ANAMNESIS

Chieft Complaint

Decreased urination
 HISTORY OF ILLNESS

Present illness

• The newborn infant was born from his mother by SC

delivery because of premature rupture of membrane.
• Then, from birth until when he was 2 days old, he just
urinating 2 times.
• Defecating > 10 x times (yellow, mucus (-), blood (-))
• He strong breast milk, active
 HISTORY OF PAST ILLNESS

Conclusion: there are no history of past illness that related to

current illness
 HISTORY OF ILLNESS IN FAMILY

History of icterus neonatus : Denied

History of seizure : Denied
History of alergy : Denied
Blood Type of mother :A Rh (+)
Blood Type of father :B

Conclusion: there is no history of illness in family that correlated with

patient’s disease
 PEDIGREE

Mr. D 35 years old

Mrs. A 29 years old

By. NI 5 days old

Conclusion : there is no illness inherited

 HISTORY OF PREGNANCY

Mother with P2A0 is pregnant at 29 years old. Mother began to

check pregnancy and routinely control to the doctor. During
pregnancy the mother does feel nausea, vomiting and dizziness
that interfere with daily activities. During pregnancy there is no
history of trauma, bleeding, infection, and hypertension during
pregnancy.

Conclusion : history of pregnancy was good

 HISTORY OF DELIVERY

The mother gave birth to her baby assisted by a doctor with a SC delivery.
38 weeks pregnancy age, baby born with body weight 3520 grams with
body length 50 cm and head circumference 35 cm. At the time of birth the
baby cries instantly, there is no congenital defect at birth.

Conclusion : history of delivery was not good

HISTORY OF POST DELIVERY

The baby girl was born crying, active motion, red skin color, not
blue and not yellow skin color, got milk on first day, urination
and defecated less than 24 hours

Conclusion : history of post delivery was good

 HISTORY OF ENVIRONMENT

The patient lives at home with his parents and sister.

Cheramic-floored patient houses, walled walls, tile roofs, ventilation,
bathrooms in the house, water source from PDAM.

Conclusion : there is no risk factors for transmitted disease

 HISTORY OF VACCINE

• At that time of examination, the mother was bring

KMS.
• The patient has received the basic vaccine, there are
Hepatitis B (0) Vaccinations are obtained at the PKU
Muhammadiyah hospital.

Conclusion : history of vaccine was good

 HISTORY OF FEEDING

Age 0 – 3 days

• Exclusive breastmilk

Conclusion : history of feeding from quality and quantity was good

 Physical Examination

 General appearance
General appearance : Crying strong, active moving

 Vital Sign
Heart rate : 140/ menit
Respiratory Rate : 40x/ menit
Temperature : 36,7º C
 Nutrisional status

- Weight : 3500 grams

- Lenght : 50 cm
- Head Circumference : 35 cm
- Chest Circumference : 32 cm

Conclusion : The patient's nutritional status was good

 Physical examination
• Skin examination
Color : yellow, from face, neck, until chest.
The skin looks like a leather paper, cracked in, invisible
vein
Skin turgor: <2 sec (good)
Moisture: moist
Edema (-) does not exist

• Conclusion : the examination of skin is kramer 2.

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Kesan : Berat badan lahir sesuai masa kehamilan
Gafik Lubchenko

12/29/2018 Impression: Birth weight according to pregnancy 14

 PEMERIKSAAN KHUSUS
Neck : No enlargement of lymph node and increase jugular venous, look yellow (+)
Chest : Simetris, retration (-), miss the motion (-), and look yellow (+)
• Heart
Inspeksi : The ictus cordis is not visible
Palpasi : Ictus cordis not strong lift
Perkusi : sound “redup”
Auskultasi : sound of cor I-II reguler, bising jantung (-)
• Lung
Inspeksi : Simetris, retraksi intercostal (-/-), retraksi
subcostal (-/-), retraksi substernal (-), retraksi suprasternal (-)
Palpasi : Simetris kanan kiri, There is no missed breath
Perkusi : sonor
Auskultasi : Vesicular (+/+) normal, rhonki (-/-), wheezing (-/-)

