CHAPTER 1

CASE REPORT
1. Identification of Patients
Name: Baby of Mrs. S
Female gender
Age / Date of Birth: 4 day / 23 October 2015
Address: Perbalan Semarang
Sign RSDK: 24 October 2015
No. CM: C556501
Ward: NICU
Mother's Name: Mrs. S
Age: 40th
Education: elementary school
Occupation: self-employed
Father's Name: Mr. P
Age: 42th
Education: elementary school
Occupation: self-employed
2. Basic Data
2.1 History
Alloanamnesis with the father and mother of the patient and medical record on
October 28th 2015, at 12.00 pm in room NICU
Main complaints: Referral newborns with severe asphyxia
History of present illness
On 23 October 2015 at 20.30 born baby girl from Mother P3A0, 38 weeks pregnant,
40 years, ANC (+) in Sp.OG, antenatal bleeding (-), Mother had a hystory of gestational
disease, Hipertension (+), DM (+), consumption outside of prescription drugs (-), a history of
herbal drink (-), a history of abortion (-), a baby girl born in SCTP in RS Tugu on indications
severe preeclampsia, fetal distress, and polyhidramnion, at birth the baby didnt immediately
cry, APGAR Score 1-2-3, BBL 3500 gram, ASI (+), manual delivery of the placenta 15
minutes after delivery, complete cotyledons, no infarct, no hematom. History injection of
vitamin K (+), the baby was referred to RSDK for reasons of infant severe asphyxia. when the
baby arrived in the ER RSDK, the baby experienced apnea, looked bluish, and HR was
68x/minute then performed intubation and CPR, after CPR the baby breathe spontaneously.
and HR increased by more than 100x / min, the baby have experienced shock given 0.9%

NaCl bolus of 20 cc / kg and drip bobutamin 5 mcg / kg / min. Patients programmed to do

babygram, routine blood test, blood sugar when, urea, creatinine, sodium, potassium, calcium
and blood gas analysis. Attach the pipe orogastrik then flowed, then the patient was
transferred to the NICU, the patient is placed in an incubator and installed monitors and
ventilators with RR 25 mode, PEEP 5, PIP 15, FiO 2 of 60%. Patient's general condition is
still less active, looking limp and not crying. Ampicillin injection of 175 mg/12 h, intravenous
injection of gentamycin 20mg/24 jam , intravenous drip of dopamine 5 mcg / kg / min.
2.2 Family History
- No family members or people in the neighborhood around the house sick like this
- No member of the family with a history of congenital heart disease, shortness of birth, blue
birth
- No member of the family with a history of birth defects
2.3. Socioeconomic history
Father and mother worked as a self-employed (the shop owner). Earnings per month
on average Rp 2.000.000,00. The cost of treatment by using non PBI BPJS.
Impression: lack of socioeconomic
3. Special Data
3.1 History of prenatal, natal, postnatal:
Prenatal: Mother G3P2A0 38 weeks pregnant, antenatal care regular 7 times in
doctor, immunization TT 2 times. A history of vaginal discharge during pregnancy denied, a
history of fever during pregnancy denied, denied a history of bleeding during pregnancy,
denied a history of trauma, history of herbal drink, drugs, and alcohol is undeniable.
Natal: Birth mothers 38 weeks pregnant P3A0, born SCTP helped SpOG on
indications severe preeclampsia, fetal distress, and polyhidramnion,500 grams birth weight,
body length 50 cm, birth indirect cry, jaundice (-).
Postnatal: After birth 1 day ago referred to RSDK because of severe asfixia
3.2 History of Eating and Drinking
Age 0 days giving breast milk diet was delayed due to severe asphyxia.
1 days given breast milk through a pipe orogastrik., dieting ASI 8 x 10-15 ml.
3.3 Basic immunization history and repeatedly
Hepatitis B

: not done

Polio

: not done

BCG

: not done

Impression: basic immunization has not been done.

3.5 History of Family Planning parents

Mother patients not using birth control.
4. Physical Examination (October 27, 2015)
Held on 27 october 2015 at 14:00 pm
Baby girl aged 27 days, weight 3500 grams, length50 cm.
General state: apatis, less active,spontaneous breathe
Vital signs

Blood pressure: 68/34mmHg MAP(46)

Heart rate : 107 times per minute
Breathing: 40 times per minute
Temperature: 36,2oC(axillary)

SpO2= 90%

Status internus:
Head:

Normosefali, head circumference = 32 cm, the large fontanelle = not closed, not
tensed, not obtrusived, caput succedaneum (-), cephal hematoma (-), black hair
evenly distributed, are not easily removed, scalp no abnormalities.
Eyes: Round pupils, isokor, light reflex direct and indirect (+ / +)
Nose: Normal form, the nostril breath (+ / +), secretions (- / -), septal deviation (-).
Ear: Normotia, secretions (- / -), back quickly after being folded.
Mouth : ET is attached, Cyanosis (-), trismus (-), labiopalatognatoschizis (-)

Thorax
Lung :
Inspection: hemithoraks dextra and the left symmetrically on
a state of inspiration and expiration, epigastric retraction (-)
Palpation: not examined
Percussion: not examined
Auscultation: vesicular breath sounds (+ / +), additional breath sounds (- / -)
Heart :
Inspection: ictus cordis invisible pulsation
Palpation: ictus cordis was not palpated
Percussion: not examined
Auscultation: heart sounds I - II regular pure, murmur (-), gallops (-)
Abdomen
Inspection: flat
Auscultation: bowel (+) 1 times per minute
Palpation: sociable, liver and spleen not palpable enlarged

