MORNING REPORT

MONDAY, MARCH 13th 2023

CASE REPORT
 IDENTITY
• Name : By. NNND
• Gender : Male
• Age : 3 day
• Nationality : Indonesia
• Religion : Hindu
• Address : Banjar Demulih, Susut, Bangli
• Medical record : 23011598
• Date of admission : March 10th , 2023 at 11.44 PM
 HISTORY TAKING
Present History
Chief complaint: Shortness of breath
• The patient referred from BMC Hospital for comprehensive management with referral
diagnosis Term Baby, Appropiate for Gestational Age, Post Sectio Caesarea,
Respiratory Distress ec Pneumonia, Left Basal Lung Bulla, Early Onset Neonatal
Sepsis.
• The patient was delivered by caesarean section (07/03/2023) due to fetal distress
(fetal heart rate 60 bpm) and cephalopelvic disproportion.
• Patient cried immediately after birth, but found rapid breathing with chest retraction
and oxygen saturation 93% accompanied by groaning cry. The amniotic fluid was
green.
• Cyanosis when birth was denied. Lethargic and temperature instability was denied.
• At pediatric triage, there were no respiratory distress and chest retraction. No bluish
appearance, lethargy, temperature instability and fever or cough.
• The patient had already defecated and urinated.
• The patient has been hospitalized for 3 days and received therapy with ampicillin 170
mg every 12 hours and amikacin 25 mg every 12 hours.
 HETEROANAMNESIS
Antenatal History
The patient was the first child. The mother said to have regular antenatal
visit at the midwife and at obstetrician with USG examination. The first day
of last menstruation was forgotten.

Mother's diagnosis
G1P0000 gestational age 39-40 weeks S/L, Fetal distress (fetal heart
rate 60 bpm) + Cephalopelvic disproportion.

Mother's Disease History

During pregnancy the patient complained of itching and received 3 allergy
medicine. History of diabetes mellitus, hepatitis B, tuberculosis infection,
hypertension, immunodeficiency, cardiac problem, syphilis infection was denied.
 HETEROANAMNESIS
Intranatal History
History of urinary tract infection (-)
History of vaginal discharge (-)
History of fever, bleeding, ruptured membranes, history of dexamethasone
therapy or other therapy was denied.

Risk factors of infection

MAYOR MINOR (+2)
Mother fever >38oC - PRM >12 hour -
PRM >24 jam - Asphyxia -
Chorioamnionitis - Very low birth weight baby -
Fetal distress + Gestation age < 37 week -
Green amniotic fluid + twin -
    vaginal discharge -
    Suspected urinary tract infection -
    Fever (>37,5OC) -
 Pemeriksaan
PHYSICAL Fisis
EXAMINATION
Status Present
Reflex Tone Activity : weak
Cry : weak
Pulse : 110 beats per minute
Respiration : 50 times per minute
Axillary Temperature : 37 °C
O2 saturation : 98 % pre and post ductal rooms air
 PHYSICAL EXAMINATION
Head : normocephalic, opened and flat anterior
fontanelle, opened and flat posterior
fontanel,cephalhepatoma (-), caput succadenum (-)
Eye : pale (-/-), icteric (-/-), pupil isochore +/+,
light reflex (+/+)
ENT : no nostril breath, no cyanosis
• Mouth : no cleft palate, no cyanosis
• Neck : no gland enlargement.
Thorax : symmetrical, no retraction,
areola mama bud 5 mm/5 mm
Cor : S1S2 normal, regular, no murmur
Pulmo : bronchovesicular +/+, no rales, no wheezing
 Pemeriksaan Fisis
PHYSICAL EXAMINATION
Abdomen : distension (-), bowel sound is normal, no great
vein venectation, liver just palpable, spleen not
palpable, umbilical hernia (-)
Genitalia : testes down, good ruggae
Anus : present
Extremity : warm, CRT ≤3 seconds, plantar creases 2/3
anterior
Skin : No Cyanosis
Nail : reaches fingertips
Congenital anomaly : there was no congenital anomaly
 Pemeriksaan Fisis
ANTROPOMETRIC STATE
• Birth weight : 3270 gram
• Birth length : 51 cm
• Current Weight : 2985 gram
• Current Length : 51 cm
• Head circumference : 34 cm
• Chest circumference : 33 cm
Pemeriksaan Fisis
APGAR SCORE

