LONG CASE REPORT

VERY LOW BIRTH WEIGHT (1450 GRAMS) (P07.15),

APPROPRIATE FOR GESTATIONAL AGE, VERY PRETERM
INFANT (P07.34), GRADE I HYALINE MEMBRANE DISEASE
(P22.0), CLINICALLY EARLY-ONSET SEPSIS (P36.9),
NEONATAL JAUNDICE DUE TO PREMATURITY DD
CLINICALLY EARLY-ONSET SEPSIS (P59.0)

By :
Heriyanto

Local Evaluation
Denpasar, July 18th , 2019

POSTGRADUATED PEDIATRIC TRAINING PROGRAMME

DEPARTMENT OF CHILD HEALTH
FACULTY OF MEDICINE UDAYANA UNIVERSITY
SANGLAH HOSPITAL DENPASAR
2019
 a. Patient identity
Name : Baby NNS
Age at case determination : 12 days old
Date of birth : June 26th, 2019
Sex : Female
Address : Indonesia
Date of admission : June 26th 2019
Date of case determination : July 8th 2019
Medical record number : 19028994
b. Parents identity
Father Mother
Name (initial) KA NNS
Age 33 years old 29 years old
Education Diploma Senior high school
Occupation Tour Guide Hotel employee

II. History taking (Subjective)

History of illness was gathered from parents and paramedics.
1. Chief complaint: shortness of breath
The patient was born prematurely at 31 weeks of gestational age. Baby was delivered
by emergency caesarean section due to fetal distress. The patient cried immediately
after birth and was vigorous baby. When the patient was observed, the patient had
shortness of breath accompanied by chest indrawing and grunting. There was no
discoloration on mouth and extremities. The patient was stabilized and admitted to
level III neonatal ward with incubator and continuous positive airway pressure
(CPAP) support. Respiratory distress was still noted after patient admitted in neonatal
ward. Due to her instability, patient must be treated with breathing support and being
fasted during first day of care and was given parenteral nutrition.
Two days after birth the patient was given breastmilk through orogastric tube
because the sucking and swallow reflexes of the patient were still poor. The amount
of breast milk given was 10ml/kg/day and due to good tolerance, the amount of
feeding is increased gradually. He had never complained abdominal distention nor
vomiting.

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 Patient also had received vitamin K injection and Hepatitis B vaccination. There was
no history of temperature instability or seizure. The patient had urinated and passed
meconeum during 24 hours of life.
2. History of past illness
No history of past illness.
3. History of family health
Parents never suffered from severe illness. There is no history of prematurity in
parent’s family.
Conclusion: there is no history of prematurity in family.
4. Social history
a. Mother pregnancy history
The patient was born from a 29 years old mother. It was the second pregnancy.
The first day of the last menstrual period was February 27th, 2018, with estimation
date of delivery at August 27th, 2019. Mother routinely visited obstetrician and
midwife for antenatal care. Ultrasonography examination revealed normal
pregnancy. Mother routinely consumed multivitamins during pregnancy given by
the obstetrician.
The mother complained of vaginal discharge since the first week of
pregnancy. She said it was yellow–greenish coloured thick mucuos and sometimes
itchy and smelly. She was given antibiotic from obstretician for 7 days (she
forgotten the name). After taking antibiotics the condition was getting better.
Severel weeks later, she had the same complaint but she did not feel disturbed.
She did not report it to the obstetrician thus she did not received any treatment.
She did not experience any fever nor urinary pain during pregnancy.
On the 30 weeks of pregnancy (June 19th 2019), the mother went to the a
private hospital due to leakage of amniotic fluid since morning. The mother was
administered dexamethasone injection for 3 times intravenously. After 6 days
being treated in that private hospital, the amniotic fluid leakage had not stopped
and she started to complain of uterine contraction, so that the mother then was
reffered to A hospital for further examination and treatment.
No history of smoking nor alcohol consumption before as well as during
pregnancy. There was also no history of hypertension nor high blood glucose
during pregnancy.