 Percussion: timpani in the entire quadrant of the abdomen

Spine
There does not appear deformities, spina bifida (-), meningokel (-)
Genitalia and anorectal
Female gender, partially covering the labia majora labia minora, anus (+) no
abnormalities.
Skin
There does not appear efloresensi meaningful, jaundice (-), pale (-), coloring
mekoneum (-)
Extremities
Superior

Inferior

Deformity

-/-

-/-

Akral Cold

-/-

-/-

Acral cyanosis

-/-

-/-

Jaundice

-/-

-/-

CRT

<2 "

<2"

Tonus

Normotonus

Normotonus

5. HEMATOLOGY (October 27th, 2015)

Examination
Result Unit
Normal value
Description
Hematology Package
Hemoglobin
17.9
g%
13.6 - 19.6
Hematocrit
53.7
%
44 - 62
Erythrocytes
5.98
million/mmk
3.9 5.9
MCH
29.8
pg
24,0 34,0
MCV
89.7
fL
83,0 110,0
MCHC
33.2
g/dL
29,0 36,0
Leukocyte
11.3
thousand/mmk
9 - 30
Platelets
168
thousand/mmk
150,0 400,0
Differential Counts
Eosinophyls
2%
24
Basophyls
1%
04
Staf
1%
25
Segment
61%
45 75
Lymphocytes 20%
20 40
Monocytes
10%
3 - 12
Peripheral blood figure
Erythrocyte
anisocytosis moderate (macrocytes, normosit,micrositik)),
light poikilositosis moderate (tear drop,fragmentosit,pear
shapeovalosit, eliptosit), polikromasi (+), young eritrosit +
+/pos 2
Trombocytes
Estimates of the number of normal platelets, form a large,
Giant platelets (+)
Leukocytes
The estimated amount of normal leukocytes
Clinical Chemistry

GDS
Ureum
Kreatinin
Calcium
Sodium
Pottasium
Chloride
Total Bilirubin
Direct Bilirubin
Albumin
CRP Kualitatif
TSHs
Free T4

64
15
0.9
2.1
127
3.2
98
8.03
0.97
2.6
0.02
12.52
22.29

mg/dL
mg/dL
mg/dL
mmol/L
mmol/L
mmol/L
mmol/L
mg/dL
mg/dl
g/dl
mg/L
uIU/mL
pmol/L

80 160
15 39
0,6 1,3
2,12 2,52
136 145
3,5 5,1
98 107
0.0-1.0
0.0-1.0
3.4-5.0
0-0.30
0.25-5
10.6-19.4

L
H

6. X PHOTOS BABYGRAM (24 October 2015, 00:40 pm)

CLINICAL: severe asphyxia, cardiogenic shock observation
Looks endotracheal tube attached to the distal end of the third thoracic vertebral body height
COR: CTR = 62% The shape and location of the normal heart
Pulmo: vascular markings appear to be increasing Looks patches on top of the left lung field
Looks opacity lobulated form on the right trachea vertebral body height thoraca 1-6 tend
thymus structure
Right hemidiaphragm as high as 8 posterior costa
Sinus costofrenikus left and right taper
ABDOMINAL
Looks attached umbilical catheter with cranial end looks superposition with thoracic
vertebra 11
Invisible dilated and distended intestines
Air is not visible on the pelvic cavity
Invisible free water
IMPRESSIONS
The distal end of the endotracheal tube thoracic vertebral body height 3
The shape and location of the normal heart
Overview of neonatal pneumonia
Abdomen within normal limits

7. X-Thorax AP photo (24 October 2015 06:50)

(compared with x-photo dated 24 October 2015, 00:40 pm)
CLINICAL: severe asphyxia, reintubation
Looks endotracheal tube attached to the distal end of the thoracic vertebral body height 3-4
Looks gastric tube attached to the distal end of the thoracic vertebral body height 9
COR: CTR = 60%
The shape and location of the normal heart
Pulmo: vascular markings appear to be normal

Looks spots on the field on the left lung is relatively the same compared to the previous photo
Linear opacities appear at the bottom right lung field DD / Vascular, thickening interseptal
Tubular opacity appear on the right hemkithorak vertebral body height 2-7 thoraca tend
thymus structure
Right hemidiaphragm as high as 8 posterior costa
Sinus right costofrenicus left taper superposition with costa
IMPRESSIONS:
The distal end of the endotracheal tube 3-4 thoracic vertebral body height (height carina)
Configuration is relatively the same heart
Pulmonary infiltrates relatively equal

8. Assesment
Severe Respiratory Distress on VM
Aterm neonates
Post severe asphyxia
neonatal infections
A history of recurrent hypoglycemia
Post-shock dd / cardiogenic shock
suspect cardiomegaly
9. Program
O2 VM SIMV PEEP 5 PIP 15 RR 30 FiO 2 50%
Infusion of D 12.5% 288 ml / 24 hours 12 ml / h (7.1 GIR)
+ NaCl 3% (4 meq) 47 ml
Being a 500 ml D 12.5%
+ Kcl Otsu (2 mEq) 12 ml
Aminosteril 6% 86.4 ml / 24 hours 3.6 ml / hour (3gr / kg / day)
Ivelip 20% 12 ml / 4 hours 0.5 ml / h (1 g / kg / day)
Intravenous: ampicillin 175 mg / 12 h ()
Gentamicin 20 mg / 24 hours
Ca gluconas 1.5 ml / 12 hours 1v slowly
5 mcgram dobutamine / kg / min
Diet ASI 8x10 ml / pregistimil
Program: blood culture (26/10/2015)

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