APGAR Score 7-8

 SPECIAL EXAMINATION

DOWNE SCORE
Examination 0 1 2
Respiration <60 60-80 times/minute >80 times/minute
rate times/minute
Retraction No retraction Mild retraction Severe retraction
Cyanosis No cyanosis Cyanosis reduced by O2 Cyanosis with O2

Air entry Good bilateral Mild decrease in air No air entry

air entry entry
Grunting No grunting Audible by stethocsope Audible with ear

TOTAL SCORE 1
Special Examination

3
3
3
2
3
2
2
Total : 18
 Special Examination

•Lubchenco score
Special Examination
 COMPLETE BLOOD COUNT at BMC HOSPITAL (07/03/2023)
Parameter Result Normal limit
WBC 7,31 10 /µL
3
9.10 – 20.00
NE% 55,8 % 17.0 – 68.0
LY% 32,7 % 20.0 - 70.0
MO% 10,3 % 0.0 – 14.0
EO% 0,5 % 0.0 – 6.0
BA% 0,7 % 0.0 – 1.0
NE# 4,08 103/µL 6.00 – 28.00
LY# 2,39 103/µL 2.00 – 11.00
MO# 0,75 103/µL 0.00 – 0.70
EO# 0,04 103/µL 0.00 - 0.40
BA# 0,05 103/µL 0.00 - 0.10
RBC 3,96 106/µL 4.0 – 6.8
HGB 14,6 g/dL 15.2 – 20.4
HCT 41,3 % 44 – 72
MCV 104,3 fL 94 – 150.0
MCH 36,9 pg 29 - 45
MCHC 35,4 g/dL 24 – 36
RDW 16 % 14.9 – 20.0
PLT 277 103/µL 150 – 440
MPV 9,8 fL 6.8 – 10.0
 BLOOD SUGAR LEVEL at BMC HOSPITAL (07/03/2023)

Parameter Result Normal limit

Random Blood 85 mg/dL 50 -60
Glucose

Procalcitonin count at B HOSPITAL (07/03/2023)

Parameter Result Normal limit

Procalcitonin (PCT) 17,17 ng/mL <0,5: Normal
0,5 – 1,9:
Probably
infected
2 -10: Infected
>10: Sepsis
 ]

SUMMARY
• 3 day male patient was referred from BMC Hospital with diagnosis term
Baby, Appropiate for Gestational Age, Post Sectio Caesarea, Respiratory
Distress ec Pneumonia, Left Basal Lung Bulla, Early Onset Neonatal
Sepsis.
• The patient was delivered by caesarean section due to fetal distress (fetal
heart rate 60 bpm). Patient cried immediately after birth, but found
rapid breathing with chest retraction and oxygen saturation 93%
accompanied by groaning cry. The amniotic fluid was green. Patient
with 2 mayor risk factor of infection.
• From physical examination, found normal without rapid breathing and
retraction, oxygen saturation was 98% pre and post ductal room air.
From laboratories found increasing procalcitonin.
 WORKUP DIAGNOSIS

Term baby (O80) + Appropriate for gestational age + Vigorous

baby + Respiratory distress due to suspect neonatal pneumonia
(P23.0) dd/ early onset neonatal sepsis (P36.9) + Suspect early
onset neonatal sepsis (P36.9)
 PLAN OF CARE