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 Conclusion: the mother had been hospitalized once during pregnancy due to
leakage of amniotic fluid.
b. Intranatal history
Mother experienced intermittent abdominal pain approximately 12 hours before
delivery. The patient was delivered by emergency cesarean section due to fetal
distress. He was vigorous baby with good muscle tone with APGAR score 7-8
and the body weight was low (1450 grams). The amniotic fluid was clear.
Conclusion: patient was born by cesarean section. Patient was born on 31st week
of pregnancy, very low birth weight (1450 grams).
c. Post natal history
The patient was given umbilical cord care and vitamin K1 (phytomenadione)
injection 1 mg intramuscularly short after delivery. Short after delivery, patient
had cyanosis on mouth and both extremities, as well as chest indrawing. Patient
still had grunting after being resuscitated.
Conclusion: the patient had respiratory distress.
d. Nutritional history
After birth, patient was fasted for 24 hours then given preterm milk formula 10
ml/kg/day. Fluid and energy requirements were fulfilled with parenteral nutrition.
Enteral nutrition volume was gradually increased in second day as the patient
showed good tolerance. Patient had preterm formula every 3 hours through
orogastric tube (OGT).
Conclusion: appropriate nutrition fulfillment.
e. Growth history
Patient birth weight was 1.450 gram, birth length was 44 cm, and head
circumference was 29 cm, and chest circumference was 26 cm. The movement of
four extremities were symmetrical.
Conclusion: growth was appropriate for gestational age.
f. Immunization history
No history of immunization.
g. Basic needs history
Stimulation : The mother started to do intermittent kangaroo mother care. She
often talk, cares and sings lullaby to the patient.
Parenting : Patient was the second child of the family, and was conceived from
an intended pregnancy. Parents seemed to love and support the

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 patient. His mother always visit the patient regularly but her father
had limited time to visit him due to his work. But they still follow
the progress by asking the patients’s condition
Caring : Patient was given parenteral nutrition at birth. Trophic feeding was
started on the second day of life. Enteral nutrition was gradually
increased in volume.
Conclusion : optimal fulfillment of stimulation, parenting, and caring.

h. Socio-economic family condition

Patient was the second child. The patient’s family live in their own house. The
house was facilitated with kitchen, private bathroom with electricity and water.
The electricity source was from the state electricity company, and the water source
was from the state water company. Her father work as tour guide and mother as a
hotel employee. Family income was approximately 3,000,000 - 5,000,000
IDR/month.
Conclusion: family with middle socioeconomic status.

III. History During Admission Until Determination as Case

On the first day of treatment in level III neonatal ward (June 27th 2019), patient was
unstable with respiratory distress. But the patient was not lethargic, without any
temperature instability nor vomiting. Physical examination showed patient was
moderately ill, poor activity, muscle tone and reflexes, with temperatures ranged between
35.6-36.40C, pulse rate 140-150 beats/minute, respiratory rate 40-50 breaths/minute.
Oxygen saturation ranged between 85-90%. and pain score was four with Neonatal Pain
Assessment Tools (NPAT). There were slight chest indrawing, lung auscultation revealed
no rales and wheezing and no heart murmur. He had poor sucking reflex. Complete blood
count obtained leukocytes 28.23 K/uL (neutrophils 18.90 (66.94%), lymphocytes 5.23
(18.52%)); hemoglobin 12.77 g/dL; hematocrit 37.84%; platelets 279.20 K/mL; IT ratio
0.59; blood smear revealed normal limit without vacuolization nor toxic granule; blood
glucose 90 mg/dL after birth. Antero-posterior chest x-ray showed slight reticulogranular
pattern in both lung fields in accordance to grade I hyaline membrane disease. Patient was
assessed with very low birth weight (1450 gram) (P07.1), appropriate for gestational age
(P05.0), very preterm infant (31 weeks) (P07.3), grade I hyaline membrane disease
(P22.0) clinically early-onset sepsis (P36.9). Patient was treated in level III neonatal ward

