Baby. Boy Mrs.

SH / 2 Days Old / 01146339 / BPJS

Attending: dr. Ismar, SpB, SpBA

April 25th , 2024

Arip
Reza
Febrian
Irsyad
Hamdan
Iqbal
 Baby. Boy Mrs. SH / 2 Days Old / 01146339 / BPJS
Attending: dr. Ismar, SpB, SpBA
Chief complaint
• Shortness of breath since birth since 2 days before admission

Present Illness
• Patient came from Syafira Hospital to the emergency room at Arifin Achmad Hospital with
complaints of shortness of breath since 2 days ago. Nausea(-), vomiting (-), normal
defecation and urination (+), flatus (+), cough complaints (-), fever (-),
• Previously patient was born with caesarean section on April 23th, 2024 with apgar score of
8/9. His mother always has a pregnancy check with an ob-gyn doctor and the ultrasound
picture was normal, there is no polyhydramnios.
• After carrying out an X-ray babygram examination after birth, it was found that there was a
left diaphragmatic hernia
• Due to limited facilities, the patient was referred to Arifin Achmad Regional Hospital for
further treatment.
 Baby. Boy Mrs. SH / 2 Days Old / 01146339 / BPJS
Attending: dr. Ismar, SpB, SpBA
History of past illness :
• History of prenatal infection (-)
 Baby. Boy Mrs. SH / 2 Days Old / 01146339 / BPJS
Attending: dr. Ismar, SpB, SpBA

History of birth :
• Third child, born was aterm 37-38 weeks, Caesarean delivery due to history of SC
2 times. Strong crying.

History of Maternal pregnancy :

• Maternal pregnancy history: the patient's mother ANC every month at the ob-gyn
Doctor
• History during pregnancy the his mother had no fever, cough (-), vaginal discharge
was absent
 Physical Examination

• Awareness : Alert • RR: 50 x/minutes

• Birth Body Weight : 2743 gram • HR: 140 x/minutes
• Body Weight : 2654 gram • T: 36,9 C
• SpO2: 98% room air
• BL : 48 cm
• HC : 37 cm
• CC : 27,5 cm
• AC : 30 cm
• Upper arm circumference : 9 cm
• Vital Sign
 Physical Examination

• Head: anemic conjunctiva (-/-), icteric • Abdomen: Localized Status

sclera (-/-), Mongoloid face (-), • Extremity: warm acral, CRT <2s,
Sunken fontanel (-), good turgor
• Eyes : Sunken eyes (-/-), Tears (+),
Dry lips (-), microtia (-/-)
• Neck: Normal
• Thorax: Localized Status
• Heart: normal 1st and 2nd heart sound,
murmur (-/-), gallop (-/-).
 VACTREL SYNDROME
• Vertebrae : Normal
• Atresia ani : Normal
• Cardiac : Need further examination
• Tracheoesofageal : Normal
• Renal : Need further examination
• Limb : Normal
 Dehidration scorring
Maurice King Score
0 1 2

restless crybaby, Delirious,

General Condition Healthy
apathetic, sleepy coma/shock
Turgor Normal Little, less Very less

Eye Normal Slightly sunken Very sunken

back crown Normal Slightly sunken Very sunken

Mouth Normal Dry Dry, cyanosis
Currently (120-140 Weak
Pulse Strong (<120 x/minute)
x/minute) > 140 x/minute

Score :
Total Score : 1
– 0-2 mild dehydration

– 3-6 moderate dehydration

– 7-12 Severe dehydration

 Localized status of Chest

• I : Symmetrical chest wall movement,

Retraction (+)
• P : (-)
• P : resonance percussion at Right and left
chest
• A : Vesicular (+/Decrease), Bowel sound at
left hemithorax, Rales (-/-) , Wheezing (-/-)
 Localized status of Chest

Right View Left View

 Localized status of Abdomen

• I : Scaphoid (+) ,venectation (-), darm steifung

(-), Darm contour (-),
• A : Bowel Sound (+) increased
• P : Defans muscular (-)
• P : Tympani
 Localized status of Abdomen

Right View Left View

 Localized status of Genitalia

• Penis : OUE Normal

• Anus: Anal dimple (+)
• Anal canals (+)
• Stool (+) coming out through the
Anal Canal
 Working Diagnosis Therapy
• Suspected Left Diagphragmatic Hernia Syafira Hospital therapy:
• DD left Evatratio Diapghragmatic • N5KCL 12,3cc/hours
• Pycin 2x135 mg IV
• Gentamicin 1x14 mg IV

Suggestion:
• Laboratory test
• Consult to Pediatric Surgeon
Laboratory Result (April 25th 2024) RS Syafira
Type Value Unit Normal Value

Haemoglobin 15,5 g/dL 13,0 - 16,0

Haematocrit 42.7 % 40,0 - 48,0

WBC 15,8 10^3/µl

Platelet 292 10^3/µl 150 - 400

BT 3 Minutes 1-3

CT 12 Minutes 5-15

CRP quantitative <6 mg/L 0.0 – 6.0

ABO O

Rh + +/-
 Baby gram X-Ray (April 25th,
2024)
Thorax:
• Airway: trachea was at middle site
• Bone : no discontinuity
• Cardiac: normal (CTR < 50%), Deviation to the right
• Diaphragm: Left diaphragm was not visible
• Field of the lung: There was heterogenous opacity on
left lung and bowel gas

Abdomen:
• Air fluid level (-)
• hearing bone appearance (-)
• dilatation of intestinal (-)
• double bubble (-)
• Gas distribution at the pelvic (-)
 Diagnosis Performed
• Left Diagphragmatic Hernia Bochdalek Consult to dr. Ismar Sp.B Sp.BA
Type Non Pharmacotherapy
• O2 0.5 Lpm
• NICU Care
• Planning For Exloration Laparatomy Repair
Diagphragma

Pharmacotherapy
• Pycin 2x135 mg
• Gentamicin 1x14 mg

ICD 10
K44.9/Diapghragma Hernia
THANK YOU