Morning Report

Tuesday, July 6th 2021

Onsite: dr. Heru Noviat Herdata, Sp.A
Moderator: dr. Rusdi Andid, Sp.A

Pediatric Residents
Chief: dr. Budi Permana
Emergency room: dr. Cut Muliana, dr. Amelia
Pediatric Intensive Care Unit: dr. Eva
Neonatology Intensive Care Unit: dr. Firda, dr. Nisa
Ward : dr. Riki, dr. Siska, dr. Diana Sari
Department of Pediatric Medical Faculty of Syiah Kuala University/
Zainoel Abidin General Hospital Banda Aceh
2021
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 PATIENT ADMISSION on 05-07-2021 until 06-07-2021

No Name Sex Diagnose Division

1. Agustin Wijaya Male, 9 - Seizure ec metabolic Neuropediatric
CM 1278941 years 11 encephalopaty
months - Epilepsy
- Mild Malnutrition
- Immunization not complete

2. Muhammad Arsyad Male, 5 - Respiratory distress of Neonatology

CM: 1278964 days newborn
- Infection of Newborn
- Icterus Neonatorum

3. Muhammad Qiyas Male, 6 - Microcytic hypochromic HOM

Andi Putra months 17 anemia
CM: 1261375 days
 PATIENT ADMISSION on 05-07-2021 until 06-07-2021

No Name Sex Diagnose Division

4. Nayla Furafisha Female - Cyanotic spell Cardiology
CM 1278870 1 month 1 - TGA
day
5. Muhammad Rizqi Male - Status Epilepticus Neuropeditric
CM 1276269 1 month 5 - Epilepsy
days - Encephalocele
- Patent Foramen Ovale
- Patent Ductus Arteriosus
 PATIENT SC/PV on 05-07-2021 until 06-07-2021

No Name Indication of SC/PV Diagnose Summary

1. Ny. Titin Fitriani G5P2A2 Gravid 27-28 - Respiratory Failure Boys
weeks, singleton with head - Severe asfiksia
- Very low birth baby BBW 1210 gram
presentation, BSC 2x, Apgar Score 0/3
preeclamsia, DM type 2, - Preterm baby with
Solutio Plasenta appropriate gestational Transfer to NICU
age post sectio caesarea Level III
 IDENTITY
• Name : Muhammad Arsyad
• Sex : Male
• Date of Birth: June, 30th 2021
• Age : 5 days
• Address : Matang Kuli, Aceh Utara
• MR No. : 1-27-89-54
• Date of Admission : July, 5th 2021, 22.25 WIB
 ANAMNESIS
• Chief Complaint:
Dyspnea

• Additional Complaint:
Yellowish skin

• Present history :
- Patient referred from Kasih Ibu hospital Lhokseumawe
with diagnosed susp CHD + asphyxia. Patient with chief
complaint dyspnea from newborn and had NICU room
care for 5 days in Lhokseumawe.
- Patient with yellowish skin that appeared in 3 days of life.
The feces has yellow color.
- The patient was born by sectio caesaria, immediately
crying, with gestation age 38 weeks. The Apgar score is
5/6/6.
 ANAMNESIS
• History of illness:
Patient had dyspnea from right after born and
had NICU room care for 5 days in Lhokseumawe

• Family History
No family member had history of liver disease,
no history of heart disease

• Drug History
- Inj. Cefotaxime 150 mg/12 hours
- Inj. Gentamicin 8 mg/24 hours
- Inj. Vit K 1 mg (once after born)
 ANAMNESIS
• Pre Natal, Natal and Post Natal Care
Patient was the third child, born aterm by section
caesaria with indication transversal position. Patient born
immediately crying, 2900 gram of birth weight.

– History of Nutritional
Patient had formula milk since born

• Immunization History
Patient has not get immunization yet

• Growth and Development History

Patient had birth weight 2.900 gr. Patient was unable to
raise his head yet.
 Time Table

5 days ago 3 days ago Now

Born in NICU Dyspnea Referred to

Lhokseumawe Yellowish skin RSUDZA
Dyspnea

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 Appearance
Work of Breathing
- Tone : normal
- Nasal flare
- Interactiveness:
- Retraction
Consolable
intercostal and
- Look normal
epigastrial
- Speech: Able to cry

SAGA

Circulation
Conclusion: - Not pale
Respiratory - Not cyanosis
- Capillary refill time: < 2 secs
Distress - Warm extremities
Referral Letter
 ANTHROPOMETRY

• Body Weight : 2900 gram

• Body Length : 49 cm
• Head of Circumferrence : 34 cm
• Arm Circumferrence : 9,5 cm

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 Vital Sign
– Consciousness : Stage 5
– Pulse : 172 x/minute
– RR : 100 x/minute
– Temp : 36,9 0C
– Saturation : 89% (Room air)
– Pain scale : O nips
– Down Score : 5
 Physical Examination
• Head : Normocephaly
• Face : Symmetrical
• Eyes : Conj. Palp inferior not pale,
pupil isochor (3mm/3mm), light reflexes positive,
sclera icteric
• Nose : Nasal flare
• Mouth : No cyanosis, normal palate
• Neck : Symmetrical, no enlargement of lymph node
• Ears : Normotia

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• Thorax
Anterior:
Inspection : symmetrical, retraction epigastrial and intercostal, icteric
Auscultaion : Vesicular, no rhonchi, no wheezing

• Posterior:
Inspection : retraction, symmetrical, icteric
Auscultation : Vesicular, no rhonchi, no wheezing

• Cor
Inspection : Ictus cordis not seen
Palpation : Ictus cordis palpable on ics 5 linea midclavicula sinistra
Auscultation : S I > SII, Reguler, murmur negative.