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with incubator and NIV support. Patient was given parenteral nutrition containing
dextrose that was given with total fluid of 90 ml/kg/day (glucose infusion rate (GIR) 5.5
mg/kg/minute). First line intravenous antibiotic was given, ampicillin 50 mg/kg/dose
every 12 hours and amikacin 7.5 mg/kg/dose every 18 hours. Administration of preterm
formula start at 10 ml/kg/day.Intramuscular vitamin K1 0,5 mg was given in the delivery
room. Monitoring was performed for symptoms, vital signs, and fluid balance.
On the second to fourth day of treatment (June 28th– 30th 2019) in level III
neonatal ward, the patient was stable, not lethargic, without any temperature instability,
vomiting, bradycardia, or respiratory distress. Slight yellowish skin appeared on her face.
Physical examination revealed good activity, tone, and reflexes, temperature ranging
between 36.6-37.3oC, heart rate was 128-142 beats/minute, respiratory rate was 40-48
breaths/minute. Blood sugar 80-100 mg/dL. Patient was assessed with very low birth
weight (1450 gram) (P07.1), appropriate for gestational age (P05.0), very preterm infant
(31 weeks) (P07.3), grade I hyaline membrane disease (P22.0) clinically early-onset
sepsis (P36.9). Fluid requirement was increased from 100 to 120 ml/kg/day. The patient
then use CPAP support then the setting was gradually decreased until replaced with high
flow O2 nasal canule. Administration of preterm formula increased gradually up to 40
ml/kg/day. Parenteral nutrition was given with GIR 4-5 mg/kg/minute. Antibiotics was
continued. Monitoring was performed for symptoms, vital signs, and fluid balance.
On the fifth to eight day of treatment (July 1st–4th 2019) in level III neonatal
ward, the patient was stable, not lethargic, without any temperature instability, vomiting,
bradycardia, nor respiratory distress. Yellowish skin with grade IV kramer. Physical
examination revealed good activity, tone, and reflexes, temperature ranging between
36.6-37.3oC, heart rate was 134-145 beats/minute, respiratory rate was 40-48
breaths/minute. Blood sugar 80-90 mg/dL. Complete blood count was evaluated obtained
leukocytes 34.31 K/uL (neutrophils 23.61 (68.80%), lymphocytes 5.20 (15.14%));
hemoglobin 12.99 g/dL; hematocrit 36.52%; platelets 440.70 K/mL, IT ratio 0.48.
Bilirubin evaluation showed total bilirubin 9.57 mg/dL, indirect bilirubin 9.05 mg/dL,
direct bilirubin 0.52 mg/dL. Patient was assessed very low birth weight (1450 gram)
(P07.1), appropriate for gestational age (P05.0), very preterm infant (31 weeks) (P07.3),
grade I hyaline membrane disease (P22.0) clinically early-onset sepsis (P36.9), neonatal
jaundice due to prematurity diferential diagnosed clinically early-onset sepsis (P59.0)
Fluid requirement was increased from 130 to 150 ml/kg/day. Administration of preterm
formula increased gradually up to 100 ml/kg/day. Parenteral nutrition was given with GIR

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3.5-5 mg/kg/minute. Antibiotics was continued. Phototherapy was given for two days.
Monitoring was performed for symptoms, vital signs, and fluid balance.
On the ninth to twelve day of treatment (July 5th–8th 2019) in level II neonatal ward,
the patient was stable, not lethargic, without any temperature instability, vomiting,
bradycardia, or respiratory distress. Slight yellowish skin with grade IV kramer. Physical
examination revealed good activity, tone, and reflexes, temperature ranging between
36.6-37.6oC, heart rate was 136-142 beats/minute, respiratory rate was 40-48
breaths/minute. He showed poor sucking reflex. Body weight started to increased from
1400 to 1500 grams. Blood sugar 70-90 mg/dL. Complete blood count was evaluated
obtained leukocytes 21.52 K/uL (neutrophils 11.81 (54.89%), lymphocytes 5.92
(27.49%)); hemoglobin 10.89 g/dL; hematocrit 30.85%; platelets 527.40 K/mL, IT ratio
0.07, procalcitonin 0.29 ng/mL. Bilirubin evaluation after fototherapy showed total
bilirubin 6.71 mg/dL, indirect bilirubin 5.81 mg/dL, direct bilirubin 0.9 mg/dL. Patient
was assessed with very low birth weight (1450 gram) (P07.1), appropriate for gestational
age (P05.0), very preterm infant (31 weeks) (P07.3), grade I hyaline membrane disease
(P22.0) clinically early-onset sepsis (P36.9), neonatal jaundice due to prematurity
differential diagnosed clinically early-onset sepsis (P59.0). Fluid requirement was 150
ml/kg/day. Nutritional requirements was with breast milk through orogastric tube. Iron
supplementation, multivitamins and minerals were initiated. Monitoring was performed
for symptoms, vital signs, and fluid balance. Monitoring was performed for symptoms,
vital signs, and fluid balance. Patient was moved to level II neonatal ward.
IV. Physical examination (objective) on July 8th, 2019
a. Present status
General condition : good activity, muscle tone, reflex, and cry
Pulse rate : 132 times/minutes, regular
Respiration rate : 40 times/minutes, regular
Axila temperature : 36.9°C
Oxygen saturation : 96% (room air)
Neonatal Pain Assessment Tools (NPAT) score: 0
b. General status
Head : normochepaly (head circumference 27 cm), major fontanelle
opened and flat, diameter 1 cm, thin and smooth hair. Minor
fontanelle was closed.
Face : no abnormality, no edema, no syndromic facies.

