaliva.
Past Medical History: None
Family History: None
Pregnancy History: Mother with G2P1A0 (age: 33 years old)
• ANC: with midwife, routinely
• The mother did USG examination once. Had never taken certain drugs, only vitamins obtained from
midwife. The mother had followed recommended balanced food from midwife. Had experienced
nausea and vomiting at the beginning of pregnancy. Weight gaining from 55kg (before pregnancy) to
64kg.

Birth History:
The baby was born premature by section caesaria with birth weight 3700g and birth length 51cm.
Immunization History:
Unknown
Feeding History:
Formula milk
 Physical Examination
General Condition Vital Signs: Antropometry:
•Looks Icteric all over the body •HR: 115x/minutes •Weight: 3,7 kg
(Kramer Scale 5th Grade) •RR: 24 x/minutes •Length: 51 cm
•Less Active •T: 36,5 ºC •Arm Cicumference : 10,5 cm
•Impression: moderate illness •SpO2: 100 % •Head Circumference : 39,5 cm
•BMI : 14,2
Spesific Condition
Head
Makrocephaly (susp. Hydrocephalus)
Eye: Sclera Icteric (+/+)

Thorax: 
Inspection : normal
Percussion: normal
Palpation : normal, ictus cordis palpable
Auscultation: normal

Abdomen:
Inspection : Abdominal distension
Auscultation: normal
Percussion: normal
Palpation : palpable hard in the RUQ

Extremity: 
Superior: CRT <2 seconds, edema (-/-), icteric (+/+)
Inferior: CRT <2 seconds, edema (-/-), icteric (+/+)
WHO
WHO CHART
CHART

Length : 51 cm

(2SD) to (-2SD)
Interpretation:
Normal length
WHO
WHO CHART
CHART

Weight : 3,7 kg

(2SD) to (-2SD)
Interpretation:
Normal weight
WHO
WHO CHART
CHART

Weight : 3,7 kg
Length : 51 cm

-> Median
Interpretation:
Normal
WHO
WHO CHART
CHART

BMI : 14,2

-> Median
Interpretation:
Normal
WHO
WHO CHART
CHART

HC : 39,5 cm

Above 3SD
Interpretation:
Makrocephaly
 DOWNE SCORE
Criteria 0 1 2
Respiratory rate <60x/min 60-80x/min >80x/min
Retractions No retraction Mild Berat
Cyanosis No cyanosis Relieved by O2 Cyanosis on O2

Air entry Good bilateral air Mild decrease air No air entry
entry entry

Grunting No grunting Audible by Audible with ear

stethoscope

Score : 0  No respiratory distress

Problem Assessment
1. Ptekie on face Whole body jaundice
2. Crying weakly Makcrocephaly

Diagnosis/Differential Working Diagnosis

Diagnosis Susp Hidrosefalus + icterus
1. Hematom subdural neonatorum patologis
2. Brain tumor
3. Icterus neonatorum
fisiologis
Medikamentosa Non Medikamentosa
1. Okesigen 0.5-1 liter
1. - 2. Infant Inkubator

Monitoring

2. Monitoring data has not been

obtained because the patient was
sent to the perine isolation room.