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• Abdomen
Inspection : Not distented, icteric
Palpation : Soepel, normal skin turgor
Auscultation : Normal peristaltic

• Extremities
Superior : No edema, warm, CRT 2 seconds, icteric
Inferior : No edema, warm, CRT 2 seconds, icteric

• Anogenital : Male, testis palpable bilateral

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Ro. Babygram
(6/07/2021)
RSUDZA
 Laboratory Examination (5/7/2021)
Types Result Normal Range
Hemoglobin 15,4 12.7 – 18,7 g/dl
Hematokrit 44 45 - 55 % ANC: 12.768
Eritrosit 4,2 4,7 – 6,1 x 106/mm3
Trombosit 184 150 – 450 x 106/mm3
Leukosit 16,8 5 – 21 x 103/mm3
MCV 105 80 – 100 fL
MCH 37 27 – 31 pg
MCHC 35 32 – 36 %
RDW 16,3 11,5 – 14,5 fL
Eosinofil 2 0–6%
Basofil 1 0–2%
Netrofil Batang 0 2–6%
Netrofil Segmen 76 50 – 70 %
Limfosit 8 20 – 40 %
Monosit 13 2–8%
 Types 05/07/2021 Normal Range
GDS 224 < 200
Ca 8,2 8.6-10,3

Na 138 132-146

K 4,70 3,7-5,4

Cl 109 98-106

Ur 52 13-43

Cr 0,50 0,51-0,95

GFR 36.26 41,4-51,8

Bilirubin Total 23,13 0,3-1,2

Bilirubin Direct 0,65 <0,5

Bilirubin Indirect 23,13 <0,5

SGOT 40 < 35 U/L

SGPT 12 < 45 U/L

Albumin 3,10 3,5 – 5,2

 Types Result Normal Range
SGOT < 35 U/L
SGPT < 45 U/L
Albumin 3,5-5,2 g/dL
Blood glucose
at anytime < 200 mg/dL
Ureum 13-43 mg/dL
Creatinin 0,67-1,17 mg/dL
Calcium 8,6-10,3 mg/dL
Natrium 129-143 mmol/L
Kalium 3,6-5,8 mmol/L
Clorida 109 mmol/L

*GFR: 81 ml/minute/1,73 mm3

Normal Range: 61-74
 Differential Diagnosis
Respiratory Distress of Newborn ec dd/
1. Neonatal Pneumonia
2. Transient Tacypnea of Newborn
Susp sepsis neonatorum
Icterus Neonatorum ec dd/ 1. Late onset sepsis
2. Breast feeding jaundice
3. Hypothyroid
Aterm baby with appropriate gestational post sectio caesarea
 Working Diagnosis
- Respiratory Distress of Newborn ec Neonatal
Pneumonia
- Susp sepsis neonatorum
- Icterus Neonatorum ec Late onset sepsis
- Aterm baby with appropriate gestational post sectio
caesarea
 Fluid Requirement

Patient with actual body weight 2,9 kg

= 150cc x 2,9kg
= 435 cc/ day
 Nutritional Requirements
• Calories to boy with body weight 2,9 kg
= 100 x 2,9
= 290 kcal/day

• Proteins to boy with body weight 2,9 kg

= 3 x 2,9
= 8,7 grams/day
 Management
Supportif
• CPAP FiO2 40%, PEEP 8 cmH2O
• IVFD N5 17 cc/hour (GIR 10)
• Drip Aminosteril 10% 1gr/kgBB 29cc/day = 1,2cc/hour
• Diet fasting temporaly
• Light therapy 1 x 24 hours

Therapy
• Inj. Cefotaxime 145mg/12 Hours IV
• Inj. Gentamicin 15mg/ 24 Hours IV
• Drip Paracetamol 30mg IV prn
 PLANNING
• Main division Neonatology
• Septic work up : Blood culture, Procalcitonin
• Blood gas analysis
• Screening thyroid function
• Monitoring of vital sign
• Consult to Cardiology division
Clinical Video
 Follow up
• S/ Sesak napas masih ada, demam
• O/
– Consciousness : Stage 5
– Pulse : 145 beats/minute
– RR : 60x/minute
– Temp : 38,2 0C
– Saturation : 99 % (on CPAP)
– Pain scale : O nips
– Diuresis : 2,1 cc/kg/hour