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 Eye : no sunken eyes, no palpebral edema, symmetrical of both
eyelids, conjunctiva was not pale, sclera was not icteric, both
pupils were round, diameter were 2 mm with good light reflexes.
Ear : no abnormality in shape, no secretion was found. Soft curved
pinna, soft, slow recoil.
Nose : no nasal flare, no septal deviation, no secretion, no bleeding,
excoriation was observed on nasal septum.
Throat : no palatal cleft, pharynx and tonsils were normal.
Mouth : no cyanosis on surrounding mouth and tongue, no enlargement
of tongue, no white plaque on tongue and mouth, symmetrical of
both corners of the mouth, no drooling, weak sucking reflex,
good swallowing reflex, positive rooting reflex.
Chest : strippled areola, bud diameter both 2 mm
Cardiac :
Inspection : no ictus cordis was seen, no pulsation.
Palpation : ictus cordis was palpable in the intersection of left midclavicular
line and fourth intercostals space, without thrill.
Auscultation : normal heart sounds, regular, M1>T1, P2>A2, no murmur.
Lung :
Inspection : normal chest shaped, symmetrical on static and dynamic,
without retraction.
Palpation : symmetrical chest movement.
Auscultation : bronchovesicular, neither rales nor wheezing were found.
Breast : stippled areola 3 mm in diameter, 1.5 cm bud, pink colour
Abdominal :
Inspection : no distension, superficial vein apparent, no umbilical hernia
Auscultation : normal peristaltic
Palpation : liver was just palpable, unpalpable spleen
Percusion : tympanic
Genitals : testis in upper canal, rare rugae
Anus : normal anus
Limbs :
Upper : no single palmar crease, no short fingers, warm on palpation, no
cyanosis of fingers, no clubbing fingers, palm was not pale,

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 normal muscle tone, palmar grasp reflex on both hands, positive
Moro reflex, no edema.
Lower : no short fingers, warm on palpation, no cyanosis of fingers, no
clubbing fingers, sole was not pale, normal muscle tone, no
edema, positive Babinsky reflexes. Anterior one third crease on
plantar surfaces.
Skin : reddish, not pale, superficial peeled, not icteric, visible vein, no
petechiae or hematoma on the skin, no cutis marmorata, lanugo
was abundant with bald areas found, Kramer IV
Lymph nodes: no lymph nodes enlargement found on neck, axilla, or inguinals.
c. Anthropometric status
Current weight : 1525 gram
Birth weight : 1450 gram (Lubchenco curve p 50)
Current body length : 45 cm
Birth body length : 44 cm (Lubchenco curve p 50)
Current head circumference : 29 cm
Head circumference on birth : 29 cm (Lubchenco curve p 75 )

Anthropometric status on Fenton Growth Chart

Weight/age : 10 – 50th percentile
Length/age : 10th – 50th percentile
Head circumference/age : 10th – 50th percentile

d. Primitive reflex examination

Tone : within normal limit.
Movement : spontaneous movement of the limbs, trunk, face and
neck. No tremor or clonic movement.
Reflex examination :
Palmar grasp reflex : positive
Rooting reflex : positive
Swalowing reflex : positive
Sucking reflex : positive
Grasp reflex : positive
Moro reflex : positive

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 Cranial nerve :
N I,II : can not be evaluated.
N III, IV, VI : no palpebral retraction, no ptosis, pupil reflex
+/+ equally, normal eyes movement.
NV : can not be evaluated.
N VII : equal nasolabial folds, symmetric facial
movement.
N VIII : can not be evaluated.
N IX, X : swallowing reflexf (+).
N XI, XII : can not be evaluated.

