23 Agt Inggris

MORNING REPORT
MONDAY, 30 AUGUST 2021
KEPANITERAAN KLINIK ILMU KESEHATAN ANAK

FAKULTAS KEDOKTERAN
UNIVERSITAS LAMPUNG
2021
CO-ASSISTANT ON DUTY
GROUP 2
Alamanda 2nd Floor Perinatology
 Beni Wibowo  Helen Kusuma W
 Dzikrina Citra F  Melia Munasiah
 Riska Priyani
Alamanda 3rd Floor
 Clara Firhan Emergency Room
 Nurul Fitri Insani  Efrans Caesar
 Muhammad Bagus Nitei Ago
 Rifqi Fadhil M
Mrs.Sumarni’s baby/male/
3 days Pediatric Assessment
Appearance Breathing
Abormal Normal
Circulation
Normal
Appearance: Respiratory & Breathing :

T: Tone (+) Nasal flare (-), retraction(-)
I: interactiveness (+)
C: consobility (+)
L: look/gaze( ) Circulation:
S: speech/cry ( ) Pale extremity (-), CRT < 2”
THE HISTORY
Identity : Baby Mrs. Sumarni /Male/ 3 days
Birth date : August 23rd 2021
Time of Admission in Emergency Department : 07.30 PM local time
Gestational Age : 38 weeks
Corrected Age : 38 weeks + 3
Chronological Age: 3 days
Main Complaint : Hydrocephalus
Additional Complaint : Neonatal jaundice
Present History:
Patient was referred to the Emergency Department of Abdul Moeloek Regional General Hospital from Panti
Secanti Hospital at 07.30 PM on August 26th 2021 to get better care with better equipment with birth weight
3700g and birth length 51cm. Patient came with weak condition and hypoactive. The patient looks yellowish
tint of skin and head enlargement. The patient was with OGT with no product, no vomiting, no bloating, no
hypersaliva.
Past Medical History: None
Family History: None
Pregnancy History: Mother with G2P1A0 (age: 33 years old)
• ANC: with midwife, routinely
• The mother did USG examination once. Had never taken certain drugs, only vitamins obtained from
midwife. The mother had followed recommended balanced food from midwife. Had experienced
nausea and vomiting at the beginning of pregnancy. Weight gaining from 55kg (before pregnancy) to
64kg.
Birth History:
The baby was born premature by section caesaria with birth weight 1500g and birth length 43cm.
Immunization History:
Unknown
Feeding History:
Formula milk
Physical Examination
General Condition Vital Signs:
•Impression: moderate illness •HR: 110 x/minutes
•Weight: 1500 gram •RR: 48 x/minutes
•Length: 43 cm •T: 38,5 ºC
•SpO2: 91%
Spesific Condition
• Head: normocephal
• Nose: Nasal flare
• Mouth: sianosis(-) OGT used
Thorax:
Inspection : subcostal retractions (+/+), intercostal retractions (+/+),
Palpation : not rated
Percussion: not rated
Auscultation: not rated
Abdomen:
Inspection : flat, bloated (-)
Auscultation: not rated
Percussion: not rated
Palpation : not rated
Extremity:
Superior: CRT <2 seconds, edema (-/-), icteric (-)
Inferior: CRT >2 seconds, edema (-/-), icteric (-)
LUBCHENCO
LUBCHENCO
CHART
CHART
BB: 1500 gram

Interpretation :
BB : 10-90 percentile
SMK (Relevant to
Pregnancy)
LUBCHENCO
LUBCHENCO
CHART
CHART
PB: 43 cm
Interpretation:
PB : 10-90 percentile
SMK (Relevant to
Pregnancy)
FENTON
FENTON CHART
CHART
BB: 1500 gr
PB: 43 cm
Gestation Age: 32 Weeks
Interpretation :
PB: Percentile 10-90
BB: Percentile 10-90
Normal
DOWNE SCORE
Criteria 0 1 2
Respiratory rate <60x/min 60-80x/min >80x/min
Retractions No retraction Mild Berat
Cyanosis No cyanosis Relieved by O2 Cyanosis on O2
Air entry Good bilateral air Mild decrease air No air entry
entry entry
Grunting No grunting Audible by Audible with ear

stethoscope
Score : 3  Mild respiratory distress

Laboratory Finding
Result Normal Value Unit
Haematology :
Haemoglobin 19.0 12-16 gr%
Leukocyte 6.100 5-10 Thousand
Erythrosite 4.96 4-6 Million
Thrombocyte 86.000 150.000-450.000 -
Hematocryte 51 37-48 %
Lymphocyte 34 20-40 %
Monocyte 8 2-8 %
Billirubin Test:
Total Billirubin 11.34 <1,35 mg/dL
Direct Billirubin 2,17 <0,35 mg/dL
11
Indirect Billirubin 9,13 <1,35 mg/dL
Laboratory Finding
Blood Glucose Level 47 mg/dL
Covid-19 PCR Test + (Positive)

RESUME
Patient on behalf of Mrs. Fitriyani’s baby was born on August 7, 2021, entered the
emergency room on August 18, 2021 at 15:34 which was then referred to
perinatology on August 18, 2021 at 18:30. The patient was crying and hipoactive,
with shortness of breath and CPAP installed. Gestational age was 30-31 weeks.
Apgar score was 5/7. Physical examination showed mild retractions, no cyanosis.
The laboratory examination showed decrease in thrombosite and increase in total
bilirubin, hematocryte, and hemoglobin.
Problem Assessment
1. Very low birth weight Very low birth weight + RDS
(BBLSR) + premature 30-31 weeks
2. Premature birth
3. RDS (Respiratory Distress
Syndrome)
Diagnosis/Differential Working Diagnosis

Diagnosis Premature + low birth weight
1. Transient tachypnea of + NKB-KMK (Premature
the newborn (TTN) neonates – small for
2. Meconium aspiration gestational age) 30-31 weeks+
Syndrome (MAS) RDS
Medikamentosa Non Medikamentosa
• RDS Aminophiline 3x3, 6 mg 1. CPAP (continuous positive
• low birth weight (risk of airway pressure)
infection) : Ceftazine 2x 75 mg + 2. OGT (orogastric tube)
Gentamicine 6 mg/ 36 jam
• Antifungal (prophylactic therapy)
: Nystatin drop 3 x 0,3 ml +
Flukonazole 1 x 15 mg (oral)
• Electrolyte fluid: IVFD Kaen 1B
5TPM
Monitoring
Done during the referral trip.
At the referral hospital, monitoring data has not been obtained
because the patient is in the perine isolation room.
THANK YOU

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MORNING REPORT

MONDAY, 30 AUGUST 2021

KEPANITERAAN KLINIK ILMU KESEHATAN ANAK

Appearance: Respiratory & Breathing :

BB: 1500 gram

Grunting No grunting Audible by Audible with ear

Score : 3  Mild respiratory distress

Blood Glucose Level 47 mg/dL

Covid-19 PCR Test + (Positive)

Diagnosis/Differential Working Diagnosis

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