No Problem List Intervention Plan Target

1 Risk of hypotermia put on full clothes and
- hypothermia does not
take care in box occur

2 Risk of Breastfeeding and fluid - hypoglicemia does not

hypoglicemia
occur

3 Respiratory Septic marker Diagnosis Estabilished

distress et causa -
  suspected Chest X-Ray - infection resolved
  neonatal Antibiotic
pneumonia dd/
Early onset of Blood culture
neonatal sepsis
 COMPLETE BLOOD COUNT AT PN HOSPITAL (11/03/2023)
Parameter Result Normal limit
WBC 12.74 103/µL 9.10 - 34.0
NE% 42.90 % 65.90 - 69.10
LY% 41.70 % 27.40 - 30.80
MO% 10.80 % 0.0 - 10.30
EO% 4.40 % 0.0 - 5.80
BA% 0.20 % 0.0 - 1.10
NE# 5.46 103/µL 6.00 - 23.50
LY# 5.31 103/µL 2.50 - 10.50
MO# 1.38 103/µL 0.00 - 3.50
EO# 0.56 103/µL 0.00 - 2.00
BA# 0.03 103/µL 0.0 - 0.4
RBC 4.21 106/µL 4.0 - 6.6
HGB 14.60 g/dL 14.5 - 22.5
HCT 40.00 % 45.0 - 67.0
MCV 95.00 fL 92.0 - 121.0
MCH 34.70 pg 31.0 - 37.00
MCHC 36.50 g/dL 29.00 - 36.00
RDW 15.40 % 14.9 - 18.7
PLT 387.00 103/µL 140 - 440
MPV 9.80 fL 6.80-10.00
NLR 1.03 <=3.13
 IT RATIO & CRP AT PN HOSPITAL (11/03/2023)

Parameter Result Unit Reference Value

IT Ratio 0.24 < 0.20
Quantitative CRP 29.40 mg/dL <5
 Thorax AP AT PN HOSPITAL (11/03/2023)

Interpretation
- Pneumonia
- Cor was no abnormality
 ASSESMENT

Term baby (O80) + Appropriate for gestational age + Vigorous

baby + Respiratory distress due to neonatal pneumonia (P23.0)
(P36.9) + Suspect early onset neonatal sepsis (P36.9)
 INSTRUCTION

• Wear complete clothes (hat, shirt, gloves, socks) in box

• Fluid requirement 90 ml/kg/day ~ 280 ml/day~ IVFD D10% 12 ml per hour
• O2 low flow 0,2 lpm
• 4/ Ampicilin 50 mg/kgBW/times ~ 156 – 160 mg every 8 hour intravenously
• 4/ Amikacin 15 mg/kgBW/times ~ 47 – 50 mg every 24 hour intravenous
• Blood culture before antibiotics
FOLLOW UP
 FOLLOW UP
11/03/2023 at 08.00 AM
Subjective General status
No lethargic, no temperature instability, no jaundice. • Head : normocephalic
No rapid breathing, No chest indrawing • Thorax : Symmetrical, no retraction
• Cor : S1S2 normal, murmur (-)
Objective • Lungs : Vesicular, rales -/-, wheezing -/-
Status present • Abdomen: not distended, normal peristaltic
• Pulse : 132 beats/minutes • Extremities : warm, CRT < 3 seconds
• Respiration : 26 times/minutes
• Temperature : 36,6 oC
• O2 Saturation : 98% rooms air
 ASSESMENT

Term baby (O80) + Appropriate for gestational age + Vigorous

baby + Respiratory distress due to neonatal pneumonia (P23.0)
(P36.9) + Suspect early onset neonatal sepsis (P36.9)
 INSTRUCTION

• Wear complete clothes (hat, shirt, gloves, socks) in box

• Fluid requirement 90 ml/kg/day ~ 280 ml/day~ IVFD D10% 12 ml per hour
• O2 low flow 0,2 lpm
• 5/ Ampicilin 50 mg/kgBW/times ~ 156 – 160 mg every 8 hour intravenously
• 5/ Amikacin 15 mg/kgBW/times ~ 47 – 50 mg every 24 hour intravenous
• Blood culture before antibiotics
THANK YOU