V. Resume
Patient was 12 days old female, second child from married parents.He was born by
emergency caesarean section due fetal distress with gestational age of 31-32 weeks (New
Ballard Score), with Apgar score 7-8. Her birthweight was 1450 grams, body length was
44 cm, and head circumference was 29 cm. Amniotic fluid was clear and foul-smelling
with complete placenta, no hematoma or calcification were found. During pregnancy
mother had routine antenatal care in obstetrician and midwife. There was two major risk
factor of neonatal sepsis i.e rupture of membrane more than 24 hours and fetal distress.
Two minor risk factors of neonatal sepsis were also found, i.e gestational age less than 37
weeks, and very low birth weight. Physical examination revealed lethargic baby with
respiratory distress (Downe’s score was 4). Chest x-ray showed reticulo-granular pattern
supporting for grade I hyaline membrane disease. First line antibiotics were administered
accompanied with neonatal nutritional care. Sucking reflex was poor, still using the
orogastric tube. Evaluation of clinical condition and septic marker of first line antibiotics
showed good improvement.

VI. Diagnosis
Very low birth weight (1450 grams) (P07.1), appropriate for gestational age (P05.0),
preterm infant (31-32 weeks) (P07.3), respiratory distress due to grade I hyaline
membrane disease (P22.0), clinically early-onset sepsis (P36.9), neonatal jaundice due to
prematurity (P59.0) differential diagnosis clinically early-onset sepsis.

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VII. Problems
1.
2. What is choice of oxygen therapy that should be used in Infant with respiratory
distress syndrome?
3. What are the risk factors for ROP in preterm and low birth weight infant?
4. How is the neurodevelopmental outcome in preterm infant?

VIII. Planning
a. Emergency management
Emergency management is not necessary due to normal physical findings and
stable haemodynamic status.
b. Diagnostic
1. Screening for ROP
2. Screening for hearing impairment
3. Screening neurologic abnormalities
c. Supportive and pharmacological therapy
1. Nursing the patient in incubator
2. Continous positive airway pressure (CPAP) support for ventilation
3. Intermittent kangaroo mother care
4. Iron and multivitamin supplementation
d. Nutritional pediatric care
1. Nutritional assessment: 50th percentiles of weight/age Fenton growth chart,
10-50th percentiles of length/age Fenton growth chart, 10-50th percentiles head
circumference/age Fenton growth chart.
2. Nutritional requirement: daily fluid requirement for patient is increased until
150 ml/kg. Minimal energy requirement is 120 kcal/kg/day, protein 3.5
gr/kg/day, and lipid 40-55 % from total daily energy requirement.
3. Nutritional route: enteral with OGT due to poor sucking reflexes.
4. Nutritional selection: breast milk or preterm formula
5. Monitoring: nutritional tolerance (vomiting, diarrhea, abdomen distention),
complications (including necrotizing enterocolitis, and overfeeding), fluid
balance, urine production (1-3 ml/kg/hour), and growth.
e. Monitoring

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1. Monitoring of temperature and humidity, patient was put in incubator with neutral
thermal environment (temperature range of 30.5°C–33.5°C). The body
temperature was observed every 3 hours and kept in the range of 36.5-37.5°C.
2. Monitoring of blood sugar to avoid hypoglycemia or hyperglycemia, in
accordance to clinical symptoms and signs.
3. Monitoring of fluid balance (including insessible water loss 20-30 ml/kg/day for
weight >1500 g) and urine production.
4. Monitoring nutritional tolerance and complete blood count every 7 days. Liver
function test, renal function test, blood sugar and electrolite if necessary or
according to clinical condition.
5. Monitoring of body weight daily with increment target of 10-20 g/kg
bodyweight/day. Monitoring of length every week with increment target of 0.8-1
cm/week. Monitoring of head circumference with increment target of 0.5-0.8
cm/week. Monitoring of growth is adjusted with Fenton growth chart until 40
weeks of post conceptional age.

f. Prevention of complication
1. Risk of iron deficiency. Patient was given iron supplementation of 2 mg/kg/day
elemental iron when the patient is stable or full feed. Vitamin and mineral
supplementation was administered when the patient was full feed.
2. Risk of growth and development disorder (neurodevelopment and cognitive).
Patient was monitored for body weight, length and head circumference. Growth
was plotted on Fenton curve until 40 weeks of postconceptional age. Patient was
stimulated by infant massage therapy. Developmental screening examination will
performed by Denver II when the patient has reached 40 weeks of post
conceptional age. Screening will performed every 2 weeks in the first month and
then every month.
3. Risk of complication from the disease and therapy. Prematurity, infection and
oxygen treatment can cause retinopathy of prematurity (ROP) or periventricular
leukomalacia. Prematurity or aminoglycoside can give risks for patient of having
hearing disorder. Patient was already conducted for ROP screening.
4. Hearing disorder will be screened at outpatient clinic by performing oto acoustic
emission (OAE) examination. If it reveals pass, the patient will be monitored for
speech development and audiology every 6 months for 3 years, however if it