Conclusion : Neck,and Chest look joundiced

Stomach : Inspeksi : Datar, tali pusat kering,
Auskultasi : Peristaltik (+) normal
Perkusi : Timpani (+)
Palpasi : Supel, massa abnormal (-), nyeri tekan (-),
turgor kulit menurun (-), acites (-)
Liver : Hepatomegali (-)
Spleen : Splenomegali (-)

Conclusion : the examination of Stomach is normal

 Genitalia

• Normal, testis down, good rugae

•Anus (+)

Result : Genitalia examination there are within normal limits

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12/29/2018 17
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 12/29/2018
Ektremitas
Anggota Gerak Superior Inferior
Tonus normotoni normotoni
Reflek primitif(moro,rooting,hisap) + +

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Sianosis -/- -/-

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Cap refill < 3 detik < 3 detik

Permukaan plantar kaki Garis2 pd

seluruh telapak
kaki

Result : Extremity examination there are within normal limits

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 PHYSICAL EXAMINATION

Head : Normochephal
Eyes : CA (-/-), ScIera icteric (-/-), edema palpebra (-/-), reflek cahaya (+/+)
isokor (+/+), decreased tears (-),
Nose : Sekret (-), epistaksis (-), nafas cuping hidung (-/-)
Ears : Sekret (-), hiperemis (-)
Mouth : Stomatitis (-), perdarahan gusi (-), sianosis (-), pharynx hiperemis (-),
dry lips (+)
Skin : Warna sawo matang, Pucat (-), Ikterik (+), Sianosis (-), turgor kulit (< 2
detik)
Lymph nodes : Tidak didapatkan pembesaran limfonodi
Muscle : Tidak didapatkan kelemahan, atrofi, maupun nyeri otot
Bone : Tidak didapatkan deformitas tulang
Joints : Gerakan bebas

Conclusion: positive skin of joundiced and dry lips (+)

 RESUME
Anamnesis Physical examination
• The Baby was born on 10 December 2018 at  General appearance
07.20 from a mother 29 years old,G2P1A0. General appearance : crying strong and active
• The Baby was born with caesarean section at motion
39 weeks' gestation because of premature Awareness : alert
rupture of membrane  Vital Sign
• The baby's weight is 3520 grams, 50 cm baby's Heart rate : 140/ menit
length and 35 cm head circumference. Respiratory Rate : 40x/ menit
Temperature : 36,0º C
• Then, from birth until when he was 2 days old,
he just urinating 2 times.
Nutritional status
• Defecating > 10 x times (yellow, mucus (-),
• Weight : 3500 g
blood (-))
• Lenght : 50,0 cm
History of illness in family
• Head circumference: 35,0 cm
• No history of illness Skin examination :
History of pregnancy Color yellow, from face, neck, until chest
history of pregnancy was normal • dry lips (+)
 Assesment
Diagnosis :
1. Dehidration

et causa DD :
- inadequate intake oral
2. Hiperbilirubinemia
DD :
- Polisitemia
- Defisiensi G6PD
- Sferositosis
- autoimun hemolitik

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 ACTION PLAN
• Observation of vital signs (temperature, frequency of
respiratory)
• Observation sign of dehidration
• Observation of fluid input and output

DIAGNOSIS ENFORCEMENT PLAN

• Blood examination
• Glucose examination
 ` PLAN
THERAPY

Rehidration :
• Rehidration plan C with RL
1 jam pertama : 30 ml x 3.5 kg = 105 ml = 105 dpm mikro
5 jam kemudian : 70 ml x 3.5 kg = 245 ml = 49 dpm mikro
 Kebutuhan cairan rumatan
• Kebutuhan ASI 80 ml/kgBB/hari + 10 %
ASI = 3.500 kg x 80ml/kg/hari = 280
ml/hari
 Intake 35 ml/ 3 jam
THANK YOU