Morning Report

Wednesday, Marc 17th 2021

MAY / STH / SRI
NO NAME GENDER DIAGNOSIS
1 Baby Y Boy, 1. RDS ec. Dd/ Neonatal Pneumonia +
5 days old Unproven Sepsis + Suspect Peritonitis
d/t Necrotizing Enterocolitis + Neonatal
Jaundice + Aterm baby, Approppriate
gestational age
New Patient of Perinatology admitted at 02.30 A.M, baby Y, Boy, 5 days,
address: Jamin Ginting, Medan.
BW: 2480 gr BH : 49 cm
BW/A : -3<zs<-2 BH/A -2<zs<0 BW/BH zs=-3

Chief complain : Shortness of Breath

- Shortness of breath has been found since from birth, born by section
caesarea at Sylvani Hospital, after the patient’s birth in care NICU and
installed with canul nasal and with CPAP yesterday morning
- An enlarged stomach has been found since 1 day ago, the patient don’t
want to breastfeed since 2 days ago and the patient is always vomiting if
give breast milk, while the patient is fasting since 1 day ago
- Fever was found since 1 day ago
- Yellowish was found since 2 day ago
- Baby was not cry, suck and movements was not found
- Urinary only a little
- defecation was slimy and yellow
Past Medical History
Patient was referred from Pediatrician at Sylvani Hospital with diagnose RDS + NEC +
Aterm baby- Approppriate gestational age (38-40 weeks)

History of Medication
-CPAP
- IVFD N5 9 gtt/i
- Inj. Meropenem 100 mg
- Inj. Metronidazole
- Inj. Ampicillin
- Inj. Gentamicyn
Pregnancy History
Patient is the first child. Mother's age when pregnant 30 years. ANC
routinely goes to midwife and has no history of diabetes mellitus,
hypertension or other diseases.

Birth History
Patient is born full term, , born by section caesarea at Sylvani Hospital, born
spontaneously cried but weak, bluish was not found, APGAR score was
unknown. Seizure was not found. Birth weight 2.480 gram and lenght 48
centimeter. Get Inj vit k.
Physical Examination
Neurological System : not stable
Sensorium: GCS 2: E1M1Vett
Head : Eye : Light reflexes (+/+), isochoric pupil, Ø 2mm/2mm, pale inferior
palpebral conjunctiva (-/-) , palpebra oedeme (-/-)

Respiration System : Not stable

ETT was inserted no.3 cuffed at lip 8 cm connect to ambu bag with
oksigen 8 ltr/mnt
Troraks: Symetrical Fusiform, With epigastrial retraction,
RR = VTP 20-30 x/I, reguler, ronchi was found (+/+), both lung fields.
Cardiovascular System : Not Stable
HR : 62x/min, reguler, murmur was not found.
Pulse : 62x/min, no adequate pulsation Central, Cold Extremities, CRT >2 sec.

Metabolic system : Not Stable

Abdomen : Distension , Peristaltic was not found
(16/03) pH 6,9/ pCO2 22/ pO2 188/ HCO3 5,3/TotCO2 6/ BE -24,7/ SatO2 99
Ca 6,9 /Na 125 / K 6 / Cl 94
Albumin 2,2
Bil tot 7,7/ Bil Direct 0,7/ SGOT 110/ SGPT 11

Hematologic System : Not Stable

Pale(-), Bleeding from NGT (+)
(16/03) Hb 14,6/ Ht 43/ Trombocyte 28.000

Urologic system : Not stable

(16/3) BUN 26/ Ur 56/ Cr 1,83
Infection System : Not Stable
Fever and Hipoterm was not found Temp: 36.7
WBC: 4020/ N: 61/ L 24,6
PCT : > 100

Musculoskeletal System: Not Stable

Edema was found

Nutritional system : not stable

Diet : Fasting for a moment
 Down Score
breath frequency 2

Retraction 2

Cyanotic 1

Air entry 1

whimpering 2

Total 8
Laboratory result RSUP HAM 16/03/2021

•Hemoglobin : 14.6 g/dL • Blood Glucose ad random : 13 mg/dL

•Hematocrit : 43 % • CRP : 1,4
•Leukocytes : 4020 /µL • PCT : > 100
•Platelets : 28.000 /µL
Ca 6,9 /Na 125 / K 6 / Cl 94
•MCV : 106 fl
•MCH : 36,3 pg pH 6,9/ pCO2 22/ pO2 188/ HCO3
5,3/TotCO2 6/ BE -24,7/ SatO2 99
•MCHC : 34,4 g/dl
Bil tot 7,7/ Bil Direct 0,7/ SGOT 110/
SGPT 11/ Albumin 2,2
E 3,5/B 1,20/N 61/L 24,6/M 9,7
BUN 26/ Ur 56/ Cr 1,83
Antigen SARS CoV-2 : Negative
Differential Diagnosis :
1. Respiratory distress ec Neonatal pneumonia+ severe metabolic acidosis + suspec sepsis+
Suspected Peritonitis d/t NEC + Neonatal Jaundice + Trombocytopenia + Upper GI bleeding+
electrolyte imbalance + Hypoalbuminemia + Aterm baby + Small gestational age
2. Respiratory distress ec Aspiration pneumonia+ severe metabolic acidosis + suspec sepsis+
Suspected Peritonitis d/t NEC + Neonatal Jaundice + Trombocytopenia + Upper GI bleeding+
electrolyte imbalance + Hypoalbuminemia + Aterm baby + Small gestational age

Working diagnosis :
Respiratory distress ec Neonatal pneumonia+ severe metabolic acidosis + suspec sepsis+
Suspected Peritonitis d/t NEC + Neonatal Jaundice + Trombocytopenia + Upper GI bleeding+
electrolyte imbalance + Hypoalbuminemia + Aterm baby + Small gestational age
Therapy
- Keep the baby in incubator with target skin temperature 36,5-37,5’C
- Ventilator with FiO2 70%, PEEP 6, PIP 20, RR 40x/mnt, VTE 4-6cc/KgBW
- Daily fluid req 120cc/KgBW/day
- Parenteral : N5  7cc/hour (GIR 4,8)
Aminosteril 2,5gr/KgBw/day  4,2cc/hour
- Inj Meropenem 50mg/8hour
- Inj metronidazole LD 37,5mg and then MD 18mg/8hour

Plan:
- Correct metabolic acidosis
- Consult anastesiologi to instal CVC
- Correct hypoalbuminemia
- Consult to pediatric surgeon
- Platelet transfusion
Time Sens HR RR Temp SaO2 Additional
(bpm) (tpm)
02.30 E1M1Vett 62 VTP 36,4 38% VTP
Fluid challenge 10cc/KgBw
Check DOPE
Inform concern parents with critical condition

03.00 E1M1Vett 35 VTP 36,5 28% VTP + kompresion

Inj epinefrin 1:10000

03.45 E1M1Vett 26 VTP 36,9 20% VTP + kompresion

Inj epinefrin 1:10000

04.00 E0M1Vett - VTP 36,6 - No pupil reflex and cornea reflex,

VTP + kompresion

04:15 E0M0Vett - - - - exit

Thank You