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 reveals refer, the patient will be evaluated for otoscopy, tympanometry and
automated auditory brainstem responses (AABR) at 3 months of age.
5. Osteopenia: calcium, phosphate, and ALP evaluation performed for infant with
gestational age <34 weeks and birth weight <1800 grams, and conducted until 3
months corrected age.
g. Communication, information, and education
1. Parents were given explanation about the disease, therapy, risk of complication,
and prognostic of patients.
2. Mother was informed and prepared for caring the baby with kangaroo mother care
and also suggest to breastfeed her baby, informed about hygiene and how to
stimulate preterm infants to reach optimal growth and development.
3. Parents were informed about examination that will performed such as screening
of ROP, hearing disorder, and growth and developmental.
4. Parents were informed about immunization planning that will be given started
with hepatitis B and polio vaccine.

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IX. FOLLOW-UP

Day Subjectives Objectives Assessment Planning

Day 14th The patient Physical examination: Very low birth weight (1450 Therapy
(July, 9th - was stable, not Present status grams) (P07.1), appropriate for  Incubator with room air
2019) lethargic, Good activity, muscle tone, reflexes, and cry gestational age (P05.0),  Fluid requirement 150 ml/kg/d ~ 218
without any Vital signs: preterm infant (31-32 weeks) ml/d
temperature Heart rate: 132-140 times/minute. (P07.3), respiratory distress  Breastmilk/LBW formula 30 ml
instability, Respiratory rate: 40 times/minutes, reguler. due to grade I hyaline every 3 hours (8 times)
vomiting, Axillary temperature: 36.7-36.9°C. membrane disease (P22.0),
bradycardia, Oxygen saturation: 96% (room air). clinically early-onset sepsis Diagnostic
or respiratory NPAT scale: 0 (P36.9), neonatal jaundice due  Screening for ROP
distress. General status to prematurity (P59.0)  Screening for hearing impairment
There was Head: normocephali, anterior fontanelle open and differential diagnosis clinically
 Screening neurologic abnormalities
slight flat, diameter 1 cm, thin and smooth hair, early-onset sepsis.
yellowish skin head circumference 27 cm Monitor: symptoms, vital sign, body
with grade IV Eyes: pale (-), icteric (-/-), sunken eyes (-), weight, fluid balance, nutrition
kramer palpebral edema (-/-), good light reflexes. tolerance, urine production, length
Heart and lungs within normal limits (every week), head circumference
Abdomen: no distention, normal bowel sound, (every week)
superficial vein apparent.
Extremities: grasp reflexes (+), warm, capillary
refill time <3 second.
Skin: reddish, not pale, superficial peeled, not
icteric, visible vein, no petechiae or hematoma
on the skin, no cutis marmorata, lanugo was
abundant with bald areas found, Kramer IV
Swallowing reflex (+), mild sucking reflex (+),
Moro reflex (+), rooting reflexes (+)

Cumulative fluid balance: +2 ml

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Urine production : 3,83 ml/kg/h.
Body weight : 1520 gram
Length: 44 cm

Laboratory:
Leucocytes 21.52 K/uL (neutrophils 11.81
(54.89%), lymphocytes 5.92 (27.49%);
hemoglobin 10.89 g/dL; hematocrit 30.85%;
platelets 527.4 K/mL; IT ratio 0.07, Procalcitonin
0.29 ng/mL; Total bilirubin 6.71 mg/dL, direct
bilirubin 1.17 mg/dL, indirect bilirubin 5.54
mg/dL

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X. PROGNOSIS
Ad vitam: dubius ad bonam
Patient already passed the critical condition and have good responses to therapy.
Ad functionam: dubius ad dubia
Patient is at risk for having long term complications such as neurological disorder,
hearing disorder, visual disorder, and growth and developmental disturbance. Some
screening examination need to re-evaluate at outpatient clinic. Long term follow-up
is needed to achieve good functional condition in the future.
Ad sanactionam: dubius ad bonam
Improvement was excellent during treatment in Level II Neonatal ward. Patient still
has risks of infection due to immature immune status and organ function.

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XI. SCHEME OF ILLNESS HISTORY
Day 1
(June 27th 2019)
Patient was unstable, respiratory distress
(+), No lethargic, no temperature
instability, no vomiting.
moderate ill, poor activity, muscle tone
and reflexes.
Complete blood count showed leucocytes
28.23 K/uL (neutrophils 18.9 (66.94%),
lymphocytes 5.23 (18.52%)); hemoglobin
12.77 g/dL; hematocrit 37.84%; platelets
279.2 K/mL; IT ratio 0.59; blood smear
revealed normal limit; blood glucose 90
mg/dL; blood smear: normal limit
without vacuolization nor toxic granule ;
chest x-ray with grade I hyaline
membrane disease
Diagnosis:
very low birth weight (1450 gram)
(P07.1), appropriate for gestational age
(P05.0), very preterm infant (31 weeks)
(P07.3), grade I hyaline membrane
disease (P22.0) clinically early-onset
sepsis (P36.9).
Treatment:
Treated in level III neonatal ward
(incubator), NIV support, parenteral
nutrition, early start trophic feeding, first
line antibiotics, vitamin K injection
Day 2-4
(June 28th -June 30th 2019)
Pasien was stable, not lethargic, no
temperature instability, no bradycardia,
no respiratory distress.. Slight yellowish
skin appeared on her face.
Good activity, muscle tone and reflexes
Diagnosis:
very low birth weight (1450 gram)
(P07.1), appropriate for gestational age
(P05.0), very preterm infant (31 weeks)
(P07.3), grade I hyaline membrane
disease (P22.0) clinically early-onset
sepsis (P36.9)
Treatment:
CPAP support until replaced with high
flow O2 nasal canule, preterm formula
increased gradually up to 40 ml/kg/day.
Parenteral nutrition, first line antibiotics.
Day 5-8
(July 1st – July 4th 2019)
Pasien was stable, not lethargic, no
temperature instability, no bradycardia, no
respiratory distress. Yellowish skin with
grade IV Kramer.
Good activity, muscle tone and reflexes.
Complete blood count showed leucocytes
34.31 K/uL (neutrophils 32.61 (68.80%),
lymphocytes 5.20 (15.14%); hemoglobin
12.99 g/dL; hematocrit 36.52%; platelets
440.70 K/mL; IT ratio 0.48;
Total bilirubin 9.57 mg/dL, direct
bilirubin 0.52 mg/dL, indirect bilirubin
9.05 mg/dL)
Diagnosis:
very low birth weight (1450 gram)
(P07.1), appropriate for gestational age
(P05.0), very preterm infant (31 weeks)
(P07.3), grade I hyaline membrane disease
(P22.0) clinically early-onset sepsis
(P36.9), neonatal jaundice due to
prematurity diferential diagnosed
clinically early-onset sepsis (P59.0)
Treatment:
Preterm formula increased gradually up to
100 ml/kg/day. Parenteral nutrition, first
linee antibiotics. Phototherapy for two
days
Day 9-12
(July 5th – July 8th 2019)
Pasien was stable, not lethargic, no
temperature instability, no bradycardia, no
respiratory distress. Slight yellowish skin
with grade IV Kramer.
Good activity, muscle tone and reflexes.
Poor sucking reflex
Complete blood count showed leucocytes
21.52 K/uL (neutrophils 11.81 (54.89%),
lymphocytes 5.92 (27.49%); hemoglobin
10.89 g/dL; hematocrit 30.85%; platelets
527.40 K/mL; IT ratio 0.07, Procalcitonin
0.29 ng/mL;
Total bilirubin 6.71 mg/dL, direct bilirubin
0.9 mg/dL, indirect bilirubin 5.81 mg/dL)
Diagnosis:
very low birth weight (1450 gram) (P07.1),
appropriate for gestational age (P05.0), very
preterm infant (31 weeks) (P07.3), grade I
hyaline membrane disease (P22.0) clinically
early-onset sepsis (P36.9), neonatal jaundice
due to prematurity differential diagnosed
clinically early-onset sepsis (P59.0)
Treatment:
Preterm formula increased gradually up to
150 ml/kg/day (breastmilk through orogastric
tube), iron supplementation, multivitamins,
and minerals. Moved to level II neonatal
ward
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